What do a medical itemized statement look like?

Medical Itemized Statement

Patient Name: [Patient Name]

Date: [Date]

Account Number: [Account Number]

Procedure/Service | Amount

--- | ---

Routine check-up | $50.00

X-ray | $150.00

Laboratory tests | $100.00

Medical supplies | $50.00

Medication | $30.00

Hospitalization | $1,000.00

Physical therapy | $200.00

Durable medical equipment | $150.00

Total Amount: $1,780.00

Insurance Payment: $1,000.00

Patient Responsibility: $780.00