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
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 24 20.144442 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 20.144442 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 2.838890 $137.6900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.266667 $12.0800 $45.2900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.222222 $3.1900 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.222222 $4.1000 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.222222 $2.2300 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.222222 $1.8700 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.222222 $1.7200 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.222222 $4.6700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.222222 $13.9200 $62.6200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.222222 $4.8900 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 0.622221 $37.3300 $59.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.461111 $168.0300 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 1.872224 $90.8100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 1.022223 $49.5800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 2.811113 $136.3500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 10.142857 $1014.2900 $100.0000
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Subtotal (Total Children Is Unduplicated) 32 44 22.815082 $1682.7400 $73.7600
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 19.074603 $953.7300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 145 146 210.088895 $10504.4800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 135 135 258.081742 $12904.0700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 152 152 241.336509 $12066.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 404 405 458.822225 $22941.1400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.644444 $16.1100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.800000 $20.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 66 406.925397 $20346.2800 $50.0000
INTR -INTR INTERPRETER 1 1 9.600000 $480.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 24 135.847619 $9221.3400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 33 34 177.920634 $12077.2400 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.727778 $47.3100 $65.0000
SENS -V5264 EARMOLD 1 1 0.733333 $13.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 3.366666 $168.3300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 45 238.188098 $16168.2200 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 2 2 14.400000 $1440.0000 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1127 1561 10227.148413 $102271.4700 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 115 258 61523.945233 $30761.9700 $0.5000
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Subtotal (Total Children Is Unduplicated) 1297 2840 73927.651589 $252401.7200 $3.4100
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Total 2908 73970.611113 $254084.4600 $3.4300
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Number of Children (Unduplicated) With at Least One Authorization 1327