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: 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 3 3 1.511112 $55.9100 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.250000 $83.2500 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 3.761112 $139.1600 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 77 88 39.746827 $1927.7300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.777778 $162.4100 $42.9900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 81 81 80.288889 $1047.7700 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 1.361796 $22.8500 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 85 85 81.516667 $742.6200 $9.1100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.4500 $23.4500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 84 84 80.516667 $752.0300 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 84 84 81.172907 $1763.8900 $21.7300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.188889 $4.7700 $25.2600
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 11 11 14.720635 $838.2000 $56.9400
AUDE -92586 AUD EVOKED RESPONSE (SCREEN) 1 1 1.000000 $33.5400 $33.5400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 58 58 56.033334 $1371.1400 $24.4700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $27.2800 $27.2800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 192 204 254.832344 $15289.9400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 20 21 12.565984 $565.4800 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 36 37 25.987345 $2988.5500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 4.000000 $500.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 24 27 40.450000 $2022.5000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 307 331 519.233403 $25961.6200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 4.666667 $350.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 38 38 57.842442 $4338.1700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.233333 $17.5000 $74.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 13 21.744444 $1630.8300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 37 37 48.133712 $2671.4100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 356 356 639.746912 $47981.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 73 73 131.066667 $9830.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 320 323 616.594214 $34220.9800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 246 296 569.072145 $42680.4100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 23 24 11.410320 $553.4100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 314 336 187.842026 $9110.3000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 3.444446 $167.0600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 280 303 135.418429 $6567.7500 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 48 48 76.055560 $3802.8000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 1.179604 $17.6900 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 400 417 315.123575 $15283.5100 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.450793 $245.0800 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 2115 3426 4150.918754 $237674.6600 $57.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 67 70 130.109676 $195164.7000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.105556 $7.2700 $68.8900
AUD -HA_FUP AUDIOLOGY SERVICES 54 56 97.912698 $4895.6300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 656 806 453.609025 $22680.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 22 22 14.237107 $355.9400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1914 3265 4743.752629 $237187.5500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 49 51 79.460712 $1986.5200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1299 1404 2601.662745 $130083.0900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 17 17 40.723808 $1018.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1239 1342 2156.728559 $107836.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 15 20.733333 $518.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2065 2220 3302.788832 $165139.2900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 42 42 72.015077 $1800.3800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 19.933334 $1461.5200 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 400.000000 $5000.0000 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.933333 $48.3300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 194 228 1301.428575 $32535.6900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 70.409524 $3520.4800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.277778 $13.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3994 4495 26490.619857 $1324530.3500 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 3 10.471429 $523.5700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 69 80 315.639687 $15781.9700 $50.0000
INTR -INTR INTERPRETER 138 214 683.296390 $34164.8400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 922 1075 5417.330761 $367728.2800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 18 18 102.819048 $5585.1300 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1113 1266 6384.530430 $433381.8400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 39 41 212.347620 $11534.7200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 270 277 1381.922227 $1381.9200 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 7.204762 $11887.7600 $1649.9900
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 14 11.872984 $5936.5500 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 3.586301 $233.1100 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 9 4.241173 $967.0200 $228.0100
SENS -V5264 EARMOLD 45 47 45.788816 $824.2100 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 8 9 9.344444 $467.2200 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 59 62 208.426987 $10421.3600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1548 1708 9151.396095 $621196.4600 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.285714 $178.4800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 45 47 284.935719 $3761.1500 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4203 7398 1184856.903751 $592428.4800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 9 10 51.339286 $2566.9700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 68 76 390.660719 $19533.0200 $50.0000
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Subtotal (Total Children Is Unduplicated) 6725 26418 1251535.786501 $4376268.2300 $3.5000
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Total 29849 1255690.466367 $4614082.0500 $3.6700
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Number of Children (Unduplicated) With at Least One Authorization 7078