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: 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 5 5 6.14 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 9.13 $337.81 $37.00
TCON -TCON TRANSITION CONFERENCE 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 9 10 17.27 $337.81 $19.56
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 56 57 63.00 $3055.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 11.62 $419.21 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 62 64 63.07 $669.77 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 56 57 56.07 $495.07 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 58 59 62.78 $678.03 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 56 57 56.07 $1221.69 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 5.71 $310.74 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 47 47 46.07 $1302.77 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 5.71 $181.77 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 118 119 123.58 $7414.86 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 14 14.81 $692.94 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 115 116 131.21 $15692.85 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 22.86 $2857.15 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 12 14 18.00 $2250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 18 18 26.47 $1323.34 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 242 254 454.14 $22707.15 $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 32 32 62.00 $4650.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 41 41 70.50 $3912.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 445 457 896.00 $67200.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 119 120 227.86 $17089.28 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 131 134 261.00 $19575.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 361 366 714.07 $39630.70 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 274 291 573.00 $42975.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.00 $145.56 $72.78
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 1.67 $83.34 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 61 67 67.00 $3249.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 371 400 441.14 $21395.11 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 67 72 78.75 $3819.26 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 326 351 370.12 $17950.78 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 28 28 28.00 $1400.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 810 866 912.89 $44275.22 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 17.14 $1714.29 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 2480 4179 5993.29 $358463.63 $59.81
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 42 51 83.37 $125049.90 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.23 $84.90 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 46 49 146.83 $7341.35 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 526 742 1249.56 $62477.95 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 31 28.60 $714.89 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 614 683 1098.24 $54911.94 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 53 56 46.23 $1155.72 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 282 304 444.88 $22244.13 $50.00
CONOP -CONOP CONSULT, OT, PHONE 11 11 12.30 $307.38 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 269 290 470.00 $23500.08 $50.00
CONPP -CONPP CONSULT, PT, PHONE 14 15 17.17 $429.35 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 795 848 1166.99 $58349.65 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 53 58 50.77 $1269.31 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 12.77 $937.33 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 283.00 $3537.50 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 3.71 $92.86 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 156 178 1035.88 $25897.02 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 13.57 $678.57 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 6 7 3.27 $163.33 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 10 11 53.95 $2697.63 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 26.59 $664.76 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2842 3164 17927.51 $896375.72 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 18 18 16.56 $827.78 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 24 25 127.25 $6362.63 $50.00
INTR -INTR INTERPRETER 176 222 648.91 $32445.62 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1002 1131 5669.27 $384830.09 $67.88
OCCT -97530HM OT SESSION BY OT ASST 66 70 380.56 $20671.89 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1244 1415 6838.86 $464221.75 $67.88
PHY -97110HM PT SESSION BY PT ASST 46 47 303.43 $16482.39 $54.32
RSPT -RSPT RESPITE 1 1 10.13 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 340 345 367.92 $367.92 $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 4 4 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 6.00 $390.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 7 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 24 25 33.94 $635.44 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 5.13 $256.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 50 54 104.74 $5237.21 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2191 2511 12616.67 $856419.34 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 123 126 845.60 $11161.95 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 4 16.00 $1600.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2143 2896 394006.22 $197003.09 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 3.15 $157.50 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 40 43 192.14 $9606.78 $50.00
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Subtotal (Total Children Is Unduplicated) 5666 15472 446386.91 $3304649.31 $7.40
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Total 19661 452397.47 $3663450.75 $8.10
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Number of Children (Unduplicated) With at Least One Authorization 6150