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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 6 30.63 $1133.17 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 9 11 7.43 $274.86 $37.00
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Subtotal (Total Children Is Unduplicated) 13 17 38.05 $1408.03 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 19 20.00 $970.00 $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) 1 1 1.00 $54.38 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 73 75 74.94 $4496.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 9.00 $421.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 21 22 31.00 $3707.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 9.25 $462.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 101 121 202.25 $10112.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 26 26 40.50 $3037.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 6.50 $487.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 11 15.00 $1125.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 30 32 46.53 $2582.60 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 451 455 668.36 $50126.79 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 50 50 78.21 $5866.07 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 83 83 105.14 $7885.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 295 296 419.50 $23282.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 385 393 530.71 $39803.58 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 3 3 5.00 $750.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 14.00 $679.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 17.29 $838.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 13.00 $630.50 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 22 22 73.57 $3568.22 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.14 $7.15 $50.00
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Subtotal (Total Children Is Unduplicated) 892 1667 2395.91 $161399.24 $67.36
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 29 31.00 $46500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 31 37 75.77 $3788.58 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 94 109 136.70 $6835.24 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 16 12.07 $301.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 40 45 54.20 $2710.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 21 23 62.84 $1570.95 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 10 17.12 $855.83 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 7 27.80 $695.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 36 43.21 $2160.36 $50.00
CONPP -CONPP CONSULT, PT, PHONE 17 17 39.93 $998.34 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 51 76.45 $3822.49 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 49 52 99.52 $2488.05 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 74 88 1434.42 $35860.54 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 6 71.43 $3571.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 827 967 7087.15 $354357.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 4 29.03 $1451.67 $50.00
INTR -INTR INTERPRETER 102 117 801.49 $40074.63 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 167 224 1771.41 $120243.58 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 9 55.71 $3026.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 321 412 3245.06 $220274.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 13 95.50 $5187.55 $54.32
RSPT -RSPT RESPITE 2 2 97.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 85 90 169.97 $169.97 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 10.00 $5000.00 $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 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 17 20 38.54 $721.47 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 12 53.28 $2664.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 983 1231 10096.71 $685364.54 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 47 50 365.61 $4826.01 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 13.29 $1328.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1537 2641 18908.13 $9454.06 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 10 76.71 $3835.71 $50.00
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Subtotal (Total Children Is Unduplicated) 1823 6346 45113.13 $1579288.99 $35.01
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Total 8030 47547.09 $1742096.27 $36.64
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Number of Children (Unduplicated) With at Least One Authorization 1998