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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.044444 $1.6400 $36.9600
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Subtotal (Total Children Is Unduplicated) 1 1 0.044444 $1.6400 $36.9600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 11.000000 $533.5000 $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 91 99 108.758730 $6525.5200 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 15 17.055555 $767.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 45 47 56.933333 $6547.3300 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 18 18 41.142857 $5142.8600 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 21 21 27.000000 $1350.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 8 12.000000 $900.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 16 16 28.000000 $2100.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 5.000000 $375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 44 46 82.571429 $4582.7100 $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 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.000000 $242.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 4.428571 $214.7900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 16.000000 $776.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 40 41 45.285714 $2196.3600 $48.5000
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Subtotal (Total Children Is Unduplicated) 233 357 470.176189 $32810.5300 $69.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 32 33 50.142857 $75214.3500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 20 23 137.230158 $6861.5100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 2.500000 $125.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.377778 $9.4500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 69 86 156.023014 $7801.1500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 13 15 16.400000 $410.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 42 67.100000 $3355.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 7 4.922223 $123.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 93 109 124.792858 $6239.6400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 9 7.900000 $197.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 99 120 151.977559 $7598.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 17 18 16.692063 $417.3000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 16 44.807938 $3285.3200 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 13.000000 $325.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 68 336.699993 $8417.4900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 67.999999 $3400.0100 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 6.033333 $150.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 502 781 4452.536521 $222626.8400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 15 36.453967 $1822.7000 $50.0000
INTR -INTR INTERPRETER 1 2 3.755556 $187.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 33 300.519050 $20399.2200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 6 6 62.000000 $3367.8400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 48 65 535.757143 $36367.1900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 19 20 137.695237 $7479.6100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 27 20.215871 $20.2200 $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 7 7 7.249315 $471.2000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 15 16 28.666666 $516.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 23 38.831744 $1941.5800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 64 80 531.461907 $36075.6500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 15 16 111.461904 $1471.3000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 179 338 44322.584120 $22161.2900 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 14.000000 $700.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 585 1992 51812.788774 $481064.7300 $9.2800
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Total 2350 52283.009407 $513876.9000 $9.8300
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Number of Children (Unduplicated) With at Least One Authorization 588