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: 04-01-13 and 06-30-13 Date of Report: 08-18-13 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 218 240 304.989676 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 218 240 304.989676 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 83 104 32.766452 $1589.2400 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 63 64 18.666661 $243.5900 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.166666 $36.3600 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 66 67 20.355550 $185.4300 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 68 68 20.577772 $192.1900 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 67 69 21.083328 $458.1300 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 16 18 5.283336 $300.8500 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 55 56 14.538884 $355.7500 $24.4700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.072222 $1.9700 $27.2700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 120 133 113.445820 $6806.7800 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 17 16.366571 $736.5100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 25 28 24.098524 $2771.3500 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 0.202739 $10.1400 $50.0200
EXIT -EXIT EXIT ASSESSMENT 75 75 11.281432 $564.0700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 0.074846 $5.6100 $74.9500
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.010958 $0.6100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 120 120 0.962265 $72.1900 $75.0200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 34 34 0.181352 $13.6300 $75.1400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 76 76 0.621796 $34.5500 $55.5600
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 29 0.223893 $16.7900 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 11 12 14.477777 $702.1700 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 410 489 250.364062 $12142.8400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 19 19 5.477529 $265.6700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 341 417 153.322714 $7436.3600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 327 366 143.357087 $6952.9700 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 13.212699 $1321.2700 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.505556 $25.2800 $50.0000
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Subtotal (Total Children Is Unduplicated) 1448 2283 883.720560 $43243.9500 $48.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 35 39 28.654874 $143276.0000 $5000.0600
AUD -HA_FUP AUDIOLOGY SERVICES 27 31 81.393769 $4069.6800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 316 396 36.517234 $1826.1700 $50.0100
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 20 20 1.529133 $38.2400 $25.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1802 2584 4196.337724 $209816.2500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 54 64 120.549997 $3013.7400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1511 1974 3423.732882 $171185.9600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 18 22 30.438887 $760.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1516 1989 3348.347884 $167416.7400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 25 44.033334 $1100.8400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2345 3055 4624.379773 $231218.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 39 43 75.869840 $1896.7400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.066667 $78.2100 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 17 21 2918.714287 $36483.9300 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 136 190 1496.391271 $37409.7700 $25.0000
EIIF -90812 INDIVIDUAL PSYCHOTHERAPY, 45-50 MIN 1 1 0.688889 $34.4500 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 2 2 0.888889 $44.4500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3908 5240 38528.350409 $1926417.3200 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 19 22 106.333333 $5316.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 44 54 292.155557 $14607.7900 $50.0000
INTR -INTR INTERPRETER 64 94 726.686139 $36334.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1073 1429 9082.457558 $616517.1900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 9 50.357143 $2735.4000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1306 1736 10318.114704 $700393.7500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 24 26 132.447618 $7194.5600 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 1.633335 $816.7500 $500.0500
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 7 4.759742 $309.3900 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 13 14 8.530596 $1945.0200 $228.0100
SENS -V5264 EARMOLD 40 47 39.623812 $713.2300 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 12 12 38.466667 $1923.3400 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 50 59 144.199207 $7209.9600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1402 1829 11404.679759 $774149.4700 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 5.785714 $314.2800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 13 14 78.061907 $1030.4100 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1260 1776 12115.115911 $121151.1300 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 3002 5344 1124446.591917 $562223.3100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 25 29 91.638889 $4581.9500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 42 55 310.616668 $15530.8400 $50.0000
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Subtotal (Total Children Is Unduplicated) 5892 28260 1228356.141919 $5811086.4800 $4.7300
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Total 30783 1229544.852155 $5854330.4300 $4.7600
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Number of Children (Unduplicated) With at Least One Authorization 6136