Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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 -AUDE UNSPECIFIED AUDE SERVICES 5 5 4.47 $268.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 20 24 42.00 $2100.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 8.00 $600.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 7.00 $525.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 6 11.00 $610.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 22 22 28.00 $1554.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 103 103 176.00 $13200.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 27 27 44.00 $3300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 38 38 64.00 $4800.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 65 65 128.14 $7111.93 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 54 55 82.00 $6150.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 38 38.00 $1843.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 18 18.00 $873.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 27 27.00 $1309.50 $48.50
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Subtotal (Total Children Is Unduplicated) 236 440 682.61 $44600.43 $65.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 29 36.00 $54000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 14.12 $705.88 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 241 507 1079.29 $53964.29 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 232 251 500.57 $25028.57 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 125 135 268.57 $13428.57 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 115 122 244.00 $12200.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 197 210 438.57 $21928.57 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.00 $100.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 2.57 $64.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 24 47.90 $1197.62 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 8 59.43 $2971.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 228 1308.59 $65429.32 $50.00
INTR -INTR INTERPRETER 4 4 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 84 90 420.02 $28511.27 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.64 $143.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 96 98 328.25 $22281.46 $67.88
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.21 $13.72 $65.00
SENS -V5264 EARMOLD 3 3 3.91 $73.22 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 176 189 800.67 $54349.72 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.79 $142.37 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 331 438 924.60 $462.30 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.57 $128.57 $50.00
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Subtotal (Total Children Is Unduplicated) 389 2351 6506.28 $357674.59 $54.97
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Total 2791 7188.89 $402275.02 $55.96
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Number of Children (Unduplicated) With at Least One Authorization 425