Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 12 12 4.816668 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 4.816668 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.022222 $10.2400 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.022222 $8.6000 $8.4100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.022222 $21.4700 $21.0000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.066667 $64.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 8.511938 $383.0400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.432724 $854.7500 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 4.037302 $195.8100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 16 18.331745 $889.0900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 2.888888 $140.1100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 3.794443 $184.0200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 37 37 11.501597 $557.8200 $48.5000
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Subtotal (Total Children Is Unduplicated) 63 97 60.631970 $3308.9500 $54.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.082496 $5412.5000 $5000.0200
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 29.009710 $1450.4900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 2.258448 $112.9300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 24 11.028538 $551.4200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 24 24 41.333338 $1033.3500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 0.372603 $18.6300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 10.666667 $266.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 9.544443 $477.2200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 14 25.033337 $625.8400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 18 84.662699 $4233.1400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 12.833335 $320.8400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 42 42 258.000002 $12900.0100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 53.352381 $2667.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 81 81 564.546819 $38321.4900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 7 30.250001 $1643.1800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 60 60 420.235716 $28525.6200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 11 11 74.071430 $4023.5600 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.043836 $21.9000 $499.5900
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 1.381888 $89.8300 $65.0100
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 1.619331 $369.2000 $228.0000
SENS -V5264 EARMOLD 8 8 10.077168 $181.3900 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 22.571428 $1128.5800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 185 185 1374.147626 $93277.1700 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 9.571429 $519.9200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 7 8 49.714286 $656.2300 $13.2000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 268 395 183351.317312 $91675.6600 $0.5000
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Subtotal (Total Children Is Unduplicated) 285 944 186448.726267 $290504.3400 $1.5600
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Total 1053 186514.174905 $293813.2800 $1.5800
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Number of Children (Unduplicated) With at Least One Authorization 299