Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 4.12 $67.19 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 6.95 $61.37 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 8.56 $92.46 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 8.56 $186.55 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 3.00 $163.14 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.00 $56.56 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 3.12 $99.32 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.16 $69.34 $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
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Subtotal (Total Children Is Unduplicated) 14 51 43.47 $1367.92 $31.47
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 13.52 $676.19 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 28 30 29.47 $1473.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 39 56.18 $2808.82 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 25 51.86 $2593.10 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 49 82.85 $4142.38 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 375 482 2232.59 $111629.56 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 321 422 2216.91 $150484.07 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 3.36 $182.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 324 427 2070.92 $140574.30 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 24 22.63 $22.63 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $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 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 10 10 9.16 $171.39 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 2.00 $100.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 12.43 $621.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 691 958 4638.27 $314845.91 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.14 $41.49 $13.20
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Subtotal (Total Children Is Unduplicated) 1066 2507 11459.29 $740634.08 $64.63
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Total 2558 11502.77 $742002.00 $64.51
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Number of Children (Unduplicated) With at Least One Authorization 1067