Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 3.03 $112.23 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 3.03 $112.23 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 5.00 $300.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 5 6 8.50 $425.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 17.50 $1312.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 46 84.50 $6337.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.00 $145.56 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 10.00 $485.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 56 61 65.55 $3179.41 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 12 13 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 53 54 47.69 $2312.92 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 163 178 176.53 $8561.52 $48.50
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Subtotal (Total Children Is Unduplicated) 259 388 436.27 $24087.01 $55.21
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 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 4.53 $226.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.27 $6.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 39 45 50.87 $2543.33 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 10 17.92 $447.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 32 37.14 $1857.02 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 2.47 $61.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 34 29.37 $1468.62 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 10.72 $267.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 45 74.18 $3709.04 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 17 18 24.19 $604.73 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 34.57 $432.14 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.29 $464.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 520 650 5063.49 $253174.26 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 25.54 $1277.15 $50.00
INTR -INTR INTERPRETER 3 3 24.32 $1216.07 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 91 113 793.85 $53886.72 $67.88
OCCT -97530HM OT SESSION BY OT ASST 23 32 247.58 $13448.34 $54.32
PHY -97110 PT SESSION BY LICENSED PT 108 134 1086.16 $73728.51 $67.88
PHY -97110HM PT SESSION BY PT ASST 24 26 288.71 $15682.96 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 67 72 73.47 $73.47 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -V5264 EARMOLD 3 3 4.31 $80.70 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 250 316 2445.71 $166015.13 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 56 66 580.73 $7665.68 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 28 33 788.60 $394.30 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 65.00 $3250.00 $50.00
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Subtotal (Total Children Is Unduplicated) 831 1666 11789.99 $607002.13 $51.48
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Total 2055 12229.29 $631201.37 $51.61
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Number of Children (Unduplicated) With at Least One Authorization 841