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
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 103 104 104.00 $1104.48 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 102 103 103.00 $909.49 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 101 102 102.00 $1101.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 101 102 102.00 $2222.58 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 92 93 93.00 $2630.04 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 101 110 110.00 $6600.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 11.00 $1315.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 2.38 $118.89 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 34 40 40.00 $1940.00 $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 12 14 14.00 $679.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 32 34 34.00 $1649.00 $48.50
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Subtotal (Total Children Is Unduplicated) 267 720 722.38 $20599.98 $28.52
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 30 106.00 $159000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 17 37.00 $1850.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 108 103.77 $5188.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 65 48.51 $2425.27 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 4.80 $240.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 90 109 67.20 $3359.94 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 36 160.57 $4014.16 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.56 $27.78 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 194 249 1691.87 $84593.33 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 17 18 28.81 $1440.70 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 24 28 95.41 $4770.55 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 211 284 1036.08 $70329.34 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.60 $32.59 $54.32
PHY -97110 PT SESSION BY LICENSED PT 321 407 1140.47 $77414.90 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 96 101 100.33 $100.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $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 4 4 8.00 $1896.96 $237.12
SENS -V5264 EARMOLD 15 16 31.00 $580.32 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 3.95 $197.50 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 20 26 72.87 $3643.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 503 666 2069.02 $140444.85 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 13.40 $176.88 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 17 21 131.17 $6558.61 $50.00
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Subtotal (Total Children Is Unduplicated) 890 2204 6961.37 $570615.65 $81.97
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Total 2924 7683.75 $591215.63 $76.94
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Number of Children (Unduplicated) With at Least One Authorization 1031