SNFData - 325060 - 12/2009

PALOMA BLANCA HEALTH AND REHAB
ALBUQUERQUE, NM 87102

Medicare Provider Number: 325060

Cost report status: Settled Without Audit

[Record Code 381192 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 325060	PERIOD: FROM 01/01/2009 TO 12/31/2009	WORKSHEET C
Cost Center		TOTAL (From Wkst B, Pt. I, Col. 18)	Total Charges	Ratio (col. 1 ÷ col. 2)
Cost Center		1	2	3
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	###	###	###	29
30	Drugs Charged to Patients	###	###	###	30
31	Dental Care - Title XIX only				31
32	Support Surfaces	###	###	###	32
33	Other Ancillary Service Cost	###	###	###	33
OUTPATIENT SERVICE COST CENTERS
34	Clinic				34
35	R H C				35
36	Other Outpatient Service Cost				36
48	Ambulance				48
75	Total	###	###		75

Worksheet C