Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 55 60 65.71 $3187.14 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 2.04 $122.66 $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 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 46 47 47.00 $2350.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 7.57 $378.57 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 310 372 413.86 $20072.07 $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 263 319 319.00 $15471.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 361 423 485.86 $23564.07 $48.50
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Subtotal (Total Children Is Unduplicated) 702 1228 1346.04 $65529.03 $48.68
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 41.67 $2083.33 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 46 55 73.57 $3678.58 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.37 $84.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 21 16.11 $805.55 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 7.76 $387.78 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 36 36.84 $1842.07 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.79 $19.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 109 139 1155.00 $28875.04 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 834 1080 8648.96 $432448.01 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 433 564 3544.42 $240594.97 $67.88
PHY -97110 PT SESSION BY LICENSED PT 398 533 3428.61 $232733.92 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.14 $713.92 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 38 48 40.78 $40.78 $1.00
SENS -V5264 EARMOLD 1 1 6.13 $114.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 22 27 85.47 $4273.50 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 504 644 3726.59 $252960.85 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 756 1113 6930.42 $3465.20 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 20 26 92.74 $4637.16 $50.00
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Subtotal (Total Children Is Unduplicated) 1114 4317 27853.36 $1211259.33 $43.49
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Total 5545 29199.40 $1276788.35 $43.73
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Number of Children (Unduplicated) With at Least One Authorization 1144