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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 8 8 4.37 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 15 18 28.48 $1053.89 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 9 11 7.43 $274.86 $37.00
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Subtotal (Total Children Is Unduplicated) 26 37 40.28 $1328.74 $32.99
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 34 34 34.00 $1649.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $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 2.07 $33.69 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 114 115 113.99 $1006.52 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 113 114 112.02 $1209.84 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 117 118 116.99 $2549.19 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 2.07 $112.39 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 104 106 106.52 $3012.45 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.07 $65.74 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 268 276 275.28 $16516.95 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 37 37 39.17 $1833.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 159 160 179.88 $21513.19 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 11 11 17.29 $2160.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 30 30 48.57 $6071.43 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 41 41 49.03 $2451.51 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 202 222 382.75 $19137.50 $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 31 31 49.50 $3712.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 11.50 $862.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 12 17.00 $1275.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 48 50 69.57 $3860.95 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 20 20 39.00 $2164.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 736 742 1199.86 $89989.29 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 156 157 265.21 $19891.07 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 156 157 251.14 $18835.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 584 585 950.03 $52726.85 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 530 571 824.21 $61816.08 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 5 5 7.00 $1050.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 124 133 136.51 $6620.52 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 689 743 775.38 $37605.83 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 117 129 129.00 $6256.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 436 456 494.14 $23965.67 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 36 36 36.00 $1800.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1353 1459 1523.59 $73893.95 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 5 5 12.97 $1296.67 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 5.64 $282.15 $50.00
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Subtotal (Total Children Is Unduplicated) 3822 6706 8408.93 $489182.08 $58.17
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 102 114 231.00 $346500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 9.42 $648.93 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 13.14 $905.02 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 130 134 235.79 $11789.40 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 796 1146 1835.82 $91791.20 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 29 32 21.86 $546.46 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1273 1331 2243.36 $112167.93 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 58 59 95.62 $2390.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 573 612 878.74 $43937.24 $50.00
CONOP -CONOP CONSULT, OT, PHONE 15 16 16.28 $406.88 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 477 509 802.18 $40108.97 $50.00
CONPP -CONPP CONSULT, PT, PHONE 19 19 28.28 $707.11 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1427 1516 2248.61 $112430.64 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 64 65 100.29 $2507.25 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 19 20 247.00 $18134.74 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 12 12 1119.71 $13996.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 223 253 1659.99 $41499.82 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 9 254.43 $12721.43 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 6.18 $308.97 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 41.40 $2070.01 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 8.14 $203.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3716 4089 24290.17 $1214508.35 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 13 14 13.07 $653.61 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 44 63 452.60 $22630.03 $50.00
INTR -INTR INTERPRETER 114 122 576.93 $28846.61 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1890 2204 11223.48 $761849.99 $67.88
OCCT -97530HM OT SESSION BY OT ASST 84 87 481.49 $26154.68 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1932 2211 10588.98 $718779.62 $67.88
PHY -97110HM PT SESSION BY PT ASST 95 99 609.28 $33096.26 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 339 346 343.92 $343.92 $1.00
SENS -FM FM RECEIVER HEARING AID 5 5 5.00 $8250.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 20 20 26.00 $13000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 12 12 10.36 $673.33 $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 15 26.00 $6165.12 $237.12
SENS -V5264 EARMOLD 70 72 95.27 $1783.45 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 6.78 $339.17 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 74 75 256.53 $12826.70 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 1.43 $71.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4374 5062 25894.83 $1757740.73 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 39.66 $2154.43 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 203 212 1547.50 $20426.99 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3019 4265 445725.04 $222862.52 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 0.60 $30.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 66 86 312.42 $15621.09 $50.00
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Subtotal (Total Children Is Unduplicated) 8909 24935 534626.61 $5724794.42 $10.71
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Total 31678 543075.82 $6215305.25 $11.44
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Number of Children (Unduplicated) With at Least One Authorization 9463