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: 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.00 $74.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 6 10.77 $646.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 6.04 $722.91 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 107 115 275.43 $13771.43 $50.00
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 31 31 62.00 $3441.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 133 133 266.00 $19950.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 50.00 $3750.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 58 58 116.00 $8700.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 135 135 270.00 $14985.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 18 36.00 $2700.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 47 49 74.78 $3626.87 $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 20 20 21.00 $1018.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 46 59.81 $2900.99 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 359 645 1256.83 $76622.18 $60.96
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 58 69 94.00 $141000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 111.37 $5568.41 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 558 1230 2481.82 $124091.19 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 567 632 1298.46 $64922.85 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 228 251 519.46 $25972.85 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 8 15.00 $375.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 304 339 689.43 $34471.66 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 458 506 1026.36 $51317.85 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 11 22.00 $550.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 12 12 115.63 $2890.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 38 459.01 $11475.36 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 51 56 519.44 $25972.18 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 32.86 $821.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 466 505 4484.32 $224216.24 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 13.14 $657.15 $50.00
INTR -INTR INTERPRETER 10 11 52.43 $2621.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 116 126 752.86 $51104.11 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 93.00 $5051.75 $54.32
PHY -97110 PT SESSION BY LICENSED PT 173 204 1052.00 $71409.74 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 16 76.92 $4178.48 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 62 62 92.30 $92.30 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 2 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.19 $77.47 $65.00
SENS -V5264 EARMOLD 7 7 17.53 $328.22 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 309 346 2365.85 $160593.56 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.86 $263.84 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 32 32 316.81 $4181.89 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 4 102.14 $10214.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 601 884 13043.38 $6521.69 $0.50
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Subtotal (Total Children Is Unduplicated) 673 5381 29858.58 $1032491.65 $34.58
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Total 6027 31117.42 $1109187.83 $35.65
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Number of Children (Unduplicated) With at Least One Authorization 702