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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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 25 43.503969 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 25 43.503969 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 29 37 12.216666 $592.5100 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 1.966666 $118.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 0.994444 $44.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 1.966667 $226.1700 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 245 298 108.440465 $5259.3100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 177 237 68.169044 $3306.1800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 90 109 39.050005 $1893.9500 $48.5000
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Subtotal (Total Children Is Unduplicated) 454 697 232.803957 $11440.8600 $49.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.494444 $2472.0000 $4999.5600
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 10.428571 $521.4400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.928571 $146.4300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 52 28.295237 $1414.7600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 59 32.906346 $1645.3100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 22 21.617459 $1080.8700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 84 123 881.509519 $22037.7400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1008 1376 10375.996840 $518799.2500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 313 409 2713.566675 $184196.6500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 260 371 2292.138092 $155590.2000 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 0.733333 $47.6600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 0.733333 $167.1900 $227.9900
SENS -V5264 EARMOLD 5 5 1.611112 $29.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 21 29 77.255556 $3862.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 153 216 1223.446821 $83047.5700 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 1008 1523 15329.674660 $7664.8600 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 13 63.647618 $3182.3800 $50.0000
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Subtotal (Total Children Is Unduplicated) 1235 4216 33056.984187 $985906.0900 $29.8200
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Total 4938 33333.292113 $997346.9500 $29.9200
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Number of Children (Unduplicated) With at Least One Authorization 1245