Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 8.00 $480.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 4.00 $478.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 46 50 93.00 $4650.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 2 2 4.00 $222.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 10.00 $750.00 $75.00
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 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 27 27 53.00 $2941.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 120 120 240.00 $18000.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 30 30 60.00 $4500.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 68 68 135.00 $10125.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 134 134 268.00 $14874.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.00 $600.00 $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 57 61 62.00 $3007.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 14.00 $679.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 62 66 69.53 $3372.37 $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) 309 604 1049.53 $66084.14 $62.97
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 60 72 131.00 $196500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 31.81 $1590.72 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 489 1310 2657.14 $132857.14 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 517 661 1321.73 $66086.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 239 298 596.00 $29800.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 278 357 718.20 $35910.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 439 560 1152.17 $57608.57 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 8 8 17.63 $440.84 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 73 90 266.76 $6668.97 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 37 45 350.57 $17528.55 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 438 546 4033.31 $201665.32 $50.00
INTR -INTR INTERPRETER 7 9 24.43 $1221.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 133 173 882.42 $59898.45 $67.88
PHY -97110 PT SESSION BY LICENSED PT 205 271 1398.85 $94953.67 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.64 $89.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 19.00 $19.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 3 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.25 $81.03 $65.00
SENS -V5264 EARMOLD 3 4 3.37 $63.02 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 335 434 2465.32 $167345.93 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 36.43 $480.86 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 3 14.86 $1485.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 558 930 5020.27 $2510.14 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 6.43 $321.43 $50.00
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Subtotal (Total Children Is Unduplicated) 578 5809 21158.58 $1076751.68 $50.89
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Total 6413 22208.12 $1142835.81 $51.46
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Number of Children (Unduplicated) With at Least One Authorization 599