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: 07/01/10 and 09/30/10 Date of Report: 11-17-10 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 11 11 14.000000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.000000 $37.0000 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 4.000000 $148.0000 $37.0000
TCON -TCON TRANSITION CONFERENCE 4 4 4.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 18 23.000000 $185.0000 $8.0400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 120 129 132.000000 $6402.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 4.000000 $162.5600 $40.6400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 72 72 72.000000 $887.7600 $12.3300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 8.000000 $126.8800 $15.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 80 80 80.000000 $688.8000 $8.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 85 85 85.000000 $918.0000 $10.8000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 79 79 79.000000 $1731.6800 $21.9200
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 8 8 8.000000 $430.6400 $53.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 73 73 73.000000 $2064.4400 $28.2800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.000000 $94.5600 $31.5200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 204 208 207.341269 $12440.4700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 43 44 53.366667 $2401.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 128 132 159.355555 $18325.8800 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 9 18.604761 $2325.5900 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 17 17 24.000000 $3000.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 9.000000 $450.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 338 355 653.792857 $32689.6400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 49 50 100.000000 $7500.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 17.500000 $1312.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 14 14 27.500000 $2062.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 41 42 84.000000 $6300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 55 55 92.500000 $5133.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 568 568 1116.066667 $83705.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 209 210 390.066666 $29255.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 182 182 359.500000 $26962.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 475 475 931.066667 $51674.2000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 501 531 1030.550000 $77291.2500 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.000000 $145.5600 $72.7800
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 9 9 13.433333 $671.6700 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 96 106 109.428571 $5307.2900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 615 675 694.988096 $33706.9200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 107 115 115.077778 $5581.2700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 466 479 484.191271 $23483.2800 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 46 47 47.000000 $2350.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1251 1326 1550.851589 $75216.3100 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.133333 $13.3300 $99.9800
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.000000 $145.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 3726 6211 8842.315080 $523148.2300 $59.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 99 115 205.211112 $307816.8000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 2.477778 $177.4400 $71.6100
AUD -HA_FUP AUDIOLOGY SERVICES 121 130 250.242062 $12512.1000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 834 1211 1926.672225 $96333.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 41 48.350001 $1208.7500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1037 1130 1860.016288 $93000.9000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 74 78 85.182144 $2129.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 495 530 771.504768 $38575.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 28 28 42.157144 $1053.9300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 442 483 791.070642 $39553.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 33 34 58.040477 $1451.0100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1401 1503 1913.844049 $95692.2500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 92 95 111.511506 $2787.7800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 11 30.590477 $2245.9500 $73.4200
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 95.714285 $1196.4300 $12.5000
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 1 1 1.000000 $12.5000 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 386 440 2707.847645 $67696.1500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 9 149.466665 $7473.3400 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 16 16 8.344443 $417.2200 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 13 13 41.214286 $2060.7100 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 24.857143 $621.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4125 4649 26911.012064 $1345551.7600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 22 25 24.266666 $1213.3300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 63 70 236.407932 $11820.4100 $50.0000
INTR -INTR INTERPRETER 184 256 1055.821426 $52791.0700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1755 2079 10044.120180 $681795.2600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 95 104 695.569047 $37783.3100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1938 2293 10519.582484 $714069.5500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 80 82 570.330953 $30980.4000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 492 504 564.153175 $564.1500 $1.0000
SENS -FM FM RECEIVER HEARING AID 5 5 6.000000 $9900.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 32 33 54.000000 $27000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 7.000000 $455.0000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 8 8 16.000000 $3648.0000 $228.0000
SENS -V5264 EARMOLD 79 81 121.244443 $2182.4000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 5 5 26.580953 $1329.0500 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 71 76 163.044046 $8152.2100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3845 4509 23305.358599 $1581968.3400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.000000 $271.6000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 194 214 1598.742850 $21103.4100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3142 4331 695463.157005 $347731.5500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 2.445238 $122.2700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 74 88 326.800001 $16340.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 8796 25305 782843.952202 $5670975.3600 $7.2400
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Total 31534 791709.267282 $6194308.5900 $7.8200
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Number of Children (Unduplicated) With at Least One Authorization 9484