Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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 1.000000 $37.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.000000 $37.0000 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 12 12.000000 $582.0000 $48.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $10.3800 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $21.0800 $21.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 77 83 91.304761 $5478.2800 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 17 20 22.544444 $1014.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 59 63 68.733334 $7904.3400 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 25 26 37.595237 $4699.4000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 13 13 22.000000 $1100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 40 41 70.142857 $3892.9300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 6 6 6.000000 $300.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 21.000000 $1018.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 22.000000 $1067.0000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 74 78 89.142857 $4323.4300 $48.5000
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Subtotal (Total Children Is Unduplicated) 267 400 480.463490 $32561.8400 $67.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 32 51.571429 $77357.1000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $137.7200 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 18 25 122.193652 $6109.6800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 3 3.000000 $150.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 59 70 134.499999 $6724.9800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 14 18 18.151190 $453.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 26 35.366666 $1768.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 87 98 123.052382 $6152.6200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 11 10.000000 $250.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 92 124.735390 $6236.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 17 18 24.666666 $616.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 18 61.446031 $4505.2200 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 10.428572 $260.7100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 57 61 303.428577 $7585.7300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 6 69.466667 $3473.3400 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 13.142857 $657.1500 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 15.509524 $387.7400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 509 715 4535.439670 $226772.0900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 13 17 60.150795 $3007.5400 $50.0000
INTR -INTR INTERPRETER 2 2 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 53 463.071429 $31433.3000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 22 24 229.900000 $12488.1700 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 69 79 749.995239 $50909.6900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 20 22 132.780952 $7212.6700 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 27 29 23.193650 $23.1900 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 6 5.252055 $341.3800 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 3 6.000000 $1368.0000 $228.0000
SENS -V5264 EARMOLD 15 20 32.544443 $585.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 24 28 40.698411 $2034.9200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 77 89 657.809521 $44652.1400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 25 28 195.961906 $2586.7000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 445.714286 $222.8600 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.857143 $642.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 601 1606 8718.029102 $507258.8200 $58.1900
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Total 2007 9199.492592 $539857.6600 $58.6800
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Number of Children (Unduplicated) With at Least One Authorization 607