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
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
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 2.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 0.494444 $23.9800 $48.5000
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) 4 4 0.383333 $24.0100 $62.6200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.011111 $0.2400 $22.0000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.072222 $1.7700 $24.5400
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.194444 $11.6600 $59.9900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.316666 $14.2500 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.211111 $139.2800 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 54 54 7.288891 $353.5200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 0.283333 $13.7400 $48.4900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 62 62 20.768253 $1007.2500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 75 75 12.255563 $594.4300 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 178 217 43.346037 $2185.0200 $50.4100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.557143 $127.8600 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 103 104 90.365881 $4518.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 118 118 105.380960 $5269.0900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 109 111 98.888102 $4944.4400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 212 213 139.885725 $6994.3400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 18 71.714285 $1792.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 354 356 1153.149190 $57657.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 90 91 223.666667 $15182.4700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.800000 $43.4600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 141 141 309.518650 $21010.1100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.133333 $66.6500 $499.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.183333 $11.9100 $64.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.366667 $83.6100 $228.0200
SENS -V5264 EARMOLD 2 2 1.000000 $18.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 7.857937 $392.9000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 127 128 338.835711 $23000.1700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 16.428571 $216.8600 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 343 506 1431.532541 $14315.3300 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 111 280 24388.303968 $12194.1500 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.285714 $164.2900 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 629 2089 28383.854378 $168004.2200 $5.9200
-------------------------------------------------------------------------------------------------------------------------------------
Total 2309 28429.711526 $170189.2400 $5.9900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 641