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: 07/01/09 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 2.00 $74.00 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5 3.31 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 9.93 $367.36 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 19.00 $703.00 $37.00
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Subtotal (Total Children Is Unduplicated) 13 14 34.23 $1144.36 $33.43
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 46 51 65.43 $3173.29 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.00 $144.28 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 98 98 99.00 $1051.38 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 8 5.09 $82.95 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 111 112 106.81 $943.14 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 113 114 109.14 $1178.76 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 111 112 108.12 $2355.98 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 7 7 6.39 $347.43 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 47 47 46.71 $1320.99 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 7 4.09 $130.06 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 0.02 $0.47 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 232 239 258.64 $15518.48 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 43 46 53.14 $2487.09 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 162 165 197.77 $23653.87 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 11 12 34.71 $4339.29 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 16 16 20.86 $2607.15 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 24 27 36.82 $1840.95 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 242 262 509.21 $25460.71 $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 17.00 $1275.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 5.87 $440.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 26 28 36.87 $2765.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 56 58 98.79 $5482.61 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 23 23 45.50 $2525.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 586 586 904.27 $67820.01 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 140 141 248.36 $18626.78 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 131 131 196.71 $14753.57 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 495 496 760.63 $42215.15 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 397 436 623.36 $46751.79 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.14 $57.15 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 107 114 114.00 $5529.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 639 712 765.25 $37114.77 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 116 117 118.95 $5769.19 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 486 535 561.90 $27252.22 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 24 25 25.00 $1250.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1333 1465 1607.47 $77962.40 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 3591 6256 7859.54 $448584.72 $57.08
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 112 127 229.00 $343500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 9.07 $624.66 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 119 125 331.92 $16595.89 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 753 1040 1609.66 $80482.98 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 44 44 26.53 $663.30 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1161 1231 2053.96 $102698.03 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 44 47 60.94 $1523.60 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 579 621 838.62 $41930.87 $50.00
CONOP -CONOP CONSULT, OT, PHONE 21 22 29.01 $725.18 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 439 451 713.89 $35694.73 $50.00
CONPP -CONPP CONSULT, PT, PHONE 20 20 25.14 $628.61 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1256 1339 1959.83 $97991.65 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 88 90 121.89 $3047.35 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 60.86 $4468.13 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 92.29 $1153.57 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 13.85 $346.19 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 316 367 2732.76 $68318.99 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 6 208.86 $10442.86 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 3 3 0.29 $14.45 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 31 32 175.12 $8755.83 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 7 7 49.14 $1228.58 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3746 4269 24414.20 $1220709.85 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 14 15 25.95 $1297.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 65 78 318.11 $15905.75 $50.00
INTR -INTR INTERPRETER 134 151 771.41 $38570.47 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1771 2091 10496.70 $712516.17 $67.88
OCCT -97530HM OT SESSION BY OT ASST 92 98 629.43 $34190.85 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1915 2232 10409.90 $706623.97 $67.88
PHY -97110HM PT SESSION BY PT ASST 95 98 491.36 $26690.68 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 413 420 427.79 $427.79 $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 32 33 48.00 $24000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 7.59 $493.29 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 16 16 25.20 $5975.42 $237.12
SENS -V5264 EARMOLD 86 90 129.35 $2421.36 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 4.63 $231.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 62 73 228.66 $11432.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4217 4983 24655.22 $1673596.63 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 38.71 $2102.97 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 233 243 1472.44 $19436.23 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 6 95.29 $9528.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2856 3862 478523.13 $239261.55 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 23.80 $1190.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 61 78 338.67 $16933.57 $50.00
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Subtotal (Total Children Is Unduplicated) 8714 24455 564940.17 $5592736.45 $9.90
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Total 30725 572833.95 $6042465.53 $10.55
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Number of Children (Unduplicated) With at Least One Authorization 9266