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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4 4.00 $0.00 $0.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 6 7 7.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 5.00 $250.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 28 28 55.00 $2750.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.50 $487.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 81 81 142.79 $10708.93 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 50 52 95.50 $7162.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 12 12 18.00 $1350.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 79 79 138.35 $7678.56 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 25 28 54.00 $4050.00 $75.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 171 304 533.64 $35521.24 $66.56
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 6.00 $300.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 24 26.00 $1300.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.27 $56.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 22 26 20.25 $1012.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 19 17.62 $881.11 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 17.72 $885.84 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 80.71 $2017.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 92 99 524.92 $26245.96 $50.00
INTR -INTR INTERPRETER 11 18 24.50 $1225.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 47 265.40 $18015.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 13.03 $707.97 $54.32
PHY -97110 PT SESSION BY LICENSED PT 27 28 170.49 $11572.89 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.14 $7.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.00 $5.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 57 375.14 $25464.42 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 38.88 $513.17 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 6.71 $335.72 $50.00
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Subtotal (Total Children Is Unduplicated) 202 373 1605.78 $101196.89 $63.02
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Total 684 2146.42 $136718.12 $63.70
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Number of Children (Unduplicated) With at Least One Authorization 334