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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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 3 3 2.685714 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.685714 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 4 1.866667 $31.3200 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 4 1.866667 $17.0100 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 4 1.866667 $17.4400 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 5 2.272223 $49.3800 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.505555 $12.3700 $24.4700
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 1.161112 $52.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 0.705556 $81.1400 $115.0100
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Subtotal (Total Children Is Unduplicated) 3 26 10.244447 $260.9100 $25.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.211111 $1055.5000 $4999.7400
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 3.455556 $172.7800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1078 1463 2731.845229 $136592.2100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1079 1449 2655.061893 $132753.0300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1077 1443 2625.403167 $131270.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1074 1455 2626.326971 $131316.3000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 698 933 6388.440501 $319421.6600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 148 205 1149.484923 $78026.9400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 251 352 2319.476983 $157446.0000 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.205556 $102.8000 $500.1100
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 0.500000 $114.0000 $228.0000
SENS -V5264 EARMOLD 3 4 1.638889 $29.5000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 15 18 22.490476 $1124.5200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 324 441 2564.841850 $174101.2900 $67.8800
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Subtotal (Total Children Is Unduplicated) 1088 7770 23089.383105 $1263526.6400 $54.7200
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Total 7799 23102.313266 $1263787.5500 $54.7000
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Number of Children (Unduplicated) With at Least One Authorization 1089