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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 2.142857 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 2.142857 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.444444 $57.8000 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.444444 $31.3800 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.444444 $32.1700 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.444444 $74.8500 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.533333 $37.5200 $24.4700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.022222 $46.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.022222 $117.5500 $115.0000
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Subtotal (Total Children Is Unduplicated) 3 18 17.355553 $397.2600 $22.8900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.322222 $483.3000 $1499.9000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 4.466667 $223.3400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1109 1454 2887.477106 $144374.4600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1112 1433 2821.285042 $141064.8600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1109 1429 2753.273929 $137664.2900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1110 1448 2772.266785 $138613.9300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 720 922 6729.231754 $336462.0600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 135 190 1152.102379 $78204.8000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 271 365 2478.178177 $168219.0000 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.511111 $255.5500 $499.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.511111 $116.5300 $228.0000
SENS -V5264 EARMOLD 2 2 2.044444 $36.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 25 26.486508 $1324.3300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 377 519 3140.427787 $213172.4800 $67.8800
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Subtotal (Total Children Is Unduplicated) 1138 7792 24768.585022 $1360215.7200 $54.9200
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Total 7811 24788.083432 $1360612.9900 $54.8900
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Number of Children (Unduplicated) With at Least One Authorization 1138