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
PARTS II & III
TITLE XVIII ONLY
 
PART II - APPORTIONMENT OF VACCINE COST
1 Drugs charged to patients - ratio of cost to charges (from Wkst. C, col. 3, line 49) 1
2 Program vaccine charges (From your records or the PS&R report) 2
3 Program costs (line 1 x line 2) (Title XVIII, PPS providers, transfer this amount to Wkst. E, Pt. I, line 18) 3
 
PART III - CALCULATION OF PASS THROUGH COSTS FOR NURSING & ALLIED HEALTH
Cost Center Description Total Cost (from Wkst. B, Pt. I, col. 18) Nursing & Allied Health (from Wkst. B, Pt. I, col. 14) Ratio of Nursing & Allied Health Costs to Total Costs - Part A (col. 2 / col. 1) Program Part A Cost (from Wkst. D., Pt. I, col. 4) Part A Nursing & Allied Health Costs for Pass Through (col. 3 x col. 4)  
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
100 Total (sum of lines 40 - 52)   100
FORM CMS-2540-10 (03/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4124.1)
03-18   Rev. 8