Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 1.750000 $64.7500 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.750000 $64.7500 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 2.733333 $164.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.000000 $180.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 10.500000 $1207.5000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.000000 $250.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 22 24 27.571429 $1337.2100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 55 59 59.000000 $2861.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 16 16.000000 $776.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 25 23.766667 $1152.6900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 85 96 103.630953 $5026.0900 $48.5000
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Subtotal (Total Children Is Unduplicated) 156 234 250.202382 $13004.9900 $51.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 10.000000 $15000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 8 13.044445 $652.2300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 15 12.033333 $601.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 9 10 21.733335 $543.3400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 41 46 38.892063 $1944.6000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 50 56 130.285720 $3257.1600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 20 16.600000 $830.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 20 21 43.566669 $1089.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 16 9.616668 $480.8400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 19 20 40.800001 $1020.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 40 38.297619 $1914.8800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 37 42 98.476195 $2461.9200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 100 116 1050.099994 $52505.0600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 10 80.857143 $4042.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 155 191 1451.490477 $98527.2800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 37.571428 $2040.8800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 82 107 691.861909 $46963.6100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 14 16 83.142858 $4516.3200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 34 39 45.347620 $45.3500 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.000000 $1368.0000 $228.0000
SENS -V5264 EARMOLD 7 7 8.155555 $146.8000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 10.285714 $514.2900 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 329 407 2920.969046 $198275.5500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 92.428571 $1220.0600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 461 708 7767.403930 $3883.6900 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 13.142857 $657.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 537 1929 14736.103150 $445617.6900 $30.2400
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Total 2164 14988.055532 $458687.4300 $30.6000
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Number of Children (Unduplicated) With at Least One Authorization 538