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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 10 7.97 $129.95 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 14 11.02 $97.28 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 15 11.89 $128.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 8.51 $185.46 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 4.59 $249.85 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 6 4.58 $145.80 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 2 2 1.38 $29.40 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 11 12.67 $760.37 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 15 15.00 $832.50 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 4.29 $207.86 $48.50
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Subtotal (Total Children Is Unduplicated) 40 104 95.90 $3936.57 $41.05
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 12 12.00 $18000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 1.01 $69.62 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 22 28 73.88 $3693.80 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 72 81 95.71 $4785.71 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 105 128 136.34 $6817.15 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 75 93.71 $4685.72 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 146 185 202.90 $10145.01 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 21.71 $1594.26 $73.42
EIIF -COUN UNSPECIFIED COUNSELING 2 2 11.29 $564.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 582 826 5517.93 $275896.65 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.71 $235.72 $50.00
INTR -INTR INTERPRETER 5 5 5.00 $250.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 664 993 5921.46 $401949.02 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 50.53 $2744.97 $54.32
PHY -97110 PT SESSION BY LICENSED PT 601 871 5350.92 $363220.67 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 7.14 $388.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 36 40 40.00 $40.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 9 5.42 $352.42 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 21 28 40.57 $759.41 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 14 25.90 $1295.24 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1181 1733 11487.60 $779778.34 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 61.71 $814.63 $13.20
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Subtotal (Total Children Is Unduplicated) 1798 5060 29178.48 $1881316.22 $64.48
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Total 5164 29274.38 $1885252.78 $64.40
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Number of Children (Unduplicated) With at Least One Authorization 1798