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
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 310 344 500.00 $5310.00 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 273 297 297.00 $2622.51 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 274 299 300.00 $3240.00 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 267 293 293.00 $6384.47 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 247 269 270.00 $7635.60 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 221 293 466.10 $27966.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 30 45 45.23 $2116.92 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 35 39 55.00 $6578.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 38 55 60.26 $3013.06 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 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) 532 1938 2290.59 $65074.62 $28.41
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 67 86 305.00 $457500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 33 54 261.96 $13097.87 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 320 435 616.25 $30812.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 4.38 $219.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 224 352 633.90 $31694.79 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.20 $80.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 53 93.87 $4693.60 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 309 494 960.32 $48016.02 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 9 13.39 $334.72 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 10 10 80.53 $2013.33 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 73 1062.06 $26551.39 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 3 4 5.66 $282.78 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 61 71 462.37 $23118.62 $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 518 1092 12979.20 $648959.99 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 4 4 26.10 $1305.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 34 70 585.81 $29290.55 $50.00
INTR -INTR INTERPRETER 3 3 9.00 $450.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 558 1183 7694.23 $522284.60 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 11 19.57 $1062.85 $54.32
PHY -97110 PT SESSION BY LICENSED PT 669 1414 9157.42 $621605.50 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 20.89 $1134.83 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 45 45.00 $45.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 12 22.00 $11000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 8 12 15.00 $975.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 3 3 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 10 10 17.00 $4031.04 $237.12
SENS -V5264 EARMOLD 26 41 81.67 $1528.80 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.80 $90.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 31 59 361.60 $18080.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1064 2173 15508.75 $1052734.00 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.80 $43.46 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 41.07 $542.08 $13.20
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 4 4 46.10 $2305.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 27 82 552.83 $27641.25 $50.00
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Subtotal (Total Children Is Unduplicated) 1728 7892 51702.85 $3584144.07 $69.32
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Total 9830 53993.44 $3649218.70 $67.59
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Number of Children (Unduplicated) With at Least One Authorization 1864