     Summary Report for FSPSAs Ending During the Report Period                                             Statewide

    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: 10/01/08 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 Cost of        Avg Fee
                                                             Children    Records     Authorized   Auth Services     Per Unit Auth

    EI Services, Class # 03
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM          1          1            5.43           $2.71            $0.50
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                      1          1            5.43           $2.71            $0.50

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                     1            5.43           $2.71            $0.50
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  1