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: 07-01-11 and 09-30-11 Date of Report: 11-30-11 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 3.428571 $126.8600 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 3.678571 $136.1100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 11.000000 $533.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.800000 $70.3400 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 61 61 62.244444 $3734.6600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 12 11.555555 $520.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 74 76 76.077777 $8748.9400 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 14 14 18.133334 $2266.6800 $125.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 8 9.000000 $675.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 37 37 53.285714 $2957.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 3.000000 $225.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 9 9 9.900000 $495.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 29 29.000000 $1406.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 33 33 33.000000 $1600.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 95 97 109.142857 $5293.4300 $48.5000
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Subtotal (Total Children Is Unduplicated) 278 395 433.139681 $28951.9000 $66.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 25 53.642858 $80464.2000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.400000 $165.2600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 17 21 74.114287 $3705.7200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 56 60 115.071429 $5753.5900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 13 14 18.019048 $450.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 22.133333 $1106.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.000000 $125.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 70 78 103.314286 $5165.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 10 10.000000 $250.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 93 114.938812 $5746.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 18 18 25.740477 $643.5100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 24 70.677779 $5182.0900 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.285714 $107.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 81 93 354.147621 $8853.7100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 26.285714 $1314.2900 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 16.285714 $407.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 521 756 4319.280942 $215964.2400 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 1.233333 $61.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 14 16 48.814284 $2440.7200 $50.0000
INTR -INTR INTERPRETER 2 2 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 49 378.707139 $25706.6400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 21 26 189.561905 $10297.0200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 67 85 772.466665 $52435.0900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 34 39 256.466666 $13931.2800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 28 32 24.260316 $24.2600 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 5.117808 $332.6600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 17 21 27.688888 $498.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 24 28 76.917461 $3845.8700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 71 524.690475 $35616.0100 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 17.571428 $954.4800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 50 54 381.280952 $5032.9100 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 11.285714 $564.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 607 1655 8058.401048 $488208.9900 $60.5800
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Total 2054 8495.219300 $517297.0000 $60.8900
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Number of Children (Unduplicated) With at Least One Authorization 614