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: 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 -V5010 ASSESSMENT FOR HEARING AID 10 11 12.20 $570.96 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 10.00 $1196.00 $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) 11 22 23.20 $1815.46 $78.25
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 22 31 58.54 $2926.99 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 9 9.00 $450.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 0.75 $18.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 2 1.67 $83.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 11.19 $279.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 26 37.82 $1890.89 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.66 $66.46 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 21 36.11 $1805.59 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 5 3.26 $81.46 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 15 27.59 $1379.53 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 13.27 $331.76 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 59 85 1091.07 $27276.79 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 237 318 2198.28 $109914.21 $50.00
INTR -INTR INTERPRETER 33 37 120.43 $6021.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 81 107 481.29 $32669.94 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 6 34.29 $1862.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 190 269 1288.56 $87467.75 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 8 50.71 $2754.80 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 50 51.43 $51.43 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 10 10 10.00 $5000.00 $500.00
SENS -V5264 EARMOLD 10 10 4.37 $81.74 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 372 515 2680.32 $181940.31 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 14 16 88.36 $1166.31 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5 5 383.14 $191.57 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 52.43 $2621.43 $50.00
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Subtotal (Total Children Is Unduplicated) 674 1572 8738.54 $469934.54 $53.78
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Total 1594 8761.74 $471750.00 $53.84
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Number of Children (Unduplicated) With at Least One Authorization 674