Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 46 47 1321.398413 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 46 47 1321.398413 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 4.088888 $175.7800 $42.9900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 2.003654 $120.2200 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.252055 $28.9900 $115.0200
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 20.321907 $985.6100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.544445 $26.4100 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.294444 $4.4200 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 20 20 33.950935 $1646.6300 $48.5000
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Subtotal (Total Children Is Unduplicated) 36 41 61.456328 $2988.0600 $48.6200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.294444 $14.7200 $49.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 26.285715 $1314.2900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 17.857143 $446.4300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 103 117 788.280956 $39414.1100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 4.933334 $123.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 21 128.676191 $6433.8100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 25 147.214288 $7360.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 5.800000 $145.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 38 249.847621 $12492.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.495238 $137.3800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 96.571428 $2414.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 400 416 3385.611901 $169280.7700 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 6.571429 $328.5700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 13.880954 $694.0600 $50.0000
INTR -INTR INTERPRETER 1 1 26.285714 $1314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 15 136.571428 $9270.4800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 13.142857 $713.9200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 14 14 72.446031 $4917.6400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 4.714286 $256.0800 $54.3200
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.022222 $233.0600 $228.0000
SENS -V5264 EARMOLD 2 2 1.533333 $27.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 43 396.071424 $26885.3800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 74.142858 $978.6900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 391 460 231877.552405 $115938.7700 $0.5000
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Subtotal (Total Children Is Unduplicated) 462 1190 237480.803200 $401135.7500 $1.6900
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Total 1278 238863.657941 $404123.8000 $1.6900
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Number of Children (Unduplicated) With at Least One Authorization 509