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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 0.16 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 2.00 $74.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 7 7 4.41 $157.25 $35.65
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 42 45 50.00 $2425.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 59 59 53.20 $564.98 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 55 55 50.17 $442.97 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.03 $28.00 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 56 56 50.33 $543.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 57 57 50.37 $1097.49 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.18 $9.67 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 53 53 47.20 $1334.81 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 139 146 149.06 $8943.86 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 22 22 23.00 $1076.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 91 91 100.56 $12026.45 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 5 5.00 $625.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 12 12 19.29 $2410.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 14 14 15.54 $776.79 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 156 163 305.00 $15250.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 49 51 90.50 $6787.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 21.00 $1575.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 12 12 22.30 $1672.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 42 42 78.80 $5910.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 35 60.50 $3357.75 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 14.00 $777.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 461 509 957.78 $71833.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 134 140 262.86 $19714.28 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 133 142 268.00 $20100.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 436 487 914.24 $50740.48 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 284 324 593.29 $44496.43 $75.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 4.82 $240.95 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 57 64 64.00 $3104.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 401 436 479.19 $23240.51 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 68 74 78.90 $3826.72 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 324 336 348.28 $16891.58 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 18 18 18.00 $900.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 737 800 860.48 $41733.52 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 2393 4278 6065.85 $364792.68 $60.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 51 53 101.00 $151500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 7.57 $521.37 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 70 72 154.09 $7704.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 349 455 674.51 $33725.48 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 14 14 10.20 $255.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 666 720 1145.30 $57265.03 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 39 39 46.52 $1163.11 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 296 328 415.02 $20751.01 $50.00
CONOP -CONOP CONSULT, OT, PHONE 14 14 18.53 $463.13 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 231 247 367.90 $18395.11 $50.00
CONPP -CONPP CONSULT, PT, PHONE 11 11 13.71 $342.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 706 750 1098.65 $54932.43 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 54 54 71.80 $1795.12 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 74.00 $5433.08 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 61.86 $773.21 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 18.00 $450.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 178 199 1384.94 $34623.59 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 4 4 2.54 $127.23 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 9 59.36 $2967.87 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 7 7 52.00 $1300.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2511 2735 16227.89 $811394.64 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 8 8 21.49 $1074.36 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 36 38 277.64 $13881.80 $50.00
INTR -INTR INTERPRETER 147 175 651.46 $32572.87 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1035 1157 5746.10 $390045.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 46 47 378.31 $20549.77 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1270 1438 6485.23 $440217.24 $67.88
PHY -97110HM PT SESSION BY PT ASST 67 67 491.02 $26672.28 $54.32
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 358 363 370.13 $370.13 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 10 10 10.00 $5000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.43 $158.14 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 11 11 21.80 $5169.22 $237.12
SENS -V5264 EARMOLD 42 44 58.40 $1093.16 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 4.37 $218.33 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 53 70 205.64 $10282.09 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2206 2498 11985.39 $813568.06 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 8.02 $435.59 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 103 110 780.98 $10308.95 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 10.14 $1014.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1856 2544 303223.82 $151611.92 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.97 $98.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 38 40 244.52 $12225.87 $50.00
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Subtotal (Total Children Is Unduplicated) 5328 14363 352988.25 $3147401.65 $8.92
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Total 18648 359058.51 $3512351.57 $9.78
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Number of Children (Unduplicated) With at Least One Authorization 6216