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: 10/01/08 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 11 11 6.40 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 4.00 $148.00 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 13 18 13.40 $148.00 $11.04
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 31.00 $1503.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 13.00 $468.91 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 59 59 59.00 $626.58 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 58 58 58.00 $512.14 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 57 57 57.00 $615.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 53 53 53.00 $1154.87 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 52.00 $1470.56 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 102 115 115.21 $6912.34 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 18 20.03 $937.56 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 85 87 95.56 $11428.45 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 6 6 9.70 $1212.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 21 21 27.14 $3392.86 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 44 44 60.36 $3018.02 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 44 45 76.04 $3801.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 3.00 $225.00 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 17.57 $1317.86 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.00 $225.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 4.57 $342.86 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 25.00 $1387.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 9 9 16.00 $888.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 243 243 373.00 $27975.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 45 45 66.50 $4987.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 97 98 168.64 $12648.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 274 274 409.89 $22748.92 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 216 237 358.36 $26876.79 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 37 39 38.07 $1846.24 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 246 266 274.98 $13336.73 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 45 46 52.43 $2542.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 186 196 227.11 $11014.74 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 525 546 591.25 $28675.43 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 7.00 $700.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1565 2710 3389.69 $197024.06 $58.12
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 41 44 47.00 $70500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.56 $38.26 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 44 47 95.88 $4793.82 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 281 434 719.08 $35953.93 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 12 12 6.82 $170.42 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 593 624 1077.57 $53878.38 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 27 27 48.43 $1210.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 272 297 447.50 $22375.20 $50.00
CONOP -CONOP CONSULT, OT, PHONE 11 12 17.26 $431.46 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 205 212 384.41 $19220.59 $50.00
CONPP -CONPP CONSULT, PT, PHONE 15 16 19.15 $478.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 643 687 1008.41 $50420.57 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 40 45 57.62 $1440.53 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 25.71 $1887.95 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 385.71 $4821.43 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 2.10 $52.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 130 141 939.54 $23488.58 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 6.86 $342.86 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.23 $11.67 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 9 9 78.14 $3907.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 18.29 $457.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1789 1963 12096.84 $604841.85 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 25 27 90.04 $4501.98 $50.00
INTR -INTR INTERPRETER 57 61 298.57 $14928.70 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 841 944 5122.82 $347737.22 $67.88
OCCT -97530HM OT SESSION BY OT ASST 69 73 294.56 $16000.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 941 1043 5503.30 $373564.14 $67.88
PHY -97110HM PT SESSION BY PT ASST 76 78 268.28 $14572.78 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 200 202 193.17 $193.17 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 9.50 $4750.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 7.04 $457.67 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 9 18.00 $4268.16 $237.12
SENS -V5264 EARMOLD 24 29 53.88 $1008.59 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 33 35 114.34 $5717.03 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1670 1890 10294.17 $698768.12 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 25.02 $1359.03 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 147 151 901.17 $11895.42 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 6 7 38.25 $3824.76 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1389 1856 139781.81 $69890.90 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 32 34 175.00 $8750.12 $50.00
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Subtotal (Total Children Is Unduplicated) 4026 11044 180676.03 $2484904.13 $13.75
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Total 13772 184079.12 $2682076.18 $14.57
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Number of Children (Unduplicated) With at Least One Authorization 4287