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: 10/01/08 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
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 6.14 $767.86 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 33 35 33.58 $1628.52 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 70 73 73.00 $3540.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 20 22 21.51 $1043.29 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 50 50 49.51 $2401.29 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 175 182 183.82 $8915.30 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.00 $600.00 $100.00
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Subtotal (Total Children Is Unduplicated) 227 368 378.56 $19283.07 $50.94
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.17 $208.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 10.71 $535.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 3.07 $153.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 5.67 $283.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.77 $19.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 8.60 $430.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 3 1.33 $33.13 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 841.71 $21042.86 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 46.43 $2321.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 78 96 816.79 $40839.32 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.14 $7.15 $50.00
INTR -INTR INTERPRETER 1 2 12.14 $607.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 219 264 2101.87 $142674.79 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 12 61.71 $3352.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 137 166 1292.32 $87722.35 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 10 52.30 $2840.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 3.23 $3.23 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 1 2.27 $42.43 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 61.14 $3057.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 364 439 3547.07 $240775.06 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 20 20 123.29 $1627.37 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 196 281 21241.63 $10620.81 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 15.14 $757.15 $50.00
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Subtotal (Total Children Is Unduplicated) 501 1332 30261.49 $567428.55 $18.75
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Total 1700 30640.05 $586711.62 $19.15
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Number of Children (Unduplicated) With at Least One Authorization 517