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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 72 76 76.00 $807.12 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 70 74 74.00 $653.42 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 70 76 76.00 $820.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 70 74 74.00 $1612.46 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 68 68.00 $1923.04 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 36 39 39.00 $2340.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 8 8.00 $374.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 8 11.00 $1315.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 3.19 $159.73 $50.00
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Subtotal (Total Children Is Unduplicated) 115 428 430.19 $10033.67 $23.32
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 34.00 $51000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 15.71 $785.72 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 59 67 79.28 $3963.75 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 62 57.87 $2893.60 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.23 $61.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 72 64.58 $3229.14 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 3 21.47 $536.67 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 118 156 722.31 $36115.52 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 10.10 $505.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 19 68.69 $3434.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 114 139 401.95 $27284.37 $67.88
OCCT -97530HM OT SESSION BY OT ASST 18 19 65.77 $3572.45 $54.32
PHY -97110 PT SESSION BY LICENSED PT 204 241 616.12 $41821.95 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 17 40.92 $2222.59 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 53 53.00 $53.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 8.00 $1896.96 $237.12
SENS -V5264 EARMOLD 10 12 23.00 $430.56 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 10 26.08 $1304.17 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 204 257 804.65 $54619.64 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 0.13 $7.25 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 30 32 122.33 $1614.80 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 8 28.70 $1435.00 $50.00
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Subtotal (Total Children Is Unduplicated) 523 1190 3268.90 $238943.49 $73.10
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Total 1618 3699.09 $248977.15 $67.31
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Number of Children (Unduplicated) With at Least One Authorization 573