Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-12 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 13.826983 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 13.826983 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.194521 $11.6700 $59.9900
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.009589 $0.4800 $50.0600
EXIT -EXIT EXIT ASSESSMENT 32 33 19.537072 $976.8600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.011111 $0.8300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 3.567845 $267.5900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 0.094290 $5.2300 $55.4400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 3.565144 $267.3800 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.252055 $12.2300 $48.5100
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Subtotal (Total Children Is Unduplicated) 55 69 27.242585 $1542.9800 $56.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.983333 $2974.9500 $1499.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 20 0.178865 $8.9400 $49.9500
CONIF -CONIF CONSULT ITDS, FACE TO FACE 40 49 79.852381 $3992.6200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 36 50.188095 $2509.4000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 10.900001 $545.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 50 83.584923 $4179.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.971429 $74.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 20 20 123.071432 $6153.5700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.700000 $35.0000 $50.0000
INTR -INTR INTERPRETER 13 16 1.236244 $61.8100 $49.9900
OCCT -97530 OT SESSION BY LICENSED OT 4 4 18.509523 $1256.4200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 3 16.728571 $1135.5400 $67.8800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 11 63.138096 $4285.8100 $67.8800
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Subtotal (Total Children Is Unduplicated) 107 219 453.042893 $27212.6000 $60.0700
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Total 300 494.112461 $28755.5800 $58.2000
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Number of Children (Unduplicated) With at Least One Authorization 151