SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_PART3 pot

STATE OF CALIFORNIA CONTRACT SCH 7
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
Provider No:
HSC 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 Contract Sch 3)
(Adj )(Adj ) (Adj )
PHYSICIAN'S REMUNERATION
TO CHARGES
MEDI-CAL
CHARGES
MEDI-CAL
COSTREMUNERATION
COMPUTATION OF PROFESSIONAL
COMPONENT OF HOSPITAL BASED
TO ALL PATIENTS
RATIO OF
REMUNERATION

TOTAL CHARGES HBP
This is trial version
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
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 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07
COMPUTATION OF COST ALLOCATION (W/S B)
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
6,928,870
2.00
Old Cap Rel Costs-Movable Equipmen
2,980,023
0
3.00
New Cap Rel Costs-Bldg & Fixtures
821,239
0
0
4.00
New Cap Rel Costs-Movable Equipme

3,054,161
0
0
0
4.01

0
0
0
0
0
4.02

0
0
0
0
0
0
4.03

0
0
0
0
0
0
0
4.04

0
0
0
0
0
0
0
0
4.05

0
0
0
0
0
0
0
0
0
4.06

0
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

29,364,734
86,664
24,820
10,272
25,437
0
0
0
0
0
0
0
6.01
Purchasing/Receiving
984,282
122,631
23,449
14,535
24,033
0
0
0
0
0
0
0
6.02
Patient Admitting
3,232,813
12,999

7,656
1,541
7,846
0
0
0
0
0
0
0
6.03
Cashiering/Accounts Receivable
2,720,410
28,228
17,093
3,346
17,519
0
0
0
0
0
0
0
6.04

0
0
0
0

0
0
0
0
0
0
0
0
6.05

0
0
0
0
0
0
0
0
0
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
6.04
Administrative and General
22,907,483
625,290
1,051,699
74,112
1,077,863
0
0
0
0
0
0
0
7.00
Maintenance and Repairs
7,658,350
300,354
38,103
35,599
39,051
0
0
0
0
0

0
0
8.00
Operation of Plant
1,622,838
264,004
19,756
31,291
20,247
0
0
0
0
0
0
0
9.00
Laundry and Linen Service
1,270,296
31,224
792
3,701
812
0
0
0
0
0
0
0

10.00
Housekeeping
4,240,720
37,315
17,228
4,423
17,657
0
0
0
0
0
0
0
11.00
Dietary
2,374,193
92,806
12,803
11,000
13,122
0
0
0
0
0
0
0
12.00
Cafeteria

469,952
106,770
3,965
12,655
4,064
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
2,129,514
56,672

29,160
6,717
29,885
0
0
0
0
0
0
0
15.00 Central Services & Supply 1,377,590 57,671 60,004 6,835 61,4970000000
16.00 Pharmacy 4,143,905 64,594 35,864 7,656 36,7560000000
17.00 Medical Records and Library 3,482,042 178,521 41,144 21,159 42,1670000000
18.00
Social Service
0
0
0
0
0
0
0
0
0
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
0
0
0
0
0
0
0
0
0
0
0
0
23.00Intern & Res Other Program 000000000000
24.00Paramedical Ed Program 000000000000
INPATIENT ROUTINE COST CENTERS
25.00
Adults & Pediatrics (Gen Routine)

28,191,560
2,392,859
138,859
283,612
142,313
0
0
0
0
0
0
0
26.00 Intensive Care Unit 9,281,322 140,623 71,741 16,667 73,5260000000
27.00 Coronary Care Unit 000000000000
30.00 Neonatal Intensive Care Unit 4,533,513 121,866 37,171 14,444 38,0950000000
31.00Surgical Intensive Care 000000000000
32.00 Subprovider I 000000000000
32.01 Subprovider II 000000000000
32.02 000000000000
33.00 Nursery 4,365,555 103,424 0 12,25800000000
34.00
Medicare Certified Nursing Facility
0
0
0
0
0
0
0
0

0
0
0
0
35.00
Distinct Part Nursing Facility
0
0
0
0
0
0
0
0
0
0
0
0
36.00
Adult Subacute Care Unit
0
0
0
0
0
0
0
0
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
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL JUNE 30, 2008
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 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07

COMPUTATION OF COST ALLOCATION (W/S B)
ANCILLARY COST CENTERS
37.00
Operating Room
10,644,786
383,822
372,307
45,492
381,569
0
0
0
0
0
0
0
38.00
Recovery Room
0
0
0
0
0
0
0
0
0
0
0
0

39.00
Delivery Room and Labor Room
6,503,092
874,830
60,137
103,689
61,633
0
0
0
0
0
0
0
40.00
Anesthesiology
0
0
0
0
0
0
0
0
0
0
0
0
41.00 Radiology - Diagnostic 4,368,516 192,901 354,051 22,863 362,8590000000
41.01 000000000000

41.02

0
0
0
0
0
0
0
0
0
0
0
0
42.00
Radiology - Therapeutic
0
0
0
0
0
0
0
0
0
0
0
0
43.00 Radioisotope 811,895 35,418 43,351 4,198 44,4290000000
44.00 Laboratory 10,103,951 202,472 135,929 23,998 139,3100000000

44.01Pathological Lab 000000000000
46.00Whole Blood 000000000000
47.00 Blood Storing and Processing 000000000000
48.00 Intravenous Therapy 000000000000
49.00 Respiratory Therapy 4,466,932 39,329 63,944 4,661 65,5350000000
50.00
Physical Therapy
842,975
39,446
1,858
4,675
1,904
0
0
0
0
0
0
0
51.00
Occupational Therapy
52,904
16,144
49
1,914
50
0
0
0
0

0
0
0
52.00 Speech Pathology 59,340 2,380 0 28200000000
53.00 Electrocardiology 522,042 16,860 15,537 1,998 15,9240000000
54.00 Electroencephalography 192,438 0 10,366 0 10,6240000000
55.00 Medical Supplies Charged to Patients 19,869,12400000000000
56.00 Drugs Charged to Patients 9,349,52400000000000
57.00
Renal Dialysis
1,025,061
0
0
0
0
0
0
0
0
0
0
0
58.00
ASC (Non-Distinct Part)
0
0
0
0
0
0

0
0
0
0
0
0
59.00
Patient Education & Family Counseling
13,57500000000000
59.01 Ultrasound 866,964 0 11,072 0 11,3470000000
59.02 Magnetic Resonance Imaging 402,430 83,219 38,191 9,863 39,1410000000
59.03 000000000000
60.00Clinic 000000000000
60.01
Other Clinic Services
0
0
0
0
0
0
0
0
0
0
0
0
61.00
Emergency
12,945,407

193,068
54,820
22,883
56,184
0
0
0
0
0
0
0
62.00Observation Beds 000000000000
71.00 Home Health Agency 1,709,43800000000000
82.00 000000000000
83.00 000000000000
84.00

0
0
0
0
0
0
0
0
0
0
0
0
85.00

0
0
0
0
0
0
0
0
0
0
0
0
86.00

0
0
0
0
0
0
0
0
0
0
0
0
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen 000000000000
97.00Research 000000000000

98.00 Physicians' Private Office 5,937,587 0 185,548 0 190,1640000000
99.00 Nonpaid Workers 000000000000
99.01
Community Benefits
3,356,270
0
1,095
0
1,123
0
0
0
0
0
0
0
99.02
Marketing
715,541
24,466
463
2,900
475
0
0
0
0
0
0
0

99.03Dialysis 21,95500000000000
99.04 000000000000
99.05 000000000000
100.00 000000000000
100.01 000000000000
100.02 000000000000
100.03

0
0
0
0
0
0
0
0
0
0
0
0
100.04 000000000000
TOTAL
242,917,112
6,928,870
2,980,023
821,239
3,054,161
0
0
0

0
0
0
0
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ANTELOPE VALLEY HOSPITAL
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
Purchasing/Receiving
6.02
Patient Admitting
6.03
Cashiering/Accounts Receivable
6.04

6.05

6.06

6.07

6.08

6.04
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
30.00 Neonatal Intensive Care Unit
31.00 Surgical Intensive Care
32.00 Subprovider I
32.01 Subprovider II
32.02
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:
JUNE 30, 2008
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 6.04
COMPUTATION OF COST ALLOCATION (W/S B)
0
0
134,782

0
599,435
4,863
0
386,199
2,242
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
2,566,628
11,583
0
0
0
0
0
0
0
28,314,658
0
672,171
2,376
0
0
0
0

0
0
0
8,746,004
1,153,948
0
287,562
387
0
0
0
0
0
0
0
2,246,084
296,348
0
27,423
229
0
0
0
0
0
0
0
1,334,476
176,071
0

513,001
871
0
0
0
0
0
0
0
4,831,215
637,431
0
365,963
62,962
0
0
0
0
0
0
0
2,932,849
386,960
0
69,952
69,650
0
0
0
0

0
0
0
737,009
97,241
0
0
0
0
0
0
0
0
0
0
0
0
0
452,806
916
0
0
0
0
0
0
0
2,705,670
356,986
0 259,166 19,55000000001,842,313 243,075

0 839,571 71,99400000005,200,340 686,133
0 527,917 5,01800000004,297,968 567,074
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
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0

0
0
0
0
0000000000 00
0000000000 00
0
6,358,525
83,131
591,502
485,639
0
0
0
0
0
38,668,001
5,101,858
0 2,086,516 20,689 157,953 129,6830000011,978,720 1,580,473
0000000000 00
0 1,016,638 21,235 83,400 68,474000005,934,835 783,042
0000000000 00
0000000000 00
0000000000 00
0000000000 00
0 946,036 16,659 58,367 47,921000005,550,221 732,296
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
0000000000 00
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ANTELOPE VALLEY HOSPITAL
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00
Operating Room
38.00
Recovery Room
39.00
Delivery Room and Labor Room
40.00

Anesthesiology
41.00 Radiology - Diagnostic
41.01
41.02

42.00
Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole 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
56.00 Drugs Charged to Patients
57.00
Renal Dialysis
58.00
ASC (Non-Distinct Part)
59.00
Patient Education & Family Counseling
59.01 Ultrasound

59.02 Magnetic Resonance Imaging
59.03
60.00 Clinic
60.01
Other Clinic Services
61.00
Emergency
62.00 Observation Beds
71.00 Home Health Agency
82.00
83.00
84.00

85.00

86.00

NONREIMBURSABLE COST CENTE
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01
Community Benefits
99.02
Marketing
99.03 Dialysis
99.04
99.05
100.00

100.01
100.02
100.03

100.04
TOTAL
SCHEDULE 8.1
Fiscal Period Ended:
JUNE 30, 2008
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 6.04
COMPUTATION OF COST ALLOCATION (W/S B)
0
2,198,170
54,493
295,161
242,335
0
0
0
0
0
14,618,136
1,928,718
0
0
0
0

0
0
0
0
0
0
0
0
0
1,348,216
75,379
232,444
190,843
0
0
0
0
0
9,450,264
1,246,868
0
0
0
0
0
0
0
0
0
0

0
0
0 974,297 117,956 470,151 386,007000007,249,602 956,513
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
098,29334,43120,03916,452000001,108,506 146,256
0 1,374,621 41,413 365,669 300,2240000012,687,587 1,674,001

0000000000 00
0000000000 00
0000000000 00
0000000000 00
0 956,440 82,536 325,730 267,433000006,272,541 827,599
0
194,426
863
18,271
15,001
0
0
0
0
0
1,119,419
147,696
0
12,278
128
1,401
1,150
0
0
0
0
0
86,018
11,349
0001,1209190000064,0418,450

0 114,034 1,218 39,475 32,41000000759,499 100,208
036,4026976,6065,42400000262,556 34,642
0 0 484,698 417,549 342,8190000021,114,189 2,785,807
0 0 0 301,361 247,426000009,898,311 1,305,984
0
0
0
21,706
17,821
0
0
0
0
0
1,064,588
140,462
0
0
0
0
0
0
0
0
0
0
0
0
017,84504683840000032,2734,258
0 186,730 3,605 59,048 48,480000001,187,246 156,645

061,23075034,95328,69700000698,475 92,157
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0
2,897,922
1,560
364,778
299,493
0
0
0
0
0
16,836,115
2,221,358
0000000000 00
0 336,151000000002,045,589 269,895
0000000000 00

0000000000 00
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
00000000006,313,299 832,977
0000000000 00
0
550,797
8,862
0
0
0
0
0
0
0
3,918,148
516,961
0
43,783
767
0
0
0
0

0
0
0
788,395
104,021
000000000021,9552,897
0000000000 00
0000000000 00
0000000000 00
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0
29,511,927
1,303,712
3,867,152
3,175,038
0

0
0
0
0
242,917,112
28,314,658
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ANTELOPE VALLEY HOSPITAL
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
Purchasing/Receiving
6.02
Patient Admitting
6.03
Cashiering/Accounts Receivable
6.04

6.05

6.06

6.07

6.08

6.04
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
30.00 Neonatal Intensive Care Unit
31.00 Surgical Intensive Care
32.00 Subprovider I
32.01 Subprovider II
32.02
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, 2008
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)
454,329

53,734
17,048
64,217
20,374
0
159,711
50,671
0
95,083
183,742
58,295
0
109,441
0
0
0
0
0
0
0
97,528
30,942
0
58,063
0
21,855
0
99,247 31,487 6,245 59,086 0 26,219 0 73,688
111,162 35,268 0 66,180 0 32,493 0 91,322 151,978
307,221 97,470 0 182,902 0 36,030 0 101,261 10,594 30,293

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
4,117,922
1,306,471
769,000
2,451,585
2,974,434
377,390
0
1,060,647
175,488
501,805
861,264
0
242,002 76,779 152,697 144,074 270,671 85,007 0 238,911 43,673 124,882 229,989 0
000000000000
209,721 66,537 1,122 124,857 0 37,608 0 105,696 44,827 128,182 121,435 0
000000000000
000000000000
000000000000
000000000000
177,985 56,468 0 105,963000035,168100,561 84,986 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
0
000000000000
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ANTELOPE VALLEY HOSPITAL
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00
Operating Room
38.00
Recovery Room
39.00
Delivery Room and Labor Room
40.00
Anesthesiology
41.00 Radiology - Diagnostic
41.01

41.02

42.00
Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole 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
56.00 Drugs Charged to Patients
57.00
Renal Dialysis
58.00
ASC (Non-Distinct Part)
59.00
Patient Education & Family Counseling
59.01 Ultrasound
59.02 Magnetic Resonance Imaging
59.03
60.00 Clinic

60.01
Other Clinic Services
61.00
Emergency
62.00 Observation Beds
71.00 Home Health Agency
82.00
83.00
84.00

85.00

86.00

NONREIMBURSABLE COST CENTE
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01
Community Benefits
99.02
Marketing
99.03 Dialysis
99.04
99.05
100.00
100.01
100.02
100.03

100.04
TOTAL
SCHEDULE 8.2
Fiscal Period Ended:
JUNE 30, 2008
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)
660,528
209,562
107,300
393,242
9,875
92,974
0
261,301
115,035
328,939
429,773
0
0
0
0
0
0
0
0

0
0
0
0
0
1,505,514
477,646
8,517
896,300
104,816
58,522
0
164,475
159,124
455,011
338,453
0
0
0
0
0
0
0
0
0
0
0
0
0
331,968 105,322 66,768 197,636 0 45,736 0 128,540 249,003 712,019 684,570 0

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
60,952 19,338 0 36,287 0 3,612 0 10,153 72,684 207,838 29,178 0
348,438 110,547 0 207,441 0 83,163 0 233,728 87,422 249,983 532,437 0
000000000000
000000000000
000000000000

000000000000
67,683 21,473 0 40,294 0 51,820 0 145,639 174,231 498,209 474,283 0
67,883
21,537
3,805
40,414
0
7,700
0
21,641
1,822
5,210
26,604
0
27,783
8,815
0
16,541
0
665
0
1,870
269
770
2,040
0
4,0961,29902,4380000001,6300
29,015 9,205 2,161 17,274 0 3,964 0 11,141 2,571 7,353 57,478 0
0 0 278 0 0 1,340 0 3,767 1,470 4,204 9,619 0
000000001,023,186 2,925,781 607,977 0

0000000000438,800 0
0
0
0
0
0
0
0
0
0
0
31,605
0
0
0
0
0
0
0
0
0
0
0
0
0
00000000006820
0 0 24,214 0 0 8,546 0 24,019 7,610 21,762 85,977 0
143,213 45,436 0 85,261 0 2,139 0 6,012 1,584 4,530 50,894 0
000000000000
000000000000

0
0
0
0
0
0
0
0
0
0
0
0
332,254
105,413
439,220
197,806
265,478
159,187
0
447,391
3,294
9,418
531,140
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
0
0
0
0
0
0
0
0

0
0
0
0
000000000000
000000000000
000000000000
000000000000
0
0
0
0
0
39,395
0
110,719
18,708
53,496
0
0
42,105
13,358
0
25,067
0
10,362
0
29,123
1,618
4,628

0
0
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
9,899,952
2,996,762
1,581,328
5,553,236
3,625,274
1,185,728
0
3,271,045
2,381,360

6,374,876
5,630,814
0
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ANTELOPE VALLEY HOSPITAL
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
Purchasing/Receiving
6.02
Patient Admitting
6.03
Cashiering/Accounts Receivable
6.04

6.05

6.06

6.07

6.08

6.04
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
30.00 Neonatal Intensive Care Unit
31.00 Surgical Intensive Care
32.00 Subprovider I
32.01 Subprovider II
32.02
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, 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
0
0
0
58,365,865
58,365,865
0000000015,167,877 15,167,877
000000000 0
000000007,557,863 7,557,863
000000000 0
000000000 0
000000000 0
000000000 0
000000006,843,649 6,843,649

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
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ANTELOPE VALLEY HOSPITAL
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00 Operating Room
38.00 Recovery Room
39.00 Delivery Room and Labor Room
40.00 Anesthesiology
41.00 Radiology - Diagnostic
41.01
41.02
42.00 Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab

46.00 Whole 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
56.00 Drugs Charged to Patients
57.00 Renal Dialysis
58.00 ASC (Non-Distinct Part)
59.00 Patient Education & Family Counseling
59.01 Ultrasound
59.02 Magnetic Resonance Imaging
59.03
60.00 Clinic
60.01 Other Clinic Services
61.00 Emergency
62.00 Observation Beds
71.00 Home Health Agency
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 Community Benefits
99.02 Marketing
99.03 Dialysis
99.04
99.05
100.00
100.01
100.02
100.03
100.04
TOTAL
SCHEDULE 8.3
Fiscal Period Ended:
JUNE 30, 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 0 000019,155,383 19,155,383
0 0 0 0 00000 0
0 0 0 0 000014,865,512 14,865,512
0 0 0 0 00000 0
0 0 0 0 000010,727,676 10,727,676
0 0 0 0 00000 0
0 0 0 0 00000 0
0 0 0 0 00000 0

0 0 0 0 00001,694,803 1,694,803
0 0 0 0 000016,214,746 16,214,746
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 00008,573,772 8,573,772
0 0 0 0 00001,463,732 1,463,732
0 0 0 0 0000156,122 156,122
0 0 0 0 000081,955 81,955
0 0 0 0 0000999,870 999,870
0 0 0 0 0000317,877 317,877
0 0 0 0 000028,456,941 28,456,941
0 0 0 0 000011,643,094 11,643,094
0 0 0 0 00001,236,654 1,236,654
0 0 0 0 00000 0
0 0 0 0 000037,212 37,212
0 0 0 0 00001,516,020 1,516,020
0 0 0 0 00001,129,701 1,129,701
0 0 0 0 00000 0
0 0 0 0 00000 0
0 0 0 0 00000 0
0 0 0 0 000021,548,072 21,548,072
0 0 0 0 00000 0
0 0 0 0 00002,315,484 2,315,484
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 00007,146,276 7,146,276
0 0 0 0 00000 0
0 0 0 0 00004,657,426 4,657,426
0 0 0 0 00001,018,676 1,018,676
0 0 0 0 000024,852 24,852
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 0 0 0 0 242,917,112 0 242,917,112
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
SCHEDULE 9
Provider Name:
Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL
JUNE 30, 2008
OLD BLDG OLD MOVBLE NEW BLDG
NEW MOVBLE
STAT STAT STAT STAT STAT STAT STAT STAT
& FIXTURES EQUIP & FIXTURES EQUIP
(SQ FT) (Dollar Value) (SQ FT) (Dollar 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 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
(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 5,207 788,633 5,207 788,633
6.01 Purchasing/Receiving 7,368 745,081 7,368 745,081
6.02 Patient Admitting 781 243,253 781 243,253
6.03 Cashiering/Accounts Receivable 1,696 543,134 1,696 543,134
6.04
6.05
6.06
6.07
6.08
6.04 Administrative and General 37,569 33,417,041 37,569 33,417,041
7.00 Maintenance and Repairs 18,046 1,210,701 18,046 1,210,701
8.00 Operation of Plant 15,862 627,725 15,862 627,725
9.00 Laundry and Linen Service 1,876 25,167 1,876 25,167
10.00 Housekeeping 2,242 547,423 2,242 547,423
11.00 Dietary 5,576 406,817 5,576 406,817

12.00 Cafeteria 6,415 126,001 6,415 126,001
13.00 Maintenance of Personnel
14.00 Nursing Administration 3,405 926,527 3,405 926,527
15.00 Central Services & Supply 3,465 1,906,584 3,465 1,906,584
16.00 Pharmacy 3,881 1,139,541 3,881 1,139,541
17.00 Medical Records and Library 10,726 1,307,308 10,726 1,307,308
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)
143,769
4,412,151
143,769
4,412,151
26.00 Intensive Care Unit 8,449 2,279,516 8,449 2,279,516
27.00 Coronary Care Unit
30.00 Neonatal Intensive Care Unit 7,322 1,181,071 7,322 1,181,071
31.00 Surgical Intensive Care
32.00 Subprovider I
32.01 Subprovider II
32.02
33.00 Nursery 6,214 6,214

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
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STATE OF CALIFORNIA
SCHEDULE 9
Provider Name:
Fiscal Period Ended:
ANTELOPE VALLEY HOSPITAL
JUNE 30, 2008
OLD BLDG OLD MOVBLE NEW BLDG
NEW MOVBLE
STAT STAT STAT STAT STAT STAT STAT STAT
& FIXTURES EQUIP & FIXTURES EQUIP
(SQ FT) (Dollar Value) (SQ FT) (Dollar 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 ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj )
(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 23,061 11,829,801 23,061 11,829,801
38.00 Recovery Room
39.00 Delivery Room and Labor Room 52,562 1,910,824 52,562 1,910,824
40.00 Anesthesiology
41.00 Radiology - Diagnostic 11,590 11,249,728 11,590 11,249,728
41.01

41.02
42.00 Radiology - Therapeutic
43.00 Radioisotope 2,128 1,377,438 2,128 1,377,438
44.00 Laboratory 12,165 4,319,039 12,165 4,319,039
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing and Processing
48.00 Intravenous Therapy
49.00 Respiratory Therapy 2,363 2,031,792 2,363 2,031,792
50.00 Physical Therapy 2,370 59,027 2,370 59,027
51.00 Occupational Therapy 970 1,564 970 1,564
52.00 Speech Pathology 143 143
53.00 Electrocardiology 1,013 493,689 1,013 493,689
54.00 Electroencephalography 329,363 329,363
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 Patient Education & Family Counseling
59.01 Ultrasound 351,795 351,795
59.02 Magnetic Resonance Imaging 5,000 1,213,479 5,000 1,213,479
59.03
60.00 Clinic
60.01 Other Clinic Services
61.00 Emergency 11,600 1,741,869 11,600 1,741,869
62.00 Observation Beds
71.00 Home Health Agency
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 5,895,666 5,895,666
99.00 Nonpaid Workers
99.01 Community Benefits 34,803 34,803
99.02 Marketing 1,470 14,725 1,470 14,725
99.03 Dialysis
99.04
99.05
100.00
100.01
100.02
100.03
100.04
TOTAL 416,304 94,688,276 416,304 94,688,27600000000
COST TO BE ALLOCATED 6,928,870 2,980,023 821,239 3,054,16100000000
UNIT COST MULTIPLIER - SCH 8 16.643775 0.031472 1.972691 0.032255 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000
This is trial version
www.adultpdf.com