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: 07-01-14 and 09-30-14 Date of Report: 11-19-14 Page: 1
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 3 3 2.511111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 0.494444 $23.9800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.011111 $0.1600 $14.3500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.011111 $0.2000 $18.4400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.011111 $0.1100 $10.0100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.011111 $0.0900 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.011111 $0.0900 $7.7400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.011111 $0.2300 $20.9800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 0.383333 $24.0100 $62.6200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.011111 $0.2400 $22.0000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.072222 $1.7700 $24.5400
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.194444 $11.6600 $59.9900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.316666 $14.2500 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.233333 $256.8300 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 54 54 7.288891 $353.5200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 0.283333 $13.7400 $48.4900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 63 63 21.279364 $1032.0400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 75 75 12.255563 $594.4300 $48.5000
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Subtotal (Total Children Is Unduplicated) 180 219 44.879370 $2327.3600 $51.8600
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.557143 $127.8600 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 103 104 90.365881 $4518.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 118 118 105.380960 $5269.0900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 109 111 98.888102 $4944.4400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 212 213 139.885725 $6994.3400 $50.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 65.714286 $821.4300 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 18 71.714285 $1792.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 359 361 1210.977761 $60548.8700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 90 92 229.800000 $15598.8000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.800000 $43.4600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 141 141 309.518650 $21010.1100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.133333 $66.6500 $499.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.183333 $11.9100 $64.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.366667 $83.6100 $228.0200
SENS -V5264 EARMOLD 2 2 1.000000 $18.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 7.857937 $392.9000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 130 355.045235 $24100.4800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 16.428571 $216.8600 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 344 507 1437.665874 $14376.6600 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 112 281 25124.303968 $12562.1500 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.285714 $164.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 638 2100 29271.873425 $173663.0500 $5.9300
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Total 2322 29319.263906 $175990.4200 $6.0000
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Number of Children (Unduplicated) With at Least One Authorization 652