Summary Report for FSPSAs Ending During the Report Period Center: 10
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 174 195 277.00 $2941.74 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 153 169 169.00 $1492.27 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 154 170 170.00 $1836.00 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 147 164 164.00 $3573.56 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 140 155 155.00 $4383.40 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 139 187 312.07 $18724.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 20 27 27.00 $1263.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 26 28 39.00 $4664.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 31 47 54.32 $2715.84 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 312 1144 1369.38 $41705.88 $30.46
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 29 77.00 $115500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 25 39 211.03 $10551.68 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 143 181 245.50 $12275.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 102 165 300.69 $15034.51 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.20 $30.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 33 61.24 $3061.95 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 170 276 522.38 $26118.88 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.40 $60.00 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 2 2 25.07 $626.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 19 283.47 $7086.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 2 3 4.26 $212.78 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 23 24 145.48 $7273.88 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.13 $203.33 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 276 571 5357.38 $267868.85 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 25 54 483.61 $24180.55 $50.00
INTR -INTR INTERPRETER 3 3 9.00 $450.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 283 596 3947.23 $267938.25 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 5.57 $302.37 $54.32
PHY -97110 PT SESSION BY LICENSED PT 428 872 5808.10 $394253.93 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 5.93 $321.85 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 34 36 36.00 $36.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 5 10.00 $5000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 10 12.00 $780.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 9 9 16.00 $3793.92 $237.12
SENS -V5264 EARMOLD 17 25 48.00 $898.56 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.80 $90.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 25 51 306.73 $15336.68 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 501 1005 7110.30 $482647.26 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 24.00 $316.80 $13.20
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 29.83 $1491.67 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 59 386.14 $19306.94 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 948 4093 25489.46 $1683287.96 $66.04
-----------------------------------------------------------------------------------------------------------------------------
Total 5237 26858.85 $1724993.84 $64.22
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1030