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
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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 10.142857 $375.2900 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 10.142857 $375.2900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.044444 $79.9000 $39.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -AUDE UNSPECIFIED AUDE SERVICES 24 29 29.022222 $1741.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.000000 $180.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.233333 $716.8300 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
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 7 7 14.000000 $777.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 52 72 200.071428 $15005.3600 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.000000 $300.0000 $150.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 10.000000 $485.0000 $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 14 15 15.000000 $727.5000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 40 41 62.581746 $3035.2200 $48.5000
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Subtotal (Total Children Is Unduplicated) 146 197 362.953173 $24055.8900 $66.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.533333 $174.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 12 14 21.280952 $1064.0500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 20 24.166667 $1208.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 204 279 379.097618 $18954.9000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 21 32 43.042857 $1076.0700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 72 112.338890 $5616.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 12 15 25.295238 $632.3800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 60 78.423810 $3921.1900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 120 137 181.328572 $9066.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 21 25 24.916667 $622.9200 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 8.857143 $110.7100 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 13 208.714284 $5217.8600 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 9 10 94.895237 $2372.3900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 831 1075 8348.391643 $417420.0900 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 9.638096 $481.9100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 15 74.961907 $3748.1100 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 71 564.390475 $38310.8800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 6 8 64.214285 $3488.1300 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 72 92 554.704761 $37653.4100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 9 12 90.428572 $4912.0800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 113 129 127.544445 $127.5400 $1.0000
SENS -FM FM RECEIVER HEARING AID 4 4 6.000000 $9900.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.000000 $1500.0000 $500.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 10 12 18.688888 $336.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 155 193 1342.248409 $91111.9300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 26.285714 $1427.8400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 20 23 160.857143 $2123.3100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 90 95 11058.152381 $5529.0800 $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) 1115 2425 23668.612273 $670590.0300 $28.3300
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Total 2623 24041.708303 $695021.2100 $28.9100
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Number of Children (Unduplicated) With at Least One Authorization 1129