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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 Page: 1
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 301 301 341.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 301 301 341.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.34 $12.42 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.00 $48.90 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.00 $32.40 $10.80
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 2 2 2.00 $42.68 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 4.21 $252.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 7.79 $364.52 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 16.00 $1913.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 10.00 $555.00 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 9.00 $436.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 48 69 69.34 $4244.66 $61.21
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 11.00 $16500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 1.02 $70.40 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.86 $58.92 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 27 33 91.87 $4593.66 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 55 67 77.05 $3852.62 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 79 88.70 $4435.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 50 62.14 $3107.15 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 148 159.53 $7976.44 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 19 21 74.43 $5464.55 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 6 25.57 $639.29 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 3.00 $150.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 18.07 $903.34 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 3 3 5.71 $285.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 549 744 4979.83 $248991.27 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 12.93 $646.43 $50.00
INTR -INTR INTERPRETER 4 4 30.29 $1514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 647 921 5601.36 $380220.26 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 15 63.92 $3472.10 $54.32
PHY -97110 PT SESSION BY LICENSED PT 591 834 5490.55 $372698.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 27.71 $1505.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 14.00 $14.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 13 14.00 $7000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 15 17 5.77 $375.23 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 27 32 46.81 $876.36 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 13.25 $662.38 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1194 1734 11251.35 $763741.95 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 35.00 $462.00 $13.20
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Subtotal (Total Children Is Unduplicated) 1700 4777 28216.73 $1831815.03 $64.92
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Total 5147 28627.07 $1836059.69 $64.14
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Number of Children (Unduplicated) With at Least One Authorization 1733