| A | B | C | D | E | F | G | |
|---|---|---|---|---|---|---|---|
1 | |||||||
2 | |||||||
3 | PAITIENT FEE CALCULATOR | Full Revive (Flatbacked) | 1000 | ||||
4 | BASIC TREATMENT COST | 1 | $1,500 | Downed (Bleeding Out) | 500 | ||
5 | NUMBER OF TIMES IFAK USED | $1,500 | 1500 | ||||
6 | |||||||
7 | ADDITIONAL COSTS | (TICK ALL EXTRA THAT APPLY) | |||||
8 | 0 | Transport (Within City Limits) | $0 | Icepack/Bandage (Standing) | 250 | ||
9 | 0 | Transport (Outside City Limits) | $0 | 500 | |||
10 | 0 | Helicoptor Transportation | $0 | 1000 | |||
11 | 0 | Problem Patient Fee | $0 | 500 | |||
12 | |||||||
13 | EXTRA SERVICES | (TICK ALL EXTRA THAT APPLY) | |||||
14 | 0 | Check Up/Doctor Examination | $0 | 500 | |||
15 | 0 | X-Ray Or MRI | $0 | 500 | |||
16 | 0 | Surgery | $0 | 1000 | |||
17 | 0 | Additional Services (Misc) | $0 | 500 | 1000 | ||
18 | 0 | Prescription Fee (If Script Written) | $0 | 1000 | 1000 | ||
19 | TOTAL TO CHARGE: | $3,000 | |||||
20 | |||||||
21 | |||||||