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
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 101 102 102.00 $1083.24 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 97 98 98.00 $865.34 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 97 98 98.00 $1058.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 94 95 95.00 $2070.05 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 88 89 89.00 $2516.92 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 61 73 74.07 $4444.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 16 16.00 $748.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 17 24.00 $2870.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 1.96 $97.78 $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) 176 595 601.02 $15893.10 $26.44
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 16 40.00 $60000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 17 19 41.20 $2060.01 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 116 135 162.75 $8137.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 90 119 106.24 $5312.20 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 8 7.32 $365.84 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 109 132 107.65 $5382.51 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 19 85.60 $2140.00 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.23 $11.67 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 223 315 1794.31 $89715.69 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 2.53 $126.67 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 27 30 74.46 $3723.06 $50.00
INTR -INTR INTERPRETER 2 2 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 220 270 1008.42 $68451.38 $67.88
OCCT -97530HM OT SESSION BY OT ASST 59 64 128.20 $6963.81 $54.32
PHY -97110 PT SESSION BY LICENSED PT 239 280 903.86 $61353.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 67 68 116.53 $6329.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 47 47 47.00 $47.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.00 $3000.00 $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 6 8 16.00 $3793.92 $237.12
SENS -V5264 EARMOLD 13 17 34.00 $636.48 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 14 34.48 $1724.17 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 416 502 1927.85 $130862.43 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 4 9.80 $532.34 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 90 95 186.67 $2464.00 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 19 81.65 $4082.64 $50.00
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Subtotal (Total Children Is Unduplicated) 873 2195 6937.76 $468095.87 $67.47
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Total 2790 7538.78 $483988.97 $64.20
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Number of Children (Unduplicated) With at Least One Authorization 911