REPORT ON THE COST REPORT REVIEW CENTINELA HOSPITAL MEDICAL CENTER INGLEWOOD, CALIFORNIA PROVIDER NUMBER: HSC30240H NATIONAL PROVIDER IDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD FEBRUARY 1, 2008 TO DECEMBER 31, 2008_part2 potx

STATE OF CALIFORNIA SCHEDULE 4B
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008

Provider No.
ZZT30240H
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 Schedule 4)
COMPUTATION OF
MEDI-CAL INPATIENT ROUTINE SERVICE COST
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA SCHEDULE 5
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
ZZT30240H
RATIO
COST TO
CHARGES
ANCILLARY COST CENTERS

37.00 Operating Room $ 18,934,192 $ 107,341,144 0.176393 $ 0 $ 0
38.00 Recovery Room 0 0 0.000000 0 0
39.00 Delivery Room and Labor Room 4,781,770 8,964,037 0.533439 0 0
40.00 Anesthesiology 388,502 22,301,238 0.017421 0 0
41.00 Radiology - Diagnostic 6,616,923 32,512,124 0.203522 16,888 3,437
41.01 CAT Scan 1,514,471 57,470,248 0.026352 0 0
41.02 Ultra Sound 1,438,472 16,361,285 0.087919 461 41
41.03 Magnetic Resonance Imaging (MRI) 1,040,649 13,178,801 0.078964 4,888 386
42.00 Radiology - Therapeutic 1,369,353 11,432,966 0.119772 0 0
43.00 Radioisotope 0 0 0.000000 0 0
44.00 Laboratory 10,642,370 162,889,960 0.065335 214,730 14,029
44.01 Pathological Lab 733,891 1,211,146 0.605948 0 0
46.00 Whole Blood 0 0 0.000000 0 0
47.00 Blood Storing and Processing 2,785,082 2,563,444 1.086461 0 0
49.00 Respiratory Therapy 7,520,142 53,903,767 0.139511 0 0
50.00 Physical Therapy 1,858,158 4,641,624 0.400325 29,795 11,928
51.00 Occupational Therapy 650,986 1,594,903 0.408166 6,093 2,487
52.00 Speech Pathology 319,970 406,182 0.787751 355 280
53.00 Electrocardiology 2,095,525 40,462,624 0.051789 0 0
53.01 Cardiology 9,528,752 29,275,216 0.325489 0 0
53.02 Cardiac Rehab 0 0 0.000000 0 0
54.00 Electroencephalography 255,057 1,579,673 0.161462 0 0
55.00 Medical Supplies Charged to Patients 2,135,134 234,412,470 0.009108 0 0
56.00 Drugs Charged to Patients 15,706,800 241,708,950 0.064982 626,116 40,686
57.00 Renal Dialysis 2,198,142 17,837,132 0.123234 0 0
59.00 Lithotripsy 17,136 190,845 0.089792 0 0
59.01 Pain Management 65,785 541,722 0.121437 0 0
59.02 Rehab Nuero 60,492 610 99.167922 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 15,000,989 86,098,626 0.174230 0 0
62.00 Observation Beds 0 0 0.000000 0 0
71.00 0 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 $ 107,658,744 $ 1,148,880,737 $ 899,326 $ 73,274
(To Schedule 3)
* From Schedule 8, Column 27
TOTAL ANCILLARY
MEDI-CAL
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL
COST *
CHARGES
MEDI-CAL
(Adj 3)
COSTCHARGES
(From Schedule 6)
ANCILLARY
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA SCHEDULE 6
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
ZZT30240H

ANCILLARY CHARGES
37.00 Operating Room $ $ $ 0
38.00 Recovery Room 0
39.00 Delivery Room and Labor Room 0
40.00 Anesthesiology 0
41.00 Radiology - Diagnostic 0 16,888 16,888
41.01 CAT Scan 0
41.02 Ultra Sound 0 461 461
41.03 Magnetic Resonance Imaging (MRI) 0 4,888 4,888
42.00 Radiology - Therapeutic 0
43.00 Radioisotope 0
44.00 Laboratory 0 214,730 214,730
44.01 Pathological Lab 0
46.00 Whole Blood 0
47.00 Blood Storing and Processing 0
49.00 Respiratory Therapy 0
50.00 Physical Therapy 0 29,795 29,795
51.00 Occupational Therapy 0 6,093 6,093
52.00 Speech Pathology 0 355 355
53.00 Electrocardiology 0
53.01 Cardiology 0
53.02
Cardiac Rehab 0
54.00 Electroencephalography 0
55.00 Medical Supplies Charged to Patients 0
56.00 Drugs Charged to Patients 0 626,116 626,116
57.00 Renal Dialysis 0
59.00 Lithotripsy 0
59.01 Pain Management 0
59.02 Rehab Nuero 0

60.00 Clinic 0
60.01 Other Clinic Services 0
61.00 Emergency 0
62.00 Observation Beds 0
71.00 0
82.00 0
83.00 0
84.00 0
85.00 0
86.00 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 899,326 $ 899,326
(To Schedule 5)
(Adj 5)
ADJUSTMENTS TO MEDI-CAL CHARGES
REPORTED ADJUSTMENTS AUDITED
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA SCHEDULE 7
PROGRAM: NONCONTRACT
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008

Provider No:
ZZT30240H
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
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA CONTRACT SCH 1
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
REPORTED AUDITED
1. Net Cost of Covered Services Rendered to

Medi-Cal Patients (Contract Sch 3) $ 39,169,928 $ 39,228,184

2. Excess Reasonable Cost Over Charges (Contract Sch 2) $ 0 $ 0
3. Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ N/A
4. $0 $0
5. Subtotal (Sum of Lines 1 through 4) $ 39,169,928 $ 39,228,184
6. $0 $0
7. $0 $0

8. Total Medi-Cal Cost (Sum of Lines 5 through 7) $ 39,169,928 $ 39,228,184
(To Summary of Findings)
9. Medi-Cal Overpayments (Adj ) $ 0 $ 0
10. Medi-Cal Credit Balances (Adj ) $ 0 $ 0
11. $0 $0
12. $0 $0
13. TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 0 $ 0
(To Summary of Findings)
COMPUTATION OF MEDI-CAL CONTRACT COST
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA CONTRACT SCH 2
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
REPORTED AUDITED

REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1. Cost of Covered Services (Contract Sch 3) $ 39,169,928 $ 39,904,252
CHARGES FOR MEDI-CAL INPATIENT SERVICES

2. Inpatient Routine Service Charges (Adj 10) $ 118,181,100 $ 92,678,133
3. Inpatient Ancillary Service Charges (Adj 10) $ 217,292,074 $ 167,992,519
4. Total Charges - Medi-Cal Inpatient Services $ 335,473,174 $ 260,670,652
5. Excess of Customary Charges Over Reasonable Cost
(Line 4 minus Line 1) * $ 296,303,246 $ 220,766,401
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
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA CONTRACT SCH 3
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
REPORTED AUDITED
1. Medi-Cal Inpatient Ancillary Services (Contract Sch 5) $ 19,714,567 $ 14,987,303
2. Medi-Cal Inpatient Routine Services (Contract Sch 4) $ 19,455,361 $ 24,916,949
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) $ 39,169,928 $ 39,904,252
7. Medi-Cal Inpatient Hospital Based Physician ( See
for Acute Care Services (Contract Sch 7) $ Contract Sch 1) $ 0
8. SUBTOTAL $ 39,169,928 $ 39,904,252
(To Contract Sch 2)

9. Coinsurance (Adj 11) $ 0 $ (659,039)
10. Patient and Third Party Liability (Adj 11) $ 0 $ (17,029)
11. Net Cost of Covered Services Rendered to Medi-Cal
Inpatients $ 39,169,928 $ 39,228,184
(To Contract Sch 1)
MEDI-CAL NET COST OF COVERED SERVICES
COMPUTATION OF
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA CONTRACT SCH 4
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
GENERAL SERVICE UNIT NET OF SWING-BEDS COSTS REPORTED AUDITED
INPATIENT DAYS
1. Total Inpatient Days (include private & swing-bed) (Adj ) 62,121 62,121
2. Inpatient Days (include private, exclude swing-bed) 62,121 62,121
3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0
4. Semi-Private Room Days (exclude swing-bed) (Adj ) 62,121 62,121
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 8) 13,474 5,666

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) $ 64,008,208 $ 63,347,793
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) $ 64,008,208 $ 63,347,793

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT
28. Gen Inpatient Routine Serv Charges (excl swing-bed charges)(Adj ) $ 369,411,300 $ 369,411,300
29. Private Room Charges (excluding swing-bed charges)(Adj ) $ 0 $ 0
30. Semi-Private Room Charges (excluding swing-bed charges)(Adj ) $ 369,411,300 $ 369,411,300
31. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.173271 $ 0.171483
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) $ 5,946.64 $ 5,946.64
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) $ 64,008,208 $ 63,347,793
PROGRAM INPATIENT OPERATING COST
38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 1,030.38 $ 1,019.75
39. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 13,883,340 $ 5,777,904
40. Cost Applicable to Medi-Cal (Contract Sch 4A) $ 5,572,021 $ 19,139,045
41. Cost Applicable to Medi-Cal (Contract Sch 4B) $ 0 $ 0
42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39, 40 & 41) $ 19,455,361 $ 24,916,949
(To Contract Sch 3)
COMPUTATION OF
MEDI-CAL INPATIENT ROUTINE SERVICE COST
This is trial version

www.adultpdf.com
STATE OF CALIFORNIA CONTRACT SCH 4A
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITED
NURSERY
1. Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 1,244,249 $ 1,231,396
2. Total Inpatient Days (Adj ) 4,391 4,391
3. Average Per Diem Cost $ 283.36 $ 280.44
4. Medi-Cal Inpatient Days (Adj 8) 2,358 3,113
5. Cost Applicable to Medi-Cal $ 668,163 $ 873,010
INTENSIVE CARE UNIT
6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 17,992,564 $ 17,806,741
7. Total Inpatient Days (Adj ) 9,258 9,258
8. Average Per Diem Cost $ 1,943.46 $ 1,923.39
9. Medi-Cal Inpatient Days (Adj 8) 1,036 9,109
10. Cost Applicable to Medi-Cal $ 2,013,425 $ 17,520,160
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) $ 3,892,517 $ 3,852,313
17. Total Inpatient Days (Adj ) 2,789 2,789
18. Average Per Diem Cost $ 1,395.67 $ 1,381.25
19. Medi-Cal Inpatient Days (Adj 8) 2,071 540

20. Cost Applicable to Medi-Cal $ 2,890,433 $ 745,875
SURGICAL INTENSIVE CARE UNIT
21. Total Inpatient Routine Cost (Sch 8, Line 29, 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
30. Cost Applicable to Medi-Cal $ 0 $ 0
31. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,30) $ 5,572,021 $ 19,139,045
(To Contract Sch 4)
MEDI-CAL INPATIENT ROUTINE SERVICE COST
COMPUTATION OF
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA CONTRACT SCH 4B
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
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
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA CONTRACT SCH 5
Provider Name: Fiscal Period Ended:
CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008
Provider No:
HSC30240H
RATIO
COST TO
CHARGES
ANCILLARY COST CENTERS
37.00 Operating Room $ 18,934,192 $ 107,341,144 0.176393 $ 10,870,227 $ 1,917,428
38.00 Recovery Room 0 0 0.000000 0 0
39.00 Delivery Room and Labor Room 4,781,770 8,964,037 0.533439 2,808,700 1,498,271
40.00 Anesthesiology 388,502 22,301,238 0.017421 3,582,170 62,404
41.00 Radiology - Diagnostic 6,616,923 32,512,124 0.203522 4,199,349 854,659
41.01 CAT Scan 1,514,471 57,470,248 0.026352 5,744,943 151,392
41.02 Ultra Sound 1,438,472 16,361,285 0.087919 1,495,478 131,481
41.03 Magnetic Resonance Imaging (MRI) 1,040,649 13,178,801 0.078964 1,375,731 108,633
42.00 Radiology - Therapeutic 1,369,353 11,432,966 0.119772 1,402,881 168,026
43.00 Radioisotope 0 0 0.000000 0 0
44.00 Laboratory 10,642,370 162,889,960 0.065335 29,216,590 1,908,858
44.01 Pathological Lab 733,891 1,211,146 0.605948 160,952 97,529
46.00 Whole Blood 0 0 0.000000 0 0

47.00 Blood Storing and Processing 2,785,082 2,563,444 1.086461 500,511 543,786
49.00 Respiratory Therapy 7,520,142 53,903,767 0.139511 7,078,803 987,567
50.00 Physical Therapy 1,858,158 4,641,624 0.400325 591,294 236,710
51.00 Occupational Therapy 650,986 1,594,903 0.408166 180,749 73,776
52.00 Speech Pathology 319,970 406,182 0.787751 61,051 48,093
53.00 Electrocardiology 2,095,525 40,462,624 0.051789 3,906,558 202,317
53.01 Cardiology 9,528,752 29,275,216 0.325489 1,998,419 650,463
53.02 Cardiac Rehab 0 0 0.000000 0 0
54.00 Electroencephalography 255,057 1,579,673 0.161462 917,862 148,200
55.00 Medical Supplies Charged to Patients 2,135,134 234,412,470 0.009108 34,162,549 311,168
56.00 Drugs Charged to Patients 15,706,800 241,708,950 0.064982 45,503,632 2,956,930
57.00 Renal Dialysis 2,198,142 17,837,132 0.123234 3,959,772 487,979
59.00 Lithotripsy 17,136 190,845 0.089792 0 0
59.01 Pain Management 65,785 541,722 0.121437 0 0
59.02 Rehab Nuero 60,492 610 99.167922 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 15,000,989 86,098,626 0.174230 8,274,298 1,441,633
62.00 Observation Beds 0 0 0.000000 0 0
71.00 0 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 $ 107,658,744 $ 1,148,880,737 $ 167,992,519 $ 14,987,303
(To Contract Sch 3)
* From Schedule 8, Column 27
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
TOTAL MEDI-CAL

CHARGES
TOTAL ANCILLARY
MEDI-CAL
ANCILLARY
COST*
COST
(Contract Sch 6)
CHARGES
(Adj 3)
This is trial version
www.adultpdf.com