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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.400000 $0.0000 $0.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 31 31 18.988889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 32 19.388889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 9 2.149999 $104.2700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.253968 $56.7800 $45.2800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 4.022223 $57.7600 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 10 10 3.166667 $58.4600 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 4.022223 $40.3000 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 4.022223 $33.8300 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 10 10 3.166667 $24.5400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 3.922223 $82.3700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 15 15 4.283334 $268.2700 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 11 11 4.022223 $88.5700 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 43 43 209.800001 $12588.0100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 0.388889 $17.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 4.561109 $524.5000 $114.9900
EXIT -EXIT EXIT ASSESSMENT 4 4 1.017503 $50.8800 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.694444 $33.6800 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 153 159 52.687298 $2555.3200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.605555 $29.3700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 121 126 48.282548 $2341.7500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 124 129 43.429379 $2106.3400 $48.5000
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Subtotal (Total Children Is Unduplicated) 431 579 395.498476 $21062.4900 $53.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 15.433334 $77167.0000 $5000.0200
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 14.163493 $708.1800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 87 109 80.902383 $4045.1300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 943 1473 2172.349374 $108618.2900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 916 1436 2104.456520 $105223.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 936 1457 2102.855726 $105143.6300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1148 1684 2295.972397 $114799.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.594444 $39.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 89 93 562.790475 $14069.7700 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1574 1783 11587.891251 $579394.6900 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 11 82.433333 $4121.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 8 32.888889 $1644.4500 $50.0000
INTR -INTR INTERPRETER 2 2 6.422222 $321.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 373 409 2218.926180 $150620.7500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 7 53.892857 $2927.4600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 462 503 2610.808731 $177221.8100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 35.506350 $1928.7100 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.150000 $9.7500 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.238889 $54.4700 $228.0100
SENS -V5264 EARMOLD 8 8 5.477779 $98.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 31 31 61.474603 $3073.7300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 489 537 2844.349601 $193074.4200 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.071429 $166.8400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 37.452382 $494.3700 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1221 1764 11405.426951 $114054.2900 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 449 1452 170106.052379 $85053.0300 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 6 6 33.088889 $1654.4500 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 5.728571 $286.4300 $50.0000
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Subtotal (Total Children Is Unduplicated) 2543 12810 210491.632766 $1846888.5000 $8.7700
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Total 13421 210906.520131 $1867950.9900 $8.8600
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Number of Children (Unduplicated) With at Least One Authorization 2605