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
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 102 103 103.00 $1093.86 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 101 102 102.00 $900.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 100 101 101.00 $1090.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 100 101 101.00 $2200.79 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 91 92 92.00 $2601.76 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 89 98 98.00 $5880.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 9.00 $1076.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 38 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 16 16.00 $776.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 35 39 39.00 $1891.50 $48.50
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Subtotal (Total Children Is Unduplicated) 261 706 710.00 $19852.41 $27.96
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 23 80.00 $120000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 14 15 31.68 $1584.05 $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 7 7 4.64 $231.95 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 64 47.61 $2380.56 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 4.12 $205.84 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 103 122 65.16 $3258.04 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 25 31 163.93 $4098.33 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 9 9 5.74 $287.23 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 195 248 1866.68 $93333.88 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 17 17 39.50 $1975.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 30 35 59.97 $2998.47 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 222 277 1128.92 $76630.88 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.87 $210.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 328 389 1173.98 $79690.01 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 9.20 $499.74 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 91 93 93.00 $93.00 $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 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 8.00 $1896.96 $237.12
SENS -V5264 EARMOLD 16 16 30.00 $561.60 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 27 30 77.92 $3895.83 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 499 605 2086.22 $141612.40 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.93 $865.50 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 19.23 $253.88 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 14 16 70.64 $3531.95 $50.00
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Subtotal (Total Children Is Unduplicated) 911 2133 7192.71 $546348.45 $75.96
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Total 2839 7902.71 $566200.86 $71.65
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Number of Children (Unduplicated) With at Least One Authorization 980