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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 6.572223 $243.1800 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 7.572223 $243.1800 $32.1100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 26 29.000000 $1406.5000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 71 72 70.571428 $836.9800 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 5.000000 $76.2500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 74 75 73.571428 $609.1700 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 75 76 73.649206 $764.4800 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 75 76 73.649206 $1552.5300 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 7 7 7.000000 $362.3200 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 53 52.285714 $1421.6500 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 163 169 163.422223 $9805.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 27 27 27.000000 $1215.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 53 53 57.822223 $6649.5600 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 8 21.147619 $2643.4500 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 29 31 55.166666 $6895.8300 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 25 26 34.687301 $1734.3700 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 240 250 467.783333 $23389.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 22 22 42.000000 $3150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 7.500000 $562.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 23 24 45.000000 $3375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 42 48 76.508220 $4246.2100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 253 253 492.500000 $36937.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 107 107 200.000000 $15000.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 41 41 80.500000 $6037.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 255 255 492.500000 $27333.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 308 335 662.533333 $49690.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.000000 $100.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 38 40 44.571429 $2161.7100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 301 321 321.866667 $15610.5400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 34 36 36.000000 $1746.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 264 274 289.999208 $14064.9700 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 19 21 21.000000 $1050.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.000000 $30.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 466 493 531.592848 $25782.2600 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2014 3242 4572.828052 $267140.5100 $58.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 60 67 175.142857 $262714.3500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.488889 $102.5300 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 73 75 135.088888 $6754.4500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 574 828 1301.209883 $65060.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 24 24 20.688096 $517.2000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 848 931 1409.636504 $70481.8000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 34 35 46.819045 $1170.4700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 346 363 515.771826 $25788.5800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 11 11 14.252778 $356.3200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 371 400 654.899204 $32744.9500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 28 44.142856 $1103.5700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1031 1116 1425.735721 $71286.8000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 50 51 77.159918 $1928.9900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 23.776190 $1743.2700 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 61.000000 $762.5000 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 8.857143 $221.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 155 163 1151.028580 $28775.7100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 7 68.571429 $3428.5700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 20.714285 $1035.7100 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 16.800000 $420.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3047 3374 19511.605250 $975579.8800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 29 30 173.347619 $8667.3700 $50.0000
INTR -INTR INTERPRETER 190 274 1047.222626 $52361.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 788 872 4514.230973 $306425.9500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 35 37 252.942857 $13739.8500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1128 1262 5626.690913 $381939.6500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 24 26 123.938097 $6732.3300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 371 386 400.788888 $400.7900 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 13 19.000000 $9500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 8.208219 $533.5300 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 12.000000 $2736.0000 $228.0000
SENS -V5264 EARMOLD 42 42 46.211110 $831.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 63 64 159.718252 $7985.9200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1560 1716 8353.606373 $567042.7800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 30.990476 $1683.4000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 46 47 288.426189 $3807.2300 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.000000 $100.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2235 3134 536407.023852 $268203.5200 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 4 4 13.254762 $662.7400 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 42 46 179.601989 $8980.1000 $50.0000
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Subtotal (Total Children Is Unduplicated) 5585 15468 584343.592537 $3194425.6200 $5.4700
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Total 18718 588923.992812 $3461809.3100 $5.8800
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Number of Children (Unduplicated) With at Least One Authorization 6212