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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.400000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.400000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.866667 $12.4500 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.377778 $25.4300 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.377778 $13.8100 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 2.355556 $19.8100 $8.4100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 2.355556 $49.4700 $21.0000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.433333 $9.5400 $22.0200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.433333 $10.6400 $24.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.433333 $19.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.433333 $49.8300 $114.9900
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Subtotal (Total Children Is Unduplicated) 3 15 10.066667 $210.4700 $20.9100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 2.355556 $117.7800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1030 2186 3403.473851 $170173.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1030 2169 3370.536556 $168527.0700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1031 2167 3388.450047 $169422.7300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1032 2187 3418.992902 $170949.8700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 703 978 6550.166631 $327508.6700 $50.0000
INTR -INTR INTERPRETER 1 1 6.285714 $314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 122 181 1112.363487 $75507.2900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 223 322 2106.198403 $142968.9200 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.433333 $98.7900 $227.9800
SENS -V5264 EARMOLD 3 3 2.355556 $42.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 21 10.722221 $536.1100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 315 437 2574.026182 $174725.0900 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 374 1372 175164.038095 $87582.0200 $0.5000
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Subtotal (Total Children Is Unduplicated) 1034 12028 201110.398534 $1488474.9100 $7.4000
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Total 12044 201120.865201 $1488685.3800 $7.4000
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Number of Children (Unduplicated) With at Least One Authorization 1034