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
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 6.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 38 39 40.285714 $1953.8600 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 16 17 17.000000 $201.6200 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 16 17 17.000000 $140.7600 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 17 17.000000 $176.4600 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 16 17 17.000000 $358.3600 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 15.000000 $407.8500 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 11 9.711111 $582.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 5.785714 $723.2100 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 7.000000 $875.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.000000 $150.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 232 246 463.142857 $23157.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.500000 $337.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 4.063888 $225.5400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 37 37 18.277773 $1014.3900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 15 30.000000 $2250.0000 $75.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 1.166667 $56.5900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 19 17.272222 $837.7000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 11.438888 $554.7800 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 5 5 5.000000 $250.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 34 35 28.033334 $1359.6200 $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) 433 556 777.463882 $38683.3300 $49.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 17 16.350000 $24525.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 29 29 50.234921 $2511.7400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 669 917 1418.880172 $70944.2700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 32 34 27.751786 $693.8000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 912 1011 2909.211912 $145460.6400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 54 58 74.566668 $1864.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 351 375 1007.621823 $50381.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 24 24 26.455557 $661.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 386 413 1224.328965 $61216.4300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 24 47.840476 $1196.0100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1140 1231 2550.244231 $127512.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 54 54 46.752779 $1168.8200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.222222 $16.2900 $73.3100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 15 79.742858 $1993.5700 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 4.400000 $220.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 36.571428 $1828.5800 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 5.000000 $125.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 184 202 1226.369060 $61318.4400 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 6.571429 $328.5700 $50.0000
INTR -INTR INTERPRETER 192 259 1101.515796 $55075.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 70 76 313.161112 $21257.3500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 18.838096 $1023.2900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 99 110 429.071434 $29125.3700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 26.357142 $1431.7200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 345 354 398.925397 $398.9300 $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 2 2 3.000000 $1500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.000000 $130.0000 $65.0000
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 2.142857 $107.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 170 188 940.953173 $63871.8400 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 3 3 7.000000 $700.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2614 3798 713147.750057 $356573.8700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 4144 9221 727155.831351 $1090197.3700 $1.5000
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Total 9783 727939.295233 $1128880.7000 $1.5500
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Number of Children (Unduplicated) With at Least One Authorization 4308