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
TCON -TCON TRANSITION CONFERENCE 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 6.044444 $1.6400 $0.2700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 31 31.027778 $1504.8500 $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 13 13 12.322222 $739.3300 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 4.000000 $500.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 3.000000 $150.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 244 263 499.928571 $24996.4300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 3.500000 $262.5000 $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 8 8 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 36 36 16.277773 $903.3900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 13 13 26.000000 $1950.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 1.166667 $56.5900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 18 15.283333 $741.2400 $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 7 7 5.344444 $259.2000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 4 3.100000 $155.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 36 36 28.277778 $1371.4700 $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
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Subtotal (Total Children Is Unduplicated) 421 545 781.792454 $38612.3100 $49.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 20 16.561112 $24841.8000 $1500.0100
AUD -HA_FUP AUDIOLOGY SERVICES 38 38 88.163493 $4408.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 603 825 1226.440769 $61322.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 32 34 24.858135 $621.4600 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1092 1203 2420.366667 $121018.3500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 66 66 92.083334 $2302.0900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 425 449 659.133731 $32956.7100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 23 25 29.422222 $735.5600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 498 529 1087.606338 $54380.2800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 23 27.716667 $692.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1316 1407 2129.288887 $106464.4400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 63 65 77.395239 $1934.8800 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 7.466667 $186.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 11 53.171429 $1329.2900 $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 2 2 1.571429 $78.5700 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.866667 $96.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 179 197 1321.188101 $66059.4200 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 6.428571 $321.4300 $50.0000
INTR -INTR INTERPRETER 181 258 899.357067 $44967.8300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 68 77 367.869052 $24970.9700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 87 100 411.047619 $27901.9200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 7.295238 $396.2800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 304 307 372.129367 $372.1300 $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 3 3 5.000000 $2500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.010959 $260.7200 $65.0000
SENS -V5264 EARMOLD 3 3 5.311111 $95.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 142 157 795.217458 $53979.3600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.142857 $147.0900 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 8 8 39.161905 $3916.1800 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3236 5093 997382.376960 $498691.2000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 16.000000 $800.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 4466 10921 1009746.363336 $1151435.9000 $1.1400
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Total 11473 1010534.200234 $1190049.8500 $1.1800
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Number of Children (Unduplicated) With at Least One Authorization 4633