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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.07 $155.36 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $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 2 2 2.50 $138.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 36.00 $2700.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 4.50 $337.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 19 19 30.00 $1665.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 13.00 $975.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 57 72 84.14 $4080.93 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 45 46 46.00 $2231.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 63 78 84.43 $4094.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 45 45 45.00 $2182.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 177 213 214.00 $10379.00 $48.50
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Subtotal (Total Children Is Unduplicated) 284 515 571.21 $29746.88 $52.08
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 3.02 $151.24 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 74 88 121.05 $6052.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 155 192 420.10 $21005.08 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 66 157.81 $7890.36 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 53 63 134.80 $6740.01 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.30 $57.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 147 179 346.28 $17313.81 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 221 273 2154.27 $107713.25 $50.00
INTR -INTR INTERPRETER 7 9 79.00 $3950.13 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 94 118 930.65 $63172.59 $67.88
PHY -97110 PT SESSION BY LICENSED PT 102 124 1085.61 $73691.21 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 38 42 40.72 $40.72 $1.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 2 3 6.00 $112.32 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 221 1622.15 $110111.33 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 8.71 $435.72 $50.00
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Subtotal (Total Children Is Unduplicated) 408 1385 7117.47 $419165.10 $58.89
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Total 1900 7688.69 $448911.98 $58.39
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Number of Children (Unduplicated) With at Least One Authorization 413