Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 11.14 $412.29 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 11.14 $412.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 16 32.94 $1976.48 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.43 $553.58 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 30.43 $3803.58 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 76 107.50 $8062.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 12.00 $582.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 110 118 119.20 $5781.35 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 16 17 17.00 $824.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 79 85 68.40 $3317.59 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 353 369 374.05 $18141.57 $48.50
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Subtotal (Total Children Is Unduplicated) 508 718 788.46 $44501.61 $56.44
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 6.40 $9600.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 22 22 34.83 $1741.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 11 12.90 $645.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.58 $114.58 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 25 54.87 $2743.28 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 4.62 $115.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 36 61.75 $3087.74 $50.00
CONOP -CONOP CONSULT, OT, PHONE 10 11 21.23 $530.84 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 30 50.85 $2542.45 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 8 15.68 $392.09 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 45 56.53 $2826.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 17 21 41.60 $1039.89 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 7 8 130.71 $1633.93 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 58.43 $2921.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 12.86 $321.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 607 728 5359.64 $267981.92 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 18 20 150.86 $7542.85 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 202 235 1998.30 $135644.31 $67.88
OCCT -97530HM OT SESSION BY OT ASST 39 45 279.54 $15184.39 $54.32
PHY -97110 PT SESSION BY LICENSED PT 222 268 2230.42 $151401.02 $67.88
PHY -97110HM PT SESSION BY PT ASST 40 50 365.78 $19869.22 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 66 68 92.53 $92.53 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 9 9 16.62 $311.17 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 584 708 6161.66 $418253.54 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 17.43 $946.72 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 124 137 1113.46 $14697.69 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 66.36 $3317.86 $50.00
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Subtotal (Total Children Is Unduplicated) 1294 2520 18428.43 $1072499.58 $58.20
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Total 3240 19228.04 $1117413.48 $58.11
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Number of Children (Unduplicated) With at Least One Authorization 1317