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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
EXIT -EXIT TRANSITION ASSESSMENT 2 2 4.00 $200.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $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 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 34 34 57.50 $4312.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 13 13 19.00 $1425.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 15.00 $1125.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 38 38 66.50 $3690.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 6.50 $487.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 56 73 80.43 $3900.79 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 34 34 34.00 $1649.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 62 81 92.86 $4503.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 50 50 50.00 $2425.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 181 221 222.00 $10767.00 $48.50
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Subtotal (Total Children Is Unduplicated) 286 565 659.79 $35372.31 $53.61
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.94 $96.99 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 83 90 132.00 $6600.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 162 193 372.25 $18612.27 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 65 142.57 $7128.69 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 75 152.67 $7633.27 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 3.00 $75.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 154 181 341.13 $17056.44 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 215 264 2017.43 $100871.33 $50.00
INTR -INTR INTERPRETER 9 13 49.65 $2482.26 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 83 107 876.62 $59505.09 $67.88
PHY -97110 PT SESSION BY LICENSED PT 103 132 1058.86 $71875.18 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 71 73 71.81 $71.81 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 2 2 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 191 239 1639.67 $111300.87 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 15.79 $789.29 $50.00
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Subtotal (Total Children Is Unduplicated) 425 1443 6884.37 $406197.58 $59.00
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Total 2008 7544.16 $441569.88 $58.53
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Number of Children (Unduplicated) With at Least One Authorization 441