Summary Report for FSPSAs Initiated During the Report Period                                             Center: 02

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: 10-01-13 and 12-31-13                  Date of Report: 02-18-14                  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      EXIT ASSESSMENT                              4          4            1.017503          $50.8800           $50.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      4          4            1.017503          $50.8800           $50.0000


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Total                                                                     4            1.017503          $50.8800           $50.0000
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Number of Children (Unduplicated) With at Least One Authorization  4