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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 13.772223 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.005479 $0.2000 $37.1400
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Subtotal (Total Children Is Unduplicated) 13 13 13.777702 $0.2000 $0.0100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 3 2.082192 $124.9300 $60.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.009589 $0.4800 $50.0600
EXIT -EXIT EXIT ASSESSMENT 52 53 50.217124 $2510.8600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.008333 $0.6200 $74.7000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 0.058103 $4.3600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 0.021916 $1.6500 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 0.027701 $2.0800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 0.046839 $2.6000 $55.5600
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 114 114 9.381217 $703.5800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 33 33 6.188845 $464.1800 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 57 57 9.383777 $520.8000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 67 68 6.000289 $450.0200 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 2.438889 $118.2900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.549619 $26.6600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 1.350000 $65.4800 $48.5000
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Subtotal (Total Children Is Unduplicated) 211 362 88.764433 $5045.0700 $56.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.433333 $3649.9500 $1499.9800
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 2.472222 $123.6100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 21 0.181605 $9.0700 $49.9400
CONIF -CONIF CONSULT ITDS, FACE TO FACE 35 38 70.719050 $3535.9700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 38 52.559523 $2627.9800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 41 44 67.372226 $3368.6300 $50.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 323.142857 $4039.2900 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 164.285714 $4107.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 106 114 766.066666 $38303.3200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 11.942857 $597.1500 $50.0000
INTR -INTR INTERPRETER 12 16 2.502911 $125.1400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 57 292.110322 $19828.4300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 36 37 190.285713 $12916.6100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 4.285714 $232.8000 $54.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 60 393.099996 $26683.6400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 10.357143 $136.7100 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 4.000000 $200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 218 447 2357.817852 $120485.4100 $51.1000
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Total 822 2460.359987 $125530.6900 $51.0200
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Number of Children (Unduplicated) With at Least One Authorization 378