Summary Report for FSPSAs Initiated During the Report Period Center: 10
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 31 36 36.00 $2160.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 10 10.00 $468.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 10.00 $1196.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 9 5.01 $250.28 $50.00
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Subtotal (Total Children Is Unduplicated) 99 362 361.01 $8812.03 $24.41
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 40.00 $60000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 22.30 $1114.99 $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 31 40 35.62 $1780.95 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 4.10 $205.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 42 50 40.11 $2005.70 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 45.60 $1140.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 108 149 908.77 $45438.34 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 19 21 72.49 $3624.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 124 148 471.92 $32033.72 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.03 $1.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 197 233 646.57 $43889.00 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 9.35 $507.89 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 33 33 32.89 $32.89 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $43.00 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 6 6 10.00 $187.20 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 17 55.08 $2754.18 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 209 252 867.67 $58897.24 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.60 $126.72 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 15 25 66.58 $3328.75 $50.00
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Subtotal (Total Children Is Unduplicated) 483 1060 3399.42 $262834.90 $77.32
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Total 1422 3760.43 $271646.92 $72.24
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Number of Children (Unduplicated) With at Least One Authorization 518