Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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 3 3 5.00 $185.00 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 5.00 $185.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 12 11.24 $674.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 9 10.00 $1196.00 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 8 27.00 $1350.01 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 4.00 $300.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.00 $750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 36 37.00 $1794.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 24 24.00 $1164.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 58 59 83.71 $4060.14 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 123 172 226.96 $12855.18 $56.64
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 9.57 $659.09 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 25.86 $1780.52 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 12 15 47.01 $2350.65 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 235 291 477.97 $23898.39 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.50 $37.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 103 130 201.35 $10067.62 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.50 $112.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 127 155 223.86 $11192.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 6.22 $155.56 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 218 252 375.52 $18776.06 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 11 11 18.00 $450.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.00 $146.84 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 11 131.00 $3275.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 7 516.00 $25800.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.03 $51.67 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.29 $482.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 329 390 3270.61 $163530.49 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 3 4 8.77 $438.33 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 14.52 $726.19 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 163 214 1854.46 $125880.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.43 $1218.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 189 245 2203.08 $149545.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 12.86 $698.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 6 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 9 12 10.06 $188.24 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 6 8 37.39 $1869.53 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.97 $148.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 356 445 3893.07 $264261.28 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 30.07 $396.94 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 8.23 $411.67 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 57.73 $2886.66 $50.00
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Subtotal (Total Children Is Unduplicated) 596 2239 13499.93 $816361.69 $60.47
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Total 2414 13731.89 $829401.87 $60.40
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Number of Children (Unduplicated) With at Least One Authorization 605