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: 07/01/10 and 09/30/10 Date of Report: 11-17-10 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 11 11 14.000000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.000000 $37.0000 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 3 5.000000 $185.0000 $37.0000
TCON -TCON TRANSITION CONFERENCE 3 3 3.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 18 23.000000 $222.0000 $9.6500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 56 64 66.000000 $3201.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 7.500000 $304.8000 $40.6400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 52 52 52.000000 $641.1600 $12.3300
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 52 52 52.000000 $447.7200 $8.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 53 53 53.000000 $572.4000 $10.8000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 51 51 51.000000 $1117.9200 $21.9200
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $53.8300 $53.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 51 51 51.000000 $1442.2800 $28.2800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $31.5200 $31.5200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 167 172 196.288889 $11777.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 31 33 34.700000 $1561.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 108 112 120.722222 $13883.0500 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 6.142857 $767.8600 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 16 18 27.000000 $3375.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 11 11 13.300000 $665.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 208 219 409.821428 $20491.0700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 30 30 60.000000 $4500.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 15.500000 $1162.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 28 28 56.000000 $4200.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 37 37 63.500000 $3524.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 405 406 798.566667 $59892.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 143 144 265.566666 $19917.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 142 142 279.500000 $20962.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 322 322 629.066667 $34913.2000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 374 394 769.550000 $57716.2500 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.000000 $145.5600 $72.7800
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 5.400000 $270.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 64 70 70.000000 $3395.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 418 452 475.223017 $23048.3200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 71 73 86.142857 $4177.9300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 314 329 356.984128 $17313.7300 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 35 37 37.000000 $1850.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 806 881 976.836510 $47376.5800 $48.5000
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.000000 $145.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 2546 4266 6112.311908 $366344.7600 $59.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 47 56 92.000000 $138000.0000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.307241 $236.8400 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 5.000000 $358.0500 $71.6100
AUD -HA_FUP AUDIOLOGY SERVICES 69 74 143.401589 $7170.0900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 497 716 1182.940477 $59147.0300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 17 20 17.383334 $434.5900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 710 776 1189.953182 $59497.6700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 60 63 70.672623 $1766.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 354 378 538.669845 $26933.5100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 12 12 21.988097 $549.7100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 324 350 551.775007 $27588.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 23 27.341669 $683.5500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 889 967 1294.194849 $64709.7500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 65 68 74.832144 $1870.8100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 16.333334 $1199.2000 $73.4200
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 15.857143 $198.2100 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 40.142857 $1003.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 227 260 1564.176199 $39104.3700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 89.428571 $4471.4300 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 7 8 3.611112 $180.5600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 11 11 80.452381 $4022.6300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 30.571429 $764.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2983 3380 19922.422318 $996121.1100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 16 18 17.305556 $865.2800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 35 40 148.680956 $7434.0500 $50.0000
INTR -INTR INTERPRETER 185 245 765.807142 $38290.3600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1193 1350 6523.241670 $442797.7200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 72 74 395.271430 $21471.1500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1405 1576 7404.688122 $502630.2500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 68 68 366.366671 $19901.0100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 401 422 454.768254 $454.7700 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 3.000000 $4950.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 15 20.000000 $10000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 9 10.671233 $693.6300 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 10 11 19.000000 $4332.0000 $228.0000
SENS -V5264 EARMOLD 36 39 42.599083 $766.7800 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 3.800000 $190.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 56 62 191.391666 $9569.6000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2430 2758 13674.774822 $928243.5500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 122 127 873.940471 $11536.0100 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 21.714286 $2171.4200 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2170 3115 428346.800816 $214173.4000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 2.150000 $107.5000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 42 46 217.651188 $10882.5600 $50.0000
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Subtotal (Total Children Is Unduplicated) 5990 17169 486480.078767 $3667473.5600 $7.5400
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Total 21453 492615.390675 $4034040.3200 $8.1900
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Number of Children (Unduplicated) With at Least One Authorization 6889