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
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 -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 97 103 104.14 $6248.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 11.00 $514.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 1.59 $79.73 $50.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 214 668 675.77 $16557.77 $24.50
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 25 128.00 $192000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 19 19 46.79 $2339.29 $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 4 5 4.66 $233.06 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 85 73.39 $3669.72 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 3.57 $178.54 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 123 148 106.99 $5349.71 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 32 206.90 $5172.50 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.32 $16.11 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 18.40 $920.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 218 286 2067.36 $103367.79 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 13 14 13.07 $653.61 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 29 47 123.23 $6161.68 $50.00
INTR -INTR INTERPRETER 1 1 2.75 $137.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 242 321 1100.38 $74693.66 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.07 $57.94 $54.32
PHY -97110 PT SESSION BY LICENSED PT 334 416 1112.05 $75486.02 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 20.48 $1112.65 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 60 63 63.00 $63.00 $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 3 3 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 15 15 28.00 $524.16 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.05 $2.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 17 31.59 $1579.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 530 689 2384.05 $161829.35 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.73 $202.79 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 42.37 $559.24 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 0.60 $30.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 24 42 124.25 $6212.51 $50.00
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Subtotal (Total Children Is Unduplicated) 950 2382 7849.06 $652608.11 $83.14
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Total 3050 8524.83 $669165.88 $78.50
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Number of Children (Unduplicated) With at Least One Authorization 998