Worksheet B Part I

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HIGLEY HEALTHCARE INC.
MESA, AZ  85206

Medicare Provider Number: 035103
Cost report status: Settled Without Audit
[Record Code 1325700 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 035103
PERIOD:
FROM 01/01/2021
TO 12/31/2021
 WORKSHEET B PART I
Cost Center Description Net Expenses for Cost Allocation (from Wkst. A, col. 7) Cap. Rel Buildings & Fixtures Cap. Rel Movable Equipment Employee Benefits Subtotal (Sum of cols. 0 - 3) Administrative & General Plant Oper. Maintenance & Repairs Laundry & Linen Service House Keeping Dietary Nursing Administration Central Services & Supply Pharmacy Medical Records & Library Social Service Nursing & Allied Health Education Other General Service Cost Subtotal Post Step-down Adjustments Total  
0 1 2 3 3 A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS                                          
1 Capital-Related Costs - Buildings & Fixtures 1,017,019 ###                                     1
2 Capital-Related Costs - Moveable Equipment 82,373 ###                                   2
3 Employee Benefits 352,188 ### ### ###                               3
4 Administrative and General 2,593,302 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 313,971 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 111,264 ### ### ### ### ### ### ###                         6
7 Housekeeping 251,407 ### ### ### ### ### ### ###                       7
8 Dietary 584,658 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 253,456 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 120,184 ### ### ### ### ### ### ### ###             12
13 Social Service 602,068 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,150,225 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 47,643 ### ### ### ### ### 40
41 Laboratory 96,429 ### ### ### ### ### 41
42 Intravenous Therapy 24,212 ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 472,543 ### ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 443,371 ### ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 152,298 ### ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 65,252 ### ### ### ### ### 48
49 Drugs Charged to Patients 436,011 ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 42,304 ### ### ### ### ### 51
52 Other Ancillary Service Cost 36,359 ### ### ### ### 52
OUTPATIENT SERVICE COST CENTERS                                          
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
OTHER REIMBURSABLE COST CENTERS                                          
70 Home Health Agency Cost 70
71 Ambulance 71
72 Outpatient Rehabilitation (specify) 72
73 CMHC 73
74 Other Reimbursable Cost 74
SPECIAL PURPOSE COST CENTERS                                          
83 Hospice 83
84 Other Special Purpose Cost 84
89 Subtotals 12,248,537 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 12,248,537 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7