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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 13.00 $630.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.18 $9.67 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 8.00 $374.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 160 164 170.20 $20355.92 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 15 15 21.00 $2625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.86 $92.86 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 13.86 $769.07 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 10 10 11.67 $583.33 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 40 57.98 $2812.08 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 49 51 68.00 $3298.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 76 81 120.86 $5861.57 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 267 386 488.60 $37572.40 $76.90
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 15.00 $22500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 6.57 $452.51 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 15 18 58.76 $2938.10 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 42 44 74.45 $3722.39 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 11 63.65 $1591.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 17 41.65 $2082.61 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 6.73 $168.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 33.20 $1659.76 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.75 $18.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 27 70.38 $3519.04 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 16 17 70.66 $1766.55 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 13.13 $964.25 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 112 124 313.76 $7843.93 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 484 617 4165.49 $208274.34 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 3 3 6.04 $302.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 16 76.48 $3824.04 $50.00
INTR -INTR INTERPRETER 6 6 77.14 $3857.13 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 6 8 126.57 $8591.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 58 70 762.68 $41428.69 $54.32
PHY -97110 PT SESSION BY LICENSED PT 4 5 102.29 $6943.15 $67.88
PHY -97110HM PT SESSION BY PT ASST 86 107 1099.59 $59729.58 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 49 56 46.44 $46.44 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 8.00 $4000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 11 8.69 $564.73 $65.00
SENS -V5264 EARMOLD 12 15 21.30 $398.74 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 12 27.55 $1377.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 5 116.57 $7912.87 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 96 113 1511.62 $19953.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.14 $57.15 $50.00
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Subtotal (Total Children Is Unduplicated) 610 1353 8927.28 $416513.89 $46.66
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Total 1739 9415.88 $454086.28 $48.23
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Number of Children (Unduplicated) With at Least One Authorization 629