SNFData - 015429 - 06/2002

SEA BREEZE HEALTH CARE CENTER
MOBILE, AL 36603-

Medicare Provider Number: 015429

Cost report status: Settled Without Audit

[Record Code 169268 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 015429	PERIOD: FROM 07/01/2001 TO 06/30/2002	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