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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 1.000000 $50.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 44 44 88.000000 $4400.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 9.000000 $675.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 7.000000 $525.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 13.500000 $749.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 64 74 143.500000 $8054.2500 $56.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 6.000000 $9000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 26 27.505480 $1375.2700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 3.071429 $76.7900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 20 23.949999 $1197.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 23 25.100000 $1255.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 3.600000 $180.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 19 21.752380 $1087.6200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.250000 $56.2500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 23.285713 $582.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 21 126.714285 $6335.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 10.428571 $521.4300 $50.0000
INTR -INTR INTERPRETER 10 13 15.000000 $750.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 1.714286 $116.3700 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 7.000000 $7.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 52.071429 $3534.6100 $67.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 95 157 350.443572 $26125.6800 $74.5500
-------------------------------------------------------------------------------------------------------------------------------------
Total 231 493.943572 $34179.9300 $69.2000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 147