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: 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
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.00 $100.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 43 43 86.00 $4300.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 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 42 43 77.00 $5775.00 $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 43 43 82.50 $6187.50 $75.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 3.00 $145.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 154 265 485.67 $32609.40 $67.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 7.00 $350.00 $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 0.83 $20.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 14.00 $700.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 20 17.87 $893.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 15.17 $758.33 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 112.86 $2821.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 86 88 620.05 $31002.62 $50.00
INTR -INTR INTERPRETER 7 7 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 36 36 212.92 $14452.96 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 51.40 $2792.31 $54.32
PHY -97110 PT SESSION BY LICENSED PT 24 25 191.50 $12999.04 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 25.95 $1409.41 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 42 411.01 $27899.35 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.54 $152.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 5.00 $250.00 $50.00
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Subtotal (Total Children Is Unduplicated) 173 283 1718.60 $98854.98 $57.52
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Total 548 2204.27 $131464.38 $59.64
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Number of Children (Unduplicated) With at Least One Authorization 241