Summary Report for FSPSAs Initiated During the Report Period                                             Center: 04

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: 01-01-13 and 03-31-13                  Date of Report: 05-17-13                  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



Service Coordination, Class # 01
 SCONLY-SCONLY    SERVICE COORDINATION ONLY                   13         14           25.320636           $0.0000            $0.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                     13         14           25.320636           $0.0000            $0.0000


Screening, Eval, and Assessment, Class # 02
 ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   17         17            4.322220         $209.6200           $48.5000
 OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL              4          4            0.666667          $32.3400           $48.5000
 PSTH  -97001     EVAL BY LICENSED PT, INITIAL                 6          7            1.611112          $78.1400           $48.5000
 SPCH  -92506     SPEECH EVAL BY LICENSED SLP                  8          9            2.055555          $99.6900           $48.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                     32         37            8.655554         $419.7900           $48.5000


EI Services, Class # 03
 AUD   -HA_FUP    AUDIOLOGY SERVICES                           2          2            5.857142         $292.8600           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                   29         30           10.511112         $525.5600           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                   29         33           16.766664         $838.3200           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                  10         10           10.955554         $547.7700           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF           120        128          700.373816       $35018.6500           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                    6          7           19.980953        $1356.3000           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                    7          8           47.285715        $3209.7500           $67.8800
 SENS  -HA_INS    SENSORY AID INSURANCE PER EAR                1          1            0.383333          $24.9100           $64.9900
 SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL           5          5            6.399999         $320.0000           $50.0000
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          6          7           37.000001        $2511.5500           $67.8800
 TRAV  -TRAV      PROV TRAVEL TO NATURAL ENV PER MINU        659        803         6636.288126        $3318.1500            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                    670       1034         7491.802415       $47963.8300            $6.4000


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Total                                                                  1085         7525.778605       $48383.6100            $6.4300
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Number of Children (Unduplicated) With at Least One Authorization  689