Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 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
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 6 7 4.09 $66.65 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 13 14 8.10 $71.52 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 14 15 9.43 $101.88 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 12 13 8.41 $183.28 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 3.08 $167.37 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 7 4.09 $130.06 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 0.02 $0.47 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.52 $31.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 45.29 $2513.36 $55.50
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Subtotal (Total Children Is Unduplicated) 39 94 92.03 $4051.12 $44.02
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 15 20.56 $1028.10 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 36 40 41.72 $2086.08 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 31 38.96 $1947.98 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 23 30.86 $1542.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 50 50.65 $2532.27 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 2 2.00 $146.84 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 355 489 2254.39 $112719.63 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 340 447 1923.13 $130542.39 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 3 4.00 $217.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 317 400 1783.49 $121062.96 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 14.00 $14.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 15 15 13.78 $257.95 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 10.00 $500.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 674 919 4492.06 $304921.05 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 18.57 $245.14 $13.20
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Subtotal (Total Children Is Unduplicated) 1042 2477 10710.17 $687979.51 $64.24
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Total 2571 10802.20 $692030.63 $64.06
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Number of Children (Unduplicated) With at Least One Authorization 1047