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 26 27 10.188887 $132.9600 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 26 27 10.188887 $92.8200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 27 10.188887 $95.1600 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 26 27 10.188887 $221.4000 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 22 9.144443 $223.7600 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 22 46.522225 $2791.3500 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.688889 $31.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.111111 $357.7800 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 5.500002 $266.7600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.544445 $26.4100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 12 13.955557 $676.8500 $48.5000
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Subtotal (Total Children Is Unduplicated) 59 180 120.222220 $4916.2500 $40.8900
EI Services, Class # 03
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 -T1027SC EI INDIVIDUAL SESSION BY EI PROF 75 106 817.253969 $40862.7100 $50.0000
INTR -INTR INTERPRETER 3 5 12.383333 $619.1700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 68 317.900001 $21579.0600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 20.400000 $1108.1300 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 76 98 406.933332 $27622.6300 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.111111 $1055.5500 $500.0000
SENS -V5264 EARMOLD 2 2 2.111111 $38.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 92 126 674.700000 $45798.6400 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 717 1186 231156.634900 $115578.3100 $0.5000
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Subtotal (Total Children Is Unduplicated) 818 2410 233982.805114 $280307.2600 $1.2000
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Total 2708 234174.205105 $285223.5100 $1.2200
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Number of Children (Unduplicated) With at Least One Authorization 909