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 1 1 0.411111 $6.9000 $16.7800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.411111 $10.0600 $24.4700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.205556 $9.2500 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.205556 $23.6400 $115.0200
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Subtotal (Total Children Is Unduplicated) 1 4 1.233334 $49.8500 $40.4200
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 1077 1460 2728.845229 $136442.2100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1078 1446 2652.061893 $132603.0300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1077 1443 2625.403167 $131270.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1073 1452 2623.326971 $131166.3000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 22 125.561905 $6278.1000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 10 57.028571 $3871.1000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 4 5 36.000000 $2443.6800 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.205556 $102.8000 $500.1100
SENS -V5264 EARMOLD 1 1 0.411111 $7.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 2 1.000000 $50.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 16 103.490478 $7024.9100 $67.8800
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Subtotal (Total Children Is Unduplicated) 1080 5862 10957.001548 $552487.9300 $50.4200
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Total 5869 10960.920596 $552537.7800 $50.4100
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Number of Children (Unduplicated) With at Least One Authorization 1081