Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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 -92552 PURE TONE AUDIOMETRY -AIR ONLY 60 63 63.00 $669.06 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 57 60 60.00 $529.80 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 59 62 62.00 $669.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 56 59 59.00 $1285.61 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 56 56.00 $1583.68 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 53 66 66.00 $3960.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 14 14.00 $655.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 13.00 $1554.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 23 26 15.67 $783.33 $50.00
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Subtotal (Total Children Is Unduplicated) 127 416 408.67 $11691.08 $28.61
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 18 58.00 $87000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 16 20 59.69 $2984.51 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 37 48.75 $2437.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 77 84.22 $4210.94 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 10.41 $520.28 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 105 102.09 $5104.31 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.23 $55.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 12 75.20 $1880.00 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.02 $51.11 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 24.53 $613.33 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 151 228 1528.20 $76409.99 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 20 22 83.69 $4184.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 218 300 1238.88 $84095.45 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.03 $1.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 359 496 1801.98 $122318.65 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 31.48 $1710.18 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 53 52.89 $52.89 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.00 $172.00 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 9 10 18.00 $336.96 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 17 29 98.80 $4940.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 382 529 2198.45 $149230.73 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 17.33 $228.80 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 15 39 113.28 $5663.76 $50.00
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Subtotal (Total Children Is Unduplicated) 743 2012 7666.16 $557963.30 $72.78
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Total 2428 8074.83 $569654.38 $70.55
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Number of Children (Unduplicated) With at Least One Authorization 761