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
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Subtotal (Total Children Is Unduplicated) 123 124 147.769044 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 37 13.249999 $642.6200 $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 0.077778 $4.4300 $56.9600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 22 9.144443 $223.7600 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 13 16 16.144446 $968.6800 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.822222 $127.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.244444 $488.1100 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.009589 $0.4800 $50.0600
EXIT -EXIT EXIT ASSESSMENT 46 50 45.532810 $2276.6400 $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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.366667 $17.7900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 5.094447 $247.0900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.372222 $18.0500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 10 1.900002 $92.1600 $48.5100
SPCH -92506 SPEECH EVAL BY LICENSED SLP 30 31 12.384129 $600.6400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.161111 $16.1100 $99.9900
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Subtotal (Total Children Is Unduplicated) 203 343 155.598551 $6515.8300 $41.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 11 6.736225 $10104.3000 $1499.9900
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 60.482464 $3024.1400 $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 866 1188 2022.694921 $101134.7400 $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 696 740 1140.134921 $57006.7400 $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 1 1 0.800000 $58.6600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 39.600001 $990.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 107 127 899.984128 $44999.1900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.700000 $35.0000 $50.0000
INTR -INTR INTERPRETER 40 47 241.232276 $12061.6100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 61 293.871432 $19948.0000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.361904 $236.9400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 67 85 334.916666 $22734.1300 $67.8800
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 3 3 1.091629 $70.9500 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.133333 $486.3900 $228.0000
SENS -V5264 EARMOLD 4 4 4.661111 $83.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 1.200000 $60.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 96 115 619.152381 $42028.0600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.000000 $132.0000 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 22.428572 $2242.8500 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1770 2821 538285.181140 $269142.5900 $0.5000
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Subtotal (Total Children Is Unduplicated) 2513 7517 546943.088501 $732515.7300 $1.3400
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Total 7984 547246.456096 $739031.5600 $1.3500
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Number of Children (Unduplicated) With at Least One Authorization 2700