Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 26.93 $996.36 $37.00
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Subtotal (Total Children Is Unduplicated) 5 5 26.93 $996.36 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 12 13.00 $630.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 3.00 $108.21 $36.07
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 -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.00 $43.58 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 50 51 50.82 $3049.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 19.00 $2272.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 11 16.00 $800.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 66 69 97.46 $4873.22 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 25 35.00 $2625.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 9.00 $675.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 10 15.50 $1162.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 32.50 $1803.75 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 353 356 503.50 $37762.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 31 31 42.00 $3150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 99 99 152.50 $11437.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 302 304 426.00 $23643.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 328 337 456.00 $34200.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 13.86 $672.07 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 17 17.00 $824.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 15 16.00 $776.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 38.71 $1877.64 $48.50
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Subtotal (Total Children Is Unduplicated) 724 1411 1972.86 $132966.64 $67.40
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 27 28.00 $42000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 26 31 99.39 $4969.30 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 74 83 106.83 $5341.44 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 20 20 9.59 $239.70 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 22 25 42.64 $2132.02 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 24 31 75.50 $1887.62 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 20.46 $1022.86 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 8 22.47 $561.79 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 27.08 $1354.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 18 20 50.45 $1261.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 41 61.61 $3080.37 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 60 67 82.16 $2053.94 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 72 87 1725.60 $43139.99 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 10 85.07 $4253.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 693 843 5588.89 $279444.75 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 4 16.06 $802.86 $50.00
INTR -INTR INTERPRETER 60 75 471.96 $23598.08 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 180 223 1964.00 $133316.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 112.57 $6114.87 $54.32
PHY -97110 PT SESSION BY LICENSED PT 313 395 3218.09 $218444.28 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 14 121.14 $6580.48 $54.32
RSPT -RSPT RESPITE 2 2 70.93 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 84 90 279.06 $279.06 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 16 19 34.04 $637.21 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 34.43 $1721.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 960 1241 9717.79 $659643.74 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.43 $512.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 69 79 644.65 $8509.42 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 22.57 $2257.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1370 2402 16152.01 $8076.02 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 11 103.71 $5185.71 $50.00
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Subtotal (Total Children Is Unduplicated) 1650 5908 41013.19 $1476850.28 $36.01
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Total 7324 43012.98 $1610813.27 $37.45
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Number of Children (Unduplicated) With at Least One Authorization 1792