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: 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
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 11 11 11.000000 $569.3600 $51.7600
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.000000 $460.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 81 89 101.142857 $4905.4300 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 127 142 165.928571 $8047.5400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 154 175 213.521429 $10355.7900 $48.5000
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Subtotal (Total Children Is Unduplicated) 281 423 497.592857 $24431.6300 $49.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 6.142857 $9214.3500 $1500.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 3.316666 $165.8300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 35 56.803968 $2840.1800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 57 52.657935 $2632.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 451 519 326.422201 $16320.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 1.988889 $49.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 78 97 831.571430 $20789.3200 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 8.571429 $214.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 600 720 6565.499980 $328275.4400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 122 148 953.747627 $64740.3800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 13.142857 $713.9200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 166 202 1186.640492 $80549.1300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 26.285714 $1427.8400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 26 23.699999 $23.7000 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 31.066668 $1553.3300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 210 254 1511.892870 $102627.3000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 6 7 26.642858 $351.6900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 636 815 17864.501569 $8932.2500 $0.5000
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Subtotal (Total Children Is Unduplicated) 798 2908 29491.596009 $641447.5300 $21.7500
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Total 3331 29989.188866 $665879.1500 $22.2000
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Number of Children (Unduplicated) With at Least One Authorization 799