SNFData - 315485 - 12/2011

CARE ONE AT WALL
WALL, NJ 07719

Medicare Provider Number: 315485

Cost report status: Settled Without Audit

[Record Code 1028642 - 2010]

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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS		Provider CCN: 315485	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