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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4 3.14 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 9.00 $333.00 $37.00
TCON -TCON TRANSITION CONFERENCE 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 8 9 14.14 $333.00 $23.55
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 55 58 60.00 $2910.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 62 64 63.07 $669.77 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 57 58 57.07 $503.90 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 59 60 63.78 $688.83 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 57 58 57.07 $1243.48 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 6.71 $365.12 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 47 47 46.07 $1302.77 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 6.71 $213.58 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 143 144 141.86 $8511.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 12.01 $562.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 94 94 95.82 $11460.35 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 16.86 $2107.15 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 12 13 19.71 $2464.29 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 22 22 25.00 $1250.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 234 246 450.71 $22535.72 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 45 46 89.00 $6675.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 9.00 $675.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 9.00 $675.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 34 34 64.00 $4800.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 34 61.64 $3421.18 $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 457 469 920.00 $69000.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 116 117 220.86 $16564.28 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 132 135 262.00 $19650.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 381 386 753.07 $41795.20 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 262 279 548.00 $41100.00 $75.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.00 $200.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 52 60 60.00 $2910.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 376 405 433.19 $21009.88 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 68 72 71.14 $3450.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 329 349 345.08 $16736.47 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 27 27 27.00 $1350.00 $50.00
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 778 848 911.47 $44206.29 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 2540 4174 5931.91 $352057.35 $59.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 42 49 80.93 $121399.95 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.07 $73.45 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 62 67 144.54 $7226.82 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 515 722 1170.07 $58503.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 27 28 18.60 $465.12 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 742 816 1200.56 $60028.18 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 53 56 117.29 $2932.37 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 333 360 503.97 $25198.45 $50.00
CONOP -CONOP CONSULT, OT, PHONE 15 15 15.81 $395.30 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 289 312 502.35 $25117.48 $50.00
CONPP -CONPP CONSULT, PT, PHONE 16 16 26.55 $663.70 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 798 875 1185.21 $59260.60 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 58 63 132.12 $3302.99 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 24.27 $1781.65 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 169.29 $2116.07 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 7 8 62.06 $1551.43 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 198 228 1670.93 $41773.31 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 65.71 $3285.72 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 5 5 1.93 $96.66 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 20 23 149.46 $7472.94 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 18.87 $471.79 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2721 3054 17227.70 $861384.86 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 16 18 18.98 $949.17 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 35 42 189.08 $9453.88 $50.00
INTR -INTR INTERPRETER 170 217 687.25 $34362.35 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1050 1176 5654.39 $383820.16 $67.88
OCCT -97530HM OT SESSION BY OT ASST 54 58 340.69 $18506.18 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1290 1433 6498.84 $441140.97 $67.88
PHY -97110HM PT SESSION BY PT ASST 60 62 459.99 $24986.69 $54.32
RSPT -RSPT RESPITE 2 2 39.40 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 344 357 358.39 $358.39 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 9 9 12.00 $6000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 7 8.00 $520.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 35 37 45.52 $852.15 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.93 $46.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 45 52 124.16 $6207.80 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2283 2587 12622.18 $856793.38 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 19.54 $1061.18 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 105 109 845.07 $11154.91 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 5 8.57 $857.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2045 2866 314721.33 $157360.67 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 5.22 $260.84 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 53 60 262.16 $13107.78 $50.00
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Subtotal (Total Children Is Unduplicated) 5670 15826 367417.97 $3256665.08 $8.86
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Total 20009 373364.02 $3609055.43 $9.67
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Number of Children (Unduplicated) With at Least One Authorization 6600