Summary Report for FSPSAs Ending During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 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 Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 23 24 9.29 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 13 15 20.89 $773.04 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 10 12 17.71 $655.43 $37.00
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Subtotal (Total Children Is Unduplicated) 42 52 48.90 $1465.47 $29.97
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 31 35 36.00 $1746.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 14 14 16.00 $577.12 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 108 109 110.00 $1168.20 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.38 $38.76 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 112 113 114.00 $1006.62 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 112 113 112.41 $1214.04 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 113 114 116.00 $2527.64 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 3.00 $163.14 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 103 105 106.00 $2997.68 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.00 $63.62 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 2 2 1.38 $29.40 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 250 264 263.06 $15783.68 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 29 32 32.06 $1500.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 165 170 191.89 $22950.09 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 13 13 12.80 $1600.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 27 28 65.29 $8160.73 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 73 75 86.73 $4336.75 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 180 200 345.25 $17262.50 $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 32 32 51.50 $3862.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $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 47 50 69.53 $3859.10 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 25 25 49.00 $2719.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 741 747 1207.86 $90589.29 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 154 155 260.71 $19553.57 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 141 143 222.14 $16660.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 571 572 924.03 $51283.85 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 534 576 828.71 $62153.58 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 4 4 6.00 $900.00 $150.00
NURS -NURS NURSING ASSESSMENT 4 4 9.60 $480.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 136 147 145.79 $7070.76 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 589 630 678.01 $32883.38 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 114 125 129.34 $6272.90 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 380 395 406.39 $19709.67 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 33 35 34.30 $1715.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1295 1392 1485.90 $72066.26 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 9.14 $914.29 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 5.01 $250.48 $50.00
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Subtotal (Total Children Is Unduplicated) 3833 6474 8192.71 $479643.52 $58.55
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 94 107 325.29 $487928.55 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.59 $247.02 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 134 144 264.84 $13241.99 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 740 1113 1764.02 $88200.77 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 25 28 21.42 $535.42 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1232 1328 2071.27 $103563.58 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 57 61 88.04 $2201.08 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 593 643 931.41 $46570.57 $50.00
CONOP -CONOP CONSULT, OT, PHONE 22 23 21.22 $530.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 452 483 756.88 $37843.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 23 23 15.30 $382.51 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1383 1512 2123.72 $106185.97 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 81 83 114.63 $2865.74 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 19 20 146.50 $10755.66 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 562.29 $7028.57 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 5.30 $132.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 269 298 3128.45 $78211.15 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 289.14 $14457.15 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 11.49 $574.29 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 17 17 86.57 $4328.57 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 9 9 66.97 $1674.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3456 3861 22773.47 $1138673.39 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 9 9 21.22 $1060.83 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 62 80 306.97 $15348.59 $50.00
INTR -INTR INTERPRETER 100 106 465.47 $23273.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1929 2213 10870.66 $737900.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 130 133 671.13 $36455.54 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1909 2171 9959.66 $676061.65 $67.88
PHY -97110HM PT SESSION BY PT ASST 125 131 651.64 $35397.12 $54.32
RSPT -RSPT RESPITE 1 1 48.53 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 336 353 422.09 $422.09 $1.00
SENS -FM FM RECEIVER HEARING AID 4 4 5.00 $8250.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 20 20 31.00 $15500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 9 6.18 $401.39 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 8 16.00 $3793.92 $237.12
SENS -V5264 EARMOLD 58 65 104.69 $1959.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 64 70 224.71 $11235.72 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 2 2.57 $128.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4259 4896 24609.50 $1670493.13 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 17.77 $965.35 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 252 263 1707.94 $22544.76 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 6.55 $655.24 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2871 3916 305313.20 $152656.59 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 6.50 $325.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 65 81 376.93 $18846.67 $50.00
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Subtotal (Total Children Is Unduplicated) 8794 24317 391417.69 $5579808.63 $14.26
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Total 30843 399659.30 $6060917.61 $15.17
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Number of Children (Unduplicated) With at Least One Authorization 10072