BARKLEY CENTER
PADUCAH, KY  42001

Medicare Provider Number: 185312
Cost report status: Settled Without Audit
[Record Code 1207616 - 2010]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST Provider CCN: 185312
PERIOD:
FROM 01/01/2017
TO 12/31/2017
WORKSHEET D PART I
SNF - SNF Medicare - Title XVIII
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST
Cost Center Description Ratio of Cost to Charges (from Wkst. C, col. 3) Health Care Program Charges Healthcare Program Cost  
Part A Part B Part A ( col. 1 x col. 2 ) Part B ( col. 1 x col. 3 )
1 2 3 4 5
ANCILLARY SERVICE COST CENTERS
40 Radiology ### ### ### 40
41 Laboratory ### ### ### 41
42 Intravenous Therapy ### ### ### 42
43 Oxygen (Inhalation) Therapy ### ### ### 43
44 Physical Therapy ### ### ### 44
45 Occupational Therapy ### ### ### 45
46 Speech Pathology ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients ### ### ### 49
50 Dental Care - Title XIX only     50
51 Support Surfaces ### ### ### 51
52 Other Ancillary Service Cost 52
OUTPATIENT COST CENTERS            
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
71 Ambulance (2) 71
100 Total (sum of lines 40 - 71)   ### ### 100
(1) For titles V and XIX use columns 1, 2 and 4 only.
(2) Line 71 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII.
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124)
08-16   Rev. 7