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
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Subtotal (Total Children Is Unduplicated) 4 4 1.688890 $62.4900 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 98 124 81.311110 $3943.5800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 23 23 23.000000 $300.1500 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.611111 $10.2500 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 23 23 23.000000 $209.5300 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 22 22 22.000000 $205.4800 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 22 22 22.000000 $478.0600 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.116667 $6.6400 $56.9600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 20 20 19.611111 $479.8800 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 34 38 31.272602 $1876.3500 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.344445 $60.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 4.042694 $464.9100 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 14 17 31.000000 $1550.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 333 355 565.523575 $28276.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.144444 $310.8300 $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 2 2 2.144444 $119.0100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 26.063888 $1954.7900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 27.000000 $1498.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.000000 $750.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.427778 $20.7500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 32 16.892062 $819.2600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 23 14.699998 $712.9400 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 6 6 8.011112 $400.5600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.800000 $42.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 50 54 96.680952 $4689.0200 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 3.450793 $345.0800 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 5.252055 $262.6100 $50.0000
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Subtotal (Total Children Is Unduplicated) 618 830 1050.400841 $50383.8300 $47.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 35 38 39.776028 $59664.1500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 78 90 225.995706 $11299.7700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 471 569 366.828901 $18341.6100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 30 58.452978 $1461.3300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2566 4362 8895.567333 $444779.5300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 91 108 190.006748 $4750.1800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1733 2077 4684.002602 $234200.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 34 38 65.155556 $1628.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1806 2166 4647.708491 $232386.2200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 35 63.744447 $1593.6200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2958 3603 6448.858476 $322443.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 84 95 148.171828 $3704.3000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 6.133333 $449.6900 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 150.000000 $1875.0000 $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 28 30 385.628574 $9640.7100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 86.276190 $4313.8100 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 52.571428 $2628.5800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 362 443 3474.709534 $173735.5800 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 3 12.685715 $634.2900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 14.982540 $749.1300 $50.0000
INTR -INTR INTERPRETER 192 306 1889.870195 $94493.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 113 136 730.596824 $49592.9100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 7 60.495237 $3286.1000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 135 169 951.469043 $64585.7100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 8 57.400000 $3117.9700 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 504 576 6492.957140 $6492.9600 $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 8 8 7.783334 $3891.7000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 13 13 13.745814 $893.4800 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.533333 $288.8000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.533333 $577.5900 $228.0000
SENS -V5264 EARMOLD 8 8 8.049999 $144.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 10.153969 $507.7000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 223 286 1876.234917 $127358.9000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 36.631747 $483.5400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 4 4 29.376190 $2937.6200 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5853 11811 2423694.794402 $1211847.3900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 5 33.242857 $1662.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 7636 27054 2465928.629504 $3118443.5700 $1.2600
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Total 27888 2466980.719235 $3168889.8900 $1.2800
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Number of Children (Unduplicated) With at Least One Authorization 7746