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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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 2.714286 $100.4300 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 8 23.123809 $855.5800 $37.0000
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Subtotal (Total Children Is Unduplicated) 7 9 25.838095 $956.0100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 54 58 66.634922 $3231.8000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $78.1600 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 114 115 115.000000 $1363.9000 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 5.000000 $76.2500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 119 120 119.844444 $992.3100 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 122 123 123.655555 $1283.5400 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 122 123 123.655555 $2606.6600 $21.0800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $45.9200 $22.9600
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 8 8 7.011111 $362.8900 $51.7600
AUDE -92586 AUD EVOKED RESPONSE (SCREEN) 1 1 1.000000 $30.4900 $30.4900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 103 104 105.533333 $2869.4500 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 172 182 168.473018 $10108.4000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 16 21.242857 $955.9300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 43 43 45.827779 $5270.2100 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 11 11 15.585715 $1948.2100 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 43 46 51.694443 $2584.7200 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 328 357 656.742856 $32837.1400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 7.000000 $525.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 41 42 78.566667 $5892.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 20 21 42.000000 $3150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 48 50 80.544444 $4470.2100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 377 377 739.500000 $55462.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 83 83 143.550000 $10766.2500 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 19 19 38.000000 $2850.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 355 355 566.161101 $31421.8800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 241 285 556.066667 $41705.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 21 21 21.581745 $1046.7000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 328 345 334.638888 $16229.9800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 17 17 13.678572 $663.4200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 281 297 273.512697 $13265.3600 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 86 88 107.294450 $5364.7500 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.000000 $30.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 498 544 524.883330 $25456.8400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.000000 $100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 12.000000 $600.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2410 3879 5186.880149 $286646.3800 $55.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 99 107 211.641270 $317461.8000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 85 86 156.107980 $7805.4200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 903 1321 1872.724852 $93636.5700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 29 17.283930 $432.1000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1506 1711 4102.684134 $205134.1800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 67 75 89.668254 $2241.7100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 690 741 1408.748033 $70437.4300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 24 24 36.743253 $918.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 788 843 2042.728579 $102136.4200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 36 38 45.011508 $1125.2900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1929 2121 3701.220240 $185060.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 71 76 91.055159 $2276.3800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 23.323809 $1710.1100 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 817.428572 $10217.8600 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 22.504762 $562.6200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 216 242 1769.204771 $44230.1400 $25.0000
EIIF -90846 FAMILY PSYCHOTHERAPY W/O PATIENT 1 1 8.000000 $400.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 121.714285 $6085.7200 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.844444 $42.2200 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 18 18 104.976188 $5248.8100 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 13.014286 $325.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4494 5082 28861.798785 $1443090.0600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 2.566667 $128.3400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 61 66 259.959919 $12997.9900 $50.0000
INTR -INTR INTERPRETER 166 227 838.742859 $41937.1300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1088 1221 6042.027784 $410132.9200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 39 40 239.128573 $12989.4700 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1406 1576 7481.698323 $507857.7200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 34 35 153.295237 $8327.0000 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 361 380 607.398413 $607.4000 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 1.000000 $1650.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 9 9 13.900000 $6950.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 4.428311 $287.8400 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 2.000000 $228.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 6 8.185236 $1866.2300 $228.0000
SENS -V5264 EARMOLD 49 53 67.741268 $1219.3400 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 6.800000 $340.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 76 83 227.082540 $11354.1200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2216 2492 12175.297623 $826459.2600 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 12.857143 $698.4000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 56 58 324.154759 $4278.8400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 4.142857 $414.2900 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4061 6090 1321058.961848 $660529.4900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 7 7 22.795239 $1139.7700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 61 71 315.317459 $15765.8800 $50.0000
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Subtotal (Total Children Is Unduplicated) 8015 24971 1395387.909152 $5028739.1100 $3.6000
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Total 28859 1400600.627396 $5316341.4900 $3.8000
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Number of Children (Unduplicated) With at Least One Authorization 8804