Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 4.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 4.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 33 36.86 $1787.57 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 209 230 309.80 $15489.77 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 342 410 438.42 $21263.33 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 242 292 338.49 $16416.56 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 422 494 580.44 $28151.48 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 8.57 $428.57 $50.00
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Subtotal (Total Children Is Unduplicated) 848 1465 1717.57 $83923.27 $48.86
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 29 29 32.57 $1628.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 362 455 920.98 $46049.22 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 155 187 376.79 $18839.37 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 91 110 248.28 $12414.11 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 231 277 527.26 $26362.95 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 16 18.78 $1378.89 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 169 209 1170.02 $29250.46 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 5.43 $271.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 918 1175 9363.02 $468150.87 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 452 592 3250.40 $220637.12 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.00 $651.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 391 518 3107.75 $210953.82 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.29 $341.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 47 54 38.08 $38.08 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 3 3 3.36 $62.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 24 31 101.44 $5072.15 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 11.86 $592.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 546 697 3722.82 $252705.17 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 7 7 36.20 $3620.47 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 776 1098 5401.92 $2700.95 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 16 87.00 $4350.24 $50.00
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Subtotal (Total Children Is Unduplicated) 1303 5480 28446.25 $1308072.58 $45.98
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Total 6946 30167.96 $1391995.86 $46.14
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Number of Children (Unduplicated) With at Least One Authorization 1351