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| Ημέρα | Α/Α τελευταίας συνταγής | Αξία Συνταγών (με τιμές αποζημίωσης) | Συμμετοχή Ασφ/νων (10 ή 25% επί της τιμής αποζημίωσης) | Επιβάρυνση ΕΟΠΥΥ | ||||||||
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| ΣΥΝΤΑΓΕΣ | ΠΟΣΟ | |||||||||||
| 1 € | ΑΙΤΟΥΜΕΝΟ ΠΟΣΟ : | |||||||||||
| ΣΤΟΙΧΕΙΑ ΤΙΜΟΛΟΓΙΟΥ | ||||||||||||
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