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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 1 1 6.43 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 18.57 $687.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
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Subtotal (Total Children Is Unduplicated) 5 5 32.21 $954.07 $29.62
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 55 57 59.00 $2861.50 $48.50
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 102 103 103.00 $1093.86 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 3.31 $53.97 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 107 108 105.47 $931.27 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.00 $54.20 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 108 109 105.73 $1141.92 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 108 109 105.73 $2303.93 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 2.88 $156.49 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 91 92 92.00 $2601.76 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 2.31 $73.52 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 216 225 223.64 $13418.18 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 27 27 27.01 $1264.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 106 106 111.31 $13312.82 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 3 3.00 $375.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 20 20 30.43 $3803.58 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 19 19 23.93 $1196.43 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 235 248 471.29 $23564.29 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.00 $300.00 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 40 40 65.00 $4875.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 13.00 $975.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 13 13 21.50 $1612.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 36 37 57.50 $4312.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 46 46 88.21 $4895.89 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 21 21 42.00 $2331.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 544 545 966.50 $72487.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 230 231 421.29 $31596.43 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 115 115 205.89 $15441.79 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 466 469 831.85 $46167.54 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 382 402 677.21 $50791.07 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 6.00 $436.68 $72.78
NURS -NURS NURSING ASSESSMENT 1 1 4.80 $240.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 122 130 142.00 $6887.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 604 655 716.75 $34762.37 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 118 129 141.14 $6845.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 428 449 467.68 $22682.65 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 25 26 26.00 $1300.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 3.00 $45.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1326 1423 1503.51 $72920.31 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 3565 5995 7881.88 $450383.85 $57.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 93 100 169.00 $253500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.66 $114.00 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 117 122 194.78 $9739.14 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 651 851 1273.65 $63682.35 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 35 36 33.97 $849.23 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1033 1091 1871.53 $93576.39 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 52 53 76.96 $1923.96 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 509 546 758.90 $37945.11 $50.00
CONOP -CONOP CONSULT, OT, PHONE 18 18 22.38 $559.58 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 371 395 597.37 $29868.63 $50.00
CONPP -CONPP CONSULT, PT, PHONE 17 17 16.94 $423.57 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1167 1243 1933.74 $96686.87 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 78 78 144.02 $3600.53 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 53.43 $3923.07 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 101.43 $1267.86 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 6 6 47.29 $1182.14 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 211 222 1663.81 $41595.13 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 5 195.29 $9764.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 10 10 8.03 $401.51 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 16 100.07 $5003.57 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 7 7 49.57 $1239.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3616 3972 25767.74 $1288386.92 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 18 18 40.16 $2007.78 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 46 51 114.21 $5710.69 $50.00
INTR -INTR INTERPRETER 148 157 666.79 $33339.31 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1719 1963 10904.77 $740215.68 $67.88
OCCT -97530HM OT SESSION BY OT ASST 81 87 512.26 $27826.07 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1828 2068 10587.66 $718690.19 $67.88
PHY -97110HM PT SESSION BY PT ASST 102 106 688.07 $37375.87 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 428 436 439.03 $439.03 $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 19 19 26.00 $13000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 16 16 16.30 $1059.59 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 3 3 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 8 8 14.00 $3319.68 $237.12
SENS -V5264 EARMOLD 61 62 81.99 $1534.94 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 4.57 $228.57 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 77 82 235.64 $11781.79 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3988 4565 25509.54 $1731587.73 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 33.72 $1831.62 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 190 196 1586.42 $20940.70 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 14.57 $1457.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2850 3877 496207.59 $248103.77 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 1.23 $61.67 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 51 54 276.95 $13847.32 $50.00
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Subtotal (Total Children Is Unduplicated) 8430 22590 583051.01 $5568184.25 $9.55
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Total 28590 590965.10 $6019522.17 $10.19
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Number of Children (Unduplicated) With at Least One Authorization 9013