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
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Subtotal (Total Children Is Unduplicated) 1 1 2.714286 $100.4300 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 35 44.351588 $2151.0500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 30 30 30.000000 $355.8000 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 30 30 30.000000 $248.4000 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 30 30 30.000000 $311.4000 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 30 30 30.000000 $632.4000 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 26 26 26.000000 $706.9400 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 20 22 20.261111 $1215.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.000000 $345.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 8 15.000000 $750.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 234 255 467.176190 $23358.8100 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 4.011111 $222.6200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $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 17 17 8.130554 $451.2400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 9 18.000000 $1350.0000 $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 5 5 0.744444 $36.1000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 28.405555 $1377.6700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 15 15.523016 $752.8700 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 11 11 12.916668 $645.8400 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 30 27.606349 $1338.9100 $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) 429 602 849.126586 $38910.7100 $45.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 18.205555 $27308.2500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 30 31 51.671428 $2583.5700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 584 833 1122.015563 $56100.9700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 19 20 11.117263 $277.9300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1011 1140 2587.549605 $129377.4500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 49 55 69.744444 $1743.6100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 405 440 805.436118 $40271.8100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 14 14 26.943253 $673.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 536 573 1315.137307 $65756.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 29 31 38.744842 $968.6200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1243 1367 2240.422622 $112021.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 47 51 60.870635 $1521.7700 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 11.904762 $297.6200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 10 53.004761 $1325.1200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 115.428571 $5771.4300 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 6.400000 $160.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 205 227 1441.627782 $72081.4000 $50.0000
INTR -INTR INTERPRETER 151 209 804.726987 $40236.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 85 96 459.388095 $31183.2500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 15.895239 $863.4300 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 107 131 503.928566 $34206.6500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 3.285714 $178.4800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 282 299 515.676984 $515.6800 $1.0000
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 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 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 5 5 8.000000 $144.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.033333 $201.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 184 207 971.683335 $65957.8600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.771429 $142.1800 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.142857 $214.2900 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2847 4207 870103.364234 $435051.6800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 9.571429 $478.5700 $50.0000
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Subtotal (Total Children Is Unduplicated) 4196 9988 883394.900932 $1129535.6800 $1.2800
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Total 10591 884246.741804 $1168546.8200 $1.3200
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Number of Children (Unduplicated) With at Least One Authorization 4381