     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: 10/01/08 and 12/31/08                  Date of Report: 02-16-09                  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
     IFSP  -IFSP      INDIVIDUALIZED FAMILY SUPPORT PLAN         185        187          168.38           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                   6          6           18.57         $687.15           $37.00
     TCM   -T1017TL   TARGETED CASE MANAGEMENT                     7          7            8.20         $303.28           $37.00
     TCON  -TCON      TRANSITION CONFERENCE                        3          3            3.00           $0.00            $0.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                    194        203          198.15         $990.42            $5.00

    Screening, Eval, and Assessment, Class # 02
     ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   44         51           56.86        $2757.57           $48.50
     AUD   -92626     EVAL OF AUD REHAB STATUS                    18         18           30.49        $1099.68           $36.07
     AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY              59         59           59.00         $626.58           $10.62
     AUDE  -92553     PURE TONE AUDIOMETRY AIR & BONE              1          1            1.00          $16.30           $16.30
     AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)            59         59           59.00         $520.97            $8.83
     AUDE  -92557     COMP AUDIO THRESHOLD EVAL/SPCH RECO          1          1            1.00          $27.10           $27.10
     AUDE  -92567     TYPMANOMETRY (IMPEDANCE TESTING)            57         57           57.00         $615.60           $10.80
     AUDE  -92579     VISUAL REINFORCEMENT AUDIOMETRY             53         53           53.00        $1154.87           $21.79
     AUDE  -92585     AUD EVOKED RESPONSE (DIAG)                   2          2            2.00         $108.76           $54.38
     AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)             52         52           52.00        $1470.56           $28.28
     AUDE  -92682     CONDITIONED PLAY AUDIOMETRY                  1          1            1.00          $21.34           $21.34
     AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                  201        222          239.05       $14343.23           $60.00
     AUDE  -V5010     ASSESSMENT FOR HEARING AID                  24         29           30.07        $1407.12           $46.80
     AUDE  -V5090     DISPENSING FEE PER HEARING AID             143        149          160.12       $19149.95          $119.60
     BEHV  -90801     PSYCHIATRIC DIAG INTERVIEW                   1          1           11.29        $1410.71          $125.00
     BEHV  -BEHV      BEHAVIORAL ASSESSMENT                        8          8           11.70        $1462.50          $125.00
     BEHV  -H0031HO   COMP BEHAVIORAL HEALTH ASSESSMENT           38         39           92.76       $11594.86          $125.00
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                   194        219          319.43       $15971.47           $50.00
     EXIT  -EXIT      TRANSITION ASSESSMENT                       62         70          112.04        $5601.79           $50.00
     IPDEF -IPDEF     FOLLOW-UP PSYCH AND DEV EVAL                 2          3            3.00         $225.00           $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              15         15           19.57        $1467.86           $75.00
     IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT                 4          4            6.00         $450.00           $75.00
     IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT                 4          4            7.00         $525.00           $75.00
     IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF            4          4            4.57         $342.86           $75.00
     IPDEF -T1024TS   F/U PSYCH AND DEV EVAL BY ITDS              26         26           37.00        $2053.50           $55.50
     IPDEI -IPDEI_NM  INITIAL PSYCH & DEV EVAL BY NON-MED         13         13           20.00        $1110.00           $55.50
     IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT         262        262          403.00       $30225.00           $75.00
     IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT            51         51           74.50        $5587.50           $75.00
     IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT           106        107          179.64       $13473.22           $75.00
     IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS         287        287          435.89       $24191.92           $55.50
     IPDEI -T1024TL   INITIAL PSYCH AND DEV EVAL BY EI PR        229        250          371.86       $27889.29           $75.00
     MED   -MED       UNSPECIFIED MED OFFICE VISIT                 1          1            1.00         $150.00          $150.00
     NUTR  -NUTR      UNSPECIFIED NUTRITIONAL EVAL                 1          1            1.00          $50.00           $50.00
     OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP           94        111          135.49        $6571.29           $48.50
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL            552        621          712.52       $34557.37           $48.50
     PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP              98        114          120.43        $5840.79           $48.50
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL               480        522          569.77       $27633.96           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                  9          9            9.00         $450.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP               1144       1268         1466.65       $71132.34           $48.50
     VISD  -VISD      VISION EVALUATION DIAGNOSTIC                 3          3            8.00         $800.00          $100.00
     VISF  -VISF      VISION EVALUATION FUNCTIONAL                 7          7           13.57         $678.57           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   2798       4775         5949.26      $334821.92           $56.28

    EI Services, Class # 03
     ASST  -ASST      ASSISTIVE TECHNOLOGY                        77         93          106.00      $159000.00         $1500.00
     AUD   -92630     AUD REHAB PRELING HEARING LOSS               1          2            1.02          $70.40           $68.86
     AUD   -HA_FUP    AUDIOLOGY SERVICES                          97        110          250.54       $12527.17           $50.00
     COIFF -COIFF     IFSP CONSULT, PROF, FACE TO FACE           415        817         1504.75       $75237.51           $50.00
     COIFP -COIFP     IFSP CONSULT, PRO, BY PHONE                 19         21           20.75         $518.75           $25.00
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                1375       1658         3284.04      $164202.03           $50.00
     CONIP -CONIP     CONSULT, ITDS, PHONE                        75         83          150.56        $3764.11           $25.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                  655        781         1372.79       $68639.67           $50.00
     CONOP -CONOP     CONSULT, OT, PHONE                          32         36           48.70        $1217.51           $25.00
     CONPF -CONPF     CONSULT, PT, FACE TO FACE                  515        611         1169.71       $58485.58           $50.00
     CONPP -CONPP     CONSULT, PT, PHONE                          40         44           62.85        $1571.28           $25.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                1350       1620         2818.60      $140930.15           $50.00
     CONSP -CONSP     CONSULT, SLP, PHONE                         92        106          160.40        $4010.00           $25.00
     COUN  -H2019HR   INDIVIDUAL/FAMILY THERAPY                   25         27           95.39        $7003.53           $73.42
     ECE   -ECE       EARLY CHILDHOOD EDUCATION                   10         10         1511.29       $18891.07           $12.50
     EIGF  -EIGF_NM   EI GROUP SESSION BY NONMED PROF              5          5            9.90         $247.50           $25.00
     EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                324        389         3007.40       $75184.97           $25.00
     EIIF  -96154     HEALTH AND BEHAVIOR INTERVENTION             6          7           73.57        $3678.58           $50.00
     EIIF  -COUN      UNSPECIFIED COUNSELING                       2          2            0.80          $40.00           $50.00
     EIIF  -EIIF_NM   EI INDIVIDUAL SESSION BY NONMED PRO         27         29          285.29       $14264.31           $50.00
     EIIF  -T1024HN   *EI INDIVIDUAL SESSION BY PROF               3          3           32.71        $1635.72           $50.00
     EIIF  -T1027HM   EI INDIVIDUAL SESSION BY PARAPROF            5          7           38.14         $953.58           $25.00
     EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF          3895       4914        37060.72     $1853035.91           $50.00
     HERN  -EIIF_NM   EI HEARING SERVICES AFTER SHINE NON          1          1            0.14           $7.15           $50.00
     HERN  -T1027SC   EI HEARING SERVICES AFTER SHINE             48         58          306.51       $15325.59           $50.00
     INTR  -INTR      INTERPRETER                                 99        116          738.82       $36940.75           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                 1807       2317        14904.71     $1011732.00           $67.88
     OCCT  -97530HM   OT SESSION BY OT ASST                      145        163          997.72       $54196.01           $54.32
     PHY   -97110     PT SESSION BY LICENSED PT                 2192       2796        18235.98     $1237858.26           $67.88
     PHY   -97110HM   PT SESSION BY PT ASST                      176        185         1088.80       $59143.41           $54.32
     RSPT  -RSPT      RESPITE                                      1          1           49.07           $0.00            $0.00
     SCONLY-SCONLY    SERVICE COORDINATION ONLY                  329        344          576.30         $576.30            $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                 13         14           18.50        $9250.00          $500.00
     SENS  -HA_INS    SENSORY AID INSURANCE PER EAR               17         19           12.71         $826.31           $65.00
     SENS  -V5014     HEARING AID REPAIR BY MANUFACTURER           2          2            3.00         $342.00          $114.00
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL            11         13           24.00        $5690.88          $237.12
     SENS  -V5264     EARMOLD                                     49         58           93.42        $1748.76           $18.72
     SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL          66         77          314.81       $15740.37           $50.00
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP       3531       4496        29717.96     $2017255.17           $67.88
     SPL   -92507HM   SPL THERAPY SESSION BY SLP ASST              9          9           78.73        $4276.80           $54.32
     SPL   -92508     GROUP SPL SESSION PER CHILD                268        283         2252.03       $29726.85           $13.20
     TRAN  -TRAN      FAMILY TRANSPORTATION                        9         11           46.53        $4653.33          $100.00
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM       2724       4401       414038.14      $207019.03            $0.50
     VISN  -EIIF_NM   EI VISION SERVICES, IND NONMED               2          2           31.57        $1578.58           $50.00
     VISN  -T1027SC   EI VISION SERVICES, INDIVIDUAL              70         89          557.12       $27855.84           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   7834      26831       537153.50     $7408502.65           $13.79

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                 31809       543300.91     $7744314.99           $14.25
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  8109