Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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 -V5090 DISPENSING FEE PER HEARING AID 5 5 9.00 $1076.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 14 14.00 $679.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 38 39 48.57 $2355.72 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 15 20.86 $1011.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 18 18.00 $873.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 60 67 72.08 $3496.12 $48.50
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Subtotal (Total Children Is Unduplicated) 114 164 189.51 $9841.80 $51.93
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 5 15.93 $796.43 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 25 18.93 $946.38 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 22 22 40.72 $1017.91 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 30.35 $1517.70 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 9 16.43 $410.84 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 3.54 $177.22 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 5.80 $145.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 18 12.14 $607.22 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 20 22 37.60 $940.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.20 $30.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 73 84 608.25 $30412.57 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 8 209.46 $10473.10 $50.00
INTR -INTR INTERPRETER 1 1 0.86 $42.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 112 143 1061.08 $72026.03 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 2.07 $112.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 67 88 643.33 $43669.51 $67.88
PHY -97110HM PT SESSION BY PT ASST 12 13 93.71 $5090.56 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 7.00 $7.00 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 9.80 $2323.78 $237.12
SENS -V5264 EARMOLD 6 7 13.27 $248.35 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.29 $214.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 283 355 2421.72 $164386.45 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 14.43 $783.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 39.00 $514.80 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 278 427 3803.12 $1901.56 $0.50
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Subtotal (Total Children Is Unduplicated) 395 1278 9121.04 $342345.82 $37.53
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Total 1442 9310.55 $352187.63 $37.83
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Number of Children (Unduplicated) With at Least One Authorization 397