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: 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 63 66 67.14 $4028.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 7.00 $327.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 0.18 $8.89 $50.00
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Subtotal (Total Children Is Unduplicated) 123 399 401.32 $9975.27 $24.86
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 30.00 $45000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 31.15 $1557.38 $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 43 47 43.62 $2181.11 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 2.72 $136.04 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 70 49.93 $2496.39 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 16 86.67 $2166.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.32 $16.11 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 117 147 993.31 $49665.57 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 11 12 11.07 $553.61 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 23 34 84.53 $4226.68 $50.00
INTR -INTR INTERPRETER 1 1 2.75 $137.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 126 167 562.52 $38183.62 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.07 $57.94 $54.32
PHY -97110 PT SESSION BY LICENSED PT 219 268 742.25 $50383.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 16.95 $920.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 52 55 55.00 $55.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 9 9 17.00 $318.24 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.05 $2.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 15 28.79 $1439.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 271 344 1151.05 $78133.29 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.53 $86.24 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 0.60 $30.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 16 30 83.33 $4166.67 $50.00
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Subtotal (Total Children Is Unduplicated) 554 1304 4068.47 $286055.78 $70.31
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Total 1703 4469.79 $296031.05 $66.23
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Number of Children (Unduplicated) With at Least One Authorization 583