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: 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 123 124 147.769044 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.005479 $0.2000 $37.1400
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Subtotal (Total Children Is Unduplicated) 124 125 147.774523 $0.2000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 39 13.999999 $679.0000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 74 76 26.830153 $350.1300 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 75 77 26.841264 $244.5200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 74 75 26.841264 $250.6900 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 74 76 26.852375 $583.4900 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 8 8 1.917579 $109.1800 $56.9300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 66 24.763487 $605.9500 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 69 74 134.894296 $8093.6800 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 6.330973 $284.8900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 12.517504 $1439.5100 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.009589 $0.4800 $50.0600
EXIT -EXIT EXIT ASSESSMENT 48 53 47.188365 $2359.4100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 0.375456 $28.1600 $74.9900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 1.964649 $147.3500 $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 16 17 3.570431 $198.1600 $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 7.350794 $356.5200 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 169 175 70.038190 $3396.8800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 12.265873 $594.8900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 125 131 34.617896 $1678.9800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 180 187 59.014863 $2862.2200 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.161111 $16.1100 $99.9900
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Subtotal (Total Children Is Unduplicated) 837 1393 565.446364 $26131.9100 $46.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 26 22.302891 $33454.2000 $1499.9900
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.433333 $29.8400 $68.8500
AUD -HA_FUP AUDIOLOGY SERVICES 17 17 67.217689 $3360.9000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 254 307 33.603865 $1680.4300 $50.0100
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 14 15 5.676317 $141.9200 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 868 1196 2039.428254 $101971.4100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 24 24 38.683332 $967.0800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 728 772 1254.963480 $62748.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 13 15 22.155555 $553.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 697 741 1141.534921 $57076.7400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 11.933332 $298.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1048 1118 1549.094436 $77454.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 25 25 33.087302 $827.1800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 8.076190 $592.1500 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 93.571430 $1169.6400 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 93 95 710.547629 $17763.6800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1923 2141 14874.480546 $743723.9600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 7 35.816667 $1790.8400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 20 21 94.470213 $4723.5100 $50.0000
INTR -INTR INTERPRETER 40 47 241.232276 $12061.6100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 520 576 3196.546051 $216981.4800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 8 8 37.290477 $2025.6100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 612 684 3494.278985 $237191.6400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 17 17 92.576191 $5028.7400 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 2.527778 $1263.9000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.080518 $135.2300 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 6 5.728615 $1306.1200 $228.0000
SENS -V5264 EARMOLD 15 15 17.211947 $309.8100 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 9 15 24.083333 $1204.1700 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 22 22 57.058731 $2852.9400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 708 810 4417.206375 $299839.9400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.000000 $380.2400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 41.723810 $550.7500 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 22.428572 $2242.8500 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1775 2831 540532.377172 $270266.1900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 16 16 69.725000 $3486.2500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 28 30 145.237673 $7261.8800 $50.0000
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Subtotal (Total Children Is Unduplicated) 3075 11629 574443.390886 $2174717.8600 $3.7900
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Total 13147 575156.611773 $2200849.9800 $3.8300
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Number of Children (Unduplicated) With at Least One Authorization 3333