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: 04-01-14 and 06-30-14 Date of Report: 08-18-14 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 2.433333 $0.0000 $0.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 21 13.066665 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 22 15.499998 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 2.333334 $113.1700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 5.623810 $254.6500 $45.2800
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 0.644445 $9.2600 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 0.644445 $11.9000 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.644445 $6.4600 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 0.644445 $5.4200 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 0.644445 $4.9900 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 0.644445 $13.5300 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 5 1.316667 $82.4600 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 0.644445 $14.1900 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 12 12 2.583332 $154.9900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 1.500001 $67.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 2.433333 $279.8300 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.327778 $15.9000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 87 87 20.546032 $996.4800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 97 97 40.918256 $1984.5400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 70 70 13.238889 $642.0900 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 10.142857 $1014.2900 $100.0000
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Subtotal (Total Children Is Unduplicated) 259 315 105.475404 $5671.6600 $53.7700
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 19.074603 $953.7300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 461 468 1049.816679 $52490.9000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 439 443 1081.665088 $54083.3000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 464 466 1069.730967 $53486.6300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 625 632 1186.572234 $59328.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.644444 $16.1100 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 85.714286 $1071.4300 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 78 79 482.871422 $12071.8000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1064 1085 6177.654727 $308882.6900 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 6 6 12.333333 $616.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 34.050000 $1702.5000 $50.0000
INTR -INTR INTERPRETER 1 1 9.600000 $480.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 248 250 1161.584124 $78848.3700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 17.957142 $975.4400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 344 347 1522.638097 $103356.7100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 10.142857 $550.9600 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.727778 $47.3100 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.772223 $176.0800 $228.0200
SENS -V5264 EARMOLD 4 4 3.022221 $54.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 21 21 29.246030 $1462.2900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 301 303 1276.233329 $86630.7900 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.500000 $190.1200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 11.814286 $155.9500 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 14.400000 $1440.0000 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 857 1165 5949.420637 $59494.2000 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 270 833 252199.100787 $126099.5500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 4.411111 $220.5600 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 29.466667 $1473.3400 $50.0000
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Subtotal (Total Children Is Unduplicated) 1613 6143 273444.165072 $1006360.4600 $3.6800
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Total 6480 273565.140474 $1012032.1200 $3.7000
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Number of Children (Unduplicated) With at Least One Authorization 1652