Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 Page: 1
Child has a MEDICAID # Filter: Y
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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 33 46.14 $2237.93 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
EVAL -EVAL DEVELOPMENTAL EVALUATION 198 223 243.71 $12185.40 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 198 239 258.44 $12534.25 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 181 227 242.14 $11743.94 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 243 286 313.49 $15204.29 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 13.14 $657.15 $50.00
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Subtotal (Total Children Is Unduplicated) 589 1012 1120.07 $54699.02 $48.84
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 16 16 18.07 $903.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 361 478 935.45 $46772.57 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 161 214 408.43 $20421.75 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 100 134 249.33 $12466.35 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 217 262 472.53 $23626.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.23 $30.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 17.00 $1248.03 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 150 223 902.73 $22568.28 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 13.14 $657.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 5.14 $128.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 669 949 7049.93 $352496.38 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 261 357 1581.51 $107353.00 $67.88
PHY -97110 PT SESSION BY LICENSED PT 290 420 2011.81 $136561.87 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.14 $713.92 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 27 21.97 $21.97 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 24 58.02 $2901.19 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 324 411 1792.65 $121685.22 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 551 805 2796.31 $1398.15 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 14 21 71.92 $3596.20 $50.00
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Subtotal (Total Children Is Unduplicated) 934 4356 18421.83 $855594.80 $46.44
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Total 5368 19541.89 $910293.83 $46.58
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Number of Children (Unduplicated) With at Least One Authorization 977