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: 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
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 9.00 $1076.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 7 7 7.00 $350.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 23 25 25.00 $1212.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 60 62 70.19 $3404.36 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 16 22 27.86 $1351.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 28 36.14 $1752.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 98 107 113.21 $5490.54 $48.50
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Subtotal (Total Children Is Unduplicated) 180 261 295.40 $15134.60 $51.23
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 7 21.50 $1075.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 9.00 $450.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 28 19.56 $977.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 27 28 51.95 $1298.75 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 17 35.04 $1751.86 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 9 16.43 $410.84 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 10.10 $504.76 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 10.73 $268.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 22 13.15 $657.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 25 28 43.37 $1084.16 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.20 $30.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 103 119 842.99 $42149.47 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 10 225.32 $11265.95 $50.00
INTR -INTR INTERPRETER 3 4 3.86 $192.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 169 217 1579.33 $107204.80 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 6.79 $368.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 102 131 918.01 $62314.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 18 20 124.96 $6788.07 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 11.84 $11.84 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 9.80 $2323.78 $237.12
SENS -V5264 EARMOLD 8 9 40.40 $756.35 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.29 $214.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 450 558 3823.72 $259554.14 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 14.43 $783.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 51.11 $674.62 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 446 673 6149.49 $3074.75 $0.50
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Subtotal (Total Children Is Unduplicated) 616 1944 14051.36 $521117.06 $37.09
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Total 2205 14346.76 $536251.67 $37.38
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Number of Children (Unduplicated) With at Least One Authorization 619