Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 82 88 59.522213 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 82 88 59.522213 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 21 21 5.822223 $83.6100 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 20 20 4.966667 $91.6900 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 21 21 5.822223 $58.3400 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 20 20 5.566667 $46.8200 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 19 19 4.711111 $36.5100 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 20 5.722223 $120.1700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 20 20 4.966667 $311.0600 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 21 5.822223 $128.2100 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 102 110 418.355561 $25101.3700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.522222 $68.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 16.899999 $1943.4900 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 72 75 37.755555 $1831.1400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 9 4.877778 $236.5700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 70 74 40.833335 $1980.4200 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 234 441 563.644454 $32037.8900 $56.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 21 26.622222 $133111.0000 $5000.0000
AUD -HA_FUP AUDIOLOGY SERVICES 3 4 7.155556 $357.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 131 162 114.155958 $5707.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 265 291 235.546031 $11777.3000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 150 175 129.477769 $6473.8500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 147 171 147.366656 $7368.2800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 397 463 347.405536 $17370.1800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 8 56.400000 $1410.0000 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1017 1472 11461.738891 $573086.9600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 32 36 248.616666 $12430.8300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 46.400000 $2320.0000 $50.0000
INTR -INTR INTERPRETER 3 4 28.755555 $1437.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 392 514 3139.196819 $213088.6400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.866667 $264.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 617 784 4000.738859 $271569.9500 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 2.711111 $618.1300 $228.0000
SENS -V5264 EARMOLD 12 15 14.488888 $260.8000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 5.300000 $265.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 17 72.555556 $3627.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 618 813 4854.585706 $329529.2200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 25.466667 $336.1600 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1214 2169 15431.209518 $154312.0900 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 49 55 696.992064 $348.5000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 27 33 172.408136 $8620.4200 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 22.522222 $1126.1100 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1784 7237 41303.983054 $1757764.7600 $42.5600
-------------------------------------------------------------------------------------------------------------------------------------
Total 7766 41927.149721 $1789802.6500 $42.6900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1860