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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 6.000000 $690.0000 $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
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 12 76.571428 $5742.8600 $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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 19.000000 $921.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 33 38 117.571428 $8396.8600 $71.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 10.000000 $500.0000 $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 196 268 343.495237 $17174.7800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 21 32 43.042857 $1076.0700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 62 91.129366 $4556.4700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 12 15 25.295238 $632.3800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 49 54.571429 $2728.5700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 104 121 140.404762 $7020.2400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 20 24 24.600000 $615.0000 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 5 33.180952 $829.5300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 191 234 1828.197613 $91410.0100 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 66.428571 $4509.1800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 2 13.142857 $713.9200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 13 16 67.347618 $4571.5700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 5 23.285714 $1264.8800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 112 127 125.544445 $125.5400 $1.0000
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 3 3 6.000000 $108.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 48 384.388092 $26092.3200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 6 8 53.285713 $703.3700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 90 95 11058.152381 $5529.0800 $0.5000
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Subtotal (Total Children Is Unduplicated) 567 1157 14427.659512 $173739.2500 $12.0400
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Total 1196 14555.373797 $182511.3900 $12.5400
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Number of Children (Unduplicated) With at Least One Authorization 569