     Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period                                             Statewide

    This report estimates subtotals of units and fees for the number of days of overlap between each included
    FSPSA record and the user-selected report period.  For example, if the FSPSA record authorizes services from
    01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
    authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01).  Note that service authorization periods
    may range from 1 to 12 months and may vary in intensity from child to child.

    FSPSAs overlapping: 07/01/08 and 09/30/08                  Date of Report: 11-18-08                  Page: 1

    Child has a MEDICAID # Filter: Y
    Eligibility Filter: Program Patients

    Services  Cpt Code                                       Number of   Number of   Total Units    Total Fees        Avg Fee
                                                             Children    Records     Overlapping    Overlapping     Per Unit Auth
                                                                                    Report Period  Report Period

    Service Coordination, Class # 01
     CASE  -CASE      NON-TCM CASE MANAGEMENT                      2          2            1.43          $52.83           $37.00
     IFSP  -IFSP      INDIVIDUALIZED FAMILY SUPPORT PLAN         267        268          286.81           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                   7          8           27.07        $1001.65           $37.00
     TCM   -T1017TL   TARGETED CASE MANAGEMENT                    20         20           23.99         $887.80           $37.00
     TCON  -TCON      TRANSITION CONFERENCE                        1          1            1.00           $0.00            $0.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                    293        299          340.31        $1942.27            $5.71

    Screening, Eval, and Assessment, Class # 02
     ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   51         56           69.14        $3353.43           $48.50
     AUD   -92626     EVAL OF AUD REHAB STATUS                     7          7            7.02         $253.29           $36.07
     AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY              60         63           63.00         $669.06           $10.62
     AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)            58         61           61.00         $538.63            $8.83
     AUDE  -92567     TYPMANOMETRY (IMPEDANCE TESTING)            59         62           62.00         $669.60           $10.80
     AUDE  -92579     VISUAL REINFORCEMENT AUDIOMETRY             56         59           59.00        $1285.61           $21.79
     AUDE  -92585     AUD EVOKED RESPONSE (DIAG)                   3          3            3.00         $163.14           $54.38
     AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)             54         56           56.00        $1583.68           $28.28
     AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                  210        230          251.02       $15061.12           $60.00
     AUDE  -V5010     ASSESSMENT FOR HEARING AID                  19         24           24.50        $1146.60           $46.80
     AUDE  -V5090     DISPENSING FEE PER HEARING AID             111        114          118.87       $14216.65          $119.60
     BEHV  -BEHV      BEHAVIORAL ASSESSMENT                        3          4           15.00        $1875.00          $125.00
     BEHV  -H0031HO   COMP BEHAVIORAL HEALTH ASSESSMENT           39         40           86.87       $10859.14          $125.00
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                   250        278          309.94       $15497.18           $50.00
     EXIT  -EXIT      TRANSITION ASSESSMENT                       61         71           91.64        $4582.15           $50.00
     FANE  -FANE      FAMILY INTERVIEW BY COMMUNITY PROVI          3          3            3.00          $90.00           $30.00
     IPDEF -IPDEF     FOLLOW-UP PSYCH AND DEV EVAL                 3          3            2.56         $192.08           $75.00
     IPDEF -IPDEF_NM  F/U PSYCH & DEV EVAL BY NON-MED PRO          1          1            1.00          $55.50           $55.50
     IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT              13         13           16.86        $1264.28           $75.00
     IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT                 2          2            3.00         $225.00           $75.00
     IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT                 8          8           11.27         $845.42           $75.00
     IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF           15         15           18.00        $1350.00           $75.00
     IPDEF -T1024TS   F/U PSYCH AND DEV EVAL BY ITDS              36         36           48.86        $2711.57           $55.50
     IPDEI -IPDEI_NM  INITIAL PSYCH & DEV EVAL BY NON-MED         10         10           11.00         $610.50           $55.50
     IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT         263        263          370.14       $27760.72           $75.00
     IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT            72         74          106.00        $7950.00           $75.00
     IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT            85         85          116.03        $8702.50           $75.00
     IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS         263        271          403.14       $22374.43           $55.50
     IPDEI -T1024TL   INITIAL PSYCH AND DEV EVAL BY EI PR        244        267          361.00       $27075.00           $75.00
     MED   -MED       UNSPECIFIED MED OFFICE VISIT                 1          1            1.00         $150.00          $150.00
     NUTR  -97803     NUTRITIONAL EVAL, FOLLOW-UP                  1          1            1.00          $50.00           $50.00
     NUTR  -NUTR      UNSPECIFIED NUTRITIONAL EVAL                 2          2            2.00         $100.00           $50.00
     OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP           92        103          151.44        $7344.75           $48.50
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL            546        608          689.83       $33456.76           $48.50
     PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP             106        117          117.00        $5674.50           $48.50
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL               472        529          574.96       $27885.37           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                 13         13           13.00         $650.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP               1040       1153         1222.12       $59272.90           $48.50
     VISD  -VISD      VISION EVALUATION DIAGNOSTIC                 2          2            2.00         $200.00          $100.00
     VISF  -VISF      VISION EVALUATION FUNCTIONAL                11         11           23.14        $1157.15           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   2682       4719         5547.37      $308902.70           $55.68

    EI Services, Class # 03
     ASST  -ASST      ASSISTIVE TECHNOLOGY                        86        110          169.00      $253500.00         $1500.00
     AUD   -92630     AUD REHAB PRELING HEARING LOSS               2          2            2.02         $139.25           $68.86
     AUD   -HA_FUP    AUDIOLOGY SERVICES                          89         94          205.05       $10252.32           $50.00
     COIFF -COIFF     IFSP CONSULT, PROF, FACE TO FACE           398        826         1553.88       $77694.18           $50.00
     COIFP -COIFP     IFSP CONSULT, PRO, BY PHONE                 16         19           26.63         $665.84           $25.00
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                1322       1657         3364.01      $168200.44           $50.00
     CONIP -CONIP     CONSULT, ITDS, PHONE                        91         96          176.60        $4414.97           $25.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                  644        793         1379.87       $68993.26           $50.00
     CONOP -CONOP     CONSULT, OT, PHONE                          34         34           44.45        $1111.25           $25.00
     CONPF -CONPF     CONSULT, PT, FACE TO FACE                  517        637         1147.86       $57392.75           $50.00
     CONPP -CONPP     CONSULT, PT, PHONE                          37         40           65.80        $1644.94           $25.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                1233       1487         2620.84      $131041.98           $50.00
     CONSP -CONSP     CONSULT, SLP, PHONE                         93        101          160.84        $4020.92           $25.00
     COUN  -H2019HR   INDIVIDUAL/FAMILY THERAPY                   36         38           96.90        $7114.13           $73.42
     ECE   -ECE       EARLY CHILDHOOD EDUCATION                   16         17         2266.71       $28333.93           $12.50
     EIGF  -EIGF_NM   EI GROUP SESSION BY NONMED PROF              4          4            8.13         $203.34           $25.00
     EIGF  -T1024TTHN *EI GROUP SESSION BY PROF                    1          1            1.77          $44.17           $25.00
     EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                320        417         2368.68       $59217.05           $25.00
     EIIF  -96154     HEALTH AND BEHAVIOR INTERVENTION             7          7          141.14        $7057.15           $50.00
     EIIF  -COUN      UNSPECIFIED COUNSELING                       2          2           11.02         $551.11           $50.00
     EIIF  -EIIF_NM   EI INDIVIDUAL SESSION BY NONMED PRO         24         25          228.57       $11428.58           $50.00
     EIIF  -T1024HN   *EI INDIVIDUAL SESSION BY PROF              15         15           91.00        $4550.00           $50.00
     EIIF  -T1027HM   EI INDIVIDUAL SESSION BY PARAPROF            8          9           98.96        $2474.05           $25.00
     EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF          3686       4781        36190.11     $1809505.58           $50.00
     HERN  -EIIF_NM   EI HEARING SERVICES AFTER SHINE NON          1          1           13.14         $657.15           $50.00
     HERN  -T1027SC   EI HEARING SERVICES AFTER SHINE             32         35          167.86        $8392.79           $50.00
     INTR  -INTR      INTERPRETER                                 83        100          650.49       $32524.45           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                 1761       2275        14816.79     $1005764.04           $67.88
     OCCT  -97530HM   OT SESSION BY OT ASST                      136        153         1080.03       $58666.96           $54.32
     PHY   -97110     PT SESSION BY LICENSED PT                 2138       2840        17830.63     $1210342.86           $67.88
     PHY   -97110HM   PT SESSION BY PT ASST                      165        176         1338.93       $72730.45           $54.32
     SCONLY-SCONLY    SERVICE COORDINATION ONLY                  111        115          380.83         $380.83            $1.00
     SENS  -FM        FM RECEIVER HEARING AID                      1          1            1.00        $1650.00         $1650.00
     SENS  -HA_EIP    ONE UNIT UP TO $500 PER AID                  9         10           14.00        $7000.00          $500.00
     SENS  -HA_INS    SENSORY AID INSURANCE PER EAR               15         15            7.48         $321.63           $43.00
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL             7          7           11.00        $2608.32          $237.12
     SENS  -V5264     EARMOLD                                     42         45           67.26        $1259.11           $18.72
     SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL          59         85          310.95       $15547.63           $50.00
     SIC   -SIC       SPECIAL INSTRUCTION CONSULTATION             1          1            7.71         $385.72           $50.00
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP       3362       4340        28435.86     $1930226.47           $67.88
     SPL   -92507HM   SPL THERAPY SESSION BY SLP ASST              9          9           50.71        $2754.80           $54.32
     SPL   -92508     GROUP SPL SESSION PER CHILD                218        236         1916.23       $25294.23           $13.20
     TRAN  -TRAN      FAMILY TRANSPORTATION                       12         15           54.75        $5475.25          $100.00
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM       2538       4236       415671.91      $207835.93            $0.50
     VISN  -EIIF_NM   EI VISION SERVICES, IND NONMED               2          2           65.71        $3285.72           $50.00
     VISN  -T1024HN   *EI VISION SERVICES, INDIVIDUAL              1          1            2.50         $125.00           $50.00
     VISN  -T1027SC   EI VISION SERVICES, INDIVIDUAL              68        101          544.15       $27207.52           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   7261      26011       535859.77     $7329987.98           $13.68

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                 31029       541747.45     $7640832.95           $14.10
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  7547