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: 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 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 4.70 $282.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 4.00 $500.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 13 17 17.00 $850.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 80 101 109.71 $5321.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 36 43 43.00 $2085.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 17 17 17.00 $850.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 122 140 145.33 $7048.44 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 233 338 353.74 $17588.41 $49.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 8 15.80 $790.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 0.82 $40.84 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 127 167 274.55 $13727.74 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 74 100.57 $5028.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 80 121.33 $6066.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 134 176 266.06 $13302.80 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.28 $57.08 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 11.43 $571.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 4 25.00 $625.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 256 375 2289.85 $114492.26 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 13.14 $657.15 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 136 177 1290.24 $87581.22 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.11 $168.78 $54.32
PHY -97110 PT SESSION BY LICENSED PT 169 217 1342.12 $91103.14 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.88 $47.98 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 5.61 $5.61 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 3 4 8.79 $164.53 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 25.14 $1257.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 440 598 3159.80 $214487.39 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 67.64 $892.89 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 540 1030 511903.93 $255951.96 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 22 70.92 $3546.19 $50.00
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Subtotal (Total Children Is Unduplicated) 654 2966 521009.02 $821666.11 $1.58
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Total 3305 521363.76 $839254.52 $1.61
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Number of Children (Unduplicated) With at Least One Authorization 667