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
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 13 16 9.399998 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 16 9.399998 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 19 19 6.638889 $415.7900 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.022222 $22.5100 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.166667 $10.0000 $60.0100
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.377778 $62.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 6.666665 $766.6500 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.511111 $24.7900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 58 63 28.280158 $1371.5800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.211111 $10.2400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 52 62 33.092857 $1605.0100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 163 187 90.088089 $4369.2400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.200000 $120.0000 $100.0000
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Subtotal (Total Children Is Unduplicated) 226 344 169.255547 $8777.8100 $51.8600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.211111 $1055.5000 $4999.7400
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.866667 $43.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 121 145 199.425396 $9971.2600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.877778 $21.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 85 72.278571 $3613.9300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 702 874 810.499193 $40524.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 1.922222 $48.0600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 8.142857 $203.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 270 342 2628.142842 $131407.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 35 203.284127 $13798.9400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.285714 $667.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 53 65 435.285714 $29547.2100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 1.533333 $766.6500 $499.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.866667 $197.6100 $228.0100
SENS -V5264 EARMOLD 5 6 3.788889 $68.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 3.966666 $198.3300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 153 192 1372.071420 $93136.3400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 21.714286 $1179.5200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 34.857142 $460.1200 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 777 1794 8170.175318 $81701.8000 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 211 269 12829.638083 $6414.8200 $0.5000
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Subtotal (Total Children Is Unduplicated) 1021 3832 26811.833996 $415026.6000 $15.4800
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Total 4192 26990.489541 $423804.4200 $15.7000
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Number of Children (Unduplicated) With at Least One Authorization 1049