Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 36 37 12.71 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 13 9.00 $333.00 $37.00
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Subtotal (Total Children Is Unduplicated) 42 50 21.71 $333.00 $15.34
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 11.00 $396.77 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 48 48 48.00 $2880.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 13.00 $1554.80 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 21 21 20.80 $2600.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 18 18 18.00 $2250.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 9 9 9.00 $270.00 $30.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 5.50 $412.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 188 204 206.03 $9992.62 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 193 218 218.00 $10573.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 7 7 7.00 $350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 639 717 746.58 $36209.22 $48.50
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Subtotal (Total Children Is Unduplicated) 824 1273 1305.92 $67785.70 $51.91
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 29 29 27.17 $1358.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 3.03 $151.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 744 906 1818.24 $90912.04 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 63 70 140.72 $3517.90 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 29.99 $1499.44 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.03 $75.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 11.70 $585.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 702 852 1679.89 $83994.48 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 62 67 143.65 $3591.23 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 34 36 420.92 $30904.22 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 72.86 $1821.43 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 10.29 $257.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 822 1010 8361.69 $418084.63 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 10.43 $521.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 170 202 977.86 $66376.95 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 26.00 $1412.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 197 237 1255.07 $85194.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 34.29 $1862.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.02 $0.42 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 19 21 170.50 $8524.76 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 639 754 3900.87 $264790.84 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 31 31 166.86 $2202.51 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 16.30 $1630.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 889 1289 27040.02 $13520.01 $0.50
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Subtotal (Total Children Is Unduplicated) 1179 5551 46324.39 $1083291.24 $23.38
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Total 6874 47652.01 $1151409.94 $24.16
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Number of Children (Unduplicated) With at Least One Authorization 1214