Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 03
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: 01/01/08 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 138 152 187.60 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 138 152 187.60 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 5.00 $250.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.07 $230.36 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.57 $42.86 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.50 $360.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 33 33 57.50 $4312.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 41.50 $3112.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 14.00 $1050.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 50 50 85.00 $4717.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 20.50 $1537.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 105 191 216.25 $10488.28 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 95 97 97.00 $4704.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 126 212 218.43 $10593.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 110 113 113.00 $5480.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 324 518 519.00 $25171.50 $48.50
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Subtotal (Total Children Is Unduplicated) 481 1276 1403.32 $72680.93 $51.79
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 3.09 $154.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 134 165 228.05 $11402.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 238 397 1623.80 $81190.20 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 127 584.68 $29234.16 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 84 122 504.12 $25206.23 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.30 $57.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 237 366 1312.07 $65603.47 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 70 71 417.48 $20873.82 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 344 591 8207.63 $410381.30 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.40 $120.00 $50.00
INTR -INTR INTERPRETER 27 50 309.20 $15459.97 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 156 286 3574.13 $242611.89 $67.88
PHY -97110 PT SESSION BY LICENSED PT 190 336 4475.66 $303807.61 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 38 42 45.99 $45.99 $1.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 5 7 11.00 $205.92 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 323 530 6434.48 $436772.52 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 10 152.49 $7624.60 $50.00
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Subtotal (Total Children Is Unduplicated) 645 3111 27898.57 $1653291.67 $59.26
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Total 4539 29489.50 $1725972.60 $58.53
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Number of Children (Unduplicated) With at Least One Authorization 656