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: 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 0.355556 $13.1600 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 1.901587 $70.3600 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 5 2.257143 $83.5100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 84 90 80.979370 $3927.5200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.266667 $10.4200 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 114 115 115.000000 $1363.9000 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $30.5000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 115 116 116.000000 $960.4800 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 116 117 117.000000 $1214.4600 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 117 118 118.000000 $2487.4400 $21.0800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $22.9600 $22.9600
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 16.794444 $869.2800 $51.7600
AUDE -92586 AUD EVOKED RESPONSE (SCREEN) 1 1 1.000000 $30.4900 $30.4900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 101 102 102.000000 $2773.3800 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 170 183 156.900005 $9414.0300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 20 20 18.800001 $846.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 55 55 83.185747 $9566.3600 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 6.000000 $750.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 42 43 49.533334 $2476.6700 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 331 354 658.099999 $32905.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 52 53 102.566667 $7692.5000 $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 52 53 92.544444 $5136.2100 $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 241 285 554.066667 $41555.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 21 21 16.316665 $791.3500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 294 306 287.959520 $13966.0200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 7.611111 $369.1400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 255 265 251.582537 $12201.7500 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 73 75 102.027783 $5101.4200 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 1.866667 $28.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 430 460 469.608722 $22775.9900 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 9.000000 $450.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2289 3730 5081.921451 $284541.9000 $55.9900
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.533333 $61.3300 $40.0000
ASST -ASST ASSISTIVE TECHNOLOGY 88 96 189.955556 $284933.4000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.000000 $275.4400 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 5.071429 $349.2200 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 63 64 135.384179 $6769.2200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 663 823 532.572782 $26628.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 33 35 34.207740 $855.1900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2025 2514 4071.032144 $203551.6300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 43 44 86.604762 $2165.1200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1574 1733 2298.984134 $114949.2500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 19 19 30.274999 $756.8700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1567 1728 2331.607153 $116580.4300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 16 22.174999 $554.3700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2531 2782 3476.984527 $173849.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 48 48 93.196827 $2329.9300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 13 40.438096 $2964.9200 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 241.285714 $3016.0700 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.200000 $30.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 121 144 863.042844 $21576.0700 $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 71.438096 $3571.9100 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 12 12 128.047618 $6402.3800 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 8.400000 $210.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4186 4701 29402.671835 $1470133.0100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 53 55 244.442858 $12222.1300 $50.0000
INTR -INTR INTERPRETER 170 236 968.574610 $48428.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 912 1026 5447.959117 $369807.4200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 36 36 248.850000 $13517.5400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1164 1303 6696.247228 $454541.0700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 48 48 255.204761 $13862.7300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 294 300 2716.237299 $2716.2400 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 1.333333 $2199.9500 $1649.9600
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 14 14 15.513471 $7756.8000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 13 13 20.000000 $1300.0000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 3 3 1.866667 $212.8000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 26.960318 $6146.9500 $228.0000
SENS -V5264 EARMOLD 48 49 72.692889 $1308.4700 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 3.800000 $190.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 68 75 199.422220 $9971.1200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1818 2006 11223.326179 $761839.3600 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 17.428572 $946.7200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 49 51 274.811107 $3627.5100 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 5 5 27.857144 $2785.7100 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4439 6913 1327331.977799 $663666.0000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 4 4 12.450793 $622.5400 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 52 58 286.009529 $14300.4700 $50.0000
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Subtotal (Total Children Is Unduplicated) 7173 26996 1400171.074661 $4834884.2200 $3.4500
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Total 30731 1405255.253255 $5119509.6300 $3.6400
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Number of Children (Unduplicated) With at Least One Authorization 7634