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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.00 $100.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 49 50 100.00 $5000.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 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 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 73 74 143.00 $10725.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 43 44 78.00 $5850.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 13.03 $977.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 41 42 70.13 $3892.40 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 44 44 83.50 $6262.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 9.00 $436.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 8.41 $840.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 176 288 523.08 $34993.86 $66.90
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 10 9.50 $475.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.25 $31.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 13 16.00 $800.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 7.86 $196.43 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 14.63 $731.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.25 $106.25 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 17.00 $850.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.93 $123.22 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 496.00 $6200.00 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 10.71 $267.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 95 97 527.74 $26386.89 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 8.14 $407.15 $50.00
INTR -INTR INTERPRETER 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 36 37 231.91 $15741.71 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 10 53.70 $2916.73 $54.32
PHY -97110 PT SESSION BY LICENSED PT 28 29 175.20 $11892.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 2 6.86 $372.48 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.00 $5.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 47 416.40 $28264.92 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 22.18 $292.73 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 19.29 $964.29 $50.00
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Subtotal (Total Children Is Unduplicated) 189 315 2056.53 $101750.88 $49.48
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Total 603 2579.60 $136744.73 $53.01
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Number of Children (Unduplicated) With at Least One Authorization 309