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 31 36 8.938890 $433.5400 $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 0.066667 $3.8000 $56.9700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 16 16 2.155554 $52.7400 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 3.033333 $182.0000 $60.0000
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 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 23 26 7.530954 $365.2600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.322222 $15.6300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 3.016666 $146.3100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 25 20.897618 $1013.5300 $48.5000
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Subtotal (Total Children Is Unduplicated) 170 264 71.452378 $2842.7600 $39.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 5.616667 $28083.5000 $5000.0300
AUD -HA_FUP AUDIOLOGY SERVICES 12 13 35.822234 $1791.1100 $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
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 49.733333 $1243.3300 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.533333 $26.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 119 141 778.661908 $38933.0600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 0.833333 $41.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 5.714286 $285.7200 $50.0000
INTR -INTR INTERPRETER 39 51 260.240899 $13012.0200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 56 300.406350 $20391.6000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 71 75 335.919844 $22802.2400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.733333 $637.3500 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.055556 $27.8000 $500.4000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.861112 $55.9800 $65.0100
SENS -V5264 EARMOLD 4 4 1.266668 $22.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 2.655556 $132.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 123 743.432149 $50464.1600 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1259 1774 12100.534958 $121005.3200 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 712 1252 336296.820914 $168148.4100 $0.5000
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Subtotal (Total Children Is Unduplicated) 2641 7804 356370.240559 $737280.0500 $2.0700
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Total 8166 356546.916744 $740122.8000 $2.0800
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Number of Children (Unduplicated) With at Least One Authorization 2792