STATE OF CALIFORNIA ADULT SUBACUTE SCH 2 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 Provider No: LTC70046F / 1174736839 COST CENTER COL. DIRECT AND ALLOCATED EXPENSE 0.00 Adult Subacute $ 5,040,827 $ 2,266,789 $ (2,774,038) 1.00 Old Cap Rel Costs-Bldg & Fixtures 0 0 2.00 Old Cap Rel Costs-Movable Equipment 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 539,009 153,104 (385,905) 3.01 New Cap Bldg. Memorial 0 0 3.02 New Cap Bldg. - Midtown 11,632 0 (11,632) 3.03 New Cap Bldg. Infusion 0 0 4.00 New Cap Rel Costs-Movable Equipment 66,887 51,624 (15,263) 4.01 New Equip Memorial 0 0 4.02 New Equip - Midtown 13,861 0 (13,861) 4.03 New Equip Infusion 0 0 4.07 00 4.08 00 5.00 Employee Benefits 1,247,208 665,496 (581,712) 6.01 Communication 7,902 0 (7,902) 6.02 Data Processing 0 0 6.03 Purchasing 4,536 1,138 (3,398) 6.04 Admitting 30,287 3,158 (27,129) 6.05 Business Office 31,527 19,093 (12,434) 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 1,289,585 538,189 (751,396) 7.00 Maintenance and Repairs 1,978,078 1,012,179 (965,899) 8.00 Operation of Plant 3,695 1,422 (2,273) 9.00 Laundry and Linen Service 15,226 14,985 (241) 10.00 Housekeeping 1,246,422 705,851 (540,571) 11.00 Dietary 285,342 38,840 (246,502) 12.00 Cafeteria 220,556 117,672 (102,884) 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 58,416 10,882 (47,534) 15.00 Central Services & Supply 2,087 544 (1,543) 16.00 Pharmacy 2,411 2,188 (223) 17.00 Medical Records and Library 187,580 27,809 (159,771) 18.00 Social Service 1,065,495 243,795 (821,700) 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 479,860 447,018 (32,842) TOTAL DIRECT AND 101.00 ALLOCATED EXPENSES $ 13,828,429 $ 6,321,774 $ (7,506,655) (To Adult Subacute Sch 1) * From Schedule 8, Part I, Line 36.00 SUMMARY OF ADULT SUBACUTE FACILITY EXPENSES REPORTED AUDITED * DIFFERENCE This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 3 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 Provider No: LTC70046F / 1174736839 TOTAL RATIO TOTAL SUBACUTE SUBACUTE ANCILLARY CHARGES COST TO ANCILLARY ANCILLARY COST * CHARGES CHARGES ** COSTS*** ANCILLARY COST CENTERS (Adult SA Sch 4) 37.00 Operating Room $ 51,301,416 $ 395,738,167 0.129635 $ 0 $ 0 41.00 Radiology - Diagnostic 18,502,870 68,721,118 0.269246 44,211 11,904 41.01 Ultrasound 2,687,148 23,489,714 0.114397 0 0 42.01 CT Scan 3,774,503 92,143,955 0.040963 0 0 44.00 Laboratory 17,229,864 185,096,760 0.093086 443,334 41,268 44.01 Pathology 1,372,240 30,641,729 0.044783 1,072 48 47.00 Blood Storing, Processing & Tra 6,308,423 7,552,437 0.835283 0 0 49.00 Respiratory Therapy 11,782,174 100,782,051 0.116907 2,724,445 318,508 50.00 Physical Therapy 4,797,291 16,189,980 0.296312 3,158 936 51.00 Occupational Therapy 914,453 3,198,707 0.285882 14,649 4,188 52.00 Speech Pathology 751,535 1,711,434 0.439126 6,534 2,869 53.00 Electrocardiology 1,664,553 23,342,567 0.071310 0 0 54.00 Electroencephalography 2,511,765 13,971,098 0.179783 0 0 55.00 Med Supply Charged to Patients 87,731,244 225,163,517 0.389633 571,773 222,782 56.00 Drugs Charged to Patients 34,831,693 221,077,833 0.157554 0 0 60.03 Peds Audiology 493,343 1,677,204 0.294146 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 101.00 TOTAL $ 246,654,516 $ 1,410,498,271 $ 3,809,176 $ 602,503 (To Adult Subacute Sch 1) * From Schedule 8, Column 27 ** Total Other Allowable Ancillary Charges included in the rate. *** Total Other Ancillary Costs included in the rate. SCHEDULE OF TOTAL OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY COSTS** TOTAL ANCILLARY This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 4 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 Provider No: LTC70046F / 1174736839 ANCILLARY CHARGES 37.00 Operating Room $ 7,916 $ (7,916) $ 0 41.00 Radiology - Diagnostic 19,699 24,512 44,211 41.01 Ultrasound 1,524 (1,524) 0 42.01 CT Scan 21,517 (21,517) 0 44.00 Laboratory 197,539 245,795 443,334 44.01 Pathology 478 594 1,072 47.00 Blood Storing, Processing & Tra 1,617 (1,617) 0 49.00 Respiratory Therapy 1,213,950 1,510,495 2,724,445 50.00 Physical Therapy 1,407 1,751 3,158 51.00 Occupational Therapy 6,527 8,122 14,649 52.00 Speech Pathology 2,911 3,623 6,534 53.00 Electrocardiology 818 (818) 0 54.00 Electroencephalography 3,072 (3,072) 0 55.00 Med Supply Charged to Patients 254,769 317,004 571,773 56.00 Drugs Charged to Patients 1,577,915 (1,577,915) 0 60.03 Peds Audiology 2,845 (2,845) 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 0 101.00 TOTAL ANCILLARY CHARGES $ 3,314,504 $ 494,672 $ 3,809,176 (Adj 40) AUDITED ADJUSTMENTS TO OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY CHARGES (To Adult Subacute Sch 3) REPORTED ADJUSTMENTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 Provider No: LTC70046F / 1174736839 COL. 1.00 Old Cap Rel Costs-Bldg & Fixtures $ 0 $ N/A 2.00 Old Cap Rel Costs-Movable Equipment 0 N/A 3.00 New Cap Rel Costs-Bldg & Fixtures 153,104 N/A 3.01 New Cap Bldg. Memorial 0 N/A 3.02 New Cap Bldg. - Midtown 0 N/A 3.03 New Cap Bldg. Infusion 0 N/A 4.00 New Cap Rel Costs-Movable Equipment 51,624 N/A 4.01 New Equip Memorial 0 N/A 4.02 New Equip - Midtown 0 N/A 4.03 New Equip Infusion 0 N/A 4.07 0N/A 4.08 0N/A 5.00 Employee Benefits 1,620 663,875 6.01 Communication 0 0 6.02 Data Processing 0 0 6.03 Purchasing 0 0 6.04 Admitting 54 0 6.05 Business Office 117 75 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 5,106 44,342 7.00 Maintenance and Repairs 205,238 234,048 8.00 Operation of Plant 2 17 9.00 Laundry and Linen Service 864 180 10.00 Housekeeping 23,316 443,473 11.00 Dietary 3,269 27,823 12.00 Cafeteria 3,098 81,402 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 179 8,545 15.00 Central Services & Supply 171 297 16.00 Pharmacy 23 1,452 17.00 Medical Records and Library 623 1,389 18.00 Social Service 3,160 201,085 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 8,842 301,564 101.00 TOTAL ALLOCATED INDIRECT EXPENSES $ 460,410 $ 2,009,566 (To Adult Subacute Sch 1) ADULT SUBACUTE SCH 5 COST CENTER EMP BENEFITS AUDITED SAL &AUDITED CAP ALLOCATION OF INDIRECT EXPENSES ADULT SUBACUTE (COL 2) RELATED (COL 1)ALLOCATED EXPENSES This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 3.01 3.02 3.03 4.00 4.01 4.02 4.03 4.07 COMPUTATION OF COST ALLOCATION (W/S B) GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 0 2.00 Old Cap Rel Costs-Movable Equipmen 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 3,624,811 0 0 3.01 New Cap Bldg. Memorial 2,058,835 0 0 0 3.02 New Cap Bldg. - Midtown 81,184 0 0 0 0 3.03 New Cap Bldg. Infusion 85,371 0 0 0 0 0 4.00 New Cap Rel Costs-Movable Equipme 9,048,996 0 0 0 0 0 0 4.01 New Equip Memorial 7,634,577 0 0 0 0 0 0 0 4.02 New Equip - Midtown 56,100 0 0 0 0 0 0 0 0 4.03 New Equip Infusion 12,844 0 0 0 0 0 0 0 0 0 4.07 0 0 0 0 0 0 0 0 0 0 0 4.08 0 0 0 0 0 0 0 0 0 0 0 0 5.00 Employee Benefits 54,287,436 0 0 78,270 53,460 781 0 0 0 0 0 0 6.01 Communication 0 0 0 0 0 0 0 0 0 0 0 0 6.02 Data Processing 3,578,879 0 0 0 0 0 0 1,881 0 0 0 0 6.03 Purchasing 567,818 0 0 0 0 0 0 0 0 0 0 0 6.04 Admitting 789,022 0 0 5,057 8,747 0 0 0 0 0 0 0 6.05 Business Office 5,977,967 0 0 0 10,144 322 0 4,041 22,411 0 0 0 6.06 0 0 0 0 0 0 0 0 0 0 0 0 6.07 0 0 0 0 0 0 0 0 0 0 0 0 6.08 0 0 0 0 0 0 0 0 0 0 0 0 6.00 Administrative and General 75,013,766 0 0 159,987 54,393 2,329 0 398,755 103,026 4,262 4,835 0 7.00 Maintenance and Repairs 8,975,014 0 0 1,333,173 770,381 11,679 0 502,160 354,462 1,180 0 0 8.00 Operation of Plant 894,464 0 0 0 0 0 0 0 0 0 0 0 9.00 Laundry and Linen Service 308,632 0 0 0 0 16,341 0 0 4,849 575 0 0 10.00 Housekeeping 6,183,103 0 0 59,448 41,469 2,865 0 84,055 18,581 1,848 0 0 11.00 Dietary 1,767,455 0 0 92,829 37,876 4,009 0 33,532 13,997 8,167 0 0 12.00 Cafeteria 3,962,807 0 0 57,191 13,086 0 0 0 0 0 0 0 13.00 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 14.00 Nursing Administration 7,229,372 0 0 27,032 9,986 1,561 0 53,477 25,330 0 0 0 15.00 Central Services & Supply 804,773 0 0 107,387 81,542 1,435 0 529,907 407,569 20,391 0 0 16.00 Pharmacy 10,837,954 0 0 32,743 16,727 427 0 29,886 8,686000 17.00 Medical Records and Library 6,763,293 0 0 65,340 17,196 0 0 2,592 2,636000 18.00 Social Service 3,782,897 0 0 7,495 36,948 391 0 0 4,459 0 0 0 19.00 0 0 0 0 0 0 0 0 0 0 0 0 19.02 0 0 0 0 0 0 0 0 0 0 0 0 19.03 0 0 0 0 0 0 0 0 0 0 0 0 20.00 000000000000 21.00 Nursing School 000000000000 22.00 Intern & Res Service-Salary & Fringes 2,804,116 0 0 0 0 0 0 0 0 0 0 0 23.00Intern & Res Other Program 000000000000 24.00 Paramedical Ed Program 518,315 0 0 4,953 1,7890000000 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 52,969,669 0 0 584,694 287,998 0 0 92,977 209,140 0 0 0 26.00 Intensive Care Unit 11,537,199 0 0 112,401 32,134 0 0 292,210 163,799000 27.00 Coronary Care Unit 6,094,10200035,57000072,435000 28.00 000000000000 29.00 000000000000 30.00 Neonatal Intensive Care Unit 14,564,61400044,264000468,251000 30.01 Pediatric ICU 4,680,84000033,19700068,270000 32.00 000000000000 33.00 Nursery 2,905,60600014,4690000000 34.00 Medicare Certified Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 35.00 Distinct Part Nursing Facility 4,656,561 0 0 0 0 38,190 0 18,498 0 18,987 0 0 36.00 Adult Subacute Care Unit 2,266,789 0 0 153,104 0 0 0 51,624 0 0 0 0 36.01 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 36.02 Transitional Care Unit 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: SUTTER MEDICAL CENTER - SACRAMENTO DECEMBER 31, 2007 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 3.01 3.02 3.03 4.00 4.01 4.02 4.03 4.07 COMPUTATION OF COST ALLOCATION (W/S B) ANCILLARY COST CENTERS 37.00 Operating Room 27,675,926 0 0 213,723 74,704 0 0 1,871,095 1,665,426 0 0 0 37.01 Lithotripsy 230,652 0 0 0 0 0 0 0 0 0 0 0 39.00 Delivery Room and Labor Room 8,926,636 0 0 0 77,527 0 0 0 241,305 0 0 0 40.00 Anesthesiology 2,227,337 0 0 1,878 627 0 0 253,612 207,770 0 0 0 41.00 Radiology - Diagnostic 8,918,663 0 0 82,560 23,417 0 0 2,844,524 1,034,840000 41.01 Ultrasound 1,629,422 0 0 5,729 4,947 0 0 47,879 106,173000 41.02 Gamma Knife 404,246 0 0 2,584 0 0 0 430,120 0 0 0 0 42.01 CT Scan 1,807,193 0 0 7,874 2,464 0 0 172,183 353,625 0 0 0 43.00 Radioisotope 2,256,256 0 0 31,399 11,555 0 0 425,535 2,259000 44.00 Laboratory 10,755,367 0 0 37,929 40,211 0 0 1,255 340,495000 44.01 Pathology 749,468 0 0 18,900 7,206 0 0 14,910 20,264000 47.00 Blood Storing, Processing & Tra 5,194,563 0 0 9,36400000000 49.00 Respiratory Therapy 6,804,891 0 0 33,579 9,546 0 0 197,017 322,658000 50.00 Physical Therapy 2,532,546 0 0 62,782 10,766 0 0 5,350 1,566000 51.00 Occupational Therapy 504,046 0 0 11,785 5,8230000000 52.00 Speech Pathology 452,350 0 0 4,376 837 0 0 385 18,692 0 0 0 53.00 Electrocardiology 785,849 0 0 7,520 13,904 0 0 2,918 213,461 0 0 0 54.00 Electroencephalography 1,324,453 0 0 23,035 9,536 0 0 184,534 27,085000 55.00 Medical Supplies Charged to Patients 70,229,7300000006,598069100 56.00 Drugs Charged to Patients 15,847,405 0 0 1,215 1,211 0 0 1,112 21,581000 57.00 Renal Dialysis 5,607,350 0 0 70,276 1,775 0 0 175,7720000 59.00 Cath Lab Invasive 5,777,62000034,761000938,528000 59.01 O/P Pediatric Treatment 773,912 0 0 0 12,048 0 0 0 19,582 0 0 0 60.01 Heart Fail Clinic 354,986 0 0 0 0 0 0 0 50,797 0 0 0 60.02 Sleep Center 1,292,63200000077,2520000 60.03 Peds Audiology 335,9600003,87100013,334000 60.04 Development OP Clinic 2,396,73400025,0100009,151000 60.05 Infusion 8,051,6000000043,0620008,0090 60.00 Clinic 527,54700011,1290004,484000 60.06 Cancer Risk Assess Clinic 167,151 0 0 14,472 0 0 0 0 0 0 0 0 61.00 Emergency 11,820,076 0 0 62,153 20,474 0 0 233,990 64,326 0 0 0 62.00Observation Beds 000000000000 64.00Home Program Dialysis 9,49200000000000 83.00 Kidney Acquisition 1,263,58900018,431000611000 85.00 Heart Acquistion 273,90000000001,699000 85.01 Pancreas Acquisition 40,137 0 0 0 0 0 0 0 0 0 0 0 88.00 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 90.00 Other Capital Related Costs 0 0 0 0 0 0 0 0 0 0 0 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 000000000000 97.00 Research 1,171,169 0 0 24,7660002,9443,561000 98.00Physicians' Private Office 000000000000 99.00 Nonpaid Workers 000000000000 100.00 Beauty Clinic 17,894 0 0 0 0 853 0 0 0 0 0 0 100.01 Grants 2,288,204 0 0 0 24,895 0 0 0 1,323 0 0 0 100.02 Dialysis Contract Services 237,1590000008160000 100.03 Home Infusion 000000000000 100.04 Long Term Care Pharmacy 261,593 0 0 15,807 0 0 42,309 690000 100.05 Spa OP Lab 20,35800000000000 100.06 Foundation 00000003,5322,082000 100.08 SHSSR Home Office 000000000000 100.09 Other Related Organization 0 0 0 0 10,785 0 0 0 0 0 0 0 100.10 SCP 000000000000 TOTAL 529,271,243 0 0 3,624,811 2,058,835 81,184 85,371 9,048,996 7,634,577 56,100 12,844 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SUTTER MEDICAL CENTER - SACRAMENTO 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 3.01 New Cap Bldg. Memorial 3.02 New Cap Bldg. - Midtown 3.03 New Cap Bldg. Infusion 4.00 New Cap Rel Costs-Movable Equipme 4.01 New Equip Memorial 4.02 New Equip - Midtown 4.03 New Equip Infusion 4.07 4.08 5.00 Employee Benefits 6.01 Communication 6.02 Data Processing 6.03 Purchasing 6.04 Admitting 6.05 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 CENTER 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 30.00 Neonatal Intensive Care Unit 30.01 Pediatric ICU 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 8.1 Fiscal Period Ended: DECEMBER 31, 2007 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,578 0 11 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 1,234,584 0 39,229 179 0 0 0 0 0 77,015,345 0 630,065 0 42,463 612 0 0 0 0 0 12,621,189 2,149,282 0 0 0 0 0 0 0 0 0 0 894,464 152,320 0 0 0 0 0 0 0 0 0 0 330,396 56,264 0 1,082,713 0 17,584 5,033 0 0 0 0 0 7,496,700 1,276,624 0 466,947 0 75,525 1,199 0 0 0 0 0 2,501,536 425,990 0 782,998 0 615 2,011 0 0 0 0 0 4,818,708 820,585 0 0 0 0 0 0 0 0 0 0 0 0 0 1,615,934 0 53,455 546 0 0 0 0 0 9,016,691 1,535,466 0 334,372 0 30,211 377000002,317,963394,729 0 2,061,170 0 775,961 1,8590000013,765,4152,344,133 09,87402,2805000006,863,2171,168,748 0 883,695 0 369 216 0 0 0 0 0 4,716,470 803,175 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 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 2,804,116 477,517 0000000000 00 096,818001400000621,890105,903 0 12,871,775 0 1,658,106 15,402 132,572 801,549 0 0 0 69,623,883 11,856,357 0 2,559,374 0 293,740 3,750 27,287 164,98400015,186,8792,586,197 0 1,407,552 0 110,091 1,627 13,369 80,8310007,815,5781,330,927 0000000000 00 0000000000 00 0 3,442,823 0 53,845 3,557 52,196 315,58600018,945,1363,226,196 0 1,101,235 0 61,584 1,237 12,890 77,9350006,037,1871,028,082 0000000000 00 0 537,349 0 10,203 1,057 4,802 29,0310003,502,515596,449 0 0 0 0 0 0 0 0 0 0 0 0 0 837,813 0 0 292 7,281 44,020 0 0 0 5,621,641 957,318 0 665,496 0 0 1,138 3,158 19,093 0 0 0 3,160,401 538,189 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SUTTER MEDICAL CENTER - SACRAMENTO TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Lithotripsy 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 Ultrasound 41.02 Gamma Knife 42.01 CT Scan 43.00 Radioisotope 44.00 Laboratory 44.01 Pathology 47.00 Blood Storing, Processing & Tra 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 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Cath Lab Invasive 59.01 O/P Pediatric Treatment 60.01 Heart Fail Clinic 60.02 Sleep Center 60.03 Peds Audiology 60.04 Development OP Clinic 60.05 Infusion 60.00 Clinic 60.06 Cancer Risk Assess Clinic 61.00 Emergency 62.00 Observation Beds 64.00 Home Program Dialysis 83.00 Kidney Acquisition 85.00 Heart Acquistion 85.01 Pancreas Acquisition 88.00 Interest Expense 90.00 Other Capital Related Costs NONREIMBURSABLE COST CENTER 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 100.00 Beauty Clinic 100.01 Grants 100.02 Dialysis Contract Services 100.03 Home Infusion 100.04 Long Term Care Pharmacy 100.05 Spa OP Lab 100.06 Foundation 100.08 SHSSR Home Office 100.09 Other Related Organization 100.10 SCP TOTAL SCHEDULE 8.1 Fiscal Period Ended: DECEMBER 31, 2007 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 5,579,556 0 22,068 282,566 117,807 955,170 0 0 0 38,458,041 6,549,078 0 0 0 0 0 51 5,798 0 0 0 236,501 40,274 0 2,071,567 0 27,790 5,854 27,540 186,486 0 0 0 11,564,705 1,969,371 0 488,547 0 3,833 11,943 24,198 174,438 0 0 0 3,394,184 578,001 0 1,317,721 0 26,703 21,353 17,729 165,86800014,453,3792,461,288 0 284,692 0 3 117 5,304 56,6960002,140,962364,588 0 9,117 0 0 16 54 20,391 0 0 0 866,530 147,563 0 252,633 0 0 1,403 19,171 222,403 0 0 0 2,838,948 483,449 0 265,887 0 18,587 5,696 5,167 43,6040003,065,945522,105 0 1,679,563 0 36,703 18,818 55,553 446,75700013,412,6512,284,061 0006,492447,63773,958000898,880153,072 039,76701302832,49718,2290005,264,833896,556 0 1,477,504 0 71,722 6,809 38,711 243,2520009,205,6881,567,651 0 660,913 0 21,379 199 6,156 39,0770003,340,734568,899 0 116,642 0 0 94 1,231 7,721000647,342110,237 0 102,760 0 0 1 524 4,131 0 0 0 584,057 99,460 0 165,723 0 4,361 108 8,474 56,341 0 0 0 1,258,660 214,339 0 201,733 0 44,669 856 4,407 33,7210001,854,028315,725 000010,03189,288543,46400070,879,80212,070,229 00017,4085,96172,827533,60300016,502,3222,810,206 0 967,180 0 0 6,033 3,780 78,2150006,910,3811,176,779 0 1,055,920 0 11,233 99,296 25,225 237,8880008,180,4721,393,065 0 180,935 0 0 305 39 4,255 0 0 0 991,076 168,772 0 80,545 0 0 59 0 637 0 0 0 487,023 82,936 0 247,565 0 0 328 0 12,1410001,629,918277,561 049,370008884904,048000407,96069,472 0 673,206 0 141 254 0 7,0120003,111,508529,863 0 206,387 0 0 38,822 2,327 56,5650008,406,7721,431,602 0 128,481 0 0 81 0 3,055000674,777114,909 0 27,106 0 0 12 0 1,171 0 0 0 209,913 35,746 0 2,363,897 0 42,268 8,123 13,081 246,985 0 0 0 14,875,372 2,533,150 0000000000 00 0000433078300010,7081,824 0 151,018 0 0 51 0 1,6800001,435,379244,433 039,11900130365000315,09553,658 0 1,397 0 0 0 0 114 0 0 0 41,648 7,092 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0 243,572 0 0 87000001,446,099246,258 0000000000 00 0000000000 00 0 4,228 0 0 2 0 17 0 0 0 22,993 3,916 0 477,682 0 0 424 0 0 0 0 0 2,792,529 475,544 049,188001170404000287,68448,990 0000000000 00 0 131,660 0 0 20600000451,64576,911 0000190400020,3813,471 00000000005,614956 0000000000 00 0 0 0 0 0 0 0 0 0 0 10,785 1,837 0000000000 00 0 54,419,947 0 3,580,760 567,818 802,825 6,019,472 0 0 0 529,271,243 77,015,345 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SUTTER MEDICAL CENTER - SACRAMENTO 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 3.01 New Cap Bldg. Memorial 3.02 New Cap Bldg. - Midtown 3.03 New Cap Bldg. Infusion 4.00 New Cap Rel Costs-Movable Equipme 4.01 New Equip Memorial 4.02 New Equip - Midtown 4.03 New Equip Infusion 4.07 4.08 5.00 Employee Benefits 6.01 Communication 6.02 Data Processing 6.03 Purchasing 6.04 Admitting 6.05 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 CENTER 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 30.00 Neonatal Intensive Care Unit 30.01 Pediatric ICU 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: DECEMBER 31, 2007 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 0 0 393,014 0 2,928 613,697 84 3,461 427,966 378,093 0 0 263,666 0 0 0 0 0 0 0 178,710 2,676 6,772 124,625 0 211,084 0 709,943 188,150 0 495,084 0 78,311 0 0 216,468 3,345 0 150,956 0 209,461 0 0 6,481 431,968 0 0 301,237 0 2,388 0 0 45 0 49,547 0 0 34,552 0 136,277 0 15,468 1,657 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 32,7460022,836012,7190107119000 3,865,448 118,660 134,753 2,695,600 2,861,667 1,553,953 0 4,421,089 34,029 161,444 1,167,489 2,964,429 743,088 23,331 17,510 518,198 135,817 265,362 0 887,739 7,044 27,901 240,306 283,025 0 19,150 9,812 0 144,662 155,943 0 476,674 3,136 16,896 117,734 176,552 000000000000 000000000000 0 89,810 9,745 0 0 361,826 0 1,295,820 7,489 9,376 459,664 618,655 0 9,282 4,821 0 0 122,079 0 383,750 2,409 10,703 113,515 157,445 000000000000 083600068,763048,136739342,284321,608 0 0 0 0 0 0 0 0 0 0 0 0 1,228,875 26,007 0 0 637,943 198,247 0 44,250 2,213 66,394 64,117 991,636 1,012,179 1,422 14,985 705,851 38,840 117,672 0 10,882 544 2,188 27,809 243,795 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: SUTTER MEDICAL CENTER - SACRAMENTO TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Lithotripsy 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 Ultrasound 41.02 Gamma Knife 42.01 CT Scan 43.00 Radioisotope 44.00 Laboratory 44.01 Pathology 47.00 Blood Storing, Processing & Tra 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 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Cath Lab Invasive 59.01 O/P Pediatric Treatment 60.01 Heart Fail Clinic 60.02 Sleep Center 60.03 Peds Audiology 60.04 Development OP Clinic 60.05 Infusion 60.00 Clinic 60.06 Cancer Risk Assess Clinic 61.00 Emergency 62.00 Observation Beds 64.00 Home Program Dialysis 83.00 Kidney Acquisition 85.00 Heart Acquistion 85.01 Pancreas Acquisition 88.00 Interest Expense 90.00 Other Capital Related Costs NONREIMBURSABLE COST CENTER 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 100.00 Beauty Clinic 100.01 Grants 100.02 Dialysis Contract Services 100.03 Home Infusion 100.04 Long Term Care Pharmacy 100.05 Spa OP Lab 100.06 Foundation 100.08 SHSSR Home Office 100.09 Other Related Organization 100.10 SCP TOTAL SCHEDULE 8.2 Fiscal Period Ended: DECEMBER 31, 2007 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) 1,412,938 153,781 62,942 985,323 0 595,566 0 1,087,457 61,841 36,352 1,391,244 0 0 0 0 0 0 0 0 0 0 0 8,446 0 0 46,996 30,403 0 0 236,203 0 726,782 8,193 14,239 271,624 0 12,415 0 0 8,658 0 52,402 0 7,995 6,672 286,349 254,076 0 545,812 122,256 12,484 380,626 0 191,558 0 76,285 8,047 9,541 241,594 0 37,872 1,422 2,550 26,410 0 30,407 0 247 112 0 82,580 0 17,085 84 0 11,914 0 2,039 0 0 46 59 29,701 0 52,053 2,174 2,633 36,299 0 33,891 0 987 132 0 323,938 0 207,584 6,606 5,073 144,760 0 24,595 0 8,701 591 8,796 63,511 0 250,752 34,285 602 174,864 0 267,873 0 0 146,899 7,156 650,720 0 124,949 0 111 87,13400003720107,7230 61,905 2,091 0 43,170 0 3,886 0 5,348 2,199 1,883 26,551 0 221,992 79,190 0 154,808 0 194,1870004,351354,3060 415,054 1,171 1,019 289,441 0 123,146 0 0 909 0 56,917 0 77,908 0 0 54,330 0 13,196 0 0 196 0 11,245 0 28,931 0 0 20,175 0 12,889 0 0 7 0 6,017 0 49,718 3,010 77 34,671 0 21,245 0 84 686 0 82,062 0 152,285 2,509 1,192 106,197 0 28,836 0 0 1,146 728 49,116 0 000000003,833,190156,445791,5770 8,030 24,418 0 5,600 0 37,727 0 155,378 491 14,510,309 777,214 0 464,601 0 1,657 323,993 0 129,447 0 209,883 13,218 1,292,827 113,923 0 0 0 7,682 0 34,021 108,151 0 230,811 5,195 2,184 346,494 0 0 6,606 2,081 0 0 21,345 0 66,838 534 2,476 6,197 0 0 0 58 0 0 10,404 0 0 463 0 928 0 0000038,958001,04917217,6840 02510009,6000016405,8960 0000082,349015,0082,016010,2130 0 33,031 2,997 0 21,043 27,852 0 68,453 1,811 1,326 82,389 0 016700018,26601636162534,4490 95,677 13,380 0 66,721 0 5,425 0 0 69 7 1,706 0 410,897 23,163 48,311 286,542 34,923 301,671 0 802,372 15,393 15,706 359,744 0 000000000000 00000000048,2271,1410 01,42200015,9710036702,4460 03340004,13700405310 0 0 0 0 0 148 0 0 0 0 166 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 163,732 1,338 0 114,180 0 39,520 0 39 704000 000000000000 000000000000 0 0 0 0 0 1,041 0 0 16 0 24 0 0 251 0 0 0 78,531 0 11,667 3,400 3 0 0 000004,260017,6152681,9085890 000000000000 104,504 4,097 0 72,877 0 20,245 0 0 1,098 59 0 0 00000000163050 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 000063,8180000000 14,770,471 1,046,784 386,660 9,169,267 3,972,735 6,281,053 0 11,076,025 4,184,181 16,696,260 8,767,601 5,757,145 This is trial version www.adultpdf.com . EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 3.01 3.02 3.03 4.00 4.01 4.02 4.03 4.07 COMPUTATION OF COST ALLOCATION (W/S B) GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg. ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,578 0 11 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 1,234,584 0 39,229 179 0 0 0 0 0 77,015,345 0 630,065 0 42,463 612 0 0 0 0 0 12,621,189 2,149,282 0 0 0 0 0 0 0 0 0 0 894,464 152,320 0 0 0 0 0 0 0 0 0 0 330,396 56,264 0 1,082,713 0 17,584 5,033 0 0 0 0 0 7,496,700 1,276,624 0 466,947 0 75,525 1,199 0 0 0 0 0 2,501,536 425,990 0 782,998 0 615 2,011 0 0 0 0 0 4,818,708 820,585 0 0 0 0 0 0 0 0 0 0 0 0 0 1,615,934 0 53,455 546 0 0 0 0 0 9,016,691 1,535,466 0. ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 5,579,556 0 22,068 282,566 117,807 955,170 0 0 0 38,458,041 6,549,078 0 0 0 0 0 51 5,798 0 0 0 236,501 40,274 0 2,071,567 0 27,790 5,854 27,540 186,486 0 0 0 11,564,705 1,969,371 0 488,547 0 3,833 11,943 24,198 174,438 0 0 0 3,394,184 578,001 0