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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 8 8 10.03 $469.56 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.14 $614.29 $100.00
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Subtotal (Total Children Is Unduplicated) 10 17 24.18 $1969.55 $81.47
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 24 32 61.20 $3059.75 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 11 9.75 $487.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 1.50 $37.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 2.77 $138.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 0.69 $17.26 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 17 39.50 $1974.94 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.33 $58.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 15 25.65 $1282.37 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.20 $55.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 10 15.14 $757.03 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 2.58 $64.55 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 46 74 834.07 $20851.80 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 248 326 2327.88 $116393.81 $50.00
INTR -INTR INTERPRETER 35 41 164.29 $8214.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 84 113 540.94 $36719.19 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 5 35.64 $1936.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 200 283 1449.39 $98384.48 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 43.21 $2347.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 54 59 59.00 $59.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 7.00 $3500.00 $500.00
SENS -V5264 EARMOLD 7 7 5.27 $98.59 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 362 512 2934.20 $199173.33 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 21 27 165.14 $2179.89 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 2 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 27 31 353.43 $176.71 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 34.14 $1707.15 $50.00
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Subtotal (Total Children Is Unduplicated) 685 1603 9119.90 $501374.32 $54.98
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Total 1620 9144.08 $503343.87 $55.05
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Number of Children (Unduplicated) With at Least One Authorization 686