Worksheet C
- Return to Cost Report Summary
- Form C000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3527, REV 10
ACCORDIUS HEALTH AT LYNCHBURG LLC
LYNCHBURG, VA 24501-1443
LYNCHBURG, VA 24501-1443
Medicare Provider Number: 495151
Cost report status: Settled Without Audit
[Record Code 1346266 - 2010]
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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS | Provider CCN: 495151 | PERIOD: FROM 01/01/2021 TO 12/31/2021 |
WORKSHEET C | ||
Cost Center Description | Total ( from Wkst. B, Pt. I, col. 18 ) | Total Charges | Ratio ( col. 1 divided by col. 2 ) | ||
1 | 2 | 3 | |||
ANCILLARY SERVICE COST CENTERS | |||||
40 | Radiology | 40 | |||
41 | Laboratory | ### | 41 | ||
42 | Intravenous Therapy | 42 | |||
43 | Oxygen (Inhalation) Therapy | 43 | |||
44 | Physical Therapy | ### | ### | ### | 44 |
45 | Occupational Therapy | ### | ### | ### | 45 |
46 | Speech Pathology | ### | ### | ### | 46 |
47 | Electrocardiology | 47 | |||
48 | Medical Supplies Charged to Patients | 48 | |||
49 | Drugs Charged to Patients | ### | ### | ### | 49 |
50 | Dental Care - Title XIX only | 50 | |||
51 | Support Surfaces | 51 | |||
52 | Other Ancillary Service Cost | 52 | |||
OUTPATIENT SERVICE COST CENTERS | |||||
60 | Clinic | 60 | |||
61 | Rural Health Clinic (RHC) | 61 | |||
62 | FQHC | 62 | |||
63 | Other Outpatient Service Cost | 63 | |||
71 | Ambulance | 71 | |||
100 | Total | ### | ### | 100 | |
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4123) | |||||
05-11 | Rev. 1 |