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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 4.03 $149.23 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 4.03 $149.23 $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 14 14 11.63 $698.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.90 $88.92 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 11 27.90 $1395.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 19 19 32.00 $2400.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 5.00 $277.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 35.00 $2625.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 27 29 29.00 $1406.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 26 26.00 $1261.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 41 42 53.00 $2570.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 8.00 $400.00 $50.00
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Subtotal (Total Children Is Unduplicated) 120 187 260.43 $15408.86 $59.17
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 8.86 $609.91 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 9.00 $619.74 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 12 13 58.29 $2914.28 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 236 294 473.76 $23688.03 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.00 $75.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 131 162 242.44 $12121.91 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.00 $75.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 147 179 275.46 $13772.87 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 241 285 422.86 $21142.92 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 10.50 $262.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 13.86 $1017.39 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 6 323.00 $8075.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 435.43 $21771.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.57 $89.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 301 365 3805.23 $190261.58 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 9.10 $455.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 10 48.92 $2446.12 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 187 235 2204.93 $149670.69 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 42.29 $2296.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 210 263 2804.84 $190392.80 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 38.29 $2079.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 5.00 $2500.00 $500.00
SENS -V5264 EARMOLD 8 8 5.50 $102.96 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 6.73 $336.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 13.25 $662.38 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 363 443 4231.42 $287228.53 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.29 $395.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 52.64 $694.89 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 9 54.00 $2700.00 $50.00
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Subtotal (Total Children Is Unduplicated) 598 2334 15618.94 $938648.74 $60.10
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Total 2523 15883.41 $954206.84 $60.08
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Number of Children (Unduplicated) With at Least One Authorization 609