Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 0.16 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 0.16 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 29 29 29.00 $1740.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 11.00 $1315.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 4.00 $500.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 114 127 127.00 $6159.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 143 159 159.00 $7711.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 371 411 468.29 $22711.86 $48.50
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Subtotal (Total Children Is Unduplicated) 489 744 801.29 $40513.46 $50.56
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 11.00 $550.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 400 428 1001.91 $50095.38 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 30 31 76.00 $1900.12 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 24.02 $1200.88 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.14 $3.47 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 15 20.47 $1023.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 7.06 $176.55 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 457 517 1112.47 $55623.30 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 35 36 73.31 $1832.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 86.00 $6314.12 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 16 110.43 $2760.72 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 13.86 $346.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 530 623 5112.08 $255604.07 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 110 127 662.21 $44951.13 $67.88
OCCT -97530HM OT SESSION BY OT ASST 27 27 117.57 $6386.50 $54.32
PHY -97110 PT SESSION BY LICENSED PT 124 142 769.08 $52205.16 $67.88
PHY -97110HM PT SESSION BY PT ASST 27 27 134.57 $7309.94 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 8.80 $8.80 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 55.09 $2754.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 407 467 2593.93 $176076.03 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 24 25 151.29 $1996.97 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 12.86 $1285.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 565 729 8033.40 $4016.71 $0.50
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Subtotal (Total Children Is Unduplicated) 733 3274 20190.54 $678922.41 $33.63
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Total 4020 20991.99 $719435.86 $34.27
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Number of Children (Unduplicated) With at Least One Authorization 744