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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5 6.14 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 16.13 $596.81 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 4.03 $149.23 $37.00
TCON -TCON TRANSITION CONFERENCE 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 13 14 28.31 $746.05 $26.36
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 117 133 140.00 $6790.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 14.62 $527.42 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 62 64 63.07 $669.77 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 57 58 57.07 $503.90 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 59 60 63.78 $688.83 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 57 58 57.07 $1243.48 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 6.71 $365.12 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 47 47 46.07 $1302.77 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 6.71 $213.58 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 283 300 317.09 $19025.51 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 41 42 46.35 $2168.96 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 233 238 262.33 $31375.06 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 5 38.00 $4750.01 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 24 27 37.71 $4714.29 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 55 58 75.00 $3750.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 315 331 595.71 $29785.72 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 45 46 89.00 $6675.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 9.00 $675.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 9.00 $675.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 34 34 64.00 $4800.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 45 45 74.64 $4142.68 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 14.00 $777.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 477 489 960.00 $72000.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 122 123 232.86 $17464.28 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 145 148 288.00 $21600.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 392 397 775.07 $43016.20 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 281 298 586.00 $43950.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.00 $145.56 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 9 9 10.70 $535.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 106 138 138.00 $6693.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 805 915 1038.05 $50345.49 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 124 161 166.89 $8094.19 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 707 794 833.24 $40411.95 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 45 45 45.00 $2250.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1598 1845 2017.94 $97869.88 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 17.14 $1714.29 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 4.00 $200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 4058 6950 9202.82 $531923.95 $57.80
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 79 100 158.37 $237549.90 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 4 5 15.30 $1053.53 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 16.00 $1101.76 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 123 145 458.10 $22905.07 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 698 1272 2350.28 $117514.06 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 32 37 38.34 $958.46 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1500 1880 3342.85 $167142.62 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 129 144 248.87 $6221.66 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 665 831 1415.05 $70752.38 $50.00
CONOP -CONOP CONSULT, OT, PHONE 29 32 48.58 $1214.47 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 615 775 1443.61 $72180.74 $50.00
CONPP -CONPP CONSULT, PT, PHONE 42 46 79.42 $1985.55 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1767 2154 3357.77 $167888.46 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 146 162 277.79 $6944.65 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 17 17 49.03 $3600.02 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 6 7 504.29 $6303.57 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 10 12 104.77 $2619.29 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 381 479 3929.81 $98245.22 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 205.00 $10250.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 12 13 6.89 $344.44 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 33 43 297.83 $14891.75 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 9 10 84.46 $2111.55 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5791 7544 55908.45 $2795422.69 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 28 39 44.52 $2226.11 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 69 82 474.53 $23726.48 $50.00
INTR -INTR INTERPRETER 261 344 1911.91 $95595.30 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 2053 2708 17753.77 $1205125.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 138 157 1082.43 $58797.41 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2576 3407 20894.49 $1418318.04 $67.88
PHY -97110HM PT SESSION BY PT ASST 143 159 1436.42 $78026.44 $54.32
RSPT -RSPT RESPITE 2 3 49.53 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 772 866 926.65 $926.65 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 20 20 27.00 $13500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 15 17 21.53 $1399.57 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 15 16 22.00 $5216.64 $237.12
SENS -V5264 EARMOLD 73 82 119.99 $2246.22 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 4 5 21.23 $1061.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 109 131 442.20 $22109.92 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4381 5778 37169.30 $2523052.10 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 19.54 $1061.18 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 244 276 2435.85 $32153.19 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 8 9 56.71 $5671.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4165 6914 1058642.14 $529321.05 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 4 4 11.28 $564.17 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 83 111 596.41 $29820.44 $50.00
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Subtotal (Total Children Is Unduplicated) 10509 36850 1218503.29 $9862535.61 $8.09
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Total 43814 1227734.42 $10395205.61 $8.47
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Number of Children (Unduplicated) With at Least One Authorization 10905