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 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) 4 4 12.067460 $409.5000 $33.9300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 23 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 -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 6.000000 $163.1400 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 8 8.000000 $480.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 8.000000 $1000.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 223 226 428.783333 $21439.1700 $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 16 16 32.000000 $2400.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $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 34 34 66.500000 $3690.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 35 70.000000 $5250.0000 $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 3 3 3.000000 $145.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 15 15.066667 $730.7400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.000000 $436.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 23 23 23.000000 $1115.5000 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 9.000000 $450.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 383 470 776.492856 $41483.2500 $53.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 33.000000 $49500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 27 27 69.138096 $3456.9000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 556 779 1516.749550 $75837.4300 $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 298 312 869.937296 $43496.8600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 15 15 31.020238 $775.5100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 383 405 1475.798013 $73789.9600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 20 51.787301 $1294.6800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1062 1118 2481.898809 $124094.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 45 46 59.374205 $1484.3500 $25.0000
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 12 13 84.485716 $2112.1500 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 25.142857 $1257.1500 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 7.866667 $196.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 166 180 1120.495248 $56024.7500 $50.0000
INTR -INTR INTERPRETER 166 250 960.455950 $48022.8000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 55 243.528574 $16530.7300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 16.009524 $869.6400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 102 119 383.397623 $26025.0500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 17.785714 $966.1200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 272 276 292.846823 $292.8500 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.043836 $2.8500 $64.9500
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 2 2 3.000000 $54.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 152 164 980.270634 $66540.7700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.642858 $206.4900 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.285714 $128.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2347 3237 604363.402374 $302181.7000 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3661 8033 618245.065996 $1051268.0600 $1.7000
-------------------------------------------------------------------------------------------------------------------------------------
Total 8507 619033.626312 $1093160.8100 $1.7700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 3821