SNFData - 055206 - 12/2003 - Worksheet D, Part II

COUNTRY VILLA PLAZA H C
LOS ANGELES, CA 92707-

Medicare Provider Number: 055206

Cost report status: As Submitted

[Record Code 179568 - 1996]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST FOR TITLE XVIII			PROVIDER NO: 055206	PERIOD: FROM 01/01/2003 TO 12/31/2003		WORKSHEET D Part II
SNF - SNF Medicare - Title XVIII
PART II - APPORTIONMENT OF VACCINE COST
1	Drugs charged to patients - ratio of cost to charges (From Worksheet C, column 3, line 30)					###	1
2	Program vaccine charges (From your records, or the P S & R.)						2
3	Program costs (Line 1 X line 2) (Title XVIII, PPS providers, transfer this amount to Worksheet E, Part III, line 20)						3
PART III - CALCULATION OF PASS THROUGH COSTS FOR INTERNS & RESIDENTS
Cost Centers		Total Cost (From Worksheet B, Part I, Col 18)	Intern and Residents Costs (From Wkst. B, Part I, Column 14)	Ratio of Intern & Residents Costs To Total Costs - Part A (Col. 2 / Col.. 1)	Program Part A Cost (From Wkst. D. Part 1, Col. 4)	Program Intern & Residents Costs for Pass Through (Col. 3 X Col. 4)
Cost Centers		1	2	3	4	5
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						29
30	Drugs Charged to Patients						30
31	Dental Care - Title XIX only						31
32	Support Surfaces						32
33	Other Ancillary Service Costs						33
75	Total (Sum of lines 21 - 33)						75