HBS

ANTI HCV

LUAR PAKET
Rp
120,000
Rp
90,000
Rp
10,000
Rp
44,000
Rp
54,000
Rp
44,000
Rp
24,000
Rp
90,000
Rp
125,000
Rp
24,000
Rp
10,000
Rp
24,000
Rp
24,000
Rp
100,000
Rp
24,000
Rp
44,000
Rp
120,000
Rp
100,000
Rp
125,000
Rp
12,000
Rp
10,000
Rp
100,000
Rp
24,000
Rp
44,000
Rp
10,000
Rp
10,000
Rp
300,000
Rp
24,000
Rp
12,000
Rp
44,000
Rp
80,000
Rp
20,000
Rp
10,000
Rp
70,000
Rp
20,000
Rp
100,000
Rp
125,000
Rp
24,000
Rp
24,000
Rp
10,000
Rp
105,000
Rp
10,000
Rp
10,000
Rp
10,000
Rp
24,000
Rp
24,000

PAKET P2A
Rp
40,000
Rp
28,000
Rp
28,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
896,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp 1,296,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
40,000
Rp
85,000
Rp
40,000
Rp
85,000
Rp
40,000
Rp
40,000
Rp
40,000

Rp
24,000
Rp
10,000
Rp
10,000
Rp
105,000
Rp
12,000
Rp
125,000
Rp
16,500
Rp
24,000
Rp
10,000
Rp
10,000
Rp
10,000
Rp
10,000
Rp
10,000
Rp
24,000
Rp
105,000
Rp
24,000
Rp
10,000
Rp
90,000
Rp
10,000
Rp
100,000
Rp
44,000
Rp
24,000
Rp
10,000
Rp
12,000
Rp
100,000
Rp
24,000
Rp
44,000
Rp
40,000
Rp
24,000
Rp
10,000
Rp
240,000
Rp
120,000
Rp
44,000
Rp
10,000
Rp
10,000
Rp
44,000
Rp
11,500
Rp
11,500
Rp
11,500
Rp
16,000
Rp 4,042,000
Rp
105,000
Rp
10,000
Rp
100,000
Rp
44,000
Rp
24,000
Rp
100,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
2,186,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
28,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
3,494,000
40,000
40,000
40,000

Rp
44,000
Rp
54,000
Rp
10,000
Rp
100,000
Rp
10,000
Rp
24,000
Rp
54,000
Rp
100,000
Rp
125,000
Rp
24,000
Rp 4,970,000

Rp 12,493,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

40,000
40,000
40,000
40,000
40,000
40,000
55,000
40,000
40,000
40,000
40,000
22,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
4,851,000
40,000
40,000
40,000
40,000
40,000
55,000
40,000
40,000
40,000
40,000
40,000
40,000
5,346,000
40,000
55,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

40,000
40,000
40,000
40,000
22,000
28,000
22,000
40,000
24,000
40,000
40,000
66,000
40,000
40,000
4,000
40,000
40,000
40,000
40,000
40,000
40,000
6,207,000
40,000
40,000
85,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
55,000
40,000
40,000
40,000
40,000
28,000
28,000
40,000
40,000
40,000
40,000
40,000
7,163,000
40,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

40,000
40,000
40,000
40,000
40,000
40,000
40,000
40,000
7,523,000

17500
17500
9000
44000

NO.

RM

NOKA ASKES

NAMA PASIEN

JENIS PEMERIKSAAN

1
2

091302
088900

0000127110161
0000125761094

IBRAHIM MANWAN,PROF
HADIJAH SITTI

UREUM,CREATININ,SGOT,SGPT
ALBUMIN
EKG

012600

0000127709291

SAIFUL.M

USG ABDOMEN
PT/APTT
PT/APTT
BNO
PROTOT,ALB,LIPID

078642

0000129106269

MUNDING,DRS

5
6

090835
090968

0001081681795
0000136831735

SANIA
KAFRAWI.MOH

080350

0000127207888

MURNI HAYUNG

LIPID,GDP,HBA1C
HBSAG
GDP

090961

0000155707582

ELIA DATUAN RANTAELLO

HBSAG
SPUTUM BTA 3X

091566

0000127665044

RAHMATIAH

KLORIDA,KALIUM

10

035611

0000127231964

DAUD MAHASUNI,DRS

GDS
EKG,THORAX

11
12

091736
024875

0000128660905
0000129820803

FADLIAH JAMALUDDIN
ALIHKANG

UREUM,CREATINI,SGOT,SGPT
SGOT,SGPT
UREUM,CREATINI,SGOT,AU,GDS

13
14

076583
091514

0000125606327
0000133929257

MARHAENI KARIM
MAHMUDDIN

UREUM,CREATININ,SGOT,SGPT
THORAX
ALBUMIN

15
16
17
18

091124
091498
091988
046569

0000136806827
0000131807081
0000173563738
0000127176579

NURHANA,S.AG
HADIJAH SITTI
MUTIA REZKI SYEISA
CHRISTINA RANGAN

TG,LDL,HDL
UREUM,CREATINI,SGOT,SGPT
UREUM.CREATININ,SGOT,SGPT
GDP
GDP

19

033828

00001660987248

MARYAM ANDI,HJ

LIPID

UREUM,CREATININ,SGOT,SGPT,GD
S,PT/APTT
ALBUMIN
ELEKTROLIT,GDP
LIPID,GDP,GD2PP
ELEKTROLIT

20
21
22

084456
064081
090957

0000126220116
0000131363335
0000165541599

sarifuddin
USMAN KOCI
NURWAHIDAH

ELEKTROLIT
GDS
LIPID.GDP
USG ABDOMEN

23

025516

0000126988097

HAIRUDDIN LARIS

UR/CR.GDS
EKG

24

090906

0000127567001

WIDIAWATI

URE/CR

TGL

TARIF

9/16/2013 Rp
9/15/2013 Rp
9/10/2013 Rp
Rp
8/13/2013 Rp
9/6/2013 Rp
9/10/2013 Rp
9/12/2013 Rp
8/14/2013 Rp
Rp
8/27/2013
9/11/2013
8/28/2013
9/6/2013
9/10/2013
9/26/2013
9/7/2013
9/10/2013
8/27/2013
8/30/2013
9/14/2013

KETERANGAN

48,000
12,000 TIDAK U/PASIEN KEMOTERAPI
55,000
67,000
150,000
105,000
105,000
100,000
74,500
534,500

Rp

163,000

Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

12,000
54,000
70,500
44,000
168,500
180,500 TDAK SESUAI TGL MASUK DENGAN PENGANTAR LAB
100,000 BAYAR UMUM HBSAG-NYA
10,000
290,500
100,000 BAYAR UMUM HBSAG-NYA
65,000
165,000
26,500

Rp
9/18/2013 Rp
9/18/2013 Rp
Rp
9/19/2013 Rp
9/23/2013 Rp
9/21/2013 Rp
Rp
9/19/2013 Rp
9/13/2013 Rp
9/14/2013 Rp
Rp
9/3/2013 Rp
9/12/2013 Rp
9/27/2013 Rp
9/12/2013 Rp
9/14/2013 Rp
Rp
9/13/2013 Rp

SUDAH DIPERIKSA DI RJTL

26,500
10,000
155,000
165,000
48,000
24,000
56,000
80,000
48,000
100,000
12,000
112,000
39,000
24,000
48,000 SUDAH DIPERIKSA DI RJTL
10,000
10,000
20,000
74,500

8/31/2013
8/10/2013
8/27/2013
8/27/2013

Rp
Rp
Rp
Rp
Rp
8/27/2013 Rp
8/30/2013 Rp
Rp
8/26/2013 Rp
Rp
Rp
Rp

44,000
10,000
50,500
150,000
200,500
34,000
55,000
89,000
24,000 TIDAK SESUAI DIAGNOSANYA
744,000
1,226,500
(482,500)