Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.000000 $120.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 8 8 12.000000 $1500.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 52 55 114.000000 $5700.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 94 94 188.000000 $14100.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 58 58 116.000000 $8700.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 58 58 116.000000 $6438.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 96 97 194.000000 $14550.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 16 16.000000 $776.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.000000 $291.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 13 13 14.000000 $679.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 240 437 837.000000 $57202.0000 $68.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 12.000000 $18000.0000 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 277 570 1742.566652 $87128.2700 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 264 292 3195.114283 $159755.8300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 6.857143 $171.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 96 1013.061901 $50653.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 13.428571 $335.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 121 134 1672.811898 $83640.6900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 25.428571 $635.7200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 191 204 2065.214286 $103260.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.000000 $50.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 32 34 199.400001 $4985.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 7.400001 $370.0100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 258 273 1626.100013 $81304.9200 $50.0000
INTR -INTR INTERPRETER 8 9 23.714286 $1185.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 33 114.238095 $7754.4800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 6 6 25.840477 $1403.6500 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 65 68 255.923811 $17372.1100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 14.214285 $772.1200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 20 49.000000 $49.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 113 115 509.854759 $34608.9400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.714286 $9.4300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 307 601 365660.466668 $182830.2300 $0.5000
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Subtotal (Total Children Is Unduplicated) 347 2476 378235.349987 $836277.1600 $2.2100
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Total 2913 379072.349987 $893479.1600 $2.3600
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Number of Children (Unduplicated) With at Least One Authorization 423