Summary Report for FSPSAs Ending During the Report Period                                             Center: 53

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: 07-01-14 and 09-30-14                  Date of Report: 11-19-14                  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
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF             1          1            5.357143         $267.8600           $50.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          1            5.357143         $267.8600           $50.0000


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Total                                                                     1            5.357143         $267.8600           $50.0000
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Number of Children (Unduplicated) With at Least One Authorization  1