Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.69 $201.99 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 5 6.00 $750.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 4 4 4.00 $200.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 65 84 84.00 $4074.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 30 30.00 $1455.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 23 26 26.00 $1300.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 81 95 94.97 $4605.89 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 164 254 256.66 $13112.82 $51.09
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 6 8.00 $12000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 4 16.13 $806.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.63 $131.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 99 131 242.28 $12114.12 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 68 111.25 $5562.48 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 62 115.97 $5798.31 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 125 230.70 $11534.89 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.14 $7.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.00 $200.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 182 255 1469.91 $73495.65 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 26.14 $1307.15 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 97 126 860.48 $58409.33 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.29 $232.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 108 146 886.97 $60207.63 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.57 $31.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 6 2.24 $2.24 $1.00
SENS -V5264 EARMOLD 2 4 9.38 $175.55 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 14.86 $742.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 226 343 1769.95 $120143.91 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.71 $147.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 27.86 $367.71 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 340 692 328256.52 $164128.26 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 10 29.14 $1457.15 $50.00
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Subtotal (Total Children Is Unduplicated) 381 1996 334099.13 $529153.98 $1.58
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Total 2250 334355.79 $542266.80 $1.62
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Number of Children (Unduplicated) With at Least One Authorization 398