STATE OF CALIFORNIA SCHEDULE 5 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: ZZT 30625F RATIO COST TO CHARGES ANCILLARY COST CENTERS 37.00 Operating Room $ 95,710,199 $ 585,456,449 0.163480 $ 0 $ 0 39.00 Delivery Room and Labor Room 29,518,483 75,488,257 0.391034 0 0 40.00 Anesthesiology 55,602,856 446,285,096 0.124590 0 0 41.00 Radiology-Diagnostic 49,746,582 193,969,630 0.256466 9,574 2,455 43.01 Ultrasound 4,215,379 29,801,839 0.141447 14,563 2,060 43.02 CAT Scan 12,997,062 201,731,626 0.064427 0 0 44.00 Laboratory 81,858,827 694,170,211 0.117923 643,608 75,896 44.01 Laboratory-Pathological 25,512,941 62,236,846 0.409933 0 0 44.02 HLA Lab 4,969,551 11,666,069 0.425983 0 0 47.00 Blood Storing, Processing & Trans 25,970,759 39,817,972 0.652237 0 0 49.00 Respiratory Therapy 29,840,758 292,629,267 0.101975 0 0 50.00 Physical Therapy 11,777,981 41,779,821 0.281906 21,403 6,034 51.00 Occupational Therapy 4,439,833 22,511,543 0.197225 7,380 1,456 52.00 Speech Pathology 1,689,666 8,339,831 0.202602 2,806 569 53.00 Electrocardiology 13,588,420 98,869,613 0.137438 0 0 54.00 Electroencephalography 4,408,169 21,049,131 0.209423 0 0 54.01 Electromyography 166,799 1,342,237 0.124269 0 0 55.00 Medical Supplies Charged to Patients 125,543,810 522,478,410 0.240285 0 0 56.00 Drugs Charged to Patients 93,304,736 462,202,429 0.201870 48,946 9,881 57.00 Renal Dialysis 8,102,366 31,845,109 0.254430 0 0 59.00 Gastro Intestinal Services 17,677,073 51,780,517 0.341385 0 0 59.01 Eye Laboratory 116,474 643,684 0.180950 0 0 59.02 Cardiac Catheterization Laboratory 10,383,847 81,800,167 0.126942 0 0 59.03 Vascular Laboratory 4,491,186 49,819,261 0.090150 0 0 59.04 Psychiatric/Psychological Services 948,688 4,444,067 0.213473 0 0 59.05 Nuclear Medicine - Therapeutic 14,418,226 116,313,021 0.123961 8,965 1,111 59.06 Magnetic Resonance Imaging 15,976,382 140,454,524 0.113748 296,745 33,754 59.07 Pulmonary Function Testing 1,901,599 3,728,114 0.510070 0 0 59.08 Recreational Therapy 139,834 833,837 0.167700 0 0 60.00 Clinic 5,867,508 3,544,413 1.655425 0 0 60.01 Psychiatric Clinic 4,048,115 6,939,317 0.583359 0 0 60.02 Medical Oncology 101,988,606 315,812,474 0.322940 0 0 60.03 Psych - Partial Hospitalization 894,863 2,902,036 0.308357 0 0 60.04 Clinic 2 - Gen Risk Center 406,378 124,968 3.251855 0 0 60.05 Clinic 3 - Neuro Surgical Institute 5,137,193 1,367,847 3.755678 0 0 60.06 Clinic 4 - Prostate Cancer Program 463,111 194,947 2.375574 0 0 60.07 Clinic 5 -Endocrinology Center 1,082,093 973,406 1.111657 0 0 60.08 Clinic 6 - Spine Injury Institute 4,253,159 2,992,983 1.421044 0 0 60.09 Clinic 7 - Pediatric Center 2,929,172 1,490,379 1.965387 0 0 61.00 Emergency 38,372,548 260,197,483 0.147475 0 0 TOTAL $ 910,461,233 $ 4,890,028,831 $ 1,053,990 $ 133,216 (To Schedule 3) * From Schedule 8, Column 27 ANCILLARY COST (Adj ) (From Schedule 6) MEDI-CAL CHARGES MEDI-CAL SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL ANCILLARY CHARGES TOTAL COST * This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 6 PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: ZZT 30625F ANCILLARY CHARGES 37.00 Operating 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 9,574 9,574 43.01 Ultrasound 0 14,563 14,563 43.02 CAT Scan 0 0 0 44.00 Laboratory 0 643,608 643,608 44.01 Laboratory-Pathological 0 0 0 44.02 HLA Lab 0 0 0 47.00 Blood Storing, Processing & Trans 0 0 0 49.00 Respiratory Therapy 0 0 0 50.00 Physical Therapy 0 21,403 21,403 51.00 Occupational Therapy 0 7,380 7,380 52.00 Speech Pathology 0 2,806 2,806 53.00 Electrocardiology 0 0 0 54.00 Electroencephalography 0 0 0 54.01 Electromyography 0 0 0 55.00 Medical Supplies Charged to Patients 000 56.00 Drugs Charged to Patients 0 48,946 48,946 57.00 Renal Dialysis 0 0 0 59.00 Gastro Intestinal Services 0 0 0 59.01 Eye Laboratory 0 0 0 59.02 Cardiac Catheterization Laboratory 0 0 0 59.03 Vascular Laboratory 0 0 0 59.04 Psychiatric/Psychological Services 0 0 0 59.05 Nuclear Medicine - Therapeutic 0 8,965 8,965 59.06 Magnetic Resonance Imaging 0 296,745 296,745 59.07 Pulmonary Function Testing 0 0 0 59.08 Recreational Therapy 0 0 0 60.00 Clinic 0 0 0 60.01 Psychiatric Clinic 0 0 0 60.02 Medical Oncology 0 0 0 60.03 Psych - Partial Hospitalization 0 0 0 60.04 Clinic 2 - Gen Risk Center 0 0 0 60.05 Clinic 3 - Neuro Surgical Institute 0 0 0 60.06 Clinic 4 - Prostate Cancer Program 0 0 0 60.07 Clinic 5 -Endocrinology Center 0 0 0 60.08 Clinic 6 - Spine Injury Institute 0 0 0 60.09 Clinic 7 - Pediatric Center 0 0 0 61.00 Emergency 0 0 0 TOTAL MEDI-CAL ANCILLARY CHARGES $ 0 $ 1,053,990 $ 1,053,990 (To Schedule 5) (Adj 11) 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: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: ZZT 30625F 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) COMPONENT OF HOSPITAL BASED COMPUTATION OF PROFESSIONAL TO ALL PATIENTS RATIO OF REMUNERATION REMUNERATION HBP TOTAL CHARGES TO CHARGES CHARGES MEDI-CAL COST MEDI-CAL (Adj ) (Adj ) (Adj ) PHYSICIAN'S REMUNERATION This is trial version www.adultpdf.com SCHEDULE 1-1 PROGRAM: PSYCHIATRIC Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: HSM 30625F REPORTED AUDITED 1. Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3-1) $ 3,471,218 $ 0 2. Excess Reasonable Cost Over Charges (Schedule 2-1) $ 0 $ 0 3. Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ 0 4. $ 0 $ 0 5. TOTAL COST - Reimbursable to Provider (Lines 1 through 4) $ 3,471,218 $ 0 6. Interim Payments (Adj 18) $ (3,471,218) $ 0 7. Balance Due Provider (State) $ 0 $ 0 8. Duplicate Payments (Adj ) $ 0 $ 0 9. $ 0 $ 0 10. $0 $0 11. TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 0 $ 0 (To Summary of Findings) COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 2-1 PROGRAM: PSYCHIATRIC Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: HSM 30625F REPORTED AUDITED REASONABLE COST OF MEDI-CAL INPATIENT SERVICES 1. Cost of Covered Services (Schedule 3-1) $ 3,471,218 $ 0 CHARGES FOR MEDI-CAL INPATIENT SERVICES 2. Inpatient Routine Service Charges (Adj 17) $ 9,032,552 $ 0 3. Inpatient Ancillary Service Charges (Adj 17) $ 1,382,525 $ 0 4. Total Charges - Medi-Cal Inpatient Services** $ 10,415,077 $ 0 5. Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) * $ 6,943,859 $ 0 6. Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0 (To Schedule 1-1) * 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 SCHEDULE 3-1 PROGRAM: PSYCHIATRIC Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: HSM 30625F REPORTED AUDITED 1. Medi-Cal Inpatient Ancillary Services (Schedule 5-1) $ 192,997 $ 0 2. Medi-Cal Inpatient Routine Services (Schedule 4-1) $ 3,278,221 $ 0 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) $ 3,471,218 $ 0 7. Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7-1) $ 0 $ 0 8. SUBTOTAL $ 3,471,218 $ 0 (To Schedule 2-1) 9. Coinsurance (Adj ) $ 0 $ 0 10. Patient and Third Party Liability (Adj ) $ 0 $ 0 11. Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 3,471,218 $ 0 (To Schedule 1-1) COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 4-1 PROGRAM: PSYCHIATRIC Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: HSM 30625F GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED INPATIENT DAYS 1. Total Inpatient Days (include private & swing-bed) (Adj 6) 17,043 0 2. Inpatient Days (include private, exclude swing-bed) 17,043 0 3. Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4. Semi-Private Room Days (exclude swing-bed) (Adj 6) 17,043 0 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 15) 2,574 0 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 31, Col 27) $ 21,705,840 $ 0 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) $ 21,705,840 $ 0 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28. Gen Inpatient Routine Serv Charges (excl swing-bed charges)(Adj 8) $ 60,363,671 $ 0 29. Private Room Charges (excluding swing-bed charges)(Adj ) $ 0 $ 0 30. Semi-Private Room Charges (excluding swing-bed charges)(Adj 8) $ 60,363,671 $ 0 31. Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) $ 0.359584 $ 0.000000 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) $ 3,541.85 $ 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) $ 21,705,840 $ 0 PROGRAM INPATIENT OPERATING COST 38. Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) $ 1,273.59 $ 0.00 39. Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3,278,221 $ 0 40. Cost Applicable to Medi-Cal (Schedule 4A-1) $ 0 $ 0 41. Cost Applicable to Medi-Cal (Schedule 4B-1) $ 0 $ 0 42. TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39,40&41) $ 3,278,221 $ 0 (To Schedule 3-1) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 4A-1 PROGRAM: PSYCHIATRIC Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: HSM 30625F SPECIAL CARE AND/OR NURSERY UNITS REPORTED AUDITED NURSERY 1. Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) $ 7,910,324 $ 7,910,329 2. Total Inpatient Days (Adj ) 16,584 16,584 3. Average Per Diem Cost $ 476.99 $ 476.99 4. Medi-Cal Inpatient Days (Adj ) 0 0 5. Cost Applicable to Medi-Cal $ 0 $ 0 INTENSIVE CARE UNIT 6. Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) $ 34,664,749 $ 34,664,771 7. Total Inpatient Days (Adj ) 10,680 10,680 8. Average Per Diem Cost $ 3,245.76 $ 3,245.77 9. Medi-Cal Inpatient Days (Adj ) 0 0 10. Cost Applicable to Medi-Cal $ 0 $ 0 CORONARY CARE UNIT 11. Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) $ 2,780,566 $ 2,780,568 12. Total Inpatient Days (Adj ) 890 890 13. Average Per Diem Cost $ 3,124.23 $ 3,124.23 14. Medi-Cal Inpatient Days (Adj ) 0 0 15. Cost Applicable to Medi-Cal $ 0 $ 0 SURGICAL INTENSIVE CARE UNIT 16. Total Inpatient Routine Cost (Sch 8, Line 29, Col 27) $ 23,895,533 $ 23,895,548 17. Total Inpatient Days (Adj ) 7,325 7,325 18. Average Per Diem Cost $ 3,262.19 $ 3,262.19 19. Medi-Cal Inpatient Days (Adj ) 0 0 20. Cost Applicable to Medi-Cal $ 0 $ 0 SURGICAL ICU-8 26. Total Inpatient Routine Cost (Sch 8, Line 29.02 , Col 27) $ 22,082,665 $ 22,082,681 27. Total Inpatient Days (Adj) 7,306 7,306 23. Average Per Diem Cost $ 3,022.54 $ 3,022.54 24. Medi-Cal Inpatient Days (Adj ) 0 0 25. Cost Applicable to Medi-Cal $ 0 $ 0 ADMINISTRATIVE DAYS 26. Per Diem Rate (Adj ) $ 0.00 $ 0.00 27. Medi-Cal Inpatient Days (Adj ) 0 0 28. Cost Applicable to Medi-Cal $ 0 $ 0 ADMINISTRATIVE DAYS 29. Per Diem Rate (Adj ) $ 0.00 $ 0.00 30. Medi-Cal Inpatient Days (Adj ) 0 0 31. Cost Applicable to Medi-Cal $ 0 $ 0 32. Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,28,31) $ 0 $ 0 (To Schedule 4-1) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 4B-1 PROGRAM: PSYCHIATRIC Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: HSM 30625F SPECIAL CARE UNITS REPORTED AUDITED PEDIATRIC INTENSIVE CARE UNIT 1. Total Inpatient Routine Cost (Sch 8, Line 29.03, Col 27) $ 7,410,985 $ 7,410,989 2. Total Inpatient Days (Adj ) 1,912 1,912 3. Average Per Diem Cost $ 3,876.04 $ 3,876.04 4. Medi-Cal Inpatient Days (Adj ) 0 0 5. Cost Applicable to Medi-Cal $ 0 $ 0 NEONATAL INTENSIVE CARE UNIT 6. Total Inpatient Routine Cost (Sch 8, Line 30, Col 27) $ 32,319,451 $ 32,319,475 7. Total Inpatient Days (Adj ) 14,302 14,302 8. Average Per Diem Cost $ 2,259.79 $ 2,259.79 9. Medi-Cal Inpatient Days (Adj ) 0 0 10. Cost Applicable to Medi-Cal $ 0 $ 0 N/A 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 N/A 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 N/A 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 N/A 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 4-1) COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 5-1 PROGRAM: PSYCHIATRIC Provider Name: Fiscal Period Ended: CEDARS-SINAI MEDICAL CENTER JUNE 30, 2008 Provider No: HSM 30625F RATIO COST TO CHARGES ANCILLARY COST CENTERS 37.00 Operating Room $ 95,710,199 $ 585,456,449 0.163480 $ 0 $ 0 39.00 Delivery Room and Labor Room 29,518,483 75,488,257 0.391034 0 0 40.00 Anesthesiology 55,602,856 446,285,096 0.124590 0 0 41.00 Radiology-Diagnostic 49,746,582 193,969,630 0.256466 0 0 43.01 Ultrasound 4,215,379 29,801,839 0.141447 0 0 43.02 CAT Scan 12,997,062 201,731,626 0.064427 0 0 44.00 Laboratory 81,858,827 694,170,211 0.117923 0 0 44.01 Laboratory-Pathological 25,512,941 62,236,846 0.409933 0 0 44.02 HLA Lab 4,969,551 11,666,069 0.425983 0 0 47.00 Blood Storing, Processing & Trans 25,970,759 39,817,972 0.652237 0 0 49.00 Respiratory Therapy 29,840,758 292,629,267 0.101975 0 0 50.00 Physical Therapy 11,777,981 41,779,821 0.281906 0 0 51.00 Occupational Therapy 4,439,833 22,511,543 0.197225 0 0 52.00 Speech Pathology 1,689,666 8,339,831 0.202602 0 0 53.00 Electrocardiology 13,588,420 98,869,613 0.137438 0 0 54.00 Electroencephalography 4,408,169 21,049,131 0.209423 0 0 54.01 Electromyography 166,799 1,342,237 0.124269 0 0 55.00 Medical Supplies Charged to Patients 125,543,810 522,478,410 0.240285 0 0 56.00 Drugs Charged to Patients 93,304,736 462,202,429 0.201870 0 0 57.00 Renal Dialysis 8,102,366 31,845,109 0.254430 0 0 59.00 Gastro Intestinal Services 17,677,073 51,780,517 0.341385 0 0 59.01 Eye Laboratory 116,474 643,684 0.180950 0 0 59.02 Cardiac Catheterization Laboratory 10,383,847 81,800,167 0.126942 0 0 59.03 Vascular Laboratory 4,491,186 49,819,261 0.090150 0 0 59.04 Psychiatric/Psychological Services 948,688 4,444,067 0.213473 0 0 59.05 Nuclear Medicine - Therapeutic 14,418,226 116,313,021 0.123961 0 0 59.06 Magnetic Resonance Imaging 15,976,382 140,454,524 0.113748 0 0 59.07 Pulmonary Function Testing 1,901,599 3,728,114 0.510070 0 0 59.08 Recreational Therapy 139,834 833,837 0.167700 0 0 60.00 Clinic 5,867,508 3,544,413 1.655425 0 0 60.01 Psychiatric Clinic 4,048,115 6,939,317 0.583359 0 0 60.02 Medical Oncology 101,988,606 315,812,474 0.322940 0 0 60.03 Psych - Partial Hospitalization 894,863 2,902,036 0.308357 0 0 60.04 Clinic 2 - Gen Risk Center 406,378 124,968 3.251855 0 0 60.05 Clinic 3 - Neuro Surgical Institute 5,137,193 1,367,847 3.755678 0 0 60.06 Clinic 4 - Prostate Cancer Program 463,111 194,947 2.375574 0 0 60.07 Clinic 5 -Endocrinology Center 1,082,093 973,406 1.111657 0 0 60.08 Clinic 6 - Spine Injury Institute 4,253,159 2,992,983 1.421044 0 0 60.09 Clinic 7 - Pediatric Center 2,929,172 1,490,379 1.965387 0 0 61.00 Emergency 38,372,548 260,197,483 0.147475 0 0 TOTAL $ 910,461,233 $ 4,890,028,831 $ 0 $ 0 (To Schedule 3-1) * From Schedule 8, Column 27 MEDI-CAL CHARGES (Schedule 6-1) MEDI-CAL COST SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL ANCILLARY COST * TOTAL ANCILLARY CHARGES (Adj ) This is trial version www.adultpdf.com [...].. .STATE OF CALIFORNIA SCHEDULE 6-1 PROGRAM: PSYCHIATRIC ADJUSTMENTS TO MEDI-CAL CHARGES Provider Name: CEDARS-SINAI MEDICAL CENTER Fiscal Period Ended: JUNE 30, 2008 Provider No: HSM 30625F REPORTED 37.00 39.00 40.00 41.00 43.01 43.02 44.00 44.01 44.02 47.00 49.00 50 .00 51 .00 52 .00 53 .00 54 .00 54 .01 55 .00 56 .00 57 .00 59 .00 59 .01 59 .02 59 .03 59 .04 59 . 05 59.06 59 .07 59 .08 60.00 60.01... Institute Clinic 4 - Prostate Cancer Program Clinic 5 -Endocrinology Center Clinic 6 - Spine Injury Institute Clinic 7 - Pediatric Center Emergency TOTAL MEDI-CAL ANCILLARY CHARGES $ ADJUSTMENTS (Adj 16) $ 72,066 15, 691 1,906 35, 384 876,438 2, 350 56 5 0 9, 154 11,436 0 1,424 19,007 2,922 0 6,2 25 236, 453 2,2 35 3,138 0 0 4,321 37,369 0 16, 958 0 0 0 0 0 0 0 0 0 0 0 0 27,483 $ 1,382 ,52 5 $ This is trial version... $ 1,382 ,52 5 $ This is trial version www.adultpdf.com (72,066) ( 15, 691) (1,906) ( 35, 384) (876,438) (2, 350 ) (56 5) (9, 154 ) (11,436) (1,424) (19,007) (2,922) (6,2 25) (236, 453 ) (2,2 35) (3,138) (4,321) (37,369) (16, 958 ) (27,483) AUDITED $ 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 (1,382 ,52 5) $ 0 (To Schedule 5- 1) ... 43.01 43.02 44.00 44.01 44.02 47.00 49.00 50 .00 51 .00 52 .00 53 .00 54 .00 54 .01 55 .00 56 .00 57 .00 59 .00 59 .01 59 .02 59 .03 59 .04 59 . 05 59.06 59 .07 59 .08 60.00 60.01 60.02 60.03 60.04 60. 05 60.06 60.07 60.08 60.09 61.00 ANCILLARY CHARGES Operating Room Delivery Room and Labor Room Anesthesiology Radiology-Diagnostic Ultrasound CAT Scan Laboratory Laboratory-Pathological HLA Lab Blood Storing, Processing . Operating Room $ 95, 710,199 $ 58 5, 456 ,449 0.163480 $ 0 $ 0 39.00 Delivery Room and Labor Room 29 ,51 8,483 75, 488, 257 0.391034 0 0 40.00 Anesthesiology 55 ,602, 856 446,2 85, 096 0.12 459 0 0 0 41.00 Radiology-Diagnostic. (From Schedule 6) MEDI-CAL CHARGES MEDI-CAL SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL ANCILLARY CHARGES TOTAL COST * This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 6 PROGRAM:. Operating Room $ 95, 710,199 $ 58 5, 456 ,449 0.163480 $ 0 $ 0 39.00 Delivery Room and Labor Room 29 ,51 8,483 75, 488, 257 0.391034 0 0 40.00 Anesthesiology 55 ,602, 856 446,2 85, 096 0.12 459 0 0 0 41.00 Radiology-Diagnostic