住院费用清单模板.docx 3页

'住院费用清单***医院住院号：姓名：总费用：预交金额：项目三磷酸腺苷二纳注射液开塞露维生素B6注射液0.9%氯化钠注射液地塞米松磷酸钠注射液盐酸利多卡因注射液10%葡萄糖注射液（可立袋）5%葡萄糖注射液（可立袋）0.9%氯化钠注射液（可立袋）米索前列醇片盐酸麻黄碱注射液盐酸吗啡注射液盐酸布比卡因注射液维生素C注射液硫酸阿托品注射液复方氯化钠注射液注射用铺本酶A注射用头孢他啶西药合计吸引连接管一次性备皮刀产腹带一次性枕套一次床单留置针贴膜爱惜康幕丝线一次性便盆一次性采血管留置针一次性氧管一次性导尿管电极板一次性麻醉包肝素帽无菌敷贴一次性引流瓶抗凝采血管缓排空型一次性输液器一次性婴儿吸痰器材料费合计围产保健访视住院诊查费诊查费合计血常规（五分类）尿常规检查（尿十一项）尿常规（手工法）葡萄糖测定肝功能常规检查肾功能常规检查乙肝三对检测输血前常规检查ABO血型鉴定（微柱法）Rh血型鉴定（微柱法）检验费合计输卵管结扎术剖宫产术肠粘连松解术经腹子宫肌痛剔除术科室：尚欠：规格20mg:2ml20ml100mg:2ml10ml5mg:1ml200mg:10ml100ml500ml100ml200ug×3片30mg:1ml10mg:1ml37.5mg:5ml500mg:2ml0.5mg:1ml500ml100IU0.75g45﹡65120﹡220肝功能生化ssssAS_E10﹡151:41:9小单位：元床位：类别：自费住院天数：天数量单价金额自负金额保险金额20.250.500.5020.601.21.280.171.361.3610.240.240.2440.200.800.8010.800.800.8012.602.602.6094.9044.1044.1025.2010.4010.4012.432.432.4311.061.061.0614.04.904.9011.921.921.92260.174.424.4210.900.900.9042.6010.4010.4013.203.203.20538.5192.5192.5283.73283.7333.009.009.0011.081.081.0815.405.405.4010.860.860.8626.4812.9612.9613.243.243.24254.00108.00108.00112.9612.9612.9617.567.567.5650.864.304.30119.8719.8719.8721.943.883.88123.7623.7623.7650.653.253.25121.6021.6021.6032.708.108.1014.104.104.10242.1284.2484.2410.970.970.9765.4032.4032.4011.701.701.70369.23369.2345.0020.0020.0054.0020.0020.0040.0040.00218.00363619.009.009.0013.003.003.0014.004.004.00155.0055.0055.00118.0018.0018.00125.0025.0025.00180.0080.0080.00127.0027.0027.00127.0027.0027.00284.00284.000.5240.00120.00120.001800.00800.00800.000.5800.00400.00400.000.5720.00360.00360.00制表：邓美男第1页其2页 住院费用清单衡南县人民医院单位：元项目规格数量单价金额自负金额保险金额镇痛泵体内置入术1720720720手术费合计2400.002400.00超声计算机图文报告19.009.009.00计算机图文合计9.009.00新生儿油浴护理55.0025.0025.00Ⅰ级护理113.0013.0013.00Ⅱ级护理47.0028.0028.00新生儿护理59.0045.0045.00新生儿抚触护理920.00180.00180.00新生儿呼吸道清理护理15.005.005.00动静脉置管护理35.0015.0015.00护理合计311.00311.00产前检查28.0016.0016.00胎心监测523.00115.00115.00新生儿量表检查118.0018.0018.00会阴冲洗84.0032.0032.00小换药17.007.007.00宫颈注射118.0018.0018.00新生儿经皮胆红素测定59.0045.0045.00心电监测62.0012.0012.00血氧饱和度监测61.006.006.00治疗费合计269.00269.00住院床位费婴儿床（母婴同室双人间）710.0070.0075.00普通病房床位费（单人间）720.00140.00125.00床位费合计肌肉注射皮试皮下注射静脉注射静脉输液连续输液第二组起每组加收静脉穿刺置管术注射费合计低流量吸氧输氧合计椎管内麻醉术后镇痛麻醉中监测麻醉合计常规心电图检查常规心电图检查（12导联加收）频谱心电图心电图合计临床操作的彩色多普勒超声引导彩超合计凝血常规检测血凝全套合计病房空调费（单人间）其他合计静脉采血抽血费合计总计210.00210.0032.006.006.0013.003.003.0022.004.004.0053.0015.0015.00134.0052.0052.00111.0011.0011.00120.0020.0020.00111.00111.0032.57.507.507.57.51250.00250.00250.00185.0085.0085.00415.0060.0060.00395.00395.0019.009.009.00110.0010.0010.00123.0023.0023.0042.0042.001100.00100.00100.00100.00100.00170.0070.0070.0070.0070.0071070.0070.0070.0070.0023.006.006.006.006.004947.464947.46制表：保险金额：0第2页共2页 '