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: 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.044444 $1.6400 $36.9600
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.750000 $27.7500 $37.0000
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 8 8 6.794444 $29.3900 $4.3300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 31 32 32.027778 $1553.3500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.311111 $90.3200 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 45 46 46.000000 $545.5600 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $61.0000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 48 49 49.000000 $405.7200 $8.2800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $26.0600 $26.0600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 49 51 51.000000 $529.3800 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 48 49 49.000000 $1032.9200 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 5.055556 $261.6800 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 37 38 38.000000 $1033.2200 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 142 144 134.634130 $8078.0600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 22.480953 $1011.6500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 33 33 38.561111 $4434.5300 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 16 16 29.900000 $3737.5000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 15 17 7.127777 $356.3900 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 245 264 501.928571 $25096.4300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 43 43 82.000000 $6150.0000 $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 3 3 5.500000 $412.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 25 27 50.785714 $3808.9300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 44 44 63.605554 $3530.1000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 301 301 589.000000 $44175.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 79 79 146.500000 $10987.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 31 31 62.000000 $4650.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 340 341 483.991652 $26861.4500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 273 291 569.050000 $42678.7500 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 7.550001 $366.1800 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 233 246 217.369842 $10542.4400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 4.522222 $219.3300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 207 216 185.934922 $9017.8500 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 53 59 49.177780 $2458.9000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 320 341 315.802388 $15316.4500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 4 4 8.714286 $871.4300 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 4.285714 $214.2900 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1782 2823 3878.317062 $232027.3400 $59.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 56 63 127.494445 $191241.7500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 50 51 117.496827 $5874.8400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 610 832 1233.690769 $61684.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 32 34 24.858135 $621.4600 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1093 1205 2423.566667 $121178.3500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 66 66 92.083334 $2302.0900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 432 457 673.914684 $33695.7600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 23 25 29.422222 $735.5600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 504 535 1105.353957 $55267.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 23 27.716667 $692.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1325 1416 2148.188886 $107409.4400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 63 65 77.395239 $1934.8800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 17.871430 $1310.3400 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 68.571428 $857.1400 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 11.333334 $283.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 151 153 1025.847624 $25646.1800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 153.714285 $7685.7200 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 10 34.942857 $1747.1400 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 5.001588 $125.0400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3501 3887 22602.199223 $1130109.5600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 10.714285 $535.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 44 48 136.198414 $6809.9200 $50.0000
INTR -INTR INTERPRETER 181 258 899.357067 $44967.8300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 701 782 3983.806344 $270420.7400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 18 21 120.684523 $6555.5900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 996 1118 5297.191663 $359573.3700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 30 31 164.251189 $8922.1300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 306 309 374.129367 $374.1300 $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 4 4 8.600000 $4300.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.010959 $260.7200 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 7.639878 $1741.9000 $228.0000
SENS -V5264 EARMOLD 34 35 115.139682 $2072.5100 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 47 49 121.293651 $6064.7000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1315 1458 7467.876986 $506919.3300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.142857 $225.0400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 24 25 188.652381 $2490.2200 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 8 8 39.161905 $3916.1800 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3244 5114 999200.429342 $499600.2200 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 5 5 23.009524 $1150.4800 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 35 40 144.649602 $7232.4700 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 5706 18162 1050315.603220 $3489555.9100 $3.3200
-------------------------------------------------------------------------------------------------------------------------------------
Total 20993 1054200.714726 $3721612.6500 $3.5300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 6052