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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 10 14 14.000000 $213.5000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 14 14.000000 $115.9200 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 15 15.000000 $155.7000 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 14 14.000000 $295.1200 $21.0800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $22.9600 $22.9600
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.000000 $103.5200 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 5.000000 $135.9500 $27.1900
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.000000 $225.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.000000 $575.0000 $115.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 13 76 76.000000 $1891.1700 $24.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 14.000000 $21000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 12 16 21.571429 $1078.5700 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 498 622 685.581749 $34279.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 51 58.305557 $2915.2900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 52 60.033334 $3001.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 496 602 670.742860 $33537.1600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 710 935 6703.638108 $335182.0800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 343 480 3077.985715 $208933.7900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 485 650 4382.726199 $297499.6800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 1.000000 $54.3200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 21 21.585714 $21.5900 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 12 16 16.000000 $288.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.000000 $50.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 37 46 58.142857 $2907.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 846 1173 8377.204745 $568645.1700 $67.8800
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Subtotal (Total Children Is Unduplicated) 1513 4686 24155.518267 $1510964.5500 $62.5500
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Total 4762 24231.518267 $1512855.7200 $62.4300
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Number of Children (Unduplicated) With at Least One Authorization 1513