tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D tables in J-2d have been completed. Level(s) of Care Hospital, Nursing Facility (specify): Col. Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7 Col. 8 1 Difference Total: Total: (Column 7 less Factor D′ D+D′ Factor G′ G+G′ Year Factor D Factor G Column 4) 1 $177,526.02 $ 16,025.00 $ 193,551.02 $198,672.78 $13,296.21 $211,968.99 $ 18,417.97 2 $188,142.38 $ 16,969.28 $ 205,111.66 $210,379.61 $14,079.69 $224,459.30 $ 19,347.64 3 $195,594.07 $ 17,642.17 $ 213,236.24 $218,721.88 $14,638.00 $233,359.88 $ 20,123.64 4 $204,522.24 $ 18,443.09 $ 222,965.33 $228,651.50 $15,302.54 $243,954.04 $ 20,988.71 5 $212,651.18 $ 19,158.00 $ 231,809.18 $237,514.68 $15,895.71 $253,410.39 $ 21,601.21
tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D tables in J-2d have been completed. Level(s) of Care (specify): Hospital, Nursing Facility Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7 Col. 8 Year Factor D Factor D′ Total: D+D′ Factor G Factor G′ Total: G+G′ Difference (Column 7 less Column 4) 1 $177,526.02 $ 16,025.00 $ 193,551.02 $198,672.78 $13,296.21 $211,968.99 $ 18,417.97 2 $188,142.38 $ 16,969.28 $ 205,111.66 $210,379.61 $14,079.69 $224,459.30 $ 19,347.64 3 $195,594.07 $ 17,642.17 $ 213,236.24 $218,721.88 $14,638.00 $233,359.88 $ 20,123.64 4 $204,522.24 $ 18,443.09 $ 222,965.33 $228,651.50 $15,302.54 $243,954.04 $ 20,988.71 5 $212,651.18 $ 19,158.00 $ 231,809.18 $237,514.68 $15,895.71 $253,410.39 $ 21,601.21
ABI-RH%20Renewal%20Application-Redlined%20draft-October%202017.docx