Worksheet D Part II
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FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1
SKYRIDGE MEDICAL CENTER - CLEVELAND, TN
Cost report status - Reopened
[Record Code 740357 - 2010]
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APPORTIONMENT OF INPATIENT ANCILLARY SERVICE CAPITAL COSTS | Provider CCN: 440185 | PERIOD: FROM 09/01/2018 TO 08/31/2019 |
WORKSHEET D, PART II |
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- Select other programs and provider types available | |||||||
Capital Related Cost (from Wkst. B, Part II, col. 26) | Total Charges (from Wkst. C, Part I, col. 8) | Ratio of Cost to Charges (col. 1 ÷ col. 2) | Inpatient Program Charges | Capital Costs (column 3 x column 4) | |||
(A) | Cost Center Description | 1 | 2 | 3 | 4 | 5 | |
ANCILLARY SERVICE COST CENTERS | |||||||
50 | Operating Room | ### | ### | ### | ### | ### | 50 |
51 | Recovery Room | 51 | |||||
52 | Labor Room and Delivery Room | ### | ### | ### | ### | ### | 52 |
53 | Anesthesiology | ### | ### | ### | ### | ### | 53 |
54 | Radiology-Diagnostic | ### | ### | ### | ### | ### | 54 |
55 | Radiology-Therapeutic | 55 | |||||
56 | Radioisotope | ### | ### | ### | ### | ### | 56 |
57 | Computed Tomography (CT) Scan | 57 | |||||
58 | Magnetic Resonance Imaging (MRI) | 58 | |||||
59 | Cardiac Catheterization | 60 | |||||
60 | Laboratory | ### | ### | ### | ### | ### | 60 |
61 | PBP Clinical Laboratory Services-Prgm. Only | 61 | |||||
62 | Whole Blood & Packed Red Blood Cells | 62 | |||||
63 | Blood Storing, Processing, & Transfusing | 63 | |||||
64 | Intravenous Therapy | 64 | |||||
65 | Respiratory Therapy | ### | ### | ### | ### | ### | 65 |
66 | Physical Therapy | ### | ### | ### | ### | ### | 66 |
67 | Occupational Therapy | ### | ### | ### | 67 | ||
68 | Speech Pathology | ### | ### | ### | 68 | ||
69 | Electrocardiology | ### | ### | ### | ### | ### | 69 |
70 | Electroencephalography | 70 | |||||
71 | Medical Supplies Charged to Patients | ### | ### | ### | ### | ### | 71 |
72 | Implantable Devices Charged to Patients | ### | ### | ### | ### | ### | 72 |
73 | Drugs Charged to Patients | ### | ### | ### | ### | ### | 73 |
74 | Renal Dialysis | ### | ### | ### | ### | ### | 74 |
75 | ASC (Non-Distinct Part) | 75 | |||||
76 | Other Ancillary (specify) | 76 | |||||
76.30 | Other Ancillary Cost Centers | ### | ### | ### | ### | ### | 76.30 |
77 | Allogeneic HSCT Acquisition | 77 | |||||
78 | CAR T-Cell Immunotherapy | 78 | |||||
OUTPATIENT SERVICE COST CENTERS | |||||||
88 | Rural Health Clinic (RHC) | 88 | |||||
89 | Federally Qualified Health Center (FQHC) | 89 | |||||
90 | Clinic | 90 | |||||
91 | Emergency | ### | ### | ### | ### | ### | 91 |
92 | Observation Beds (Non-Distinct Part) | ### | ### | ### | ### | ### | 92 |
92.01 | Observation Beds (Distinct Part) | 92.01 | |||||
93 | Other Outpatient Service (specify) | 93 | |||||
93.99 | Partial Hospitalization Program | 93.99 | |||||
OTHER REIMBURSABLE COST CENTERS | |||||||
94 | Home Program Dialysis | 94 | |||||
95 | Ambulance Services | 95 | |||||
96 | Durable Medical Equipment-Rented | 96 | |||||
97 | Durable Medical Equipment-Sold | 97 | |||||
98 | Other Reimbursable (specify) | 98 | |||||
200 | Total (sum of lines 50 through 199) | ### | ### | ### | ### | ### | 200 |
(A) Worksheet A line numbers | |||||||
FORM CMS-2552-10 (07-2023) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4024.2) | |||||||
07-23 | Rev. 21 |