住院費用清單模板

1、住院費用清單*醫(yī)院單位：元住院號:姓名：科室：床位：類別：自費總費用：預交金額：尚欠：住院天數(shù)：天項目規(guī)格數(shù)量單價金額自負金額保險金額三磷酸腺甘二納注射液20mg:2ml20.250.500.50開塞露20ml20.601.21.2維生素b6注射液100mg:2ml80.171.361.360.9%氯化鈉注射液10ml10.240.240.24地塞米松磷酸鈉注射液5mg:1ml40.200.800.80鹽酸利多卡因注射液200mg:10ml10.800.800.8010%葡萄糖注射液（可立袋）100ml12.602.602.605%葡萄糖注射液（可立袋）500ml94.9044.1044.10

2、0.9%氯化鈉注射液（可立袋）100ml25.2010.4010.40米索前列醇片200ug切片12.432.432.43鹽酸麻黃堿注射液30mg:1ml11.061.061.06鹽酸嗎啡注射液10mg:1ml14.04.904.90鹽酸布比卡因注射液37.5mg:5ml11.921.921.92維生素c注射液500mg:2ml260.174.424.42硫酸阿托品注射液0.5mg:1ml10.900.900.90復方氯化鈉注射液500ml42.6010.4010.40注射用鋪本酶a100iu13.203.203.201注射用頭抱他咤0.75g538.5192.5192.5西藥合計283.73

3、283.73吸引連接管33.009.009.00一次性備皮刀11.081.081.08產(chǎn)腹帶15.405.405.40一次性枕套45 6510.860.860.86一次床單120 22026.4812.9612.96留置針貼膜13.243.243.24愛惜康254.00108.00108.00幕絲線112.9612.9612.96一次性便盆17.567.567.56一次性采血管肝功能生化50.864.304.30留置針119.8719.8719.87一次性氧管ssss21.943.883.88一次性導尿管123.7623.7623.76電極板50.653.253.25一次性麻醉包as_e121

4、.6021.6021.60肝素帽32.708.108.10無菌敷貼10 1514.104.104.10一次性引流瓶242.1284.2484.24抗凝采血管1:4 1:910.970.970.97緩排空型一次性輸液器65.4032.4032.401一次性嬰兒吸痰器小11.701.701.70材料費合計369.23369.23圍產(chǎn)保健訪視45.0020.0020.00住院診查費54.0020.0020.00診查費合計40.0040.00血常規(guī)（五分類）218.003636尿常規(guī)檢查（尿十一項）19.009.009.00尿常規(guī)（手工法）13.003.003.00葡萄糖測定14.004.004.00

5、肝功能常規(guī)檢查155.0055.0055.00腎功能常規(guī)檢查118.0018.0018.00乙肝三對檢測125.0025.0025.00輸血前常規(guī)檢查180.0080.0080.00abo血型鑒定（微柱法）127.0027.0027.001rh血型鑒定（微柱法）127.0027.0027.00檢驗費合計284.00284.00輸卵管結(jié)扎術0.5240.00120.00120.00剖宮產(chǎn)術1800.00800.00800.00腸粘連松解術0.5800.00400.00400.00經(jīng)腹子宮肌痛剔除術0.5720.00360.00360.00精品資料制表：鄧美男第1頁其2頁住院費用清單精品資料衡南縣

6、人民醫(yī)院單位：元項目規(guī)格數(shù)量單價金額自負金額鎮(zhèn)痛泵體內(nèi)置入木1720720720手術費合計2400.002400.00超聲計算機圖文報告19.009.009.00計算機圖文合計9.00119.00新生兒油浴護理55.0025.0025.00i級護理113.0013.0013.00口級護理47.0028.0028.00新生兒護理59.0045.0045.00新生兒撫觸護理920.00180.00180.00新生兒呼吸道清理護理15.005.005.00動靜脈置管護理35.0015.0015.00護理合計311.00311.00產(chǎn)前檢查28.0016.0016.00胎心監(jiān)測523.00115.00

7、115.00新生兒量表檢查118.0018.0018.00會陰沖洗84.0032.0032.00小換藥17.007.007.00宮頸注射118.0018.0018.00新生兒經(jīng)皮膽紅素測定59.0045.0045.00心電監(jiān)測62.0012.0012.00血氧飽和度監(jiān)測61.006.006.00治療費合計 269.00 269.00住院床位費嬰兒床（母嬰同室雙人間）710.0070.0075.00普通病房床位費（單人間）720.00140.00125.00床位費合計210.00210.00肌肉注射32.006.006.00皮試13.003.003.00皮下注射22.004.004.00靜脈注射

8、53.0015.0015.00靜脈輸液134.0052.0052.00連續(xù)輸液第二組起每組加收111.0011.0011.00靜脈穿刺置管術120.0020.0020.00注射費合計111.00111.00低流量吸氧32.57.50 7.50輸氧合計7.57.5椎管內(nèi)麻醉1250.00250.00250.00術后鎮(zhèn)痛185.0085.0085.00麻醉中監(jiān)測415.0060.0060.00麻醉合計395.0011395.00常規(guī)心電圖檢查19.009.009.00常規(guī)心電圖檢查（12導聯(lián)加收）110.0010.0010.00頻譜心電圖123.0023.0023.00心電圖合計42.0042.00臨床操作的彩色多普勒超聲引導1100.00100.00100.00彩超合計 100.00 100.00凝血常規(guī)檢測170.0070.001170.00血凝全套合計70.00 70.00病房空調(diào)費（單人間）71070.0