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
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 6 6 2.105556 $38.8700 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 2.105556 $21.1000 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 2.105556 $17.7100 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 0.644445 $4.9900 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 2.105556 $44.2200 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 14 14 7.070636 $442.8400 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 0.644445 $14.1900 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 17 17 4.066665 $243.9900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 2.188890 $98.5100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 8.634920 $993.0000 $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 146 146 31.834919 $1543.9800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 150 150 52.787305 $2560.2000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 180 180 39.805561 $1930.6000 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 10.142857 $1014.2900 $100.0000
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Subtotal (Total Children Is Unduplicated) 455 566 175.172234 $9361.4600 $53.4400
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 26.067459 $1303.3700 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 684 692 1621.400016 $81070.0800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 671 679 1665.569848 $83278.5400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 684 687 1630.347635 $81517.4700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 923 933 1794.865092 $89743.3400 $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 91 92 535.299992 $13382.5200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1400 1427 8171.064244 $408553.2100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 9 9 26.925000 $1346.2500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 42.950000 $2147.5000 $50.0000
INTR -INTR INTERPRETER 1 1 9.600000 $480.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 369 372 1729.928167 $117427.5700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 17.957142 $975.4400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 511 514 2287.039674 $155244.2900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 13.571428 $737.2000 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 1.416667 $92.0900 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.777778 $88.6700 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 1.461112 $333.1500 $228.0100
SENS -V5264 EARMOLD 9 9 5.099998 $91.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 27 27 33.168253 $1658.4100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 591 594 2761.852371 $187474.6800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 11.928571 $647.9600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 12.885715 $170.0900 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 2 2 14.400000 $1440.0000 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1108 1551 7903.387301 $79033.8700 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 400 1241 391096.575388 $195548.2900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 4 4 4.569444 $228.4700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 36.123810 $1806.1900 $50.0000
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Subtotal (Total Children Is Unduplicated) 2313 8886 421542.590835 $1506907.9500 $3.5700
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Total 9474 421733.263067 $1516269.4100 $3.6000
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Number of Children (Unduplicated) With at Least One Authorization 2356