Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 -V5090 DISPENSING FEE PER HEARING AID 4 4 5.00 $598.00 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 15 16 30.00 $1500.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 3.50 $262.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 5.50 $305.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 66 66 114.50 $8587.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 43.50 $3262.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 68 68 117.50 $6521.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 15.00 $1125.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 139 191 191.00 $9263.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 117 120 120.00 $5820.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 142 200 204.57 $9921.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 117 121 126.71 $6145.64 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 474 617 618.00 $29973.00 $48.50
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Subtotal (Total Children Is Unduplicated) 674 1443 1594.79 $83285.86 $52.22
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 10.00 $15000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 239 271 337.35 $16867.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 334 431 777.24 $38861.87 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.70 $67.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 168 216 368.60 $18430.04 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 150 203 365.16 $18257.98 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.80 $20.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 345 453 789.37 $39468.61 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 408 544 3948.88 $197443.87 $50.00
INTR -INTR INTERPRETER 15 21 206.19 $10309.48 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 235 313 2285.99 $155172.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.00 $380.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 228 331 2647.11 $179686.11 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 146 166 165.02 $165.02 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 5 5 10.00 $187.20 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 9.93 $496.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 489 649 5099.91 $346182.17 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 25.57 $1278.58 $50.00
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Subtotal (Total Children Is Unduplicated) 932 3627 17068.83 $1041473.42 $61.02
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Total 5070 18663.62 $1124759.27 $60.26
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Number of Children (Unduplicated) With at Least One Authorization 947