Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3875 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 61 65 2768.209522 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 97 102 41297.482541 $1536266.3500 $37.2000
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Subtotal (Total Children Is Unduplicated) 155 167 44065.692063 $1536266.3500 $34.8600
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 29 35 41.694826 $2084.7400 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 8 9 12.723288 $636.1700 $50.0000
EXIT -EXIT EXIT ASSESSMENT 14 14 25.644444 $1282.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 17 17 34.000000 $2550.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 123 127 254.000000 $19050.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 44 44 88.000000 $6600.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 20 20 40.000000 $3000.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 29 30 60.000000 $4500.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 15 15 30.000000 $2250.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 67 68 136.000000 $7548.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 27 28 56.000000 $3108.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 88 112 41.603168 $2138.7900 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.216667 $11.1400 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 5.616666 $288.7500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 17 21 6.149998 $316.1600 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 75 80 65.421786 $3363.3200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 5 5 3.661112 $188.2200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 3.000000 $154.2300 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 3.000000 $154.2300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 52 62 38.479363 $1978.2100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 4 6 1.800000 $92.5400 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 7 1.972222 $101.3900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 30 31 17.505556 $899.9600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 1.500000 $77.1200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 5.733333 $294.7500 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.022222 $1.1400 $51.3600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 164 202 98.411102 $5059.2700 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.688889 $35.4200 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.338889 $17.4200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.177778 $7.9800 $44.8700
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Subtotal (Total Children Is Unduplicated) 535 994 1127.361309 $71510.8000 $63.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 2.700000 $13500.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.488889 $24.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 3 1.533333 $355.1400 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 25 16.038889 $801.9500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 14.333333 $358.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 251 321 257.011102 $12850.5100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.188889 $59.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 169 282.270638 $7056.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 138 305 189.191651 $9459.5100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 2 1.644444 $82.2200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 65 157 186.266657 $4656.6400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 150 91.588876 $4579.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 83 120.422221 $3010.5500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 226 273 224.542054 $11227.0600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 1.188889 $59.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 129 157 235.766671 $5894.1800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 269 346 3053.919030 $152696.1200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 9 10 101.090475 $5054.5300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 106 130 1061.225393 $76365.8300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 15.285714 $1099.9700 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 121 165 1709.285708 $98454.9400 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 16.285714 $938.0600 $57.6000
OCCT -97530TLHM OT SESSION BY OT ASST 3 3 58.714285 $3381.9400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 51 67 553.185712 $39807.3000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 2 13.142857 $945.7600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 60 86 835.360316 $48083.3700 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 2 13.142857 $756.5100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.428571 $390.6400 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 2.285714 $131.5600 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 2 13.142857 $756.5100 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 3 1.744445 $801.1100 $459.2300
SENS -V5264 EARMOLD 2 3 1.533333 $27.8000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 170 212 1825.090468 $131333.6900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 5 40.857143 $2940.0800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 7 8 63.714286 $4584.8900 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 2 6.133334 $441.3600 $71.9600
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Subtotal (Total Children Is Unduplicated) 595 2714 11016.744748 $642967.5200 $58.3600
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Total 3875 56209.798120 $2250744.6700 $40.0400
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Number of Children (Unduplicated) With at Least One Authorization 771