SNFData - 185248 - 09/2010

SAYRE CHRISTIAN VILLAGE NURSING HOME
LEXINGTON, KY 40517

Medicare Provider Number: 185248

Cost report status: Settled With Audit

[Record Code 423291 - 1996]

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RATIO OF COST TO CHARGES		PROVIDER NO: 185248	PERIOD: FROM 10/01/2009 TO 09/30/2010	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