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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 33.43 $1236.86 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 33.43 $1236.86 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 24 24 24.00 $1440.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 32.29 $1510.97 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 13.00 $1554.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 8 8 11.75 $587.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.50 $112.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 38 38 60.00 $4500.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 26 28 45.00 $2497.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 56 76 123.50 $9262.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 5 5 7.00 $509.46 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 13.00 $630.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 126 134 153.60 $7449.60 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 23 24 23.02 $1116.58 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 101 108 101.92 $4942.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 345 375 347.46 $16852.04 $48.50
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Subtotal (Total Children Is Unduplicated) 587 859 970.04 $53856.35 $55.52
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 7.00 $10500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 19 20 23.62 $1180.87 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 11 13.93 $696.54 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 7 8.05 $201.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 37 45 50.30 $2515.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 13 13 22.28 $557.08 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 38 34.78 $1739.06 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 7 12.28 $307.09 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 35 35.62 $1780.85 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 10 31.81 $795.24 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 57 69.39 $3469.48 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 21 21 53.98 $1349.41 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 12 12 176.14 $2201.78 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 7.14 $178.57 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.14 $203.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 665 828 6477.37 $323868.61 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 14 14 104.74 $5236.93 $50.00
INTR -INTR INTERPRETER 2 3 8.87 $443.33 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 204 259 1998.63 $135667.26 $67.88
OCCT -97530HM OT SESSION BY OT ASST 31 35 270.63 $14700.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 213 261 2165.37 $146985.59 $67.88
PHY -97110HM PT SESSION BY PT ASST 34 36 284.65 $15462.19 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 88 96 104.67 $104.67 $1.00
SENS -FM FM RECEIVER HEARING AID 8 8 8.00 $13200.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 8.00 $4000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 11 12 13.52 $253.14 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 575 719 6060.33 $411375.23 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 9 9 77.29 $4198.18 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 97 105 918.93 $12129.87 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 12 12 2454.95 $1227.48 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.00 $50.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 8 73.60 $3680.01 $50.00
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Subtotal (Total Children Is Unduplicated) 1332 2699 21589.03 $1120852.16 $51.92
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Total 3560 22592.50 $1175945.37 $52.05
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Number of Children (Unduplicated) With at Least One Authorization 1360