     Summary Report for FSPSAs Initiated During the Report Period                                             Statewide

    This report shows the total number of units/fees for FSPSAs initiated during the report period.
    (i.e., start 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 starting between: 07/01/08 and 09/30/08                  Date of Report: 11-18-08                  Page: 1

    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                      1          1            0.25           $9.25           $37.00
     IFSP  -IFSP      INDIVIDUALIZED FAMILY SUPPORT PLAN          51         54           27.27           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                  21         25           17.00         $629.00           $37.00
     TCM   -T1017TL   TARGETED CASE MANAGEMENT                     9          9           10.54         $390.07           $37.00
     TCON  -TCON      TRANSITION CONFERENCE                        1          1            1.00           $0.00            $0.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     71         90           56.06        $1028.32           $18.34

    Screening, Eval, and Assessment, Class # 02
     ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   41         46           49.13        $2382.97           $48.50
     AUD   -92626     EVAL OF AUD REHAB STATUS                     6          6           10.71         $386.46           $36.07
     AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY             105        108          108.00        $1146.96           $10.62
     AUDE  -92553     PURE TONE AUDIOMETRY AIR & BONE              1          1            1.00          $16.30           $16.30
     AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)           104        107          107.00         $944.81            $8.83
     AUDE  -92557     COMP AUDIO THRESHOLD EVAL/SPCH RECO          1          1            1.00          $27.10           $27.10
     AUDE  -92567     TYPMANOMETRY (IMPEDANCE TESTING)           105        108          108.00        $1166.40           $10.80
     AUDE  -92579     VISUAL REINFORCEMENT AUDIOMETRY            102        105          105.00        $2287.95           $21.79
     AUDE  -92585     AUD EVOKED RESPONSE (DIAG)                   2          3            3.00         $163.14           $54.38
     AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)             96         98           98.00        $2771.44           $28.28
     AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                  176        186          199.66       $11979.71           $60.00
     AUDE  -V5010     ASSESSMENT FOR HEARING AID                  33         36           36.13        $1691.04           $46.80
     AUDE  -V5090     DISPENSING FEE PER HEARING AID             125        129          160.66       $19214.88          $119.60
     BEHV  -90801     PSYCHIATRIC DIAG INTERVIEW                   2          2            2.00         $250.00          $125.00
     BEHV  -BEHV      BEHAVIORAL ASSESSMENT                        4          5           16.00        $2000.00          $125.00
     BEHV  -H0031HO   COMP BEHAVIORAL HEALTH ASSESSMENT           36         36          103.08       $12884.53          $125.00
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                    98        104          124.47        $6223.45           $50.00
     EXIT  -EXIT      TRANSITION ASSESSMENT                       97        113          147.04        $7351.79           $50.00
     FANE  -FANE      FAMILY INTERVIEW BY COMMUNITY PROVI         20         20           20.00         $600.00           $30.00
     IPDEF -IPDEF     FOLLOW-UP PSYCH AND DEV EVAL                 3          3            2.56         $192.08           $75.00
     IPDEF -IPDEF_NM  F/U PSYCH & DEV EVAL BY NON-MED PRO          2          2            2.50         $138.75           $55.50
     IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT              22         22           28.86        $2164.28           $75.00
     IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT                 3          3            3.00         $225.00           $75.00
     IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT                 9          9           12.27         $920.42           $75.00
     IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF           26         26           33.00        $2475.00           $75.00
     IPDEF -T1024TS   F/U PSYCH AND DEV EVAL BY ITDS              57         58           75.86        $4210.07           $55.50
     IPDEI -IPDEI_NM  INITIAL PSYCH & DEV EVAL BY NON-MED         33         33           37.50        $2081.25           $55.50
     IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT         519        519          728.07       $54605.36           $75.00
     IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT           121        123          182.00       $13650.00           $75.00
     IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT           158        160          242.53       $18190.00           $75.00
     IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS         465        478          727.57       $40380.22           $55.50
     IPDEI -T1024TL   INITIAL PSYCH AND DEV EVAL BY EI PR        495        551          757.43       $56807.14           $75.00
     MED   -99205     OUTPATIENT VISIT, NEW, 60 MINS               1          1            1.00          $72.78           $72.78
     MED   -MED       UNSPECIFIED MED OFFICE VISIT                 1          1            1.00         $150.00          $150.00
     NUTR  -NUTR      UNSPECIFIED NUTRITIONAL EVAL                 2          2            2.00         $100.00           $50.00
     OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP          107        112          123.89        $6008.84           $48.50
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL            504        547          612.40       $29701.63           $48.50
     PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP             121        126          125.39        $6081.36           $48.50
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL               392        423          423.27       $20528.76           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                 32         32           32.00        $1600.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP               1155       1253         1295.22       $62817.93           $48.50
     VISD  -VISD      VISION EVALUATION DIAGNOSTIC                 1          1            1.00         $100.00          $100.00
     VISF  -VISF      VISION EVALUATION FUNCTIONAL                 2          2            2.00         $100.00           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   3200       5701         6852.21      $396789.79           $57.91

    EI Services, Class # 03
     ASST  -ASST      ASSISTIVE TECHNOLOGY                       121        143          253.00      $379500.00         $1500.00
     AUD   -92630     AUD REHAB PRELING HEARING LOSS               1          1            1.00          $68.86           $68.86
     AUD   -HA_FUP    AUDIOLOGY SERVICES                         105        114          228.15       $11407.47           $50.00
     COIFF -COIFF     IFSP CONSULT, PROF, FACE TO FACE           644       1142         2071.22      $103560.83           $50.00
     COIFP -COIFP     IFSP CONSULT, PRO, BY PHONE                 29         31           29.50         $737.50           $25.00
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                1186       1288         2088.64      $104432.11           $50.00
     CONIP -CONIP     CONSULT, ITDS, PHONE                        56         58           96.03        $2400.72           $25.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                  574        618          959.29       $47964.50           $50.00
     CONOP -CONOP     CONSULT, OT, PHONE                          24         24           26.36         $659.03           $25.00
     CONPF -CONPF     CONSULT, PT, FACE TO FACE                  418        439          716.95       $35847.53           $50.00
     CONPP -CONPP     CONSULT, PT, PHONE                          24         24           46.44        $1160.92           $25.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                1193       1291         1925.22       $96261.10           $50.00
     CONSP -CONSP     CONSULT, SLP, PHONE                         92         98          116.32        $2908.11           $25.00
     COUN  -H2019HR   INDIVIDUAL/FAMILY THERAPY                   36         37           88.59        $6504.20           $73.42
     ECE   -ECE       EARLY CHILDHOOD EDUCATION                   10         10         1947.00       $24337.50           $12.50
     EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                305        345         2306.03       $57650.75           $25.00
     EIIF  -90801     PSYCHIATRIC DIAG INTERVIEW                   1          1           10.71         $535.72           $50.00
     EIIF  -96154     HEALTH AND BEHAVIOR INTERVENTION            17         20          230.86       $11542.86           $50.00
     EIIF  -EIIF_NM   EI INDIVIDUAL SESSION BY NONMED PRO         11         11           68.57        $3428.58           $50.00
     EIIF  -T1027HM   EI INDIVIDUAL SESSION BY PARAPROF            5          5           41.51        $1037.86           $25.00
     EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF          3247       3789        22176.74     $1108836.84           $50.00
     HERN  -T1027SC   EI HEARING SERVICES AFTER SHINE             39         41          145.01        $7250.71           $50.00
     INTR  -INTR      INTERPRETER                                 65         70          311.94       $15596.80           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                 1693       1982         9616.25      $652750.94           $67.88
     OCCT  -97530HM   OT SESSION BY OT ASST                      101        107          565.86       $30737.60           $54.32
     PHY   -97110     PT SESSION BY LICENSED PT                 1804       2101        10145.31      $688663.38           $67.88
     PHY   -97110HM   PT SESSION BY PT ASST                      102        107          679.19       $36893.70           $54.32
     SCONLY-SCONLY    SERVICE COORDINATION ONLY                   94         95           92.14          $92.14            $1.00
     SENS  -FM        FM RECEIVER HEARING AID                      4          4            4.00        $6600.00         $1650.00
     SENS  -HA_EIP    ONE UNIT UP TO $500 PER AID                 25         27           37.00       $18500.00          $500.00
     SENS  -HA_INS    SENSORY AID INSURANCE PER EAR               10         11            8.57         $368.39           $43.00
     SENS  -V5014     HEARING AID REPAIR BY MANUFACTURER           2          2            2.00         $228.00          $114.00
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL            10         11           35.00        $8299.20          $237.12
     SENS  -V5264     EARMOLD                                     56         60           84.36        $1579.14           $18.72
     SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL          46         55          163.24        $8161.80           $50.00
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP       3738       4407        22441.73     $1523344.55           $67.88
     SPL   -92507HM   SPL THERAPY SESSION BY SLP ASST              8          8           68.14        $3701.52           $54.32
     SPL   -92508     GROUP SPL SESSION PER CHILD                231        236         1672.49       $22076.93           $13.20
     TRAN  -TRAN      FAMILY TRANSPORTATION                        8          9           31.42        $3141.91          $100.00
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM       2382       3373       235617.26      $117808.62            $0.50
     VISN  -T1027SC   EI VISION SERVICES, INDIVIDUAL              57         72          297.76       $14887.87           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   7762      22267       317446.79     $5161466.15           $16.26

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                 28058       324355.07     $5559284.26           $17.14
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  8319