Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 51
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 2.00 $74.00 $37.00
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 8 10 8.58 $514.67 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 7 7.00 $837.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 5 14.86 $742.86 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 3.00 $225.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.00 $750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 19 20.00 $970.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 18 18.00 $873.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 36 37 37.00 $1794.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 77 114 133.44 $7795.80 $58.42
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 9.57 $659.09 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 10.00 $688.60 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 7 10 27.79 $1389.29 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 167 205 352.44 $17622.08 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 80 130.60 $6530.12 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.50 $112.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 89 109 160.56 $8027.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.72 $43.06 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 130 146 222.75 $11137.32 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 15.00 $375.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.00 $146.84 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 10 130.00 $3250.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 131.43 $6571.43 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.03 $51.67 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.29 $482.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 233 270 2259.64 $112982.23 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 3 7.53 $376.67 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 14.52 $726.19 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 97 127 1183.93 $80365.01 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.43 $1218.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 121 157 1435.56 $97445.72 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 12.86 $698.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 6 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 5 8 3.86 $72.18 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 4 6 19.47 $973.34 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.77 $38.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 199 239 2128.53 $144484.57 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 30.07 $396.94 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 8.23 $411.67 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 57.73 $2886.66 $50.00
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Subtotal (Total Children Is Unduplicated) 372 1421 8413.81 $503587.98 $59.85
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Total 1537 8549.24 $511457.77 $59.82
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Number of Children (Unduplicated) With at Least One Authorization 379