Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 32 33 45.00 $2182.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 2.02 $121.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 6.00 $717.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 114 123 186.43 $9321.43 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 5 5 5.00 $250.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 400 521 557.96 $27060.91 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 281 336 404.00 $19594.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 489 601 683.43 $33146.29 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.37 $118.34 $50.00
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Subtotal (Total Children Is Unduplicated) 913 1628 1896.20 $92777.80 $48.93
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 28 30 74.57 $3728.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 201 268 555.40 $27769.91 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.07 $1.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 80 100 191.68 $9583.86 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 66 157.58 $7878.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 137 188 337.72 $16885.97 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.83 $45.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 9.29 $681.76 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 88 132 824.50 $20612.51 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 969 1335 10142.48 $507124.18 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 524 719 4268.59 $289751.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.14 $170.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 437 575 3448.48 $234083.07 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.43 $23.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 57 71 57.53 $57.53 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 4 4 11.80 $220.90 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 22 28 88.78 $4439.05 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 2 2.57 $128.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 641 845 4485.72 $304490.81 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.64 $127.29 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 3.00 $300.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 887 1283 7601.36 $3800.68 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 17 21 90.25 $4512.26 $50.00
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Subtotal (Total Children Is Unduplicated) 1399 5680 32373.40 $1439483.57 $44.47
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Total 7309 34270.61 $1532298.37 $44.71
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Number of Children (Unduplicated) With at Least One Authorization 1445