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: 07-01-14 and 09-30-14 Date of Report: 11-19-14 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 3 3 2.511111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.233333 $11.3200 $48.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.011111 $0.1600 $14.3500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.011111 $0.2000 $18.4400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.011111 $0.1100 $10.0100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.011111 $0.0900 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.011111 $0.0900 $7.7400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.011111 $0.2300 $20.9800
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 0.144444 $9.0400 $62.6100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.011111 $0.2400 $22.0000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.011111 $0.6700 $59.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.133333 $6.0000 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.477778 $54.9500 $115.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 39 39 5.527780 $268.1100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 44 44 18.301586 $887.6200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 27 4.088892 $198.3300 $48.5000
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Subtotal (Total Children Is Unduplicated) 98 125 28.996034 $1437.1500 $49.5600
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 75 75 67.676989 $3383.8700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 90 90 80.657942 $4032.9200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 80 82 73.854767 $3692.7600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 165 166 104.526196 $5226.3300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 64.428571 $1610.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 280 282 942.092045 $47104.5900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 65 66 165.947619 $11264.5000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 102 102 230.804367 $15667.0000 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.133333 $66.6500 $499.8800
SENS -V5264 EARMOLD 1 1 0.266667 $4.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 4.600794 $230.0500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 62 159.809524 $10847.8600 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 272 399 1156.461904 $11564.6200 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 82 211 18619.653174 $9309.8300 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.285714 $164.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 460 1563 21674.199606 $124170.7700 $5.7300
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Total 1691 21705.706751 $125607.9200 $5.7900
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Number of Children (Unduplicated) With at Least One Authorization 464