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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 1.901587 $70.3600 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 4 1.901587 $70.3600 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 60 64 63.012702 $3056.1300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 70 71 71.000000 $842.0600 $11.8600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $15.2500 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 71 72 72.000000 $596.1600 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 70 71 71.000000 $736.9800 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 71 72 72.000000 $1517.7600 $21.0800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 65 65.000000 $1767.3500 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 102 110 96.061115 $5763.6900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 10.155556 $457.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 32 32 39.823810 $4579.7400 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.000000 $500.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 22 23 21.322223 $1066.1200 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 249 265 486.533333 $24326.6700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 34 35 68.500000 $5137.5000 $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 39 40 69.536111 $3859.2500 $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 156 187 366.066667 $27455.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 15 15 9.310316 $451.5400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 182 191 182.503967 $8851.4400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 8 4.611111 $223.6400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 171 179 172.957142 $8388.4200 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 47 49 68.288891 $3414.4600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.866667 $13.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 232 250 250.367457 $12142.8100 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 9.000000 $450.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1486 2415 3351.825397 $188541.3300 $56.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 45 48 106.805555 $160208.2500 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.000000 $275.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 36 37 87.088095 $4354.4100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 448 550 378.054700 $18902.9500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 25 27 29.207740 $730.1900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1372 1698 2601.573427 $130078.7000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 31 31 46.666666 $1166.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1030 1129 1403.153981 $70157.7500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 13 13 19.374999 $484.3700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1096 1203 1640.294062 $82014.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 14 20.208332 $505.2100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1649 1804 2230.525005 $111526.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 33 33 52.153971 $1303.8600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 30.171429 $2212.1700 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 241.285714 $3016.0700 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 97 119 685.557130 $17138.9200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 40.580953 $2029.0500 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 9 9 81.076190 $4053.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3114 3484 21049.512713 $1052475.1300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 38 40 165.711905 $8285.5900 $50.0000
INTR -INTR INTERPRETER 154 214 887.487309 $44374.3500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 590 658 3513.640077 $238505.8700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 22 22 152.319049 $8273.9700 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 803 898 4601.578982 $312355.0400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 33 33 162.785713 $8842.5400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 244 250 1999.953963 $1999.9500 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 1.333333 $2199.9500 $1649.9600
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 3.866667 $1933.3500 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 8 8.200000 $533.0000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 0.866667 $98.8000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 4.200000 $957.6000 $228.0000
SENS -V5264 EARMOLD 24 24 24.666667 $444.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 3.800000 $190.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 50 56 143.084126 $7154.2200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1019 1125 5959.163077 $404507.9800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.571429 $519.9200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 27 29 156.963488 $2071.9200 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 25.285715 $2528.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3157 4860 875540.957950 $437770.4900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 11.042857 $552.1500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 38 41 216.523815 $10826.1900 $50.0000
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Subtotal (Total Children Is Unduplicated) 4979 18495 924340.293451 $3157559.4000 $3.4200
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Total 20914 927694.020435 $3346171.0900 $3.6100
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Number of Children (Unduplicated) With at Least One Authorization 5290