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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 0.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 10 12 11.09 $180.84 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 16 19 14.89 $131.52 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 18 23 19.64 $212.10 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 18 23 19.64 $427.93 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 5 4.09 $222.35 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.00 $56.56 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 11 10.09 $321.11 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.01 $120.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 8 5.72 $267.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 9 9.00 $1076.40 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
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Subtotal (Total Children Is Unduplicated) 23 116 100.18 $3099.88 $30.94
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.00 $9000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 0.30 $20.63 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 20 28 63.52 $3175.95 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 83 89 89.67 $4483.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 73 102.70 $5134.77 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 45 90.50 $4525.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 26.00 $650.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 93 166.46 $8323.10 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.29 $214.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 2 2.00 $100.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 711 1023 6553.51 $327675.49 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 602 902 5569.95 $378088.37 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.00 $54.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 634 923 5899.41 $400451.84 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 58 76.69 $76.69 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
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 4 5 4.10 $266.23 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 4 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 19 27 22.09 $413.50 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 2.00 $100.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 26 37 48.13 $2406.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1240 1868 12559.11 $852512.16 $67.88
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Subtotal (Total Children Is Unduplicated) 1885 5197 31298.41 $2002344.21 $63.98
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Total 5314 31398.74 $2005444.09 $63.87
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Number of Children (Unduplicated) With at Least One Authorization 1886