     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

    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          24         24           14.95           $0.00            $0.00
     SCTT  -SCTT      SERVICE COORDINATOR TRAVEL                  21         23           18.00         $666.00           $37.00
     TCM   -T1017TL   TARGETED CASE MANAGEMENT                     1          1            2.77         $102.37           $37.00
     TCON  -TCON      TRANSITION CONFERENCE                        3          3            3.00           $0.00            $0.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                     35         51           38.71         $768.37           $19.85

    Screening, Eval, and Assessment, Class # 02
     ASTE  -ASTE      ASSISTIVE TECHNOLOGY EVAL                   39         41           43.00        $2085.50           $48.50
     AUD   -92626     EVAL OF AUD REHAB STATUS                    23         23           25.00         $901.75           $36.07
     AUDE  -92552     PURE TONE AUDIOMETRY -AIR ONLY             102        103          103.00        $1093.86           $10.62
     AUDE  -92553     PURE TONE AUDIOMETRY AIR & BONE              4          4            4.00          $65.20           $16.30
     AUDE  -92555     SPEECH AUD THRESHOLD (DETECTION)           100        101          101.00         $891.83            $8.83
     AUDE  -92557     COMP AUDIO THRESHOLD EVAL/SPCH RECO          2          2            2.00          $54.20           $27.10
     AUDE  -92567     TYPMANOMETRY (IMPEDANCE TESTING)           102        103          103.00        $1112.40           $10.80
     AUDE  -92579     VISUAL REINFORCEMENT AUDIOMETRY             95         96           96.00        $2091.84           $21.79
     AUDE  -92585     AUD EVOKED RESPONSE (DIAG)                   1          1            1.00          $54.38           $54.38
     AUDE  -92587     OTOACOUSTIC EMISSIONS (LIMITED)             89         90           90.00        $2545.20           $28.28
     AUDE  -92588     OTOACOUSTIC EMISSIONS (COMP)                 1          1            1.00          $31.81           $31.81
     AUDE  -92682     CONDITIONED PLAY AUDIOMETRY                  2          2            2.00          $42.68           $21.34
     AUDE  -AUDE      UNSPECIFIED AUDE SERVICES                  169        187          194.20       $11652.25           $60.00
     AUDE  -V5010     ASSESSMENT FOR HEARING AID                  38         41           42.35        $1981.98           $46.80
     AUDE  -V5090     DISPENSING FEE PER HEARING AID             159        162          185.56       $22192.45          $119.60
     BEHV  -90801     PSYCHIATRIC DIAG INTERVIEW                   1          1           11.29        $1410.71          $125.00
     BEHV  -BEHV      BEHAVIORAL ASSESSMENT                        7          7           10.70        $1337.50          $125.00
     BEHV  -H0031HO   COMP BEHAVIORAL HEALTH ASSESSMENT           34         34           41.29        $5160.73          $125.00
     EVAL  -EVAL      DEVELOPMENTAL EVALUATION                    61         62           81.03        $4051.35           $50.00
     EXIT  -EXIT      TRANSITION ASSESSMENT                       89         95          152.54        $7626.79           $50.00
     FANE  -FANE      FAMILY INTERVIEW BY COMMUNITY PROVI          6          6            6.00         $180.00           $30.00
     IPDEF -IPDEF     FOLLOW-UP PSYCH AND DEV EVAL                 3          4            4.50         $337.50           $75.00
     IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT              32         32           47.07        $3530.36           $75.00
     IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT                 4          4            6.50         $487.50           $75.00
     IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT                 5          5            9.50         $712.50           $75.00
     IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF           10         10           14.07        $1055.36           $75.00
     IPDEF -T1024TS   F/U PSYCH AND DEV EVAL BY ITDS              38         39           53.00        $2941.50           $55.50
     IPDEI -IPDEI_NM  INITIAL PSYCH & DEV EVAL BY NON-MED         17         17           31.00        $1720.50           $55.50
     IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT         481        484          735.43       $55157.15           $75.00
     IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT            98         98          145.50       $10912.50           $75.00
     IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT           151        152          254.64       $19098.22           $75.00
     IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS         452        452          697.32       $38701.22           $55.50
     IPDEI -T1024TL   INITIAL PSYCH AND DEV EVAL BY EI PR        405        464          711.36       $53351.79           $75.00
     MED   -99205     OUTPATIENT VISIT, NEW, 60 MINS               4          4            6.00         $436.68           $72.78
     NURS  -NURS      NURSING ASSESSMENT                           4          4            2.80         $140.00           $50.00
     NUTR  -NUTR      UNSPECIFIED NUTRITIONAL EVAL                 2          2            2.00         $100.00           $50.00
     OCTF  -97004     OT EVAL BY LICENSED OT, FOLLOW-UP          102        104          102.24        $4958.59           $48.50
     OCTH  -97003     OT EVAL BY LICENSED OT, INITIAL            514        552          567.84       $27540.30           $48.50
     PSTF  -97002     EVAL BY LICENSED PT, FOLLOW-UP              91         98          105.76        $5129.45           $48.50
     PSTH  -97001     EVAL BY LICENSED PT, INITIAL               336        361          394.14       $19115.66           $48.50
     SCREEN-T1023     INTERDISCIPLINARY SCREENING                 21         21           20.73        $1036.67           $50.00
     SPCH  -92506     SPEECH EVAL BY LICENSED SLP               1092       1147         1209.06       $58639.46           $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)                   3014       5220         6425.41      $372467.30           $57.97

    EI Services, Class # 03
     ASST  -ASST      ASSISTIVE TECHNOLOGY                       105        113          147.71      $221571.45         $1500.00
     AUD   -92630     AUD REHAB PRELING HEARING LOSS               1          1            0.56          $38.26           $68.86
     AUD   -HA_FUP    AUDIOLOGY SERVICES                         130        138          235.27       $11763.68           $50.00
     COIFF -COIFF     IFSP CONSULT, PROF, FACE TO FACE           616        929         1523.61       $76180.72           $50.00
     COIFP -COIFP     IFSP CONSULT, PRO, BY PHONE                 39         40           34.00         $849.94           $25.00
     CONIF -CONIF     CONSULT ITDS, FACE TO FACE                1126       1186         2090.49      $104524.59           $50.00
     CONIP -CONIP     CONSULT, ITDS, PHONE                        57         58          110.21        $2755.28           $25.00
     CONOF -CONOF     CONSULT, OT, FACE TO FACE                  536        586          879.43       $43971.30           $50.00
     CONOP -CONOP     CONSULT, OT, PHONE                          28         29           64.90        $1622.48           $25.00
     CONPF -CONPF     CONSULT, PT, FACE TO FACE                  365        385          664.63       $33231.68           $50.00
     CONPP -CONPP     CONSULT, PT, PHONE                          27         28           44.87        $1121.67           $25.00
     CONSF -CONSF     CONSULT, SLP, FACE TO FACE                1261       1336         2044.38      $102219.20           $50.00
     CONSP -CONSP     CONSULT, SLP, PHONE                         83         91          124.91        $3122.78           $25.00
     COUN  -H2019HR   INDIVIDUAL/FAMILY THERAPY                   13         13           67.01        $4919.84           $73.42
     ECE   -ECE       EARLY CHILDHOOD EDUCATION                    4          4          412.57        $5157.14           $12.50
     EIGF  -EIGF_NM   EI GROUP SESSION BY NONMED PROF              2          3            3.83          $95.83           $25.00
     EIGF  -T1027TTSC EI GROUP SESSION BY EI PROF                223        240         1660.09       $41502.27           $25.00
     EIIF  -96154     HEALTH AND BEHAVIOR INTERVENTION             7          7           44.14        $2207.15           $50.00
     EIIF  -COUN      UNSPECIFIED COUNSELING                       2          2           11.80         $590.24           $50.00
     EIIF  -EIIF_NM   EI INDIVIDUAL SESSION BY NONMED PRO         12         13          102.43        $5121.44           $50.00
     EIIF  -T1027HM   EI INDIVIDUAL SESSION BY PARAPROF            6          7           38.71         $967.86           $25.00
     EIIF  -T1027SC   EI INDIVIDUAL SESSION BY EI PROF          3152       3481        22009.87     $1100493.55           $50.00
     HERN  -EIIF_NM   EI HEARING SERVICES AFTER SHINE NON          1          1            2.53         $126.67           $50.00
     HERN  -T1027SC   EI HEARING SERVICES AFTER SHINE             38         42          122.82        $6141.16           $50.00
     INTR  -INTR      INTERPRETER                                 67         72          340.57       $17028.70           $50.00
     OCCT  -97530     OT SESSION BY LICENSED OT                 1711       1935        10764.70      $730707.66           $67.88
     OCCT  -97530HM   OT SESSION BY OT ASST                      157        166          674.45       $36636.00           $54.32
     PHY   -97110     PT SESSION BY LICENSED PT                 1660       1868        10017.09      $679959.86           $67.88
     PHY   -97110HM   PT SESSION BY PT ASST                      132        135          540.82       $29377.32           $54.32
     SCONLY-SCONLY    SERVICE COORDINATION ONLY                  280        283          287.29         $287.29            $1.00
     SENS  -FM        FM RECEIVER HEARING AID                      7          7            8.00       $13200.00         $1650.00
     SENS  -HA_EIP    ONE UNIT UP TO $500 PER AID                 28         29           40.72       $20361.10          $500.00
     SENS  -HA_INS    SENSORY AID INSURANCE PER EAR               11         11            9.43         $612.96           $65.00
     SENS  -V5014     HEARING AID REPAIR BY MANUFACTURER           3          3            5.00         $570.00          $114.00
     SENS  -V5050     MED HEARING AID - ANALOG/DIGITAL            11         13           26.00        $6165.12          $237.12
     SENS  -V5264     EARMOLD                                     61         67           99.63        $1865.11           $18.72
     SHIN  -T1027SC   INITIAL SHINE SERVICES, INDIVIDUAL          48         50          242.37       $12118.70           $50.00
     SIC   -SIC       SPECIAL INSTRUCTION CONSULTATION             1          1           11.86         $592.86           $50.00
     SPL   -92507     SPL THERAPY SESSION BY LICENSED SLP       3788       4346        24229.55     $1644701.58           $67.88
     SPL   -92507HM   SPL THERAPY SESSION BY SLP ASST              8          9           44.19        $2400.55           $54.32
     SPL   -92508     GROUP SPL SESSION PER CHILD                290        296         1733.52       $22882.48           $13.20
     TRAN  -TRAN      FAMILY TRANSPORTATION                       11         13           59.37        $5936.66          $100.00
     TRAV  -TRAV      PROVIDER TRAVEL TO NATURAL ENVIRONM       2576       3467       275833.02      $137916.50            $0.50
     VISN  -T1027SC   EI VISION SERVICES, INDIVIDUAL              54         58          284.14       $14206.92           $50.00
                                                             --------------------------------------------------------------------
    Subtotal (Total Children Is Unduplicated)                   7768      21562       357692.52     $5147823.49           $14.39

    -----------------------------------------------------------------------------------------------------------------------------
    Total                                                                 26833       364156.64     $5521059.16           $15.16
    -----------------------------------------------------------------------------------------------------------------------------

    Number of Children (Unduplicated) With at Least One Authorization  8235