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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 15 13.644445 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 1.888889 $69.8900 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 18 15.533334 $69.8900 $4.5000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.033333 $292.6200 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 3.044444 $182.6600 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.252055 $28.9900 $115.0200
EXIT -EXIT EXIT ASSESSMENT 37 37 43.633646 $2181.6800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.022222 $76.6700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.022222 $56.7300 $55.5000
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Subtotal (Total Children Is Unduplicated) 47 50 55.007922 $2819.3400 $51.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 3.629376 $5443.9500 $1499.9700
AUD -HA_FUP AUDIOLOGY SERVICES 18 19 104.884127 $5244.2100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 15 4.677781 $233.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 117 558 1258.396106 $62920.1700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 4.372222 $109.3100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 42 113.188893 $5659.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 48 117.504767 $5875.2600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 6.733334 $168.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 66 68 152.896039 $7644.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 9.044445 $226.1100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.466667 $180.8600 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 13 91.834920 $4591.7500 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 1.571428 $106.6700 $67.8800
SENS -FM FM RECEIVER HEARING AID 1 1 13.142857 $21685.7900 $1650.0100
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.511111 $255.5500 $499.9900
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.155556 $400.1100 $65.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 329 1000 267489.534881 $133744.7700 $0.5000
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Subtotal (Total Children Is Unduplicated) 335 1794 269380.550066 $254491.1800 $0.9400
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Total 1862 269451.091322 $257380.4100 $0.9600
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Number of Children (Unduplicated) With at Least One Authorization 342