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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 73 77 77.00 $817.74 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 71 75 75.00 $662.25 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 71 77 77.00 $831.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 71 75 75.00 $1634.25 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 65 69 69.00 $1951.32 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 54 61 66.40 $3984.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 11 11.00 $514.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 9 13.00 $1554.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 4.24 $212.23 $50.00
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 131 462 469.64 $12238.59 $26.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 73.00 $109500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 15 73.57 $3678.59 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 59 67 79.28 $3963.75 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 71 101 110.77 $5538.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 3.09 $154.52 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 107 138 144.00 $7199.98 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 17 108.40 $2710.00 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.93 $23.33 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 192 299 1975.49 $98774.39 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 8 33.21 $1660.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 37 49 180.72 $9036.11 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 217 310 1187.85 $80631.29 $67.88
OCCT -97530HM OT SESSION BY OT ASST 33 36 192.43 $10452.98 $54.32
PHY -97110 PT SESSION BY LICENSED PT 330 477 1525.57 $103556.00 $67.88
PHY -97110HM PT SESSION BY PT ASST 56 57 265.72 $14433.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 123 132 132.00 $132.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 5.00 $325.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 8.00 $1896.96 $237.12
SENS -V5264 EARMOLD 11 15 29.00 $542.88 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 22 77.48 $3874.17 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 382 540 2147.95 $145802.83 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 7.87 $427.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 55 58 310.07 $4092.88 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 7.60 $380.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 17 24 146.53 $7326.67 $50.00
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Subtotal (Total Children Is Unduplicated) 833 2400 8827.53 $616189.24 $69.80
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Total 2862 9297.18 $628427.82 $67.59
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Number of Children (Unduplicated) With at Least One Authorization 841