Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period                                             Center: 06

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: 10-01-12 and 12-31-12                  Date of Report: 02-16-13                  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                



EI Services, Class # 03
 CONIF -CONIF     CONSULT ITDS, FACE TO FACE                  28         28           17.773812         $888.7000           $50.0000
 CONIP -CONIP     CONSULT, ITDS, PHONE                         1          1            0.100000           $2.5000           $25.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                   10         10            4.650001         $232.5100           $50.0000
 CONOP -CONOP     CONSULT, OT, PHONE                           1          1            0.166667           $4.1700           $25.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                   10         10            4.400000         $220.0000           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                  14         14            7.033334         $351.6700           $50.0000
 CONSP -CONSP     CONSULT, SLP, PHONE                          2          2            0.266667           $6.6700           $25.0000
 EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF             1          1            1.571429          $78.5700           $50.0000
 INTR  -INTR      INTERPRETER                                  1          1            3.714286         $185.7200           $50.0000
 OCCT  -97530     OT SESSION BY LICENSED OT                    2          2            3.571429         $242.4300           $67.8800
 PHY   -97110     PT SESSION BY LICENSED PT                    3          3            3.704762         $251.4800           $67.8800
 SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP          2          2           12.714285         $863.0500           $67.8800
 TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM         52         91         9601.714290        $4800.8600            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                     53        166         9661.380962        $8128.3000            $0.8400


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Total                                                                   166         9661.380962        $8128.3000            $0.8400
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Number of Children (Unduplicated) With at Least One Authorization  53