Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.75 $27.75 $37.00
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Subtotal (Total Children Is Unduplicated) 1 2 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 17 17.00 $824.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 41 42 45.09 $2705.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 8.43 $394.68 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 19.00 $2272.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 11.25 $562.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 42 46 64.04 $3201.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.50 $187.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.50 $83.25 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 19 19 25.86 $1939.28 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 12.00 $900.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 25 25 32.00 $2400.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 46 47 65.36 $3627.32 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 9.50 $527.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 288 288 385.57 $28917.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 22 26.50 $1987.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 76 78 127.00 $9525.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 278 285 394.57 $21898.72 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 274 303 413.21 $30991.07 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 36.43 $1766.79 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 24 37.43 $1815.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 36 36 51.71 $2508.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 58 61 85.14 $4129.43 $48.50
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Subtotal (Total Children Is Unduplicated) 731 1366 1887.09 $123830.98 $65.62
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 38 52 60.00 $90000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 26 30 71.26 $3563.09 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 66 70 87.63 $4381.55 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 17 23 37.81 $945.13 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 29 33.53 $1676.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 31 34 90.18 $2254.41 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 6.37 $318.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 8 23.30 $582.62 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 9 9.67 $483.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 17 19 50.54 $1263.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 33 69.99 $3499.39 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 57 62 123.39 $3084.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.86 $485.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 70 76 746.29 $18657.16 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 11 13 113.29 $5664.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 570 679 4939.90 $246994.76 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 13.14 $657.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 7 56.71 $2835.72 $50.00
INTR -INTR INTERPRETER 26 30 243.06 $12152.88 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 177 214 1970.60 $133764.47 $67.88
OCCT -97530HM OT SESSION BY OT ASST 24 25 226.46 $12301.54 $54.32
PHY -97110 PT SESSION BY LICENSED PT 327 403 3597.83 $244220.89 $67.88
PHY -97110HM PT SESSION BY PT ASST 31 32 248.40 $13493.10 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 380.57 $380.57 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 8.00 $4000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 14 15 28.04 $524.99 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 2 13.14 $657.14 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 21.07 $1053.34 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 7.71 $385.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 948 1194 10085.07 $684574.36 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 24.14 $1311.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 41 42 428.71 $5659.03 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 5 43.14 $4314.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1165 1942 14550.27 $7275.11 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 65.71 $3285.72 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 10 81.29 $4064.30 $50.00
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Subtotal (Total Children Is Unduplicated) 1415 5103 38600.07 $1524609.35 $39.50
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Total 6471 40488.17 $1648477.32 $40.72
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Number of Children (Unduplicated) With at Least One Authorization 1594