     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: 07/01/08 and 09/30/08                  Date of Report: 11-18-08                  Page: 1

    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

    Service Coordination, Class # 01
     CASE  -CASE      NON-TCM CASE MANAGEMENT                      2          2            1.43          $52.83           $37.00
     IFSP  -IFSP      INDIVIDUALIZED FAMILY SUPPORT PLAN         125        125          126.13           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                   6          7           13.93         $515.36           $37.00
     TCM   -T1017TL   TARGETED CASE MANAGEMENT                    12         12           13.23         $489.69           $37.00
     TCON  -TCON      TRANSITION CONFERENCE                        1          1            1.00           $0.00            $0.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                    143        147          155.72        $1057.88            $6.79

    Screening, Eval, and Assessment, Class # 02
     ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   33         35           36.00        $1746.00           $48.50
     AUD   -92626     EVAL OF AUD REHAB STATUS                     3          3            3.00         $108.21           $36.07
     AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY              60         63           63.00         $669.06           $10.62
     AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)            57         60           60.00         $529.80            $8.83
     AUDE  -92567     TYPMANOMETRY (IMPEDANCE TESTING)            59         62           62.00         $669.60           $10.80
     AUDE  -92579     VISUAL REINFORCEMENT AUDIOMETRY             56         59           59.00        $1285.61           $21.79
     AUDE  -92585     AUD EVOKED RESPONSE (DIAG)                   2          2            2.00         $108.76           $54.38
     AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)             54         56           56.00        $1583.68           $28.28
     AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                  118        130          131.15        $7868.95           $60.00
     AUDE  -V5010     ASSESSMENT FOR HEARING AID                  11         13           14.37         $672.36           $46.80
     AUDE  -V5090     DISPENSING FEE PER HEARING AID              56         57           60.59        $7246.61          $119.60
     BEHV  -BEHV      BEHAVIORAL ASSESSMENT                        1          1            1.00         $125.00          $125.00
     BEHV  -H0031HO   COMP BEHAVIORAL HEALTH ASSESSMENT           22         23           38.57        $4821.44          $125.00
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                   103        106          101.23        $5061.67           $50.00
     EXIT  -EXIT      TRANSITION ASSESSMENT                       46         49           61.64        $3082.15           $50.00
     FANE  -FANE      FAMILY INTERVIEW BY COMMUNITY PROVI          3          3            3.00          $90.00           $30.00
     IPDEF -IPDEF     FOLLOW-UP PSYCH AND DEV EVAL                 3          3            2.56         $192.08           $75.00
     IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT              11         11           14.86        $1114.28           $75.00
     IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT                 8          8           11.27         $845.42           $75.00
     IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF           15         15           18.00        $1350.00           $75.00
     IPDEF -T1024TS   F/U PSYCH AND DEV EVAL BY ITDS              29         29           37.86        $2101.07           $55.50
     IPDEI -IPDEI_NM  INITIAL PSYCH & DEV EVAL BY NON-MED          7          7            8.00         $444.00           $55.50
     IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT         253        253          358.14       $26860.72           $75.00
     IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT            69         71          103.00        $7725.00           $75.00
     IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT            78         78          109.03        $8177.50           $75.00
     IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS         261        269          399.14       $22152.43           $55.50
     IPDEI -T1024TL   INITIAL PSYCH AND DEV EVAL BY EI PR        229        252          345.50       $25912.50           $75.00
     NUTR  -97803     NUTRITIONAL EVAL, FOLLOW-UP                  1          1            1.00          $50.00           $50.00
     NUTR  -NUTR      UNSPECIFIED NUTRITIONAL EVAL                 1          1            1.00          $50.00           $50.00
     OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP           42         42           68.29        $3311.86           $48.50
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL            264        270          297.98       $14452.23           $48.50
     PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP              57         57           57.00        $2764.50           $48.50
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL               220        232          231.00       $11203.56           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                  7          7            7.00         $350.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP                474        493          506.71       $24575.57           $48.50
     VISD  -VISD      VISION EVALUATION DIAGNOSTIC                 1          1            1.00         $100.00          $100.00
     VISF  -VISF      VISION EVALUATION FUNCTIONAL                 7          7            7.00         $350.00           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   1632       2829         3337.90      $189751.60           $56.85

    EI Services, Class # 03
     ASST  -ASST      ASSISTIVE TECHNOLOGY                        54         65          114.00      $171000.00         $1500.00
     AUD   -92630     AUD REHAB PRELING HEARING LOSS               1          1            1.00          $68.86           $68.86
     AUD   -HA_FUP    AUDIOLOGY SERVICES                          37         38           57.91        $2895.32           $50.00
     COIFF -COIFF     IFSP CONSULT, PROF, FACE TO FACE           302        473          838.78       $41939.17           $50.00
     COIFP -COIFP     IFSP CONSULT, PRO, BY PHONE                 10         10            9.73         $243.34           $25.00
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                 634        696         1261.58       $63079.07           $50.00
     CONIP -CONIP     CONSULT, ITDS, PHONE                        42         43           65.78        $1644.40           $25.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                  309        338          521.88       $26094.12           $50.00
     CONOP -CONOP     CONSULT, OT, PHONE                          11         11            8.38         $209.58           $25.00
     CONPF -CONPF     CONSULT, PT, FACE TO FACE                  248        261          449.31       $22465.49           $50.00
     CONPP -CONPP     CONSULT, PT, PHONE                          13         13           13.72         $343.06           $25.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 568        621          921.72       $46085.92           $50.00
     CONSP -CONSP     CONSULT, SLP, PHONE                         42         45           63.35        $1583.65           $25.00
     COUN  -H2019HR   INDIVIDUAL/FAMILY THERAPY                   14         15           55.34        $4062.72           $73.42
     ECE   -ECE       EARLY CHILDHOOD EDUCATION                    8          8          900.29       $11253.57           $12.50
     EIGF  -EIGF_NM   EI GROUP SESSION BY NONMED PROF              2          2            2.00          $50.00           $25.00
     EIGF  -T1024TTHN *EI GROUP SESSION BY PROF                    1          1            1.77          $44.17           $25.00
     EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                156        186          936.00       $23400.01           $25.00
     EIIF  -96154     HEALTH AND BEHAVIOR INTERVENTION             3          3           99.00        $4950.00           $50.00
     EIIF  -COUN      UNSPECIFIED COUNSELING                       1          1           10.00         $500.00           $50.00
     EIIF  -EIIF_NM   EI INDIVIDUAL SESSION BY NONMED PRO         11         11           71.29        $3564.28           $50.00
     EIIF  -T1024HN   *EI INDIVIDUAL SESSION BY PROF              13         13           76.86        $3842.86           $50.00
     EIIF  -T1027HM   EI INDIVIDUAL SESSION BY PARAPROF            5          5           35.86         $896.43           $25.00
     EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF          1762       1992        12186.24      $609312.12           $50.00
     HERN  -T1027SC   EI HEARING SERVICES AFTER SHINE              6          6           37.68        $1884.05           $50.00
     INTR  -INTR      INTERPRETER                                 43         45          264.94       $13247.15           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                  882        994         4922.01      $334105.73           $67.88
     OCCT  -97530HM   OT SESSION BY OT ASST                       70         73          358.50       $19473.79           $54.32
     PHY   -97110     PT SESSION BY LICENSED PT                 1085       1217         6108.89      $414671.41           $67.88
     PHY   -97110HM   PT SESSION BY PT ASST                       72         73          439.69       $23884.12           $54.32
     SCONLY-SCONLY    SERVICE COORDINATION ONLY                   17         17           14.97          $14.97            $1.00
     SENS  -FM        FM RECEIVER HEARING AID                      1          1            1.00        $1650.00         $1650.00
     SENS  -HA_EIP    ONE UNIT UP TO $500 PER AID                  3          3            5.00        $2500.00          $500.00
     SENS  -HA_INS    SENSORY AID INSURANCE PER EAR                4          4            3.16         $135.72           $43.00
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL             3          3            5.00        $1185.60          $237.12
     SENS  -V5264     EARMOLD                                     16         18           28.93         $541.51           $18.72
     SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL          33         45          127.44        $6371.91           $50.00
     SIC   -SIC       SPECIAL INSTRUCTION CONSULTATION             1          1            7.71         $385.72           $50.00
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP       1684       1897         9768.62      $663093.91           $67.88
     SPL   -92507HM   SPL THERAPY SESSION BY SLP ASST              4          4           15.43         $838.08           $54.32
     SPL   -92508     GROUP SPL SESSION PER CHILD                102        107          643.25        $8490.90           $13.20
     TRAN  -TRAN      FAMILY TRANSPORTATION                        8         10           24.47        $2446.67          $100.00
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM       1315       1834       135689.92       $67844.96            $0.50
     VISN  -T1024HN   *EI VISION SERVICES, INDIVIDUAL              1          1            2.50         $125.00           $50.00
     VISN  -T1027SC   EI VISION SERVICES, INDIVIDUAL              35         49          174.80        $8739.99           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   3926      11254       177345.67     $2611159.29           $14.72

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                 14230       180839.29     $2801968.77           $15.49
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  4529