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: 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 262 281 296.23 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 35 40 103.57 $3832.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 27 27 55.50 $2053.40 $37.00
TCON -TCON TRANSITION CONFERENCE 13 13 13.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 309 364 472.65 $6046.58 $12.79
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 90 118 147.86 $7171.07 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 21 21 39.86 $1437.65 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 174 196 278.00 $2952.36 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 156 173 173.00 $1527.59 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 156 173 173.00 $1868.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 148 166 166.00 $3617.14 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 5 5.00 $271.90 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 140 156 156.00 $4411.68 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 396 482 724.33 $43460.05 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 38 54 61.39 $2873.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 257 272 343.92 $41132.63 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 11 11 14.70 $1837.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 69 72 249.45 $31181.38 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 447 550 783.91 $39195.48 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 142 155 212.68 $10633.93 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 20 20 20.00 $600.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 14 15 18.50 $1387.50 $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 58 58 75.48 $5661.20 $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 16 16 24.23 $1817.09 $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 125 129 168.91 $9374.57 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 39 39 48.00 $2664.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 884 892 1281.57 $96117.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 206 209 285.50 $21412.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 318 320 459.68 $34475.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 974 993 1418.42 $78722.53 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 998 1108 1538.28 $115370.73 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.00 $300.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.00 $50.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 172 241 366.09 $17755.39 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 947 1123 1416.10 $68680.92 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 197 256 288.79 $14006.30 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 799 932 1084.78 $52611.86 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 31 31 31.00 $1550.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1918 2323 2719.11 $131876.61 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 4 4 9.00 $900.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 15 17 43.71 $2185.72 $50.00
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Subtotal (Total Children Is Unduplicated) 5632 11412 14936.61 $859366.00 $57.53
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 174 235 327.62 $491428.50 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 3 3.34 $230.30 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.93 $133.13 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 152 178 604.98 $30248.80 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 870 1817 3333.56 $166677.95 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 41 49 101.40 $2535.12 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1940 2758 9477.05 $473852.57 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 133 148 572.92 $14322.89 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 940 1344 3855.85 $192792.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 49 54 125.93 $3148.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 729 1014 3119.54 $155976.99 $50.00
CONPP -CONPP CONSULT, PT, PHONE 52 61 160.86 $4021.49 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1914 2604 7721.55 $386077.74 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 164 188 544.47 $13611.64 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 41 44 322.89 $23706.77 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 21 22 7036.29 $87953.57 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 14 14 58.97 $1474.16 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 523 752 9000.35 $225008.86 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 9 291.14 $14557.14 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 2.19 $109.45 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 49 57 1073.00 $53650.01 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 5.86 $292.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 12 15 229.13 $5728.34 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5361 8213 119078.68 $5953934.09 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 30.71 $1535.72 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 58 95 884.77 $44238.41 $50.00
INTR -INTR INTERPRETER 171 243 2108.28 $105413.91 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 2486 3987 46979.57 $3188972.97 $67.88
OCCT -97530HM OT SESSION BY OT ASST 231 269 3603.68 $195751.65 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2847 4713 56327.79 $3823530.57 $67.88
PHY -97110HM PT SESSION BY PT ASST 266 294 3819.13 $207455.06 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 344 369 1299.94 $1299.94 $1.00
SENS -FM FM RECEIVER HEARING AID 4 4 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 16 20 29.50 $14750.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 21 24 18.84 $1224.49 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 18 20 34.00 $8062.08 $237.12
SENS -V5264 EARMOLD 67 91 208.12 $3896.10 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 97 147 1001.47 $50073.62 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 22.29 $1114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4875 7659 89987.35 $6108341.53 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 14 14 206.09 $11194.83 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 421 466 6944.84 $91671.85 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 28 41 162.22 $16222.39 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3837 7537 1262188.54 $631094.24 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 145.14 $7257.14 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 94 165 1662.95 $83147.58 $50.00
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Subtotal (Total Children Is Unduplicated) 10452 45749 1644825.19 $22904663.32 $13.93
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Total 57525 1660234.45 $23770075.90 $14.32
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Number of Children (Unduplicated) With at Least One Authorization 11173