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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 7 7.28 $436.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 79 80 148.00 $7400.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.00 $450.00 $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 3 3 6.00 $450.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.00 $333.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 25 25 50.00 $2775.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 152 153 306.00 $22950.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 36 72.00 $5400.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 75 77 154.00 $11550.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 166 166 332.00 $18426.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 17 33.00 $2475.00 $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 58 62 67.57 $3277.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.00 $727.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 0.30 $15.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 58 61 66.00 $3201.00 $48.50
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Subtotal (Total Children Is Unduplicated) 375 719 1284.15 $81099.38 $63.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 65 76 160.00 $240000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 8 30.59 $1529.68 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 544 1449 2899.07 $144953.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 555 712 1425.13 $71256.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 248 313 624.00 $31200.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 310 397 801.13 $40056.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 473 598 1202.27 $60113.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 14.00 $350.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 8.33 $208.33 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 75 87 397.85 $9946.32 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 26 26 192.14 $9607.14 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 473 595 4227.57 $211378.26 $50.00
INTR -INTR INTERPRETER 8 11 32.00 $1600.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 148 180 1044.35 $70890.46 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.07 $58.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 211 272 1489.60 $101114.04 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 21.93 $1191.16 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 18 21.40 $21.40 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.02 $1511.10 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.25 $81.20 $65.00
SENS -V5264 EARMOLD 3 4 4.94 $92.56 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 364 459 2740.02 $185992.65 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 13 14 85.71 $1131.43 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 15.00 $1500.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 623 1004 6377.16 $3188.58 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.86 $42.86 $50.00
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Subtotal (Total Children Is Unduplicated) 652 6249 23823.40 $1189090.37 $49.91
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Total 6968 25107.55 $1270189.75 $50.59
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Number of Children (Unduplicated) With at Least One Authorization 673