Summary Report for FSPSAs Ending During the Report Period Center: 10
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 60 63 63.00 $669.06 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 57 60 60.00 $529.80 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 59 62 62.00 $669.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 56 59 59.00 $1285.61 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 56 56.00 $1583.68 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 39 51 51.00 $3060.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 10 10.00 $468.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 5.59 $279.73 $50.00
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Subtotal (Total Children Is Unduplicated) 106 377 373.59 $9382.68 $25.11
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 17 57.00 $85500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 21.55 $1077.38 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 37 48.75 $2437.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 46 49.33 $2466.37 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 5.72 $285.84 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 66 65.16 $3258.06 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.23 $55.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 4 34.53 $863.33 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 105 132 813.76 $40687.76 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 19.97 $998.33 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 123 152 547.20 $37143.97 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.03 $1.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 201 234 740.05 $50234.64 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 12.80 $695.30 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 9.00 $9.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.00 $86.00 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 7 8 15.00 $280.80 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 18 64.30 $3215.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 219 262 884.72 $60054.54 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.60 $100.32 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 23 57.36 $2867.92 $50.00
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Subtotal (Total Children Is Unduplicated) 456 1043 3467.05 $294605.29 $84.97
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Total 1420 3840.64 $303987.97 $79.15
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Number of Children (Unduplicated) With at Least One Authorization 502