Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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
TCM -T1017TL TARGETED CASE MANAGEMENT 10 10 49.67 $1837.66 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10 10 49.67 $1837.66 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 27 30 63.07 $3784.27 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 7 42.98 $5140.14 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 10.00 $1250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 19 20 68.49 $3424.29 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 52 52 64.14 $4810.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 17.00 $1275.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 20 20 28.00 $2100.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 12 13 18.00 $999.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 77 81 108.14 $8110.72 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 51 161.71 $7843.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 12 11.52 $558.83 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 40 42 42.00 $2037.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 85 94 286.00 $13871.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 10 13 16.57 $828.57 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 271 472 957.63 $57153.32 $59.68
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 9 9.42 $14133.30 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 5.87 $403.98 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 22 29 192.46 $9622.86 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 6 7.50 $375.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 277 415 926.57 $46328.37 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 166 236 439.61 $21980.40 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.85 $146.24 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 161 230 432.76 $21637.84 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 17.33 $433.13 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 213 277 458.00 $22899.82 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 8 51.86 $3807.36 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 3 3 138.00 $3450.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 19 1683.86 $42096.43 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 5 528.29 $26414.29 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 75 76 397.06 $19853.09 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 71.00 $1775.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 380 549 10708.61 $535430.69 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 7 69.97 $3498.57 $50.00
INTR -INTR INTERPRETER 1 1 26.14 $1307.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 294 487 8508.91 $577584.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 19 19 469.39 $25497.30 $54.32
PHY -97110 PT SESSION BY LICENSED PT 278 470 9050.44 $614343.59 $67.88
PHY -97110HM PT SESSION BY PT ASST 19 20 399.78 $21716.10 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 6 8 14.86 $278.10 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 16 143.65 $7182.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 509 803 13166.28 $893727.23 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 32.71 $1777.04 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 21 21 397.36 $5245.11 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 98 152 189440.79 $94720.39 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 9.57 $478.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 15 17 187.54 $9376.92 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 864 3912 238001.41 $3029972.37 $12.73
-----------------------------------------------------------------------------------------------------------------------------
Total 4394 239008.70 $3088963.35 $12.92
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 910