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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 7 9 9.000000 $137.2500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 9 9.000000 $74.5200 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 9 9.000000 $93.4200 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 9 9.000000 $189.7200 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $81.5700 $27.1900
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 8 47 47.000000 $1156.7400 $24.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.000000 $9000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 9 9.000000 $450.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 336 420 462.890478 $23144.5300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 26 30.133334 $1506.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 30 34.133334 $1706.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 330 402 446.890478 $22344.5400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 492 642 4628.138111 $231407.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 193 258 1736.657145 $117884.4100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 310 398 2718.442863 $184528.0400 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 14.585714 $14.5900 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 7 9 9.000000 $162.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 25 29 29.000000 $1450.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 475 636 4455.566663 $302444.1400 $67.8800
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Subtotal (Total Children Is Unduplicated) 973 2882 14583.438120 $896563.5600 $61.4800
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Total 2929 14630.438120 $897720.3000 $61.3600
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Number of Children (Unduplicated) With at Least One Authorization 973