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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 9.43 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 9.43 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 9 13 10.29 $167.71 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 17 24 16.23 $143.34 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 21 28 20.54 $221.88 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 27 19.88 $433.14 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 5.14 $279.75 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.00 $56.56 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 13 10.32 $328.35 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 0.87 $18.50 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 4 7.43 $445.72 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 9.00 $1076.40 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
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Subtotal (Total Children Is Unduplicated) 26 137 111.71 $3645.75 $32.64
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 8.00 $12000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 23 32 77.82 $3891.21 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 71 79 90.63 $4531.55 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 90 115.42 $5770.84 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 60 102.00 $5100.25 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 88 109 160.12 $8005.84 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.00 $146.84 $73.42
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 649 935 5841.47 $292073.30 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 602 912 5837.81 $396270.80 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 28.21 $1532.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 615 944 5846.95 $396891.06 $67.88
RSPT -RSPT RESPITE 1 2 2.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 37 43 43.57 $43.57 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 6.41 $416.72 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 22 30 35.23 $659.43 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 2.00 $100.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 29 33 36.43 $1821.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1207 1859 11820.20 $802355.03 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 4 26.57 $350.74 $13.20
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Subtotal (Total Children Is Unduplicated) 1792 5172 30098.84 $1938342.17 $64.40
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Total 5310 30219.98 $1941987.92 $64.26
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Number of Children (Unduplicated) With at Least One Authorization 1793