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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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 4 4 1.688890 $62.4900 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.000000 $74.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 3.688890 $136.4900 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 10.094444 $489.5800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.044444 $87.8900 $42.9900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $21.7300 $21.7300
AUDE -AUDE UNSPECIFIED AUDE SERVICES 99 108 102.652379 $6159.1300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 13 10.283334 $462.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 38 40 45.606978 $5244.7800 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.857143 $607.1400 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 66 69 83.196318 $4159.8300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 7.600000 $570.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 36 59.755554 $4481.6600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 45 46 72.577776 $4028.0600 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 0.033333 $1.8500 $55.4400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 0.033333 $2.5000 $74.9300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 16.142857 $782.9300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 3.355556 $162.7500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 35.652381 $1729.1400 $48.5000
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Subtotal (Total Children Is Unduplicated) 234 362 454.896941 $28992.5400 $63.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 21 29.917763 $44876.5500 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 3.022222 $208.1100 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.105556 $7.2700 $68.8900
AUD -HA_FUP AUDIOLOGY SERVICES 24 26 151.147621 $7557.3800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 26 5.056549 $252.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.644444 $16.1100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 147 595 1060.941897 $53047.2000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 3.430555 $85.7600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 76 90 192.367457 $9618.3700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 84 169.722227 $8486.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.866667 $71.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 106 128 253.784123 $12689.1900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 16 23.411111 $585.2800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 20 27 94.214286 $6907.7900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 39 127.609522 $3190.2400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 25.571429 $1278.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 476 759 4398.432533 $219921.8200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 15 62.087302 $3104.3700 $50.0000
INTR -INTR INTERPRETER 2 2 5.266667 $263.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 23 161.961906 $10993.9800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 48.428572 $2630.6400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 28 33 202.361905 $13736.3300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 22 26 212.357144 $11535.2500 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 27 16.455559 $16.4600 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 6.571429 $10842.8100 $1649.9900
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.255556 $2127.8000 $500.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 10 11.511111 $748.2200 $65.0000
SENS -V5264 EARMOLD 15 16 30.477776 $548.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 20 27 95.717461 $4785.8800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 32 38 220.904761 $14995.0500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 8 10 54.671429 $721.6600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 488 1614 347387.757719 $173693.8800 $0.5000
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Subtotal (Total Children Is Unduplicated) 545 3678 355065.165592 $619597.8600 $1.7500
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Total 4045 355523.751423 $648726.8800 $1.8200
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Number of Children (Unduplicated) With at Least One Authorization 546