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: 10/01/08 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
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 8 9 7.72 $463.34 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 37 42 75.00 $3750.00 $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 6 6 9.00 $675.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 7.00 $525.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 7 12.00 $666.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 32 32 47.00 $2608.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 132 132 234.00 $17550.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 35 60.00 $4500.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 57 57 101.00 $7575.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 94 94 186.14 $10330.93 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 58 88.00 $6600.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 64 70 70.00 $3395.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 23 23.00 $1115.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 0.73 $36.67 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 52 56 56.00 $2716.00 $48.50
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Subtotal (Total Children Is Unduplicated) 329 633 986.60 $63162.50 $64.02
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 64 73 90.00 $135000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 11 29.76 $1487.78 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 485 1315 2757.00 $137850.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 524 661 1322.04 $66101.91 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 256 321 691.14 $34557.14 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 264 335 670.00 $33500.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 437 553 1175.14 $58757.14 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.00 $150.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 8 9 17.77 $444.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 68 80 278.33 $6958.22 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 39 43 474.14 $23707.20 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 432 561 4231.99 $211599.27 $50.00
INTR -INTR INTERPRETER 7 10 29.14 $1457.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 154 192 1060.31 $71973.54 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.64 $143.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 212 264 1356.85 $92102.69 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 10.00 $10.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.22 $1111.10 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 0.25 $16.39 $65.00
SENS -V5264 EARMOLD 5 5 5.54 $103.79 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 365 456 2565.58 $174151.49 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 18.14 $239.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 3 14.71 $1471.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 566 969 2933.79 $1466.89 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 6.57 $328.57 $50.00
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Subtotal (Total Children Is Unduplicated) 605 5883 19749.05 $1054688.91 $53.40
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Total 6516 20735.65 $1117851.41 $53.91
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Number of Children (Unduplicated) With at Least One Authorization 620