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: 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 4.17 $154.17 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 4.17 $154.17 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 13 10.24 $614.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 15.17 $1813.75 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 6 22.50 $1125.00 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 21.00 $1575.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 6 6 10.00 $750.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 21 22 38.00 $2850.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 24.14 $1170.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 19 19.00 $921.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 38 40 160.29 $7773.87 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 103 154 345.34 $20295.87 $58.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.02 $1533.30 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 10 60.83 $3041.68 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.50 $125.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 167 192 339.96 $16998.19 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 117 135 221.93 $11096.51 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.78 $69.45 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 113 130 202.57 $10128.38 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.62 $115.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 155 181 280.02 $14000.93 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 4 16.14 $1185.21 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 110.00 $2750.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 223.43 $11171.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 10.14 $253.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 217 249 2555.04 $127751.81 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 4 10.94 $546.91 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 174 222 2023.49 $137354.52 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 27.57 $1497.68 $54.32
PHY -97110 PT SESSION BY LICENSED PT 173 210 2102.46 $142715.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 79.28 $4306.28 $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 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 4.09 $76.54 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 7 22.56 $1128.10 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 287 356 3338.28 $226602.38 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.71 $419.04 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 97.64 $1288.89 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 10 14 1837.71 $918.86 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 9 65.57 $3278.58 $50.00
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Subtotal (Total Children Is Unduplicated) 498 1765 13654.29 $721331.12 $52.83
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Total 1922 14003.80 $741781.16 $52.97
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Number of Children (Unduplicated) With at Least One Authorization 522