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: 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
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 -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 7.63 $457.71 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
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Subtotal (Total Children Is Unduplicated) 10 17 20.63 $1030.94 $49.98
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 6 6.00 $9000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.57 $39.02 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 13.07 $653.58 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 22 27.51 $1375.72 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 29 30.27 $1513.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 24.71 $1235.72 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 37 36.97 $1848.34 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 178 228 1176.60 $58830.01 $50.00
INTR -INTR INTERPRETER 2 2 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 181 229 1083.25 $73531.21 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 10.43 $566.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 176 220 1049.59 $71245.89 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 8.00 $8.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 5 5 4.57 $85.49 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 5.47 $273.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 276 357 1831.50 $124322.30 $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) 511 1180 5314.79 $345408.54 $64.99
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Total 1197 5335.42 $346439.48 $64.93
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Number of Children (Unduplicated) With at Least One Authorization 511