Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 8 9.11 $546.66 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 35 47 68.00 $3400.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 4.00 $300.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 28 28 30.00 $1665.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 128 128 148.00 $11100.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 29 29 34.00 $2550.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 55 55 64.00 $4800.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 20 26.00 $1443.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 120 120 138.50 $10387.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 62 67 67.00 $3249.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 21.00 $1018.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 41 45 45.00 $2182.50 $48.50
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Subtotal (Total Children Is Unduplicated) 304 580 663.61 $43282.86 $65.22
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 60 69 91.00 $136500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 7 9 22.72 $1135.87 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 509 1467 3056.14 $152807.14 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 513 683 1391.00 $69550.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 253 331 740.14 $37007.14 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 258 335 670.00 $33500.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 424 539 1147.43 $57371.43 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.00 $150.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 10.70 $267.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 60 79 137.64 $3441.12 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 24 26 188.57 $9428.58 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 448 602 4378.02 $218901.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 7.00 $350.00 $50.00
INTR -INTR INTERPRETER 7 10 28.71 $1435.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 168 214 1236.46 $83930.86 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.29 $178.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 201 266 1281.06 $86958.11 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.71 $364.72 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.25 $10.84 $43.00
SENS -V5264 EARMOLD 4 5 7.16 $133.95 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 369 465 2569.20 $174397.30 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 40.57 $535.54 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 3.00 $300.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 554 1014 2104.48 $1052.24 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 6.57 $328.57 $50.00
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Subtotal (Total Children Is Unduplicated) 597 6139 19135.83 $1071036.25 $55.97
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Total 6719 19799.44 $1114319.11 $56.28
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Number of Children (Unduplicated) With at Least One Authorization 603