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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 3 3 3.00 $358.80 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 4 4 8.00 $400.00 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.00 $225.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 95 95 181.29 $13596.43 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 7.50 $416.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 7.00 $525.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 147 198 210.00 $10185.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 116 120 120.00 $5820.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 153 210 218.57 $10600.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 109 115 121.71 $5903.14 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 427 607 607.00 $29439.50 $48.50
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Subtotal (Total Children Is Unduplicated) 669 1367 1494.07 $77880.83 $52.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 259 288 346.03 $17301.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 415 536 914.79 $45739.49 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 211 295 517.33 $25866.43 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 183 246 407.78 $20388.79 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 397 527 855.72 $42785.99 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 456 590 4325.37 $216268.72 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.43 $121.67 $50.00
INTR -INTR INTERPRETER 17 23 404.78 $20239.21 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 209 308 2477.58 $168178.00 $67.88
PHY -97110 PT SESSION BY LICENSED PT 221 319 2467.27 $167478.22 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 184 213 213.00 $213.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 6 6 10.00 $187.20 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 5.50 $275.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 417 595 4413.69 $299601.14 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 15.61 $780.48 $50.00
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Subtotal (Total Children Is Unduplicated) 968 3963 17388.88 $1029735.59 $59.22
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Total 5330 18882.95 $1107616.42 $58.66
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Number of Children (Unduplicated) With at Least One Authorization 996