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: 10/01/08 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
Screening, Eval, and Assessment, Class # 02
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 1 1 1.01 $60.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 6 11 12.01 $676.04 $56.28
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.56 $38.26 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 10.64 $531.91 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 7 7.23 $361.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 17.43 $871.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 7.00 $350.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 36 37.43 $1871.67 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $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 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 145 184 962.08 $48103.84 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.93 $96.43 $50.00
INTR -INTR INTERPRETER 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 162 198 983.41 $66753.68 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 4 22.47 $1220.65 $54.32
PHY -97110 PT SESSION BY LICENSED PT 160 203 1044.85 $70924.64 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.00 $325.92 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 6.00 $6.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 7.62 $142.69 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 5.68 $283.81 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 265 341 1975.44 $134092.74 $67.88
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Subtotal (Total Children Is Unduplicated) 455 1022 5104.77 $329713.22 $64.59
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Total 1033 5116.78 $330389.25 $64.57
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Number of Children (Unduplicated) With at Least One Authorization 455