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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 1.688890 $62.4900 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.300000 $85.1000 $37.0000
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Subtotal (Total Children Is Unduplicated) 6 6 3.988890 $147.5900 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 102 129 83.149998 $4032.7700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 4 4.044445 $173.8700 $42.9900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 46 46 46.000000 $600.3000 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 6 6 6.955555 $116.7100 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 52 52 52.011111 $473.8200 $9.1100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.4500 $23.4500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 51 51 51.955555 $485.2600 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 52 52.955555 $1150.7200 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 10 10 5.605556 $319.1800 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 40 40 38.727778 $947.6700 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 258 284 225.780844 $13546.8500 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 24 26 19.364537 $871.4100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 63 68 85.239520 $9802.5400 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 17.714286 $2214.2900 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 30 35 39.066667 $1953.3400 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 337 361 584.669173 $29233.4200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 9 9.666667 $725.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 44 45 77.664209 $5824.8200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 7 12.011111 $900.8300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 50 51 79.955479 $4437.5300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 242 242 430.116358 $32258.7200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 60 60 108.500000 $8137.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 236 238 450.083103 $24979.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 181 216 409.572145 $30717.9100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 27 28 13.927779 $675.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 373 426 284.228528 $13785.0300 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 3.627779 $175.9500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 353 436 261.762305 $12695.4200 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 26 26 38.038892 $1901.9600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 3.311111 $49.6700 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 399 436 367.624740 $17829.7800 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 3.450793 $345.0800 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 6.252055 $312.6100 $50.0000
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Subtotal (Total Children Is Unduplicated) 2153 3420 3891.033634 $223023.5200 $57.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 71 81 190.856424 $286284.6000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 3.022222 $208.1100 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.105556 $7.2700 $68.8900
AUD -HA_FUP AUDIOLOGY SERVICES 80 92 229.573484 $11478.6600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 473 572 370.043187 $18502.3200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 30 58.452978 $1461.3300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2570 4369 8904.053048 $445203.8200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 91 108 190.006748 $4750.1800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1742 2087 4692.362920 $234618.9900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 34 38 65.155556 $1628.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1818 2181 4681.641825 $234082.8800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 35 63.744447 $1593.6200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2973 3618 6483.527525 $324177.1400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 84 95 148.171828 $3704.3000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 22 82.880953 $6076.8300 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 9 9 961.571428 $12019.6400 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 2 3.866666 $96.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 253 333 2440.933332 $61023.3500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 138.847619 $6942.3800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 52.849206 $2642.4700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5888 8006 59100.987296 $2955052.0800 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 5 19.257144 $962.8600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 83 106 565.092068 $28254.6100 $50.0000
INTR -INTR INTERPRETER 192 306 1889.870195 $94493.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1154 1537 9471.294459 $642911.7900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 36 37 248.822618 $13516.0500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1569 2104 12958.770073 $879641.7000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 62 69 401.998811 $21836.5700 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 505 578 6547.671426 $6547.6700 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 9.638096 $15902.8700 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 10 10 10.827778 $5413.9000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 15 15 17.064536 $1109.2000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 3.044444 $347.0600 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 11 12 11.819407 $2694.8500 $228.0000
SENS -V5264 EARMOLD 51 64 85.149161 $1532.6800 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 4 4 6.161111 $308.0600 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 86 105 335.608735 $16780.4500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1852 2405 15875.601595 $1077636.3800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 26.285714 $1427.8400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 44 49 383.900796 $5067.5000 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 4 4 29.376190 $2937.6200 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5861 11843 2429965.427736 $1214982.7100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 6 8 54.942857 $2747.1500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 86 112 692.139288 $34607.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 8689 41071 2568472.418486 $8683215.5600 $3.3800
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Total 44497 2572367.441010 $8906386.6700 $3.4600
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Number of Children (Unduplicated) With at Least One Authorization 8823