Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.02 $9.03 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.02 $11.04 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.02 $22.27 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.02 $57.19 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 5.27 $316.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 14 19 20.00 $1000.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 97 136 136.00 $6596.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 43 47 53.57 $2598.21 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 35 38 38.00 $1900.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 189 234 234.23 $11360.32 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 301 492 502.16 $24683.52 $49.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 14 20.00 $30000.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.00 $137.72 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 20.00 $1000.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.71 $85.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 180 250 434.47 $21723.31 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 115 151 258.59 $12929.69 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 89 111 235.00 $11750.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 210 270 479.91 $23995.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.07 $1.67 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 257 403 2290.60 $114530.02 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 6 49.57 $2478.58 $50.00
INTR -INTR INTERPRETER 4 4 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 177 239 1750.41 $118818.16 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 15.54 $843.90 $54.32
PHY -97110 PT SESSION BY LICENSED PT 169 236 1592.50 $108099.23 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 11.30 $613.56 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 21 14.14 $14.14 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 6.58 $123.13 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 7.43 $371.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 466 662 3738.59 $253775.43 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 83.21 $1098.43 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 575 1251 575714.65 $287857.32 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 21 62.70 $3135.24 $50.00
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Subtotal (Total Children Is Unduplicated) 659 3677 586799.98 $995206.40 $1.70
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Total 4169 587302.14 $1019889.92 $1.74
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Number of Children (Unduplicated) With at Least One Authorization 679