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: 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 -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.70 $42.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 10 16 14.70 $998.60 $67.93
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 16 32.18 $1608.88 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 20 22.00 $1100.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 12 24.83 $1241.66 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 10 5.89 $147.29 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 35 61.96 $3098.15 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 8 6.30 $157.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 28 49.51 $2475.35 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 4.61 $115.21 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 36 55.79 $2789.27 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 11 7.05 $176.25 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 74 1064.29 $26607.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 227 294 1993.64 $99681.75 $50.00
INTR -INTR INTERPRETER 18 19 61.50 $3075.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 85 107 553.48 $37570.29 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 12 83.45 $4532.74 $54.32
PHY -97110 PT SESSION BY LICENSED PT 149 204 1137.50 $77213.30 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 15 59.89 $3253.39 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 18 23.90 $23.90 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 4 4 2.83 $53.04 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 283 371 2067.46 $140339.34 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 39 48 260.00 $3432.00 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 5 29.93 $1496.43 $50.00
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Subtotal (Total Children Is Unduplicated) 593 1363 7618.98 $418337.87 $54.91
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Total 1379 7633.68 $419336.47 $54.93
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Number of Children (Unduplicated) With at Least One Authorization 594