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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.177778 $6.5800 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.300000 $85.1000 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.477778 $91.6800 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 40 50 39.527776 $1917.0900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.688889 $29.6200 $42.9900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 46 46 46.000000 $600.3000 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.044444 $51.0900 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 49 49 48.100000 $438.1900 $9.1100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.4500 $23.4500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 48 48 48.044444 $448.7300 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 49 49 49.044444 $1065.7300 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 5 4.466667 $254.3300 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 38 38 38.000000 $929.8600 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 134 141 120.674606 $7240.4900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 9.444444 $425.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 28 28 33.499999 $3852.4900 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 15.714286 $1964.2900 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 24 28 35.216668 $1760.8400 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 255 277 493.052374 $24652.5800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 6 7.066667 $530.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 29 29 52.005479 $3900.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 7 12.011111 $900.8300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 31 31 53.016590 $2942.4200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 242 242 430.116358 $32258.7200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 60 60 108.500000 $8137.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 236 238 450.083103 $24979.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 181 216 409.572145 $30717.9100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 16 16 8.505555 $412.5200 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 191 203 162.657141 $7888.8600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 2.833334 $137.4200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 179 198 159.269048 $7724.5500 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 26 26 38.038892 $1901.9600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 2.533333 $38.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 205 212 164.632541 $7984.6800 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.000000 $100.0000 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1452 2277 3068.360338 $177734.4800 $57.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 37 40 143.838889 $215758.3500 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 37 37 43.096824 $2154.8400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 448 530 306.540275 $15327.1900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 21 21 12.781548 $319.5400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 975 1303 2236.951185 $111847.5400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 52 55 88.937301 $2223.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 621 694 1182.036918 $59101.9300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 14 15 20.200000 $505.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 670 741 1239.515880 $61975.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 15.177777 $379.4400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1211 1347 1851.481741 $92574.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 47 49 53.108332 $1327.7100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 12 50.414286 $3696.3800 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 19.285714 $241.0700 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 2 3.866666 $96.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 124 147 903.385709 $22584.6500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 70.285714 $3514.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3048 3555 21184.732548 $1059237.0000 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 3 14.500001 $725.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 31 32 155.666668 $7783.3300 $50.0000
INTR -INTR INTERPRETER 142 214 856.374961 $42818.7600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 587 676 3404.953170 $231128.3500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 19 20 113.160714 $6146.8900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 809 922 4679.930408 $317673.7200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 24 26 88.708333 $4818.6300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 267 283 2522.050797 $2522.0500 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.533333 $3266.6500 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 6.533333 $424.6600 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.533333 $288.8000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 3.633333 $828.3900 $228.0000
SENS -V5264 EARMOLD 24 24 31.583333 $568.5000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.650000 $82.5000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 35 37 100.429368 $5021.4700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1002 1132 5962.975400 $404766.7100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 16 18 111.709527 $1474.5700 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 16.233333 $1623.3300 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3027 4903 794528.884556 $397264.4400 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 4 13.185714 $659.2900 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 31 38 157.019047 $7850.9700 $50.0000
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Subtotal (Total Children Is Unduplicated) 4946 16911 842204.885969 $3090670.7700 $3.6700
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Total 19191 845275.724085 $3268496.9200 $3.8700
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Number of Children (Unduplicated) With at Least One Authorization 5385