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: 10-01-12 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 20 23 13.511108 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 23 13.511108 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.111111 $5.3900 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 0.255556 $14.5500 $56.9500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.133333 $96.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.133333 $245.3300 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 15 16.392858 $795.0600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 14 3.161111 $153.3100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 29 9.636508 $467.3700 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 13.142857 $1314.2900 $100.0000
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Subtotal (Total Children Is Unduplicated) 38 64 46.966667 $3091.3000 $65.8200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.066667 $53.3400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.261111 $13.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 44 65.014284 $3250.7000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.488889 $12.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 52 52.468251 $2623.4000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 474 539 451.046801 $22552.2100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 4.394444 $109.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 11.428571 $285.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 41 49 609.142854 $30457.1800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 3 8.071429 $547.8900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 5 8 41.500000 $2817.0300 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.511111 $255.5500 $499.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.133333 $486.3900 $228.0000
SENS -V5264 EARMOLD 1 1 2.133333 $38.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 6.571429 $328.5700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 10 56.071429 $3806.1200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 2 13.142857 $173.4900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 603 1253 128021.079328 $64010.5400 $0.5000
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Subtotal (Total Children Is Unduplicated) 613 1978 129346.526121 $131821.6400 $1.0200
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Total 2065 129407.003896 $134912.9400 $1.0400
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Number of Children (Unduplicated) With at Least One Authorization 642