04-05			FORM CMS-2552-96									   3690 (Cont.)
COMPUTATION OF AVERAGE COST PER TREATMENT					PROVIDER NO.:			PERIOD:			WORKSHEET I-4	
FOR OUTPATIENT RENAL DIALYSIS					___________________			FROM ____________				
								TO ________________				
Check applicable box:		[  ]  Renal Dialysis Department	[  ]  Home Program Dialysis									
												
					Average Cost			Total			Total	
			Number	Total Cost	of Program	Number of Program Treatments		Program			Program	
			of Total	(from Wkst.	Treatments			Expenses			Payment	
			Treatments	"I-2, col. 11)"	(col. 2 ´ col. 1)			(col. 4 x col. 3)	Payment Rate		(col. 4 x col. 6)	
			1	2	3	4	4.01	5	6	6.01	7	
1 	 Maintenance - Hemodialysis		X		X	X	X		X	X	X	1 
2 	 Maintenance - Peritoneal Dialysis		X		X	X	X		X	X	X	2 
3 	 Training - Hemodialysis		X		X	X	X		X	X	X	3 
4 	 Training - Peritoneal Dialysis		X		X	X	X		X	X	X	4 
5 	 Training - Continous Ambulatory Peritoneal Dialysis		X		X	X	X		X	X	X	5 
6 	 Training - Continous Cycling Peritoneal Dialysis		X		X	X	X		X	X	X	6 
7 	 Home Program - Hemodialysis		X		X	X	X		X	X	X	7 
8 	 Home Program - Peritoneal Dialysis		X		X	X	X		X	X	X	8 
			Patient Weeks		X	Patient Weeks	X		X	X	X	
9 	 Home Program - Continuous Ambulatory Peritoneal Dialysis		X			X	X			X		9 
10 	 Home Program - Continuous Cycling Peritoneal Dialysis		X		X	X	X		X	X	X	10 
11 	" Totals (sum of lines 1-8, columns 1 and 4)"		X			X		X		X	X	11 
	"                (sum of lines 1-10, columns 2, 5, and 7)"											
												
												
												
												
												
												
												
												
												
												
												
												
												
												
												
												
												
"FORM CMS-2552-96 (9/96)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3654)"												
												
												
												
Rev. 14												        36-623