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: 07/01/10 and 09/30/10 Date of Report: 11-17-10 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 3.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 3.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.000000 $194.0000 $48.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $21.6000 $10.8000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.000000 $180.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $180.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 163 172 188.753967 $21706.7000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 19 22 26.000000 $3250.0000 $125.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 32 32 40.000000 $2220.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 14 14 24.966666 $1248.3300 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 43 43 51.833333 $2513.9200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 66 67 71.180953 $3452.2800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 108 116 214.142857 $10385.9300 $48.5000
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Subtotal (Total Children Is Unduplicated) 293 481 631.877776 $45452.7500 $71.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 17 25.744445 $38616.7500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.700000 $193.3500 $71.6100
AUD -HA_FUP AUDIOLOGY SERVICES 20 21 82.228573 $4111.4300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 7.000000 $350.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 23 29.500002 $1475.0100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 11 11 9.242859 $231.0800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 15.500001 $775.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.658334 $141.4600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 24.809524 $1240.4800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 5 5 6.383334 $159.5900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 30 30 62.600003 $3130.0200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 15.426191 $385.6600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 17 18 61.066668 $4483.5200 $73.4200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 109 117 335.123817 $8378.1200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.233333 $61.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 489 600 3975.922208 $198796.3900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 19 137.384125 $6869.2200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 10 87.714285 $5954.0500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 71 80 809.816665 $43989.2600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 10 11 97.638095 $6627.6800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 90 102 1085.047615 $58939.8100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 45 35.099999 $35.1000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.000000 $3000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.671233 $433.6300 $65.0000
SENS -V5264 EARMOLD 14 15 23.355554 $420.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 17 62.012699 $3100.6400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 183.142858 $12431.7300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 124 151 1611.261895 $21268.6600 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.022222 $102.2200 $100.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 16.209524 $810.4800 $50.0000
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Subtotal (Total Children Is Unduplicated) 628 1365 8822.516061 $426512.3900 $48.3400
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Total 1847 9457.393837 $471965.1400 $49.9000
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Number of Children (Unduplicated) With at Least One Authorization 650