Summary Report for FSPSAs Ending During the Report Period                                             Center: 09

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



EI Services, Class # 03
 ASST  -ASST      ASSISTIVE TECHNOLOGY                         3          3            3.000000        $4500.0000         $1500.0000
 AUD   -HA_FUP    AUDIOLOGY SERVICES                           5          5            5.000000         $250.0000           $50.0000
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                 217        242          277.952381       $13897.6300           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                   22         23           25.000000        $1250.0000           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                   18         19           20.833333        $1041.6700           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 210        236          266.152381       $13307.6200           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF           128        145          765.623812       $38281.1900           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                   11         11           46.285714        $3141.8700           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                   10         11           28.514287        $1935.5400           $67.8800
 SCONLY-SCONLY    SERVICE COORDINATION ONLY                   14         14           14.585714          $14.5900            $1.0000
 SENS  -HA_INS    SENSORY AID INSURANCE PER EAR                1          1            1.000000          $65.0000           $65.0000
 SHIN  -EIIF_NM   INITIAL SHINE SERVICES, IND NONMED           1          1            1.000000          $50.0000           $50.0000
 SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL           6          6            6.000000         $300.0000           $50.0000
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP         23         29          174.000000       $11811.1300           $67.8800
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                    347        746         1634.947622       $89846.2200           $54.9500


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Total                                                                   746         1634.947622       $89846.2200           $54.9500
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Number of Children (Unduplicated) With at Least One Authorization  347