Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 11 13.31 $798.67 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 10.00 $500.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 32 38 61.00 $3050.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 9.00 $675.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 11.00 $610.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 36 36 44.00 $2442.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 149 151 205.00 $15375.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 48 48 60.00 $4500.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 100 101 128.00 $9600.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 102 103 151.00 $8380.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 106 107 130.00 $9750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 64 72 72.00 $3492.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 35 36 36.00 $1746.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 65 79 79.00 $3831.50 $48.50
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Subtotal (Total Children Is Unduplicated) 354 817 1021.31 $65539.74 $64.17
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 42 60 81.00 $121500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 6 32.58 $1629.05 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 380 1370 2761.86 $138092.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 405 733 1508.61 $75430.48 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 202 350 699.00 $34950.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 240 427 853.00 $42650.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 334 565 1151.00 $57550.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 14 14 60.67 $1516.66 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 12 12 23.12 $577.98 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 46 62 253.14 $6328.51 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 54 72 1153.86 $57692.87 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 84 84 553.13 $27656.68 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 306 511 7797.63 $389881.73 $50.00
INTR -INTR INTERPRETER 17 28 84.93 $4246.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 126 221 2440.67 $165672.93 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.36 $19.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 205 367 3486.51 $236664.36 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.29 $721.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 7.00 $7.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 3 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 0.55 $35.44 $65.00
SENS -V5264 EARMOLD 3 5 12.27 $229.63 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 271 442 4638.82 $314883.04 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 87.93 $1160.66 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 6 19.85 $1984.76 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 478 1145 2831.92 $1415.96 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 4 62.21 $3110.72 $50.00
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Subtotal (Total Children Is Unduplicated) 508 6505 30619.90 $1687158.79 $55.10
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Total 7322 31641.21 $1752698.54 $55.39
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Number of Children (Unduplicated) With at Least One Authorization 514