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
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 7 7 5.62 $91.55 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 6.76 $59.70 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 7.37 $79.56 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 9 5.69 $124.08 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 5 2.62 $142.60 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 3.94 $125.29 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 8.30 $498.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 16.00 $888.00 $55.50
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Subtotal (Total Children Is Unduplicated) 33 73 61.30 $2390.08 $38.99
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 13 27.70 $1384.76 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 32 32 32.01 $1600.48 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 42 50.58 $2529.05 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 28 33.14 $1657.15 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 77 85.25 $4262.62 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 396 472 2381.69 $119084.54 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 400 465 2300.64 $156167.33 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 4 19.00 $1032.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 347 385 2069.11 $140451.41 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 19 19 19.00 $19.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 12 12 19.84 $371.49 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.67 $33.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 741 879 4332.65 $294100.58 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 31.14 $411.09 $13.20
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Subtotal (Total Children Is Unduplicated) 1164 2445 11415.43 $730680.45 $64.01
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Total 2518 11476.73 $733070.53 $63.87
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Number of Children (Unduplicated) With at Least One Authorization 1166