Summary Report for FSPSAs Initiated During the Report Period                                             Center: 57

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

    Child has a MEDICAID # Filter: Y
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
 OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL              3          3            3.000000         $145.5000           $48.5000
 PSTH  -97001     EVAL BY LICENSED PT, INITIAL                 2          2            2.000000          $97.0000           $48.5000
 SPCH  -92506     SPEECH EVAL BY LICENSED SLP                  5          5            5.000000         $242.5000           $48.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      8         10           10.000000         $485.0000           $48.5000


EI Services, Class # 03
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                   2          2            0.500000          $25.0000           $50.0000
 CONIP -CONIP     CONSULT, ITDS, PHONE                         1          1            1.000000          $25.0000           $25.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                   13         13            6.834126         $341.7100           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                   25         26           20.675397        $1033.7800           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 194        195          115.579358        $5778.9400           $50.0000
 CONSP -CONSP     CONSULT, SLP, PHONE                          1          1            0.477778          $11.9500           $25.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF            20         20          149.285716        $7464.2900           $50.0000
 PHY   -97110     PT SESSION BY LICENSED PT                    1          1            0.071429           $4.8500           $67.8500
 SCONLY-SCONLY    SERVICE COORDINATION ONLY                   10         10            8.955555           $8.9600            $1.0000
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          5          6           92.214286        $6259.5100           $67.8800
 SPL   -92508     GROUP SPL SESSION PER CHILD                  1          1            4.071429          $53.7400           $13.2000
 TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM        275        291         9283.525392        $4641.7600            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                    288        567         9683.190466       $25649.4700            $2.6500


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Total                                                                   577         9693.190466       $26134.4700            $2.7000
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Number of Children (Unduplicated) With at Least One Authorization  292