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 45 47 11.030441 $534.9700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.677778 $29.1400 $42.9900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 30 30 0.333330 $4.3500 $13.0400
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) 26 26 0.288886 $7.0600 $24.4400
AUDE -AUDE UNSPECIFIED AUDE SERVICES 15 16 7.138891 $428.3500 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.188889 $8.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.866667 $99.6700 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.092466 $4.6200 $49.9600
EXIT -EXIT EXIT ASSESSMENT 39 39 5.770852 $288.5300 $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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 7.153176 $346.9400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 15 3.533334 $171.3700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 31 32 9.438889 $457.7900 $48.5000
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Subtotal (Total Children Is Unduplicated) 205 341 47.724545 $2411.0600 $50.5200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 3.332192 $16661.0000 $5000.0100
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 20.941269 $1047.0700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 316 388 5.906982 $295.6700 $50.0500
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 15 0.544410 $13.6200 $25.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 894 959 1335.853317 $66792.6300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 24 25 34.166666 $854.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 775 830 1141.161215 $57057.9900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 5.755557 $143.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 745 799 1076.094425 $53804.6300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 8 11.766666 $294.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1156 1247 1522.196805 $76109.7700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 20 21 31.522221 $788.0500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 46.533333 $1163.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 122 147 784.020640 $39201.0300 $50.0000
INTR -INTR INTERPRETER 35 45 299.382376 $14969.1200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 65 321.976192 $21855.7400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.000000 $162.9600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 77 92 410.664289 $27875.9000 $67.8800
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 -V5264 EARMOLD 7 7 2.911111 $52.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 5.772222 $288.6100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 107 546.774599 $37115.0400 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 1734 2683 402361.267881 $201180.6500 $0.5000
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Subtotal (Total Children Is Unduplicated) 2524 7483 409972.865068 $618086.3500 $1.5100
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Total 7926 410127.412625 $620497.4100 $1.5100
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Number of Children (Unduplicated) With at Least One Authorization 2677