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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 44 44 88.00 $4400.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $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 2 2 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 74 74 138.57 $10392.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 40 40 70.00 $5250.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 8.00 $600.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 52 52 95.03 $5274.35 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 31 31 58.00 $4350.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 8 8 7.33 $355.67 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 4.86 $485.71 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 162 267 490.79 $32385.23 $65.99
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 15 13.50 $675.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 17 14.20 $710.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 5.97 $298.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.25 $31.25 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.27 $6.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 21 21.60 $1080.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.27 $6.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 19.29 $241.07 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.57 $214.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 107 117 745.44 $37271.92 $50.00
INTR -INTR INTERPRETER 4 5 10.29 $514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 31 31 134.17 $9107.60 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 19.93 $1082.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 27 27 191.16 $12975.90 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 13.43 $729.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 11.00 $11.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 60 420.90 $28570.67 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 34.40 $454.08 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.29 $14.29 $50.00
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Subtotal (Total Children Is Unduplicated) 209 339 1673.90 $100194.96 $59.86
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Total 606 2164.70 $132580.19 $61.25
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Number of Children (Unduplicated) With at Least One Authorization 326