DAFTAR ACUAN UNTUK PENGADAAN DANA JKN

TAHUN 2022

BULAN : ....... S/D ......

PUSKESMAS : .........................

DAFTAR USULAN PENGADAAN OBAT DAN BMHP PUSKESMAS CAMPLONG TAHUN 2022

NAMA OBAT DAN PERBEKALAN HARGA SATUAN

NO KODE SATUAN
KESEHATAN (HNA)
1 2 3 4 5
A. OBAT RUTIN
1 A008 Ambroxol Tablet 30 mg Tablet 160
2 A016 Amoxicillin Sirup Kering 125mg/5 ml Botol 4,200.00
Anti Influenza + DMP Kombinasi
3 A029 Kaplet 560.00
(Phenzacol)
4 A030 Anti Influenza Kombinasi (Demacolin) Tablet 600.00

5 A035 Asam Askorbat / Vitamin C Injeksi 200 mg Ampul 8,550.00

Betahistine Mesylate Tablet 6 mg

6 A052 Tablet 360
(Samcohistine)
7 A062 Calcium Lactate Tablet 500 mg Tablet 180.00
8 A068 Cefadroxil Kapsul 500mg Kapsul 850
9 A071 Cefotaxime Injeksi 1 g Vial 6,800
10 A072 Ceftriaxone Serbuk Injeksi 1 g/vial Vial 7,000
11 A074 Cetirizine Sirup 5 mg/5 ml Botol 6,600
12 A085 Ciprofloxacin Tablet 500mg Tablet 530
13 A095 Dexamethasone Tablet 0,5 mg Tablet 140
14 A128 Glyceryl Guaiacolate Tablet 100 mg Tablet 150
15 A143 Ibuprofen Sirup 100 mg/5 ml Botol 5,500.00
16 A146 Ibuprofen Tablet 400 mg Tablet 350

17 A148 Isosorbide Dinitrate Tablet Sublingual 5 mg Tablet 140.00

18 A155 Lactobacillus Serbuk (Lacto B) Sachet 7,000.00

19 A163 Levofloxacin Tablet 500 mg Tablet 600.00
20 A191 Misoprostol Tablet Tablet 7,600.00

21 A193 Multivitamin dan Multimineral (Caviplex) Tablet 800.00

22 A196 Nifedipine Tablet 10 mg Tablet 240
Oxytetracycline HCl Salep Kulit 3% (Terra
23 A206 Tube 6,100.00
Cortil)
24 A208 Oxytocin Injeksi 10 IU/ml Ampul 3,550
25 A219 Piroxicam Tablet 10 mg Tablet 120.00
26 A230 Ranitidine Injeksi 25 mg/ml Ampul 2,700
27 A231 Ranitidine Tablet 150 mg Tablet 230
28 A238 Risperidone Tablet 2 mg Tablet 1,040
29 A240 Salbutamol 2,5 mg (Fartolin Nebules) Ampul 10,000.00
30 A249 Sucralfate Suspensi 500 mg/5 ml Botol 16,700.00
Tambah Darah + Multivitamin Mineral
31 A252 Tablet 350.00
(Hufabion)

32 A261 Vitamin B Kompleks Injeksi (Biocombin) Ampul 7,000

33 A262 Vitamin B Kompleks Tablet (Hufaneuron) Tablet 700

34 B007 Alat Suntik Sekali Pakai 3 ml Pcs 760

35 B004 Alat Suntik Sekali Pakai 10 ml Pcs 1,070.00
36 B006 Alat Suntik Sekali Pakai 20 ml Pcs 1,720.00
37 B025 Bayclin Botol 62,900.00
38 B029 Biss Mess 11 Pcs 3,600.00
39 B037 Catgut Chromic 2/0 + Jarum Set 11,900.00
40 B039 Catgut Plain 3/0 + Jarum Set 11,900.00
41 B092 Larutan Klorin (One Clean) Botol 1 L 30,000.00
42 B096 Masker Nebuleser Anak Pcs 18,600.00
43 B097 Masker Nebuleser Dewasa Pcs 18,600.00
44 B103 My Jelly Tube 82 gr 32,000.00
45 B107 Needle 23 (One Med/Terumo) Pcs 2,550.00
46 B129 Sarung Tangan Non Steril (L) Pasang 1,500.00
47 B130 Sarung Tangan Non Steril (M) Pasang 1,500.00
48 B137 Silk 2/0 Set 7,900.00
49 B139 Softex Maternity Pack 37,000.00
50 B144 Stik Asam Urat Botol 94,500.00
51 B145 Stik Gula Darah Botol 94,500.00
52 B146 Stik Kolesterol Botol 175,000.00
53 B149 Tes Kehamilan Strip 1,700.00
54 B154 Underpad Pcs 3,740.00
55 B159 combur test carik celup/protein urin
56 B164 eugenol

MENGETAHUI
KEPALA UPTD PUSKESMAS CAMPLONG

dr.INTAN RETNOSARI
NIP.197604102002122002
GADAAN DANA JKN
2

PUSKESMAS CAMPLONG TAHUN 2022

HARGA SATUAN
JUMLAH NILAI
(HNA + PPN 11%)
6 7 8

177.60 5,000 888,000.00

4,662.00 300 1,398,600.00

621.60 10,000 6,216,000.00

666.00 10,000 6,660,000.00

9,490.50 100 949,050.00

399.60 - Sudah ada d gudang

199.80 10,000 1,998,000.00

943.50 12,000 11,322,000.00
7,548.00 300 2,264,400.00
7,770.00 300 2,331,000.00
7,326.00 250 1,831,500.00
588.30 - Sudah ada d gudang
155.40 10,000 1,554,000.00
166.50 10,000 1,665,000.00
6,105.00 - Sudah ada d gudang
388.50 10,000 3,885,000.00

155.40 1,000 155,400.00

7,770.00 280 2,175,600.00

666.00 5,000 3,330,000.00
8,436.00 960 8,098,560.00

888.00 10,000 8,880,000.00

266.40 3,000 799,200.00

6,771.00 500 3,385,500.00

3,940.50 - Sudah ada d gudang

133.20 10,000 1,332,000.00
2,997.00 500 1,498,500.00
255.30 - Sudah ada d gudang
1,154.40 1,000 1,154,400.00
11,100.00 200 2,220,000.00
18,537.00 300 5,561,100.00

388.50 10,000 3,885,000.00

7,770.00 500 3,885,000.00

777.00 - Sudah ada d gudang

89,322,810.00

843.60 1,200 1,012,320.00

1,187.70 2,000 2,375,400.00
1,909.20 1,000 1,909,200.00
69,819.00 5 349,095.00
3,996.00 200 799,200.00
13,209.00 288 3,804,192.00
13,209.00 192 2,536,128.00
 33,300.00 5 166,500.00
20,646.00 200 4,129,200.00
20,646.00 200 4,129,200.00
35,520.00 5 177,600.00
2,830.50 300 849,150.00
1,665.00 3,000 4,995,000.00
1,665.00 2,000 3,330,000.00
8,769.00 216 1,894,104.00
41,070.00 100 4,107,000.00
104,895.00 25 2,622,375.00
104,895.00 40 4,195,800.00
194,250.00 - -
1,887.00 100 188,700.00
4,151.40 1,000 4,151,400.00
5
2

TOTAL NILAI 89,322,810.00 79,497,300.90

PPN 9,825,509.10 Harga sudah include ppn pph
PPH 22 1,192,459.51
JUMLAH 80,689,760.41

PETUGAS OBAT

ROFIATUL HASANAH.S,Kep.NS
NIP.198301192010012004