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 1 1 1.022222 $17.1500 $16.7800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.022222 $25.0100 $24.4700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.511111 $23.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.511111 $58.7800 $115.0000
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Subtotal (Total Children Is Unduplicated) 1 4 3.066666 $123.9400 $40.4200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 4.466667 $223.3400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1108 1453 2884.410439 $144221.1300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1111 1432 2818.218375 $140911.5300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1109 1429 2753.273929 $137664.2900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1109 1447 2769.200118 $138460.6000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 18 129.404763 $6470.2400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 7 61.428572 $4169.7700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 3 26.714285 $1813.3700 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.511111 $255.5500 $499.9900
SENS -V5264 EARMOLD 1 1 1.022222 $18.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.211111 $10.5600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 11 96.142858 $6526.1800 $67.8800
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Subtotal (Total Children Is Unduplicated) 1116 5805 11545.004450 $580744.9400 $50.3000
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Total 5810 11550.213973 $580868.8800 $50.2900
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Number of Children (Unduplicated) With at Least One Authorization 1116