Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 81 90 247.911113 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 81 90 247.911113 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 54 67 19.788888 $959.7600 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 32 33 15.516666 $931.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.405556 $18.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.433333 $164.8300 $115.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.022222 $1.6700 $74.9300
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.011111 $0.8300 $74.9300
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 42 42 0.416659 $31.1900 $74.8600
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 12 12 0.111110 $8.3300 $74.9300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 5.438890 $263.7900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.588889 $28.5600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 3.933332 $190.7600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 30 32 7.116668 $345.1700 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.161111 $16.1100 $99.9900
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Subtotal (Total Children Is Unduplicated) 195 230 54.944435 $2960.2400 $53.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 33 18.544444 $27816.6000 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 159 194 1.472265 $73.8300 $50.1400
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 0.012501 $0.3200 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 332 431 944.563515 $47228.2900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 149 297.494450 $14874.7500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 122 159 290.611114 $14530.5700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 337 439 865.556382 $43277.9800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 325 423 3307.188087 $165359.6300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 22 27 225.219047 $11260.9600 $50.0000
INTR -INTR INTERPRETER 39 55 571.731748 $28586.6000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 81 109 959.020630 $65098.4000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 59 83 616.212696 $41828.5300 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.416667 $208.3500 $500.0400
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.744444 $397.7200 $227.9900
SENS -V5264 EARMOLD 6 7 4.172222 $75.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 66 92 726.077779 $49286.2000 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 501 1353 478874.474608 $239437.2400 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 29 43 270.090477 $13504.5400 $50.0000
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Subtotal (Total Children Is Unduplicated) 526 3605 487974.603076 $762845.5700 $1.5600
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Total 3925 488277.458624 $765805.8100 $1.5700
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Number of Children (Unduplicated) With at Least One Authorization 626