Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 53 54 107.00 $5350.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 4 7.00 $388.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 81 81 145.77 $10932.51 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 40 40 67.00 $5025.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 5.50 $412.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 63 63 114.13 $6334.40 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 31 31 59.00 $4425.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 11.57 $561.21 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 11.87 $575.54 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 174 300 538.84 $34663.16 $64.33
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 15.25 $762.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 3.61 $90.18 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 10 12 11.03 $551.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 16.50 $825.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.61 $90.18 $25.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.28 $57.08 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 15 18.43 $921.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.28 $32.08 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 47.14 $589.29 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 128.57 $3214.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 87 92 523.11 $26155.51 $50.00
INTR -INTR INTERPRETER 2 2 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 23 23 122.33 $8303.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 32.36 $1757.64 $54.32
PHY -97110 PT SESSION BY LICENSED PT 17 17 108.73 $7380.74 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 13.86 $752.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 13.00 $13.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 40 259.89 $17641.04 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 47.57 $627.95 $13.20
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Subtotal (Total Children Is Unduplicated) 176 265 1377.55 $74541.19 $54.11
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Total 565 1916.39 $109204.35 $56.98
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Number of Children (Unduplicated) With at Least One Authorization 251