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
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Subtotal (Total Children Is Unduplicated) 1 1 0.177778 $6.5800 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 40 49 39.366665 $1909.2800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 23 23 23.000000 $300.1500 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 23 23 23.000000 $209.5300 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 22 22 22.000000 $205.4800 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 22 22 22.000000 $478.0600 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 19 19 19.000000 $464.9300 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 19 16.938889 $1016.3300 $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 3.533333 $406.3300 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 13 16 30.000000 $1500.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 253 274 487.052374 $24352.5800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 26.063888 $1954.7900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 27.000000 $1498.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.000000 $750.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.172222 $8.3500 $48.4900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 16 9.872222 $478.8000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 9.494444 $460.4800 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 6 6 8.011112 $400.5600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 2.533333 $38.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 29 21.294445 $1032.7800 $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) 422 583 819.332927 $38692.9300 $47.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 17 15.438889 $23158.3500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 37 37 43.096824 $2154.8400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 446 527 303.325989 $15166.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 21 21 12.781548 $319.5400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 973 1300 2233.965471 $111698.2500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 52 55 88.937301 $2223.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 617 689 1178.933743 $58946.7700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 14 15 20.200000 $505.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 664 735 1233.701594 $61685.1100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 15.177777 $379.4400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1205 1341 1844.386503 $92219.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 47 49 53.108332 $1327.7100 $25.0000
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 18 18 88.923812 $2223.0900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 70.285714 $3514.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 202 224 1473.691274 $73684.6000 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 12.285715 $614.2900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 12.982540 $649.1300 $50.0000
INTR -INTR INTERPRETER 142 214 856.374961 $42818.7600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 71 79 365.099996 $24782.9700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.933333 $50.7000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 82 92 381.461903 $25893.6300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 6 31.114286 $1690.1300 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 265 281 2467.336511 $2467.3400 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.000000 $2000.0000 $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 1 1 2.533333 $577.5900 $228.0000
SENS -V5264 EARMOLD 6 6 7.283332 $131.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 158 805.781744 $54696.4600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 4 29.609525 $390.8500 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 3 3 16.233333 $1623.3300 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3019 4885 792693.598842 $396346.8000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 3 11.385714 $569.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 4066 10789 806386.903171 $1005318.6800 $1.2500
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Total 11373 807206.413876 $1044018.1900 $1.2900
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Number of Children (Unduplicated) With at Least One Authorization 4214