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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 Page: 1
Child has a MEDICAID # Filter: Y
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
CASE -CASE NON-TCM CASE MANAGEMENT 3 3 4.35 $161.04 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 741 780 1064.45 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 35 40 91.00 $3367.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 35 35 68.09 $2519.23 $37.00
TCON -TCON TRANSITION CONFERENCE 13 13 13.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 796 871 1240.89 $6047.27 $4.87
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 90 123 150.86 $7316.57 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 8 9 11.39 $410.80 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 174 195 277.00 $2941.74 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 154 170 170.00 $1501.10 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 155 171 171.00 $1846.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 148 165 165.00 $3595.35 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 5 5.00 $271.90 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 140 155 155.00 $4383.40 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 374 444 665.72 $39943.22 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 33 43 48.36 $2263.04 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 236 248 322.08 $38520.59 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 8 8.00 $1000.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 48 51 191.45 $23931.38 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 536 696 860.49 $43024.25 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 128 140 187.68 $9383.93 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 23 23 27.00 $810.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 14 14 17.50 $1312.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 2 2 2.50 $138.75 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 57 57 74.48 $5586.20 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 8.01 $600.42 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 17 17 25.23 $1892.09 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 60 62 78.57 $5892.86 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 123 127 167.72 $9308.59 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 33 33 36.00 $1998.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 870 877 1249.57 $93717.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 202 205 276.50 $20737.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 309 311 439.68 $32975.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 962 980 1388.42 $77057.53 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 995 1105 1532.78 $114958.23 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 3 3 3.00 $450.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.77 $88.34 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 6 6 6.00 $300.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 198 272 367.92 $17843.88 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 899 1045 1231.16 $59711.46 $48.50
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 4 4 8.10 $1215.21 $150.00
PDFO -T1024HTTS *PSY-DEV EVAL OUTPATIENT, FOLLOW-UP 2 2 0.68 $102.11 $150.00
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 235 304 362.49 $17580.94 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 777 887 1056.49 $51239.78 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 30 30 33.00 $1650.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1727 2090 2367.43 $114820.36 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 3.00 $300.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 19 23 62.20 $3109.77 $50.00
WHEELO-97003TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 5.00 $242.50 $48.50
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Subtotal (Total Children Is Unduplicated) 5518 11117 14223.21 $816022.75 $57.37
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 182 238 334.62 $501928.50 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 3 4.51 $310.63 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 4 3.93 $270.85 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 150 173 587.87 $29393.31 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 853 1619 2980.59 $149029.57 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 45 52 115.60 $2890.12 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1719 2617 9261.50 $463075.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 133 148 700.39 $17509.86 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 878 1323 3876.56 $193828.22 $50.00
CONOP -CONOP CONSULT, OT, PHONE 46 52 136.93 $3423.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 699 1034 3134.97 $156748.28 $50.00
CONPP -CONPP CONSULT, PT, PHONE 42 50 146.47 $3661.78 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1645 2361 7509.36 $375467.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 185 212 809.06 $20226.56 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 45 49 437.00 $32084.42 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 35 43 8635.57 $107944.64 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 12 12 54.03 $1350.83 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 81 82 1542.42 $38560.51 $25.00
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 2 2 15.00 $187.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 452 669 8362.48 $209061.89 $25.00
EIIF -90846 FAMILY PSYCHOTHERAPY W/O PATIENT 1 1 7.71 $385.72 $50.00
EIIF -90847 FAMILY PSYCHOTHERAPY WITH PATIENT 1 1 8.29 $414.29 $50.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 10 10 258.80 $12940.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 5 6 25.26 $1262.78 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 49 62 1071.14 $53557.14 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1008 1028 8699.67 $434983.73 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 15 16 272.28 $6806.91 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4487 6845 111400.24 $5570012.03 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 39.29 $1964.29 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 6 6 94.57 $4728.57 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 47 78 835.31 $41765.55 $50.00
INTR -INTR INTERPRETER 144 210 2089.74 $104487.23 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 2459 4058 49171.56 $3337765.57 $67.88
OCCT -97530HM OT SESSION BY OT ASST 254 284 4153.94 $225642.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2858 4735 57689.39 $3915955.88 $67.88
PHY -97110HM PT SESSION BY PT ASST 292 329 4941.64 $268429.98 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 117 123 800.08 $800.08 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 12 16 24.50 $12250.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 13 17 16.47 $1070.81 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 16 17 25.17 $5967.50 $237.12
SENS -V5264 EARMOLD 56 71 167.33 $3132.36 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 4 4 24.08 $1203.81 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 81 127 929.94 $46496.95 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 22.29 $1114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4533 7277 87262.25 $5923361.66 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 46 46 422.16 $22931.56 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 403 476 7761.63 $102453.53 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 29 44 170.77 $17077.17 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3401 6612 971600.42 $485800.18 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 145.14 $7257.14 $50.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 28 28 272.30 $13615.13 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 81 144 1578.64 $78932.25 $50.00
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Subtotal (Total Children Is Unduplicated) 9858 43425 1360740.34 $23016811.84 $16.91
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Total 55413 1376204.44 $23838881.87 $17.32
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Number of Children (Unduplicated) With at Least One Authorization 11063