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: 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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 58 58 58.00 $615.96 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 56 56 56.00 $494.48 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 55 55 55.00 $594.00 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 52 52.00 $1133.08 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 51 51 51.00 $1442.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 41 46 47.07 $2824.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 10.00 $468.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 18.00 $2152.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 13 15 8.64 $431.95 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
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Subtotal (Total Children Is Unduplicated) 115 357 357.71 $10267.62 $28.70
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 37.57 $1878.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 67 83.25 $4162.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 49 45.37 $2268.57 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 4 1.98 $99.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 64 50.81 $2540.69 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 8 72.53 $1813.34 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.57 $28.34 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 110 144 761.42 $38071.12 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 18 93.73 $4686.53 $50.00
INTR -INTR INTERPRETER 2 2 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 129 160 509.57 $34589.42 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 5.53 $300.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 193 221 601.88 $40855.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 4.86 $263.90 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 25 25 25.00 $25.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 5.00 $325.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 10.00 $2371.20 $237.12
SENS -V5264 EARMOLD 9 9 17.00 $318.24 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 13 35.12 $1755.84 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 218 280 932.12 $63272.17 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 8.67 $114.40 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 14 57.83 $2891.67 $50.00
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Subtotal (Total Children Is Unduplicated) 454 1124 3378.81 $214120.52 $63.37
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Total 1481 3736.52 $224388.14 $60.05
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Number of Children (Unduplicated) With at Least One Authorization 504