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

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: 10-01-13 and 12-31-13                  Date of Report: 02-18-14                  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



EI Services, Class # 03
 AUD   -HA_FUP    AUDIOLOGY SERVICES                           1          1            0.866667          $43.3400           $50.0000
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                 941       1180         1717.760971       $85887.3600           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                  940       1170         1699.750656       $84986.8600           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                  941       1168         1709.183195       $85458.4800           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 944       1183         1727.949860       $86396.8000           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF            11         12           50.285713        $2514.3000           $50.0000
 INTR  -INTR      INTERPRETER                                  1          1            6.285714         $314.2900           $50.0000
 PHY   -97110     PT SESSION BY LICENSED PT                    2          4           14.257143         $967.7700           $67.8800
 SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL           1          1            0.233333          $11.6700           $49.9900
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          3          3            7.567460         $513.6800           $67.8800
 TRAV  -TRAV      PROV TRAVEL TO NATURAL ENV PER MINU          5         13         5502.361904        $2751.1800            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                    945       4736        12436.502616      $349845.7000           $28.1300


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Total                                                                  4736        12436.502616      $349845.7000           $28.1300
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Number of Children (Unduplicated) With at Least One Authorization  945