     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: 10/01/08 and 12/31/08                  Date of Report: 02-16-09                  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
     IFSP  -IFSP      INDIVIDUALIZED FAMILY SUPPORT PLAN          11         11            6.40           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                   4          4            4.00         $148.00           $37.00
     TCON  -TCON      TRANSITION CONFERENCE                        3          3            3.00           $0.00            $0.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     13         18           13.40         $148.00           $11.04

    Screening, Eval, and Assessment, Class # 02
     ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   27         29           31.00        $1503.50           $48.50
     AUD   -92626     EVAL OF AUD REHAB STATUS                    12         12           13.00         $468.91           $36.07
     AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY              59         59           59.00         $626.58           $10.62
     AUDE  -92553     PURE TONE AUDIOMETRY AIR & BONE              1          1            1.00          $16.30           $16.30
     AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)            58         58           58.00         $512.14            $8.83
     AUDE  -92557     COMP AUDIO THRESHOLD EVAL/SPCH RECO          1          1            1.00          $27.10           $27.10
     AUDE  -92567     TYPMANOMETRY (IMPEDANCE TESTING)            57         57           57.00         $615.60           $10.80
     AUDE  -92579     VISUAL REINFORCEMENT AUDIOMETRY             53         53           53.00        $1154.87           $21.79
     AUDE  -92585     AUD EVOKED RESPONSE (DIAG)                   1          1            1.00          $54.38           $54.38
     AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)             52         52           52.00        $1470.56           $28.28
     AUDE  -92682     CONDITIONED PLAY AUDIOMETRY                  1          1            1.00          $21.34           $21.34
     AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                  102        115          115.21        $6912.34           $60.00
     AUDE  -V5010     ASSESSMENT FOR HEARING AID                  16         18           20.03         $937.56           $46.80
     AUDE  -V5090     DISPENSING FEE PER HEARING AID              85         87           95.56       $11428.45          $119.60
     BEHV  -90801     PSYCHIATRIC DIAG INTERVIEW                   1          1           11.29        $1410.71          $125.00
     BEHV  -BEHV      BEHAVIORAL ASSESSMENT                        6          6            9.70        $1212.50          $125.00
     BEHV  -H0031HO   COMP BEHAVIORAL HEALTH ASSESSMENT           21         21           27.14        $3392.86          $125.00
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                    44         44           60.36        $3018.02           $50.00
     EXIT  -EXIT      TRANSITION ASSESSMENT                       44         45           76.04        $3801.79           $50.00
     IPDEF -IPDEF     FOLLOW-UP PSYCH AND DEV EVAL                 2          3            3.00         $225.00           $75.00
     IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT              13         13           17.57        $1317.86           $75.00
     IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT                 2          2            3.00         $225.00           $75.00
     IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT                 3          3            6.00         $450.00           $75.00
     IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF            4          4            4.57         $342.86           $75.00
     IPDEF -T1024TS   F/U PSYCH AND DEV EVAL BY ITDS              18         18           25.00        $1387.50           $55.50
     IPDEI -IPDEI_NM  INITIAL PSYCH & DEV EVAL BY NON-MED          9          9           16.00         $888.00           $55.50
     IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT         243        243          373.00       $27975.00           $75.00
     IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT            45         45           66.50        $4987.50           $75.00
     IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT            97         98          168.64       $12648.22           $75.00
     IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS         274        274          409.89       $22748.92           $55.50
     IPDEI -T1024TL   INITIAL PSYCH AND DEV EVAL BY EI PR        216        237          358.36       $26876.79           $75.00
     OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP           37         39           38.07        $1846.24           $48.50
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL            246        266          274.98       $13336.73           $48.50
     PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP              45         46           52.43        $2542.79           $48.50
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL               186        196          227.11       $11014.74           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                  3          3            3.00         $150.00           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP                525        546          591.25       $28675.43           $48.50
     VISD  -VISD      VISION EVALUATION DIAGNOSTIC                 2          2            7.00         $700.00          $100.00
     VISF  -VISF      VISION EVALUATION FUNCTIONAL                 2          2            2.00         $100.00           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   1565       2710         3389.69      $197024.06           $58.12

    EI Services, Class # 03
     ASST  -ASST      ASSISTIVE TECHNOLOGY                        41         44           47.00       $70500.00         $1500.00
     AUD   -92630     AUD REHAB PRELING HEARING LOSS               1          1            0.56          $38.26           $68.86
     AUD   -HA_FUP    AUDIOLOGY SERVICES                          44         47           95.88        $4793.82           $50.00
     COIFF -COIFF     IFSP CONSULT, PROF, FACE TO FACE           281        434          719.08       $35953.93           $50.00
     COIFP -COIFP     IFSP CONSULT, PRO, BY PHONE                 12         12            6.82         $170.42           $25.00
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                 593        624         1077.57       $53878.38           $50.00
     CONIP -CONIP     CONSULT, ITDS, PHONE                        27         27           48.43        $1210.83           $25.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                  272        297          447.50       $22375.20           $50.00
     CONOP -CONOP     CONSULT, OT, PHONE                          11         12           17.26         $431.46           $25.00
     CONPF -CONPF     CONSULT, PT, FACE TO FACE                  205        212          384.41       $19220.59           $50.00
     CONPP -CONPP     CONSULT, PT, PHONE                          15         16           19.15         $478.75           $25.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                 643        687         1008.41       $50420.57           $50.00
     CONSP -CONSP     CONSULT, SLP, PHONE                         40         45           57.62        $1440.53           $25.00
     COUN  -H2019HR   INDIVIDUAL/FAMILY THERAPY                    5          5           25.71        $1887.95           $73.42
     ECE   -ECE       EARLY CHILDHOOD EDUCATION                    1          1          385.71        $4821.43           $12.50
     EIGF  -EIGF_NM   EI GROUP SESSION BY NONMED PROF              1          1            2.10          $52.50           $25.00
     EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                130        141          939.54       $23488.58           $25.00
     EIIF  -96154     HEALTH AND BEHAVIOR INTERVENTION             2          2            6.86         $342.86           $50.00
     EIIF  -COUN      UNSPECIFIED COUNSELING                       1          1            0.23          $11.67           $50.00
     EIIF  -EIIF_NM   EI INDIVIDUAL SESSION BY NONMED PRO          9          9           78.14        $3907.15           $50.00
     EIIF  -T1027HM   EI INDIVIDUAL SESSION BY PARAPROF            4          4           18.29         $457.15           $25.00
     EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF          1789       1963        12096.84      $604841.85           $50.00
     HERN  -T1027SC   EI HEARING SERVICES AFTER SHINE             25         27           90.04        $4501.98           $50.00
     INTR  -INTR      INTERPRETER                                 57         61          298.57       $14928.70           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                  841        944         5122.82      $347737.22           $67.88
     OCCT  -97530HM   OT SESSION BY OT ASST                       69         73          294.56       $16000.48           $54.32
     PHY   -97110     PT SESSION BY LICENSED PT                  941       1043         5503.30      $373564.14           $67.88
     PHY   -97110HM   PT SESSION BY PT ASST                       76         78          268.28       $14572.78           $54.32
     SCONLY-SCONLY    SERVICE COORDINATION ONLY                  200        202          193.17         $193.17            $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                  7          7            9.50        $4750.00          $500.00
     SENS  -HA_INS    SENSORY AID INSURANCE PER EAR                7          7            7.04         $457.67           $65.00
     SENS  -V5014     HEARING AID REPAIR BY MANUFACTURER           2          2            3.00         $342.00          $114.00
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL             7          9           18.00        $4268.16          $237.12
     SENS  -V5264     EARMOLD                                     24         29           53.88        $1008.59           $18.72
     SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL          33         35          114.34        $5717.03           $50.00
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP       1670       1890        10294.17      $698768.12           $67.88
     SPL   -92507HM   SPL THERAPY SESSION BY SLP ASST              3          3           25.02        $1359.03           $54.32
     SPL   -92508     GROUP SPL SESSION PER CHILD                147        151          901.17       $11895.42           $13.20
     TRAN  -TRAN      FAMILY TRANSPORTATION                        6          7           38.25        $3824.76          $100.00
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM       1389       1856       139781.81       $69890.90            $0.50
     VISN  -T1027SC   EI VISION SERVICES, INDIVIDUAL              32         34          175.00        $8750.12           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   4026      11044       180676.03     $2484904.13           $13.75

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                 13772       184079.12     $2682076.18           $14.57
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  4287