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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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 -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
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 1 1 1.00 $60.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 5.00 $598.00 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 12.86 $1607.14 $125.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 34 37 34.98 $1696.69 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 61 61 69.71 $3381.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 28 30 29.33 $1422.40 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 32 32 31.17 $1511.59 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 141 160 177.46 $8606.71 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 12.86 $1285.71 $100.00
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Subtotal (Total Children Is Unduplicated) 200 332 380.36 $20431.44 $53.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 9.67 $483.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.50 $225.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 3.08 $154.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.90 $22.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 5 8.03 $401.68 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 3 1.65 $41.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 7 10.70 $535.24 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.38 $69.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 2 0.75 $18.75 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 822.86 $20571.43 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 36.86 $1842.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 80 98 790.78 $39539.25 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 4.17 $208.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 44.43 $2221.43 $50.00
INTR -INTR INTERPRETER 2 2 13.57 $678.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 211 253 1822.56 $123715.22 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 131.14 $7123.66 $54.32
PHY -97110 PT SESSION BY LICENSED PT 144 174 1180.12 $80106.43 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 11 94.67 $5142.29 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 18.49 $18.49 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 2 2 5.24 $98.18 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 119.57 $5978.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 353 439 3196.63 $216987.30 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.29 $450.08 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 24 25 196.86 $2598.51 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 272 414 15607.77 $7803.89 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 5 19.00 $950.01 $50.00
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Subtotal (Total Children Is Unduplicated) 503 1498 24161.67 $523459.89 $21.66
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Total 1830 24542.04 $543891.33 $22.16
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Number of Children (Unduplicated) With at Least One Authorization 513