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

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: 10-01-12 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



Screening, Eval, and Assessment, Class # 02
 OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL              2          2            0.633334          $30.7200           $48.5100
 PSTH  -97001     EVAL BY LICENSED PT, INITIAL                 4          4            1.800001          $87.3100           $48.5000
 SPCH  -92506     SPEECH EVAL BY LICENSED SLP                  9          9            5.033335         $244.1300           $48.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                     12         15            7.466670         $362.1500           $48.5000


EI Services, Class # 03
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                  20         21           10.300002         $515.0100           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                    9          9            2.833334         $141.6700           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                    8          8            4.533333         $226.6700           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                  20         20            9.766668         $488.3400           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF            27         28           38.565478        $1928.2900           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                    7          7           11.192859         $759.7600           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                    5          5           19.499999        $1323.6600           $67.8800
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP         11         11           21.785713        $1478.8300           $67.8800
 TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM         32         60        10359.714286        $5179.8600            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                     37        169        10478.191672       $12042.0800            $1.1500


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Total                                                                   184        10485.658342       $12404.2300            $1.1800
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Number of Children (Unduplicated) With at Least One Authorization  40