Summary Report for FSPSAs Initiated During the Report Period Center: 10
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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 59 59 59.00 $626.58 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 57 57 57.00 $503.31 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 56 56 56.00 $604.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 53 53 53.00 $1154.87 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 52.00 $1470.56 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 38 45 46.07 $2764.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 12 12.00 $561.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 10 16.00 $1913.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 1.29 $64.44 $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) 106 350 355.36 $9801.93 $27.58
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 14 34.36 $1717.86 $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 46 60 53.97 $2698.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 3 0.75 $37.51 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 79 59.31 $2965.28 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 5 21.87 $546.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.23 $11.67 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 117 166 723.95 $36197.75 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 20 22 60.14 $3007.22 $50.00
INTR -INTR INTERPRETER 2 2 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 117 148 539.55 $36624.68 $67.88
OCCT -97530HM OT SESSION BY OT ASST 27 28 59.70 $3242.90 $54.32
PHY -97110 PT SESSION BY LICENSED PT 152 174 563.13 $38224.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 41 42 78.06 $4240.13 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 37 37 37.00 $37.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 6.00 $390.00 $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 7 14.00 $3319.68 $237.12
SENS -V5264 EARMOLD 9 13 26.00 $486.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 12 24.22 $1210.84 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 210 257 942.73 $63992.77 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.73 $202.79 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 41 44 91.37 $1206.04 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 13 60.20 $3010.00 $50.00
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Subtotal (Total Children Is Unduplicated) 486 1207 3499.51 $216522.28 $61.87
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Total 1557 3854.87 $226324.21 $58.71
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Number of Children (Unduplicated) With at Least One Authorization 511