Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 4.04 $242.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 4 4 3.57 $178.57 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 54 65 65.00 $3152.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 34 40.86 $1981.57 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 42 42 42.00 $2100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 90 117 117.00 $5674.50 $48.50
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Subtotal (Total Children Is Unduplicated) 197 268 278.47 $13818.28 $49.62
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 8.43 $12649.95 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.00 $137.72 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 5.03 $251.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 2 4.73 $118.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 128 167 294.41 $14720.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 71 94 174.50 $8724.95 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 68 135.66 $6783.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 179 309.35 $15467.53 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 8.86 $221.43 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 13.00 $650.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 167 246 1363.73 $68186.69 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 30.29 $1514.29 $50.00
INTR -INTR INTERPRETER 2 4 5.31 $265.56 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 89 121 900.14 $61101.31 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 8 31.59 $1715.87 $54.32
PHY -97110 PT SESSION BY LICENSED PT 101 134 806.31 $54732.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 4 9.07 $492.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 16 8.78 $8.78 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 2 2 8.09 $151.42 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 29.00 $1450.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 287 414 2261.72 $153525.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 50.46 $666.13 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 358 732 352753.05 $176376.52 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 11 18.94 $947.14 $50.00
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Subtotal (Total Children Is Unduplicated) 395 2229 359235.45 $581383.38 $1.62
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Total 2497 359513.92 $595201.65 $1.66
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Number of Children (Unduplicated) With at Least One Authorization 429