Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 10.86 $401.71 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 18.07 $668.64 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 6.00 $291.00 $48.50
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -AUDE UNSPECIFIED AUDE SERVICES 39 40 40.08 $2404.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 14.00 $1674.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.64 $232.15 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 71 76 151.04 $7551.79 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 21 35.50 $2662.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 6.50 $487.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 9.50 $712.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 18 18 30.00 $2250.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 20 34.30 $1903.65 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 230 230 393.00 $29475.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 43 43 74.00 $5550.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 29 29 47.93 $3594.65 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 201 201 344.43 $19115.79 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 187 187 304.71 $22853.57 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 6.29 $304.86 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 11 11.00 $533.50 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 18 24.29 $1177.86 $48.50
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Subtotal (Total Children Is Unduplicated) 493 936 1548.20 $103248.87 $66.69
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 24 27.00 $40500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 29.41 $1470.48 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 65 69 112.43 $5621.43 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 30 35 23.36 $584.11 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 25 29 40.78 $2039.23 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 14 16 21.85 $546.26 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 14.31 $715.42 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 6 12.45 $311.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 16 25.98 $1298.76 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.32 $107.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 50 56 113.38 $5669.12 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 35 40 60.54 $1513.52 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 27 31 290.36 $7258.94 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 21.86 $546.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 722 875 6815.18 $340759.11 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 34.00 $1700.00 $50.00
INTR -INTR INTERPRETER 102 126 853.97 $42698.36 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 64 82 588.56 $39951.64 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 13.14 $713.92 $54.32
PHY -97110 PT SESSION BY LICENSED PT 178 242 1850.85 $125635.65 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 9 65.43 $3554.09 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 108 122 143.53 $143.53 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.00 $195.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 8 8 18.57 $347.55 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 23.05 $1152.63 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 427 550 4346.25 $295023.33 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 38 43 325.45 $4295.98 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 10.00 $1000.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1034 1691 12929.26 $6464.61 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 23.57 $1178.57 $50.00
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Subtotal (Total Children Is Unduplicated) 1186 4118 28865.85 $935296.40 $32.40
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Total 5057 30432.12 $1039213.91 $34.15
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Number of Children (Unduplicated) With at Least One Authorization 1284