STATE OF CALIFORNIA SCHEDULE 4B PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No. ZZR00228W 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 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 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 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 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 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 30. Cost Applicable to Medi-Cal $ 0 $ 0 31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 0 $ 0 (To Schedule 4) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 5 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: ZZR00228W RATIO COST TO CHARGES ANCILLARY COST CENTERS 37.00 Operating Room $ 40,164,281 $ 77,824,637 0.516087 $ 0 $ 0 39.00 Delivery Room and Labor Room 6,753,212 4,642,051 1.454790 0 0 40.00 Anesthesiology 8,903,388 55,955,476 0.159116 0 0 41.00 Radiology - Diagnostic 31,344,601 106,236,045 0.295047 0 0 43.00 Radioisotope 0 0 0.000000 0 0 44.00 Laboratory 29,184,568 124,559,091 0.234303 0 0 44.01 Laboratory Pathology 4,371,801 11,664,392 0.374799 0 0 46.00 Whole Blood 3,739,180 5,017,971 0.745158 0 0 49.00 Respiratory Therapy 5,914,642 21,779,813 0.271565 0 0 50.00 Physical Therapy 7,084,268 8,575,913 0.826066 0 0 51.00 Occupational Therapy 1,048,315 3,598,702 0.291304 0 0 53.00 Electrocardiology 4,955,322 12,735,645 0.389091 0 0 54.00 Electroencephalography 204,869 86,333 2.373007 0 0 55.00 Medical Supplies Charged to Patients 4,151,690 58,257,007 0.071265 0 0 55.01 Implantable Devices 6,037,873 8,387,370 0.719877 0 0 56.00 Drugs Charged to Patients 36,768,548 190,339,444 0.193174 0 0 57.00 Renal Dialysis 3,622,976 9,880,790 0.366669 0 0 59.00 Other Ancillary Services 3,078,942 5,262,883 0.585030 0 0 59.01 0 0 0.000000 0 0 59.02 0 0 0.000000 0 0 59.03 0 0 0.000000 0 0 59.04 0 0 0.000000 0 0 59.05 0 0 0.000000 0 0 59.06 0 0 0.000000 0 0 59.07 0 0 0.000000 0 0 59.08 0 0 0.000000 0 0 59.09 0 0 0.000000 0 0 59.10 0 0 0.000000 0 0 60.00 Clinic 24,536,192 19,131,357 1.282512 0 0 61.00 Emergency 31,050,160 99,660,181 0.311560 0 0 61.01 Psych Emergency 8,866,289 16,775,979 0.528511 0 0 62.00 Observation Beds 0 0 0.000000 0 0 63.60 Adult Medical Center FQHC I 30,394,153 42,651,814 0.712611 0 0 63.61 Women's Health Center FQHC II 11,281,068 13,112,752 0.860313 0 0 63.62 Family Health Center FQHC III 11,789,429 13,935,626 0.845992 0 0 63.63 Children's Health Center FQHC IV 7,541,033 9,930,227 0.759402 0 0 63.64 Urgent Care FQHC V 4,318,580 6,905,864 0.625350 0 0 64.00 Home Program Dialysis 633,103 1,543,286 0.410231 0 0 TOTAL $ 327,738,482 $ 928,450,649 $ 0 $ 0 (To Schedule 3) * From Schedule 8, Column 27 less Column 26 ANCILLARY COST (Adj 20) (From Schedule 6) MEDI-CAL CHARGES MEDI-CAL SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL ANCILLARY CHARGES TOTAL COST * This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 6 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: ZZR00228W ANCILLARY CHARGES 37.00 Operating Room $ $ $ 0 39.00 Delivery Room and Labor Room 0 40.00 Anesthesiology 0 41.00 Radiology - Diagnostic 0 43.00 Radioisotope 0 44.00 Laboratory 0 44.01 Laboratory Pathology 0 46.00 Whole Blood 0 49.00 Respiratory Therapy 0 50.00 Physical Therapy 0 51.00 Occupational Therapy 0 53.00 Electrocardiology 0 54.00 Electroencephalography 0 55.00 Medical Supplies Charged to Patients 0 55.01 Implantable Devices 0 56.00 Drugs Charged to Patients 0 57.00 Renal Dialysis 0 59.00 Other Ancillary Services 0 59.01 0 59.02 0 59.03 0 59.04 0 59.05 0 59.06 0 59.07 0 59.08 0 59.09 0 59.10 0 60.00 Clinic 0 61.00 Emergency 0 61.01 Psych Emergency 0 62.00 Observation Beds 0 63.60 Adult Medical Center FQHC I 0 63.61 Women's Health Center FQHC II 0 63.62 Family Health Center FQHC III 0 63.63 Children's Health Center FQHC IV 0 63.64 Urgent Care FQHC V 0 64.00 Home Program Dialysis 0 TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 0 $ 0 (To Schedule 5) (Adj ) 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: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: ZZR00228W PROFESSIONAL SERVICE COST CENTERS 60.00 Clinic $ 0 $ 0 0.000000 $ $ 0 60.01 Adult Medical Center 0 0 0.000000 0 60.02 Women's Health Center 0 0 0.000000 0 60.03 Family Health Center 0 0 0.000000 0 60.04 Children's Health Center 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 0 0 0.000000 0 0 0 0.000000 0 TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3) COMPONENT OF HOSPITAL BASED COMPUTATION OF PROFESSIONAL TO ALL PATIENTS RATIO OF REMUNERATION REMUNERATION HBP TOTAL CHARGES TO CHARGES CHARGES MEDI-CAL COST MEDI-CAL (Adj ) (Adj ) (Adj ) PHYSICIAN'S REMUNERATION This is trial version www.adultpdf.com STATE OF CALIFORNIA DESIG PUB HOSP SCH 1 Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: HSC00228W REPORTED AUDITED 1. Net Cost of Covered Services Rendered to Medi-Cal Patients (Desig Pub Hosp Sch 3) $ 100,059,542 $ 105,991,878 2. Excess Reasonable Cost Over Charges (Desig Pub Hosp Sch 2) $0 $0 3. Medi-Cal Inpatient Hospital Based Physician Services $ $ N/A 4. $ $ 0 5. Subtotal (Sum of Lines 1 through 4) $ 100,059,542 $ 105,991,878 6. $ $ 0 7. $ $ 0 8. Total Medi-Cal Cost (Sum of Lines 5 through 7) $ 100,059,542 $ 105,991,878 (To Summary of Findings) 9. Interim Payments (Adjs 25, 29) $ (47,718,905) $ (57,180,719) 10. Medi-Cal Overpayments (Adj 31 ) $ $ (1,607) 11. $ $ 0 12. $ $ 0 13. TOTAL MEDI-CAL OVERPAYMENT SETTLEMENT $ 0 $ (1,607) (To Summary of Findings) COMPUTATION OF MEDI-CAL CONTRACT COST This is trial version www.adultpdf.com STATE OF CALIFORNIA DESIG PUB HOSP SCH 2 Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: HSC00228W REPORTED AUDITED REASONABLE COST OF MEDI-CAL INPATIENT SERVICES 1. Cost of Covered Services (Desig Pub Hosp Sch 3) $ 100,559,823 $ 106,613,078 CHARGES FOR MEDI-CAL INPATIENT SERVICES 2. Inpatient Routine Service Charges (Adjs 23, 27) $ 171,200,845 $ 193,376,726 3. Inpatient Ancillary Service Charges (Adjs 23, 27) $ 139,371,813 $ 159,392,108 4. Total Charges - Medi-Cal Inpatient Services $ 310,572,658 $ 352,768,834 5. Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) * $ 210,012,835 $ 246,155,756 6. Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0 (To Desig Pub Hosp 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 DESIG PUB HOSP SCH 3 Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: HSC00228W REPORTED AUDITED 1. Medi-Cal Inpatient Ancillary Services (Desig Pub Hosp Sch 5) $ 39,516,007 $ 40,733,254 2. Medi-Cal Inpatient Routine Services (Desig Pub Hosp Sch 4) $ 61,043,816 $ 65,879,824 3. Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ $ 0 4. $ $ 0 5. $ $ 0 6. SUBTOTAL (Sum of Lines 1 through 5) $ 100,559,823 $ 106,613,078 7. Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Desig Pub Hosp Sch 7) $ 0 $ 0 8. SUBTOTAL $ 100,559,823 $ 106,613,078 (To Desig Pub Hosp Sch 2) 9. Deductibles (Adjs 24, 28) $ $ (191,042) 10. Coinsurance (Adjs 24, 28) $ (500,281) $ (430,158) 11. Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 100,059,542 $ 105,991,878 (To Desig Pub Hosp Sch 1) COMPUTATION OF MEDI-CAL NET COST OF COVERED SERVICES This is trial version www.adultpdf.com STATE OF CALIFORNIA DESIG PUB HOSP SCH 4 Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: HSC00228W REPORTED AUDITED GENERAL SERVICE UNIT NET OF SWING-BEDS COSTS INPATIENT DAYS 1. Total Inpatient Days (include private & swing-bed) (Adj ) 90,598 90,598 2. Inpatient Days (include private, exclude swing-bed) 90,598 90,598 3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4. Semi-Private Room Days (exclude swing-bed) (Adj ) 90,598 90,598 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) (Adjs 21, 25) 32,744 35,998 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) $ 128,241,548 $ 124,397,241 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) $ 128,241,548 $ 124,397,241 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28. Gen Inpatient Routine Serv Charges (excl swing-bed charges)(Adj ) $ 315,955,304 $ 315,955,304 29. Private Room Charges (excluding swing-bed charges)(Adj ) $ 0 $ 0 30. Semi-Private Room Charges (excluding swing-bed charges)(Adj ) $ 315,955,304 $ 315,955,304 31. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0 $ 0.393718 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) $ 3,487.44 $ 3,487.44 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) $ 128,241,548 $ 124,397,241 PROGRAM INPATIENT OPERATING COST 38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 1,415.50 $ 1,373.07 39. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 46,349,132 $ 49,427,774 40. Cost Applicable to Medi-Cal (Desig Pub Hosp Sch 4A) $ 14,694,684 $ 16,452,050 41. Cost Applicable to Medi-Cal (Desig Pub Hosp Sch 4B) $ 0 $ 0 42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39, 40 & 41) $ 61,043,816 $ 65,879,824 (To Desig Pub Hosp Sch 3) MEDI-CAL INPATIENT ROUTINE SERVICE COST COMPUTATION OF This is trial version www.adultpdf.com STATE OF CALIFORNIA DESIG PUB HOSP SCH 4A Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: HSC00228W SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITED NURSERY 1. Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 6,582,830 $ 6,404,622 2. Total Inpatient Days (Adj ) 3,657 3,657 3. Average Per Diem Cost $ 1,800.06 $ 1,751.33 4. Medi-Cal Inpatient Days (Adj 21 ) 1,567 1,581 5. Cost Applicable to Medi-Cal $ 2,820,694 $ 2,768,853 INTENSIVE CARE UNIT 6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 18,619,438 $ 18,213,346 7. Total Inpatient Days (Adj ) 4,681 4,681 8. Average Per Diem Cost $ 3,977.66 $ 3,890.91 9. Medi-Cal Inpatient Days (Adj 21 ) 2,609 3,083 10. Cost Applicable to Medi-Cal $ 10,377,715 $ 11,995,676 CORONARY CARE UNIT 11. Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 13,804,162 $ 13,658,014 12. Total Inpatient Days (Adj ) 3,316 3,316 13. Average Per Diem Cost $ 4,162.90 $ 4,118.82 14. Medi-Cal Inpatient Days (Adj 21 ) 7 6 15. Cost Applicable to Medi-Cal $ 29,140 $ 24,713 NEONATAL INTENSIVE CARE UNIT 16. Total Inpatient Routine Cost (Sch 8, Line 30, Col 27) $ 2,030,200 $ 2,149,895 17. Total Inpatient Days (Adj ) 512 512 18. Average Per Diem Cost $ 3,965.23 $ 4,199.01 19. Medi-Cal Inpatient Days (Adj 21 ) 370 396 20. Cost Applicable to Medi-Cal $ 1,467,135 $ 1,662,808 SURGICAL INTENSIVE CARE UNIT 21. Total Inpatient Routine Cost (Sch 8, Line 29, 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 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 30. Cost Applicable to Medi-Cal $ 0 $ 0 31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 14,694,684 $ 16,452,050 (To Desig Pub Hosp Sch 4) MEDI-CAL INPATIENT ROUTINE SERVICE COST COMPUTATION OF This is trial version www.adultpdf.com STATE OF CALIFORNIA DESIG PUB HOSP SCH 4B Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No: HSC00228W 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 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 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 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 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 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 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 Desig Pub Hosp Sch 4) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com [...].. .STATE OF CALIFORNIA DESIG PUB HOSP SCH 5 SCHEDULE OF MEDI-CAL ANCILLARY COSTS Provider Name: SAN FRANCISCO GENERAL HOSPITAL Fiscal Period Ended: JUNE 30, 2009 Provider No: HSC00228W TOTAL ANCILLARY COST* ANCILLARY COST CENTERS 37.00 Operating Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00... RATIO COST TO CHARGES 0.516087 1.454790 0.159116 0.295047 0.000000 0.234303 0.374799 0.745158 0.271565 0.826066 0.291304 0.389091 2.373007 0.071265 0.719877 0.190744 0.366669 0.585030 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 1.282512 0.311560 0.528511 0.000000 0.712611 0.860313 0.845992 0.759402 0.625350 0.366012 928,450,649 MEDI-CAL CHARGES MEDI-CAL COST. .. Therapy 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implantable Devices 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Other Ancillary Services 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 61.00 Emergency 61.01 Psych Emergency 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 63.61 Women's Health Center... 5,112,306 443,166 1,485,742 887,291 2,603,515 175,418 1,173,589 0 1,818,840 125,189 8,455,608 236,999 106,626 0 0 0 0 0 0 0 0 0 0 7,073 2,436,044 0 0 0 0 0 0 0 0 40,733,254 (To Desig Pub Hosp Sch 3) * From Schedule 8, Column 27 less Column 26 This is trial version www.adultpdf.com . Cost $ 0.00 $ 0.00 29. Medi-Cal Inpatient Days (Adj ) 0 30. Cost Applicable to Medi-Cal $ 0 $ 0 31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 0 $ 0 (To Schedule 4) COMPUTATION OF MEDI-CAL. 0 $ 0 (To Schedule 4) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 5 PROGRAM: NONCONTRACT Provider Name: Fiscal Period. COST OF MEDI-CAL INPATIENT SERVICES 1. Cost of Covered Services (Desig Pub Hosp Sch 3) $ 100,559,823 $ 106,613,078 CHARGES FOR MEDI-CAL INPATIENT SERVICES 2. Inpatient Routine Service Charges