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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 9.00 $333.00 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 9.00 $333.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 14 15.00 $727.50 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 6.71 $72.51 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 7.71 $419.50 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 6.71 $213.58 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 50 51 54.00 $3240.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 11.51 $538.46 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 26 26 31.01 $3708.93 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.00 $500.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 17.00 $850.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 156 170 324.25 $16212.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 56 57 114.00 $8550.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 41 41 82.50 $6187.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 30 30 60.00 $3330.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 465 479 958.50 $71887.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 57 114.00 $8550.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 98 100 199.50 $14962.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 388 394 787.50 $43706.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 192 193 384.50 $28837.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 17 23.29 $1129.36 $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 19 19 29.14 $1413.43 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.00 $30.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 46 46 132.32 $6417.47 $48.50
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Subtotal (Total Children Is Unduplicated) 925 1726 3380.16 $222476.99 $65.82
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 34 36.00 $54000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 29 32 100.33 $5016.27 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 140 153 238.26 $11912.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 36 41 40.46 $1011.49 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 46 53 98.62 $4931.10 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 43 52 115.67 $2891.66 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 12 26.12 $1306.11 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 10 27.97 $699.16 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 40 73.95 $3697.37 $50.00
CONPP -CONPP CONSULT, PT, PHONE 23 24 54.20 $1355.05 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 52 119.41 $5970.30 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 49 57 112.87 $2821.69 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 13.00 $325.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 66 85 702.57 $17564.30 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 7 7 62.86 $1571.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1216 1519 11642.49 $582124.55 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 57.00 $2850.00 $50.00
INTR -INTR INTERPRETER 142 197 821.33 $41066.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 99 131 1073.10 $72842.35 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.57 $628.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 291 359 3170.61 $215221.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 12 125.21 $6801.64 $54.32
RSPT -RSPT RESPITE 1 2 48.53 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 130 139 153.67 $153.67 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 10.00 $5000.00 $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 2 2 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 22 25 49.37 $924.21 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 11 63.60 $3180.24 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 557 729 6141.61 $416892.38 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 35 40 390.90 $5159.85 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 4 35.14 $3514.28 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1644 2713 21011.73 $10505.86 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 52.71 $2635.72 $50.00
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Subtotal (Total Children Is Unduplicated) 1846 6567 46699.86 $1491867.63 $31.95
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Total 8296 50089.02 $1714677.62 $34.23
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Number of Children (Unduplicated) With at Least One Authorization 2097