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
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 124 129 129.00 $1369.98 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 121 126 126.00 $1112.58 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 121 128 128.00 $1382.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 121 126 126.00 $2745.54 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 107 112 112.00 $3167.36 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 86 93 98.40 $5904.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 9 9.00 $421.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 10 15.00 $1794.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 5 5.48 $274.17 $50.00
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Subtotal (Total Children Is Unduplicated) 204 738 748.88 $18171.23 $24.26
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 25 98.00 $147000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 31.43 $1571.44 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 117 135 152.04 $7602.09 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 2.13 $106.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 80 105 103.38 $5168.77 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.86 $42.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 143 144.08 $7204.25 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 30 170.27 $4256.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.74 $37.22 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 45.33 $1133.33 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 305 1890.49 $94524.41 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 9 11 36.21 $1810.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 29 36 71.88 $3594.17 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 248 311 1004.09 $68157.94 $67.88
OCCT -97530HM OT SESSION BY OT ASST 26 27 153.10 $8316.39 $54.32
PHY -97110 PT SESSION BY LICENSED PT 301 377 1004.23 $68166.84 $67.88
PHY -97110HM PT SESSION BY PT ASST 27 29 134.32 $7296.07 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 54 54.00 $54.00 $1.00
SENS -FM FM RECEIVER HEARING AID 1 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.14 $1071.45 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 4 8.00 $1896.96 $237.12
SENS -V5264 EARMOLD 12 14 27.00 $505.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 19 56.37 $2818.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 483 616 1933.06 $131215.86 $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 37 38 180.77 $2386.12 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 7.60 $380.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 13 56.20 $2810.00 $50.00
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Subtotal (Total Children Is Unduplicated) 882 2323 7374.58 $572684.21 $77.66
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Total 3061 8123.47 $590855.44 $72.73
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Number of Children (Unduplicated) With at Least One Authorization 920