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: 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 28 31.86 $1545.07 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 169 188 268.30 $13414.77 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 216 256 282.35 $13694.10 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 182 213 255.46 $12389.90 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 270 307 361.87 $17550.77 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 7.57 $378.57 $50.00
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Subtotal (Total Children Is Unduplicated) 603 996 1211.41 $59309.17 $48.96
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 16.57 $828.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 267 337 656.54 $32826.79 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 139 285.09 $14254.35 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 89 198.96 $9948.15 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 163 197 368.93 $18446.26 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 14.25 $1046.06 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 128 161 982.79 $24569.66 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 5.43 $271.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 689 868 7085.94 $354296.97 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 298 380 2093.30 $142092.98 $67.88
PHY -97110 PT SESSION BY LICENSED PT 309 400 2389.42 $162194.16 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 41 47 32.11 $32.11 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 3 3 3.36 $62.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 20 25 77.43 $3871.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 354 441 2320.75 $157532.56 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 3 3 24.00 $2400.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 562 776 3956.01 $1978.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 13 84.08 $4203.81 $50.00
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Subtotal (Total Children Is Unduplicated) 957 3905 20598.94 $932856.10 $45.29
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Total 4901 21810.35 $992165.27 $45.49
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Number of Children (Unduplicated) With at Least One Authorization 999