Tên nhà cung cấp: Seton Y TẾ TRUNG TÂM cung cấp số ZZR00289G đơn vị chăm sóc đặc biệt 1. 2. 3. 4. 5. Tổng chi phí bệnh nhân nội trú thường xuyên (8 Sch, Line , Col 27) Tổng số ngày bệnh nhân nội trú (adj) trung bình mỗi Diệm ngày Chi phí nội trú Medi-Cal (adj) Chi phí áp dụng cho Medi-Cal $ $ $ BÁO CÁO | STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST Provider Name SETON MEDICAL CENTER Fiscal Period Ended JUNE 30 2008 Provider No. ZZR00289G 1. SPECIAL CARE UNITS Total Inpatient Routine Cost Sch 8 Line Col 27 E REPORTED 1 L AUDITED 0 0 2. Total Inpatient Days Adj 0 0 3. Average Per Diem Cost 4. Medi-Cal Inpatient Days Adj 0 0 5. Cost Applicable to Medi-Cal 0 0 6. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 7. Total Inpatient Days Adj 0 0 8. Average Per Diem Cost 9. Medi-Cal Inpatient Days Adj 0 0 10. Cost Applicable to Medi-Cal 0 0 11. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 12. Total Inpatient Days Adj 0 0 13. Average Per Diem Cost 14. Medi-Cal Inpatient Days Adj 0 0 15. Cost Applicable to Medi-Cal 0 0 16. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 17. Total Inpatient Days Adj 0 0 18. Average Per Diem Cost 19. Medi-Cal Inpatient Days Adj 0 0 20. Cost Applicable to Medi-Cal 0 0 21. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 22. Total Inpatient Days Adj 0 0 23. Average Per Diem Cost 24. Medi-Cal Inpatient Days Adj 0 0 25. Cost Applicable to Medi-Cal 0 0 26. Total Inpatient Routine Cost Sch 8 Line Col 27 0 0 27. Total Inpatient Days Adj 0 0 28. Average Per Diem Cost 29. Medi-Cal Inpatient Days Adj 0 0 30. Cost Applicable to Medi-Cal 0 0 31. Medi-Cal Routine Cost Sum of Lines 5 10 15 20 25 30 0 0 To Schedule 4 This is trial version STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT SCHEDULE OF MEDI-CAL ANCILLARY COSTS Provider Name SETON MEDICAL CENTER Fiscal Period Ended JUNE 30 2008 Provider No ZZR00289G TOTAL ANCILLARY COST TOTAL ANCILLARY CHARGES Adj RATIO COST TO CHARGES MEDI-CAL CHARGES From Schedule 6 MEDI-CAL COST ANCILLARY COST CENTERS Operating Room 13 091 529 46 551 832 0 0 Recovery Room 0 0 0 0 Delivery Room and Labor Room 2 076 319 9 753 262 0 0
