SNFData - 235401 - 04/2008

CLARK RETIREMENT COMMUNITY
GRAND RAPIDS, MI 49506

Medicare Provider Number: 235401

Cost report status: Settled Without Audit

[Record Code 336553 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 235401	PERIOD: FROM 05/01/2007 TO 04/30/2008	WORKSHEET C
Cost Center		TOTAL (From Wkst B, Pt. I, Col. 18)	Total Charges	Ratio (col. 1 ÷ col. 2)
Cost Center		1	2	3
ANCILLARY SERVICE COST CENTERS
21	Radiology		###		21
22	Laboratory	###	###	###	22
23	Intravenous Therapy				23
24	Oxygen ( Inhalation ) Therapy	###			24
25	Physical Therapy	###	###	###	25
26	Occupational Therapy				26
27	Speech Pathology				27
28	Electrocardiology				28
29	Medical Supplies Charged	###	###	###	29
30	Drugs Charged to Patients				30
31	Dental Care - Title XIX only				31
32	Support Surfaces				32
33	Other Ancillary Service Cost				33
OUTPATIENT SERVICE COST CENTERS
34	Clinic				34
35	R H C				35
36	Other Outpatient Service Cost				36
48	Ambulance				48
75	Total	###	###		75

Worksheet C