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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.01 $120.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 1.88 $87.88 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 3.00 $358.80 $119.60
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Subtotal (Total Children Is Unduplicated) 4 13 11.89 $694.96 $58.45
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 0.30 $20.63 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 6 9 29.63 $1481.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 38 40 40.60 $2030.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 37 49.00 $2450.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 29 55.87 $2793.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 41 77.00 $3849.77 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.29 $214.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 435 625 3855.55 $192777.63 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 334 486 2939.17 $199511.14 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.00 $54.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 378 553 3433.17 $233043.71 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 44 48 65.82 $65.82 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 5 8 5.90 $110.45 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 19 18.13 $906.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 601 902 5705.61 $387297.01 $67.88
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Subtotal (Total Children Is Unduplicated) 1052 2808 16288.05 $1027521.19 $63.08
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Total 2822 16300.08 $1028216.15 $63.08
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Number of Children (Unduplicated) With at Least One Authorization 1052