Summary Report for FSPSAs Ending During the Report Period                                             Center: 03

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: 10-01-15 and 12-31-15                  Date of Report: 02-12-16                  Page: 1

    Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
   
With the filters selected there were 655 FSPSA's found of which 167 had no frequency modifier field, FORCE FREQ MODIFIER to 0


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
 ASTE  -ASTE        ASSISTIVE TECHNOLOGY EVAL                    6          6            3.209055         $155.6400           $48.5000
 AUDE  -V5090       DISPENSING FEE PER HEARING AID               1          1            0.493151          $58.9900          $119.6100
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        7          7            3.702206         $214.6200           $57.9700


EI Services, Class # 03
 ASST  -ASST        ASSISTIVE TECHNOLOGY                         1          1            0.219178        $1096.0000         $5000.5000
 COIFF -COIFF       IFSP CONSULT, PROF, FACE TO FACE            92        105            0.814900          $40.8400           $50.1200
 COIFP -COIFP       IFSP CONSULT, PROF, BY PHONE                 2          3            0.012500           $0.3100           $25.0000
 CONIF -CONIF       CONSULT, FACE TO FACE                       50         78          177.198414        $8859.9200           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            26         28           81.865078        $4093.2500           $50.0000
 INTR  -T1013       INTERPRETER                                  6          6            1.377778          $68.8900           $50.0000
 NESF  -99600       NATURAL ENVIRONMENT SUPPORT FEE             12         24            8.653969          $86.5400           $10.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                    1          1            8.714286         $622.5500           $71.4400
 PHY   -97110       PT SESSION BY LICENSED PT                    1          1            6.285714         $449.0500           $71.4400
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP          7          7           23.395238        $1671.3600           $71.4400
 TRAV  -A0160       *PROV TRAVEL TO NATURAL ENV-BY MIN         205        392          476.146027         $238.0700            $0.5000
 TRAV  -TRAVS       Travel by mile                               1          1            0.666667           $0.3000            $0.4500
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      273        647          785.349749       $17227.0800           $21.9400


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Total                                                                     654          789.051955       $17441.7100           $22.1000
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Number of Children (Unduplicated) With at Least One Authorization      275