Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 09
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 3 2.51 $22.12 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 3 2.51 $27.06 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.51 $32.81 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.51 $27.49 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 6 8.65 $519.04 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 6.00 $333.00 $55.50
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Subtotal (Total Children Is Unduplicated) 15 32 33.67 $1714.58 $50.92
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 6 6.00 $9000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 1.01 $69.62 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 11 33.03 $1651.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 37 43 52.58 $2629.05 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 64 69.33 $3466.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 37 43.71 $2185.72 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 91 93.00 $4650.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 316 445 2802.30 $140115.22 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.71 $235.72 $50.00
INTR -INTR INTERPRETER 4 4 4.00 $200.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 325 472 2681.76 $182038.20 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 23.43 $1272.64 $54.32
PHY -97110 PT SESSION BY LICENSED PT 347 483 2975.28 $201962.06 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 7.14 $388.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 26 26.00 $26.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 3 2.07 $134.81 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 9 11 16.84 $315.27 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 8 13.30 $665.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 532 741 4919.41 $333929.23 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 26.29 $346.97 $13.20
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Subtotal (Total Children Is Unduplicated) 892 2462 13808.22 $887017.44 $64.24
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Total 2494 13841.89 $888732.02 $64.21
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Number of Children (Unduplicated) With at Least One Authorization 892