Summary Report for FSPSAs Ending During the Report Period Center: 05
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
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 9.000000 $1125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 59 68 141.000000 $7050.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 52.000000 $3900.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 48 49 98.000000 $5439.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 34 68.000000 $5100.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.000000 $145.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.000000 $97.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 149 202 401.000000 $24864.5000 $62.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.533333 $126.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 302 616 1252.428571 $62621.4300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 272 308 615.857143 $30792.8600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 97 105 210.347619 $10517.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 145 157 357.771428 $17888.5800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 201 224 449.857143 $22492.8600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 21 25 102.809526 $2570.2400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 95 100 621.071437 $31053.5300 $50.0000
INTR -INTR INTERPRETER 10 11 104.142857 $5207.1400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 27.928571 $1895.7900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 9 9 13.047620 $885.6800 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 26 42.428571 $42.4300 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.357143 $17.8600 $49.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 16 76.595240 $5199.2800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.066667 $40.4800 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 378 669 374563.376190 $187281.6900 $0.5000
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Subtotal (Total Children Is Unduplicated) 427 2279 378450.619059 $383233.8600 $1.0100
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Total 2481 378851.619059 $408098.3600 $1.0800
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Number of Children (Unduplicated) With at Least One Authorization 472