STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER 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 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 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 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 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, 2009 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) 0 62,441 29,619 48,192 22,860 0 99,496 47,196 0 50,880 203,865 96,703 0 104,253 0 0 0 0 0 0 0 38,283 18,160 0 19,577 0 56,898 0 184,661 87,594 97,393 94,432 0 21,682 0 982 77,181 36,611 0 39,469 0 82,962 0 654 0 89,833 42,612 0 45,939 0 62,026 0 0 263 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 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 1,007,571 477,940 324,040 515,254 827,883 486,312 0 1,120,542 8,832 0 237,693 0 189,943 90,099 70,039 97,134 54,395 90,719 0 194,985 1,431 0 51,057 0 000000000000 000000000000 000000000000 000000000000 000000000000 000000000000 69,074 32,765 23,183 35,323 0 35,509 0 88,501 616 0 24,884 0 509,764 241,805 235,340 260,684 1,134,552 263,783 0 637,383 5,760 0 43,114 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: MARIAN MEDICAL CENTER TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Gastro Intestinal Service 37.20 Cardicac Cath Lab 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 CT Scan and MRI 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood & Packed Red 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 55.01 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 89.00 Utilization Review 93.00 Hospice NONREIMBURSABLE COST CENTE 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 99.05 100.00 100.01 Foundation 100.02 100.03 Community Relations 100.04 TOTAL SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2009 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) 865,329 410,467 148,154 442,513 10,476 141,190 0 238,952 198,792 0 287,555 0 35,868 17,014 0 18,342 0 4,934 0 6,047 935 0 3,165 0 27,679 13,129 4,403 14,154 0 28,011 0 26,574 107,094 0 82,827 0 0 0 0 0 0 0 0 0 0 0 0 0 231,912 110,007 63,275 118,595 31,630 90,686 0 200,039 5,951 0 52,864 0 2,4981,18501,27700004,693099,8770 337,017 159,864 51,935 172,344 0 131,648 0 2,712 7,732 0 140,866 0 15,191 7,206 4,729 7,768 0 20,968 0 489 1,837 0 99,220 0 16,378 7,769 0 8,375 0 7,303 0 0 19,721 0 45,173 0 176,472 83,709 0 90,245 0 131,648 0 0 1,782 0 199,889 0 000000000000 8,5574,05904,376000063,324013,0100 000000000000 000004,25209,938001,6920 230,274 109,230 0 117,758 0 53,101 0 375 4,697 0 22,999 0 143,757 68,191 0 73,515 0 36,385 0 6,859 250 0 28,143 0 62,564 29,677 0 31,994 0 28,628 0 19,324 152 0 10,920 0 000000000000 254,145 120,553 20,828 129,965 0 42,390 0 22,143 406 0 30,500 0 000001,461063007230 00000000368,377 0 94,706 0 00000000383,171 0 101,929 0 0 0 0 0 0 0 0 0 0 3,361,878 216,153 0 11,301 5,361 0 5,779 0 0 0 0 10 0 1,772 0 000000000000 8,230 3,904 0 4,209 0 10,873 0 71 38 0 21,106 0 000000000000 000000000000 382,384 181,383 21,790 195,544 0 20,481 0 51,129 111 0 10,851 0 0 0 0 0 0 0 0 0 0 0 0 0 530,768 251,769 161,092 271,425 13,777 174,167 0 340,414 3,060 0 116,354 0 000000000000 345,575 163,92300000021,454737,183 0 0 000000001,259200,070 0 0 202,268 95,9450000000000 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 000000000000 163,779 77,688 0 83,75400000000 000000000000 181,345 86,021 0 92,736 0 415,911 0 13,577 1,010 0 0 0 000000000000 6,813,595 3,232,016 1,226,201 3,147,616 2,072,713 2,443,926 0 2,981,753 1,212,759 4,299,130 2,039,044 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER 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 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 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 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 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, 2009 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 27,321,085 27,321,085 000000006,398,014 6,398,014 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000002,492,392 2,492,392 0 0 0 0 0 0 0 0 10,927,168 10,927,168 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: MARIAN MEDICAL CENTER TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Gastro Intestinal Service 37.20 Cardicac Cath Lab 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 CT Scan and MRI 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood & Packed Red 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 55.01 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 89.00 Utilization Review 93.00 Hospice NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 99.05 100.00 100.01 Foundation 100.02 100.03 Community Relations 100.04 TOTAL SCHEDULE 8.3 Fiscal Period Ended: JUNE 30, 2009 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 000011,051,806 11,051,806 0 0 0 0 0000443,025 443,025 0 0 0 0 00002,706,650 2,706,650 0 0 0 0 00000 0 0 0 0 0 00007,254,402 7,254,402 0 0 0 0 0000346,015 346,015 0 0 0 0 00008,300,061 8,300,061 0 0 0 0 00001,870,488 1,870,488 0 0 0 0 00001,777,070 1,777,070 0 0 0 0 00008,154,976 8,154,976 0 0 0 0 00000 0 0 0 0 0 00001,987,954 1,987,954 0 0 0 0 00000 0 0 0 0 0 0000180,685 180,685 0 0 0 0 00003,502,733 3,502,733 0 0 0 0 00002,800,043 2,800,043 0 0 0 0 00001,235,588 1,235,588 0 0 0 0 00000 0 0 0 0 0 00002,533,069 2,533,069 0 0 0 0 0000113,498 113,498 0 0 0 0 00009,262,769 9,262,769 0 0 0 0 000010,610,140 10,610,140 0 0 0 0 00008,085,390 8,085,390 0 0 0 0 0000381,009 381,009 0 0 0 0 00000 0 0 0 0 0 0000694,280 694,280 0 0 0 0 00000 0 0 0 0 0 00000 0 0 0 0 0 00001,793,163 1,793,163 0 0 0 0 00000 0 0 0 0 0 000010,105,355 10,105,355 0 0 0 0 00000 0 0 0 0 0 000016,300,486 16,300,486 0 0 0 0 0000980,387 980,387 0 0 0 0 00002,970,702 2,970,702 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 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 0000385,790 385,790 0 0 0 0 00000 0 0 0 0 0 00003,837,005 3,837,005 0 0 0 0 00000 0 0 0 0 0 0 0 0 0 166,803,199 0 166,803,199 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 9 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (EQUIP.VALUE) (SQ FT) (EQUIP.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 15) (Adj 16) (Adj 15) (Adj 16) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 17 ) (Adj ) (Adj 17) (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 4,000 7,016 4,000 7,016 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 167,951 672,122 167,951 672,122 7.00 Maintenance and Repairs 19,270 125,953 19,270 125,953 8.00 Operation of Plant 127 27,499 127 27,499 9.00 Laundry and Linen Service 1,525 1,525 10.00 Housekeeping 1,177 575 1,177 575 11.00 Dietary 2,430 6,327 2,430 6,327 12.00 Cafeteria 4,979 8,072 4,979 8,072 13.00 Maintenance of Personnel 14.00 Nursing Administration 935 2,246 935 2,246 15.00 Central Services & Supply 4,510 37,517 4,510 37,517 16.00 Pharmacy 1,885 109,173 1,885 109,173 17.00 Medical Records and Library 2,194 40,132 2,194 40,132 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) 24,608 411,668 24,608 411,668 26.00 Intensive Care Unit 4,639 139,081 4,639 139,081 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 33.00 Nursery 1,687 14,876 1,687 14,876 34.00 Medicare Certified Nursing Facility 12,450 31,985 12,450 31,985 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 STATE OF CALIFORNIA SCHEDULE 9 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (EQUIP.VALUE) (SQ FT) (EQUIP.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 15) (Adj 16) (Adj 15) (Adj 16) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 17 ) (Adj ) (Adj 17) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) ANCILLARY COST CENTERS 37.00 Operating Room 21,134 403,628 21,134 403,628 37.01 Gastro Intestinal Service 876 7,643 876 7,643 37.20 Cardicac Cath Lab 676 439,753 676 439,753 38.00 Recovery Room 39.00 Delivery Room and Labor Room 5,664 102,425 5,664 102,425 40.00 Anesthesiology 61 45,808 61 45,808 41.00 Radiology - Diagnostic 8,231 1,322,888 8,231 1,322,888 41.01 CT Scan and MRI 371 584,268 371 584,268 43.00 Radioisotope 400 6,081 400 6,081 44.00 Laboratory 4,310 87,272 4,310 87,272 44.01 Pathological Lab 46.00 Whole Blood & Packed Red Blood 209 1,268 209 1,268 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 5,624 41,331 5,624 41,331 50.00 Physical Therapy 3,511 9,551 3,511 9,551 51.00 Occupational Therapy 1,528 1,495 1,528 1,495 52.00 Speech Pathology 53.00 Electrocardiology 6,207 69,701 6,207 69,701 54.00 Electroencephalography 6,894 6,894 55.00 Medical Supplies Charged to Patients 360,888 360,888 55.01 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 6,637 6,637 57.00 Renal Dialysis 276 276 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 201 66,031 201 66,031 59.02 59.03 60.00 Clinic 9,339 3,216 9,339 3,216 60.01 Other Clinic Services 61.00 Emergency 12,963 54,513 12,963 54,513 62.00 Observation Beds 71.00 Home Health Agency 8,440 66,716 8,440 66,716 89.00 Utilization Review 0 130,729 0 130,729 93.00 Hospice 4,940 4,940 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 0 0 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 99.05 100.00 100.01 Foundation 4,000 4,000 100.02 100.03 Community Relations 4,429 15,760 4,429 15,760 100.04 TOTAL 357,757 5,468,738 357,757 5,468,73800000000 COST TO BE ALLOCATED 004,459,7936,975,93800000000 UNIT COST MULTIPLIER - SCH 8 0.000000 0.000000 12.465984 1.275603 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER 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 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 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 CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 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 9.1 Fiscal Period Ended: JUNE 30, 2009 EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM & GEN MAINT & (GROSS (ACCUM REPAIRS SALARIES) COST) (SQ FT) 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 7.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 15) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) 11,087,319 1,143,914 5,609,443 695,886 2,660,829 89,706 933,707 1,525 1,135,168 2,532,849 1,177 330,078 1,543,751 2,430 421,314 1,678,739 4,979 00 1,692,168 2,345,366 935 297,350 597,708 4,510 2,536,763 3,344,340 1,885 868,950 1,480,548 2,194 00 00 00 00 00 00 00 00 00 0 12,635,278 18,371,335 24,608 2,993,006 4,575,922 4,639 00 00 00 00 00 00 896,620 1,796,823 1,687 4,382,428 6,252,739 12,450 00 00 00 00 STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Gastro Intestinal Service 37.20 Cardicac Cath Lab 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 CT Scan and MRI 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood & Packed Red 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 55.01 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 89.00 Utilization Review 93.00 Hospice NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 99.05 100.00 100.01 Foundation 100.02 100.03 Community Relations 100.04 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 SCHEDULE 9.1 Fiscal Period Ended: JUNE 30, 2009 EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM & GEN MAINT & (GROSS (ACCUM REPAIRS SALARIES) COST) (SQ FT) 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 7.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 15) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 0 3,717,253 6,840,056 21,134 197,201 293,678 876 1,009,571 1,978,140 676 00 3,001,965 5,227,319 5,664 194,692 61 2,904,385 6,006,546 8,231 473,151 1,410,332 371 248,734 1,376,800 400 2,768,735 6,150,856 4,310 00 1,559,793 209 00 102,728 135,677 0 1,493,583 2,440,425 5,624 866,324 2,011,206 3,511 614,529 866,353 1,528 00 1,027,585 1,574,211 6,207 63,197 91,590 0 7,244,537 0 8,335,663 0 3,710,783 0 293,733 276 00 338,938 531,710 201 00 00 453,959 765,223 9,339 00 4,341,206 6,785,843 12,963 00 6,632,529 12,375,717 8,440 1,532,154 641,377 0 2,200,186 4,940 00 00 00 0 00 00 00 00 00 00 00 00 00 00 49,864 4,000 00 605,293 2,508,020 4,429 0 73,598,96800000000137,324,432 166,409 22,798,9140000000029,478,767 6,813,595 0.309772 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.214665 40.944872 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER 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 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 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 CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 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 9.2 Fiscal Period Ended: JUNE 30, 2009 OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT & LINEN KEEPING (MEALS (FTEs) PERSONNEL ADMIN & SUPPLY (COSTS (GROSS (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) (# HOUSED) (NURSE HR) (CST REQ) REQUIS) REVENUE) SPENT) 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 (Adj 15) (Adj ) (Adj 15) (Adj 18) (Adj 19) (Adj ) (Adj 21) (Adj 23) (Adj ) (Adj 22) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 20) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) 1,525 1,177 2,430 2,430 4,979 4,979 0 00 935 935 1,753 4,510 111,299 4,510 668 249 1,885 1,885 2,556 166 2,194 2,194 1,911 5,717 00 00 00 00 00 00 00 00 00 00 24,608 370,307 24,608 94,043 14,983 284,248 192,142 87,904,796 4,639 80,039 4,639 6,179 2,795 49,462 31,121 18,882,029 00 00 00 00 00 00 1,687 26,493 1,687 1,094 22,450 13,399 9,202,653 12,450 268,943 12,450 128,879 8,127 161,685 125,306 15,944,453 00 00 00 00 STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Gastro Intestinal Service 37.20 Cardicac Cath Lab 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 CT Scan and MRI 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood & Packed Red 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 55.01 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 89.00 Utilization Review 93.00 Hospice NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 99.05 100.00 100.01 Foundation 100.02 100.03 Community Relations 100.04 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 SCHEDULE 9.2 Fiscal Period Ended: JUNE 30, 2009 OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT & LINEN KEEPING (MEALS (FTEs) PERSONNEL ADMIN & SUPPLY (COSTS (GROSS (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) (# HOUSED) (NURSE HR) (CST REQ) REQUIS) REVENUE) SPENT) 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 (Adj 15) (Adj ) (Adj 15) (Adj 18) (Adj 19) (Adj ) (Adj 21) (Adj 23) (Adj ) (Adj 22) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 20) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 00 21,134 169,308 21,134 1,190 4,350 60,615 4,324,602 106,344,799 876 876 152 1,534 20,351 1,170,465 676 5,032 676 863 6,741 2,329,761 30,631,594 000 5,664 72,310 5,664 3,593 2,794 50,744 129,464 19,550,277 61 61 102,084 36,937,085 8,231 59,351 8,231 4,056 688 168,200 52,095,736 371 5,404 371 646 124 39,970 36,694,158 400 400 225 429,013 16,706,218 4,310 4,310 4,056 38,769 73,924,038 00 209 209 1,377,585 4,811,561 00 0 0 131 2,521 625,923 5,624 5,624 1,636 95 102,190 8,505,764 3,511 3,511 1,121 1,740 5,432 10,407,977 1,528 1,528 882 4,902 3,317 4,038,475 00 6,207 23,802 6,207 1,306 5,617 8,829 11,279,552 0 0 45 16 2 267,478 0 0 8,013,824 35,024,732 0 0 8,335,663 37,696,037 00 4,891,038 79,938,761 276 276 219 655,266 00 201 201 335 18 836 7,805,337 00 00 9,339 24,901 9,339 631 12,970 2,415 4,012,970 000 12,963 184,093 12,963 1,565 5,366 86,353 66,579 43,030,654 00 8,440 466,714 1,072,493 0 27,380 291,072 4,940 00 00 00 00 00 00 00 00 00 00 00 00 00 00 4,000 4,000 00 4,429 4,429 12,814 3,444 21,981 166,409 1,401,282 150,327 235,449 75,296 0 756,382 26,382,865 6,254,603 754,088,788 0 0 3,232,016 1,226,201 3,147,616 2,072,713 2,443,926 0 2,981,753 1,212,759 4,299,130 2,039,044 0 0 19.422125 0.875057 20.938460 8.803235 32.457578 0.000000 3.942126 0.045968 0.687355 0.002704 0.000000 0.000000 This is trial version www.adultpdf.com . 0 2,4981,18501, 277 00004,693099, 877 0 3 37, 0 17 159,864 51,935 172 ,344 0 131,648 0 2 ,71 2 7, 732 0 140,866 0 15,191 7, 206 4 ,72 9 7, 768 0 20,968 0 489 1,8 37 0 99,220 0 16, 378 7, 769 0 8, 375 0 7, 303 0 0 19 ,72 1 0 45, 173 . B-1) 0 3 ,71 7,253 6,840,056 21,134 1 97, 201 293, 678 876 1,009, 571 1, 978 ,140 676 00 3,001,965 5,2 27, 319 5,664 194,692 61 2,904,385 6,006,546 8,231 473 ,151 1,410,332 371 248 ,73 4 1, 376 ,800 400 2 ,76 8 ,73 5. 5,609,443 695,886 2,660,829 89 ,70 6 933 ,70 7 1,525 1,135,168 2,532,849 1, 177 330, 078 1,543 ,75 1 2,430 421,314 1, 678 ,73 9 4, 979 00 1,692,168 2,345,366 935 2 97, 350 5 97, 708 4,510 2,536 ,76 3 3,344,340 1,885 868,950