SNFData - 135065 - 06/2000 - Worksheet D, Part II

409 - MOUNTAIN VALLEY CARE & REHAB
KELLOGG, ID 83837-

Medicare Provider Number: 135065

Cost report status: Settled Without Audit

[Record Code 155526 - 1996]

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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST FOR TITLE XVIII			PROVIDER NO: 135065	PERIOD: FROM 07/01/1999 TO 06/30/2000		WORKSHEET D Part II
SNF - SNF Medicare - Title XVIII
PART II - APPORTIONMENT OF VACCINE COST
1	Drugs charged to patients - ratio of cost to charges (From Worksheet C, column 3, line 30)					###	1
2	Program vaccine charges (From your records, or the P S & R.)					###	2
3	Program costs (Line 1 X line 2) (Title XVIII, PPS providers, transfer this amount to Worksheet E, Part III, line 20)					###	3
PART III - CALCULATION OF PASS THROUGH COSTS FOR INTERNS & RESIDENTS
Cost Centers		Total Cost (From Worksheet B, Part I, Col 18)	Intern and Residents Costs (From Wkst. B, Part I, Column 14)	Ratio of Intern & Residents Costs To Total Costs - Part A (Col. 2 / Col.. 1)	Program Part A Cost (From Wkst. D. Part 1, Col. 4)	Program Intern & Residents Costs for Pass Through (Col. 3 X Col. 4)
Cost Centers		1	2	3	4	5
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					###	29
30	Drugs Charged to Patients						30
31	Dental Care - Title XIX only						31
32	Support Surfaces						32
33	Other Ancillary Service Costs						33
75	Total (Sum of lines 21 - 33)						75