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
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 3 3 3.00 $48.90 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.00 $32.40 $10.80
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 2 2 2.00 $42.68 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 2.17 $130.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 5.00 $277.50 $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) 16 27 27.17 $1299.95 $47.85
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.00 $9000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.56 $38.26 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 22.58 $1128.98 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 28 31 31.67 $1583.33 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 39 42.33 $2116.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 19 19.00 $950.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 74 76 76.97 $3848.34 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 12.57 $922.99 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 5 17.71 $442.86 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.00 $50.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 11.57 $578.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 282 355 1851.46 $92572.90 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.93 $96.43 $50.00
INTR -INTR INTERPRETER 2 2 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 330 422 2072.09 $140653.52 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 8 27.47 $1492.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 284 361 1872.84 $127128.52 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.00 $325.92 $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 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.39 $155.29 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 9 9 13.23 $247.70 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 3 5.68 $283.81 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 609 822 4324.22 $293528.29 $67.88
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Subtotal (Total Children Is Unduplicated) 970 2197 10441.27 $678929.59 $65.02
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Total 2224 10468.43 $680229.54 $64.98
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Number of Children (Unduplicated) With at Least One Authorization 970