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 28 30 7.483333 $362.9400 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 0.527778 $33.0600 $62.6300
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 8 3.766667 $226.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 4.500000 $517.5000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 3.130747 $156.5300 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 16.535714 $801.9800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 2.133332 $103.4600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 29 30 22.014286 $1067.6900 $48.5000
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Subtotal (Total Children Is Unduplicated) 104 120 60.091857 $3269.1600 $54.4000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 1.605556 $8028.0000 $5000.1400
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 43.035716 $2151.7900 $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 1237 1483 2065.107765 $103254.7000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 18 18 26.300003 $657.5100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1113 1351 1909.220883 $95460.3900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 6.355555 $158.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1144 1381 1907.254614 $95362.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 11 19.200003 $480.0100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1531 1793 2272.904636 $113644.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 7.500001 $187.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 22.933333 $573.3300 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 148 162 815.073013 $40753.7000 $50.0000
INTR -INTR INTERPRETER 17 17 149.887301 $7494.3600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 56 252.800795 $17160.1300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 69 74 320.319044 $21743.2500 $67.8800
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 -V5264 EARMOLD 3 3 1.722223 $31.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 4.666666 $233.3300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 102 498.329367 $33826.6100 $67.8800
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 534 890 232115.094272 $116057.5500 $0.5000
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Subtotal (Total Children Is Unduplicated) 2866 9408 253465.522376 $771729.2500 $3.0400
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Total 9602 253577.024549 $774998.4200 $3.0600
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Number of Children (Unduplicated) With at Least One Authorization 2967