     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
    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         230        230          229.37           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                   1          1            1.00          $37.00           $37.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                    231        231          230.37          $37.00            $0.16

    Screening, Eval, and Assessment, Class # 02
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                    13         13           13.00         $650.00           $50.00
     FANE  -FANE      FAMILY INTERVIEW BY COMMUNITY PROVI          3          3           11.00         $330.00           $30.00
     MED   -MED       UNSPECIFIED MED OFFICE VISIT                 1          1            1.00         $150.00          $150.00
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL              2          2            3.00         $145.50           $48.50
     PDEO  -T1024     *PSY-DEV EVAL OUTPATIENT, INITIAL            3          3            6.24         $936.17          $150.00
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL                 3          3            3.00         $145.50           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                  2          2            6.00         $300.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP                  2          2            2.00          $97.00           $48.50
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     26         29           45.24        $2754.17           $60.88

    EI Services, Class # 03
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                   4          4           18.22         $910.83           $50.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                    3          5            4.93         $246.67           $50.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                   4          4            7.40         $370.00           $50.00
     EIGF  -T1024TTHN *EI GROUP SESSION BY PROF                    1          1          209.14        $5228.57           $25.00
     EIIF  -COUN      UNSPECIFIED COUNSELING                       3          3           30.00        $1500.00           $50.00
     EIIF  -T1024HN   *EI INDIVIDUAL SESSION BY PROF              17         17          165.57        $8278.57           $50.00
     INTR  -INTR      INTERPRETER                                  1          1            4.86         $242.86           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                    2          2           14.57         $989.11           $67.88
     PHY   -97110     PT SESSION BY LICENSED PT                    5          5           35.29        $2395.19           $67.88
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL             1          1            2.73         $648.12          $237.12
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          9          9          102.92        $6986.47           $67.88
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM          8          8          150.93          $75.46            $0.50
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     41         60          746.56       $27871.84           $37.33

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                   320         1022.17       $30663.01           $30.00
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  268