Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 Page: 1
Child has a MEDICAID # Filter: Y
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 5 5 5.000000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 13.044444 $482.6400 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 19.044444 $482.6400 $25.3400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 61 72 73.819048 $3580.2300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 16 17 17.000000 $201.6200 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 16 17 17.000000 $140.7600 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 17 17.000000 $176.4600 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 16 17 17.000000 $358.3600 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 15.000000 $407.8500 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 20 17.722223 $1063.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 5.785714 $723.2100 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 8.000000 $1000.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 6.000000 $300.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 321 342 646.428571 $32321.4300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.500000 $337.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 6.063888 $336.5400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 37 37 18.277773 $1014.3900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 15 30.000000 $2250.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 5 5 5.000000 $250.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 1.838890 $89.1900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 34 40.688888 $1973.4100 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 19.438888 $942.7800 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 5 6 5.100000 $255.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 58 60 48.838890 $2368.6900 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 4 4 8.714286 $871.4300 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 13.285714 $664.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 596 758 1078.002773 $54227.4700 $50.3000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 31 27.161112 $40741.8000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 68 79 212.861905 $10643.0900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 838 1390 3615.456147 $180773.4100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 39 42 38.762897 $969.0700 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2008 2584 8645.815858 $432290.7400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 128 150 234.488884 $5862.2100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 782 937 2599.296018 $129964.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 42 50 89.130555 $2228.2600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 944 1153 4060.855918 $203042.6500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 54 63 144.193251 $3604.8200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2526 3104 7331.349785 $366567.5300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 128 142 190.978568 $4774.4500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.222222 $16.2900 $73.3100
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 20.466667 $511.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 25 28 159.014287 $3975.3600 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 9 9 189.285713 $9464.3000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 1.571429 $78.5700 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 17.133333 $428.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 373 458 3510.201606 $175510.0900 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 13.000000 $650.0000 $50.0000
INTR -INTR INTERPRETER 251 374 2261.852306 $113092.5900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 132 160 920.550403 $62486.9700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 6 6 41.371429 $2247.2900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 173 218 1136.745243 $77162.2600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 8 8 40.152380 $2181.0800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 667 750 982.738882 $982.7400 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 3.000000 $4950.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 8.000000 $4000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 7.260274 $471.9200 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 4 4 6.311111 $113.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 3.142857 $157.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 315 380 2464.587302 $167296.1400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 20.892857 $275.7900 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 8 8 39.161905 $3916.1800 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5481 9924 2581648.234145 $1290824.1200 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 16.000000 $800.0000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 7736 22090 2620708.647249 $3303667.2400 $1.2600
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Total 22856 2621805.694466 $3358377.3500 $1.2800
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Number of Children (Unduplicated) With at Least One Authorization 7840