1.00 2.00 3.00 3.01 4.00 4.01 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 21.00 21.01 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 31.01 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Other Long Term Care Subacute Care Unit II Transitional Care Unit Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults and Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider Subprovider Psych Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and 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 and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 26 19 599,609 11,027,194 5,545,755 28,117,790 6,152,260 5,741,984 96 12 12 20 11 26 44 4,148,442 140,520 3,033,057 1,487,897 573,301 216,673 2,414,892 1,875,596 1,673,609 98 37 11 24 30 11 23 5,198,704 2,129,985 1,372,878 1,431,609 376,503 600 600 2,306 393 713 560,713 17,597 752,459 1,429,951 312,320 276,563 201,934 90,174 7,865,722 209,452 1,102 432,089 5,520 23,120 95,396 321,501 1,542,421 1,376,067 157,839 57,386,505 4,011,290 47,692,933 236,227,228 43,249,710 43,834,825 EMP BENE NONPATIENT DATA PURCHASING ADMITTING (GROSS TELEPHONES PROCESSING RECEIVING (GROSS SALARIES) (# OF PHONES) (DP TIME) (SUPPLY COST) REVENUE) 5.00 6.01 6.02 6.03 6.04 57,386,505 4,011,290 47,692,933 236,227,228 43,249,710 43,834,825 CASHIERING ACCOUNTS (GROSS REV) 6.05 STATISTICS FOR COST ALLOCATION (W/S B-1) STAT 6.07 STAT 6.06 6.08 STAT 44,324,632 9,678,945 8,661,144 0 0 799,818 16,809,136 9,161,041 0 5,468,128 4,077,426 1,783,889 3,967,073 4,047,559 2,839,822 6,307,305 1,713,757 5,863,502 3,530,881 783,791 0 0 0 37,500 ADM & GEN (ACCUM COST) 13,441 229 32,395 70,870 6,016 6,052 3,621 8,016 4,107 10,473 480 8,450 4,534 2,572 10,211 8,318 MAINT & REPAIRS (SQ FT) 7.00 (Adj 3) Fiscal Period Ended: JUNE 30, 2008 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 60.02 60.03 60.04 61.00 62.00 71.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 100.00 100.01 100.02 100.04 100.05 100.07 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop and Canteen Research Physicians' Private Office Nonpaid Workers Satelite Clinic - Airport HIV Serviceis Women Service Line Community Health Education Marketing SF Heart Institute MD Office Building Mission Servicies Auxillary Group Foundation Clinic Wound Care Out-Patient Psychiatry Diabetes Treatment Center OB/GYN Clinic Emergency Observation Beds Home Health Agency 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) Gastro Intestinal Services Cardiac Cath Lab CT/MRI ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - P O B Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 92 1,187 1,047,157 882.188016 4,612 5,844,447 1267.226203 7,249,740 986,994 158,827 1,821,437 68,445,820 2,644,037 61,636,378 19,344,898 4,375,860 1,907,513 33,984,619 523,728 198,819,832 161,356,094 7,884,886 28,444,139 8,806,895 66,299,845 41,721,087 42,126,994 1,451,666,457 5,744,864 2,821,576 0.136370 0.001944 6,095 8 131,263,368 42,603,915 0.324568 6,687 6,392 91,698 25 41 294,602 457,067 41,183 126,279 159,719 385,164 41,615 2,976 54,162 105,171 85,623 253,207 58,791 352,924 4,900 46,198 279,241 54,468 83,578 2,559 35,201 6,458 18,683,105 1,841,109 1,653,269 72 35,728,737 21,822,957 110,799,606 9,753,262 24,227,696 34,164,284 17,961,854 46,551,832 171,111 808,405 2,051,344 9,202 129,638 351,837 72,858 275,179 86,268 35 4,255,334 26 12 32 46 17 19 23 924,040 266,749 217,518 394,484 6,388,928 747,385 2,240,201 1,113,147 1,746,224 157,561 441,775 3,668,069 1,503,733 368,122 194,949 1,277,417 56,496 1,451,300 733,590 5,300,912 14 16 52 1,096,290 5,343,667 742,410 12 67 25 6,495,689 EMP BENE NONPATIENT DATA PURCHASING ADMITTING (GROSS TELEPHONES PROCESSING RECEIVING (GROSS SALARIES) (# OF PHONES) (DP TIME) (SUPPLY COST) REVENUE) 5.00 6.01 6.02 6.03 6.04 1,459,168,770 5,781,754 0.003962 7,502,313 7,249,740 986,994 158,827 1,821,437 68,445,820 2,644,037 61,636,378 19,344,898 4,375,860 1,907,513 33,984,619 523,728 198,819,832 161,356,094 7,884,886 28,444,139 8,806,895 66,299,845 41,721,087 1,841,109 35,728,737 21,822,957 110,799,606 9,753,262 24,227,696 34,164,284 17,961,854 46,551,832 CASHIERING ACCOUNTS (GROSS REV) 6.05 STATISTICS FOR COST ALLOCATION (W/S B-1) STAT 0 0.000000 6.06 0 0.000000 6.07 STAT 0 0.000000 6.08 STAT 254,860,118 23,749,024 0.093185 288,612 0 0 0 897,862 1,013,897 3,058,101 110,567 149,549 44,655 10,819,069 1,653,622 404,892 9,054,560 1,684,632 3,063,051 2,343,063 11,304,644 1,901,135 728,879 6,190,355 3,707,064 890,500 283,403 2,148,351 105,218 22,405,161 8,750,085 1,160,081 4,004,561 1,655,461 3,562,407 541,514 0 2,108,205 629,837 349,679 1,757,116 9,761,739 6,473,243 0 ADM & GEN (ACCUM COST) 355,590 5,977,673 16.810577 487 5,977 112 135 1,436 1,083 949 7,129 9,774 4,300 960 4,294 11,566 548 8,336 1,444 8,922 2,246 1,644 8,141 10,894 7,314 80 4,083 334 351 7,705 4,391 11,940 3,175 2,904 17,406 8,606 7,139 MAINT & REPAIRS (SQ FT) 7.00 (Adj 3) Fiscal Period Ended: JUNE 30, 2008 SCHEDULE 9.1 1.00 2.00 3.00 3.01 4.00 4.01 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 21.00 21.01 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 31.01 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Other Long Term Care Subacute Care Unit II Transitional Care Unit Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults and Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider Subprovider Psych Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and 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 and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 668,569 70,595 70,392 LAUNDRY & LINEN (LB LNDRY) 9.00 800,037 128,668 70,870 6,016 6,052 3,621 8,016 4,107 10,473 480 4,534 2,572 10,211 8,318 OPER PLANT (SQ FT) 8.00 (Adj 3) 229 32,395 13,441 2,912 17,056 20,384 3,328 1,872 936 936 2,392 HOUSEKEEPING (HR SERV) 10.00 52,898 178,192 157,088 5,598 11,818 DIETARY (MEALS SERVED) 11.00 (Adj 4) 120,453 249,204 423,313 74,647 70,833 65,816 2,832 53,308 43,849 12,881 113,780 235,505 378,634 68,932 65,747 CAFETERIA MAINT OF NURSING (PROD PERSONNEL ADMIN HRS) (# HOUSED) (NURSE HR) 12.00 13.00 14.00 STATISTICS FOR COST ALLOCATION (W/S B-1) 457,474 15,323 323,767 940,030 218,662 198,683 10,141 CENT SERV & SUPPLY (CST REQ) 15.00 28,870 229 9,615 46,141 10,771 8,912 PHARMACY (COSTS REQUIS) 16.00 57,386,505 4,011,290 47,692,933 236,227,228 43,249,710 43,834,825 MED REC (GROSS REVENUE) 17.00 1,495 5,164 4,464 396 401 SOC SERV (TIME SPENT) 18.00 19.00 STAT Fiscal Period Ended: JUNE 30, 2008 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 60.02 60.03 60.04 61.00 62.00 71.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 100.00 100.01 100.02 100.04 100.05 100.07 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop and Canteen Research Physicians' Private Office Nonpaid Workers Satelite Clinic - Airport HIV Serviceis Women Service Line Community Health Education Marketing SF Heart Institute MD Office Building Mission Servicies Auxillary Group Foundation Clinic Wound Care Out-Patient Psychiatry Diabetes Treatment Center OB/GYN Clinic Emergency Observation Beds Home Health Agency 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) Gastro Intestinal Services Cardiac Cath Lab CT/MRI ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - P O B Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 1,248 5,928 728 728 2,704 405,594 4,880,098 12.031978 77,716 17,202 7,101 5,066 11,912 86,330 16,589 39,526 12,599 17,297 2,031 2,106,857 2,086,413 0.990296 148,819 12,217 20,358 31,456 71,136 4,414,057 62.050963 1,956,965 3,354,489 1.714128 487 5,977 112 135 1,436 1,083 347,140 4,599,429 13.249492 7,199 8,504 1,739 2,091 1,883 949 7,129 9,774 4,300 960 4,294 11,566 548 8,336 1,444 8,922 2,246 5,867 69,792 36,704 7,272 3,864 20,313 1,550 24,004 12,124 119,692 94,463 14,141 17,616 97,642 0 0.000000 32,462 632 24,032 23,911 952 34,663 316,811 4,129 17,224 21,468 8,116 36,774 CENT SERV & SUPPLY (CST REQ) 15.00 1,134,597 7,116,713 6.272459 30,507 75,730 13,036 3,208,330 2,177,348 0.678655 2,488 52 107,795 236,447 312 255 14,791 30,114 74,881 21,522 5,473 8,443 4,418 1,679 23,543 12,594 9,195 12,001 4,083 4,955 347 10,025 99 51 1,149 8,755 17,616 62,712 CAFETERIA MAINT OF NURSING (PROD PERSONNEL ADMIN HRS) (# HOUSED) (NURSE HR) 12.00 13.00 14.00 7,983,987 6,689,686 0.837888 768 10,512 18 933 7,797,109 2,104 12,317 2,180 19,252 453 1,620 1,658 53 117 715 86 1,333 5,425 3,862 156 18,771 PHARMACY (COSTS REQUIS) 16.00 35,728,737 21,822,957 110,799,606 9,753,262 24,227,696 34,164,284 17,961,854 46,551,832 MED REC (GROSS REVENUE) 17.00 1,451,666,457 4,249,886 0.002928 7,249,740 986,994 158,827 1,821,437 68,445,820 2,644,037 61,636,378 19,344,898 4,375,860 1,907,513 33,984,619 523,728 198,819,832 161,356,094 7,884,886 28,444,139 8,806,895 66,299,845 41,721,087 19,441 DIETARY (MEALS SERVED) 11.00 (Adj 4) 1,644 8,141 10,894 7,314 80 4,083 334 2,184 3,640 4,160 HOUSEKEEPING (HR SERV) 10.00 1,841,109 14,794 67,124 54,387 LAUNDRY & LINEN (LB LNDRY) 9.00 351 7,705 4,391 11,940 3,175 2,904 17,406 8,606 7,139 OPER PLANT (SQ FT) 8.00 (Adj 3) STATISTICS FOR COST ALLOCATION (W/S B-1) 11,920 893,337 74.944403 SOC SERV (TIME SPENT) 18.00 0 0.000000 19.00 STAT Fiscal Period Ended: JUNE 30, 2008 SCHEDULE 9.2 1.00 2.00 3.00 3.01 4.00 4.01 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 21.00 21.01 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 31.01 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Other Long Term Care Subacute Care Unit II Transitional Care Unit Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults and Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider Subprovider Psych Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and 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 and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com STAT 19.03 STAT 19.02 NONPHY ANESTH (ASG TIME) 21.00 NURSE SCHOOL (ASG TIME) 21.01 100 I&R-SAL & FRINGES (ASG TIME) 22.00 100 I&R-PRG COST (ASG TIME) 23.00 PARAMED EDUCAT (ASG TIME) 24.00 STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2008 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 60.02 60.03 60.04 61.00 62.00 71.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 100.00 100.01 100.02 100.04 100.05 100.07 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop and Canteen Research Physicians' Private Office Nonpaid Workers Satelite Clinic - Airport HIV Serviceis Women Service Line Community Health Education Marketing SF Heart Institute MD Office Building Mission Servicies Auxillary Group Foundation Clinic Wound Care Out-Patient Psychiatry Diabetes Treatment Center OB/GYN Clinic Emergency Observation Beds Home Health Agency 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) Gastro Intestinal Services Cardiac Cath Lab CT/MRI ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - P O B Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com STAT 0 0.000000 19.02 0 0.000000 19.03 STAT 0 0.000000 NONPHY ANESTH (ASG TIME) 21.00 0 0.000000 NURSE SCHOOL (ASG TIME) 21.01 100 0.000000 I&R-SAL & FRINGES (ASG TIME) 22.00 100 40,994 409.944204 I&R-PRG COST (ASG TIME) 23.00 0 0.000000 PARAMED EDUCAT (ASG TIME) 24.00 STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2008 SCHEDULE 9.3 STATE OF CALIFORNIA SCHEDULE 10 TRIAL BALANCE OF EXPENSES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 REPORTED 1.00 2.00 3.00 3.01 4.00 4.01 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 21.00 21.01 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 31.01 32.00 33.00 34.00 35.00 36.00 36.01 36.02 GENERAL SERVICE COST CENTERS Old Cap Rel Costs - Bldg and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) $ ADJUSTMENTS (From Sch 10A) $ 5,821,852 223,990 5,960,225 235,710 Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office 42,277,282 913,175 5,742,357 2,202,391 1,660,196 4,878,222 Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Social Service 20,619,332 3,759,864 3,780,037 1,561,107 3,057,978 2,883,233 1,827,951 Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults and Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider Subprovider Psych Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Other Long Term Care Subacute Care Unit II Transitional Care Unit 4,803,473 1,397,214 3,644,295 2,621,955 579,884 37,500 31,013,785 7,164,651 6,280,183 618,890 12,111,585 6,462,288 This is trial version www.adultpdf.com AUDITED $ 0 0 0 0 0 119,954 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,821,852 223,990 5,960,225 235,710 0 0 0 42,397,236 913,175 5,742,357 2,202,391 1,660,196 4,878,222 0 20,619,332 3,759,864 3,780,037 1,561,107 3,057,978 2,883,233 1,827,951 4,803,473 1,397,214 3,644,295 2,621,955 579,884 0 0 0 37,500 49,491 0 0 0 (49,491) 0 0 31,063,276 7,164,651 6,280,183 0 0 569,399 12,111,585 6,462,288 0 STATE OF CALIFORNIA SCHEDULE 10 TRIAL BALANCE OF EXPENSES Provider Name: SETON MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 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 60.02 60.03 60.04 61.00 62.00 71.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 100.00 100.01 100.02 100.04 100.05 100.07 100.99 101 ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - P O B $ 8,069,310 $ 1,118,132 142,425 6,529,583 1,164,303 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) Gastro Intestinal Services Cardiac Cath Lab CT/MRI 2,077,814 1,699,278 8,219,868 1,652,619 536,586 4,298,321 2,875,053 479,862 205,737 1,371,483 68,665 18,683,105 7,797,109 836,705 2,897,500 1,184,007 2,217,970 162,680 Clinic Wound Care Out-Patient Psychiatry Diabetes Treatment Center OB/GYN Clinic Emergency Observation Beds Home Health Agency SUBTOTAL NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop and Canteen Research Physicians' Private Office Nonpaid Workers Satelite Clinic - Airport HIV Serviceis Women Service Line Community Health Education Marketing SF Heart Institute MD Office Building Mission Servicies Auxillary Group Foundation SUBTOTAL TOTAL ADJUSTMENTS (From Sch 10A) 1,350,693 371,887 239,997 1,540,437 6,875,131 4,860,028 $ 273,666,893 $ 213,432 781,507 635,121 2,994,547 105,880 91,807 $ $ 4,822,294 $ 278,489,187 $ This is trial version www.adultpdf.com $ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 119,954 $ AUDITED 8,069,310 1,118,132 142,425 6,529,583 1,164,303 2,077,814 1,699,278 8,219,868 1,652,619 536,586 4,298,321 2,875,053 479,862 205,737 1,371,483 68,665 18,683,105 7,797,109 836,705 2,897,500 1,184,007 2,217,970 162,680 0 1,350,693 371,887 239,997 1,540,437 6,875,131 4,860,028 0 273,786,847 213,432 0 0 0 0 0 0 0 781,507 635,121 2,994,547 105,880 91,807 0 $ 4,822,294 119,954 $ 278,609,141 (To Schedule 8) 1.00 2.00 3.00 3.01 4.00 4.01 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 21.00 21.01 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 31.01 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Other Long Term Care Subacute Care Unit II Transitional Care Unit Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults and Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider Subprovider Psych Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and 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 CENTER Old Cap Rel Costs - Bldg and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com SCHEDULE 10A Page Fiscal Period Ended: JUNE 30, 2008 49,491 0 0 0 (49,491) 0 0 $0 0 0 0 0 0 119,954 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (49,491) 49,491 119,954 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1) ADJUSTMENTS TO REPORTED COSTS 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 60.02 60.03 60.04 61.00 62.00 71.00 85.00 86.00 NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop and Canteen Research Physicians' Private Office Nonpaid Workers Satelite Clinic - Airport HIV Serviceis Women Service Line Community Health Education Marketing SF Heart Institute MD Office Building Mission Servicies Auxillary Group Foundation 101.00 TOTAL 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 100.00 100.01 100.02 100.04 100.05 100.07 Clinic Wound Care Out-Patient Psychiatry Diabetes Treatment Center OB/GYN Clinic Emergency Observation Beds Home Health Agency 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) Gastro Intestinal Services Cardiac Cath Lab CT/MRI ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - P O B Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com SCHEDULE 10A Page Fiscal Period Ended: JUNE 30, 2008 (To Sch 10) $119,954 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 0 119,954 0 0 0 0 0 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1) ADJUSTMENTS TO REPORTED COSTS 1.00 2.00 3.00 3.01 4.00 4.01 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 21.00 21.01 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 31.00 31.01 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Other Long Term Care Subacute Care Unit II Transitional Care Unit Nursing School Clinical Pastoral Education Intern and Res Service - Salary and Fringes Intern and Res - Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults and Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider Subprovider Psych Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and 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 CENTER Old Cap Rel Costs - Bldg and Fixtures Old Cap Rel Costs - Movable Equipment New Cap Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SCHEDULE 10A Page Fiscal Period Ended: JUNE 30, 2008 ... Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA. .. Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA. .. Rel Costs - Bldg and Fixtures New Cap Rel Costs - Bldg (Coastside) New Cap Rel Costs - Movable Equipment New Cap Rel Costs - Equip (Coastside) Provider Name: SETON MEDICAL CENTER STATE OF CALIFORNIA