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: 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 -92552 PURE TONE AUDIOMETRY -AIR ONLY 51 52 52.00 $552.24 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 52 53 53.00 $467.99 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 52 53 53.00 $572.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 53 53.00 $1154.87 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 46 47 47.00 $1329.16 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 84 98 98.00 $5880.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 7.00 $327.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 13.00 $1554.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 2.38 $118.89 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 25 25.00 $1212.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 13 13.00 $630.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 27 27.00 $1309.50 $48.50
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Subtotal (Total Children Is Unduplicated) 184 441 445.38 $15180.29 $34.08
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 39.00 $58500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 16 24 62.52 $3126.18 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 43 47 47.00 $2350.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 3.60 $180.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 79 65.67 $3283.32 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 7 5.80 $290.01 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 91 115 64.40 $3219.99 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 33 183.27 $4581.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 7 7 5.82 $291.11 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 200 273 2320.08 $116003.90 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 21 29 58.75 $2937.65 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 36 46 114.81 $5740.69 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 208 300 1393.95 $94621.31 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.27 $177.45 $54.32
PHY -97110 PT SESSION BY LICENSED PT 397 575 1977.93 $134262.00 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 178 200 199.33 $199.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.00 $260.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 14 15 29.00 $542.88 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 3.95 $197.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 23 31 88.97 $4448.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 446 644 2493.55 $169262.16 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.00 $108.64 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 20.67 $272.80 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 25 186.84 $9342.22 $50.00
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Subtotal (Total Children Is Unduplicated) 948 2488 9386.18 $617570.32 $65.80
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Total 2929 9831.56 $632750.61 $64.36
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Number of Children (Unduplicated) With at Least One Authorization 964