Worksheet S-7, Part I

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STONEYBROOK RETIREMENT COMMUNITY
MANHATTAN, KS  66502-

Medicare Provider Number: 175191
Cost report status: Settled Without Audit
[Record Code 87307 - 1996]
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NHCMQ DEMONSTRATION AND PPS STATISTICAL DATA
PROVIDER NO:
175191
PERIOD:
FROM 01/01/1998
TO 12/31/1998
WORKSHEET S-7 Part I
PART I - NHCMQ DEMONSTRATION STATISTICAL DATA
FOR COST REPORTING PERIODS BEGINNING PRIOR TO JULY 1, 1998
  GROUP
M3PI
REVENUE
CODE
 SERVICES PRIOR TO JANUARY 1ST (1) SERVICES ON OR AFTER JANUARY 1ST (1)
TOTAL
(See Instructions)
  
RATE DAYS RATE DAYS
1 2 3 3.01 4 4.01 5
1 RVC 9044 ### ### ### ### 1
2 RVB 9043 ### ### ### ### 2
3 RVA 9042 ### ### ### ### 3
4 RHD 9041 ### ### ### ### 4
5 RHC 9040 ### ### ### ### 5
6 RHB 9039 ### ### ### ### 6
7 RHA 9038 ### ### ### ### 7
8 RMC 9037 ### ### ### ### 8
9 RMB 9036 ### ### ### ### 9
10 RMA 9035 ### ### ### ### 10
11 RLB 9034 ### ### ### ### 11
12 RLA 9033 ### ### ### ### 12
13 SE3 9032 ### ### ### ### 13
14 SE2 9031 ### ### 14
15 SE1 9030 ### ### ### ### 15
16 SSC 9029 ### ### ### ### 16
17 SSB 9028 ### ### 17
18 SSA 9027 ### ### 18
19 CD2 9026 ### ### ### ### 19
20 CD1 9025 ### ### 20
21 CC2 9024 ### ### 21
22 CC1 9023 ### ### ### ### 22
23 CB2 9022 ### ### 23
24 CB1 9021 ### ### 24
25 CA2 9020 ### ### ### ### 25
26 CA1 9019 ### ### ### ### 26
27 IB2 9018 ### ### 27
28 IB1 9017 ### ### ### ### 28
29 IA2 9016 ### ### 29
30 IA1 9015 ### ### ### ### 30
31 BB2 9014 ### ### 31
32 BB1 9013 ### ### 32
33 BA2 9012 ### ### 33
34 BA1 9011 ### ### 34
35 PE2 9010 ### ### 35
36 PE1 9009 ### ### 36
37 PD2 9008 ### ### 37
38 PD1 9007 ### ### 38
39 PC2 9006 ### ### 39
40 PC1 9005 ### ### 40
41 PB2 9004 ### ### 41
42 PB1 9003 ### ### 42
43 PA2 9002 ### ### 43
44 PA1 9001 ### ### ### ### 44
45 Other Group 9000 ### ### 45
46 TOTAL       ### ### 46
(1) Calendar Year Providers: Complete columns 1, 2, 4, 4.01, and 5
Fiscal Year Providers - Rate change as of January 1st: Complete ALL columns.
Fiscal Year Providers - Rate DOES NOT change as of January 1st: Complete columns 1, 2, 3, 3.01, and 5.