SNFData - 676411 - 08/2017

CLARENDON NURSING HOME
CLARENDON, TX 79226

Medicare Provider Number: 676411

Cost report status: Settled Without Audit

[Record Code 1188674 - 2010]

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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS		Provider CCN: 676411	PERIOD: FROM 02/02/2017 TO 08/31/2017	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