Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 9.43 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 9.43 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 6 6 4.17 $67.92 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 5.78 $51.07 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 12 12 6.48 $70.02 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 5.82 $126.75 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.14 $7.85 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 4.20 $133.61 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 0.87 $18.50 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 6.27 $376.38 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.00 $111.00 $55.50
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Subtotal (Total Children Is Unduplicated) 17 58 41.73 $1535.09 $36.78
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 15 42.01 $2100.73 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 35 38 48.16 $2408.22 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 39 52.74 $2637.03 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 24 32.05 $1602.39 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 60 63.91 $3195.60 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 377 414 1982.43 $99121.64 $50.00
INTR -INTR INTERPRETER 3 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 384 446 2132.80 $144774.31 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 13.79 $748.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 389 447 1947.29 $132182.29 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 19 19 20.77 $20.77 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
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 4 4 3.16 $205.69 $65.00
SENS -V5264 EARMOLD 14 14 20.82 $389.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 10.00 $500.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 796 922 4495.45 $305151.23 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.57 $139.54 $13.20
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Subtotal (Total Children Is Unduplicated) 1175 2471 10889.97 $705576.50 $64.79
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Total 2530 10941.13 $707111.58 $64.63
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Number of Children (Unduplicated) With at Least One Authorization 1176