Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 2.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 27.14 $1004.29 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 3.14 $116.29 $37.00
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Subtotal (Total Children Is Unduplicated) 6 8 32.29 $1120.57 $34.71
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 4 4.00 $217.52 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 130 134 132.29 $7937.41 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 50 52 58.80 $7033.04 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 3.00 $375.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 13 14 14.00 $1750.00 $125.00
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 1 1 1.00 $55.50 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 28 28 34.44 $1670.25 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 105 113 119.43 $5792.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 17 17 17.00 $824.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 60 61 77.14 $3741.43 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 226 236 242.71 $11771.64 $48.50
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Subtotal (Total Children Is Unduplicated) 420 668 708.82 $41437.18 $58.46
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 27 28 60.04 $3001.82 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 31.15 $1557.51 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 8.30 $207.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 162 192 395.57 $19778.65 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 23 24 36.24 $906.09 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 122 184.07 $9203.49 $50.00
CONOP -CONOP CONSULT, OT, PHONE 14 14 22.78 $569.59 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 39 57.77 $2888.32 $50.00
CONPP -CONPP CONSULT, PT, PHONE 12 14 23.44 $585.95 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 202 341.49 $17074.59 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 23 24 40.19 $1004.70 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 6.50 $477.23 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 12.14 $607.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.57 $114.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 416 508 4557.79 $227889.34 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 5 21.21 $1060.48 $50.00
INTR -INTR INTERPRETER 27 35 222.82 $11141.09 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 275 340 3214.45 $218197.16 $67.88
OCCT -97530HM OT SESSION BY OT ASST 28 31 258.08 $14018.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 149 200 1377.20 $93484.26 $67.88
PHY -97110HM PT SESSION BY PT ASST 20 20 190.71 $10359.46 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 14 14 21.13 $395.61 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 10 25.40 $1270.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 370 450 3584.49 $243315.20 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 13.00 $706.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 37 37 294.32 $3885.04 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 590 964 159821.76 $79910.87 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 72.14 $3607.15 $50.00
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Subtotal (Total Children Is Unduplicated) 831 3313 174908.76 $972371.39 $5.56
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Total 3989 175649.87 $1014929.14 $5.78
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Number of Children (Unduplicated) With at Least One Authorization 852