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 5 5 12.705556 $470.1100 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 12.705556 $470.1100 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 15 15 14.285714 $169.4300 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 14 13.285714 $110.0100 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 15 15 14.285714 $148.2900 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 14.285714 $301.1400 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 9 9.000000 $244.7100 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 23 25 25.000000 $1500.0000 $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 4.000000 $460.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 15 14.966667 $725.8900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 14.966667 $725.8900 $48.5000
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Subtotal (Total Children Is Unduplicated) 62 124 126.076190 $4475.3400 $35.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 11 36.000000 $54000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 30.809523 $1540.4800 $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 127 158 80.461108 $4023.0400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 50 45.316662 $2265.8100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 301 371 249.388873 $12469.3700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 50 342.066669 $8551.6700 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 11.333333 $566.6700 $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 3 3 21.466667 $536.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 340 2963.544447 $148177.2400 $50.0000
INTR -INTR INTERPRETER 2 9 18.000000 $900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 95 131 658.811114 $44720.1200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 6 6 43.200000 $2346.6200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 148 206 755.275002 $51268.0800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 32.000000 $1738.2400 $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 1 1 1.000000 $500.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 4 4 6.000000 $108.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 213 290 1680.801582 $114092.7700 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.600000 $86.9100 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 12.000000 $158.4000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5 5 738.666666 $369.3300 $0.5000
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Subtotal (Total Children Is Unduplicated) 932 2216 8184.103148 $460702.9500 $56.2900
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Total 2345 8322.884894 $465648.4000 $55.9500
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Number of Children (Unduplicated) With at Least One Authorization 949