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: 10-01-12 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 19 19 15.422223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 19 15.422223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 33 13.044445 $632.6600 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 1.349999 $80.9900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.149999 $51.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.300000 $264.5000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 222 251 100.434119 $4871.0200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 177 207 85.853964 $4163.9000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 86 96 43.498407 $2109.6500 $48.5000
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Subtotal (Total Children Is Unduplicated) 424 597 247.630933 $12174.4700 $49.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.511111 $766.6500 $1499.9700
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 15.213492 $760.6800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 4.838889 $241.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 41 35.714283 $1785.7000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 48 40.077775 $2003.8800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 31 23.284123 $1164.1900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 98 132 1075.142852 $26878.6000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 999 1369 11203.880929 $560194.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 296 362 2567.346032 $174271.6500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 264 348 2590.611112 $175850.9200 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 1.877778 $122.0600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 1.877778 $428.1400 $228.0000
SENS -V5264 EARMOLD 3 3 3.755555 $67.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 28 29 85.922227 $4296.1300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 165 206 1362.176191 $92464.5700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.571429 $33.9400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 22.428572 $2242.8500 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 988 1482 15344.541214 $7672.2600 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 15 109.716667 $5485.8400 $50.0000
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Subtotal (Total Children Is Unduplicated) 1247 4084 34491.488009 $1056732.2900 $30.6400
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Total 4700 34754.541165 $1068906.7600 $30.7600
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Number of Children (Unduplicated) With at Least One Authorization 1256