PLEASANT VIEW
CONCORD, NH  03301

Medicare Provider Number: 305045
Cost report status: Settled Without Audit
[Record Code 198321 - 1996]

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PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA
PROVIDER NO:
305045
PERIOD FROM 10/01/2002
TO 09/30/2003
WORKSHEET S-7, PART IV
  GROUP (1) M3PI REV CODE SERVICES PRIOR TO October 1 SERVICES ON OR AFTER October 1 AIDS Diagnosis 042 Prior to 10/01 HIGH COST RUGs (2) TOTAL (see instructions)  
RATE DAYS RATE DAYS RATE DAYS DAYS
1 2 3 3.01 4 4.01 4.02 4.03 4.05 5
1 RUC   ###   1
2 RUB   ###   2
3 RUA   ###   3
3.01 RUX     3.01
3.02 RUL     3.02
4 RVC   ###   4
5 RVB   ###   5
6 RVA   ###   6
6.01 RVX     6.01
6.02 RVL     6.02
7 RHC   ### 7
8 RHB   ###   8
9 RHA   ###   9
9.01 RHX     9.01
9.02 RHL     9.02
10 RMC   ### 10
11 RMB   ### 11
12 RMA   ###   12
12.01 RMX     12.01
12.02 RML     12.02
13 RLB     13
14 RLA     14
14.01 RLX     14.01
15 SE3   ### 15
16 SE2   ### 16
17 SE1   ### 17
18 SSC   ### 18
19 SSB   ### 19
20 SSA   ### 20
21 CC2   ### 21
22 CC1   22
23 CB2   ### 23
24 CB1   ### 24
25 CA2   ### 25
26 CA1   ### 26
27 IB2   ###   27
28 IB1   ### 28
29 IA2   ###   29
30 IA1   ###   30
31 BB2     31
32 BB1     32
33 BA2     33
34 BA1     34
35 PE2     35
36 PE1   ###   36
37 PD2     37
38 PD1   ###   38
39 PC2     39
40 PC1   ###   40
41 PB2   ###   41
42 PB1   ###   42
43 PA2   ###   43
44 PA1   ###   44
45 Default rate   ### 45
46 TOTAL     ###   46