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: 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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 21 25 26.98 $1618.58 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 25.14 $3142.86 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 3.00 $150.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 13 14 23.00 $1725.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 6.50 $487.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 14.00 $777.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 75 108 166.00 $12450.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.00 $300.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 20 20.00 $970.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 126 134 132.64 $6433.27 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 19 19 19.00 $921.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 96 105 99.87 $4843.84 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 347 372 379.27 $18394.66 $48.50
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Subtotal (Total Children Is Unduplicated) 559 827 928.41 $53088.45 $57.18
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 27 27 33.34 $1667.15 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 18 22.37 $1118.61 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 9.96 $248.96 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 25 30 60.59 $3029.61 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 3 1.73 $43.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 44 87.30 $4364.99 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 5.37 $134.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 32 49.88 $2494.06 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 8 13.37 $334.16 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 59 99.04 $4952.13 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 13 24.17 $604.28 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 9 10 196.00 $2450.00 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 28.57 $1428.57 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.43 $21.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.71 $117.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 647 768 6080.41 $304020.32 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 17 17 125.86 $6292.86 $50.00
INTR -INTR INTERPRETER 1 2 5.93 $296.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 218 291 2287.68 $155287.47 $67.88
OCCT -97530HM OT SESSION BY OT ASST 30 36 208.88 $11346.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 240 304 2604.69 $176806.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 41 49 309.92 $16834.81 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 92 97 115.18 $115.18 $1.00
SENS -FM FM RECEIVER HEARING AID 4 4 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 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 12 12 11.88 $222.35 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 609 750 6175.78 $419212.02 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 4 27.71 $1505.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 95 108 870.66 $11492.71 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 1.10 $0.55 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 9 66.10 $3305.24 $50.00
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Subtotal (Total Children Is Unduplicated) 1385 2725 19544.62 $1144921.76 $58.58
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Total 3552 20473.03 $1198010.20 $58.52
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Number of Children (Unduplicated) With at Least One Authorization 1405