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
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 56 66 66.00 $3960.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 16 16.00 $748.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 10 14.00 $1674.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 12 13 8.43 $421.67 $50.00
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Subtotal (Total Children Is Unduplicated) 170 627 626.43 $15072.18 $24.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 31 125.00 $187500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 17 40.01 $2000.47 $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 72 87 85.29 $4264.43 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 7.13 $356.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 100 84.15 $4207.36 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.00 $25.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 25 26 160.13 $4003.33 $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 211 309 2087.26 $104362.80 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 24 26 86.53 $4326.66 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 251 306 1014.03 $68832.61 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 1.37 $74.23 $54.32
PHY -97110 PT SESSION BY LICENSED PT 314 385 1061.22 $72035.43 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 9.35 $507.89 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 50 50 49.89 $49.89 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 5 9.00 $4500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.00 $172.00 $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 13 23.67 $443.04 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 19 23 72.42 $3620.85 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 459 568 1925.65 $130713.10 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 14.67 $193.60 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 23 35 106.67 $5333.34 $50.00
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Subtotal (Total Children Is Unduplicated) 879 2114 7114.97 $605930.90 $85.16
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Total 2741 7741.41 $621003.08 $80.22
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Number of Children (Unduplicated) With at Least One Authorization 930