Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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 -AUDE UNSPECIFIED AUDE SERVICES 105 117 105.54 $6332.14 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 13.00 $608.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 12.00 $1435.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 4.36 $544.64 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 15.86 $1982.14 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 47 48 55.00 $2750.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 5 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.30 $397.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 5.80 $435.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 6.50 $360.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 5.29 $396.43 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 18 18 18.00 $873.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 55 60 83.00 $4025.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 15 26.86 $1302.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 26 26.00 $1261.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 114 120 121.00 $5868.50 $48.50
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Subtotal (Total Children Is Unduplicated) 290 456 510.49 $29097.76 $57.00
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 18 20 42.10 $2105.01 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 15 24.64 $1232.22 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 115 136 256.42 $12820.98 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 12 6.81 $170.28 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 67 130.59 $6529.45 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 36 61.80 $3089.77 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.56 $39.03 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 168 195 350.39 $17519.68 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 15 15 9.31 $232.64 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 229.71 $2871.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.00 $200.00 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.43 $210.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 359 436 3449.82 $172491.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 8 18.30 $915.25 $50.00
INTR -INTR INTERPRETER 38 43 290.31 $14515.58 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 139 176 1473.37 $100012.16 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 64.36 $3495.87 $54.32
PHY -97110 PT SESSION BY LICENSED PT 104 137 995.59 $67580.53 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 10 128.93 $7003.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 31 34 47.37 $47.37 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 11 13 16.56 $310.04 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 19 21 108.00 $5400.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 213 276 2244.90 $152383.67 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 20.07 $1090.28 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 37.25 $491.70 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 535 1041 471449.77 $235724.89 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 13 67.02 $3351.19 $50.00
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Subtotal (Total Children Is Unduplicated) 603 2732 481550.88 $814742.59 $1.69
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Total 3188 482061.37 $843840.35 $1.75
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Number of Children (Unduplicated) With at Least One Authorization 610