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: 01-01-14 and 03-31-14 Date of Report: 06-03-14 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 53 55 27.066665 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 53 55 27.066665 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 23 4.900609 $237.6800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 9 9 5.133334 $73.7200 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 9 9 5.077779 $93.7400 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 5.700001 $57.1100 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 5.700001 $47.9400 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 8 8 4.611112 $35.7400 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 4.788890 $100.5700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 18 18 15.234128 $954.1200 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 9 5.133334 $113.0400 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 36 36 66.544445 $3992.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 0.396728 $17.8600 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 4.028571 $463.2900 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 0.651826 $32.5900 $50.0000
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 1 1 1.900000 $57.0000 $30.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 0.383334 $18.6000 $48.5100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 194 228 45.644449 $2213.7800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.044445 $2.1600 $48.5600
PSTH -97001 EVAL BY LICENSED PT, INITIAL 173 210 51.883964 $2516.4300 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 135 147 31.399998 $1522.8900 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.138889 $6.9500 $50.0000
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Subtotal (Total Children Is Unduplicated) 488 753 259.295837 $12557.8600 $48.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.933333 $4666.5000 $4999.8200
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 1.811112 $90.5600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 0.349505 $17.4800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 543 615 1382.770617 $69138.4400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 0.500000 $12.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 545 624 1382.047597 $69102.2700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 562 640 1399.692838 $69984.5500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.433333 $10.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 823 920 1605.688870 $80284.3600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.066667 $1.6700 $25.0100
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 52.142857 $651.7900 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 110 125 717.428569 $17935.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1555 1867 9320.765052 $466038.5100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 10 10 65.808333 $3290.4200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 12.180953 $609.0500 $50.0000
INTR -INTR INTERPRETER 4 4 13.044444 $652.2200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 413 493 2125.830948 $144301.5500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 8 8 40.142857 $2180.5600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 527 581 2478.615863 $168248.5500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 12 12 42.001587 $2281.5300 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.105556 $52.8000 $500.2100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.291172 $18.9300 $65.0100
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.071233 $16.2600 $228.2100
SENS -V5264 EARMOLD 13 13 5.883334 $105.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 26 33 38.771428 $1938.5700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 510 568 2443.737700 $165881.0100 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.714286 $38.8000 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 6.614286 $87.3100 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.571429 $57.1400 $99.9900
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1175 1822 9442.611882 $94426.1400 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 412 1249 250458.502369 $125229.2500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 13 13 42.641667 $2132.0900 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 12 18.229365 $911.4700 $50.0000
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Subtotal (Total Children Is Unduplicated) 2335 9646 283101.001042 $1490394.6700 $5.2600
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Total 10454 283387.363544 $1502952.5300 $5.3000
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Number of Children (Unduplicated) With at Least One Authorization 2422