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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 56 58 58.229368 $2824.1400 $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 22 24 20.127779 $1207.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.600000 $69.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 8 14.000000 $700.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 249 265 486.533333 $24326.6700 $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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 0.577777 $28.0200 $48.4900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 16 11.522223 $558.8300 $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 16 17 17.673016 $857.1500 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 10 10 12.016668 $600.8400 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.600000 $9.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 20 19.678571 $954.4100 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 4 4 9.000000 $450.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 449 618 854.700400 $39008.0200 $45.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 23 22.811110 $34216.5000 $1499.9900
AUD -HA_FUP AUDIOLOGY SERVICES 30 31 79.099206 $3954.9700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 442 542 368.804700 $18440.4500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 25 27 29.207740 $730.1900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1367 1691 2578.716284 $128935.8500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 31 31 46.666666 $1166.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1027 1126 1394.096838 $69704.9000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 13 13 19.374999 $484.3700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1089 1195 1622.370253 $81118.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 14 20.208332 $505.2100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1641 1795 2209.482148 $110474.1300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 33 33 52.153971 $1303.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 17 129.704758 $3242.6200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 20.580953 $1029.0500 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 18.000000 $900.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 180 203 1412.806349 $70640.3100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.100000 $105.0000 $50.0000
INTR -INTR INTERPRETER 154 214 887.487309 $44374.3500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 82 354.254760 $24046.7800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 32.419048 $1761.0100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 95 110 458.085711 $31094.8400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 22.642858 $1229.9600 $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 1 1 1.000000 $500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 5.600000 $364.0000 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.600000 $68.4000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.600000 $136.8000 $228.0000
SENS -V5264 EARMOLD 4 4 4.800000 $86.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 1.642857 $82.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 145 160 874.230955 $59342.7900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 18.325396 $241.8900 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 25.285715 $2528.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3151 4846 874067.605568 $437033.8100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 11.042857 $552.1500 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4324 12445 888793.094637 $1134596.4100 $1.2800
-------------------------------------------------------------------------------------------------------------------------------------
Total 13063 889647.795037 $1173604.4200 $1.3200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 4512