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 5 5 1.455556 $70.6000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.788889 $11.3300 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.788889 $14.5600 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.788889 $7.9000 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.788889 $6.6300 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.788889 $6.1100 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.788889 $16.5700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 0.833333 $52.1900 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.788889 $17.3700 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 3.422222 $205.3300 $60.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 0.061111 $3.0600 $49.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 1.755556 $85.1500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 0.977778 $47.4200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 2.344444 $113.7000 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.000000 $1100.0000 $100.0000
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Subtotal (Total Children Is Unduplicated) 28 40 27.372223 $1757.9300 $64.2200
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 47 47 94.638893 $4731.9700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 63 110.067461 $5503.3700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 53 54 106.316668 $5315.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 213 222 230.194442 $11509.7100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 28 193.680954 $9684.0400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 17 116.895238 $7934.8400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 17 18 112.090477 $7608.7100 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.372222 $24.1900 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.277777 $113.8900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 28 168.833335 $11460.4100 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 2 2 12.171429 $1217.1400 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 658 961 5795.080167 $57950.8100 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 67 138 27853.734127 $13926.8700 $0.5000
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Subtotal (Total Children Is Unduplicated) 752 1583 34796.730968 $137000.6700 $3.9400
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Total 1638 34840.092079 $138758.6000 $3.9800
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Number of Children (Unduplicated) With at Least One Authorization 774