Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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 -AUDE UNSPECIFIED AUDE SERVICES 5 5 10.24 $614.29 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 9.83 $460.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 14 22 29.07 $2010.18 $69.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 17 23.97 $1198.38 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 17 21.00 $1050.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 27 42.62 $2130.78 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 4.99 $124.79 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 53 79.74 $3986.96 $50.00
CONOP -CONOP CONSULT, OT, PHONE 9 10 11.61 $290.21 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 32 45.71 $2285.60 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 8 11.33 $283.34 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 52 68.73 $3436.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 10 11.80 $295.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 53 69 1135.71 $28392.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 189 240 1687.69 $84384.45 $50.00
INTR -INTR INTERPRETER 16 22 80.00 $4000.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 86 105 576.55 $39136.28 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 9 54.12 $2940.01 $54.32
PHY -97110 PT SESSION BY LICENSED PT 150 198 1225.41 $83181.07 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 34.00 $1846.89 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 16 18.13 $18.13 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 7.00 $3500.00 $500.00
SENS -V5264 EARMOLD 7 7 3.01 $56.37 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 261 334 2086.94 $141661.70 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 27 27 138.50 $1828.20 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.63 $163.33 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 24.00 $1200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 514 1290 7404.21 $416490.87 $56.25
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Total 1312 7433.28 $418501.06 $56.30
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Number of Children (Unduplicated) With at Least One Authorization 514