Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 3.79 $103.07 $27.23
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 11 10.70 $642.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 7.00 $837.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 11.00 $1375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 40 48 48.00 $2400.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 192 262 278.43 $13503.79 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 79 103 103.00 $4995.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 40 40 40.00 $2000.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 276 346 365.76 $17739.22 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 490 845 886.89 $44547.58 $50.23
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 21 24.00 $36000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 14 20 37.23 $1861.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 10.82 $540.83 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 197 314 844.11 $42205.70 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 111 168 403.65 $20182.75 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 95 163 425.66 $21283.20 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 214 348 854.22 $42711.14 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 19.45 $486.37 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 11.43 $571.43 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 47 47 447.62 $22381.18 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 5 62.29 $1557.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 400 795 8510.15 $425507.64 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 42.29 $2114.29 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 235 408 4881.92 $331384.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.11 $168.78 $54.32
PHY -97110 PT SESSION BY LICENSED PT 265 518 5283.93 $358673.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 8.94 $485.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 5.61 $5.61 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 5.00 $2500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 4 8 20.70 $387.50 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 29.71 $1485.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 700 1325 11897.69 $807615.05 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 41 46 478.76 $6319.60 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 716 1731 1503683.91 $751841.96 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 4 4 30.36 $1518.22 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 20 35 179.43 $8971.67 $50.00
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Subtotal (Total Children Is Unduplicated) 1018 5991 1538207.32 $2889367.82 $1.88
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Total 6838 1539097.99 $2934018.48 $1.91
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Number of Children (Unduplicated) With at Least One Authorization 1046