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: 04-01-13 and 06-30-13 Date of Report: 08-18-13 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 116 119 115.605555 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 116 119 115.605555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 38 8.344445 $404.7100 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 62 63 18.522217 $241.7100 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 62 63 17.522217 $159.6200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 63 63 17.522217 $163.6500 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 62 63 17.522217 $380.7500 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 7 7 1.794446 $102.1800 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 55 14.466662 $353.9900 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 77 81 94.337520 $5660.2600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 3.372223 $151.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 4.355556 $500.8900 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 0.202739 $10.1400 $50.0200
EXIT -EXIT EXIT ASSESSMENT 49 49 6.766365 $338.3100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 0.074846 $5.6100 $74.9500
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.010958 $0.6100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 120 120 0.962265 $72.1900 $75.0200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 34 34 0.181352 $13.6300 $75.1400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 76 76 0.621796 $34.5500 $55.5600
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 29 0.223893 $16.7900 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 1.361111 $66.0100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 182 203 64.677034 $3136.8100 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 13 4.277528 $207.4600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 159 170 45.317837 $2197.8900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 169 177 43.593686 $2114.3000 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.355556 $35.5600 $100.0100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 836 1343 366.408755 $16371.0400 $44.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 19 4.744446 $23723.0000 $5000.1600
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 14.992847 $749.6500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 307 385 16.715049 $836.0700 $50.0200
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 19 19 1.451355 $36.2900 $25.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 920 1210 1372.882267 $68644.1100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 28 29 41.533335 $1038.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 727 799 1077.236439 $53861.8500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 12 13 15.261111 $381.5300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 708 775 999.814296 $49990.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 9 14.500002 $362.5100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1140 1249 1386.333476 $69316.6800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 21 22 23.864286 $596.6100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.066667 $78.2100 $73.3200
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 718.571429 $8982.1400 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 103 121 845.761911 $21144.0400 $25.0000
EIIF -90812 INDIVIDUAL PSYCHOTHERAPY, 45-50 MIN 1 1 0.688889 $34.4500 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 2 2 0.888889 $44.4500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1971 2290 12718.667787 $635933.5900 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 19 21 105.500000 $5275.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 18 19 83.488096 $4174.4100 $50.0000
INTR -INTR INTERPRETER 47 63 318.775821 $15938.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 553 637 3006.545627 $204084.3800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.357143 $779.8800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 641 724 3077.401963 $208894.1800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 12 12 36.019046 $1956.5600 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.500000 $250.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.400000 $221.0000 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 4.266667 $972.8100 $228.0000
SENS -V5264 EARMOLD 12 12 9.261111 $166.7000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 11 11 33.916667 $1695.8400 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 19 19 44.162699 $2208.1400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 716 816 3815.857115 $259020.4500 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.357143 $128.0400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 36.104763 $476.5800 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 238 316 1757.917461 $17579.1900 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 1748 2784 405223.267631 $202611.6300 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 25 29 91.638889 $4581.9500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 26 27 139.823807 $6991.2000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3160 12471 437059.536130 $1873760.9500 $4.2900
-------------------------------------------------------------------------------------------------------------------------------------
Total 13933 437541.550440 $1890131.9900 $4.3200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 3508