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: 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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 65 66 66.00 $700.92 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 66 67 67.00 $591.61 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 65 66 66.00 $712.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 67 68 68.00 $1481.72 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 59 61 61.00 $1725.08 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 84 91 93.84 $5630.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 10 10.00 $468.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 6.00 $717.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 3 1.51 $75.28 $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) 144 436 440.35 $12152.08 $27.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 69.00 $103500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 16 23 58.79 $2939.53 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 43 51 61.25 $3062.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 91 97.54 $4876.95 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 6 7.37 $368.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 140 126.39 $6319.46 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 30 177.60 $4440.00 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 1.20 $60.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.00 $50.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 296 2366.89 $118344.45 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 19 20 30.59 $1529.73 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 33 65 192.19 $9609.47 $50.00
INTR -INTR INTERPRETER 1 1 2.75 $137.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 235 350 1529.82 $103843.97 $67.88
OCCT -97530HM OT SESSION BY OT ASST 17 17 78.53 $4265.93 $54.32
PHY -97110 PT SESSION BY LICENSED PT 375 526 1817.73 $123387.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 42 43 180.80 $9821.06 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 131 149 149.00 $149.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 5.00 $325.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 10 12 23.00 $430.56 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.05 $2.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 22 28 78.77 $3938.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 436 646 2546.72 $172871.20 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 8.33 $452.67 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 29 29 141.77 $1871.32 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 7.10 $355.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 19 47 158.03 $7901.67 $50.00
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Subtotal (Total Children Is Unduplicated) 895 2601 9922.20 $685801.92 $69.12
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Total 3037 10362.55 $697954.00 $67.35
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Number of Children (Unduplicated) With at Least One Authorization 905