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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 408 451 2963.749201 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 1.888889 $69.8900 $37.0000
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Subtotal (Total Children Is Unduplicated) 409 454 2965.638090 $69.8900 $0.0200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 103 118 48.824275 $2367.9700 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 26 27 10.188887 $132.9600 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.022222 $17.1500 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 26 27 10.188887 $92.8200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 27 10.188887 $95.1600 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 26 27 10.188887 $221.4000 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 0.255556 $14.5500 $56.9500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 23 10.166665 $248.7700 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 29 34 59.398860 $3563.9400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.788889 $170.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 6.918721 $795.6500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 1.009589 $50.4800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 127 132 130.831220 $6541.5500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 1.044444 $78.3300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.022222 $56.7300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 1.740217 $130.4900 $74.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 0.044444 $3.3300 $74.9300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 0.022222 $1.2300 $55.4400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 1.509589 $113.2200 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.366667 $17.7900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 40 26.287305 $1274.9500 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.372222 $18.0500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 26 6.488889 $314.7100 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.294444 $4.4200 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 51 56 33.120636 $1606.3500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 13.303968 $1330.4000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 1.046575 $52.3300 $50.0000
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Subtotal (Total Children Is Unduplicated) 415 603 390.635389 $19440.2500 $49.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 31 38 29.715602 $44573.4000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 64 66 189.816414 $9490.8200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 283 350 118.801626 $5940.3200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 21 24 34.744571 $868.6200 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2561 4372 8777.909092 $438896.6800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 70 78 147.308340 $3682.7300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1813 2238 4608.762502 $230438.8700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 30 39 63.800001 $1595.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1829 2246 4256.545776 $212827.9500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 29 54.772223 $1369.3100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2898 3514 5878.453732 $293923.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 73 76 127.176990 $3179.4400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.466667 $180.8600 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 328.571429 $4107.1400 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 17 122.219050 $3055.4800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.695238 $834.7700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 28.571427 $1428.5800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 317 372 3105.093648 $155254.8200 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 6.133333 $306.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 1.800000 $90.0000 $50.0000
INTR -INTR INTERPRETER 116 141 1134.097355 $56704.9100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 102 130 759.733336 $51570.7200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 8 37.400000 $2031.5700 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 131 168 853.215072 $57916.2700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 15.571429 $845.8400 $54.3200
SENS -FM FM RECEIVER HEARING AID 2 2 14.909524 $24600.8400 $1650.0100
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 9 9 8.038889 $4019.4500 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 11 12 8.052665 $523.4300 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.133333 $486.3900 $228.0000
SENS -V5264 EARMOLD 6 6 7.505555 $135.1000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 21.397620 $1069.8800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 204 255 1647.373813 $111823.7700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 2 13.142857 $173.4900 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 22.428572 $2242.8500 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5363 10057 2197287.858206 $1098643.8800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 22.000000 $1100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 6796 24274 2229754.215887 $2825933.2800 $1.2700
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Total 25331 2233110.489366 $2845443.4100 $1.2700
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Number of Children (Unduplicated) With at Least One Authorization 7238