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
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 34 34 21.733334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 35 22.133334 $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 21 21 5.822223 $83.6100 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 25 26 6.677778 $123.2700 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 26 27 7.533334 $75.4800 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 25 26 7.277778 $61.2100 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 19 19 4.711111 $36.5100 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 25 26 7.433334 $156.1000 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 38 38 12.178572 $762.7500 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 22 5.833334 $128.4500 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 66 68 362.133336 $21728.0200 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 1.277778 $57.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 8.934124 $1027.4000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 1.017503 $50.8800 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 0.811111 $39.3400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 256 272 89.242853 $4328.2600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 1.199999 $58.2000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 196 206 82.830167 $4017.3100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 286 302 103.835726 $5036.0300 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.200000 $120.0000 $100.0000
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Subtotal (Total Children Is Unduplicated) 746 1095 713.354028 $38051.3600 $53.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 12 18.833333 $94166.5000 $4999.9900
AUD -HA_FUP AUDIOLOGY SERVICES 12 13 20.478572 $1023.9300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 130 161 113.389291 $5669.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1443 2279 3377.800278 $168891.3800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1432 2255 3339.093928 $166956.0800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1426 2242 3292.979646 $164650.3700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1760 2615 3603.422494 $180172.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.594444 $39.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 113 120 752.290473 $18807.2800 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2139 2412 15915.930923 $795796.6600 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 13 13 89.316666 $4465.8300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 36.488889 $1824.4500 $50.0000
INTR -INTR INTERPRETER 2 2 6.422222 $321.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 595 660 3775.117054 $256255.0400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 9 9 79.178571 $4300.9800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 691 758 3964.357141 $269100.6400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 7 7 55.363493 $3007.3500 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.150000 $9.7500 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.255556 $29.1400 $114.0200
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 1.683333 $383.7900 $228.0000
SENS -V5264 EARMOLD 20 21 13.527779 $243.5000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 5.000000 $250.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 40 41 81.774603 $4088.7300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 970 1073 6019.757535 $408621.0900 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 4 24.785715 $1346.3600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 50.952382 $672.5700 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1643 2415 15930.444390 $159304.4500 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 652 2129 254132.975394 $127066.4900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 9 9 42.680556 $2134.0300 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 26.893650 $1344.6900 $50.0000
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Subtotal (Total Children Is Unduplicated) 3762 19290 314782.771645 $2841816.4800 $9.0300
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Total 20420 315518.259007 $2879867.8400 $9.1300
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Number of Children (Unduplicated) With at Least One Authorization 3845