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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.07 $9.42 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 3 1.93 $20.88 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 3 1.93 $42.13 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.07 $3.63 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 7 14.16 $849.34 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 11 11.00 $610.50 $55.50
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Subtotal (Total Children Is Unduplicated) 19 35 38.16 $2084.90 $54.64
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.02 $70.39 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 10 13 28.88 $1443.80 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 45 50 54.89 $2744.30 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 62 65.33 $3266.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 35 47.14 $2357.15 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 80 84.00 $4200.01 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 338 479 3000.58 $150028.81 $50.00
INTR -INTR INTERPRETER 5 7 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 325 458 2973.42 $201835.58 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 30.57 $1660.64 $54.32
PHY -97110 PT SESSION BY LICENSED PT 352 504 3102.62 $210605.63 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 24 24.00 $24.00 $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 2 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 10 12 16.36 $306.26 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 10.07 $503.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 536 768 5044.12 $342395.18 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 38.86 $512.92 $13.20
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Subtotal (Total Children Is Unduplicated) 918 2523 14539.85 $929696.01 $63.94
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Total 2558 14578.01 $931780.92 $63.92
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Number of Children (Unduplicated) With at Least One Authorization 918