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
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 21 13.066665 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 13.066665 $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 1 1 0.266667 $12.0800 $45.2900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.222222 $3.1900 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.222222 $4.1000 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.222222 $2.2300 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.222222 $1.8700 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.222222 $1.7200 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.222222 $4.6700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.222222 $13.9200 $62.6200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.222222 $4.8900 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 0.622221 $37.3300 $59.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.450000 $51.7500 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 0.355556 $17.2500 $48.5100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.011111 $0.5400 $48.4600
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 0.283333 $13.7400 $48.4900
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 10.142857 $1014.2900 $100.0000
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Subtotal (Total Children Is Unduplicated) 23 32 16.242855 $1296.7200 $79.8300
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 19.074603 $953.7300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 126 127 154.983332 $7749.1600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 101 101 176.831741 $8841.5700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 128 128 176.697619 $8834.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 294 294 294.805552 $14740.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.644444 $16.1100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.800000 $20.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 55 56 294.152381 $14707.6300 $50.0000
INTR -INTR INTERPRETER 1 1 9.600000 $480.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 17 73.447619 $4985.6200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 27 27 102.087301 $6929.6800 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.727778 $47.3100 $65.0000
SENS -V5264 EARMOLD 1 1 0.733333 $13.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.333333 $16.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 35 137.654765 $9344.0200 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 2 2 14.400000 $1440.0000 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 856 1164 5949.353970 $59493.5300 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 91 207 44961.800788 $22480.9000 $0.5000
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Subtotal (Total Children Is Unduplicated) 990 2169 52368.128559 $161094.2800 $3.0800
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Total 2222 52397.438079 $162391.0000 $3.1000
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Number of Children (Unduplicated) With at Least One Authorization 1018