Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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 13 13 24.516668 $907.1200 $37.0000
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Subtotal (Total Children Is Unduplicated) 13 13 24.516668 $907.1200 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 102 103 101.571428 $1204.6400 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 100 101 99.571428 $824.4500 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 100 101 99.571428 $1033.5500 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 100 101 99.571428 $2098.9700 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 71 72 71.285714 $1938.2600 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 124 141 140.233333 $8414.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 4.133333 $186.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 11.000000 $1265.0000 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 39 53 43.461109 $2173.0500 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 51 63 65.333334 $3168.6700 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 11.400000 $552.9000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 14.000000 $679.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 59 73 84.205545 $4083.9700 $48.5000
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Subtotal (Total Children Is Unduplicated) 348 837 845.338080 $27622.4500 $32.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 36 43 197.000000 $295500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 10 12 34.809523 $1740.4800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 125 148 141.480953 $7074.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 153 187 80.913883 $4045.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 128 159 80.672219 $4033.6000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 50 45.316662 $2265.8100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 303 374 249.663872 $12483.1100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 51 349.800002 $8745.0100 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 11.333333 $566.6700 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.533333 $26.6700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 9.466666 $473.3300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 47.000001 $1175.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 592 836 6753.330559 $337666.5500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 27 33 223.988888 $11199.4400 $50.0000
INTR -INTR INTERPRETER 2 9 18.000000 $900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 380 535 2718.161112 $184508.7800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 23 23 143.333331 $7785.8500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 642 912 3889.185789 $263997.8100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 16 16 92.850000 $5043.6100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 190 222 222.000000 $222.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.000000 $2000.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.000000 $1368.0000 $228.0000
SENS -V5264 EARMOLD 12 13 23.000000 $414.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 22 52.833333 $2641.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 639 918 4989.558719 $338691.1600 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 20.733333 $1126.2300 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 56.466669 $745.3600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5 5 738.666666 $369.3300 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 11.300000 $565.0000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 35 50 188.180556 $9409.0300 $50.0000
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Subtotal (Total Children Is Unduplicated) 1556 4652 21400.079402 $1506795.7000 $70.4100
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Total 5502 22269.934150 $1535325.2700 $68.9400
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Number of Children (Unduplicated) With at Least One Authorization 1577