     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: 01/01/08 and 12/31/08                  Date of Report: 02-16-09                  Page: 1

             Payor Filter: PARH   PAHM   DEI    DEIM
    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         123        123          123.00           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                   1          1            1.00          $37.00           $37.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                    124        124          124.00          $37.00            $0.30

    Screening, Eval, and Assessment, Class # 02
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                     9          9            9.00         $450.00           $50.00
     FANE  -FANE      FAMILY INTERVIEW BY COMMUNITY PROVI          1          1            4.00         $120.00           $30.00
     MED   -MED       UNSPECIFIED MED OFFICE VISIT                 1          1            1.00         $150.00          $150.00
     PDEO  -T1024     *PSY-DEV EVAL OUTPATIENT, INITIAL            1          1            3.00         $450.00          $150.00
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL                 2          2            2.00          $97.00           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                  1          1            4.00         $200.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP                  1          1            1.00          $48.50           $48.50
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     16         16           24.00        $1515.50           $63.15

    EI Services, Class # 03
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                   1          1            0.68          $34.17           $50.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                    1          1            0.93          $46.67           $50.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                   1          1            2.00         $100.00           $50.00
     EIIF  -COUN      UNSPECIFIED COUNSELING                       1          1           10.00         $500.00           $50.00
     EIIF  -T1024HN   *EI INDIVIDUAL SESSION BY PROF               9          9           57.43        $2871.43           $50.00
     INTR  -INTR      INTERPRETER                                  1          1            4.86         $242.86           $50.00
     PHY   -97110     PT SESSION BY LICENSED PT                    1          1           11.57         $785.47           $67.88
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          1          1           20.43        $1386.69           $67.88
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM          6          6           83.36          $41.68            $0.50
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     18         22          191.26        $6008.95           $31.42

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                   162          339.26        $7561.45           $22.29
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  148