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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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 99 102 106.823012 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 99 102 106.823012 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 48 50 12.808218 $621.1900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.677778 $29.1400 $42.9900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 88 88 0.988879 $12.9000 $13.0400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.266667 $21.2600 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 90 90 2.266657 $20.6400 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 90 90 2.266657 $21.1600 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 87 88 2.638880 $57.3200 $21.7200
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 1.244444 $70.8600 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 77 77 0.877769 $21.4600 $24.4400
AUDE -AUDE UNSPECIFIED AUDE SERVICES 66 75 33.759672 $2025.6200 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 2.204948 $99.2300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 6.971310 $801.7200 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.092466 $4.6200 $49.9600
EXIT -EXIT EXIT ASSESSMENT 40 40 5.943074 $297.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 0.055479 $4.1600 $75.0300
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.016590 $1.2500 $75.0500
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.016590 $1.2500 $75.0500
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 0.022069 $1.2300 $55.5700
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 122 122 1.011774 $75.8600 $74.9700
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 0.120813 $9.0700 $75.0500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 49 49 0.292989 $16.2800 $55.5700
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 42 42 0.292686 $21.9500 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 0.683334 $33.1500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 210 219 65.827293 $3192.5900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 0.916667 $44.4600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 177 188 44.776633 $2171.6600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 183 190 58.880893 $2855.7600 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.444444 $22.2200 $50.0000
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Subtotal (Total Children Is Unduplicated) 882 1485 247.365673 $12555.1200 $50.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 18 26.237062 $131185.0000 $4999.9900
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 20.941269 $1047.0700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 317 392 5.927816 $296.7100 $50.0500
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 15 0.544410 $13.6200 $25.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 897 965 1345.519984 $67275.9700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 24 25 34.166666 $854.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 776 832 1142.461215 $57122.9900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 5.755557 $143.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 746 800 1077.894425 $53894.6300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 8 11.766666 $294.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1157 1249 1523.496805 $76174.7700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 20 21 31.522221 $788.0500 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 448.428572 $5605.3600 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 74 79 578.685713 $14467.1600 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.122222 $6.1100 $49.9900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1960 2211 13302.124710 $665105.8800 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 11 31.400000 $1570.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 21 24 89.604367 $4480.2200 $50.0000
INTR -INTR INTERPRETER 35 45 299.382376 $14969.1200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 578 635 3303.857565 $224265.6700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 16.371429 $889.2900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 663 736 3599.326605 $244322.2700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 7 36.423810 $1978.5400 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 0.627778 $313.9000 $500.0200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.692922 $45.0400 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 6 2.352511 $536.3700 $228.0000
SENS -V5264 EARMOLD 25 27 14.733332 $265.2000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 12 13 41.811111 $2090.5600 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 22 23 57.967461 $2898.3700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 746 838 4092.606141 $277806.0200 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.428571 $23.2800 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 31.797619 $419.7300 $13.2000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 1734 2686 403242.839310 $201621.4300 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 15 15 41.075000 $2053.7500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 20 120.464288 $6023.2200 $50.0000
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Subtotal (Total Children Is Unduplicated) 3088 11745 434579.357509 $2060847.5000 $4.7400
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Total 13332 434933.546194 $2073402.6100 $4.7700
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Number of Children (Unduplicated) With at Least One Authorization 3301