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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.044444 $1.6400 $36.9600
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Subtotal (Total Children Is Unduplicated) 1 1 0.044444 $1.6400 $36.9600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 76 83 92.758730 $5565.5200 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 15.033333 $676.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 39 41 50.933333 $5857.3300 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 11 11 35.000000 $4375.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 16 16 20.000000 $1000.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 15 15 26.000000 $1950.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 3.000000 $225.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 35 37 67.571429 $3750.2100 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.000000 $582.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 29 30 30.000000 $1455.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 185 280 372.296825 $26546.5600 $71.3000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 24 35.000000 $52500.0000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 18 20 109.063491 $5453.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.500000 $125.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.377778 $9.4500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 54 68 132.211903 $6610.5900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 13 15 16.400000 $410.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 32 52.733333 $2636.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 2.555556 $63.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 85 100 112.535715 $5626.7900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 9 7.900000 $197.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 95 124.172798 $6208.6400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 12 8.044444 $201.1100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 14 39.474605 $2894.2800 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 13.000000 $325.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 46 50 181.442852 $4536.0700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 28.428571 $1421.4300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 415 624 3682.719058 $184136.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 12 32.409523 $1620.4800 $50.0000
INTR -INTR INTERPRETER 1 2 3.755556 $187.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 23 153.804763 $10440.2600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 7.000000 $380.2400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 33 47 367.614286 $24953.6500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 13 13 81.552380 $4429.9300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 22 18.349205 $18.3500 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.249315 $406.2000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 13 13 22.599999 $406.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 17 21 35.798411 $1789.9200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 46 289.690479 $19664.2000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 95.428571 $1259.6600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 147 267 34949.431737 $17474.7200 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 14.000000 $700.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 470 1566 40634.244329 $358687.6100 $8.8300
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Total 1847 41006.585598 $385235.8200 $9.3900
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Number of Children (Unduplicated) With at Least One Authorization 473