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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 2 2 1.62 $26.44 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 2.93 $25.90 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 3.93 $42.48 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 2.96 $64.40 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 2.80 $152.26 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.62 $51.61 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 10.88 $652.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 16.71 $927.64 $55.50
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Subtotal (Total Children Is Unduplicated) 31 59 55.46 $3014.61 $54.36
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.00 $7500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.37 $25.25 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 19.52 $976.19 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 42 43 53.30 $2665.24 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 66 68.96 $3448.10 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 37 41.57 $2078.57 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 92 104.17 $5208.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 369 439 2128.64 $106432.13 $50.00
INTR -INTR INTERPRETER 2 2 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 396 472 1940.51 $131722.15 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 9.21 $500.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 367 410 1785.03 $121167.60 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 16.00 $16.00 $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 7 7 4.21 $273.36 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 13 13 14.50 $271.48 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 12 11.30 $565.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 775 922 4232.64 $287311.29 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 7 17.29 $228.17 $13.20
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Subtotal (Total Children Is Unduplicated) 1197 2566 10460.23 $672963.84 $64.34
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Total 2625 10515.69 $675978.45 $64.28
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Number of Children (Unduplicated) With at Least One Authorization 1199