Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 8355 FSPSA's found
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 87 95 435.149204 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 4 17.571429 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 4.066667 $150.4700 $37.0000
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Subtotal (Total Children Is Unduplicated) 94 106 456.787300 $150.4700 $0.3300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 26 53.511731 $2595.3300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.032877 $1.5500 $47.1200
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 2.013492 $30.0600 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 2.013492 $38.6600 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 2.013492 $20.9800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 2.013492 $44.2000 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 2.013492 $17.6200 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 5 5 2.013492 $16.2300 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 2.391270 $52.2300 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 2.013492 $58.1900 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 2.013492 $131.1600 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 2.202381 $56.2300 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.188889 $8.8400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.022222 $122.2600 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 113 116 232.000000 $11600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 16 16 25.008219 $1875.6200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 14.077778 $1055.8400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 12 19.500000 $1462.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 17 23.010959 $1277.1000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 166 169 407.661641 $30574.6400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 67 67 139.578082 $10468.3600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 46 46 75.506850 $5663.0100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 215 215 496.598629 $27561.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 88 106 149.124953 $11184.3500 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 3.285714 $164.2900 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 2.000000 $102.1000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 6 17.844227 $910.9500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 3.000000 $153.1500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 24 171.565526 $8758.4200 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.022222 $15.9500 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 20 120.092130 $6130.7100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 497 914 1983.334236 $122555.9100 $61.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 19 50.069114 $250345.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 21 21 479.308729 $23965.4300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 4.142857 $296.6700 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 181 204 238.723982 $11936.1800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 5.452778 $136.3200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 159 254 725.575927 $36278.8400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 2.733334 $68.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 33 195.587300 $9779.3500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 74 213.333157 $10666.7000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 80 93 214.557148 $10727.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 9.428571 $235.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1165 1489 11970.696181 $598535.3000 $50.0000
INTR -T1013 INTERPRETER 79 98 533.478767 $26673.9400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1287 2253 15409.950341 $154099.6100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 50 396.057274 $28294.3500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 16.419048 $939.1700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 110 144 989.249214 $70671.9600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 38.669842 $2210.3700 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.022222 $66.4400 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 1.400000 $165.9800 $118.5600
SENS -V5264 EARMOLD 1 1 0.377778 $6.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 123 170 1154.747157 $82495.1600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.857143 $53.5400 $13.8800
TRAV -TRAVS Travel by mile 1316 2407 42549.001474 $18934.3100 $0.4500
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Subtotal (Total Children Is Unduplicated) 1334 7335 75204.839338 $1337633.3500 $17.7900
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Total 8355 77644.960874 $1460339.7300 $18.8100
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Number of Children (Unduplicated) With at Least One Authorization 1437