Summary Report for FSPSAs Ending During the Report Period                                             Center: 09

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 235 FSPSA's found of which 21 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
 EXIT  -EXIT        EXIT ASSESSMENT                              5          5            3.025875         $151.3000           $50.0000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                        5          5            3.025875         $151.3000           $50.0000


EI Services, Class # 03
 COIFF -COIFF       IFSP CONSULT, PROF, FACE TO FACE            27         39            0.924953          $46.2400           $49.9900
 CONIF -CONIF       CONSULT, FACE TO FACE                       19         28           23.363377        $1168.1500           $50.0000
 EIIF  -T1027SC     EI INDIVIDUAL SESSION BY EI PROF            21         21          116.519050        $5825.9600           $50.0000
 INTR  -T1013       INTERPRETER                                 20         21          705.928573       $35296.4200           $50.0000
 OCCT  -97530       OT SESSION BY LICENSED OT                   14         14          103.400000        $7386.9000           $71.4400
 PHY   -97110       PT SESSION BY LICENSED PT                   14         14           73.876191        $5277.7200           $71.4400
 SPL   -92507       SPL THERAPY SESSION BY LICENSED SLP         25         27          145.647620       $10405.0600           $71.4400
 TRAV  -A0160       *PROV TRAVEL TO NATURAL ENV-BY MIN          51         65          249.676252         $124.8400            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                      132        229         1419.336016       $65531.2800           $46.1700


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Total                                                                     234         1422.361891       $65682.5700           $46.1800
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Number of Children (Unduplicated) With at Least One Authorization      136