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 17 19 4.083942 $198.0700 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.133334 $16.2800 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.133334 $20.9200 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.133334 $11.3600 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.133334 $9.5300 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 1.133334 $8.7800 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.133334 $23.8000 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 2.016667 $126.3100 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.133334 $24.9600 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 19.100001 $1146.0100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.233334 $10.5000 $45.0100
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 2 2 0.338889 $16.4400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 4.305556 $208.8200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 2.333333 $113.1600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 3.900000 $189.1500 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.138889 $6.9500 $50.0000
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Subtotal (Total Children Is Unduplicated) 69 106 46.935775 $2220.6300 $47.3100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 1.344445 $67.2300 $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 175 181 223.792064 $11189.6100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 0.500000 $12.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 171 185 219.595233 $10979.7300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 196 210 252.378566 $12618.9000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.433333 $10.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 455 489 449.617454 $22480.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.066667 $1.6700 $25.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 69 78 373.108731 $18655.4400 $50.0000
INTR -INTR INTERPRETER 4 4 13.044444 $652.2200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 32 112.976191 $7668.8200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 37 40 118.226191 $8025.1900 $67.8800
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 -V5264 EARMOLD 4 4 1.438890 $25.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 2.226984 $111.3500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 60 230.128573 $15621.1400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.400000 $5.2800 $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 1821 9440.326168 $94403.2800 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 212 419 75545.334116 $37772.6700 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 5.100000 $255.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1479 3547 86991.355712 $240703.9300 $2.7700
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Total 3708 87065.358152 $242924.5500 $2.7900
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Number of Children (Unduplicated) With at Least One Authorization 1553