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: 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
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 8.00 $374.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 8.00 $956.80 $119.60
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 9 17 17.00 $1379.70 $81.16
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 21 28 66.44 $3321.79 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 14 9.50 $475.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 5.90 $295.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 10 14.62 $365.48 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 20 39.71 $1985.37 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 6 5.55 $138.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 32 59.41 $2970.38 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 4 5.55 $138.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 16 28.82 $1440.96 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 11 12 22.85 $571.34 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 67 84 1468.14 $36703.59 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 263 331 2543.92 $127196.10 $50.00
INTR -INTR INTERPRETER 37 39 107.29 $5364.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 87 111 542.06 $36795.34 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 9 71.43 $3880.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 171 223 1206.44 $81893.43 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 13 54.93 $2983.73 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 33 36 36.80 $36.80 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 8 8.00 $4000.00 $500.00
SENS -V5264 EARMOLD 8 8 6.98 $130.62 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 345 450 2679.42 $181879.02 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 16 21 123.64 $1632.09 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3 3 110.86 $55.43 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 87.14 $4357.14 $50.00
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Subtotal (Total Children Is Unduplicated) 690 1487 9307.40 $501610.38 $53.89
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Total 1504 9324.40 $502990.08 $53.94
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Number of Children (Unduplicated) With at Least One Authorization 690