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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 103 104 104.00 $1104.48 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 102 103 103.00 $909.49 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 101 102 102.00 $1101.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 101 102 102.00 $2222.58 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 92 93 93.00 $2630.04 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 129 152 152.00 $9120.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 11 11.00 $514.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 18.00 $2152.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 4.38 $218.89 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 44 50 50.00 $2425.00 $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 15 20 20.00 $970.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 44 49 49.00 $2376.50 $48.50
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Subtotal (Total Children Is Unduplicated) 314 805 810.38 $25816.02 $31.86
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 33 114.00 $171000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 24 32 81.73 $4086.66 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 108 103.77 $5188.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 9 10 7.17 $358.61 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 116 142 117.75 $5887.71 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 10 6.75 $337.50 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 183 243 157.52 $7876.04 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 47 64 390.43 $9760.84 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 12 12 8.81 $440.56 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 355 511 4458.63 $222931.69 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 29 37 71.38 $3569.03 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 50 68 166.81 $8340.68 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 363 549 2532.93 $171935.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.87 $210.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 571 825 2911.50 $197632.52 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 9.20 $499.74 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 224 249 248.33 $248.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.00 $260.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 14.00 $3319.68 $237.12
SENS -V5264 EARMOLD 21 23 44.00 $823.68 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 3.95 $197.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 32 42 113.42 $5670.83 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 856 1250 5030.06 $341440.21 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.93 $865.50 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 31.23 $412.28 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 26 39 244.91 $12245.28 $50.00
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Subtotal (Total Children Is Unduplicated) 1511 4279 16898.10 $1178538.73 $69.74
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Total 5084 17708.47 $1204354.75 $68.01
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Number of Children (Unduplicated) With at Least One Authorization 1544