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: 10-01-13 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 12 15 8.599998 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 15 8.599998 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 18 18 6.866667 $430.0600 $62.6300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.511111 $23.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 11 24.890474 $2862.3800 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.705555 $34.2200 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 58 61 31.391266 $1522.4600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 119 131 81.135713 $3935.0900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 137 156 55.535717 $2693.5000 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.142857 $14.2900 $100.0300
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Subtotal (Total Children Is Unduplicated) 279 381 201.179360 $11515.0000 $57.2400
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.488889 $24.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 87 111.861110 $5593.0500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.877778 $21.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 72 65.656348 $3282.8100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 489 602 528.758723 $26437.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 1.922222 $48.0600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 88 107 860.714277 $21517.9000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 603 749 6299.209469 $314960.8300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 108 138 798.250000 $54185.2500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 25.321428 $1375.4600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 144 171 1075.652383 $73015.3400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 23.792064 $1292.3900 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.511111 $255.5500 $499.9900
SENS -V5264 EARMOLD 3 5 5.109524 $91.9700 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 8.255555 $412.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 232 1516.206742 $102920.2800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 15.214286 $826.4400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 26.785715 $353.5700 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 546 1248 5850.181689 $58501.8600 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 150 191 10365.589674 $5182.7900 $0.5000
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Subtotal (Total Children Is Unduplicated) 839 3633 27580.358987 $670300.5800 $24.3000
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Total 4029 27790.138345 $681815.5800 $24.5300
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Number of Children (Unduplicated) With at Least One Authorization 850