Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 67 68 68.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 67 68 68.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 3.00 $145.50 $48.50
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.97 $238.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.00 $150.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 5.00 $277.50 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 3 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 27 37 38.97 $2329.17 $59.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 7.00 $10500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 2.34 $161.44 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.93 $64.27 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 15 16 123.39 $6169.29 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 22 26 33.37 $1668.33 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 50 73.47 $3673.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 24 24.00 $1200.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 72 89.53 $4476.67 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 22.79 $1672.93 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.00 $25.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 2.00 $100.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 332 523 5926.45 $296322.44 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.93 $96.43 $50.00
INTR -INTR INTERPRETER 4 6 35.71 $1785.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 378 693 7093.61 $481514.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 10 54.31 $2950.35 $54.32
PHY -97110 PT SESSION BY LICENSED PT 377 698 8110.81 $550561.72 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 6.71 $364.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 8.00 $8.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 11 11 6.29 $409.05 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 16 17 52.29 $978.81 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 5.68 $283.81 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 659 1253 13619.00 $924457.40 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.71 $9.43 $13.20
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Subtotal (Total Children Is Unduplicated) 963 3445 35312.32 $2292901.21 $64.93
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Total 3550 35419.29 $2295230.37 $64.80
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Number of Children (Unduplicated) With at Least One Authorization 966