Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 2 2 4.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 4.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
EXIT -EXIT TRANSITION ASSESSMENT 27 27 52.00 $2600.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 2 2.00 $111.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.53 $196.10 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 90 90 162.00 $12150.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 52 52 84.50 $6337.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 12 12 21.00 $1575.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 91 91 157.03 $8715.35 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 31 32 60.50 $4537.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 11.00 $533.50 $48.50
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Subtotal (Total Children Is Unduplicated) 183 336 570.07 $37628.33 $66.01
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 11.50 $575.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 13 14.43 $721.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 3.96 $99.11 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 9 9.95 $497.50 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.53 $63.33 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.22 $5.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 23 25.10 $1254.76 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 7 7 5.16 $129.11 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 492.86 $6160.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 132.14 $3303.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 69 73 401.08 $20054.06 $50.00
INTR -INTR INTERPRETER 2 2 6.71 $335.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 32 32 225.96 $15338.29 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 15.58 $846.10 $54.32
PHY -97110 PT SESSION BY LICENSED PT 25 25 139.62 $9477.26 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 9.29 $504.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 13.00 $13.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 54 301.06 $20435.74 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 179.46 $2368.90 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.98 $198.81 $50.00
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Subtotal (Total Children Is Unduplicated) 169 301 1999.59 $89932.44 $44.98
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Total 639 2573.66 $127560.76 $49.56
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Number of Children (Unduplicated) With at Least One Authorization 315