SNFData - 115612 - 06/2012

WARNER ROBINS REHABILITATION CENTER
WARNER ROBINS, GA 31093

Medicare Provider Number: 115612

Cost report status: Settled Without Audit

[Record Code 1050734 - 2010]

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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS		Provider CCN: 115612	PERIOD: FROM 07/01/2011 TO 06/30/2012	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