FORM USULAN BARANG BAHAN KIMIA GIGI, REAGEN LAB, DAN REAGEN HIV 2016

POLI/RUANG .

A. BAHAN KIMIA GIGI

HARGA / Satuan TOTAL
NO NAMA BARANG MEREK SPESIFIKASI
(Tahun 2015) USULAN
1 Absorbent Threatment No. 25,30
2 Amalgam Alloy Powder SDI Australia F 400 Powder/botol 30 gr IDR 1,400,000
3 Amalgam Capsule SDI Tipe F400 Capsule isi 5 x 10/box
1 spill
Doridont
5 Calcium Hidroxyde Pasta 2 set/box, Base 13 gr, Catalyst 11 gr IDR 480,000
Austria
6 Chlor Ethyl Spray Walter Ritter Kemasan Kaleng 100mL IDR 95,000
Tokuyama
7 Composite Resin Light Curing Set (1 bot Etching, 1 bot Bonding dan 6 syringe) IDR 3,750,000
Japan
Septodont
8 Cresophene (Rockless) 13 mL botol/solution IDR 604,500
France
Septodont
9 Devitalisasi Paste Non Arsen botol 4,5 gr IDR 250,000
France
10 Elite Cement Liquid GC 100 gr IDR 403,535
11 Endomethasone Septodont 7 gr Botol Powder IDR 515,000
France
12 Eugenol Ghimas Italy 10 mL botol/solution IDR 21,667
13 Fletcher Powder Apotik Roxi Topples Plastik kecil IDR 25,000
Glass Ionomer Cement GC Gold
14 Label Fuji IX A3 Fuji IX A3, 5 gram IDR 319,000
Glass Ionomer Cement GC Gold
15 Label Fuji IX A3,5
Fuji IX A3,5 , 15 gram IDR 790,000
16 Guttap Percha Points No. 15/80 kotak IDR 66,000
17 Guttap Percha Points Inline Pegisian Saluran Akar, Uk 40 & 50 IDR 66,000
18 Guttap protaper Box isi 60 IDR 85,000
19 Hg (Air Raksa) Botol 100 gr IDR 300,000
Larutan Antiseptik Root
20 Canal/CHKM botol/10 ml IDR 70,000
21 Matrik + Holder Stainless Steel IDR 235,000
22 Oil Spray NSK Japan Handpiece Lubricant, 480 mL IDR -
23 Oil Spray kaleng, pelumas handpiece, 170 ml IDR 450,000
24 Paper Points uk 15 dan 20, 15 - 40 IDR 60,000
25 Paper Points Inline Pengering Saluran Akar/Endodontic, Uk 25 & IDR -
30
26 Pasta Mumifikasi IDR 214,500
27 Pehacain Kalbe Farma Lidocain HCl Box isi 20 amp IDR 71,469
28 Protaper 25 mm (hand) kotak isi 6 IDR 85,000
29 Pulperil Septodont 13 mL botol/solution IDR 404,800
France

30 Scandonest 3%
Septodont Adrenalin 18 mcg, Meficain 36 mg, 50 IDR 513,500
France ampul/box
31 Spongostan Curaspon Cube 1x1x1 xm, steril, 50 cube/ box IDR 493,350
32 Temporary Filling Pasta Cavit G Pot Glass 28 gr Paste IDR 115,000
32 Zn PO4 (Zinc Phospat) cement GC Pot ( Powder 125 gr,) IDR 350,000
Doridont
33 Zn PO4 (Zinc Phospat) cement Multifix, powder 30 gr Liquid 10 mL IDR 222,453
Austria

B. REAGEN LABORATORIUM
HARGA / Satuan TOTAL
NO NAMA BARANG MEREK SPESIFIKASI
(Tahun 2015) USULAN
1 Bilirubin Direk Reflotron 30 strip/tube IDR 652,740
2 Bilirubin Total Reflotron 30 strip/tube IDR 652,740
3 Bilirubin Total Liquid Human 2 x 100 mL IDR 838,063
4 BTA Reagen - Asam Alkohol 3% StReagen 100 mL
5 BTA Reagen - Carbol Fuchsin 1% StReagen 100 mL
BTA Reagen - Metylen Blue
6 StReagen 100 mL
0,1%
7 BTA Ziehl Nelson Aim (1:2:1) 4 x Botol 100 mL IDR 242,000
8 Cholesterol Total Liquid Human CHOD PAP mono, 4 x 30 mL IDR 1,087,900
9 Control Serum/Kimia Darah Human 6 x 5 mL IDR 1,196,250
10 Creatinine Reflotron 30 strip/tube IDR 694,485
11 Creatinine Liquid Human 1 x 200 mL IDR 800,000
Hb 301 Microcuvettes (4x50 pcs) vials
12 Cuvettest Hb HemoCue Untuk Alat Hb Fotometri IDR 14,231
13 Eter Alkohol IndoReagen 500 mL IDR 161,700
Reagen anti A, anti B, anti AB, anti D / Rhesus 10
14 Golongan Darah Proven/RPA
ml
IDR 494,000
15 HbsAb (Anti Hbs) SD Anti HBs Test, 30 test/tube IDR 924,000
16 HBsAg SD Hepatitis B Surface Antigen, 30 test/tube IDR 792,000
17 HDL Cholesterol Human 4 x 80 mL IDR 1,406,900
18 KOH 10% IndoReagen 100 mL IDR 35,000
19 Laboratory Detergent Extran 500 mL IDR 747,500
Cardio Chec/
20 Lipid Panel 15 strip/tube, Total Chol., HDL, Trig., calc. LDL) USD 124.89
PTS Panels
4 parameter (benzo,opiat,THC,amfetamin) box
21 Multi Panel Urine Drug Test IDR 79,200
isi 25 pcs
22 Natrium Citrat 3.8 % IndoReagen 100 mL IDR 96,250
23 Olium Emersi/Olie Immersion IndoReagen 500 mL IDR 465,850

24 Reagensia Hematologi - Human 1 L, HC Cleaner, Humacon 30 TS IDR 722,189

Cleaner M
25 Reagensia Hematologi - Diluent Human 20 L, HC Diluent IDR 2,713,425
M

26 Reagensia Hematologi - M-Lyse Human 1 L, HC Lyse CF, Humacon 30 TS IDR 1,885,483

Reagensia Hematology - Control

27 Hematology Human HC Control, Humacon 30 TS, Low, High, Normal IDR 6,181,043
28 SGOT Reflotron 30 strip/tube IDR 652,740
29 SGOT Liquid Human 10 x 10 mL IDR 710,000
30 SGPT Reflotron 30 strip/tube IDR 652,740
31 SGPT Liquid Human 10 x 10 mL IDR 710,000
32 Spiritus Bakar/Putih Lokal 20 L IDR 445,500
33 Strip Gula Darah Major II isi 50 strip/tube IDR 9,410
34 Strip Hb Mission
35 Strip Kolesterol Total Family Dr. 10 strip/tube IDR 330,000
36 Strip Uric Acid Family Dr. 25 strip/tube IDR 253,000
37 Tes Kehamilan (HCG strip) Oncoprobe 25 stik/box IDR 331,350
38 Triglyseride Liquid Human 9 x 15 mL IDR 2,012,500
39 Ureum Reflotron 15 strip/tube IDR 326,370
40 Ureum Liquid Human 2 x 100 mL IDR 695,750
41 Uric Acid Liquid Human 4 x botol 30 mL IDR 1,140,000
42 Urine Analysis 3 Tube Isi 50 Strip (Proteiin, PH, Glukosa) IDR 179,000
43 Urine Tes 10 Parameter 50 strip/box IDR 220,000
44 Widal Test Proven/RPA 8 Vial IDR 1,265,000

C. REAGEN HIV
HARGA / Satuan TOTAL
NO NAMA BARANG MEREK SPESIFIKASI
(Tahun 2015) USULAN
1 Anti HCV BioFarma 50 Stik/Box IDR 3,110,640
2 Rapid Test Syohilis Hexagon 20 strip/box IDR 1,188,560
3 Metylen Blue 0,3% StReagen 100 mL IDR 113,750
4 Pewarna Giemsa 100 mL IDR 509,450
Human/Hexag
5 Reagen HIV Rapid ke-3 Human 1 & 2 isi 40 IDR 42,000
on
6 Reagen HIV Rapid ke-1 Triline/intec isi 100 test IDR 42,000
7 Reagen HIV Rapid ke-2 SD Bioline isi 100 IDR 42,000

TOTAL
NO USULAN TAMBAHAN MEREK SPESIFIKASI HARGA / Satuan
USULAN
 Penanggung Jawab

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SATUAN

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Botol

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Botol
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Botol
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Kit
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Kit
Test
Botol
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Set
Botol
Botol
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Strip
Botol
Botol

Botol

Jerigen

Botol

Kit
Tube
Kit
Tube
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Galon
Strip
Tube
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Box
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SATUAN
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 FORM USULAN BARANG BAHAN KIMIA GIGI, REAGEN LAB, DAN REAGEN HIV 2016
PUSKESMAS KELURAHAN .

A. BAHAN KIMIA GIGI

HARGA / Satuan TOTAL
NO NAMA BARANG MEREK SPESIFIKASI
(Tahun 2015) USULAN
1 Absorbent Threatment No. 25,30
2 Amalgam Alloy Powder SDI Australia F 400 Powder/botol 30 gr IDR 1,400,000
3 Amalgam Capsule SDI Tipe F400 Capsule isi 5 x 10/box
1 spill
Doridont
5 Calcium Hidroxyde Pasta 2 set/box, Base 13 gr, Catalyst 11 gr IDR 480,000
Austria
6 Chlor Ethyl Spray Walter Ritter Kemasan Kaleng 100mL IDR 95,000
Tokuyama
7 Composite Resin Light Curing Set (1 bot Etching, 1 bot Bonding dan 6 syringe) IDR 3,750,000
Japan
Septodont
8 Cresophene (Rockless) 13 mL botol/solution IDR 604,500
France
Septodont
9 Devitalisasi Paste Non Arsen botol 4,5 gr IDR 250,000
France
10 Elite Cement Liquid GC 100 gr IDR 403,535
11 Endomethasone Septodont 7 gr Botol Powder IDR 515,000
France
12 Eugenol Ghimas Italy 10 mL botol/solution IDR 21,667
13 Fletcher Powder Apotik Roxi Topples Plastik kecil IDR 25,000
Glass Ionomer Cement GC Gold
14 Label Fuji IX A3 Fuji IX A3, 5 gram IDR 319,000
Glass Ionomer Cement GC Gold
15 Label Fuji IX A3,5
Fuji IX A3,5 , 15 gram IDR 790,000
16 Guttap Percha Points No. 15/80 kotak IDR 66,000
17 Guttap Percha Points Inline Pegisian Saluran Akar, Uk 40 & 50 IDR 66,000
18 Guttap protaper Box isi 60 IDR 85,000
19 Hg (Air Raksa) Botol 100 gr IDR 300,000
Larutan Antiseptik Root
20 Canal/CHKM botol/10 ml IDR 70,000
21 Matrik + Holder Stainless Steel IDR 235,000
22 Oil Spray NSK Japan Handpiece Lubricant, 480 mL IDR -
23 Oil Spray kaleng, pelumas handpiece, 170 ml IDR 450,000
24 Paper Points uk 15 dan 20, 15 - 40 IDR 60,000
25 Paper Points Inline Pengering Saluran Akar/Endodontic, Uk 25 & IDR -
30
26 Pasta Mumifikasi IDR 214,500
27 Pehacain Kalbe Farma Lidocain HCl Box isi 20 amp IDR 71,469
28 Protaper 25 mm (hand) kotak isi 6 IDR 85,000
29 Pulperil Septodont 13 mL botol/solution IDR 404,800
France

30 Scandonest 3%
Septodont Adrenalin 18 mcg, Meficain 36 mg, 50 IDR 513,500
France ampul/box
31 Spongostan Curaspon Cube 1x1x1 xm, steril, 50 cube/ box IDR 493,350
32 Temporary Filling Pasta Cavit G Pot Glass 28 gr Paste IDR 115,000
32 Zn PO4 (Zinc Phospat) cement GC Pot ( Powder 125 gr,) IDR 350,000
Doridont
33 Zn PO4 (Zinc Phospat) cement Multifix, powder 30 gr Liquid 10 mL IDR 222,453
Austria

B. REAGEN LABORATORIUM
HARGA / Satuan TOTAL
NO NAMA BARANG MEREK SPESIFIKASI
(Tahun 2015) USULAN
1 Bilirubin Direk Reflotron 30 strip/tube IDR 652,740
2 Bilirubin Total Reflotron 30 strip/tube IDR 652,740
3 Bilirubin Total Liquid Human 2 x 100 mL IDR 838,063
4 BTA Reagen - Asam Alkohol 3% StReagen 100 mL
5 BTA Reagen - Carbol Fuchsin 1% StReagen 100 mL
BTA Reagen - Metylen Blue
6 StReagen 100 mL
0,1%
7 BTA Ziehl Nelson Aim (1:2:1) 4 x Botol 100 mL IDR 242,000
8 Cholesterol Total Liquid Human CHOD PAP mono, 4 x 30 mL IDR 1,087,900
9 Control Serum/Kimia Darah Human 6 x 5 mL IDR 1,196,250
10 Creatinine Reflotron 30 strip/tube IDR 694,485
11 Creatinine Liquid Human 1 x 200 mL IDR 800,000
Hb 301 Microcuvettes (4x50 pcs) vials
12 Cuvettest Hb HemoCue Untuk Alat Hb Fotometri IDR 14,231
13 Eter Alkohol IndoReagen 500 mL IDR 161,700
Reagen anti A, anti B, anti AB, anti D / Rhesus 10
14 Golongan Darah Proven/RPA
ml
IDR 494,000
15 HbsAb (Anti Hbs) SD Anti HBs Test, 30 test/tube IDR 924,000
16 HBsAg SD Hepatitis B Surface Antigen, 30 test/tube IDR 792,000
17 HDL Cholesterol Human 4 x 80 mL IDR 1,406,900
18 KOH 10% IndoReagen 100 mL IDR 35,000
19 Laboratory Detergent Extran 500 mL IDR 747,500
Cardio Chec/
20 Lipid Panel 15 strip/tube, Total Chol., HDL, Trig., calc. LDL) USD 124.89
PTS Panels
4 parameter (benzo,opiat,THC,amfetamin) box
21 Multi Panel Urine Drug Test IDR 79,200
isi 25 pcs
22 Natrium Citrat 3.8 % IndoReagen 100 mL IDR 96,250
23 Olium Emersi/Olie Immersion IndoReagen 500 mL IDR 465,850

24 Reagensia Hematologi - Human 1 L, HC Cleaner, Humacon 30 TS IDR 722,189

Cleaner M
25 Reagensia Hematologi - Diluent Human 20 L, HC Diluent IDR 2,713,425
M

26 Reagensia Hematologi - M-Lyse Human 1 L, HC Lyse CF, Humacon 30 TS IDR 1,885,483

Reagensia Hematology - Control

27 Hematology Human HC Control, Humacon 30 TS, Low, High, Normal IDR 6,181,043
28 SGOT Reflotron 30 strip/tube IDR 652,740
29 SGOT Liquid Human 10 x 10 mL IDR 710,000
30 SGPT Reflotron 30 strip/tube IDR 652,740
31 SGPT Liquid Human 10 x 10 mL IDR 710,000
32 Spiritus Bakar/Putih Lokal 20 L IDR 445,500
33 Strip Gula Darah Major II isi 50 strip/tube IDR 9,410
34 Strip Hb Mission
35 Strip Kolesterol Total Family Dr. 10 strip/tube IDR 330,000
36 Strip Uric Acid Family Dr. 25 strip/tube IDR 253,000
37 Tes Kehamilan (HCG strip) Oncoprobe 25 stik/box IDR 331,350
38 Triglyseride Liquid Human 9 x 15 mL IDR 2,012,500
39 Ureum Reflotron 15 strip/tube IDR 326,370
40 Ureum Liquid Human 2 x 100 mL IDR 695,750
41 Uric Acid Liquid Human 4 x botol 30 mL IDR 1,140,000
42 Urine Analysis 3 Tube Isi 50 Strip (Proteiin, PH, Glukosa) IDR 179,000
43 Urine Tes 10 Parameter 50 strip/box IDR 220,000
44 Widal Test Proven/RPA 8 Vial IDR 1,265,000

C. REAGEN HIV
HARGA / Satuan TOTAL
NO NAMA BARANG MEREK SPESIFIKASI
(Tahun 2015) USULAN
1 Anti HCV BioFarma 50 Stik/Box IDR 3,110,640
2 Rapid Test Syohilis Hexagon 20 strip/box IDR 1,188,560
3 Metylen Blue 0,3% StReagen 100 mL IDR 113,750
4 Pewarna Giemsa 100 mL IDR 509,450
Human/Hexag
5 Reagen HIV Rapid ke-3 Human 1 & 2 isi 40 IDR 42,000
on
6 Reagen HIV Rapid ke-1 Triline/intec isi 100 test IDR 42,000
7 Reagen HIV Rapid ke-2 SD Bioline isi 100 IDR 42,000

TOTAL
NO USULAN TAMBAHAN MEREK SPESIFIKASI HARGA / Satuan
USULAN
 Kepala Puskesmas
Kelurahan

(..)
NIP: ..
HIV 2016

SATUAN

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Botol

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Jerigen

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Kit
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Galon
Strip
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