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
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 9 9 2.855557 $138.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.411111 $18.6100 $45.2800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.633333 $23.4500 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.655555 $30.5600 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.655555 $16.5900 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.655555 $13.9200 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 1.633333 $12.6600 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.655555 $34.7700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 6 6 2.844444 $178.1400 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 1.655555 $36.4500 $22.0200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.433333 $10.6400 $24.5500
AUDE -AUDE UNSPECIFIED AUDE SERVICES 21 22 13.005556 $780.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 1.850000 $83.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 9 9.996826 $1149.6400 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 0.215079 $10.7600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 137 143 42.261111 $2049.6600 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 1.233333 $59.8200 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 120 128 57.430957 $2785.4200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 187 193 61.111112 $2963.8900 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.000000 $1100.0000 $100.0000
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Subtotal (Total Children Is Unduplicated) 430 546 216.215082 $11498.7500 $53.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.922222 $4611.0000 $4999.8800
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 9.805556 $490.2800 $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 287 294 806.111105 $40305.5300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 306 312 820.693645 $41034.6500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 289 296 796.176977 $39808.8200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 500 521 981.219041 $49060.9200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 67 69 455.785721 $11394.6300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 994 1054 7316.557178 $365827.9800 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 4 4 33.300000 $1665.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 9.866667 $493.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 275 290 1767.223810 $119959.1500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 19.023810 $1033.3700 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 294 306 1890.574608 $128332.2000 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 0.805555 $402.7500 $499.9700
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 4 1.455556 $94.6100 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 3 1.400000 $319.2000 $228.0000
SENS -V5264 EARMOLD 6 6 4.566666 $82.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 25 26 40.555556 $2027.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 393 404 2357.367474 $160018.0600 $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 31.714287 $418.6300 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 12.171429 $1217.1400 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 832 1235 7873.244452 $78732.4700 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 340 1008 283777.536511 $141888.7700 $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) 1582 5864 309050.578621 $1191346.5800 $3.8500
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Total 6425 309282.782591 $1202845.3300 $3.8900
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Number of Children (Unduplicated) With at Least One Authorization 1624