Bahan Habis Pakai Operasi Pakdir

1.
HERNIA
a Material Bedah
Nama Obat Sat Keb Harga Total
Sat.
Electroda bh 4 22,800 91,200
Glove Gammex 7 bh 1
Glove Gammex 7,5 bh 2
Glove unsteril bh 5 12,000 60,000
Hansaplast bh 1 350 350
Hypafix cm 10 400 4,000
Kasa bh 30 7,000 210,000
Masker bh 5 31,700 158,500
Mess 10 bh 1 12,750 12,750
Oksigen nasal
bh 1 2,000 2,000
/masker
Spinocam 25 bh 1 21,300 21,300
Syringe 3 bh 2 250,000 500,000
Topi disposable bh 5 47,400 237,000
Nylon 2,0 sct 1 71,500 71,500
Polisorb 2,0 sct 1 19,500 19,500
sct 1 4,500 4,500

Siede atraumatik 2,0
Alkohol cc 50
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1 11,300 11,300
Povidon cc 300 12,300 3,690,000
PZ fles 1 1,100 1,100
RL fles 2 1,300 2,600
Masker bh 3 800 2,400
Hernia mess bh 1 250,000 250,000
NGT 12 bh 1
b HERNIA BILATERAL
a Material Bedah
Sat.
Electroda bh 4
Glove Gammex 7 bh 2
Glove unsteril bh 5
Hansaplast bh 1
Hypafix cm 10 65 650
Kasa bh 30 300 9,000
Masker bh 5 22,800 114,000
Mess 10 bh 2 350 700
Oksigen nasal
bh 1 400 400
/masker
Spinocam 25 bh 1 7,000 7,000
Syringe 10 bh 1
Syringe 5 bh 2 176 352
Syringe 3 bh 1
Topi disposable bh 5 127 635
Nylon 2,0 sct 1 200,000 200,000
Polisorb 2,0 sct 2 4,800 9,600
Siede atraumatik 2,0 sct 1 19,500 19,500

Alkohol cc 50 12,000 600,000
Epineprin amp 1 2,300 2,300
Hibiscrub cc 100 21,300 2,130,000
Lidodex amp 1 47,400 47,400
Oksigen lpm 2 71,500 143,000
Povidon cc 300 11,300 3,390,000
PZ fles 1 12,300 12,300
RL fles 3 800 2,400
Hernia mess 10x5 bh 2 1,100 2,200
NGT 12 bh 1 10,300 10,300
DEKAIN amp 1
2 APPENDICITIS ACUTA
a Material Bedah
Sat.
Electroda bh 4
Glove Gammex 7.5 bh 2
Glove Gammex 7 bh 2
Glove unsteril bh 5
Hansaplast bh 1
Hypafix cm 10
Kasa bh 30
Masker bh 5 65 325
Mess 10 bh 2 300 600
Oksigen nasal
bh 1 22,800 22,800
/masker
Spinocam 25 bh 1 350 350
Nylon 2.0 sct 1 31,700 31,700
Polisorb 2.0 sct 2 12,750 25,500
Siede atraumatik 2.0 sct 1 12,750 12,750

Alkohol cc 50 2,300 115,000
Hibiscrub cc 100 47,400 4,740,000
Lidodex amp 1 71,500 71,500
Oksigen lpm 2 4,500 9,000
Povidon cc 300 12,300 3,690,000
PZ fles 1 800 800
RL fles 3 10,300 30,900
a HERNIA INCACERATA (LAPARATOMI)
a Material Bedah
Sat.
Electroda bh 4 65 260
Glove Gammex 7 bh 2 300 600
Hansaplast bh 1 93,100 93,100
Hypafix CM 20 6,300 126,000
Kasa bh 30 350 10,500
Masker bh 5 400 2,000
Mess 20 bh 1 7,000 7,000
Oksigen nasal
bh 1 2,000 2,000
/masker
Spinocam 25 bh 1 31,700 31,700
Syringe 3 bh 1
Syringe 5 bh 1
Syringe 10 bh 2 12,750 25,500
Nylon 2.0 sct 1 16,200 16,200
Polisorb 1 sct 2 21,300 42,600
Polisorb 2.0 sct 1
Siede atraumatik 0 sct 1 4,500 4,500
Alkohol cc 50 8,000 400,000
Hibiscrub cc 100 10,400 1,040,000
Lidodex amp 1 12,300 12,300
Oksigen lpm 2 5,550 11,100
Povidon cc 300 5,300 1,590,000
PZ fles 3 2,800 8,400
RL fles 3 12,700 38,100
b APPENDICITIS INFILTRAT / KRONIS
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 300 600
Glove Gammex 7 bh 2
Hypafix cm 10 6,300 63,000
Kasa bh 30 350 10,500
Masker bh 5 400 2,000
Mess 10 bh 1 4,500 4,500
Oksigen nasal
bh 1 2,000 2,000
/masker
Spinocam 25 bh 1 31,700 31,700
Syringe 3 bh 2 12,750 25,500
Nylon 2.0 sct 1 21,300 21,300
Polisorb 2.0 sct 1 4,500 4,500

Alkohol cc 50 42,050 2,102,500
Hibiscrub cc 100 12,300 1,230,000
Lidodex amp 1 5,550 5,550
Povidon cc 300 16,200 4,860,000
PZ fles 1 2,800 2,800
RL fles 3 12,700 38,100
4 STRUMA
a Material Bedah
Sat.
Glove Gammex 7.5 bh 2 300 600
Glove Gammex 7 bh 2
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 7,000 35,000
Mess 10 bh 2 2,000 4,000
Oksigen nasal 31,700
bh 1 31,700
/masker
Syringe 10 bh 2 72,000 144,000
Syringe 5 bh 2
Syringe 3 bh 2
Nylon 2.0 sct 1 1,100 1,100
Polisorb 2.0 sct 1
Alkohol 50 42,050 2,102,500
Atracrium / Tracrium 1 11,300 11,300
Fentanyl amp 1 12,300 12,300
Hibiscrub cc 100 14,000 1,400,000
Isoflurane cc 30 16,200 486,000
Midazolam / Milloz amp 1 2,800 2,800
Oksigen lpm 3 34,300 102,900
Ondancetron 1 800 800
Pethidin amp 1 10,300 10,300
Povidon 300
PZ fles 1
RL fles 2
Sulfas Atropin amp 1
Trivam/recofol/savol/
amp 1
propofol
WFI amp 1
alkohol swab bh 6
5a CA MAMAE (MASTEKTOMIE)
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix cm 10 400 4,000
Kasa bh 30 7,000 210,000
Masker bh 5 31,700 158,500
Mess 20 bh 1 12,750 12,750
bh 1 12,750
/masker
Syringe 10 bh 3 2,000 6,000
Syringe 5 bh 2
Syringe 3 bh 1
Nylon 2.0 sct 1 1,100 1,100
Polisorb 2.0 sct 1 21,300 21,300
Alkohol 50 8,000 400,000
Fentanyl amp 1 11,300 11,300
Hibiscrub cc 100 12,300 1,230,000
Isoflurane cc 30 5,550 166,500
Oksigen lpm 3 5,300 15,900
Pethidin amp 1 2,800 2,800
Povidon cc 300 34,300 10,290,000
PZ fles 1 12,700 12,700
RL fles 2 800 1,600
Sulfas Atropin amp 1 103,300 103,300
Trivam/recofol/savol/ 14,000
amp 1 14,000
propofol
WFI amp 1
Alkohol swab bh 6
5b CA MAMAE SKIN GRAF
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 4,500 22,500
Mess 10 bh 2 31,700 63,400
bh 1 12,750
/masker
Syringe 10 bh 3 250 750
Syringe 5 bh 2
Syringe 3 bh 1
Nylon 3.0 sct 2 1,300 2,600
Alkohol 50 8,000 400,000
Fentanyl amp 1 10,400 10,400
Hibiscrub cc 100 12,300 1,230,000
Oksigen lpm 3 5,300 15,900
sutratulle bh 5
Povidon 300 34,300 10,290,000
PZ fles 1 12,700 12,700
RL fles 2 14,000 28,000
Sulfas Atropin amp 1 800 800
Trivam/recofol/savol/ 103,300
amp 1 103,300
propofol
WFI amp 1 1,500 1,500
Alkohol swab bh 6
6 DISEKSI KELENJAR
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Glove unsteril bh 5 228 1,140
Hypafix cm 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 4,500 22,500
Mess 15 bh 2 176 352
Oksigen nasal 127
bh 1 127
/masker
Syringe 10 bh 3 127 381
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 3.0 sct 1 15,000 15,000

nylon 3,0 sct 1
Alkohol 50 47,400 2,370,000
Fentanyl amp 1 22,000 22,000
Hibiscrub cc 100 1,100 1,100
Oksigen lpm 3 10,400 31,200
Ondancetron 1 12,300 12,300
Pethidin amp 1 14,000 14,000
Povidon 300 5,300 1,590,000
PZ fles 1 34,300 34,300
RL fles 2 7,500 15,000
propofol amp 1 800 800
WFI amp 1 103,300 103,300
Alkohol swab bh 6 101,400 608,400
7 FAM
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix vcm 10 176 1,760
Kasa bh 30 350 10,500
Masker bh 5 400 2,000
Mess 15 bh 2 4,500 9,000
Oksigen nasal 1,500
bh 1 1,500
/masker
Syringe 10 bh 3
Syringe 5 bh 2
Syringe 3 bh 1 1,300 2,600
monofilamen
sct 1 4,500 4,500
absorbable 2.0
Alkohol 50 42,050 2,102,500
Fentanyl amp 1
Hibiscrub cc 100
Isoflurane cc 30
Midazolam / Milloz amp 1
Oksigen lpm 3
Ondancetron 1
Pethidin amp 1
Povidon 300
PZ fles 1 5,550 5,550
RL fles 2 4,300 8,600
propofol amp 1 16,200 16,200
WFI amp 1 2,800 2,800
Alkohol swab bh 6 800 4,800
8 COLLOSTOMI
a
Sat.
Electroda bh 4 6,300 25,200
Glove Gammex 7,5 bh 2 7,000 14,000
Glove Gammex 7 bh 2
Hypafix bh 10 65 650
Kasa bh 30 350 10,500
Masker bh 5 93,100 465,500
Mess 20 bh 1 70,700 70,700
Mess 11 bh 1
bh 1 12,750
/masker
Spinocam 25 bh 1 10,000 10,000
Syringe bh 2 1,300 2,600
Polisorb 3.0 sct 2 72,000 144,000
Polisorb 1 sct 1
Alkohol cc 50 14,000 700,000
Hibiscrub cc 100 4,300 430,000
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 3
RL amp 3 12,300 36,900
colostomi bag bh 1 10,400 10,400
kasa laparatomi bh 1 800 800
alkohol swab bh 6
9 HEMOROID
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 12,750 127,500
Kasa bh 20 22,800 456,000
Masker bh 5 350 1,750
Mess 10 bh 2 2,000 4,000
Oksigen nasal
bh 1 71,500 71,500
/masker
Spinocam 25 bh 1 47,400 47,400
Syringe 10 bh 1 1,300 2,600
Syringe 3 bh 1
Polisorb 2.0 sct 1 4,300 4,300

Alkohol cc 50 2,300 115,000
Hibiscrub cc 100 15,000 1,500,000
Lidodex amp 1 800 800
Oksigen lpm 2 10,300 20,600
Povidon cc 300
PZ fles 1
RL amp 1
10 POLIP RECTI
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 500 5,000
Kasa bh 20 2,000 40,000
Masker bh 5 71,500 357,500
Mess 10 bh 2 47,400 94,800
Oksigen nasal
bh 1 1,300 2,600
/masker
Spinocam 25 bh 1 1,100 1,100
Syringe 3 bh 1 4,300 4,300
Syringe 10 bh 1
Polisorb 2.0 sct 1 15,000 15,000
Siede 800
sct 1 800
atraumatikn2.0
Alkohol cc 50 10,300 515,000
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 1
RL amp 1
11 FISTEL
a Material Bedah
Sat.
Electroda bh 4 71,500 286,000
Glove Gammex 7.5 bh 2 2,300 4,600
Glove Gammex 7 bh 2
Hypafix bh 10 7,000 70,000
Kasa bh 20 400 8,000
Masker bh 5 1,300 2,600
Mess 11 bh 1 1,100 1,100
Oksigen nasal
bh 1 21,300 21,300
/masker
Spinocam 25 bh 1 4,300 4,300
Syringe 10 bh 2 12,300 24,600
Syringe 3 bh 1
Polisorb 2.0 sct 1 300 300
Siede atraumatik 2.0 sct 1 350 350

Alkohol cc 50 22,800 1,140,000
Epineprin amp 1 800 800
Hibiscrub cc 100 10,300 1,030,000
Oksigen lpm 2 -
Ondancetron amp 1
Povidon cc 300
PZ fles 1
RL amp 1
12 TUMOR PAROTIS
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 79,900 799,000
Kasa bh 30 6,300 189,000
Masker bh 5 1,300 2,600
Mess 10 bh 1 1,100 1,100
Oksigen nasal 350
bh 1 350
/masker
Syringe 10 bh 3
Syringe 5 bh 2
Syringe 3 bh 1 7,000 7,000
Polisorb 3.0 sct 1 31,500 31,500
Nylon 3.0 sct 1
Alkohol 50 72,000 3,600,000
Fentanyl amp 1 4,500 4,500
Hibiscrub cc 100 42,050 4,205,000
hibicet cc 50
Isoflurane cc 30 11,300 339,000
Oksigen lpm 3 14,000 42,000
Povidon 300 34,300 10,290,000
PZ fles 1 800 800
RL fles 2 10,300 20,600
propofol amp 1
WFI amp 1
Alkohol swab bh 6
13 HIDROCELE
a
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 1,100 1,100
Kasa bh 20 350 7,000
Masker bh 5 400 2,000
Mess 10 bh 2 7,000 14,000
Oksigen nasal
bh 1 31,700 31,700
/masker
Spinocam 25 bh 1 12,750 12,750
Syringe 10 bh 1 12,750 12,750
Syringe 3 bh 1
Polisorb 2.0 sct 1 2,300 2,300
Siede atraumatik2.0 sct 1 15,000 15,000
Alkohol cc 50 21,300 1,065,000
Hibiscrub cc 100 71,500 7,150,000
Oksigen lpm 2 12,300 24,600
Ondancetron amp 1 800 800
Povidon cc 300 10,300 3,090,000
PZ fles 1 4,300 4,300
RL amp 1
14 GIANT LIPOMA
a
Sat.
Glove Gammex 7 bh 2
Hypafix cm 10 31,700 317,000
Kasa bh 30 350 10,500
Masker bh 5 1,300 2,600
Mess 10 bh 1 1,100 1,100
Oksigen nasal
bh 1 400 400
/masker
Syringe 10 bh 2
Syringe 5 bh 2 2,000 4,000
monoflilamen
sct 1 4,500 4,500
absorbable 2.0
Alkohol 50 42,050 2,102,500
Hibiscrub cc 100 4,300 430,000
Oksigen lpm 3 800 2,400
Pethidin amp 1 12,700 12,700
Povidon 300
PZ fles 1
RL fles 2
propofol amp 1
WFI amp 1
Alkohol swab bh 6
15 DEBRIDEMENT
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix cm 10 1,300 2,600
Kasa bh 30 1,100 1,100
Masker bh 5 31,700 158,500
Mess 20 bh 2 350 700
Oksigen nasal
bh 1 400 400
/masker
Syringe 10 bh 3 2,000 6,000
Syringe 5 bh 2
Syringe 3 bh 1
Siede atraumatik 1 sct 1
Alkohol 50 42,050 2,102,500
Hibiscrub cc 100 4,300 430,000
Pethidin amp 1 12,700 12,700
Povidon 300
PZ fles 2
RL fles 2
pehidrol cc 50
propofol amp 1
WFI amp 1
Alkohol swab bh 6
16 CHOLELITHIASIS
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 30 350 10,500
Kasa bh 30 400 12,000
Masker bh 5 1,300 2,600
Mess 20 bh 1 1,100 1,100
Syringe 10 bh 4 21,300 85,200
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 2.0 sct 1 8,000 8,000
Polisorb 1 sct 1 42,050 42,050
Alkohol cc 50 5,550 277,500
Hibiscrub cc 100 5,300 530,000
Povidon cc 300 12,700 3,810,000
PZ fles 2
RL amp 3
kasa laparatomi bh 2
Isoflurane cc 50
Oksigen lpm 3
Ondancetron 1
Pethidin amp 1
Povidon 300
PZ fles 2
RL fles 3
propofol amp 1
WFI amp 1
Alkohol swab bh 6
17 MILES PROSEDUR
a
Sat.
Glove Gammex 7 bh 1
Glove Gammex 6 bh 1
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 7,000 35,000
Mess 10 bh 1 1,300 2,600
Oksigen nasal
bh 1 1,100 1,100
/masker
Syringe 10 bh 4 21,300 85,200
Syringe 5 bh 3
Syringe 3 bh 1
Nylon 3.0 sct 1 8,000 8,000
Polisorb 3.0 sct 2 42,050 84,100
Alkohol cc 50 5,550 277,500
Hibiscrub cc 100 5,300 530,000
Povidon cc 300 12,700 3,810,000
PZ fles 3
RL amp 3
Isoflurane cc 50
Oksigen lpm 3
Ondancetron 1
Pethidin amp 1
Povidon 300
PZ fles 2
RL fles 2
propofol amp 1
WFI amp 1
Alkohol swab bh 6
18 FIBROMA PEDIS
a Material Bedah
Sat.
Glove Gammex bh 5 300 1,500
Hypafix bh 10 350 3,500
Kasa bh 20 1,300 2,600
Masker bh 5 1,100 1,100
Mess bh 2 400 800
Oksigen nasal
bh 1 4,500 4,500
/masker
Spinocam bh 1 2,000 2,000
Syringe bh 2 21,300 42,600
Polisorb sct 3 8,000 24,000
Siede atraumatik sct 2 42,050 84,100
monofilament
sct 1
absorbable 2.0
Alkohol cc 50 12,300 615,000
Hibiscrub cc 100 4,300 430,000
Povidon cc 300 10,300 3,090,000
PZ fles 1 12,700 12,700
RL amp 1
1 BPH
a BPH (OPEN)
a Material Bedah
Sat.
Glove unsteril bh 5 65 325
Hypafix bh 10 1,100 1,100
Kasa bh 30 350 10,500
Masker bh 5 400 2,000
Mess 10 bh 2 22,800 45,600
Oksigen nasal
bh 1 52,000 52,000
/masker
Spinocam 25 bh 1 31,700 31,700
Syringe 3 bh 1 12,750 12,750
Syringe 5 bh 1
Syringe 10 bh 1
Nylon 3.0 sct 1 71,500 71,500
Polisorb 2.0 sct 1 47,400 47,400
Alkohol cc 50 21,300 1,065,000
Hibiscrub cc 100 11,300 1,130,000
Oksigen lpm 2 15,000 30,000
Povidon cc 300 7,500 2,250,000
PZ fles 3 34,300 102,900
RL amp 3 800 2,400
kasa laparatomi bh 1 10,300 10,300
b BPH (TURP)
a Material Bedah
Nama ObatSat Keb Harga Total
Sat.
Glov
Electr
e bh 4 300 1,200
oda
Glov
Game bh 5 350 1,750
Glov
mex
Gam bh
e
7
mex
Glov
Gam bh
7,5
e
mex 2,000
Hans bh 5 400
unste
8
aplas
ril bh 1 7,000 7,000
Hypat 20,000
bh 10 2,000
fix
Kasa bh 20 2,300 46,000
Mask 2,600
bh 5 1,300
er
Oksig
Mess
en bh 1 1,100 1,100
10
nasal
Spino bh 1 12,500 12,500
/mas
cam bh 1 125,000 125,000
ker
Syrin
25 30,000
bh 2 15,000
ge
Syrin 3
bh 1
ge 5
Syrin
Topi bh 1
ge 10
dispo bh 5 21,300 106,500
Alkoh
sable 1,100,000
cc 50 22,000
ol
Epine
amp 1 11,300 11,300
prin
Hibis
cc 100 12,300 1,230,000
crub
Lidod
amp 1 5,550 5,550
ex
Oksig
Onda lpm 2 9,650 19,300
en
ncetr amp 1 4,300 4,300
Povid
on 10,290,000
cc 300 34,300
on
PZ fles 1 8,600 8,600
RL amp 1 65,000 65,000
urine bag bh 1 32,600 32,600
blood set bh 1 800 800
underpad bh 1 7,500 7,500
ky jelli sct 2
threeway cath bh20 1
a BATU URETER (OPEN)
a Material Bedah
Sat.
1 bh 4 116,400 465,600
Glove Gammex 8 bh 1 79,900 79,900
Glove Gammex 7 bh 2
Hypafix bh 10 7,000 70,000
Kasa bh 20 300 6,000
Masker bh 5 65 325
Mess 11 bh 1 31,700 31,700
Mess 20 bh 1
bh 1 31,700
/masker
Spinocam 26 bh 1 1,300 2,600
Syringe 3 bh 1 1,100 1,100
Syringe 5 bh 2
Syringe 10 bh 2
Polisorb 3.0 sct 1 2,000 2,000
Polisorb 1 sct 1
Alkohol cc 50 21,300 1,065,000
Hibiscrub cc 100 71,500 7,150,000
Lidodex amp 1 29,500 29,500
Oksigen lpm 2 11,300 22,600
Povidon cc 300 9,650 2,895,000
PZ fles 1 4,300 4,300
RL amp 1 34,300 34,300
urine bag tube 1 800 800
blood set bh 1 10,300 10,300
underpad bh 1 7,500 7,500
ky jelli sct 2
foley cath bh 1
urine bag bh 1
NGT 10 bh 1
Dj Stend bh 1
b BATU URETER (URS)
a Material Bedah

Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 350 3,500
Kasa bh 20 71,500 1,430,000
Masker bh 5 22,000 110,000
Oksigen nasal 1,100
bh 1 1,100
/masker
Spinocam 25 bh 1 15,000 15,000
Syringe 10 bh 1
Syringe 5 bh 2
Syringe 3 bh 1 2,300 2,300
Alkohol cc 50 7,500 375,000
Hibiscrub cc 100 12,300 1,230,000
Lidodex amp 1 12,500 12,500
Oksigen lpm 2 9,900 19,800
Povidon cc 300 32,600 9,780,000
WFI 1000 fles 1 800 800
RL amp 1 150,000 150,000
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
Folley cath 16 sct 1
dj stent/ureter cathete sct 1
a BATU BULI-BULI (OPEN)
a Material Bedah
Sat.
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 1,300 2,600
Mess 10 bh 2 1,100 1,100
Oksigen nasal
bh 1 7,000 7,000
/masker
Spinocam 25 bh 1 31,700 31,700
Syringe 10 bh 2 12,750 25,500
Syringe 5 bh 1
Syringe 3 bh 1
Polisorb 2.0 sct 1 2,300 2,300
monofilament
sct 1
absorbable 3.0
Alkohol cc 50 21,300 1,065,000
Hibiscrub cc 100 4,500 450,000
Lidodex amp 1 11,300 11,300
Oksigen lpm 2 12,300 24,600
Povidon cc 300 34,300 10,290,000
PZ fles 1 7,500 7,500
RL amp 1 800 800
urine bag tube 1 10,300 10,300
blood set bh 1 71,500 71,500
underpad bh 1
ky jelli sct 2
foley cath 16 bh 1
b BATU BULI-BULI (LITHOTRIPSI)
a Material Bedah
Sat.
Electroda bh 4 300 1,200
Hypafix bh 10 1,100 1,100
Kasa bh 20 8,500 170,000
Masker bh 5 2,000 10,000
bh 1 12,500
/masker
Spinocam 25 bh 1 49,900 49,900
Syringe 10 bh 2 21,300 42,600
Syringe 5 bh 2
Syringe 3 bh 1
Alkohol cc 50 12,300 615,000
Hibiscrub cc 100 32,600 3,260,000
Ondancetron amp 1
Povidon cc 300
PZ fles 1
RL amp 1
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
foley cath bh 1
NGT 10 bh 1
b Dj Stend bh 1
c - CA Buli (TURP)
a Material Bedah
Sat.
Hypafix bh 10 1,100 1,100
Kasa bh 20 8,500 170,000
Masker bh 5 2,000 10,000
Oksigen nasal
bh 1 12,500 12,500
/masker
Spinocam 25 bh 1 49,900 49,900
Syringe 10 bh 2 21,300 42,600
Syringe 5 bh 2
Syringe 3 bh 1
Alkohol cc 50 12,300 615,000
Hibiscrub cc 100 32,600 3,260,000
Ondancetron amp 1
Povidon cc 300
PZ fles 1
RL amp 1
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
threeway cath 20 bh 1
4 STRICTURA URETRA (Sachze)
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 1,300 2,600
Kasa bh 20 1,100 1,100
Masker bh 5 7,000 35,000
Oksigen nasal 2,300
bh 1 2,300
/masker
Spinocam 25 bh 1 12,500 12,500
Syringe 10 bh 1 66,550 66,550
Syringe 5 bh 2
Syringe 3 bh 2
Alkohol cc 50 11,300 565,000
Hibiscrub cc 100 5,550 555,000
Povidon cc 300 8,600 2,580,000
PZ fles 1 65,000 65,000
RL amp 1 32,600 32,600
urine bag tube 1 800 800
blood set bh 1 7,500 7,500
underpad bh 1
ky jelli sct 2
foley cath 16 bh 1
5 BATU URETRA
a Material Bedah
Sat.
Hypafix bh 10 1,100 1,100
Kasa bh 30 7,000 210,000
Masker bh 5 2,000 10,000
bh 1 12,500
/masker
Spinocam 25 bh 1 49,900 49,900
Syringe 10 bh 1 21,300 21,300
Syringe 5 bh 2
Syringe 3 bh 2
Alkohol cc 50 12,300 615,000
Hibiscrub cc 100 32,600 3,260,000
Ondancetron amp 1
Povidon cc 300
PZ fles 1
RL amp 1
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
foley cath 16 bh 1
NGT 10 bh 1
Dj Stend bh 1
6 BATU GINJAL
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 1,300 2,600
Kasa bh 40 1,100 1,100
Masker bh 5 350 1,750
Mess 20 bh 1 400 400
Mess 11 bh 1
Oksigen nasal
bh 1 7,000 7,000
/masker
Spinocam 26 bh 1 31,700 31,700
Syringe 10 bh 1 12,750 12,750
Syringe 5 bh 2
Syringe 3 bh 2
Syringe 50 bh 1
Polisorb 1 sct 2 2,000 4,000
Polisorb 3.0 sct 1

cromic blunt point 2 sct 2
Alkohol cc 50 49,900 2,495,000
Hibiscrub cc 100 23,000 2,300,000
Lidodex amp 1 21,300 21,300
dekain amp 1
Oksigen lpm 2 29,500 59,000
Povidon cc 300 8,000 2,400,000
PZ fles 1 42,050 42,050
RL amp 1 11,300 11,300
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
foley cath 16 bh 1
NGT 10 bh 1
Dj Stend bh 1
7 HYPOSPADIA
a Material Bedah
Sat.
Hypafix bh 10 400 4,000
Kasa bh 30 1,300 2,600
Masker bh 5 1,100 1,100
Mess 10 bh 2 7,000 14,000
Oksigen nasal
bh 1 12,750 12,750
/masker
Spinocam 26 bh 1 105,500 105,500
Syringe 10 bh 2
Syringe 5 bh 2
Syringe 3 bh 1 2,000 2,000
Polisorb 5.0 sct 1 49,900 49,900
polisorb 4.0 sct 1 21,300 21,300
nylon 4.0 sct 1
Alkohol cc 50 4,500 225,000
Hibiscrub cc 100 42,050 4,205,000
Lidodex amp 1 12,300 12,300
Povidon cc 300 2,800 840,000
PZ fles 1 7,500 7,500
RL amp 1 12,700 12,700
8 VARICOCEL
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 400 4,000
Kasa bh 30 7,000 210,000
Masker bh 5 31,700 158,500
Mess 10 bh 2 12,750 25,500
Oksigen nasal
bh 1 12,750 12,750
/masker
Spinocam 25 bh 1 2,000 2,000
Syringe 10 bh 1 2,300 2,300
Syringe 5 bh 2
Syringe 3 bh 2
Polisorb 3.0 sct 1 1,300 2,600
Polisorb 2.0 sct 1

Alkohol cc 50 21,300 1,065,000
Hibiscrub cc 100 71,500 7,150,000
Oksigen lpm 2 12,300 24,600
Povidon cc 300 10,300 3,090,000
PZ fles 1 4,300 4,300
2 RL amp 1
9 AFF DJ STAND
a Material Bedah
Sat.
Hypafix bh 10 15,000 150,000
Kasa bh 20 1,300 2,600
Masker bh 5 1,100 1,100
Oksigen nasal
bh 1 42,050 42,050
/masker
Spinocam 25 bh 1 4,300 4,300
Syringe 10 bh 1 2,800 2,800
Syringe 5 bh 1
Syringe 3 bh 1
Alkohol cc 50
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
blood set cc 1
WFI 1000 fles 1
RL amp 1
10 EXTRAKSI BATU URETRA
a Material Bedah
Sat.
Glove Gammex bh 5 350 1,750
Hypafix bh 10 15,000 150,000
Kasa bh 30 21,300 639,000
Masker bh 5 1,300 2,600
Mess 20 bh 1 1,100 1,100
Mess 11 bh 1
Oksigen nasal
bh 1 42,050 42,050
/masker
Spinocam 25 bh 1 4,300 4,300
Syringe 10 bh 1 2,800 2,800
Syringe 5 bh 2
Syringe 3 bh 2
Polisorb 3.0 sct 1 18,800 18,800
polisorb 2.0 sct 1
Alkohol cc 50
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
foley cath 16 bh 1
urine bag bh 1
Povidon cc 300
PZ fles 1
b RL amp 1
1 SINUSITIS / Polip Nasal
a Material Bedah
Sat.
Glove Gammex 7 bh 1
Hypafix bh 10 250 2,500
Kasa bh 30 8,500 255,000
Masker bh 5 1,300 2,600
Oksigen nasal
bh 1 2,000 2,000
/masker
Spinocam 25 bh 1 8,000 8,000
Syringe 10 bh 1 42,050 42,050
Syringe 5 bh 2
Syringe 3 bh 2
Syringe 50 bh 2
Alkohol 50 4,300 215,000
Fentanyl amp 1 16,200 16,200
Hibiscrub cc 100 2,800 280,000
Oksigen lpm 3 3,500 10,500
Pethidin amp 1
Povidon 300
PZ fles 1
RL fles 2
propofol amp 1
WFI amp 1
Alkohol swab bh 6
2 TONSILITIS
a Material Bedah
Sat.
Hypafix bh 10 7,000 70,000
Kasa bh 30 1,300 2,600
Masker bh 5 1,100 1,100
Mess 11 bh 2 2,000 4,000
Oksigen nasal
bh 1 2,000 2,000
/masker
Syringe 10 bh 2
Syringe 5 bh 2
Syringe 3 bh 1 23,000 23,000
Polisorb 3.0 sct 1 42,050 42,050

Alkohol 50 5,550 277,500
Hibiscrub cc 100 16,200 1,620,000
Oksigen lpm 3 12,700 38,100
Ondancetron 1
Pethidin amp 1
Povidon 300
PZ fles 1
RL fles 2
propofol amp 1
WFI amp 1
Alkohol swab bh 6
1 SECSIO CAESAR
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hansaplast bh 1 116,400 116,400
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 1,300 2,600
Mess 20 bh 1 1,100 1,100
Oksigen nasal
bh 1 7,000 7,000
/masker
Spinocam 25 bh 1 31,750 31,750
Syringe 10 bh 2 12,750 25,500
Syringe 5 bh 1
Syringe 3 bh 2
plain2.0 sct 1 2,300 2,300
Polisorb 1 sct 1 15,000 15,000
monofilament
sct 1
absorbable 1
monofilament
sct 1 21,300 21,300
absorbable 3.0
Alkohol cc 50 47,400 2,370,000
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 3
RL amp 3
. . induxin amp 2
2 MYOMA UTERI
a Material Bedah
Sat.
Hansaplast bh 1 116,400 116,400
Hypafix bh 10 1,300 2,600
Kasa bh 30 1,100 1,100
Masker bh 5 350 1,750
Mess 20 bh 1 400 400
Oksigen nasal 7,000
bh 1 7,000
/masker
Spinocam 25 bh 1 2,000 2,000
Syringe 10 bh 2 31,700 63,400
Syringe 5 bh 1
Syringe 3 bh 1
plain 2.0 sct 1 10,000 10,000
Polisorb 1 sct 1 2,300 2,300
monofilament
sct 1 15,000 15,000
absorbable 1
monofilament
sct 1
absorbable 3.0
cromic 2 sct 5
siede 2 sct 2
Alkohol cc 50 21,300 1,065,000
Hibiscrub cc 100 71,500 7,150,000
Lidodex amp 1 22,000 22,000
Povidon cc 300 12,300 3,690,000
PZ fles 3 800 2,400
RL amp 3 103,300 309,900
3 PROLAP UTERI
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hansaplast bh 1 116,400 116,400
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 1,300 2,600
Mess 20 bh 1 1,100 1,100
Oksigen nasal 7,000
bh 1 7,000
/masker
Spinocam 25 bh 1 2,000 2,000
Syringe 10 bh 2 31,700 63,400
Syringe 5 bh 1
Syringe 3 bh 1
cromic 2 sct 1 10,000 10,000
Polisorb 1 sct 1 2,300 2,300
siede 2 sct 1 15,000 15,000
Alkohol cc 50 21,300 1,065,000
Hibiscrub cc 100 71,500 7,150,000
Lidodex amp 1 22,000 22,000
Povidon cc 300 12,300 3,690,000
PZ fles 3 800 2,400
RL amp 3 10,300 30,900
a
Sat.
Electroda bh 4 22,800 91,200
Glove Gammex 8 bh 1 116,400 116,400
Hypafix bh 10 350 3,500
Kasa bh 30 1,300 2,600
Masker bh 5 1,100 1,100
Mess 20 bh 1 400 400
Oksigen nasal 7,000
bh 1 7,000
/masker
Spinocam 25 bh 1 31,700 31,700
Syringe 10 bh 2 12,750 25,500
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 1 sct 1
cromic 2 sct 2
siede 2 sct 2
monofilamen
sct 1
absorbable 3.0
Alkohol cc 50
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1 49,900 49,900
Oksigen lpm 2 15,000 30,000
Povidon cc 300 47,400 14,220,000
PZ fles 3 71,500 214,500
RL amp 3 22,000 66,000
5 KET
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hansaplast bh 1 116,400 116,400
Hypafix bh 10 1,300 2,600
Kasa bh 30 1,100 1,100
Masker bh 5 350 1,750
Mess 20 bh 2 400 800
Oksigen nasal
bh 1 7,000 7,000
/masker
Spinocam 26 bh 1 31,700 31,700
Syringe 10 bh 2 12,750 25,500
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 1 sct 1
monofilament
sct 1
absorbable 3.0
Alkohol cc 50
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Povidon cc 300
PZ fles 3
. . RL amp 3
6 CURETTAGE
a Material Bedah
Sat.
Glove Gammex 5 bh 2
Glove Gammex 3 bh 1
Glove unsteril bh 5
Hypafix bh 10
Kasa bh 30
Masker bh 5
Mess 20 bh 1
Oksigen nasal
bh 1
/masker
Spinocam 25 bh 1
Syringe 10 bh 2
Syringe 5 bh 2
Syringe 3 bh 1
Topi disposable bh 5
Alkohol 50
Atracrium / Tracrium 1
Fentanyl amp 1
Hibiscrub cc 100
Isoflurane cc 30
Oksigen lpm 3
Ondancetron 1
Povidon 300 2,000 600,000
PZ fles 1 15,000 15,000
RL fles 2 1,300 2,600
propofol amp 1 21,300 21,300
WFI amp 1 42,050 42,050
Alkohol swab bh 6 4,300 25,800
. Fr. Femur
a. Open
a Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 1,300 2,600
Kasa bh 40 1,100 1,100
Masker bh 5 350 1,750
Mess 10 bh 1 400 400
mess 20 bh 1
Oksigen nasal
bh 1 250 250
/masker
Spinocam 25 bh 1 2,000 2,000
Syringe 3 bh 2 31,700 63,400
Syringe 10 bh 3
Syringe 5 bh 2
Polisorb 1 sct 2 2,300 4,600
Polisorb 0 sct 1
Polisorb 2.0 sct 2
nilon 0 sct 1 21,300 21,300
siede atraumatik 2.0 sct 1
Alkohol cc 50 47,400 2,370,000
hibicet cc 100
Hibiscrub cc 100 22,000 2,200,000
Oksigen lpm 2 11,300 22,600
Povidon cc 300 14,000 4,200,000
PZ fles 5 9,650 48,250
RL amp 1 5,300 5,300
pehidrol cc 100
blood set bh 1 800 800
underpad bh 1 10,300 10,300
ky jelli sct 2 34,300 68,600
foley cath no 16 bh 1
kasa hidrofil 15 cm bh 2
sufratule bh 1
softband 6 inc bh 1
tensocrepe 6 inc bh 1
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 116,400 232,800
Hypafix bh 10 400 4,000
Kasa bh 40 250 10,000
Masker bh 5 2,000 10,000
Mess bh 2 31,700 63,400
Oksigen nasal
bh 1 4,500 4,500
/masker
Spinocam 25 bh 1 12,750 12,750
Syringe 3 bh 2 2,300 4,600
Syringe 10 bh 3 21,300 63,900
Syringe 5 bh 2 47,400 94,800
Polisorb 1 sct 2 22,000 44,000
Polisorb 0 sct 1 4,500 4,500
Polisorb 2.0 sct 2
nilon 0 sct 1
Alkohol cc 50
hibicet cc 100
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
. . PZ fles 5
RL amp 1
pehidrol cc 100 11,300 1,130,000
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
sufratule bh 1
softband 6 inc bh 1
2 Fr. Cruris/Tibia
a OPEN
a Material Bedah
Sat.
Glove Gammex 7 bh 2 1,300 2,600
Hypafix bh 10 31,700 317,000
Kasa bh 30 12,750 382,500
Masker bh 5 2,300 11,500
Mess 10 bh 1 15,000 15,000
mess 20 bh 1
Oksigen nasal
bh 1 21,300 21,300
/masker
Spinocam 25 bh 1 47,400 47,400
Syringe 3 bh 2 71,500 143,000
Syringe 10 bh 3 4,500 13,500
Syringe 5 bh 2 11,300 22,600
Polisorb 3.0 sct 1 14,000 14,000
Polisorb 2.0 sct 2 9,650 19,300
nilon 2.0 sct 1 4,300 4,300
Alkohol cc 50 10,300 515,000
hibicet cc 100 67,000 6,700,000
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
pehidrol cc 100
urine bag tube 1
underpad bh 1
sufratule bh 1
softband 6 inc bh 1
. CLOSE
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 1,300 2,600
Hypafix bh 10 31,700 317,000
Kasa bh 30 12,750 382,500
Masker bh 5 15,000 75,000
Mess 10 bh 1 21,300 21,300
mess 20 bh 1 2,300 2,300
bh 1 47,400
/masker
Spinocam 25 bh 1 71,500 71,500
Syringe 3 bh 2 4,500 9,000
Syringe 10 bh 3 10,400 31,200
Syringe 5 bh 2 12,300 24,600
Polisorb 2.0 sct 2 10,300 20,600
nilon 2.0 sct 1
Alkohol cc 50
hibicet cc 100
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
pehidrol cc 100
urine bag tube 1
underpad bh 1
sufratule bh 1
softband 6 inc bh 1
softband 6 inc bh 1
3 Fr. ANTEBRACHII
. - OPEN
a
Sat.
Glove Gammex 7 bh 2
Kasa bh 20 1,100 1,100
Masker bh 5 7,000 35,000
Mess 10 bh 1 2,000 2,000
Mess 20 bh
Oksigen nasal
bh 1 31,700 31,700
/masker
Syringe 10 bh 4
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 2.0 sct 2
Polisorb 3.0 sct 2
nilon 3.0 sct 1
Alkohol cc 50
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
pehidrol cc 50
. . PZ fles 5
RL amp 1
sufratule bh 2 42,050 84,100
softband 4 inc bh 1 10,400 10,400
tensocrepe 4 inc bh 1 12,300 12,300
Atracrium / Tracrium amp 1 14,000 14,000
WFI amp 1 10,300 10,300
arm sling bh 1
. CLOSE
a Material Bedah
Sat.
Kasa bh 20 350 7,000
Masker bh 5 7,000 35,000
Mess 10 bh 1 8,000 8,000
Mess 20 bh 42,050 -
Oksigen nasal
bh 1 2,000 2,000
/masker
Syringe 10 bh 4 21,300 85,200
Syringe 5 bh 2 4,500 9,000
Syringe 3 bh 1 11,300 11,300
Polisorb 2.0 sct 2
Polisorb 3.0 sct 2
nilon 3.0 sct 1
Alkohol cc 50
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
pehidrol cc 50
PZ fles 5
RL amp 1
sufratule bh 2
softband 4 inc bh 1 14,000 14,000
Isoflurane cc 30 16,200 486,000
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
arm sling bh 1
Alkohol swab bh 6
4 Fr. ANTEBRACHII
. - GIPS
a Material Bedah
Sat.
Electroda bh 4
Glove unsteril bh 5
Kasa bh 10
Masker bh 5
Oksigen nasal
bh 1
/masker
Syringe bh 5
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
PZ fles 5
RL amp 1
softband 4 inc bh 1
armsling bh 1
gipsona 4 inc bh 3 2,000 6,000
Pethidin amp 1 23,000 23,000
WFI amp 1 2,800 2,800
5 Fr. PATELLA
. - OPEN
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 116,400 232,800
Hypafix bh 10 6,300 63,000
Kasa bh 30 2,000 60,000
Masker bh 5 350 1,750
Mess 10 bh 1 12,750 12,750
mess 20 bh 1 31,700 31,700
Oksigen nasal
bh 1
/masker
Spinocam 25 bh 1
Syringe 3 bh 2
Syringe 10 bh 3
Syringe 5 bh 2
Polisorb 3.0 sct 1
Polisorb 2.0 sct 2
nilon 2.0 sct 1
Alkohol cc 50
. . hibicet cc 100
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300 72,000 21,600,000
PZ fles 5 21,300 106,500
RL amp 1 4,500 4,500
pehidrol cc 100 8,000 800,000
underpad bh 1 11,300 11,300
sufratule bh 1 12,300 12,300
softband 6 inc bh 1
. CLOSE
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 116,400 232,800
Glove Gammex 7 bh 2 31,700 63,400
Hypafix bh 10 350 3,500
Kasa bh 30 1,300 2,600
Masker bh 5 1,100 1,100
Mess 10 bh 1 7,000 7,000
mess 20 bh 1 2,000 2,000
Oksigen nasal
bh 1 72,000 72,000
/masker
Spinocam 25 bh 1 21,300 21,300
Syringe 3 bh 2 4,500 9,000
Syringe 10 bh 3 8,000 24,000
Syringe 5 bh 2 42,050 84,100
Polisorb 3.0 sct 1 12,300 12,300
Polisorb 2.0 sct 2
nilon 2.0 sct 1
Alkohol cc 50
hibicet cc 100
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
. . RL amp 1
urine bag tube 1
underpad bh 1
sufratule bh 1
softband 6 inc bh 1
6 Fr. CLAVICULA
. - OPEN
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 22,800 45,600
Glove Gammex 7 bh 2 12,750 25,500
Kasa bh 20 1,300 2,600
Masker bh 5 1,100 1,100
Mess 10 bh 1 400 400
Mess 20 bh 31,700 -
Oksigen nasal
bh 1 2,000 2,000
/masker
Syringe 10 bh 4
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 2.0 sct 2
Polisorb 3.0 sct 2
nilon 3.0 sct 1
Alkohol cc 50
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
pehidrol cc 50 72,000 3,600,000
PZ fles 5 21,300 106,500
RL amp 1 4,500 4,500
sufratule bh 2 11,300 22,600
Fentanyl amp 1 16,200 16,200
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
arm sling bh 1
Alkohol swab bh 6
. CLOSE
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 22,800 45,600
Kasa bh 20 1,100 1,100
Masker bh 5 350 1,750
Mess 10 bh 1 400 400
Mess 20 bh 7,000 -
Oksigen nasal
bh 1 2,000 2,000
/masker
Syringe 10 bh 4 31,700 126,800
Syringe 5 bh 2 12,750 25,500
Syringe 3 bh 1 72,000 72,000
Polisorb 2.0 sct 2 4,500 9,000
Polisorb 3.0 sct 2 8,000 16,000
nilon 3.0 sct 1 11,300 11,300
Alkohol cc 50 12,300 615,000
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
sufratule bh 2
Atracrium / Tracrium amp 1
Fentanyl amp 1
. . Isoflurane cc 30
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
arm sling bh 1
Alkohol swab bh 6
7 Fr. Humerus
. - OPEN
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 1,300 2,600
Kasa bh 20 300 6,000
Masker bh 5 93,100 465,500
Mess 10 bh 1 2,000 2,000
Mess 20 bh 6,300 -
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 4
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 2.0 sct 2
Polisorb 3.0 sct 2
nilon 3.0 sct 1
. . Alkohol cc 50
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300 21,300 6,390,000
pehidrol cc 50 2,000 100,000
PZ fles 5 72,000 360,000
RL amp 1 4,500 4,500
sufratule bh 2 8,000 16,000
softband 4 inc bh 1 42,050 42,050
Fentanyl amp 1 14,000 14,000
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
arm sling bh 1
Alkohol swab bh 6
. CLOSE
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 93,100 186,200
Kasa bh 30 1,300 2,600
Masker bh 5 1,100 1,100
Mess 10 bh 1 7,000 7,000
Mess 20 bh 2,000 -
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 4 2,000 8,000
Syringe 5 bh 2 72,000 144,000
Syringe 3 bh 1 21,300 21,300
Polisorb 2.0 sct 2 8,000 16,000
Polisorb 3.0 sct 2 42,050 84,100
nilon 3.0 sct 1 11,300 11,300
Alkohol cc 50 12,300 615,000
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
. . sufratule bh 2
softband 4 inc bh 1
Fentanyl amp 1
Isoflurane cc 30
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
arm sling bh 1
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 6,300 12,600
Kasa bh 30 1,100 1,100
Masker bh 5 7,000 35,000
Mess 15 bh 1 2,000 2,000
Oksigen nasal
bh 1 4,500 4,500
/masker
Syringe 10 bh 4 2,000 8,000
Syringe 5 bh 2 21,300 42,600
Syringe 3 bh 1
Polisorb 3.0 sct 1
Alkohol cc 50
hibicet cc 100
pehidrol cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
. . Povidon cc 300
PZ fles 5
RL amp 1
sufratule bh 2
Fentanyl amp 1 10,400 10,400
Isoflurane cc 30 12,300 369,000
Pethidin amp 1
propofol amp 1
WFI amp 1
elastomul haft 4 cm bh 1
Alkohol swab bh 6
. CLOSE
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 6,300 12,600
Kasa bh 30 1,100 1,100
Masker bh 5 7,000 35,000
Mess 15 bh 1 2,000 2,000
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 4 2,000 8,000
Syringe 5 bh 2 21,300 42,600
Syringe 3 bh 1 4,500 4,500
Polisorb 3.0 sct 1 42,050 42,050
siede atraumatik 3.0 sct 2 11,300 22,600
Alkohol cc 50 12,300 615,000
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
sufratule bh 2
Fentanyl amp 1
Isoflurane cc 30
. . Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
Alkohol swab bh 6
9 Fr. METACARPAL
. - OPEN
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 6,300 12,600
Kasa bh 30 1,100 1,100
Masker bh 5 7,000 35,000
Mess 15 bh 1 2,000 2,000
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 4 2,000 8,000
Syringe 5 bh 2 21,300 42,600
Syringe 3 bh 1 4,500 4,500
Polisorb 3.0 sct 1
Alkohol cc 50
hibicet cc 100
pehidrol cc 100
Hibiscrub cc 100
Oksigen lpm 2
Povidon cc 300
PZ fles 5
RL amp 1 8,000 8,000
sufratule bh 2 42,050 84,100
Fentanyl amp 1 12,300 12,300
Isoflurane cc 30 14,000 420,000
propofol amp 1 2,800 2,800
WFI amp 1
Alkohol swab bh 6
. CLOSE
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 4,500 9,000
Kasa bh 30 1,500 45,000
Masker bh 5 300 1,500
Mess 15 bh 1 6,300 6,300
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 4 21,300 85,200
Syringe 5 bh 2 4,500 9,000
Syringe 3 bh 1 2,000 2,000
Polisorb 3.0 sct 1 42,050 42,050
Alkohol cc 50 12,300 615,000
hibicet cc 100 14,000 1,400,000
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
sufratule bh 2
Fentanyl amp 1
Isoflurane cc 30
Pethidin amp 1
propofol amp 1
WFI amp 1
Alkohol swab bh 6
10 Fr. METATARSAL
. - OPEN
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 6,300 12,600
Kasa bh 30 350 10,500
Masker bh 5 7,000 35,000
Mess 15 bh 1 2,000 2,000
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 4 2,000 8,000
Syringe 5 bh 2 21,300 42,600
Syringe 3 bh 1 4,500 4,500
Polisorb 3.0 sct 1
Alkohol cc 50
hibicet cc 100
pehidrol cc 100
Hibiscrub cc 100
. . Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5 8,000 40,000
RL amp 1 42,050 42,050
sufratule bh 2 11,300 22,600
Fentanyl amp 1 14,000 14,000
Pethidin amp 1 16,200 16,200
propofol amp 1 12,700 12,700
WFI amp 1
Alkohol swab bh 6
. CLOSE
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 7,000 14,000
Kasa bh 30 6,300 189,000
Masker bh 5 1,300 2,600
Mess 15 bh 1 1,100 1,100
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 4 21,300 85,200
Syringe 5 bh 2 4,500 9,000
Syringe 3 bh 1 2,000 2,000
Polisorb 3.0 sct 1 42,050 42,050
Alkohol cc 50 12,300 615,000
hibicet cc 100 14,000 1,400,000
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
sufratule bh 2
Fentanyl amp 1
Isoflurane cc 30
. . Midazolam / Milloz amp 1
Ondancetron amp 1
Pethidin amp 1
propofol amp 1 5,550 5,550
WFI amp 1 4,300 4,300
Alkohol swab bh 6
11 Fr. Collum Femur Non Patologis
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 116,400 232,800
Hypafix bh 10 1,100 1,100
Kasa bh 40 7,000 280,000
Masker bh 5 2,000 10,000
Mess 10 bh 1 2,300 2,300
mess 20 bh 1 49,900 49,900
Oksigen nasal
bh 1 15,000 15,000
/masker
Spinocam 25 bh 1 21,300 21,300
Syringe 3 bh 2 47,400 94,800
Syringe 10 bh 3 71,500 214,500
Syringe 5 bh 2 22,000 44,000
Polisorb 1 sct 2
Polisorb 0 sct 1
Polisorb 2.0 sct 2
nilon 0 sct 1
Alkohol cc 50
hibicet cc 100
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
PZ fles 5
RL amp 1
. . pehidrol cc 100
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
sufratule bh 1
softband 6 inc bh 1
12 DISLOKASI COLLUM FEMUR
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 1,100 1,100
Hypafix bh 10 5,300 53,000
Kasa bh 40 4,300 172,000
Masker bh 5 12,700 63,500
Oksigen nasal
bh 1 85,000 85,000
/masker
Spinocam 25 bh 1
Syringe 3 bh 2
Syringe 10 bh 3
Syringe 5 bh 2
Alkohol cc 50
hibicet cc 100
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300 x 75,000
PZ fles 5
RL amp 1
softband 6 inc bh 1
14 Angkat Plate Humerus / Femur
a
Sat.
Glove Gammex 7,5 bh 2 7,000 14,000
Kasa bh 20 400 8,000
Masker bh 5 12,750 63,750
Mess 10 bh 1 31,700 31,700
Mess 20 bh 22,800 -
Oksigen nasal
bh 1 2,000 2,000
/masker
Syringe 10 bh 4 350 1,400
Syringe 5 bh 2 71,500 143,000
Syringe 3 bh 1 47,400 47,400
Polisorb 2.0 sct 2 2,300 4,600
Polisorb 3.0 sct 2 21,300 42,600
nilon 3.0 sct 1 15,000 15,000
Alkohol cc 50 800 40,000
hibicet cc 100 10,300 1,030,000
Hibiscrub cc 100 4,500 450,000
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300
pehidrol cc 50
PZ fles 5
RL amp 1
sufratule bh 2
softband 4 inc bh 1
Fentanyl amp 1
Isoflurane cc 30
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
arm sling bh 1
Alkohol swab bh 6
15 Angkat Plate / Cruris / Tibia / Antebrachii / Patela
a Material Bedah
Sat.
Electroda bh 4
Glove Gammex 8 bh 1
Glove Gammex 7 bh 2
Glove unsteril bh 5
Hansaplast bh 1
Hypafix bh 10
Kasa bh 40
Masker bh 5
Mess 10 bh 1
mess 20 bh 1
Oksigen nasal
bh 1
/masker
Spinocam 25 bh 1
Syringe 3 bh 2
Syringe 10 bh 3
Syringe 5 bh 2
Polisorb 1 sct 2
Polisorb 0 sct 1
Polisorb 2.0 sct 2
nilon 0 sct 1
Alkohol cc 50
hibicet cc 100
Hibiscrub cc 100 7,000 700,000
Oksigen lpm 2 12,750 25,500
Povidon cc 300 22,800 6,840,000
PZ fles 5 2,000 10,000
RL amp 1 350 350
pehidrol cc 100 71,500 7,150,000
urine bag tube 1
blood set bh 1
underpad bh 1
ky jelli sct 2
sufratule bh 1
softband 6 inc bh 1
tensocrepe 6 inc bh 1 x 60,000
16 Ganglion Poplitea
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 7,000 14,000
Kasa bh 20 400 8,000
Masker bh 5 12,750 63,750
Mess 15 bh 1 31,700 31,700
Oksigen nasal
bh 1 350 350
/masker
Syringe 10 bh 4 71,500 286,000
Syringe 5 bh 2 47,400 94,800
Syringe 3 bh 1 4,300 4,300
Polisorb 2.0 sct 2 21,300 42,600
Polisorb 3.0 sct 2 15,000 30,000
nilon 3.0 sct 1 85,000 85,000
Alkohol cc 50 14,000 700,000
hibicet cc 100 800 80,000
Hibiscrub cc 100 10,300 1,030,000
Ondancetron amp 1
Povidon cc 300
pehidrol cc 50
PZ fles 5
RL amp 1
sufratule bh 2
softband 4 inc bh 1
Fentanyl amp 1
Isoflurane cc 30
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1
arm sling bh 1
Alkohol swab bh 6
22 ULCUS PLANTAR,SEPTIK (DEBRIDEMENT FRAKTUR TERBUKA)
a Material Bedah
Sat.
Kasa bh 20 12,750 255,000
Masker bh 5 250 1,250
Mess 15 bh 1 250 250
Oksigen nasal 2,300
bh 1 2,300
/masker
Syringe 10 bh 4 15,000 60,000
Syringe 5 bh 2 21,300 42,600
Syringe 3 bh 1 47,400 47,400
Polisorb 2.0 sct 2 1,100 1,100
Polisorb 3.0 sct 2 71,500 143,000
nilon 3.0 sct 1 4,500 4,500
Alkohol cc 50 11,300 565,000
hibicet cc 100 12,300 1,230,000
Hibiscrub cc 100 14,000 1,400,000
Povidon cc 300 27,500 8,250,000
pehidrol cc 50 800 40,000
PZ fles 5 10,300 51,500
RL amp 1 11,300 11,300
sufratule bh 2
. . softband 4 inc bh 1
Fentanyl amp 1
Isoflurane cc 30
Ondancetron amp 1
Pethidin amp 1 x 60,000
propofol amp 1
WFI amp 1
arm sling bh 1
Alkohol swab bh 6
23 RUPTUR TENDON
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 8,000 16,000
Glove Gammex 7 bh 2 16,200 32,400
Kasa bh 20 12,700 254,000
Masker bh 5 2,800 14,000
Mess 10 bh 1 2,000 2,000
Mess 20 bh 1
needle 18 bh 4
Oksigen nasal
bh 1 7,000 7,000
/masker
Syringe 10 bh 4 67,000 268,000
Syringe 5 bh 2 14,000 28,000
Syringe 3 bh 1 21,300 21,300
Polisorb 2.0 sct 2 11,300 22,600
nilon 3.0 sct 1 1,300 2,600
Alkohol cc 50 1,100 1,100
hibicet cc 100 65 6,500
Hibiscrub cc 100 350 35,000
Oksigen lpm 2 51,250 102,500
Povidon cc 300 36,350 10,905,000
pehidrol cc 50 27,500 1,375,000
PZ fles 5 800 4,000
RL amp 1 10,300 10,300
sufratule bh 2 4,500 9,000
softband 4 inc bh 1
Fentanyl amp 1
Isoflurane cc 30
Ondancetron amp 1
Pethidin amp 1
propofol amp 1
WFI amp 1 x 60,000
poligip 4 inc bh 1
softband 4 inc bh 1
25 C. ALIENUM JARUM
a Material Bedah
Sat.
Glove Gammex 7,5 bh 2 1,300 2,600
Kasa bh 20 16,200 324,000
Masker bh 5 5,550 27,750
Mess 10 bh 1 5,300 5,300
Mess 20 bh 1 4,300 4,300
needle 18 bh 4
Oksigen nasal
bh 1
/masker
Syringe 10 bh 4
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 2.0 sct 2
Polisorb 3.0 sct 2
nilon 3.0 sct 1
Alkohol cc 50
hibicet cc 100
Hibiscrub cc 100
Oksigen lpm 2
Ondancetron amp 1
Povidon cc 300 12,700 3,810,000
pehidrol cc 50 2,800 140,000
PZ fles 5 27,500 137,500
RL amp 1 36,350 36,350
sufratule bh 2 800 1,600
softband 4 inc bh 1
Fentanyl amp 1
Isoflurane cc 30
Ondancetron amp 1
Pethidin amp 1 x 60,000
. . propofol amp 1
WFI amp 1
1 KATARAK
a Material Bedah
Electroda bh 4
Glove Gammex 7 bh 1
Glove unsteril bh 5
Hypafix cm 10
Kasa bh 30
Masker bh 5
Mess 11 bh 1
Syringe 1 tuberculin bh 5
Syringe 3 bh 5
Syringe 5 bh 5
Blood Tranfussion
bh 2
Set
Hibiscrub cc 100 Sat.
Povidon cc 200 1,300 2,600
PZ fles 1 1,100 1,100
RL amp 2 7,000 14,000
lidocain amp 1
efrisel vial 1
medriatil vial 1
pantocain vial 1
gentamicin amp 1
lidocain amp 1
dexamethason amp 1
DISEKSI KELENJAR
Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix cm 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 4,500 22,500
Mess 15 bh 2 176 352
Oksigen nasal /masker bh 1 127 127
Syringe 10 bh 3 127 381
Syringe 5 bh 2
Syringe 3 bh 1
Polisorb 3.0 sct 1 15,000 15,000
nylon 3,0 sct 1
Alkohol 50 47,400 2,370,000
Fentanyl amp 1 22,000 22,000
Hibiscrub cc 100 1,100 1,100
Oksigen lpm 3 10,400 31,200
Pethidin amp 1 14,000 14,000
Povidon 300 5,300 1,590,000
PZ fles 1 34,300 34,300
RL fles 2 7,500 15,000
WFI amp 1 103,300 103,300
Alkohol swab bh 6 101,400 608,400
CA MAMAE SKIN GRAF
Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 4,500 22,500
Mess 10 bh 2 31,700 63,400
Oksigen nasal
bh 1 12,750 12,750
/masker
Syringe 10 bh 3 250 750
Syringe 5 bh 2
Syringe 3 bh 1
Nylon 3.0 sct 2 1,300 2,600
Alkohol 50 8,000 400,000
Fentanyl amp 1 10,400 10,400
Hibiscrub cc 100 12,300 1,230,000
Oksigen lpm 3 5,300 15,900
sutratulle bh 5
Povidon 300 34,300 10,290,000
PZ fles 1 12,700 12,700
RL fles 2 14,000 28,000
Sulfas Atropin amp 1 800 800
Trivam/recofol/savol/
amp 1 103,300 103,300
propofol
WFI amp 1 1,500 1,500
Alkohol swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi ( Post Ca Mamae) 3 x 75,000
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
Hematologi Analyzer Rp 30,000
SGOT Rp 10,000
SGPT Rp 10,000
By Akomodasi RI 1 x 30,000
Biaya Makan 1 x 42,000
Js. Pelayanan RI 1 x -
Pasang Infus 1 x 30,000
injeksi 3 x 5,000
Persiapan Operasi
By Akomodasi ICU x 75,000
Biaya Makan x 42,000
Js. Pelayanan ICU x 66,500
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Natriu fles 2 10,400 20,800
Ecosol fles 2 11,350 22,700
Etason amp 1 6,000 6,000
Spuit 2 bh 1 9,650 9,650
Spt 3 c bh 1 4,300 4,300
Spt 5 c bh 1 5,300 5,300
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Piralen amp 1 6,600 6,600
Magtra fles 1 25,000 25,000
Nerrad kap 5 2,300 11,500
Gamex bh 1 21,300 21,300
Kliran Inj 2 24,200 48,400
Paket Kemo 1,700,000
Doxorumg 1 961,000 961,000
5 FU 2 mg 1 60,500 60,500
Etason amp 1 6,000 6,000
Jasa Khemoteraphi
Dokter Ahli Bedah
Crew perawatan
Transport Ambil Obat Kemo

Adiministrasi
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 15 x 5,000
Persiapan Operasi
Huknah
Skiren
By Akomodasi ICU 2 x 75,000
Js. Pelayanan ICU 2 x 66,500
Rawat Luka 2 x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Aquadefles 2 2,000 4,000
Spt 5 c bh 3 5,300 15,900
Profeni bh 4 14,000 56,000
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Lomatulbr 1 14,000 14,000
Kasa st dos 3 8,500 25,500
Leucoprol 1 48,200 48,200
Amobiotab 10 3,000 30,000
Benost tab 10 1,300 13,000
Material Bedah
Nama
GloveObat
Sat Keb Harga Total
Electr Sat.
Gam
oda
mex bh 4 65 260
Glove
Glove
7,5
Gam bh 2 300 600
Gam
mex
Glove7 bh
mex 2
6,5
unster bh 1
ilHypaf bh 5 228 1,140
ix cm 10 350 3,500
Oksig
Kasa bh
Mask 30 400 12,000
en
er
Mess
nasal bh 5 4,500 22,500
15
/mask bh 2 176 352
er
Syrin bh 1 127 127
ge 10 bh
Syrin 3 127 381
ge
Syrin
Topi 5 bh 2
ge
dispo3 bh 1
sable bh 5 1,500 7,500
rb
3.0 sct 1 15,000 15,000
matik
3,0 sct 1 21,300 21,300
nylon
3,0
Alkoh sct 1
ol 50 47,400 2,370,000
Tracri
um
Fenta 1 71,500 71,500
nyl amp 1 22,000 22,000
Hibisc
rub
Isoflur cc 100 1,100 1,100
Midaz
ane / cc
olam 30 4,500 135,000
Milloz amp
Oksig
Onda 1 4,500 4,500
en
ncetro lpm 3 10,400 31,200
n 1 12,300 12,300
Pethi
din amp 1 14,000 14,000
Povid
on 300 5,300 1,590,000
PZ fles 1 34,300 34,300
RL fles 2 7,500 15,000
Atropi
n
propo amp 1 19,000 19,000
fol amp 1 800 800
WFI amp 1 103,300 103,300
ol
swab bh 6 101,400 608,400
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi 2 x 60,000
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
sc Rp 20,000
LFT Rp 40,000
GDA Rp 10,000
FNA Rp 260,000
FNA ###
Transport ###
Radiologi
Thorax Rp 50,000
ECG
injeksi 2 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 2 12,300 24,600
Ecosol fles 2 11,350 22,700
Vicilli vial 3 13,600 40,800
Jarum bh 1 1,600 1,600
Profeni bh 1 14,000 14,000
Spt 5 c bh 1 5,300 5,300
Kasa st dos 8,500 -
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinecc 300 -
Material Bedah
Glove
Electr Sat.
Gam
oda
mex bh 4 65 260
Glove
Glove
7.5
Gam bh 2
Gam
mex 7 bh
mex 2
Glove
6.5
unster bh 1 300 300
ilHypaf bh 5 60,600 303,000
ix vcm 10 176 1,760
Kasa bh
Mask 30 350 10,500
er bh 5 400 2,000
Oksig
en
Mess
nasal
15
/mask bh 2 4,500 9,000
er
Syrin bh 1 1,500 1,500
ge 10
Syrin bh 3
monof
ge 5 bh 2
Syrin
Topi
ilame
ge 3
dispo bh 1 1,300 2,600
n
sable
absor bh 5 1,100 1,100
Siede
bable
atrau
2.0
matik sct 1 4,500 4,500
Atracr
2.0
Alkoh sct 1 8,000 8,000
ium /
ol
Tracri 50 42,050 2,102,500
um
Fenta 1 12,300 12,300
nyl
Hibisc amp 1
rub
Isoflur cc 100
Midaz
ane
olam / cc 30
Milloz
Oksig amp 1
Onda
en
ncetro lpm 3
n
Pethi 1
din
Povid amp 1
on 300
PZ fles 1 5,550 5,550
Sulfas
RL
Atropi fles 2 4,300 8,600
n
propo amp 1 5,300 5,300
fol
Alkoh amp 1 16,200 16,200
WFI
ol amp 1 2,800 2,800
swab bh 6 800 4,800
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
BOF Rp 60,000
USG Rp 300,000
ECG
injeksi 15 x 5,000
Persiapan Operasi
Huknah 2 x 15,000
Skiren
Ps. Cateter 1 x 75,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 7 12,300 86,100
Ecosol fles 8 11,350 90,800
Aminovfles 1 82,500 82,500
Vicilli vial 8 13,600 108,800
Anitid amp 6 16,800 100,800
Spt 5 c bh 5 5,300 26,500
Spt 3 c bh 3 4,300 12,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 4 14,000 56,000
Colost bh 4 3,500 14,000
Material Bedah
Glove
Electr Sat.
Gam
oda
mex bh 4 6,300 25,200
Glove
Glove
7,5
Gam bh 2 7,000 14,000
Gam
mex
mex 7 bh 2
Glove
unster bh
6,5 1
il
Hans bh 5 400 2,000
aplast bh
Hypaf 1 300 300
ix bh 10 65 650
Kasa
Mask bh 30 350 10,500
Oksig
er bh 5 93,100 465,500
Mess
en
20
Mess bh 1 70,700 70,700
nasal
11
/mask bh 1
Spino
er
cam bh 1 12,750 12,750
25
Syrin bh 1 10,000 10,000
Topi
ge
dispo bh 2 1,300 2,600
sable
Poliso bh 5 1,100 1,100
Siede
rb 3.0 sct
Poliso 2 72,000 144,000
atrau
rb 1
matik sct 1
2.0
Alkoh sct 2 2,800 5,600
Epine cc
ol 50 14,000 700,000
prin
Hibisc amp 1 21,300 21,300
rub
Lidod cc 100 4,300 430,000
ex
Oksig amp 1
Onda
ncetro lpm
en 2
Povid amp
n 1
on cc 300
PZ fles 3
RL amp 3 12,300 36,900
colost bh 1 10,400 10,400
kasa l bh 1 800 800
alkoho bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
LFT Rp 40,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 8 x 5,000
Persiapan Operasi
Huknah 2 x 15,000
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Trolac amp 4 33,600 134,400
Fentani amp 1 42,050 42,050
Spt 5 c bh 3 5,300 15,900
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Tranxa amp 3 8,600 25,800
PK bks 10 500 5,000
Laxadi btl 1 29,650 29,650
Nerrad kap 10 2,300 23,000
Codein Tab 10 1,150 11,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
mex
7.5 bh 2 300 600
mex
7 bh 2
mex
6.5 bh 1
unster
il bh 5 7,000 35,000
Hans
aplast bh 1 400 400
Hypaf
ix bh 10 12,750 127,500
Kasa bh 20 22,800 456,000
Mask
er bh 5 350 1,750
Mess
10 bh 2 2,000 4,000
/mask
er bh 1 71,500 71,500
cam
25 bh 1 47,400 47,400
Syrin
ge 10 bh 1 1,300 2,600
Syrin
ge 3 bh 1
dispo
sable bh 5 1,100 1,100
Poliso
rb 2.0 sct 1 4,300 4,300
matik
2.0 sct 1 5,300 5,300
Alkoh
ol cc 50 2,300 115,000
Epine
prin amp 1 21,300 21,300
Hibisc
rub
Lidod cc 100 15,000 1,500,000
ex
Oksig amp 1 800 800
en lpm 2 10,300 20,600
ncetro
n amp 1 4,500 4,500
Povid
on cc 300
PZ fles 1
RL amp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi (Post Op. Hemoroid) 2 x 60,000
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
SC Rp 20,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 2 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 2 11,350 22,700
Vicilli vial 3 13,600 40,800
Trolac amp 2 33,600 67,200
Jarum Bh 1 1,600 1,600
Spt 5 c bh 1 5,300 5,300
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Laxadi btl 29,650 -
PK bks 500 -
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
mex
7.5 bh 2 300 600
Gam
mex 7 bh 2
mex
6.5 bh 1
unster
il bh 5 7,000 35,000
Hans
aplast bh 1 350 350
Hypaf
ix bh 10 500 5,000
Kasa bh 20 2,000 40,000
Mask
er bh 5 71,500 357,500
Mess
10 bh 2 47,400 94,800
/mask
er bh 1 1,300 2,600
cam
25 bh 1 1,100 1,100
Syrin
ge 3 bh 1 4,300 4,300
Syrin
ge 10 bh 1
dispo
Siede
sable bh 5 21,300 106,500
Poliso
atrau
rb 2.0
matik sct 1 15,000 15,000
n2.0
Alkoh sct 1 800 800
ol cc 50 10,300 515,000
Epine
prin amp 1 4,500 4,500
Hibisc
rub cc 100
Lidod
ex amp 1
Oksig
en lpm 2
ncetro
n amp 1
Povid
on cc 300
PZ fles 1
RL amp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
SC Rp 20,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
Fistulugrafi Rp 200,000
ECG
injeksi 6 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 6 12,300 73,800
Ecosol fles 4 11,350 45,400
Vicilli vial 6 13,600 81,600
Trolac amp 4 33,600 134,400
Spt 5 c bh 3 5,300 15,900
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Laxadi btl 1 29,650 29,650
PK bks 10 500 5,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 71,500 286,000
mex
7.5 bh 2 2,300 4,600
Gam
mex 7 bh 2
mex
6.5 bh 1
unster
il bh 5 47,400 237,000
Hans
aplast bh 1 2,000 2,000
Hypaf
ix bh 10 7,000 70,000
Kasa bh 20 400 8,000
Mask
er bh 5 1,300 2,600
Mess
11 bh 1 1,100 1,100
/mask
er bh 1 21,300 21,300
cam
25 bh 1 4,300 4,300
Syrin
ge 10 bh 2 12,300 24,600
Syrin
ge 3 bh 1
dispo
sable bh 5 11,300 56,500
rb
2.0 sct 1 300 300
matik
2.0 sct 1 350 350
Alkoh
ol
Epine cc 50 22,800 1,140,000
prin
Hibisc amp 1 800 800
rub cc 100 10,300 1,030,000
Lidod
ex amp 1 4,500 4,500
Oksig
en lpm 2 -
ncetro
n amp 1
Povid
on cc 300
PZ fles 1
RL amp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 8 12,300 98,400
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Etason amp 6 6,000 36,000
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Lomatulbr 1 14,000 14,000
Kasa st dos 2 8,500 17,000
Amobiotab 10 3,000 30,000
Benost tab 10 1,300 13,000
Hypafi cm 30 400 12,000
Material Bedah
Glove Sat.
Electr
Gam
oda
mex bh 4 65 260
Glove
Glove
7,5
Gam bh 1 300 300
Gam
mex
mex 7 bh 2
Glove
6.5
unster bh 1
ilHypaf bh 5 51,250 256,250
ix bh 10 79,900 799,000
Kasa
Mask bh
Oksig 30 6,300 189,000
en
er bh 5 1,300 2,600
Mess
nasal
10
/mask bh 1 1,100 1,100
Syrin bh
er 1 350 350
ge 10 bh
Syrin 3
ge 5 bh
Syrin 2
Topi
ge 3 bh
dispo 1 7,000 7,000
Siede
sable bh 5 2,000 10,000
Poliso
atrau
rb 3.0 sct
matik 1 31,500 31,500
2.0
Nylon sct 1 12,750 12,750
Atracr
3.0 sct 1
Alkoh
ium /
ol
Tracri 50 72,000 3,600,000
um
Fenta 1 21,300 21,300
nyl
Hibisc amp 1 4,500 4,500
rub cc 100 42,050 4,205,000
hibice
tIsoflur cc 50
Midaz
ane /
olam cc 30 11,300 339,000
Milloz
Oksig amp 1 12,300 12,300
Onda
en
ncetro lpm 3 14,000 42,000
n
Pethi 1 16,200 16,200
din
Povid amp 1 2,800 2,800
on 300 34,300 10,290,000
PZ fles 1 800 800
Sulfas
RL
Atropi fles 2 10,300 20,600
n
propo amp 1 12,700 12,700
fol amp 1
Alkoh
WFI
ol amp 1
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
SC Rp 20,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 3 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 2 11,350 22,700
Vicilli vial 3 13,600 40,800
Profeni bh 2 14,000 28,000
Spt 5 c bh 2 5,300 10,600
Jarum Bh 1 1,600 1,600
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinecc 300 -
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
mex
7,5 bh 2 300 600
Gam
mex 7 bh 2
mex
6,5 bh 1
unster
il bh 5 22,800 114,000
Hans
aplast bh 1 1,300 2,600
Hypaf
ix bh 10 1,100 1,100
Kasa bh 20 350 7,000
Mask
er bh 5 400 2,000
Mess
10 bh 2 7,000 14,000
/mask
er bh 1 31,700 31,700
cam
25 bh 1 12,750 12,750
Syrin
ge 10 bh 1 12,750 12,750
Syrin
ge 3 bh 1
dispo
sable bh 5 2,000 10,000
Poliso
rb 2.0 sct 1 2,300 2,300
matik
2.0 sct 1 15,000 15,000
Alkoh
ol cc 50 21,300 1,065,000
Epine
prin amp 1 47,400 47,400
Hibisc
rub cc 100 71,500 7,150,000
Lidod
ex amp 1 4,500 4,500
Oksig
Onda
en
ncetro lpm 2 12,300 24,600
n
Povid amp 1 800 800
on cc 300 10,300 3,090,000
PZ fles 1 4,300 4,300
RL amp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 2 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 2 11,350 22,700
Vicilli vial 3 13,600 40,800
Profeni bh 1 14,000 14,000
Jarum bh 1 1,600 1,600
Spt 5 c bh 1 5,300 5,300
Kasa st dos 8,500 -
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinecc 300 -
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
mex
7.5 bh 2 300 600
Gam
mex 7 bh 2
mex
6.5 bh 1
unster
il bh 5 61,000 305,000
Hypaf
ix cm 10 31,700 317,000
Kasa bh 30 350 10,500
Mask
er bh 5 1,300 2,600
Mess
10 bh 1 1,100 1,100
/mask
er bh 1 400 400
Syrin
ge 10 bh 2
Syrin
ge 5 bh 2 2,000 4,000
dispo
sable
absor bh 5 21,300 106,500
bable
2.0 sct 1 4,500 4,500
Alkoh
ol 50 42,050 2,102,500
Tracri
um 1 12,300 12,300
Fenta
nyl amp 1 5,550 5,550
Hibisc
rub cc 100 4,300 430,000
Isoflur
ane cc 30 5,300 159,000
olam /
Milloz
Oksig amp 1 2,800 2,800
Onda
en
ncetro lpm 3 800 2,400
n 1 10,300 10,300
Pethi
din amp 1 12,700 12,700
Povid
on 300
PZ fles 1
RL fles 2
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 8 12,300 98,400
Ecosol fles 4 11,350 45,400
Vicilli vial 6 13,600 81,600
Profeni bh 4 14,000 56,000
Jarum bh 1 1,600 1,600
Spt 5 c bh 4 5,300 21,200
Kasa st dos 4 8,500 34,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinecc 300 -
Material Bedah
Glove Sat.
Electr
Gam
oda
mex bh 4 65 260
Glove
Glove
7,5
Gam bh 2 300 600
Gam
mex
mex 7 bh 2
Glove
6.5
unster bh 1
ilHypaf bh 5 61,000 305,000
ix cm 10 1,300 2,600
Kasa
Oksig
Mask bh 30 1,100 1,100
en
er bh 5 31,700 158,500
Mess
nasal
20
/mask bh 2 350 700
er
Syrin bh 1 400 400
ge 10 bh
Syrin 3 2,000 6,000
ge 5 bh
Syrin 2
ge 3 bh 1
Topi
Siede
dispo
atrau
Siede
sable bh 5 21,300 106,500
matik
atrau
2.0
matik sct 1 8,000 8,000
Atracr
1 sct 1
Alkoh
ium /
ol
Tracri 50 42,050 2,102,500
um
Fenta 1 12,300 12,300
nyl
Hibisc amp 1 5,550 5,550
rub
Isoflur cc 100 4,300 430,000
Midaz
ane
olam / cc 30 5,300 159,000
Milloz
Oksig amp 1 2,800 2,800
Onda
en
n
Pethi 1 10,300 10,300
Povid amp
din 1 12,700 12,700
on 300
PZ fles 2
RL
pehid fles 2
Sulfas
Atropi cc
rol 50
n
propo amp 1
fol amp 1
Alkoh
WFI
ol amp 1
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
SC Rp 20,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
USG Rp 300,000
ECG
injeksi 15 x 5,000
Persiapan Operasi
Huknah
Skiren
rawat luka 2 x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 15 12,300 184,500
Ecosol fles 10 11,350 113,500
Vicilli vial 15 13,600 204,000
Profeni bh 15 14,000 210,000
Jarum bh 1 1,600 1,600
Spt 5 c bh 1 5,300 5,300
Kasa st dos 3 8,500 25,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinecc 10 300 3,000
Material Bedah
Glove Sat.
Electr
Gam
oda
mex bh 4 65 260
Glove
Glove
7.5
Gam bh 2 300 600
Gam
mex 7 bh
mex 2
Glove
unster bh
6,5 1
ilHypaf bh 5 61,000 305,000
ix bh 30 350 10,500
Kasa
Mask bh 30 400 12,000
Mess bh
er 5 1,300 2,600
Syrin bh
20 1 1,100 1,100
ge 10 bh
Syrin 4 21,300 85,200
ge 5 bh
Syrin 2
Topi
ge 3 bh
dispo 1
sable
Poliso bh 5 4,500 22,500
Siede
rb 2.0 sct 1 8,000 8,000
Poliso
atrau
rb 1
matik sct 1 42,050 42,050
2.0
Alkoh sct 1 12,300 12,300
ol
Hibisc cc 50 5,550 277,500
rub
Oksig cc 100 5,300 530,000
Onda
en
n
Povid amp 1 10,300 10,300
on cc 300 12,700 3,810,000
PZ fles 2
RL amp 3
kasa l
Isoflur bh 2
Midaz
ane / cc
olam 50
Milloz
Oksig amp 1
Onda
en
ncetro lpm 3
n
Pethi 1
din
Povid amp 1
on 300
PZ fles 2
Sulfas
RL
Atropi fles 3
n
propo amp 1
fol amp 1
Alkoh
WFI
ol amp 1
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
SC Rp 20,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
USG Rp 300,000
ECG
injeksi 21 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 14 12,300 172,200
Ecosol fles 14 11,350 158,900
Vicilli vial 9 13,600 122,400
Profeni bh 6 14,000 84,000
Jarum bh 1 1,600 1,600
Spt 5 c bh 7 5,300 37,100
Kasa st dos 4 8,500 34,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Glove Sat.
Electr
Gam
oda
mex bh 4 65 260
Glove
7,5
Gam bh 2 300 600
Glove
mex
Gam 7 bh 1
Glove
mex 6 bh
unster 1
ilHypaf bh 5 61,000 305,000
ix bh 10 350 3,500
Kasa
Oksig
Mask bh 30 400 12,000
en
er bh 5 7,000 35,000
Mess
nasal
10
/mask bh 1 1,300 2,600
er
Syrin bh 1 1,100 1,100
ge 10
Syrin bh 4 21,300 85,200
ge 5
Syrin bh 3
Topi
ge 3
dispo bh 1
sable
Nylon bh 5 4,500 22,500
3.0
Poliso sct 1 8,000 8,000
Alkoh sct
rb 3.0 2 42,050 84,100
Hibisc cc
ol 50 5,550 277,500
rub
Oksig cc 100 5,300 530,000
Onda
en
n
Povid amp 1 10,300 10,300
on cc 300 12,700 3,810,000
PZ fles 3
RL amp 3
Isoflur
Midaz
olam / cc
ane 50
Milloz
Oksig amp 1
Onda
en
ncetro lpm 3
n
Pethi 1
Povid amp
din 1
on 300
PZ fles 2
Sulfas
RL
Atropi fles 2
n
propo amp 1
fol amp 1
Alkoh
WFI amp
ol 1
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
SC Rp 20,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
pedis Rp 50,000
ECG
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 6 12,300 73,800
Ecosol fles 4 11,350 45,400
Vicilli vial 6 13,600 81,600
Profeni bh 4 14,000 56,000
Jarum bh 1 1,600 1,600
Spt 5 c bh 4 5,300 21,200
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Electr Sat.
Glove
oda
Gam bh 4 65 260
Glove
mex bh
unster 5 300 1,500
ilHans bh 5 61,000 305,000
Hypaf bh
aplast 1 31,700 31,700
ix bh 10 350 3,500
Kasa
Oksig
Mask bh 20 1,300 2,600
en
er bh 5 1,100 1,100
nasal
Mess
/mask bh 2 400 800
er
Spino bh 1 4,500 4,500
cam
Syrin bh 1 2,000 2,000
Topi
ge
dispo bh 2 21,300 42,600
sable
Poliso bh 5 4,500 22,500
monof
Siede
rb
ilame
atrau sct 3 8,000 24,000
nt
matik sct 2 42,050 84,100
absor
bable
2.0
Alkoh sct 1
Epine cc
ol 50 12,300 615,000
Hibisc amp
prin 1 5,550 5,550
rub
Lidod cc 100 4,300 430,000
ex
Oksig amp 1 5,300 5,300
Onda
en
ncetro lpm 2 2,800 5,600
n
Povid amp 1 800 800
on cc 300 10,300 3,090,000
PZ fles 1 12,700 12,700
RL amp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
B BEDAH UROLOGI
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
BOF Rp 60,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Profeni bh 4 14,000 56,000
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Tranxa amp 3 8,600 25,800
Material Bedah
Nama Obat
Sat Keb Harga Total
Electr Sat.
Glove
Glove
oda
Gam bh 4 7,000 28,000
Gam
Glove
mex
mex 8bh 1 300 300
Gam
7,5
mex bh 2
Glove
7,5
unster bh 2
ilHans bh 5 65 325
aplast
Hypaf bh 1 1,300 2,600
ix bh 10 1,100 1,100
Kasa
Oksig
Mask bh 30 350 10,500
en
er bh 5 400 2,000
Mess
nasal
10
/mask bh 2 22,800 45,600
Spino
er
cam bh 1 52,000 52,000
25
Syrin bh 1 31,700 31,700
ge 3
Syrin bh 1 12,750 12,750
ge 5
Syrin bh 1
Topi
ge 10
dispo bh 1
sable
Nylon bh 5 2,300 11,500
Siede
3.0 sct 1 71,500 71,500
Poliso
atrau
rb 2.0
matik sct 1 47,400 47,400
2.0
Alkoh sct 1 4,300 4,300
ol
Epine cc 50 21,300 1,065,000
prin
Hibisc amp 1 12,300 12,300
rub
Lidod cc 100 11,300 1,130,000
ex
Oksig amp 1 4,500 4,500
Onda
en
ncetro lpm 2 15,000 30,000
n
Povid amp 1 66,550 66,550
on cc 300 7,500 2,250,000
PZ fles 3 34,300 102,900
RL amp 3 800 2,400
kasa l bh 1 10,300 10,300
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp #REF!
BOF Rp 60,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Cateter 1 x 20,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Profeni bh 4 14,000 56,000
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Tranxa amp 6 8,600 51,600
Natriu fles 20 10,400 208,000
Transe bh 1 34,300 34,300
Material Bedah
Nama Obat
Sat Keb Harga Total
Electr Sat.
Glove
Glove
oda
Gam bh 4 300 1,200
Gam
mex 7
mex bh 5 350 1,750
Glove
7,5
Gam bh
Glove
mex
unster8bh
ilHans bh 5 400 2,000
aplast
Hypaf bh 1 7,000 7,000
ix bh 10 2,000 20,000
Oksig
Kasa bh 20 2,300 46,000
Mask
en
er
Mess bh 5 1,300 2,600
nasal
10
/mask bh 1 1,100 1,100
Spino
er
cam bh 1 12,500 12,500
25
Syrin bh 1 125,000 125,000
ge 3
Syrin bh 2 15,000 30,000
ge 5
Syrin bh 1
Topi
ge 10
dispo bh 1
sable
Alkoh bh 5 21,300 106,500
ol
Epine cc 50 22,000 1,100,000
prin
Hibisc amp 1 11,300 11,300
rub
Lidod cc 100 12,300 1,230,000
ex
Oksig amp 1 5,550 5,550
Onda
en
ncetro lpm 2 9,650 19,300
n
Povid amp 1 4,300 4,300
on cc 300 34,300 10,290,000
PZ fles 1 8,600 8,600
RL amp 1 65,000 65,000
urine bh 1 32,600 32,600
blood sbh 1 800 800
underp bh 1 7,500 7,500
ky jelli sct 2
threew bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Alat dr
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
BOF Rp 60,000
IVP 250,000 Rp 589,275
Obat : Omnipage 50cc 316,800
Spuit 2,5 cc 2,475
Spt 50 cc 20,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Profeni bh 1 14,000 14,000
Ecosol fles 1 12,300 12,300
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 4 12,300 49,200
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Profeni bh 4 14,000 56,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Glove1 bh 4 116,400 465,600
Gam bh 1 79,900 79,900
mex 8
Glove
Gam
Glove bh 2
mex
Gam
Glove
7,5 bh 2
mex 7
unster bh 5 350 1,750
Hans
il 400 400
bh 1
aplast
Hypaf
bh 10 7,000 70,000
ix
Kasa bh 20 300 6,000
Mask 65 325
bh 5
er
Mess
bh 1 31,700 31,700
Oksig
11
Mess
en bh 1
20
nasal
Spino bh 1 31,700 31,700
/mask
cam bh 1 1,300 2,600
Syrin
er
26 1,100 1,100
bh 1
ge 3
Syrin
bh 2
ge 5
Syrin
Topi10 bh 2
ge
dispo bh 5 2,300 11,500
Poliso
sable
sct 1 2,000 2,000
rb 3.0
Poliso
Siede sct 1
rb 1
atrau
sct 1 49,900 49,900
matik
Alkoh
cc 50 21,300 1,065,000
2.0
ol
Epine
amp 1 47,400 47,400
prin
Hibisc
cc 100 71,500 7,150,000
rub
Lidod
amp 1 29,500 29,500
ex
Oksig
lpm 2 11,300 22,600
Onda
en
ncetro amp 1 12,300 12,300
Povid
n
cc 300 9,650 2,895,000
on
PZ fles 1 4,300 4,300
RL amp 1 34,300 34,300
urine tube 1 800 800
blood sbh 1 10,300 10,300
underp bh 1 7,500 7,500
ky jelli sct 2
foley c bh 1
urine bh 1
NGT 1 bh 1
Dj Ste bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
BOF Rp 60,000
IVP 250,000 Rp 589,275
Spuit 2,5 cc 2,475
Spt 50 cc 20,000 26500
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Profeni bh 1 14,000 14,000
Ecosol fles 1 12,300 12,300
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 3 11,350 34,050
Vicilli vial 2 13,600 27,200
Spt 5 c bh 2 5,300 10,600
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 2 14,000 28,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Electr Sat.
Glove
Glove
oda
Gam bh 4 7,000 28,000
Gam
mex
mex 8 bh 1 400 400
Glove
7,5
Gam bh 2
Glove
mex 7
unster bh 2
ilHans bh 5 300 1,500
aplast
Hypaf bh 1 65 65
ix
Oksig bh 10 350 3,500
en
Kasa bh 20 71,500 1,430,000
Mask
nasal
er
/mask bh 5 22,000 110,000
Spino
er
cam bh 1 1,100 1,100
25
Syrin bh 1 15,000 15,000
ge 10
Syrin bh 1
ge 5
Syrin bh 2
Topi
ge 3
dispo bh 1 2,300 2,300
sable
Alkoh bh 5 47,400 237,000
ol
Epine cc 50 7,500 375,000
prin
Hibisc amp 1 49,900 49,900
rub
Lidod cc 100 12,300 1,230,000
ex
Oksig amp 1 12,500 12,500
Onda
en
ncetro lpm 2 9,900 19,800
n
Povid amp 1 65,000 65,000
on
WFI cc 300 32,600 9,780,000
1000 fles 1 800 800
RL amp 1 150,000 150,000
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
Folley sct 1
dj sten sct 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp #REF!
BOF Rp 60,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Profeni bh 4 14,000 56,000
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Tranxa amp 3 8,600 25,800
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr 65 260
Glove bh 4
oda
Glove
Gam bh 1 300 300
Gam
mex 8
Glove bh 2
mex
Gam
7,5
Glove bh 2
mex
unster
7,5 bh 5 22,800 114,000
ilHans bh 1 79,900 79,900
aplast
Hypaf
bh 10 350 3,500
ix
Kasa bh 30 400 12,000
Mask
bh 5 1,300 2,600
er
Oksig
Mess
en bh 2 1,100 1,100
10
nasal
Spino bh 1 7,000 7,000
/mask
cam bh 1 31,700 31,700
er
Syrin
25 bh 2 12,750 25,500
ge 10
Syrin
bh 1
ge 5
Syrin
Topi bh 1
ge 3
dispo bh 5 2,000 10,000
monof
Poliso
sable sct 1 2,300 2,300
ilame
rb 2.0
nt
sct 1
absor
Alkoh
bable 21,300 1,065,000
cc 50
ol
3.0
Epine
amp 1 47,400 47,400
prin
Hibisc
cc 100 4,500 450,000
rub
Lidod 11,300 11,300
amp 1
ex
Oksig
Onda lpm 2 12,300 24,600
en
ncetro amp 1 4,300 4,300
Povid
n cc 300 34,300 10,290,000
on
PZ fles 1 7,500 7,500
RL amp 1 800 800
urine tube 1 10,300 10,300
blood sbh 1 71,500 71,500
underp bh 1
ky jelli sct 2
foley c bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
BOF Rp 60,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
Profeni bh 1 14,000 14,000
injeksi 6 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 2 11,350 22,700
Vicilli vial 6 13,600 81,600
Spt 5 c bh 1 5,300 5,300
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 4 14,000 56,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr 300 1,200
Glove bh 4
oda
Glove
Gam bh 1 350 350
Gam
mex
Glove8 bh 2
mex
Gam
7,5
Glove bh 2
mex
unster
7,5 bh 5 400 2,000
ilHans bh 1 1,300 2,600
aplast
Hypaf
bh 10 1,100 1,100
ix
Kasa bh 20 8,500 170,000
Oksig
Mask
en bh 5 2,000 10,000
er
nasal
Spino bh 1 12,500 12,500
/mask
cam bh 1 49,900 49,900
er
Syrin
25 bh 2 21,300 42,600
ge 10
Syrin
bh 2
ge 5
Syrin
Topi bh 1
ge 3
dispo bh 5 47,400 237,000
Alkoh
sable 12,300 615,000
cc 50
ol
Epine
amp 1 65,000 65,000
prin
Hibisc
cc 100 32,600 3,260,000
rub
Lidod
amp 1 800 800
ex
Oksig
Onda lpm 2 4,300 8,600
en
ncetro amp 1
Povid
n cc 300
on
PZ fles 1
RL amp 1
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
foley c bh 1
NGT 1 bh 1
Jasa Tindakan Dj Ste bh 1
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Adiministrasi
Fisioterapi (POST. OPS. TU BULI) 1 x 60,000
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
BOF Rp 60,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
Profeni bh 1 14,000 14,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 2 11,350 22,700
Vicilli vial 2 13,600 27,200
Spt 5 c bh 1 5,300 5,300
Kasa st dos 8,500 -
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 1 14,000 14,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 300 1,200
Gam
mex 8 bh 1 350 350
mex
7,5 bh 2
mex
7,5 bh 2
unster
il bh 5 400 2,000
Hans
aplast bh 1 1,300 2,600
Hypaf
ix bh 10 1,100 1,100
Kasa bh 20 8,500 170,000
Mask
er bh 5 2,000 10,000
/mask
er bh 1 12,500 12,500
cam
25 bh 1 49,900 49,900
Syrin
ge 10 bh 2 21,300 42,600
Syrin
ge 5 bh 2
Syrin
ge 3 bh 1
dispo
sable bh 5 47,400 237,000
Alkoh
ol cc 50 12,300 615,000
Epine
prin amp 1 65,000 65,000
Hibisc
rub cc 100 32,600 3,260,000
Lidod
ex amp 1 800 800
Oksig
en lpm 2 4,300 8,600
ncetro
n amp 1
Povid
on cc 300
PZ fles 1
RL amp 1
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
threew bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax 50,000 50,000
BOF 60,000 60,000
Uretrogram 200,000 216,000
Obat : 16,000
Omnipace 20 cc - 115600
Aquades 2 16,000
Spuit 2,5 cc -
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
Profeni bh 1 14,000 14,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 3 11,350 34,050
Vicilli vial 5 13,600 68,000
Spt 5 c bh 2 5,300 10,600
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Profeni bh 2 14,000 28,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr 65 260
Glove bh 4
oda
Glove
Gam bh 1 300 300
Gam
mex 8
Glove bh 2
mex
Gam
7,5
Glove bh 2
mex
unster7 bh 5 350 1,750
ilHans bh 1 400 400
aplast
Hypaf
bh 10 1,300 2,600
ix
Kasa bh 20 1,100 1,100
Oksig
Mask
en bh 5 7,000 35,000
er
nasal
Spino bh 1 2,300 2,300
/mask
cam bh 1 12,500 12,500
er
Syrin
25 66,550 66,550
bh 1
ge 10
Syrin
bh 2
ge 5
Syrin
Topi bh 2
ge 3
dispo bh 5 21,300 106,500
Alkoh
sable 11,300 565,000
cc 50
ol
Epine
amp 1 12,300 12,300
prin
Hibisc
cc 100 5,550 555,000
rub
Lidod
amp 1 9,650 9,650
ex
Oksig
Onda lpm 2 4,300 8,600
en
ncetro amp 1 34,300 34,300
Povid
n 8,600 2,580,000
cc 300
on
PZ fles 1 65,000 65,000
RL amp 1 32,600 32,600
urine tube 1 800 800
blood sbh 1 7,500 7,500
underp bh 1
ky jelli sct 2
foley c bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000 50,000
BOF 60,000
Uretrogram 200,000 216,000
Obat : 16,000
Omnipace 20 - 115600
Aquades 2 16,000
Spuit 2,5 cc -
ECG
Fungsi Blass (Ps. Cateter)
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Urine bh 1 7,500 7,500
Optiva bh 1 23,000 23,000
Pehaca amp 1 3,500 3,500
Spt 3 c bh 1 4,300 4,300
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 3 11,350 34,050
Vicilli vial 2 13,600 27,200
Spt 5 c bh 1 5,300 5,300
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 2 14,000 28,000
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr 300 1,200
Glove bh 4
oda
Glove
Gam bh 1 350 350
Gam
mex 8
Glove bh 2
mex
Gam
7,5
Glove bh 2
mex
unster
7,5 bh 5 400 2,000
Hans
il 1,300 2,600
bh 1
aplast
Hypaf
bh 10 1,100 1,100
ix
Kasa bh 30 7,000 210,000
Oksig
Mask
en bh 5 2,000 10,000
er
nasal
Spino bh 1 12,500 12,500
/mask
cam bh 1 49,900 49,900
er
Syrin
25 21,300 21,300
bh 1
ge 10
Syrin
bh 2
ge 5
Syrin
Topi bh 2
ge 3
dispo bh 5 47,400 237,000
Alkoh
sable 12,300 615,000
cc 50
ol
Epine
amp 1 65,000 65,000
prin
Hibisc
cc 100 32,600 3,260,000
rub
Lidod
amp 1 800 800
ex
Oksig
Onda lpm 2 4,300 8,600
en
ncetro amp 1
Povid
n cc 300
on
PZ fles 1
RL amp 1
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
foley c bh 1
NGT 1 bh 1
Dj Ste bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000 50,000
BOF 60,000
IVP 250,000 589,275
Obat : 339,275
Omnipage 50cc 316,800
Spuit 2,5 cc 2,475
Spt 50 cc 20,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Profeni bh 1 14,000 14,000
Ecosol fles 1 12,300 12,300
injeksi 18 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 4 12,300 49,200
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Profeni bh 4 14,000 56,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
Glove
oda
Gam bh 1 300 300
Gam
mex 8
bh 2
Glove
mex
Gam bh 2
Glove
mex 7
unster bh 5 116,400 582,000
ilHans
bh 1 6,300 6,300
aplast
Hypaf
bh 10 1,300 2,600
ix
Kasa bh 40 1,100 1,100
Mask
bh 5 350 1,750
er
Mess
bh 1 400 400
20
Mess
bh 1
en
11
nasal bh 1 7,000 7,000
Spino
/mask
cam bh 1 31,700 31,700
Syrin
26
bh 1 12,750 12,750
ge 10
Syrin
bh 2
ge 5
Syrin
bh 2
ge 3
Syrin
bh 1
ge 50
Topi
dispo bh 5 12,750 63,750
Poliso
sable
sct 2 2,000 4,000
rb 1
Poliso
sct 1
rb 3.0
atrau
sct 1 2,000 2,000
c
matik
blunt sct 2
Alkoh
point
cc 50 49,900 2,495,000
ol
Epine
amp 1 72,000 72,000
prin
Hibisc
cc 100 23,000 2,300,000
rub
Lidod
amp 1 21,300 21,300
ex
dekai
amp 1
n
Oksig
lpm 2 29,500 59,000
Onda
en
ncetro amp 1 4,500 4,500
Povid
n
cc 300 8,000 2,400,000
on
PZ fles 1 42,050 42,050
RL amp 1 11,300 11,300
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
foley c bh 1
NGT 1 bh 1
Dj Ste bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
injeksi 18 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
D ¼ NS 4 11,800 47,200
Vicilli vial 2 13,600 27,200
Spt 5 c bh 1 5,300 5,300
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 2 14,000 28,000
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ikamicetube 2 4,150 8,300
Kasa st dos 2 8,500 17,000
Natriu fles 1 10,400 10,400
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
Gam
mex 8 bh 1 300 300
mex
7,5 bh 2
mex
7,5 bh 2
unster
il bh 5 6,300 31,500
Hans
aplast bh 1 350 350
Hypaf
ix bh 10 400 4,000
Kasa bh 30 1,300 2,600
Mask
er bh 5 1,100 1,100
Mess
10 bh 2 7,000 14,000
/mask
er bh 1 12,750 12,750
cam
26 bh 1 105,500 105,500
Syrin
ge 10 bh 2
Syrin
ge 5 bh 2
Syrin
ge 3 bh 1 2,000 2,000
dispo
sable bh 5 84,200 421,000
Poliso
rb 5.0 sct 1 49,900 49,900
poliso
rb 4.0 sct 1 21,300 21,300
nylon
4.0 sct 1
Alkoh
ol cc 50 4,500 225,000
Epine
prin amp 1 8,000 8,000
Hibisc
rub cc 100 42,050 4,205,000
Lidod
ex amp 1 12,300 12,300
Oksig
en lpm 2 4,300 8,600
ncetro
n amp 1 16,200 16,200
Povid
on cc 300 2,800 840,000
PZ fles 1 7,500 7,500
RL amp 1 12,700 12,700
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
SC Rp 20,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 2 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 2 11,350 22,700
Vicilli vial 2 13,600 27,200
Profeni bh 1 14,000 14,000
Spt 5 c bh 1 5,300 5,300
Jarum bh 1 1,600 1,600
Kasa st dos 8,500 -
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinecc 300 -
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
Gam
mex 8 bh 1 300 300
mex
7,5 bh 2
Gam
mex 7 bh 2
unster
il bh 5 22,800 114,000
Hans
aplast bh 1 350 350
Hypaf
ix bh 10 400 4,000
Kasa bh 30 7,000 210,000
Mask
er bh 5 31,700 158,500
Mess
10 bh 2 12,750 25,500
/mask
er bh 1 12,750 12,750
cam
25 bh 1 2,000 2,000
Syrin
ge 10 bh 1 2,300 2,300
Syrin
ge 5 bh 2
Syrin
ge 3 bh 2
dispo
sable bh 5 15,000 75,000
Poliso
rb 3.0 sct 1 1,300 2,600
Poliso
rb 2.0 sct 1
matik
2.0 sct 1 1,100 1,100
Alkoh
ol cc 50 21,300 1,065,000
Epine
prin amp 1 47,400 47,400
Hibisc
rub cc 100 71,500 7,150,000
Lidod
ex amp 1 4,500 4,500
Oksig
Onda
en
ncetro lpm 2 12,300 24,600
n
Povid amp 1 800 800
on cc 300 10,300 3,090,000
PZ fles 1 4,300 4,300
Jasa Tindakan RL amp 1
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
RFT Rp 58,000
Radiologi
BOF Rp 60,000
ECG 1 x 21,000
injeksi 2 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 2 12,300 24,600
Vicilli vial 2 13,600 27,200
Spt 5 c bh 1 5,300 5,300
Jarum bh 1 1,600 1,600
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 2 14,000 28,000
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 300 1,200
Gam
mex 8 bh 1 350 350
mex
7.5 bh 2
mex
7.5 bh 2
unster
il bh 5 7,000 35,000
Hans
aplast bh 1 2,000 2,000
Hypaf
ix bh 10 15,000 150,000
Kasa bh 20 1,300 2,600
Mask
er bh 5 1,100 1,100
/mask
er bh 1 42,050 42,050
cam
25 bh 1 4,300 4,300
Syrin
ge 10 bh 1 2,800 2,800
Syrin
ge 5 bh 1
Syrin
ge 3 bh 1
dispo
sable bh 5 12,700 63,500
Alkoh
ol cc 50
Epine
prin amp 1
Hibisc
rub cc 100
Lidod
ex amp 1
Oksig
en lpm 2
ncetro
n amp 1
Povid
on cc 300
blood
set cc 1
WFI
1000 fles 1
RL amp 1
Jasa Tindakan
Dokter Ahli Bedah
Sewa Alat dr
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
RFT Rp 58,000
Radiologi
BOF Rp 60,000
ECG 1 x 21,000
injeksi 3 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 2 12,300 24,600
Vicilli vial 2 13,600 27,200
Spt 5 c bh 1 5,300 5,300
Jarum bh 1 1,600 1,600
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Profeni bh 2 14,000 28,000
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 300 1,200
Gam
mex bh 5 350 1,750
unster
il bh 5 7,000 35,000
Hans
aplast bh 1 2,000 2,000
Hypaf
ix bh 10 15,000 150,000
Kasa bh 30 21,300 639,000
Mask
er bh 5 1,300 2,600
Mess
20 bh 1 1,100 1,100
Mess
11 bh 1
/mask
er bh 1 42,050 42,050
cam
25 bh 1 4,300 4,300
Syrin
ge 10 bh 1 2,800 2,800
Syrin
ge 5 bh 2
Syrin
ge 3 bh 2
dispo
sable bh 5 12,700 63,500
Poliso
rb 3.0 sct 1 18,800 18,800
poliso
rb 2.0 sct 1
Alkoh
ol cc 50
Epine
prin amp 1
Hibisc
rub cc 100
Lidod
ex amp 1
Oksig
en lpm 2
ncetro
n amp 1
cath
16 bh 1
urine
bag bh 1
Povid
on cc 300
PZ fles 1
Jasa Tindakan RL amp 1
Dokter Ahli Bedah
Sewa Alat dr
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
C THT
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
Waters Rp 50,000
ECG
injeksi 12 x 5,000
Persiapan Operasi
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 4 12,300 49,200
Ecosol fles 4 11,350 45,400
Vicilli vial 5 13,600 68,000
Profeni bh 3 14,000 42,000
Spt 5 c bh 3 5,300 15,900
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Plasmi tab 3 2,750 8,250
Etason amp 3 6,000 18,000
Chirus Tab 6 6,000 36,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 6,300 25,200
mex
7,5 bh 1 250 250
Gam
mex 7 bh 1
mex
6,5 bh 1
unster
il bh 5 350 1,750
Hypaf
ix bh 10 250 2,500
Kasa bh 30 8,500 255,000
Mask
er bh 5 1,300 2,600
/mask
er bh 1 2,000 2,000
cam
25 bh 1 8,000 8,000
Syrin
ge 10 bh 1 42,050 42,050
Syrin
ge 5 bh 2
Syrin
ge 3 bh 2
Syrin
ge 50 bh 2
dispo
sable bh 5 11,300 56,500
Alkoh
ol 50 4,300 215,000
Tracri
um 1 5,300 5,300
Fenta
nyl amp 1 16,200 16,200
Hibisc
rub cc 100 2,800 280,000
Isoflur
ane cc 30 8,600 258,000
olam /
Milloz amp 1 21,300 21,300
Oksig
en lpm 3 3,500 10,500
ncetro
n 1 4,150 4,150
Pethi
din amp 1
Povid
on 300
PZ fles 1
RL fles 2
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
SC Rp 20,000
OT PT Rp 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 6 x 5,000
Persiapan Operasi
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 3 11,350 34,050
Vicilli vial 5 13,600 68,000
Profeni bh 2 14,000 28,000
Spt 5 c bh 2 5,300 10,600
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinefles 1 19,000 19,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 6,300 25,200
Gam
mex 7 bh 1 350 350
mex
7,5 bh 1
mex
6,5 bh 1
unster
il bh 5 250 1,250
Hypaf
ix bh 10 7,000 70,000
Kasa bh 30 1,300 2,600
Mask
er bh 5 1,100 1,100
Mess
11 bh 2 2,000 4,000
/mask
er bh 1 2,000 2,000
Syrin
ge 10 bh 2
Syrin
ge 5 bh 2
Syrin
ge 3 bh 1 23,000 23,000
dispo
sable bh 5 21,300 106,500
Poliso
rb 3.0 sct 1 42,050 42,050
matik
2.0 sct 1 12,300 12,300
Alkoh
ol 50 5,550 277,500
Tracri
um 1 4,300 4,300
Fenta
nyl amp 1 5,300 5,300
Hibisc
rub cc 100 16,200 1,620,000
Isoflur
ane cc 30 2,800 84,000
olam /
Milloz amp 1 8,600 8,600
Oksig
en lpm 3 12,700 38,100
ncetro
n 1
Pethi
din amp 1
Povid
on 300
PZ fles 1
RL fles 2
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
. OBSTETRY GYNAECOLOGY
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb post op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
USG Rp 300,000
ECG
Obat-Obatan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 1 12,300 12,300
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
AlinamInj 6 14,150 84,900
Spt 5 c bh 3 5,300 15,900
Spuit 1 bh 2 5,550 11,100
Optiva bh 1 23,000 23,000
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Nerrad kap 10 2,300 23,000
Meterg tab 6 3,550 21,300
Extrac amp 6 7,300 43,800
Ottogenamp 4 11,000 44,000
Gurita bh 1 36,650 36,650
Profeni bh 4 14,000 56,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
Gam
mex 8 bh 1 300 300
mex
7,5 bh 2
Gam
mex 7 bh 2
unster
il bh 5 22,800 114,000
Hans
aplast bh 1 116,400 116,400
Hypaf
ix bh 10 350 3,500
Kasa bh 30 400 12,000
Mask
er bh 5 1,300 2,600
Mess
20 bh 1 1,100 1,100
/mask
er bh 1 7,000 7,000
cam
25 bh 1 31,750 31,750
Syrin
ge 10 bh 2 12,750 25,500
Syrin
ge 5 bh 1
Syrin
ge 3 bh 2
dispo
sable bh 5 10,000 50,000
plain2
.0 sct 1 2,300 2,300
Poliso
rb 1
absor sct 1 15,000 15,000
bable
1
absor sct 1
bable
3.0 sct 1 21,300 21,300
Alkoh
ol cc 50 47,400 2,370,000
Epine
prin amp 1
Hibisc
rub cc 100
Lidod
ex amp 1
Oksig
en lpm 2
ncetro
n amp 1
Povid
on cc 300
PZ fles 3
RL amp 3
kasa l bh 1
induxin amp 2
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
USG Rp 300,000
ECG
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
AlinamInj 6 14,150 84,900
Spt 5 c bh 3 5,300 15,900
Spuit 1 bh 2 5,550 11,100
Optiva bh 1 23,000 23,000
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Nerrad kap 10 2,300 23,000
Extrac amp 6 7,300 43,800
Ottogenamp 4 11,000 44,000
Gurita bh 1 36,650 36,650
Profeni bh 4 14,000 56,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Electr Sat.
Glove
Glove
oda
Gam bh 4 65 260
Gam
Glove
mex 8
mex bh 1 300 300
Gam
7,5
mex bh 3
Glove
7,5
unster bh 2
ilHans bh 5 22,800 114,000
aplast
Hypaf bh 1 116,400 116,400
ix bh 10 1,300 2,600
Oksig
Kasa bh 30 1,100 1,100
Mask
en
er
Mess bh 5 350 1,750
nasal
20
/mask bh 1 400 400
Spino
er
cam bh 1 7,000 7,000
25
Syrin bh 1 2,000 2,000
ge 10
Syrin bh 2 31,700 63,400
ge 5
Syrin bh 1
Topi
ge 3
dispo bh 1
sable
plain bh 5 12,750 63,750
2.0 sct 1 10,000 10,000
Poliso
rb 1
absor sct 1 2,300 2,300
bable
1
absor sct 1 15,000 15,000
bable
3.0 sct 1
cromi
c2 sct 5
siede
2 sct 2
Alkoh
ol cc 50 21,300 1,065,000
Epine
prin amp 1 47,400 47,400
Hibisc
rub cc 100 71,500 7,150,000
Lidod
ex amp 1 22,000 22,000
Oksig
en lpm 2 4,500 9,000
ncetro
n amp 1 11,300 11,300
Povid
on cc 300 12,300 3,690,000
PZ fles 3 800 2,400
RL amp 3 103,300 309,900
kasa l bh 1 4,300 4,300
induxin amp 2
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
Thorax Rp #REF!
ECG
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
AlinamInj 6 14,150 84,900
Spt 5 c bh 3 5,300 15,900
Spuit 1 bh 2 5,550 11,100
Optiva bh 1 23,000 23,000
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Nerrad kap 10 2,300 23,000
Extrac amp 6 7,300 43,800
Ottogenamp 4 11,000 44,000
Gurita bh 1 36,650 36,650
Profeni bh 4 14,000 56,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Electr Sat.
Glove
Glove
oda
Gam bh 4 65 260
Gam
mex 8
mex bh 1 300 300
Glove
7,5
Gam bh 3
Glove
mex 7
unster bh 2
ilHans bh 5 22,800 114,000
aplast
Hypaf bh 1 116,400 116,400
ix bh 10 350 3,500
Kasa
Oksig
Mask bh 30 400 12,000
en
er bh 5 1,300 2,600
Mess
nasal
20
/mask bh 1 1,100 1,100
Spino
er
cam bh 1 7,000 7,000
25
Syrin bh 1 2,000 2,000
ge 10
Syrin bh 2 31,700 63,400
ge 5
Syrin bh 1
Topi
ge 3
dispo bh 1
sable
cromi bh 5 12,750 63,750
c2
Poliso sct 1 10,000 10,000
rb 1
siede sct 1 2,300 2,300
2
Alkoh sct 1 15,000 15,000
ol
Epine cc 50 21,300 1,065,000
prin
Hibisc amp 1 47,400 47,400
rub
Lidod cc 100 71,500 7,150,000
ex
Oksig amp 1 22,000 22,000
Onda
en
ncetro lpm 2 4,500 9,000
n
Povid amp 1 11,300 11,300
on cc 300 12,300 3,690,000
PZ fles 3 800 2,400
RL amp 3 10,300 30,900
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Radiologi
USG Rp 300,000
Thorax Rp 50,000
ECG
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
AlinamInj 6 14,150 84,900
Spt 5 c bh 3 5,300 15,900
Spuit 1 bh 2 5,550 11,100
Optiva bh 1 23,000 23,000
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Nerrad kap 10 2,300 23,000
Extrac amp 6 7,300 43,800
Ottogenamp 4 11,000 44,000
Gurita bh 1 36,650 36,650
Profeni bh 4 14,000 56,000
Material Bedah
Electr
Glove Sat.
Glove
oda
Gam
Gam bh 4 22,800 91,200
Glove
mex 8 bh
mex
Gam 1 116,400 116,400
7,5
mex
Glove bh 3
7,5
unster bh 2
ilHans bh 5 65 325
aplast bh
Hypaf 1 300 300
ix bh 10 350 3,500
Oksig
Kasa
Mask bh 30 1,300 2,600
en
er
Mess bh 5 1,100 1,100
nasal
20
/mask bh 1 400 400
Spino
cam bh
er 1 7,000 7,000
25
Syrin bh 1 31,700 31,700
ge 10 bh
Syrin 2 12,750 25,500
ge 5 bh
Syrin 2
Topi
ge 3 bh
dispo 1
Poliso bh
sable 5 2,300 11,500
rb 1
cromi sct 1
c2
siede sct 2
2 sct 2
ilame
n
absor
bable
3.0
Alkoh sct 1
ol
Epine cc 50
prin
Hibisc amp 1
rub cc 100
Lidod
ex
Oksig
Onda amp 1 49,900 49,900
en
ncetro lpm 2 15,000 30,000
n
Povid amp 1 21,300 21,300
on cc 300 47,400 14,220,000
PZ fles 3 71,500 214,500
RL amp 3 22,000 66,000
kasa l bh 1 4,500 4,500
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
RFT Rp 58,000
LFT Rp 40,000
GDA Rp 10,000
Plano Rp 10,000
Radiologi
Thorax Rp 50,000
USG Rp 300,000
ECG
Obat-Obatan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 1 12,300 12,300
Foley cbh 1 49,900 49,900
Urine bh 1 7,500 7,500
Profeni bh 1 14,000 14,000
injeksi 12 x 5,000
Persiapan Operasi
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 6 11,350 68,100
Vicilli vial 8 13,600 108,800
AlinamInj 6 14,150 84,900
Spt 5 c bh 3 5,300 15,900
Spuit 1 bh 2 5,550 11,100
Optiva bh 1 23,000 23,000
Kasa st dos 2 8,500 17,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Nerrad kap 10 2,300 23,000
Extrac amp 6 7,300 43,800
Ottogenamp 4 11,000 44,000
Gurita bh 1 36,650 36,650
Profeni bh 4 14,000 56,000
Tranxa amp 6 8,600 51,600
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 65 260
Gam
mex 8 bh 1 300 300
mex
7,5 bh 2
Gam
mex 7 bh 2
unster
il bh 5 22,800 114,000
Hans
aplast bh 1 116,400 116,400
Hypaf
ix bh 10 1,300 2,600
Kasa bh 30 1,100 1,100
Mask
er bh 5 350 1,750
Mess
20 bh 2 400 800
/mask
er bh 1 7,000 7,000
cam
26 bh 1 31,700 31,700
Syrin
ge 10 bh 2 12,750 25,500
Syrin
ge 5 bh 2
Syrin
ge 3 bh 1
dispo
sable bh 5 12,750 63,750
Poliso
rb 1
absor sct 1
bable
3.0 sct 1
Alkoh
ol cc 50
Epine
prin amp 1
Hibisc
rub cc 100
Lidod
ex amp 1
Oksig
en lpm 2
Povid
on cc 300
PZ fles 3
RL amp 3
kasa l bh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
sc Rp 20,000
OT PT Rp 20,000
GDA 10,000
Plano Rp 10,000
Obat-Obatan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 1 12,300 12,300
injeksi 2 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 2 11,350 22,700
Vicilli vial 2 13,600 27,200
Jarum bh 1 1,600 1,600
Spt 5 c bh 1 5,300 5,300
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Nerrad kap 10 2,300 23,000
Profeni bh 1 14,000 14,000
Meterg tab 6 3,550 21,300
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
oda bh 4 300 1,200
mex
10 bh 2 350 700
Gam
mex 5 bh 2
Gam
mex 3 bh 1
unster
il bh 5
Hypaf
ix bh 10
Kasa bh 30
Mask
er bh 5
Mess
20 bh 1
/mask
er bh 1
cam
25 bh 1
Syrin
ge 10 bh 2
Syrin
ge 5 bh 2
Syrin
ge 3 bh 1
dispo
sable bh 5
Alkoh
ol 50
Tracri
um 1
Fenta
nyl amp 1
Hibisc
rub cc 100
Isoflur
ane cc 30
olam /
Milloz amp 1
Oksig
en lpm 3
ncetro
n 1
Pethi
din amp 1 7,000 7,000
Povid
on 300 2,000 600,000
PZ fles 1 15,000 15,000
RL fles 2 1,300 2,600
Atropi
n amp 1 1,100 1,100
propo
fol amp 1 21,300 21,300
WFI amp 1 42,050 42,050
ol
swab bh 6 4,300 25,800
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
E BEDAH PLASTIK
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
D ¼ NS 3 11,800 35,400
Vicilli vial 1 13,600 13,600
Spt 5 c bh 1 5,300 5,300
Optiva bh 1 23,000 23,000
Kasa st dos 1 8,500 8,500
Novalgfles 1 37,300 37,300
Amobiotab 1 3,000 3,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Halota cc 70 6,300 441,000
T.Vio sach 2 79,900 159,800
Hibisc cc 60 350 21,000
Hibice cc 50 250 12,500
hanscobh 2 1,300 2,600
Topi bh 1 1,100 1,100
Kasa st dos 2 8,500 17,000
Oksige ltr 21 2,000 42,000
Plain 4 pcs 1 70,700 70,700
T.Lene sach 1 84,200 84,200
Miloz amp 1 23,000 23,000
Gamex bh 3 21,300 63,900
Mess bh 3 4,500 13,500
Safol cc 10 8,000 80,000
Fentani amp 1 42,050 42,050
Spt 3 c bh 1 4,300 4,300
Succyn cc 1 16,200 16,200
Atropi amp 1 2,800 2,800
Tranxa amp 1 8,600 8,600
Pehaca amp 2 3,500 7,000
Maske bh 3 800 2,400
Jarum bh 1 103,300 103,300
Curosp bh 1 65,500 65,500
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
SC Rp 20,000
OT PT Rp 20,000
GDA Rp 10,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
D ¼ NS 3 11,800 35,400
Vicilli vial 1 13,600 13,600
Spt 5 c bh 1 5,300 5,300
Optiva bh 1 23,000 23,000
Kasa st dos 1 8,500 8,500
Novalgfles 1 37,300 37,300
Amobiotab 1 3,000 3,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Halota cc 70 6,300 441,000
T.Vio sach 2 79,900 159,800
Hibisc cc 60 350 21,000
Hibice cc 50 250 12,500
hanscobh 2 1,300 2,600
Topi bh 1 1,100 1,100
Kasa st dos 2 8,500 17,000
Oksige ltr 21 2,000 42,000
Plain 4 pcs 1 70,700 70,700
T.Lene sach 1 84,200 84,200
Miloz amp 1 23,000 23,000
Gamex bh 3 21,300 63,900
Mess bh 3 4,500 13,500
Safol cc 10 8,000 80,000
Fentani amp 1 42,050 42,050
Spt 3 c bh 1 4,300 4,300
Succyn cc 1 16,200 16,200
Atropi amp 1 2,800 2,800
Tranxa amp 1 8,600 8,600
Pehaca amp 2 3,500 7,000
Maske bh 3 800 2,400
Jarum bh 1 103,300 103,300
Curosp bh 1 65,500 65,500
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Angkle Rp 50,000
Pedis Rp 50,000
ECG
Fisioterapi (Tibialis Posterior Transfer 4 x 60,000
Persiapan Operasi
Huknah
Skiren
injeksi 12 x 5,000
Ro. Angkle + Pedis 1 x 100,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Gamex bh 1 21,300 21,300
Ecosole fles 7 12,300 86,100
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Vicilli vial 7 13,600 95,200
Ottogenamp 5 11,000 55,000
Spt 5 c bh 4 5,300 21,200
Optiva bh 1 23,000 23,000
Kasa st dos 4 8,500 34,000
Lomatulbr 2 14,000 28,000
Isodine cc 60 300 18,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Verban rol 15 1,300 19,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Alkoho cc 50 65 3,250
Isodine cc 150 300 45,000
Cut Gut cm 100 176 17,600
Halota cc 35 6,300 220,500
Hibisc cc 60 350 21,000
Hypafi cm 20 400 8,000
hanscobh 2 1,300 2,600
Topi bh 1 1,100 1,100
Kasa g pak 3 7,000 21,000
Oksige ltr 21 2,000 42,000
Silk 2/ cm 100 127 12,700
Miloz amp 1 23,000 23,000
Gibson bh 3 36,350 109,050
Gibson bh 2 47,650 95,300
Gamex bh 4 21,300 85,200
Mess 1 bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Fentani amp 1 42,050 42,050
T.Lene sach 2 83,900 167,800
Ecosol fles 2 11,300 22,600
Ecosole fles 3 12,300 36,900
Soffba rol 2 27,500 55,000
Soffba rol 1 32,250 32,250
Spt 3 c bh 1 4,300 4,300
Spt 5 c bh 1 5,300 5,300
Tensoc rol 1 67,000 67,000
Ticron bh 1 70,550 70,550
Valisanamp 1 12,700 12,700
Maske bh 3 800 2,400
Jarum bh 1 103,300 103,300
Verban rol 2 1,300 2,600
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi (Tibialis Posterior Transfer 7 x 60,000
Jasa Service Layanan
Kruk
Total
BEDAH ORTOPEDI
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Femur Rp 60,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
Profeni bh 2 14,000 28,000
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Femur 1 x 60,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 9 12,300 110,700
Ecosol fles 12 11,350 136,200
Profeni bh 7 14,000 98,000
Cefaso vial 9 103,200 928,800
Spt 5 c bh 4 5,300 21,200
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 3 14,000 42,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
Glove
oda
Gam bh 1 300 300
Gam
mex 8
bh 2
Glove
mex
Gam bh 2
Glove
mex 7
unster bh 5 116,400 582,000
ilHans
bh 1 7,000 7,000
aplast
Hypaf
bh 10 1,300 2,600
ix
Kasa bh 40 1,100 1,100
Mask
bh 5 350 1,750
er
Mess
bh 1 400 400
10
mess
bh 1
en
20
nasal bh 1 250 250
Spino
/mask
cam bh 1 2,000 2,000
Syrin
25
bh 2 31,700 63,400
ge 3
Syrin
bh 3
ge 10
Syrin
bh 2
Topi
ge 5
dispo bh 5 12,750 63,750
sable
Poliso
sct 2 2,300 4,600
rb 1
Poliso
sct 1
rb 0
Poliso
sct 2
rb 2.0
nilon
sct 1 21,300 21,300
0
atrau
sct 1
matik
Alkoh
cc 50 47,400 2,370,000
ol
hibice
cc 100
t
Epine
amp 1 71,500 71,500
prin
Hibisc
cc 100 22,000 2,200,000
rub
Lidod
amp 1 4,500 4,500
ex
Oksig
lpm 2 11,300 22,600
Onda
en
ncetro amp 1 12,300 12,300
Povid
n
cc 300 14,000 4,200,000
on
PZ fles 5 9,650 48,250
RL amp 1 5,300 5,300
pehidr cc 100
urine tube 1 85,000 85,000
blood sbh 1 800 800
underp bh 1 10,300 10,300
ky jelli sct 2 34,300 68,600
foley c bh 1
kasa hi bh 2
sufratu bh 1
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr. Femur) 2 x 75,000
Kruk
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Femur Rp 60,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 7 12,300 86,100
Ecosol fles 9 11,350 102,150
Profeni bh 8 14,000 112,000
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 3 8,500 25,500
Lomatulbr 3 14,000 42,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Glove
Gam bh 1 300 300
Gam
mex 8
bh 2 116,400 232,800
Glove
mex
Gam bh 2 350 700
Glove
mex 7
unster bh 5 1,300 2,600
ilHans
bh 1 1,100 1,100
aplast
Hypaf
bh 10 400 4,000
ix
Kasa bh 40 250 10,000
Mask
bh 5 2,000 10,000
er
Mess bh 2 31,700 63,400
en
nasal bh 1 4,500 4,500
Spino
/mask
cam bh 1 12,750 12,750
Syrin
25
bh 2 2,300 4,600
ge 3
Syrin
bh 3 21,300 63,900
ge 10
Syrin
bh 2 47,400 94,800
Topi
ge 5
dispo bh 5 71,500 357,500
Poliso
sable
sct 2 22,000 44,000
rb 1
Poliso
sct 1 4,500 4,500
rb 0
Poliso
sct 2
rb 2.0
nilon
sct 1
0
atrau
sct 1
matik
Alkoh
cc 50
ol
hibice
cc 100
t
Epine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
lpm 2
Onda
en
ncetro amp 1
P
n ovid cc 300
on
PZ fles 5
RL amp 1
pehidr cc 100 11,300 1,130,000
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
foley c bh 1
sufratu bh 1
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant
Adiministrasi
a/j dr
Kruk
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Cruris Rp 60,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Cruris 1 x 60,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 8 12,300 98,400
Ecosol fles 12 11,350 136,200
Profeni bh 8 14,000 112,000
Cefaso vial 7 103,200 722,400
Spt 5 c bh 4 5,300 21,200
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 350 1,400
Glove
oda
Gam bh 1 65 65
Gam
mex 8
bh 2 300 600
Glove
mex
Gam bh 2 1,300 2,600
Glove
mex 7
unster bh 5 1,100 1,100
ilHans
bh 1 8,500 8,500
aplast
Hypaf
bh 10 31,700 317,000
ix
Kasa bh 30 12,750 382,500
Mask
bh 5 2,300 11,500
er
Mess
bh 1 15,000 15,000
10
mess
bh 1
en
20
nasal bh 1 21,300 21,300
Spino
/mask
cam bh 1 47,400 47,400
Syrin
25
bh 2 71,500 143,000
ge 3
Syrin
bh 3 4,500 13,500
ge 10
Syrin
bh 2 11,300 22,600
ge 5
Topi
dispo bh 5 12,300 61,500
Poliso
sable
sct 1 14,000 14,000
rb 3.0
Poliso
sct 2 9,650 19,300
rb 2.0
nilon
sct 1 4,300 4,300
2.0
Alkoh
cc 50 10,300 515,000
ol
hibice
cc 100 67,000 6,700,000
t
Epine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
pehidr cc 100
urine tube 1
underp bh 1
sufratu bh 1
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi 3 x 60,000
Sewa alat dr
Implant Total
Adiministrasi
a/j dr
Fisioterapi (Fr. Cruris)
Kruk
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Cruris Rp 60,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 8 12,300 98,400
Ecosol fles 12 11,350 136,200
Profeni bh 7 14,000 98,000
Vicilli vial 8 13,600 108,800
Spt 5 c bh 4 5,300 21,200
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr 350 1,400
Glove bh 4
oda
Glove
Gam bh 1 8,500 8,500
Gam
mex 8 1,300 2,600
Glove bh 2
mex
Gam
7,5
Glove bh 2 1,100 1,100
mex 7
unster bh 5 65 325
Hans
il 300 300
bh 1
aplast
Hypaf
bh 10 31,700 317,000
ix
Kasa bh 30 12,750 382,500
Mask 15,000 75,000
bh 5
er
Mess
bh 1 21,300 21,300
10
Oksig
mess
en bh 1 2,300 2,300
20
nasal
Spino bh 1 47,400 47,400
/mask
cam bh 1 71,500 71,500
er
Syrin
25 4,500 9,000
bh 2
ge 3
Syrin
bh 3 10,400 31,200
ge 10
Syrin
Topi bh 2 12,300 24,600
ge 5
dispo bh 5 9,650 48,250
Poliso
sable sct 1 800 800
rb 3.0
Poliso
sct 2 10,300 20,600
rb 2.0
nilon
sct 1
2.0
Alkoh
cc 50
ol
hibice
cc 100
tEpine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
Onda lpm
en
2
ncetro amp 1
P
n ovid cc 300
on
PZ fles 5
RL amp 1
pehidr cc 100
urine tube 1
underp bh 1
sufratu bh 1
softbanbh 1
tensocrbh 1
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr. Cruris) 2 x 60,000
Kruk
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Antebrachii Rp 50,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Antebrachii 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 6 12,300 73,800
Ecosol fles 9 11,350 102,150
Profeni bh 6 14,000 84,000
Cefaso vial 6 103,200 619,200
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2
mex
Gam
bh 2
Glove
mex
unster bh 5 6,300 31,500
il
Kasa bh 20 1,100 1,100
Mask
bh 5 7,000 35,000
er
Mess
bh 1 2,000 2,000
10
Mess
bh
en
20
nasal bh 1 31,700 31,700
Syrin
/mask
bh 4
ge 10
Syrin
bh 2
ge 5
Syrin
bh 1
Topi
ge 3
dispo bh 5
Poliso
sable
rb sct 2
Poliso
2.0
rb sct 2
nilon
3.0
sct 1
3.0
Alkoh
cc 50
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
n
Povid
cc 300
on
pehid
cc 50
rol
PZ fles 5
RL amp 1
sufratu bh 2 42,050 84,100
Atracr bh
softban 1 10,400 10,400
ium /
tensocrbh
Tracri 1 12,300 12,300
um amp 1 14,000 14,000
Fenta
nyl amp 1 5,550 5,550
Isoflur
ane cc 30 4,300 129,000
olam /
Milloz amp 1 5,300 5,300
ncetro
n amp 1 16,200 16,200
Pethi
din amp 1 2,800 2,800
Atropi
propo amp
n 1 67,000 67,000
fol amp 1 800 800
WFI amp
arm 1 10,300 10,300
sling bh 1
ol
swab bh 6 12,700 76,200
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr. Antebrachi) 2 x 60,000
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 6 12,300 73,800
Ecosol fles 9 11,350 102,150
Profeni bh 7 14,000 98,000
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 176 176
mex
Gam
bh 2 300 600
mex
Gam
bh 2 1,300 2,600
Glove
mex
unster bh 5 1,100 1,100
il
Kasa bh 20 350 7,000
Mask
bh 5 7,000 35,000
er
Mess
bh 1 8,000 8,000
10
Mess
bh 42,050 -
en
20
nasal bh 1 2,000 2,000
Syrin
/mask
bh 4 21,300 85,200
ge 10
Syrin
bh 2 4,500 9,000
ge 5
Syrin
bh 1 11,300 11,300
ge 3
Topi
dispo bh 5 12,300 61,500
Poliso
sable
rb sct 2
Poliso
2.0
rb sct 2
nilon
3.0
sct 1
3.0
Alkoh
cc 50
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
P
n ovid
cc 300
on
pehid
cc 50
rol
PZ fles 5
RL amp 1
sufratu bh 2
softbanbh 1 14,000 14,000
tensocrbh 1 5,550 5,550
Tracri
um amp 1 4,300 4,300
Fenta
nyl amp 1 5,300 5,300
Isoflur
ane cc 30 16,200 486,000
olam /
Milloz amp 1 2,800 2,800
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr. Antebrachi) 2 x 60,000
Total
GIPS
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
LFT Rp 40,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
By Akomodasi RI x 30,000
Js. Pelayanan RI x -
injeksi 12 x 5,000
Persiapan Operasi
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 6 12,300 73,800
Profeni bh 6 14,000 84,000
Mitela bh 1 44,500 44,500
Benost tab 10 1,300 13,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4
Glove
oda
unster bh 5
il
Kasa bh 10
Mask
bh 5
en
er
nasal bh 1
Syrin
/mask
bh 5
Topi
ge
dispo bh 5
Hibisc
sable
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
n
PZ fles 5
RL amp 1
softbanbh 1
armsli bh 1
gipsonabh 3 2,000 6,000
Tracri
um amp 1 8,000 8,000
Fenta
nyl amp 1 5,550 5,550
Isoflur
ane cc 30 4,300 129,000
olam /
Milloz amp 1 5,300 5,300
ncetro
n amp 1 27,500 27,500
Pethi
din
propo amp 1 23,000 23,000
fol amp 1 800 800
Alkoh
WFI
ol amp 1 2,800 2,800
swab bh 6 10,300 61,800
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Patella (Genu) Rp 50,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Patela (Genu) x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 8 12,300 98,400
Ecosol fles 12 11,350 136,200
Profeni bh 6 14,000 84,000
Cefaso vial 7 103,200 722,400
Spt 5 c bh 4 5,300 21,200
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
Glove
oda
Gam bh 1 300 300
Gam
mex 8
bh 2 116,400 232,800
Glove
mex
Gam bh 2 1,300 2,600
Glove
mex 7
unster bh 5 1,100 1,100
ilHans
bh 1 7,000 7,000
aplast
Hypaf
bh 10 6,300 63,000
ix
Kasa bh 30 2,000 60,000
Mask
bh 5 350 1,750
er
Mess
bh 1 12,750 12,750
10
mess
bh 1 31,700 31,700
en
20
nasal bh 1
Spino
/mask
cam bh 1
Syrin
25
bh 2
ge 3
Syrin
bh 3
ge 10
Syrin
bh 2
Topi
ge 5
dispo bh 5
Poliso
sable
sct 1
rb 3.0
Poliso
sct 2
rb 2.0
nilon
sct 1
2.0
Alkoh
cc 50
ol
hibice
cc 100
t
Epine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300 72,000 21,600,000
on
PZ fles 5 21,300 106,500
RL amp 1 4,500 4,500
pehidr cc 100 8,000 800,000
urine tube 1 42,050 42,050
underp bh 1 11,300 11,300
sufratu bh 1 12,300 12,300
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa alat dr
Implant
Adiministrasi
a/j dr 2 x 75,000
Fisioterapi (Fr. Patella)
Kruk Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Patella (Genu) Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Patela (Genu) 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 8 12,300 98,400
Ecosol fles 12 11,350 136,200
Profeni bh 6 14,000 84,000
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
Glove
oda
Gam bh 1 300 300
Gam
mex 8
bh 2 116,400 232,800
Glove
mex
Gam bh 2 31,700 63,400
Glove
mex 7
unster bh 5 6,300 31,500
ilHans
bh 1 12,750 12,750
aplast
Hypaf
bh 10 350 3,500
ix
Kasa bh 30 1,300 2,600
Mask
bh 5 1,100 1,100
er
Mess
bh 1 7,000 7,000
10
mess
bh 1 2,000 2,000
en
20
nasal bh 1 72,000 72,000
Spino
/mask
cam bh 1 21,300 21,300
Syrin
25
bh 2 4,500 9,000
ge 3
Syrin
bh 3 8,000 24,000
ge 10
Syrin
bh 2 42,050 84,100
Topi
ge 5
dispo bh 5 11,300 56,500
Poliso
sable
sct 1 12,300 12,300
rb 3.0
Poliso
sct 2
rb 2.0
nilon
sct 1
2.0
Alkoh
cc 50
ol
hibice
cc 100
t
Epine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
urine tube 1
underp bh 1
sufratu bh 1
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr. Patella) 2 x 75,000
Kruk
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
injeksi 16 x 5,000
Persiapan Operasi
Huknah
Skiren
Thorax 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Cefaso vial 6 103,200 619,200
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 22,800 45,600
mex
Gam
bh 2 12,750 25,500
Glove
mex
unster bh 5 350 1,750
il
Kasa bh 20 1,300 2,600
Mask
bh 5 1,100 1,100
er
Mess
bh 1 400 400
10
Mess
bh 31,700 -
en
20
nasal bh 1 2,000 2,000
Syrin
/mask
bh 4
ge 10
Syrin
bh 2
ge 5
Syrin
bh 1
ge 3
Topi
dispo bh 5
Poliso
sable
rb sct 2
Poliso
2.0
rb sct 2
nilon
3.0
sct 1
3.0
Alkoh
cc 50
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
pehid
cc 50 72,000 3,600,000
rol
PZ fles 5 21,300 106,500
RL amp 1 4,500 4,500
sufratu bh 2 11,300 22,600
Tracri
um amp 1 5,300 5,300
Fenta
nyl amp 1 16,200 16,200
Isoflur
ane cc 30 2,800 84,000
olam /
Milloz amp 1 12,700 12,700
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator 2 x 60,000
Sewa Kamar Operasi Total
Sewa alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr.Clavicula)
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Thorax 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 6 12,300 73,800
Ecosol fles 8 11,350 90,800
Profeni bh 4 14,000 56,000
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 22,800 45,600
mex
Gam
bh 2 6,300 12,600
Glove
mex
unster bh 5 1,300 2,600
il
Kasa bh 20 1,100 1,100
Mask
bh 5 350 1,750
er
Mess
bh 1 400 400
10
Mess
bh 7,000 -
en
20
nasal bh 1 2,000 2,000
Syrin
/mask
bh 4 31,700 126,800
ge 10
Syrin
bh 2 12,750 25,500
ge 5
Syrin
bh 1 72,000 72,000
Topi
ge 3
dispo bh 5 21,300 106,500
Poliso
sable
rb sct 2 4,500 9,000
Poliso
2.0
rb sct 2 8,000 16,000
nilon
3.0
sct 1 11,300 11,300
3.0
Alkoh
cc 50 12,300 615,000
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
sufratu bh 2
Tracri
um
Fenta amp 1
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant 2 x 60,000
Total
Adiministrasi
a/j dr
Fisioterapi (Fr.Clavicula)
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Humerus Rp 50,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Humerus 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 6 12,300 73,800
Ecosol fles 9 11,350 102,150
Profeni bh 6 14,000 84,000
Cefaso vial 6 103,200 619,200
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 350 350
mex
Gam
bh 2 1,300 2,600
mex
Gam
bh 2 1,100 1,100
Glove
mex
unster bh 5 7,000 35,000
il
Kasa bh 20 300 6,000
Mask
bh 5 93,100 465,500
er
Mess
bh 1 2,000 2,000
10
Mess
bh 6,300 -
en
20
nasal bh 1 12,750 12,750
Syrin
/mask
bh 4
ge 10
Syrin
bh 2
ge 5
Syrin
bh 1
Topi
ge 3
dispo bh 5
Poliso
sable
rb sct 2
Poliso
2.0
rb sct 2
nilon
3.0
sct 1
3.0
Alkoh
cc 50
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300 21,300 6,390,000
on
pehid
cc 50 2,000 100,000
rol
PZ fles 5 72,000 360,000
RL amp 1 4,500 4,500
sufratu bh 2 8,000 16,000
softbanbh 1 42,050 42,050
tensocrbh 1 11,300 11,300
Tracri
um amp 1 12,300 12,300
Fenta
nyl amp 1 14,000 14,000
Isoflur
ane cc 30 5,550 166,500
olam /
Milloz amp 1 4,300 4,300
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Sewa Kamar Operasi Total
Sewa alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr.Humerus)
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Humerus Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 9 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Humerus 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 6 12,300 73,800
Ecosol fles 8 11,350 90,800
Profeni bh 4 14,000 56,000
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 93,100 186,200
mex
Gam
bh 2 6,300 12,600
Glove
mex
unster bh 5 350 1,750
il
Kasa bh 30 1,300 2,600
Mask
bh 5 1,100 1,100
er
Mess
bh 1 7,000 7,000
10
Mess
bh 2,000 -
en
20
nasal bh 1 12,750 12,750
Syrin
/mask
bh 4 2,000 8,000
ge 10
Syrin
bh 2 72,000 144,000
ge 5
Syrin
bh 1 21,300 21,300
ge 3
Topi
dispo bh 5 4,500 22,500
Poliso
sable
rb sct 2 8,000 16,000
Poliso
2.0
rb sct 2 42,050 84,100
nilon
3.0
sct 1 11,300 11,300
3.0
Alkoh
cc 50 12,300 615,000
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
sufratu bh 2
softbanbh 1
tensocrbh 1
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
Jasa Tindakan swab bh 6
Dokter Ahli Bedah
Penata Anastesi 2 x 60,000
Tim Operator Total
Sewa Kamar Operasi
Sewa Alat dr
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr.Humerus)
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Phalang (Digit) Rp 50,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
Persiapan Operasi
Huknah
Skiren
Ro. Phalang (Digit) 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Cefaso vial 6 103,200 619,200
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 6,300 12,600
mex
Gam
bh 2 350 700
Glove
mex
unster bh 5 1,300 2,600
il
Kasa bh 30 1,100 1,100
Mask
bh 5 7,000 35,000
er
Mess
bh 1 2,000 2,000
en
15
nasal bh 1 4,500 4,500
Syrin
/mask
bh 4 2,000 8,000
ge 10
Syrin
bh 2 21,300 42,600
ge 5
Syrin
bh 1
Topi
ge 3
dispo bh 5
Poliso
sable
rb sct 1
atrau
3.0
sct 2
matik
Alkoh
cc 50
ol
hibice
cc 100
t
pehid
cc 100
rol
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n cc 300
on
PZ fles 5
RL amp 1
sufratu bh 2
Tracri
um amp 1 42,050 42,050
Fenta
nyl amp 1 10,400 10,400
Isoflur
ane cc 30 12,300 369,000
olam /
Milloz amp 1 14,000 14,000
ncetro
n amp 1 5,550 5,550
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
l 15
cm bh 1
haft 4
cm bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi 2 x 60,000
Sewa alat dr
Implant Total
Adiministrasi
a/j dr
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 3 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 3 11,350 34,050
Profeni bh 1 14,000 14,000
Jarum bh 1 1,400 1,400
Vicilli vial 3 13,600 40,800
Spt 5 c bh 1 5,300 5,300
Kasa st dos 8,500 -
Lomatulbr 1 14,000 14,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 6,300 12,600
mex
Gam
bh 2 350 700
Glove
mex
unster bh 5 1,300 2,600
il
Kasa bh 30 1,100 1,100
Mask
bh 5 7,000 35,000
er
Mess
bh 1 2,000 2,000
en
15
nasal bh 1 12,750 12,750
Syrin
/mask
bh 4 2,000 8,000
ge 10
Syrin
bh 2 21,300 42,600
ge 5
Syrin
bh 1 4,500 4,500
ge 3
Topi
dispo bh 5 8,000 40,000
Poliso
sable
rb sct 1 42,050 42,050
atrau
3.0
sct 2 11,300 22,600
matik
Alkoh
cc 50 12,300 615,000
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
sufratu bh 2
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
Midaz
ane /
olam cc 30
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
l 15
cm bh 1
haft 4
cm bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant 2 x 60,000
Adiministrasi Total
a/j dr
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Manus Rp 50,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Manus 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Cefaso vial 6 103,200 619,200
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 6,300 12,600
mex
Gam
bh 2 350 700
Glove
mex
unster bh 5 1,300 2,600
il
Kasa bh 30 1,100 1,100
Mask
bh 5 7,000 35,000
er
Mess
bh 1 2,000 2,000
en
15
nasal bh 1 12,750 12,750
Syrin
/mask
bh 4 2,000 8,000
ge 10
Syrin
bh 2 21,300 42,600
ge 5
Syrin
bh 1 4,500 4,500
Topi
ge 3
dispo bh 5
Poliso
sable
rb sct 1
atrau
3.0
sct 2
matik
Alkoh
cc 50
ol
hibice
cc 100
t
pehid
cc 100
rol
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1 8,000 8,000
sufratu bh 2 42,050 84,100
Tracri
um amp 1 11,300 11,300
Fenta
nyl amp 1 12,300 12,300
Isoflur
ane cc 30 14,000 420,000
olam /
Milloz amp 1 5,550 5,550
ncetro
n amp 1 4,300 4,300
Pethi
din amp 1 5,300 5,300
Atropi
n amp 1 16,200 16,200
propo
fol amp 1 2,800 2,800
WFI amp 1
l 15
cm bh 1
haft 4
cm bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa alat dr 2 x 60,000
Implant
Total
Adiministrasi
Kruk
a/j dr
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Manus Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 3 11,350 34,050
Profeni bh 1 14,000 14,000
Jarum BH 1 1,600 1,600
Vicilli vial 3 13,600 40,800
Spt 5 c bh 2 5,300 10,600
Kasa st dos 8,500 -
Lomatulbr 14,000 -
Isodinecc 300 -
Tensoc rol 67,000 -
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 350 350
mex
Gam
bh 2 4,500 9,000
mex
Gam
bh 2 1,300 2,600
Glove
mex
unster bh 5 1,100 1,100
il
Kasa bh 30 1,500 45,000
Mask
bh 5 300 1,500
er
Mess
bh 1 6,300 6,300
en
15
nasal bh 1 12,750 12,750
Syrin
/mask
bh 4 21,300 85,200
ge 10
Syrin
bh 2 4,500 9,000
ge 5
Syrin
bh 1 2,000 2,000
Topi
ge 3
dispo bh 5 8,000 40,000
Poliso
sable
rb sct 1 42,050 42,050
atrau
3.0
sct 2 11,300 22,600
matik
Alkoh
cc 50 12,300 615,000
ol
hibice
cc 100 14,000 1,400,000
t
Hibisc
cc 100
rub
Oksig
lpm 2
en
Onda
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
sufratu bh 2
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
Midaz
ane /
olam cc 30
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
l 15
cm bh 1
haft 4
cm bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant 1 x 60,000
Adiministrasi Total
a/j dr
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Manus Rp 50,000
ECG
Ps. Spalk
Hecting
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Cefaso vial 1 103,200 103,200
Spt 5 c bh 1 5,300 5,300
ATS 15amp 1 119,800 119,800
Spt 3 c bh 1 4,300 4,300
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 5 12,300 61,500
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Cefaso vial 6 103,200 619,200
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 6,300 12,600
mex
Gam
bh 2 1,300 2,600
Glove
mex
unster bh 5 1,100 1,100
il
Kasa bh 30 350 10,500
Mask
bh 5 7,000 35,000
er
Mess
bh 1 2,000 2,000
en
15
nasal bh 1 12,750 12,750
Syrin
/mask
bh 4 2,000 8,000
ge 10
Syrin
bh 2 21,300 42,600
ge 5
Syrin
bh 1 4,500 4,500
Topi
ge 3
dispo bh 5
Poliso
sable
rb sct 1
atrau
3.0
sct 2
matik
Alkoh
cc 50
ol
hibice
cc 100
t
pehid
cc 100
rol
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5 8,000 40,000
RL amp 1 42,050 42,050
sufratu bh 2 11,300 22,600
Tracri
um amp 1 12,300 12,300
Fenta
nyl amp 1 14,000 14,000
Isoflur
ane cc 30 5,550 166,500
olam /
Milloz amp 1 4,300 4,300
ncetro
n amp 1 5,300 5,300
Pethi
din amp 1 16,200 16,200
Atropi
n amp 1 2,800 2,800
propo
fol amp 1 12,700 12,700
WFI amp 1
l 15
cm bh 1
haft 4
cm bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa alat dr 2 x 60,000
Implant
Total
Adiministrasi
Kruk
a/j dr
IGD
Laboratorium
DL Rp 30,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Manus Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 3 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 3 11,350 34,050
Profeni bh 1 14,000 14,000
Jarum BH 1 1,600 1,600
Vicilli vial 3 13,600 40,800
Spt 5 c bh 2 5,300 10,600
Kasa st dos 8,500 -
Lomatulbr 14,000 -
Isodinecc 300 -
Tensoc rol 67,000 -
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 350 350
mex
Gam
bh 2 7,000 14,000
mex
Gam
bh 2 2,000 4,000
Glove
mex
unster bh 5 300 1,500
il
Kasa bh 30 6,300 189,000
Mask
bh 5 1,300 2,600
er
Mess
bh 1 1,100 1,100
en
15
nasal bh 1 12,750 12,750
Syrin
/mask
bh 4 21,300 85,200
ge 10
Syrin
bh 2 4,500 9,000
ge 5
Syrin
bh 1 2,000 2,000
Topi
ge 3
dispo bh 5 8,000 40,000
Poliso
sable
rb sct 1 42,050 42,050
atrau
3.0
sct 2 11,300 22,600
matik
Alkoh
cc 50 12,300 615,000
ol
hibice
cc 100 14,000 1,400,000
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
sufratu bh 2
Tracri
um amp 1
Fenta
nyl
Isoflur amp 1
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1 5,550 5,550
WFI amp 1 4,300 4,300
l 15
cm bh 1
haft 4
cm bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant 1 x 60,000
Adiministrasi Total
a/j dr
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Femur Rp 60,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 15 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 7 12,300 86,100
Ecosol fles 9 11,350 102,150
Profeni bh 6 14,000 84,000
Vicilli vial 8 13,600 108,800
Spt 5 c bh 3 5,300 15,900
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 85,000 85,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
Glove
oda
Gam bh 1 300 300
Gam
mex 8
bh 2 116,400 232,800
Glove
mex
Gam bh 2 350 700
Glove
mex 7
unster bh 5 400 2,000
ilHans
bh 1 1,300 2,600
aplast
Hypaf
bh 10 1,100 1,100
ix
Kasa bh 40 7,000 280,000
Mask
bh 5 2,000 10,000
er
Mess
bh 1 2,300 2,300
10
mess
bh 1 49,900 49,900
en
20
nasal bh 1 15,000 15,000
Spino
/mask
cam bh 1 21,300 21,300
Syrin
25
bh 2 47,400 94,800
ge 3
Syrin
bh 3 71,500 214,500
ge 10
Syrin
bh 2 22,000 44,000
ge 5
Topi
dispo bh 5 4,500 22,500
Poliso
sable
sct 2
rb 1
Poliso
sct 1
rb 0
Poliso
sct 2
rb 2.0
nilon
sct 1
0
atrau
sct 1
matik
Alkoh
cc 50
ol
hibice
cc 100
t
Epine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
pehidr cc 100
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
foley c bh 1
kasa hi bh 2
sufratu bh 1
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Sewa Kamar Operasi
Sewa Alat dr Total
Implant
Adiministrasi
a/j dr
Fisioterapi (Fr. Femur)
Kruk
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Pelvis Rp 60,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 6 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Pelvis 1 x 60,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Ecosol fles 3 11,350 34,050
Profeni bh 6 14,000 84,000
Benost tab 10 1,300 13,000
Tensoc rol 1 85,000 85,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 2,000 8,000
Glove
oda
Gam bh 1 1,300 2,600
Gam
mex 8
bh 2 1,100 1,100
Glove
mex
Gam bh 2 8,000 16,000
Glove
mex 7
unster bh 5 16,200 81,000
ilHans
bh 1 5,550 5,550
aplast
Hypaf
bh 10 5,300 53,000
ix
Kasa bh 40 4,300 172,000
Mask
bh 5 12,700 63,500
en
er
nasal bh 1 85,000 85,000
Spino
/mask
cam bh 1
Syrin
25
bh 2
ge 3
Syrin
bh 3
ge 10
Syrin
bh 2
Topi
ge 5
dispo bh 5
atrau
sable
sct 1
matik
Alkoh
cc 50
ol
hibice
cc 100
t
Epine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300 x 75,000
on
PZ fles 5
RL amp 1
kasa hi bh 2
softbanbh 1
tensocrbh 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi (Fr. femur)
a/j dr
Kruk
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Cruris Rp 60,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Kasa st dos 1 8,500 8,500
Gamex bh 1 21,300 21,300
Vicilli vial 1 13,600 13,600
Ottogenamp 1 11,000 11,000
Spt 5 c bh 1 5,300 5,300
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 6 12,300 73,800
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Vicilli vial 6 13,600 81,600
Ottogenamp 4 11,000 44,000
Spt 5 c bh 3 5,300 15,900
Optiva bh 1 23,000 23,000
Kasa st dos 3 8,500 25,500
Lomatulbr 2 14,000 28,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Verban rol 5 1,300 6,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
Glove
oda
Gam bh 5 300 1,500
Glove
mex
unster bh 5 22,800 114,000
ilHypaf
bh 10 1,300 2,600
ix
Kasa bh 20 1,100 1,100
Mask
bh 5 350 1,750
er
Mess bh 1 7,000 7,000
en
nasal bh 1 127 127
Syrin
/mask
bh 5 250 1,250
ge
Topi
dispo bh 5 2,300 11,500
Poliso
sable
sct 3 15,000 45,000
rb
nilon sct 1 21,300 21,300
Alkoh
cc 50 47,400 2,370,000
ol
hibice
cc 100 -
t
Hibisc
cc 100
rub
Oksig
lpm 2
en
pehid
cc 50
Onda
rol
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
elastomcm 50
sufratu bh 1
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1 71,500 71,500
ncetro
n amp 1 4,500 4,500
Pethi
din amp 1 11,300 11,300
Atropi
n amp 1 12,300 12,300
propo
fol amp 1 14,000 14,000
WFI amp 1 4,300 4,300
ol
swab bh 6 1,300 7,800
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Fisioterapi (Amputasi Bellow Knee) 3 x 75,000
Kruk
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
GDA Rp 10,000
OT PT Rp 20,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Femur Rp 60,000
ECG
injeksi 6 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 3 11,350 34,050
Vicilli vial 2 13,600 27,200
Profeni bh 2 14,000 28,000
Spt 5 c bh 1 5,300 5,300
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 7,000 14,000
mex
Gam
bh 2 1,300 2,600
Glove
mex
unster bh 5 1,100 1,100
il
Kasa bh 20 400 8,000
Mask
bh 5 12,750 63,750
er
Mess
bh 1 31,700 31,700
10
Mess
bh 22,800 -
en
20
nasal bh 1 2,000 2,000
Syrin
/mask
bh 4 350 1,400
ge 10
Syrin
bh 2 71,500 143,000
ge 5
Syrin
bh 1 47,400 47,400
ge 3
Topi
dispo bh 5 5,300 26,500
Poliso
sable
rb sct 2 2,300 4,600
Poliso
2.0
rb sct 2 21,300 42,600
nilon
3.0
sct 1 15,000 15,000
3.0
Alkoh
cc 50 800 40,000
ol
hibice
cc 100 10,300 1,030,000
tHibisc
cc 100 4,500 450,000
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
pehid
cc 50
rol
PZ fles 5
RL amp 1
sufratu bh 2
softbanbh 1
tensocrbh 1
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Total
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
GDA Rp 10,000
OT PT Rp 20,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Femur Rp 60,000
ECG
injeksi 3 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 2 11,350 22,700
Vicilli vial 2 13,600 27,200
Profeni bh 1 14,000 14,000
Jarum bh 1 1,600 1,600
Spt 5 c bh 1 5,300 5,300
Kasa st dos 8,500 -
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinecc 300 -
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4
Glove
oda
Gam bh 1
Gam
mex 8
bh 2
Glove
mex
Gam bh 2
Glove
mex 7
unster bh 5
ilHans
bh 1
aplast
Hypaf
bh 10
ix
Kasa bh 40
Mask
bh 5
er
Mess
bh 1
10
mess
bh 1
en
20
nasal bh 1
Spino
/mask
cam bh 1
Syrin
25
bh 2
ge 3
Syrin
bh 3
ge 10
Syrin
bh 2
Topi
ge 5
dispo bh 5
Poliso
sable
sct 2
rb 1
Poliso
sct 1
rb 0
Poliso
sct 2
rb 2.0
nilon
sct 1
0
atrau
sct 1
matik
Alkoh
cc 50
ol
hibice
cc 100
t
Epine
amp 1 1,100 1,100
prin
Hibisc
cc 100 7,000 700,000
rub
Lidod
amp 1 400 400
ex
Oksig
lpm 2 12,750 25,500
Onda
en
ncetro amp 1 31,700 31,700
Povid
n
cc 300 22,800 6,840,000
on
PZ fles 5 2,000 10,000
RL amp 1 350 350
pehidr cc 100 71,500 7,150,000
urine tube 1
blood sbh 1
underp bh 1
ky jelli sct 2
foley c bh 1
kasa hi bh 2
sufratu bh 1
softbanbh 1
tensocrbh 1 x 60,000
Jasa Tindakan
Dokter Ahli Bedah Total
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
a/j dr
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
GDA Rp 10,000
OT PT Rp 20,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 3 x 5,000
Persiapan Operasi
Huknah
Skiren
Rawat Luka x 25,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 3 11,350 34,050
Vicilli vial 2 13,600 27,200
Profeni bh 2 14,000 28,000
Spt 5 c bh 2 5,300 10,600
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
oda
Gam
bh 1 300 300
mex
Gam
bh 2 7,000 14,000
mex
Gam
bh 2 1,300 2,600
Glove
mex
unster bh 5 1,100 1,100
il
Kasa bh 20 400 8,000
Mask
bh 5 12,750 63,750
er
Mess
bh 1 31,700 31,700
en
15
nasal bh 1 350 350
Syrin
/mask
bh 4 71,500 286,000
ge 10
Syrin
bh 2 47,400 94,800
ge 5
Syrin
bh 1 4,300 4,300
ge 3
Topi
dispo bh 5 12,300 61,500
Poliso
sable
rb sct 2 21,300 42,600
Poliso
2.0
rb sct 2 15,000 30,000
nilon
3.0
sct 1 85,000 85,000
3.0
Alkoh
cc 50 14,000 700,000
ol
hibice
cc 100 800 80,000
tHibisc
cc 100 10,300 1,030,000
rub
Oksig
lpm 2 4,500 9,000
Onda
en
ncetro amp 1
Povid
n
cc 300
on
pehid
cc 50
rol
PZ fles 5
RL amp 1
sufratu bh 2
softbanbh 1
tensocrbh 1
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Sewa Kamar Operasi
Total
Adiministrasi
Fisioterapi
a/j dr
Poli MH
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Pedis Rp 50,000
ECG
injeksi 12 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro. Pedis 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Gamex bh 1 21,300 21,300
Ecosole fles 7 12,300 86,100
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Vicilli vial 7 13,600 95,200
Ottogenamp 5 11,000 55,000
Spt 5 c bh 4 5,300 21,200
Optiva bh 1 23,000 23,000
Kasa st dos 4 8,500 34,000
Lomatulbr 2 14,000 28,000
Isodine cc 60 300 18,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Verban rol 15 1,300 19,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
Glove bh 4 65 260
oda
Gam
Glove bh 1 300 300
mex
Gam
Glove bh 2 228 456
8
mex
Gam 350 700
7,5
Glove bh 2
mex
unster
7 bh 5 7,000 35,000
ilKasa bh 20 12,750 255,000
Mask 250 1,250
bh 5
er
Oksig
Mess
en bh 1 250 250
15
nasal bh 1 2,300 2,300
Syrin
/mask 15,000 60,000
bh 4
ge
er 10
Syrin
bh 2 21,300 42,600
ge 5
Syrin
Topi bh 1 47,400 47,400
ge 3
dispo
Poliso bh 5 1,300 2,600
sable
rb sct 2 1,100 1,100
Poliso
2.0
rb sct 2 71,500 143,000
nilon
3.0 4,500 4,500
sct 1
3.0
Alkoh
cc 50 11,300 565,000
ol
hibice
cc 100 12,300 1,230,000
tHibisc
cc 100 14,000 1,400,000
rub
Oksig
Onda lpm 2 4,300 8,600
en
ncetro amp 1 1,300 1,300
Povid
n 27,500 8,250,000
cc 300
on
pehid
cc 50 800 40,000
rol
PZ fles 5 10,300 51,500
RL amp 1 11,300 11,300
sufratu bh 2
softbanbh 1
tensocrbh 1
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1 x 60,000
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
arm
sling bh 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi
Kruk
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
SC Rp 20,000
OT PT 20,000
GDA Rp 10,000
Radiologi
Thorax Rp 50,000
ECG
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Optiva bh 1 23,000 23,000
Transe bh 1 34,300 34,300
Ecosol fles 3 12,300 36,900
Ecosol fles 3 11,350 34,050
Vicilli vial 2 13,600 27,200
Profeni bh 2 14,000 28,000
Spt 5 c bh 2 5,300 10,600
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Gam
bh 1 6,300 6,300
mex
Gam
bh 2 8,000 16,000
mex
Gam
bh 2 16,200 32,400
Glove
mex
unster bh 5 42,050 210,250
il
Kasa bh 20 12,700 254,000
Mask
bh 5 2,800 14,000
er
Mess
bh 1 2,000 2,000
10
Mess
bh 1
20
needl
bh 4
en
e 18
nasal bh 1 7,000 7,000
/mask
Syrin
bh 4 67,000 268,000
ge 10
Syrin
bh 2 14,000 28,000
ge 5
Syrin
bh 1 21,300 21,300
Topi
ge 3
dispo bh 5 12,300 61,500
Poliso
sable
rb sct 2 11,300 22,600
Poliso
2.0
rb sct 2 300 600
nilon
3.0
sct 1 1,300 2,600
3.0
Alkoh
cc 50 1,100 1,100
ol
hibice
cc 100 65 6,500
t
Hibisc
cc 100 350 35,000
rub
Oksig
lpm 2 51,250 102,500
Onda
en
ncetro amp 1 31,700 31,700
Povid
n
cc 300 36,350 10,905,000
on
pehid
cc 50 27,500 1,375,000
rol
PZ fles 5 800 4,000
RL amp 1 10,300 10,300
sufratu bh 2 4,500 9,000
softbanbh 1
tensocrbh 1
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1 x 60,000
p4
inc bh 1
nd 4
inc bh 1
crepe
4 inc bh 1
Total
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi
a/j dr
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
injeksi 3 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 3 12,300 36,900
Ecosol fles 3 11,350 34,050
Profeni bh 2 14,000 28,000
Vicilli vial 6 13,600 81,600
Spt 5 c bh 2 5,300 10,600
Kasa st dos 1 8,500 8,500
Lomatulbr 1 14,000 14,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Mitela bh 1 44,500 44,500
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Electr
bh 4 65 260
Glove
oda
Gam bh 5 300 1,500
Glove
mex
unster bh 5 6,300 31,500
ilHans
bh 1 350 350
aplast
Hypaf
bh 10 7,000 70,000
ix
Kasa bh 20 2,000 40,000
Mask
bh 5 127,500 637,500
er
Mess bh 2 2,000 4,000
en
nasal bh 1 1,300 2,600
Spino
/mask
bh 1 1,100 1,100
cam
Syrin
bh 5 21,300 106,500
Topi
ge
dispo bh 5 4,500 22,500
Poliso
sable
sct 3 8,000 24,000
rb
nilon sct 1 42,050 42,050
Alkoh
cc 50 11,300 565,000
ol
hibice
cc 100 12,300 1,230,000
t
Epine
amp 1
prin
Hibisc
cc 100
rub
Lidod
amp 1
ex
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300
on
PZ fles 5
RL amp 1
pehidr cc 100
sufratu bh 1
kasa hi bh 2
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Sewa Alat dr
Implant
Adiministrasi
a/j dr
Total
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 3 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Mitela bh 1 44,500 44,500
Profeni bh 6 14,000 84,000
Benost tab 10 1,300 13,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Gam
bh 1 2,000 2,000
mex
Gam
bh 2 1,300 2,600
mex
Gam
bh 2 1,100 1,100
Glove
mex
unster bh 5 8,000 40,000
il
Kasa bh 20 16,200 324,000
Mask
bh 5 5,550 27,750
er
Mess
bh 1 5,300 5,300
10
Mess
bh 1 4,300 4,300
20
needl
bh 4
e 18
en
nasal bh 1
Syrin
/mask
bh 4
ge 10
Syrin
bh 2
ge 5
Syrin
bh 1
Topi
ge 3
dispo bh 5
Poliso
sable
rb sct 2
Poliso
2.0
rb sct 2
nilon
3.0
sct 1
3.0
Alkoh
cc 50
ol
hibice
cc 100
t
Hibisc
cc 100
rub
Oksig
lpm 2
Onda
en
ncetro amp 1
Povid
n
cc 300 12,700 3,810,000
on
pehid
cc 50 2,800 140,000
rol
PZ fles 5 27,500 137,500
RL amp 1 36,350 36,350
sufratu bh 2 800 1,600
softbanbh 1
tensocrbh 1
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1 x 60,000
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Adiministrasi
Fisioterapi (fr. Cruris)
a/j dr
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
Ps. Spalk
Obat-obatan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
Verban rol 10 1,300 13,000
Profeni bh 1 14,000 14,000
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 2 12,300 24,600
Mitela bh 1 44,500 44,500
Profeni bh 6 14,000 84,000
Benost tab 10 1,300 13,000
Material Bedah
Nama Obat
Sat Keb Harga Total
Sat.
Gam
bh 1
mex
Gam
bh 2
mex
Gam
bh 2
Glove
mex
unster bh 5
il
Kasa bh 20
Mask
bh 5
er
Mess
bh 1
en
10
nasal bh 1
Syrin
/mask
bh 4
ge 10
Syrin
bh 2
ge 5
Syrin
bh 1
Topi
ge 3
dispo bh 5
Poliso
sable
rb sct 2 2,000 4,000
nilon
3.0
sct 2 16,200 32,400
3.0
Alkoh
cc 50 5,550 277,500
ol
hibice
cc 100 5,300 530,000
t
Hibisc
cc 100 4,300 430,000
rub
Oksig
lpm 2 12,700 25,400
Onda
en
ncetro amp 1 2,800 2,800
Povid
n
cc 300 27,500 8,250,000
on
pehid
cc 50 36,350 1,817,500
rol
PZ fles 5 800 4,000
RL amp 1 10,300 10,300
sufratu bh 2
Tracri
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
din amp 1
Atropi
n amp 1
propo
fol amp 1
WFI amp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
2 x 60,000
Adiministrasi
Fisioterapi (fr. Cruris) Total
a/j dr
IGD
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
Waters Rp 50,000
Skull Rp 75,000
ECG
Obat UGD
Nama Obat
Sat Keb Harga Total
Sat.
Profeni bh 1 14,000 14,000
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosol fles 1 12,300 12,300
injeksi 9 x 5,000
Persiapan Operasi
Huknah
Skiren
Ro Waters 1 x 50,000
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Ecosol fles 7 12,300 86,100
Ecosol fles 11 11,350 124,850
Vicilli vial 11 13,600 149,600
Profeni bh 6 14,000 84,000
Spt 5 c bh 4 5,300 21,200
Kasa st dos 1 8,500 8,500
Benost tab 10 1,300 13,000
Amobiotab 10 3,000 30,000
Isodinefles 1 19,000 19,000
Magslabh 1 29,500 29,500
Spuit 2 bh 1 9,650 9,650
Etason amp 6 6,000 36,000
Material Bedah
Glove Sat.
Gam
Glove 93,100 93,100
bh 1
mex
Gam
Glove
8 bh 2 6,300 12,600
mex
Gam
7,5
Glove bh 2 350 700
mex
unster
7 bh 5 250 1,250
ilKasa bh 20 1,300 2,600
Mask 1,100 1,100
bh 5
er
Oksig
Mess
en bh 1 7,000 7,000
10
nasal bh 1 2,000 2,000
Syrin
/mask bh 89,500 358,000
4
ge
er 10
Syrin
bh 2 2,000 4,000
ge
Syrin5
Topi bh 1 72,000 72,000
ge 3
Poliso bh
dispo 5 21,300 106,500
sable sct
rb 2 4,500 9,000
nilon
3.0 42,050 84,100
sct 2
3.0
Alkoh
cc 50 11,300 565,000
ol
hibice
cc 100 12,300 1,230,000
tHibisc
cc 100 5,550 555,000
rub
Oksig
Onda lpm 2 9,650 19,300
en
ncetro amp 1 4,300 4,300
P
n ovid cc 5,300 1,590,000
300
on
pehid
cc 50 16,200 810,000
rol
PZ fles 5 12,700 63,500
RL amp 1 800 800
sufratu
Tracri
bh 2 10,300 20,600
um amp 1
Fenta
nyl amp 1
Isoflur
ane cc 30
olam /
Milloz amp 1
ncetro
n amp 1
Pethi
Sulfas
Atropi amp
din 1
n amp 1
propo
fol amp 1
WFI amp 1
ol
swab bh 6
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa Kamar Operasi
Implant
Adiministrasi
a/j dr
Total
J. MATA
Poli Umum
Laboratorium
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
LFT Rp 40,000
GDA Rp 10,000
SC Rp 20,000
Radiologi
Thorax Rp 50,000
ECG
injeksi 3 x 5,000
Persiapan Operasi
Obat Ruangan
Nama Obat
Sat Keb Harga Total
Sat.
Transe bh 1 34,300 34,300
Optiva bh 1 23,000 23,000
Ecosole fles 7 12,300 86,100
Gamex bh 1 21,300 21,300
Transe bh 1 34,300 34,300
Ecosol fles 8 11,350 90,800
Profeni bh 6 14,000 84,000
Vicilli vial 7 13,600 95,200
Ottogenamp 5 11,000 55,000
Spt 5 c bh 4 5,300 21,200
Optiva bh 1 23,000 23,000
Kasa st dos 4 8,500 34,000
Lomatulbr 2 14,000 28,000
Isodine cc 60 300 18,000
Tensoc rol 1 67,000 67,000
Benost tab 10 1,300 13,000
Bernof tab 10 13,600 136,000
Verban rol 15 1,300 19,500
Material Bedah
Electr
oda bh 4
mex
7,5 bh 1
mex
7 bh 1
mex
6,5 bh 1
unster
il bh 5
Hypaf
ix cm 10
Kasa bh 30
Mask
er bh 5
Mess
11 bh 1
tuberc
ulin bh 5
Syrin
ge 3 bh 5
Syrin
ge 5 bh 5
ussio
n Set bh 2
dispo
sable bh 5
Hibisc
rub cc 100 Sat.
Povid
on cc 200 1,300 2,600
PZ fles 1 1,100 1,100
RL amp 2 7,000 14,000
lidocai amp 1
efrisel vial 1
medriatvial 1
pantoc vial 1
gentamiamp 1
lidocai amp 1
dexameamp 1
Jasa Tindakan
Dokter Ahli Bedah
Penata Anastesi
Tim Operator
Sewa alat
Sewa Kamar Operasi
Adiministrasi
CA MAMAE (MASTEKTOMIE)
Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix cm 10 400 4,000
Kasa bh 30 7,000 210,000
Masker bh 5 31,700 158,500
Mess 20 bh 1 12,750 12,750
Oksigen nasal /masker bh 1 12,750 12,750
Syringe 10 bh 3 2,000 6,000
Syringe 5 bh 2
Syringe 3 bh 1
Nylon 2.0 sct 1 1,100 1,100
Polisorb 2.0 sct 1 21,300 21,300
Alkohol 50 8,000 400,000
Fentanyl amp 1 11,300 11,300
Hibiscrub cc 100 12,300 1,230,000
Oksigen lpm 3 5,300 15,900
Povidon cc 300 34,300 10,290,000
PZ fles 1 12,700 12,700
RL fles 2 800 1,600
Sulfas Atropin
Trivam/recofol/savol/prop amp 1 103,300 103,300
ofol amp 1 14,000 14,000
WFI amp 1
Alkohol swab bh 6
STRUMA
Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix bh 10 350 3,500
Kasa bh 30 400 12,000
Masker bh 5 7,000 35,000
Mess 10 bh 2 2,000 4,000
Syringe 10 bh 2 72,000 144,000
Syringe 5 bh 2
Syringe 3 bh 2
Nylon 2.0 sct 1 1,100 1,100
Polisorb 2.0 sct 1
Alkohol 50 42,050 2,102,500
Fentanyl amp 1 12,300 12,300
Hibiscrub cc 100 14,000 1,400,000
Isoflurane cc 30 16,200 486,000
Oksigen lpm 3 34,300 102,900
Ondancetron 1 800 800
Pethidin amp 1 10,300 10,300
Povidon 300
PZ fles 1
RL fles 2
Sulfas Atropin
Trivam/recofol/savol/prop amp 1
ofol amp 1
WFI amp 1
alkohol swab bh 6
APPENDICITIS INFILTRAT / KRONIS
Material Bedah
Sat.
Glove Gammex 7 bh 2
Hypafix cm 10 6,300 63,000
Kasa bh 30 350 10,500
Masker bh 5 400 2,000
Mess 10 bh 1 4,500 4,500
Spinocam 25 bh 1 31,700 31,700
Syringe 3 bh 2 12,750 25,500
Nylon 2.0 sct 1 21,300 21,300
Polisorb 2.0 sct 1 4,500 4,500
Alkohol cc 50 42,050 2,102,500
Hibiscrub cc 100 12,300 1,230,000
Povidon cc 300 16,200 4,860,000
PZ fles 1 2,800 2,800
RL fles 3 12,700 38,100
HERNIA INCACERATA (LAPARATOMI)
Material Bedah
Sat.

Hypafix CM 20 6,300 126,000
Kasa bh 30 350 10,500
Masker bh 5 400 2,000
Mess 20 bh 1 7,000 7,000
Spinocam 25 bh 1 31,700 31,700

Syringe 3 bh 1
Syringe 5 bh 1
Syringe 10 bh 2 12,750 25,500
Nylon 2.0 sct 1 16,200 16,200

Polisorb 1 sct 2 21,300 42,600
Polisorb 2.0 sct 1
Siede atraumatik 0 sct 1 4,500 4,500
Alkohol cc 50 8,000 400,000

Hibiscrub cc 100 10,400 1,040,000
Lidodex amp 1 12,300 12,300
Oksigen lpm 2 5,550 11,100
Povidon cc 300 5,300 1,590,000
PZ fles 3 2,800 8,400
RL fles 3 12,700 38,100
APPENDICITIS ACUTA
Material Bedah
Sat.
Electroda bh 4
Glove Gammex 7 bh 2
Glove unsteril bh 5
Hansaplast bh 1
Hypafix cm 10
Kasa bh 30
Masker bh 5 65 325
Mess 10 bh 2 300 600
Spinocam 25 bh 1 350 350
Nylon 2.0 sct 1 31,700 31,700
Polisorb 2.0 sct 2 12,750 25,500
Alkohol cc 50 2,300 115,000
Hibiscrub cc 100 47,400 4,740,000
Lidodex amp 1 71,500 71,500
Povidon cc 300 12,300 3,690,000
PZ fles 1 800 800
RL fles 3 10,300 30,900
HERNIA BILATERAL
Material Bedah
Sat.
Electroda bh 4
Glove Gammex 7 bh 2
Glove unsteril bh 5
Hansaplast bh 1
Hypafix cm 10 65 650
Kasa bh 30 300 9,000
Masker bh 5 22,800 114,000
Mess 10 bh 2 350 700
Oksigen nasal
bh 1 400 400
/masker
Spinocam 25 bh 1 7,000 7,000
Syringe 10 bh 1
Syringe 3 bh 1
Topi disposable bh 5 127 635
Nylon 2,0 sct 1 200,000 200,000

Polisorb 2,0 sct 2 4,800 9,600
Alkohol cc 50 12,000 600,000

Hibiscrub cc 100 21,300 2,130,000
Lidodex amp 1 47,400 47,400
Oksigen lpm 2 71,500 143,000
Povidon cc 300 11,300 3,390,000
PZ fles 1 12,300 12,300
RL fles 3 800 2,400
Hernia mess 10x5 bh 2 1,100 2,200
NGT 12 bh 1 10,300 10,300
DEKAIN amp 1
HERNIA UNILATERAL
Sat.
Electroda bh 4 22,800 91,200
Glove
Gammex 7 bh 1
Glove
bh 2
Gammex 7,5
Glove
Gammex 6,5 bh 1

Hypafix cm 10 400 4,000
Kasa bh 30 7,000 210,000
Masker bh 5 31,700 158,500
Mess 10 bh 1 12,750 12,750
Oksigen
nasal /masker bh 1 2,000 2,000
Spinocam 25 bh 1 21,300 21,300

Syringe 3 bh 2 250,000 500,000
Topi
disposable bh 5 47,400 237,000
Nylon 2,0 sct 1 71,500 71,500

Polisorb 2,0 sct 1 19,500 19,500
Siede
sct 1 4,500 4,500
atraumatik 2,0
Alkohol cc 50
Epineprin amp 1
Hibiscrub cc 100
Lidodex amp 1
Oksigen lpm 2
Povidon cc 300 12,300 ###
PZ fles 1 1,100 1,100
RL fles 2 1,300 2,600
Masker bh 3 800 2,400
Hernia mess bh 1 250,000 250,000
NGT 12 bh 1
. .
m BEDAH MAYOR
A. BEDAH UMUM
1. HERNIA
a HERNIA UNILATERAL
KELAS III
1. Rawat Jalan :
1 Poli Umum 15,000
2 Laboratorium 105,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
SGOT/SGPT Rp 40,000 48,000
GDA Rp 10,000 12,000
3 Radiologi
Thorax Rp 50,000 50,000 60,000
4 ECG 25,000
2 Rawat Inap
a By Akomodasi RI 1 x 30,000 30,000 50,000
b Biaya Makan 1 x 42,000 42,000 45,000
c Js. Pelayanan RI 1 x - 20,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 2 x 5,000 10,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g By Akomodasi ICU x 30,000 - 75,000
h Biaya Makan x 42,000 58,500
i Js. Pelayanan ICU x 66,500
j Rawat Luka x -
k Obat Ruangan 210,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Ecosol Ringer Laktat inf, fles 3 12,300 36,900
Ecosol Glukose 5 % inf, fles 2 11,350 22,700
Nedle 23 Bh 1 1,600 1,600
Vicillin vial 2 13,600 27,200
Profenid supp. bh 1 14,000 14,000
Spt 5 cc bh 1 5,300 5,300
Aquades 25 cc fles 1 2,000 2,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
a Material Bedah 676,700
Sat.
Alkohol 70 % cc 50 65 3,250
Isodine sol. cc 100 300 30,000
Cromix 1 m 1 22,800 22,800
antrain amp 1 12,000 12,000
Hypafix cm 10 400 4,000
Kasa gulung pak 2 7,000 14,000
Plain 2/0 m 1 31,700 31,700
Silk 3/0 m 1 12,750 12,750
Oksigen ltr 20 2,000 40,000
Gamex 7,5 bh 4 21,300 85,200
Surgimesh 6 x 10 cm pcs 1 200,000 200,000
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
anitid amp 1 19,500 19,500
Mess bh 1 4,500 4,500
Natrium Klorida 0,9 %, fles 1 11,300 11,300
topi bh 1 1,100 1,100
hanscoen ns bh 2 1,300 2,600
Masker bh 3 800 2,400
Jarum heacthing bh 1 10,300 10,300
Spt 3 cc bh 1 4,800 4,800
2 Jasa Tindakan
. Dokter Ahli Bedah 600,000
Penata Anastesi 150,000
Tim Operator 300,000
3 Sewa Kamar Operasi 205,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post OPS. HIL/HERNIA) 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 2,778,700
. .
b HERNIA BILATERAL
KELAS III
1. Rawat Jalan :
a Poli Umum 15,000
b Laboratorium 105,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi
Thorax Rp 50,000 50,000 60,000
4 ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 2 x 5,000 10,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
j Obat Ruangan 196,000
Sat.
Spt 5 cc bh 1 5,300 5,300
Transet bh 1 34,300 34,300
Kasa steril dos 8,500 -
Jarum nedle 23 bh 1 1,600 1,600
Profenid Supp. bh 1 14,000 14,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
a Material Bedah 863,256 -
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 2 22,800 45,600
Hypafix cm 20 400 8,000
Plain 2/0 m 2 176 352
Silk 3/0 m 2 127 254
Surgimesh 6 x 10 cm pcs 2 200,000 400,000
Spt 3 cc bh 1 4,800 4,800
anitid amp 1 19,500 19,500
antrain amp 1 12,000 12,000
Ephineprin amp 1 2,300 2,300
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Mess bh 1 4,500 4,500
Masker bh 3 800 2,400
topi bh 1 1,100 1,100
Epedrin amp 1 15,000 15,000
b Jasa Tindakan
. Dokter Ahli Bedah 1,200,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post OPS. HIL/HERNIA) 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 4,056,256
. .
2 APPENDICITIS ACUTA
KELAS III
1. Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
UL Rp 25,000 30,000
c Radiologi
Thorax Rp 50,000 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Skiren 5,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 4 5,300 21,200
Transet bh 1 34,300 34,300
Kasa steril dos 1 8,500 8,500
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Anitid inj amp 3 16,800 50,400
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 1 22,800 22,800
Hypafix cm 15 400 6,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 1 12,750 12,750
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Mess bh 1 4,500 4,500
Masker bh 3 800 2,400
topi bh 1 1,100 1,100
Spt 3 cc bh 3 4,800 14,400
b Jasa Tindakan
c Sewa Kamar Operasi 210,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post Ops. Appendix ) 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,366,500
. .
3 LAPARATOMI
a HERNIA INCACERATA (LAPARATOMI)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
Hb Post Op Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
f Pasang Infus 1 x 30,000 30,000 36,000
g Pasang MS 30,000
h Obat-Obatan 213,500
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Magslang bh 1 29,500 29,500
Foley cateter no 10 bh 1 49,900 49,900
Urine Bag bh 1 7,500 7,500
Valisanbe inj amp 2 12,700 25,400
Spt 5 cc bh 1 5,300 5,300
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
f By Akomodasi ICU 1 x 75,000 75,000 75,000
g Biaya Makan 1 x 58,500 58,500
h Js. Pelayanan ICU 1 x 66,500
i Rawat Luka 1 x 25,000 25,000 30,000
j Obat Ruangan 1,706,900
Sat.
Goforan inj vial 8 127,050 1,016,400
Aminovel 600 fles 2 82,500 165,000
Anitid inj amp 6 16,800 100,800
Spt 5 cc bh 3 5,300 15,900
Spt 3 cc bh 3 4,300 12,900
Optiva No.18 bh 23,000 -
Benostan tab 10 1,300 13,000
Bernoflox tab tab 10 13,600 136,000
Magtral Sups 120 ml fles 25,000 -
. .
3 Kamar Operasi
a Material Bedah 1,228,000
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
T.Vio 3-0 V5O sach 1 93,100 93,100
Halotan cc 50 6,300 315,000
Hypafix cm 20 400 8,000
Oksigen ltr 20 2,000 40,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 2 12,750 25,500
Succynil cc 3 16,200 48,600
Gamex 7,5 bh 4 21,300 85,200
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Fentanil inj. amp 1 42,050 42,050
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Atropin Sulfas amp 1 2,800 2,800
Masker bh 3 800 2,400
Asering inf fles 5 19,000 95,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post Ops. Laparatomi) 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,550,400
. .
b APPENDICITIS INFILTRAT / KRONIS
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
UL Rp 25,000 30,000
c Radiologi 470,000
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
LLD Rp 60,000 72,000
USG Rp 300,000 360,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
f Pasang Infus 1 x 30,000 30,000 36,000
g Obat-Obatan 144,600
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
Spt 5 cc bh 1 5,300 5,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang MS 1 x 30,000 30,000 36,000
e Injeksi 15 x 5,000 75,000 6,000
f Persiapan Operasi
- Skiren 5,000
g By Akomodasi ICU 2 x 75,000 150,000
h Biaya Makan 2 x 58,500 117,000
i Js. Pelayanan ICU 2 x 66,500
j Rawat Luka 2 x 25,000 50,000 30,000
k Obat Ruangan 2,903,650

Sat.
Aminovel 600 fles 2 82,500 165,000
Goforan inj vial 7 127,050 889,350
Anitid inj amp 10 16,800 168,000
Spt 5 cc bh 5 5,300 26,500
Spt 3 cc bh 3 4,300 12,900
Benostan tab 10 1,300 13,000
. .
3 Kamar Operasi

Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
T.Vio 3-0 V5O sach 1 93,100 93,100
Halotan cc 50 6,300 315,000
Hypafix cm 20 400 8,000
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 2 12,750 25,500
Gamex 7,5 bh 4 21,300 85,200
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Oksigen ltr 20 2,000 40,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post Appendix) 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 8,589,250
. .
c TRAUMA ABDOMENT / APP PERFORASI (LAPARATOMY)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
UL Rp 25,000 30,000
c Radiologi 470,000
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
LLD Rp 60,000 72,000
USG Rp 300,000 360,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000

f Pasang Infus 1 x 30,000 30,000 36,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
Spt 5 cc bh 1 5,300 5,300
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 15 x 5,000 75,000 6,000
e Persiapan Operasi
- Skiren 5,000
g Biaya Makan 3 x 58,500 58,500
i Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Aminovel 600 fles 2 82,500 165,000
Goforan inj vial 7 127,050 889,350
Otsutran fles 2 101,400 202,800
Anitid inj amp 6 16,800 100,800
Spt 5 cc bh 5 5,300 26,500
Spt 3 cc bh 3 4,300 12,900
Benostan tab 10 1,300 13,000
. .
3 Kamar Operasi

Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
T.Vio 3-0 V5O sach 1 93,100 93,100
Halotan cc 50 6,300 315,000
Hypafix cm 20 400 8,000
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 2 12,750 25,500
Gamex 7,5 bh 4 21,300 85,200
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Topi bh 1 1,100 1,100
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post Ops. TU ABDOMEN) 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 7,674,550
. .
4 STRUMA
KELAS III
1 Rawat Jalan
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi
Thorax Rp 50,000 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g By Akomodasi ICU 1 x 75,000 75,000 75,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Etason inj amp 6 6,000 36,000
Spt 5 cc bh 3 5,300 15,900
Ca. Glukonas amp 3 11,400 34,200
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Lomatuel lbr 1 14,000 14,000
Amobiotik 500 mg tab 10 3,000 30,000
Benostan tab 10 1,300 13,000
Hypafix cm 30 400 12,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 3-0 VIO sach 2 79,900 159,800
Halotan cc 50 6,300 315,000
Hypafix cm 20 400 8,000
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
DHBP amp 1 72,000 72,000
Topi bh 1 1,100 1,100
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Lomatuel lbr 2 14,000 28,000
Succynil cc 3 16,200 48,600
Transet bh 2 34,300 68,600
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post Op. Struma) 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,021,050
. .
5a CA MAMAE (MASTEKTOMIE)
KELAS III
1 Rawat Jalan
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
GDA Rp 10,000 12,000
FNA Rp 260,000 312,000
FNA 175,000
Transport 85,000
c Radiologi
Thorax Rp 50,000 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 12 x 5,000 60,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Vicillin vial 12 13,600 163,200
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Lomatuel lbr 2 14,000 28,000
Amobiotik 500 mg tab 10 3,000 30,000
Benostan tab 10 1,300 13,000
Hypafix cm 50 400 20,000
9 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 50 6,300 315,000
Hypafix cm 40 400 16,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 3 12,750 38,250
Formalin 8% cc 1000 250 250,000
Oksigen ltr 21 2,000 42,000
Topi bh 1 1,100 1,100
Gamex 7,5 bh 4 21,300 85,200
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Transet bh 2 34,300 68,600
Masker bh 3 800 2,400
Lomatuel lbr 3 14,000 42,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi ( Post Ca Mamae) 3 x 75,000 225,000 90,000
c a/j dr 250,000
. . Total 5,918,150
. .
5b CA MAMAE SKIN GRAF
KELAS III
1 Rawat Jalan
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
GDA Rp 10,000 12,000
FNA Rp 260,000 312,000
FNA 175,000
Transport 85,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 4 x 42,000 168,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 18 x 5,000 90,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 2 x 58,500 58,500
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Vicillin vial 18 13,600 244,800
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Lomatuel lbr 2 14,000 28,000
Amobiotik 500 mg tab 10 3,000 30,000
Benostan tab 10 1,300 13,000
Hypafix cm 50 400 20,000
9 Kamar Operasi
Sat.
Alkohol 70 % cc 100 65 6,500
Halotan cc 60 6,300 378,000
Hypafix cm 60 400 24,000
Plain 2/0 m 2 31,700 63,400
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 3 12,750 38,250
Formalin 8% cc 1000 250 250,000
Gamex 7,5 bh 6 21,300 127,800
Topi bh 1 1,100 1,100
Mess bh 3 4,500 13,500
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Transet bh 2 34,300 68,600
Lomatuel lbr 6 14,000 84,000
Masker bh 3 800 2,400
Oksigen ltr 21 1,500 31,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi ( Post Ca Mamae) 3 x 75,000 225,000 90,000
c a/j dr 250,000
. . Total 7,013,900
. .
5c KEMOTHERAPI
KELAS III
1 Rawat Jalan
a Poli Umum 15,000
DL Rp 30,000 36,000
Hematologi Analyzer Rp 30,000 36,000
SGOT Rp 10,000 12,000
SGPT Rp 10,000 12,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 3 x 5,000 15,000 6,000
f Persiapan Operasi
g By Akomodasi ICU x 75,000 -
Sat.
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Piralen inj / Piralen tab amp 1 6,600 6,600
Magtral Sups 120 ml fles 1 25,000 25,000
Nerradin kap 5 2,300 11,500
Gamex 7,5 bh 1 21,300 21,300
Kliran 4 mg inj Inj 2 24,200 48,400
Paket Kemo 1,700,000
Doxorubicin 10/50 mg mg 1 961,000 961,000
5 FU 250, 5 FU 500 mg 1 60,500 60,500
i Jasa Khemoteraphi
Crew perawatan 25,000
4 Lain-lain
a Transport Ambil Obat Kemo 70,000
b Adiministrasi -
. . Total 3,498,350
. .
6 DISEKSI KELENJAR
KELAS III
1 Rawat Jalan
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 15 x 5,000 75,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 2 x 58,500 58,500
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Lomatuel lbr 1 14,000 14,000
Leucoplast rol 1 48,200 48,200
Amobiotik 500 mg tab 10 3,000 30,000
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 cm 60 228 13,680
Hypafix cm 75 400 30,000
Plain 2/0 cm 100 176 17,600
Silk 1 cm 60 127 7,620
Silk 2/0 cm 120 127 15,240
Silk 3/0 cm 120 127 15,240
Oksigen ltr 21 1,500 31,500
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 5 21,300 106,500
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 2 22,000 44,000
Topi bh 1 1,100 1,100
Mess bh 3 4,500 13,500
Mess bh 2 4,500 9,000
Lomatuel lbr 3 14,000 42,000
Spt 5 cc bh 1 5,300 5,300
Transet bh 2 34,300 68,600
Urine Bag bh 1 7,500 7,500
Masker bh 3 800 2,400
Otsutran fles 1 101,400 101,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,285,130
. .
7 FAM
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
sc Rp 20,000 24,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
FNA Rp 260,000
FNA 175000
Transport 85,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 2 x 5,000 10,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
j Rawat Luka x 25,000 -
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Isodine sol. cc 300 -
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 (1756-31) sach 1 60,600 60,600
Plain 3/0 cm 50 176 8,800
Hypafix cm 10 400 4,000
Oksigen ltr 21 1,500 31,500
Gamex 7,5 bh 3 21,300 63,900
Topi bh 1 1,100 1,100
Mess bh 1 4,500 4,500
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 3,022,950
. .
8 COLLOSTOMI
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
GDA Rp 10,000 12,000
c Radiologi 410,000
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
USG Rp 300,000 360,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 15 x 5,000 75,000 6,000
e Persiapan Operasi
- Huknah 2 x 15,000 30,000 18,000
- Skiren 5,000
f Pasang Infus 1 x 30,000 30,000 36,000
g Ps. Cateter 1 x 75,000 75,000 90,000
h By Akomodasi ICU 2 x 75,000 150,000 75,000
i Biaya Makan 2 x 58,500 58,500
j Js. Pelayanan ICU 2 x 66,500
k Rawat Luka 4 x 25,000 100,000 30,000
l Obat Ruangan 673,900
Sat.
Aminovel 600 fles 1 82,500 82,500
Anitid inj amp 6 16,800 100,800
Spt 5 cc bh 5 5,300 26,500
Spt 3 cc bh 3 4,300 12,900
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Colostomy Bag bh 4 3,500 14,000
3 Kamar Operasi
Sat.
Halotan cc 90 6,300 567,000
Hypafix cm 20 400 8,000
Alkohol 70 % cc 50 65 3,250
T.Vio 3-0 V5O sach 2 93,100 186,200
Plain 4/0 atr pcs 2 70,700 141,400
Zide Silk 2/0 m 2 12,750 25,500
Kasa Buntut bh 2 10,000 20,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 1,500 31,500
DHBP amp 1 72,000 72,000
Lomatuel lbr 1 14,000 14,000
Gamex 7,5 bh 4 21,300 85,200
Spt 3 cc bh 1 4,300 4,300
Masker bh 3 800 2,400
Mess bh 2 4,500 9,000
b Jasa Tindakan
c Sewa Kamar Operasi 1,350,000

4 Lain-lain
a Adiministrasi -
b Fisioterapi 3 x 60,000 180,000 72,000
c a/j dr 250,000
. . Total 7,072,150
. .
9 HEMOROID
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 8 x 5,000 40,000 6,000
f Persiapan Operasi
- Huknah 2 x 15,000 30,000 18,000
- Skiren 5,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Trolac 30 mg inj amp 4 33,600 134,400
Spt 5 cc bh 3 5,300 15,900
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Tranxa 250 inj amp 3 8,600 25,800
PK bks 10 500 5,000
Laxadin Syr btl 1 29,650 29,650
Nerradin kap 10 2,300 23,000
Codein 10 mg, 15 mg, 2 Tab 10 1,150 11,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Hypafix Cm 15 400 6,000
Zide Silk 2/0 m 1 12,750 12,750
Cromik 1 ,75 m 2 22,800 45,600
Oksigen ltr 21 2,000 42,000
Lidodex amp 1 71,500 71,500
Spinocain bh 1 47,400 47,400
Topi bh 1 1,100 1,100
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Ephineprin Amp 1 2,300 2,300
Gamex 7,5 bh 4 21,300 85,200
Epedrin amp 1 15,000 15,000
Masker bh 3 800 2,400
Mess bh 1 4,500 4,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Post Op. Hemoroid) 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,184,000
. .
10 POLIP RECTI
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 2 x 5,000 10,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan x 58,500 - 58,500
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Trolac 30 mg inj amp 2 33,600 67,200
Jarum nedle 23 Bh 1 1,600 1,600
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Laxadin Syr btl 29,650 -
PK bks 500 -
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Aquagel mg 10 500 5,000
Oksigen ltr 21 2,000 42,000
Lidodex amp 1 71,500 71,500
Spinocain bh 1 47,400 47,400
Topi bh 1 1,100 1,100
Spt 3 cc bh 1 4,300 4,300
Gamex 7,5 bh 4 21,300 85,200
Epedrin amp 1 15,000 15,000
Masker bh 3 800 2,400
Mess bh 4,500 -
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 2,482,850
. .
11 FISTEL
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 250,000
Thorax Rp 50,000 60,000
Fistulugrafi Rp 200,000 240,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 6 x 5,000 30,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Trolac 30 mg inj amp 4 33,600 134,400
Spt 5 cc bh 3 5,300 15,900
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Laxadin Syr btl 1 29,650 29,650
PK bks 10 500 5,000
3 Kamar Operasi
Sat.
Lidodex amp 1 71,500 71,500
Spinocain bh 1 47,400 47,400
Oksigen ltr 21 2,000 42,000
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Gamex 7,5 bh 4 21,300 85,200
Spt 3 cc bh 1 4,300 4,300
Ecosole Ringer Laktat in fles 3 12,300 36,900
Ecosol NaCl Inf fles 1 11,300 11,300
Cromix 2/0 m 1 22,800 22,800
Masker bh 3 800 2,400
Mess 10 bh 1 4,500 4,500
-
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,130,650
. .
12 TUMOR PAROTIS
KELAS III
1 Rawat Jalan
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi
Thorax Rp 50,000 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 12 x 5,000 60,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Lomatuel lbr 1 14,000 14,000
Amobiotik 500 mg tab 10 3,000 30,000
Benostan tab 10 1,300 13,000
Hypafix cm 30 400 12,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 (1756-41) sach 1 51,250 51,250
T.Vio 4-0 VIO sach 2 79,900 159,800
Halotan cc 50 6,300 315,000
Topi bh 1 1,100 1,100
Hypafix cm 20 400 8,000
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,500 31,500
Silk 2/0 m 1 12,750 12,750
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Lomatuel lbr 2 14,000 28,000
Succynil cc 3 16,200 48,600
Transet bh 2 34,300 68,600
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,228,800
. .
13 HIDROCELE
KELAS III
1. Rawat Jalan :
1 Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
3 Radiologi 50,000
Thorax Rp 50,000 60,000
4 ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 3 x 5,000 15,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Spt 5 cc bh 2 5,300 10,600
Jarum nedle 23 Bh 1 1,600 1,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 1 22,800 22,800
Topi bh 1 1,100 1,100
Hypafix cm 10 400 4,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 1 12,750 12,750
Oksigen ltr 21 2,000 42,000
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Mess bh 1 4,500 4,500
Masker bh 3 800 2,400
Spt 3 cc bh 1 4,300 4,300
2 Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 3,097,150
. .
14 GIANT LIPOMA
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 2 x 5,000 10,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 sach 1 61,000 61,000
Plain 3/0 m 1 31,700 31,700
Topi bh 1 1,100 1,100
Hypafix cm 10 400 4,000
Oksigen ltr 21 2,000 42,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 2,347,950
. .
15 DEBRIDEMENT
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 4 x 42,000 168,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 12 x 5,000 60,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 4 5,300 21,200
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 sach 1 61,000 61,000
Topi bh 1 1,100 1,100
Plain 3/0 m 1 31,700 31,700
Hypafix cm 10 400 4,000
Oksigen ltr 21 2,000 42,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,067,850
. .
16 CHOLELITHIASIS
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
c Radiologi 350,000
Thorax Rp 50,000 60,000
USG Rp 300,000 360,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 15 x 5,000 75,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 2 x 58,500 58,500
j rawat luka 2 x 25,000 50,000 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Vicillin vial 15 13,600 204,000
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 sach 1 61,000 61,000
Plain 3/0 m 1 31,700 31,700
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,559,050
. .
17 MILES PROSEDUR
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
c Radiologi 350,000
Thorax Rp 50,000 50,000 60,000
USG Rp 300,000 360,000
d ECG 25,000
2 Rawat Inap
c Biaya Makan 5 x 42,000 210,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 21 x 5,000 105,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 2 x 58,500 58,500
j rawat luka 3 x 25,000 75,000 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 7 5,300 37,100
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 sach 1 61,000 61,000
Plain 3/0 m 1 31,700 31,700
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 7,580,350
. .
18 FIBROMA PEDIS
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
pedis Rp 50,000 6,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
c Pasang Infus 1 x 30,000 30,000 36,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
f By Akomodasi ICU x 75,000 - 75,000
g Biaya Makan x 58,500 58,500
h Js. Pelayanan ICU x 66,500
i rawat luka 1 x 25,000 25,000 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 4 5,300 21,200
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 sach 1 61,000 61,000
Plain 3/0 m 1 31,700 31,700
Topi bh 1 1,100 1,100
Hypafix cm 10 400 4,000
Oksigen ltr 21 2,000 42,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,037,250
3 .
B BEDAH UROLOGI
1 BPH
a BPH (OPEN) KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
f Obat-obatan 57,400
Sat.
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Tranxa 250 inj amp 3 8,600 25,800
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Cromix 1 m 2 22,800 45,600
T.Vio 2-0 sach 1 52,000 52,000
Plain 2/0 m 1 31,700 31,700
Zide 3-0 m 1 12,750 12,750
Lidodex amp 1 71,500 71,500
Spinocain bh 1 47,400 47,400
Spt 3 cc bh 1 4,300 4,300
Gamex 7,5 bh 4 21,300 85,200
Mess bh 2 4,500 9,000
Epedrin amp 1 15,000 15,000
Try Way cateter no 24 bh 1 66,550 66,550
Urine Bag bh 1 7,500 7,500
Transet bh 2 34,300 68,600
Masker bh 3 800 2,400
Regivell amp 2 22,000 44,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,162,050
. .
b BPH (TURP)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 110,000
Thorax Rp 50,000 50,000 60,000
BOF Rp 60,000 72,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
F Obat-obatan 57,400
Sat.
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Rawat Cateter 1 x 20,000 20,000
h By Akomodasi ICU 1 x 75,000 75,000 75,000
i Biaya Makan 1 x 58,500 58,500
j Js. Pelayanan ICU 1 x 66,500
Sat.
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Tranxa 250 inj amp 6 8,600 51,600
Transet bh 1 34,300 34,300
3 Kamar Operasi
Sat.
Hypafix cm 20 400 8,000
Oksigen ltr 21 2,000 42,000
Topi bh 1 1,100 1,100
Aquades 1 L fles 25 12,500 312,500
Cateter Try way no 18,2 bh 1 125,000 125,000
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 3 21,300 63,900
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Spuit 10 cc bh 1 5,550 5,550
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 1 4,300 4,300
Transet bh 1 34,300 34,300
Tranxa 250 inj amp 2 8,600 17,200
Alkohol 1l ltr 2 65,000 130,000
Aquagel (82 gram) tube 0.5 32,600 16,300
Masker bh 3 800 2,400
Urine Bag bh 1 7,500 7,500
b Jasa Tindakan
c Sewa Alat dr 250,000
d Sewa Kamar Operasi 550,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 6,234,100
. .
2 BATU URETER
a BATU URETER (OPEN)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 699,275
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
IVP 250,000 Rp 589,275 300,000
Spuit 2,5 cc 2,475
Spt 50 cc 20,000
d ECG 25,000
e Pasang Infus 1 x 30,000 30,000 36,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
f Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
T.Vio 1 sach 1 116,400 116,400
T.Vio 4-0 VIO sach 1 79,900 79,900
Hypafix cm 20 400 8,000
Alkohol 70 % cc 50 65 3,250
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 31,700 31,700
Topi bh 1 1,100 1,100
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Magslang bh 1 29,500 29,500
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 1 4,300 4,300
Transet bh 1 34,300 34,300
Masker bh 3 800 2,400
Urine Bag bh 1 7,500 7,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,168,275
. .
b BATU URETER (URS)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 699,275
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
IVP 250,000 Rp 589,275 300,000
Spuit 2,5 cc 2,475
Spt 50 cc 20,000 26500
d ECG 25,000
e Pasang Infus 1 x 30,000 30,000 36,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
f Ps. Cateter 1 x 75,000 75,000 90,000
h Biaya Makan 1 x 58,500 58,500
Sat.
Spt 5 cc bh 2 5,300 10,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi

Sat.
Hypafix cm 15 400 6,000
Alkohol 70 % cc 50 65 3,250
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Topi bh 1 1,100 1,100
Epedrin amp 1 15,000 15,000
Spinocain bh 1 47,400 47,400
Gamex 7,5 bh 1 21,300 21,300
Spt 3 cc bh 1 4,300 4,300
Urine Bag bh 1 7,500 7,500
Aquades 1 L fles 10 12,500 125,000
Roxemid inj amp 1 9,900 9,900
Alkohol 1l ltr 2 65,000 130,000
Masker bh 3 800 2,400
Ureter Cateter bh 1 150,000 150,000
b Jasa Tindakan
d Sewa Alat dr 1,000,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 7,289,375
. .
3 BATU BULI-BULI
a BATU BULI-BULI (OPEN)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
Sat.
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Tranxa 250 inj amp 3 8,600 25,800
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 1 22,800 22,800
T.Vio 4-0 VIO sach 1 79,900 79,900
Hypafix cm 15 400 6,000
Topi bh 1 1,100 1,100
Plain 2/0 m 1 31,700 31,700
Silk 3/0 m 1 12,750 12,750
Oksigen ltr 21 2,000 42,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Mess bh 2 4,500 9,000
Spt 3 cc bh 1 4,300 4,300
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
Masker bh 3 800 2,400
Lidodex amp 1 71,500 71,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,730,200
. .
b BATU BULI-BULI (LITHOTRIPSI)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
Sat.
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 6 x 5,000 30,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Rawat Cateter 1 x 20,000 20,000
Sat.
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Aquades 1 L fles 5 12,500 62,500
Gamex 7,5 bh 3 21,300 63,900
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Alkohol 1l ltr 2 65,000 130,000
Masker bh 3 800 2,400
Spt 3 cc bh 1 4,300 4,300
b Jasa Tindakan
d Sewa Alat dr 250,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi (POST. OPS. TU BULI) 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 5,464,800
. .
c - CA Buli (TURP)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
BOF Rp 60,000 72,000
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
Sat.
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
Sat.
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Aquades 1 L fles 5 12,500 62,500
Gamex 7,5 bh 3 21,300 63,900
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Alkohol 1l ltr 2 65,000 130,000
Masker bh 3 800 2,400
Spt 3 cc bh 1 4,300 4,300
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,421,400
. .
4 STRICTURA URETRA (Sachze)
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 326,000
Thorax 50,000 50,000 60,000
BOF 60,000 60,000 72,000
Uretrogram 200,000 216,000 240,000
Obat : 16,000
Aquades 2 16,000
Spuit 2,5 cc -
d ECG 25,000
e Ps. Cateter 1 x 75,000 75,000 90,000
Sat.
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
Sat.
Spt 5 cc bh 2 5,300 10,600
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 1000 65 65,000
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Aquades 1 L fles 25 12,500 312,500
Cat. Two way no
12,14,16,18 bh 1 66,550 66,550
Gamex 7,5 bh 3 21,300 63,900
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Spuit 10 cc bh 1 5,550 5,550
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 1 4,300 4,300
Transet bh 1 34,300 34,300
Tranxa 250 inj amp 2 8,600 17,200
Alkohol 1l ltr 2 65,000 130,000
Masker bh 3 800 2,400
Urine Bag bh 1 7,500 7,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,947,500
. .
5 BATU URETRA
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 326,000
Thorax Rp 50,000 50,000 60,000
BOF 60,000 72,000
Uretrogram 200,000 216,000 240,000
Obat : 16,000
Aquades 2 16,000
Spuit 2,5 cc -
d ECG 25,000
e Fungsi Blass (Ps. Cateter) 75,000
Sat.
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
Optiva No.18 bh 1 23,000 23,000
Pehacain amp 1 3,500 3,500
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Cateter 1 x 20,000 20,000
Sat.
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
3 Kamar Operasi
Sat.
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Aquades 1 L fles 5 12,500 62,500
Gamex 7,5 bh 3 21,300 63,900
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Alkohol 1l ltr 2 65,000 130,000
Masker bh 3 800 2,400
Spt 3 cc bh 1 4,300 4,300
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 5,386,750
. .
6 BATU GINJAL
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 699,275
Thorax Rp 50,000 50,000 60,000
BOF 60,000 72,000
IVP 250,000 589,275 300,000
Obat : 339,275
Omnipage 50cc 316,800
Spuit 2,5 cc 2,475
Spt 50 cc 20,000
d ECG 25,000
e Pasang Infus 1 x 30,000 30,000 36,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
2 Rawat Inap
b Biaya Makan 4 x 42,000 168,000 45,000
d injeksi 18 x 5,000 90,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
Halotan cc 50 6,300 315,000
Topi bh 1 1,100 1,100
Hypafix cm 30 400 12,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 1 12,750 12,750
Oksigen ltr 21 2,000 42,000
DHBP amp 1 72,000 72,000
Miloz Inj amp 1 23,000 23,000
Gamex 7,5 bh 3 21,300 63,900
Magslang bh 1 29,500 29,500
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
. .

Spuit 10 cc bh 1 5,550 5,550
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,576,275
. .
7 HYPOSPADIA
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
2 Rawat Inap
b Biaya Makan 7 x 42,000 294,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 18 x 5,000 90,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 2 x 58,500 58,500
j Rawat Cateter 10 x 20,000 200,000
Sat.
D ¼ NS 4 11,800 47,200
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Ikamicetin e.o tube 2 4,150 8,300
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 60 6,300 378,000
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Silk 3/0 m 1 12,750 12,750
Vicril 6/0 sach 1 105,500 105,500
Oksigen ltr 21 2,000 42,000
T.Lene 4-0 L18^ sach 1 84,200 84,200
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Safol cc 10 8,000 80,000
Spt 3 cc bh 1 4,300 4,300
Succynil cc 1 16,200 16,200
Urine Bag bh 1 7,500 7,500
Masker bh 3 800 2,400
Nebacetin oint. tube 1 21,200 21,200
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,585,050
. .
8 VARICOCEL
KELAS III
1. Rawat Jalan :
1 Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
3 Radiologi 50,000
Thorax Rp 50,000 60,000
4 ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
c Pasang Infus 1 x 30,000 30,000 36,000
d injeksi 2 x 5,000 10,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
f By Akomodasi ICU x 75,000 -
g Biaya Makan x 58,500
h Rawat Luka x 25,000 -
i Obat Ruangan 210,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Spt 5 cc bh 1 5,300 5,300
Jarum nedle 23 bh 1 1,600 1,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 1 22,800 22,800
Hypafix cm 10 400 4,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 1 12,750 12,750
Oksigen ltr 21 2,000 42,000
Epedrin amp 1 15,000 15,000
Topi bh 1 1,100 1,100
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Mess bh 1 4,500 4,500
Masker bh 3 800 2,400
Spt 3 cc bh 1 4,300 4,300
2 Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 3,107,750
. .
9 AFF DJ STAND
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
RFT Rp 58,000 70,000
c Radiologi 60,000
BOF Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 1 x 21,000 25,000
2 Rawat Inap
a By Akomodasi RI 1 x 30,000 30,000
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 2 x 5,000 10,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Spt 5 cc bh 1 5,300 5,300
Jarum nedle 23 bh 1 1,600 1,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Ketamin Hameln cc 1 15,000 15,000
Topi bh 1 1,100 1,100
Gamex 7,5 bh 2 21,300 42,600
Spt 3 cc bh 1 4,300 4,300
Metergin amp 1 18,800 18,800
b Jasa Tindakan
Sewa Alat dr 100,000
Tim Operator 50,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 2,016,550
. .
10 EXTRAKSI BATU URETRA
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
RFT Rp 58,000 70,000
c Radiologi 60,000
BOF Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 1 x 21,000 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 3 x 5,000 15,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Spt 5 cc bh 1 5,300 5,300
Jarum nedle 23 bh 1 1,600 1,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Gamex 7,5 bh 2 21,300 42,600
Topi bh 1 1,100 1,100
Spt 3 cc bh 1 4,300 4,300
Metergin amp 1 18,800 18,800
b Jasa Tindakan
Sewa Alat dr 100,000
Tim Operator 50,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 1,986,550
. .
C THT
1 SINUSITIS / Polip Nasal
KELAS III
1. Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Waters Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 12 x 5,000 60,000 6,000
f Persiapan Operasi
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Spt 5 cc bh 3 5,300 15,900
Benostan tab 10 1,300 13,000
Plasminex 500 mg tab tab 3 2,750 8,250
Chirus Tab 6 6,000 36,000
3 Kamar Operasi
Sat.
Halotan cc 20 6,300 126,000
H2 O2 cc 30 250 7,500
Hibicef cc 10 250 2,500
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Tranxa 250 inj amp 2 8,600 17,200
Gamex 7,5 bh 3 21,300 63,900
2 Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,630,950
. .
2 TONSILITIS
KELAS III
1. Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 6 x 5,000 30,000 6,000
f Persiapan Operasi
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Spt 5 cc bh 2 5,300 10,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Isodine gargle fles 1 19,000 19,000
3 Kamar Operasi
Sat.
Halotan cc 30 6,300 189,000
Hibicef cc 20 250 5,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
DHBP amp 1 72,000 72,000
Miloz Inj amp 1 23,000 23,000
Gamex 7,5 bh 3 21,300 63,900
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 1 16,200 16,200
Tranxa 250 inj amp 2 8,600 17,200
2 Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 3,332,150
. .
D. OBSTETRY GYNAECOLOGY
KELAS III
1 SECSIO CAESAR
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
Hb post op Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 300,000
USG Rp 300,000 360,000
d ECG 25,000
e Pasang Infus 1 x 30,000 30,000 36,000
f Ps. Cateter 1 x 75,000 75,000 90,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Alinamin Inj 6 14,150 84,900
Spt 5 cc bh 3 5,300 15,900
Spuit 10 cc bh 2 5,550 11,100
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Nerradin kap 10 2,300 23,000
Metergin tab tab 6 3,550 21,300
Extrace amp 6 7,300 43,800
Ottogenta inj amp 4 11,000 44,000
Gurita bh 1 36,650 36,650
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 1 22,800 22,800
T.Vio 1 sach 1 116,400 116,400
Hypafix cm 15 400 6,000
Topi bh 1 1,100 1,100
Plain 2/0 m 1 31,750 31,750
Silk 3/0 m 1 12,750 12,750
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
. .
KELAS III
Lidodex amp 1 71,500 71,500

Mess bh 1 4,500 4,500
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Metergin amp 1 18,800 18,800
Masker bh 3 800 2,400
Induxin inj. amp 3 9,050 27,150
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,227,050
. .
2 MYOMA UTERI
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 350,000
Thorax Rp 50,000 60,000
USG Rp 300,000 360,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
f Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Alinamin Inj 6 14,150 84,900
Spt 5 cc bh 3 5,300 15,900
Spuit 10 cc bh 2 5,550 11,100
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Nerradin kap 10 2,300 23,000
Extrace amp 6 7,300 43,800
Gurita bh 1 36,650 36,650
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 2 m 2 22,800 45,600
T.Vio 1 sach 1 116,400 116,400
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 2 31,700 63,400
Silk 3/0 m 1 12,750 12,750
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Mess bh 1 4,500 4,500
Masker bh 3 800 2,400
Spt 3 cc bh 1 4,300 4,300
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,434,550
. .
3 PROLAP UTERI
1 UGD
KELAS III
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
c Pasang Infus 1 x 30,000 30,000 36,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Alinamin Inj 6 14,150 84,900
Spt 5 cc bh 3 5,300 15,900
Spuit 10 cc bh 2 5,550 11,100
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Nerradin kap 10 2,300 23,000
Extrace amp 6 7,300 43,800
Gurita bh 1 36,650 36,650
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 2 m 2 22,800 45,600
T.Vio 1 sach 1 116,400 116,400
Hypafix cm 15 400 6,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 2 31,700 63,400
Silk 3/0 m 1 12,750 12,750
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Mess bh 1 4,500 4,500
Masker bh 3 800 2,400
Spt 3 cc bh 1 4,300 4,300
b Jasa Tindakan

4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 4,671,550
. .
4 CYSTOMA OVARI
1 UGD
KELAS III
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
c Radiologi 350,000
USG Rp 300,000 360,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Alinamin Inj 6 14,150 84,900
Spt 5 cc bh 3 5,300 15,900
Spuit 10 cc bh 2 5,550 11,100
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Nerradin kap 10 2,300 23,000
Extrace amp 6 7,300 43,800
Gurita bh 1 36,650 36,650
3 Kamar Operasi
Sat.
Cromix 1 m 1 22,800 22,800
T.Vio 1 sach 1 116,400 116,400
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Plain 2/0 m 1 31,700 31,700
Silk 3/0 m 1 12,750 12,750
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Mess bh 1 4,500 4,500
Spt 3 cc bh 1 4,300 4,300
Masker bh 3 800 2,400
Urine Bag bh 1 7,500 7,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,293,150
. .
5 KET
1 UGD KELAS III
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
RFT Rp 58,000 70,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
Plano Rp 10,000 12,000
c Radiologi 350,000
Thorax Rp 50,000 60,000
USG Rp 300,000 360,000
d ECG 25,000
e Pasang Infus 1 x 30,000 30,000 36,000
F Ps. Cateter 1 x 75,000 75,000 90,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
f Persiapan Operasi
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Alinamin Inj 6 14,150 84,900
Spt 5 cc bh 3 5,300 15,900
Spuit 10 cc bh 2 5,550 11,100
Optiva No.18 bh 1 23,000 23,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Nerradin kap 10 2,300 23,000
Extrace amp 6 7,300 43,800
Gurita bh 1 36,650 36,650
Tranxa 250 inj amp 6 8,600 51,600
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 1 22,800 22,800
T.Vio 1 sach 1 116,400 116,400
Topi bh 1 1,100 1,100
Hypafix cm 20 400 8,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Silk 3/0 m 1 12,750 12,750
. .

Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Mess bh 1 4,500 4,500
Spt 5 cc bh 1 5,300 5,300
Masker bh 3 800 2,400
Urine Bag bh 1 7,500 7,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,714,400
. .
6 CURETTAGE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
sc Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA 10,000 12,000
Plano Rp 10,000 12,000
c Pasang Infus 1 x 30,000 30,000 36,000
d Obat-Obatan 69,600
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 2 x 5,000 10,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Nerradin kap 10 2,300 23,000
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Topi bh 1 1,100 1,100
Gamex 7,5 bh 2 21,300 42,600
Spt 3 cc bh 1 4,300 4,300
Metergin amp 1 18,800 18,800
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 2,026,250
. .
E BEDAH PLASTIK
1 PALATO SCHIZIS / LABIO SCHIZIS
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
D ¼ NS 3 11,800 35,400
Spt 5 cc bh 1 5,300 5,300
Optiva No.18 bh 1 23,000 23,000
Novalgin syr fles 1 37,300 37,300
Amobiotik 500 mg tab 1 3,000 3,000
3 Kamar Operasi
Sat.
Halotan cc 70 6,300 441,000
T.Vio 4-0 VIO sach 2 79,900 159,800
Hibicef cc 50 250 12,500
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Plain 4/0 atr pcs 1 70,700 70,700
T.Lene 4-0 L18^ sach 1 84,200 84,200
Miloz Inj amp 1 23,000 23,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 3 4,500 13,500
Safol cc 10 8,000 80,000
Spt 3 cc bh 1 4,300 4,300
Succynil cc 1 16,200 16,200
Tranxa 250 inj amp 1 8,600 8,600
Masker bh 3 800 2,400
Curospon bh 1 65,500 65,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 4,477,700
. .
2 LABIO PALATO SCHIZIS
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 9 x 5,000 45,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
D ¼ NS 3 11,800 35,400
Spt 5 cc bh 1 5,300 5,300
Optiva No.18 bh 1 23,000 23,000
Amobiotik 500 mg tab 1 3,000 3,000
3 Kamar Operasi
Sat.
Halotan cc 70 6,300 441,000
T.Vio 4-0 VIO sach 2 79,900 159,800
Hibicef cc 50 250 12,500
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Plain 4/0 atr pcs 1 70,700 70,700
T.Lene 4-0 L18^ sach 1 84,200 84,200
Miloz Inj amp 1 23,000 23,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 3 4,500 13,500
Safol cc 10 8,000 80,000
Spt 3 cc bh 1 4,300 4,300
Succynil cc 1 16,200 16,200
Tranxa 250 inj amp 1 8,600 8,600
Masker bh 3 800 2,400
Curospon bh 1 65,500 65,500
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 4,487,700
. .
3 LAT(KONTRAKTUR)
KELAS III
1 Poli MH
a IGD 20,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 150,000
Thorax Rp 50,000
Angkle Rp 50,000
Pedis Rp 50,000
d ECG 25,000
e Fisioterapi (Tibialis Posterior Transfer ) 4 x 60,000 240,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000
c Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
d Pasang Infus 1 x 30,000 30,000
e injeksi 12 x 5,000 60,000
f Ro. Angkle + Pedis 1 x 100,000 100,000
g Rawat Luka 2 x 25,000 50,000
h Obat Ruangan 855,400
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
. .
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cut Gut Plain 2/0 cm 100 176 17,600
Halotan cc 35 6,300 220,500
Hypafix cm 20 400 8,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 2/0 cm 100 127 12,700
Miloz Inj amp 1 23,000 23,000
Gibsona 4 " bh 3 36,350 109,050
Gibsona 6 " bh 2 47,650 95,300
Gamex 7,5 bh 4 21,300 85,200
Mess 10 bh 2 4,500 9,000
Safol cc 10 8,000 80,000
T.Lene 6-0 L42^ sach 2 83,900 167,800
Soffband 4 rol 2 27,500 55,000
Soffband 6 rol 1 32,250 32,250
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Tensocrepe 4" rol 1 67,000 67,000
Ticron 1 bh 1 70,550 70,550
Masker bh 3 800 2,400
Verban rol 2 1,300 2,600
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Tibialis Posterior Transfer ) 7 x 60,000 420,000
Jasa Service Layanan 90,200
c Kruk 180,000
. . Total 5,836,650
. .
F BEDAH ORTOPEDI
. Fr. Femur
a. Open
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
Femur Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
g Hecting 120,000
H Obat-obatan 384,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Femur 1 x 60,000 60,000 60,000
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Cefasole vial 9 103,200 928,800
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 3 14,000 42,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
. .
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
Topi bh 1 1,100 1,100
Hypafix cm 10 400 4,000
Hibicef cc 5 250 1,250
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Mess bh 1 4,500 4,500
Lomatuel lbr 2 14,000 28,000
Spuit 20 cc bh 1 9,650 9,650
Spt 5 cc bh 1 5,300 5,300
Tensocrepe 6" rol 1 85,000 85,000
Masker bh 3 800 2,400
Transet bh 1 34,300 34,300
b Jasa Tindakan
d Sewa alat dr 100,000
Implant 1,100,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr. Femur) 2 x 75,000 180,000 90,000
d Kruk 180,000
. . Total 7,936,400
. .
b. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
Femur Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
g Obat-obatan 82,600
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Femur 1 x 60,000 60,000 60,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Lomatuel lbr 3 14,000 42,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
Topi bh 1 1,100 1,100
Hypafix cm 10 400 4,000
Hibicef cc 5 250 1,250
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 1 22,000 22,000
Mess bh 1 4,500 4,500
. .

Lomatuel lbr 2 14,000 28,000
Spuit 20 cc bh 1 9,650 9,650
Spt 5 cc bh 1 5,300 5,300
Tensocrepe 6" rol 1 85,000 85,000
Masker bh 3 800 2,400
Transet bh 1 34,300 34,300
b Jasa Tindakan
Implant 1,100,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
d Kruk 180,000
. . Total 6,511,050
. .
2 Fr. Cruris/Tibia
KELAS III
a OPEN
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
Cruris Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Cruris 1 x 60,000 60,000 60,000
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Cefasole vial 7 103,200 722,400
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
. .
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Mess bh 2 4,500 9,000
Lomatuel lbr 1 14,000 14,000
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 3 4,300 12,900
Masker bh 3 800 2,400
Tensocrepe 4" rol 1 67,000 67,000
b Jasa Tindakan
Implant 850,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr. Cruris) 3 x 60,000 216,000 72,000
d Kruk 180,000
. . Total 6,830,550
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
Cruris Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Cruris 1 x 60,000 60,000 60,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 4 5,300 21,200
Lomatuel lbr 2 14,000 28,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Topi bh 1 1,100 1,100
Alkohol 70 % cc 50 65 3,250
Plain 2/0 m 1 31,700 31,700
Silk 2/0 m 1 12,750 12,750
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Mess bh 2 4,500 9,000
Lomatuel lbr 1 14,000 14,000
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 3 4,300 12,900
Masker bh 3 800 2,400
Tensocrepe 4" rol 1 67,000 67,000
b Jasa Tindakan
Implant 850,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
d Kruk 180,000
. . Total 5,600,650
. .
3 Fr. ANTEBRACHII
. - OPEN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Antebrachii Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Antebrachii 1 x 50,000 50,000 50,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Cefasole vial 6 103,200 619,200
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 50 6,300 315,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,700 31,700
Silk 3/0 m 1 12,750 12,750
. .
Gamex 7,5 bh 3 21,300 63,900

Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Lomatuel lbr 2 14,000 28,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Tensocrepe 4" rol 1 67,000 67,000
Masker bh 3 800 2,400
b Jasa Tindakan
Implant 850,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr. Antebrachi) 2 x 60,000 144,000 72,000
. . Total 6,971,350
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Lomatuel lbr 2 14,000 28,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Plain 2/0 cm 50 176 8,800
Halotan cc 50 6,300 315,000
Silk 3/0 cm 50 127 6,350
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Safol cc 10 8,000 80,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Lomatuel lbr 2 14,000 28,000

Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Tensocrepe 4" rol 1 67,000 67,000
Masker bh 3 800 2,400
b Jasa Tindakan
Implant 850,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr. Antebrachi) 2 x 60,000 - 72,000
. . Total 5,786,050
### ###
. .
4 Fr. ANTEBRACHII
. - GIPS
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
a By Akomodasi RI x 30,000 - 50,000
b Biaya Makan x 42,000 - 45,000
c Js. Pelayanan RI x - 20,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Mitela bh 1 44,500 44,500
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Safol cc 10 8,000 80,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Soffband 4 rol 2 27,500 55,000
Miloz Inj amp 1 23,000 23,000
Gipsona 4" bh 2 50,000 100,000
Masker bh 3 800 2,400
Succynil cc 3 16,200 48,600
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
. . Total 3,436,550
. .
5 Fr. PATELLA
. - OPEN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Patella (Genu) Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 4 x 42,000 168,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Patela (Genu) x 50,000 - 50,000
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Cefasole vial 7 103,200 722,400
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
Topi bh 1 1,100 1,100
Halotan cc 20 6,300 126,000
Oksigen ltr 21 2,000 42,000
Silk 2/0 m 1 12,750 12,750
Plain 2/0 m 1 31,700 31,700
. .
DHBP amp 1 72,000 72,000

Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Lomatuel lbr 1 14,000 14,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Tensocrepe 4" rol 1 67,000 67,000
Masker bh 3 800 2,400
Verban rol 2 1,300 2,600
b Jasa Tindakan
Implant 400,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr. Patella) 2 x 75,000 180,000 90,000
d Kruk 180,000
. . Total 6,852,800
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Patella (Genu) Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Patela (Genu) 1 x 50,000 50,000 50,000
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Lomatuel lbr 2 14,000 28,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
Plain 2/0 m 1 31,700 31,700
Halotan cc 20 6,300 126,000
Silk 2/0 m 1 12,750 12,750
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
. .
Lomatuel lbr 1 14,000 14,000

Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Tensocrepe 4" rol 1 67,000 67,000
Masker bh 3 800 2,400
Verban rol 2 1,300 2,600
b Jasa Tindakan
Implant 400,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr. Patella) 2 x 75,000 180,000 90,000
d Kruk 180,000
. . Total 5,674,500
. .
6 Fr. CLAVICULA
. - OPEN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
2 Rawat Inap
b Biaya Makan 4 x 42,000 168,000 45,000
d injeksi 16 x 5,000 80,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Thorax 1 x 50,000 50,000 60,000
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Cefasole vial 6 103,200 619,200
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Benostan tab 10 1,300 13,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 2/0 m 1 22,800 22,800
Halotan cc 30 6,300 189,000
Silk 3/0 m 1 12,750 12,750
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Plain 2/0 m 1 31,700 31,700
Oksigen ltr 21 2,000 42,000
. .
Safol cc 10 8,000 80,000

DHBP amp 1 72,000 72,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 550,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr.Clavicula) 2 x 60,000 144,000 72,000
. . Total 6,367,600
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Thorax 1 x 50,000 50,000 60,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Lomatuel lbr 2 14,000 28,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 2/0 m 1 22,800 22,800
Halotan cc 30 6,300 189,000
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Oksigen ltr 21 2,000 42,000
Plain 2/0 m 1 31,700 31,700
Silk 3/0 m 1 12,750 12,750
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
. .
Spuit 10 cc bh 1 5,550 5,550

Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 550,000
4 Lain-lain -
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr.Clavicula) 2 x 60,000 144,000 72,000
. . Total 5,270,100
. .
7 Fr. Humerus
. - OPEN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Humerus Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 12 x 5,000 60,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Humerus 1 x 50,000 50,000 50,000
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Cefasole vial 6 103,200 619,200
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
T.Vio 3-0 V5O sach 1 93,100 93,100
Oksigen ltr 21 2,000 42,000
Halotan cc 50 6,300 315,000
Silk 3/0 m 1 12,750 12,750
. .
Gamex 7,5 bh 3 21,300 63,900

DHBP amp 1 72,000 72,000
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Lomatuel lbr 1 14,000 14,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Tensocrepe 4" rol 1 67,000 67,000
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 700,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr.Humerus) 2 x 60,000 144,000 72,000
. . Total 7,722,150
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Humerus Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 9 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Humerus 1 x 50,000 50,000 50,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Lomatuel lbr 2 14,000 28,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 3-0 V5O sach 1 93,100 93,100
Halotan cc 50 6,300 315,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 3/0 m 1 12,750 12,750
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
. .
Lomatuel lbr 1 14,000 14,000

Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Tensocrepe 4" rol 1 67,000 67,000
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 700,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Fr.Humerus) 2 x 60,000 144,000 72,000
. . Total 6,570,000
. .
8 FR. PHALANG
. - OPEN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Phalang (Digit) Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
e By Akomodasi ICU 1 x 75,000 75,000 75,000
f Biaya Makan 1 x 58,500 58,500
g Js. Pelayanan ICU 1 x 66,500
h Ro. Phalang (Digit) 1 x 50,000 50,000 50,000
i Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Cefasole vial 6 103,200 619,200
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 15 6,300 94,500
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 2/0 m 1 12,750 12,750
Mess bh 2 4,500 9,000
Gamex 7,5 bh 3 21,300 63,900
. .
Safol cc 10 8,000 80,000

Lomatuel lbr 1 14,000 14,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 300,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Fr. Cruris) 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 5,153,050
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d injeksi 3 x 5,000 15,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Phalang (Digit) 1 x 50,000 50,000 50,000
Sat.
Jarum nedle23 bh 1 1,400 1,400
Spt 5 cc bh 1 5,300 5,300
Lomatuel lbr 1 14,000 14,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 15 6,300 94,500
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 2/0 m 1 12,750 12,750
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
. .
Lomatuel lbr 1 14,000 14,000

Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 300,000
4 Lain-lain
a Adiministrasi -
c a/j dr 250,000
. . Total 3,598,800
. .
9 Fr. METACARPAL
. - OPEN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Manus Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Manus 1 x 50,000 50,000 50,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Cefasole vial 6 103,200 619,200
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 15 6,300 94,500
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 2/0 m 1 12,750 12,750
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
. .
Safol cc 10 8,000 80,000

Lomatuel lbr 1 14,000 14,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 300,000
4 Lain-lain
a Adiministrasi -
b Kruk 180,000
d a/j dr 250,000
. . Total 5,328,950
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Manus Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
e By Akomodasi ICU x 75,000 - 75,000
f Biaya Makan x 58,500 58,500
g Js. Pelayanan ICU x 66,500
h Ro. Manus 1 x 50,000 50,000 50,000
i Rawat Luka x 25,000 -
Sat.
Jarum nedle 23 BH 1 1,600 1,600
Spt 5 cc bh 2 5,300 10,600
Lomatuel lbr 14,000 -
Tensocrepe 4" rol 67,000 -
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Oksigen ltr 21 1,500 31,500
Halotan cc 15 6,300 94,500
Silk 2/0 m 1 12,750 12,750
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Lomatuel lbr 1 14,000 14,000
. .
Spuit 10 cc bh 1 5,550 5,550

Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 300,000
4 Lain-lain
a Adiministrasi -
c a/j dr 250,000
. . Total 3,455,300
. .
10 Fr. METATARSAL
. - OPEN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Manus Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
F Ps. Spalk 20,000
f Hecting 120,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Cefasole vial 1 103,200 103,200
Spt 5 cc bh 1 5,300 5,300
ATS 1500 ui amp 1 119,800 119,800
Spt 3 cc bh 1 4,300 4,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Manus 1 x 50,000 50,000 50,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Cefasole vial 6 103,200 619,200
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 15 6,300 94,500
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 2/0 m 1 12,750 12,750
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
. .
Safol cc 10 8,000 80,000

Lomatuel lbr 1 14,000 14,000
Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 300,000
4 Lain-lain
a Adiministrasi -
b Kruk 180,000
d a/j dr 250,000
. . Total 5,339,250
. .
. CLOSE
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
Manus Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d injeksi 3 x 5,000 15,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Manus 1 x 50,000 50,000 44,000
Sat.
Jarum nedle 23 BH 1 1,600 1,600
Spt 5 cc bh 2 5,300 10,600
Lomatuel lbr 14,000 -
Tensocrepe 4" rol 67,000 -
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Oksigen ltr 21 2,000 42,000
Halotan cc 15 6,300 94,500
Topi bh 1 1,100 1,100
Silk 2/0 m 1 12,750 12,750
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
Lomatuel lbr 1 14,000 14,000
. .
Spuit 10 cc bh 1 5,550 5,550

Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 300,000
4 Lain-lain
a Adiministrasi -
c a/j dr 250,000
. . Total 3,493,600
. .
11 Fr. Collum Femur Non Patologis
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
Femur Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000 45,000
d injeksi 15 x 5,000 75,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
i Ro. Femur 1 x 60,000 60,000 60,000
j Rawat Luka 3 x 25,000 75,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Lomatuel lbr 2 14,000 28,000
Tensocrepe 6" rol 1 85,000 85,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
T.Vio 1 sach 1 116,400 116,400
Hypafix cm 25 400 10,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Regivell amp 2 22,000 44,000
Mess bh 2 4,500 9,000
. .
Plain 2/0 cm 120 176 21,120

Silk 2/0 cm 120 127 15,240
Lomatuel lbr 2 14,000 28,000
Spt 5 cc bh 5 5,300 26,500
Transet bh 1 34,300 34,300
Urine Bag bh 1 7,500 7,500
Verban rol 2 1,300 2,600
Masker bh 3 800 2,400
b Jasa Tindakan
Implant 2,500,000
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
d Kruk 180,000
. . Total 8,137,160
. .
12 DISLOKASI COLLUM FEMUR
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
Pelvis Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d injeksi 6 x 5,000 30,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Pelvis 1 x 60,000 60,000 60,000
Sat.
Benostan tab 10 1,300 13,000
Tensocrepe 6" rol 1 85,000 85,000
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Topi bh 1 1,100 1,100
Safol cc 10 8,000 80,000
Succynil cc 3 16,200 48,600
Spuit 10 cc bh 1 5,550 5,550
Spt 5 cc bh 1 5,300 5,300
Spt 3 cc bh 1 4,300 4,300
DHBP amp 1 72,000 72,000
Tensocrepe 6" rol 2 85,000 170,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Fr. femur) 2 x 75,000 150,000 90,000
c a/j dr 250,000
d Kruk 180,000
. . Total 3,338,200
. .
13 AMPUTASI
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 110,000
Thorax Rp 50,000 60,000
Cruris Rp 60,000 72,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 1 5,300 5,300
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Cruris 1 x 60,000 60,000 60,000
j Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Spt 5 cc bh 3 5,300 15,900
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 5 1,300 6,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 m 2 22,800 45,600
Topi bh 1 1,100 1,100
Silk 2/0 cm 60 127 7,620
H2 O2 cc 30 250 7,500
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
-
. .
Lidodex amp 1 71,500 71,500

Mess bh 1 4,500 4,500
Lomatuel lbr 1 14,000 14,000
Spt 3 cc bh 1 4,300 4,300
Verban rol 2 1,300 2,600
Soffband 4 rol 1 27,500 27,500
Masker bh 3 800 2,400
Kanamicin vial 1 11,300 11,300
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b a/j dr 250,000
c Fisioterapi (Amputasi Bellow Knee) 3 x 75,000 270,000 90,000
d Kruk 180,000
. . Total 4,958,870
. .
14 Angkat Plate Humerus / Femur
KELAS III
1. Rawat Jalan :
1 Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
GDA Rp 10,000 12,000
OT PT Rp 20,000 24,000
SC Rp 20,000 24,000
3 Radiologi 110,000
Thorax Rp 50,000 60,000
Femur Rp 60,000 72,000
4 ECG 25,000
2 Rawat Inap
b Biaya Makan 2 x 42,000 84,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 6 x 5,000 30,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
j Rawat Luka x 25,000 - 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Zide 3-0 m 1 12,750 12,750
Plain 2/0 m 1 31,700 31,700
Cromix 1 m 1 22,800 22,800
Oksigen ltr 21 2,000 42,000
Lidodex amp 1 71,500 71,500
Spinocain bh 1 47,400 47,400
Spt 5 cc bh 1 5,300 5,300
Gamex 7,5 bh 4 21,300 85,200
Epedrin amp 1 15,000 15,000
Masker bh 3 800 2,400
Mess bh 1 4,500 4,500
2 Jasa Tindakan
4 Lain-lain
1 Adiministrasi -
2 Fisioterapi (Fr. Femur) 2 x 75,000 150,000 90,000
3 a/j dr 250,000
. . Total 3,429,450
. .
15 Angkat Plate / Cruris / Tibia / Antebrachii / Patela
KELAS III
1. Rawat Jalan :
1 Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
GDA Rp 10,000 12,000
OT PT Rp 20,000 24,000
SC Rp 20,000 24,000
3 Radiologi 110,000
Thorax Rp 50,000 60,000
Femur Rp 60,000 72,000
4 ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 3 x 5,000 15,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Jarum nedle 23 bh 1 1,600 1,600
Spt 5 cc bh 1 5,300 5,300
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Zide 3-0 m 1 12,750 12,750
Plain 2/0 m 1 31,700 31,700
Cromix 1 m 1 22,800 22,800
Oksigen ltr 21 2,000 42,000
Lidodex amp 1 71,500 71,500
Spinocain bh 1 47,400 47,400
Spt 5 cc bh 1 5,300 5,300
Gamex 7,5 bh 4 21,300 85,200
Epedrin amp 1 15,000 15,000
Masker bh 3 800 2,400
Mess bh 1 4,500 4,500
2 Jasa Tindakan
4 Lain-lain
1 Adiministrasi -
2 Fisioterapi (Fr. Cruris) 1 x 60,000 60,000 72,000
3 a/j dr 250,000
. . Total 3,211,200
. .
16 Ganglion Poplitea
KELAS III
1. Rawat Jalan :
1 Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
GDA Rp 10,000 12,000
OT PT Rp 20,000 24,000
SC Rp 20,000 24,000
3 Radiologi 50,000
Thorax Rp 50,000 60,000
4 ECG 25,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 3 x 5,000 15,000 6,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
j Rawat Luka x 25,000 - 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Spt 5 cc bh 2 5,300 10,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Hypafix cm 15 400 6,000
Zide Silk 2/0 m 1 12,750 12,750
Plain 2/0 m 1 31,700 31,700
T.Vio 2-0 sach 1 52,000 52,000
Lidodex amp 1 71,500 71,500
Spinocain bh 1 47,400 47,400
Spt 3 cc bh 1 4,300 4,300
Gamex 7,5 bh 4 21,300 85,200
Epedrin amp 1 15,000 15,000
Tensocrepe 6" rol 1 85,000 85,000
Lomatuel Lbr 1 14,000 14,000
Masker bh 3 800 2,400
Mess bh 1 4,500 4,500
2 Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 2,717,350
. .
17 LUMBRICALIS REPLACEMENT (EF4T+ EE4T)
KELAS III
1 Rawat Jalan
a Poli MH 15,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post Op Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 100,000
Thorax Rp 50,000
Manus Rp 50,000
e ECG 25,000
f Fisioterapi (Lumbricallis Replacement) 14 x 60,000 840,000
2 Rawat Inap

b Biaya Makan 5 x 42,000 210,000
c Js. Pelayanan RI 5 x -
d Pasang Infus 1 x 30,000 -
e injeksi 12 x 5,000 60,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
h Biaya Makan x 58,500
j Ro. Manus 1 x 50,000 50,000
k Rawat Luka 2 x 25,000 50,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Novalgin inj amp 6 11,500 69,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Isodine Solution 60 ml cc 60 343 20,580
Tensocrepe 4" rol 1 67,000 67,000
Povidon Iodida 10 % tab 10 150 1,500
Ciprofloxasin tab 10 400 4,000
Verban rol 15 1,300 19,500
. .
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cut Gut Plain 2/0 cm 100 176 17,600
Miloz Inj amp 1 23,000 23,000
Topi bh 1 1,100 1,100
Hypafix cm 20 400 8,000
Oksigen ltr 21 2,000 42,000
Silk 2/0 m 1 12,750 12,750
Gibsona 4 " bh 3 36,350 109,050
Gibsona 6 " bh 2 47,650 95,300
Halotan cc 35 6,300 220,500
Gamex 7,5 bh 4 21,300 85,200
Mess 10 bh 2 4,500 9,000
Safol cc 10 8,000 80,000
T.Lene 6-0 L42^ sach 2 83,900 167,800
Soffband 4 rol 2 27,500 55,000
Soffband 6 rol 1 32,250 32,250
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Tensocrepe 4" rol 1 67,000 67,000
Ticron 1 bh 1 70,550 70,550
Masker bh 3 800 2,400
Verban rol 2 1,300 2,600
b Jasa Tindakan
4 Lain-lain
Jasa Service Layanan 211800
a Adiministrasi -
. . Total 6,115,780
. .
18 TIBIALIS POSTERIOR TRANSFER
KELAS III
1 UGD
a Poli MH 15,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 150,000
Thorax Rp 50,000
Angkle Rp 50,000
Pedis Rp 50,000
d ECG 25,000
e Fisioterapi (Drop Hand) 4 x 60,000 240,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000
c Js. Pelayanan RI 5 x -
d Pasang Infus 1 x 30,000 30,000
e injeksi 12 x 5,000 60,000
f Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Ro. Angkle + Pedis 1 x 100,000 100,000
h Rawat Luka 2 x 25,000 50,000
Sat.
Transet bh 1 34,300 34,300
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
. .
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Catgut Plain 3-0 cm 100 176 17,600
Halotan cc 35 6,300 220,500
Hypafix cm 20 400 8,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 3/0 m 1 12,750 12,750
Miloz Inj amp 1 23,000 23,000
Gibsona 4 " bh 3 36,350 109,050
Gibsona 6 " bh 2 47,650 95,300
Gamex 7,5 bh 4 21,300 85,200
Mess 10 bh 2 4,500 9,000
Safol cc 10 8,000 80,000
T.Lene 6-0 L42^ sach 2 83,900 167,800
Soffband 4 rol 2 27,500 55,000
Soffband 6 rol 1 32,250 32,250
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Tensocrepe 4" rol 1 67,000 67,000
Ticron 1 bh 1 70,550 70,550
Masker bh 3 800 2,400
Verban rol 2 1,300 2,600
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Tibialis Posterior Transfer ) 14 x 60,000 840,000
c Kruk 180,000
. . Total 6,116,100
. .
19 OPPONEN REPLACEMENT
KELAS III
1 Poli MH
a Poli Umum 15,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 100,000
Thorax Rp 50,000
Manus Rp 50,000
d ECG 25,000
e Fisioterapi (Clow Hand) 4 x 60,000 240,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000
c Pasang Infus 1 x 30,000 30,000
d injeksi 12 x 5,000 60,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
f Ro. Manus 1 x 50,000 50,000
g Rawat Luka 2 x 25,000 50,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
. .
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cut Gut Plain 2/0 m 1 31,700 31,700
Halotan cc 35 6,300 220,500
Hypafix cm 20 400 8,000
Topi bh 1 1,100 1,100
Oksigen ltr 21 2,000 42,000
Silk 3/0 m 1 12,750 12,750
Miloz Inj amp 1 23,000 23,000
Gibsona 4 " bh 3 36,350 109,050
Gibsona 6 " bh 2 47,650 95,300
Gamex 7,5 bh 2 21,300 42,600
Mess 10 bh 2 4,500 9,000
Safol cc 10 8,000 80,000
T.Lene 6-0 L42^ sach 2 83,900 167,800
Soffband 4 rol 2 27,500 55,000
Soffband 6 rol 1 32,250 32,250
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Tensocrepe 4" rol 1 67,000 67,000
Ticron 1 bh 1 70,550 70,550
Masker bh 3 800 2,400
Verban rol 2 1,300 2,600
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Opponen Replacement) 14 x 60,000 840,000
. . Total 6,266,900
. .
20 TEMPORALIS MUSCULUS TRANSFER
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 175,000
Thorax Rp 50,000
Skull Rp 75,000
Waters Rp 50,000
d ECG 25,000
e Fisioterapi (Opponen Replacement) 4 x 60,000 240,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000
c injeksi 12 x 5,000 60,000
d Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
e Ro. Skull + Waters 1 x 125,000 125,000
f Rawat Luka 2 x 25,000 50,000
g Obat Ruangan 846,400
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cut Gut Plain 2/0 m 1 31,700 31,700
Hypafix cm 20 400 8,000
Topi bh 1 1,100 1,100
Silk 3/0 m 1 12,750 12,750
Regivell amp 4 22,000 88,000
Gamex 7,5 bh 4 21,300 85,200
Mess 10 bh 2 4,500 9,000
T.Lene 6-0 L42^ sach 2 83,900 167,800
Spt 3 cc bh 1 4,300 4,300
Masker bh 3 800 2,400
Spt 5 cc bh 1 5,300 5,300
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Opponen Replacement) 7 x 60,000 420,000
. . Total 5,453,325
. .
21 ULCUS PEDIS (DEBRIDEMENT FRAKTUR TERBUKA)
KELAS III
1 Rawat Jalan
a Poli MH 15,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 100,000
Thorax Rp 50,000
Pedis Rp 50,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000
d injeksi 12 x 5,000 60,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
f Ro. Pedis 1 x 50,000 50,000
g Rawat Luka 3 x 25,000 75,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 cm 120 228 27,360
Silk 2/0 m 1 12,750 12,750
H2 O2 cc 30 250 7,500
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Lidodex amp 1 71,500 71,500
Mess 10 bh 1 4,500 4,500
Topi bh 1 1,100 1,100
Lomatuel lbr 1 14,000 14,000
Spt 3 cc bh 1 4,300 4,300
Verban rol 2 1,300 2,600
Soffband 4 rol 1 27,500 27,500
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 3 x 60,000 180,000
c Kruk 180,000
. . Total 3,764,760
. .
22 ULCUS PLANTAR,SEPTIK (DEBRIDEMENT FRAKTUR TERBUKA)
KELAS III
1 Rawat Jalan
a Poli MH 15,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
OT PT Rp 20,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 100,000
Thorax Rp 50,000
Pedis Rp 50,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000
c injeksi 12 x 5,000 60,000
d Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
e Ro. Pedis 1 x 50,000 50,000
f Rawat Luka 2 x 25,000 50,000
g Obat Ruangan 855,400
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Cromix 1 cm 120 228 27,360
Silk 2/0 m 1 12,750 12,750
H2 O2 cc 30 250 7,500
H2 O2 cc 30 250 7,500
Epedrin amp 1 15,000 15,000
Gamex 7,5 bh 4 21,300 85,200
Spinocain bh 1 47,400 47,400
Topi bh 1 1,100 1,100
Lidodex amp 1 71,500 71,500
Mess 10 bh 1 4,500 4,500
Lomatuel lbr 1 14,000 14,000
Spt 3 cc bh 1 4,300 4,300
Verban rol 2 1,300 2,600
Soffband 4 rol 1 27,500 27,500
Masker bh 3 800 2,400
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 3 x 60,000 180,000
c Kruk 180,000
. . Total 3,717,260
. .
23 RUPTUR TENDON
KELAS III
1. Rawat Jalan :
1 IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT 20,000 24,000
GDA Rp 10,000 12,000
3 Radiologi 50,000
Thorax Rp 50,000 60,000
4 ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Optiva No.18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Spt 5 cc bh 2 5,300 10,600
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
3 Kamar Operasi
Sat.
Halotan cc 30 6,300 189,000
Safol cc 10 8,000 80,000
Succynil cc 3 16,200 48,600
Oksigen ltr 21 2,000 42,000
Tensocrepe 4" rol 1 67,000 67,000
Lomatuel lbr 1 14,000 14,000
Gamex 7,5 bh 3 21,300 63,900
Topi bh 1 1,100 1,100
Alkohol 70 % cc 50 65 3,250
T.Nylon 4-0 (1756-41) sach 1 51,250 51,250
Plain 2/0 m 1 31,700 31,700
Gibsona 4 " bh 2 36,350 72,700
Soffband 4 rol 1 27,500 27,500
Masker bh 3 800 2,400
Mess 15 bh 1 4,500 4,500
2 Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 3 x 60,000 180,000 72,000
c a/j dr 250,000
. . Total 3,508,200
. .
24 POLIDACTILI
KELAS III
1 Rawat Jalan :
1 Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d injeksi 3 x 5,000 15,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
i Ro. Phalang (Digit) 1 x 50,000 50,000 50,000
Sat.
Spt 5 cc bh 2 5,300 10,600
Lomatuel lbr 1 14,000 14,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Mitela bh 1 44,500 44,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Halotan cc 15 6,300 94,500
Oksigen ltr 21 2,000 42,000
Silk 2/0 m 1 127,500 127,500
Topi bh 1 1,100 1,100
Gamex 7,5 bh 3 21,300 63,900
Mess bh 2 4,500 9,000
Safol cc 10 8,000 80,000
. .
Lomatuel lbr 1 14,000 14,000

Spuit 10 cc bh 1 5,550 5,550
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
Verban rol 1 1,300 1,300
b Jasa Tindakan
Implant 300,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 3,917,100
. .
25 C. ALIENUM JARUM
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d injeksi 3 5,000 15,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
Sat.
Mitela bh 1 44,500 44,500
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Topi bh 1 1,100 1,100
Safol cc 10 8,000 80,000
Succynil cc 3 16,200 48,600
Spuit 10 cc bh 1 5,550 5,550
Spt 5 cc bh 1 5,300 5,300
Spt 3 cc bh 1 4,300 4,300
Soffband 4 rol 1 27,500 27,500
Gibsona 4 " bh 2 36,350 72,700
Masker bh 3 800 2,400
DHBP amp 1 72,000 72,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (fr. Cruris) 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 2,956,400
.
26 BASALIOMA SKIN GRAFT
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
Sat.
Mitela bh 1 44,500 44,500
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Topi bh 1 1,100 1,100
Safol cc 10 8,000 80,000
Succynil cc 3 16,200 48,600
Spuit 10 cc bh 1 5,550 5,550
Spt 5 cc bh 1 5,300 5,300
Spt 3 cc bh 1 4,300 4,300
Soffband 4 rol 1 27,500 27,500
Gibsona 4 " bh 2 36,350 72,700
Masker bh 3 800 2,400
DHBP amp 1 72,000 72,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
c a/j dr 250,000
. . Total 5,009,150
.
27 BASALIOMA
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 100,000
Thorax Rp 50,000 60,000
d Pasang Infus 1 x 30,000 30,000 36,000
e ECG 25,000
f Ps. Spalk 20,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Verban rol 10 1,300 13,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 1 x 58,500 58,500
Sat.
Mitela bh 1 44,500 44,500
Benostan tab 10 1,300 13,000
3 Kamar Operasi
Sat.
Oksigen ltr 21 2,000 42,000
Topi bh 1 1,100 1,100
Safol cc 10 8,000 80,000
Succynil cc 3 16,200 48,600
Spuit 10 cc bh 1 5,550 5,550
Spt 5 cc bh 1 5,300 5,300
Spt 3 cc bh 1 4,300 4,300
Soffband 4 rol 1 27,500 27,500
Gibsona 4 " bh 2 36,350 72,700
Masker bh 3 800 2,400
DHBP amp 1 72,000 72,000
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
c a/j dr 250,000
. . Total 4,384,150
. .
1. FRAKTUR MANDIBULA (Spesialis Bedah Mulut)

KELAS III
1. UGD
1 IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
3 Radiologi 175,000
Thorax Rp 50,000 60,000
Waters Rp 50,000 60,000
Skull Rp 75,000 90000
4 ECG 25,000
5 Pasang Infus 1 x 30,000 30,000 36,000
6 Obat UGD 83,600
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d injeksi 9 x 5,000 45,000 6,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
g Biaya Makan 2 x 58,500 58,500
i Ro Waters 1 x 50,000 50,000 46,000
j Rawat Luka 1 x 25,000 25,000 30,000
Sat.
Vicillin vial 11 13,600 149,600
Spt 5 cc bh 4 5,300 21,200
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Magslang bh 1 29,500 29,500
Spuit 20 cc bh 1 9,650 9,650
3 Kamar Operasi
Sat.
T.Vio 3-0 V5O sach 1 93,100 93,100
Halotan cc 60 6,300 378,000
Hibicef cc 20 250 5,000
Topi bh 1 1,100 1,100
Oksigen ltr 35 2,000 70,000
T.Silk 3-0 S23 sach 1 89,500 89,500
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Spuit 10 cc bh 1 5,550 5,550
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
. .
2 Jasa Tindakan
Tim Operator 1,200,000
Implant 2,000,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 10,023,950
.
2 REPOSISI MANDIBULA
KELAS III
1. UGD
1 IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
OT PT Rp 20,000 24,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
3 Radiologi 175,000
Thorax Rp 50,000 60,000
Waters Rp 50,000 60,000
Skull Rp 75,000 90,000
4 ECG 25,000
5 Pasang Infus 1 x 30,000 30,000 36,000
6 Obat UGD 83,600
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Injeksi 3 x 5,000 15,000 6,000
e Persiapan Operasi
g Biaya Makan 1 x 58,500 58,500
i Ro Waters 1 x 50,000 50,000 46,000
j Rawat Luka x 25,000 - 30,000
Sat.
Vicillin vial 11 13,600 149,600
Spt 5 cc bh 4 5,300 21,200
Benostan tab 10 1,300 13,000
Amobiotik 500 mg tab 10 3,000 30,000
Magslang bh 1 29,500 29,500
Spuit 20 cc bh 1 9,650 9,650
3 Kamar Operasi
Sat.
T.Vio 3-0 V5O sach 1 93,100 93,100
Halotan cc 60 6,300 378,000
Hibicef cc 20 250 5,000
Oksigen ltr 35 2,000 70,000
T.Silk 3-0 S23 sach 1 89,500 89,500
Topi bh 1 1,100 1,100
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 3 21,300 63,900
Mess bh 1 4,500 4,500
Spuit 10 cc bh 1 5,550 5,550
Spuit 20 cc bh 1 9,650 9,650
Spt 3 cc bh 1 4,300 4,300
Spt 5 cc bh 1 5,300 5,300
Succynil cc 3 16,200 48,600
Masker bh 3 800 2,400
. .
2 Jasa Tindakan
Implant
4 Lain-lain
a Adiministrasi -
b Fisioterapi 1 x 60,000 60,000 72,000
c a/j dr 250,000
. . Total 3,164,950
. .
H BEDAH ANAK
1. ANUS PLASTY
KELAS III
1. UGD
1 IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
LFT Rp 40,000 48,000
Albumin Rp 15,000 18,000
3 Radiologi 60,000
BOF Rp 60,000 72,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 12 x 5,000 60,000 6,000
f Persiapan Operasi
- Huknah 15,000
h Biaya Makan 1 x 58,500 58,500
j Rawat Luka 3 x 25,000 75,000 30,000
k tindakan khusus
- Huknah 3 x 15,000 45,000 18,000
Sat.
D ¼ NS 5 11,800 59,000
Spt 5 cc bh 3 5,300 15,900
Opimox syr fles 1 20,000 20,000
Infus set bh 1 18,000 18,000
Optiva No.18 bh 1 23,000 23,000
3 Kamar Operasi
Sat.
Halotan cc 75 6,300 472,500
Topi bh 1 1,100 1,100
Hypafix cm 10 400 4,000
Alkohol 70 % cc 50 65 3,250
T.Vio 3-0 V5O sach 1 93,100 93,100
T.Silk 3-0 S220 sach 2 98,600 197,200
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 1 21,300 21,300
Spt 3 cc bh 1 4,300 4,300
Urine Bag bh 1 7,500 7,500
Magslang bh 1 29,500 29,500
Masker bh 3 800 2,400
Nebacetin Salep mata tube 1 17,200 17,200
2 Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,000,050
.
2 HIRSCPRUNG
KELAS III
1. UGD
1 IGD 20,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
SC Rp 20,000 24,000
OT PT Rp 20,000 24,000
Albumin Rp 15,000 18,000
GDA 10,000 12,000
3 Radiologi 60,000
BOF Rp 60,000 72,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 15 x 5,000 75,000 6,000
f Persiapan Operasi
- Huknah 15,000
h Biaya Makan 2 x 58,500 58,500
j Rawat Luka 5 x 25,000 125,000 30,000
k tindakan khusus
- Huknah 3 x 15,000 45,000 18,000
Sat.
D ¼ NS 5 11,800 59,000
Spt 5 cc bh 3 5,300 15,900
Opimox syr fles 1 20,000 20,000
Infus set bh 1 18,000 18,000
Optiva No.18 bh 1 23,000 23,000
3 Kamar Operasi
Sat.
Halotan cc 75 6,300 472,500
Hypafix cm 10 400 4,000
Topi bh 1 1,100 1,100
Alkohol 70 % cc 50 65 3,250
T.Vio 3-0 V5O sach 1 93,100 93,100
T.Silk 3-0 S220 sach 2 98,600 197,200
DHBP amp 1 72,000 72,000
Gamex 7,5 bh 1 21,300 21,300
Spt 3 cc bh 1 4,300 4,300
Urine Bag bh 1 7,500 7,500
Magslang bh 1 29,500 29,500
Masker bh 3 800 2,400
Nebacetin Salep mata tube 1 17,200 17,200
2 Jasa Tindakan
3 Sewa Kamar Operasi 1,000,000
4 Lain-lain
a Adiministrasi -
b Fisioterapi 2 x 60,000 120,000 72,000
c a/j dr 250,000
. . Total 6,699,350
. .
I. BEDAH SYARAF
1 RELEASE N. ULNARIS (BIOPSI SARAF KUTANEUS/OTOT)
KELAS III
1 Poli MH
a Poli Umum 15,000
DL Rp 30,000
BT, CT Rp 5,000
Hb Post OP Rp 5,000
LFT Rp 40,000
GDA Rp 10,000
SC Rp 20,000
c Radiologi 100,000
Thorax Rp 50,000
Elbow Rp 50,000
d ECG 25,000
e Fisioterapi (Lumbricallis Replacement) 2 x 60,000 120,000
2 Rawat Inap
b Biaya Makan 5 x 42,000 210,000
d injeksi 15 x 5,000 75,000
e Persiapan Operasi
- Huknah 15,000
- Skiren 5,000
f Ro. Elbow 1 x 50,000 50,000
g Rawat Luka 2 x 25,000 50,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Gamex 7,5 bh 1 21,300 21,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
. .
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Regivell amp 25 22,000 550,000
Gamex 7,5 bh 4 21,300 85,200
Mess 15 bh 1 4,500 4,500
Mess 10 bh 1 4,500 4,500
Dermalon bh 1 75,550 75,550
Lomatuel lbr 1 14,000 14,000
Verban rol 1 1,300 1,300
Spuit 10 cc bh 1 5,550 5,550
Vicril Rapid 4 bh 1 123,000 123,000
Masker bh 3 800 2,400
Nedle no 23 G bh 1 1,600 1,600
b Jasa Tindakan
4 Lain-lain
a Adiministrasi -
b Fisioterapi (Lumbricallis Replacement) 4 x 60,000 240,000
. . Total 4,892,275
. .
J. MATA
1 KATARAK
KELAS III
1 Rawat Jalan :
a Poli Umum 15,000
DL Rp 30,000 36,000
BT, CT Rp 5,000 6,000
Hb Post OP Rp 5,000 6,000
LFT Rp 40,000 48,000
GDA Rp 10,000 12,000
SC Rp 20,000 24,000
c Radiologi 50,000
Thorax Rp 50,000 60,000
d ECG 25,000
2 Rawat Inap
b Biaya Makan 3 x 42,000 126,000 45,000
d Pasang Infus 1 x 30,000 30,000 36,000
e injeksi 3 x 5,000 15,000 6,000
f Persiapan Operasi
h Biaya Makan x 58,500
k Rawat Luka 2 x 25,000 50,000 30,000
Sat.
Transet bh 1 34,300 34,300
Optiva No.18 bh 1 23,000 23,000
Gamex 7,5 bh 1 21,300 21,300
Transet bh 1 34,300 34,300
Spt 5 cc bh 4 5,300 21,200
Optiva No.18 bh 1 23,000 23,000
Lomatuel lbr 2 14,000 28,000
Tensocrepe 4" rol 1 67,000 67,000
Benostan tab 10 1,300 13,000
Verban rol 15 1,300 19,500
3 Kamar Operasi
Sat.
Alkohol 70 % cc 50 65 3,250
Topi bh 1 1,100 1,100
Regivell amp 25 22,000 550,000
Gamex 7,5 bh 4 21,300 85,200
Mess 15 bh 1 4,500 4,500
Dermalon bh 1 75,550 75,550
Verban rol 1 1,300 1,300
Spuit 10 cc bh 1 5,550 5,550
Vicril Rapid 4 bh 1 123,000 123,000
Masker bh 3 800 2,400
Lensa bh 1 400,000 400,000
Nedle no 23 G bh 1 1,600 1,600
b Jasa Tindakan
Sewa alat 100,000
4 Lain-lain
a Adiministrasi -
4,153,650
###
. .
K. PERSALINAN
1 PERSALINAN NORMAL OLEH BIDAN

KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000
2 KAMAR BERSALIN (VK) 163,070

Sat.
Kapas gr 10 352 3,520
Savlon cc 10 225 2,250
Alkohol cc 20 25 500
Betadine cc 50 150 7,500
Gammex 7,5 bh 2 21,300 42,600
U-pad bh 2 8,000 16,000
Mucus bh 1 34,650 34,650
Oksitosin amp 1 9,050 9,050
Vit K amp 1 2,125 2,125
Sp 3cc bh 2 3,550 7,100
Sp 1cc bh 1 2,625 2,625
Kasa box bh 1 7,150 7,150
Waslap bh 1 3,000 3,000
Salep mata bh 1 2,000 2,000
Jarum heacting bh 1 11,000 11,000
Cromix 1 cm 50 175 8,750
lidokain amp 1 3,250 3,250
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
d Biaya ADM RI 1 x -
e Rawat Gabung Bayi Baru Lahir 40,000
- Akomodasi 20,000 24,000
- Jasa Pelayanan - 10,000
- Perawatan Bayi baru lahir 20,000 24,000
f Obat Ruangan / pulang 66,000

Sat.
Amobiotik 500mg bj 10 3000 30,000
Benostan bj 10 1300 13,000
Nerradin bj 10 2300 23,000
g Jasa Tindakan
- Sewa VK 100,000
- Persalinan Oleh Bidan 500,000
- Konsul dr Specialist 50,000
1,041,070
###
. .
2 PERSALINAN NORMAL OLEH DOKTER
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000

Sat.
Kapas gr 10 352 3,520
Savlon cc 10 225 2,250
Alkohol cc 20 25 500
Betadine cc 50 150 7,500
Gammex 7,5 bh 2 21,300 42,600
U-pad bh 2 8,000 16,000
Mucus bh 1 34,650 34,650
Vit K amp 1 2,125 2,125
Sp 3cc bh 2 3,550 7,100
Sp 1cc bh 1 2,625 2,625
Kasa box bh 1 7,150 7,150
Waslap bh 1 3,000 3,000
Jarum heacting bh 1 11,000 11,000
Cromix 1 cm 50 175 8,750
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
- Akomodasi 20,000 24000
- Jasa Pelayanan - 10000
- Perawatan Bayi baru lahir 20,000 24000

Sat.
Amobiotik 500mg bj 10 3000 30,000
Benostan bj 10 1300 13,000
Nerradin bj 10 2300 23,000
g Jasa Tindakan
- Sewa VK 100,000
- Persalinan Oleh Dokter Spesialis 750,000
- Tim Bidan 375,000
1,616,070
###
. .
3 PERSALINAN DENGAN PENYULIT DITOLONG OLEH BIDAN
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000
UL Rp 25,000
d Obat - Obatan 73,050
Sat.
Optiva 18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Ecosol RL flash 1 12,300 12,300
Pro IV bh 1 3,450 3,450

Sat.
Kapas gr 15 352 5,280
Savlon cc 20 225 4,500
Alkohol cc 50 25 1,250
Betadine cc 100 150 15,000
Gammex 7,5 bh 2 21,300 42,600
U-pad bh 3 8,000 24,000
Mucus bh 1 34,650 34,650
Vit K bh 1 2,125 2,125
Sp 3cc bh 3 3,550 10,650
Sp 1cc bh 1 2,625 2,625
Kasa box box 3 7,150 21,450
Waslap bh 1 3,000 3,000
metergin amp 1 9,750 9,750
Ecosol D5 flash 3 9,550 28,650
cefo vial 3 12,500 37,500
aquades flash 1 2,000 2,000
Sp 5cc bh 1 4,250 4,250
cytotec tab 3 8,400 25,200
0ksigen ltr 21 800 16,800
Sp 10cc bh 1 5,600 5,600
Nedle 23 bh 2 1,400 2,800
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
- Akomodasi 20,000 24,000
- Jasa Pelayanan - 10,000
- Perawatan Bayi baru lahir 20,000 24,000

Sat.
Amobiotik 500mg bj 10 3000 30,000
Benostan bj 10 1300 13,000
Nerradin bj 10 2300 23,000
g Jasa Tindakan
- Sewa VK 100,000
- Persalinan Oleh Bidan 750,000
- Konsultasi dr. Spesialis 50,000
1,668,480
###
. .
4 PERSALINAN DENGAN PENYULIT DITOLONG OLEH DOKTER AHLI
KELAS III
1 UGD
a IGD 20,000
DL Rp 30,000
UL Rp 25,000
d Obat - Obatan 73,050
Sat.
Optiva 18 bh 1 23,000 23,000
Transet bh 1 34,300 34,300
Pro IV bh 1 3,450 3,450

Sat.
Kapas gr 15 352 5,280
Savlon cc 20 225 4,500
Alkohol cc 50 25 1,250
Betadine cc 100 150 15,000
Gammex 7,5 bh 2 21,300 42,600
U-pad bh 3 8,000 24,000
Mucus bh 1 34,650 34,650
Vit K bh 1 2,125 2,125
Sp 3cc bh 3 3,550 10,650
Sp 1cc bh 1 2,625 2,625
Kasa box box 3 7,150 21,450
Waslap bh 1 3,000 3,000
metergin amp 1 9,750 9,750
Ecosol D5 flash 3 9,550 28,650
cefo vial 3 12,500 37,500
aquades flash 1 2,000 2,000
Sp 5cc bh 1 4,250 4,250
cytotec tab 3 8,400 25,200
0ksigen ltr 21 800 16,800
Sp 10cc bh 1 5600 5,600
Nedle 23 bh 2 1,400 2,800
2 Rawat Inap
b Biaya Makan 1 x 42,000 42,000 45,000
- Akomodasi 20,000 24000
- Perawatan Bayi baru lahir 20,000 24000

Sat.
Amobiotik 500mg bj 10 3000 30,000
Benostan bj 10 1300 13,000
Nerradin bj 10 2300 23,000
g Jasa Tindakan
- Sewa VK 100,000
- Persalinan Oleh dr. Ahli 1,000,000
- Tim Bidan 500,000
2,368,480
###
. . Total 21,695,500
TRAUMA ABDOMEN 1 1,200,000

300,000
600,000
TRAUMA ABDOMEN REVISI 1,400,000
350,000
700,000
4 9 -10 11
RFT ###
.
.
KELAS II KELAS I KELAS
UTAMA Rp ### Rp
###
15,000 15,000 15,000

126,000 137,000 158,000
39,000 45,000
7,000 8,000
26,000 30,000
52,000 60,000
13,000 15,000
60,000 65,000 65,000 75,000 75,000

- -
30,000 33,000 38,000
- -
50,000 100,000 100,000 150,000 150,000
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
- - -
210,000 210,000 210,000
676,700 676,700 676,700 2,186,700 ### ###

720,000 780,000 900,000
180,000 200,000 230,000
360,000 390,000 450,000
250,000 270,000 310,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,211,700 3,483,200 3,914,700
5 ### 10 -10 12
.

UTAMA
15,000 15,000 15,000

126,000 137,000 158,000
39,000 45,000
7,000 8,000
26,000 30,000
52,000 60,000
13,000 15,000
60,000 65,000 65,000 75,000 75,000

30,000 33,000 38,000
- -
50,000 100,000 100,000 150,000 150,000
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
196,000 196,000 196,000
863,256 863,256 863,256 3,703,256 ### ###

1,440,000 1,560,000 1,800,000
360,000 360,000 360,000
720,000 720,000 720,000
- -
320,000 340,000 390,000
- -
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
4,714,256 4,995,756 5,467,256
6 11 -10 13
.

UTAMA
15,000 15,000 15,000

156,000 170,000 196,000
39,000 45,000
7,000 8,000
26,000 30,000
52,000 60,000
13,000 15,000
33,000 38,000
60,000 65,000 65,000 75,000 75,000

30,000 33,000 38,000
-
150,000 100,000 300,000 150,000 450,000
135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
6,000 7,000 8,000

- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
30,000 33,000 33,000 38,000 38,000
565,050 565,050 565,050
455,450 455,450 455,450 2,185,450 ### ###
840,000 910,000 1,050,000

210,000 230,000 270,000
420,000 460,000 530,000
260,000 280,000 320,000
-
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
3,951,500 4,427,000 5,067,500
7 12 -10 14
.
.

UTAMA
20,000 20,000 20,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
60,000 65,000 75,000
65,000 75,000
30,000 33,000 38,000
90,000 98,000 98,000 113,000 113,000
36,000 39,000 39,000 45,000 45,000
36,000 39,000 45,000
213,500 213,500 213,500
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
1,706,900 1,706,900 1,706,900
8 ### 13 -10 15
1,228,000 1,228,000 1,228,000

1,440,000 1,560,000 1,800,000
360,000 390,000 450,000
720,000 780,000 900,000
300,000 320,000 370,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
7,425,400 7,912,400 8,688,408
9 ### 14 -10 16
.
UTAMA
20,000 20,000 20,000

208,000 227,000 261,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
33,000 38,000
564,000 611,000 705,000

65,000 75,000
78,000 90,000
78,000 90,000
390,000 450,000
30,000 33,000 38,000

90,000 98,000 98,000 113,000 113,000
36,000 39,000 39,000 45,000 45,000
144,600 144,600 144,600
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
90,000 7,000 105,000 8,000 120,000
6,000 7,000 8,000
150,000 150,000 150,000
117,000 117,000 117,000
133,000 133,000 133,000
60,000 33,000 66,000 38,000 76,000
2,903,650 2,903,650 2,903,650
10 ### 15 -10 17
1,260,000 1,260,000 1,260,000 4,230,000 ### ###

1,440,000 1,560,000 1,800,000 APPENDICITIS INFILTRAT / K
360,000 390,000 450,000
720,000 780,000 900,000
450,000 490,000 570,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
9,632,250 10,274,750 11,249,260 APPENDICITIS INFILTRAT / K
11 ### 16 -10 18
.

UTAMA
20,000 20,000 20,000

208,000 227,000 261,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
33,000 38,000
564,000 611,000 705,000

65,000 75,000
78,000 90,000
78,000 90,000
390,000 450,000
30,000 33,000 38,000
90,000 98,000 98,000 113,000 113,000

36,000 39,000 39,000 45,000 45,000
144,600 144,600 144,600
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
90,000 7,000 105,000 8,000 120,000
6,000 7,000 8,000

225,000 75,000 225,000 75,000 225,000
175,500 58,500 175,500 58,500 175,500
199,500 199,500 199,500
60,000 33,000 66,000 38,000 76,000
1,744,250 1,744,250 1,744,250
12 ### 17 -10 19
1,223,700 1,223,700 1,223,700 4,703,700 ### ###
1,680,000 1,820,000 2,100,000 TRAUMA ABDOMENT / APP PERFORASI (LAPARA

420,000 460,000 530,000
840,000 910,000 1,050,000
- -
540,000 590,000 680,000
- -
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
8,995,550 9,601,550 10,578,562 TRAUMA ABDOMENT / APP PERFORASI (LAPARA
13 ### 18 -10 20
.

UTAMA
15,000 15,000 15,000

172,000 187,000 215,000
39,000 45,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
60,000 65,000 65,000 75,000 75,000

30,000 33,000 38,000
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
471,800 471,800 471,800
1,052,250 1,052,250 1,052,250 4,122,250 ### ###

1,440,000 1,560,000 1,800,000
360,000 390,000 450,000
720,000 780,000 900,000
550,000 600,000 690,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
5,914,050 6,419,050 7,213,050
14 ### 19 -10 21
.

UTAMA
15,000 15,000 15,000

442,000 479,500 553,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
13,000 15,000
337,500 390,000
60,000 65,000 65,000 75,000 75,000

30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000
6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
613,200 613,200 613,200
1,385,950 1,385,950 1,385,950 4,465,950 ### ###

1,440,000 1,560,000 1,800,000 CA MAMAE (MASTEK
360,000 390,000 450,000
720,000 780,000 900,000
560,000 600,000 690,000
- -
25,000 25,000 25,000
270,000 98,000 294,000 113,000 339,000
300,000 325,000 375,000
6,928,150 7,544,150 8,479,150 CA MAMAE (MASTEK
15 ### 20 -10 22
.

UTAMA
15,000 15,000 15,000

442,000 479,500 553,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
13,000 15,000
337,500 390,000
60,000 65,000 75,000

65,000 75,000
30,000 33,000 38,000
200,000 100,000 400,000 150,000 600,000

180,000 58,500 234,000 60,000 240,000
80,000 40,000 160,000 60,000 240,000
36,000 39,000 39,000 45,000 45,000
108,000 7,000 126,000 8,000 144,000
18,000 20,000 23,000

6,000 7,000 8,000
150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
60,000 33,000 66,000 38,000 76,000
778,800 778,800 778,800
1,576,600 1,576,600 1,576,600 5,306,600 ### ###
1,740,000 1,890,000 2,180,000 CA MAMAE SKIN

440,000 480,000 550,000
870,000 950,000 1,090,000
680,000 730,000 840,000
- -
25,000 25,000 25,000
270,000 98,000 294,000 113,000 339,000
300,000 325,000 375,000
8,315,400 9,093,900 10,211,400 CA MAMAE SKIN
16 ### 21 -10 23
.

UTAMA
15,000 15,000 15,000

96,000 104,000 120,000
39,000 45,000
39,000 45,000
13,000 15,000
13,000 15,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
18,000 7,000 21,000 8,000 24,000
- - -
- 58,500 - 58,500 -
- - -
2,966,350 2,966,350 2,966,350
270,000 293,000 338,000

25,000 25,000 25,000
- -
84,000 91,000 105,000
25,000 25,000 25,000
3,650,350 3,777,850 3,933,350
17 ### 22 -10 24
.
UTAMA
15,000 15,000 15,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
60,000 65,000 75,000
65,000 75,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
90,000 7,000 105,000 8,000 120,000
18,000 20,000 23,000

6,000 7,000 8,000
150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
60,000 33,000 66,000 38,000 76,000
502,300 502,300 502,300
1,001,330 1,001,330 1,001,330 5,371,330 ### ###

2,100,000 2,280,000 2,630,000
530,000 570,000 660,000
1,050,000 1,140,000 1,320,000
690,000 750,000 860,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
7,580,630 8,289,130 9,386,630
18 ### 23 -10 25
.

UTAMA
15,000 15,000 15,000

365,000 365,000 365,000
39,000 45,000
7,000 8,000
26,000 30,000
52,000 60,000
13,000 15,000
60,000 65,000 75,000

65,000 75,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000
6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
- - -
211,300 211,300 211,300
564,650 564,650 564,650 2,154,650 ### ###
720,000 780,000 900,000

150,000 200,000 230,000
360,000 390,000 450,000
360,000 390,000 450,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,419,950 3,720,450 4,150,950
19 ### 24 -10 26
.
UTAMA
20,000 20,000 20,000

130,000 142,000 163,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
13,000 15,000
492,000 533,000 615,000
65,000 75,000
78,000 90,000
390,000 450,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
90,000 7,000 105,000 8,000 120,000
36,000 20,000 40,000 23,000 46,000

6,000 7,000 8,000
36,000 39,000 39,000 45,000 45,000
90,000 98,000 98,000 113,000 113,000
150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
120,000 33,000 132,000 38,000 152,000
673,900 673,900 673,900
1,274,250 1,274,250 1,274,250 5,414,250 ### ###
1,440,000 1,560,000 1,800,000

360,000 390,000 450,000
720,000 780,000 900,000
- -
1,620,000 1,760,000 2,030,000
- -
25,000 25,000 25,000
216,000 78,000 234,000 90,000 270,000
300,000 325,000 375,000
8,424,150 9,166,650 10,328,150
20 ### 25 -10 27
UTAMA
15,000 15,000 15,000

110,000 110,000 110,000
39,000 45,000
7,000 8,000
7,000 8,000
52,000 60,000
13,000 15,000
26,000 30,000
60,000 - 65,000 75,000
65,000 75,000
30,000 33,000 38,000
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
48,000 7,000 56,000 8,000 64,000
36,000 20,000 40,000 23,000 46,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
30,000 33,000 33,000 38,000 38,000
638,500 638,500 638,500
426,500 426,500 426,500 1,956,500 ### ###

720,000 780,000 900,000
180,000 200,000 230,000
360,000 390,000 450,000
270,000 300,000 340,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
3,665,000 4,036,000 4,544,000
21 ### 26 -10 28
.

UTAMA
15,000 15,000 15,000

126,000 137,000 158,000
39,000 45,000
7,000 8,000
26,000 30,000
52,000 60,000
13,000 15,000
60,000 - 65,000 - 75,000
65,000 75,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
276,800 276,800 276,800
319,050 319,050 319,050 1,819,050 ### ###
720,000 780,000 900,000

180,000 200,000 450,000
360,000 390,000 230,000
240,000 260,000 300,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
2,910,850 3,182,350 3,613,850
22 ### 27 -10 29
.

UTAMA
15,000 15,000 15,000

132,000 144,000 166,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
52,000 60,000
13,000 15,000
300,000 325,000 375,000
65,000 75,000
260,000 300,000
30,000 33,000 38,000
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
36,000 7,000 42,000 8,000 48,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
488,050 488,050 488,050
398,600 398,600 398,600 1,898,600 ### ###
720,000 780,000 900,000

180,000 200,000 230,000
360,000 390,000 450,000
240,000 260,000 300,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
3,658,650 4,044,650 4,604,650
23 ### 28 -10 30
.

UTAMA
15,000 15,000 15,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
60,000 65,000 65,000 75,000 75,000

30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
474,500 474,500 474,500
1,110,300 1,110,300 1,110,300 4,250,300 ### ###

1,440,000 1,560,000 1,800,000
360,000 390,000 450,000
720,000 780,000 900,000
620,000 670,000 770,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,183,800 6,776,300 7,655,800
24 ### 29 -10 31
.

UTAMA
15,000 15,000 15,000

102,000 111,000 128,000
39,000 45,000
7,000 8,000
26,000 30,000
26,000 30,000
13,000 15,000
60,000 65,000 75,000
65,000 75,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
- - -
251,400 251,400 251,400
448,750 448,750 448,750 2,578,750 ### ###
1,080,000 1,170,000 1,350,000

270,000 300,000 340,000
540,000 590,000 680,000
240,000 260,000 300,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,627,150 3,957,650 4,486,150
25 ### 30 -10 32
.

UTAMA
15,000 15,000 15,000

78,000 85,000 98,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
60,000 65,000 75,000
65,000 75,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
223,600 223,600 223,600
452,350 452,350 452,350 1,742,350 ### ###
600,000 650,000 750,000

150,000 170,000 190,000
300,000 330,000 380,000
240,000 260,000 300,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
2,732,950 2,990,450 3,373,950
26
UTAMA
15,000 15,000 15,000

78,000 85,000 98,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
60,000 65,000 75,000
65,000 75,000
30,000 33,000 38,000
200,000 100,000 400,000 150,000 600,000

180,000 58,500 234,000 60,000 240,000
80,000 40,000 160,000 60,000 240,000
36,000 39,000 39,000 45,000 45,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
442,500 442,500 442,500
452,350 452,350 452,350

720,000 780,000 900,000
180,000 200,000 230,000
360,000 390,000 450,000
240,000 260,000 300,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
3,638,850 4,172,850 4,832,850
27

UTAMA
15,000 15,000 15,000

108,000 118,000 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
26,000 30,000
13,000 15,000
420,000 455,000 525,000
65,000 75,000
390,000 450,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
90,000 7,000 105,000 8,000 120,000
18,000 20,000 23,000

6,000 7,000 8,000
150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
60,000 33,000 66,000 38,000 76,000
849,700 849,700 849,700
452,350 452,350 452,350
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
600,000 650,000 750,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,709,050 7,304,550 8,268,050
28

UTAMA
15,000 15,000 15,000

108,000 118,000 136,000
39,000 45,000
7,000 8,000
26,000 30,000
7,000 8,000
26,000 30,000
13,000 15,000
420,000 455,000 525,000
65,000 75,000
390,000 450,000
30,000 33,000 38,000
250,000 100,000 500,000 150,000 750,000

225,000 58,500 292,500 60,000 300,000
100,000 40,000 200,000 60,000 300,000
36,000 39,000 39,000 45,000 45,000
126,000 7,000 147,000 8,000 168,000
18,000 20,000 23,000

6,000 7,000 8,000
150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
90,000 33,000 99,000 38,000 114,000
725,500 725,500 725,500
452,350 452,350 452,350
2,100,000 2,280,000 2,630,000

530,000 570,000 660,000
1,050,000 1,140,000 1,320,000
2,040,000 2,210,000 2,550,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
9,190,850 10,209,350 11,739,850
29

UTAMA
15,000 15,000 15,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
26,000 30,000
7,000 8,000
26,000 30,000
13,000 15,000
66,000 130,000 150,000
65,000 75,000
65,000 75,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
30,000 33,000 33,000 38,000 38,000
403,900 403,900 403,900
447,350 447,350 447,350

720,000 780,000 900,000
180,000 200,000 230,000
360,000 390,000 450,000
240,000 260,000 300,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
3,528,250 4,040,750 4,646,250
30 ### 31 -10 33
.
UTAMA
20,000 20,000 20,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
132,000 143,000 165,000
65,000 75,000
78,000 90,000
30,000 33,000 38,000
90,000 98,000 98,000 113,000 113,000
57,400 57,400 57,400
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
423,600 423,600 423,600
794,050 794,050 794,050 4,154,050 ### ###

1,680,000 1,820,000 2,100,000
420,000 460,000 530,000
840,000 910,000 1,050,000
420,000 460,000 530,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,128,050 6,678,050 7,550,050
31 ### 32 -10 34
.

UTAMA
20,000 20,000 20,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
132,000 143,000 165,000
65,000 75,000
78,000 90,000
30,000 33,000 38,000
90,000 98,000 98,000 113,000 113,000
57,400 57,400 57,400
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
20,000 20,000 20,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
788,700 788,700 788,700
1,066,000 1,066,000 1,066,000 4,306,000 ### ###
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
300,000 330,000 380,000
660,000 720,000 830,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
7,223,100 7,814,100 8,759,100
32 ### 33 -10 35
.

UTAMA
20,000 20,000 20,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
771,275 807,275 879,275
65,000 75,000
78,000 90,000
325,000 375,000
30,000 33,000 38,000

36,000 39,000 39,000 45,000 45,000
83,600 83,600 83,600
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
468,000 468,000 468,000
778,400 778,400 778,400 4,558,400 ### ###
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
840,000 910,000 1,050,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
7,285,275 7,968,775 9,020,275
33 ### 34 -10 36
.

UTAMA
20,000 20,000 20,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
771,275 807,275 879,275
65,000 75,000
78,000 90,000
325,000 375,000
30,000 33,000 38,000

36,000 39,000 39,000 45,000 45,000
83,600 83,600 83,600
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
90,000 98,000 98,000 113,000 113,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
177,950 177,950 177,950
826,550 826,550 826,550 6,286,550 ### ###
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
1,320,000 1,430,000 1,650,000
1,200,000 1,300,000 1,500,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
8,650,375 9,392,375 10,659,375
34 ### 35 -10 37
.
.

UTAMA
20,000 20,000 20,000

178,000 ### 194,000 ### 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
30,000 33,000 38,000
90,000 98,000 98,000 113,000 113,000
57,400 57,400 57,400
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
30,000 33,000 33,000 38,000 38,000
538,100 538,100 538,100
650,700 650,700 650,700 2,330,700 ### ###

720,000 780,000 900,000 BATU BULI-BULI
180,000 200,000 230,000
360,000 390,000 450,000
420,000 460,000 530,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
4,334,200 4,827,700 5,491,200 BATU BULI-BULI
35 ### 36 -10 38
.

UTAMA
20,000 20,000 20,000

178,000 ### 194,000 ### 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
30,000 33,000 38,000
90,000 98,000 98,000 113,000 113,000
71,400 71,400 71,400
100,000 100,000 200,000 150,000 300,000
90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 7,000 42,000 8,000 48,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
20,000 20,000 20,000
243,700 243,700 243,700
597,700 597,700 597,700 4,977,700 ### ###
1,680,000 1,820,000 2,100,000 BATU BULI-BULI (LITHO

420,000 460,000 530,000
840,000 910,000 1,050,000
1,140,000 1,240,000 1,430,000
300,000 325,000 375,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
6,449,800 7,069,800 8,085,800 BATU BULI-BULI (LITHO
36

UTAMA
20,000 20,000 20,000

178,000 ### 194,000 ### 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
132,000 143,000 165,000
65,000 75,000
78,000 90,000
30,000 33,000 38,000
90,000 98,000 98,000 113,000 113,000
71,400 71,400 71,400
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
40,000 40,000 40,000
138,800 138,800 138,800
589,200 589,200 589,200
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
2,220,000 2,410,000 2,780,000
300,000 325,000 375,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
7,726,400 8,445,400 9,656,400
37 ### 37 -10 39
.

UTAMA
20,000 20,000 20,000

178,000 ### 194,000 ### 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
372,000 ### 403,000 ### 465,000
65,000 75,000
78,000 90,000
260,000 300,000
30,000 33,000 38,000

90,000 98,000 98,000 113,000 113,000
71,400 71,400 71,400
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
20,000 20,000 20,000
316,250 316,250 316,250
1,041,850 1,041,850 1,041,850 4,941,850 ### ###

1,680,000 1,820,000 2,100,000 STRICTURA URETRA (S
420,000 460,000 530,000
840,000 910,000 1,050,000
660,000 720,000 830,000
300,000 325,000 375,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
7,016,500 7,625,500 8,616,500 STRICTURA URETRA (S
38 ### 38 -10 40
.

UTAMA
20,000 20,000 20,000

172,000 ### 187,000 ### 215,000
39,000 45,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
326,000 326,000 326,000
65,000 75,000
78,000 90,000
260,000 300,000
30,000 33,000 38,000

90,000 98,000 113,000
72,600 72,600 72,600
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
20,000 20,000 20,000
221,450 221,450 221,450
609,700 609,700 609,700 4,509,700 ### ###

1,680,000 1,820,000 2,100,000
420,000 460,000 530,000
840,000 910,000 1,050,000
660,000 720,000 830,000
300,000 325,000 375,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
6,402,750 6,976,750 7,898,750
39 ### 39 -10 41
.

UTAMA
20,000 20,000 20,000

178,000 ### 194,000 ### 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
771,275 ### 807,275 ### 879,275
65,000 75,000
78,000 90,000
325,000 375,000
30,000 33,000 38,000

36,000 39,000 39,000 45,000 45,000
83,600 83,600 83,600
200,000 100,000 400,000 150,000 600,000

180,000 58,500 234,000 60,000 240,000
80,000 40,000 160,000 60,000 240,000
108,000 7,000 126,000 8,000 144,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
468,000 468,000 468,000
1,234,400 1,234,400 1,234,400 4,834,400 ### ###

40 40 -10 42
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
660,000 720,000 830,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
7,712,275 8,475,275 9,574,315
41 ### 41 -10 43
.

UTAMA
20,000 20,000 20,000
42,000 ### 46,000 ### 53,000
39,000 45,000
7,000 8,000
350,000 100,000 700,000 150,000 1,050,000

315,000 58,500 409,500 60,000 420,000
140,000 40,000 280,000 60,000 420,000
36,000 39,000 39,000 45,000 45,000
108,000 7,000 126,000 8,000 144,000
18,000 20,000 23,000

6,000 7,000 8,000
150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
200,000 200,000 200,000
270,300 270,300 270,300
1,063,250 1,063,250 1,063,250 5,673,250 ### ###

2,100,000 2,280,000 2,630,000
530,000 570,000 660,000
1,050,000 1,140,000 1,320,000
930,000 1,010,000 1,160,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
8,047,550 9,087,050 10,466,550
42 ### 42 -10 44
.

UTAMA
15,000 15,000 15,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
26,000 30,000
13,000 15,000
50,000 - 50,000 - 50,000
65,000 75,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000

6,000 7,000 8,000
- - -
- - -
- - -
210,000 210,000 210,000
455,750 455,750 455,750 2,645,750 ### ###
1,080,000 1,170,000 1,350,000

270,000 300,000 340,000
540,000 590,000 680,000
300,000 330,000 380,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,616,750 3,931,250 4,438,750
43 43 -10 45
### .

UTAMA
15,000 15,000 15,000

70,000 ### 76,000 ### 87,000
76,000 87,000
72,000 ### 78,000 ### 90,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
- - -
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
213,600 213,600 213,600
212,950 212,950 212,950 1,372,950 ### ###

600,000 650,000 750,000
120,000 130,000 150,000
30,000 40,000 40,000
60,000 70,000 80,000
350,000 380,000 430,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
2,343,550 2,544,050 2,853,550
44

UTAMA
15,000 15,000 15,000

70,000 ### 76,000 ### 87,000
76,000 87,000
72,000 ### 78,000 ### 90,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
- - -
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
213,600 213,600 213,600
212,950 212,950 212,950
600,000 650,000 750,000 EXTRAKSI BATU U

120,000 130,000 150,000
30,000 40,000 40,000
60,000 70,000 80,000
300,000 330,000 380,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
2,299,550 2,501,050 2,811,550 EXTRAKSI BATU U
45 ### 44 -10 46

UTAMA
15,000 15,000 15,000

78,000 85,000 ### 98,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
120,000 130,000 150,000
65,000 75,000
65,000 75,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
72,000 7,000 84,000 8,000 96,000
6,000 7,000 8,000

75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
499,550 499,550 499,550
545,400 545,400 545,400 2,465,400 ### ###
720,000 780,000 900,000 SINUSITIS / Poli

180,000 200,000 230,000
360,000 390,000 450,000
660,000 720,000 830,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
4,365,950 4,862,450 5,532,950 SINUSITIS / Poli
46 ### 45 -10 47
.

UTAMA
15,000 15,000 15,000

102,000 111,000 128,000
39,000 45,000
7,000 8,000
26,000 30,000
26,000 30,000
13,000 15,000
60,000 - 65,000 - 75,000
65,000 75,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
36,000 7,000 42,000 8,000 48,000
6,000 7,000 8,000

75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
298,850 298,850 298,850
566,300 566,300 566,300 2,696,300 ### ###

720,000 780,000 900,000
180,000 200,000 230,000
360,000 390,000 450,000
870,000 940,000 1,080,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,992,150 4,313,650 4,842,150
47 ### 46 -10 48

UTAMA
.
20,000 20,000 20,000

178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
360,000 - 390,000 450,000
390,000 450,000
30,000 33,000 38,000
36,000 39,000 39,000 45,000 45,000
90,000 98,000 98,000 113,000 113,000
127,000 127,000 127,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
662,050 662,050 662,050
624,000 624,000 624,000 3,564,000 ### ###

48 47 -10 49

UTAMA
1,440,000 1,560,000 1,800,000

360,000 390,000 450,000
720,000 780,000 900,000
420,000 460,000 530,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,207,050 6,822,550 7,737,098
49 ### 48 -10 50
.

UTAMA
20,000 20,000 20,000
178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
420,000 455,000 525,000
65,000 75,000
390,000 450,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
640,750 640,750 640,750
834,800 834,800 834,800 4,014,800 ### ###

1,440,000 1,560,000 1,800,000
360,000 390,000 450,000
720,000 780,000 900,000
660,000 720,000 830,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,443,550 7,073,050 8,016,550
50 ### 49 -10 51
.

UTAMA
20,000 20,000 20,000
178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
60,000 65,000 75,000
65,000 75,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
640,750 640,750 640,750
741,800 741,800 741,800 3,441,800 ### ###

1,440,000 1,560,000 1,800,000
360,000 390,000 450,000
720,000 780,000 900,000
- - -
180,000 200,000 230,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
5,546,550 6,109,050 6,918,550
51 ### 50 -10 52
.

UTAMA
20,000 20,000 20,000
178,000 194,000 223,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
420,000 455,000 525,000
390,000 450,000
65,000 75,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
640,750 640,750 640,750
743,400 743,400 743,400 3,903,400 ### ###
1,440,000 1,560,000 1,800,000

360,000 390,000 450,000
720,000 780,000 900,000
640,000 690,000 800,000
- -
25,000 25,000 25,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,296,150 6,906,650 7,844,150
52 ### 51 -10 53
.

UTAMA
20,000 20,000 20,000
190,000 207,000 238,000
39,000 45,000
7,000 8,000
7,000 8,000
76,000 87,000
52,000 60,000
13,000 15,000
13,000 15,000
420,000 455,000 525,000
65,000 75,000
390,000 450,000
30,000 33,000 38,000
36,000 39,000 39,000 45,000 45,000
90,000 98,000 98,000 113,000 113,000
141,000 141,000 141,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
6,000 7,000 8,000

75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
692,350 692,350 692,350
842,050 842,050 842,050 4,002,050 ### ###
53 ### 52 -10 54
1,440,000 1,560,000 1,800,000
360,000 390,000 450,000
720,000 780,000 900,000
640,000 690,000 800,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,743,400 7,372,900 8,336,453
54 53 -10 55
### .

UTAMA
20,000 20,000 20,000

120,000 131,000 151,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
26,000 30,000
13,000 15,000
13,000 15,000
36,000 39,000 39,000 45,000 45,000
69,600 69,600 69,600
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
12,000 7,000 14,000 8,000 16,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
184,700 184,700 184,700
219,950 219,950 219,950 1,379,950 ### ###
480,000 520,000 600,000

120,000 130,000 150,000
240,000 260,000 300,000
320,000 340,000 390,000
- -
25,000 25,000 25,000
72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
2,394,250 2,620,750 2,982,250
55 54 -10 56
###

UTAMA
20,000 20,000 20,000

48,000 ### 53,000 ### 61,000
39,000 45,000
7,000 8,000
7,000 8,000
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
132,250 132,250 132,250
1,286,450 1,286,450 1,286,450 4,106,450 ### ###

1,440,000 1,560,000 1,800,000 PALATO SCHIZIS / LABIO S
360,000 390,000 450,000
720,000 780,000 900,000
300,000 330,000 380,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
5,277,700 5,738,700 6,445,700 PALATO SCHIZIS / LABIO S
56 55 -10 57
.

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
26,000 30,000
13,000 15,000
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
30,000 33,000 33,000 38,000 38,000
132,250 132,250 132,250
1,286,450 1,286,450 1,286,450 3,986,450 ### ###

1,440,000 1,560,000 1,800,000 LABIO PALATO S
360,000 390,000 450,000
600,000 650,000 750,000
300,000 330,000 380,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
5,289,700 5,751,700 6,460,700 LABIO PALATO S
57 56 -10 58
MH
UTAMA
58 ### 57 -10 59
59 ### 58 -10 60
.
.
UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000 -
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
384,000 384,000 384,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
60,000 60,000 60,000 60,000 60,000
60,000 33,000 66,000 38,000 76,000
1,632,400 1,632,400 1,632,400
60 ### 59 -10 61
814,000 814,000 814,000 4,914,000 ### ###
1,440,000 1,560,000 1,800,000

360,000 390,000 450,000
720,000 780,000 900,000
360,000 390,000 450,000
120,000 130,000 150,000
1,100,000 1,100,000 1,100,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
180,000 98,000 196,000 113,000 226,000
216,000 234,000 270,000
8,906,400 9,527,900 10,463,460
61 ### 60 -10 62
.
UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
82,600 82,600 82,600
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
60,000 60,000 60,000 60,000 60,000
30,000 33,000 33,000 38,000 38,000
633,450 633,450 633,450
804,000 804,000 804,000 4,904,000 ### ###
62 ### 61 -10 63
1,440,000 1,560,000 1,800,000

360,000 390,000 450,000
720,000 780,000 900,000
360,000 390,000 450,000
120,000 130,000 150,000
1,100,000 1,100,000 1,100,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
270,000 98,000 294,000 113,000 339,000
216,000 234,000 270,000
7,494,050 8,105,550 9,024,112 Fr. Femur (CL
63 ### 62 -10 64
.

UTAMA .
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
356,000 356,000 356,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000
6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
60,000 60,000 60,000 60,000 60,000
60,000 33,000 66,000 38,000 76,000
1,395,700 1,395,700 1,395,700
64 63 -10 65
###
536,850 536,850 536,850 3,966,850 ### ###

1,200,000 1,300,000 1,500,000 Fr. Cruris/Tibia
300,000 330,000 380,000
600,000 650,000 750,000
360,000 390,000 450,000
120,000 130,000 150,000
850,000 850,000 850,000
- -
- -
25,000 25,000 25,000
300,000 325,000 375,000
216,000 78,000 234,000 90,000 270,000
216,000 234,000 270,000
7,730,550 8,324,050 9,195,614
### Fr. Cruris/Tibia
65 64 -10 66
### .

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
82,600 82,600 82,600
150,000 100,000 300,000 150,000 450,000
135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
60,000 60,000 60,000 60,000 60,000
30,000 33,000 33,000 38,000 38,000
657,100 657,100 657,100
535,950 535,950 535,950 3,965,950 ### ###

1,200,000 1,300,000 1,500,000 Fr. Cruris/Tibia (C
300,000 330,000 380,000
600,000 650,000 750,000
360,000 390,000 450,000
120,000 130,000 150,000
850,000 850,000 850,000
25,000 25,000 25,000

300,000 325,000 375,000
144,000 78,000 156,000 90,000 180,000
216,000 234,000 270,000
6,471,650 - 7,044,150 - 7,874,650 Fr. Cruris/Tibia (C
66 ### 65 -10 67
.
.
UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
356,000 356,000 356,000
150,000 100,000 300,000 150,000 450,000
135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
50,000 50,000 50,000 50,000 50,000
30,000 33,000 33,000 38,000 38,000
1,245,050 1,245,050 1,245,050
925,300 925,300 925,300 4,595,300 ### ###

67 66 -10 68
1,200,000 1,300,000 1,500,000 Fr. ANTEBRACHII

300,000 330,000 380,000
600,000 650,000 750,000
600,000 650,000 750,000
120,000 130,000 150,000
850,000 850,000 850,000
25,000 25,000 25,000

300,000 325,000 375,000
144,000 78,000 156,000 90,000 180,000
7,868,350 8,453,850 9,310,417 Fr. ANTEBRACHII
68 ### 67 -10 69
.
UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
100,000 100,000 200,000 150,000 300,000
90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
50,000 50,000 50,000 50,000 50,000
30,000 33,000 33,000 38,000 38,000
637,650 637,650 637,650
957,800 957,800 957,800 11,853,850 ### ###

69
1,200,000 1,300,000 1,500,000 Fr. ANTEBRACHII (C

300,000 330,000 380,000
600,000 650,000 750,000
600,000 650,000 750,000
120,000 130,000 150,000
850,000 850,000 850,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
144,000 78,000 156,000 90,000 180,000
6,757,050 ### 7,244,050 ### 8,002,119 Fr. ANTEBRACHII (C
70 ### 65 -10 67
.
.
UTAMA
20,000 20,000 20,000
132,000 ### 144,000 ### 166,000
39,000 45,000
7,000 8,000
7,000 8,000
52,000 60,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
- 100,000 - 150,000 -
- 58,500 - 60,000 -
- 40,000 - 60,000 -
72,000 7,000 84,000 8,000 96,000
6,000 7,000 8,000

75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
50,000 50,000 50,000 50,000 50,000
30,000 33,000 33,000 38,000 38,000
215,300 215,300 215,300
404,650 404,650 404,650 2,744,650 ### ###

1,200,000 1,300,000 1,500,000 Fr. ANTEBRACHII
300,000 330,000 380,000
600,000 650,000 750,000
240,000 260,000 300,000
25,000 25,000 25,000

300,000 325,000 375,000
4,101,550 4,372,550 4,887,550 Fr. ANTEBRACHII
71 ### 69 -10 71
.
.

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
356,000 356,000 356,000
200,000 100,000 400,000 150,000 600,000
180,000 58,500 234,000 60,000 240,000
80,000 40,000 160,000 60,000 240,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
- 50,000 - 50,000 -
60,000 33,000 66,000 38,000 76,000
1,385,700 1,385,700 1,385,700
928,100 928,100 928,100 4,148,100 ### ###

72 70 -10 72
1,200,000 1,300,000 1,500,000

300,000 330,000 380,000
600,000 650,000 750,000
600,000 650,000 750,000
120,000 130,000 150,000
400,000 400,000 400,000
- - -
300,000 325,000 375,000
180,000 98,000 196,000 113,000 226,000
216,000 234,000 270,000
7,683,800 8,377,800 9,352,872
73 ### 71 -10 73
.

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
82,600 82,600 82,600
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
50,000 50,000 50,000 50,000 50,000
60,000 33,000 66,000 38,000 76,000
637,800 637,800 637,800
928,100 928,100 928,100 4,148,100 ### ###

74 72 -10 74
1,200,000 1,300,000 1,500,000

300,000 330,000 380,000
600,000 650,000 750,000
600,000 650,000 750,000
120,000 130,000 150,000
400,000 400,000 400,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
180,000 98,000 196,000 113,000 226,000
216,000 234,000 270,000
6,460,500 7,056,000 7,932,574
75 ### 73 -10 75
.
.

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
60,000 ### 65,000 ### 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
144,000 156,000 180,000
231,900 231,900 231,900
200,000 100,000 400,000 150,000 600,000

180,000 58,500 234,000 60,000 240,000
80,000 40,000 160,000 60,000 240,000
96,000 7,000 112,000 8,000 128,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
60,000 65,000 65,000 75,000 75,000
60,000 33,000 66,000 38,000 76,000
1,154,400 1,154,400 1,154,400
789,300 789,300 789,300 4,159,300 ### ###
76 74 -10 76
1,200,000 1,300,000 1,500,000 Fr. CLAVICULA
300,000 330,000 380,000
600,000 650,000 750,000
600,000 650,000 750,000
120,000 130,000 150,000
550,000 550,000 550,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
144,000 78,000 156,000 90,000 180,000
7,312,600 7,986,600 8,919,676 Fr. CLAVICULA
77 ### 75 -10 77
.

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
60,000 ### 65,000 ### 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
96,600 96,600 96,600
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
60,000 65,000 65,000 75,000 75,000
30,000 33,000 33,000 38,000 38,000
499,300 499,300 499,300
806,200 806,200 806,200 4,176,200 ### ###

78 76 -10 78
1,200,000 1,300,000 1,500,000 Fr. CLAVICULA (C

300,000 330,000 380,000
600,000 650,000 750,000
600,000 650,000 750,000
120,000 130,000 150,000
550,000 550,000 550,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
144,000 78,000 156,000 90,000 180,000
6,093,100 6,578,100 7,332,178 Fr. CLAVICULA (C
79 77 -10 79
### .
.

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
356,000 356,000 356,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
50,000 50,000 50,000 50,000 50,000
60,000 33,000 66,000 38,000 76,000
1,245,050 1,245,050 1,245,050
1,051,100 1,051,100 1,051,100 5,471,100 ### ###

80 78 -10 80
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
660,000 720,000 830,000
120,000 130,000 150,000
700,000 700,000 700,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
144,000 78,000 156,000 90,000 180,000
8,774,150 9,442,650 10,454,230
80 81 ### 79 70 81
.

UTAMA
20,000 20,000 20,000
108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
50,000 50,000 50,000 50,000 50,000
30,000 33,000 33,000 38,000 38,000
584,300 584,300 584,300
1,051,100 1,051,100 1,051,100 5,471,100 ### ###
82 80 -10 82
1,680,000 1,820,000 2,100,000

420,000 460,000 530,000
840,000 910,000 1,050,000
660,000 720,000 830,000
120,000 130,000 150,000
700,000 700,000 700,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
144,000 78,000 156,000 90,000 180,000
7,547,000 8,114,000 9,022,082
83 ### 81 -10 83
.
.

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
356,000 356,000 356,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
50,000 50,000 50,000 50,000 50,000
60,000 33,000 66,000 38,000 76,000
1,221,400 1,221,400 1,221,400
558,400 558,400 558,400 2,728,400 ### ###
84 82 -10 84
890,000 960,000 1,110,000
230,000 240,000 280,000
450,000 480,000 560,000
180,000 200,000 230,000
120,000 130,000 150,000
300,000 300,000 300,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
5,929,800 6,405,300 7,103,884
85 ### 83 -10 85
.

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
50,000 50,000 50,000 50,000 50,000
- - -
299,650 299,650 299,650
559,300 559,300 559,300 2,729,300 ### ###

86 84 -10 86
890,000 960,000 1,110,000 FR. PHALANG (C

230,000 240,000 280,000
450,000 480,000 560,000
180,000 200,000 230,000
120,000 130,000 150,000
300,000 300,000 300,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
4,133,550 4,427,050 4,951,636 FR. PHALANG (C
87 ### 85 -10 87
.
.

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
356,000 356,000 356,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
50,000 50,000 50,000 50,000 50,000
30,000 33,000 33,000 38,000 38,000
1,221,400 1,221,400 1,221,400
559,300 559,300 559,300 2,789,300 ### ###

88 86 -10 88
890,000 960,000 1,110,000 Fr. METACARPAL

230,000 240,000 280,000
450,000 480,000 560,000
240,000 260,000 300,000
120,000 130,000 150,000
300,000 300,000 300,000
25,000 25,000 25,000

216,000 234,000 270,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,030,700 6,530,200 7,278,788 Fr. METACARPAL
89 ### 87 -10 89
.

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
50,000 50,000 50,000 50,000 50,000
- - -
215,150 215,150 215,150
525,300 525,300 525,300 2,755,300 ### ###
90 88 -10 90
890,000 960,000 1,110,000 Fr. METACARPAL (C

230,000 240,000 280,000
450,000 480,000 560,000
240,000 260,000 300,000
120,000 130,000 150,000
300,000 300,000 300,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,985,050 4,269,550 4,789,140 Fr. METACARPAL (C
91

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
144,000 156,000 180,000
356,000 356,000 356,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
50,000 50,000 50,000 50,000 50,000
30,000 33,000 33,000 38,000 38,000
1,221,400 1,221,400 1,221,400
569,600 569,600 569,600
92
890,000 960,000 1,110,000 Fr. METATARSAL
230,000 240,000 280,000
450,000 480,000 560,000
240,000 260,000 300,000
120,000 130,000 150,000
300,000 300,000 300,000
25,000 25,000 25,000

216,000 234,000 270,000
144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
6,041,000 6,540,500 7,289,092 Fr. METATARSAL
93

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
50,000 100,000 100,000 150,000 150,000
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
44,000 44,000 44,000 44,000 44,000
- - -
215,150 215,150 215,150
548,600 548,600 548,600

94
890,000 960,000 1,110,000 Fr. METATARSAL (C

230,000 240,000 280,000
450,000 480,000 560,000
240,000 260,000 300,000
120,000 130,000 150,000
300,000 300,000 300,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
4,020,350 4,307,850 4,830,444 Fr. METATARSAL (C
95 ### 89 -10 91
.

UTAMA
20,000 20,000 20,000
102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
250,000 100,000 500,000 150,000 750,000

225,000 58,500 292,500 60,000 300,000
100,000 40,000 200,000 60,000 300,000
90,000 7,000 105,000 8,000 120,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
60,000 60,000 60,000 60,000 60,000
90,000 33,000 99,000 38,000 114,000
591,450 591,450 591,450
854,110 854,110 854,110 6,174,110 ### ###

96 90 -10 92
1,320,000 1,430,000 1,650,000 Fr. Collum Femur Non Pa

360,000 390,000 450,000
720,000 780,000 900,000
300,000 330,000 380,000
120,000 130,000 150,000
2,500,000 2,500,000 2,500,000
- -
25,000 25,000 25,000
300,000 325,000 375,000
360,000 98,000 392,000 113,000 452,000
216,000 234,000 270,000
9,146,160 9,933,660 10,995,256 Fr. Collum Femur Non Pa
97 ### 91 -10 93

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 7,000 42,000 8,000 48,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
60,000 60,000 60,000 60,000 60,000
240,650 240,650 240,650
446,950 446,950 446,950 2,156,950 ### ###
840,000 910,000 1,050,000 DISLOKASI COLLUM F

210,000 230,000 270,000
420,000 460,000 530,000
240,000 260,000 300,000
25,000 25,000 25,000

180,000 98,000 196,000 113,000 226,000
300,000 325,000 375,000
216,000 234,000 270,000
3,915,200 4,329,200 4,943,200 DISLOKASI COLLUM F
98 ### 92 -10 94
.

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
153,300 153,300 153,300
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
60,000 60,000 60,000 60,000 60,000
60,000 33,000 66,000 38,000 76,000
702,100 702,100 702,100
487,470 487,470 487,470 3,187,470 ### ###

99 93 -10 95
1,440,000 1,560,000 1,800,000

300,000 330,000 380,000
600,000 650,000 750,000
360,000 390,000 450,000
25,000 25,000 25,000

300,000 325,000 375,000
270,000 98,000 294,000 113,000 339,000
216,000 234,000 270,000
5,722,870 6,315,370 7,184,969
100 ### 94 -10 96

UTAMA
15,000 15,000 15,000

108,000 90,000 90,000
39,000 45,000
7,000 8,000
7,000 8,000
13,000 15,000
26,000 30,000
26,000 30,000
132,000 ### 143,000 ### 165,000
65,000 75,000
78,000 90,000
30,000 33,000 38,000
100,000 100,000 200,000 150,000 300,000

90,000 58,500 117,000 60,000 120,000
40,000 40,000 80,000 60,000 120,000
36,000 39,000 39,000 45,000 45,000
36,000 7,000 42,000 8,000 48,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
- 33,000 - 38,000 -
251,250 251,250 251,250
451,700 451,700 451,700 2,691,700 ### ###

1,020,000 1,110,000 1,280,000 Angkat Plate Humerus
260,000 280,000 320,000
510,000 560,000 640,000
450,000 490,000 570,000
25,000 25,000 25,000

180,000 98,000 196,000 113,000 226,000
300,000 325,000 375,000
4,058,950 4,474,950 5,110,950 Angkat Plate Humerus /
101 95 -10 97
.

UTAMA
15,000 15,000 15,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
13,000 15,000
26,000 30,000
26,000 30,000
110,000 132,000 132,000
65,000 75,000
78,000 90,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
- - -
210,000 210,000 210,000
451,700 451,700 451,700 2,691,700 ### ###

1,020,000 1,110,000 1,280,000 Angkat Plate / Cruris / Tibia / Antebrachii
260,000 280,000 320,000
510,000 560,000 640,000
450,000 490,000 570,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,754,700 4,113,200 4,652,700 Angkat Plate / Cruris / Tibia / Antebrachii
102 96 -10 98
###
.

UTAMA
15,000 15,000 15,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
13,000 15,000
26,000 30,000
26,000 30,000
60,000 ### 65,000 ### 75,000
65,000 75,000
30,000 33,000 38,000
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
36,000 39,000 39,000 45,000 45,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
- 33,000 - 38,000 -
256,550 256,550 256,550
583,800 583,800 583,800 2,083,800 ### ###
720,000 780,000 900,000

180,000 200,000 230,000
360,000 390,000 450,000
240,000 260,000 300,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,143,350 - 3,414,850 - 3,844,350
103 97 -10 99
MH
UTAMA
104 98 -10 100
LUMBRICALIS REPLACEMENT (EF4T+
LUMBRICALIS REPLACEMENT (EF4T+

105 99 -10 101
MH

UTAMA
18,000 20,000 23,000

106 100 -10 102
TIBIALIS POSTERIOR TRA
TIBIALIS POSTERIOR TRA

107 101 -10 103
MH

UTAMA
108 102 -10 104
OPPONEN REPLAC
OPPONEN REPLAC
109 103 -10 105

MH

UTAMA
TEMPORALIS MUSCULUS TRA
TEMPORALIS MUSCULUS TRA
110 105 -10 107

MH

UTAMA
ULCUS PEDIS (DEBRIDEMENT FRAKTUR TER
ULCUS PEDIS (DEBRIDEMENT FRAKTUR TER
111 106 -10 108

MH

UTAMA
18,000 20,000 23,000

ULCUS PLANTAR,SEPTIK (DEBRIDEMENT FRAKTUR TER
ULCUS PLANTAR,SEPTIK (DEBRIDEMENT FRAKTUR TER
112 107 -10 109

.

UTAMA
20,000 20,000 20,000
108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
26,000 30,000
13,000 15,000
60,000 65,000 75,000
65,000 75,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
60,000 33,000 66,000 38,000 76,000
256,550 256,550 256,550
895,650 895,650 895,650 2,605,650 ### ###

840,000 910,000 1,050,000
210,000 230,000 270,000
420,000 460,000 530,000
240,000 260,000 300,000
-
25,000 25,000 25,000
216,000 78,000 234,000 90,000 270,000
300,000 325,000 375,000
4,086,200 4,559,700 5,203,200
113 108 -10 110

.

UTAMA
15,000 15,000 15,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
69,600 69,600 69,600
50,000 100,000 100,000 150,000 150,000
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
50,000 50,000 50,000 50,000 50,000
381,150 381,150 381,150
684,350 684,350 684,350 3,024,350 ### ###

114 109 -10 111
960,000 1,040,000 1,200,000

240,000 260,000 300,000
480,000 520,000 600,000
240,000 260,000 300,000
120,000 130,000 150,000
300,000 300,000 300,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
4,454,100 4,775,600 5,316,214
115 ### 110 -10 112

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
- - -
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
18,000 7,000 21,000 8,000 24,000
18,000 20,000 23,000

6,000 7,000 8,000
- 75,000 - 75,000 -
- 58,500 - 58,500 -
- - -
166,100 166,100 166,100
410,450 410,450 410,450

890,000 960,000 1,110,000
230,000 240,000 280,000
450,000 480,000 560,000
360,000 390,000 450,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,439,150 3,676,650 4,149,150
116

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
- - -
135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
166,100 166,100 166,100
410,450 410,450 410,450
1,800,000 1,950,000 2,250,000 BASALIOMA SKIN

450,000 490,000 570,000
900,000 980,000 1,130,000
840,000 910,000 1,050,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
5,943,150 6,460,650 7,335,150 BASALIOMA SKIN
117

UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
120,000 ### 130,000 ### 150,000
65,000 75,000
65,000 75,000
36,000 39,000 39,000 45,000 45,000
30,000 33,000 38,000
24,000 26,000 30,000
96,600 96,600 96,600
- - -
135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
166,100 166,100 166,100
410,450 410,450 410,450

1,440,000 1,560,000 1,800,000
360,000 390,000 450,000
720,000 780,000 900,000
720,000 780,000 900,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
5,193,150 5,640,650 6,385,150
118 111 -10 113
.
UTAMA
20,000 20,000 20,000

108,000 ### 118,000 ### 136,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
210,000 ### 228,000 ### 263,000
65,000 75,000
65,000 75,000
98,000 113,000
30,000 33,000 38,000
36,000 39,000 39,000 45,000 45,000
83,600 83,600 83,600
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
54,000 7,000 63,000 8,000 72,000
18,000 20,000 23,000

6,000 7,000 8,000
150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
46,000 46,000 46,000 46,000 46,000
30,000 33,000 33,000 38,000 38,000
617,400 617,400 617,400
1,056,950 1,056,950 1,056,950 9,116,950 ### ###

119 112 -10 114
2,880,000 3,120,000 3,600,000 FRAKTUR MANDIBULA (Spesialis Bedah

720,000 780,000 900,000
1,440,000 1,560,000 1,800,000
1,020,000 1,110,000 1,280,000
2,000,000 2,000,000 2,000,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
11,589,950 12,436,450 13,817,069 FRAKTUR MANDIBULA (Spesialis Bedah
120

UTAMA
20,000 20,000 20,000

102,000 ### 111,000 ### 128,000
39,000 45,000
7,000 8,000
26,000 30,000
13,000 15,000
26,000 30,000
210,000 ### 228,000 ### 263,000
65,000 75,000
65,000 75,000
98,000 113,000
30,000 33,000 38,000
36,000 39,000 39,000 45,000 45,000
83,600 83,600 83,600
50,000 100,000 100,000 150,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
18,000 7,000 21,000 8,000 24,000
75,000 75,000 75,000 75,000 75,000

58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
46,000 46,000 46,000 46,000 46,000
- 33,000 - 38,000 -
617,400 617,400 617,400
1,056,950 1,056,950 1,056,950
121
240,000 260,000 300,000 REPOSISI MAND

60,000 70,000 80,000
120,000 130,000 150,000
240,000 260,000 300,000
25,000 25,000 25,000

72,000 78,000 78,000 90,000 90,000
300,000 325,000 375,000
3,591,950 3,802,450 4,112,071 REPOSISI MAND
122 ### 113 -10 115

UTAMA
20,000 20,000 20,000

138,000 ### 151,000 ### 174,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
52,000 60,000
20,000 23,000
72,000 78,000 90,000
78,000 90,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
72,000 7,000 84,000 8,000 96,000
18,000 20,000 23,000

75,000 75,000 75,000 75,000 75,000
58,500 58,500 58,500 58,500 58,500
66,500 66,500 66,500
90,000 33,000 99,000 38,000 114,000
54,000 20,000 60,000 23,000 69,000

296,200 296,200 296,200
1,110,350 1,110,350 1,110,350 5,330,350 ### ###
2,100,000 2,280,000 2,630,000

530,000 570,000 660,000
1,050,000 1,140,000 1,320,000
540,000 590,000 680,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
7,140,550 7,839,050 8,917,550
123
UTAMA
20,000 20,000 20,000

126,000 ### 138,000 ### 159,000
39,000 45,000
7,000 8,000
7,000 8,000
26,000 30,000
26,000 30,000
20,000 23,000
13,000 15,000
72,000 78,000 90,000
78,000 90,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
90,000 7,000 105,000 8,000 120,000
18,000 20,000 23,000

150,000 75,000 150,000 75,000 150,000
117,000 58,500 117,000 58,500 117,000
133,000 133,000 133,000
150,000 33,000 165,000 38,000 190,000
54,000 20,000 60,000 23,000 69,000

296,200 296,200 296,200
1,139,650 1,139,650 1,139,650

2,100,000 2,280,000 2,630,000
530,000 570,000 660,000
1,050,000 1,140,000 1,320,000
1,200,000 1,300,000 1,500,000
25,000 25,000 25,000

144,000 78,000 156,000 90,000 180,000
300,000 325,000 375,000
8,095,850 8,852,350 10,051,850
124 114 -10 116
MH

UTAMA
125 115 -10 117
RELEASE N. ULNARIS (BIOPSI SARAF KUTANEUS
RELEASE N. ULNARIS (BIOPSI SARAF KUTANEUS

126 114 -10 116
MH

UTAMA
132,000 ### 144,000 ### 166,000
39,000 45,000
7,000 8,000
7,000 8,000
52,000 60,000
13,000 15,000
26,000 30,000
60,000 ### 65,000 ### 75,000
65,000 75,000
30,000 33,000 38,000
150,000 100,000 300,000 150,000 450,000

135,000 58,500 175,500 60,000 180,000
60,000 40,000 120,000 60,000 180,000
36,000 39,000 39,000 45,000 45,000
18,000 7,000 21,000 8,000 24,000
- - -
60,000 33,000 66,000 38,000 76,000
889,700 889,700 889,700
1,397,950 1,397,950 1,397,950

720,000 780,000 900,000
180,000 200,000 230,000
360,000 390,000 450,000
120,000 130,000 150,000
250,000 270,000 310,000
25,000 25,000 25,000
4,623,650 5,046,150 5,586,650
127

UTAMA
20,000 20,000 20,000

30,000 30,000 30,000
163,070 163,070 163,070

50,000 100,000 150,000
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
25,000 25,000 25,000
58,000 84,750 185,000
43,750 95,000
15,000 60,000
26,000 30,000
66,000 66,000 66,000
120,000 130,000 150,000

600,000 650,000 750,000
60,000 65,000 75,000
1,257,070 1,432,320 1,734,070
128

UTAMA
20,000 20,000 20,000

30,000 30,000 30,000
163,070 163,070 163,070
50,000 100,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
25,000 25,000 25,000
58,000 84,750 185,000
43,750 95,000
15,000 60,000
26,000 30,000
66,000 66,000 66,000

120,000 130,000 150,000
900,000 980,000 1,130,000
450,000 490,000 570,000
1,947,070 2,187,320 2,609,070
129

UTAMA
20,000 20,000 20,000

55,000 55,000 55,000
30,000 30,000 30,000

73,050 73,050 73,050
391,130 391,130 391,130
50,000 100,000 150,000

45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
25,000 25,000 25,000
58,000 84,750 185,000
43,750 95,000
15,000 60,000
26,000 30,000
87,300 87,300 87,300

120,000 130,000 150,000
900,000 980,000 1,130,000
60,000 70,000 80,000
1,934,480 2,144,730 2,496,480
130

UTAMA
20,000 20,000 20,000

55,000 55,000 55,000
30,000 30,000 30,000

73,050 73,050 73,050
391,130 391,130 391,130

50,000 100,000 150,000
45,000 58,500 58,500 60,000 60,000
20,000 40,000 40,000 60,000 60,000
25,000 25,000 25,000
48,000 69,750 125,000
43,750 95,000
26,000 30,000
87,300 87,300 87,300
120,000 130,000 150,000

1,200,000 1,300,000 1,500,000
600,000 650,000 750,000
2,764,480 3,029,730 3,476,480
1,440,000 1,620,000 1,620,000

300,000 300,000 300,000
600,000 600,000 600,000
1,750,000 1,970,000 1,970,000
350,000 350,000 350,000
700,000 700,000 700,000
Rp 2,500,000 Rp 2,500,000
HERNIA UNILATERAL Dokter Ahli Bedah wek
HERNIA UNILATERAL
HERNIA UNILATERAL Total

HERNIA BILATERAL Dokter Ahli Bedah wek
HERNIA BILATERAL
HERNIA BILATERAL Total

APPENDICITIS ACUTA Dokter Ahli Bedah wek
APPENDICITIS ACUTA
APPENDICITIS ACUTA Total

0 Dokter Ahli Bedah
0 Total
APPENDICITIS INFILTRAT / KRONIS Dokter Ahli Bedah wek
APPENDICITIS INFILTRAT / KRONIS
APPENDICITIS INFILTRAT / KRONIS Total

NT / APP PERFORASI (LAPARATOMY) Dokter Ahli Bedah wek
TRAUMA ABDOMENT / APP PERFORASI (LAPARATOMY)

NT / APP PERFORASI (LAPARATOMY) Total
STRUMA Dokter Ahli Bedah wek
STRUMA
STRUMA Total
CA MAMAE (MASTEKTOMIE) Dokter Ahli Bedah wek
CA MAMAE (MASTEKTOMIE)
CA MAMAE (MASTEKTOMIE) Total

CA MAMAE SKIN GRAF Dokter Ahli Bedah wek
CA MAMAE SKIN GRAF
CA MAMAE SKIN GRAF Total

KEMOTHERAPI Dokter Ahli Bedah wek
KEMOTHERAPI Total
DISEKSI KELENJAR Dokter Ahli Bedah wek
DISEKSI KELENJAR
DISEKSI KELENJAR Total

F A M Dokter Ahli Bedah wek
FAM
F A M Total
COLLOSTOMI Dokter Ahli Bedah wek
COLLOSTOMI
COLLOSTOMI Total
HEMOROID Dokter Ahli Bedah wek
HEMOROID
HEMOROID Total
POLIP RECTI Dokter Ahli Bedah wek
POLIP RECTI
POLIP RECTI Total
FISTEL Dokter Ahli Bedah wek
FISTEL
FISTEL Total
TUMOR PAROTIS Dokter Ahli Bedah wek
TUMOR PAROTIS
TUMOR PAROTIS Total

HIDROCELE Dokter Ahli Bedah wek
HIDROCELE
HIDROCELE Total
GIANT LIPOMA Dokter Ahli Bedah wek
GIANT LIPOMA
GIANT LIPOMA Total

DEBRIDEMENT Dokter Ahli Bedah wek
DEBRIDEMENT
DEBRIDEMENT Total
CHOLELITHIASIS Dokter Ahli Bedah wek
CHOLELITHIASIS
CHOLELITHIASIS Total
MILES PROSEDUR Dokter Ahli Bedah wek
MILES PROSEDUR
MILES PROSEDUR Total

FIBROMA PEDIS Dokter Ahli Bedah wek
FIBROMA PEDIS
FIBROMA PEDIS Total

BPH (OPEN) Dokter Ahli Bedah wek
BPH (OPEN)
BPH (OPEN) Total

BPH (TURP) Dokter Ahli Bedah wek
BPH (TURP)
BPH (TURP) Total
0 Dokter Ahli Bedah
BATU URETER (OPEN)
0 Total
BATU URETER (URS) Dokter Ahli Bedah wek
BATU URETER (URS)
BATU URETER (URS) Total

BATU BULI-BULI (OPEN) Dokter Ahli Bedah wek
BATU BULI-BULI (OPEN)
BATU BULI-BULI (OPEN) Total

BATU BULI-BULI (LITHOTRIPSI) Dokter Ahli Bedah wek
BATU BULI-BULI (LITHOTRIPSI)
BATU BULI-BULI (LITHOTRIPSI) Total

- CA Buli (TURP) Dokter Ahli Bedah wek
- CA Buli (TURP)
- CA Buli (TURP) Total

STRICTURA URETRA (Sachze) Dokter Ahli Bedah wek
STRICTURA URETRA (Sachze)
STRICTURA URETRA (Sachze) Total

BATU URETRA Dokter Ahli Bedah wek
BATU URETRA
BATU URETRA Total

BATU GINJAL Dokter Ahli Bedah wek
BATU GINJAL
BATU GINJAL Total

HYPOSPADIA Dokter Ahli Bedah wek
HYPOSPADIA
HYPOSPADIA Total
VARICOCEL Dokter Ahli Bedah wek
VARICOCEL
VARICOCEL Total
AFF DJ STAND Dokter Ahli Bedah wek
AFF DJ STAND
AFF DJ STAND Total

EXTRAKSI BATU URETRA Dokter Ahli Bedah wek
EXTRAKSI BATU URETRA

EXTRAKSI BATU URETRA Total
SINUSITIS / Polip Nasal Dokter Ahli Bedah wek
SINUSITIS / Polip Nasal
SINUSITIS / Polip Nasal Total

TONSILITIS Dokter Ahli Bedah wek
TONSILITIS
TONSILITIS Total
SECSIO CAESAR Dokter Ahli Bedah wek
SECSIO CAESAR
SECSIO CAESAR Total

MYOMA UTERI Dokter Ahli Bedah wek
MYOMA UTERI
MYOMA UTERI Total

PROLAP UTERI Dokter Ahli Bedah wek
PROLAP UTERI
PROLAP UTERI Total

CYSTOMA OVARI Dokter Ahli Bedah wek
CYSTOMA OVARI
CYSTOMA OVARI Total
KET Dokter Ahli Bedah wek
KET
KET Total
CURETTAGE Dokter Ahli Bedah
CURETTAGE
CURETTAGE Total
PALATO SCHIZIS / LABIO SCHIZIS Dokter Ahli Bedah wek
PALATO SCHIZIS / LABIO SCHIZIS
PALATO SCHIZIS / LABIO SCHIZIS Total

LABIO PALATO SCHIZIS Dokter Ahli Bedah wek
LABIO PALATO SCHIZIS
LABIO PALATO SCHIZIS Total

LAT(KONTRAKTUR) Dokter Ahli Bedah wek
LAT(KONTRAKTUR)
LAT(KONTRAKTUR) Total
Fr. Femur (OPEN) Dokter Ahli Bedah wek
Fr. Femur (OPEN)
Fr. Femur (OPEN) Total

Fr. Femur (CLOSE) Dokter Ahli Bedah wek
Fr. Femur (CLOSE)

Fr. Femur (CLOSE) Total
Fr. Cruris/Tibia (OPEN) Dokter Ahli Bedah wek
Fr. Cruris/Tibia (OPEN)
Fr. Cruris/Tibia (OPEN) Total

Fr. Cruris/Tibia (CLOSE) Dokter Ahli Bedah wek
Fr. Cruris/Tibia (CLOSE)
Fr. Cruris/Tibia (CLOSE) Total

Fr. ANTEBRACHII (OPEN) Dokter Ahli Bedah
Fr. ANTEBRACHII (OPEN)
Fr. ANTEBRACHII (OPEN) Total

Fr. ANTEBRACHII (CLOSE) Dokter Ahli Bedah wek
Fr. ANTEBRACHII (CLOSE)
Fr. ANTEBRACHII (CLOSE) Total

Fr. ANTEBRACHII (OPEN) Dokter Ahli Bedah
Fr. ANTEBRACHII (OPEN)
Fr. ANTEBRACHII (OPEN) Total

Fr. PATELLA (OPEN) Dokter Ahli Bedah wek
Fr. PATELLA (OPEN)
Fr. PATELLA (OPEN) Total

Fr. PATELLA (CLOSE) Dokter Ahli Bedah wek
Fr. PATELLA (CLOSE)

Fr. PATELLA (CLOSE) Total
Fr. CLAVICULA (OPEN) Dokter Ahli Bedah wek
Fr. CLAVICULA (OPEN)
Fr. CLAVICULA (OPEN) Total

Fr. CLAVICULA (CLOSE) Dokter Ahli Bedah wek
Fr. CLAVICULA (CLOSE)
Fr. CLAVICULA (CLOSE) Total

Fr. Humerus (OPEN) Dokter Ahli Bedah wek
Fr. Humerus (OPEN)
Fr. Humerus (OPEN) Total

Fr. Humerus (CLOSE) Dokter Ahli Bedah wek
Fr. Humerus (CLOSE)

Fr. Humerus (CLOSE) Total
FR. PHALANG (OPEN) Dokter Ahli Bedah wek
FR. PHALANG (OPEN)
FR. PHALANG (OPEN) Total

FR. PHALANG (CLOSE) Dokter Ahli Bedah wek
FR. PHALANG (CLOSE)
FR. PHALANG (CLOSE) Total

Fr. METACARPAL (OPEN) Dokter Ahli Bedah wek
Fr. METACARPAL (OPEN)
Fr. METACARPAL (OPEN) Total

Fr. METACARPAL (CLOSE) Dokter Ahli Bedah wek
Fr. METACARPAL (CLOSE)

Fr. METACARPAL (CLOSE) Total
Fr. METATARSAL (OPEN) Dokter Ahli Bedah wek
Fr. METATARSAL (OPEN)
Fr. METATARSAL (OPEN) Total

Fr. METATARSAL (CLOSE) Dokter Ahli Bedah wek
Fr. METATARSAL (CLOSE)
Fr. METATARSAL (CLOSE) Total

Fr. Collum Femur Non Patologis Dokter Ahli Bedah wek
Fr. Collum Femur Non Patologis

Fr. Collum Femur Non Patologis Total
DISLOKASI COLLUM FEMUR Dokter Ahli Bedah wek
DISLOKASI COLLUM FEMUR
DISLOKASI COLLUM FEMUR Total

AMPUTASI Dokter Ahli Bedah wek
AMPUTASI
AMPUTASI Total
Angkat Plate Humerus / Femur Dokter Ahli Bedah wek
Angkat Plate Humerus / Femur
Angkat Plate Humerus / Femur Total

e / Cruris / Tibia / Antebrachii / Patela Dokter Ahli Bedah wek
Angkat Plate / Cruris / Tibia / Antebrachii / Patela
e / Cruris / Tibia / Antebrachii / Patela Total

Ganglion Poplitea Dokter Ahli Bedah wek
Ganglion Poplitea
Ganglion Poplitea Total

9000
CALIS REPLACEMENT (EF4T+ EE4T) Dokter Ahli Bedah wek
LUMBRICALIS REPLACEMENT (EF4T+ EE4T)
CALIS REPLACEMENT (EF4T+ EE4T) Total

TIBIALIS POSTERIOR TRANSFER Dokter Ahli Bedah wek
TIBIALIS POSTERIOR TRANSFER
TIBIALIS POSTERIOR TRANSFER Total

OPPONEN REPLACEMENT Dokter Ahli Bedah wek
OPPONEN REPLACEMENT
OPPONEN REPLACEMENT Total
EMPORALIS MUSCULUS TRANSFER Dokter Ahli Bedah wek
TEMPORALIS MUSCULUS TRANSFER
EMPORALIS MUSCULUS TRANSFER Total

DEBRIDEMENT FRAKTUR TERBUKA) Dokter Ahli Bedah wek
ULCUS PEDIS (DEBRIDEMENT FRAKTUR TERBUKA)

DEBRIDEMENT FRAKTUR TERBUKA) Total
DEBRIDEMENT FRAKTUR TERBUKA) Dokter Ahli Bedah wek
ULCUS PLANTAR,SEPTIK (DEBRIDEMENT FRAKTUR TERBUKA)
DEBRIDEMENT FRAKTUR TERBUKA) Total

RUPTUR TENDON Dokter Ahli Bedah wek
RUPTUR TENDON
RUPTUR TENDON Total

POLIDACTILI Dokter Ahli Bedah wek
POLIDACTILI
POLIDACTILI Total
C. ALIENUM JARUM Dokter Ahli Bedah wek
C. ALIENUM JARUM
C. ALIENUM JARUM Total

BASALIOMA SKIN GRAFT Dokter Ahli Bedah wek
BASALIOMA SKIN GRAFT
BASALIOMA SKIN GRAFT Total

BASALIOMA Dokter Ahli Bedah wek
BASALIOMA
BASALIOMA Total
MANDIBULA (Spesialis Bedah Mulut) Dokter Ahli Bedah wek
FRAKTUR MANDIBULA (Spesialis Bedah Mulut)
MANDIBULA (Spesialis Bedah Mulut) Total

REPOSISI MANDIBULA Dokter Ahli Bedah wek
REPOSISI MANDIBULA
REPOSISI MANDIBULA Total
ANUS PLASTY Dokter Ahli Bedah wek
ANUS PLASTY
ANUS PLASTY Total

HIRSCPRUNG Dokter Ahli Bedah wek
HIRSCPRUNG
HIRSCPRUNG Total
S (BIOPSI SARAF KUTANEUS/OTOT) Dokter Ahli Bedah wek
RELEASE N. ULNARIS (BIOPSI SARAF KUTANEUS/OTOT)
S (BIOPSI SARAF KUTANEUS/OTOT) Total

KATARAK Dokter Ahli Bedah wek
KATARAK
KATARAK Total
ARATOMY)
AKTUR TERBUKA)
EUS/OTOT)

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1.

sct 1 4,500 4,500

Siede atraumatik 2,0 sct 1 19,500 19,500

Siede atraumatik 2.0 sct 1 12,750 12,750

Siede atraumatik 2.0 sct 1 8,000 8,000

Siede atraumatik 3,0 sct 1 21,300 21,300

Siede atraumatik 2.0 sct 1 5,300 5,300

Siede atraumatik 2.0 sct 1 350 350

Nama Obat Sat Keb Harga Total

Siede atraumatik 2.0 sct 1 2,000 2,000

Siede atraumatik 2.0 sct 1 1,100 1,100

Siede atraumatik 2.0 sct 1 12,300 12,300

Transport Ambil Obat Kemo

Sewa Kamar Operasi

Sewa Kamar Operasi

Glove Gammex 7 bh 2 300 600

Glove Gammex 7,5 bh 2

Glove Gammex 6,5 bh 1

Glove unsteril bh 5 116,400 582,000

Oksigen nasal /masker bh 1 2,000 2,000

Spinocam 25 bh 1 31,700 31,700

Topi disposable bh 5 12,750 63,750

Nylon 2.0 sct 1 16,200 16,200

Siede atraumatik 0 sct 1 4,500 4,500

Alkohol cc 50 8,000 400,000

Topi disposable bh 5 127 635

Nylon 2,0 sct 1 200,000 200,000

Siede atraumatik 2,0 sct 1 19,500 19,500

Alkohol cc 50 12,000 600,000

Glove unsteril bh 5 12,000 60,000

Spinocam 25 bh 1 21,300 21,300

Nylon 2,0 sct 1 71,500 71,500

3 Sewa Kamar Operasi 260,000

Nama Obat Sat Keb Harga Total

Nama Obat Sat Keb Harga Total

e Ps. Cateter 1 x 75,000 75,000 90,000

Nama Obat Sat Keb Harga Total

c Sewa Kamar Operasi 450,000

c Sewa Kamar Operasi 1,350,000

Nama Obat Sat Keb Harga Total

Ecosol Ringer Laktat inf, fles 4 12,300 49,200

Lidodex amp 1 71,500 71,500

c Sewa Kamar Operasi 150,000

1 UGD KELAS III

Ephineprin amp 1 2,300 2,300

1 PALATO SCHIZIS / LABIO SCHIZIS

Natrium Klorida 0,9 %, fles 2 11,300 22,600

Gamex 7,5 bh 3 21,300 63,900

Lomatuel lbr 2 14,000 28,000

DHBP amp 1 72,000 72,000

Lomatuel lbr 1 14,000 14,000

Safol cc 10 8,000 80,000

Spuit 10 cc bh 1 5,550 5,550

Gamex 7,5 bh 3 21,300 63,900

Lomatuel lbr 1 14,000 14,000

Safol cc 10 8,000 80,000

Lomatuel lbr 1 14,000 14,000

Safol cc 10 8,000 80,000

Spuit 10 cc bh 1 5,550 5,550

Safol cc 10 8,000 80,000

Spuit 10 cc bh 1 5,550 5,550

Plain 2/0 cm 120 176 21,120

12 DISLOKASI COLLUM FEMUR