Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.59 $25.90 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 4.35 $38.41 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 7.63 $82.38 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 7.63 $166.21 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 2.09 $113.59 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 3.59 $114.16 $31.81
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 3.08 $144.04 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
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Subtotal (Total Children Is Unduplicated) 13 49 37.95 $1484.90 $39.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.07 $4.59 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 21.23 $1061.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 42 43 42.53 $2126.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 40 50.60 $2530.24 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 29 54.90 $2745.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 41 46 84.96 $4247.86 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.29 $214.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 436 491 2194.49 $109724.32 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 379 454 1995.09 $135426.89 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.00 $54.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 387 435 1943.35 $131914.81 $67.88
RSPT -RSPT RESPITE 1 1 1.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 24 24.00 $24.00 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.10 $136.23 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 13 13 9.17 $171.60 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 14 13.13 $656.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 796 921 4449.39 $302024.43 $67.88
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Subtotal (Total Children Is Unduplicated) 1236 2539 10900.30 $699311.24 $64.16
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Total 2589 10938.39 $700796.13 $64.07
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Number of Children (Unduplicated) With at Least One Authorization 1237