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: 01-01-14 and 03-31-14 Date of Report: 06-03-14 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 3.000000 $0.0000 $0.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 76 79 61.955554 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 77 80 64.955554 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 32 9.617276 $466.4400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 6.928571 $313.7300 $45.2800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 12 12 7.766667 $111.5300 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 12 12 7.711112 $142.3500 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 14 8.333334 $83.5000 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 14 14 8.333334 $70.0800 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 11 11 7.244445 $56.1400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 7.422223 $155.8700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 23 24 19.261905 $1206.3800 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 7.766667 $171.0200 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 47 48 76.372222 $4582.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 10 2.663394 $119.8500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 18 11.061904 $1272.1200 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 0.651826 $32.5900 $50.0000
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 1 1 1.900000 $57.0000 $30.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 0.883334 $42.8500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 297 354 108.317461 $5253.4000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.044445 $2.1600 $48.5600
PSTH -97001 EVAL BY LICENSED PT, INITIAL 293 352 166.040316 $8053.0200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 220 244 80.477776 $3903.1600 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.000000 $1100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.138889 $6.9500 $50.0000
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Subtotal (Total Children Is Unduplicated) 787 1186 549.937101 $27202.4800 $49.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.933333 $4666.5000 $4999.8200
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 28.397620 $1419.8900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 0.349505 $17.4800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1041 1158 4112.376968 $205618.7700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 0.500000 $12.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1027 1156 4070.086485 $203504.2100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1066 1188 4089.633314 $204481.5800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.433333 $10.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1506 1718 4587.488867 $229374.3600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.066667 $51.6700 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 437.857142 $5473.2100 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 184 218 1761.500013 $44037.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2641 3233 25295.719157 $1264784.6900 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 16 16 122.808333 $6140.4200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 12 81.680953 $4084.0500 $50.0000
INTR -INTR INTERPRETER 5 5 31.044444 $1552.2200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 671 809 5381.330960 $365284.5700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 13 13 89.428571 $4857.7600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 890 1026 6593.203969 $447546.4600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 16 16 87.001587 $4725.9200 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 2 0.500000 $250.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 1.163394 $75.6200 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 1.071233 $244.2600 $228.0100
SENS -V5264 EARMOLD 16 18 10.416667 $187.5000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 50 63 110.792062 $5539.6000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 820 932 5805.023425 $394044.8100 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.142857 $388.0000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 43.900000 $579.4800 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 24.171429 $2417.1400 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 2052 3385 25855.125479 $258551.1000 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 719 2293 803864.846026 $401932.4200 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 15 15 52.641667 $2632.0900 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 14 17 57.100794 $2855.0400 $50.0000
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Subtotal (Total Children Is Unduplicated) 3882 17343 892607.736254 $4067341.5500 $4.5600
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Total 18609 893222.628909 $4094544.0200 $4.5800
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Number of Children (Unduplicated) With at Least One Authorization 3957