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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 3.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 11.00 $533.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.27 $76.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 196 202 219.46 $26246.89 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 19 22 28.87 $3608.34 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 14 18.14 $1006.93 $55.50
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.00 $50.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 11 11 15.03 $751.67 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 43 43 57.03 $2766.12 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 63 66 78.00 $3783.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 123 128 165.29 $8016.36 $48.50
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Subtotal (Total Children Is Unduplicated) 328 503 600.08 $47079.20 $78.45
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 7.93 $11899.95 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 13 15 58.40 $2919.77 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 6.00 $300.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 27 36.83 $1841.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 9 46.51 $1162.70 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 33.45 $1672.62 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 6.37 $159.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 22 44.24 $2211.91 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.91 $122.71 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 29 74.46 $3722.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 75.32 $1883.06 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 12 22.03 $1617.68 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 119 123 294.14 $7353.55 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 6.86 $342.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 530 650 4455.45 $222772.37 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 16 94.23 $4711.67 $50.00
INTR -INTR INTERPRETER 6 6 70.29 $3514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 5 6 124.14 $8426.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 65 84 741.03 $40252.66 $54.32
PHY -97110 PT SESSION BY LICENSED PT 6 7 101.00 $6855.88 $67.88
PHY -97110HM PT SESSION BY PT ASST 87 106 1128.94 $61324.20 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 46 48 37.27 $37.27 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 11 12.84 $834.70 $65.00
SENS -V5264 EARMOLD 12 14 24.56 $459.68 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 46.75 $2337.62 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 8 158.14 $10734.73 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 112 126 1549.10 $20448.12 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 13.00 $650.00 $50.00
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Subtotal (Total Children Is Unduplicated) 671 1381 9281.19 $423639.35 $45.64
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Total 1885 9884.27 $470718.55 $47.62
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Number of Children (Unduplicated) With at Least One Authorization 690