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
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) 6 6 1.311111 $82.1100 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.222222 $4.8900 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 0.972221 $58.3300 $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 22 22 4.488888 $217.7100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 18 3.794445 $184.0300 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 50 50 11.011114 $534.0500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 10.142857 $1014.2900 $100.0000
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Subtotal (Total Children Is Unduplicated) 88 119 36.326191 $2290.1900 $63.0500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 19.074603 $953.7300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 157 158 203.266669 $10163.3500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 139 139 223.507929 $11175.3700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 161 161 227.814287 $11390.7300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 405 405 392.665076 $19633.2600 $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 373 380 2205.830153 $110291.5500 $50.0000
INTR -INTR INTERPRETER 1 1 9.600000 $480.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 57 244.347618 $16586.3200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 67 67 310.396821 $21069.7300 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.727778 $47.3100 $65.0000
SENS -V5264 EARMOLD 2 2 0.816666 $14.7000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 3.477778 $173.8900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 139 140 629.409523 $42724.3900 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.428571 $457.8400 $54.3200
TRAN -TRAN FAMILY TRANSPORTATION 2 2 14.400000 $1440.0000 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1107 1549 7901.177777 $79011.7700 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 122 276 59044.389676 $29522.1900 $0.5000
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Subtotal (Total Children Is Unduplicated) 1466 3352 71440.775369 $355172.2200 $4.9700
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Total 3492 71490.168225 $357462.4100 $5.0000
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Number of Children (Unduplicated) With at Least One Authorization 1497