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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 8 8 17.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 17.733333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 22 5.727778 $277.8000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 1.577778 $94.6700 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.766668 $203.1800 $115.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 2.311111 $112.0900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.200000 $58.2000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 2.255555 $109.3900 $48.5000
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Subtotal (Total Children Is Unduplicated) 45 48 14.838890 $855.3300 $57.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 1.883333 $9416.5000 $4999.9100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 201 201 351.529367 $17576.4800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 49 93.000003 $4650.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 93 93 142.955555 $7147.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 175 296.430170 $14821.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 194 194 1144.407933 $57220.4500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 13 13 85.514286 $4275.7300 $50.0000
INTR -INTR INTERPRETER 16 16 213.246033 $10662.3100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 31 252.476191 $17138.1000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 41 41 275.260313 $18684.7100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $605.2800 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.966667 $483.3500 $500.0200
SENS -V5264 EARMOLD 8 8 6.333334 $114.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 40 300.079362 $20369.4200 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 308 599 178928.047622 $89464.0200 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 8 54.319049 $2715.9500 $50.0000
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Subtotal (Total Children Is Unduplicated) 316 1476 182157.592075 $275345.6600 $1.5100
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Total 1532 182190.164298 $276200.9800 $1.5200
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Number of Children (Unduplicated) With at Least One Authorization 326