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 1 1 0.250000 $9.2500 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 1.761112 $65.1600 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 68 79 37.813494 $1833.9600 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 27 27 27.000000 $352.3500 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.611111 $10.2500 $16.7800
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) 6 6 12.953968 $737.6000 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 23 23 22.611111 $553.2900 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 35 37 71.489268 $4289.3500 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.622223 $28.0000 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 1.661188 $191.0500 $115.0100
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 3.000000 $375.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 15 18 33.000000 $1650.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 298 319 489.087805 $24454.3500 $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 6 6 8.288888 $621.6600 $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 4 4 5.733333 $430.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.288888 $349.0300 $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 3 3 1.999207 $96.9600 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 51 49.552380 $2403.2800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 1.466667 $71.1400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 27 27 13.561110 $657.7100 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 21 21 32.027780 $1601.4000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.335160 $5.0300 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 80 81 99.800716 $4840.3200 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.450793 $245.0800 $100.0000
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Subtotal (Total Children Is Unduplicated) 687 961 1277.293976 $65697.4300 $51.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 30 42.479204 $63719.1000 $1500.0100
AUD -HA_FUP AUDIOLOGY SERVICES 37 39 74.350793 $3717.5300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 644 793 438.394739 $21920.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 22 22 14.237107 $355.9400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1901 3226 4706.974057 $235348.6200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 49 51 79.460712 $1986.5200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1289 1393 2588.238934 $129411.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 17 17 40.723808 $1018.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1224 1327 2125.433320 $106271.6200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 15 20.733333 $518.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2044 2198 3253.202323 $162659.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 40 40 65.157935 $1628.9500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.333333 $24.4400 $73.3100
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 150.000000 $1875.0000 $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 20 20 118.290475 $2957.2600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 70.409524 $3520.4800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 985 1082 7099.924895 $354996.0300 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 6.114286 $305.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 2.142857 $107.1500 $50.0000
INTR -INTR INTERPRETER 138 214 683.296390 $34164.8400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 127 152 734.998420 $49891.6800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 28.004762 $1521.2200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 146 158 822.617461 $55839.2500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 8 41.061904 $2230.4900 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 269 276 1381.788894 $1381.7900 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 6.571429 $10842.8100 $1649.9900
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 2.783334 $1391.7000 $500.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 3.586301 $233.1100 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.136986 $31.2400 $228.0200
SENS -V5264 EARMOLD 6 6 3.955557 $71.2000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.233333 $11.6700 $49.9900
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 14 40.214287 $2010.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 270 295 1691.244450 $114801.6200 $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 14 15 97.971431 $1293.2200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 4171 7324 1165056.651369 $582528.3500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 13.457143 $672.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 5715 18747 1191510.394133 $1951487.2400 $1.6400
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Total 19712 1192789.449221 $2017249.8400 $1.6900
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Number of Children (Unduplicated) With at Least One Authorization 5954