Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.01 $0.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
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Subtotal (Total Children Is Unduplicated) 5 10 10.01 $510.44 $50.99
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 4 4.00 $6000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.44 $30.60 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.93 $196.43 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 13 13.00 $650.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 19 18.27 $913.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 14.00 $700.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 31 31.00 $1550.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 173 203 832.40 $41620.24 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.71 $235.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 197 223 840.38 $57044.81 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.29 $15.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 194 219 963.45 $65398.99 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 7.14 $388.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 12 12.00 $12.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.07 $69.81 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 1.73 $32.39 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 7.83 $391.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 306 346 1548.68 $105124.49 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.29 $3.77 $13.20
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Subtotal (Total Children Is Unduplicated) 533 1102 4306.62 $280852.00 $65.21
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Total 1112 4316.63 $281362.43 $65.18
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Number of Children (Unduplicated) With at Least One Authorization 533