Summary Report for FSPSAs Initiated During the Report Period                                             Center: 52

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
 EXIT  -EXIT      TRANSITION ASSESSMENT                        3          4            4.000000         $200.0000           $50.0000
 OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL              2          2            2.000000          $97.0000           $48.5000
 SCREEN-T1023     INTERDISCIPLINARY SCREENING                  3          3            3.000000         $150.0000           $50.0000
 SPCH  -92506     SPEECH EVAL BY LICENSED SLP                  1          1            1.000000          $48.5000           $48.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      9         10           10.000000         $495.5000           $49.5500


EI Services, Class # 03
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                  82        102          138.752375        $6937.5900           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                   49         56           81.633332        $4081.6600           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                   44         50           63.033332        $3151.6600           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                  97        116          180.357145        $9017.8700           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF             5          6           40.142857        $2007.1400           $50.0000
 INTR  -INTR      INTERPRETER                                  8          8           69.428572        $3471.4300           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                    1          1           11.571429         $785.4700           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                    1          1           11.571429         $785.4700           $67.8800
 SCONLY-SCONLY    SERVICE COORDINATION ONLY                    7          7            3.766665           $3.7700            $1.0000
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP         11         16           61.159526        $4151.5100           $67.8800
 TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM        237        360       125093.085698       $62546.5400            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                    258        723       125754.502360       $96940.1000            $0.7700


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Total                                                                   733       125764.502360       $97435.6000            $0.7700
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Number of Children (Unduplicated) With at Least One Authorization  261