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 2 2 0.638889 $23.6400 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 1.638889 $23.6400 $14.4200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 22 25.000000 $1212.5000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 10.285714 $121.9900 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 10 9.285714 $76.8900 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 10.285714 $106.7700 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 10.285714 $216.8200 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 6.000000 $163.1400 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 17 17.000000 $1020.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.000000 $805.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 7.000000 $875.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 8 8.000000 $400.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 235 244 455.783333 $22789.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 40.000000 $3000.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 39 39 76.500000 $4245.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 32 33 66.000000 $4950.0000 $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 10 10 11.000000 $533.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 27 27 26.900000 $1304.6500 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 5.000000 $242.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 19 19 19.000000 $921.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 43 45 44.900000 $2177.6500 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 4.000000 $200.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 458 574 896.226189 $47921.5800 $53.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 17 35.000000 $52500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 44 45 89.960317 $4498.0200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 571 824 1295.709883 $64785.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 24 24 20.688096 $517.2000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 845 928 1404.636504 $70231.8000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 34 35 46.819045 $1170.4700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 341 358 505.986112 $25299.3000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 11 11 14.252778 $356.3200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 367 396 643.756347 $32187.8100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 27 43.109523 $1077.7400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1021 1106 1403.843658 $70192.2000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 49 50 74.626585 $1865.6600 $25.0000
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 16 19 100.000001 $2500.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 63.571429 $3178.5700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 16.999999 $850.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 195 216 1526.555568 $76327.7300 $50.0000
INTR -INTR INTERPRETER 190 274 1047.222626 $52361.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 79 86 420.057145 $28513.4900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.533333 $463.5300 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 128 150 525.367072 $35661.9200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 31.780953 $1726.3400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 369 384 398.788888 $398.7900 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 12.000000 $6000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 5.208219 $338.5300 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 4 4 6.000000 $108.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.133333 $6.6700 $49.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 219 234 1136.387302 $77137.9600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.066667 $40.4800 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.000000 $100.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2228 3122 536360.295280 $268180.1500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.571429 $78.5700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 2.357143 $117.8600 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3901 8342 547258.142378 $879905.1200 $1.6100
-------------------------------------------------------------------------------------------------------------------------------------
Total 8919 548156.007456 $927850.3400 $1.6900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 4075