Summary Report for FSPSAs Ending During the Report Period                                             Statewide

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: 10-01-14 and 12-31-14                  Date of Report: 01-12-15                  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  -V5090     DISPENSING FEE PER HEARING AID               1          1            0.866667          $99.6700          $115.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          1            0.866667          $99.6700          $115.0000


EI Services, Class # 03
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF             1          1            1.000000          $50.0000           $50.0000
 TRAV  -FLAT      PROV TRAVEL TO NATL ENV $10 PER CHI          1          1            1.000000          $10.0000           $10.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      1          2            2.000000          $60.0000           $30.0000


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Total                                                                     3            2.866667         $159.6700           $55.7000
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Number of Children (Unduplicated) With at Least One Authorization  2