Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 1.33 $21.64 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 8 4.62 $40.77 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 9 6.04 $65.28 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 7 4.23 $92.12 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 2.84 $154.68 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.52 $16.44 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 0.48 $10.20 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.83 $50.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 12.00 $666.00 $55.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 24 53 36.89 $1451.63 $39.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 11 23.90 $1195.24 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 33 37 44.17 $2208.57 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 52 53.43 $2671.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 28 33.86 $1692.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 77 86.84 $4342.15 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 2 12.14 $891.52 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.29 $214.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 2.00 $100.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 294 366 1780.17 $89008.63 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 350 459 2065.19 $140184.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 5 20.00 $1086.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 302 385 1641.93 $111454.18 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 20 20.00 $20.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 9 10 22.10 $413.68 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.30 $115.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 619 842 4119.78 $279650.89 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.86 $50.91 $13.20
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Subtotal (Total Children Is Unduplicated) 979 2311 9947.96 $645515.76 $64.89
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Total 2364 9984.85 $646967.39 $64.79
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Number of Children (Unduplicated) With at Least One Authorization 982