Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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 75 81 54.955547 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 75 81 54.955547 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 0.577778 $8.3000 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.577778 $10.6700 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.577778 $5.7900 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.577778 $4.8600 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 0.577778 $4.4800 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.577778 $12.1300 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 0.577778 $36.1900 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.577778 $12.7200 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 17 86.533334 $5192.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.844444 $97.1100 $114.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 11 4.766667 $231.1900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.788889 $38.2600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 13 13 8.211111 $398.2400 $48.5000
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Subtotal (Total Children Is Unduplicated) 40 59 105.766669 $6051.9300 $57.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.333333 $1666.5000 $4999.5000
AUD -HA_FUP AUDIOLOGY SERVICES 1 2 4.360318 $218.0200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 88 110 81.669050 $4083.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 181 196 179.783331 $8989.1600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 107 122 92.461105 $4623.0300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 129 149 124.944435 $6247.1800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 262 304 236.022208 $11801.0400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 6 31.866666 $796.6700 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 86 112 818.966669 $40948.3500 $50.0000
INTR -INTR INTERPRETER 3 4 28.755555 $1437.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 65 319.522222 $21689.1700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 72 88 417.188887 $28318.7700 $67.8800
SENS -V5264 EARMOLD 1 1 0.888889 $16.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 92 117 679.766667 $46142.5600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 12.266667 $161.9200 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 841 1503 10115.504773 $101155.0600 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 29 31 277.955557 $138.9800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 9.200000 $460.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 950 2817 13441.289666 $279766.1200 $20.8100
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Total 2957 13602.011882 $285818.0500 $21.0100
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Number of Children (Unduplicated) With at Least One Authorization 1019