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: 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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.27 $196.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 6 9 9.00 $450.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 62 86 86.00 $4171.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 30 32 38.57 $1870.71 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 27 29 29.00 $1450.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 121 158 158.00 $7663.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 186 323 331.84 $16444.58 $49.56
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 10 15.00 $22500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.00 $137.72 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.67 $233.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 112 154 266.82 $13340.77 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 71 88 157.91 $7895.50 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 67 137.76 $6888.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 151 277.05 $13852.44 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 162 259 1449.33 $72466.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 23.29 $1164.29 $50.00
INTR -INTR INTERPRETER 4 4 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 102 139 1036.42 $70352.14 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 15.54 $843.90 $54.32
PHY -97110 PT SESSION BY LICENSED PT 107 146 1025.04 $69579.65 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.90 $103.21 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 11 6.41 $6.41 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 2 2 4.53 $84.86 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 7.43 $371.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 264 366 2195.46 $149027.74 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 72.93 $962.66 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 332 743 354152.85 $177076.42 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 16 45.04 $2251.91 $50.00
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Subtotal (Total Children Is Unduplicated) 379 2184 360906.36 $609963.04 $1.69
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Total 2507 361238.20 $626407.62 $1.73
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Number of Children (Unduplicated) With at Least One Authorization 395