RETRIBUSI TINDAKAN

NO TGL
UMUM GIGI KIA/KB UMUM GIGI
1 1/2/2021 Rp 40,000 Rp 10,000
2 1/4/2021 Rp 50,000 Rp 10,000
3 1/5/2021 Rp 60,000 Rp 25,000
4 1/6/2021 Rp 40,000 Rp 5,000 Rp 35,000 Rp 15,000
5 1/7/2021 Rp 15,000 Rp 5,000
6 1/8/2021 Rp 50,000 Rp 10,000
7 1/9/2021 Rp 40,000
8 1/11/2021 Rp 55,000 Rp 5,000
9 1/12/2021 Rp 50,000 Rp 10,000
10 1/13/2021 Rp 55,000 Rp 5,000
11 1/14/2021 Rp 10,000 Rp 15,000
12 1/15/2021 Rp 40,000
13 1/16/2021 Rp 40,000
14 1/18/2021 Rp 70,000 Rp 15,000 Rp 20,000
15 1/19/2021 Rp 50,000
16 1/20/2021 Rp 40,000 Rp 40,000
17 1/21/2021 Rp 45,000 Rp 30,000 Rp 17,500
18 1/22/2021 Rp 60,000
19 1/23/2021 Rp 35,000
20 1/25/2021 Rp 60,000 Rp 5,000 Rp 20,000 Rp 30,000
21 1/26/2021 Rp 35,000 Rp 20,000
22 1/27/2021 Rp 30,000
23 1/28/2021 Rp 20,000 Rp 5,000
24 1/29/2021 Rp 5,000
25 1/30/2021 Rp 50,000
26
27
TOTAL Rp 1,045,000 Rp 80,000 Rp 190,000 Rp 62,500 Rp 20,000
TINDAKAN
Jumlah Keterangan Tindakan
LAB KIA/KB
Rp 50,000
Rp 20,000 Rp 80,000 Hb, Urine Lengkap
Rp 85,000
Rp 75,000 Rp 170,000 Angkat Jahitan, Hb 2x, Urin Lengkap, Widal
Rp 20,000
Rp 33,000 Rp 93,000 gdp, colesterol
Rp 40,000
Rp 60,000
Rp 15,000 Rp 75,000 KB 3 bulan
Rp 60,000
Rp 25,000
Rp 40,000
Rp 40,000
Rp 20,000 Rp 125,000 cabut gigi. Asam urat
Rp 20,000 Rp 70,000
Rp 40,000 Rp 120,000 Hb 2x, Urine Lengkap2x
Rp 92,500 ganti perban 1x
Rp 15,000 Rp 75,000 gula darah
Rp 35,000
Rp 115,000 up hecting
Rp 55,000
Rp 30,000
Rp 25,000
Rp 5,000
Rp 50,000
Rp -
Rp -
Rp 203,000 Rp 35,000 Rp 1,635,500
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 2/1/2021 Rp 60,000 Rp 10,000 Rp 43,000
2 2/2/2021 Rp 15,000 Rp 45,000
3 2/3/2021 Rp 25,000 Rp 5,000 Rp 15,000 Rp 50,000
4 2/4/2021 Rp 50,000 Rp 5,000 Rp 30,000
5 2/5/2021 Rp 30,000 Rp 10,000
6 2/6/2021 Rp 15,000
7 2/8/2021 Rp 70,000 Rp 68,000
8 2/9/2021 Rp 50,000 Rp 5,000 Rp 20,000
9 2/10/2021 Rp 25,000 Rp 10,000 Rp 35,000
10 2/11/2021 Rp 45,000
11 2/13/2021 Rp 35,000 Rp 15,000
12 2/15/2021 Rp 45,000 Rp 15,000 Rp 78,000
13 2/16/2021 Rp 40,000 Rp 5,000 Rp 25,000
14 2/17/2021 Rp 25,000 Rp 5,000 Rp 53,000
15 2/18/2021 Rp 55,000 Rp 15,000
16 2/19/2021 Rp 40,000 Rp 5,000 Rp 55,000
17 2/20/2021 Rp 30,000
18 2/22/2021 Rp 45,000
19 2/23/2021 Rp 55,000 Rp 5,000 Rp 40,000
20 2/24/2021 Rp 35,000 Rp 20,000 Rp 20,000
21 2/25/2021 Rp 35,000 Rp 40,000
22 2/26/2021 Rp 55,000
23 2/27/2021 Rp 40,000
24
25
26
27
TOTAL Rp 920,000 Rp 50,000 Rp 295,000 Rp - Rp - Rp 402,000
KAN
Jumlah Keterangan Tindakan
KIA/KB
Rp 113,000 hb 2x, gula darah, kolesterol
Rp 60,000
Rp 95,000 Asam urat, urin lengkap 2x
Rp 85,000
Rp 40,000
Rp 15,000
Rp 138,000 hb 3x. Goldar, gds, colesterol, urin rutin
Rp 75,000
Rp 70,000 hb, Gula darah 2x
Rp 45,000
Rp 50,000
Rp 138,000 hb2x, goldar 2x. Gds, colesterol, urin lengkap
Rp 70,000
Rp 83,000 gd, colesterol,asamurat
Rp 70,000
Rp 100,000 Hb, goldar, dl
Rp 30,000
Rp 15,000 Rp 60,000 suntik tt
Rp 100,000
Rp 75,000 hb,gula darah
Rp 75,000
Rp 55,000
Rp 40,000
Rp -
Rp -
Rp -
Rp -
Rp 15,000 Rp 1,682,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 3/1/2021 Rp 55,000 Rp 5,000
2 3/2/2021 Rp 30,000
3 3/3/2021 Rp 100,000 Rp 5,000 Rp 10,000 Rp 43,000
4 3/4/2021 Rp 45,000 Rp 10,000 Rp 30,000 Rp 20,000
5 3/5/2021 Rp 30,000 Rp 5,000
6 3/6/2021 Rp 25,000 Rp 5,000
7 3/8/2021 Rp 60,000 Rp 25,000 Rp 48,000
8 3/9/2021 Rp 65,000 Rp 25,000
9 3/10/2021 Rp 40,000 Rp 5,000 Rp 10,000 Rp 20,000 Rp 5,000
10 3/11/2021
11 3/12/2021 Rp 40,000 Rp 5,000 Rp 10,000
12 3/13/2021 Rp 25,000 Rp - Rp -
13 3/15/2021 Rp 55,000 Rp 15,000 Rp 5,000
14 3/16/2021 Rp 35,000 Rp 5,000 Rp 20,000
15 3/17/2021 Rp 55,000 Rp 5,000
16 3/18/2021 Rp 65,000 Rp 30,000
17 3/19/2021 Rp 30,000
18 3/20/2021 Rp 65,000 Rp 5,000
19 3/22/2021 Rp 15,000 Rp 5,000 Rp 20,000
20 3/23/2021 Rp 50,000 Rp 25,000
21 3/24/2021 Rp 50,000 Rp 5,000
22 3/25/2021 Rp 70,000 Rp 25,000
23 3/26/2021 Rp 55,000 Rp 5,000 Rp 18,000
24 3/27/2021 Rp 35,000
25 3/29/2021 Rp 60,000 Rp 5,000 Rp 5,000 Rp 15,000
26 3/30/2021 Rp 85,000 Rp 25,000
27 3/31/2021 Rp 70,000 Rp 5,000
TOTAL Rp 1,310,000 Rp 90,000 Rp 270,000 Rp - Rp 40,000 Rp 129,000
KAN
Jumlah Keterangan Tindakan
KIA/KB
Rp 60,000
Rp 30,000
Rp 158,000 hb 2x, kolesterol, gula darah
Rp 105,000 cabut gigi
Rp 35,000
Rp 30,000
Rp 133,000 hb, goldar, colesterol,urin lengkap
Rp 90,000
Rp 80,000 cabut gigi, hb
Rp -
Rp 55,000
Rp 25,000
Rp 75,000
Rp 60,000
Rp 60,000
Rp 95,000
Rp 30,000
Rp 70,000
Rp 40,000
Rp 75,000
Rp 55,000
Rp 95,000
Rp 78,000 colesterol
Rp 35,000
Rp 85,000
Rp 110,000
Rp 75,000
Rp - Rp 1,839,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 4/1/2021 Rp 30,000 Rp 10,000 Rp 35,000 paledang
2 4/3/2021 Rp 35,000
3 4/5/2021 Rp 70,000 Rp 5,000 Rp 10,000
4 4/6/2021 Rp 45,000 Rp 5,000 Rp 40,000
5 4/7/2021 Rp 70,000 Rp 5,000 Rp 5,000
6 4/8/2021 Rp 45,000 Rp 20,000 Rp 15,000 Rp 20,000
7 4/9/2021 Rp 20,000 Rp 5,000
8 4/10/2021 Rp 35,000
9 4/12/2021 Rp 60,000 Rp 20,000
10 4/13/2021 Rp 25,000 Rp 5,000 Rp 25,000
11 4/14/2021 Rp 20,000 Rp 5,000 Rp 5,000 Rp 5,000
12 4/15/2021 Rp 45,000 Rp 10,000
13 4/16/2021 Rp 60,000 Rp 35,000
14 4/17/2021 Rp 30,000
15 4/19/2021 Rp 50,000 Rp 5,000 Rp 15,000 Rp 10,000
16 4/20/2021 Rp 85,000 Rp 15,000
17 4/21/2021 Rp 20,000 Rp 5,000
18 4/22/2021 Rp 40,000 Rp 20,000 Rp 25,000
19 4/23/2021 Rp 50,000 Rp 5,000 Rp 5,000
20 4/24/2021 Rp 30,000
21 4/26/2021 Rp 45,000 Rp 10,000 Rp 10,000 Rp 5,000
22 4/27/2021 Rp 55,000 Rp 5,000
23 4/28/2021 Rp 40,000
24 4/29/2021 Rp 70,000 Rp 10,000 Rp 30,000
25 4/30/2021 Rp 50,000 Rp 10,000 Rp 20,000 Rp 33,000

TOTAL Rp 1,125,000 Rp 145,000 Rp 245,000 Rp - Rp 40,000 Rp 93,000

KAN
Jumlah Keterangan Tindakan
KIA/KB
Rp 75,000
Rp 35,000
Rp 85,000
Rp 40,000 Rp 130,000 KB 2X
Rp 80,000
Rp 100,000 CABUT GIGI
Rp 25,000
Rp 35,000
Rp 80,000
Rp 55,000
Rp 35,000 hb
Rp 55,000
Rp 95,000 colesterol, gds
Rp 30,000
Rp 80,000 hb
Rp 100,000
Rp 25,000
Rp 85,000
Rp 60,000 hb
Rp 30,000
Rp 70,000 hb
Rp 60,000
Rp 40,000
Rp 110,000
Rp 113,000
Rp -
Rp -
Rp 40,000 Rp 1,688,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI
1 5/3/2021 Rp 65,000 Rp 10,000 Rp 10,000
2 5/4/2021 Rp 35,000 Rp 15,000
3 5/5/2021 Rp 35,000 Rp 10,000
4 5/6/2021 Rp 40,000 Rp 5,000 Rp 15,000
5 5/7/2021 Rp 55,000 Rp 5,000
6 5/8/2021 Rp 30,000 Rp 5,000
7 5/10/2021 Rp 75,000 Rp 10,000 Rp 15,000
8 5/11/2021 Rp 65,000 Rp 10,000
9 5/12/2021 Rp - Rp - Rp - Rp - Rp -
10 5/15/2021 Rp 8,000
11 5/17/2021 Rp 88,000 Rp 16,000 Rp 8,000 Rp 75,000
12 5/18/2021 Rp 72,000 Rp 16,000 Rp 24,000
13 5/19/2021 Rp 104,000 Rp 32,000 Rp 8,000 Rp 75,000
14 5/20/2021 Rp 128,000 Rp 16,000 Rp 24,000
15 5/21/2021 Rp 88,000 Rp 16,000 Rp 8,000 Rp 50,000
16 5/22/2021 Rp 128,000 Rp 8,000
17 5/24/2021 Rp 80,000 Rp 48,000 Rp 32,000 Rp 50,000
18 5/25/2021 Rp 88,000 Rp 8,000 Rp 88,000
19 5/27/2021 Rp 128,000 Rp 24,000 Rp 32,000 Rp 30,000
20 5/28/2021 Rp 64,000 Rp 24,000 Rp 50,000
21 5/29/2021 Rp 88,000 Rp 8,000
22 5/31/2021 Rp 88,000
23
24
25

TOTAL Rp 1,552,000 Rp 251,000 Rp 299,000 Rp - Rp 330,000

TINDAKAN
Jumlah Keterangan Tindakan
LAB KIA/KB
Rp 5,000 Rp 90,000
Rp 50,000
Rp 45,000
Rp 60,000
Rp 60,000
Rp 35,000
Rp 15,000 Rp 115,000 hb 3x
Rp 25,000 Rp 100,000 kb 1x
Rp - Rp - Rp -
Rp 8,000
Rp 18,000 Rp 205,000
Rp 112,000
Rp 219,000
Rp 168,000
Rp 162,000
Rp 136,000
Rp 58,000 Rp 268,000
Rp 184,000
Rp 214,000 tambal gigi sementara 1x
Rp 50,000 Rp 188,000 cabut gigi susu & dl
Rp 96,000
Rp 13,000 Rp 101,000
Rp -
Rp -
Rp -
Rp -
Rp -
Rp 159,000 Rp 25,000 Rp 2,616,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI
1 6/2/2021 Rp 104,000 Rp 8,000 Rp 32,000
2 6/3/2021 Rp 128,000 Rp 16,000 Rp 48,000 Rp 75,000
3 6/4/2021 Rp 152,000 Rp 8,000 Rp 15,000 Rp 50,000
4 6/5/2021 Rp 184,000 Rp 8,000
5 6/7/2021 Rp 112,000 Rp 8,000 Rp 16,000 Rp 15,000
6 6/8/2021 Rp 96,000 Rp 16,000 Rp 80,000 Rp 60,000
7 6/9/2021 Rp 80,000 Rp 48,000 Rp 60,000
8 6/10/2021 Rp 72,000 Rp 16,000 Rp 32,000 Rp 60,000
9 6/11/2021 Rp 112,000 Rp - Rp - Rp 75,000 Rp -
10 6/12/2021 Rp 88,000 Rp 16,000 Rp 8,000
11 6/14/2021 Rp 96,000 Rp 16,000 Rp 45,000
12 6/15/2021 Rp 80,000 Rp 16,000 Rp 32,000 Rp 15,000
13 6/16/2021 Rp 64,000 Rp 16,000 Rp 16,000 Rp 30,000
14 6/17/2021 Rp 160,000 Rp 8,000 Rp 225,000
15 6/18/2021 Rp 96,000 Rp 45,000
16 6/19/2021 Rp 104,000 Rp 8,000 Rp 60,000 Rp 75,000
17 6/21/2021 Rp 144,000 Rp 24,000
18 6/22/2021 Rp 96,000 Rp 16,000 Rp 40,000 Rp 15,000
19 6/23/2021 Rp 128,000 Rp 16,000 Rp 30,000
20 6/24/2021 Rp 72,000 Rp 16,000 ,
21 6/25/2021 Rp 72,000 Rp 8,000 Rp -
22 6/26/2021 Rp 112,000 Rp 16,000 Rp 45,000
23 6/28/2021 Rp 96,000 Rp 24,000 Rp 30,000
24 6/29/2021 Rp 96,000 Rp 8,000 Rp 24,000 Rp 30,000
25 6/30/2021 Rp 88,000 Rp 8,000 Rp 16,000 Rp 15,000

TOTAL Rp 2,632,000 Rp 192,000 Rp 496,000 Rp 870,000 Rp 200,000

TINDAKAN
Jumlah Keterangan Tindakan
LAB KIA/KB
Rp 31,000 Rp 175,000
Rp 267,000 Cabut gigi susu dengan suntik
Rp 15,000 Rp 240,000 cabut gigi susu, kir anak sekolah, golongan darah
Rp 192,000
Rp 15,000 Rp 166,000
Rp 252,000 kir anak sekolah 2x,kir kerja 1x
Rp 117,500 Rp 305,500 kir anak sekolah 4, hb, gdp, colesterol
Rp 180,000 kir anak sekolah 2x,kir kerja 1x
Rp - Rp - Rp 187,000
Rp 25,000 Rp 137,000 kb 3 bulan
Rp 36,500 Rp 193,500
Rp 143,000 kir anak sekolah 1x
Rp 21,500 Rp 147,500 hb, goldar, gv
Rp 393,000 kir kerja 7x,kir anak sekolah 1x
Rp 30,000 Rp 171,000 Goldar 2x, KIR anak sekolah 3
Rp 247,000 Cabut gigi susu dengan suntik 1x,kir kerja 2x
Rp 168,000
Rp 167,000 kir anak sekolah 1x
Rp 76,000 Rp 250,000 hb, goldar, gdp, colesterol
Rp 88,000
Rp 50,000 Rp 130,000
Rp 173,000 kir anak sekolah 1x,kir kerja 1x
Rp 83,000 Rp 233,000 Goldar, gds, colesterol; asam urat
Rp 25,000 Rp 183,000 kir anak sekolah 2x,kb 3 bulan 1x
Rp 62,500 Rp 189,500 hb, colesterol2x, asam urat
Rp -
Rp -
Rp 50,000 Rp 4,978,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 7/1/2021 Rp 56,000 Rp 32,000 Rp 15,000
2 7/2/2021 Rp 88,000 Rp 53,000
3 7/3/2021 Rp 64,000 Rp 8,000 Rp 15,000
4 7/5/2021 Rp 88,000 Rp 40,000 Rp 28,000
5 7/6/2021 Rp 88,000 Rp 32,000
6 7/7/2021 Rp 72,000 Rp 16,000 Rp 15,000
7 7/8/2021 Rp 32,000 Rp 24,000
8 7/9/2021 Rp 48,000 Rp 8,000
9 7/10/2021 Rp 40,000 Rp 45,000
10 7/12/2021 Rp 108,000 Rp 8,000 Rp 32,000 Rp 15,000 Rp 86,000
11 7/13/2021 Rp 120,000 Rp 60,000
12 7/14/2021 Rp 32,000 Rp 8,000 Rp 30,000
13 7/15/2021 Rp 72,000
14 7/16/2021 Rp 72,000 Rp 8,000 Rp 8,000 Rp 36,500
15 7/17/2021 Rp 40,000 Rp 45,000
16 7/19/2021 Rp 40,000 Rp 16,000 Rp 60,000 Rp 61,000
17 7/21/2021 Rp 72,000 Rp 8,000 Rp 24,000 Rp 30,000
18 7/22/2021 Rp 96,000 Rp 60,000
19 7/23/2021 Rp 72,000 Rp - Rp - Rp - Rp - Rp -
20 7/24/2021 Rp 72,000 Rp 30,000
21 7/26/2021 Rp 80,000 Rp 8,000 Rp 21,500
22 7/27/2021 Rp 32,000 Rp 8,000 Rp 32,000
23 7/28/2021 Rp 56,000 Rp 16,000 Rp 13,000
24 7/29/2021 Rp 48,000 Rp 8,000 Rp 30,000
25 7/30/2021 Rp 56,000 Rp 8,000
26 7/31/2021 Rp 72,000

TOTAL Rp 1,716,000 Rp 72,000 Rp 280,000 Rp 435,000 Rp -

AN
Jumlah Keterangan Tindakan
KIA/KB
Rp 103,000 kir anak sekolah 1x
Rp 141,000 au, col, gds
Rp 87,000 kir anak sekolah 1x
Rp 156,000 hb, goldar
Rp 120,000
Rp 103,000 goldar
Rp 25,000 Rp 81,000 kb 3 bulan 1x
Rp 56,000
Rp 85,000 kir anak sekolah 1x, kir umum 1x
Rp 249,000 gdp 2, col 2, au, kir anak sekolah
Rp 180,000 kir sekolah 2x, kir umum 1x
Rp 70,000
Rp 72,000 qa5
Rp 124,500
Rp 85,000 kir anak sekolah 1x,kir kerja 1x
Rp 177,000 kir 2x, gd 2x, col, hb 2x
Rp 134,000 KIR
Rp 156,000 KIR umum 2x
Rp - Rp 72,000 belum di setor
Rp 102,000 KIR umum 1x
Rp 109,500 hb, goldar
Rp 72,000
Rp 85,000 hb2x
Rp 86,000 kir kerja 1x
Rp 64,000
Rp 72,000
Rp -
Rp 25,000 Rp 2,842,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 8/2/2021 Rp 72,000 Rp 16,000 Rp 30,000 Rp 6,500
2 8/3/2021 Rp 88,000
3 8/4/2021 Rp 32,000 Rp 16,000 Rp 94,500
4 8/5/2021 Rp 64,000
5 8/6/2021 Rp 56,000 Rp 8,000 Rp 60,000
6 8/7/2021 Rp 40,000
7 8/9/2021 Rp 104,000 Rp 8,000 Rp 16,000
8 8/10/2021 Rp 32,000 Rp 30,000
9 8/12/2021 Rp 72,000 Rp 88,000
10 8/13/2021 Rp 88,000 Rp 16,000 Rp 60,000 Rp 18,000
11 8/14/2021 Rp 112,000 Rp 8,000 Rp 30,000
12 8/16/2021 Rp 32,000 Rp 8,000 Rp 40,000 Rp 33,000
13 8/18/2021 Rp 40,000 Rp 24,000 Rp 28,000
14 8/19/2021 Rp 112,000 Rp 40,000
15 8/20/2021 Rp 40,000 Rp 30,000
16 8/21/2021 Rp 72,000
17 8/23/2021 Rp 40,000 Rp 16,000 Rp 32,000 Rp 28,000
18 8/24/2021 Rp 112,000 Rp 16,000 Rp 88,000
19 8/25/2021 Rp 80,000 Rp 16,000 Rp 48,000 Rp 128,000
20 8/26/2021 Rp 64,000 Rp 16,000 Rp 32,000
21 8/27/2021 Rp 64,000 Rp 16,000 Rp 15,000
22 8/28/2021 Rp 104,000 Rp 8,000
23 8/30/2021 Rp 120,000 Rp 8,000 Rp 24,000 Rp 6,500
24 8/31/2021 Rp 64,000 Rp 32,000 Rp 30,000
25
26

TOTAL Rp 1,704,000 Rp 144,000 Rp 496,000 Rp 270,000 Rp -

AN
Jumlah Keterangan Tindakan
KIA/KB
Rp 124,500
Rp 88,000
Rp 142,500 hb. Gds 2x, col, au
Rp 64,000
Rp 124,000 kir 2x
Rp 40,000
Rp 128,000
Rp 62,000 kir umum 1x
Rp 160,000
Rp 182,000 kir 2x, col
Rp 150,000 kir kerja 1x
Rp 113,000 gdp,hb2x, ul
Rp 92,000 hb2x, gdp
Rp 152,000
Rp 70,000 kir
Rp 72,000
Rp 116,000 hb2x, urine rutin
Rp 216,000
Rp 272,000 hb 2x, goldar, widal,
Rp 112,000
Rp 95,000 goldar
Rp 112,000
Rp 158,500
Rp 126,000 kir umum 1x
Rp -
Rp -
Rp -
Rp - Rp 2,971,500
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 9/1/2021 Rp 16,000 Rp 24,000 Rp 54,500
2 9/2/2021 Rp 112,000 Rp 24,000 Rp 30,000
3 9/3/2021 Rp 40,000 Rp 41,500
4 9/4/2021 Rp 72,000
5 9/6/2021 Rp 120,000 Rp 16,000 Rp 24,000 Rp 6,500
6 9/7/2021 Rp 136,000
7 9/8/2021 Rp 80,000 Rp 8,000 Rp 8,000 Rp 20,000
8 9/9/2021 Rp 112,000
9 9/10/2021 Rp 128,000 Rp 24,000
10 9/11/2021 Rp 72,000
11 9/13/2021 Rp 72,000 Rp 33,000
12 9/14/2021 Rp 64,000
13 9/15/2021 Rp 104,000 Rp 56,000 Rp 30,000 Rp 19,500
14 9/16/2021 Rp 152,000
15 9/17/2021 Rp 48,000 Rp 8,000
16 9/18/2021 Rp 56,000 Rp 50,000
17 9/20/2021 Rp 72,000 Rp 8,000 Rp 16,000
18 9/21/2021 Rp 96,000 Rp 16,000 Rp 104,000
19 9/22/2021 Rp 72,000 Rp 32,000 Rp 28,000
20 9/23/2021 Rp 72,000
21 9/24/2021 Rp 56,000 Rp 8,000
22 9/25/2021 Rp 72,000 Rp 16,000
23 9/27/2021 Rp 136,000 Rp 16,000 Rp 24,000 Rp 90,000 Rp 150,000 Rp 21,500
24 9/28/2021 Rp 72,000 Rp 24,000
25 9/29/2021 Rp 96,000 Rp 8,000 Rp 8,000 Rp 15,000
26 9/30/2021 Rp 112,000 Rp 8,000 Rp 8,000 Rp 30,000

TOTAL Rp 2,240,000 Rp 136,000 Rp 352,000 Rp 180,000 Rp 200,000

Rp 280 17 Rp 44
AN
Jumlah Keterangan Tindakan
KIA/KB
Rp 94,500 hb 3x, gds, au
Rp 166,000 kir umum 1x
Rp 81,500 hb, gds,au
Rp 72,000
Rp 166,500 hb
Rp 136,000
Rp 116,000 ul
Rp 112,000
Rp 152,000
Rp 72,000
Rp 105,000 gds, col
Rp 64,000
Rp 209,500 hb3x
Rp 152,000
Rp 56,000
Rp 106,000 cabut gigi
Rp 96,000
Rp 25,000 Rp 241,000 kb
Rp 132,000 hb2x, goldar
Rp 72,000
Rp 64,000
Rp 88,000
Rp 437,500 kir 3x, cabut gigi 3x, hb, urin rutin
Rp 96,000
Rp 127,000 gd
Rp 158,000 KIR 1X
Rp -
Rp 25,000 Rp 3,372,500
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 10/1/2021 Rp 48,000 Rp 32,000 Rp 30,000 Rp 50,000 Rp 45,000
2 10/2/2021 Rp 48,000 Rp 16,000 Rp 50,000
3 10/4/2021 Rp 64,000 Rp 16,000 Rp 24,000 Rp 21,500
4 10/5/2021 Rp 48,000 Rp 32,000 Rp 56,000
5 10/6/2021 Rp 56,000 Rp 16,000 Rp 6,500
6 10/7/2021 Rp 104,000 Rp 8,000 Rp 24,000 Rp 60,000
7 10/8/2021 Rp 72,000 Rp 8,000 Rp 8,000 Rp 30,000 Rp 51,500
8 10/9/2021 Rp 96,000 Rp 16,000 Rp 30,000 Rp 100,000
9 10/11/2021 Rp 120,000
10 10/12/2021 Rp 40,000 Rp 8,000 Rp 32,000
11 10/13/2021 Rp 120,000 Rp 32,000 Rp 104,500
12 10/14/2021 Rp 104,000 Rp 16,000 Rp 104,000
13 10/15/2021 Rp 112,000 Rp 33,000
14 10/16/2021 Rp 48,000 Rp 60,000
15 10/18/2021 Rp 56,000 Rp 16,000 Rp 24,000
16 10/19/2021 Rp 104,000 Rp 80,000
17 10/21/2021 Rp 168,000 Rp 8,000 Rp 64,000
18 10/22/2021 Rp 136,000 Rp 32,000 Rp 50,000
19 10/23/2021 Rp 120,000 Rp 30,000
20 10/25/2021 Rp 88,000 Rp 8,000 Rp 16,000 Rp 21,500
21 10/26/2021 Rp 80,000 Rp 8,000 Rp 56,000 Rp 30,000
22 10/27/2021 Rp 96,000 Rp 24,000 Rp 26,500
23 10/28/2021 Rp 64,000 Rp 16,000
24 10/29/2021 Rp 88,000 Rp 8,000 Rp 30,000 Rp 15,000
25 10/30/2021 Rp 112,000 Rp 8,000
26

TOTAL Rp 2,192,000 Rp 240,000 Rp 576,000 Rp 300,000 Rp 250,000

AN
Jumlah Keterangan Tindakan
KIA/KB
Rp 205,000 KIR, cabut gigi, gds 3x
Rp 114,000 cabut gigi susu 1x
Rp 125,500
Rp 136,000
Rp 78,500
Rp 196,000 kir,gv
Rp 169,500
Rp 242,000 kir kerja,tambal glass ionomer
Rp 120,000
Rp 80,000
Rp 256,500 hb, goldar, gdp,col,dl
Rp 224,000
Rp 145,000
Rp 108,000 kir umum 2x
Rp 96,000
Rp 184,000
Rp 240,000
Rp 218,000
Rp 150,000 kir kerja1x
Rp 133,500
Rp 50,000 Rp 224,000 kb 3 bulan 2x,kir kerja
Rp 146,500 hb,urine lengkap
Rp 80,000
Rp 141,000
Rp 120,000
Rp -
Rp -
Rp 50,000 Rp 3,933,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 11/1/2021 Rp 80,000 Rp 16,000 Rp 16,000 Rp 61,000
2 11/2/2021 Rp 128,000 Rp 24,000 Rp 40,000
3 11/3/2021 Rp 104,000 Rp 16,000 Rp 16,000
4 11/4/2021 Rp 64,000 Rp 8,000
5 11/5/2021 Rp 88,000
6 11/6/2021 Rp 136,000
7 11/8/2021 Rp 120,000 Rp 24,000 Rp 32,000 Rp 75,000 Rp 13,000
8 11/9/2021 Rp 112,000 Rp 16,000 Rp 72,000 Rp 60,000 Rp 71,500
9 11/10/2021 Rp 96,000 Rp 8,000 Rp 24,000 Rp 21,500
10 11/11/2021 Rp 224,000 Rp 48,000 Rp 53,000
11 11/12/2021 Rp 152,000
12 11/13/2021 Rp 96,000
13 11/15/2021 Rp 160,000 Rp 8,000 Rp 24,000 Rp 43,000
14 11/16/2021 Rp 152,000 Rp 32,000 Rp 48,000 Rp 30,000
15 11/17/2021 Rp 152,000 Rp 8,000 Rp 16,000 Rp 85,000 Rp 30,000 Rp 69,500
16 11/18/2021 Rp 128,000 Rp 8,000 Rp 48,000
17 11/19/2021 Rp 136,000
18 11/20/2021 Rp 64,000 Rp 16,000
19 11/22/2021 Rp 192,000 Rp 16,000 Rp 16,000 Rp 98,000
20 11/23/2021 Rp 88,000 Rp 40,000
21 11/24/2021 Rp 80,000 Rp 8,000 Rp 24,000 Rp 36,500
22 11/25/2021 Rp 104,000 Rp 16,000 Rp 24,000
23 11/26/2021 Rp 168,000 Rp 24,000
24 11/27/2021 Rp 128,000
25 11/29/2021 Rp 176,000 Rp 8,000 Rp 40,000 Rp 165,000
26 11/30/2021 Rp 152,000 Rp 32,000 Rp 24,000 Rp 60,000 Rp 15,000

TOTAL Rp 3,280,000 Rp 288,000 Rp 552,000 Rp 205,000 Rp 135,000

AN
Jumlah Keterangan Tindakan
KIA/KB
Rp 173,000 goldar, hb 2x, gula darah,chol
Rp 192,000
Rp 136,000
Rp 72,000
Rp 88,000
Rp 136,000
Rp 264,000 cabut gigi, hb2x
Rp 331,500 kir 2x, hb, gds, dl
Rp 149,500 hb, urin rutin
Rp 325,000
Rp 152,000
Rp 96,000
Rp 235,000 HB 2X, GOLDAR 2X
Rp 262,000 tambal gigi sementara 1x
Rp 360,500 tambal gigi sementara 1x,hb 1x,gula darah 3x, kolestrol 1x,ekg 1x
Rp 25,000 Rp 209,000 kb 3 bulan 1x
Rp 136,000
Rp 80,000
Rp 322,000 goldar3x, gdp,kolesterol,asam urat
Rp 128,000
Rp 148,500 hb1x,goldar 1x,urine rutin 1x
Rp 144,000
Rp 192,000
Rp 128,000
Rp 389,000 goldar 1x, hematologi lengkap 1x, widal 1x,dl 1x
Rp 25,000 Rp 308,000 kir kerja 2x, kb 3 bulan 1x, guladarah 1 x
Rp -
Rp 50,000 Rp 5,157,000
 RETRIBUSI TINDAKAN
NO TGL
UMUM GIGI KIA/KB UMUM GIGI LAB
1 12/1/2021 Rp 112,000 Rp 24,000 Rp 15,000 Rp 69,500
2 12/2/2021 Rp 120,000 Rp 16,000 Rp 8,000 Rp 6,500
3 12/3/2021 Rp 72,000 Rp 40,000 Rp 35,000
4 12/4/2021 Rp 72,000 Rp 48,000 Rp 30,000
5 12/6/2021 Rp 104,000 Rp 16,000 Rp 8,000
6 12/7/2021 Rp 88,000 Rp 8,000 Rp 32,000
7 12/8/2021 Rp 56,000 Rp 24,000 Rp 115,500
8 12/9/2021 Rp 56,000 Rp 80,000
9 12/10/2021 Rp 64,000 Rp 24,000
10 12/11/2021 Rp 96,000 Rp 8,000 Rp 45,000
11 12/13/2021 Rp 120,000 Rp 24,000 Rp 60,000 Rp 48,000
12 12/14/2021 Rp 144,000 Rp 16,000 Rp 32,000
13 12/15/2021 Rp 128,000 Rp 48,000
14 12/16/2021 Rp 96,000 Rp 8,000 Rp 56,000 Rp 30,000 Rp 50,000
15 12/17/2021 Rp 64,000
16 12/18/2021 Rp 64,000 Rp 8,000
17 12/20/2021 Rp 120,000 Rp 16,000 Rp 24,000 Rp 21,500
18 12/21/2021 Rp 96,000 Rp 16,000 Rp 96,000 Rp 85,000
19 12/22/2021 Rp 88,000 Rp 8,000 Rp 30,000 Rp 50,000
20 12/23/2021 Rp 120,000 Rp 24,000 Rp 16,000
21 12/24/2021 Rp 112,000 Rp 16,000 Rp 30,000
22 12/27/2021 Rp 96,000 Rp 8,000 Rp 8,000
23 12/28/2021 Rp 96,000 Rp 16,000 Rp 80,000 Rp 65,000
24 12/29/2021 Rp 128,000 Rp 16,000 Rp 79,500
25 12/30/2021 Rp 72,000 Rp 24,000 Rp 32,000 Rp 30,000 Rp 18,000
26 12/31/2021 Rp 80,000

TOTAL Rp 2,464,000 Rp 328,000 Rp 600,000 Rp 270,000 Rp 50,000

N
Jumlah Keterangan Tindakan
KIA/KB
Rp 220,500 hb 1x,goldar 1x,gula darah 2x,kolesterol 1x,kir anak sekolah 1x
Rp 15,000 Rp 165,500 hb, catin
Rp 147,000 au, gdp
Rp 150,000 KIR KERJA 1X
Rp 128,000
Rp 128,000
Rp 195,500 hb 1x,widal1x.dl 1x.led 1x
Rp 136,000
Rp 88,000
Rp 149,000 kir KERJA 1X, kir anak sekolah 1
Rp 252,000 KIR KERJA 2X,Cholestrol 1X.Tes Kehamilan 1X Catin 1X
Rp 192,000
Rp 176,000
Rp 240,000
Rp 64,000
Rp 72,000
Rp 181,500 tes kehamilan, hb
Rp 293,000 kir kerja 1x,goldar 1x,asam urat1x,dl 1x
Rp 176,000 kir, sifilis
Rp 160,000
Rp 158,000 KIR KERJA 1X
Rp 112,000
Rp 257,000 goldar 1x,dl 1x
Rp 223,500 hb, gds, col,ul,au
Rp 176,000 KIR KERJA 1X, CHOLESTEROL 1X
Rp 80,000
Rp -
Rp 15,000 Rp 4,320,500