STATE OF CALIFORNIA COMPUTATION OF MEDICAL INPATIENT ROUTINE SERVICE COST_PART3 potx

STATE OF CALIFORNIA
Provider Name:
USC KENNETH NORRIS JR. CANCER HOSPIT
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 CENTER
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:
MAY 31, 2008
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
126
825,499
0
15,792,068
15,792,068
000000007,294,013 7,294,013
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
000000000 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
000000000 0
This is trial version
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STATE OF CALIFORNIA
Provider Name:
USC KENNETH NORRIS JR. CANCER HOSPITAL
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00 Operating Room
38.00 Recovery Room
39.00 Delivery Room and Labor Room
41.00 Radiology - Diagnostic
41.01 CT Scan
41.02 Ultrasound
41.03 Endoscopy
42.00 Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00
Blood Storing, Processing & Transfusion
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
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)
59.00
59.01
59.02
59.03
60.00 Clinic
60.01 Infusion Therapy Clinic
60.02 Cancer Clinic
62.00 Observation Beds
65.00 Ambulance Services
82.00
83.00
84.00
85.00
86.00
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 Doctors Meals
100.01
100.02
100.03
100.05 Public Relations
TOTAL
SCHEDULE 8.3
Fiscal Period Ended:
MAY 31, 2008
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)
00000135887,040 0 5,222,093 5,222,093
000000001,014,352 1,014,352
000000000 0
000001493,37304,823,241 4,823,241
00000000932,163 932,163
00000000448,066 448,066
00000000272,997 272,997
000001065,78506,118,075 6,118,075
00000532,8930551,454 551,454
0000020131,570 0 9,222,600 9,222,600
000000000 0
000000000 0
000000003,484,612 3,484,612

000000000 0
000000001,182,676 1,182,676
00000000160,142 160,142
000000000 0
000000000 0
00000000116,782 116,782
000000000 0
000000006,512,926 6,512,926
0000000035,718,461 35,718,461
00000000270,958 270,958
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
00000426,52605,795,254 5,795,254
000000003,827,283 3,827,283
00000000776,882 776,882
000000000 0
0000000085,605 85,605
000000000 0
000000000 0
000000000 0
000000000 0
000000000 0
00000000345,976 345,976
000000000 0
000000000 0
000000000 0
000000000 0

000000000 0
000000000 0
000000000 0
000000000 0
00000000138,869 138,869
000000000 0
000000000 0
000000000 0
00000000800,060 800,060
0
0 0 0 0 314 2,062,685 0 110,907,611 0 110,907,611
This is trial version
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STATE OF CALIFORNIA
SCHEDULE 9
Provider Name:
Fiscal Period Ended:
USC KENNETH NORRIS JR. CANCER HOSPITAL
MAY 31, 2008
OLD BLDG OLD MOVBLE NEW BLDG
NEW MOVBLE
STAT STAT STAT STAT STAT STAT STAT STAT
& FIXTURES EQUIP & FIXTURES EQUIP
(SQ FT) (SQ FT) (SQ FT) (SQ FT)
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 ) (Adj ) (Adj ) (Adj ) (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 332 332 332 332
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 17,786 17,786 17,786 17,786
7.00 Maintenance and Repairs
8.00 Operation of Plant 197 197 197 197
9.00 Laundry and Linen Service 777 777 777 777
10.00 Housekeeping 806 806 806 806
11.00 Dietary 4,133 4,133 4,133 4,133
12.00 Cafeteria
13.00 Maintenance of Personnel
14.00 Nursing Administration 173 173 173 173
15.00 Central Services & Supply 1,897 1,897 1,897 1,897
16.00 Pharmacy 2,886 2,886 2,886 2,886
17.00 Medical Records and Library 2,833 2,833 2,833 2,833

18.00 Social Service 569 569 569 569
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)
18,166
18,166
18,166
18,166
26.00 Intensive Care Unit 3,633 3,633 3,633 3,633
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
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:
USC KENNETH NORRIS JR. CANCER HOSPITAL
MAY 31, 2008
OLD BLDG OLD MOVBLE NEW BLDG
NEW MOVBLE
STAT STAT STAT STAT STAT STAT STAT STAT
& FIXTURES EQUIP & FIXTURES EQUIP
(SQ FT) (SQ FT) (SQ FT) (SQ FT)
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 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
STATISTICS FOR COST ALLOCATION (W/S B-1)
ANCILLARY COST CENTERS
37.00 Operating Room 7,275 7,275 7,275 7,275
38.00 Recovery Room 1,313 1,313 1,313 1,313
39.00 Delivery Room and Labor Room
41.00 Radiology - Diagnostic 7,102 7,102 7,102 7,102
41.01 CT Scan 620 620 620 620
41.02 Ultrasound 125 125 125 125
41.03 Endoscopy
42.00 Radiology - Therapeutic 16,372 16,372 16,372 16,372
43.00 Radioisotope 530 530 530 530
44.00 Laboratory 14,531 14,531 14,531 14,531
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing, Processing & Transfusion 624 624 624 624

48.00 Intravenous Therapy
49.00 Respiratory Therapy 1,803 1,803 1,803 1,803
50.00 Physical Therapy
51.00 Occupational Therapy
52.00 Speech Pathology
53.00 Electrocardiology 125 125 125 125
54.00 Electroencephalography
55.00 Medical Supplies Charged to Patients
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)
59.00
59.01
59.02
59.03
60.00 Clinic 12,545 12,545 12,545 12,545
60.01 Infusion Therapy Clinic 7,218 7,218 7,218 7,218
60.02 Cancer Clinic 2,034 2,034 2,034 2,034
62.00 Observation Beds
65.00 Ambulance Services
82.00
83.00
84.00
85.00
86.00
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen 865 865 865 865
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers

99.01
99.02
99.03
99.04
99.05
100.00 Doctors Meals
100.01
100.02
100.03
100.05 Public Relations 94 94 94 94
TOTAL 127,364 127,364 127,364 127,36400000000
COST TO BE ALLOCATED 2,100,657 3,155,027 1,666,012 946,99300000000
UNIT COST MULTIPLIER - SCH 8 16.493334 24.771733 13.080714 7.435327 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:
USC KENNETH NORRIS JR. CANCER HOSPITAL
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:
MAY 31, 2008
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 6.00 7.00
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
4,440,021
0
29,932 2,721,654
271,277
973,495

415,826 1,460,724
0
0
1,101,066 1,467,994
130,033 495,924
832,404 3,376,609
1,103,850 2,430,297
337,534 483,900
0
0
0
0
0
245 248
1,625,790
0
5,446,136
9,616,994
2,264,612 4,697,697
0
0
0
0
0
0
0
0
0
0
0

0
STATISTICS FOR COST ALLOCATION (W/S B-1)
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
USC KENNETH NORRIS JR. CANCER HOSPITAL
ANCILLARY COST CENTERS
37.00 Operating Room
38.00 Recovery Room
39.00 Delivery Room and Labor Room
41.00 Radiology - Diagnostic
41.01 CT Scan
41.02 Ultrasound
41.03 Endoscopy
42.00 Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing, Processing & Transfusion
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
56.00 Drugs Charged to Patients

57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)
59.00
59.01
59.02
59.03
60.00 Clinic
60.01 Infusion Therapy Clinic
60.02 Cancer Clinic
62.00 Observation Beds
65.00 Ambulance Services
82.00
83.00
84.00
85.00
86.00
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 Doctors Meals
100.01
100.02
100.03

100.05 Public Relations
TOTAL
COST TO BE ALLOCATED
UNIT COST MULTIPLIER - SCH 8
SCHEDULE 9.1
Fiscal Period Ended:
MAY 31, 2008
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 6.00 7.00
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
STATISTICS FOR COST ALLOCATION (W/S B-1)
1,234,795 2,766,058
277,189 617,299
0
1,052,546 3,348,336
331,410 539,167
332,382
88,204 196,681
1,017,897 3,893,666
101,093 375,131
2,098,348 6,245,362
0
0
126,199 2,693,688
0
541,590 817,712
99,924 115,903
0

0
6,757 82,907
0
4,388,485
23,403,761
208,227
0
0
0
0
0
2,057,221 3,940,254
1,535,135 2,373,423
297,355 524,836
0
67,473
0
0
0
0
0
45,722 239,375
0
0
0
0
0
0
0
0

0
0
0
0
69,618 623,651
27,082,6620000000087,416,378 0
292,8550000000023,491,233 0
0.010813 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.268728 0.000000
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
USC KENNETH NORRIS JR. CANCER HOSPITAL
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:
MAY 31, 2008
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT
PLANT & LINEN KEEPING (MEALS (FTES) PERSONNEL ADMIN & SUPPLY (COSTED (GROSS (TIME
(SQ FT) (LB LNDRY) (SQ FT) SERVED) (# HOUSED) (NURSE HR) (CST REQ) REQUIS) REV) 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 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
777
806
4,133 4,133
196,141
173 173 10
1,897 1,897 2
2,886 2,886 25
2,833 2,833 30
569 569 4

18,166
18,606
18,166
39,530
75
50
17,133,181
72
3,633 4,430 3,633 7,742 32 43 9,441,901 56
STATISTICS FOR COST ALLOCATION (W/S B-1)
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
USC KENNETH NORRIS JR. CANCER HOSPITAL
ANCILLARY COST CENTERS
37.00 Operating Room
38.00 Recovery Room
39.00 Delivery Room and Labor Room
41.00 Radiology - Diagnostic
41.01 CT Scan
41.02 Ultrasound
41.03 Endoscopy
42.00 Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing, Processing & Transfusion
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
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)
59.00
59.01
59.02
59.03
60.00 Clinic
60.01 Infusion Therapy Clinic
60.02 Cancer Clinic
62.00 Observation Beds
65.00 Ambulance Services
82.00
83.00
84.00
85.00
86.00
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 Doctors Meals
100.01
100.02
100.03
100.05 Public Relations
TOTAL
COST TO BE ALLOCATED
UNIT COST MULTIPLIER - SCH 8
SCHEDULE 9.2

Fiscal Period Ended:
MAY 31, 2008
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT
PLANT & LINEN KEEPING (MEALS (FTES) PERSONNEL ADMIN & SUPPLY (COSTED (GROSS (TIME
(SQ FT) (LB LNDRY) (SQ FT) SERVED) (# HOUSED) (NURSE HR) (CST REQ) REQUIS) REV) 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 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
STATISTICS FOR COST ALLOCATION (W/S B-1)
7,275 5,759 7,275 17 13 17,129,932
1,313 2,658 1,313 3 8 1,343,948
7,102 7,102 16 9,282,915
620 620 4 19,210,120
125 125 1,988,914
1 1,778,573
16,372 3,101 16,372 15 23,386,128 20
530 530 1 1,413,368

14,531 6,645 14,531 28 33,129,665
624 624 1 3,346,946
1,803 1,803 6 3,662,096
1 793,685
125 125 586,182
100 21,289,421
100 142,260,796
643,412
12,545 3,101 12,545 4,711 26 3,825,526
7,218 7,218 13 10 6,031,984 76
2,034 2,034 4 360,197
865 865 1
18,195
94 94 1
109,049 44,300 107,466 266,319 316 0 124 100 100 318,038,890 224 0
3,453,038 368,780 1,260,622 2,032,615 1,496,998 0 1,917,366 720,988 4,527,672 3,348,446 657,579 0
31.665015 8.324613 11.730425 7.632255 4737.336115 0.000000 15462.632578 7209.883369 45276.717135 0.010528 2935.621806 0.000000
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
USC KENNETH NORRIS JR. CANCER HOSPITAL
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 9.3
Fiscal Period Ended:
MAY 31, 2008
STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED
ANESTH SCHOOL & FRINGES COST EDUCAT
(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME)
19.02 19.03 20.00 21.00 22.00 23.00 24.00
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
3,112

3,112
STATISTICS FOR COST ALLOCATION (W/S B-1)
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STATE OF CALIFORNIA
Provider Name:
USC KENNETH NORRIS JR. CANCER HOSPITAL
ANCILLARY COST CENTERS
37.00 Operating Room
38.00 Recovery Room
39.00 Delivery Room and Labor Room
41.00 Radiology - Diagnostic
41.01 CT Scan
41.02 Ultrasound
41.03 Endoscopy
42.00 Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing, Processing & Transfusion
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
56.00 Drugs Charged to Patients

57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)
59.00
59.01
59.02
59.03
60.00 Clinic
60.01 Infusion Therapy Clinic
60.02 Cancer Clinic
62.00 Observation Beds
65.00 Ambulance Services
82.00
83.00
84.00
85.00
86.00
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 Doctors Meals
100.01
100.02
100.03

100.05 Public Relations
TOTAL
COST TO BE ALLOCATED
UNIT COST MULTIPLIER - SCH 8
SCHEDULE 9.3
Fiscal Period Ended:
MAY 31, 2008
STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED
ANESTH SCHOOL & FRINGES COST EDUCAT
(ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME)
19.02 19.03 20.00 21.00 22.00 23.00 24.00
(Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
STATISTICS FOR COST ALLOCATION (W/S B-1)
3,344 3,344
352 352
248 248
124 124
496 496
100 100


00007,7767,7760
00003142,062,685 0
0.000000 0.000000 0.000000 0.000000 0.040406 265.263039 0.000000
This is trial version
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