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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 3.725397 $137.8400 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.725397 $137.8400 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 82 91 91.229369 $4424.6400 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 30 30 30.000000 $355.8000 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 30 30 30.000000 $248.4000 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 30 30 30.000000 $311.4000 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 30 30 30.000000 $632.4000 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 26 26 26.000000 $706.9400 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 31 34 28.883334 $1733.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 4.600000 $529.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.000000 $375.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 17.000000 $850.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 343 368 674.676190 $33733.8100 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 6.011111 $333.6200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $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 17 17 8.130554 $451.2400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 9 18.000000 $1350.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 0.744444 $36.1000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 34 35.983334 $1745.1900 $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 26 28 27.517461 $1334.6000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 11 11 12.916668 $645.8400 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 2 1.600000 $24.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 46 49 41.800794 $2027.3400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.000000 $200.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 13.000000 $650.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 629 839 1162.093259 $54736.8300 $47.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 34 37 35.811110 $53716.5000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 72 85 206.281743 $10314.0800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 683 1022 2058.625611 $102931.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 34 36 47.152183 $1178.8000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2528 3314 7648.482496 $382423.8200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 115 129 239.052766 $5976.2900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1488 1705 2971.852380 $148592.5800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 36 38 69.787694 $1744.6800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1682 1961 4044.601974 $202230.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 49 53 80.344838 $2008.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3043 3728 6397.538851 $319876.7000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 114 123 207.659518 $5191.4800 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 17.971429 $449.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 31 232.109518 $5802.7300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 6 149.009524 $7450.4800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 44.000000 $2200.0000 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 6.400000 $160.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 390 470 3751.988889 $187599.4300 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 13.000000 $650.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.100000 $105.0000 $50.0000
INTR -INTR INTERPRETER 237 333 2204.628582 $110231.4100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 143 175 1013.976188 $68828.6600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 8 9 45.247620 $2457.8600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 191 228 1127.559518 $76538.7000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 8 8 57.995239 $3150.3000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 581 669 4561.146808 $4561.1500 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 1.333333 $2199.9500 $1649.9600
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 5 8.000000 $4000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 11 12 11.057534 $718.7400 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 2 1.600000 $182.4000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 1.600000 $364.8000 $228.0000
SENS -V5264 EARMOLD 8 9 12.327778 $221.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 5.676190 $283.8100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 316 380 2418.819845 $164189.4900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 26.896825 $355.0400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 7 7 56.461905 $5646.1900 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 6304 11309 3037867.549930 $1518933.7900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 4 5 33.614286 $1680.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 8339 25915 3077679.262105 $3405146.9000 $1.1100
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Total 26756 3078845.080761 $3460021.5800 $1.1200
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Number of Children (Unduplicated) With at Least One Authorization 8463