SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_part5 pdf

37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 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 M.O.S.T Outpatient Dailysis Whittier - NRCC El Monte - NRCC Garfield - NRCC NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Marketing Clinic Other Clinic Services Emergency Observation Beds Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic TRIAL BALANCE EXPENSES Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com ALLOC COST 19.00 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 ALLOC COST 19.02 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 0 0 0 ALLOC COST 19.03 NONPHYSICIAN ANESTH 20.00 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 NURSING SCHOOL 21.00 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 COMPUTATION OF COST ALLOCATION (W/S B) 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 INT & RES SALARY & FRINGES 22.00 INT & RES PROGRAM 23.00 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 PARAMED EDUCAT 24.00 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 48,043,790 24,993 0 16,159 0 0 148,019 112,677 0 3,167,973 0 2,434,853 0 431,248 3,175,765 873,403 0 2,532,287 699,685 77,916 735,125 75,249 3,159,034 4,077,315 447,219 0 0 0 3,003,592 0 0 0 25.00 SUBTOTAL 685,278 74,094 213 610,971 POST STEP-DOWN ADJUSTMENT (Adj 4, 12) 26.00 48,729,068 24,993 0 16,159 0 0 148,019 112,677 74,094 213 610,971 3,167,973 0 2,434,853 0 431,248 3,175,765 873,403 0 2,532,287 699,685 77,916 735,125 75,249 3,159,034 4,077,315 447,219 0 0 0 3,003,592 0 0 0 27.00 TOTAL COST Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 8.3 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 0.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider I Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 1,475 11,618 1,304 2,319 1,475 11,618 1,304 2,319 15,092 5,268 16,432 1,051 1,141 2,045 5,233 16,432 1,051 1,141 2,045 5,233 16,350 8,804 16,350 8,804 15,092 5,268 9,639 377 9,639 377 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 2.00 3.00 4.00 (Adj ) (Adj ) (Adj ) (Adj ) STAT 4.02 (Adj ) STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 4.01 (Adj ) 4.03 (Adj ) STAT 4.04 (Adj ) STAT 4.05 (Adj ) STAT 4.06 (Adj ) STAT 4.07 (Adj ) STAT 4.08 (Adj ) STAT Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 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 M.O.S.T Outpatient Dailysis Whittier - NRCC El Monte - NRCC Garfield - NRCC NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Marketing Clinic Other Clinic Services Emergency Observation Beds Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 0 0.000000 0 0.000000 9,932 200 3,527 13,668 480 1,782 1,072 1,014 4,858 480 1,782 1,072 480 144,139 2,769,328 19.212899 144,139 0.000000 303 2,164 200 303 2,164 200 480 6,268 1,014 4,858 43 6,268 43 200 3,527 13,668 9,932 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 2.00 3.00 4.00 (Adj ) (Adj ) (Adj ) (Adj ) STAT 0 0.000000 4.01 (Adj ) 0 0.000000 4.02 (Adj ) STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 0 0.000000 4.03 (Adj ) STAT 0 0.000000 4.04 (Adj ) STAT 0 0.000000 4.05 (Adj ) STAT 0 0.000000 4.06 (Adj ) STAT 0 0.000000 4.07 (Adj ) STAT 0 0.000000 4.08 (Adj ) STAT Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 0.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider I Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 1,828,926 1,532,748 5,517,521 2,192,256 753,985 108,545 891,124 311,318 50,804 389,348 218,628 7,817 3,497,465 EMP BENE (GROSS SALARIES) 5.00 (Adj ) STAT 6.02 (Adj ) STAT 6.01 (Adj ) 6.03 (Adj ) STAT 6.04 (Adj ) STAT 6.05 (Adj ) STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 6.06 (Adj ) STAT 6.07 (Adj ) STAT 6.08 (Adj ) STAT 7,609,181 3,241,588 0 2,648,039 0 0 2,699,815 0 3,039,656 280,940 111,684 868,174 643,769 1,122,757 426,480 1,312,419 681,026 62,825 0 0 0 0 ADM & GEN (ACCUM COST) MAINT & REPAIRS (SQ FT) 7.00 (Adj ) Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 9.1 37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 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 M.O.S.T Outpatient Dailysis Whittier - NRCC El Monte - NRCC Garfield - NRCC NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Marketing Clinic Other Clinic Services Emergency Observation Beds Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 23,366,378 280,580 0.012008 28,386 1,175,508 92,325 1,325,290 1,228,107 794,334 1,421,943 EMP BENE (GROSS SALARIES) 5.00 (Adj ) STAT 0 0.000000 6.01 (Adj ) 0 0.000000 6.02 (Adj ) STAT 0 0.000000 6.03 (Adj ) STAT 0 0.000000 6.04 (Adj ) STAT 0 0.000000 6.05 (Adj ) STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 0 0.000000 6.06 (Adj ) STAT 0 0.000000 6.07 (Adj ) STAT 0 0.000000 6.08 (Adj ) STAT 42,686,132 5,357,658 0.125513 9,222 0 3,843 0 0 120,820 41,577 0 2,168,770 0 1,710,477 0 369,491 2,525,786 772,065 0 2,055,624 464,604 53,881 564,698 37,389 2,123,993 2,113,763 389,381 0 0 0 2,412,395 0 0 0 ADM & GEN (ACCUM COST) 0 0.000000 MAINT & REPAIRS (SQ FT) 7.00 (Adj ) Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 9.1 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 0.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider I Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 385,244 95,602 210,242 8,804 16,350 91,730 15,092 5,268 16,350 8,804 15,092 5,268 1,475 11,618 1,304 2,319 1,475 11,618 1,304 2,319 4,640 HOUSEKEEPING (HR SERV) 10.00 (Adj ) 2,045 5,233 LAUNDRY & LINEN (LB LNDRY) 9.00 (Adj ) 1,051 1,141 2,045 5,233 OPER PLANT (SQ FT) 8.00 (Adj ) 3,540 9,584 40,523 3,180 DIETARY (MEALS SERVED) 11.00 (Adj ) 3,648 2,873 9,815 2,324 2,457 381 1,535 1,025 2,080 4,160 2,080 CAFETERIA MAINT OF NURSING (MEALS PERSONNEL ADMIN SERVED) (# HOUSED) (NURSE HR) 12.00 13.00 14.00 (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 8,949 117 8,738 5,478 CENT SERV & SUPPLY (CST REQ) 15.00 (Adj ) PHARMACY (COSTS REQUIS) 16.00 (Adj ) 8,914,800 34,105,250 8,674,500 MED REC (GROSS SALARIES) 17.00 (Adj 13) 2,170 3,838 158 SOC SERV (TIME SPENT) 18.00 (Adj ) 19.00 (Adj ) STAT Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 9.2 37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 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 M.O.S.T Outpatient Dailysis Whittier - NRCC El Monte - NRCC Garfield - NRCC NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Marketing Clinic Other Clinic Services Emergency Observation Beds Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 30,924 LAUNDRY & LINEN (LB LNDRY) 9.00 (Adj ) 200 303 2,164 115,499 158,870 1.375506 200 303 2,164 117,691 3,421,172 29.069106 935,510 346,753 0.370657 6,268 480 73,754 480 1,782 1,072 480 6,268 480 1,782 1,072 1,014 4,858 1,014 4,858 9,102 43 200 3,527 13,668 9,932 HOUSEKEEPING (HR SERV) 10.00 (Adj ) 43 21,342 13,668 200 3,527 12,930 9,932 OPER PLANT (SQ FT) 8.00 (Adj ) 56,827 1,039,400 18.290598 DIETARY (MEALS SERVED) 11.00 (Adj ) 34,922 883,887 25.310330 111 227 1,329 976 2,103 2,232 1,377 2,509 0 0.000000 10,400 1,370,770 131.804852 2,080 CAFETERIA MAINT OF NURSING (MEALS PERSONNEL ADMIN SERVED) (# HOUSED) (NURSE HR) 12.00 13.00 14.00 (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 1,721,855 845,077 0.490795 9,377 1,502,617 77,881 2,155 106,469 71 CENT SERV & SUPPLY (CST REQ) 15.00 (Adj ) 2,195,398 1,555,697 0.708617 2,195,398 PHARMACY (COSTS REQUIS) 16.00 (Adj ) 172,254,563 863,048 0.005010 6,232,588 530,593 4,110,438 105,813 6,182,537 28,451,429 1,789,364 19,155,590 3,958,002 623,641 1,854,743 21,740,182 10,756,349 15,068,744 MED REC (GROSS SALARIES) 17.00 (Adj 13) 6,711 70,710 10.536492 74 34 437 SOC SERV (TIME SPENT) 18.00 (Adj ) 0 0.000000 19.00 (Adj ) STAT Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 9.2 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 0.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider I Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com STAT 19.03 (Adj ) STAT 19.02 (Adj ) NONPHY ANESTH (ASG TIME) 20.00 (Adj ) NURSE SCHOOL (ASG TIME) 21.00 (Adj ) I&R-SAL & FRINGES (ASG TIME) 22.00 (Adj ) I&R-PRG COST (ASG TIME) 23.00 (Adj ) PARAMED EDUCAT (ASG TIME) 24.00 (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 9.3 37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 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 M.O.S.T Outpatient Dailysis Whittier - NRCC El Monte - NRCC Garfield - NRCC NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Marketing Clinic Other Clinic Services Emergency Observation Beds Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com STAT 0 0.000000 19.02 (Adj ) 0 0.000000 19.03 (Adj ) STAT 0 0.000000 NONPHY ANESTH (ASG TIME) 20.00 (Adj ) 0 0.000000 NURSE SCHOOL (ASG TIME) 21.00 (Adj ) 0 0.000000 I&R-SAL & FRINGES (ASG TIME) 22.00 (Adj ) 0 0.000000 I&R-PRG COST (ASG TIME) 23.00 (Adj ) 0 0.000000 PARAMED EDUCAT (ASG TIME) 24.00 (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 9.3 STATE OF CALIFORNIA SCHEDULE 10 TRIAL BALANCE OF EXPENSES Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 REPORTED 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider I Subprovider II Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit $ ADJUSTMENTS (From Sch 10A) $ 2,324,939 284,883 5,267,374 2,723,856 260,747 89,762 824,208 540,603 1,085,364 201,961 1,217,448 632,733 62,215 $ 444,389 0 0 0 0 (11,546) 0 0 0 0 (136,906) 0 0 0 0 59,217 0 0 0 0 0 7,252,966 3,114,050 2,460,484 2,363,723 This is trial version www.adultpdf.com 0 0 0 0 0 0 0 AUDITED 0 2,769,328 0 0 0 0 273,337 0 0 0 0 5,130,468 2,723,856 260,747 89,762 824,208 540,603 1,085,364 201,961 1,276,665 632,733 62,215 0 0 0 0 7,252,966 3,114,050 0 2,460,484 0 0 2,363,723 0 STATE OF CALIFORNIA SCHEDULE 10 TRIAL BALANCE OF EXPENSES Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2007 REPORTED 37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 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 99.05 100.00 100.01 100.02 100.03 100.04 100.99 101 ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic $ 365,648 2,443,275 771,239 2,020,228 371,268 44,659 529,352 16,793 2,123,993 2,172,980 389,381 Clinic Other Clinic Services Emergency Observation Beds M.O.S.T Outpatient Dailysis Whittier - NRCC El Monte - NRCC Garfield - NRCC SUBTOTAL TOTAL 1,960,873 $ 1,438,337 Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Intravenous Therapy Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis ASC (Non-Distinct Part) SUBTOTAL NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Marketing ADJUSTMENTS (From Sch 10A) 2,277,853 $ 47,633,195 $ 114,658 $ $ 114,658 $ 47,747,853 $ This is trial version www.adultpdf.com $ 0 0 0 0 0 0 0 0 0 0 (59,217) 0 0 0 0 0 0 0 0 295,937 $ AUDITED 1,960,873 0 1,438,337 0 365,648 2,443,275 771,239 0 2,020,228 371,268 44,659 529,352 16,793 2,123,993 2,113,763 389,381 0 0 0 2,277,853 0 0 0 47,929,132 0 0 0 0 0 0 0 0 0 114,658 0 0 0 0 $ 114,658 295,937 $ 48,043,790 (To Schedule 8) ... 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. .. 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. .. 30, 2007 SCHEDULE 9.2 37.00 38.00 39.00 40.00 41.00 41.01 41.02 42.00 43.00 44.00 44.01 46.00 47.00 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