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: 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 -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 42 45 50.40 $3024.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 8.00 $956.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 1.05 $52.50 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 111 426 432.45 $10084.14 $23.32
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 73.00 $109500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 22.36 $1117.86 $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 44 57 53.31 $2665.56 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.86 $42.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 62 78 68.22 $3411.12 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 12 56.80 $1420.00 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.93 $23.33 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 120 170 1039.93 $51996.64 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 8 33.21 $1660.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 22 28 62.32 $3116.11 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 131 164 481.78 $32703.48 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 12 71.20 $3867.58 $54.32
PHY -97110 PT SESSION BY LICENSED PT 188 234 621.99 $42220.84 $67.88
PHY -97110HM PT SESSION BY PT ASST 17 18 74.52 $4047.74 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 45 46 46.00 $46.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 8 9 17.00 $318.24 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 11 34.32 $1715.84 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 218 275 846.17 $57437.81 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 1.87 $101.40 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 15 16 77.13 $1018.16 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 7.60 $380.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 8 28.50 $1425.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 487 1242 3803.30 $324829.10 $85.41
-----------------------------------------------------------------------------------------------------------------------------
Total 1668 4235.75 $334913.24 $79.07
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 510