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: 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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 110 111 112.00 $1189.44 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 111 112 113.00 $997.79 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 110 111 111.03 $1199.16 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 114 115 116.00 $2527.64 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 105 107 108.00 $3054.24 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 138 155 157.84 $9470.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 17 18.00 $842.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 8 15.00 $1794.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 7 4.22 $211.12 $50.00
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
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Subtotal (Total Children Is Unduplicated) 256 746 758.10 $21404.70 $28.23
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 36 176.00 $264000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 23 32 86.36 $4317.87 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 102 122 128.50 $6425.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 9 8.53 $426.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 129 169 181.42 $9071.07 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 11 10.55 $527.51 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 204 277 241.07 $12053.74 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 52 64 394.37 $9859.16 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 2.21 $110.56 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 18.40 $920.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 38.40 $960.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 369 559 4622.55 $231127.63 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 23 24 43.33 $2166.39 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 48 92 255.12 $12756.14 $50.00
INTR -INTR INTERPRETER 1 1 2.75 $137.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 426 631 2779.86 $188696.63 $67.88
OCCT -97530HM OT SESSION BY OT ASST 43 43 207.80 $11287.71 $54.32
PHY -97110 PT SESSION BY LICENSED PT 563 815 2792.46 $189552.31 $67.88
PHY -97110HM PT SESSION BY PT ASST 65 66 282.62 $15351.75 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 161 179 179.00 $179.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.00 $390.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 5 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 17 22 42.00 $786.24 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.05 $2.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 28 35 102.58 $5129.16 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 859 1307 5443.48 $369503.71 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 19.00 $1032.09 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 63 64 302.13 $3988.16 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 7.10 $355.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 30 67 244.52 $12225.85 $50.00
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Subtotal (Total Children Is Unduplicated) 1494 4655 18632.67 $1357723.02 $72.87
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Total 5401 19390.77 $1379127.72 $71.12
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Number of Children (Unduplicated) With at Least One Authorization 1515