Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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) 2 2 1.07 $9.42 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.07 $11.52 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.07 $23.24 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.07 $3.63 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 7.50 $450.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $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 5 5 5.00 $277.50 $55.50
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Subtotal (Total Children Is Unduplicated) 12 20 20.77 $1038.32 $50.00
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 15.63 $781.43 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 17 16.61 $830.48 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 23 22.87 $1143.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 13.00 $650.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 34 36 35.87 $1793.34 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 198 229 1143.00 $57150.25 $50.00
INTR -INTR INTERPRETER 2 2 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 181 205 1065.08 $72297.51 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 9.00 $488.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 202 226 1228.61 $83398.22 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 13.00 $13.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 5 5 9.90 $185.42 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 322 364 1871.89 $127064.14 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 30.00 $396.00 $13.20
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Subtotal (Total Children Is Unduplicated) 559 1146 5481.47 $350079.11 $63.87
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Total 1166 5502.23 $351117.43 $63.81
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Number of Children (Unduplicated) With at Least One Authorization 561