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
SCONLY-SCONLY SERVICE COORDINATION ONLY 34 34 21.733334 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 34 34 21.733334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 8 1.838888 $89.1800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.111111 $5.0300 $45.2800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 1.033333 $14.8400 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 1.033333 $19.0700 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.033333 $10.3500 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 1.033333 $8.6900 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 1.033333 $8.0100 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.033333 $21.7000 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 13 13 3.522222 $220.6000 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 1.033333 $22.7500 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 18 164.900001 $9894.0100 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.422221 $163.5400 $114.9900
EXIT -EXIT EXIT ASSESSMENT 4 4 1.017503 $50.8800 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 51 53 18.172224 $881.3600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.211111 $10.2400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 29 8.938890 $433.5400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 91 98 40.761902 $1976.9300 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.200000 $120.0000 $100.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 174 257 249.329404 $13950.7200 $55.9500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 0.844444 $4222.0000 $4999.7400
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 15.030160 $751.5100 $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 802 896 1113.157172 $55658.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 776 860 1037.101603 $51855.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 784 873 1039.953995 $51997.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1120 1234 1336.400023 $66820.1300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.594444 $39.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 17.076190 $426.9100 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 629 700 4876.556333 $243827.8200 $50.0000
INTR -INTR INTERPRETER 2 2 6.422222 $321.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 110 118 691.656350 $46949.6600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.285714 $667.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 106 113 581.234922 $39454.2400 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.150000 $9.7500 $65.0000
SENS -V5264 EARMOLD 5 5 3.738889 $67.3000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 6.660318 $333.0200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 238 260 1548.057932 $105082.1800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 21.714286 $1179.5200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 6.285714 $82.9700 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1642 2412 15909.158676 $159091.5900 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 211 505 47318.442060 $23659.2200 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2653 8170 75666.744072 $859039.1400 $11.3500
-------------------------------------------------------------------------------------------------------------------------------------
Total 8461 75937.806810 $872989.8600 $11.5000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 2716