| Act and services (to be mentioned) | Quantity | Unit Cost | Total cost |
| Intensive care unit |
|
|
|
| Blood transfusion kit |
|
|
|
| Hospitalisation |
|
|
|
| Consultation |
|
|
|
| Restauration |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Total |
|
|
|