LEEWARD INTEGRATED HEALTH SERVICES
WAIANAE, HI  96792

Medicare Provider Number: 125046
Cost report status: Settled Without Audit
[Record Code 202272 - 1996]

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RATIO OF COST TO CHARGES
PROVIDER NO:
125046
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)  
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