     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

    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                      1          1            0.25           $9.25           $37.00
     IFSP  -IFSP      INDIVIDUALIZED FAMILY SUPPORT PLAN          25         26           15.38           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                   5          6            3.50         $129.50           $37.00
     TCM   -T1017TL   TARGETED CASE MANAGEMENT                     8          8           10.03         $371.16           $37.00
     TCON  -TCON      TRANSITION CONFERENCE                        1          1            1.00           $0.00            $0.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     36         42           30.16         $509.91           $16.90

    Screening, Eval, and Assessment, Class # 02
     ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   24         27           27.00        $1309.50           $48.50
     AUD   -92626     EVAL OF AUD REHAB STATUS                     2          2            2.00          $72.14           $36.07
     AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY              60         63           63.00         $669.06           $10.62
     AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)            58         61           61.00         $538.63            $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)                   1          1            1.00          $54.38           $54.38
     AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)             54         56           56.00        $1583.68           $28.28
     AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                  105        110          122.18        $7331.05           $60.00
     AUDE  -V5010     ASSESSMENT FOR HEARING AID                  15         17           16.13         $755.04           $46.80
     AUDE  -V5090     DISPENSING FEE PER HEARING AID              50         50           53.28        $6372.04          $119.60
     BEHV  -BEHV      BEHAVIORAL ASSESSMENT                        2          3           14.00        $1750.00          $125.00
     BEHV  -H0031HO   COMP BEHAVIORAL HEALTH ASSESSMENT           17         17           41.08        $5134.53          $125.00
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                    76         79           92.54        $4627.06           $50.00
     EXIT  -EXIT      TRANSITION ASSESSMENT                       52         62           80.64        $4032.15           $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 -IPDEF_NM  F/U PSYCH & DEV EVAL BY NON-MED PRO          1          1            1.00          $55.50           $55.50
     IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT              13         13           16.86        $1264.28           $75.00
     IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT                 1          1            1.00          $75.00           $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              31         31           39.86        $2212.07           $55.50
     IPDEI -IPDEI_NM  INITIAL PSYCH & DEV EVAL BY NON-MED         10         10           11.00         $610.50           $55.50
     IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT         255        255          362.14       $27160.72           $75.00
     IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT            67         69          101.00        $7575.00           $75.00
     IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT            76         76          107.03        $8027.50           $75.00
     IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS         259        267          399.14       $22152.43           $55.50
     IPDEI -T1024TL   INITIAL PSYCH AND DEV EVAL BY EI PR        231        254          347.00       $26025.00           $75.00
     OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP           47         49           62.44        $3028.25           $48.50
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL            271        297          339.19       $16450.51           $48.50
     PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP              58         60           60.00        $2910.00           $48.50
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL               228        251          251.88       $12216.40           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                 10         10           10.00         $500.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP                541        575          585.62       $28402.79           $48.50
     VISD  -VISD      VISION EVALUATION DIAGNOSTIC                 1          1            1.00         $100.00          $100.00
     VISF  -VISF      VISION EVALUATION FUNCTIONAL                 1          1            1.00          $50.00           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   1615       2919         3482.86      $197477.89           $56.70

    EI Services, Class # 03
     ASST  -ASST      ASSISTIVE TECHNOLOGY                        49         61           96.00      $144000.00         $1500.00
     AUD   -92630     AUD REHAB PRELING HEARING LOSS               1          1            1.00          $68.86           $68.86
     AUD   -HA_FUP    AUDIOLOGY SERVICES                          34         35           62.45        $3122.64           $50.00
     COIFF -COIFF     IFSP CONSULT, PROF, FACE TO FACE           271        462          827.17       $41358.34           $50.00
     COIFP -COIFP     IFSP CONSULT, PRO, BY PHONE                 11         12           12.70         $317.50           $25.00
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                 622        673         1086.36       $54318.02           $50.00
     CONIP -CONIP     CONSULT, ITDS, PHONE                        29         30           45.12        $1127.91           $25.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                  297        314          436.54       $21826.82           $50.00
     CONOP -CONOP     CONSULT, OT, PHONE                          15         15           17.45         $436.25           $25.00
     CONPF -CONPF     CONSULT, PT, FACE TO FACE                  251        259          416.63       $20831.68           $50.00
     CONPP -CONPP     CONSULT, PT, PHONE                          14         14           21.71         $542.71           $25.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 567        618          891.16       $44557.89           $50.00
     CONSP -CONSP     CONSULT, SLP, PHONE                         40         42           52.77        $1319.35           $25.00
     COUN  -H2019HR   INDIVIDUAL/FAMILY THERAPY                   14         15           21.14        $1552.20           $73.42
     ECE   -ECE       EARLY CHILDHOOD EDUCATION                    5          5         1207.71       $15096.43           $12.50
     EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                172        203         1163.92       $29097.91           $25.00
     EIIF  -96154     HEALTH AND BEHAVIOR INTERVENTION             4          4           42.14        $2107.15           $50.00
     EIIF  -EIIF_NM   EI INDIVIDUAL SESSION BY NONMED PRO          7          7           52.14        $2607.15           $50.00
     EIIF  -T1027HM   EI INDIVIDUAL SESSION BY PARAPROF            1          1           12.29         $307.14           $25.00
     EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF          1806       2073        11886.30      $594314.93           $50.00
     HERN  -T1027SC   EI HEARING SERVICES AFTER SHINE             25         27           93.38        $4668.97           $50.00
     INTR  -INTR      INTERPRETER                                 53         57          253.05       $12652.28           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                  841        957         4679.43      $317639.46           $67.88
     OCCT  -97530HM   OT SESSION BY OT ASST                       47         48          291.01       $15807.63           $54.32
     PHY   -97110     PT SESSION BY LICENSED PT                 1044       1199         5843.58      $396662.37           $67.88
     PHY   -97110HM   PT SESSION BY PT ASST                       48         50          300.03       $16297.36           $54.32
     SCONLY-SCONLY    SERVICE COORDINATION ONLY                   61         61           53.36          $53.36            $1.00
     SENS  -HA_EIP    ONE UNIT UP TO $500 PER AID                  7          7           11.00        $5500.00          $500.00
     SENS  -HA_INS    SENSORY AID INSURANCE PER EAR                5          5            1.32          $56.55           $43.00
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL             5          5            7.00        $1659.84          $237.12
     SENS  -V5264     EARMOLD                                     22         23           30.91         $578.66           $18.72
     SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL          32         40          125.30        $6264.90           $50.00
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP       1675       1937         9933.48      $674284.63           $67.88
     SPL   -92507HM   SPL THERAPY SESSION BY SLP ASST              3          3           21.14        $1148.48           $54.32
     SPL   -92508     GROUP SPL SESSION PER CHILD                 83         84          631.82        $8339.98           $13.20
     TRAN  -TRAN      FAMILY TRANSPORTATION                        6          6            9.13         $913.34          $100.00
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM       1295       1839       139040.38       $69520.19            $0.50
     VISN  -T1027SC   EI VISION SERVICES, INDIVIDUAL              35         47          187.96        $9397.81           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   3954      11239       179865.96     $2520356.61           $14.01

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                 14200       183378.98     $2718344.42           $14.82
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  4254