RSUD Kab.

Mukomuko
Jl. Danau Nibung Kota Praja, Kab. Mukomuko Kode Pos 38365 Telp. 0737-71148
http://www.rsud.mukomukokab.go.id/, rsud.mukomuko@gmail.com

LAPORAN BULANAN PASIEN

Periode January 2021 s/d June 2021

Tanggal Rincian Obat yang

No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1 Faizal UJUNG PADANG 128758 Ceftriaxone Inj
14/04/2021 00:00:00 12.498,00 ASKES, PT
Electroda (Ambu) @25 Pc 81.570,00
Nassal Mask O2 Anak 41.828,00
Paracetamol tablet 500 m 645,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ventolin Nebules 2.5 mg 20.000,00
Total 169.659,00
2 Ernawati AIR DIKIT 166622 Ascorbid Acid 1000mg/5m
02/01/2021 00:00:00 156.750,00 ASKES, PT
Azitromycin 500 mg 22.500,00
Ceftriaxone Inj 24.996,00
NACL 0,9 % 500 ml 25.650,00
Vectrine Tab 300 mg 20.000,00
Zinc Sulfate Syr 60 ml 4.569,00
Abbocath 20 Terumo @5
03/01/2021 00:00:00 22.276,00
Ascorbid Acid 1000mg/5m 52.250,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Erdosteine Syr 36.575,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 25.650,00
Zink Tablet 1.378,00
Azitromycin 500 mg
04/01/2021 00:00:00 5.625,00
Erdosteine Syr 36.575,00
Extrace Injeksi 100 mg/m 19.250,00
Oseltamivir 75 mg 10,00
Paracetamol tablet 500 m 2.000,00
Vectrine Tab 300 mg 50.000,00
Vitamin C 500 mg 10,00
Zink Tablet 6.890,00
Zink Tablet 1.378,00
Total 559.680,00
3 Tusinem BUMI MULIA 181750 Abbocath 20 Terumo @5
03/01/2021 00:00:00 11.138,00 ASKES, PT
Abbocath 20 Terumo @5 44.552,00
Abbocath 22 Terumo @5 11.138,00
Azitromycin 500 mg 11.250,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 25.650,00
Nassal Cannula O2 Dewas 11.625,00
Ringer Laktat Otsuka 19.076,00
vestein 300 mg 9.350,00
Vitamin C tablet @100 Ta 276,00
Zink Tablet 1.378,00
Azitromycin 500 mg
04/01/2021 00:00:00 22.500,00

19/08/2021 12:41:23 Page 1 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3 Tusinem BUMI MULIA 181750 NACL 0,9 % 500 ml
04/01/2021 00:00:00 17.100,00 ASKES, PT
Ondansetron Inj 4.950,00
Oseltamivir 75 mg 10,00
Vectrine Tab 300 mg 50.000,00
Vitamin C 500 mg 10,00
Vitamin C tablet @100 Ta 0,00
Zink Tablet 6.890,00
Amlodipine 5 mg @30 T
05/01/2021 00:00:00 1.010,00
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 2.000,00
vestein 300 mg 46.750,00
Vitamin C 500 mg 10,00
Zink Tablet 6.890,00
Total 340.013,00
4 Martis SURIAN BUNGKAL 181754 Bisturi No. 23
04/01/2021 00:00:00 3.836,00 ASKES, PT
Bucain Spinal 0.5 % Inj 52.181,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 5.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 24.062,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
viamac 1 R 364.370,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00

19/08/2021 12:42:30 Page 2 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
4 Martis SURIAN BUNGKAL 181754 Ringer Laktat Otsuka
04/01/2021 00:00:00 28.614,00 ASKES, PT
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
06/01/2021 00:00:00 3.575,00
Bisturi No. 15 7.672,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 19.350,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 1.350,00
NGT (Feeding Tube) Fr. 8 140.840,00
Oxytetracycline Salep Ma 6.502,00
Phytomenadione 2 Mg/1M 9.668,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 4.522,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Postofix (leukomed) 36.726,00
Total 1.707.455,00
5 Meili Angistia BANDAR RATU 150809 Dexametason Injeksi
05/01/2021 00:00:00 6.256,00 ASKES, PT
Ephedrine Injeksi 21.422,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 43.662,00
Hypafix 10cm x 5cm (25 c 14.550,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 800,00
Cefotaxime Injeksi
06/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Suprafenid Supositoria 10 42.075,00
Asam Mefenamat 500 m
07/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 21.000,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 14.550,00
Ketorolac inj 30 mg/1ml 8.070,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 9.538,00
Total 298.858,00
6 Sinta PONDOK PANJANG 180087 Bisturi No. 23
08/01/2021 00:00:00 3.836,00 ASKES, PT
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00

19/08/2021 12:42:30 Page 3 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
6 Sinta PONDOK PANJANG 180087 Gelaufusal Infusion 500 m
08/01/2021 00:00:00 181.269,00 ASKES, PT
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
oxytocin inj 2.998,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 2.105,00
Urine bag 10.088,00
Cefotaxime Injeksi
09/01/2021 00:00:00 11.502,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
10/01/2021 00:00:00 3.575,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 270,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 11.043,00
NonWoven Fixation 15x 13.388,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00

19/08/2021 12:42:30 Page 4 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
6 Sinta PONDOK PANJANG 180087 umbilical Cord Clamp
10/01/2021 00:00:00 2.261,00 ASKES, PT
Asam Mefenamat 500 m
11/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 19.350,00
Postofix (leukomed) 36.726,00
Total 1.585.328,00
7 Jabarwi DUSUN GEDANG 161528 abbocath 18 Terumo @5
09/01/2021 00:00:00 11.138,00 ASKES, PT
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
NACL 0,9 % 500 ml
10/01/2021 00:00:00 25.650,00
NonWoven Fixation 15x 13.388,00
Transfusi Set Terumo 16.500,00
Lansoprazole kapsul 30 m
11/01/2021 00:00:00 11.550,00
Total 170.199,00
8 Zulmaini UJUNG PADANG 154372 Catheter 2 Way No. 16 (
13/01/2021 00:00:00 39.025,00 ASKES, PT
Urine bag 10.088,00
Cefotaxime Injeksi
14/01/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Total 112.341,00
9 Nadine Claudia Kinanti TIRTA MAKMUR 182020 Cefixime syrup 100mg/5 M
17/01/2021 00:00:00 23.823,00 ASKES, PT
Paracetamol syrup 1.388,00
Total 25.211,00
10 Ahmad Davan Ali Pas SIBAK 182025 Abbocath 24 Terumo @5
19/01/2021 00:00:00 11.138,00 ASKES, PT
Epinephrin inj 30.662,00
Hypafix 15cmx5cm (25 c 19.632,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 19.350,00
Pehacain Injeksi 9.960,00
Polyglycolide T-Vio 3-0 R ( 258.000,00
Ringer Laktat Otsuka 19.076,00
Total 374.362,00
11 Zamhari BANDARATU 122356 Amlodipine 5 mg @30 T
19/01/2021 00:00:00 3.030,00 ASKES, PT
Aspilet 80 mg @100 mg 4.140,00
Bisoprolol 5 mg @100 Ta 8.880,00
Captopril 12,5 mg 2.400,00
Furosemide 40 mg Tablet 2.880,00
Ranitidine tablet 150 mg 1.440,00

19/08/2021 12:42:30 Page 5 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
11 Zamhari BANDARATU 122356 Spironolaktone 25 mg
19/01/2021 00:00:00 7.800,00 ASKES, PT
Total 30.570,00
12 Sari Ajis BANDARATU 139196 Paracetamol tablet 500 m
22/01/2021 00:00:00 2.000,00 ASKES, PT
Renax @50 Kapsul 113.440,00
Urinter Kapsul @100 cap 21.980,00
Total 137.420,00
13 Titik Sumanti PELOKAN 122011 Catheter 2 Way No. 16 (
23/01/2021 00:00:00 39.025,00 ASKES, PT
Induxin 1 ml Injeksi 18.562,00
Lidocain injk 40 mg/2 ml 1.611,00
Misoprostol Tab 16.500,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Total 94.362,00
14 Sari Ajis BANDARATU 139196 Azitromycin 500 mg
25/01/2021 00:00:00 56.250,00 ASKES, PT
Azitromycin 500 mg 56.250,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 4.000,00
Paracetamol tablet 500 m 2.000,00
Ranitidine tablet 150 mg 1.440,00
Zinc Sulfate Syr 60 ml 4.569,00
Zink Tablet 6.890,00
Total 138.009,00
15 Ibrahim Katar UJUNG PADANG 182209 Abbocath 20 Terumo @5
27/01/2021 00:00:00 11.138,00 ASKES, PT
Bisoprolol 5 mg @100 Ta 296,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj
28/01/2021 00:00:00 12.498,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 154,00
Biocombin 5000 Injeksi
29/01/2021 00:00:00 6.531,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 25.878,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
30/01/2021 00:00:00 12.498,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Cefixime Kapsul 100 mg
31/01/2021 00:00:00 9.380,00
Levofloxacin Tablet 500 m 6.820,00
Paracetamol tablet 500 m 2.000,00
Total 340.737,00
16 Addarimi BANDARATU 127606 Allopurinol 300 Mg @100
28/01/2021 00:00:00 4.910,00 ASKES, PT

19/08/2021 12:42:30 Page 6 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
16 Addarimi BANDARATU 127606 Candesartan tab 8 mg
28/01/2021 00:00:00 20.430,00 ASKES, PT
Hexymer 2 Mg Tab (THP) 14.340,00
Lansoprazole kapsul 30 m 11.550,00
Retaphyl SR Tab 14.740,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 29.220,00
thyrozol 5 mg 8.260,00
Total 122.700,00
17 Vinda Dwi Utari LUBUK BENTO 182382 Abbocath 20 Terumo @5
06/02/2021 00:00:00 11.138,00 ASKES, PT
Abu (Serum Anti Bisa Ul 295.250,00
CTM (Klorfeniramina mal 87,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Total 349.932,00
18 Adha SUNGAI LINTANG 144634 Amlodipine 5 mg @30 T
10/02/2021 00:00:00 3.030,00 ASKES, PT
Cetirgi Tab 10 mg 30.960,00
Total 33.990,00
19 Sri Rahayu KOTA PRAJA 129208 Abbocath 22 Terumo @5
11/02/2021 00:00:00 11.138,00 ASKES, PT
azitromicin inj 500 mg 144.376,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Neurodex tablet 1.482,00
Paracetamol tablet 500 m 600,00
Transfusi Set Terumo 16.500,00
Vectrine Tab 300 mg 10.000,00
Vitamin C 500 mg 2,00
Azitromycin 500 mg
13/02/2021 00:00:00 11.250,00
Ceftriaxone Inj 24.996,00
NACL 0,9 % 500 ml 25.650,00
Neurodex tablet 2.223,00
Paracetamol tablet 500 m 800,00
vestein 300 mg 9.350,00
Vitamin C 500 mg 3,00
Zinc Sulfate Syr 60 ml 13.707,00
Total 311.294,00
20 Ajumali BANDAR RATU 118683 Metformin tablet 500 mg
14/02/2021 00:00:00 1.330,00 ASKES, PT
Vitamin B Komplek @100 1.540,00
Total 2.870,00
21 Iis Herawati DANAU NIBUNG 130346 Abbocath 20 Terumo @5
16/02/2021 00:00:00 26.341,00 ASKES, PT
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 69.648,00
22 Mardiana PENARIK 167606 Alprazolam 0,5 mg @100
17/02/2021 00:00:00 590,00 ASKES, PT
Amlodipine 5 mg @30 T 1.515,00
Bisoprolol 5 mg @100 Ta 4.440,00
Omeprazol kapsul 20 mg 6.610,00
Total 13.155,00
23 Surya Darma ujung padang 109809 Aminoleban inf 500 ml
19/02/2021 00:00:00 177.426,00 ASKES, PT

19/08/2021 12:42:30 Page 7 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
23 Surya Darma ujung padang 109809 Curcuma Tab
19/02/2021 00:00:00 3.810,00 ASKES, PT
Curcuma Tab 12.700,00
Esomeprazol Injeksi 40 m 34.956,00
Flunarizine 5 mg tab 4.950,00
Flunarizine 5 mg tab 9.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 17.100,00
Neurodex tablet 1.482,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Perifas @100 Tab 5.775,00
Perifas @100 Tab 7.700,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 462,00
Aminoleban inf 500 ml
20/02/2021 00:00:00 88.713,00
Curcuma Tab 3.810,00
Dimenhidrinat tab 50 mg 414,00
Esomeprazol Injeksi 40 m 34.956,00
Flunarizine 5 mg tab 4.950,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 600,00
Perifas @100 Tab 5.775,00
Betahistin Mesilat 6 mg @
21/02/2021 00:00:00 1.380,00
Flunarizine 5 mg tab 24.750,00
Hypafix 10cm x 5cm (25 c 9.700,00
Total 557.596,00
24 Ramon Hosky DANAU NIBUNG 123514 Chromic catgut 1 R (Tri
21/02/2021 00:00:00 78.875,00 ASKES, PT
Chromic catgut 3-0 R (Tr 66.250,00
Cuticell Classic 10cmx10c 35.121,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Pehacain Injeksi 3.320,00
Silk 3/0 C scimitar 67.750,00
Tetagam 1 Ml Injeksi 184.000,00
Total 445.866,00
25 Indra Neli TIRTA MULYA 180790 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 ASKES, PT
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 117.340,00
26 Rusmi ujung padang 118365 Ketorolac inj 30 mg/1ml
24/02/2021 00:00:00 4.035,00 ASKES, PT
NonWoven Fixation 10x 4.815,00
OMZ 270.000,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 1.000,00

19/08/2021 12:42:30 Page 8 of 1855

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
26 Rusmi ujung padang 118365 Ringer Laktat Otsuka
24/02/2021 00:00:00 28.614,00 ASKES, PT
Alprazolam 1 mg @100 T
25/02/2021 00:00:00 160,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Ketorolac inj 30 mg/1ml 1.345,00
Omeprazole Inj 12.499,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 9.538,00
Urinter Kapsul @100 cap 4.396,00
Alprazolam 1 mg @100 T
26/02/2021 00:00:00 160,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazol kapsul 20 mg 661,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 4.396,00
Alprazolam 1 mg @100 T
27/02/2021 00:00:00 1.600,00
Candesartan tab 8 mg 3.405,00
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Total 513.293,00
27 Bustam Bustomo PENARIK 123901 abbocath 18 Terumo @5
25/02/2021 00:00:00 26.341,00 ASKES, PT
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 R (Sc 88.798,00
Cefotaxime Injeksi 5.751,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
methyl ergometrin amp 8.662,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Omeprazol kapsul 20 mg 661,00
Ondansetron Inj 3.300,00
Polypropylene 3/0 C (Ass 235.200,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
27 Bustam Bustomo PENARIK 123901 Spinocain 27 (BBraund)
25/02/2021 00:00:00 47.875,00 ASKES, PT
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
viamac 1 R 364.370,00
Abbocath 20 Terumo @5
26/02/2021 00:00:00 79.023,00
Catgut Chromic 2/0 Roll ( 188.100,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 1.535,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Levofloxacin Tablet 500 m 13.640,00
NonWoven Fixation 15x 13.388,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 2.000,00
Polypropylene 3/0 C (Ass 235.200,00
Propofol Lipuro 1% 75.900,00
Provein 4/0 R (Scimitar) @ 146.899,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj 12.498,00
Chromic catgut 3-0 R (Tr 66.250,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Levofloxacin Tablet 500 m 13.640,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Total 2.851.377,00
28 Bulan Humaira Hakiki SIDO MAKMUR 150807 Paracetamol Infus
27/02/2021 00:00:00 14.438,00 ASKES, PT
Pharmafix 10x50 cm (Hy 4.850,00
Cefixime syrup 100mg/5 M
28/02/2021 00:00:00 23.823,00
Diazepam Tab 5 Mg 272,00
Cefixime syrup 100mg/5 M
01/03/2021 00:00:00 23.823,00
Diazepam Tab 5 Mg 136,00

19/08/2021 12:42:30 Page 10 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
28 Bulan Humaira Hakiki SIDO MAKMUR 150807 Paracetamol syrup
01/03/2021 00:00:00 1.388,00 ASKES, PT
Total 68.730,00
29 Amriadi KOTA PRAJA 120116 Abbocath 20 Terumo @5
27/02/2021 00:00:00 26.341,00 ASKES, PT
Amlodipine 5 mg @30 T 101,00
Amlodipine 5 mg @30 T 303,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Pharmafix 10x50 cm (Hy 4.850,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 14.025,00
Tramadol 50 mg/ml Inj 12.375,00
Amlodipine 5 mg @30 T
28/02/2021 00:00:00 101,00
Ceftriaxone Inj 12.498,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Amlodipine 10 mg @50 T
01/03/2021 00:00:00 590,00
Cefixime Kapsul 100 mg 9.380,00
Sucralfate Suspensi 100 m 19.250,00
Total 247.640,00
30 Sukemi Haryono AGUNG JAYA 119891 Ambroxol Syr 15mg/ml
04/03/2021 00:00:00 4.538,00 ASKES, PT
Ceftriaxone Inj 12.498,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
NACL 0,9 % 500 ml 17.100,00
Novo Twist 32 G Tip 3.856,00
Novorapid Flexpen 108.750,00
Asam Folat 1 mg @100 T
05/03/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 10 % 9.375,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Mikro (Gea) 7.861,00
NACL 0,9 % 500 ml 8.550,00
Novo Twist 32 G Tip 3.856,00
Novorapid Flexpen 217.500,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 47.690,00
Candesartan tab 8 mg
06/03/2021 00:00:00 681,00
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 4.950,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 5.775,00
Ringer Laktat Otsuka 9.538,00
Candesartan tab 8 mg
07/03/2021 00:00:00 681,00
Flunarizine 5 mg tab 4.950,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 11 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
30 Sukemi Haryono AGUNG JAYA 119891 Ringer Laktat Otsuka
07/03/2021 00:00:00 28.614,00 ASKES, PT
Ambroxol Syr 15mg/ml
08/03/2021 00:00:00 4.538,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 4.950,00
Hypafix 15cmx5cm (25 c 13.088,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 5.775,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Candesartan tab 8 mg
09/03/2021 00:00:00 3.405,00
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Total 764.311,00
31 Razha Pujangga Rons BANDARATU 176658 Cefixime syrup 100mg/5 M
05/03/2021 00:00:00 23.823,00 ASKES, PT
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol syrup 1.388,00
Tetagam 1 Ml Injeksi 184.000,00
Total 233.980,00
32 Panca Irawan BANDARATU 151148 Abbocath 20 Terumo @5
06/03/2021 00:00:00 26.341,00 ASKES, PT
Ibuprofen tab 400 mg 1.374,00
Infusion Makro (terumo) 27.225,00
Isosorbid dinitrat 5 mg (I 111,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Total 88.713,00
33 Teti Marlina DANAU NIBUNG 154738 Abbocath 20 Terumo @5
07/03/2021 00:00:00 26.341,00 ASKES, PT
Aqua Pro Injeksi 3.575,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Antrain Injeksi
08/03/2021 00:00:00 28.875,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 8.626,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 16.500,00
Omeprazol kapsul 20 mg
09/03/2021 00:00:00 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 82.500,00
Vitamin B Komplek @100 1.540,00
Total 307.577,00
34 Mulyanti TANAH REKAH 182980 Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00 ASKES, PT

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
34 Mulyanti TANAH REKAH 182980 Hypafix 15cmx5cm (25 c
10/03/2021 00:00:00 6.544,00 ASKES, PT
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 103.047,00
35 Mulyadi M LUBUK PINANG 110596 Avamys
15/03/2021 00:00:00 129.000,00 ASKES, PT
Cetirizine 10 mg 1.260,00
Methylprednisolone tab 4 2.630,00
Total 132.890,00
36 Iras UJUNG PADANG 183166 Abbocath 20 Terumo @5
20/03/2021 00:00:00 26.341,00 ASKES, PT
Amlodipine 10 mg @50 T 118,00
Captopril 12,5 mg 320,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 1.650,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Rofiden Supp 12.031,00
Amlodipine 10 mg @50 T 1.180,00
Captopril 12,5 mg 960,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Ibuprofen tab 200 mg 398,00
Metoclopramide inj 5Mg/M 17.637,00
Ranitidin inj 3.580,00
Amlodipine 10 mg @50 T
21/03/2021 00:00:00 1.180,00
Captopril 12,5 mg 3.200,00
Ciprofloxacin tab 500 mg 5.590,00
Ibuprofen tab 400 mg 4.580,00
Metoclorapamide tab 10 m 1.510,00
Ranitidin inj 3.580,00
Total 143.116,00
37 Nazwa Iqrami Sakinah BANDARATU 183204 Abbocath 20 Terumo @5
22/03/2021 00:00:00 26.341,00 ASKES, PT
Abbocath 22 Terumo @5 22.276,00
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Hypafix 10cm x 5cm (25 c
23/03/2021 00:00:00 4.850,00
Antasida Syrup 60 ml 2.736,00
Ceftriaxone Inj 12.498,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Cefotaxime Injeksi
24/03/2021 00:00:00 11.502,00

19/08/2021 12:42:30 Page 13 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
37 Nazwa Iqrami Sakinah BANDARATU 183204 Hypafix 15cmx5cm (25 c
24/03/2021 00:00:00 13.088,00 ASKES, PT
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
PARAMOL INFUS 96.250,00
Ranitidin inj 3.580,00
Antasida Syrup 60 ml
25/03/2021 00:00:00 2.736,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Thiampenicol 500 mg @10 18.150,00
Total 381.916,00
38 Sumarlin SUNGAI JERINJING 135814 Abbocath 20 Terumo @5
23/03/2021 00:00:00 26.341,00 ASKES, PT
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Levofloxacin Tablet 500 m
24/03/2021 00:00:00 1.364,00
NonWoven Fixation 10x 9.630,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Neurodex tablet
25/03/2021 00:00:00 7.410,00
Ofloxacin Tab 200 mg 2.670,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 231.954,00
39 Dewi Rosa Yuana BANDARATU 126724 Abbocath 20 Terumo @5
23/03/2021 00:00:00 26.341,00 ASKES, PT
Amlodipine 10 mg @50 T 318,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
KSR (potassium chloride) 6.909,00
Mecobalamin 500 mg 1.540,00
NACL 0,9 % 500 ml 8.550,00
Otsu KCL 4.029,00
Ringer Laktat Otsuka 9.538,00
Valsartan tab 80 mg 4.125,00
Total 131.998,00
40 Zidane PIAN TOKUNG 159108 Amoxicillin Syr
25/03/2021 00:00:00 6.531,00 ASKES, PT
Paracetamol syrup 1.388,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 7.919,00
41 Kasan Bisri BANDARATU 126209 Abbocath 20 Terumo @5
25/03/2021 00:00:00 26.341,00 ASKES, PT
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Curcuma Tab
26/03/2021 00:00:00 2.540,00
Hypafix 15cmx5cm (25 c 19.632,00
Neurodex tablet 7.410,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Antasida Syrup 60 ml
27/03/2021 00:00:00 2.736,00
Neurodex tablet 11.115,00
Ranitidine tablet 150 mg 1.440,00
Total 177.751,00
42 Dian Eka Wati DANAU NIBUNG 117183 Abbocath 20 Terumo @5
26/03/2021 00:00:00 26.341,00 ASKES, PT
Cefixime syrup 100mg/5 M 23.823,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 1.650,00
Paracetamol syrup 1.388,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Total 106.853,00
43 Itmawita INDRAPURA 183421 Betahistin Mesilat 6 mg @
31/03/2021 00:00:00 414,00 ASKES, PT
Flunarizine 5 mg tab 2.475,00
Hypafix 10cm x 5cm (25 c 9.700,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 0,00
Zink Tablet 689,00
Betahistin Mesilat 6 mg @
01/04/2021 00:00:00 414,00
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 2.475,00
Glukosa Infus 5 % 17.252,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 1.790,00
Zink Tablet 689,00
Betahistin Mesilat 6 mg @
02/04/2021 00:00:00 552,00
Ceftriaxone Inj 6.249,00
Flunarizine 5 mg tab 2.475,00
Hypafix 10cm x 5cm (25 c 9.700,00
Metoclopramide inj 5Mg/M 23.516,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 0,00

19/08/2021 12:42:30 Page 15 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
43 Itmawita INDRAPURA 183421 Betahistin Mesilat 6 mg @
03/04/2021 00:00:00 1.380,00 ASKES, PT
Cefixime Kapsul 100 mg 9.380,00
Flunarizine 5 mg tab 24.750,00
Furamin Injeksi 57.476,00
Glukosa Infus 5 % 17.252,00
Nucral Syrup 100 ml 53.350,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 2.000,00
Piralen Injeksi 2 ml 35.200,00
Zink Tablet 2.067,00
Zink Tablet 6.890,00
Total 376.676,00
44 Watri Aminita PAUH TERENJA 127302 abbocath 18 Terumo @5
31/03/2021 00:00:00 26.341,00 ASKES, PT
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole Infus 30.939,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 35.475,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 53.555,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 37.124,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 37.500,00
Masker 3 Play N. 95 37.500,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 25.650,00
Nassal Cannula O2 Anak 16.473,00
Ondansetron Inj 3.300,00

19/08/2021 12:42:30 Page 16 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
44 Watri Aminita PAUH TERENJA 127302 Ondansetron Inj
31/03/2021 00:00:00 8.250,00 ASKES, PT
Pharmafix 10x50 cm (Hy 9.700,00
Phytomenadione 2 Mg/1M 4.834,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suction Chateter no. 8 (R 20.625,00
Suction no. 1/4 25.950,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 6.796,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 9.263,00
Cefotaxime Injeksi
01/04/2021 00:00:00 17.253,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Ketorolac inj 30 mg/1ml 5.380,00
Metrodinazole Infus 41.252,00
Phytomenadione 2 Mg/1M 4.834,00
Protocin Inj 28.215,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 12.630,00
Tranexamic Acid Inj (Asa 8.420,00
Abbocath 22 Terumo @5
02/04/2021 00:00:00 33.414,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 15cmx5cm (25 c 13.088,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole Infus 30.939,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
03/04/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 2.295.106,00
45 Abd Muluk LUBUK PINANG 129454 Abbocath 22 Terumo @5
04/04/2021 00:00:00 11.138,00 ASKES, PT
Ambroxol Syr 15mg/ml 4.538,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 10x 4.815,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 17 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
45 Abd Muluk LUBUK PINANG 129454 Paracetamol tablet 500 m
04/04/2021 00:00:00 800,00 ASKES, PT
Ringer Laktat Otsuka 9.538,00
Total 88.001,00
46 Abdul Muluk LUBUK PINANG 116835 Ambroxol Syr 15mg/ml
06/04/2021 00:00:00 4.538,00 ASKES, PT
Omeprazole Inj 24.998,00
Total 29.536,00
47 Abd Muluk LUBUK PINANG 129454 Ceftriaxone Inj
05/04/2021 00:00:00 12.498,00 ASKES, PT
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 19.076,00
Cefixime Kapsul 100 mg
06/04/2021 00:00:00 9.380,00
Cefixime Kapsul 100 mg 9.380,00
Metoclopramide Tab 5 m 1.510,00
Metoclorapamide tab 10 m 1.510,00
Paracetamol tablet 500 m 2.000,00
Ranitidine tablet 150 mg 1.440,00
Ranitidine tablet 150 mg 1.440,00
Total 98.682,00
48 Sukasni TANAH REKAH 127806 Alprazolam 0,5 mg @100
11/04/2021 00:00:00 118,00 ASKES, PT
Ambroxol 30 mg @100 T 579,00
Ceftriaxone Inj 12.498,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 645,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Simvastatin tab 10 mg 241,00
Tramadol 50 mg/ml Inj 12.375,00
Levofloxacin Infus
12/04/2021 00:00:00 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 645,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 20 mg 311,00
Alprazolam 0,5 mg @100
13/04/2021 00:00:00 118,00
Aminofluid Infus 500 ml 155.204,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 645,00
Simvastatin tab 10 mg 241,00
Sucralfate Suspensi 100 m 19.250,00
Alprazolam 0,5 mg @100
14/04/2021 00:00:00 1.180,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 4.300,00
Simvastatin tab 10 mg 2.410,00
Total 374.431,00
49 Singgih Suggiyanto AIR MANJUNTO 108642 Alprazolam 0,5 mg @100
13/04/2021 00:00:00 354,00 ASKES, PT
Alprazolam 0,5 mg @100 354,00
Total 708,00

19/08/2021 12:42:30 Page 18 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
50 M.akbar Yudha Nasuh BANDARATU 183740 Nebulizer O2 Anak
14/04/2021 00:00:00 18.219,00 ASKES, PT
Ventolin Nebules 2.5 mg 15.000,00
Total 33.219,00
51 Sigaryadi PONDOK PANJANG 166256 Abbocath 22 Terumo @5
18/04/2021 00:00:00 22.276,00 ASKES, PT
Ambroxol 30 mg @100 T 579,00
Aminofluid Infus 500 ml 155.204,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Furamin Injeksi 28.738,00
Infusion Makro (terumo) 54.450,00
Nassal Cannula O2 Anak 16.473,00
NonWoven Fixation 10x 4.815,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Total 342.293,00
52 Gunawan TIRTA MAKMUR 110961 Abbocath 20 Terumo @5
19/04/2021 00:00:00 26.341,00 ASKES, PT
glimepiride tab 4 mg 5.000,00
Infusion Makro (terumo) 27.225,00
Metformin tablet 500 mg 1.330,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Total 75.140,00
53 Marzuki KAMPUNG DALAM 094337 Aspilet 80 mg @100 mg
20/04/2021 00:00:00 4.140,00 ASKES, PT
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Ranitidine tablet 150 mg 1.930,00
Simvastatin tab 10 mg 7.230,00
Total 90.820,00
54 Syahbani UJUNG PADANG 123212 Amlodipine 10 mg @50 T
26/04/2021 00:00:00 118,00 ASKES, PT
Amlodipine 5 mg @30 T 1.010,00
Captopril 12,5 mg 1.600,00
Captopril 25 mg 600,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 5 % 24.002,00
Hypafix 15cmx5cm (25 c 6.544,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 35.274,00
Metoclorapamide tab 10 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Pantoprazole Inj 25.713,00
Total 122.284,00
55 Mawi UJUNG PADANG 110466 Alprazolam 0,5 mg @100
29/04/2021 00:00:00 2.360,00 ASKES, PT
Amlodipine 5 mg @30 T 3.030,00
Bisoprolol 5 mg @100 Ta 5.920,00
Candesartan tab 8 mg 20.430,00
Miniaspi 80 Mg @100 Ta 3.750,00
Ranitidine tablet 150 mg 3.860,00
Simvastatin tab 20 mg 6.220,00

19/08/2021 12:42:30 Page 19 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 45.570,00
56 Nurmisam UJUNG PADANG 110659 Alprazolam 0,5 mg @100
29/04/2021 00:00:00 2.360,00 ASKES, PT
Amlodipine 5 mg @30 T 3.030,00
Bisoprolol 5 mg @100 Ta 5.920,00
Candesartan tab 8 mg 13.620,00
Candesartan tab 8 mg 6.810,00
Miniaspi 80 Mg @100 Ta 3.750,00
Ranitidine tablet 150 mg 3.860,00
Simvastatin tab 20 mg 9.330,00
Total 48.680,00
57 Nurdin Syarif BANDARATU 132217 Abbocath 22 Terumo @5
30/04/2021 00:00:00 11.138,00 ASKES, PT
Atropin injek 1 ml 13.938,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 52.250,00
Norepinephrine Inj 30.938,00
Urine bag 9.263,00
Total 305.589,00
58 Yuzarman LUBUK PINANG 131294 abbocath 18 Terumo @5
30/04/2021 00:00:00 52.682,00 ASKES, PT
Amlodipine 10 mg @50 T 118,00
Candesartan Tab 16 mg 1.179,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 5.380,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Ranitidin inj 3.580,00
Abbocath 22 Terumo @5
01/05/2021 00:00:00 22.276,00
Amlodipine 10 mg @50 T 118,00
Candesartan Tab 16 mg 1.179,00
Ciprofloxacin infus 2% 48.126,00
Infusion Makro (terumo) 54.450,00
Ketorolac inj 30 mg/1ml 2.690,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Amlodipine 10 mg @50 T
02/05/2021 00:00:00 118,00
Candesartan Tab 16 mg 1.179,00
Ciprofloxacin tab 500 mg 1.677,00
Ketoprofen tab 100 mg 3.714,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 9.538,00
Amlodipine 5 mg @30 T
03/05/2021 00:00:00 725,00
Candesartan Tab 16 mg 28.875,00
Ciprofloxacin tab 500 mg 5.590,00
Hypafix 15cmx5cm (25 c 13.088,00

19/08/2021 12:42:30 Page 20 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
58 Yuzarman LUBUK PINANG 131294 Ketoprofen tab 100 mg
03/05/2021 00:00:00 12.380,00 ASKES, PT
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Total 446.471,00
59 Rubiyono TANAH HARAPAN 123004 abbocath 18 Terumo @5
07/05/2021 00:00:00 26.341,00 ASKES, PT
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00
Infusion set Mikro (Terumo 18.026,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 25.650,00
Nassal Cannula O2 Dewas 11.749,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Transfusi Set Terumo 16.500,00
Total 305.633,00
60 Naufal Adzaki SUNGAI GADING 145341 Cefixime syrup 100mg/5 M
07/05/2021 00:00:00 23.823,00 ASKES, PT
Ceftriaxone Inj 12.498,00
Domperidone Syrup 5mg 10.279,00
Ka-En 1 B 37.974,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.150,00
Vitamin C tablet @100 Ta 1.380,00
Zink Tablet 689,00
Amoxicillin Syr
08/05/2021 00:00:00 6.531,00
Total 100.274,00
61 Rubiyono TANAH HARAPAN 123004 abbocath 18 Terumo @5
08/05/2021 00:00:00 52.682,00 ASKES, PT
Amlodipine 5 mg @30 T 101,00
Asam Folat 1 mg @100 T 297,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 681,00
Catheter 2 Way No. 18 ( 31.251,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 39.984,00
Furosemide Injeksi @2ml 13.328,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Methylprednisolone Inje 104.769,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Ranitidin inj 3.580,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 21 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
61 Rubiyono TANAH HARAPAN 123004 Urine bag
08/05/2021 00:00:00 9.263,00 ASKES, PT
Ceftriaxone Inj
09/05/2021 00:00:00 12.498,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 28.322,00
Methylprednisolone Inje 69.846,00
Ondansetron Inj 3.300,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 19.076,00
Amlodipine 5 mg @30 T
10/05/2021 00:00:00 101,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 11.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Methylprednisolone Inje 104.769,00
Metoclopramide inj 5Mg/M 21.657,00
Opilax Syr 49.156,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 0,00
abbocath 18 Terumo @5
11/05/2021 00:00:00 26.341,00
Candesartan tab 8 mg 6.810,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide 40 mg Tablet 1.440,00
Methylprednisolone Inje 34.923,00
Metoclopramide inj 5Mg/M 7.219,00
Opilax Syr 49.156,00
Ranitidine tablet 150 mg 1.930,00
Spironolaktone 100 mg 10.785,00
Total 1.049.423,00
62 Hamzah TANJUNG HARAPAN 184122 Candesartan tab 8 mg
13/05/2021 00:00:00 681,00 ASKES, PT
Infusion Makro (terumo) 27.225,00
KSR (potassium chloride) 2.303,00
Amlodipine 5 mg @30 T
14/05/2021 00:00:00 101,00
Aspilet 80 mg @100 mg 138,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 24.996,00
Ketorolac inj 30 mg/1ml 10.760,00
KSR (potassium chloride) 2.303,00
Omeprazole Inj 16.500,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Amlodipine 5 mg @30 T
15/05/2021 00:00:00 145,00
Aspilet 80 mg @100 mg 138,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 24.996,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 12.105,00
KSR (potassium chloride) 2.303,00
Nystatin Drop 27.830,00

19/08/2021 12:42:30 Page 22 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
62 Hamzah TANJUNG HARAPAN 184122 Omeprazole Inj
15/05/2021 00:00:00 16.500,00 ASKES, PT
Ringer Laktat Otsuka 76.304,00
Aspilet 80 mg @100 mg
16/05/2021 00:00:00 276,00
Candesartan tab 8 mg 1.362,00
Ceftriaxone Inj 12.498,00
Ketorolac inj 30 mg/1ml 10.760,00
Ketorolac inj 30 mg/1ml 10.760,00
KSR (potassium chloride) 4.606,00
Metrodinazole tab 500 m 1.716,00
Omeprazole Inj 33.000,00
Ringer Laktat Otsuka 28.614,00
abbocath 18 Terumo @5
17/05/2021 00:00:00 79.023,00
Amlodipine 5 mg @30 T 505,00
Asam Mefenamat 500 m 1.935,00
Aspilet 80 mg @100 mg 690,00
Ciprofloxacin tab 500 mg 5.590,00
Hypafix 15cmx5cm (25 c 19.632,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
KSR (potassium chloride) 11.515,00
Nystatin Drop 27.830,00
Total 561.900,00
63 Hajah Istiyanah PONDOK TENGAH 141880 Catheter 2 Way No. 16 (
17/05/2021 00:00:00 20.625,00 ASKES, PT
Cefixime Kapsul 100 mg 9.840,00
Chromic catgut 2-0 R (Tr 144.500,00
Lidocain injk 40 mg/2 ml 4.833,00
Metrodinazole tab 500 m 1.287,00
Metrodinazole tab 500 m 6.435,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 645,00
Phytomenadione 2 Mg/1M 5.363,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 15.162,00
umbilical Cord Clamp 2.261,00
Vitamin B Komplek @100 1.540,00
Total 249.616,00
64 Laili Suryani BANDARATU 119935 abbocath 18 Terumo @5
20/05/2021 00:00:00 26.341,00 ASKES, PT
Antasida Doen 400 mg @ 225,00
Aqua Pro Injeksi 3.575,00
Betahistin Mesilat 6 mg @ 414,00
Flunarizine 5 mg tab 2.475,00
Glukosa Infus 5 % 24.002,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 21.657,00
NACL 0,9 % 500 ml 34.200,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 33.000,00
Paracetamol tablet 500 m 645,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Total 218.779,00
65 Hadi Sukamto TANJUNG BERINGIN I 156085 Bunascan Spinal 0.5
21/05/2021 00:00:00 63.525,00 ASKES, PT

19/08/2021 12:42:30 Page 23 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
65 Hadi Sukamto TANJUNG BERINGIN I 156085 catheter 2 Way No. 18 (G
21/05/2021 00:00:00 20.906,00 ASKES, PT
Ceftriaxone Inj 12.498,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Tali 41.600,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 16.500,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 10.108,00
Transfusi Set Terumo 16.500,00
Urine bag 9.263,00
Ceftriaxone Inj
22/05/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole Infus 30.939,00
Metrodinazole Infus 20.626,00
Metrodinazole tab 500 m 0,00
Omeprazole Inj 16.500,00
Otsu Nacl PiggyBack 100 m 18.975,00
Ringer Laktat Otsuka 28.614,00
abbocath 18 Terumo @5
24/05/2021 00:00:00 79.023,00
abbocath 18 Terumo @5 79.023,00
Cefixime Kapsul 100 mg 9.840,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 12.001,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 16.500,00
Paracetamol tablet 500 m 4.300,00
Ringer Laktat Otsuka 9.538,00
Total 1.176.061,00
66 Darmadi LUBUK GEDANG 120729 Amlodipine 10 mg @50 T
21/05/2021 00:00:00 3.540,00 ASKES, PT
Cilostazol 100 mg @100 T 352.680,00
Citicoline kaplet 500 mg 115.500,00
Ranitidine tablet 150 mg 1.930,00

19/08/2021 12:42:30 Page 24 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 473.650,00
67 Zasmili Inda Roza UJUNG PADANG 126150 Ambroxol 30 mg @100 T
21/05/2021 00:00:00 2.480,00 ASKES, PT
Cetirizine 10 mg 1.475,00
Dexametason 0,5 mg Ta 1.025,00
Nassal Cannula O2 Dewas 11.749,00
Nebulizer O2 Dewasa 34.783,00
Pulmicort Resp 0.25 mg/ 0 17.884,00
Salbutamol 4 mg 930,00
Ventolin Nebules 2.5 mg 15.000,00
Total 85.326,00
68 Muhammad Ali LUBUK PINANG 158360 Abbocath 20 Terumo @5
25/05/2021 00:00:00 26.341,00 ASKES, PT
Ascorbid Acid 200mg/ml 44.550,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.749,00
NonWoven Fixation 15x 13.388,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 860,00
Phytomenadione 10 Mg/1 5.959,00
Ranitidin inj 3.580,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 15.162,00
vestein 300 mg 9.350,00
Vitamin B Komplek @100 308,00
Zink Tablet 689,00
Total 319.672,00
69 Aandriadi TANAH REKAH 155738 abbocath 18 Terumo @5
26/05/2021 00:00:00 26.341,00 ASKES, PT
Amlodipine 10 mg @50 T 236,00
Aqua Pro Injeksi 3.575,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Nucral Syrup 100 ml 53.350,00
Omeprazole Inj 16.500,00
Paracetamol tablet 500 m 645,00
Ringer Laktat Otsuka 28.614,00
Vitamin B Komplek @100 462,00
Total 177.861,00
70 Ijal SILAUT 135099 abbocath 18 Terumo @5
03/06/2021 00:00:00 26.341,00 ASKES, PT
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
Ringer Laktat Otsuka 19.076,00
Urinter Kapsul @100 cap 4.396,00
Total 86.272,00
71 Rumini SINAR JAYA 184531 abbocath 18 Terumo @5
03/06/2021 00:00:00 26.341,00 ASKES, PT
Amlodipine 5 mg @30 T 101,00

19/08/2021 12:42:30 Page 25 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
71 Rumini SINAR JAYA 184531 Candesartan tab 8 mg
03/06/2021 00:00:00 681,00 ASKES, PT
Flunarizine 5 mg tab 4.950,00
Infusion Makro (terumo) 27.225,00
Loperamide HCL tab 2 m 300,00
Nassal Cannula O2 Dewas 11.749,00
Omeprazole Inj 16.500,00
Paracetamol tablet 500 m 645,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Zink Tablet 1.378,00
Amlodipine 5 mg @30 T
04/06/2021 00:00:00 145,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 4.950,00
Hypafix 10cm x 5cm (25 c 9.700,00
Loperamide HCL tab 2 m 1.500,00
Omeprazole Inj 16.500,00
Ringer Laktat Otsuka 19.076,00
Zink Tablet 689,00
Amlodipine 5 mg @30 T
05/06/2021 00:00:00 725,00
Candesartan tab 8 mg 3.405,00
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 3.225,00
Sucralfate Suspensi 100 m 19.250,00
Zink Tablet 3.445,00
Total 261.578,00
72 Heni Ridiarti PASAR BELAKANG 112385 abbocath 18 Terumo @5
09/06/2021 00:00:00 52.682,00 ASKES, PT
Betahistin Mesilat 6 mg @ 414,00
Cefotaxime Injeksi 11.502,00
Farmalat Tab ( Nifedipin 1 1.044,00
Infusion Makro (terumo) 27.225,00
Nassal Cannula O2 Dewas 11.749,00
NonWoven Fixation 15x 13.388,00
Paracetamol Infus 31.281,00
Ringer Laktat Otsuka 28.614,00
Total 177.899,00
73 Susi Susanti TERAS TERUNJAM 184648 abbocath 18 Terumo @5
10/06/2021 00:00:00 26.341,00 ASKES, PT
Aspilet 80 mg @100 mg 138,00
Captopril 12,5 mg 160,00
Captopril 12,5 mg 800,00
Furosemide Injeksi @2ml 9.996,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
Ranitidin inj 3.580,00
Ranitidin inj 3.580,00
Ranitidine tablet 150 mg 1.930,00
Spironolaktone 100 mg 2.157,00
Spironolaktone 25 mg 4.560,00
Sucralfate Suspensi 100 m 19.250,00
Urine bag 9.263,00

19/08/2021 12:42:30 Page 26 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
73 Susi Susanti TERAS TERUNJAM 184648 Aspilet 80 mg @100 mg
11/06/2021 00:00:00 138,00 ASKES, PT
Captopril 12,5 mg 1.600,00
Furosemide Injeksi @2ml 49.980,00
Pharmafix 15x50 (Hypap 19.632,00
Ranitidine tablet 150 mg 1.930,00
Spironolaktone 25 mg 5.200,00
Total 221.660,00
74 Rosmawati SERAMI BARU 184773 Cefixime Kapsul 100 mg
15/06/2021 00:00:00 9.840,00 ASKES, PT
Dexametason 0,5 mg Ta 2.050,00
Tarivid otic 5 ml 105.900,00
Total 117.790,00
75 Silya Wana BANDARATU 117469 Atorvastatin 20 mg @30 T
23/01/2021 00:00:00 10.450,00 BPJS
Calcium Laktat 790,00
Cefixime Kapsul 100 mg 9.380,00
Clonidine 0.15 mg @100 T 1.145,00
Psidii Capsule 500 mg 39.208,00
Tambah Darah Neo Tab 4.650,00
Tranexamic Acid Inj (Asa 21.050,00
Total 86.673,00
76 Surati KOTA PRAJA 132066 Alkohol 1Liter
06/03/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 1.345,00
Lidocain injk 40 mg/2 ml 3.222,00
Masker Karet 11.000,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Oxytetracycline Salep Ma 3.251,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Polyglycolic Acid 1 R (dTe 227.000,00
Polyvinylidene 3-0 R (Tri 92.000,00

19/08/2021 12:42:30 Page 27 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
76 Surati KOTA PRAJA 132066 Protocin Inj
06/03/2021 00:00:00 18.810,00 BPJS
Protocin Inj 28.215,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 4.210,00
Total 1.434.907,00
77 Nofrianti LUBUK PINANG 142468 Fentanyl Injeksi 5 Ampul 2
13/03/2021 00:00:00 52.000,00 BPJS
Spinocain 27 (BBraund) 47.875,00
Total 99.875,00
78 Budiono ATAP SENG 146162 Furosemide Injeksi @2ml
05/03/2021 00:00:00 16.660,00 BPJS
Phytomenadione 2 Mg/1M 4.834,00
Total 21.494,00
79 Nida Putri LUBUK GEDANG 155032 Cefoperazon Inj
20/02/2021 00:00:00 82.500,00 BPJS
Induxin 1 ml Injeksi 18.562,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 19.076,00
Total 122.138,00
80 Yupita Sari PT AGRO MUKO TALA 115269 Cuticell Classic 10cmx10c
19/03/2021 00:00:00 35.121,00 BPJS
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 3.000,00
Total 74.801,00
81 Suminah MEKAR JAYA 160326 Abbocath 20 Terumo @5
28/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 10 % 9.375,00
Infusion set Mikro (Terumo 18.026,00
Metoclopramide inj 5Mg/M 5.879,00
Nassal Cannula O2 Anak 16.473,00
NonWoven Fixation 10x 4.815,00
OMZ 90.000,00
Otsu D40 25.026,00
Ringer Laktat Otsuka 9.538,00
Total 210.714,00
82 Sumiati SUKA RAMI 113194 Acetylcystein 200 mg Ka
30/04/2021 00:00:00 1.650,00 BPJS
Ascorbid Acid 1000mg/5m 26.125,00
azitromicin inj 500 mg 144.376,00
Levofloxacin Infus 48.976,00
Methylprednisolone Inje 69.846,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ventolin Nebules 2.5 mg 20.000,00

19/08/2021 12:42:30 Page 28 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
82 Sumiati SUKA RAMI 113194 Vitamin B Komplek @100
30/04/2021 00:00:00 154,00 BPJS
Total 343.321,00
83 Erawita Agradia Sapuhe BANDAR RATU 110422 abbocath 18 Terumo @5
29/04/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 89.501,00
84 Herlina Wani SUKA RAME 163015 Cefotaxime Injeksi
24/01/2021 00:00:00 11.502,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Biocombin 5000 Injeksi
25/01/2021 00:00:00 6.531,00
Total 34.043,00
85 Sadiyem TIRTA MULYA 174852 Omeprazole Inj
22/02/2021 00:00:00 12.499,00 BPJS
Amlodipine 5 mg @30 T 101,00
Citicoline Injeksi 125mg/ 11.250,00
Metformin tablet 500 mg 266,00
Omeprazole Inj 12.499,00
Total 36.615,00
86 Ibnu Sabil TANAH REKAH 155517 Anadium @30 Tab
02/01/2021 00:00:00 84.700,00 BPJS
Asam Folat 1 mg @100 T 594,00
Ascorbid Acid 1000mg/5m 156.750,00
Azitromycin 500 mg 33.750,00
Ceftriaxone Inj 24.996,00
Furosemide Injeksi @2ml 9.996,00
Neurodex tablet 7.410,00
Nuzym Kapsul 66.000,00
Pantoprazole Inj 93.500,00
Phytomenadione 10 Mg/1 35.754,00
Ringer Laktat Otsuka 57.228,00
Sulcolon Tablet 49.500,00
Tranexamic Acid Inj (Asa 12.630,00
Zinc Sulfate Syr 60 ml 4.569,00
Anadium @30 Tab
03/01/2021 00:00:00 25.410,00
Asam Folat 1 mg @100 T 297,00
Ascorbid Acid 1000mg/5m 78.375,00
azitromicin inj 500 mg 0,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 4.998,00
Opilax Syr 49.156,00
Pantoprazole Inj 46.750,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 16.500,00
Tranexamic Acid Inj (Asa 6.315,00
Zink Tablet 689,00
Omeprazol kapsul 20 mg
04/01/2021 00:00:00 3.305,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 29 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
86 Ibnu Sabil TANAH REKAH 155517 Vitamin C 500 mg
04/01/2021 00:00:00 5,00 BPJS
Total 968.916,00
87 Azura Kusradani PONDOK SUGUH 181662 Gips putih
11/05/2021 00:00:00 107.500,00 BPJS
Tensocrepe 15 x 4.5 cm ( 71.000,00
Total 178.500,00
88 Kholishoh LUNANG 179702 Amlodipine 5 mg @30 T
02/01/2021 00:00:00 1.010,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Furosemide 40 mg Tablet 960,00
Methylprednisolone tab 4 2.630,00
vestein syr 48.125,00
Total 63.225,00
89 Iskandar PENARIK 181690 azitromicin inj 500 mg
02/01/2021 00:00:00 288.752,00 BPJS
Furosemide Injeksi @2ml 1.666,00
Pantoprazole Inj 23.375,00
vestein 300 mg 14.025,00
Abbocath 22 Terumo @5
03/01/2021 00:00:00 22.276,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Extrace Injeksi 100 mg/m 28.875,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 25.650,00
Pantoprazole Inj 23.375,00
Phytomenadione 2 Mg/1M 14.502,00
Tranexamic Acid Inj (Asa 2.105,00
vestein 300 mg 102.850,00
Asam Mefenamat 500 m
04/01/2021 00:00:00 387,00
Ascorbid Acid 1000mg/5m 78.375,00
Cefixime kapsul 200 mg 26.480,00
Esomeprazol Injeksi 40 m 34.956,00
Extrace Injeksi 100 mg/m 67.375,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 10 Mg/1 35.754,00
vestein 300 mg 46.750,00
Asam Mefenamat 500 m
05/01/2021 00:00:00 1.935,00
Hypafix 10cm x 5cm (25 c 9.700,00
Salbutamol 4 mg 1.860,00
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 46.750,00
Total 990.837,00
90 Sardi BANDARATU 142491 Ambroxol Syr 15mg/ml
02/01/2021 00:00:00 4.538,00 BPJS
Antrain Injeksi 28.875,00
azitromicin inj 500 mg 721.880,00
Azitromycin 500 mg 5.625,00
Meropenem Inj 0.5 g 165.000,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Pantoprazole Inj 23.375,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 3.000,00
Perifas @100 Tab 3.850,00

19/08/2021 12:42:30 Page 30 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
90 Sardi BANDARATU 142491 Perifas @100 Tab
02/01/2021 00:00:00 19.250,00 BPJS
Ringer Laktat Otsuka 38.152,00
Sistenol kaplet 5.262,00
Sistenol kaplet 24.556,00
Total 1.081.925,00
91 Siti Komariah SELAGAN JAYA 120258 Antrain Injeksi
22/01/2021 00:00:00 28.875,00 BPJS
Phytomenadione 10 mg ( 2.802,00
Phytomenadione 10 Mg/1 17.877,00
Total 49.554,00
92 Wirdah RANAH KARYA 181725 Amlodipine 5 mg @30 T
02/01/2021 00:00:00 101,00 BPJS
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 6.810,00
Cefoperazon Inj 41.250,00
Citicoline kaplet 500 mg 16.500,00
Glukosa Infus 5 % 17.252,00
Ketorolac inj 30 mg/1ml 2.690,00
Pantoprazole Inj 23.375,00
Perifas @100 Tab 3.850,00
Perifas @100 Tab 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 151.009,00
93 risda br sagala PENARIK 111822 Atorvastatin 20 mg @30 T
02/01/2021 00:00:00 10.450,00 BPJS
Ketorolac inj 30 mg/1ml 10.760,00
Omeprazol kapsul 20 mg 6.610,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Urdahek 151.950,00
Total 227.634,00
94 Saidi BUKIT MAKMUR 181741 Abbocath 22 Terumo @5
02/01/2021 00:00:00 22.276,00 BPJS
Candesartan tab 8 mg 1.362,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Miniaspi 80 Mg @100 Ta 1.250,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 24.998,00
Piracetam injek 200 mg 23.100,00
Renax @50 Kapsul 22.688,00
Candesartan Tab 16 mg
03/01/2021 00:00:00 1.179,00
Candesartan tab 8 mg 681,00
Cefixime Kapsul 100 mg 1.876,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Citicoline Injeksi 125mg/ 45.000,00
Dulcolax Sup 10 mg 27.800,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00

19/08/2021 12:42:30 Page 31 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
94 Saidi BUKIT MAKMUR 181741 Omeprazole Inj
03/01/2021 00:00:00 24.998,00 BPJS
Piracetam injek 200 mg 5.775,00
Piracetam injek 200 mg 69.300,00
Renax @50 Kapsul 22.688,00
Renax @50 Kapsul 22.688,00
Atorvastatin 20 mg @30 T
04/01/2021 00:00:00 10.450,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 24.998,00
Piracetam injek 200 mg 23.100,00
Aspilet 80 mg @100 mg
05/01/2021 00:00:00 1.380,00
Atorvastatin 20 mg @30 T 10.450,00
Candesartan tab 8 mg 6.810,00
Cefixime Kapsul 100 mg 9.380,00
Citicoline kaplet 500 mg 16.500,00
Omeprazol kapsul 20 mg 6.610,00
Piralen tab 4.540,00
Renax @50 Kapsul 113.440,00
Total 874.457,00
95 Abu Daud AIR RAMI 171447 Abbocath 20 Terumo @5
02/01/2021 00:00:00 11.138,00 BPJS
Azitromycin 500 mg 5.625,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metformin tablet 500 mg 399,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 9.538,00
Zink Tablet 1.378,00
Total 136.981,00
96 Media Warismi PASAR MUKOMUKO 181743 Azitromycin 500 mg
02/01/2021 00:00:00 33.750,00 BPJS
Calcium Laktat 474,00
Ceftriaxone Inj 31.245,00
NACL 0,9 % 500 ml 25.650,00
Neurodex tablet 4.446,00
Ondansetron Inj 9.900,00
Pantoprazole Inj 93.500,00
Paracetamol Infus 86.628,00
Zinc Sulfate Syr 60 ml 4.569,00
Calcium Laktat
03/01/2021 00:00:00 79,00
Ceftriaxone Inj 12.498,00
Loremid Tab 5.752,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 23.375,00
Paracetamol Infus 43.314,00
Zink Tablet 1.378,00
Calcium Laktat
04/01/2021 00:00:00 790,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 32 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
96 Media Warismi PASAR MUKOMUKO 181743 Paracetamol tablet 500 m
04/01/2021 00:00:00 2.000,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Vectrine Tab 300 mg 50.000,00
Zink Tablet 6.890,00
Omeprazol kapsul 20 mg
05/01/2021 00:00:00 3.305,00
Omeprazole Inj 49.996,00
Paracetamol tablet 500 m 2.000,00
vestein 300 mg 46.750,00
Zink Tablet 6.890,00
Total 591.429,00
97 Fidiawati Pasar mukomuko 111187 Diazepam Tab 5 Mg
02/01/2021 00:00:00 544,00 BPJS
Eperisone Hcl 50 mg @1 23.280,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazol kapsul 20 mg 6.610,00
Total 36.978,00
98 Asmansyah SIBAK 140995 Dexametason Injeksi
02/01/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
NACL 0,9 % 500 ml 42.750,00
Transfusi Set Terumo 16.500,00
Total 68.576,00
99 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
02/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
100 Bahman SIBAK 155872 NACL 0,9 % 500 ml
02/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
101 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
02/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
102 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
02/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
103 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
02/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
104 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
02/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
105 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
02/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
106 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
02/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
107 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
02/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
108 Bustim PONDOK BARU 163473 NACL 0,9 % 500 ml
02/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
109 Bima Aryandika BANDARATU 178714 Abbocath 20 Terumo @5
02/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 10 mg @50 T 118,00
Asam Folat 1 mg @100 T 198,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00
Gabapentin kapsul 300 m 2.538,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 18.026,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00

19/08/2021 12:42:30 Page 33 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
109 Bima Aryandika BANDARATU 178714 Ondansetron Inj
02/01/2021 00:00:00 1.650,00 BPJS
Phenytoin Sodium Injeksi 47.733,00
Abbocath 22 Terumo @5 22.276,00
Amlodipine 10 mg @50 T 118,00
Asam Folat 1 mg @100 T 198,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 6.249,00
Extention Tube 8.801,00
Gabapentin kapsul 300 m 1.269,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Nicardipine HCl Inj 0,00
Ondansetron Inj 4.950,00
Osteor Plus @30 Kap 13.476,00
Pantoprazole Inj 23.375,00
Stesolid Inj 2 ml 25.959,00
Three Way stopcock 37.125,00
Clonidine 0.15 mg @100 T
03/01/2021 00:00:00 687,00
Glucosamine 250 mg 770,00
Ketorolac inj 30 mg/1ml 1.345,00
NACL 0,9 % 500 ml 0,00
Nicardipine HCl Inj 0,00
Phytomenadione 2 Mg/1M 14.502,00
Amlodipine 5 mg @30 T
04/01/2021 00:00:00 1.010,00
Asam Folat 1 mg @100 T 990,00
Candesartan Tab 16 mg 11.790,00
Cefadroxil tab 500 mg @1 10.500,00
Ceftriaxone Inj 6.249,00
Clonidine 0.15 mg @100 T 4.580,00
Gabapentin kapsul 300 m 12.690,00
Glucosamine 250 mg 7.700,00
Tambah Darah Neo Tab 4.650,00
Total 491.771,00
110 Racana SARI BULAN 181747 Abbocath 24 Terumo @5
02/01/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 17.253,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 28.614,00
Cefadroxil tab 500 mg @1
03/01/2021 00:00:00 10.500,00
Paracetamol tablet 500 m 2.000,00
Total 87.187,00
111 Abigail Alaika Azura AGUNG JAYA 181748 Amoxicillin Syr
02/01/2021 00:00:00 6.531,00 BPJS
Lidocain injk 40 mg/2 ml 1.611,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol syrup 1.388,00
Provein 4/0 C (Scimitar) @ 146.900,00
Tetagam 1 Ml Injeksi 184.000,00
Total 348.980,00
112 Martina PT.AGRO AIR DIKIT 181749 Abbocath 20 Terumo @5
02/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
112 Martina PT.AGRO AIR DIKIT 181749 NACL 0,9 % 500 ml
02/01/2021 00:00:00 8.550,00 BPJS
Neurodex tablet 741,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 200,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 107.820,00
113 Silya Wana BANDARATU 117469 Abbocath 20 Terumo @5
02/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 10 mg @50 T 118,00
Aqua Pro Injeksi 3.575,00
Candesartan Tab 16 mg 1.179,00
Captopril 12,5 mg 160,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 12.700,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 4.569,00
Amlodipine 5 mg @30 T
03/01/2021 00:00:00 101,00
Asam Folat 1 mg @100 T 297,00
Asam Folat 1 mg @100 T 198,00
Bisoprolol 5 mg @100 Ta 296,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan Tab 16 mg 1.179,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Kalitake 18.750,00
Kalitake 18.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Urine bag 10.088,00
Ventolin Nebules 2.5 mg 15.000,00
Ventolin Nebules 2.5 mg 15.000,00
Zink Tablet 1.378,00
Abbocath 22 Terumo @5
04/01/2021 00:00:00 11.138,00
Captopril 12,5 mg 160,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
NACL 0,9 % 500 ml 8.550,00
Octalbin 25% 50 cc (Huma 956.250,00
Ondansetron Inj 4.950,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
113 Silya Wana BANDARATU 117469 Transfusi Set Terumo
04/01/2021 00:00:00 16.500,00 BPJS
Zink Tablet 689,00
Abbocath 20 Terumo @5
05/01/2021 00:00:00 22.276,00
Amlodipine 10 mg @50 T 118,00
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 15cmx5cm (25 c 6.544,00
Kalitake 18.750,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 42.750,00
Nassal Cannula O2 Dewas 11.625,00
Octalbin 25% 50 cc (Huma 956.250,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 9.538,00
Three Way stopcock 37.125,00
Transfusi Set Terumo 16.500,00
Ventolin Nebules 2.5 mg 10.000,00
Amlodipine 10 mg @50 T
06/01/2021 00:00:00 118,00
Amlodipine 10 mg @50 T 1.180,00
Asam Folat 1 mg @100 T 297,00
Asam Folat 1 mg @100 T 1.980,00
Bisoprolol 5 mg @100 Ta 2.960,00
Candesartan Tab 16 mg 5.775,00
Ceftriaxone Inj 6.249,00
Clonidine 0.15 mg @100 T 2.290,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ventolin Nebules 2.5 mg 5.000,00
Total 2.635.271,00
114 Martina PT.AGRO AIR DIKIT 181749 Azitromycin 500 mg
03/01/2021 00:00:00 5.625,00 BPJS
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Zink Tablet 1.378,00
Azitromycin 500 mg
04/01/2021 00:00:00 16.875,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 1.000,00
Sucralfate Suspensi 100 m 19.250,00
Zink Tablet 6.890,00
Ondansetron Inj
05/01/2021 00:00:00 9.900,00
Azitromycin 500 mg
06/01/2021 00:00:00 28.125,00
Domperidone Tab 1.080,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
114 Martina PT.AGRO AIR DIKIT 181749 Omeprazol kapsul 20 mg
06/01/2021 00:00:00 6.610,00 BPJS
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 2.000,00
Zinc Sulfate Syr 60 ml 9.138,00
Total 209.494,00
115 S Sianturi AIR BIKUK 181751 Abbocath 20 Terumo @5
03/01/2021 00:00:00 11.138,00 BPJS
Abbocath 22 Terumo @5 11.138,00
Ambroxol 30 mg @100 T 193,00
Aminofluid Infus 500 ml 155.204,00
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 54.450,00
meropenem Injeksi 1 g 41.250,00
Metamizole Sodium Mono 4.594,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol Infus 14.438,00
Psidii Capsule 500 mg 4.901,00
Ringer Laktat Otsuka 9.538,00
Sistenol kaplet 1.754,00
Abbocath 22 Terumo @5 22.276,00
Cetadop inj 7.700,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 8.550,00
Opilax Syr 49.156,00
Three Way stopcock 37.125,00
Antrain Injeksi
04/01/2021 00:00:00 28.875,00
Azitromycin 500 mg 5.625,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Cetadop inj 23.100,00
Dulcolax Sup 10 mg 27.800,00
Hepa Q @30 tab 8.662,00
meropenem Injeksi 1 g 123.750,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Urine bag 10.088,00
Urine bag 10.088,00
Abbocath 22 Terumo @5
05/01/2021 00:00:00 22.276,00
Antrain Injeksi 28.875,00
Azitromycin 500 mg 5.625,00
Cetadop inj 23.100,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
115 S Sianturi AIR BIKUK 181751 Furamin Injeksi
05/01/2021 00:00:00 14.369,00 BPJS
Hepa Q @30 tab 8.662,00
meropenem Injeksi 1 g 123.750,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 8.550,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Psidii Capsule 500 mg 19.604,00
Ringer Laktat Otsuka 38.152,00
Sistenol kaplet 1.754,00
Three Way stopcock 37.125,00
ursodeoxycholic acid 5.670,00
Abbocath 22 Terumo @5
06/01/2021 00:00:00 11.138,00
Aminofluid Infus 500 ml 155.204,00
Azitromycin 500 mg 5.625,00
Cetadop inj 7.700,00
Cetadop inj 15.400,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 17.100,00
Norepinephrine Inj 61.876,00
Norepinephrine Inj 30.938,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 1.650,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 38.152,00
Three Way stopcock 37.125,00
Ambroxol 30 mg @100 T
07/01/2021 00:00:00 772,00
Ambroxol 30 mg @100 T 579,00
Ambroxol 30 mg @100 T 579,00
Antrain Injeksi 28.875,00
Azitromycin 500 mg 5.625,00
Azitromycin 500 mg 5.625,00
Cetadop inj 15.400,00
Dopamin Giulini 200 mg I 195.250,00
Gentamycin 0.1 % salep k 2.983,00
Hypafix 15cmx5cm (25 c 13.088,00
Meropenem Inj 0.5 g 165.000,00
meropenem Injeksi 1 g 123.750,00
NonWoven Fixation 15x 13.388,00
Norepinephrine Inj 30.938,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 38 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
115 S Sianturi AIR BIKUK 181751 Ondansetron Inj
07/01/2021 00:00:00 4.950,00 BPJS
Psidii Capsule 500 mg 14.703,00
Psidii Capsule 500 mg 14.703,00
Renax @50 Kapsul 22.688,00
Renax @50 Kapsul 22.688,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
ursodeoxycholic acid 5.670,00
ursodeoxycholic acid 5.670,00
Ambroxol 30 mg @100 T
08/01/2021 00:00:00 579,00
Antrain Injeksi 28.875,00
Azitromycin 500 mg 5.625,00
Cetadop inj 23.100,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Renax @50 Kapsul 22.688,00
ursodeoxycholic acid 2.835,00
Antrain Injeksi
09/01/2021 00:00:00 28.875,00
Azitromycin 500 mg 5.625,00
Dopamin Giulini 200 mg I 292.875,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Gentamycin 0.1 % salep k 2.983,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 8.550,00
Norepinephrine Inj 61.876,00
Ondansetron Inj 4.950,00
Renax @50 Kapsul 22.688,00
Urdahek 20.260,00
Ambroxol 30 mg @100 T
10/01/2021 00:00:00 1.930,00
Hepa Q @30 tab 43.310,00
Levofloxacin Tablet 500 m 13.640,00
NonWoven Fixation 15x 6.694,00
Renax @50 Kapsul 22.688,00
Sistenol kaplet 8.770,00
ursodeoxycholic acid 28.350,00
Total 6.646.029,00
116 Asep Darmawan DANAU NIBUNG 179742 Domperidone Tab
04/01/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 26.940,00
117 Syafniar RETAK MUDIK 181695 Amlodipine 5 mg @30 T
04/01/2021 00:00:00 2.020,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 27.880,00
118 M.zen TANAH HARAPAN 129190 Aspilet 80 mg @100 mg
04/01/2021 00:00:00 4.140,00 BPJS
Captopril 12,5 mg 2.400,00
Cetirgi Tab 10 mg 15.480,00
Furosemide 40 mg Tablet 2.880,00

19/08/2021 12:42:30 Page 39 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
118 M.zen TANAH HARAPAN 129190 Ranitidine tablet 150 mg
04/01/2021 00:00:00 4.320,00 BPJS
Spironolaktone 25 mg 7.800,00
Total 37.020,00
119 Narti SILAUT 175653 Cetirgi Tab 10 mg
04/01/2021 00:00:00 4.644,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 164.269,00
120 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
04/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
121 Yusran RANAH KARYA 169861 Amlodipine 5 mg @30 T
04/01/2021 00:00:00 1.010,00 BPJS
Betahistin Mesilat 6 mg @ 1.380,00
Paracetamol tablet 500 m 2.000,00
Total 4.390,00
122 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
04/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
123 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
04/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
124 Jaka Arnando TALANG BUAI 180938 Amlodipine 5 mg @30 T
04/01/2021 00:00:00 1.010,00 BPJS
Clopidogrel 75 mg @30 T 17.550,00
Ramipril tab 5 mg 3.060,00
Spironolaktone 25 mg 2.600,00
Total 24.220,00
125 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
04/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
126 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
04/01/2021 00:00:00 59.850,00 BPJS
Renogen 3000 UI 116.875,00
Total 176.725,00
127 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
04/01/2021 00:00:00 68.400,00 BPJS
Renogen 3000 UI 116.875,00
Total 185.275,00
128 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
04/01/2021 00:00:00 68.400,00 BPJS
Renogen 3000 UI 116.875,00
Total 185.275,00
129 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
04/01/2021 00:00:00 68.400,00 BPJS
Renogen 3000 UI 116.875,00
Total 185.275,00
130 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
04/01/2021 00:00:00 59.850,00 BPJS
Renogen 3000 UI 116.875,00
Total 176.725,00
131 Siti Fatimah UJUNG PADANG 115314 Amlodipine 5 mg @30 T
04/01/2021 00:00:00 2.020,00 BPJS
Paracetamol tablet 500 m 4.000,00
Simvastatin tab 10 mg 4.820,00
Total 10.840,00
132 Saras Murdalian RESNO 168737 Asam Mefenamat 500 m
04/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00

19/08/2021 12:42:30 Page 40 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 66.941,00
133 Mardini MUKOMUKO 125373 Amlodipine 5 mg @30 T
04/01/2021 00:00:00 3.030,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Metformin tablet 500 mg 7.980,00
Omeprazol kapsul 20 mg 3.305,00
Simvastatin tab 10 mg 7.230,00
Total 50.555,00
134 Napi TALANG BUAI 181761 Omeprazol kapsul 20 mg
04/01/2021 00:00:00 3.305,00 BPJS
Paracetamol tablet 500 m 2.000,00
Salbutamol 2 mg 790,00
Total 6.095,00
135 Istiqomah SUMBER MAKMUR 181774 Mecobalamin 500 mg
04/01/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 7.280,00
Total 14.980,00
136 Septiyani RAWA MULYA 136667 Asam Folat 1 mg @100 T
04/01/2021 00:00:00 2.970,00 BPJS
Kutoin 100 mg kaps 104.400,00
Total 107.370,00
137 Dianti AIR DIKIT 181633 Asam Mefenamat 500 m
04/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Postofix (leukomed) 36.726,00
Total 57.266,00
138 Armi. Z PULAI PAYUNG 167860 Propylthiourasil 100 mg (
04/01/2021 00:00:00 39.180,00 BPJS
Total 39.180,00
139 Ponirah PONDOK SUGUH 154097 abbocath 18 Terumo @5
04/01/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Combivent 25.024,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Furosemide 40 mg Tablet 96,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00

19/08/2021 12:42:30 Page 41 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
139 Ponirah PONDOK SUGUH 154097 Infusion Makro (terumo)
04/01/2021 00:00:00 27.225,00 BPJS
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
KSR (potassium chloride) 2.303,00
Masker Tali 41.600,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Proster Tablet 200 mcg 15.126,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Cefotaxime Injeksi
05/01/2021 00:00:00 11.502,00
Dexametason Injeksi 9.384,00
Handscoon steril 7,5 (Ga 58.252,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 36.093,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 20 Terumo @5
06/01/2021 00:00:00 22.276,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 1.350,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00

19/08/2021 12:42:30 Page 42 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
139 Ponirah PONDOK SUGUH 154097 Metrodinazole tab 500 m
07/01/2021 00:00:00 810,00 BPJS
Asam Mefenamat 500 m
08/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 1.900.789,00
140 Faiq Bukhair TUNGGANG 176380 Abbocath 20 Terumo @5
04/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 99,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 0,00
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Vitamin B Komplek @100 462,00
Asam Folat 1 mg @100 T
05/01/2021 00:00:00 297,00
Hypafix 10cm x 5cm (25 c 4.850,00
Transfusi Set Terumo 16.500,00
Total 99.360,00
141 Malludin SUNGAI LINTANG 129184 Electroda (Ambu) @25 Pc
04/01/2021 00:00:00 81.570,00 BPJS
Ceftriaxone Inj
05/01/2021 00:00:00 12.498,00
Combivent 12.512,00
Combivent 18.768,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 25.650,00
Nassal Mask O2 Dewasa 41.828,00
NGT (Stomach Tube) Fr. 1 60.046,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Pulmicort Resp 0.25 mg/ 0 17.884,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 0,00
Total 341.654,00
142 Firanza tri novelan LUBUK PINANG 142118 Abbocath 20 Terumo @5
04/01/2021 00:00:00 11.138,00 BPJS
Abbocath 22 Terumo @5 33.414,00
Aqua Pro Injeksi 3.575,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 100.778,00
143 Rosmaini LUBUK PINANG 181782 Abbocath 20 Terumo @5
04/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Aspilet 80 mg @100 mg 138,00
Catheter 2 Way No. 18 ( 31.251,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
143 Rosmaini LUBUK PINANG 181782 Mecobalamin 500 mg
04/01/2021 00:00:00 770,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 3.580,00
Urine bag 10.088,00
Total 131.300,00
144 Rahminda Hidayanti DANAU NIBUNG 173673 Asam Mefenamat 500 m
04/01/2021 00:00:00 2.580,00 BPJS
Gabapentin kapsul 300 m 25.380,00
Kalxetin 10 mg @30 Kap 55.000,00
Mecobalamin 500 mg 15.400,00
Natrium diclofenac 50 m 2.890,00
Paracetamol tablet 500 m 2.000,00
Ranitidine tablet 150 mg 1.440,00
Total 104.690,00
145 Rosmaini LUBUK PINANG 181782 Electroda (Ambu) @25 Pc
04/01/2021 00:00:00 81.570,00 BPJS
NACL 0,9 % 500 ml 76.950,00
Nassal Cannula O2 Dewas 11.625,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Amlodipine 5 mg @30 T
05/01/2021 00:00:00 101,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 10 % 9.375,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 11.758,00
NACL 0,9 % 500 ml 34.200,00
NGT (Stomach Tube) Fr. 1 60.046,00
Otsu D40 25.026,00
Ranitidin inj 3.580,00
Dobutamin Injeksi 50 mg
06/01/2021 00:00:00 14.536,00
Epinephrin inj 15.331,00
Extention Tube 17.602,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 10 % 9.375,00
Guedel No 40 MM 44.916,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 0,00
Norepinephrine Inj 30.938,00
Three Way stopcock 74.250,00
Total 688.879,00
146 Siti Uswatun Khasana DANAU LEBAR 163298 Abbocath 20 Terumo @5
04/01/2021 00:00:00 11.138,00 BPJS
Antasida Syrup 60 ml 2.736,00
Infusion Makro (terumo) 27.225,00
Pantoprazole Inj 0,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 14.025,00
Omeprazole Inj
05/01/2021 00:00:00 12.499,00
Hypafix 10cm x 5cm (25 c 9.700,00

19/08/2021 12:42:30 Page 44 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
146 Siti Uswatun Khasana DANAU LEBAR 163298 Omeprazol kapsul 20 mg
05/01/2021 00:00:00 6.610,00 BPJS
Total 131.797,00
147 Anita Astuti LUBUK CABAU 170810 abbocath 18 Terumo @5
05/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Nassal Cannula O2 Dewas 11.625,00
Ringer Laktat Otsuka 19.076,00
Tonotan tab 4.573,00
Transfusi Set Terumo 16.500,00
Aqua Pro Injeksi 7.150,00
Cefotaxime Injeksi 17.253,00
Dexametason Injeksi 9.384,00
Metrodinazole tab 500 m 810,00
Tonotan tab 13.719,00
Bisturi No. 23
06/01/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril 7,5 (Ga 72.815,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 6.5 (G 72.770,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 56.926,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 512.740,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
NGT (Stomach Tube) Fr. 1 52.250,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
silk 1 R scimitar 81.851,00
Spinocain 25 (BBraund) 85.526,00

19/08/2021 12:42:30 Page 45 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
147 Anita Astuti LUBUK CABAU 170810 Spinocain 27 (BBraund)
06/01/2021 00:00:00 47.875,00 BPJS
Spuit 10 cc Disposible (T 3.230,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 42.075,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 8.495,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Cefotaxime Injeksi
08/01/2021 00:00:00 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Nifedipin Tab 10 mg 350,00
Paracetamol tablet 500 m 600,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 3.172.822,00
148 Kasmi Juwita UJUNG PADANG 176839 Amlodipine 10 mg @50 T
05/01/2021 00:00:00 3.540,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Citicoline kaplet 500 mg 49.500,00
Total 84.390,00
149 Marni Wati UJUNG PADANG 177033 Citicoline Injeksi 125mg/
05/01/2021 00:00:00 112.500,00 BPJS
Mecobalamin 500 mg 3.850,00
Total 116.350,00
150 Hamilah LUBUK SANAI 122728 Cefixime Kapsul 100 mg
05/01/2021 00:00:00 9.380,00 BPJS
Glucosamine 250 mg 7.700,00
Ibuprofen tab 400 mg 4.580,00
ursodeoxycholic acid 28.350,00
Total 50.010,00
151 Ardini Gulo AIR DIKIT 180797 Ciprofloxacin tab 500 mg
05/01/2021 00:00:00 5.590,00 BPJS
Clindamycin 150 mg tabl 8.750,00
Ketorolac Tab 10 Mg 25.300,00
Total 39.640,00

19/08/2021 12:42:30 Page 46 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
152 Hartini SUMBER MAKMUR 120785 Candesartan tab 8 mg
05/01/2021 00:00:00 20.430,00 BPJS
Citicoline kaplet 500 mg 49.500,00
Flunarizine 5 mg tab 24.750,00
Furosemide 40 mg Tablet 2.880,00
Spironolaktone 25 mg 7.800,00
Total 105.360,00
153 Amandeka Jaya AIR BIKUK 161881 Alinamin F 50 mg @100 T
05/01/2021 00:00:00 11.500,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Gitas Plus 50.330,00
Total 71.210,00
154 Meili Angistia BANDAR RATU 150809 abbocath 18 Terumo @5
05/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 57.103,00
155 M. Iqbal Maulana DUSUN BARU PELOKA 181785 Clindamycin 150 mg tabl
05/01/2021 00:00:00 8.750,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 10.750,00
156 Ranggi SELAGAN RAYA 149940 Calcium Laktat
05/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
157 Azwir Taufan RANAH KARYA 167368 Alinamin F 50 mg @100 T
05/01/2021 00:00:00 11.500,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Paracetamol tablet 500 m 2.000,00
ursodeoxycholic acid 85.050,00
Total 107.930,00
158 Rahman Ade Ghaniy DESA GIRI MULYA 163322 Doxycyclin kapsul 100 m
05/01/2021 00:00:00 3.640,00 BPJS
Flunarizine 5 mg tab 24.750,00
Loratadine tab 10 mg 1.660,00
Total 30.050,00
159 Yunita PONDOK BARU 149270 Asam Folat 1 mg @100 T
05/01/2021 00:00:00 2.970,00 BPJS
Propylthiourasil 100 mg ( 19.590,00
Total 22.560,00
160 Egi Habag Tangi SUNGAI IPUH 149659 Atorvastatin 20 mg @30 T
05/01/2021 00:00:00 31.350,00 BPJS
Captopril 12,5 mg 2.400,00
Total 33.750,00
161 Dahalimun LUBUK CABAU 155405 Bisoprolol 5 mg @100 Ta
05/01/2021 00:00:00 8.880,00 BPJS
Citicoline kaplet 500 mg 23.100,00
Mecobalamin 500 mg 23.100,00
Perifas @100 Tab 19.250,00
Total 74.330,00
162 Sugini PONDOK MAKMUR 110687 Atorvastatin 20 mg @30 T
05/01/2021 00:00:00 31.350,00 BPJS
Candesartan tab 8 mg 20.430,00
Citicoline kaplet 500 mg 49.500,00
Flunarizine 5 mg tab 24.750,00
Total 126.030,00
163 Rama Danus PASAR BARU 147803 Ambroxol Syr 15mg/ml
05/01/2021 00:00:00 4.538,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Paracetamol tablet 500 m 2.000,00
Total 22.018,00
164 Vita Zurnilawati AIR DIKIT 132186 Asam Traneksamat @10
05/01/2021 00:00:00 21.050,00 BPJS

19/08/2021 12:42:30 Page 47 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
164 Vita Zurnilawati AIR DIKIT 132186 Cefixime Kapsul 100 mg
05/01/2021 00:00:00 9.380,00 BPJS
Zinc Sulfate Syr 60 ml 4.569,00
Total 34.999,00
165 Wina Febrina AIR BERAU 180586 Asam Mefenamat 500 m
05/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Total 20.540,00
166 Hadengganan UJUNG PADANG 117403 Loratadine tab 10 mg
05/01/2021 00:00:00 1.660,00 BPJS
Zinc Sulfate Syr 60 ml 4.569,00
Total 6.229,00
167 Adeng Caniago PELOKAN 168831 Gitas Plus
05/01/2021 00:00:00 50.330,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Total 72.885,00
168 Remina TALANG PETAI 181604 Meprolut Tab
05/01/2021 00:00:00 125.400,00 BPJS
Total 125.400,00
169 Ani Mariani TUNGGAL JAYA 109603 Asam Folat 1 mg @100 T
05/01/2021 00:00:00 990,00 BPJS
Flunarizine 5 mg tab 24.750,00
Paracetamol tablet 500 m 2.000,00
Total 27.740,00
170 Salami SILAUT I 134774 NACL 0,9 % 500 ml
05/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Renogen 3000 UI 116.875,00
Total 184.651,00
171 Wahiri TALANG SEPAKAT 181795 Cefixime Kapsul 100 mg
05/01/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Methylprednisolone tab 4 2.630,00
Total 37.310,00
172 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
05/01/2021 00:00:00 42.750,00 BPJS
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Total 197.575,00
173 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
05/01/2021 00:00:00 42.750,00 BPJS
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Total 197.575,00
174 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
05/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Renogen 3000 UI 116.875,00
Total 184.651,00
175 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
05/01/2021 00:00:00 42.750,00 BPJS
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Total 197.575,00
176 Katiyem BUMI MULYA 179888 Cetirgi Tab 10 mg
05/01/2021 00:00:00 15.480,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 17.480,00
177 Mei Rita Sari SUMBER MAKMUR 181796 abbocath 18 Terumo @5
05/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00

19/08/2021 12:42:30 Page 48 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
177 Mei Rita Sari SUMBER MAKMUR 181796 Ringer Laktat Otsuka
05/01/2021 00:00:00 9.538,00 BPJS
Transfusi Set Terumo 16.500,00
Total 84.328,00
178 Lamthina Hasibuan AIR BIKUK 131511 Flunarizine 5 mg tab
05/01/2021 00:00:00 24.750,00 BPJS
Glimepiride tab 2 mg 3.885,00
Mecobalamin 500 mg 3.850,00
Metformin tablet 500 mg 1.995,00
Paracetamol tablet 500 m 2.000,00
Total 36.480,00
179 Lena Br Panggabean SIDO MAKMUR 174000 Asam Mefenamat 500 m
05/01/2021 00:00:00 1.290,00 BPJS
Eperisone Hcl 50 mg @1 23.280,00
Metformin tablet 500 mg 3.990,00
Metrodinazole tab 500 m 4.050,00
Total 32.610,00
180 Tono DUSUN 3 TIRTA MUL 181740 Bisoprolol 5 mg @100 Ta
05/01/2021 00:00:00 1.184,00 BPJS
Paracetamol tablet 500 m 2.000,00
Renax @50 Kapsul 45.376,00
Urinter Kapsul @100 cap 21.980,00
Total 70.540,00
181 Herli Junita TALANG PETAI 181603 Asam Mefenamat 500 m
05/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 67.586,00
182 Herman AIR PUNGGUR 119713 Alprazolam 0,5 mg @100
05/01/2021 00:00:00 3.540,00 BPJS
Levopar tab 100mg 38.730,00
Sifrol tab 0,375 mg 311.250,00
Total 353.520,00
183 Media Noravita PONDOK BARU 181797 Ciprofloxacin tab 500 mg
05/01/2021 00:00:00 11.180,00 BPJS
Ketoprofen tab 100 mg 24.760,00
Total 35.940,00
184 Ny.ponirah PONDOK SUGUH 181798 Abbocath 24 Terumo @5
05/01/2021 00:00:00 33.414,00 BPJS
Bisturi no. 10 3.836,00
Chromic catgut 1 R (Tri 78.875,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 0,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 6 (R 16.333,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
07/01/2021 00:00:00 44.552,00
Hypafix 15cmx5cm (25 c 6.544,00
Abbocath 20 Terumo @5
08/01/2021 00:00:00 0,00
Abbocath 24 Terumo @5 22.276,00
Abbocath 24 Terumo @5 22.276,00
Bactesyn inj 0,75 gr 118.018,00
Bactesyn inj 0,75 gr
09/01/2021 00:00:00 59.009,00
Total 462.514,00

19/08/2021 12:42:30 Page 49 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
185 Sumaji TANJUNG MULYA 179779 Betahistin Mesilat 6 mg @
05/01/2021 00:00:00 1.380,00 BPJS
Total 1.380,00
186 Mei Rita Sari SUMBER MAKMUR 181796 Bisturi No. 23
05/01/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protofen Supositoria 60,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 36.093,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Aqua Pro Injeksi
06/01/2021 00:00:00 3.575,00
Bisturi No. 15 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 1.350,00
Nassal Cannula O2 Dewas 11.625,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 19.076,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 6.315,00

19/08/2021 12:42:30 Page 50 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
186 Mei Rita Sari SUMBER MAKMUR 181796 umbilical Cord Clamp
06/01/2021 00:00:00 2.261,00 BPJS
Asam Mefenamat 500 m
08/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 1.183.380,00
187 Zukriman LUBUK GEDANG 160918 Amlodipine 10 mg @50 T
05/01/2021 00:00:00 954,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 59.850,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 183.556,00
188 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
05/01/2021 00:00:00 68.400,00 BPJS
Renogen 3000 UI 116.875,00
Total 185.275,00
189 Roslina TERAS TERUNJAM 176003 Epodion 3000 IU
05/01/2021 00:00:00 116.875,00 BPJS
NACL 0,9 % 500 ml 68.400,00
Total 185.275,00
190 Susi Martini KOTO JAYA 145038 Amlodipine 10 mg @50 T
05/01/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 148.756,00
191 Suwarni SUKA MAJU 164065 Amlodipine 10 mg @50 T
05/01/2021 00:00:00 954,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 68.400,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 191.809,00
192 Iga Yusti LUBUK SANAI 147283 abbocath 18 Terumo @5
06/01/2021 00:00:00 22.276,00 BPJS
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 41.250,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 236.625,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
192 Iga Yusti LUBUK SANAI 147283 Handscoond Non Steril S
06/01/2021 00:00:00 8.510,00 BPJS
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spinocain 27 (BBraund) 143.625,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suction no. 1/4 25.950,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Cefotaxime Injeksi
08/01/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 2.198.520,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
193 Siti Yulaika RAWA MULYA 181800 abbocath 18 Terumo @5
06/01/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 5.751,00
Combivent 0,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 58.915,00
194 Ravina Laila Oktaviana SUMBER MAKMUR 181801 abbocath 18 Terumo @5
06/01/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 58.915,00
195 Siti Yulaika RAWA MULYA 181800 Alkohol 1Liter
06/01/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bisturi No. 23 7.672,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 13.088,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 3.230,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
195 Siti Yulaika RAWA MULYA 181800 Spuit 3 cc Disposible
06/01/2021 00:00:00 3.640,00 BPJS
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 42.075,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Cefotaxime Injeksi
08/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 1.624.331,00
196 Ravina Laila Oktaviana SUMBER MAKMUR 181801 Bisturi No. 23
06/01/2021 00:00:00 3.836,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 53.555,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 6.5 (G 72.770,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 13.088,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 46.405,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 256.370,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
196 Ravina Laila Oktaviana SUMBER MAKMUR 181801 Masker Karet Boism
06/01/2021 00:00:00 47.580,00 BPJS
Metoclopramide inj 5Mg/M 29.395,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ondansetron Inj 1.650,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ranitidin inj 8.950,00
Ringer Laktat Otsuka 19.076,00
Spinocain 25 (BBraund) 128.289,00
Spinocain 27 (BBraund) 47.875,00
Spinocain 27 (BBraund) 239.375,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Aqua Pro Injeksi
08/01/2021 00:00:00 7.150,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 2.366.377,00
197 Nazira Adibah BANDAR RATU 181803 Cefixime syrup 100mg/5 M
05/01/2021 00:00:00 23.823,00 BPJS
Combivent 12.512,00
Nassal Cannula O2 Dewas 11.625,00
Total 47.960,00
198 Riska Malasari LUBUK PINANG 181804 abbocath 18 Terumo @5
06/01/2021 00:00:00 22.276,00 BPJS
Catheter 2 Way No. 18 ( 31.251,00
Cefotaxime Injeksi 5.751,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
198 Riska Malasari LUBUK PINANG 181804 NACL 0,9 % 500 ml
06/01/2021 00:00:00 8.550,00 BPJS
oxytocin inj 4.497,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Total 126.957,00
199 Noureen Calista Alecia MUKOMUKO 181805 Abbocath 22 Terumo @5
05/01/2021 00:00:00 11.138,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Diazepam Tab 5 Mg 272,00
Infusion set Mikro (Terumo 18.026,00
Ka-En 1 B 25.316,00
Pamol 125 Supositoria 52.800,00
Paracetamol syrup 1.388,00
Ampicilin Serbuk Injeksi 1
06/01/2021 00:00:00 10.811,00
Ampicilin Serbuk Injeksi 1 21.622,00
Cefixime syrup 100mg/5 M 23.823,00
Gentamicin Injeksi 4.606,00
Hypafix 15cmx5cm (25 c 13.088,00
Ampicilin Serbuk Injeksi 1
07/01/2021 00:00:00 32.433,00
Aqua Pro Injeksi 7.150,00
Cefixime syrup 100mg/5 M 23.823,00
Diazepam Tab 5 Mg 272,00
Injection plug 20.213,00
Ka-En 1 B 25.316,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol syrup 1.388,00
Stesolid Supp 5 mg 66.012,00
Total 387.408,00
200 Tiara IPUH 181806 abbocath 18 Terumo @5
06/01/2021 00:00:00 11.138,00 BPJS
Catheter 2 Way No. 10 14.300,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Anak 16.473,00
Nassal Mask O2 Anak 41.828,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Total 125.421,00
201 Ahmad Damiri UJUNG PADANG 114580 Amlodipine 10 mg @50 T
06/01/2021 00:00:00 3.540,00 BPJS
Asam Folat 1 mg @100 T 2.970,00
Atorvastatin 20 mg @30 T 31.350,00
Miniaspi 80 Mg @100 Ta 3.750,00
Piracetam tab 800 mg 15.060,00
Topamax 100 mg Tab 358.500,00
Total 415.170,00
202 Any Desmawati UJUNG PADANG 111289 Atorvastatin 20 mg @30 T
06/01/2021 00:00:00 31.350,00 BPJS
Citicoline kaplet 500 mg 49.500,00
Miniaspi 80 Mg @100 Ta 3.750,00
Total 84.600,00
203 Sidah LUNANG 181811 Calcium Laktat
06/01/2021 00:00:00 1.580,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 1.580,00
204 Duta Darmazola TANAH HARAPAN 172224 Cefixime syrup 100mg/5 M
06/01/2021 00:00:00 23.823,00 BPJS
Ostarin Syr 16.638,00
Total 40.461,00
205 Tazia Ayu Maningsih PAUH TERENJA 153435 Valproic Acid Syrup 250mg
06/01/2021 00:00:00 62.925,00 BPJS
Total 62.925,00
206 Sri wulandari PT AGRO MUKO 118179 Calcium Laktat
06/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
207 Sefitri PT.AGRO 129210 Asam Mefenamat 500 m
06/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 11.790,00
208 Asia PENARIK 181684 Azitromycin 500 mg
06/01/2021 00:00:00 28.125,00 BPJS
Phytomenadione 10 mg ( 18.680,00
Tranexamic Acid Inj (Asa 42.100,00
vestein 300 mg 93.500,00
Total 182.405,00
209 Risna Junita TANAH HARAPAN 151132 Asam Mefenamat 500 m
06/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 11.790,00
210 Asmansyah SIBAK 140995 Azitromycin 500 mg
06/01/2021 00:00:00 16.875,00 BPJS
Codein tab 10 mg 2.250,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Sucralfate Suspensi 100 m 19.250,00
Total 218.220,00
211 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
212 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
213 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
214 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
215 Bustim PONDOK BARU 163473 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
216 Bahman SIBAK 155872 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
217 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
218 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
219 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
220 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
06/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
221 Antoni PT AGRO MUKO 181826 Abbocath 20 Terumo @5
06/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Mefenamat 500 m 1.290,00
Ascorbid Acid 1000mg/5m 78.375,00
Ceftriaxone Inj 12.498,00
Chromic catgut 3-0 R (Tr 66.250,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 19.632,00
Infusion Makro (terumo) 27.225,00
Lidocain injk 40 mg/2 ml 9.666,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol syrup 1.388,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 10 Mg/1 17.877,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Total 394.786,00
222 Ghaziya Alya Hafiza DANAU NIBUNG 146563 Amoxicillin Syr
06/01/2021 00:00:00 6.531,00 BPJS
Paracetamol syrup 1.388,00
Pehacain Injeksi 6.640,00
Total 14.559,00
223 Riyanti MARGA MULYA SAKTI 181828 abbocath 18 Terumo @5
06/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
handscoon steril 6.5 (Tr 29.976,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 13.088,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 56.926,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
223 Riyanti MARGA MULYA SAKTI 181828 Kassa kotak stril DRC
06/01/2021 00:00:00 9.675,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 8.495,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
08/01/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 5.751,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 73.452,00
Total 1.869.335,00
224 Delia Saputri TANAH REKAH 181498 Cefadroxil tab 500 mg @1
06/01/2021 00:00:00 10.500,00 BPJS
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 43.662,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lidocain injk 40 mg/2 ml 9.666,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Total 289.214,00
225 Mimi Sulita TANAH HARAPAN 181816 Abbocath 20 Terumo @5
06/01/2021 00:00:00 0,00 BPJS
Cefotaxime Injeksi 0,00
Chromic catgut 2-0 R (Tr 0,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
225 Mimi Sulita TANAH HARAPAN 181816 Cuticell Classic 10cmx10c
06/01/2021 00:00:00 0,00 BPJS
Handscoon steril 7,5 (Ga 0,00
handscoond steril 6.5 (G 14.554,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 0,00
Lidocain injk 40 mg/2 ml 0,00
Polyvinylidene 3-0 R (Tri 0,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 0,00
Spuit 3 cc Disposible 0,00
Spuit 5 cc Disposible 0,00
Transfusi Set Terumo 16.500,00
Total 45.442,00
226 Wirda BANDAR RATU 136453 Abbocath 20 Terumo @5
06/01/2021 00:00:00 22.276,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker Karet 10.450,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Transfusi Set Terumo 16.500,00
Ciprofloxacin tab 500 mg
07/01/2021 00:00:00 5.590,00
Paracetamol tablet 500 m 4.000,00
Total 391.985,00
227 Nurkewi TANAH REKAH 181810 Abbocath 20 Terumo @5
06/01/2021 00:00:00 22.276,00 BPJS
Bisturi no. 10 3.836,00
Bisturi No. 15 7.672,00
Cefotaxime Injeksi 5.751,00
Ceftriaxone Inj 12.498,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Lidocain injk 40 mg/2 ml 9.666,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
227 Nurkewi TANAH REKAH 181810 Spuit 5 cc Disposible
06/01/2021 00:00:00 2.840,00 BPJS
Transfusi Set Terumo 16.500,00
Cefixime kapsul 200 mg
07/01/2021 00:00:00 39.720,00
Paracetamol tablet 500 m 4.000,00
Total 336.296,00
228 M Pagal RANAH KARYA 138853 Asam Mefenamat 500 m
06/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Lidocain injk 40 mg/2 ml 4.833,00
Metrodinazole tab 500 m 2.700,00
Total 19.323,00
229 Imelda Susanti BUNGA TANJUNG 126931 abbocath 18 Terumo @5
06/01/2021 00:00:00 22.276,00 BPJS
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Suprafenid Supositoria 10 28.050,00
Three Way stopcock 37.125,00
Topi Operasi (Dokter) @5 8.495,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Cefotaxime Injeksi
08/01/2021 00:00:00 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
229 Imelda Susanti BUNGA TANJUNG 126931 Ketorolac inj 30 mg/1ml
08/01/2021 00:00:00 4.035,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 1.743.550,00
230 Wiji Lestari PENARIK 181753 abbocath 18 Terumo @5
06/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Bisturi No. 23
08/01/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 4.758,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 5.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
oxytocin inj 2.998,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
230 Wiji Lestari PENARIK 181753 Spuit 5 cc Disposible
08/01/2021 00:00:00 2.840,00 BPJS
Suprafenid Supositoria 10 28.050,00
Suprafenid Supositoria 10 42.075,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
09/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Paracetamol tablet 500 m 400,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
10/01/2021 00:00:00 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 15x 6.694,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
11/01/2021 00:00:00 1.290,00
Asam Mefenamat 500 m 645,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 19.350,00
Postofix (leukomed) 36.726,00
Total 1.895.028,00
231 Ny Anita LUBUK CABAU 181832 Abbocath 24 Terumo @5
06/01/2021 00:00:00 33.414,00 BPJS
Abbocath 24 Terumo @5 44.552,00
Abbocath 24 Terumo @5 44.552,00
Bisturi No. 15 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Hypafix 15cmx5cm (25 c 13.088,00
Hypafix 15cmx5cm (25 c 13.088,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NGT (Feeding Tube) Fr. 8 11.043,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Calcii Glukonas Inj 100 m
07/01/2021 00:00:00 12.939,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
Total 265.350,00
232 Widia Apriana KARYA MULYA 181833 abbocath 18 Terumo @5
06/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 77.873,00
233 Saarifah TANJUNG MULYA 181834 abbocath 18 Terumo @5
07/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
233 Saarifah TANJUNG MULYA 181834 Cefotaxime Injeksi
07/01/2021 00:00:00 11.502,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 37.124,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Cefadroxil tab 500 mg @1 10.500,00
Paracetamol tablet 500 m 3.000,00
Total 126.521,00
234 Rica Gusmawati MEKAR JAYA 177877 abbocath 18 Terumo @5
07/01/2021 00:00:00 11.138,00 BPJS
abbocath 18 Terumo @5 22.276,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 0,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 0,00
Nifedipin Tab 10 mg 525,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 0,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 221.678,00
235 Alwi Jaya LUBUK SANAI 109331 Alprazolam 0,5 mg @100
07/01/2021 00:00:00 2.360,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Aspilet 80 mg @100 mg 2.760,00
Atorvastatin 20 mg @30 T 20.900,00
Candesartan tab 8 mg 13.620,00
Citicoline kaplet 500 mg 49.500,00
Lansoprazole kapsul 30 m 23.100,00
Piracetam tablet 1200 m 41.880,00
Total 157.150,00
236 Sajuri LUBUK BUNTA 181839 Cefixime kapsul 200 mg
07/01/2021 00:00:00 26.480,00 BPJS
Omeprazol kapsul 20 mg 13.220,00
Paracetamol tablet 500 m 4.000,00
Renax @50 Kapsul 113.440,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 43.960,00
Total 220.350,00
237 Sasnani Bentara TALANG MEDAN 135659 Calcium Laktat
07/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
238 Herlina Wani SUKA RAME 163015 Asam Mefenamat 500 m
07/01/2021 00:00:00 1.935,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 7.525,00
239 Rindi Triswantoro LUNANG 180921 Cefixime kapsul 200 mg
07/01/2021 00:00:00 26.480,00 BPJS
Meloxicam 15 mg 12.600,00
Natrium diclofenac 50 m 8.670,00
Renax @50 Kapsul 113.440,00
Urinter Kapsul @100 cap 65.940,00
Total 227.130,00
240 Indil SARI BULAN 130372 Domperidone Tab
07/01/2021 00:00:00 3.240,00 BPJS
Flunarizine 5 mg tab 74.250,00
Lansoprazole kapsul 30 m 11.550,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 166.040,00
241 Ratmani GADING JAYA 177319 Asam Folat 1 mg @100 T
07/01/2021 00:00:00 2.970,00 BPJS
Candesartan tab 8 mg 20.430,00
Lansoprazole kapsul 30 m 23.100,00
Paracetamol tablet 500 m 4.000,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 4.620,00
Total 74.370,00
242 Jang Nawir AIR DIKIT 151069 Candesartan tab 8 mg
07/01/2021 00:00:00 20.430,00 BPJS
Furosemide 40 mg Tablet 2.880,00
Lansoprazole kapsul 30 m 23.100,00
Natrium diclofenac 50 m 5.780,00
Retaphyl SR Tab 44.220,00
Sucralfate Suspensi 100 m 19.250,00
Symbicort Turbuhaler 80 167.855,00
Total 283.515,00
243 Wirdah RANAH KARYA 181725 Paracetamol tablet 500 m
07/01/2021 00:00:00 0,00 BPJS
Total 0,00
244 Ngadenin RAWA MULYA 146823 Ambroxol Syr 15mg/ml
07/01/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 56.250,00
Candesartan tab 8 mg 20.430,00
Lansoprazole kapsul 30 m 23.100,00
Meloxicam 15 mg 18.900,00
Methylprednisolone tab 4 7.890,00
Natrium diclofenac 50 m 8.670,00
Sucralfate Suspensi 100 m 19.250,00
Total 159.028,00
245 Suci Rahma Diana TALANG MEDAN 160525 Calcium Laktat
07/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
246 risda br sagala PENARIK 111822 Atorvastatin 20 mg @30 T
07/01/2021 00:00:00 10.450,00 BPJS
Cefixime kapsul 200 mg 26.480,00
Lansoprazole kapsul 30 m 23.100,00
Sucralfate Suspensi 100 m 19.250,00
ursodeoxycholic acid 85.050,00
Total 164.330,00
247 Warno PULAI PAYUNG 181845 Lansoprazole kapsul 30 m
07/01/2021 00:00:00 23.100,00 BPJS
Metoclorapamide tab 10 m 4.530,00
Nuzym Kapsul 132.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 178.880,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
248 W. Saragi RAWA BANGUN 138068 Aspilet 80 mg @100 mg
07/01/2021 00:00:00 4.140,00 BPJS
Bisoprolol 5 mg @100 Ta 8.880,00
Furosemide 40 mg Tablet 2.880,00
Lansoprazole kapsul 30 m 23.100,00
Ramipril tab 5 mg 9.180,00
Spironolaktone 25 mg 7.800,00
Total 55.980,00
249 Caury Elfia BANDARATU 144001 abbocath 18 Terumo @5
07/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 47.777,00
250 Suriyani KAMPUNG DALAM 113149 Aspilet 80 mg @100 mg
07/01/2021 00:00:00 2.760,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Furosemide 40 mg Tablet 2.880,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 13.220,00
Spironolaktone 100 mg 21.570,00
Sucralfate Suspensi 100 m 19.250,00
Total 71.310,00
251 Muslim BANDARATU 181722 Atorvastatin 20 mg @30 T
07/01/2021 00:00:00 10.450,00 BPJS
Betahistin Mesilat 6 mg @ 2.760,00
Citicoline kaplet 500 mg 16.500,00
Flunarizine 5 mg tab 49.500,00
Miniaspi 80 Mg @100 Ta 1.250,00
Total 80.460,00
252 Caury Elfia BANDARATU 144001 Alkohol 1Liter
07/01/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker 3 Play N. 95 256.370,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
252 Caury Elfia BANDARATU 144001 Ringer Laktat Otsuka
07/01/2021 00:00:00 28.614,00 BPJS
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 23
08/01/2021 00:00:00 3.836,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding Tube) Fr. 8 11.043,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Aqua Pro Injeksi
09/01/2021 00:00:00 3.575,00
Cefotaxime Injeksi 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Cefadroxil tab 500 mg @1
10/01/2021 00:00:00 10.500,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 20.175,00
Postofix (leukomed) 36.726,00
Total 1.882.954,00
253 Karsinah KOTO JAYA 086793 Alprazolam 1 mg @100 T
07/01/2021 00:00:00 4.800,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Bisoprolol 5 mg @100 Ta 4.440,00
Clopidogrel 75 mg @30 T 52.650,00
Lansoprazole kapsul 30 m 23.100,00
Meloxicam 15 mg 18.900,00
Thrombo Aspilets 29.220,00
Total 164.460,00
254 Sri Hartati TALANG BARU 181643 Asam Mefenamat 500 m
07/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 11.790,00
255 Ibnu Sabil TANAH REKAH 155517 Azitromycin 500 mg
08/01/2021 00:00:00 5.625,00 BPJS
Dulcolax Sup 10 mg 27.800,00
Dulcolax tab 5 mg 3.166,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Oseltamivir 75 mg 2,00
Zink Tablet 689,00
Azitromycin 500 mg
09/01/2021 00:00:00 5.625,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 42.750,00
Omeprazole Inj 12.499,00
Tranexamic Acid Inj (Asa 6.315,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
255 Ibnu Sabil TANAH REKAH 155517 Azitromycin 500 mg
10/01/2021 00:00:00 11.250,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Oseltamivir 75 mg 1,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 6.315,00
Azitromycin 500 mg
11/01/2021 00:00:00 5.625,00
Dopamin Giulini 200 mg I 97.625,00
Metoclopramide inj 5Mg/M 17.637,00
Ngt (Feeding Tube) Fr.16 10.588,00
Omeprazole Inj 12.499,00
Oseltamivir 75 mg 2,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 6.315,00
Total 437.291,00
256 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
07/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
257 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
07/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
258 Narti SILAUT 175653 NACL 0,9 % 500 ml
07/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
259 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
07/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
260 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
07/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
261 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
07/01/2021 00:00:00 68.400,00 BPJS
Otsu D40 25.026,00
Total 93.426,00
262 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
07/01/2021 00:00:00 68.400,00 BPJS
Total 68.400,00
263 Supangat PONDOK LUNANG 147511 Amlodipine 10 mg @50 T
07/01/2021 00:00:00 0,00 BPJS
Candesartan tab 8 mg 0,00
Clonidine 0.15 mg @100 T 0,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 0,00
Otsu D40 0,00
Otsu D40 25.026,00
Paracetamol tablet 500 m 0,00
Total 93.426,00
264 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
07/01/2021 00:00:00 59.850,00 BPJS
Total 59.850,00
265 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
07/01/2021 00:00:00 68.400,00 BPJS
Otsu D40 12.513,00
Total 80.913,00
266 Afrizal UJUNG PADANG 116493 Abbocath 20 Terumo @5
07/01/2021 00:00:00 22.276,00 BPJS
Infusion Makro (terumo) 27.225,00
Mecobalamin 500 mg 1.540,00
Methylprednisolone Inje 279.384,00
NonWoven Fixation 15x 6.694,00
Pantoprazole Inj 46.750,00
Ranitidin inj 3.580,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
266 Afrizal UJUNG PADANG 116493 Ringer Laktat Otsuka
07/01/2021 00:00:00 19.076,00 BPJS
Total 406.525,00
267 Giran TANAH HARAPAN 181844 abbocath 18 Terumo @5
07/01/2021 00:00:00 22.276,00 BPJS
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 18.000,00
Iodine povidone 300 ml 28.463,00
Masker 3 Play N. 95 256.370,00
Masker Tali 41.600,00
Massa Cauter Dewasa 90.240,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 2-0 R (Tri 94.250,00
Polyvinylidene 3-0 R (Tri 92.000,00
Premilene (Mesh Duzey) 6 167.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Ceftriaxone Inj
08/01/2021 00:00:00 12.498,00
Paracetamol tablet 500 m 600,00
Hypafix 10cm x 5cm (25 c
09/01/2021 00:00:00 4.850,00
Kassa kotak stril DRC 9.675,00
Paracetamol tablet 500 m 2.000,00
Total 1.627.659,00
268 Wirdah RANAH KARYA 181725 Abbocath 20 Terumo @5
07/01/2021 00:00:00 11.138,00 BPJS
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 5.751,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
268 Wirdah RANAH KARYA 181725 Ceftriaxone Inj
07/01/2021 00:00:00 12.498,00 BPJS
Celemek Plastik 8.993,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 512.740,00
Masker Tali 41.600,00
Massa Cauter Dewasa 90.240,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
08/01/2021 00:00:00 12.498,00
Paracetamol tablet 500 m 600,00
Hypafix 10cm x 5cm (25 c
09/01/2021 00:00:00 4.850,00
Kassa kotak stril DRC 9.675,00
Paracetamol tablet 500 m 2.000,00
Total 1.449.386,00
269 Dina Nur Aliyah UJUNG PADANG 181856 Abbocath 20 Terumo @5
07/01/2021 00:00:00 22.276,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Masker Tali 41.600,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00

19/08/2021 12:42:30 Page 70 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
269 Dina Nur Aliyah UJUNG PADANG 181856 NACL 0,9 % 500 ml
07/01/2021 00:00:00 17.100,00 BPJS
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 3 cc Terumo 13.916,00
Suprafenid Supositoria 10 28.050,00
Transfusi Set Terumo 16.500,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
08/01/2021 00:00:00 11.502,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 6.315,00
Total 1.519.933,00
270 Sariani AIR BERAU 180523 Azitromycin 500 mg
07/01/2021 00:00:00 5.625,00 BPJS
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Vitamin B Komplek @100 308,00
Zink Tablet 1.378,00
Total 11.491,00
271 Afrizal UJUNG PADANG 116493 Methylprednisolone Inje
09/01/2021 00:00:00 558.768,00 BPJS
Pantoprazole Inj 46.750,00
Ranitidin inj 10.740,00
Total 616.258,00
272 Sariani AIR BERAU 180523 NACL 0,9 % 500 ml
08/01/2021 00:00:00 17.100,00 BPJS
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Zinc Sulfate Syr 60 ml 4.569,00
NACL 0,9 % 500 ml
09/01/2021 00:00:00 34.200,00
Octalbin 25% 100 cc (Hu 1.887.500,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Azitromycin 500 mg
10/01/2021 00:00:00 11.250,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Ranitidin inj 5.370,00
Curcuma Tab
12/01/2021 00:00:00 3.810,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Dipenhydramin Injeksi 10 15.350,00
Furosemide 40 mg Tablet 192,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.000,00

19/08/2021 12:42:30 Page 71 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
272 Sariani AIR BERAU 180523 Ranitidin inj
12/01/2021 00:00:00 3.580,00 BPJS
Ranitidin inj 3.580,00
vestein 300 mg 46.750,00
Vitamin B Komplek @100 1.540,00
Zinc Sulfate Syr 60 ml 4.569,00
Dexametason Injeksi
13/01/2021 00:00:00 6.256,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 2.000,00
Ranitidin inj 3.580,00
Vitamin B Komplek @100 1.540,00
Betahistin Mesilat 6 mg @
14/01/2021 00:00:00 1.380,00
Ranitidin inj 5.370,00
vestein 300 mg 46.750,00
Betahistin Mesilat 6 mg @
15/01/2021 00:00:00 1.380,00
Guaifenesin 100 mg 1.680,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00
Total 2.252.212,00
273 Syafniar RETAK MUDIK 181695 Omeprazol kapsul 20 mg
07/01/2021 00:00:00 3.305,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 4.650,00
Total 27.205,00
274 Rica Gusmawati MEKAR JAYA 177877 Cefotaxime Injeksi
09/01/2021 00:00:00 17.253,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 4.210,00
Asam Mefenamat 500 m
10/01/2021 00:00:00 1.935,00
Bisturi No. 23 3.836,00
Cefadroxil tab 500 mg @1 10.500,00
Chloramphenicol Salep M 2.351,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
Total 157.179,00
275 Dina Nur Aliyah UJUNG PADANG 181856 Cefotaxime Injeksi
08/01/2021 00:00:00 11.502,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 42.075,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
275 Dina Nur Aliyah UJUNG PADANG 181856 Tranexamic Acid Inj (Asa
08/01/2021 00:00:00 6.315,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
09/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Asam Mefenamat 500 m
10/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 280.983,00
276 Gusvita Rahayu koto jaya 162989 Utrogestan 100 mg Kapsu
08/01/2021 00:00:00 205.740,00 BPJS
Total 205.740,00
277 Abdullah PASAR MUKOMUKO 181859 Amlodipine 5 mg @30 T
08/01/2021 00:00:00 3.030,00 BPJS
Total 3.030,00
278 Fitri Yani LUBUK SANAI 181861 Glucosamine 250 mg
08/01/2021 00:00:00 7.700,00 BPJS
Propanolol tab 10 mg 6.660,00
Propylthiourasil 100 mg ( 58.770,00
Total 73.130,00
279 Aminatun TANAH HARAPAN 181276 Cefixime syrup 100mg/5 M
08/01/2021 00:00:00 23.823,00 BPJS
Methylprednisolone Inje 698.460,00
Paracetamol tablet 500 m 4.000,00
Total 726.283,00
280 Mulyadi M LUBUK PINANG 110596 Mecobalamin 500 mg
08/01/2021 00:00:00 3.850,00 BPJS
Meloxicam 7,5 mg 21.840,00
Omeprazol kapsul 20 mg 3.305,00
Total 28.995,00
281 Tarani TUNGGANG 164476 Hexymer 2 Mg Tab (THP)
08/01/2021 00:00:00 28.680,00 BPJS
Levopar tab 100mg 77.460,00
Sifrol tab 0,375 mg 311.250,00
Total 417.390,00
282 Kholishoh LUNANG 179702 Cefixime kapsul 200 mg
08/01/2021 00:00:00 26.480,00 BPJS
Dulcolax Sup 10 mg 83.400,00
Erphafillin Tab 7.380,00
Salbutamol 2 mg 1.580,00
Symbicort Turbuhaler 80 167.855,00
Total 286.695,00
283 Dian Indah Purnama S KARYA MULYA 151685 Acetylcystein 200 mg Ka
08/01/2021 00:00:00 34.380,00 BPJS
Vitamin B Komplek @100 2.310,00
Vitamin C tablet @100 Ta 2.070,00
Total 38.760,00
284 Jabarwi DUSUN GEDANG 161528 Asam Folat 1 mg @100 T
08/01/2021 00:00:00 990,00 BPJS
Betahistin Mesilat 6 mg @ 1.380,00
Omeprazol kapsul 20 mg 3.305,00
Total 5.675,00
285 Desi Komalasari SINAR JAYA 131508 Mecobalamin 500 mg
08/01/2021 00:00:00 7.700,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 2.000,00
Total 13.005,00
286 Basori TANJUNG MULYA 180019 Curcuma Tab
08/01/2021 00:00:00 12.700,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
286 Basori TANJUNG MULYA 180019 Lansoprazole kapsul 30 m
08/01/2021 00:00:00 11.550,00 BPJS
Propanolol tab 10 mg 1.110,00
Total 25.360,00
287 Rohana BANTAL 127561 Glimepiride tab 1 mg
08/01/2021 00:00:00 6.540,00 BPJS
Hexymer 2 Mg Tab (THP) 28.680,00
Levopar tab 100mg 77.460,00
Metformin tablet 500 mg 7.980,00
Sifrol tab 0,375 mg 311.250,00
Total 431.910,00
288 Syamil Hafizhan LUNANG 181870 Cefixime syrup 100mg/5 M
08/01/2021 00:00:00 23.823,00 BPJS
Total 23.823,00
289 Salami SILAUT I 134774 NACL 0,9 % 500 ml
08/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
290 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
08/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
291 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
08/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
292 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
08/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
293 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
08/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
294 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
08/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
295 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
08/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
296 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
08/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
297 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
08/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
298 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
08/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
299 Meti Hartati NELAN INDAH 148863 Urinter Kapsul @100 cap
08/01/2021 00:00:00 21.980,00 BPJS
Total 21.980,00
300 Sumarno BANDAR JAYA 177049 Abbocath 20 Terumo @5
08/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Total 78.069,00
301 Nova Hariani PASAR MUKOMUKO 168488 abbocath 18 Terumo @5
08/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Misoprostol Tab 22.000,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 73.352,00
302 Siti Kodijah LUNANG 181875 abbocath 18 Terumo @5
08/01/2021 00:00:00 11.138,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
302 Siti Kodijah LUNANG 181875 Aqua Pro Injeksi
08/01/2021 00:00:00 3.575,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 9.281,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 60.633,00
303 Nova Hariani PASAR MUKOMUKO 168488 Dexametason Injeksi
08/01/2021 00:00:00 6.256,00 BPJS
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Suprafenid Supositoria 10 42.075,00
Handscoon steril 7,5 (Ga
09/01/2021 00:00:00 43.689,00
handscoond steril 6.5 (G 43.662,00
Handscoond Sterille 7 (G 58.252,00
Misoprostol Tab 16.500,00
Asam Mefenamat 500 m
10/01/2021 00:00:00 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Misoprostol Tab 55.000,00
Total 368.083,00
304 Sumarno BANDAR JAYA 177049 Ceftriaxone Inj
08/01/2021 00:00:00 6.249,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Ondansetron Inj 4.950,00
Ceftriaxone Inj
09/01/2021 00:00:00 12.498,00
Dulcolax Sup 10 mg 27.800,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 4.035,00
Meloxicam 7,5 mg 3.640,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj
10/01/2021 00:00:00 12.498,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Ngt (Feeding Tube) Fr.16 10.588,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 1.000,00
Ringer Laktat Otsuka 28.614,00
Cefixime Kapsul 100 mg
11/01/2021 00:00:00 9.380,00
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazol kapsul 20 mg 6.610,00
Piralen tab 4.540,00
Total 250.757,00
305 Indah Syahfitri LUBUK CABAU 181608 Bisturi No. 23
08/01/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00

19/08/2021 12:42:30 Page 75 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
305 Indah Syahfitri LUBUK CABAU 181608 Cuticell Classic 10cmx10c
08/01/2021 00:00:00 6.900,00 BPJS
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 256.370,00
Masker Karet 20.900,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 4.260,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 364.370,00
Abbocath 20 Terumo @5
09/01/2021 00:00:00 22.276,00
Cefotaxime Injeksi 17.253,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Nifedipin Tab 10 mg 350,00
Bisturi No. 23
10/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 11.043,00
NonWoven Fixation 15x 6.694,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
11/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 19.350,00
Postofix (leukomed) 36.726,00
Total 1.727.093,00
306 Nuraini RETAK ILIR 181876 Abbocath 20 Terumo @5
08/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
306 Nuraini RETAK ILIR 181876 Ceftriaxone Inj
08/01/2021 00:00:00 6.249,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Zink Tablet 2.067,00
Total 85.640,00
307 Siti Kodijah LUNANG 181875 Catheter 2 Way No. 16 (
09/01/2021 00:00:00 39.025,00 BPJS
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 72.250,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Feeding Tube) Fr. 8 11.043,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
10/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Vitamin B Komplek @100 1.540,00
Total 239.404,00
308 Nuraini RETAK ILIR 181876 Hypafix 10cm x 5cm (25 c
08/01/2021 00:00:00 9.700,00 BPJS
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Zink Tablet 2.067,00
Cefixime Kapsul 100 mg
09/01/2021 00:00:00 9.380,00
Omeprazol kapsul 20 mg 6.610,00
Zink Tablet 6.890,00
Total 63.861,00
309 Gusvita Rahayu koto jaya 162989 Abbocath 20 Terumo @5
08/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Infusion Makro (terumo) 27.225,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 22.000,00
Misoprostol Tab 11.000,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 9.538,00
Suprafenid Supositoria 10 28.050,00
Total 211.817,00
310 Silya Wana BANDARATU 117469 abbocath 18 Terumo @5
08/01/2021 00:00:00 11.138,00 BPJS
Diazepam Inj 3.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
310 Silya Wana BANDARATU 117469 Electroda (Ambu) @25 Pc
08/01/2021 00:00:00 81.570,00 BPJS
Glukosa Infus 5 % 8.626,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 148.321,00
311 Nursani UJUNG PADANG 115837 Abbocath 20 Terumo @5
08/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 10 mg @50 T 1.180,00
Amlodipine 10 mg @50 T 236,00
Candesartan tab 8 mg 1.362,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Infus 24.488,00
Metformin tablet 500 mg 1.330,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 17.100,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Amlodipine 5 mg @30 T
09/01/2021 00:00:00 202,00
Candesartan tab 8 mg 1.362,00
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 25.650,00
Opilax Syr 49.156,00
Ranitidin inj 3.580,00
Abbocath 22 Terumo @5
10/01/2021 00:00:00 11.138,00
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Opilax Syr 49.156,00
Ranitidin inj 5.370,00
Amlodipine 5 mg @30 T
11/01/2021 00:00:00 1.010,00
Candesartan tab 8 mg 6.810,00
Cefixime Kapsul 100 mg 9.380,00
Levofloxacin Infus 24.488,00
Metformin tablet 500 mg 1.330,00
Omeprazol kapsul 20 mg 3.305,00
Piralen tab 4.540,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 638.305,00
312 Silya Wana BANDARATU 117469 Ranitidin inj
08/01/2021 00:00:00 5.370,00 BPJS
Abbocath 22 Terumo @5
09/01/2021 00:00:00 22.276,00
Abbocath 24 Terumo @5 22.276,00
Cuticell Classic 10cmx10c 13.800,00
Diazepam Inj 3.500,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kalitake 6.250,00
NACL 0,9 % 500 ml 8.550,00
Novorapid Flexpen 108.750,00
Ondansetron Inj 4.950,00
Ranitidin inj 1.790,00
Stesolid Inj 2 ml 25.959,00
NACL 0,9 % 500 ml
10/01/2021 00:00:00 8.550,00
Ondansetron Inj 1.650,00
Ranitidin inj 1.790,00
Stesolid Inj 2 ml 34.612,00
Total 289.473,00
313 Ny.wiji Lestari MAJU MAKMUR 181878 Abbocath 24 Terumo @5
08/01/2021 00:00:00 33.414,00 BPJS
Bisturi No. 23 3.836,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00
Injection plug 20.213,00
NGT (Feeding Tube) Fr. 8 11.043,00
umbilical Cord Clamp 2.261,00
Total 77.968,00
314 Gusvita Rahayu koto jaya 162989 Cefadroxil tab 500 mg @1
09/01/2021 00:00:00 10.500,00 BPJS
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 18.562,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 28.614,00
Total 84.880,00
315 Joko Suprianto ARGA JAYA 181880 Abbocath 20 Terumo @5
09/01/2021 00:00:00 11.138,00 BPJS
Abbocath 22 Terumo @5 11.138,00
Antrain Injeksi 19.250,00
Antrain Injeksi 28.875,00
Catheter 2 Way No. 16 ( 39.025,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 13.328,00
Furosemide Injeksi @2ml 13.328,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 18.026,00
L-Ornithine Injeksi 10 ml 155.926,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 13.388,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
315 Joko Suprianto ARGA JAYA 181880 Pantoprazole Inj
09/01/2021 00:00:00 46.750,00 BPJS
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Antrain Injeksi
10/01/2021 00:00:00 19.250,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 13.328,00
Glukosa Infus 5 % 25.878,00
Hepa Q @30 tab 8.662,00
KSR (potassium chloride) 2.303,00
L-Ornithine Injeksi 10 ml 155.926,00
L-Ornithine Injeksi 10 ml 155.926,00
Pantoprazole Inj 46.750,00
Spironolaktone 100 mg 2.157,00
Antrain Injeksi
11/01/2021 00:00:00 28.875,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 13.328,00
Glukosa Infus 5 % 25.878,00
Glukosa Infus 5 % 17.252,00
Hypafix 15cmx5cm (25 c 13.088,00
L-Ornithine Injeksi 10 ml 155.926,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Anak 16.473,00
Opilax Syr 49.156,00
Pantoprazole Inj 46.750,00
Pantoprazole Inj 46.750,00
Antrain Injeksi
12/01/2021 00:00:00 28.875,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 13.328,00
Glukosa Infus 5 % 8.626,00
L-Ornithine Injeksi 10 ml 155.926,00
Metoclopramide inj 5Mg/M 17.637,00
Pantoprazole Inj 46.750,00
Alprazolam 0,5 mg @100
13/01/2021 00:00:00 118,00
Antrain Injeksi 28.875,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 13.328,00
Glukosa Infus 5 % 8.626,00
Glukosa Infus 5 % 8.626,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 37.497,00
Pantoprazole Inj 46.750,00
Hepa Q @30 tab
14/01/2021 00:00:00 43.310,00
Hypafix 10cm x 5cm (25 c 4.850,00
KSR (potassium chloride) 11.515,00
Piralen tab 6.810,00
Spironolaktone 100 mg 10.785,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.895.362,00
316 Partowiyono TANJUNG BERINGIN / 136784 Amlodipine 5 mg @30 T
09/01/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Ibuprofen tab 200 mg 1.990,00
Loratadine tab 10 mg 1.660,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
316 Partowiyono TANJUNG BERINGIN / 136784 Spironolaktone 25 mg
09/01/2021 00:00:00 7.800,00 BPJS
Furosemide 40 mg Tablet
09/06/2021 00:00:00 2.880,00
Spironolaktone 25 mg 7.800,00
Total 45.590,00
317 Abdi Lubis RAWA MULYA 152783 Gabapentin kapsul 300 m
09/01/2021 00:00:00 6.345,00 BPJS
Mecobalamin 500 mg 7.700,00
Metformin tablet 500 mg 11.970,00
Total 26.015,00
318 Riayati LUBUK BANGKO 152742 Domperidone Tab
09/01/2021 00:00:00 1.620,00 BPJS
Ibuprofen tab 200 mg 1.990,00
Total 3.610,00
319 Asmansyah SIBAK 140995 Ambroxol 30 mg @100 T
09/01/2021 00:00:00 2.895,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 45.645,00
320 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
09/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
321 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
09/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
322 Bustim PONDOK BARU 163473 NACL 0,9 % 500 ml
09/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
323 Bahman SIBAK 155872 NACL 0,9 % 500 ml
09/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
324 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
09/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
325 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
09/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
326 Lailatul Kadar TANAH REKAH 158354 Amlodipine 10 mg @50 T
09/01/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Simvastatin tab 10 mg 723,00
Total 77.040,00
327 Sumidah RAWA MULYA 163860 Amlodipine 10 mg @50 T
09/01/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Simvastatin tab 10 mg 723,00
Total 77.040,00
328 Kasmidi Kasim BANDAR RATU 135355 Amlodipine 10 mg @50 T
09/01/2021 00:00:00 354,00 BPJS
Azitromycin 500 mg 16.875,00
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
328 Kasmidi Kasim BANDAR RATU 135355 Simvastatin tab 10 mg
09/01/2021 00:00:00 723,00 BPJS
Total 93.915,00
329 Bima Aryandika BANDARATU 178714 Amlodipine 10 mg @50 T
09/01/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Simvastatin tab 10 mg 723,00
Total 77.040,00
330 Hartati PONDOK BARU 136239 Hexymer 2 Mg Tab (THP)
09/01/2021 00:00:00 43.020,00 BPJS
Levopar tab 100mg 77.460,00
Total 120.480,00
331 Nasib Yulianto Butar B TANJUNG MULYA 181882 abbocath 18 Terumo @5
09/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefoperazon Inj 41.250,00
Furamin Injeksi 14.369,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 9.538,00
Suprafenid Supositoria 10 14.025,00
Cefoperazon Inj
10/01/2021 00:00:00 82.500,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 8.070,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Renax @50 Kapsul 22.688,00
Renax @50 Kapsul 113.440,00
Ringer Laktat Otsuka 28.614,00
Urinter Kapsul @100 cap 21.980,00
Total 476.451,00
332 Ema Rismawati MEKAR SARI 181885 abbocath 18 Terumo @5
09/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Electroda (Ambu) @25 Pc 0,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 0,00
Ringer Laktat Otsuka 9.538,00
Tonotan tab 45.730,00
abbocath 18 Terumo @5
10/01/2021 00:00:00 22.276,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Kassa kotak stril DRC 9.675,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
332 Ema Rismawati MEKAR SARI 181885 Cefadroxil tab 500 mg @1
12/01/2021 00:00:00 15.750,00 BPJS
Tonotan tab 68.595,00
Total 293.068,00
333 Fitriani PONDSOK BATU 181886 abbocath 18 Terumo @5
09/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Cefotaxime Injeksi
10/01/2021 00:00:00 11.502,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Otsu MgSO4 40 % 4.745,00
Paracetamol Infus 43.314,00
Suprafenid Supositoria 10 42.075,00
Paracetamol Infus
11/01/2021 00:00:00 28.876,00
Aqua Pro Injeksi
12/01/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Paracetamol Infus 43.314,00
PARAMOL INFUS 192.500,00
Ringer Laktat Otsuka 19.076,00
Catheter 2 Way No. 16 (
13/01/2021 00:00:00 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Paracetamol Infus 43.314,00
Suprafenid Supositoria 10 28.050,00
Tonotan tab 9.146,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Abbocath 20 Terumo @5
15/01/2021 00:00:00 22.276,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
16/01/2021 00:00:00 3.575,00
Asam Mefenamat 500 m 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 5.751,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 784.025,00
334 Aini Desmarlita LUBUK GEDANG 115118 abbocath 18 Terumo @5
10/01/2021 00:00:00 11.138,00 BPJS
Antasida Syrup 60 ml 2.736,00
Aqua Pro Injeksi 3.575,00
Betahistin Mesilat 6 mg @ 414,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
334 Aini Desmarlita LUBUK GEDANG 115118 Glukosa Infus 5 %
10/01/2021 00:00:00 8.626,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 80.844,00
335 Sabariah PONDOK BATU 168430 abbocath 18 Terumo @5
10/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ascorbid Acid 1000mg/5m 78.375,00
Ceftriaxone Inj 12.498,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 15x 6.694,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 201.461,00
336 Aini Desmarlita LUBUK GEDANG 115118 Betahistin Mesilat 6 mg @
11/01/2021 00:00:00 1.380,00 BPJS
Flunarizine 5 mg tab 24.750,00
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 2.000,00
Total 41.135,00
337 Chandra Setiawan DUSUN AIR DIKIT 171081 Abbocath 20 Terumo @5
10/01/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Candesartan tab 8 mg
11/01/2021 00:00:00 681,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
NGT (Stomach Tube) Fr. 1 60.046,00
Nuzym Kapsul 13.200,00
Opilax Syr 49.156,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 100 mg 2.157,00
Urine bag 10.088,00
Candesartan tab 8 mg
12/01/2021 00:00:00 681,00
Cathejell 12.5g (Kateter J 52.000,00
Catheter 2 Way No. 16 ( 20.625,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
337 Chandra Setiawan DUSUN AIR DIKIT 171081 Ceftriaxone Inj
12/01/2021 00:00:00 12.498,00 BPJS
Furosemide Injeksi @2ml 1.666,00
Metoclopramide inj 5Mg/M 17.637,00
Ngt (Feeding Tube) Fr.16 10.588,00
NGT (Stomach Tube) Fr. 1 60.046,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Spironolaktone 100 mg 2.157,00
Spironolaktone 100 mg 1.438,00
Sucralfate Suspensi 100 m 19.250,00
Urine bag 10.088,00
Candesartan tab 8 mg
13/01/2021 00:00:00 681,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Metoclopramide inj 5Mg/M 17.637,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 100 mg 2.157,00
Candesartan tab 8 mg
14/01/2021 00:00:00 3.405,00
Furosemide 40 mg Tablet 480,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 49.996,00
Piralen tab 4.540,00
Sucralfate Suspensi 100 m 19.250,00
Total 786.563,00
338 Sabariah PONDOK BATU 168430 Dexametason Injeksi
10/01/2021 00:00:00 3.128,00 BPJS
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Kassa kotak stril DRC 29.025,00
Paracetamol tablet 500 m 1.000,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Abbocath 20 Terumo @5
11/01/2021 00:00:00 11.138,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Extrace Injeksi 100 mg/m 28.875,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 0,00
Kassa kotak stril DRC 29.025,00
Kassa kotak stril DRC 38.700,00
NACL 0,9 % 500 ml 8.550,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Ambroxol 30 mg @100 T
12/01/2021 00:00:00 579,00
Ascorbid Acid 1000mg/5m 78.375,00
Ceftriaxone Inj 12.498,00
Phytomenadione 10 Mg/1 17.877,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
338 Sabariah PONDOK BATU 168430 Tranexamic Acid Inj (Asa
12/01/2021 00:00:00 6.315,00 BPJS
Ambroxol 30 mg @100 T
13/01/2021 00:00:00 1.930,00
Cuticell Classic 10cmx10c 13.800,00
Kassa kotak stril DRC 29.025,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 4.000,00
Vitamin C tablet @100 Ta 966,00
Total 496.382,00
339 Afrizal UJUNG PADANG 116493 abbocath 18 Terumo @5
10/01/2021 00:00:00 11.138,00 BPJS
Infusion Makro (terumo) 27.225,00
Omeprazol kapsul 20 mg 6.610,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Zink Tablet 6.890,00
Total 85.427,00
340 Sri Sunarmi RAWA MULYA 181891 abbocath 18 Terumo @5
10/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Catgut Chromic 2/0 Roll ( 376.200,00
Chloramphenicol Salep M 2.351,00
Induxin 1 ml Injeksi 27.843,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
Misoprostol Tab 27.500,00
Phytomenadione 2 Mg/1M 4.834,00
Polyglycolide T-Vio 2-0 R ( 180.250,00
Ringer Laktat Otsuka 19.076,00
umbilical Cord Clamp 4.522,00
Cefadroxil tab 500 mg @1
11/01/2021 00:00:00 10.500,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 3.000,00
Total 794.308,00
341 Yustina Wati BUMI MULYA 179940 abbocath 18 Terumo @5
10/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 6.249,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 52.250,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 17.100,00
Abbocath 22 Terumo @5
11/01/2021 00:00:00 11.138,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
341 Yustina Wati BUMI MULYA 179940 Asam Folat 1 mg @100 T
11/01/2021 00:00:00 297,00 BPJS
Ceftriaxone Inj 18.747,00
Cetadop inj 15.400,00
Cetadop inj 7.700,00
Cetadop inj 7.700,00
Dobutamin Injeksi 50 mg 29.072,00
Dobutamin Injeksi 50 mg 14.536,00
Extention Tube 17.602,00
Gentamicin Injeksi 9.212,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 18.026,00
meropenem Injeksi 1 g 82.500,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 17.100,00
Opilax Syr 49.156,00
Otsu Nacl PiggyBack 100 m 37.950,00
Pantoprazole Inj 23.375,00
Three Way stopcock 74.250,00
Cetadop inj
12/01/2021 00:00:00 15.400,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Dobutamin Injeksi 50 mg 87.216,00
Dobutamin Injeksi 50 mg 29.072,00
Dobutamin Injeksi 50 mg 58.144,00
Dopamin Giulini 200 mg I 390.500,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Dewasa 41.828,00
Otsu Nacl PiggyBack 100 m 37.950,00
Transfusi Set Terumo 16.500,00
Abbocath 22 Terumo @5
13/01/2021 00:00:00 22.276,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 18.747,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Dobutamin Injeksi 50 mg 43.608,00
Dobutamin Injeksi 50 mg 14.536,00
Dopamin Giulini 200 mg I 97.625,00
Dopamin Giulini 200 mg I 195.250,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 13.088,00
meropenem Injeksi 1 g 82.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
341 Yustina Wati BUMI MULYA 179940 Methylprednisolone Inje
13/01/2021 00:00:00 104.769,00 BPJS
NACL 0,9 % 500 ml 34.200,00
NACL 0,9 % 500 ml 25.650,00
Pantoprazole Inj 23.375,00
Pantoprazole Inj 46.750,00
Abbocath 22 Terumo @5
14/01/2021 00:00:00 22.276,00
Asam Folat 1 mg @100 T 297,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 24.996,00
Cetadop inj 23.100,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
meropenem Injeksi 1 g 82.500,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 17.100,00
Nystatin Drop 27.830,00
Pantoprazole Inj 46.750,00
Urine bag 10.088,00
Ceftriaxone Inj
15/01/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
meropenem Injeksi 1 g 82.500,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 34.200,00
Pantoprazole Inj 46.750,00
Venturi Mask Dewasa Ge 34.375,00
Cetadop inj
16/01/2021 00:00:00 23.100,00
Dobutamin Injeksi 50 mg 43.608,00
Dobutamin Injeksi 50 mg 43.608,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 24.998,00
Total 3.228.367,00
342 Kurnia Wulandari TIRTA MAKMUR 172942 Abbocath 20 Terumo @5
11/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 9.384,00
Infusion Makro (terumo) 27.225,00
Otsu MgSO4 40 % 4.745,00
Ringer Laktat Otsuka 9.538,00
Tonotan tab 9.146,00
Tonotan tab 9.146,00
Total 106.959,00
343 Afrizal UJUNG PADANG 116493 Methylprednisolone Inje
11/01/2021 00:00:00 558.768,00 BPJS
Pantoprazole Inj 46.750,00
Ranitidin inj 7.160,00
Methylprednisolone Inje
13/01/2021 00:00:00 419.076,00
Pantoprazole Inj 46.750,00
Ranitidin inj 7.160,00
Ringer Laktat Otsuka 38.152,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
343 Afrizal UJUNG PADANG 116493 Mecobalamin 500 mg
14/01/2021 00:00:00 4.620,00 BPJS
Methylprednisolone Inje 139.692,00
Pantoprazole Inj 23.375,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Methylprednisolone Inje
15/01/2021 00:00:00 139.692,00
Pantoprazole Inj 23.375,00
Ranitidin inj 3.580,00
Methylprednisolone Inje
16/01/2021 00:00:00 139.692,00
Pantoprazole Inj 23.375,00
Ranitidin inj 3.580,00
Furamin Injeksi
15/03/2021 00:00:00 0,00
Furamin Injeksi 0,00
Psidii Capsule 500 mg 0,00
Psidii Capsule 500 mg 0,00
Total 1.647.453,00
344 Kurnia Wulandari TIRTA MAKMUR 172942 Aqua Pro Injeksi
12/01/2021 00:00:00 3.575,00 BPJS
Cefotaxime Injeksi 11.502,00
Hystolan Tab 20 mg 11.138,00
Cefotaxime Injeksi
13/01/2021 00:00:00 11.502,00
Tonotan tab 4.573,00
Cefotaxime Injeksi
15/01/2021 00:00:00 11.502,00
Tonotan tab 9.146,00
Total 62.938,00
345 Arlan LUBUK BENTO 181893 Abbocath 20 Terumo @5
11/01/2021 00:00:00 33.414,00 BPJS
Ambroxol 30 mg @100 T 579,00
Aspilet 80 mg @100 mg 138,00
Digoxsin tab 0,25 mg 288,00
Furosemide 40 mg Tablet 288,00
Infusion Makro (terumo) 27.225,00
Methylprednisolon tablet 8 2.874,00
Ringer Laktat Otsuka 9.538,00
Aspilet 80 mg @100 mg 138,00
Ceftriaxone Inj 12.498,00
Digoxsin tab 0,25 mg 432,00
Erphafillin Tab 1.107,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 9.700,00
Metoclopramide inj 5Mg/M 17.637,00
Ranitidin inj 5.370,00
Sucralfate Suspensi 100 m 19.250,00
Digoxsin tab 0,25 mg
12/01/2021 00:00:00 1.440,00
Erphafillin Tab 3.690,00
Furosemide 40 mg Tablet 960,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Piralen tab 4.540,00
Total 163.964,00
346 Yosi Komalasari LUBUK SANAI 181894 Abbocath 20 Terumo @5
11/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 7.150,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
346 Yosi Komalasari LUBUK SANAI 181894 Catheter 2 Way No. 16 (
11/01/2021 00:00:00 20.625,00 BPJS
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 8.244,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Pethidin HCL Injeksi 50 m 24.351,00
Polypropylene 3/0 C (Ass 235.200,00
Polypropylene 3/0 C (Ass 235.200,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.758.931,00
347 Philia Maika Putri LUBUK SANAI 181897 Ambroxol Syr 15mg/ml
11/01/2021 00:00:00 4.538,00 BPJS
Combivent 6.256,00
CTM (Klorfeniramina mal 232,00
Nebulizer O2 Anak 18.219,00
Prednison tab 5 mg 3.585,00
Salbutamol 2 mg 1.185,00
Total 34.015,00
348 Yani AIR DIKIT 141940 Cetirgi Tab 10 mg
11/01/2021 00:00:00 15.480,00 BPJS
Erphafillin Tab 22.140,00
Omeprazol kapsul 20 mg 3.305,00
Symbicort Turbuhaler 80 167.855,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 208.780,00
349 Rahina SEMUNDAM 181900 Omeprazol kapsul 20 mg
11/01/2021 00:00:00 3.305,00 BPJS
Total 3.305,00
350 Hoky Hermansyah MARGA MULIA 181901 Cefadroxil tab 500 mg @1
11/01/2021 00:00:00 15.750,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Hypafix 15cmx5cm (25 c 6.544,00
Paracetamol tablet 500 m 2.000,00
Total 31.194,00
351 Afrianto TAPAN 144878 Meloxicam 15 mg
11/01/2021 00:00:00 12.600,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 2.000,00
Renogen 3000 UI 116.875,00
Total 174.225,00
352 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
11/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
353 Narti SILAUT 175653 NACL 0,9 % 500 ml
11/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
354 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
11/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
355 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
11/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
356 Ashari Liwandi PONDOK LUNANG 139398 Amlodipine 10 mg @50 T
11/01/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Azitromycin 500 mg 16.875,00
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 59.850,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 201.814,00
357 M Akil PASAR BELAKANG 115376 Amlodipine 10 mg @50 T
11/01/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 59.850,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 182.392,00
358 Supangat PONDOK LUNANG 147511 Amlodipine 10 mg @50 T
11/01/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 76.614,00
359 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
11/01/2021 00:00:00 68.400,00 BPJS
Nassal Cannula O2 Anak 16.473,00
Renogen 3000 UI 116.875,00
Total 201.748,00
360 Wardoyo TANJUNG MULYA 125079 Amlodipine 10 mg @50 T
11/01/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 193.192,00
361 Effendi penarik 181556 Betahistin Mesilat 6 mg @
11/01/2021 00:00:00 1.380,00 BPJS
Candesartan tab 8 mg 13.620,00
Flunarizine 5 mg tab 24.750,00
Total 39.750,00
362 Masri Pani UJUNG PADANG 157866 Omeprazol kapsul 20 mg
11/01/2021 00:00:00 6.610,00 BPJS
Piralen tab 4.540,00
ursodeoxycholic acid 28.350,00
Total 39.500,00
363 Sapril SIBAK 181906 Amlodipine 10 mg @50 T
11/01/2021 00:00:00 3.540,00 BPJS
Candesartan tab 8 mg 20.430,00
Metformin tablet 500 mg 7.980,00
Total 31.950,00
364 Nurhayati LUBUK PINANG 178631 Betahistin Mesilat 6 mg @
11/01/2021 00:00:00 1.380,00 BPJS
Methylprednisolone tab 4 7.890,00
Omeprazol kapsul 20 mg 3.305,00
Total 12.575,00
365 Marlin TRAS TERUNJAM 179516 Salbutamol 4 mg
11/01/2021 00:00:00 465,00 BPJS
Ventolin Nebules 2.5 mg 10.000,00
Total 10.465,00
366 Zulkifli DUSUN BARU PELOKA 181910 Acetylcystein 200 mg Ka
11/01/2021 00:00:00 34.380,00 BPJS
Erphafillin Tab 7.380,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 2.000,00
Salbutamol 4 mg 1.860,00
Total 48.925,00
367 Saidi BUKIT MAKMUR 181741 Amlodipine 5 mg @30 T
11/01/2021 00:00:00 3.030,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Candesartan tab 8 mg 20.430,00
Citicoline kaplet 500 mg 49.500,00
Total 77.100,00
368 Suhardi BANDAR RATU 115774 Alprazolam 1 mg @100 T
11/01/2021 00:00:00 1.600,00 BPJS
Amlodipine 10 mg @50 T 2.360,00
Clopidogrel 75 mg @30 T 35.100,00
Total 39.060,00
369 Asmira Fadhilla Janna AGUNG JAYA 181915 abbocath 18 Terumo @5
11/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
369 Asmira Fadhilla Janna AGUNG JAYA 181915 Otsu MgSO4 40 %
11/01/2021 00:00:00 4.745,00 BPJS
Ringer Laktat Otsuka 9.538,00
Tonotan tab 9.146,00
Transfusi Set Terumo 16.500,00
Utrogestan 100 mg Kapsu 27.432,00
Total 98.426,00
370 Anggi Lianto LUBUK BENTO 125958 Dexametason Injeksi
11/01/2021 00:00:00 9.384,00 BPJS
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 17.100,00
Codein tab 10 mg
12/01/2021 00:00:00 7.500,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Transfusi Set Terumo 16.500,00
Total 82.445,00
371 Desma Zalnita SILAUT 181848 Abbocath 20 Terumo @5
11/01/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Transfusi Set Terumo 16.500,00
Ciprofloxacin tab 500 mg
12/01/2021 00:00:00 5.590,00
Paracetamol tablet 500 m 3.000,00
Total 478.611,00
372 Sukamad AIR KASAI 143420 Abbocath 20 Terumo @5
11/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Gentamicin Injeksi 9.212,00
Infusion Makro (terumo) 27.225,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
NGT (Stomach Tube) Fr. 1 60.046,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
372 Sukamad AIR KASAI 143420 NonWoven Fixation 15x
11/01/2021 00:00:00 6.694,00 BPJS
Ringer Laktat Otsuka 19.076,00
Urine bag 10.088,00
Total 198.087,00
373 Bisyri Mustofa SUMBER MAKMUR 181907 Abbocath 20 Terumo @5
11/01/2021 00:00:00 11.138,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
NACL 0,9 % 500 ml 34.200,00
Nassal Cannula O2 Anak 16.473,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Total 349.440,00
374 Asmira Fadhilla Janna AGUNG JAYA 181915 Cefadroxil tab 500 mg @1
13/01/2021 00:00:00 10.500,00 BPJS
Cefotaxime Injeksi 11.502,00
Tonotan tab 13.719,00
Tonotan tab 22.865,00
Utrogestan 100 mg Kapsu 301.752,00
Utrogestan 100 mg Kapsu 384.048,00
Total 744.386,00
375 Zhagita Natasya Putri DESA TUNGGANG 176591 abbocath 18 Terumo @5
11/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 99,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Vitamin B Komplek @100 462,00
Total 56.813,00
376 Yosi Komalasari LUBUK SANAI 181894 Cefotaxime Injeksi
11/01/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
12/01/2021 00:00:00 3.575,00
Bisturi No. 15 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Aqua Pro Injeksi
13/01/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
376 Yosi Komalasari LUBUK SANAI 181894 Ketorolac inj 30 mg/1ml
13/01/2021 00:00:00 2.690,00 BPJS
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Asam Mefenamat 500 m
14/01/2021 00:00:00 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 268.311,00
377 Bisyri Mustofa SUMBER MAKMUR 181907 Ceftriaxone Inj
11/01/2021 00:00:00 12.498,00 BPJS
Codein tab 10 mg 1.500,00
Diltiazem 30 mg 338,00
Metoclopramide inj 5Mg/M 0,00
NACL 0,9 % 500 ml 51.300,00
Nassal Cannula O2 Dewas 11.625,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Ceftriaxone Inj
12/01/2021 00:00:00 0,00
Codein tab 10 mg 0,00
Diltiazem 30 mg 0,00
Epinephrin inj 30.662,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
Ranitidin inj 1.790,00
Stesolid Inj 2 ml 0,00
Total 246.886,00
378 Zhagita Natasya Putri DESA TUNGGANG 176591 NACL 0,9 % 500 ml
11/01/2021 00:00:00 8.550,00 BPJS
Asam Folat 1 mg @100 T
12/01/2021 00:00:00 99,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
NACL 0,9 % 500 ml 8.550,00
Vitamin B Komplek @100 308,00
Total 22.170,00
379 Sukamad AIR KASAI 143420 Antrain Injeksi
12/01/2021 00:00:00 28.875,00 BPJS
Ceftriaxone Inj 12.498,00
Gentamicin Injeksi 9.212,00
Kassa kotak stril DRC 19.350,00
Metrodinazole Infus 41.252,00
Miniaspi 80 Mg @100 Ta 125,00
NACL 0,9 % 500 ml 8.550,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 308,00
Antrain Injeksi
13/01/2021 00:00:00 28.875,00
Aspilet 80 mg @100 mg 138,00
Ceftriaxone Inj 12.498,00
Gentamicin Injeksi 9.212,00
Kassa kotak stril DRC 29.025,00
Metrodinazole Infus 41.252,00

19/08/2021 12:42:30 Page 95 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
379 Sukamad AIR KASAI 143420 NACL 0,9 % 500 ml
13/01/2021 00:00:00 8.550,00 BPJS
NonWoven Fixation 15x 20.082,00
Ottogenta inj 39.600,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 9.538,00
Vitamin B Komplek @100 308,00
Aspilet 80 mg @100 mg
14/01/2021 00:00:00 690,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Levofloxacin Tablet 500 m 6.820,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 487.700,00
380 Chumaidah LUBUK MUKTI 181610 abbocath 18 Terumo @5
11/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Alkohol 1Liter
12/01/2021 00:00:00 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 8.993,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 18.000,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 256.370,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00

19/08/2021 12:42:30 Page 96 of 185

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
380 Chumaidah LUBUK MUKTI 181610 Polyvinylidene 3-0 R (Tri
12/01/2021 00:00:00 92.000,00 BPJS
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Abbocath 20 Terumo @5
13/01/2021 00:00:00 22.276,00
Cefotaxime Injeksi 11.502,00
Ceftriaxone Inj 12.498,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Bisturi no. 10
14/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
15/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 2.108.648,00
381 Anuar PONDOK PANJANG 181916 abbocath 18 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 10 mg @50 T 590,00
Cefixime Kapsul 100 mg 9.380,00
Total 141.285,00
382 Normita SARI BULAN 181917 Combivent
12/01/2021 00:00:00 12.512,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
382 Normita SARI BULAN 181917 Salbutamol 2 mg
12/01/2021 00:00:00 790,00 BPJS
Total 13.302,00
383 Azzalea Lovika Rahmada LUBUK SANAI 173113 Gentamicin Injeksi
12/01/2021 00:00:00 4.606,00 BPJS
Otopain Ear Drops 8 ml 99.688,00
Paracetamol syrup 1.388,00
Total 105.682,00
384 Rusli Asbi SILAUT 174646 Gitas Plus
12/01/2021 00:00:00 50.330,00 BPJS
Renax @50 Kapsul 113.440,00
Urinter Kapsul @100 cap 21.980,00
Total 185.750,00
385 Samudi DANAU NIBUNG 143871 Bisoprolol 5 mg @100 Ta
12/01/2021 00:00:00 4.440,00 BPJS
Codein tab 10 mg 7.500,00
Furosemide 40 mg Tablet 1.440,00
Isosorbid dinitrat 5 mg (I 1.665,00
Spironolaktone 25 mg 3.900,00
Total 18.945,00
386 Sudarman PENARIK 179781 Gitas Plus
12/01/2021 00:00:00 50.330,00 BPJS
Renax @50 Kapsul 340.320,00
Urinter Kapsul @100 cap 21.980,00
Total 412.630,00
387 Ida Rayani LUBUK SANAI 180191 abbocath 18 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 62.430,00
388 Martis SURIAN BUNGKAL 181754 Postofix (leukomed)
12/01/2021 00:00:00 36.726,00 BPJS
Total 36.726,00
389 Tri Citra Retha Sandi GAJAH MATI 180509 Gitas Plus
12/01/2021 00:00:00 50.330,00 BPJS
Renax @50 Kapsul 340.320,00
Urinter Kapsul @100 cap 21.980,00
Total 412.630,00
390 Slamet SILAUT 113415 Bisoprolol 5 mg @100 Ta
12/01/2021 00:00:00 4.440,00 BPJS
Candesartan tab 8 mg 20.430,00
Flunarizine 5 mg tab 24.750,00
Isosorbid dinitrat 5 mg (I 1.110,00
Spironolaktone 25 mg 7.800,00
Total 58.530,00
391 Melda Restita PAUH TERENJA 164287 abbocath 18 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 62.430,00
392 Idrus TANJUNG ALAI 111671 Paracetamol tablet 500 m
12/01/2021 00:00:00 2.000,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 23.980,00
393 Wirda BANDAR RATU 136453 Cefadroxil tab 500 mg @1
12/01/2021 00:00:00 10.500,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 10.500,00
394 Slamet Suhari PT AGRO TALANG PET 173868 Asam Mefenamat 500 m
12/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Methylprednisolone tab 4 2.630,00
Total 14.420,00
395 Amandeka Jaya AIR BIKUK 161881 Cefixime syrup 100mg/5 M
12/01/2021 00:00:00 23.823,00 BPJS
Furamin Injeksi 143.690,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 2.000,00
Total 218.669,00
396 Vita Zurnilawati AIR DIKIT 132186 Asam Folat 1 mg @100 T
12/01/2021 00:00:00 990,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 16.630,00
397 Maryati AIR DIKIT 146596 KSR (potassium chloride)
12/01/2021 00:00:00 46.060,00 BPJS
Mecobalamin 500 mg 11.550,00
Omeprazol kapsul 20 mg 3.305,00
Total 60.915,00
398 Rabaiti AUR CINA 150014 Levemir FlexPen
12/01/2021 00:00:00 104.938,00 BPJS
Metformin tablet 500 mg 3.990,00
Novo Twist 32 G Tip 7.812,00
Pregabalin Kap 75 mg 64.460,00
Total 181.200,00
399 Merri Lestary PONDOK BATU 125314 Alprazolam 0,5 mg @100
12/01/2021 00:00:00 354,00 BPJS
Clopidogrel 75 mg @30 T 17.550,00
Paracetamol tablet 500 m 2.000,00
Pregabalin Kap 75 mg 64.460,00
Total 84.364,00
400 Hanisa DANAU LEBAR 161905 CAL-95 tab
12/01/2021 00:00:00 62.700,00 BPJS
Emibion kapsul 19.660,00
Total 82.360,00
401 Wahiri TALANG SEPAKAT 181795 Glucosamine 250 mg
12/01/2021 00:00:00 15.400,00 BPJS
Meloxicam 15 mg 12.600,00
Pregabalin Kap 75 mg 64.460,00
Total 92.460,00
402 Adeng Caniago PELOKAN 168831 Gitas Plus
12/01/2021 00:00:00 50.330,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 76.190,00
403 M.ilham Erdin Satria LUBUK PINANG 138074 Cefadroxil tab 500 mg @1
12/01/2021 00:00:00 15.750,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 18.750,00
404 Azwani KOTO JAYA 112288 Bisoprolol 5 mg @100 Ta
12/01/2021 00:00:00 4.440,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 3.305,00
Pregabalin Kap 75 mg 64.460,00
Simvastatin tab 10 mg 2.410,00
Total 147.695,00
405 Nur Aripin KOTO JAYA 115218 Betametason krim 0,1%
12/01/2021 00:00:00 1.675,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
405 Nur Aripin KOTO JAYA 115218 Clopidogrel 75 mg @30 T
12/01/2021 00:00:00 52.650,00 BPJS
Renax @50 Kapsul 56.720,00
Simvastatin tab 10 mg 7.230,00
Total 143.145,00
406 Lena Br Panggabean SIDO MAKMUR 174000 Flunarizine 5 mg tab
12/01/2021 00:00:00 24.750,00 BPJS
Mecobalamin 500 mg 11.550,00
Metformin tablet 500 mg 3.990,00
Paracetamol tablet 500 m 2.000,00
Total 42.290,00
407 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
12/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
408 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
12/01/2021 00:00:00 42.750,00 BPJS
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 164.995,00
409 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
12/01/2021 00:00:00 42.750,00 BPJS
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 164.995,00
410 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
12/01/2021 00:00:00 42.750,00 BPJS
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 164.995,00
411 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
12/01/2021 00:00:00 42.750,00 BPJS
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 164.995,00
412 Maijon Purba PT AGRO ABE 154034 Doxycyclin kapsul 100 m
12/01/2021 00:00:00 7.280,00 BPJS
Mecobalamin 500 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Total 16.980,00
413 Alamsyah AIR PUNGGUR 121137 Atorvastatin 20 mg @30 T
12/01/2021 00:00:00 15.675,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Clopidogrel 75 mg @30 T 26.325,00
Isosorbid dinitrat 5 mg (I 2.220,00
Omeprazol kapsul 20 mg 3.305,00
Total 50.485,00
414 Muhtasim PENARIK 147374 Atorvastatin 20 mg @30 T
12/01/2021 00:00:00 15.675,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Isosorbid dinitrat 5 mg (I 1.665,00
Paracetamol tablet 500 m 2.000,00
Total 22.300,00
415 Nelda Suprianti RAWA MULYA 136291 Alprazolam 0,5 mg @100
12/01/2021 00:00:00 590,00 BPJS
Flunarizine 5 mg tab 24.750,00
Levemir FlexPen 104.938,00
Metformin tablet 500 mg 3.990,00
Novo Twist 32 G Tip 7.812,00
Pregabalin Kap 75 mg 64.460,00
Total 206.540,00
416 Alfiah PENARIK 139228 Asam Mefenamat 500 m
12/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00

19/08/2021 12:42:30 Page 100 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
416 Alfiah PENARIK 139228 Metrodinazole tab 500 m
12/01/2021 00:00:00 4.050,00 BPJS
Postofix (leukomed) 36.726,00
Total 52.566,00
417 Ida Rayani LUBUK SANAI 180191 abbocath 18 Terumo @5
12/01/2021 00:00:00 22.276,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 10 Mg/1 5.959,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 14.025,00
Topi Operasi (Perawat) @ 4.690,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefadroxil tab 500 mg @1
13/01/2021 00:00:00 10.500,00
Cefadroxil tab 500 mg @1 10.500,00
Paracetamol tablet 500 m 3.000,00
Paracetamol tablet 500 m 3.000,00
Total 1.501.616,00
418 Melda Restita PAUH TERENJA 164287 Asam Mefenamat 500 m
12/01/2021 00:00:00 387,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 17.253,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
418 Melda Restita PAUH TERENJA 164287 Dexametason Injeksi
12/01/2021 00:00:00 6.256,00 BPJS
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Metrodinazole Infus 30.939,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 14.025,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Asam Traneksamat @10
13/01/2021 00:00:00 4.210,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Metrodinazole Infus 20.626,00
Metrodinazole Infus 20.626,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 20.082,00
NonWoven Fixation 15x 20.082,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 22 Terumo @5
14/01/2021 00:00:00 33.414,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metrodinazole Infus 30.939,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00

19/08/2021 12:42:30 Page 102 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
418 Melda Restita PAUH TERENJA 164287 Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 2.140.436,00
419 Pensi Juliati SUNGAI GADING 181929 Azitromycin 500 mg
12/01/2021 00:00:00 28.125,00 BPJS
Codein tab 10 mg 7.500,00
Curcuma Tab 6.350,00
Tranexamic Acid Inj (Asa 21.050,00
Total 63.025,00
420 Buyung Anam LUBUK GEDANG 133634 Abbocath 20 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Antrain Injeksi 28.875,00
Aqua Pro Injeksi 3.575,00
Cefoperazon Inj 82.500,00
Ciprofloxacin tab 500 mg 5.590,00
Furamin Injeksi 14.369,00
Hepa Q @30 tab 8.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Ondansetron Inj 1.650,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Sistenol kaplet 5.262,00
Total 253.858,00
421 Asupli LUBUK SANAI 181921 Abbocath 20 Terumo @5
12/01/2021 00:00:00 22.276,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Bisturi No. 15 3.836,00
Ceftriaxone Inj 12.498,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
handscoond steril 8 (Gam 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 2.000,00
Pehacain Injeksi 6.640,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Silk 3/0 R scimitar 122.090,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Perawat) @ 4.690,00
Transfusi Set Terumo 16.500,00
Ciprofloxacin tab 500 mg
13/01/2021 00:00:00 5.590,00
Paracetamol tablet 500 m 3.000,00
Ranitidine tablet 150 mg 1.440,00
Amlodipine 5 mg @30 T
14/01/2021 00:00:00 2.020,00

19/08/2021 12:42:30 Page 103 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
421 Asupli LUBUK SANAI 181921 Azitromycin 500 mg
14/01/2021 00:00:00 56.250,00 BPJS
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 520.016,00
422 Afrilia Novita Sari PT AGRO TANAH REKA 181924 Abbocath 20 Terumo @5
12/01/2021 00:00:00 22.276,00 BPJS
ATRACURIUM BESYLATE 2 14.671,00
Bisturi No. 23 3.836,00
Ceftriaxone Inj 6.249,00
Celemek Plastik 89.930,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Polyvinylidene 3-0 R (Tri 92.000,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 8.495,00
Cefadroxil tab 500 mg @1
13/01/2021 00:00:00 10.500,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Paracetamol tablet 500 m 4.000,00
Total 912.295,00
423 Mustofa Apriyendi MEKAR MULYA 181895 Abbocath 20 Terumo @5
12/01/2021 00:00:00 22.276,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Hypafix 10cm x 5cm (25 c 14.550,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Metrodinazole Infus 20.626,00
Polyglycolide T-Vio 1 R ( 98.500,00

19/08/2021 12:42:30 Page 104 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
423 Mustofa Apriyendi MEKAR MULYA 181895 Polyvinylidene 3-0 R (Tri
12/01/2021 00:00:00 92.000,00 BPJS
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Perawat) @ 4.690,00
Transfusi Set Terumo 16.500,00
viamac 1 R 182.185,00
Ceftriaxone Inj
13/01/2021 00:00:00 12.498,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Omeprazole Inj 12.499,00
Abbocath 20 Terumo @5
14/01/2021 00:00:00 22.276,00
Antasida Doen 400 mg @ 750,00
Cathejell 12.5g (Kateter J 52.000,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 25.878,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
NGT (Stomach Tube) Fr. 1 60.046,00
NGT (Stomach Tube) Fr. 1 60.046,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 19.076,00
Urine bag 10.088,00
Atropin injek 1 ml
15/01/2021 00:00:00 20.907,00
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Ephedrine Injeksi 53.555,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 72.770,00
Handscoond Sterille 7 (G 43.689,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Masker Karet 22.000,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 68.400,00
NGT (Stomach Tube) Fr. 1 52.250,00

19/08/2021 12:42:30 Page 105 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
423 Mustofa Apriyendi MEKAR MULYA 181895 Omeprazole Inj
15/01/2021 00:00:00 12.499,00 BPJS
Paracetamol Infus 43.314,00
Polyglycolide T-Vio 1 R ( 98.500,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 47.690,00
Ringer Laktat Otsuka 19.076,00
silk 1 R scimitar 81.851,00
Spinocain 25 (BBraund) 85.526,00
Spinocain 27 (BBraund) 95.750,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj
16/01/2021 00:00:00 12.498,00
Metrodinazole Infus 20.626,00
Omeprazole Inj 12.499,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Aminofluid Infus 500 ml
17/01/2021 00:00:00 465.612,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 13.088,00
Ka-En Mg3 26.208,00
Metrodinazole Infus 30.939,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Aminofluid Infus 500 ml
18/01/2021 00:00:00 310.408,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Furamin Injeksi 28.738,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole Infus 30.939,00
Omeprazole Inj 12.499,00
Aminofluid Infus 500 ml
19/01/2021 00:00:00 310.408,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Furamin Injeksi 28.738,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ka-En Mg3 13.104,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole Infus 20.626,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00

19/08/2021 12:42:30 Page 106 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
423 Mustofa Apriyendi MEKAR MULYA 181895 Ciprofloxacin tab 500 mg
20/01/2021 00:00:00 5.590,00 BPJS
Cuticell Classic 10cmx10c 20.700,00
Fentanyl Injeksi 5 Ampul 2 156.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Omeprazole Inj 62.495,00
Paracetamol tablet 500 m 2.000,00
Total 5.202.506,00
424 Andres Suprianto LUBUK SANAI 152538 Abbocath 20 Terumo @5
12/01/2021 00:00:00 22.276,00 BPJS
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 7.150,00
Bisturi No. 23 0,00
Bucain Spinal 0.5 % Inj 0,00
Catheter 2 Way No. 16 ( 0,00
Cauter (Hand-controlled P 162.161,00
Ceftriaxone Inj 12.498,00
Celestik tablet 16.850,00
Chromic catgut 1 R (Tri 0,00
Chromic catgut 2-0 R (Tr 0,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 0,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 0,00
Gelaufusal Infusion 500 m 0,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril 7,5 (Ga 0,00
Handscoond Non Steril M 0,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 6.5 (G 0,00
handscoond steril 8 (Gam 14.554,00
handscoond steril 8 (Gam 0,00
Handscoond Sterille 7 (G 0,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 0,00
Induxin 1 ml Injeksi 0,00
Infusion Makro (terumo) 27.225,00
Iodine povidone 300 ml 0,00
Ketorolac inj 30 mg/1ml 0,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Masker Tali 0,00
Misoprostol Tab 0,00
Myotonic inj 0,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 0,00
Ondansetron Inj 0,00
Pehacain Injeksi 0,00
Polyglycolide T-Vio 1 R ( 0,00
Polyglycolide T-Vio 3-0 R ( 172.000,00
Polyvinylidene 3-0 R (Tri 0,00

19/08/2021 12:42:30 Page 107 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
424 Andres Suprianto LUBUK SANAI 152538 Ranitidin inj
12/01/2021 00:00:00 1.790,00 BPJS
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 0,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 0,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 10 cc Disposible (T 0,00
Spuit 3 cc Terumo 0,00
Spuit 5 cc Disposible 7.100,00
Spuit 5 cc terumo 0,00
Suction Chateter no. 12 ( 21.176,00
Suprafenid Supositoria 10 0,00
Topi Operasi (Perawat) @ 4.690,00
Topi Operasi (Perawat) @ 0,00
Tramadol 50 mg/ml Inj 0,00
Tranexamic Acid Inj (Asa 8.420,00
Tranexamic Acid Inj (Asa 0,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 0,00
Aqua Pro Injeksi
13/01/2021 00:00:00 7.150,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Pantoprazole Inj 23.375,00
Ranitidin inj 3.580,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Cefadroxil tab 500 mg @1
14/01/2021 00:00:00 10.500,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 3.000,00
Total 876.337,00
425 Zukriman LUBUK GEDANG 160918 Meloxicam 7,5 mg
12/01/2021 00:00:00 2.184,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 153.859,00
426 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
12/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
427 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
12/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
428 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
12/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
429 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
12/01/2021 00:00:00 34.200,00 BPJS

19/08/2021 12:42:30 Page 108 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
429 Susi Martini KOTO JAYA 145038 Renogen 3000 UI
12/01/2021 00:00:00 116.875,00 BPJS
Total 151.075,00
430 Yayuk Basuki PONDOK BATU 181930 Aqua Pro Injeksi
12/01/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole Infus 30.939,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Cefotaxime Injeksi
13/01/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Cefotaxime Injeksi
14/01/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
430 Yayuk Basuki PONDOK BATU 181930 Ringer Laktat Otsuka
14/01/2021 00:00:00 9.538,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
15/01/2021 00:00:00 3.575,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.431.284,00
431 Erna Irawati Lubis DUSUN BARU PELOKA 181931 Abbocath 20 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 34.200,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 125.703,00
432 Buyung Anam LUBUK GEDANG 133634 Antrain Injeksi
12/01/2021 00:00:00 28.875,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Acetylcystein 200 mg Ka
13/01/2021 00:00:00 5.157,00
Antrain Injeksi 19.250,00
Cefadroxil tab 500 mg @1 2.100,00
Cefoperazon Inj 82.500,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
ursodeoxycholic acid 5.670,00
vestein 300 mg 14.025,00
Antrain Injeksi
14/01/2021 00:00:00 28.875,00
Cefoperazon Inj 82.500,00
Ciprofloxacin tab 500 mg 1.118,00
Furamin Injeksi 14.369,00
Hepa Q @30 tab 8.662,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 28.614,00
ursodeoxycholic acid 5.670,00
Hepa Q @30 tab
15/01/2021 00:00:00 64.965,00
Levofloxacin Tablet 500 m 13.640,00
Opilax Syr 49.156,00
Sistenol kaplet 17.540,00
ursodeoxycholic acid 42.525,00
Total 732.201,00

19/08/2021 12:42:30 Page 110 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
433 Erna Irawati Lubis DUSUN BARU PELOKA 181931 Abbocath 20 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 51.300,00
NACL 0,9 % 500 ml 34.200,00
NGT (Stomach Tube) Fr. 1 60.046,00
Novo Twist 32 G Tip 5.208,00
Omeprazole Inj 12.499,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Ceftriaxone Inj
13/01/2021 00:00:00 12.498,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 2.000,00
Ceftriaxone Inj
14/01/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ceftriaxone Inj
15/01/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Levofloxacin Infus
16/01/2021 00:00:00 24.488,00
Levofloxacin Tablet 500 m 13.640,00
Metformin tablet 500 mg 1.330,00
Novo Twist 32 G Tip 5.208,00
Novorapid Flexpen 108.750,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 49.996,00
Omeprazole Inj 24.998,00
Piralen tab 4.540,00
Total 898.792,00
434 Pepti Mahtika Sari AIR BULUH 181932 abbocath 18 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole Infus 10.313,00
Ringer Laktat Otsuka 9.538,00

19/08/2021 12:42:30 Page 111 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
434 Pepti Mahtika Sari AIR BULUH 181932 Transfusi Set Terumo
12/01/2021 00:00:00 16.500,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 3.128,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 58.216,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker 3 Play N. 95 51.274,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 5.879,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 98.500,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 4.260,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Cefotaxime Injeksi
13/01/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Cefotaxime Injeksi
14/01/2021 00:00:00 17.253,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.080,00
Metrodinazole tab 500 m 810,00

19/08/2021 12:42:30 Page 112 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
434 Pepti Mahtika Sari AIR BULUH 181932 Tranexamic Acid Inj (Asa
14/01/2021 00:00:00 6.315,00 BPJS
Asam Mefenamat 500 m
15/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.475.661,00
435 Nurhayati ARAH TIGA 114028 Abbocath 20 Terumo @5
12/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Levemir FlexPen 104.938,00
NACL 0,9 % 500 ml 8.550,00
Novo Twist 32 G Tip 2.604,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Total 210.197,00
436 Ny Yayuk Basuki PONDOK BATU 181933 Abbocath 24 Terumo @5
12/01/2021 00:00:00 33.414,00 BPJS
Bisturi No. 15 3.836,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00
Injection plug 20.213,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
15/01/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Nassal Cannula O2 bayi
16/01/2021 00:00:00 9.530,00
Total 225.015,00
437 Nurhayati ARAH TIGA 114028 azitromicin syr 200mg/5m
13/01/2021 00:00:00 30.776,00 BPJS
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 4.950,00
NACL 0,9 % 500 ml 25.650,00
Omeprazol kapsul 20 mg 0,00
Ondansetron Inj 4.950,00
Azitromycin 500 mg
14/01/2021 00:00:00 5.625,00
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 4.950,00
Loratadine tab 10 mg 166,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Flunarizine 5 mg tab
15/01/2021 00:00:00 24.750,00
Hypafix 10cm x 5cm (25 c 14.550,00
Levofloxacin Tablet 500 m 6.820,00
Loratadine tab 10 mg 1.660,00
Novo Twist 32 G Tip 5.208,00

19/08/2021 12:42:30 Page 113 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 231.349,00
438 Agus Setiawan GAJAH MAKMUR 181934 Antrain Injeksi
12/01/2021 00:00:00 28.875,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Cetadop inj 7.700,00
Electroda (Ambu) @25 Pc 81.570,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 18.026,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 19.076,00
Sistenol kaplet 1.754,00
Urine bag 10.088,00
Zink Tablet 689,00
Cetadop inj 15.400,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 19.076,00
Three Way stopcock 37.125,00
Abbocath 20 Terumo @5
13/01/2021 00:00:00 22.276,00
Abbocath 22 Terumo @5 22.276,00
Acetylcystein 200 mg Ka 6.876,00
Antrain Injeksi 19.250,00
Azitromycin 500 mg 28.125,00
Bisoprolol 5 mg @100 Ta 1.480,00
Ceftriaxone Inj 12.498,00
Dopamin Giulini 200 mg I 97.625,00
Hypafix 10cm x 5cm (25 c 4.850,00
Loperamide HCL tab 2 m 300,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Psidii Capsule 500 mg 49.010,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Zink Tablet 2.067,00
Antrain Injeksi
14/01/2021 00:00:00 28.875,00
Azitromycin 500 mg 5.625,00
Bisoprolol 5 mg @100 Ta 296,00
Ceftriaxone Inj 12.498,00
Cetadop inj 23.100,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00

19/08/2021 12:42:30 Page 114 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
438 Agus Setiawan GAJAH MAKMUR 181934 Hypafix 15cmx5cm (25 c
14/01/2021 00:00:00 13.088,00 BPJS
Infusion set Mikro (Terumo 36.052,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Sistenol kaplet 7.016,00
Zink Tablet 689,00
Cefadroxil tab 500 mg @1
15/01/2021 00:00:00 10.500,00
Ceftriaxone Inj 6.249,00
Furamin Injeksi 14.369,00
Metamizole Sodium Mono 9.188,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Perifas @100 Tab 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Zink Tablet 10.335,00
Antrain Injeksi
16/01/2021 00:00:00 28.875,00
Antrain Injeksi 19.250,00
Loperamide HCL tab 2 m 300,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Sistenol kaplet 17.540,00
Sistenol kaplet 8.770,00
Zink Tablet 2.067,00
Zink Tablet 6.890,00
Total 1.334.941,00
439 Basir. T PONDOK SUGUH 161322 Abbocath 20 Terumo @5
13/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Aspilet 80 mg @100 mg 138,00
Atorvastatin 20 mg @30 T 1.045,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 6.249,00
Ceftriaxone Inj 12.498,00
Clopidogrel 75 mg @30 T 1.755,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Isosorbid dinitrat 5 mg (I 333,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Abbocath 22 Terumo @5
14/01/2021 00:00:00 33.414,00
Aspilet 80 mg @100 mg 138,00
Atorvastatin 20 mg @30 T 1.045,00

19/08/2021 12:42:30 Page 115 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
439 Basir. T PONDOK SUGUH 161322 Candesartan tab 8 mg
14/01/2021 00:00:00 681,00 BPJS
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Clopidogrel 75 mg @30 T 1.755,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Isosorbid dinitrat 5 mg (I 222,00
Isosorbid dinitrat 5 mg (I 333,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Total 374.170,00
440 Suyekti TANJUNG MULYA 181939 Ambroxol Syr 15mg/ml
13/01/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 10.215,00
Furosemide 40 mg Tablet 960,00
Spironolaktone 25 mg 2.600,00
Total 50.878,00
441 Iskandar PENARIK 181690 Acetylcystein 200 mg Ka
13/01/2021 00:00:00 17.190,00 BPJS
Amlodipine 5 mg @30 T 1.010,00
Cefadroxil Syrup 125 mg 50.830,00
Onbrez Breezhaler HGCI 0 440.640,00
Paracetamol tablet 500 m 2.000,00
Vitamin B Komplek @100 1.540,00
Total 513.210,00
442 Yulmidar SIBAK 171923 Cefadroxil tab 500 mg @1
13/01/2021 00:00:00 10.500,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 12.500,00
443 Misran PONDOK MAKMUR 119068 Hexymer 2 Mg Tab (THP)
13/01/2021 00:00:00 28.680,00 BPJS
Levopar tab 100mg 77.460,00
Sifrol tab 0,375 mg 103.750,00
Total 209.890,00
444 Helmi PONDOK PANJANG 129186 Acetylcystein 200 mg Ka
13/01/2021 00:00:00 17.190,00 BPJS
Azitromycin 500 mg 28.125,00
Total 45.315,00
445 Dian Rahmawati Sang PASAR SEBELAH 181943 Cetirizine Sirup
13/01/2021 00:00:00 3.718,00 BPJS
Paracetamol syrup 1.388,00
Total 5.106,00
446 Antoni PT TALANG PETAI 181946 Asam Mefenamat 500 m
13/01/2021 00:00:00 1.290,00 BPJS
Meloxicam 15 mg 12.600,00
Total 13.890,00
447 Nur Aminah Pulungan PT AGRO TALANG PET 181947 Eperisone Hcl 50 mg @1
13/01/2021 00:00:00 23.280,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 31.890,00
448 Ani Mariani TUNGGAL JAYA 109603 Cetirgi Tab 10 mg
13/01/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 18.110,00
449 Joni Kartio SUNGAI IPUH 178142 Paracetamol tablet 500 m
13/01/2021 00:00:00 2.000,00 BPJS

19/08/2021 12:42:30 Page 116 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
449 Joni Kartio SUNGAI IPUH 178142 Urinter Kapsul @100 cap
13/01/2021 00:00:00 21.980,00 BPJS
Total 23.980,00
450 Herli Junita TALANG PETAI 181603 Asam Mefenamat 500 m
13/01/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
451 Itma Yunita AIR DIKIT 174033 Asam Mefenamat 500 m
13/01/2021 00:00:00 1.290,00 BPJS
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Pehacain Injeksi 6.640,00
Total 20.305,00
452 Muh Juliandika Pratam PASAR MUKOUKO 181951 Cefadroxil tab 500 mg @1
13/01/2021 00:00:00 21.000,00 BPJS
Total 21.000,00
453 Ny Pepti Mahtika AIR BULUH 181950 Abbocath 24 Terumo @5
13/01/2021 00:00:00 33.414,00 BPJS
Bisturi no. 10 3.836,00
Chloramphenicol Salep M 2.351,00
Injection plug 20.213,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 15x 6.694,00
umbilical Cord Clamp 2.261,00
Total 148.864,00
454 Ponirah PONDOK SUGUH 154097 Asam Mefenamat 500 m
13/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 62.241,00
455 Agustina Luxmana Sa LUNANG 181953 Calcium Laktat
13/01/2021 00:00:00 790,00 BPJS
Total 790,00
456 M. Iqbal Maulana DUSUN BARU PELOKA 181785 Cefadroxil tab 500 mg @1
13/01/2021 00:00:00 10.500,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 12.500,00
457 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
13/01/2021 00:00:00 34.200,00 BPJS
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 156.445,00
458 Mei Rita Sari SUMBER MAKMUR 181796 Asam Mefenamat 500 m
13/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 52.566,00
459 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
13/01/2021 00:00:00 34.200,00 BPJS
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 156.445,00
460 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
13/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
461 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
13/01/2021 00:00:00 34.200,00 BPJS
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 156.445,00
462 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
13/01/2021 00:00:00 34.200,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
462 Sadiyono SUMBER MAKMUR 180239 Renogen 3000 UI
13/01/2021 00:00:00 116.875,00 BPJS
Total 151.075,00
463 Bahman SIBAK 155872 NACL 0,9 % 500 ml
13/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
464 Bustim PONDOK BARU 163473 NACL 0,9 % 500 ml
13/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
465 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
13/01/2021 00:00:00 68.400,00 BPJS
Renogen 3000 UI 116.875,00
Total 185.275,00
466 Sumidah RAWA MULYA 163860 Metoclopramide inj 5Mg/M
13/01/2021 00:00:00 11.758,00 BPJS
NACL 0,9 % 500 ml 68.400,00
Renogen 3000 UI 116.875,00
Total 197.033,00
467 Bima Aryandika BANDARATU 178714 Ambroxol 30 mg @100 T
13/01/2021 00:00:00 579,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Chromic catgut 1 R (Tri 78.875,00
Cuticell Classic 10cmx10c 6.900,00
NACL 0,9 % 500 ml 68.400,00
NonWoven Fixation 15x 6.694,00
Renogen 3000 UI 116.875,00
Total 330.504,00
468 Kasmidi Kasim BANDAR RATU 135355 Metoclopramide inj 5Mg/M
13/01/2021 00:00:00 5.879,00 BPJS
NACL 0,9 % 500 ml 68.400,00
Renogen 3000 UI 116.875,00
Total 191.154,00
469 Kemis AGUNG JAYA SP6 114066 abbocath 18 Terumo @5
13/01/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 60.399,00
470 Titin Sumarni KOTO JAYA 112327 Amlodipine 10 mg @50 T
13/01/2021 00:00:00 1.180,00 BPJS
Meloxicam 7,5 mg 7.280,00
Total 8.460,00
471 Eka Diana Dwi S SIDODADI 179625 abbocath 18 Terumo @5
13/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Induxin 1 ml Injeksi 9.281,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Catheter 2 Way No. 16 ( 20.625,00
Chloramphenicol Salep M 2.351,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 1.611,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Suction Chateter no. 8 (R 20.625,00

19/08/2021 12:42:30 Page 118 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
471 Eka Diana Dwi S SIDODADI 179625 umbilical Cord Clamp
13/01/2021 00:00:00 2.261,00 BPJS
Urine bag 10.088,00
Cefadroxil tab 500 mg @1
14/01/2021 00:00:00 10.500,00
Chromic catgut 2-0 R (Tr 144.500,00
Paracetamol tablet 500 m 3.000,00
Total 333.723,00
472 Kemis AGUNG JAYA SP6 114066 Bisturi no. 10
14/01/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 3 Way No. 24 ( 44.688,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 44.965,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker Karet 22.000,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 42.750,00
NACL 0,9 % 500 ml 171.000,00
Novorapid Flexpen 108.750,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Topamax 100 mg Tab 59.750,00
Tramadol 50 mg/ml Inj 8.250,00
Ceftriaxone Inj
15/01/2021 00:00:00 12.498,00
NACL 0,9 % 500 ml 171.000,00
Tramadol 50 mg/ml Inj 12.375,00
Cefadroxil tab 500 mg @1
16/01/2021 00:00:00 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Paracetamol tablet 500 m 2.000,00
Total 1.112.845,00
473 Ny Fitriani PONDOK BARTU 181962 Bisturi no. 10
13/01/2021 00:00:00 3.836,00 BPJS
Calcii Glukonas Inj 100 m 12.939,00
Chloramphenicol Salep M 2.351,00
Hypafix 15cmx5cm (25 c 13.088,00
Infusion set Mikro (Terumo 18.026,00
Ka-En 1 B 12.658,00
NGT (Feeding Tube) Fr. 8 11.043,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
15/01/2021 00:00:00 33.414,00
Bactesyn inj 0,75 gr 59.009,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Bactesyn inj 0,75 gr
16/01/2021 00:00:00 59.009,00
NGT (Feeding Tube) Fr. 8 70.420,00

19/08/2021 12:42:30 Page 119 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
473 Ny Fitriani PONDOK BARTU 181962 NonWoven Fixation 15x
16/01/2021 00:00:00 6.694,00 BPJS
Ottogenta inj 9.900,00
Abbocath 24 Terumo @5
17/01/2021 00:00:00 44.552,00
Bactesyn inj 0,75 gr
18/01/2021 00:00:00 177.027,00
Ottogenta inj 29.700,00
Total 575.383,00
474 Sutri Maideska PT AGRO AIR DIKIT 181963 Abbocath 22 Terumo @5
13/01/2021 00:00:00 11.138,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Antrain Injeksi
14/01/2021 00:00:00 28.875,00
Antrain Injeksi 9.625,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 15cmx5cm (25 c 13.088,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Omeprazol kapsul 20 mg
15/01/2021 00:00:00 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Total 311.656,00
475 Ahmad Rahino SILAUT 168082 Abbocath 22 Terumo @5
13/01/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
14/01/2021 00:00:00 6.249,00
Ceftriaxone Inj 12.498,00
Dulcolax Sup 10 mg 0,00
Dulcolax tab 5 mg 1.583,00
Ringer Laktat Otsuka 19.076,00
Dulcolax tab 5 mg
15/01/2021 00:00:00 3.166,00
Ringer Laktat Otsuka 19.076,00
Alkohol 1Liter
18/01/2021 00:00:00 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Bisturi no. 10 11.508,00
Bisturi No. 15 3.836,00
Bisturi No. 15 11.508,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Chromic catgut 2-0 R (Tr 72.250,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Sterille 6.5 16.488,00
Hypafix 15cmx5cm (25 c 6.544,00
Iodine Povidone 1 L 158.594,00
Lidocain injk 40 mg/2 ml 9.666,00

19/08/2021 12:42:30 Page 120 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
475 Ahmad Rahino SILAUT 168082 NACL 0,9 % 500 ml
18/01/2021 00:00:00 8.550,00 BPJS
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Polyglycolide T-Vio 2-0 R ( 90.125,00
Polyglycolide T-Vio 3-0 R ( 172.000,00
Prolene no. 3/0 cutting 129.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
silk 1 R scimitar 81.851,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00
Tramadol 50 mg/ml Inj 4.125,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Aminofluid Infus 500 ml
19/01/2021 00:00:00 310.408,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 89.930,00
Dexametason Injeksi 6.256,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ka-En Mg3 13.104,00
Ketorolac inj 30 mg/1ml 2.690,00
KTM (ketamin) Injeksi 214.500,00
Omeprazole Inj 12.499,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 4.210,00
Aminofluid Infus 500 ml
20/01/2021 00:00:00 310.408,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dulcolax Sup 10 mg 55.600,00
Ka-En Mg3 26.208,00
Kassa kotak stril DRC 29.025,00
Ketorolac inj 30 mg/1ml 2.690,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Spuit 5 cc Disposible 14.200,00
Tramadol 50 mg/ml Inj 12.375,00
Aminofluid Infus 500 ml
21/01/2021 00:00:00 310.408,00
Ceftriaxone Inj 12.498,00
Ka-En Mg3 13.104,00
Metrodinazole Infus 30.939,00

19/08/2021 12:42:30 Page 121 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
475 Ahmad Rahino SILAUT 168082 Omeprazole Inj
21/01/2021 00:00:00 12.499,00 BPJS
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj
22/01/2021 00:00:00 12.498,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole Infus 30.939,00
Ringer Laktat Otsuka 28.614,00
Abbocath 22 Terumo @5
23/01/2021 00:00:00 22.276,00
Aminofluid Infus 500 ml 310.408,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Ka-En Mg3 13.104,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole Infus 30.939,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Abbocath 22 Terumo @5
24/01/2021 00:00:00 22.276,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 19.350,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
25/01/2021 00:00:00 12.498,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Abbocath 22 Terumo @5
26/01/2021 00:00:00 33.414,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 13.088,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 3.000,00
Transfusi Set Terumo 16.500,00
Total 4.170.113,00
476 Farel Alvaro BUKIT MULYA 181965 Ampicilin Serbuk Injeksi 1
13/01/2021 00:00:00 10.811,00 BPJS
Infusion set Mikro (Terumo 18.026,00
Ka-En 1 B 25.316,00
Paracetamol syrup 1.388,00
Transfusi Set Terumo 16.500,00
Abbocath 22 Terumo @5
14/01/2021 00:00:00 11.138,00
Abbocath 24 Terumo @5 22.276,00
Abbocath 24 Terumo @5 111.380,00

19/08/2021 12:42:30 Page 122 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
476 Farel Alvaro BUKIT MULYA 181965 Abbocath 24 Terumo @5
14/01/2021 00:00:00 33.414,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Handscoond Sterille 7.5 16.488,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 32.720,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker Karet 22.000,00
NGT (Stomach Tube) Fr. 1 60.046,00
Paracetamol Infus 14.438,00
Paracetamol Infus 28.876,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 C scimitar 66.993,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Perawat) @ 4.690,00
Transfusi Set Terumo 16.500,00
Abbocath 24 Terumo @5
15/01/2021 00:00:00 55.690,00
Ampicilin Serbuk Injeksi 1 21.622,00
Gentamicin Injeksi 9.212,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Paracetamol syrup 1.388,00
Ringer Laktat Otsuka 28.614,00
Ampicilin Serbuk Injeksi 1
16/01/2021 00:00:00 21.622,00
Bisturi No. 23 3.836,00
Cuticell Classic 10cmx10c 6.900,00
Gentamicin Injeksi 9.212,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 13.388,00
Paracetamol Infus 28.876,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ampicilin Serbuk Injeksi 1
17/01/2021 00:00:00 21.622,00
Hypafix 15cmx5cm (25 c 13.088,00
Ottogenta inj 19.800,00
Paracetamol Infus 14.438,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Cefixime syrup 100mg/5 M
18/01/2021 00:00:00 23.823,00

19/08/2021 12:42:30 Page 123 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
476 Farel Alvaro BUKIT MULYA 181965 Cuticell Classic 10cmx10c
18/01/2021 00:00:00 13.800,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 9.675,00
Ottogenta inj 59.400,00
Paracetamol syrup 1.388,00
Total 1.587.839,00
477 Renata Nurmila Sarum PENARIK 181964 abbocath 18 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Massa Cauter Dewasa 90.240,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ondansetron Inj 4.950,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suction no. 1/4 25.950,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00

19/08/2021 12:42:30 Page 124 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
477 Renata Nurmila Sarum PENARIK 181964 Urine bag
14/01/2021 00:00:00 10.088,00 BPJS
viamac 1 R 364.370,00
Cefotaxime Injeksi
15/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 33.000,00
Abbocath 20 Terumo @5
16/01/2021 00:00:00 22.276,00
Transfusi Set Terumo 16.500,00
Asam Mefenamat 500 m
17/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Phytomenadione 10 Mg/1 5.959,00
Phytomenadione 2 Mg/1M 4.834,00
Postofix (leukomed) 36.726,00
Total 2.041.123,00
478 Rosi Trisnawati LUBUK MUKTI 181966 Cefadroxil tab 500 mg @1
14/01/2021 00:00:00 10.500,00 BPJS
Cetirgi Tab 10 mg 3.096,00
Dexametason Injeksi 9.384,00
Metrodinazole tab 500 m 810,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 3.000,00
Total 27.390,00
479 Siti Rahmah SILAUT 181967 abbocath 18 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 23.004,00
Cefotaxime Injeksi 17.253,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 19.632,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 37.124,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00

19/08/2021 12:42:30 Page 125 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
479 Siti Rahmah SILAUT 181967 Miloz Injeksi 5 mg
14/01/2021 00:00:00 5.611,00 BPJS
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 47.690,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
viamac 1 R 364.370,00
Alkohol 1Liter
16/01/2021 00:00:00 42.111,00
Asam Mefenamat 500 m 1.935,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 34.506,00
Cefotaxime Injeksi 5.751,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 12.105,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 2.700,00
Metrodinazole tab 500 m 4.050,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 13.388,00
NonWoven Fixation 15x 13.388,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
479 Siti Rahmah SILAUT 181967 Ondansetron Inj
16/01/2021 00:00:00 3.300,00 BPJS
Polyglycolide T-Vio 1 R ( 197.000,00
Polypropylene 3/0 C (Ass 235.200,00
Postofix (leukomed) 36.726,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 18.945,00
Urine bag 10.088,00
Total 3.023.018,00
480 Linda Depi Yanti SIBAK 181973 Abbocath 22 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS
Asam Mefenamat 500 m 1.290,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 54.041,00
481 Nantiono LUNANG 181970 abbocath 18 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Dipenhydramin Injeksi 10 4.605,00
Esomeprazol Injeksi 40 m 69.912,00
Furosemide 40 mg Tablet 288,00
Opilax Syr 49.156,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
15/01/2021 00:00:00 297,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 69.912,00
Meloxicam 7,5 mg 728,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
16/01/2021 00:00:00 297,00
Asam Folat 1 mg @100 T 297,00
Asam Traneksamat @10 6.315,00
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 681,00
Cefotaxime Injeksi 11.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
481 Nantiono LUNANG 181970 Ceftriaxone Inj
16/01/2021 00:00:00 6.249,00 BPJS
Dexametason Injeksi 3.128,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 9.700,00
Meloxicam 7,5 mg 728,00
Meloxicam 7,5 mg 728,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Pantoprazole Inj 46.750,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 4.210,00
Aqua Pro Injeksi
17/01/2021 00:00:00 3.575,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
18/01/2021 00:00:00 1.485,00
Candesartan tab 8 mg 6.810,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Phytomenadione 2 Mg/1M 9.668,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 2.310,00
Total 800.149,00
482 Ny Siti Rahmah SILAUT 181975 Abbocath 24 Terumo @5
14/01/2021 00:00:00 44.552,00 BPJS
Bisturi no. 10 3.836,00
Hypafix 10cm x 5cm (25 c 9.700,00
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
16/01/2021 00:00:00 59.009,00
Ottogenta inj 9.900,00
Total 199.678,00
483 Samuji MEKAR JAYA 135578 Amlodipine 5 mg @30 T
14/01/2021 00:00:00 3.030,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Omeprazol kapsul 20 mg 3.305,00
Retaphyl SR Tab 22.110,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
483 Samuji MEKAR JAYA 135578 Spironolaktone 100 mg
14/01/2021 00:00:00 21.570,00 BPJS
Total 130.115,00
484 Iga Yusti LUBUK SANAI 147283 Asam Mefenamat 500 m
14/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 52.566,00
485 Anita Astuti LUBUK CABAU 170810 Asam Mefenamat 500 m
14/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 59.466,00
486 Nayur Marni PULAI PAYUNG 153355 Allopurinol 300 Mg @100
14/01/2021 00:00:00 9.820,00 BPJS
Atorvastatin 20 mg @30 T 20.900,00
Loratadine tab 10 mg 4.980,00
Meloxicam 7,5 mg 21.840,00
Methylprednisolone tab 4 7.890,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 3.305,00
Total 77.405,00
487 Asfindo Luspi Janisli LUBUK SANAI 181759 Cetirgi Tab 10 mg
14/01/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 18.110,00
488 Abdul Aziz ATAP SENG 181978 Cefadroxil tab 500 mg @1
14/01/2021 00:00:00 10.500,00 BPJS
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 2.000,00
Total 15.130,00
489 Suburni UJUNG PADANG 157140 Ambroxol Syr 15mg/ml
14/01/2021 00:00:00 4.538,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Atorvastatin 20 mg @30 T 10.450,00
Azitromycin 500 mg 28.125,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Retaphyl SR Tab 44.220,00
Total 147.003,00
490 Masinem KOTA PRAJA 136621 Allopurinol 300 Mg @100
14/01/2021 00:00:00 9.820,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Betahistin Mesilat 6 mg @ 4.140,00
Bisoprolol 5 mg @100 Ta 8.880,00
Clopidogrel 75 mg @30 T 52.650,00
Flunarizine 5 mg tab 74.250,00
Furosemide 40 mg Tablet 2.880,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Total 179.315,00
491 Riyanti MARGA MULYA SAKTI 181828 Asam Mefenamat 500 m
14/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 57.416,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
492 Ravina Laila Oktaviana SUMBER MAKMUR 181801 Asam Mefenamat 500 m
14/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 57.416,00
493 M Irsyan TERUNTUNG 171905 Asam Mefenamat 500 m
14/01/2021 00:00:00 3.870,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Candesartan tab 8 mg 20.430,00
Flunarizine 5 mg tab 0,00
Flunarizine 5 mg tab 74.250,00
Omeprazol kapsul 20 mg 3.305,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 182.995,00
494 Fitria TERUNTUNG 140368 Asam Mefenamat 500 m
14/01/2021 00:00:00 3.870,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 247.500,00
Total 273.925,00
495 M. Sugiarto TERUNTUNG 113418 Alprazolam 0,5 mg @100
14/01/2021 00:00:00 1.180,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Candesartan tab 8 mg 13.620,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Isosorbid dinitrat 5 mg (I 3.330,00
Total 77.800,00
496 Susilo TERUNTUNG 109867 Meloxicam 7,5 mg
14/01/2021 00:00:00 21.840,00 BPJS
Methylprednisolone tab 4 7.890,00
Metrodinazole tab 500 m 8.100,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 165.000,00
Total 234.055,00
497 Marzuki KAMPUNG DALAM 094337 Aspilet 80 mg @100 mg
14/01/2021 00:00:00 4.140,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 3.305,00
Total 116.315,00
498 Uun Maimunah LUBUK BENTO 156061 CAL-95 tab
14/01/2021 00:00:00 62.700,00 BPJS
Emibion kapsul 9.830,00
Hystolan Tab 20 mg 27.845,00
Total 100.375,00
499 Kismo LUNANG 159271 Meloxicam 15 mg
14/01/2021 00:00:00 12.600,00 BPJS
Metformin tablet 500 mg 1.330,00
Paracetamol tablet 500 m 6.000,00
Vitamin B Komplek @100 4.620,00
Total 24.550,00
500 Imelda Susanti BUNGA TANJUNG 126931 Asam Mefenamat 500 m
14/01/2021 00:00:00 1.290,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
500 Imelda Susanti BUNGA TANJUNG 126931 Cefadroxil tab 500 mg @1
14/01/2021 00:00:00 10.500,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 52.566,00
501 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
14/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
502 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
14/01/2021 00:00:00 42.750,00 BPJS
Ranitidin inj 3.580,00
Total 46.330,00
503 Narti SILAUT 175653 NACL 0,9 % 500 ml
14/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 37.539,00
Total 80.289,00
504 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
14/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
505 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
14/01/2021 00:00:00 42.750,00 BPJS
Nassal Cannula O2 Dewas 11.625,00
Otsu D40 37.539,00
Total 91.914,00
506 Mawi UJUNG PADANG 110466 Atorvastatin 20 mg @30 T
14/01/2021 00:00:00 31.350,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Clopidogrel 75 mg @30 T 52.650,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 3.305,00
Total 95.495,00
507 Nurmisam UJUNG PADANG 110659 Alprazolam 1 mg @100 T
14/01/2021 00:00:00 4.800,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Atorvastatin 20 mg @30 T 20.900,00
Bisoprolol 5 mg @100 Ta 8.880,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Metformin tablet 500 mg 3.990,00
Total 98.240,00
508 Warto RAWA MULYA 140167 Methylprednisolone tab 4
14/01/2021 00:00:00 5.260,00 BPJS
Paracetamol tablet 500 m 4.000,00
Total 9.260,00
509 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
14/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
510 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
14/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
511 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
14/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
512 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
14/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
513 Wardoyo TANJUNG MULYA 125079 Glucosamine 250 mg
14/01/2021 00:00:00 2.310,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Total 36.510,00
514 Wiwi Siti Mai Sari SIBAK 181976 abbocath 18 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 53.046,00
515 Yuni Kartini TALANG MEDAN 127780 abbocath 18 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Masker 3 Play N. 95 256.370,00
Masker Karet Boism 47.580,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 4.690,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 23
15/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Wing needle 27 G 63.250,00
Asam Mefenamat 500 m
17/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 5.751,00
Clindamycin 150 mg tabl 8.750,00

19/08/2021 12:42:30 Page 132 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
515 Yuni Kartini TALANG MEDAN 127780 Hypafix 15cmx5cm (25 c
17/01/2021 00:00:00 6.544,00 BPJS
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 1.832.105,00
516 Wiwi Siti Mai Sari SIBAK 181976 Bisturi No. 23
14/01/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 600,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suction Chateter no. 8 (R 20.625,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 2.105,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Abbocath 20 Terumo @5
15/01/2021 00:00:00 22.276,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 17.253,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00

19/08/2021 12:42:30 Page 133 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
516 Wiwi Siti Mai Sari SIBAK 181976 Metrodinazole tab 500 m
15/01/2021 00:00:00 810,00 BPJS
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
17/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 1.683.980,00
517 Din Afrianto RAWA MULYA 181987 Abbocath 20 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 69.912,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 1.650,00
Opilax Syr 49.156,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Ceftriaxone Inj 12.498,00
Ringer Laktat Otsuka 28.614,00
Asam Folat 1 mg @100 T
15/01/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
16/01/2021 00:00:00 297,00
Asam Folat 1 mg @100 T 297,00
Calos cmewable tab 2.409,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 9.700,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
517 Din Afrianto RAWA MULYA 181987 Hypafix 10cm x 5cm (25 c
16/01/2021 00:00:00 9.700,00 BPJS
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 23.375,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
17/01/2021 00:00:00 3.575,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 15cmx5cm (25 c 6.544,00
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
18/01/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ngt (Feeding Tube) Fr.16 10.588,00
Ondansetron Inj 4.950,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
19/01/2021 00:00:00 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 15cmx5cm (25 c 13.088,00
NGT (Stomach Tube) Fr. 1 60.046,00
NGT (Stomach Tube) Fr. 1 60.046,00
Omeprazole Inj 74.994,00
Ondansetron Inj 4.950,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Vit K Infant Injeksi 82.500,00
Asam Folat 1 mg @100 T
20/01/2021 00:00:00 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Asam Folat 1 mg @100 T
21/01/2021 00:00:00 1.485,00
Calos cmewable tab 12.045,00
Candesartan tab 8 mg 10.215,00
Domperidone Tab 1.620,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.293.388,00
518 Lindawati SEMUNDAM 181988 abbocath 18 Terumo @5
14/01/2021 00:00:00 11.138,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
518 Lindawati SEMUNDAM 181988 Aqua Pro Injeksi
14/01/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Loremid Tab 2.876,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Zinc Sulfate Syr 60 ml 4.569,00
Abbocath 20 Terumo @5
15/01/2021 00:00:00 22.276,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Paracetamol Infus 14.438,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 28.050,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
518 Lindawati SEMUNDAM 181988 Suprafenid Supositoria 10
15/01/2021 00:00:00 28.050,00 BPJS
umbilical Cord Clamp 2.261,00
viamac 1 R 182.185,00
abbocath 18 Terumo @5
17/01/2021 00:00:00 22.276,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
Postofix (leukomed) 36.726,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Total 2.066.039,00
519 Sulaiman BANDARATU 137555 Abbocath 20 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 4.569,00
Cefixime kapsul 200 mg
16/01/2021 00:00:00 26.480,00
Injection plug 20.213,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 179.537,00
520 Rosnen LALANG LUAS 174341 Antasida Doen 400 mg @
15/01/2021 00:00:00 750,00 BPJS
Loremid Tab 11.504,00
Metrodinazole tab 500 m 2.700,00
Omeprazol kapsul 20 mg 6.610,00
Oralit 1.715,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 27.848,00
521 Sukati TIRTA MULYA 127724 Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
522 Giran TANAH HARAPAN 181844 Cefadroxil tab 500 mg @1
15/01/2021 00:00:00 10.500,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Total 32.800,00
523 Rica Gusmawati MEKAR JAYA 177877 Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
523 Rica Gusmawati MEKAR JAYA 177877 Cefadroxil tab 500 mg @1
15/01/2021 00:00:00 10.500,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 52.566,00
524 Ngatini LUBUK MUKTI 179230 Candesartan tab 8 mg
15/01/2021 00:00:00 13.620,00 BPJS
Furosemide 40 mg Tablet 2.880,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 6.610,00
Total 26.860,00
525 Maril LUBUK SANAI 173422 Guaifenesin 100 mg
15/01/2021 00:00:00 3.360,00 BPJS
Isoniazide 300 mg 6.480,00
Phytomenadione 10 mg ( 18.680,00
Rifampicin 450 33.840,00
Tranexamic Acid Inj (Asa 42.100,00
Total 104.460,00
526 Hariyono AIR DIKIT 159843 Ambroxol Syr 15mg/ml
15/01/2021 00:00:00 4.538,00 BPJS
Cetirgi Tab 10 mg 46.440,00
Erphafillin Tab 33.210,00
Symbicort Turbuhaler 80 167.855,00
Total 252.043,00
527 Heri Budiono TUNGGAL JAYA 181992 Aspilet 80 mg @100 mg
15/01/2021 00:00:00 4.140,00 BPJS
Captopril 12,5 mg 2.400,00
Furosemide 40 mg Tablet 2.880,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 25 mg 7.800,00
Total 23.830,00
528 Lucy Cresentia AIR BIKUK 179069 Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 2.700,00
Total 14.490,00
529 Mustafa Dewa PT AGRO AIR DIKIT 168042 Mecobalamin 500 mg
15/01/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 7.280,00
Omeprazol kapsul 20 mg 6.610,00
Total 21.590,00
530 Siti Azli Gulo AGRO MUKO 121291 Betahistin Mesilat 6 mg @
15/01/2021 00:00:00 4.140,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Orasic Kap 36.580,00
Paracetamol tablet 500 m 4.000,00
Total 51.330,00
531 T Br Bagariang AIR DIKIT 129955 Propanolol tab 10 mg
15/01/2021 00:00:00 6.660,00 BPJS
thyrozol 5 mg 49.560,00
Total 56.220,00
532 Susilawati AIR DIKIT 181995 Mecobalamin 500 mg
15/01/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 14.560,00
Omeprazol kapsul 20 mg 6.610,00
Total 28.870,00
533 Yusmeri DESA RAWA MULYA 113571 Alprazolam 0,5 mg @100
15/01/2021 00:00:00 1.180,00 BPJS
Mecobalamin 500 mg 7.700,00
Total 8.880,00
534 Ilnah PANTAI INDAH 147796 Betahistin Mesilat 6 mg @
15/01/2021 00:00:00 2.760,00 BPJS
Gabapentin kapsul 300 m 38.070,00
Metformin tablet 500 mg 7.980,00

19/08/2021 12:42:30 Page 138 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
534 Ilnah PANTAI INDAH 147796 Omeprazol kapsul 20 mg
15/01/2021 00:00:00 6.610,00 BPJS
Piralen tab 13.620,00
Sucralfate Suspensi 100 m 19.250,00
Total 88.290,00
535 Wirdah RANAH KARYA 181725 Cefadroxil tab 500 mg @1
15/01/2021 00:00:00 10.500,00 BPJS
Total 10.500,00
536 Dina Nur Aliyah UJUNG PADANG 181856 Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 52.566,00
537 Salami SILAUT I 134774 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
538 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 37.539,00
Total 80.289,00
539 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 37.539,00
Total 80.289,00
540 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
541 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
542 Samsudin DUSUN BARU PELOKA 181997 Asam Traneksamat @10
15/01/2021 00:00:00 42.100,00 BPJS
Azitromycin 500 mg 28.125,00
Phytomenadione 10 mg ( 18.680,00
Total 88.905,00
543 S Sianturi AIR BIKUK 181751 Captopril 12,5 mg
15/01/2021 00:00:00 2.400,00 BPJS
Furosemide 40 mg Tablet 2.880,00
Simvastatin tab 10 mg 7.230,00
Spironolaktone 100 mg 21.570,00
ursodeoxycholic acid 85.050,00
Total 119.130,00
544 Sakarudin LUBUK SANAI 175447 Acetylcystein 200 mg Ka
15/01/2021 00:00:00 34.380,00 BPJS
Azitromycin 500 mg 28.125,00
Omeprazol kapsul 20 mg 6.610,00
Total 69.115,00
545 Caury Elfia BANDARATU 144001 Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 57.416,00
546 Wiji Lestari PENARIK 181753 Asam Mefenamat 500 m
15/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 52.566,00
547 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
548 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
549 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
550 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
551 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
15/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
552 Masdikin UJUNG PADANG 137400 Abbocath 20 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Total 75.074,00
553 Intanti PAUH TERENJA 152393 Abbocath 20 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Suprafenid Supositoria 10 14.025,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Asam Mefenamat 500 m
16/01/2021 00:00:00 1.290,00
Total 93.262,00
554 Masdikin UJUNG PADANG 137400 Ceftriaxone Inj
16/01/2021 00:00:00 12.498,00 BPJS
Omeprazole Inj 12.499,00
Total 24.997,00
555 Samiyon JL PENDAKIAN NO 2 D 182001 Cefadroxil tab 500 mg @1
15/01/2021 00:00:00 10.500,00 BPJS
Codein tab 10 mg 7.500,00
Methylprednisolone tab 4 2.630,00
Salbutamol 2 mg 790,00
Total 21.420,00
556 Widia Sartika LALANG LUAS 179707 abbocath 18 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Masker Karet 22.000,00

19/08/2021 12:42:30 Page 140 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
556 Widia Sartika LALANG LUAS 179707 Metrodinazole Infus
15/01/2021 00:00:00 10.313,00 BPJS
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Vitamin B Komplek @100 308,00
Ambroxol 30 mg @100 T
16/01/2021 00:00:00 772,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
17/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
18/01/2021 00:00:00 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 25.300,00
Postofix (leukomed) 36.726,00
Total 1.771.906,00
557 Sarmila LUBUK PINANG 164606 abbocath 18 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS

19/08/2021 12:42:30 Page 141 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
557 Sarmila LUBUK PINANG 164606 Aqua Pro Injeksi
15/01/2021 00:00:00 3.575,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 65.790,00
558 Baharudin GAJAH MATI 182002 Abbocath 20 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Ceftriaxone Inj 6.249,00
Electroda (Ambu) @25 Pc 81.570,00
Glukosa Infus 10 % 9.375,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
NonWoven Fixation 15x 6.694,00
Norepinephrine Inj 30.938,00
Ringer Laktat Otsuka 9.538,00
Three Way stopcock 37.125,00
Total 292.993,00
559 Sarmila LUBUK PINANG 164606 Cefotaxime Injeksi
16/01/2021 00:00:00 11.502,00 BPJS
Misoprostol Tab 11.000,00
Paracetamol Infus 28.876,00
PARAMOL INFUS 192.500,00
Ringer Laktat Otsuka 28.614,00
Misoprostol Tab
17/01/2021 00:00:00 82.500,00
Total 354.992,00
560 Baharudin GAJAH MATI 182002 Extention Tube
15/01/2021 00:00:00 8.801,00 BPJS
Glukosa Infus 10 % 9.375,00
Infusion Makro (terumo) 0,00
NACL 0,9 % 500 ml 8.550,00
Abbocath 20 Terumo @5
16/01/2021 00:00:00 22.276,00
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 10 % 18.750,00
NACL 0,9 % 500 ml 8.550,00
Norepinephrine Inj 0,00
Omeprazole Inj 12.499,00
Tranexamic Acid Inj (Asa 2.105,00
Ventolin Nebules 2.5 mg 15.000,00
Ceftriaxone Inj
17/01/2021 00:00:00 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 10 % 0,00
Glukosa Infus 10 % 28.125,00
NACL 0,9 % 500 ml 17.100,00

19/08/2021 12:42:30 Page 142 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
560 Baharudin GAJAH MATI 182002 NGT (Stomach Tube) Fr. 1
17/01/2021 00:00:00 60.046,00 BPJS
Norepinephrine Inj 92.814,00
Omeprazole Inj 0,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj
18/01/2021 00:00:00 6.249,00
Cetadop inj 15.400,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Extention Tube 8.801,00
Glukosa Infus 10 % 28.125,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Norepinephrine Inj 92.814,00
Norepinephrine Inj 92.814,00
Omeprazole Inj 12.499,00
Three Way stopcock 37.125,00
Ventolin Nebules 2.5 mg 5.000,00
Total 684.437,00
561 Iksan Andi Syahputra SILAUT 145355 Abbocath 20 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Total 103.290,00
562 Elvi Indrayani PASAR SEBELAH 182003 abbocath 18 Terumo @5
17/01/2021 00:00:00 33.414,00 BPJS
Abbocath 20 Terumo @5 22.276,00
Aqua Pro Injeksi 10.725,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 28.755,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 13.088,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 8.070,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
562 Elvi Indrayani PASAR SEBELAH 182003 Ketorolac inj 30 mg/1ml
17/01/2021 00:00:00 1.345,00 BPJS
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 1.620,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 12.630,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.538.624,00
563 Ny Widia Sartika LALANG LUAS 182004 Abbocath 24 Terumo @5
15/01/2021 00:00:00 44.552,00 BPJS
Bisturi No. 23 3.836,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00
Injection plug 20.213,00
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
Total 148.483,00
564 Iksan Andi Syahputra SILAUT 145355 Ceftriaxone Inj
16/01/2021 00:00:00 12.498,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 9.700,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Zinc Sulfate Syr 60 ml 4.569,00
Amoxicillin 500 mg @ 10
17/01/2021 00:00:00 4.590,00
Ondansetron tablet 8 mg 10.560,00
Oralit 1.715,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 151.987,00
565 Yusmaniar PASAR GEDANG 126586 Abbocath 20 Terumo @5
15/01/2021 00:00:00 22.276,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
565 Yusmaniar PASAR GEDANG 126586 Infusion Makro (terumo)
15/01/2021 00:00:00 54.450,00 BPJS
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Total 127.724,00
566 Sumir Wati LUNANG 182005 abbocath 18 Terumo @5
15/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 54.450,00
Masker Karet 22.000,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Otsu MgSO4 40 % 4.745,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.432.891,00
567 Yusmaniar PASAR GEDANG 126586 Abbocath 22 Terumo @5
16/01/2021 00:00:00 22.276,00 BPJS
Ceftriaxone Inj 6.249,00
Cetadop inj 7.700,00
Dopamin Giulini 200 mg I 195.250,00
Extention Tube 17.602,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
NonWoven Fixation 15x 6.694,00
Norepinephrine Inj 30.938,00
Norepinephrine Inj 61.876,00
Omeprazole Inj 12.499,00

19/08/2021 12:42:30 Page 145 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
567 Yusmaniar PASAR GEDANG 126586 Three Way stopcock
16/01/2021 00:00:00 74.250,00 BPJS
Ceftriaxone Inj
17/01/2021 00:00:00 12.498,00
Cetadop inj 23.100,00
Epinephrin inj 15.331,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 42.750,00
Nassal Mask O2 Dewasa 41.828,00
Norepinephrine Inj 61.876,00
Omeprazole Inj 12.499,00
Suction Chateter no. 8 (R 20.625,00
Total 706.585,00
568 Sumir Wati LUNANG 182005 Amlodipine 10 mg @50 T
16/01/2021 00:00:00 118,00 BPJS
Amlodipine 10 mg @50 T 236,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 23
17/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Amlodipine 10 mg @50 T
18/01/2021 00:00:00 590,00
Amlodipine 10 mg @50 T 1.180,00
Aqua Steril Infus 1 Liter 38.363,00
Cefotaxime Injeksi 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 875,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 810,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 371.516,00
569 Sulaiman BANDARATU 137555 Ceftriaxone Inj
16/01/2021 00:00:00 12.498,00 BPJS
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00

19/08/2021 12:42:30 Page 146 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
569 Sulaiman BANDARATU 137555 Loremid Tab
16/01/2021 00:00:00 14.380,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 116.620,00
570 Elvi Indrayani PASAR SEBELAH 182003 Aqua Pro Injeksi
18/01/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 7.672,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 144.500,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Sterille 6.5 16.488,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine Povidone 1 L 475.782,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac Tab 10 Mg 37.950,00
Metrodinazole tab 500 m 810,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Postofix (leukomed) 36.726,00
Prolene no. 3/0 cutting 129.000,00
Ringer Laktat Otsuka 28.614,00
Silk 2/0 C scimitar 66.993,00
Spinocain 27 (BBraund) 95.750,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00
Topi Operasi (Dokter) @5 5.097,00
Tramadol tab 50 mg 1.179,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Total 1.260.792,00
571 Ny Elvi Indaryani PASAR SEBELAH 182006 Abbocath 24 Terumo @5
16/01/2021 00:00:00 44.552,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Bisturi No. 15 3.836,00
Chloramphenicol Salep M 2.351,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 15x 6.694,00
Ottogenta inj 9.900,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
18/01/2021 00:00:00 59.009,00

19/08/2021 12:42:30 Page 147 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
571 Ny Elvi Indaryani PASAR SEBELAH 182006 Ottogenta inj
18/01/2021 00:00:00 9.900,00 BPJS
Vit K Infant Injeksi 8.250,00
Total 281.016,00
572 Andi Hendra UJUNG PADANG 119627 Diazepam Tab 5 Mg
16/01/2021 00:00:00 1.360,00 BPJS
Eperisone Hcl 50 mg @1 23.280,00
Ketoprofen tab 100 mg 12.380,00
Mecobalamin 500 mg 7.700,00
Suprafenid Supositoria 10 42.075,00
Total 86.795,00
573 Bahman SIBAK 155872 NACL 0,9 % 500 ml
16/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
574 Bustim PONDOK BARU 163473 NACL 0,9 % 500 ml
16/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
575 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
16/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
576 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
16/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
577 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
16/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Total 67.776,00
578 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
16/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Total 67.776,00
579 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
16/01/2021 00:00:00 68.400,00 BPJS
Total 68.400,00
580 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
16/01/2021 00:00:00 59.850,00 BPJS
Total 59.850,00
581 Bima Aryandika BANDARATU 178714 Codein tab 10 mg
16/01/2021 00:00:00 7.500,00 BPJS
NACL 0,9 % 500 ml 68.400,00
Otsu D40 25.026,00
Total 100.926,00
582 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
16/01/2021 00:00:00 59.850,00 BPJS
Total 59.850,00
583 Putriani LUBUK SANAI 182012 Asam Mefenamat 500 m
16/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Lidocain injk 40 mg/2 ml 1.611,00
NACL 0,9 % 500 ml 8.550,00
Tetagam 1 Ml Injeksi 184.000,00
Total 205.951,00
584 Megawati SIDODADI 182013 Abbocath 20 Terumo @5
16/01/2021 00:00:00 11.138,00 BPJS
Ambroxol 30 mg @100 T 579,00
Azitromycin 500 mg 11.250,00
Candesartan tab 8 mg 1.362,00
Catheter 2 Way No. 16 ( 20.625,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 3.332,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 25.650,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00

19/08/2021 12:42:30 Page 148 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
584 Megawati SIDODADI 182013 Urine bag
16/01/2021 00:00:00 10.088,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 25.650,00
Ambroxol 30 mg @100 T
17/01/2021 00:00:00 579,00
Amlodipine 5 mg @30 T 303,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 15cmx5cm (25 c 6.544,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ambroxol Syr 15mg/ml
18/01/2021 00:00:00 4.538,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
Isosorbid dinitrat 5 mg (I 111,00
Isosorbid dinitrat 5 mg (I 111,00
meropenem Injeksi 1 g 123.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Urinter Kapsul @100 cap 4.396,00
Urinter Kapsul @100 cap 4.396,00
Ambroxol 30 mg @100 T
19/01/2021 00:00:00 1.158,00
Ambroxol 30 mg @100 T 2.895,00
Atorvastatin 20 mg @30 T 6.270,00
Candesartan tab 8 mg 4.767,00
Furosemide 40 mg Tablet 480,00
Isosorbid dinitrat 5 mg (I 1.110,00
Isosorbid dinitrat 5 mg (I 777,00
Natrium diclofenac 50 m 4.335,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 24.998,00
Total 889.841,00
585 Marwan SUMBER MAKMUR 131412 Abbocath 20 Terumo @5
16/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 101,00
Candesartan tab 8 mg 681,00
Cefoperazon Inj 82.500,00
Infusion Makro (terumo) 27.225,00
Levemir FlexPen 104.938,00
NACL 0,9 % 500 ml 25.650,00
Novo Twist 32 G Tip 2.604,00
Omeprazole Inj 12.499,00
Amlodipine 5 mg @30 T
17/01/2021 00:00:00 101,00
Candesartan Tab 16 mg 1.179,00
Cefoperazon Inj 82.500,00
Hypafix 15cmx5cm (25 c 13.088,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Amlodipine 5 mg @30 T
18/01/2021 00:00:00 101,00

19/08/2021 12:42:30 Page 149 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
585 Marwan SUMBER MAKMUR 131412 Antrain Injeksi
18/01/2021 00:00:00 28.875,00 BPJS
Azitromycin 500 mg 5.625,00
Catheter 2 Way No. 16 ( 20.625,00
Cefoperazon Inj 82.500,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Urinter Kapsul @100 cap 4.396,00
Abbocath 22 Terumo @5
19/01/2021 00:00:00 22.276,00
Abbocath 22 Terumo @5 11.138,00
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Electroda (Ambu) @25 Pc 81.570,00
Epinephrin inj 30.662,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 54.450,00
Kassa kotak stril DRC 9.675,00
Meylon 84 B.P 24.183,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Ondansetron Inj 1.650,00
Total 942.817,00
586 Efrizal KOTO JAYA 182014 Abbocath 20 Terumo @5
16/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Hepa Q @30 tab 4.331,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
ursodeoxycholic acid 5.670,00
Cefoperazon Inj
17/01/2021 00:00:00 82.500,00
Furamin Injeksi 14.369,00
Glukosa Infus 5 % 17.252,00
Hepa Q @30 tab 4.331,00
Hepa Q @30 tab 8.662,00
Hypafix 15cmx5cm (25 c 13.088,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 600,00
ursodeoxycholic acid 5.670,00
Catheter 2 Way No. 16 (
18/01/2021 00:00:00 20.625,00
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Glukosa Infus 5 % 25.878,00

19/08/2021 12:42:30 Page 150 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
586 Efrizal KOTO JAYA 182014 Hepa Q @30 tab
18/01/2021 00:00:00 8.662,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Sistenol kaplet 5.262,00
Sistenol kaplet 5.262,00
ursodeoxycholic acid 5.670,00
ursodeoxycholic acid 8.505,00
Cefoperazon Inj
19/01/2021 00:00:00 41.250,00
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Glukosa Infus 5 % 25.878,00
Hepa Q @30 tab 12.993,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sistenol kaplet 5.262,00
ursodeoxycholic acid 8.505,00
Alinamin F 50 mg @100 T
20/01/2021 00:00:00 11.500,00
Glukosa Infus 5 % 17.252,00
Levofloxacin Tablet 500 m 13.640,00
Pantoprazole Inj 93.500,00
Urdahek 202.600,00
Total 966.028,00
587 Siti Komariah SELAGAN JAYA 120258 Abbocath 20 Terumo @5
16/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 99,00
Ceftriaxone Inj 6.249,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Opilax Syr 49.156,00
Phytomenadione 10 Mg/1 5.959,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 2.105,00
Aqua Pro Injeksi
17/01/2021 00:00:00 3.575,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Levemir FlexPen 104.938,00
NGT (Stomach Tube) Fr. 1 52.250,00
Novo Twist 32 G Tip 5.208,00
Novorapid Flexpen 108.750,00
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Asam Folat 1 mg @100 T
18/01/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
587 Siti Komariah SELAGAN JAYA 120258 Curcuma Tab
18/01/2021 00:00:00 3.810,00 BPJS
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 47.032,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 0,00
Vomil b6 9.075,00
Ceftriaxone Inj
19/01/2021 00:00:00 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 47.032,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Vitamin B Komplek @100 308,00
Vomil b6 9.075,00
Antrain Injeksi
20/01/2021 00:00:00 28.875,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Metoclopramide inj 5Mg/M 47.032,00
Metoclopramide inj 5Mg/M 0,00
Neurodex tablet 1.482,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Vomil b6 9.075,00
Antrain Injeksi
21/01/2021 00:00:00 28.875,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Metoclorapamide tab 10 m 1.208,00
Neurodex tablet 1.482,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Vomil b6 9.075,00
Asam Folat 1 mg @100 T
22/01/2021 00:00:00 297,00
Ceftriaxone Inj 6.249,00
Curcuma Tab 12.700,00
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac Tab 10 Mg 37.950,00
Metamizole Sodium Mono 13.782,00
Metoclopramide inj 5Mg/M 94.064,00
Omeprazol kapsul 20 mg 3.305,00
Phytomenadione 10 mg ( 9.340,00
Phytomenadione 10 Mg/1 17.877,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
587 Siti Komariah SELAGAN JAYA 120258 Ringer Laktat Otsuka
22/01/2021 00:00:00 0,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
Vitamin B Komplek @100 1.540,00
Vomil b6 30.250,00
Total 1.454.252,00
588 Sawir ARAH TIGA 113253 Aminofluid Infus 500 ml
17/01/2021 00:00:00 155.204,00 BPJS
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Aminofluid Infus 500 ml 155.204,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 4.569,00
Ceftriaxone Inj
18/01/2021 00:00:00 12.498,00
Furamin Injeksi 14.369,00
Loratadine tab 10 mg 498,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 38.152,00
Zink Tablet 1.378,00
Ceftriaxone Inj
19/01/2021 00:00:00 12.498,00
Furamin Injeksi 43.107,00
Omeprazole Inj 37.497,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Zink Tablet 1.378,00
Alinamin F 50 mg @100 T
20/01/2021 00:00:00 11.500,00
Ceftriaxone Inj 12.498,00
Furamin Injeksi 43.107,00
Levofloxacin Tablet 500 m 13.640,00
Natrium diclofenac 50 m 867,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 37.497,00
Ondansetron Inj 4.950,00
Ondansetron tablet 8 mg 52.800,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Zink Tablet 1.378,00
Zink Tablet 10.335,00
Total 863.183,00
589 Sugiyem PONDOK MAKMUR 141117 Abbocath 20 Terumo @5
17/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 6.249,00
Esomax Inj 148.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
589 Sugiyem PONDOK MAKMUR 141117 Levemir FlexPen
17/01/2021 00:00:00 104.938,00 BPJS
Novorapid Flexpen 108.750,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Catheter 2 Way No. 16 (
18/01/2021 00:00:00 20.625,00
Epinephrin inj 30.662,00
Nassal Mask O2 Dewasa 41.828,00
Urine bag 10.088,00
Total 564.809,00
590 Sumidah RAWA MULYA 163860 Abbocath 20 Terumo @5
17/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 198,00
Ciprofloxacin infus 2% 26.328,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Total 110.952,00
591 Dul Rahman TIRTA MAKMUR 166301 Abbocath 20 Terumo @5
17/01/2021 00:00:00 11.138,00 BPJS
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Sistenol kaplet 5.262,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 95.820,00
592 Sumidah RAWA MULYA 163860 Ciprofloxacin infus 2%
18/01/2021 00:00:00 26.328,00 BPJS
Ciprofloxacin tab 500 mg 1.118,00
Hypafix 15cmx5cm (25 c 6.544,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Asam Folat 1 mg @100 T
19/01/2021 00:00:00 99,00
Ciprofloxacin infus 2% 26.328,00
Ciprofloxacin infus 2% 26.328,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Glucosamine 250 mg 770,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketocid @100 Tab 19.494,00
NACL 0,9 % 500 ml 17.100,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Tambah Darah Neo Tab 465,00
Tambah Darah Neo Tab 465,00
Zink Tablet 1.378,00

19/08/2021 12:42:30 Page 154 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
592 Sumidah RAWA MULYA 163860 Calos cmewable tab
20/01/2021 00:00:00 803,00 BPJS
Hypafix 15cmx5cm (25 c 13.088,00
Ketocid @100 Tab 12.996,00
NACL 0,9 % 500 ml 34.200,00
Natrium diclofenac 50 m 867,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Renogen 3000 UI 116.875,00
Ringer Laktat Otsuka 19.076,00
Tambah Darah Neo Tab 465,00
Zink Tablet 689,00
Asam Folat 1 mg @100 T
21/01/2021 00:00:00 1.485,00
Ciprofloxacin tab 500 mg 5.590,00
Ketorolac Tab 10 Mg 37.950,00
Loremid Tab 2.876,00
Loremid Tab 14.380,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 2.490.391,00
593 Dul Rahman TIRTA MAKMUR 166301 Omeprazole Inj
18/01/2021 00:00:00 24.998,00 BPJS
Omeprazole Inj 37.497,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 28.614,00
Sistenol kaplet 7.016,00
Sistenol kaplet 3.508,00
Spironolaktone 100 mg 1.438,00
Zink Tablet 2.756,00
Zink Tablet 1.378,00
Ciprofloxacin tab 500 mg
19/01/2021 00:00:00 1.118,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Sistenol kaplet 3.508,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 2.105,00
Zink Tablet 1.378,00
Asam Traneksamat @10
20/01/2021 00:00:00 21.050,00
Ciprofloxacin tab 500 mg 1.118,00
Ciprofloxacin tab 500 mg 5.590,00
Ciprofloxacin tab 500 mg 1.118,00
Ciprofloxacin tab 500 mg 1.118,00
Ciprofloxacin tab 500 mg 5.590,00
Hypafix 15cmx5cm (25 c 13.088,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 24.998,00
Omeprazole Inj 24.998,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 38.152,00
Sistenol kaplet 5.262,00
Sistenol kaplet 35.080,00
Sistenol kaplet 5.262,00

19/08/2021 12:42:30 Page 155 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
593 Dul Rahman TIRTA MAKMUR 166301 Sistenol kaplet
20/01/2021 00:00:00 5.262,00 BPJS
Sistenol kaplet 14.032,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 2.105,00
Zink Tablet 1.378,00
Zink Tablet 6.890,00
Zink Tablet 1.378,00
Zink Tablet 6.890,00
Total 490.093,00
594 Nurlaela Sari SIDODADI 179676 abbocath 18 Terumo @5
17/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Aqua Pro Injeksi
18/01/2021 00:00:00 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Toramine inj 18.706,00
Tranexamic Acid Inj (Asa 2.105,00

19/08/2021 12:42:30 Page 156 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
594 Nurlaela Sari SIDODADI 179676 Tranexamic Acid Inj (Asa
18/01/2021 00:00:00 4.210,00 BPJS
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
19/01/2021 00:00:00 11.502,00
Celemek Plastik 89.930,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Aqua Pro Injeksi
20/01/2021 00:00:00 7.150,00
Cefotaxime Injeksi 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.080,00
Tranexamic Acid Inj (Asa 6.315,00
Cefoperazon Inj
21/01/2021 00:00:00 82.500,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 25.300,00
Postofix (leukomed) 36.726,00
Total 1.844.622,00
595 Nurujut LUBUK PINANG 124282 Abbocath 20 Terumo @5
17/01/2021 00:00:00 11.138,00 BPJS
Candesartan tab 8 mg 681,00
Catheter 2 Way No. 16 ( 20.625,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 260,00
Urine bag 10.088,00
Furosemide Injeksi @2ml 6.664,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 8.550,00
Candesartan tab 8 mg
18/01/2021 00:00:00 681,00
Flunarizine 5 mg tab 4.950,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
meropenem Injeksi 1 g 123.750,00
Omeprazole Inj 12.499,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
595 Nurujut LUBUK PINANG 124282 Spironolaktone 25 mg
18/01/2021 00:00:00 260,00 BPJS
Ambroxol 30 mg @100 T
19/01/2021 00:00:00 193,00
Candesartan tab 8 mg 2.043,00
Candesartan tab 8 mg 681,00
Furosemide Injeksi @2ml 3.332,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Meropenem Inj 0.5 g 110.000,00
Meropenem Inj 0.5 g 165.000,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Perifas @100 Tab 5.775,00
Perifas @100 Tab 3.850,00
Spironolaktone 25 mg 260,00
Candesartan tab 8 mg
20/01/2021 00:00:00 10.215,00
Furosemide 40 mg Tablet 1.920,00
Ketorolac Tab 10 Mg 37.950,00
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 13.220,00
Omeprazole Inj 12.499,00
Perifas @100 Tab 3.850,00
Perifas @100 Tab 19.250,00
Spironolaktone 25 mg 3.900,00
Total 950.671,00
596 Yarjianto MARGA MUKTI 182021 Ceftriaxone Inj
18/01/2021 00:00:00 6.249,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 2.105,00
Asam Traneksamat @10 42.100,00
Paracetamol tablet 500 m 4.000,00
Asam Traneksamat @10 42.100,00
Ascorbid Acid 1000mg/5m 26.125,00
Paracetamol tablet 500 m 4.000,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Total 194.415,00
597 Istiqomah DS.PADANG GADING 114560 Cetirgi Tab 10 mg
18/01/2021 00:00:00 46.440,00 BPJS
Gabapentin kapsul 300 m 38.070,00
Meloxicam 15 mg 18.900,00
Metformin tablet 500 mg 11.970,00
Omeprazol kapsul 20 mg 3.305,00
Total 118.685,00
598 Muriyani TANAH HARAPAN 181452 Vitamin B Komplek @100
18/01/2021 00:00:00 1.540,00 BPJS
Vitamin C tablet @100 Ta 1.380,00
Total 2.920,00
599 Bainah LUNANG 179402 Calcium Laktat
18/01/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00

19/08/2021 12:42:30 Page 158 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
600 Sudimin PONDOK SUGUH 180795 Acetylcystein 200 mg Ka
18/01/2021 00:00:00 34.380,00 BPJS
Allopurinol 300 Mg @100 4.910,00
Paracetamol tablet 500 m 4.000,00
Vitamin B Komplek @100 3.080,00
Total 46.370,00
601 Boti TERAS TERUNJAM 182024 Asam Mefenamat 500 m
18/01/2021 00:00:00 1.290,00 BPJS
Metrodinazole tab 500 m 2.700,00
Total 3.990,00
602 Zulkifli DUSUN BARU PELOKA 181910 Paracetamol tablet 500 m
18/01/2021 00:00:00 3.000,00 BPJS
Salbutamol 4 mg 1.860,00
Vitamin B Komplek @100 2.310,00
Total 7.170,00
603 Ahmad Davan Ali Pas SIBAK 182025 Methylprednisolone tab 4
18/01/2021 00:00:00 2.630,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 5.630,00
604 Desma Zalnita SILAUT 181848 Ciprofloxacin tab 500 mg
18/01/2021 00:00:00 5.590,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Hypafix 15cmx5cm (25 c 6.544,00
Total 19.034,00
605 Asupli LUBUK SANAI 181921 Chloramphenicol Salep M
18/01/2021 00:00:00 2.351,00 BPJS
Ciprofloxacin tab 500 mg 559,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 2.000,00
Total 7.540,00
606 Roslimah AGUNG JAYA 113830 Omeprazol kapsul 20 mg
18/01/2021 00:00:00 6.610,00 BPJS
Renax @50 Kapsul 113.440,00
Urinter Kapsul @100 cap 21.980,00
Total 142.030,00
607 Zainal Asri TUNGGANG 179690 Amlodipine 5 mg @30 T
18/01/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Piracetam tablet 1200 m 41.880,00
Total 65.340,00
608 Ujang Samsudin UJUNG PADANG 127171 Azitromycin 500 mg
18/01/2021 00:00:00 56.250,00 BPJS
Captopril 25 mg 6.000,00
Codein tab 10 mg 7.500,00
Esomeprazol Injeksi 40 m 1.048.680,00
Furosemide 40 mg Tablet 1.920,00
Metoclorapamide tab 10 m 1.510,00
Spironolaktone 25 mg 7.800,00
Total 1.129.660,00
609 Nursani UJUNG PADANG 115837 Gabapentin kapsul 300 m
18/01/2021 00:00:00 38.070,00 BPJS
Glimepiride tab 1 mg 6.540,00
Meloxicam 15 mg 12.600,00
Metformin tablet 500 mg 11.970,00
Omeprazol kapsul 20 mg 6.610,00
Total 75.790,00
610 Siti Yuniangsih TERUNTUNG 173066 Amlodipine 5 mg @30 T
18/01/2021 00:00:00 2.020,00 BPJS
Furosemide 40 mg Tablet 960,00
Metrodinazole tab 500 m 2.700,00
Spironolaktone 25 mg 2.600,00
Vitamin C tablet @100 Ta 1.380,00
Total 9.660,00

19/08/2021 12:42:30 Page 159 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
611 Elly Zabeth Hutapea UJUNG PADANG 119672 Piracetam tab 800 mg
18/01/2021 00:00:00 7.530,00 BPJS
Total 7.530,00
612 Sinta PONDOK PANJANG 180087 Cefixime Kapsul 100 mg
18/01/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
613 Arpan Agus PASAR BELAKANG 112261 Amlodipine 5 mg @30 T
18/01/2021 00:00:00 3.030,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
glimepiride tab 4 mg 15.000,00
Metformin tablet 500 mg 11.970,00
Ranitidine tablet 150 mg 4.320,00
Valsartan Tablet 160 Mg 40.440,00
Total 79.200,00
614 Dedi Iras Sinuraya LUBUK CABAU 151953 Mecobalamin 500 mg
18/01/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 7.280,00
Ranitidine tablet 150 mg 1.440,00
Total 16.420,00
615 Anita Astuti LUBUK CABAU 170810 Asam Mefenamat 500 m
18/01/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
616 Yasma GADING JAYA 117647 Mecobalamin 500 mg
18/01/2021 00:00:00 7.700,00 BPJS
Total 7.700,00
617 Liza Noviyanti PT AGRO 182034 Omeprazol kapsul 20 mg
18/01/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 27.400,00
618 Nurhaida PONDOK PANJANG 149750 Abbocath 18 (Gea)
18/01/2021 00:00:00 10.720,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Antasida Syrup 60 ml
19/01/2021 00:00:00 2.736,00
Paracetamol tablet 500 m 2.000,00
Piralen tab 4.540,00
Total 78.904,00
619 Nelda Suprianti RAWA MULYA 136291 Lansoprazole kapsul 30 m
18/01/2021 00:00:00 11.550,00 BPJS
Metoclorapamide tab 10 m 1.510,00
Total 13.060,00
620 Jabarwi DUSUN GEDANG 161528 Ambroxol Syr 15mg/ml
18/01/2021 00:00:00 4.538,00 BPJS
Cefixime syrup 100mg/5 M 238.230,00
Cetirizine 10 mg 1.260,00
Paracetamol tablet 500 m 200,00
Total 244.228,00
621 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
18/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
622 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
18/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
623 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
18/01/2021 00:00:00 34.200,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
623 Afrianto TAPAN 144878 Renogen 3000 UI
18/01/2021 00:00:00 116.875,00 BPJS
Total 151.075,00
624 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
18/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
625 Narti SILAUT 175653 NACL 0,9 % 500 ml
18/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
626 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
18/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Renogen 3000 UI 116.875,00
Total 184.651,00
627 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
18/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
628 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
18/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
629 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
18/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
630 Jumarno LUNANG 180796 Abbocath 20 Terumo @5
18/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Ferro Sulfate 400,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Metoclopramide inj 5Mg/M 11.758,00
NACL 0,9 % 500 ml 8.550,00
Natrium diclofenac 50 m 867,00
Abbocath 22 Terumo @5
19/01/2021 00:00:00 22.276,00
Amlodipine 5 mg @30 T 1.010,00
Asam Folat 1 mg @100 T 297,00
Glucosamine 250 mg 770,00
Hypafix 15cmx5cm (25 c 13.088,00
Lidocain injk 40 mg/2 ml 3.222,00
Omeprazol kapsul 20 mg 6.610,00
Silk 2/0 R scimitar 29.125,00
Total 137.456,00
631 Ateng Hidayat SETIA BUDI 130819 Abbocath 20 Terumo @5
19/01/2021 00:00:00 11.138,00 BPJS
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 5.751,00
Ceftriaxone Inj 6.249,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 3-0 R (Tr 66.250,00
Hypafix Kamar Operasi 18.000,00
Ketorolac inj 30 mg/1ml 2.690,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Premilene (Mesh Duzey) 6 167.000,00
Prolene no. 3/0 cutting 129.000,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
631 Ateng Hidayat SETIA BUDI 130819 Ringer Laktat Otsuka
19/01/2021 00:00:00 9.538,00 BPJS
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 29.125,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
20/01/2021 00:00:00 12.498,00
Paracetamol tablet 500 m 600,00
Cefadroxil tab 500 mg @1
21/01/2021 00:00:00 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 19.350,00
NonWoven Fixation 15x 13.388,00
Paracetamol tablet 500 m 2.000,00
Total 730.374,00
632 Dian Rohana Harianja DUSUN BARU V KOTO 180645 abbocath 18 Terumo @5
18/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 29.394,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00

19/08/2021 12:42:30 Page 162 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
632 Dian Rohana Harianja DUSUN BARU V KOTO 180645 Topi Operasi (Dokter) @5
18/01/2021 00:00:00 16.990,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
19/01/2021 00:00:00 11.502,00
Celemek Plastik 89.930,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
20/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefoperazon Inj
21/01/2021 00:00:00 82.500,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 25.300,00
Postofix (leukomed) 36.726,00
Total 1.789.778,00
633 Sariani PONDOK MAKMUR 182038 Abbocath 20 Terumo @5
18/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 5.879,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
NACL 0,9 % 500 ml 85.500,00
Ceftriaxone Inj
19/01/2021 00:00:00 12.498,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 11.758,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Total 582.154,00
634 Sindi Kartika BATU EJUNG 174163 abbocath 18 Terumo @5
19/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol Infus 14.438,00

19/08/2021 12:42:30 Page 163 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
634 Sindi Kartika BATU EJUNG 174163 Ringer Laktat Otsuka
19/01/2021 00:00:00 47.690,00 BPJS
Transfusi Set Terumo 16.500,00
Total 106.118,00
635 Ny Dian Rohana DUSUN BARU V KOTO 182041 Bisturi no. 10
19/01/2021 00:00:00 3.836,00 BPJS
Chloramphenicol Salep M 2.351,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
Total 88.543,00
636 Sindi Kartika BATU EJUNG 174163 Asam Mefenamat 500 m
21/01/2021 00:00:00 1.290,00 BPJS
ATRACURIUM BESYLATE 2 14.671,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon kebidanan @ 325.130,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril L 509.190,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 14.563,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metrodinazole Infus 30.939,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 55.000,00
Misoprostol Tab 33.000,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Ondansetron Inj 3.300,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 6.796,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 6.315,00
Total 1.364.192,00
637 Azwir Taufan RANAH KARYA 167368 Levofloxacin Tablet 500 m
19/01/2021 00:00:00 13.640,00 BPJS
ursodeoxycholic acid 85.050,00
Total 98.690,00
638 Buyung Anam LUBUK GEDANG 133634 Levofloxacin Tablet 500 m
19/01/2021 00:00:00 13.640,00 BPJS
Loratadine tab 10 mg 1.660,00
ursodeoxycholic acid 85.050,00
Total 100.350,00
639 Wartono TIRTA MAKMUR 182043 Ciprofloxacin tab 500 mg
19/01/2021 00:00:00 5.590,00 BPJS
Total 5.590,00

19/08/2021 12:42:30 Page 164 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
640 Nasib Yulianto Butar B TANJUNG MULYA 181882 Renax @50 Kapsul
19/01/2021 00:00:00 226.880,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 248.860,00
641 Zuariah PAUH TERENJA 131979 Bisoprolol 5 mg @100 Ta
19/01/2021 00:00:00 8.880,00 BPJS
Glucosamine 250 mg 23.100,00
Micardis tab 80 mg 202.830,00
Total 234.810,00
642 Malyardianti TALANG SAKTI 182047 Calcium Laktat
19/01/2021 00:00:00 790,00 BPJS
Total 790,00
643 Krisnawati TALANG SEPAKAT 180344 Calcium Laktat
19/01/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
644 Ali Murni UJUNG PADANG 116447 Mecobalamin 500 mg
19/01/2021 00:00:00 7.700,00 BPJS
Total 7.700,00
645 Rahmat Al Amin MARGA MUKTI 171088 Ketokonazole tablet 200 m
19/01/2021 00:00:00 3.710,00 BPJS
Loratadine tab 10 mg 1.660,00
Sistenol kaplet 17.540,00
Total 22.910,00
646 Nurhayati ARAH TIGA 114028 Metformin tablet 500 mg
19/01/2021 00:00:00 3.990,00 BPJS
Paracetamol tablet 500 m 2.000,00
Pregabalin Kap 75 mg 64.460,00
Total 70.450,00
647 Dewi Indrawati Nembel AIR DIKIT 129204 Ketoprofen tab 100 mg
19/01/2021 00:00:00 24.760,00 BPJS
Meloxicam 15 mg 12.600,00
Vitamin B Komplek @100 3.080,00
Total 40.440,00
648 Jangkep PT.AGRO MUKO 134160 Mecobalamin 500 mg
19/01/2021 00:00:00 23.100,00 BPJS
Vitamin B Komplek @100 4.620,00
Total 27.720,00
649 Nazilla Gakisya Putri DUSUN BARU 164264 Ambroxol 30 mg @100 T
19/01/2021 00:00:00 965,00 BPJS
Cefixime syrup 100mg/5 M 23.823,00
Paracetamol syrup 1.388,00
Triamcort 4 mg Tab 20.625,00
Total 46.801,00
650 Maryati AIR DIKIT 146596 Cefixime Kapsul 100 mg
19/01/2021 00:00:00 9.380,00 BPJS
Total 9.380,00
651 Rahman Ade Ghaniy DESA GIRI MULYA 163322 Flunarizine 5 mg tab
19/01/2021 00:00:00 24.750,00 BPJS
Loratadine tab 10 mg 1.660,00
Total 26.410,00
652 Sri Wahyuni TUNGGAL JAYA 181008 Ethambutol 500 mg
19/01/2021 00:00:00 38.745,00 BPJS
Isoniazide 300 mg 6.480,00
Pyrazinamid 500 mg 36.270,00
Rifampicin 450 33.840,00
Total 115.335,00
653 Wahiri TALANG SEPAKAT 181795 Glucosamine 250 mg
19/01/2021 00:00:00 7.700,00 BPJS
Ketoprofen tab 100 mg 12.380,00
Total 20.080,00
654 Ajratul Aini AIR BIKUK 134349 Asam Mefenamat 500 m
19/01/2021 00:00:00 1.290,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 3.920,00
655 Warso Handoyo UJUNG PADANG 178016 Amoxicillin 500 mg @ 10
19/01/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00

19/08/2021 12:42:30 Page 165 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
655 Warso Handoyo UJUNG PADANG 178016 Dexametason 0,5 mg Ta
19/01/2021 00:00:00 1.160,00 BPJS
Lidocain injk 40 mg/2 ml 3.222,00
Total 8.732,00
656 Hersa Nurhidayah PT AGRO AIR BIKUK 181926 azitromicin syr 200mg/5m
19/01/2021 00:00:00 92.328,00 BPJS
Total 92.328,00
657 Latipah BUNGA TANJUNG 182057 Calcium Laktat
19/01/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
658 Yosi Komalasari LUBUK SANAI 181894 Cefixime Kapsul 100 mg
19/01/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
659 Auliani Putri PIAN TOKUNG 129449 Asam Folat 1 mg @100 T
22/01/2021 00:00:00 2.970,00 BPJS
Bamgetol 200 @100 Tab 148.500,00
Valproic Acid Syrup 250mg 104.875,00
Total 256.345,00
660 Mira Yani PASAR MUKOMUKO 155879 Asam Folat 1 mg @100 T
19/01/2021 00:00:00 2.970,00 BPJS
Piracetam tab 800 mg 75.300,00
Valproic Acid Syrup 250mg 62.925,00
Total 141.195,00
661 Sukirman LUBUK SANAI 159456 Alinamin F Injeksi 10 ml
19/01/2021 00:00:00 180.000,00 BPJS
Alprazolam 0,5 mg @100 590,00
Cefixime Kapsul 100 mg 9.380,00
Total 189.970,00
662 Abdul Ghofur SUNGAI RUMBAI 153798 Allopurinol 100 mg @100
19/01/2021 00:00:00 2.340,00 BPJS
Mecobalamin 500 mg 7.700,00
Pregabalin Kap 75 mg 64.460,00
Total 74.500,00
663 Salami SILAUT I 134774 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
664 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
665 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
666 Bahman SIBAK 155872 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
667 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
668 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
669 S Sianturi AIR BIKUK 181751 Gentamycin 0.1 % salep k
19/01/2021 00:00:00 5.966,00 BPJS
Total 5.966,00
670 Roslina TERUNTUNG 130072 Amlodipine 10 mg @50 T
19/01/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00

19/08/2021 12:42:30 Page 166 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 151.429,00
671 Salbiyah LUBUK MUKTI 173013 Amlodipine 10 mg @50 T
19/01/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Total 151.429,00
672 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
673 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
19/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
674 Dera Putri Rahmadani UJUNG PADANG 154327 Bisturi No. 23
19/01/2021 00:00:00 3.836,00 BPJS
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Lidocain injk 40 mg/2 ml 9.666,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 28.614,00
Spuit 3 cc Disposible 3.640,00
Ciprofloxacin tab 500 mg
20/01/2021 00:00:00 5.590,00
Paracetamol tablet 500 m 4.000,00
Total 268.757,00
675 Susi Martini KOTO JAYA 145038 Amlodipine 10 mg @50 T
19/01/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Total 151.429,00
676 Amran BATU EJUNG 182051 abbocath 18 Terumo @5
19/01/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Abbocath 22 Terumo @5
20/01/2021 00:00:00 33.414,00
Bisturi No. 23 3.836,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Handscoond Sterille 6.5 16.488,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 15cmx5cm (25 c 6.544,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Prolene no. 3/0 cutting 129.000,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00

19/08/2021 12:42:30 Page 167 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
676 Amran BATU EJUNG 182051 Spuit 3 cc Disposible
20/01/2021 00:00:00 3.640,00 BPJS
Spuit 5 cc Disposible 2.840,00
Tramadol 50 mg/ml Inj 8.250,00
Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00
Metrodinazole Infus 30.939,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Cefadroxil tab 500 mg @1
22/01/2021 00:00:00 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Ketoprofen tab 100 mg 12.380,00
Ketoprofen tab 100 mg 12.380,00
Total 963.249,00
677 Sohimatul Munawaroh LUNANG 182046 abbocath 18 Terumo @5
19/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 4.210,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
677 Sohimatul Munawaroh LUNANG 182046 Transfusi Set Terumo
19/01/2021 00:00:00 16.500,00 BPJS
Total 1.161.982,00
678 Ilfan Candra LUBUK PINANG 166962 Abbocath 22 Terumo @5
19/01/2021 00:00:00 22.276,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23
20/01/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 3.128,00
handscoon steril 6.5 (Tr 29.976,00
Handscoond Sterille 7.5 16.488,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Provein 3/0 C (Scimitar) @ 92.336,00
Spinocain 27 (BBraund) 47.875,00
Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Cefadroxil tab 500 mg @1
22/01/2021 00:00:00 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Total 521.924,00
679 Sohimatul Munawaroh LUNANG 182046 Cefotaxime Injeksi
19/01/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Spinocain 25 (BBraund) 85.526,00
Spinocain 27 (BBraund) 143.625,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
20/01/2021 00:00:00 10.725,00
Cefotaxime Injeksi 17.253,00
Hypafix 15cmx5cm (25 c 32.720,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 5.380,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 8.420,00
Bisturi no. 10
21/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Ketorolac inj 30 mg/1ml 4.035,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
679 Sohimatul Munawaroh LUNANG 182046 Metrodinazole tab 500 m
21/01/2021 00:00:00 810,00 BPJS
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
22/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 513.506,00
680 Nopi Lestari DESA BARU PELOKAN 182063 Bisturi No. 23
19/01/2021 00:00:00 3.836,00 BPJS
Bisturi No. 15 7.672,00
Chromic catgut 2-0 R (Tr 72.250,00
Ciprofloxacin tab 500 mg 5.590,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Sterille 6.5 16.488,00
Lidocain injk 40 mg/2 ml 9.666,00
Paracetamol tablet 500 m 2.000,00
Provein 6/0 C (Scimitar) 110.555,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Total 266.893,00
681 Novri Kaswara DUSUN BARU PELOKA 182064 Ciprofloxacin tab 500 mg
19/01/2021 00:00:00 5.590,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7.5 16.488,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lidocain injk 40 mg/2 ml 9.666,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 1.820,00
Total 177.520,00
682 Hotlan Nasution PT AGRO BUNGA TANJ 182056 Abbocath 20 Terumo @5
19/01/2021 00:00:00 22.276,00 BPJS
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 0,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00

19/08/2021 12:42:30 Page 170 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
682 Hotlan Nasution PT AGRO BUNGA TANJ 182056 Infusion Makro (terumo)
19/01/2021 00:00:00 27.225,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 0,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Ciprofloxacin tab 500 mg
20/01/2021 00:00:00 5.590,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Paracetamol tablet 500 m 2.000,00
Total 686.971,00
683 Adhitya Yoga Prasetyo AGUNG JAYA 144788 abbocath 18 Terumo @5
19/01/2021 00:00:00 11.138,00 BPJS
ATRACURIUM BESYLATE 2 14.671,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Masker Karet 22.000,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tetagam 1 Ml Injeksi 184.000,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Ciprofloxacin tab 500 mg
20/01/2021 00:00:00 8.385,00
Kassa kotak stril DRC 19.350,00
Kassa kotak stril DRC 19.350,00
Paracetamol tablet 500 m 3.000,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
683 Adhitya Yoga Prasetyo AGUNG JAYA 144788 Paracetamol tablet 500 m
20/01/2021 00:00:00 3.000,00 BPJS
Total 796.769,00
684 Kurnadi ARAH TIGA 154209 Abbocath 20 Terumo @5
19/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 101,00
Aspilet 80 mg @100 mg 138,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole Infus 10.313,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Total 78.405,00
685 Susiatun SILAUT 180433 abbocath 18 Terumo @5
19/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole Infus 10.313,00
Nassal Cannula O2 Dewas 11.625,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metrodinazole tab 500 m 1.350,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00

19/08/2021 12:42:30 Page 172 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
685 Susiatun SILAUT 180433 Tranexamic Acid Inj (Asa
19/01/2021 00:00:00 6.315,00 BPJS
viamac 1 R 364.370,00
Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
22/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.508.210,00
686 Kurnadi ARAH TIGA 154209 Novo Twist 32 G Tip
19/01/2021 00:00:00 2.604,00 BPJS
Novorapid Flexpen 108.750,00
Abbocath 20 Terumo @5
20/01/2021 00:00:00 33.414,00
Amlodipine 5 mg @30 T 101,00
Aspilet 80 mg @100 mg 138,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 1.270,00
Infusion Makro (terumo) 27.225,00
Metrodinazole Infus 30.939,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Amlodipine 10 mg @50 T
21/01/2021 00:00:00 1.180,00
Aspilet 80 mg @100 mg 1.380,00
Candesartan tab 8 mg 6.810,00
Cefixime syrup 100mg/5 M 23.823,00
Metformin tablet 500 mg 1.330,00
Omeprazol kapsul 20 mg 6.610,00
Total 271.852,00
687 Syafniar RETAK MUDIK 181695 Amlodipine 5 mg @30 T
19/01/2021 00:00:00 101,00 BPJS
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 3.850,00
Ringer Laktat Otsuka 9.538,00
Amlodipine 5 mg @30 T
20/01/2021 00:00:00 101,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 13.088,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 1.925,00
Perifas @100 Tab 3.850,00
Ringer Laktat Otsuka 38.152,00
Amlodipine 5 mg @30 T
21/01/2021 00:00:00 1.010,00
Candesartan tab 8 mg 6.810,00
Omeprazol kapsul 20 mg 6.610,00
Ondansetron tablet 8 mg 26.400,00

19/08/2021 12:42:30 Page 173 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
687 Syafniar RETAK MUDIK 181695 Perifas @100 Tab
21/01/2021 00:00:00 19.250,00 BPJS
Total 221.189,00
688 Sutriani TANJUNG ALAI 182066 Dexametason Injeksi
19/01/2021 00:00:00 9.384,00 BPJS
Aqua Pro Injeksi
20/01/2021 00:00:00 10.725,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 104.362,00
Cefotaxime Injeksi 17.253,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 90.000,00
Induxin 1 ml Injeksi 37.124,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 24.960,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Prolene no. 3/0 cutting 129.000,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00
Topi Operasi (Perawat) @ 2.814,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Viamac 2/0 R (scimitar) 210.718,00
Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 20 Terumo @5
22/01/2021 00:00:00 22.276,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00

19/08/2021 12:42:30 Page 174 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
688 Sutriani TANJUNG ALAI 182066 Tranexamic Acid Inj (Asa
22/01/2021 00:00:00 6.315,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Aqua Pro Injeksi
23/01/2021 00:00:00 7.150,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.378.537,00
689 Ny Susiatun SILAUT 182067 Abbocath 24 Terumo @5
19/01/2021 00:00:00 44.552,00 BPJS
Bisturi No. 15 3.836,00
Chloramphenicol Salep M 2.351,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 15x 6.694,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
20/01/2021 00:00:00 33.414,00
Hypafix 10cm x 5cm (25 c 4.850,00
NGT (Feeding Tube) Fr. 8 70.420,00
Bactesyn inj 0,75 gr
21/01/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Abbocath 24 Terumo @5
24/01/2021 00:00:00 44.552,00
Abbocath 24 Terumo @5 33.414,00
Abbocath 24 Terumo @5 55.690,00
Bactesyn inj 0,75 gr 59.009,00
Calcii Glukonas Inj 100 m 12.939,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion set Mikro (Terumo 36.052,00
Ka-En Mg3 13.104,00
NonWoven Fixation 15x 6.694,00
Ottogenta inj 9.900,00
Bactesyn inj 0,75 gr
25/01/2021 00:00:00 59.009,00
Ottogenta inj 9.900,00
Phytomenadione 2 Mg/1M 4.834,00
Total 693.190,00
690 Murliyati KARYA MULIA PONDO 182068 abbocath 18 Terumo @5
19/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Catheter 2 Way No. 16 ( 20.625,00
Urine bag 10.088,00
Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
abbocath 18 Terumo @5
22/01/2021 00:00:00 22.276,00
Abbocath 20 Terumo @5 22.276,00
Paracetamol Infus 14.438,00
CAL-95 tab
24/01/2021 00:00:00 0,00

19/08/2021 12:42:30 Page 175 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
690 Murliyati KARYA MULIA PONDO 182068 Cefotaxime Injeksi
24/01/2021 00:00:00 11.502,00 BPJS
Hystolan Tab 20 mg 0,00
NonWoven Fixation 15x 6.694,00
Nulacta ibu hamil & meny 0,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 19.076,00
Total 277.538,00
691 Siti Nur Chasanah AGUNG JAYA 173794 Abbocath 18 (Gea)
20/01/2021 00:00:00 10.720,00 BPJS
Aqua Pro Injeksi 3.575,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
oxytocin inj 2.998,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Proster Tablet 200 mcg 15.126,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
Nassal Cannula O2 Dewas 23.250,00
Suction no. 1/4 25.950,00
Tranexamic Acid Inj (Asa 6.315,00
abbocath 18 Terumo @5
22/01/2021 00:00:00 22.276,00
Abbocath 20 Terumo @5 22.276,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Asam Mefenamat 500 m
23/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 1.051.328,00
692 Hayatil Khairi AIR BULUH 126702 Aqua Pro Injeksi
20/01/2021 00:00:00 3.575,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
692 Hayatil Khairi AIR BULUH 126702 Celemek Plastik
20/01/2021 00:00:00 17.986,00 BPJS
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon Steril 8.5 (Ga 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 37.124,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
methyl ergometrin amp 3.350,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 25.650,00
NGT (Stomach Tube) Fr. 1 52.250,00
oxytocin inj 2.998,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Proster Tablet 200 mcg 15.126,00
Ringer Laktat Otsuka 9.538,00
silk 1 R scimitar 81.851,00
Spinocain 27 (BBraund) 47.875,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Bisturi no. 10
21/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Furamin Injeksi 14.369,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Nassal Cannula O2 bayi 9.530,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
22/01/2021 00:00:00 11.502,00
Cefotaxime Injeksi 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
23/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.220.026,00
693 Ahmad Davan Ali Pas SIBAK 182025 Cefadroxil tab 500 mg @1
21/01/2021 00:00:00 10.500,00 BPJS
Cuticell Classic 10cmx10c 6.900,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
693 Ahmad Davan Ali Pas SIBAK 182025 Fentanyl Injeksi 5 Ampul 2
21/01/2021 00:00:00 52.000,00 BPJS
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 3.000,00
Total 99.429,00
694 Dahlia Astuti TALANG MEDAN 150212 Cefadroxil tab 500 mg @1
23/01/2021 00:00:00 10.500,00 BPJS
Chromic catgut 2-0 R (Tr 72.250,00
Induxin 1 ml Injeksi 18.562,00
Lidocain injk 40 mg/2 ml 1.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Tranexamic Acid Inj (Asa 4.210,00
Vitamin B Komplek @100 1.540,00
Total 147.369,00
695 Caury Elfia BANDARATU 144001 Asam Mefenamat 500 m
20/01/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
696 Andres Suprianto LUBUK SANAI 152538 Cefixime kapsul 200 mg
20/01/2021 00:00:00 26.480,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Paracetamol tablet 500 m 3.000,00
Total 41.030,00
697 Chumaidah LUBUK MUKTI 181610 Cefixime kapsul 200 mg
20/01/2021 00:00:00 26.480,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 92.556,00
698 Siska Anggraini LUBUK PINANG 147615 Asam Mefenamat 500 m
20/01/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
699 Siti Sundri TUNGGAL JAYA 182073 Glucosamine 250 mg
20/01/2021 00:00:00 7.700,00 BPJS
Natrium diclofenac 50 m 8.670,00
Urinter Kapsul @100 cap 21.980,00
Total 38.350,00
700 Rakpan SUNGAI IPUH 123036 Aspilet 80 mg @100 mg
20/01/2021 00:00:00 4.140,00 BPJS
Bisoprolol 5 mg @100 Ta 8.880,00
Candesartan tab 8 mg 13.620,00
Loratadine tab 10 mg 1.660,00
Paracetamol tablet 500 m 2.000,00
Ranitidine tablet 150 mg 1.440,00
Total 31.740,00
701 Darwin SIDODADI 161429 Alprazolam 0,5 mg @100
20/01/2021 00:00:00 590,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Isosorbid dinitrat 5 mg (I 3.330,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 19.830,00
Total 85.070,00
702 Masinta CINTA ASIH 181532 Ketorolac Tab 10 Mg
20/01/2021 00:00:00 25.300,00 BPJS
Vitamin B Komplek @100 1.540,00
Total 26.840,00
703 M. Nasir TALANG BUAI 161843 Acetylcystein 200 mg Ka
20/01/2021 00:00:00 34.380,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
703 M. Nasir TALANG BUAI 161843 Aminophyline 200 mg @1
20/01/2021 00:00:00 4.000,00 BPJS
Onbrez Breezhaler HGCI 0 102.816,00
Salbutamol 2 mg 1.580,00
Total 142.776,00
704 Suhendra PASAR BANTAL 143029 Azitromycin 500 mg
20/01/2021 00:00:00 56.250,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 62.860,00
705 Rica Gusmawati MEKAR JAYA 177877 Asam Mefenamat 500 m
20/01/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
706 Helmi PONDOK PANJANG 129186 Azitromycin 500 mg
20/01/2021 00:00:00 28.125,00 BPJS
Sistenol kaplet 17.540,00
Total 45.665,00
707 Yayuk Basuki PONDOK BATU 181930 Cefixime Kapsul 100 mg
20/01/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
708 Zulmaini UJUNG PADANG 154372 Cefixime Kapsul 100 mg
20/01/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Total 38.730,00
709 Lasikin TANAH REKAH 155404 Ambroxol Syr 15mg/ml
20/01/2021 00:00:00 4.538,00 BPJS
azitromicin inj 500 mg 721.880,00
Sistenol kaplet 17.540,00
Total 743.958,00
710 Farel Alvaro BUKIT MULYA 181965 Amikasin Injeksi 250 mg
20/01/2021 00:00:00 72.188,00 BPJS
Cefixime syrup 100mg/5 M 23.823,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 15cmx5cm (25 c 6.544,00
Total 109.455,00
711 Enita Erawati LUBUK PINANG 182078 Dexametason Injeksi
20/01/2021 00:00:00 9.384,00 BPJS
Fentanyl Injeksi 5 Ampul 2 52.000,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00
Suprafenid Supositoria 10 28.050,00
Total 190.745,00
712 Revina PASAR SEBELAH 182080 abbocath 18 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 77.873,00
713 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
20/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
714 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
20/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
715 Sadiyono SUMBER MAKMUR 180239 Gabapentin kapsul 300 m
20/01/2021 00:00:00 12.690,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
715 Sadiyono SUMBER MAKMUR 180239 Meloxicam 7,5 mg
20/01/2021 00:00:00 7.280,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 179.595,00
716 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
20/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
717 Bustim PONDOK BARU 163473 NACL 0,9 % 500 ml
20/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
718 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
20/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
719 Surono LUBUK SANAI 143077 Alprazolam 0,5 mg @100
20/01/2021 00:00:00 354,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Cefixime syrup 100mg/5 M 23.823,00
Isosorbid dinitrat 5 mg (I 555,00
Urdahek 101.300,00
Total 128.992,00
720 Yati TANJUNG MULYA 133159 Acetylcystein 200 mg Ka
20/01/2021 00:00:00 25.785,00 BPJS
Asam Traneksamat @10 21.050,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 10 Mg/1 59.590,00
Ranitidine tablet 150 mg 1.440,00
Total 109.865,00
721 Zaman SUNGAI IPUH 118579 Abbocath 20 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Anak 16.473,00
Vitamin B Komplek @100 154,00
Total 88.163,00
722 Bima Aryandika BANDARATU 178714 Dexametason Injeksi
20/01/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Transfusi Set Terumo 16.500,00
Total 176.901,00
723 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
20/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
724 Maria Ulfa GAJAH MATI 181088 Abbocath 20 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 37.124,00
Ketokonazole krim 2 % 3.148,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
724 Maria Ulfa GAJAH MATI 181088 Tranexamic Acid Inj (Asa
20/01/2021 00:00:00 6.315,00 BPJS
Transfusi Set Terumo 16.500,00
Total 140.807,00
725 Ranggi SELAGAN RAYA 149940 Abbocath 18 (Gea)
20/01/2021 00:00:00 10.720,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 85.145,00
726 Zaman SUNGAI IPUH 118579 Ceftriaxone Inj
21/01/2021 00:00:00 12.498,00 BPJS
NACL 0,9 % 500 ml 17.100,00
Neurodex tablet 7.410,00
vestein 300 mg 46.750,00
vestein 300 mg 46.750,00
Vitamin C 500 mg 10,00
Acetylcystein 200 mg Ka
22/01/2021 00:00:00 34.380,00
Cefixime kapsul 200 mg 26.480,00
Vitamin B Komplek @100 3.080,00
Vitamin C tablet @100 Ta 2.760,00
Total 197.218,00
727 Enita Erawati LUBUK PINANG 182078 Abbocath 20 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 76.179,00
728 Farel Alvaro BUKIT MULYA 181965 Abbocath 22 Terumo @5
20/01/2021 00:00:00 22.276,00 BPJS
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 29.025,00
Metrodinazole Infus 30.939,00
Paracetamol Infus 43.314,00
Amikasin Injeksi 250 mg
21/01/2021 00:00:00 72.188,00
Ceftriaxone Inj 6.249,00
Metrodinazole Infus 10.313,00
Paracetamol Infus 14.438,00
Amikasin Injeksi 250 mg
22/01/2021 00:00:00 36.094,00
Amikasin Injeksi 250 mg 36.094,00
Ceftriaxone Inj 6.249,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Paracetamol tablet 500 m 200,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
23/01/2021 00:00:00 12.498,00
Metrodinazole Infus 30.939,00
NonWoven Fixation 15x 13.388,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
728 Farel Alvaro BUKIT MULYA 181965 Ringer Laktat Otsuka
23/01/2021 00:00:00 19.076,00 BPJS
Abbocath 24 Terumo @5
24/01/2021 00:00:00 11.138,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Metrodinazole Infus 20.626,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol syrup 1.388,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
25/01/2021 00:00:00 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 19.350,00
NonWoven Fixation 15x 6.694,00
Cefixime syrup 100mg/5 M
26/01/2021 00:00:00 23.823,00
Total 633.974,00
729 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
20/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
730 Adelia Nis Cahya TIRTA MAKMUR 129069 Abu (Serum Anti Bisa Ul
20/01/2021 00:00:00 590.500,00 BPJS
Dexametason Injeksi 6.256,00
Furosemide Injeksi @2ml 1.666,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol syrup 1.388,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 652.486,00
731 Tri Astuti BUKIT MAKMUR 181958 Abbocath 20 Terumo @5
20/01/2021 00:00:00 22.276,00 BPJS
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Cefoperazon Inj 41.250,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 3.128,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
NACL 0,9 % 500 ml 8.550,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Cefadroxil tab 500 mg @1
22/01/2021 00:00:00 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
731 Tri Astuti BUKIT MAKMUR 181958 Kassa kotak stril DRC
22/01/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Total 595.384,00
732 Nova Maulida TIRTA MULYA 177763 abbocath 18 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Misoprostol Tab 16.500,00
Ringer Laktat Otsuka 9.538,00
Total 96.290,00
733 Adelia Nis Cahya TIRTA MAKMUR 129069 Dipenhydramin Injeksi 10
20/01/2021 00:00:00 1.535,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Tranexamic Acid Inj (Asa 2.105,00
NACL 0,9 % 500 ml
21/01/2021 00:00:00 17.100,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 19.076,00
Total 55.060,00
734 Siti Khotimah SIDODADI 154909 Abbocath 20 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 10 mg @50 T 318,00
Candesartan Tab 16 mg 5.775,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 11.250,00
Esomeprazol Injeksi 40 m 34.956,00
Infusion Makro (terumo) 27.225,00
Levemir FlexPen 104.938,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Stomach Tube) Fr. 1 60.046,00
Novorapid Flexpen 108.750,00
Piracetam injek 200 mg 17.325,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj 6.249,00
Citicoline Injeksi 125mg/ 11.250,00
Electroda (Ambu) @25 Pc 81.570,00
Piracetam injek 200 mg 5.775,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
21/01/2021 00:00:00 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Esomax Inj 148.500,00
Guedel No. 02 MM 199.614,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Dewasa 41.828,00
Nicardipine HCl Inj 29.566,00
Nicardipine HCl Inj 29.566,00
Nicardipine HCl Inj 118.264,00
Otsu Nacl PiggyBack 100 m 18.975,00
Paracetamol Infus 14.438,00

19/08/2021 12:42:30 Page 183 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
734 Siti Khotimah SIDODADI 154909 Phenytoin Sodium Injeksi
21/01/2021 00:00:00 15.911,00 BPJS
Phenytoin Sodium Injeksi 15.911,00
Phenytoin Sodium Injeksi 63.644,00
Piracetam injek 200 mg 17.325,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Suction Chateter no. 12 ( 10.588,00
Three Way stopcock 37.125,00
Abbocath 22 Terumo @5
22/01/2021 00:00:00 11.138,00
Aqua Pro Injeksi 7.150,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 11.250,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol Infus 28.876,00
Phenytoin Sodium Injeksi 31.822,00
Piracetam injek 200 mg 11.550,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
23/01/2021 00:00:00 12.498,00
Cetadop inj 7.700,00
Cetadop inj 23.100,00
Citicoline Injeksi 125mg/ 22.500,00
Dobutamin Injeksi 50 mg 14.536,00
Esomeprazol Injeksi 40 m 34.956,00
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Otsu Nacl PiggyBack 100 m 18.975,00
Paracetamol Infus 14.438,00
Piracetam injek 200 mg 17.325,00
Ringer Laktat Otsuka 19.076,00
Three Way stopcock 37.125,00
Three Way stopcock 37.125,00
Diazepam Inj
24/01/2021 00:00:00 8.215,00
Epinephrin inj 15.331,00
Phenytoin Sodium Injeksi 31.822,00
Total 2.060.890,00
735 Safitri Nur Hasanah SUMBER MAKMUR 179106 abbocath 18 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole Infus 30.939,00
Transfusi Set Terumo 16.500,00
Total 74.929,00
736 Nelma SILAUT 182081 Catheter 2 Way No. 16 (
20/01/2021 00:00:00 39.025,00 BPJS
Ceftriaxone Inj 12.498,00
Paracetamol Infus 28.876,00
Tramadol 50 mg/ml Inj 8.250,00
Urine bag 10.088,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
736 Nelma SILAUT 182081 Ascorbid Acid 1000mg/5m
21/01/2021 00:00:00 0,00 BPJS
Betahistin Mesilat 6 mg @ 414,00
Ceftriaxone Inj 12.498,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol Infus 43.314,00
Phytomenadione 10 Mg/1 0,00
Tranexamic Acid Inj (Asa 6.315,00
Betahistin Mesilat 6 mg @
22/01/2021 00:00:00 2.760,00
Citicoline kaplet 500 mg 33.000,00
Paracetamol tablet 500 m 4.000,00
Total 218.138,00
737 Rosi Mustika PASAR BARU 182082 abbocath 18 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 60.736,00
738 Fidiawati Pasar mukomuko 111187 Abbocath 20 Terumo @5
20/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Mecobalamin 500 mg 1.540,00
Nassal Cannula O2 Dewas 11.625,00
Ringer Laktat Otsuka 19.076,00
Total 79.029,00
739 Safitri Nur Hasanah SUMBER MAKMUR 179106 Alkohol 1Liter
20/01/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 3.128,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker 3 Play N. 95 51.274,00
Masker Karet 22.000,00
Masker Karet Boism 23.790,00
Metoclopramide inj 5Mg/M 5.879,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
739 Safitri Nur Hasanah SUMBER MAKMUR 179106 Myotonic inj
20/01/2021 00:00:00 19.596,00 BPJS
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Bisturi no. 10
21/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Total 1.372.995,00
740 Fidiawati Pasar mukomuko 111187 Betahistin Mesilat 6 mg @
21/01/2021 00:00:00 1.380,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Total 6.230,00
741 Desi Reliningsih SUNGAI GADING 145658 ATRACURIUM BESYLATE 2
21/01/2021 00:00:00 14.671,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
handscoond steril 8 (Gam 145.540,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metrodinazole Infus 30.939,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Misoprostol Tab 55.000,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.000,00
Suprafenid Supositoria 10 14.025,00
Topi Operasi (Perawat) @ 9.380,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 6.315,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 582.260,00
742 Riswandi Dani KOTO JAYA 114377 Amlodipine 5 mg @30 T
20/01/2021 00:00:00 101,00 BPJS
Antasida Syrup 60 ml 2.736,00
Candesartan tab 8 mg 681,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Pantoprazole Inj 23.375,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 95.301,00
743 Revina PASAR SEBELAH 182080 Cefixime syrup 100mg/5 M
21/01/2021 00:00:00 238.230,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Ketorolac inj 30 mg/1ml 6.725,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 2.700,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 27.500,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron tablet 8 mg 26.400,00
Paracetamol tablet 500 m 2.000,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Tranexamic Acid Inj (Asa 4.210,00
Total 518.388,00
744 Riswandi Dani KOTO JAYA 114377 Amlodipine 5 mg @30 T
21/01/2021 00:00:00 1.010,00 BPJS
Candesartan tab 8 mg 6.810,00
Metformin tablet 500 mg 2.660,00
Metoclorapamide tab 10 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 25 mg 2.600,00
Total 21.200,00
745 Enita Erawati LUBUK PINANG 182078 Asam Mefenamat 500 m
21/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril M 20.080,00

19/08/2021 12:42:30 Page 187 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
745 Enita Erawati LUBUK PINANG 182078 handscoond steril 6.5 (G
21/01/2021 00:00:00 29.108,00 BPJS
handscoond steril 8 (Gam 29.108,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 22.000,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 55.000,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 800,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Total 405.315,00
746 Nova Maulida TIRTA MULYA 177763 Asam Mefenamat 500 m
21/01/2021 00:00:00 1.290,00 BPJS
ATRACURIUM BESYLATE 2 14.671,00
Cefadroxil tab 500 mg @1 10.500,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Masker Karet 22.000,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 55.000,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 8.550,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Total 373.664,00
747 Rosi Mustika PASAR BARU 182082 Cefixime Kapsul 100 mg
21/01/2021 00:00:00 9.380,00 BPJS
Neurodex tablet 7.410,00
Paracetamol tablet 500 m 3.000,00
Total 19.790,00
748 Ranggi SELAGAN RAYA 149940 Alkohol 1Liter
21/01/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 26.979,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00

19/08/2021 12:42:30 Page 188 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
748 Ranggi SELAGAN RAYA 149940 handscoond steril 8 (Gam
21/01/2021 00:00:00 29.108,00 BPJS
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine Povidone 1 L 158.594,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Bisturi No. 23
22/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
23/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 540,00
NonWoven Fixation 15x 13.388,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
24/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.510.319,00
749 Maria Ulfa GAJAH MATI 181088 Bisturi No. 23
22/01/2021 00:00:00 3.836,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 157.750,00

19/08/2021 12:42:30 Page 189 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
749 Maria Ulfa GAJAH MATI 181088 Chromic catgut 2-0 R (Tr
22/01/2021 00:00:00 72.250,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 6.5 (G 145.540,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7 (G 72.815,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 1.350,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 bayi 9.530,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ondansetron Inj 3.300,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Asam Mefenamat 500 m
23/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.890.002,00
750 Safitri Nur Hasanah SUMBER MAKMUR 179106 Aqua Pro Injeksi
23/01/2021 00:00:00 3.575,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Bisturi No. 23
26/01/2021 00:00:00 3.836,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
750 Safitri Nur Hasanah SUMBER MAKMUR 179106 Bucain Spinal 0.5 % Inj
26/01/2021 00:00:00 52.181,00 BPJS
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 3.128,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 4.255,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 11.000,00
Metoclopramide inj 5Mg/M 5.879,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 98.500,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
Total 1.121.299,00
751 Evi Tamala desa air kasa 152301 abbocath 18 Terumo @5
21/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 10 mg @50 T 236,00
Aqua Pro Injeksi 3.575,00
Catgut Chromic 2 R (SMI 82.000,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lidocain injk 40 mg/2 ml 3.222,00
Misoprostol Tab 16.500,00
Otsu MgSO4 20 % 4.160,00
Phytomenadione 10 mg ( 934,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Abbocath 20 Terumo @5 22.276,00
Cefotaxime Injeksi 11.502,00
Metrodinazole tab 500 m 1.350,00
Misoprostol Tab 16.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
751 Evi Tamala desa air kasa 152301 Paracetamol tablet 500 m
21/01/2021 00:00:00 1.000,00 BPJS
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Total 274.304,00
752 Ny.sutriani TANJUNG ALAI 182083 Bisturi no. 10
21/01/2021 00:00:00 3.836,00 BPJS
Chloramphenicol Salep M 2.351,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 10 Mg/1 5.959,00
umbilical Cord Clamp 2.261,00
Total 84.827,00
753 Liza Fitri Marlini RAWA MULYA 161745 Betahistin Mesilat 6 mg @
21/01/2021 00:00:00 2.070,00 BPJS
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 247.500,00
Total 296.875,00
754 Balui GAJAH MATI 118528 Natrium diclofenac 50 m
21/01/2021 00:00:00 8.670,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 165.000,00
Total 245.381,00
755 Septi Putriani LUBUK PINANG 119099 Asam Folat 1 mg @100 T
21/01/2021 00:00:00 2.970,00 BPJS
Valproic Acid Syrup 250mg 104.875,00
Vomil b6 90.750,00
Total 198.595,00
756 Sumar SUNGAI IPUH 181576 Alprazolam 0,5 mg @100
21/01/2021 00:00:00 2.360,00 BPJS
Cetirizine 10 mg 1.260,00
Ketokonazole krim 2 % 6.296,00
Ketokonazole tablet 200 m 3.710,00
Paracetamol tablet 500 m 2.000,00
Total 15.626,00
757 Razali PERNYAH 175986 Amlodipine 5 mg @30 T
21/01/2021 00:00:00 3.030,00 BPJS
Glimepiride tab 2 mg 7.770,00
Metformin tablet 500 mg 11.970,00
Miniaspi 80 Mg @100 Ta 2.375,00
Miniaspi 80 Mg @100 Ta 1.375,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 52.380,00
758 Titis Sumarni PERNYAH 141441 Meloxicam 7,5 mg
21/01/2021 00:00:00 7.280,00 BPJS
Natrium diclofenac 50 m 5.780,00
Omeprazol kapsul 20 mg 3.305,00
Renax @50 Kapsul 45.376,00
Urinter Kapsul @100 cap 21.980,00
Total 83.721,00
759 Yendri Saputri LUBUK PINANG 148482 abbocath 18 Terumo @5
21/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
NonWoven Fixation 15x 6.694,00

19/08/2021 12:42:30 Page 192 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
759 Yendri Saputri LUBUK PINANG 148482 Ringer Laktat Otsuka
21/01/2021 00:00:00 9.538,00 BPJS
Transfusi Set Terumo 16.500,00
Total 53.196,00
760 Manis TANAH HARAPAN 171326 Amlodipine 10 mg @50 T
21/01/2021 00:00:00 3.540,00 BPJS
Candesartan Tab 16 mg 35.370,00
Omeprazol kapsul 20 mg 3.305,00
Propanolol tab 10 mg 2.220,00
Sucralfate Suspensi 100 m 19.250,00
thyrozol 5 mg 8.260,00
Total 71.945,00
761 Sutri Maideska PT AGRO AIR DIKIT 181963 Gitas Plus
21/01/2021 00:00:00 50.330,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 41.250,00
Vitamin B Komplek @100 3.080,00
Total 117.215,00
762 Winaryo AIR HITAM 159690 thyrozol 5 mg
21/01/2021 00:00:00 24.780,00 BPJS
Vitamin B Komplek @100 3.080,00
Total 27.860,00
763 Fitriani PONDSOK BATU 181886 Asam Mefenamat 500 m
21/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 68.935,00
764 Muslim Munajat WONOSOBO 145054 Gabapentin kapsul 300 m
21/01/2021 00:00:00 25.380,00 BPJS
Loratadine tab 10 mg 1.660,00
Miniaspi 80 Mg @100 Ta 3.750,00
Natrium diclofenac 50 m 5.780,00
Sucralfate Suspensi 100 m 19.250,00
Total 55.820,00
765 M.supomo LUBUK PINANG 136126 Domperidone Tab
21/01/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Total 23.635,00
766 Annur Manudin TANJUNG ALAI 119525 Cefadroxil tab 500 mg @1
21/01/2021 00:00:00 10.500,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 2.000,00
Total 32.994,00
767 Amri Kusna Yanti BUMI MULYA 133486 Amlodipine 10 mg @50 T
21/01/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Otsu D40 37.539,00
Total 72.093,00
768 Sugito MEKAR MULYA 147062 Meloxicam 7,5 mg
21/01/2021 00:00:00 1.456,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Total 35.656,00
769 Darmawan LUBUK PINANG 140187 Meloxicam 7,5 mg
21/01/2021 00:00:00 2.184,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Total 36.384,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
770 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
21/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
771 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
21/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
772 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
21/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
773 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
21/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
774 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
21/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
775 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
21/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
776 Siti Rahmah SILAUT 181967 Asam Mefenamat 500 m
21/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 59.260,00
777 Yendri Saputri LUBUK PINANG 148482 Bisturi No. 23
21/01/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Gelaufusal Infusion 500 m 181.269,00
handscoon steril 7.5 (Tr 29.976,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 24.062,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
777 Yendri Saputri LUBUK PINANG 148482 Spuit 5 cc terumo
21/01/2021 00:00:00 8.538,00 BPJS
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Bisturi No. 23
22/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Paracetamol Infus 14.438,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Abbocath 22 Terumo @5
23/01/2021 00:00:00 11.138,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Ciprofloxacin tab 500 mg
24/01/2021 00:00:00 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 25.300,00
Postofix (leukomed) 36.726,00
Total 1.523.443,00
778 Leni bumi mekar jaya 182094 Cefotaxime Injeksi
21/01/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Misoprostol Tab 16.500,00
Total 32.037,00
779 Wulandari TERUNTUNG 182090 Nassal Cannula O2 Dewas
21/01/2021 00:00:00 11.625,00 BPJS
Total 11.625,00
780 Wulan Nurpa Sepriani BUKIT MAKMUR 182097 abbocath 18 Terumo @5
21/01/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 79.024,00
781 Rika Sundari SINAR JAYA 182087 Abbocath 20 Terumo @5
21/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 67.886,00
782 Wulandari TERUNTUNG 182090 Bisturi No. 23
23/01/2021 00:00:00 0,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
782 Wulandari TERUNTUNG 182090 Bucain Spinal 0.5 % Inj
23/01/2021 00:00:00 0,00 BPJS
Catheter 2 Way No. 16 ( 0,00
Celemek Plastik 0,00
Chromic catgut 1 R (Tri 0,00
Chromic catgut 2-0 R (Tr 0,00
Cuticell Classic 10cmx10c 0,00
Dexametason Injeksi 0,00
Ephedrine Injeksi 0,00
Gelaufusal Infusion 500 m 0,00
Handscoon steril 7,5 (Ga 0,00
Handscoond Non Steril M 0,00
handscoond steril 6.5 (G 0,00
handscoond steril 8 (Gam 0,00
Handscoond Sterille 7 (G 0,00
Hypafix 15cmx5cm (25 c 0,00
Induxin 1 ml Injeksi 9.281,00
Ketorolac inj 30 mg/1ml 0,00
Masker Karet Boism 0,00
Miloz Injeksi 5 mg 0,00
Misoprostol Tab 0,00
Myotonic inj 0,00
NACL 0,9 % 500 ml 0,00
Ondansetron Inj 0,00
Polyvinylidene 3-0 R (Tri 0,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 0,00
Spuit 10 cc Disposible (T 0,00
Spuit 3 cc Terumo 0,00
Spuit 5 cc terumo 0,00
Suprafenid Supositoria 10 0,00
Topi Operasi (Dokter) @5 0,00
Tranexamic Acid Inj (Asa 0,00
Urine bag 0,00
viamac 1 R 0,00
Total 28.357,00
783 Andita Lestari TUNGGANG 171562 abbocath 18 Terumo @5
21/01/2021 00:00:00 22.276,00 BPJS
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Midazolam 5mg/1ml 9.859,00

19/08/2021 12:42:30 Page 196 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
783 Andita Lestari TUNGGANG 171562 Misoprostol Tab
21/01/2021 00:00:00 16.500,00 BPJS
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
abbocath 18 Terumo @5
22/01/2021 00:00:00 11.138,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Dexametason Injeksi 6.256,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
23/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
24/01/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
25/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.468.941,00
784 Wulan Nurpa Sepriani BUKIT MAKMUR 182097 Cefadroxil tab 500 mg @1
25/01/2021 00:00:00 10.500,00 BPJS
Total 10.500,00
785 Rasidi PASAR MUKO MUKO 182100 Asam Mefenamat 500 m
21/01/2021 00:00:00 1.290,00 BPJS
Lidocain injk 40 mg/2 ml 1.611,00
NACL 0,9 % 500 ml 8.550,00
Tetagam 1 Ml Injeksi 184.000,00
Total 195.451,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
786 Arief Kumala Fadhilalh AIR BULUH 180026 abbocath 18 Terumo @5
21/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 61.890,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Masker Karet 22.000,00
Misoprostol Tab 16.500,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 8.420,00
Cefotaxime Injeksi
22/01/2021 00:00:00 11.502,00
Dexametason Injeksi 12.512,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 8.550,00
Cefadroxil tab 500 mg @1
23/01/2021 00:00:00 10.500,00
Cefotaxime Injeksi 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Paracetamol tablet 500 m 2.000,00
Tranexamic Acid Inj (Asa 6.315,00
Vitamin B Komplek @100 1.540,00
Total 367.251,00
787 Rika Sundari SINAR JAYA 182087 Asam Mefenamat 500 m
22/01/2021 00:00:00 1.935,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Cefadroxil tab 500 mg @1 10.500,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 144.500,00
Chromic catgut 2-0 R (Tr 144.500,00
handscoond steril 6.5 (G 87.324,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suction Chateter no. 8 (R 20.625,00

19/08/2021 12:42:30 Page 198 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
787 Rika Sundari SINAR JAYA 182087 Tranexamic Acid Inj (Asa
22/01/2021 00:00:00 4.210,00 BPJS
umbilical Cord Clamp 2.261,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Total 589.702,00
788 Leni bumi mekar jaya 182094 Asam Mefenamat 500 m
22/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Ketorolac Tab 10 Mg 25.300,00
Misoprostol Tab 55.000,00
Total 92.090,00
789 Evi Tamala desa air kasa 152301 Amlodipine 5 mg @30 T
22/01/2021 00:00:00 1.010,00 BPJS
Asam Mefenamat 500 m 1.290,00
Asam Traneksamat @10 31.575,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Total 54.050,00
790 Sumarni SILAUT 182103 abbocath 18 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Dexametason Injeksi 12.512,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 54.538,00
791 Silya Wana BANDARATU 117469 abbocath 18 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 101,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
meropenem Injeksi 1 g 82.500,00
Octalbin 25% 100 cc (Hu 1.887.500,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Aqua Pro Injeksi 7.150,00
Fresofol ( propopol ) inj 13.448,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Psidii Capsule 500 mg 14.703,00
Psidii Capsule 500 mg 9.802,00
Ringer Laktat Otsuka 9.538,00
Clonidine 0.15 mg @100 T
23/01/2021 00:00:00 458,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
meropenem Injeksi 1 g 82.500,00
meropenem Injeksi 1 g 82.500,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 19.076,00
Tambah Darah Neo Tab 465,00

19/08/2021 12:42:30 Page 199 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
791 Silya Wana BANDARATU 117469 Tranexamic Acid Inj (Asa
23/01/2021 00:00:00 6.315,00 BPJS
Total 2.423.666,00
792 Munasiroh PONDOK MAKMUR 182106 Abbocath 20 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Domperidone Tab
23/01/2021 00:00:00 1.620,00
Neurodex tablet 7.410,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 24.998,00
Sucralfate Suspensi 100 m 19.250,00
Total 212.479,00
793 Elvi Indrayani PASAR SEBELAH 182003 Cefixime Kapsul 100 mg
22/01/2021 00:00:00 9.380,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 80.306,00
794 Sumir Wati LUNANG 182005 Cefixime Kapsul 100 mg
22/01/2021 00:00:00 9.380,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 80.306,00
795 Darmawas DUSUN BARU PELOKA 152558 Acetylcystein 200 mg Ka
22/01/2021 00:00:00 17.190,00 BPJS
Aminophyline 200 mg @1 1.800,00
Cefixime Kapsul 100 mg 9.380,00
Lansoprazole kapsul 30 m 11.550,00
Methylprednisolone tab 4 2.630,00
Onbrez Breezhaler HGCI 0 440.640,00
Paracetamol tablet 500 m 2.000,00
Salbutamol 4 mg 1.395,00
Total 486.585,00
796 Amiruddin BANDAR RATU 089119 Amlodipine 5 mg @30 T
22/01/2021 00:00:00 4.350,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 4.000,00
Simvastatin tab 10 mg 7.230,00
Vbloc 6,25 mg 65.550,00
Total 140.390,00
797 Sudartoyo TANJUNG ALAI 182109 Ketoprofen tab 100 mg
22/01/2021 00:00:00 24.760,00 BPJS
Paracetamol tablet 500 m 4.000,00
Tensocrepe 15 x 4.5 cm ( 71.000,00

19/08/2021 12:42:30 Page 200 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 99.760,00
798 Dasmiati BANDAR RATU 089122 Amlodipine 5 mg @30 T
22/01/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 4.000,00
Simvastatin tab 10 mg 7.230,00
ursodeoxycholic acid 28.350,00
Total 122.300,00
799 Adriani BANDARATU 120948 Amlodipine 5 mg @30 T
22/01/2021 00:00:00 4.350,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 4.000,00
Simvastatin tab 10 mg 7.230,00
Total 47.060,00
800 Daliman SINAR JAYA 151163 Acetylcystein 200 mg Ka
22/01/2021 00:00:00 17.190,00 BPJS
Aminophyline 200 mg @1 2.400,00
Cefixime kapsul 200 mg 26.480,00
Methylprednisolone tab 4 2.630,00
Onbrez Breezhaler HGCI 0 440.640,00
Paracetamol tablet 500 m 2.000,00
Salbutamol 2 mg 1.580,00
Total 492.920,00
801 Rina Novita Handayani RAWA BANGUN 152528 Bisoprolol 5 mg @100 Ta
22/01/2021 00:00:00 2.960,00 BPJS
Metoclopramide Tab 5 m 1.510,00
Total 4.470,00
802 Titin Sumarni KOTO JAYA 112327 Leparson tablet
22/01/2021 00:00:00 164.400,00 BPJS
Triheksifenidil tab 2 mg 9.000,00
Total 173.400,00
803 Kemis AGUNG JAYA SP6 114066 Cefixime Kapsul 100 mg
22/01/2021 00:00:00 18.760,00 BPJS
Cuticell Classic 10cmx10c 13.800,00
NonWoven Fixation 15x 13.388,00
Paracetamol tablet 500 m 4.000,00
Total 49.948,00
804 Erniati PENARIK 141742 Alprazolam 1 mg @100 T
22/01/2021 00:00:00 1.600,00 BPJS
Amlodipine 5 mg @30 T 4.350,00
Candesartan tab 8 mg 20.430,00
Citicoline kaplet 500 mg 49.500,00
Mecobalamin 500 mg 23.100,00
Metformin tablet 500 mg 7.980,00
Total 106.960,00
805 Widia Sartika LALANG LUAS 179707 Asam Mefenamat 500 m
22/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 57.416,00
806 Nurseha PASAR BELAKANG 132717 Ambroxol Syr 15mg/ml
22/01/2021 00:00:00 4.538,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Captopril 12,5 mg 2.400,00
Furosemide 40 mg Tablet 2.880,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
806 Nurseha PASAR BELAKANG 132717 Omeprazol kapsul 20 mg
22/01/2021 00:00:00 6.610,00 BPJS
Spironolaktone 25 mg 7.800,00
Total 28.368,00
807 Indah Derita AIR DIKIT 121845 Antasida Syrup 60 ml
22/01/2021 00:00:00 2.736,00 BPJS
Metoclopramide Tab 5 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 30.106,00
808 Meston Arianto AIR DIKIT 182113 Renax @50 Kapsul
22/01/2021 00:00:00 113.440,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 135.420,00
809 Sarinem PENARIK 182114 Antasida Syrup 60 ml
22/01/2021 00:00:00 2.736,00 BPJS
Metoclopramide Tab 5 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 30.106,00
810 Karsini TANAH REKAH 182117 Ketoprofen tab 100 mg
22/01/2021 00:00:00 24.760,00 BPJS
Paracetamol tablet 500 m 4.000,00
Total 28.760,00
811 Solin RANAH KARYA 175604 Renax @50 Kapsul
22/01/2021 00:00:00 113.440,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 135.420,00
812 Nazhirah Azhara BANDARA RATU 182118 Amoxicillin Syr
22/01/2021 00:00:00 6.531,00 BPJS
Lidocain injk 40 mg/2 ml 1.611,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol syrup 1.388,00
Polyvinylidene 3-0 R (Tri 92.000,00
Total 110.080,00
813 Renata Nurmila Sarum PENARIK 181964 Asam Mefenamat 500 m
22/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 62.241,00
814 Erna Irawati Lubis DUSUN BARU PELOKA 181931 Aspilet 80 mg @100 mg
22/01/2021 00:00:00 4.140,00 BPJS
Gabapentin kapsul 300 m 38.070,00
Glimepiride tab 2 mg 7.770,00
Metformin tablet 500 mg 7.980,00
Omeprazol kapsul 20 mg 6.610,00
Total 64.570,00
815 Yuni Kartini TALANG MEDAN 127780 Asam Mefenamat 500 m
22/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 62.241,00
816 Alim Fernando DUSUN BARU 138099 Paracetamol tablet 500 m
22/01/2021 00:00:00 2.000,00 BPJS
Vitamin B Komplek @100 1.540,00
Vitamin C tablet @100 Ta 1.380,00
Total 4.920,00
817 Sumarni SILAUT 182103 Bisturi No. 23
22/01/2021 00:00:00 7.672,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
817 Sumarni SILAUT 182103 Catheter 2 Way No. 16 (
22/01/2021 00:00:00 20.625,00 BPJS
Cefotaxime Injeksi 23.004,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
handscoond steril 8 (Gam 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 37.124,00
Induxin 1 ml Injeksi 27.843,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 0,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
23/01/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
24/01/2021 00:00:00 11.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
817 Sumarni SILAUT 182103 Ketorolac inj 30 mg/1ml
24/01/2021 00:00:00 4.035,00 BPJS
Metrodinazole Infus 30.939,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
25/01/2021 00:00:00 2.580,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Ketorolac inj 30 mg/1ml
26/01/2021 00:00:00 0,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 0,00
Total 1.903.492,00
818 Siti Khotijah LUBUK MUKTI 163011 Calcium Laktat
22/01/2021 00:00:00 790,00 BPJS
Total 790,00
819 Salami SILAUT I 134774 Infusion Makro (terumo)
22/01/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Otsu D40 37.539,00
Total 107.514,00
820 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
22/01/2021 00:00:00 42.750,00 BPJS
Omeprazol kapsul 20 mg 1.983,00
Otsu D40 37.539,00
Total 82.272,00
821 Hasan TANAH HARAPAN 123437 Abbocath 20 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Amlodipine 10 mg @50 T 3.180,00
Aqua Pro Injeksi 3.575,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Total 86.157,00
822 Suparmi SILAUT 156450 Infusion Makro (terumo)
22/01/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 69.975,00
823 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
22/01/2021 00:00:00 42.750,00 BPJS
Omeprazol kapsul 20 mg 1.983,00
Total 44.733,00
824 Misni TANJUNG BERINGIN 162425 Infusion Makro (terumo)
22/01/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 69.975,00
825 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
22/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
826 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
22/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
827 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
22/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
828 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
22/01/2021 00:00:00 34.200,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 34.200,00
829 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
22/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
830 Nurwati TANAH REKAH 182121 Paracetamol tablet 500 m
22/01/2021 00:00:00 2.000,00 BPJS
Total 2.000,00
831 Suhardi BANDAR RATU 115774 Alprazolam 1 mg @100 T
22/01/2021 00:00:00 1.600,00 BPJS
Asam Mefenamat 500 m 2.580,00
Candesartan Tab 16 mg 28.875,00
Clopidogrel 75 mg @30 T 35.100,00
Paracetamol tablet 500 m 4.000,00
Total 72.155,00
832 Julianda gita putri PONDOK BARU 182122 abbocath 18 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metrodinazole Infus 10.313,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
832 Julianda gita putri PONDOK BARU 182122 Suprafenid Supositoria 10
22/01/2021 00:00:00 28.050,00 BPJS
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.718.177,00
833 Kurnia Wulandari TIRTA MAKMUR 172942 abbocath 18 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ondansetron Inj 3.300,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
833 Kurnia Wulandari TIRTA MAKMUR 172942 Topi Operasi (Dokter) @5
22/01/2021 00:00:00 16.990,00 BPJS
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Furamin Injeksi
24/01/2021 00:00:00 43.107,00
Total 1.795.656,00
834 Ita Nurhayati IPUH 182123 abbocath 18 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Abbocath 24 Terumo @5 55.690,00
Aqua Pro Injeksi 3.575,00
Bactesyn inj 0,75 gr 59.009,00
Bisturi No. 23 3.836,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 41.250,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 13.088,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metrodinazole Infus 10.313,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Ottogenta inj 9.900,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
834 Ita Nurhayati IPUH 182123 Spuit 5 cc terumo
22/01/2021 00:00:00 8.538,00 BPJS
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Urine bag 20.176,00
viamac 1 R 364.370,00
Total 1.794.253,00
835 Erlina SARIBULAN 182124 abbocath 18 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
abbocath 18 Terumo @5 22.276,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Ondansetron Inj 3.300,00
Paracetamol Infus 43.314,00
Paracetamol Infus 14.438,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00

19/08/2021 12:42:30 Page 208 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
835 Erlina SARIBULAN 182124 Transfusi Set Terumo
22/01/2021 00:00:00 16.500,00 BPJS
Utrogestan 200 mg 50.946,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
23/01/2021 00:00:00 11.502,00
Dexametason Injeksi 12.512,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
24/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Total 1.779.347,00
836 Ny Julianda PONDOK BARU 182125 Cefotaxime Injeksi
23/01/2021 00:00:00 17.253,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Total 28.413,00
837 Ny Ita Nurhayati IPUH 182126 Bactesyn inj 0,75 gr
25/01/2021 00:00:00 59.009,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Gentamicin Injeksi 4.606,00
NonWoven Fixation 15x 6.694,00
Ottogenta inj 9.900,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Vit K Infant Injeksi 8.250,00
Total 154.563,00
838 Ny Kurnia Wulandari TIRTA MAKMUR 182127 Cefotaxime Injeksi
23/01/2021 00:00:00 17.253,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Total 28.413,00
839 muhamad dion dirg TALANG MEDAN 168982 Abbocath 24 Terumo @5
22/01/2021 00:00:00 33.414,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Infusion set Mikro (Terumo 18.026,00
Ka-En 1 B 12.658,00
Nassal Cannula O2 bayi 9.530,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ottogenta inj 9.900,00
Extention Tube
23/01/2021 00:00:00 8.801,00
Hypafix 15cmx5cm (25 c 6.544,00
Miconazole krim 2 % 4.481,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Ottopan Drops 18.906,00
Three Way stopcock 37.125,00
Abbocath 24 Terumo @5
24/01/2021 00:00:00 33.414,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Fuson Cream
25/01/2021 00:00:00 38.500,00
Abbocath 24 Terumo @5
27/01/2021 00:00:00 44.552,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
839 muhamad dion dirg TALANG MEDAN 168982 Hypafix 10cm x 5cm (25 c
27/01/2021 00:00:00 4.850,00 BPJS
Abbocath 24 Terumo @5
28/01/2021 00:00:00 33.414,00
NonWoven Fixation 15x 6.694,00
Total 448.710,00
840 Yuli Andesah KOTA JAYA 113447 Abbocath 20 Terumo @5
22/01/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Cefotaxime Injeksi
23/01/2021 00:00:00 11.502,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
24/01/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 28.614,00
Cefixime syrup 100mg/5 M
25/01/2021 00:00:00 23.823,00
Vitamin B Komplek @100 1.540,00
Total 209.583,00
841 Kurnia Wulandari TIRTA MAKMUR 172942 abbocath 18 Terumo @5
25/01/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 22.276,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 5.751,00
Cuticell Classic 10cmx10c 13.800,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 13.388,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Total 155.016,00
842 Ita Nurhayati IPUH 182123 Aqua Pro Injeksi
25/01/2021 00:00:00 7.150,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix Kamar Operasi 18.000,00
Hypafix Kamar Operasi 18.000,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
842 Ita Nurhayati IPUH 182123 Ketorolac inj 30 mg/1ml
25/01/2021 00:00:00 4.035,00 BPJS
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 13.388,00
Postofix (leukomed) 36.726,00
Postofix (leukomed) 36.726,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Vitamin B Komplek @100 1.540,00
Total 287.633,00
843 Julianda gita putri PONDOK BARU 182122 Aqua Pro Injeksi
25/01/2021 00:00:00 7.150,00 BPJS
Aqua Pro Injeksi 7.150,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Total 116.200,00
844 Erlina SARIBULAN 182124 Cefotaxime Injeksi
25/01/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
NonWoven Fixation 10x 4.815,00
Tranexamic Acid Inj (Asa 4.210,00
Asam Mefenamat 500 m
26/01/2021 00:00:00 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 77.128,00
845 Dola Hendriyani PT ALNO SAPTA BUAN 182129 abbocath 18 Terumo @5
23/01/2021 00:00:00 11.138,00 BPJS
Abbocath 22 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00

19/08/2021 12:42:30 Page 211 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
845 Dola Hendriyani PT ALNO SAPTA BUAN 182129 Gelaufusal Infusion 500 m
23/01/2021 00:00:00 181.269,00 BPJS
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Vicryl 2/0 C 108.200,00
Total 1.447.694,00
846 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
847 Bahman SIBAK 155872 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
848 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
849 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
850 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
851 Bustim PONDOK BARU 163473 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
852 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
23/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
853 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
23/01/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Total 67.776,00
854 Jumarno LUNANG 180796 Gentamicin Injeksi
23/01/2021 00:00:00 9.212,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
854 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Total 43.412,00
855 Bima Aryandika BANDARATU 178714 Dexametason Injeksi
23/01/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
NACL 0,9 % 500 ml 34.200,00
Transfusi Set Terumo 16.500,00
Total 60.026,00
856 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
23/01/2021 00:00:00 34.200,00 BPJS
Otsu D40 37.539,00
Total 71.739,00
857 Yasir PONDOK MAKMUR 131315 Abbocath 20 Terumo @5
23/01/2021 00:00:00 11.138,00 BPJS
Allopurinol 100 mg @100 234,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Zink Tablet 1.378,00
Abbocath 22 Terumo @5
24/01/2021 00:00:00 22.276,00
Allopurinol 100 mg @100 234,00
Ceftriaxone Inj 12.498,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Zinc Sulfate Syr 60 ml 4.569,00
Allopurinol 100 mg @100
25/01/2021 00:00:00 2.340,00
Ketocid @100 Tab 32.490,00
Total 170.986,00
858 Bustari PONDOK SUGUH 142999 Abbocath 20 Terumo @5
23/01/2021 00:00:00 22.276,00 BPJS
Allopurinol 100 mg @100 234,00
Ambroxol 30 mg @100 T 579,00
Aminofluid Infus 500 ml 155.204,00
Aqua Pro Injeksi 7.150,00
Catheter 2 Way No. 16 ( 39.025,00
Citicoline Injeksi 125mg/ 11.250,00
Infusion Makro (terumo) 54.450,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
NGT (Stomach Tube) Fr. 1 52.250,00
NonWoven Fixation 15x 13.388,00
Nystatin Drop 27.830,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Citicoline Injeksi 125mg/ 22.500,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 34.200,00

19/08/2021 12:42:30 Page 213 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
858 Bustari PONDOK SUGUH 142999 Nassal Cannula O2 Dewas
23/01/2021 00:00:00 11.625,00 BPJS
NonWoven Fixation 15x 13.388,00
Ondansetron Inj 4.950,00
Three Way stopcock 37.125,00
Allopurinol 100 mg @100
24/01/2021 00:00:00 234,00
Aminofluid Infus 500 ml 155.204,00
Azitromycin 500 mg 5.625,00
Citicoline Injeksi 125mg/ 11.250,00
Nystatin Drop 27.830,00
Ondansetron Inj 3.300,00
Allopurinol 100 mg @100
25/01/2021 00:00:00 234,00
Ambroxol 30 mg @100 T 579,00
Ambroxol 30 mg @100 T 1.737,00
Aminofluid Infus 500 ml 155.204,00
Azitromycin 500 mg 5.625,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix Kamar Operasi 18.000,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 34.200,00
Omeprazole Inj 12.499,00
Omeprazole Inj 37.497,00
Ondansetron Inj 4.950,00
Sistenol kaplet 5.262,00
Sistenol kaplet 15.786,00
Abbocath 22 Terumo @5
26/01/2021 00:00:00 22.276,00
Allopurinol 100 mg @100 234,00
Ambroxol 30 mg @100 T 579,00
Aminofluid Infus 500 ml 155.204,00
Azitromycin 500 mg 5.625,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 42.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sistenol kaplet 5.262,00
Three Way stopcock 21.252,00
Allopurinol 100 mg @100
27/01/2021 00:00:00 234,00
Ambroxol 30 mg @100 T 579,00
Azitromycin 500 mg 5.625,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sistenol kaplet 3.508,00
Allopurinol 100 mg @100
28/01/2021 00:00:00 2.340,00
Citicoline Injeksi 125mg/ 112.500,00
Levofloxacin Tablet 500 m 13.640,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 2.073.419,00
859 Algazali Fatiri Satini BANDARATU 182133 Tetagam 1 Ml Injeksi
23/01/2021 00:00:00 184.000,00 BPJS
Total 184.000,00
860 Darwin SIDODADI 161429 Abbocath 20 Terumo @5
24/01/2021 00:00:00 11.138,00 BPJS
Allopurinol 100 mg @100 234,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Catheter 2 Way No. 16 ( 20.625,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 4.850,00
Isosorbid dinitrat 5 mg (I 333,00
Meropenem Inj 0.5 g 110.000,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Urine bag 10.088,00
Allopurinol 100 mg @100 234,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Allopurinol 100 mg @100
25/01/2021 00:00:00 234,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Furosemide Injeksi @2ml 3.332,00
Hypafix Kamar Operasi 18.000,00
Isosorbid dinitrat 5 mg (I 333,00
Meropenem Inj 0.5 g 110.000,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 1.000,00
Ringer Laktat Otsuka 19.076,00
Abbocath 22 Terumo @5
26/01/2021 00:00:00 22.276,00
Allopurinol 100 mg @100 234,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 681,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Lapikot Forte 35.720,00
meropenem Injeksi 1 g 82.500,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Three Way stopcock 10.626,00
Allopurinol 100 mg @100
27/01/2021 00:00:00 2.340,00
Azitromycin 500 mg 56.250,00

19/08/2021 12:42:30 Page 215 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
860 Darwin SIDODADI 161429 Bisoprolol 5 mg @100 Ta
27/01/2021 00:00:00 2.960,00 BPJS
Candesartan tab 8 mg 6.810,00
Furosemide 40 mg Tablet 960,00
Hypafix 10cm x 5cm (25 c 4.850,00
Isosorbid dinitrat 5 mg (I 999,00
Kassa kotak stril DRC 9.675,00
Omeprazole Inj 49.996,00
Opilax Syr 49.156,00
Total 981.704,00
861 Dola Hendriyani PT ALNO SAPTA BUAN 182129 Aqua Pro Injeksi
26/01/2021 00:00:00 7.150,00 BPJS
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac Tab 10 Mg 37.950,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Postofix (leukomed) 36.726,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Total 263.643,00
862 Fidiawati Pasar mukomuko 111187 Abbocath 20 Terumo @5
24/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
KSR (potassium chloride) 2.303,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
KSR (potassium chloride) 2.303,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Alprazolam 1 mg @100 T
25/01/2021 00:00:00 800,00
Total 106.614,00
863 Sri Rahayu KOTA PRAJA 135407 Abbocath 22 Terumo @5
24/01/2021 00:00:00 11.138,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Paracetamol tablet 500 m 600,00

19/08/2021 12:42:30 Page 216 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
863 Sri Rahayu KOTA PRAJA 135407 Ambroxol 30 mg @100 T
26/01/2021 00:00:00 579,00 BPJS
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 15cmx5cm (25 c 13.088,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Ambroxol 30 mg @100 T
27/01/2021 00:00:00 579,00
Antrain Injeksi 28.875,00
Lansoprazole kapsul 30 m 5.775,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 3.000,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 273.969,00
864 Gusni SINDANG 133910 Abbocath 22 Terumo @5
24/01/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 297,00
Infusion Makro (terumo) 27.225,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Total 142.595,00
865 Lusiana ARAH TIGA 182137 abbocath 18 Terumo @5
24/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 66.853,00
866 Fitri Andri Wenny LUBUK PINANG 182138 abbocath 18 Terumo @5
24/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 66.853,00
867 Lusiana ARAH TIGA 182137 Bisturi No. 23
24/01/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cauter (Hand-controlled P 162.161,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 3.070,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 40.160,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
867 Lusiana ARAH TIGA 182137 Handscoond Sterille 7 (G
24/01/2021 00:00:00 29.126,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
abbocath 18 Terumo @5
25/01/2021 00:00:00 22.276,00
Abbocath 20 Terumo @5 22.276,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
NonWoven Fixation 10x 4.815,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
abbocath 18 Terumo @5
26/01/2021 00:00:00 22.276,00
Abbocath 20 Terumo @5 22.276,00
Cefotaxime Injeksi 17.253,00
Ketorolac Tab 10 Mg 7.590,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Asam Mefenamat 500 m
27/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.708.185,00
868 Gusni SINDANG 133910 Abbocath 20 Terumo @5
24/01/2021 00:00:00 22.276,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 28.614,00
Alprazolam 0,5 mg @100
25/01/2021 00:00:00 118,00
Asam Folat 1 mg @100 T 297,00
Nystatin Drop 27.830,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
868 Gusni SINDANG 133910 Paracetamol tablet 500 m
25/01/2021 00:00:00 600,00 BPJS
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
26/01/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Esomax Inj 148.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
27/01/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Esomax Inj 148.500,00
NGT (Stomach Tube) Fr. 1 60.046,00
NGT (Stomach Tube) Fr. 1 52.250,00
Nystatin Drop 27.830,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 38.152,00
Spuit 50 cc Lbg tengah ( 9.776,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
28/01/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin tab 500 mg 1.118,00
Esomeprazol Injeksi 40 m 34.956,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Alprazolam 0,5 mg @100
29/01/2021 00:00:00 118,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Esomeprazol Injeksi 40 m 104.868,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Alprazolam 0,5 mg @100
30/01/2021 00:00:00 118,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Esomeprazol Injeksi 40 m 34.956,00
Gentamicin Injeksi 9.212,00
NACL 0,9 % 500 ml 8.550,00
Nystatin Drop 27.830,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 14.502,00

19/08/2021 12:42:30 Page 219 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
868 Gusni SINDANG 133910 Ringer Laktat Otsuka
30/01/2021 00:00:00 9.538,00 BPJS
Alprazolam 0,5 mg @100
31/01/2021 00:00:00 118,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Esomax Inj 148.500,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 17.877,00
Psidii Capsule 500 mg 14.703,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Alprazolam 1 mg @100 T
01/02/2021 00:00:00 160,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide Injeksi @2ml 4.998,00
Nystatin Drop 27.830,00
Opilax Syr 49.156,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 17.877,00
Psidii Capsule 500 mg 14.703,00
Ringer Laktat Otsuka 9.538,00
Sulcolon Tablet 16.500,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
02/02/2021 00:00:00 1.485,00
Betadine Obat Kumur 13.750,00
Betadine Obat Kumur 27.500,00
Kassa kotak stril DRC 9.675,00
Nystatin Drop 27.830,00
Omeprazole Inj 62.495,00
Omeprazole Inj 74.994,00
Opilax Syr 49.156,00
Ottogenta inj 29.700,00
Phytomenadione 2 Mg/1M 116.016,00
Sucralfate Suspensi 100 m 19.250,00
Total 2.300.857,00
869 Fitri Andri Wenny LUBUK PINANG 182138 Bisturi No. 23
24/01/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00

19/08/2021 12:42:30 Page 220 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
869 Fitri Andri Wenny LUBUK PINANG 182138 Gelaufusal Infusion 500 m
24/01/2021 00:00:00 181.269,00 BPJS
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 14.554,00
Handscoond Non Steril L 41.260,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 8.550,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Bisturi No. 15
25/01/2021 00:00:00 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Metrodinazole tab 500 m 1.350,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 15x 13.388,00
Phytomenadione 2 Mg/1M 4.834,00
Toramine inj 56.118,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
26/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
27/01/2021 00:00:00 3.575,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.469.297,00
870 Mardesi Putri ARAH TIGA 174870 Abbocath 18 (Gea)
24/01/2021 00:00:00 10.720,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00

19/08/2021 12:42:30 Page 221 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
870 Mardesi Putri ARAH TIGA 174870 Catheter 2 Way No. 16 (
24/01/2021 00:00:00 20.625,00 BPJS
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole Infus 30.939,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 184.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Alinamin F Injeksi 10 ml
26/01/2021 00:00:00 36.000,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron tablet 8 mg 7.920,00
Paracetamol tablet 500 m 600,00

19/08/2021 12:42:30 Page 222 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
870 Mardesi Putri ARAH TIGA 174870 Tranexamic Acid Inj (Asa
26/01/2021 00:00:00 6.315,00 BPJS
Transfusi Set Terumo 16.500,00
Asam Mefenamat 500 m
27/01/2021 00:00:00 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Total 2.007.326,00
871 Adri Yani LUNANG 182139 Cefotaxime Injeksi
24/01/2021 00:00:00 5.751,00 BPJS
Dexametason Injeksi 6.256,00
Dexametason Injeksi 12.512,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 58.252,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril S 8.510,00
Hypafix Kamar Operasi 18.000,00
Levemir FlexPen 104.938,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Novorapid Flexpen 108.750,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Cefotaxime Injeksi
25/01/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Novo Twist 32 G Tip 10.416,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Amlodipine 10 mg @50 T
26/01/2021 00:00:00 1.180,00
Asam Mefenamat 500 m 1.290,00
Candesartan Tab 16 mg 11.790,00
Cefixime Kapsul 100 mg 9.380,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Misoprostol Tab 55.000,00
Total 730.964,00
872 Ny.mardesi I ARAH TIGA 182140 Abbocath 24 Terumo @5
24/01/2021 00:00:00 33.414,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Bisturi No. 15 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Chloramphenicol Salep M 2.351,00

19/08/2021 12:42:30 Page 223 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
872 Ny.mardesi I ARAH TIGA 182140 Hypafix 10cm x 5cm (25 c
24/01/2021 00:00:00 4.850,00 BPJS
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NGT (Feeding Tube) Fr. 8 11.043,00
umbilical Cord Clamp 2.261,00
Total 112.635,00
873 Ny.madesi I I ARAH TIGA 182141 Abbocath 24 Terumo @5
24/01/2021 00:00:00 33.414,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Bisturi No. 15 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NGT (Feeding Tube) Fr. 8 11.043,00
umbilical Cord Clamp 2.261,00
Hypafix 10cm x 5cm (25 c
25/01/2021 00:00:00 4.850,00
NGT (Feeding tube) Fr. 5 17.603,00
Total 135.088,00
874 David Maulana Maksu PASAR GEDANG 182143 Asam Mefenamat 500 m
24/01/2021 00:00:00 1.290,00 BPJS
Chromic catgut 3-0 R (Tr 132.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lidocain injk 40 mg/2 ml 1.611,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Tetagam 1 Ml Injeksi 184.000,00
Total 433.351,00
875 Ike Nopita GAJAH MATI 182145 Abbocath 20 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Total 74.576,00
876 Faula Yonara TANJUNG ALAI 182065 Abbocath 24 Terumo @5
25/01/2021 00:00:00 11.138,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Aqua Pro Injeksi 3.575,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
NGT (Feeding tube) Fr. 3 0,00
NGT (Feeding tube) Fr. 5 17.603,00
Total 100.813,00
877 Ike Nopita GAJAH MATI 182145 Cefotaxime Injeksi
25/01/2021 00:00:00 11.502,00 BPJS
Omeprazole Inj 24.998,00
Cefotaxime Injeksi
26/01/2021 00:00:00 11.502,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 19.076,00

19/08/2021 12:42:30 Page 224 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
877 Ike Nopita GAJAH MATI 182145 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Total 105.881,00
878 Faula Yonara TANJUNG ALAI 182065 Abbocath 24 Terumo @5
25/01/2021 00:00:00 11.138,00 BPJS
Abbocath 24 Terumo @5 33.414,00
Calcii Glukonas Inj 100 m 12.939,00
Gentamicin Injeksi 4.606,00
Glukosa Infus 10 % 9.375,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix Kamar Operasi 18.000,00
NACL 0,9 % 500 ml 8.550,00
NGT (Feeding tube) Fr. 5 17.603,00
NGT (Feeding Tube) Fr. 8 70.420,00
Otsu D40 12.513,00
Hypafix 10cm x 5cm (25 c
26/01/2021 00:00:00 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Otsu D40 25.026,00
Abbocath 24 Terumo @5
27/01/2021 00:00:00 44.552,00
Abbocath 24 Terumo @5 33.414,00
Abbocath 24 Terumo @5 55.690,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Total 418.959,00
879 Sudarman PENARIK 179781 Renax @50 Kapsul
25/01/2021 00:00:00 113.440,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 135.420,00
880 Muris SUNGAI LINTANG 161172 Bisoprolol 5 mg @100 Ta
25/01/2021 00:00:00 4.440,00 BPJS
Isosorbid dinitrat 5 mg (I 3.330,00
Lansoprazole kapsul 30 m 34.650,00
Simvastatin tab 10 mg 7.230,00
Total 49.650,00
881 Parji Darsono AGUNG JAYA 118047 Hexymer 2 Mg Tab (THP)
25/01/2021 00:00:00 43.020,00 BPJS
Levopar tab 100mg 116.190,00
Meloxicam 7,5 mg 14.560,00
Methylprednisolon tablet 8 9.580,00
Paracetamol tablet 500 m 6.000,00
Ranitidine tablet 150 mg 4.320,00
Sifrol tab 0,375 mg 933.750,00
Vitamin C tablet @100 Ta 4.140,00
Total 1.131.560,00
882 Rajulaini TUNGGANG 182152 Amlodipine 5 mg @30 T
25/01/2021 00:00:00 3.030,00 BPJS
Betahistin Mesilat 6 mg @ 2.760,00
Candesartan tab 8 mg 20.430,00
Citicoline kaplet 500 mg 49.500,00
Lansoprazole kapsul 30 m 23.100,00
Paracetamol tablet 500 m 4.000,00
Total 102.820,00
883 Rosnidar PENARIK 131980 Captopril 12,5 mg
25/01/2021 00:00:00 2.400,00 BPJS
Digoxsin tab 0,25 mg 2.160,00
Furosemide 40 mg Tablet 2.880,00
Spironolaktone 25 mg 7.800,00

19/08/2021 12:42:30 Page 225 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 15.240,00
884 Rosna SUNGAI GADING 182153 Calcium Laktat
25/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
885 Airin Dwi Salsabila TELUK RUMBIA 110236 Asam Folat 1 mg @100 T
25/01/2021 00:00:00 2.970,00 BPJS
Valproic Acid Syrup 250mg 104.875,00
Total 107.845,00
886 Suwarni BANDAR RATU 157282 Cefadroxil tab 500 mg @1
25/01/2021 00:00:00 10.500,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Total 25.980,00
887 M.Nasir TALANG BUAI 127144 Acetylcystein 200 mg Ka
25/01/2021 00:00:00 34.380,00 BPJS
Methylprednisolone tab 4 2.630,00
Onbrez Breezhaler HGCI 0 440.640,00
Total 477.650,00
888 Gimin SELAGAN JAYA 182158 Amoxicillin 500 mg @ 10
25/01/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Dexametason 0,5 mg Ta 1.160,00
Pehacain Injeksi 6.640,00
Total 12.150,00
889 Isah PASAR SEBELAH 178221 Cetirizine 10 mg
25/01/2021 00:00:00 1.260,00 BPJS
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 3.000,00
Spuit 5 cc Disposible 1.420,00
Total 22.780,00
890 Suparlan TANJUNG MULYA 127490 Aspilet 80 mg @100 mg
25/01/2021 00:00:00 4.140,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Furosemide 40 mg Tablet 960,00
Isosorbid dinitrat 5 mg (I 3.330,00
Simvastatin tab 10 mg 7.230,00
Spironolaktone 25 mg 7.800,00
Total 27.900,00
891 Ahmad Dani Kurniaw LUNANG 163501 Asam Folat 1 mg @100 T
25/01/2021 00:00:00 2.970,00 BPJS
Phenobarbital Tablet 30 m 810,00
Valproic Acid Syrup 250mg 104.875,00
Total 108.655,00
892 Ajratul Aini AIR BIKUK 134349 Amoxicillin 500 mg @ 10
25/01/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Pehacain Injeksi 3.320,00
Total 7.670,00
893 Ahmad Davan Ali Pas SIBAK 182025 Cefadroxil tab 500 mg @1
25/01/2021 00:00:00 10.500,00 BPJS
Loratadine tab 10 mg 1.660,00
Otopain Ear Drops 8 ml 99.688,00
Total 111.848,00
894 Binti Maslahah BUMI MULYA 182163 Cefadroxil tab 500 mg @1
25/01/2021 00:00:00 10.500,00 BPJS
Loratadine tab 10 mg 1.660,00
Otopain Ear Drops 8 ml 99.688,00
Total 111.848,00
895 Pratiwi LUBUK SANAI II 182164 Asam Mefenamat 500 m
25/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Methylprednisolone tab 4 2.630,00
Pehacain Injeksi 6.640,00
Total 21.060,00
896 Samsudin DUSUN BARU PELOKA 181997 Lansoprazole kapsul 30 m
25/01/2021 00:00:00 11.550,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
896 Samsudin DUSUN BARU PELOKA 181997 Onbrez Breezhaler HGCI 0
25/01/2021 00:00:00 440.640,00 BPJS
Vitamin B Komplek @100 2.310,00
Total 454.500,00
897 Sugito MEKAR MULYA 147062 Epodion 3000 IU
25/01/2021 00:00:00 116.875,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Otsu Nacl PiggyBack 100 m 94.875,00
Total 245.950,00
898 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
25/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
899 Narti SILAUT 175653 NACL 0,9 % 500 ml
25/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
900 Darmawan LUBUK PINANG 140187 Epodion 3000 IU
25/01/2021 00:00:00 116.875,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Total 151.075,00
901 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
25/01/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
902 Ahmad Mujiono MARGA MULYA SAKTI 113737 Azitromycin 500 mg
25/01/2021 00:00:00 16.875,00 BPJS
Codein tab 10 mg 2.250,00
Epodion 3000 IU 116.875,00
NACL 0,9 % 500 ml 68.400,00
Paracetamol tablet 500 m 600,00
Total 205.000,00
903 Ashari Liwandi PONDOK LUNANG 139398 Azitromycin 500 mg
25/01/2021 00:00:00 16.875,00 BPJS
Codein tab 10 mg 2.250,00
Epodion 3000 IU 116.875,00
NACL 0,9 % 500 ml 68.400,00
Paracetamol tablet 500 m 600,00
Total 205.000,00
904 Supangat PONDOK LUNANG 147511 Azitromycin 500 mg
25/01/2021 00:00:00 16.875,00 BPJS
Epodion 3000 IU 116.875,00
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 204.733,00
905 M Akil PASAR BELAKANG 115376 Epodion 3000 IU
25/01/2021 00:00:00 116.875,00 BPJS
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 187.858,00
906 Wardoyo TANJUNG MULYA 125079 Epodion 3000 IU
25/01/2021 00:00:00 116.875,00 BPJS
NACL 0,9 % 500 ml 68.400,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 187.858,00
907 Rimson Siboro TUNGGAL JAYA 182167 Abbocath 20 Terumo @5
25/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 10x 4.815,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
907 Rimson Siboro TUNGGAL JAYA 182167 Paracetamol tablet 500 m
25/01/2021 00:00:00 600,00 BPJS
Ringer Laktat Otsuka 28.614,00
Total 87.469,00
908 Emah Triyanti PENARIK 124217 Vitamin B Komplek @100
25/01/2021 00:00:00 3.080,00 BPJS
Total 3.080,00
909 Asroni LUNANG 168311 Gabapentin kapsul 300 m
25/01/2021 00:00:00 38.070,00 BPJS
Glimepiride tab 2 mg 7.770,00
Meloxicam 7,5 mg 43.680,00
Metformin tablet 500 mg 7.980,00
Ranitidine tablet 150 mg 4.320,00
Total 101.820,00
910 Aripedro PONDOK SUGUH 176121 Abbocath 20 Terumo @5
25/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Vitamin B Komplek @100 154,00
Total 63.942,00
911 Jan Piteher Gultom LUBUK BENTO 182168 Cefixime syrup 100mg/5 M
25/01/2021 00:00:00 23.823,00 BPJS
Paracetamol syrup 1.388,00
Total 25.211,00
912 Noni Fitrianingsih TANJUNG BERINGIN 182169 abbocath 18 Terumo @5
25/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 63.066,00
913 Aripedro PONDOK SUGUH 176121 Dexametason Injeksi
25/01/2021 00:00:00 3.128,00 BPJS
Dipenhydramin Injeksi 10 1.535,00
Total 4.663,00
914 Noni Fitrianingsih TANJUNG BERINGIN 182169 Cefotaxime Injeksi
25/01/2021 00:00:00 11.502,00 BPJS
Celemek Plastik 44.965,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoond Non Steril M 60.240,00
Masker Karet 22.000,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Spinocain 25 (BBraund) 42.763,00
Spinocain 27 (BBraund) 47.875,00
Suprafenid Supositoria 10 28.050,00
Asam Mefenamat 500 m
26/01/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Misoprostol Tab 55.000,00
Total 462.380,00
915 Rimson Siboro TUNGGAL JAYA 182167 Alkohol 1Liter
26/01/2021 00:00:00 42.111,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
915 Rimson Siboro TUNGGAL JAYA 182167 Bisturi No. 23
26/01/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 8.993,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Ephedrine Injeksi 21.422,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Infusion Makro (terumo) 27.225,00
Iodine povidone 300 ml 28.463,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Cefotaxime Injeksi
27/01/2021 00:00:00 11.502,00
Metrodinazole Infus 30.939,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Total 750.156,00
916 eva lestari LUBUK GEDANG 163877 Bisturi No. 23
26/01/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 60.240,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
916 eva lestari LUBUK GEDANG 163877 Myotonic inj
26/01/2021 00:00:00 19.596,00 BPJS
NACL 0,9 % 500 ml 17.100,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyglycolide T-Vio 1 R ( 295.500,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 36.093,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Aqua Pro Injeksi
27/01/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
28/01/2021 00:00:00 11.502,00
Metrodinazole tab 500 m 810,00
Pharmafix 10x50 cm (Hy 9.700,00
Toramine inj 56.118,00
Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.768.695,00
917 Erma Wati KOTO JAYA 157023 abbocath 18 Terumo @5
25/01/2021 00:00:00 11.138,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
meropenem Injeksi 1 g 41.250,00
Metoclopramide inj 5Mg/M 5.879,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Zinc Sulfate Syr 60 ml 4.569,00
Abbocath 20 Terumo @5
26/01/2021 00:00:00 22.276,00
Abbocath 22 Terumo @5 33.414,00
Ascorbid Acid 1000mg/5m 26.125,00
Hypafix 15cmx5cm (25 c 13.088,00
Infusion Makro (terumo) 54.450,00
Meropenem Inj 0.5 g 165.000,00
meropenem Injeksi 1 g 123.750,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
917 Erma Wati KOTO JAYA 157023 NACL 0,9 % 500 ml
26/01/2021 00:00:00 17.100,00 BPJS
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ascorbid Acid 1000mg/5m
27/01/2021 00:00:00 104.500,00
Meropenem Inj 0.5 g 330.000,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.000,00
vestein 300 mg 46.750,00
Cuticell Classic 10cmx10c
28/01/2021 00:00:00 6.900,00
Extrace Injeksi 100 mg/m 9.625,00
Methylprednisolone Inje 34.923,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ascorbid Acid 1000mg/5m
29/01/2021 00:00:00 52.250,00
Dulcolax Sup 10 mg 55.600,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 17.100,00
Meropenem Inj 0.5 g
30/01/2021 00:00:00 165.000,00
Methylprednisolone Inje 69.846,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.000,00
Vectrine Tab 300 mg 50.000,00
Azitromycin 500 mg
31/01/2021 00:00:00 5.625,00
Cefadroxil tab 500 mg @1 10.500,00
Cefixime kapsul 200 mg 5.296,00
Domperidone Tab 324,00
Lansoprazole kapsul 30 m 1.155,00
Methylprednisolone tab 4 1.052,00
Methylprednisolone tab 4 2.630,00
NACL 0,9 % 500 ml 25.650,00
Omeprazol kapsul 20 mg 3.305,00
Ondansetron 4mg 16.360,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 14.025,00
Total 1.924.139,00
918 Edi Yanto BANDAR RATU 109770 Aspilet 80 mg @100 mg
26/01/2021 00:00:00 4.140,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Citicoline kaplet 500 mg 49.500,00
Total 84.990,00
919 Syafniar RETAK MUDIK 181695 Alinamin F 50 mg @100 T
26/01/2021 00:00:00 11.500,00 BPJS
Alprazolam 0,5 mg @100 590,00
Bisoprolol 5 mg @100 Ta 4.440,00
Omeprazol kapsul 20 mg 6.610,00
Total 23.140,00
920 Rapani SIBAK 182162 Ciprofloxacin tab 500 mg
26/01/2021 00:00:00 5.590,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
920 Rapani SIBAK 182162 Paracetamol tablet 500 m
26/01/2021 00:00:00 3.000,00 BPJS
Total 8.590,00
921 Sukirman LUBUK SANAI 159456 Alinamin F 50 mg @100 T
26/01/2021 00:00:00 11.500,00 BPJS
Alprazolam 0,5 mg @100 590,00
ursodeoxycholic acid 85.050,00
Total 97.140,00
922 Mustofa Apriyendi MEKAR MULYA 181895 Ciprofloxacin tab 500 mg
26/01/2021 00:00:00 5.590,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Total 32.995,00
923 Jusa Dwi Alfiandra DUSUN BARU V KOTO 144268 CTM (Klorfeniramina mal
26/01/2021 00:00:00 145,00 BPJS
Guaifenesin 100 mg 1.008,00
Ketricin Tablet 4 mg 19.290,00
Total 20.443,00
924 Rusli Asbi SILAUT 174646 Levofloxacin Tablet 500 m
26/01/2021 00:00:00 13.640,00 BPJS
Total 13.640,00
925 Nurlaela Sari SIDODADI 179676 Asam Mefenamat 500 m
26/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 15.750,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 72.986,00
926 Nurjati NELAN INDAH 144449 Atorvastatin 20 mg @30 T
26/01/2021 00:00:00 5.225,00 BPJS
Glucosamine 250 mg 7.700,00
Total 12.925,00
927 Amandeka Jaya AIR BIKUK 161881 Alprazolam 0,5 mg @100
26/01/2021 00:00:00 590,00 BPJS
Mecobalamin 500 mg 11.550,00
Paracetamol tablet 500 m 2.000,00
Total 14.140,00
928 Yayuk Basuki PONDOK BATU 181930 Asam Mefenamat 500 m
26/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 12.435,00
929 Sumidah RAWA MULYA 163860 Asam Folat 1 mg @100 T
26/01/2021 00:00:00 2.970,00 BPJS
Calos cmewable tab 24.090,00
Furosemide 40 mg Tablet 960,00
Zink Tablet 6.890,00
Total 34.910,00
930 Juleha MANDI ANGIN JAYA 169663 Alprazolam 1 mg @100 T
26/01/2021 00:00:00 4.800,00 BPJS
Total 4.800,00
931 Komsatun MEKAR MULYA 114172 Mecobalamin 500 mg
26/01/2021 00:00:00 23.100,00 BPJS
Metformin tablet 500 mg 11.970,00
Total 35.070,00
932 Nur Aminah Pulungan PT AGRO TALANG PET 181947 Eperisone Hcl 50 mg @1
26/01/2021 00:00:00 23.280,00 BPJS
Paracetamol tablet 500 m 2.000,00
Pregabalin Kap 75 mg 64.460,00
Total 89.740,00
933 Resdi Nawati Sinaga TALANG PETAI 148722 Calcium Laktat
26/01/2021 00:00:00 790,00 BPJS
Ondansetron tablet 8 mg 26.400,00
Paracetamol tablet 500 m 2.000,00
Total 29.190,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
934 Sihar Panaili Panggabea PT AGRO BUNGA TANJ 180882 Zinc Sulfate Syr 60 ml
26/01/2021 00:00:00 4.569,00 BPJS
Total 4.569,00
935 Dera Putri Rahmadani UJUNG PADANG 154327 Cefadroxil tab 500 mg @1
26/01/2021 00:00:00 10.500,00 BPJS
Total 10.500,00
936 Abdul Ghofur SUNGAI RUMBAI 153798 Mecobalamin 500 mg
26/01/2021 00:00:00 7.700,00 BPJS
Paracetamol tablet 500 m 2.000,00
Pregabalin Kap 75 mg 64.460,00
Total 74.160,00
937 Tiama LUBUK TALANG 182176 Azitromycin 500 mg
26/01/2021 00:00:00 28.125,00 BPJS
Meloxicam 7,5 mg 7.280,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 39.974,00
938 Fitriani PONDOK BATU 179369 Asam Mefenamat 500 m
26/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 11.790,00
939 Slamet Suhari PT AGRO TALANG PET 173868 Asam Mefenamat 500 m
26/01/2021 00:00:00 1.290,00 BPJS
Clindamycin 150 mg tabl 8.750,00
Dexametason 0,5 mg Ta 1.160,00
Total 11.200,00
940 Evi Indiani AGUNG JAYA 129328 Amlodipine 5 mg @30 T
26/01/2021 00:00:00 3.030,00 BPJS
Miniaspi 80 Mg @100 Ta 2.500,00
Simvastatin tab 10 mg 4.820,00
Total 10.350,00
941 Mella Elviza PT AGRO MME 161769 Ciprofloxacin tab 500 mg
26/01/2021 00:00:00 5.590,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 8.220,00
942 Feni Febrianti DUSUN BARU PELOKA 182177 Cefadroxil tab 500 mg @1
26/01/2021 00:00:00 10.500,00 BPJS
Total 10.500,00
943 Darsi PAUH TERENJA 132886 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix Kamar Operasi 18.000,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 79.791,00
944 Enfarina PT AGROMUKO PENAR 144179 Alinamin F 50 mg @100 T
26/01/2021 00:00:00 11.500,00 BPJS
Gitas Plus 25.165,00
Omeprazol kapsul 20 mg 6.610,00
Total 43.275,00
945 Devano Meyondi Prat PT AGRO MME 182178 Cefixime syrup 100mg/5 M
26/01/2021 00:00:00 23.823,00 BPJS
Cetirizine Sirup 3.718,00
Otopain Ear Drops 8 ml 99.688,00
Total 127.229,00
946 Siti Hoeriyah PENARIK 138381 Avamys
26/01/2021 00:00:00 129.000,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Methylprednisolone tab 4 2.630,00
Total 137.220,00
947 Sawir ARAH TIGA 113253 Alinamin F 50 mg @100 T
26/01/2021 00:00:00 11.500,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 18.110,00
948 Mayu Anggia AIR MERAH 182180 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00

19/08/2021 12:42:30 Page 233 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
948 Mayu Anggia AIR MERAH 182180 Cefotaxime Injeksi
26/01/2021 00:00:00 11.502,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 57.103,00
949 Dian Rohana Harianja DUSUN BARU V KOTO 180645 Asam Mefenamat 500 m
26/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
950 Nopi Lestari DESA BARU PELOKAN 182063 Cefadroxil tab 500 mg @1
26/01/2021 00:00:00 10.500,00 BPJS
Hypafix 15cmx5cm (25 c 13.088,00
Paracetamol tablet 500 m 2.000,00
Total 25.588,00
951 Novri Kaswara DUSUN BARU PELOKA 182064 Cefadroxil tab 500 mg @1
26/01/2021 00:00:00 10.500,00 BPJS
Hypafix 15cmx5cm (25 c 13.088,00
Total 23.588,00
952 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
26/01/2021 00:00:00 51.300,00 BPJS
Renogen 3000 UI 116.875,00
Total 168.175,00
953 Salami SILAUT I 134774 NACL 0,9 % 500 ml
26/01/2021 00:00:00 51.300,00 BPJS
Renogen 3000 UI 116.875,00
Total 168.175,00
954 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
26/01/2021 00:00:00 51.300,00 BPJS
Renogen 3000 UI 116.875,00
Total 168.175,00
955 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
26/01/2021 00:00:00 51.300,00 BPJS
NACL 0,9 % 500 ml 51.300,00
Renogen 3000 UI 116.875,00
Renogen 3000 UI 116.875,00
Total 336.350,00
956 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
26/01/2021 00:00:00 51.300,00 BPJS
Renogen 3000 UI 116.875,00
Total 168.175,00
957 Siti Rahmah SILAUT 181967 Asam Mefenamat 500 m
26/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 12.435,00
958 Hersa Nurhidayah PT AGRO AIR BIKUK 181926 CTM (Klorfeniramina mal
26/01/2021 00:00:00 261,00 BPJS
Guaifenesin 100 mg 1.512,00
Triamcinolon tablet 4 mg 7.528,00
Total 9.301,00
959 Bambang Sulistiono AIR BIKUK 182183 Asam Traneksamat @10
26/01/2021 00:00:00 21.050,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 27.660,00
960 Sarmita Sari BANDAR RATU 109335 Atorvastatin 20 mg @30 T
26/01/2021 00:00:00 31.350,00 BPJS
Candesartan tab 8 mg 20.430,00
Isosorbid dinitrat 5 mg (I 3.330,00
Levemir FlexPen 104.938,00
Metformin tablet 500 mg 7.980,00
NACL 0,9 % 500 ml 25.650,00
Total 193.678,00
961 Megawati SIDODADI 182013 Aspilet 80 mg @100 mg
26/01/2021 00:00:00 2.070,00 BPJS

19/08/2021 12:42:30 Page 234 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
961 Megawati SIDODADI 182013 Candesartan tab 8 mg
26/01/2021 00:00:00 10.215,00 BPJS
Isosorbid dinitrat 5 mg (I 1.665,00
Metformin tablet 500 mg 1.995,00
Total 15.945,00
962 Siti Maesaroh KARANG JAYA 180496 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 4.255,00
handscoond steril 6.5 (G 58.216,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker 3 Play N. 95 51.719,00
Masker Karet 11.000,00
Metoclopramide inj 5Mg/M 5.879,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 98.500,00
Polyvinylidene 3-0 R (Tri 184.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Total 1.358.730,00
963 Mayu Anggia AIR MERAH 182180 Bisturi No. 23
26/01/2021 00:00:00 3.836,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00

19/08/2021 12:42:30 Page 235 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
963 Mayu Anggia AIR MERAH 182180 Catheter 2 Way No. 16 (
26/01/2021 00:00:00 20.625,00 BPJS
Cauter (Hand-controlled P 162.161,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suction Chateter no. 8 (R 20.625,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Aqua Pro Injeksi
27/01/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Ambroxol Syr 15mg/ml
28/01/2021 00:00:00 4.538,00
Cefotaxime Injeksi 11.502,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 13.388,00
Toramine inj 56.118,00
Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00

19/08/2021 12:42:30 Page 236 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
963 Mayu Anggia AIR MERAH 182180 Kassa kotak stril DRC
29/01/2021 00:00:00 9.675,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.819.903,00
964 Siti Maesaroh KARANG JAYA 180496 Bisturi No. 23
26/01/2021 00:00:00 3.836,00 BPJS
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Aqua Pro Injeksi
27/01/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
28/01/2021 00:00:00 11.502,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 6.694,00
Toramine inj 56.118,00
Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Safil 1 R 299.400,00
Total 638.448,00
965 Darsi PAUH TERENJA 132886 Alkohol 1Liter
26/01/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 8.993,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 26.176,00
Hypafix Kamar Operasi 18.000,00
Induxin 1 ml Injeksi 18.562,00

19/08/2021 12:42:30 Page 237 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
965 Darsi PAUH TERENJA 132886 Iodine povidone 300 ml
26/01/2021 00:00:00 28.463,00 BPJS
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 258.595,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suction Chateter no. 8 (R 20.625,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
27/01/2021 00:00:00 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Hypafix 10cm x 5cm (25 c
28/01/2021 00:00:00 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Ringer Laktat Otsuka 47.690,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Suprafenid Supositoria 10 14.025,00
Hypafix 10cm x 5cm (25 c
30/01/2021 00:00:00 4.850,00

19/08/2021 12:42:30 Page 238 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
965 Darsi PAUH TERENJA 132886 Kassa Gulung New DRC
30/01/2021 00:00:00 195.750,00 BPJS
Paracetamol tablet 500 m 2.000,00
Postofix (leukomed) 36.726,00
Sucralfate Suspensi 100 m 19.250,00
Total 2.374.324,00
966 Zukriman LUBUK GEDANG 160918 Epodion 3000 IU
26/01/2021 00:00:00 116.875,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 159.625,00
967 Roslina TERUNTUNG 130072 Epodion 3000 IU
26/01/2021 00:00:00 116.875,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 159.625,00
968 Salbiyah LUBUK MUKTI 173013 Abbocath 20 Terumo @5
26/01/2021 00:00:00 22.276,00 BPJS
Epodion 3000 IU 116.875,00
NACL 0,9 % 500 ml 42.750,00
Total 181.901,00
969 Silya Wana BANDARATU 117469 Dexametason Injeksi
26/01/2021 00:00:00 3.128,00 BPJS
Dipenhydramin Injeksi 10 1.535,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 42.750,00
Otsu D40 25.026,00
Total 99.664,00
970 Tarsono SINAR JAYA 115102 Abbocath 20 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Aminophyllin Inj 7.768,00
Combivent 18.768,00
Combivent 6.256,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 3.128,00
Infusion Makro (terumo) 27.225,00
Methylprednisolone Inje 34.923,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 9.538,00
Total 195.299,00
971 Susi Martini KOTO JAYA 145038 Abbocath 22 Terumo @5
26/01/2021 00:00:00 22.276,00 BPJS
Epodion 3000 IU 116.875,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 28.614,00
Total 224.953,00
972 Suwarni SUKA MAJU 164065 Abbocath 20 Terumo @5
26/01/2021 00:00:00 22.276,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Epodion 3000 IU 116.875,00
NACL 0,9 % 500 ml 42.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 223.427,00
973 Dylan Alfarizki KAMPUNG DALAM 182188 Abbocath 22 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Abbocath 24 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Hypafix 10cm x 5cm (25 c 4.850,00

19/08/2021 12:42:30 Page 239 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
973 Dylan Alfarizki KAMPUNG DALAM 182188 Ka-En 1 B
26/01/2021 00:00:00 12.658,00 BPJS
Nassal Cannula O2 Anak 16.473,00
Vitamin B Komplek @100 462,00
Total 60.393,00
974 Agus Marni SUNGAI GADING 182157 Abbocath 20 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Combivent 18.768,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
Lyrica 27.200,00
Omeprazole Inj 24.998,00
Phytomenadione 10 Mg/1 11.918,00
Ringer Laktat Otsuka 19.076,00
Vitamin B Komplek @100 308,00
Total 143.321,00
975 Yanatun LUNANG 182150 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 60.890,00
976 Kemis AGUNG JAYA 114109 Abbocath 20 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 18 ( 31.251,00
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Orasic Kap 36.580,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 146.745,00
977 Yanatun LUNANG 182150 Aqua Pro Injeksi
26/01/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 3.836,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 3.128,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 4.255,00
handscoond steril 6.5 (G 58.216,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00

19/08/2021 12:42:30 Page 240 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
977 Yanatun LUNANG 182150 Ketorolac inj 30 mg/1ml
26/01/2021 00:00:00 1.345,00 BPJS
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 51.719,00
Masker Karet 11.000,00
Metoclopramide inj 5Mg/M 5.879,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 2 Mg/1M 4.834,00
Polyglycolide T-Vio 1 R ( 295.500,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Aqua Pro Injeksi
27/01/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
28/01/2021 00:00:00 11.502,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 13.388,00
Toramine inj 56.118,00
Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.597.089,00
978 Agus Marni SUNGAI GADING 182157 Hypafix 15cmx5cm (25 c
26/01/2021 00:00:00 13.088,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Phytomenadione 2 Mg/1M 9.668,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 28.614,00
Vitamin B Komplek @100 308,00
Ascorbid Acid 1000mg/5m
27/01/2021 00:00:00 52.250,00

19/08/2021 12:42:30 Page 241 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
978 Agus Marni SUNGAI GADING 182157 Hypafix 10cm x 5cm (25 c
27/01/2021 00:00:00 4.850,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Lyrica 13.600,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Omeprazole Inj 37.497,00
Phytomenadione 10 Mg/1 11.918,00
Ringer Laktat Otsuka 19.076,00
Vitamin B Komplek @100 308,00
Ketorolac inj 30 mg/1ml
28/01/2021 00:00:00 4.035,00
Omeprazole Inj 12.499,00
Perifas @100 Tab 3.850,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 28.614,00
Vitamin B Komplek @100 1.540,00
Paracetamol tablet 500 m
29/01/2021 00:00:00 2.000,00
Perifas @100 Tab 19.250,00
Pregabalin Kap 75 mg 32.230,00
Total 358.255,00
979 Tarsono SINAR JAYA 115102 Aminophyllin Inj
26/01/2021 00:00:00 23.304,00 BPJS
Hypafix 15cmx5cm (25 c 13.088,00
NACL 0,9 % 500 ml 25.650,00
Acetylcystein 200 mg Ka
27/01/2021 00:00:00 17.190,00
Combivent 37.536,00
Methylprednisolone Inje 69.846,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Vitamin B Komplek @100 1.540,00
Acetylcystein 200 mg Ka
28/01/2021 00:00:00 8.595,00
Combivent 37.536,00
Methylprednisolone Inje 69.846,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Vitamin B Komplek @100 770,00
Acetylcystein 200 mg Ka
29/01/2021 00:00:00 3.438,00
Acetylcystein 200 mg Ka 17.190,00
Aminophyline 200 mg @1 3.000,00
Combivent 37.536,00
Methylprednisolone Inje 69.846,00
Methylprednisolone tab 4 2.630,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Salbutamol 4 mg 1.395,00
Vitamin B Komplek @100 1.540,00
Zink Tablet 689,00
Total 552.694,00
980 Miswanto TANJUNG BERINGIN 182189 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
980 Miswanto TANJUNG BERINGIN 182189 Catheter 2 Way No. 16 (
26/01/2021 00:00:00 20.625,00 BPJS
Catheter 2 Way No. 16 ( 39.025,00
Cefoperazon Inj 82.500,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 3.332,00
Kalitake 18.750,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 10x 4.815,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Cefoperazon Inj 41.250,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kalitake 6.250,00
Three Way stopcock 10.626,00
Asam Folat 1 mg @100 T
27/01/2021 00:00:00 99,00
Candesartan tab 8 mg 681,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kalitake 18.750,00
NACL 0,9 % 500 ml 0,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 0,00
Asam Folat 1 mg @100 T
28/01/2021 00:00:00 99,00
Candesartan tab 8 mg 681,00
Cefoperazon Inj 41.250,00
Furosemide Injeksi @2ml 1.666,00
Gentamicin Injeksi 4.606,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 0,00
NonWoven Fixation 15x 6.694,00
Nystatin Drop 27.830,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 0,00
Tambah Darah Neo Tab 930,00
Asam Folat 1 mg @100 T
29/01/2021 00:00:00 198,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
980 Miswanto TANJUNG BERINGIN 182189 Ondansetron Inj
29/01/2021 00:00:00 4.950,00 BPJS
Ringer Laktat Otsuka 0,00
Tambah Darah Neo Tab 930,00
Asam Folat 1 mg @100 T
30/01/2021 00:00:00 990,00
Candesartan tab 8 mg 6.810,00
Furosemide 40 mg Tablet 960,00
Nystatin Drop 27.830,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 824.167,00
981 Siti Jalisah AIR MERAH 182190 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 23
27/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
981 Siti Jalisah AIR MERAH 182190 Ketorolac inj 30 mg/1ml
27/01/2021 00:00:00 4.035,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Spinocain 27 (BBraund) 47.875,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
28/01/2021 00:00:00 11.502,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 13.388,00
Toramine inj 56.118,00
Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.811.626,00
982 Denti Mayang Sari SENDANG MULYO 182191 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Tonotan tab 4.573,00
Transfusi Set Terumo 16.500,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 2-0 R (Tr 144.500,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00
Cefixime kapsul 200 mg 26.480,00
Neurodex tablet 7.410,00
Paracetamol tablet 500 m 3.000,00
Vitamin B Komplek @100 1.540,00
Total 396.382,00
983 Yanti Jullia Sari DUSUN JARANG 182192 abbocath 18 Terumo @5
26/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Nassal Cannula O2 Dewas 11.625,00
Ringer Laktat Otsuka 9.538,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
983 Yanti Jullia Sari DUSUN JARANG 182192 Transfusi Set Terumo
26/01/2021 00:00:00 16.500,00 BPJS
Catheter 2 Way No. 16 (
27/01/2021 00:00:00 20.625,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 144.500,00
Induxin 1 ml Injeksi 27.843,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
Lidocain injk 40 mg/2 ml 3.222,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 5.959,00
Phytomenadione 10 Mg/1 5.959,00
Ringer Laktat Otsuka 19.076,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 2.105,00
umbilical Cord Clamp 2.261,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Cefadroxil tab 500 mg @1
28/01/2021 00:00:00 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Paracetamol tablet 500 m 3.000,00
Total 425.674,00
984 Anidah KAMPUNG DALAM 182062 Abbocath 20 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Antrain Injeksi 19.250,00
Aqua Pro Injeksi 3.575,00
Candesartan tab 8 mg 681,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazol kapsul 20 mg 661,00
Ondansetron Inj 4.950,00
Ondansetron tablet 8 mg 2.640,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 28.050,00
Amlodipine 10 mg @50 T 118,00
Amlodipine 5 mg @30 T 505,00
Antrain Injeksi 28.875,00
Candesartan Tab 16 mg 1.179,00
Candesartan tab 8 mg 3.405,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 18.747,00
Curcuma Tab 6.350,00
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac inj 30 mg/1ml 5.380,00
Neurodex tablet 3.705,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Vitamin B Komplek @100 308,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 271.747,00
985 Emma siregar LUBUK GEDANG 126130 Alprazolam 0,5 mg @100
27/01/2021 00:00:00 590,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 7.200,00
986 Fatmawati LUBUK GEDANG 149442 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 19.110,00
987 Sohimatul Munawaroh LUNANG 182046 Asam Mefenamat 500 m
27/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 2.700,00
Total 15.135,00
988 Nasib Yulianto Butar B TANJUNG MULYA 181882 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Hepa Q @30 tab 43.310,00
Total 53.810,00
989 Bahman SIBAK 155872 Amlodipine 5 mg @30 T
27/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 159.928,00
990 Asmansyah SIBAK 140995 Amlodipine 5 mg @30 T
27/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 159.928,00
991 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
27/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
992 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
27/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
993 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
27/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
994 Mutmainnah SUNGAI RENGAS 114676 Amlodipine 5 mg @30 T
27/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 159.928,00
995 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
27/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
996 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
27/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
997 Jumarno LUNANG 180796 Gentamicin Injeksi
27/01/2021 00:00:00 9.212,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 168.837,00
998 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
27/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
999 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
27/01/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.000 Elvi Indrayani PASAR SEBELAH 182003 Asam Mefenamat 500 m
27/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 12.435,00
1.001 Dewi Wulandari PADANG JAYA 163184 Asam Mefenamat 500 m
27/01/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
1.002 Indra Lasmana BANDAR RATU 162029 Mecobalamin 500 mg
27/01/2021 00:00:00 7.700,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 10.330,00
1.003 Lamhot Heryanto S BANDARATU 174880 Phenol Glycerol (tts teli
27/01/2021 00:00:00 3.456,00 BPJS
Total 3.456,00
1.004 Nenah SINAR JAYA 182196 Gentamycin 0.1 % salep k
27/01/2021 00:00:00 5.966,00 BPJS
Levemir FlexPen 104.938,00
Levofloxacin Tablet 500 m 13.640,00
Metformin tablet 500 mg 3.990,00
Metoclorapamide tab 10 m 1.510,00
Total 130.044,00
1.005 Rashaminawati DUSUN GEDANG 138060 Propanolol tab 10 mg
27/01/2021 00:00:00 6.660,00 BPJS
Propylthiourasil 100 mg ( 58.770,00
Total 65.430,00
1.006 Suyekti TANJUNG MULYA 181939 Bisoprolol 5 mg @100 Ta
27/01/2021 00:00:00 2.960,00 BPJS
Candesartan tab 8 mg 10.215,00
Furosemide 40 mg Tablet 1.440,00
Spironolaktone 25 mg 3.900,00
Total 18.515,00
1.007 Ateng Hidayat SETIA BUDI 130819 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 2.000,00
Total 39.730,00
1.008 Ilfan Candra LUBUK PINANG 166962 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Total 15.350,00
1.009 Siam DUSUN BARU V KOTO 112242 Acetylcystein 200 mg Ka
27/01/2021 00:00:00 34.380,00 BPJS
Asam Traneksamat @10 42.100,00
Phytomenadione 10 mg ( 18.680,00
Vitamin B Komplek @100 3.080,00
Total 98.240,00
1.010 Wince Sasmira UJUNG PADANG 116622 Asam Folat 1 mg @100 T
27/01/2021 00:00:00 0,00 BPJS
Asam Mefenamat 500 m 1.935,00
Pehacain Injeksi 6.640,00
Total 8.575,00
1.011 Andi Hendra UJUNG PADANG 119627 Asam Mefenamat 500 m
27/01/2021 00:00:00 1.290,00 BPJS
Pehacain Injeksi 6.640,00
Total 7.930,00
1.012 Joni Kartio SUNGAI IPUH 178142 Levofloxacin Tablet 500 m
27/01/2021 00:00:00 13.640,00 BPJS
Opilax Syr 49.156,00
Total 62.796,00
1.013 Tri Astuti BUKIT MAKMUR 181958 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Total 15.350,00
1.014 Syamsul SILAUT 182197 Domperidone Tab
27/01/2021 00:00:00 1.620,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.014 Syamsul SILAUT 182197 Levofloxacin Tablet 500 m
27/01/2021 00:00:00 13.640,00 BPJS
Total 15.260,00
1.015 Susiatun SILAUT 180433 Asam Mefenamat 500 m
27/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 61.536,00
1.016 Samio SP4, SETIA BUDI 121632 Aspilet 80 mg @100 mg
27/01/2021 00:00:00 4.140,00 BPJS
Captopril 12,5 mg 2.400,00
Furosemide 40 mg Tablet 2.880,00
Ranitidine tablet 150 mg 1.440,00
Spironolaktone 25 mg 7.800,00
Total 18.660,00
1.017 Teki Widiarsih LUBUK MUKTI 146222 Avamys
27/01/2021 00:00:00 129.000,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Methylprednisolone tab 4 2.630,00
Sucralfate Suspensi 100 m 19.250,00
Total 166.360,00
1.018 Juniarti TALANG SEPAKAT 182199 Calcium Laktat
27/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.019 Liswartini PONDOK MAKMUR 112461 Avamys
27/01/2021 00:00:00 129.000,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Methylprednisolone tab 4 2.630,00
Total 147.110,00
1.020 Yuni Astuti SUNGAI JERINJING 172193 Calcium Laktat
27/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.021 Hetik Suningsih LUNANG 182202 Calcium Laktat
27/01/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.022 Yuni Kartini TALANG MEDAN 127780 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Metrodinazole tab 500 m 2.700,00
Total 13.200,00
1.023 Rizki Utami SIDO MULYO 182165 abbocath 18 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 51.352,00
1.024 Eko Susanto CINTA ASIH 182203 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Methylprednisolone tab 4 2.630,00
Otopain Ear Drops 8 ml 99.688,00
Paracetamol tablet 500 m 3.000,00
Total 115.818,00
1.025 Amran BATU EJUNG 182051 Cefadroxil tab 500 mg @1
27/01/2021 00:00:00 10.500,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Total 15.350,00
1.026 Desi Derita Hati KAMPUNG DALAM 151397 Gitas Plus
27/01/2021 00:00:00 50.330,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 65.970,00
1.027 Eri Yadi KOTO JAYA 110699 Bisoprolol 5 mg @100 Ta
27/01/2021 00:00:00 5.920,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.027 Eri Yadi KOTO JAYA 110699 Candesartan tab 8 mg
27/01/2021 00:00:00 20.430,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Simvastatin tab 10 mg 7.230,00
Total 86.230,00
1.028 Efrizal KOTO JAYA 182014 Hepa Q @30 tab
27/01/2021 00:00:00 64.965,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
ursodeoxycholic acid 42.525,00
Total 121.130,00
1.029 Husni PONDOK SUGUH 182206 abbocath 18 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 51.352,00
1.030 Rizki Utami SIDO MULYO 182165 Alkohol 1Liter
27/01/2021 00:00:00 42.111,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 4.255,00
handscoond steril 6.5 (G 58.216,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 51.719,00
Masker Karet 11.000,00
Metoclopramide inj 5Mg/M 5.879,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.030 Rizki Utami SIDO MULYO 182165 Suprafenid Supositoria 10
27/01/2021 00:00:00 28.050,00 BPJS
Topi Operasi (Perawat) @ 4.690,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Wing needle 27 G 63.250,00
Cefotaxime Injeksi
28/01/2021 00:00:00 11.502,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 13.388,00
Toramine inj 56.118,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
29/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
30/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa Gulung New DRC 195.750,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.743.438,00
1.031 Husni PONDOK SUGUH 182206 Bisturi No. 23
27/01/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 58.216,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 51.719,00
Masker Karet 22.000,00
Massa Cauter Dewasa 90.240,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.031 Husni PONDOK SUGUH 182206 NACL 0,9 % 500 ml
27/01/2021 00:00:00 17.100,00 BPJS
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Bisturi No. 15
28/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 11.043,00
NonWoven Fixation 15x 13.388,00
Oxytetracycline Salep Ma 3.251,00
Phytomenadione 10 mg ( 934,00
Toramine inj 56.118,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
30/01/2021 00:00:00 0,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa Gulung New DRC 195.750,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.980.828,00
1.032 Yon Zeni ARAH TIGA 156405 Abbocath 20 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Cefoperazon Inj 41.250,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 9.138,00
Cefadroxil tab 500 mg @1
28/01/2021 00:00:00 1.050,00
Cefoperazon Inj 82.500,00
Ketorolac inj 30 mg/1ml 4.035,00
Loremid Tab 7.190,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Zink Tablet 1.378,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.032 Yon Zeni ARAH TIGA 156405 Abbocath 20 Terumo @5
29/01/2021 00:00:00 33.414,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Abbocath 22 Terumo @5 33.414,00
Cefoperazon Inj 82.500,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Zinc Sulfate Syr 60 ml 4.569,00
Cefadroxil tab 500 mg @1
30/01/2021 00:00:00 2.100,00
Cefoperazon Inj 82.500,00
Ciprofloxacin tab 500 mg 1.677,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Zinc Sulfate Syr 60 ml 4.569,00
Paracetamol tablet 500 m
31/01/2021 00:00:00 600,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 2.591.048,00
1.033 Sumir Wati LUNANG 182005 Abbocath 20 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Ciprofloxacin infus 2% 26.328,00
Dexametason Injeksi 6.256,00
Infusion Makro (terumo) 27.225,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 23
28/01/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet 22.000,00
Metrodinazole tab 500 m 810,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.033 Sumir Wati LUNANG 182005 Misoprostol Tab
28/01/2021 00:00:00 16.500,00 BPJS
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Ciprofloxacin infus 2%
29/01/2021 00:00:00 39.492,00
Dexametason Injeksi 6.256,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Total 1.261.246,00
1.034 Ny Rizki Utami SIDO MULYO 182210 Bisturi No. 15
27/01/2021 00:00:00 3.836,00 BPJS
Chloramphenicol Salep M 2.351,00
NGT (Feeding Tube) Fr. 8 11.043,00
umbilical Cord Clamp 2.261,00
Total 19.491,00
1.035 Linda Junita PADANG GADING 180757 abbocath 18 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Masker Karet 22.000,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00

19/08/2021 12:42:30 Page 254 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.035 Linda Junita PADANG GADING 180757 Polyvinylidene 3-0 R (Tri
27/01/2021 00:00:00 92.000,00 BPJS
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 3.752,00
Urine bag 10.088,00
viamac 1 R 546.555,00
Cefotaxime Injeksi
28/01/2021 00:00:00 11.502,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 13.388,00
Toramine inj 56.118,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
29/01/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.080,00
Transfusi Set Terumo 49.500,00
Asam Mefenamat 500 m
30/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa Gulung New DRC 195.750,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 2.043.529,00
1.036 Nurjani TALANG PETAI 182211 abbocath 18 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lansoprazole kapsul 30 m 2.310,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 65.728,00
1.037 Siti Fatimah UJUNG PADANG 115314 Abbocath 20 Terumo @5
27/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 1.650,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Alprazolam 0,5 mg @100
28/01/2021 00:00:00 118,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide Injeksi @2ml 1.666,00
Infusion set Mikro (Terumo 18.026,00

19/08/2021 12:42:30 Page 255 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.037 Siti Fatimah UJUNG PADANG 115314 NonWoven Fixation 15x
28/01/2021 00:00:00 6.694,00 BPJS
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 520,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 16.500,00
Vitamin B Komplek @100 308,00
Total 239.386,00
1.038 Nurjani TALANG PETAI 182211 Cefotaxime Injeksi
29/01/2021 00:00:00 11.502,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazol kapsul 20 mg 1.983,00
Omeprazol kapsul 20 mg 1.983,00
Omeprazol kapsul 20 mg 1.322,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Total 56.643,00
1.039 Ny Linda Junita PADANG GADING 182213 Abbocath 24 Terumo @5
28/01/2021 00:00:00 33.414,00 BPJS
Abbocath 24 Terumo @5 33.414,00
Bactesyn inj 0,75 gr 59.009,00
Bisturi No. 23 3.836,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
NonWoven Fixation 15x 6.694,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
Total 168.709,00
1.040 Rindi Triswantoro LUNANG 180921 Asam Mefenamat 500 m
28/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Natrium diclofenac 50 m 2.890,00
Renax @50 Kapsul 56.720,00
Urinter Kapsul @100 cap 21.980,00
Total 93.380,00
1.041 Sutriani TANJUNG ALAI 182066 Asam Mefenamat 500 m
28/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 69.580,00
1.042 Maria Ulfa GAJAH MATI 181088 Asam Mefenamat 500 m
28/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 59.905,00
1.043 Yeli Zarni SEI JERINJING 125945 Cefadroxil tab 500 mg @1
28/01/2021 00:00:00 10.500,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Natrium diclofenac 50 m 2.890,00
Renax @50 Kapsul 56.720,00

19/08/2021 12:42:30 Page 256 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.043 Yeli Zarni SEI JERINJING 125945 Urinter Kapsul @100 cap
28/01/2021 00:00:00 21.980,00 BPJS
Total 103.640,00
1.044 Sudarto SARI BULAN 150138 Alprazolam 1 mg @100 T
28/01/2021 00:00:00 1.600,00 BPJS
Total 1.600,00
1.045 Muhammad Dailami DESA MEKAR JAYA 180065 Asam Folat 1 mg @100 T
28/01/2021 00:00:00 990,00 BPJS
Furosemide 40 mg Tablet 960,00
KSR (potassium chloride) 23.030,00
Lansoprazole kapsul 30 m 11.550,00
Spironolaktone 100 mg 21.570,00
Sucralfate Suspensi 100 m 19.250,00
Total 77.350,00
1.046 Suriyani KAMPUNG DALAM 113149 Bisoprolol 5 mg @100 Ta
28/01/2021 00:00:00 4.440,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Flunarizine 5 mg tab 24.750,00
Furosemide 40 mg Tablet 960,00
Lansoprazole kapsul 30 m 11.550,00
Metformin tablet 500 mg 3.990,00
Miniaspi 80 Mg @100 Ta 3.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 121.340,00
1.047 Usman Seden TELUK RUMBIA 109167 Betahistin Mesilat 6 mg @
28/01/2021 00:00:00 1.380,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 960,00
Hytroz tab 2 mg 35.190,00
Lansoprazole kapsul 30 m 11.550,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 29.220,00
Total 175.070,00
1.048 Bambang Sutoyo PT. AGRO MUKO POM 133423 Furosemide 40 mg Tablet
28/01/2021 00:00:00 960,00 BPJS
Glimepiride tab 2 mg 7.770,00
Lansoprazole kapsul 30 m 11.550,00
Metformin tablet 500 mg 3.990,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Total 114.656,00
1.049 Sumiasih PT AGRO,BUNGA TANJ 112422 Clopidogrel 75 mg @30 T
28/01/2021 00:00:00 52.650,00 BPJS
Furosemide 40 mg Tablet 960,00
Glimepiride tab 2 mg 7.770,00
Lansoprazole kapsul 30 m 11.550,00
Metformin tablet 500 mg 3.990,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 29.220,00
Total 125.390,00
1.050 Masri Pani UJUNG PADANG 157866 Amlodipine 5 mg @30 T
28/01/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Furosemide 40 mg Tablet 960,00
Lansoprazole kapsul 30 m 11.550,00
Levofloxacin Tablet 500 m 13.640,00
Spironolaktone 100 mg 21.570,00

19/08/2021 12:42:30 Page 257 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.050 Masri Pani UJUNG PADANG 157866 Urinter Kapsul @100 cap
28/01/2021 00:00:00 21.980,00 BPJS
Total 93.160,00
1.051 Widi Astuti BUMI MULYA 167059 abbocath 18 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 22.276,00
Amlodipine 5 mg @30 T 101,00
Amlodipine 5 mg @30 T 303,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 11.508,00
Bisturi no. 10 3.836,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 12.512,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 7 (G 87.378,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Masker Karet 22.000,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 1.000,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Spinocain 25 (BBraund) 42.763,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Total 1.357.320,00
1.052 Adri Yani LUNANG 182139 Ambroxol Syr 15mg/ml
28/01/2021 00:00:00 4.538,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.052 Adri Yani LUNANG 182139 Azitromycin 500 mg
28/01/2021 00:00:00 56.250,00 BPJS
Candesartan tab 8 mg 20.430,00
Retaphyl SR Tab 14.740,00
Total 95.958,00
1.053 Hermansyah PASAR MUKOMUKO 182219 Alprazolam 1 mg @100 T
28/01/2021 00:00:00 1.600,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Levofloxacin Tablet 500 m 13.640,00
Natrium diclofenac 50 m 2.890,00
Renax @50 Kapsul 56.720,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Total 127.630,00
1.054 Nurlela PENARIK 131881 Paracetamol tablet 500 m
28/01/2021 00:00:00 3.000,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 22.250,00
1.055 Suprihatin SILAUT 181069 Calcium Laktat
28/01/2021 00:00:00 790,00 BPJS
Total 790,00
1.056 Ranggi SELAGAN RAYA 149940 Ambroxol Syr 15mg/ml
28/01/2021 00:00:00 4.538,00 BPJS
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 74.118,00
1.057 M Irsyan TERUNTUNG 171905 Flunarizine 5 mg tab
28/01/2021 00:00:00 24.750,00 BPJS
Gabapentin kapsul 300 m 12.690,00
Lansoprazole kapsul 30 m 11.550,00
Perifas @100 Tab 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 19.480,00
Total 106.970,00
1.058 Dahlan Elon Kartiwa SUMBER MAKMUR 165954 Lansoprazole kapsul 30 m
28/01/2021 00:00:00 11.550,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Meloxicam 7,5 mg 7.280,00
Natrium diclofenac 50 m 2.890,00
Sucralfate Suspensi 100 m 19.250,00
Total 54.610,00
1.059 Wulan Nurpa Sepriani BUKIT MAKMUR 182097 abbocath 18 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.059 Wulan Nurpa Sepriani BUKIT MAKMUR 182097 Spuit 10 cc Disposible (T
28/01/2021 00:00:00 3.230,00 BPJS
Spuit 5 cc terumo 17.076,00
Transfusi Set Terumo 16.500,00
Total 225.575,00
1.060 Adeng Caniago PELOKAN 168831 Omeprazol kapsul 20 mg
28/01/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Tonotan tab 45.730,00
Total 71.590,00
1.061 Kartini TANJUNG ALAI 180947 Abbocath 20 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 9.538,00
Urinter Kapsul @100 cap 4.396,00
Total 116.691,00
1.062 Candra Dewi BUNGA TANJUNG 111584 Asam Mefenamat 500 m
28/01/2021 00:00:00 1.290,00 BPJS
Metrodinazole tab 500 m 2.700,00
Nystatin Tab Vaginal 2.952,00
Total 6.942,00
1.063 Maria Yosefa PASAR BELAKANG 141148 abbocath 18 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 51.352,00
1.064 Jailani SARIBULAN 182224 abbocath 18 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Total 76.918,00
1.065 Paryati WONOSOBO 182225 abbocath 18 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 78.875,00
Cuticell Classic 10cmx10c 0,00
Gelaufusal Infusion 500 m 0,00
Handscoond Sterille 7 (G 87.378,00
NACL 0,9 % 500 ml 8.550,00
NGT (Feeding tube) Fr. 5 17.603,00
NonWoven Fixation 15x 6.694,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.065 Paryati WONOSOBO 182225 NonWoven Fixation 15x
28/01/2021 00:00:00 0,00 BPJS
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 0,00
Spuit 10 cc Disposible (T 0,00
Spuit 3 cc Disposible 0,00
Spuit 5 cc Disposible 0,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Total 289.385,00
1.066 Fahis Afwaja LUNANG 182226 Abbocath 20 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Total 76.918,00
1.067 Susi Ambarwati LUNANG 182227 Calcium Laktat
28/01/2021 00:00:00 790,00 BPJS
Total 790,00
1.068 Sugito MEKAR MULYA 147062 Codein tab 10 mg
28/01/2021 00:00:00 2.250,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Nassal Cannula O2 Anak 16.473,00
Total 52.923,00
1.069 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
28/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.070 Darmawan LUBUK PINANG 140187 Codein tab 10 mg
28/01/2021 00:00:00 2.250,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Total 36.450,00
1.071 Amri Kusna Yanti BUMI MULYA 133486 Lansoprazole kapsul 30 m
28/01/2021 00:00:00 3.465,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Otsu D40 37.539,00
Ranitidin inj 3.580,00
Total 78.784,00
1.072 Narti SILAUT 175653 Amlodipine 10 mg @50 T
28/01/2021 00:00:00 354,00 BPJS
Codein tab 10 mg 2.250,00
Gentamicin Injeksi 9.212,00
NACL 0,9 % 500 ml 34.200,00
Otsu D40 37.539,00
Total 83.555,00
1.073 Kartini TANJUNG ALAI 180947 Ketorolac inj 30 mg/1ml
28/01/2021 00:00:00 4.035,00 BPJS
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
29/01/2021 00:00:00 12.498,00
Ketorolac inj 30 mg/1ml 4.035,00
Natrium diclofenac 50 m 578,00
Omeprazole Inj 12.499,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 4.396,00
Asam Mefenamat 500 m
30/01/2021 00:00:00 1.935,00
Natrium diclofenac 50 m 2.890,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.073 Kartini TANJUNG ALAI 180947 NonWoven Fixation 15x
30/01/2021 00:00:00 13.388,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Urinter Kapsul @100 cap 21.980,00
Total 172.973,00
1.074 Maria Yosefa PASAR BELAKANG 141148 Bisturi No. 23
28/01/2021 00:00:00 3.836,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 17.253,00
Chloramphenicol Salep M 2.351,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 87.324,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Masker Tali 41.600,00
Metoclopramide inj 5Mg/M 35.274,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding tube) Fr. 5 17.603,00
Ondansetron Inj 3.300,00
Phytomenadione 10 Mg/1 5.959,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 47.690,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 27.832,00
Tranexamic Acid Inj (Asa 10.525,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Abbocath 22 Terumo @5
29/01/2021 00:00:00 11.138,00
Ceftriaxone Inj 12.498,00
Metrodinazole tab 500 m 2.700,00
Asam Mefenamat 500 m
31/01/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 610.943,00
1.075 Jailani SARIBULAN 182224 Cauter (Hand-controlled P
28/01/2021 00:00:00 162.161,00 BPJS
Chromic catgut 1 R (Tri 157.750,00
Hypafix 10cm x 5cm (25 c 9.700,00
Amlodipine 5 mg @30 T
29/01/2021 00:00:00 303,00
Dulcolax Sup 10 mg 27.800,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol Infus 43.314,00
Cefadroxil tab 500 mg @1
30/01/2021 00:00:00 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa Gulung New DRC 195.750,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.075 Jailani SARIBULAN 182224 NACL 0,9 % 500 ml
30/01/2021 00:00:00 8.550,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 647.215,00
1.076 Riono PT AGROAIR DIKIT 182228 Abbocath 20 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 56.368,00
1.077 Wardoyo TANJUNG MULYA 125079 Amlodipine 5 mg @30 T
28/01/2021 00:00:00 1.010,00 BPJS
Asam Folat 1 mg @100 T 990,00
Cefadroxil tab 500 mg @1 10.500,00
Cetirgi Tab 10 mg 15.480,00
NACL 0,9 % 500 ml 59.850,00
Total 87.830,00
1.078 Ashari Liwandi PONDOK LUNANG 139398 Amlodipine 5 mg @30 T
28/01/2021 00:00:00 1.010,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
NACL 0,9 % 500 ml 59.850,00
Sucralfate Suspensi 100 m 19.250,00
Total 90.610,00
1.079 Supangat PONDOK LUNANG 147511 Amlodipine 5 mg @30 T
28/01/2021 00:00:00 1.010,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Metoclorapamide tab 10 m 1.510,00
NACL 0,9 % 500 ml 68.400,00
Total 82.470,00
1.080 M Akil PASAR BELAKANG 115376 Amlodipine 5 mg @30 T
28/01/2021 00:00:00 1.010,00 BPJS
Metoclorapamide tab 10 m 1.510,00
NACL 0,9 % 500 ml 59.850,00
Sucralfate Suspensi 100 m 19.250,00
Total 81.620,00
1.081 Ahmad Mujiono MARGA MULYA SAKTI 113737 Amlodipine 5 mg @30 T
28/01/2021 00:00:00 1.010,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
NACL 0,9 % 500 ml 59.850,00
Paracetamol tablet 500 m 2.000,00
Total 73.360,00
1.082 Fahis Afwaja LUNANG 182226 Ceftriaxone Inj
28/01/2021 00:00:00 6.249,00 BPJS
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Ketorolac inj 30 mg/1ml 2.690,00
Lidocain injk 40 mg/2 ml 9.666,00
Omeprazole Inj 12.499,00
Polyvinylidene 3-0 R (Tri 92.000,00
Silk 2/0 R scimitar 29.125,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Cefadroxil tab 500 mg @1
29/01/2021 00:00:00 10.500,00
Fentanyl Injeksi 5 Ampul 2 52.000,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.082 Fahis Afwaja LUNANG 182226 Omeprazole Inj
29/01/2021 00:00:00 12.499,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 507.531,00
1.083 Siti Komariyah TIRTA MAKMUR 182182 abbocath 18 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 7 (G 72.815,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 1.000,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Transfusi Set Terumo 16.500,00
Total 275.036,00
1.084 Haikal Virendra TALANG SEPAKAT 178649 Ambroxol 30 mg @100 T
28/01/2021 00:00:00 386,00 BPJS
Cefixime syrup 100mg/5 M 23.823,00
CTM (Klorfeniramina mal 58,00
Dexametason Injeksi 3.128,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Miconazole krim 2 % 8.962,00
Paracetamol syrup 1.388,00
Abbocath 24 Terumo @5
29/01/2021 00:00:00 33.414,00
Ambroxol 30 mg @100 T 386,00
Cefixime syrup 100mg/5 M 23.823,00
CTM (Klorfeniramina mal 87,00
Dexametason Injeksi 3.128,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ka-En 1 B 12.658,00
Miconazole krim 2 % 4.481,00
Triamcinolon tablet 4 mg 1.882,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 149.899,00
1.085 Tamni TANJUNG ALAI 182229 abbocath 18 Terumo @5
30/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 66.641,00
1.086 Zonni Fourwanda BANDAR RATU 144412 abbocath 18 Terumo @5
28/01/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 31.245,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.086 Zonni Fourwanda BANDAR RATU 144412 Metoclopramide inj 5Mg/M
28/01/2021 00:00:00 17.637,00 BPJS
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 47.690,00
Total 128.118,00
1.087 Widi Astuti BUMI MULYA 167059 Cefotaxime Injeksi
29/01/2021 00:00:00 17.253,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Amlodipine 5 mg @30 T
30/01/2021 00:00:00 303,00
Aqua Pro Injeksi
31/01/2021 00:00:00 7.150,00
Asam Mefenamat 500 m 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 104.139,00
1.088 Wulan Nurpa Sepriani BUKIT MAKMUR 182097 Asam Mefenamat 500 m
29/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Paracetamol tablet 500 m 2.000,00
Total 13.790,00
1.089 Paryati WONOSOBO 182225 Chromic catgut 1 R (Tri
29/01/2021 00:00:00 0,00 BPJS
Dexametason Injeksi 0,00
Aqua Pro Injeksi
31/01/2021 00:00:00 7.150,00
Asam Mefenamat 500 m 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 76.768,00
1.090 Siti Komariyah TIRTA MAKMUR 182182 Asam Mefenamat 500 m
29/01/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Paracetamol tablet 500 m 2.000,00
Vitamin B Komplek @100 1.540,00
Total 15.330,00
1.091 Zonni Fourwanda BANDAR RATU 144412 Azitromycin 500 mg
30/01/2021 00:00:00 11.250,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 47.690,00
Vectrine Tab 300 mg 15.000,00
Ascorbid Acid 1000mg/5m
31/01/2021 00:00:00 52.250,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 12.700,00
Extrace Injeksi 100 mg/m 38.500,00
NACL 0,9 % 500 ml 42.750,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 24.998,00

19/08/2021 12:42:30 Page 265 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.091 Zonni Fourwanda BANDAR RATU 144412 Omeprazole Inj
31/01/2021 00:00:00 12.499,00 BPJS
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Oseltamivir 75 mg 20,00
Otsu Nacl PiggyBack 100 m 37.950,00
Otsu Nacl PiggyBack 100 m 56.925,00
Paracetamol Infus 43.314,00
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 9.350,00
vestein 300 mg 46.750,00
vestein 300 mg 9.350,00
Zink Tablet 1.378,00
Zink Tablet 1.378,00
azitromicin syr 200mg/5m
02/02/2021 00:00:00 30.776,00
Ondansetron Inj 4.950,00
Oseltamivir 75 mg 10,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 47.690,00
Ringer Laktat Otsuka 47.690,00
Ceftriaxone Inj
04/02/2021 00:00:00 12.498,00
Infusion Makro (terumo) 54.450,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
azitromicin syr 200mg/5m
09/02/2021 00:00:00 30.776,00
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Oseltamivir 75 mg 10,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 47.690,00
vestein 300 mg 46.750,00
Cefixime Kapsul 100 mg
15/02/2021 00:00:00 9.380,00
CTM (Klorfeniramina mal 290,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Triamcinolon tablet 4 mg 9.410,00
Total 1.205.989,00
1.092 Paryati WONOSOBO 182225 Aqua Pro Injeksi
31/01/2021 00:00:00 7.150,00 BPJS
Asam Mefenamat 500 m 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 12.512,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 168.155,00
1.093 Tamni TANJUNG ALAI 182229 Bisturi No. 23
30/01/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.093 Tamni TANJUNG ALAI 182229 Chromic catgut 1 R (Tri
30/01/2021 00:00:00 78.875,00 BPJS
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
methyl ergometrin amp 8.662,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding Tube) Fr. 8 11.043,00
Ondansetron Inj 3.300,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 1-0 R (Tri 105.000,00
Polyvinylidene 2-0 C (Tri 92.250,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Safil 1 R 199.600,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Suprafenid Supositoria 10 42.075,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Aqua Pro Injeksi
31/01/2021 00:00:00 7.150,00
Asam Mefenamat 500 m 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.402.748,00
1.094 Selvia Sri Ayu Lestari TANJUNG JAYA 182231 abbocath 18 Terumo @5
29/01/2021 00:00:00 11.138,00 BPJS
abbocath 18 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.094 Selvia Sri Ayu Lestari TANJUNG JAYA 182231 Catheter 2 Way No. 16 (
29/01/2021 00:00:00 39.025,00 BPJS
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Celemek Plastik 35.972,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 8.032,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 1.345,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 4.050,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 3 % (OTSU SALIN) 120.000,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Prolene no. 3/0 cutting 387.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Safil 1 R 199.600,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 42.075,00
Topi Operasi (Perawat) @ 3.752,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Total 1.601.234,00
1.095 Ita Nurhayati IPUH 182123 Ambroxol Syr 15mg/ml
29/01/2021 00:00:00 4.538,00 BPJS
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 74.118,00
1.096 Kemis AGUNG JAYA SP6 114066 Cefixime kapsul 200 mg
29/01/2021 00:00:00 26.480,00 BPJS
Total 26.480,00
1.097 Siti Dewi TALANG BUAI 181762 Gabapentin kapsul 300 m
29/01/2021 00:00:00 12.690,00 BPJS
Meloxicam 7,5 mg 7.280,00
Omeprazol kapsul 20 mg 6.610,00
Total 26.580,00
1.098 Sambusri PANTAI INDAH 122146 Amlodipine 5 mg @30 T
29/01/2021 00:00:00 1.010,00 BPJS
Clopidogrel 75 mg @30 T 17.550,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 2.000,00
Ramipril tab 5 mg 3.060,00
Spironolaktone 25 mg 2.600,00
Total 28.850,00
1.099 Khamdanah PASAR SEBELAH 182232 Gabapentin kapsul 300 m
29/01/2021 00:00:00 12.690,00 BPJS
Glimepiride tab 2 mg 7.770,00
Lansoprazole kapsul 30 m 11.550,00
Metformin tablet 500 mg 3.990,00
Metoclorapamide tab 10 m 1.510,00
Total 37.510,00
1.100 Rosna PAUH TERENJA 152824 Natrium diclofenac 50 m
29/01/2021 00:00:00 2.890,00 BPJS
Vitamin B Komplek @100 2.310,00
Total 5.200,00
1.101 Armeiyani LUBUK SANAI 177144 Propanolol tab 10 mg
29/01/2021 00:00:00 6.660,00 BPJS
Propylthiourasil 100 mg ( 39.180,00
Vitamin B Komplek @100 1.540,00
Total 47.380,00
1.102 Ida Laila POndok kandang 151024 Bucain Spinal 0.5 % Inj
29/01/2021 00:00:00 52.181,00 BPJS
Catheter 2 Way No. 16 ( 39.025,00
Celemek Plastik 35.972,00
Chromic catgut 2-0 R (Tr 72.250,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 4.016,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
Prolene no. 3/0 cutting 129.000,00
Safil 1 R 199.600,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 3.752,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Total 969.956,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.103 Wiwik Kadarwati BANDA RATU 132602 Meloxicam 7,5 mg
29/01/2021 00:00:00 7.280,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 13.890,00
1.104 Kurnia Wulandari TIRTA MAKMUR 172942 Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 15cmx5cm (25 c 13.088,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 74.624,00
1.105 Munrawati DUSUN PALAU 160348 Acetylcystein 200 mg Ka
29/01/2021 00:00:00 17.190,00 BPJS
Azitromycin 500 mg 28.125,00
Symbicort Turbuhaler 16 186.575,00
Vitamin C tablet @100 Ta 1.380,00
Total 233.270,00
1.106 Yendri Saputri LUBUK PINANG 148482 Asam Mefenamat 500 m
29/01/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 68.230,00
1.107 Tunah Titik Muntamah AIR MANJUTO 182240 Norelut
29/01/2021 00:00:00 70.125,00 BPJS
Total 70.125,00
1.108 Ida Laila POndok kandang 151024 abbocath 18 Terumo @5
29/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 36.093,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Bisturi no. 10
31/01/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 342.198,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.109 Salami SILAUT I 134774 NACL 0,9 % 500 ml
29/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.110 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
29/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.111 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
29/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.112 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
29/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.113 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
29/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.114 Suwarni SUKA MAJU 164065 Amlodipine 5 mg @30 T
29/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Total 43.653,00
1.115 Susi Martini KOTO JAYA 145038 Amlodipine 5 mg @30 T
29/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Total 43.653,00
1.116 Roslina TERUNTUNG 130072 Amlodipine 5 mg @30 T
29/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Total 43.653,00
1.117 Salbiyah LUBUK MUKTI 173013 Amlodipine 5 mg @30 T
29/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Total 43.653,00
1.118 Zukriman LUBUK GEDANG 160918 Amlodipine 5 mg @30 T
29/01/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Total 43.653,00
1.119 Suhardi BANDAR RATU 115774 Alprazolam 0,5 mg @100
29/01/2021 00:00:00 0,00 BPJS
Amlodipine 10 mg @50 T 1.180,00
Candesartan tab 8 mg 6.810,00
Clopidogrel 75 mg @30 T 17.550,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 46.790,00
1.120 Helma Yanti LALANG LUAS 182215 abbocath 18 Terumo @5
29/01/2021 00:00:00 11.138,00 BPJS
Misoprostol Tab 22.000,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Hypafix 10cm x 5cm (25 c 4.850,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 24.062,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.120 Helma Yanti LALANG LUAS 182215 Spuit 5 cc terumo
29/01/2021 00:00:00 8.538,00 BPJS
Cefadroxil tab 500 mg @1
30/01/2021 00:00:00 10.500,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 18.562,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 3.000,00
Total 234.925,00
1.121 Rudi Saputra BUMI MEKAR JAYA 182244 Abbocath 20 Terumo @5
29/01/2021 00:00:00 11.138,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Cefixime Kapsul 100 mg 9.380,00
Cetirgi Tab 10 mg 1.548,00
Combivent 6.256,00
Infusion Makro (terumo) 27.225,00
Paracetamol syrup 1.388,00
Prednison tab 5 mg 2.390,00
Ringer Laktat Otsuka 9.538,00
Salbutamol 2mg/5ml Siru 5.558,00
Total 78.959,00
1.122 Isnan AGUNG JAYA 132306 Cefadroxil tab 500 mg @1
29/01/2021 00:00:00 10.500,00 BPJS
Gentamycin 0.1 % salep k 2.983,00
Lidocain injk 40 mg/2 ml 4.833,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Tetagam 1 Ml Injeksi 184.000,00
Total 296.316,00
1.123 Rasmini BUKIT MAKMUR 182246 Dexametason Injeksi
29/01/2021 00:00:00 6.256,00 BPJS
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
Hypafix 10cm x 5cm (25 c 9.700,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 38.500,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Cefadroxil tab 500 mg @1
30/01/2021 00:00:00 10.500,00
Paracetamol tablet 500 m 3.000,00
Total 231.157,00
1.124 Putri Khairunisa IPUH 182248 Abbocath 20 Terumo @5
29/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.124 Putri Khairunisa IPUH 182248 Gelaufusal Infusion 500 m
29/01/2021 00:00:00 181.269,00 BPJS
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 40.160,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 22.000,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Cefotaxime Injeksi
30/01/2021 00:00:00 11.502,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 24 Terumo @5
31/01/2021 00:00:00 44.552,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Injection plug 20.213,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
viamac 1 R 546.555,00
Total 2.077.552,00
1.125 Patmawati SELAGAN JAYA 182249 Abbocath 20 Terumo @5
29/01/2021 00:00:00 11.138,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00

19/08/2021 12:42:30 Page 273 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.125 Patmawati SELAGAN JAYA 182249 Ringer Laktat Otsuka
29/01/2021 00:00:00 9.538,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 72.001,00
1.126 Erma Wati AIR DIKIT 182251 abbocath 18 Terumo @5
30/01/2021 00:00:00 11.138,00 BPJS
Captopril 12,5 mg 80,00
Ceftriaxone Inj 12.498,00
Combivent 18.768,00
Digoxsin tab 0,25 mg 144,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Nassal Cannula O2 Dewas 11.625,00
Nebulizer O2 Dewasa 34.783,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Cefadroxil tab 500 mg @1 2.100,00
Ceftriaxone Inj 12.498,00
Digoxsin tab 0,25 mg 144,00
Furamin Injeksi 43.107,00
NACL 0,9 % 500 ml 25.650,00
Ambroxol Syr 15mg/ml
31/01/2021 00:00:00 4.538,00
Captopril 12,5 mg 80,00
Digoxsin tab 0,25 mg 2.304,00
Furosemide 40 mg Tablet 960,00
Total 212.971,00
1.127 Selvia Sri Ayu Lestari TANJUNG JAYA 182231 Abbocath 20 Terumo @5
30/01/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Aqua Pro Injeksi
31/01/2021 00:00:00 3.575,00
Asam Mefenamat 500 m 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
Metrodinazole tab 500 m 2.700,00
Paracetamol tablet 500 m 600,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Total 164.168,00
1.128 Ai Rosmiati AIR HITAM 182253 abbocath 18 Terumo @5
30/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00

19/08/2021 12:42:30 Page 274 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.128 Ai Rosmiati AIR HITAM 182253 NACL 0,9 % 500 ml
30/01/2021 00:00:00 17.100,00 BPJS
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
31/01/2021 00:00:00 11.502,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Total 248.716,00
1.129 Bahman SIBAK 155872 NACL 0,9 % 500 ml
30/01/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.130 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
30/01/2021 00:00:00 25.650,00 BPJS
Total 25.650,00
1.131 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
30/01/2021 00:00:00 34.200,00 BPJS
Paracetamol tablet 500 m 600,00
Total 34.800,00
1.132 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
30/01/2021 00:00:00 34.200,00 BPJS
Nassal Mask O2 Dewasa 41.828,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 200,00
Total 81.178,00
1.133 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
30/01/2021 00:00:00 25.650,00 BPJS
Total 25.650,00
1.134 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
30/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.135 Sumidah RAWA MULYA 163860 Ambroxol 30 mg @100 T
30/01/2021 00:00:00 1.930,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Total 36.130,00
1.136 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
30/01/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.137 Bima Aryandika BANDARATU 178714 Cetirgi Tab 10 mg
30/01/2021 00:00:00 15.480,00 BPJS
NACL 0,9 % 500 ml 51.300,00
Total 66.780,00
1.138 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
30/01/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
1.139 M Munir ibnu shalla BANDARATU 136635 Erdosteine Syr
30/01/2021 00:00:00 146.300,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Nassal Cannula O2 Anak 16.473,00
Nassal Mask O2 Dewasa 41.828,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 23.375,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 95.380,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.139 M Munir ibnu shalla BANDARATU 136635 Ascorbid Acid 1000mg/5m
31/01/2021 00:00:00 52.250,00 BPJS
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 12.700,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Oseltamivir 75 mg 20,00
Otsu Nacl PiggyBack 100 m 56.925,00
Paracetamol Infus 43.314,00
vestein 300 mg 9.350,00
vestein 300 mg 46.750,00
Zink Tablet 1.378,00
azitromicin syr 200mg/5m
02/02/2021 00:00:00 30.776,00
NACL 0,9 % 500 ml 51.300,00
Ondansetron Inj 4.950,00
Oseltamivir 75 mg 10,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 47.690,00
Ambroxol 30 mg @100 T
04/02/2021 00:00:00 1.930,00
Azitromycin 500 mg 56.250,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
CTM (Klorfeniramina mal
09/02/2021 00:00:00 290,00
Paracetamol tablet 500 m 2.000,00
Triamcort 4 mg Tab 41.250,00
vestein syr 48.125,00
Cefixime Kapsul 100 mg
15/02/2021 00:00:00 9.380,00
CTM (Klorfeniramina mal 290,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Triamcinolon tablet 4 mg 9.410,00
Total 1.190.717,00
1.140 Painem KOTO JAYA 167802 Abbocath 22 Terumo @5
30/01/2021 00:00:00 11.138,00 BPJS
Dexametason Injeksi 3.128,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Nassal Cannula O2 Dewas 11.625,00
Ngt (Feeding Tube) Fr.16 21.176,00
NGT (Stomach Tube) Fr. 1 60.046,00
Ranitidin inj 5.370,00
Ranitidine tablet 150 mg 144,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Total 197.618,00
1.141 Jailani SARIBULAN 182224 Abbocath 20 Terumo @5
30/01/2021 00:00:00 11.138,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.141 Jailani SARIBULAN 182224 Aqua Pro Injeksi
30/01/2021 00:00:00 3.575,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Kamadol Injeksi 5.700,00
Ketorolac inj 30 mg/1ml 1.345,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 112.832,00
1.142 Irama TERAS TERUNJAM 182254 Aqua Pro Injeksi
30/01/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
methyl ergometrin amp 6.700,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 11.000,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 3 cc Disposible 3.640,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Suprafenid Supositoria 10 42.075,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
viamac 1 R 182.185,00
Total 1.112.645,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.143 Jailani SARIBULAN 182224 Abbocath 22 Terumo @5
31/01/2021 00:00:00 11.138,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 18.747,00
Ceftriaxone Inj 18.747,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Ephedrine Injeksi 10.711,00
Esomeprazol Injeksi 40 m 34.956,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 37.497,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 C scimitar 66.993,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tramadol 50 mg/ml Inj 12.375,00
Tramadol 50 mg/ml Inj 12.375,00
Abbocath 22 Terumo @5
01/02/2021 00:00:00 22.276,00
Hypafix 15cmx5cm (25 c 6.544,00
Asam Mefenamat 500 m
02/02/2021 00:00:00 2.580,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Ketoprofen tab 100 mg 12.380,00
Nephrolit Kapsul 12.075,00
Nephrolit Kapsul 12.075,00
Omeprazole Inj 37.497,00
Paracetamol tablet 500 m 4.000,00
Total 941.901,00
1.144 Afrizal KAMPUNG NELAYAN 123393 Cefadroxil tab 500 mg @1
30/01/2021 00:00:00 10.500,00 BPJS
Lidocain injk 40 mg/2 ml 3.222,00
Methylprednisolon tablet 8 9.580,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Pehacain Injeksi 3.320,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 37.172,00
1.145 Painem KOTO JAYA 167802 Dexametason Injeksi
31/01/2021 00:00:00 6.256,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Biocombin 5000 Injeksi
01/02/2021 00:00:00 13.062,00
Dexametason Injeksi 6.256,00
Ketorolac inj 30 mg/1ml 2.690,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
02/02/2021 00:00:00 12.498,00
Dexametason Injeksi 6.256,00
Ketorolac inj 30 mg/1ml 4.035,00
Ringer Laktat Otsuka 28.614,00
Spuit 5 cc terumo 42.690,00
Alprazolam 0,5 mg @100
03/02/2021 00:00:00 118,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Ketorolac inj 30 mg/1ml 4.035,00
Ranitidin inj 3.580,00
Ceftriaxone Inj
04/02/2021 00:00:00 12.498,00
Cetirgi Tab 10 mg 4.644,00
Dexametason Injeksi 6.256,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 2.690,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 38.152,00
Cefadroxil tab 500 mg @1
05/02/2021 00:00:00 10.500,00
Cefadroxil tab 500 mg @1 10.500,00
Methylprednisolone tab 4 2.630,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00
Paracetamol tablet 500 m 3.000,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 359.634,00
1.146 Irama TERAS TERUNJAM 182254 Cefotaxime Injeksi
30/01/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi no. 10
31/01/2021 00:00:00 3.836,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Nassal Cannula O2 bayi 9.530,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 6.315,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.146 Irama TERAS TERUNJAM 182254 umbilical Cord Clamp
31/01/2021 00:00:00 2.261,00 BPJS
Dexametason Injeksi
01/02/2021 00:00:00 6.256,00
Ephedrine Injeksi 32.133,00
Spinocain 27 (BBraund) 95.750,00
viamac 1 R 182.185,00
Asam Mefenamat 500 m
02/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 623.493,00
1.147 Amelinda MEDAN JAYA 182256 abbocath 18 Terumo @5
30/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Catgut Chromic 2/0 R (Sc 177.596,00
Chloramphenicol Salep M 2.351,00
Misoprostol Tab 16.500,00
Nassal Cannula O2 Dewas 11.625,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 4.522,00
Alkohol 1Liter
31/01/2021 00:00:00 42.111,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7 (G 58.252,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
methyl ergometrin amp 8.662,00
Metrodinazole tab 500 m 810,00
Miloz 1mg/ml Injeksi 5.259,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Proster Tablet 200 mcg 15.126,00
Ringer Laktat Otsuka 19.076,00
Safil 1 R 299.400,00
Spinocain 27 (BBraund) 47.875,00
Spuit 1cc terumo 9.488,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.147 Amelinda MEDAN JAYA 182256 Spuit 3 cc Terumo
31/01/2021 00:00:00 13.916,00 BPJS
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
01/02/2021 00:00:00 17.253,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 32.133,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Spinocain 27 (BBraund) 95.750,00
Tranexamic Acid Inj (Asa 6.315,00
Ciprofloxacin tab 500 mg
02/02/2021 00:00:00 5.590,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 1.807.903,00
1.148 Bambang Supriadi RESNO 182258 abbocath 18 Terumo @5
31/01/2021 00:00:00 11.138,00 BPJS
Betahistin Mesilat 6 mg @ 828,00
Flunarizine 5 mg tab 4.950,00
Infusion Makro (terumo) 27.225,00
Methylprednisolone tab 4 3.156,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Diazepam Tab 5 Mg 136,00
Flunarizine 5 mg tab 4.950,00
Methylprednisolone tab 4 789,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Betahistin Mesilat 6 mg @
01/02/2021 00:00:00 1.380,00
Diazepam Tab 5 Mg 408,00
Flunarizine 5 mg tab 24.750,00
Methylprednisolone tab 4 5.260,00
Ranitidin inj 1.790,00
Betahistin Mesilat 6 mg @
02/02/2021 00:00:00 1.380,00
Flunarizine 5 mg tab 24.750,00
Mecobalamin 500 mg 7.700,00
Total 211.164,00
1.149 Nazwa Sofia AIR DIKIT 174600 Oralit
31/01/2021 00:00:00 1.029,00 BPJS
Paracetamol syrup 1.388,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 6.986,00
1.150 Gatot Santoyo IPUH 182218 Abbocath 20 Terumo @5
31/01/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.150 Gatot Santoyo IPUH 182218 Ceftriaxone Inj
31/01/2021 00:00:00 12.498,00 BPJS
Clindamycin 300 mg Tabl 1.750,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Meropenem Inj 0.5 g 55.000,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol Infus 14.438,00
Perifas @100 Tab 1.925,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 392.659,00
1.151 Ipaniati PAUH TERENJA 116961 Abbocath 20 Terumo @5
31/01/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Vomil b6 3.025,00
Cefotaxime Injeksi
01/02/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Vomil b6 3.025,00
Sucralfate Suspensi 100 m
02/02/2021 00:00:00 19.250,00
Cefotaxime Injeksi
03/02/2021 00:00:00 11.502,00
Ondansetron Inj 4.950,00
Vomil b6 9.075,00
Cefadroxil tab 500 mg @1
04/02/2021 00:00:00 10.500,00
Ondansetron tablet 8 mg 13.200,00
Total 174.918,00
1.152 Nasidi BANDAR JAYA 182261 Abbocath 20 Terumo @5
31/01/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 11.250,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Otsu Manitol 20% 54.375,00
Phytomenadione 10 Mg/1 5.959,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 2.105,00

19/08/2021 12:42:30 Page 282 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.152 Nasidi BANDAR JAYA 182261 Urine bag
31/01/2021 00:00:00 10.088,00 BPJS
Total 239.765,00
1.153 Demi TIRTA MAKMUR 182262 abbocath 18 Terumo @5
31/01/2021 00:00:00 11.138,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Bisturi No. 23 3.836,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding Tube) Fr. 8 11.043,00
umbilical Cord Clamp 2.261,00
abbocath 18 Terumo @5
01/02/2021 00:00:00 22.276,00
Cefotaxime Injeksi 17.253,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
02/02/2021 00:00:00 11.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.153 Demi TIRTA MAKMUR 182262 Hypafix 15cmx5cm (25 c
02/02/2021 00:00:00 13.088,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
03/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.310.332,00
1.154 Nasidi BANDAR JAYA 182261 Citicoline Injeksi 125mg/
01/02/2021 00:00:00 22.500,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Otsu Manitol 20% 54.375,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 31.575,00
Amlodipine 5 mg @30 T
02/02/2021 00:00:00 202,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ranitidin inj 3.580,00
Ranitidin inj 1.790,00
Tranexamic Acid Inj (Asa 8.420,00
Tranexamic Acid Inj (Asa 23.155,00
Citicoline Injeksi 125mg/
03/02/2021 00:00:00 22.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 33.680,00
Abbocath 20 Terumo @5
04/02/2021 00:00:00 22.276,00
Amlodipine 5 mg @30 T 303,00
Ceftriaxone Inj 6.249,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
NACL 0,9 % 500 ml 0,00
Paracetamol Infus 28.876,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 33.680,00
Amlodipine 5 mg @30 T
05/02/2021 00:00:00 101,00
Ceftriaxone Inj 0,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.154 Nasidi BANDAR JAYA 182261 Citicoline Injeksi 125mg/
05/02/2021 00:00:00 11.250,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 800,00
Piralen Injeksi 2 ml 26.400,00
Ranitidin inj 1.790,00
Tranexamic Acid Inj (Asa 31.575,00
Amlodipine 5 mg @30 T
06/02/2021 00:00:00 202,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 800,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 33.680,00
Amlodipine 5 mg @30 T
07/02/2021 00:00:00 101,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 25.650,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 800,00
Phytomenadione 10 Mg/1 23.836,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 8.420,00
Total 1.004.608,00
1.155 Gatot Santoyo IPUH 182218 Abbocath 20 Terumo @5
01/02/2021 00:00:00 22.276,00 BPJS
Abbocath 22 Terumo @5 33.414,00
Aminofluid Infus 500 ml 155.204,00
Asam Folat 1 mg @100 T 297,00
Catheter 2 Way No. 16 ( 20.625,00
Clindamycin 150 mg tabl 7.000,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
meropenem Injeksi 1 g 123.750,00
meropenem Injeksi 1 g 41.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 3.850,00
Ringer Laktat Otsuka 28.614,00
Three Way stopcock 10.626,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Aminofluid Infus 500 ml
02/02/2021 00:00:00 155.204,00
Asam Folat 1 mg @100 T 297,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.155 Gatot Santoyo IPUH 182218 Betadine Obat Kumur
02/02/2021 00:00:00 13.750,00 BPJS
Citicoline Injeksi 125mg/ 22.500,00
Clindamycin 150 mg tabl 7.000,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 4.035,00
meropenem Injeksi 1 g 123.750,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 3.850,00
Perifas @100 Tab 11.550,00
Ringer Laktat Otsuka 28.614,00
Cefixime kapsul 200 mg
03/02/2021 00:00:00 5.296,00
Citicoline Injeksi 125mg/ 11.250,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
meropenem Injeksi 1 g 41.250,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Total 1.281.832,00
1.156 Putri Anggraini TANJUNG JAYA 182263 Bisturi No. 23
01/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 32.133,00
Gelaufusal Infusion 500 m 181.269,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine Povidone 1 L 158.594,00
Ketamin Inj 78.705,00
Ketorolac inj 30 mg/1ml 2.690,00
Misoprostol Tab 11.000,00
Paracetamol Infus 28.876,00
Pehacain Injeksi 0,00
Polyvinylidene 3-0 R (Tri 92.000,00
Pospargin/Methergyn Inj 15.000,00
Spinocain 27 (BBraund) 47.875,00
Spinocain 27 (BBraund) 95.750,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 2.105,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Aqua Pro Injeksi
02/02/2021 00:00:00 3.575,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.156 Putri Anggraini TANJUNG JAYA 182263 Cefotaxime Injeksi
02/02/2021 00:00:00 11.502,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
03/02/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Metrodinazole tab 500 m 810,00
Paracetamol Infus 28.876,00
Asam Mefenamat 500 m
04/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.640.638,00
1.157 Irma Suryani MEKAR SARI 153351 abbocath 18 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 23.516,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 44.000,00
Misoprostol Tab 22.000,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Aqua Pro Injeksi
02/02/2021 00:00:00 3.575,00
Asam Mefenamat 500 m 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 55.000,00
Tranexamic Acid Inj (Asa 6.315,00
Total 419.135,00
1.158 Mukmin AIR DIKIT 178821 Abbocath 22 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Ambroxol 30 mg @100 T 579,00
Aspilet 80 mg @100 mg 138,00
Captopril 12,5 mg 80,00
Ceftriaxone Inj 12.498,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.158 Mukmin AIR DIKIT 178821 Furosemide Injeksi @2ml
01/02/2021 00:00:00 4.998,00 BPJS
Infusion Makro (terumo) 27.225,00
Opilax Syr 49.156,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 780,00
Total 119.710,00
1.159 Karimudin UJUNG PADANG 131563 abbocath 18 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 1.010,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 3.332,00
Infusion Makro (terumo) 27.225,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazol kapsul 20 mg 6.610,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 14.025,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Total 224.368,00
1.160 Fir Caniago LUBUK PINANG 167962 Diazepam Tab 5 Mg
01/02/2021 00:00:00 4.080,00 BPJS
Eperisone Hcl 50 mg @1 69.840,00
Gabapentin kapsul 300 m 38.070,00
Kalxetin 10 mg @30 Kap 110.000,00
Natrium diclofenac 50 m 8.670,00
Total 230.660,00
1.161 Herman Ranto LUBUK PINANG 138197 Antasida Syrup 60 ml
01/02/2021 00:00:00 2.736,00 BPJS
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 29.676,00
1.162 Rany Puji Astuti TALANG SARI 158355 Calcium Laktat
01/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.163 Sukaji RAWA MULYA 135229 Erphafillin Tab
01/02/2021 00:00:00 7.380,00 BPJS
Salbutamol 4 mg 1.860,00
Symbicort Turbuhaler 16 186.575,00
Total 195.815,00
1.164 Sohimatul Munawaroh LUNANG 182046 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 12.435,00
1.165 Anggelia Eka Putri TELUK RUMBIA 182264 Amoxicillin 500 mg @ 10
01/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Total 4.350,00
1.166 Zulkifli DUSUN BARU PELOKA 181910 Antasida Doen 400 mg @
01/02/2021 00:00:00 750,00 BPJS
Paracetamol tablet 500 m 2.000,00
Ranitidine tablet 150 mg 1.440,00
Salbutamol 2 mg 790,00
Vitamin B Komplek @100 1.540,00
Total 6.520,00
1.167 Mujais LUNANG 156894 Ambroxol Syr 15mg/ml
01/02/2021 00:00:00 4.538,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.167 Mujais LUNANG 156894 Cefadroxil tab 500 mg @1
01/02/2021 00:00:00 10.500,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 57.458,00
1.168 Balui GAJAH MATI 118528 Domperidone Tab
01/02/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Opilax Syr 49.156,00
Total 56.846,00
1.169 Ramina LUNANG 182266 Calcium Laktat
01/02/2021 00:00:00 790,00 BPJS
Nulacta ibu hamil & meny 60.500,00
Total 61.290,00
1.170 Zaidin LUBUK PINANG 142283 Furosemide 40 mg Tablet
01/02/2021 00:00:00 2.880,00 BPJS
Ranitidine tablet 150 mg 4.320,00
Symbicort Turbuhaler 16 186.575,00
Thrombo Aspilets 29.220,00
Total 222.995,00
1.171 Wulandari PASAR BANTAL 178039 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.172 Mukmin AIR DIKIT 178821 Captopril 12,5 mg
01/02/2021 00:00:00 160,00 BPJS
Captopril 12,5 mg 80,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 15cmx5cm (25 c 6.544,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spironolaktone 25 mg 780,00
Thrombo Aspilets 974,00
Captopril 12,5 mg
02/02/2021 00:00:00 240,00
Ceftriaxone Inj 12.498,00
Combivent 25.024,00
Furosemide Injeksi @2ml 4.998,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ranitidin inj 3.580,00
Spironolaktone 25 mg 780,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 46.750,00
Abbocath 22 Terumo @5
03/02/2021 00:00:00 33.414,00
Captopril 12,5 mg 160,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Combivent 25.024,00
Furosemide Injeksi @2ml 3.332,00

19/08/2021 12:42:30 Page 289 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.172 Mukmin AIR DIKIT 178821 Hypafix 10cm x 5cm (25 c
03/02/2021 00:00:00 4.850,00 BPJS
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Spironolaktone 25 mg 520,00
Vectrine Tab 300 mg 10.000,00
Ambroxol Syr 15mg/ml
04/02/2021 00:00:00 4.538,00
Captopril 12,5 mg 800,00
Domperidone Tab 1.080,00
Furosemide 40 mg Tablet 960,00
Levofloxacin Tablet 500 m 13.640,00
Opilax Syr 49.156,00
Piralen Injeksi 2 ml 79.200,00
Pulmicort Resp 0.25 mg/ 0 71.536,00
Spironolaktone 25 mg 3.800,00
vestein 300 mg 56.100,00
Total 776.820,00
1.173 Karimudin UJUNG PADANG 131563 Amlodipine 5 mg @30 T
01/02/2021 00:00:00 202,00 BPJS
Antasida Syrup 60 ml 2.736,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 3.332,00
Metoclopramide inj 5Mg/M 17.637,00
NGT (Stomach Tube) Fr. 1 60.046,00
Omeprazole Inj 24.998,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 28.050,00
Amlodipine 5 mg @30 T
02/02/2021 00:00:00 101,00
Candesartan tab 8 mg 2.043,00
Ceftriaxone Inj 12.498,00
Dulcolax Sup 10 mg 27.800,00
Dulcolax tab 5 mg 3.166,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 3.332,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 19.076,00
vestein 300 mg 0,00
vestein syr 48.125,00
Amlodipine 5 mg @30 T
03/02/2021 00:00:00 101,00
Antasida Syrup 60 ml 2.736,00
Azitromycin 500 mg 28.125,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 1.666,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00

19/08/2021 12:42:30 Page 290 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.173 Karimudin UJUNG PADANG 131563 Pantoprazole Inj
03/02/2021 00:00:00 23.375,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Amlodipine 5 mg @30 T
04/02/2021 00:00:00 1.010,00
Antasida Syrup 60 ml 2.736,00
Azitromycin 500 mg 22.500,00
Candesartan tab 8 mg 6.810,00
Cefixime kapsul 200 mg 26.480,00
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 46.750,00
Total 668.077,00
1.174 Addarimi BANDARATU 127606 Acetylcystein 200 mg Ka
01/02/2021 00:00:00 51.570,00 BPJS
Allopurinol 100 mg @100 7.020,00
Clopidogrel 75 mg @30 T 52.650,00
Flunarizine 5 mg tab 148.500,00
Levazide tablet 137.190,00
Sifrol tab 0,375 mg 311.250,00
Total 708.180,00
1.175 Feni Febrianti DUSUN BARU PELOKA 182177 Cefadroxil tab 500 mg @1
01/02/2021 00:00:00 10.500,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 8.550,00
Total 35.269,00
1.176 Marnis PAUH TERENJA 174866 Ondansetron tablet 8 mg
01/02/2021 00:00:00 52.800,00 BPJS
Total 52.800,00
1.177 Yuni Kartini TALANG MEDAN 127780 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 12.435,00
1.178 Julianda gita putri PONDOK BARU 182122 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 62.886,00
1.179 Era Purnama Sari DUSUN BARU V KOTO 171970 Paracetamol tablet 500 m
01/02/2021 00:00:00 3.000,00 BPJS
Total 3.000,00
1.180 Erlina SARIBULAN 182124 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 59.755,00
1.181 Regina Enjelika PERNYAH 150102 Domperidone Tab
01/02/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 26.940,00
1.182 Susiatun SILAUT 180433 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 11.790,00
1.183 Dul Rahman TIRTA MAKMUR 166301 Antasida Syrup 60 ml
01/02/2021 00:00:00 2.736,00 BPJS
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 29.676,00
1.184 Sukaeni TANJUNG MULYA 127131 Eperisone Hcl 50 mg @1
01/02/2021 00:00:00 23.280,00 BPJS
Meloxicam 7,5 mg 7.280,00
Omeprazol kapsul 20 mg 6.610,00
Total 37.170,00
1.185 Ermaini PERNYAH 182274 Alprazolam 0,5 mg @100
01/02/2021 00:00:00 1.180,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 3.180,00
1.186 Mardini PASAR GEDANG 127199 Amlodipine 5 mg @30 T
01/02/2021 00:00:00 3.030,00 BPJS
Asam Folat 1 mg @100 T 2.970,00
Aspilet 80 mg @100 mg 4.140,00
Bisoprolol 5 mg @100 Ta 4.440,00
Cetirgi Tab 10 mg 46.440,00
Ibuprofen tab 200 mg 3.980,00
Metformin tablet 500 mg 7.980,00
Omeprazol kapsul 20 mg 19.830,00
Paracetamol tablet 500 m 4.000,00
Thrombo Aspilets 29.220,00
Total 126.030,00
1.187 Ujang Samsudin UJUNG PADANG 127171 Codein tab 10 mg
01/02/2021 00:00:00 7.500,00 BPJS
Furosemide 40 mg Tablet 2.880,00
Glimepiride tab 2 mg 7.770,00
Metformin tablet 500 mg 7.980,00
Ranitidine tablet 150 mg 4.320,00
Spironolaktone 25 mg 7.800,00
Thrombo Aspilets 29.220,00
Total 67.470,00
1.188 Amrin A nelan indah 179023 Meloxicam 7,5 mg
01/02/2021 00:00:00 7.280,00 BPJS
Paracetamol tablet 500 m 4.000,00
Vitamin B Komplek @100 3.080,00
Total 14.360,00
1.189 Ahmad Rahino SILAUT 168082 Cefadroxil tab 500 mg @1
01/02/2021 00:00:00 10.500,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Total 34.494,00
1.190 Putriyani PENARIK 148961 Meloxicam 7,5 mg
01/02/2021 00:00:00 7.280,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 29.260,00
1.191 Enfarina PT AGROMUKO PENAR 144179 Alprazolam 0,5 mg @100
01/02/2021 00:00:00 1.180,00 BPJS
Antasida Syrup 60 ml 2.736,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 29.776,00
1.192 Elly Zabeth Hutapea UJUNG PADANG 119672 Cefixime Kapsul 100 mg
01/02/2021 00:00:00 18.760,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 20.760,00
1.193 Urnita LUNANG 182276 Calcium Laktat
01/02/2021 00:00:00 790,00 BPJS
Nulacta ibu hamil & meny 60.500,00
Total 61.290,00
1.194 Anuar TERAS TERUNJAM 178456 Abbocath 20 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.194 Anuar TERAS TERUNJAM 178456 Abbocath 22 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 101.941,00
1.195 Samsu Hardi SUNGAI GADING 182278 Asam Traneksamat @10
01/02/2021 00:00:00 21.050,00 BPJS
Azitromycin 500 mg 56.250,00
Codein tab 10 mg 7.500,00
Total 84.800,00
1.196 Sumarni SILAUT 182103 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.197 Pratiwi LUBUK SANAI II 182164 Amoxicillin 500 mg @ 10
01/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Pehacain Injeksi 3.320,00
Total 7.670,00
1.198 Herawati PENARIK 181611 abbocath 18 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 10.040,00
handscoond steril 6.5 (G 58.216,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 51.719,00
Masker Karet 11.000,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.198 Herawati PENARIK 181611 Polyglycolide T-Vio 1 R (
01/02/2021 00:00:00 197.000,00 BPJS
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 4.690,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Cuticell Classic 10cmx10c
02/02/2021 00:00:00 6.900,00
Phytomenadione 2 Mg/1M 4.834,00
viamac 1 R 364.370,00
Total 1.630.134,00
1.199 Selvi PONDOK SUGUH 182279 abbocath 18 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Gelaufusal Infusion 500 m 181.269,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Pehacain Injeksi 0,00
Polyvinylidene 3-0 R (Tri 92.000,00
Pospargin/Methergyn Inj 15.000,00
Ringer Laktat Otsuka 9.538,00
Safil 1 R 199.600,00
Spinocain 27 (BBraund) 47.875,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Aqua Pro Injeksi
02/02/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole tab 500 m 810,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.199 Selvi PONDOK SUGUH 182279 Tranexamic Acid Inj (Asa
02/02/2021 00:00:00 6.315,00 BPJS
Total 1.260.311,00
1.200 Yendri Saputri LUBUK PINANG 148482 Cefadroxil tab 500 mg @1
01/02/2021 00:00:00 10.500,00 BPJS
Methylprednisolone tab 4 5.260,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 24.370,00
1.201 Lusiana ARAH TIGA 182137 Asam Mefenamat 500 m
01/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 59.755,00
1.202 Sukiman SETIA BUDI 167849 Meloxicam 7,5 mg
01/02/2021 00:00:00 7.280,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Total 10.585,00
1.203 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.204 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.205 Narti SILAUT 175653 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.206 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.207 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.208 Juminem KOTA PRAJA 152875 Abbocath 20 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Asering 500 Ml 24.116,00
Citicoline Injeksi 125mg/ 90.000,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Simvastatin tab 20 mg 311,00
Thrombo Aspilets 974,00
Total 269.429,00
1.209 Ahmad Damiri UJUNG PADANG 114580 Candesartan tab 8 mg
01/02/2021 00:00:00 20.430,00 BPJS
Donepezil MK Tablet 67.230,00
Simvastatin tab 20 mg 9.330,00
Thrombo Aspilets 29.220,00
Topamax 100 mg Tab 239.000,00
Total 365.210,00
1.210 Any Desmawati UJUNG PADANG 111289 Atorvastatin 20 mg @30 T
01/02/2021 00:00:00 10.450,00 BPJS
Candesartan tab 8 mg 20.430,00
Glimepiride tab 2 mg 7.770,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.210 Any Desmawati UJUNG PADANG 111289 Metformin tablet 500 mg
01/02/2021 00:00:00 7.980,00 BPJS
Thrombo Aspilets 9.740,00
Total 56.370,00
1.211 Netra Handayani UJUNG PADANG 127190 Codein tab 10 mg
01/02/2021 00:00:00 7.500,00 BPJS
Methylprednisolone tab 4 7.890,00
Total 15.390,00
1.212 Anuar TERAS TERUNJAM 178456 Alprazolam 0,5 mg @100
02/02/2021 00:00:00 118,00 BPJS
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Metoclopramide inj 5Mg/M 17.637,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Sucralfate Suspensi 100 m 19.250,00
Alprazolam 0,5 mg @100
03/02/2021 00:00:00 118,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Hypafix 15cmx5cm (25 c 6.544,00
Metoclopramide inj 5Mg/M 17.637,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Alprazolam 0,5 mg @100
04/02/2021 00:00:00 1.180,00
Curcuma Tab 12.700,00
Domperidone Tab 1.080,00
Levofloxacin Tablet 500 m 13.640,00
Loratadine tab 10 mg 1.660,00
Omeprazol kapsul 20 mg 6.610,00
Pantoprazole Inj 46.750,00
Paracetamol tablet 500 m 2.000,00
Piralen Injeksi 2 ml 52.800,00
Total 299.366,00
1.213 Ema Rismawati MEKAR SARI 181885 abbocath 18 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bucain Spinal 0.5 % Inj 0,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 0,00
Gelaufusal Infusion 500 m 181.269,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 0,00
Ketorolac inj 30 mg/1ml 0,00
Misoprostol Tab 0,00
Myotonic inj 0,00
Polyglycolide T-Vio 1 R ( 0,00
Polyvinylidene 3-0 R (Tri 0,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 0,00
Spinocain 27 (BBraund) 0,00
Suprafenid Supositoria 10 0,00
Tramadol 50 mg/ml Inj 0,00
Tranexamic Acid Inj (Asa 0,00
Transfusi Set Terumo 16.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.213 Ema Rismawati MEKAR SARI 181885 Urine bag
01/02/2021 00:00:00 10.088,00 BPJS
viamac 1 R 0,00
Total 265.028,00
1.214 Zhagita Natasya Putri DESA TUNGGANG 176591 Abbocath 24 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 297,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
NACL 0,9 % 500 ml 8.550,00
Total 77.350,00
1.215 M.renza PONDOK SUGUH 176594 Abbocath 22 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 297,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Ferospat Tab Effervesent 173.250,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 240.650,00
1.216 Ria Julita LUBUK BENTO 157655 abbocath 18 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 53.046,00
1.217 Miswanto LUNANG 128267 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.218 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.219 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.220 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.221 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.222 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
01/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.223 Nazarudin PONDOK SUGUH 152888 Abbocath 20 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Electroda (Ambu) @25 Pc 81.570,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.223 Nazarudin PONDOK SUGUH 152888 Hypafix 15cmx5cm (25 c
01/02/2021 00:00:00 6.544,00 BPJS
Infusion Makro (terumo) 27.225,00
Miniaspi 80 Mg @100 Ta 125,00
NACL 0,9 % 500 ml 8.550,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 172.245,00
1.224 M.renza PONDOK SUGUH 176594 NACL 0,9 % 500 ml
01/02/2021 00:00:00 8.550,00 BPJS
Total 8.550,00
1.225 Ria Julita LUBUK BENTO 157655 Abbocath 14 Terumo @5
02/02/2021 00:00:00 41.772,00 BPJS
abbocath 18 Terumo @5 44.552,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 34.200,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suction no. 1/4 25.950,00
Suprafenid Supositoria 10 28.050,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.225 Ria Julita LUBUK BENTO 157655 Suprafenid Supositoria 10
02/02/2021 00:00:00 42.075,00 BPJS
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 23
03/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Piralen Injeksi 2 ml 26.400,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 13.450,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 2.198.809,00
1.226 Nazarudin PONDOK SUGUH 152888 Hypafix 10cm x 5cm (25 c
01/02/2021 00:00:00 4.850,00 BPJS
NACL 0,9 % 500 ml 25.650,00
Ranitidin inj 1.790,00
Hypafix 15cmx5cm (25 c
02/02/2021 00:00:00 6.544,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Hypafix 15cmx5cm (25 c
03/02/2021 00:00:00 6.544,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Thrombo Aspilets 9.740,00
Total 85.008,00
1.227 Jurai Ijah TANAH HARAPAN 181143 Abbocath 20 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 17.252,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 19.076,00
Vitamin B Komplek @100 154,00
Total 130.198,00
1.228 Sani TERUNTUNG 127436 abbocath 18 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
abbocath 18 Terumo @5 33.414,00
Aqua Pro Injeksi 3.575,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.228 Sani TERUNTUNG 127436 Bisturi No. 23
01/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 41.250,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 9.384,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 58.216,00
handscoond steril 8 (Gam 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 51.719,00
Masker Karet 22.000,00
Metoclopramide inj 5Mg/M 5.879,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 25 (BBraund) 42.763,00
Spinocain 27 (BBraund) 95.750,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Aqua Pro Injeksi
02/02/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 1.350,00
Tranexamic Acid Inj (Asa 6.315,00
Total 1.546.234,00
1.229 Jurai Ijah TANAH HARAPAN 181143 Ceftriaxone Inj
02/02/2021 00:00:00 12.498,00 BPJS
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 9.700,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.229 Jurai Ijah TANAH HARAPAN 181143 NACL 0,9 % 500 ml
02/02/2021 00:00:00 17.100,00 BPJS
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Vitamin B Komplek @100 154,00
Abbocath 20 Terumo @5
03/02/2021 00:00:00 22.276,00
Abbocath 22 Terumo @5 22.276,00
Abbocath 22 Terumo @5 11.138,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 33.000,00
Vitamin B Komplek @100 154,00
Ceftriaxone Inj
04/02/2021 00:00:00 12.498,00
Dulcolax tab 5 mg 3.166,00
Neurodex tablet 741,00
Omeprazole Inj 24.998,00
Levofloxacin Tablet 500 m
05/02/2021 00:00:00 13.640,00
Omeprazol kapsul 20 mg 3.305,00
Total 318.323,00
1.230 Sani TERUNTUNG 127436 Dexametason Injeksi
01/02/2021 00:00:00 6.256,00 BPJS
Metoclopramide inj 5Mg/M 58.790,00
NACL 0,9 % 500 ml 17.100,00
Ranitidin inj 17.900,00
viamac 1 R
02/02/2021 00:00:00 364.370,00
Abbocath 20 Terumo @5
03/02/2021 00:00:00 22.276,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Asam Mefenamat 500 m
04/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 606.594,00
1.231 Faiq Bukhair TUNGGANG 176380 NACL 0,9 % 500 ml
01/02/2021 00:00:00 8.550,00 BPJS
Dexametason Injeksi
02/02/2021 00:00:00 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Total 21.208,00
1.232 Anggi Lianto LUBUK BENTO 125958 Dexametason Injeksi
01/02/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 25.650,00
Ringer Laktat Otsuka 19.076,00
Total 67.084,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.233 Rini Astika DUSUN PULAU 119184 Alkohol 1Liter
01/02/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 9.384,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 5.879,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 95.750,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Bisturi No. 23
02/02/2021 00:00:00 3.836,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
03/02/2021 00:00:00 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Safil 1 R 199.600,00
Asam Mefenamat 500 m
04/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.233 Rini Astika DUSUN PULAU 119184 Metrodinazole tab 500 m
04/02/2021 00:00:00 4.050,00 BPJS
Postofix (leukomed) 36.726,00
Total 1.560.219,00
1.234 Ariani ARAH TIGA 138360 Abbocath 20 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metformin tablet 500 mg 399,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Total 144.274,00
1.235 Ny.sani TERAS TERUNJAM 182284 Abbocath 24 Terumo @5
01/02/2021 00:00:00 33.414,00 BPJS
Bisturi no. 10 3.836,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Suction Chateter no. 8 (R 41.250,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
02/02/2021 00:00:00 44.552,00
Chromic catgut 3-0 R (Tr 66.250,00
Epinephrin inj 15.331,00
Epinephrin inj 15.331,00
ETT 3.5 Kingking (Non B 21.184,00
Extention Tube 8.801,00
Extention Tube 8.801,00
Hypafix 15cmx5cm (25 c 13.088,00
Kassa kotak stril DRC 9.675,00
Miloz Injeksi 5 mg 5.611,00
Miloz Injeksi 5 mg 5.611,00
NGT (Feeding tube) Fr. 3 21.710,00
Otsu Nacl PiggyBack 100 m 18.975,00
Phenobarbital Injeksi 50 m 11.145,00
Three Way stopcock 10.626,00
Three Way stopcock 10.626,00
Total 390.954,00
1.236 Sarida PENARIK 182285 Abbocath 20 Terumo @5
01/02/2021 00:00:00 11.138,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Total 100.752,00
1.237 Ny.putri Angraini TANJUNG JAYA 182286 Bisturi no. 10
01/02/2021 00:00:00 3.836,00 BPJS
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
Total 26.722,00
1.238 Ny.selvi PONDOK SUGUH 182287 Bisturi no. 10
01/02/2021 00:00:00 3.836,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.238 Ny.selvi PONDOK SUGUH 182287 Chloramphenicol Salep M
01/02/2021 00:00:00 0,00 BPJS
Nassal Cannula O2 bayi 0,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
02/02/2021 00:00:00 0,00
Epinephrin inj 0,00
Extention Tube 0,00
Hypafix 15cmx5cm (25 c 0,00
Otsu Nacl PiggyBack 100 m 0,00
Three Way stopcock 0,00
Total 26.722,00
1.239 Sarida PENARIK 182285 Ondansetron Inj
03/02/2021 00:00:00 4.950,00 BPJS
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Omeprazol kapsul 20 mg
05/02/2021 00:00:00 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 54.066,00
1.240 Juminem KOTA PRAJA 152875 Asering 500 Ml
02/02/2021 00:00:00 24.116,00 BPJS
Asering 500 Ml 24.116,00
Citicoline Injeksi 125mg/ 90.000,00
Citicoline Injeksi 125mg/ 112.500,00
Opilax Syr 49.156,00
Otsu Manitol 20% 54.375,00
Paracetamol tablet 500 m 2.000,00
Simvastatin tab 20 mg 3.110,00
Thrombo Aspilets 9.740,00
Asering 500 Ml
03/02/2021 00:00:00 24.116,00
Citicoline Injeksi 125mg/ 90.000,00
Paracetamol tablet 500 m 600,00
Simvastatin tab 10 mg 241,00
Thrombo Aspilets 974,00
Asering 500 Ml
04/02/2021 00:00:00 24.116,00
Citicoline kaplet 500 mg 16.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazol kapsul 20 mg 6.610,00
Simvastatin tab 10 mg 3.456,00
Simvastatin tab 10 mg 2.410,00
Total 542.986,00
1.241 Selvi PONDOK SUGUH 182279 Cefotaxime Injeksi
03/02/2021 00:00:00 11.502,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Asam Mefenamat 500 m
04/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 6.900,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.241 Selvi PONDOK SUGUH 182279 Postofix (leukomed)
04/02/2021 00:00:00 36.726,00 BPJS
Total 115.568,00
1.242 Herawati PENARIK 181611 Cauter (Hand-controlled P
02/02/2021 00:00:00 162.161,00 BPJS
Celemek Plastik 89.930,00
handscoond steril 6.5 (G 43.662,00
NACL 0,9 % 500 ml 17.100,00
Suction no. 1/4 25.950,00
Bisturi No. 23
03/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Piralen Injeksi 2 ml 26.400,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
04/02/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 569.707,00
1.243 Ariani ARAH TIGA 138360 Amlodipine 5 mg @30 T
02/02/2021 00:00:00 2.020,00 BPJS
Metformin tablet 500 mg 2.660,00
Omeprazol kapsul 20 mg 13.220,00
Piralen tab 4.540,00
Sucralfate Suspensi 100 m 19.250,00
Cefixime kapsul 200 mg
03/02/2021 00:00:00 26.480,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Piralen tab 4.540,00
Total 102.846,00
1.244 Zeta Meirani BANDAR RATU 182288 abbocath 18 Terumo @5
02/02/2021 00:00:00 11.138,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol Infus 14.438,00
Paracetamol Infus 14.438,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Ambroxol 30 mg @100 T
03/02/2021 00:00:00 579,00
Ambroxol 30 mg @100 T 965,00
Ascorbid Acid 1000mg/5m 52.250,00
Azitromycin 500 mg 5.625,00
Bisturi No. 23 3.836,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.244 Zeta Meirani BANDAR RATU 182288 Bucain Spinal 0.5 % Inj
03/02/2021 00:00:00 52.181,00 BPJS
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
methyl ergometrin amp 8.662,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Otsu Nacl PiggyBack 100 m 37.950,00
Paracetamol Infus 28.876,00
Paracetamol tablet 500 m 800,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
viamac 1 R 364.370,00
Azitromycin 500 mg
04/02/2021 00:00:00 56.250,00
Cefadroxil tab 500 mg @1 10.500,00
Paracetamol tablet 500 m 3.000,00
vestein 300 mg 46.750,00
Vitamin C tablet @100 Ta 1.380,00
Total 1.685.177,00
1.245 Salbiah DESA LUBUK MUKTI 117881 Abbocath 20 Terumo @5
02/02/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 101,00
Asam Folat 1 mg @100 T 297,00
Cefoperazon Inj 82.500,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.245 Salbiah DESA LUBUK MUKTI 117881 Novo Twist 32 G Tip
02/02/2021 00:00:00 2.604,00 BPJS
Novorapid Flexpen 108.750,00
Amlodipine 5 mg @30 T 101,00
Asam Folat 1 mg @100 T 297,00
Cefoperazon Inj 41.250,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Amlodipine 10 mg @50 T
03/02/2021 00:00:00 1.180,00
Amlodipine 5 mg @30 T 101,00
Asam Folat 1 mg @100 T 99,00
Asam Folat 1 mg @100 T 2.970,00
Clonidine 0.15 mg @100 T 2.290,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Novo Twist 32 G Tip 5.208,00
Total 502.060,00
1.246 Suhadi RAWA MULYA 143895 Acetylcystein 200 mg Ka
02/02/2021 00:00:00 51.570,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Ketokonazole krim 2 % 3.148,00
Piracetam tablet 1200 m 41.880,00
Total 172.708,00
1.247 Partowiyono TANJUNG BERINGIN / 136784 Ambroxol Syr 15mg/ml
02/02/2021 00:00:00 4.538,00 BPJS
Amlodipine 5 mg @30 T 1.515,00
Azitromycin 500 mg 28.125,00
Candesartan tab 8 mg 10.215,00
Paracetamol tablet 500 m 2.000,00
Spironolaktone 25 mg 3.900,00
Total 50.293,00
1.248 Nurkasmi BANTAL 095395 Atorvastatin 20 mg @30 T
02/02/2021 00:00:00 10.450,00 BPJS
Gitas Plus 50.330,00
ursodeoxycholic acid 85.050,00
Total 145.830,00
1.249 Ade Zahratul Rahmi LUBUK PINANG 148010 Asam Folat 1 mg @100 T
02/02/2021 00:00:00 2.970,00 BPJS
Total 2.970,00
1.250 Sukesi LUNANG 177153 Norelut
02/02/2021 00:00:00 140.250,00 BPJS
Total 140.250,00
1.251 Slamet SILAUT 113415 Alprazolam 0,5 mg @100
02/02/2021 00:00:00 590,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 10.215,00
Flunarizine 5 mg tab 24.750,00
Isosorbid dinitrat 5 mg (I 3.330,00
Spironolaktone 25 mg 3.900,00
Total 47.225,00
1.252 Mely Br Rajagukguk ARGA JAYA 182295 Alinamin F 50 mg @100 T
02/02/2021 00:00:00 11.500,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.252 Mely Br Rajagukguk ARGA JAYA 182295 Cefixime Kapsul 100 mg
02/02/2021 00:00:00 9.380,00 BPJS
Opilax Syr 49.156,00
Paracetamol tablet 500 m 2.000,00
Total 72.036,00
1.253 Samsuji LUBUK TALANG 182296 Eperisone Hcl 50 mg @1
02/02/2021 00:00:00 23.280,00 BPJS
Glucosamine 250 mg 11.550,00
Meloxicam 15 mg 12.600,00
Total 47.430,00
1.254 Ijas LUBUK GEDANG 153187 Alinamin F 50 mg @100 T
02/02/2021 00:00:00 11.500,00 BPJS
Gitas Plus 50.330,00
Levofloxacin Tablet 500 m 13.640,00
Total 75.470,00
1.255 Muslim BANDARATU 181722 Atorvastatin 20 mg @30 T
02/02/2021 00:00:00 31.350,00 BPJS
Betahistin Mesilat 6 mg @ 4.140,00
Candesartan tab 8 mg 20.430,00
Flunarizine 5 mg tab 74.250,00
Thrombo Aspilets 58.440,00
Total 188.610,00
1.256 Nur Demi LUNANG 180880 Calcium Laktat
02/02/2021 00:00:00 1.580,00 BPJS
Nulacta ibu hamil & meny 121.000,00
Total 122.580,00
1.257 Tuminah TALANG SARI IV 182297 Alprazolam 0,5 mg @100
02/02/2021 00:00:00 590,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 2.000,00
Total 10.335,00
1.258 Jaenab RAWA BANGUN 145410 Flunarizine 5 mg tab
02/02/2021 00:00:00 24.750,00 BPJS
Glimepiride tab 2 mg 3.885,00
Metformin tablet 500 mg 3.990,00
Total 32.625,00
1.259 Nadi RAWA BANGUN 182299 Glimepiride tab 2 mg
02/02/2021 00:00:00 3.885,00 BPJS
Metformin tablet 500 mg 3.990,00
Pregabalin Kap 75 mg 64.460,00
Total 72.335,00
1.260 Rajulaini TUNGGANG 182152 Candesartan tab 8 mg
02/02/2021 00:00:00 6.810,00 BPJS
Citicoline Injeksi 125mg/ 168.750,00
Flunarizine 5 mg tab 24.750,00
Mecobalamin 500 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Total 210.010,00
1.261 Ery Zulhayat BANTAL 142540 Eperisone Hcl 50 mg @1
02/02/2021 00:00:00 23.280,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Simvastatin tab 10 mg 2.410,00
Total 39.330,00
1.262 Desma Zalnita SILAUT 181848 Ethambutol 500 mg
02/02/2021 00:00:00 38.745,00 BPJS
Isoniazide 300 mg 6.480,00
Pyrazinamid 500 mg 27.810,00
Rifampicin 450 33.840,00
Total 106.875,00
1.263 Mardesi Putri ARAH TIGA 174870 Ciprofloxacin tab 500 mg
02/02/2021 00:00:00 5.590,00 BPJS
Clindamycin 150 mg tabl 8.750,00
Ketorolac Tab 10 Mg 37.950,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 52.290,00
1.264 Rimson Siboro TUNGGAL JAYA 182167 Ciprofloxacin tab 500 mg
02/02/2021 00:00:00 8.385,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Paracetamol tablet 500 m 4.000,00
Vitamin B Komplek @100 3.080,00
Total 22.009,00
1.265 Teki Widiarsih LUBUK MUKTI 146222 Cetirgi Tab 10 mg
02/02/2021 00:00:00 15.480,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 18.480,00
1.266 Ani Mariani TUNGGAL JAYA 109603 Cefixime kapsul 200 mg
02/02/2021 00:00:00 26.480,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00
Total 47.590,00
1.267 Fadlli Ersa Sinaga AIR DIKIT 182301 Lidocain injk 40 mg/2 ml
02/02/2021 00:00:00 3.222,00 BPJS
Paracetamol tablet 500 m 3.000,00
Tensocrepe 10 x 4.5 cm ( 57.625,00
Total 63.847,00
1.268 Buyung Anam LUBUK GEDANG 133634 Alinamin F 50 mg @100 T
02/02/2021 00:00:00 11.500,00 BPJS
Asam Folat 1 mg @100 T 1.485,00
Levofloxacin Tablet 500 m 13.640,00
Loratadine tab 10 mg 1.660,00
ursodeoxycholic acid 85.050,00
Total 113.335,00
1.269 Lilis Arfana AIR KASAI 182303 Cefadroxil tab 500 mg @1
02/02/2021 00:00:00 10.500,00 BPJS
Total 10.500,00
1.270 Tarijah RETAK MUDIK 171236 Cefixime kapsul 200 mg
02/02/2021 00:00:00 26.480,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 4.000,00
Total 37.090,00
1.271 Egi Habag Tangi SUNGAI IPUH 149659 Atorvastatin 20 mg @30 T
02/02/2021 00:00:00 15.675,00 BPJS
Captopril 12,5 mg 2.400,00
Total 18.075,00
1.272 Kumsiyah WONOSOBO 170151 Amlodipine 10 mg @50 T
02/02/2021 00:00:00 3.540,00 BPJS
Eperisone Hcl 50 mg @1 23.280,00
Flunarizine 5 mg tab 24.750,00
Lansoprazole kapsul 30 m 11.550,00
Natrium diclofenac 50 m 289,00
Total 63.409,00
1.273 Mella Elviza PT AGRO MME 161769 Otopain Ear Drops 8 ml
02/02/2021 00:00:00 99.688,00 BPJS
Total 99.688,00
1.274 Hadi Soleh Yoga Prata AGUNG JAYA 158494 ATRACURIUM BESYLATE 2
02/02/2021 00:00:00 14.671,00 BPJS
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Fresofol ( propopol ) inj 13.448,00
Ondansetron Inj 3.300,00
Tranexamic Acid Inj (Asa 4.210,00
Total 44.955,00
1.275 Siti Hoeriyah PENARIK 138381 Cetirgi Tab 10 mg
02/02/2021 00:00:00 15.480,00 BPJS
Total 15.480,00
1.276 Madi SARI BULAN 182306 Alinamin F 50 mg @100 T
02/02/2021 00:00:00 11.500,00 BPJS
Cefixime Kapsul 100 mg 9.380,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.276 Madi SARI BULAN 182306 Domperidone Tab
02/02/2021 00:00:00 1.620,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Total 34.050,00
1.277 Dian Rohana Harianja DUSUN BARU V KOTO 180645 Asam Mefenamat 500 m
02/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Total 16.485,00
1.278 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
02/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.279 Sasrigunita MALIN DEMAN 163822 Omeprazol kapsul 20 mg
02/02/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 25.860,00
1.280 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
02/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.281 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
02/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.282 Salami SILAUT I 134774 NACL 0,9 % 500 ml
02/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.283 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
02/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.284 Agus Marni SUNGAI GADING 182157 Asam Folat 1 mg @100 T
02/02/2021 00:00:00 990,00 BPJS
Flunarizine 5 mg tab 24.750,00
Ibuprofen tab 400 mg 4.580,00
Total 30.320,00
1.285 Friska Idayani Lumbanga TUNGGANG 182308 Alprazolam 0,5 mg @100
02/02/2021 00:00:00 590,00 BPJS
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 21.840,00
1.286 Johanes Parulian PT AGRO BTE 162658 Eperisone Hcl 50 mg @1
02/02/2021 00:00:00 23.280,00 BPJS
Ibuprofen tab 400 mg 4.580,00
Total 27.860,00
1.287 Usi Lestari TANAH REKAH 163838 abbocath 18 Terumo @5
02/02/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 5.751,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 19.076,00
Asam Folat 1 mg @100 T
03/02/2021 00:00:00 297,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.287 Usi Lestari TANAH REKAH 163838 Ringer Laktat Otsuka
03/02/2021 00:00:00 28.614,00 BPJS
Asam Folat 1 mg @100 T
04/02/2021 00:00:00 297,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Asam Folat 1 mg @100 T
05/02/2021 00:00:00 1.980,00
Furamin Injeksi 43.107,00
Furamin Injeksi 14.369,00
Omeprazole Inj 37.497,00
Omeprazole Inj 12.499,00
Total 362.212,00
1.288 Gerak TALANG BUAI 139085 Abbocath 20 Terumo @5
02/02/2021 00:00:00 11.138,00 BPJS
Alinamin F 50 mg @100 T 1.150,00
Ceftriaxone Inj 6.249,00
Dulcolax Sup 10 mg 27.800,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 0,00
Omeprazole Inj 12.499,00
Ondansetron Inj 0,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 9.538,00
Total 165.668,00
1.289 Slamet Budiyono SILAUT 182293 ATRACURIUM BESYLATE 2
02/02/2021 00:00:00 14.671,00 BPJS
Bisturi no. 10 3.836,00
Bisturi No. 15 3.836,00
Cefadroxil tab 500 mg @1 10.500,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Extention Tube 8.801,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Ketorolac inj 30 mg/1ml 1.345,00
NACL 0,9 % 500 ml 51.300,00
Norepinephrine Inj 30.938,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Propofol Lipuro 1% 75.900,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Spuit 50cc terumo Lbg P 29.400,00
Tranexamic Acid Inj (Asa 2.105,00
Total 705.097,00
1.290 Hadi Soleh Yoga Prata AGUNG JAYA 158494 Aqua Pro Injeksi
02/02/2021 00:00:00 7.150,00 BPJS
Ascorbid Acid 1000mg/5m 26.125,00

19/08/2021 12:42:30 Page 311 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.290 Hadi Soleh Yoga Prata AGUNG JAYA 158494 ATRACURIUM BESYLATE 2
02/02/2021 00:00:00 29.342,00 BPJS
Atropin injek 1 ml 13.938,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 14.563,00
Iodine Povidone 1 L 158.594,00
Kassa kotak stril DRC 96.750,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Neostigmine-hameln 0.5 m 51.450,00
Pehacain Injeksi 6.640,00
Phytomenadione 10 Mg/1 5.959,00
Ranitidin inj 3.580,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
silk 1 R scimitar 163.702,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Ceftriaxone Inj
03/02/2021 00:00:00 12.498,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Ceftriaxone Inj
04/02/2021 00:00:00 12.498,00
Dexametason 0,5 mg Ta 1.160,00
Dexametason Injeksi 6.256,00
Metrodinazole Infus 30.939,00
NonWoven Fixation 15x 6.694,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefadroxil tab 500 mg @1
05/02/2021 00:00:00 1.050,00
Methylprednisolone tab 4 3.945,00
Metrodinazole tab 500 m 4.050,00
Paracetamol tablet 500 m 4.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 916.075,00
1.291 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
02/02/2021 00:00:00 8.550,00 BPJS
Renogen 3000 UI 116.875,00
Total 125.425,00
1.292 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
02/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.293 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
02/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00

19/08/2021 12:42:30 Page 312 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.294 Amirudin TANJUNG HARAPAN 182310 Abbocath 20 Terumo @5
02/02/2021 00:00:00 11.138,00 BPJS
Bunascan Spinal 0.5 63.525,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Total 173.450,00
1.295 Gerak TALANG BUAI 139085 Ketorolac inj 30 mg/1ml
02/02/2021 00:00:00 4.035,00 BPJS
Rofiden Supp 12.031,00
Suprafenid Supositoria 10 28.050,00
Alinamin F Injeksi 10 ml
03/02/2021 00:00:00 18.000,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 28.614,00
Alinamin F Injeksi 10 ml
04/02/2021 00:00:00 18.000,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 28.614,00
Alinamin F 50 mg @100 T
05/02/2021 00:00:00 11.500,00
Meloxicam 7,5 mg 7.280,00
Omeprazol kapsul 20 mg 6.610,00
Total 322.812,00
1.296 Amirudin TANJUNG HARAPAN 182310 Aqua Pro Injeksi
02/02/2021 00:00:00 7.150,00 BPJS
Bisturi No. 23 3.836,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 8.550,00
Neostigmine-hameln 0.5 m 34.300,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
Ceftriaxone Inj
03/02/2021 00:00:00 12.498,00

19/08/2021 12:42:30 Page 313 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.296 Amirudin TANJUNG HARAPAN 182310 Ketorolac inj 30 mg/1ml
03/02/2021 00:00:00 4.035,00 BPJS
Metrodinazole Infus 30.939,00
Abbocath 18 (Gea)
04/02/2021 00:00:00 10.720,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 19.076,00
Total 638.177,00
1.297 Qanita Dinda Harumi PONDOK KOPI 182311 Antasida Syrup 60 ml
02/02/2021 00:00:00 2.736,00 BPJS
Domperidone Syrup 5mg 10.279,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 17.584,00
1.298 Lolita Hestutiana PONDOK KOPI 182312 Antasida Syrup 60 ml
02/02/2021 00:00:00 2.736,00 BPJS
Domperidone Syrup 5mg 10.279,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 17.584,00
1.299 Anisa Eka Mukosaputri AGUNG JAYA 138789 abbocath 18 Terumo @5
02/02/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Glukosa Infus 5 % 25.878,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
03/02/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ondansetron Inj 4.950,00
Cefadroxil tab 500 mg @1
04/02/2021 00:00:00 10.500,00
Ondansetron tablet 8 mg 13.200,00
Total 164.528,00
1.300 Farel Alvaro BUKIT MULYA 181965 Cefixime syrup 100mg/5 M
03/02/2021 00:00:00 23.823,00 BPJS
Total 23.823,00
1.301 Darsi PAUH TERENJA 132886 Asam Mefenamat 500 m
03/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 62.886,00
1.302 Rea Putriani TIRTA MULYA 167431 Asam Folat 1 mg @100 T
03/02/2021 00:00:00 2.970,00 BPJS
Valproic Acid Syrup 250mg 62.925,00
Vomil b6 90.750,00
Total 156.645,00
1.303 Sindi Septi Agelina KUMBUNG 182318 Calcium Laktat
03/02/2021 00:00:00 790,00 BPJS
Nulacta ibu hamil & meny 60.500,00
Total 61.290,00
1.304 Purnamasari SUNGAI GADING 182319 Cefadroxil tab 500 mg @1
03/02/2021 00:00:00 10.500,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Iodine povidone 300 ml 28.463,00
Kassa kotak stril DRC 9.675,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00

19/08/2021 12:42:30 Page 314 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 60.812,00
1.305 Upik Laini GAJAH MATI 179920 Ethambutol 500 mg
03/02/2021 00:00:00 38.745,00 BPJS
Isoniazide 300 mg 6.480,00
Pyrazinamid 500 mg 36.270,00
Rifampicin 450 33.840,00
Total 115.335,00
1.306 Fatmawati SELAGAN JAYA 180719 Alinamin F 50 mg @100 T
03/02/2021 00:00:00 11.500,00 BPJS
Flunarizine 5 mg tab 24.750,00
Levofloxacin Tablet 500 m 13.640,00
Total 49.890,00
1.307 Afriyanti SIBAK 182321 Asam Folat 1 mg @100 T
03/02/2021 00:00:00 990,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Total 3.950,00
1.308 Abu Karim TANJUNG ALAI 144502 Abbocath 20 Terumo @5
03/02/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 6.249,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Total 93.803,00
1.309 Siti Maesaroh KARANG JAYA 180496 Asam Mefenamat 500 m
03/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 69.430,00
1.310 Tarsono SINAR JAYA 115102 Acetylcystein 200 mg Ka
03/02/2021 00:00:00 34.380,00 BPJS
Cefixime kapsul 200 mg 26.480,00
Erphafillin Tab 7.380,00
Omeprazol kapsul 20 mg 6.610,00
Salbutamol 4 mg 1.860,00
Sucralfate Suspensi 100 m 19.250,00
Symbicort Turbuhaler 16 186.575,00
Total 282.535,00
1.311 Syamsul SILAUT 182197 Gitas Plus
03/02/2021 00:00:00 50.330,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
ursodeoxycholic acid 85.050,00
Total 149.020,00
1.312 Septiyani RAWA MULYA 136667 Asam Folat 1 mg @100 T
03/02/2021 00:00:00 2.970,00 BPJS
Flunarizine 5 mg tab 24.750,00
Total 27.720,00
1.313 Tumijo Taruno LUBUK SANAI 182324 Abbocath 20 Terumo @5
03/02/2021 00:00:00 11.138,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00

19/08/2021 12:42:30 Page 315 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.313 Tumijo Taruno LUBUK SANAI 182324 Transfusi Set Terumo
03/02/2021 00:00:00 16.500,00 BPJS
Urine bag 10.088,00
Total 120.406,00
1.314 Rosdiyanto UJUNG PADANG 181443 Propanolol tab 10 mg
03/02/2021 00:00:00 9.990,00 BPJS
Propylthiourasil 100 mg ( 58.770,00
Sucralfate Suspensi 100 m 19.250,00
Total 88.010,00
1.315 Tumijo Taruno LUBUK SANAI 182324 Ceftriaxone Inj
03/02/2021 00:00:00 12.498,00 BPJS
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
04/02/2021 00:00:00 12.498,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
05/02/2021 00:00:00 12.498,00
Dulcolax Sup 10 mg 27.800,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Aqua Pro Injeksi
06/02/2021 00:00:00 3.575,00
Cathejell 12.5g (Kateter J 52.000,00
Catheter 2 Way No. 16 ( 20.625,00
Ringer Laktat Otsuka 19.076,00
Urine bag 10.088,00
Urinter Kapsul @100 cap 21.980,00
Total 291.062,00
1.316 Abu Karim TANJUNG ALAI 144502 abbocath 18 Terumo @5
03/02/2021 00:00:00 22.276,00 BPJS
Abbocath 20 Terumo @5 22.276,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
04/02/2021 00:00:00 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide 40 mg Tablet 96,00
Ketorolac inj 30 mg/1ml 4.035,00
Metformin tablet 500 mg 399,00
Miniaspi 80 Mg @100 Ta 125,00
Ondansetron Inj 4.950,00
Renax @50 Kapsul 34.032,00
Retaphyl SR Tab 1.474,00
Ringer Laktat Otsuka 9.538,00
Urinter Kapsul @100 cap 4.396,00
Metformin tablet 500 mg
05/02/2021 00:00:00 2.660,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Total 322.364,00
1.317 Sumir Wati LUNANG 182005 Asam Mefenamat 500 m
03/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00

19/08/2021 12:42:30 Page 316 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.317 Sumir Wati LUNANG 182005 Metrodinazole tab 500 m
03/02/2021 00:00:00 4.050,00 BPJS
Total 16.485,00
1.318 Darwin SIDODADI 161429 Alinamin F 50 mg @100 T
03/02/2021 00:00:00 11.500,00 BPJS
Alprazolam 0,5 mg @100 590,00
Atorvastatin 20 mg @30 T 31.350,00
Bisoprolol 5 mg @100 Ta 4.440,00
Isosorbid dinitrat 5 mg (I 3.330,00
Total 51.210,00
1.319 Zaini Wati AIR PUNGGUR 136856 Alinamin F 50 mg @100 T
03/02/2021 00:00:00 11.500,00 BPJS
Alprazolam 0,5 mg @100 590,00
Amlodipine 5 mg @30 T 1.010,00
Bisoprolol 5 mg @100 Ta 1.480,00
Omeprazol kapsul 20 mg 6.610,00
Total 21.190,00
1.320 Yati TANJUNG MULYA 133159 Acetylcystein 200 mg Ka
03/02/2021 00:00:00 34.380,00 BPJS
Asam Traneksamat @10 42.100,00
Azitromycin 500 mg 28.125,00
Paracetamol tablet 500 m 3.000,00
Phytomenadione 10 mg ( 18.680,00
Ranitidine tablet 150 mg 2.160,00
Vitamin B Komplek @100 2.310,00
Total 130.755,00
1.321 Basori TANJUNG MULYA 180019 Abbocath 20 Terumo @5
03/02/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 297,00
Ascorbid Acid 1000mg/5m 78.375,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
04/02/2021 00:00:00 297,00
Ascorbid Acid 1000mg/5m 78.375,00
Azitromycin 500 mg 5.625,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Esomeprazol Injeksi 40 m 139.824,00
Furosemide Injeksi @2ml 4.998,00
Nassal Mask O2 Dewasa 41.828,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 12.630,00
Vitamin B Komplek @100 308,00
Total 553.965,00
1.322 Mutabiat WONOSOBO 152562 Alinamin F 50 mg @100 T
03/02/2021 00:00:00 11.500,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Azitromycin 500 mg 28.125,00
Total 44.163,00
1.323 Pongir Sidabutar TUNGGANG 182328 Methylprednisolone tab 4
03/02/2021 00:00:00 3.945,00 BPJS
Natrium diclofenac 50 m 2.890,00
Omeprazol kapsul 20 mg 6.610,00

19/08/2021 12:42:30 Page 317 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 13.445,00
1.324 Yanatun LUNANG 182150 Asam Mefenamat 500 m
03/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.325 Anidah KAMPUNG DALAM 182062 Amlodipine 5 mg @30 T
03/02/2021 00:00:00 1.010,00 BPJS
Domperidone Tab 1.620,00
Levofloxacin Tablet 500 m 13.640,00
Sistenol kaplet 17.540,00
ursodeoxycholic acid 28.350,00
Total 62.160,00
1.326 Fitriani SIDO MAKMUR 117639 Omeprazol kapsul 20 mg
03/02/2021 00:00:00 3.305,00 BPJS
Paracetamol tablet 500 m 3.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 25.555,00
1.327 Yon Zeni ARAH TIGA 156405 Asam Folat 1 mg @100 T
03/02/2021 00:00:00 990,00 BPJS
Glucosamine 250 mg 3.850,00
Nystatin Drop 27.830,00
Sistenol kaplet 17.540,00
Total 50.210,00
1.328 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.329 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.330 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.331 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.332 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.333 Bahman SIBAK 155872 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.334 Surono LUBUK SANAI 143077 Allopurinol 300 Mg @100
03/02/2021 00:00:00 14.730,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Isosorbid dinitrat 5 mg (I 3.330,00
Ketocid @100 Tab 584.820,00
Total 607.320,00
1.335 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.336 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.337 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00

19/08/2021 12:42:30 Page 318 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 159.625,00
1.338 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.339 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
03/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.340 Suhendro SUMBER MAKMUR 182039 Abbocath 20 Terumo @5
03/02/2021 00:00:00 11.138,00 BPJS
Asam Traneksamat @10 6.315,00
Combivent 18.768,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Nebulizer O2 Dewasa 34.783,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 17.877,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 9.538,00
Total 138.158,00
1.341 Dedi Irwansyah TALANG SEPAKAT 182317 Abbocath 20 Terumo @5
03/02/2021 00:00:00 22.276,00 BPJS
ATRACURIUM BESYLATE 2 14.671,00
Bisturi no. 10 3.836,00
Bisturi No. 15 3.836,00
Bisturi No. 15 7.672,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 1.535,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Polyvinylidene 4-0 C (Tri 92.006,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 16.990,00
Cefotaxime Injeksi
04/02/2021 00:00:00 11.502,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00

19/08/2021 12:42:30 Page 319 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.341 Dedi Irwansyah TALANG SEPAKAT 182317 Cefadroxil tab 500 mg @1
05/02/2021 00:00:00 10.500,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 3.000,00
Total 964.466,00
1.342 Pita Rani AIR RAMI 169377 Abbocath 20 Terumo @5
03/02/2021 00:00:00 11.138,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00

19/08/2021 12:42:30 Page 320 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.342 Pita Rani AIR RAMI 169377 Urine bag
03/02/2021 00:00:00 10.088,00 BPJS
viamac 1 R 364.370,00
Total 1.586.870,00
1.343 Basori TANJUNG MULYA 180019 Ascorbid Acid 1000mg/5m
04/02/2021 00:00:00 78.375,00 BPJS
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Asam Folat 1 mg @100 T
05/02/2021 00:00:00 297,00
Ascorbid Acid 1000mg/5m 78.375,00
Azitromycin 500 mg 5.625,00
Esomeprazol Injeksi 40 m 69.912,00
NACL 0,9 % 500 ml 34.200,00
Neurodex tablet 1.482,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
06/02/2021 00:00:00 297,00
Ascorbid Acid 1000mg/5m 78.375,00
Azitromycin 500 mg 5.625,00
Esomeprazol Injeksi 40 m 69.912,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 12.630,00
Asam Folat 1 mg @100 T
07/02/2021 00:00:00 297,00
Ascorbid Acid 1000mg/5m 78.375,00
Azitromycin 500 mg 5.625,00
Dipenhydramin Injeksi 10 1.535,00
Esomeprazol Injeksi 40 m 69.912,00
NACL 0,9 % 500 ml 25.650,00
Tranexamic Acid Inj (Asa 6.315,00
Vit K Infant Injeksi 24.750,00
Vitamin B Komplek @100 462,00
Total 730.503,00
1.344 Suhendro SUMBER MAKMUR 182039 Asam Folat 1 mg @100 T
03/02/2021 00:00:00 297,00 BPJS
Azitromycin 500 mg 5.625,00
Glukosa Infus 5 % 8.626,00
NACL 0,9 % 500 ml 17.100,00
Ranitidin inj 1.790,00
Aminofluid Infus 500 ml
04/02/2021 00:00:00 155.204,00
azitromicin inj 500 mg 144.376,00
Berotec 0,1 mg (Botol) 179.011,00
Cefixime kapsul 200 mg 26.480,00
Ceftriaxone Inj 12.498,00
Methylprednisolone Inje 69.846,00
Methylprednisolone Inje 34.923,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Stomach Tube) Fr. 1 52.250,00
Phytomenadione 10 Mg/1 5.959,00
Phytomenadione 10 Mg/1 17.877,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 6.315,00
Vectrein Syrup 45.000,00

19/08/2021 12:42:30 Page 321 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.344 Suhendro SUMBER MAKMUR 182039 Ventolin Nebules 2.5 mg
04/02/2021 00:00:00 20.000,00 BPJS
Ventolin Nebules 2.5 mg 5.000,00
vestein syr 48.125,00
Aminofluid Infus 500 ml
05/02/2021 00:00:00 155.204,00
azitromicin inj 500 mg 144.376,00
Methylprednisolone Inje 69.846,00
NACL 0,9 % 500 ml 8.550,00
Phytomenadione 10 Mg/1 17.877,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 6.315,00
Ventolin Nebules 2.5 mg 20.000,00
Aminofluid Infus 500 ml
06/02/2021 00:00:00 155.204,00
Azitromycin 500 mg 28.125,00
Methylprednisolone tab 4 526,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 17.877,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 6.315,00
Ventolin Nebules 2.5 mg 20.000,00
Aminofluid Infus 500 ml
07/02/2021 00:00:00 155.204,00
azitromicin inj 500 mg 288.752,00
Ceftriaxone Inj 12.498,00
Methylprednisolone tab 4 526,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Tranexamic Acid Inj (Asa 6.315,00
Ventolin Nebules 2.5 mg 20.000,00
Vit K Infant Injeksi 24.750,00
Acetylcystein 200 mg Ka
08/02/2021 00:00:00 34.380,00
Asam Traneksamat @10 42.100,00
Cefadroxil tab 500 mg @1 10.500,00
Cefixime kapsul 200 mg 52.960,00
Curcuma Tab 12.700,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 10 mg ( 18.680,00
Salbutamol 2 mg 1.580,00
Vitamin C tablet @100 Ta 2.760,00
Total 2.270.667,00
1.345 Nurmawati AGUNG JAYA 111208 abbocath 18 Terumo @5
03/02/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Misoprostol Tab 22.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Dexametason Injeksi
04/02/2021 00:00:00 6.256,00
Miloz Injeksi 5 mg 5.611,00

19/08/2021 12:42:30 Page 322 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.345 Nurmawati AGUNG JAYA 111208 Misoprostol Tab
04/02/2021 00:00:00 16.500,00 BPJS
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00
Suprafenid Supositoria 10 28.050,00
Total 266.491,00
1.346 Siti Ramuto TALANG PETAI 132872 abbocath 18 Terumo @5
03/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Bisturi No. 23
04/02/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cauter (Hand-controlled P
05/02/2021 00:00:00 324.322,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Handscoon steril 7,5 (Ga 43.689,00
handscoond steril 6.5 (G 58.216,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00

19/08/2021 12:42:30 Page 323 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.346 Siti Ramuto TALANG PETAI 132872 Massa Cauter Dewasa
05/02/2021 00:00:00 90.240,00 BPJS
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Suction no. 1/4 25.950,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Total 2.160.786,00
1.347 Pita Rani AIR RAMI 169377 Cefotaxime Injeksi
04/02/2021 00:00:00 17.253,00 BPJS
Chloramphenicol Salep M 2.351,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
05/02/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 364.370,00
Asam Mefenamat 500 m
06/02/2021 00:00:00 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 582.049,00
1.348 Nurmawati AGUNG JAYA 111208 Cefotaxime Injeksi
04/02/2021 00:00:00 11.502,00 BPJS
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Sterille 6.5 16.488,00
Iodine povidone 300 ml 28.463,00
Massa Cauter Dewasa 90.240,00
Misoprostol Tab 22.000,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Suction no. 1/4 25.950,00
Asam Mefenamat 500 m
05/02/2021 00:00:00 1.290,00
Cauter (Hand-controlled P 162.161,00
Cefadroxil tab 500 mg @1 10.500,00
Misoprostol Tab 55.000,00
Total 472.396,00
1.349 Siti Ramuto TALANG PETAI 132872 Cefoperazon Inj
06/02/2021 00:00:00 82.500,00 BPJS
Ketorolac inj 30 mg/1ml 6.725,00
Metrodinazole tab 500 m 810,00
Asam Mefenamat 500 m
07/02/2021 00:00:00 1.935,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.349 Siti Ramuto TALANG PETAI 132872 Cauter (Hand-controlled P
07/02/2021 00:00:00 324.322,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Celemek Plastik 17.986,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 6.5 (G 58.216,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Invitec tab (Misoprostol) 35.424,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Massa Cauter Dewasa 90.240,00
methyl ergometrin amp 8.662,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 2.700,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Postofix (leukomed) 36.726,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suction no. 1/4 25.950,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00

19/08/2021 12:42:30 Page 325 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 2.147.023,00
1.350 Aznila Wati KOTO JAYA 116640 Lansoprazole kapsul 30 m
04/02/2021 00:00:00 23.100,00 BPJS
Natrium diclofenac 50 m 8.670,00
Nuzym Kapsul 132.000,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 247.500,00
Total 479.676,00
1.351 Rizki Utami SIDO MULYO 182165 Asam Mefenamat 500 m
04/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.352 Solmidas AIR HAJI 182335 Calcium Laktat
04/02/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
1.353 Syofyan Dirin BANDARATU 126758 Atorvastatin 20 mg @30 T
04/02/2021 00:00:00 31.350,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Lansoprazole kapsul 30 m 23.100,00
Miniaspi 80 Mg @100 Ta 3.750,00
Natrium diclofenac 50 m 8.670,00
Paracetamol tablet 500 m 6.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 165.200,00
1.354 Sucipno PONDOK MAKMUR 149782 Ambroxol Syr 15mg/ml
04/02/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 56.250,00
Lansoprazole kapsul 30 m 23.100,00
Levofloxacin Tablet 500 m 13.640,00
Methylprednisolone tab 4 7.890,00
Neurodex tablet 22.230,00
Retaphyl SR Tab 29.480,00
Total 157.128,00
1.355 M.zen TANAH HARAPAN 129190 Candesartan tab 8 mg
04/02/2021 00:00:00 20.430,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Flunarizine 5 mg tab 74.250,00
Furosemide 40 mg Tablet 2.880,00
Lansoprazole kapsul 30 m 23.100,00
Meloxicam 7,5 mg 21.840,00
Miniaspi 80 Mg @100 Ta 3.750,00
Natrium diclofenac 50 m 8.670,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 284.570,00
1.356 Fitriani PASAR SEBELAH 113952 Gitas Plus
04/02/2021 00:00:00 50.330,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Renax @50 Kapsul 113.440,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 82.500,00
Urinter Kapsul @100 cap 21.980,00
Total 294.110,00
1.357 Ngadenin RAWA MULYA 146823 Allopurinol 300 Mg @100
04/02/2021 00:00:00 14.730,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.357 Ngadenin RAWA MULYA 146823 Ambroxol Syr 15mg/ml
04/02/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 56.250,00
Furosemide 40 mg Tablet 2.880,00
Lansoprazole kapsul 30 m 23.100,00
Meloxicam 7,5 mg 21.840,00
Methylprednisolone tab 4 7.890,00
Miniaspi 80 Mg @100 Ta 3.750,00
Natrium diclofenac 50 m 8.670,00
Neurodex tablet 22.230,00
Total 165.878,00
1.358 Suparmin SILAUT 142036 Atorvastatin 20 mg @30 T
04/02/2021 00:00:00 20.900,00 BPJS
Cetirgi Tab 10 mg 46.440,00
Clopidogrel 75 mg @30 T 52.650,00
Isosorbid dinitrat 5 mg (I 2.220,00
Lansoprazole kapsul 30 m 23.100,00
Miniaspi 80 Mg @100 Ta 3.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 168.310,00
1.359 Hermansyah AIR DIKIT 178318 Paracetamol tablet 500 m
04/02/2021 00:00:00 3.000,00 BPJS
Total 3.000,00
1.360 Solin RANAH KARYA 175604 Atorvastatin 20 mg @30 T
04/02/2021 00:00:00 31.350,00 BPJS
Furosemide 40 mg Tablet 2.880,00
Lansoprazole kapsul 30 m 23.100,00
Methylprednisolone tab 4 42.080,00
Spironolaktone 25 mg 7.800,00
Sucralfate Suspensi 100 m 19.250,00
Total 126.460,00
1.361 Putri Rahayu AIR BULUH 182325 Otopain Ear Drops 8 ml
04/02/2021 00:00:00 99.688,00 BPJS
Ottopan Drops 0,00
Paracetamol tablet 500 m 2.000,00
Total 101.688,00
1.362 Ali Akbar BANTAL 182337 Cefixime kapsul 200 mg
04/02/2021 00:00:00 26.480,00 BPJS
Finpro Finasteride 165.000,00
Lansoprazole kapsul 30 m 11.550,00
Natrium diclofenac 50 m 8.670,00
Renax @50 Kapsul 340.320,00
Scopamin Tab 38.500,00
Urinter Kapsul @100 cap 65.940,00
Total 656.460,00
1.363 Edi Anjari BANDARATU 182338 Ciprofloxacin tab 500 mg
04/02/2021 00:00:00 5.590,00 BPJS
Total 5.590,00
1.364 Anas TANAH REKAH ESTAT 140299 Furosemide 40 mg Tablet
04/02/2021 00:00:00 2.880,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Natrium diclofenac 50 m 8.670,00
Renax @50 Kapsul 340.320,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 65.940,00
Total 448.610,00
1.365 Suprihatin SILAUT 181069 Lansoprazole kapsul 30 m
04/02/2021 00:00:00 23.100,00 BPJS
Natrium diclofenac 50 m 8.670,00
Sucralfate Suspensi 100 m 19.250,00
Total 51.020,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.366 Linda Junita PADANG GADING 180757 Asam Mefenamat 500 m
04/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.367 Murni GAJAH MATI 182342 Ambroxol Syr 15mg/ml
04/02/2021 00:00:00 4.538,00 BPJS
Atorvastatin 20 mg @30 T 20.900,00
Azitromycin 500 mg 56.250,00
Neurodex tablet 22.230,00
Omeprazol kapsul 20 mg 13.220,00
Retaphyl SR Tab 29.480,00
Sucralfate Suspensi 100 m 19.250,00
Total 165.868,00
1.368 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
04/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.369 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
04/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.370 Narti SILAUT 175653 NACL 0,9 % 500 ml
04/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.371 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
04/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.372 Daniel Bonfrid Sianturi BUMI MULYA 182346 Avamys
04/02/2021 00:00:00 129.000,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Total 144.480,00
1.373 Yuli Lestari TIRTA MAKMUR 129234 Methylprednisolone tab 4
04/02/2021 00:00:00 2.630,00 BPJS
Total 2.630,00
1.374 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
04/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.375 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
04/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.376 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
04/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.377 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
04/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.378 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
04/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.379 Desi Komalasari SINAR JAYA 131508 Abbocath 20 Terumo @5
04/02/2021 00:00:00 22.276,00 BPJS
Aqua Pro Injeksi 3.575,00
Esomeprazol Injeksi 40 m 34.956,00
Infusion Makro (terumo) 27.225,00
Loremid Tab 8.628,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj
05/02/2021 00:00:00 12.498,00
Loremid Tab 8.628,00
Loremid Tab 14.380,00
Neurodex tablet 1.482,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 328 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.379 Desi Komalasari SINAR JAYA 131508 Paracetamol tablet 500 m
05/02/2021 00:00:00 600,00 BPJS
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 234.595,00
1.380 Ateng PASAR SEBELAH 182349 Catheter 2 Way No. 16 (
04/02/2021 00:00:00 20.625,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 0,00
Omeprazole Inj 12.499,00
Paracetamol Infus 0,00
Tramadol 50 mg/ml Inj 0,00
Urine bag 10.088,00
Urine bag 10.088,00
Ceftriaxone Inj
05/02/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazole Inj 24.998,00
Paracetamol Infus 43.314,00
Tramadol 50 mg/ml Inj 12.375,00
ATRACURIUM BESYLATE 2
06/02/2021 00:00:00 14.671,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Electroda (Ambu) @25 Pc 81.570,00
Ephedrine Injeksi 107.110,00
Extention Tube 8.801,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Furosemide Injeksi @2ml 1.666,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker Karet Boism 47.580,00
Metrodinazole Infus 30.939,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 83.656,00
NGT (Stomach Tube) Fr. 1 52.250,00
NonWoven Fixation 15x 6.694,00
Norepinephrine Inj 92.814,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Polyvinylidene 1-0 R (Tri 105.000,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.380 Ateng PASAR SEBELAH 182349 Polyvinylidene 3-0 R (Tri
06/02/2021 00:00:00 92.000,00 BPJS
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 0,00
Ringer Laktat Otsuka 38.152,00
silk 1 R scimitar 245.553,00
Silk 2/0 C scimitar 66.993,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Three Way stopcock 51.808,00
Three Way stopcock 25.904,00
Topi Operasi (Dokter) @5 16.990,00
Tramadol 50 mg/ml Inj 8.250,00
Tramadol 50 mg/ml Inj 4.125,00
Transfusi Set Terumo 33.000,00
Urine bag 10.088,00
viamac 1 R 182.185,00
Ceftriaxone Inj
07/02/2021 00:00:00 12.498,00
Metrodinazole Infus 30.939,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 57.228,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj
08/02/2021 00:00:00 6.249,00
Electroda (Ambu) @25 Pc 97.884,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 9.675,00
Metrodinazole Infus 0,00
N-ace Inj (N-Acetylcystei 41.250,00
NACL 0,9 % 500 ml 0,00
Nassal Cannula O2 Anak 16.473,00
Omeprazole Inj 12.499,00
Paracetamol Infus 28.876,00
Ranitidin inj 1.790,00
Tramadol 50 mg/ml Inj 8.250,00
Total 2.628.245,00
1.381 Misrawati GAJAH MATI 144093 Abbocath 20 Terumo @5
04/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Fluconazole tab 150 mg 24.571,00
Glimepiride tab 2 mg 259,00
Infusion Makro (terumo) 27.225,00
Metformin tablet 500 mg 133,00
Metoclopramide inj 5Mg/M 5.879,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 200,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
05/02/2021 00:00:00 12.498,00
Fluconazole tab 150 mg 24.571,00

19/08/2021 12:42:30 Page 330 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.381 Misrawati GAJAH MATI 144093 Glimepiride tab 2 mg
05/02/2021 00:00:00 259,00 BPJS
Metformin tablet 500 mg 399,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Piralen Injeksi 2 ml 26.400,00
Renax @50 Kapsul 22.688,00
ursodeoxycholic acid 5.670,00
Alprazolam 0,5 mg @100
06/02/2021 00:00:00 118,00
Fluconazole tab 150 mg 24.571,00
Glimepiride tab 2 mg 259,00
Ketorolac inj 30 mg/1ml 1.345,00
Levofloxacin Infus 24.488,00
Metformin tablet 500 mg 399,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 800,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Urdahek 10.130,00
Alprazolam 0,5 mg @100
07/02/2021 00:00:00 118,00
Alprazolam 0,5 mg @100 118,00
Fluconazole tab 150 mg 24.571,00
Glimepiride tab 2 mg 259,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 24.488,00
Metformin tablet 500 mg 133,00
Metformin tablet 500 mg 399,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 11.758,00
Omeprazole Inj 24.998,00
Omeprazole Inj 12.499,00
Orasic Kap 7.316,00
Pantoprazole Inj 46.750,00
Paracetamol tablet 500 m 800,00
Renax @50 Kapsul 34.032,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Tramadol tab 50 mg 1.179,00
ursodeoxycholic acid 8.505,00
ursodeoxycholic acid 5.670,00
Alprazolam 0,5 mg @100
08/02/2021 00:00:00 118,00
Fluconazole tab 150 mg 24.571,00
Glimepiride tab 2 mg 518,00
Levofloxacin Infus 24.488,00
Metformin tablet 500 mg 399,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 19.076,00
Tramadol tab 50 mg 1.179,00

19/08/2021 12:42:30 Page 331 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.381 Misrawati GAJAH MATI 144093 Abbocath 22 Terumo @5
09/02/2021 00:00:00 22.276,00 BPJS
Glimepiride tab 2 mg 518,00
Levofloxacin Infus 24.488,00
Metformin tablet 500 mg 133,00
Metformin tablet 500 mg 399,00
Omeprazole Inj 12.499,00
Omeprazole Inj 99.992,00
Paracetamol Infus 43.314,00
Piralen Injeksi 2 ml 88.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 12.375,00
Glimepiride tab 2 mg
10/02/2021 00:00:00 259,00
Levofloxacin Infus 24.488,00
Levofloxacin Tablet 500 m 13.640,00
Metformin tablet 500 mg 266,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Total 1.210.686,00
1.382 Riris Yoseva Manulang SUMBER SARI 115881 Abbocath 20 Terumo @5
04/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Esomeprazol Injeksi 40 m 34.956,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Cefotaxime Injeksi
05/02/2021 00:00:00 11.502,00
Esomeprazol Injeksi 40 m 34.956,00
Neurodex tablet 1.482,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Psidii Capsule 500 mg 14.703,00
Ringer Laktat Otsuka 9.538,00
Neurodex tablet
06/02/2021 00:00:00 11.115,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 3.000,00
Psidii Capsule 500 mg 73.515,00
Sucralfate Suspensi 100 m 19.250,00
Total 346.971,00
1.383 Ahmad Dewanta MEKAR MULYA 165909 Abbocath 20 Terumo @5
04/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.383 Ahmad Dewanta MEKAR MULYA 165909 Ringer Laktat Otsuka
04/02/2021 00:00:00 9.538,00 BPJS
Vitamin B Komplek @100 154,00
Total 57.774,00
1.384 Pariman SIDO MAKMUR 157764 Abbocath 20 Terumo @5
04/02/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 9.538,00
Allopurinol 300 Mg @100
05/02/2021 00:00:00 491,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Ketorolac inj 30 mg/1ml 4.035,00
Meloxicam 7,5 mg 728,00
Natrium diclofenac 50 m 578,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Allopurinol 300 Mg @100
06/02/2021 00:00:00 491,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac inj 30 mg/1ml 4.035,00
Meloxicam 7,5 mg 728,00
Natrium diclofenac 50 m 578,00
Natrium diclofenac 50 m 867,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Allopurinol 300 Mg @100
07/02/2021 00:00:00 491,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Meloxicam 7,5 mg 728,00
Natrium diclofenac 50 m 289,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Allopurinol 300 Mg @100
08/02/2021 00:00:00 2.455,00
Curcuma Tab 19.050,00
Meloxicam 7,5 mg 3.640,00

19/08/2021 12:42:30 Page 333 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.384 Pariman SIDO MAKMUR 157764 Natrium diclofenac 50 m
08/02/2021 00:00:00 2.890,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 24.998,00
Sucralfate Suspensi 100 m 19.250,00
Total 536.147,00
1.385 Ahmad Dewanta MEKAR MULYA 165909 Dexametason Injeksi
04/02/2021 00:00:00 3.128,00 BPJS
Dipenhydramin Injeksi 10 1.535,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
05/02/2021 00:00:00 198,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Total 36.056,00
1.386 Ny. Siti Ramuto TALANG PETAI 182350 Abbocath 24 Terumo @5
04/02/2021 00:00:00 44.552,00 BPJS
Bisturi No. 15 3.836,00
Injection plug 20.213,00
NGT (Feeding Tube) Fr. 8 70.420,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 15x 6.694,00
umbilical Cord Clamp 2.261,00
Total 218.396,00
1.387 Mat Sahin B Nawawi BANDARATU 109516 Asam Mefenamat 500 m
04/02/2021 00:00:00 1.290,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Lidocain injk 40 mg/2 ml 1.611,00
Methylprednisolone tab 4 2.630,00
NACL 0,9 % 500 ml 8.550,00
Tetagam 1 Ml Injeksi 184.000,00
Total 208.581,00
1.388 Taheera Ajwa Syarif PONDOK SUGUH 162602 Abbocath 22 Terumo @5
05/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 10.725,00
Asam Folat 1 mg @100 T 297,00
Asam Folat 1 mg @100 T 495,00
Ceftriaxone Inj 18.747,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Vitamin B Komplek @100 462,00
Vitamin B Komplek @100 2.310,00
Vitamin C 500 mg 3,00
Abbocath 22 Terumo @5
06/02/2021 00:00:00 33.414,00
Abbocath 24 Terumo @5 22.276,00
Three Way stopcock 10.626,00
Total 176.282,00
1.389 Mananti Hutasoit KOTA PRAJA 182354 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
1.390 Anwar Safi"i BUMI MEKAR JAYA 182355 Amoxicillin 500 mg @ 10
05/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Total 4.350,00
1.391 Tamni TANJUNG ALAI 182229 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.391 Tamni TANJUNG ALAI 182229 Cefadroxil tab 500 mg @1
05/02/2021 00:00:00 10.500,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.392 Widi Astuti BUMI MULYA 167059 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.393 Dzafira Febriya LUBUK PINANG 178406 Acetylcystein 200 mg Ka
05/02/2021 00:00:00 17.190,00 BPJS
Vitamin B Komplek @100 1.540,00
Total 18.730,00
1.394 Titik Sumanti PELOKAN 122011 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Total 16.485,00
1.395 Ida Laila POndok kandang 151024 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.396 Huriyati SUNGAI JERINJING 182358 Calcium Laktat
05/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.397 Leni Hamnizar KAMPUNG DALAM 127045 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
1.398 Sumiati PASAR BELAKANG 182359 Antasida Syrup 60 ml
05/02/2021 00:00:00 2.736,00 BPJS
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 34.245,00
1.399 Sumarni SILAUT 182103 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Total 12.435,00
1.400 Riono PT AGROAIR DIKIT 182228 Betahistin Mesilat 6 mg @
05/02/2021 00:00:00 2.070,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 5.070,00
1.401 Sukamad AIR KASAI 143420 Amlodipine 5 mg @30 T
05/02/2021 00:00:00 3.030,00 BPJS
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazol kapsul 20 mg 3.305,00
Piracetam tablet 1200 m 41.880,00
Thrombo Aspilets 29.220,00
Total 129.685,00
1.402 Sugini PONDOK MAKMUR 110687 Amlodipine 5 mg @30 T
05/02/2021 00:00:00 3.030,00 BPJS
Omeprazol kapsul 20 mg 19.830,00
Piracetam tablet 1200 m 41.880,00
Simvastatin tab 10 mg 7.230,00
Thrombo Aspilets 19.480,00
Total 91.450,00
1.403 Selvia Verolina MANDI ANGIN 140849 Calcium Laktat
05/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.404 Jailani SARIBULAN 182224 Cefadroxil tab 500 mg @1
05/02/2021 00:00:00 10.500,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.404 Jailani SARIBULAN 182224 Nephrolit Kapsul
05/02/2021 00:00:00 12.075,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 25.575,00
1.405 Maria Yosefa PASAR BELAKANG 141148 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.406 Gusri Noveliyanti PAUH TERENJA 133095 Betahistin Mesilat 6 mg @
05/02/2021 00:00:00 1.380,00 BPJS
Domperidone Tab 1.080,00
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 6.610,00
Total 33.820,00
1.407 Erma Wati AIR DIKIT 182251 Captopril 12,5 mg
05/02/2021 00:00:00 4.800,00 BPJS
Curcuma Tab 25.400,00
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 6.000,00
Total 43.890,00
1.408 Putri Khairunisa IPUH 182248 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.409 Musli Hadaya LUBUK GEDANG 182096 Abbocath 20 Terumo @5
05/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Ascorbid Acid 1000mg/5m 78.375,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Pantoprazole Inj 23.375,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 8.420,00
Total 206.277,00
1.410 Salami SILAUT I 134774 Amlodipine 5 mg @30 T
05/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Total 45.036,00
1.411 Titin Sumarni PONDOK BARU 119023 Amlodipine 5 mg @30 T
05/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Total 45.036,00
1.412 Raknaini PAUH TERENJA 127930 Omeprazol kapsul 20 mg
05/02/2021 00:00:00 6.610,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 8.610,00
1.413 Suparmi SILAUT 156450 Amlodipine 5 mg @30 T
05/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Total 45.036,00
1.414 Rini Astuti LUBUK SANAI 2 147140 Amlodipine 5 mg @30 T
05/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.414 Rini Astuti LUBUK SANAI 2 147140 Omeprazol kapsul 20 mg
05/02/2021 00:00:00 1.983,00 BPJS
Total 45.036,00
1.415 Misni TANJUNG BERINGIN 162425 Amlodipine 5 mg @30 T
05/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Total 45.036,00
1.416 Paryati WONOSOBO 182225 Asam Mefenamat 500 m
05/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 53.211,00
1.417 Syamil Hafizhan LUNANG 181870 Epinephrin inj
05/02/2021 00:00:00 45.993,00 BPJS
Total 45.993,00
1.418 Pipi Pirdausi AIR DIKIT 182362 abbocath 18 Terumo @5
05/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
ATRACURIUM BESYLATE 2 0,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Propofol Lipuro 1% 0,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 16.990,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Total 613.619,00
1.419 Laksmi Weizzman DANAU NIBUNG 160833 Abbocath 20 Terumo @5
05/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 28.125,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 42.750,00
Oseltamivir 75 mg 10,00
Paracetamol tablet 500 m 2.000,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.419 Laksmi Weizzman DANAU NIBUNG 160833 vestein 300 mg
05/02/2021 00:00:00 46.750,00 BPJS
Vitamin B Komplek @100 1.540,00
Vitamin C tablet @100 Ta 1.380,00
Zink Tablet 6.890,00
Total 176.233,00
1.420 Alona Meysha Azhara AIR DIKIT 182367 Domperidone Syrup 5mg
05/02/2021 00:00:00 10.279,00 BPJS
Ka-En 1 B 12.658,00
Omeprazole Inj 12.499,00
Oralit 1.029,00
Transfusi Set Terumo 16.500,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 57.534,00
1.421 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
05/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.422 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
05/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.423 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
05/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.424 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
05/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.425 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
05/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.426 Silya Wana BANDARATU 117469 NACL 0,9 % 500 ml
05/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.427 ainun li hendra LUBUK GEDANG 177937 Abbocath 24 Terumo @5
05/02/2021 00:00:00 11.138,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En 1 B 37.974,00
Ottopan Drops 18.906,00
Total 107.930,00
1.428 Ilmi Pustia Narsi KOTA PRAJA 119799 Betahistin Mesilat 6 mg @
06/02/2021 00:00:00 1.380,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Vitamin C tablet @100 Ta 1.380,00
Methylprednisolone tab 4
07/02/2021 00:00:00 2.630,00
Oseltamivir 75 mg 2,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Erdosteine Syr
15/02/2021 00:00:00 36.575,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 462,00
Zinc Sulfate Syr 60 ml 4.569,00
Ambroxol 30 mg @100 T
18/02/2021 00:00:00 1.930,00
CTM (Klorfeniramina mal 290,00
Sucralfate Suspensi 100 m 19.250,00
Triamcinolon tablet 4 mg 9.410,00
Total 155.640,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.429 Ahyena Ruzam Dani DANAU NIBUNG 161723 Azitromycin 500 mg
06/02/2021 00:00:00 56.250,00 BPJS
Betahistin Mesilat 6 mg @ 1.380,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Vitamin C tablet @100 Ta 1.380,00
Ambroxol Syr 15mg/ml
07/02/2021 00:00:00 4.538,00
Methylprednisolone tab 4 2.630,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 98.607,00
1.430 Riza Hariusnal Gandi BANDARATU 182368 Azitromycin 500 mg
06/02/2021 00:00:00 56.250,00 BPJS
Vitamin C tablet @100 Ta 1.380,00
Zinc Sulfate Syr 60 ml 4.569,00
azitromicin syr 200mg/5m
07/02/2021 00:00:00 30.776,00
Methylprednisolone tab 4 2.630,00
Omeprazol kapsul 20 mg 3.305,00
Oseltamivir 75 mg 2,00
NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 462,00
Zinc Sulfate Syr 60 ml 4.569,00
Omeprazol kapsul 20 mg
18/02/2021 00:00:00 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 181.705,00
1.431 Fauziah BANDAR RATU 099173 Azitromycin 500 mg
06/02/2021 00:00:00 56.250,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin C tablet @100 Ta 1.380,00
Ambroxol 30 mg @100 T
07/02/2021 00:00:00 1.930,00
Methylprednisolone tab 4 2.630,00
Omeprazol kapsul 20 mg 3.305,00
Oseltamivir 75 mg 2,00
Betahistin Mesilat 6 mg @
18/02/2021 00:00:00 1.380,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 127.166,00
1.432 Hesti BANDARATU 111989 Azitromycin 500 mg
06/02/2021 00:00:00 56.250,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Vitamin C tablet @100 Ta 1.380,00
Zinc Sulfate Syr 60 ml 4.569,00
Ambroxol Syr 15mg/ml
07/02/2021 00:00:00 4.538,00
CTM (Klorfeniramina mal 290,00
Methylprednisolone tab 4 2.630,00
Omeprazol kapsul 20 mg 3.305,00
NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.432 Hesti BANDARATU 111989 Omeprazol kapsul 20 mg
15/02/2021 00:00:00 1.983,00 BPJS
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 462,00
Zinc Sulfate Syr 60 ml 4.569,00
Omeprazol kapsul 20 mg
18/02/2021 00:00:00 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 164.365,00
1.433 Laksmi Weizzman DANAU NIBUNG 160833 Acetylcystein 200 mg Ka
10/02/2021 00:00:00 17.190,00 BPJS
Azitromycin 500 mg 28.125,00
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 2.000,00
Vitamin B Komplek @100 1.540,00
Erdosteine Syr
15/02/2021 00:00:00 36.575,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 462,00
Zinc Sulfate Syr 60 ml 4.569,00
Ambroxol 30 mg @100 T
18/02/2021 00:00:00 1.930,00
Betahistin Mesilat 6 mg @ 1.380,00
CTM (Klorfeniramina mal 290,00
Sucralfate Suspensi 100 m 19.250,00
Triamcinolon tablet 4 mg 9.410,00
Azitromycin 500 mg
22/02/2021 00:00:00 56.250,00
Cefixime Kapsul 100 mg 9.380,00
Methylprednisolone tab 4 2.630,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Vectrine Tab 300 mg 50.000,00
Vitamin C 500 mg 10,00
Paracetamol tablet 500 m
27/02/2021 00:00:00 2.000,00
vestein 300 mg 46.750,00
Vitamin C tablet @100 Ta 1.380,00
Total 396.531,00
1.434 Alona Meysha Azhara AIR DIKIT 182367 Ambroxol 30 mg @100 T
06/02/2021 00:00:00 965,00 BPJS
Ka-En 1 B 25.316,00
Omeprazole Inj 24.998,00
Ambroxol 30 mg @100 T
07/02/2021 00:00:00 1.930,00
Domperidone Syrup 5mg 10.279,00
Omeprazole Inj 24.998,00
Oralit 1.029,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 94.084,00
1.435 Musli Hadaya LUBUK GEDANG 182096 NACL 0,9 % 500 ml
05/02/2021 00:00:00 8.550,00 BPJS
Ascorbid Acid 1000mg/5m
06/02/2021 00:00:00 78.375,00
Ceftriaxone Inj 12.498,00
Fluconazole tab 150 mg 49.142,00
NACL 0,9 % 500 ml 25.650,00
Pantoprazole Inj 23.375,00
Phytomenadione 10 Mg/1 17.877,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.435 Musli Hadaya LUBUK GEDANG 182096 Tranexamic Acid Inj (Asa
06/02/2021 00:00:00 6.315,00 BPJS
Ascorbid Acid 1000mg/5m
07/02/2021 00:00:00 78.375,00
Ceftriaxone Inj 12.498,00
Fluconazole tab 150 mg 24.571,00
NACL 0,9 % 500 ml 25.650,00
Pantoprazole Inj 46.750,00
Tranexamic Acid Inj (Asa 6.315,00
Vit K Infant Injeksi 24.750,00
Ascorbid Acid 1000mg/5m
08/02/2021 00:00:00 78.375,00
Ceftriaxone Inj 12.498,00
Extrace Injeksi 100 mg/m 57.750,00
Fluconazole tab 150 mg 122.855,00
Loratadine tab 10 mg 830,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 37.497,00
Pantoprazole Inj 23.375,00
Phytomenadione 10 Mg/1 17.877,00
Phytomenadione 10 Mg/1 35.754,00
Tranexamic Acid Inj (Asa 6.315,00
Ascorbid Acid 1000mg/5m
09/02/2021 00:00:00 78.375,00
Azitromycin 500 mg 33.750,00
Ceftriaxone Inj 12.498,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
10/02/2021 00:00:00 387,00
Asam Mefenamat 500 m 1.290,00
Asam Traneksamat @10 42.100,00
Ascorbid Acid 1000mg/5m 78.375,00
Azitromycin 500 mg 5.625,00
Cefadroxil tab 500 mg @1 21.000,00
Ceftriaxone Inj 12.498,00
Erdosteine Syr 0,00
Loratadine tab 10 mg 166,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 124.990,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 17.877,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
vestein 300 mg 93.500,00
Total 1.508.930,00
1.436 ainun li hendra LUBUK GEDANG 177937 Ceftriaxone Inj
05/02/2021 00:00:00 6.249,00 BPJS
Ceftriaxone Inj
06/02/2021 00:00:00 6.249,00
Hypafix 15cmx5cm (25 c 6.544,00
Ka-En 1 B 12.658,00
Ka-En 1 B 12.658,00
NGT (Feeding tube) Fr. 5 17.603,00
NGT (Feeding Tube) Fr. 8 70.420,00
Abbocath 24 Terumo @5
07/02/2021 00:00:00 33.414,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.436 ainun li hendra LUBUK GEDANG 177937 Ceftriaxone Inj
07/02/2021 00:00:00 6.249,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00
Ka-En 1 B 12.658,00
Total 194.402,00
1.437 Pipi Pirdausi AIR DIKIT 182362 Cefadroxil tab 500 mg @1
06/02/2021 00:00:00 10.500,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 12.500,00
1.438 Rosdaniar DANAU NIBUNG 127790 azitromicin syr 200mg/5m
08/02/2021 00:00:00 30.776,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Paracetamol tablet 500 m 2.000,00
Zinc Sulfate Syr 60 ml 4.569,00
Erdosteine Syr
15/02/2021 00:00:00 36.575,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 462,00
Zinc Sulfate Syr 60 ml 4.569,00
Ambroxol 30 mg @100 T
18/02/2021 00:00:00 1.930,00
CTM (Klorfeniramina mal 290,00
Sucralfate Suspensi 100 m 19.250,00
Triamcinolon tablet 4 mg 9.410,00
Total 166.714,00
1.439 Debby Muthia Alinda M BANDAR RATU 182366 azitromicin syr 200mg/5m
08/02/2021 00:00:00 30.776,00 BPJS
azitromicin syr 200mg/5m 30.776,00
Betahistin Mesilat 6 mg @ 1.380,00
CTM (Klorfeniramina mal 290,00
Methylprednisolone tab 4 2.630,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin C tablet @100 Ta 1.380,00
Zinc Sulfate Syr 60 ml 4.569,00
Zinc Sulfate Syr 60 ml 4.569,00
Sucralfate Suspensi 100 m
09/02/2021 00:00:00 19.250,00
Triamcort 4 mg Tab 41.250,00
vestein syr 48.125,00
Cefixime Kapsul 100 mg
15/02/2021 00:00:00 9.380,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Triamcinolon tablet 4 mg 9.410,00
Total 270.145,00
1.440 Amrin PENARIK 182371 Abbocath 20 Terumo @5
06/02/2021 00:00:00 11.138,00 BPJS
Antasida Syrup 60 ml 2.736,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Antasida Syrup 60 ml 2.736,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.440 Amrin PENARIK 182371 Omeprazole Inj
06/02/2021 00:00:00 12.499,00 BPJS
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 28.614,00
Antasida Syrup 60 ml
07/02/2021 00:00:00 2.736,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Amlodipine 5 mg @30 T
08/02/2021 00:00:00 1.010,00
Antasida Syrup 60 ml 2.736,00
Cetirgi Tab 10 mg 15.480,00
Methylprednisolone tab 4 2.630,00
Vitamin B Komplek @100 1.540,00
Total 254.252,00
1.441 Solehati BANDAR RATU 182373 Abbocath 20 Terumo @5
06/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Tonotan tab 4.573,00
Abbocath 24 Terumo @5 33.414,00
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 216.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 14.554,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 46.405,00
Induxin 1 ml Injeksi 18.562,00
Infusion set Mikro (Terumo 18.026,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.441 Solehati BANDAR RATU 182373 Myotonic inj
06/02/2021 00:00:00 19.596,00 BPJS
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 15x 13.388,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Polypropylene 3/0 C (Ass 235.200,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suction Chateter no. 8 (R 20.625,00
Suprafenid Supositoria 10 28.050,00
Tonotan tab 9.146,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 4.522,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 2.221.552,00
1.442 Bahman SIBAK 155872 Ambroxol 30 mg @100 T
06/02/2021 00:00:00 1.930,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Total 50.230,00
1.443 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
06/02/2021 00:00:00 42.750,00 BPJS
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Total 48.300,00
1.444 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
06/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.445 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
06/02/2021 00:00:00 42.750,00 BPJS
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 48.300,00
1.446 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
06/02/2021 00:00:00 42.750,00 BPJS
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Total 48.300,00
1.447 Mutmainnah SUNGAI RENGAS 114676 Ambroxol Syr 15mg/ml
06/02/2021 00:00:00 4.538,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Total 52.838,00
1.448 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
06/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.449 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
06/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.450 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
06/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.451 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
06/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.452 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
06/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
1.453 Nursini LUNANG 182378 abbocath 18 Terumo @5
06/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00

19/08/2021 12:42:30 Page 345 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.453 Nursini LUNANG 182378 Polyvinylidene 3-0 R (Tri
06/02/2021 00:00:00 92.000,00 BPJS
Pospargin/Methergyn Inj 7.500,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Massa Cauter Dewasa 90.240,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 13.388,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
09/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 15.750,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.741.299,00
1.454 Ergin Altamis Desman RETAK MUDIK 182379 Ka-En 1 B
06/02/2021 00:00:00 12.658,00 BPJS
Nassal Mask O2 Bayi 44.900,00
NGT (Feeding tube) Fr. 5 17.603,00
Paracetamol Infus 14.438,00
Suction Chateter no. 8 (R 20.625,00
Total 110.224,00
1.455 Lendo SILAUT 174339 abbocath 18 Terumo @5
06/02/2021 00:00:00 11.138,00 BPJS
Citicoline Injeksi 125mg/ 11.250,00
Infusion Makro (terumo) 27.225,00
Levemir FlexPen 104.938,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Total 175.600,00
1.456 Ny Sholehati BANDAR RATU 182380 Abbocath 24 Terumo @5
06/02/2021 00:00:00 33.414,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Bisturi No. 15 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NGT (Feeding tube) Fr. 5 17.603,00
umbilical Cord Clamp 2.261,00

19/08/2021 12:42:30 Page 346 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.456 Ny Sholehati BANDAR RATU 182380 Abbocath 24 Terumo @5
08/02/2021 00:00:00 33.414,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Abbocath 24 Terumo @5
09/02/2021 00:00:00 33.414,00
Hypafix 15cmx5cm (25 c 6.544,00
Total 197.417,00
1.457 Lendo SILAUT 174339 Alprazolam 0,5 mg @100
07/02/2021 00:00:00 118,00 BPJS
Citicoline Injeksi 125mg/ 22.500,00
Curcuma Tab 3.810,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Citicoline Injeksi 125mg/
08/02/2021 00:00:00 22.500,00
Curcuma Tab 3.810,00
Mecobalamin 500 mg 1.540,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Citicoline kaplet 500 mg
09/02/2021 00:00:00 16.500,00
Curcuma Tab 3.810,00
Curcuma Tab 12.700,00
Mecobalamin 500 mg 2.310,00
Mecobalamin 500 mg 7.700,00
Omeprazole Inj 12.499,00
Total 190.945,00
1.458 Ergin Altamis Desman RETAK MUDIK 182379 Catheter 2 Way No. 16 (
06/02/2021 00:00:00 20.625,00 BPJS
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Electroda (Ambu) @25 Pc 81.570,00
Ka-En 1 B 12.658,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Bayi 89.800,00
Urine bag 10.088,00
Ceftriaxone Inj
07/02/2021 00:00:00 6.249,00
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Ka-En 1 B 12.658,00
Paracetamol Infus 28.876,00
Paracetamol Infus 14.438,00
Ceftriaxone Inj
08/02/2021 00:00:00 6.249,00
Dexametason Injeksi 3.128,00
Ka-En 1 B 25.316,00
Nassal Cannula O2 bayi 9.530,00
NGT (Feeding tube) Fr. 5 17.603,00
Bisolvon Injeksi 2 mg/ml
09/02/2021 00:00:00 57.900,00
Ceftriaxone Inj 6.249,00
Hypafix 15cmx5cm (25 c 6.544,00
Ka-En 1 B 12.658,00
Nebulizer O2 Anak 18.219,00
Ventolin Nebules 2.5 mg 10.000,00
Bisolvon Injeksi 2 mg/ml
10/02/2021 00:00:00 57.900,00
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 3.128,00

19/08/2021 12:42:30 Page 347 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.458 Ergin Altamis Desman RETAK MUDIK 182379 Hypafix 10cm x 5cm (25 c
10/02/2021 00:00:00 4.850,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Ka-En 1 B 12.658,00
NGT (Feeding tube) Fr. 5 17.603,00
NGT (Feeding Tube) Fr. 8 70.420,00
Pulmicort Resp 0.25 mg/ 0 53.652,00
Ventolin Nebules 2.5 mg 5.000,00
Aqua Pro Injeksi
11/02/2021 00:00:00 3.575,00
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 3.128,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Total 776.891,00
1.459 Ny Nursini LUNANG 182387 Abbocath 24 Terumo @5
07/02/2021 00:00:00 55.690,00 BPJS
Bisturi No. 15 7.672,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 4.850,00
umbilical Cord Clamp 4.522,00
Glukosa Infus 10 %
08/02/2021 00:00:00 9.375,00
Total 84.460,00
1.460 Ompila Wati DUSUN BARU PELOKA 163859 Abbocath 20 Terumo @5
07/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Citicoline Injeksi 125mg/ 11.250,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
KSR (potassium chloride) 6.909,00
KSR (potassium chloride) 6.909,00
Mecobalamin 500 mg 2.310,00
Meropenem Inj 0.5 g 55.000,00
NACL 0,9 % 500 ml 42.750,00
NonWoven Fixation 15x 6.694,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Alprazolam 0,5 mg @100
08/02/2021 00:00:00 236,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix 10cm x 5cm (25 c 9.700,00
KSR (potassium chloride) 6.909,00
Levemir FlexPen 104.938,00
Mecobalamin 500 mg 2.310,00
Mecobalamin 500 mg 2.310,00
Meropenem Inj 0.5 g 110.000,00
NACL 0,9 % 500 ml 25.650,00
Novo Twist 32 G Tip 5.208,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Urinter Kapsul @100 cap 4.396,00
KSR (potassium chloride)
09/02/2021 00:00:00 23.030,00
Mecobalamin 500 mg 7.700,00
Urinter Kapsul @100 cap 21.980,00
Total 684.228,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.461 Sumirah PONDOK BATU 141436 abbocath 18 Terumo @5
07/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Furamin Injeksi 14.369,00
Glukosa Infus 10 % 9.375,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Otsu D40 25.026,00
Levemir FlexPen
08/02/2021 00:00:00 104.938,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Furamin Injeksi
09/02/2021 00:00:00 14.369,00
Omeprazole Inj 12.499,00
Total 326.187,00
1.462 Marni Sofia PULAI PAYUNG 182392 abbocath 18 Terumo @5
07/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Bisturi No. 23
08/02/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.462 Marni Sofia PULAI PAYUNG 182392 Ondansetron Inj
08/02/2021 00:00:00 1.650,00 BPJS
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Asam Mefenamat 500 m
10/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 6.900,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix Kamar Operasi 18.000,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 4.050,00
Piralen Injeksi 2 ml 26.400,00
Postofix (leukomed) 36.726,00
viamac 1 R 546.555,00
Total 2.233.700,00
1.463 Zulkifli DUSUN BARU PELOKA 181910 Cefadroxil tab 500 mg @1
08/02/2021 00:00:00 10.500,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Symbicort Turbuhaler 80 167.855,00
Vitamin B Komplek @100 2.310,00
Total 208.525,00
1.464 Huriyati SUNGAI JERINJING 182358 Novo Twist 32 G Tip
08/02/2021 00:00:00 7.812,00 BPJS
Novorapid Flexpen 108.750,00
Total 116.562,00
1.465 Sintia Agustina AUR CINA 182396 Calcium Laktat
08/02/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
1.466 Zahira Alesha TALANG BARU 166906 Cotrimoxazol 240 mg Sir
08/02/2021 00:00:00 2.565,00 BPJS
Domperidone Tab 540,00
Zink Tablet 6.890,00
Total 9.995,00
1.467 Anjeli Purnama Sari SIBAK 182398 Cetirgi Tab 10 mg
08/02/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 18.110,00
1.468 Rosna SUNGAI GADING 182153 Calcium Laktat
08/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.469 Nayla Deswita Ningru SIDODADI 151596 Asam Folat 1 mg @100 T
08/02/2021 00:00:00 1.485,00 BPJS
Valproic Acid Syrup 250mg 20.975,00
Vitamin B Komplek @100 2.310,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 24.770,00
1.470 Fitri Yani LUBUK SANAI 181861 Propanolol tab 10 mg
08/02/2021 00:00:00 6.660,00 BPJS
Propylthiourasil 100 mg ( 58.770,00
Total 65.430,00
1.471 Juminem KOTA PRAJA 152875 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 3.030,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Betahistin Mesilat 6 mg @ 2.760,00
Citicoline kaplet 500 mg 33.000,00
Ranitidine tablet 150 mg 4.320,00
Total 47.250,00
1.472 Yeli Zarni SEI JERINJING 125945 Renax @50 Kapsul
08/02/2021 00:00:00 113.440,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 135.420,00
1.473 Sri Utami MEKAR MULYA 122405 Aspilet 80 mg @100 mg
08/02/2021 00:00:00 4.140,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Lansoprazole kapsul 30 m 34.650,00
Paracetamol tablet 500 m 6.000,00
Total 49.230,00
1.474 Meri Sutriani BANDAR RATU 182402 Renax @50 Kapsul
08/02/2021 00:00:00 113.440,00 BPJS
Suprafenid Supositoria 10 42.075,00
Urinter Kapsul @100 cap 21.980,00
Total 177.495,00
1.475 Purnamasari SUNGAI GADING 182319 Cefixime kapsul 200 mg
08/02/2021 00:00:00 26.480,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Total 41.960,00
1.476 Misrini PONDOK BARU 182404 Calcium Laktat
08/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.477 Amran LUBUK PINANG 113671 Alprazolam 0,5 mg @100
08/02/2021 00:00:00 1.180,00 BPJS
Candesartan tab 8 mg 20.430,00
Ketokonazole krim 2 % 3.148,00
Ranitidine tablet 150 mg 4.320,00
Total 29.078,00
1.478 Rohana PASAR BANTAL 142325 Glimepiride tab 2 mg
08/02/2021 00:00:00 7.770,00 BPJS
Hexymer 2 Mg Tab (THP) 28.680,00
Leparson tablet 164.400,00
Metformin tablet 500 mg 7.980,00
Sifrol tab 0,375 mg 311.250,00
Total 520.080,00
1.479 Tazia Ayu Maningsih PAUH TERENJA 153435 Asam Folat 1 mg @100 T
08/02/2021 00:00:00 2.970,00 BPJS
Phenobarbital Tablet 30 m 16.200,00
Valproic Acid Syrup 250mg 20.975,00
Vit B6 10 mg 4.830,00
Total 44.975,00
1.480 Irama TERAS TERUNJAM 182254 Asam Mefenamat 500 m
08/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 67.736,00
1.481 Bina Sutra SUNGAI IPUH I 157275 Glimepiride tab 2 mg
08/02/2021 00:00:00 7.770,00 BPJS
Mecobalamin 500 mg 23.100,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.481 Bina Sutra SUNGAI IPUH I 157275 Metformin tablet 500 mg
08/02/2021 00:00:00 7.980,00 BPJS
Total 38.850,00
1.482 Erniati PENARIK 141742 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Mecobalamin 500 mg 23.100,00
Metformin tablet 500 mg 7.980,00
Piracetam tab 800 mg 22.590,00
Ranitidine tablet 150 mg 4.320,00
Total 81.450,00
1.483 Ona Sutri TALANG KUNING 168921 Alprazolam 0,5 mg @100
08/02/2021 00:00:00 1.180,00 BPJS
Flunarizine 5 mg tab 24.750,00
Paracetamol tablet 500 m 2.000,00
Total 27.930,00
1.484 Aminah BUNGA TANJUNG 164428 Ibuprofen tab 400 mg
08/02/2021 00:00:00 4.580,00 BPJS
Pronalges Suppo 100 mg 777,00
Renax @50 Kapsul 113.440,00
Urinter Kapsul @100 cap 21.980,00
Total 140.777,00
1.485 Anuar TERAS TERUNJAM 178456 Alprazolam 0,5 mg @100
08/02/2021 00:00:00 1.180,00 BPJS
Ibuprofen tab 400 mg 4.580,00
Neurodex tablet 7.410,00
Total 13.170,00
1.486 Sukaeni TANJUNG MULYA 127131 Glimepiride tab 2 mg
08/02/2021 00:00:00 7.770,00 BPJS
Mecobalamin 500 mg 15.400,00
Meloxicam 7,5 mg 7.280,00
Metformin tablet 500 mg 7.980,00
Ranitidine tablet 150 mg 4.320,00
Total 42.750,00
1.487 Nazarudin PONDOK SUGUH 152888 Aspilet 80 mg @100 mg
08/02/2021 00:00:00 4.140,00 BPJS
Ranitidine tablet 150 mg 4.320,00
Total 8.460,00
1.488 Rahmat PT. AGRO AIR BULUH E 146991 Aspilet 80 mg @100 mg
08/02/2021 00:00:00 4.140,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Captopril 12,5 mg 2.400,00
Ibuprofen tab 400 mg 4.580,00
Ranitidine tablet 150 mg 4.320,00
Total 19.880,00
1.489 Riyas Tuti AIR PUTIH 182409 Calcium Laktat
08/02/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
1.490 Aalissia Sivianti PONDOK MAKMUR 150316 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 1.010,00 BPJS
Flunarizine 5 mg tab 24.750,00
Paracetamol tablet 500 m 2.000,00
Total 27.760,00
1.491 Erma Wati KOTO JAYA 157023 Acetylcystein 200 mg Ka
08/02/2021 00:00:00 34.380,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 72.740,00
1.492 Desturiani SILAUT 163612 Aminophyline 200 mg @1
08/02/2021 00:00:00 4.000,00 BPJS
Methylprednisolone tab 4 2.630,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.492 Desturiani SILAUT 163612 Salbutamol 2 mg
08/02/2021 00:00:00 1.580,00 BPJS
Symbicort Turbuhaler 16 186.575,00
vestein 300 mg 93.500,00
Total 288.285,00
1.493 Mira BUNGA TANJUNG 128468 Calcium Laktat
08/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.494 Irwansyah SIBAK 153409 Cetirgi Tab 10 mg
08/02/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 18.110,00
1.495 Demi TIRTA MAKMUR 182262 Cefixime kapsul 200 mg
08/02/2021 00:00:00 26.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Metrodinazole tab 500 m 4.050,00
Paracetamol tablet 500 m 3.000,00
Postofix (leukomed) 36.726,00
Total 72.886,00
1.496 Saidi BUKIT MAKMUR 181741 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 3.030,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Candesartan tab 8 mg 20.430,00
Citicoline kaplet 500 mg 49.500,00
Ranitidine tablet 150 mg 4.320,00
Total 81.420,00
1.497 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
08/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.498 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
08/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.499 Amri Kusna Yanti BUMI MULYA 133486 Dexametason Injeksi
08/02/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Transfusi Set Terumo 16.500,00
Total 176.901,00
1.500 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
08/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.501 Dewa LUBUK BANGKO 182416 Paracetamol tablet 500 m
08/02/2021 00:00:00 2.000,00 BPJS
Total 2.000,00
1.502 Narti SILAUT 175653 NACL 0,9 % 500 ml
08/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.503 Rabiadi BANDARATU 180768 Mecobalamin 500 mg
08/02/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 7.280,00
Ranitidine tablet 150 mg 1.440,00
Total 16.420,00
1.504 Ahmad Mujiono MARGA MULYA SAKTI 113737 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 303,00 BPJS
Cetirizine 10 mg 378,00
Gabapentin kapsul 300 m 3.807,00
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Otsu Nacl PiggyBack 100 m 37.950,00
Paracetamol tablet 500 m 600,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.504 Ahmad Mujiono MARGA MULYA SAKTI 113737 Renogen 3000 UI
08/02/2021 00:00:00 116.875,00 BPJS
Total 207.613,00
1.505 Alissia Silvianti PONDOK MAKMUR 150281 abbocath 18 Terumo @5
08/02/2021 00:00:00 11.138,00 BPJS
Antasida Syrup 60 ml 2.736,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lansoprazole kapsul 30 m 1.155,00
Metoclopramide inj 5Mg/M 5.879,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Total 83.544,00
1.506 M Akil PASAR BELAKANG 115376 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 3.300,00
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Total 201.178,00
1.507 Supangat PONDOK LUNANG 147511 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Total 202.828,00
1.508 Ashari Liwandi PONDOK LUNANG 139398 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 303,00 BPJS
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 3.300,00
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Simvastatin tab 10 mg 723,00
Total 202.588,00
1.509 Wardoyo TANJUNG MULYA 125079 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Nassal Cannula O2 Anak 16.473,00
Ondansetron Inj 3.300,00
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Total 217.651,00
1.510 Dahyun Sunami GAJAH MATI 182417 Abbocath 20 Terumo @5
08/02/2021 00:00:00 11.138,00 BPJS
Ciprofloxacin infus 2% 26.328,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 12.375,00
Total 91.454,00
1.511 Alga Farunia Danesti KOTO JAYA 142755 Ceftriaxone Inj
08/02/2021 00:00:00 12.498,00 BPJS
Ibuprofen tab 400 mg 1.374,00
Omeprazol kapsul 20 mg 661,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 200,00
Ranitidin inj 3.580,00

19/08/2021 12:42:30 Page 354 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.511 Alga Farunia Danesti KOTO JAYA 142755 Sucralfate Suspensi 100 m
08/02/2021 00:00:00 19.250,00 BPJS
Total 50.062,00
1.512 Miswanto LUNANG 128267 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Otsu Nacl PiggyBack 100 m 37.950,00
Renogen 3000 UI 116.875,00
Total 202.828,00
1.513 Dahyun Sunami GAJAH MATI 182417 Ciprofloxacin infus 2%
08/02/2021 00:00:00 26.328,00 BPJS
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Kassa kotak stril DRC
10/02/2021 00:00:00 9.675,00
Levofloxacin Infus 48.976,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Ciprofloxacin infus 2%
14/02/2021 00:00:00 26.328,00
Ciprofloxacin infus 2% 13.164,00
Ciprofloxacin infus 2% 13.164,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kamadol Injeksi 17.100,00
Kassa kotak stril DRC 19.350,00
Kassa kotak stril DRC 19.350,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Tramadol 50 mg/ml Inj 12.375,00
Abbocath 22 Terumo @5
15/02/2021 00:00:00 22.276,00
Ciprofloxacin infus 2% 26.328,00
Paracetamol Infus 43.314,00
Abbocath 22 Terumo @5
16/02/2021 00:00:00 11.138,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Celemek Plastik 11.825,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Ephedrine Injeksi 137.500,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Infus 48.976,00
Masker 3 Play N. 95 235.080,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 34.200,00
NACL 0,9 % 500 ml 8.550,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.513 Dahyun Sunami GAJAH MATI 182417 Omeprazole Inj
16/02/2021 00:00:00 12.499,00 BPJS
Paracetamol Infus 43.314,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 61.688,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Spuit 50 cc Lbg tengah ( 4.888,00
Suction Chateter no. 12 ( 10.588,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Hypafix 10cm x 5cm (25 c
17/02/2021 00:00:00 14.550,00
Levofloxacin Infus 48.976,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Aqua Pro Injeksi
18/02/2021 00:00:00 3.575,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 19.350,00
Levofloxacin Infus 48.976,00
NonWoven Fixation 15x 6.694,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Hypafix 10cm x 5cm (25 c
19/02/2021 00:00:00 9.700,00
Kassa kotak stril DRC 19.350,00
Levofloxacin Infus 48.976,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00
Levofloxacin Infus
20/02/2021 00:00:00 48.976,00
Paracetamol Infus 28.876,00
Kassa kotak stril DRC
21/02/2021 00:00:00 38.700,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 19.076,00
Cefixime Kapsul 100 mg
22/02/2021 00:00:00 9.380,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Paracetamol tablet 500 m 3.000,00
Total 2.539.702,00
1.514 Jumiatul Khairi TALANG BARU 182408 Bisturi No. 23
08/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 89.930,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.514 Jumiatul Khairi TALANG BARU 182408 handscoond steril 8 (Gam
08/02/2021 00:00:00 29.108,00 BPJS
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 22.000,00
methyl ergometrin amp 4.331,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Prolene no. 3/0 cutting 129.000,00
Ringer Laktat Otsuka 28.614,00
Safil 1 R 299.400,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 8.495,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Bisturi No. 23
09/02/2021 00:00:00 3.836,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Chloramphenicol Salep M 2.351,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Nassal Cannula O2 Anak 16.473,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Feeding Tube) Fr. 8 70.420,00
NGT (Feeding Tube) Fr. 8 11.043,00
NGT (Feeding Tube) Fr. 8 11.043,00
Phytomenadione 2 Mg/1M 9.668,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 0,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
10/02/2021 00:00:00 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 546.555,00
Asam Mefenamat 500 m
11/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.514 Jumiatul Khairi TALANG BARU 182408 Kassa kotak stril DRC
11/02/2021 00:00:00 9.675,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 2.235.964,00
1.515 Alga Farunia Danesti KOTO JAYA 142755 Cefadroxil tab 500 mg @1
09/02/2021 00:00:00 10.500,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 17.110,00
1.516 Alissia Silvianti PONDOK MAKMUR 150281 Ceftriaxone Inj
08/02/2021 00:00:00 12.498,00 BPJS
Metoclopramide inj 5Mg/M 11.758,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 308,00
Antasida Syrup 60 ml
09/02/2021 00:00:00 2.736,00
Asam Traneksamat @10 21.050,00
Cefadroxil tab 500 mg @1 10.500,00
Ceftriaxone Inj 18.747,00
NACL 0,9 % 500 ml 17.100,00
Neurodex tablet 1.482,00
Omeprazol kapsul 20 mg 6.610,00
Phytomenadione 10 Mg/1 17.877,00
Piralen Injeksi 2 ml 26.400,00
Tranexamic Acid Inj (Asa 6.315,00
Total 190.719,00
1.517 Mukmin AIR DIKIT 178821 Amlodipine 5 mg @30 T
08/02/2021 00:00:00 101,00 BPJS
Furosemide Injeksi @2ml 1.666,00
Metformin tablet 500 mg 266,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Spironolaktone 25 mg 260,00
Amlodipine 5 mg @30 T
09/02/2021 00:00:00 1.010,00
Furosemide 40 mg Tablet 960,00
Metformin tablet 500 mg 1.330,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Piralen Injeksi 2 ml 26.400,00
Spironolaktone 25 mg 2.600,00
Ventolin Nebules 2.5 mg 15.000,00
Amlodipine 5 mg @30 T
10/02/2021 00:00:00 290,00
Amlodipine 5 mg @30 T 101,00
Furosemide 40 mg Tablet 96,00
Metformin tablet 500 mg 399,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 1.200,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 28.614,00
Spironolaktone 25 mg 260,00
Vectrein Syrup 45.000,00
Abbocath 22 Terumo @5
11/02/2021 00:00:00 22.276,00
Amlodipine 5 mg @30 T 202,00
Aqua Pro Injeksi 7.150,00
Azitromycin 500 mg 16.875,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.517 Mukmin AIR DIKIT 178821 Furosemide 40 mg Tablet
11/02/2021 00:00:00 96,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 15cmx5cm (25 c 19.632,00
Infusion Makro (terumo) 27.225,00
Metformin tablet 500 mg 399,00
Omeprazole Inj 12.499,00
Piralen Injeksi 2 ml 26.400,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ringer Laktat Otsuka 19.076,00
Spironolaktone 25 mg 260,00
Ventolin Nebules 2.5 mg 15.000,00
Amlodipine 5 mg @30 T
12/02/2021 00:00:00 1.010,00
Furosemide 40 mg Tablet 960,00
Metformin tablet 500 mg 1.330,00
Metoclopramide inj 5Mg/M 35.274,00
Omeprazol kapsul 20 mg 6.610,00
Piralen tab 4.540,00
Pulmicort Resp 0.25 mg/ 0 17.884,00
Spironolaktone 25 mg 2.600,00
Vectrein Syrup 45.000,00
Total 576.681,00
1.518 Bekti PAUH TERENJA 166637 abbocath 18 Terumo @5
08/02/2021 00:00:00 11.138,00 BPJS
Antasida Syrup 60 ml 2.736,00
Aqua Pro Injeksi 3.575,00
NonWoven Fixation 15x 6.694,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Antasida Syrup 60 ml
09/02/2021 00:00:00 2.736,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 9.700,00
Metoclopramide inj 5Mg/M 5.879,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 24.998,00
Pantoprazole Inj 46.750,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 600,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Dexametason Injeksi
10/02/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Paracetamol tablet 500 m 600,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 19.076,00
Antasida Syrup 60 ml
11/02/2021 00:00:00 2.736,00
Hypafix 15cmx5cm (25 c 6.544,00
Lansoprazole kapsul 30 m 11.550,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.518 Bekti PAUH TERENJA 166637 Paracetamol tablet 500 m
11/02/2021 00:00:00 2.000,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 419.978,00
1.519 Drameika Ucy SUNGAI GADING 175926 Asam Mefenamat 500 m
09/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Hypafix 15cmx5cm (25 c 13.088,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 600,00
Total 43.433,00
1.520 Suparmi SILAUT 156450 abbocath 18 Terumo @5
09/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 297,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Novo Twist 32 G Tip 2.604,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Total 165.295,00
1.521 Rahmat MARGA MULIA 145112 Neurodex tablet
09/02/2021 00:00:00 22.230,00 BPJS
Total 22.230,00
1.522 Lucky Aprianto LUBUK SANAI 141842 Alprazolam 0,5 mg @100
09/02/2021 00:00:00 590,00 BPJS
Bisoprolol 5 mg @100 Ta 1.480,00
Paracetamol tablet 500 m 2.000,00
Ramipril tab 5 mg 3.060,00
Simvastatin tab 10 mg 2.410,00
Thrombo Aspilets 9.740,00
Total 19.280,00
1.523 Setia Wati LUNANG 182424 CAL-95 tab
09/02/2021 00:00:00 62.700,00 BPJS
Calcium Laktat 790,00
Emibion kapsul 19.660,00
Total 83.150,00
1.524 Siti Maesaroh KARANG JAYA 180496 Antasida Syrup 60 ml
09/02/2021 00:00:00 2.736,00 BPJS
Asam Mefenamat 500 m 1.290,00
Total 4.026,00
1.525 Mely Br Rajagukguk ARGA JAYA 182295 Domperidone Tab
09/02/2021 00:00:00 540,00 BPJS
Gitas Plus 50.330,00
Levofloxacin Tablet 500 m 13.640,00
ursodeoxycholic acid 56.700,00
Total 121.210,00
1.526 Fayra Shaqueena Azza UJUNG PADANG 170610 Amoxicillin Syr
09/02/2021 00:00:00 6.531,00 BPJS
Paracetamol syrup 1.388,00
Total 7.919,00
1.527 Kasmi Juwita UJUNG PADANG 176839 Amlodipine 10 mg @50 T
09/02/2021 00:00:00 3.540,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Citicoline kaplet 500 mg 49.500,00
Vitamin B Komplek @100 4.620,00
Total 89.010,00
1.528 Rabaiti AUR CINA 150014 Glimepiride tab 2 mg
09/02/2021 00:00:00 7.770,00 BPJS
Loratadine tab 10 mg 1.660,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.528 Rabaiti AUR CINA 150014 Mecobalamin 500 mg
09/02/2021 00:00:00 23.100,00 BPJS
Metformin tablet 500 mg 11.970,00
Pregabalin Kap 75 mg 193.380,00
Total 237.880,00
1.529 Ifel Yoanda RANAH KARYA 182405 abbocath 18 Terumo @5
09/02/2021 00:00:00 22.276,00 BPJS
Aqua Pro Injeksi 7.150,00
ATRACURIUM BESYLATE 2 14.671,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Ceftriaxone Inj 12.498,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 13.388,00
Polyvinylidene 3-0 R (Tri 92.000,00
Propofol Lipuro 1% 75.900,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 16.990,00
Transfusi Set Terumo 16.500,00
Total 633.418,00
1.530 Lestari TANJUNG BERINGIN 149820 Glimepiride tab 2 mg
09/02/2021 00:00:00 7.770,00 BPJS
Metformin tablet 500 mg 11.970,00
Omeprazol kapsul 20 mg 6.610,00
Perifas @100 Tab 19.250,00
Total 45.600,00
1.531 Sani TERUNTUNG 127436 Asam Mefenamat 500 m
09/02/2021 00:00:00 1.935,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Urine bag 10.088,00
Total 83.924,00
1.532 Madi SARI BULAN 182306 Alinamin F 50 mg @100 T
09/02/2021 00:00:00 11.500,00 BPJS
Gitas Plus 25.165,00
Levofloxacin Tablet 500 m 13.640,00
ursodeoxycholic acid 56.700,00
Total 107.005,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.533 Ernawati SUNGAI GADING 154099 Cefadroxil tab 500 mg @1
09/02/2021 00:00:00 10.500,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 12.500,00
1.534 Bukhari PENARIK 182428 Ketoprofen tab 100 mg
09/02/2021 00:00:00 24.760,00 BPJS
Neurodex tablet 14.820,00
Paracetamol tablet 500 m 4.000,00
Tensocrepe 10 x 4.5 cm ( 57.625,00
Total 101.205,00
1.535 Tuti Susanti GAJAH MATI 174311 Propanolol tab 10 mg
09/02/2021 00:00:00 3.330,00 BPJS
Propylthiourasil 100 mg ( 39.180,00
Total 42.510,00
1.536 Samudi DANAU NIBUNG 143871 Bisoprolol 5 mg @100 Ta
09/02/2021 00:00:00 4.440,00 BPJS
Codein tab 10 mg 7.500,00
Furosemide 40 mg Tablet 2.880,00
Isosorbid dinitrat 5 mg (I 3.330,00
Spironolaktone 25 mg 7.800,00
Sucralfate Suspensi 100 m 19.250,00
Total 45.200,00
1.537 Zaini Wati AIR PUNGGUR 136856 Alprazolam 0,5 mg @100
09/02/2021 00:00:00 590,00 BPJS
Amlodipine 5 mg @30 T 1.515,00
Bisoprolol 5 mg @100 Ta 4.440,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 27.795,00
1.538 Yunita SUNGAI IPUH 125315 CAL-95 tab
09/02/2021 00:00:00 62.700,00 BPJS
Calcium Laktat 790,00
Emibion kapsul 19.660,00
Total 83.150,00
1.539 Wahiri TALANG SEPAKAT 181795 Glucosamine 250 mg
09/02/2021 00:00:00 7.700,00 BPJS
Meloxicam 15 mg 12.600,00
Pregabalin Kap 75 mg 193.380,00
Total 213.680,00
1.540 Suparmi SILAUT 156450 Allopurinol 100 mg @100
09/02/2021 00:00:00 234,00 BPJS
Asam Folat 1 mg @100 T 297,00
Ferro Sulfate 800,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Amlodipine 10 mg @50 T
10/02/2021 00:00:00 354,00
Amlodipine 10 mg @50 T 236,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Dexametason Injeksi 3.128,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Metoclopramide inj 5Mg/M 11.758,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 42.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 362 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.540 Suparmi SILAUT 156450 Asam Folat 1 mg @100 T
11/02/2021 00:00:00 2.970,00 BPJS
Ferro Sulfate 8.000,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazole Inj 12.499,00
Piralen tab 4.540,00
Total 222.484,00
1.541 Megawati SIDODADI 182013 Candesartan tab 8 mg
09/02/2021 00:00:00 20.430,00 BPJS
Isosorbid dinitrat 5 mg (I 3.330,00
Metformin tablet 500 mg 3.990,00
Thrombo Aspilets 29.220,00
Total 56.970,00
1.542 Buyung Anam LUBUK GEDANG 133634 Hepa Q @30 tab
09/02/2021 00:00:00 86.620,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Loratadine tab 10 mg 1.660,00
Renax @50 Kapsul 226.880,00
ursodeoxycholic acid 56.700,00
Total 385.500,00
1.543 Desi Nia Sari BANDARATU 135362 Avamys
09/02/2021 00:00:00 129.000,00 BPJS
Cefixime kapsul 200 mg 26.480,00
Sucralfate Suspensi 100 m 19.250,00
Total 174.730,00
1.544 Firma Casnyda MARGA MULIA 182431 abbocath 18 Terumo @5
10/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 53.046,00
1.545 Ny.drameka SELAGAN RAYA 182432 Abbocath 26 (GEA)
09/02/2021 00:00:00 34.467,00 BPJS
Aqua Pro Injeksi 3.575,00
Calcii Glukonas Inj 100 m 12.939,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
Nassal Cannula O2 bayi 19.060,00
NGT (Feeding Tube) Fr. 8 11.043,00
Bactesyn inj 0,75 gr
14/02/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Total 187.223,00
1.546 Yuniar Lina AIR BIKUK 132976 Calcium Laktat
09/02/2021 00:00:00 790,00 BPJS
Ondansetron tablet 8 mg 26.400,00
Total 27.190,00
1.547 M. Aslan Sakir AIR BIKUK 167379 Ambroxol Syr 15mg/ml
09/02/2021 00:00:00 4.538,00 BPJS
Apialys Syr 100 ml 39.188,00
Cefixime syrup 100mg/5 M 23.823,00
Total 67.549,00
1.548 Fitria Putri Herlina AIR BIKUK 180704 Calcium Laktat
09/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.549 Selvi PONDOK SUGUH 182279 Asam Mefenamat 500 m
09/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00

19/08/2021 12:42:30 Page 363 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.549 Selvi PONDOK SUGUH 182279 Metrodinazole tab 500 m
09/02/2021 00:00:00 4.050,00 BPJS
Postofix (leukomed) 36.726,00
Total 53.211,00
1.550 Hana Puspita SIDODADI 171025 Calcium Laktat
09/02/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.551 Ruslina Laia DUSUN SUMBER SARI 178045 Calcium Laktat
09/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.552 Reni Rahmawati AIR BIKUK 134219 CAL-95 tab
09/02/2021 00:00:00 62.700,00 BPJS
Calcium Laktat 790,00
Nulacta ibu hamil & meny 60.500,00
Total 123.990,00
1.553 Firma Casnyda MARGA MULIA 182431 Paracetamol Infus
09/02/2021 00:00:00 28.876,00 BPJS
Cefadroxil tab 500 mg @1
10/02/2021 00:00:00 10.500,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 55.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Total 177.852,00
1.554 Martina PT.AGRO AIR DIKIT 181749 Gitas Plus
09/02/2021 00:00:00 50.330,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 6.610,00
Total 70.580,00
1.555 Amirudin TANJUNG HARAPAN 182310 Allopurinol 100 mg @100
09/02/2021 00:00:00 4.680,00 BPJS
Cefadroxil tab 500 mg @1 14.700,00
Hypafix 15cmx5cm (25 c 6.544,00
Paracetamol tablet 500 m 2.000,00
Total 27.924,00
1.556 Siti Aisya TANAH HARAPAN 145317 Metrodinazole tab 500 m
09/02/2021 00:00:00 4.050,00 BPJS
Nystatin Tab Vaginal 7.380,00
Total 11.430,00
1.557 Hartati PONDOK BARU 136239 Levopar tab 100mg
09/02/2021 00:00:00 77.460,00 BPJS
Sifrol tab 0,375 mg 311.250,00
Vitamin B Komplek @100 4.620,00
Total 393.330,00
1.558 Rusminah TANJUNG MULYA 125539 Eperisone Hcl 50 mg @1
09/02/2021 00:00:00 23.280,00 BPJS
Meloxicam 15 mg 12.600,00
Pregabalin Kap 75 mg 96.690,00
Total 132.570,00
1.559 Jusmarni SUNGAI JERINJING 182433 abbocath 18 Terumo @5
09/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.559 Jusmarni SUNGAI JERINJING 182433 Chromic catgut 2-0 R (Tr
09/02/2021 00:00:00 72.250,00 BPJS
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 137.500,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet Boism 47.580,00
Metrodinazole Infus 10.313,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 5 cc terumo 8.538,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.588.185,00
1.560 Melinda Damanik AIR BIKUK 182434 Calcium Laktat
09/02/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.561 Friska Idayani Lumbanga TUNGGANG 182308 Levofloxacin Tablet 500 m
09/02/2021 00:00:00 13.640,00 BPJS
Perifas @100 Tab 19.250,00
Sucralfate Suspensi 100 m 19.250,00
ursodeoxycholic acid 56.700,00
Total 108.840,00
1.562 Rudito PT AGRO AIR BULUH 182435 Domperidone Tab
09/02/2021 00:00:00 1.080,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 23.330,00
1.563 Sukarni LUNANG 182436 Cefadroxil tab 500 mg @1
09/02/2021 00:00:00 10.500,00 BPJS
Methylprednisolone tab 4 5.260,00
Total 15.760,00
1.564 Ahmad Rahino SILAUT 168082 Ambroxol 30 mg @100 T
09/02/2021 00:00:00 3.860,00 BPJS
Cefixime kapsul 200 mg 26.480,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 30.340,00
1.565 Muid PAUH TERENJA 113471 Amlodipine 5 mg @30 T
09/02/2021 00:00:00 3.030,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Codein tab 10 mg 7.500,00
Total 14.970,00
1.566 Jusmarni SUNGAI JERINJING 182433 abbocath 18 Terumo @5
09/02/2021 00:00:00 22.276,00 BPJS
Alkohol 1Liter 84.222,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 18.768,00
Dexametason Injeksi 12.512,00
handscoond steril 6.5 (G 72.770,00
Hypafix 10cm x 5cm (25 c 9.700,00
Iodine povidone 300 ml 56.926,00
Ketorolac inj 30 mg/1ml 4.035,00
Massa Cauter Dewasa 90.240,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
Tranexamic Acid Inj (Asa 6.315,00
Catheter 2 Way No. 16 (
11/02/2021 00:00:00 20.625,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Nassal Cannula O2 Dewas 11.625,00
Paracetamol Infus 14.438,00
Urine bag 10.088,00
Asam Mefenamat 500 m
12/02/2021 00:00:00 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 35.121,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 4.050,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Phytomenadione 10 mg ( 934,00
Postofix (leukomed) 36.726,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Total 871.939,00
1.567 Salami SILAUT I 134774 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.568 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00

19/08/2021 12:42:30 Page 366 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.569 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.570 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.571 Lilis Andriyani AIR RAMI 161196 abbocath 18 Terumo @5
09/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
abbocath 18 Terumo @5
10/02/2021 00:00:00 22.276,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 44.965,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 12.512,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 4.255,00
handscoond steril 6.5 (G 58.216,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 47.016,00
Masker Karet 11.000,00
Massa Cauter Dewasa 180.480,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 23.250,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 4.260,00

19/08/2021 12:42:30 Page 367 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.571 Lilis Andriyani AIR RAMI 161196 Suprafenid Supositoria 10
10/02/2021 00:00:00 28.050,00 BPJS
Topi Operasi (Dokter) @5 8.495,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 23
11/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 12.512,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
12/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 20 Terumo @5
13/02/2021 00:00:00 79.023,00
NonWoven Fixation 15x 33.470,00
Asam Mefenamat 500 m
14/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 2.043.178,00
1.572 Devi Setya Ningsih AIR DIKIT 130800 Amlodipine 5 mg @30 T
09/02/2021 00:00:00 1.010,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 68.750,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 87.378,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 7 (G 72.815,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metoclopramide inj 5Mg/M 29.395,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 5.500,00
Myotonic inj 19.596,00

19/08/2021 12:42:30 Page 368 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.572 Devi Setya Ningsih AIR DIKIT 130800 NACL 0,9 % 500 ml
09/02/2021 00:00:00 17.100,00 BPJS
Nassal Cannula O2 Dewas 23.250,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 25 (BBraund) 213.815,00
Spinocain 27 (BBraund) 239.375,00
Spinocain 27 (BBraund) 95.750,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Amlodipine 10 mg @50 T
10/02/2021 00:00:00 118,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Otsu Nacl PiggyBack 100 m 18.975,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 19.076,00
Suction Chateter no. 6 (R 16.333,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
12/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
13/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Piralen Injeksi 2 ml 44.000,00
Postofix (leukomed) 36.726,00
Total 2.206.024,00
1.573 Suladi MEDAN JAYA 182425 Abbocath 20 Terumo @5
09/02/2021 00:00:00 11.138,00 BPJS
Abbocath 20 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00

19/08/2021 12:42:30 Page 369 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.573 Suladi MEDAN JAYA 182425 Handscoond Non Steril M
09/02/2021 00:00:00 20.080,00 BPJS
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 13.088,00
Ketorolac inj 30 mg/1ml 2.690,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker Karet Boism 47.580,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 16.990,00
Transfusi Set Terumo 16.500,00
Transfusi Set Terumo 16.500,00
Ciprofloxacin tab 500 mg
10/02/2021 00:00:00 5.590,00
Paracetamol tablet 500 m 2.000,00
Total 594.233,00
1.574 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.575 Ifel Yoanda RANAH KARYA 182405 Bisturi No. 15
09/02/2021 00:00:00 7.672,00 BPJS
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 7 (G 58.252,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metrodinazole Infus 20.626,00
Pehacain Injeksi 9.960,00
Ranitidin inj 3.580,00
Silk 3/0 C scimitar 67.750,00
Tranexamic Acid Inj (Asa 6.315,00
Ceftriaxone Inj
10/02/2021 00:00:00 12.498,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 3.128,00
Gentamycin 0.1 % salep k 2.983,00
Ketorolac inj 30 mg/1ml 1.345,00
Metrodinazole Infus 0,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Cefadroxil tab 500 mg @1
11/02/2021 00:00:00 10.500,00
Kassa kotak stril DRC 19.350,00
Methylprednisolone tab 4 2.630,00

19/08/2021 12:42:30 Page 370 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.575 Ifel Yoanda RANAH KARYA 182405 Metrodinazole tab 500 m
11/02/2021 00:00:00 4.050,00 BPJS
Paracetamol tablet 500 m 4.000,00
Total 355.397,00
1.576 Rasya Muhammad At SUMBER SARI 182426 Abbocath 22 Terumo @5
09/02/2021 00:00:00 22.276,00 BPJS
Abbocath 24 Terumo @5 22.276,00
Aqua Pro Injeksi 3.575,00
ATRACURIUM BESYLATE 2 14.671,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Bisturi No. 15 7.672,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 3-0 R (Tr 132.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 68.750,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 36.052,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Anak 32.946,00
Pamol 125 Supositoria 35.200,00
Polyvinylidene 2-0 R (Tri 94.250,00
Polyvinylidene 3-0 R (Tri 92.000,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Silk 2/0 C scimitar 66.993,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 16.990,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Urine bag 10.088,00
Cefixime syrup 100mg/5 M
10/02/2021 00:00:00 23.823,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 13.088,00
Kassa kotak stril DRC 9.675,00
Paracetamol syrup 1.388,00
Ringer Laktat Otsuka 9.538,00
Total 1.305.631,00

19/08/2021 12:42:30 Page 371 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.577 Silya Wana BANDARATU 117469 Dexametason Injeksi
09/02/2021 00:00:00 6.256,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Transfusi Set Terumo 16.500,00
Total 182.381,00
1.578 Jangkep PT.AGRO MUKO 134160 Abbocath 20 Terumo @5
09/02/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 5.751,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 19.076,00
Alkohol 1Liter
10/02/2021 00:00:00 42.111,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 8.993,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Infusion Makro (terumo) 27.225,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 470.160,00
Masker Karet 22.000,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 61.688,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Cefotaxime Injeksi
11/02/2021 00:00:00 11.502,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Furosemide 40 mg Tablet 2.880,00
Methylprednisolone tab 4 7.890,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 13.220,00
Retaphyl SR Tab 44.220,00
Sucralfate Suspensi 100 m 19.250,00
Tramadol 50 mg/ml Inj 12.375,00
Ciprofloxacin tab 500 mg
12/02/2021 00:00:00 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Paracetamol tablet 500 m 3.000,00

19/08/2021 12:42:30 Page 372 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.578 Jangkep PT.AGRO MUKO 134160 Ringer Laktat Otsuka
12/02/2021 00:00:00 28.614,00 BPJS
Total 1.425.697,00
1.579 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.580 Hasan TANAH HARAPAN 123437 Abbocath 20 Terumo @5
09/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 72.815,00
Handscoond Non Steril S 8.510,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
KTM (ketamin) Injeksi 214.500,00
KTM (ketamin) Injeksi 214.500,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 29.125,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Urine bag 10.088,00
Urine bag 10.088,00
Urine bag 10.088,00
Cefotaxime Injeksi
10/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Cefadroxil tab 500 mg @1
11/02/2021 00:00:00 10.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 19.350,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 2.000,00
Total 1.424.145,00
1.581 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 159.625,00
1.582 Salbiyah LUBUK MUKTI 173013 Dexametason Injeksi
09/02/2021 00:00:00 6.256,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Transfusi Set Terumo 16.500,00
Total 182.381,00
1.583 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
09/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.584 Ny.jusmarni SUNGAI JERINJING 182437 abbocath 18 Terumo @5
09/02/2021 00:00:00 55.690,00 BPJS
Abbocath 24 Terumo @5 33.414,00
Bactesyn inj 0,75 gr 0,00
Bisturi No. 23 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Dexametason Injeksi 18.768,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 0,00
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
12/02/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Phytomenadione 2 Mg/1M 4.834,00
Total 301.757,00
1.585 Ny Yessy Anggraini UJUNG PADANG 182439 Abbocath 24 Terumo @5
09/02/2021 00:00:00 11.138,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Calcii Glukonas Inj 100 m 12.939,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
Nassal Cannula O2 bayi 9.530,00
Ottogenta inj 9.900,00
umbilical Cord Clamp 2.261,00
Total 140.757,00
1.586 Abuama PONDOK LUNANG 143672 Asam Folat 1 mg @100 T
09/02/2021 00:00:00 297,00 BPJS
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Tambah Darah Neo Tab 1.395,00
Total 28.560,00
1.587 Suhardi BANDAR RATU 115774 Alprazolam 1 mg @100 T
09/02/2021 00:00:00 1.600,00 BPJS
Amlodipine 10 mg @50 T 2.360,00
Clopidogrel 75 mg @30 T 35.100,00
Total 39.060,00
1.588 Reki AIR DIKIT 180368 Cefadroxil tab 500 mg @1
09/02/2021 00:00:00 10.500,00 BPJS
Loremid Tab 4.314,00
Paracetamol tablet 500 m 2.000,00
Total 16.814,00
1.589 Abu Diman PELOKAN 182441 Omeprazol kapsul 20 mg
09/02/2021 00:00:00 6.610,00 BPJS
Ondansetron tablet 8 mg 26.400,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 28.050,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 80.310,00
1.590 Abuama PONDOK LUNANG 143672 Asam Folat 1 mg @100 T
10/02/2021 00:00:00 297,00 BPJS
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 4.998,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Abbocath 20 Terumo @5
11/02/2021 00:00:00 26.341,00
Abbocath 22 Terumo @5 11.138,00
Asam Folat 1 mg @100 T 297,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Tambah Darah Neo Tab 930,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
12/02/2021 00:00:00 1.485,00
Pyrantel Tab 3.032,00
Total 241.472,00
1.591 Eri Susanti GADING JAYA 127845 abbocath 18 Terumo @5
10/02/2021 00:00:00 11.138,00 BPJS
Cefotaxime Injeksi 11.502,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 17.253,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 137.500,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Induxin 1 ml Injeksi 27.843,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.591 Eri Susanti GADING JAYA 127845 Kassa kotak stril DRC
10/02/2021 00:00:00 9.675,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Lidocain injk 40 mg/2 ml 1.611,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suction Chateter no. 8 (R 20.625,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 10.088,00
Urine bag 10.088,00
viamac 1 R 364.370,00
viamac 1 R 546.555,00
Cefotaxime Injeksi
11/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 4.210,00
Cefotaxime Injeksi
12/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
13/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Phytomenadione 10 Mg/1 11.918,00
Postofix (leukomed) 36.726,00
Total 2.625.301,00
1.592 Anwar Safi"i BUMI MEKAR JAYA 182355 abbocath 18 Terumo @5
10/02/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.592 Anwar Safi"i BUMI MEKAR JAYA 182355 Dexametason Injeksi
10/02/2021 00:00:00 9.384,00 BPJS
Dexametason Injeksi 9.384,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Metrodinazole Infus 30.939,00
Ranitidin inj 3.580,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
11/02/2021 00:00:00 12.498,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole Infus 30.939,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Bucain Spinal 0.5 % Inj
12/02/2021 00:00:00 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Methylprednisolone tab 4 2.630,00
Metrodinazole tab 500 m 4.050,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Ranitidine tablet 150 mg 1.440,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Total 868.797,00
1.593 Agus Supriatin SIDO MAKMUR 171284 CAL-95 tab
10/02/2021 00:00:00 62.700,00 BPJS
Emibion kapsul 19.660,00
Total 82.360,00
1.594 Sier LUNANG 182444 Nulacta ibu hamil & meny
10/02/2021 00:00:00 60.500,00 BPJS
Utrogestan 100 mg Kapsu 274.320,00
Total 334.820,00
1.595 Nenah SINAR JAYA 182196 Mecobalamin 500 mg
10/02/2021 00:00:00 23.100,00 BPJS
Metformin tablet 500 mg 11.970,00
Novo Twist 32 G Tip 13.020,00
Total 48.090,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.596 Abdad Fawwas SIBAK 182445 Cefixime syrup 100mg/5 M
10/02/2021 00:00:00 23.823,00 BPJS
Otopain Ear Drops 8 ml 99.688,00
Total 123.511,00
1.597 Nurwati TANAH REKAH 182121 Cefadroxil tab 500 mg @1
10/02/2021 00:00:00 10.500,00 BPJS
Misoprostol Tab 55.000,00
Total 65.500,00
1.598 Suyekti TANJUNG MULYA 181939 Ambroxol Syr 15mg/ml
10/02/2021 00:00:00 4.538,00 BPJS
Candesartan tab 8 mg 20.430,00
Curcuma Tab 38.100,00
Domperidone Tab 9.720,00
Furosemide 40 mg Tablet 2.880,00
Spironolaktone 25 mg 7.800,00
Total 83.468,00
1.599 Yulia Wandini SIBAK 182446 Ambroxol Syr 15mg/ml
10/02/2021 00:00:00 4.538,00 BPJS
Cefixime syrup 100mg/5 M 23.823,00
Cetirgi Tab 10 mg 7.740,00
Methylprednisolone tab 4 2.630,00
Total 38.731,00
1.600 Nova Emiliawati UJUNG PADANG 112675 Pehacain Injeksi
10/02/2021 00:00:00 6.640,00 BPJS
Total 6.640,00
1.601 Widi Astuti BUMI MULYA 167059 Asam Mefenamat 500 m
10/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
1.602 Nur Saniwa TALANG BUAI 182250 Calcium Laktat
10/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.603 Sri Rahayu KOTA PRAJA 129208 Azitromycin 500 mg
10/02/2021 00:00:00 28.125,00 BPJS
Vectrine Tab 300 mg 50.000,00
Vitamin B Komplek @100 1.540,00
Vitamin C tablet @100 Ta 1.380,00
Total 81.045,00
1.604 Mardiana PENARIK 167606 Omeprazol kapsul 20 mg
10/02/2021 00:00:00 3.305,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 6.305,00
1.605 Tri Rahayu SIDO MULYO 162654 Calcium Laktat
10/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.606 Tasibul Hakim KOTA PRAJA 143145 Eperisone Hcl 50 mg @1
10/02/2021 00:00:00 23.280,00 BPJS
Glucosamine 250 mg 7.700,00
Meloxicam 15 mg 12.600,00
Total 43.580,00
1.607 Hermansyah PASAR MUKOMUKO 182219 Ambroxol Syr 15mg/ml
10/02/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 41.273,00
1.608 Gerak TALANG BUAI 139085 Flunarizine 5 mg tab
10/02/2021 00:00:00 24.750,00 BPJS
Glucosamine 250 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Total 34.450,00
1.609 Zaman SUNGAI IPUH 118579 Neurodex tablet
10/02/2021 00:00:00 14.820,00 BPJS
Paracetamol tablet 500 m 2.000,00
Vectrine Tab 300 mg 100.000,00
Total 116.820,00
1.610 Oos Dariana PONDOK LUNANG 174848 abbocath 18 Terumo @5
10/02/2021 00:00:00 11.138,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.610 Oos Dariana PONDOK LUNANG 174848 Aqua Pro Injeksi
10/02/2021 00:00:00 3.575,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 137.500,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 600,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.672.273,00
1.611 Semi SELAGAN JAYA 101470 Methylprednisolone tab 4
10/02/2021 00:00:00 2.630,00 BPJS
Neurodex tablet 7.410,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 31.290,00
1.612 Oos Dariana PONDOK LUNANG 174848 Cefotaxime Injeksi
10/02/2021 00:00:00 11.502,00 BPJS
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00

19/08/2021 12:42:30 Page 379 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.612 Oos Dariana PONDOK LUNANG 174848 Tranexamic Acid Inj (Asa
10/02/2021 00:00:00 6.315,00 BPJS
Cefotaxime Injeksi
12/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
13/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 179.105,00
1.613 Linawati AGUNG JAYA 182452 Amoxicillin 500 mg @ 10
10/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Total 4.350,00
1.614 Dawinar SUNGAI JERINJING 182453 Amoxicillin 500 mg @ 10
10/02/2021 00:00:00 3.060,00 BPJS
Paracetamol tablet 500 m 2.000,00
Pehacain Injeksi 3.320,00
Total 8.380,00
1.615 Joni Kartio SUNGAI IPUH 178142 Alinamin F 50 mg @100 T
10/02/2021 00:00:00 11.500,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Opilax Syr 49.156,00
Total 74.296,00
1.616 Emilya Yosmita LUNANG 138806 Eperisone Hcl 50 mg @1
10/02/2021 00:00:00 23.280,00 BPJS
Glucosamine 250 mg 7.700,00
Meloxicam 15 mg 12.600,00
Omeprazol kapsul 20 mg 6.610,00
Total 50.190,00
1.617 M.misdi SUNGAI SERIK 181415 Asam Folat 1 mg @100 T
10/02/2021 00:00:00 990,00 BPJS
Candesartan tab 8 mg 6.810,00
Furosemide 40 mg Tablet 960,00
Gentamycin 0.1 % salep k 2.983,00
Novo Twist 32 G Tip 2.604,00
Spironolaktone 25 mg 2.600,00
Total 16.947,00
1.618 Pongir Sidabutar TUNGGANG 182328 Alprazolam 0,5 mg @100
10/02/2021 00:00:00 590,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 2.590,00
1.619 Bahman SIBAK 155872 NACL 0,9 % 500 ml
10/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.620 Asmansyah SIBAK 140995 Dexametason Injeksi
10/02/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Transfusi Set Terumo 16.500,00
Total 176.901,00
1.621 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
10/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.622 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
10/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00

19/08/2021 12:42:30 Page 380 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 151.075,00
1.623 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
10/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.624 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
10/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.625 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
10/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.626 Asmara AIR BIKUK 182454 abbocath 18 Terumo @5
10/02/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Iodine Povidone 1 L 158.594,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 540,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.626 Asmara AIR BIKUK 182454 Topi Operasi (Dokter) @5
10/02/2021 00:00:00 16.990,00 BPJS
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 23
11/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Total 1.812.816,00
1.627 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
10/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.628 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
10/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.629 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
10/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.630 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
10/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.631 Gusni SINDANG 133910 Gentamycin 0.1 % salep k
10/02/2021 00:00:00 5.966,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Loratadine tab 10 mg 1.660,00
Sistenol kaplet 17.540,00
Total 38.806,00
1.632 Zamzami LUBUK GEDANG 182344 Abbocath 20 Terumo @5
10/02/2021 00:00:00 22.276,00 BPJS
Aqua Pro Injeksi 7.150,00
ATRACURIUM BESYLATE 2 14.671,00
Atropin injek 1 ml 13.938,00
Bisturi No. 23 7.672,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gypsona "6" 104.785,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00

19/08/2021 12:42:30 Page 382 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.632 Zamzami LUBUK GEDANG 182344 Infusion Makro (terumo)
10/02/2021 00:00:00 27.225,00 BPJS
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Neostigmine-hameln 0.5 m 34.300,00
Polyvinylidene 2-0 C (Tri 184.500,00
Polyvinylidene 3-0 R (Tri 92.000,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 2.105,00
Cefotaxime Injeksi
11/02/2021 00:00:00 11.502,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Cuticell Classic 10cmx10c
12/02/2021 00:00:00 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 29.025,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 28.614,00
Total 1.251.680,00
1.633 Muhamad Akbar Pria BATU EJUNG 161774 Abbocath 22 Terumo @5
10/02/2021 00:00:00 22.276,00 BPJS
Aqua Pro Injeksi 7.150,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker Karet Boism 47.580,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00

19/08/2021 12:42:30 Page 383 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.633 Muhamad Akbar Pria BATU EJUNG 161774 Spuit 5 cc terumo
10/02/2021 00:00:00 8.538,00 BPJS
Topi Operasi (Dokter) @5 16.990,00
Cefixime syrup 100mg/5 M
11/02/2021 00:00:00 23.823,00
Paracetamol tablet 500 m 2.000,00
Total 722.164,00
1.634 M Yadi LUBUK BANGKO 181321 Abbocath 20 Terumo @5
10/02/2021 00:00:00 11.138,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Infus 48.976,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Abbocath 20 Terumo @5
11/02/2021 00:00:00 52.682,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Infus 48.976,00
Paracetamol Infus 43.314,00
Ambroxol Syr 15mg/ml
12/02/2021 00:00:00 4.538,00
Levofloxacin Infus 48.976,00
Paracetamol Infus 43.314,00
Dexametason Injeksi
13/02/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Levofloxacin Tablet 500 m 2.728,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Levofloxacin Infus
14/02/2021 00:00:00 48.976,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Abbocath 20 Terumo @5
15/02/2021 00:00:00 26.341,00
Abbocath 22 Terumo @5 22.276,00
Ambroxol 30 mg @100 T 579,00
Hypafix 15cmx5cm (25 c 13.088,00
Levofloxacin Infus 48.976,00
Paracetamol Infus 43.314,00
Ambroxol 30 mg @100 T
16/02/2021 00:00:00 579,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Levofloxacin Infus 48.976,00
Paracetamol Infus 43.314,00
Ambroxol 30 mg @100 T
17/02/2021 00:00:00 579,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Levofloxacin Infus 48.976,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Levofloxacin Tablet 500 m
18/02/2021 00:00:00 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 972.595,00

19/08/2021 12:42:30 Page 384 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.635 Ny. Oos Dariana PONDOK LUNANG 182457 Ampicilin Serbuk Injeksi 1
11/02/2021 00:00:00 10.811,00 BPJS
Chloramphenicol Salep M 2.351,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
14/02/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Total 167.396,00
1.636 Ny.eri Susanti GADING JAYA 182458 Chloramphenicol Salep M
10/02/2021 00:00:00 2.351,00 BPJS
Kassa kotak stril DRC 9.675,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
11/02/2021 00:00:00 22.276,00
Hypafix 10cm x 5cm (25 c 9.700,00
Injection plug 20.213,00
Abbocath 24 Terumo @5
12/02/2021 00:00:00 11.138,00
Hypafix 10cm x 5cm (25 c 4.850,00
NonWoven Fixation 15x 6.694,00
Total 93.992,00
1.637 Asmara AIR BIKUK 182454 Asam Mefenamat 500 m
11/02/2021 00:00:00 387,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 28.614,00
abbocath 18 Terumo @5
12/02/2021 00:00:00 52.682,00
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 15x 6.694,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
13/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 243.471,00
1.638 Sajiman SUMBER MAKMUR 177386 Abbocath 26 Terumo
11/02/2021 00:00:00 19.300,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Ondansetron Inj 4.950,00
Otsu NS 100 ml 8.013,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 9.538,00
Vitamin C 500 mg 2,00
Ascorbid Acid 1000mg/5m 156.750,00
azitromicin inj 500 mg 433.128,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 9.900,00

19/08/2021 12:42:30 Page 385 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.638 Sajiman SUMBER MAKMUR 177386 Pantoprazole Inj
11/02/2021 00:00:00 70.125,00 BPJS
Paracetamol tablet 500 m 2.000,00
Vectrein Syrup 45.000,00
azitromicin inj 500 mg
12/02/2021 00:00:00 288.752,00
NACL 0,9 % 500 ml 25.650,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 1.000,00
Ascorbid Acid 1000mg/5m
13/02/2021 00:00:00 52.250,00
Nassal Mask O2 Dewasa 41.828,00
Nystatin Drop 27.830,00
Azitromycin 500 mg
14/02/2021 00:00:00 22.500,00
Extrace Injeksi 100 mg/m 38.500,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 46.750,00
Paracetamol tablet 500 m 800,00
Aminofluid Infus 500 ml
16/02/2021 00:00:00 155.204,00
Cefixime kapsul 200 mg 26.480,00
Cefixime kapsul 200 mg 26.480,00
Extrace Injeksi 100 mg/m 28.875,00
Extrace Injeksi 100 mg/m 9.625,00
Extrace Injeksi 100 mg/m 9.625,00
Extrace Injeksi 100 mg/m 9.625,00
Extrace Injeksi 100 mg/m 9.625,00
Extrace Injeksi 100 mg/m 9.625,00
Extrace Injeksi 100 mg/m 9.625,00
NACL 0,9 % 500 ml 8.550,00
Omeprazol kapsul 20 mg 6.610,00
Pantoprazole Inj 23.375,00
Paracetamol tablet 500 m 3.000,00
vestein 300 mg 14.025,00
vestein 300 mg 93.500,00
vestein 300 mg 46.750,00
vestein syr 48.125,00
Vitamin C 500 mg 15,00
Total 1.977.674,00
1.639 Lesnawati TANAH REKAH 182045 abbocath 18 Terumo @5
11/02/2021 00:00:00 11.138,00 BPJS
Amlodipine 5 mg @30 T 202,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 41.250,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 89.930,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 6.900,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00

19/08/2021 12:42:30 Page 386 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.639 Lesnawati TANAH REKAH 182045 handscoond steril 8 (Gam
11/02/2021 00:00:00 14.554,00 BPJS
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 13.388,00
Otsu MgSO4 40 % 4.745,00
Otsu MgSO4 40 % 9.490,00
Polypropylene 3/0 C (Ass 235.200,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 546.555,00
Total 1.854.330,00
1.640 Ny. Lesnawati TANAH REKAH 182459 Abbocath 24 Terumo @5
11/02/2021 00:00:00 44.552,00 BPJS
Bisturi No. 23 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Hypafix 15cmx5cm (25 c 13.088,00
Ka-En Mg3 13.104,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
NonWoven Fixation 15x
12/02/2021 00:00:00 6.694,00
Bactesyn inj 0,75 gr
14/02/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
NonWoven Fixation 15x 6.694,00
Abbocath 24 Terumo @5
15/02/2021 00:00:00 44.552,00
Total 236.810,00
1.641 Abu Karim TANJUNG ALAI 144502 Metrodinazole tab 500 m
11/02/2021 00:00:00 8.100,00 BPJS
Omeprazol kapsul 20 mg 13.220,00
Renax @50 Kapsul 340.320,00
Retaphyl SR Tab 29.480,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 65.940,00

19/08/2021 12:42:30 Page 387 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 476.310,00
1.642 Rohayati AIR DIKIT 138538 Domperidone Tab
11/02/2021 00:00:00 3.240,00 BPJS
Flunarizine 5 mg tab 74.250,00
Omeprazol kapsul 20 mg 6.610,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 161.100,00
1.643 Rosnidar PENARIK 131980 Alprazolam 1 mg @100 T
11/02/2021 00:00:00 4.800,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Candesartan tab 8 mg 20.430,00
Curcuma Tab 12.700,00
Furosemide 40 mg Tablet 960,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 6.610,00
Vitamin B Komplek @100 1.540,00
Total 53.820,00
1.644 Teti Br Nainggolan SUMBER SARI 182461 CAL-95 tab
11/02/2021 00:00:00 62.700,00 BPJS
Calcium Laktat 790,00
Emibion kapsul 19.660,00
Tonotan tab 22.865,00
Total 106.015,00
1.645 Emma siregar LUBUK GEDANG 126130 Alprazolam 1 mg @100 T
11/02/2021 00:00:00 4.800,00 BPJS
Flunarizine 5 mg tab 24.750,00
Gabapentin kapsul 300 m 25.380,00
Omeprazole Inj 124.990,00
Perifas @100 Tab 9.625,00
Sucralfate Suspensi 100 m 19.250,00
Total 208.795,00
1.646 Masinem KOTA PRAJA 136621 Atorvastatin 20 mg @30 T
11/02/2021 00:00:00 31.350,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Flunarizine 5 mg tab 74.250,00
Furosemide 40 mg Tablet 2.880,00
Omeprazol kapsul 20 mg 13.220,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 29.220,00
Total 243.250,00
1.647 Mirawati TALANG BARU 175701 Postofix (leukomed)
11/02/2021 00:00:00 36.726,00 BPJS
Total 36.726,00
1.648 Purnamasari SUNGAI GADING 182319 Cefadroxil tab 500 mg @1
11/02/2021 00:00:00 10.500,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 13.130,00
1.649 Dedi Irwansyah TALANG SEPAKAT 182317 Cefadroxil tab 500 mg @1
11/02/2021 00:00:00 10.500,00 BPJS
Total 10.500,00
1.650 Leginem TALANG PETAI 135354 Alprazolam 0,5 mg @100
11/02/2021 00:00:00 2.360,00 BPJS
Gitas Plus 150.990,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
ursodeoxycholic acid 85.050,00
Total 264.260,00
1.651 Desi Komalasari SINAR JAYA 131508 Curcuma Tab
11/02/2021 00:00:00 38.100,00 BPJS
Flunarizine 5 mg tab 74.250,00

19/08/2021 12:42:30 Page 388 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.651 Desi Komalasari SINAR JAYA 131508 Neurodex tablet
11/02/2021 00:00:00 14.820,00 BPJS
Omeprazol kapsul 20 mg 13.220,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 217.390,00
1.652 Ngatini LUBUK MUKTI 179230 Bisoprolol 5 mg @100 Ta
11/02/2021 00:00:00 4.440,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Omeprazol kapsul 20 mg 13.220,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 29.220,00
Total 121.660,00
1.653 Rosmi Yeni LUBUK MUKTI 182463 Alprazolam 0,5 mg @100
11/02/2021 00:00:00 3.540,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Omeprazol kapsul 20 mg 13.220,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 29.220,00
Total 120.760,00
1.654 Tumijo Taruno LUBUK SANAI 182324 Cefixime Kapsul 100 mg
11/02/2021 00:00:00 9.380,00 BPJS
Lidocain injk 40 mg/2 ml 4.833,00
Urinter Kapsul @100 cap 21.980,00
Total 36.193,00
1.655 Siti Juriah RESNO 167789 Candesartan tab 8 mg
11/02/2021 00:00:00 20.430,00 BPJS
Flunarizine 5 mg tab 74.250,00
Omeprazol kapsul 20 mg 13.220,00
Sucralfate Suspensi 100 m 19.250,00
ursodeoxycholic acid 85.050,00
Total 212.200,00
1.656 Yen Marleni PANTAI INDAH 134442 Nulacta Plus
11/02/2021 00:00:00 58.300,00 BPJS
Tonotan tab 22.865,00
Utrogestan 100 mg Kapsu 137.160,00
Total 218.325,00
1.657 Herma Yulita SILAUT 134287 Cefixime kapsul 200 mg
11/02/2021 00:00:00 26.480,00 BPJS
Curcuma Tab 38.100,00
Neurodex tablet 22.230,00
Omeprazol kapsul 20 mg 13.220,00
Sucralfate Suspensi 100 m 19.250,00
thyrozol 5 mg 49.560,00
Total 168.840,00
1.658 Putri Rahayu AIR BULUH 182325 Tarivid otic 5 ml
11/02/2021 00:00:00 105.900,00 BPJS
Total 105.900,00
1.659 Arpan Agus PASAR BELAKANG 112261 Alprazolam 1 mg @100 T
11/02/2021 00:00:00 4.800,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 13.220,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Thrombo Aspilets 29.220,00
Total 197.396,00
1.660 Herawati PENARIK 181611 Asam Mefenamat 500 m
11/02/2021 00:00:00 1.290,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.660 Herawati PENARIK 181611 Cefadroxil tab 500 mg @1
11/02/2021 00:00:00 10.500,00 BPJS
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 62.241,00
1.661 Indah Sari AIR DIKIT 182466 CAL-95 tab
11/02/2021 00:00:00 62.700,00 BPJS
Emibion kapsul 19.660,00
Total 82.360,00
1.662 Yarti LUBUK BANGKO 176516 Calcium Laktat
11/02/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
1.663 Neti Herawati PENARIK 129934 Calcium Laktat
11/02/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
1.664 Hadi Soleh Yoga Prata AGUNG JAYA 158494 Betadine Obat Kumur
11/02/2021 00:00:00 13.750,00 BPJS
Methylprednisolone tab 4 2.630,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 3.000,00
Total 25.990,00
1.665 Saripah TANJUNG MAKMUR 131645 Abbocath 20 Terumo @5
11/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 297,00
Ascorbid Acid 1000mg/5m 52.250,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Total 179.555,00
1.666 Teti Br Nainggolan SUMBER SARI 182461 abbocath 18 Terumo @5
11/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Otsu MgSO4 20 % 0,00
Otsu MgSO4 40 % 4.745,00
Ringer Laktat Otsuka 9.538,00
Tonotan tab 4.573,00
Transfusi Set Terumo 16.500,00
Total 89.127,00
1.667 Sugito MEKAR MULYA 147062 Amlodipine 10 mg @50 T
11/02/2021 00:00:00 354,00 BPJS
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 34.200,00
Total 61.779,00
1.668 Amri Kusna Yanti BUMI MULYA 133486 Amlodipine 10 mg @50 T
11/02/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 34.200,00
Otsu D40 37.539,00
Paracetamol tablet 500 m 600,00
Simvastatin tab 20 mg 933,00
Total 102.894,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.669 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
11/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.670 Narti SILAUT 175653 Amlodipine 10 mg @50 T
11/02/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
NACL 0,9 % 500 ml 34.200,00
Otsu D40 25.026,00
Simvastatin tab 10 mg 723,00
Total 62.346,00
1.671 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
11/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.672 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
11/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.673 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
11/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.674 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
11/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.675 Teti Br Nainggolan SUMBER SARI 182461 Cefotaxime Injeksi
12/02/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tonotan tab
13/02/2021 00:00:00 45.730,00
Vomil b6 30.250,00
Total 98.642,00
1.676 Miswanto LUNANG 128267 Dexametason Injeksi
11/02/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
NACL 0,9 % 500 ml 34.200,00
Paracetamol Infus 14.438,00
Total 57.964,00
1.677 Sumeri TIRTA MAKMUR 151166 Dimenhidrinat tab 50 mg
11/02/2021 00:00:00 4.140,00 BPJS
Flunarizine 5 mg tab 74.250,00
Neurodex tablet 22.230,00
Omeprazol kapsul 20 mg 13.220,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 190.840,00
1.678 Saripah TANJUNG MAKMUR 131645 Antrain Injeksi
12/02/2021 00:00:00 28.875,00 BPJS
Asam Folat 1 mg @100 T 297,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Esomeprazol Injeksi 40 m 34.956,00
NACL 0,9 % 500 ml 25.650,00
Vitamin B Komplek @100 308,00
Antrain Injeksi
13/02/2021 00:00:00 28.875,00
Asam Folat 1 mg @100 T 297,00
Ascorbid Acid 1000mg/5m 52.250,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 2 Mg/1M 14.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.678 Saripah TANJUNG MAKMUR 131645 Vitamin B Komplek @100
13/02/2021 00:00:00 462,00 BPJS
Antrain Injeksi
15/02/2021 00:00:00 28.875,00
Asam Folat 1 mg @100 T 297,00
Ascorbid Acid 1000mg/5m 209.000,00
Ascorbid Acid 1000mg/5m 78.375,00
Azitromycin 500 mg 11.250,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Opilax Syr 49.156,00
Vitamin B Komplek @100 308,00
Antrain Injeksi
16/02/2021 00:00:00 28.875,00
Asam Folat 1 mg @100 T 297,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
NACL 0,9 % 500 ml 8.550,00
Vitamin B Komplek @100 308,00
Aminoleban inf 500 ml
17/02/2021 00:00:00 88.713,00
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 297,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 19.400,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Aminoleban inf 500 ml
18/02/2021 00:00:00 88.713,00
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 297,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Asam Folat 1 mg @100 T
19/02/2021 00:00:00 1.485,00
Curcuma Tab 19.050,00
Neurodex tablet 7.410,00
Omeprazol kapsul 20 mg 3.305,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 82.500,00
Total 1.407.015,00
1.679 Fathih Al Barra PAUH TERENJA 177106 Cotrimoxazol 240 mg Sir
11/02/2021 00:00:00 5.130,00 BPJS
Glukosa Infus 10 % 9.375,00
Glukosa Infus 5 % 8.626,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 3.300,00
Oralit 1.372,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.679 Fathih Al Barra PAUH TERENJA 177106 Zinc Sulfate Syr 60 ml
11/02/2021 00:00:00 4.569,00 BPJS
Total 40.922,00
1.680 Firdaus Sukarno Putro TIRTA MULYA 181260 Asam Mefenamat 500 m
11/02/2021 00:00:00 1.290,00 BPJS
Ketokonazole krim 2 % 3.148,00
Orasic Kap 36.580,00
Paracetamol tablet 500 m 2.000,00
Total 43.018,00
1.681 Ahmad Mujiono MARGA MULYA SAKTI 113737 Gabapentin kapsul 300 m
11/02/2021 00:00:00 3.807,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 46.557,00
1.682 Fathih Al Barra PAUH TERENJA 177106 Hypafix 10cm x 5cm (25 c
11/02/2021 00:00:00 4.850,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Paracetamol syrup 1.388,00
Paracetamol syrup
12/02/2021 00:00:00 1.388,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 25.695,00
1.683 Firanza tri novelan LUBUK PINANG 142118 NACL 0,9 % 500 ml
11/02/2021 00:00:00 8.550,00 BPJS
Ambroxol Syr 15mg/ml
12/02/2021 00:00:00 4.538,00
NonWoven Fixation 15x 6.694,00
Paracetamol syrup 1.388,00
Cefotaxime Injeksi
13/02/2021 00:00:00 11.502,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Cefotaxime Injeksi
14/02/2021 00:00:00 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Paracetamol Infus 14.438,00
Cefotaxime Injeksi
15/02/2021 00:00:00 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ka-En 1 B 25.316,00
Nassal Mask O2 Anak 41.828,00
Paracetamol Infus 14.438,00
Paracetamol Infus 14.438,00
Total 187.021,00
1.684 Sarimbi RAWA MULYA 150445 Abbocath 22 Terumo @5
11/02/2021 00:00:00 11.138,00 BPJS
Antrain Injeksi 28.875,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 25.650,00
Nassal Cannula O2 Dewas 11.625,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Sucralfate Suspensi 100 m 19.250,00
Abbocath 22 Terumo @5
12/02/2021 00:00:00 22.276,00
Antrain Injeksi 28.875,00
Ceftriaxone Inj 12.498,00
Esomax Inj 148.500,00
Flunarizine 5 mg tab 4.950,00
Hypafix 10cm x 5cm (25 c 9.700,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.684 Sarimbi RAWA MULYA 150445 Infusion Makro (terumo)
12/02/2021 00:00:00 27.225,00 BPJS
Ketorolac inj 30 mg/1ml 5.380,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Vitamin B Komplek @100 308,00
Antrain Injeksi
13/02/2021 00:00:00 28.875,00
Antrain Injeksi 28.875,00
Ceftriaxone Inj 6.249,00
Esomeprazol Injeksi 40 m 34.956,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 13.388,00
Ondansetron Inj 4.950,00
Pantoprazole Inj 70.125,00
Paracetamol tablet 500 m 600,00
Perifas @100 Tab 1.925,00
Antrain Injeksi
14/02/2021 00:00:00 28.875,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Flunarizine 5 mg tab 4.950,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 462,00
Vomil b6 9.075,00
Antrain Injeksi
15/02/2021 00:00:00 28.875,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Flunarizine 5 mg tab 4.950,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 462,00
Antrain Injeksi
16/02/2021 00:00:00 28.875,00
Cefotaxime Injeksi 11.502,00
Dulcolax tab 5 mg 3.166,00
Esomax Inj 148.500,00
Flunarizine 5 mg tab 4.950,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 8.550,00
Natrium diclofenac 50 m 578,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 47.690,00
Vitamin B Komplek @100 308,00
Curcuma Tab
17/02/2021 00:00:00 19.050,00
Dulcolax tab 5 mg 4.749,00
Natrium diclofenac 50 m 2.890,00

19/08/2021 12:42:30 Page 394 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.684 Sarimbi RAWA MULYA 150445 Neurodex tablet
17/02/2021 00:00:00 7.410,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Perifas @100 Tab 15.400,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.296.804,00
1.685 Zukriman LUBUK GEDANG 160918 Abbocath 20 Terumo @5
11/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 4.950,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Total 74.851,00
1.686 Yuliana SELAGAN JAYA 182473 abbocath 18 Terumo @5
12/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 39.025,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Nifedipin Tab 10 mg 525,00
Otsu MgSO4 40 % 4.745,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Amlodipine 10 mg @50 T 118,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 23.650,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 2-0 R (Tr 72.250,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 10.040,00
handscoond steril 6.5 (G 58.216,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 27.843,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 47.016,00
Masker Karet 11.000,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 4.260,00

19/08/2021 12:42:30 Page 395 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.686 Yuliana SELAGAN JAYA 182473 Topi Operasi (Perawat) @
12/02/2021 00:00:00 4.690,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
viamac 1 R 364.370,00
viamac 1 R 182.185,00
Abbocath 20 Terumo @5
13/02/2021 00:00:00 79.023,00
Hypafix 15cmx5cm (25 c 13.088,00
Nassal Cannula O2 Dewas 11.625,00
Cefotaxime Injeksi
14/02/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 8.550,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
15/02/2021 00:00:00 3.575,00
Cefotaxime Injeksi 5.751,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 300 mg Tabl 17.500,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix Kamar Operasi 18.000,00
Kassa kotak stril DRC 9.675,00
Ketoprofen tab 100 mg 18.570,00
Postofix (leukomed) 36.726,00
Total 1.867.135,00
1.687 Zukriman LUBUK GEDANG 160918 Asam Folat 1 mg @100 T
12/02/2021 00:00:00 297,00 BPJS
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 69.912,00
Flunarizine 5 mg tab 4.950,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 34.200,00
Otsu D40 25.026,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Flunarizine 5 mg tab
13/02/2021 00:00:00 24.750,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 24.998,00
Perifas @100 Tab 25.025,00
Total 291.483,00
1.688 Lesnawati TANAH REKAH 182045 Cefotaxime Injeksi
13/02/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 20 Terumo @5
14/02/2021 00:00:00 79.023,00
Amlodipine 10 mg @50 T 1.180,00
Asam Mefenamat 500 m 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00

19/08/2021 12:42:30 Page 396 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.688 Lesnawati TANAH REKAH 182045 Metrodinazole tab 500 m
14/02/2021 00:00:00 2.700,00 BPJS
Postofix (leukomed) 36.726,00
Total 204.372,00
1.689 Matori TUNGGAL JAYA 180688 Abbocath 20 Terumo @5
12/02/2021 00:00:00 52.682,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 9.538,00
Total 123.667,00
1.690 Tumijo Taruno LUBUK SANAI 182324 abbocath 18 Terumo @5
12/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Nassal Cannula O2 Dewas 11.625,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Total 125.178,00
1.691 Matori TUNGGAL JAYA 180688 Ceftriaxone Inj
12/02/2021 00:00:00 6.249,00 BPJS
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 4.125,00
Ceftriaxone Inj
13/02/2021 00:00:00 12.498,00
Omeprazole Inj 24.998,00
Omeprazole Inj 74.994,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 28.614,00
Cefixime kapsul 200 mg
14/02/2021 00:00:00 26.480,00
Ceftriaxone Inj 12.498,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 28.614,00
Total 276.082,00
1.692 Tumijo Taruno LUBUK SANAI 182324 Ceftriaxone Inj
12/02/2021 00:00:00 6.249,00 BPJS
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
13/02/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
14/02/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 28.614,00
Alkohol 1Liter
15/02/2021 00:00:00 42.111,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 11.825,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00

19/08/2021 12:42:30 Page 397 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.692 Tumijo Taruno LUBUK SANAI 182324 Cuticell Classic 10cmx10c
15/02/2021 00:00:00 35.121,00 BPJS
Ephedrine Injeksi 21.422,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Iodine povidone 300 ml 28.463,00
Masker 3 Play N. 95 470.160,00
Masker Karet 22.000,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Polyvinylidene 1-0 R (Tri 105.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 61.688,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Urine bag 10.088,00
viamac 1 R 182.185,00
Ceftriaxone Inj
16/02/2021 00:00:00 6.249,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Cefixime Kapsul 100 mg
17/02/2021 00:00:00 9.380,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Omeprazole Inj 24.998,00
Total 1.958.783,00
1.693 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
12/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.694 Salami SILAUT I 134774 Amlodipine 10 mg @50 T
12/02/2021 00:00:00 354,00 BPJS
Dexametason Injeksi 9.384,00
Lansoprazole kapsul 30 m 3.465,00
NACL 0,9 % 500 ml 42.750,00
Simvastatin tab 20 mg 933,00
Total 56.886,00
1.695 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
12/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.696 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
12/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.697 Suparmi SILAUT 156450 Amlodipine 10 mg @50 T
12/02/2021 00:00:00 954,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Simvastatin tab 20 mg 933,00
Total 44.637,00
1.698 Suwarni SUKA MAJU 164065 Lansoprazole kapsul 30 m
12/02/2021 00:00:00 3.465,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Nassal Cannula O2 Dewas 11.625,00
Ranitidin inj 5.370,00
Total 63.210,00
1.699 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
12/02/2021 00:00:00 42.750,00 BPJS

19/08/2021 12:42:30 Page 398 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 42.750,00
1.700 Roslina TERUNTUNG 130072 Amlodipine 10 mg @50 T
12/02/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Total 34.554,00
1.701 Silya Wana BANDARATU 117469 Amlodipine 10 mg @50 T
12/02/2021 00:00:00 354,00 BPJS
Dexametason Injeksi 6.256,00
NACL 0,9 % 500 ml 42.750,00
Otsu D40 25.026,00
Transfusi Set Terumo 16.500,00
Total 90.886,00
1.702 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
12/02/2021 00:00:00 42.750,00 BPJS
Simvastatin tab 20 mg 933,00
Total 43.683,00
1.703 Niar TANAH REKAH 182475 abbocath 18 Terumo @5
12/02/2021 00:00:00 26.341,00 BPJS
Asam Mefenamat 500 m 1.290,00
Cefadroxil tab 500 mg @1 10.500,00
Chromic catgut 3-0 R (Tr 66.250,00
Infusion Makro (terumo) 27.225,00
Lidocain injk 40 mg/2 ml 3.222,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Polypropylene 3/0 C (Ass 235.200,00
Tetagam 1 Ml Injeksi 184.000,00
Total 569.272,00
1.704 Abdul Gani PAUH TERENJA 123542 Infusion Makro (terumo)
12/02/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Total 35.775,00
1.705 Adriell Kazshio Pratam RANAH KARYA 175878 Abbocath 24 Terumo @5
12/02/2021 00:00:00 11.138,00 BPJS
Asam Folat 1 mg @100 T 99,00
Infusion Makro (terumo) 27.225,00
Ka-En 1 B 12.658,00
Ringer Laktat Otsuka 9.538,00
Sibital Injeksi (Phenobarbit 24.750,00
Vitamin B Komplek @100 154,00
Total 85.562,00
1.706 Tono DUSUN 3 TIRTA MUL 181740 Abbocath 20 Terumo @5
12/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 3 Way No. 24 ( 44.688,00
Ceftriaxone Inj 6.249,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 5.959,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 2.105,00
Urine bag 10.088,00
Ascorbid Acid 1000mg/5m
13/02/2021 00:00:00 78.375,00
Ascorbid Acid 1000mg/5m 26.125,00
Ceftriaxone Inj 12.498,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.706 Tono DUSUN 3 TIRTA MUL 181740 Extrace Injeksi 100 mg/m
13/02/2021 00:00:00 19.250,00 BPJS
NACL 0,9 % 500 ml 42.750,00
NACL 0,9 % 500 ml 171.000,00
NACL 0,9 % 500 ml 85.500,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Ascorbid Acid 1000mg/5m
14/02/2021 00:00:00 78.375,00
Ceftriaxone Inj 12.498,00
Kamadol Injeksi 17.100,00
NACL 0,9 % 500 ml 85.500,00
NACL 0,9 % 500 ml 171.000,00
Omeprazole Inj 12.499,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Traneksamat @10
15/02/2021 00:00:00 21.050,00
Total 1.153.648,00
1.707 Adriell Kazshio Pratam RANAH KARYA 175878 Asam Folat 1 mg @100 T
13/02/2021 00:00:00 99,00 BPJS
Ka-En 1 B 12.658,00
Phenobarbital Injeksi 50 m 7.430,00
Vitamin B Komplek @100 154,00
Asam Folat 1 mg @100 T
14/02/2021 00:00:00 198,00
Ranitidin inj 1.790,00
Ambroxol Syr 15mg/ml
15/02/2021 00:00:00 4.538,00
Asam Folat 1 mg @100 T 297,00
Cefixime syrup 100mg/5 M 23.823,00
Phenobarbital Tablet 30 m 3.510,00
Vitamin B Komplek @100 1.232,00
Total 55.729,00
1.708 Andri Yadi PENARIK 182476 Abbocath 20 Terumo @5
13/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Metoclopramide inj 5Mg/M 5.879,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Mecobalamin 500 mg 770,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 400 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.708 Andri Yadi PENARIK 182476 Abbocath 20 Terumo @5
14/02/2021 00:00:00 52.682,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 14.550,00
Hypafix 10cm x 5cm (25 c 4.850,00
Mecobalamin 500 mg 2.310,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Cefixime Kapsul 100 mg
15/02/2021 00:00:00 9.380,00
Hypafix 10cm x 5cm (25 c 4.850,00
Mecobalamin 500 mg 7.700,00
Metoclorapamide tab 10 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 526.573,00
1.709 Hanifah Nurul Husna SILAUT 182477 Aqua Pro Injeksi
13/02/2021 00:00:00 3.575,00 BPJS
Glukosa Infus 10 % 9.375,00
Infusion set Mikro (Terumo 18.026,00
Ka-En 1 B 12.658,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Abbocath 24 Terumo @5 33.414,00
NGT (Feeding Tube) Fr. 8 70.420,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 15x 6.694,00
Abbocath 24 Terumo @5
16/02/2021 00:00:00 22.276,00
NonWoven Fixation 15x 6.694,00
Total 268.796,00
1.710 Poniah RAWA BANGUN 182478 Abbocath 20 Terumo @5
13/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj 12.498,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Zinc Sulfate Syr 60 ml 4.569,00
Zink Tablet 1.378,00
Ceftriaxone Inj
14/02/2021 00:00:00 12.498,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00

19/08/2021 12:42:30 Page 401 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.710 Poniah RAWA BANGUN 182478 Cefixime Kapsul 100 mg
15/02/2021 00:00:00 9.380,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 273.651,00
1.711 Asmansyah SIBAK 140995 Amlodipine 10 mg @50 T
13/02/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Simvastatin tab 20 mg 933,00
Total 35.487,00
1.712 Mutmainnah SUNGAI RENGAS 114676 Infusion Makro (terumo)
13/02/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Otsu D40 37.539,00
Paracetamol tablet 500 m 600,00
Total 99.564,00
1.713 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
13/02/2021 00:00:00 34.200,00 BPJS
Otsu D40 25.026,00
Total 59.226,00
1.714 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
13/02/2021 00:00:00 34.200,00 BPJS
Otsu D40 37.539,00
Paracetamol tablet 500 m 600,00
Transfusi Set Terumo 16.500,00
Total 88.839,00
1.715 Irwan Sakti DANAU NIBUNG 154908 Amlodipine 10 mg @50 T
13/02/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Otsu D40 37.539,00
Paracetamol tablet 500 m 600,00
Total 72.693,00
1.716 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
13/02/2021 00:00:00 42.750,00 BPJS
Transfusi Set Terumo 16.500,00
Total 59.250,00
1.717 Sumidah RAWA MULYA 163860 Infusion Makro (terumo)
13/02/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Otsu D40 25.026,00
Total 95.001,00
1.718 Kasmidi Kasim BANDAR RATU 135355 Infusion Makro (terumo)
13/02/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 69.975,00
1.719 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
13/02/2021 00:00:00 17.100,00 BPJS
Otsu D40 25.026,00
Paracetamol tablet 500 m 600,00
Total 42.726,00
1.720 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
13/02/2021 00:00:00 42.750,00 BPJS
Transfusi Set Terumo 16.500,00
Total 59.250,00
1.721 Aufa Syarif Ramadhan TIRTA MAKMUR 182483 Abbocath 22 Terumo @5
13/02/2021 00:00:00 22.276,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 24.998,00

19/08/2021 12:42:30 Page 402 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.721 Aufa Syarif Ramadhan TIRTA MAKMUR 182483 Omeprazole Inj
13/02/2021 00:00:00 12.499,00 BPJS
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 4.210,00
Total 204.227,00
1.722 Mirawati TALANG SAKTI 182482 Abbocath 20 Terumo @5
13/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 4.950,00
Otsu D40 12.513,00
Ringer Laktat Otsuka 9.538,00
Cefotaxime Injeksi
14/02/2021 00:00:00 11.502,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Ondansetron Inj 3.300,00
Cefotaxime Injeksi
15/02/2021 00:00:00 11.502,00
Ondansetron Inj 3.300,00
Ondansetron tablet 8 mg 26.400,00
Paracetamol tablet 500 m 2.000,00
Total 185.319,00
1.723 Aufa Syarif Ramadhan TIRTA MAKMUR 182483 Ceftriaxone Inj
13/02/2021 00:00:00 6.249,00 BPJS
Ringer Laktat Otsuka 9.538,00
Atropin injek 1 ml
15/02/2021 00:00:00 6.969,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Catheter 2 Way No. 16 ( 39.025,00
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7.5 16.488,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Omeprazole Inj 37.497,00
Paracetamol Infus 28.876,00
Polyvinylidene 1-0 R (Tri 105.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Silk 2/0 R scimitar 61.688,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Urine bag 10.088,00

19/08/2021 12:42:30 Page 403 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.723 Aufa Syarif Ramadhan TIRTA MAKMUR 182483 viamac 1 R
15/02/2021 00:00:00 182.185,00 BPJS
Bucain Spinal 0.5 % Inj
16/02/2021 00:00:00 52.181,00
Ceftriaxone Inj 12.498,00
Handscoon steril 7,5 (Ga 43.689,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8.0 (T 14.988,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 239.375,00
Aminofluid Infus 500 ml
17/02/2021 00:00:00 310.408,00
Ka-En Mg3 13.104,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 11.758,00
Metoclopramide inj 5Mg/M 11.758,00
NGT (Stomach Tube) Fr. 1 14.600,00
Omeprazole Inj 12.499,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Abbocath 24 Terumo @5
18/02/2021 00:00:00 11.138,00
Aminofluid Infus 500 ml 310.408,00
Cuticell Classic 10cmx10c 35.121,00
Furamin Injeksi 28.738,00
Ka-En Mg3 26.208,00
Kassa kotak stril DRC 19.350,00
Kassa kotak stril DRC 29.025,00
Levofloxacin Infus 48.976,00
Metoclopramide inj 5Mg/M 11.758,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Fentanyl Injeksi 5 Ampul 2
19/02/2021 00:00:00 52.000,00
Furamin Injeksi 57.476,00
Furamin Injeksi 28.738,00
Ka-En Mg3 26.208,00
Levofloxacin Infus 48.976,00
Metoclopramide inj 5Mg/M 29.395,00
Metoclopramide inj 5Mg/M 11.758,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 49.996,00
Omeprazole Inj 12.499,00
Paracetamol Infus 28.876,00
Piralen Injeksi 2 ml 17.600,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Furamin Injeksi
20/02/2021 00:00:00 28.738,00
Levofloxacin Infus 48.976,00
Metoclopramide inj 5Mg/M 11.758,00

19/08/2021 12:42:30 Page 404 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.723 Aufa Syarif Ramadhan TIRTA MAKMUR 182483 Omeprazole Inj
20/02/2021 00:00:00 12.499,00 BPJS
Cuticell Classic 10cmx10c
21/02/2021 00:00:00 35.121,00
Furamin Injeksi 28.738,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 29.025,00
Levofloxacin Infus 48.976,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 24.998,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00
Cefixime syrup 100mg/5 M
22/02/2021 00:00:00 47.646,00
Cuticell Classic 10cmx10c 35.121,00
Furamin Injeksi 57.476,00
Furamin Injeksi 28.738,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Omeprazole Inj 24.998,00
Omeprazole Inj 12.499,00
Omeprazole Inj 24.998,00
Paracetamol Drop 8.726,00
Paracetamol Infus 43.314,00
Piralen Injeksi 2 ml 26.400,00
Piralen Injeksi 2 ml 17.600,00
Piralen Injeksi 2 ml 26.400,00
Total 3.636.861,00
1.724 Afrianto TAPAN 144878 Abbocath 20 Terumo @5
13/02/2021 00:00:00 26.341,00 BPJS
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Venturi Mask Dewasa Ge 34.375,00
Vitamin C tablet @100 Ta 276,00
Total 224.454,00
1.725 Raffasa Friardi BANDAR RATU 182484 Ondansetron tablet 8 mg
13/02/2021 00:00:00 26.400,00 BPJS
Paracetamol tablet 500 m 4.000,00
Total 30.400,00
1.726 Afrianto TAPAN 144878 Amlodipine 5 mg @30 T
14/02/2021 00:00:00 404,00 BPJS
Asam Folat 1 mg @100 T 396,00
Azitromycin 500 mg 22.500,00
Candesartan tab 8 mg 1.362,00
Ceftriaxone Inj 18.747,00
Ceftriaxone Inj 12.498,00
Extrace Injeksi 100 mg/m 0,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.726 Afrianto TAPAN 144878 NACL 0,9 % 500 ml
14/02/2021 00:00:00 25.650,00 BPJS
Oseltamivir 75 mg 4,00
Paracetamol tablet 500 m 800,00
Vectrein Syrup 45.000,00
Vitamin C tablet @100 Ta 552,00
Total 127.913,00
1.727 Nirwana DUSUN JARANG 182487 Cefoperazon Inj
13/02/2021 00:00:00 82.500,00 BPJS
Levemir FlexPen 104.938,00
Novo Twist 32 G Tip 2.604,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Total 226.741,00
1.728 Suwarni SUKA MAJU 164065 Abbocath 20 Terumo @5
13/02/2021 00:00:00 26.341,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Transfusi Set Terumo 16.500,00
Dexametason Injeksi
14/02/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 13.388,00
Ondansetron Inj 4.950,00
Abbocath 20 Terumo @5
15/02/2021 00:00:00 26.341,00
Amlodipine 5 mg @30 T 101,00
Amlodipine 5 mg @30 T 202,00
Amlodipine 5 mg @30 T 1.010,00
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 1.362,00
Candesartan tab 8 mg 6.810,00
Erphafillin Tab 1.107,00
Erphafillin Tab 1.107,00
Erphafillin Tab 3.690,00
Furosemide 40 mg Tablet 96,00
Furosemide 40 mg Tablet 96,00
Furosemide 40 mg Tablet 960,00
Hypafix Kamar Operasi 18.000,00
NACL 0,9 % 500 ml 8.550,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Simvastatin tab 10 mg 2.410,00
Transfusi Set Terumo 16.500,00
Total 227.638,00
1.729 Nirwana DUSUN JARANG 182487 Cefoperazon Inj
14/02/2021 00:00:00 41.250,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Cefoperazon Inj
15/02/2021 00:00:00 82.500,00

19/08/2021 12:42:30 Page 406 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.729 Nirwana DUSUN JARANG 182487 Hypafix 15cmx5cm (25 c
15/02/2021 00:00:00 6.544,00 BPJS
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Cefoperazon Inj
16/02/2021 00:00:00 82.500,00
Ketorolac inj 30 mg/1ml 2.690,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 28.614,00
ursodeoxycholic acid 5.670,00
Levofloxacin Tablet 500 m
17/02/2021 00:00:00 13.640,00
Mecobalamin 500 mg 7.700,00
Novo Twist 32 G Tip 3.856,00
Sucralfate Suspensi 100 m 19.250,00
ursodeoxycholic acid 56.700,00
Total 494.471,00
1.730 Slamet Rozaki SUMBER MAKMUR 182489 Abbocath 20 Terumo @5
14/02/2021 00:00:00 26.341,00 BPJS
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Zink Tablet 689,00
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Zinc Sulfate Syr 60 ml 4.569,00
Alinamin F 50 mg @100 T
15/02/2021 00:00:00 11.500,00
Furamin Injeksi 28.738,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 24.998,00
Zink Tablet 1.378,00
Total 243.372,00
1.731 Selpi Andriyani LALANG LUAS 173623 abbocath 18 Terumo @5
14/02/2021 00:00:00 26.341,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 3-0 R (Tr 66.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril 7,5 (Ga 29.126,00

19/08/2021 12:42:30 Page 407 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.731 Selpi Andriyani LALANG LUAS 173623 handscoond steril 8 (Gam
14/02/2021 00:00:00 29.108,00 BPJS
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
methyl ergometrin amp 8.662,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 1cc terumo 9.488,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 4.260,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 182.185,00
viamac 1 R 182.185,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 36.093,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
15/02/2021 00:00:00 7.150,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 1.350,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
16/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
17/02/2021 00:00:00 1.935,00
Cefadroxil tab 500 mg @1 10.500,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.667.855,00
1.732 Ny.selpi Andriyani I LALANG LUAS 182491 Ampicilin Serbuk Injeksi 1
14/02/2021 00:00:00 10.811,00 BPJS
Bisturi no. 10 3.836,00
Chloramphenicol Salep M 2.351,00

19/08/2021 12:42:30 Page 408 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.732 Ny.selpi Andriyani I LALANG LUAS 182491 Hypafix 10cm x 5cm (25 c
14/02/2021 00:00:00 4.850,00 BPJS
umbilical Cord Clamp 2.261,00
Total 24.109,00
1.733 Ny.selpi Andriyani Ii LALANG LUAS 182492 Ampicilin Serbuk Injeksi 1
14/02/2021 00:00:00 10.811,00 BPJS
Bisturi no. 10 3.836,00
Chloramphenicol Salep M 2.351,00
Glukosa Infus 10 % 9.375,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
umbilical Cord Clamp 2.261,00
Total 51.510,00
1.734 Slamet Kurniadi BANDAR JAYA 182493 Abbocath 20 Terumo @5
14/02/2021 00:00:00 26.341,00 BPJS
ATS (Anti Tetanus Serum 150.000,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Chromic catgut 2-0 R (Tr
15/02/2021 00:00:00 72.250,00
Lidocain injk 40 mg/2 ml 20.943,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Total 426.907,00
1.735 Sri Utami PAUH TERENJA 182494 Abbocath 20 Terumo @5
14/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 200,00
Ringer Laktat Otsuka 9.538,00
Cefotaxime Injeksi
15/02/2021 00:00:00 11.502,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 1.000,00
Sucralfate Suspensi 100 m 19.250,00
Cefixime Kapsul 100 mg
16/02/2021 00:00:00 9.380,00
Pregnolin tab 5 mg 45.000,00
Total 183.093,00
1.736 Slamet Kurniadi BANDAR JAYA 182493 Ascorbid Acid 1000mg/5m
15/02/2021 00:00:00 78.375,00 BPJS
Cefotaxime Injeksi 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 19.350,00
Ketoprofen tab 100 mg 12.380,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 19.076,00
Total 215.089,00
1.737 Kurnadi ARAH TIGA 154209 Asam Folat 1 mg @100 T
14/02/2021 00:00:00 297,00 BPJS
NACL 0,9 % 500 ml 25.650,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
15/02/2021 00:00:00 297,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 25.650,00

19/08/2021 12:42:30 Page 409 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.737 Kurnadi ARAH TIGA 154209 Omeprazole Inj
15/02/2021 00:00:00 12.499,00 BPJS
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
16/02/2021 00:00:00 297,00
Ceftriaxone Inj 24.996,00
Esomeprazol Injeksi 40 m 34.956,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gentamicin Injeksi 9.212,00
Gentamicin Injeksi 9.212,00
Kassa kotak stril DRC 29.025,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 41.252,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Asam Folat 1 mg @100 T
17/02/2021 00:00:00 297,00
Ceftriaxone Inj 24.996,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Kassa kotak stril DRC 19.350,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 41.252,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Phytomenadione 10 mg ( 2.802,00
Abbocath 20 Terumo @5
18/02/2021 00:00:00 52.682,00
Abbocath 22 Terumo @5 44.552,00
Abbocath 22 Terumo @5 33.414,00
Abbocath 24 Terumo @5 33.414,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Neurodex tablet 2.223,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 2.105,00
Bisturi No. 23
19/02/2021 00:00:00 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00

19/08/2021 12:42:30 Page 410 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.737 Kurnadi ARAH TIGA 154209 Dexametason Injeksi
19/02/2021 00:00:00 6.256,00 BPJS
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Ephedrine Injeksi 10.711,00
Furosemide Injeksi @2ml 1.666,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker Karet Boism 47.580,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol Infus 43.314,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Catheter 2 Way No. 16 (
20/02/2021 00:00:00 20.625,00
Chlorpromazine @ 100m 220,00
Ketorolac inj 30 mg/1ml 1.345,00
Levofloxacin Infus 48.976,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Cuticell Classic 10cmx10c
21/02/2021 00:00:00 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 38.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 48.976,00
Novo Twist 32 G Tip 1.928,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00
Dexametason Injeksi
22/02/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Glukosa Infus 5 % 8.626,00
Ketorolac inj 30 mg/1ml 4.035,00

19/08/2021 12:42:30 Page 411 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.737 Kurnadi ARAH TIGA 154209 Ketorolac inj 30 mg/1ml
22/02/2021 00:00:00 2.690,00 BPJS
Levofloxacin Infus 24.488,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 3.300,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Abbocath 24 Terumo @5
23/02/2021 00:00:00 79.023,00
Glimepiride tab 2 mg 2.590,00
Glukosa Infus 5 % 25.878,00
Levofloxacin Tablet 500 m 13.640,00
Omeprazole Inj 49.996,00
Paracetamol Infus 28.876,00
Paracetamol tablet 500 m 4.000,00
Total 2.465.831,00
1.738 Nova Andriani BANDARATU 182495 abbocath 18 Terumo @5
14/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Cefixime Kapsul 100 mg
16/02/2021 00:00:00 9.380,00
Pregnolin tab 5 mg 45.000,00
Total 122.779,00
1.739 Joni Suhendri PENARIK 161634 Abbocath 20 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix Kamar Operasi 18.000,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 5.380,00
NACL 0,9 % 500 ml 17.100,00
Renax @50 Kapsul 34.032,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Urinter Kapsul @100 cap 4.396,00
Urinter Kapsul @100 cap 4.396,00
Alprazolam 0,5 mg @100
16/02/2021 00:00:00 118,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac inj 30 mg/1ml 4.035,00
Natrium diclofenac 50 m 867,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 308,00

19/08/2021 12:42:30 Page 412 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.739 Joni Suhendri PENARIK 161634 Ceftriaxone Inj
17/02/2021 00:00:00 12.498,00 BPJS
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac inj 30 mg/1ml 4.035,00
Ringer Laktat Otsuka 9.538,00
Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazol kapsul 20 mg 3.305,00
Renax @50 Kapsul 170.160,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Total 664.131,00
1.740 Jusmarni SUNGAI JERINJING 182433 abbocath 18 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Asam Folat 1 mg @100 T 297,00
Catheter 2 Way No. 18 ( 31.251,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Stomach Tube) Fr. 1 60.046,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 4.605,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix Kamar Operasi 18.000,00
Meropenem Inj 0.5 g 110.000,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Urine bag 10.088,00
ATRACURIUM BESYLATE 2
16/02/2021 00:00:00 29.342,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 0,00
Dopamin Giulini 200 mg I 97.625,00
Dopamin Giulini 200 mg I 97.625,00
Electroda (Ambu) @25 Pc 81.570,00
ETT 7.0 (Non Kingking B 21.184,00
Extention Tube 8.801,00
Fentanyl Injeksi 5 Ampul 2 104.000,00
Fresofol ( propopol ) inj 0,00
Furosemide Injeksi @2ml 1.666,00
Handscoond Sterille 7 (G 43.689,00

19/08/2021 12:42:30 Page 413 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.740 Jusmarni SUNGAI JERINJING 182433 Infusion Makro (terumo)
16/02/2021 00:00:00 27.225,00 BPJS
Lidocain injk 40 mg/2 ml 3.222,00
Meropenem Inj 0.5 g 110.000,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Dewasa 41.828,00
NonWoven Fixation 15x 13.388,00
NonWoven Fixation 15x 26.776,00
Norepinephrine Inj 0,00
Norepinephrine Inj 30.938,00
Omeprazole Inj 24.998,00
Renogen 3000 UI 116.875,00
Suction Chateter no. 12 ( 10.588,00
Three Way stopcock 25.904,00
Three Way stopcock 25.904,00
Venturi Mask Dewasa Ge 34.375,00
Ceftriaxone Inj
17/02/2021 00:00:00 24.996,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Asam Folat 1 mg @100 T
18/02/2021 00:00:00 297,00
Ceftriaxone Inj 24.996,00
Cetadop inj 0,00
Dexametason Injeksi 0,00
Dipenhydramin Injeksi 10 1.535,00
Guedel No 110 MM 18.233,00
Hypafix 10cm x 5cm (25 c 4.850,00
Inviclot Injeksi 5 Ml 107.062,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 42.750,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 20 Terumo @5
19/02/2021 00:00:00 52.682,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Epinephrin inj 30.662,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 9.700,00
meropenem Injeksi 1 g 41.250,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 16.840,00
Tranexamic Acid Inj (Asa 18.945,00
Tranexamic Acid Inj (Asa 16.840,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.740 Jusmarni SUNGAI JERINJING 182433 Tranexamic Acid Inj (Asa
19/02/2021 00:00:00 18.945,00 BPJS
Total 2.452.162,00
1.741 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.742 Narti SILAUT 175653 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.743 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.744 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.745 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.746 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.747 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.748 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.749 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.750 Miswanto LUNANG 128267 NACL 0,9 % 500 ml
15/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.751 Rosnidar PENARIK 131980 Abbocath 20 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Arixtra Injeksi 2.5mg/0.5 326.625,00
Aspilet 80 mg @100 mg 276,00
Clopidogrel 75 mg @30 T 7.020,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Isosorbid dinitrat 5 mg (I 1.110,00
Ranitidin inj 3.580,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Simvastatin tab 20 mg 311,00
Total 536.626,00
1.752 Okviv Hendri TANAH REKAH 170357 Simvastatin tab 20 mg
15/02/2021 00:00:00 9.330,00 BPJS
Total 9.330,00
1.753 Maril LUBUK SANAI 173422 Acetylcystein 200 mg Ka
15/02/2021 00:00:00 34.380,00 BPJS
Asam Traneksamat @10 42.100,00
Ethambutol 500 mg 38.745,00

19/08/2021 12:42:30 Page 415 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.753 Maril LUBUK SANAI 173422 Isoniazide 300 mg
15/02/2021 00:00:00 6.480,00 BPJS
Phytomenadione 10 mg ( 18.680,00
Rifampicin 450 33.840,00
Vitamin B Komplek @100 3.080,00
Total 177.305,00
1.754 Sapril SIBAK 181906 Amlodipine 5 mg @30 T
15/02/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Metformin tablet 500 mg 11.970,00
Total 35.430,00
1.755 Darzan TANJUNG ALAI 117357 Mecobalamin 500 mg
15/02/2021 00:00:00 23.100,00 BPJS
Meloxicam 7,5 mg 0,00
Omeprazol kapsul 20 mg 19.830,00
Total 42.930,00
1.756 Leni Hamnizar KAMPUNG DALAM 127045 Asam Mefenamat 500 m
15/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
1.757 Hendri Juli Pratama KOTA PRAJA 171435 Cefixime kapsul 200 mg
15/02/2021 00:00:00 26.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00
Salbutamol 4 mg 1.395,00
vestein 300 mg 93.500,00
Total 127.005,00
1.758 Damri PS MUKOMUKO 115165 Amlodipine 5 mg @30 T
15/02/2021 00:00:00 3.030,00 BPJS
Total 3.030,00
1.759 Suhardo TALANG SAKTI 182499 Abbocath 20 Terumo @5
15/02/2021 00:00:00 52.682,00 BPJS
Ceftriaxone Inj 12.498,00
NonWoven Fixation 15x 13.388,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 114.144,00
1.760 Kania Khairunnisa PASAR MUKOMUKO 170422 Urinter Kapsul @100 cap
15/02/2021 00:00:00 21.980,00 BPJS
Total 21.980,00
1.761 Mariatul Aini UJUNG PADANG 116823 Paracetamol tablet 500 m
15/02/2021 00:00:00 2.000,00 BPJS
Vitamin B Komplek @100 1.540,00
Total 3.540,00
1.762 Ismail TALANG KARET 120549 Alprazolam 1 mg @100 T
15/02/2021 00:00:00 3.200,00 BPJS
Total 3.200,00
1.763 Sonya Surya Pratama LUNANG 181678 Calcium Laktat
15/02/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.764 Nifka Maryanti TALANG SAKTI 182500 abbocath 18 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Alkohol 1Liter 42.111,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 118.250,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00

19/08/2021 12:42:30 Page 416 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.764 Nifka Maryanti TALANG SAKTI 182500 Handscoond Sterille 7 (G
15/02/2021 00:00:00 29.126,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 18.000,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 470.160,00
Masker Karet 22.000,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.969.323,00
1.765 M.nazir PONDOK LUNANG 117790 Ibuprofen tab 200 mg
15/02/2021 00:00:00 1.990,00 BPJS
Omeprazol kapsul 20 mg 13.220,00
Piralen tab 9.080,00
Total 24.290,00
1.766 Jaya TUNGGANG 172026 Amlodipine 5 mg @30 T
15/02/2021 00:00:00 3.030,00 BPJS
Asam Folat 1 mg @100 T 2.970,00
Fenitoin 100 mg @100 K 17.010,00
Fenitoin 100 mg @100 K 11.340,00
Mecobalamin 500 mg 23.100,00
Valsartan tab 80 mg 123.750,00
Total 181.200,00
1.767 Siti Nurfatonah WONOSOBO 182462 Metrodinazole tab 500 m
15/02/2021 00:00:00 2.700,00 BPJS
Nystatin Tab Vaginal 2.952,00
Total 5.652,00
1.768 Tuminah TALANG SARI IV 182297 Alprazolam 0,5 mg @100
15/02/2021 00:00:00 1.180,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Piralen tab 4.540,00
Total 14.330,00
1.769 Solehati BANDAR RATU 182373 Asam Mefenamat 500 m
15/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 51.861,00
1.770 Ria Julita LUBUK BENTO 157655 Asam Mefenamat 500 m
15/02/2021 00:00:00 1.935,00 BPJS

19/08/2021 12:42:30 Page 417 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.770 Ria Julita LUBUK BENTO 157655 Cefadroxil tab 500 mg @1
15/02/2021 00:00:00 10.500,00 BPJS
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 51.861,00
1.771 Zamhari BANDARATU 122356 Amlodipine 5 mg @30 T
15/02/2021 00:00:00 3.030,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Bisoprolol 5 mg @100 Ta 4.440,00
Captopril 12,5 mg 2.400,00
Furosemide 40 mg Tablet 960,00
Omeprazol kapsul 20 mg 19.830,00
Spironolaktone 25 mg 7.800,00
Total 42.600,00
1.772 Marzuki KAMPUNG DALAM 094337 Bisoprolol 5 mg @100 Ta
15/02/2021 00:00:00 4.440,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 0,00
Miniaspi 80 Mg @100 Ta 3.750,00
Simvastatin tab 20 mg 9.330,00
Total 90.600,00
1.773 Bekti PAUH TERENJA 166637 Ambroxol Syr 15mg/ml
15/02/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 56.250,00
Mecobalamin 500 mg 15.400,00
Paracetamol tablet 500 m 4.000,00
Total 80.188,00
1.774 Sepit SUNGAI IPUH 182512 Amlodipine 5 mg @30 T
15/02/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Gabapentin kapsul 300 m 38.070,00
Glimepiride tab 2 mg 7.770,00
Metformin tablet 500 mg 7.980,00
Total 77.280,00
1.775 Sani TERUNTUNG 127436 Asam Mefenamat 500 m
15/02/2021 00:00:00 1.935,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 2.700,00
Urine bag 10.088,00
Total 45.848,00
1.776 Lukmaini TALANG KUNING 182513 Calcium Laktat
15/02/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.777 Zahira Alesha TALANG BARU 166906 L-Bio sach @ 1gr
15/02/2021 00:00:00 43.105,00 BPJS
Zink Tablet 3.445,00
Total 46.550,00
1.778 Mustika Safitri TAPAN 182515 Calcium Laktat
15/02/2021 00:00:00 1.580,00 BPJS
Total 1.580,00
1.779 Khalisa Nur Shadika TAPAN 182516 Amoxicillin Syr
15/02/2021 00:00:00 6.531,00 BPJS
Total 6.531,00
1.780 Hermansyah PASAR MUKOMUKO 182219 Paracetamol tablet 500 m
15/02/2021 00:00:00 2.000,00 BPJS
Vitamin B Komplek @100 1.540,00
Total 3.540,00
1.781 Salis Lanjar LUBUK TALANG 116919 Ambroxol Syr 15mg/ml
15/02/2021 00:00:00 4.538,00 BPJS
Amoxicillin 500 mg @ 10 6.120,00
Captopril 12,5 mg 2.400,00
Furosemide 40 mg Tablet 2.880,00

19/08/2021 12:42:30 Page 418 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 15.938,00
1.782 A.halim BANDARATU 182517 Cefadroxil tab 500 mg @1
15/02/2021 00:00:00 10.500,00 BPJS
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 6.610,00
Total 41.860,00
1.783 Reni Salsabila Putri PENARIK 167965 Omeprazol kapsul 20 mg
15/02/2021 00:00:00 3.305,00 BPJS
Ranitidine tablet 150 mg 1.440,00
Total 4.745,00
1.784 Vito Ardiansyah LUBUK SANAI 182521 Ambroxol 30 mg @100 T
15/02/2021 00:00:00 579,00 BPJS
Dexametason 0,5 mg Ta 696,00
Paracetamol syrup 1.388,00
Salbutamol 4 mg 279,00
Total 2.942,00
1.785 Suryani Ndruhu TANAH REKAH 122047 Glimepiride tab 2 mg
15/02/2021 00:00:00 7.770,00 BPJS
Mecobalamin 500 mg 23.100,00
Metformin tablet 500 mg 7.980,00
Pregabalin Kap 75 mg 193.380,00
Total 232.230,00
1.786 Sutri Maideska PT AGRO AIR DIKIT 181963 Metrodinazole tab 500 m
15/02/2021 00:00:00 2.700,00 BPJS
Ondansetron tablet 8 mg 26.400,00
Total 29.100,00
1.787 X AIR DIKIT 182522 Domperidone Syrup 5mg
15/02/2021 00:00:00 10.279,00 BPJS
Total 10.279,00
1.788 Nursini LUNANG 182378 Asam Mefenamat 500 m
15/02/2021 00:00:00 1.935,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 51.861,00
1.789 Sukasdi LUNANG 1 114924 Ketoprofen tab 100 mg
15/02/2021 00:00:00 24.760,00 BPJS
Levofloxacin Tablet 500 m 20.460,00
Paracetamol tablet 500 m 4.000,00
Total 49.220,00
1.790 Alga Farunia Danesti KOTO JAYA 142755 Vitamin B Komplek @100
15/02/2021 00:00:00 1.540,00 BPJS
Total 1.540,00
1.791 Mega Puspita PAUH TERENJA 182532 abbocath 18 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 18.000,00

19/08/2021 12:42:30 Page 419 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.791 Mega Puspita PAUH TERENJA 182532 Induxin 1 ml Injeksi
15/02/2021 00:00:00 18.562,00 BPJS
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 470.160,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.890.929,00
1.792 Lusi TALANG KUNING 152729 abbocath 18 Terumo @5
15/02/2021 00:00:00 52.682,00 BPJS
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 11.825,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 18.000,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 470.160,00
Masker Karet 22.000,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00

19/08/2021 12:42:30 Page 420 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.792 Lusi TALANG KUNING 152729 Ringer Laktat Otsuka
15/02/2021 00:00:00 9.538,00 BPJS
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.892.995,00
1.793 Rosnidar PENARIK 131980 Arixtra Injeksi 2.5mg/0.5
16/02/2021 00:00:00 326.625,00 BPJS
Bisoprolol 5 mg @100 Ta 296,00
Clopidogrel 75 mg @30 T 1.755,00
Epinephrin inj 45.993,00
NonWoven Fixation 15x 6.694,00
Arixtra Injeksi 2.5mg/0.5
17/02/2021 00:00:00 326.625,00
Clopidogrel 75 mg @30 T 1.755,00
NonWoven Fixation 15x 6.694,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Simvastatin tab 20 mg 311,00
Amlodipine 5 mg @30 T
18/02/2021 00:00:00 1.010,00
Aspilet 80 mg @100 mg 966,00
Bisoprolol 5 mg @100 Ta 2.960,00
Candesartan tab 8 mg 6.810,00
Clopidogrel 75 mg @30 T 17.550,00
Isosorbid dinitrat 5 mg (I 1.110,00
Ranitidine tablet 150 mg 1.440,00
Simvastatin tab 10 mg 2.410,00
Total 764.122,00
1.794 Mega Puspita PAUH TERENJA 182532 Cefotaxime Injeksi
15/02/2021 00:00:00 11.502,00 BPJS
Dexametason Injeksi 18.768,00
Ephedrine Injeksi 343.750,00
Ketorolac Tab 10 Mg 7.590,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
16/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 23
17/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00

19/08/2021 12:42:30 Page 421 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.794 Mega Puspita PAUH TERENJA 182532 umbilical Cord Clamp
17/02/2021 00:00:00 2.261,00 BPJS
Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 523.963,00
1.795 Ikap LUBUK BANGKO 176074 Abbocath 20 Terumo @5
16/02/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Bunascan Spinal 0.5 63.525,00
catgut chromic 1 R (SMI) 54.921,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
handscoond steril 8 (Gam 43.662,00
Handscoond Sterille 6.5 24.732,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Premilene (Mesh Duzey) 6 167.000,00
Prolene no. 3/0 cutting 129.000,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 61.688,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Transfusi Set Terumo 16.500,00
Viamac 2/0 R (scimitar) 105.359,00
Cefotaxime Injeksi
17/02/2021 00:00:00 11.502,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Abbocath 20 Terumo @5
18/02/2021 00:00:00 26.341,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 9.538,00
Total 1.146.936,00
1.796 Iis Herawati DANAU NIBUNG 130346 Alkohol 1Liter
16/02/2021 00:00:00 42.111,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 11.825,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00

19/08/2021 12:42:30 Page 422 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.796 Iis Herawati DANAU NIBUNG 130346 Ephedrine Injeksi
16/02/2021 00:00:00 137.500,00 BPJS
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Hypafix Kamar Operasi 18.000,00
Iodine povidone 300 ml 28.463,00
Masker 3 Play N. 95 470.160,00
Masker Tali 41.600,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Silk 2/0 R scimitar 61.688,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 12.375,00
Urine bag 10.088,00
Ciprofloxacin tab 500 mg
17/02/2021 00:00:00 5.590,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 3.000,00
Total 1.596.718,00
1.797 Zahra Aysheilla Putri TERUTUNG 125109 Gypsona "4"
15/02/2021 00:00:00 161.362,00 BPJS
Softban 6 inci 34.375,00
Abbocath 20 Terumo @5
17/02/2021 00:00:00 26.341,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 19.076,00
Total 290.329,00
1.798 Lusi TALANG KUNING 152729 Cefotaxime Injeksi
15/02/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
17/02/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.080,00
Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 143.870,00

19/08/2021 12:42:30 Page 423 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.799 Nifka Maryanti TALANG SAKTI 182500 Ceftriaxone Inj
15/02/2021 00:00:00 12.498,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
16/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 6.725,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 1.350,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 23
17/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 19.350,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.080,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 176.906,00
1.800 Nurkasimah PASAR BELAKANG 124200 Abbocath 20 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 8.626,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Vitamin B Komplek @100 154,00
Total 118.093,00
1.801 Ade Susanti CINTA ASIH 182535 Abbocath 20 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 6.249,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00

19/08/2021 12:42:30 Page 424 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.801 Ade Susanti CINTA ASIH 182535 Ketorolac inj 30 mg/1ml
15/02/2021 00:00:00 2.690,00 BPJS
methyl ergometrin amp 6.700,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 1cc terumo 9.488,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
viamac 1 R 182.185,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
17/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.219.168,00
1.802 Nurkasimah PASAR BELAKANG 124200 Ambroxol Syr 15mg/ml
16/02/2021 00:00:00 4.538,00 BPJS
Amoxicillin 500 mg @ 10 918,00
Paracetamol tablet 500 m 600,00
Sucralfate Suspensi 100 m 19.250,00
Total 25.306,00
1.803 Ny.lusi TALANG KUNING 182536 Abbocath 24 Terumo @5
15/02/2021 00:00:00 44.552,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Injection plug 20.213,00
Bisturi No. 23
16/02/2021 00:00:00 3.836,00
Kassa kotak stril DRC 9.675,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
19/02/2021 00:00:00 0,00
Bactesyn inj 0,75 gr 59.009,00
Ottogenta inj 0,00
Phytomenadione 2 Mg/1M 4.834,00
Total 164.647,00
1.804 Tatan Rustiawan KARANG JAYA 179330 abbocath 18 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS

19/08/2021 12:42:30 Page 425 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.804 Tatan Rustiawan KARANG JAYA 179330 Antasida Syrup 60 ml
15/02/2021 00:00:00 2.736,00 BPJS
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Suprafenid Supositoria 10 28.050,00
Total 176.500,00
1.805 Trimo TELUK BAKUNG 182538 abbocath 18 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Kamadol Injeksi 17.100,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 28.614,00
Levofloxacin Infus
16/02/2021 00:00:00 48.976,00
Paracetamol tablet 500 m 600,00
Tramadol 50 mg/ml Inj 12.375,00
Levofloxacin Infus
17/02/2021 00:00:00 48.976,00
Novorapid Flexpen 108.750,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Abbocath 22 Terumo @5
18/02/2021 00:00:00 22.276,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 48.976,00
Metrodinazole Infus 30.939,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 19.076,00
Asam Mefenamat 500 m
19/02/2021 00:00:00 1.935,00
Hypafix 10cm x 5cm (25 c 9.700,00
Levofloxacin Tablet 500 m 13.640,00
Total 583.196,00
1.806 Tono DUSUN 3 TIRTA MUL 181740 abbocath 18 Terumo @5
15/02/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Tranexamic Acid Inj (Asa 2.105,00
Total 91.095,00
1.807 Tatan Rustiawan KARANG JAYA 179330 Antasida Syrup 60 ml
16/02/2021 00:00:00 2.736,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 24.998,00
Piralen Injeksi 2 ml 17.600,00
Piralen tab 4.540,00
Total 70.124,00
1.808 Siti Muarofah GAJAH MAKMUR 174195 Catheter 2 Way No. 16 (
16/02/2021 00:00:00 20.625,00 BPJS
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 72.250,00

19/08/2021 12:42:30 Page 426 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.808 Siti Muarofah GAJAH MAKMUR 174195 Induxin 1 ml Injeksi
16/02/2021 00:00:00 27.843,00 BPJS
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 5.959,00
Ringer Laktat Otsuka 19.076,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Total 200.937,00
1.809 Suhardo TALANG SAKTI 182499 Ceftriaxone Inj
16/02/2021 00:00:00 12.498,00 BPJS
Suprafenid Supositoria 10 28.050,00
Ceftriaxone Inj
18/02/2021 00:00:00 18.747,00
Levofloxacin Infus 73.464,00
Levofloxacin Infus 48.976,00
Levofloxacin Tablet 500 m 13.640,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Total 268.063,00
1.810 Siti Muarofah GAJAH MAKMUR 174195 Cefixime Kapsul 100 mg
16/02/2021 00:00:00 9.380,00 BPJS
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 144.500,00
Induxin 1 ml Injeksi 27.843,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 2.700,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 6 (R 16.333,00
umbilical Cord Clamp 4.522,00
Cefixime Kapsul 100 mg
18/02/2021 00:00:00 9.380,00
Metrodinazole tab 500 m 4.050,00
Neurodex tablet 7.410,00
Paracetamol tablet 500 m 3.000,00
Total 278.785,00
1.811 Tono DUSUN 3 TIRTA MUL 181740 Abbocath 20 Terumo @5
17/02/2021 00:00:00 52.682,00 BPJS
Ascorbid Acid 1000mg/5m 78.375,00
Ascorbid Acid 1000mg/5m 78.375,00
Ascorbid Acid 1000mg/5m 52.250,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00

19/08/2021 12:42:30 Page 427 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.811 Tono DUSUN 3 TIRTA MUL 181740 Furosemide Injeksi @2ml
17/02/2021 00:00:00 1.666,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Phytomenadione 2 Mg/1M 14.502,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Transfusi Set Terumo 16.500,00
Transfusi Set Terumo 16.500,00
abbocath 18 Terumo @5
18/02/2021 00:00:00 26.341,00
Abbocath 20 Terumo @5 52.682,00
Ascorbid Acid 1000mg/5m 78.375,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Asam Traneksamat @10
19/02/2021 00:00:00 31.575,00
Asam Traneksamat @10 42.100,00
Ascorbid Acid 1000mg/5m 209.000,00
Benovit C Tab multivitam 20.630,00
Hypafix 10cm x 5cm (25 c 9.700,00
Paracetamol tablet 500 m 3.000,00
Phytomenadione 2 Mg/1M 43.506,00
Total 1.072.077,00
1.812 Kardi SUNGAI RUMBAI 182540 abbocath 18 Terumo @5
16/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ascorbid Acid 1000mg/5m 78.375,00
Bisturi No. 23 7.672,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 256.570,00
1.813 Ari Mukti MUNDAM MARAP 182541 Codein tab 10 mg
16/02/2021 00:00:00 7.500,00 BPJS
Total 7.500,00
1.814 Deriati LUBUK GEDANG 132808 Amlodipine 10 mg @50 T
16/02/2021 00:00:00 1.180,00 BPJS
Candesartan tab 8 mg 6.810,00
Mecobalamin 500 mg 11.550,00
Omeprazol kapsul 20 mg 6.610,00
Total 26.150,00
1.815 Sukesi LUNANG 177153 Meprolut Tab
16/02/2021 00:00:00 125.400,00 BPJS
Total 125.400,00
1.816 Abu Razal LUBUK SANAI 160382 Eperisone Hcl 50 mg @1
16/02/2021 00:00:00 23.280,00 BPJS
Omeprazol kapsul 20 mg 6.610,00

19/08/2021 12:42:30 Page 428 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.816 Abu Razal LUBUK SANAI 160382 Paracetamol tablet 500 m
16/02/2021 00:00:00 2.000,00 BPJS
Total 31.890,00
1.817 Salami SILAUT I 134774 NACL 0,9 % 500 ml
16/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.818 Resdi Nawati Sinaga TALANG PETAI 148722 Cefixime Kapsul 100 mg
16/02/2021 00:00:00 9.380,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 28.630,00
1.819 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
16/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.820 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
16/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
1.821 Khoirul Anam PT.AGRO TALANG PET 178510 Orasic Kap
16/02/2021 00:00:00 73.160,00 BPJS
Paracetamol tablet 500 m 4.000,00
Vitamin B Komplek @100 3.080,00
Total 80.240,00
1.822 Rudito PT AGRO AIR BULUH 182435 Urinter Kapsul @100 cap
16/02/2021 00:00:00 21.980,00 BPJS
ursodeoxycholic acid 85.050,00
Total 107.030,00
1.823 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
16/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
1.824 Suwarni SUKA MAJU 164065 Amlodipine 5 mg @30 T
16/02/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 162.511,00
1.825 Rospita Diana Sihombin PENARIK 144044 Glimepiride tab 2 mg
16/02/2021 00:00:00 3.885,00 BPJS
Mecobalamin 500 mg 11.550,00
Metformin tablet 500 mg 3.990,00
Pregabalin Kap 75 mg 96.690,00
Total 116.115,00
1.826 Susi Martini KOTO JAYA 145038 Amlodipine 10 mg @50 T
16/02/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Total 151.429,00
1.827 Salbiyah LUBUK MUKTI 173013 Amlodipine 10 mg @50 T
16/02/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 68.400,00
Renogen 3000 UI 116.875,00
Total 185.629,00
1.828 Sri Wahyuni TUNGGAL JAYA 181008 Isoniazid tab 100 mg
16/02/2021 00:00:00 2.730,00 BPJS
Rifampicin 450 33.840,00
Total 36.570,00
1.829 Zakatul Aini PASAR MUKOMUKO 128408 Hexymer 2 Mg Tab (THP)
16/02/2021 00:00:00 28.680,00 BPJS
Leparson tablet 164.400,00
Sifrol tab 0,375 mg 311.250,00
Total 504.330,00
1.830 Roslina TERUNTUNG 130072 Amlodipine 5 mg @30 T
16/02/2021 00:00:00 303,00 BPJS
Lansoprazole kapsul 30 m 3.465,00

19/08/2021 12:42:30 Page 429 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.830 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
16/02/2021 00:00:00 42.750,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 163.993,00
1.831 Zukriman LUBUK GEDANG 160918 Epodion 3000 IU
16/02/2021 00:00:00 116.875,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 34.200,00
Total 168.712,00
1.832 Sulastri TALANG MEDAN 145735 Paracetamol tablet 500 m
16/02/2021 00:00:00 2.000,00 BPJS
Total 2.000,00
1.833 Yuni Kartini TALANG MEDAN 127780 Ciprofloxacin tab 500 mg
16/02/2021 00:00:00 5.590,00 BPJS
Metrodinazole tab 500 m 2.700,00
Total 8.290,00
1.834 Nayfa Ataya TALANG MEDAN 182544 Cotrimoxazol 240 mg Sir
16/02/2021 00:00:00 2.565,00 BPJS
Zink Tablet 6.890,00
Total 9.455,00
1.835 Junaidi SUNGAI IPUH 138273 Captopril 12,5 mg
16/02/2021 00:00:00 800,00 BPJS
Furosemide 40 mg Tablet 960,00
Loratadine tab 10 mg 1.660,00
Opilax Syr 49.156,00
Total 52.576,00
1.836 Herlina TALANG MEDAN 182545 Alprazolam 0,5 mg @100
16/02/2021 00:00:00 590,00 BPJS
Azitromycin 500 mg 28.125,00
Omeprazol kapsul 20 mg 6.610,00
Sistenol kaplet 17.540,00
Total 52.865,00
1.837 Ali Akbar BANTAL 182337 Eperisone Hcl 50 mg @1
16/02/2021 00:00:00 23.280,00 BPJS
Paracetamol tablet 500 m 2.000,00
Pregabalin Kap 75 mg 64.460,00
Total 89.740,00
1.838 Ijas LUBUK GEDANG 153187 Omeprazol kapsul 20 mg
16/02/2021 00:00:00 6.610,00 BPJS
Perifas @100 Tab 19.250,00
Total 25.860,00
1.839 M. Hosen UJUNG PADANG 129010 Amlodipine 10 mg @50 T
16/02/2021 00:00:00 3.540,00 BPJS
Candesartan tab 8 mg 20.430,00
Simvastatin tab 10 mg 7.230,00
Total 31.200,00
1.840 Anjellina Aprilia PENARIK 182520 Abbocath 22 Terumo @5
16/02/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Infusion set Mikro (Terumo 18.026,00
Ketorolac inj 30 mg/1ml 4.035,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Total 74.234,00
1.841 Margared Dwi Vera SUMBER SARI 175662 Calcium Laktat
16/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.842 Herawati PENARIK 181611 Asam Mefenamat 500 m
16/02/2021 00:00:00 1.935,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Total 16.275,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.843 Kusnan PENARIK 182546 Asam Mefenamat 500 m
16/02/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Dexametason 0,5 mg Ta 1.160,00
Total 8.040,00
1.844 Ahmad Khaidir Anuar UJUNG PADANG 172978 Hytroz tab 1 mg
16/02/2021 00:00:00 51.600,00 BPJS
Omeprazol kapsul 20 mg 13.220,00
Urinter Kapsul @100 cap 43.960,00
Total 108.780,00
1.845 Suhadi RAWA MULYA 143895 Acetylcystein 200 mg Ka
16/02/2021 00:00:00 34.380,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Piracetam tab 800 mg 22.590,00
Total 133.080,00
1.846 Marsem BUMI MULYA 140879 Calcium Laktat
16/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.847 Farida Ariyani BANDARATU 110785 Clopidogrel 75 mg @30 T
16/02/2021 00:00:00 52.650,00 BPJS
Ramipril tab 5 mg 9.180,00
Spironolaktone 25 mg 7.800,00
Total 69.630,00
1.848 Nining Arissetia Ningsi LUNANG SILAUT 146176 Glimepiride tab 2 mg
16/02/2021 00:00:00 3.885,00 BPJS
Mecobalamin 500 mg 11.550,00
Metformin tablet 500 mg 3.990,00
Pregabalin Kap 75 mg 96.690,00
Total 116.115,00
1.849 Herman Dani KUALA TERAMANG 181959 Alinamin F 50 mg @100 T
16/02/2021 00:00:00 11.500,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
ursodeoxycholic acid 85.050,00
Total 110.190,00
1.850 Nita Aguspa Herdalina BUKIT MAKMUR 144129 Cefixime Kapsul 100 mg
16/02/2021 00:00:00 9.380,00 BPJS
Gitas Plus 50.330,00
ursodeoxycholic acid 28.350,00
Total 88.060,00
1.851 Rahmat Al Amin MARGA MUKTI 171088 Loratadine tab 10 mg
16/02/2021 00:00:00 1.660,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 8.270,00
1.852 Arna Julita TUNGGANG 182430 Alprazolam 0,5 mg @100
16/02/2021 00:00:00 590,00 BPJS
Bisoprolol 5 mg @100 Ta 5.920,00
Domperidone Tab 1.620,00
Paracetamol tablet 500 m 2.000,00
Total 10.130,00
1.853 Santiani TERAS TERUNJAM 143154 Clindamycin 150 mg tabl
16/02/2021 00:00:00 8.750,00 BPJS
Total 8.750,00
1.854 Anjellina Aprilia PENARIK 182520 Ceftriaxone Inj
16/02/2021 00:00:00 12.498,00 BPJS
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Ketorolac inj 30 mg/1ml
17/02/2021 00:00:00 2.690,00
Ringer Laktat Otsuka 9.538,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.854 Anjellina Aprilia PENARIK 182520 Ciprofloxacin tab 500 mg
18/02/2021 00:00:00 5.590,00 BPJS
Fentanyl Injeksi 5 Ampul 2 52.000,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00
Total 170.813,00
1.855 Herman AIR PUNGGUR 119713 Alprazolam 1 mg @100 T
16/02/2021 00:00:00 800,00 BPJS
Betahistin Mesilat 6 mg @ 1.380,00
Natrium diclofenac 50 m 2.890,00
Sifrol tab 0,375 mg 311.250,00
Total 316.320,00
1.856 Rusminah TANJUNG MULYA 125539 Omeprazol kapsul 20 mg
16/02/2021 00:00:00 6.610,00 BPJS
Total 6.610,00
1.857 M. Aslan Sakir AIR BIKUK 167379 Paracetamol Drop
16/02/2021 00:00:00 8.726,00 BPJS
Total 8.726,00
1.858 Hayati AIR DIKIT 102175 Azitromycin 500 mg
16/02/2021 00:00:00 28.125,00 BPJS
Loratadine tab 10 mg 1.660,00
Omeprazol kapsul 20 mg 6.610,00
Symbicort Turbuhaler 80 167.855,00
Total 204.250,00
1.859 Omah SINAR JAYA 110951 Betahistin Mesilat 6 mg @
16/02/2021 00:00:00 2.760,00 BPJS
Paracetamol tablet 500 m 4.000,00
Total 6.760,00
1.860 Unna Zayba BANDARATU 182552 Abbocath 24 Terumo @5
16/02/2021 00:00:00 22.276,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Gentamicin Injeksi 9.212,00
Infusion set Mikro (Terumo 36.052,00
Phenobarbital Injeksi 50 m 3.715,00
Total 130.264,00
1.861 Marasai PONDOK PANJANG 175863 Cefadroxil tab 500 mg @1
16/02/2021 00:00:00 10.500,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 12.500,00
1.862 Agustina Luxmana Sa LUNANG 181953 Calcium Laktat
16/02/2021 00:00:00 790,00 BPJS
Total 790,00
1.863 Samsuar NELAN INDAH 137270 Cefixime kapsul 200 mg
16/02/2021 00:00:00 26.480,00 BPJS
Metrodinazole tab 500 m 4.050,00
Paracetamol tablet 500 m 3.000,00
Total 33.530,00
1.864 Siti Fatimah UJUNG PADANG 115314 Opilax Syr
16/02/2021 00:00:00 49.156,00 BPJS
Renax @50 Kapsul 340.320,00
Total 389.476,00
1.865 Anjeli Purnama Sari SIBAK 182398 abbocath 18 Terumo @5
16/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 2.690,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Atropin injek 1 ml 34.845,00
Betametason krim 0,1% 1.675,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.865 Anjeli Purnama Sari SIBAK 182398 Dexametason Injeksi
16/02/2021 00:00:00 15.640,00 BPJS
ETT 5.5 Balon (Non King 197.363,00
ETT 6.5 (Non KingKing B 41.250,00
Fresofol ( propopol ) inj 13.448,00
Gentamycin 0.1 % salep k 2.983,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 8.244,00
Kassa kotak stril DRC 19.350,00
Ketorolac inj 30 mg/1ml 2.690,00
Pehacain Injeksi 9.960,00
Pehacain Injeksi 3.320,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
silk 1 R scimitar 81.851,00
Silk 2/0 R scimitar 61.688,00
Spuit 5 cc Disposible 2.840,00
Spuit 5 cc Disposible 2.840,00
Tranexamic Acid Inj (Asa 4.210,00
Ceftriaxone Inj
17/02/2021 00:00:00 12.498,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole Infus 30.939,00
Nassal Cannula O2 Anak 16.473,00
Ranitidin inj 3.580,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 16.150,00
Spuit 5 cc Disposible 14.200,00
Cefixime kapsul 200 mg
18/02/2021 00:00:00 5.296,00
Methylprednisolone tab 4 526,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Cefixime Kapsul 100 mg
19/02/2021 00:00:00 9.380,00
Cetirgi Tab 10 mg 15.480,00
Methylprednisolone tab 4 2.630,00
Total 984.816,00
1.866 Unna Zayba BANDARATU 182552 Abbocath 24 Terumo @5
17/02/2021 00:00:00 33.414,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c
18/02/2021 00:00:00 4.850,00
NGT (Feeding tube) Fr. 5 17.603,00
Sibital Injeksi (Phenobarbit 12.375,00
Total 132.101,00
1.867 Dedek Subandar CINTA ASIH 182550 Abbocath 22 Terumo @5
16/02/2021 00:00:00 22.276,00 BPJS
Infusion Makro (terumo) 27.225,00
Bisturi No. 23
17/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 5.751,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.867 Dedek Subandar CINTA ASIH 182550 Cefotaxime Injeksi
17/02/2021 00:00:00 5.751,00 BPJS
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker Karet Boism 47.580,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 12.499,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 47.690,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Aqua Pro Injeksi
18/02/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Cuticell Classic 10cmx10c
19/02/2021 00:00:00 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 3.000,00
Total 814.381,00
1.868 Pelilawati TERAS TERUNJAM 119854 abbocath 18 Terumo @5
16/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Candesartan tab 8 mg 681,00
Cefoperazon Inj 82.500,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sistenol kaplet 5.262,00
Transfusi Set Terumo 16.500,00
Zink Tablet 1.378,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 17.100,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.868 Pelilawati TERAS TERUNJAM 119854 Transfusi Set Terumo
16/02/2021 00:00:00 16.500,00 BPJS
Allopurinol 300 Mg @100
17/02/2021 00:00:00 982,00
Asam Folat 1 mg @100 T 198,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Cefoperazon Inj 82.500,00
Codein tab 10 mg 1.500,00
Hypafix 10cm x 5cm (25 c 14.550,00
Infusion Makro (terumo) 27.225,00
L-Cisin tab 7.562,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sistenol kaplet 5.262,00
Transfusi Set Terumo 16.500,00
Zinc Sulfate Syr 60 ml 4.569,00
Allopurinol 300 Mg @100
18/02/2021 00:00:00 491,00
Asam Folat 1 mg @100 T 198,00
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 681,00
Cefoperazon Inj 82.500,00
Codein tab 10 mg 1.500,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sistenol kaplet 5.262,00
Zink Tablet 1.378,00
Allopurinol 300 Mg @100
19/02/2021 00:00:00 4.910,00
Asam Folat 1 mg @100 T 990,00
Candesartan tab 8 mg 6.810,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 37.497,00
Sistenol kaplet 15.786,00
Sistenol kaplet 17.540,00
Zink Tablet 1.378,00
Total 662.070,00
1.869 Rini S BATU EJUNG 180618 Aqua Pro Injeksi
16/02/2021 00:00:00 7.150,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 39.025,00
Celemek Plastik 23.650,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00

19/08/2021 12:42:30 Page 435 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.869 Rini S BATU EJUNG 180618 Hypafix 15cmx5cm (25 c
16/02/2021 00:00:00 6.544,00 BPJS
Induxin 1 ml Injeksi 18.562,00
Invitec tab (Misoprostol) 35.424,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 11.000,00
methyl ergometrin amp 8.662,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Urine bag 10.088,00
Cefotaxime Injeksi
17/02/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 15
18/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 10 Mg/1 5.959,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
20/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 1.587.886,00
1.870 Yon Zeni ARAH TIGA 156405 Dexametason Injeksi
16/02/2021 00:00:00 3.128,00 BPJS
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 9.700,00
Transfusi Set Terumo 16.500,00
Transfusi Set Terumo 16.500,00
Abbocath 20 Terumo @5
17/02/2021 00:00:00 26.341,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.870 Yon Zeni ARAH TIGA 156405 Furamin Injeksi
17/02/2021 00:00:00 14.369,00 BPJS
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Pregabalin Kap 75 mg 6.446,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Azitromycin 500 mg
18/02/2021 00:00:00 5.625,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 1.666,00
Ketorolac inj 30 mg/1ml 4.035,00
NonWoven Fixation 15x 13.388,00
Octalbin 25% 100 cc (Hu 1.887.500,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Abbocath 22 Terumo @5
19/02/2021 00:00:00 22.276,00
Abbocath 24 Terumo @5 52.682,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
NACL 0,9 % 500 ml 8.550,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Pregabalin Kap 75 mg 12.892,00
Ringer Laktat Otsuka 19.076,00
Asam Folat 1 mg @100 T
20/02/2021 00:00:00 495,00
Captopril 12,5 mg 400,00
Omeprazole Inj 12.499,00
Pregabalin Kap 75 mg 32.230,00
Total 4.467.504,00
1.871 Kardi SUNGAI RUMBAI 182540 Alkohol 1Liter
16/02/2021 00:00:00 42.111,00 BPJS
Aqua Pro Injeksi 10.725,00
ATRACURIUM BESYLATE 2 14.671,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 3 Way no. 22 64.816,00

19/08/2021 12:42:30 Page 437 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.871 Kardi SUNGAI RUMBAI 182540 Celemek Plastik
16/02/2021 00:00:00 118.250,00 BPJS
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 6.5 24.732,00
Handscoond Sterille 7 (G 29.126,00
Iodine povidone 300 ml 28.463,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 171.000,00
NACL 0,9 % 500 ml 85.500,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 60.046,00
NonWoven Fixation 15x 6.694,00
Polypropylene 3/0 C (Ass 235.200,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 76.304,00
Ringer Laktat Otsuka 19.076,00
silk 1 R scimitar 81.851,00
silk 1 R scimitar 163.702,00
Silk 2/0 R scimitar 61.688,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Spuit 50 cc Lbg tengah ( 9.776,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Ascorbid Acid 1000mg/5m
17/02/2021 00:00:00 78.375,00
Ceftriaxone Inj 12.498,00
NACL 0,9 % 500 ml 68.400,00
NACL 0,9 % 500 ml 85.500,00
NACL 0,9 % 500 ml 171.000,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Abbocath 20 Terumo @5
18/02/2021 00:00:00 52.682,00
Ascorbid Acid 1000mg/5m 78.375,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Infusion Makro (terumo) 27.225,00
Kassa kotak stril DRC 19.350,00
NACL 0,9 % 500 ml 128.250,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.871 Kardi SUNGAI RUMBAI 182540 NonWoven Fixation 15x
18/02/2021 00:00:00 6.694,00 BPJS
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Ascorbid Acid 1000mg/5m
19/02/2021 00:00:00 78.375,00
Ceftriaxone Inj 12.498,00
NACL 0,9 % 500 ml 171.000,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Ascorbid Acid 1000mg/5m
20/02/2021 00:00:00 287.375,00
Cefixime kapsul 200 mg 26.480,00
Cefixime kapsul 200 mg 26.480,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
NACL 0,9 % 500 ml 171.000,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 10 Mg/1 35.754,00
Vitamin C tablet @100 Ta 2.070,00
Total 3.731.238,00
1.872 Ani MEKAR JAYA 177355 abbocath 18 Terumo @5
16/02/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Amlodipine 10 mg @50 T 118,00
Aqua Pro Injeksi 3.575,00
Candesartan Tab 16 mg 1.179,00
Catheter 2 Way No. 16 ( 20.625,00
Citicoline Injeksi 125mg/ 22.500,00
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Infusion Makro (terumo) 27.225,00
NGT (Stomach Tube) Fr. 1 52.250,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 237.152,00
1.873 Bima Aryandika BANDARATU 178714 Electroda (Ambu) @25 Pc
16/02/2021 00:00:00 81.570,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Alprazolam 0,5 mg @100 1.180,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Amlodipine 5 mg @30 T
17/02/2021 00:00:00 202,00
Asam Folat 1 mg @100 T 297,00
Citicoline Injeksi 125mg/ 45.000,00
Eperisone Hcl 50 mg @1 23.280,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 42.750,00

19/08/2021 12:42:30 Page 439 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.873 Bima Aryandika BANDARATU 178714 Nassal Cannula O2 Anak
17/02/2021 00:00:00 16.473,00 BPJS
Renogen 3000 UI 116.875,00
Alprazolam 0,5 mg @100
18/02/2021 00:00:00 236,00
Amlodipine 5 mg @30 T 1.010,00
Asam Folat 1 mg @100 T 990,00
Candesartan tab 8 mg 6.810,00
Citicoline Injeksi 125mg/ 22.500,00
Eperisone Hcl 50 mg @1 23.280,00
Gabapentin kapsul 300 m 6.345,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 600,00
Total 483.164,00
1.874 Ani MEKAR JAYA 177355 Amlodipine 10 mg @50 T
17/02/2021 00:00:00 118,00 BPJS
Betadine Obat Kumur 13.750,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan Tab 16 mg 1.179,00
Citicoline Injeksi 125mg/ 22.500,00
Curcuma Tab 12.700,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Mecobalamin 500 mg 1.540,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 10 mg @50 T
18/02/2021 00:00:00 118,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan Tab 16 mg 1.179,00
Citicoline Injeksi 125mg/ 22.500,00
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Mecobalamin 500 mg 1.540,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 10 mg @50 T
19/02/2021 00:00:00 118,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan Tab 16 mg 1.179,00
Citicoline Injeksi 125mg/ 22.500,00
Clonidine 0.15 mg @100 T 458,00
Furamin Injeksi 14.369,00
Lapibal Injeksi 65.312,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Amlodipine 10 mg @50 T
20/02/2021 00:00:00 118,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan Tab 16 mg 1.179,00
Citicoline Injeksi 125mg/ 22.500,00
Clonidine 0.15 mg @100 T 229,00
Furamin Injeksi 14.369,00

19/08/2021 12:42:30 Page 440 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.874 Ani MEKAR JAYA 177355 Hypafix 10cm x 5cm (25 c
20/02/2021 00:00:00 4.850,00 BPJS
Lapibal Kapsul 500 mg 4.620,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 10 mg @50 T
21/02/2021 00:00:00 1.180,00
Amlodipine 5 mg @30 T 0,00
Bisoprolol 5 mg @100 Ta 296,00
Bisoprolol 5 mg @100 Ta 2.960,00
Candesartan Tab 16 mg 1.179,00
Candesartan Tab 16 mg 5.775,00
Candesartan Tab 16 mg 57.750,00
Citicoline Injeksi 125mg/ 0,00
Clonidine 0.15 mg @100 T 229,00
Clonidine 0.15 mg @100 T 2.290,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lapibal Kapsul 500 mg 4.620,00
Lapibal Kapsul 500 mg 11.550,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 0,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 0,00
Total 630.608,00
1.875 Rohayati SIDO MAKMUR 149887 Abbocath 20 Terumo @5
16/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefoperazon Inj 82.500,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Propanolol tab 10 mg 222,00
thyrozol 5 mg 1.652,00
Azitromycin 500 mg
17/02/2021 00:00:00 5.625,00
Bisoprolol 5 mg @100 Ta 296,00
Cefoperazon Inj 82.500,00
Glukosa Infus 5 % 17.252,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Propanolol tab 10 mg 333,00
Ringer Laktat Otsuka 28.614,00
Alprazolam 0,5 mg @100
18/02/2021 00:00:00 354,00
Azitromycin 500 mg 16.875,00
Propanolol tab 10 mg 2.220,00
thyrozol 5 mg 8.260,00
Total 352.218,00
1.876 Julita TANJUNG HARAPAN 182557 abbocath 18 Terumo @5
16/02/2021 00:00:00 26.341,00 BPJS
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00

19/08/2021 12:42:30 Page 441 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.876 Julita TANJUNG HARAPAN 182557 Catheter 2 Way No. 16 (
16/02/2021 00:00:00 20.625,00 BPJS
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 20.082,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 47.690,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Ceftriaxone Inj
17/02/2021 00:00:00 12.498,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
19/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.757.054,00
1.877 Ny Julita TANJUNG HARAPAN 182558 Abbocath 24 Terumo @5
17/02/2021 00:00:00 33.414,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Bisturi No. 15 3.836,00
NGT (Feeding Tube) Fr. 8 70.420,00

19/08/2021 12:42:30 Page 442 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.877 Ny Julita TANJUNG HARAPAN 182558 Phytomenadione 2 Mg/1M
17/02/2021 00:00:00 4.834,00 BPJS
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
21/02/2021 00:00:00 59.009,00
Phytomenadione 2 Mg/1M
22/02/2021 00:00:00 4.834,00
Total 237.617,00
1.878 Gatot Santoyo IPUH 182218 Acetylcystein 200 mg Ka
17/02/2021 00:00:00 5.157,00 BPJS
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 297,00
catheter 2 Way No. 18 (G 20.906,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
meropenem Injeksi 1 g 41.250,00
Nassal Cannula O2 Dewas 11.625,00
Ngt (Feeding Tube) Fr.16 10.588,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 283.700,00
1.879 Partowiyono TANJUNG BERINGIN / 136784 Amlodipine 5 mg @30 T
17/02/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Omeprazol kapsul 20 mg 6.610,00
Pregabalin Kap 75 mg 64.460,00
Total 94.530,00
1.880 Bahman SIBAK 155872 Cuticell Classic 10cmx10c
17/02/2021 00:00:00 35.121,00 BPJS
NACL 0,9 % 500 ml 25.650,00
Renogen 3000 UI 116.875,00
Total 177.646,00
1.881 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
17/02/2021 00:00:00 25.650,00 BPJS
Renogen 3000 UI 233.750,00
Total 259.400,00
1.882 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
17/02/2021 00:00:00 25.650,00 BPJS
Renogen 3000 UI 116.875,00
Total 142.525,00
1.883 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
17/02/2021 00:00:00 25.650,00 BPJS
Renogen 3000 UI 116.875,00
Total 142.525,00
1.884 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
17/02/2021 00:00:00 25.650,00 BPJS
Renogen 3000 UI 116.875,00
Total 142.525,00
1.885 Riduan Ambarita BUNGA TANJUNG 163572 Mecobalamin 500 mg
17/02/2021 00:00:00 7.700,00 BPJS
Natrium diclofenac 50 m 2.890,00
Total 10.590,00
1.886 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
17/02/2021 00:00:00 25.650,00 BPJS
Renogen 3000 UI 116.875,00
Total 142.525,00
1.887 Lailatul Kadar TANAH REKAH 158354 Amlodipine 10 mg @50 T
17/02/2021 00:00:00 118,00 BPJS
Candesartan tab 8 mg 681,00
Clonidine 0.15 mg @100 T 229,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 25.650,00

19/08/2021 12:42:30 Page 443 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.887 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
17/02/2021 00:00:00 17.100,00 BPJS
Paracetamol tablet 500 m 200,00
Renogen 3000 UI 116.875,00
Total 170.528,00
1.888 Sumidah RAWA MULYA 163860 Amlodipine 10 mg @50 T
17/02/2021 00:00:00 118,00 BPJS
Candesartan tab 8 mg 681,00
Clonidine 0.15 mg @100 T 229,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 200,00
Renogen 3000 UI 116.875,00
Total 170.528,00
1.889 Jumarno LUNANG 180796 Amlodipine 10 mg @50 T
17/02/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Kassa kotak stril DRC 19.350,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 182.659,00
1.890 Kasmidi Kasim BANDAR RATU 135355 Alprazolam 0,5 mg @100
17/02/2021 00:00:00 118,00 BPJS
Amlodipine 10 mg @50 T 118,00
Candesartan tab 8 mg 681,00
Clonidine 0.15 mg @100 T 229,00
Kassa kotak stril DRC 9.675,00
Metoclorapamide tab 10 m 151,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 661,00
Paracetamol tablet 500 m 200,00
Renogen 3000 UI 116.875,00
Sucralfate Suspensi 100 m 19.250,00
Total 190.708,00
1.891 Hasan TANAH HARAPAN 123437 Cefadroxil tab 500 mg @1
17/02/2021 00:00:00 10.500,00 BPJS
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 2.000,00
Total 52.471,00
1.892 Sakarudin LUBUK SANAI 175447 Acetylcystein 200 mg Ka
17/02/2021 00:00:00 34.380,00 BPJS
Azitromycin 500 mg 28.125,00
Onbrez Breezhaler HGCI 0 440.640,00
Vitamin B Komplek @100 2.310,00
Vitamin C 500 mg 15,00
Total 505.470,00
1.893 Juminem LUNANG 138588 Amlodipine 5 mg @30 T
17/02/2021 00:00:00 3.030,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 3.305,00
Simvastatin tab 10 mg 2.410,00
Spironolaktone 25 mg 7.800,00
Total 94.065,00
1.894 Abdi Lubis RAWA MULYA 152783 Mecobalamin 500 mg
17/02/2021 00:00:00 7.700,00 BPJS

19/08/2021 12:42:30 Page 444 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.894 Abdi Lubis RAWA MULYA 152783 Metformin tablet 500 mg
17/02/2021 00:00:00 11.970,00 BPJS
Pregabalin Kap 75 mg 64.460,00
Total 84.130,00
1.895 Ifel Yoanda RANAH KARYA 182405 Betadine Obat Kumur
17/02/2021 00:00:00 13.750,00 BPJS
Cefadroxil tab 500 mg @1 10.500,00
Cuticell Classic 10cmx10c 35.121,00
Methylprednisolone tab 4 2.630,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Total 72.745,00
1.896 Riayati LUBUK BANGKO 152742 Domperidone Syrup 5mg
17/02/2021 00:00:00 10.279,00 BPJS
Metformin tablet 500 mg 3.990,00
Total 14.269,00
1.897 Yeni Wahyuni PASAR BANTAL 150921 Cefixime Kapsul 100 mg
17/02/2021 00:00:00 9.380,00 BPJS
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00
Total 15.010,00
1.898 Dwi Maryaningsih LUNANG 179329 Catheter 2 Way No. 16 (
17/02/2021 00:00:00 20.625,00 BPJS
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 19.076,00
Urine bag 10.088,00
Total 89.247,00
1.899 Nana Lestiana TALANG SEPAKAT 137463 Asam Mefenamat 500 m
17/02/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Ibuprofen tab 400 mg 4.580,00
Total 11.460,00
1.900 Semi SELAGAN JAYA 101470 Cetirgi Tab 10 mg
17/02/2021 00:00:00 15.480,00 BPJS
Lansoprazole kapsul 30 m 23.100,00
Paracetamol tablet 500 m 3.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 60.830,00
1.901 Syamsul SILAUT 182197 Cefixime Kapsul 100 mg
17/02/2021 00:00:00 9.380,00 BPJS
ursodeoxycholic acid 85.050,00
Total 94.430,00
1.902 Musli Hadaya LUBUK GEDANG 182096 Asam Mefenamat 500 m
17/02/2021 00:00:00 1.935,00 BPJS
Asam Traneksamat @10 42.100,00
Fluconazole tab 150 mg 491.420,00
Loratadine tab 10 mg 2.490,00
Phytomenadione 10 mg ( 9.340,00
Vitamin C 500 mg 10,00
Total 547.295,00
1.903 Darwin SIDODADI 161429 Alprazolam 0,5 mg @100
17/02/2021 00:00:00 590,00 BPJS
Isosorbid dinitrat 5 mg (I 3.330,00
Omeprazol kapsul 20 mg 6.610,00
Renax @50 Kapsul 340.320,00
Total 350.850,00
1.904 Paido Simanjuntak PONDOK LUNANG 182564 Epsonal 50 mg @100 tab
17/02/2021 00:00:00 38.030,00 BPJS
Mecobalamin 500 mg 11.550,00

19/08/2021 12:42:30 Page 445 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.904 Paido Simanjuntak PONDOK LUNANG 182564 Natrium diclofenac 50 m
17/02/2021 00:00:00 2.890,00 BPJS
Total 52.470,00
1.905 Yudi Chandra LUBUK PINANG 131566 Bisoprolol 5 mg @100 Ta
17/02/2021 00:00:00 8.880,00 BPJS
Candesartan tab 8 mg 20.430,00
Levemir FlexPen 104.938,00
Metformin tablet 500 mg 11.970,00
Novo Twist 32 G Tip 9.640,00
Novorapid Flexpen 326.250,00
Total 482.108,00
1.906 Sukiman SIBAK 154783 Abbocath 20 Terumo @5
17/02/2021 00:00:00 26.341,00 BPJS
Abbocath 22 Terumo @5 33.414,00
Amlodipine 10 mg @50 T 118,00
Aspilet 80 mg @100 mg 138,00
Candesartan tab 8 mg 681,00
Flunarizine 5 mg tab 2.475,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Perifas @100 Tab 1.925,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 162.054,00
1.907 Gatot Santoyo IPUH 182218 Betadine Obat Kumur
17/02/2021 00:00:00 13.750,00 BPJS
Meropenem Inj 0.5 g 165.000,00
Paracetamol Infus 28.876,00
Antrain Injeksi
18/02/2021 00:00:00 28.875,00
Asam Folat 1 mg @100 T 297,00
Azitromycin 500 mg 5.625,00
Citicoline Injeksi 125mg/ 22.500,00
Furamin Injeksi 14.369,00
Gentamycin 0.1 % salep k 2.983,00
Hypafix 10cm x 5cm (25 c 4.850,00
Loratadine tab 10 mg 166,00
meropenem Injeksi 1 g 123.750,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 19.076,00
Sistenol kaplet 5.262,00
Antrain Injeksi
19/02/2021 00:00:00 28.875,00
Antrain Injeksi 86.625,00
Asam Folat 1 mg @100 T 297,00
Azitromycin 500 mg 5.625,00
Cetadop inj 0,00
Citicoline Injeksi 125mg/ 22.500,00
Dopamin Giulini 200 mg I 292.875,00
Furamin Injeksi 43.107,00
Gentamycin 0.1 % salep k 2.983,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Dewasa 41.828,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.907 Gatot Santoyo IPUH 182218 Omeprazole Inj
19/02/2021 00:00:00 12.499,00 BPJS
Ringer Laktat Otsuka 19.076,00
Sistenol kaplet 35.080,00
Suction Chateter no. 12 ( 10.588,00
Three Way stopcock 25.904,00
Azitromycin 500 mg
20/02/2021 00:00:00 5.625,00
Citicoline Injeksi 125mg/ 22.500,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Infusion Mikro (Gea) 7.861,00
meropenem Injeksi 1 g 123.750,00
Metamizole Sodium Mono 13.782,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Anak 41.828,00
Norepinephrine Inj 30.938,00
Norepinephrine Inj 30.938,00
Ringer Laktat Otsuka 0,00
Three Way stopcock 25.904,00
Asam Folat 1 mg @100 T
21/02/2021 00:00:00 297,00
Azitromycin 500 mg 5.625,00
Cetadop inj 23.100,00
Citicoline Injeksi 125mg/ 22.500,00
Furamin Injeksi 14.369,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 8.550,00
Norepinephrine Inj 92.814,00
Ringer Laktat Otsuka 28.614,00
Sistenol kaplet 5.262,00
Antrain Injeksi
22/02/2021 00:00:00 28.875,00
Antrain Injeksi 28.875,00
Antrain Injeksi 28.875,00
Azitromycin 500 mg 16.875,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Loratadine tab 10 mg 166,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 8.550,00
Norepinephrine Inj 30.938,00
Sistenol kaplet 5.262,00
Total 2.248.878,00
1.908 Lendo SILAUT 174339 Citicoline kaplet 500 mg
17/02/2021 00:00:00 49.500,00 BPJS
Metformin tablet 500 mg 1.995,00
Novo Twist 32 G Tip 5.784,00
Perifas @100 Tab 19.250,00
Total 76.529,00
1.909 Salehati SUNGAI GADING 182565 Alprazolam 0,5 mg @100
17/02/2021 00:00:00 590,00 BPJS
Isosorbid dinitrat 5 mg (I 1.110,00
Omeprazol kapsul 20 mg 6.610,00

19/08/2021 12:42:30 Page 447 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.909 Salehati SUNGAI GADING 182565 Paracetamol tablet 500 m
17/02/2021 00:00:00 2.000,00 BPJS
Total 10.310,00
1.910 Shony Putra Risky MEDAN JAYA 182569 Ciprofloxacin tab 500 mg
17/02/2021 00:00:00 8.385,00 BPJS
Ketoprofen tab 100 mg 24.760,00
Total 33.145,00
1.911 Adelia Nis Cahya TIRTA MAKMUR 129069 Asam Folat 1 mg @100 T
17/02/2021 00:00:00 396,00 BPJS
Furosemide Injeksi @2ml 3.332,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol syrup 1.388,00
Vitamin B Komplek @100 308,00
Total 13.974,00
1.912 Marlina BANTAL 182570 abbocath 18 Terumo @5
17/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00

19/08/2021 12:42:30 Page 448 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.912 Marlina BANTAL 182570 viamac 1 R
17/02/2021 00:00:00 364.370,00 BPJS
Bisturi No. 15
18/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Piralen Injeksi 2 ml 26.400,00
umbilical Cord Clamp 2.261,00
Abbocath 22 Terumo @5
19/02/2021 00:00:00 22.276,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Asam Mefenamat 500 m
20/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 1.814.482,00
1.913 Randi Gusti Pertama P LUBUK CABAU 162094 Clindamycin 150 mg tabl
17/02/2021 00:00:00 3.500,00 BPJS
Tranexamic Acid Inj (Asa 2.105,00
Total 5.605,00
1.914 Garbi TANJUNG JAYA 182568 Bisturi No. 23
17/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 6.249,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Handscoond Non Steril S 4.255,00
handscoond steril 6.5 (G 43.662,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker Karet 11.000,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 1.699,00
Topi Operasi (Perawat) @ 1.876,00
Tramadol 50 mg/ml Inj 12.375,00
Levofloxacin Tablet 500 m
18/02/2021 00:00:00 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 574.012,00
1.915 Randi Gusti Pertama P LUBUK CABAU 162094 Clindamycin 150 mg tabl
18/02/2021 00:00:00 8.750,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.915 Randi Gusti Pertama P LUBUK CABAU 162094 Clindamycin 300 mg Tabl
18/02/2021 00:00:00 28.000,00 BPJS
Loratadine tab 10 mg 1.660,00
scacid krim 76.250,00
scacid krim 38.125,00
Total 152.785,00
1.916 M. Baqilani Tasdiq KARANG JAYA 182561 Abbocath 20 Terumo @5
17/02/2021 00:00:00 26.341,00 BPJS
Abbocath 22 Terumo @5 33.414,00
Bisturi No. 23 3.836,00
Ceftriaxone Inj 6.249,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 10.040,00
handscoond steril 6.5 (G 43.662,00
handscoond steril 8 (Gam 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 94.032,00
Masker Karet 5.500,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 8.495,00
Levofloxacin Tablet 500 m
18/02/2021 00:00:00 13.640,00
NonWoven Fixation 15x 20.082,00
Paracetamol tablet 500 m 2.000,00
Total 738.993,00
1.917 Sukiman SIBAK 154783 Amlodipine 5 mg @30 T
18/02/2021 00:00:00 101,00 BPJS
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Clopidogrel 75 mg @30 T 1.755,00
Flunarizine 5 mg tab 4.950,00
Infusion Makro (terumo) 27.225,00
Miniaspi 80 Mg @100 Ta 125,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 5.775,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Amlodipine 5 mg @30 T
19/02/2021 00:00:00 505,00
Aspilet 80 mg @100 mg 276,00
Candesartan tab 8 mg 3.405,00

19/08/2021 12:42:30 Page 450 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.917 Sukiman SIBAK 154783 Clopidogrel 75 mg @30 T
19/02/2021 00:00:00 8.775,00 BPJS
Clopidogrel 75 mg @30 T 3.510,00
Flunarizine 5 mg tab 24.750,00
Miniaspi 80 Mg @100 Ta 625,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 12.499,00
Perifas @100 Tab 11.550,00
Perifas @100 Tab 28.875,00
Sucralfate Suspensi 100 m 19.250,00
Total 216.498,00
1.918 Omih AIR HITAM 181730 abbocath 18 Terumo @5
17/02/2021 00:00:00 52.682,00 BPJS
Abbocath 20 Terumo @5 52.682,00
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 198,00
Ceftazidime Injeksi 1 mg 15.975,00
Ciprofloxacin infus 2% 26.328,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Methylprednisolone Inje 34.923,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 400,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
18/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Levofloxacin Infus 73.464,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Asam Folat 1 mg @100 T
19/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Dexametason Injeksi 12.512,00
Dipenhydramin Injeksi 10 6.140,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide Injeksi @2ml 6.664,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Levofloxacin Infus 73.464,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Asam Folat 1 mg @100 T
20/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Esomeprazol Injeksi 40 m 34.956,00

19/08/2021 12:42:30 Page 451 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.918 Omih AIR HITAM 181730 Levofloxacin Infus
20/02/2021 00:00:00 73.464,00 BPJS
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
Asam Folat 1 mg @100 T
21/02/2021 00:00:00 990,00
Ciprofloxacin tab 500 mg 5.590,00
Methylprednisolone tab 4 3.945,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 3.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.238.055,00
1.919 M Munir ibnu shalla BANDARATU 136635 Abbocath 20 Terumo @5
17/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 24.996,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 8.250,00
Pantoprazole Inj 46.750,00
Paracetamol tablet 500 m 600,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 186.331,00
1.920 Arzan UJUNG PADANG 128346 Abbocath 20 Terumo @5
17/02/2021 00:00:00 26.341,00 BPJS
ATS (Anti Tetanus Serum 150.000,00
Ceftriaxone Inj 6.249,00
Chromic catgut 3-0 R (Tr 66.250,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 1.345,00
Lidocain injk 40 mg/2 ml 1.611,00
Polyvinylidene 3-0 R (Tri 92.000,00
Polyvinylidene 4-0 C (Tri 92.006,00
Tranexamic Acid Inj (Asa 2.105,00
Total 477.878,00
1.921 M Munir ibnu shalla BANDARATU 136635 Amoxicillin 500 mg @ 10
18/02/2021 00:00:00 3.060,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Mefenamat 500 m 1.290,00
Ceftriaxone Inj 12.498,00
Cetirgi Tab 10 mg 30.960,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron 4mg 16.360,00
Opilax Syr 49.156,00
Pantoprazole Inj 23.375,00
Paracetamol syrup 1.388,00
Paracetamol tablet 500 m 4.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 190.562,00
1.922 Arzan UJUNG PADANG 128346 Ceftriaxone Inj
17/02/2021 00:00:00 6.249,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
NACL 0,9 % 500 ml 25.650,00
Tranexamic Acid Inj (Asa 4.210,00
Catheter 2 Way No. 16 (
18/02/2021 00:00:00 20.625,00

19/08/2021 12:42:30 Page 452 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.922 Arzan UJUNG PADANG 128346 Ceftriaxone Inj
18/02/2021 00:00:00 12.498,00 BPJS
Paracetamol Infus 43.314,00
Urine bag 10.088,00
Ceftriaxone Inj
19/02/2021 00:00:00 12.498,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol Infus 43.314,00
Ceftriaxone Inj
20/02/2021 00:00:00 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Methylprednisolone Inje 104.769,00
Paracetamol Infus 28.876,00
Ceftriaxone Inj
21/02/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Mecobalamin 500 mg 2.310,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00
NACL 0,9 % 500 ml
22/02/2021 00:00:00 17.100,00
NonWoven Fixation 15x 6.694,00
Mecobalamin 500 mg
23/02/2021 00:00:00 15.400,00
Methylprednisolone tab 4 10.520,00
Total 787.638,00
1.923 Siti Maryam PENARIK 125298 abbocath 18 Terumo @5
17/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 9.281,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 86.561,00
1.924 Sugito MEKAR MULYA 147062 Amlodipine 10 mg @50 T
18/02/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
NACL 0,9 % 500 ml 42.750,00
Simvastatin tab 10 mg 723,00
Total 45.870,00
1.925 Narti SILAUT 175653 Amlodipine 10 mg @50 T
18/02/2021 00:00:00 354,00 BPJS
Lansoprazole kapsul 30 m 3.465,00
Meloxicam 7,5 mg 2.184,00
NACL 0,9 % 500 ml 42.750,00
Transfusi Set Terumo 16.500,00
Total 65.253,00
1.926 Amri Kusna Yanti BUMI MULYA 133486 Amlodipine 10 mg @50 T
18/02/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Simvastatin tab 10 mg 723,00
Total 35.277,00
1.927 M Akil PASAR BELAKANG 115376 Kassa kotak stril DRC
18/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 52.425,00

19/08/2021 12:42:30 Page 453 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.928 Ashari Liwandi PONDOK LUNANG 139398 Kassa kotak stril DRC
18/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 52.425,00
1.929 Supangat PONDOK LUNANG 147511 Kassa kotak stril DRC
18/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 52.425,00
1.930 Ahmad Mujiono MARGA MULYA SAKTI 113737 Kassa kotak stril DRC
18/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 52.425,00
1.931 Wardoyo TANJUNG MULYA 125079 Kassa kotak stril DRC
18/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 52.425,00
1.932 Miswanto LUNANG 128267 Kassa kotak stril DRC
18/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 52.425,00
1.933 Rindi Triswantoro LUNANG 180921 Asam Mefenamat 500 m
18/02/2021 00:00:00 2.580,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 6.610,00
Urinter Kapsul @100 cap 65.940,00
Total 88.770,00
1.934 Eni Maryati PT AGRO PO MILL 120024 Norelut
18/02/2021 00:00:00 140.250,00 BPJS
Total 140.250,00
1.935 Elni Alfiani LUBUK MUKTI 180579 Methylprednisolone tab 4
18/02/2021 00:00:00 2.630,00 BPJS
Total 2.630,00
1.936 M.hanif Mulyazam BANDARATU 142748 Sucralfate Suspensi 100 m
18/02/2021 00:00:00 19.250,00 BPJS
Total 19.250,00
1.937 Nayur Marni PULAI PAYUNG 153355 Allopurinol 300 Mg @100
18/02/2021 00:00:00 14.730,00 BPJS
Candesartan tab 8 mg 20.430,00
Meloxicam 7,5 mg 7.280,00
Methylprednisolone tab 4 2.630,00
Natrium diclofenac 50 m 2.890,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 73.820,00
1.938 Dawut WONOSOBO 182506 Amlodipine 10 mg @50 T
18/02/2021 00:00:00 3.540,00 BPJS
Candesartan Tab 16 mg 35.370,00
Flunarizine 5 mg tab 24.750,00
Gabapentin kapsul 300 m 12.690,00
Omeprazol kapsul 20 mg 6.610,00
Perifas @100 Tab 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 121.460,00
1.939 Oos Dariana PONDOK LUNANG 174848 Ciprofloxacin tab 500 mg
18/02/2021 00:00:00 5.590,00 BPJS
Clindamycin 300 mg Tabl 17.500,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 97.766,00
1.940 Penti Hendriyani LALANG LUAS 182576 Bisturi No. 23
18/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.940 Penti Hendriyani LALANG LUAS 182576 Dexametason Injeksi
18/02/2021 00:00:00 6.256,00 BPJS
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Methylprednisolone tab 4 263,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Tranexamic Acid Inj (Asa 2.105,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.249.009,00
1.941 Masinem KOTA PRAJA 136621 Atorvastatin 20 mg @30 T
18/02/2021 00:00:00 10.450,00 BPJS
Candesartan tab 8 mg 20.430,00
Flunarizine 5 mg tab 24.750,00
Furosemide 40 mg Tablet 960,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 86.200,00
1.942 Solin RANAH KARYA 175604 Atorvastatin 20 mg @30 T
18/02/2021 00:00:00 10.450,00 BPJS
Furosemide 40 mg Tablet 960,00
Methylprednisolone tab 4 31.560,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 100 mg 21.570,00
Vitamin B Komplek @100 1.540,00
Total 72.690,00
1.943 Nelda Suprianti RAWA MULYA 136291 Glimepiride tab 2 mg
18/02/2021 00:00:00 5.180,00 BPJS
Metformin tablet 500 mg 2.660,00
Pregabalin Kap 75 mg 32.230,00
Total 40.070,00
1.944 Muhamad Akbar Pria BATU EJUNG 161774 Cefixime Kapsul 100 mg
18/02/2021 00:00:00 9.380,00 BPJS
Cuticell Classic 10cmx10c 35.121,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 2.000,00

19/08/2021 12:42:30 Page 455 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 53.195,00
1.945 Asmara AIR BIKUK 182454 Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 48.301,00
1.946 Afrida Helmi PONDOK BARU 115846 Alprazolam 1 mg @100 T
18/02/2021 00:00:00 4.800,00 BPJS
Total 4.800,00
1.947 Nurbaina SUNGAI GADING 182581 Bisoprolol 5 mg @100 Ta
18/02/2021 00:00:00 4.440,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 960,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 100 mg 21.570,00
Sucralfate Suspensi 100 m 19.250,00
Total 129.660,00
1.948 Devi Setya Ningsih AIR DIKIT 130800 Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 48.301,00
1.949 M.hanif Mulyazam BANDARATU 142748 Abbocath 22 Terumo @5
18/02/2021 00:00:00 11.138,00 BPJS
Infusion Makro (terumo) 27.225,00
Injection plug 20.213,00
Ka-En 1 B 12.658,00
Ka-En 1 B 25.316,00
Ketorolac inj 30 mg/1ml 1.345,00
Omeprazole Inj 24.998,00
Ranitidin inj 1.790,00
Ranitidin inj 7.160,00
Ringer Laktat Otsuka 9.538,00
Hypafix 10cm x 5cm (25 c
19/02/2021 00:00:00 9.700,00
Ketorolac inj 30 mg/1ml 2.690,00
Omeprazol kapsul 20 mg
20/02/2021 00:00:00 3.305,00
Omeprazole Inj 24.998,00
Ranitidine tablet 150 mg 1.440,00
Sucralfate Suspensi 100 m 19.250,00
Total 202.764,00
1.950 Eri Susanti GADING JAYA 127845 Asam Mefenamat 500 m
18/02/2021 00:00:00 1.935,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 46.951,00
1.951 Muslim Munajat WONOSOBO 145054 Gabapentin kapsul 300 m
18/02/2021 00:00:00 25.380,00 BPJS
Meloxicam 7,5 mg 21.840,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 6.610,00
Renax @50 Kapsul 340.320,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 65.940,00
Total 488.010,00

19/08/2021 12:42:30 Page 456 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.952 Afnan Daniyah TIRTA MAKMUR.SP 5 150628 Meprolut Tab
18/02/2021 00:00:00 41.800,00 BPJS
Total 41.800,00
1.953 Nurkasimah PASAR BELAKANG 124200 Cefixime kapsul 200 mg
18/02/2021 00:00:00 26.480,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 28.480,00
1.954 Nida Putri LUBUK GEDANG 155032 abbocath 18 Terumo @5
18/02/2021 00:00:00 52.682,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Abbocath 22 (GEA) 10.720,00
Cefotaxime Injeksi 11.502,00
Glukosa Infus 5 % 17.252,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 4.950,00
Transfusi Set Terumo 16.500,00
Total 200.666,00
1.955 Masriani TANAH REKAH 132499 Abbocath 20 Terumo @5
18/02/2021 00:00:00 52.682,00 BPJS
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker Karet Boism 47.580,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Urine bag 10.088,00
Urine bag 10.088,00
Ceftriaxone Inj
19/02/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 600,00

19/08/2021 12:42:30 Page 457 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.955 Masriani TANAH REKAH 132499 Ringer Laktat Otsuka
19/02/2021 00:00:00 28.614,00 BPJS
Urine bag 10.088,00
Cuticell Classic 10cmx10c
20/02/2021 00:00:00 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 862.356,00
1.956 Mely Br Rajagukguk ARGA JAYA 182295 Suprafenid Supositoria 10
18/02/2021 00:00:00 14.025,00 BPJS
Total 14.025,00
1.957 Aliyah BANDAR RATU 153367 abbocath 18 Terumo @5
18/02/2021 00:00:00 52.682,00 BPJS
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet 11.000,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
19/02/2021 00:00:00 11.502,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Cefixime kapsul 200 mg
20/02/2021 00:00:00 26.480,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 19.350,00
Paracetamol tablet 500 m 2.000,00
Total 685.721,00
1.958 Mely Br Rajagukguk ARGA JAYA 182295 Abbocath 22 Terumo @5
18/02/2021 00:00:00 11.138,00 BPJS
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 9.538,00
Urinter Kapsul @100 cap 4.396,00

19/08/2021 12:42:30 Page 458 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.958 Mely Br Rajagukguk ARGA JAYA 182295 Ceftriaxone Inj
19/02/2021 00:00:00 12.498,00 BPJS
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 6.725,00
Opilax Syr 49.156,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 4.396,00
Asam Mefenamat 500 m
20/02/2021 00:00:00 1.935,00
Natrium diclofenac 50 m 2.890,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 12.499,00
Renax @50 Kapsul 170.160,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Total 542.931,00
1.959 Surya Darma ujung padang 109809 Abbocath 20 Terumo @5
18/02/2021 00:00:00 26.341,00 BPJS
Betahistin Mesilat 6 mg @ 414,00
Flunarizine 5 mg tab 4.950,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Total 84.929,00
1.960 Darwinarti LUBUK SAHUNG 182591 Abbocath 20 Terumo @5
18/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Total 98.632,00
1.961 Penti Hendriyani LALANG LUAS 182576 Cefixime Kapsul 100 mg
19/02/2021 00:00:00 9.380,00 BPJS
Kassa kotak stril DRC 9.675,00
Paracetamol tablet 500 m 3.000,00
Total 22.055,00
1.962 Darwinarti LUBUK SAHUNG 182591 Cefotaxime Injeksi
20/02/2021 00:00:00 28.755,00 BPJS
Ondansetron Inj 8.250,00
Ondansetron tablet 8 mg 39.600,00
Vit B6 10 mg 1.610,00
Total 78.215,00
1.963 Nida Putri LUBUK GEDANG 155032 Asam Mefenamat 500 m
21/02/2021 00:00:00 1.290,00 BPJS
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Glukosa Infus 5 % 17.252,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 22.000,00
Misoprostol Tab 11.000,00
Misoprostol Tab 55.000,00
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00

19/08/2021 12:42:30 Page 459 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.963 Nida Putri LUBUK GEDANG 155032 Suprafenid Supositoria 10
21/02/2021 00:00:00 28.050,00 BPJS
Total 277.659,00
1.964 Afriadianto TIRTA MULYA 182593 Asam Folat 1 mg @100 T
19/02/2021 00:00:00 198,00 BPJS
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 14.550,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac Tab 10 Mg 7.590,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
NGT (Stomach Tube) Fr. 1 60.046,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
20/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 69.912,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
21/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 69.912,00
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Folat 1 mg @100 T
22/02/2021 00:00:00 1.485,00
Lansoprazole kapsul 30 m 11.550,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 631.026,00
1.965 Helen Okta Putri AIR BIKUK 182029 abbocath 18 Terumo @5
19/02/2021 00:00:00 26.341,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00

19/08/2021 12:42:30 Page 460 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.965 Helen Okta Putri AIR BIKUK 182029 Chromic catgut 2-0 R (Tr
19/02/2021 00:00:00 72.250,00 BPJS
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 3.128,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Invitec tab (Misoprostol) 35.424,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 47.016,00
Masker Tali 41.600,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Rofiden Supp 36.093,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 1.377.936,00
1.966 Eti Rohayati SINAR JAYA 182594 abbocath 18 Terumo @5
19/02/2021 00:00:00 26.341,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 12.512,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00

19/08/2021 12:42:30 Page 461 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.966 Eti Rohayati SINAR JAYA 182594 handscoond steril 8 (Gam
19/02/2021 00:00:00 29.108,00 BPJS
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Induxin 1 ml Injeksi 18.562,00
Invitec tab (Misoprostol) 35.424,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 47.016,00
Masker Tali 41.600,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Nifedipin Tab 10 mg 1.750,00
Otsu MgSO4 40 % 9.490,00
Polyglycolide T-Vio 1 R ( 197.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Rofiden Supp 36.093,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 1.362.075,00
1.967 Salami SILAUT I 134774 Amlodipine 5 mg @30 T
19/02/2021 00:00:00 435,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.185,00
1.968 Titin Sumarni PONDOK BARU 119023 Amlodipine 5 mg @30 T
19/02/2021 00:00:00 435,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.185,00
1.969 Rini Astuti LUBUK SANAI 2 147140 Amlodipine 5 mg @30 T
19/02/2021 00:00:00 435,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.185,00
1.970 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
19/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.971 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
19/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
1.972 Suwarni SUKA MAJU 164065 Kassa kotak stril DRC
19/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Simvastatin tab 20 mg 933,00
Total 53.358,00
1.973 Susi Martini KOTO JAYA 145038 Kassa kotak stril DRC
19/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00

19/08/2021 12:42:30 Page 462 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.973 Susi Martini KOTO JAYA 145038 Simvastatin tab 20 mg
19/02/2021 00:00:00 933,00 BPJS
Total 53.358,00
1.974 Salbiyah LUBUK MUKTI 173013 Kassa kotak stril DRC
19/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Simvastatin tab 20 mg 933,00
Total 53.358,00
1.975 Roslina TERUNTUNG 130072 Kassa kotak stril DRC
19/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Simvastatin tab 20 mg 933,00
Total 53.358,00
1.976 Zukriman LUBUK GEDANG 160918 Kassa kotak stril DRC
19/02/2021 00:00:00 9.675,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Simvastatin tab 20 mg 933,00
Total 53.358,00
1.977 Yuliana SELAGAN JAYA 182473 Asam Mefenamat 500 m
19/02/2021 00:00:00 1.935,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 57.976,00
1.978 Lesnawati TANAH REKAH 182045 Asam Mefenamat 500 m
19/02/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 47.656,00
1.979 Sarin PONDOK BARU 154790 Amlodipine 5 mg @30 T
19/02/2021 00:00:00 1.010,00 BPJS
Paracetamol tablet 500 m 4.000,00
Acetylcystein 200 mg Ka
05/04/2021 00:00:00 17.190,00
Alprazolam 0,5 mg @100 1.180,00
Asam Mefenamat 500 m 1.935,00
Neurodex tablet 7.410,00
Total 32.725,00
1.980 Marlina BANDAR RATU 159861 Mecobalamin 500 mg
19/02/2021 00:00:00 23.100,00 BPJS
Simvastatin tab 10 mg 7.230,00
Total 30.330,00
1.981 Siur TUNGGANG 182597 Finpro Finasteride
19/02/2021 00:00:00 165.000,00 BPJS
Hytroz tab 2 mg 11.730,00
Total 176.730,00
1.982 Kasmi Juwita UJUNG PADANG 176839 Betahistin Mesilat 6 mg @
19/02/2021 00:00:00 2.760,00 BPJS
Lansoprazole kapsul 30 m 23.100,00
Paracetamol tablet 500 m 2.000,00
Total 27.860,00
1.983 Suparmin SILAUT 142036 Lansoprazole kapsul 30 m
19/02/2021 00:00:00 23.100,00 BPJS
Metoclorapamide tab 10 m 1.510,00
Simvastatin tab 10 mg 4.820,00
Total 29.430,00
1.984 Mudi PT AGRO SEI KIANG 169667 Ketoprofen tab 100 mg
19/02/2021 00:00:00 24.760,00 BPJS
Paracetamol tablet 500 m 4.000,00
Vitamin B Komplek @100 3.080,00
Total 31.840,00
1.985 Tambah TIRTA MULYA 116151 Abbocath 20 Terumo @5
19/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.985 Tambah TIRTA MULYA 116151 Esomeprazol Injeksi 40 m
19/02/2021 00:00:00 34.956,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Nassal Cannula O2 Dewas 11.625,00
Ringer Laktat Otsuka 9.538,00
Total 123.989,00
1.986 Andri Yadi PENARIK 182476 Antasida Syrup 60 ml
19/02/2021 00:00:00 2.736,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Metoclorapamide tab 10 m 1.510,00
Sucralfate Suspensi 100 m 19.250,00
Total 35.046,00
1.987 Yusni PASAR BELAKANG 126387 Amoxicillin 500 mg @ 10
19/02/2021 00:00:00 3.060,00 BPJS
Paracetamol tablet 500 m 2.000,00
Pehacain Injeksi 3.320,00
Total 8.380,00
1.988 Jangkep PT.AGRO MUKO 134160 Cuticell Classic 10cmx10c
19/02/2021 00:00:00 35.121,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Ketoprofen tab 100 mg 24.760,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 4.000,00
Total 84.065,00
1.989 Enmawati AIR DIKIT 130209 Omeprazol kapsul 20 mg
19/02/2021 00:00:00 3.305,00 BPJS
Total 3.305,00
1.990 Rina Utami AIR DIKIT 182604 Nulacta Plus
19/02/2021 00:00:00 58.300,00 BPJS
Total 58.300,00
1.991 Sabarudin SARI BULAN 182605 Orasic Kap
19/02/2021 00:00:00 36.580,00 BPJS
Renax @50 Kapsul 113.440,00
Urinter Kapsul @100 cap 21.980,00
Total 172.000,00
1.992 Ny Helen AIR BIKUK 182606 Abbocath 24 Terumo @5
19/02/2021 00:00:00 105.364,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Hypafix 10cm x 5cm (25 c 9.700,00
Total 125.875,00
1.993 Arshaka Virendra BUMI MULYA 182608 Paracetamol syrup
19/02/2021 00:00:00 2.776,00 BPJS
Total 2.776,00
1.994 Yesti Maya Putri MANDI ANGIN JAYA 158920 Nulacta Plus
19/02/2021 00:00:00 58.300,00 BPJS
Total 58.300,00
1.995 Lilis Andriyani AIR RAMI 161196 Amoxicillin 500 mg @ 10
19/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.935,00
Ciprofloxacin tab 500 mg 0,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 45.771,00
1.996 Tambah TIRTA MULYA 116151 Ceftriaxone Inj
19/02/2021 00:00:00 12.498,00 BPJS
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin C tablet @100 Ta 276,00
Ceftriaxone Inj
21/02/2021 00:00:00 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Metoclopramide inj 5Mg/M 17.637,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.996 Tambah TIRTA MULYA 116151 Paracetamol Infus
21/02/2021 00:00:00 43.314,00 BPJS
Ringer Laktat Otsuka 38.152,00
Total 207.795,00
1.997 Helen Okta Putri AIR BIKUK 182029 Cefotaxime Injeksi
19/02/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 4.210,00
Aqua Pro Injeksi
20/02/2021 00:00:00 3.575,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 47.032,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
21/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 222.048,00
1.998 Eti Rohayati SINAR JAYA 182594 Cefotaxime Injeksi
19/02/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
20/02/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Otsu MgSO4 40 % 4.745,00
Tranexamic Acid Inj (Asa 6.315,00
Ciprofloxacin tab 500 mg
21/02/2021 00:00:00 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 19.350,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 231.376,00
1.999 Trisni Hartati MEKAR MULYA 157562 abbocath 18 Terumo @5
19/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23
20/02/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.999 Trisni Hartati MEKAR MULYA 157562 Catheter 2 Way No. 16 (
20/02/2021 00:00:00 20.625,00 BPJS
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 9.384,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Massa Cauter Dewasa 90.240,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 28.614,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 2.105,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
21/02/2021 00:00:00 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 540,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Cefotaxime Injeksi
22/02/2021 00:00:00 11.502,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
1.999 Trisni Hartati MEKAR MULYA 157562 Cefotaxime Injeksi
22/02/2021 00:00:00 23.004,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 19.076,00
Asam Mefenamat 500 m
23/02/2021 00:00:00 1.935,00
Bisturi No. 23 3.836,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NGT (Feeding tube) Fr. 5 17.603,00
Phytomenadione 2 Mg/1M 4.834,00
Postofix (leukomed) 36.726,00
umbilical Cord Clamp 2.261,00
Total 2.220.370,00
2.000 Marlis KARYA MULYA 182613 Abbocath 20 Terumo @5
19/02/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 11.250,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
Ngt (Feeding Tube) Fr.16 10.588,00
Omeprazole Inj 12.499,00
Otsu Manitol 20% 54.375,00
Tranexamic Acid Inj (Asa 8.420,00
Urine bag 10.088,00
Extention Tube 8.801,00
Nicardipine HCl Inj 59.132,00
Three Way stopcock 25.904,00
Ceftriaxone Inj
20/02/2021 00:00:00 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Otsu Manitol 20% 54.375,00
Tranexamic Acid Inj (Asa 8.420,00
Ceftriaxone Inj
21/02/2021 00:00:00 0,00
Citicoline Injeksi 125mg/ 0,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 0,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.000 Marlis KARYA MULYA 182613 Otsu Manitol 20%
21/02/2021 00:00:00 0,00 BPJS
Paracetamol tablet 500 m 400,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 0,00
Total 710.265,00
2.001 Suhardi BANDAR RATU 115774 Alprazolam 1 mg @100 T
19/02/2021 00:00:00 1.600,00 BPJS
Amlodipine 10 mg @50 T 1.180,00
Amoxicillin 500 mg @ 10 3.060,00
Paracetamol tablet 500 m 4.000,00
Total 9.840,00
2.002 Nurajad SIBAK 182614 Abbocath 20 Terumo @5
19/02/2021 00:00:00 26.341,00 BPJS
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 6.594,00
Total 184.304,00
2.003 Safrin LUBUK BANGKO 163017 abbocath 18 Terumo @5
19/02/2021 00:00:00 26.341,00 BPJS
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Combivent 12.512,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 28.614,00
Spironolaktone 25 mg 260,00
Total 114.647,00
2.004 Nurajad SIBAK 182614 Asam Folat 1 mg @100 T
20/02/2021 00:00:00 297,00 BPJS
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac inj 30 mg/1ml 4.035,00
Neurodex tablet 1.482,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 9.538,00
Urinter Kapsul @100 cap 4.396,00
Asam Folat 1 mg @100 T
21/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 25.650,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 28.614,00
Urinter Kapsul @100 cap 6.594,00
Asam Folat 1 mg @100 T
22/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac inj 30 mg/1ml 4.035,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.004 Nurajad SIBAK 182614 Renax @50 Kapsul
22/02/2021 00:00:00 34.032,00 BPJS
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 4.396,00
Vitamin B Komplek @100 308,00
Abbocath 20 Terumo @5
23/02/2021 00:00:00 52.682,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Esomeprazol Injeksi 40 m 34.956,00
Furosemide Injeksi @2ml 34,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 25.650,00
Neurodex tablet 2.223,00
Renax @50 Kapsul 34.032,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Urinter Kapsul @100 cap 4.396,00
Asam Folat 1 mg @100 T
24/02/2021 00:00:00 990,00
Curcuma Tab 19.050,00
Esomeprazol Injeksi 40 m 34.956,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 24.998,00
Renax @50 Kapsul 170.160,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Vitamin B Komplek @100 1.540,00
Total 850.138,00
2.005 Safrin LUBUK BANGKO 163017 Ambroxol Syr 15mg/ml
20/02/2021 00:00:00 4.538,00 BPJS
Aminophyllin Inj 15.536,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Cetirgi Tab 10 mg 1.548,00
Combivent 25.024,00
Methylprednisolone Inje 34.923,00
Aminophyllin Inj
21/02/2021 00:00:00 31.072,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Cetirizine 10 mg 126,00
Combivent 25.024,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 9.700,00
Methylprednisolone Inje 34.923,00
NACL 0,9 % 500 ml 8.550,00
Nebulizer O2 Dewasa 34.783,00
Cefixime Kapsul 100 mg
22/02/2021 00:00:00 9.380,00
Mucera Syr Forte 29.700,00
Total 294.517,00
2.006 Indro SUMBER MAKMUR 126533 abbocath 18 Terumo @5
20/02/2021 00:00:00 26.341,00 BPJS
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.006 Indro SUMBER MAKMUR 126533 Erdosteine Syr
20/02/2021 00:00:00 36.575,00 BPJS
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 25.650,00
Total 133.914,00
2.007 Trimo TELUK BAKUNG 182538 abbocath 18 Terumo @5
20/02/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Suprafenid Supositoria 10 28.050,00
Urine bag 10.088,00
Abbocath 24 Terumo @5 52.682,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 48.976,00
Paracetamol tablet 500 m 600,00
Hypafix 10cm x 5cm (25 c
21/02/2021 00:00:00 4.850,00
Kassa kotak stril DRC 19.350,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 48.976,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Ketorolac inj 30 mg/1ml
22/02/2021 00:00:00 2.690,00
Levofloxacin Infus 48.976,00
meropenem Injeksi 1 g 123.750,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Infusion Makro (terumo)
23/02/2021 00:00:00 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Paracetamol tablet 500 m 600,00
Ceftriaxone Inj
24/02/2021 00:00:00 6.249,00
Ketorolac inj 30 mg/1ml 4.035,00
Ringer Laktat Otsuka 28.614,00
Bisturi No. 23
25/02/2021 00:00:00 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
handscoond steril 6.5 (G 43.662,00
Handscoond Sterille 7.5 16.488,00
Kassa kotak stril DRC 19.350,00
Ketoprofen inj 100 mg 10.500,00
Levofloxacin Infus 48.976,00
Lidocain injk 40 mg/2 ml 9.666,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Novo Twist 32 G Tip 5.784,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00

19/08/2021 12:42:30 Page 470 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.007 Trimo TELUK BAKUNG 182538 Polyvinylidene 3-0 R (Tri
25/02/2021 00:00:00 92.000,00 BPJS
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Urine bag 10.088,00
Cuticell Classic 10cmx10c
26/02/2021 00:00:00 35.121,00
Hypafix 10cm x 5cm (25 c 14.550,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Levofloxacin Infus 48.976,00
NonWoven Fixation 15x 13.388,00
Ringer Laktat Otsuka 9.538,00
Cuticell Classic 10cmx10c
27/02/2021 00:00:00 35.121,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 13.388,00
Octalbin 25% 50 cc (Huma 956.250,00
Ringer Laktat Otsuka 28.614,00
Cuticell Classic 10cmx10c
01/03/2021 00:00:00 35.121,00
Hypafix 15cmx5cm (25 c 13.088,00
Kassa kotak stril DRC 19.350,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 2.377.380,00
2.008 Indro SUMBER MAKMUR 126533 Aminophyllin Inj
20/02/2021 00:00:00 15.536,00 BPJS
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Combivent 25.024,00
NACL 0,9 % 500 ml 17.100,00
Nebulizer O2 Dewasa 34.783,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ranitidin inj 3.580,00
vestein 300 mg 46.750,00
Total 196.664,00
2.009 Bahman SIBAK 155872 NACL 0,9 % 500 ml
20/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.010 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
20/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.011 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
20/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.012 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
20/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.013 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
20/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.014 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
20/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.015 Sumidah RAWA MULYA 163860 Candesartan Tab 16 mg
20/02/2021 00:00:00 3.537,00 BPJS
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00

19/08/2021 12:42:30 Page 471 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.015 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
20/02/2021 00:00:00 42.750,00 BPJS
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 54.201,00
2.016 Bima Aryandika BANDARATU 178714 Candesartan Tab 16 mg
20/02/2021 00:00:00 3.537,00 BPJS
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
Lansoprazole kapsul 30 m 3.465,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 85.842,00
Total 98.775,00
2.017 Kasmidi Kasim BANDAR RATU 135355 Candesartan Tab 16 mg
20/02/2021 00:00:00 3.537,00 BPJS
Cetirizine 10 mg 378,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 49.935,00
2.018 Jumarno LUNANG 180796 Asam Folat 1 mg @100 T
20/02/2021 00:00:00 198,00 BPJS
Candesartan Tab 16 mg 3.537,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 0,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 54.399,00
2.019 Mira BUNGA TANJUNG 128468 abbocath 18 Terumo @5
20/02/2021 00:00:00 26.341,00 BPJS
Alkohol 1Liter 42.111,00
Aqua Pro Injeksi 3.575,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 94.600,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon steril 7,5 (Ga 145.630,00
Handscoon Steril 8.5 (Ga 43.662,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 6.5 24.732,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 28.463,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00

19/08/2021 12:42:30 Page 472 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.019 Mira BUNGA TANJUNG 128468 Misoprostol Tab
20/02/2021 00:00:00 16.500,00 BPJS
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 20.082,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
21/02/2021 00:00:00 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Metoclopramide inj 5Mg/M 11.758,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 540,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Suprafenid Supositoria 10 42.075,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
22/02/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Asam Mefenamat 500 m
23/02/2021 00:00:00 1.935,00
Cefixime Kapsul 100 mg 0,00
Cefixime kapsul 200 mg 26.480,00
Cefixime kapsul 200 mg 26.480,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Nucral Syrup 100 ml 53.350,00
Paracetamol tablet 500 m 2.000,00
Postofix (leukomed) 36.726,00

19/08/2021 12:42:30 Page 473 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 2.173.632,00
2.020 Suyati RAWA BANGUN 147952 Asam Folat 1 mg @100 T
21/02/2021 00:00:00 297,00 BPJS
Candesartan tab 8 mg 681,00
Levemir FlexPen 104.938,00
meropenem Injeksi 1 g 41.250,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ondansetron Inj 3.300,00
Total 273.365,00
2.021 Nina Saputri LUBUK SANAI III 135332 Abbocath 20 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Flunarizine 5 mg tab 4.950,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 200,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Total 95.807,00
2.022 Suyati RAWA BANGUN 147952 Abbocath 20 Terumo @5
21/02/2021 00:00:00 52.682,00 BPJS
Candesartan tab 8 mg 681,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kalitake 18.750,00
meropenem Injeksi 1 g 123.750,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 34.200,00
Nassal Cannula O2 Anak 16.473,00
Novo Twist 32 G Tip 3.856,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Transfusi Set Terumo 16.500,00
Ventolin Nebules 2.5 mg 15.000,00
Asam Folat 1 mg @100 T
22/02/2021 00:00:00 297,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 681,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 17,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kalitake 18.750,00
Levemir FlexPen 104.938,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 25.650,00
Nassal Mask O2 Dewasa 41.828,00
Novo Twist 32 G Tip 3.856,00
Ondansetron Inj 4.950,00
Pregabalin Kap 75 mg 6.446,00
Ventolin Nebules 2.5 mg 15.000,00

19/08/2021 12:42:30 Page 474 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.022 Suyati RAWA BANGUN 147952 Abbocath 20 Terumo @5
23/02/2021 00:00:00 52.682,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 34,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 9.700,00
Meropenem Inj 0.5 g 165.000,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Asam Folat 1 mg @100 T
24/02/2021 00:00:00 2.970,00
Candesartan tab 8 mg 6.810,00
Hypafix 15cmx5cm (25 c 13.088,00
NACL 0,9 % 500 ml 34.200,00
OMZ 90.000,00
Ondansetron Inj 4.950,00
Pregabalin Kap 75 mg 32.230,00
Kalitake
25/02/2021 00:00:00 31.250,00
Perifas @100 Tab 3.850,00
Ventolin Nebules 2.5 mg 30.000,00
Total 1.351.949,00
2.023 Ny.mira BUNGA TANJUNG 182616 Chloramphenicol Salep M
21/02/2021 00:00:00 2.351,00 BPJS
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
NonWoven Fixation 10x
24/02/2021 00:00:00 4.815,00
Abbocath 24 Terumo @5
25/02/2021 00:00:00 52.682,00
Bactesyn inj 0,75 gr 59.009,00
Hypafix 10cm x 5cm (25 c 4.850,00
Otsu Nacl PiggyBack 100 m 18.975,00
Bactesyn inj 0,75 gr
26/02/2021 00:00:00 59.009,00
Total 274.372,00
2.024 Yon Zeni ARAH TIGA 156405 Abbocath 20 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Citicoline Injeksi 125mg/ 11.250,00
Electroda (Ambu) @25 Pc 163.140,00
Infusion Makro (terumo) 27.225,00
KSR (potassium chloride) 2.303,00
Meropenem Inj 0.5 g 55.000,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Dewasa 41.828,00
NGT (Stomach Tube) Fr. 1 52.250,00
NonWoven Fixation 15x 6.694,00
Novo Twist 32 G Tip 1.928,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 200,00
Urine bag 10.088,00

19/08/2021 12:42:30 Page 475 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 567.045,00
2.025 Nina Saputri LUBUK SANAI III 135332 Omeprazol kapsul 20 mg
21/02/2021 00:00:00 3.305,00 BPJS
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Total 58.119,00
2.026 Tika Mulya Sari TALANG MEDAN 117958 Cefotaxime Injeksi
22/02/2021 00:00:00 11.502,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Ondansetron Inj 4.950,00
Paracetamol Infus 43.314,00
Sucralfate Suspensi 100 m 19.250,00
Total 83.866,00
2.027 Yon Zeni ARAH TIGA 156405 Citicoline Injeksi 125mg/
21/02/2021 00:00:00 22.500,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
KSR (potassium chloride) 6.909,00
NACL 0,9 % 500 ml 34.200,00
Nassal Cannula O2 Dewas 11.625,00
Paracetamol tablet 500 m 600,00
Candesartan tab 8 mg
22/02/2021 00:00:00 681,00
Citicoline Injeksi 125mg/ 22.500,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 10cm x 5cm (25 c 4.850,00
KSR (potassium chloride) 6.909,00
KSR (potassium chloride) 6.909,00
NACL 0,9 % 500 ml 34.200,00
NACL 0,9 % 500 ml 34.200,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Total 384.467,00
2.028 Bima Aryandika BANDARATU 178714 Ceftriaxone Inj
21/02/2021 00:00:00 12.498,00 BPJS
Diazepam Tab 5 Mg 408,00
Nassal Cannula O2 Anak 16.473,00
Ondansetron Inj 1.650,00
Phenytoin Sodium Injeksi 15.911,00
Total 46.940,00
2.029 Bima Aditia.s TALANG KARET 110070 Catheter 2 Way No. 16 (
21/02/2021 00:00:00 20.625,00 BPJS
Ceftriaxone Inj 12.498,00
Diazepam Inj 16.430,00
Extention Tube 8.801,00
Guedel No 70 MM 18.233,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 60.046,00
Nicardipine HCl Inj 88.698,00
Ondansetron Inj 4.950,00
Phenytoin Sodium Injeksi 47.733,00
Suction Chateter no. 12 ( 10.588,00
Three Way stopcock 25.904,00

19/08/2021 12:42:30 Page 476 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.029 Bima Aditia.s TALANG KARET 110070 Urine bag
21/02/2021 00:00:00 10.088,00 BPJS
Total 337.994,00
2.030 Sumarni SUNGAI LINTANG 182617 Ceftriaxone Inj
21/02/2021 00:00:00 12.498,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Ranitidin inj 1.790,00
Zinc Sulfate Syr 60 ml 4.569,00
Abbocath 22 Terumo @5 22.276,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 3.300,00
Ceftriaxone Inj
22/02/2021 00:00:00 12.498,00
Ceftriaxone Inj 12.498,00
Loperamide HCL tab 2 m 300,00
Loperamide HCL tab 2 m 300,00
Ondansetron Inj 3.300,00
Ondansetron Inj 3.300,00
Ranitidin inj 3.580,00
Ranitidin inj 3.580,00
Zinc Sulfate Syr 60 ml 4.569,00
Zinc Sulfate Syr 60 ml 4.569,00
Ceftriaxone Inj
23/02/2021 00:00:00 18.747,00
Loperamide HCL tab 2 m 300,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Zinc Sulfate Syr 60 ml 4.569,00
Levofloxacin Tablet 500 m
24/02/2021 00:00:00 13.640,00
Scopamin Inj 36.000,00
Zinc Sulfate Syr 60 ml 4.569,00
Zink Tablet 689,00
Total 247.896,00
2.031 Ali antoni PONDOK BARU 133926 abbocath 18 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Asam Folat 1 mg @100 T 99,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Urine bag 10.088,00
Total 232.511,00
2.032 Bima Aryandika BANDARATU 178714 Nicardipine HCl Inj
21/02/2021 00:00:00 88.698,00 BPJS
Asam Folat 1 mg @100 T
22/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Levofloxacin Infus 24.488,00
Levofloxacin Infus 24.488,00
NACL 0,9 % 500 ml 17.100,00
Nicardipine HCl Inj 29.566,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 477 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.032 Bima Aryandika BANDARATU 178714 Phenytoin Sodium Injeksi
22/02/2021 00:00:00 47.733,00 BPJS
Ceftriaxone Inj
23/02/2021 00:00:00 12.498,00
Levofloxacin Infus 24.488,00
Nicardipine HCl Inj 118.264,00
Nicardipine HCl Inj 177.396,00
Nicardipine HCl Inj 206.962,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Phenytoin Sodium Injeksi 31.822,00
Abbocath 22 Terumo @5
24/02/2021 00:00:00 44.552,00
Abbocath 22 Terumo @5 22.276,00
Amlodipine 5 mg @30 T 303,00
Asam Folat 1 mg @100 T 198,00
Candesartan tab 8 mg 2.043,00
Ceftriaxone Inj 12.498,00
Clonidine 0.15 mg @100 T 687,00
Electroda (Ambu) @25 Pc 81.570,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Levofloxacin Infus 24.488,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 42.750,00
Nicardipine HCl Inj 59.132,00
Nicardipine HCl Inj 177.396,00
Nicardipine HCl Inj 147.830,00
Nicardipine HCl Inj 177.396,00
Nicardipine HCl Inj 118.264,00
Ondansetron Inj 4.950,00
Phenytoin Sodium Injeksi 15.911,00
Renogen 3000 UI 116.875,00
Three Way stopcock 25.904,00
Asam Folat 1 mg @100 T
25/02/2021 00:00:00 297,00
Ceftriaxone Inj 12.498,00
Levofloxacin Infus 24.488,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron tablet 8 mg 7.920,00
Tambah Darah Neo Tab 1.395,00
Amlodipine 10 mg @50 T
26/02/2021 00:00:00 1.180,00
Asam Folat 1 mg @100 T 990,00
Calos cmewable tab 8.030,00
Candesartan tab 8 mg 6.810,00
Ceftriaxone Inj 12.498,00
Clonidine 0.15 mg @100 T 687,00
Clonidine 0.15 mg @100 T 4.580,00
Furosemide 40 mg Tablet 1.920,00
Levofloxacin Infus 24.488,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Tambah Darah Neo Tab 4.650,00
Abbocath 22 Terumo @5
27/02/2021 00:00:00 22.276,00
Abbocath 22 Terumo @5 11.138,00
Ceftriaxone Inj 12.498,00

19/08/2021 12:42:30 Page 478 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.032 Bima Aryandika BANDARATU 178714 Infusion Makro (terumo)
27/02/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 34.200,00
Ondansetron Inj 4.950,00
Total 2.265.147,00
2.033 Ali antoni PONDOK BARU 133926 Asam Folat 1 mg @100 T
21/02/2021 00:00:00 99,00 BPJS
Cetirgi Tab 10 mg 1.548,00
Combivent 18.768,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 4.998,00
Furosemide Injeksi @2ml 204,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Vectrein Syrup 45.000,00
Venturi Mask Dewasa Ge 34.375,00
Abbocath 20 Terumo @5
22/02/2021 00:00:00 26.341,00
Ascorbid Acid 1000mg/5m 78.375,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Cetirgi Tab 10 mg 3.096,00
Cetirizine 10 mg 126,00
Combivent 25.024,00
Combivent 25.024,00
Combivent 6.256,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Epinephrin inj 15.331,00
Furosemide Injeksi @2ml 238,00
Furosemide Injeksi @2ml 17,00
Furosemide Injeksi @2ml 238,00
Hypafix 10cm x 5cm (25 c 4.850,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Omeprazole Inj 0,00
Phytomenadione 10 mg ( 2.802,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 644.684,00
2.034 Chandra Setiawan DUSUN AIR DIKIT 171081 Abbocath 20 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00

19/08/2021 12:42:30 Page 479 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.034 Chandra Setiawan DUSUN AIR DIKIT 171081 Omeprazole Inj
21/02/2021 00:00:00 12.499,00 BPJS
Spironolaktone 25 mg 520,00
Urine bag 10.088,00
Nassal Cannula O2 Dewas 11.625,00
Ceftriaxone Inj
22/02/2021 00:00:00 12.498,00
Curcuma Tab 3.810,00
Furosemide Injeksi @2ml 51,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 35.274,00
Omeprazole Inj 12.499,00
Omeprazole Inj 37.497,00
Spironolaktone 25 mg 520,00
Total 307.543,00
2.035 Yalminawati PELOKAN 179039 Abbocath 20 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 11.918,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 4.210,00
Vitamin B Komplek @100 462,00
Total 77.297,00
2.036 Norbaiti LUBUK PINANG 182618 Abbocath 20 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Azitromycin 500 mg 5.625,00
Catheter 2 Way No. 16 ( 20.625,00
Electroda (Ambu) @25 Pc 81.570,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 41.250,00
Metformin tablet 500 mg 133,00
Nassal Cannula O2 Dewas 11.625,00
Urine bag 10.088,00
Vectrine Tab 300 mg 15.000,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 25.650,00
Ringer Laktat Otsuka 19.076,00
Azitromycin 500 mg
22/02/2021 00:00:00 5.625,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol tablet 500 m 600,00
Vectrine Tab 300 mg 50.000,00
Azitromycin 500 mg
23/02/2021 00:00:00 5.625,00
Paracetamol tablet 500 m 1.000,00
vestein 300 mg 23.375,00
Vitamin B Komplek @100 770,00
Aminofluid Infus 500 ml
26/02/2021 00:00:00 155.204,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol tablet 500 m 800,00
Ranitidin inj 3.580,00

19/08/2021 12:42:30 Page 480 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 912.087,00
2.037 Gerin Fortuna Dewi DUSUN GEDANG 182619 Betahistin Mesilat 6 mg @
21/02/2021 00:00:00 828,00 BPJS
Flunarizine 5 mg tab 9.900,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 31.978,00
2.038 Mujiati SUMBER MULYA 182620 abbocath 18 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Cefixime Kapsul 100 mg
22/02/2021 00:00:00 9.380,00
Neurodex tablet 7.410,00
Paracetamol tablet 500 m 3.000,00
Total 88.521,00
2.039 Yalminawati PELOKAN 179039 Hypafix 10cm x 5cm (25 c
21/02/2021 00:00:00 9.700,00 BPJS
Ondansetron Inj 3.300,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Abbocath 22 Terumo @5
22/02/2021 00:00:00 33.414,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Abbocath 22 Terumo @5
23/02/2021 00:00:00 33.414,00
Ceftriaxone Inj 12.498,00
Extrace Injeksi 100 mg/m 28.875,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Nassal Mask O2 Dewasa 41.828,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 17.877,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 4.210,00
Ventolin Nebules 2.5 mg 20.000,00
Asam Traneksamat @10
24/02/2021 00:00:00 21.050,00
Cefixime kapsul 200 mg 26.480,00
Methylprednisolone tab 4 2.630,00
NACL 0,9 % 500 ml 17.100,00
Phytomenadione 10 mg ( 9.340,00
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 70.125,00
Vitamin C tablet @100 Ta 1.380,00
Total 559.070,00
2.040 Asep Dodi Pramono TANJUNG MULYA 182622 Abbocath 20 Terumo @5
21/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
azitromicin inj 500 mg 144.376,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00

19/08/2021 12:42:30 Page 481 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.040 Asep Dodi Pramono TANJUNG MULYA 182622 NACL 0,9 % 500 ml
21/02/2021 00:00:00 8.550,00 BPJS
Nassal Cannula O2 Dewas 11.625,00
Paracetamol tablet 500 m 800,00
Vitamin C 500 mg 2,00
Ceftriaxone Inj
22/02/2021 00:00:00 12.498,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol tablet 500 m 2.000,00
Prednox 4 mg tab 13.720,00
Vectrine Tab 300 mg 50.000,00
Vitamin C 500 mg 10,00
Abbocath 24 Terumo @5
23/02/2021 00:00:00 52.682,00
Ceftriaxone Inj 18.747,00
Cotrimoxazole Tab 996,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol tablet 500 m 2.000,00
Prednison tab 5 mg 2.390,00
Ceftriaxone Inj
24/02/2021 00:00:00 12.498,00
Fluconazole tab 150 mg 49.142,00
NACL 0,9 % 500 ml 25.650,00
Paracetamol tablet 500 m 2.000,00
Prednison tab 5 mg 4.780,00
Ceftriaxone Inj
25/02/2021 00:00:00 12.498,00
Cotrimoxazole Tab 1.660,00
NACL 0,9 % 500 ml 25.650,00
Total 552.838,00
2.041 Mujiati SUMBER MULYA 182620 Cefixime Kapsul 100 mg
22/02/2021 00:00:00 9.380,00 BPJS
Misoprostol Tab 11.000,00
Paracetamol tablet 500 m 3.000,00
Suction Chateter no. 8 (R 20.625,00
Total 44.005,00
2.042 Ike Apricelia KOTO JAYA 157240 Bisturi No. 23
22/02/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 18 ( 31.251,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 25.650,00
Polyglycolide T-Vio 1 R ( 197.000,00

19/08/2021 12:42:30 Page 482 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.042 Ike Apricelia KOTO JAYA 157240 Polyvinylidene 3-0 R (Tri
22/02/2021 00:00:00 92.000,00 BPJS
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 24.062,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Bisturi No. 23
23/02/2021 00:00:00 3.836,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Induxin 1 ml Injeksi 18.562,00
Phytomenadione 2 Mg/1M 4.834,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
24/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
25/02/2021 00:00:00 1.935,00
Cuticell Classic 10cmx10c 0,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.529.960,00
2.043 Aqwezil Pradela DANAU NIBUNG 182625 Omeprazol kapsul 20 mg
22/02/2021 00:00:00 3.305,00 BPJS
Ondansetron tablet 8 mg 13.200,00
Paracetamol tablet 500 m 3.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 38.755,00
2.044 Puspita Wati BANDARATU 132071 Abbocath 20 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Total 217.376,00
2.045 Sri Rahayu KOTA PRAJA 129208 Methylprednisolone tab 4
22/02/2021 00:00:00 1.578,00 BPJS
vestein 300 mg 93.500,00
Total 95.078,00
2.046 Aqmal Faiq Azzizi KOTA PRAJA 130956 Cefixime syrup 100mg/5 M
22/02/2021 00:00:00 23.823,00 BPJS

19/08/2021 12:42:30 Page 483 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.046 Aqmal Faiq Azzizi KOTA PRAJA 130956 Cetirgi Tab 10 mg
22/02/2021 00:00:00 7.740,00 BPJS
Mucera Syr Forte 29.700,00
Total 61.263,00
2.047 Debi Burzana Saputra WONOSOBO 165026 Abbocath 20 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 62.980,00
2.048 Asyrof Atikah BANDARATU 131815 Asam Mefenamat 500 m
22/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.049 Azwani KOTO JAYA 112288 Bisoprolol 5 mg @100 Ta
22/02/2021 00:00:00 4.440,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Meloxicam 7,5 mg 21.840,00
Simvastatin tab 10 mg 7.230,00
Total 109.470,00
2.050 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
22/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.051 Sajiman SUMBER MAKMUR 177386 Omeprazol kapsul 20 mg
22/02/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 93.500,00
Vitamin B Komplek @100 3.080,00
Total 122.440,00
2.052 Narti SILAUT 175653 NACL 0,9 % 500 ml
22/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.053 Rosnidar PENARIK 131980 Captopril 12,5 mg
22/02/2021 00:00:00 2.400,00 BPJS
Digoxsin tab 0,25 mg 2.160,00
Furosemide 40 mg Tablet 2.880,00
Spironolaktone 25 mg 7.800,00
Total 15.240,00
2.054 Adriani BANDARATU 120948 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 3.030,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Mucera Syr Forte 29.700,00
Omeprazol kapsul 20 mg 19.830,00
Paracetamol tablet 500 m 6.000,00
Simvastatin tab 10 mg 7.230,00
Total 90.660,00
2.055 Ujang Samsudin UJUNG PADANG 127171 Captopril 12,5 mg
22/02/2021 00:00:00 1.600,00 BPJS
Codein tab 10 mg 7.500,00
Furosemide 40 mg Tablet 2.880,00
Glimepiride tab 2 mg 7.770,00
Metformin tablet 500 mg 7.980,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 19.830,00
Spironolaktone 25 mg 7.800,00
Total 59.110,00
2.056 Darmawan LUBUK PINANG 140187 Amlodipine 10 mg @50 T
22/02/2021 00:00:00 1.180,00 BPJS

19/08/2021 12:42:30 Page 484 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.056 Darmawan LUBUK PINANG 140187 Asam Folat 1 mg @100 T
22/02/2021 00:00:00 990,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 161.795,00
2.057 Yulita Rafika Suci PT AGRO TPE 156533 Urinter Kapsul @100 cap
22/02/2021 00:00:00 21.980,00 BPJS
Total 21.980,00
2.058 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
22/02/2021 00:00:00 42.750,00 BPJS
Ringer Laktat Otsuka 9.538,00
Total 52.288,00
2.059 Nur Aripin KOTO JAYA 115218 Betahistin Mesilat 6 mg @
22/02/2021 00:00:00 4.140,00 BPJS
Betametason krim 0,1% 1.675,00
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Simvastatin tab 10 mg 7.230,00
Total 90.565,00
2.060 Ahmad Mujiono MARGA MULYA SAKTI 113737 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 303,00 BPJS
Azitromycin 500 mg 16.875,00
Cetirgi Tab 10 mg 4.644,00
Methylprednisolone tab 4 789,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 182.836,00
2.061 M Akil PASAR BELAKANG 115376 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 303,00 BPJS
Azitromycin 500 mg 16.875,00
Cetirgi Tab 10 mg 4.644,00
Methylprednisolone tab 4 789,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 182.836,00
2.062 Ike Apricelia KOTO JAYA 157240 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 72.364,00
2.063 Dasmiati BANDAR RATU 089122 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 19.830,00
Paracetamol tablet 500 m 6.000,00
Simvastatin tab 10 mg 7.230,00
ursodeoxycholic acid 56.700,00
Vbloc 6,25 mg 65.550,00
Total 231.420,00
2.064 Ashari Liwandi PONDOK LUNANG 139398 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 303,00 BPJS
Azitromycin 500 mg 16.875,00
Cetirgi Tab 10 mg 4.644,00
Methylprednisolone tab 4 789,00

19/08/2021 12:42:30 Page 485 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.064 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
22/02/2021 00:00:00 42.750,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 182.836,00
2.065 Amiruddin BANDAR RATU 089119 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 3.030,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 19.830,00
Paracetamol tablet 500 m 6.000,00
Simvastatin tab 10 mg 7.230,00
Vbloc 6,25 mg 65.550,00
Total 154.290,00
2.066 Supangat PONDOK LUNANG 147511 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 303,00 BPJS
Azitromycin 500 mg 16.875,00
Cetirgi Tab 10 mg 4.644,00
Methylprednisolone tab 4 789,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 182.836,00
2.067 Titin Sumarni KOTO JAYA 112327 Levopar tab 100mg
22/02/2021 00:00:00 77.460,00 BPJS
Sifrol tab 0,375 mg 311.250,00
Total 388.710,00
2.068 Wardoyo TANJUNG MULYA 125079 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 303,00 BPJS
Cetirgi Tab 10 mg 4.644,00
Methylprednisolone tab 4 789,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 165.961,00
2.069 Septi Putriani LUBUK PINANG 119099 Asam Folat 1 mg @100 T
22/02/2021 00:00:00 2.970,00 BPJS
Phenobarbital Tablet 30 m 22.500,00
Valproic Acid Syrup 250mg 104.875,00
Vbloc 6,25 mg 65.550,00
Total 195.895,00
2.070 Miswanto LUNANG 128267 NACL 0,9 % 500 ml
22/02/2021 00:00:00 34.200,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 151.675,00
2.071 Merri Lestary PONDOK BATU 125314 Methylprednisolone tab 4
22/02/2021 00:00:00 7.890,00 BPJS
Omeprazol kapsul 20 mg 19.830,00
Paracetamol tablet 500 m 6.000,00
Total 33.720,00
2.072 Reni Tianingsih TANJUNG BERINGIN 180338 Asam Mefenamat 500 m
22/02/2021 00:00:00 1.290,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Paracetamol tablet 500 m 2.000,00
Total 12.670,00
2.073 Jusa Dwi Alfiandra DUSUN BARU V KOTO 144268 Cetirizine Sirup
22/02/2021 00:00:00 3.718,00 BPJS
Total 3.718,00
2.074 Mukmin AIR DIKIT 178821 Amlodipine 5 mg @30 T
22/02/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Combivent 18.768,00
Furosemide 40 mg Tablet 2.880,00

19/08/2021 12:42:30 Page 486 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.074 Mukmin AIR DIKIT 178821 Metformin tablet 500 mg
22/02/2021 00:00:00 7.980,00 BPJS
Omeprazole Inj 374.970,00
Spironolaktone 25 mg 7.800,00
Amlodipine 10 mg @50 T
19/03/2021 00:00:00 1.180,00
Candesartan tab 8 mg 6.810,00
Furosemide 40 mg Tablet 960,00
Metformin tablet 500 mg 1.330,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 25 mg 2.600,00
Total 455.348,00
2.075 Santiriani RETAK MUDIK 182641 Ketoprofen tab 100 mg
22/02/2021 00:00:00 24.760,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 6.000,00
Total 44.400,00
2.076 Jarwanto WONOSOBO 165339 Betahistin Mesilat 6 mg @
22/02/2021 00:00:00 1.380,00 BPJS
Flunarizine 5 mg tab 24.750,00
Paracetamol tablet 500 m 2.000,00
Total 28.130,00
2.077 Samsuar NELAN INDAH 137270 Levofloxacin Tablet 500 m
22/02/2021 00:00:00 13.640,00 BPJS
Metrodinazole tab 500 m 4.050,00
Paracetamol tablet 500 m 3.000,00
Total 20.690,00
2.078 Wasimin MEKAR SARI 176996 Ibuprofen tab 200 mg
22/02/2021 00:00:00 1.990,00 BPJS
Mucera Syr Forte 29.700,00
Total 31.690,00
2.079 Sadiyem LUNANG 119406 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 80.452,00
2.080 Rosida PT AGRO TRE 120367 Asam Mefenamat 500 m
22/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.081 Marwani PONDOK BATU 154687 Antasida Syrup 60 ml
22/02/2021 00:00:00 2.736,00 BPJS
Lansoprazole kapsul 30 m 11.550,00
Metoclopramide inj 5Mg/M 58.790,00
Sucralfate Suspensi 100 m 19.250,00
Total 92.326,00
2.082 Yusril Dany TANJUG ALAI 166366 Aspilet 80 mg @100 mg
22/02/2021 00:00:00 4.140,00 BPJS
Candesartan tab 8 mg 20.430,00
Mucera Syr Forte 29.700,00
Piracetam tablet 1200 m 41.880,00
Ranitidine tablet 150 mg 2.880,00
Simvastatin tab 10 mg 7.230,00
Total 106.260,00
2.083 Rasiman AIR BERAU 167855 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 81.844,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.084 Puspita Wati BANDARATU 132071 Metoclopramide inj 5Mg/M
22/02/2021 00:00:00 17.637,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 24.998,00
Omeprazole Inj 37.497,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 400,00
Sucralfate Suspensi 100 m 19.250,00
Alprazolam 0,5 mg @100
23/02/2021 00:00:00 236,00
Cefotaxime Injeksi 17.253,00
Ceftriaxone Inj 12.498,00
Metformin tablet 500 mg 665,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 28.614,00
Levofloxacin Tablet 500 m
24/02/2021 00:00:00 6.820,00
Nucral Syrup 100 ml 53.350,00
Omeprazol kapsul 20 mg 3.305,00
Total 305.483,00
2.085 Sasnani Bentara TALANG MEDAN 135659 Abbocath 18 (Gea)
22/02/2021 00:00:00 10.720,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 62.162,00
2.086 Rahmani SIBAK 169819 Gabapentin kapsul 300 m
22/02/2021 00:00:00 12.690,00 BPJS
Meloxicam 7,5 mg 7.280,00
Omeprazol kapsul 20 mg 6.610,00
Total 26.580,00
2.087 Mawi UJUNG PADANG 110466 Alprazolam 0,5 mg @100
22/02/2021 00:00:00 1.180,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Aspilet 80 mg @100 mg 4.140,00
Bisoprolol 5 mg @100 Ta 8.880,00
Candesartan tab 8 mg 20.430,00
Omeprazol kapsul 20 mg 13.220,00
Simvastatin tab 10 mg 7.230,00
Total 58.110,00
2.088 Nurmisam UJUNG PADANG 110659 Alprazolam 0,5 mg @100
22/02/2021 00:00:00 2.360,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Aspilet 80 mg @100 mg 4.140,00
Bisoprolol 5 mg @100 Ta 4.440,00
Metformin tablet 500 mg 7.980,00
Omeprazol kapsul 20 mg 13.220,00
Simvastatin tab 10 mg 7.230,00
Spironolaktone 25 mg 7.800,00
Total 50.200,00
2.089 Damuri Kaninda Putri PONDOK BARU 145892 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00

19/08/2021 12:42:30 Page 488 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.089 Damuri Kaninda Putri PONDOK BARU 145892 Misoprostol Tab
22/02/2021 00:00:00 5.500,00 BPJS
Ringer Laktat Otsuka 19.076,00
Total 94.494,00
2.090 Siti Nita TALANG PETAI 182626 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 144.500,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Misoprostol Tab 22.000,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 9.538,00
Suction Chateter no. 8 (R 20.625,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 4.522,00
Urine bag 10.088,00
Total 305.484,00
2.091 Ali Nurman IPUH 182632 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Ibuprofen tab 200 mg 398,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 19.076,00
Total 84.542,00
2.092 Novia Hartati TALANG PETAI 182233 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Misoprostol Tab 22.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 122.920,00
2.093 Agusti Dewita NENGALO 182647 abbocath 18 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Misoprostol Tab 22.000,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 84.980,00
2.094 Sadiyem LUNANG 119406 Amlodipine 5 mg @30 T
23/02/2021 00:00:00 290,00 BPJS
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Metformin tablet 500 mg 399,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 5 mg @30 T
25/02/2021 00:00:00 1.010,00
Citicoline kaplet 500 mg 16.500,00
Metformin tablet 500 mg 1.330,00
Omeprazol kapsul 20 mg 6.610,00
Total 102.250,00

19/08/2021 12:42:30 Page 489 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.095 Debi Burzana Saputra WONOSOBO 165026 Alkohol 1Liter
22/02/2021 00:00:00 42.111,00 BPJS
ATRACURIUM BESYLATE 2 14.671,00
Bisturi No. 23 3.836,00
Bisturi no. 10 3.836,00
Bisturi No. 15 3.836,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
Handscoond Sterille 6.5 24.732,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
KTM (ketamin) Injeksi 214.500,00
Lidocain injk 40 mg/2 ml 8.055,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 20.082,00
Polyvinylidene 3-0 R (Tri 92.000,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Asam Mefenamat 500 m
23/02/2021 00:00:00 1.935,00
Cefixime kapsul 200 mg 26.480,00
Total 1.023.582,00
2.096 Agusti Dewita NENGALO 182647 Cefotaxime Injeksi
22/02/2021 00:00:00 11.502,00 BPJS
Celemek Plastik 59.125,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Ketorolac inj 30 mg/1ml 2.690,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00
Rofiden Supp 24.062,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00

19/08/2021 12:42:30 Page 490 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.096 Agusti Dewita NENGALO 182647 Spuit 5 cc terumo
22/02/2021 00:00:00 8.538,00 BPJS
Asam Mefenamat 500 m
23/02/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Fentanyl Injeksi 5 Ampul 2 104.000,00
Proster Tablet 200 mcg 50.420,00
Total 565.868,00
2.097 Sasnani Bentara TALANG MEDAN 135659 Bisturi No. 23
22/02/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 18 ( 31.251,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 144.500,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Ephedrine Injeksi 21.422,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 43.662,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 22.000,00
Metrodinazole Infus 30.939,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 24.062,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suction Chateter no. 12 ( 10.588,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Bisturi No. 23
23/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding tube) Fr. 5 17.603,00
Phytomenadione 2 Mg/1M 4.834,00

19/08/2021 12:42:30 Page 491 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.097 Sasnani Bentara TALANG MEDAN 135659 Tranexamic Acid Inj (Asa
23/02/2021 00:00:00 6.315,00 BPJS
umbilical Cord Clamp 2.261,00
Aqua Pro Injeksi
24/02/2021 00:00:00 7.150,00
Cefotaxime Injeksi 17.253,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
25/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.530.321,00
2.098 Sumadi PONDOK MAKMUR 182524 Abbocath 20 Terumo @5
22/02/2021 00:00:00 52.682,00 BPJS
Cefotaxime Injeksi 5.751,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Bisturi No. 15
23/02/2021 00:00:00 3.836,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 43.662,00
Iodine povidone 300 ml 28.463,00
Masker Karet 11.000,00
NACL 0,9 % 500 ml 17.100,00
Polyglycolide T-Vio 1 R ( 98.500,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Silk 2/0 C scimitar 66.993,00
Spinocain 25 (BBraund) 42.763,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Urine bag 10.088,00
Ascorbid Acid 1000mg/5m
24/02/2021 00:00:00 52.250,00
Cefotaxime Injeksi 11.502,00
NACL 0,9 % 500 ml 34.200,00
NACL 0,9 % 500 ml 85.500,00
NonWoven Fixation 10x 14.445,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Vit K Infant Injeksi 16.500,00

19/08/2021 12:42:30 Page 492 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.098 Sumadi PONDOK MAKMUR 182524 Ceftriaxone Inj
25/02/2021 00:00:00 12.498,00 BPJS
NACL 0,9 % 500 ml 85.500,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 171.000,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Vitamin C tablet @100 Ta 414,00
Cefotaxime Injeksi
26/02/2021 00:00:00 5.751,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 19.350,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Tramadol 50 mg/ml Inj 8.250,00
Ascorbid Acid 1000mg/5m
27/02/2021 00:00:00 78.375,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 2 Mg/1M 14.502,00
Nassal Cannula O2 Anak
05/04/2021 00:00:00 16.473,00
Total 1.843.087,00
2.099 Damuri Kaninda Putri PONDOK BARU 145892 Catheter 2 Way No. 16 (
22/02/2021 00:00:00 20.625,00 BPJS
Cefotaxime Injeksi 11.502,00
Misoprostol Tab 33.000,00
Cefotaxime Injeksi
23/02/2021 00:00:00 11.502,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Misoprostol Tab
24/02/2021 00:00:00 16.500,00
Paracetamol tablet 500 m 1.000,00
Cefixime Kapsul 100 mg
25/02/2021 00:00:00 9.380,00
Cefotaxime Injeksi 17.253,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 11.000,00
Misoprostol Tab 55.000,00
Paracetamol tablet 500 m 400,00
Total 220.972,00
2.100 Novia Hartati TALANG PETAI 182233 Celemek Plastik
22/02/2021 00:00:00 59.125,00 BPJS
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 40.160,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Masker Karet 11.000,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Rofiden Supp 24.062,00

19/08/2021 12:42:30 Page 493 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.100 Novia Hartati TALANG PETAI 182233 Spuit 10 cc Disposible (T
22/02/2021 00:00:00 3.230,00 BPJS
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Cefotaxime Injeksi
23/02/2021 00:00:00 11.502,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Misoprostol Tab 16.500,00
Nassal Cannula O2 Dewas 11.625,00
Asam Mefenamat 500 m
24/02/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Misoprostol Tab 55.000,00
Total 520.392,00
2.101 Rasiman AIR BERAU 167855 Bisturi No. 23
23/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 43.662,00
Hypafix 10cm x 5cm (25 c 4.850,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 19.076,00
Spinocain 25 (BBraund) 42.763,00
Spuit 10 cc Disposible (T 9.690,00
Urine bag 10.088,00
Ketorolac inj 30 mg/1ml
24/02/2021 00:00:00 4.035,00
Levofloxacin Infus 48.976,00
OMZ 90.000,00
Ringer Laktat Otsuka 19.076,00
Cefixime Kapsul 100 mg
25/02/2021 00:00:00 9.380,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 3.000,00
Total 1.001.850,00
2.102 Ali Nurman IPUH 182632 Bisoprolol 5 mg @100 Ta
23/02/2021 00:00:00 888,00 BPJS
Cefotaxime Injeksi 11.502,00
Ibuprofen tab 200 mg 398,00
Mecobalamin 500 mg 1.540,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Vectrein Syrup 45.000,00
Cefotaxime Injeksi
24/02/2021 00:00:00 11.502,00
Ibuprofen tab 400 mg 4.580,00
Ibuprofen tab 400 mg 4.580,00

19/08/2021 12:42:30 Page 494 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.102 Ali Nurman IPUH 182632 Lapibal Kapsul 500 mg
24/02/2021 00:00:00 23.100,00 BPJS
Lapibal Kapsul 500 mg 11.550,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Total 205.432,00
2.103 Krisnawati TALANG SEPAKAT 180344 Abbocath 20 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 6.256,00
Infusion Makro (terumo) 27.225,00
Nassal Mask O2 Dewasa 41.828,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Induxin 1 ml Injeksi
24/02/2021 00:00:00 18.562,00
Total 145.770,00
2.104 Anggi Lianto LUBUK BENTO 125958 Abbocath 20 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 17,00
Asam Folat 1 mg @100 T
23/02/2021 00:00:00 297,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 3.070,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 34,00
Furosemide Injeksi @2ml 17,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Ringer Laktat Otsuka 19.076,00
Total 176.514,00
2.105 Nurlica Susanti PONDOK LUNANG 170212 Abbocath 20 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Induxin 1 ml Injeksi 9.281,00
Infusion Makro (terumo) 27.225,00
Misoprostol Tab 5.500,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Total 93.905,00
2.106 Kardi SUNGAI RUMBAI 182540 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 18.747,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 9.538,00

19/08/2021 12:42:30 Page 495 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 95.251,00
2.107 Suprihatin PENARIK 182652 Abbocath 20 Terumo @5
22/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Electroda (Ambu) @25 Pc 81.570,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Zink Tablet 689,00
Total 198.406,00
2.108 Nazlan Muhammad Al BANDAR RATU 167625 Ambroxol Syr 15mg/ml
22/02/2021 00:00:00 4.538,00 BPJS
Combivent 12.512,00
Nassal Cannula O2 Anak 16.473,00
Nassal Mask O2 Anak 41.828,00
Salbutamol 2 mg 474,00
Triamcinolon tablet 4 mg 3.764,00
Total 79.589,00
2.109 Suprihatin PENARIK 182652 Ceftriaxone Inj
23/02/2021 00:00:00 0,00 BPJS
Total 0,00
2.110 Kardi SUNGAI RUMBAI 182540 Ceftriaxone Inj
23/02/2021 00:00:00 12.498,00 BPJS
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Three Way stopcock 25.904,00
Ceftriaxone Inj
24/02/2021 00:00:00 6.249,00
Ceftriaxone Inj 6.249,00
NACL 0,9 % 500 ml 85.500,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
25/02/2021 00:00:00 12.498,00
Levofloxacin Tablet 500 m 13.640,00
Ringer Laktat Otsuka 19.076,00
Total 236.465,00
2.111 Siti Nita TALANG PETAI 182626 Bisturi No. 23
23/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 104.362,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 68.750,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Iodine povidone 300 ml 28.463,00

19/08/2021 12:42:30 Page 496 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.111 Siti Nita TALANG PETAI 182626 Ketorolac inj 30 mg/1ml
23/02/2021 00:00:00 1.345,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
methyl ergometrin amp 6.700,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
24/02/2021 00:00:00 7.150,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 17.253,00
Chloramphenicol Salep M 2.351,00
Clindamycin 150 mg tabl 8.750,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac Tab 10 Mg 37.950,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 10 Mg/1 5.959,00
Postofix (leukomed) 36.726,00
Tequinol Tab Kaplet 500 m 165.000,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
25/02/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 2.690,00
Tranexamic Acid Inj (Asa 4.210,00
Cefixime Kapsul 100 mg
26/02/2021 00:00:00 9.380,00
Clindamycin 150 mg tabl 17.500,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 1.956.212,00
2.112 Nurlica Susanti PONDOK LUNANG 170212 Asam Mefenamat 500 m
25/02/2021 00:00:00 1.935,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoond Sterille 6.5 16.488,00

19/08/2021 12:42:30 Page 497 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.112 Nurlica Susanti PONDOK LUNANG 170212 Handscoond Sterille 7 (G
25/02/2021 00:00:00 29.126,00 BPJS
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 55.000,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 16.150,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Total 355.114,00
2.113 Krisnawati TALANG SEPAKAT 180344 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Asam Mefenamat 500 m 1.935,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Ephedrine Injeksi 10.711,00
Furosemide Injeksi @2ml 3.332,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
methyl ergometrin amp 8.662,00
Metrodinazole tab 500 m 4.050,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding tube) Fr. 5 17.603,00
Nifedipin Tab 10 mg 525,00

19/08/2021 12:42:30 Page 498 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.113 Krisnawati TALANG SEPAKAT 180344 Otsu MgSO4 40 %
27/02/2021 00:00:00 9.490,00 BPJS
oxytocin inj 5.996,00
Pharmafix 15x50 (Hypap 6.544,00
Phytomenadione 2 Mg/1M 4.834,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Postofix (leukomed) 36.726,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 6.958,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Total 1.555.932,00
2.114 Indra Neli TIRTA MULYA 180790 Metoclopramide inj 5Mg/M
23/02/2021 00:00:00 17.637,00 BPJS
Nucral Syrup 100 ml 53.350,00
Omeprazole Inj 12.499,00
OMZ 90.000,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 28.614,00
Domperidone Syrup 5mg
24/02/2021 00:00:00 10.279,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Piralen Injeksi 2 ml 26.400,00
Total 284.288,00
2.115 Nurhayani LALANG LUAS 156887 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Antasida Syrup 60 ml 2.736,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Levofloxacin Infus 48.976,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 28.614,00
Levofloxacin Tablet 500 m
24/02/2021 00:00:00 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 307.501,00
2.116 Suprihatin PENARIK 182652 Atropin injek 1 ml
23/02/2021 00:00:00 34.845,00 BPJS
Paracetamol Infus 14.438,00

19/08/2021 12:42:30 Page 499 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.116 Suprihatin PENARIK 182652 Zink Tablet
23/02/2021 00:00:00 1.378,00 BPJS
Total 50.661,00
2.117 Rumi Lawati PERNYAH 164112 Alinamin F 50 mg @100 T
23/02/2021 00:00:00 11.500,00 BPJS
Amlodipine 10 mg @50 T 1.180,00
Candesartan tab 8 mg 6.810,00
Gitas Plus 50.330,00
Total 69.820,00
2.118 Deriati LUBUK GEDANG 132808 Amlodipine 10 mg @50 T
23/02/2021 00:00:00 1.770,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 10.215,00
Flunarizine 5 mg tab 24.750,00
Mecobalamin 500 mg 7.700,00
Total 48.875,00
2.119 Mega Puspita PAUH TERENJA 182532 Cefixime Kapsul 100 mg
23/02/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.120 Harni Hartati TERAS TERUNJAM 135319 Asam Mefenamat 500 m
23/02/2021 00:00:00 1.935,00 BPJS
Metrodinazole tab 500 m 4.050,00
Total 5.985,00
2.121 Nifka Maryanti TALANG SAKTI 182500 Asam Mefenamat 500 m
23/02/2021 00:00:00 1.935,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 52.091,00
2.122 Sukoyo LUNANG BARAT 162774 Domperidone Syrup 5mg
23/02/2021 00:00:00 10.279,00 BPJS
Flunarizine 5 mg tab 24.750,00
Urinter Kapsul @100 cap 21.980,00
Total 57.009,00
2.123 Ijas LUBUK GEDANG 153187 Flunarizine 5 mg tab
23/02/2021 00:00:00 24.750,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 26.750,00
2.124 Komsatun MEKAR MULYA 114172 Allopurinol 100 mg @100
23/02/2021 00:00:00 2.340,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Metformin tablet 500 mg 5.985,00
Pregabalin Kap 75 mg 64.460,00
Total 104.135,00
2.125 Saipah SUNGAI SARIK 182654 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 78.050,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 10 % 9.375,00
Glukosa Infus 5 % 8.626,00
NGT (Stomach Tube) Fr. 1 104.500,00
Otsu D40 12.513,00
Tranexamic Acid Inj (Asa 2.105,00
Urine bag 20.176,00
Total 277.759,00
2.126 Sumidah RAWA MULYA 163860 Asam Folat 1 mg @100 T
23/02/2021 00:00:00 2.970,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Calos cmewable tab 24.090,00

19/08/2021 12:42:30 Page 500 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.126 Sumidah RAWA MULYA 163860 Sistenol kaplet
23/02/2021 00:00:00 17.540,00 BPJS
Total 47.560,00
2.127 Nurhayati LUBUK PINANG 178631 Asam Folat 1 mg @100 T
23/02/2021 00:00:00 990,00 BPJS
Glucosamine 250 mg 3.850,00
Meloxicam 15 mg 12.600,00
Methylprednisolone tab 4 11.835,00
Total 29.275,00
2.128 Rohayati SIDO MAKMUR 149887 Alprazolam 0,5 mg @100
23/02/2021 00:00:00 590,00 BPJS
Asam Folat 1 mg @100 T 1.485,00
Propanolol tab 10 mg 3.330,00
thyrozol 5 mg 24.780,00
Total 30.185,00
2.129 Jangkep PT.AGRO MUKO 134160 Ketoprofen tab 100 mg
23/02/2021 00:00:00 24.760,00 BPJS
Paracetamol tablet 500 m 4.000,00
Vitamin B Komplek @100 1.540,00
Total 30.300,00
2.130 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
23/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.131 Salami SILAUT I 134774 NACL 0,9 % 500 ml
23/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.132 Deta Puspita Sari PT AGRO TPE 158632 Calcium Laktat
23/02/2021 00:00:00 790,00 BPJS
Tambah Darah Neo Tab 4.650,00
Total 5.440,00
2.133 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
23/02/2021 00:00:00 34.200,00 BPJS
Omeprazol kapsul 20 mg 3.305,00
Renogen 3000 UI 116.875,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 158.949,00
2.134 Wira Ratna Sari PT AGRO TPE 142622 CAL-95 tab
23/02/2021 00:00:00 62.700,00 BPJS
Tambah Darah Neo Tab 4.650,00
Total 67.350,00
2.135 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
23/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.136 Ani Mariani TUNGGAL JAYA 109603 Cetirgi Tab 10 mg
23/02/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 3.000,00
Total 21.110,00
2.137 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
23/02/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.138 Suwarni SUKA MAJU 164065 Amlodipine 10 mg @50 T
23/02/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 155.056,00
2.139 Susi Martini KOTO JAYA 145038 Amlodipine 10 mg @50 T
23/02/2021 00:00:00 354,00 BPJS

19/08/2021 12:42:30 Page 501 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.139 Susi Martini KOTO JAYA 145038 Asam Folat 1 mg @100 T
23/02/2021 00:00:00 297,00 BPJS
Candesartan tab 8 mg 2.043,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 34.200,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 161.683,00
2.140 Nirwana DUSUN JARANG 182487 Cefixime kapsul 200 mg
23/02/2021 00:00:00 26.480,00 BPJS
Domperidone Syrup 5mg 10.279,00
Gitas Plus 50.330,00
Urdahek 182.340,00
Total 269.429,00
2.141 Salbiyah LUBUK MUKTI 173013 Amlodipine 10 mg @50 T
23/02/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 34.200,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 161.386,00
2.142 Roslina TERUNTUNG 130072 Amlodipine 10 mg @50 T
23/02/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 2.043,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 34.200,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Sucralfate Suspensi 100 m 19.250,00
Total 180.933,00
2.143 Abu Razal LUBUK SANAI 160382 Alinamin F 50 mg @100 T
23/02/2021 00:00:00 11.500,00 BPJS
Cefixime kapsul 200 mg 26.480,00
Glucosamine 250 mg 7.700,00
Meloxicam 15 mg 12.600,00
Total 58.280,00
2.144 Zukriman LUBUK GEDANG 160918 Amlodipine 10 mg @50 T
23/02/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 34.200,00
Omeprazol kapsul 20 mg 1.983,00
Otsu D40 25.026,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 180.022,00
2.145 Rony Junifer Simanjun TUNGGAL JAYA 145662 Doxycyclin kapsul 100 m
23/02/2021 00:00:00 3.640,00 BPJS
Ketokonazole tablet 200 m 3.710,00
Loratadine tab 10 mg 1.660,00
Total 9.010,00

19/08/2021 12:42:30 Page 502 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.146 Zaini Wati AIR PUNGGUR 136856 Alinamin F 50 mg @100 T
23/02/2021 00:00:00 11.500,00 BPJS
Alprazolam 0,5 mg @100 590,00
Amlodipine 5 mg @30 T 3.030,00
Aspilet 80 mg @100 mg 4.140,00
ursodeoxycholic acid 85.050,00
Total 104.310,00
2.147 Kusnan PENARIK 182546 Amoxicillin 500 mg @ 10
23/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Vitamin C tablet @100 Ta 1.380,00
Total 5.730,00
2.148 Sukadi BUNGA TANJUNG 149552 Alinamin F 50 mg @100 T
23/02/2021 00:00:00 11.500,00 BPJS
Opilax Syr 49.156,00
Urinter Kapsul @100 cap 21.980,00
Total 82.636,00
2.149 Dewi Ratna Wati BUNGA TANJUNG 141409 Calcium Laktat
23/02/2021 00:00:00 790,00 BPJS
Calcium Laktat 790,00
Total 1.580,00
2.150 Lusi TALANG KUNING 152729 Cefixime kapsul 200 mg
23/02/2021 00:00:00 26.480,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 92.556,00
2.151 Dahalimun LUBUK CABAU 155405 Bisoprolol 5 mg @100 Ta
23/02/2021 00:00:00 4.440,00 BPJS
Candesartan tab 8 mg 6.810,00
Cefixime Kapsul 100 mg 9.380,00
Paracetamol tablet 500 m 2.000,00
Total 22.630,00
2.152 Oos Dariana PONDOK LUNANG 174848 Asam Mefenamat 500 m
23/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.153 Renata Nurmila Sarum PENARIK 181964 Betahistin Mesilat 6 mg @
23/02/2021 00:00:00 1.380,00 BPJS
Ketokonazole tablet 200 m 3.710,00
Levofloxacin Tablet 500 m 13.640,00
Methylprednisolone tab 4 3.945,00
Total 22.675,00
2.154 Salehati SUNGAI GADING 182565 Alprazolam 0,5 mg @100
23/02/2021 00:00:00 590,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Isosorbid dinitrat 5 mg (I 1.110,00
Paracetamol tablet 500 m 2.000,00
Total 13.080,00
2.155 Herlina TALANG MEDAN 182545 Alinamin F 50 mg @100 T
23/02/2021 00:00:00 11.500,00 BPJS
Alprazolam 0,5 mg @100 590,00
Cefixime Kapsul 100 mg 9.380,00
Urdahek 303.900,00
Total 325.370,00
2.156 Tarmizi PENARIK 121220 Cefixime Kapsul 100 mg
23/02/2021 00:00:00 9.380,00 BPJS
Domperidone Syrup 5mg 10.279,00
Flunarizine 5 mg tab 24.750,00
Mucera Syr Forte 29.700,00
Paracetamol tablet 500 m 2.000,00
Total 76.109,00
2.157 Junaidi SUNGAI IPUH 138273 Abbocath 22 Terumo @5
23/02/2021 00:00:00 22.276,00 BPJS
Cefotaxime Injeksi 5.751,00

19/08/2021 12:42:30 Page 503 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.157 Junaidi SUNGAI IPUH 138273 Infusion Makro (terumo)
23/02/2021 00:00:00 27.225,00 BPJS
Ringer Laktat Otsuka 9.538,00
Total 64.790,00
2.158 Devi Setya Ningsih AIR DIKIT 130800 Asam Mefenamat 500 m
23/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.159 Nurjanah AIR BIKUK 131083 Asam Folat 1 mg @100 T
23/02/2021 00:00:00 2.970,00 BPJS
Mecobalamin 500 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Pregabalin Kap 75 mg 32.230,00
Total 44.900,00
2.160 Rafka Shauqi Zhafran M PT AGRO AIR BIKUK E 182659 Cefixime syrup 100mg/5 M
23/02/2021 00:00:00 23.823,00 BPJS
Domperidone Syrup 5mg 10.279,00
Paracetamol syrup 1.388,00
Total 35.490,00
2.161 Andri Fernando MEKAR JAYA 157693 Amoxicillin 500 mg @ 10
23/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Dexametason 0,5 mg Ta 1.160,00
Total 5.510,00
2.162 Sri Mulyani SUNGAI LINTANG 122749 Glimepiride tab 2 mg
23/02/2021 00:00:00 2.590,00 BPJS
Loratadine tab 10 mg 1.660,00
Metformin tablet 500 mg 3.990,00
Total 8.240,00
2.163 Sumar Jaya DANAU LEBAR 151695 Cefixime Kapsul 100 mg
23/02/2021 00:00:00 9.380,00 BPJS
Mucera Syr Forte 29.700,00
Opilax Syr 49.156,00
Total 88.236,00
2.164 Kurniawan PT. AGRO AIR BIKUK E 135730 Asam Mefenamat 500 m
23/02/2021 00:00:00 1.290,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Mecobalamin 500 mg 7.700,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Total 86.776,00
2.165 David Firdaus TUNGGAL JAYA 153188 Cetirgi Tab 10 mg
23/02/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 18.110,00
2.166 Ade Susanti CINTA ASIH 182535 Cefixime kapsul 200 mg
23/02/2021 00:00:00 26.480,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 92.556,00
2.167 Partiwi TERUNTUNG 177361 Cefixime Kapsul 100 mg
23/02/2021 00:00:00 9.380,00 BPJS
Flunarizine 5 mg tab 24.750,00
Total 34.130,00
2.168 Rina Oktasari LUNANG 177103 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 79.111,00
2.169 Selpi Andriyani LALANG LUAS 173623 Ketorolac Tab 10 Mg
23/02/2021 00:00:00 25.300,00 BPJS
Levofloxacin Tablet 500 m 13.640,00

19/08/2021 12:42:30 Page 504 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.169 Selpi Andriyani LALANG LUAS 173623 Metrodinazole tab 500 m
23/02/2021 00:00:00 4.050,00 BPJS
Postofix (leukomed) 36.726,00
Total 79.716,00
2.170 Finka Alfianti BRANGAN MULYA 150314 abbocath 18 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hystolan Tab 20 mg 16.707,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Utrogestan 200 mg 50.946,00
Total 145.071,00
2.171 Saipah SUNGAI SARIK 182654 Gentamicin Injeksi
23/02/2021 00:00:00 4.606,00 BPJS
Kassa kotak stril DRC 19.350,00
NACL 0,9 % 500 ml 17.100,00
Otsu D40 25.026,00
Ceftriaxone Inj
24/02/2021 00:00:00 12.498,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furosemide 40 mg Tablet 96,00
Furosemide Injeksi @2ml 51,00
Glukosa Infus 10 % 9.375,00
Methylprednisolone Inje 104.769,00
OMZ 90.000,00
Opilax Syr 49.156,00
Otsu D40 37.539,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
25/02/2021 00:00:00 12.498,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide 40 mg Tablet 96,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 9.700,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Candesartan tab 8 mg
26/02/2021 00:00:00 681,00
Ceftriaxone Inj 12.498,00
Furosemide 40 mg Tablet 96,00
Infusion Makro (terumo) 27.225,00
Levemir FlexPen 104.938,00
Meloxicam 7,5 mg 728,00
Novo Twist 32 G Tip 3.856,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
27/02/2021 00:00:00 990,00
Atorvastatin 20 mg @30 T 10.450,00

19/08/2021 12:42:30 Page 505 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.171 Saipah SUNGAI SARIK 182654 Miniaspi 80 Mg @100 Ta
27/02/2021 00:00:00 1.250,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 946.347,00
2.172 Solikin MEKAR JAYA 182663 Abbocath 20 Terumo @5
23/02/2021 00:00:00 52.682,00 BPJS
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Ephedrine Injeksi 21.422,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 C scimitar 66.993,00
Spinocain 25 (BBraund) 42.763,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 12.375,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
24/02/2021 00:00:00 5.751,00
OMZ 90.000,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Abbocath 20 Terumo @5
25/02/2021 00:00:00 52.682,00
Cefixime Kapsul 100 mg 9.380,00
Infusion Makro (terumo) 27.225,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 28.614,00
Total 1.082.542,00
2.173 Junaidi BUMI MEKAR JAYA 182657 Asam Folat 1 mg @100 T
23/02/2021 00:00:00 1.980,00 BPJS
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 72.250,00

19/08/2021 12:42:30 Page 506 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.173 Junaidi BUMI MEKAR JAYA 182657 Cuticell Classic 10cmx10c
23/02/2021 00:00:00 35.121,00 BPJS
Dexametason Injeksi 6.256,00
Domperidone Syrup 5mg 10.279,00
Ephedrine Injeksi 68.750,00
Furosemide 40 mg Tablet 960,00
H2O2 3 % 1 liter 38.520,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 9.380,00
Urine bag 10.088,00
Levofloxacin Tablet 500 m
24/02/2021 00:00:00 6.820,00
Paracetamol tablet 500 m 2.000,00
Total 748.514,00
2.174 Rina Oktasari LUNANG 177103 Bisturi No. 23
23/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 43.662,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 11.000,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Polypropylene 3/0 C (Ass 235.200,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00

19/08/2021 12:42:30 Page 507 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.174 Rina Oktasari LUNANG 177103 Spuit 3 cc Terumo
23/02/2021 00:00:00 13.916,00 BPJS
Spuit 5 cc Disposible 2.840,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Aqua Pro Injeksi
24/02/2021 00:00:00 7.150,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 17.253,00
Chloramphenicol Salep M 2.351,00
Furamin Injeksi 28.738,00
Furamin Injeksi 28.738,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding tube) Fr. 5 17.603,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
25/02/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
26/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 8.385,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.717.287,00
2.175 Finka Alfianti BRANGAN MULYA 150314 Cefotaxime Injeksi
24/02/2021 00:00:00 11.502,00 BPJS
PARAMOL INFUS 192.500,00
Ringer Laktat Otsuka 19.076,00
Cefotaxime Injeksi
25/02/2021 00:00:00 17.253,00
Paracetamol tablet 500 m 600,00
Tonotan tab 45.730,00
Tonotan tab 4.573,00
Utrogestan 200 mg 25.473,00
Total 316.707,00
2.176 Linda Wati AIR RAMI 182666 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
24/02/2021 00:00:00 17.253,00
Ringer Laktat Otsuka 28.614,00
Bisturi No. 23
25/02/2021 00:00:00 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.176 Linda Wati AIR RAMI 182666 Handscoond Non Steril M
25/02/2021 00:00:00 20.080,00 BPJS
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker 3 Play N. 95 93.750,00
Masker Karet Boism 47.580,00
Massa Cauter Dewasa 90.240,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Polyglycolide T-Vio 1 R ( 98.500,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 4.690,00
Cefixime Kapsul 100 mg
26/02/2021 00:00:00 9.380,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Paracetamol tablet 500 m 4.000,00
Tranexamic Acid Inj (Asa 6.315,00
Vitamin B Komplek @100 1.540,00
Abbocath 20 Terumo @5
27/02/2021 00:00:00 52.682,00
Asam Mefenamat 500 m 1.290,00
Ciprofloxacin tab 500 mg 5.590,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Phytomenadione 2 Mg/1M 4.834,00
Postofix (leukomed) 36.726,00
Total 1.690.153,00
2.177 Maksul AIR BERAU 182667 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Cefotaxime Injeksi
24/02/2021 00:00:00 5.751,00
OMZ 90.000,00
Ringer Laktat Otsuka 19.076,00
Catheter 3 Way No. 24 (
25/02/2021 00:00:00 44.688,00
Ceftriaxone Inj 12.498,00
Extrace Injeksi 100 mg/m 28.875,00

19/08/2021 12:42:30 Page 509 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.177 Maksul AIR BERAU 182667 Hypafix 15cmx5cm (25 c
25/02/2021 00:00:00 19.632,00 BPJS
Kamadol Injeksi 17.100,00
NACL 0,9 % 500 ml 42.750,00
NACL 0,9 % 500 ml 171.000,00
NACL 0,9 % 500 ml 85.500,00
NGT (Stomach Tube) Fr. 1 52.250,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Spuit 50cc terumo Lbg P 29.400,00
Tranexamic Acid Inj (Asa 8.420,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
26/02/2021 00:00:00 12.498,00
NACL 0,9 % 500 ml 171.000,00
Tramadol 50 mg/ml Inj 12.375,00
Amlodipine 5 mg @30 T
27/02/2021 00:00:00 101,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Dulcolax Sup 10 mg 27.800,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 171.000,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Ambroxol 30 mg @100 T
28/02/2021 00:00:00 193,00
Amlodipine 5 mg @30 T 101,00
Ceftriaxone Inj 12.498,00
Tramadol 50 mg/ml Inj 12.375,00
Hypafix 15cmx5cm (25 c
01/03/2021 00:00:00 6.544,00
Kassa kotak stril DRC 29.025,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 1.379.085,00
2.178 Niesha Niel Olesia PONDOK SUGUH 182669 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Cotrimoxazol 240 mg Sir 2.565,00
Domperidone Syrup 5mg 10.279,00
Glukosa Infus 10 % 9.375,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol Drop 8.726,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 97.630,00
2.179 Amsiah BANDA RATU 115490 Amoxicillin 500 mg @ 10
23/02/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lidocain injk 40 mg/2 ml 1.611,00
Omeprazol kapsul 20 mg 6.610,00
Tetagam 1 Ml Injeksi 184.000,00
Total 236.542,00
2.180 Niesha Niel Olesia PONDOK SUGUH 182669 Cotrimoxazol 240 mg Sir
24/02/2021 00:00:00 2.565,00 BPJS
L-Bio sach @ 1gr 17.242,00
NGT (Feeding Tube) Fr. 8 70.420,00

19/08/2021 12:42:30 Page 510 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.180 Niesha Niel Olesia PONDOK SUGUH 182669 NonWoven Fixation 10x
24/02/2021 00:00:00 9.630,00 BPJS
Ottopan Drops 18.906,00
Paracetamol Infus 14.438,00
Hypafix 15cmx5cm (25 c
25/02/2021 00:00:00 6.544,00
NGT (Feeding Tube) Fr. 8 70.420,00
Total 210.165,00
2.181 Darmansyah PULAU BARU 182671 abbocath 18 Terumo @5
24/02/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Aminofluid Infus 500 ml 155.204,00
Asam Folat 1 mg @100 T 99,00
Catheter 2 Way No. 16 ( 20.625,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
Paracetamol Infus 28.876,00
Paracetamol tablet 500 m 600,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Furamin Injeksi
25/02/2021 00:00:00 14.369,00
Omeprazole Inj 12.499,00
Total 438.945,00
2.182 Pahala Parulian UJUNG PADANG 182053 Abbocath 20 Terumo @5
23/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 6.249,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Bisturi No. 23
24/02/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 104.362,00
Ceftriaxone Inj 31.245,00
Celemek Plastik 23.650,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Handscoond Sterille 7.5 16.488,00
Masker Karet 11.000,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 10x 4.815,00
NonWoven Fixation 10x 4.815,00
OMZ 270.000,00
Ondansetron tablet 8 mg 13.200,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Silk 2/0 R scimitar 61.688,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00

19/08/2021 12:42:30 Page 511 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.182 Pahala Parulian UJUNG PADANG 182053 Suction no. 1/4
24/02/2021 00:00:00 25.950,00 BPJS
Topi Operasi (Dokter) @5 5.097,00
Tramadol 50 mg/ml Inj 20.625,00
Cuticell Classic 10cmx10c
26/02/2021 00:00:00 35.121,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 49.996,00
Paracetamol tablet 500 m 2.000,00
Total 1.302.418,00
2.183 Nova Rika Rahayu MEDAN JAYA 182672 ATRACURIUM BESYLATE 2
24/02/2021 00:00:00 14.671,00 BPJS
Azitromycin 500 mg 16.875,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 118.250,00
Dexametason Injeksi 6.256,00
Erphafillin Tab 3.690,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Masker Tali 41.600,00
Methylprednisolone tab 4 2.630,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 22.000,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 9.538,00
Salbutamol 2 mg 790,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 9.380,00
Vectrine Tab 300 mg 100.000,00
Vitamin C tablet @100 Ta 1.380,00
Asam Mefenamat 500 m
25/02/2021 00:00:00 1.935,00
Cefixime Kapsul 100 mg 9.380,00
Misoprostol Tab 55.000,00
Total 610.913,00
2.184 Darmansyah PULAU BARU 182671 Aminofluid Infus 500 ml
24/02/2021 00:00:00 155.204,00 BPJS
Asam Folat 1 mg @100 T 297,00
Dulcolax Sup 10 mg 27.800,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 34.200,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 600,00
Tambah Darah Neo Tab 930,00

19/08/2021 12:42:30 Page 512 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.184 Darmansyah PULAU BARU 182671 Asam Folat 1 mg @100 T
25/02/2021 00:00:00 297,00 BPJS
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 17,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 34.200,00
Ngt (Feeding Tube) Fr.16 10.588,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 24.998,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 600,00
Asam Folat 1 mg @100 T
26/02/2021 00:00:00 297,00
Atorvastatin 20 mg @30 T 1.045,00
Hypafix 15cmx5cm (25 c 13.088,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 34.200,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 24.998,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
27/02/2021 00:00:00 297,00
Atorvastatin 20 mg @30 T 1.045,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furamin Injeksi 14.369,00
Furamin Injeksi 28.738,00
Meropenem Inj 0.5 g 110.000,00
NACL 0,9 % 500 ml 25.650,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 37.497,00
Omeprazole Inj 24.998,00
Opilax Syr 49.156,00
Tambah Darah Neo Tab 930,00
Alinamin F 50 mg @100 T
28/02/2021 00:00:00 8.050,00
Asam Folat 1 mg @100 T 198,00
Atorvastatin 20 mg @30 T 1.045,00
Atorvastatin 20 mg @30 T 7.315,00
Cefixime Kapsul 100 mg 6.566,00
Furamin Injeksi 28.738,00
Hypafix 15cmx5cm (25 c 13.088,00
meropenem Injeksi 1 g 0,00
NACL 0,9 % 500 ml 17.100,00
OMZ 180.000,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 0,00
Tambah Darah Neo Tab 930,00
Tambah Darah Neo Tab 6.510,00
Total 1.508.192,00
2.185 Rasman BRANGAN MULYA 182674 Amlodipine 10 mg @50 T
24/02/2021 00:00:00 1.180,00 BPJS
Cefixime Kapsul 100 mg 9.380,00

19/08/2021 12:42:30 Page 513 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.185 Rasman BRANGAN MULYA 182674 Eperisone Hcl 50 mg @1
24/02/2021 00:00:00 23.280,00 BPJS
Opilax Syr 49.156,00
Paracetamol tablet 500 m 2.000,00
Total 84.996,00
2.186 M Yadi LUBUK BANGKO 181321 Ambroxol 30 mg @100 T
24/02/2021 00:00:00 3.860,00 BPJS
Levofloxacin Tablet 500 m 27.280,00
Paracetamol tablet 500 m 4.000,00
Total 35.140,00
2.187 Nenah SINAR JAYA 182196 Lapibal Kapsul 500 mg
24/02/2021 00:00:00 23.100,00 BPJS
Levemir FlexPen 104.938,00
Metformin tablet 500 mg 5.985,00
Novo Twist 32 G Tip 3.856,00
Perifas @100 Tab 19.250,00
Total 157.129,00
2.188 Parji Darsono AGUNG JAYA 118047 Leparson tablet
24/02/2021 00:00:00 27.400,00 BPJS
Sifrol tab 0,375 mg 103.750,00
Total 131.150,00
2.189 M.hanif Mulyazam BANDARATU 142748 Omeprazol kapsul 20 mg
24/02/2021 00:00:00 3.305,00 BPJS
Rofiden Supp 24.062,00
Total 27.367,00
2.190 Bahman SIBAK 155872 NACL 0,9 % 500 ml
24/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.191 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
24/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.192 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
24/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.193 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
24/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.194 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
24/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.195 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
24/02/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.196 Lailatul Kadar TANAH REKAH 158354 Amlodipine 5 mg @30 T
24/02/2021 00:00:00 303,00 BPJS
Candesartan tab 8 mg 2.043,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Renogen 3000 UI 116.875,00
Sucralfate Suspensi 100 m 19.250,00
Total 183.204,00
2.197 Sumidah RAWA MULYA 163860 Amlodipine 5 mg @30 T
24/02/2021 00:00:00 303,00 BPJS
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Otsu D40 37.539,00
Renogen 3000 UI 116.875,00
Total 200.137,00

19/08/2021 12:42:30 Page 514 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.198 Kasmidi Kasim BANDAR RATU 135355 Amlodipine 5 mg @30 T
24/02/2021 00:00:00 303,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Otsu D40 12.513,00
Renogen 3000 UI 116.875,00
Total 175.171,00
2.199 Jumarno LUNANG 180796 Amlodipine 5 mg @30 T
24/02/2021 00:00:00 303,00 BPJS
Candesartan tab 8 mg 2.043,00
Clonidine 0.15 mg @100 T 687,00
Electroda (Ambu) @25 Pc 81.570,00
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Total 244.228,00
2.200 Musli Hadaya LUBUK GEDANG 182096 Asam Traneksamat @10
24/02/2021 00:00:00 42.100,00 BPJS
Fluconazole tab 150 mg 122.855,00
Loratadine tab 10 mg 3.320,00
Paracetamol tablet 500 m 3.000,00
Phytomenadione 10 mg ( 18.680,00
Vitamin C tablet @100 Ta 2.760,00
Total 192.715,00
2.201 Rido Wiradana Siregar MEKAR MULYA 182678 Codein tab 10 mg
24/02/2021 00:00:00 7.500,00 BPJS
Total 7.500,00
2.202 Dedek Subandar CINTA ASIH 182550 Cefixime kapsul 200 mg
24/02/2021 00:00:00 15.888,00 BPJS
Total 15.888,00
2.203 Anjellina Aprilia PENARIK 182520 Betadine Obat Kumur
24/02/2021 00:00:00 13.750,00 BPJS
Cefixime kapsul 200 mg 26.480,00
Total 40.230,00
2.204 Siti Ana LUBUK SANAI 173430 Amlodipine 10 mg @50 T
24/02/2021 00:00:00 3.540,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Atorvastatin 20 mg @30 T 31.350,00
Candesartan tab 8 mg 20.430,00
Citicoline kaplet 500 mg 49.500,00
Omeprazol kapsul 20 mg 3.305,00
Piracetam tab 800 mg 22.590,00
Total 134.855,00
2.205 Uswatun Hasanah ja MUNDAM MARAP 116754 Curcuma Tab
24/02/2021 00:00:00 12.700,00 BPJS
Total 12.700,00
2.206 Sukiman SIBAK 154783 Flunarizine 5 mg tab
24/02/2021 00:00:00 49.500,00 BPJS
Isosorbid dinitrat 5 mg (I 2.220,00
Total 51.720,00
2.207 Anjeli Purnama Sari SIBAK 182398 Cefixime kapsul 200 mg
24/02/2021 00:00:00 26.480,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Methylprednisolone tab 4 2.630,00
Total 44.590,00
2.208 Alim Fernando DUSUN BARU 138099 Neurodex tablet
24/02/2021 00:00:00 7.410,00 BPJS
Vitamin C tablet @100 Ta 1.380,00
Total 8.790,00
2.209 Heldi Gustian BATU EJUNG 178340 Cetirgi Tab 10 mg
24/02/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 263,00
Nucral Syrup 100 ml 53.350,00
Total 69.093,00

19/08/2021 12:42:30 Page 515 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.210 Osniwati SILAUT 181851 CAL-95 tab
24/02/2021 00:00:00 62.700,00 BPJS
Emibion kapsul 19.660,00
Total 82.360,00
2.211 Yatmin SUMBER MAKMUR 122873 Aspilet 80 mg @100 mg
24/02/2021 00:00:00 1.380,00 BPJS
Atorvastatin 20 mg @30 T 10.450,00
Bisoprolol 5 mg @100 Ta 2.960,00
Candesartan tab 8 mg 6.810,00
Lansoprazole kapsul 30 m 11.550,00
Total 33.150,00
2.212 Halima Panggabean AIR BIKUK 180706 Ketorolac Tab 10 Mg
24/02/2021 00:00:00 25.300,00 BPJS
Total 25.300,00
2.213 Elisabet Silaban TUNGGANG 180889 Calcium Laktat
24/02/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
2.214 Ratnawati LUBUK SANAI 182216 Azitromycin 500 mg
24/02/2021 00:00:00 28.125,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Candesartan tab 8 mg 10.215,00
Furosemide 40 mg Tablet 1.440,00
Spironolaktone 25 mg 3.900,00
Total 48.120,00
2.215 Wahyuni TANJUNG MULYA 182681 Fentanyl Injeksi 5 Ampul 2
24/02/2021 00:00:00 52.000,00 BPJS
Fresofol ( propopol ) inj 13.448,00
Total 65.448,00
2.216 Rusmi ujung padang 118365 Abbocath 20 Terumo @5
24/02/2021 00:00:00 26.341,00 BPJS
Amlodipine 5 mg @30 T 202,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
OMZ 90.000,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Urine bag 10.088,00
Total 185.639,00
2.217 Dahalimun LUBUK CABAU 155405 Abbocath 20 Terumo @5
24/02/2021 00:00:00 26.341,00 BPJS
Cefoperazon Inj 82.500,00
Citicoline Injeksi 125mg/ 11.250,00
Dexametason Injeksi 3.128,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
OMZ 90.000,00
Perifas @100 Tab 3.850,00
Pregabalin Kap 75 mg 12.892,00
Ringer Laktat Otsuka 9.538,00
Cefoperazon Inj
25/02/2021 00:00:00 82.500,00
Cefoperazon Inj 82.500,00
Citicoline Injeksi 125mg/ 33.750,00
Citicoline Injeksi 125mg/ 22.500,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 6.256,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
L-Cisin tab 7.562,00

19/08/2021 12:42:30 Page 516 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.217 Dahalimun LUBUK CABAU 155405 Omeprazole Inj
25/02/2021 00:00:00 12.499,00 BPJS
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Perifas @100 Tab 3.850,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 8.250,00
Tramadol 50 mg/ml Inj 4.125,00
Bisoprolol 5 mg @100 Ta
26/02/2021 00:00:00 2.960,00
Candesartan tab 8 mg 6.810,00
L-Cisin tab 41.591,00
Levofloxacin Tablet 500 m 13.640,00
Pregabalin Kap 75 mg 64.460,00
Total 746.011,00
2.218 Junaidi SUNGAI IPUH 138273 Asam Folat 1 mg @100 T
24/02/2021 00:00:00 990,00 BPJS
Cefoperazon Inj 41.250,00
Furosemide Injeksi @2ml 17,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Tambah Darah Neo Tab 4.650,00
Asam Folat 1 mg @100 T
25/02/2021 00:00:00 297,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Furosemide Injeksi @2ml 3.332,00
Gentamicin Injeksi 4.606,00
Gentamycin 0.1 % salep k 2.983,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
OMZ 90.000,00
Ondansetron Inj 4.950,00
Tambah Darah Neo Tab 930,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
26/02/2021 00:00:00 297,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 3.332,00
Gentamycin 0.1 % salep k 2.983,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
27/02/2021 00:00:00 297,00
Cefoperazon Inj 82.500,00
Furosemide Injeksi @2ml 3.332,00

19/08/2021 12:42:30 Page 517 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.218 Junaidi SUNGAI IPUH 138273 Gentamycin 0.1 % salep k
27/02/2021 00:00:00 2.983,00 BPJS
Gentamycin 0.1 % salep k 2.983,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 51.300,00
Nassal Cannula O2 Anak 16.473,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Pharmafix 10x50 cm (Hy 9.700,00
Ringer Laktat Otsuka 28.614,00
Tambah Darah Neo Tab 930,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
28/02/2021 00:00:00 297,00
Cefoperazon Inj 82.500,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 15cmx5cm (25 c 13.088,00
NACL 0,9 % 500 ml 17.100,00
Octalbin 25% 100 cc (Hu 1.887.500,00
OMZ 90.000,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Tambah Darah Neo Tab 930,00
Asam Folat 1 mg @100 T
01/03/2021 00:00:00 2.970,00
Calos cmewable tab 24.090,00
Hypafix 15cmx5cm (25 c 6.544,00
Total 2.916.746,00
2.219 M.hanif Mulyazam BANDARATU 142748 Ka-En 1 B
24/02/2021 00:00:00 12.658,00 BPJS
Omeprazole Inj 12.499,00
Ranitidin inj 1.790,00
Suprafenid Supositoria 10 14.025,00
Omeprazol kapsul 20 mg
26/02/2021 00:00:00 3.305,00
Ranitidine tablet 150 mg 2.160,00
Total 46.437,00
2.220 Rosmi Yeni LUBUK MUKTI 182463 abbocath 18 Terumo @5
25/02/2021 00:00:00 26.341,00 BPJS
Aspilet 80 mg @100 mg 138,00
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 681,00
Cefotaxime Injeksi 11.502,00
Ceftriaxone Inj 12.498,00
Clopidogrel 75 mg @30 T 1.755,00
Clopidogrel 75 mg @30 T 1.755,00
Furosemide Injeksi @2ml 17,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 5 % 17.252,00
Glukosa Infus 5 % 8.626,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
Miniaspi 80 Mg @100 Ta 125,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00

19/08/2021 12:42:30 Page 518 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.220 Rosmi Yeni LUBUK MUKTI 182463 Opilax Syr
25/02/2021 00:00:00 49.156,00 BPJS
Retaphyl SR Tab 1.474,00
Sucralfate Suspensi 100 m 19.250,00
Aspilet 80 mg @100 mg
26/02/2021 00:00:00 1.242,00
Candesartan tab 8 mg 3.405,00
Clopidogrel 75 mg @30 T 8.775,00
Furosemide 40 mg Tablet 960,00
Omeprazol kapsul 20 mg 3.305,00
Retaphyl SR Tab 7.370,00
Sucralfate Suspensi 100 m 19.250,00
Total 283.366,00
2.221 Rila Santika ARAH TIGA 126526 Abbocath 18 (Gea)
24/02/2021 00:00:00 10.720,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
Hystolan Tab 20 mg 11.138,00
Infusion Makro (terumo) 27.225,00
Otsu MgSO4 40 % 4.745,00
Ringer Laktat Otsuka 19.076,00
Cefotaxime Injeksi
25/02/2021 00:00:00 17.253,00
Dexametason Injeksi 9.384,00
Cefixime Kapsul 100 mg
26/02/2021 00:00:00 9.380,00
Levofloxacin Tablet 500 m 13.640,00
Tonotan tab 45.730,00
Tonotan tab 22.865,00
Total 206.291,00
2.222 Wahyuni TANJUNG MULYA 182681 Asam Mefenamat 500 m
25/02/2021 00:00:00 1.935,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Celemek Plastik 23.650,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Masker Karet 11.000,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 55.000,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 8.495,00
Total 355.007,00
2.223 Sarah Purwaningsih BANDAR RATU 182684 Bisturi No. 23
24/02/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 104.362,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 47.300,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00

19/08/2021 12:42:30 Page 519 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.223 Sarah Purwaningsih BANDAR RATU 182684 Cuticell Classic 10cmx10c
24/02/2021 00:00:00 35.121,00 BPJS
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Invitec tab (Misoprostol) 35.424,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 11.000,00
methyl ergometrin amp 8.662,00
Miloz Injeksi 5 mg 5.611,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 6.796,00
Urine bag 10.088,00
Total 1.332.566,00
2.224 Ny Sarah Purwaningsi BANDAR RATU 182685 Abbocath 24 Terumo @5
24/02/2021 00:00:00 105.364,00 BPJS
Glukosa Infus 10 % 9.375,00
NonWoven Fixation 10x 9.630,00
Atropin injek 1 ml
25/02/2021 00:00:00 6.969,00
Atropin injek 1 ml 6.969,00
Bactesyn inj 0,75 gr 177.027,00
Bisturi No. 23 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 3-0 R (Tr 66.250,00
Chromic catgut 3-0 R (Tr 66.250,00
Epinephrin inj 15.331,00
ETT 3.5 Kingking (Non B 21.184,00
ETT 4.0 Kingking Balon 88.000,00
ETT 4.0 Kingking Balon 88.000,00
Extention Tube 8.801,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 13.088,00
Ka-En Mg3 13.104,00
Kassa kotak stril DRC 9.675,00
Miloz Injeksi 5 mg 5.611,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 8.550,00
NGT (Feeding tube) Fr. 3 21.710,00
NGT (Feeding Tube) Fr. 8 70.420,00
NGT (Feeding Tube) Fr. 8 70.420,00

19/08/2021 12:42:30 Page 520 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.224 Ny Sarah Purwaningsi BANDAR RATU 182685 Otsu Nacl PiggyBack 100 m
25/02/2021 00:00:00 18.975,00 BPJS
Pharmafix 10x50 cm (Hy 4.850,00
umbilical Cord Clamp 2.261,00
Aqua Pro Injeksi
26/02/2021 00:00:00 3.575,00
Bactesyn inj 0,75 gr 118.018,00
ETT 4.0 Kingking Balon 88.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 13.088,00
Meropenem Inj 0.5 g 110.000,00
meropenem Injeksi 1 g 41.250,00
Ottogenta inj 9.900,00
Sibital Injeksi (Phenobarbit 24.750,00
Total 1.427.356,00
2.225 Mujiat RAWA MULYA 168154 Abbocath 20 (Gea)
24/02/2021 00:00:00 10.720,00 BPJS
Aminoleban inf 500 ml 88.713,00
Aqua Pro Injeksi 3.575,00
Candesartan tab 8 mg 681,00
Curcuma Tab 3.810,00
Glukosa Infus 5 % 8.626,00
Infusion set Mikro (Terumo 18.026,00
NonWoven Fixation 10x 4.815,00
OMZ 90.000,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Aminoleban inf 500 ml
25/02/2021 00:00:00 88.713,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Glukosa Infus 5 % 8.626,00
Ondansetron Inj 4.950,00
Abbocath 20 Terumo @5
26/02/2021 00:00:00 52.682,00
Abbocath 22 Terumo @5 33.414,00
Ambroxol Syr 15mg/ml 4.538,00
Aminoleban inf 500 ml 88.713,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 8.626,00
Meloxicam 7,5 mg 728,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Asam Folat 1 mg @100 T
27/02/2021 00:00:00 990,00
Candesartan tab 8 mg 6.810,00
Curcuma Tab 12.700,00
NonWoven Fixation 15x 13.388,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 683.261,00
2.226 Yena Sulastri LUBUK PINANG 182686 Aqua Pro Injeksi
24/02/2021 00:00:00 3.575,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00

19/08/2021 12:42:30 Page 521 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.226 Yena Sulastri LUBUK PINANG 182686 Hypafix 10cm x 5cm (25 c
24/02/2021 00:00:00 4.850,00 BPJS
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23
25/02/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 8-0 R 270.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 10.088,00
Cefotaxime Injeksi
26/02/2021 00:00:00 17.253,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
28/02/2021 00:00:00 1.935,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.399.389,00

19/08/2021 12:42:30 Page 522 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.227 Sarah Purwaningsih BANDAR RATU 182684 Cefotaxime Injeksi
25/02/2021 00:00:00 5.751,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
26/02/2021 00:00:00 11.502,00
Cefotaxime Injeksi 5.751,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Asam Mefenamat 500 m
27/02/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 0,00
Postofix (leukomed)
05/03/2021 00:00:00 36.726,00
Total 163.010,00
2.228 Widya Pransisca BANDARATU 182688 Catheter 2 Way No. 16 (
25/02/2021 00:00:00 20.625,00 BPJS
Urine bag 10.088,00
Total 30.713,00
2.229 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
25/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.230 Amri Kusna Yanti BUMI MULYA 133486 Abbocath 22 Terumo @5
25/02/2021 00:00:00 22.276,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Otsu D40 25.026,00
Paracetamol tablet 500 m 600,00
Total 90.652,00
2.231 Narti SILAUT 175653 Abbocath 22 Terumo @5
25/02/2021 00:00:00 22.276,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Total 65.626,00
2.232 Ahmad Mujiono MARGA MULYA SAKTI 113737 Amlodipine 10 mg @50 T
25/02/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 51.315,00
2.233 Ashari Liwandi PONDOK LUNANG 139398 Asam Folat 1 mg @100 T
25/02/2021 00:00:00 297,00 BPJS
Candesartan Tab 16 mg 3.537,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 54.498,00
2.234 Marlina BANTAL 182570 Cefixime Kapsul 100 mg
25/02/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00

19/08/2021 12:42:30 Page 523 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.234 Marlina BANTAL 182570 Metrodinazole tab 500 m
25/02/2021 00:00:00 4.050,00 BPJS
Postofix (leukomed) 36.726,00
Total 75.456,00
2.235 Supangat PONDOK LUNANG 147511 Amlodipine 10 mg @50 T
25/02/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 3.537,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 54.852,00
2.236 M Akil PASAR BELAKANG 115376 Amlodipine 10 mg @50 T
25/02/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 3.537,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 54.852,00
2.237 Wardoyo TANJUNG MULYA 125079 Asam Folat 1 mg @100 T
25/02/2021 00:00:00 297,00 BPJS
Candesartan Tab 16 mg 3.537,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 54.498,00
2.238 Miswanto LUNANG 128267 NACL 0,9 % 500 ml
25/02/2021 00:00:00 42.750,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 62.000,00
2.239 Rony Boby Anatoly SUMBER SARI 140456 Gitas Plus
25/02/2021 00:00:00 50.330,00 BPJS
Nuzym Kapsul 33.000,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 109.190,00
2.240 Afriadianto TIRTA MULYA 182593 Asam Folat 1 mg @100 T
25/02/2021 00:00:00 990,00 BPJS
Flunarizine 5 mg tab 24.750,00
Furosemide 40 mg Tablet 960,00
Gitas Plus 50.330,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 102.890,00
2.241 Samuji MEKAR JAYA 135578 Aspilet 80 mg @100 mg
25/02/2021 00:00:00 4.140,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 960,00
Omeprazol kapsul 20 mg 6.610,00
Retaphyl SR Tab 14.740,00
Sucralfate Suspensi 100 m 19.250,00
Total 118.780,00

19/08/2021 12:42:30 Page 524 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.242 Mely Br Rajagukguk ARGA JAYA 182295 Gitas Plus
25/02/2021 00:00:00 50.330,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Renax @50 Kapsul 56.720,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 21.980,00
Vitamin B Komplek @100 1.540,00
Total 156.430,00
2.243 Adri Yani LUNANG 182139 Ambroxol Syr 15mg/ml
25/02/2021 00:00:00 4.538,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Candesartan tab 8 mg 20.430,00
Novo Twist 32 G Tip 3.856,00
Retaphyl SR Tab 14.740,00
Total 46.594,00
2.244 Martina PT.AGRO AIR DIKIT 181749 Flunarizine 5 mg tab
25/02/2021 00:00:00 24.750,00 BPJS
Gitas Plus 50.330,00
Omeprazol kapsul 20 mg 6.610,00
Perifas @100 Tab 19.250,00
Perifas @100 Tab 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 139.440,00
2.245 Rangga Eka Putri LUBUK BANGKO 167390 Asam Mefenamat 500 m
25/02/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Dexametason 0,5 mg Ta 1.160,00
Total 8.040,00
2.246 Eni Putri Wati TANAH REKAH 155815 Flunarizine 5 mg tab
25/02/2021 00:00:00 24.750,00 BPJS
Gitas Plus 50.330,00
Omeprazol kapsul 20 mg 6.610,00
Perifas @100 Tab 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 120.190,00
2.247 Lesnawati TANAH REKAH 182045 Asam Mefenamat 500 m
25/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.248 Khairul Amri RETAK MUDIK 182691 Candesartan tab 8 mg
25/02/2021 00:00:00 20.430,00 BPJS
Furosemide 40 mg Tablet 960,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 100 mg 7.190,00
Sucralfate Suspensi 100 m 19.250,00
Total 54.440,00
2.249 Samio SP4, SETIA BUDI 121632 Atorvastatin 20 mg @30 T
25/02/2021 00:00:00 10.450,00 BPJS
Candesartan tab 8 mg 6.810,00
Clopidogrel 75 mg @30 T 17.550,00
Furosemide 40 mg Tablet 960,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 62.880,00
2.250 Ni Nyoman Rasati PONDOK BATU 119151 Ketoprofen tab 100 mg
25/02/2021 00:00:00 18.570,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 21.570,00
2.251 Razali PERNYAH 175986 Citicoline kaplet 500 mg
25/02/2021 00:00:00 49.500,00 BPJS
Gabapentin kapsul 300 m 12.690,00
Metformin tablet 500 mg 3.990,00

19/08/2021 12:42:30 Page 525 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.251 Razali PERNYAH 175986 Omeprazol kapsul 20 mg
25/02/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 92.040,00
2.252 Titis Sumarni PERNYAH 141441 Allopurinol 300 Mg @100
25/02/2021 00:00:00 4.910,00 BPJS
Gabapentin kapsul 300 m 12.690,00
Meloxicam 7,5 mg 7.280,00
Natrium diclofenac 50 m 2.890,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 53.630,00
2.253 Nora Olinchya PERNYAH 175459 Ambroxol Syr 15mg/ml
25/02/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Methylprednisolone tab 4 2.630,00
Omeprazol kapsul 20 mg 6.610,00
Retaphyl SR Tab 14.740,00
Sucralfate Suspensi 100 m 19.250,00
Total 75.893,00
2.254 Rini S BATU EJUNG 180618 Cefixime Kapsul 100 mg
25/02/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.255 Rudito PT AGRO AIR BULUH 182435 Gitas Plus
25/02/2021 00:00:00 50.330,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Perifas @100 Tab 19.250,00
Renax @50 Kapsul 56.720,00
Sucralfate Suspensi 100 m 19.250,00
Urinter Kapsul @100 cap 10.990,00
Urinter Kapsul @100 cap 21.980,00
Total 185.130,00
2.256 Mirawati PT AGRO MUKO 152031 Asam Mefenamat 500 m
25/02/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.257 Wartinah LUNANG 158025 Ambroxol Syr 15mg/ml
25/02/2021 00:00:00 4.538,00 BPJS
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 6.610,00
Retaphyl SR Tab 14.740,00
Sucralfate Suspensi 100 m 19.250,00
Symbicort Turbuhaler 80 167.855,00
Total 214.073,00
2.258 Nasution RANAH KARYA 123913 Bisturi No. 23
25/02/2021 00:00:00 3.836,00 BPJS
Cefixime kapsul 200 mg 26.480,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 14.563,00
Handscoond Sterille 6.5 24.732,00
Lidocain injk 40 mg/2 ml 9.666,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 4.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00

19/08/2021 12:42:30 Page 526 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.258 Nasution RANAH KARYA 123913 Spuit 3 cc Disposible
25/02/2021 00:00:00 3.640,00 BPJS
Spuit 5 cc Disposible 2.840,00
Total 326.678,00
2.259 Widya Pransisca BANDARATU 182688 Abbocath 18 (Gea)
25/02/2021 00:00:00 10.720,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Nifedipin Tab 10 mg 175,00
NonWoven Fixation 15x 6.694,00
Otsu MgSO4 40 % 4.745,00
Paracetamol tablet 500 m 400,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Amlodipine 10 mg @50 T
26/02/2021 00:00:00 1.180,00
Cefixime Kapsul 100 mg 9.380,00
Otsu MgSO4 20 % 8.320,00
Paracetamol tablet 500 m 4.000,00
Paracetamol tablet 500 m 800,00
Vitamin B Komplek @100 1.540,00
Total 83.318,00
2.260 Tozi Andika Puta ARAH TIGA 182694 Aminophyllin Inj
25/02/2021 00:00:00 15.536,00 BPJS
Atropin injek 1 ml 13.938,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 12.512,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 43.662,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 11.000,00
Metrodinazole Infus 30.939,00
Neostigmine-hameln 0.5 m 34.300,00
Ondansetron Inj 3.300,00
Pehacain Injeksi 6.640,00
Pehacain Injeksi 16.600,00
Ranitidin inj 3.580,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Silk 2-0 R (TriTen) 111.300,00
Spuit 5 cc Disposible 2.840,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Ceftriaxone Inj
26/02/2021 00:00:00 12.498,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00

19/08/2021 12:42:30 Page 527 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.260 Tozi Andika Puta ARAH TIGA 182694 Ringer Laktat Otsuka
26/02/2021 00:00:00 9.538,00 BPJS
Spuit 5 cc Disposible 14.200,00
Toramine inj 56.118,00
Levofloxacin Tablet 500 m
27/02/2021 00:00:00 13.640,00
Omeprazol kapsul 20 mg 6.610,00
Total 675.524,00
2.261 Marsona LUBUK CABAU 167407 abbocath 18 Terumo @5
25/02/2021 00:00:00 79.023,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Nulacta Plus
27/02/2021 00:00:00 58.300,00
Total 185.132,00
2.262 Sukiah PONDOK KOPI 109386 abbocath 18 Terumo @5
25/02/2021 00:00:00 79.023,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
OMZ 90.000,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
26/02/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
27/02/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
28/02/2021 00:00:00 12.498,00
Ceftriaxone Inj
01/03/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 28.614,00
Alkohol 1Liter
02/03/2021 00:00:00 42.111,00
Bisturi No. 23 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 11.825,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Levofloxacin Infus 48.976,00
Masker 3 Play N. 95 93.750,00
Masker Karet 11.000,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00

19/08/2021 12:42:30 Page 528 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.262 Sukiah PONDOK KOPI 109386 Spuit 3 cc Disposible
02/03/2021 00:00:00 3.640,00 BPJS
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Urine bag 9.314,00
Catheter 2 Way No. 16 (
03/03/2021 00:00:00 20.625,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 48.976,00
Omeprazole Inj 12.499,00
Urine bag 9.314,00
Cuticell Classic 10cmx10c
04/03/2021 00:00:00 35.121,00
Kassa kotak stril DRC 19.350,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 48.976,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 37.497,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Ketorolac inj 30 mg/1ml
05/03/2021 00:00:00 4.035,00
Levofloxacin Tablet 500 m 2.728,00
OMZ 90.000,00
Paracetamol Infus 43.314,00
Cuticell Classic 10cmx10c
06/03/2021 00:00:00 35.121,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
NonWoven Fixation 15x 6.694,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 1.736.146,00
2.263 Isnawati MAJU MAKMUR 182697 abbocath 18 Terumo @5
25/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Mefenamat 500 m 129,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Paracetamol tablet 500 m 200,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 126.496,00
2.264 Ny. Isnawati MAJU MAKMUR 182699 Phytomenadione 2 Mg/1M
25/02/2021 00:00:00 4.834,00 BPJS
Total 4.834,00
2.265 Sarlen SELAGAN RAYA 182700 Abbocath 20 Terumo @5
25/02/2021 00:00:00 52.682,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00

19/08/2021 12:42:30 Page 529 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.265 Sarlen SELAGAN RAYA 182700 Hypafix 10cm x 5cm (25 c
25/02/2021 00:00:00 9.700,00 BPJS
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
26/02/2021 00:00:00 12.498,00
Methylprednisolone Inje 104.769,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
27/02/2021 00:00:00 12.498,00
Methylprednisolone Inje 104.769,00
Omeprazole Inj 12.499,00
Paracetamol Drop 26.178,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Pharmafix 10x50 cm (Hy 9.700,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
28/02/2021 00:00:00 12.498,00
Hypafix 15cmx5cm (25 c 13.088,00
Methylprednisolone Inje 104.769,00
OMZ 90.000,00
Paracetamol tablet 500 m 600,00
PARAMOL INFUS 288.750,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
01/03/2021 00:00:00 12.498,00
Methylprednisolone Inje 104.769,00
Omeprazole Inj 62.495,00
Omeprazole Inj 12.499,00
Paracetamol Infus 144.380,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Psidii Capsule 500 mg 29.406,00
Ringer Laktat Otsuka 9.538,00
Omeprazol kapsul 20 mg
02/03/2021 00:00:00 3.305,00
Paracetamol tablet 500 m 3.000,00
Total 1.540.831,00
2.266 Loh Putu Widiari PONDOK BATU 182054 abbocath 18 Terumo @5
26/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 72.250,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Lidocain injk 40 mg/2 ml 3.222,00
Misoprostol Tab 16.500,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 190.792,00

19/08/2021 12:42:30 Page 530 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.267 Sabarrudin PASAR MUKOMUKO 171069 Omeprazol kapsul 20 mg
25/02/2021 00:00:00 6.610,00 BPJS
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 27.860,00
2.268 Loh Putu Widiari PONDOK BATU 182054 Asam Traneksamat @10
26/02/2021 00:00:00 6.315,00 BPJS
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 Roll ( 188.100,00
Cefixime Kapsul 100 mg 9.380,00
Cefotaxime Injeksi 11.502,00
Gentamicin Injeksi 9.212,00
Induxin 1 ml Injeksi 37.124,00
Kassa kotak stril DRC 19.350,00
Metrodinazole tab 500 m 2.700,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 4.522,00
Total 445.319,00
2.269 Yana Windari DANAU NIBUNG 182701 abbocath 18 Terumo @5
25/02/2021 00:00:00 52.682,00 BPJS
Cefotaxime Injeksi 11.502,00
Misoprostol Tab 11.000,00
Proster Tablet 200 mcg 10.084,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
26/02/2021 00:00:00 11.502,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 26.896,00
handscoond steril 8 (Gam 72.770,00
Ketorolac inj 30 mg/1ml 2.690,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00
Suprafenid Supositoria 10 28.050,00
Asam Mefenamat 500 m
27/02/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Misoprostol Tab 55.000,00
Total 517.327,00
2.270 Afrizal Chaniago dusun baru 182703 abbocath 18 Terumo @5
26/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Bisturi no. 10 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00

19/08/2021 12:42:30 Page 531 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.270 Afrizal Chaniago dusun baru 182703 Ceftriaxone Inj
26/02/2021 00:00:00 12.498,00 BPJS
Cuticell Classic 10cmx10c 35.121,00
Ephedrine Injeksi 21.422,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Polypropylene 3/0 C (Ass 235.200,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Tramadol 50 mg/ml Inj 12.375,00
Urine bag 10.088,00
viamac 1 R 182.185,00
Ceftriaxone Inj
27/02/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj
28/02/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Fentanyl Injeksi 5 Ampul 2
01/03/2021 00:00:00 52.000,00
Levofloxacin Tablet 500 m 13.640,00
Natrium diclofenac 50 m 2.890,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Total 1.274.369,00
2.271 Fatmawati SELAGAN JAYA 180719 abbocath 18 Terumo @5
26/02/2021 00:00:00 26.341,00 BPJS
Esomeprazol Injeksi 40 m 34.956,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Ondansetron Inj 4.950,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Alprazolam 0,5 mg @100 118,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 34.956,00
Ketorolac inj 30 mg/1ml 4.035,00
Neurodex tablet 1.482,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Alprazolam 0,5 mg @100
27/02/2021 00:00:00 1.180,00
Curcuma Tab 12.700,00
Domperidone Syrup 5mg 10.279,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 532 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.271 Fatmawati SELAGAN JAYA 180719 Vitamin C tablet @100 Ta
27/02/2021 00:00:00 2.070,00 BPJS
Total 270.638,00
2.272 Isnawati MAJU MAKMUR 182697 Cefixime Kapsul 100 mg
26/02/2021 00:00:00 9.380,00 BPJS
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
oxytocin inj 2.998,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
Total 74.874,00
2.273 Ny. Loh Putu Widiari I PONDOK BATU 182705 Chloramphenicol Salep M
26/02/2021 00:00:00 2.351,00 BPJS
umbilical Cord Clamp 2.261,00
Total 4.612,00
2.274 Ny. Loh Putu Widiari Ii PONDOK BATU 182706 umbilical Cord Clamp
26/02/2021 00:00:00 2.261,00 BPJS
Total 2.261,00
2.275 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
26/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.276 Salami SILAUT I 134774 NACL 0,9 % 500 ml
26/02/2021 00:00:00 42.750,00 BPJS
Omeprazol kapsul 20 mg 1.983,00
Simvastatin tab 10 mg 723,00
Total 45.456,00
2.277 Rini Astuti LUBUK SANAI 2 147140 NACL 3 % (OTSU SALIN)
26/02/2021 00:00:00 300.000,00 BPJS
Omeprazol kapsul 20 mg 1.983,00
Simvastatin tab 10 mg 723,00
Total 302.706,00
2.278 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
26/02/2021 00:00:00 42.750,00 BPJS
Omeprazol kapsul 20 mg 1.983,00
Simvastatin tab 10 mg 723,00
Total 45.456,00
2.279 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
26/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.280 Zukriman LUBUK GEDANG 160918 Amlodipine 10 mg @50 T
26/02/2021 00:00:00 354,00 BPJS
Candesartan Tab 16 mg 3.537,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 49.911,00
2.281 Suwarni SUKA MAJU 164065 Amlodipine 10 mg @50 T
26/02/2021 00:00:00 354,00 BPJS
Candesartan Tab 16 mg 3.537,00
Cetirgi Tab 10 mg 4.644,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Paracetamol tablet 500 m 600,00
Total 54.555,00
2.282 Susi Martini KOTO JAYA 145038 Allopurinol 100 mg @100
26/02/2021 00:00:00 702,00 BPJS
Amlodipine 10 mg @50 T 354,00
Candesartan Tab 16 mg 3.537,00

19/08/2021 12:42:30 Page 533 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.282 Susi Martini KOTO JAYA 145038 Clonidine 0.15 mg @100 T
26/02/2021 00:00:00 687,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Simvastatin tab 10 mg 723,00
Total 50.736,00
2.283 Roslina TERUNTUNG 130072 Allopurinol 100 mg @100
26/02/2021 00:00:00 702,00 BPJS
Amlodipine 10 mg @50 T 354,00
Candesartan Tab 16 mg 3.537,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Simvastatin tab 10 mg 723,00
Total 50.736,00
2.284 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
26/02/2021 00:00:00 42.750,00 BPJS
Omeprazol kapsul 20 mg 1.983,00
Simvastatin tab 10 mg 723,00
Total 45.456,00
2.285 Bagus Purnama Aji AGUNG JAYA 169904 Ciprofloxacin tab 500 mg
26/02/2021 00:00:00 5.590,00 BPJS
Metoclorapamide tab 10 m 1.510,00
Paracetamol tablet 500 m 4.000,00
Vitamin B Komplek @100 1.540,00
Zink Tablet 6.890,00
Total 19.530,00
2.286 M. Nasir TALANG BUAI 161843 Acetylcystein 200 mg Ka
26/02/2021 00:00:00 34.380,00 BPJS
Alprazolam 0,5 mg @100 1.180,00
Aminophyline 200 mg @1 4.000,00
Azitromycin 500 mg 28.125,00
Onbrez Breezhaler HGCI 0 440.640,00
Salbutamol 2 mg 2.370,00
Total 510.695,00
2.287 Aril Tasman SUMBER SARI 177089 Antasida Syrup 60 ml
26/02/2021 00:00:00 2.736,00 BPJS
Domperidone Tab 1.080,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 29.676,00
2.288 Juara Manalu AIR BIKUK 182709 Antasida Syrup 60 ml
26/02/2021 00:00:00 2.736,00 BPJS
Metoclorapamide tab 10 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 30.106,00
2.289 Marsyafatma PASAR MUKOMUKO 141569 Azitromycin 500 mg
26/02/2021 00:00:00 56.250,00 BPJS
Cetirgi Tab 10 mg 15.480,00
Codein tab 10 mg 7.500,00
Omeprazol kapsul 20 mg 6.610,00
Total 85.840,00
2.290 Citro Gimin SUMBER MAKMUR 182711 Abbocath 20 Terumo @5
26/02/2021 00:00:00 79.023,00 BPJS
Abbocath 20 Terumo @5 52.682,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Infusion Makro (terumo) 81.675,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00

19/08/2021 12:42:30 Page 534 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.290 Citro Gimin SUMBER MAKMUR 182711 NonWoven Fixation 15x
26/02/2021 00:00:00 6.694,00 BPJS
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Ondansetron Inj 1.650,00
Ranitidin inj 1.790,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 20 mg 311,00
Sucralfate Suspensi 100 m 19.250,00
Total 345.163,00
2.291 Tumini TANJUNG BERINGIN 180695 Mecobalamin 500 mg
26/02/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 7.280,00
Omeprazol kapsul 20 mg 6.610,00
Total 21.590,00
2.292 Arzan UJUNG PADANG 128346 Alprazolam 0,5 mg @100
26/02/2021 00:00:00 354,00 BPJS
Combivent 6.256,00
Dulcolax Sup 10 mg 139.000,00
Dulcolax tab 5 mg 15.830,00
Nebulizer O2 Dewasa 34.783,00
Orasic Kap 36.580,00
Total 232.803,00
2.293 Safrin LUBUK BANGKO 163017 Cetirgi Tab 10 mg
26/02/2021 00:00:00 30.960,00 BPJS
Methylprednisolone tab 4 2.630,00
Salbutamol 2 mg 790,00
Total 34.380,00
2.294 Erawita Agradia Sapuhe BANDAR RATU 110422 Domperidone Syrup 5mg
26/02/2021 00:00:00 10.279,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 6.610,00
Total 30.529,00
2.295 Sumar Jaya DANAU LEBAR 151695 Abbocath 20 Terumo @5
26/02/2021 00:00:00 52.682,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Clopidogrel 75 mg @30 T 1.755,00
Electroda (Ambu) @25 Pc 81.570,00
Isosorbid dinitrat 5 mg (I 333,00
Miniaspi 80 Mg @100 Ta 125,00
Nassal Mask O2 Anak 41.828,00
NonWoven Fixation 15x 6.694,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Tyarit tab 21.000,00
Urine bag 10.088,00
Total 287.804,00
2.296 Helen Okta Putri AIR BIKUK 182029 Asam Mefenamat 500 m
26/02/2021 00:00:00 1.290,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Metrodinazole tab 500 m 4.050,00
Total 18.980,00
2.297 Aliyah BANDAR RATU 153367 Cefixime Kapsul 100 mg
26/02/2021 00:00:00 9.380,00 BPJS
Cuticell Classic 10cmx10c 35.121,00

19/08/2021 12:42:30 Page 535 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.297 Aliyah BANDAR RATU 153367 NonWoven Fixation 15x
26/02/2021 00:00:00 6.694,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 53.195,00
2.298 Renisya Oktavia AIR KASAI 150070 abbocath 18 Terumo @5
26/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bisturi No. 15 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 236.500,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 93.750,00
Masker Tali 83.200,00
Massa Cauter Dewasa 90.240,00
Massa Cauter Dewasa 90.240,00
Metrodinazole Infus 10.313,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 34.200,00
NonWoven Fixation 15x 6.694,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 3-0 R ( 86.000,00
Polyvinylidene 3-0 R (Tri 0,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00

19/08/2021 12:42:30 Page 536 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.298 Renisya Oktavia AIR KASAI 150070 viamac 1 R
26/02/2021 00:00:00 364.370,00 BPJS
Total 2.274.993,00
2.299 Masrun Situmeang TERUNTUNG 182714 Bisturi No. 23
26/02/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 144.500,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 61.890,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Levofloxacin Tablet 500 m 13.640,00
Masker Karet 11.000,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Total 617.154,00
2.300 Sri Wahyuni PASAR GEDANG 134624 Levofloxacin Tablet 500 m
26/02/2021 00:00:00 13.640,00 BPJS
Methylprednisolone tab 4 10.520,00
Omeprazol kapsul 20 mg 6.610,00
Total 30.770,00
2.301 Sumar Jaya DANAU LEBAR 151695 Abbocath 20 Terumo @5
27/02/2021 00:00:00 52.682,00 BPJS
Captopril 12,5 mg 160,00
Ceftriaxone Inj 12.498,00
Clopidogrel 75 mg @30 T 1.755,00
Digoxsin tab 0,25 mg 432,00
Furosemide 40 mg Tablet 192,00
Isosorbid dinitrat 5 mg (I 333,00
Miniaspi 80 Mg @100 Ta 125,00
Pharmafix 10x50 cm (Hy 4.850,00
Piralen tab 1.362,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Spironolaktone 25 mg 520,00
Tramadol 50 mg/ml Inj 8.250,00
Tramadol 50 mg/ml Inj 8.250,00
Tyarit tab 21.000,00
Citicoline Injeksi 125mg/
28/02/2021 00:00:00 33.750,00
Nassal Mask O2 Dewasa 41.828,00
PARAMOL INFUS 192.500,00
Total 412.681,00
2.302 Renisya Oktavia AIR KASAI 150070 Cefotaxime Injeksi
26/02/2021 00:00:00 11.502,00 BPJS
Handscoon Steril 8.5 (Ga 29.108,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi no. 10
28/02/2021 00:00:00 3.836,00

19/08/2021 12:42:30 Page 537 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.302 Renisya Oktavia AIR KASAI 150070 NGT (Feeding Tube) Fr. 8
28/02/2021 00:00:00 70.420,00 BPJS
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
01/03/2021 00:00:00 17.253,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 266.165,00
2.303 Nita Insolita LUBUK BENTO 182716 abbocath 18 Terumo @5
26/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 93.072,00
2.304 Citro Gimin SUMBER MAKMUR 182711 Allopurinol 300 Mg @100
27/02/2021 00:00:00 491,00 BPJS
Glukosa Infus 5 % 8.626,00
Mecobalamin 500 mg 2.310,00
Mecobalamin 500 mg 770,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Simvastatin tab 10 mg 241,00
Ceftriaxone Inj
28/02/2021 00:00:00 12.498,00
Cetirgi Tab 10 mg 6.192,00
Glukosa Infus 5 % 17.252,00
Paracetamol tablet 500 m 600,00
Piralen Injeksi 2 ml 26.400,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 20 mg 311,00
Allopurinol 100 mg @100
01/03/2021 00:00:00 2.340,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 8.626,00
Mecobalamin 500 mg 7.700,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 10 mg 2.410,00
Allopurinol 300 Mg @100
02/03/2021 00:00:00 4.910,00
Domperidone Syrup 5mg 10.279,00
Levofloxacin Tablet 500 m 13.640,00
Mecobalamin 500 mg 1.540,00
Mecobalamin 500 mg 7.700,00
Metoclopramide inj 5Mg/M 11.758,00
Omeprazol kapsul 20 mg 6.610,00
Simvastatin tab 10 mg 4.820,00

19/08/2021 12:42:30 Page 538 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.304 Citro Gimin SUMBER MAKMUR 182711 Sucralfate Suspensi 100 m
02/03/2021 00:00:00 19.250,00 BPJS
Total 303.752,00
2.305 Yunia Ramadani SUNGAI IPUH 145845 Abbocath 20 Terumo @5
26/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ka-En 1 B 25.316,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 143.799,00
2.306 Nita Insolita LUBUK BENTO 182716 Bisturi No. 23
26/02/2021 00:00:00 3.836,00 BPJS
Bisturi No. 11 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cauter (Hand-controlled P 162.161,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril L 41.260,00
handscoond steril 6.5 (G 145.540,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 145.630,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 56.250,00
Masker Karet 11.000,00
Massa Cauter Dewasa 90.240,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 25.650,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 3.300,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 5 cc Disposible 2.840,00

19/08/2021 12:42:30 Page 539 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.306 Nita Insolita LUBUK BENTO 182716 Suprafenid Supositoria 10
26/02/2021 00:00:00 28.050,00 BPJS
Topi Operasi (Dokter) @5 16.990,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Abbocath 20 Terumo @5
28/02/2021 00:00:00 52.682,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Cefotaxime Injeksi
01/03/2021 00:00:00 17.253,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 0,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 2.191.394,00
2.307 Siami SELAGAN JAYA 151823 Abbocath 20 Terumo @5
26/02/2021 00:00:00 52.682,00 BPJS
Aqua Pro Injeksi 3.575,00
Asering 500 Ml 24.116,00
catheter 2 Way No. 18 (G 20.906,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Stomach Tube) Fr. 1 60.046,00
Nicardipine HCl Inj 29.566,00
Omeprazole Inj 12.499,00
Otsu Manitol 20% 54.375,00
Stesolid Inj 2 ml 25.959,00
Suction Chateter no. 12 ( 10.588,00
Tranexamic Acid Inj (Asa 8.420,00
Urine bag 10.088,00
Diazepam Inj 0,00
Electroda (Ambu) @25 Pc 81.570,00
Extention Tube 8.801,00
Otsu Manitol 20% 54.375,00
Paracetamol Infus 43.314,00
PARAMOL INFUS 0,00
Three Way stopcock 25.904,00
Tranexamic Acid Inj (Asa 0,00
Epinephrin inj
27/02/2021 00:00:00 30.662,00
Total 745.595,00
2.308 Yunia Ramadani SUNGAI IPUH 145845 Ceftriaxone Inj
27/02/2021 00:00:00 12.498,00 BPJS

19/08/2021 12:42:30 Page 540 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.308 Yunia Ramadani SUNGAI IPUH 145845 Ka-En 1 B
27/02/2021 00:00:00 25.316,00 BPJS
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Abbocath 24 Terumo @5
28/02/2021 00:00:00 105.364,00
Ceftriaxone Inj 6.249,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj
01/03/2021 00:00:00 6.249,00
Injection plug 20.213,00
Paracetamol tablet 500 m 2.000,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
02/03/2021 00:00:00 12.498,00
Ranitidin inj 3.580,00
Sucralfate Suspensi 100 m 19.250,00
Omeprazol kapsul 20 mg
03/03/2021 00:00:00 3.305,00
Omeprazole Inj 49.996,00
Total 421.743,00
2.309 Wirdah RANAH KARYA 181725 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Antasida Syrup 60 ml 2.736,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 35.274,00
NonWoven Fixation 15x 20.082,00
Omeprazole Inj 12.499,00
Omeprazole Inj 37.497,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 299.570,00
2.310 Nurbaiti TALANG KUNING 170203 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Infusion Makro (terumo) 27.225,00
Misoprostol Tab 16.500,00
Ringer Laktat Otsuka 9.538,00
Abbocath 20 Terumo @5 52.682,00
Abbocath 20 Terumo @5 52.682,00
Abbocath 22 Terumo @5 33.414,00
Abbocath 22 Terumo @5 33.414,00

19/08/2021 12:42:30 Page 541 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.310 Nurbaiti TALANG KUNING 170203 Hypafix 15cmx5cm (25 c
27/02/2021 00:00:00 13.088,00 BPJS
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
Ringer Laktat Otsuka 19.076,00
vestein 300 mg 37.400,00
abbocath 18 Terumo @5
01/03/2021 00:00:00 52.682,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Electroda (Ambu) @25 Pc 81.570,00
Fresofol ( propopol ) inj 13.448,00
Iodine Povidone 1 L 183.288,00
Ketamin Inj 78.705,00
Ketorolac inj 30 mg/1ml 2.690,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 22.000,00
Misoprostol Tab 16.500,00
Nassal Cannula O2 Anak 16.473,00
NonWoven Fixation 10x 9.630,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
02/03/2021 00:00:00 11.502,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Furosemide Injeksi @2ml 1.666,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 2.690,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 12.630,00
Tranexamic Acid Inj (Asa 6.315,00
Dexametason Injeksi
03/03/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
04/03/2021 00:00:00 11.502,00
Dexametason Injeksi 6.256,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 1.350,00
NACL 0,9 % 500 ml 8.550,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
05/03/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 46.405,00
Induxin 1 ml Injeksi 46.405,00
Ketorolac inj 30 mg/1ml 2.690,00

19/08/2021 12:42:30 Page 542 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.310 Nurbaiti TALANG KUNING 170203 Misoprostol Tab
05/03/2021 00:00:00 22.000,00 BPJS
Misoprostol Tab 55.000,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
Total 1.441.554,00
2.311 Sumidah RAWA MULYA 163860 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Antasida Syrup 60 ml 2.736,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 127.725,00
2.312 Khoirullina TANJUNG JAYA 182721 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Amlodipine 10 mg @50 T 118,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 26.328,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Methylprednisolone tab 4 263,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 26.328,00
Ketorolac inj 30 mg/1ml 4.035,00
Levofloxacin Infus 48.976,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Urine bag 0,00
Cefixime Kapsul 100 mg
28/02/2021 00:00:00 9.380,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 0,00
Ciprofloxacin tab 500 mg 5.590,00
Ketorolac inj 30 mg/1ml 4.035,00
Ringer Laktat Otsuka 38.152,00
Total 346.079,00
2.313 Sumidah RAWA MULYA 163860 Amlodipine 5 mg @30 T
27/02/2021 00:00:00 101,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 34.200,00
Nassal Cannula O2 Anak 16.473,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 10 mg @50 T
28/02/2021 00:00:00 118,00
Amlodipine 5 mg @30 T 1.010,00
Antasida Syrup 60 ml 2.736,00
Asam Folat 1 mg @100 T 990,00
Glucosamine 250 mg 7.700,00
Hypafix 15cmx5cm (25 c 6.544,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazol kapsul 20 mg 6.610,00

19/08/2021 12:42:30 Page 543 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.313 Sumidah RAWA MULYA 163860 OMZ
28/02/2021 00:00:00 180.000,00 BPJS
OMZ 90.000,00
Piralen tab 4.540,00
Ringer Laktat Otsuka 19.076,00
Tambah Darah Neo Tab 4.650,00
Total 451.135,00
2.314 Akbar Surya Ramadha KOTA PRAJA 182725 Abbocath 20 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Infusion Makro (terumo) 27.225,00
Ka-En 1 B 12.658,00
Omeprazole Inj 12.499,00
Ranitidin inj 1.790,00
Total 80.513,00
2.315 Bahman SIBAK 155872 NACL 0,9 % 500 ml
27/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.316 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
27/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.317 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
27/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.318 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
27/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.319 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
27/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.320 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
27/02/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.321 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
27/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.322 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
27/02/2021 00:00:00 51.300,00 BPJS
Total 51.300,00
2.323 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
27/02/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.324 Setia Wati LUNANG 182424 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet Boism 47.580,00
Midazolam 5mg/1ml 9.859,00

19/08/2021 12:42:30 Page 544 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.324 Setia Wati LUNANG 182424 Misoprostol Tab
27/02/2021 00:00:00 5.500,00 BPJS
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Otsu D40 12.513,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 38.152,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Total 1.521.023,00
2.325 Akbar Surya Ramadha KOTA PRAJA 182725 Ka-En 1 B
27/02/2021 00:00:00 25.316,00 BPJS
Ranitidin inj 3.580,00
Omeprazole Inj
28/02/2021 00:00:00 24.998,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 19.076,00
Omeprazol kapsul 20 mg
01/03/2021 00:00:00 4.627,00
Ranitidine tablet 150 mg 2.016,00
Sucralfate Suspensi 100 m 19.250,00
Total 101.253,00
2.326 Etri Nuryanti PONDOK MAKMUR 182727 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
handscoon steril 6.5 (Tr 29.976,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00

19/08/2021 12:42:30 Page 545 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.326 Etri Nuryanti PONDOK MAKMUR 182727 Ketorolac inj 30 mg/1ml
27/02/2021 00:00:00 4.035,00 BPJS
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet 11.000,00
Massa Cauter Dewasa 90.240,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suction no. 1/4 25.950,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi no. 10
28/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Urine bag 9.314,00
Total 1.551.082,00
2.327 Bulan Humaira Hakiki SIDO MAKMUR 150807 Abbocath 22 Terumo @5
27/02/2021 00:00:00 11.138,00 BPJS
Diazepam Tab 5 Mg 136,00
Infusion Makro (terumo) 27.225,00
Ka-En 1 B 12.658,00
Pamol 125 Supositoria 17.600,00
Paracetamol syrup 1.388,00
Total 70.145,00
2.328 Oka Mardela SEMUNDAM 140548 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00

19/08/2021 12:42:30 Page 546 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.328 Oka Mardela SEMUNDAM 140548 Transfusi Set Terumo
27/02/2021 00:00:00 16.500,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cetirizine 10 mg 1.260,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 72.815,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 2.000,00
Piroxicam 10 mg 1.350,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
viamac 1 R 182.185,00
Bisturi no. 10
28/02/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00

19/08/2021 12:42:30 Page 547 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.328 Oka Mardela SEMUNDAM 140548 umbilical Cord Clamp
28/02/2021 00:00:00 2.261,00 BPJS
Cefotaxime Injeksi
01/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Spinocain 27 (BBraund) 47.875,00
Urine bag 9.314,00
Total 1.953.699,00
2.329 Ari Antoni PONDOK PANJANG 182729 Abbocath 20 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 9.538,00
Total 78.497,00
2.330 Faiq Bukhair TUNGGANG 176380 Dexametason Injeksi
27/02/2021 00:00:00 3.128,00 BPJS
Furosemide Injeksi @2ml 1.666,00
NACL 0,9 % 500 ml 17.100,00
Pharmafix 10x50 cm (Hy 4.850,00
Asam Folat 1 mg @100 T
28/02/2021 00:00:00 297,00
Total 27.041,00
2.331 Khairil SARI BULAN 146663 Captopril 12,5 mg
27/02/2021 00:00:00 320,00 BPJS
Ephedrine Injeksi 21.422,00
Total 21.742,00
2.332 Widaryanti AIR HITAM 179916 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00

19/08/2021 12:42:30 Page 548 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.332 Widaryanti AIR HITAM 179916 Infusion Makro (terumo)
27/02/2021 00:00:00 27.225,00 BPJS
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
methyl ergometrin amp 6.700,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Pharmafix 10x50 cm (Hy 4.850,00
Pharmafix 15x50 (Hypap 6.544,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
Abbocath 20 Terumo @5
28/02/2021 00:00:00 52.682,00
Bisturi no. 10 3.836,00
NonWoven Fixation 10x 9.630,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
01/03/2021 00:00:00 17.253,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 1.614.791,00
2.333 Rila Santika ARAH TIGA 126526 Abbocath 20 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00

19/08/2021 12:42:30 Page 549 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.333 Rila Santika ARAH TIGA 126526 Chromic catgut 2-0 R (Tr
27/02/2021 00:00:00 72.250,00 BPJS
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 0,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
methyl ergometrin amp 6.700,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
Ondansetron Inj 1.650,00
Pharmafix 10x50 cm (Hy 4.850,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Asam Traneksamat @10
28/02/2021 00:00:00 6.315,00
Bisturi no. 10 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Abbocath 18 (Gea)
01/03/2021 00:00:00 21.440,00
Abbocath 20 Terumo @5 52.682,00

19/08/2021 12:42:30 Page 550 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.333 Rila Santika ARAH TIGA 126526 Cefotaxime Injeksi
01/03/2021 00:00:00 17.253,00 BPJS
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hystolan Tab 20 mg 11.138,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Spinocain 27 (BBraund) 47.875,00
Urine bag 9.314,00
Total 1.834.504,00
2.334 Khairil SARI BULAN 146663 Abbocath 20 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Amlodipine 10 mg @50 T 118,00
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Candesartan tab 8 mg 1.362,00
Cefoperazon Inj 41.250,00
Electroda (Ambu) @25 Pc 81.570,00
Infusion Makro (terumo) 27.225,00
Nifedipin Tab 10 mg 175,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 2.105,00
Amlodipine 10 mg @50 T
28/02/2021 00:00:00 118,00
Asam Folat 1 mg @100 T 198,00
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 1.179,00
Cefoperazon Inj 41.250,00
Cefoperazon Inj 82.500,00
Hypafix 15cmx5cm (25 c 6.544,00
OMZ 90.000,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 4.210,00
Asam Folat 1 mg @100 T
01/03/2021 00:00:00 297,00
Candesartan Tab 16 mg 1.179,00
Cefoperazon Inj 41.250,00
Clonidine 0.15 mg @100 T 229,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00

19/08/2021 12:42:30 Page 551 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.334 Khairil SARI BULAN 146663 Tranexamic Acid Inj (Asa
01/03/2021 00:00:00 4.210,00 BPJS
Amlodipine 10 mg @50 T
02/03/2021 00:00:00 1.180,00
Asam Folat 1 mg @100 T 990,00
Candesartan Tab 16 mg 11.790,00
Cefixime kapsul 200 mg 39.720,00
Clonidine 0.15 mg @100 T 2.290,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 24.998,00
Total 654.810,00
2.335 Rini Nova riani RANAH KARYA 182731 abbocath 18 Terumo @5
27/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Tali 41.600,00
methyl ergometrin amp 8.662,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Otsu MgSO4 40 % 4.745,00
Pharmafix 10x50 cm (Hy 4.850,00
Pharmafix 15x50 (Hypap 6.544,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Otsu MgSO4 40 % 4.745,00

19/08/2021 12:42:30 Page 552 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.335 Rini Nova riani RANAH KARYA 182731 Dexametason Injeksi
28/02/2021 00:00:00 9.384,00 BPJS
Amlodipine 10 mg @50 T
01/03/2021 00:00:00 118,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Electroda (Ambu) @25 Pc 81.570,00
Ephedrine Injeksi 32.133,00
Extention Tube 8.801,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
handscoond steril 8 (Gam 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Metrodinazole tab 500 m 0,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Nicardipine HCl Inj 29.566,00
Otsu MgSO4 40 % 9.490,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 24.062,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Three Way stopcock 25.904,00
Topi Operasi (Perawat) @ 4.690,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
02/03/2021 00:00:00 5.751,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 8.550,00

19/08/2021 12:42:30 Page 553 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.335 Rini Nova riani RANAH KARYA 182731 NACL 0,9 % 500 ml
02/03/2021 00:00:00 8.550,00 BPJS
Nicardipine HCl Inj 29.566,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefoperazon Inj
03/03/2021 00:00:00 82.500,00
Cefotaxime Injeksi 11.502,00
Hypafix Kamar Operasi 36.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Paracetamol tablet 500 m 1.000,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 25 (BBraund) 42.763,00
Spinocain 26 (Bbraund) 43.038,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
04/03/2021 00:00:00 1.935,00
Cefotaxime Injeksi 5.751,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Nifedipin Tab 10 mg 1.750,00
oxytocin inj 2.998,00
Postofix (leukomed) 36.726,00
Spinocain 27 (BBraund) 47.875,00
Urine bag 9.314,00
Total 3.677.549,00
2.336 Sri Utami AIR BULUH 182732 abbocath 18 Terumo @5
28/02/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Utrogestan 200 mg 50.946,00
Total 104.871,00
2.337 Setia Wati LUNANG 182424 Bisturi no. 10
28/02/2021 00:00:00 3.836,00 BPJS
Cefotaxime Injeksi 11.502,00
Glukosa Infus 10 % 9.375,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding Tube) Fr. 8 70.420,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
abbocath 18 Terumo @5
01/03/2021 00:00:00 79.023,00
Abbocath 20 Terumo @5 79.023,00
Abbocath 20 Terumo @5 52.682,00
Cefotaxime Injeksi 17.253,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00

19/08/2021 12:42:30 Page 554 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.337 Setia Wati LUNANG 182424 Ketorolac inj 30 mg/1ml
01/03/2021 00:00:00 4.035,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Ciprofloxacin tab 500 mg 2.795,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 603.898,00
2.338 Nurhayati SILAUT 182733 Abbocath 20 Terumo @5
28/02/2021 00:00:00 26.341,00 BPJS
Allopurinol 100 mg @100 702,00
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 681,00
Catheter 2 Way No. 16 ( 20.625,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 1.666,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 41.250,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Pharmafix 10x50 cm (Hy 4.850,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 260,00
Urine bag 10.088,00
Total 272.785,00
2.339 Winda Mutiara Indah SILAUT 181956 abbocath 18 Terumo @5
28/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 2-0 R (Tr 72.250,00
Chromic catgut 3-0 R (Tr 66.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
Handscoond Non Steril M 20.080,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00

19/08/2021 12:42:30 Page 555 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.339 Winda Mutiara Indah SILAUT 181956 Handscoond Sterille 7 (G
28/02/2021 00:00:00 29.126,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
methyl ergometrin amp 8.662,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Pharmafix 10x50 cm (Hy 4.850,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
viamac 1 R 182.185,00
Total 1.121.922,00
2.340 Nurhayati SILAUT 182733 Abbocath 22 Terumo @5
28/02/2021 00:00:00 22.276,00 BPJS
Allopurinol 300 Mg @100 491,00
Azitromycin 500 mg 5.625,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 681,00
Codein tab 10 mg 1.500,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 1.666,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 41.250,00
meropenem Injeksi 1 g 41.250,00
NonWoven Fixation 15x 6.694,00
OMZ 90.000,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 260,00
Azitromycin 500 mg
01/03/2021 00:00:00 5.625,00
Bisoprolol 5 mg @100 Ta 296,00
Codein tab 10 mg 1.500,00
Codein tab 10 mg 750,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
Isosorbid dinitrat 5 mg (I 222,00
meropenem Injeksi 1 g 82.500,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 260,00

19/08/2021 12:42:30 Page 556 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.340 Nurhayati SILAUT 182733 Allopurinol 300 Mg @100
02/03/2021 00:00:00 982,00 BPJS
Azitromycin 500 mg 11.250,00
Bisoprolol 5 mg @100 Ta 592,00
Candesartan tab 8 mg 1.362,00
Codein tab 10 mg 750,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
Isosorbid dinitrat 5 mg (I 222,00
meropenem Injeksi 1 g 82.500,00
Omeprazole Inj 12.499,00
Spironolaktone 25 mg 520,00
Allopurinol 100 mg @100
03/03/2021 00:00:00 234,00
Azitromycin 500 mg 5.625,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 681,00
Codein tab 10 mg 1.500,00
Furamin Injeksi 28.738,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 13.088,00
Hypafix 15cmx5cm (25 c 13.088,00
Ketorolac inj 30 mg/1ml 4.035,00
meropenem Injeksi 1 g 82.500,00
meropenem Injeksi 1 g 82.500,00
Omeprazole Inj 24.998,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 19.076,00
Spironolaktone 25 mg 260,00
Allopurinol 300 Mg @100
04/03/2021 00:00:00 491,00
Ambroxol 30 mg @100 T 579,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 681,00
Codein tab 10 mg 1.500,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 3.332,00
L-Cisin tab 7.562,00
meropenem Injeksi 1 g 82.500,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 260,00
Allopurinol 300 Mg @100
05/03/2021 00:00:00 4.910,00
Ambroxol 30 mg @100 T 579,00
Ambroxol Syr 15mg/ml 4.538,00
Azitromycin 500 mg 33.750,00
Bisoprolol 5 mg @100 Ta 2.960,00
Candesartan tab 8 mg 6.810,00
Codein tab 10 mg 7.500,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Furamin Injeksi 28.738,00

19/08/2021 12:42:30 Page 557 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.340 Nurhayati SILAUT 182733 Furamin Injeksi
05/03/2021 00:00:00 14.369,00 BPJS
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Isosorbid dinitrat 5 mg (I 222,00
Isosorbid dinitrat 5 mg (I 222,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Spironolaktone 25 mg 2.600,00
Urine bag 9.314,00
Total 1.231.230,00
2.341 Ari Antoni PONDOK PANJANG 182729 Ceftriaxone Inj
28/02/2021 00:00:00 12.498,00 BPJS
Ceftriaxone Inj 12.498,00
Furamin Injeksi 43.107,00
Furamin Injeksi 43.107,00
OMZ 90.000,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Psidii Capsule 500 mg 19.604,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
01/03/2021 00:00:00 12.498,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 2.690,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Psidii Capsule 500 mg 19.604,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
02/03/2021 00:00:00 12.498,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 2.690,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 800,00
Perifas @100 Tab 3.850,00
Psidii Capsule 500 mg 19.604,00
Ringer Laktat Otsuka 28.614,00
NonWoven Fixation 15x
03/03/2021 00:00:00 13.388,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 2.000,00
Psidii Capsule 500 mg 19.604,00
Total 543.241,00
2.342 Sri Utami AIR BULUH 182732 abbocath 18 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Cefixime Kapsul 100 mg 14.070,00
Cefotaxime Injeksi 5.751,00

19/08/2021 12:42:30 Page 558 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.342 Sri Utami AIR BULUH 182732 Hypafix 15cmx5cm (25 c
01/03/2021 00:00:00 32.720,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 122.189,00
2.343 Winda Mutiara Indah SILAUT 181956 Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00 BPJS
Asam Mefenamat 500 m 387,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Cefotaxime Injeksi 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix Kamar Operasi 90.000,00
Induxin 1 ml Injeksi 37.124,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 4.050,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Total 329.319,00
2.344 Ny Winda Mutiara SILAUT 182734 Abbocath 24 Terumo @5
28/02/2021 00:00:00 79.023,00 BPJS
Abbocath 24 Terumo @5 105.364,00
Ampicilin Serbuk Injeksi 1 10.811,00
Bisturi no. 10 3.836,00
Hypafix 15cmx5cm (25 c 13.088,00
Kassa kotak stril DRC 9.675,00
umbilical Cord Clamp 2.261,00
Phytomenadione 2 Mg/1M
02/03/2021 00:00:00 4.834,00
Total 228.892,00
2.345 M Munir ibnu shalla BANDARATU 136635 Abbocath 20 Terumo @5
28/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Infusion set Mikro (Terumo 18.026,00
Metrodinazole tab 500 m 3.510,00
NonWoven Fixation 10x 4.815,00
Omeprazol kapsul 20 mg 1.983,00
OMZ 0,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.600,00
Ringer Laktat Otsuka 9.538,00

19/08/2021 12:42:30 Page 559 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.345 M Munir ibnu shalla BANDARATU 136635 Zinc Sulfate Syr 60 ml
28/02/2021 00:00:00 4.569,00 BPJS
Total 79.907,00
2.346 Muslim PONDOK BARU 182735 Abbocath 20 Terumo @5
28/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Curcuma Tab 1.270,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Anak 16.473,00
Neurodex tablet 741,00
NGT (Stomach Tube) Fr. 1 52.250,00
NonWoven Fixation 10x 4.815,00
OMZ 90.000,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Aminofluid Infus 500 ml
01/03/2021 00:00:00 155.204,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 25.650,00
Ranitidin inj 3.580,00
Abbocath 20 Terumo @5
02/03/2021 00:00:00 52.682,00
Aminofluid Infus 500 ml 155.204,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 3.580,00
Aminofluid Infus 500 ml
03/03/2021 00:00:00 155.204,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 3.580,00
Aminofluid Infus 500 ml
04/03/2021 00:00:00 155.204,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 1.790,00
Nassal Cannula O2 Dewas
05/03/2021 00:00:00 11.625,00
Omeprazol kapsul 20 mg 3.305,00
OMZ 90.000,00
Total 1.147.518,00
2.347 Sumidah RAWA MULYA 163860 Ceftriaxone Inj
28/02/2021 00:00:00 12.498,00 BPJS
Ceftriaxone Inj 6.249,00
Asam Folat 1 mg @100 T
01/03/2021 00:00:00 99,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Tambah Darah Neo Tab 465,00
vestein 300 mg 14.025,00
Asam Folat 1 mg @100 T
02/03/2021 00:00:00 99,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Tambah Darah Neo Tab 930,00
vestein 300 mg 46.750,00

19/08/2021 12:42:30 Page 560 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.347 Sumidah RAWA MULYA 163860 Asam Folat 1 mg @100 T
03/03/2021 00:00:00 99,00 BPJS
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Renogen 3000 UI 116.875,00
Asam Folat 1 mg @100 T
04/03/2021 00:00:00 990,00
Cefixime Kapsul 100 mg 9.380,00
Cefixime Kapsul 100 mg 9.380,00
Cefixime kapsul 200 mg 26.480,00
Cetirgi Tab 10 mg 15.480,00
Furosemide 40 mg Tablet 960,00
Furosemide Injeksi @2ml 1.666,00
Levofloxacin Tablet 500 m 2.728,00
Levofloxacin Tablet 500 m 1.364,00
Metoclopramide inj 5Mg/M 58.790,00
Metoclorapamide tab 10 m 1.510,00
NACL 0,9 % 500 ml 17.100,00
Total 568.543,00
2.348 Siti Pertiwi LUBUK SAHUNG 177876 Abbocath 20 Terumo @5
28/02/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Infusion Makro (terumo) 27.225,00
Nassal Cannula O2 Anak 16.473,00
NonWoven Fixation 10x 4.815,00
Phenytoin Sodium Injeksi 15.911,00
Ringer Laktat Otsuka 9.538,00
abbocath 18 Terumo @5 26.341,00
Asam Folat 1 mg @100 T 297,00
Citicoline Injeksi 125mg/ 22.500,00
Furamin Injeksi 43.107,00
Nassal Cannula O2 Anak 16.473,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Tambah Darah Neo Tab 930,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
01/03/2021 00:00:00 297,00
Citicoline Injeksi 125mg/ 22.500,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 4.998,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 930,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 561 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.348 Siti Pertiwi LUBUK SAHUNG 177876 Abbocath 20 Terumo @5
02/03/2021 00:00:00 79.023,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Asam Folat 1 mg @100 T 297,00
Citicoline Injeksi 125mg/ 22.500,00
Furamin Injeksi 43.107,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
03/03/2021 00:00:00 297,00
Betahistin Mesilat 6 mg @ 276,00
Citicoline Injeksi 125mg/ 22.500,00
Furamin Injeksi 43.107,00
Hypafix 15cmx5cm (25 c 13.088,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Tambah Darah Neo Tab 930,00
Tranexamic Acid Inj (Asa 4.210,00
Urdahek 20.260,00
Asam Folat 1 mg @100 T
04/03/2021 00:00:00 990,00
Asam Folat 1 mg @100 T 1.188,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 86.214,00
Furosemide Injeksi @2ml 1.666,00
NonWoven Fixation 15x 6.694,00
Nucral Syrup 100 ml 53.350,00
Omeprazole Inj 87.493,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 4.650,00
Total 1.133.911,00
2.349 Nurazizah SUKA MAJU 181998 Aqua Pro Injeksi
01/03/2021 00:00:00 3.575,00 BPJS
Candesartan tab 8 mg 681,00
Catheter 2 Way No. 16 ( 39.025,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00

19/08/2021 12:42:30 Page 562 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.349 Nurazizah SUKA MAJU 181998 Hypafix 15cmx5cm (25 c
01/03/2021 00:00:00 6.544,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
02/03/2021 00:00:00 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Handscoond Sterille 7 (G 29.126,00
HD Catheter Kit Doubel L 1.175.625,00
Lidocain injk 40 mg/2 ml 4.833,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Ondansetron tablet 8 mg 2.640,00
Ringer Laktat Otsuka 28.614,00
Silk 2/0 C scimitar 66.993,00
Candesartan tab 8 mg
03/03/2021 00:00:00 1.362,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix Kamar Operasi 18.000,00
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 4.950,00
Renogen 3000 UI 116.875,00
Transfusi Set Terumo 16.500,00
Total 1.846.911,00
2.350 Rabaiyah RETAK MUDIK 182738 Amlodipine 10 mg @50 T
01/03/2021 00:00:00 118,00 BPJS
Amlodipine 10 mg @50 T 118,00
Candesartan Tab 16 mg 1.179,00
Candesartan Tab 16 mg 1.179,00
Catheter 2 Way No. 16 ( 20.625,00
Citicoline Injeksi 125mg/ 11.250,00
Citicoline Injeksi 125mg/ 33.750,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
meropenem Injeksi 1 g 41.250,00
meropenem Injeksi 1 g 82.500,00
Nassal Cannula O2 Anak 16.473,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Amlodipine 10 mg @50 T
02/03/2021 00:00:00 118,00
Candesartan Tab 16 mg 1.179,00
Citicoline Injeksi 125mg/ 33.750,00
Clonidine 0.15 mg @100 T 229,00

19/08/2021 12:42:30 Page 563 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.350 Rabaiyah RETAK MUDIK 182738 Furamin Injeksi
02/03/2021 00:00:00 14.369,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
meropenem Injeksi 1 g 82.500,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Piracetam tab 800 mg 1.506,00
Abbocath 22 Terumo @5
03/03/2021 00:00:00 11.138,00
Candesartan Tab 16 mg 1.179,00
Citicoline Injeksi 125mg/ 33.750,00
Clonidine 0.15 mg @100 T 229,00
Furamin Injeksi 14.369,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 82.500,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Piracetam tab 800 mg 1.506,00
Ringer Laktat Otsuka 19.076,00
Total 731.789,00
2.351 Adriell Kazshio Pratam RANAH KARYA 175878 Abbocath 24 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Asam Folat 1 mg @100 T 99,00
Ceftriaxone Inj 6.249,00
Ceftriaxone Inj 6.249,00
Electroda (Ambu) @25 Pc 81.570,00
Extention Tube 8.801,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Ka-En 1 B 12.658,00
NACL 0,9 % 500 ml 8.550,00
NGT (Feeding Tube) Fr. 8 70.420,00
Paracetamol syrup 1.388,00
Phenytoin Sodium Injeksi 31.822,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 28.614,00
Spuit 50cc terumo Lbg P 29.400,00
Stesolid Supp 10 mg 23.991,00
Stesolid Supp 5 mg 16.503,00
Three Way stopcock 25.904,00
Vitamin B Komplek @100 154,00
Asam Folat 1 mg @100 T
02/03/2021 00:00:00 99,00
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 12.512,00
NonWoven Fixation 15x 6.694,00
Phenytoin Sodium Injeksi 15.911,00
Ceftriaxone Inj
03/03/2021 00:00:00 6.249,00
Dexametason Injeksi 9.384,00
Phenytoin Sodium Injeksi 15.911,00
Abbocath 24 Terumo @5
04/03/2021 00:00:00 52.682,00
NonWoven Fixation 10x 9.630,00
Phenytoin Sodium Injeksi 47.733,00
Abbocath 24 Terumo @5
05/03/2021 00:00:00 26.341,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 6.249,00

19/08/2021 12:42:30 Page 564 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.351 Adriell Kazshio Pratam RANAH KARYA 175878 Dexametason Injeksi
05/03/2021 00:00:00 3.128,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00
Phenytoin Sodium Injeksi 15.911,00
Ambroxol Syr 15mg/ml
06/03/2021 00:00:00 4.538,00
Asam Folat 1 mg @100 T 198,00
Phenytoin Sodium Injeksi 15.911,00
Abbocath 24 Terumo @5
07/03/2021 00:00:00 79.023,00
Ceftriaxone Inj 6.249,00
Hypafix 15cmx5cm (25 c 6.544,00
Injection plug 20.213,00
Phenytoin Sodium Injeksi 15.911,00
Hypafix 10cm x 5cm (25 c
08/03/2021 00:00:00 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Abbocath 24 Terumo @5
09/03/2021 00:00:00 79.023,00
Ambroxol Syr 15mg/ml 4.538,00
Asam Folat 1 mg @100 T 990,00
Cefixime syrup 100mg/5 M 23.823,00
Ceftriaxone Inj 12.498,00
Fuson Cream 38.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Phenytoin Sodium Injeksi 31.822,00
Valproic Acid Syrup 250mg 20.975,00
Vitamin B Komplek @100 1.540,00
Total 1.055.747,00
2.352 Miswanto TANJUNG BERINGIN 182189 Abbocath 20 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Infusion Makro (terumo) 27.225,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
abbocath 18 Terumo @5 26.341,00
Asam Folat 1 mg @100 T 198,00
Calos cmewable tab 2.409,00
Cefoperazon Inj 82.500,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 25.650,00
NGT (Stomach Tube) Fr. 1 52.250,00
Paracetamol tablet 500 m 600,00
Tambah Darah Neo Tab 930,00
Total 326.358,00
2.353 Salmaini RESNO 114055 Abbocath 20 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 9.538,00
Urinter Kapsul @100 cap 4.396,00
Total 71.295,00
2.354 Mujiono SIDO MAKMUR 151305 Atorvastatin 20 mg @30 T
01/03/2021 00:00:00 31.350,00 BPJS
Candesartan tab 8 mg 20.430,00
Cilostazol 100 mg @100 T 705.360,00
Donepezil MK Tablet 67.230,00

19/08/2021 12:42:30 Page 565 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.354 Mujiono SIDO MAKMUR 151305 Metformin tablet 500 mg
01/03/2021 00:00:00 3.990,00 BPJS
Total 828.360,00
2.355 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
01/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.356 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
01/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.357 Darmawan LUBUK PINANG 140187 Amlodipine 10 mg @50 T
01/03/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 160.876,00
2.358 Narti SILAUT 175653 NACL 0,9 % 500 ml
01/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.359 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
01/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.360 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
01/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.361 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
01/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.362 Armeiyani LUBUK SANAI 177144 Meloxicam 7,5 mg
01/03/2021 00:00:00 7.280,00 BPJS
Propylthiourasil 100 mg ( 39.180,00
Total 46.460,00
2.363 Wardoyo TANJUNG MULYA 125079 Abbocath 20 Terumo @5
01/03/2021 00:00:00 52.682,00 BPJS
Codein tab 10 mg 2.250,00
NACL 0,9 % 500 ml 42.750,00
Omeprazol kapsul 20 mg 1.983,00
Ranitidin inj 1.790,00
Renogen 3000 UI 116.875,00
Total 218.330,00
2.364 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
01/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.365 Ahmad Dewanta MEKAR MULYA 165909 Abbocath 24 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Total 66.654,00
2.366 Addarimi BANDARATU 127606 Candesartan tab 8 mg
01/03/2021 00:00:00 20.430,00 BPJS
Cilostazol 100 mg @100 T 352.680,00
Flunarizine 5 mg tab 74.250,00
Ketoprofen tab 100 mg 37.140,00
Levopar tab 100mg 38.730,00
Sifrol tab 0,375 mg 311.250,00
Total 834.480,00
2.367 M Salim BANDAR RATU 170187 Diazepam Tab 2 mg
01/03/2021 00:00:00 4.080,00 BPJS

19/08/2021 12:42:30 Page 566 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.367 M Salim BANDAR RATU 170187 Haloperidol 1,5 mg
01/03/2021 00:00:00 3.900,00 BPJS
Ibuprofen tab 200 mg 3.980,00
Risperidon tab 2 mg 10.770,00
Total 22.730,00
2.368 Deni Sartika PONDOK BARU 167133 CAL-95 tab
01/03/2021 00:00:00 62.700,00 BPJS
Tambah Darah Neo Tab 4.650,00
Total 67.350,00
2.369 Selo TUNGGAL JAYA 182745 Mecobalamin 500 mg
01/03/2021 00:00:00 7.700,00 BPJS
Total 7.700,00
2.370 Trisni Hartati MEKAR MULYA 157562 Cefixime Kapsul 100 mg
01/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.371 Marsidis TANJUNG ALAI 182747 Orasic Kap
01/03/2021 00:00:00 36.580,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 58.560,00
2.372 Jaskani BANDA RATU 111418 Meloxicam 7,5 mg
01/03/2021 00:00:00 7.280,00 BPJS
Opilax Syr 49.156,00
Total 56.436,00
2.373 Yun Ahmadi KAMPUNG DALAM 170277 Candesartan tab 8 mg
01/03/2021 00:00:00 20.430,00 BPJS
Mecobalamin 500 mg 23.100,00
Paracetamol tablet 500 m 3.000,00
Simvastatin tab 20 mg 9.330,00
Total 55.860,00
2.374 Nasran DUSUN BARU V KOTO 182749 Antasida Syrup 60 ml
01/03/2021 00:00:00 2.736,00 BPJS
Metoclorapamide tab 10 m 1.510,00
Omeprazole Inj 124.990,00
Sucralfate Suspensi 100 m 19.250,00
Total 148.486,00
2.375 Eti Rohayati SINAR JAYA 182594 Cefixime Kapsul 100 mg
01/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.376 Airin Dwi Salsabila TELUK RUMBIA 110236 Asam Folat 1 mg @100 T
01/03/2021 00:00:00 2.970,00 BPJS
Valproic Acid Syrup 250mg 62.925,00
Vitamin B Komplek @100 4.620,00
Total 70.515,00
2.377 Elisabeth Hutasoit PT AGRO BTE 141827 CAL-95 tab
01/03/2021 00:00:00 62.700,00 BPJS
Emibion kapsul 19.660,00
Total 82.360,00
2.378 Zaunatul Aini LUBUK PINANG 153422 abbocath 18 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Asam Folat 1 mg @100 T 99,00
Ringer Laktat Otsuka 9.538,00
Tambah Darah Neo Tab 465,00
Transfusi Set Terumo 16.500,00
Total 52.943,00
2.379 Azwani KOTO JAYA 112288 Mecobalamin 500 mg
01/03/2021 00:00:00 7.700,00 BPJS
Omeprazol kapsul 20 mg 13.220,00
Sucralfate Suspensi 100 m 19.250,00
Total 40.170,00

19/08/2021 12:42:30 Page 567 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.380 Yalminawati PELOKAN 179039 Azitromycin 500 mg
01/03/2021 00:00:00 28.125,00 BPJS
vestein 300 mg 93.500,00
Total 121.625,00
2.381 Erniati PENARIK 141742 Alprazolam 0,5 mg @100
01/03/2021 00:00:00 3.540,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Candesartan tab 8 mg 20.430,00
Latropil ( Piracetam ) Syr 60.088,00
Mecobalamin 500 mg 23.100,00
Metformin tablet 500 mg 7.980,00
Total 118.168,00
2.382 Any Desmawati UJUNG PADANG 111289 Aspilet 80 mg @100 mg
01/03/2021 00:00:00 4.140,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Citicoline kaplet 500 mg 49.500,00
Glimepiride tab 2 mg 7.770,00
Metformin tablet 500 mg 11.970,00
Total 104.730,00
2.383 Ahmad Damiri UJUNG PADANG 114580 Amlodipine 10 mg @50 T
01/03/2021 00:00:00 3.540,00 BPJS
Asam Folat 1 mg @100 T 5.940,00
Aspilet 80 mg @100 mg 4.140,00
Atorvastatin 20 mg @30 T 31.350,00
Piracetam tab 800 mg 22.590,00
Topamax 100 mg Tab 717.000,00
Total 784.560,00
2.384 Rosna BANDARRATU 119153 Amlodipine 10 mg @50 T
01/03/2021 00:00:00 3.540,00 BPJS
Asam Folat 1 mg @100 T 2.970,00
Atorvastatin 20 mg @30 T 31.350,00
Mecobalamin 500 mg 23.100,00
Total 60.960,00
2.385 Tri Mulyadi BUMI MULYA 182753 Levofloxacin Tablet 500 m
01/03/2021 00:00:00 13.640,00 BPJS
Metoclorapamide tab 10 m 1.510,00
Total 15.150,00
2.386 Miswanto TANJUNG BERINGIN 182189 Bisoprolol 5 mg @100 Ta
01/03/2021 00:00:00 296,00 BPJS
Electroda (Ambu) @25 Pc 81.570,00
Gentamycin 0.1 % salep k 2.983,00
Loratadine tab 10 mg 166,00
Loratadine tab 10 mg 166,00
Metamizole Sodium Mono 13.782,00
NACL 0,9 % 500 ml 42.750,00
Renogen 3000 UI 116.875,00
Abbocath 22 Terumo @5
02/03/2021 00:00:00 33.414,00
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 198,00
Bisoprolol 5 mg @100 Ta 592,00
Cefoperazon Inj 165.000,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 15cmx5cm (25 c 6.544,00
Meylon 84 B.P 24.183,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00

19/08/2021 12:42:30 Page 568 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.386 Miswanto TANJUNG BERINGIN 182189 Antrain Injeksi
03/03/2021 00:00:00 28.875,00 BPJS
Asam Folat 1 mg @100 T 297,00
Cefoperazon Inj 82.500,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Zink Tablet 1.378,00
Antrain Injeksi
04/03/2021 00:00:00 28.875,00
Cefoperazon Inj 82.500,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 1.666,00
Metamizole Sodium Mono 4.594,00
NonWoven Fixation 10x 4.815,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 1.000,00
Zinc Sulfate Syr 60 ml 4.569,00
Abbocath 22 Terumo @5
05/03/2021 00:00:00 11.138,00
Amlodipine 10 mg @50 T 590,00
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 2.970,00
Calos cmewable tab 24.090,00
Cefoperazon Inj 41.250,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Electroda (Ambu) @25 Pc 81.570,00
Furosemide Injeksi @2ml 1.666,00
Gentamycin 0.1 % salep k 8.949,00
Metamizole Sodium Mono 4.594,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 2.000,00
Tambah Darah Neo Tab 9.300,00
Three Way stopcock 25.904,00
Transfusi Set Terumo 16.500,00
Urine bag 9.314,00
Total 1.507.389,00
2.387 Atika Agustin SUNGAI GADING 132606 Asam Folat 1 mg @100 T
01/03/2021 00:00:00 2.970,00 BPJS
Valproic Acid Syrup 250mg 104.875,00
Total 107.845,00
2.388 Musli Hadaya LUBUK GEDANG 182096 Asam Mefenamat 500 m
01/03/2021 00:00:00 2.580,00 BPJS
Asam Traneksamat @10 42.100,00
Vitamin B Komplek @100 2.310,00

19/08/2021 12:42:30 Page 569 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 46.990,00
2.389 Apsal PONDOK BARU 121223 Ambroxol Syr 15mg/ml
01/03/2021 00:00:00 4.538,00 BPJS
Aminophyline 200 mg @1 6.000,00
Cetirgi Tab 10 mg 15.480,00
Total 26.018,00
2.390 Rukmini NENGGALO 182756 Omeprazol kapsul 20 mg
01/03/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 25.860,00
2.391 Danar Agustian Raamd PT AGRO MME 141048 Cefixime syrup 100mg/5 M
01/03/2021 00:00:00 23.823,00 BPJS
Paracetamol tablet 500 m 2.000,00
Prednison tab 5 mg 2.390,00
Salbutamol 2 mg 790,00
Total 29.003,00
2.392 Dwi Purwanti PADANG GADING 182662 Antasida Syrup 60 ml
01/03/2021 00:00:00 2.736,00 BPJS
Metoclorapamide tab 10 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 30.106,00
2.393 Saidi BUKIT MAKMUR 181741 Atorvastatin 20 mg @30 T
01/03/2021 00:00:00 31.350,00 BPJS
Candesartan tab 8 mg 20.430,00
Donepezil MK Tablet 67.230,00
Piracetam tab 800 mg 22.590,00
Total 141.600,00
2.394 Ali Nurman IPUH 182632 Omeprazol kapsul 20 mg
01/03/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 46.750,00
Vitamin B Komplek @100 1.540,00
Total 74.150,00
2.395 Lusi TERUNTUNG 182757 Asam Mefenamat 500 m
01/03/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.396 Ayu Laras Saputri LUBUK SANAI 182679 Betahistin Mesilat 6 mg @
01/03/2021 00:00:00 4.140,00 BPJS
Flunarizine 5 mg tab 74.250,00
Piracetam tablet 1200 m 41.880,00
Total 120.270,00
2.397 Ira Afrianti RANAH KARYA 125559 Amoxicillin 500 mg @ 10
01/03/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Pehacain Injeksi 3.320,00
Total 7.670,00
2.398 Tuhanan MANJUNTO JAYA 182760 Cefixime Kapsul 100 mg
01/03/2021 00:00:00 9.380,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 11.380,00
2.399 Traniyanti MANJUTO JAYA 179912 Orasic Kap
01/03/2021 00:00:00 36.580,00 BPJS
Renax @50 Kapsul 113.440,00
Urinter Kapsul @100 cap 21.980,00
Total 172.000,00
2.400 Hajidawati TANJUNG BERINGIN 137315 Amlodipine 5 mg @30 T
01/03/2021 00:00:00 3.030,00 BPJS
Diazepam Tab 5 Mg 4.080,00
Natrium diclofenac 50 m 8.670,00
Total 15.780,00
2.401 Arzan UJUNG PADANG 128346 Alprazolam 0,5 mg @100
01/03/2021 00:00:00 3.540,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Methylprednisolone tab 4 2.630,00

19/08/2021 12:42:30 Page 570 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.401 Arzan UJUNG PADANG 128346 Omeprazol kapsul 20 mg
01/03/2021 00:00:00 6.610,00 BPJS
Total 22.160,00
2.402 Tarsono SINAR JAYA 115102 abbocath 18 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Aminophyllin Inj 7.768,00
Combivent 37.536,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 3.580,00
Sucralfate Suspensi 100 m 19.250,00
Symbicort Turbuhaler 80 167.855,00
Vitamin B Komplek @100 154,00
Total 298.259,00
2.403 Ginah MEKAR SARI 182539 Amlodipine 10 mg @50 T
01/03/2021 00:00:00 3.540,00 BPJS
Candesartan tab 8 mg 20.430,00
Ibuprofen tab 200 mg 3.980,00
Mecobalamin 500 mg 23.100,00
Total 51.050,00
2.404 Nurgianto TALANG GADING 182761 Amlodipine 10 mg @50 T
01/03/2021 00:00:00 3.540,00 BPJS
Mecobalamin 500 mg 15.400,00
Metformin tablet 500 mg 2.660,00
Metoclorapamide tab 10 m 3.020,00
Omeprazol kapsul 20 mg 13.220,00
Total 37.840,00
2.405 Imas Yulianti AIR HITAM 182739 abbocath 18 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Misoprostol Tab 44.000,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 102.130,00
2.406 Salmaini RESNO 114055 Ketorolac inj 30 mg/1ml
01/03/2021 00:00:00 4.035,00 BPJS
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Azitromycin 500 mg
02/03/2021 00:00:00 5.625,00
Mecobalamin 500 mg 770,00
Meloxicam 7,5 mg 728,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Urinter Kapsul @100 cap 4.396,00
Total 68.794,00
2.407 Ahmad Dewanta MEKAR MULYA 165909 Transfusi Set Terumo
01/03/2021 00:00:00 16.500,00 BPJS
Asam Folat 1 mg @100 T
02/03/2021 00:00:00 990,00
NACL 0,9 % 500 ml 17.100,00
Vitamin B Komplek @100 1.540,00
Total 36.130,00
2.408 Imas Yulianti AIR HITAM 182739 Dexametason Injeksi
01/03/2021 00:00:00 6.256,00 BPJS
Fresofol ( propopol ) inj 13.448,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00

19/08/2021 12:42:30 Page 571 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.408 Imas Yulianti AIR HITAM 182739 Masker Karet Boism
01/03/2021 00:00:00 47.580,00 BPJS
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00
Cefixime Kapsul 100 mg 9.380,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Misoprostol Tab 55.000,00
Spinocain 27 (BBraund) 47.875,00
Total 691.300,00
2.409 Trisnawati TALANG ARAH 182764 abbocath 18 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Infusion Makro (terumo) 27.225,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 10 Mg/1 5.959,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 172.906,00
2.410 Zaunatul Aini LUBUK PINANG 153422 Dexametason Injeksi
01/03/2021 00:00:00 12.512,00 BPJS
Dipenhydramin Injeksi 10 6.140,00
Furosemide Injeksi @2ml 6.664,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 19.076,00
Abbocath 20 Terumo @5
02/03/2021 00:00:00 79.023,00
Abbocath 22 Terumo @5 22.276,00
Asam Folat 1 mg @100 T 99,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Alprazolam 0,5 mg @100
03/03/2021 00:00:00 236,00
Asam Folat 1 mg @100 T 990,00
Total 233.036,00
2.411 Veti Indriyani SILAUT 182758 Bisturi No. 23
01/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00

19/08/2021 12:42:30 Page 572 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.411 Veti Indriyani SILAUT 182758 Chromic catgut 1 R (Tri
01/03/2021 00:00:00 157.750,00 BPJS
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet Boism 47.580,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 10.088,00
viamac 1 R 364.370,00
Bisturi No. 15
02/03/2021 00:00:00 3.836,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
03/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
04/03/2021 00:00:00 1.290,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00

19/08/2021 12:42:30 Page 573 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.411 Veti Indriyani SILAUT 182758 Metrodinazole tab 500 m
04/03/2021 00:00:00 2.700,00 BPJS
Postofix (leukomed) 36.726,00
Urine bag 9.314,00
Total 1.789.378,00
2.412 Trisnawati TALANG ARAH 182764 Kassa kotak stril DRC
02/03/2021 00:00:00 9.675,00 BPJS
Metrodinazole tab 500 m 2.700,00
Paracetamol tablet 500 m 2.000,00
Total 14.375,00
2.413 Suyati RAWA BANGUN 147952 Abbocath 20 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Urine bag 10.088,00
Total 126.869,00
2.414 Ny. Trisnawati TALANG ARAH 182765 umbilical Cord Clamp
01/03/2021 00:00:00 2.261,00 BPJS
Total 2.261,00
2.415 Sakinem SUMBER MULYA 182762 Abbocath 20 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Methylprednisolone Inje 34.923,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Tambah Darah Neo Tab 465,00
Asam Folat 1 mg @100 T
02/03/2021 00:00:00 99,00
Dexametason Injeksi 12.512,00
Dipenhydramin Injeksi 10 6.140,00
Furosemide Injeksi @2ml 6.664,00
Hypafix 10cm x 5cm (25 c 9.700,00
Methylprednisolone Inje 34.923,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 19.076,00
Asam Folat 1 mg @100 T
03/03/2021 00:00:00 99,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Methylprednisolone tab 4 263,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Asam Folat 1 mg @100 T
04/03/2021 00:00:00 297,00
Asam Folat 1 mg @100 T 990,00
Asam Folat 1 mg @100 T 198,00
Ceftriaxone Inj 12.498,00
Guaifenesin 100 mg 504,00
Infusion Makro (terumo) 27.225,00
Methylprednisolone Inje 34.923,00

19/08/2021 12:42:30 Page 574 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.415 Sakinem SUMBER MULYA 182762 Methylprednisolone tab 4
04/03/2021 00:00:00 2.630,00 BPJS
Miniaspi 80 Mg @100 Ta 125,00
Neurodex tablet 1.482,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 4.650,00
Tambah Darah Neo Tab 930,00
Total 426.573,00
2.416 Tarsono SINAR JAYA 115102 Nebulizer O2 Dewasa
01/03/2021 00:00:00 34.783,00 BPJS
Aminophyllin Inj
02/03/2021 00:00:00 15.536,00
Combivent 37.536,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Symbicort Turbuhaler 16 186.575,00
vestein 300 mg 46.750,00
Vitamin B Komplek @100 770,00
Aminophyllin Inj
03/03/2021 00:00:00 23.304,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Azitromycin 500 mg
04/03/2021 00:00:00 11.250,00
Combivent 37.536,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Aminophyline 200 mg @1
05/03/2021 00:00:00 4.000,00
Azitromycin 500 mg 56.250,00
Omeprazol kapsul 20 mg 6.610,00
Salbutamol 4 mg 1.860,00
Sucralfate Suspensi 100 m 19.250,00
Vectrine Tab 300 mg 50.000,00
Total 707.437,00
2.417 Ny.rini Nova Riani RANAH KARYA 182770 Abbocath 24 Terumo @5
01/03/2021 00:00:00 105.364,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Bisturi No. 23 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Chloramphenicol Salep M 2.351,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding tube) Fr. 5 35.206,00

19/08/2021 12:42:30 Page 575 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.417 Ny.rini Nova Riani RANAH KARYA 182770 Phytomenadione 2 Mg/1M
01/03/2021 00:00:00 4.834,00 BPJS
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
04/03/2021 00:00:00 59.009,00
Calcii Glukonas Inj 100 m 12.939,00
Gentamicin Injeksi 4.606,00
NGT (Feeding Tube) Fr. 8 70.420,00
Abbocath 24 Terumo @5
05/03/2021 00:00:00 105.364,00
Bactesyn inj 0,75 gr 59.009,00
Gentamycin 0.1 % salep k 2.983,00
Hypafix 15cmx5cm (25 c 6.544,00
Phytomenadione 10 Mg/1
12/03/2021 00:00:00 5.959,00
Total 602.894,00
2.418 Suyati RAWA BANGUN 147952 Cetadop inj
01/03/2021 00:00:00 7.700,00 BPJS
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
Nassal Mask O2 Dewasa 41.828,00
Ringer Laktat Otsuka 9.538,00
Three Way stopcock 25.904,00
Total 146.973,00
2.419 Aptiawan Jaya Pratam AIR KASSAI 161225 Abbocath 20 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ka-En 1 B 12.658,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Total 102.565,00
2.420 Mustadarudin LUBUK SANAI 109455 Abbocath 20 Terumo @5
01/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Dipenhydramin Injeksi 10 1.535,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Betahistin Mesilat 6 mg @
02/03/2021 00:00:00 276,00
Diazepam Tab 5 Mg 136,00
Flunarizine 5 mg tab 2.475,00
Methylprednisolone tab 4 526,00
Perifas @100 Tab 1.925,00
Ranitidin inj 1.790,00
Total 81.842,00
2.421 Aptiawan Jaya Pratam AIR KASSAI 161225 Ka-En 1 B
02/03/2021 00:00:00 12.658,00 BPJS
Ka-En 1 B 25.316,00
Omeprazole Inj 12.499,00
Omeprazole Inj 24.998,00
Omeprazole Inj 12.499,00
Piralen Injeksi 2 ml 17.600,00
Ranitidin inj 3.580,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 576 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.421 Aptiawan Jaya Pratam AIR KASSAI 161225 Metoclopramide inj 5Mg/M
03/03/2021 00:00:00 5.879,00 BPJS
Suprafenid Supositoria 10 14.025,00
Omeprazol kapsul 20 mg
04/03/2021 00:00:00 6.610,00
Total 174.164,00
2.422 Anis Purwanti KOTA PRAJA 125509 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 67.456,00
2.423 Mustadarudin LUBUK SANAI 109455 Betahistin Mesilat 6 mg @
02/03/2021 00:00:00 276,00 BPJS
Betahistin Mesilat 6 mg @ 414,00
Diazepam Tab 5 Mg 136,00
Flunarizine 5 mg tab 2.475,00
Flunarizine 5 mg tab 4.950,00
Methylprednisolone Inje 0,00
Methylprednisolone tab 4 526,00
Methylprednisolone tab 4 1.578,00
Methylprednisolone tab 4 1.052,00
NonWoven Fixation 15x 13.388,00
Perifas @100 Tab 1.925,00
Ranitidin inj 1.790,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Asam Mefenamat 500 m
03/03/2021 00:00:00 1.290,00
Betahistin Mesilat 6 mg @ 1.380,00
Diazepam Tab 5 Mg 680,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 72.664,00
2.424 Lilis Suryanti LALANG LUAS 124782 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Hystolan Tab 20 mg 16.707,00
PARAMOL INFUS 192.500,00
Ringer Laktat Otsuka 9.538,00
abbocath 18 Terumo @5 52.682,00
Atropin injek 1 ml 13.938,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 15.640,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 14.563,00
handscoond steril 6.5 (G 58.216,00
handscoond steril 8 (Gam 29.108,00
Ketorolac inj 30 mg/1ml 2.690,00
Lidocain injk 40 mg/2 ml 3.222,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00

19/08/2021 12:42:30 Page 577 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.424 Lilis Suryanti LALANG LUAS 124782 Myotonic inj
02/03/2021 00:00:00 19.596,00 BPJS
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 36.093,00
Spuit 10 cc Disposible (T 9.690,00
Tonotan tab 13.719,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 10.088,00
Cefotaxime Injeksi
03/03/2021 00:00:00 11.502,00
Dexametason Injeksi 12.512,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 8.550,00
Tranexamic Acid Inj (Asa 6.315,00
Dexametason Injeksi
05/03/2021 00:00:00 6.256,00
NACL 0,9 % 500 ml 17.100,00
Asam Mefenamat 500 m
06/03/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Misoprostol Tab 55.000,00
Total 888.106,00
2.425 Anis Purwanti KOTA PRAJA 125509 Cefotaxime Injeksi
02/03/2021 00:00:00 11.502,00 BPJS
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Ketorolac inj 30 mg/1ml 2.690,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Suprafenid Supositoria 10 28.050,00
Asam Mefenamat 500 m
03/03/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Misoprostol Tab 55.000,00
Spinocain 27 (BBraund) 47.875,00
Total 269.402,00
2.426 Ridani SINDANG 182773 Ketoprofen tab 100 mg
02/03/2021 00:00:00 24.760,00 BPJS
Natrium diclofenac 50 m 2.890,00
Paracetamol tablet 500 m 4.000,00
Total 31.650,00
2.427 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
02/03/2021 00:00:00 42.750,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 160.225,00
2.428 Salami SILAUT I 134774 NACL 0,9 % 500 ml
02/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.429 Yunita PONDOK BARU 149270 Propylthiourasil 100 mg (
02/03/2021 00:00:00 19.590,00 BPJS
Total 19.590,00

19/08/2021 12:42:30 Page 578 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.430 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
02/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.431 Sukoyo LUNANG BARAT 162774 Domperidone Syrup 5mg
02/03/2021 00:00:00 10.279,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Total 23.919,00
2.432 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
02/03/2021 00:00:00 42.750,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 160.225,00
2.433 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
02/03/2021 00:00:00 34.200,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 151.675,00
2.434 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
02/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.435 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
02/03/2021 00:00:00 34.200,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 151.675,00
2.436 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
02/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.437 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
02/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.438 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
02/03/2021 00:00:00 42.750,00 BPJS
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 160.225,00
2.439 Eri Yadi KOTO JAYA 110699 Bisoprolol 5 mg @100 Ta
02/03/2021 00:00:00 8.880,00 BPJS
Candesartan tab 8 mg 20.430,00
Clopidogrel 75 mg @30 T 52.650,00
Simvastatin tab 10 mg 7.230,00
Total 89.190,00
2.440 Edi Yanto BANDAR RATU 109770 Allopurinol 100 mg @100
02/03/2021 00:00:00 2.340,00 BPJS
Atorvastatin 20 mg @30 T 31.350,00
Citicoline kaplet 500 mg 16.500,00
Pregabalin Kap 75 mg 193.380,00
Total 243.570,00
2.441 Ike Apricelia KOTO JAYA 157240 Asam Mefenamat 500 m
02/03/2021 00:00:00 129,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 59.960,00
2.442 Robais KARANG TINGGI 180581 Gabapentin kapsul 300 m
02/03/2021 00:00:00 25.380,00 BPJS
Kalxetin 10 mg @30 Kap 110.000,00
Mecobalamin 500 mg 15.400,00
Natrium diclofenac 50 m 5.780,00
Omeprazol kapsul 20 mg 13.220,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 169.780,00
2.443 Sasnani Bentara TALANG MEDAN 135659 Asam Mefenamat 500 m
02/03/2021 00:00:00 1.935,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 61.766,00
2.444 Fitriani PASAR SEBELAH 113952 Alinamin F 50 mg @100 T
02/03/2021 00:00:00 11.500,00 BPJS
Paracetamol tablet 500 m 2.000,00
Urinter Kapsul @100 cap 21.980,00
Total 35.480,00
2.445 Abu Razal LUBUK SANAI 160382 Alinamin F Injeksi 10 ml
02/03/2021 00:00:00 180.000,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Sistenol kaplet 17.540,00
ursodeoxycholic acid 85.050,00
Total 296.230,00
2.446 Sri Mulyani SUNGAI LINTANG 122749 Loratadine tab 10 mg
02/03/2021 00:00:00 1.660,00 BPJS
Metformin tablet 500 mg 7.980,00
Pregabalin Kap 75 mg 64.460,00
Total 74.100,00
2.447 Dahalimun LUBUK CABAU 155405 Allopurinol 100 mg @100
02/03/2021 00:00:00 2.340,00 BPJS
Alprazolam 0,5 mg @100 1.180,00
Citicoline kaplet 500 mg 16.500,00
Levofloxacin Tablet 500 m 13.640,00
Natrium diclofenac 50 m 2.890,00
Paracetamol tablet 500 m 3.000,00
Total 39.550,00
2.448 Cica Elia PULAU BARU 182780 Cefixime Kapsul 100 mg
02/03/2021 00:00:00 9.380,00 BPJS
Misoprostol Tab 82.500,00
Total 91.880,00
2.449 Semi SELAGAN JAYA 101470 Omeprazol kapsul 20 mg
02/03/2021 00:00:00 13.220,00 BPJS
Paracetamol tablet 500 m 3.000,00
Ranitidine tablet 150 mg 2.880,00
Vitamin B Komplek @100 1.540,00
Total 20.640,00
2.450 Renoti BATU EJUNG 182645 Cuticell Classic 10cmx10c
02/03/2021 00:00:00 35.121,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
NonWoven Fixation 15x 6.694,00
Total 55.455,00
2.451 Abu Salim LUBUK SANAI 182781 Alinamin F 50 mg @100 T
02/03/2021 00:00:00 11.500,00 BPJS
Amlodipine 10 mg @50 T 1.180,00
Candesartan tab 8 mg 6.810,00
Domperidone Syrup 5mg 10.279,00
Levofloxacin Tablet 500 m 13.640,00
Total 43.409,00
2.452 Teki Widiarsih LUBUK MUKTI 146222 Cetirizine 10 mg
02/03/2021 00:00:00 2.520,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 5.150,00
2.453 Kernauli Girsang TALANG PETAI 088993 Bisoprolol 5 mg @100 Ta
02/03/2021 00:00:00 2.960,00 BPJS
Flunarizine 5 mg tab 24.750,00
Isosorbid dinitrat 5 mg (I 1.110,00
Total 28.820,00

19/08/2021 12:42:30 Page 580 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.454 Hartuti DESA TALANG SEPAKA 142782 Ambroxol Syr 15mg/ml
02/03/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Flunarizine 5 mg tab 24.750,00
Paracetamol tablet 500 m 3.000,00
Total 60.413,00
2.455 Popi Pitrianti TALANG BARU 182782 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 77.783,00
2.456 Egi Habag Tangi SUNGAI IPUH 149659 Atorvastatin 20 mg @30 T
02/03/2021 00:00:00 31.350,00 BPJS
Captopril 12,5 mg 2.400,00
Total 33.750,00
2.457 Ni Nyoman Rasati PONDOK BATU 119151 Domperidone Syrup 5mg
02/03/2021 00:00:00 10.279,00 BPJS
Epsonal 50 mg @100 tab 38.030,00
Paracetamol tablet 500 m 2.000,00
Total 50.309,00
2.458 Zhelgiyana KARANG JAYA 143181 Amoxicillin Syr
02/03/2021 00:00:00 6.531,00 BPJS
Paracetamol syrup 1.388,00
Total 7.919,00
2.459 Pahala Parulian UJUNG PADANG 182053 Cuticell Classic 10cmx10c
02/03/2021 00:00:00 35.121,00 BPJS
Hypafix Kamar Operasi 18.000,00
Levofloxacin Tablet 500 m 13.640,00
Total 66.761,00
2.460 Aufa Syarif Ramadhan TIRTA MAKMUR 182483 Cuticell Classic 10cmx10c
02/03/2021 00:00:00 35.121,00 BPJS
Hypafix Kamar Operasi 18.000,00
Levofloxacin Tablet 500 m 13.640,00
Total 66.761,00
2.461 Hasmara TERAS TERUNJAM 109584 Cefixime Kapsul 100 mg
02/03/2021 00:00:00 9.380,00 BPJS
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 6.610,00
ursodeoxycholic acid 85.050,00
Total 125.790,00
2.462 Sukadi BUNGA TANJUNG 149552 Alinamin F 50 mg @100 T
02/03/2021 00:00:00 11.500,00 BPJS
Asam Traneksamat @10 31.575,00
Levofloxacin Tablet 500 m 13.640,00
Total 56.715,00
2.463 Wida BUNGA TANJUNG 176025 Amoxicillin 500 mg @ 10
02/03/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Methylprednisolone tab 4 2.630,00
Total 6.980,00
2.464 Kamal Huda TANAH REKAH 182740 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 68.399,00
2.465 Yespi Madena BUNGA TANJUNG 176027 Calcium Laktat
02/03/2021 00:00:00 790,00 BPJS

19/08/2021 12:42:30 Page 581 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 790,00
2.466 Desma Zalnita SILAUT 181848 Ethambutol 500 mg
02/03/2021 00:00:00 38.745,00 BPJS
Isoniazide 300 mg 6.480,00
Pyrazinamid 500 mg 36.270,00
Rifampicin 450 33.840,00
Total 115.335,00
2.467 Hotman Simatupang BUNGA TANJUNG 109409 Ketoprofen tab 100 mg
02/03/2021 00:00:00 24.760,00 BPJS
Methylprednisolone tab 4 5.260,00
Paracetamol tablet 500 m 4.000,00
Total 34.020,00
2.468 Yulia Hastuti BANDAR RATU 114122 Cetirizine 10 mg
02/03/2021 00:00:00 1.260,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 3.890,00
2.469 Bahrun J LUBUK CABAU 137378 Amlodipine 5 mg @30 T
02/03/2021 00:00:00 3.030,00 BPJS
Candesartan tab 8 mg 20.430,00
Flunarizine 5 mg tab 24.750,00
Mecobalamin 500 mg 23.100,00
Total 71.310,00
2.470 Karsinah KOTO JAYA 086793 Bisoprolol 5 mg @100 Ta
02/03/2021 00:00:00 8.880,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 89.390,00
2.471 Partiwi TERUNTUNG 177361 Alinamin F 50 mg @100 T
02/03/2021 00:00:00 11.500,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Gitas Plus 50.330,00
ursodeoxycholic acid 85.050,00
Total 156.260,00
2.472 Kamal Huda TANAH REKAH 182740 Amlodipine 10 mg @50 T
02/03/2021 00:00:00 118,00 BPJS
Betahistin Mesilat 6 mg @ 276,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 41.260,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 11.000,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00
Rofiden Supp 24.062,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 6.315,00
Amlodipine 10 mg @50 T
03/03/2021 00:00:00 118,00
Cefotaxime Injeksi 11.502,00

19/08/2021 12:42:30 Page 582 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.472 Kamal Huda TANAH REKAH 182740 Ephedrine Injeksi
03/03/2021 00:00:00 10.711,00 BPJS
Masker 3 Play N. 95 18.750,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Amlodipine 10 mg @50 T
04/03/2021 00:00:00 1.180,00
ATRACURIUM BESYLATE 2 14.671,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Ephedrine Injeksi 10.711,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 2.690,00
Levofloxacin Tablet 500 m 6.820,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 61.688,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Tramadol 50 mg/ml Inj 12.375,00
Total 1.141.661,00
2.473 Watri Aminita PAUH TERENJA 127302 Omeprazol kapsul 20 mg
02/03/2021 00:00:00 6.610,00 BPJS
Ondansetron tablet 8 mg 26.400,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 54.260,00
2.474 Solin RANAH KARYA 175604 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Cefoperazon Inj 41.250,00
Flunarizine 5 mg tab 2.475,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 1.345,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Simvastatin tab 10 mg 241,00
Transfusi Set Terumo 16.500,00
Captopril 12,5 mg 80,00
Natrium diclofenac 50 m 289,00
Betahistin Mesilat 6 mg @
03/03/2021 00:00:00 276,00
Captopril 12,5 mg 80,00

19/08/2021 12:42:30 Page 583 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.474 Solin RANAH KARYA 175604 Cefoperazon Inj
03/03/2021 00:00:00 41.250,00 BPJS
Cefoperazon Inj 82.500,00
Flunarizine 5 mg tab 2.475,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 10 mg 241,00
Captopril 12,5 mg
04/03/2021 00:00:00 80,00
Cefoperazon Inj 82.500,00
Flunarizine 5 mg tab 2.475,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 2.690,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 10 mg 241,00
Betahistin Mesilat 6 mg @
05/03/2021 00:00:00 2.070,00
Captopril 12,5 mg 800,00
Flunarizine 5 mg tab 24.750,00
Simvastatin tab 20 mg 3.110,00
Total 493.467,00
2.475 Sugiyono RAWA MULYA 182774 Abbocath 20 Terumo @5
02/03/2021 00:00:00 52.682,00 BPJS
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 11.000,00
Miloz Injeksi 5 mg 5.611,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 4.210,00

19/08/2021 12:42:30 Page 584 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.475 Sugiyono RAWA MULYA 182774 Transfusi Set Terumo
02/03/2021 00:00:00 16.500,00 BPJS
Levofloxacin Tablet 500 m
03/03/2021 00:00:00 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 728.734,00
2.476 Hilman Novriadi LUBUK SANAI 139914 Bisturi No. 23
02/03/2021 00:00:00 3.836,00 BPJS
Cefixime kapsul 200 mg 26.480,00
Celemek Plastik 11.825,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker 3 Play N. 95 187.500,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Total 720.809,00
2.477 Popi Pitrianti TALANG BARU 182782 Alkohol 1Liter
02/03/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 11.825,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 3.128,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix Kamar Operasi 18.000,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 187.500,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00

19/08/2021 12:42:30 Page 585 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.477 Popi Pitrianti TALANG BARU 182782 Misoprostol Tab
02/03/2021 00:00:00 16.500,00 BPJS
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
Cefotaxime Injeksi
03/03/2021 00:00:00 11.502,00
Ephedrine Injeksi 68.750,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 18.750,00
Metoclopramide inj 5Mg/M 17.637,00
Metrodinazole tab 500 m 810,00
Spinocain 25 (BBraund) 42.763,00
Spinocain 27 (BBraund) 47.875,00
Tranexamic Acid Inj (Asa 6.315,00
Ciprofloxacin tab 500 mg
05/03/2021 00:00:00 5.590,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 1.825.711,00
2.478 Heru Cahyono PENARIK 182785 Abbocath 20 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Ambroxol 30 mg @100 T 579,00
Azitromycin 500 mg 5.625,00
Metamizole Sodium Mono 4.594,00
Pamol Inf 1g Berno 82.000,00
Paracetamol tablet 500 m 200,00
Perifas @100 Tab 3.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 149.227,00
2.479 Sutarman ARGA JAYA 182795 Abbocath 22 Terumo @5
02/03/2021 00:00:00 11.138,00 BPJS
azitromicin inj 500 mg 144.376,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 586 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.479 Sutarman ARGA JAYA 182795 Vitamin B Komplek @100
02/03/2021 00:00:00 308,00 BPJS
Total 247.338,00
2.480 Ade Resmana PELOKAN 181223 Abbocath 20 Terumo @5
02/03/2021 00:00:00 52.682,00 BPJS
Alkohol 1Liter 42.111,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 11.825,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Ephedrine Injeksi 21.422,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix Kamar Operasi 18.000,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Lidocain injk 40 mg/2 ml 9.666,00
Masker 3 Play N. 95 187.500,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Transfusi Set Terumo 16.500,00
Cefixime Kapsul 100 mg
03/03/2021 00:00:00 9.380,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 922.159,00
2.481 Wagirah WONOSOBO 182508 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Misoprostol Tab 33.000,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 127.590,00
2.482 Oti Hani Miwarni MAJU MAKMUR 182788 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.482 Oti Hani Miwarni MAJU MAKMUR 182788 Celemek Plastik
02/03/2021 00:00:00 59.125,00 BPJS
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 41.260,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 37.500,00
Masker Karet 11.000,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 25.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 24.062,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc terumo 8.538,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 9.314,00
Total 1.448.907,00
2.483 Heru Cahyono PENARIK 182785 Ambroxol 30 mg @100 T
03/03/2021 00:00:00 579,00 BPJS
Azitromycin 500 mg 5.625,00
Cefoperazon Inj 82.500,00
Hypafix 15cmx5cm (25 c 13.088,00
Metamizole Sodium Mono 13.782,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Perifas @100 Tab 3.850,00
Ambroxol 30 mg @100 T
04/03/2021 00:00:00 1.930,00
Paracetamol tablet 500 m 2.000,00
Perifas @100 Tab 19.250,00
Total 160.304,00
2.484 Sutarman ARGA JAYA 182795 Nassal Cannula O2 Anak
02/03/2021 00:00:00 16.473,00 BPJS
Azitromycin 500 mg
03/03/2021 00:00:00 16.875,00
Ceftriaxone Inj 12.498,00
Clindamycin 300 mg Tabl 17.500,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 588 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.484 Sutarman ARGA JAYA 182795 Sucralfate Suspensi 100 m
03/03/2021 00:00:00 19.250,00 BPJS
vestein 300 mg 46.750,00
Meropenem Inj 0.5 g
04/03/2021 00:00:00 165.000,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 17.100,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 37.497,00
Ondansetron Inj 4.950,00
Tramadol 50 mg/ml Inj 12.375,00
Meropenem Inj 0.5 g
05/03/2021 00:00:00 165.000,00
Metrodinazole Infus 30.939,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
azitromicin inj 500 mg
06/03/2021 00:00:00 144.376,00
Cefixime kapsul 200 mg 26.480,00
Cefixime kapsul 200 mg 26.480,00
Clindamycin 300 mg Tabl 17.500,00
Clindamycin 300 mg Tabl 17.500,00
Clindamycin 300 mg Tabl 17.500,00
Curcuma Tab 8.890,00
Erdosteine Syr 36.575,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Vectrein Syrup 45.000,00
vestein 300 mg 46.750,00
Total 1.176.395,00
2.485 Wagirah WONOSOBO 182508 Asam Mefenamat 500 m
03/03/2021 00:00:00 1.290,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 4.255,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 5.500,00
Metrodinazole tab 500 m 2.700,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Misoprostol Tab 55.000,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00

19/08/2021 12:42:30 Page 589 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 441.043,00
2.486 Oti Hani Miwarni MAJU MAKMUR 182788 Cefotaxime Injeksi
02/03/2021 00:00:00 11.502,00 BPJS
Ephedrine Injeksi 21.422,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ondansetron Inj 3.300,00
Ranitidin inj 3.580,00
Spinocain 26 (Bbraund) 43.038,00
Spinocain 27 (BBraund) 47.875,00
Tranexamic Acid Inj (Asa 6.315,00
abbocath 18 Terumo @5
03/03/2021 00:00:00 52.682,00
Abbocath 20 Terumo @5 52.682,00
Alkohol 1Liter 42.111,00
Cefotaxime Injeksi 11.502,00
Iodine Povidone 1 L 183.288,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 18.750,00
Metrodinazole tab 500 m 810,00
Spinocain 25 (BBraund) 42.763,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 23
04/03/2021 00:00:00 3.836,00
Oxytetracycline Salep Ma 3.251,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Ciprofloxacin tab 500 mg
05/03/2021 00:00:00 5.590,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Total 735.938,00
2.487 Roslaini TRAMANG JAYA 182797 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Aminofusin Pediatrik 250 m 70.980,00
Catheter 2 Way No. 16 ( 20.625,00
Cefoperazon Inj 41.250,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Urine bag 9.314,00
Azitromycin 500 mg 0,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Sucralfate Suspensi 100 m 0,00
Tambah Darah Neo Tab 1.395,00
Dexametason Injeksi
03/03/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00

19/08/2021 12:42:30 Page 590 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.487 Roslaini TRAMANG JAYA 182797 Octalbin 25% 50 cc (Huma
03/03/2021 00:00:00 956.250,00 BPJS
Three Way stopcock 25.904,00
Aminofluid Infus 500 ml
04/03/2021 00:00:00 155.204,00
Azitromycin 500 mg 0,00
Cefoperazon Inj 0,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 14.369,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
NGT (Stomach Tube) Fr. 1 0,00
Octalbin 25% 100 cc (Hu 1.887.500,00
Omeprazole Inj 12.499,00
Abbocath 22 Terumo @5
05/03/2021 00:00:00 22.276,00
Aminofluid Infus 500 ml 0,00
Catheter 2 Way No. 16 ( 20.625,00
Cetadop inj 7.700,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dopamin Giulini 200 mg I 97.625,00
Electroda (Ambu) @25 Pc 81.570,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Mikro (Gea) 7.861,00
meropenem Injeksi 1 g 123.750,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 0,00
Nucral Syrup 100 ml 53.350,00
Octalbin 25% 50 cc (Huma 956.250,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Suction Chateter no. 12 ( 10.588,00
Three Way stopcock 25.904,00
Total 5.134.479,00
2.488 Ny.popi Pitrianti TALANG BARU 182799 Bisturi No. 23
03/03/2021 00:00:00 3.836,00 BPJS
Chloramphenicol Salep M 2.351,00
umbilical Cord Clamp 2.261,00
Total 8.448,00
2.489 Siti Eriah BANDAR JAYA 182800 abbocath 18 Terumo @5
02/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 6.256,00
Nassal Cannula O2 Dewas 11.625,00
Otsu MgSO4 40 % 4.745,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 591 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 80.756,00
2.490 Aqsan Wahyudi BANDA RATU 169133 Ostarin Syr
02/03/2021 00:00:00 16.638,00 BPJS
Tensocrepe 15 x 4.5 cm ( 71.000,00
Vitamin C 500 mg 3,00
Total 87.641,00
2.491 Siti Eriah BANDAR JAYA 182800 Cefotaxime Injeksi
03/03/2021 00:00:00 11.502,00 BPJS
Ringer Laktat Otsuka 19.076,00
Tambah Darah Neo Tab 1.395,00
Bunascan Spinal 0.5
04/03/2021 00:00:00 63.525,00
catgut chromic 1 R (SMI) 109.842,00
Catgut Chromic 2/0 Roll ( 188.100,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 12.512,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon Steril 8.5 (Ga 43.662,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 6.5 24.732,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 37.500,00
Masker Karet 11.000,00
Metrodinazole tab 500 m 540,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 17.100,00
Polyglycolide T-Vio 3-0 C ( 92.400,00
Protocin Inj 37.620,00
Protofen Supositoria 60,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 16.990,00
Tramus Injeksi 1 % 5 ml 0,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
viamac 1 R 364.370,00
abbocath 18 Terumo @5
05/03/2021 00:00:00 79.023,00
Abbocath 20 Terumo @5 79.023,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
06/03/2021 00:00:00 11.502,00

19/08/2021 12:42:30 Page 592 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.491 Siti Eriah BANDAR JAYA 182800 Ketorolac inj 30 mg/1ml
06/03/2021 00:00:00 4.035,00 BPJS
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
07/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.837.203,00
2.492 Susanti PONDOK KANDANG 182642 abbocath 18 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Ketorolac inj 30 mg/1ml 4.035,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Suprafenid Supositoria 10 28.050,00
Asam Mefenamat 500 m
04/03/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Fentanyl Injeksi 5 Ampul 2 104.000,00
Misoprostol Tab 55.000,00
Total 341.427,00
2.493 Julita TANJUNG HARAPAN 182557 Abbocath 20 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Cefoperazon Inj 41.250,00
Electroda (Ambu) @25 Pc 81.570,00
Glukosa Infus 10 % 9.375,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 52.250,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Ringer Laktat Otsuka 9.538,00
Urine bag 9.314,00
abbocath 18 Terumo @5
04/03/2021 00:00:00 52.682,00
Abbocath 20 Terumo @5 52.682,00
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 297,00
Ceftazidime Injeksi 1 mg 15.975,00
Ciprofloxacin infus 2% 26.328,00
Esomeprazol Injeksi 40 m 34.956,00

19/08/2021 12:42:30 Page 593 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.493 Julita TANJUNG HARAPAN 182557 Methylprednisolone Inje
04/03/2021 00:00:00 34.923,00 BPJS
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Antrain Injeksi
03/03/2021 00:00:00 28.875,00
Asam Folat 1 mg @100 T 297,00
Bisoprolol 5 mg @100 Ta 296,00
Cefoperazon Inj 82.500,00
Cetadop inj 15.400,00
Cetadop inj 7.700,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 123.750,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
Ngt (Feeding Tube) Fr.16 10.588,00
Omeprazole Inj 24.998,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
Three Way stopcock 25.904,00
Catheter 2 Way No. 16 (
04/03/2021 00:00:00 20.625,00
Omeprazole Inj 24.998,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Total 1.130.813,00
2.494 Nuraya BUNGA TANJUNG 113240 Alprazolam 0,5 mg @100
03/03/2021 00:00:00 590,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Cefixime Kapsul 100 mg 9.380,00
Metformin tablet 500 mg 1.995,00
Total 14.925,00
2.495 Sukaji RAWA MULYA 135229 Erphafillin Tab
03/03/2021 00:00:00 7.380,00 BPJS
Natrium diclofenac 50 m 2.890,00
Salbutamol 4 mg 1.860,00
Symbicort Turbuhaler 16 186.575,00
Total 198.705,00
2.496 Siti Nita TALANG PETAI 182626 Asam Mefenamat 500 m
03/03/2021 00:00:00 1.290,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 51.446,00
2.497 Eni Putri Wati TANAH REKAH 155815 Azitromycin 500 mg
03/03/2021 00:00:00 28.125,00 BPJS
Flunarizine 5 mg tab 24.750,00
Loratadine tab 10 mg 1.660,00
Sucralfate Suspensi 100 m 19.250,00
Total 73.785,00
2.498 Tukimun LUBUK MUKTI 179908 Omeprazol kapsul 20 mg
03/03/2021 00:00:00 3.305,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 22.555,00

19/08/2021 12:42:30 Page 594 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.499 Kardi SUNGAI RUMBAI 182540 Levofloxacin Tablet 500 m
03/03/2021 00:00:00 13.640,00 BPJS
Total 13.640,00
2.500 Ringga Nina Silvana Sa LUBUK MUKTI 178202 Alinamin F 50 mg @100 T
03/03/2021 00:00:00 11.500,00 BPJS
Domperidone Syrup 5mg 10.279,00
Paracetamol tablet 500 m 2.000,00
Total 23.779,00
2.501 Rosmi Yeni LUBUK MUKTI 182463 Alprazolam 0,5 mg @100
03/03/2021 00:00:00 590,00 BPJS
Azitromycin 500 mg 28.125,00
Bisoprolol 5 mg @100 Ta 4.440,00
Sistenol kaplet 17.540,00
Symbicort Turbuhaler 16 186.575,00
Total 237.270,00
2.502 Mardiana PENARIK 167606 Asam Folat 1 mg @100 T
03/03/2021 00:00:00 1.980,00 BPJS
Bisoprolol 5 mg @100 Ta 5.920,00
Total 7.900,00
2.503 Denis Tania.r. DSN. BARU AIR KASAI 118855 Pregabalin Kap 75 mg
03/03/2021 00:00:00 128.920,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 150.900,00
2.504 Rasiman AIR BERAU 167855 Cuticell Classic 10cmx10c
03/03/2021 00:00:00 35.121,00 BPJS
Hypafix Kamar Operasi 18.000,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 68.761,00
2.505 Norlian SUNGAI IPUH 138398 Azitromycin 500 mg
03/03/2021 00:00:00 28.125,00 BPJS
Codein tab 10 mg 7.500,00
Paracetamol tablet 500 m 2.000,00
Total 37.625,00
2.506 Daniel Bonfrid Sianturi BUMI MULYA 182346 NACL 0,9 % 500 ml
03/03/2021 00:00:00 17.100,00 BPJS
Total 17.100,00
2.507 Syamsul SILAUT 182197 Alinamin F 50 mg @100 T
03/03/2021 00:00:00 11.500,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
ursodeoxycholic acid 85.050,00
Total 103.160,00
2.508 Amran SUNGAI LINTANG 182811 Abbocath 20 Terumo @5
03/03/2021 00:00:00 52.682,00 BPJS
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 78.720,00
2.509 Ahmad Dani Kurniaw LUNANG 163501 Asam Folat 1 mg @100 T
03/03/2021 00:00:00 2.970,00 BPJS
Carbamazepine Tablet 20 9.270,00
Valproic Acid Syrup 250mg 104.875,00
Total 117.115,00
2.510 Evi Sp BUKIT MULYA 122316 Asam Traneksamat @10
03/03/2021 00:00:00 21.050,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Meprolut Tab 50.160,00
Total 80.590,00
2.511 Isna Juwita TALANG BARU 166905 Cuticell Classic 10cmx10c
03/03/2021 00:00:00 35.121,00 BPJS
Hypafix Kamar Operasi 18.000,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 69.761,00
2.512 Nurseha PASAR BELAKANG 132717 Amlodipine 10 mg @50 T
03/03/2021 00:00:00 1.770,00 BPJS
Azitromycin 500 mg 28.125,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.512 Nurseha PASAR BELAKANG 132717 Codein tab 10 mg
03/03/2021 00:00:00 7.500,00 BPJS
Furosemide 40 mg Tablet 2.880,00
Miniaspi 80 Mg @100 Ta 3.750,00
Paracetamol tablet 500 m 2.000,00
Spironolaktone 25 mg 7.800,00
Total 53.825,00
2.513 Arna Julita TUNGGANG 182430 Alinamin F 50 mg @100 T
03/03/2021 00:00:00 11.500,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Paracetamol tablet 500 m 2.000,00
ursodeoxycholic acid 85.050,00
Total 107.930,00
2.514 Lendo SILAUT 174339 Mecobalamin 500 mg
03/03/2021 00:00:00 23.100,00 BPJS
Metformin tablet 500 mg 3.990,00
Pregabalin Kap 75 mg 193.380,00
Total 220.470,00
2.515 Bahman SIBAK 155872 NACL 0,9 % 500 ml
03/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.516 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
03/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.517 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
03/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.518 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
03/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.519 Irwan Sakti DANAU NIBUNG 154908 Amlodipine 10 mg @50 T
03/03/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Otsu D40 25.026,00
Renogen 3000 UI 116.875,00
Total 176.455,00
2.520 Mutmainnah SUNGAI RENGAS 114676 Metoclopramide inj 5Mg/M
03/03/2021 00:00:00 17.637,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Ondansetron Inj 4.950,00
Otsu D40 37.539,00
Ranitidin inj 5.370,00
Renogen 3000 UI 116.875,00
Total 216.571,00
2.521 Santi PAUH TERENJA 149343 Ambroxol Syr 15mg/ml
03/03/2021 00:00:00 4.538,00 BPJS
Asam Folat 1 mg @100 T 990,00
Levofloxacin Tablet 500 m 6.820,00
Paracetamol tablet 500 m 2.000,00
Total 14.348,00
2.522 Lailatul Kadar TANAH REKAH 158354 Amlodipine 10 mg @50 T
03/03/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 161.563,00
2.523 Kasmidi Kasim BANDAR RATU 135355 Amlodipine 10 mg @50 T
03/03/2021 00:00:00 354,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.523 Kasmidi Kasim BANDAR RATU 135355 Asam Folat 1 mg @100 T
03/03/2021 00:00:00 297,00 BPJS
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 161.563,00
2.524 Bima Aryandika BANDARATU 178714 Amlodipine 10 mg @50 T
03/03/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 161.563,00
2.525 Bulan Humaira Hakiki SIDO MAKMUR 150807 Diazepam Tab 5 Mg
03/03/2021 00:00:00 1.360,00 BPJS
Stesolid Supp 10 mg 23.991,00
Total 25.351,00
2.526 Jumarno LUNANG 180796 Amlodipine 10 mg @50 T
03/03/2021 00:00:00 354,00 BPJS
Asam Folat 1 mg @100 T 297,00
Clonidine 0.15 mg @100 T 687,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 161.563,00
2.527 Sukamad AIR KASAI 143420 Miniaspi 80 Mg @100 Ta
03/03/2021 00:00:00 3.750,00 BPJS
Ngt (Feeding Tube) Fr.16 10.588,00
Paracetamol tablet 500 m 2.000,00
Total 16.338,00
2.528 Sutarti RAWA BANGUN 182816 Eperisone Hcl 50 mg @1
03/03/2021 00:00:00 23.280,00 BPJS
Glucosamine 250 mg 7.700,00
Pregabalin Kap 75 mg 64.460,00
Total 95.440,00
2.529 Westini PT. AGRO SEI JERING 142482 Lodomer Tab (Haloperi
03/03/2021 00:00:00 43.140,00 BPJS
Valproic Acid Syrup 250mg 62.925,00
Total 106.065,00
2.530 Misiyem PENARIK 182817 Alprazolam 0,5 mg @100
03/03/2021 00:00:00 3.540,00 BPJS
Total 3.540,00
2.531 Rila Kontensa PONDOK BARU 182820 Eperisone Hcl 50 mg @1
03/03/2021 00:00:00 23.280,00 BPJS
Glucosamine 250 mg 7.700,00
Paracetamol tablet 500 m 3.000,00
Total 33.980,00
2.532 Zhagita Natasya Putri DESA TUNGGANG 176591 Abbocath 20 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Abbocath 22 Terumo @5 11.138,00
Asam Folat 1 mg @100 T 99,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 89.236,00
2.533 Jhon Espa Hasugian SIDODADI 180948 Bisturi No. 23
03/03/2021 00:00:00 3.836,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00

19/08/2021 12:42:30 Page 597 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.533 Jhon Espa Hasugian SIDODADI 180948 Cuticell Classic 10cmx10c
03/03/2021 00:00:00 35.121,00 BPJS
Dexametason Injeksi 6.256,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Tali 20.800,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Silk 2/0 R scimitar 61.688,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 2.105,00
Urine bag 9.314,00
Ceftriaxone Inj
04/03/2021 00:00:00 12.498,00
Tramadol 50 mg/ml Inj 8.250,00
Abbocath 20 Terumo @5
05/03/2021 00:00:00 26.341,00
Abbocath 20 Terumo @5 52.682,00
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 15cmx5cm (25 c 13.088,00
Hypafix Kamar Operasi 36.000,00
Infusion Makro (terumo) 27.225,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 17.637,00
Ringer Laktat Otsuka 19.076,00
Cuticell Classic 10cmx10c
06/03/2021 00:00:00 35.121,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 2.000,00
Total 950.301,00
2.534 Zhagita Natasya Putri DESA TUNGGANG 176591 Dexametason Injeksi
03/03/2021 00:00:00 3.128,00 BPJS
Dipenhydramin Injeksi 10 1.535,00
Total 4.663,00
2.535 Sartini TANJUNG MEDAN 182823 abbocath 18 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 89.501,00
2.536 Siti Rosidah TANJUNG MULYA 182825 Amlodipine 10 mg @50 T
03/03/2021 00:00:00 118,00 BPJS

19/08/2021 12:42:30 Page 598 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.536 Siti Rosidah TANJUNG MULYA 182825 Asam Folat 1 mg @100 T
03/03/2021 00:00:00 99,00 BPJS
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Glukosa Infus 5 % 8.626,00
Infusion set Mikro (Terumo 18.026,00
Metamizole Sodium Mono 4.594,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Abbocath 22 Terumo @5 22.276,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Ringer Laktat Otsuka 19.076,00
Induxin 1 ml Injeksi
04/03/2021 00:00:00 9.281,00
NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00
Renogen 3000 UI 116.875,00
Antrain Injeksi
14/03/2021 00:00:00 28.875,00
Omeprazole Inj 12.499,00
Total 413.451,00
2.537 Sartini TANJUNG MEDAN 182823 Bisturi No. 23
03/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Celemek Plastik 47.300,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 11.000,00
methyl ergometrin amp 8.662,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 14.025,00
Topi Operasi (Dokter) @5 5.097,00
Tranexamic Acid Inj (Asa 4.210,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
05/03/2021 00:00:00 11.502,00
Dexametason Injeksi 12.512,00

19/08/2021 12:42:30 Page 599 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.537 Sartini TANJUNG MEDAN 182823 Hypafix 15cmx5cm (25 c
05/03/2021 00:00:00 13.088,00 BPJS
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Total 1.395.277,00
2.538 Rison PULAI PAYUNG 182801 Bisturi No. 23
03/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 2-0 C (Tri 92.250,00
Polyvinylidene 3-0 R (Tri 92.000,00
Premilene (Mesh Duzey) 6 167.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tramadol 50 mg/ml Inj 8.250,00
Urine bag 9.314,00
Cefotaxime Injeksi
04/03/2021 00:00:00 11.502,00
Tramadol 50 mg/ml Inj 8.250,00
Cuticell Classic 10cmx10c
05/03/2021 00:00:00 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 29.025,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 1.059.722,00
2.539 Ego Dirga Wahyu DESA TALANG BUAI 144989 abbocath 18 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 24.996,00
Dexametason Injeksi 12.512,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
NGT (Stomach Tube) Fr. 1 52.250,00
NGT (Stomach Tube) Fr. 1 52.250,00
PARAMOL INFUS 385.000,00
Phenytoin Sodium Injeksi 47.733,00
Urine bag 9.314,00

19/08/2021 12:42:30 Page 600 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.539 Ego Dirga Wahyu DESA TALANG BUAI 144989 Stesolid Inj 2 ml
04/03/2021 00:00:00 8.653,00 BPJS
Total 699.093,00
2.540 Juminem AGUNG JAYA 162083 abbocath 18 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Asam Folat 1 mg @100 T 297,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Miniaspi 80 Mg @100 Ta 125,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
PARAMOL INFUS 96.250,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 204.623,00
2.541 Amran SUNGAI LINTANG 182811 Bisturi No. 15
03/03/2021 00:00:00 3.836,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 47.300,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker Karet 11.000,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 25.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 16.990,00
Tramadol 50 mg/ml Inj 8.250,00
Urine bag 9.314,00
Ceftriaxone Inj
04/03/2021 00:00:00 12.498,00
Paracetamol tablet 500 m 600,00
Cuticell Classic 10cmx10c
05/03/2021 00:00:00 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 707.970,00
2.542 Juminem AGUNG JAYA 162083 Ambroxol Syr 15mg/ml
05/03/2021 00:00:00 4.538,00 BPJS
Asam Folat 1 mg @100 T 1.485,00
Azitromycin 500 mg 28.125,00
Miniaspi 80 Mg @100 Ta 625,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 60.633,00
2.543 Tina Rustinawati AIR KASAI 182571 abbocath 18 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Aminofluid Infus 500 ml 310.408,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Furamin Injeksi 28.738,00
Infusion Makro (terumo) 27.225,00
Ka-En Mg3 26.208,00
Metoclopramide inj 5Mg/M 17.637,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
PARAMOL INFUS 96.250,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Urine bag 9.314,00
Total 668.607,00
2.544 Siti Rosidah TANJUNG MULYA 182825 Amlodipine 10 mg @50 T
04/03/2021 00:00:00 118,00 BPJS
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Amlodipine 10 mg @50 T
05/03/2021 00:00:00 118,00
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Furosemide Injeksi @2ml 1.666,00
NonWoven Fixation 10x 4.815,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Amlodipine 10 mg @50 T
06/03/2021 00:00:00 118,00
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Amlodipine 10 mg @50 T
07/03/2021 00:00:00 118,00
Antrain Injeksi 28.875,00
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 6.249,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 24.998,00

19/08/2021 12:42:30 Page 602 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.544 Siti Rosidah TANJUNG MULYA 182825 Ringer Laktat Otsuka
07/03/2021 00:00:00 28.614,00 BPJS
Amlodipine 10 mg @50 T
08/03/2021 00:00:00 1.180,00
Antrain Injeksi 115.500,00
Asam Folat 1 mg @100 T 990,00
Asam Folat 1 mg @100 T 1.584,00
Candesartan Tab 16 mg 11.790,00
Furosemide 40 mg Tablet 960,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 49.996,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 580.678,00
2.545 Novian Indrajaya TUNGGANG 182828 Abbocath 20 Terumo @5
03/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 6.249,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Bisturi No. 23
04/03/2021 00:00:00 3.836,00
catheter 2 Way No. 18 (G 20.906,00
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Polyglycolide T-Vio 3-0 R ( 86.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Silk 2/0 R scimitar 61.688,00
Urine bag 9.314,00
Ceftriaxone Inj
05/03/2021 00:00:00 12.498,00
Codein tab 10 mg 1.500,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 28.614,00
Codein tab 10 mg
06/03/2021 00:00:00 7.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 6.820,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 2.000,00
Total 776.318,00
2.546 Tina Rustinawati AIR KASAI 182571 Ceftriaxone Inj
04/03/2021 00:00:00 12.498,00 BPJS
Furamin Injeksi 28.738,00
Omeprazole Inj 12.499,00
Dulcolax 5 mg Supositori
05/03/2021 00:00:00 39.852,00
Furamin Injeksi 14.369,00
Metoclopramide inj 5Mg/M 11.758,00
Omeprazole Inj 12.499,00

19/08/2021 12:42:30 Page 603 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.546 Tina Rustinawati AIR KASAI 182571 Levofloxacin Tablet 500 m
06/03/2021 00:00:00 6.820,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 145.643,00
2.547 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
04/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.548 Narti SILAUT 175653 NACL 0,9 % 500 ml
04/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.549 Rosdin Efendi BANDARATU 138467 NACL 0,9 % 500 ml
04/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.550 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
04/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.551 Ahmad Mujiono MARGA MULYA SAKTI 113737 Infusion Makro (terumo)
04/03/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Otsu D40 25.026,00
Total 95.001,00
2.552 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
04/03/2021 00:00:00 42.750,00 BPJS
Transfusi Set Terumo 16.500,00
Total 59.250,00
2.553 Ashari Liwandi PONDOK LUNANG 139398 Infusion Makro (terumo)
04/03/2021 00:00:00 27.225,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Ondansetron Inj 1.650,00
Otsu D40 25.026,00
Total 96.651,00
2.554 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
04/03/2021 00:00:00 42.750,00 BPJS
Ondansetron Inj 1.650,00
Otsu MgSO4 20 % 4.160,00
Ranitidin inj 1.790,00
Transfusi Set Terumo 16.500,00
Total 66.850,00
2.555 Miswanto LUNANG 128267 NACL 0,9 % 500 ml
04/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.556 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
04/03/2021 00:00:00 42.750,00 BPJS
Transfusi Set Terumo 16.500,00
Total 59.250,00
2.557 M.zen TANAH HARAPAN 129190 Clopidogrel 75 mg @30 T
04/03/2021 00:00:00 52.650,00 BPJS
Flunarizine 5 mg tab 74.250,00
Furosemide 40 mg Tablet 2.880,00
Miniaspi 80 Mg @100 Ta 3.750,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 13.220,00
Opilax Syr 49.156,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 281.576,00
2.558 Upik Hartati PONDOK PANJANG 152646 Cefixime Kapsul 100 mg
04/03/2021 00:00:00 9.380,00 BPJS
Tonotan tab 22.865,00
Total 32.245,00
2.559 Siti Juriah RESNO 167789 Atorvastatin 20 mg @30 T
04/03/2021 00:00:00 31.350,00 BPJS
Gitas Plus 25.165,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 604 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.559 Siti Juriah RESNO 167789 ursodeoxycholic acid
04/03/2021 00:00:00 28.350,00 BPJS
Total 107.420,00
2.560 Jang Nawir AIR DIKIT 151069 Codein tab 10 mg
04/03/2021 00:00:00 22.500,00 BPJS
Furosemide 40 mg Tablet 2.880,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 3.305,00
Retaphyl SR Tab 44.220,00
Sucralfate Suspensi 100 m 19.250,00
Symbicort Turbuhaler 80 167.855,00
Total 268.680,00
2.561 Rosida Natalia Sihombi LUNANG 116316 Metrodinazole tab 500 m
04/03/2021 00:00:00 4.050,00 BPJS
Nystatin Tab Vaginal 3.690,00
Total 7.740,00
2.562 Herlina TALANG MEDAN 182545 Gitas Plus
04/03/2021 00:00:00 50.330,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 6.610,00
ursodeoxycholic acid 85.050,00
Total 155.630,00
2.563 Muliana AIR BIKUK 182830 Neurodex tablet
04/03/2021 00:00:00 22.230,00 BPJS
Omeprazol kapsul 20 mg 13.220,00
Propanolol tab 10 mg 3.330,00
Sucralfate Suspensi 100 m 19.250,00
thyrozol 5 mg 16.520,00
Total 74.550,00
2.564 Rudito PT AGRO AIR BULUH 182435 Flunarizine 5 mg tab
04/03/2021 00:00:00 74.250,00 BPJS
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 3.305,00
Perifas @100 Tab 57.750,00
Sucralfate Suspensi 100 m 19.250,00
Total 163.225,00
2.565 Rince MANDI ANGIN JAYA 182833 Calcium Laktat
04/03/2021 00:00:00 790,00 BPJS
Tambah Darah Neo Tab 4.650,00
Total 5.440,00
2.566 Suriyani KAMPUNG DALAM 113149 Atorvastatin 20 mg @30 T
04/03/2021 00:00:00 31.350,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Furosemide 40 mg Tablet 2.880,00
Miniaspi 80 Mg @100 Ta 3.750,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 125.160,00
2.567 Suburni UJUNG PADANG 157140 Ambroxol Syr 15mg/ml
04/03/2021 00:00:00 4.538,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Atorvastatin 20 mg @30 T 31.350,00
Azitromycin 500 mg 56.250,00
Clopidogrel 75 mg @30 T 52.650,00
Flunarizine 5 mg tab 74.250,00
Furosemide 40 mg Tablet 2.880,00
Retaphyl SR Tab 44.220,00
Total 270.278,00
2.568 Haura Gwen Ayca PIANTOKUNG 180319 Abbocath 24 Terumo @5
04/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00

19/08/2021 12:42:30 Page 605 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.568 Haura Gwen Ayca PIANTOKUNG 180319 Cefixime syrup 100mg/5 M
04/03/2021 00:00:00 23.823,00 BPJS
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Total 105.097,00
2.569 Sumadi PONDOK MAKMUR 182524 Cuticell Classic 10cmx10c
04/03/2021 00:00:00 35.121,00 BPJS
Levofloxacin Tablet 500 m 6.820,00
NonWoven Fixation 15x 6.694,00
Paracetamol tablet 500 m 3.000,00
Total 51.635,00
2.570 Maria Veeroneka SILAUT 179790 Gabapentin kapsul 300 m
04/03/2021 00:00:00 25.380,00 BPJS
Vitamin B Komplek @100 3.080,00
Total 28.460,00
2.571 Farah Bunga Fauziah LUBUK MUKTI 182839 Gitas Plus
04/03/2021 00:00:00 150.990,00 BPJS
Lansoprazole kapsul 30 m 23.100,00
Natrium diclofenac 50 m 8.670,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 247.500,00
Total 449.510,00
2.572 Uswatun Hasanah ja MUNDAM MARAP 116754 Cefixime kapsul 200 mg
04/03/2021 00:00:00 26.480,00 BPJS
Opilax Syr 49.156,00
Paracetamol tablet 500 m 3.000,00
Total 78.636,00
2.573 Solikin MEKAR JAYA 182663 Levofloxacin Tablet 500 m
04/03/2021 00:00:00 6.820,00 BPJS
Paracetamol tablet 500 m 2.800,00
Total 9.620,00
2.574 Yunia Ramadani SUNGAI IPUH 145845 Anti Hemoroid
04/03/2021 00:00:00 16.624,00 BPJS
Levofloxacin Tablet 500 m 6.820,00
Total 23.444,00
2.575 Haura Gwen Ayca PIANTOKUNG 180319 Abbocath 26 Terumo
04/03/2021 00:00:00 19.300,00 BPJS
Aqua Pro Injeksi 3.575,00
Infusion set Mikro (Terumo 18.026,00
L-Bio sach @ 1gr 17.242,00
NonWoven Fixation 10x 4.815,00
Oralit 1.029,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 4.569,00
Glukosa Infus 5 %
05/03/2021 00:00:00 17.252,00
Injection plug 20.213,00
L-Bio sach @ 1gr 17.242,00
Cefixime syrup 100mg/5 M
06/03/2021 00:00:00 23.823,00
Oralit 1.715,00
Zink Tablet 4.823,00
Total 163.162,00
2.576 Rosmani GAJAH MATI 182840 Amlodipine 10 mg @50 T
04/03/2021 00:00:00 3.540,00 BPJS
Candesartan tab 8 mg 20.430,00
Ketorolac Tab 10 Mg 75.900,00
Meloxicam 7,5 mg 21.840,00
Natrium diclofenac 50 m 8.670,00
Omeprazol kapsul 20 mg 19.830,00
Sucralfate Suspensi 100 m 19.250,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 169.460,00
2.577 Isnar Dianti BUMI MULYA 128971 Calcium Laktat
04/03/2021 00:00:00 790,00 BPJS
Emibion kapsul 19.660,00
Total 20.450,00
2.578 Mutiara Indah Nainggo PENARIK 172751 Amoxicillin 500 mg @ 10
04/03/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Methylprednisolone tab 4 2.630,00
Total 6.980,00
2.579 Elni Alfiani LUBUK MUKTI 180579 Cetirgi Tab 10 mg
04/03/2021 00:00:00 15.480,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 18.110,00
2.580 Lili Suharni BUNGA TANJUNG 129799 abbocath 18 Terumo @5
04/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 102.610,00
2.581 Nia Wahyuni DUSUN BARU PELOKA 147939 Neurodex tablet
04/03/2021 00:00:00 14.820,00 BPJS
Orasic Kap 18.290,00
Paracetamol tablet 500 m 4.000,00
Total 37.110,00
2.582 Wiwit Purwanti PENARIK 144289 abbocath 18 Terumo @5
04/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Otsu MgSO4 20 % 8.320,00
Ringer Laktat Otsuka 28.614,00
Tonotan tab 13.719,00
Transfusi Set Terumo 16.500,00
Total 113.147,00
2.583 Lili Suharni BUNGA TANJUNG 129799 Bisturi No. 23
04/03/2021 00:00:00 3.836,00 BPJS
Bisturi No. 23 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 14.554,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 8.244,00
Kamadol Injeksi 11.400,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 11.000,00
Miloz Injeksi 5 mg 5.611,00

19/08/2021 12:42:30 Page 607 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.583 Lili Suharni BUNGA TANJUNG 129799 Misoprostol Tab
04/03/2021 00:00:00 16.500,00 BPJS
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 10x 4.815,00
Ondansetron Inj 3.300,00
Paracetamol Infus 14.438,00
Polypropylene 3/0 C (Ass 235.200,00
Ringer Laktat Otsuka 28.614,00
Safil 1 R 199.600,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 16.990,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 9.314,00
viamac 1 R 182.185,00
Cefotaxime Injeksi
05/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 540,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
06/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
07/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.686.761,00
2.584 Wiwit Purwanti PENARIK 144289 Cefotaxime Injeksi
05/03/2021 00:00:00 11.502,00 BPJS
Dexametason Injeksi 6.256,00
Ringer Laktat Otsuka
07/03/2021 00:00:00 19.076,00
Tambah Darah Neo Tab 4.650,00
Total 41.484,00
2.585 Siti Aisyah SINAR JAYA 182846 Abbocath 20 Terumo @5
04/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 10x 4.815,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00

19/08/2021 12:42:30 Page 608 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.585 Siti Aisyah SINAR JAYA 182846 Ringer Laktat Otsuka
04/03/2021 00:00:00 28.614,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 150.234,00
2.586 Suhardi BANDAR RATU 115774 Alprazolam 1 mg @100 T
04/03/2021 00:00:00 1.600,00 BPJS
Amlodipine 10 mg @50 T 2.360,00
Amoxicillin 500 mg @ 10 6.120,00
Clopidogrel 75 mg @30 T 35.100,00
Paracetamol tablet 500 m 4.000,00
Total 49.180,00
2.587 Safrina UJUNG PADANG 126429 Abbocath 20 Terumo @5
04/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Infusion set Mikro (Terumo 18.026,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
05/03/2021 00:00:00 11.502,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Paracetamol Infus 28.876,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
06/03/2021 00:00:00 11.502,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
07/03/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
08/03/2021 00:00:00 11.502,00
Ibuprofen tab 400 mg 1.374,00
Ketorolac inj 30 mg/1ml 2.690,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
09/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Meprolut Tab 8.360,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
10/03/2021 00:00:00 5.751,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 1.345,00
Norelut 4.675,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 609 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.587 Safrina UJUNG PADANG 126429 Asam Traneksamat @10
11/03/2021 00:00:00 21.050,00 BPJS
Norelut 46.750,00
Tambah Darah Neo Tab 4.650,00
Total 479.274,00
2.588 Rusmi ujung padang 118365 Abbocath 20 Terumo @5
04/03/2021 00:00:00 26.341,00 BPJS
Alprazolam 1 mg @100 T 160,00
Antrain Injeksi 28.875,00
Glukosa Infus 5 % 17.252,00
Guedel No 50 MM 44.916,00
Guedel No 70 MM 18.233,00
Infusion set Mikro (Terumo 18.026,00
NGT (Stomach Tube) Fr. 1 52.250,00
NonWoven Fixation 10x 4.815,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Sucralfate Suspensi 100 m 19.250,00
Suction Catheter No. 10 R 3.494,00
Suction Chateter no. 12 ( 10.588,00
Total 257.299,00
2.589 Ny.siti Eriah BANDAR JAYA 182847 Abbocath 24 Terumo @5
04/03/2021 00:00:00 79.023,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Bisturi no. 10 3.836,00
Chloramphenicol Salep M 2.351,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NonWoven Fixation 10x 4.815,00
umbilical Cord Clamp 2.261,00
Calcii Glukonas Inj 100 m
06/03/2021 00:00:00 12.939,00
Chromic catgut 3-0 R (Tr 66.250,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding tube) Fr. 3 21.710,00
NonWoven Fixation 15x 6.694,00
Abbocath 24 Terumo @5
08/03/2021 00:00:00 158.046,00
Ampicilin Serbuk Injeksi 1 21.622,00
Infusion set Mikro (Terumo 18.026,00
Injection plug 20.213,00
Ka-En Mg3 13.104,00
Hypafix 10cm x 5cm (25 c
14/03/2021 00:00:00 9.700,00
Total 492.206,00
2.590 Siti Aisyah SINAR JAYA 182846 Ambroxol Syr 15mg/ml
05/03/2021 00:00:00 4.538,00 BPJS
Antrain Injeksi 28.875,00
Cefotaxime Injeksi 11.502,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
PARAMOL INFUS 96.250,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Antrain Injeksi
06/03/2021 00:00:00 28.875,00
Cefotaxime Injeksi 11.502,00

19/08/2021 12:42:30 Page 610 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.590 Siti Aisyah SINAR JAYA 182846 Omeprazole Inj
06/03/2021 00:00:00 12.499,00 BPJS
Ondansetron Inj 4.950,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Abbocath 22 Terumo @5
07/03/2021 00:00:00 22.276,00
Cefotaxime Injeksi 11.502,00
Metamizole Sodium Mono 13.782,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
PARAMOL INFUS 288.750,00
Ringer Laktat Otsuka 47.690,00
Ringer Laktat Otsuka 28.614,00
Antrain Injeksi
08/03/2021 00:00:00 28.875,00
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 10x 14.445,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Omeprazol kapsul 20 mg
09/03/2021 00:00:00 3.305,00
Paracetamol tablet 500 m 3.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.013.415,00
2.591 Rusmi ujung padang 118365 Abbocath 20 Terumo @5
05/03/2021 00:00:00 52.682,00 BPJS
Abbocath 22 Terumo @5 22.276,00
Antrain Injeksi 28.875,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 6.256,00
Extention Tube 8.801,00
Fentanyl Injeksi 5 Ampul 2 104.000,00
Fentanyl Injeksi 5 Ampul 2 104.000,00
Glukosa Infus 5 % 17.252,00
Infusion set Mikro (Terumo 18.026,00
Miloz Injeksi 5 mg 11.222,00
Miloz Injeksi 5 mg 22.444,00
Nassal Cannula O2 Dewas 11.625,00
Nicardipine HCl Inj 118.264,00
NonWoven Fixation 10x 9.630,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 24.998,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 800,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 611 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.591 Rusmi ujung padang 118365 Sucralfate Suspensi 100 m
05/03/2021 00:00:00 19.250,00 BPJS
Three Way stopcock 25.904,00
Urine bag 9.314,00
Vitamin B Komplek @100 154,00
Alprazolam 1 mg @100 T
06/03/2021 00:00:00 160,00
Antrain Injeksi 28.875,00
Candesartan Tab 16 mg 4.716,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 10 % 18.750,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Vitamin B Komplek @100 154,00
ATRACURIUM BESYLATE 2
07/03/2021 00:00:00 44.013,00
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00
Extention Tube 8.801,00
Fargoxin inj 2 ml (Digoxi 34.788,00
Fargoxin inj 2 ml (Digoxi 34.788,00
Fentanyl Injeksi 5 Ampul 2 104.000,00
Guedel No 60 MM 18.233,00
Guedel No 70 MM 18.233,00
Infusion Makro (terumo) 27.225,00
Miloz Injeksi 5 mg 16.833,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Anak 16.473,00
Nassal Mask O2 Anak 41.828,00
Neurodex tablet 741,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Otsu KCL 8.058,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Suction Chateter no. 12 ( 10.588,00
Alprazolam 1 mg @100 T
08/03/2021 00:00:00 160,00
Ambroxol Syr 15mg/ml 4.538,00
Amlodipine 10 mg @50 T 118,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Fargoxin inj 2 ml (Digoxi 34.788,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 24.998,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Vitamin B Komplek @100 154,00
Alprazolam 1 mg @100 T
09/03/2021 00:00:00 160,00
Ceftriaxone Inj 12.498,00
Fargoxin inj 2 ml (Digoxi 34.788,00
Gitas Plus 10.066,00

19/08/2021 12:42:30 Page 612 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.591 Rusmi ujung padang 118365 Gitas Plus
09/03/2021 00:00:00 15.099,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Alprazolam 1 mg @100 T
10/03/2021 00:00:00 160,00
Ambroxol Syr 15mg/ml 4.538,00
Antrain Injeksi 57.750,00
Candesartan Tab 16 mg 5.775,00
Ceftriaxone Inj 12.498,00
Fetik supp (Ketoprofen) 24.502,00
Gitas Plus 10.066,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Omeprazole Inj 62.495,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Tramadol 50 mg/ml Inj 12.375,00
Alprazolam 0,5 mg @100
11/03/2021 00:00:00 590,00
Curcuma Tab 3.810,00
Domperidone Tab 1.620,00
Lansoprazole kapsul 30 m 11.550,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.942.951,00
2.592 Haryati PONDOK MAKMUR 182850 abbocath 18 Terumo @5
05/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 144.500,00
Chromic catgut 2-0 R (Tr 144.500,00
Induxin 1 ml Injeksi 27.843,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
Myotonic inj 19.596,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Phytomenadione 2 Mg/1M 4.834,00
Protocin Inj 28.215,00
Suction Chateter no. 8 (R 20.625,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 4.210,00

19/08/2021 12:42:30 Page 613 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.592 Haryati PONDOK MAKMUR 182850 umbilical Cord Clamp
05/03/2021 00:00:00 4.522,00 BPJS
Urine bag 9.314,00
Metrodinazole tab 500 m
06/03/2021 00:00:00 2.700,00
Paracetamol tablet 500 m 3.000,00
Vitamin B Komplek @100 1.540,00
Total 611.915,00
2.593 Radius PONDOK LUNANG 182851 Betahistin Mesilat 6 mg @
05/03/2021 00:00:00 1.380,00 BPJS
Flunarizine 5 mg tab 24.750,00
Total 26.130,00
2.594 Fatmawati SELAGAN JAYA 180719 Domperidone Tab
05/03/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
ursodeoxycholic acid 28.350,00
Total 36.040,00
2.595 Marzuki TALANG MEDAN 154878 Eperisone Hcl 50 mg @1
05/03/2021 00:00:00 23.280,00 BPJS
Mecobalamin 500 mg 7.700,00
Meloxicam 7,5 mg 7.280,00
Total 38.260,00
2.596 Sarah Purwaningsih BANDAR RATU 182684 Ambroxol Syr 15mg/ml
05/03/2021 00:00:00 4.538,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 79.994,00
2.597 Kardi SUNGAI RUMBAI 182540 Levofloxacin Tablet 500 m
05/03/2021 00:00:00 8.184,00 BPJS
Total 8.184,00
2.598 Sadiyem LUNANG 119406 Amlodipine 5 mg @30 T
05/03/2021 00:00:00 3.030,00 BPJS
Citicoline kaplet 500 mg 49.500,00
Miniaspi 80 Mg @100 Ta 3.750,00
Ranitidine tablet 150 mg 4.320,00
Total 60.600,00
2.599 Indah Derita AIR DIKIT 121845 Domperidone Tab
05/03/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 28.940,00
2.600 Kasmilawati KOTO JAYA 182862 Ambroxol Syr 15mg/ml
05/03/2021 00:00:00 4.538,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Loratadine tab 10 mg 1.660,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 2.000,00
Total 20.208,00
2.601 Wardi PASAR SEBELAH 143195 Omeprazol kapsul 20 mg
05/03/2021 00:00:00 6.610,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
ursodeoxycholic acid 28.350,00
Total 54.210,00
2.602 Renisya Oktavia AIR KASAI 150070 Cefixime Kapsul 100 mg
05/03/2021 00:00:00 9.380,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 54.191,00
2.603 Selvia Verolina MANDI ANGIN 140849 abbocath 18 Terumo @5
05/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00

19/08/2021 12:42:30 Page 614 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.603 Selvia Verolina MANDI ANGIN 140849 Dexametason Injeksi
05/03/2021 00:00:00 9.384,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Infus 24.488,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 94.676,00
2.604 Jasmani LUBUK PINANG 137330 Domperidone Tab
05/03/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
ursodeoxycholic acid 28.350,00
Total 36.040,00
2.605 Traniyanti MANJUTO JAYA 179912 Domperidone Tab
05/03/2021 00:00:00 1.080,00 BPJS
Mecobalamin 500 mg 7.700,00
Omeprazol kapsul 20 mg 6.610,00
Total 15.390,00
2.606 Yena Sulastri LUBUK PINANG 182686 Cefixime Kapsul 100 mg
05/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.607 Muris RESNO 182868 Abbocath 20 Terumo @5
05/03/2021 00:00:00 26.341,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Sistenol kaplet 5.262,00
Total 120.293,00
2.608 Merli Anggraini NELAN INDAH 158244 abbocath 18 Terumo @5
05/03/2021 00:00:00 26.341,00 BPJS
abbocath 18 Terumo @5 105.364,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 17.253,00
Dexametason Injeksi 9.384,00
Hypafix Kamar Operasi 90.000,00
NonWoven Fixation 15x 6.694,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Alkohol 1Liter
06/03/2021 00:00:00 42.111,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00

19/08/2021 12:42:30 Page 615 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.608 Merli Anggraini NELAN INDAH 158244 Handscoond Sterille 7 (G
06/03/2021 00:00:00 29.126,00 BPJS
Iodine Povidone 1 L 183.288,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 29.394,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
oxytocin inj 2.998,00
Polypropylene 2/0 R (Ass 235.200,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
07/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
08/03/2021 00:00:00 11.502,00
Hypafix Kamar Operasi 18.000,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 4.210,00
Asam Mefenamat 500 m
09/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 73.452,00
Total 2.156.925,00
2.609 Muris RESNO 182868 Levofloxacin Tablet 500 m
06/03/2021 00:00:00 13.640,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 22.250,00
2.610 Selvia Verolina MANDI ANGIN 140849 Aqua Pro Injeksi
05/03/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00

19/08/2021 12:42:30 Page 616 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.610 Selvia Verolina MANDI ANGIN 140849 Cuticell Classic 10cmx10c
05/03/2021 00:00:00 35.121,00 BPJS
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 11.000,00
Metrodinazole Infus 30.939,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
06/03/2021 00:00:00 11.502,00
Furamin Injeksi 28.738,00
Furamin Injeksi 28.738,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
07/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
08/03/2021 00:00:00 1.290,00
Ciprofloxacin tab 500 mg 5.590,00
Furamin Injeksi 28.738,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
NonWoven Fixation 15x 6.694,00
Postofix (leukomed) 36.726,00
Total 1.709.576,00

19/08/2021 12:42:30 Page 617 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.611 Santiani TERAS TERUNJAM 143154 Mecobalamin 500 mg
05/03/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 79.352,00
Total 87.052,00
2.612 Salami SILAUT I 134774 NACL 0,9 % 500 ml
05/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.613 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
05/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.614 Rina Oktasari LUNANG 177103 Cefixime Kapsul 100 mg
05/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Ranitidine tablet 150 mg 1.440,00
Total 76.896,00
2.615 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
05/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.616 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
05/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.617 Nurajad SIBAK 182614 Domperidone Tab
05/03/2021 00:00:00 1.080,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
ursodeoxycholic acid 28.350,00
Total 38.040,00
2.618 Suwarni SUKA MAJU 164065 Amlodipine 10 mg @50 T
05/03/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.104,00
2.619 Zukriman LUBUK GEDANG 160918 Amlodipine 10 mg @50 T
05/03/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.104,00
2.620 Susi Martini KOTO JAYA 145038 Amlodipine 10 mg @50 T
05/03/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.104,00
2.621 Salbiyah LUBUK MUKTI 173013 Amlodipine 10 mg @50 T
05/03/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.104,00
2.622 Roslina TERUNTUNG 130072 Amlodipine 10 mg @50 T
05/03/2021 00:00:00 354,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 43.104,00
2.623 Manawiah LUBUK PINANG 142418 Amlodipine 10 mg @50 T
05/03/2021 00:00:00 1.180,00 BPJS
Mecobalamin 500 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Tugesal Filco 50 mg Tab ( 27.438,00
Tugesal Filco 50 mg Tab ( 54.876,00
Total 93.194,00
2.624 Damin KOTA PRAJA 130551 abbocath 18 Terumo @5
05/03/2021 00:00:00 79.023,00 BPJS
Abbocath 20 Terumo @5 79.023,00
Abbocath 22 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 618 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 264.097,00
2.625 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
05/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.626 Marfuah SINAR JAYA 150306 Abbocath 20 Terumo @5
05/03/2021 00:00:00 52.682,00 BPJS
Aqua Pro Injeksi 3.575,00
Esomeprazol Injeksi 40 m 34.956,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (Gea) 7.425,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol syrup 4.164,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 154.077,00
2.627 H Zainal Maksum SINAR JAYA 182871 Ambroxol Syr 15mg/ml
05/03/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Nebulizer O2 Dewasa 34.783,00
Paracetamol tablet 500 m 2.000,00
Salbutamol 2 mg 790,00
Total 70.236,00
2.628 Damin KOTA PRAJA 130551 Dulcolax tab 5 mg
05/03/2021 00:00:00 3.166,00 BPJS
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
06/03/2021 00:00:00 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Paracetamol Infus 28.876,00
Ringer Laktat Otsuka 9.538,00
Ceftriaxone Inj
07/03/2021 00:00:00 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Dulcolax tab 5 mg 1.583,00
Furosemide Injeksi @2ml 1.666,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
08/03/2021 00:00:00 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00
Dexametason Injeksi
09/03/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dulcolax Sup 10 mg 0,00
Dulcolax tab 5 mg 3.166,00
PARAMOL INFUS 96.250,00
Abbocath 20 Terumo @5
10/03/2021 00:00:00 52.682,00
Abbocath 22 Terumo @5 22.276,00
Bisturi No. 23 3.836,00
Catheter 2 Way No. 16 ( 39.025,00

19/08/2021 12:42:30 Page 619 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.628 Damin KOTA PRAJA 130551 Ceftriaxone Inj
10/03/2021 00:00:00 12.498,00 BPJS
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Fresofol ( propopol ) inj 13.448,00
Furosemide Injeksi @2ml 1.666,00
Gentamycin 0.1 % salep k 2.983,00
Gentamycin 0.1 % salep k 5.966,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet 5.500,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Polyglycolide 3-0 C (TriTe 82.875,00
Ringer Laktat Otsuka 9.538,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Spuit 50 cc Lbg tengah ( 4.888,00
Topi Operasi (Perawat) @ 4.690,00
Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Cefixime kapsul 200 mg
12/03/2021 00:00:00 26.480,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 3.000,00
Total 1.008.693,00
2.629 Sumino TIRTA MULYA 182872 abbocath 18 Terumo @5
05/03/2021 00:00:00 26.341,00 BPJS
abbocath 18 Terumo @5 26.341,00
Amlodipine 5 mg @30 T 101,00
Amlodipine 5 mg @30 T 101,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
Metformin tablet 500 mg 399,00
Metformin tablet 500 mg 399,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 178.302,00

19/08/2021 12:42:30 Page 620 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.630 Masganyang TANAH REKAH 120264 Bisturi No. 15
05/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Masker Karet 11.000,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Total 697.099,00
2.631 Sumino TIRTA MULYA 182872 Amlodipine 10 mg @50 T
06/03/2021 00:00:00 590,00 BPJS
Metformin tablet 500 mg 1.330,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 1.000,00
Amlodipine 5 mg @30 T
07/03/2021 00:00:00 101,00
Metformin tablet 500 mg 399,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 5 mg @30 T
08/03/2021 00:00:00 1.010,00
Levofloxacin Tablet 500 m 13.640,00
Metformin tablet 500 mg 1.330,00
Omeprazole Inj 37.497,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 38.500,00
Sucralfate Suspensi 100 m 19.250,00
Total 170.859,00
2.632 Nita Insolita LUBUK BENTO 182716 Cefixime Kapsul 100 mg
05/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.633 Tuti Anggrayani PADANG GADING 182859 abbocath 18 Terumo @5
05/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00

19/08/2021 12:42:30 Page 621 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.633 Tuti Anggrayani PADANG GADING 182859 Misoprostol Tab
05/03/2021 00:00:00 33.000,00 BPJS
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 118.631,00
2.634 Mega Kurniawati air hitam 182863 Bisturi No. 23
05/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 58.252,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Karet 11.000,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 10.525,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
06/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
07/03/2021 00:00:00 11.502,00

19/08/2021 12:42:30 Page 622 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.634 Mega Kurniawati air hitam 182863 Hypafix 10cm x 5cm (25 c
07/03/2021 00:00:00 4.850,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
08/03/2021 00:00:00 1.935,00
Catheter 2 Way No. 16 ( 20.625,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Spinocain 25 (BBraund) 42.763,00
Tranexamic Acid Inj (Asa 12.630,00
Total 1.767.918,00
2.635 Tuti Anggrayani PADANG GADING 182859 abbocath 18 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Bisturi No. 23 0,00
Bucain Spinal 0.5 % Inj 0,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 0,00
Chromic catgut 2-0 R (Tr 0,00
Cuticell Classic 10cmx10c 0,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Gelaufusal Infusion 500 m 0,00
Handscoon steril 7,5 (Ga 0,00
Handscoond Non Steril M 0,00
handscoond steril 6.5 (G 0,00
handscoond steril 8 (Gam 0,00
Handscoond Sterille 7 (G 0,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 0,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 0,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Myotonic inj 0,00
NACL 0,9 % 500 ml 0,00
NonWoven Fixation 15x 0,00
Ondansetron Inj 0,00
Ondansetron Inj 3.300,00
Polyglycolic Acid 1 R (dTe 0,00
Polyvinylidene 3-0 R (Tri 0,00
Protocin Inj 0,00
Ringer Laktat Otsuka 0,00
Spinocain 27 (BBraund) 0,00
Spuit 10 cc Disposible (T 0,00
Spuit 3 cc Disposible 0,00
Spuit 5 cc Disposible 0,00
Suprafenid Supositoria 10 0,00

19/08/2021 12:42:30 Page 623 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.635 Tuti Anggrayani PADANG GADING 182859 Suprafenid Supositoria 10
06/03/2021 00:00:00 28.050,00 BPJS
Topi Operasi (Dokter) @5 0,00
Topi Operasi (Perawat) @ 0,00
Tranexamic Acid Inj (Asa 0,00
Asam Mefenamat 500 m
07/03/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Misoprostol Tab 55.000,00
Total 301.434,00
2.636 Ny.mega Kurniawati AIR HITAM 182874 Abbocath 24 Terumo @5
05/03/2021 00:00:00 26.341,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Bisturi No. 23 3.836,00
Hypafix 10cm x 5cm (25 c 4.850,00
Injection plug 20.213,00
NGT (Feeding tube) Fr. 5 17.603,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
07/03/2021 00:00:00 79.023,00
NonWoven Fixation 15x 13.388,00
Total 178.326,00
2.637 Masganyang TANAH REKAH 120264 Ceftriaxone Inj
05/03/2021 00:00:00 6.249,00 BPJS
OMZ 90.000,00
OMZ 90.000,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 8.250,00
Tramadol 50 mg/ml Inj 8.250,00
Ceftriaxone Inj
06/03/2021 00:00:00 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj
07/03/2021 00:00:00 12.498,00
Kamadol Injeksi 17.100,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
08/03/2021 00:00:00 12.498,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Cefixime Kapsul 100 mg
09/03/2021 00:00:00 9.380,00
Paracetamol tablet 500 m 2.000,00
Total 485.141,00
2.638 Rahayu Wilujeng SIDO MAKMUR 182875 Abbocath 20 Terumo @5
06/03/2021 00:00:00 52.682,00 BPJS
Infusion Makro (terumo) 54.450,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
Ringer Laktat Otsuka 9.538,00
Abbocath 22 Terumo @5 33.414,00
Acetylcystein 200 mg Ka 5.157,00
Alprazolam 1 mg @100 T 160,00
Ascorbid Acid 1000mg/5m 52.250,00

19/08/2021 12:42:30 Page 624 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.638 Rahayu Wilujeng SIDO MAKMUR 182875 Ascorbid Acid 1000mg/5m
06/03/2021 00:00:00 52.250,00 BPJS
azitromicin inj 500 mg 144.376,00
NACL 0,9 % 500 ml 25.650,00
NACL 3 % (OTSU SALIN) 180.000,00
Neurodex tablet 741,00
Neurodex tablet 2.223,00
NonWoven Fixation 15x 13.388,00
Omeprazol kapsul 20 mg 1.322,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Ondansetron Inj 4.950,00
Oseltamivir 75 mg 2,00
Zinc Sulfate Syr 60 ml 4.569,00
Zink Tablet 2.067,00
Ascorbid Acid 1000mg/5m
07/03/2021 00:00:00 78.375,00
Bionicom Zink 10,00
NACL 0,9 % 500 ml 25.650,00
Neurodex tablet 1.482,00
Omeprazole Inj 24.998,00
Ondansetron Inj 3.300,00
Oseltamivir 75 mg 3,00
Ascorbid Acid 1000mg/5m
08/03/2021 00:00:00 104.500,00
Erdosteine Syr 36.575,00
Levofloxacin Tablet 500 m 6.820,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Alprazolam 0,5 mg @100
09/03/2021 00:00:00 118,00
Ascorbid Acid 1000mg/5m 52.250,00
Ascorbid Acid 1000mg/5m 52.250,00
Erdosteine Syr 36.575,00
Erdosteine Syr 36.575,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 25.650,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Ascorbid Acid 1000mg/5m
10/03/2021 00:00:00 52.250,00
Loratadine tab 10 mg 830,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ascorbid Acid 1000mg/5m
11/03/2021 00:00:00 52.250,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Omeprazole Inj
12/03/2021 00:00:00 12.499,00
Omeprazol kapsul 20 mg
13/03/2021 00:00:00 3.305,00
Vitamin C tablet @100 Ta 1.380,00
Zink Tablet 6.890,00
Alprazolam 0,5 mg @100
14/03/2021 00:00:00 590,00
Erdosteine Syr 36.575,00
Erdosteine Syr 36.575,00
Loratadine tab 10 mg 830,00
Oseltamivir 75 mg 5,00

19/08/2021 12:42:30 Page 625 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.638 Rahayu Wilujeng SIDO MAKMUR 182875 Sucralfate Suspensi 100 m
14/03/2021 00:00:00 19.250,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Vitamin C 500 mg 5,00
Zink Tablet 3.445,00
Erdosteine Syr
16/03/2021 00:00:00 36.575,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Ondansetron tablet 8 mg
18/03/2021 00:00:00 26.400,00
Vectrein Syrup 45.000,00
Vitamin B Komplek @100 1.540,00
Vitamin C tablet @100 Ta 2.070,00
Total 1.758.694,00
2.639 Marfuah SINAR JAYA 150306 Amlodipine 5 mg @30 T
06/03/2021 00:00:00 303,00 BPJS
Esomeprazol Injeksi 40 m 69.912,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 10x 9.630,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 5 mg @30 T
07/03/2021 00:00:00 1.010,00
Amlodipine 5 mg @30 T 202,00
Curcuma Tab 3.810,00
Esomeprazol Injeksi 40 m 69.912,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Vitamin C tablet @100 Ta 276,00
Amlodipine 5 mg @30 T
08/03/2021 00:00:00 101,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Metoclopramide inj 5Mg/M 17.637,00
Oseltamivir 75 mg 2,00
Paracetamol tablet 500 m 600,00
Vitamin C tablet @100 Ta 552,00
Total 345.839,00
2.640 Surati Khowiyah BUMI MULYA 182873 Cefotaxime Injeksi
06/03/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 4.210,00
Cefotaxime Injeksi
07/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
08/03/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 13.088,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 4.210,00

19/08/2021 12:42:30 Page 626 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.640 Surati Khowiyah BUMI MULYA 182873 Ciprofloxacin tab 500 mg
09/03/2021 00:00:00 5.590,00 BPJS
Clindamycin 300 mg Tabl 17.500,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
Phytomenadione 10 mg ( 1.868,00
Postofix (leukomed) 36.726,00
Spinocain 27 (BBraund) 47.875,00
Tranexamic Acid Inj (Asa 8.420,00
Total 315.704,00
2.641 Panca Irawan BANDARATU 151148 Candesartan tab 8 mg
06/03/2021 00:00:00 681,00 BPJS
Furosemide Injeksi @2ml 4.998,00
Omeprazole Inj 12.499,00
Spironolaktone 25 mg 260,00
Aspilet 80 mg @100 mg
07/03/2021 00:00:00 138,00
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 2.043,00
Furosemide Injeksi @2ml 1.666,00
Ibuprofen tab 400 mg 458,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spironolaktone 25 mg 260,00
Tramadol tab 50 mg 2.751,00
Candesartan tab 8 mg
08/03/2021 00:00:00 6.810,00
Furosemide 40 mg Tablet 960,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Orasic Kap 36.580,00
Paracetamol tablet 500 m 2.000,00
Spironolaktone 25 mg 2.600,00
Total 144.151,00
2.642 Joni Suhendri PENARIK 161634 Abbocath 20 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Antasida Syrup 60 ml 2.736,00
Cefixime Kapsul 100 mg 938,00
Domperidone Syrup 5mg 10.279,00
Dulcolax Sup 10 mg 111.200,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Tablet 500 m 6.820,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazol kapsul 20 mg 3.305,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 225.161,00
2.643 Margono sidodadi 182877 abbocath 18 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Abbocath 22 Terumo @5 11.138,00
Candesartan tab 8 mg 681,00

19/08/2021 12:42:30 Page 627 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.643 Margono sidodadi 182877 Ceftriaxone Inj
06/03/2021 00:00:00 12.498,00 BPJS
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 5.380,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Alprazolam 1 mg @100 T 800,00
Candesartan tab 8 mg 2.043,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 69.912,00
Ketorolac inj 30 mg/1ml 16.140,00
Ketorolac Tab 10 Mg 5.060,00
NACL 0,9 % 500 ml 25.650,00
NonWoven Fixation 10x 9.630,00
Ondansetron Inj 4.950,00
Vitamin B Komplek @100 462,00
Candesartan tab 8 mg
07/03/2021 00:00:00 2.043,00
Ceftriaxone Inj 18.747,00
Ketorolac inj 30 mg/1ml 5.380,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Candesartan tab 8 mg
08/03/2021 00:00:00 681,00
Ceftriaxone Inj 18.747,00
Ketorolac inj 30 mg/1ml 5.380,00
NACL 0,9 % 500 ml 8.550,00
Neurodex tablet 1.482,00
Omeprazol kapsul 20 mg 1.322,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Candesartan tab 8 mg
10/03/2021 00:00:00 6.810,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 492.319,00
2.644 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.645 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.646 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.647 Bahman SIBAK 155872 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.648 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.649 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.650 Junaidi SUNGAI IPUH 138273 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00

19/08/2021 12:42:30 Page 628 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.651 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Total 67.776,00
2.652 Bima Aryandika BANDARATU 178714 Amlodipine 5 mg @30 T
06/03/2021 00:00:00 303,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 600,00
Total 43.653,00
2.653 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Total 67.776,00
2.654 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Total 67.776,00
2.655 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
06/03/2021 00:00:00 42.750,00 BPJS
Ranitidin inj 1.790,00
Total 44.540,00
2.656 Ona Sutri TALANG KUNING 168921 abbocath 18 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Asam Folat 1 mg @100 T 99,00
Ketorolac inj 30 mg/1ml 1.345,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Tambah Darah Neo Tab 465,00
Transfusi Set Terumo 16.500,00
Asam Folat 1 mg @100 T
07/03/2021 00:00:00 198,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 2.690,00
Mecobalamin 500 mg 1.540,00
Tambah Darah Neo Tab 930,00
Asam Folat 1 mg @100 T
08/03/2021 00:00:00 198,00
Mecobalamin 500 mg 1.540,00
Orasic Kap 10.974,00
Paracetamol tablet 500 m 600,00
Asam Folat 1 mg @100 T
09/03/2021 00:00:00 990,00
Mecobalamin 500 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Total 101.756,00
2.657 Trimo TELUK BAKUNG 182538 abbocath 18 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 6.249,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 58.628,00
2.658 Ny Merli Anggraini NELAN INDAH 182881 Abbocath 24 Terumo @5
06/03/2021 00:00:00 79.023,00 BPJS
Kassa kotak stril DRC 9.675,00
NGT (Feeding tube) Fr. 5 17.603,00
NGT (Feeding Tube) Fr. 8 70.420,00
NonWoven Fixation 10x 4.815,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
10/03/2021 00:00:00 59.009,00

19/08/2021 12:42:30 Page 629 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.658 Ny Merli Anggraini NELAN INDAH 182881 Gentamicin Injeksi
10/03/2021 00:00:00 4.606,00 BPJS
Total 252.246,00
2.659 Marni Wati UJUNG PADANG 177033 Abbocath 20 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Candesartan tab 8 mg 681,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 3.128,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Total 183.425,00
2.660 Nur Haji ARAH TIGA 143579 abbocath 18 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
meropenem Injeksi 1 g 123.750,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Total 222.147,00
2.661 Dilah LUNANG 182882 abbocath 18 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 (Gea) 10.720,00
Aminofluid Infus 500 ml 155.204,00
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 930,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Total 294.514,00
2.662 Nur Haji ARAH TIGA 143579 Dexametason Injeksi
06/03/2021 00:00:00 9.384,00 BPJS
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Hypafix 15cmx5cm (25 c 13.088,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Amlodipine 5 mg @30 T
07/03/2021 00:00:00 101,00
Candesartan tab 8 mg 681,00
Furamin Injeksi 14.369,00
Furamin Injeksi 28.738,00
Meropenem Inj 0.5 g 165.000,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00

19/08/2021 12:42:30 Page 630 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.662 Nur Haji ARAH TIGA 143579 Sucralfate Suspensi 100 m
07/03/2021 00:00:00 19.250,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
Amlodipine 5 mg @30 T
08/03/2021 00:00:00 101,00
Candesartan tab 8 mg 681,00
Furamin Injeksi 43.107,00
Furamin Injeksi 14.369,00
Meropenem Inj 0.5 g 165.000,00
NGT (Stomach Tube) Fr. 1 60.046,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 38.152,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Amlodipine 10 mg @50 T
09/03/2021 00:00:00 118,00
Candesartan tab 8 mg 681,00
Dulcolax Sup 10 mg 55.600,00
Furamin Injeksi 14.369,00
meropenem Injeksi 1 g 123.750,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Amlodipine 10 mg @50 T
10/03/2021 00:00:00 1.180,00
Candesartan tab 8 mg 6.810,00
Cefixime kapsul 200 mg 26.480,00
Dulcolax Sup 10 mg 55.600,00
Total 1.095.173,00
2.663 Marni Wati UJUNG PADANG 177033 Abbocath 22 Terumo @5
07/03/2021 00:00:00 22.276,00 BPJS
Candesartan tab 8 mg 681,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 3.128,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (Gea) 7.425,00
Nassal Cannula O2 Anak 16.473,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Psidii Capsule 500 mg 19.604,00
Psidii Capsule 500 mg 19.604,00
Ringer Laktat Otsuka 28.614,00
Ventolin Nebules 2.5 mg 15.000,00
Bisoprolol 5 mg @100 Ta
08/03/2021 00:00:00 296,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 3.128,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 47.690,00

19/08/2021 12:42:30 Page 631 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.663 Marni Wati UJUNG PADANG 177033 Ventolin Nebules 2.5 mg
08/03/2021 00:00:00 30.000,00 BPJS
Betadine Obat Kumur
09/03/2021 00:00:00 13.750,00
Candesartan tab 8 mg 6.810,00
Furamin Injeksi 28.738,00
Omeprazole Inj 37.497,00
Paracetamol tablet 500 m 3.000,00
Ventolin Nebules 2.5 mg 20.000,00
Total 563.582,00
2.664 Syahril PASAR GEDANG 131219 Amoxicillin 500 mg @ 10
06/03/2021 00:00:00 3.060,00 BPJS
Dexametason 0,5 mg Ta 696,00
Paracetamol tablet 500 m 2.000,00
Tetagam 1 Ml Injeksi 184.000,00
Vitamin B Komplek @100 770,00
Total 190.526,00
2.665 Rosna PASAR MUKOMUKO 143640 abbocath 18 Terumo @5
06/03/2021 00:00:00 26.341,00 BPJS
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 6.249,00
Citicoline Injeksi 125mg/ 22.500,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion set Mikro (Terumo 18.026,00
Novorapid Flexpen 108.750,00
Paracetamol tablet 500 m 200,00
Ringer Laktat Otsuka 9.538,00
Abbocath 22 Terumo @5
07/03/2021 00:00:00 22.276,00
Amlodipine 5 mg @30 T 101,00
Catheter 2 Way No. 16 ( 39.025,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 90.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Urine bag 9.314,00
Amlodipine 10 mg @50 T
09/03/2021 00:00:00 1.180,00
Cefixime Kapsul 100 mg 9.380,00
Citicoline kaplet 500 mg 16.500,00
Novo Twist 32 G Tip 5.784,00
Novorapid Flexpen 108.750,00
Total 577.921,00
2.666 Dilah LUNANG 182882 Dexametason Injeksi
07/03/2021 00:00:00 6.256,00 BPJS
Dipenhydramin Injeksi 10 3.070,00
Ferro Sulfate 800,00
Furamin Injeksi 14.369,00
Furamin Injeksi 28.738,00
NonWoven Fixation 15x 13.388,00
Octalbin 25% 100 cc (Hu 1.887.500,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 3.850,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 4.210,00

19/08/2021 12:42:30 Page 632 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.666 Dilah LUNANG 182882 Cefoperazon Inj
08/03/2021 00:00:00 82.500,00 BPJS
Ferro Sulfate 800,00
Furamin Injeksi 14.369,00
Omeprazole Inj 24.998,00
Ondansetron Inj 3.300,00
Ringer Laktat Otsuka 38.152,00
Cefoperazon Inj
09/03/2021 00:00:00 82.500,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 17.100,00
Octalbin 25% 100 cc (Hu 1.887.500,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 3.850,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Furamin Injeksi
10/03/2021 00:00:00 71.845,00
Levofloxacin Tablet 500 m 6.820,00
Omeprazole Inj 49.996,00
Opilax Syr 49.156,00
Perifas @100 Tab 7.700,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 10.525,00
Total 4.488.328,00
2.667 Trimo TELUK BAKUNG 182538 Abbocath 20 Terumo @5
08/03/2021 00:00:00 52.682,00 BPJS
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Hypafix Kamar Operasi 36.000,00
Novo Twist 32 G Tip 5.784,00
Novorapid Flexpen 326.250,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Transfusi Set Terumo 16.500,00
Levofloxacin Tablet 500 m
10/03/2021 00:00:00 2.728,00
Cefixime Kapsul 100 mg
11/03/2021 00:00:00 9.380,00
Cuticell Classic 10cmx10c 35.121,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 3.000,00
Catheter 2 Way No. 18 (
15/03/2021 00:00:00 31.251,00
Urine bag 9.263,00
Total 698.387,00
2.668 Mul Kasno AGUNG JAYA 161320 Abbocath 20 Terumo @5
07/03/2021 00:00:00 26.341,00 BPJS
Aminophyllin Inj 15.536,00
Ceftriaxone Inj 12.498,00

19/08/2021 12:42:30 Page 633 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.668 Mul Kasno AGUNG JAYA 161320 Infusion Makro (Gea)
07/03/2021 00:00:00 7.425,00 BPJS
Methylprednisolone Inje 34.923,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 4.950,00
Pulmicort Resp 0.25 mg/ 0 17.884,00
Ranitidin inj 3.580,00
Ventolin Nebules 2.5 mg 15.000,00
Ventolin Nebules 2.5 mg 30.000,00
Vitamin B Komplek @100 154,00
Total 193.941,00
2.669 Turminah SIDO MAKMUR 171713 Abbocath 20 Terumo @5
07/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 52.682,00
Amlodipine 10 mg @50 T 118,00
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 99,00
Aspilet 80 mg @100 mg 138,00
Candesartan Tab 16 mg 2.358,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (Gea) 7.425,00
Infusion Makro (Gea) 7.425,00
Infusion set Mikro (Terumo 18.026,00
Levemir FlexPen 104.938,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 15x 6.694,00
Novo Twist 32 G Tip 3.856,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Amlodipine 5 mg @30 T
08/03/2021 00:00:00 101,00
Asam Folat 1 mg @100 T 297,00
Asam Folat 1 mg @100 T 396,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 15cmx5cm (25 c 6.544,00
Miniaspi 80 Mg @100 Ta 125,00
Miniaspi 80 Mg @100 Ta 500,00
Omeprazole Inj 12.499,00
Omeprazole Inj 24.998,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Amlodipine 5 mg @30 T
09/03/2021 00:00:00 145,00
Asam Folat 1 mg @100 T 297,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00

19/08/2021 12:42:30 Page 634 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.669 Turminah SIDO MAKMUR 171713 Furosemide Injeksi @2ml
09/03/2021 00:00:00 1.666,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Miniaspi 80 Mg @100 Ta 125,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Asam Folat 1 mg @100 T
10/03/2021 00:00:00 297,00
Candesartan tab 8 mg 3.405,00
Candesartan tab 8 mg 3.405,00
Miniaspi 80 Mg @100 Ta 125,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazol kapsul 20 mg 3.305,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 722.229,00
2.670 Mul Kasno AGUNG JAYA 161320 Nassal Mask O2 Dewasa
07/03/2021 00:00:00 41.828,00 BPJS
Abbocath 22 Terumo @5
08/03/2021 00:00:00 22.276,00
Aminophyllin Inj 15.536,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 18.026,00
L-Cisin tab 3.781,00
Methylprednisolone Inje 69.846,00
Methylprednisolone Inje 69.846,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
Pulmicort Resp 0.25 mg/ 0 17.884,00
Ranitidin inj 3.580,00
Ventolin Nebules 2.5 mg 30.000,00
Ventolin Nebules 2.5 mg 15.000,00
Ventolin Nebules 2.5 mg 30.000,00
abbocath 18 Terumo @5
09/03/2021 00:00:00 26.341,00
Aminophyllin Inj 23.304,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 9.666,00
Methylprednisolone Inje 69.846,00
Methylprednisolone Inje 69.846,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
Ondansetron Inj 3.300,00
Ranitidin inj 3.580,00
Three Way stopcock 25.904,00
Urine bag 9.314,00
Vectrine Tab 300 mg 10.000,00
Ventolin Nebules 2.5 mg 30.000,00
vestein 300 mg 9.350,00

19/08/2021 12:42:30 Page 635 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.670 Mul Kasno AGUNG JAYA 161320 Abbocath 14 Terumo @5
10/03/2021 00:00:00 10.443,00 BPJS
Aminophyllin Inj 23.304,00
Combivent 50.048,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 4.833,00
Methylprednisolone Inje 69.846,00
NACL 0,9 % 500 ml 17.100,00
Ranitidin inj 3.580,00
Spuit 10 cc Disposible (T 1.615,00
Spuit 50 cc non Terumo ( 8.872,00
Three Way stopcock 25.904,00
vestein 300 mg 46.750,00
Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00
Erdosteine Syr 73.150,00
Methylprednisolone Inje 69.846,00
Ondansetron Inj 1.650,00
Ranitidin inj 3.580,00
Ventolin Nebules 2.5 mg 20.000,00
Vitamin B Komplek @100 154,00
Aminophyline 200 mg @1
12/03/2021 00:00:00 5.000,00
Aminophyllin Inj 15.536,00
Cefixime kapsul 200 mg 39.720,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00
Erdosteine Syr 36.575,00
Methylprednisolone Inje 34.923,00
Methylprednisolone tab 4 3.945,00
NACL 0,9 % 500 ml 17.100,00
Ranitidin inj 3.580,00
Salbutamol 4 mg 2.325,00
Ventolin Nebules 2.5 mg 30.000,00
vestein 300 mg 46.750,00
Vitamin B Komplek @100 1.540,00
Total 1.569.014,00
2.671 Yulaeha PONDOK MAKMUR 182885 abbocath 18 Terumo @5
07/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chloramphenicol Salep M 2.351,00
Lidocain injk 40 mg/2 ml 3.222,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
oxytocin inj 2.998,00

19/08/2021 12:42:30 Page 636 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.671 Yulaeha PONDOK MAKMUR 182885 Paracetamol tablet 500 m
07/03/2021 00:00:00 600,00 BPJS
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 9.314,00
Catheter 2 Way No. 16 (
08/03/2021 00:00:00 20.625,00
Cefixime Kapsul 100 mg 9.380,00
Cefixime kapsul 200 mg 26.480,00
Paracetamol tablet 500 m 3.000,00
Phytomenadione 10 Mg/1 5.959,00
Tranexamic Acid Inj (Asa 4.210,00
Total 342.574,00
2.672 Indriyani SUNGAI RENGAS 149913 abbocath 18 Terumo @5
07/03/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 9.314,00
abbocath 18 Terumo @5 52.682,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 23.650,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
methyl ergometrin amp 4.331,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00

19/08/2021 12:42:30 Page 637 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.672 Indriyani SUNGAI RENGAS 149913 Protocin Inj
07/03/2021 00:00:00 37.620,00 BPJS
Ringer Laktat Otsuka 38.152,00
Spinocain 25 (BBraund) 42.763,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 6.796,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 9.314,00
Cefotaxime Injeksi
08/03/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Metrodinazole Infus 10.313,00
NACL 0,9 % 500 ml 17.100,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
09/03/2021 00:00:00 11.502,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 10.313,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 8.420,00
abbocath 18 Terumo @5
10/03/2021 00:00:00 52.682,00
Abbocath 20 Terumo @5 52.682,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
11/03/2021 00:00:00 1.935,00
Catheter 2 Way No. 16 ( 39.025,00
Cefixime kapsul 200 mg 26.480,00
Cefixime kapsul 200 mg 26.480,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Phytomenadione 2 Mg/1M 4.834,00
Postofix (leukomed) 36.726,00

19/08/2021 12:42:30 Page 638 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.672 Indriyani SUNGAI RENGAS 149913 Tranexamic Acid Inj (Asa
11/03/2021 00:00:00 29.470,00 BPJS
Total 2.308.090,00
2.673 Karni SELAGAN JAYA 182886 Captopril 12,5 mg
07/03/2021 00:00:00 320,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Glukosa Infus 5 % 8.626,00
Nicardipine HCl Inj 29.566,00
Omeprazole Inj 12.499,00
Phytomenadione 10 mg ( 934,00
Sucralfate Suspensi 100 m 19.250,00
Urine bag 9.314,00
Total 101.134,00
2.674 Baringgi LUBUK BANGKO 182888 Abbocath 20 Terumo @5
07/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Ambroxol 30 mg @100 T 193,00
Aqua Pro Injeksi 3.575,00
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 6.249,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Anak 16.473,00
NGT (Stomach Tube) Fr. 1 52.250,00
NGT (Stomach Tube) Fr. 1 52.250,00
Omeprazole Inj 12.499,00
Paracetamol Infus 14.438,00
Urine bag 9.314,00
Urine bag 9.314,00
Zink Tablet 689,00
Total 370.252,00
2.675 Brayyan Akbar DUSUN JARANG 182889 Abbocath 24 Terumo @5
07/03/2021 00:00:00 26.341,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Aqua Pro Injeksi 3.575,00
Dexametason Injeksi 3.128,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En 1 B 12.658,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 bayi 9.530,00
Nebulizer O2 Bayi 60.626,00
NGT (Feeding tube) Fr. 5 17.603,00
Paracetamol Infus 14.438,00
Ventolin Nebules 2.5 mg 5.000,00
Total 203.762,00
2.676 Ny.indriyani SUNGAI RENGAS 182891 Bisturi No. 23
07/03/2021 00:00:00 3.836,00 BPJS
Nassal Cannula O2 bayi 9.530,00

19/08/2021 12:42:30 Page 639 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.676 Ny.indriyani SUNGAI RENGAS 182891 NGT (Feeding tube) Fr. 5
07/03/2021 00:00:00 17.603,00 BPJS
umbilical Cord Clamp 2.261,00
Total 33.230,00
2.677 Karni SELAGAN JAYA 182886 Infusion set Mikro (Terumo
07/03/2021 00:00:00 18.026,00 BPJS
Nicardipine HCl Inj 29.566,00
Asam Folat 1 mg @100 T
08/03/2021 00:00:00 297,00
Asam Folat 1 mg @100 T 297,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 8.626,00
Glukosa Infus 5 % 17.252,00
Nicardipine HCl Inj 29.566,00
Omeprazole Inj 12.499,00
Omeprazole Inj 24.998,00
Phytomenadione 10 mg ( 2.802,00
Phytomenadione 10 Mg/1 17.877,00
Phytomenadione 10 Mg/1 41.713,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Vitamin B Komplek @100 308,00
Ceftriaxone Inj
09/03/2021 00:00:00 12.498,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
NACL 0,9 % 500 ml 8.550,00
Nicardipine HCl Inj 29.566,00
Omeprazole Inj 12.499,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Amlodipine 10 mg @50 T
10/03/2021 00:00:00 590,00
Asam Traneksamat @10 31.575,00
Candesartan Tab 16 mg 28.875,00
Glukosa Infus 5 % 8.626,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Sucralfate Suspensi 100 m 19.250,00
Total 510.181,00
2.678 Baringgi LUBUK BANGKO 182888 Abbocath 20 Terumo @5
07/03/2021 00:00:00 26.341,00 BPJS
Cetadop inj 7.700,00
Dobutamin Injeksi 50 mg 14.536,00
Electroda (Ambu) @25 Pc 81.570,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 36.052,00
NACL 0,9 % 500 ml 17.100,00
Three Way stopcock 25.904,00
Three Way stopcock 25.904,00
Ambroxol 30 mg @100 T
08/03/2021 00:00:00 193,00
Catheter 2 Way No. 16 ( 20.625,00
Epinephrin inj 30.662,00
Glukosa Infus 5 % 8.626,00

19/08/2021 12:42:30 Page 640 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.678 Baringgi LUBUK BANGKO 182888 Omeprazole Inj
08/03/2021 00:00:00 12.499,00 BPJS
Zink Tablet 689,00
Total 335.626,00
2.679 Sulaimah TIRTA MAKMUR 182892 Amlodipine 10 mg @50 T
07/03/2021 00:00:00 118,00 BPJS
Citicoline Injeksi 125mg/ 11.250,00
Abbocath 20 Terumo @5
08/03/2021 00:00:00 26.341,00
Aqua Pro Injeksi 3.575,00
Candesartan tab 8 mg 681,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Citicoline Injeksi 125mg/ 22.500,00
Glukosa Infus 5 % 8.626,00
Glukosa Infus 5 % 25.878,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Mecobalamin 500 mg 2.310,00
Miniaspi 80 Mg @100 Ta 125,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Piracetam injek 200 mg 17.325,00
Piracetam tablet 1200 m 4.188,00
Sucralfate Suspensi 100 m 19.250,00
Candesartan tab 8 mg
09/03/2021 00:00:00 681,00
Ceftriaxone Inj 12.498,00
Citicoline Injeksi 125mg/ 22.500,00
Glukosa Infus 5 % 8.626,00
Hypafix 15cmx5cm (25 c 13.088,00
Infusion set Mikro (Terumo 18.026,00
Mecobalamin 500 mg 2.310,00
Mecobalamin 500 mg 770,00
Miniaspi 80 Mg @100 Ta 125,00
Omeprazole Inj 12.499,00
Piracetam injek 200 mg 17.325,00
Aspilet 80 mg @100 mg
10/03/2021 00:00:00 690,00
Candesartan tab 8 mg 3.405,00
Candesartan tab 8 mg 3.405,00
Citicoline kaplet 500 mg 16.500,00
Citicoline kaplet 500 mg 16.500,00
Glukosa Infus 5 % 8.626,00
Mecobalamin 500 mg 11.550,00
Mecobalamin 500 mg 11.550,00
Miniaspi 80 Mg @100 Ta 625,00
Miniaspi 80 Mg @100 Ta 625,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 24.998,00
Piracetam tab 800 mg 11.295,00
Piracetam tablet 1200 m 13.960,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 641 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.679 Sulaimah TIRTA MAKMUR 182892 Sucralfate Suspensi 100 m
10/03/2021 00:00:00 19.250,00 BPJS
Sucralfate Suspensi 100 m 19.250,00
Total 552.580,00
2.680 Brayyan Akbar DUSUN JARANG 182889 Abbocath 24 Terumo @5
08/03/2021 00:00:00 79.023,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Dexametason Injeksi 3.128,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 13.088,00
Infusion set Mikro (Terumo 18.026,00
Injection plug 20.213,00
NGT (Feeding Tube) Fr. 8 70.420,00
Ottogenta inj 9.900,00
Paracetamol Infus 14.438,00
Transfusi Set Terumo 16.500,00
Hypafix 15cmx5cm (25 c
09/03/2021 00:00:00 26.176,00
Ka-En 1 B 12.658,00
Abbocath 24 Terumo @5
10/03/2021 00:00:00 79.023,00
Ampicilin Serbuk Injeksi 1 64.866,00
Hypafix 10cm x 5cm (25 c 9.700,00
Sibital Injeksi (Phenobarbit 24.750,00
Abbocath 24 Terumo @5
13/03/2021 00:00:00 105.364,00
Abbocath 24 Terumo @5 52.682,00
Ampicilin Serbuk Injeksi 1 21.622,00
Aqua Pro Injeksi 3.575,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol syrup 1.388,00
Phenobarbital Tablet 30 m 3.240,00
Miconazole krim 2 %
15/03/2021 00:00:00 4.481,00
Nystatin Drop 27.830,00
Total 716.908,00
2.681 Yutina AGRO SARI 128952 abbocath 18 Terumo @5
08/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Alkohol 1Liter 42.111,00
Asam Traneksamat @10 6.315,00
ATRACURIUM BESYLATE 2 29.342,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 94.600,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Ephedrine Injeksi 53.555,00

19/08/2021 12:42:30 Page 642 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.681 Yutina AGRO SARI 128952 Gelaufusal Infusion 500 m
08/03/2021 00:00:00 181.269,00 BPJS
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 4.035,00
KTM (ketamin) Injeksi 214.500,00
Masker Tali 41.600,00
Massa Cauter Dewasa 90.240,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 34.200,00
NonWoven Fixation 15x 20.082,00
Oxytetracycline Salep Ma 9.753,00
Polypropylene 3/0 C (Ass 235.200,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Urine bag 9.314,00
viamac 1 R 364.370,00
viamac 1 R 182.185,00
Cefotaxime Injeksi
09/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
10/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
11/03/2021 00:00:00 1.935,00
Cefixime kapsul 200 mg 26.480,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Spinocain 27 (BBraund) 47.875,00
Tranexamic Acid Inj (Asa 6.315,00
Total 2.672.313,00

19/08/2021 12:42:30 Page 643 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.682 Suhadi RAWA MULYA 143895 Abbocath 20 Terumo @5
08/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Candesartan Tab 16 mg 1.179,00
Citicoline Injeksi 125mg/ 22.500,00
Glukosa Infus 5 % 8.626,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Miniaspi 80 Mg @100 Ta 125,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Piracetam injek 200 mg 17.325,00
Sucralfate Suspensi 100 m 19.250,00
Glukosa Infus 5 % 25.878,00
Ambroxol Syr 15mg/ml
09/03/2021 00:00:00 4.538,00
Candesartan Tab 16 mg 5.775,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 0,00
Ceftriaxone Inj 12.498,00
Cetirgi Tab 10 mg 4.644,00
Citicoline Injeksi 125mg/ 11.250,00
Citicoline Injeksi 125mg/ 22.500,00
Glukosa Infus 5 % 0,00
Glukosa Infus 5 % 25.878,00
Hypafix 10cm x 5cm (25 c 4.850,00
Mecobalamin 500 mg 2.310,00
Mecobalamin 500 mg 2.310,00
Miniaspi 80 Mg @100 Ta 125,00
Miniaspi 80 Mg @100 Ta 125,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Piracetam injek 200 mg 5.775,00
Piracetam injek 200 mg 17.325,00
Abbocath 22 Terumo @5
10/03/2021 00:00:00 0,00
Amlodipine 10 mg @50 T 590,00
Candesartan Tab 16 mg 11.550,00
Candesartan tab 8 mg 3.405,00
Ceftriaxone Inj 6.249,00
Citicoline Injeksi 125mg/ 0,00
Loratadine tab 10 mg 332,00
Mecobalamin 500 mg 2.310,00
Omeprazol kapsul 20 mg 3.305,00
Piracetam injek 200 mg 0,00
Piracetam tab 800 mg 11.295,00
Sucralfate Suspensi 100 m 19.250,00
Total 386.560,00
2.683 Slamet SILAUT 113415 Candesartan tab 8 mg
08/03/2021 00:00:00 20.430,00 BPJS
Omeprazol kapsul 20 mg 19.830,00
Spironolaktone 25 mg 7.800,00
Total 48.060,00
2.684 Sakinem SUMBER MULYA 182762 Methylprednisolone tab 4
08/03/2021 00:00:00 7.890,00 BPJS
Omeprazol kapsul 20 mg 19.830,00
Total 27.720,00

19/08/2021 12:42:30 Page 644 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.685 Rosdiyanto UJUNG PADANG 181443 Propanolol tab 10 mg
09/03/2021 00:00:00 6.660,00 BPJS
Propylthiourasil 100 mg ( 58.770,00
Total 65.430,00
2.686 Bina Sutra SUNGAI IPUH I 157275 Gabapentin kapsul 300 m
08/03/2021 00:00:00 12.690,00 BPJS
Glimepiride tab 2 mg 7.770,00
Mecobalamin 500 mg 15.400,00
Metformin tablet 500 mg 7.980,00
Total 43.840,00
2.687 Toha TANJUNG MULYA 176822 Acetylcystein 200 mg Ka
08/03/2021 00:00:00 24.066,00 BPJS
Acetylcystein 200 mg Ka 24.066,00
Acetylcystein 200 mg Ka 3.438,00
Erphafillin Tab 7.380,00
Onbrez Breezhaler HGCI 0 440.640,00
Salbutamol 2 mg 1.580,00
Total 501.170,00
2.688 Effendi penarik 181556 Cefixime Kapsul 100 mg
08/03/2021 00:00:00 9.380,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Piralen tab 4.540,00
Sucralfate Suspensi 100 m 19.250,00
Total 39.780,00
2.689 Etri Nuryanti PONDOK MAKMUR 182727 Asam Mefenamat 500 m
08/03/2021 00:00:00 1.290,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 42.066,00
2.690 Tarani TUNGGANG 164476 Hexymer 2 Mg Tab (THP)
08/03/2021 00:00:00 28.680,00 BPJS
Leparson tablet 164.400,00
Sifrol tab 0,375 mg 311.250,00
Total 504.330,00
2.691 Setia Wati LUNANG 182424 Postofix (leukomed)
08/03/2021 00:00:00 36.726,00 BPJS
Total 36.726,00
2.692 Winda Mutiara Indah SILAUT 181956 Postofix (leukomed)
08/03/2021 00:00:00 36.726,00 BPJS
Total 36.726,00
2.693 Sugito MEKAR MULYA 147062 NACL 0,9 % 500 ml
08/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.694 Narti SILAUT 175653 NACL 0,9 % 500 ml
08/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.695 Darmawan LUBUK PINANG 140187 NACL 0,9 % 500 ml
08/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.696 Widaryanti AIR HITAM 179916 Asam Mefenamat 500 m
08/03/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 47.656,00
2.697 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
08/03/2021 00:00:00 42.750,00 BPJS
Otsu D40 25.026,00
Renogen 3000 UI 116.875,00
Total 184.651,00
2.698 Zainal Asri TUNGGANG 179690 Amlodipine 10 mg @50 T
08/03/2021 00:00:00 3.540,00 BPJS
Candesartan tab 8 mg 20.430,00

19/08/2021 12:42:30 Page 645 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.698 Zainal Asri TUNGGANG 179690 Piracetam tablet 1200 m
08/03/2021 00:00:00 41.880,00 BPJS
Total 65.850,00
2.699 Rosdin Efendi BANDARATU 138467 Gentamicin Injeksi
08/03/2021 00:00:00 4.606,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Otsu D40 25.026,00
Renogen 3000 UI 116.875,00
Total 189.257,00
2.700 Rila Santika ARAH TIGA 126526 Postofix (leukomed)
08/03/2021 00:00:00 36.726,00 BPJS
Total 36.726,00
2.701 Valentin Dea Fransisk PT AGRO TRE 182908 Alprazolam 0,5 mg @100
08/03/2021 00:00:00 1.180,00 BPJS
Neurodex tablet 7.410,00
Total 8.590,00
2.702 Suarmi TIRTA KENCANA 111144 Ibuprofen tab 400 mg
08/03/2021 00:00:00 4.580,00 BPJS
Mecobalamin 500 mg 7.700,00
Omeprazol kapsul 20 mg 6.610,00
Total 18.890,00
2.703 Rahmat PT. AGRO AIR BULUH E 146991 Bisoprolol 5 mg @100 Ta
08/03/2021 00:00:00 4.440,00 BPJS
Captopril 12,5 mg 2.400,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 6.610,00
Total 17.200,00
2.704 Erma Wati KOTO JAYA 157023 Omeprazol kapsul 20 mg
08/03/2021 00:00:00 6.610,00 BPJS
Paracetamol tablet 500 m 2.000,00
vestein 300 mg 70.125,00
Total 78.735,00
2.705 Zuriati SIBAK 182910 Mecobalamin 500 mg
08/03/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 7.280,00
Total 14.980,00
2.706 Musli Hadaya LUBUK GEDANG 182096 Asam Mefenamat 500 m
08/03/2021 00:00:00 1.935,00 BPJS
Asam Traneksamat @10 42.100,00
Fluconazole tab 150 mg 491.420,00
Phytomenadione 10 mg ( 9.340,00
Total 544.795,00
2.707 Samsuar NELAN INDAH 137270 Cetirgi Tab 10 mg
08/03/2021 00:00:00 15.480,00 BPJS
Neurodex tablet 7.410,00
Total 22.890,00
2.708 Mariatul NELAN INDAH 136649 Captopril 12,5 mg
08/03/2021 00:00:00 2.400,00 BPJS
Codein tab 10 mg 7.500,00
Furosemide 40 mg Tablet 5.760,00
Miniaspi 80 Mg @100 Ta 3.750,00
Omeprazol kapsul 20 mg 19.830,00
Spironolaktone 100 mg 21.570,00
Total 60.810,00
2.709 Acit Juarsih TANJUNG MULYA 182918 Mecobalamin 500 mg
08/03/2021 00:00:00 7.700,00 BPJS
Meloxicam 7,5 mg 21.840,00
Omeprazol kapsul 20 mg 39.660,00
Piralen tab 9.080,00
Total 78.280,00
2.710 Tazia Ayu Maningsih PAUH TERENJA 153435 Asam Folat 1 mg @100 T
08/03/2021 00:00:00 2.970,00 BPJS
Valproic Acid Syrup 250mg 62.925,00
Total 65.895,00
2.711 Azolla Elvi Junita PONDOK TALANG 182921 Alkohol 1Liter
08/03/2021 00:00:00 42.111,00 BPJS

19/08/2021 12:42:30 Page 646 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.711 Azolla Elvi Junita PONDOK TALANG 182921 Bisturi No. 23
08/03/2021 00:00:00 46.032,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cauter (Hand-controlled P 324.322,00
Celemek Plastik 94.600,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Iodine povidone 300 ml 28.463,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 20.082,00
Polypropylene 3/0 C (Ass 235.200,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suction no. 1/4 51.900,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Total 2.032.290,00
2.712 Ahmad Mujiono MARGA MULYA SAKTI 113737 Gabapentin kapsul 300 m
08/03/2021 00:00:00 12.690,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Total 163.765,00
2.713 Miswanto LUNANG 128267 NACL 0,9 % 500 ml
08/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.714 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
08/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.715 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
08/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.716 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
08/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00

19/08/2021 12:42:30 Page 647 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.717 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
08/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.718 Echa Dwi Hartika DUSUN BARU PELOKA 171670 Catheter 2 Way No. 16 (
08/03/2021 00:00:00 39.025,00 BPJS
Chromic catgut 2-0 R (Tr 144.500,00
Handscoond Non Steril S 8.512,50
Lidocain injk 40 mg/2 ml 3.222,50
Masker Tali 41.600,00
Misoprostol Tab 16.500,00
Myotonic inj 29.392,50
Oxytetracycline Salep Ma 3.251,25
Phytomenadione 2 Mg/1M 4.833,75
Protocin Inj 18.810,00
Suction Chateter no. 8 (R 20.625,00
Topi Operasi (Perawat) @ 4.687,50
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,25
Urine bag 9.313,75
Cefixime Kapsul 100 mg
09/03/2021 00:00:00 9.375,00
Paracetamol tablet 500 m 3.000,00
Paracetamol tablet 500 m 3.000,00
Total 366.120,00
2.719 Murni SUNGAI LINTANG 182912 Abbocath 20 Terumo @5
08/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon Steril 8.5 (Ga 14.554,00
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Infusion Makro (Gea) 7.425,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 3.300,00
Propofol Lipuro 1% 75.900,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00

19/08/2021 12:42:30 Page 648 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.719 Murni SUNGAI LINTANG 182912 Spuit 5 cc Disposible
08/03/2021 00:00:00 2.840,00 BPJS
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Total 686.929,00
2.720 Dika Love vina PENARIK 159965 abbocath 18 Terumo @5
08/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 83.990,00
2.721 M.renza PONDOK SUGUH 176594 Asam Folat 1 mg @100 T
08/03/2021 00:00:00 99,00 BPJS
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Vitamin C 500 mg 1,00
Dexametason Injeksi
09/03/2021 00:00:00 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Total 9.426,00
2.722 Dika Love vina PENARIK 159965 Bisturi No. 23
08/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 104.362,00
Catheter 2 Way No. 16 ( 20.625,00
Celemek Plastik 94.600,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoond Non Steril S 8.510,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Iodine povidone 300 ml 28.463,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 75.000,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 20.082,00
Polypropylene 3/0 C (Ass 235.200,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Total 1.664.092,00
2.723 Syahminar LUBUK PINANG 147670 abbocath 18 Terumo @5
08/03/2021 00:00:00 26.341,00 BPJS

19/08/2021 12:42:30 Page 649 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.723 Syahminar LUBUK PINANG 147670 Amlodipine 5 mg @30 T
08/03/2021 00:00:00 101,00 BPJS
Aspilet 80 mg @100 mg 138,00
Citicoline Injeksi 125mg/ 45.000,00
Electroda (Ambu) @25 Pc 81.570,00
Infusion set Mikro (Terumo 18.026,00
NACL 0,9 % 500 ml 17.100,00
NGT (Stomach Tube) Fr. 1 60.046,00
NGT (Stomach Tube) Fr. 1 52.250,00
Ranitidin inj 3.580,00
Simvastatin tab 20 mg 311,00
Total 304.463,00
2.724 Dika Love vina PENARIK 159965 Asam Traneksamat @10
08/03/2021 00:00:00 6.315,00 BPJS
Cefotaxime Injeksi 17.253,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Cefotaxime Injeksi
09/03/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 13.088,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
10/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
11/03/2021 00:00:00 1.935,00
Cefixime kapsul 200 mg 26.480,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 260.512,00
2.725 Murni SUNGAI LINTANG 182912 Cefotaxime Injeksi
08/03/2021 00:00:00 11.502,00 BPJS
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 600,00
Asam Mefenamat 500 m
09/03/2021 00:00:00 1.290,00
Cefixime Kapsul 100 mg 9.380,00
Misoprostol Tab 55.000,00
Total 94.272,00
2.726 Azolla Elvi Junita PONDOK TALANG 182921 Cefotaxime Injeksi
09/03/2021 00:00:00 11.502,00 BPJS
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
10/03/2021 00:00:00 11.502,00

19/08/2021 12:42:30 Page 650 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.726 Azolla Elvi Junita PONDOK TALANG 182921 Hypafix 10cm x 5cm (25 c
10/03/2021 00:00:00 4.850,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
11/03/2021 00:00:00 1.935,00
Catheter 2 Way No. 16 ( 39.025,00
Cefixime kapsul 200 mg 26.480,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Phytomenadione 10 mg ( 934,00
Postofix (leukomed) 36.726,00
Total 291.170,00
2.727 Syahminar LUBUK PINANG 147670 Amlodipine 5 mg @30 T
09/03/2021 00:00:00 145,00 BPJS
Citicoline Injeksi 125mg/ 67.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 17.100,00
Ranitidin inj 1.790,00
Simvastatin tab 10 mg 241,00
Amlodipine 10 mg @50 T
10/03/2021 00:00:00 590,00
Aspilet 80 mg @100 mg 1.380,00
Citicoline Injeksi 125mg/ 90.000,00
Citicoline kaplet 500 mg 16.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ranitidin inj 1.790,00
Ranitidine tablet 150 mg 1.440,00
Simvastatin tab 10 mg 2.410,00
Total 227.686,00
2.728 Tasali PONDOK MAKMUR 182924 Abbocath 20 Terumo @5
09/03/2021 00:00:00 0,00 BPJS
Aminophyllin Inj 0,00
Aminophyllin Inj 0,00
Aqua Pro Injeksi 0,00
Catheter 2 Way No. 16 ( 0,00
Ceftriaxone Inj 0,00
Ceftriaxone Inj 0,00
Combivent 0,00
Combivent 0,00
Dexametason Injeksi 0,00
Electroda (Ambu) @25 Pc 0,00
Electroda (Ambu) @25 Pc 0,00
Erdosteine Syr 0,00
Hypafix 10cm x 5cm (25 c 0,00
Hypafix 10cm x 5cm (25 c 0,00
Infusion Makro (terumo) 0,00
Nassal Cannula O2 Dewas 0,00
Nassal Mask O2 Dewasa 0,00
Pulmicort Resp 0.25 mg/ 0 0,00
Ringer Laktat Otsuka 0,00
Ringer Laktat Otsuka 0,00
Urine bag 0,00
Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00

19/08/2021 12:42:30 Page 651 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.728 Tasali PONDOK MAKMUR 182924 Aminophyllin Inj
10/03/2021 00:00:00 7.768,00 BPJS
Aminophyllin Inj 15.536,00
Aminophyllin Inj 15.536,00
Amlodipine 5 mg @30 T 202,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Combivent 62.560,00
Combivent 37.536,00
Combivent 37.536,00
Dexametason Injeksi 6.256,00
Electroda (Ambu) @25 Pc 163.140,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 13.088,00
Infusion Makro (terumo) 27.225,00
Methylprednisolone Inje 69.846,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Mask O2 Dewasa 41.828,00
Pulmicort Resp 0.25 mg/ 0 89.420,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 57.228,00
Ringer Laktat Otsuka 19.076,00
Urine bag 9.314,00
vestein 300 mg 9.350,00
vestein syr 48.125,00
Aminophyllin Inj
11/03/2021 00:00:00 15.536,00
Candesartan tab 8 mg 3.405,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 6.249,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Aminophyllin Inj
12/03/2021 00:00:00 15.536,00
Amlodipine 5 mg @30 T 101,00
Ceftriaxone Inj 12.498,00
Combivent 12.512,00
Combivent 12.512,00
Combivent 50.048,00
Methylprednisolone Inje 69.846,00
NGT (Stomach Tube) Fr. 1 60.046,00
Omeprazole Inj 12.499,00
OMZ 90.000,00
Paracetamol tablet 500 m 2.000,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Pulmicort Resp 0.25 mg/ 0 71.536,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 652 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.728 Tasali PONDOK MAKMUR 182924 vestein 300 mg
12/03/2021 00:00:00 18.700,00 BPJS
Azitromycin 500 mg
13/03/2021 00:00:00 28.125,00
Meropenem Inj 0.5 g 165.000,00
meropenem Injeksi 1 g 123.750,00
Ringer Laktat Otsuka 19.076,00
Amlodipine 10 mg @50 T
14/03/2021 00:00:00 118,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 800,00
Amlodipine 10 mg @50 T
15/03/2021 00:00:00 590,00
Azitromycin 500 mg 5.625,00
Erdosteine Syr 36.575,00
meropenem Injeksi 1 g 123.750,00
Nebulizer O2 Dewasa 34.783,00
Omeprazole Inj 12.499,00
OMZ 270.000,00
Paracetamol tablet 500 m 800,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Ventolin Nebules 2.5 mg 20.000,00
vestein syr 48.125,00
Azitromycin 500 mg
16/03/2021 00:00:00 16.875,00
Cefixime Kapsul 100 mg 9.380,00
Erdosteine Syr 36.575,00
NGT (Stomach Tube) Fr. 1 52.250,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 2.976.850,00
2.729 Enfarina PT AGROMUKO PENAR 144179 Abbocath 20 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
OMZ 90.000,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 154,00
Metoclopramide inj 5Mg/M
10/03/2021 00:00:00 17.637,00
Omeprazol kapsul 20 mg 1.322,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Curcuma Tab
11/03/2021 00:00:00 3.810,00

19/08/2021 12:42:30 Page 653 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.729 Enfarina PT AGROMUKO PENAR 144179 Dexametason Injeksi
11/03/2021 00:00:00 9.384,00 BPJS
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Dipenhydramin Injeksi 10 4.605,00
Furosemide Injeksi @2ml 4.998,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 13.088,00
Hypafix 15cmx5cm (25 c 19.632,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Domperidone Tab
12/03/2021 00:00:00 1.080,00
Metoclopramide inj 5Mg/M 35.274,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 541.537,00
2.730 Nurhayati SEMUNDAM 182925 Abbocath 20 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS
Amlodipine 5 mg @30 T 101,00
Aqua Pro Injeksi 3.575,00
Infusion Makro (Gea) 7.425,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Simvastatin tab 10 mg 482,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 154,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Amlodipine 10 mg @50 T
10/03/2021 00:00:00 1.180,00
Amlodipine 10 mg @50 T 590,00
Curcuma Tab 8.890,00
Domperidone Syrup 5mg 10.279,00
Domperidone Tab 1.620,00
Omeprazol kapsul 20 mg 9.915,00
Omeprazol kapsul 20 mg 13.220,00
Paracetamol tablet 500 m 4.000,00
Paracetamol tablet 500 m 3.000,00
Simvastatin tab 10 mg 2.410,00
Simvastatin tab 10 mg 4.820,00
Sucralfate Suspensi 100 m 19.250,00
Total 221.098,00
2.731 Yenti Komala Sari TUNGGANG 160442 abbocath 18 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS

19/08/2021 12:42:30 Page 654 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.731 Yenti Komala Sari TUNGGANG 160442 Aqua Pro Injeksi
09/03/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 13.088,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 5.500,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
oxytocin inj 2.998,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
10/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Paracetamol tablet 500 m 600,00
Tranexamic Acid Inj (Asa 6.315,00
abbocath 18 Terumo @5
11/03/2021 00:00:00 52.682,00
Abbocath 22 Terumo @5 22.276,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 655 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.731 Yenti Komala Sari TUNGGANG 160442 Asam Mefenamat 500 m
12/03/2021 00:00:00 1.290,00 BPJS
Bisturi No. 15 3.836,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
NGT (Feeding tube) Fr. 5 17.603,00
NonWoven Fixation 15x 13.388,00
Oxytetracycline Salep Ma 3.251,00
Phytomenadione 2 Mg/1M 4.834,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 18.945,00
umbilical Cord Clamp 2.261,00
Total 1.800.793,00
2.732 Safrin LUBUK BANGKO 160300 Abbocath 20 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS
Aminophyllin Inj 7.768,00
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Combivent 37.536,00
Electroda (Ambu) @25 Pc 81.570,00
Erdosteine Syr 36.575,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Nebulizer O2 Dewasa 34.783,00
Paracetamol tablet 500 m 800,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Urine bag 9.314,00
Aminophyllin Inj 15.536,00
Amlodipine 10 mg @50 T 590,00
Bionicom Zink 2,00
Catheter 2 Way No. 16 ( 20.625,00
Combivent 12.512,00
Combivent 50.048,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 6.256,00
Glukosa Infus 5 % 8.626,00
Glukosa Infus 5 % 17.252,00
meropenem Injeksi 1 g 82.500,00
meropenem Injeksi 1 g 123.750,00
Oseltamivir 75 mg 2,00
Oseltamivir 75 mg 2,00
Paracetamol tablet 500 m 800,00
Phytomenadione 10 Mg/1 11.918,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 9.314,00
Ventolin Nebules 2.5 mg 10.000,00

19/08/2021 12:42:30 Page 656 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.732 Safrin LUBUK BANGKO 160300 Venturi Mask Dewasa Ge
09/03/2021 00:00:00 34.375,00 BPJS
vestein syr 48.125,00
Aminophyllin Inj
10/03/2021 00:00:00 15.536,00
Amlodipine 10 mg @50 T 590,00
Ascorbid Acid 1000mg/5m 78.375,00
Dexametason Injeksi 6.256,00
Glukosa Infus 5 % 34.504,00
meropenem Injeksi 1 g 123.750,00
Paracetamol tablet 500 m 800,00
Phytomenadione 10 Mg/1 11.918,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ranitidin inj 3.580,00
Ventolin Nebules 2.5 mg 30.000,00
vestein 300 mg 46.750,00
Zinc Sulfate Syr 60 ml 4.569,00
Aminophyllin Inj
11/03/2021 00:00:00 23.304,00
Amlodipine 10 mg @50 T 636,00
Dexametason Injeksi 9.384,00
meropenem Injeksi 1 g 123.750,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ventolin Nebules 2.5 mg 30.000,00
Zinc Sulfate Syr 60 ml 4.569,00
Aminophyllin Inj
12/03/2021 00:00:00 15.536,00
Ascorbid Acid 1000mg/5m 52.250,00
Dexametason Injeksi 6.256,00
Erdosteine Syr 36.575,00
Glukosa Infus 5 % 17.252,00
Meropenem Inj 0.5 g 165.000,00
Paracetamol tablet 500 m 800,00
Ranitidin inj 5.370,00
Ventolin Nebules 2.5 mg 30.000,00
Venturi Mask Dewasa Ge 34.375,00
Aminophyllin Inj
13/03/2021 00:00:00 15.536,00
Ascorbid Acid 1000mg/5m 26.125,00
Candesartan Tab 16 mg 2.358,00
Dexametason Injeksi 6.256,00
Glukosa Infus 5 % 25.878,00
meropenem Injeksi 1 g 82.500,00
Paracetamol tablet 500 m 2.000,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ranitidin inj 3.580,00
Ventolin Nebules 2.5 mg 25.000,00
vestein 300 mg 46.750,00
Zink Tablet 6.890,00
Acetylcystein 200 mg Ka
14/03/2021 00:00:00 5.157,00
Amlodipine 10 mg @50 T 354,00
Ascorbid Acid 1000mg/5m 130.625,00
Candesartan tab 8 mg 2.043,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 9.384,00
Dipenhydramin Injeksi 10 1.535,00

19/08/2021 12:42:30 Page 657 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.732 Safrin LUBUK BANGKO 160300 Furosemide Injeksi @2ml
14/03/2021 00:00:00 1.666,00 BPJS
Glukosa Infus 5 % 17.252,00
Levofloxacin Infus 24.488,00
meropenem Injeksi 1 g 123.750,00
Paracetamol tablet 500 m 1.000,00
Pulmicort Resp 0.25 mg/ 0 89.420,00
Ranitidin inj 5.370,00
Ventolin Nebules 2.5 mg 25.000,00
Aminophyllin Inj
15/03/2021 00:00:00 31.072,00
Ascorbid Acid 1000mg/5m 52.250,00
Bisoprolol 5 mg @100 Ta 2.960,00
Candesartan Tab 16 mg 5.895,00
Erdosteine Syr 36.575,00
Glukosa Infus 5 % 25.878,00
Levofloxacin Infus 24.488,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ranitidin inj 3.580,00
Ventolin Nebules 2.5 mg 20.000,00
Amlodipine 10 mg @50 T
16/03/2021 00:00:00 1.180,00
Ascorbid Acid 1000mg/5m 52.250,00
Candesartan Tab 16 mg 5.895,00
Candesartan tab 8 mg 6.810,00
Dexametason Injeksi 6.256,00
Furosemide 40 mg Tablet 960,00
Glukosa Infus 5 % 25.878,00
Ranitidin inj 5.370,00
Abbocath 22 Terumo @5
17/03/2021 00:00:00 11.138,00
Ceftriaxone Inj 24.996,00
Levofloxacin Infus 73.464,00
Paracetamol Infus 57.752,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Ranitidin inj 3.580,00
Ventolin Nebules 2.5 mg 20.000,00
Furosemide 40 mg Tablet
18/03/2021 00:00:00 960,00
Paracetamol tablet 500 m 2.000,00
Salbutamol 2 mg 790,00
Zink Tablet 6.890,00
Total 3.149.799,00
2.733 Sri Lestari Hernaningsi TALANG MEDAN 170825 Asam Mefenamat 500 m
09/03/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Dexametason 0,5 mg Ta 1.160,00
Total 8.040,00
2.734 Taufik MANDI ANGIN JAYA 182928 Asam Mefenamat 500 m
09/03/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Methylprednisolone tab 4 2.630,00
Total 9.510,00
2.735 Kamal Huda TANAH REKAH 182740 CAL-95 tab
09/03/2021 00:00:00 62.700,00 BPJS
Total 62.700,00
2.736 Joni Suhendri PENARIK 161634 Amlodipine 5 mg @30 T
09/03/2021 00:00:00 1.450,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 3.450,00
2.737 Nining Arissetia Ningsi LUNANG SILAUT 146176 Ambroxol Syr 15mg/ml
09/03/2021 00:00:00 4.538,00 BPJS

19/08/2021 12:42:30 Page 658 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.737 Nining Arissetia Ningsi LUNANG SILAUT 146176 Glimepiride tab 2 mg
09/03/2021 00:00:00 2.590,00 BPJS
Metformin tablet 500 mg 1.330,00
Pregabalin Kap 75 mg 64.460,00
ursodeoxycholic acid 28.350,00
Total 101.268,00
2.738 Yunia Ramadani SUNGAI IPUH 145845 Anti Hemoroid
09/03/2021 00:00:00 20.780,00 BPJS
Total 20.780,00
2.739 Deli Puspita Sari LUNANG 159997 Ondansetron 4mg
09/03/2021 00:00:00 16.360,00 BPJS
Total 16.360,00
2.740 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.741 Salami SILAUT I 134774 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.742 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.743 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.744 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.745 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.746 Abu Salim LUBUK SANAI 182781 Candesartan tab 8 mg
09/03/2021 00:00:00 13.620,00 BPJS
Digoxsin tab 0,25 mg 720,00
Spironolaktone 25 mg 2.600,00
ursodeoxycholic acid 28.350,00
Total 45.290,00
2.747 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.748 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.749 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
09/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.750 Raki SIDO DADI 182856 Cefixime Kapsul 100 mg
09/03/2021 00:00:00 9.380,00 BPJS
Ketoprofen tab 100 mg 18.570,00
Total 27.950,00
2.751 Sugiyono RAWA MULYA 182774 Cuticell Classic 10cmx10c
09/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 55.611,00
2.752 Umi Masfufah TANAH HARAPAN 180160 Abbocath 14 Terumo @5
09/03/2021 00:00:00 10.443,00 BPJS
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 9.384,00

19/08/2021 12:42:30 Page 659 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.752 Umi Masfufah TANAH HARAPAN 180160 Infusion Makro (terumo)
09/03/2021 00:00:00 27.225,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 4.210,00
Total 80.913,00
2.753 Ari Antoni PONDOK PANJANG 182729 Flunarizine 5 mg tab
09/03/2021 00:00:00 24.750,00 BPJS
Paracetamol tablet 500 m 2.000,00
Zink Tablet 6.890,00
Total 33.640,00
2.754 Yulia Hastuti BANDAR RATU 114122 Betahistin Mesilat 6 mg @
09/03/2021 00:00:00 2.070,00 BPJS
Flunarizine 5 mg tab 24.750,00
Mecobalamin 500 mg 7.700,00
Total 34.520,00
2.755 Rini Nova riani RANAH KARYA 182731 Asam Mefenamat 500 m
09/03/2021 00:00:00 1.290,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 61.121,00
2.756 Ponirin TIRTA MULYA 182736 Cuticell Classic 10cmx10c
09/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 55.611,00
2.757 Heru Cahyono PENARIK 182785 Paracetamol tablet 500 m
09/03/2021 00:00:00 2.000,00 BPJS
Total 2.000,00
2.758 Siti Pertiwi LUBUK SAHUNG 177876 Alinamin F 50 mg @100 T
09/03/2021 00:00:00 11.500,00 BPJS
Flunarizine 5 mg tab 24.750,00
Levofloxacin Tablet 500 m 13.640,00
Omeprazol kapsul 20 mg 6.610,00
Total 56.500,00
2.759 Mira Yani PASAR MUKOMUKO 155879 Piracetam tablet 1200 m
09/03/2021 00:00:00 125.640,00 BPJS
Valproic Acid Syrup 250mg 62.925,00
Total 188.565,00
2.760 Wahiri TALANG SEPAKAT 181795 Glucosamine 250 mg
09/03/2021 00:00:00 3.850,00 BPJS
Meloxicam 15 mg 12.600,00
Pregabalin Kap 75 mg 64.460,00
Total 80.910,00
2.761 Kernauli Girsang TALANG PETAI 088993 Bisoprolol 5 mg @100 Ta
09/03/2021 00:00:00 8.880,00 BPJS
Domperidone Tab 1.080,00
Flunarizine 5 mg tab 24.750,00
Total 34.710,00
2.762 Hartuti DESA TALANG SEPAKA 142782 Azitromycin 500 mg
09/03/2021 00:00:00 28.125,00 BPJS
Flunarizine 5 mg tab 24.750,00
Meloxicam 15 mg 12.600,00
Total 65.475,00
2.763 Remina TALANG PETAI 181604 Asam Traneksamat @10
09/03/2021 00:00:00 21.050,00 BPJS
Total 21.050,00
2.764 Deriati LUBUK GEDANG 132808 Amlodipine 5 mg @30 T
09/03/2021 00:00:00 1.010,00 BPJS
Candesartan tab 8 mg 13.620,00
Citicoline kaplet 500 mg 33.000,00

19/08/2021 12:42:30 Page 660 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.764 Deriati LUBUK GEDANG 132808 Pregabalin Kap 75 mg
09/03/2021 00:00:00 64.460,00 BPJS
Total 112.090,00
2.765 Ade Resmana PELOKAN 181223 Cuticell Classic 10cmx10c
09/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Tablet 500 m 13.640,00
Total 53.611,00
2.766 Rospita Diana Sihombin PENARIK 144044 Glimepiride tab 2 mg
09/03/2021 00:00:00 7.770,00 BPJS
Metformin tablet 500 mg 11.970,00
Pregabalin Kap 75 mg 64.460,00
Total 84.200,00
2.767 Yunia Estiana Prihatin PT.AGRO SEI KIANG 148671 Metformin tablet 500 mg
09/03/2021 00:00:00 1.330,00 BPJS
Paracetamol tablet 500 m 2.000,00
Urinter Kapsul @100 cap 21.980,00
Total 25.310,00
2.768 Mudi PT AGRO SEI KIANG 169667 Glucosamine 250 mg
09/03/2021 00:00:00 7.700,00 BPJS
Total 7.700,00
2.769 Siti Nurlaini LUNANG 182792 Glucosamine 250 mg
09/03/2021 00:00:00 7.700,00 BPJS
Meloxicam 15 mg 12.600,00
Total 20.300,00
2.770 Sumidah RAWA MULYA 163860 Bisoprolol 5 mg @100 Ta
09/03/2021 00:00:00 8.880,00 BPJS
Pregabalin Kap 75 mg 64.460,00
Total 73.340,00
2.771 Dauri Putra TERAS TERUNJAM 171810 Ketoprofen tab 100 mg
09/03/2021 00:00:00 24.760,00 BPJS
Levofloxacin Tablet 500 m 20.460,00
Total 45.220,00
2.772 Hartati PONDOK BARU 136239 Hexymer 2 Mg Tab (THP)
09/03/2021 00:00:00 28.680,00 BPJS
Levopar tab 100mg 77.460,00
Vitamin B Komplek @100 4.620,00
Total 110.760,00
2.773 Sri Hayati PT AGRO SEI KIANG 182938 Ondansetron tablet 8 mg
09/03/2021 00:00:00 26.400,00 BPJS
Total 26.400,00
2.774 Yulna Lisma RETAK ILIR 182915 Amoxicillin 500 mg @ 10
09/03/2021 00:00:00 918,00 BPJS
Asam Mefenamat 500 m 387,00
Amoxicillin 500 mg @ 10
10/03/2021 00:00:00 918,00
Asam Mefenamat 500 m 387,00
Amoxicillin 500 mg @ 10
11/03/2021 00:00:00 3.060,00
Ketorolac Tab 10 Mg 25.300,00
Total 30.970,00
2.775 Maksul AIR BERAU 182667 Cuticell Classic 10cmx10c
09/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Tablet 500 m 13.640,00
Total 53.611,00
2.776 Pontri Doni LUBUK SANAI 162277 Omeprazol kapsul 20 mg
09/03/2021 00:00:00 6.610,00 BPJS
Total 6.610,00
2.777 Yuliadi BUNGA TANJUNG 178977 Omeprazol kapsul 20 mg
09/03/2021 00:00:00 6.610,00 BPJS
Total 6.610,00
2.778 Nursalim PAUH TERENJA 115949 Azitromycin 500 mg
09/03/2021 00:00:00 33.750,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 40.360,00
2.779 Umi Masfufah TANAH HARAPAN 180160 Aminophyllin Inj
09/03/2021 00:00:00 7.768,00 BPJS
ATRACURIUM BESYLATE 2 29.342,00
Atropin injek 1 ml 13.938,00

19/08/2021 12:42:30 Page 661 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.779 Umi Masfufah TANAH HARAPAN 180160 Ceftriaxone Inj
09/03/2021 00:00:00 12.498,00 BPJS
Celemek Plastik 59.125,00
Dexametason Injeksi 9.384,00
Ephedrine Injeksi 10.711,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 14.563,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 14.554,00
handscoond steril 8 (Gam 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Iodine Povidone 1 L 183.288,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 5.500,00
Neostigmine-hameln 0.5 m 34.300,00
Ondansetron Inj 1.650,00
Pehacain Injeksi 6.640,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Spuit 3 cc Terumo 13.916,00
Sucralfate Suspensi 100 m 19.250,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 6.315,00
Ceftriaxone Inj
10/03/2021 00:00:00 12.498,00
Cetirgi Tab 10 mg 15.480,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Betametason krim 0,1%
11/03/2021 00:00:00 1.675,00
Ceftriaxone Inj 12.498,00
Cetirgi Tab 10 mg 15.480,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 8.550,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefixime kapsul 200 mg
12/03/2021 00:00:00 26.480,00
Metrodinazole tab 500 m 4.050,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 19.076,00
Total 918.487,00
2.780 Marzuki TALANG MEDAN 154878 Alprazolam 0,5 mg @100
09/03/2021 00:00:00 3.540,00 BPJS
Total 3.540,00
2.781 Dodi Indra PT. AGRO SEI KIANG 129999 Paracetamol tablet 500 m
09/03/2021 00:00:00 2.000,00 BPJS

19/08/2021 12:42:30 Page 662 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 2.000,00
2.782 Dahalimun LUBUK CABAU 155405 Alprazolam 0,5 mg @100
09/03/2021 00:00:00 590,00 BPJS
Amlodipine 10 mg @50 T 708,00
Citicoline kaplet 500 mg 24.750,00
L-Cisin tab 37.810,00
Levofloxacin Tablet 500 m 13.640,00
Total 77.498,00
2.783 Misran PONDOK MAKMUR 119068 Mecobalamin 500 mg
09/03/2021 00:00:00 7.700,00 BPJS
Total 7.700,00
2.784 Zaunatul Aini LUBUK PINANG 153422 Asam Folat 1 mg @100 T
09/03/2021 00:00:00 990,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 7.600,00
2.785 Meisi Daria Celsi BAJU EJUNG 167168 Captopril 12,5 mg
09/03/2021 00:00:00 3.360,00 BPJS
Methylprednisolone tab 4 110.460,00
Total 113.820,00
2.786 Zanuraini GAJAH MATI 163354 Flunarizine 5 mg tab
09/03/2021 00:00:00 24.750,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 26.750,00
2.787 Riska Ayu Lestari LUBUK GEDANG 182787 Amoxicillin 500 mg @ 10
09/03/2021 00:00:00 7.344,00 BPJS
Captopril 12,5 mg 3.200,00
Total 10.544,00
2.788 Sean Fransisco Hutaga PT AGRO BUNGA TANJ 182943 Amoxicillin Syr
09/03/2021 00:00:00 6.531,00 BPJS
Total 6.531,00
2.789 Nurjanah AIR BIKUK 131083 Cefixime Kapsul 100 mg
09/03/2021 00:00:00 9.380,00 BPJS
Paracetamol tablet 500 m 2.000,00
Vitamin B Komplek @100 1.540,00
Total 12.920,00
2.790 S Pasaribu AIR BIKUK 131631 Amoxicillin 500 mg @ 10
09/03/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Dexametason 0,5 mg Ta 1.160,00
Total 5.510,00
2.791 Dewi AIR BIKUK 137730 Paracetamol tablet 500 m
09/03/2021 00:00:00 2.000,00 BPJS
Total 2.000,00
2.792 Indra LUNANG 182944 Paracetamol tablet 500 m
09/03/2021 00:00:00 2.000,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 23.980,00
2.793 Sugiman TUNGGAL JAYA 182932 Bisturi No. 23
09/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Cefixime Kapsul 100 mg 9.380,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Iodine Povidone 1 L 183.288,00
Lidocain injk 40 mg/2 ml 6.444,00
Masker 3 Play N. 95 93.750,00
Masker Karet 11.000,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 2.000,00

19/08/2021 12:42:30 Page 663 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.793 Sugiman TUNGGAL JAYA 182932 Polyvinylidene 3-0 R (Tri
09/03/2021 00:00:00 92.000,00 BPJS
Ringer Laktat Otsuka 9.538,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Total 792.440,00
2.794 Rika Wira Rahayu UJUNG PADANG 095523 ursodeoxycholic acid
09/03/2021 00:00:00 28.350,00 BPJS
Total 28.350,00
2.795 Siti Isro"in RAWA MULYA 169980 Abbocath 20 Terumo @5
10/03/2021 00:00:00 52.682,00 BPJS
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 5.751,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Lidocain injk 40 mg/2 ml 4.833,00
Masker Karet 5.500,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 24.998,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Polyglycolide 3-0 C (TriTe 82.875,00
Polyglycolide T-Vio 1 R ( 98.500,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tramadol 50 mg/ml Inj 8.250,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00
Kamadol Injeksi 5.700,00
Ringer Laktat Otsuka 19.076,00
Total 726.322,00
2.796 Baban SUMBER MAKMUR 182934 Abbocath 20 Terumo @5
09/03/2021 00:00:00 52.682,00 BPJS
Atropin injek 1 ml 6.969,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00

19/08/2021 12:42:30 Page 664 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.796 Baban SUMBER MAKMUR 182934 Cuticell Classic 10cmx10c
09/03/2021 00:00:00 35.121,00 BPJS
Ephedrine Injeksi 21.422,00
Glukosa Infus 5 % 8.626,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril S 8.510,00
handscoond steril 6.5 (G 43.662,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 56.250,00
Masker Karet 11.000,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 8.550,00
Polyvinylidene 2-0 R (Tri 94.250,00
Polyvinylidene 2-0 R (Tri 94.250,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Silk 2/0 R scimitar 61.688,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Perawat) @ 4.690,00
Transfusi Set Terumo 16.500,00
Wing Needle 25 G 14.106,00
Catheter 2 Way No. 16 (
10/03/2021 00:00:00 20.625,00
Ceftriaxone Inj 12.498,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Paracetamol tablet 500 m 600,00
Levofloxacin Infus
11/03/2021 00:00:00 48.976,00
Methylprednisolone Inje 34.923,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 Mg/1 5.959,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Levofloxacin Infus
12/03/2021 00:00:00 48.976,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 14.502,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Cuticell Classic 10cmx10c
13/03/2021 00:00:00 35.121,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 19.350,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 2.000,00
Total 1.482.859,00

19/08/2021 12:42:30 Page 665 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.797 Mulyati MANDI ANGIN JAYA 182948 abbocath 18 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
NACL 0,9 % 500 ml 17.100,00
Urine bag 9.314,00
Total 107.149,00
2.798 Suwarni SUKA MAJU 164065 Abbocath 20 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Nassal Cannula O2 Dewas 11.625,00
Omeprazole Inj 12.499,00
Ondansetron tablet 8 mg 7.920,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 157.829,00
2.799 Mulyati MANDI ANGIN JAYA 182948 Allopurinol 100 mg @100
09/03/2021 00:00:00 2.340,00 BPJS
Citicoline Injeksi 125mg/ 22.500,00
meropenem Injeksi 1 g 82.500,00
Novo Twist 32 G Tip 1.928,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Simvastatin tab 20 mg 3.110,00
Amlodipine 10 mg @50 T
10/03/2021 00:00:00 118,00
Candesartan Tab 16 mg 5.775,00
Citicoline Injeksi 125mg/ 22.500,00
Citicoline Injeksi 125mg/ 22.500,00
Gentamycin 0.1 % salep k 8.949,00
Kassa kotak stril DRC 9.675,00
meropenem Injeksi 1 g 123.750,00
meropenem Injeksi 1 g 123.750,00
NACL 0,9 % 500 ml 25.650,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
PARAMOL INFUS 96.250,00
Antrain Injeksi
11/03/2021 00:00:00 28.875,00
Catheter 2 Way No. 16 ( 20.625,00
Electroda (Ambu) @25 Pc 81.570,00
Epinephrin inj 30.662,00
PARAMOL INFUS 192.500,00
PARAMOL INFUS 96.250,00
Urine bag 9.314,00
Total 1.182.988,00
2.800 Suwarni SUKA MAJU 164065 Ketorolac inj 30 mg/1ml
09/03/2021 00:00:00 2.690,00 BPJS
Omeprazole Inj 24.998,00
Ranitidin inj 3.580,00
Antasida Syrup 60 ml
10/03/2021 00:00:00 2.736,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00

19/08/2021 12:42:30 Page 666 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.800 Suwarni SUKA MAJU 164065 Sucralfate Suspensi 100 m
10/03/2021 00:00:00 19.250,00 BPJS
Hypafix 10cm x 5cm (25 c
11/03/2021 00:00:00 14.550,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Glucosamine 250 mg
12/03/2021 00:00:00 2.310,00
NACL 0,9 % 500 ml 34.200,00
Opilax Syr
13/03/2021 00:00:00 49.156,00
Total 232.818,00
2.801 Effendi penarik 181556 abbocath 18 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS
Amlodipine 10 mg @50 T 318,00
Asam Folat 1 mg @100 T 99,00
Cefoperazon Inj 41.250,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Ringer Laktat Otsuka 9.538,00
Simvastatin tab 20 mg 311,00
Tambah Darah Neo Tab 465,00
Amlodipine 10 mg @50 T
10/03/2021 00:00:00 118,00
Asam Folat 1 mg @100 T 99,00
Cefoperazon Inj 82.500,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 13.088,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 10 mg 241,00
Transfusi Set Terumo 16.500,00
Amlodipine 10 mg @50 T
11/03/2021 00:00:00 318,00
Asam Folat 1 mg @100 T 99,00
Candesartan tab 8 mg 681,00
Cefotaxime Injeksi 5.751,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Simvastatin tab 20 mg 311,00
Tambah Darah Neo Tab 465,00
Amlodipine 10 mg @50 T
12/03/2021 00:00:00 1.180,00
Asam Folat 1 mg @100 T 990,00
Biocombin 5000 Injeksi 19.593,00
Candesartan tab 8 mg 6.810,00
Cefoperazon Inj 41.250,00
Infusion Makro (Gea) 7.425,00

19/08/2021 12:42:30 Page 667 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.801 Effendi penarik 181556 Omeprazole Inj
12/03/2021 00:00:00 12.499,00 BPJS
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 4.650,00
Abbocath 22 Terumo @5
13/03/2021 00:00:00 22.276,00
Amlodipine 10 mg @50 T 1.180,00
Asam Folat 1 mg @100 T 990,00
Candesartan tab 8 mg 6.810,00
Simvastatin tab 10 mg 2.410,00
Transfusi Set Terumo 16.500,00
Transfusi Set Terumo 16.500,00
Total 618.450,00
2.802 Bekti PAUH TERENJA 166637 abbocath 18 Terumo @5
09/03/2021 00:00:00 26.341,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Pamol Inf 1g Berno 82.000,00
Paracetamol tablet 500 m 200,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
abbocath 18 Terumo @5 26.341,00
Abbocath 20 Terumo @5 52.682,00
Aminofluid Infus 500 ml 155.204,00
Cefotaxime Injeksi 5.751,00
Furamin Injeksi 14.369,00
Omeprazole Inj 12.499,00
Psidii Capsule 500 mg 19.604,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Abbocath 20 Terumo @5
10/03/2021 00:00:00 79.023,00
Abbocath 22 Terumo @5 33.414,00
Aminofluid Infus 500 ml 155.204,00
Cefoperazon Inj 82.500,00
Ferro Sulfate 800,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Psidii Capsule 500 mg 14.703,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Aminofluid Infus 500 ml
11/03/2021 00:00:00 155.204,00
Cefoperazon Inj 41.250,00
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Psidii Capsule 500 mg 19.604,00
Ringer Laktat Otsuka 19.076,00

19/08/2021 12:42:30 Page 668 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.802 Bekti PAUH TERENJA 166637 Tambah Darah Neo Tab
11/03/2021 00:00:00 930,00 BPJS
Tranexamic Acid Inj (Asa 6.315,00
Dexametason Injeksi
12/03/2021 00:00:00 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 4.850,00
Total 1.215.068,00
2.803 Kadin SUKA MAJU 182949 Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 1.345,00
Mecobalamin 500 mg 1.540,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Ketorolac inj 30 mg/1ml 2.690,00
Mecobalamin 500 mg 1.540,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 4.125,00
Hypafix 10cm x 5cm (25 c
11/03/2021 00:00:00 4.850,00
Ketorolac inj 30 mg/1ml 2.690,00
Mecobalamin 500 mg 1.540,00
Omeprazole Inj 12.499,00
Pregabalin Kap 75 mg 6.446,00
Ringer Laktat Otsuka 19.076,00
Cefixime kapsul 200 mg
12/03/2021 00:00:00 26.480,00
Mecobalamin 500 mg 7.700,00
Pregabalin Kap 75 mg 90.244,00
Total 278.015,00
2.804 Peni Astuti TANAH HARAPAN 182950 abbocath 18 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Chromic catgut 2-0 R (Tr 72.250,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Lidocain injk 40 mg/2 ml 1.611,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Metrodinazole tab 500 m 2.700,00
Paracetamol tablet 500 m 2.000,00
Total 156.046,00
2.805 Siti Rubiyanti LUBUK MUKTI 180670 abbocath 18 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00

19/08/2021 12:42:30 Page 669 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.805 Siti Rubiyanti LUBUK MUKTI 180670 Cuticell Classic 10cmx10c
10/03/2021 00:00:00 35.121,00 BPJS
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 5.500,00
Methylprednisolone Inje 34.923,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 2-0 R ( 90.125,00
Polyvinylidene 3-0 R (Tri 92.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Cefixime kapsul 200 mg
12/03/2021 00:00:00 26.480,00
Cefotaxime Injeksi 11.502,00
Cuticell Classic 10cmx10c 35.121,00
Ephedrine Injeksi 21.422,00
Glukosa Infus 10 % 9.375,00
Handscoond Sterille 7 (G 29.126,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metoclopramide inj 5Mg/M 11.758,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 10x 9.630,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 3.000,00
Ranitidin inj 3.580,00
Spinocain 25 (BBraund) 85.526,00
Spinocain 26 (Bbraund) 86.076,00
Spinocain 27 (BBraund) 95.750,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
13/03/2021 00:00:00 1.935,00
Cefotaxime Injeksi 5.751,00

19/08/2021 12:42:30 Page 670 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.805 Siti Rubiyanti LUBUK MUKTI 180670 Ciprofloxacin tab 500 mg
13/03/2021 00:00:00 5.590,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 2.177.882,00
2.806 Ruswi Suprianzah PT ALNO AIR IKAN 182953 Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 1.345,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 9.538,00
Suprafenid Supositoria 10 14.025,00
Total 90.615,00
2.807 Afnan Sakhi Irawan DESA BUMI MULYA 179188 Diazepam Tab 5 Mg
10/03/2021 00:00:00 816,00 BPJS
Pamol 125 Supositoria 17.600,00
Stesolid Supp 5 mg 16.503,00
Total 34.919,00
2.808 Sunarso KOTA PRAJA 182954 Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Amlodipine 10 mg @50 T 118,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 8.626,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 94.546,00
2.809 Ruswi Suprianzah PT ALNO AIR IKAN 182953 Ceftriaxone Inj
10/03/2021 00:00:00 12.498,00 BPJS
Ketorolac inj 30 mg/1ml 2.690,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 4.125,00
Catheter 2 Way No. 16 (
11/03/2021 00:00:00 20.625,00
Ceftriaxone Inj 6.249,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 2.690,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 19.076,00
Urine bag 9.314,00
Betahistin Mesilat 6 mg @
12/03/2021 00:00:00 1.380,00
Catheter 2 Way No. 16 ( 41.250,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Furamin Injeksi 43.107,00
Furamin Injeksi 43.107,00
Ketorolac inj 30 mg/1ml 2.690,00
Metoclopramide inj 5Mg/M 5.879,00

19/08/2021 12:42:30 Page 671 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.809 Ruswi Suprianzah PT ALNO AIR IKAN 182953 Omeprazole Inj
12/03/2021 00:00:00 37.497,00 BPJS
OMZ 270.000,00
Ondansetron Inj 3.300,00
Opilax Syr 49.156,00
Piralen Injeksi 2 ml 8.800,00
Renax @50 Kapsul 113.440,00
Ringer Laktat Otsuka 19.076,00
Urinter Kapsul @100 cap 21.980,00
Total 872.712,00
2.810 Sunarso KOTA PRAJA 182954 Amlodipine 10 mg @50 T
10/03/2021 00:00:00 118,00 BPJS
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Zinc Sulfate Syr 60 ml 4.569,00
Zink Tablet 689,00
Amlodipine 5 mg @30 T
11/03/2021 00:00:00 505,00
Candesartan tab 8 mg 3.405,00
Ceftriaxone Inj 12.498,00
Nucral Syrup 100 ml 53.350,00
Zinc Sulfate Syr 60 ml 4.569,00
Amlodipine 10 mg @50 T
12/03/2021 00:00:00 1.180,00
Candesartan tab 8 mg 6.810,00
Cefixime Kapsul 100 mg 9.380,00
Omeprazol kapsul 20 mg 6.610,00
Urinter Kapsul @100 cap 21.980,00
Zink Tablet 6.890,00
Total 176.302,00
2.811 Ani BUNGA TANJUNG 146312 Bisoprolol 5 mg @100 Ta
10/03/2021 00:00:00 4.440,00 BPJS
Codein tab 10 mg 7.500,00
Furosemide 40 mg Tablet 960,00
Retaphyl SR Tab 7.370,00
Total 20.270,00
2.812 Nuraya BUNGA TANJUNG 113240 Alprazolam 0,5 mg @100
10/03/2021 00:00:00 590,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Metformin tablet 500 mg 2.660,00
Total 7.690,00
2.813 Fitriani PASAR SEBELAH 113952 Ketoprofen tab 100 mg
23/04/2021 00:00:00 24.760,00 BPJS
Paracetamol tablet 500 m 4.300,00
Vitamin B Komplek @100 3.080,00
Total 32.140,00
2.814 Oti Hani Miwarni MAJU MAKMUR 182788 Asam Mefenamat 500 m
10/03/2021 00:00:00 1.290,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 42.066,00
2.815 Rison PULAI PAYUNG 182801 Levofloxacin Tablet 500 m
10/03/2021 00:00:00 13.640,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 16.640,00
2.816 Maria Dwi Defysa BANDARATU 115307 Asam Mefenamat 500 m
10/03/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
2.817 Khairul Amri RETAK MUDIK 182691 Omeprazol kapsul 20 mg
10/03/2021 00:00:00 6.610,00 BPJS

19/08/2021 12:42:30 Page 672 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.817 Khairul Amri RETAK MUDIK 182691 Spironolaktone 25 mg
10/03/2021 00:00:00 2.600,00 BPJS
Total 9.210,00
2.818 Rica Gusmawati MEKAR JAYA 177877 Ketorolac Tab 10 Mg
10/03/2021 00:00:00 25.300,00 BPJS
Metrodinazole tab 500 m 2.700,00
Total 28.000,00
2.819 Sutarti RAWA BANGUN 182816 Meloxicam 7,5 mg
10/03/2021 00:00:00 7.280,00 BPJS
Pregabalin Kap 75 mg 64.460,00
Total 71.740,00
2.820 Bahman SIBAK 155872 NACL 0,9 % 500 ml
10/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.821 Novian Indrajaya TUNGGANG 182828 Cuticell Classic 10cmx10c
10/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 2.000,00
Total 41.971,00
2.822 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
10/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.823 Amran SUNGAI LINTANG 182811 Levofloxacin Tablet 500 m
10/03/2021 00:00:00 13.640,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 15.640,00
2.824 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
10/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.825 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
10/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.826 Tingah TALANG SARI IV 157987 Flunarizine 5 mg tab
10/03/2021 00:00:00 24.750,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 31.360,00
2.827 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
10/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.828 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
10/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
2.829 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
10/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.830 Suyekti TANJUNG MULYA 181939 Candesartan tab 8 mg
10/03/2021 00:00:00 10.215,00 BPJS
Codein tab 10 mg 7.500,00
Furosemide 40 mg Tablet 1.440,00
Retaphyl SR Tab 14.740,00
Spironolaktone 25 mg 3.900,00
Total 37.795,00
2.831 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
10/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.832 Junaidi SUNGAI IPUH 138273 NACL 0,9 % 500 ml
10/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.833 Eni Putri Wati TANAH REKAH 155815 Methylprednisolone tab 4
10/03/2021 00:00:00 2.630,00 BPJS

19/08/2021 12:42:30 Page 673 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.833 Eni Putri Wati TANAH REKAH 155815 Paracetamol tablet 500 m
10/03/2021 00:00:00 2.000,00 BPJS
Total 4.630,00
2.834 Fitri Yani LUBUK SANAI 181861 Propanolol tab 10 mg
10/03/2021 00:00:00 6.660,00 BPJS
Propylthiourasil 100 mg ( 39.180,00
Total 45.840,00
2.835 Zuariah PAUH TERENJA 131979 Meloxicam 7,5 mg
10/03/2021 00:00:00 7.280,00 BPJS
Micardis tab 40 mg 228.360,00
Total 235.640,00
2.836 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
10/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.837 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
10/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
2.838 Jumarno LUNANG 180796 Gentamicin Injeksi
10/03/2021 00:00:00 4.606,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Opilax Syr 49.156,00
Ranitidin inj 1.790,00
Renogen 3000 UI 116.875,00
Total 215.177,00
2.839 Godfrid Ss RANAH KARYA 163602 Glucosamine 250 mg
10/03/2021 00:00:00 11.550,00 BPJS
Paracetamol tablet 500 m 2.000,00
Urinter Kapsul @100 cap 21.980,00
Total 35.530,00
2.840 Herlina TALANG MEDAN 182545 Alprazolam 0,5 mg @100
10/03/2021 00:00:00 590,00 BPJS
Total 590,00
2.841 Ngatini LUBUK MUKTI 179230 Bisoprolol 5 mg @100 Ta
10/03/2021 00:00:00 0,00 BPJS
Candesartan tab 8 mg 0,00
Furosemide 40 mg Tablet 0,00
Spironolaktone 25 mg 0,00
Total 0,00
2.842 Isah PASAR SEBELAH 178221 Methylprednisolone tab 4
10/03/2021 00:00:00 2.630,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 5.630,00
2.843 Sukiah PONDOK KOPI 109386 Levofloxacin Tablet 500 m
10/03/2021 00:00:00 13.640,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 15.640,00
2.844 Jhon Espa Hasugian SIDODADI 180948 Cuticell Classic 10cmx10c
10/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 4.000,00
Total 57.611,00
2.845 M. Hud Sadri PONDOK SUGUH 182964 Erdosteine Syr
10/03/2021 00:00:00 36.575,00 BPJS
Salbutamol 2 mg 1.580,00
Total 38.155,00
2.846 Rea Putriani TIRTA MULYA 167431 Valproic Acid Syrup 250mg
10/03/2021 00:00:00 62.925,00 BPJS
Total 62.925,00
2.847 Norlian SUNGAI IPUH 138398 Codein tab 10 mg
10/03/2021 00:00:00 7.500,00 BPJS
Total 7.500,00
2.848 Firas Akhtar Arkani PASAR MUKO MUKO 182965 Abbocath 22 Terumo @5
10/03/2021 00:00:00 11.138,00 BPJS
Aqua Pro Injeksi 3.575,00
Hypafix 15cmx5cm (25 c 6.544,00

19/08/2021 12:42:30 Page 674 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.848 Firas Akhtar Arkani PASAR MUKO MUKO 182965 Infusion set Mikro (Terumo
10/03/2021 00:00:00 18.026,00 BPJS
Ka-En 1 B 12.658,00
NGT (Feeding tube) Fr. 5 17.603,00
Ondansetron Inj 1.650,00
Total 71.194,00
2.849 Remina TALANG PETAI 181604 abbocath 18 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Misoprostol Tab 11.000,00
Ringer Laktat Otsuka 28.614,00
Total 125.307,00
2.850 Ghina Maisa Zahirah NENGGALO 137661 Omeprazol kapsul 20 mg
10/03/2021 00:00:00 6.610,00 BPJS
Total 6.610,00
2.851 Razali NENGGALO 160811 Eperisone Hcl 50 mg @1
10/03/2021 00:00:00 23.280,00 BPJS
Glucosamine 250 mg 7.700,00
Meloxicam 15 mg 12.600,00
Total 43.580,00
2.852 Firas Akhtar Arkani PASAR MUKO MUKO 182965 Hypafix 15cmx5cm (25 c
10/03/2021 00:00:00 6.544,00 BPJS
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol syrup 1.388,00
Abbocath 24 Terumo @5
11/03/2021 00:00:00 79.023,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ka-En 1 B 37.974,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Suprafenid Supositoria 10 28.050,00
Total 191.077,00
2.853 Supriadi LUBUK MUKTI 182968 Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Alinamin F Injeksi 10 ml 18.000,00
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Citicoline Injeksi 125mg/ 11.250,00
Codein tab 10 mg 1.500,00
Hypafix Kamar Operasi 18.000,00
Infusion Makro (terumo) 27.225,00
Mecobalamin 500 mg 1.540,00
Omeprazole Inj 12.499,00
Piracetam injek 200 mg 5.775,00
Ringer Laktat Otsuka 9.538,00
Simvastatin tab 10 mg 241,00
Total 141.109,00
2.854 Rosmi Yeni LUBUK MUKTI 182463 Bisoprolol 5 mg @100 Ta
10/03/2021 00:00:00 4.440,00 BPJS
Codein tab 10 mg 7.500,00
Omeprazol kapsul 20 mg 6.610,00
Total 18.550,00
2.855 Ringga Nina Silvana Sa LUBUK MUKTI 178202 Alprazolam 0,5 mg @100
10/03/2021 00:00:00 590,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 2.590,00
2.856 Nurjasmi PERNYAH 120782 Methylprednisolone tab 4
10/03/2021 00:00:00 2.630,00 BPJS
Total 2.630,00

19/08/2021 12:42:30 Page 675 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.857 Rajinla Giawa TANAH HARAPAN 143391 Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 17.252,00
Infusion Makro (terumo) 27.225,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 5.380,00
Levofloxacin Infus 73.464,00
Natrium diclofenac 50 m 867,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Urine bag 9.314,00
Urinter Kapsul @100 cap 4.396,00
Total 390.713,00
2.858 Ulfa Muhim RETAK MUDIK 182960 abbocath 18 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 100.766,00
2.859 Nurhayati SILAUT 182733 Allopurinol 300 Mg @100
10/03/2021 00:00:00 7.365,00 BPJS
Candesartan tab 8 mg 10.215,00
L-Cisin tab 18.905,00
Spironolaktone 25 mg 3.900,00
Total 40.385,00
2.860 Supiyani TALANG KUNING 182966 abbocath 18 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 11.825,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix Kamar Operasi 18.000,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker 3 Play N. 95 187.500,00

19/08/2021 12:42:30 Page 676 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.860 Supiyani TALANG KUNING 182966 Masker Tali
10/03/2021 00:00:00 41.600,00 BPJS
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Total 1.501.570,00
2.861 Rizka Ilahi TANJUNG ALAI 182977 Pamol 250 Supositoria
10/03/2021 00:00:00 26.125,00 BPJS
Total 26.125,00
2.862 Syamsori LUBUK SANAI 182978 Abbocath 20 Terumo @5
10/03/2021 00:00:00 26.341,00 BPJS
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Transfusi Set Terumo 16.500,00
Allopurinol 300 Mg @100 982,00
Allopurinol 300 Mg @100
11/03/2021 00:00:00 491,00
Hypafix 10cm x 5cm (25 c 4.850,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Ambroxol Syr 15mg/ml
12/03/2021 00:00:00 4.538,00
Aminoleban inf 500 ml 88.713,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Gitas Plus 15.099,00
Glukosa Infus 5 % 8.626,00
Methylprednisolone Inje 104.769,00
Omeprazole Inj 37.497,00
Ondansetron Inj 4.950,00
Vitamin B Komplek @100 308,00
Ambroxol Syr 15mg/ml
13/03/2021 00:00:00 4.538,00
Ambroxol Syr 15mg/ml 4.538,00
Curcuma Tab 19.050,00
Glukosa Infus 5 % 8.626,00
Lansoprazole kapsul 30 m 5.775,00
Methylprednisolone Inje 104.769,00
Methylprednisolone tab 4 2.630,00

19/08/2021 12:42:30 Page 677 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.862 Syamsori LUBUK SANAI 182978 Omeprazole Inj
13/03/2021 00:00:00 12.499,00 BPJS
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Sulcolon Tablet 16.500,00
Sulcolon Tablet 82.500,00
Vitamin B Komplek @100 1.540,00
Total 758.273,00
2.863 Supriadi LUBUK MUKTI 182968 Alinamin F Injeksi 10 ml
11/03/2021 00:00:00 18.000,00 BPJS
Azitromycin 500 mg 5.625,00
Candesartan tab 8 mg 3.405,00
Citicoline Injeksi 125mg/ 22.500,00
Codein tab 10 mg 1.500,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Mecobalamin 500 mg 1.540,00
NACL 0,9 % 500 ml 8.550,00
Novo Twist 32 G Tip 1.928,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Piracetam injek 200 mg 17.325,00
Ringer Laktat Otsuka 28.614,00
Simvastatin tab 10 mg 241,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Citicoline kaplet 500 mg
12/03/2021 00:00:00 16.500,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Vitamin B Komplek @100 1.540,00
Total 217.211,00
2.864 Fenti Sulasmi KARANG JAYA 182958 Bisturi No. 23
10/03/2021 00:00:00 3.836,00 BPJS
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 60.240,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Levofloxacin Tablet 500 m 13.640,00
Lidocain injk 40 mg/2 ml 8.055,00
Masker Karet 11.000,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 2.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Total 453.296,00
2.865 Ulfa Muhim RETAK MUDIK 182960 Bisturi No. 23
10/03/2021 00:00:00 3.836,00 BPJS

19/08/2021 12:42:30 Page 678 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.865 Ulfa Muhim RETAK MUDIK 182960 Bisturi No. 23
10/03/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
handscoond steril 8 (Gam 58.216,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Induxin 1 ml Injeksi 37.124,00
Iodine Povidone 1 L 183.288,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 5.500,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.314,00
viamac 1 R 364.370,00
Fentanyl Injeksi 5 Ampul 2
11/03/2021 00:00:00 52.000,00
Tranexamic Acid Inj (Asa 6.315,00
Amlodipine 5 mg @30 T
12/03/2021 00:00:00 303,00
Bisturi No. 15 3.836,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00

19/08/2021 12:42:30 Page 679 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.865 Ulfa Muhim RETAK MUDIK 182960 Ketorolac inj 30 mg/1ml
12/03/2021 00:00:00 4.035,00 BPJS
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
NACL 0,9 % 500 ml 17.100,00
NGT (Feeding tube) Fr. 5 17.603,00
NonWoven Fixation 10x 9.630,00
Oxytetracycline Salep Ma 3.251,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
13/03/2021 00:00:00 1.935,00
Cefotaxime Injeksi 5.751,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 300 mg Tabl 0,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 2.049.772,00
2.866 Ny Siti Rubiyanti LUBUK MUKTI 182979 Abbocath 24 Terumo @5
10/03/2021 00:00:00 79.023,00 BPJS
Bisturi No. 15 3.836,00
Hypafix 15cmx5cm (25 c 6.544,00
Injection plug 20.213,00
NGT (Feeding tube) Fr. 5 17.603,00
umbilical Cord Clamp 2.261,00
Bisturi No. 15
13/03/2021 00:00:00 3.836,00
Chloramphenicol Salep M 2.351,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Total 213.182,00
2.867 Andi PONDOK SUGUH 182929 Abbocath 22 Terumo @5
10/03/2021 00:00:00 22.276,00 BPJS
Bisturi No. 15 7.672,00
Cauter (Hand-controlled P 324.322,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Karet 5.500,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00

19/08/2021 12:42:30 Page 680 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.867 Andi PONDOK SUGUH 182929 Ringer Laktat Otsuka
10/03/2021 00:00:00 19.076,00 BPJS
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Ketorolac inj 30 mg/1ml
11/03/2021 00:00:00 4.035,00
Levofloxacin Infus 48.976,00
Ringer Laktat Otsuka 19.076,00
Cefixime kapsul 200 mg
12/03/2021 00:00:00 26.480,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 3.000,00
Total 1.003.989,00
2.868 Rajinla Giawa TANAH HARAPAN 143391 Ketorolac inj 30 mg/1ml
10/03/2021 00:00:00 8.070,00 BPJS
Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00
Ciprofloxacin infus 2% 26.328,00
Ciprofloxacin infus 2% 26.328,00
Ketorolac inj 30 mg/1ml 4.035,00
Natrium diclofenac 50 m 578,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Renax @50 Kapsul 22.688,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Urinter Kapsul @100 cap 4.396,00
Candesartan tab 8 mg
12/03/2021 00:00:00 681,00
Catheter 2 Way No. 18 ( 31.251,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Gentamicin Injeksi 9.212,00
Glukosa Infus 5 % 8.626,00
Infusion Makro (Gea) 7.425,00
Infusion set Mikro (Terumo 18.026,00
Kassa kotak stril DRC 29.025,00
Ketorolac inj 30 mg/1ml 5.380,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 8.550,00
Natrium diclofenac 50 m 578,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Renax @50 Kapsul 34.032,00
Urine bag 9.263,00
Urinter Kapsul @100 cap 4.396,00
Candesartan tab 8 mg
13/03/2021 00:00:00 681,00
Catheter 2 Way No. 18 ( 31.251,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Ciprofloxacin infus 2% 39.492,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 9.700,00

19/08/2021 12:42:30 Page 681 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.868 Rajinla Giawa TANAH HARAPAN 143391 Ketorolac inj 30 mg/1ml
13/03/2021 00:00:00 6.725,00 BPJS
Ketorolac inj 30 mg/1ml 5.380,00
Ketorolac inj 30 mg/1ml 6.725,00
Methylprednisolone Inje 104.769,00
Natrium diclofenac 50 m 578,00
Omeprazole Inj 12.499,00
Renax @50 Kapsul 34.032,00
Urinter Kapsul @100 cap 4.396,00
Candesartan tab 8 mg
14/03/2021 00:00:00 681,00
Ceftriaxone Inj 12.498,00
Ciprofloxacin infus 2% 39.492,00
Glukosa Infus 5 % 17.252,00
Ketorolac inj 30 mg/1ml 5.380,00
Methylprednisolone Inje 104.769,00
Natrium diclofenac 50 m 578,00
Omeprazole Inj 12.499,00
Renax @50 Kapsul 34.032,00
Urine bag 18.526,00
Alprazolam 0,5 mg @100
15/03/2021 00:00:00 118,00
Candesartan tab 8 mg 3.405,00
Glukosa Infus 5 % 17.252,00
Ketorolac Tab 10 Mg 37.950,00
Levofloxacin Tablet 500 m 6.820,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.216.730,00
2.869 Eka Bunyani AIR KASAI 180362 Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00
Metformin tablet 500 mg 399,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 800,00
Ranitidin inj 5.370,00
Total 60.792,00
2.870 Siti Rukomah AIR HITAM 182981 Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00 BPJS
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 6.544,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Catheter 2 Way No. 16 (
10/03/2021 00:00:00 39.025,00
Ceftriaxone Inj 6.249,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
NGT (Stomach Tube) Fr. 1 60.046,00
Novo Twist 32 G Tip 1.928,00
Novorapid Flexpen 108.750,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00

19/08/2021 12:42:30 Page 682 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.870 Siti Rukomah AIR HITAM 182981 Paracetamol tablet 500 m
10/03/2021 00:00:00 600,00 BPJS
Ringer Laktat Otsuka 9.538,00
Urine bag 9.314,00
Candesartan tab 8 mg
11/03/2021 00:00:00 3.405,00
Electroda (Ambu) @25 Pc 81.570,00
Novo Twist 32 G Tip 3.856,00
Paracetamol tablet 500 m 1.000,00
Ceftriaxone Inj
12/03/2021 00:00:00 12.498,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 10x 4.815,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 308,00
Cefixime Kapsul 100 mg
13/03/2021 00:00:00 9.380,00
Levemir FlexPen 104.938,00
Novo Twist 32 G Tip 3.856,00
Novorapid Flexpen 108.750,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 804.254,00
2.871 Hermanto AIR DIKIT 182983 Ceftriaxone Inj
10/03/2021 00:00:00 6.249,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 86.255,00
2.872 Supriadi SUNGAI RENGAS 182982 Arixtra Injeksi 2.5mg/0.5
11/03/2021 00:00:00 326.625,00 BPJS
Clopidogrel 75 mg @30 T 1.755,00
Electroda (Ambu) @25 Pc 81.570,00
Hypafix 15cmx5cm (25 c 13.088,00
Hypafix 15cmx5cm (25 c 6.544,00
Miniaspi 80 Mg @100 Ta 125,00
Ondane 2 ml inj 131.589,00
Paracetamol tablet 500 m 600,00
Piracetam injek 200 mg 17.325,00
Ringer Laktat Otsuka 28.614,00
Arixtra Injeksi 2.5mg/0.5
12/03/2021 00:00:00 326.625,00
Citicoline kaplet 500 mg 16.500,00
Clopidogrel 75 mg @30 T 1.755,00
Miniaspi 80 Mg @100 Ta 125,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00

19/08/2021 12:42:30 Page 683 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.872 Supriadi SUNGAI RENGAS 182982 Vitamin B Komplek @100
12/03/2021 00:00:00 1.540,00 BPJS
Betadine Obat Kumur
13/03/2021 00:00:00 13.750,00
Catheter 2 Way No. 16 ( 39.025,00
Clopidogrel 75 mg @30 T 8.775,00
Clopidogrel 75 mg @30 T 14.040,00
Curcuma Tab 19.050,00
Lansoprazole kapsul 30 m 5.775,00
Miniaspi 80 Mg @100 Ta 625,00
Miniaspi 80 Mg @100 Ta 1.000,00
Nystatin Drop 27.830,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 57.750,00
Vitamin B Komplek @100 1.540,00
Total 1.229.986,00
2.873 Hermanto AIR DIKIT 182983 Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00 BPJS
Hypafix 10cm x 5cm (25 c 14.550,00
NACL 0,9 % 500 ml 25.650,00
Omeprazole Inj 12.499,00
Ondane 2 ml inj 131.589,00
Zink Tablet 689,00
Ambroxol Syr 15mg/ml
12/03/2021 00:00:00 4.538,00
Aminoleban inf 500 ml 88.713,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Glukosa Infus 5 % 8.626,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 308,00
Zink Tablet 689,00
Azitromycin 500 mg
13/03/2021 00:00:00 28.125,00
Curcuma Tab 12.700,00
Gitas Plus 75.495,00
Mucera Syr Forte 29.700,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 532.401,00
2.874 Eka Bunyani AIR KASAI 180362 abbocath 18 Terumo @5
11/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 18.747,00
Infusion Makro (terumo) 27.225,00
Metformin tablet 500 mg 133,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Novo Twist 32 G Tip 1.928,00
Novorapid Flexpen 108.750,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 800,00
Ranitidin inj 3.580,00
Ceftriaxone Inj
12/03/2021 00:00:00 12.498,00

19/08/2021 12:42:30 Page 684 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.874 Eka Bunyani AIR KASAI 180362 Metformin tablet 500 mg
12/03/2021 00:00:00 1.330,00 BPJS
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 4.950,00
vestein 300 mg 46.750,00
Ceftriaxone Inj
13/03/2021 00:00:00 12.498,00
NACL 0,9 % 500 ml 17.100,00
Ranitidin inj 3.580,00
Cefixime kapsul 200 mg
14/03/2021 00:00:00 26.480,00
Curcuma Tab 12.700,00
vestein 300 mg 9.350,00
vestein 300 mg 46.750,00
Total 423.715,00
2.875 Supiyani TALANG KUNING 182966 Cefotaxime Injeksi
11/03/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
oxytocin inj 4.497,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 15
12/03/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding tube) Fr. 5 17.603,00
NonWoven Fixation 10x 9.630,00
Oxytetracycline Salep Ma 3.251,00
Phytomenadione 2 Mg/1M 4.834,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
13/03/2021 00:00:00 1.935,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Ciprofloxacin tab 500 mg 5.590,00
Ciprofloxacin tab 500 mg 5.590,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Hypafix 10cm x 5cm (25 c 4.850,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 18.945,00
Total 260.457,00
2.876 Remina TALANG PETAI 181604 Catheter 2 Way No. 16 (
11/03/2021 00:00:00 20.625,00 BPJS
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Handscoon steril M 305.514,00
Miloz 1mg/ml Injeksi 5.259,00
Misoprostol Tab 16.500,00
Ondansetron Inj 4.950,00
Protofen Supositoria 60,00
Recofol N Injeksi 99.000,00
Spuit 1cc terumo 14.232,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00

19/08/2021 12:42:30 Page 685 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.876 Remina TALANG PETAI 181604 Urine bag
11/03/2021 00:00:00 9.314,00 BPJS
Cefixime kapsul 200 mg
12/03/2021 00:00:00 26.480,00
Meprolut Tab 41.800,00
Paracetamol tablet 500 m 3.000,00
Total 614.710,00
2.877 Dwi Rini Pratiwi SUMBER MAKMUR 176413 abbocath 18 Terumo @5
11/03/2021 00:00:00 26.341,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 27.843,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
methyl ergometrin amp 12.993,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 4.950,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 4.260,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 16.990,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 182.185,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
12/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 10x 9.630,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
13/03/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 13.088,00
Ketorolac inj 30 mg/1ml 4.035,00

19/08/2021 12:42:30 Page 686 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.877 Dwi Rini Pratiwi SUMBER MAKMUR 176413 Metrodinazole tab 500 m
13/03/2021 00:00:00 810,00 BPJS
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
14/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 1.417.288,00
2.878 Rosdin Efendi BANDARATU 138467 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.879 Amri Kusna Yanti BUMI MULYA 133486 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
NACL 0,9 % 500 ml
15/03/2021 00:00:00 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 185.875,00
2.880 Narti SILAUT 175653 NACL 0,9 % 500 ml
11/03/2021 00:00:00 42.750,00 BPJS
NACL 0,9 % 500 ml
15/03/2021 00:00:00 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 194.425,00
2.881 M Akil PASAR BELAKANG 115376 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.882 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.883 Wardoyo TANJUNG MULYA 125079 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.884 Ashari Liwandi PONDOK LUNANG 139398 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.885 Supangat PONDOK LUNANG 147511 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.886 Miswanto LUNANG 128267 NACL 0,9 % 500 ml
11/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.887 Huriyati SUNGAI JERINJING 182358 abbocath 18 Terumo @5
11/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Infuset Makro (Ideal Care 10.306,00
Novo Twist 32 G Tip 1.928,00
Novorapid Flexpen 108.750,00
Ringer Laktat Otsuka 9.538,00
Urine bag 9.314,00
Alkohol 1Liter 42.111,00
Bisturi No. 23 0,00
Bucain Spinal 0.5 % Inj 0,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 17.253,00
Celemek Plastik 0,00
Chloramphenicol Salep M 2.351,00
Chromic catgut 1 R (Tri 0,00

19/08/2021 12:42:30 Page 687 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.887 Huriyati SUNGAI JERINJING 182358 Chromic catgut 2-0 R (Tr
11/03/2021 00:00:00 0,00 BPJS
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 0,00
Handscoond Non Steril S 0,00
handscoond steril 8 (Gam 0,00
Handscoond Sterille 6.5 0,00
Handscoond Sterille 7 (G 0,00
Handscoond Sterille 7.5 0,00
Induxin 1 ml Injeksi 18.562,00
Iodine povidone 300 ml 0,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 1.611,00
Masker Tali 0,00
methyl ergometrin amp 8.662,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 0,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Myotonic inj 0,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 13.388,00
Paracetamol tablet 500 m 600,00
Phytomenadione 2 Mg/1M 4.834,00
Polyvinylidene 3-0 R (Tri 0,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 38.152,00
Spinocain 27 (BBraund) 0,00
Spuit 10 cc Disposible (T 0,00
Spuit 3 cc Disposible 0,00
Spuit 5 cc Disposible 0,00
Suction Chateter no. 8 (R 20.625,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 0,00
Topi Operasi (Perawat) @ 0,00
Tranexamic Acid Inj (Asa 4.210,00
umbilical Cord Clamp 2.261,00
Urine bag 9.314,00
Urine bag 9.314,00
viamac 1 R 0,00
Metrodinazole tab 500 m
12/03/2021 00:00:00 4.050,00
Paracetamol tablet 500 m 3.000,00
Vitamin B Komplek @100 1.694,00
Total 684.881,00
2.888 Rita Susanti ARAH TIGA 182984 Abbocath 20 Terumo @5
11/03/2021 00:00:00 26.341,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Nucral Syrup 100 ml 53.350,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
PARAMOL INFUS 288.750,00

19/08/2021 12:42:30 Page 688 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.888 Rita Susanti ARAH TIGA 182984 Ringer Laktat Otsuka
11/03/2021 00:00:00 28.614,00 BPJS
Omeprazole Inj
12/03/2021 00:00:00 12.499,00
Ondansetron Inj 4.950,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Vitamin B Komplek @100 308,00
Curcuma Tab
13/03/2021 00:00:00 19.050,00
Lansoprazole kapsul 30 m 11.550,00
OMZ 90.000,00
Paracetamol tablet 500 m 3.000,00
Psidii Capsule 500 mg 4.901,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 1.540,00
Total 677.261,00
2.889 Puji Pasiah ARGA JAYA 146552 abbocath 18 Terumo @5
11/03/2021 00:00:00 26.341,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
handscoon steril 6.5 (Tr 44.964,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 29.108,00
Handscoond Non Steril M 20.080,00
Hypafix 15cmx5cm (25 c 13.088,00
Induxin 1 ml Injeksi 18.562,00
Infusion Makro (terumo) 27.225,00
Iodine povidone 300 ml 28.463,00
Masker Karet 11.000,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc Disposible 2.840,00
Urine bag 9.314,00
Total 1.185.219,00
2.890 Charles SUKA MAJU 182986 Abbocath 20 Terumo @5
11/03/2021 00:00:00 26.341,00 BPJS
Alprazolam 0,5 mg @100 118,00
Aspilet 80 mg @100 mg 276,00
Catheter 2 Way No. 16 ( 20.625,00

19/08/2021 12:42:30 Page 689 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.890 Charles SUKA MAJU 182986 Ceftriaxone Inj
11/03/2021 00:00:00 12.498,00 BPJS
Clopidogrel 75 mg @30 T 7.020,00
Infusion Makro (terumo) 27.225,00
Isosorbid dinitrat 5 mg (I 333,00
NACL 0,9 % 500 ml 8.550,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Sucralfate Suspensi 100 m 19.250,00
Urine bag 9.314,00
Atorvastatin 20 mg @30 T 2.090,00
Alprazolam 0,5 mg @100
12/03/2021 00:00:00 118,00
Arixtra Injeksi 2.5mg/0.5 326.625,00
Atorvastatin 20 mg @30 T 1.045,00
Ceftriaxone Inj 12.498,00
Clopidogrel 75 mg @30 T 1.755,00
Clopidogrel 75 mg @30 T 17.550,00
Isosorbid dinitrat 5 mg (I 333,00
Miniaspi 80 Mg @100 Ta 125,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Alprazolam 0,5 mg @100
13/03/2021 00:00:00 118,00
Arixtra Injeksi 2.5mg/0.5 326.625,00
Atorvastatin 20 mg @30 T 1.045,00
Ceftriaxone Inj 12.498,00
Isosorbid dinitrat 5 mg (I 333,00
NACL 0,9 % 500 ml 17.100,00
Arixtra Injeksi 2.5mg/0.5
14/03/2021 00:00:00 326.625,00
Atorvastatin 20 mg @30 T 10.450,00
Clopidogrel 75 mg @30 T 17.550,00
Isosorbid dinitrat 5 mg (I 1.110,00
Miniaspi 80 Mg @100 Ta 1.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 1.318.897,00
2.891 Puji Pasiah ARGA JAYA 146552 Cefotaxime Injeksi
11/03/2021 00:00:00 11.502,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 15
12/03/2021 00:00:00 3.836,00
Kassa kotak stril DRC 9.675,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
13/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
14/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00

19/08/2021 12:42:30 Page 690 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.891 Puji Pasiah ARGA JAYA 146552 Tranexamic Acid Inj (Asa
14/03/2021 00:00:00 12.630,00 BPJS
Total 163.962,00
2.892 Bainah LUNANG 179402 Alkohol 1Liter
12/03/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Iodine Povidone 1 L 183.288,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker 3 Play N. 95 93.750,00
Masker Karet 11.000,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 10x 4.815,00
Ondansetron Inj 1.650,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 37.620,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Urine bag 9.263,00
Total 1.697.723,00
2.893 Suyati AGUNG JAYA 182987 Abbocath 20 Terumo @5
11/03/2021 00:00:00 26.341,00 BPJS
Antrain Injeksi 9.625,00
Infusion Makro (terumo) 27.225,00
Nucral Syrup 100 ml 53.350,00

19/08/2021 12:42:30 Page 691 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.893 Suyati AGUNG JAYA 182987 OMZ
11/03/2021 00:00:00 90.000,00 BPJS
Piralen Injeksi 2 ml 8.800,00
Ringer Laktat Otsuka 9.538,00
Gitas Plus
12/03/2021 00:00:00 75.495,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin C tablet @100 Ta 1.380,00
Total 327.614,00
2.894 Rasidah GAJAH MATI 180865 Abbocath 20 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Antrain Injeksi 19.250,00
Catheter 2 Way No. 16 ( 20.625,00
Gentamicin Injeksi 13.818,00
Infusion Makro (terumo) 27.225,00
Methylprednisolone Inje 104.769,00
NACL 0,9 % 500 ml 25.650,00
Nucral Syrup 100 ml 53.350,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
OMZ 90.000,00
Ondansetron Inj 1.650,00
Ondansetron Inj 4.950,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Antrain Injeksi
13/03/2021 00:00:00 19.250,00
Antrain Injeksi 28.875,00
Antrain Injeksi 28.875,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Curcuma Tab 3.810,00
Curcuma Tab 3.810,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Vitamin B Komplek @100 308,00
Vitamin B Komplek @100 308,00
Omeprazol kapsul 20 mg
14/03/2021 00:00:00 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 714.175,00
2.895 Bainah LUNANG 179402 Asam Mefenamat 500 m
14/03/2021 00:00:00 1.935,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Postofix (leukomed) 36.726,00
Total 56.626,00
2.896 Wagiyem SELAGAN JAYA 182990 Abbocath 20 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS

19/08/2021 12:42:30 Page 692 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.896 Wagiyem SELAGAN JAYA 182990 Flunarizine 5 mg tab
12/03/2021 00:00:00 4.950,00 BPJS
Infusion Makro (terumo) 27.225,00
OMZ 90.000,00
Ondansetron Inj 1.650,00
Perifas @100 Tab 5.775,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 19.076,00
Alprazolam 0,5 mg @100 118,00
Ceftriaxone Inj 12.498,00
Dimenhidrinat tab 50 mg 414,00
Flunarizine 5 mg tab 4.950,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Perifas @100 Tab 5.775,00
Ringer Laktat Otsuka 9.538,00
Abbocath 20 Terumo @5
13/03/2021 00:00:00 79.023,00
Abbocath 22 Terumo @5 33.414,00
Alprazolam 0,5 mg @100 118,00
Ceftriaxone Inj 12.498,00
Dimenhidrinat tab 50 mg 414,00
Flunarizine 5 mg tab 4.950,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Alprazolam 0,5 mg @100
14/03/2021 00:00:00 118,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Dimenhidrinat tab 50 mg 1.380,00
Dimenhidrinat tab 50 mg 1.380,00
Flunarizine 5 mg tab 24.750,00
Flunarizine 5 mg tab 24.750,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 4.035,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ondansetron Inj 4.950,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Dimenhidrinat tab 50 mg
15/03/2021 00:00:00 1.380,00
Flunarizine 5 mg tab 9.900,00
Omeprazole Inj 24.998,00
Perifas @100 Tab 9.625,00
Sucralfate Suspensi 100 m 19.250,00
Total 673.019,00
2.897 Siti Nurhidayah teluk bakung 099036 Abbocath 20 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00

19/08/2021 12:42:30 Page 693 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.897 Siti Nurhidayah teluk bakung 099036 Ringer Laktat Otsuka
12/03/2021 00:00:00 9.538,00 BPJS
Transfusi Set Terumo 16.500,00
Total 58.130,00
2.898 Zulkifli DUSUN BARU PELOKA 181910 Amlodipine 5 mg @30 T
12/03/2021 00:00:00 1.010,00 BPJS
Paracetamol tablet 500 m 2.000,00
Ranitidine tablet 150 mg 1.440,00
Symbicort Turbuhaler 80 167.855,00
Total 172.305,00
2.899 Panca Irawan BANDARATU 151148 Diazepam Tab 5 Mg
12/03/2021 00:00:00 1.360,00 BPJS
Kalxetin 10 mg @30 Kap 55.000,00
Urinter Kapsul @100 cap 21.980,00
Total 78.340,00
2.900 Sofyan Afifuddin MEKAR MULYA 166104 Cefotaxime Injeksi
12/03/2021 00:00:00 57.510,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 59.510,00
2.901 Nofrianti LUBUK PINANG 142468 abbocath 18 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 44.000,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
NonWoven Fixation 10x 4.815,00
Ondansetron Inj 1.650,00
Ondansetron Inj 1.650,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 28.614,00
Suprafenid Supositoria 10 28.050,00
Transfusi Set Terumo 16.500,00
Total 358.129,00
2.902 Herlinda LUBUK SANAI 182956 Captopril 12,5 mg
12/03/2021 00:00:00 1.600,00 BPJS
Furosemide 40 mg Tablet 960,00
Spironolaktone 25 mg 7.800,00
Total 10.360,00
2.903 Zamhari BANDARATU 122356 Amlodipine 5 mg @30 T
12/03/2021 00:00:00 1.010,00 BPJS
Bisoprolol 5 mg @100 Ta 1.480,00
Captopril 12,5 mg 800,00
Furosemide 40 mg Tablet 960,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 25 mg 7.800,00
Total 19.910,00
2.904 Siti Eriah BANDAR JAYA 182800 Cefixime Kapsul 100 mg
12/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00

19/08/2021 12:42:30 Page 694 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.905 Arpan Agus PASAR BELAKANG 112261 Amlodipine 5 mg @30 T
12/03/2021 00:00:00 1.010,00 BPJS
Bisoprolol 5 mg @100 Ta 2.960,00
Glimepiride tab 2 mg 2.590,00
Ibuprofen tab 400 mg 4.580,00
Metformin tablet 500 mg 7.980,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Valsartan tab 80 mg 41.250,00
Total 68.980,00
2.906 Selvia Verolina MANDI ANGIN 140849 Cefixime Kapsul 100 mg
12/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.907 Solin RANAH KARYA 175604 Betahistin Mesilat 6 mg @
12/03/2021 00:00:00 1.380,00 BPJS
Flunarizine 5 mg tab 24.750,00
Mecobalamin 500 mg 7.700,00
Total 33.830,00
2.908 Ngatini LUBUK MUKTI 179230 Captopril 12,5 mg
12/03/2021 00:00:00 2.400,00 BPJS
Metoclopramide Tab 5 m 1.510,00
Omeprazol kapsul 20 mg 6.610,00
Spironolaktone 25 mg 7.800,00
Total 18.320,00
2.909 Feri Maryani AIR BIKUK 142297 Calcium Laktat
12/03/2021 00:00:00 790,00 BPJS
Tambah Darah Neo Tab 4.650,00
Total 5.440,00
2.910 Ikrimatul Khasanah SUMBER MAKMUR 152617 Amoxicillin 500 mg @ 10
12/03/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Pehacain Injeksi 3.320,00
Total 7.670,00
2.911 Septiyani RAWA MULYA 136667 Asam Folat 1 mg @100 T
12/03/2021 00:00:00 2.970,00 BPJS
Total 2.970,00
2.912 Upik Hartati PONDOK PANJANG 152646 Cefixime Kapsul 100 mg
12/03/2021 00:00:00 9.380,00 BPJS
Misoprostol Tab 82.500,00
Total 91.880,00
2.913 Rina Novita Handayani RAWA BANGUN 152528 Betahistin Mesilat 6 mg @
12/03/2021 00:00:00 2.070,00 BPJS
Mecobalamin 500 mg 7.700,00
Total 9.770,00
2.914 Safaraz Hafuza Putra BANDARATU 182997 Cefixime syrup 100mg/5 M
12/03/2021 00:00:00 23.823,00 BPJS
Cetirizine 10 mg 1.260,00
Dexametason 0,5 mg Ta 1.160,00
Nassal Mask O2 Anak 41.828,00
Nebulizer O2 Anak 18.219,00
Salbutamol 2 mg 790,00
Ventolin Nebules 2.5 mg 10.000,00
Total 97.080,00
2.915 Darmawas DUSUN BARU PELOKA 152558 Alprazolam 0,5 mg @100
12/03/2021 00:00:00 118,00 BPJS
Levofloxacin Tablet 500 m 6.820,00
Methylprednisolone tab 4 1.578,00
Onbrez Breezhaler HGCI 0 440.640,00
Paracetamol tablet 500 m 2.000,00
vestein 300 mg 46.750,00

19/08/2021 12:42:30 Page 695 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 497.906,00
2.916 Rohana PASAR BANTAL 142325 Glimepiride tab 2 mg
12/03/2021 00:00:00 7.770,00 BPJS
Hexymer 2 Mg Tab (THP) 43.020,00
Levazide tablet 91.460,00
Levazide tablet 91.460,00
Levazide tablet 91.460,00
Metformin tablet 500 mg 11.970,00
Sifrol tab 0,375 mg 311.250,00
Total 648.390,00
2.917 Ispianti PASAR GEDANG 117122 Azitromycin 500 mg
12/03/2021 00:00:00 56.250,00 BPJS
Total 56.250,00
2.918 Muhammad Hatta UJUNG PADANG 109078 Abbocath 20 Terumo @5
12/03/2021 00:00:00 52.682,00 BPJS
Amlodipine 10 mg @50 T 118,00
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Esomeprazol Injeksi 40 m 34.956,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Total 163.644,00
2.919 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.920 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.921 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.922 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.923 Salami SILAUT I 134774 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.924 Siti Nurhidayah teluk bakung 099036 Alkohol 1Liter
12/03/2021 00:00:00 42.111,00 BPJS
Alkohol 1Liter 42.111,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoon Steril 8.5 (Ga 14.554,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Iodine Povidone 1 L 183.288,00

19/08/2021 12:42:30 Page 696 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.924 Siti Nurhidayah teluk bakung 099036 Ketorolac inj 30 mg/1ml
12/03/2021 00:00:00 1.345,00 BPJS
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 93.750,00
Masker Karet 11.000,00
Massa Cauter Dewasa 180.480,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
NonWoven Fixation 10x 4.815,00
Ondansetron Inj 1.650,00
Oxytetracycline Salep Ma 3.251,00
Phytomenadione 2 Mg/1M 4.834,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyglycolide T-Vio 1 R ( 98.500,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 18.810,00
Protocin Inj 37.620,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suction Chateter no. 8 (R 20.625,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
13/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Ciprofloxacin tab 500 mg
15/03/2021 00:00:00 5.590,00
Clindamycin 150 mg tabl 8.750,00
Clindamycin 300 mg Tabl 17.500,00
Kassa kotak stril DRC 9.675,00
Ketoprofen tab 100 mg 18.570,00
Ketorolac Tab 10 Mg 37.950,00
Metoclopramide inj 5Mg/M 11.758,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 12.630,00
Total 2.283.744,00
2.925 Septi Indarti BANDAR RATU 113713 abbocath 18 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
NonWoven Fixation 10x 4.815,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 697 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.925 Septi Indarti BANDAR RATU 113713 Alkohol 1Liter
12/03/2021 00:00:00 42.111,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 37.124,00
Iodine Povidone 1 L 183.288,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 93.750,00
Masker Karet 11.000,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 10x 4.815,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 4.845,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 9.380,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.263,00
Cefotaxime Injeksi
13/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 2.690,00
Metrodinazole Infus 10.313,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23
14/03/2021 00:00:00 3.836,00
Ceftriaxone Inj 12.498,00
Chloramphenicol Salep M 2.351,00
Metrodinazole Infus 30.939,00

19/08/2021 12:42:30 Page 698 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.925 Septi Indarti BANDAR RATU 113713 NGT (Feeding tube) Fr. 5
14/03/2021 00:00:00 17.603,00 BPJS
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 28.614,00
umbilical Cord Clamp 2.261,00
Catheter 2 Way No. 16 (
15/03/2021 00:00:00 20.625,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 70.242,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 19.350,00
Ketorolac Tab 10 Mg 37.950,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Total 2.073.931,00
2.926 Nasri MANDI ANGIN JAYA 173798 abbocath 18 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Abbocath 20 Terumo @5 26.341,00
Aqua Pro Injeksi 3.575,00
Candesartan tab 8 mg 1.362,00
Infusion set Mikro (Terumo 18.026,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 4.833,00
NonWoven Fixation 10x 4.815,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 121.006,00
2.927 Muhammad Hatta UJUNG PADANG 109078 Amlodipine 10 mg @50 T
13/03/2021 00:00:00 118,00 BPJS
Ceftriaxone Inj 12.498,00
Metoclopramide inj 5Mg/M 17.637,00
NonWoven Fixation 10x 4.815,00
OMZ 90.000,00
Paracetamol tablet 500 m 600,00
Piralen Injeksi 2 ml 26.400,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 10 mg @50 T
14/03/2021 00:00:00 118,00
Cefotaxime Injeksi 11.502,00
Esomeprazol Injeksi 40 m 34.956,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Amlodipine 10 mg @50 T
15/03/2021 00:00:00 590,00
Cefixime Kapsul 100 mg 9.380,00
Metoclopramide Tab 5 m 1.510,00
Omeprazol kapsul 20 mg 3.305,00
Paracetamol tablet 500 m 2.000,00
Total 281.356,00
2.928 Fithriyyah Atila SUNGAI SERIK 183001 abbocath 18 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason 0,5 mg Ta 348,00
NonWoven Fixation 10x 4.815,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00

19/08/2021 12:42:30 Page 699 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 82.157,00
2.929 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
2.930 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Nassal Cannula O2 Dewas 11.625,00
Total 45.825,00
2.931 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
12/03/2021 00:00:00 34.200,00 BPJS
Nassal Cannula O2 Dewas 11.625,00
Total 45.825,00
2.932 Susi Martini KOTO JAYA 145038 Glucosamine 250 mg
12/03/2021 00:00:00 2.310,00 BPJS
NACL 0,9 % 500 ml 42.750,00
Total 45.060,00
2.933 Nasri MANDI ANGIN JAYA 173798 Abbocath 18 (Gea)
13/03/2021 00:00:00 10.720,00 BPJS
Bisoprolol 5 mg @100 Ta 1.480,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Infusion Makro (Gea) 7.425,00
Kassa kotak stril DRC 9.675,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 6.444,00
Ondansetron tablet 8 mg 26.400,00
Ringer Laktat Otsuka 28.614,00
Spironolaktone 25 mg 2.600,00
Transfusi Set Terumo 16.500,00
Total 133.697,00
2.934 Ali Martopo PONDOK TENGAH 126369 Abbocath 20 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Erdosteine Syr 36.575,00
Infusion Makro (Gea) 7.425,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
Nassal Cannula O2 Dewas 11.625,00
Nebulizer O2 Dewasa 34.783,00
NonWoven Fixation 15x 6.694,00
Ventolin Nebules 2.5 mg 10.000,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Total 234.593,00
2.935 Pasman SUMBER MAKMUR 183004 Abbocath 20 Terumo @5
12/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Biosat -1.5 (ATS 1500 ui) 163.749,00
Ceftriaxone Inj 12.498,00
Extrace Injeksi 100 mg/m 19.250,00
Infusion Makro (Gea) 7.425,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00

19/08/2021 12:42:30 Page 700 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 270.686,00
2.936 Sriyono LUNANG 183006 Ceftriaxone Inj
13/03/2021 00:00:00 12.498,00 BPJS
Electroda (Ambu) @25 Pc 81.570,00
Glukosa Infus 10 % 9.375,00
Glukosa Infus 10 % 9.375,00
NGT (Stomach Tube) Fr. 1 60.046,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 200,00
Ceftriaxone Inj
14/03/2021 00:00:00 12.498,00
Glukosa Infus 10 % 9.375,00
Hypafix 15cmx5cm (25 c 6.544,00
Paracetamol tablet 500 m 400,00
Ceftriaxone Inj
15/03/2021 00:00:00 0,00
Glukosa Infus 10 % 9.375,00
Glukosa Infus 10 % 0,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Cefixime Kapsul 100 mg
16/03/2021 00:00:00 9.380,00
Paracetamol tablet 500 m 2.000,00
Total 286.180,00
2.937 Solmidas AIR HAJI 182335 abbocath 18 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 12.512,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hystolan Tab 20 mg 5.569,00
Hystolan Tab 20 mg 27.845,00
Infusion Makro (terumo) 27.225,00
Otsu MgSO4 40 % 4.745,00
Ringer Laktat Otsuka 9.538,00
Total 155.863,00
2.938 Fithriyyah Atila SUNGAI SERIK 183001 Bisturi No. 23
12/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 6.5 16.488,00
Handscoond Sterille 7 (G 29.126,00
Handscoond Sterille 7.5 16.488,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 2.690,00
methyl ergometrin amp 8.662,00
Miloz Injeksi 5 mg 5.611,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Pethidin HCL Injeksi 50 m 121.755,00
Polyvinylidene 3-0 R (Tri 92.000,00

19/08/2021 12:42:30 Page 701 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.938 Fithriyyah Atila SUNGAI SERIK 183001 Protofen Supositoria
12/03/2021 00:00:00 60,00 BPJS
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Suprafenid Supositoria 10 28.050,00
Tranexamic Acid Inj (Asa 4.210,00
viamac 1 R 182.185,00
Cefotaxime Injeksi
13/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Ciprofloxacin tab 500 mg
15/03/2021 00:00:00 5.590,00
Clindamycin 150 mg tabl 8.750,00
Kassa kotak stril DRC 9.675,00
Ketoprofen tab 100 mg 18.570,00
Ketorolac Tab 10 Mg 37.950,00
Postofix (leukomed) 36.726,00
Bisturi No. 15
18/03/2021 00:00:00 3.836,00
Chloramphenicol Salep M 2.351,00
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Total 1.340.789,00
2.939 Safrina UJUNG PADANG 126429 abbocath 18 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Glukosa Infus 5 % 25.878,00
Ketorolac inj 30 mg/1ml 4.035,00
Norelut 9.350,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Abbocath 20 Terumo @5 52.682,00
Abbocath 22 Terumo @5 11.138,00
Aqua Pro Injeksi 3.575,00
Catheter 2 Way No. 16 ( 20.625,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 18.026,00
Meropenem Inj 0.5 g 110.000,00
NACL 0,9 % 500 ml 34.200,00
NACL 0,9 % 500 ml 25.650,00
Nassal Cannula O2 Dewas 11.625,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 9.538,00
Three Way stopcock 15.789,00

19/08/2021 12:42:30 Page 702 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.939 Safrina UJUNG PADANG 126429 Tranexamic Acid Inj (Asa
13/03/2021 00:00:00 4.210,00 BPJS
Transfusi Set Terumo 16.500,00
Urine bag 9.263,00
Cefotaxime Injeksi
14/03/2021 00:00:00 11.502,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 0,00
Ketorolac inj 30 mg/1ml 1.345,00
meropenem Injeksi 1 g 41.250,00
NACL 0,9 % 500 ml 17.100,00
Norelut 9.350,00
Phytomenadione 2 Mg/1M 14.502,00
Tranexamic Acid Inj (Asa 12.630,00
Abbocath 20 Terumo @5
15/03/2021 00:00:00 52.682,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 4.035,00
meropenem Injeksi 1 g 41.250,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 25.650,00
Phytomenadione 10 Mg/1 17.877,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
meropenem Injeksi 1 g 123.750,00
Phytomenadione 10 Mg/1 17.877,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
17/03/2021 00:00:00 11.502,00
Nassal Cannula O2 Anak 16.473,00
Novo Twist 32 G Tip 3.856,00
Novorapid Flexpen 217.500,00
Aminophyllin Inj
18/03/2021 00:00:00 15.536,00
Amlodipine 10 mg @50 T 1.180,00
Dexametason Injeksi 3.128,00
Glukosa Infus 5 % 17.252,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 10x 4.815,00
Phytomenadione 10 Mg/1 17.877,00
Pulmicort Resp 0.25 mg/ 0 35.768,00
Tranexamic Acid Inj (Asa 6.315,00
Ventolin Nebules 2.5 mg 20.000,00
Cefotaxime Injeksi
19/03/2021 00:00:00 17.253,00
Ketorolac inj 30 mg/1ml 4.035,00
meropenem Injeksi 1 g 123.750,00
meropenem Injeksi 1 g 82.500,00
NACL 0,9 % 500 ml 8.550,00
Norelut 93.500,00

19/08/2021 12:42:30 Page 703 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 1.884.795,00
2.940 Puput Anista TALANG PETAI 183008 Catheter 2 Way No. 16 (
13/03/2021 00:00:00 20.625,00 BPJS
Chloramphenicol Salep M 2.351,00
Chromic catgut 2-0 R (Tr 144.500,00
Handscoon kebidanan @ 130.052,00
Handscoond Sterille 6.5 49.464,00
Induxin 1 ml Injeksi 18.562,00
Kassa kotak stril DRC 9.675,00
Lidocain injk 40 mg/2 ml 3.222,00
methyl ergometrin amp 8.662,00
Misoprostol Tab 16.500,00
Phytomenadione 2 Mg/1M 4.834,00
Spuit 1cc terumo 4.744,00
Spuit 3 cc Disposible 5.460,00
Spuit 5 cc Disposible 2.840,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Urine bag 9.263,00
Cefixime Kapsul 100 mg
14/03/2021 00:00:00 9.380,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 2.700,00
Paracetamol tablet 500 m 2.000,00
Total 483.710,00
2.941 Bahman SIBAK 155872 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.942 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.943 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.944 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.945 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.946 Mutmainnah SUNGAI RENGAS 114676 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.947 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.948 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.949 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.950 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.951 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.952 Junaidi SUNGAI IPUH 138273 NACL 0,9 % 500 ml
13/03/2021 00:00:00 42.750,00 BPJS
Total 42.750,00
2.953 Khairul Razikin UJUNG PADANG 180624 Abbocath 20 Terumo @5
13/03/2021 00:00:00 52.682,00 BPJS
Aqua Pro Injeksi 3.575,00
Catheter 3 Way No. 24 ( 44.688,00
Ceftriaxone Inj 12.498,00

19/08/2021 12:42:30 Page 704 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.953 Khairul Razikin UJUNG PADANG 180624 Hypafix 10cm x 5cm (25 c
13/03/2021 00:00:00 4.850,00 BPJS
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Lidocain injk 40 mg/2 ml 1.611,00
Omeprazole Inj 12.499,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 49.500,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 9.263,00
Ceftriaxone Inj 6.249,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furosemide Injeksi @2ml 1.666,00
Ketorolac inj 30 mg/1ml 1.345,00
NACL 0,9 % 500 ml 8.550,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 4.125,00
Catheter 2 Way No. 10
14/03/2021 00:00:00 14.300,00
Catheter 2 Way No. 8 (R 48.450,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Dipenhydramin Injeksi 10 1.535,00
Extrace Injeksi 100 mg/m 28.875,00
Extrace Injeksi 100 mg/m 28.875,00
Furosemide Injeksi @2ml 1.666,00
Furosemide Injeksi @2ml 1.666,00
Ketorolac inj 30 mg/1ml 4.035,00
NACL 0,9 % 500 ml 17.100,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.263,00
Abbocath 14 Terumo @5
15/03/2021 00:00:00 10.443,00
Abbocath 14 Terumo @5 20.886,00
Amlodipine 10 mg @50 T 118,00
Catheter 2 Way No.12 (R 29.394,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Extrace Injeksi 100 mg/m 19.250,00
Furosemide Injeksi @2ml 1.666,00
Infusion Makro (terumo) 27.225,00
NonWoven Fixation 15x 6.694,00
Omeprazole Inj 12.499,00

19/08/2021 12:42:30 Page 705 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.953 Khairul Razikin UJUNG PADANG 180624 Phytomenadione 10 Mg/1
15/03/2021 00:00:00 17.877,00 BPJS
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Ascorbid Acid 1000mg/5m
16/03/2021 00:00:00 78.375,00
Ceftriaxone Inj 12.498,00
Kassa kotak stril DRC 38.700,00
Ketorolac inj 30 mg/1ml 4.035,00
NonWoven Fixation 15x 13.388,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Total 1.015.894,00
2.954 Rosi PONDOK PANJANG 182653 abbocath 18 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Nassal Cannula O2 Dewas 11.625,00
Pamol Inf 1g Berno 246.000,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 339.469,00
2.955 Seva Purnama Sari LUBUK PINANG 157073 abbocath 18 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Hypafix 10cm x 5cm (25 c 4.850,00
Metoclopramide inj 5Mg/M 17.637,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 28.614,00
Tonotan tab 4.573,00
Transfusi Set Terumo 16.500,00
Total 102.690,00
2.956 Sutini ARGA JAYA 183011 abbocath 18 Terumo @5
14/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 5.751,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 64.674,00
2.957 Sari Budiman LUBUK PINANG 146614 Abbocath 20 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
azitromicin inj 500 mg 144.376,00
Extrace Injeksi 100 mg/m 48.125,00
Infusion Makro (Gea) 7.425,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 10x 4.815,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
vestein 300 mg 14.025,00

19/08/2021 12:42:30 Page 706 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.957 Sari Budiman LUBUK PINANG 146614 Zink Tablet
13/03/2021 00:00:00 1.378,00 BPJS
Total 316.298,00
2.958 Ny.solmidas AIR HAJI 183012 Abbocath 24 Terumo @5
13/03/2021 00:00:00 79.023,00 BPJS
Bactesyn inj 0,75 gr 59.009,00
Bactesyn inj 0,75 gr 59.009,00
Bisturi no. 10 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Catgut Chromic 3/0 R (Sc 79.156,00
Chloramphenicol Salep M 2.351,00
Gentamicin Injeksi 4.606,00
Gentamicin Injeksi 4.606,00
Glukosa Infus 10 % 9.375,00
Infusion Makro (Gea) 7.425,00
Kassa kotak stril DRC 9.675,00
NGT (Feeding tube) Fr. 3 21.710,00
NonWoven Fixation 10x 9.630,00
Phytomenadione 2 Mg/1M 4.834,00
Phytomenadione 2 Mg/1M 4.834,00
Suction Chateter no. 8 (R 20.625,00
umbilical Cord Clamp 2.261,00
Bactesyn inj 0,75 gr
15/03/2021 00:00:00 59.009,00
Hypafix 10cm x 5cm (25 c 9.700,00
NGT (Feeding Tube) Fr. 8
16/03/2021 00:00:00 70.420,00
Abbocath 24 Terumo @5
17/03/2021 00:00:00 105.364,00
Abbocath 24 Terumo @5 79.023,00
Bactesyn inj 0,75 gr 59.009,00
Gentamicin Injeksi 4.606,00
NonWoven Fixation 10x 4.815,00
NonWoven Fixation 10x 4.815,00
Bactesyn inj 0,75 gr
18/03/2021 00:00:00 59.009,00
Calcii Glukonas Inj 100 m 12.939,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NonWoven Fixation 10x 4.815,00
Abbocath 24 Terumo @5
19/03/2021 00:00:00 105.364,00
Bactesyn inj 0,75 gr
21/03/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Abbocath 24 Terumo @5
22/03/2021 00:00:00 79.023,00
Bactesyn inj 0,75 gr 59.009,00
Epinephrin inj 15.331,00
Gentamicin Injeksi 4.606,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ka-En Mg3 13.104,00
NGT (Feeding tube) Fr. 5 17.603,00
Total 1.266.913,00
2.959 Sari Budiman LUBUK PINANG 146614 Acetylcystein 200 mg Ka
14/03/2021 00:00:00 8.595,00 BPJS
Azitromycin 500 mg 16.875,00
Omeprazole Inj 37.497,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 1.000,00
Ringer Laktat Otsuka 28.614,00

19/08/2021 12:42:30 Page 707 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.959 Sari Budiman LUBUK PINANG 146614 Vitamin C 500 mg
14/03/2021 00:00:00 5,00 BPJS
Zink Tablet 3.445,00
Ascorbid Acid 1000mg/5m
15/03/2021 00:00:00 52.250,00
azitromicin inj 500 mg 144.376,00
Codein tab 10 mg 7.500,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 38.152,00
vestein 300 mg 46.750,00
Ascorbid Acid 1000mg/5m
16/03/2021 00:00:00 104.500,00
azitromicin inj 500 mg 288.752,00
Omeprazole Inj 12.499,00
Ondansetron Inj 3.300,00
Abbocath 22 Terumo @5
17/03/2021 00:00:00 11.138,00
azitromicin inj 500 mg 144.376,00
Azitromycin 500 mg 16.875,00
Omeprazole Inj 12.499,00
Oseltamivir 75 mg 10,00
Ringer Laktat Otsuka 28.614,00
Vectrine Tab 300 mg 50.000,00
vestein 300 mg 23.375,00
Vitamin B Komplek @100 1.540,00
Zink Tablet 6.890,00
Total 1.113.826,00
2.960 Mujiatun PASAR SEBELAH 183013 abbocath 18 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Curcuma Tab 3.810,00
Furamin Injeksi 14.369,00
Ibuprofen tab 400 mg 916,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Total 109.979,00
2.961 Nur Haji ARAH TIGA 143579 abbocath 18 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Cefoperazon Inj 82.500,00
Ferro Sulfate 800,00
Furamin Injeksi 14.369,00
Infusion Makro (terumo) 27.225,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 9.538,00
Sucralfate Suspensi 100 m 19.250,00
Zink Tablet 1.378,00
Total 211.349,00
2.962 Solmidas AIR HAJI 182335 Aqua Pro Injeksi
13/03/2021 00:00:00 3.575,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 39.025,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 157.750,00

19/08/2021 12:42:30 Page 708 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.962 Solmidas AIR HAJI 182335 Chromic catgut 2-0 R (Tr
13/03/2021 00:00:00 72.250,00 BPJS
Cuticell Classic 10cmx10c 35.121,00
Electroda (Ambu) @25 Pc 81.570,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix Kamar Operasi 18.000,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole Infus 30.939,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 9.798,00
NACL 0,9 % 500 ml 17.100,00
NGT (Stomach Tube) Fr. 1 52.250,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 56.430,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.263,00
viamac 1 R 546.555,00
Cefotaxime Injeksi
14/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 10.313,00
oxytocin inj 2.998,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 12.630,00
Cefotaxime Injeksi
15/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 540,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 2.105,00
Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 21.050,00
Tranexamic Acid Inj (Asa 8.420,00

19/08/2021 12:42:30 Page 709 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.962 Solmidas AIR HAJI 182335 Aqua Pro Injeksi
17/03/2021 00:00:00 3.575,00 BPJS
Cefotaxime Injeksi 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 300 mg Tabl 17.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
NonWoven Fixation 10x 4.815,00
Postofix (leukomed) 36.726,00
Total 2.214.006,00
2.963 Seva Purnama Sari LUBUK PINANG 157073 Cetirizine 10 mg
14/03/2021 00:00:00 378,00 BPJS
Dexametason Injeksi 9.384,00
Hystolan Tab 20 mg 16.707,00
Metoclopramide inj 5Mg/M 17.637,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Abbocath 22 Terumo @5
15/03/2021 00:00:00 11.138,00
Asam Folat 1 mg @100 T 297,00
Dexametason Injeksi 6.256,00
Metoclopramide inj 5Mg/M 11.758,00
Injection plug
16/03/2021 00:00:00 20.213,00
NonWoven Fixation 15x 13.388,00
Paracetamol tablet 500 m 3.000,00
Total 155.270,00
2.964 Rosi PONDOK PANJANG 182653 Dexametason Injeksi
13/03/2021 00:00:00 9.384,00 BPJS
Cefotaxime Injeksi
14/03/2021 00:00:00 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol Infus 43.314,00
Cefotaxime Injeksi
15/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Paracetamol Infus 43.314,00
Tranexamic Acid Inj (Asa 6.315,00
Cefixime kapsul 200 mg
17/03/2021 00:00:00 26.480,00
Cefixime kapsul 200 mg 26.480,00
Paracetamol Infus 28.876,00
Paracetamol tablet 500 m 3.000,00
Paracetamol tablet 500 m 3.000,00
Total 232.246,00
2.965 Afriza Nurhayati PONDOK LUNANG 183014 Abbocath 20 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Furamin Injeksi 14.369,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 800,00
Psidii Capsule 500 mg 19.604,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 118.905,00
2.966 Nur Haji ARAH TIGA 143579 Cefoperazon Inj
13/03/2021 00:00:00 82.500,00 BPJS
Hypafix 10cm x 5cm (25 c 9.700,00

19/08/2021 12:42:30 Page 710 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.966 Nur Haji ARAH TIGA 143579 Hypafix 10cm x 5cm (25 c
13/03/2021 00:00:00 9.700,00 BPJS
Ondansetron Inj 4.950,00
Cefoperazon Inj
14/03/2021 00:00:00 82.500,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 6.544,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Cefoperazon Inj
15/03/2021 00:00:00 82.500,00
Dexametason Injeksi 6.256,00
Dipenhydramin Injeksi 10 3.070,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 3.332,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 9.700,00
Omeprazole Inj 24.998,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 38.152,00
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 930,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Zink Tablet 1.378,00
Cefoperazon Inj
16/03/2021 00:00:00 82.500,00
Furamin Injeksi 14.369,00
Omeprazole Inj 24.998,00
Ondansetron Inj 4.950,00
Phytomenadione 10 Mg/1 17.877,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 6.315,00
Furamin Injeksi
17/03/2021 00:00:00 14.369,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 49.996,00
Phytomenadione 10 mg ( 5.604,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Tambah Darah Neo Tab 4.650,00
Tranexamic Acid Inj (Asa 12.630,00
Zink Tablet 6.890,00
Zink Tablet 8.268,00
Total 853.275,00
2.967 Mujiatun PASAR SEBELAH 183013 Hypafix 10cm x 5cm (25 c
13/03/2021 00:00:00 9.700,00 BPJS
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Furamin Injeksi
14/03/2021 00:00:00 14.369,00
Hypafix 15cmx5cm (25 c 13.088,00
Ibuprofen tab 200 mg 398,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 711 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.967 Mujiatun PASAR SEBELAH 183013 Ranitidin inj
14/03/2021 00:00:00 3.580,00 BPJS
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Hypafix 10cm x 5cm (25 c
15/03/2021 00:00:00 4.850,00
Ibuprofen tab 200 mg 1.990,00
Ranitidine tablet 150 mg 1.440,00
Sucralfate Suspensi 100 m 19.250,00
Total 163.435,00
2.968 Dea Susilawati IPUH 183015 Abbocath 20 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Cefixime Kapsul 100 mg 1.876,00
Infusion Makro (terumo) 27.225,00
Ka-En 1 B 12.658,00
Nassal Cannula O2 Anak 16.473,00
Ondansetron Inj 1.650,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 99.341,00
2.969 Sri Rahayu KOTA PRAJA 129208 Abbocath 20 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 1.650,00
Ondansetron Inj 3.300,00
Paracetamol Infus 14.438,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Zinc Sulfate Syr 60 ml 4.569,00
Total 126.602,00
2.970 Sakdiah PAUH TERENJA 160239 Abbocath 20 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Ambroxol Syr 15mg/ml 4.538,00
Aqua Pro Injeksi 3.575,00
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 103.320,00
2.971 Afriza Nurhayati PONDOK LUNANG 183014 Ceftriaxone Inj
14/03/2021 00:00:00 12.498,00 BPJS
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 13.088,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 1.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 47.690,00
Ceftriaxone Inj
15/03/2021 00:00:00 12.498,00

19/08/2021 12:42:30 Page 712 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.971 Afriza Nurhayati PONDOK LUNANG 183014 Furamin Injeksi
15/03/2021 00:00:00 14.369,00 BPJS
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 2.690,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Psidii Capsule 500 mg 19.604,00
Psidii Capsule 500 mg 49.010,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 38.152,00
Sucralfate Suspensi 100 m 19.250,00
Total 336.713,00
2.972 Adriani ARAH TIGA 183016 Abbocath 20 Terumo @5
13/03/2021 00:00:00 26.341,00 BPJS
Amlodipine 10 mg @50 T 118,00
Aqua Pro Injeksi 3.575,00
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 93.356,00
2.973 Dea Susilawati IPUH 183015 Ambroxol 30 mg @100 T
14/03/2021 00:00:00 579,00 BPJS
Cefixime kapsul 200 mg 7.944,00
Ka-En 1 B 12.658,00
Ranitidin inj 1.790,00
Abbocath 24 Terumo @5
15/03/2021 00:00:00 131.705,00
Ambroxol Syr 15mg/ml 4.538,00
Cefixime Kapsul 100 mg 9.380,00
Combivent 18.768,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Nassal Mask O2 Dewasa 41.828,00
Nassal Mask O2 Dewasa 41.828,00
Prednison tab 5 mg 2.390,00
Ranitidin inj 3.580,00
Ambroxol Syr 15mg/ml
16/03/2021 00:00:00 4.538,00
Cefixime syrup 100mg/5 M 23.823,00
Salbutamol 2 mg 790,00
Total 343.064,00
2.974 Adriani ARAH TIGA 183016 Amlodipine 10 mg @50 T
14/03/2021 00:00:00 118,00 BPJS
Candesartan tab 8 mg 681,00
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 13.088,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Amlodipine 10 mg @50 T
15/03/2021 00:00:00 590,00
Candesartan tab 8 mg 6.810,00
Ranitidine tablet 150 mg 1.440,00

19/08/2021 12:42:30 Page 713 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.974 Adriani ARAH TIGA 183016 Sucralfate Suspensi 100 m
15/03/2021 00:00:00 19.250,00 BPJS
Total 91.619,00
2.975 Sakdiah PAUH TERENJA 160239 Azitromycin 500 mg
14/03/2021 00:00:00 5.625,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Azitromycin 500 mg
15/03/2021 00:00:00 28.125,00
NonWoven Fixation 15x 6.694,00
Sistenol kaplet 17.540,00
Sucralfate Suspensi 100 m 19.250,00
Total 134.020,00
2.976 Muktarudin LUBUK SANAI 108581 Abbocath 20 Terumo @5
14/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefoperazon Inj 82.500,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 4.035,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 176.613,00
2.977 Sri Rahayu KOTA PRAJA 129208 Ambroxol 30 mg @100 T
14/03/2021 00:00:00 1.930,00 BPJS
Azitromycin 500 mg 56.250,00
Ceftriaxone Inj 12.498,00
Loratadine tab 10 mg 1.660,00
Ondansetron Inj 4.950,00
Ondansetron tablet 8 mg 26.400,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Vitamin C tablet @100 Ta 1.380,00
Zink Tablet 1.378,00
Zink Tablet 6.890,00
Total 191.444,00
2.978 Sutini ARGA JAYA 183011 Asam Mefenamat 500 m
14/03/2021 00:00:00 1.290,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Cefotaxime Injeksi 17.253,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Fresofol ( propopol ) inj 13.448,00
Ketorolac inj 30 mg/1ml 4.035,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 55.000,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00

19/08/2021 12:42:30 Page 714 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.978 Sutini ARGA JAYA 183011 Rofiden Supp
14/03/2021 00:00:00 24.062,00 BPJS
Total 224.635,00
2.979 Nofrianti LUBUK PINANG 142468 Asam Mefenamat 500 m
14/03/2021 00:00:00 1.290,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Misoprostol Tab 16.500,00
Misoprostol Tab 22.000,00
Misoprostol Tab 55.000,00
Total 125.458,00
2.980 Suhardi BANDAR RATU 115774 Alprazolam 1 mg @100 T
14/03/2021 00:00:00 1.600,00 BPJS
Amlodipine 10 mg @50 T 2.360,00
Total 3.960,00
2.981 Muktarudin LUBUK SANAI 108581 Cefoperazon Inj
14/03/2021 00:00:00 82.500,00 BPJS
Furamin Injeksi 14.369,00
Hypafix 15cmx5cm (25 c 13.088,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tramadol 50 mg/ml Inj 12.375,00
Cefoperazon Inj
15/03/2021 00:00:00 82.500,00
Flunarizine 5 mg tab 2.475,00
Furamin Injeksi 14.369,00
Ketorolac inj 30 mg/1ml 4.035,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 12.031,00
Furamin Injeksi
16/03/2021 00:00:00 14.369,00
Ketorolac inj 30 mg/1ml 4.035,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 36.093,00
Tramadol 50 mg/ml Inj 4.125,00
Flunarizine 5 mg tab
17/03/2021 00:00:00 24.750,00
Flunarizine 5 mg tab 24.750,00
Furamin Injeksi 28.738,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
ursodeoxycholic acid 28.350,00
Total 534.185,00
2.982 Gracia Kristiani Gule SUMBER SARI 183017 Abbocath 24 Terumo @5
14/03/2021 00:00:00 52.682,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Aqua Pro Injeksi 3.575,00
ETT 3.5 Kingking (Balon) 119.563,00
Gentamicin Injeksi 4.606,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00

19/08/2021 12:42:30 Page 715 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.982 Gracia Kristiani Gule SUMBER SARI 183017 NACL 0,9 % 500 ml
14/03/2021 00:00:00 8.550,00 BPJS
Nassal Cannula O2 Anak 16.473,00
NGT (Feeding tube) Fr. 5 17.603,00
Total 278.469,00
2.983 Addarimi BANDARATU 127606 Abbocath 20 Terumo @5
14/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Asam Folat 1 mg @100 T 297,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Furamin Injeksi 14.369,00
Hydroclorothiazide tab 25 204,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Kalitake 18.750,00
Nassal Cannula O2 Anak 16.473,00
Ondansetron Inj 4.950,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 143.829,00
2.984 Gracia Kristiani Gule SUMBER SARI 183017 Extention Tube
14/03/2021 00:00:00 8.801,00 BPJS
Hypafix 15cmx5cm (25 c 13.088,00
NGT (Feeding Tube) Fr. 8 70.420,00
Paracetamol Drop 0,00
Sibital Injeksi (Phenobarbit 24.750,00
Three Way stopcock 15.789,00
Abbocath 24 Terumo @5
15/03/2021 00:00:00 79.023,00
Bactesyn inj 0,75 gr 59.009,00
Calcii Glukonas Inj 100 m 38.817,00
Gentamicin Injeksi 4.606,00
Gentamycin 0.1 % salep k 2.983,00
Glukosa Infus 10 % 9.375,00
Glukosa Infus 5 % 8.626,00
Hypafix 10cm x 5cm (25 c 9.700,00
NACL 0,9 % 500 ml 8.550,00
NGT (Feeding Tube) Fr. 8 70.420,00
NGT (Feeding Tube) Fr. 8 140.840,00
Ottopan Drops 18.906,00
Phenobarbital Injeksi 50 m 7.430,00
Abbocath 24 Terumo @5
16/03/2021 00:00:00 79.023,00
Nassal Cannula O2 Anak 16.473,00
Abbocath 24 Terumo @5
17/03/2021 00:00:00 79.023,00
NonWoven Fixation 15x 13.388,00
Total 779.040,00
2.985 Idri Nelvia Siska Reni bandar ratu 168857 abbocath 18 Terumo @5
14/03/2021 00:00:00 26.341,00 BPJS
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00

19/08/2021 12:42:30 Page 716 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.985 Idri Nelvia Siska Reni bandar ratu 168857 Handscoond Sterille 7.5
14/03/2021 00:00:00 16.488,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 18.000,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 2.690,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Ondansetron Inj 3.300,00
Phytomenadione 2 Mg/1M 4.834,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suction Chateter no. 8 (R 20.625,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
umbilical Cord Clamp 2.261,00
Urine bag 9.263,00
viamac 1 R 182.185,00
Total 905.047,00
2.986 Addarimi BANDARATU 127606 Asam Folat 1 mg @100 T
14/03/2021 00:00:00 297,00 BPJS
Candesartan Tab 16 mg 3.537,00
Kalitake 18.750,00
Asam Folat 1 mg @100 T
16/03/2021 00:00:00 297,00
Candesartan tab 8 mg 1.362,00
Ceftriaxone Inj 12.498,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 1.666,00
Kalitake 18.750,00
Ketorolac inj 30 mg/1ml 6.725,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 28.614,00
Asam Folat 1 mg @100 T
17/03/2021 00:00:00 297,00
Candesartan tab 8 mg 681,00
Captopril 12,5 mg 160,00
Ceftriaxone Inj 31.245,00
Ceftriaxone Inj 12.498,00
Dexametason Injeksi 3.128,00
Dipenhydramin Injeksi 10 1.535,00
Furamin Injeksi 14.369,00
Furosemide Injeksi @2ml 3.332,00
Furosemide Injeksi @2ml 1.666,00
Hydroclorothiazide tab 25 1.020,00
Hydroclorothiazide tab 25 204,00
Kalitake 18.750,00
Ketorolac inj 30 mg/1ml 6.725,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 8.250,00
Ondansetron Inj 4.950,00

19/08/2021 12:42:30 Page 717 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.986 Addarimi BANDARATU 127606 Ranitidin inj
17/03/2021 00:00:00 8.950,00 BPJS
Ringer Laktat Otsuka 47.690,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Amlodipine 10 mg @50 T
18/03/2021 00:00:00 1.180,00
Asam Folat 1 mg @100 T 990,00
Candesartan tab 8 mg 6.810,00
NonWoven Fixation 15x 13.388,00
Sucralfate Suspensi 100 m 19.250,00
Total 363.009,00
2.987 Nurhayati MEKAR SARI 183018 abbocath 18 Terumo @5
14/03/2021 00:00:00 26.341,00 BPJS
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 14.554,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix Kamar Operasi 18.000,00
Ketorolac inj 30 mg/1ml 2.690,00
Miloz Injeksi 5 mg 11.222,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 36.093,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 9.263,00
viamac 1 R 364.370,00
abbocath 18 Terumo @5 26.341,00
Catgut Chromic 1R (Scim 119.538,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Induxin 1 ml Injeksi 37.124,00

19/08/2021 12:42:30 Page 718 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.987 Nurhayati MEKAR SARI 183018 Ketorolac inj 30 mg/1ml
14/03/2021 00:00:00 4.035,00 BPJS
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 16.500,00
Urine bag 9.263,00
Cefotaxime Injeksi
15/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00
Hypafix 10cm x 5cm (25 c 9.700,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Aqua Pro Injeksi
17/03/2021 00:00:00 3.575,00
Cefotaxime Injeksi 11.502,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 300 mg Tabl 17.500,00
Cuticell Classic 10cmx10c 35.121,00
Kassa kotak stril DRC 9.675,00
Ketorolac Tab 10 Mg 37.950,00
NonWoven Fixation 10x 4.815,00
Postofix (leukomed) 36.726,00
Total 1.875.573,00
2.988 Loisa Fitri Martilova Hu MEKAR MULYA 182815 abbocath 18 Terumo @5
14/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Bisturi No. 23 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Catgut Chromic 1R (Scim 119.538,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 14.554,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix Kamar Operasi 18.000,00
Ketorolac inj 30 mg/1ml 2.690,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00

19/08/2021 12:42:30 Page 719 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.988 Loisa Fitri Martilova Hu MEKAR MULYA 182815 Polyvinylidene 3-0 R (Tri
14/03/2021 00:00:00 92.000,00 BPJS
Protocin Inj 18.810,00
Ringer Laktat Otsuka 19.076,00
Rofiden Supp 36.093,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.263,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
15/03/2021 00:00:00 11.502,00
Ephedrine Injeksi 53.555,00
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 4.035,00
Massa Cauter Dewasa 180.480,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
Bisturi No. 23
17/03/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
18/03/2021 00:00:00 1.935,00
Catheter 2 Way No. 16 ( 20.625,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Clindamycin 150 mg tabl 8.750,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 104.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Total 2.063.778,00
2.989 Novin Haryadi BANDAR RATU 183020 Asam Mefenamat 500 m
14/03/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Lidocain injk 40 mg/2 ml 4.833,00
Polyvinylidene 3-0 R (Tri 92.000,00

19/08/2021 12:42:30 Page 720 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.989 Novin Haryadi BANDAR RATU 183020 Tetagam 1 Ml Injeksi
14/03/2021 00:00:00 184.000,00 BPJS
Vitamin C tablet @100 Ta 690,00
Total 288.403,00
2.990 Sofendi LUBUK PINANG 118125 abbocath 18 Terumo @5
14/03/2021 00:00:00 26.341,00 BPJS
Azitromycin 500 mg 5.625,00
Ceftriaxone Inj 12.498,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Phytomenadione 10 mg ( 2.802,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 6.315,00
Azitromycin 500 mg
15/03/2021 00:00:00 28.125,00
Ceftriaxone Inj 12.498,00
Omeprazole Inj 12.499,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 38.152,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj
16/03/2021 00:00:00 12.498,00
Ondansetron Inj 4.950,00
Ringer Laktat Otsuka 19.076,00
Azitromycin 500 mg
17/03/2021 00:00:00 16.875,00
Cefixime syrup 100mg/5 M 238.230,00
Ceftriaxone Inj 12.498,00
Dulcolax Sup 10 mg 27.800,00
Metformin tablet 500 mg 1.330,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 800,00
Phytomenadione 2 Mg/1M 14.502,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Tranexamic Acid Inj (Asa 6.315,00
Vectrine Tab 300 mg 50.000,00
Total 740.260,00
2.991 Idri Nelvia Siska Reni bandar ratu 168857 abbocath 18 Terumo @5
14/03/2021 00:00:00 0,00 BPJS
Infusion Makro (terumo) 0,00
Metrodinazole tab 500 m 0,00
Nassal Cannula O2 Dewas 0,00
Paracetamol tablet 500 m 0,00
Ringer Laktat Otsuka 0,00
Ringer Laktat Otsuka 0,00
Anti Hemoroid
15/03/2021 00:00:00 0,00
Flunarizine 5 mg tab 0,00
Gabapentin kapsul 300 m 0,00
Metrodinazole tab 500 m 0,00
Paracetamol tablet 500 m 0,00
Total 0,00
2.992 Siti Patimah LUBUK SANAI 140158 Abbocath 20 Terumo @5
15/03/2021 00:00:00 52.682,00 BPJS
Antasida Syrup 60 ml 2.736,00

19/08/2021 12:42:30 Page 721 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.992 Siti Patimah LUBUK SANAI 140158 Hypafix 15cmx5cm (25 c
15/03/2021 00:00:00 6.544,00 BPJS
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
Sucralfate Suspensi 100 m 19.250,00
LUBUK SANAI II 147954 Antasida Syrup 60 ml 2.736,00
Domperidone Syrup 5mg 10.279,00
Metoclopramide inj 5Mg/M 5.879,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 174.169,00
2.993 Idri Nelvia Siska Reni bandar ratu 168857 abbocath 18 Terumo @5
15/03/2021 00:00:00 52.682,00 BPJS
Anti Hemoroid 8.312,00
Cefixime Kapsul 100 mg 9.380,00
Flunarizine 5 mg tab 24.750,00
Gabapentin kapsul 300 m 12.690,00
Infusion Makro (terumo) 27.225,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 2.700,00
Nassal Cannula O2 Dewas 11.625,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Total 190.926,00
2.994 Osa MARGA MULYA 183024 Abbocath 20 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 6.249,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Nassal Cannula O2 Anak 16.473,00
Ringer Laktat Otsuka 9.538,00
Abbocath 22 Terumo @5 22.276,00
Aspilet 80 mg @100 mg 138,00
Ceftriaxone Inj 12.498,00
Digoxsin tab 0,25 mg 144,00
Furosemide Injeksi @2ml 3.332,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Tablet 500 m 6.820,00
Nassal Mask O2 Dewasa 41.828,00
Nebulizer O2 Dewasa 34.783,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Spironolaktone 25 mg 260,00
Ventolin Nebules 2.5 mg 20.000,00
vestein 300 mg 28.050,00
Ceftriaxone Inj
16/03/2021 00:00:00 12.498,00
Erdosteine Syr 36.575,00
Furosemide Injeksi @2ml 3.332,00
Levofloxacin Tablet 500 m 2.728,00
Ranitidin inj 3.580,00

19/08/2021 12:42:30 Page 722 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
2.994 Osa MARGA MULYA 183024 Ringer Laktat Otsuka
16/03/2021 00:00:00 19.076,00 BPJS
Ringer Laktat Otsuka 38.152,00
Spironolaktone 25 mg 260,00
Ventolin Nebules 2.5 mg 20.000,00
Ceftriaxone Inj
17/03/2021 00:00:00 12.498,00
Digoxsin tab 0,25 mg 144,00
Digoxsin tab 0,25 mg 144,00
Furosemide Injeksi @2ml 3.332,00
Furosemide Injeksi @2ml 3.332,00
Levofloxacin Tablet 500 m 1.364,00
Miniaspi 80 Mg @100 Ta 125,00
Miniaspi 80 Mg @100 Ta 250,00
Ranitidin inj 3.580,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Spironolaktone 25 mg 260,00
Spironolaktone 25 mg 520,00
Ventolin Nebules 2.5 mg 20.000,00
Cefixime Kapsul 100 mg
18/03/2021 00:00:00 9.380,00
Furosemide 40 mg Tablet 960,00
Levofloxacin Tablet 500 m 2.728,00
Miniaspi 80 Mg @100 Ta 1.250,00
Omeprazol kapsul 20 mg 6.610,00
Salbutamol 2 mg 790,00
Spironolaktone 25 mg 2.600,00
Vectrine Tab 300 mg 50.000,00
Total 591.104,00
2.995 Maril LUBUK SANAI 173422 Acetylcystein 200 mg Ka
15/03/2021 00:00:00 34.380,00 BPJS
Allopurinol 100 mg @100 2.340,00
Isoniazide 300 mg 6.480,00
Paracetamol tablet 500 m 2.000,00
Rifampicin 450 33.840,00
Total 79.040,00
2.996 Ismail TALANG KARET 120549 Loratadine tab 10 mg
15/03/2021 00:00:00 3.320,00 BPJS
Total 3.320,00
2.997 Surati Khowiyah BUMI MULYA 182873 Cefixime Kapsul 100 mg
15/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
2.998 Muhamad Ali SUNGAI LINTANG 111979 Omeprazol kapsul 20 mg
15/03/2021 00:00:00 6.610,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 28.590,00
2.999 Sri Utami MEKAR MULYA 122405 Aspilet 80 mg @100 mg
15/03/2021 00:00:00 1.380,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Mecobalamin 500 mg 15.400,00
Ranitidine tablet 150 mg 1.440,00
Total 22.660,00
3.000 Rosna PASAR MUKOMUKO 143640 Amlodipine 5 mg @30 T
15/03/2021 00:00:00 3.030,00 BPJS
Aspilet 80 mg @100 mg 4.140,00
Candesartan tab 8 mg 20.430,00
Citicoline kaplet 500 mg 33.000,00

19/08/2021 12:42:30 Page 723 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 60.600,00
3.001 Chalimah WONOSOBO 179737 Ibuprofen tab 200 mg
15/03/2021 00:00:00 1.990,00 BPJS
Renax @50 Kapsul 113.440,00
Total 115.430,00
3.002 Heny Hartini PONDOK PANJANG 108383 Ciprofloxacin tab 500 mg
15/03/2021 00:00:00 5.590,00 BPJS
Gentamicin Injeksi 4.606,00
Gentamycin 0.1 % salep k 2.983,00
NACL 0,9 % 500 ml 8.550,00
Paracetamol tablet 500 m 2.000,00
Total 23.729,00
3.003 Auliani Putri PIAN TOKUNG 129449 Asam Folat 1 mg @100 T
15/03/2021 00:00:00 2.970,00 BPJS
Carbamazepine Tablet 20 18.540,00
Valproic Acid Syrup 250mg 104.875,00
Total 126.385,00
3.004 Merli Anggraini NELAN INDAH 158244 Asam Mefenamat 500 m
15/03/2021 00:00:00 1.290,00 BPJS
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 42.066,00
3.005 Dini Trisnawati SP 1 AIR MANJUNTO 138282 Tugesal Filco 50 mg Tab (
15/03/2021 00:00:00 45.730,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 67.710,00
3.006 Bailasani MANDI ANGIN JAYA 178232 Amlodipine 10 mg @50 T
15/03/2021 00:00:00 3.540,00 BPJS
Total 3.540,00
3.007 Misiyem PONDOK BATU 183037 abbocath 18 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Misoprostol Tab 22.000,00
Ringer Laktat Otsuka 9.538,00
Total 96.606,00
3.008 Nilpia SILAUT 183038 Calcium Laktat
15/03/2021 00:00:00 790,00 BPJS
Total 790,00
3.009 Eni Putri Wati TANAH REKAH 155815 Cetirizine 10 mg
15/03/2021 00:00:00 1.260,00 BPJS
Methylprednisolone tab 4 2.630,00
Total 3.890,00
3.010 Rosdin Efendi BANDARATU 138467 NACL 0,9 % 500 ml
15/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.011 Apriansyah UJUNG PADANG 138239 Cetirgi Tab 10 mg
15/03/2021 00:00:00 15.480,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
H2O2 3 % 1 liter 0,00
Total 21.070,00
3.012 Sugito MEKAR MULYA 147062 Cetirizine 10 mg
15/03/2021 00:00:00 378,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 152.053,00
3.013 Darmawan LUBUK PINANG 140187 Amlodipine 10 mg @50 T
15/03/2021 00:00:00 1.180,00 BPJS
Asam Folat 1 mg @100 T 990,00
NACL 0,9 % 500 ml 42.750,00
Paracetamol tablet 500 m 2.000,00
Renogen 3000 UI 116.875,00
Total 163.795,00

19/08/2021 12:42:30 Page 724 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.014 Adriell Kazshio Pratam RANAH KARYA 175878 Asam Folat 1 mg @100 T
15/03/2021 00:00:00 2.970,00 BPJS
Valproic Acid Syrup 250mg 41.950,00
Total 44.920,00
3.015 Sudarto SARI BULAN 150138 Azitromycin 500 mg
15/03/2021 00:00:00 56.250,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Urinter Kapsul @100 cap 21.980,00
Total 84.840,00
3.016 Miswanto LUNANG 128267 Amlodipine 10 mg @50 T
15/03/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 154.072,00
3.017 M Akil PASAR BELAKANG 115376 Amlodipine 10 mg @50 T
15/03/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 154.072,00
3.018 Ashari Liwandi PONDOK LUNANG 139398 Glukosa Infus 5 %
15/03/2021 00:00:00 34.504,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Otsu D40 37.539,00
Renogen 3000 UI 116.875,00
Total 223.118,00
3.019 Supangat PONDOK LUNANG 147511 Glukosa Infus 10 %
15/03/2021 00:00:00 37.500,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Renogen 3000 UI 116.875,00
Total 188.575,00
3.020 Wardoyo TANJUNG MULYA 125079 Amlodipine 10 mg @50 T
15/03/2021 00:00:00 354,00 BPJS
Candesartan tab 8 mg 2.043,00
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 600,00
Renogen 3000 UI 116.875,00
Total 154.072,00
3.021 Ishak As PASAR BELAKANG 109144 Aspilet 80 mg @100 mg
15/03/2021 00:00:00 4.140,00 BPJS
Bisoprolol 5 mg @100 Ta 4.440,00
Mecobalamin 500 mg 7.700,00
Meloxicam 7,5 mg 7.280,00
Omeprazol kapsul 20 mg 19.830,00
Simvastatin tab 10 mg 7.230,00
Total 50.620,00
3.022 Ahmad Mujiono MARGA MULYA SAKTI 113737 NACL 0,9 % 500 ml
15/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.023 Syahminar LUBUK PINANG 147670 Alprazolam 0,5 mg @100
15/03/2021 00:00:00 1.180,00 BPJS
Amlodipine 5 mg @30 T 3.030,00
Bisoprolol 5 mg @100 Ta 4.440,00
Omeprazol kapsul 20 mg 6.610,00
Total 15.260,00
3.024 Suwardi KOTO JAYA 157604 Aspilet 80 mg @100 mg
15/03/2021 00:00:00 4.140,00 BPJS
Candesartan Tab 16 mg 35.370,00
Omeprazol kapsul 20 mg 13.220,00

19/08/2021 12:42:30 Page 725 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.024 Suwardi KOTO JAYA 157604 Simvastatin tab 10 mg
15/03/2021 00:00:00 7.230,00 BPJS
Total 59.960,00
3.025 Arif Iman Maulana AIR DIKIT 183043 Amoxicillin Syr
15/03/2021 00:00:00 6.531,00 BPJS
Tarivid otic 5 ml 105.900,00
Total 112.431,00
3.026 Rosdiana KOTO JAYA 157605 Omeprazol kapsul 20 mg
15/03/2021 00:00:00 6.610,00 BPJS
ursodeoxycholic acid 28.350,00
Total 34.960,00
3.027 Sukmi Harti TAPAN 156801 abbocath 18 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason 0,5 mg Ta 348,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 9.538,00
Total 74.954,00
3.028 Misiyem PONDOK BATU 183037 Bucain Spinal 0.5 % Inj
15/03/2021 00:00:00 52.181,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 21.422,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
Ketorolac inj 30 mg/1ml 2.690,00
Masker Tali 41.600,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suprafenid Supositoria 10 28.050,00
Asam Mefenamat 500 m
16/03/2021 00:00:00 1.290,00
Cefixime kapsul 200 mg 26.480,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Misoprostol Tab 55.000,00
Total 505.703,00
3.029 Supriyanto SIDO MULYO 165719 Azitromycin 500 mg
15/03/2021 00:00:00 56.250,00 BPJS
Total 56.250,00
3.030 Ani Sriyatun TIRTA MAKMUR 182834 Bisturi No. 23
15/03/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Cuticell Classic 10cmx10c 35.121,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00

19/08/2021 12:42:30 Page 726 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.030 Ani Sriyatun TIRTA MAKMUR 182834 Handscoond Sterille 7 (G
15/03/2021 00:00:00 29.126,00 BPJS
Induxin 1 ml Injeksi 37.124,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Polypropylene 3/0 C (Ass 235.200,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.263,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00
Metrodinazole tab 500 m 810,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 4.210,00
Bisturi No. 23
17/03/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
18/03/2021 00:00:00 1.935,00
Catheter 2 Way No. 16 ( 20.625,00
Ciprofloxacin tab 500 mg 5.590,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa Gulung Biasa 187.500,00
Metrodinazole tab 500 m 810,00
Paracetamol tablet 500 m 2.000,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00

19/08/2021 12:42:30 Page 727 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 1.989.905,00
3.031 Sunarti PENARIK 161028 Meloxicam 7,5 mg
15/03/2021 00:00:00 14.560,00 BPJS
Ranitidine tablet 150 mg 2.880,00
Total 17.440,00
3.032 Harapan Siadari PT. AGRO MUKO 120994 Tugesal Filco 50 mg Tab (
15/03/2021 00:00:00 45.730,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 67.710,00
3.033 Santiani TERAS TERUNJAM 143154 Meloxicam 7,5 mg
15/03/2021 00:00:00 7.280,00 BPJS
Total 7.280,00
3.034 Salis Lanjar LUBUK TALANG 116919 Amoxicillin 500 mg @ 10
15/03/2021 00:00:00 3.060,00 BPJS
Captopril 12,5 mg 2.400,00
Furosemide 40 mg Tablet 2.880,00
Spironolaktone 25 mg 2.600,00
Total 10.940,00
3.035 Yuniar PASAR MUKOMUKO 111073 abbocath 18 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Amlodipine 5 mg @30 T 101,00
Ceftriaxone Inj 12.498,00
Infusion Mikro (Gea) 7.861,00
Metformin tablet 500 mg 266,00
Paracetamol Infus 14.438,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 9.538,00
Total 71.643,00
3.036 Sukmi Harti TAPAN 156801 abbocath 18 Terumo @5
15/03/2021 00:00:00 105.364,00 BPJS
Alkohol 1Liter 42.111,00
Bisturi No. 23 3.836,00
Bunascan Spinal 0.5 63.525,00
Catgut Chromic 2/0 R (Sc 88.798,00
Catheter 2 Way No. 16 ( 20.625,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Dexametason Injeksi 6.256,00
Dexametason Injeksi 18.768,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 37.124,00
Iodine Povidone 1 L 183.288,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker 3 Play N. 95 75.000,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NonWoven Fixation 15x 6.694,00
Polypropylene 3/0 C (Ass 235.200,00

19/08/2021 12:42:30 Page 728 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.036 Sukmi Harti TAPAN 156801 Protocin Inj
15/03/2021 00:00:00 18.810,00 BPJS
Ringer Laktat Otsuka 28.614,00
Rofiden Supp 24.062,00
Spinocain 26 (Bbraund) 43.038,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Suction no. 1/4 25.950,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Transfusi Set Terumo 49.500,00
Urine bag 9.263,00
Vacum tube EDTA ungu 0 36.300,00
viamac 1 R 364.370,00
Bisturi No. 23
17/03/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
18/03/2021 00:00:00 1.290,00
Asam Mefenamat 500 m 645,00
Catheter 2 Way No. 16 ( 20.625,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 35.121,00
Kassa Gulung Biasa 187.500,00
Metrodinazole tab 500 m 810,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Total 2.437.822,00
3.037 muhamad dion dirg TALANG MEDAN 168982 Miconazole krim 2 %
15/03/2021 00:00:00 4.481,00 BPJS
Total 4.481,00
3.038 Yupita Sari PT AGRO MUKO TALA 115269 Ceftriaxone Inj
15/03/2021 00:00:00 12.498,00 BPJS
Paracetamol tablet 500 m 200,00
Tramadol 50 mg/ml Inj 8.250,00
Ceftriaxone Inj
16/03/2021 00:00:00 12.498,00
Hypafix 10cm x 5cm (25 c 9.700,00
Kassa kotak stril DRC 38.700,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Bisturi No. 23
17/03/2021 00:00:00 3.836,00
Bisturi no. 10 3.836,00
Bisturi No. 15 3.836,00
Bisturi No. 15 3.836,00

19/08/2021 12:42:30 Page 729 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.038 Yupita Sari PT AGRO MUKO TALA 115269 Bucain Spinal 0.5 % Inj
17/03/2021 00:00:00 52.181,00 BPJS
Ceftriaxone Inj 12.498,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 144.500,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Hypafix Kamar Operasi 18.000,00
Masker Tali 41.600,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 85.500,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Tramadol 50 mg/ml Inj 12.375,00
Levofloxacin Infus
18/03/2021 00:00:00 48.976,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Total 1.089.354,00
3.039 Weni Astari PONDOK PANJANG 114282 Urinter Kapsul @100 cap
15/03/2021 00:00:00 21.980,00 BPJS
Total 21.980,00
3.040 Rosany Simarmata DUSUN BARU 127030 abbocath 18 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Total 87.653,00
3.041 Suci Rahma Diana TALANG MEDAN 160525 abbocath 18 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Dexametason Injeksi 9.384,00
Hystolan Tab 20 mg 5.569,00
Infusion Makro (terumo) 27.225,00
Otsu MgSO4 40 % 4.745,00
Ringer Laktat Otsuka 9.538,00
Total 82.802,00
3.042 Rosany Simarmata DUSUN BARU 127030 Bisturi No. 23
16/03/2021 00:00:00 3.836,00 BPJS
Bunascan Spinal 0.5 63.525,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00

19/08/2021 12:42:30 Page 730 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.042 Rosany Simarmata DUSUN BARU 127030 Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00 BPJS
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 15.640,00
Dipenhydramin Injeksi 10 7.675,00
Ephedrine Injeksi 53.555,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Furosemide Injeksi @2ml 8.330,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 15cmx5cm (25 c 6.544,00
Induxin 1 ml Injeksi 46.405,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 11.000,00
Metoclopramide inj 5Mg/M 29.395,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 3.300,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 18.810,00
Ranitidin inj 8.950,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.263,00
viamac 1 R 364.370,00
Abbocath 20 Terumo @5
17/03/2021 00:00:00 52.682,00
Cefotaxime Injeksi 11.502,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
19/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00

19/08/2021 12:42:30 Page 731 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.042 Rosany Simarmata DUSUN BARU 127030 Clindamycin 300 mg Tabl
19/03/2021 00:00:00 17.500,00 BPJS
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 810,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 12.630,00
Total 1.633.682,00
3.043 Suci Rahma Diana TALANG MEDAN 160525 abbocath 18 Terumo @5
15/03/2021 00:00:00 0,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 0,00
Dexametason Injeksi 9.384,00
Hystolan Tab 20 mg 0,00
Hystolan Tab 20 mg 16.707,00
Infusion Makro (terumo) 0,00
Otsu MgSO4 40 % 0,00
Ringer Laktat Otsuka 0,00
Ringer Laktat Otsuka 19.076,00
Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00
Dexametason Injeksi 6.256,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hystolan Tab 20 mg 16.707,00
Ringer Laktat Otsuka 19.076,00
Cefotaxime Injeksi
17/03/2021 00:00:00 11.502,00
Hystolan Tab 20 mg 11.138,00
Nassal Cannula O2 Dewas 11.625,00
Paracetamol tablet 500 m 600,00
Ringer Laktat Otsuka 19.076,00
Paracetamol Infus
18/03/2021 00:00:00 28.876,00
Bisturi No. 23
19/03/2021 00:00:00 3.836,00
Bucain Spinal 0.5 % Inj 52.181,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 9.384,00
Dexametason Injeksi 6.256,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril M 20.080,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 29.126,00
Induxin 1 ml Injeksi 18.562,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 1.345,00
Masker Tali 41.600,00
methyl ergometrin amp 8.662,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
Paracetamol tablet 500 m 2.200,00
Pharmafix 15x50 (Hypap 6.544,00

19/08/2021 12:42:30 Page 732 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.043 Suci Rahma Diana TALANG MEDAN 160525 Polyglycolide T-Vio 1 R (
19/03/2021 00:00:00 295.500,00 BPJS
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spironolaktone 100 mg 7.909,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Spuit 50 cc Lbg tengah ( 4.888,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Bisturi No. 15
20/03/2021 00:00:00 3.836,00
Cefotaxime Injeksi 11.502,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Phytomenadione 2 Mg/1M 4.834,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Asam Mefenamat 500 m
22/03/2021 00:00:00 1.290,00
Catheter 2 Way No. 16 ( 20.625,00
Ciprofloxacin tab 500 mg 5.590,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 150 mg tabl 8.750,00
Clindamycin 150 mg tabl 8.750,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Kassa kotak stril DRC 9.675,00
Metrodinazole tab 500 m 810,00
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 6.315,00
Total 1.866.075,00
3.044 Supriyanto SIDO MULYO 165719 Abbocath 20 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Total 102.365,00
3.045 Syafri RESNO 183054 Abbocath 20 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Ringer Laktat Otsuka 28.614,00
Sucralfate Suspensi 100 m 19.250,00
Abbocath 22 Terumo @5
16/03/2021 00:00:00 22.276,00

19/08/2021 12:42:30 Page 733 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.045 Syafri RESNO 183054 Domperidone Tab
16/03/2021 00:00:00 1.080,00 BPJS
Metoclopramide inj 5Mg/M 17.637,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Sucralfate Suspensi 100 m 19.250,00
Sucralfate Suspensi 100 m 19.250,00
Total 285.868,00
3.046 Supriyanto SIDO MULYO 165719 Ceftriaxone Inj
15/03/2021 00:00:00 12.498,00 BPJS
Tramadol 50 mg/ml Inj 8.250,00
Ceftriaxone Inj
16/03/2021 00:00:00 12.498,00
Kassa kotak stril DRC 38.700,00
NonWoven Fixation 15x 13.388,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj
17/03/2021 00:00:00 12.498,00
Ketorolac inj 30 mg/1ml 4.035,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Ceftriaxone Inj
18/03/2021 00:00:00 6.249,00
Cuticell Classic 10cmx10c 35.121,00
Ketorolac inj 30 mg/1ml 4.035,00
Ringer Laktat Otsuka 19.076,00
Tramadol tab 50 mg 1.179,00
Cuticell Classic 10cmx10c
19/03/2021 00:00:00 35.121,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 3.000,00
Cetirgi Tab 10 mg
26/03/2021 00:00:00 15.480,00
Ofloxacin Tab 200 mg 5.340,00
Total 326.050,00
3.047 Rian Suharsono BUNGA TANJUNG 150340 abbocath 18 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Azitromycin 500 mg 5.625,00
Candesartan Tab 16 mg 1.179,00
Ceftriaxone Inj 12.498,00
Furosemide Injeksi @2ml 1.666,00
Hypafix 15cmx5cm (25 c 6.544,00
Ringer Laktat Otsuka 9.538,00
Spironolaktone 25 mg 260,00
Transfusi Set Terumo 16.500,00
Vitamin C 500 mg 2,00
Total 80.153,00
3.048 Tapoyon DESA SUNGAI IPUH 127173 Abbocath 20 Terumo @5
15/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Hypafix 15cmx5cm (25 c 6.544,00
Infusion Makro (terumo) 27.225,00
Metoclopramide inj 5Mg/M 17.637,00
Omeprazole Inj 12.499,00
Opilax Syr 49.156,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 28.614,00

19/08/2021 12:42:30 Page 734 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.048 Tapoyon DESA SUNGAI IPUH 127173 Sucralfate Suspensi 100 m
15/03/2021 00:00:00 19.250,00 BPJS
Ceftriaxone Inj
16/03/2021 00:00:00 12.498,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
Nucral Syrup 100 ml 53.350,00
Omeprazole Inj 12.499,00
Paracetamol tablet 500 m 600,00
PARAMOL INFUS 288.750,00
Ranitidin inj 3.580,00
Abbocath 20 Terumo @5
17/03/2021 00:00:00 52.682,00
Abbocath 22 Terumo @5 33.414,00
Ceftriaxone Inj 12.498,00
Glukosa Infus 5 % 25.878,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NGT (Stomach Tube) Fr. 1 60.046,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Ringer Laktat Otsuka 28.614,00
Spuit 5 cc Disposible 1.420,00
Ceftriaxone Inj
18/03/2021 00:00:00 12.498,00
Dopamin Giulini 200 mg I 97.625,00
Electroda (Ambu) @25 Pc 81.570,00
Extention Tube 8.801,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 17.100,00
Nassal Cannula O2 Dewas 11.625,00
Paracetamol tablet 500 m 800,00
Ranitidine tablet 150 mg 288,00
Three Way stopcock 15.789,00
Ceftriaxone Inj
19/03/2021 00:00:00 12.498,00
Dopamin Giulini 200 mg I 195.250,00
Electroda (Ambu) @25 Pc 163.140,00
Glukosa Infus 5 % 8.626,00
Glukosa Infus 5 % 8.626,00
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 9.538,00
Abbocath 22 Terumo @5
20/03/2021 00:00:00 22.276,00
Ceftriaxone Inj 12.498,00
Cetadop inj 23.100,00
Glukosa Infus 5 % 8.626,00

19/08/2021 12:42:30 Page 735 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.048 Tapoyon DESA SUNGAI IPUH 127173 Glukosa Infus 5 %
20/03/2021 00:00:00 8.626,00 BPJS
Levofloxacin Infus 24.488,00
Metoclopramide inj 5Mg/M 17.637,00
Metoclopramide inj 5Mg/M 17.637,00
NACL 0,9 % 500 ml 8.550,00
Nassal Mask O2 Dewasa 41.828,00
NGT (Stomach Tube) Fr. 1 60.046,00
Ranitidin inj 7.160,00
Total 2.044.483,00
3.049 Baban SUMBER MAKMUR 182934 Ceftriaxone Inj
15/03/2021 00:00:00 12.498,00 BPJS
Metrodinazole Infus 30.939,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Sucralfate Suspensi 100 m 19.250,00
Ceftriaxone Inj
16/03/2021 00:00:00 12.498,00
Kassa kotak stril DRC 38.700,00
Metrodinazole Infus 30.939,00
NonWoven Fixation 15x 13.388,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Ringer Laktat Otsuka 19.076,00
Ceftriaxone Inj
17/03/2021 00:00:00 12.498,00
Levofloxacin Tablet 500 m 13.640,00
Metrodinazole Infus 30.939,00
Omeprazole Inj 12.499,00
Paracetamol Infus 43.314,00
Paracetamol tablet 500 m 4.000,00
Ringer Laktat Otsuka 19.076,00
Total 424.880,00
3.050 Masganyang TANAH REKAH 120264 Glukosa Infus 5 %
15/03/2021 00:00:00 17.252,00 BPJS
NGT (Stomach Tube) Fr. 1 60.046,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Urine bag 9.263,00
Ceftriaxone Inj
16/03/2021 00:00:00 12.498,00
Dulcolax 5 mg Supositori 19.926,00
Omeprazol kapsul 20 mg 6.610,00
Omeprazole Inj 12.499,00
Dulcolax 5 mg Supositori
17/03/2021 00:00:00 19.926,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Ringer Laktat Otsuka 28.614,00
Total 234.849,00
3.051 Rian Suharsono BUNGA TANJUNG 150340 Azitromycin 500 mg
16/03/2021 00:00:00 56.250,00 BPJS
Candesartan tab 8 mg 6.810,00
Cefixime kapsul 200 mg 26.480,00
Furosemide 40 mg Tablet 960,00
Spironolaktone 25 mg 2.600,00
Vitamin C 500 mg 10,00
Total 93.110,00
3.052 Wira Oktavia LALANG LUAS 183060 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Alkohol 1Liter 42.111,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.052 Wira Oktavia LALANG LUAS 183060 Bisturi No. 23
16/03/2021 00:00:00 3.836,00 BPJS
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 118.250,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 43.689,00
Handscoond Non Steril M 20.080,00
Handscoond Non Steril M 200.800,00
Handscoond Non Steril S 85.100,00
handscoond steril 8 (Gam 14.554,00
Handscoond Sterille 7 (G 43.689,00
Induxin 1 ml Injeksi 18.562,00
Iodine Povidone 1 L 183.288,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Tali 41.600,00
Metrodinazole tab 500 m 810,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
NACL 0,9 % 500 ml 25.650,00
Ondansetron Inj 1.650,00
Otsu MgSO4 40 % 9.490,00
Pharmafix 15x50 (Hypap 6.544,00
Polyglycolide T-Vio 1 R ( 197.000,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Sojourn 250 ml Sevoflura 1.576.959,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 3 cc Terumo 13.916,00
Suprafenid Supositoria 10 28.050,00
Topi Operasi (Perawat) @ 9.380,00
Tramadol 50 mg/ml Inj 4.125,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 6.315,00
Urine bag 9.263,00
Cefotaxime Injeksi
17/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 27.500,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
19/03/2021 00:00:00 1.935,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.052 Wira Oktavia LALANG LUAS 183060 Ciprofloxacin tab 500 mg
19/03/2021 00:00:00 5.590,00 BPJS
Clindamycin 300 mg Tabl 17.500,00
Kassa kotak stril DRC 9.675,00
Postofix (leukomed) 36.726,00
Total 3.618.351,00
3.053 Yuniar PASAR MUKOMUKO 111073 Amlodipine 10 mg @50 T
16/03/2021 00:00:00 118,00 BPJS
Amlodipine 10 mg @50 T 118,00
Ceftriaxone Inj 12.498,00
Ceftriaxone Inj 12.498,00
Metformin tablet 500 mg 399,00
Metformin tablet 500 mg 399,00
NonWoven Fixation 15x 13.388,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Cefixime Kapsul 100 mg
17/03/2021 00:00:00 9.380,00
Metformin tablet 500 mg 1.330,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 4.000,00
Total 60.143,00
3.054 Riki Muliansep AGRO MUKO 137053 Abbocath 20 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Azitromycin 500 mg 5.625,00
Azitromycin 500 mg 16.875,00
Codein tab 10 mg 7.500,00
Infusion Makro (terumo) 27.225,00
Kassa kotak stril DRC 29.025,00
NACL 0,9 % 500 ml 8.550,00
NACL 0,9 % 500 ml 17.100,00
Paracetamol tablet 500 m 600,00
Pharmafix 10x50 cm (Hy 4.850,00
Ringer Laktat Otsuka 38.152,00
vestein 300 mg 14.025,00
vestein 300 mg 46.750,00
Vitamin C 500 mg 2,00
Vitamin C tablet @100 Ta 1.380,00
Hypafix 10cm x 5cm (25 c
17/03/2021 00:00:00 4.850,00
NACL 0,9 % 500 ml 25.650,00
Azitromycin 500 mg
18/03/2021 00:00:00 28.125,00
Codein tab 10 mg 6.000,00
Codein tab 10 mg 5.250,00
vestein 300 mg 46.750,00
vestein 300 mg 70.125,00
Total 430.750,00
3.055 Yanti LUBUK SANAI 183062 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Cefotaxime Injeksi 5.751,00
Hypafix 10cm x 5cm (25 c 4.850,00
Lidocain injk 40 mg/2 ml 4.833,00
Misoprostol Tab 16.500,00
Paracetamol tablet 500 m 2.000,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 95.693,00

19/08/2021 12:42:30 Page 738 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.056 Ny Fera Astuti DESA BUMI MULYA 183063 Abbocath 24 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Calcii Glukonas Inj 100 m 12.939,00
Extention Tube 8.801,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NACL 0,9 % 500 ml 8.550,00
Pharmafix 10x50 cm (Hy 4.850,00
Three Way stopcock 15.789,00
Abbocath 24 Terumo @5
17/03/2021 00:00:00 79.023,00
Bactesyn inj 0,75 gr 59.009,00
NonWoven Fixation 10x 4.815,00
Bactesyn inj 0,75 gr
19/03/2021 00:00:00 118.018,00
Gentamicin Injeksi 4.606,00
Total 378.721,00
3.057 Rahmat MARGA MULIA 145112 Loratadine tab 10 mg
16/03/2021 00:00:00 1.660,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
ursodeoxycholic acid 28.350,00
Total 38.620,00
3.058 Partowiyono TANJUNG BERINGIN / 136784 Amlodipine 5 mg @30 T
16/03/2021 00:00:00 1.010,00 BPJS
Candesartan Tab 16 mg 11.790,00
Furosemide Injeksi @2ml 16.660,00
Pregabalin Kap 75 mg 64.460,00
Spironolaktone 25 mg 2.600,00
Total 96.520,00
3.059 Trimo TELUK BAKUNG 182538 Levofloxacin Tablet 500 m
16/03/2021 00:00:00 13.640,00 BPJS
Total 13.640,00
3.060 Rina Oktasari LUNANG 177103 Asam Mefenamat 500 m
16/03/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
3.061 Rusli Asbi SILAUT 174646 Urinter Kapsul @100 cap
16/03/2021 00:00:00 21.980,00 BPJS
Total 21.980,00
3.062 Jauna SERAMI BARU 183067 Dexametason Injeksi
16/03/2021 00:00:00 6.256,00 BPJS
Fresofol ( propopol ) inj 13.448,00
Miloz Injeksi 5 mg 5.611,00
Misoprostol Tab 16.500,00
Ondansetron Inj 3.300,00
Paracetamol tablet 500 m 600,00
Rofiden Supp 24.062,00
Total 69.777,00
3.063 Sri Mulyani SUNGAI LINTANG 122749 Metformin tablet 500 mg
16/03/2021 00:00:00 11.970,00 BPJS
Pregabalin Kap 75 mg 64.460,00
Total 76.430,00
3.064 Raki SIDO DADI 182856 Ketoprofen tab 100 mg
16/03/2021 00:00:00 24.760,00 BPJS
Levofloxacin Tablet 500 m 13.640,00
Total 38.400,00
3.065 Rabaiti AUR CINA 150014 Glimepiride tab 2 mg
16/03/2021 00:00:00 5.180,00 BPJS
Loratadine tab 10 mg 1.660,00
Metformin tablet 500 mg 11.970,00
Pregabalin Kap 75 mg 64.460,00
Total 83.270,00
3.066 Abu Razal LUBUK SANAI 160382 Cefixime Kapsul 100 mg
16/03/2021 00:00:00 9.380,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.066 Abu Razal LUBUK SANAI 160382 Eperisone Hcl 50 mg @1
16/03/2021 00:00:00 23.280,00 BPJS
ursodeoxycholic acid 56.700,00
Total 89.360,00
3.067 Sarin PONDOK BARU 154790 Azitromycin 500 mg
16/03/2021 00:00:00 28.125,00 BPJS
Codein tab 10 mg 7.500,00
Paracetamol tablet 500 m 2.000,00
Total 37.625,00
3.068 Sugiman TUNGGAL JAYA 182932 Cuticell Classic 10cmx10c
16/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 56.611,00
3.069 Pontri Doni LUBUK SANAI 162277 Sucralfate Suspensi 100 m
16/03/2021 00:00:00 19.250,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 41.230,00
3.070 Acit Juarsih TANJUNG MULYA 182918 Domperidone Syrup 5mg
16/03/2021 00:00:00 10.279,00 BPJS
Eperisone Hcl 50 mg @1 23.280,00
Opilax Syr 49.156,00
Paracetamol tablet 500 m 2.000,00
Total 84.715,00
3.071 Fenti Sulasmi KARANG JAYA 182958 Cuticell Classic 10cmx10c
16/03/2021 00:00:00 35.121,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Paracetamol tablet 500 m 2.000,00
Total 41.971,00
3.072 Dika Love vina PENARIK 159965 Ambroxol Syr 15mg/ml
16/03/2021 00:00:00 4.538,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Ketoprofen tab 100 mg 12.380,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 67.074,00
3.073 Dilah LUNANG 182882 Cefixime Kapsul 100 mg
16/03/2021 00:00:00 9.380,00 BPJS
Flunarizine 5 mg tab 24.750,00
Omeprazol kapsul 20 mg 6.610,00
Sucralfate Suspensi 100 m 19.250,00
Total 59.990,00
3.074 Imas Suprihatin TANJUNG MULYA 183071 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Total 78.115,00
3.075 Jalelo Sitepu TALANG SEPAKAT 137802 Eperisone Hcl 50 mg @1
16/03/2021 00:00:00 23.280,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 25.280,00
3.076 Teki Widiarsih LUBUK MUKTI 146222 Loratadine tab 10 mg
16/03/2021 00:00:00 1.660,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 4.660,00
3.077 Hartuti DESA TALANG SEPAKA 142782 Ambroxol Syr 15mg/ml
16/03/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Loratadine tab 10 mg 1.660,00
Paracetamol tablet 500 m 3.000,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 37.323,00
3.078 Titin Sumarni PONDOK BARU 119023 NACL 0,9 % 500 ml
16/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
3.079 Riko TALANG SEPAKAT 183074 Domperidone Tab
16/03/2021 00:00:00 1.620,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 3.620,00
3.080 Salami SILAUT I 134774 NACL 0,9 % 500 ml
16/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
3.081 Wahiri TALANG SEPAKAT 181795 Meloxicam 15 mg
16/03/2021 00:00:00 12.600,00 BPJS
Pregabalin Kap 75 mg 64.460,00
Total 77.060,00
3.082 Rini Astuti LUBUK SANAI 2 147140 NACL 0,9 % 500 ml
16/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
3.083 Misni TANJUNG BERINGIN 162425 NACL 0,9 % 500 ml
16/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
3.084 Ani Mariani TUNGGAL JAYA 109603 Loratadine tab 10 mg
16/03/2021 00:00:00 1.660,00 BPJS
Paracetamol tablet 500 m 3.000,00
Total 4.660,00
3.085 Suparmi SILAUT 156450 NACL 0,9 % 500 ml
16/03/2021 00:00:00 42.750,00 BPJS
Renogen 3000 UI 116.875,00
Total 159.625,00
3.086 Suwarni SUKA MAJU 164065 NACL 0,9 % 500 ml
16/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.087 Elpina Pandu Winata MEKAR MULYA 183076 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 11.502,00
Dexametason Injeksi 9.384,00
NonWoven Fixation 15x 6.694,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 28.614,00
Transfusi Set Terumo 16.500,00
Total 104.400,00
3.088 Zukriman LUBUK GEDANG 160918 NACL 0,9 % 500 ml
16/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.089 Susi Martini KOTO JAYA 145038 NACL 0,9 % 500 ml
16/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.090 Salbiyah LUBUK MUKTI 173013 NACL 0,9 % 500 ml
16/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.091 Yuliasih PT AGRO SUNGAI BET 110303 Ambroxol Syr 15mg/ml
16/03/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Flunarizine 5 mg tab 24.750,00
Paracetamol tablet 500 m 2.000,00
Total 59.413,00
3.092 Ghina Maisa Zahirah NENGGALO 137661 Cefixime Kapsul 100 mg
16/03/2021 00:00:00 9.380,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.092 Ghina Maisa Zahirah NENGGALO 137661 Opilax Syr
16/03/2021 00:00:00 49.156,00 BPJS
Total 58.536,00
3.093 Roslina TERUNTUNG 130072 NACL 0,9 % 500 ml
16/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.094 Azolla Elvi Junita PONDOK TALANG 182921 Asam Mefenamat 500 m
16/03/2021 00:00:00 1.290,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 47.656,00
3.095 Sari Bulan PAUH TERENJA 135076 Alprazolam 0,5 mg @100
16/03/2021 00:00:00 590,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Total 7.200,00
3.096 Marni Wati UJUNG PADANG 177033 thyrozol 5 mg
16/03/2021 00:00:00 24.780,00 BPJS
Total 24.780,00
3.097 Rita Herlina SUMBER SARI 144492 Amoxicillin 500 mg @ 10
16/03/2021 00:00:00 3.060,00 BPJS
Dexametason 0,5 mg Ta 1.160,00
Paracetamol tablet 500 m 2.000,00
Total 6.220,00
3.098 Indriyani SUNGAI RENGAS 149913 Asam Mefenamat 500 m
16/03/2021 00:00:00 1.290,00 BPJS
Methylprednisolone tab 4 2.630,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 44.696,00
3.099 Zaunatul Aini LUBUK PINANG 153422 Allopurinol 300 Mg @100
16/03/2021 00:00:00 4.910,00 BPJS
Total 4.910,00
3.100 Yuliadi LUBUK SANAI 128329 Opilax Syr
16/03/2021 00:00:00 49.156,00 BPJS
Ranitidine tablet 150 mg 1.440,00
Total 50.596,00
3.101 Nasri MANDI ANGIN JAYA 173798 Omeprazol kapsul 20 mg
16/03/2021 00:00:00 13.220,00 BPJS
Total 13.220,00
3.102 Siti Marfuah PAUH TERENJA 115600 Avamys
16/03/2021 00:00:00 129.000,00 BPJS
Loratadine tab 10 mg 1.660,00
Methylprednisolone tab 4 2.630,00
Total 133.290,00
3.103 Suhendra PASAR BANTAL 143029 Domperidone Syrup 5mg
16/03/2021 00:00:00 10.279,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 12.279,00
3.104 Eliza Putriani MANDI ANGIN JAYA 161191 Amlodipine 10 mg @50 T
16/03/2021 00:00:00 2.360,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 24.340,00
3.105 Zanuraini GAJAH MATI 163354 Paracetamol tablet 500 m
16/03/2021 00:00:00 2.000,00 BPJS
Ranitidine tablet 150 mg 1.440,00
Total 3.440,00
3.106 Darlan DUSUN BARU PELOKA 175629 Azitromycin 500 mg
16/03/2021 00:00:00 28.125,00 BPJS
Paracetamol tablet 500 m 2.000,00
Total 30.125,00
3.107 Sudirman PASAR SEBELAH 117138 Asam Mefenamat 500 m
16/03/2021 00:00:00 1.290,00 BPJS
Levofloxacin Tablet 500 m 20.460,00
Total 21.750,00
3.108 Titik Supartini AIR PUTIH 183081 Abbocath 20 Terumo @5
16/03/2021 00:00:00 52.682,00 BPJS
Electroda (Ambu) @25 Pc 163.140,00

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.108 Titik Supartini AIR PUTIH 183081 Epinephrin inj
16/03/2021 00:00:00 45.993,00 BPJS
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion Makro (terumo) 27.225,00
Nassal Cannula O2 Anak 16.473,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 19.076,00
Stesolid Inj 2 ml 8.653,00
Suction Chateter no. 12 ( 10.588,00
Total 354.050,00
3.109 Sapril SIBAK 181906 Amlodipine 10 mg @50 T
16/03/2021 00:00:00 590,00 BPJS
Candesartan tab 8 mg 6.810,00
Metformin tablet 500 mg 2.660,00
Total 10.060,00
3.110 Arna Julita TUNGGANG 182430 Alprazolam 0,5 mg @100
16/03/2021 00:00:00 590,00 BPJS
Domperidone Syrup 5mg 10.279,00
Omeprazol kapsul 20 mg 6.610,00
Total 17.479,00
3.111 Tugimin SILAUT IIII 154221 Captopril 25 mg
16/03/2021 00:00:00 1.000,00 BPJS
Glucosamine 250 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Total 10.700,00
3.112 Deva Haryanti LUBUK CABAU 134650 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 2.475,00
Furamin Injeksi 14.369,00
Infusion Makro (terumo) 27.225,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Total 101.576,00
3.113 Surneti LUBUK PINANG 119584 Asam Folat 1 mg @100 T
16/03/2021 00:00:00 990,00 BPJS
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Total 9.600,00
3.114 Ida Fitri BUNGA TANJUNG 128265 Paracetamol tablet 500 m
16/03/2021 00:00:00 2.000,00 BPJS
Ranitidine tablet 150 mg 1.440,00
Total 3.440,00
3.115 Bekti PAUH TERENJA 166637 Omeprazol kapsul 20 mg
16/03/2021 00:00:00 6.610,00 BPJS
Total 6.610,00
3.116 Jauna SERAMI BARU 183067 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Cefotaxime Injeksi 11.502,00
Infusion Makro (terumo) 27.225,00
Misoprostol Tab 33.000,00
Ringer Laktat Otsuka 9.538,00
Total 107.606,00
3.117 Siti Juwariah BUNGA TANJUNG PO 130171 Glimepiride tab 2 mg
16/03/2021 00:00:00 2.590,00 BPJS
Loratadine tab 10 mg 1.660,00
Omeprazol kapsul 20 mg 6.610,00
Pregabalin Kap 75 mg 64.460,00
Total 75.320,00
3.118 Imas Suprihatin TANJUNG MULYA 183071 Bunascan Spinal 0.5
16/03/2021 00:00:00 63.525,00 BPJS

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 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.118 Imas Suprihatin TANJUNG MULYA 183071 Cefotaxime Injeksi
16/03/2021 00:00:00 11.502,00 BPJS
Celemek Plastik 59.125,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 1 R (Tri 157.750,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
handscoond steril 8 (Gam 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 5.500,00
Metrodinazole tab 500 m 810,00
Midazolam 5mg/1ml 9.859,00
Misoprostol Tab 16.500,00
Myotonic inj 19.596,00
NACL 0,9 % 500 ml 17.100,00
Ondansetron Inj 1.650,00
oxytocin inj 2.998,00
Polyvinylidene 3-0 R (Tri 92.000,00
Protocin Inj 18.810,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Tranexamic Acid Inj (Asa 6.315,00
viamac 1 R 364.370,00
viamac 1 R 364.370,00
Cefotaxime Injeksi
17/03/2021 00:00:00 17.253,00
Chloramphenicol Salep M 2.351,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NGT (Feeding tube) Fr. 5 17.603,00
Phytomenadione 2 Mg/1M 4.834,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
umbilical Cord Clamp 2.261,00
Cefotaxime Injeksi
18/03/2021 00:00:00 11.502,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
NonWoven Fixation 10x 4.815,00
Tranexamic Acid Inj (Asa 6.315,00
Asam Mefenamat 500 m
19/03/2021 00:00:00 1.935,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 300 mg Tabl 17.500,00

19/08/2021 12:42:30 Page 744 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.118 Imas Suprihatin TANJUNG MULYA 183071 Kassa kotak stril DRC
19/03/2021 00:00:00 9.675,00 BPJS
Postofix (leukomed) 36.726,00
Tranexamic Acid Inj (Asa 12.630,00
Total 2.063.713,00
3.119 Harandi Pizar DESA LUBUK BANGKO 178422 Lidocain injk 40 mg/2 ml
16/03/2021 00:00:00 1.611,00 BPJS
Polyvinylidene 5-0 C (Tri 92.006,00
Total 93.617,00
3.120 Jauna SERAMI BARU 183067 Asam Mefenamat 500 m
18/03/2021 00:00:00 1.290,00 BPJS
Cefixime Kapsul 100 mg 3.752,00
Cefixime Kapsul 100 mg 3.752,00
Cefixime Kapsul 100 mg 1.876,00
Cefixime kapsul 200 mg 26.480,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Misoprostol Tab 55.000,00
Total 144.150,00
3.121 Ny.wira Oktavia LALANG LUAS 183089 Abbocath 24 Terumo @5
16/03/2021 00:00:00 79.023,00 BPJS
Ampicilin Serbuk Injeksi 1 10.811,00
Bisturi No. 15 3.836,00
Calcii Glukonas Inj 100 m 12.939,00
Chloramphenicol Salep M 2.351,00
Hypafix 10cm x 5cm (25 c 9.700,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
Ka-En Mg3 13.104,00
NGT (Feeding Tube) Fr. 8 70.420,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
17/03/2021 00:00:00 131.705,00
Atropin injek 1 ml 6.969,00
Epinephrin inj 15.331,00
ETT 3.5 Kingking (Balon) 119.563,00
Hypafix 10cm x 5cm (25 c 4.850,00
Midazolam 5mg/1ml 9.859,00
NGT (Feeding tube) Fr. 5 17.603,00
NonWoven Fixation 10x 9.630,00
Hypafix 10cm x 5cm (25 c
18/03/2021 00:00:00 4.850,00
Sibital Injeksi (Phenobarbit 12.375,00
Bactesyn inj 0,75 gr
21/03/2021 00:00:00 118.018,00
Gentamicin Injeksi 4.606,00
Abbocath 24 Terumo @5
22/03/2021 00:00:00 79.023,00
Bactesyn inj 0,75 gr 59.009,00
Epinephrin inj 15.331,00
Gentamicin Injeksi 4.606,00
NACL 0,9 % 500 ml 8.550,00
NGT (Feeding tube) Fr. 5 17.603,00
Bactesyn inj 0,75 gr
23/03/2021 00:00:00 236.036,00
Gentamicin Injeksi 9.212,00
Hypafix 10cm x 5cm (25 c 4.850,00
Bactesyn inj 0,75 gr
25/03/2021 00:00:00 59.009,00
Gentamicin Injeksi 4.606,00
Glukosa Infus 5 % 8.626,00
Phytomenadione 2 Mg/1M 4.834,00
Total 1.193.975,00

19/08/2021 12:42:30 Page 745 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.122 Arni Mulyana PELOKAN 178223 Abbocath 22 Terumo @5
16/03/2021 00:00:00 11.138,00 BPJS
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00
Hypafix 15cmx5cm (25 c 6.544,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 5.500,00
Midazolam 5mg/1ml 9.859,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
Transfusi Set Terumo 16.500,00
Abbocath 20 Terumo @5
17/03/2021 00:00:00 52.682,00
Bisturi No. 15 3.836,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 5.751,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix Kamar Operasi 18.000,00
Ketorolac inj 30 mg/1ml 2.690,00
NonWoven Fixation 10x 4.815,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Transfusi Set Terumo 16.500,00
Cefixime Kapsul 100 mg
18/03/2021 00:00:00 9.380,00
Levofloxacin Tablet 500 m 13.640,00
Paracetamol tablet 500 m 3.000,00
Total 780.890,00
3.123 Sesmajulita BANDAR RATU 183072 Abbocath 20 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 11.502,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Fresofol ( propopol ) inj 13.448,00
Handscoon steril 7,5 (Ga 29.126,00
Handscoond Non Steril L 20.630,00
handscoond steril 6.5 (G 29.108,00

19/08/2021 12:42:30 Page 746 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.123 Sesmajulita BANDAR RATU 183072 Hypafix 15cmx5cm (25 c
16/03/2021 00:00:00 6.544,00 BPJS
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 1.345,00
Ketorolac inj 30 mg/1ml 4.035,00
Masker Karet 5.500,00
NACL 0,9 % 500 ml 8.550,00
Ondansetron Inj 1.650,00
Polyvinylidene 3-0 R (Tri 92.000,00
Ringer Laktat Otsuka 9.538,00
Ringer Laktat Otsuka 19.076,00
Spuit 10 cc Disposible (T 3.230,00
Spuit 3 cc Terumo 13.916,00
Spuit 5 cc terumo 8.538,00
Topi Operasi (Perawat) @ 4.690,00
abbocath 18 Terumo @5
17/03/2021 00:00:00 52.682,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 5.751,00
NonWoven Fixation 10x 4.815,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 8.250,00
Transfusi Set Terumo 16.500,00
Cefotaxime Injeksi
18/03/2021 00:00:00 11.502,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Cuticell Classic 10cmx10c
19/03/2021 00:00:00 35.121,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 3.000,00
Total 746.441,00
3.124 Ena Susanti DUSUN BARU 159708 Abbocath 20 Terumo @5
16/03/2021 00:00:00 52.682,00 BPJS
ATRACURIUM BESYLATE 2 14.671,00
Bisturi No. 23 3.836,00
Cefotaxime Injeksi 5.751,00
Celemek Plastik 59.125,00
Chromic catgut 2-0 R (Tr 72.250,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 6.256,00
Ephedrine Injeksi 10.711,00
Handscoond Non Steril S 8.510,00
Handscoond Sterille 7 (G 43.689,00
Handscoond Sterille 7.5 16.488,00
Iodine povidone 300 ml 28.463,00
Masker Tali 41.600,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 15x 13.388,00
Polyvinylidene 3-0 R (Tri 92.000,00
Propofol Lipuro 1% 75.900,00
Ringer Laktat Otsuka 19.076,00
Spinocain 27 (BBraund) 47.875,00

19/08/2021 12:42:30 Page 747 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.124 Ena Susanti DUSUN BARU 159708 Spuit 10 cc Disposible (T
16/03/2021 00:00:00 3.230,00 BPJS
Spuit 3 cc Disposible 3.640,00
Spuit 5 cc Disposible 2.840,00
Topi Operasi (Dokter) @5 3.398,00
Topi Operasi (Perawat) @ 7.504,00
Transfusi Set Terumo 16.500,00
Abbocath 20 Terumo @5
17/03/2021 00:00:00 52.682,00
Cefotaxime Injeksi 5.751,00
Cefotaxime Injeksi 5.751,00
NonWoven Fixation 10x 4.815,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 9.538,00
Tramadol 50 mg/ml Inj 8.250,00
Transfusi Set Terumo 16.500,00
Ceftriaxone Inj
18/03/2021 00:00:00 12.498,00
Ringer Laktat Otsuka 19.076,00
Tramadol 50 mg/ml Inj 12.375,00
Cuticell Classic 10cmx10c
19/03/2021 00:00:00 35.121,00
Kassa kotak stril DRC 9.675,00
Levofloxacin Tablet 500 m 13.640,00
Levopar tab 100mg 12.910,00
NACL 0,9 % 500 ml 8.550,00
NonWoven Fixation 10x 4.815,00
Paracetamol tablet 500 m 3.000,00
Total 947.077,00
3.125 Deva Haryanti LUBUK CABAU 134650 Ceftriaxone Inj
16/03/2021 00:00:00 18.747,00 BPJS
Furamin Injeksi 43.107,00
Ondansetron Inj 4.950,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 28.614,00
Ceftriaxone Inj
17/03/2021 00:00:00 12.498,00
Eperisone Hcl 50 mg @1 6.984,00
Furamin Injeksi 14.369,00
Loratadine tab 10 mg 166,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Azitromycin 500 mg
18/03/2021 00:00:00 28.125,00
Loratadine tab 10 mg 1.660,00
Meloxicam 15 mg 12.600,00
NonWoven Fixation 10x 9.630,00
Paracetamol tablet 500 m 2.000,00
Total 217.026,00
3.126 Sawilah RAWA MULYA 183091 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 681,00
Captopril 12,5 mg 160,00
Catheter 2 Way No. 16 ( 20.625,00
Ceftriaxone Inj 12.498,00
Electroda (Ambu) @25 Pc 81.570,00

19/08/2021 12:42:30 Page 748 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.126 Sawilah RAWA MULYA 183091 Flunarizine 5 mg tab
16/03/2021 00:00:00 2.475,00 BPJS
Infusion Makro (Gea) 7.425,00
Ketorolac inj 30 mg/1ml 2.690,00
Metformin tablet 500 mg 399,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 15x 6.694,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 9.538,00
Urine bag 9.263,00
Total 199.435,00
3.127 Ny.rosany Simarmata DUSUN BARU 183092 Chloramphenicol Salep M
16/03/2021 00:00:00 2.351,00 BPJS
NGT (Feeding Tube) Fr. 8 70.420,00
Phytomenadione 2 Mg/1M 4.834,00
umbilical Cord Clamp 2.261,00
Abbocath 24 Terumo @5
17/03/2021 00:00:00 79.023,00
Ampicilin Serbuk Injeksi 1 10.811,00
Hypafix 10cm x 5cm (25 c 4.850,00
Infusion set Mikro (Terumo 18.026,00
NGT (Feeding tube) Fr. 5 17.603,00
Ciprofloxacin tab 500 mg
19/03/2021 00:00:00 5.590,00
Clindamycin 300 mg Tabl 17.500,00
Gentamicin Injeksi 9.212,00
Total 242.481,00
3.128 Sawilah RAWA MULYA 183091 Abbocath 20 Terumo @5
17/03/2021 00:00:00 52.682,00 BPJS
Bisoprolol 5 mg @100 Ta 296,00
Candesartan tab 8 mg 3.405,00
Ceftriaxone Inj 12.498,00
Flunarizine 5 mg tab 2.475,00
Infusion Makro (terumo) 27.225,00
Ketorolac inj 30 mg/1ml 2.690,00
Metformin tablet 500 mg 399,00
Nassal Cannula O2 Dewas 23.250,00
NonWoven Fixation 10x 4.815,00
Pregabalin Kap 75 mg 6.446,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Bisoprolol 5 mg @100 Ta
18/03/2021 00:00:00 296,00
Ceftriaxone Inj 12.498,00
Dulcolax Sup 10 mg 27.800,00
Flunarizine 5 mg tab 2.475,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ketorolac inj 30 mg/1ml 2.690,00
Levemir FlexPen 104.938,00
Metformin tablet 500 mg 399,00
NACL 0,9 % 500 ml 42.750,00
Novo Twist 32 G Tip 1.928,00
Ondansetron Inj 4.950,00
Opilax Syr 49.156,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Bisoprolol 5 mg @100 Ta
19/03/2021 00:00:00 296,00

19/08/2021 12:42:30 Page 749 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.128 Sawilah RAWA MULYA 183091 Ceftriaxone Inj
19/03/2021 00:00:00 12.498,00 BPJS
Dulcolax Sup 10 mg 27.800,00
Flunarizine 5 mg tab 2.475,00
Ketorolac inj 30 mg/1ml 2.690,00
Metformin tablet 500 mg 399,00
NonWoven Fixation 10x 9.630,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 38.152,00
Betahistin Mesilat 6 mg @
20/03/2021 00:00:00 1.380,00
Bisoprolol 5 mg @100 Ta 1.480,00
Candesartan tab 8 mg 3.405,00
KSR (potassium chloride) 23.030,00
Metformin tablet 500 mg 2.660,00
Pregabalin Kap 75 mg 32.230,00
Total 626.542,00
3.129 Ny.sukmayani PONDOK TENGAH 183093 Ampicilin Serbuk Injeksi 1
17/03/2021 00:00:00 10.811,00 BPJS
Gentamicin Injeksi 4.606,00
NGT (Feeding tube) Fr. 5 17.603,00
Abbocath 24 Terumo @5
18/03/2021 00:00:00 79.023,00
Calcii Glukonas Inj 100 m 12.939,00
Glukosa Infus 10 % 9.375,00
Infusion set Mikro (Terumo 18.026,00
NonWoven Fixation 10x 9.630,00
Total 162.013,00
3.130 Tasali PONDOK MAKMUR 182924 Azitromycin 500 mg
17/03/2021 00:00:00 5.625,00 BPJS
Catheter 2 Way No. 16 ( 20.625,00
Cefoperazon Inj 41.250,00
Furamin Injeksi 14.369,00
Nassal Mask O2 Dewasa 41.828,00
Omeprazole Inj 12.499,00
Ondansetron Inj 1.650,00
Urine bag 9.263,00
Total 147.109,00
3.131 Markis ARAH TIGA 099286 Abbocath 20 Terumo @5
17/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Ascorbid Acid 1000mg/5m 52.250,00
azitromicin inj 500 mg 144.376,00
Bionicom Zink 2,00
Ceftriaxone Inj 12.498,00
Infusion Makro (Gea) 7.425,00
NACL 0,9 % 500 ml 8.550,00
Nassal Cannula O2 Dewas 11.625,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 5.370,00
vestein 300 mg 14.025,00
Total 298.281,00
3.132 Tasali PONDOK MAKMUR 182924 Azitromycin 500 mg
17/03/2021 00:00:00 5.625,00 BPJS
Cefoperazon Inj 82.500,00
Cefoperazon Inj 82.500,00
Furamin Injeksi 14.369,00

19/08/2021 12:42:30 Page 750 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.132 Tasali PONDOK MAKMUR 182924 Ondansetron Inj
17/03/2021 00:00:00 4.950,00 BPJS
Ringer Laktat Otsuka 19.076,00
Azitromycin 500 mg
18/03/2021 00:00:00 16.875,00
Azitromycin 500 mg 28.125,00
Cefixime kapsul 200 mg 26.480,00
Cefoperazon Inj 82.500,00
Erdosteine Syr 36.575,00
Furamin Injeksi 14.369,00
Furamin Injeksi 14.369,00
Levopar tab 100mg 12.910,00
Omeprazol kapsul 20 mg 3.305,00
Omeprazole Inj 12.499,00
Omeprazole Inj 12.499,00
Ringer Laktat Otsuka 19.076,00
Sucralfate Suspensi 100 m 19.250,00
vestein 300 mg 46.750,00
vestein syr 48.125,00
vestein syr 48.125,00
Vitamin B Komplek @100 770,00
Total 651.622,00
3.133 Nur"aini DANAU NIBUNG 183090 abbocath 18 Terumo @5
16/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Cefotaxime Injeksi 5.751,00
Chromic catgut 1 R (Tri 157.750,00
Hypafix 10cm x 5cm (25 c 4.850,00
Ringer Laktat Otsuka 19.076,00
Transfusi Set Terumo 16.500,00
Aqua Pro Injeksi
20/03/2021 00:00:00 3.575,00
Asam Mefenamat 500 m 1.935,00
Bucain Spinal 0.5 % Inj 52.181,00
Catheter 2 Way No. 16 ( 20.625,00
Cefotaxime Injeksi 11.502,00
Cefotaxime Injeksi 11.502,00
Chromic catgut 1 R (Tri 78.875,00
Chromic catgut 2-0 R (Tr 72.250,00
Ciprofloxacin tab 500 mg 5.590,00
Clindamycin 300 mg Tabl 17.500,00
Cuticell Classic 10cmx10c 35.121,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Gelaufusal Infusion 500 m 181.269,00
Handscoon steril 7,5 (Ga 29.126,00
handscoond steril 6.5 (G 29.108,00
Handscoond Sterille 7 (G 29.126,00
Hypafix 15cmx5cm (25 c 6.544,00
Hypafix 15cmx5cm (25 c 6.544,00
Kassa kotak stril DRC 9.675,00
Ketorolac inj 30 mg/1ml 4.035,00
Ketorolac inj 30 mg/1ml 2.690,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole tab 500 m 810,00
Metrodinazole tab 500 m 810,00
Misoprostol Tab 16.500,00

19/08/2021 12:42:30 Page 751 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.133 Nur"aini DANAU NIBUNG 183090 Myotonic inj
20/03/2021 00:00:00 19.596,00 BPJS
NACL 0,9 % 500 ml 17.100,00
Polyvinylidene 3-0 R (Tri 92.000,00
Postofix (leukomed) 36.726,00
Protocin Inj 37.620,00
Ringer Laktat Otsuka 28.614,00
Spinocain 27 (BBraund) 47.875,00
Suprafenid Supositoria 10 28.050,00
Tramadol 50 mg/ml Inj 8.250,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 4.210,00
Tranexamic Acid Inj (Asa 6.315,00
Tranexamic Acid Inj (Asa 12.630,00
Tranexamic Acid Inj (Asa 18.945,00
Urine bag 9.263,00
viamac 1 R 364.370,00
Total 1.654.650,00
3.134 Yanti LUBUK SANAI 183062 Cefotaxime Injeksi
20/03/2021 00:00:00 34.506,00 BPJS
Metrodinazole tab 500 m 4.050,00
Paracetamol tablet 500 m 3.000,00
Total 41.556,00
3.135 Maryatun TIRTA MAKMUR 120142 Abbocath 20 Terumo @5
17/03/2021 00:00:00 26.341,00 BPJS
Aqua Pro Injeksi 3.575,00
Infusion Makro (Gea) 7.425,00
Lyrica 27.200,00
Mecobalamin 500 mg 1.540,00
NonWoven Fixation 15x 6.694,00
Ondansetron Inj 1.650,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Cefoperazon Inj 41.250,00
Ciprofloxacin infus 2% 26.328,00
Furamin Injeksi 14.369,00
Hypafix 10cm x 5cm (25 c 4.850,00
Hypafix 10cm x 5cm (25 c 9.700,00
Infusion Makro (terumo) 27.225,00
Infusion set Mikro (Terumo 18.026,00
Mecobalamin 500 mg 1.540,00
Metamizole Sodium Mono 13.782,00
NACL 0,9 % 500 ml 17.100,00
Nassal Mask O2 Dewasa 41.828,00
Ondansetron Inj 4.950,00
Otsu KCL 4.029,00
Paracetamol tablet 500 m 600,00
Paracetamol tablet 500 m 600,00
Pregabalin Kap 75 mg 12.892,00
Ranitidin inj 5.370,00
Ringer Laktat Otsuka 19.076,00
Ringer Laktat Otsuka 19.076,00
Three Way stopcock 15.789,00
Antrain Injeksi
18/03/2021 00:00:00 28.875,00
Cefoperazon Inj 82.500,00

19/08/2021 12:42:30 Page 752 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.135 Maryatun TIRTA MAKMUR 120142 Furamin Injeksi
18/03/2021 00:00:00 14.369,00 BPJS
KSR (potassium chloride) 2.303,00
Mecobalamin 500 mg 1.540,00
Ondansetron Inj 4.950,00
Paracetamol tablet 500 m 600,00
Pregabalin Kap 75 mg 6.446,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 38.152,00
Antrain Injeksi
19/03/2021 00:00:00 28.875,00
Ciprofloxacin tab 500 mg 5.590,00
Hypafix 15cmx5cm (25 c 13.088,00
KSR (potassium chloride) 23.030,00
Mecobalamin 500 mg 7.700,00
Paracetamol tablet 500 m 2.000,00
Total 647.731,00
3.136 Alamsyah DESA BARU PELOKAN 124485 Ambroxol Syr 15mg/ml
17/03/2021 00:00:00 4.538,00 BPJS
Bisoprolol 5 mg @100 Ta 1.480,00
Furosemide 40 mg Tablet 960,00
Levofloxacin Tablet 500 m 13.640,00
Meloxicam 15 mg 12.600,00
Pregabalin Kap 75 mg 64.460,00
Total 97.678,00
3.137 Abdi Lubis RAWA MULYA 152783 Mecobalamin 500 mg
17/03/2021 00:00:00 7.700,00 BPJS
Metformin tablet 500 mg 11.970,00
Pregabalin Kap 75 mg 64.460,00
Total 84.130,00
3.138 Sugini PONDOK MAKMUR 110687 Azitromycin 500 mg
17/03/2021 00:00:00 28.125,00 BPJS
Bisoprolol 5 mg @100 Ta 1.480,00
Candesartan tab 8 mg 6.810,00
Flunarizine 5 mg tab 24.750,00
Furosemide 40 mg Tablet 960,00
Opilax Syr 49.156,00
Total 111.281,00
3.139 Umi Masfufah TANAH HARAPAN 180160 Cetirizine 10 mg
17/03/2021 00:00:00 1.260,00 BPJS
Ciprofloxacin tab 500 mg 5.590,00
Metrodinazole tab 500 m 4.050,00
Omeprazol kapsul 20 mg 6.610,00
Paracetamol tablet 500 m 2.000,00
Sucralfate Suspensi 100 m 19.250,00
Total 38.760,00
3.140 Riayati LUBUK BANGKO 152742 Betahistin Mesilat 6 mg @
17/03/2021 00:00:00 1.380,00 BPJS
Metformin tablet 500 mg 3.990,00
Total 5.370,00
3.141 Suriasna LUNANG 183099 Asam Traneksamat @10
17/03/2021 00:00:00 21.050,00 BPJS
Cefixime Kapsul 100 mg 9.380,00
Total 30.430,00
3.142 Rita Susanti ARAH TIGA 182984 Ambroxol Syr 15mg/ml
17/03/2021 00:00:00 4.538,00 BPJS
Azitromycin 500 mg 28.125,00
Domperidone Tab 1.080,00
Flunarizine 5 mg tab 24.750,00
Total 58.493,00
3.143 Yunia Estiana Prihatin PT.AGRO SEI KIANG 148671 Metformin tablet 500 mg
17/03/2021 00:00:00 3.990,00 BPJS

19/08/2021 12:42:30 Page 753 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
Total 3.990,00
3.144 Irwansyah SUMBER SARI 183103 Amoxicillin 500 mg @ 10
17/03/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Pehacain Injeksi 6.640,00
Total 10.990,00
3.145 Siti Eriah BANDAR JAYA 182800 Asam Mefenamat 500 m
17/03/2021 00:00:00 1.290,00 BPJS
Total 1.290,00
3.146 Maryati SIDODADI 140968 Alprazolam 0,5 mg @100
17/03/2021 00:00:00 590,00 BPJS
Bisoprolol 5 mg @100 Ta 1.480,00
Flunarizine 5 mg tab 24.750,00
Total 26.820,00
3.147 Sangkur TALANG MEDAN 146229 Cefixime Kapsul 100 mg
17/03/2021 00:00:00 9.380,00 BPJS
Domperidone Tab 1.620,00
Total 11.000,00
3.148 Afriani PONDOK BARU 136645 Flunarizine 5 mg tab
17/03/2021 00:00:00 24.750,00 BPJS
Opilax Syr 49.156,00
Urinter Kapsul @100 cap 21.980,00
Total 95.886,00
3.149 Amusi Gea MME 154744 Eperisone Hcl 50 mg @1
17/03/2021 00:00:00 23.280,00 BPJS
Paracetamol tablet 500 m 2.000,00
Vitamin B Komplek @100 1.540,00
Total 26.820,00
3.150 Parji Darsono AGUNG JAYA 118047 Allopurinol 100 mg @100
17/03/2021 00:00:00 2.340,00 BPJS
Leparson tablet 27.400,00
Sifrol tab 0,375 mg 103.750,00
Total 133.490,00
3.151 Ani Mariani TUNGGAL JAYA 109603 abbocath 18 Terumo @5
17/03/2021 00:00:00 26.341,00 BPJS
Ceftriaxone Inj 12.498,00
Cuticell Classic 10cmx10c 35.121,00
Dexametason Injeksi 3.128,00
Dexametason Injeksi 3.128,00
Kassa kotak stril DRC 19.350,00
Kassa kotak stril DRC 9.675,00
Ranitidin inj 1.790,00
Ringer Laktat Otsuka 9.538,00
Tranexamic Acid Inj (Asa 2.105,00
Tranexamic Acid Inj (Asa 2.105,00
Transfusi Set Terumo 16.500,00
Total 141.279,00
3.152 Bahman SIBAK 155872 Candesartan tab 8 mg
17/03/2021 00:00:00 2.724,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 200,00
Renogen 3000 UI 116.875,00
Total 153.999,00
3.153 Asmansyah SIBAK 140995 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.154 Sadiyono SUMBER MAKMUR 180239 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.155 Irwan Sakti DANAU NIBUNG 154908 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Paracetamol tablet 500 m 600,00

19/08/2021 12:42:30 Page 754 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.155 Irwan Sakti DANAU NIBUNG 154908 Renogen 3000 UI
17/03/2021 00:00:00 116.875,00 BPJS
Total 151.675,00
3.156 Mutmainnah SUNGAI RENGAS 114676 Candesartan tab 8 mg
17/03/2021 00:00:00 2.724,00 BPJS
NACL 0,9 % 500 ml 34.200,00
Paracetamol tablet 500 m 200,00
Renogen 3000 UI 116.875,00
Total 153.999,00
3.157 Lailatul Kadar TANAH REKAH 158354 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.158 Sumidah RAWA MULYA 163860 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.159 Jumarno LUNANG 180796 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.160 Supiyani TALANG KUNING 182966 Cefixime Kapsul 100 mg
17/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
3.161 Bima Aryandika BANDARATU 178714 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Paracetamol Infus 28.876,00
Renogen 3000 UI 116.875,00
Total 179.951,00
3.162 Kasmidi Kasim BANDAR RATU 135355 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Total 34.200,00
3.163 Yati TANJUNG MULYA 133159 Acetylcystein 200 mg Ka
17/03/2021 00:00:00 17.190,00 BPJS
Asam Traneksamat @10 21.050,00
Cefixime kapsul 200 mg 26.480,00
Paracetamol tablet 500 m 2.000,00
Phytomenadione 10 mg ( 9.340,00
Ranitidine tablet 150 mg 1.440,00
Total 77.500,00
3.164 Junaidi SUNGAI IPUH 138273 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Renogen 3000 UI 116.875,00
Total 151.075,00
3.165 Mardiani PIAN TOKUNG 116430 NACL 0,9 % 500 ml
17/03/2021 00:00:00 34.200,00 BPJS
Paracetamol tablet 500 m 200,00
Renogen 3000 UI 116.875,00
Total 151.275,00
3.166 Godfrid Ss RANAH KARYA 163602 Meloxicam 15 mg
17/03/2021 00:00:00 18.900,00 BPJS
Urinter Kapsul @100 cap 21.980,00
Total 40.880,00
3.167 Kania Khairunnisa PASAR MUKOMUKO 170422 Alprazolam 0,5 mg @100
17/03/2021 00:00:00 590,00 BPJS
Total 590,00
3.168 Ani Mariani TUNGGAL JAYA 109603 Ceftriaxone Inj
17/03/2021 00:00:00 12.498,00 BPJS
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 4.035,00
Metrodinazole Infus 30.939,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00

19/08/2021 12:42:30 Page 755 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai
3.168 Ani Mariani TUNGGAL JAYA 109603 Tranexamic Acid Inj (Asa
17/03/2021 00:00:00 6.315,00 BPJS
Ceftriaxone Inj
18/03/2021 00:00:00 12.498,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 2.690,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 19.076,00
Tranexamic Acid Inj (Asa 6.315,00
Ceftriaxone Inj
19/03/2021 00:00:00 12.498,00
Dexametason Injeksi 9.384,00
Ketorolac inj 30 mg/1ml 4.035,00
Methylprednisolone tab 4 526,00
Methylprednisolone tab 4 2.630,00
Paracetamol tablet 500 m 600,00
Ranitidin inj 3.580,00
Ringer Laktat Otsuka 28.614,00
Tranexamic Acid Inj (Asa 21.050,00
Cetirizine 10 mg
20/03/2021 00:00:00 1.260,00
Ciprofloxacin tab 500 mg 5.590,00
Fentanyl Injeksi 5 Ampul 2 52.000,00
Mecobalamin 500 mg 11.550,00
Methylprednisolone tab 4 3.945,00
Paracetamol tablet 500 m 3.000,00
Tranexamic Acid Inj (Asa 6.315,00
Total 315.485,00
3.169 Darwin SIDODADI 161429 Alprazolam 0,5 mg @100
17/03/2021 00:00:00 590,00 BPJS
Clopidogrel 75 mg @30 T 52.650,00
Isosorbid dinitrat 5 mg (I 1.110,00
Renax @50 Kapsul 56.720,00
Total 111.070,00
3.170 Yenti Komala Sari TUNGGANG 160442 Cefixime Kapsul 100 mg
17/03/2021 00:00:00 9.380,00 BPJS
Ketorolac Tab 10 Mg 25.300,00
Metrodinazole tab 500 m 4.050,00
Postofix (leukomed) 36.726,00
Total 75.456,00
3.171 Tarsono SINAR JAYA 115102 Aminophyline 200 mg @1
17/03/2021 00:00:00 2.000,00 BPJS
Azitromycin 500 mg 56.250,00
Ranitidine tablet 150 mg 1.440,00
Salbutamol 4 mg 930,00
Symbicort Turbuhaler 80 167.855,00
Vectrine Tab 300 mg 50.000,00
Total 278.475,00
3.172 Katiem SUKA MAJU 183115 Amlodipine 5 mg @30 T
17/03/2021 00:00:00 1.010,00 BPJS
Candesartan tab 8 mg 6.810,00
Cefixime Kapsul 100 mg 9.380,00
Paracetamol tablet 500 m 2.000,00
Total 19.200,00
3.173 Agung Nugraha Apri PONDOK BARU 135352 Ambroxol Syr 15mg/ml
17/03/2021 00:00:00 4.538,00 BPJS
Cefixime syrup 100mg/5 M 23.823,00
Total 28.361,00
3.174 Rasidi PIAN TOKUNG 146613 Amoxicillin 500 mg @ 10
17/03/2021 00:00:00 3.060,00 BPJS
Asam Mefenamat 500 m 1.290,00
Dexametason 0,5 mg Ta 1.160,00

19/08/2021 12:42:30 Page 756 of 18

 Tanggal Rincian Obat yang
No Nama Pasien Alamat No. CM Harga Penjamin
Resep Dipakai