SNFData - 195530 - 10/2003

SOUTHERN ACRES CARE CENTER
MONROE, LA 71202-

Medicare Provider Number: 195530

Cost report status: Settled Without Audit

[Record Code 188748 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 195530	PERIOD: FROM 08/14/2003 TO 10/31/2003	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