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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 7 7 14.00 $700.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $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 32 32 52.50 $3937.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 26.50 $1987.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 34 34 56.00 $3108.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 10.50 $787.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 55 75 75.00 $3637.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 47 49 49.00 $2376.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 66 86 90.57 $4392.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 60 61 61.00 $2958.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 192 237 238.00 $11543.00 $48.50
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Subtotal (Total Children Is Unduplicated) 307 607 681.07 $36039.91 $52.92
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 106 114 163.00 $8150.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 184 235 425.22 $21261.18 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 87 169.07 $8453.41 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 80 104 205.43 $10271.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.80 $20.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 176 225 413.98 $20699.14 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 218 294 2166.90 $108344.76 $50.00
INTR -INTR INTERPRETER 13 18 200.75 $10037.74 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 95 122 965.60 $65545.21 $67.88
PHY -97110 PT SESSION BY LICENSED PT 109 149 1279.05 $86822.06 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 96 107 107.00 $107.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 198 244 1980.25 $134419.19 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 22.14 $1107.15 $50.00
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Subtotal (Total Children Is Unduplicated) 475 1707 8106.20 $477299.82 $58.88
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Total 2314 8787.27 $513339.73 $58.42
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Number of Children (Unduplicated) With at Least One Authorization 483