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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4167 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 70 77 1986.699997 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 90 97 30206.594445 $1123685.3200 $37.2000
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Subtotal (Total Children Is Unduplicated) 158 174 32193.294442 $1123685.3200 $34.9000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 33.042542 $1652.1300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 4 4.568797 $228.4400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 10 10 18.300000 $915.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 24.005479 $1800.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 246 246 488.066667 $36605.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 40 40 80.000000 $6000.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 29 29 58.000000 $4350.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 64 64 126.000000 $9450.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 159 159 316.066667 $17541.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 22 22 44.000000 $2442.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 96 115 44.486508 $2287.0500 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.683333 $35.1300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 2.850000 $146.5200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 20 22 7.305555 $375.5800 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 89 94 90.638095 $4659.7000 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 4 4 6.000000 $308.4600 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 2.450000 $125.9500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 53 62 34.007141 $1748.2900 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 5 5 1.905555 $97.9600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 8 3.438889 $176.7900 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 33 37 24.772224 $1273.5500 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 4 1.400000 $71.9700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 18 21 8.572223 $440.7000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 169 197 75.353972 $3873.9700 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.872222 $44.8400 $51.4100
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Subtotal (Total Children Is Unduplicated) 653 1235 1577.791348 $102366.4400 $64.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 2.933333 $14666.5000 $4999.9400
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 18 12.900001 $645.0100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 4 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 3.033334 $75.8400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 253 338 234.848410 $11742.4100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 0.650000 $32.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 137 173 265.071431 $6626.7900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 156 345 210.303965 $10515.1900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 5 3.822222 $191.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 63 139 193.622214 $4840.5400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 133 82.572224 $4128.6200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 70 110.205555 $2755.1400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 230 292 205.205559 $10260.3000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.422222 $21.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 134 164 239.927778 $5998.2000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.571429 $278.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 270 355 2798.342854 $139917.0600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 15 18 124.571429 $6228.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 117 141 1103.488101 $79406.9300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 24.857143 $1788.7200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 132 167 1770.187306 $101962.7300 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 15.428571 $888.6900 $57.6000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.094444 $6.7900 $71.9300
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 47.142857 $2715.4300 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 53 67 596.650794 $42934.9500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 12.857143 $925.2000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 56 73 749.142859 $43120.6300 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 12.857143 $740.0500 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 12.857143 $925.2000 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 12.857143 $740.0500 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 12.857143 $740.0500 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 156 206 1548.678574 $111442.8300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 51.142858 $3680.2400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 13 94.404761 $6793.3600 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $431.7600 $71.9600
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Subtotal (Total Children Is Unduplicated) 612 2758 10572.507943 $619076.0100 $58.5600
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Total 4167 44343.593733 $1845127.7700 $41.6100
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Number of Children (Unduplicated) With at Least One Authorization 835