Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period                                             Statewide

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: 10-01-14 and 12-31-14                  Date of Report: 01-12-15                  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                



Screening, Eval, and Assessment, Class # 02
 AUDE  -V5090     DISPENSING FEE PER HEARING AID               1          1            0.866667          $99.6700          $115.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          1            0.866667          $99.6700          $115.0000


EI Services, Class # 03
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF             1          1            1.000000          $50.0000           $50.0000
 TRAV  -FLAT      PROV TRAVEL TO NATL ENV $10 PER CHI          1          1            1.000000          $10.0000           $10.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          2            2.000000          $60.0000           $30.0000


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Total                                                                     3            2.866667         $159.6700           $55.7000
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Number of Children (Unduplicated) With at Least One Authorization  2