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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3595 FSPSA's found
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 3 3 3.221429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 3.221429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.511111 $33.2900 $65.1400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 10 5.016666 $256.1000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 39 14.838888 $757.5200 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 11 4.849999 $247.5900 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 24 11.322222 $578.0000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 58 66 25.522223 $1302.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 97 153 66.061109 $3436.4100 $52.0200
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.633333 $151.4900 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 8 3.566667 $178.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 10 10 12.339682 $616.9900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 224 277 206.230139 $10311.4100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 70 46.299994 $2314.9700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 622 754 558.135673 $27906.5800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 22.000000 $550.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 40 356.234923 $17811.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 831 2143 9868.793589 $98687.9400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 16 130.917461 $9352.7600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 26.285714 $1503.5500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 10 62.428573 $4459.9000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 10 63.214287 $3613.3300 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 2 4.000000 $948.4800 $237.1200
SENS -V5264 EARMOLD 1 2 1.022222 $18.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 21 146.735713 $10482.8100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 19.857143 $275.6200 $13.8800
TRAV -TRAVS Travel by mile 50 68 65664.630952 $29220.7600 $0.4500
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Subtotal (Total Children Is Unduplicated) 843 3439 77193.326065 $218405.0500 $2.8300
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Total 3595 77262.608603 $221841.4600 $2.8700
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Number of Children (Unduplicated) With at Least One Authorization 867