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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 3 3 43.43 $1606.85 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
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Subtotal (Total Children Is Unduplicated) 5 5 50.64 $1873.78 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 13 15.00 $727.50 $48.50
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 57 58 58.08 $3484.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 9.01 $421.72 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 20 21 25.00 $2990.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 7.64 $382.15 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 98 103 202.04 $10101.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.00 $300.00 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 34 34 55.50 $4162.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 8.50 $637.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 17.50 $1312.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 31 31 51.50 $3862.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 31 31 54.30 $3013.65 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 351 351 601.50 $45112.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 74 74 126.50 $9487.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 59 59 99.86 $7489.29 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 307 307 532.71 $29565.64 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 265 265 439.21 $32941.07 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 8.29 $401.86 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 19 46.29 $2244.86 $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 17 18 18.00 $873.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 4 4.00 $60.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 42 43 72.29 $3505.86 $48.50
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Subtotal (Total Children Is Unduplicated) 776 1475 2464.71 $163335.63 $66.27
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 37 46 54.00 $81000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 25 28 73.89 $3694.53 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 95 105 160.06 $8003.10 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 42 49 39.94 $998.40 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 38 44 68.90 $3445.18 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 27 32 52.10 $1302.57 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 14.56 $727.92 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 16.95 $423.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 24 46.35 $2317.57 $50.00
CONPP -CONPP CONSULT, PT, PHONE 13 14 24.57 $614.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 78 164.78 $8238.88 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 58 66 127.38 $3184.62 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 56 66 576.50 $14412.52 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.14 $307.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 27.29 $682.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1032 1252 9794.12 $489706.25 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 34.00 $1700.00 $50.00
INTR -INTR INTERPRETER 114 139 932.25 $46612.66 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 122 159 1182.79 $80287.89 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 19.79 $1074.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 302 405 3167.41 $215003.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 13 89.57 $4865.53 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 135 150 171.36 $171.36 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 9.00 $4500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 8.00 $520.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 4 4 4.00 $456.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 6 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 22 25 42.25 $791.00 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 13 45.48 $2274.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 765 1007 7933.87 $538550.81 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 59 66 562.41 $7423.78 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 10.00 $1000.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1589 2616 20467.95 $10233.94 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 48.00 $2400.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1812 6458 46003.67 $1542595.66 $33.53
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Total 7938 48519.02 $1707805.08 $35.20
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Number of Children (Unduplicated) With at Least One Authorization 1962