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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5383 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 2 2 6.890476 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 6.890476 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 68 87 36.562876 $1773.3400 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.018874 $50.6800 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 0.886453 $19.1000 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 3.510503 $29.0000 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 3.066667 $77.6200 $25.3100
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 13.586693 $630.6900 $46.4200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 4.066667 $84.1000 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 13.331899 $599.9300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 13.515461 $1554.2700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 104 104 175.083694 $8754.1800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 0.016437 $1.2400 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 4.350684 $241.4600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 69 69 53.754782 $4031.6600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 50 50 58.612321 $4395.9500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 94 94 91.752037 $5092.2800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 45 45 48.605473 $3645.4400 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.167123 $8.5300 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 11 12 4.212482 $215.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 23 24 5.479681 $279.7600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 24 29 5.119102 $261.3500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 9 12 14.923680 $761.8600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 9 10 4.795054 $244.8000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 9 9 2.108370 $107.6400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 32 38 15.813122 $807.2900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 1.169027 $59.6800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 6 9 2.317200 $118.2900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 53 58 15.611419 $796.9900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 15 15 3.442618 $175.7600 $51.0500
VISD -99202 VISION EVAL DIAG (SIMPLE) 1 1 0.186301 $6.7000 $35.9800
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 0.186301 $9.3200 $50.0000
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Subtotal (Total Children Is Unduplicated) 362 704 604.258480 $35134.3600 $58.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 70 90 42.114854 $210578.0000 $5000.0900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 3.066667 $153.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 2 0.282192 $64.9100 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 51 53 51.245725 $2562.2700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.344444 $58.6100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 401 547 1159.709577 $57985.7500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 8.783333 $219.5800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 144 179 359.500023 $17975.1200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 58 115.250004 $5762.5200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.866667 $21.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 299 368 743.400036 $37170.1800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.600000 $90.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 25 818.571433 $20464.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 463 583 4604.922246 $230246.3200 $50.0000
INTR -T1013 INTERPRETER 30 49 71.052760 $3552.6500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 471 854 4833.019447 $48330.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 110 136 1132.316670 $80892.7700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 54.642856 $3125.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 110 131 1146.422571 $81900.5200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 9.428571 $538.9400 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 2 0.504110 $114.9300 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 3 13.329159 $6078.0700 $456.0000
SENS -V5264 EARMOLD 4 6 16.250316 $292.5000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 122 147 1225.642855 $87560.0200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
TRAV -TRAVS Travel by mile 562 1425 373357.449865 $166144.0700 $0.4500
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Subtotal (Total Children Is Unduplicated) 604 4677 389779.278285 $1062132.2700 $2.7200
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Total 5383 390390.427241 $1097266.6300 $2.8100
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Number of Children (Unduplicated) With at Least One Authorization 610