Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 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 5 5 5.00 $81.50 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 5.53 $48.86 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 7.00 $75.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 7.00 $152.53 $21.79
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 4.00 $127.24 $31.81
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 4 1.72 $80.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 4 4.00 $478.40 $119.60
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Subtotal (Total Children Is Unduplicated) 9 37 34.26 $1044.73 $30.50
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.23 $16.04 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 11 21.45 $1072.62 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 44 45 46.13 $2306.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 19 37.36 $1867.87 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 11.57 $578.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 37 39.97 $1998.57 $50.00
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 376 493 2509.65 $125482.68 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 321 425 1877.49 $127444.27 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.00 $54.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 317 415 1967.01 $133520.76 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 32 46.62 $46.62 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 9 11 7.99 $149.55 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 14 14.00 $700.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 679 908 4610.74 $312977.04 $67.88
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Subtotal (Total Children Is Unduplicated) 1064 2431 11204.51 $714255.97 $63.75
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Total 2469 11238.91 $715300.70 $63.65
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Number of Children (Unduplicated) With at Least One Authorization 1065