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
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 103 103 96.23 $1022.00 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 93 93 87.20 $769.97 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.03 $28.00 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 93 93 87.20 $941.76 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 94 94 87.23 $1900.81 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 83 83 77.20 $2183.21 $28.28
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 85 90 89.70 $5381.99 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 8.00 $374.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 13.00 $1554.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 38 38.43 $1864.02 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 32 37 38.37 $1860.79 $48.50
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Subtotal (Total Children Is Unduplicated) 246 661 635.60 $18438.09 $29.01
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 21 105.00 $157500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 40.63 $2031.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 112 140 162.53 $8126.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 4.15 $207.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 86 43.78 $2188.88 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 4 3.41 $170.56 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 105 121 63.95 $3197.74 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 28 139.20 $3480.01 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 6 6 3.79 $189.45 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 230 303 2039.38 $101968.85 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 9 9 21.06 $1053.06 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 24 27 50.61 $2530.56 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 211 280 1017.42 $69062.30 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 7.87 $427.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 304 390 1118.87 $75948.71 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 4.67 $253.50 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 100 102 102.00 $102.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 9.00 $2134.08 $237.12
SENS -V5264 EARMOLD 14 16 33.00 $617.76 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 21 33 83.83 $4191.25 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 465 611 1967.45 $133550.79 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 7.60 $412.83 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 6.40 $84.48 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 15 82.74 $4136.80 $50.00
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Subtotal (Total Children Is Unduplicated) 913 2231 7127.83 $575859.24 $80.79
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Total 2892 7763.43 $594297.33 $76.55
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Number of Children (Unduplicated) With at Least One Authorization 1038