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[null," CAPITAL FEDERAL AMOUNT"]
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[2,"   Capital DRG outlier payments",{"$nulls":6},2]
[3,"   Total inpatient days divided by number of days in the cost reporting period (see instructions)",{"$nulls":6},3]
[4,"   Number of interns & residents (see instructions)",{"$nulls":6},4]
[5,"   Indirect medical education percentage (see instructions)",{"$nulls":6},5]
[6,"   Indirect medical education adjustment (sum of lines 1 & 2 times line 5)",{"$nulls":6},6]
[7,"   Percentage of SSI recipient patient days to Medicare Part A patient days (Worksheet E, part A line 27 see instructions)",{"$nulls":6},7]
[8,"   Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I (see instructions)",{"$nulls":6},8]
[9,"   Sum of lines 3 and 4",{"$nulls":6},9]
[10,"   Allowable disproportionate share percentage (see instructions)",{"$nulls":6},10]
[11,"   Disproportionate share adjustment (line 6 times the sum of lines 1 and 2)",{"$nulls":6},11]
[12," Total prospective capital payments (sum of lines 1-2, and 7)",{"$nulls":6},12]
["PART II - PAYMENT UNDER REASONABLE COST"]
[1," Program inpatient routine capital cost (see instructions)",{"$nulls":6},1]
[2," Program inpatient ancillary capital cost (see instructions)",{"$nulls":6},2]
[3," Total inpatient program capital cost (line 1 plus line 2)",{"$nulls":6},3]
[4," Capital cost payment factor (see instructions)",{"$nulls":6},4]
[5," Total inpatient program capital cost (line 3 x line 4)",{"$nulls":6},5]
["PART III - COMPUTATION OF EXCEPTION PAYMENTS"]
[1," Program inpatient capital costs (see instructions)",{"$nulls":6},1]
[2," Program inpatient capital costs for extraordinary circumstances (see instructions)",{"$nulls":6},2]
[3," Net program inpatient capital costs (line 1 minus line 2)",{"$nulls":6},3]
[4," Applicable exception percentage (see instructions)",{"$nulls":6},4]
[5," Capital cost for comparison to payments (line 3 x line 4)",{"$nulls":6},5]
[6," Percentage adjustment for extraordinary circumstances (see instructions)",{"$nulls":6},6]
[7," Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6)",{"$nulls":6},7]
[8," Capital minimum payment level (line 5 plus line 7)",{"$nulls":6},8]
[9," Current year capital payments (from Part I, line 8, as applicable)",{"$nulls":6},9]
[10," Current year comparison of capital minimum payment level to capital payments (line 8 less line 9)",{"$nulls":6},10]
[11," Carryover of accumulated capital minimum payment level over capital payment",{"$nulls":6},11]
[null," (from prior year Worksheet L,  Part III, line 14)"]
[12," Net comparison of capital minimum payment level to capital payments (line 10 plus line 11)",{"$nulls":6},12]
[13," Current year exception payment (if line 12 is positive, enter the amount on this line)",{"$nulls":6},13]
[14," Carryover of accumulated capital minimum payment level over capital payment",{"$nulls":6},14]
[null," for the following period (if line 12 is negative, enter the amount on this line)"]
[15,"Current year  allowable operating and capital payment (see instructions)",{"$nulls":6},15]
[16,"Current year operating and capital costs (see instructions)",{"$nulls":6},16]
[17,"Current year exception offset amount (see instructions)",{"$nulls":6},17]
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[73,"Drugs Charged to Patients",{"$nulls":8},73,73,"Drugs Charged to Patients",{"$nulls":10},73,73,"Drugs Charged to Patients",{"$nulls":9},73]
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