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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.02 $11.04 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.02 $22.27 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 6 10.40 $624.19 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 4.00 $478.40 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 8.00 $444.00 $55.50
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Subtotal (Total Children Is Unduplicated) 14 21 25.45 $1626.71 $63.92
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.00 $7500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 1.02 $70.40 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 12 29.96 $1498.10 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 38 44 56.68 $2833.81 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 61 65.88 $3294.05 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 34 40.86 $2042.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 62 63.67 $3183.34 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 351 506 3088.56 $154427.84 $50.00
INTR -INTR INTERPRETER 5 5 5.00 $250.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 339 484 3008.01 $204183.59 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 6 31.50 $1711.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 383 529 3202.20 $217365.08 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 28 30.00 $30.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 6 4.25 $276.39 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 8 11 11.20 $209.73 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 15 16.20 $810.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 569 848 5290.42 $359113.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 8 9 44.71 $590.23 $13.20
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Subtotal (Total Children Is Unduplicated) 962 2670 14998.11 $959937.65 $64.00
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Total 2691 15023.56 $961564.36 $64.00
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Number of Children (Unduplicated) With at Least One Authorization 962