09-01 FORM CMS-2552-96 3690 (Cont.) CALCULATION OF OUTPATIENT SERVICE COST TO PROVIDER NO.: PERIOD: "WORKSHEET C," CHARGE RATIOS NET OF REDUCTIONS FROM __________ PART II ______________ TO ___________ Capital Cost Operating Cost Cost Net of Total Total Cost "(Wkst. B, sum" Net of Operating Cost Capital and Charges Outpatient Cost I/P Part B Cost Cost Center Descriptions "(Wkst. B," of Parts II & Capital Cost Capital Reduction Operating Cost "(Wkst. C," to Charge Ratio to Charge Ratio "Part I, col. 27)" "III, col. 27)" (col. 1 - col. 2) Reduction Amount Reduction "Part I, col. 8)" (col. 6 ÷ col. 7) (see instruc.) 1 2 3 4 5 6 7 8 9 ANCILLARY SERVICE COST CENTERS 37 Operating Room X X X X 37 38 Recovery Room X X X X 38 39 Delivery Room and Labor Room X X X X 39 40 Anesthesiology X X X X 40 41 Radiology-Diagnostic X X X X 41 42 Radiology-Therapeutic X X X X 42 43 Radioisotope X X X X 43 44 Laboratory X X X X 44 45 PBP Clinical Laboratory Services-Prgm. Only X X X X 45 46 Whole Blood & Packed Red Blood Cells X X X X 46 47 "Blood Storing, Processing, & Trans." X X X X 47 48 Intravenous Therapy X X X X 48 49 Respiratory Therapy X X X X 49 50 Physical Therapy X X X X 50 51 Occupational Therapy X X X X 51 52 Speech Pathology X X X X 52 53 Electrocardiology X X X X 53 54 Electroencephalography X X X X 54 55 Medical Supplies Charged to Patients X X X X 55 56 Drugs Charged to Patients X X X X 56 57 Renal Dialysis X X X X 57 58 ASC (Non-Distinct Part) X X X X 58 59 Other Ancillary (specify) X X X X 59 "FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3620 & 3620.2)" Rev. 8 36-563 09-01 FORM CMS-2552-96 3690 (Cont.) CALCULATION OF OUTPATIENT SERVICE COST TO PROVIDER NO.: PERIOD "WORKSHEET C," CHARGE RATIOS NET OF REDUCTIONS FROM: __________ PART II (CONT.) ______________ TO: __________ Capital Cost Operating Cost Cost Net of Total Total Cost "(Wkst. B, sum" Net of Operating Cost Capital and Charges Outpatient Cost I/P Part B Cost Cost Center Descriptions "(Wkst. B," of Parts II & Capital Cost Capital Reduction Operating Cost "(Wkst. C," to Charge Ratio to Charge Ratio "Part I, col. 27)" "III, col. 27)" (col. 1 - col. 2) Reduction Amount Reduction "Part I, col. 8)" (col. 6 ÷ col. 7) (see instruc.) 1 2 3 4 5 6 7 8 9 OUTPATIENT SERVICE COST CENTERS 60 Clinic X X X X 60 61 Emergency X X X X 61 62 Observation Beds (see instructions) X X X X 62 63 Other Outpatient Service (specify) X X X X 63 OTHER REIMBURSABLE COST CENTERS 64 Home Program Dialysis X X X X 64 65 Ambulance Services X X X X 65 66 Durable Medical Equipment - Rented X X X X 66 67 Durable Medical Equipment - Sold X X X X 67 68 Other Reimbursable (specify) X X X X 68 101 Subtotal (sum of lines 37-68) X X X X 101 102 Less Observation Beds X X X X 102 103 Total (sum of line 101 minus line 102) X X X X 103 "FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3620 & 3620.2)" Rev. 8 36-564