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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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 1.011111 $37.4100 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.011111 $37.4100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 12 12.000000 $582.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.266667 $10.4200 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.000000 $240.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 49 50 83.500000 $4175.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 9.000000 $499.5000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 73 79 116.766667 $6225.4200 $53.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 9.000000 $13500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 19 25 126.687299 $6334.3700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.011111 $25.2800 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 55 73 133.425396 $6671.2800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 8.300000 $207.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 60 127.619047 $6380.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.166666 $104.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 85 107 194.897618 $9744.8800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 7.833333 $195.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 105 201.682536 $10084.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 12 25.511111 $637.7800 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 11.571429 $289.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 15 97.571428 $2439.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 24.428571 $1221.4300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.700000 $17.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 80 108 584.690474 $29234.5400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 9.480952 $474.0500 $50.0000
INTR -INTR INTERPRETER 2 3 7.044445 $352.2300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 7.571429 $513.9500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 5 25.714285 $1745.4900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 2.428571 $131.9200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 26 17.322221 $17.3200 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.000000 $2000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 10 10.208219 $663.5300 $65.0000
SENS -V5264 EARMOLD 2 2 0.822222 $14.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.747619 $237.3800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 24.204761 $1643.0200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.714286 $115.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 385 869 194535.838090 $97267.9200 $0.5000
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Subtotal (Total Children Is Unduplicated) 477 1464 196219.193119 $192364.8000 $0.9800
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Total 1544 196336.970897 $198627.6300 $1.0100
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Number of Children (Unduplicated) With at Least One Authorization 478