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: 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 -AUDE UNSPECIFIED AUDE SERVICES 66 69 69.27 $4155.99 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.03 $841.18 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.60 $80.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 30 29.40 $1425.90 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 30 32 32.27 $1564.94 $48.50
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Subtotal (Total Children Is Unduplicated) 180 430 403.53 $12673.24 $31.41
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 20 71.00 $106500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 4.68 $233.81 $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 0.12 $6.12 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 47 26.24 $1312.23 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.41 $70.56 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 66 39.69 $1984.46 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 15 53.47 $1336.67 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.14 $7.22 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 160 204 1228.86 $61442.78 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 7 7 13.14 $657.09 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 15 28.07 $1403.34 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 152 200 640.02 $43444.31 $67.88
PHY -97110 PT SESSION BY LICENSED PT 274 338 843.83 $57279.38 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.67 $36.22 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 54 54.00 $54.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 9 11 23.00 $430.56 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 19 47.88 $2393.75 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 269 337 1003.27 $68101.69 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.47 $25.35 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.33 $17.60 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 20 23 101.86 $5092.78 $50.00
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Subtotal (Total Children Is Unduplicated) 619 1446 4277.38 $357103.75 $83.49
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Total 1876 4680.91 $369776.99 $79.00
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Number of Children (Unduplicated) With at Least One Authorization 655