STATE OF CALIFORNIA SCHEDULE 5 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: ZZT 30056F RATIO COST TO CHARGES ANCILLARY COST CENTERS 37.00 Operating Room $ 19,155,383 $ 52,806,536 0.362746 $ 0 $ 0 38.00 Recovery Room 0 0 0.000000 0 0 39.00 Delivery Room and Labor Room 14,865,512 50,935,422 0.291850 0 0 40.00 Anesthesiology 0 0 0.000000 0 0 41.00 Radiology - Diagnostic 10,727,676 103,024,136 0.104128 47,249 4,920 41.01 0 0 0.000000 0 0 41.02 0 0 0.000000 0 0 42.00 Radiology - Therapeutic 0 0 0.000000 0 0 43.00 Radioisotope 1,694,803 4,391,070 0.385966 740 286 44.00 Laboratory 16,214,746 80,129,005 0.202358 180,794 36,585 44.01 Pathological Lab 0 0 0.000000 0 0 46.00 Whole Blood 0 0 0.000000 0 0 47.00 Blood Storing and Processing 0 0 0.000000 0 0 48.00 Intravenous Therapy 0 0 0.000000 0 0 49.00 Respiratory Therapy 8,573,772 71,377,030 0.120119 0 0 50.00 Physical Therapy 1,463,732 4,003,812 0.365585 70,914 25,925 51.00 Occupational Therapy 156,122 306,981 0.508571 4,274 2,174 52.00 Speech Pathology 81,955 245,375 0.334000 1,620 541 53.00 Electrocardiology 999,870 8,750,091 0.114270 0 0 54.00 Electroencephalography 317,877 1,347,672 0.235871 0 0 55.00 Medical Supplies Charged to Patients 28,456,941 109,573,890 0.259705 0 0 56.00 Drugs Charged to Patients 11,643,094 66,037,141 0.176311 464,391 81,877 57.00 Renal Dialysis 1,236,654 4,756,348 0.260001 0 0 58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0 59.00 Patient Education & Family Counseling 37,212 102,595 0.362712 0 0 59.01 Ultrasound 1,516,020 12,939,156 0.117165 18,576 2,176 59.02 Magnetic Resonance Imaging 1,129,701 7,659,264 0.147495 28,505 4,204 59.03 0 0 0.000000 0 0 60.00 Clinic 0 0 0.000000 0 0 60.01 Other Clinic Services 0 0 0.000000 0 0 61.00 Emergency 21,548,072 73,729,290 0.292259 0 0 62.00 Observation Beds 0 0 0.000000 0 0 71.00 Home Health Agency 2,315,484 0 0.000000 0 0 82.00 0 0 0.000000 0 0 83.00 0 0 0.000000 0 0 84.00 0 0 0.000000 0 0 85.00 0 0 0.000000 0 0 86.00 0 0 0.000000 0 0 TOTAL $ 142,134,628 $ 652,114,814 $ 817,063 $ 158,688 (To Schedule 3) * From Schedule 8, Column 27 TOTAL ANCILLARY MEDI-CAL SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL COST * CHARGES MEDI-CAL (Adj 9) COSTCHARGES (From Schedule 6) ANCILLARY This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 6 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: ZZT 30056F ANCILLARY CHARGES 37.00 Operating Room $ 0 $ 0 $ 0 38.00 Recovery Room 0 0 0 39.00 Delivery Room and Labor Room 0 0 0 40.00 Anesthesiology 0 0 0 41.00 Radiology - Diagnostic 0 47,249 47,249 41.01 0 0 0 41.02 0 0 0 42.00 Radiology - Therapeutic 0 0 0 43.00 Radioisotope 0 740 740 44.00 Laboratory 0 180,794 180,794 44.01 Pathological Lab 0 0 0 46.00 Whole Blood 0 0 0 47.00 Blood Storing and Processing 0 0 0 48.00 Intravenous Therapy 0 0 0 49.00 Respiratory Therapy 0 0 0 50.00 Physical Therapy 0 70,914 70,914 51.00 Occupational Therapy 0 4,274 4,274 52.00 Speech Pathology 0 1,620 1,620 53.00 Electrocardiology 0 0 0 54.00 Electroencephalography 0 0 0 55.00 Medical Supplies Charged to Patients 000 56.00 Drugs Charged to Patients 0 464,391 464,391 57.00 Renal Dialysis 0 0 0 58.00 ASC (Non-Distinct Part) 0 0 0 59.00 Patient Education & Family Counseling 0 0 0 59.01 Ultrasound 0 18,576 18,576 59.02 Magnetic Resonance Imaging 0 28,505 28,505 59.03 0 0 0 60.00 Clinic 0 0 0 60.01 Other Clinic Services 0 0 0 61.00 Emergency 0 0 0 62.00 Observation Beds 0 0 0 71.00 Home Health Agency 0 0 0 82.00 0 83.00 0 84.00 0 85.00 0 86.00 0 TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 817,063 $ 817,063 (To Schedule 5) (Adj 11) ADJUSTMENTS TO MEDI-CAL CHARGES REPORTED ADJUSTMENTS AUDITED This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 7 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: ZZT 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 Schedule 3) TO CHARGES (Adj ) (Adj ) (Adj ) PHYSICIAN'S REMUNERATION TOTAL CHARGES TO ALL PATIENTS MEDI-CAL MEDI-CAL COST RATIO OF REMUNERATION CHARGES COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED REMUNERATION HBP This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 1 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F REPORTED AUDITED 1. Net Cost of Covered Services Rendered to Medi-Cal Patients (Contract Sch 3) $ 43,133,298 $ 37,818,792 2. Excess Reasonable Cost Over Charges (Contract Sch 2) $ 0 $ 0 3. Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ 0 4. $0 $0 5. Subtotal (Sum of Lines 1 through 4) $ 43,133,298 $ 37,818,792 6. $0 $0 7. $0 $0 8. Total Medi-Cal Cost (Sum of Lines 5 through 7) $ 43,133,298 $ 37,818,792 (To Summary of Findings) 9. Medi-Cal Overpayments (Adj ) $ 0 $ 0 10. Medi-Cal Credit Balances (Adj 18) $ 0 $ (2,414) 11. $0 $0 12. $0 $0 13. TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 0 $ (2,414) (To Summary of Findings) COMPUTATION OF MEDI-CAL CONTRACT COST This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 2 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F REPORTED AUDITED REASONABLE COST OF MEDI-CAL INPATIENT SERVICES 1. Cost of Covered Services (Contract Sch 3) $ 43,133,298 $ 38,335,357 CHARGES FOR MEDI-CAL INPATIENT SERVICES 2. Inpatient Routine Service Charges (Adj 16) $ 44,604,908 $ 46,514,275 3. Inpatient Ancillary Service Charges (Adj 16) $ 75,794,994 $ 85,881,246 4. Total Charges - Medi-Cal Inpatient Services $ 120,399,902 $ 132,395,521 5. Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) * $ 77,266,604 $ 94,060,164 6. Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0 (To Contract Sch 1) * If charges exceed reasonable cost, no further calculation necessary for this schedule. COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 3 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F REPORTED AUDITED 1. Medi-Cal Inpatient Ancillary Services (Contract Sch 5) $ 16,490,092 $ 19,015,396 2. Medi-Cal Inpatient Routine Services (Contract Sch 4) $ 26,643,206 $ 19,319,961 3. Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0 4. $0 $0 5. $0 $0 6. SUBTOTAL (Sum of Lines 1 through 5) $ 43,133,298 $ 38,335,357 7. Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Contract Sch 7) $ 0 $ 0 8. SUBTOTAL $ 43,133,298 $ 38,335,357 (To Contract Sch 2) 9. Coinsurance (Adj 17) $ 0 $ (359,771) 10. Patient and Third Party Liability (Adj 17) $ 0 $ (156,794) 11. Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 43,133,298 $ 37,818,792 (To Contract Sch 1) MEDI-CAL NET COST OF COVERED SERVICES COMPUTATION OF This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 4 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F GENERAL SERVICE UNIT NET OF SWING-BEDS COSTS REPORTED AUDITED INPATIENT DAYS 1. Total Inpatient Days (include private & swing-bed) (Adj ) 81,540 81,540 2. Inpatient Days (include private, exclude swing-bed) 81,540 81,540 3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4. Semi-Private Room Days (exclude swing-bed) (Adj ) 81,540 81,540 5. Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6. Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7. Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8. Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9. Medi-Cal Days (excluding swing-bed) (Adj 14) 18,143 16,454 SWING-BED ADJUSTMENT 17. Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 0.00 $ 0.00 18. Medicare NF Swing-Bed Rates after Dec 31(Adj ) $ 0.00 $ 0.00 19. Medi-Cal NF Swing-Bed Rates through July 31(Adj ) $ 0.00 $ 0.00 20. Medi-Cal NF Swing-Bed Rates after July 31(Adj ) $ 0.00 $ 0.00 21. Total Routine Serv Cost (Sch 8, Part I, Line 25, Col 27) $ 59,913,484 $ 58,365,865 22. Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23. Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24. Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25. Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26. Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27. Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 59,913,484 $ 58,365,865 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28. Gen Inpatient Routine Serv Charges (excl swing-bed charges)(Adj ) $ 195,293,122 $ 195,293,122 29. Private Room Charges (excluding swing-bed charges)(Adj ) $ 0 $ 0 30. Semi-Private Room Charges (excluding swing-bed charges)(Adj ) $ 0 $ 0 31. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.306787 $ 0.298863 32. Average Private Room Per Diem Charge (L 29 / L 3) $ 0.00 $ 0.00 33. Average Semi-Private Room Per Diem Charge (L 30 / L 4) $ 0.00 $ 0.00 34. Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 0.00 $ 0.00 35. Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 0.00 $ 0.00 36. Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37. Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ 59,913,484 $ 58,365,865 PROGRAM INPATIENT OPERATING COST 38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 734.77 $ 715.79 39. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 13,330,932 $ 11,777,609 40. Cost Applicable to Medi-Cal (Contract Sch 4A) $ 13,312,274 $ 7,542,352 41. Cost Applicable to Medi-Cal (Contract Sch 4B) $ 0 $ 0 42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39, 40 & 41) $ 26,643,206 $ 19,319,961 (To Contract Sch 3) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 4A Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITED NURSERY 1. Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 6,856,607 $ 6,843,649 2. Total Inpatient Days (Adj ) 12,898 12,898 3. Average Per Diem Cost $ 531.60 $ 530.60 4. Medi-Cal Inpatient Days (Adj 14) 8,042 6,625 5. Cost Applicable to Medi-Cal $ 4,275,127 $ 3,515,225 INTENSIVE CARE UNIT 6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 15,619,821 $ 15,167,877 7. Total Inpatient Days (Adj ) 7,256 7,256 8. Average Per Diem Cost $ 2,152.68 $ 2,090.39 9. Medi-Cal Inpatient Days (Adj 14) 2,587 1,517 10. Cost Applicable to Medi-Cal $ 5,568,983 $ 3,171,122 CORONARY CARE UNIT 11. Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 0 $ 0 12. Total Inpatient Days (Adj ) 0 0 13. Average Per Diem Cost $ 0.00 $ 0.00 14. Medi-Cal Inpatient Days (Adj ) 0 0 15. Cost Applicable to Medi-Cal $ 0 $ 0 NEONATAL INTENSIVE CARE UNIT 16. Total Inpatient Routine Cost (Sch 8, Line 30, Col 27) $ 7,788,641 $ 7,557,863 17. Total Inpatient Days (Adj ) 9,924 9,924 18. Average Per Diem Cost $ 784.83 $ 761.57 19. Medi-Cal Inpatient Days (Adj 14) 4,419 1,124 20. Cost Applicable to Medi-Cal $ 3,468,164 $ 856,005 SURGICAL INTENSIVE CARE UNIT 21. Total Inpatient Routine Cost (Sch 8, Line 31, Col 27) $ 0 $ 0 22. Total Inpatient Days (Adj ) 0 0 23. Average Per Diem Cost $ 0.00 $ 0.00 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 $ 0.00 $ 0.00 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) $ 13,312,274 $ 7,542,352 (To Contract Sch 4) MEDI-CAL INPATIENT ROUTINE SERVICE COST COMPUTATION OF This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 4B Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F SPECIAL CARE UNITS REPORTED AUDITED 1. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0 2. Total Inpatient Days (Adj ) 0 0 3. Average Per Diem Cost $ 0.00 $ 0.00 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 $ 0.00 $ 0.00 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 $ 0.00 $ 0.00 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 $ 0.00 $ 0.00 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 $ 0.00 $ 0.00 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 $ 0.00 $ 0.00 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 Contract Sch 4) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 5 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30056F RATIO COST TO CHARGES ANCILLARY COST CENTERS 37.00 Operating Room $ 19,155,383 $ 52,806,536 0.362746 $ 13,408,176 $ 4,863,768 38.00 Recovery Room 0 0 0.000000 0 0 39.00 Delivery Room and Labor Room 14,865,512 50,935,422 0.291850 9,124,756 2,663,062 40.00 Anesthesiology 0 0 0.000000 0 0 41.00 Radiology - Diagnostic 10,727,676 103,024,136 0.104128 7,120,544 741,447 41.01 0 0 0.000000 0 0 41.02 0 0 0.000000 0 0 42.00 Radiology - Therapeutic 0 0 0.000000 0 0 43.00 Radioisotope 1,694,803 4,391,070 0.385966 333,409 128,684 44.00 Laboratory 16,214,746 80,129,005 0.202358 11,815,086 2,390,877 44.01 Pathological Lab 0 0 0.000000 0 0 46.00 Whole Blood 0 0 0.000000 0 0 47.00 Blood Storing and Processing 0 0 0.000000 0 0 48.00 Intravenous Therapy 0 0 0.000000 0 0 49.00 Respiratory Therapy 8,573,772 71,377,030 0.120119 8,999,557 1,081,022 50.00 Physical Therapy 1,463,732 4,003,812 0.365585 220,898 80,757 51.00 Occupational Therapy 156,122 306,981 0.508571 8,648 4,398 52.00 Speech Pathology 81,955 245,375 0.334000 8,772 2,930 53.00 Electrocardiology 999,870 8,750,091 0.114270 5,262,779 601,376 54.00 Electroencephalography 317,877 1,347,672 0.235871 65,952 15,556 55.00 Medical Supplies Charged to Patients 28,456,941 109,573,890 0.259705 8,367,399 2,173,059 56.00 Drugs Charged to Patients 11,643,094 66,037,141 0.176311 13,092,109 2,308,287 57.00 Renal Dialysis 1,236,654 4,756,348 0.260001 719,482 187,066 58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0 59.00 Patient Education & Family Counseling 37,212 102,595 0.362712 0 0 59.01 Ultrasound 1,516,020 12,939,156 0.117165 1,304,165 152,803 59.02 Magnetic Resonance Imaging 1,129,701 7,659,264 0.147495 980,060 144,554 59.03 0 0 0.000000 0 0 60.00 Clinic 0 0 0.000000 0 0 60.01 Other Clinic Services 0 0 0.000000 0 0 61.00 Emergency 21,548,072 73,729,290 0.292259 5,049,454 1,475,750 62.00 Observation Beds 0 0 0.000000 0 0 71.00 Home Health Agency 2,315,484 0 0.000000 0 0 82.00 0 0 0.000000 0 0 83.00 0 0 0.000000 0 0 84.00 0 0 0.000000 0 0 85.00 0 0 0.000000 0 0 86.00 0 0 0.000000 0 0 TOTAL $ 142,134,628 $ 652,114,814 $ 85,881,246 $ 19,015,396 (To Contract Sch 3) * From Schedule 8, Column 27 SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL MEDI-CAL CHARGES TOTAL ANCILLARY MEDI-CAL COST (Contract Sch 6) CHARGES (Adj 9) ANCILLARY COST* This is trial version www.adultpdf.com [...]... Agency TOTAL MEDI-CAL ANCILLARY CHARGES ADJUSTMENTS (Adj 15) $ 2, 652 ,171 $ 0 (2,232,481) 0 (689,310) 0 0 0 (160 ,53 2) 1,830,970 0 0 0 0 (4,406,648) (100,9 05) ( 15, 964) ( 15, 528) 4,117,442 (229, 354 ) 7,137,199 1,476,189 (109,619) 0 0 116 ,55 5 20,890 0 0 0 6 95, 177 0 0 10,086, 252 $ AUDITED 13,408,176 0 9,124, 756 0 7,120 ,54 4 0 0 0 333,409 11,8 15, 086 0 0 0 0 8,999 ,55 7 220,898 8,648 8,772 5, 262,779 65, 952 8,367,399.. .STATE OF CALIFORNIA CONTRACT SCH 6 ADJUSTMENTS TO MEDI-CAL CHARGES Provider Name: ANTELOPE VALLEY HOSPITAL Fiscal Period Ended: JUNE 30, 2008 Provider No: HSC 30 056 F 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... 61.00 62.00 71.00 82.00 83.00 84.00 85. 00 86.00 ANCILLARY CHARGES Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic $ 10, 756 ,0 05 0 11, 357 ,237 0 7,809, 854 0 0 0 493,941 9,984,116 0 0 0 0 13,406,2 05 321,803 24,612 24,300 1,1 45, 337 2 95, 306 1,230,200 11,6 15, 920 829,101 0 0 1,187,610 959 ,170 0 0 0 4, 354 ,277 0 0 $ 75, 794,994 $ Radiology - Therapeutic Radioisotope... AUDITED 13,408,176 0 9,124, 756 0 7,120 ,54 4 0 0 0 333,409 11,8 15, 086 0 0 0 0 8,999 ,55 7 220,898 8,648 8,772 5, 262,779 65, 952 8,367,399 13,092,109 719,482 0 0 1,304,1 65 980,060 0 0 0 5, 049, 454 0 0 0 0 0 0 0 0 0 85, 881,246 (To Contract Sch 5) This is trial version www.adultpdf.com . Pathology 81, 955 2 45, 3 75 0.334000 8,772 2,930 53 .00 Electrocardiology 999,870 8, 750 ,091 0.114270 5, 262,779 601,376 54 .00 Electroencephalography 317,877 1,347,672 0.2 358 71 65, 952 15, 556 55 .00 Medical. 8 ,57 3,772 71,377,030 0.120119 0 0 50 .00 Physical Therapy 1,463,732 4,003,812 0.3 655 85 70,914 25, 9 25 51.00 Occupational Therapy 156 ,122 306,981 0 .50 857 1 4,274 2,174 52 .00 Speech Pathology 81, 955 . Therapy 8 ,57 3,772 71,377,030 0.120119 8,999 ,55 7 1,081,022 50 .00 Physical Therapy 1,463,732 4,003,812 0.3 655 85 220,898 80, 757 51 .00 Occupational Therapy 156 ,122 306,981 0 .50 857 1 8,648 4,398 52 .00