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: 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 95 98 105.223807 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 95 98 105.223807 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 38 9.108068 $441.7500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 63 64 18.666661 $243.5900 $13.0500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.144444 $2.4200 $16.7700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 64 65 18.333328 $167.0100 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 66 66 18.555550 $173.3000 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 65 66 18.555550 $403.2000 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 7 7 1.466666 $83.5100 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 55 56 14.538884 $355.7500 $24.4700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.072222 $1.9700 $27.2700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 64 68 89.547872 $5372.8900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 8 12.606144 $567.2800 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 13.793653 $1586.2900 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.175342 $8.7700 $50.0200
EXIT -EXIT EXIT ASSESSMENT 43 43 7.298781 $364.9200 $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 9 9 13.638888 $661.4800 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 228 245 77.953448 $3780.7600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 14 2.402132 $116.5100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 164 174 53.213735 $2580.8700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 160 168 55.547088 $2694.0400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 12.857143 $1285.7100 $100.0000
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Subtotal (Total Children Is Unduplicated) 873 1379 440.572778 $21037.0800 $47.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 20 9.416667 $47083.5000 $5000.0200
AUD -HA_FUP AUDIOLOGY SERVICES 14 15 36.263634 $1813.1800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 308 387 22.927997 $1146.7100 $50.0100
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 18 18 0.129133 $3.2400 $25.0700
CONIF -CONIF CONSULT ITDS, FACE TO FACE 898 962 1398.431038 $69921.5900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 21 21 32.700000 $817.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 749 801 1134.894752 $56744.7000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 8 8 8.438888 $210.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 776 828 1171.506738 $58575.2900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 12 15.366667 $384.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1171 1242 1639.814024 $81990.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 15.188889 $379.7200 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 874.142858 $10926.7900 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 57 71 504.047614 $12601.1900 $25.0000
EIIF -90812 INDIVIDUAL PSYCHOTHERAPY, 45-50 MIN 1 1 0.688889 $34.4500 $50.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.533333 $26.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2048 2282 13949.614384 $697480.4800 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 7 25.150000 $1257.5000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 22 22 83.600001 $4180.0100 $50.0000
INTR -INTR INTERPRETER 39 51 260.240899 $13012.0200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 542 613 3359.803198 $228063.3500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 16.500000 $896.2800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 633 710 3359.380976 $228034.6400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 9 9 56.161905 $3050.7100 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 0.122223 $61.1500 $500.3100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.861112 $55.9800 $65.0100
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 8 8 4.594447 $1047.5900 $228.0100
SENS -V5264 EARMOLD 21 22 16.046035 $288.8300 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 13.250000 $662.5000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 27 27 36.036508 $1801.8300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 705 785 4025.117090 $273224.7600 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $186.2400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 41.957144 $553.8300 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1260 1776 12115.115911 $121151.1300 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 713 1255 336695.392343 $168347.7000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 5 5 16.900000 $845.0000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 20 69.883337 $3494.1600 $50.0000
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Subtotal (Total Children Is Unduplicated) 3177 12012 381013.647205 $2090355.9800 $5.4900
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Total 13489 381559.443790 $2111393.0500 $5.5300
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Number of Children (Unduplicated) With at Least One Authorization 3387