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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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 2.714286 $100.4300 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 7 6.590476 $243.8400 $37.0000
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Subtotal (Total Children Is Unduplicated) 6 8 9.304762 $344.2700 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 38 40 50.351588 $2442.0500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $39.0800 $39.0800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 70 71 71.000000 $842.0600 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $30.5000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 73 74 73.844444 $611.4300 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 73 74 74.655555 $774.9200 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 74 75 75.655555 $1594.8200 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 3.000000 $155.2800 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 66 67 68.533333 $1863.4200 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 106 111 100.072224 $6004.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 14.242857 $640.9300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 28 28 29.544445 $3397.6200 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 14.585715 $1823.2100 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 25 28 24.638887 $1231.9400 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 235 256 469.176190 $23458.8100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 28 52.500000 $3937.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 15 30.000000 $2250.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 33 35 55.536111 $3082.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 256 256 502.500000 $37687.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 58 58 101.050000 $7578.7500 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 241 241 403.358329 $22386.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 156 187 368.066667 $27605.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 17 17 18.409523 $892.8500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 224 235 226.842856 $11001.8800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 5.516667 $267.5600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 200 211 201.290475 $9762.5800 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 56 58 70.788892 $3539.4600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 281 305 296.280952 $14369.6200 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.000000 $100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 7.000000 $350.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1583 2530 3451.441265 $192536.7400 $55.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 54 58 106.943651 $160415.4000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 55 56 103.119048 $5155.9700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 590 841 1131.265563 $56563.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 19 20 11.117263 $277.9300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1014 1144 2589.582938 $129479.1100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 49 55 69.744444 $1743.6100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 410 445 820.576595 $41028.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 14 14 26.943253 $673.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 544 582 1340.687307 $67034.3500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 29 31 38.744842 $968.6200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1254 1380 2263.165478 $113158.2500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 47 51 60.870635 $1521.7700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 17.923809 $1314.1800 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 631.714286 $7896.4300 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 17.638095 $440.9500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 171 195 1444.857151 $36121.4500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 117.142857 $5857.1500 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 8 78.504761 $3925.2400 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 11.114286 $277.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3333 3750 21342.843620 $1067142.3200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 39 42 159.773413 $7988.6700 $50.0000
INTR -INTR INTERPRETER 151 209 804.726987 $40236.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 688 775 3756.199205 $254970.8800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 25 26 120.400001 $6540.1200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 962 1088 5097.254763 $346001.6800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 24 24 88.647617 $4815.3400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 283 300 516.676984 $516.6800 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 5.000000 $2500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.208219 $78.5300 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 7.263014 $1655.9600 $228.0000
SENS -V5264 EARMOLD 30 31 35.685713 $642.3400 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 6.800000 $340.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 59 64 154.034922 $7701.7400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1255 1411 6763.001597 $459072.5300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 12.857143 $698.4000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 28 29 127.602380 $1684.3500 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.142857 $214.2900 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2856 4223 871102.207093 $435551.1100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 6 6 17.580953 $879.0500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 47 53 252.097618 $12604.8800 $50.0000
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Subtotal (Total Children Is Unduplicated) 5549 16945 921256.660361 $3285803.3200 $3.5700
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Total 19483 924717.406388 $3478684.3400 $3.7600
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Number of Children (Unduplicated) With at Least One Authorization 6066