Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 12.00 $1435.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 22 24 23.51 $1140.29 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 55 55 70.80 $3433.65 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 19 21 21.00 $1018.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 24 48.86 $2369.57 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 92 101 128.39 $6226.71 $48.50
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Subtotal (Total Children Is Unduplicated) 166 234 308.55 $15814.31 $51.25
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 7 23.24 $1162.22 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 1.40 $70.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.60 $90.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 42.16 $2107.87 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 4 7.07 $353.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 12.77 $638.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 15.97 $399.17 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 7.14 $357.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 80 101 773.32 $38666.23 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 10 334.09 $16704.53 $50.00
INTR -INTR INTERPRETER 1 2 13.14 $657.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 181 228 1678.86 $113961.28 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 6.86 $372.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 110 134 933.27 $63350.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 18 19 104.12 $5655.87 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 15 15.93 $15.93 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 12.13 $2877.05 $237.12
SENS -V5264 EARMOLD 8 11 33.91 $634.76 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 439 539 4071.61 $276380.99 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 16 16 93.43 $1233.25 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 439 627 6478.36 $3239.17 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.00 $600.01 $50.00
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Subtotal (Total Children Is Unduplicated) 614 1757 14684.39 $539026.97 $36.71
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Total 1991 14992.94 $554841.29 $37.01
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Number of Children (Unduplicated) With at Least One Authorization 617