Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 1.07 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 3 3 1.07 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 28 29 29.00 $1740.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 8 8.00 $1000.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 104 107 107.00 $5189.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 129 142 142.00 $6887.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 310 346 366.00 $17751.00 $48.50
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Subtotal (Total Children Is Unduplicated) 416 637 657.00 $33170.90 $50.49
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 10.92 $546.11 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 429 491 1215.80 $60790.13 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 21 23 47.75 $1193.84 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 12.60 $630.01 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 13.79 $689.37 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.14 $28.57 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 414 473 1156.87 $57843.54 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 22 23 59.56 $1489.08 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 12 134.00 $9838.28 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 24.71 $617.86 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 39.29 $982.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 465 538 4732.30 $236614.84 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.57 $128.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 103 110 656.36 $44553.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 80.00 $4345.59 $54.32
PHY -97110 PT SESSION BY LICENSED PT 127 138 749.14 $50851.81 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 14 76.29 $4143.84 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 7 4.56 $4.56 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 13 128.50 $6425.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 329 368 2053.84 $139414.48 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 17 18 96.36 $1271.91 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 12.57 $1257.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 509 682 10279.15 $5139.56 $0.50
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Subtotal (Total Children Is Unduplicated) 646 2964 21588.06 $628799.71 $29.13
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Total 3604 22246.13 $661970.61 $29.76
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Number of Children (Unduplicated) With at Least One Authorization 658