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 6 6 21.531746 $796.6800 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 32.960317 $1182.5300 $35.8800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 31 32 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) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 9 9.000000 $244.7100 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 23 24 23.022222 $1381.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $180.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 15.000000 $1725.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 17 17 23.000000 $2875.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 289 295 556.283333 $27814.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 14.000000 $1050.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 14 26.000000 $1443.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 40 40 79.000000 $5925.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 23.000000 $1725.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 108 108 205.000000 $11377.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 76 78 159.500000 $11962.5000 $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 4 4 4.000000 $194.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 44 46 46.066667 $2234.2400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 25 25.000000 $1212.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.000000 $150.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 76 77 96.800794 $4694.8300 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 6 6 15.000000 $750.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 722 895 1453.815872 $82190.4000 $56.5300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 33 36 88.428571 $132642.9000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 36 37 84.352381 $4217.6100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 872 1257 2469.014194 $123450.6600 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 40 41 33.371429 $834.2900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1216 1333 4669.908325 $233495.5100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 63 67 103.859128 $2596.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 484 514 1563.123806 $78156.2400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 25 26 52.123810 $1303.1000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 545 579 2289.633722 $114481.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 24 61.787301 $1544.6800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1623 1728 3833.856340 $191692.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 70 72 98.746824 $2468.6700 $25.0000
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 32 35 251.442860 $6286.0700 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 11.333333 $566.6700 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 200.428572 $10021.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 7.400001 $370.0100 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 20.461905 $511.5500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1004 1093 7125.644477 $356282.0800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 25.879365 $1293.9700 $50.0000
INTR -INTR INTERPRETER 188 275 1041.384522 $52069.2300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 157 171 1004.971435 $68217.4500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 39.504761 $2145.9000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 201 231 977.628569 $66361.4700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 9 9 43.361903 $2355.4200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 357 361 383.818251 $383.8200 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.000000 $3000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.043836 $67.8500 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.000000 $1140.0000 $228.0000
SENS -V5264 EARMOLD 8 8 14.000000 $252.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.000000 $50.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 12.466667 $623.3400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 460 507 3057.025393 $207510.8400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.600000 $86.9100 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 95.071428 $1254.9400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.285714 $128.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3340 4648 959010.900801 $479505.4600 $0.5000
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Subtotal (Total Children Is Unduplicated) 5498 13113 988855.145339 $2149594.4100 $2.1700
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Total 14016 990341.921528 $2232967.3500 $2.2500
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Number of Children (Unduplicated) With at Least One Authorization 5767