Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.79 $103.07 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.00 $240.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 5.00 $625.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 15 18 18.00 $900.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 78 89 90.00 $4365.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 40 47 47.00 $2279.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 22 22 22.00 $1100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 107 123 123.00 $5965.50 $48.50
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Subtotal (Total Children Is Unduplicated) 216 313 316.00 $15915.65 $50.37
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 9 11.00 $16500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 16.07 $803.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 4.40 $220.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 95 124 202.53 $10126.70 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 74 106.35 $5317.51 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 67 97.11 $4855.73 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 106 142 202.28 $10114.20 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.51 $62.86 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 2 13.14 $328.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 238 364 2293.61 $114680.60 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 10.29 $514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 128 173 1209.10 $82073.57 $67.88
PHY -97110 PT SESSION BY LICENSED PT 167 241 1291.01 $87633.82 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.53 $83.29 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 3 6.09 $113.98 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.14 $107.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 375 536 2874.66 $195132.25 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 15 17 121.90 $1609.11 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 503 997 505566.52 $252783.26 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 12 47.96 $2397.86 $50.00
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Subtotal (Total Children Is Unduplicated) 583 2778 514083.53 $786490.57 $1.53
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Total 3092 514402.31 $802509.29 $1.56
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Number of Children (Unduplicated) With at Least One Authorization 601