Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1291 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.777778 $28.9300 $37.2000
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Subtotal (Total Children Is Unduplicated) 1 1 0.777778 $28.9300 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.9600 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 5 0.861111 $50.0400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.366667 $79.4200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 12 4.144445 $240.8400 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.088889 $63.2800 $58.1100
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Subtotal (Total Children Is Unduplicated) 16 26 12.461112 $685.7500 $55.0300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.155556 $7.7800 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 365 412 477.758703 $23887.8100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 48 92.761113 $4638.0500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 572 656 547.459489 $27372.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 86 103 1005.414288 $54292.3600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 6 26.000000 $2114.3200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 8 11 80.857143 $6575.3100 $81.3200
TRAV -TRAVS Travel by mile 20 27 203.760317 $90.6700 $0.4500
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Subtotal (Total Children Is Unduplicated) 766 1264 2434.166609 $118979.1000 $48.8800
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Total 1291 2447.405499 $119693.7900 $48.9100
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Number of Children (Unduplicated) With at Least One Authorization 770