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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 59 59 53.20 $564.98 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 55 55 50.17 $442.97 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.03 $28.00 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 55 55 50.17 $541.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 56 56 50.20 $1093.85 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 46.20 $1306.53 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 87 98 98.27 $5895.99 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 11.03 $1319.58 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.60 $180.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 36 35.40 $1716.90 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 15 15.00 $727.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 35 40 40.27 $1952.94 $48.50
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Subtotal (Total Children Is Unduplicated) 209 485 460.53 $16026.38 $34.80
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 21 73.00 $109500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 14 58.05 $2902.63 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 75 88.25 $4412.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 3.19 $159.45 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 88 51.68 $2584.18 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 4.82 $241.11 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 131 80.90 $4045.01 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 25 137.87 $3446.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 7 8 5.69 $284.45 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 232 339 2377.52 $118876.08 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 18 20 48.44 $2421.81 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 34 45 94.25 $4712.50 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 238 360 1445.17 $98097.94 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.67 $362.14 $54.32
PHY -97110 PT SESSION BY LICENSED PT 445 654 2110.47 $143258.49 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.67 $36.22 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 163 187 187.00 $187.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 11 16 32.00 $599.04 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 31 76.93 $3846.25 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 441 644 2335.20 $158513.29 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 1.20 $65.18 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 6.40 $84.48 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 24 36 192.94 $9647.22 $50.00
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Subtotal (Total Children Is Unduplicated) 990 2720 9431.30 $670273.44 $71.07
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Total 3205 9891.83 $686299.82 $69.38
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Number of Children (Unduplicated) With at Least One Authorization 1007