Medicare Provider Number: -E
[Record Code 1322370 - 2010]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST Provider CCN:
PERIOD:
FROM 12/31/1969
TO 12/31/1969
WORKSHEET D PART I
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