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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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 0.177778 $6.5800 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.427778 $15.8300 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 53 62 49.352378 $2393.5800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 27 27 27.000000 $352.3500 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 27 27 27.000000 $245.9700 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 25 25 25.000000 $233.5000 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 26 26 26.000000 $564.9800 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 7 7 5.627778 $320.4500 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 22 22.000000 $538.3400 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 26 30 26.066667 $1564.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.855556 $128.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.233333 $831.8300 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 15 18 33.000000 $1650.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 324 351 628.938446 $31446.8800 $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 4 4 8.000000 $600.0000 $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 3 3 5.500000 $412.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 59 59 89.127775 $6684.5600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 7.066667 $530.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 53 54 102.011111 $5661.6200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 36 72.000000 $5400.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 1.172222 $56.8500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 47 47 40.938095 $1985.4900 $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 20.944445 $1015.8100 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 21 21 32.027780 $1601.4000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 2.533333 $38.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 65 67 57.462504 $2786.9400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.000000 $100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 676 939 1339.358090 $68336.0400 $51.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 33 35 30.027777 $45041.5500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 41 41 47.544443 $2377.2200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 645 784 388.678146 $19434.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 28 13.898216 $347.4600 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1403 1830 3185.517073 $159275.8800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 63 67 128.689682 $3217.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 960 1071 1821.148832 $91057.5600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 18 19 27.775000 $694.3800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 955 1057 1709.253977 $85462.7400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 15.177777 $379.4400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1807 2005 2744.155958 $137207.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 56 58 68.111903 $1702.7900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 2 3.866666 $96.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 33 33 214.490481 $5362.2600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 116.428572 $5821.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 10.857142 $542.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 944 1065 7710.718265 $385536.0000 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 12.285715 $614.2900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 8 32.796826 $1639.8400 $50.0000
INTR -INTR INTERPRETER 152 225 875.482104 $43774.1200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 149 169 803.382538 $54533.6300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 5 24.719047 $1342.7400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 158 178 827.737292 $56186.8200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 9 11 52.390476 $2845.8500 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 327 349 3096.950001 $3096.9500 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.983334 $2491.7000 $500.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 6.533333 $424.6600 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.533333 $288.8000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.377777 $770.1200 $227.9900
SENS -V5264 EARMOLD 11 11 12.072221 $217.3000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 14 30.000001 $1500.0100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 348 388 2036.830958 $138260.0700 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.142857 $279.3600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 12 13 83.809525 $1106.2900 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 16.233333 $1623.3300 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4130 6665 1127133.808364 $563566.9000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 3 11.385714 $569.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 5737 16171 1153309.794659 $1818758.4600 $1.5800
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Total 17112 1154649.580527 $1887110.3300 $1.6300
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Number of Children (Unduplicated) With at Least One Authorization 5981