Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 1 1 4.07 $150.47 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 4.79 $177.19 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 8.86 $327.66 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 3 3.00 $48.90 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.00 $54.20 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.00 $21.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 24 25 38.39 $2303.24 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 10 12.00 $1435.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 5.86 $732.14 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 20 21 298.93 $37366.10 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 39 39 45.51 $2275.56 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 7.81 $433.52 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 5.00 $375.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 3.00 $225.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 7.50 $562.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 11 20.50 $1137.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 289 405 660.85 $49563.57 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 9 10 12.00 $873.36 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 3 3 3.00 $450.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.77 $88.34 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 33 42 38.39 $1861.86 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 243 265 291.82 $14153.22 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 40 47 49.93 $2421.46 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 210 236 259.65 $12593.25 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 642 765 765.28 $37116.08 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 1049 1919 2549.18 $166675.18 $65.38
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 17.00 $25500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 40 42 89.44 $4471.90 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 40 62.81 $3140.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 12 31.01 $775.18 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 47 52 88.26 $4413.10 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 19.85 $496.19 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 46 104.26 $5213.09 $50.00
CONOP -CONOP CONSULT, OT, PHONE 14 16 39.63 $990.78 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 47 113.78 $5688.93 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 13 36.45 $911.16 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 57 72 146.01 $7300.29 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 22 27 64.11 $1602.77 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 25 35 2148.86 $26860.71 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 3.29 $82.14 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 19.57 $489.29 $25.00
EIIF -90812 INDIVIDUAL PSYCHOTHERAPY, 45-50 MIN 1 1 3.77 $188.34 $50.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 136.71 $6835.71 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 233 239 1978.09 $98904.41 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 57.14 $1428.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 887 1314 19652.43 $982621.44 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 12 12 194.00 $9700.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 26 33 468.82 $23441.20 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 265 375 5366.90 $364304.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 129 156 2134.43 $115942.43 $54.32
PHY -97110 PT SESSION BY LICENSED PT 282 429 6543.97 $444204.68 $67.88
PHY -97110HM PT SESSION BY PT ASST 160 197 2896.85 $157357.01 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 34 76.99 $76.99 $1.00
SENS -FM FM RECEIVER HEARING AID 6 6 9.43 $15557.19 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 8 13.00 $6500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 4.00 $260.00 $65.00
SENS -V5264 EARMOLD 16 18 46.29 $866.56 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 5.00 $250.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 805 1220 18753.61 $1272995.17 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 19 19 151.93 $8252.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 335 415 6507.02 $85892.63 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3 3 40.00 $20.00 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 4 4 42.29 $2114.29 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 12 155.41 $7770.59 $50.00
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Subtotal (Total Children Is Unduplicated) 1925 4934 68222.40 $3693421.04 $54.14
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Total 6857 70780.43 $3860423.88 $54.54
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Number of Children (Unduplicated) With at Least One Authorization 2030