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: 10-01-11 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 0.638889 $23.6400 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.638889 $23.6400 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 10.285714 $121.9900 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 10 9.285714 $76.8900 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 10.285714 $106.7700 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 10.285714 $216.8200 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 6.000000 $163.1400 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 14 15 15.000000 $900.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.000000 $460.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 6.966667 $337.8900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 3.966667 $192.3900 $48.5000
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Subtotal (Total Children Is Unduplicated) 36 79 78.076190 $2665.8700 $34.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 9.000000 $13500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 6 7 21.095238 $1054.7600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 66 78 77.714286 $3885.7200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 83 100 40.038885 $2001.9300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 107 58.388884 $2919.4200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 43 41.338885 $2066.9300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 183 220 149.516656 $7475.7800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 20 143.200002 $3580.0100 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 3.333333 $166.6700 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 7.866667 $196.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 51 79 610.011111 $30500.5600 $50.0000
INTR -INTR INTERPRETER 2 9 18.000000 $900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 46 210.061114 $14258.9700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 13.400000 $727.8900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 91 129 408.008336 $27695.6200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 21.066667 $1144.3400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 160 192 192.000000 $192.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.000000 $500.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 3 3 4.000000 $72.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 87 116 585.161109 $39720.7200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4 4 630.666666 $315.3300 $0.5000
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Subtotal (Total Children Is Unduplicated) 601 1168 3251.767839 $153563.8000 $47.2200
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Total 1249 3330.482918 $156253.3100 $46.9200
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Number of Children (Unduplicated) With at Least One Authorization 615