Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 1 1 11.14 $412.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 11.14 $412.29 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 137 145 156.22 $9373.42 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 12 12.00 $561.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 28 29 30.00 $3588.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 6 11.00 $1375.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 19.71 $2464.29 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 33 36 42.00 $2100.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 7.00 $525.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 7.07 $530.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 7 9.07 $680.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 12.50 $693.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 13.14 $985.72 $75.00
NURS -NURS NURSING ASSESSMENT 1 1 4.80 $240.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 27 29 36.14 $1752.93 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 83 92 92.00 $4462.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 26 29 43.57 $2113.22 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 36 37 37.00 $1794.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 206 221 223.00 $10815.50 $48.50
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Subtotal (Total Children Is Unduplicated) 439 677 760.73 $44300.49 $58.23
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 12.00 $826.32 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 26 27 63.95 $3197.39 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 13 22.27 $1113.73 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.60 $65.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 189 224 441.32 $22066.04 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 15 17 18.92 $473.06 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 117 141 256.71 $12835.53 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 7 6.43 $160.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 57 104.84 $5241.93 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 5 4.54 $113.61 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 252 305 541.14 $27056.89 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 14 19.27 $481.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.57 $482.14 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 13.14 $657.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 517 653 5809.73 $290486.28 $50.00
INTR -INTR INTERPRETER 27 33 248.02 $12400.96 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 261 333 2899.44 $196813.85 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 13 78.34 $4255.58 $54.32
PHY -97110 PT SESSION BY LICENSED PT 182 236 1862.47 $126424.51 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 15 105.42 $5726.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 48 50 57.09 $57.09 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 8.00 $4000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 16 17 26.58 $497.56 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 21 26 117.02 $5851.21 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 417 545 4558.86 $309455.41 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.36 $291.00 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 16 16 104.75 $1382.70 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 832 1594 804401.82 $402200.90 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 14 15 110.06 $5502.85 $50.00
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Subtotal (Total Children Is Unduplicated) 977 4368 821940.66 $1440591.65 $1.75
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Total 5046 822712.54 $1485304.43 $1.81
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Number of Children (Unduplicated) With at Least One Authorization 982