Worksheet C
- Return to Cost Report Summary
- Form C000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3527, REV 10
VICTORY MEMORIAL HOSPITAL SNC
NY, NY 11228
NY, NY 11228
Medicare Provider Number: 335710
Cost report status: Settled Without Audit
[Record Code 394557 - 1996]
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RATIO OF COST TO CHARGES | PROVIDER NO: 335710 |
PERIOD: FROM 01/01/2009 TO 08/30/2009 |
WORKSHEET C |
||
Cost Center | TOTAL (From Wkst B, Pt. I, Col. 18) | Total Charges | Ratio (col. 1 ÷ col. 2) | ||
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 |