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: 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 3 5.00 $185.00 $37.00
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Subtotal (Total Children Is Unduplicated) 2 3 5.00 $185.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 22 22 19.71 $1182.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 5.08 $607.30 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 6 17.57 $878.58 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 15.00 $1125.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.00 $300.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 11 20.00 $1500.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 25.14 $1219.43 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 13.14 $637.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 20 21 32.86 $1593.57 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 41 43 120.29 $5833.86 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 102 150 290.79 $15884.37 $54.63
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.66 $983.40 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 16 68.86 $3442.86 $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 227 272 455.30 $22765.04 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.00 $75.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 140 167 265.40 $13270.11 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.00 $75.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 139 166 246.49 $12324.28 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.00 $75.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 200 236 372.29 $18614.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.50 $187.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 5 11.71 $860.06 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 5 266.71 $13335.71 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.86 $96.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 286 347 3509.28 $175463.97 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 3 3 8.00 $399.76 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 28.92 $1446.03 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 192 243 2282.23 $154917.59 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.29 $124.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 201 250 2549.79 $173079.68 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 62.29 $3383.36 $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 2 3 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 7 9 5.42 $101.51 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.00 $50.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 8 22.28 $1114.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 329 405 3966.19 $269224.64 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.86 $698.40 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 54.86 $724.11 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 13 71.43 $3571.42 $50.00
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Subtotal (Total Children Is Unduplicated) 576 2185 14298.09 $873105.83 $61.06
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Total 2338 14593.88 $889175.21 $60.93
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Number of Children (Unduplicated) With at Least One Authorization 585