Summary Report for FSPSAs Ending During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 4.705556 $174.1100 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 5.705556 $174.1100 $30.5200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 31 31 34.000000 $1649.0000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 15 15 14.285714 $169.4300 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 14 13.285714 $110.0100 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 15 15 14.285714 $148.2900 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 14.285714 $301.1400 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.000000 $103.5200 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 9 9.000000 $244.7100 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 28 29 29.000000 $1740.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.000000 $225.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 16.000000 $1840.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 13 14 22.000000 $2750.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 8 8.000000 $400.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 304 318 592.283333 $29614.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 13.000000 $975.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 11 21.000000 $1165.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 46 46 91.000000 $6825.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 13 13 25.000000 $1875.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 121 122 233.000000 $12931.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 77 79 161.500000 $12112.5000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.000000 $300.0000 $150.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.000000 $150.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 14.000000 $679.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 60 61 62.757143 $3043.7200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 10.000000 $485.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 39 39 39.000000 $1891.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 120 122 137.044445 $6646.6500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 3.000000 $300.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 829 1039 1624.727777 $91175.6300 $56.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 43 47 97.000000 $145500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 52 54 108.907935 $5445.4000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 887 1291 1969.557861 $98477.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 41 43 36.409525 $910.2400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1223 1345 2019.330151 $100966.4600 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 50 53 71.550393 $1788.7600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 532 565 826.741281 $41337.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 20 22 35.773015 $894.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 524 562 944.422220 $47221.1100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 31 31 46.417856 $1160.4500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1575 1723 2140.057951 $107002.9600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 78 80 118.146823 $2953.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 3.000000 $219.9600 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 8.857143 $221.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 60 69 347.800000 $8695.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 84.895239 $4244.7600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 26.857142 $1342.8500 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 7.200000 $180.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 995 1108 7022.941300 $351146.9800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 13.428571 $671.4300 $50.0000
INTR -INTR INTERPRETER 216 303 1110.255959 $55512.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 206 226 1088.395238 $73880.2200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 27.428572 $1489.9200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 247 281 1091.293268 $74077.0100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 9 49.380953 $2682.3800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 463 480 497.160317 $497.1600 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 12.000000 $6000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 6.208219 $403.5300 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 9 9 12.911111 $232.4000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.000000 $50.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 10.661905 $533.0900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 610 675 3373.668257 $229004.5600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 7 8 34.047619 $449.4300 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.000000 $100.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3112 4387 782849.185758 $391424.6000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.571429 $78.5700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.500000 $625.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 5855 13425 806112.963011 $1758447.4100 $2.1800
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Total 14469 807743.396344 $1849797.1400 $2.2900
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Number of Children (Unduplicated) With at Least One Authorization 6182