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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 1 1 6.43 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 6.43 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 10 7.49 $122.07 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 16 20 14.56 $128.53 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 19 23 16.82 $181.68 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 18 22 14.82 $322.98 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 6 4.70 $255.59 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.51 $14.45 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 9 6.98 $221.97 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.02 $21.81 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 8 12.11 $726.86 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 8 8.00 $374.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 11 11.00 $1315.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 19 19 19.71 $1094.14 $55.50
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Subtotal (Total Children Is Unduplicated) 44 138 117.73 $4780.08 $40.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 9.00 $13500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 1.02 $70.40 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 24 32 82.75 $4137.54 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 80 91 116.23 $5811.55 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 95 114 120.99 $6049.65 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 72 98.43 $4921.43 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 149 163.33 $8166.31 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.00 $146.84 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 613 896 5742.59 $287129.63 $50.00
INTR -INTR INTERPRETER 5 5 5.00 $250.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 642 951 6036.87 $409782.48 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 6 31.50 $1711.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 653 916 5770.91 $391729.08 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 35 37.00 $37.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 7 7.00 $3500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 13 8.42 $547.61 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 24 32 37.18 $696.05 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 25 33 34.20 $1710.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1226 1833 12029.79 $816582.05 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 10 45.71 $603.43 $13.20
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Subtotal (Total Children Is Unduplicated) 1839 5211 30382.93 $1957581.34 $64.43
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Total 5350 30507.08 $1962361.42 $64.32
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Number of Children (Unduplicated) With at Least One Authorization 1840