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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 2 2 0.29 $10.57 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 14.57 $539.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 2.96 $109.68 $37.00
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Subtotal (Total Children Is Unduplicated) 6 8 17.82 $659.39 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 49 57 58.00 $2813.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 4.00 $144.28 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.00 $10.62 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 64 68 76.08 $4564.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 17 20.29 $949.52 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 42 43 61.00 $7295.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 32 34 51.68 $2583.93 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 119 126 175.07 $8753.58 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 15 15 21.50 $1612.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 2 2 3.00 $166.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 82 85 115.41 $8655.84 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 13 13 21.00 $1575.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 86 88 115.00 $8625.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 144 155 207.41 $11511.32 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 11 11 14.50 $804.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1079 1091 1487.07 $111530.37 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 97 97 117.50 $8812.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 205 208 333.14 $24985.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 983 996 1378.93 $76530.55 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1137 1227 1691.71 $126878.58 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 57 60 166.57 $8078.71 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 119 123 156.71 $7600.64 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 98 103 148.71 $7212.64 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 130 135 210.76 $10221.94 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 398 429 683.93 $33170.58 $48.50
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Subtotal (Total Children Is Unduplicated) 2471 5199 7332.99 $475597.88 $64.86
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 123 185 205.14 $307714.35 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 53 66 243.70 $12185.25 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 216 244 334.25 $16712.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 47 57 116.18 $2904.41 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 52 61 111.98 $5599.06 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 44 52 263.46 $6586.60 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 12 34.83 $1741.43 $50.00
CONOP -CONOP CONSULT, OT, PHONE 14 17 88.34 $2208.57 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 19 31.24 $1561.91 $50.00
CONPP -CONPP CONSULT, PT, PHONE 24 32 154.32 $3858.09 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 99 269.04 $13452.06 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 104 120 399.39 $9984.71 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 105.71 $1321.43 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 20 21 518.00 $12950.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 104 139 2461.50 $61537.49 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 12 16 275.71 $13785.73 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 188 191 1695.66 $84783.19 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 7.57 $189.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 913 1262 17851.25 $892562.56 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 39.29 $1964.29 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 2 2 2.00 $100.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 8 152.71 $7635.72 $50.00
INTR -INTR INTERPRETER 48 67 1327.89 $66394.66 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 332 528 8030.43 $545105.64 $67.88
OCCT -97530HM OT SESSION BY OT ASST 59 63 1053.17 $57208.41 $54.32
PHY -97110 PT SESSION BY LICENSED PT 501 848 14038.58 $952938.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 82 88 1422.36 $77262.47 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 71 73 1186.45 $1186.45 $1.00
SENS -FM FM RECEIVER HEARING AID 6 6 7.00 $11550.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 11 11 20.00 $10000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 9.73 $2307.96 $237.12
SENS -V5264 EARMOLD 29 42 79.95 $1496.63 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 2 26.43 $1321.43 $50.00
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 16.14 $807.15 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 86.90 $4345.24 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 2 2 25.14 $1257.14 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1537 2522 38552.74 $2616960.21 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 26 28 283.71 $15411.35 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 130 137 2048.07 $27034.53 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 6 86.43 $8642.86 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2053 4540 56848.24 $28424.11 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 153.71 $7685.71 $50.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 5 5 109.57 $5478.58 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 18 282.57 $14128.58 $50.00
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Subtotal (Total Children Is Unduplicated) 2430 11616 151164.00 $5918599.58 $39.15
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Total 16823 158514.81 $6394856.85 $40.34
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Number of Children (Unduplicated) With at Least One Authorization 2956