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
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Subtotal (Total Children Is Unduplicated) 1 1 0.250000 $9.2500 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 9.000000 $436.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.000000 $180.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.000000 $575.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.000000 $500.0000 $125.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 8.000000 $444.0000 $55.5000
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 3 3 3.000000 $145.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.000000 $291.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 8 8 8.000000 $388.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 51 56 60.900000 $3755.0000 $61.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.071429 $4607.1000 $1499.9900
AUD -HA_FUP AUDIOLOGY SERVICES 15 17 56.780953 $2839.0500 $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 55 59 114.071429 $5703.5900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 12 13 17.019048 $425.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 22.133333 $1106.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.000000 $100.0000 $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 82 91 112.938812 $5646.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 18 18 25.740477 $643.5100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 9.011111 $660.6900 $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 21 22 114.523810 $2863.1100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 26.285714 $1314.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 109 148 754.776185 $37738.8300 $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 2 2 4.700000 $235.0000 $50.0000
INTR -INTR INTERPRETER 2 2 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 62.571428 $4247.3500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 23.285714 $1264.8800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 8 8 50.223810 $3409.1900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $605.2800 $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
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 7.155555 $357.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 52.485714 $3562.7300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 48.490475 $640.0700 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 10.285714 $514.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 318 560 1681.905025 $84577.2600 $50.2900
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Total 617 1743.055025 $88341.5100 $50.6800
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Number of Children (Unduplicated) With at Least One Authorization 327