SNFData - 055855 - 12/2003

ARDEN REHAB & HEALTH CENTER
SACRAMENTO, CA 95825-

Medicare Provider Number: 055855

Cost report status: Settled Without Audit

[Record Code 186839 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 055855	PERIOD: FROM 01/01/2003 TO 12/31/2003	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