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: 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 140 150 130.728572 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 140 150 130.728572 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 37 8.891174 $431.2300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 30 30 0.333330 $4.3500 $13.0400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.411111 $6.9000 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 30 30 0.333330 $3.0300 $9.1000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 30 30 0.333330 $3.1100 $9.3300
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 29 29 0.322219 $6.9900 $21.7100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 27 27 0.699997 $17.1200 $24.4600
AUDE -AUDE UNSPECIFIED AUDE SERVICES 12 14 5.416668 $325.0100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.205556 $9.2500 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.850000 $97.7500 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 0.007534 $0.3800 $49.7700
EXIT -EXIT EXIT ASSESSMENT 26 26 12.621003 $631.0500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.016667 $1.2500 $75.1500
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 0.199921 $14.9800 $74.9200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.405556 $19.6700 $48.5100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 11.044443 $535.6500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 16 4.022223 $195.0800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 31 33 9.849998 $477.7200 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 10.285714 $1028.5700 $100.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 180 325 66.255253 $3809.5000 $57.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 14 5.309589 $26548.0000 $5000.0100
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 11.138096 $556.9100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 316 388 4.507667 $225.7000 $50.0700
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 16 16 1.611077 $40.2900 $25.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 814 925 1340.291162 $67014.5600 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 28 29 37.466667 $936.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 726 818 1115.070959 $55753.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 8 8 11.766667 $294.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 685 769 1045.791275 $52289.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 9 12.966667 $324.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1071 1214 1410.211114 $70510.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 22 24 24.327779 $608.2000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 17.466666 $436.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 135 161 802.879357 $40143.9700 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 5.533333 $276.6700 $50.0000
INTR -INTR INTERPRETER 33 40 252.313327 $12615.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 63 75 359.480952 $24401.5700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.628571 $197.1100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 78 92 395.748811 $26863.4600 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 1.411111 $705.5500 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 0.727626 $47.2900 $65.0000
SENS -V5264 EARMOLD 4 5 2.888888 $52.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 5.619047 $280.9600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 102 115 533.204766 $36193.9500 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.477778 $47.7800 $100.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 1619 2598 359732.965016 $179866.4800 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2390 7328 367134.803968 $597231.4900 $1.6300
-------------------------------------------------------------------------------------------------------------------------------------
Total 7803 367331.787793 $601040.9900 $1.6400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 2592