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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 Page: 1
Child has a MEDICAID # Filter: Y
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
CASE -CASE NON-TCM CASE MANAGEMENT 3 3 4.35 $161.04 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 778 823 1102.20 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 36 41 104.57 $3869.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 36 37 71.64 $2650.58 $37.00
TCON -TCON TRANSITION CONFERENCE 13 13 13.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 830 917 1295.77 $6680.76 $5.16
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 106 146 175.86 $8529.07 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 23 24 45.25 $1632.02 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 174 196 278.00 $2952.36 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 156 173 173.00 $1527.59 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 156 173 173.00 $1868.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 148 166 166.00 $3617.14 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 6 6.00 $326.28 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 140 156 156.00 $4411.68 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 438 534 780.88 $46853.08 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 39 56 63.39 $2966.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 312 334 413.49 $49453.37 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 13 13 16.70 $2087.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 76 81 300.88 $37609.95 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 608 819 1102.99 $55149.65 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 142 155 212.68 $10633.93 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 23 23 27.00 $810.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 14 15 18.50 $1387.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 2 2 2.50 $138.75 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 58 58 75.48 $5661.20 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 8.01 $600.42 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 17 17 25.23 $1892.09 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 60 62 78.57 $5892.86 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 127 131 171.72 $9530.59 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 39 39 48.00 $2664.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 887 895 1284.57 $96342.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 207 210 286.50 $21487.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 320 322 461.68 $34625.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 979 998 1423.42 $79000.03 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1000 1110 1540.28 $115520.73 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 3 3 3.00 $450.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.77 $88.34 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 6 6 6.00 $300.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 227 327 475.49 $23061.10 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1139 1365 1684.95 $81720.14 $48.50
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 4 4 8.10 $1215.21 $150.00
PDFO -T1024HTTS *PSY-DEV EVAL OUTPATIENT, FOLLOW-UP 2 2 0.68 $102.11 $150.00
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 267 364 428.92 $20802.73 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 993 1183 1372.72 $66576.86 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 32 32 35.00 $1750.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2247 2805 3302.84 $160187.64 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 5 5 10.00 $1000.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 20 24 63.20 $3159.77 $50.00
WHEELO-97003TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 5.00 $242.50 $48.50
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Subtotal (Total Children Is Unduplicated) 6316 13050 16929.52 $967352.80 $57.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 199 269 370.62 $555928.50 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 4 5.07 $348.89 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 4 3.93 $270.85 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 189 229 783.31 $39165.70 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 915 1993 3735.36 $186767.90 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 46 55 121.50 $3037.62 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2263 3628 11906.53 $595326.47 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 170 193 830.47 $20761.76 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1115 1766 4909.30 $245465.19 $50.00
CONOP -CONOP CONSULT, OT, PHONE 65 74 180.65 $4516.37 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 896 1419 4107.07 $205353.62 $50.00
CONPP -CONPP CONSULT, PT, PHONE 58 71 196.73 $4918.27 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2238 3335 9750.78 $487539.18 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 227 265 930.26 $23256.52 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 58 64 517.10 $37965.61 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 38 47 10586.43 $132330.36 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 15 15 64.47 $1611.66 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 81 82 1542.42 $38560.51 $25.00
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 2 2 15.00 $187.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 567 872 10711.48 $267786.91 $25.00
EIIF -90846 FAMILY PSYCHOTHERAPY W/O PATIENT 1 1 7.71 $385.72 $50.00
EIIF -90847 FAMILY PSYCHOTHERAPY WITH PATIENT 1 1 8.29 $414.29 $50.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 14 15 370.09 $18504.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 6 7 25.49 $1274.45 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 62 80 1322.71 $66135.72 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1009 1029 8804.25 $440212.30 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 16 19 290.28 $7256.91 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5923 9723 143874.69 $7193734.62 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 39.29 $1964.29 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 6 6 94.57 $4728.57 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 66 113 1091.31 $54565.54 $50.00
INTR -INTR INTERPRETER 184 273 2680.25 $134012.36 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 3013 5289 61171.46 $4152318.98 $67.88
OCCT -97530HM OT SESSION BY OT ASST 325 383 5082.42 $276077.23 $54.32
PHY -97110 PT SESSION BY LICENSED PT 3488 6318 74206.07 $5037108.28 $67.88
PHY -97110HM PT SESSION BY PT ASST 383 438 5855.07 $318047.32 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 344 369 1299.94 $1299.94 $1.00
SENS -FM FM RECEIVER HEARING AID 4 4 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 18 24 35.50 $17750.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 22 28 23.84 $1549.49 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 20 23 35.17 $8338.70 $237.12
SENS -V5264 EARMOLD 75 103 236.34 $4424.21 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 4 4 24.08 $1203.81 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 109 173 1184.79 $59239.45 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 22.29 $1114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5816 9773 112493.26 $7636042.49 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 53 53 512.46 $27836.91 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 563 658 9603.67 $126768.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 34 51 208.92 $20891.93 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4338 9156 1328734.49 $664367.21 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 145.14 $7257.14 $50.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 28 28 272.30 $13615.13 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 106 193 2000.78 $100039.17 $50.00
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Subtotal (Total Children Is Unduplicated) 12169 58730 1823135.87 $29256520.56 $16.05
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Total 72697 1841361.16 $30230554.12 $16.42
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Number of Children (Unduplicated) With at Least One Authorization 12874