Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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 4952 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 7 7 7.899999 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 7.899999 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 54 73 22.916511 $1111.5000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.035616 $0.5300 $14.9200
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.468949 $25.7300 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 1.345207 $29.5300 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.468949 $21.6000 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.468949 $53.9200 $21.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.046575 $1.7900 $38.3900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.035616 $0.8200 $22.8900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.433333 $62.1200 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 13.142857 $615.0900 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 13.142857 $1571.8900 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 4 4 2.339725 $116.9900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 78 80 42.349162 $2117.4800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 2.020547 $151.5500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 4.015068 $222.8400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 103 103 84.472581 $6335.5100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 12.046573 $903.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 116 117 118.819939 $6594.5600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 30 30.097256 $2257.3100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 11 11 2.564309 $130.9200 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 40 13.323216 $680.1500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 12 15 13.875770 $708.3600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 58 64 25.057862 $1279.2200 $51.0500
SCREEN-T1023 SCREENING 9 11 3.284704 $164.2400 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.287671 $14.6900 $51.0600
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.161644 $8.2500 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 32 34 8.740032 $446.1800 $51.0500
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Subtotal (Total Children Is Unduplicated) 337 633 423.966957 $25626.6700 $60.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 57 76 26.631351 $133162.0000 $5000.2000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.433333 $121.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 66 27.826146 $1391.3000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 13 18.484721 $462.1200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 347 495 1084.492835 $54224.9000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 12 17 36.990476 $924.7600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 93 189.539275 $9476.9900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 8.800000 $220.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 65 148.285396 $7414.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 6.944445 $173.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 258 304 674.776227 $33738.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 8 20.900002 $522.5100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 43 46 2218.347625 $55458.6800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 415 522 4218.254281 $210912.8700 $50.0000
INTR -T1013 INTERPRETER 15 21 115.742205 $5787.1100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 463 902 5053.531384 $50535.3700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 101 126 1322.252440 $94461.7700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 138 172 1621.674100 $115852.5100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 27.571428 $1575.9900 $57.1600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 2 13.142857 $6232.8900 $474.2400
SENS -V5264 EARMOLD 2 3 14.765079 $265.7700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 116 139 1319.118195 $94237.8600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 13.356556 $185.3900 $13.8800
TRAV -TRAVS Travel by mile 523 1228 304363.589711 $135441.8000 $0.4500
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Subtotal (Total Children Is Unduplicated) 569 4312 322547.450068 $1012781.1500 $3.1400
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Total 4952 322979.317024 $1038407.8200 $3.2200
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Number of Children (Unduplicated) With at Least One Authorization 580