Summary Report for FSPSAs Ending During the Report Period Center: 10
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
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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 51 52 52.00 $552.24 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 52 53 53.00 $467.99 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 52 53 53.00 $572.40 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 52 53 53.00 $1154.87 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 46 47 47.00 $1329.16 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 67 72 72.00 $4320.00 $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 9.00 $1076.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.38 $18.89 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 19 19.00 $921.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 19 19.00 $921.50 $48.50
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Subtotal (Total Children Is Unduplicated) 156 389 391.38 $12007.15 $30.68
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 37.00 $55500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 13 29.04 $1452.14 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 43 47 47.00 $2350.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 38 31.92 $1596.11 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 4.48 $224.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 43 52 19.57 $978.34 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 22 97.80 $2445.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 107 137 966.59 $48329.45 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 15 16 27.30 $1365.14 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 16 63.97 $3198.33 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 107 143 510.60 $34659.50 $67.88
PHY -97110 PT SESSION BY LICENSED PT 210 264 706.03 $47925.55 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 78 83 82.33 $82.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 10 10 20.00 $374.40 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 3.95 $197.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 15 20 59.47 $2973.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 265 347 1053.88 $71537.58 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.53 $99.44 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 12 83.06 $4152.78 $50.00
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Subtotal (Total Children Is Unduplicated) 545 1246 3863.53 $282093.79 $73.01
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Total 1635 4254.91 $294100.94 $69.12
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Number of Children (Unduplicated) With at Least One Authorization 623