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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 10.29 $380.57 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 6 6 12.54 $463.82 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 74 88 92.00 $4462.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 103 103 96.23 $1022.00 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 6.12 $99.79 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 103 103 94.93 $838.21 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.03 $28.00 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 105 105 97.76 $1055.82 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 104 104 95.79 $2087.36 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 9 9 9.00 $489.42 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 85 85 79.20 $2239.77 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 5.12 $162.94 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 255 260 260.74 $15644.55 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 41 41 46.20 $2162.16 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 145 145 164.95 $19727.91 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 3.36 $419.64 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 16 16 22.29 $2785.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 28 29 35.82 $1790.88 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 294 313 588.64 $29432.15 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 64 66 118.50 $8887.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 21.00 $1575.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 13 13 23.50 $1762.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 57 58 106.00 $7950.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 49 53 91.00 $5050.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 29 29 58.00 $3219.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 743 813 1532.78 $114958.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 215 221 415.36 $31151.78 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 202 211 400.00 $30000.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 675 741 1395.24 $77435.98 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 430 495 896.00 $67200.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 5 5 6.00 $436.68 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 9 9 9.13 $456.67 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 121 140 140.00 $6790.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 686 748 801.26 $38861.33 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 130 151 160.25 $7772.31 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 429 451 477.65 $23166.06 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 34 37 38.00 $1900.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1420 1523 1621.64 $78649.77 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 4051 7198 10015.51 $591844.01 $59.09
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 110 116 249.00 $373500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 9.57 $659.09 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 12.00 $826.32 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 129 135 221.32 $11066.17 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 705 893 1319.22 $65960.91 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 31 31 30.82 $770.48 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 962 1029 1525.94 $76296.97 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 89 92 131.28 $3281.93 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 547 599 829.94 $41497.24 $50.00
CONOP -CONOP CONSULT, OT, PHONE 25 29 44.18 $1104.56 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 404 431 682.29 $34114.60 $50.00
CONPP -CONPP CONSULT, PT, PHONE 33 34 37.50 $937.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1296 1375 1770.56 $88527.96 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 113 117 132.29 $3307.33 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 28.13 $2065.55 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 53.29 $666.07 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 7 7 40.29 $1007.14 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 279 309 2178.72 $54468.10 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 149.71 $7485.71 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 1.14 $57.22 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 24 26 139.73 $6986.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 9 9 55.26 $1381.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3907 4289 24394.61 $1219730.64 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 15 15 31.38 $1568.76 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 51 52 149.81 $7490.65 $50.00
INTR -INTR INTERPRETER 174 213 828.35 $41417.65 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1755 2059 10538.12 $715327.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 91 94 573.29 $31141.15 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1932 2271 10925.93 $741652.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 99 101 622.26 $33801.41 $54.32
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 411 420 410.29 $410.29 $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 27 27 38.00 $19000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 10 10 12.43 $808.16 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 11 11 16.00 $3793.92 $237.12
SENS -V5264 EARMOLD 86 89 122.97 $2301.94 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 5 5 11.10 $555.01 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 74 81 175.71 $8785.63 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4181 4953 24871.12 $1688251.34 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 56.75 $3082.80 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 199 208 1565.22 $20660.95 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 6 27.71 $2770.96 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2964 4056 482704.21 $241352.09 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 9.70 $484.77 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 52 55 233.17 $11658.44 $50.00
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Subtotal (Total Children Is Unduplicated) 8924 24277 567965.34 $5577079.04 $9.82
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Total 31481 577993.39 $6169386.87 $10.67
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Number of Children (Unduplicated) With at Least One Authorization 9693