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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 Page: 1
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 1 1 1.00 $37.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 39 40 17.71 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 17 20 46.13 $1706.67 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 13 15 28.25 $1045.16 $37.00
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Subtotal (Total Children Is Unduplicated) 63 76 93.08 $2788.83 $29.96
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 70 75 88.00 $4268.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 17 17 19.00 $685.33 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 110 111 112.00 $1189.44 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 10 7.97 $129.95 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 125 128 125.54 $1108.51 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 126 129 125.44 $1354.80 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 127 128 127.03 $2768.06 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 11 11 9.59 $521.75 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 108 110 110.52 $3125.57 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 7 5.58 $177.61 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 3 3 2.38 $50.74 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 489 526 525.90 $31553.72 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 66 70 72.22 $3380.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 330 343 489.16 $58502.99 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 28 28 34.09 $4260.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 51 53 108.86 $13607.15 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 143 155 245.52 $12275.76 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 252 274 474.25 $23712.50 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 9 9 9.00 $270.00 $30.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 2 2.00 $111.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 33 33 52.50 $3937.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.00 $225.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 13.50 $1012.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 14 21.00 $1575.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 57 61 81.57 $4526.95 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 28 28 55.00 $3052.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 791 797 1305.86 $97939.29 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 168 169 288.71 $21653.57 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 175 177 290.14 $21760.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 634 635 1073.03 $59553.35 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 544 586 846.71 $63503.58 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 5 5 7.00 $1050.00 $150.00
NURS -NURS NURSING ASSESSMENT 8 8 35.60 $1780.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 7 7 7.00 $350.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 225 283 309.46 $15008.87 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1272 1469 1589.89 $77109.54 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 211 270 297.84 $14445.42 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 891 999 1113.33 $53996.74 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 44 47 46.30 $2315.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2730 3155 3447.28 $167192.98 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 7 7 21.11 $2110.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 12 12 14.51 $725.48 $50.00
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Subtotal (Total Children Is Unduplicated) 6186 10967 13620.40 $778297.51 $57.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 174 212 453.29 $679928.55 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 4 9.87 $679.53 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 13.14 $905.02 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 264 306 676.28 $33813.99 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1083 2065 3679.24 $183962.09 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 40 43 45.72 $1143.12 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2713 3390 6474.74 $323737.15 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 128 147 276.48 $6912.02 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1216 1507 2471.49 $123574.60 $50.00
CONOP -CONOP CONSULT, OT, PHONE 45 52 75.97 $1899.31 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1001 1264 2276.63 $113831.26 $50.00
CONPP -CONPP CONSULT, PT, PHONE 47 50 85.38 $2134.48 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2914 3638 6231.60 $311580.23 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 179 194 373.06 $9326.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 41 44 465.78 $34197.63 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 21 23 2111.00 $26387.50 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 8.33 $208.33 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 517 643 6616.60 $165414.91 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 18 19 551.43 $27571.43 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 6 6 19.35 $967.70 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 30 30 231.97 $11598.57 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 11 11 75.11 $1877.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7449 9602 72547.01 $3627350.58 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 27 28 66.44 $3321.95 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 101 149 847.07 $42353.45 $50.00
INTR -INTR INTERPRETER 182 214 1391.42 $69571.02 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 3676 4964 32038.99 $2174806.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 236 261 1905.54 $103509.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 3868 5216 32841.37 $2229272.46 $67.88
PHY -97110HM PT SESSION BY PT ASST 236 270 1828.15 $99305.25 $54.32
RSPT -RSPT RESPITE 2 2 97.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 758 835 946.18 $946.18 $1.00
SENS -FM FM RECEIVER HEARING AID 8 8 9.00 $14850.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 47 47 67.02 $33511.10 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 22 25 19.78 $1285.93 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 21 22 40.00 $9484.80 $237.12
SENS -V5264 EARMOLD 129 149 224.94 $4210.88 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 6.78 $339.17 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 138 160 677.23 $33861.52 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 2 2.57 $128.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8382 11171 72926.39 $4950243.52 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 12 14 64.50 $3503.65 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 522 570 4620.96 $60996.70 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 9 9 48.59 $4858.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5708 9460 1126756.04 $563378.01 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 7.10 $355.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 112 169 804.36 $40218.23 $50.00
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Subtotal (Total Children Is Unduplicated) 15946 57009 1384008.00 $16133428.08 $11.66
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Total 68052 1397721.48 $16914514.43 $12.10
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Number of Children (Unduplicated) With at Least One Authorization 16417