Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 47 47 1423.341270 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 47 47 1423.341270 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 13 9.344443 $453.2000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 14.996575 $899.8000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.427778 $154.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 24.292822 $2793.6500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 3.066667 $383.3400 $125.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 2.466667 $123.3400 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.819842 $136.7700 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.511111 $24.7900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 3.983333 $193.1900 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.395205 $5.9300 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 23.390542 $1134.4400 $48.5000
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Subtotal (Total Children Is Unduplicated) 49 59 88.694985 $6302.6800 $71.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 14 39.713492 $59570.2500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 21.473808 $1073.7000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 18 120.366667 $6018.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 5 9.677777 $241.9400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 460 699 3040.199278 $152010.3100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 14.333335 $358.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 250 255 1127.211133 $56360.6500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 11 11 28.900001 $722.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 325 329 1290.199234 $64510.0800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 5 5 8.900000 $222.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 412 419 1536.390519 $76819.7300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 14 14 28.211113 $705.2800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 18 132.571429 $3314.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 22.409524 $1120.4800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 24.142856 $1207.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 857 866 6931.117481 $346556.3900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 21.066668 $1053.3300 $50.0000
INTR -INTR INTERPRETER 50 51 424.107935 $21205.4400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 12 66.010568 $4480.7900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.714285 $256.0800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 106 108 949.885713 $64478.3200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 10 10 86.714287 $4710.3200 $54.3200
SENS -FM FM RECEIVER HEARING AID 2 2 1.800000 $2970.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 3.294444 $1647.2000 $499.9900
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.123744 $203.0400 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.250000 $28.5000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 7.138030 $1627.4600 $228.0000
SENS -V5264 EARMOLD 14 14 20.567252 $370.2100 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 48.114287 $2405.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 112 1126.066668 $76437.4900 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.000000 $488.8800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 95.133333 $1255.7600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1039 1221 9914.496876 $4957.2500 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 56.285713 $2814.3000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1079 4246 27213.587450 $962202.0000 $35.3600
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Total 4352 28725.623705 $968504.6800 $33.7200
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Number of Children (Unduplicated) With at Least One Authorization 1122