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
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 10 10 10.000000 $485.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.000000 $240.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.000000 $625.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 21 21 27.000000 $1350.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 8.000000 $444.0000 $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 1 1 1.000000 $48.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.000000 $97.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 49 59 68.000000 $4129.5000 $60.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 10.142857 $15214.3500 $1500.0100
AUD -HA_FUP AUDIOLOGY SERVICES 19 20 121.063491 $6053.1700 $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 65 80 144.989680 $7249.4800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 13 15 16.400000 $410.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 41 64.066667 $3203.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 6 4.555556 $113.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 92 108 124.226191 $6211.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 9 7.900000 $197.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 115 147.177560 $7358.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 16 17 16.258730 $406.4700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.222222 $16.2900 $73.3100
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 15 16 140.199998 $3505.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 67.999999 $3400.0100 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.033333 $75.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 85 121 611.368258 $30568.4100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 3 4.044444 $202.2200 $50.0000
INTR -INTR INTERPRETER 1 2 3.755556 $187.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 13.000000 $882.4400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 2 4 13.357143 $906.6800 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 27 20.215871 $20.2200 $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 7 7 7.249315 $471.2000 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 2 3.033333 $151.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 31.138095 $2113.6600 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 178 336 43962.536501 $21981.2700 $0.5000
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Subtotal (Total Children Is Unduplicated) 402 953 45555.812578 $112360.4800 $2.4700
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Total 1013 45623.857022 $116491.6200 $2.5500
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Number of Children (Unduplicated) With at Least One Authorization 405