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: 10-01-13 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



EI Services, Class # 03
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                 663        754          959.512726       $47975.7800           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                  646        725          911.334944       $45566.8700           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                  663        744          954.590506       $47729.6800           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 661        760          970.346062       $48517.4600           $50.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF           175        203         1115.500000       $55775.0000           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                   13         14           57.888888        $3929.5100           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                    7         10           38.974602        $2645.5900           $67.8800
 SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL           6          6            3.066667         $153.3400           $50.0000
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP         22         27          175.774604       $11931.5900           $67.8800
 TRAV  -TRAV      PROV TRAVEL TO NATURAL ENV PER MINU        107        379        42840.614286       $21420.3100            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                    731       3622        48027.603285      $285645.1000            $5.9500


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Total                                                                  3622        48027.603285      $285645.1000            $5.9500
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Number of Children (Unduplicated) With at Least One Authorization  731