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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 1 1 2.00 $74.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 1.07 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 10.86 $401.71 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 26.50 $980.50 $37.00
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Subtotal (Total Children Is Unduplicated) 10 10 40.42 $1456.22 $36.02
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 71 77 83.71 $4060.14 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 51 52 52.00 $552.24 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 52 53 53.00 $467.99 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 53 54 54.02 $583.44 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 53 54 54.02 $1177.14 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 2.04 $111.17 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 47 48 48.00 $1357.44 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 271 296 326.01 $19560.56 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 36 37 38.33 $1794.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 183 188 210.76 $25206.92 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 13 14 19.00 $2375.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 25 25 39.71 $4964.29 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 58 59 65.59 $3279.61 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 195 207 395.29 $19764.29 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 25 42.50 $3187.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 11.00 $825.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 14.57 $1092.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 21 22 36.07 $2705.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 40 40 71.51 $3969.04 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 12 12 24.00 $1332.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 347 347 613.00 $45975.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 129 129 228.79 $17158.93 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 68 68 121.96 $9147.14 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 299 301 527.46 $29274.14 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 266 279 474.36 $35576.79 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 5 5 7.00 $509.46 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 7.57 $378.57 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 104 125 131.23 $6364.43 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 781 892 1001.27 $48561.67 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 121 151 165.08 $8006.51 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 662 749 783.74 $38011.19 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 31 33 33.00 $1650.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1461 1701 1797.07 $87157.77 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 9.41 $940.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 6.00 $300.00 $50.00
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 3529 6076 7557.08 $427675.20 $56.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 93 112 164.00 $246000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 4 12.02 $827.86 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 8 8 24.57 $1691.99 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 127 152 505.03 $25251.30 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 538 898 1590.28 $79514.05 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 38 44 33.25 $831.19 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1557 1871 3620.79 $181039.53 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 73 81 134.39 $3359.70 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 664 788 1306.64 $65332.13 $50.00
CONOP -CONOP CONSULT, OT, PHONE 25 30 41.75 $1043.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 595 712 1210.95 $60547.63 $50.00
CONPP -CONPP CONSULT, PT, PHONE 23 26 48.73 $1218.35 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1567 1859 3396.64 $169831.94 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 116 123 254.88 $6371.93 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 18 19 148.29 $10887.48 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 13 13 586.00 $7325.00 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 7 7 78.64 $1965.95 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 353 424 4308.75 $107718.79 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 43.86 $2192.86 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 7 7 5.82 $291.11 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 21 25 246.51 $12325.73 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 10 10 91.29 $2282.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5116 6468 50136.79 $2506839.71 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 26 34 92.30 $4614.79 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 76 89 670.96 $33547.93 $50.00
INTR -INTR INTERPRETER 212 252 1694.32 $84715.76 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1996 2625 17511.96 $1188711.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 110 129 1244.80 $67617.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2431 3223 19705.05 $1337578.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 148 169 1435.97 $78001.87 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 725 811 856.14 $856.14 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 14 15 18.00 $9000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 16 19 17.95 $1166.63 $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 21 37.13 $8805.05 $237.12
SENS -V5264 EARMOLD 73 81 142.48 $2667.25 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 5 5 23.85 $1192.74 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 101 125 468.42 $23421.13 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4225 5524 35778.91 $2428672.44 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 33.50 $1819.72 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 232 259 2172.26 $28673.87 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 6 45.86 $4585.72 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3752 6084 859130.30 $429565.08 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 4 12.53 $626.43 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 83 110 692.97 $34648.43 $50.00
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Subtotal (Total Children Is Unduplicated) 9683 33281 1009796.52 $9271892.67 $9.18
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Total 39367 1017394.02 $9701024.09 $9.54
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Number of Children (Unduplicated) With at Least One Authorization 9971