Summary Report for FSPSAs Initiated During the Report Period                                             Statewide

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: 04-01-14 and 06-30-14                  Date of Report: 08-18-14                  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
 AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY               1          1            1.011111          $14.5200           $14.3600
 AUDE  -92553     PURE TONE AUDIOMETRY AIR & BONE              1          1            1.011111          $18.6600           $18.4600
 AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)             1          1            1.011111          $10.1300           $10.0200
 AUDE  -92567     TYPMANOMETRY (IMPEDANCE TESTING)             1          1            1.011111           $8.5000            $8.4100
 AUDE  -92568     ACOUSTIC REFLEX TESTING (MEMR)               1          1            1.011111           $7.8400            $7.7500
 AUDE  -92579     VISUAL REINFORCEMENT AUDIOMETRY              1          1            1.011111          $21.2300           $21.0000
 AUDE  -92585     AUD EVOKED RESPONSE (DIAG)                   1          1            1.011111          $63.3300           $62.6300
 AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)              1          1            1.011111          $22.2600           $22.0200
 AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                    1          1            1.011111          $60.6700           $60.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          9            9.099999         $227.1400           $24.9600


EI Services, Class # 03
 EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                  2          2            5.285715         $132.1400           $25.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF             6          6           30.428570        $1521.4400           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                    1          1            0.857143          $58.1800           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                    4          4            7.714286         $523.6500           $67.8800
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          3          3            4.285715         $290.9100           $67.8800
 TRAV  -FLAT      PROV TRAVEL TO NATL ENV $10 PER CHI          1          1           13.000000         $130.0000           $10.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      8         17           61.571429        $2656.3200           $43.1400


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Total                                                                    26           70.671428        $2883.4600           $40.8000
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Number of Children (Unduplicated) With at Least One Authorization  9