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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 6 6 7.14 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 17.56 $649.67 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 4.29 $158.57 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 14 15 31.99 $808.24 $25.27
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 68 70 78.00 $3783.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 12.62 $455.28 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 114 117 115.10 $1222.36 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 5.00 $81.50 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 111 113 111.60 $985.43 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 114 116 120.21 $1298.26 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 111 113 111.17 $2422.32 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 10.71 $582.64 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 85 86 85.07 $2405.69 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 10.71 $340.82 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 189 198 207.76 $12465.43 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 24 26 26.80 $1254.02 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 164 166 184.10 $22018.36 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 23.86 $2982.15 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 16 18 23.87 $2983.34 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 20 20 27.66 $1382.78 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 364 387 680.14 $34007.15 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 65 66 128.00 $9600.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 11.00 $825.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 9.00 $675.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 43 43 84.50 $6337.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 59 59 103.50 $5744.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 682 696 1363.79 $102283.93 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 206 208 398.00 $29850.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 186 189 369.50 $27712.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 558 565 1103.85 $61263.81 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 395 422 817.50 $61312.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 3.00 $218.34 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 2.00 $300.00 $150.00
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.00 $50.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 5.00 $250.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 116 127 127.00 $6159.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 670 716 768.42 $37268.24 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 120 131 146.46 $7103.40 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 484 510 531.70 $25787.57 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 42 42 42.00 $2100.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1447 1543 1652.16 $80129.99 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 18.14 $1814.29 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 4015 6803 9522.90 $557571.35 $58.55
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 96 112 195.65 $293478.45 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.23 $84.90 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 102 108 240.43 $12021.43 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 891 1281 2066.00 $103299.82 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 46 50 43.95 $1098.64 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1008 1140 1741.91 $87095.28 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 85 88 72.00 $1800.02 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 511 556 793.76 $39688.23 $50.00
CONOP -CONOP CONSULT, OT, PHONE 19 19 24.52 $613.04 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 431 465 731.75 $36587.26 $50.00
CONPP -CONPP CONSULT, PT, PHONE 25 26 37.39 $934.82 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1360 1469 2020.91 $101045.26 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 87 92 73.29 $1832.17 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 25.77 $1891.79 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 300.43 $3755.36 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 3.71 $92.86 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 247 282 1556.51 $38912.74 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 133.57 $6678.57 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 8 9 4.68 $233.89 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 15 16 72.08 $3603.89 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 7 7 39.88 $996.91 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4176 4693 27024.40 $1351220.08 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 23 23 21.56 $1077.78 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 30 31 148.29 $7414.29 $50.00
INTR -INTR INTERPRETER 191 241 684.68 $34233.95 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1748 2009 10301.20 $699245.31 $67.88
OCCT -97530HM OT SESSION BY OT ASST 105 115 648.98 $35252.42 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1903 2172 10710.92 $727057.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 78 80 525.24 $28530.83 $54.32
RSPT -RSPT RESPITE 1 1 10.13 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 456 463 491.14 $491.14 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 13 19.00 $9500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 10.00 $650.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 8 9 12.00 $2845.44 $237.12
SENS -V5264 EARMOLD 50 52 64.09 $1199.75 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 5.13 $256.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 66 70 142.93 $7146.69 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4112 4793 24940.44 $1692956.98 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 6.36 $345.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 236 245 1669.45 $22036.68 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 5 20.29 $2028.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3219 4370 655611.57 $327805.77 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 3.15 $157.50 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 49 54 242.96 $12147.98 $50.00
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Subtotal (Total Children Is Unduplicated) 9084 25198 743497.29 $5702828.62 $7.67
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Total 32016 753052.18 $6261208.21 $8.31
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Number of Children (Unduplicated) With at Least One Authorization 9816