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: 10-01-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 75 81 54.955547 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 75 81 54.955547 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 4.022223 $57.7600 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 10 10 3.166667 $58.4600 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 4.022223 $40.3000 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 4.022223 $33.8300 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 10 10 3.166667 $24.5400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 3.922223 $82.3700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 10 10 3.166667 $198.3300 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 11 11 4.022223 $88.5700 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 67 71 256.244448 $15374.6900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.633333 $28.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 3.188888 $366.7100 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 41 43 21.766665 $1055.6800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 2.233334 $108.3200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 49 51 28.166667 $1366.0800 $48.5000
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Subtotal (Total Children Is Unduplicated) 153 258 341.744451 $18884.1400 $55.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 21.377778 $106889.0000 $5000.0100
AUD -HA_FUP AUDIOLOGY SERVICES 1 2 4.360318 $218.0200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 88 110 81.669050 $4083.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 181 196 179.783331 $8989.1600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 107 122 92.461105 $4623.0300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 129 150 125.499991 $6274.9600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 262 304 236.022208 $11801.0400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 6 31.866666 $796.6700 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 712 1034 7585.066683 $379253.4200 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 23 26 181.333333 $9066.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 8 42.000000 $2100.0000 $50.0000
INTR -INTR INTERPRETER 3 4 28.755555 $1437.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 258 334 2033.388879 $138026.3700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 442 558 2842.505538 $192949.1600 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.266667 $288.8100 $228.0100
SENS -V5264 EARMOLD 5 6 7.222223 $130.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.300000 $15.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 47.233334 $2361.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 361 459 2745.099998 $186337.3700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 25.466667 $336.1600 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 841 1503 10115.504773 $101155.0600 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 29 31 277.955557 $138.9800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 23 26 152.341469 $7617.0800 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.500000 $625.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1231 4916 26882.281124 $1166459.6700 $43.3900
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Total 5255 27278.981122 $1185343.8100 $43.4500
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Number of Children (Unduplicated) With at Least One Authorization 1298