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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 0.25 $9.25 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 46.57 $1723.14 $37.00
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Subtotal (Total Children Is Unduplicated) 6 6 46.82 $1732.39 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 18 21.00 $1018.50 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.00 $21.60 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 5 5.00 $271.90 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.00 $63.62 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 62 65 72.14 $4328.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 9.50 $444.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 23 24 30.33 $3627.86 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 6.25 $312.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 102 108 213.50 $10675.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 52 54 98.50 $7387.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 16.00 $1200.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 17.00 $1275.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 53 54 101.00 $7575.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 31 32 58.50 $3246.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 528 597 1121.71 $84128.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 84 90 172.00 $12900.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 124 133 244.50 $18337.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 488 554 1040.21 $57731.63 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 307 339 618.50 $46387.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.00 $145.56 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 17 27.43 $1330.28 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 22.86 $1108.57 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 44 45 73.88 $3583.23 $48.50
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Subtotal (Total Children Is Unduplicated) 963 2186 3981.81 $267358.40 $67.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 33 37 46.00 $69000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 26 30 97.49 $4874.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 107 121 171.67 $8583.46 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 23 23 33.61 $840.18 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 36 43 67.97 $3398.65 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 36 45 69.78 $1744.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 13 18.44 $922.22 $50.00
CONOP -CONOP CONSULT, OT, PHONE 11 16 23.52 $588.04 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 35 50.83 $2541.43 $50.00
CONPP -CONPP CONSULT, PT, PHONE 20 25 34.97 $874.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 64 125.91 $6295.56 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 50 60 116.23 $2905.66 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.86 $21.43 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 74 532.50 $13312.49 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.00 $450.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 7 7 68.43 $1710.71 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1106 1379 10272.47 $513623.54 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 7 46.14 $2307.14 $50.00
INTR -INTR INTERPRETER 113 164 893.55 $44677.62 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 107 139 1053.78 $71530.91 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.79 $477.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 276 362 2955.96 $200650.49 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 12 110.07 $5979.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 133 151 167.85 $167.85 $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 5 5 8.00 $4000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 7.00 $455.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 12.00 $2845.44 $237.12
SENS -V5264 EARMOLD 23 27 55.74 $1043.45 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 8 45.86 $2292.85 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 619 807 6792.50 $461074.67 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 46 47 472.11 $6231.81 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 16.29 $1628.58 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1559 2556 19826.62 $9913.33 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 13.86 $692.86 $50.00
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Subtotal (Total Children Is Unduplicated) 1768 6280 44228.80 $1451068.94 $32.81
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Total 8472 48257.43 $1720159.74 $35.65
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Number of Children (Unduplicated) With at Least One Authorization 2099