Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.000000 $375.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 11 11 18.000000 $900.0000 $50.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 5 5 5.000000 $250.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.000000 $194.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 31 36 43.000000 $2420.5000 $56.2900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 16 21 93.574605 $4678.7300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 3 3.000000 $150.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 47 58 111.738094 $5586.8900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 14 18 18.151190 $453.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 21 26.566667 $1328.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 76 87 106.814286 $5340.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 11 10.000000 $250.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 64 69 87.652056 $4382.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 13 20.166666 $504.1700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.022222 $74.9500 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 10.428572 $260.7100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 20.800000 $520.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 39.428571 $1971.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 24 103.909522 $5195.4600 $50.0000
INTR -INTR INTERPRETER 2 2 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.000000 $203.6400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 2 2 10.714286 $727.2900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.571429 $628.5600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 26 22.782538 $22.7800 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 4.252055 $276.3800 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.133333 $6.6700 $49.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 6.419047 $435.7200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.571429 $152.7400 $13.2000
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Subtotal (Total Children Is Unduplicated) 229 379 729.696568 $37776.5500 $51.7700
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Total 415 772.696568 $40197.0500 $52.0200
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Number of Children (Unduplicated) With at Least One Authorization 239