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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 224 230 2101.816670 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.866667 $32.0700 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.005479 $0.2000 $37.1400
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Subtotal (Total Children Is Unduplicated) 225 233 2102.688816 $32.2700 $0.0200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 59 61 21.505558 $1043.0300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 74 76 26.830153 $350.1300 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.400000 $23.4900 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 76 78 28.241264 $257.2700 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 75 76 28.241264 $263.7700 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 75 77 28.252375 $613.9100 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 0.616667 $35.1100 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 66 24.763487 $605.9500 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 108 113 119.514313 $7170.8900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 14 7.311568 $329.0200 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 26 27 31.612849 $3635.4700 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 2.026255 $101.3100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 101 108 101.205608 $5060.2700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 2.008333 $150.6200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 21 26.155125 $1961.6300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 0.016437 $1.2400 $75.2900
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 0.061034 $4.5800 $74.9600
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 27 29 24.969975 $1385.8300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 128 128 7.573721 $567.9600 $74.9900
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 28 28 6.155742 $461.6900 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 12 12 0.111110 $8.3300 $74.9300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 42 42 9.267724 $514.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 55 56 3.903374 $292.7600 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 14 14 6.017459 $291.8400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 160 166 104.973508 $5091.2200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 1.244444 $60.3500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 155 159 43.247566 $2097.5100 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.544444 $8.1700 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 207 211 127.589355 $6188.0700 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 1.046575 $52.3300 $50.0000
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Subtotal (Total Children Is Unduplicated) 985 1601 788.418398 $38878.9400 $49.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 39 44 33.853794 $50780.5500 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.144444 $78.8000 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.238889 $16.4500 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 38 38 60.315698 $3015.8000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 262 323 41.282533 $2064.3600 $50.0100
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 17 19 23.466792 $586.6800 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1308 1889 2794.057966 $139702.9000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 29 29 39.141667 $978.5400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 926 991 1462.787997 $73139.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 17 20 21.777777 $544.4400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 950 1010 1406.578969 $70328.9400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 14.216666 $355.4200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1523 1636 2042.608350 $102130.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 35 35 46.861114 $1171.5400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 7 12.342858 $904.9900 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 323.142857 $4039.2900 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 126 136 865.866664 $21646.6600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 31.552381 $1577.6200 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 28.571427 $1428.5800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2931 3266 18802.081393 $940103.9700 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 2.800000 $140.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 41 41 210.577356 $10528.8700 $50.0000
INTR -INTR INTERPRETER 77 88 428.229102 $21411.4500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 579 647 2975.774589 $201995.5700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 11 11 34.314286 $1863.9500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 762 836 3761.707121 $255344.8200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 29 30 124.349999 $6754.6900 $54.3200
SENS -FM FM RECEIVER HEARING AID 1 1 1.766667 $2915.0600 $1650.0300
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 5.605556 $2802.8000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 3.852816 $250.4300 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.250000 $28.5000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 7 7 5.903652 $1346.0000 $227.9900
SENS -V5264 EARMOLD 22 22 18.492692 $332.8700 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 7 10 26.138888 $1306.9400 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 44 45 78.619052 $3930.9700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 947 1061 5217.855557 $354188.0300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 16.857143 $915.6800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 19 19 95.442859 $1259.8400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2904 4761 756340.150064 $378170.0700 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 4 4 21.542857 $1077.1400 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 56 61 359.945212 $17997.2700 $50.0000
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Subtotal (Total Children Is Unduplicated) 4384 17126 797782.065704 $2679156.3800 $3.3600
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Total 18960 800673.172918 $2718067.5900 $3.3900
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Number of Children (Unduplicated) With at Least One Authorization 4893