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
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 108 109 110.00 $1168.20 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 109 110 111.00 $980.13 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 108 109 109.03 $1177.56 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 112 113 114.00 $2484.06 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 103 105 106.00 $2997.68 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 93 101 103.84 $6230.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 12 12.00 $561.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 12.00 $1435.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 5 3.63 $181.39 $50.00
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 217 672 683.50 $17313.39 $25.33
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 31 169.00 $253500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 18 40.69 $2034.30 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 102 122 128.50 $6425.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 4 2.59 $129.45 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 93 96.94 $4846.90 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 8 7.90 $395.08 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 131 154 138.13 $6906.50 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 27 32 122.00 $3050.00 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 1.20 $60.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 38.40 $960.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 228 306 2060.93 $103046.52 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 9 9 21.22 $1060.83 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 37 55 181.96 $9097.79 $50.00
INTR -INTR INTERPRETER 1 1 2.75 $137.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 238 327 1108.84 $75268.37 $67.88
OCCT -97530HM OT SESSION BY OT ASST 38 38 179.43 $9746.83 $54.32
PHY -97110 PT SESSION BY LICENSED PT 275 360 961.23 $65248.58 $67.88
PHY -97110HM PT SESSION BY PT ASST 56 56 239.88 $13030.47 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 76 78 78.00 $78.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.00 $195.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 3 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 9 14 28.00 $524.16 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 19 23 54.60 $2730.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 474 657 2147.07 $145742.92 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 9.20 $499.75 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 51 52 231.00 $3049.20 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 6.50 $325.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 27 41 167.70 $8385.01 $50.00
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Subtotal (Total Children Is Unduplicated) 937 2498 8237.16 $719908.35 $87.40
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Total 3170 8920.66 $737221.74 $82.64
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Number of Children (Unduplicated) With at Least One Authorization 1047