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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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 4 4 1.688890 $62.4900 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 1.688890 $62.4900 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 9.511111 $461.2900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.044444 $87.8900 $42.9900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 4.449999 $266.9900 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 3.126027 $359.4900 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 65 68 81.196318 $4059.8300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 2.288888 $171.6600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 2.288888 $127.0300 $55.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 3.333333 $161.6700 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 88 97 108.239008 $5695.8400 $52.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 6.870471 $10305.6000 $1499.9800
AUD -HA_FUP AUDIOLOGY SERVICES 23 25 150.480954 $7524.0500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 26 5.056549 $252.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.644444 $16.1100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 147 595 1060.941897 $53047.2000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 3.430555 $85.7600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 89 189.300790 $9465.0400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 84 169.722227 $8486.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.866667 $71.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 106 128 253.784123 $12689.1900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 15 16.982540 $424.5600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 6.466666 $474.1300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 41.623810 $1040.6000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 25.571429 $1278.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 69 87 564.999205 $28249.9900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.276190 $663.8100 $50.0000
INTR -INTR INTERPRETER 2 2 5.266667 $263.3400 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 23.857143 $1619.4300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 11.785715 $640.2000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 27 16.455559 $16.4600 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 6.571429 $10842.8100 $1649.9900
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.255556 $2127.8000 $500.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 10 11.511111 $748.2200 $65.0000
SENS -V5264 EARMOLD 2 2 6.133333 $110.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 5 20.542857 $1027.1400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 8.857143 $601.2200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.571429 $205.5400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 487 1604 343007.957718 $171503.9800 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 517 2743 345652.917510 $323835.0800 $0.9400
-------------------------------------------------------------------------------------------------------------------------------------
Total 2844 345762.845408 $329593.4100 $0.9500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 517