Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.62 $59.81 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 1.62 $59.81 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 33.47 $2008.24 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 21 25 24.58 $1150.24 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 20 22 21.18 $2533.52 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.00 $150.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 39 68 90.23 $6308.00 $69.91
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 15 17.71 $26571.45 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 39 50 72.15 $3607.51 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 37 57.14 $2857.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 41 46 108.66 $5432.76 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 9 10.67 $266.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 123 212.30 $10615.18 $50.00
CONOP -CONOP CONSULT, OT, PHONE 20 24 26.75 $668.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 67 72 132.84 $6642.15 $50.00
CONPP -CONPP CONSULT, PT, PHONE 13 16 15.23 $380.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 104 114 217.76 $10887.83 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 26 26.21 $655.21 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 100 118 2185.43 $54635.74 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 426 554 4161.75 $208087.52 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 5 3.60 $180.00 $50.00
INTR -INTR INTERPRETER 20 22 85.14 $4257.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 291 378 1911.63 $129761.74 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 10 85.25 $4630.66 $54.32
PHY -97110 PT SESSION BY LICENSED PT 376 513 2876.40 $195249.92 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 10.44 $567.06 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 27 26.20 $26.20 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 16 18 17.50 $8750.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 19 22 12.37 $231.50 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 892 1203 7848.87 $532781.09 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 4 23.00 $1249.36 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 16 19 144.71 $1910.23 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 5 4.53 $453.33 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 14 19 148.28 $7414.06 $50.00
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Subtotal (Total Children Is Unduplicated) 1368 3459 20449.52 $1219197.94 $59.62
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Total 3529 20541.37 $1225565.75 $59.66
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Number of Children (Unduplicated) With at Least One Authorization 1371