Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 37 40 55.142857 $2674.4300 $48.5000
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 9.000000 $450.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.000000 $388.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.000000 $436.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 11.000000 $533.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 69 76 92.142857 $4482.4300 $48.6500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 3.000000 $150.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 13 16.338093 $816.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 14 7.522221 $376.1100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 9.988889 $499.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 10.699205 $534.9500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 34 38 284.926986 $14246.3700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 9 38.428573 $2608.5200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 6 6 38.571429 $2618.2300 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 25 24.533333 $24.5300 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 16.209524 $810.4800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 11 94.642856 $6424.3700 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.285714 $28.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 868 1383 9365.007918 $4682.5000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 2.357143 $117.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 899 1526 9912.511884 $33938.8000 $3.4200
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Total 1602 10004.654741 $38421.2300 $3.8400
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Number of Children (Unduplicated) With at Least One Authorization 926