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
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Subtotal (Total Children Is Unduplicated) 224 232 2102.683337 $32.0700 $0.0200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 56 58 21.211113 $1028.7500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 26 27 10.188887 $132.9600 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 26 27 10.188887 $92.8200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 27 10.188887 $95.1600 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 26 27 10.188887 $221.4000 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.177778 $10.1200 $56.9500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 22 9.144443 $223.7600 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 22 23 47.465527 $2847.9400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.277778 $147.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.422222 $623.5500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 1.009589 $50.4800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 98 102 89.586452 $4479.3200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.022222 $1.6700 $74.9300
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 1.740217 $130.4900 $74.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 0.044444 $3.3300 $74.9300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 0.022222 $1.2300 $55.4400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 1.509589 $113.2200 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 8.688891 $421.4200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.172222 $8.3500 $48.4900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 15 2.805555 $136.0700 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.294444 $4.4200 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 27 24.570635 $1191.6700 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 1.046575 $52.3300 $50.0000
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Subtotal (Total Children Is Unduplicated) 292 431 259.967466 $12142.9600 $46.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 22 15.384933 $23077.5000 $1500.0100
AUD -HA_FUP AUDIOLOGY SERVICES 35 35 57.632365 $2881.6300 $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 1307 1888 2793.772252 $139688.6100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 29 29 39.141667 $978.5400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 925 990 1461.254664 $73062.7900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 17 20 21.777777 $544.4400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 944 1004 1388.826588 $69441.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 14.216666 $355.4200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1517 1630 2026.294063 $101314.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 35 35 46.861114 $1171.5400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.466667 $180.8600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 13 73.952382 $1848.8100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.695238 $834.7700 $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 189 213 1516.679367 $75833.9600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 1.800000 $90.0000 $50.0000
INTR -INTR INTERPRETER 77 88 428.229102 $21411.4500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 59 71 293.330954 $19911.2800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 14.638096 $795.1400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 78 91 314.013091 $21315.2200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 15.571429 $845.8400 $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 4 4 5.355556 $2677.8000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.204871 $143.3200 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.133333 $486.3900 $228.0000
SENS -V5264 EARMOLD 3 3 5.333333 $96.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.483333 $24.1700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 115 135 645.602384 $43823.4700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.142857 $41.4900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2902 4750 753518.769110 $376759.3800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 8.857143 $442.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 3695 11400 764829.507754 $987073.4100 $1.2900
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Total 12063 767192.158557 $999248.4400 $1.3000
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Number of Children (Unduplicated) With at Least One Authorization 4019