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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 11.86 $438.71 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 11.86 $438.71 $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) 3 3 3.00 $163.14 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 15 15 15.00 $900.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 13.00 $1554.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.29 $535.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 0.29 $14.29 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 10 12 18.00 $900.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 4 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 33 33 57.50 $4312.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 3.50 $262.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 25 43.00 $2386.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 68 101 172.00 $12900.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 4.00 $291.12 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 19 19.00 $921.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 113 116 129.20 $6266.04 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 28 33 33.75 $1636.99 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 88 94 88.70 $4301.91 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 324 351 318.80 $15461.95 $48.50
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Subtotal (Total Children Is Unduplicated) 538 831 939.02 $53656.24 $57.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.00 $6000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 20 21 31.10 $1554.77 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 10 12.58 $629.17 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 3.73 $93.33 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 55 66 78.43 $3921.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 17 17 26.40 $660.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 40 36.20 $1810.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 8 15.57 $389.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 47 44.45 $2222.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 14 14 29.89 $747.20 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 73 88.13 $4406.31 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 23 24 46.39 $1159.70 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 110.43 $1380.36 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.43 $471.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 705 873 6672.17 $333608.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 15 92.80 $4639.76 $50.00
INTR -INTR INTERPRETER 4 5 21.00 $1050.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 194 236 1835.26 $124577.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 31 36 294.98 $16023.10 $54.32
PHY -97110 PT SESSION BY LICENSED PT 194 249 1956.97 $132839.15 $67.88
PHY -97110HM PT SESSION BY PT ASST 29 36 305.29 $16583.11 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 81 89 93.63 $93.63 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 9.00 $4500.00 $500.00
SENS -V5264 EARMOLD 12 14 18.00 $336.96 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 553 671 5792.04 $393163.38 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 53.14 $2886.72 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 101 118 907.08 $11973.39 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 19 22 2753.00 $1376.50 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 2 7.43 $371.43 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 8 80.77 $4038.57 $50.00
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Subtotal (Total Children Is Unduplicated) 1329 2725 21433.26 $1078526.05 $50.32
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Total 3558 22384.14 $1132621.00 $50.60
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Number of Children (Unduplicated) With at Least One Authorization 1340