Summary Report for FSPSAs Initiated During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 07/01/08 and 09/30/08 Date of Report: 11-18-08 Page: 1
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 51 54 27.27 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 21 25 17.00 $629.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 10.54 $390.07 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 71 90 56.06 $1028.32 $18.34
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 41 46 49.13 $2382.97 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 10.71 $386.46 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 105 108 108.00 $1146.96 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 104 107 107.00 $944.81 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 105 108 108.00 $1166.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 102 105 105.00 $2287.95 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 3 3.00 $163.14 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 96 98 98.00 $2771.44 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 176 186 199.66 $11979.71 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 33 36 36.13 $1691.04 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 125 129 160.66 $19214.88 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 5 16.00 $2000.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 36 36 103.08 $12884.53 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 98 104 124.47 $6223.45 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 97 113 147.04 $7351.79 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 20 20 20.00 $600.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 2.56 $192.08 $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 22 22 28.86 $2164.28 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 3.00 $225.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 12.27 $920.42 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 26 26 33.00 $2475.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 57 58 75.86 $4210.07 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 33 33 37.50 $2081.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 519 519 728.07 $54605.36 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 121 123 182.00 $13650.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 158 160 242.53 $18190.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 465 478 727.57 $40380.22 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 495 551 757.43 $56807.14 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 107 112 123.89 $6008.84 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 504 547 612.40 $29701.63 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 121 126 125.39 $6081.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 392 423 423.27 $20528.76 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 32 32 32.00 $1600.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1155 1253 1295.22 $62817.93 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 3200 5701 6852.21 $396789.79 $57.91
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 121 143 253.00 $379500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 105 114 228.15 $11407.47 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 644 1142 2071.22 $103560.83 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 29 31 29.50 $737.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1186 1288 2088.64 $104432.11 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 56 58 96.03 $2400.72 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 574 618 959.29 $47964.50 $50.00
CONOP -CONOP CONSULT, OT, PHONE 24 24 26.36 $659.03 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 418 439 716.95 $35847.53 $50.00
CONPP -CONPP CONSULT, PT, PHONE 24 24 46.44 $1160.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1193 1291 1925.22 $96261.10 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 92 98 116.32 $2908.11 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 36 37 88.59 $6504.20 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 10 10 1947.00 $24337.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 305 345 2306.03 $57650.75 $25.00
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 10.71 $535.72 $50.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 17 20 230.86 $11542.86 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 11 11 68.57 $3428.58 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 41.51 $1037.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3247 3789 22176.74 $1108836.84 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 39 41 145.01 $7250.71 $50.00
INTR -INTR INTERPRETER 65 70 311.94 $15596.80 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1693 1982 9616.25 $652750.94 $67.88
OCCT -97530HM OT SESSION BY OT ASST 101 107 565.86 $30737.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1804 2101 10145.31 $688663.38 $67.88
PHY -97110HM PT SESSION BY PT ASST 102 107 679.19 $36893.70 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 94 95 92.14 $92.14 $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 25 27 37.00 $18500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 11 8.57 $368.39 $43.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 10 11 35.00 $8299.20 $237.12
SENS -V5264 EARMOLD 56 60 84.36 $1579.14 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 46 55 163.24 $8161.80 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3738 4407 22441.73 $1523344.55 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 68.14 $3701.52 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 231 236 1672.49 $22076.93 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 8 9 31.42 $3141.91 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2382 3373 235617.26 $117808.62 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 57 72 297.76 $14887.87 $50.00
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Subtotal (Total Children Is Unduplicated) 7762 22267 317446.79 $5161466.15 $16.26
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Total 28058 324355.07 $5559284.26 $17.14
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Number of Children (Unduplicated) With at Least One Authorization 8319