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: 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 6.43 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 6.43 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.31 $21.37 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 2.47 $21.78 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 3.73 $40.32 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 3.73 $81.35 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.88 $47.73 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 1.31 $41.71 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.21 $72.86 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $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) 15 38 24.65 $1057.03 $42.88
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 0.66 $45.14 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 21.21 $1060.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 33 34 34.97 $1748.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 38 41.35 $2067.38 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 28 37.71 $1885.72 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 43 52 53.54 $2676.90 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 331 432 2133.76 $106688.16 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 336 430 2177.69 $147821.43 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.29 $1210.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 326 406 1948.99 $132297.35 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 18 20.00 $20.00 $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 7 7 5.22 $339.25 $65.00
SENS -V5264 EARMOLD 10 10 8.09 $151.38 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 13 14.90 $745.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 657 884 4617.06 $313406.33 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 20.00 $264.00 $13.20
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Subtotal (Total Children Is Unduplicated) 1028 2380 11166.43 $721026.06 $64.57
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Total 2419 11197.51 $722083.09 $64.49
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Number of Children (Unduplicated) With at Least One Authorization 1028