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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 0.25 $9.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 0.16 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 36.00 $1332.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 3.00 $111.00 $37.00
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Subtotal (Total Children Is Unduplicated) 10 10 39.41 $1452.25 $36.85
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 98 121 127.00 $6159.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 3 3.00 $108.21 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 59 59 53.20 $564.98 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 56 56 51.17 $451.80 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.03 $28.00 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 57 57 51.33 $554.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 58 58 51.37 $1119.28 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 1.18 $64.05 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 53 53 47.20 $1334.81 $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 286 316 317.00 $19019.75 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 43 45 49.20 $2302.56 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 192 199 216.23 $25861.50 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 7 7 8.36 $1044.64 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 23 23 43.14 $5392.85 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 47 50 61.71 $3085.36 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 224 234 438.14 $21907.15 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 49 51 90.50 $6787.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 21.00 $1575.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 12 12 22.30 $1672.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 44 44 80.80 $6060.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 37 38 75.36 $4182.32 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 13 13 26.00 $1443.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 484 532 1003.78 $75283.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 137 143 267.86 $20089.28 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 142 151 286.00 $21450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 455 506 951.24 $52793.98 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 290 330 604.29 $45321.43 $75.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 9 9 11.95 $597.62 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 109 133 133.00 $6450.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 790 910 1028.26 $49870.85 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 124 160 176.76 $8572.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 645 737 755.75 $36653.99 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 34 34 34.00 $1700.00 $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 1703 1871.64 $90774.30 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 4.00 $200.00 $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) 3763 6812 8972.74 $520723.35 $58.03
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 94 102 176.00 $264000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 11.57 $796.81 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 7 19.57 $1347.69 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 136 159 422.78 $21138.83 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 572 929 1621.79 $81089.36 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 20 20 25.84 $646.07 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1524 1798 3304.46 $165222.84 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 106 114 251.59 $6289.63 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 653 811 1260.55 $63027.75 $50.00
CONOP -CONOP CONSULT, OT, PHONE 32 36 57.47 $1436.72 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 571 689 1203.50 $60174.76 $50.00
CONPP -CONPP CONSULT, PT, PHONE 36 40 60.99 $1524.79 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1643 1936 3319.63 $165981.40 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 142 150 304.12 $7602.94 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 15 102.13 $7498.63 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 317.43 $3967.86 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 9 11 121.57 $3039.28 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 377 476 3733.45 $93336.29 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 131.43 $6571.43 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 7 8 5.69 $284.45 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 32 36 265.22 $13260.94 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 13 14 111.97 $2799.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5324 6827 50382.71 $2519135.55 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 22 25 61.25 $3062.28 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 78 94 526.35 $26317.50 $50.00
INTR -INTR INTERPRETER 229 293 1802.02 $90100.82 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1969 2639 16991.82 $1153404.83 $67.88
OCCT -97530HM OT SESSION BY OT ASST 120 132 1054.58 $57284.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2405 3332 19612.69 $1331309.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 149 174 1437.60 $78090.30 $54.32
RSPT -RSPT RESPITE 1 2 2.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 726 831 870.99 $870.99 $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 21 21 23.00 $11500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 13 14 14.87 $966.30 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 16 20 33.80 $8014.66 $237.12
SENS -V5264 EARMOLD 76 95 134.84 $2524.23 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 4 6 19.47 $973.34 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 104 138 432.17 $21608.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4167 5568 34661.58 $2352828.15 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 42.99 $2334.99 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 223 253 2193.73 $28957.20 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 6 36.00 $3600.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3834 6284 878464.60 $439232.35 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 8.23 $411.67 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 83 104 567.50 $28374.83 $50.00
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Subtotal (Total Children Is Unduplicated) 9763 34235 1026208.51 $9138654.33 $8.91
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Total 41057 1035220.66 $9660829.93 $9.33
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Number of Children (Unduplicated) With at Least One Authorization 10164