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 12 12 7.944443 $385.3000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 11.300000 $678.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.044445 $47.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.056316 $121.4700 $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 1 1 2.714286 $131.6400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.511111 $24.7900 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.145205 $2.1800 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 0.137367 $6.6600 $48.5100
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Subtotal (Total Children Is Unduplicated) 25 29 30.386507 $1903.7200 $62.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 34.085715 $51128.7000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 9.839681 $491.9900 $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 458 697 3036.846897 $151842.6900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 14.333335 $358.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 249 254 1125.444466 $56272.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 11 11 28.900001 $722.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 324 328 1288.432567 $64421.7500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 5 5 8.900000 $222.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 411 418 1536.323852 $76816.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 14 14 28.211113 $705.2800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 14.857143 $371.4300 $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 213 215 1836.861910 $91843.2400 $50.0000
INTR -INTR INTERPRETER 50 51 424.107935 $21205.4400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.428571 $232.7300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $178.4800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 9 9 105.142857 $7137.1100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 30.714286 $1668.4000 $54.3200
SENS -FM FM RECEIVER HEARING AID 1 1 1.766667 $2915.0600 $1650.0300
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.911111 $455.5500 $499.9900
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.290411 $18.8800 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.290411 $66.2100 $227.9900
SENS -V5264 EARMOLD 2 2 3.000000 $54.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 14 156.428572 $10618.3900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 26.285714 $346.9700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1033 1205 9810.958779 $4905.4800 $0.5000
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Subtotal (Total Children Is Unduplicated) 1056 3283 19706.244532 $553587.7000 $28.0900
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Total 3359 21159.972309 $555491.4200 $26.2500
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Number of Children (Unduplicated) With at Least One Authorization 1099