`Ͻ 13"3313"3313#3!SAS FILEPPS99 DATA A/^U'A/^U'єє z9.0101M3SunOS5.9SUNsun4uU'BBBA/^U'(hXZYYTotal Medicare Part A Ancillary CostsF991General Inpatient Routine Service CostF992General Inpatient Routine Service CostF993Total Program General Inpatient RoutinF994Medicare Inpatient Ancillary CostF995Total Medicare Inpatient Operating CosF996Pass Through Costs - Program InpatientF997Pass Through Costs - Program InpatientF998Total Program Excludable CostsF999Total Program Inpatient Operating CostF1000TEFRA Target Amount Per DischargeF1001Target AmountF1002Difference Between Target Amount andF1003Incentive / Bonus PaymentF1003ARelief PaymentF1004Inpatient Cost Plus Incentive PaymentF1005Operating RoomF1006Recovery RoomF1007Delivery Room & Labor RoomF1008AnesthesiologyF1009Radiology - DiagnosticF1010Radiology - TherapeuticF1011RadioisotopeF1012LaboratoryF1013PBP Clinical Lab Services (Program OnlF1014Whole Blood & Packed Red Blood CellsF1015'Blood Storing, Processing, Trans.'F1016Intravenous TherapyF1017Respiratory TherapyF1018Physical TherapyF1019Occupational TherapyF1020Speech PathologyF1021ElectrocardiologyF1022ElectroencephalographyF1023Medical Supplies Charged to PatientsF1024Drugs Charged to PatientsF1025Renal DialysisF1026ASC (Non-Distinct Part)F1027Other AncillaryF1028ClinicF1029EmergencyF1030Non Distinct Observation BedsF1030ADistinct Observation Bed UnitF1031Other Outpt. ServicesF1031ARHCF1031BFQHCF1032Home Program DialysisF1033Durable Medical Equipment - RentedF1034Durable Medical Equipment - SoldF1035Other Reimbursable CostsF1036Total Medicare Part A Ancillary CostsF1037General Inpatient Routine Service CostF1038General Inpatient Routine Service CostF1039Total Program General Inpatient RoutinF1040Medicare Inpatient Ancillary CostF1041Total Medicare Inpatient Operating CosF1042Pass Through Costs - Program InpatientF1043Pass Through Costs - Program InpatientF1044Total Program Excludable CostsF1045Total Program Inpatient Operating CostF1046TEFRA Target Amount Per DischargeF1047Target AmountF1048Difference Between Target Amount andF1049Incentive / Bonus PaymentF1049ARelief PaymentF1050Inpatient Cost Plus Incentive PaymentF1051Operating RoomF1052Recovery RoomF1053Delivery Room & Labor RoomF1054AnesthesiologyF1055Radiology - DiagnosticF1056Radiology - TherapeuticF1057RadioisotopeF1058LaboratoryF1059PBP Clinical Lab Services (Program OnlF1060Whole Blood & Packed Red Blood CellsF1061'Blood Storing, Processing, Trans.'F1062Intravenous TherapyF1063Respiratory TherapyF1064Physical TherapyF1065Occupational TherapyF1066Speech PathologyF1067ElectrocardiologyF1068ElectroencephalographyF1069Medical Supplies Charged to PatientsF1070Drugs Charged to PatientsF1071Renal DialysisF1072ASC (Non-Distinct Part)F1073Other AncillaryF1074ClinicF1075EmergencyF1076Non Distinct Observation BedsF1076ADistinct Observation Bed UnitF1077Other Outpt. ServicesF1077ARHCF1077BFQHCF1078Home Program DialysisF1079AmbulanceF1080Durable Medical Equipment - RentedF1081Durable Medical Equipment - SoldF1082Other Reimbursable CostsF1083CRNA ChargesF1084Total ASC Medicare Part B Charges - HoF1085Operating RoomF1086Recovery RoomF1087Delivery Room & Labor RoomF1088AnesthesiologyF1089Radiology - DiagnosticF1090Radiology - TherapeuticF1091RadioisotopeF1092LaboratoryF1093PBP Clinical Lab Services (Program OnlF1094Whole Blood & Packed Red Blood CellsF1095'Blood Storing, Processing, Trans.'F1096Intravenous TherapyF1097Respiratory TherapyF1098Physical TherapyF1099Occupational TherapyF1100Speech PathologyF1101ElectrocardiologyF1102ElectroencephalographyF1103Medical Supplies Charged to PatientsF1104Drugs Charged to PatientsF1105Renal DialysisF1106ASC (Non-Distinct Part)F1107Other AncillaryF1108ClinicF1109EmergencyF1110Non Distinct Observation BedsF1110ADistinct Observation Bed UnitF1111Other Outpt. ServicesF1111ARHCF1111BFQHCF1112Home Program DialysisF1113AmbulanceF1114Durable Medical Equipment - RentedF1115Durable Medical Equipment - SoldF1116Other Reimbursable CostsF1117Total ASC Medicare Part B Charges - HoF1118Operating RoomF1119Recovery RoomF1120Delivery Room & Labor RoomF1121AnesthesiologyF1122Radiology - DiagnosticF1123Radiology - TherapeuticF1124RadioisotopeF1125LaboratoryF1126PBP Clinical Lab Services (Program OnlF1127Whole Blood & Packed Red Blood CellsF1128'Blood Storing, Processing, Trans.'F1129Intravenous TherapyF1130Respiratory TherapyF1131Physical TherapyF1132Occupational TherapyF1133Speech PathologyF1134ElectrocardiologyF1135ElectroencephalographyF1136Medical Supplies Charged to PatientsF1137Drugs Charged to PatientsF1138Renal DialysisF1139ASC (Non-Distinct Part)F1140Other AncillaryF1141ClinicF1142EmergencyF1143Non Distinct Observation BedsF1143ADistinct Observation Bed UnitF1144Other Outpt. ServicesF1144ARHCF1144BRHCF1145Home Program DialysisF1146AmbulanceF1147Durable Medical Equipment - RentedF1148Durable Medical Equipment - SoldF1149Other Reimbursable CostsF1150Total ASC Medicare Part B Charges - HoF1151Operating RoomF1152Recovery RoomF1153Delivery Room & Labor RoomF1154AnesthesiologyF1155Radiology - DiagnosticF1156Radiology - TherapeuticF1157RadioisotopeF1158LaboratoryF1159PBP Clinical Lab Services (Program OnlF1160Whole Blood & Packed Red Blood CellsF1161'Blood Storing, Processing, Trans.'F1162Intravenous TherapyF1163Respiratory TherapyF1164Physical TherapyF1165Occupational TherapyF1166Speech PathologyF1167ElectrocardiologyF1168ElectroencephalographyF1169Medical Supplies Charged to PatientsF1170Drugs Charged to PatientsF1171Renal DialysisF1172ASC (Non-Distinct Part)F1173Other AncillaryF1174ClinicF1175EmergencyF1176Non Distinct Observation BedsF1176ADistinct Observation Bed UnitF1177Other Outpt. ServicesF1177ARHCF1177BFQHCF1178Home Program DialysisF1179AmbulanceF1180Durable Medical Equipment - RentedF1181Durable Medical Equipment - SoldF1182Other Reimbursable CostsF1183CRNA ChargesF1184PBP Other Part B ChargesF1185Total Other Medicare Part B Charges -F1186Operating RoomF1187Recovery RoomF1188Delivery Room & Labor RoomF1189AnesthesiologyF1190Radiology - DiagnosticF1191Radiology - TherapeuticF1192RadioisotopeF1193LaboratoryF1194PBP Clinical Lab Services (Program OnlF1195Whole Blood & Packed Red Blood CellsF1196'Blood Storing, Processing, Trans.'F1197Intravenous TherapyF1198Respiratory TherapyF1199Physical TherapyF1200Occupational TherapyF1201Speech PathologyF1202ElectrocardiologyF1203ElectroencephalographyF1204Medical Supplies Charged to PatientsF1205Drugs Charged to PatientsF1206Renal DialysisF1207ASC (Non-Distinct Part)F1208Other AncillaryF1209ClinicF1210EmergencyF1211Non Distinct Observation BedsF1211ADistinct Observation Bed UnitF1212Other Outpt. ServicesF1212ARHCF1212BFQHCF1213Home Program DialysisF1214AmbulanceF1215Durable Medical Equipment - RentedF1216Durable Medical Equipment - SoldF1217Other Reimbursable CostsF1218CRNA ChargesF1219PBP Clinical Lab ChargesF1220Total Other Medicare Part B Charges -F1221Operating RoomF1222Recovery RoomF1223Delivery Room & Labor RoomF1224AnesthesiologyF1225Radiology - DiagnosticF1226Radiology - TherapeuticF1227RadioisotopeF1228LaboratoryF1229PBP Clinical Lab Services (Program OnlF1230Whole Blood & Packed Red Blood CellsF1231'Blood Storing, Processing, Trans.'F1232Intravenous TherapyF1233Respiratory TherapyF1234Physical TherapyF1235Occupational TherapyF1236Speech PathologyF1237ElectrocardiologyF1238ElectroencephalographyF1239Medical Supplies Charged to PatientsF1240Drugs Charged to PatientsF1241Renal DialysisF1242ASC (Non-Distinct Part)F1243Other AncillaryF1244ClinicF1245EmergencyF1246Non Distinct Observation BedsF1246ADistinct Observation Bed UnitF1247Other Outpt. ServicesF1247ARHCF1247BFQHCF1248Home Program DialysisF1249AmbulanceF1250Durable Medical Equipment - RentedF1251Durable Medical Equipment - SoldF1252Other Reimbursable CostsF1253CRNA ChargesF1254PBP Clinical Lab ChargesF1255Total Other Medicare Part B ChargesF1256Operating RoomF1257Recovery RoomF1258Delivery Room & Labor RoomF1259AnesthesiologyF1260Radiology - DiagnosticF1261Radiology - TherapeuticF1262RadioisotopeF1263LaboratoryF1264PBP Clinical Lab Services (Program OnlF1265Whole Blood & Packed Red Blood CellsF1266'Blood Storing, Processing, Trans.'F1267Intravenous TherapyF1268Respiratory TherapyF1269Physical TherapyF1270Occupational TherapyF1271Speech PathologyF1272ElectrocardiologyF1273ElectroencephalographyF1274Medical Supplies Charged to PatientsF1275Drugs Charged to PatientsF1276Renal DialysisF1277ASC (Non-Distinct Part)F1278Other AncillaryF1279ClinicF1280EmergencyF1281Non Distinct Observation BedsF1281ADistinct Observation Bed UnitF1282Other Outpt. ServicesF1282ARHCF1282BFQHCF1283Home Program DialysisF1284AmbulanceF1285Durable Medical Equipment - RentedF1286Durable Medical Equipment - SoldF1287Other Reimbursable CostsF1288CRNA CostsF1289Total ASC Medicare Part B Charges - HoF1290Operating RoomF1291Recovery RoomF1292Delivery Room & Labor RoomF1293AnesthesiologyF1294Radiology - DiagnosticF1295Radiology - TherapeuticF1296RadioisotopeF1297LaboratoryF1298PBP Clinical Lab Services (Program OnlF1299Whole Blood & Packed Red Blood CellsF1300'Blood Storing, Processing, Trans.'F1301Intravenous TherapyF1302Respiratory TherapyF1303Physical TherapyF1304Occupational TherapyF1305Speech PathologyF1306ElectrocardiologyF1307ElectroencephalographyF1308Medical Supplies Charged to PatientsF1309Drugs Charged to PatientsF1310Renal DialysisF1311ASC (Non-Distinct Part)F1312Other AncillaryF1313ClinicF1314EmergencyF1315Non Distinct Observation BedsF1315ADistinct Observation Bed UnitF1316Other Outpt. ServicesF1316ARHCF1316BFQHCF1317Home Program DialysisF1318AmbulanceF1319Durable Medical Equipment - RentedF1320Durable Medical Equipment - SoldF1321Other Reimbursable CostsF1322Total ASC Medicare Part B Charges - HoF1323Operating RoomF1324Recovery RoomF1325Delivery Room & Labor RoomF1326AnesthesiologyF1327Radiology - DiagnosticF1328Radiology - TherapeuticF1329RadioisotopeF1330LaboratoryF1331PBP Clinical Lab Services (Program OnlF1332Whole Blood & Packed Red Blood CellsF1333'Blood Storing, Processing, Trans.'F1334Intravenous TherapyF1335Respiratory TherapyF1336Physical TherapyF1337Occupational TherapyF1338Speech PathologyF1339ElectrocardiologyF1340ElectroencephalographyF1341Medical Supplies Charged to PatientsF1342Drugs Charged to PatientsF1343Renal DialysisF1344ASC (Non-Distinct Part)F1345Other AncillaryF1346ClinicF1347EmergencyF1348Non Distinct Observation BedsF1348ADistinct Observation Bed UnitF1349Other Outpt. ServicesF1349ARHCF1349BFQHCF1350Home Program DialysisF1351AmbulanceF1352Durable Medical Equipment - RentedF1353Durable Medical Equipment - SoldF1354Other Reimbursable CostsF1355Total ASC Medicare Part B Charges - HoF1356Operating RoomF1357Recovery RoomF1358Delivery Room & Labor RoomF1359AnesthesiologyF1360Radiology - DiagnosticF1361Radiology - TherapeuticF1362RadioisotopeF1363LaboratoryF1364PBP Clinical Lab Services (Program OnlF1365Whole Blood & Packed Red Blood CellsF1366'Blood Storing, Processing, Trans.'F1367Intravenous TherapyF1368Respiratory TherapyF1369Physical TherapyF1370Occupational TherapyF1371Speech PathologyF1372ElectrocardiologyF1373ElectroencephalographyF1374Medical Supplies Charged to PatientsF1375Drugs Charged to PatientsF1376Renal DialysisF1377ASC (Non-Distinct Part)F1378Other AncillaryF1379ClinicF1380EmergencyF1381Non Distinct Observation BedsF1381ADistinct Observation Bed UnitF1382Other Outpt. ServicesF1382ARHCF1382BFQHCF1383Home Program DialysisF1384AmbulanceF1385Durable Medical Equipment - RentedF1386Durable Medical Equipment - SoldF1387Other Reimbursable CostsF1388CRNA CostsF1389Total Other Medicare Part B Costs - HoF1390Operating RoomF1391Recovery RoomF1392Delivery Room & Labor RoomF1393AnesthesiologyF1394Radiology - DiagnosticF1395Radiology - TherapeuticF1396RadioisotopeF1397LaboratoryF1398PBP Clinical Lab Services (Program OnlF1399Whole Blood & Packed Red Blood CellsF1400'Blood Storing, Processing, Trans.'F1401Intravenous TherapyF1402Respiratory TherapyF1403Physical TherapyF1404Occupational TherapyF1405Speech PathologyF1406ElectrocardiologyF1407ElectroencephalographyF1408Medical Supplies Charged to PatientsF1409Drugs Charged to PatientsF1410Renal DialysisF1411ASC (Non-Distinct Part)F1412Other AncillaryF1413ClinicF1414EmergencyF1415Non Distinct Observation BedsF1415ADistinct Observation Bed UnitF1416Other Outpt. ServicesF1416ARHCF1416BFQHCF1417Home Program DialysisF1418AmbulanceF1419Durable Medical Equipment - RentedF1420Durable Medical Equipment - SoldF1421Other Reimbursable CostsF1422CRNA CostsF1423Total Other Medicare Part B Costs - SuF1424Operating RoomF1425Recovery RoomF1426Delivery Room & Labor RoomF1427AnesthesiologyF1428Radiology - DiagnosticF1429Radiology - TherapeuticF1430RadioisotopeF1431LaboratoryF1432PBP Clinical Lab Services (Program OnlF1433Whole Blood & Packed Red Blood CellsF1434'Blood Storing, Processing, Trans.'F1435Intravenous TherapyF1436Respiratory TherapyF1437Physical TherapyF1438Occupational TherapyF1439Speech PathologyF1440ElectrocardiologyF1441ElectroencephalographyF1442Medical Supplies Charged to PatientsF1443Drugs Charged to PatientsF1444Renal DialysisF1445ASC (Non-Distinct Part)F1446Other AncillaryF1447ClinicF1448EmergencyF1449Non Distinct Observation BedsF1449ADistinct Observation Bed UnitF1450Other Outpt. ServicesF1450ARHCF1450BFQHCF1451Home Program DialysisF1452AmbulanceF1453Durable Medical Equipment - RentedF1454Durable Medical Equipment - SoldF1455Other Reimbursable CostsF1456CRNA CostsF1457Total Other Medicare Part B Costs - SuF1458LandF1459Land ImprovementsF1460Buildings and FixturesF1461Building ImprovementsF1462Fixed EquipmentF1463Movable EquipmentF1464SubtotalF1465Total Assets - FacilityF1466LandF1467Land ImprovementsF1468Buildings and FixturesF1469Building ImprovementsF1470Fixed EquipmentF1471Movable EquipmentF1472SubtotalF1473Total Purchases - FacilityF1474LandF1475Land ImprovementsF1476Buildings and FixturesF1477Building ImprovementsF1478Fixed EquipmentF1479Movable EquipmentF1480SubtotalF1481Total Donations - FacilityF1482LandF1483Land ImprovementsF1484Buildings and FixturesF1485Building ImprovementsF1486Fixed EquipmentF1487Movable EquipmentF1488SubtotalF1489Total Disposals & Retirements - FaciliF1490LandF1491Land ImprovementsF1492Buildings and FixturesF1493Building ImprovementsF1494Fixed EquipmentF1495Movable EquipmentF1496SubtotalF1497Total Fully Depreciated Assets - FacilF1498LandF1499Land ImprovementsF1500Buildings and FixturesF1501Building ImprovementsF1502Fixed EquipmentF1503Movable EquipmentF1504SubtotalF1505Total Assets - FacilityF1506LandF1507Land ImprovementsF1508Buildings and FixturesF1509Building ImprovementsF1510Fixed EquipmentF1511Movable EquipmentF1512SubtotalF1513Total Purchases - FacilityF1514LandF1515Land ImprovementsF1516Buildings and FixturesF1517Building ImprovementsF1518Fixed EquipmentF1519Movable EquipmentF1520SubtotalF1521Total Donations - FacilityF1522LandF1523Land ImprovementsF1524Buildings and FixturesF1525Building ImprovementsF1526Fixed EquipmentF1527Movable EquipmentF1528SubtotalF1529Total Disposals & Retirements FacilityF1530LandF1531Land ImprovementsF1532Buildings and FixturesF1533Building ImprovementsF1534Fixed EquipmentF1535Movable EquipmentF1536SubtotalF1537Total Fully Depreciated Assets - FacilF1538Old Capital-Related Cost - Building &F1539Old Capital-Related Cost - Movable EquF1540New Capital-Related Cost - Building &F1541New Capital-Related Cost - Movable EquF1542Total Insurance Costs - FacilityF1543Old Capital-Related Cost - Building &F1544Old Capital-Related Cost - Movable EquF1545New Capital-Related Cost - Building &F1546New Capital-Related Cost - Movable EquF1547Total Taxes - FacilityF1548Old Capital-Related Cost - Building &F1549Old Capital-Related Cost - Movable EquF1550New Capital-Related Cost - Building &F1551New Capital-Related Cost - Movable EquF1552Total Other Capital-Related Costs - FaF1553Old Capital-Related Cost - Building &F1554Old Capital-Related Cost - Movable EquF1555New Capital-Related Cost - Building &F1556New Capital-Related Cost - Movable EquF1557Total Depreciation - FacilityF1558Old Capital-Related Cost - Building &F1559Old Capital-Related Cost - Movable EquF1560New Capital-Related Cost - Building &F1561New Capital-Related Cost - Movable EquF1562Total Lease Costs - FacilityF1563Old Capital-Related Cost - Building &F1564Old Capital-Related Cost - Movable EquF1565New Capital-Related Cost - Building &F1566New Capital-Related Cost - Movable EquF1567Total Interest Costs - FacilityF1568Old Capital-Related Cost - Building &F1569Old Capital-Related Cost - Movable EquF1570New Capital-Related Cost - Building &F1571New Capital-Related Cost - Movable EquF1572Total Capital-Related Costs - FacilityF1573Total Directly Assigned Old Capital ReF1574Adults and Pediatrics (General RoutineF1575ICUF1576Coronary Care UnitF1577Burn ICUF1578Surgical ICUF1579Other Special Care UnitF1580Sub. Prov. IF1581Sub. Prov. IIF1582NurseryF1583Skilled Nursing FacilityF1584Nursing FacilityF1584AIntermediate Care FacilityF1585Other Long Term CareF1586Operating RoomF1587Recovery RoomF1588Delivery Room and Labor RoomF1589AnesthesiologyF1590Radiology - DiagnosticF1591Radiology - TherapeuticF1592RadioisotopeF1593LaboratoryF1594Whole Blood and Packed Red Blood CellsF1595'Blood Storing, Processing, Trans.'F1596Intravenous TherapyF1597Respiratory TherapyF1598Physical TherapyF1599Occupational TherapyF1600Speech PathologyF1601ElectrocardiologyF1602ElectroencephalographyF1603Medical Supplies Charged to PatientsF1604Drugs Charged to PatientsF1605Renal DialysisF1606ASC (Non-Distinct Part)F1607Other AncillaryF1608ClinicF1609EmergencyF1609ADistinct Observation Bed UnitF1610Other Outpt. ServicesF1610ARHCF1610BFQHCF1611Home Program DialysisF1612AmbulanceF1613Durable Medical Equipment - RentedF1614Durable Medical Equipment - SoldF1615Other Reimbursable CostsF1616Outpt. Rehabilitation Providers (TotalF1617Intern - Resident Service (not in apprF1618Home Health AgencyF1619Lung AcquisitionF1620Kidney AcquisitionF1621Liver AcquisitionF1622Heart AcquisitionF1622APancreas AcquisitionF1623Other Organ AcquisitionF1624Ambulatory Surgical Center (Distinct PF1625HospiceF1626Other Special PurposeF1627Nonreimbursable CostsF1628Cross Foot AdjustmentsF1629Negative Cost CentersF1630Total Old Capital Related Costs - FaciF1631Total Directly Assigned New Capital ReF1632Adults & Pediatrics (General Routine CF1633ICUF1634Coronary Care UnitF1635Burn ICUF1636Surgical ICUF1637Other Special Care UnitF1638Sub. Prov. IF1639Sub. Prov. IIF1640NurseryF1641Skilled Nursing FacilityF1642Nursing FacilityF1642AIntermediate Care FacilityF1643Other Long Term CareF1644Operating RoomF1645Recovery RoomF1646Delivery Room & Labor RoomF1647AnesthesiologyF1648Radiology - DiagnosticF1649Radiology - TherapeuticF1650RadioisotopeF1651LaboratoryF1652Whole Blood & Packed Red Blood CellsF1653'Blood Storing, Processing, Trans.'F1654Intravenous TherapyF1655Respiratory TherapyF1656Physical TherapyF1657Occupational TherapyF1658Speech PathologyF1659ElectrocardiologyF1660ElectroencephalographyF1661Medical Supplies Charged to PatientsF1662Drugs Charged to PatientsF1663Renal DialysisF1664ASC (Non-Distinct Part)F1665Other AncillaryF1666ClinicF1667EmergencyF1667ADistinct Observation Bed UnitF1668Other Outpt. ServicesF1668ARHCF1668BFQHCF1669Home Program DialysisF1670AmbulanceF1671Durable Medical Equipment - RentedF1672Durable Medical Equipment - SoldF1673Other Reimbursable CostsF1674Outpt. Rehab Providers (Total)F1675Intern - Resident Service (not in apprF1676Home Health AgencyF1677Lung AcquisitionF1678Kidney AcquisitionF1679Liver AcquisitionF1680Heart AcquisitionF1680APancreas AcquisitionF1681Other Organ AcquisitionF1682Ambulatory Surgical CenterF1683HospiceF1684  DATASTEPF1Prov. Num. - Hosp.F2Prov. Num. - Sub. Prov.F3Prov. Num. - Sub. Prov. IIF4Prov. Num. - Swing Bed SNFF5Prov. Num. - Swing Bed NFF6Prov. Num. - Hosp.-Based SNFF7Prov. Num. - Hosp.-Based NFF7AProv. Num. - Hosp.-Based ICF/MRF8Prov. Num. - Hosp.-Based HHA IF9Prov. Num. - Separately Certified ASCF10Prov. Num. - Hosp.-Based Hospice IF11Prov. Num. - Hosp.-Based RHC IF11AProv. Num. - Hosp.-Based FQHC IF12Prov. Num. - Outpt. CORF IF13Prov. Num. - Outpt. CMHC IF14Prov. Num. - OPT Facility IF15Prov. Num. - OOT Facility IF16Prov. Num. - OSP Facility IF17Sat. Num. - Renal Dialysis IF18Hosp. NameMANManual Cost Report Indicator (M=ManualF19Hosp. Title XVIII Payment SystemF20Sub. Prov. I Title XVIII Payment SysteF21Sub. Prov. II Title XVIII Payment SystF22Cost Reporting Period Begin Date (CCYF23Cost Reporting Period End Date (CCYF24Number of Months in Reporting PeriodF25Type of Control (See Table I)F26Type of Hosp. (See Table II)F27Type of Sub. Prov. I (See Table II)F28Type of Sub. Prov. II (See Table II)F29Is Hosp. (1) Urban (2) Rural?F30Does this facility qualify and is currF31Is Hosp. Classified as Referral CenterF32Does Hosp. Operate Transplant Center?F33Kidney Transplant Center (CCYYMMDDF34Heart Transplant Center (CCYYMMDF35Liver Transplant Center (CCYYMMF36Lung Transplant Center (CCYYMMDF36APancreas Transplant Center (CCYYMMDD)F37If this is an Organ Procurement OrganiF38Is this a Teaching Hosp. or affiliatedF39'If a Sole Community Hosp. (SCH), 'F40SCH Beginning Date of First Period (CCF41SCH Ending Date of First Period (CCYYMF41ASCH Beginning Date of Second Period (CF41BSCH Ending Date of Second Period (CCYYF42Does Hosp. Have an Agreement for SwingF43'If F42 is Yes, Enter Swing Bed AgreemF44Does Facility Have Hosp.-Based SNF WhiF45'Is this a Rural Hosp. with a CertifieF46'If F45 is Yes, Enter SNF Prov. Num. 'F47Does Hosp. Qualify as a Rural PrimaryF48'If the hospital is a RPCH, Is this thF49'If a RPCH, Is the All-Inclusive MethoF50Is Hosp. a Rural Hosp. Qualifying forF51Is Hosp. an All-Inclusive Provider? (YF52'If Hosp. is an All-Inclusive ProviderF53Is this a New Hosp. Under 42 CFR 412.3F54Is this a New Hosp. Under 42 CFR 413.4F55Has a New Sub. Prov. Been Established?F56Do You Elect Fully PPS Methodology forF57Does this facility qualify and receiveF58Do You Elect Hold Harmless PaymentF59'If Hold Harmless Provider, Are You onF60Do You Have Title XIX Inpatient ServicF61Are Title XIX NF patients occupying TiF61ADoes this facility operate an ICF/MR fF62Are There Any Related Organization orF63Are Provider Based Physician Costs IncF64Are Physical Therapy Services ProvidedF64AAre Occupational Therapy Services ProvF64BAre Speech Therapy Services Provided bF65Are Respiratory Therapy Services ProviF66'If Costs for Renal Services are on WoF67If Participating in the NHCMQ DemonstrF68Does this hospital claim expendituresF68A'If this is a Medicare Dependent Hosp.F68BMDH Beginning Date of First Period (CF68CMDH Ending Date of First Period (CCYYF68DMDH Beginning Date of Second Period (F68EMDH Ending Date of Second Period (CCYF68FMalpractice PremiumsF68GMalpractice Paid LossesF68HMalpractice Self InsuranceF68IAre Malpractice premiums and paid lossF68JDoes your facility qualify for additioF68KAre you claiming ambulance costs? (Y/NF68L'If you are claiming ambulance costs,F68M'If you are claiming ambulance costs,F68N'If you are claiming ambulance costs iF69File Creation Date (CCYYMMDD) (See NoF70System Identification (See Note 10 onF71SSA State Code (See Table III)F72MSA/NECMA CodeF73Fiscal Intermediary NumberF74Cost Report Status (See Table IV)F75'Medicare Utilization Indicator (L, N,F76Census Division (See Table V)F77HCFA Region (See Table VI)F77AWas this cost report filed using TransF78Hosp. Adults & Pediatrics Beds (See NoF79ICU BedsF80Coronary Care Unit BedsF81Burn ICU BedsF82Surgical ICU BedsF83Other Special Care BedsF84Nursery BedsF85Total Hosp. BedsF86Sub. Prov. I BedsF87Sub. Prov. II BedsF88Skilled Nursing Facility BedsF89Nursing Facility BedsF89AIntermediate Care Facility/Mental RetaF90Other Long Term Care BedsF91Hospice BedsF92Total Beds Available in FacilityF93Hosp. Adults & Pediatrics Bed Days AvaF94Intensive Care Bed Days AvailableF95Coronary Care Bed Days AvailableF96Burn Intensive Care Bed Days AvailableF97Surgical Intensive Care Bed Days AvailF98Other Special Care Bed Days AvailableF99Nursery Bed Days AvailableF100Total Hosp. Bed Days AvailableF101Sub. Prov. I Bed Days AvailableF102Sub. Prov. II Bed Days AvailableF103Skilled Nursing Facility Bed Days AvaiF104Nursing Facility Bed Days AvailableF104AIntermediate Care Facility/Mental RetaF105Other Long Term Care Bed Days AvailablF106Hospice Bed Days AvailableF107Medicare Hosp. Adults & Pediatrics DayF107ATitle XVIII Inpatient Days (HMO)F108Medicare Swing Bed SNF DaysF109Total Medicare Routine DaysF110Medicare ICU DaysF111Medicare Coronary Care Unit DaysF112Medicare Burn ICU DaysF113Medicare Surgical ICU DaysF114Medicare Other Special Care Unit DaysF115Medicare Inpatient Days- Total Hosp.F116Medicare RPCH VisitsF117Medicare Sub. Prov. I DaysF118Medicare Sub. Prov. II DaysF119Medicare Skilled Nursing Facility DaysF120Medicare Home Health Agency VisitsF121Medicare Hospice DaysF122Medicare RHC/FQHC Outpt. VisitsF122AAmbulance TripsF123Medicaid Hosp. Adults & Pediatrics DayF124Medicaid HMO DaysF125Medicaid Swing Bed SNF DaysF126Medicaid Swing Bed NF DaysF127Total Medicaid Routine DaysF128Medicaid ICU DaysF129Medicaid Coronary Care Unit DaysF130Medicaid Burn ICU DaysF131Medicaid Surgical ICU DaysF132Medicaid Other Special Care DaysF133Medicaid Nursery DaysF134Medicaid Inpatient Days- Total Hosp.F135Medicaid RPCH VisitsF136Medicaid Sub. Prov. I DaysF137Medicaid Sub. Prov. II DaysF138Medicaid Skilled Nursing Facility DaysF139Medicaid Nursing Facility DaysF139AIntermediate Care Facility/Mental RetaF140Medicaid Home Health Agency VisitsF141Medicaid Hospice DaysF142Medicaid RHC/FQHC Outpt. VisitsF143Total Adults & Pediatrics DaysF144Total Swing Bed SNF DaysF145Total Swing Bed NF DaysF146Total Routine DaysF147Total ICU DaysF148Total Coronary Care Unit DaysF149Total Burn ICU DaysF150Total Surgical ICU DaysF151Total Other Special Care Unit DaysF152Total Nursery DaysF153Total Inpatient Days - Hosp.F154Total RPCH VisitsF155Total Sub. Prov. I DaysF156Total Sub. Prov. II DaysF157Total Skilled Nursing Facility DaysF158Total Nursing Facility DaysF158ATotal Intermediate Care Facility/MentaF159Total Other Long Term DaysF160Total Home Health Agency VisitsF161Total Hospice DaysF162Total RHC/FQHC Outpt. VisitsF163Total Observation Bed DaysF163ATotal Observation Bed Days (Off Site SF163BEmployee Discount DaysF164Interns & Residents - Total Hosp.F165Interns & Residents - Total FacilityF166Net Interns & Residents Replacing Non-F167Net Interns & Residents Replacing Non-F168Full Time Employees - Total Hosp.F169Full Time Employees - Total FacilityF170Nonpaid Workers - Total Hosp.F171Nonpaid Workers - Total FacilityF172Medicare Discharges - Total Hosp.F173Medicare Sub. Prov. I DischargesF174Medicare Sub. Prov. II DischargesF175Medicaid Discharges - Total Hosp.F176Medicaid Sub. Prov. I - DischargesF177Medicaid Sub. Prov. II - DischargesF178Total Discharges - All Patients - HospF179Total Discharges - All Patients - Sub.F180Total Discharges - All Patients - Sub.F181Total SalariesF182Non-Physician Anesthetist Part AF183Non-Physician Anesthetist Part BF184Physician - Part AF184ATeaching PhysicianF185Physician - Part BF186Interns & Residents (Approved Program)F187Home Office PersonnelF188Skilled Nursing FacilityF189Excluded AreasF190Contract LaborF190APharmacy Services Under ContractF190BLaboratory Services Under ContractF191Contract Labor: Physician - Part AF191ATeaching Physician Under ContractF192Home Office Salaries & Wage-Related CoF193Home Office: Physician Part AF193ASalaries and Wage Related Costs for TeF194Wage- Related Costs (Core)F195Wage- Related Costs (Other)F196Excluded AreasF197Non-Physician Anesthetist - Part AF198Non-Physician Anesthetist - Part BF199Physician Part AF199APart A Teaching PhysiciansF200Physician Part BF201Interns & Residents (Approved Program)F202Employee BenefitsF203Administrative & GeneralF204Maintenance & RepairsF205Operation of PlantF206Laundry & Linen ServiceF207HousekeepingF208DietaryF209CafeteriaF210Maintenance of PersonnelF211Nursing AdministrationF212Central Services & SupplyF213PharmacyF214Medical Records & Medical Records LibrF215Social ServiceF216Other General ServiceF217Total SalariesF218Non-Physician Anesthetist Part AF219Non-Physician Anesthetist Part BF220Physician - Part AF220ATeaching PhysicianF221Physician - Part BF222Interns & Residents (Approved Program)F223Home Office PersonnelF224Skilled Nursing FacilityF225Excluded AreasF226Contract LaborF226APharmacy Services Under ContractF226BLaboratory Services Under ContractF227Contract Labor: Physician - Part AF227ATeaching Physician Under ContractF228Home Office Salaries & Wage-Related CoF229Home Office: Physician Part AF229ASalaries and Wage Related Costs for TeF230Wage- Related Costs (Core)F231Wage- Related Costs (Other)F232Excluded AreasF233Non-Physician Anesthetist - Part AF234Non-Physician Anesthetist - Part BF235Physician Part AF235APart A Teaching PhysiciansF236Physician Part BF237Interns & Residents (Approved Program)F238Employee BenefitsF239Administrative & GeneralF240Maintenance & RepairsF241Operation of PlantF242Laundry & Linen ServiceF243HousekeepingF244DietaryF245CafeteriaF246Maintenance of PersonnelF247Nursing AdministrationF248Central Services & SupplyF249PharmacyF250Medical Records & Medical Records LibrF251Social ServiceF252Other General ServiceF253Paid Hours Related to Adjusted SalarieF254Non-Physician Anesthetist Part AF255Non-Physician Anesthetist Part BF256Physician - Part AF256ATeaching PhysicianF257Physician - Part BF258Interns & Residents (Approved Program)F259Home Office PersonnelF260Skilled Nursing FacilityF261Excluded AreasF262Contract LaborF262APharmacy Services Under ContractF262BLaboratory Services Under ContractF263Contract Labor: Physician - Part AF263ATeaching Physician Under ContractF264Home Office Salaries & Wage-Related CoF265Home Office: Physician Part AF265ASalaries and Wage Related Costs for TeF266Employee BenefitsF267Administrative & GeneralF268Maintenance & RepairsF269Operation of PlantF270Laundry & Linen ServiceF271HousekeepingF272DietaryF273CafeteriaF274Maintenance of PersonnelF275Nursing AdministrationF276Central Services & SupplyF277PharmacyF278Medical Records & Medical Records LibrF279Social ServiceF280Other General ServiceF281Average Hourly Wage Related to Total AF282Non-Physician Anesthetist Part AF283Non-Physician Anesthetist Part BF284Physician - Part AF284ATeaching PhysicianF285Physician - Part BF286Interns & Residents (Approved Program)F287Home Office PersonnelF288Skilled Nursing FacilityF289Excluded AreasF290Contract LaborF290APharmacy Services Under ContractF290BLaboratory Services Under ContractF291Contract Labor: Physicians Part AF291ATeaching Physician Under ContractF292Home Office Salaries & Wage Related CoF293Home Office: Physician Part AF293ASalaries and Wage Related Costs for TeF294Employee BenefitsF295Administrative & GeneralF296Maintenance & RepairsF297Operation of PlantF298Laundry & Linen ServiceF299HousekeepingF300DietaryF301CafeteriaF302Maintenance of PersonnelF303Nursing AdministrationF304Central Services & SupplyF305PharmacyF306Medical Records & LibraryF307Social ServicesF308Other General ServiceF309Net SalariesF310Excluded Area SalariesF311Subtotal SalariesF312Subtotal Other Wages & Related CostsF313Subtotal Wage-Related CostsF314Total (Sum of Lines 3-5)F315Net SalariesF316Excluded Area SalariesF317Subtotal Salaries (Line 7 minus Line 8F318Subtotal - Other Wages & Related CostsF319Subtotal Wage Related CostsF320Total (Sum of Lines 9-11)F321Total Overhead CostsF322Net SalariesF323Excluded Area SalariesF324Subtotal SalariesF325Subtotal Other Wages & Related CostsF326Subtotal Wage-Related CostsF327Total (Sum of Lines 3-5)F328Net SalariesF329Excluded Area SalariesF330Subtotal Salaries (Line 7 minus LineF331Subtotal - Other Wages & Related CostsF332Subtotal Wage Related CostsF333Total (Sum of Lines 9-11)F334Total Overhead CostsF335Net SalariesF336Excluded Area SalariesF337Subtotal SalariesF338Subtotal Other Wages & Related CostsF339Subtotal Wage-Related CostsF340Total (Sum of Lines 3-5)F341Net SalariesF342Excluded Area SalariesF343Subtotal Salaries (Line 7 minus Line 8F344Subtotal - Other Wages & Related CostsF345Subtotal Wage Related CostsF346Total (Sum of Lines 9-11)F347Total Overhead CostsF348Net SalariesF349Excluded Area SalariesF350Subtotal SalariesF351Subtotal Other Wages & Related CostsF352Subtotal Wage-Related CostsF353Total (Sum of Lines 3-5)F354Net SalariesF355Excluded Area SalariesF356Subtotal Salaries (Line 7 minus Line 8F357Subtotal - Other Wages & Related CostsF358Subtotal Wage Related CostsF359Total (Sum of Lines 9-11)F360Total Overhead CostsF361Employee BenefitsF362Administrative & GeneralF363Maintenance & RepairsF364Operation of PlantF365Laundry & Linen ServiceF366HousekeepingF367DietaryF368CafeteriaF369Maintenance of PersonnelF370Nursing AdministrationF371Central Services & SupplyF372PharmacyF373Medical Records & Medical Records LibrF374Social ServiceF375Other General ServiceF376Nonphysician AnesthetistsF377Nursing SchoolF378Interns & Residents in Approved PrograF379Interns & Residents in Approved Prog -F380Paramedical Education ProgramF381Adults & Pediatrics - (General RoutineF382ICUF383Coronary Care UnitF384Burn ICUF385Surgical ICUF386Other Special CareF387Sub. Prov. IF388Sub. Prov. IIF389NurseryF390Skilled Nursing FacilityF391Nursing FacilityF391AIntermediate Care Facility/Mental RetaF392Other Long Term CareF393Operating RoomF394Recovery RoomF395Delivery Room & Labor RoomF396AnesthesiologyF397Radiology - DiagnosticF398Radiology - TherapeuticF399RadioisotopeF400LaboratoryF401Whole Blood & Packed Red Blood CellsF402'Blood Storing, Processing, & Trans.'F403Intravenous TherapyF404Respiratory TherapyF405Physical TherapyF406Occupational TherapyF407Speech PathologyF408ElectrocardiologyF409ElectrocephalographyF410Medical Supplies Charged to PatientsF411Drugs Charged to PatientsF412Renal DialysisF413ASC (Non-Distinct Part)F414Other AncillaryF415ClinicF416EmergencyF416ADistinct Observation Bed UnitF417Other Outpt. ServicesF417ARural Health ClinicF417BFederally Qualified Health CenterF418Home Program DialysisF419Ambulance ServicesF420Durable Medical Equipment - RentedF421Durable Medical Equipment - SoldF422Other ReimbursableF423Outpt. Rehabilitation Provider - CORFF424Outpt. Rehabilitation Provider -CMHCF425Outpt. Rehabilitation Provider - OPTF426Outpt. Rehabilitation Provider - OOTF427Outpt. Rehabilitation Provider - OSPF428Interns & Residents (Non Approved ProgF429Home Health AgencyF430Lung AcquisitionF431Kidney AcquisitionF432Liver AcquisitionF433Heart AcquisitionF433APancreas AcquisitionF434Other Organ AcquisitionF435Utilization Review - SNFF436ASC (Distinct Part)F437HospiceF438Other Special PurposeF439Non-Reimbursable Cost CentersF440Total Salaries - FacilityF441Old Capital-Related Costs - BuildingsF442Old Capital-Related Costs - Movable EqF443New Capital-Related Costs - BuildingsF444New Capital-Related Costs - Movable EqF445Employee BenefitsF446Administrative & GeneralF447Maintenance & RepairsF448Operation of PlantF449Laundry & Linen ServiceF450HousekeepingF451DietaryF452CafeteriaF453Maintenance of PersonnelF454Nursing AdministrationF455Central Services & SupplyF456PharmacyF457Medical Records & Medical Records LibrF458Social ServiceF459Other General ServiceF460Nonphysician AnesthetistsF461Nursing SchoolF462Interns & Residents - Salaries & FringF463Interns & Residents - Other Program CoF464Paramedical Education ProgramF465Adults & Pediatrics - (General RoutineF466ICUF467Coronary Care UnitF468Burn ICUF469Surgical ICUF470Other Special CareF471Sub. Prov. IF472Sub. Prov. IIF473NurseryF474Skilled Nursing FacilityF475Nursing FacilityF475AIntermediate Care Facility/Mental RetaF476Other Long Term CareF477Operating RoomF478Recovery RoomF479Delivery Room & Labor RoomF480AnesthesiologyF481Radiology - DiagnosticF482Radiology - TherapeuticF483RadioisotopeF484LaboratoryF485PBP Clinical Laboratory Service (ProgrF486Whole Blood & Packed Red Blood CellsF487'Blood Storing, Processing, & Trans.'F488Intravenous TherapyF489Respiratory TherapyF490Physical TherapyF491Occupational TherapyF492Speech PathologyF493ElectrocardiologyF494ElectrocephalographyF495Medical Supplies Charged to PatientsF496Drugs Charged to PatientsF497Renal DialysisF498ASC (Non-Distinct Part)F499Other AncillaryF500ClinicF501EmergencyF501ADistinct Observation Bed UnitF502Other Outpt. ServicesF502ARural Health ClinicF502BFederally Qualified Health CenterF503Home Program DialysisF504Ambulance ServicesF505Durable Medical Equipment - RentedF506Durable Medical Equipment - SoldF507Other ReimbursableF508Outpt. Rehabilitation Provider - CORFF509Outpt. Rehabilitation Provider -CMHCF510Outpt. Rehabilitation Provider - OPTF511Outpt. Rehabilitation Provider - OOTF512Outpt. Rehabilitation Provider - OSPF513Interns & Residents (Non Approved ProgF514Home Health AgencyF515Lung AcquisitionF516Kidney AcquisitionF517Liver AcquisitionF518Heart AcquisitionF518APancreas AcquisitionF519Other Organ AcquisitionF520Interest ExpenseF521Utilization Review - SNFF522Other Capital-Related CostsF523ASC (Distinct Part)F524HospiceF525Other Special PurposeF526Nonreimbursable Cost CentersF527Total Other Costs - FacilityF528Old Capital-Related Costs - BuildingsF529Old Capital-Related Costs - Movable EqF530New Capital-Related Costs- BuildingsF531New Capital-Related Costs - Movable EqF532Employee BenefitsF533Administrative & GeneralF534Maintenance & RepairsF535Operation of PlantF536Laundry & Linen ServiceF537HousekeepingF538DietaryF539CafeteriaF540Maintenance of PersonnelF541Nursing AdministrationF542Central Services & SupplyF543PharmacyF544Medical Records & Medical Records LibrF545Social ServiceF546Other General ServiceF547Nonphysician AnesthetistsF548Nursing SchoolF549Interns & Residents - Salaries & FringF550Interns & Residents - Other Program CoF551Paramedical Education ProgramF552Adults & Pediatrics - (General RoutineF553ICUF554Coronary Care UnitF555Burn ICUF556Surgical ICUF557Other Special CareF558Sub. Prov. IF559Sub. Prov. IIF560NurseryF561Skilled Nursing FacilityF562Nursing FacilityF562AIntermediate Care Facility/Mental RetaF563Other Long Term CareF564Operating RoomF565Recovery RoomF566Delivery Room and Labor RoomF567AnesthesiologyF568Radiology - DiagnosticF569Radiology - TherapeuticF570RadioisotopeF571LaboratoryF572PBP Clinical Lab Services (Program OnlF573Whole Blood & Packed Red Blood CellsF574'Blood Storing, Processing, & Trans.'F575Intravenous TherapyF576Respiratory TherapyF577Physical TherapyF578Occupational TherapyF579Speech PathologyF580ElectrocardiologyF581ElectroencephalographyF582Medical Supplies Charged to PatientsF583Drugs Charged to PatientsF584Renal DialysisF585ASC (Non-Distinct Part)F586Other AncillaryF587ClinicF588EmergencyF588ADistinct Observation Bed UnitF589Other Outpt. ServicesF589ARural Health ClinicF589BFederally Qualified Health CenterF590Home Program DialysisF591Ambulance ServicesF592Durable Medical Equipment - RentedF593Durable Medical Equipment - SoldF594Other ReimbursableF595Outpt. Rehabilitation Provider - CORFF596Outpt. Rehabilitation Provider - CMHCF597Outpt. Rehabilitation Provider - OPTF598Outpt. Rehabilitation Provider - OOTF599Outpt. Rehabilitation Provider - OSPF600Intern & Resident Service (Non-ApproveF601Home Health AgencyF602Lung AcquisitionF603Kidney AcquisitionF604Liver AcquisitionF605Heart AcquisitionF605APancreas AcquisitionF606Other Organ AcquisitionF607ASC (Distinct Part)F608HospiceF609Other Special PurposeF610Nonreimbursable Cost CentersF611Total Cost Before Allocation - FacilitF612Nonphysician AnesthetistsF613Nursing SchoolF614Interns & Residents - Salary & FringesF615Interns & Residents - Program Costs (AF616Paramedical EducationF617Adults & Pediatrics - (General RoutineF618ICUF619Coronary Care UnitF620Burn ICUF621Surgical ICUF622Other Special CareF623Sub. Prov. IF624Sub. Prov. IIF625NurseryF626Skilled Nursing FacilityF627Nursing FacilityF627AIntermediate Care Facility/Mental RetaF628Other Long Term CareF629Operating RoomF630Recovery RoomF631Delivery Room and Labor RoomF632AnesthesiologyF633Radiology - DiagnosticF634Radiology - TherapeuticF635RadioisotopeF636LaboratoryF637PBP Clinical Lab Services (Program OnlF638Whole Blood & Packed Red Blood CellsF639'Blood Storing, Processing, & Trans.'F640Intravenous TherapyF641Respiratory TherapyF642Physical TherapyF643Occupational TherapyF644Speech PathologyF645ElectrocardiologyF646ElectroencephalographyF647Medical Supplies Charged to PatientsF648Drugs Charged to PatientsF649Renal DialysisF650ASC (Non-Distinct Part)F651Other AncillaryF652ClinicF653EmergencyF653ADistinct Observation Bed UnitF654Other Outpt. ServicesF654ARural Health ClinicF654BFederally Qualified Health CenterF655Home Program DialysisF656Ambulance ServicesF657Durable Medical Equipment - RentedF658Durable Medical Equipment - SoldF659Other ReimbursableF660Outpt. Rehabilitation Provider - CORFF661Outpt. Rehabilitation Provider - CMHCF662Outpt. Rehabilitation Provider - OPTF663Outpt. Rehabilitation Provider - OOTF664Outpt. Rehabilitation Provider - OSPF665Interns & Residents Service (Non-ApproF666Home Health AgencyF667Lung AcquisitionF668Kidney AcquisitionF669Liver AcquisitionF670Heart AcquisitionF670APancreas AcquisitionF671Other Organ AcquisitionF672ASC (Distinct Part)F673HospiceF674Other Special PurposeF675Nonreimbursable Cost CentersF676Cross Foot AdjustmentsF677Negative Cost CentersF678Total Costs - FacilityF679Respiratory Therapy Limit AdjustmentF680Physical Therapy Limit AdjustmentF680AOccupational Therapy Limit AdjustmentF680BSpeech Pathology Therapy Limit AdjustmF681Adults & Pediatrics - (General RoutineF682ICUF683Coronary Care UnitF684Burn ICUF685Surgical ICUF686Other Special CareF687Sub. Prov. IF688Sub. Prov. IIF689NurseryF690Skilled Nursing FacilityF691Nursing FacilityF691AIntermediate Care Facility/Mental RetaF692Other Long Term CareF693Operating RoomF694Recovery RoomF695Delivery Room & Labor RoomF696AnesthesiologyF697Radiology - DiagnosticF698Radiology - TherapeuticF699RadioisotopeF700LaboratoryF701PBP Clinical Lab Services (Program OnlF702Whole Blood & Packed Red Blood CellsF703'Blood Storing, Processing, Trans.'F704Intravenous TherapyF705Respiratory TherapyF706Physical TherapyF707Occupational TherapyF708Speech PathologyF709ElectrocardiologyF710ElectroencephalographyF711Medical Supplies Charged to PatientsF712Drugs Charged to PatientsF713Renal DialysisF714ASC (Non-Distinct Part)F715Other AncillaryF716ClinicF717EmergencyF718Non Distinct Observation Bed UnitF718ADistinct Observation BedsF719Other Outpt. ServicesF719ARural Health CenterF719BFederally Qualified Health CenterF720Home Program DialysisF721Ambulance ServicesF722Durable Medical Equipment - RentedF723Durable Medical Equipment - SoldF724Other Reimbursable CostsF725SubtotalF726Less: Observation BedsF727Total Costs - Facility (Line 101 minusF728Total Capital Reduction - FacilityF728AInpatient Capital Reduction FactorF728BOutpt. Capital Reduction FactorF729Total Operating Cost Reduction - FacilF729AOutpt. Operating Cost Reduction FactorF730Adults & Pediatrics - (General RoutineF731ICUF732Coronary Care UnitF733Burn ICUF734Surgical ICUF735Other Special CareF736Sub. Prov. IF737Sub. Prov. IIF738NurseryF739Skilled Nursing FacilityF740Nursing FacilityF740AIntermediate Care Facility/Mental RetaF741Other Long Term CareF742Operating RoomF743Recovery RoomF744Delivery Room & Labor RoomF745AnesthesiologyF746Radiology - DiagnosticF747Radiology - TherapeuticF748RadioisotopeF749LaboratoryF750PBP Clinical Lab Services (Program OnlF751Whole Blood & Packed Red Blood CellsF752'Blood Storing, Processing, Trans.'F753Intravenous TherapyF754Respiratory TherapyF755Physical TherapyF756Occupational TherapyF757Speech PathologyF758ElectrocardiologyF759ElectroencephalographyF760Medical Supplies Charged to PatientsF761Drugs Charged to PatientsF762Renal DialysisF763ASC (Non-Distinct Part)F764Other AncillaryF765ClinicF766EmergencyF767Non Distinct Observation BedsF767ADistinct Observation Bed UnitF768Other Outpt. ServicesF768ARHCF768BFQHCF769Home Program DialysisF770Ambulance ServicesF771Durable Medical Equipment - RentedF772Durable Medical Equipment - SoldF773Other Reimbursable CostsF774Operating RoomF775Recovery RoomF776Delivery Room & Labor RoomF777AnesthesiologyF778Radiology - DiagnosticF779Radiology - TherapeuticF780RadioisotopeF781LaboratoryF782PBP Clinical Lab Services (Program OnlF783Whole Blood & Packed Red Blood CellsF784'Blood Storing, Processing, Trans.'F785Intravenous TherapyF786Respiratory TherapyF787Physical TherapyF788Occupational TherapyF789Speech PathologyF790ElectrocardiologyF791ElectroencephalographyF792Medical Supplies Charged to PatientsF793Drugs Charged to PatientsF794Renal DialysisF795ASC (Non-Distinct Part)F796Other AncillaryF797ClinicF798EmergencyF799Non Distinct Observation BedsF799ADistinct Observation Bed UnitF800Other Outpt. ServicesF800ARHCF800BFQHCF801Home Program DialysisF802Ambulance ServicesF803Durable Medical Equipment - RentedF804Durable Medical Equipment - SoldF805Other Reimbursable CostsF806Operating RoomF807Recovery RoomF808Delivery Room & Labor RoomF809AnesthesiologyF810Radiology - DiagnosticF811Radiology - TherapeuticF812RadioisotopeF813LaboratoryF814PBP Clinical Lab ServicesF815Whole Blood & Packed Red Blood CellsF816'Blood Storing, Processing, Trans.'F817Intravenous TherapyF818Respiratory TherapyF819Physical TherapyF820Occupational TherapyF821Speech PathologyF822ElectrocardiologyF823ElectroencephalographyF824Medical Supplies Charged to PatientsF825Drugs Charged to PatientsF826Renal DialysisF827ASC (Non-Distinct Part)F828Other AncillaryF829ClinicF830EmergencyF831Non Distinct Observation BedsF831ADistinct Observation Bed UnitF832Other Outpt. ServiceF832ARHCF832BFQHCF833Home Program DialysisF834Durable Medical Equipment - RentedF835Durable Medical Equipment - SoldF836Other Reimbursable CostsF837Operating RoomF838Recovery RoomF839Delivery Room & Labor RoomF840AnesthesiologyF841Radiology - DiagnosticF842Radiology - TherapeuticF843RadioisotopeF844LaboratoryF845PBP Clinical Lab Services (Program OnlF846Whole Blood & Packed Red Blood CellsF847'Blood Storing, Processing, Trans.'F848Intravenous TherapyF849Respiratory TherapyF850Physical TherapyF851Occupational TherapyF852Speech PathologyF853ElectrocardiologyF854ElectroencephalographyF855Medical Supplies Charged to PatientsF856Drugs Charged to PatientsF857Renal DialysisF858ASC (Non-Distinct Part)F859Other AncillaryF860ClinicF861EmergencyF862Non Distinct Observation BedsF862ADistinct Observation Bed UnitF863Other Outpt. ServicesF863ARHCF863BFQHCF864Home Program DialysisF864AAmbulance ServicesF865Durable Medical Equipment - RentedF866Durable Medical Equipment - SoldF867Other Reimbursable CostsF868Adults & Pediatrics - (General RoutineF869ICUF870Coronary Care UnitF871Burn ICUF872Surgical ICUF873Other Special Care UnitF874Operating RoomF875Recovery RoomF876Delivery Room & Labor RoomF877AnesthesiologyF878Radiology - DiagnosticF879Radiology - TherapeuticF880RadioisotopeF881LaboratoryF882PBP Clinical Lab Services (Program OnlF883Whole Blood & Packed Red Blood CellsF884'Blood Storing, Processing, Trans.'F885Intravenous TherapyF886Respiratory TherapyF887Physical TherapyF888Occupational TherapyF889Speech PathologyF890ElectrocardiologyF891ElectroencephalographyF892Medical Supplies Charged to PatientsF893Drugs Charged to PatientsF894Renal DialysisF895ASC (Non-Distinct Part)F896Other AncillaryF897ClinicF898EmergencyF899Non Distinct Observation BedsF899ADistinct Observation Bed UnitF900Other Outpt. ServiceF900ARHCF900BFQHCF901Home Program DialysisF902Durable Medical Equipment - RentedF903Durable Medical Equipment - SoldF904Other Reimbursable CostsF905Total Medicare Part A Ancillary ChargeF906Net Medicare Part A Ancillary ChargesF907Operating RoomF908Recovery RoomF909Delivery Room & Labor RoomF910AnesthesiologyF911Radiology - DiagnosticF912Radiology - TherapeuticF913RadioisotopeF914LaboratoryF915PBP Clinical Lab Services (Program OnlF916Whole Blood & Packed Red Blood CellsF917'Blood Storing, Processing, Trans.'F918Intravenous TherapyF919Respiratory TherapyF920Physical TherapyF921Occupational TherapyF922Speech PathologyF923ElectrocardiologyF924ElectroencephalographyF925Medical Supplies Charged to PatientsF926Drugs Charged to PatientsF927Renal DialysisF928ASC (Non-Distinct Part)F929Other AncillaryF930ClinicF931EmergencyF932Non Distinct Observation BedsF932ADistinct Observation Bed UnitF933Other Outpt. ServiceF933ARHCF933BFQHCF934Home Program DialysisF935Durable Medical Equipment - RentedF936Durable Medical Equipment - SoldF937Other Reimbursable CostsF938Total Medicare Part A Costs - Hosp.F939Total Swing-Bed CostF940General Inpatient Routine ServiceF941General Inpatient Routine Service CostF942General Inpatient Routine ServiceF943ICU - Medicare CostF944Coronary Care Unit - Medicare CostF945Burn ICU - Medicare CostF946Surgical ICU - Medicare CostF947Other Special Care Unit - Medicare CosF948Medicare Inpatient AncillaryF949'Total Medicare Inpatient Operating CoF950Pass Through Costs - Program InpatientF951Pass Through Costs - Program InpatientF952Total Program Excludable CostsF953Total Program Inpatient Operating CostF954TEFRA Target Amount per DischargeF955Target AmountF956Difference Between Target Amount andF957Incentive / Bonus PaymentF957ARelief PaymentF958Inpatient Cost Plus Incentive PaymentF959Operating RoomF960Recovery RoomF961Delivery Room & Labor RoomF962AnesthesiologyF963Radiology - DiagnosticF964Radiology - TherapeuticF965RadioisotopeF966LaboratoryF967PBP Clinical Lab Services (Program OnlF968Whole Blood & Packed Red Blood CellsF969'Blood Storing, Processing, Trans.'F970Intravenous TherapyF971Respiratory TherapyF972Physical TherapyF973Occupational TherapyF974Speech PathologyF975ElectrocardiologyF976ElectroencephalographyF977Medical Supplies Charged to PatientsF978Drugs Charged to PatientsF979Renal DialysisF980ASC (Non-Distinct Part)F981Other AncillaryF982ClinicF983EmergencyF984Non Distinct Observation BedsF984ADistinct Observation Bed UnitF985Other Outpt. 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"<"\"""""##,#@#p###$$@$h$$$$%% %<%`%x%%%%&&H&d&&&&''8'T't''''(((D(l((())0)H)d))))***<*l***+++4+\+++,,(,@,\,,,,,--4-d-----.$.T.p...//$/L/h/////0,0\0|00001181h11112202`2223 3<3l3334,4\44455L5|556 606P6h666677787`7l7777788<8T8t88889989`99999::(:@:l:::::; ;L;d;|;;;<<4>(><>\>t>>>>>? ?,?\???@@@@@`@|@@AA4A`AxAAAABB4BdBBBBC$CLClCCCCDDHDpDDDE(EXEEEFF0FDFXFpFFFG GPGpGGGH HDHpHHHI$ITIIIJJ4JdJJOther Special PurposeF1685Nonreimbursable CostsF1686Cross Foot AdjustmentsF1687Negative Cost CentersF1688Total New Capital Related Costs - FaciF1689Adults & Pediatrics (General Routine CF1690ICUF1691Coronary Care UnitF1692Burn ICUF1693Surgical ICUF1694Other Special Care UnitF1695Sub. Prov. IF1696Sub. Prov. IIF1697NurseryF1698Total Medicare Part A Inpatient RoutinF1699Adults & Pediatrics (General Routine CF1700ICUF1701Coronary Care UnitF1702Burn ICUF1703Surgical ICUF1704Other Special Care UnitF1705Sub. Prov. IF1706Sub. Prov. IIF1707NurseryF1708Total Medicare A Inpatient Routine NewF1709Operating RoomF1710Recovery RoomF1711Delivery Room & Labor RoomF1712AnesthesiologyF1713Radiology - DiagnosticF1714Radiology - TherapeuticF1715RadioisotopeF1716LaboratoryF1717Whole Blood & Packed Red Blood CellsF1718'Blood Storing, Processing, Trans.'F1719Intravenous TherapyF1720Respiratory TherapyF1721Physical TherapyF1722Occupational TherapyF1723Speech PathologyF1724ElectrocardiologyF1725ElectroencephalographyF1726Medial Supplies Charged to PatientsF1727Drugs Charged to PatientsF1728Renal DialysisF1729ASC (Non-Distinct Part)F1730Other AncillaryF1731ClinicF1732EmergencyF1733Non Distinct Observation BedsF1733ADistinct Observation Bed UnitF1734Other Outpt. ServicesF1734ARHCF1734BFQHCF1735Home Program DialysisF1736Durable Medical Equipment - RentedF1737Durable Medical Equipment - SoldF1738Other Reimbursable CostsF1739Total Medicare Part A Ancillary Old CaF1740Operating RoomF1741Recovery RoomF1742Delivery Room & Labor RoomF1743AnesthesiologyF1744Radiology - DiagnosticF1745Radiology - TherapeuticF1746RadioisotopeF1747LaboratoryF1748Whole Blood & Packed Red Blood CellsF1749'Blood Storing, Processing, Trans.'F1750Intravenous TherapyF1751Respiratory TherapyF1752Physical TherapyF1753Occupational TherapyF1754Speech PathologyF1755ElectrocardiologyF1756ElectroencephalographyF1757Medial Supplies Charged to PatientsF1758Drugs Charged to PatientsF1759Renal DialysisF1760ASC (Non-Distinct Part)F1761Other AncillaryF1762ClinicF1763EmergencyF1764Non Distinct Observation BedsF1764ADistinct Observation Bed UnitF1765Other Outpt. ServicesF1765ARHCF1765BFQHCF1766Home Program DialysisF1767Durable Medical Equipment - RentedF1768Durable Medical Equipment - SoldF1769Other Reimbursable CostsF1770Total Medicare Part A Ancillary New CaF1771Total Medicare Part A Ancillary Old CF1772Total Medicare Part A Ancillary New CF1773Total Medicare Part A Ancillary Old CF1774Total Medicare Part A Ancillary New CF1775Adults & Pediatrics (General Routine CF1776ICUF1777Coronary Care UnitF1778Burn ICUF1779Surgical ICUF1780Other Special Care UnitF1781Sub. Prov. IF1782Sub. Prov. IIF1783NurseryF1783ASNFF1783BNFF1783CICF/MRF1784Total Medicare Part A Inpatient RoutinF1785Operating RoomF1786Recovery RoomF1787Delivery Room & Labor RoomF1788AnesthesiologyF1789Radiology - DiagnosticF1790Radiology - TherapeuticF1791RadioisotopeF1792LaboratoryF1793Whole Blood & Packed Red Blood CellsF1794'Blood Storing, Processing, Trans.'F1795Intravenous TherapyF1796Respiratory TherapyF1797Physical TherapyF1798Occupational TherapyF1799Speech PathologyF1800ElectrocardiologyF1801ElectroencephalographyF1802Medial Supplies Charged to PatientsF1803Drugs Charged to PatientsF1804Renal DialysisF1805ASC (Non-Distinct Part)F1806Other AncillaryF1807ClinicF1808EmergencyF1809Non Distinct Observation BedsF1809ADistinct Observation Bed UnitF1810Other Outpt. ServicesF1810ARHCF1810BFQHCF1811Home Program DialysisF1812Durable Medical Equipment - RentedF1813Durable Medical Equipment - SoldF1814Other Reimbursable CostsF1815Total Medicare Part A Ancillary OtherF1816Total Medicare Part A Ancillary OtherF1817Total Medicare Part A Ancillary OtherF1818Other than Outlier PaymentsF1819Outlier PaymentsF1819BAdditional amount received or to be reF1820Indirect Medical Education AdjustmentF1821Disproportionate Share AdjustmentF1822Additional Payment - High Percentage EF1823Subtotal of Above LinesF1824Hosp. Specific Payments (SCH or MDHF1825Total Payment for Inpatient OperatingF1826Payment for Inpatient Program CapitalF1827Exceptive Payment for Inpatient PrograF1828Direct Graduate Medical Education PaymF1829Net Organ Acquisition CostF1830Cost of Teaching PhysiciansF1831Medicare Part A Inpatient Routine ServF1832Medicare Part A Ancillary Service OtheF1833Total Payments (Lines 8 -15)F1834Primary Payer PaymentsF1835Total Amount Payable for Program BenefF1836Deductibles Billed to Program BeneficiF1837Coinsurance Billed to Program BeneficiF1838Reimbursable Bad DebtsF1838AReimbursable Bad Debt AdjustmentF1839'Subtotal (Line 18 Plus Line 21or 21.0F1840Recovery of Excess DepreciationF1841Other AdjustmentsF1842Amounts Applicable to Prior CostF1843Amount Due Provider before SequestratiF1844Sequestration AdjustmentF1845Interim PaymentsF1845ATentative SettlementsF1846Balance Due Provider (Program)F1847Protested AmountsF1848Medical and Other ServicesF1849Interns & ResidentsF1850Organ Acquisition CostsF1851Cost of Teaching PhysiciansF1852Total CostsF1853Total Customary ChargesF1854Lesser of Cost or ChargesF1855Deductibles and CoinsuranceF1856'Sum of Worksheets E, Parts C, D, andF1857Direct Graduate Medical Education PaymF1858ESRD Direct Medical Education CostsF1859Primary Payer PaymentsF1860Composite Rate ESRD Bad DebtsF1861All Other Bad DebtsF1861AReimbursable Bad Debt AdjustmentF1862Recovery of Excess Depreciation from PF1863Other AdjustmentsF1864Amounts Applicable to Prior ReportingF1864AAmount Due Provider Before SequestratiF1865Sequestration AdjustmentF1866Interim PaymentsF1866ATentative SettlementF1867Balance Due Provider (Program)F1868Protested AmountsF1869Medical and Other ServicesF1870Interns & ResidentsF1871Organ Acquisition CostsF1872Cost of Teaching PhysiciansF1873Total CostsF1874Total Customary ChargesF1875Lesser of Cost or ChargesF1876Deductibles and CoinsuranceF1877'Sum of Worksheets E, Parts C, D, andF1878Direct Graduate Medical Education PaymF1879ESRD Direct Medical Education CostsF1880Primary Payer PaymentsF1881Composite Rate ESRD Bad DebtsF1882All Other Bad DebtsF1882AReimbursable Bad Debt AdjustmentF1883Recovery of Excess Depreciation from PF1884Other AdjustmentsF1885Amounts Applicable to Prior ReportingF1885AAmount Due Provider Before SequestratiF1886Sequestration AdjustmentF1887Interim PaymentsF1887ATentative SettlementF1888Balance Due Provider (Program)F1889Protested AmountsF1890Medical and Other ServicesF1891Interns & ResidentsF1892Organ Acquisition CostsF1893Cost of Teaching PhysiciansF1894Total CostsF1895Total Customary ChargesF1896Lesser of Cost or ChargesF1897Deductibles and CoinsuranceF1898'Sum of Worksheets E, Parts C, D, andF1899Direct Graduate Medical Education PaymF1900ESRD Direct Medical Education CostsF1901Primary Payer PaymentsF1902Composite Rate ESRD Bad DebtsF1903All Other Bad DebtsF1903AReimbursable Bad Debt AdjustmentF1904Recovery of Excess Depreciation from PF1905Other AdjustmentsF1906Amounts Applicable to Prior ReportingF1906AAmount Due Provider Before SequestratiF1907Sequestration AdjustmentF1908Interim PaymentsF1908ATentative PaymentF1909Balance Due Provider (Program)F1910Protested AmountsF1911ASC Portion of BlendF1913Hosp. Specific Portion of BlendF1914ASC Blended AmountF1915Lesser of Lines 16 or 18F1915AASC Payment AmountF1916Blended Charge ProportionF1917Deductibles and CoinsuranceF1918Cost ProportionF1919Outpt. Radiology Blended AmountF1920Lesser of Lines 16 or 18F1920ARadiology Payment AmountF1921Blended Charge ProportionF1922Deductibles and CoinsuranceF1923Cost ProportionF1924Other Outpt. Diagnostic Blended AmountF1925Lesser of Lines 16 or 18F1925ADiagnostic Payment AmountF1926Inpatient Hosp. ServicesF1927Organ AcquisitionF1928Cost of Teaching PhysiciansF1929Sum of Lines 1-3F1930Primary Payer PaymentsF1931DeductiblesF1932CoinsuranceF1933Reimbursable Bad Debts (Bad Debts forF1933AReimbursable Bad Debt AdjustmentF1934Direct Graduate Medical EducationF1935Recovery of Excess Depreciation From PF1936Other AdjustmentsF1937Amounts Applicable to Prior ReportingF1938Total Amount Payable to ProviderF1939Sequestration AdjustmentF1940Interim PaymentsF1940ATentative SettlementF1941Balance Due Provider (Program)F1942Protested AmountsF1943Inpatient Hosp. ServicesF1944Organ AcquisitionF1945Cost of Teaching PhysiciansF1946Sum of Lines 1-3F1947Primary Payer PaymentsF1948DeductiblesF1949CoinsuranceF1950Reimbursable Bad Debts (Bad Debts forF1950AReimbursable Bad Debt AdjustmentF1951Recovery of Excess Depreciation From PF1952Other AdjustmentsF1953Amounts Applicable to Prior ReportingF1954Total Amount Payable to ProviderF1955Sequestration AdjustmentF1956Interim PaymentsF1956ATentative SettlementF1957Balance Due Provider (Program)F1958Protested AmountsF1959Inpatient Hosp. ServicesF1960Organ AcquisitionF1961Cost of Teaching PhysiciansF1962Sum of Lines 1-3F1963Primary Payer PaymentsF1964DeductiblesF1965CoinsuranceF1966Reimbursable Bad Debts (Bad Debts forF1966AReimbursable Bad Debt AdjustmentF1967Recovery of Excess Depreciation From PF1968Other AdjustmentsF1969Amounts Applicable to Prior ReportingF1970Total Amount Payable to ProviderF1971Sequestration AdjustmentF1972Interim PaymentsF1972ATentative SettlementF1973Balance Due Provider (Program)F1974Protested AmountsF1975Inpatient ServicesF1976Organ AcquisitionF1977Cost of Teaching PhysiciansF1978Sum of Lines 1-3F1979Primary Payer PaymentsF1980Excess of Customary Charges Over ReasoF1981Excess of Reasonable Cost Over CustomaF1982Direct Graduate Medical Education PaymF1983Cost of Covered ServicesF1984DeductiblesF1985CoinsuranceF1986Reimbursable Bad DebtsF1986AReimbursable Bad Debt AdjustmentF1987Recovery of Excess Depreciation ResultF1988Other AdjustmentsF1989Amounts Applicable to Prior ReportingF1990Amount Due Provider Before SequestratiF1991Sequestration AdjustmentF1992Interim PaymentsF1992ATentative SettlementF1993Balance Due Provider (Program)F1994Protested AmountsF1995Inpatient ServicesF1996Organ AcquisitionF1997Cost of Teaching PhysiciansF1998Sum of Lines 1-3F1999Primary Payer PaymentsF2000Excess of Customary Charges Over ReasoF2001Excess of Reasonable Cost Over CustomaF2002Cost of Covered ServicesF2003DeductiblesF2004CoinsuranceF2005Reimbursable Bad DebtsF2005AReimbursable Bad Debt AdjustmentF2006Recovery of Excess Depreciation ResultF2007Other AdjustmentsF2008Amounts Applicable to Prior ReportingF2009Amount Due Provider Before SequestratiF2010Sequestration AdjustmentF2011Interim PaymentsF2011ATentative SettlementF2012Balance Due Provider (Program)F2013Protested AmountsF2014Inpatient ServicesF2015Organ AcquisitionF2016Cost of Teaching PhysiciansF2017Sum of Lines 1-3F2018Primary Payer PaymentsF2019Excess of Customary Charges Over ReasoF2020Excess of Reasonable Cost Over CustomaF2021Cost of Covered ServicesF2022DeductiblesF2023CoinsuranceF2024Reimbursable Bad DebtsF2024AReimbursable Bad Debt AdjustmentF2025Recovery of Excess Depreciation ResultF2026Other AdjustmentsF2027Amounts Applicable to Prior ReportingF2028Amount Due Provider Before SequestratiF2029Sequestration AdjustmentF2030Interim PaymentsF2030ATentative SettlementF2031Balance Due Provider (Program)F2032Protested AmountsF2033Number of FTE Residents for OB/GYN andF2034Number of FTE Residents for All OtherF2035Updated Per Resident Amount for OB/GYNF2036Updated Per Resident Amount for All OtF2037Aggregate Approved Amount for ResidentF2037AFTE Adjustment CapF2037BUnweighted Resident FTE Count for alloF2037B1Weighted FTE count for primary care phF2037B2Weighted FTE count for all other physiF2037CWeighted FTE Count for primary care phF2037DWeighted Dental and Podiatric ResidentF2037ETotal Weighted Resident FTE count forF2037FTotal Weighted Resident FTE count forF2037GWeighted Number of FTE Residents in thF2037HWeighted Number of FTE Residents in thF2037IUpdated Per Resident Amount for OB/GYNF2037JUpdated Per Resident Amount for All OtF2037KTotal Primary Care Unadjusted ApprovedF2037LAggregate Approved Amount for ResidentF2037MGME payment for Non Managed Care DaysF2037NGME payment for Managed Care Days (forF2038Cash on Hand and in BanksF2039Temporary InvestmentsF2040Notes ReceivableF2041Accounts ReceivableF2042Other ReceivablesF2043Allowance for Uncollectible Notes andF2044InventoryF2045Prepared ExpensesF2046Other Current AssetsF2047Due From Other FundsF2048Total Current Assets - FacilityF2049LandF2050Accumulated DepreciationF2051Land ImprovementsF2052Accumulated DepreciationF2053BuildingsF2054Accumulated DepreciationF2055Leasehold ImprovementsF2056Accumulated DepreciationF2057Fixed EquipmentF2058Accumulated DepreciationF2059Automobiles and TrucksF2060Accumulated DepreciationF2061Major Movable EquipmentF2062Accumulated DepreciationF2063Minor Depreciable EquipmentF2064Accumulated DepreciationF2065Minor Nondepreciable EquipmentF2066Total Fixed Assets - FacilityF2067InvestmentsF2068Deposits on LeasesF2069Due From Owners/OfficersF2070Other AssetsF2071Total Other AssetsF2072Total Assets - FacilityF2073Accounts PayableF2074'Salaries, Wages, and Fees Payable'F2075Payroll Taxes PayableF2076Notes and Loans PayableF2077Deferred IncomeF2078Accelerated PaymentsF2079Due to Other FundsF2080Other Current LiabilitiesF2081Total Current Liabilities - FacilityF2082Mortgage PayableF2083Notes PayableF2084Unsecured LoansF2085Loans From Owners Prior to 7/1/66F2086Loans From Owners On or After 7/1/66F2087Other Long Term LiabilitiesF2088Total Long Term LiabilitiesF2089Total Liabilities - FacilityF2090General Fund BalanceF2091Specific Purpose FundF2092Donor Endowment Fund - RestrictedF2093Donor Endowment Fund - UnrestrictedF2094Governing Body Created - Endowment FunF2095Plant Fund Balance - Invested in PlantF2096'Plant Fund Balance - Reserved for PlaF2097Total Fund Balances - FacilityF2098Total Liabilities and Fund Balances -F2099Hosp.F2100Sub. Prov. IF2101Sub. Prov. IIF2102Swing Bed SNFF2103Swing Bed NFF2104Skilled Nursing FacilityF2105Nursing FacilityF2106Other Long Term CareF2107Total General Inpatient Care - FacilitF2108ICUF2109Coronary Care UnitF2110Burn ICUF2111Surgical ICUF2112Other Special Care UnitF2113Total Intensive Care Type Inpatient HoF2114Total Inpatient Routine Care ServicesF2115Inpatient Ancillary ServicesF2116Outpt. Ancillary ServicesF2117Outpt. Services Rendered in an InpatieF2118Outpt. ServicesF2119Home Health Agency - Outpt.F2120Ambulance - InpatientF2121Ambulance - Outpt.F2122Outpt. Rehabilitation Provider - CORFF2123Outpt. Rehabilitation Provider - CMHCF2124Outpt. Rehabilitation Provider - OPTF2125Outpt. Rehabilitation Provider - OOTF2126Outpt. Rehabilitation Provider - OSPF2127ASC InpatientF2128ASC Outpt.F2129Hospice InpatientF2130Hospice Outpt.F2131All Other Inpatient RevenueF2132All Other Outpt. RevenueF2133Total Patient Revenue - Inpatient -F2134Total Patient Revenue - Outpt. - FacF2135Total Patient RevenueF2136Less: Contractual Allowances and DiscF2137Net Patient RevenuesF2138Less: Total Operating ExpensesF2139Net Income From Service to PatientsF2140'Contributions, Donations, Etc.'F2141Income From InvestmentsF2142Governmental AppropriationsF2143Total Other IncomeF2144Total (Line 5 Plus Line 25)F2145Total Other ExpensesF2146Net Income or (Loss) for Period (LineF2147Capital Hosp. 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