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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 10.86 $401.71 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 18.07 $668.64 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 40 42 43.00 $2085.50 $48.50
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 50 51 51.00 $541.62 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 51 52 52.00 $459.16 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 51 52 52.00 $561.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 51 52 52.00 $1133.08 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 45 46 46.00 $1300.88 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 134 137 137.36 $8241.52 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 15 16.00 $748.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 68 68 70.34 $8413.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 15 15 24.43 $3053.58 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 15 15 16.64 $832.15 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 143 152 283.29 $14164.29 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 24 24 41.50 $3112.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 9.00 $675.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 11.50 $862.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 20 21 33.00 $2475.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 29 60.21 $3341.89 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 9 9 18.00 $999.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 328 328 575.00 $43125.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 124 124 220.29 $16521.43 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 59 59 103.96 $7797.14 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 280 282 489.96 $27192.89 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 260 273 452.21 $33916.07 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 6.00 $436.68 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 58 58 58.00 $2813.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 342 370 416.54 $20202.25 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 65 73 85.14 $4129.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 268 284 301.11 $14603.93 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 21 22 22.00 $1100.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 677 730 771.36 $37410.89 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 2036 3409 4527.85 $262729.71 $58.03
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 50 55 88.00 $132000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.66 $114.00 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 58 61 102.65 $5132.31 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 333 418 628.60 $31429.77 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 25 26 21.31 $532.86 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 585 617 1026.40 $51319.75 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 35 35 49.07 $1226.85 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 280 294 418.27 $20913.25 $50.00
CONOP -CONOP CONSULT, OT, PHONE 12 12 15.00 $375.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 219 235 361.22 $18061.12 $50.00
CONPP -CONPP CONSULT, PT, PHONE 11 11 7.96 $198.99 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 635 664 1059.36 $52968.03 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 52 52 87.07 $2176.68 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 41.43 $3042.03 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 80.86 $1010.71 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 29.57 $739.29 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 150 157 1227.08 $30676.92 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 24.29 $1214.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 4 4 2.76 $137.78 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 32.43 $1621.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 38.86 $971.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2334 2539 16067.14 $803357.16 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 12 12 29.38 $1469.17 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 31 33 77.18 $3859.22 $50.00
INTR -INTR INTERPRETER 132 139 607.30 $30365.02 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 970 1073 6041.38 $410088.93 $67.88
OCCT -97530HM OT SESSION BY OT ASST 45 49 298.13 $16194.21 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1141 1294 6325.01 $429341.80 $67.88
PHY -97110HM PT SESSION BY PT ASST 55 58 406.86 $22100.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 298 306 305.28 $305.28 $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 5 5 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 9.08 $590.34 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 6 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 28 29 34.70 $649.66 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 4.57 $228.57 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 52 56 171.48 $8573.82 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1997 2254 12309.97 $835600.72 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 7.36 $399.64 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 100 104 821.85 $10848.45 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 14.57 $1457.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1789 2432 288735.77 $144367.87 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 0.23 $11.67 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 40 42 209.83 $10491.44 $50.00
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Subtotal (Total Children Is Unduplicated) 4941 13120 337838.91 $3093298.65 $9.16
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Total 16532 342384.84 $3356697.00 $9.80
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Number of Children (Unduplicated) With at Least One Authorization 5297