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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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 17 17 6.28 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 10.79 $399.07 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 3.86 $142.71 $37.00
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Subtotal (Total Children Is Unduplicated) 23 25 20.92 $541.78 $25.90
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 45 48 50.71 $2459.64 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 5.00 $180.35 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 98 98 99.00 $1051.38 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 6.62 $107.85 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 109 109 105.07 $927.79 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 111 111 107.68 $1162.92 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 108 108 105.01 $2288.07 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 8 8 5.62 $305.74 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 46 46 45.31 $1281.40 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 3.94 $125.29 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 269 274 271.24 $16274.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 33 35 37.97 $1776.84 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 155 157 199.47 $23856.98 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 14 15 37.71 $4714.29 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 22 22 24.86 $3107.14 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 45 46 76.68 $3833.93 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 218 234 449.00 $22450.00 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 6 6 6.00 $180.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.00 $225.00 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 30 30 45.50 $3412.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 16.00 $1200.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 5.50 $412.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 24 26 34.50 $2587.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 49 51 67.50 $3746.25 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 17 17 33.50 $1859.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 588 588 907.27 $68045.01 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 145 146 259.86 $19489.28 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 152 152 237.71 $17828.57 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 519 520 809.13 $44906.90 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 394 433 612.36 $45926.79 $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
NURS -NURS NURSING ASSESSMENT 4 4 12.00 $600.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 5 5 5.00 $250.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 115 121 120.08 $5824.04 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 691 746 790.78 $38352.65 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 110 115 113.94 $5526.11 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 470 498 521.75 $25304.90 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 20 20 20.00 $1000.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1376 1492 1568.52 $76073.10 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 6.50 $325.00 $50.00
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Subtotal (Total Children Is Unduplicated) 3759 6325 7830.29 $449223.75 $57.37
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 104 127 200.00 $300000.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 3.14 $216.42 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 106 109 205.90 $10295.24 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 724 1052 1640.65 $82032.29 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 30 30 25.20 $630.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1251 1344 2156.92 $107845.92 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 57 60 88.02 $2200.60 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 598 647 909.93 $45496.50 $50.00
CONOP -CONOP CONSULT, OT, PHONE 19 20 28.70 $717.54 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 467 489 750.12 $37505.99 $50.00
CONPP -CONPP CONSULT, PT, PHONE 19 19 46.10 $1152.48 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1330 1439 2113.62 $105681.23 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 84 87 151.53 $3788.22 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 20 20 151.14 $11096.90 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 9 9 344.57 $4307.14 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.43 $10.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 310 338 2348.93 $58723.21 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 11 12 175.43 $8771.42 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 1.26 $62.78 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 13 14 110.14 $5507.14 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 11.43 $285.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3810 4305 25626.96 $1281347.76 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 16 16 25.16 $1258.02 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 49 68 432.51 $21625.75 $50.00
INTR -INTR INTERPRETER 122 135 562.34 $28117.16 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1982 2269 11914.92 $808784.63 $67.88
OCCT -97530HM OT SESSION BY OT ASST 80 85 546.36 $29678.14 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2082 2360 11816.16 $802080.69 $67.88
PHY -97110HM PT SESSION BY PT ASST 63 70 426.84 $23185.97 $54.32
RSPT -RSPT RESPITE 1 1 25.60 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 353 366 367.72 $367.72 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 24 24 36.22 $18111.10 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 5.00 $325.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 9 17.00 $4031.04 $237.12
SENS -V5264 EARMOLD 60 62 91.06 $1704.62 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 4.60 $230.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 63 72 271.86 $13593.22 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4470 5150 26683.19 $1811254.89 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 9.29 $504.40 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 205 218 1201.99 $15866.24 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 17.44 $1743.82 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2860 3946 476497.31 $238248.65 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 12.60 $630.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 70 87 357.07 $17853.57 $50.00
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Subtotal (Total Children Is Unduplicated) 8997 25083 568416.36 $5911933.92 $10.40
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Total 31433 576267.57 $6361699.45 $11.04
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Number of Children (Unduplicated) With at Least One Authorization 10194