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

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

    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



Service Coordination, Class # 01
 SCONLY-SCONLY    SERVICE COORDINATION ONLY                    1          1            2.142857           $0.0000            $0.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          1            2.142857           $0.0000            $0.0000


EI Services, Class # 03
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                 531        570         1040.550002       $52027.5100           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                  534        564          942.449208       $47122.4700           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                  530        560          919.503176       $45975.1700           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 527        566          914.303174       $45715.1600           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF           376        408         2613.361947      $130668.0900           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                   68         79          443.179370       $30082.9800           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                  123        137          826.213099       $56083.3600           $67.8800
 SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL           9          9           13.420634         $671.0300           $50.0000
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP        182        212         1121.108746       $76100.8500           $67.8800
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                    590       3105         8834.089356      $484446.6000           $54.8400


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Total                                                                  3106         8836.232213      $484446.6000           $54.8300
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Number of Children (Unduplicated) With at Least One Authorization  591