Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 05
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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 9.00 $540.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 55 55 132.00 $6600.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 4 8.00 $444.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 13 13 26.00 $1443.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 66 66 132.00 $9900.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 13 13 25.00 $1875.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 40 40 80.00 $6000.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 74 74 147.00 $8158.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 18.00 $1350.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 28.00 $1358.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 24 39.57 $1919.21 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 189 345 672.57 $41363.79 $61.50
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 29 41.00 $61500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 79.21 $3960.72 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 286 600 1201.00 $60050.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 295 329 660.80 $33040.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 121 131 262.80 $13140.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.00 $125.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 173 190 381.80 $19090.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 233 259 517.80 $25890.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.00 $100.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 9 11 121.57 $3039.28 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 17 136.07 $3401.79 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 29 33 262.33 $13116.42 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 17.83 $445.71 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 245 276 2382.38 $119118.86 $50.00
INTR -INTR INTERPRETER 12 14 41.71 $2085.71 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 53 58 364.27 $24726.75 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 22.00 $1195.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 86 100 511.54 $34723.36 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 17.83 $968.71 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 57 57 84.00 $84.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 5 5 13.14 $246.06 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 139 167 1055.58 $71652.97 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 83.83 $1106.60 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 9.14 $914.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 312 466 17446.80 $8723.40 $0.50
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Subtotal (Total Children Is Unduplicated) 371 2784 25729.45 $503594.66 $19.57
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Total 3129 26402.02 $544958.45 $20.64
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Number of Children (Unduplicated) With at Least One Authorization 389