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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 5 5 5.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 10.742064 $397.4600 $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 16.742064 $397.4600 $23.7400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 41 42 43.285714 $2099.3600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.711111 $27.7900 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 45 46 46.000000 $545.5600 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.000000 $45.7500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 47 48 48.000000 $397.4400 $8.2800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $26.0600 $26.0600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 48 50 50.000000 $519.0000 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 47 48 48.000000 $1011.8400 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 3.000000 $155.2800 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 36 37 37.000000 $1006.0300 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 144 147 137.946827 $8276.8200 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 18 19.211111 $864.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 31 31 36.077778 $4148.9500 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 8.304761 $1038.0900 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 23 23 36.000000 $4500.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 21 23 12.894444 $644.7200 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 233 247 465.142857 $23257.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 31 31 60.000000 $4500.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 14.500000 $1087.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 7.500000 $562.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 29 31 55.785714 $4183.9300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 40 41 61.176983 $3395.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 313 313 613.000000 $45975.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 81 81 150.500000 $11287.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 42 42 84.000000 $6300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 351 352 505.991652 $28082.4500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 286 304 595.050000 $44628.7500 $75.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 18 19 10.844445 $525.9600 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 257 270 269.547620 $13073.0700 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 14 8.711111 $422.4900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 233 247 238.688095 $11576.3700 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 49 49 45.311112 $2265.5600 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 406 434 422.572221 $20494.7400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.000000 $100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 9.285714 $464.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 1896 3021 4153.039270 $247689.7400 $59.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 56 61 127.250000 $190875.0000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 2.533333 $174.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 46 48 83.414288 $4170.7200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 676 924 1426.130172 $71306.7700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 32 34 27.751786 $693.8000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 914 1014 2913.778579 $145688.9700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 54 58 74.566668 $1864.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 356 380 1013.821823 $50691.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 24 24 26.455557 $661.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 389 417 1227.595631 $61379.7600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 24 47.840476 $1196.0100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1146 1238 2556.264073 $127813.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 54 54 46.752779 $1168.8200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 7 8.603175 $630.7900 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 844.285714 $10553.5700 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 191 200 1374.304759 $34357.6200 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 48.999999 $2450.0100 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 6 12.714286 $635.7200 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 9 9 29.506350 $737.6600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3274 3737 21733.515944 $1086675.7400 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 8.785715 $439.2900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 47 52 246.407936 $12320.3900 $50.0000
INTR -INTR INTERPRETER 193 260 1109.515796 $55475.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 814 912 4451.565088 $302172.2100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 26 27 118.082145 $6414.2200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 1126 1273 5713.076995 $387803.5800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 39 40 227.404760 $12352.6300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 349 358 401.980953 $401.9800 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 3.000000 $4950.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 9.000000 $4500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.522222 $293.9400 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.000000 $1368.0000 $228.0000
SENS -V5264 EARMOLD 36 36 41.955555 $755.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 64 68 190.564286 $9528.2200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1482 1677 8377.244868 $568647.0700 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 22.428572 $1218.3200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 33 34 207.207140 $2735.1400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 7.000000 $700.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2630 3825 715176.526247 $357588.2600 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 5 5 24.357143 $1217.8600 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 40 44 154.506350 $7725.3200 $50.0000
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Subtotal (Total Children Is Unduplicated) 5763 16885 770131.617163 $3532552.7000 $4.5900
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Total 19915 774301.398497 $3780639.9000 $4.8800
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Number of Children (Unduplicated) With at Least One Authorization 6374