Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 35.955555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 35.955555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 30 7.577779 $367.5300 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 8 2.577778 $154.6700 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.766668 $203.1800 $115.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 2.822222 $136.8800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 1.788889 $86.7600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 3.177777 $154.1200 $48.5000
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Subtotal (Total Children Is Unduplicated) 60 67 19.711113 $1103.1400 $55.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 2.150000 $10750.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.183333 $9.1700 $49.9900
CONIF -CONIF CONSULT ITDS, FACE TO FACE 280 280 517.316674 $25865.8800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 99 99 185.355560 $9267.8000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 138 138 266.675396 $13333.7700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 279 279 475.469063 $23773.5300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 273 273 1626.531739 $81326.6800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 15 98.085714 $4904.3100 $50.0000
INTR -INTR INTERPRETER 17 17 217.334922 $10866.7500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 55 444.738097 $30188.8400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 67 67 511.717452 $34735.4500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $605.2800 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 1.211111 $605.5500 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.366667 $83.6100 $228.0200
SENS -V5264 EARMOLD 10 10 7.311111 $131.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 89 89 738.226978 $50110.9100 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 482 931 291686.666671 $145843.3300 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 11 64.947620 $3247.3800 $50.0000
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Subtotal (Total Children Is Unduplicated) 493 2276 296855.430965 $445649.8200 $1.5000
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Total 2360 296911.097633 $446752.9500 $1.5000
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Number of Children (Unduplicated) With at Least One Authorization 512