4290 (Cont.),,,,      FORM CMS-265-11     ,,,,,04-14
 COMPUTATION  OF  AVERAGE  COST  PER  TREATMENT,,,,,,, PROVIDER CCN:, PERIOD:, WORKSHEET C
 ESRD  PPS  BUNDLED PAYMENT,,,,,,,, From:   ,
,,,,,,,, To:   ,
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,,,,TOTAL,,,,,
,,,NUMBER,COSTS,AVERAGE COST,,,,
,,,OF,(Transferred from,PER TREATMENT,,,,
,,,TREATMENTS,"Wkst. B, col. 13A)",(col. 2 divided by col. 1),,,,
,,,1,2,3,,,,
8.01 , Maintenance-Hemo Adult,,,,,8.01 ,,,
8.02 , Maintenance-Hemo Pediatric,,,,,8.02 ,,,
9.01 , Maintenance-IPD Adult,,,,,9.01 ,,,
9.02 , Maintenance-IPD Pediatric,,,,,9.02 ,,,
10.01 , Training-Hemo Adult,,,,,10.01 ,,,
10.02 , Training-Hemo Pediatric,,,,,10.02 ,,,
11.01 , Training-IPD Adult,,,,,11.01 ,,,
11.02 , Training-IPD Pediatric,,,,,11.02 ,,,
12.01 , Training-CAPD Adult,,,,,12.01 ,,,
12.02 , Training-CAPD Pediatric,,,,,12.02 ,,,
13.01 , Training-CCPD Adult,,,,,13.01 ,,,
13.02 , Training-CCPD Pediatric,,,,,13.02 ,,,
14.01 , Home Program-Hemodialysis Adult,,,,,14.01 ,,,
14.02 , Home Program-Hemodialysis Pediatric,,,,,14.02 ,,,
15.01 , Home Program-IPD Adult,,,,,15.01 ,,,
15.02 , Home Program-IPD Pediatric,,,,,15.02 ,,,
16.01 , Home Program-CAPD Adult,,Patient Weeks,,,16.01 ,,,
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16.02 , Home Program-CAPD Pediatric,,Patient Weeks,,,16.02 ,,,
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17.01 , Home Program-CCPD Adult,,Patient Weeks,,,17.01 ,,,
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17.02 , Home Program-CCPD Pediatric,,Patient Weeks,,,17.02 ,,,
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18 , Totals,(Column 1 - sum of lines 8.01 through 15.02),,,,18 ,,,
,,(Column 2 - sum of lines 8.01 through 17.02),,,,,,,
19 , Total provider treatments ,,,,,19 ,,,
, (informational only),,,,,,,,
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"FORM CMS-265-11 (04/2014)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4212)",,,,,,,,,
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42-314,,,,,,,,,Rev. 3