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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 59 59 53.20 $564.98 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 55 55 50.17 $442.97 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.03 $28.00 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 55 55 50.17 $541.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 56 56 50.20 $1093.85 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 52 52 46.20 $1306.53 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 54 58 58.67 $3520.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 8.00 $956.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 20 19.47 $944.14 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 19 19.37 $939.29 $48.50
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Subtotal (Total Children Is Unduplicated) 145 396 371.47 $11031.69 $29.70
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 49.00 $73500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 26.84 $1341.91 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 75 88.25 $4412.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 3.07 $153.33 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 48 24.28 $1213.89 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 4 3.41 $170.56 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 57 28.46 $1422.78 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 10 49.87 $1246.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 4 4 2.54 $127.23 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 129 164 1056.92 $52846.07 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 4 4 12.54 $627.22 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 19 21 27.85 $1392.50 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 125 165 560.95 $38077.33 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.67 $362.14 $54.32
PHY -97110 PT SESSION BY LICENSED PT 221 282 755.83 $51306.01 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.67 $36.22 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 77 78 78.00 $78.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 9 11 23.00 $430.56 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 27 68.28 $3413.75 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 244 320 980.18 $66534.79 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.73 $39.83 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 6.40 $84.48 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 11 71.09 $3554.44 $50.00
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Subtotal (Total Children Is Unduplicated) 574 1317 3936.82 $304312.02 $77.30
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Total 1713 4308.29 $315343.71 $73.19
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Number of Children (Unduplicated) With at Least One Authorization 645