SNFData - 525276 - 12/2004 - Worksheet D, Part I

ST MARYS CARE CENTER
MADISON, WI 53719

Medicare Provider Number: 525276

Cost report status: Settled Without Audit

[Record Code 230981 - 1996]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST COSTS							PROVIDER NO: 525276	PERIOD: FROM 01/01/2004 TO 12/31/2004		WORKSHEET D Part I
SNF - SNF Medicare - Title XVIII
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST
Cost Center		RATIO OF COST TO CHARGES (Fr. Wkst. C Column 3)	HEALTH CARE PROGRAM CHARGES		HEALTH CARE PROGRAM COST		TITLE XVIII CHARGES ON AND AFTER 1/1/1998	PART B THERAPY COSTS ON AND AFTER 1/1/1998 Col. 1 X 6)	10% REDUCTION OF THERAPY (Col. 7 X 10%)	NET ALLOWABLE PART B COSTS Col. 5 less Col. 8)
		RATIO OF COST TO CHARGES (Fr. Wkst. C Column 3)	Part A	Part B	Part A (Col. 1 X Col. 2)	Part B (Col. 1 X Col. 3)	TITLE XVIII CHARGES ON AND AFTER 1/1/1998	PART B THERAPY COSTS ON AND AFTER 1/1/1998 Col. 1 X 6)	10% REDUCTION OF THERAPY (Col. 7 X 10%)	NET ALLOWABLE PART B COSTS Col. 5 less Col. 8)
		1	2	3	4	5	6	7	8	9
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 To Patients		###		###						29
30	Drugs Charged to Patients		###		###						30
31	Dental Care - Title XIX										31
32	Support Surfaces										32
33	Other Ancillary Services										33
OUTPATIENT COST CENTERS
34	Clinic										34
35	R H C										35
36	Other Outpatient Services										36
48	Ambulance (2)										48
75	Total (Sum of lines 21 - 48)		###		###						75
(1) For titles V and XIX use columns 1, 2 and 4 only.
(2) Line 48 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.