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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 13.14 $486.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 13.14 $486.29 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 14 15.00 $727.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 25 25 24.26 $1455.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.00 $100.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 27 27 44.04 $2201.79 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 11.50 $862.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 19.50 $1082.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 141 141 194.00 $14550.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 11.00 $825.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 47 48 82.14 $6160.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 167 167 228.86 $12701.57 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 143 147 200.36 $15026.79 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 14.14 $685.93 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 13 22.14 $1073.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 17.14 $831.43 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 33.29 $1614.36 $48.50
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Subtotal (Total Children Is Unduplicated) 354 645 930.36 $60792.47 $65.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 34 35.00 $52500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 9.07 $453.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 30 31 38.14 $1907.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 13 11.88 $297.08 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 12 13 22.03 $1101.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 15 17 52.58 $1314.53 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 12.43 $621.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 11 25.01 $625.24 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 28.94 $1447.02 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 26 28 43.12 $1078.06 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 33 41 353.71 $8842.87 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 39.43 $1971.44 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 389 454 3379.46 $168973.07 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 0.14 $7.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 13.14 $657.15 $50.00
INTR -INTR INTERPRETER 37 40 290.60 $14529.90 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 95 118 885.01 $60074.54 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 129.57 $7038.33 $54.32
PHY -97110 PT SESSION BY LICENSED PT 191 240 1979.46 $134365.42 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 14 122.11 $6633.00 $54.32
RSPT -RSPT RESPITE 1 1 49.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 54 301.19 $301.19 $1.00
SENS -V5264 EARMOLD 3 3 3.76 $70.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 15.14 $757.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 503 622 5069.98 $344150.44 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 13.14 $713.92 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 40 40 366.57 $4838.74 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 4.29 $428.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 699 1156 8556.52 $4278.25 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 31.57 $1578.58 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 24.86 $1242.86 $50.00
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Subtotal (Total Children Is Unduplicated) 877 2992 21906.93 $822798.58 $37.56
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Total 3638 22850.44 $884077.34 $38.69
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Number of Children (Unduplicated) With at Least One Authorization 961