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

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
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF             1          1            3.428571         $171.4300           $50.0000
 PHY   -97110     PT SESSION BY LICENSED PT                    1          1            3.428571         $232.7300           $67.8800
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          1          1            1.714286         $116.3700           $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)                      3          4           21.571428         $650.5300           $30.1600


-------------------------------------------------------------------------------------------------------------------------------------
Total                                                                     4           21.571428         $650.5300           $30.1600
-------------------------------------------------------------------------------------------------------------------------------------

Number of Children (Unduplicated) With at Least One Authorization  3