Summary Report for FSPSAs Initiated During the Report Period                                             Center: 55

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

    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
 OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP            1          1            0.500000          $24.2500           $48.5000
 PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP               2          2            0.605555          $29.3700           $48.5000
 SPCH  -92506     SPEECH EVAL BY LICENSED SLP                  2          2            0.118265           $5.7300           $48.4700
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      3          5            1.223820          $59.3500           $48.5000


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Total                                                                     5            1.223820          $59.3500           $48.5000
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Number of Children (Unduplicated) With at Least One Authorization  3