Summary Report for FSPSAs Initiated During the Report Period Center: 10
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
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 50 51 51.00 $541.62 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 51 52 52.00 $459.16 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 51 52 52.00 $561.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 51 52 52.00 $1133.08 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 45 46 46.00 $1300.88 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 53 56 56.00 $3360.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 6.00 $717.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 20 20.00 $970.00 $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 8 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 21 22 22.00 $1067.00 $48.50
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Subtotal (Total Children Is Unduplicated) 145 371 374.00 $10902.98 $29.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 37.00 $55500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 11 26.14 $1306.91 $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 5 5 3.60 $180.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 33 25.81 $1290.56 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 3.48 $174.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 45 51 24.99 $1249.46 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 18 93.80 $2345.00 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 4 4 2.76 $137.78 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 103 125 866.02 $43301.09 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 12 12 29.38 $1469.17 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 21 23 43.50 $2174.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 122 145 549.48 $37298.95 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.27 $177.45 $54.32
PHY -97110 PT SESSION BY LICENSED PT 235 281 803.63 $54550.62 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 67 69 69.00 $69.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 10 10 19.00 $355.68 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 19 22 58.77 $2938.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 247 298 941.47 $63906.75 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.00 $108.64 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 14.53 $191.84 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 9 45.37 $2268.34 $50.00
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Subtotal (Total Children Is Unduplicated) 548 1193 3717.00 $274832.30 $73.94
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Total 1564 4091.00 $285735.28 $69.84
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Number of Children (Unduplicated) With at Least One Authorization 591