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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 6.20 $372.00 $60.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 42 43 82.00 $4100.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.00 $333.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 22 22 44.00 $2442.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 108 109 218.00 $16350.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 23 46.00 $3450.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 43 45 90.00 $6750.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 109 109 218.00 $12099.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 19.00 $1425.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 35 36.00 $1746.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 0.30 $15.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 32 32 33.00 $1600.50 $48.50
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Subtotal (Total Children Is Unduplicated) 246 457 828.50 $52820.50 $63.75
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 24 96.00 $144000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 12.85 $642.54 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 233 532 1063.00 $53150.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 231 248 495.00 $24750.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 122 130 260.00 $13000.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 130 141 286.07 $14303.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 205 231 462.00 $23100.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 5.30 $132.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 40 83.52 $2088.00 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 15 15 65.57 $3278.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 202 219 1116.52 $55826.16 $50.00
INTR -INTR INTERPRETER 5 6 12.00 $600.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 63 69 313.79 $21300.26 $67.88
PHY -97110 PT SESSION BY LICENSED PT 96 104 436.18 $29607.63 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 10.00 $10.00 $1.00
SENS -V5264 EARMOLD 1 1 1.42 $26.62 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 162 182 788.53 $53525.44 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 11.14 $147.09 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 342 424 1892.90 $946.45 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.86 $42.86 $50.00
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Subtotal (Total Children Is Unduplicated) 392 2390 7419.15 $440789.94 $59.41
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Total 2847 8247.65 $493610.44 $59.85
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Number of Children (Unduplicated) With at Least One Authorization 443