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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 73 74 51.410316 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 73 74 51.410316 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 29 31 7.700000 $373.4500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.555556 $22.3400 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.555556 $28.7200 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.555556 $15.5900 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 2.533334 $21.3100 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.688889 $5.3400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 2.533334 $53.2000 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 9 9 3.316668 $207.7300 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.122222 $24.7100 $22.0200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.433333 $10.6400 $24.5500
AUDE -AUDE UNSPECIFIED AUDE SERVICES 46 49 106.931206 $6415.9000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 7 10.363383 $466.3500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 16.419841 $1888.2800 $115.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 3.130747 $156.5300 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 2.020635 $98.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 189 203 64.446824 $3125.6600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 1.172222 $56.8500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 150 154 63.505513 $3080.0300 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 177 188 70.890495 $3438.2200 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.142857 $14.2900 $100.0300
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Subtotal (Total Children Is Unduplicated) 572 700 362.018171 $19503.1300 $53.8700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 19 25.994444 $129972.0000 $4999.9900
AUD -HA_FUP AUDIOLOGY SERVICES 11 12 44.502383 $2225.1200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 115 89.329129 $4466.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 1.444444 $36.1100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1243 1687 2250.541100 $112526.3800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 18 18 26.300003 $657.5100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1121 1553 2102.616123 $105130.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 6.355555 $158.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1151 1577 2094.149855 $104706.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 11 19.200003 $480.0100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1537 1994 2464.799877 $123239.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 7.500001 $187.5000 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 861.142858 $10764.2900 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 102 112 720.004747 $18000.1500 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1989 2230 12936.707842 $646835.7100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 11 59.733333 $2986.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 18 18 108.222222 $5411.1300 $50.0000
INTR -INTR INTERPRETER 17 17 149.887301 $7494.3600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 541 599 3103.680139 $210677.9400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 31.714286 $1722.7200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 648 700 3213.430942 $218127.8400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 10 10 46.857144 $2545.2800 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.966667 $483.3500 $500.0200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 1.477778 $96.0600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 6 6 3.600000 $820.8000 $228.0000
SENS -V5264 EARMOLD 19 20 22.973017 $413.5200 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.300000 $15.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 32 33 63.377776 $3168.8900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 769 829 4198.365074 $284985.1800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 21.714286 $1179.5200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 8 9 35.747619 $471.8700 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1289 1907 10931.526945 $109315.3000 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 544 914 234124.951415 $117062.4800 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 11 11 59.152579 $2957.6300 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 12 49.200001 $2460.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 3439 14459 279880.400222 $2231928.6400 $7.9700
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Total 15233 280293.828709 $2251431.7700 $8.0300
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Number of Children (Unduplicated) With at Least One Authorization 3551