SNFData - 525276 - 12/2005

ST MARYS CARE CENTER
MADISON, WI 53719

Medicare Provider Number: 525276

Cost report status: Settled Without Audit

[Record Code 276640 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 525276	PERIOD: FROM 01/01/2005 TO 12/31/2005	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