Worksheet C
- Return to Cost Report Summary
- Form C000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3527, REV 10
THE JEFFERSON
ARLINGTON, VA 22203
ARLINGTON, VA 22203
Medicare Provider Number: 495269
Cost report status: Settled Without Audit
[Record Code 96092 - 1996]
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RATIO OF COST TO CHARGES | PROVIDER NO: 495269 |
PERIOD: FROM 01/01/1997 TO 12/31/1997 |
WORKSHEET C |
||
Cost Center | TOTAL (From Wkst B, Pt. I, Col. 18) | Total Charges | Ratio (col. 1 ÷ col. 2) | ||
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 |