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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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 1.011111 $37.4100 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 1.000000 $37.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 3 2.011111 $74.4100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 13 13.000000 $630.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.266667 $10.4200 $39.0800
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 83 92 109.766667 $6586.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 12 12.622222 $568.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 46 49 58.022222 $6672.5500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 23.285715 $2910.7100 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 51 52 87.500000 $4375.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 10 14.000000 $1050.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 32 32 61.000000 $4575.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 49 50 89.000000 $4939.5000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 12.142857 $588.9300 $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 12 12 12.000000 $582.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 25.285714 $1226.3600 $48.5000
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Subtotal (Total Children Is Unduplicated) 233 350 525.320635 $35011.2200 $66.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 33 45.000000 $67500.0000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.000000 $275.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 20 26 141.853966 $7092.7000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.011111 $25.2800 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 57 76 140.425396 $7021.2800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 8.300000 $207.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 61 127.785714 $6389.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.166666 $104.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 108 195.930951 $9796.5400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 7.833333 $195.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 106 202.682536 $10134.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 12 25.511111 $637.7800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 17 22 76.528571 $5611.0800 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 11.571429 $289.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 46 203.380951 $5084.5200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 24.428571 $1221.4300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.700000 $17.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 496 752 4461.144435 $223057.2400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 16 20 45.787300 $2289.3500 $50.0000
INTR -INTR INTERPRETER 2 3 7.044445 $352.2300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 28 224.695239 $15252.3100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 34.285714 $1862.4000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 35 45 364.628567 $24751.0000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 17 18 166.504762 $9044.5300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 26 17.322221 $17.3200 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.000000 $2000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 10 10.208219 $663.5300 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 13 18 38.355553 $690.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 21 23 50.395236 $2519.7500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 45 287.128571 $19490.3000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 9 11 89.833333 $1185.8000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 385 873 195165.904757 $97582.9500 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.285714 $164.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 565 2395 202195.634372 $523083.1300 $2.5900
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Total 2748 202722.966118 $558168.7700 $2.7500
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Number of Children (Unduplicated) With at Least One Authorization 568