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: 04-01-14 and 06-30-14 Date of Report: 08-18-14 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 2.433333 $0.0000 $0.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 24 20.144442 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 25 25 22.577775 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 3.344446 $162.2100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 5.623810 $254.6500 $45.2800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 1.655556 $23.7700 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 1.655556 $30.5600 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.655556 $16.5900 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 1.655556 $13.9200 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 1.655556 $12.8300 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.655556 $34.7700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 7 7 2.833334 $177.4600 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 1.655556 $36.4600 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 13 13 3.594443 $215.6600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 2.005557 $90.2600 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 4.455556 $512.3900 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.327778 $15.9000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 126 126 40.262716 $1952.8200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 142 142 101.151608 $4905.9500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 97 97 26.888901 $1304.1700 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 10.142857 $1014.2900 $100.0000
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Subtotal (Total Children Is Unduplicated) 359 442 212.219898 $10774.6600 $50.7700
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 19.074603 $953.7300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 536 543 1464.588927 $73229.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 528 532 1516.515107 $75825.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 544 548 1506.169876 $75308.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 790 798 1704.188925 $85209.6400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.644444 $16.1100 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 150.714286 $1883.9300 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 93 95 668.442851 $16711.0900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1343 1372 9785.972184 $489298.5600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 6 6 12.333333 $616.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 34.050000 $1702.5000 $50.0000
INTR -INTR INTERPRETER 1 1 9.600000 $480.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 313 317 1898.684126 $128882.7300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 17.957142 $975.4400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 443 449 2578.019451 $174996.0200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 10.142857 $550.9600 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.505556 $252.8000 $500.0400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.727778 $47.3100 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.772223 $176.0800 $228.0200
SENS -V5264 EARMOLD 5 5 4.033332 $72.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 30 30 49.396029 $2469.7900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 364 367 1955.247616 $132722.2800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.500000 $190.1200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 11.814286 $155.9500 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 14.400000 $1440.0000 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1128 1564 10252.348413 $102523.4700 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 351 1044 380957.311899 $190478.6600 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 4.411111 $220.5600 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 42.466667 $2123.3400 $50.0000
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Subtotal (Total Children Is Unduplicated) 2064 7714 414674.033022 $1559514.5100 $3.7600
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Total 8181 414908.830695 $1570289.1600 $3.7800
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Number of Children (Unduplicated) With at Least One Authorization 2099