SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_PART2 potx

STATE OF CALIFORNIA SCHEDULE 5
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
ZZT 30056F
RATIO
COST TO
CHARGES
ANCILLARY COST CENTERS
37.00 Operating Room $ 19,155,383 $ 52,806,536 0.362746 $ 0 $ 0
38.00 Recovery Room 0 0 0.000000 0 0
39.00 Delivery Room and Labor Room 14,865,512 50,935,422 0.291850 0 0
40.00 Anesthesiology 0 0 0.000000 0 0
41.00 Radiology - Diagnostic 10,727,676 103,024,136 0.104128 47,249 4,920
41.01 0 0 0.000000 0 0
41.02 0 0 0.000000 0 0
42.00 Radiology - Therapeutic 0 0 0.000000 0 0
43.00 Radioisotope 1,694,803 4,391,070 0.385966 740 286
44.00 Laboratory 16,214,746 80,129,005 0.202358 180,794 36,585
44.01 Pathological Lab 0 0 0.000000 0 0
46.00 Whole Blood 0 0 0.000000 0 0
47.00 Blood Storing and Processing 0 0 0.000000 0 0
48.00 Intravenous Therapy 0 0 0.000000 0 0
49.00 Respiratory Therapy 8,573,772 71,377,030 0.120119 0 0
50.00 Physical Therapy 1,463,732 4,003,812 0.365585 70,914 25,925
51.00 Occupational Therapy 156,122 306,981 0.508571 4,274 2,174
52.00 Speech Pathology 81,955 245,375 0.334000 1,620 541
53.00 Electrocardiology 999,870 8,750,091 0.114270 0 0
54.00 Electroencephalography 317,877 1,347,672 0.235871 0 0
55.00 Medical Supplies Charged to Patients 28,456,941 109,573,890 0.259705 0 0

56.00 Drugs Charged to Patients 11,643,094 66,037,141 0.176311 464,391 81,877
57.00 Renal Dialysis 1,236,654 4,756,348 0.260001 0 0
58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0
59.00 Patient Education & Family Counseling 37,212 102,595 0.362712 0 0
59.01 Ultrasound 1,516,020 12,939,156 0.117165 18,576 2,176
59.02 Magnetic Resonance Imaging 1,129,701 7,659,264 0.147495 28,505 4,204
59.03 0 0 0.000000 0 0
60.00 Clinic 0 0 0.000000 0 0
60.01 Other Clinic Services 0 0 0.000000 0 0
61.00 Emergency 21,548,072 73,729,290 0.292259 0 0
62.00 Observation Beds 0 0 0.000000 0 0
71.00 Home Health Agency 2,315,484 0 0.000000 0 0
82.00 0 0 0.000000 0 0
83.00 0 0 0.000000 0 0
84.00 0 0 0.000000 0 0
85.00 0 0 0.000000 0 0
86.00 0 0 0.000000 0 0
TOTAL $ 142,134,628 $ 652,114,814 $ 817,063 $ 158,688
(To Schedule 3)
* From Schedule 8, Column 27
TOTAL ANCILLARY
MEDI-CAL
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL
COST *
CHARGES
MEDI-CAL
(Adj 9)
COSTCHARGES
(From Schedule 6)

ANCILLARY
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STATE OF CALIFORNIA SCHEDULE 6
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
ZZT 30056F
ANCILLARY CHARGES
37.00 Operating Room $ 0 $ 0 $ 0
38.00 Recovery Room 0 0 0
39.00 Delivery Room and Labor Room 0 0 0
40.00 Anesthesiology 0 0 0
41.00 Radiology - Diagnostic 0 47,249 47,249
41.01 0 0 0
41.02 0 0 0
42.00 Radiology - Therapeutic 0 0 0
43.00 Radioisotope 0 740 740
44.00 Laboratory 0 180,794 180,794
44.01 Pathological Lab 0 0 0
46.00 Whole Blood 0 0 0
47.00 Blood Storing and Processing 0 0 0
48.00 Intravenous Therapy 0 0 0
49.00 Respiratory Therapy 0 0 0
50.00 Physical Therapy 0 70,914 70,914
51.00 Occupational Therapy 0 4,274 4,274
52.00 Speech Pathology 0 1,620 1,620
53.00 Electrocardiology 0 0 0
54.00 Electroencephalography 0 0 0

55.00
Medical Supplies Charged to Patients 000
56.00 Drugs Charged to Patients 0 464,391 464,391
57.00 Renal Dialysis 0 0 0
58.00 ASC (Non-Distinct Part) 0 0 0
59.00 Patient Education & Family Counseling 0 0 0
59.01 Ultrasound 0 18,576 18,576
59.02 Magnetic Resonance Imaging 0 28,505 28,505
59.03 0 0 0
60.00 Clinic 0 0 0
60.01 Other Clinic Services 0 0 0
61.00 Emergency 0 0 0
62.00 Observation Beds 0 0 0
71.00 Home Health Agency 0 0 0
82.00 0
83.00 0
84.00 0
85.00 0
86.00 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 817,063 $ 817,063
(To Schedule 5)
(Adj 11)
ADJUSTMENTS TO MEDI-CAL CHARGES
REPORTED ADJUSTMENTS AUDITED
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STATE OF CALIFORNIA SCHEDULE 7
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008

Provider No:
ZZT 30056F
PROFESSIONAL
SERVICE
COST CENTERS
40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 0
41.00 Radiology - Diagnostic 0 0 0.000000 0
43.00 Radioisotope 0 0 0.000000 0
44.00 Laboratory 0 0 0.000000 0
53.00 Electrocardiology 0 0 0.000000 0
54.00 Electroencephalography 0 0 0.000000 0
61.00 Emergency 0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0

0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
0 0 0.000000 0
TOTAL $ 0 $ 0 $ 0 $ 0
(To Schedule 3)
TO CHARGES
(Adj ) (Adj ) (Adj )
PHYSICIAN'S REMUNERATION
TOTAL CHARGES
TO ALL PATIENTS
MEDI-CAL MEDI-CAL
COST
RATIO OF
REMUNERATION CHARGES
COMPUTATION OF PROFESSIONAL
COMPONENT OF HOSPITAL BASED
REMUNERATION
HBP

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STATE OF CALIFORNIA CONTRACT SCH 1
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
REPORTED AUDITED
1. Net Cost of Covered Services Rendered to
Medi-Cal Patients (Contract Sch 3) $ 43,133,298 $ 37,818,792

2. Excess Reasonable Cost Over Charges (Contract Sch 2) $ 0 $ 0
3. Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ 0
4. $0 $0
5. Subtotal (Sum of Lines 1 through 4) $ 43,133,298 $ 37,818,792
6. $0 $0
7. $0 $0

8. Total Medi-Cal Cost (Sum of Lines 5 through 7) $ 43,133,298 $ 37,818,792
(To Summary of Findings)
9. Medi-Cal Overpayments (Adj ) $ 0 $ 0
10. Medi-Cal Credit Balances (Adj 18) $ 0 $ (2,414)
11. $0 $0
12. $0 $0
13. TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 0 $ (2,414)
(To Summary of Findings)
COMPUTATION OF MEDI-CAL CONTRACT COST
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STATE OF CALIFORNIA CONTRACT SCH 2

Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
REPORTED AUDITED

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1. Cost of Covered Services (Contract Sch 3) $ 43,133,298 $ 38,335,357
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2. Inpatient Routine Service Charges (Adj 16) $ 44,604,908 $ 46,514,275
3. Inpatient Ancillary Service Charges (Adj 16) $ 75,794,994 $ 85,881,246
4. Total Charges - Medi-Cal Inpatient Services $ 120,399,902 $ 132,395,521
5. Excess of Customary Charges Over Reasonable Cost
(Line 4 minus Line 1) * $ 77,266,604 $ 94,060,164
6. Excess of Reasonable Cost Over Customary Charges
(Line 1 minus Line 4) $ 0 $ 0
(To Contract Sch 1)
* If charges exceed reasonable cost, no further calculation necessary for this schedule.
COMPUTATION OF LESSER OF
MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
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STATE OF CALIFORNIA CONTRACT SCH 3
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
REPORTED AUDITED
1. Medi-Cal Inpatient Ancillary Services (Contract Sch 5) $ 16,490,092 $ 19,015,396
2. Medi-Cal Inpatient Routine Services (Contract Sch 4) $ 26,643,206 $ 19,319,961

3. Medi-Cal Inpatient Hospital Based Physician
for Intern and Resident Services (Sch ) $ 0 $ 0
4. $0 $0
5. $0 $0
6. SUBTOTAL (Sum of Lines 1 through 5) $ 43,133,298 $ 38,335,357
7. Medi-Cal Inpatient Hospital Based Physician
for Acute Care Services (Contract Sch 7) $ 0 $ 0
8. SUBTOTAL $ 43,133,298 $ 38,335,357
(To Contract Sch 2)
9. Coinsurance (Adj 17) $ 0 $ (359,771)
10. Patient and Third Party Liability (Adj 17) $ 0 $ (156,794)
11. Net Cost of Covered Services Rendered to Medi-Cal
Inpatients $ 43,133,298 $ 37,818,792
(To Contract Sch 1)
MEDI-CAL NET COST OF COVERED SERVICES
COMPUTATION OF
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STATE OF CALIFORNIA CONTRACT SCH 4
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
GENERAL SERVICE UNIT NET OF SWING-BEDS COSTS REPORTED AUDITED
INPATIENT DAYS
1. Total Inpatient Days (include private & swing-bed) (Adj ) 81,540 81,540
2. Inpatient Days (include private, exclude swing-bed) 81,540 81,540
3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0
4. Semi-Private Room Days (exclude swing-bed) (Adj ) 81,540 81,540
5. Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0

6. Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0
7. Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0
8. Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0
9. Medi-Cal Days (excluding swing-bed) (Adj 14) 18,143 16,454

SWING-BED ADJUSTMENT
17. Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 0.00 $ 0.00
18. Medicare NF Swing-Bed Rates after Dec 31(Adj ) $ 0.00 $ 0.00
19. Medi-Cal NF Swing-Bed Rates through July 31(Adj ) $ 0.00 $ 0.00
20. Medi-Cal NF Swing-Bed Rates after July 31(Adj ) $ 0.00 $ 0.00
21. Total Routine Serv Cost (Sch 8, Part I, Line 25, Col 27) $ 59,913,484 $ 58,365,865
22. Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0
23. Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0
24. Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0
25. Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0
26. Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0
27. Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 59,913,484 $ 58,365,865

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28. Gen Inpatient Routine Serv Charges (excl swing-bed charges)(Adj ) $ 195,293,122 $ 195,293,122
29. Private Room Charges (excluding swing-bed charges)(Adj ) $ 0 $ 0
30. Semi-Private Room Charges (excluding swing-bed charges)(Adj ) $ 0 $ 0
31. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.306787 $ 0.298863
32. Average Private Room Per Diem Charge (L 29 / L 3) $ 0.00 $ 0.00
33. Average Semi-Private Room Per Diem Charge (L 30 / L 4) $ 0.00 $ 0.00
34. Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 0.00 $ 0.00
35. Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 0.00 $ 0.00
36. Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0
37. Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ 59,913,484 $ 58,365,865
PROGRAM INPATIENT OPERATING COST

38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 734.77 $ 715.79
39. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 13,330,932 $ 11,777,609
40. Cost Applicable to Medi-Cal (Contract Sch 4A) $ 13,312,274 $ 7,542,352
41. Cost Applicable to Medi-Cal (Contract Sch 4B) $ 0 $ 0
42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39, 40 & 41) $ 26,643,206 $ 19,319,961
(To Contract Sch 3)
COMPUTATION OF
MEDI-CAL INPATIENT ROUTINE SERVICE COST
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STATE OF CALIFORNIA CONTRACT SCH 4A
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITED
NURSERY
1. Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 6,856,607 $ 6,843,649
2. Total Inpatient Days (Adj ) 12,898 12,898
3. Average Per Diem Cost $ 531.60 $ 530.60
4. Medi-Cal Inpatient Days (Adj 14) 8,042 6,625
5. Cost Applicable to Medi-Cal $ 4,275,127 $ 3,515,225
INTENSIVE CARE UNIT
6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 15,619,821 $ 15,167,877
7. Total Inpatient Days (Adj ) 7,256 7,256
8. Average Per Diem Cost $ 2,152.68 $ 2,090.39
9. Medi-Cal Inpatient Days (Adj 14) 2,587 1,517
10. Cost Applicable to Medi-Cal $ 5,568,983 $ 3,171,122
CORONARY CARE UNIT
11. Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 0 $ 0

12. Total Inpatient Days (Adj ) 0 0
13. Average Per Diem Cost $ 0.00 $ 0.00
14. Medi-Cal Inpatient Days (Adj ) 0 0
15. Cost Applicable to Medi-Cal $ 0 $ 0
NEONATAL INTENSIVE CARE UNIT
16. Total Inpatient Routine Cost (Sch 8, Line 30, Col 27) $ 7,788,641 $ 7,557,863
17. Total Inpatient Days (Adj ) 9,924 9,924
18. Average Per Diem Cost $ 784.83 $ 761.57
19. Medi-Cal Inpatient Days (Adj 14) 4,419 1,124
20. Cost Applicable to Medi-Cal $ 3,468,164 $ 856,005
SURGICAL INTENSIVE CARE UNIT
21. Total Inpatient Routine Cost (Sch 8, Line 31, Col 27) $ 0 $ 0
22. Total Inpatient Days (Adj ) 0 0
23. Average Per Diem Cost $ 0.00 $ 0.00
24. Medi-Cal Inpatient Days (Adj ) 0 0
25. Cost Applicable to Medi-Cal $ 0 $ 0

26. Total Inpatient Routine Cost (Sch 8, Line__ , Col 27) $ 0 $ 0
27. Total Inpatient Days (Adj ) 0 0
28. Average Per Diem Cost $ 0.00 $ 0.00
29. Medi-Cal Inpatient Days (Adj ) 0 0
30. Cost Applicable to Medi-Cal $ 0 $ 0
31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 13,312,274 $ 7,542,352
(To Contract Sch 4)
MEDI-CAL INPATIENT ROUTINE SERVICE COST
COMPUTATION OF
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STATE OF CALIFORNIA CONTRACT SCH 4B
Provider Name: Fiscal Period Ended:

ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
SPECIAL CARE UNITS REPORTED AUDITED

1. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
2. Total Inpatient Days (Adj ) 0 0
3. Average Per Diem Cost $ 0.00 $ 0.00
4. Medi-Cal Inpatient Days (Adj ) 0 0
5. Cost Applicable to Medi-Cal $ 0 $ 0


6. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
7. Total Inpatient Days (Adj ) 0 0
8. Average Per Diem Cost $ 0.00 $ 0.00
9. Medi-Cal Inpatient Days (Adj ) 0 0
10. Cost Applicable to Medi-Cal $ 0 $ 0

11. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
12. Total Inpatient Days (Adj ) 0 0
13. Average Per Diem Cost $ 0.00 $ 0.00
14. Medi-Cal Inpatient Days (Adj ) 0 0
15. Cost Applicable to Medi-Cal $ 0 $ 0

16. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
17. Total Inpatient Days (Adj ) 0 0
18. Average Per Diem Cost $ 0.00 $ 0.00
19. Medi-Cal Inpatient Days (Adj ) 0 0
20. Cost Applicable to Medi-Cal $ 0 $ 0

21. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
22. Total Inpatient Days (Adj ) 0 0
23. Average Per Diem Cost $ 0.00 $ 0.00
24. Medi-Cal Inpatient Days (Adj ) 0 0
25. Cost Applicable to Medi-Cal $ 0 $ 0

26. Total Inpatient Routine Cost (Sch 8, Line ___, Col 27) $ 0 $ 0
27. Total Inpatient Days (Adj ) 0 0
28. Average Per Diem Cost $ 0.00 $ 0.00
29. Medi-Cal Inpatient Days (Adj ) 0 0
30. Cost Applicable to Medi-Cal $ 0 $ 0
31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 0 $ 0
(To Contract Sch 4)
COMPUTATION OF
MEDI-CAL INPATIENT ROUTINE SERVICE COST
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STATE OF CALIFORNIA CONTRACT SCH 5
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
RATIO
COST TO
CHARGES
ANCILLARY COST CENTERS
37.00 Operating Room $ 19,155,383 $ 52,806,536 0.362746 $ 13,408,176 $ 4,863,768
38.00 Recovery Room 0 0 0.000000 0 0
39.00 Delivery Room and Labor Room 14,865,512 50,935,422 0.291850 9,124,756 2,663,062
40.00 Anesthesiology 0 0 0.000000 0 0

41.00 Radiology - Diagnostic 10,727,676 103,024,136 0.104128 7,120,544 741,447
41.01 0 0 0.000000 0 0
41.02 0 0 0.000000 0 0
42.00 Radiology - Therapeutic 0 0 0.000000 0 0
43.00 Radioisotope 1,694,803 4,391,070 0.385966 333,409 128,684
44.00 Laboratory 16,214,746 80,129,005 0.202358 11,815,086 2,390,877
44.01 Pathological Lab 0 0 0.000000 0 0
46.00 Whole Blood 0 0 0.000000 0 0
47.00 Blood Storing and Processing 0 0 0.000000 0 0
48.00 Intravenous Therapy 0 0 0.000000 0 0
49.00 Respiratory Therapy 8,573,772 71,377,030 0.120119 8,999,557 1,081,022
50.00 Physical Therapy 1,463,732 4,003,812 0.365585 220,898 80,757
51.00 Occupational Therapy 156,122 306,981 0.508571 8,648 4,398
52.00 Speech Pathology 81,955 245,375 0.334000 8,772 2,930
53.00 Electrocardiology 999,870 8,750,091 0.114270 5,262,779 601,376
54.00 Electroencephalography 317,877 1,347,672 0.235871 65,952 15,556
55.00 Medical Supplies Charged to Patients 28,456,941 109,573,890 0.259705 8,367,399 2,173,059
56.00 Drugs Charged to Patients 11,643,094 66,037,141 0.176311 13,092,109 2,308,287
57.00 Renal Dialysis 1,236,654 4,756,348 0.260001 719,482 187,066
58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0
59.00 Patient Education & Family Counseling 37,212 102,595 0.362712 0 0
59.01 Ultrasound 1,516,020 12,939,156 0.117165 1,304,165 152,803
59.02 Magnetic Resonance Imaging 1,129,701 7,659,264 0.147495 980,060 144,554
59.03 0 0 0.000000 0 0
60.00 Clinic 0 0 0.000000 0 0
60.01 Other Clinic Services 0 0 0.000000 0 0
61.00 Emergency 21,548,072 73,729,290 0.292259 5,049,454 1,475,750
62.00 Observation Beds 0 0 0.000000 0 0
71.00 Home Health Agency 2,315,484 0 0.000000 0 0
82.00 0 0 0.000000 0 0

83.00 0 0 0.000000 0 0
84.00 0 0 0.000000 0 0
85.00 0 0 0.000000 0 0
86.00 0 0 0.000000 0 0
TOTAL $ 142,134,628 $ 652,114,814 $ 85,881,246 $ 19,015,396
(To Contract Sch 3)
* From Schedule 8, Column 27
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL MEDI-CAL
CHARGES
TOTAL ANCILLARY
MEDI-CAL
COST
(Contract Sch 6)
CHARGES
(Adj 9)
ANCILLARY
COST*
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STATE OF CALIFORNIA CONTRACT SCH 6

Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 30056F
ANCILLARY CHARGES
37.00 Operating Room $ 10,756,005 $ 2,652,171 $ 13,408,176
38.00 Recovery Room 0 0 0
39.00 Delivery Room and Labor Room 11,357,237 (2,232,481) 9,124,756

40.00 Anesthesiology 0 0 0
41.00 Radiology - Diagnostic 7,809,854 (689,310) 7,120,544
41.01 0 0 0
41.02 0 0 0
42.00 Radiology - Therapeutic 0 0 0
43.00 Radioisotope 493,941 (160,532) 333,409
44.00 Laboratory 9,984,116 1,830,970 11,815,086
44.01 Pathological Lab 0 0 0
46.00 Whole Blood 0 0 0
47.00 Blood Storing and Processing 0 0 0
48.00 Intravenous Therapy 0 0 0
49.00 Respiratory Therapy 13,406,205 (4,406,648) 8,999,557
50.00 Physical Therapy 321,803 (100,905) 220,898
51.00 Occupational Therapy 24,612 (15,964) 8,648
52.00 Speech Pathology 24,300 (15,528) 8,772
53.00 Electrocardiology 1,145,337 4,117,442 5,262,779
54.00 Electroencephalography 295,306 (229,354) 65,952
55.00
Medical Supplies Charged to Patients 1,230,200 7,137,199 8,367,399
56.00 Drugs Charged to Patients 11,615,920 1,476,189 13,092,109
57.00 Renal Dialysis 829,101 (109,619) 719,482
58.00 ASC (Non-Distinct Part) 0 0 0
59.00 Patient Education & Family Counseling 0 0 0
59.01 Ultrasound 1,187,610 116,555 1,304,165
59.02 Magnetic Resonance Imaging 959,170 20,890 980,060
59.03 0 0 0
60.00 Clinic 0 0 0
60.01 Other Clinic Services 0 0 0
61.00 Emergency 4,354,277 695,177 5,049,454
62.00 Observation Beds 0 0 0

71.00 Home Health Agency 0 0 0
82.00 0
83.00 0
84.00 0
85.00 0
86.00 0
0
0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 75,794,994 $ 10,086,252 $ 85,881,246
(To Contract Sch 5)
ADJUSTMENTS TO MEDI-CAL CHARGES
(Adj 15)
AUDITEDADJUSTMENTSREPORTED
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