Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 Page: 1
Child has a MEDICAID # Filter: Y
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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.044444 $79.9000 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.000000 $540.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.233333 $256.8300 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 32 42 89.000000 $6675.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.000000 $145.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 6 6.000000 $291.0000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 18 29.581746 $1434.7200 $48.5000
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Subtotal (Total Children Is Unduplicated) 73 97 168.859523 $11067.9400 $65.5500
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.533333 $174.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 4.000000 $200.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 12 12.666667 $633.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 129 175 195.576190 $9778.8100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 14 21 22.400000 $560.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 40 65.342858 $3267.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 7 8.366667 $209.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 42 54.852381 $2742.6200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 69 79 106.123810 $5306.1900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 15 19 19.600000 $490.0000 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 8.857143 $110.7100 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 12 182.428570 $4560.7200 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 51.638095 $1290.9600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 564 735 5663.589273 $283179.7600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 6.571429 $328.5700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 42.257145 $2112.8700 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 26 32 274.857143 $18657.3200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 5 47.357142 $2572.4500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 35 43 294.857144 $20014.9300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 6 6 55.857144 $3034.1600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 92 105 102.844445 $102.8400 $1.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 5 5 8.577777 $154.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 64 73 509.914284 $34613.0300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 13.142857 $713.9200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 11 12 93.857144 $1238.9100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 63 68 7579.723810 $3789.8600 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.214286 $110.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 740 1520 15439.006737 $400678.8200 $25.9500
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Total 1617 15607.866260 $411746.7600 $26.3800
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Number of Children (Unduplicated) With at Least One Authorization 748