OFFICER OR ADMINISTRATOR OF PROVIDER(S) TITLE DATE

Transcription

1 PREPARED 5/ 2/2006 THS REPORT S REQURED BY LAW (42 USC 1395g; 42 CFR (b)). FORM APPROVED FALURE TO REPORT CA RESULT ALL TERM PAYMETS MADE SCE OMB O THE BEGG OF THE COST REPORT PEROD BEG DEEMED OVERPAYMETS (42 USC 1395g). WORKSHEET S PARTS & HOSPTAL AD HOSPTAL HEALTH PROVDER O: PEROD TERMEDARY USE OLY DATE RECEVED: CARE COMPLEX FROM 1/ 1/ AUDTED --DESK REVEW / / COST REPORT CERTFCATO TO 12/31/ TAL --REOPEED TERMEDARY O: AD SETTLEMET SUMMARY --FAL 1-MCR CODE 00 - # OF REOPEGS MAUALLY SUBMTTED COST REPORT PART - CERTFCATO MSREPRESETATO OR FALSFCATO OF AY FORMATO COTAED THS COST REPORT MAY BE PUSHABLE BY CRMAL, CVL AD ADMSTRATVE ACTO, FE AD/OR MPRSOMET UDER FEDERAL LAW. FURTHERMORE, F SERVCES DETFED BY THS REPORT WERE PROVDED OR PROCURED THROUGH THE PAYMET DRECTLY OR DRECTLY OF A KCKBACK OR WHERE OTHERWSE LLEGAL, CRMAL, CVL AD ADMSTRATVE ACTO, FES AD/OR MPRSOMET MAY RESULT. CERTFCATO BY OFFCER OR ADMSTRATOR OF PROVDER(S) HEREBY CERTFY THAT HAVE READ THE ABOVE STATEMET AD THAT HAVE EXAMED THE ACCOMPAYG ELECTROCALLY FLED OR MAUALLY SUBMTTED COST REPORT AD THE BALACE SHEET AD STATEMET OF REVEUE AD EXPESES PREPARED BY: FOR THE COST REPORTG PEROD BEGG 1/ 1/2005 AD EDG 12/31/2005 AD THAT TO THE BEST OF MY KOWLEDGE AD BELEF, T S A TRUE, CORRECT, AD COMPLETE STATEMET PREPARED FROM THE BOOKS AD RECORDS OF THE PROVDER ACCORDACE WTH APPLCABLE STRUCTOS, EXCEPT AS OTED. FURTHER CERTFY THAT AM FAMLAR WTH THE LAWS AD REGULATOS REGARDG THE PROVSO OF HEALTH CARE SERVCES, AD THAT THE SERVCES DETFED THS COST REPORT WERE PROVDED COMPLACE WTH SUCH LAWS AD REGULATOS. OFFCER OR ADMSTRATOR OF PROVDER(S) TTLE DATE PART - SETTLEMET SUMMARY TTLE TTLE TTLE V XV XX A B HOSPTAL , SWG BED - SF 0-38, HOSPTAL-BASED HHA TOTAL 0-38, ,610 0 THE ABOVE AMOUTS REPRESET "DUE TO" OR "DUE FROM" THE APPLCABLE PROGRAM FOR THE ELEMET OF THE ABOVE COMPLEX DCATED According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated 662 hours per response, including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. f you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, , Baltimore, MD , and to the Office of the nformation and Regulatory Affairs, Office of Management and Budget, Washington, D.C MCRS/PC-W version nterface version v

2 HOSPTAL & HOSPTAL HEALTH CARE COMPLEX PROVDER O: PEROD: PREPARED 5/ 2/2006 FROM 1/ 1/2005 WORKSHEET S-2 DETFCATO DATA TO 12/31/2005 HOSPTAL AD HOSPTAL HEALTH CARE COMPLEX ADDRESS 1 STREET: STATE: ZP CODE: COUTY: HOSPTAL AD HOSPTAL-BASED COMPOET DETFCATO; PAYMET SYSTEM DATE (P,T,O OR ) COMPOET COMPOET AME PROVDER O. CERTFED V XV XX HOSPTAL 7/ 1/1966 O SWG BED - SF 4/11/1984 O HOSPTAL-BASED HHA 5/ 8/1986 P 17 COST REPORTG PEROD (MM/DD/YYYY) FROM: 1/ 1/2005 TO: 12/31/ TYPE OF COTROL 8 TYPE OF HOSPTAL/SUBPROVDER 19 HOSPTAL 1 20 SUBPROVDER OTHER FORMATO 21 DCATE F YOUR HOSPTAL S ETHER (1)URBA OR (2)RURAL AT THE ED OF THE COST REPORT PEROD COLUM 1. F YOUR HOSPTAL S GEOGRAPHCALLY CLASSFED OR LOCATED A RURAL AREA, S YOUR BED SZE ACCORDACE WTH CFR LESS THA OR EQUAL TO 100 BEDS, ETER COLUM 2 "Y" FOR YES OR "" FOR O DOES YOUR FACLTY QUALFY AD S CURRETLY RECEVG PAYMET FOR DSPROPORTOATE SHARE HOSPTAL ADJUSTMET ACCORDACE WTH 42 CFR ? HAS YOUR FACLTY RECEVED A EW GEOGRAPHC RECLASSCATO STATUS CHAGE AFTER THE FRST DAY OF THE COST REPORTG PEROD FROM RURAL TO URBA AD VCE VERSA? ETER "Y" FOR YES AD "" FOR O. F YES, ETER COLUM 2 THE EFFECTVE DATE (MM/DD/YYYY) (SEE STRUCTOS) ETER COLUM 1 YOUR GEOGRAPHC LOCATO ETHER (1)URBA OR (2)RURAL. F YOU ASWERED URBA COLUM 1 DCATE F YOU RECEVED ETHER A WAGE OR STADARD GEOGRAPHCAL RECLASSFCATO TO A RURAL LOCATO, ETER COLUM 2 "Y" FOR YES AD "" FOR O. F COLUM 2 S YES, ETER COLUM 3 THE EFFECTVE DATE (DD/MM/YYYY)(SEE STRUCTOS) DOES YOUR FACLTY COTA 100 OR FEWER BEDS ACCORDACE WTH 42 CFR ? ETER COLUM 4 "Y" OR "". 2 Y FOR STADARD GEOGRAPHC CLASSFCATO (OT WAGE), WHAT S YOUR STATUS AT THE BEGG OF THE COST REPORTG PEROD. ETER (1)URBA OR (2)RURAL FOR STADARD GEOGRAPHC CLASSFCATO (OT WAGE), WHAT S YOUR STATUS AT THE ED OF THE COST REPORTG PEROD. ETER (1)URBA OR (2)RURAL 22 ARE YOU CLASSFED AS A REFERRAL CETER? 23 DOES THS FACLTY OPERATE A TRASPLAT CETER? F YES, ETER CERTFCATO DATE(S) BELOW F THS S A MEDCARE CERTFED KDEY TRASPLAT CETER, ETER THE CERTFCATO DATE. / / F THS S A MEDCARE CERTFED HEART TRASPLAT CETER, ETER THE CERTFCATO DATE. / / F THS S A MEDCARE CERTFED LVER TRASPLAT CETER, ETER THE CERTFCATO DATE. / / F THS S A MEDCARE CERTFED LUG TRASPLAT CETER, ETER THE CERTFCATO DATE. / / F MEDCARE PACREAS TRASPLATS ARE PERFORMED SEE STRUCTOS FOR ETERG CERTFCATO DATE / / F THS S A MEDCARE CERTFED TESTAL TRASPLAT CETER, ETER THE CERTFCATO DATE. / / 24 F THS S A ORGA PROCUREMET ORGAZATO (OPO), ETER THE OPO UMBER COLUM S THS A TEACHG HOSPTAL OR AFFLATED WTH A TEACHG HOSPTAL AD YOU ARE RECEVG PAYMETS FOR &R? S THS TEACHG PROGRAM APPROVED ACCORDACE WTH CMS PUB. 15-, CHAPTER 4? F LE S YES, WAS MEDCARE PARTCPATO AD APPROVED TEACHG PROGRAM STATUS EFFECT DURG THE FRST MOTH OF THE COST REPORTG PEROD? F YES, COMPLETE WORKSHEET E-3, PART V. F O, COMPLETE WORKSHEET D-2, PART AS A TEACHG HOSPTAL, DD YOU ELECT COST REMBURSEMET FOR PHYSCAS' SERVCES AS DEFED CMS PUB. 15-, SECTO 2148? F YES, COMPLETE WORKSHEET D ARE YOU CLAMG COSTS O LE 70 OF WORKSHEET A? F YES, COMPLETE WORKSHEET D-2, PART HAS YOUR FACLTY DRECT GME FTE CAP (COLUM 1) OR ME FTE CAP (COLUM 2) BEE REDUCED UDER 42 CFR (c)(3) OR 42 CFR (f)(1)(iv)(B)? ETER "Y" FOR YES AD "" FOR O THE APPLCABLE COLUMS. (SEE STRUCTOS) HAS YOUR FACLTY RECEVED ADDTOAL DRECT GME FTE RESDET CAP SLOTS OR ME FTE RESDETS CAP SLOTS UDER 42 CFR (c)(4) OR 42 CFR (f)(1)(iv)(C)? ETER "Y" FOR YES AD "" FOR O THE APPLCABLE COLUMS (SEE STRUCTOS) 26 F THS S A SOLE COMMUTY HOSPTAL (SCH),ETER THE UMBER OF PERODS SCH STATUS EFFECT THE C/R PEROD. ETER BEGG AD EDG DATES OF SCH STATUS O LE SUBSCRPT LE FOR UMBER OF PERODS EXCESS OF OE AD ETER SUBSEQUET DATES ETER THE APPLCABLE SCH DATES: BEGG: / / EDG: / / ETER THE APPLCABLE SCH DATES: BEGG: / / EDG: / / 27 DOES THS HOSPTAL HAVE A AGREEMET UDER ETHER SECTO 1883 OR SECTO 1913 Y 4/11/1984 FOR SWG BEDS. F YES, ETER THE AGREEMET DATE (MM/DD/YYYY) COLUM v

3 HOSPTAL & HOSPTAL HEALTH CARE COMPLEX PROVDER O: PEROD: PREPARED 5/ 2/2006 FROM 1/ 1/2005 WORKSHEET S-2 DETFCATO DATA TO 12/31/ F THS FACLTY COTAS A HOSPTAL-BASED SF, ARE ALL PATETS UDER MAAGED CARE OR THERE WERE O MEDCARE UTLZATO ETER "Y", F "" COMPLETE LES AD F HOSPTAL BASED SF, ETER APPROPRATE TRASTO PEROD 1, 2, 3, OR 100 COLUM ETER COLUMS 2 AD 3 THE WAGE DEX ADJUSTMET FACTOR BEFORE AD O OR AFTER THE OCTOBER 1ST (SEE STRUCTOS) ETER COLUM 1 THE HOSPTAL BASED SF FACLTY SPECFC RATE(FROM YOUR FSCAL TERMEDARY) F YOU HAVE OT TRASTOED TO 100% PPS SF PPS PAYMET. COLUM 2 ETER THE FACLTY CLASSFCATO URBA(1) OR RURAL (2). COLUM 3 ETER THE SF MSA CODE OR TWO CHARACTER STATE CODE F A RURAL BASED FACLTY. COLUM 4, ETER THE SF CBSA CODE OR TWO CHARACTER CODE F RURAL BASED FACLTY A OTCE PUBLSHED THE "FEDERAL REGSTER" VOL. 68, O. 149 AUGUST 4, 2003 PROVDED FOR A CREASE THE RUG PAYMETS BEGG 10/01/2003. COGRESS EXPECTED THS CREASE TO BE USED FOR DRECT PATET CARE AD RELATED EXPESES. ETER COLUM 1 THE PERCETAGE OF TOTAL EXPESES FOR EACH CATEGORY TO TOTAL SF REVEUE FROM WORKSHEET G-2, PART, LE 6, COLUM 3. DCATE COLUM 2 "Y" FOR YES OR "" FOR O F THE SPEDG REFLECTS CREASES ASSOCATED WTH DRECT PATET CARE AD RELATED EXPESES FOR EACH CATEGORY. (SEE STR) % Y/ STAFFG 0.00% RECRUTMET 0.00% RETETO 0.00% TRAG 0.00% 29 S THS A RURAL HOSPTAL WTH A CERTFED SF WHCH HAS FEWER THA 50 BEDS THE AGGREGATE FOR BOTH COMPOETS, USG THE SWG BED OPTOAL METHOD OF REMBURSEMET? 30 DOES THS HOSPTAL QUALFY AS A RURAL PRMARY CARE HOSPTAL (RPCH)/CRTCAL ACCESS Y HOSPTAL(CAH)? (SEE 42 CFR ff) F SO, S THS THE TAL 12 MOTH PEROD FOR THE FACLTY OPERATED AS A RPCH/CAH? SEE 42 CFR F THS FACLTY QUALFES AS A RPCH/CAH, HAS T ELECTED THE ALL-CLUSVE METHOD OF PAYMET FOR OUTPATET SERVCES? (SEE STRUCTOS) F THS FACLTY QUALFES AS A CAH, S T ELBBLE FOR COST REMBURSEMET FOR AMBULACE SERVCES? F YES, ETER COLUM 2 THE DATE OF ELGBLTY DETERMATO (DATE MUST BE O OR AFTER 12/21/2000) F THS FACLTY QUALFES AS A CAH, S T ELBBLE FOR COST REMBURSEMET FOR &R TRAG PROGRAMS? ETER "Y" FOR YES AD "" FOR O. F YES, THE GME ELMATO WOULD OT BE O WORKSHEET B, PART, COLUM 26 AD THE PROGRAM WOULD BE COST REMBURSED. F YES COMPLETE WORKSHEET D-2, PART 31 S THS A RURAL HOSPTAL QUALFYG FOR A EXCEPTO TO THE CRA FEE SCHEDULE? SEE 42 CFR (c) S THS A RURAL SUBPROVDER 1 QUALFYG FOR A EXCEPTO TO THE CRA FEE SCHEDULE? SEE 42 CFR (c) S THS A RURAL SUBPROVDER 2 QUALFYG FOR A EXCEPTO TO THE CRA FEE SCHEDULE? SEE 42 CFR (c) S THS A RURAL SUBPROVDER 3 QUALFYG FOR A EXCEPTO TO THE CRA FEE SCHEDULE? SEE 42 CFR (c) S THS A RURAL SUBPROVDER 4 QUALFYG FOR A EXCEPTO TO THE CRA FEE SCHEDULE? SEE 42 CFR (c) S THS A RURAL SUBPROVDER 5 QUALFYG FOR A EXCEPTO TO THE CRA FEE SCHEDULE? SEE 42 CFR (c). MSCELLAEOUS COST REPORT FORMATO 32 S THS A ALL-CLUSVE PROVDER? F YES, ETER THE METHOD USED (A, B, OR E OLY) COL S THS A EW HOSPTAL UDER 42 CFR PPS CAPTAL? ETER "Y" FOR YES AD "" FOR O COLUM 1. F YES, FOR COST REPORTG PERODS BEGG O OR AFTER OCTOBER 1, 2002, DO YOU ELECT TO BE REMBURSED AT 100% FEDERAL CAPTAL PAYMET? ETER "Y" FOR YES AD "" FOR O COLUM 2 34 S THS A EW HOSPTAL UDER 42 CFR (f)(1)(i) TEFRA? 35 HAVE YOU ESTABLSHED A EW SUBPROVDER (EXCLUDED UT) UDER 42 CFR (f)(1)(i)? HAVE YOU ESTABLSHED A EW SUBPROVDER (EXCLUDED UT) UDER 42 CFR (f)(1)(i)? HAVE YOU ESTABLSHED A EW SUBPROVDER (EXCLUDED UT) UDER 42 CFR (f)(1)(i)? HAVE YOU ESTABLSHED A EW SUBPROVDER (EXCLUDED UT) UDER 42 CFR (f)(1)(i)? HAVE YOU ESTABLSHED A EW SUBPROVDER (EXCLUDED UT) UDER 42 CFR (f)(1)(i)? V XV XX PROSPECTVE PAYMET SYSTEM (PPS)-CAPTAL DO YOU ELECT FULLY PROSPECTVE PAYMET METHODOLOGY FOR CAPTAL COSTS? (SEE STRUCTOS) DOES YOUR FACLTY QUALFY AD RECEVE PAYMET FOR DSPROPORTOATE SHARE ACCORDACE WTH 42 CFR ? (SEE STRUCTOS) 37 DO YOU ELECT HOLD HARMLESS PAYMET METHODOLOGY FOR CAPTAL COSTS? (SEE STRUCTOS) F YOU ARE A HOLD HARMLESS PROVDER, ARE YOU FLG O THE BASS OF 100% OF THE FED RATE? v

4 HOSPTAL & HOSPTAL HEALTH CARE COMPLEX PROVDER O: PEROD: PREPARED 5/ 2/2006 FROM 1/ 1/2005 WORKSHEET S-2 DETFCATO DATA TO 12/31/2005 TTLE XX PATET SERVCES 38 DO YOU HAVE TTLE XX PATET HOSPTAL SERVCES? Y S THS HOSPTAL REMBURSED FOR TTLE XX THROUGH THE COST REPORT ETHER FULL OR PART? DOES THE TTLE XX PROGRAM REDUCE CAPTAL FOLLOWG THE MEDCARE METHODOLOGY? ARE TTLE XX F PATETS OCCUPYG TTLE XV SF BEDS (DUAL CERTFCATO)? DO YOU OPERATE A CF/MR FACLTY FOR PURPOSES OF TTLE XX? 40 ARE THERE AY RELATED ORGAZATO OR HOME OFFCE COSTS AS DEFED CMS PUB 15-, CHAP 10? F YES, AD THERE ARE HOME OFFCE COSTS, ETER COL 2 THE HOME OFFCE PROVDER UMBER. Y 41 ARE PROVDER BASED PHYSCAS' COSTS CLUDED WORKSHEET A? Y 42 ARE PHYSCAL THERAPY SERVCES PROVDED BY OUTSDE SUPPLERS? ARE OCCUPATOAL THERAPY SERVCES PROVDED BY OUTSDE SUPPLERS? Y ARE SPEECH PATHOLOGY SERVCES PROVDED BY OUTSDE SUPPLERS? 43 ARE RESPRATORY THERAPY SERVCES PROVDED BY OUTSDE SUPPLERS? 44 F YOU ARE CLAMG COST FOR REAL SERVCES O WORKSHEET A, ARE THEY PATET SERVCES OLY? 45 HAVE YOU CHAGED YOUR COST ALLOCATO METHODOLOGY FROM THE PREVOUSLY FLED COST REPORT? 00/00/0000 SEE CMS PUB. 15-, SECTO F YES, ETER THE APPROVAL DATE COLUM WAS THERE A CHAGE THE STATSTCAL BASS? WAS THERE A CHAGE THE ORDER OF ALLOCATO? WAS THE CHAGE TO THE SMPLFED COST FDG METHOD? 46 F YOU ARE PARTCPATG THE HCMQ DEMOSTRATO PROJECT (MUST HAVE A HOSPTAL-BASED SF) DURG THS COST REPORTG PEROD, ETER THE PHASE (SEE STRUCTOS). F THS FACLTY COTAS A PROVDER THAT QUALFES FOR A EXEMPTO FROM THE APPLCATO OF THE LOWER OF COSTS OR CHARGES, ETER "Y" FOR EACH COMPOET AD TYPE OF SERVCE THAT QUALFES FOR THE EXEMPTO. ETER "" F OT EXEMPT. (SEE 42 CFR ) OUTPATET OUTPATET OUTPATET PART A PART B ASC RADOLOGY DAGOSTC HOSPTAL Y Y Y Y Y HHA 52 DOES THS HOSPTAL CLAM EXPEDTURES FOR EXTRAORDARY CRCUMSTACES ACCORDACE WTH 42 CFR (e)? (SEE STRUCTOS) F YOU ARE A FULLY PROSPECTVE OR HOLD HARMLESS PROVDER ARE YOU ELGBLE FOR THE SPECAL EXCEPTOS PAYMET PURSUAT TO 42 CFR (g)? F YES, COMPLETE WORKSHEET L, PART V 53 F YOU ARE A MEDCARE DEPEDET HOSPTAL (MDH), ETER THE UMBER OF PERODS MDH STATUS EFFECT. ETER BEGG AD EDG DATES OF MDH STATUS O LE SUBSCRPT LE FOR UMBER OF PERODS EXCESS OF OE AD ETER SUBSEQUET DATES MDH PEROD: BEGG: / / EDG: / / 54 LST AMOUTS OF MALPRACTCE PREMUMS AD PAD LOSSES: PREMUMS: 6,698 PAD LOSSES: 0 AD/OR SELF SURACE: ARE MALPRACTCE PREMUMS AD PAD LOSSES REPORTED OTHER THA THE ADMSTRATVE AD GEERAL COST CETER? F YES, SUBMT SUPPORTG SCHEDULE LSTG COST CETERS AD AMOUTS COTAED THERE. 55 DOES YOUR FACLTY QUALFY FOR ADDTOAL PROSPECTVE PAYMET ACCORDACE WTH 42 CFR ETER "Y" FOR YES AD "" FOR O. 56 ARE YOU CLAMG AMBULACE COSTS? F YES, ETER COLUM 2 THE PAYMET LMT PROVDED FROM YOUR FSCAL TERMEDARY AD THE APPLCABLE DATES FOR THOSE LMTS DATE Y OR LMT Y OR FEES COLUM 0. F THS S THE FRST YEAR OF OPERATO O ETRY S REQURED COLUM F COLUM 1 S Y, ETER Y OR COLUM 3 WHETHER THS S YOUR FRST YEAR OF OPERATOS FOR REDERG AMBULACE SERVCES. ETER COLUM 4, F APPLCABLE, 1/ 1/2005 Y ,219 THE FEE SCHEDULES AMOUTS FOR THE PEROD BEGG O OR AFTER 4/1/ ETER SUBSEQUET AMBULACE PAYMET LMT AS REQURED. SUBSCRPT F MORE THA LMTS APPLY. ETER COLUM 4 THE FEE SCHEDULES AMOUTS FOR TAL OR SUBSEQUET PEROD AS APPLCABLE THRD AMBULACE LMT AD FEE SCHEDULE F ECESSARY FOURTH AMBULACE LMT AD FEE SCHEDULE F ECESSARY ARE YOU CLAMG URSG AD ALLED HEALTH COSTS? 58 ARE YOU A PATET REHABLTATO FACLTY(RF), OR DO YOU COTA A RF SUBPROVDER? ETER COLUM 1 "Y" FOR YES AD "" FOR O. F YES HAVE YOU MADE THE ELECTO FOR 100% FEDERAL PPS REMBURSEMET? ETER COLUM 2 "Y" FOR YES AD "" FOR O. THS OPTO S OLY AVALABLE FOR COST REPORTG PERODS BEGG O OR AFTER 1/1/2002 AD BEFORE 10/1/ ARE YOU A LOG TERM CARE HOSPTAL (LTCH)? ETER COLUM 1 "Y" FOR YES AD "" FOR O. F YES, HAVE YOU MADE THE ELECTO FOR 100% FEDERAL PPS REMBURSEMET? ETER COLUM 2 "Y" FOR YES AD "" FOR O. (SEE STRUCTOS) 60 ARE YOU A PATET PSYCHATRC FACLTY (PF), OR DO YOU COTA A PF SUBPROVDER? ETER COLUM 1 "Y" FOR YES AD "" FOR O. F YES, S THE PF OR PF SUBPROVDER A EW FACLTY? ETER COLUM 2 "Y" FOR YES AD "" FOR O. (SEE STRUCTOS) F LE 60 COLUM 1 S Y, DOES THE FACLTY HAVE A TEACHG PROGRAM THE MOST RECET COST 0 REPORTG PEROD EDG O OR BEFORE OVEMBER 15, 2004? ETER "Y" FOR YES OR "" FOR O. S THE FACLTY TRAG RESDETS A EW TEACHG PROGRAM ACCORDACE WTH 42 CFR SEC (d)(1)(iii)(2)? ETER COLUM 2 "Y"FOR YES OR "" FOR O. F COLUM 2 S Y, ETER 1, 2 OR 3 RESPECTVELY COLUM 3 (SEE STRUCTOS). F THE CURRET COST REPORTG PEROD COVERS THE BEGG OF THE FOURTH ETER 4 COLUM 3, OR F THE SUBSEQUET ACADEMC YEARS OF THE EW TEACHG PROGRAM EXSTECE, ETER 5. (SEE STR) v

5 PROVDER O: PEROD: PREPARED 5/ 2/2006 HOSPTAL AD HOSPTAL HEALTH CARE FROM 1/ 1/2005 WORKSHEET S-3 COMPLEX STATSTCAL DATA TO 12/31/2005 PART /P DAYS / O/P VSTS / TRPS O. OF BED DAYS CAH TTLE TTLE OT LTCH TOTAL COMPOET BEDS AVALABLE HOURS V XV /A TTLE XX ADULTS & PEDATRCS 25 9,125 84, , HMO 2 01 HMO - (RF PPS SUBPROVDER) 3 ADULTS & PED-SB SF ADULTS & PED-SB F 5 TOTAL ADULTS AD PEDS 25 9,125 2, URSERY TOTAL 25 9,125 2, RPCH VSTS 18 HOME HEALTH AGECY 2, HOSPCE 25 TOTAL OBSERVATO BED DAYS 27 AMBULACE TRPS (01/01/ EMPLOYEE DSCOUT DAYS EMP DSCOUT DAYS -RF /P DAYS / O/P VSTS / TRPS TERS & RES. FTES -- TTLE XX OBSERVATO BEDS TOTAL TOTAL OBSERVATO BEDS LESS &R REPL COMPOET ADMTTED OT ADMTTED ALL PATS ADMTTED OT ADMTTED TOTAL O-PHYS AES ADULTS & PEDATRCS 3,606 2 HMO 2 01 HMO - (RF PPS SUBPROVDER) 3 ADULTS & PED-SB SF ADULTS & PED-SB F 59 5 TOTAL ADULTS AD PEDS 4, URSERY TOTAL 4, RPCH VSTS 18 HOME HEALTH AGECY 4, HOSPCE 25 TOTAL 26 OBSERVATO BED DAYS AMBULACE TRPS (01/01/ EMPLOYEE DSCOUT DAYS EMP DSCOUT DAYS -RF & R FTES --- FULL TME EQUV DSCHARGES EMPLOYEES OPAD TTLE TTLE TTLE TOTAL ALL COMPOET ET O PAYROLL WORKERS V XV XX PATETS ADULTS & PEDATRCS ,146 2 HMO 2 01 HMO - (RF PPS SUBPROVDER) 3 ADULTS & PED-SB SF 4 ADULTS & PED-SB F 5 TOTAL ADULTS AD PEDS 11 URSERY 12 TOTAL , RPCH VSTS 18 HOME HEALTH AGECY 2, HOSPCE 25 TOTAL 2, OBSERVATO BED DAYS 27 AMBULACE TRPS (01/01/ EMPLOYEE DSCOUT DAYS EMP DSCOUT DAYS -RF v

6 PROVDER O: PEROD: PREPARED 5/ 2/2006 RECLASSFCATO AD ADJUSTMET OF FROM 1/ 1/2005 WORKSHEET A TRAL BALACE OF EXPESES TO 12/31/2005 COST COST CETER DESCRPTO SALARES OTHER TOTAL RECLASS- RECLASSFED CETER FCATOS TRAL BALACE GEERAL SERVCE COST CTR EW CAP REL COSTS-BLDG & FXT 429, ,594 22, , EW CAP REL COSTS-MVBLE EQUP 328, , , , EMPLOYEE BEEFTS 1,560,251 1,560,251 1,560, ADMSTRATVE & GEERAL 809,239 1,878,018 2,687, ,163 2,400, OPERATO OF PLAT 100, , , , LAUDRY & LE SERVCE 69,142 69,142 69, HOUSEKEEPG 98,358 76, , , DETARY 81,604 81,604 81, CAFETERA 6,470 6,470 6, URSG ADMSTRATO 353,876 31, , , MEDCAL RECORDS & LBRARY 440,633 63, , ,724 PAT ROUTE SRVC CTRS ADULTS & PEDATRCS 1,711, ,420 2,116,168-10,121 2,106, URSERY 8,130 5,357 13, ,426 ACLLARY SRVC COST CTRS OPERATG ROOM 518, ,280 1,176,323 18,392 1,194, DELVERY ROOM & LABOR ROOM 12,774 13,589 26,363 1,900 28, AESTHESOLOGY RADOLOGY-DAGOSTC 286, ,934 1,228,579 46,971 1,275, LABORATORY 639, ,344 1,430,873 40,152 1,471, RESPRATORY THERAPY 56, , , , PHYSCAL THERAPY 188,545 29, ,132 3, , OCCUPATOAL THERAPY 25,549 25, , SPEECH PATHOLOGY 46,255 14,643 60,898 1,077 61, ELECTROCARDOLOGY 51,260 51,260-46,751 4, MEDCAL SUPPLES CHARGED TO PATETS 30, , ,906 7, , DRUGS CHARGED TO PATETS 372,435 1,251,783 1,624,218 37,722 1,661, CARDAC REHAB 134,599 13, , ,097 OUTPAT SERVCE COST CTRS CLC 747,227 2,602,456 3,349,683 39,854 3,389, DABETC EDUCATO 40,974 40, , EMERGECY 34, , ,168 3, , OBSERVATO BEDS (O-DSTCT PART) OTHER REMBURS COST CTRS AMBULACE SERVCES 105,603 26, ,777 4, , HOME HEALTH AGECY 833,568 88, , ,540 SPEC PURPOSE COST CETERS TEREST EXPESE OTHER CAPTAL RELATED COSTS HOSPCE OTHER SPECAL PURPOSE (SPECFY) BAD DEBT EXPESE HOSPCE 95 SUBTOTALS 7,528,901 12,823,535 20,352, ,352,436 OREMBURS COST CETERS GFT, FLOWER, COFFEE SHOP & CATEE DALYSS MASSAGE THERAPY VA MEDCAL CETER 25,618 25,618 25, TOTAL 7,528,901 12,849,153 20,378, ,378, v

7 RECLASSFCATO AD ADJUSTMET OF TRAL BALACE OF EXPESES PROVDER O: PEROD: FROM 1/ 1/2005 TO 12/31/2005 PREPARED 5/ 2/2006 WORKSHEET A COST COST CETER DESCRPTO ADJUSTMETS ET EXPESES CETER FOR ALLOC 6 7 GEERAL SERVCE COST CTR 0300 EW CAP REL COSTS-BLDG & FXT -245, , EW CAP REL COSTS-MVBLE EQUP -63, , EMPLOYEE BEEFTS -53,091 1,507, ADMSTRATVE & GEERAL -486,970 1,913, OPERATO OF PLAT -74, , LAUDRY & LE SERVCE 69, HOUSEKEEPG -12, , DETARY -3,350 78, CAFETERA 6, URSG ADMSTRATO 385, MEDCAL RECORDS & LBRARY -15, , PAT ROUTE SRVC CTRS ADULTS & PEDATRCS URSERY ACLLARY SRVC COST CTRS OPERATG ROOM DELVERY ROOM & LABOR ROOM AESTHESOLOGY RADOLOGY-DAGOSTC LABORATORY RESPRATORY THERAPY PHYSCAL THERAPY OCCUPATOAL THERAPY SPEECH PATHOLOGY ELECTROCARDOLOGY MEDCAL SUPPLES CHARGED TO PATETS DRUGS CHARGED TO PATETS CARDAC REHAB OUTPAT SERVCE COST CTRS CLC DABETC EDUCATO EMERGECY OBSERVATO BEDS (O-DSTCT PART) OTHER REMBURS COST CTRS AMBULACE SERVCES HOME HEALTH AGECY SPEC PURPOSE COST CETERS ,106,047 13,018-28,043 1,166,672 28,263-1,384-27,368-2,822, ,428 1,275,550 1,471, , ,558 26,005 60,591 4, ,494 1,661, , TEREST EXPESE OTHER CAPTAL RELATED COSTS HOSPCE HOSPCE 95 SUBTOTALS OTHER SPECAL PURPOSE (SPECFY) BAD DEBT EXPESE OREMBURS COST CETERS MASSAGE THERAPY GFT, FLOWER, COFFEE SHOP & CATEE DALYSS 9603 VA MEDCAL CETER TOTAL -3,981, ,846 41, , , ,540-3,981,867 16,370,569 25,618 16,396, v

8 PROVDER O: PEROD: PREPARED 5/ 2/2006 RECLASSFCATOS FROM 1/ 1/2005 WORKSHEET A-6 TO 12/31/ CREASE CODE LE EXPLAATO OF RECLASSFCATO (1) COST CETER O SALARY OTHER RECLASS OF EQUPMET RETAL B EW CAP REL COSTS-MVBLE EQUP 4 113, RECLASS OF PROPERTY SURACE A EW CAP REL COSTS-BLDG & FXT 3 22, EW CAP REL COSTS-MVBLE EQUP 4 1, RECLASS OF M CARE AD SURCHARGE C ADULTS & PEDATRCS 25 33, URSERY 33 1, OPERATG ROOM 37 18, DELVERY ROOM & LABOR ROOM 39 1, RADOLOGY-DAGOSTC 41 46, LABORATORY 44 40, RESPRATORY THERAPY 49 3, PHYSCAL THERAPY 50 3, OCCUPATOAL THERAPY SPEECH PATHOLOGY 52 1, ELECTROCARDOLOGY 53 1, MEDCAL SUPPLES CHARGED TO PATETS 55 12, DRUGS CHARGED TO PATETS 56 41, CARDAC REHAB 59 1, DABETC EDUCATO CLC 60 39, EMERGECY 61 7, ADULTS & PEDATRCS 25 3, AMBULACE SERVCES 65 4, TOTAL RECLASSFCATOS 262, ,742 (1) A letter (A, B, etc) must be entered on each line to identify each reclassification entry. Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate. See instructions for column 10 referencing to Worksheet A-7, Part, columns 9 through v

9 PROVDER O: PEROD: PREPARED 5/ 2/2006 RECLASSFCATOS FROM 1/ 1/2005 WORKSHEET A-6 TO 12/31/ DECREASE CODE LE A-7 EXPLAATO OF RECLASSFCATO (1) COST CETER O SALARY OTHER REF RECLASS OF EQUPMET RETAL B OPERATG ROOM DRUGS CHARGED TO PATETS 56 4,248 3 ADULTS & PEDATRCS 25 46,681 4 URSERY 33 1,100 5 RESPRATORY THERAPY 49 3,878 6 ELECTROCARDOLOGY 53 47,912 7 MEDCAL SUPPLES CHARGED TO PATETS 55 4,157 8 CARDAC REHAB 59 1,163 9 EMERGECY 61 3, RECLASS OF PROPERTY SURACE A ADMSTRATVE & GEERAL 6 24, RECLASS OF M CARE AD SURCHARGE C ADMSTRATVE & GEERAL 6 262, TOTAL RECLASSFCATOS 400,407 (1) A letter (A, B, etc) must be entered on each line to identify each reclassification entry. Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate. See instructions for column 10 referencing to Worksheet A-7, Part, columns 9 through v

10 PROVDER O: PEROD: PREPARED 5/ 2/2006 ADJUSTMETS TO EXPESES FROM 1/ 1/2005 WORKSHEET A-8 TO 12/31/2005 EXPESE CLASSFCATO O DESCRPTO (1) WORKSHEET A TO/FROM WHCH THE WKST. (2) AMOUT S TO BE ADJUSTED A-7 BASS/CODE AMOUT COST CETER LE O REF VST COME-OLD BLDGS AD FXTURES **COST CETER DELETED** 1 2 VESTMET COME-OLD MOVABLE EQUP **COST CETER DELETED** 2 3 VST COME-EW BLDGS AD FXTURES EW CAP REL COSTS-BLDG & 3 4 VESTMET COME-EW MOVABLE EQUP EW CAP REL COSTS-MVBLE E 4 5 VESTMET COME-OTHER 6 TRADE, QUATTY AD TME DSCOUTS 7 REFUDS AD REBATES OF EXPESES 8 RETAL OF PRVDER SPACE BY SUPPLERS 9 TELEPHOE SERVCES A -3,571 ADMSTRATVE & GEERAL 6 10 TELEVSO AD RADO SERVCE 11 PARKG LOT 12 PROVDER BASED PHYSCA ADJUSTMET A ,668, SALE OF SCRAP, WASTE, ETC. 14 RELATED ORGAZATO TRASACTOS A , LAUDRY AD LE SERVCE 16 CAFETERA--EMPLOYEES AD GUESTS 17 RETAL OF QTRS TO EMPLYEE AD OTHRS 18 SALE OF MED AD SURG SUPPLES 19 SALE OF DRUGS TO OTHER THA PATETS 20 SALE OF MEDCAL RECORDS & ABSTRACTS B -15,592 MEDCAL RECORDS & LBRARY URSG SCHOOL(TUT,FEES,BOOKS, ETC.) 22 VEDG MACHES B -11,164 ADMSTRATVE & GEERAL 6 23 COME FROM MPOSTO OF TEREST B -53,670 ADMSTRATVE & GEERAL 6 24 TRST EXP O MEDCARE OVERPAYMETS 25 ADJUSTMET FOR RESPRATORY THERAPY A-8-3/A-8-4 RESPRATORY THERAPY ADJUSTMET FOR PHYSCAL THERAPY A-8-3/A-8-4 PHYSCAL THERAPY ADJUSTMET FOR HHA PHYSCAL THERAPY A-8-3 HOME HEALTH AGECY UTLZATO REVEW-PHYSA COMP **COST CETER DELETED** DEPRECATO-OLD BLDGS AD FXTURES **COST CETER DELETED** 1 30 DEPRECATO-OLD MOVABLE EQUP **COST CETER DELETED** 2 31 DEPRECATO-EW BLDGS AD FXTURES EW CAP REL COSTS-BLDG & 3 32 DEPRECATO-EW MOVABLE EQUP EW CAP REL COSTS-MVBLE E 4 33 O-PHYSCA AESTHETST **COST CETER DELETED** PHYSCAS' ASSSTAT 35 ADJUSTMET FOR OCCUPATOAL THERAPY A-8-4 OCCUPATOAL THERAPY ADJUSTMET FOR SPEECH PATHOLOGY A-8-4 SPEECH PATHOLOGY MSCELLAEOUS PLAT COME B -4,397 OPERATO OF PLAT MSCELLAEOUS A & G B -3,210 ADMSTRATVE & GEERAL SUP SOLD DETARY B -3,350 DETARY PHYSCA RECRUTMET EXPESE A -99,438 ADMSTRATVE & GEERAL AESTHESA RET B -9,756 OPERATO OF PLAT SUP SOLD URSERY B -408 URSERY BAD DEBT O ALLOWABLE A -240,346 ADMSTRATVE & GEERAL CRD SHARED SVCS BLDG A -26,106 EW CAP REL COSTS-BLDG & CRC SHARED SVCS EQUP A -12,485 EW CAP REL COSTS-MVBLE E ADM SHARED SERVCES B -2,270 ADMSTRATVE & GEERAL PLAT SHARED SVCS A -60,157 OPERATO OF PLAT HOUSEKEEPG SHARED SVCS A -12,485 HOUSEKEEPG OUTREACH MED SUPPLES SOLD B -27,368 MEDCAL SUPPLES CHARGED OUTREACH OR STAFF AD EQUP SOLD B -28,043 OPERATG ROOM OUTREACH CLC TME B -39,118 CLC OUTREACH AUDOLOGY B -1,384 SPEECH PATHOLOGY CLC ADM COECT RETAL COME B -5,656 CLC CLC DEPRECATO MOVABLE EQUPME A -50,557 EW CAP REL COSTS-MVBLE E CLC DEPRECATO BULDG A -219,599 EW CAP REL COSTS-BLDG & MDLEVEL SALARES A -256,844 CLC MDLEVEL BEEFTS A -53,091 EMPLOYEE BEEFTS 5 44 CLC REMB FOR PAYROLL SERVCES FO B -4,000 ADMSTRATVE & GEERAL 6 45 MD MALPRACTCE SURACE A -82,570 ADMSTRATVE & GEERAL 6 46 LOBBYG DUES OFFSET A -1,924 ADMSTRATVE & GEERAL 6 47 OTHER ADJUSTMETS (SPECFY) 48 OTHER ADJUSTMETS (SPECFY) 49 OTHER ADJUSTMETS (SPECFY) 50 TOTAL (SUM OF LES 1 THRU 49) -3,981,867 (1) Description - all chapter references in this columnpertain to CMS Pub (2) Basis for adjustment (see instructions). A. Costs - if cost, including applicable overhead, can be determined. B. Amount Received - if cost cannot be determined. (3) Additional adjustments may be made on lines 37 thru 49 and subscripts thereof. ote: See instructions for column 5 referencing to Worksheet A v

11 STATEMET OF COSTS OF SERVCES PROVDER O: PEROD: PREPARED 5/ 2/2006 FROM RELATED ORGAZATOS AD FROM 1/ 1/2005 HOME OFFCE COSTS TO 12/31/2005 WORKSHEET A-8-1 A. COSTS CURRED AD ADJUSTMETS REQURED AS A RESULT OF TRASACTOS WTH RELATED ORGAZATOS OR THE CLAMG OF HOME OFFCE COSTS: AMOUT OF ET* WKSHT A-7 ALLOWABLE ADJUST- COL. REF. LE O. COST CETER EXPESE TEMS COST AMOUT METS ADMSTRATVE & GEERAL 15,193 15, TOTALS 15,193 15,193 * THE AMOUTS O LES 1-4 AD SUBSCRPTS AS APPROPRATE ARE TRASFERRED DETAL TO WORKSHEET A, COLUM 6, LES AS APPROPRATE. POSTVE AMOUTS CREASE COST AD EGATVE AMOUTS DECREASE COST. FOR RELATED ORGAZATOAL OR HOME OFFCE COST WHCH HAS OT BEE POSTED TO WORKSHEET A, COLUMS 1 AD/OR 2, THE AMOUT ALLOWABLE SHOULD BE COLUM 4 OF THS PART. B. TERRELATOSHP TO RELATED ORGAZATO(S) AD/OR HOME OFFCE: THE SECRETARY, BY VRTUE OF AUTHORTY GRATED UDER SECTO 1814(B)(1) OF THE SOCAL SECURTY ACT, REQURES THAT YOU FURSH THE FORMATO REQUESTED UDER PART B OF THS WORKSHEET. THS FORMATO S USED BY THE CETERS FOR MEDCARE & MEDCAD SERVCES AD TS TERMEDARES DETERMG THAT THE COSTS APPLCABLE TO SERVCES, FACLTES, AD SUPPLES FURSHED BY ORGAZATOS RELATED TO YOU BY COMMO OWERSHP OR COTROL REPRESET REASOABLE COSTS AS DETERMED UDER SECTO 1861 OF THE SOCAL SECURTY ACT. F YOU DO OT PROVDE ALL OR AY PART OF THE REQUESTED FORMATO, THE COST REPORT S COSDERED COMPLETE AD OT ACCEPTABLE FOR PURPOSES OF CLAMG REMBURSEMET UDER TTLE XV. SYMBOL AME PERCETAGE RELATED ORGAZATO(S) AD/OR HOME OFFCE (1) OF AME PERCETAGE OF TYPE OF OWERSHP OWERSHP BUSESS G (1) USE THE FOLLOWG SYMBOLS TO DCATE TERELATOSHP TO RELATED ORGAZATOS: A. DVDUAL HAS FACAL TEREST (STOCKHOLDER, PARTER, ETC.) BOTH RELATED ORGAZATO AD PROVDER. B. CORPORATO, PARTERSHP OR OTHER ORGAZATO HAS FACAL TEREST PROVDER. C. PROVDER HAS FACAL TEREST CORPORATO, PARTERSHP OR OTHER ORGAZATO. D. DRECTOR, OFFCER, ADMSTRATOR OR KEY PERSO OF PROVDER OR RELATVE OF SUCH PERSO HAS A FACAL TEREST RELATED ORGAZATO. E. DVDUAL S DRECTOR, OFFCER, ADMSTRATOR OR KEY PERSO OF PROVDER AD RELATED ORGAZATO. F. DRECTOR, OFFCER, ADMSTRATOR OR KEY PERSO OF RELATED ORGAZATO OR RELATVE OF SUCH PERSO HAS FACAL TEREST PROVDER. G. OTHER (FACAL OR O-FACAL) SPECFY v

12 PROVDER O: PEROD: PREPARED 5/ 2/2006 PROVDER BASED PHYSCA ADJUSTMETS FROM 1/ 1/2005 WORKSHEET A-8-2 TO 12/31/2005 GROUP 1 PHYSCA/ COST CETER/ TOTAL PROFES- PROVDER 5 PERCET OF WKSHT A PHYSCA REMU- SOAL PROVDER RCE COMPOET UADJUSTED UADJUSTED LE O. DETFER ERATO COMPOET COMPOET AMOUT HOURS RCE LMT RCE LMT ER PHYSCAS - O CALL 567, , , LABORATORY 24,750 24, CLC MDS 2,521,073 2,521, TOTAL 3,112,854 2,668, ,353 COST OF PROVDER PHYSCA PROVDER COST CETER/ MEMBERSHPS COMPOET COST OF COMPOET ADJUSTED RCE WKSHT A PHYSCA & COTUG SHARE OF MALPRACTCE SHARE OF RCE DS- LE O. DETFER EDUCATO COL 12 SURACE COL 14 LMT ALLOWACE ADJUSTMET ER PHYSCAS - O CALL 147, LABORATORY 3 60 CLC MDS 2,521, TOTAL 2,668, v

13 PROVDER O: PEROD: PREPARED 5/ 2/2006 COST ALLOCATO - GEERAL SERVCE COSTS FROM 1/ 1/2005 WORKSHEET B TO 12/31/2005 PART ET EXPESES EW CAP REL C EW CAP REL C EMPLOYEE BEE SUBTOTAL ADMSTRATV OPERATO OF COST CETER FOR COST OSTS-BLDG & OSTS-MVBLE E FTS E & GEERAL PLAT DESCRPTO ALLOCATO a GEERAL SERVCE COST CTR 003 EW CAP REL COSTS-BLDG & 206, , EW CAP REL COSTS-MVBLE E 380, , EMPLOYEE BEEFTS 1,507,160 1,507, ADMSTRATVE & GEERAL 1,913,124 23,188 39, ,703 2,143,256 2,143, OPERATO OF PLAT 290,654 9,060 15,331 20, ,850 50, , LAUDRY & LE SERVCE 69,142 69,142 10, HOUSEKEEPG 162, , ,277 27, DETARY 78,254 78,254 11, CAFETERA 6,470 6, URSG ADMSTRATO 385,062 2,990 5,059 73, ,446 70,141 5, MEDCAL RECORDS & LBRARY 488,132 2,327 3,937 91, ,711 88,075 4,661 PAT ROUTE SRVC CTRS 025 ADULTS & PEDATRCS 2,106,047 36,127 61, ,732 2,558, ,663 72, URSERY 13,018 2,262 3,827 1,685 20,792 3,127 4,531 ACLLARY SRVC COST CTRS 037 OPERATG ROOM 1,166,672 31,152 52, ,357 1,357, ,191 62, DELVERY ROOM & LABOR ROO 28,263 2,990 5,059 2,647 38,959 5,858 5, AESTHESOLOGY 041 RADOLOGY-DAGOSTC 1,275,550 8,600 14,554 59,403 1,358, ,223 17, LABORATORY 1,471,025 3,150 5, ,533 1,612, ,407 6, RESPRATORY THERAPY 193, ,686 11, ,316 31,325 1, PHYSCAL THERAPY 221,558 7,444 12,596 39, ,671 42,205 14, OCCUPATOAL THERAPY 26, ,576 3, SPEECH PATHOLOGY 60,591 9,586 70,177 10, ELECTROCARDOLOGY 4,509 4, MEDCAL SUPPLES CHARGED 354,494 13,522 22,883 6, ,124 59,717 27, DRUGS CHARGED TO PATETS 1,661,940 4,679 7,919 77,182 1,751, ,411 9, CARDAC REHAB 149,097 2,743 4,641 27, ,375 27,725 5,494 OUTPAT SERVCE COST CTRS 060 CLC 566,846 88, , , , , DABETC EDUCATO 41,433 7,143 48,576 7, EMERGECY 483,341 7,509 12, ,556 75,721 15, OBSERVATO BEDS (O-DS OTHER REMBURS COST CTRS 065 AMBULACE SERVCES 135,787 4,320 7,310 21, ,302 25,458 8, HOME HEALTH AGECY 922,540 1,993 3, ,744 1,100, ,508 3,992 SPEC PURPOSE COST CETERS 093 HOSPCE 094 OTHER SPECAL PURPOSE (SP BAD DEBT EXPESE HOSPCE 997 1,686 2, , SUBTOTALS 16,370, , ,472 1,507,160 16,319,920 2,131, ,942 OREMBURS COST CETERS 096 GFT, FLOWER, COFFEE SHOP DALYSS 6,196 10,485 16,681 2,508 12, MASSAGE THERAPY VA MEDCAL CETER 25,618 33,968 59,586 8, CROSS FOOT ADJUSTMET 102 EGATVE COST CETER 103 TOTAL 16,396, , ,957 1,507,160 16,396,187 2,143, , v

14 PROVDER O: PEROD: PREPARED 5/ 2/2006 COST ALLOCATO - GEERAL SERVCE COSTS FROM 1/ 1/2005 WORKSHEET B TO 12/31/2005 PART LAUDRY & L HOUSEKEEPG DETARY CAFETERA URSG ADM MEDCAL RECOR SUBTOTAL COST CETER E SERVCE STRATO DS & LBRARY DESCRPTO GEERAL SERVCE COST CTR 003 EW CAP REL COSTS-BLDG & 004 EW CAP REL COSTS-MVBLE E 005 EMPLOYEE BEEFTS 006 ADMSTRATVE & GEERAL 008 OPERATO OF PLAT LAUDRY & LE SERVCE HOUSEKEEPG DETARY CAFETERA URSG ADMSTRATO MEDCAL RECORDS & LBRARY PAT ROUTE SRVC CTRS ADULTS & PEDATRCS URSERY ACLLARY SRVC COST CTRS OPERATG ROOM DELVERY ROOM & LABOR ROO AESTHESOLOGY RADOLOGY-DAGOSTC LABORATORY RESPRATORY THERAPY PHYSCAL THERAPY OCCUPATOAL THERAPY SPEECH PATHOLOGY ELECTROCARDOLOGY MEDCAL SUPPLES CHARGED DRUGS CHARGED TO PATETS CARDAC REHAB OUTPAT SERVCE COST CTRS CLC 01 DABETC EDUCATO EMERGECY OBSERVATO BEDS (O-DS OTHER REMBURS COST CTRS AMBULACE SERVCES HOME HEALTH AGECY SPEC PURPOSE COST CETERS 093 HOSPCE 094 OTHER SPECAL PURPOSE (SP BAD DEBT EXPESE HOSPCE 095 SUBTOTALS OREMBURS COST CETERS GFT, FLOWER, COFFEE SHOP 01 DALYSS 02 MASSAGE THERAPY 79,539 3, ,125 44,833 1,425 8,433 1,357 4,128 2,557 2,589 3,859 6,408 79,539 3,337 2,597 40,335 2,525 34,777 3,337 9,601 3,516 1,112 8, ,096 5,224 3,062 58,601 8,382 4,822 2,225 90,021 7, ,206 90,021 1, ,538 1, ,624 2, ,828 88,910 3, , , , ,228 1, , , , ,638 3, ,255 67, ,195 3,068 1, ,208 90,021 7, , ,828 3,633,547 37,099 21,682 1,796,559 58,152 1,660,992 1,889, , ,055 32,257 81,788 7, ,982 2,086, ,484 1,414,018 55, , ,379 1,276,638 6,194 16,289,124 6,917 38, VA MEDCAL CETER 68, CROSS FOOT ADJUSTMET 102 EGATVE COST CETER 103 TOTAL 79, ,125 90,021 7, , ,828 16,396, v

15 COST ALLOCATO - GEERAL SERVCE COSTS PROVDER O: PEROD: FROM 1/ 1/2005 TO 12/31/2005 PREPARED 5/ 2/2006 WORKSHEET B PART COST CETER DESCRPTO GEERAL SERVCE COST CTR 003 EW CAP REL COSTS-BLDG & 004 EW CAP REL COSTS-MVBLE E 005 EMPLOYEE BEEFTS 006 ADMSTRATVE & GEERAL 008 OPERATO OF PLAT 009 LAUDRY & LE SERVCE 010 HOUSEKEEPG 011 DETARY 012 CAFETERA 014 URSG ADMSTRATO 017 MEDCAL RECORDS & LBRARY PAT ROUTE SRVC CTRS 025 ADULTS & PEDATRCS 033 URSERY ACLLARY SRVC COST CTRS 037 OPERATG ROOM 039 DELVERY ROOM & LABOR ROO 040 AESTHESOLOGY 041 RADOLOGY-DAGOSTC 044 LABORATORY 049 RESPRATORY THERAPY 050 PHYSCAL THERAPY 051 OCCUPATOAL THERAPY 052 SPEECH PATHOLOGY 053 ELECTROCARDOLOGY 055 MEDCAL SUPPLES CHARGED 056 DRUGS CHARGED TO PATETS 059 CARDAC REHAB OUTPAT SERVCE COST CTRS 060 CLC DABETC EDUCATO 061 EMERGECY 062 OBSERVATO BEDS (O-DS OTHER REMBURS COST CTRS 065 AMBULACE SERVCES 071 HOME HEALTH AGECY SPEC PURPOSE COST CETERS 093 HOSPCE 094 OTHER SPECAL PURPOSE (SP BAD DEBT EXPESE HOSPCE 095 SUBTOTALS OREMBURS COST CETERS 096 GFT, FLOWER, COFFEE SHOP DALYSS MASSAGE THERAPY VA MEDCAL CETER 101 CROSS FOOT ADJUSTMET 102 EGATVE COST CETER 103 TOTAL &R COST TOTAL POST STEP- DOW ADJ ,633,547 37,099 1,796,559 58,152 1,660,992 1,889, , ,055 32,257 81,788 7, ,982 2,086, ,484 1,414,018 55, , ,379 1,276,638 6,194 16,289,124 38,517 68,546 16,396, v

16 COST ALLOCATO - STATSTCAL BASS PROVDER O: PEROD: PREPARED 5/ 2/2006 FROM 1/ 1/2005 WORKSHEET B-1 TO 12/31/2005 COST CETER EW CAP REL C EW CAP REL C EMPLOYEE BEE ADMSTRATV OPERATO OF DESCRPTO OSTS-BLDG & OSTS-MVBLE E FTS E & GEERAL PLAT (SQUARE FT (SQUARE FEET ( RECOCL- ( ACCUM. (SQUARE FEET ) ) ) ATO COST ) ) a GEERAL SERVCE COST CTR 003 EW CAP REL COSTS-BLDG & 47, EW CAP REL COSTS-MVBLE E 51, EMPLOYEE BEEFTS 7,272, ADMSTRATVE & GEERAL 5,352 5, ,239-2,143,256 14,252, OPERATO OF PLAT 2,091 2, , ,850 44, LAUDRY & LE SERVCE 69, HOUSEKEEPG , , DETARY 78, CAFETERA 6, URSG ADMSTRATO , , MEDCAL RECORDS & LBRARY , , PAT ROUTE SRVC CTRS 025 ADULTS & PEDATRCS 8,339 8,339 1,711,748 2,558,048 8, URSERY ,130 20, ACLLARY SRVC COST CTRS 037 OPERATG ROOM 7,190 7, ,043 1,357,898 7, DELVERY ROOM & LABOR ROO ,774 38, AESTHESOLOGY 041 RADOLOGY-DAGOSTC 1,985 1, ,645 1,358,107 1, LABORATORY ,529 1,612, RESPRATORY THERAPY , , PHYSCAL THERAPY 1,718 1, , ,671 1, OCCUPATOAL THERAPY , SPEECH PATHOLOGY 46,255 70, ELECTROCARDOLOGY 4, MEDCAL SUPPLES CHARGED 3,121 3,121 30, ,124 3, DRUGS CHARGED TO PATETS 1,080 1, ,435 1,751,720 1, CARDAC REHAB , , OUTPAT SERVCE COST CTRS 060 CLC 12, , ,437 12, DABETC EDUCATO 34,468 48, EMERGECY 1,733 1, ,556 1, OBSERVATO BEDS (O-DS OTHER REMBURS COST CTRS 065 AMBULACE SERVCES , , HOME HEALTH AGECY ,568 1,100, SPEC PURPOSE COST CETERS 093 HOSPCE 094 OTHER SPECAL PURPOSE (SP BAD DEBT EXPESE HOSPCE , SUBTOTALS 38,413 50,528 7,272,715-2,143,256 14,176,664 43,085 OREMBURS COST CETERS 096 GFT, FLOWER, COFFEE SHOP DALYSS 1,430 1,430 16,681 1, MASSAGE THERAPY VA MEDCAL CETER 7,840 59, CROSS FOOT ADJUSTMET 102 EGATVE COST CETER 103 COST TO BE ALLOCATED 206, ,957 1,507,160 2,143, ,353 (WRKSHT B, PART ) 104 UT COST MULTPLER (WRKSHT B, PT ) COST TO BE ALLOCATED (WRKSHT B, PART ) 106 UT COST MULTPLER (WRKSHT B, PT ) 107 COST TO BE ALLOCATED 62,429 25,862 (WRKSHT B, PART ) 108 UT COST MULTPLER (WRKSHT B, PT ) v

17 COST ALLOCATO - STATSTCAL BASS PROVDER O: PEROD: PREPARED 5/ 2/2006 FROM 1/ 1/2005 WORKSHEET B-1 TO 12/31/2005 COST CETER LAUDRY & L HOUSEKEEPG DETARY CAFETERA URSG ADM MEDCAL RECOR DESCRPTO E SERVCE STRATO DS & LBRARY (LBS OF LAUD (SQUARE FEET (PATET DAY (FTE'S (URS FTE'S (%OF TME ) ) ) ) ) ) GEERAL SERVCE COST CTR 003 EW CAP REL COSTS-BLDG & 004 EW CAP REL COSTS-MVBLE E 005 EMPLOYEE BEEFTS 006 ADMSTRATVE & GEERAL 008 OPERATO OF PLAT 009 LAUDRY & LE SERVCE 39, HOUSEKEEPG 1,982 44, DETARY CAFETERA 14, URSG ADMSTRATO , MEDCAL RECORDS & LBRARY 537 1,494 10,000 PAT ROUTE SRVC CTRS 025 ADULTS & PEDATRCS 22,495 8, ,475 3,475 1, URSERY ACLLARY SRVC COST CTRS 037 OPERATG ROOM 4,231 7,190 1,051 1, DELVERY ROOM & LABOR ROO AESTHESOLOGY 041 RADOLOGY-DAGOSTC 2,071 1, LABORATORY 727 1, RESPRATORY THERAPY PHYSCAL THERAPY 1,283 1, OCCUPATOAL THERAPY SPEECH PATHOLOGY ELECTROCARDOLOGY 1, MEDCAL SUPPLES CHARGED 3, DRUGS CHARGED TO PATETS 1, CARDAC REHAB OUTPAT SERVCE COST CTRS 060 CLC 1,936 12,115 1,563 5, DABETC EDUCATO 061 EMERGECY 3,215 1, OBSERVATO BEDS (O-DS OTHER REMBURS COST CTRS 065 AMBULACE SERVCES HOME HEALTH AGECY 460 2, SPEC PURPOSE COST CETERS 093 HOSPCE 094 OTHER SPECAL PURPOSE (SP BAD DEBT EXPESE HOSPCE SUBTOTALS 39,908 43, ,191 5,384 10,000 OREMBURS COST CETERS 096 GFT, FLOWER, COFFEE SHOP DALYSS 1, MASSAGE THERAPY VA MEDCAL CETER 101 CROSS FOOT ADJUSTMET 102 EGATVE COST CETER 103 COST TO BE ALLOCATED 79, ,125 90,021 7, , ,828 (PER WRKSHT B, PART ) 104 UT COST MULTPLER (WRKSHT B, PT ) COST TO BE ALLOCATED (PER WRKSHT B, PART ) 106 UT COST MULTPLER (WRKSHT B, PT ) 107 COST TO BE ALLOCATED 303 1, ,514 9,160 (PER WRKSHT B, PART 108 UT COST MULTPLER (WRKSHT B, PT ) v

18 PROVDER O: PEROD: PREPARED 5/ 2/2006 COMPUTATO OF RATO OF COSTS TO CHARGES FROM 1/ 1/2005 WORKSHEET C TO 12/31/2005 PART WKST A COST CETER DESCRPTO WKST B, PT THERAPY TOTAL RCE TOTAL LE O. COL. 27 ADJUSTMET COSTS DSALLOWACE COSTS PAT ROUTE SRVC CTRS 25 ADULTS & PEDATRCS 3,633,547 3,633,547 3,633, URSERY 37,099 37,099 37,099 ACLLARY SRVC COST CTRS 37 OPERATG ROOM 1,796,559 1,796,559 1,796, DELVERY ROOM & LABOR ROO 58,152 58,152 58, AESTHESOLOGY 41 RADOLOGY-DAGOSTC 1,660,992 1,660,992 1,660, LABORATORY 1,889,569 1,889,569 1,889, RESPRATORY THERAPY 243, , , PHYSCAL THERAPY 374, , , OCCUPATOAL THERAPY 32,257 32,257 32, SPEECH PATHOLOGY 81,788 81,788 81, ELECTROCARDOLOGY 7,776 7,776 7, MEDCAL SUPPLES CHARGED 501, , , DRUGS CHARGED TO PATETS 2,086,222 2,086,222 2,086, CARDAC REHAB 247, , ,484 OUTPAT SERVCE COST CTRS 60 CLC 1,414,018 1,414,018 1,414, DABETC EDUCATO 55,881 55,881 55, EMERGECY 676, , , OBSERVATO BEDS (O-DS 193, , ,919 OTHER REMBURS COST CTRS 65 AMBULACE SERVCES 208, , , SUBTOTAL 15,200,211 15,200,211 15,200, LESS OBSERVATO BEDS 193, , , TOTAL 15,006,292 15,006,292 15,006, v

19 PROVDER O: PEROD: PREPARED 5/ 2/2006 COMPUTATO OF RATO OF COSTS TO CHARGES FROM 1/ 1/2005 WORKSHEET C TO 12/31/2005 PART WKST A COST CETER DESCRPTO PATET OUTPATET TOTAL COST OR TEFRA PAT- PPS PAT- LE O. CHARGES CHARGES CHARGES OTHER RATO ET RATO ET RATO PAT ROUTE SRVC CTRS 25 ADULTS & PEDATRCS 3,109,914 3,109, URSERY 97,180 97,180 ACLLARY SRVC COST CTRS 37 OPERATG ROOM 790, ,200 1,775, DELVERY ROOM & LABOR ROO 126,580 51, , AESTHESOLOGY 41 RADOLOGY-DAGOSTC 772,832 3,589,698 4,362, LABORATORY 1,183,983 2,572,830 3,756, RESPRATORY THERAPY 231,755 90, , PHYSCAL THERAPY 40, , , OCCUPATOAL THERAPY 26,036 16,596 42, SPEECH PATHOLOGY 26,926 73, , ELECTROCARDOLOGY 61,710 46, , MEDCAL SUPPLES CHARGED 842, ,492 1,133, DRUGS CHARGED TO PATETS 1,506,675 2,420,200 3,926, CARDAC REHAB 6, , , OUTPAT SERVCE COST CTRS 60 CLC , , DABETC EDUCATO ,780 42, EMERGECY 98, , , OBSERVATO BEDS (O-DS 310, , OTHER REMBURS COST CTRS 65 AMBULACE SERVCES 161, , , SUBTOTAL 9,084,777 12,305,850 21,390, LESS OBSERVATO BEDS 103 TOTAL 9,084,777 12,305,850 21,390, v

20 PROVDER O: PEROD: PREPARED 5/ 2/2006 APPORTOMET OF MEDCAL, OTHER HEALTH SERVCES & VACCE COSTS FROM 1/ 1/2005 WORKSHEET D COMPOET O: TO 12/31/2005 PART V TTLE XV, PART B HOSPTAL Cost Center Description (A) ACLLARY SRVC COST CTRS 37 OPERATG ROOM 39 DELVERY ROOM & LABOR ROOM 40 AESTHESOLOGY 41 RADOLOGY-DAGOSTC 44 LABORATORY 49 RESPRATORY THERAPY 50 PHYSCAL THERAPY 51 OCCUPATOAL THERAPY 52 SPEECH PATHOLOGY 53 ELECTROCARDOLOGY 55 MEDCAL SUPPLES CHARGED TO PATETS 56 DRUGS CHARGED TO PATETS 59 CARDAC REHAB OUTPAT SERVCE COST CTRS 60 CLC DABETC EDUCATO 61 EMERGECY 62 OBSERVATO BEDS (O-DSTCT PART) OTHER REMBURS COST CTRS 65 AMBULACE SERVCES (01/01/2005 LMT 101 SUBTOTAL 102 CRA CHARGES 103 LESS PBP CLC LAB SVCS- PROGRAM OLY CHARGES 104 ET CHARGES Cost/Charge Ratio (C, Pt, col. 9) Cost/Charge Ratio (C, Pt, col. 9) Cost/Charge Ratio (C, Pt, col. 9) Outpatient Ambulatory Surgical Ctr Outpatient Radialogy (A) WORKSHEET A LE UMBERS (1) REPORT O HOSPTAL AD O SUBPROVDER COMPOETS COST FOR THE PEROD HERE (SEE STRUCTOS) v

21 PROVDER O: PEROD: PREPARED 5/ 2/2006 APPORTOMET OF MEDCAL, OTHER HEALTH SERVCES & VACCE COSTS FROM 1/ 1/2005 WORKSHEET D COMPOET O: TO 12/31/2005 PART V TTLE XV, PART B HOSPTAL Cost Center Description (A) ACLLARY SRVC COST CTRS 37 OPERATG ROOM 39 DELVERY ROOM & LABOR ROOM 40 AESTHESOLOGY 41 RADOLOGY-DAGOSTC 44 LABORATORY 49 RESPRATORY THERAPY 50 PHYSCAL THERAPY 51 OCCUPATOAL THERAPY 52 SPEECH PATHOLOGY 53 ELECTROCARDOLOGY 55 MEDCAL SUPPLES CHARGED TO PATETS 56 DRUGS CHARGED TO PATETS 59 CARDAC REHAB OUTPAT SERVCE COST CTRS 60 CLC DABETC EDUCATO 61 EMERGECY 62 OBSERVATO BEDS (O-DSTCT PART) OTHER REMBURS COST CTRS 65 AMBULACE SERVCES (01/01/2005 LMT 101 SUBTOTAL 102 CRA CHARGES 103 LESS PBP CLC LAB SVCS- PROGRAM OLY CHARGES 104 ET CHARGES Other Outpatient Diagnostic All Other (1) PPS Services 1/1/05 to 12/31/05 Outpatient Ambulatory Surgical Ctr Outpatient Radialogy ,852 1,339, ,428 26,239 67,952 6,500 29,136 46,209 76,442 1,295,078 83, ,117 18,267 83,202 96, ,866 4,993,978 4,993,978 (A) WORKSHEET A LE UMBERS (1) REPORT O HOSPTAL AD O SUBPROVDER COMPOETS COST FOR THE PEROD HERE (SEE STRUCTOS) v

22 PROVDER O: PEROD: PREPARED 5/ 2/2006 APPORTOMET OF MEDCAL, OTHER HEALTH SERVCES & VACCE COSTS FROM 1/ 1/2005 WORKSHEET D COMPOET O: TO 12/31/2005 PART V TTLE XV, PART B HOSPTAL Cost Center Description (A) ACLLARY SRVC COST CTRS 37 OPERATG ROOM 39 DELVERY ROOM & LABOR ROOM 40 AESTHESOLOGY 41 RADOLOGY-DAGOSTC 44 LABORATORY 49 RESPRATORY THERAPY 50 PHYSCAL THERAPY 51 OCCUPATOAL THERAPY 52 SPEECH PATHOLOGY 53 ELECTROCARDOLOGY 55 MEDCAL SUPPLES CHARGED TO PATETS 56 DRUGS CHARGED TO PATETS 59 CARDAC REHAB OUTPAT SERVCE COST CTRS 60 CLC DABETC EDUCATO 61 EMERGECY 62 OBSERVATO BEDS (O-DSTCT PART) OTHER REMBURS COST CTRS 65 AMBULACE SERVCES (01/01/2005 LMT 101 SUBTOTAL 102 CRA CHARGES 103 LESS PBP CLC LAB SVCS- PROGRAM OLY CHARGES 104 ET CHARGES Other Outpatient Diagnostic All Other PPS Services 1/1/05 to 12/31/05 Hospital /P Part B Charges Hospital /P Part B Costs , , ,859 19,884 79,301 4,918 23,653 3,307 33, , , ,704 23, ,863 60,009 81,493 3,193,575 3,193,575 (A) WORKSHEET A LE UMBERS (1) REPORT O HOSPTAL AD O SUBPROVDER COMPOETS COST FOR THE PEROD HERE (SEE STRUCTOS) v

23 PROVDER O: PEROD: PREPARED 5/ 2/2006 COMPUTATO OF PATET OPERATG COST FROM 1/ 1/2005 WORKSHEET D-1 COMPOET O: TO 12/31/2005 PART TTLE XV PART A HOSPTAL OTHER PART - ALL PROVDER COMPOETS PATET DAYS 1 PATET DAYS (CLUDG PRVATE ROOM AD SWG BED DAYS, EXCLUDG EWBOR) 2 PATET DAYS (CLUDG PRVATE ROOM, EXCLUDG SWG-BED AD EWBOR DAYS) 3 PRVATE ROOM DAYS (EXCLUDG SWG-BED PRVATE ROOM DAYS) 4 SEM-PRVATE ROOM DAYS (EXCLUDG SWG-BED PRVATE ROOM DAYS) 5 TOTAL SWG-BED SF-TYPE PATET DAYS (CLUDG PRVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 6 TOTAL SWG-BED SF-TYPE PATET DAYS (CLUDG PRVATE ROOM DAYS) AFTER DECEMBER 31 OF COST REPORTG PEROD (F CALEDAR YEAR, ETER 0 O THS LE) 7 TOTAL SWG-BED F TYPE PATET DAYS (CLUDG PRVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 8 TOTAL SWG-BED F TYPE PATET DAYS (CLUDG PRVATE ROOM DAYS) AFTER DECEMBER 31 OF COST REPORTG PEROD (F CALEDAR YEAR, ETER 0 O THS LE) 9 TOTAL PATET DAYS CLUDG PRVATE ROOM DAYS APPLCABLE TO THE PROGRAM (EXCLUDG SWG-BED AD EWBOR DAYS) 10 SWG-BED SF-TYPE PATET DAYS APPLCABLE TO TTLE XV OLY (CLUDG PRVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 11 SWG-BED SF-TYPE PATET DAYS APPLCABLE TO TTLE XV OLY (CLUDG PRVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTG PEROD (F CALEDAR YEAR, ETER 0 O THS LE) 12 SWG-BED F-TYPE PATET DAYS APPLCABLE TO TTLES V & XX OLY (CLUDG PRVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 13 SWG-BED F-TYPE PATET DAYS APPLCABLE TO TTLE V & XX OLY (CLUDG PRVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTG PEROD (F CALEDAR YEAR, ETER 0 O THS LE) 14 MEDCALLY ECESSARY PRVATE ROOM DAYS APPLCABLE TO THE PROGRAM (EXCLUDG SWG-BED DAYS) 15 TOTAL URSERY DAYS (TTLE V OR XX OLY) 16 URSERY DAYS (TTLE V OR XX OLY) SWG-BED ADJUSTMET 17 MEDCARE RATE FOR SWG-BED SF SERVCES APPLCABLE TO SERVCES THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 18 MEDCARE RATE FOR SWG-BED SF SERVCES APPLCABLE TO SERVCES AFTER DECEMBER 31 OF THE COST REPORTG PEROD 19 MEDCAD RATE FOR SWG-BED F SERVCES APPLCABLE TO SERVCES THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 20 MEDCAD RATE FOR SWG-BED F SERVCES APPLCABLE TO SERVCES AFTER DECEMBER 31 OF THE COST REPORTG PEROD 21 TOTAL GEERAL PATET ROUTE SERVCE COST 22 SWG-BED COST APPLCABLE TO SF-TYPE SERVCES THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 23 SWG-BED COST APPLCABLE TO SF-TYPE SERVCES AFTER DECEMBER 31 OF THE COST REPORTG PEROD 24 SWG-BED COST APPLCABLE TO F-TYPE SERVCES THROUGH DECEMBER 31 OF THE COST REPORTG PEROD 25 SWG-BED COST APPLCABLE TO F-TYPE SERVCES AFTER DECEMBER 31 OF THE COST REPORTG PEROD 26 TOTAL SWG-BED COST (SEE STRUCTOS) 27 GEERAL PATET ROUTE SERVCE COST ET OF SWG-BED COST PRVATE ROOM DFFERETAL ADJUSTMET 28 GEERAL PATET ROUTE SERVCE CHARGES (EXCLUDG SWG-BED CHARGES) 29 PRVATE ROOM CHARGES (EXCLUDG SWG-BED CHARGES) 30 SEM-PRVATE ROOM CHARGES (EXCLUDG SWG-BED CHARGES) 31 GEERAL PATET ROUTE SERVCE COST/CHARGE RATO 32 AVERAGE PRVATE ROOM PER DEM CHARGE 33 AVERAGE SEM-PRVATE ROOM PER DEM CHARGE 34 AVERAGE PER DEM PRVATE ROOM CHARGE DFFERETAL 35 AVERAGE PER DEM PRVATE ROOM COST DFFERETAL 36 PRVATE ROOM COST DFFERETAL ADJUSTMET 37 GEERAL PATET ROUTE SERVCE COST ET OF SWG-BED COST AD PRVATE ROOM COST DFFERETAL 1 4,583 3,848 3, , ,633,547 8, ,057 3,083,490 3,245,122 3,245, ,083, v