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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 4.00 $148.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 4.00 $148.00 $37.00
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 0.68 $5.99 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 5.04 $302.66 $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
EXIT -EXIT TRANSITION ASSESSMENT 13 14 13.57 $678.57 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 79 96 100.29 $4863.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 29 37 43.86 $2127.07 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 57 57 57.00 $2850.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 137 174 182.86 $8868.57 $48.50
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Subtotal (Total Children Is Unduplicated) 292 386 409.29 $20185.19 $49.32
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 18.43 $27649.95 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.00 $137.72 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 20.20 $1010.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 5.28 $264.17 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 2 4.73 $118.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 201 272 472.81 $23640.33 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 111 145 264.37 $13218.26 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 97 121 240.26 $12013.15 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 215 284 490.16 $24508.22 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.03 $75.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 10 47.14 $1178.58 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 15.07 $753.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 252 372 2079.27 $103963.63 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 49.86 $2492.86 $50.00
INTR -INTR INTERPRETER 2 4 5.31 $265.56 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 138 194 1364.35 $92612.25 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 10 63.45 $3446.34 $54.32
PHY -97110 PT SESSION BY LICENSED PT 166 219 1411.65 $95822.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 16.42 $892.01 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 26 13.40 $13.40 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 9.44 $176.80 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 29.00 $1450.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 464 675 3691.89 $250605.70 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 62.54 $825.47 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 574 1161 542326.51 $271163.25 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 18 35.90 $1794.88 $50.00
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Subtotal (Total Children Is Unduplicated) 643 3570 552745.49 $931067.04 $1.68
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Total 3957 553158.78 $951400.23 $1.72
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Number of Children (Unduplicated) With at Least One Authorization 688