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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 11 11 11.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.607143 $96.4600 $37.0000
TCON -TCON TRANSITION CONFERENCE 3 3 3.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 16 16.607143 $96.4600 $5.8100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 46 46.652381 $2262.6400 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 19 20 20.000000 $237.2000 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 19 20 20.000000 $165.6000 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 19 20 20.000000 $207.6000 $10.3800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.300000 $2.4300 $8.1000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 19 20 20.000000 $421.6000 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 18 18 18.000000 $489.4200 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 21 24 20.872222 $1252.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.683334 $308.5900 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 6.785714 $848.2100 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 14 14 18.000000 $2250.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.000000 $150.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 282 300 565.142857 $28257.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 8.500000 $637.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 15 15 10.094443 $560.2300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 71 71 139.500000 $10462.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 21.000000 $1575.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 146 146 123.833318 $6872.6600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 82 87 181.785714 $13633.9400 $75.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 7.595238 $368.3700 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 53 56 53.483333 $2593.9400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 3.138889 $152.2400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 36 36 40.711904 $1974.5300 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 12 12 11.005556 $550.2800 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 99 104 103.947621 $5041.4700 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.000000 $100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 9.285714 $464.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 807 1075 1509.818238 $84198.9700 $55.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 33 39 43.511111 $65266.6500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 38 39 67.363492 $3368.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1041 1462 2282.964891 $114148.6900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 46 49 36.544049 $913.6000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1300 1448 4358.100399 $217905.0300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 69 73 111.989684 $2799.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 567 608 1638.036512 $81901.8600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 38 38 47.375795 $1184.4000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 547 586 1858.289283 $92914.4300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 28 55.707143 $1392.6800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1705 1860 3950.134708 $197506.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 70 70 78.774208 $1969.3600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.222222 $16.2900 $73.3100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 39 196.895237 $4922.3800 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 7.866667 $393.3400 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 71.571427 $3578.5800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 11.190476 $559.5200 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 24.000001 $600.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1046 1199 7417.384963 $370869.2000 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 6.571429 $328.5700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 19.842857 $992.1400 $50.0000
INTR -INTR INTERPRETER 218 289 1180.977701 $59048.8700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 184 202 855.869055 $58096.4000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 9 9 39.454763 $2143.1800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 221 245 1028.192868 $69793.6900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 10 10 42.833332 $2326.7100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 447 458 517.186509 $517.1900 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 3.000000 $4950.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.000000 $1500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.000000 $130.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.683334 $155.8200 $228.0200
SENS -V5264 EARMOLD 10 11 7.972222 $143.5000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 15 15 39.671428 $1983.5800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 513 568 3130.043664 $212467.2200 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.200000 $10.8600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 27.304762 $360.4200 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 7.000000 $700.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3723 5434 1060788.400880 $530394.2000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 6173 14823 1089959.127072 $2108303.0200 $1.9300
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Total 15914 1091485.552453 $2192598.4500 $2.0100
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Number of Children (Unduplicated) With at Least One Authorization 6508