SNFData - 425074 - 06/1997

C.M. TUCKER JR. HUMAN RESOURCE CTR
COLUMBIA, SC 29202

Medicare Provider Number: 425074

Cost report status: Settled Without Audit

[Record Code 58323 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 425074	PERIOD: FROM 07/01/1996 TO 06/30/1997	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