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: 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 38 38 76.00 $3800.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $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 75 75 140.57 $10542.50 $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 53 53 97.03 $5385.35 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 31 31 58.00 $4350.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 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 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 3.73 $181.07 $48.50
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Subtotal (Total Children Is Unduplicated) 152 259 474.33 $31331.42 $66.05
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 8.00 $12000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $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 17 20 18.80 $940.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 3 2.86 $71.43 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 14.07 $703.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.25 $31.25 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.25 $31.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 21 20.00 $1000.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.27 $56.66 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 101 108 613.78 $30688.88 $50.00
INTR -INTR INTERPRETER 2 2 6.29 $314.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 39 40 159.28 $10811.69 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.93 $322.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 19 21 108.93 $7394.08 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 15.93 $865.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.00 $5.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 66 395.64 $26856.21 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 24.90 $328.68 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 11.71 $585.72 $50.00
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Subtotal (Total Children Is Unduplicated) 209 343 1432.37 $93830.73 $65.51
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Total 602 1906.71 $125162.15 $65.64
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Number of Children (Unduplicated) With at Least One Authorization 257