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: 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 -92552 PURE TONE AUDIOMETRY -AIR ONLY 64 65 65.00 $690.30 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 65 66 66.00 $582.78 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 64 65 65.00 $702.00 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 66 67 67.00 $1459.93 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 58 60 60.00 $1696.80 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 56 59 61.84 $3710.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 1.33 $66.39 $50.00
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 121 393 397.17 $9716.47 $24.46
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 13 65.00 $97500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 14 28.29 $1414.30 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 43 51 61.25 $3062.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 49 50.80 $2540.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 4 4.82 $241.19 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 78 74.13 $3706.39 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 15 53.87 $1346.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 1.20 $60.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.00 $50.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 126 161 1113.08 $55653.90 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 7 10.48 $524.17 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 25 37 135.66 $6783.07 $50.00
INTR -INTR INTERPRETER 1 1 2.75 $137.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 129 184 614.93 $41741.68 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 59.27 $3219.37 $54.32
PHY -97110 PT SESSION BY LICENSED PT 177 228 628.20 $42642.24 $67.88
PHY -97110HM PT SESSION BY PT ASST 35 35 145.65 $7911.71 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 63 65 65.00 $65.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.00 $195.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 4 6 12.00 $224.64 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 17 39.88 $1994.16 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 244 327 1055.73 $71663.20 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.27 $123.13 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 22 22 101.87 $1344.64 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 6.50 $325.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 18 30 115.97 $5798.34 $50.00
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Subtotal (Total Children Is Unduplicated) 546 1367 4455.59 $350742.01 $78.72
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Total 1760 4852.77 $360458.49 $74.28
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Number of Children (Unduplicated) With at Least One Authorization 606