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
- 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