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: 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 10.428571 $385.8600 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 6.872223 $254.2800 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 18.300794 $640.1300 $34.9800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 28 30.000000 $1455.0000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 71 72 70.571428 $836.9800 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $30.5000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 71 72 70.571428 $584.3300 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 72 73 71.515872 $742.3300 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 72 73 71.515872 $1507.5500 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 3.000000 $155.2800 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 51 52 51.285714 $1394.4600 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 116 119 121.765078 $7305.9000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 15 16.633333 $748.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 32 32 37.777778 $4344.4500 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 5.000000 $625.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 34 36 75.142857 $9392.8600 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 19 20 13.888095 $694.4000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 226 229 434.783333 $21739.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 20 20 40.000000 $3000.0000 $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 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 22 23 45.000000 $3375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 35 41 66.508220 $3691.2100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 245 245 476.500000 $35737.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 103 103 192.000000 $14400.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 38 38 74.500000 $5587.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 244 244 470.500000 $26112.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 310 337 668.533333 $50140.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 19 25.285715 $1226.3600 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 222 236 252.376191 $12240.2500 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 11.000000 $533.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 189 199 196.922222 $9550.7300 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 22 23 23.000000 $1150.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 287 307 306.247607 $14853.0000 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 9.000000 $450.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1640 2686 3947.324076 $234767.0000 $59.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 57 64 136.714286 $205071.4500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 45 47 99.384127 $4969.2000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 559 783 1522.249550 $76112.4300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 23 23 18.650000 $466.2500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 827 906 3044.662297 $152233.1600 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 49 51 66.418650 $1660.4600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 304 319 882.972217 $44148.6100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 15 15 31.020238 $775.5100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 388 410 1486.507537 $74325.4400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 21 52.820634 $1320.5200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1068 1124 2497.238491 $124861.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 45 46 59.374205 $1484.3500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 19.504762 $1430.0800 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.571429 $39.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 114 119 895.776189 $22394.4100 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 7 34.071428 $1703.5800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 4.428571 $221.4300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 34.009524 $850.2400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3020 3257 20556.545677 $1027826.7400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 37 39 188.400000 $9420.0000 $50.0000
INTR -INTR INTERPRETER 167 251 971.884521 $48594.2300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 643 709 3630.645244 $246448.2200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 28 28 136.145238 $7395.4100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 912 1022 5172.540086 $351111.9700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 29 30 145.211904 $7887.9200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 274 278 294.446823 $294.4500 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 6.000000 $3000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.999392 $64.9600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 8.000000 $1824.0000 $228.0000
SENS -V5264 EARMOLD 25 25 32.077777 $577.4000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 10.285714 $514.2900 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 48 51 111.417458 $5570.8700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1212 1350 7422.570243 $503843.9700 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 15.790476 $857.7300 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 28 29 190.509525 $2514.7200 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.285714 $128.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2355 3251 605902.545231 $302951.2800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 6 6 24.514286 $1225.7100 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 38 44 223.536903 $11176.8400 $50.0000
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Subtotal (Total Children Is Unduplicated) 5055 14338 655938.126347 $3247586.4300 $4.9500
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Total 17033 659903.751217 $3482993.5600 $5.2800
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Number of Children (Unduplicated) With at Least One Authorization 5383