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
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Subtotal (Total Children Is Unduplicated) 3 3 1.511112 $55.9100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 53 64 29.966668 $1453.3900 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 23 23 23.000000 $300.1500 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.611111 $10.2500 $16.7800
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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.116667 $6.6400 $56.9600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 20 20 19.611111 $479.8800 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 21 23 17.267046 $1036.0100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.344445 $15.5000 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.509361 $58.5800 $115.0100
EVAL -EVAL DEVELOPMENTAL EVALUATION 13 16 30.000000 $1500.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 234 249 381.670911 $19083.5100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.144444 $310.8300 $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 2 2 2.144444 $119.0100 $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 2 2 0.427778 $20.7500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 9.175396 $445.0000 $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 6 6 1.627777 $78.9400 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 6 6 8.011112 $400.5600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.266667 $4.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 28 76.242063 $3697.7300 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.450793 $245.0800 $100.0000
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Subtotal (Total Children Is Unduplicated) 420 583 743.651682 $34785.7000 $46.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 6.114916 $9172.3500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 33 34 69.567460 $3478.3700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 443 536 313.534644 $15676.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 15 11.253772 $281.3500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1295 2318 3227.629804 $161381.3900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 42 43 67.305155 $1682.6200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 833 895 1677.204411 $83860.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 14 14 22.699998 $567.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 821 882 1363.946424 $68197.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 17.133333 $428.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1337 1428 2011.483312 $100574.0700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 31 31 50.596824 $1264.9200 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 150.000000 $1875.0000 $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 9 9 47.714286 $1192.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.857143 $492.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 177 197 1307.508745 $65375.4000 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 6.114286 $305.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.000000 $100.0000 $50.0000
INTR -INTR INTERPRETER 130 205 645.417819 $32270.9100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 61 236.349208 $16043.3800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.933333 $811.1800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 68 75 337.311905 $22896.7100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 6.714286 $364.7200 $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 -V5264 EARMOLD 2 2 0.766667 $13.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 9.642858 $482.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 108 121 655.853175 $44519.3000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 3 19.428572 $256.4600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3059 5383 823065.391388 $411532.7200 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 12.857143 $642.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 4028 12524 836380.243679 $1059247.5000 $1.2700
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Total 13110 837125.406473 $1094089.1100 $1.3100
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Number of Children (Unduplicated) With at Least One Authorization 4191