3490 (Cont.),,,,Form CMS-265-94,,,,,,,12-05
COMPUTATION OF AVERAGE COST ,,,,FACILITY NO.:,,REPORTING PERIOD,,,WORKSHEET C,,
,     PER TREATMENT,,,,,FROM_______________,,,,,
,,,,_________________,,TO_______________,,,,,
,,,TOTAL,,,,MEDICARE,,,,
,,,,,NUMBER OF,NUMBER OF,,PAYMENT ,PAYMENT ,,
,,NUMBER,COSTS,AVERAGE COST,TREATMENTS,TREATMENTS,TOTAL,RATE,RATE,TOTAL,
,,OF,(TRANSFERRED FROM,OF TREATMENTS,"(Pre 4/1/2005, ","(Post 4/1/2005,",EXPENSES,"(Pre 4/1/2005, ","(Post 4/1/2005,",PAYMENT DUE,
,,TREATMENTS,"WKST. B., COL.11)",(COL.2/COL.1),see instructions),see instructions),(COL.4 x COL.3),see instructions),see instructions),(COL.4 x COL.6),
,,,,,,,,,,,
,,1,2,3,4,4.01,5,6,6.01,7,
,,,Line 7,,,,,,,,
1,Maintenance-Hemodialysis,,,,,,,,,,1 
,,,Line 8,,,,,,,,
2,Maintenance-Peritoneal Dialysis,,,,,,,,,,2 
,,,Line 9,,,,,,,,
3,Training-Hemodialysis,,,,,,,,,,3 
,,,Line 10,,,,,,,,
4,Training-Peritoneal Dialysis,,,,,,,,,,4 
,,,Line 11,,,,,,,,
5,Training-CAPD,,,,,,,,,,5 
,,,Line 12,,,,,,,,
6,Training-CCPD,,,,,,,,,,6 
,,,Line 13,,,,,,,,
7,Home Program-Hemodialysis,,,,,,,,,,7 
,,,Line 14,,,,,,,,
8,Home Program-Peritoneal Dialysis,,,,,,,,,,8 
,,Patient Wks,Line 15,,,,,,,,
9,Home Program-CAPD,,,,,,,,,,9 
,,Patient Wks,Line 16,,,,,,,,
10,Home Program-CCPD,,,,,,,,,,10 
11,Totals Sum of Lines 1-8 (Cols. 1 & 4),,,,,,,,,,11 
,"Sum of Lines 1-10 (Cols. 2,5, &  7)",,,,,,,,,,
,,,,,,,,,,,
"FORM CMS-265-94 (12-2005)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3412)",,,,,,,,,,,
,,,,,,,,,,,
34-312,,,,,,,,,,,Rev. 9