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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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 42 42 42.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 42 42 42.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 6 7 4.33 $70.54 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 10 6.62 $58.43 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 12 9.04 $97.68 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 7 4.23 $92.12 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 2.84 $154.68 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 1.52 $48.25 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 2 3 2.48 $52.88 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 7 4.54 $272.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 11.00 $1315.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 17 17.00 $943.50 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 41 90 73.60 $3586.04 $48.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 9 9.00 $13500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 23 31 73.30 $3664.76 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 58 69 87.43 $4371.43 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 88 99 103.47 $5173.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 58 68.86 $3442.86 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 149 173 184.31 $9215.49 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 12 42.00 $3083.63 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 11.29 $282.14 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 6.29 $314.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 14.86 $742.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 543 756 4915.10 $245754.85 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 6.43 $321.43 $50.00
INTR -INTR INTERPRETER 5 7 24.43 $1221.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 624 947 5635.91 $382565.28 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 11 45.86 $2490.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 590 851 5216.77 $354114.54 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 12.86 $698.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 28 33 33.00 $33.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 8 8.00 $4000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 11 11 5.34 $347.08 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 23 30 46.89 $877.73 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 19.23 $961.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1121 1691 10923.21 $741467.19 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.86 $50.91 $13.20
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Subtotal (Total Children Is Unduplicated) 1678 4818 27505.65 $1779787.34 $64.71
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Total 4950 27621.25 $1783373.39 $64.57
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Number of Children (Unduplicated) With at Least One Authorization 1679