Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 13.23 $489.64 $37.00
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Subtotal (Total Children Is Unduplicated) 6 6 13.23 $489.64 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 17 38.38 $2302.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 15.10 $1805.78 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 27.21 $1360.71 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 16.00 $1200.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 7.00 $525.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.00 $225.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 7 11.00 $610.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 15 19.00 $1425.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 21 40.14 $1946.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 20 20 20.00 $970.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 46 68.43 $3318.78 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 10 10 10.00 $500.00 $50.00
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Subtotal (Total Children Is Unduplicated) 124 184 294.26 $17542.05 $59.61
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 15 51.15 $2557.39 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.50 $75.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 183 221 442.18 $22108.81 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 108 121 188.50 $9425.02 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.69 $67.36 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 101 120 184.01 $9200.53 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 9.87 $246.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 156 214.92 $10745.79 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 10.71 $786.64 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 203.00 $5075.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 189.14 $9457.14 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 32.43 $810.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 256 308 2875.62 $143781.19 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 8.28 $413.82 $50.00
INTR -INTR INTERPRETER 1 1 4.00 $200.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 188 227 2042.22 $138625.74 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 12 107.15 $5820.25 $54.32
PHY -97110 PT SESSION BY LICENSED PT 171 217 2039.30 $138427.88 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 11 115.00 $6246.54 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 4 5 4.03 $75.51 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 26.63 $1331.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 300 370 3286.43 $223082.78 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.43 $186.24 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 63.43 $837.26 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 63 96 35990.36 $17995.18 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.50 $125.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 9 63.29 $3164.53 $50.00
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Subtotal (Total Children Is Unduplicated) 536 1942 48172.76 $757818.85 $15.73
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Total 2132 48480.25 $775850.53 $16.00
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Number of Children (Unduplicated) With at Least One Authorization 549