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: 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 3.96 $146.56 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 3.96 $146.56 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 21.98 $1318.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 34.43 $4303.59 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 85 128 221.50 $16612.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 6.00 $436.68 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 16 17 15.51 $752.29 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 108 117 119.67 $5804.02 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 18 19 18.11 $878.12 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 89 94 75.77 $3675.07 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 326 338 319.84 $15512.45 $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) 500 748 846.81 $49959.97 $59.00
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 9.00 $13500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 20 20 43.34 $2166.90 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 12 17.21 $860.71 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 4.28 $107.08 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 19 30.48 $1523.94 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 4.82 $120.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 31 46.75 $2337.27 $50.00
CONOP -CONOP CONSULT, OT, PHONE 10 12 20.13 $503.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 28 46.75 $2337.26 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 8 11.55 $288.76 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 35 51.22 $2560.81 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 15 29.48 $736.97 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 9 9 147.71 $1846.43 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 3.86 $192.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 13.57 $339.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 595 729 5386.88 $269343.91 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 15 122.17 $6108.59 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 180 212 1670.14 $113368.88 $67.88
OCCT -97530HM OT SESSION BY OT ASST 56 68 397.85 $21610.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 196 243 1989.09 $135019.59 $67.88
PHY -97110HM PT SESSION BY PT ASST 66 72 500.50 $27186.90 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 34 57.17 $57.17 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5264 EARMOLD 9 9 20.72 $387.92 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 549 665 5842.62 $396596.75 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 48.79 $2650.04 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 134 141 1232.98 $16275.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 41.75 $2087.74 $50.00
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Subtotal (Total Children Is Unduplicated) 1232 2413 17798.79 $1025545.82 $57.62
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Total 3164 18649.57 $1075652.35 $57.68
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Number of Children (Unduplicated) With at Least One Authorization 1272