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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 -92552 PURE TONE AUDIOMETRY -AIR ONLY 174 196 278.00 $2952.36 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 153 170 170.00 $1501.10 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 154 171 171.00 $1846.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 147 165 165.00 $3595.35 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 140 156 156.00 $4411.68 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 146 203 328.07 $19684.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 21 33 33.00 $1544.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 26 30 43.00 $5142.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 32 51 56.54 $2826.95 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
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Subtotal (Total Children Is Unduplicated) 320 1178 1403.61 $43643.61 $31.09
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 29 77.00 $115500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 27 49 246.53 $12326.69 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 143 181 245.50 $12275.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 123 208 350.80 $17539.78 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.20 $30.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 36 65.60 $3280.01 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 195 334 583.37 $29168.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.40 $60.00 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 2 2 25.07 $626.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 24 305.33 $7633.34 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 3 4 4.49 $224.45 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 23 24 145.48 $7273.88 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.13 $203.33 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 317 692 6244.25 $312212.72 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 37 76 589.98 $29498.88 $50.00
INTR -INTR INTERPRETER 3 3 9.00 $450.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 341 736 4819.00 $327113.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 28 29 59.73 $3244.71 $54.32
PHY -97110 PT SESSION BY LICENSED PT 524 1104 7178.64 $487285.74 $67.88
PHY -97110HM PT SESSION BY PT ASST 42 43 79.13 $4298.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 106 109 109.00 $109.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 5 10.00 $5000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 13 15.00 $975.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 10 12 22.00 $5216.64 $237.12
SENS -V5264 EARMOLD 18 31 60.00 $1123.20 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.80 $90.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 33 62 345.52 $17275.85 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 609 1260 8583.12 $582622.05 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.73 $202.79 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 43 46 109.63 $1447.16 $13.20
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 29.83 $1491.67 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 23 74 467.72 $23386.11 $50.00
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Subtotal (Total Children Is Unduplicated) 1209 5197 30801.98 $2009423.81 $65.24
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Total 6375 32205.58 $2053067.41 $63.75
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Number of Children (Unduplicated) With at Least One Authorization 1247