BLUE RIDGE NURSING CENTER
STUART, VA  24171

Medicare Provider Number: 495306
Cost report status: Settled Without Audit
[Record Code 1052767 - 2010]

You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').

If you would like to become a subscriber, please look at our subscription details.

If you are already a subscriber, please login.

APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST Provider CCN: 495306
PERIOD:
FROM 01/01/2012
TO 12/31/2012
WORKSHEET D
PARTS II & III
TITLE XVIII ONLY
 
PART II - APPORTIONMENT OF VACCINE COST
1 Drugs charged to patients - ratio of cost to charges (from Wkst. C, col. 3, line 49) ### 1
2 Program vaccine charges (From your records or the PS&R report) ### 2
3 Program costs (line 1 x line 2) (Title XVIII, PPS providers, transfer this amount to Wkst. E, Pt. I, line 18) ### 3
 
PART III - CALCULATION OF PASS THROUGH COSTS FOR NURSING & ALLIED HEALTH
Cost Center Description Total Cost (from Wkst. B, Pt. I, col. 18) Nursing & Allied Health (from Wkst. B, Pt. I, col. 14) Ratio of Nursing & Allied Health Costs to Total Costs - Part A (col. 2 / col. 1) Program Part A Cost (from Wkst. D., Pt. I, col. 4) Part A Nursing & Allied Health Costs for Pass Through (col. 3 x col. 4)  
1 2 3 4 5  
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
100 Total (sum of lines 40 - 52) ###   ### 100
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124.1)
03-18   Rev. 8