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
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 94 99 98.30 $5897.99 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 17.50 $2093.56 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 2.14 $106.95 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 48 53 53.37 $2588.29 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 44 48 48.67 $2360.34 $48.50
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Subtotal (Total Children Is Unduplicated) 280 697 672.08 $20634.90 $30.70
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 31 141.00 $211500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 7 12.29 $614.29 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 112 139 157.07 $7853.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 8 2.66 $132.92 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 70 37.72 $1886.13 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.41 $70.56 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 120 132 89.52 $4476.17 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 32 128.67 $3216.68 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 0.14 $7.22 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 262 337 2199.68 $109983.88 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 13 13 26.28 $1313.76 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 21 22 45.69 $2284.45 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 242 320 1104.28 $74958.75 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.20 $65.18 $54.32
PHY -97110 PT SESSION BY LICENSED PT 372 463 1254.71 $85169.61 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.67 $36.22 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 78 80 80.00 $80.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 13 15 31.00 $580.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 21 48.93 $2446.25 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 522 654 2250.41 $152757.89 $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 21 24 102.63 $5131.53 $50.00
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Subtotal (Total Children Is Unduplicated) 998 2381 7728.25 $667481.92 $86.37
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Total 3078 8400.32 $688116.83 $81.92
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Number of Children (Unduplicated) With at Least One Authorization 1051