SNFData - 315449 - 12/2022

ALARIS HEALTH AT WEST ORANGE
WEST ORANGE, NJ 07052

Medicare Provider Number: 315449

Cost report status: As Submitted

[Record Code 1355893 - 2010]

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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS		Provider CCN: 315449	PERIOD: FROM 01/01/2022 TO 12/31/2022	WORKSHEET C
Cost Center Description		Total ( from Wkst. B, Pt. I, col. 18 )	Total Charges	Ratio ( col. 1 divided by col. 2 )
Cost Center Description		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

Worksheet C