<eSOA
    pHciPan="X12345678"
    pHciTransmittalId="X12345678-2023-02-13-1">
    <SummaryOfFees>
         <RoomAndBoard>
            <SummaryOfFee
                pActualCharges="0"
                pSeniorCitizenDiscount="0"
                pPWDDiscount="0"
                pPCSO="0"
                pDSWD="1000.00"
                pDOHMAP="0"
                pHMO="0"
            />
            <OtherFundSource
                pDescription="Henry Sy Foundation"
                pAmount="3000.00"
            />
        </RoomAndBoard>
        <DrugsAndMedicine>
            <SummaryOfFee
                pActualCharges="3500"
                pSeniorCitizenDiscount="0"
                pPWDDiscount="0"
                pPCSO="0"
                pDSWD="1000.00"
                pDOHMAP="0"
                pHMO="0"
            />
        </DrugsAndMedicine>
        <LaboratoryAndDiagnostic>
            <SummaryOfFee
                pActualCharges="4000.00"
                pSeniorCitizenDiscount="0"
                pPWDDiscount="0"
                pPCSO="0"
                pDSWD="0"
                pDOHMAP="0"
                pHMO="0"
            />
        </LaboratoryAndDiagnostic>
        <OperatingRoomFees>
            <SummaryOfFee
                pActualCharges="12000.00"
                pSeniorCitizenDiscount="0"
                pPWDDiscount="0"
                pPCSO="0"
                pDSWD="0"
                pDOHMAP="0"
                pHMO="0"
            />
        </OperatingRoomFees>
        <MedicalSupplies>
            <SummaryOfFee
                pActualCharges="2000.00"
                pSeniorCitizenDiscount="1000.00"
                pPWDDiscount="0"
                pPCSO="0"
                pDSWD="0"
                pDOHMAP="0"
                pHMO="0"
            />
        </MedicalSupplies>
        <PhilHealth 
            pTotalCaseRateAmount="15000.00"
        />
        <Balance 
            pAmount="3500.00"
        />
    </SummaryOfFees>
    <ProfessionalFees>
        <ProfessionalFee>
            <ProfessionalInfo 
                pPAN="1234-4567890-1"
                pFirstName="JUAN"
                pMiddleName="TAMAD"
                pLastName="DELA CRUZ"
                pSuffixName=""
            />
            <SummaryOfFee
                pActualCharges="0"
                pSeniorCitizenDiscount="0"
                pPWDDiscount="0"
                pPCSO="0"
                pDSWD="0"
                pDOHMAP="0"
                pHMO="0"
            />
        </ProfessionalFee>
        <PhilHealth 
            pTotalCaseRateAmount="2000.00"
        />
        <Balance 
            pAmount="27180.00"
        />
    </ProfessionalFees>
    <ItemizedBillingItems>
        <ItemizedBillingItem
            pServiceDate="06-30-2021"
            pItemCode="DM-1353"
            pItemName="Paracetamol"
            pUnitOfMeasurement="Box"
            pUnitPrice="700.00"
            pQuantity="5"
            pTotalAmount="3500.00"        
        />
        <ItemizedBillingItem
            pServiceDate="06-30-2021"
            pItemCode="LD-13434"
            pItemName="CT Scan"
            pUnitOfMeasurement="Box"
            pUnitPrice="500.00"
            pQuantity="3"
            pTotalAmount="4000.00"        
        />
        <ItemizedBillingItem
            pServiceDate="06-30-2021"
            pItemCode="OR-13452"
            pItemName="Operating Room"
            pUnitOfMeasurement="Item"
            pUnitPrice="12000"
            pQuantity="1"
            pTotalAmount="12000"        
        />
        <ItemizedBillingItem
            pServiceDate="06-30-2021"
            pItemCode="MS-2521"
            pItemName="Gloves"
            pUnitOfMeasurement="Box"
            pUnitPrice="500.00"
            pQuantity="1"
            pTotalAmount="500"        
        />
        <ItemizedBillingItem
            pServiceDate="06-30-2021"
            pItemCode="MS-2522"
            pItemName="Face Mask"
            pUnitOfMeasurement="Box"
            pUnitPrice="500.00"
            pQuantity="3"
            pTotalAmount="1500.00"        
        />
    </ItemizedBillingItems>                
</eSOA>
