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
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 105 108 108.00 $1146.96 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 102 105 105.00 $927.15 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 104 107 107.00 $1155.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 101 104 104.00 $2266.16 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 96 98 98.00 $2771.44 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 62 76 76.00 $4560.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 14 14.00 $655.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 12.00 $1435.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 11 11 6.59 $329.73 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 177 633 630.59 $15247.44 $24.18
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 37 138.00 $207000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 15 28.58 $1429.05 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 94 107 129.75 $6487.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 80 97 99.99 $4999.72 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 9.08 $454.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 109 124 131.91 $6595.47 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.38 $84.44 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 18 119.67 $2991.66 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 6.80 $170.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 210 270 1935.22 $96761.11 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 19.97 $998.33 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 257 317 1088.98 $73920.21 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.03 $1.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 319 389 1194.32 $81070.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 12.80 $695.30 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 11.00 $11.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 5.00 $215.00 $43.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 11 12 22.67 $424.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 20 69.17 $3458.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 477 590 2042.25 $138627.69 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 8.27 $109.12 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 31 89.20 $4460.14 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 848 2077 7181.03 $635215.33 $88.46
-----------------------------------------------------------------------------------------------------------------------------
Total 2710 7811.63 $650462.77 $83.27
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 924