STATE OF CALIFORNIA CONTRACT SCH 7 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F PROFESSIONAL SERVICE COST CENTERS 40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 0 41.00 Radiology - Diagnostic 0 0 0.000000 0 43.00 Radioisotope 0 0 0.000000 0 44.00 Laboratory 0 0 0.000000 0 53.00 Electrocardiology 0 0 0.000000 0 54.00 Electroencephalography 0 0 0.000000 0 61.00 Emergency 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 TOTAL $ 0 $ 0 $ 0 $ 0 (To Contract Sch 3) (Adj )(Adj ) (Adj ) PHYSICIAN'S REMUNERATION TO CHARGES MEDI-CAL CHARGES MEDI-CAL COSTREMUNERATION COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED TO ALL PATIENTS RATIO OF REMUNERATION TOTAL CHARGES HBP This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 6,928,870 2.00 Old Cap Rel Costs-Movable Equipmen 2,980,023 0 3.00 New Cap Rel Costs-Bldg & Fixtures 821,239 0 0 4.00 New Cap Rel Costs-Movable Equipme 3,054,161 0 0 0 4.01 0 0 0 0 0 4.02 0 0 0 0 0 0 4.03 0 0 0 0 0 0 0 4.04 0 0 0 0 0 0 0 0 4.05 0 0 0 0 0 0 0 0 0 4.06 0 0 0 0 0 0 0 0 0 0 4.07 0 0 0 0 0 0 0 0 0 0 0 4.08 0 0 0 0 0 0 0 0 0 0 0 0 5.00 Employee Benefits 29,364,734 86,664 24,820 10,272 25,437 0 0 0 0 0 0 0 6.01 Purchasing/Receiving 984,282 122,631 23,449 14,535 24,033 0 0 0 0 0 0 0 6.02 Patient Admitting 3,232,813 12,999 7,656 1,541 7,846 0 0 0 0 0 0 0 6.03 Cashiering/Accounts Receivable 2,720,410 28,228 17,093 3,346 17,519 0 0 0 0 0 0 0 6.04 0 0 0 0 0 0 0 0 0 0 0 0 6.05 0 0 0 0 0 0 0 0 0 0 0 0 6.06 0 0 0 0 0 0 0 0 0 0 0 0 6.07 0 0 0 0 0 0 0 0 0 0 0 0 6.08 0 0 0 0 0 0 0 0 0 0 0 0 6.04 Administrative and General 22,907,483 625,290 1,051,699 74,112 1,077,863 0 0 0 0 0 0 0 7.00 Maintenance and Repairs 7,658,350 300,354 38,103 35,599 39,051 0 0 0 0 0 0 0 8.00 Operation of Plant 1,622,838 264,004 19,756 31,291 20,247 0 0 0 0 0 0 0 9.00 Laundry and Linen Service 1,270,296 31,224 792 3,701 812 0 0 0 0 0 0 0 10.00 Housekeeping 4,240,720 37,315 17,228 4,423 17,657 0 0 0 0 0 0 0 11.00 Dietary 2,374,193 92,806 12,803 11,000 13,122 0 0 0 0 0 0 0 12.00 Cafeteria 469,952 106,770 3,965 12,655 4,064 0 0 0 0 0 0 0 13.00 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 14.00 Nursing Administration 2,129,514 56,672 29,160 6,717 29,885 0 0 0 0 0 0 0 15.00 Central Services & Supply 1,377,590 57,671 60,004 6,835 61,4970000000 16.00 Pharmacy 4,143,905 64,594 35,864 7,656 36,7560000000 17.00 Medical Records and Library 3,482,042 178,521 41,144 21,159 42,1670000000 18.00 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 19.00 0 0 0 0 0 0 0 0 0 0 0 0 19.02 0 0 0 0 0 0 0 0 0 0 0 0 19.03 0 0 0 0 0 0 0 0 0 0 0 0 20.00 000000000000 21.00 Nursing School 000000000000 22.00 Intern & Res Service-Salary & Fringes 0 0 0 0 0 0 0 0 0 0 0 0 23.00Intern & Res Other Program 000000000000 24.00Paramedical Ed Program 000000000000 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 28,191,560 2,392,859 138,859 283,612 142,313 0 0 0 0 0 0 0 26.00 Intensive Care Unit 9,281,322 140,623 71,741 16,667 73,5260000000 27.00 Coronary Care Unit 000000000000 30.00 Neonatal Intensive Care Unit 4,533,513 121,866 37,171 14,444 38,0950000000 31.00Surgical Intensive Care 000000000000 32.00 Subprovider I 000000000000 32.01 Subprovider II 000000000000 32.02 000000000000 33.00 Nursery 4,365,555 103,424 0 12,25800000000 34.00 Medicare Certified Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 35.00 Distinct Part Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 36.00 Adult Subacute Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 36.01 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 36.02 Transitional Care Unit 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) ANCILLARY COST CENTERS 37.00 Operating Room 10,644,786 383,822 372,307 45,492 381,569 0 0 0 0 0 0 0 38.00 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 39.00 Delivery Room and Labor Room 6,503,092 874,830 60,137 103,689 61,633 0 0 0 0 0 0 0 40.00 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 41.00 Radiology - Diagnostic 4,368,516 192,901 354,051 22,863 362,8590000000 41.01 000000000000 41.02 0 0 0 0 0 0 0 0 0 0 0 0 42.00 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 43.00 Radioisotope 811,895 35,418 43,351 4,198 44,4290000000 44.00 Laboratory 10,103,951 202,472 135,929 23,998 139,3100000000 44.01Pathological Lab 000000000000 46.00Whole Blood 000000000000 47.00 Blood Storing and Processing 000000000000 48.00 Intravenous Therapy 000000000000 49.00 Respiratory Therapy 4,466,932 39,329 63,944 4,661 65,5350000000 50.00 Physical Therapy 842,975 39,446 1,858 4,675 1,904 0 0 0 0 0 0 0 51.00 Occupational Therapy 52,904 16,144 49 1,914 50 0 0 0 0 0 0 0 52.00 Speech Pathology 59,340 2,380 0 28200000000 53.00 Electrocardiology 522,042 16,860 15,537 1,998 15,9240000000 54.00 Electroencephalography 192,438 0 10,366 0 10,6240000000 55.00 Medical Supplies Charged to Patients 19,869,12400000000000 56.00 Drugs Charged to Patients 9,349,52400000000000 57.00 Renal Dialysis 1,025,061 0 0 0 0 0 0 0 0 0 0 0 58.00 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 59.00 Patient Education & Family Counseling 13,57500000000000 59.01 Ultrasound 866,964 0 11,072 0 11,3470000000 59.02 Magnetic Resonance Imaging 402,430 83,219 38,191 9,863 39,1410000000 59.03 000000000000 60.00Clinic 000000000000 60.01 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 61.00 Emergency 12,945,407 193,068 54,820 22,883 56,184 0 0 0 0 0 0 0 62.00Observation Beds 000000000000 71.00 Home Health Agency 1,709,43800000000000 82.00 000000000000 83.00 000000000000 84.00 0 0 0 0 0 0 0 0 0 0 0 0 85.00 0 0 0 0 0 0 0 0 0 0 0 0 86.00 0 0 0 0 0 0 0 0 0 0 0 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 000000000000 97.00Research 000000000000 98.00 Physicians' Private Office 5,937,587 0 185,548 0 190,1640000000 99.00 Nonpaid Workers 000000000000 99.01 Community Benefits 3,356,270 0 1,095 0 1,123 0 0 0 0 0 0 0 99.02 Marketing 715,541 24,466 463 2,900 475 0 0 0 0 0 0 0 99.03Dialysis 21,95500000000000 99.04 000000000000 99.05 000000000000 100.00 000000000000 100.01 000000000000 100.02 000000000000 100.03 0 0 0 0 0 0 0 0 0 0 0 0 100.04 000000000000 TOTAL 242,917,112 6,928,870 2,980,023 821,239 3,054,161 0 0 0 0 0 0 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Purchasing/Receiving 6.02 Patient Admitting 6.03 Cashiering/Accounts Receivable 6.04 6.05 6.06 6.07 6.08 6.04 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTE 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 30.00 Neonatal Intensive Care Unit 31.00 Surgical Intensive Care 32.00 Subprovider I 32.01 Subprovider II 32.02 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.1 Fiscal Period Ended: JUNE 30, 2008 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.04 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 134,782 0 599,435 4,863 0 386,199 2,242 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,566,628 11,583 0 0 0 0 0 0 0 28,314,658 0 672,171 2,376 0 0 0 0 0 0 0 8,746,004 1,153,948 0 287,562 387 0 0 0 0 0 0 0 2,246,084 296,348 0 27,423 229 0 0 0 0 0 0 0 1,334,476 176,071 0 513,001 871 0 0 0 0 0 0 0 4,831,215 637,431 0 365,963 62,962 0 0 0 0 0 0 0 2,932,849 386,960 0 69,952 69,650 0 0 0 0 0 0 0 737,009 97,241 0 0 0 0 0 0 0 0 0 0 0 0 0 452,806 916 0 0 0 0 0 0 0 2,705,670 356,986 0 259,166 19,55000000001,842,313 243,075 0 839,571 71,99400000005,200,340 686,133 0 527,917 5,01800000004,297,968 567,074 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0 6,358,525 83,131 591,502 485,639 0 0 0 0 0 38,668,001 5,101,858 0 2,086,516 20,689 157,953 129,6830000011,978,720 1,580,473 0000000000 00 0 1,016,638 21,235 83,400 68,474000005,934,835 783,042 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 946,036 16,659 58,367 47,921000005,550,221 732,296 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Patient Education & Family Counseling 59.01 Ultrasound 59.02 Magnetic Resonance Imaging 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTE 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Community Benefits 99.02 Marketing 99.03 Dialysis 99.04 99.05 100.00 100.01 100.02 100.03 100.04 TOTAL SCHEDULE 8.1 Fiscal Period Ended: JUNE 30, 2008 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.04 COMPUTATION OF COST ALLOCATION (W/S B) 0 2,198,170 54,493 295,161 242,335 0 0 0 0 0 14,618,136 1,928,718 0 0 0 0 0 0 0 0 0 0 0 0 0 1,348,216 75,379 232,444 190,843 0 0 0 0 0 9,450,264 1,246,868 0 0 0 0 0 0 0 0 0 0 0 0 0 974,297 117,956 470,151 386,007000007,249,602 956,513 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 098,29334,43120,03916,452000001,108,506 146,256 0 1,374,621 41,413 365,669 300,2240000012,687,587 1,674,001 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 956,440 82,536 325,730 267,433000006,272,541 827,599 0 194,426 863 18,271 15,001 0 0 0 0 0 1,119,419 147,696 0 12,278 128 1,401 1,150 0 0 0 0 0 86,018 11,349 0001,1209190000064,0418,450 0 114,034 1,218 39,475 32,41000000759,499 100,208 036,4026976,6065,42400000262,556 34,642 0 0 484,698 417,549 342,8190000021,114,189 2,785,807 0 0 0 301,361 247,426000009,898,311 1,305,984 0 0 0 21,706 17,821 0 0 0 0 0 1,064,588 140,462 0 0 0 0 0 0 0 0 0 0 0 0 017,84504683840000032,2734,258 0 186,730 3,605 59,048 48,480000001,187,246 156,645 061,23075034,95328,69700000698,475 92,157 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 2,897,922 1,560 364,778 299,493 0 0 0 0 0 16,836,115 2,221,358 0000000000 00 0 336,151000000002,045,589 269,895 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 00000000006,313,299 832,977 0000000000 00 0 550,797 8,862 0 0 0 0 0 0 0 3,918,148 516,961 0 43,783 767 0 0 0 0 0 0 0 788,395 104,021 000000000021,9552,897 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0 29,511,927 1,303,712 3,867,152 3,175,038 0 0 0 0 0 242,917,112 28,314,658 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Purchasing/Receiving 6.02 Patient Admitting 6.03 Cashiering/Accounts Receivable 6.04 6.05 6.06 6.07 6.08 6.04 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTE 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 30.00 Neonatal Intensive Care Unit 31.00 Surgical Intensive Care 32.00 Subprovider I 32.01 Subprovider II 32.02 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2008 CENTRAL MEDICAL MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 COMPUTATION OF COST ALLOCATION (W/S B) 454,329 53,734 17,048 64,217 20,374 0 159,711 50,671 0 95,083 183,742 58,295 0 109,441 0 0 0 0 0 0 0 97,528 30,942 0 58,063 0 21,855 0 99,247 31,487 6,245 59,086 0 26,219 0 73,688 111,162 35,268 0 66,180 0 32,493 0 91,322 151,978 307,221 97,470 0 182,902 0 36,030 0 101,261 10,594 30,293 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 4,117,922 1,306,471 769,000 2,451,585 2,974,434 377,390 0 1,060,647 175,488 501,805 861,264 0 242,002 76,779 152,697 144,074 270,671 85,007 0 238,911 43,673 124,882 229,989 0 000000000000 209,721 66,537 1,122 124,857 0 37,608 0 105,696 44,827 128,182 121,435 0 000000000000 000000000000 000000000000 000000000000 177,985 56,468 0 105,963000035,168100,561 84,986 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Patient Education & Family Counseling 59.01 Ultrasound 59.02 Magnetic Resonance Imaging 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTE 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Community Benefits 99.02 Marketing 99.03 Dialysis 99.04 99.05 100.00 100.01 100.02 100.03 100.04 TOTAL SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2008 CENTRAL MEDICAL MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 COMPUTATION OF COST ALLOCATION (W/S B) 660,528 209,562 107,300 393,242 9,875 92,974 0 261,301 115,035 328,939 429,773 0 0 0 0 0 0 0 0 0 0 0 0 0 1,505,514 477,646 8,517 896,300 104,816 58,522 0 164,475 159,124 455,011 338,453 0 0 0 0 0 0 0 0 0 0 0 0 0 331,968 105,322 66,768 197,636 0 45,736 0 128,540 249,003 712,019 684,570 0 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 60,952 19,338 0 36,287 0 3,612 0 10,153 72,684 207,838 29,178 0 348,438 110,547 0 207,441 0 83,163 0 233,728 87,422 249,983 532,437 0 000000000000 000000000000 000000000000 000000000000 67,683 21,473 0 40,294 0 51,820 0 145,639 174,231 498,209 474,283 0 67,883 21,537 3,805 40,414 0 7,700 0 21,641 1,822 5,210 26,604 0 27,783 8,815 0 16,541 0 665 0 1,870 269 770 2,040 0 4,0961,29902,4380000001,6300 29,015 9,205 2,161 17,274 0 3,964 0 11,141 2,571 7,353 57,478 0 0 0 278 0 0 1,340 0 3,767 1,470 4,204 9,619 0 000000001,023,186 2,925,781 607,977 0 0000000000438,800 0 0 0 0 0 0 0 0 0 0 0 31,605 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000006820 0 0 24,214 0 0 8,546 0 24,019 7,610 21,762 85,977 0 143,213 45,436 0 85,261 0 2,139 0 6,012 1,584 4,530 50,894 0 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 332,254 105,413 439,220 197,806 265,478 159,187 0 447,391 3,294 9,418 531,140 0 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 39,395 0 110,719 18,708 53,496 0 0 42,105 13,358 0 25,067 0 10,362 0 29,123 1,618 4,628 0 0 000000000000 000000000000 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 9,899,952 2,996,762 1,581,328 5,553,236 3,625,274 1,185,728 0 3,271,045 2,381,360 6,374,876 5,630,814 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Purchasing/Receiving 6.02 Patient Admitting 6.03 Cashiering/Accounts Receivable 6.04 6.05 6.06 6.07 6.08 6.04 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTE 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 30.00 Neonatal Intensive Care Unit 31.00 Surgical Intensive Care 32.00 Subprovider I 32.01 Subprovider II 32.02 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.3 Fiscal Period Ended: JUNE 30, 2008 POST NON- INT & RES STEP-DOWN TOTAL ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY & INT & RES PARAMED SUBTOTAL ADJUSTMENT COST COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 000 0000 0 0 0 0 0 000000 0000000 0 0 0 0 0 0 0 0 58,365,865 58,365,865 0000000015,167,877 15,167,877 000000000 0 000000007,557,863 7,557,863 000000000 0 000000000 0 000000000 0 000000000 0 000000006,843,649 6,843,649 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Patient Education & Family Counseling 59.01 Ultrasound 59.02 Magnetic Resonance Imaging 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Community Benefits 99.02 Marketing 99.03 Dialysis 99.04 99.05 100.00 100.01 100.02 100.03 100.04 TOTAL SCHEDULE 8.3 Fiscal Period Ended: JUNE 30, 2008 POST NON- INT & RES STEP-DOWN TOTAL ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY & INT & RES PARAMED SUBTOTAL ADJUSTMENT COST COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 000019,155,383 19,155,383 0 0 0 0 00000 0 0 0 0 0 000014,865,512 14,865,512 0 0 0 0 00000 0 0 0 0 0 000010,727,676 10,727,676 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00001,694,803 1,694,803 0 0 0 0 000016,214,746 16,214,746 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00008,573,772 8,573,772 0 0 0 0 00001,463,732 1,463,732 0 0 0 0 0000156,122 156,122 0 0 0 0 000081,955 81,955 0 0 0 0 0000999,870 999,870 0 0 0 0 0000317,877 317,877 0 0 0 0 000028,456,941 28,456,941 0 0 0 0 000011,643,094 11,643,094 0 0 0 0 00001,236,654 1,236,654 0 0 0 0 00000 0 0 0 0 0 000037,212 37,212 0 0 0 0 00001,516,020 1,516,020 0 0 0 0 00001,129,701 1,129,701 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 000021,548,072 21,548,072 0 0 0 0 00000 0 0 0 0 0 00002,315,484 2,315,484 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00007,146,276 7,146,276 0 0 0 0 00000 0 0 0 0 0 00004,657,426 4,657,426 0 0 0 0 00001,018,676 1,018,676 0 0 0 0 000024,852 24,852 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 0 0 0 0 242,917,112 0 242,917,112 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 9 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (Dollar Value) (SQ FT) (Dollar Value) 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 5,207 788,633 5,207 788,633 6.01 Purchasing/Receiving 7,368 745,081 7,368 745,081 6.02 Patient Admitting 781 243,253 781 243,253 6.03 Cashiering/Accounts Receivable 1,696 543,134 1,696 543,134 6.04 6.05 6.06 6.07 6.08 6.04 Administrative and General 37,569 33,417,041 37,569 33,417,041 7.00 Maintenance and Repairs 18,046 1,210,701 18,046 1,210,701 8.00 Operation of Plant 15,862 627,725 15,862 627,725 9.00 Laundry and Linen Service 1,876 25,167 1,876 25,167 10.00 Housekeeping 2,242 547,423 2,242 547,423 11.00 Dietary 5,576 406,817 5,576 406,817 12.00 Cafeteria 6,415 126,001 6,415 126,001 13.00 Maintenance of Personnel 14.00 Nursing Administration 3,405 926,527 3,405 926,527 15.00 Central Services & Supply 3,465 1,906,584 3,465 1,906,584 16.00 Pharmacy 3,881 1,139,541 3,881 1,139,541 17.00 Medical Records and Library 10,726 1,307,308 10,726 1,307,308 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 143,769 4,412,151 143,769 4,412,151 26.00 Intensive Care Unit 8,449 2,279,516 8,449 2,279,516 27.00 Coronary Care Unit 30.00 Neonatal Intensive Care Unit 7,322 1,181,071 7,322 1,181,071 31.00 Surgical Intensive Care 32.00 Subprovider I 32.01 Subprovider II 32.02 33.00 Nursery 6,214 6,214 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com [...]... 48.00 49.00 50 .00 51 .00 52 .00 53 .00 54 .00 55 .00 56 .00 57 .00 58 .00 59 .00 59 .01 59 .02 59 .03 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85. 00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99. 05 100.00 100.01 100.02 100.03 100.04 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers... www.adultpdf.com 11,829,801 11 ,59 0 1,377,438 4,319,039 11,249,728 52 ,56 2 416,304 6,928,870 16.6437 75 1,470 11,600 5, 000 2,363 2,370 970 143 1,013 94,688,276 2,980,023 0.031472 416,304 821,239 1.972691 94,688,276 3, 054 ,161 0.032 255 34,803 14,7 25 34,803 14,7 25 1,470 1,741,869 351 ,7 95 1,213,479 493,689 329,363 2,031,792 59 ,027 1 ,56 4 1,377,438 4,319,039 11,249,728 1,910,824 11,829,801 5, 8 95, 666 11,600 5, 000 2,363 2,370... 493,689 329,363 2,031,792 59 ,027 1 ,56 4 1,377,438 4,319,039 11,249,728 1,910,824 11,829,801 5, 8 95, 666 11,600 5, 000 2,363 2,370 970 143 1,013 2,128 12,1 65 11 ,59 0 52 ,56 2 23,061 5, 8 95, 666 1,741,869 351 ,7 95 1,213,479 493,689 329,363 2,031,792 59 ,027 1 ,56 4 2,128 12,1 65 1,910,824 23,061 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (Dollar Value) (SQ FT) (Dollar Value) 1.00 2.00... Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non- Distinct Part) Patient Education & Family Counseling Ultrasound Magnetic Resonance Imaging ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Provider Name: ANTELOPE VALLEY HOSPITAL STATE OF CALIFORNIA This is trial version... FOR COST ALLOCATION (W/S B-1) 0 0 0.000000 4.03 (Adj ) (Adj ) STAT 0 0 0.000000 4.04 (Adj ) (Adj ) STAT 0 0 0.000000 4. 05 (Adj ) (Adj ) STAT 0 0 0.000000 4.06 (Adj ) (Adj ) STAT 0 0 0.000000 4.07 (Adj ) (Adj ) STAT 0 0 0.000000 4.08 (Adj ) (Adj ) STAT Fiscal Period Ended: JUNE 30, 2008 SCHEDULE 9 . 00 0 6, 358 ,52 5 83,131 59 1 ,50 2 4 85, 639 0 0 0 0 0 38,668,001 5, 101, 858 0 2,086 ,51 6 20,689 157 , 953 129,6830000011,978,720 1 ,58 0,473 0000000000 00 0 1,016,638 21,2 35 83,400 68,4740000 05, 934,8 35 783,042 0000000000. 18.00 COMPUTATION OF COST ALLOCATION (W/S B) 454 ,329 53 ,734 17,048 64,217 20,374 0 159 ,711 50 ,671 0 95, 083 183,742 58 ,2 95 0 109,441 0 0 0 0 0 0 0 97 ,52 8 30,942 0 58 ,063 0 21, 855 0 99,247 31,487 6,2 45 59,086. Administration 2,129 ,51 4 56 ,672 29,160 6,717 29,8 85 0 0 0 0 0 0 0 15. 00 Central Services & Supply 1,377 ,59 0 57 ,671 60,004 6,8 35 61,4970000000 16.00 Pharmacy 4,143,9 05 64 ,59 4 35, 864 7, 656 36, 756 0000000 17.00 Medical