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: 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
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 13 16 22.53 $1352.01 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 21 21 21.00 $1050.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 69 84 128.00 $6400.00 $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 10 10 13.00 $975.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 8.00 $600.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 15 20.00 $1110.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 83 83 101.00 $5605.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 393 396 526.00 $39450.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 109 109 140.00 $10500.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 171 172 226.93 $17019.65 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 227 229 335.07 $18596.47 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 245 248 296.50 $22237.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 136 155 155.00 $7517.50 $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 59 61 61.00 $2958.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 0.73 $36.67 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 108 128 128.00 $6208.00 $48.50
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Subtotal (Total Children Is Unduplicated) 758 1746 2199.77 $142766.43 $64.90
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 100 138 175.00 $262500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 17 66.25 $3312.62 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 798 2975 6268.00 $313400.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 836 1497 3080.04 $154001.91 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 413 724 1689.57 $84478.58 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 423 757 1545.86 $77292.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 722 1224 2694.86 $134742.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 12.00 $300.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 20 23 87.57 $2189.16 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 20 20 39.17 $979.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 99 147 605.30 $15132.42 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 95 133 2041.43 $102071.46 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 151 151 982.44 $49122.17 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 638 1073 15359.49 $767974.26 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 11.00 $550.00 $50.00
INTR -INTR INTERPRETER 18 29 85.93 $4296.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 276 469 4861.38 $329990.16 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 7.00 $380.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 339 625 5869.97 $398453.90 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.29 $721.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 11.00 $11.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 5 5.22 $2611.10 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 0.55 $35.44 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.50 $355.68 $237.12
SENS -V5264 EARMOLD 6 8 17.30 $323.86 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 630 1044 10811.30 $733871.20 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.15 $8.15 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 166.29 $2194.97 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 6 19.85 $1984.76 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 957 2351 5977.03 $2988.51 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 29.14 $1457.15 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 4 62.21 $3110.72 $50.00
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Subtotal (Total Children Is Unduplicated) 1031 13460 62599.07 $3450892.37 $55.13
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Total 15206 64798.83 $3593658.80 $55.46
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Number of Children (Unduplicated) With at Least One Authorization 1045