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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 3.32 $122.80 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 3.32 $122.80 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.43 $26.23 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 2 1.01 $22.03 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 6 6.00 $326.28 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 21 24 29.14 $1748.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 9.00 $1076.40 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 14 15 24.50 $1225.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.00 $555.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 46.00 $3450.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 15.00 $832.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 78 135.00 $10125.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 5.00 $363.90 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 2.00 $300.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 20 20.00 $970.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 114 120 138.06 $6695.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 25 27 38.51 $1867.52 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 80 82 73.55 $3567.18 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 339 361 357.65 $17346.06 $48.50
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Subtotal (Total Children Is Unduplicated) 537 796 923.85 $51037.48 $55.24
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 27 30 45.13 $2256.66 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 13 12.18 $609.17 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 0.73 $18.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 68 83 94.70 $4734.99 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 21 29.68 $742.08 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 46 50.11 $2505.36 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 7.72 $192.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 56 56.06 $2802.78 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 11 18.08 $452.09 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 81 115.45 $5772.36 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 26 28 35.62 $890.56 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 78.00 $975.00 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 22.29 $1114.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 753 932 7248.19 $362409.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 13 75.07 $3753.58 $50.00
INTR -INTR INTERPRETER 6 7 34.39 $1719.41 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 199 241 1847.60 $125414.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 34 43 343.15 $18639.79 $54.32
PHY -97110 PT SESSION BY LICENSED PT 185 232 1833.82 $124479.80 $67.88
PHY -97110HM PT SESSION BY PT ASST 35 37 363.86 $19764.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 87 96 105.78 $105.78 $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 4 4 6.00 $3000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 6.07 $1438.54 $237.12
SENS -V5264 EARMOLD 12 13 18.31 $342.78 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 565 718 5836.46 $396179.08 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 88 104 876.95 $11575.71 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 39 48 866.18 $433.09 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 80.86 $4042.86 $50.00
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Subtotal (Total Children Is Unduplicated) 1377 2887 20114.43 $1104384.95 $54.91
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Total 3685 21041.60 $1155545.24 $54.92
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Number of Children (Unduplicated) With at Least One Authorization 1401