SNFData - 035192 - 12/2011

WESTMINSTER VILLAGE
SCOTTSDALE, AZ 85260

Medicare Provider Number: 035192

Cost report status: Settled Without Audit

[Record Code 1016105 - 2010]

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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS		Provider CCN: 035192	PERIOD: FROM 01/01/2011 TO 12/31/2011	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