SNFData - 065221 - 12/2022

CREEKSIDE VILLAGE HEALTH & REHAB
FT. COLLINS, CO 80525

Medicare Provider Number: 065221

Cost report status: As Submitted

[Record Code 1350020 - 2010]

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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS		Provider CCN: 065221	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