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
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Subtotal (Total Children Is Unduplicated) 116 119 115.605555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 36 8.088889 $392.3100 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 19 19 5.166665 $67.4200 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 19 19 4.166665 $37.9600 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 19 19 4.166665 $38.9200 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 19 19 4.166665 $90.5400 $21.7300
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.438889 $24.9900 $56.9400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 16 16 2.155554 $52.7400 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 11 3.927779 $235.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.500000 $22.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.500000 $57.5000 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 0.202739 $10.1400 $50.0200
EXIT -EXIT EXIT ASSESSMENT 48 48 6.760809 $338.0300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.008333 $0.6200 $74.7000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 0.141588 $10.6100 $74.9000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 0.010958 $0.6100 $55.7000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.172222 $8.3500 $48.4900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 24 6.055555 $293.6900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.222222 $10.7800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 13 3.322223 $161.1300 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 29 8.794444 $426.5300 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.355556 $35.5600 $100.0100
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Subtotal (Total Children Is Unduplicated) 186 282 59.341010 $2317.8500 $39.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 3.233335 $16167.5000 $5000.2600
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 14.140488 $707.0300 $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 919 1201 1365.882267 $68294.1100 $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
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 31.333332 $783.3300 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.533333 $26.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 128 155 858.346031 $42917.3000 $50.0000
INTR -INTR INTERPRETER 47 63 318.775821 $15938.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 55 266.164288 $18067.2500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 67 71 286.547620 $19450.8800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 17.304762 $939.9900 $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 -V5264 EARMOLD 1 1 0.500000 $9.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.322222 $16.1100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 110 127 616.866658 $41872.9100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.714286 $35.8300 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 238 315 1756.050794 $17560.5200 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 1746 2779 404474.124773 $202237.0600 $0.5000
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Subtotal (Total Children Is Unduplicated) 2563 8103 413593.449359 $621915.8900 $1.5000
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Total 8504 413768.395924 $624233.7400 $1.5100
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Number of Children (Unduplicated) With at Least One Authorization 2742