Ritl Oktober 2017 PDF

Rekapitulasi Pengajuan Tagihan
Peserta Tanggal Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

Nama PPK : IFRS UNHAS
RITL
No Jml Harga Harga

No. No Ka Peserta Nama Rsp Tgl Pel Nama Obat R/N Obt Obat Diajukan
1 0000976099779 P ASDAR ARSYAD 00002 03/10/2017 DBL Carboplatin 150 150 mg/15 N 5 645,000.00 3,233,750
Brexel 20 mg 20 mg/vial N 3 1,263,750.0

0
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0
0
2 0002069356296 P LAHUDDIN 00003 03/10/2017 Cisplatin 50 mg/vial N 3 330,000.00 1,730,000
Paclitaxel 100 mg/via N 2 1,000,000.0

0
Paclitaxel 30 mg/vial N 2 400,000.00
3 0001853957981 P ARINY ALVA 00004 03/10/2017 Vincristine 1 mg/vial N 1 48,500.00 87,000

ALTAVUNNISA
Metotreksat 50 mg/2 ml N 1 38,500.00
4 0002199966939 P LIONEL ANDRESS 00005 03/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000

MARAMIS
Vincristine 1 mg/vial N 1 48,500.00
5 0001072955946 P RISNA BITE 00008 04/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
6 0002256708993 P SITI AISYAH 00009 04/10/2017 Brexel 20 mg 20 mg/vial N 1 421,250.00 2,262,250
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
DBL Carboplatin 150 150 mg/15 N 4 516,000.00
7 0000947178268 P dambu 00010 04/10/2017 DBL Carboplatin 150 150 mg/15 N 3 387,000.00 2,554,500
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
Brexel 20 mg 20 mg/vial N 2 842,500.00
8 0002093172041 P nur rahmi halim 00012 05/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750
9 0002091517784 P muhammad m 00013 05/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750
10 0001558943651 P HJ.SURI 00014 05/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 1,906,000

0
11 0000127676924 P SALIRUDDIN 00015 05/10/2017 Paclitaxel 30 mg/vial N 3 600,000.00 1,955,250
Halaman : 1
No Jml Harga Harga
Paclitaxel 100 mg/via N
0
Cisplatin 10 mg/vial N 1 25,250.00
12 0000127705869 P HJ.ST.RAHMATIAH S 00016 06/10/2017 Eloxatin 50 mg N 1 400,000.00 2,936,000
Eloxatin 100 mg N 1 800,000.00
Xeloda 500 mg N 56 1,736,000.0

0
13 0000921839769 p BAU ASNI 00017 06/10/2017 DBL Carboplatin 150 150 mg/15 N 2 258,000.00 2,155,000

0
14 0000937715501 P NANONG 00018 06/10/2017 Paclitaxel 30 mg/vial N 1 200,000.00 1,587,000

0
15 0000130883376 I SYAMSIAH 00019 06/10/2017 Curacil 500 mg/via N 2 72,100.00 1,090,141
Cyclovid 1000 1000 mg/vi N 1 231,116.00
Epirubicin 50 mg/vial N 1 475,000.00
16 0002269473715 P azijah 00022 07/10/2017 DBL Carboplatin 150 150 mg/15 N 1 129,000.00 1,826,000

0
17 0000126609311 P NY. NURBIAH DG 00024 09/10/2017 Brexel 20 mg 20 mg/vial N 3 1,263,750.0 4,013,750

SANGNGING 0
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0
0
Epirubicin 50 mg/vial N 3 1,425,000.0
0
18 0001939785131 P ANDI SABIL 00023 10/10/2017 Brexel 20 mg 20 mg/vial N 2 842,500.00 2,593,500
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
19 0001325073892 P M. ASWID ABBAS 00026 10/10/2017 Cisplatin 50 mg/vial N 2 220,000.00 1,420,000
Halaman : 2
No Jml Harga Harga
0
20 0001325011702 P SERLY SALONG 00027 10/10/2017 Mabthera 500mg/50mL 500 mg/50 N 2 15,824,026. 15,824,026
00
21 0002199966939 P LIONEL ANDRESS 00028 10/10/2017 Vincristine 1 mg/vial N 1 48,500.00 48,500
MARAMIS
22 0001554849167 P HAMKA JAYA GINTANG 00029 10/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 1,511,366
Bleocin 15 mg/mL N 2 690,000.00
Cyclovid 1000 1000 mg/vi N 1 231,116.00
23 0001933071254 P A. SURIANTI 00030 10/10/2017 Paclitaxel 100 mg/via N 2 1,000,000.0 2,290,900

0
24 0000140279411 P boki abubakar 00031 10/10/2017 Paclitaxel 30 mg/vial N 1 200,000.00 1,626,000

0
25 0001800536499 P HARDIANA 00032 10/10/2017 Eloxatin 100 mg N 2 1,600,000.0 3,336,000

0
Xeloda 500 mg N 56 1,736,000.0
0
26 0000931197712 P KADU 00035 11/10/2017 DBL Carboplatin 450 450 mg/45 N 1 297,000.00 2,464,500
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
27 0000136250605 P SWARNI MAHIWA 00036 11/10/2017 Paclitaxel 100 mg/via N 2 1,000,000.0 2,026,000
0
28 0001936500963 P adinda ainun 00037 11/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750
29 0002238748942 P lyra nabila gani 00038 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750
30 0001907845402 P NAUFAL ABD. KAHAR 00039 11/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750
Halaman : 3
No Jml Harga Harga
31 0002091517784 P muhammad m 00040 11/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
32 0002201513308 P ARSYIL RAMADHAN SB 00041 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000
33 0000937352182 P aldianto 00042 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750
34 0001556481339 P Dana Berliyanti 00043 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750
35 0001200892972 P Muh. Masri Ramadhan 00044 11/10/2017 Vincristine 1 mg/vial N 1 48,500.00 87,000
36 0001872993104 P ANJU ROMAULI PASI 00045 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000
37 0002226564099 P SITTI KHADIJAH 00046 12/10/2017 Paclitaxel 100 mg/via N 2 1,000,000.0 2,026,000
0
38 0000938459046 P MEGAWATI 00048 12/10/2017 Paclitaxel 30 mg/vial N 1 200,000.00 1,745,000

0
Leucogen 0,3 mg/0,5 N 1 215,000.00
39 0002080465907 P Andi Muh. Refal 00050 12/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750
40 0001808644645 P ARDIANSYAH UMASUGI 00051 12/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750
41 0002221933959 P jihan ghefira 00053 12/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750
42 0000922633773 P ASTI AULIA PUTRI 00054 12/10/2017 Vincristine 1 mg/vial N 1 48,500.00 87,000
43 0002208545886 P RAHMAWATI 00055 12/10/2017 Epirubicin 50 mg/vial N 2 950,000.00 3,556,566
Halaman : 4
No Jml Harga Harga
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
Cyclovid 1000 1000 mg/vi N 1 231,116.00
44 0002205988119 P zaki al fatih 00052 13/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000
45 0002242076365 P TITIN SUPRIATIN 00056 13/10/2017 Epirubicin 50 mg/vial N 1 475,000.00 1,090,141
Cyclovid 1000 1000 mg/vi N 1 231,116.00
Curacil 500 mg/via N 2 72,100.00
46 0002259967408 P SUMIATI 00057 13/10/2017 DBL Carboplatin 450 450 mg/45 N 1 297,000.00 1,497,000

0
47 0002093172041 P nur rahmi halim 00058 13/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
48 0001305623981 P durika 00059 13/10/2017 Brexel 20 mg 20 mg/vial N 2 842,500.00 2,459,600
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
49 0000939421383 P suasa 00060 13/10/2017 DBL Carboplatin 450 450 mg/45 N 1 297,000.00 1,497,000

0
50 0000942778045 P nirwana 00064 16/10/2017 Doxorubicin 50 mg/vial N 2 506,000.00 1,811,000
Anzatax 30 30 mg/vial N 10 1,305,000.0

0
51 0000152684717 P JUMLIA PAULLE 00065 17/10/2017 Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0 2,167,500
0
52 0002258217009 P WIDYA JUSMAL 00067 17/10/2017 Doksorubisin 50 mg/vial N 1 253,000.00 568,366
Cyclovid 1000 1000 mg/vi N 1 231,116.00
53 0001558395189 P NAHURIA 00068 17/10/2017 Cyclovid 1000 1000 mg/vi N 1 231,116.00 809,216
Halaman : 5
No Jml Harga Harga
Doksorubisin 50 mg/vial N 2 506,000.00
54 0001561601957 P H HARISA 00069 17/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 809,216
Cyclovid 1000 1000 mg/vi N 1 231,116.00
55 0001934131408 P USMAN SINUKE 00070 17/10/2017 Paclitaxel 100 mg/via N 2 1,000,000.0 1,955,250
0
56 0000202887887 P NURUL HARDIYANTI 00071 17/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 3,149,500
DBL Dacarbazine 200 mg/20 N 10 2,475,000.0

0
57 0001564207931 P SALAWATI 00091 17/10/2017 Epirubicin 50 mg/vial N 2 950,000.00 2,450,000

0
58 0001872993104 P ANJU ROMAULI PASI 00072 18/10/2017 Vincristine 1 mg/vial N 1 48,500.00 48,500
59 0002082298083 P IDA KUMALA SARI 00073 18/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 2,483,366
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
Cyclovid 1000 1000 mg/vi N 1 231,116.00
60 0001859927758 P NAURA 00074 18/10/2017 Vincristine 1 mg/vial N 1 48,500.00 87,000
61 0001964631148 P NUR AISYAH 00075 18/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000
62 0001200892972 P Muh. Masri Ramadhan 00076 18/10/2017 Vincristine 1 mg/vial N 1 48,500.00 48,500
63 0002248172504 P ALAN ALFIAN 00077 18/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
64 0002238748942 P lyra nabila gani 00078 18/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
65 0001556481339 P Dana Berliyanti 00079 18/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
66 0001936500963 P adinda ainun 00080 18/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
67 0001791238127 P LANY SATRIA ANANDA 00083 18/10/2017 Herceptin 440 mg/20 N 1 9,804,017.0 9,804,017
0
Halaman : 6
No Jml Harga Harga
68 0000937352182 P aldianto 00084 18/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
69 0001896955749 P CLARISA TARUK TIKU 00085 18/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750
70 0002229269951 P AGUS RAMADHAN 00086 18/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750

SUARDI
71 0002208203706 P SUMERANA 00088 18/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 809,216
Cyclovid 1000 1000 mg/vi N 1 231,116.00
72 0000924644766 P EDA 00089 18/10/2017 Cyclovid 1000 1000 mg/vi N 1 231,116.00 2,618,616
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
73 0001076270668 P SITTI AISYAH 00090 18/10/2017 Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0 1,622,000

0
74 0002201513308 P ARSYIL RAMADHAN SB 00094 18/10/2017 Vincristine 1 mg/vial N 1 48,500.00 48,500
75 0000126609311 P NY. NURBIAH DG 00096 19/10/2017 Leucogen 0,3 mg/0,5 N 1 215,000.00 215,000
SANGNGING
76 0001907845402 P NAUFAL ABD. KAHAR 00097 19/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
77 0001933836456 P HENDRI 00098 19/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750
78 0002221933959 P jihan ghefira 00102 19/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
79 0000922633773 P ASTI AULIA PUTRI 00103 19/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
80 0002205988119 P zaki al fatih 00104 19/10/2017 Vincristine 1 mg/vial N 1 48,500.00 48,500
81 0002080465907 P Andi Muh. Refal 00105 19/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
82 0000194447171 P DESIANTI PALINGGI 00106 19/10/2017 Paclitaxel 30 mg/vial N 1 200,000.00 1,497,000

0
83 0002282363932 P RUWAYA 00099 20/10/2017 DBL Carboplatin 450 450 mg/45 N 1 297,000.00 1,697,000

0
Halaman : 7
No Jml Harga Harga
84 0000164735245 P ERNY DACHLAN 00100 20/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 809,216
Cyclovid 1000 1000 mg/vi N 1 231,116.00
85 0001305623981 P durika 00109 21/10/2017 Leucogen 0,3 mg/0,5 N 1 215,000.00 215,000
86 0001305623981 P durika 00117 22/10/2017 Leucogen 0,3 mg/0,5 N 1 215,000.00 215,000
87 0001305694631 P HASNAH 00110 23/10/2017 Epirubicin 50 mg/vial N 3 1,425,000.0 3,592,500

0
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
88 0001936396844 P HASNAH DG.TASA 00111 23/10/2017 Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0 2,904,616
0
Cyclovid 1000 1000 mg/vi N 1 231,116.00
89 0000132334942 P RAHEL ARRUAN 00115 23/10/2017 Hydroxyurea Medac 500 mg N 60 235,620.00 235,620
90 0001938248572 P KALBIA 00112 24/10/2017 Paclitaxel 100 mg/via N 3 1,500,000.0 2,326,000

0
91 0002069356296 P LAHUDDIN 00113 24/10/2017 Cisplatin 50 mg/vial N 3 330,000.00 1,730,000

0
92 0000976099779 P ASDAR ARSYAD 00116 24/10/2017 Brexel 20 mg 20 mg/vial N 3 1,263,750.0 3,014,750
0
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0
0
93 0000149284146 P NADYA SALSABILA 00120 25/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750

ACHMAD
94 0001808373802 P MEDIANA ANNISA SRI 00121 25/10/2017 Vincristine 1 mg/vial N 1 48,500.00 87,000
WATI
95 0002063923042 P ARDAWIYAH PUSPITA 00122 25/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000

SARI
Halaman : 8
No Jml Harga Harga
96 0000947178268 P dambu 00124 25/10/2017 Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0 2,464,500

0
97 0002229269951 P AGUS RAMADHAN 00125 25/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250

SUARDI
98 0001964631148 P NUR AISYAH 00126 25/10/2017 Vincristine 1 mg/vial N 1 48,500.00 48,500
99 0001970262292 P A. MUH. RIZQI AL 00127 25/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750

GHAZALI
100 0001832678706 P AHMAD FAUZAN 00128 25/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750
101 0000937715501 P NANONG 00130 26/10/2017 Paclitaxel 100 mg/via N 2 1,000,000.0 1,497,000
0
102 0000127676924 P SALIRUDDIN 00131 26/10/2017 Cisplatin 50 mg/vial N 3 330,000.00 1,955,250

0
103 0001785930039 P KARTINI K 00132 26/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 1,941,500
Anzatax 30 30 mg/vial N 11 1,435,500.0

0
104 0002242521088 P darmiati 00133 26/10/2017 Cisplatin 50 mg/vial N 2 220,000.00 1,620,000

0
105 0002064157525 P ALETA GABRIEL 00134 26/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000
TUMEWA
106 0002048554056 P MUH FAQIH SIKRULLAH 00135 26/10/2017 Vincristine 1 mg/vial N 1 48,500.00 87,000
107 0002235673449 P ASIZAH SAHRA 00136 26/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000
108 0001933836456 P HENDRI 00137 26/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250
Halaman : 9
No Jml Harga Harga
109 0002256708993 P SITI AISYAH 00123 27/10/2017 Brexel 20 mg 20 mg/vial N 1 421,250.00 2,172,250
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
110 0000128833953 P ABD KADIR 00138 27/10/2017 DBL Carboplatin 150 150 mg/15 N 1 129,000.00 1,926,000

0
111 0002269473715 P azijah 00140 27/10/2017 Paclitaxel 100 mg/via N 2 1,000,000.0 1,826,000
0
112 0001939785131 P ANDI SABIL 00141 27/10/2017 DBL Carboplatin 150 150 mg/15 N 1 129,000.00 2,593,500
Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

0
113 0000921839769 p BAU ASNI 00143 27/10/2017 Paclitaxel 30 mg/vial N 3 600,000.00 2,155,000

0
114 0000127705869 P HJ.ST.RAHMATIAH S 00144 27/10/2017 Eloxatin 50 mg N 3 1,200,000.0 2,936,000

0
Xeloda 500 mg N 56 1,736,000.0
0
115 0000130883376 I SYAMSIAH 00146 27/10/2017 Epirubicin 50 mg/vial N 2 950,000.00 1,253,216
Cyclovid 1000 1000 mg/vi N 1 231,116.00
116 0000136250605 P SWARNI MAHIWA 00148 31/10/2017 DBL Carboplatin 150 150 mg/15 N 1 129,000.00 2,026,000

0
117 0000140279411 P boki abubakar 00149 31/10/2017 Paclitaxel 30 mg/vial N 1 200,000.00 1,626,000

Halaman : 10
No Jml Harga Harga
Paclitaxel 100 mg/via N
0
118 0001325073892 P M. ASWID ABBAS 00150 31/10/2017 Cisplatin 50 mg/vial N 2 220,000.00 1,635,000
Leucogen 0,3 mg/0,5 N 1 215,000.00

0
119 0001933071254 P A. SURIANTI 00151 31/10/2017 Paclitaxel 30 mg/vial N 2 400,000.00 2,350,000

0
120 0001554849167 P HAMKA JAYA GINTANG 00152 31/10/2017 Vincristine 2 mg/vial N 1 84,250.00 1,511,366
Bleocin 15 mg/mL N 2 690,000.00
Cyclovid 1000 1000 mg/vi N 1 231,116.00
121 0000977603657 P ANDI SUDARNI 00153 31/10/2017 DBL Carboplatin 450 450 mg/45 N 1 297,000.00 1,497,000

0
122 0002276232445 P SITTI HAMISAH 00154 31/10/2017 Mabthera 100mg/mL 100 mg/10 N 4 6,329,612.0 6,897,978
0
Cyclovid 1000 1000 mg/vi N 1 231,116.00
Total : 170,258,265.0
Menyetujui,
Halaman : 11

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Rekapitulasi Pengajuan Tagihan

Peserta Tanggal Pelayanan : 01 Oktober 2017 s/d 31 Oktober 2017

No Jml Harga Harga

Brexel 20 mg 20 mg/vial N 3 1,263,750.0

Paclitaxel 100 mg/via N 2 1,000,000.0

3 0001853957981 P ARINY ALVA 00004 03/10/2017 Vincristine 1 mg/vial N 1 48,500.00 87,000

4 0002199966939 P LIONEL ANDRESS 00005 03/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000

5 0001072955946 P RISNA BITE 00008 04/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250

6 0002256708993 P SITI AISYAH 00009 04/10/2017 Brexel 20 mg 20 mg/vial N 1 421,250.00 2,262,250

Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

Vincristine 2 mg/vial N 1 84,250.00

9 0002091517784 P muhammad m 00013 05/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750

Metotreksat 50 mg/2 ml N 1 38,500.00

10 0001558943651 P HJ.SURI 00014 05/10/2017 Doksorubisin 50 mg/vial N 2 506,000.00 1,906,000

Paclitaxel 100 mg/via N 2 1,000,000.0

11 0000127676924 P SALIRUDDIN 00015 05/10/2017 Paclitaxel 30 mg/vial N 3 600,000.00 1,955,250

Paclitaxel 100 mg/via N 2 1,000,000.0

Cisplatin 50 mg/vial N 3 330,000.00

12 0000127705869 P HJ.ST.RAHMATIAH S 00016 06/10/2017 Eloxatin 50 mg N 1 400,000.00 2,936,000

Eloxatin 100 mg N 1 800,000.00

Xeloda 500 mg N 56 1,736,000.0

Paclitaxel 100 mg/via N 2 1,000,000.0

DBL Carboplatin 450 450 mg/45 N 1 297,000.00

14 0000937715501 P NANONG 00018 06/10/2017 Paclitaxel 30 mg/vial N 1 200,000.00 1,587,000

Paclitaxel 100 mg/via N 2 1,000,000.0

15 0000130883376 I SYAMSIAH 00019 06/10/2017 Curacil 500 mg/via N 2 72,100.00 1,090,141

Cyclovid 1000 1000 mg/vi N 1 231,116.00

Epirubicin 50 mg/vial N 1 475,000.00

Epirubicin 10 mg/vial N 3 311,925.00

DBL Carboplatin 450 450 mg/45 N 1 297,000.00

Paclitaxel 100 mg/via N 2 1,000,000.0

17 0000126609311 P NY. NURBIAH DG 00024 09/10/2017 Brexel 20 mg 20 mg/vial N 3 1,263,750.0 4,013,750

Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

DBL Carboplatin 150 150 mg/15 N 1 129,000.00

19 0001325073892 P M. ASWID ABBAS 00026 10/10/2017 Cisplatin 50 mg/vial N 2 220,000.00 1,420,000

Paclitaxel 30 mg/vial N 1 200,000.00

Vincristine 2 mg/vial N 1 84,250.00

Bleocin 15 mg/mL N 2 690,000.00

Cyclovid 1000 1000 mg/vi N 1 231,116.00

23 0001933071254 P A. SURIANTI 00030 10/10/2017 Paclitaxel 100 mg/via N 2 1,000,000.0 2,290,900

Epirubicin 50 mg/vial N 1 475,000.00

Epirubicin 10 mg/vial N 4 415,900.00

24 0000140279411 P boki abubakar 00031 10/10/2017 Paclitaxel 30 mg/vial N 1 200,000.00 1,626,000

Paclitaxel 100 mg/via N 2 1,000,000.0

DBL Carboplatin 450 450 mg/45 N 1 297,000.00

25 0001800536499 P HARDIANA 00032 10/10/2017 Eloxatin 100 mg N 2 1,600,000.0 3,336,000

Brexel 20 mg 20 mg/vial N 2 842,500.00

Brexel 80 mg 80 mg/2 ml N 1 1,325,000.0

DBL Carboplatin 450 450 mg/45 N 1 297,000.00

DBL Carboplatin 150 150 mg/15 N 1 129,000.00

28 0001936500963 P adinda ainun 00037 11/10/2017 Vincristine 2 mg/vial N 1 84,250.00 122,750

Metotreksat 50 mg/2 ml N 1 38,500.00

Vincristine 2 mg/vial N 1 84,250.00

31 0002091517784 P muhammad m 00040 11/10/2017 Vincristine 2 mg/vial N 1 84,250.00 84,250

32 0002201513308 P ARSYIL RAMADHAN SB 00041 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 87,000

Vincristine 1 mg/vial N 1 48,500.00

33 0000937352182 P aldianto 00042 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750

Vincristine 2 mg/vial N 1 84,250.00

34 0001556481339 P Dana Berliyanti 00043 11/10/2017 Metotreksat 50 mg/2 ml N 1 38,500.00 122,750

Vincristine 2 mg/vial N 1 84,250.00

Metotreksat 50 mg/2 ml N 1 38,500.00

Vincristine 1 mg/vial N 1 48,500.00