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: 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 3 3 1.511112 $55.9100 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.000000 $74.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 3.511112 $129.9100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 54 65 30.111112 $1460.3900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.355556 $144.2600 $42.9900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 46 46 46.000000 $600.3000 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.844444 $14.1700 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 48 48 46.844444 $426.7500 $9.1100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.4500 $23.4500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 47 47 45.844444 $428.1900 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 47 47 45.844444 $996.2000 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 0.627778 $35.7500 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 39 39 37.727778 $923.2000 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 130 137 89.729911 $5383.8100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 5.371539 $241.7300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 21 21 12.916037 $1485.3500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 17 20 32.733333 $1636.6700 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 238 255 400.816509 $20040.7900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 2.666667 $200.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 25 38.664209 $2899.8200 $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 25 25 30.955479 $1718.0300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 241 241 429.183025 $32188.7200 $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 17 18 7.133335 $345.9700 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 209 224 117.081711 $5678.4400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 1.627779 $78.9500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 191 210 85.719454 $4157.3700 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 26 26 38.038892 $1901.9600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.266667 $4.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 225 229 208.087445 $10092.2500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.450793 $245.0800 $100.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1446 2287 2759.809144 $159462.4300 $57.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 32 72.154368 $108231.3000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.105556 $7.2700 $68.8900
AUD -HA_FUP AUDIOLOGY SERVICES 33 34 69.567460 $3478.3700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 445 539 316.748930 $15837.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 15 11.253772 $281.3500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1297 2322 3233.129805 $161656.4000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 42 43 67.305155 $1682.6200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 838 900 1682.461554 $84123.0300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 14 14 22.699998 $567.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 828 889 1382.865472 $69143.2600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 17.133333 $428.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1345 1436 2029.652360 $101482.5200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 31 31 50.596824 $1264.9200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 15.866668 $1163.3500 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 377.142857 $4714.2900 $12.5000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.933333 $48.3300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 157 187 1030.852385 $25771.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.857143 $492.8600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.277778 $13.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2993 3380 19493.336238 $974666.3500 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 3 10.471429 $523.5700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 51 58 241.168257 $12058.3900 $50.0000
INTR -INTR INTERPRETER 130 205 645.417819 $32270.9100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 633 729 3478.372243 $236111.8400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 14 14 75.747619 $4114.6100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 783 894 4393.134390 $298205.9000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 23 24 121.614286 $6606.0800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 215 222 999.175401 $999.1800 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 6.571429 $10842.8100 $1649.9900
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 2.783334 $1391.7000 $500.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 3.449315 $224.2000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 6 1.548631 $353.1000 $228.0100
SENS -V5264 EARMOLD 27 27 24.899164 $448.1900 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 4 4 6.161111 $308.0600 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 39 40 125.587304 $6279.3700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 899 994 5136.673037 $348677.2100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 22 23 153.635716 $2027.9900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3064 5394 824914.167578 $412457.1000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 5 5 34.557143 $1727.8600 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 54 62 342.353576 $17117.6700 $50.0000
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Subtotal (Total Children Is Unduplicated) 4750 18566 870602.429771 $2947800.5600 $3.3900
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Total 20857 873365.750027 $3107392.9000 $3.5600
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Number of Children (Unduplicated) With at Least One Authorization 5004