Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 2573 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 38 46 768.529366 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 38 46 768.529366 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.255556 $13.1300 $51.3600
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 2.000000 $35.8400 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 7.000000 $149.4500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $25.2200 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 13 13 17.202740 $370.7200 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 31 31 15.657066 $129.3300 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 33 33 15.236974 $385.6500 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 7 7 7.000000 $244.7900 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 2.466667 $190.2600 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 3.466667 $160.9200 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 28 28 12.657066 $234.7900 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 9.466667 $195.7700 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 2.509665 $112.9400 $45.0000
EXIT -EXIT EXIT ASSESSMENT 81 81 53.357459 $2667.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 10.568298 $792.6200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.139727 $7.7500 $55.4900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 17.005479 $1275.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 26 26 10.684929 $593.0300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 21 2.679450 $200.9800 $75.0100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.061111 $54.1700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 6.746195 $344.3900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 40.000000 $2042.0000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.087671 $4.4800 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 34 35 22.284398 $1137.6100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 11 11 5.800000 $296.0900 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 199 352 273.333785 $12019.4200 $43.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.488889 $74.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 22.638128 $1131.9000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.400000 $322.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 120 136 120.893333 $6044.6600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 1.938890 $48.4800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 288 549 1636.165267 $81808.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.800000 $70.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 10 32.138096 $1606.9100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 28.842857 $1442.1500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.866667 $21.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 31 114.342858 $5717.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.800000 $70.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 12.857143 $321.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 894 1205 10576.626970 $528831.7700 $50.0000
INTR -T1013 INTERPRETER 7 11 116.466666 $5823.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 157.285714 $11236.5000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.428571 $138.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 18 21 176.495237 $12608.8500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 7.000000 $400.1200 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.800000 $364.8000 $456.0000
SENS -V5264 EARMOLD 1 1 0.800000 $14.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 90 111 940.142859 $67163.8900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 44.142856 $612.7000 $13.8800
TRAV -TRAVS Travel by mile 36 48 420.104764 $186.9500 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 922 2175 14422.465765 $731061.3500 $50.6900
-------------------------------------------------------------------------------------------------------------------------------------
Total 2573 15464.328916 $743080.7700 $48.0500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 961