Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period                                             Center: 52

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                  20         21           10.300002         $515.0100           $50.0000
 CONOF -CONOF     CONSULT, OT, FACE TO FACE                    9          9            2.833334         $141.6700           $50.0000
 CONPF -CONPF     CONSULT, PT, FACE TO FACE                    8          8            4.533333         $226.6700           $50.0000
 CONSF -CONSF     CONSULT, SLP, FACE TO FACE                  20         20            9.766668         $488.3400           $50.0000
 TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM         33         61        11148.285715        $5574.1400            $0.5000
                                                         ----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated)                     35        119        11175.719052        $6945.8300            $0.6200


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Total                                                                   119        11175.719052        $6945.8300            $0.6200
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Number of Children (Unduplicated) With at Least One Authorization  35