Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 19 19.00 $921.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.31 $71.30 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 2.04 $122.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 176 182 206.17 $24658.12 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 9.86 $1232.14 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 11.29 $564.29 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 52 52 72.35 $3509.09 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 46 49 53.92 $2615.30 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 104 105 119.14 $5778.43 $48.50
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Subtotal (Total Children Is Unduplicated) 275 425 501.09 $39760.03 $79.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 32 33.00 $49500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 8.07 $555.80 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 72.39 $3619.60 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.83 $20.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 36 37 100.58 $5028.82 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 22.23 $555.66 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 8 25.46 $1273.09 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 2 3.07 $76.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 28 53.45 $2672.55 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 19.78 $494.53 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 29 30 88.25 $4412.39 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 12 27.32 $682.98 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 120 125 263.28 $6582.05 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 536 649 4211.21 $210560.34 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 8.43 $421.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 14 14 61.84 $3092.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.71 $863.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 58 69 782.93 $42528.70 $54.32
PHY -97110 PT SESSION BY LICENSED PT 5 5 63.71 $4324.93 $67.88
PHY -97110HM PT SESSION BY PT ASST 58 70 709.87 $38560.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 45 45.44 $45.44 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 7.00 $3500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 10 7.84 $509.68 $65.00
SENS -V5264 EARMOLD 10 10 18.22 $341.12 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 27.36 $1368.10 $50.00
SPL -92508 GROUP SPL SESSION PER CHILD 81 100 1362.93 $17990.66 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 658 1293 8038.21 $399630.77 $49.72
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Total 1718 8539.30 $439390.81 $51.46
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Number of Children (Unduplicated) With at Least One Authorization 681