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: 10-01-12 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 96 118 71.177771 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 96 118 71.177771 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 74 76 26.830153 $350.1300 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 75 77 26.841264 $244.5200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 74 75 26.841264 $250.6900 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 74 76 26.852375 $583.4900 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 66 24.763487 $605.9500 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 64 72 168.900006 $10134.0400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.547641 $69.6500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 4.828615 $555.2900 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 1.016666 $50.8300 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 3 0.494445 $27.4400 $55.5100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 36 37 60.544448 $2936.4200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 2.733333 $132.5700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 49 69.644447 $3377.7700 $48.5000
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Subtotal (Total Children Is Unduplicated) 206 553 441.838144 $19318.7800 $43.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 12 16.011110 $24016.5000 $1499.9900
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 23.280952 $1164.0500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 63 75 14.816669 $740.8500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 1.013890 $25.3500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 122 153 59.777771 $2988.8600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 122 84.333328 $4216.6400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.427778 $10.7000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 112 90.777774 $4538.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 251 324 196.444430 $9822.1500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 15 101.504765 $2537.6300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.022222 $51.1100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 604 905 6624.817472 $331240.9300 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 7 35.816667 $1790.8400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 14 15 148.388094 $7419.4100 $50.0000
INTR -INTR INTERPRETER 3 5 12.383333 $619.1700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 283 396 2200.265866 $149353.9900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 9 9 46.266666 $2513.2000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 477 634 2958.327761 $200811.1800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 7 40.700000 $2210.8200 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.111111 $1055.5500 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.717504 $391.5900 $228.0000
SENS -V5264 EARMOLD 5 5 4.273059 $76.9100 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 10 19 37.827777 $1891.3900 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 10.527778 $526.3900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 385 534 2950.641268 $200289.5100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 23.933334 $315.9200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 717 1186 231156.634900 $115578.3100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 17 18 81.460714 $4073.0400 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 26 26 157.441666 $7872.0800 $50.0000
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Subtotal (Total Children Is Unduplicated) 1130 4606 247082.945659 $1078142.9000 $4.3600
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Total 5277 247595.961574 $1097461.6800 $4.4300
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Number of Children (Unduplicated) With at Least One Authorization 1218