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: 10-01-11 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 10.428571 $385.8600 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 12 12 28.765080 $1064.3100 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 40.193651 $1450.1700 $36.0800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 41 42 45.000000 $2182.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $39.0800 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 102 103 101.571428 $1204.6400 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $61.0000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 104 105 103.571428 $857.5700 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 106 107 105.515872 $1095.2500 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 106 107 105.515872 $2224.2700 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 8 8 8.000000 $414.0800 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 72 73 72.285714 $1965.4500 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 183 192 194.553967 $11673.2300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 25 25 36.633333 $1648.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 55 55 68.777778 $7909.4500 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 5 7.000000 $875.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 54 56 106.142857 $13267.8600 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 26 27 16.549206 $827.4600 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 340 352 666.283333 $33314.1700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 43 43 84.000000 $6300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 9.500000 $712.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 31 32 63.000000 $4725.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 59 66 113.508220 $6299.7100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 357 357 697.000000 $52275.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 132 132 246.000000 $18450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 62 62 122.500000 $9187.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 366 366 702.500000 $38988.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 423 466 927.033333 $69527.5000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.000000 $300.0000 $150.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 25 25 31.285715 $1517.3600 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 335 354 375.980953 $18235.0800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 19 21 31.400000 $1522.9000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 276 288 284.655555 $13805.7900 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 27 28 28.000000 $1400.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 523 555 611.578561 $29661.5500 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 15.000000 $750.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2530 4075 5996.343125 $353833.1400 $59.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 108 121 244.142857 $366214.3500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 80 86 164.565081 $8228.2600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 887 1274 2488.764194 $124438.1600 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 40 41 33.371429 $834.2900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1230 1347 4685.951181 $234297.6500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 63 67 103.859128 $2596.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 504 536 1594.429361 $79721.5100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 26 27 52.440477 $1311.0200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 559 595 2309.584515 $115479.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 25 62.820634 $1570.5200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1649 1757 3891.642049 $194582.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 71 73 99.380157 $2484.5000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 20.504762 $1503.4000 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 165.714286 $2071.4300 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.571429 $39.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 160 168 1252.466666 $31311.6700 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 11.333333 $566.6700 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 11 14 211.357143 $10567.8600 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.533333 $26.6700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 14.685715 $734.2900 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 9 9 46.604762 $1165.1200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4101 4446 28237.743323 $1411886.4700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 49 51 256.296825 $12814.8400 $50.0000
INTR -INTR INTERPRETER 189 276 1052.813093 $52640.6600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1038 1158 6236.076201 $423304.7600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 47 47 280.492855 $15236.3700 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1350 1523 7937.834070 $538820.1500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 44 47 223.192854 $12123.8400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 363 367 389.418251 $389.4200 $1.0000
SENS -FM FM RECEIVER HEARING AID 4 4 5.000000 $8250.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 11 11 17.000000 $8500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 4.350077 $282.7600 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 2.000000 $228.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 8 8 15.000000 $3420.0000 $228.0000
SENS -V5264 EARMOLD 46 47 64.166665 $1155.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 11.285714 $564.2900 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 62 65 141.248411 $7062.4200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2216 2488 13952.026979 $947063.4400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 30.533333 $1658.5700 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 51 52 348.966667 $4606.3600 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.285714 $128.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3366 4695 966625.472231 $483312.7400 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 6 6 24.514286 $1225.7100 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 48 55 270.989284 $13549.4600 $50.0000
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Subtotal (Total Children Is Unduplicated) 7400 21521 1043584.429325 $5128037.2000 $4.9100
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Total 25610 1049620.966101 $5483320.5100 $5.2200
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Number of Children (Unduplicated) With at Least One Authorization 7918