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: 10/01/08 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 59 59 59.00 $626.58 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 57 57 57.00 $503.31 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 56 56 56.00 $604.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 53 53 53.00 $1154.87 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 52.00 $1470.56 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 51 62 63.07 $3784.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 16 16.00 $748.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 14 22.00 $2631.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 15 19 10.71 $535.28 $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) 126 391 391.77 $12197.57 $31.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 17 24 68.71 $3435.71 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 67 83.25 $4162.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 92 88.69 $4434.68 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 7 5.74 $287.23 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 92 122 103.29 $5164.31 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 13 94.40 $2360.00 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 0.80 $40.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 173 265 1497.52 $74876.12 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 31 40 190.00 $9499.87 $50.00
INTR -INTR INTERPRETER 2 2 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 214 300 1256.10 $85264.11 $67.88
OCCT -97530HM OT SESSION BY OT ASST 27 28 59.70 $3242.90 $54.32
PHY -97110 PT SESSION BY LICENSED PT 345 453 1691.53 $114820.74 $67.88
PHY -97110HM PT SESSION BY PT ASST 41 42 78.06 $4240.13 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 98 98 98.00 $98.00 $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 6 7 8.00 $520.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 8 16.00 $3793.92 $237.12
SENS -V5264 EARMOLD 10 15 29.00 $542.88 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 22 24 69.18 $3459.17 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 377 535 2176.62 $147748.80 $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 42 45 94.30 $1244.76 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 19 29 136.43 $6821.66 $50.00
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Subtotal (Total Children Is Unduplicated) 812 2228 7868.06 $487749.27 $61.99
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Total 2619 8259.83 $499946.84 $60.53
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Number of Children (Unduplicated) With at Least One Authorization 824