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: 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 1 2 4.000000 $148.0000 $37.0000
TCON -TCON TRANSITION CONFERENCE 3 3 3.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 17 22.000000 $185.0000 $8.4100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 100 107 109.000000 $5286.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.000000 $81.2800 $40.6400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 52 52 52.000000 $641.1600 $12.3300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $15.8600 $15.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 53 53 53.000000 $456.3300 $8.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 56 56 56.000000 $604.8000 $10.8000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 52 52.000000 $1139.8400 $21.9200
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $53.8300 $53.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 52.000000 $1470.5600 $28.2800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $31.5200 $31.5200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 140 142 145.030158 $8701.8100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 23 23 27.366667 $1231.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 78 80 92.911111 $10684.7800 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 6 10.999999 $1375.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 14 14 19.000000 $2375.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 7.000000 $350.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 205 217 403.935714 $20196.7900 $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 27 27 54.000000 $4050.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 39 39 64.500000 $3579.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 404 404 794.566667 $59592.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 141 142 261.566666 $19617.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 137 137 269.500000 $20212.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 324 324 633.066667 $35135.2000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 371 391 763.550000 $57266.2500 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 7 7 11.433333 $571.6700 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 54 62 65.428571 $3173.2900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 364 402 417.338889 $20240.9300 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 65 69 69.077778 $3350.2700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 309 318 316.876985 $15368.5400 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 34 35 35.000000 $1750.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 729 774 900.751589 $43686.4600 $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) 2381 4044 5841.400794 $349649.4100 $59.8600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 48 59 90.611112 $135916.8000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 2.477778 $177.4400 $71.6100
AUD -HA_FUP AUDIOLOGY SERVICES 56 62 99.637302 $4981.8700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 499 732 1207.776986 $60388.8600 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 20 31 36.616667 $915.4200 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 685 745 1282.275409 $64113.8200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 54 55 61.326192 $1533.1600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 315 342 508.052388 $25402.6600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 18 18 20.833335 $520.8400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 288 315 537.665086 $26883.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 22 27.450000 $686.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 870 928 1215.747226 $60787.4100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 58 59 59.419444 $1485.4900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 27.690477 $2033.0400 $73.4200
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 71.714285 $896.4300 $12.5000
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 1 1 1.000000 $12.5000 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 285 331 1959.990496 $48999.7300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 73.090475 $3654.5300 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 14 14 7.499999 $375.0000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 8 19.985714 $999.2900 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 19.857143 $496.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2931 3297 19111.802607 $955590.9100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 15 18 17.266666 $863.3300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 44 51 174.334126 $8716.7200 $50.0000
INTR -INTR INTERPRETER 171 236 1012.892854 $50644.6400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1074 1273 5958.007503 $404429.7700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 55 58 357.278569 $19407.3800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1290 1518 6792.801147 $461095.5500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 56 57 400.769048 $21769.7900 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 381 390 449.053175 $449.0500 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 2.000000 $3300.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 11 11 17.000000 $8500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 10.000000 $2280.0000 $228.0000
SENS -V5264 EARMOLD 31 31 48.866664 $879.6000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 14.438096 $721.9100 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 43 47 107.722618 $5386.1300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2161 2520 12742.062228 $864931.5100 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.000000 $271.6000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 98 107 738.166659 $9743.8100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2173 2968 440620.577684 $220310.2700 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 2.445238 $122.2700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 64 77 260.797620 $13039.8800 $50.0000
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Subtotal (Total Children Is Unduplicated) 5694 16418 496175.000016 $3493779.3200 $7.0400
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Total 20479 502038.400810 $3843613.7300 $7.6600
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Number of Children (Unduplicated) With at Least One Authorization 6131