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: 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 15 15 15.988888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 15.988888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 2.138890 $103.7400 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.633333 $23.4500 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.633333 $30.1500 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.633333 $16.3700 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.633333 $13.7400 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 1.633333 $12.6600 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.633333 $34.3000 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 2.072221 $129.7800 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.633333 $35.9700 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 13 13 8.583332 $514.9900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.766666 $34.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.833333 $95.8300 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 0.061111 $3.0600 $49.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 93 98 25.361110 $1230.0100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 86 93 48.403180 $2347.5800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 71 73 29.011111 $1407.0400 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.000000 $1100.0000 $100.0000
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Subtotal (Total Children Is Unduplicated) 242 310 139.664285 $7133.1500 $51.0700
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.372222 $18.6100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 188 193 549.338887 $27466.9400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 203 209 563.429361 $28171.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 191 197 551.045234 $27552.2500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 350 363 669.323011 $33466.1300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 58 60 402.357149 $10058.9200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 782 828 5514.053997 $275702.7700 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 14.600000 $730.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 184 196 1212.872220 $82329.7500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.357143 $453.9600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 196 205 1289.784130 $87550.5400 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.394444 $197.2000 $499.9400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.372222 $24.1900 $65.0000
SENS -V5264 EARMOLD 2 2 1.533333 $27.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 21 21 33.350793 $1667.5400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 193 196 1164.559533 $79050.2700 $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 2 2 2.571429 $33.9400 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 12.171429 $1217.1400 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 659 965 5816.586515 $58165.8800 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 221 669 188890.940477 $94445.4700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 41.780953 $2089.0500 $50.0000
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Subtotal (Total Children Is Unduplicated) 1117 4123 206740.514324 $810458.6600 $3.9200
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Total 4448 206896.167497 $817591.8100 $3.9500
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Number of Children (Unduplicated) With at Least One Authorization 1145