Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 6.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 3 3 6.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 63 98 125.86 $6104.07 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 10.00 $1196.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 450 635 788.10 $39405.00 $50.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.50 $25.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.00 $200.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 535 758 837.18 $40603.05 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 376 553 637.39 $30913.21 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 674 930 1158.67 $56195.55 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 5 7 42.86 $2142.86 $50.00
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Subtotal (Total Children Is Unduplicated) 1384 3006 3615.55 $177404.67 $49.07
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 70 72 79.10 $3955.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 802 1446 5974.63 $298731.41 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 19 195.84 $4896.07 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 352 594 2307.53 $115376.72 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 48.04 $1200.95 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 200 364 1469.64 $73482.09 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 20.57 $514.29 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 544 872 3183.02 $159151.09 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 18 176.22 $4405.48 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 16 37.51 $2754.18 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 22 22 169.40 $4235.04 $25.00
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 2 2 15.00 $187.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 341 590 4554.54 $113863.44 $25.00
EIIF -90846 FAMILY PSYCHOTHERAPY W/O PATIENT 1 1 7.71 $385.72 $50.00
EIIF -90847 FAMILY PSYCHOTHERAPY WITH PATIENT 1 1 8.29 $414.29 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 189 197 1664.21 $83210.27 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 90.57 $2264.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1338 2537 41626.35 $2081317.58 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 668 1239 9755.42 $662197.86 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 3 41.82 $2271.74 $54.32
PHY -97110 PT SESSION BY LICENSED PT 571 1135 10097.48 $685417.03 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 23.57 $1280.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 49 62 85.37 $85.37 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 3 3 3.36 $62.82 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 3 3 11.18 $559.05 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 37 67 328.65 $16432.40 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 11.86 $592.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 889 1505 11478.97 $779192.63 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.50 $151.80 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 13 13 89.32 $8931.91 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1245 2450 15090.26 $7545.12 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 2.80 $139.77 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 23 42 360.73 $18036.67 $50.00
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Subtotal (Total Children Is Unduplicated) 1928 13292 109024.96 $5135267.75 $47.10
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Total 16301 112646.65 $5312672.42 $47.16
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Number of Children (Unduplicated) With at Least One Authorization 2016