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,,zt RS. Jantuno I P.mbutuh Deh HaEDan Xita Jl. Lctlen S. Paman X.vA7, SttEt, Jatalt BaEt.|l / / T.lF (021) 568'lllr {H(nlrno) F . ltzl} 56&rio
page 1 of8
{20
Prnrbd by LAPORAN RS / D3Le _ 12/oll20t9 09.30.31
RINCIAN BIAYA SEMENTARA
NoMR Nama
Pasien
:132305
Pengirim
:
dr
:
Masuk
:
O4lO1l2O19 09:17:27
MUHAMMAD ANDRE AJ, TN.
Alamat : PERUM BUMI l\rAS U3 01/04 I/IOJOREJO, Koia : MADIUN Jaminan i 01 PRIBADi Tanggal
TAt\rAN MADTUN
Kode Yan/ltem Layanan
Sp/CAR/Paru/Anak/dll
No.Kunjungan: 190'1MEE02R0027 Paoses
Masuk
:
RSCC
Nama
Dokter
:
POPPY S. ROEBIONO
otv
Tarif
Subtotal
Diskon
Umum 05-01-2019
962111
KAMAR
OPERASI
o5-01-2019 s.d. os-o1-2019
04-01-2019
999181
0
2OO2
qqo
MEDICAL DAN BE 2oo2
0
2.600.000
KAMAR & VISITE ICU MEDICAL DAN BE 2002
3
2.600 000
DO55
3
17.73a
53.214
0
DO55
-,|
't7.738
-17.734
0
05-01-2019
999931
KAMAR & VISITE
lcu
2OO2
05-01-2019 s.d. 05-01-2019 05-01-2019 s.d. 08-01-2019
05-01-2019
710006
09-0'1-2019
7'10006
09-0'1-201S
710006
I
710006
05-01-2019
710008
06-01-2019
710008
I
710008
09-01-2019
710008
11-01-2019
710008
r
1-01-2019
710008
v-01-2019
710009
0&01-2019
71000s
09-01-2019
710009
11-O1-2019
71000s
1
'1-0't -201
07-0'1 -20't
0t01-2019
7'100'10
06-01-201S
710010
07-0'1-2019
7'10010
09-01-2019
710010
I
710010
11-01-2019
710010
11-01-2019
7100'10
05-0'1-2019
710011
06-01-20't9
710011
06-0'1-2019
710011
07-01-20'19
710011
09-01-201S
71001'1
10-01-2019
710011
11-O1-2019
7
05-01-201S
710012
'1
0-0'1 -201
too1'l
0
3.000
KAMARRAWAT.I.W.MEDIKALANAK 08-01-2019 s.d. 11-01-2019
710001
':t
1 000 000
999927
09-01-2019
0
3
-01-201S
710001
e'r'
1.650.000
KAMAR RWT PAV SUKAMAN SAPPHIRE 2Oo2 11-01-2019 s.d. 12-01-2019
05-01-2019
0
1.650.000
999.18.1
9S9931
5qo
1.650.000
20'19
05-01-2019
0
0
KAMAR RWT PAV SUKAMAN SAPPHIRE 2oO2
o4-01-2019 s.d. o5-01-2019
11-01
0
SET BLOOD SET BLOOD
CC DISP SYRINGE 1CC DISP SYRINGE 1 CC DISP SYRINGE 1CC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 5 cC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 10Cc DISP SYRINGE 10 CC DISP SYRINGE 10Cc DISP SYRINGE 10 Cc DISP SYRINGE 20 CC DISPSYRINGE20CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC CATH TIP DISP SYRINGE
'1
1.,1.'
0oo |
e
.'-
0
0
7.8oo.0oo ' rr.\.,;:i,::
,l
0
D055
7
2-0'18
14.126
0
DO55
-,|
2.O1A
-2.O18
0
D055
1
2.O14
2.O18
0
DO55
2
2.O18
4.036
0
DOS5
7
2.000
14.000
0
D055
5
2.000
10.000
0
Do55
4
2.000
8.000
0
Do55
2
2.000
4-000
0
DO55
3
2,000
6.000
0
0055
1
2.000
2.000
0
D055
10
2.500
25.000
0
DO55
3
2.500
7.500
0
D055
-2
2.500
-5_000
0
2.500
5.000
0
D055 Do55
4
ooss
3.850
15.400
0
3.850
19.250
0
Doss
1
3.850
3.850
0
DO55
1
3.850
3.850
0
,|
3.850
3_850
0
DO55
1
3.850
3,850
0
DO5S
2
3.850
7.700
0
Do55
3
9.676
29.02a
0
DO55
2
s.676
D0S5
19.352
0
48.380
0
s.676
29.024
0
DO55
D055 Do55
2
9_676
'19.352
0
DOS5
1
s-676
9.676
0
DO55
2
9.676
19.352
0
Do55
1
21.450
21.450
0
2
RS. J.ntu.c a P.mbuluh O.6h H.ap.n Kita Jl. L.tl.n S. P.m. Xav87,slipi, J.*arE BaEt 11420 TalP: {o2l) 5631111 (Hunling) F&: {o21) 56a4130
page 2 of 8 Print€d by LAPORAN RS / Date: 12f01/2019 09:32:58
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengidm
dr Sp/CAR/Paru/AnaUdll
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
MlO1nO19 09.17:.27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
1S0104EE02R0027
Kota
:
IUADIUN
Proses Masuk
RSCC
Jaminan
I
01
Nama Dokter
POPPY S- ROEBIONO
Tanggal
Kode Yan/ltem Layanan
PRIBADI
atv
Tarif
Subtotal
Diskon
Umum 1't{1-2019
710025
0
1-2019
710032
0m't-2019
710032
07-01-2019
7'loo32
09-01-20'19
710032
09{1-2019
710032
10-01-2019
710032
10-01-2019
710032
'10-01-2019
710032
11-01-2019
710032
11-01-2019
710032
09{1-2019 't'1{1-20't9
710040
22 18 DISP NEEoLE No. '18 DISP NEEDLE NO. 18 DISP NEEDLE No. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO, 18 DISP NEEDLE NO. '18 DISP NEEDLE NO. 18 IV CATHETER NO
DISP. NEEDLE NO.
710'153
1141-2019
710153
I
710207
INFUSION SET WITH BURETTE
0$.01-2019 09-01-2019
7'10065
710071
09-01-2019
710081
09-01-2019
710087
11-0't-2019
7'10087
114't-20'19
vooaT
11-01-2019
710091
0to1-2019
710092
07-0'1-2019
710092
09{1-20'19
710092
0t01-20'i
09-01-2019
'1o.444
10.444
0
Do55
544
5.,14O
0
D05S
10
544
5.440
0
DO55
1
544
544
0
DoS5
3
544
oo55
1
544
544
0
Doss
3
544
1.632
0
Do55
2
544
1_088
0
,i
u4
544
0
1
544
544
0
D055
09-01-2019
11-01-2019
09.01-2019
1
10
Do55
JMS SOLADM SET/ INFUS SET JMS THREE WAY BERBUNTUT TEGADERM 1622 FLOW CONTROLLER CIAVE CLAVE CONNECTOR CLAVE CONNECTOR CLAVE CONNECTOR TEGADERM 1624 NITRIL GLOVE NITRIL GLOVE NITRIL GLOVE MEDITAPE 1/2inch JMS( 300 ) MEDITAPE 1/2inchJMS( 300 )
710040
DO55
SOLADM SET/ INFUS SET
D05S
1
4
u4
0
Do55
1
9.213
9.213
0
DO55
1
9.213
9.213
0
Do55
1
22.243
22.243
0
DO55
1
5.989
5.989
0
DO55
1
88.625
88.625
0
DO55
1
21.313
21.313
0
DO55
2
21.313
42.626
0
Do55
1
21.313
oO55
I
2.803
2-803
0
Do55
100
843
84.300
0
D055
'100
843
84.300
0
DO55
-100
843
-84.300
0
D055
1
9.166
9.166
D055
1
9.166
9.166
0
DO55
I
75.625
75.625
0
710207
INFUSIoN SET WITH BURETTE lF-BR-o oo55
1
7s.625
75.625
0
710299
LINEAR BAG
1
59.606
59.606
0
710341
NASAL CANULLA PEDIATRIC ( 0206 )
1
8.250
8.250
0
lF-BR{
wlTHoUT SOLIDIFYING
A Do55
B
Do55
1
4.500
4.500
0
D055
6
1.423
8.538
0
0055
10
1.423
14.230
0 0
OXYGEN SUPPLYTUBING ( 0401 ) B-Mt Do55
05-01-2019
710473
DISP SYRINGE 3
06-01-2019
710473
07-01-20'19
710473
09-01-2019
710473
10-01-2019
710473
10-01-2019
710/.73
11-01-2019
710473
05-01-2019
710/41
06-01-2019
710481
07-01-2019
710441
0741-2019
0
0
710436
0941-20'19
0
710441
cc DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB
DO55
8
1.423
'11.384
DO55
6
1.423
8.538
0
DO55
5
1.423
7.'115
0
1.423
8.538
0
3
1.423
4.269
0
D055
20
250
5.000
0
DO55
10
250
2.500
0
DO55
10
250
2.500
0
250
250
0
D055 D055
DO55
1
Page J
ps Janruno t Pembuluh Da6h Ha6D6n Kir. -^ I .r'itirli, s nam"n Kav87, iripl, r.k.n.8arai i1420 --,/ i;lo. rb21t s5a1r11 (Hunt,ns) ru. tozlr 55a4130
ftlrned
ol8
by LAPORAN RA / Dato , 1201/2019 09-32 58
RINCIAN BIAYA SEMENTARA Pengirim
:
drsp/CAR/Paru/Anaudll
MUHAMMAD ANDRE AJ' TN.
Masuk
:
O4lO1l2O19 09:17.27
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
:'190't04EE02R0027
Kota
:
MADIUN
Proses Masuk
:
RSCC
Jaminan
:01
Nama Dokter
:
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltem Layanan
No MR
:
132305
Nama Pasien
:
Alamat
PRIBADI
Tarif
atv
Subtotal
Diskon
Umum 0941-2019
71c/,8',1
09{'r -2019
nMal
1G01-2019
71(N81
10-01-2019
71M41
10-01-2019 ,1-01-20',|9
710481
\-r1
-01 -20'l
I
06-01-2019 06-01-2019
710481
ALKOHOLSWAB ALKOHOLSWAA ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB
DO55
1
250
250
0
DO55
8
250
2-000
0
DO55
6
250
1.500
0
OO55
1
250
2fi
0
DO55
10
250
2.500
0
D055
8
250
2-000
0
0055
4
250
1.000
0
'1',t0521
TRG.SENSOSURGE STERIL GLOVE NO Dos5
4
29.976
0
710521
TRO-SENSOSURGE STERIL GLOVE NO D055
10
7AU 7AU
74.940
0
7.494
'14.988
0
7't0481
09{1-2019
710521
TRO-SENSoSURGE STERIL GLOVE No Dos5
044't-2019
711007
SURGICAL CLIPPER
090't -2019
711147
1'1-01-2019
7',t1147
11-01-2019
711158
09-0'1-201S
711393
BLADE MANOMETER LINE MANOMETERLINE NEBULIZER PAED SALTER '1'173
D055
1
76.863
76.863
0
D055
5
25.438
127.190
0
25.438
50.876
0
D055 D055
1
24.990
24.990
0
THREE WAY STOPCOCK 4624 BD BIAS, DO55
4
11.688
46.752
0
1
'11.688
11.688
0
4
4.496
17.9U
0
44.960
0
I
7't'1393
THREE WAY STOPCOCK 4624 BD BIAS, D055
0641-2019
711691
SUCTION CATH No.14
'1'1-01 -201
HOSPITECH HOSPITECH
D055
09i't -2019
71't69't
SUCTION CATH NO.14
DO55
10
4.496
0s-0't -2019
711698
CONECTING TUBE NO.7 EUROPLAST/ I D055
2
26.250
52.500
0
04{1-2019
71172',1
ONESCRUB 4 % lOO
'1
27
04-o't -2019
712242
Ecc
I
712242
ECG TAB ELECTRODE
11-01-2019
ML
_5N
27.500
0
D055
10
1.733
'17-330
0
DO55
10
'I
_733
17.330
0
712243
ECG ELECTRoDE NEoNATE PRE WIRE D055
1
36.094
36.0S4
0
-201 9
714089
SWIFEL ELBOW 15 F
DO55
1
59.606
59.606
0
09-01 -2019
714091
D055
1
97.350
97.350
0
05-01-2019
716079
Do55
1
43.312.500
43.312.500
0
2
57.475
'114.950
0
OO55
2
57.475
114.950
0
57.475
-57.475
0
1.760
7.UO
0
'11
-01 -20'l
DO55
24 RT 24
TAB ELECTRODE RT
09{1-2019
730007
3512 RESERVOTR BAG I L28'10 CoNTEGRA MEDTRONIC 20 MM GELOFUSIN INF 5OO ML GELOFUSIN INF 5OO ML GELOFUSIN INF 5OO ML
DO55
-1
0101-2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG / oo55
4
054'l-2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG / 9655
..-,$0't
0
1-2019
730007
05-o'l -2019
730007
OO55
'l
-760
14_080
0
5.280
0
064 r -20'19
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG
/
D055
3
1.760
06{'l -2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG
/ 0055
10
1.760
17.600
0
08-01-2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG
i
-7
1-760
-12.320
0
1
54.994
54.994
0 0
09-0'l-201s
730065
0641-2019
730066
10-01-2019
730066
11-01-2019
730066
05-01-20'19
730067
0t01-20'19
730067
0G01-2019
730067
tNVtcLoT tNJ 25.000 lu / 5
ML LASIX INJ 20 MG/2 ML LASIX INJ 20 MGi2 ML MORPHINE INJ 10 MG MORPHINE INJ 10 MG 10 MG MORPHINE LASIX INJ 20 MG/2
'NJ
ML
Do55 D055 DOSS
10
15.196
'r51.960
DO55
-5
15-196
-75.980
0 0
OO5S
1
15-196
15.196
DO55
2
42.563
85-'126
0
OOSS
2
42.563
85.126
0
42.563
'127.689
0
DO55
J
.)
RS. Janlunq E P.mbuluh Da6h HaED.n Kit Jl. L.ten S. Pa@an Kav.87, Sllpr, J.k+rrr Ba.rt 11420 (021) 668,Itl {Hunung) Fir:(o21) 56a!130
page 4 of 8 Print€d by IAPORAN RS / Dal6 : lZOlZO.tg 09:32:5a
ftrp:
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
dr. Sp/CAR/Paru/Anak/dll
Nama Pasien
:
MUHAMMAD ANORE AJ, TN.
Masuk
MlO1l2O19 09.17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
190104EE02R0027
Kotia
:
MADIUN
Proses Masuk
RSCC
Jaminan
:01
Nama Dokter
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltein Layanan
PRIBADI
otv
Tarif
Subtotal
Diskon
Umum 0s01-2019
7s0073
OTSU KCL 7.46% 25 ML
D055
2
4.029
1041-2019
730073
D055
2
oto1-2019
730078
OTSU KCL 7,46% 25 ML OTSU NACL 0.9 % . 25 ML
D055
6
0s01-2019
730078
OTSU NACL 0,9 % - 25 ML
D055
6
06-01-2019
730078
OTSU NACL 0,9
' 25 ML
D055
06-0'l-201s
730078
6
730078
D055
6
09-01-2019
730078
D055
6
'10-01-2019
730078
OTSU NACL 0,9 % - 25 ML OTSU NACL 0,9 % . 25 ML OTSU NACL 0,9 % . 25 ML OTSU NACL 0,9 % . 25 ML
D055
07-01-2019
D055
3
't0-01-2019
730078
OTSU NACL 0,9 % - 25 ML
D055
2
6.s31
13.062
0
11-O1-2019 '11-01-2019
730078
OTSU NACL 0,9
' 25 ML
D055
4
6.531
26.124
0
730078
OTSU NACL 0,9 % - 25 ML
D055
3
6.53't
'19.593
0
05{'t -2019
730079
OTSU MGSO4 20 25 ML
D055
2
4.'160
8.320
0
06-01-20'19
73008'1
OTSU WFI 25 ML
D055
3.575
17.87s
0
0901-2019
73008'r
OTSU WFI 25 ML
09-0'1-201I
730081
OTSU WFI 25 ML
O/O
O/O
8.058
0
4.O29
8.058
0
6.531
39.186
0
6.53't
39.186
0
6.53'1
32.655
0
6-531
39.'t 86
0
6.531
39.'186
0
6.531
39.186
0
19-593
0
D055
1
3.575
3.575
0
D055
b
3.57s
21.450
0
3.575
0
1041-2019
730081
OTSU WFI 25 ML
D055
1
3.575
11-01-20'19
730081
OTSU WFI 25 ML
3-575
3.575
0
I
D055
1
73008'l
OTSU WFI 25 ML
D055
3.575
10.725
0
'11-01-2019
730'163
VENTOLIN NEBULES 2,5 MG
D055
2
5.000
'10.000
0
0tu1-20'19
730252
CALCIUM GLUCONAS INJ
10 ML
D055
5
12.939
64.695
0
0641-2019
730252
CALCIUM GLUCONAS INJ 10% 10 ML
D055
3
12.939
38.817
0
I
730252
CALCIUM GLUCONAS INJ 10% 10 ML
D055
.,|
'12.939
-'12.939
0
,|
11-01-20't
1
'1
-0'l -201
1OON
0m1-2019
730373
OTSU NACL 0,9 % PIGGY BACK
1OO
ML D055
10.725
10.725
0
1041-2019
730373
OTSU NACL 0,9 % PIGGY BACK
1OO
ML D055
1
10.725
10.725
0
0
1-2019
730469
SEDACUM INJ 15 MG / 3 ML
D055
2
u.375
64.750
0
08{1-2019
730469
SEDACUM INJ 15 MG / 3 ML
D055
-2
34.375
s8.750
0
04-01-2019
730512
OXTERCIO INJ 750 MG
D055
12
58.988
707.856
0
05{1-20'19
7305'12
OXTERCID INJ 750 MG
D055
4
58.988
235.952
0
o7-01-2019
730s12
OXTERCID INJ 750 MG
D055
2
58.988
117.976
0
05-0't-20'1s
730525
ECRON INJ 10 MG
D055
2
133.646
267.292
0
05-01-20't9
730529
ECRON INJ
MG
D055
4
133.646
534.584
0
05-01-201S
730529
ECRON INJ 10 MG
D055
2
133.646
267.292
0
08-01-2019
730529
ECRON INJ 10 MG
D055
-1
'133.646
-133.646
0
D055
3
257.125
771.375
0
257.125
514.250
0
1O
05-01-2019
730589
INOVAD INJ 10 MG/10 ML
05-01-2019
730589
INOVAD INJ 10 MG/10 ML
D055
2
06-01-2019
730s89
INOVAD INJ
1O
MG/10 ML
D055
3
257.125
771.375
0
06-01-2019
730589
INOVAD INJ
1O
MG/10 ML
D055
3
257.'t25
771.375
0
07-o't-2019
730589
INOVAD INJ '10 MG/10 ML
D055
257.125
514.250
0
08-01-2019
730589
INOVAD INJ
07-o t-2019
730604
1O
MG/l0 ML
PROSOGAN INJ 30 MG
D055
o055
4
257 _125
2
'1'15.050
-1.028.500
0
230.'100
0
Jantunq E Pembuluh Oa6h HaED.n Krra /^ RS.L.tien S. Parman Xav,87, Stipi,Jalana Ean|t lr42o _/ Jl Icrp: "-/ {021) 563tlll {Huhtrng) Fd: (02,t,5634,t30
pag6 5 of 8 Printad by LAPORAN RS / Dat6 : 1Z0il2019 O9:32:s8
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
;
dr. Sp/CAFYPaT/Anak/dll
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
i
MlO1l2O19 09,'17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
;
'190 t
Kota
:
MADIUN
Proses Masuk
:
RSCC
Jaminan
:
01
Nama Dokter
:
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltem Latranan
PRIBADI
otv
04EE02R0027
Tarit
Subtotal
Oiskon
Umum 09-01-2019
7306M
10{1-2019
730604
11{1-2019
730604
06-01-2019
730759
0m1-2019
730759
'41-2019
730759
l\rc MG PROSOGAN INJ 30 MG PROSoGAN INJ 30
PROSoGAN INJ 30
ML oNDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2
D055
'l
115.050
115.050
0
OOSS
1
115.050
115.050
0
ooss
1
115.050
115.050
0
D05b
2
1.338
2.676
0
D055
2
1.338
2.676
0
Do55
2
,'.338
2.676
0
1.338
-2.676
0
1
2.431
2.431
0
1
't2.155
12.155
0
12.155
08{1-2019
730759
05-01-2019
730915
07{1-2019
730950
ASAM TRANEKSAMAT INJ 500 MG / 5 M OO55 WIDA D5 - 1/4 NS D055
0901-2019
730950
DO5S
1
12.155
0
06-01-2019
730951
DO55
1
8.013
8.013
0
DO55
1
8.013
8.013
0
10-01-2019
730951
1141-2019
730951
05{'1-2019
730962
0
1-2019
730962
06{1-2019
730962
08-01-2019
730962
0441-2019
730972
06-01-2019
730975
08{1-2019
730975
0M1-20't9
730992
0G01-2019
730992
-01-20'19
730992
08-01-2019
730992
09-01-2019
73'1000
11-O1-2019
731000
11-01-20't9
731000
05-01-20'19
731042
06{1-2019
731125
07-o1-2019
731125
09{1-2019
732399
0s01-20't9
732429
1G0't -2019
733112
1141-20'19
733't't2
10-01-2019
733485
11-O't-2019
733485
06-01-2019
73/-216
09-01-2019
73r'.216
10-01-2019
73r'216
11-O',t-2019
734216
I
734249
09-0'1 -20'1
iTM WIDA D5 - 1/4 NS /TM
ML OTSU NACL 0,9 7o INF 5O0 ML oTSU NACL 0,9 Yo INF 500 ML OTSU NACL 0,9 % INF 500
DO55
Do55
ML D055 PARACETAMOL INFUS 1 cR / 100 ML DO55 PARACETAMOL INFUS '1 GR / '100 ML OO5S PARACETAMOL INFUS I GR/ 100 ML DOsE MINOSEP GARGLE 0,2% 60 ML DO55 KEToROLAC INJ 30 MG/ML D055 KETOROLAC INJ 30 MG/ML DO55 RANITIDIN INJ 50 MG / 2 ML DO55 RANITIDIN INJ 50 MG / 2 I\,IL Do55 RANITIDIN INJ 50 MG / 2 ML D055 RANITIDIN INJ 50 MG / 2 ML D055 CEFTRIAXoNE INJ 1GR Do55 CEFTRIAXONE INJ 1 GR DO55 CEFTRIAXoNE INJ 1 GR D055 PHYToMENADION INJ 10 MG / ML Do55 CEFUROXIM INJ 750 MG DO55 CEFUROXIM INJ 750 MG DO55 AQUAPACK 340 HUDSON DO55 CUSTODIOL INF 1000 ML DO5S LASIX TAB 40 MG Do55 LASIX TAB 40 MG DO55 THROMBO ASPILETS TAB 80 MG DO55 THROMBOASPILETS TAB 80 MG DO55 SPIRONOLACTONE TAB 25 MG DO55 SPIRONOLACTONE TAB 25 MG DO55 SPIRONOLACTONE TAB 25 MG DOSs SPIRONOLACTONE TAB 25 MG DOS5 FUROSEMIDE TAB 40 MG Do55 PARACEIAMOL INFUS 1 GR / '100
1
8.013
8.0'i3
0
2
'14.513
29.026
0
3
14.513
43.539
0
3
'14.513
43.539
0
2
14.513
29.026
0
1
20.900
20.900
0
1
1.306
1.306
0
-1
1.306
-1.30,6
0
2
'1.444
2.888
0
2
't.444
2.888
0
2
1.444
2.888
0
1.444
-2.888
0
2
5-604
11.204
0
2
5.604
11.208
0
2
5.604
11.208
0
1
5.363
5.363
0
4
37.469
149.876
0
4
37-469
-'t49.876
0
56.513
56.513
0
,1
0
4
2.102.760
2
5.355
10.7'10
'1.040
0
6
5.355
32.130
0
8.4
,|
556
556
0
3
556
't.668
0
2
244
488
0
1
244
244
0
1
244
244
0
3
244
732
0
2
96
't92
0
,...\ / --.2
RS. Jantunq & Pemburuh Danh H.ED.n Xrt S. Parman K.v.07, sirpi. Jatarr. B.,dr tr42o Llp:(021) 553'll'tt 0ruoring, Far lo2i) 5€a4130
Jr L.licn
page 6 of 8 Print€d by LAPoRAN RS / Dare : 1201/2018 0s:32:5a
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
d.
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
0d,IO1DO'19 09,17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO. TAMAN MADIUN
No. Kunjungan
1901 04EE02R0027
Kota
:
MADIUN
Proses Masuk
RSCC
Jaminan
:01
Nama Doliter
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltem Layanan
PRIBADI
otv
Sp/CARYPaT/Analddll
Tarif
Subtotal
Diskon
Umum 09{1-2019
7U345 73/345
0{1-201s
07-o',-2019
CAPTOPRIL TAB 12,5 MG
D055
'100
900
0
D055
100
300
0
734345
CAPTOPRIL TAB 12,5 MG CAPTOPRIL TAB ,I2,5 MG
D055
3
100
300
0
11-01-2019
73{345
CAPTOPRIL TAB 12,5 MG
10
'100
I
D055
1.000
0
734727
FLEET ENEMA
D055
,|
44.688
44.688
0
04-01-2019
900091
REHAB FASE
1
o050
1
110.000
110.000
0
1
't
04-01 -20't
07-01-2019
900091
REHAB FASE
D050
1
1'10.000
110.000
0
08{1-2019
9000s8
FISIOTERAPI
D050
1
80.000
80.000
0
09-01-2019
900098
FISIOTERAPI
D050
,|
80.000
80.000
0
't0.01-2019
900098
FISIOTERAPI
D050
1
80.000
80.000
0
05{1-2019
900r/0
05{1-20'19
901021
Pemasangan dan Tata Laksana Ventilato. s061 WES Rasteily Prosedure + Contegta D099
05-01-2019
751149
06-01-2019
751149
CoMPLETE BLOOD CoUNT(CBC:Hb,Ht, D054 CoMPLETE BLOOD COUNT(CBC:Hb,Ht, D054
1 1
8.500.000 203_4sO.000
8.500.000
0
203.450.000
0
1
85-000
85.000
0
1
85.000
85.000
0 0
07-01-2019
751149
COMPLETE BLoOD COUNT(CBC:Hb,HI,
D054
1
85.000
85.000
0&01-2019
751150
CBC + Difi.Count (Hitung Jenis)
D054
1
100.000
100.000
0
05{1-2019
751205
PT
o054
1
60.000
60.000
0
06{1-2019
751205
PT
D054
1
60.000
60.000
0
07-01-2019
751205
PT
D054
1
60-000
60.000
0
10{1-2019
751205
PT
D054
,|
60-000
60.000
0
11-01-2019
751205
PT
D054
1
60.000
60.000
0 0
05-01-201S
751206
APTT
D054
1
65-000
65.000
06-01-2019
751206
APTT
D054
1
65.000
65_000
0
07{1-2019
751206
APTT
0054
1
65.000
65.000
0
09{1-2019
751206
APTT
D054
1
65.000
65.000
0
09-01-20't 9
751206
APTT
D054
,|
65.000
65.000
0
1G01-2019
75'1206
APTT
0054
I
65.000
65.000
0
11-01-2019
751206
APTT
0054
1
65.000
65.000
0
05-0't-2019
751207
TT
D054
,|
60.000
60.000
0
07-01-2019
751207
TT
D054
I
60.000
60.000
0
0$01-2019
751204
FIBRINOGEN
D054
I
100_000
100.000
0
06{'t-2019
75120A
FIBRINOGEN
D054
1
100.000
100.000
0
07-01-20',t9
751204
FIBRINOGEN
D054
1
100.000
't
00.000
0
0t0'1-2019
752102
ALBUMIN
DO
1
30.000
30.000
0
05-01-2019
752401
UREUM
D054
,|
25.000
25.000
0
05-01-2019
752402
CREATININ
D054
1
25.000
25.000
0
05-01-2019
752404
OSMOLALITAS SERUM
D054
1
50.000
50.000
0
10-01-2019
752621
GD Sowaktu POCT
D054
1
25.000
25.000
0
10-01-2019
752621
GD Sewaktu POCT
D054
1
25.000
25.000
0
'1041-2019
752621
GD Setlraktu POCT
D054
1
25.000
25.000
0
10{1-201S
752621
GD S6waktu POCT
,|
25.000
25.000
0
D054
,,-\ -,/ /
RS. Jantunq A Pembutuh OaEh HaEban Kira Jl. Le{en s. Pamah lGvl/, sttpt, JEt rt BaEr 1t4,au Ierp: {o2i) 5631111 thu.rlnqt Fu:1021t 56a.t130
pagc 7 of 8 Printed by LAPORAN RS / Dare : 12y01/20.19 09:32:58
RINCIAN BIAYA SEMENTARA
NoMR Nama
Pasien
:
132305
Pengi.im
dr Sp/CAR/ParuiAnaUdll
:
MUHAMMADANDRE AJ, TN.
Masuk
O4lO1t2O19 09:17.27
No.Kunjungan
190104EE02R0027
Proses Masuk
RSCC
Nama Dokter
POPPY S. ROEBIONO
Alamat : PERUM BUMI MAS U3 01/04 MOJOREJO, Kota : MADIUN Jaminan : 01 PRIBAD| Tanggal
TAMAN MADTUN
Kode Yan/ltem Layanan
otv
Tarif
Subtotal
Diskon
Umum 05-01-2019
752701
ANALISA GAS DARAH
D054
145.000
145.000
0
05-01-2019
752701
ANALISA GAS DARAH
D054
1
145.000
145.000
0
0s01-2019
752701
ANALISA GAS DARAH
D054
1
145.000
145.000
0
06-01-2019
752701
ANALISA GAS DARAH
D054
1
145.000
'145.000
0
06-01-2019
752701
ANALISA GAS DARAH
D054
1
'145.000
145-000
0
i-01-2019
752701
ANALISA GAS DARAH
D0g
1
145.000
'145.000
0
752701
ANALISA GAS DARAH
D054
1
'145.000
145-000
0
07-o1-20 t9
752701
ANALISA GAS DARAH
D054
,1
145.000
145.000
0
08-0't-2019
752701
ANALISA GAS DARAH
D054
1
'!45.000
145.000
0
08-01-2019
752704
CALSIUM TOTAL
D054
1
35.000
s5.000
0
'nt-o1-2019
,|
10-01-20'19
752704
CALSIUM TOTAL
D054
1
35.000
35.000
0
11-0'1-2019
752704
CALSIUM TOTAL
D054
1
35.000
3s.000
0
08-01-2019
752707
MAGNESIUM
D054
1
35.000
35.000
0
10-01-2019
752707
MAGNESIUIVI
D054
1
35.000
35.000
0
'11-01-2019
752707
MAGNESIUM
D054
1
35.000
35.000
0
05-01-2019
752718
Analisa Gas Darah
D0g
1
145.000
145.000
0
0H1-2019
752718
Analisa Gas Darah
D054
1
145.000
145.000
0
06-01-2019
752718
Analisa Gas Darah
D054
1
145.000
145_000
0
08-0'1-2019
752720
09,01-2019
752720
10-01-2019
752720
11-01-2019
752720
Cl Cl Na, K, Cl Na, K, Cl
01-2019
753602
CRP
E-01-2019
753629
PROCALCITONIN
09-01-2019
756101
URINE RUTIN
04-01-2019
758'130
Biaya pengolahan darah
04-01-2019
758130
Biaya pengolahan darah
04-01-2019
754134
PMI/ PRC
05-0'1-2019
758135
PA/llI/
FFP
D054
05-01-20'19
758136
PMI/AHF
04-01-2019
758138
PMI/TC
04-01-2019
758'138
PMI/TC
D054
05-01-20'19
900043
THORAX PAJAP
Na, K,
(Natrium, Kalium, Chlorida)
D054
1
75.000
75.000
0
Na, K,
(Natrium, Kalium, Chlorida)
D054
'l
75.000
75.000
0
(Natrium, Kalium, Chlorida)
D054
1
75.000
75.000
0
(Natrium, Kalium, Chlorida)
D054
1
75.000
75.000
0
D054
1
145.000
'145.000
0
D054
I
455.000
455-000
0
D054
'|
30.000
30.000
0
D054
3
70.000
210.000
0
D054
't5
70-000
1.050.000
0
D054
3
535.000
1.605.000
0
535.000
2.675.000
0
06-01-2019
900043
THORAX PA./AP
07-01-2019
900043
THORAX PA/AP
D054
4
535_000
2.140-000
0
D054
3
535.000
1.605.000
0
535.000
'1.605.000
0
1
160,000
'160.000
0
,|
160.000
160.000
0
'160.000
160.000
0
907S
1
,,-t / --,/
RS, J.nlu.o A P.mbuluh O.r.h H.ED.. Kit Jl. LctiGn S. Pirrnan Xav87, Stilr. J.klria AlEt 1la2o lerp: lo2l, s6atlt,t tHunfng, fu: tt 2t, !ir,r413r,
I
Pago 8 of Priflted by LAPOMN RS / Date : 1ZO1l2019 09:32:50
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
dr. Sp/CAFYPatu/Analddll
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
O4lO1l2O19 09:17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
'190104EE02R0027
Kota
:
MADIUN
Proses Masuk
RSCC
Jaminan
:
O,I
Nama Dokter
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltom Lat6nan
PRIBADI
atv
Tarif
Subtotal
Diskon
[Jmum
08{1-2019 12-01-2019
900043
THORAX PfuAP
1
Bill Umum
160.000
160.000
302.742.975
Bill Non Askes
0
Bill Tslpon
0
Jumlah Tarif
302.742.975
Diskon
0
t,rl fd
*
Total Tagihan
Deposit
302.742.975
{
Sisa Tagihan
CATATAN
0
PERINCIAN INI TIDAK BERLAKU SEBAGAI TANDA BUKTI PEMBAYARAN
&'t"'
302.742.975
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page 1 of8
{20
Prnrbd by LAPORAN RS / D3Le _ 12/oll20t9 09.30.31
RINCIAN BIAYA SEMENTARA
NoMR Nama
Pasien
:132305
Pengirim
:
dr
:
Masuk
:
O4lO1l2O19 09:17:27
MUHAMMAD ANDRE AJ, TN.
Alamat : PERUM BUMI l\rAS U3 01/04 I/IOJOREJO, Koia : MADIUN Jaminan i 01 PRIBADi Tanggal
TAt\rAN MADTUN
Kode Yan/ltem Layanan
Sp/CAR/Paru/Anak/dll
No.Kunjungan: 190'1MEE02R0027 Paoses
Masuk
:
RSCC
Nama
Dokter
:
POPPY S. ROEBIONO
otv
Tarif
Subtotal
Diskon
Umum 05-01-2019
962111
KAMAR
OPERASI
o5-01-2019 s.d. os-o1-2019
04-01-2019
999181
0
2OO2
qqo
MEDICAL DAN BE 2oo2
0
2.600.000
KAMAR & VISITE ICU MEDICAL DAN BE 2002
3
2.600 000
DO55
3
17.73a
53.214
0
DO55
-,|
't7.738
-17.734
0
05-01-2019
999931
KAMAR & VISITE
lcu
2OO2
05-01-2019 s.d. 05-01-2019 05-01-2019 s.d. 08-01-2019
05-01-2019
710006
09-0'1-2019
7'10006
09-0'1-201S
710006
I
710006
05-01-2019
710008
06-01-2019
710008
I
710008
09-01-2019
710008
11-01-2019
710008
r
1-01-2019
710008
v-01-2019
710009
0&01-2019
71000s
09-01-2019
710009
11-O1-2019
71000s
1
'1-0't -201
07-0'1 -20't
0t01-2019
7'100'10
06-01-201S
710010
07-0'1-2019
7'10010
09-01-2019
710010
I
710010
11-01-2019
710010
11-01-2019
7100'10
05-0'1-2019
710011
06-01-20't9
710011
06-0'1-2019
710011
07-01-20'19
710011
09-01-201S
71001'1
10-01-2019
710011
11-O1-2019
7
05-01-201S
710012
'1
0-0'1 -201
too1'l
0
3.000
KAMARRAWAT.I.W.MEDIKALANAK 08-01-2019 s.d. 11-01-2019
710001
':t
1 000 000
999927
09-01-2019
0
3
-01-201S
710001
e'r'
1.650.000
KAMAR RWT PAV SUKAMAN SAPPHIRE 2Oo2 11-01-2019 s.d. 12-01-2019
05-01-2019
0
1.650.000
999.18.1
9S9931
5qo
1.650.000
20'19
05-01-2019
0
0
KAMAR RWT PAV SUKAMAN SAPPHIRE 2oO2
o4-01-2019 s.d. o5-01-2019
11-01
0
SET BLOOD SET BLOOD
CC DISP SYRINGE 1CC DISP SYRINGE 1 CC DISP SYRINGE 1CC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 5 cC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 5 CC DISP SYRINGE 10Cc DISP SYRINGE 10 CC DISP SYRINGE 10Cc DISP SYRINGE 10 Cc DISP SYRINGE 20 CC DISPSYRINGE20CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 20 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC DISP SYRINGE 50 CC CATH TIP DISP SYRINGE
'1
1.,1.'
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0
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7
2-0'18
14.126
0
DO55
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2.O1A
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0
D055
1
2.O14
2.O18
0
DO55
2
2.O18
4.036
0
DOS5
7
2.000
14.000
0
D055
5
2.000
10.000
0
Do55
4
2.000
8.000
0
Do55
2
2.000
4-000
0
DO55
3
2,000
6.000
0
0055
1
2.000
2.000
0
D055
10
2.500
25.000
0
DO55
3
2.500
7.500
0
D055
-2
2.500
-5_000
0
2.500
5.000
0
D055 Do55
4
ooss
3.850
15.400
0
3.850
19.250
0
Doss
1
3.850
3.850
0
DO55
1
3.850
3.850
0
,|
3.850
3_850
0
DO55
1
3.850
3,850
0
DO5S
2
3.850
7.700
0
Do55
3
9.676
29.02a
0
DO55
2
s.676
D0S5
19.352
0
48.380
0
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29.024
0
DO55
D055 Do55
2
9_676
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0
DOS5
1
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9.676
0
DO55
2
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19.352
0
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1
21.450
21.450
0
2
RS. J.ntu.c a P.mbuluh O.6h H.ap.n Kita Jl. L.tl.n S. P.m. Xav87,slipi, J.*arE BaEt 11420 TalP: {o2l) 5631111 (Hunling) F&: {o21) 56a4130
page 2 of 8 Print€d by LAPORAN RS / Date: 12f01/2019 09:32:58
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengidm
dr Sp/CAR/Paru/AnaUdll
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
MlO1nO19 09.17:.27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
1S0104EE02R0027
Kota
:
IUADIUN
Proses Masuk
RSCC
Jaminan
I
01
Nama Dokter
POPPY S- ROEBIONO
Tanggal
Kode Yan/ltem Layanan
PRIBADI
atv
Tarif
Subtotal
Diskon
Umum 1't{1-2019
710025
0
1-2019
710032
0m't-2019
710032
07-01-2019
7'loo32
09-01-20'19
710032
09{1-2019
710032
10-01-2019
710032
10-01-2019
710032
'10-01-2019
710032
11-01-2019
710032
11-01-2019
710032
09{1-2019 't'1{1-20't9
710040
22 18 DISP NEEoLE No. '18 DISP NEEDLE NO. 18 DISP NEEDLE No. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO. 18 DISP NEEDLE NO, 18 DISP NEEDLE NO. '18 DISP NEEDLE NO. 18 IV CATHETER NO
DISP. NEEDLE NO.
710'153
1141-2019
710153
I
710207
INFUSION SET WITH BURETTE
0$.01-2019 09-01-2019
7'10065
710071
09-01-2019
710081
09-01-2019
710087
11-0't-2019
7'10087
114't-20'19
vooaT
11-01-2019
710091
0to1-2019
710092
07-0'1-2019
710092
09{1-20'19
710092
0t01-20'i
09-01-2019
'1o.444
10.444
0
Do55
544
5.,14O
0
D05S
10
544
5.440
0
DO55
1
544
544
0
DoS5
3
544
oo55
1
544
544
0
Doss
3
544
1.632
0
Do55
2
544
1_088
0
,i
u4
544
0
1
544
544
0
D055
09-01-2019
11-01-2019
09.01-2019
1
10
Do55
JMS SOLADM SET/ INFUS SET JMS THREE WAY BERBUNTUT TEGADERM 1622 FLOW CONTROLLER CIAVE CLAVE CONNECTOR CLAVE CONNECTOR CLAVE CONNECTOR TEGADERM 1624 NITRIL GLOVE NITRIL GLOVE NITRIL GLOVE MEDITAPE 1/2inch JMS( 300 ) MEDITAPE 1/2inchJMS( 300 )
710040
DO55
SOLADM SET/ INFUS SET
D05S
1
4
u4
0
Do55
1
9.213
9.213
0
DO55
1
9.213
9.213
0
Do55
1
22.243
22.243
0
DO55
1
5.989
5.989
0
DO55
1
88.625
88.625
0
DO55
1
21.313
21.313
0
DO55
2
21.313
42.626
0
Do55
1
21.313
oO55
I
2.803
2-803
0
Do55
100
843
84.300
0
D055
'100
843
84.300
0
DO55
-100
843
-84.300
0
D055
1
9.166
9.166
D055
1
9.166
9.166
0
DO55
I
75.625
75.625
0
710207
INFUSIoN SET WITH BURETTE lF-BR-o oo55
1
7s.625
75.625
0
710299
LINEAR BAG
1
59.606
59.606
0
710341
NASAL CANULLA PEDIATRIC ( 0206 )
1
8.250
8.250
0
lF-BR{
wlTHoUT SOLIDIFYING
A Do55
B
Do55
1
4.500
4.500
0
D055
6
1.423
8.538
0
0055
10
1.423
14.230
0 0
OXYGEN SUPPLYTUBING ( 0401 ) B-Mt Do55
05-01-2019
710473
DISP SYRINGE 3
06-01-2019
710473
07-01-20'19
710473
09-01-2019
710473
10-01-2019
710473
10-01-2019
710/.73
11-01-2019
710473
05-01-2019
710/41
06-01-2019
710481
07-01-2019
710441
0741-2019
0
0
710436
0941-20'19
0
710441
cc DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC DISP SYRINGE 3 CC ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB
DO55
8
1.423
'11.384
DO55
6
1.423
8.538
0
DO55
5
1.423
7.'115
0
1.423
8.538
0
3
1.423
4.269
0
D055
20
250
5.000
0
DO55
10
250
2.500
0
DO55
10
250
2.500
0
250
250
0
D055 D055
DO55
1
Page J
ps Janruno t Pembuluh Da6h Ha6D6n Kir. -^ I .r'itirli, s nam"n Kav87, iripl, r.k.n.8arai i1420 --,/ i;lo. rb21t s5a1r11 (Hunt,ns) ru. tozlr 55a4130
ftlrned
ol8
by LAPORAN RA / Dato , 1201/2019 09-32 58
RINCIAN BIAYA SEMENTARA Pengirim
:
drsp/CAR/Paru/Anaudll
MUHAMMAD ANDRE AJ' TN.
Masuk
:
O4lO1l2O19 09:17.27
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
:'190't04EE02R0027
Kota
:
MADIUN
Proses Masuk
:
RSCC
Jaminan
:01
Nama Dokter
:
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltem Layanan
No MR
:
132305
Nama Pasien
:
Alamat
PRIBADI
Tarif
atv
Subtotal
Diskon
Umum 0941-2019
71c/,8',1
09{'r -2019
nMal
1G01-2019
71(N81
10-01-2019
71M41
10-01-2019 ,1-01-20',|9
710481
\-r1
-01 -20'l
I
06-01-2019 06-01-2019
710481
ALKOHOLSWAB ALKOHOLSWAA ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB ALKOHOLSWAB
DO55
1
250
250
0
DO55
8
250
2-000
0
DO55
6
250
1.500
0
OO55
1
250
2fi
0
DO55
10
250
2.500
0
D055
8
250
2-000
0
0055
4
250
1.000
0
'1',t0521
TRG.SENSOSURGE STERIL GLOVE NO Dos5
4
29.976
0
710521
TRO-SENSOSURGE STERIL GLOVE NO D055
10
7AU 7AU
74.940
0
7.494
'14.988
0
7't0481
09{1-2019
710521
TRO-SENSoSURGE STERIL GLOVE No Dos5
044't-2019
711007
SURGICAL CLIPPER
090't -2019
711147
1'1-01-2019
7',t1147
11-01-2019
711158
09-0'1-201S
711393
BLADE MANOMETER LINE MANOMETERLINE NEBULIZER PAED SALTER '1'173
D055
1
76.863
76.863
0
D055
5
25.438
127.190
0
25.438
50.876
0
D055 D055
1
24.990
24.990
0
THREE WAY STOPCOCK 4624 BD BIAS, DO55
4
11.688
46.752
0
1
'11.688
11.688
0
4
4.496
17.9U
0
44.960
0
I
7't'1393
THREE WAY STOPCOCK 4624 BD BIAS, D055
0641-2019
711691
SUCTION CATH No.14
'1'1-01 -201
HOSPITECH HOSPITECH
D055
09i't -2019
71't69't
SUCTION CATH NO.14
DO55
10
4.496
0s-0't -2019
711698
CONECTING TUBE NO.7 EUROPLAST/ I D055
2
26.250
52.500
0
04{1-2019
71172',1
ONESCRUB 4 % lOO
'1
27
04-o't -2019
712242
Ecc
I
712242
ECG TAB ELECTRODE
11-01-2019
ML
_5N
27.500
0
D055
10
1.733
'17-330
0
DO55
10
'I
_733
17.330
0
712243
ECG ELECTRoDE NEoNATE PRE WIRE D055
1
36.094
36.0S4
0
-201 9
714089
SWIFEL ELBOW 15 F
DO55
1
59.606
59.606
0
09-01 -2019
714091
D055
1
97.350
97.350
0
05-01-2019
716079
Do55
1
43.312.500
43.312.500
0
2
57.475
'114.950
0
OO55
2
57.475
114.950
0
57.475
-57.475
0
1.760
7.UO
0
'11
-01 -20'l
DO55
24 RT 24
TAB ELECTRODE RT
09{1-2019
730007
3512 RESERVOTR BAG I L28'10 CoNTEGRA MEDTRONIC 20 MM GELOFUSIN INF 5OO ML GELOFUSIN INF 5OO ML GELOFUSIN INF 5OO ML
DO55
-1
0101-2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG / oo55
4
054'l-2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG / 9655
..-,$0't
0
1-2019
730007
05-o'l -2019
730007
OO55
'l
-760
14_080
0
5.280
0
064 r -20'19
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG
/
D055
3
1.760
06{'l -2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG
/ 0055
10
1.760
17.600
0
08-01-2019
730051
ADRENALIN (EPINEPHRINE) INJ 1 MG
i
-7
1-760
-12.320
0
1
54.994
54.994
0 0
09-0'l-201s
730065
0641-2019
730066
10-01-2019
730066
11-01-2019
730066
05-01-20'19
730067
0t01-20'19
730067
0G01-2019
730067
tNVtcLoT tNJ 25.000 lu / 5
ML LASIX INJ 20 MG/2 ML LASIX INJ 20 MGi2 ML MORPHINE INJ 10 MG MORPHINE INJ 10 MG 10 MG MORPHINE LASIX INJ 20 MG/2
'NJ
ML
Do55 D055 DOSS
10
15.196
'r51.960
DO55
-5
15-196
-75.980
0 0
OO5S
1
15-196
15.196
DO55
2
42.563
85-'126
0
OOSS
2
42.563
85.126
0
42.563
'127.689
0
DO55
J
.)
RS. Janlunq E P.mbuluh Da6h HaED.n Kit Jl. L.ten S. Pa@an Kav.87, Sllpr, J.k+rrr Ba.rt 11420 (021) 668,Itl {Hunung) Fir:(o21) 56a!130
page 4 of 8 Print€d by IAPORAN RS / Dal6 : lZOlZO.tg 09:32:5a
ftrp:
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
dr. Sp/CAR/Paru/Anak/dll
Nama Pasien
:
MUHAMMAD ANORE AJ, TN.
Masuk
MlO1l2O19 09.17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
190104EE02R0027
Kotia
:
MADIUN
Proses Masuk
RSCC
Jaminan
:01
Nama Dokter
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltein Layanan
PRIBADI
otv
Tarif
Subtotal
Diskon
Umum 0s01-2019
7s0073
OTSU KCL 7.46% 25 ML
D055
2
4.029
1041-2019
730073
D055
2
oto1-2019
730078
OTSU KCL 7,46% 25 ML OTSU NACL 0.9 % . 25 ML
D055
6
0s01-2019
730078
OTSU NACL 0,9 % - 25 ML
D055
6
06-01-2019
730078
OTSU NACL 0,9
' 25 ML
D055
06-0'l-201s
730078
6
730078
D055
6
09-01-2019
730078
D055
6
'10-01-2019
730078
OTSU NACL 0,9 % - 25 ML OTSU NACL 0,9 % . 25 ML OTSU NACL 0,9 % . 25 ML OTSU NACL 0,9 % . 25 ML
D055
07-01-2019
D055
3
't0-01-2019
730078
OTSU NACL 0,9 % - 25 ML
D055
2
6.s31
13.062
0
11-O1-2019 '11-01-2019
730078
OTSU NACL 0,9
' 25 ML
D055
4
6.531
26.124
0
730078
OTSU NACL 0,9 % - 25 ML
D055
3
6.53't
'19.593
0
05{'t -2019
730079
OTSU MGSO4 20 25 ML
D055
2
4.'160
8.320
0
06-01-20'19
73008'1
OTSU WFI 25 ML
D055
3.575
17.87s
0
0901-2019
73008'r
OTSU WFI 25 ML
09-0'1-201I
730081
OTSU WFI 25 ML
O/O
O/O
8.058
0
4.O29
8.058
0
6.531
39.186
0
6.53't
39.186
0
6.53'1
32.655
0
6-531
39.'t 86
0
6.531
39.'186
0
6.531
39.186
0
19-593
0
D055
1
3.575
3.575
0
D055
b
3.57s
21.450
0
3.575
0
1041-2019
730081
OTSU WFI 25 ML
D055
1
3.575
11-01-20'19
730081
OTSU WFI 25 ML
3-575
3.575
0
I
D055
1
73008'l
OTSU WFI 25 ML
D055
3.575
10.725
0
'11-01-2019
730'163
VENTOLIN NEBULES 2,5 MG
D055
2
5.000
'10.000
0
0tu1-20'19
730252
CALCIUM GLUCONAS INJ
10 ML
D055
5
12.939
64.695
0
0641-2019
730252
CALCIUM GLUCONAS INJ 10% 10 ML
D055
3
12.939
38.817
0
I
730252
CALCIUM GLUCONAS INJ 10% 10 ML
D055
.,|
'12.939
-'12.939
0
,|
11-01-20't
1
'1
-0'l -201
1OON
0m1-2019
730373
OTSU NACL 0,9 % PIGGY BACK
1OO
ML D055
10.725
10.725
0
1041-2019
730373
OTSU NACL 0,9 % PIGGY BACK
1OO
ML D055
1
10.725
10.725
0
0
1-2019
730469
SEDACUM INJ 15 MG / 3 ML
D055
2
u.375
64.750
0
08{1-2019
730469
SEDACUM INJ 15 MG / 3 ML
D055
-2
34.375
s8.750
0
04-01-2019
730512
OXTERCIO INJ 750 MG
D055
12
58.988
707.856
0
05{1-20'19
7305'12
OXTERCID INJ 750 MG
D055
4
58.988
235.952
0
o7-01-2019
730s12
OXTERCID INJ 750 MG
D055
2
58.988
117.976
0
05-0't-20'1s
730525
ECRON INJ 10 MG
D055
2
133.646
267.292
0
05-01-20't9
730529
ECRON INJ
MG
D055
4
133.646
534.584
0
05-01-201S
730529
ECRON INJ 10 MG
D055
2
133.646
267.292
0
08-01-2019
730529
ECRON INJ 10 MG
D055
-1
'133.646
-133.646
0
D055
3
257.125
771.375
0
257.125
514.250
0
1O
05-01-2019
730589
INOVAD INJ 10 MG/10 ML
05-01-2019
730589
INOVAD INJ 10 MG/10 ML
D055
2
06-01-2019
730s89
INOVAD INJ
1O
MG/10 ML
D055
3
257.125
771.375
0
06-01-2019
730589
INOVAD INJ
1O
MG/10 ML
D055
3
257.'t25
771.375
0
07-o't-2019
730589
INOVAD INJ '10 MG/10 ML
D055
257.125
514.250
0
08-01-2019
730589
INOVAD INJ
07-o t-2019
730604
1O
MG/l0 ML
PROSOGAN INJ 30 MG
D055
o055
4
257 _125
2
'1'15.050
-1.028.500
0
230.'100
0
Jantunq E Pembuluh Oa6h HaED.n Krra /^ RS.L.tien S. Parman Xav,87, Stipi,Jalana Ean|t lr42o _/ Jl Icrp: "-/ {021) 563tlll {Huhtrng) Fd: (02,t,5634,t30
pag6 5 of 8 Printad by LAPORAN RS / Dat6 : 1Z0il2019 O9:32:s8
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
;
dr. Sp/CAFYPaT/Anak/dll
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
i
MlO1l2O19 09,'17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
;
'190 t
Kota
:
MADIUN
Proses Masuk
:
RSCC
Jaminan
:
01
Nama Dokter
:
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltem Latranan
PRIBADI
otv
04EE02R0027
Tarit
Subtotal
Oiskon
Umum 09-01-2019
7306M
10{1-2019
730604
11{1-2019
730604
06-01-2019
730759
0m1-2019
730759
'41-2019
730759
l\rc MG PROSOGAN INJ 30 MG PROSoGAN INJ 30
PROSoGAN INJ 30
ML oNDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2 ML ONDANCETRON INJ 4 MG / 2
D055
'l
115.050
115.050
0
OOSS
1
115.050
115.050
0
ooss
1
115.050
115.050
0
D05b
2
1.338
2.676
0
D055
2
1.338
2.676
0
Do55
2
,'.338
2.676
0
1.338
-2.676
0
1
2.431
2.431
0
1
't2.155
12.155
0
12.155
08{1-2019
730759
05-01-2019
730915
07{1-2019
730950
ASAM TRANEKSAMAT INJ 500 MG / 5 M OO55 WIDA D5 - 1/4 NS D055
0901-2019
730950
DO5S
1
12.155
0
06-01-2019
730951
DO55
1
8.013
8.013
0
DO55
1
8.013
8.013
0
10-01-2019
730951
1141-2019
730951
05{'1-2019
730962
0
1-2019
730962
06{1-2019
730962
08-01-2019
730962
0441-2019
730972
06-01-2019
730975
08{1-2019
730975
0M1-20't9
730992
0G01-2019
730992
-01-20'19
730992
08-01-2019
730992
09-01-2019
73'1000
11-O1-2019
731000
11-01-20't9
731000
05-01-20'19
731042
06{1-2019
731125
07-o1-2019
731125
09{1-2019
732399
0s01-20't9
732429
1G0't -2019
733112
1141-20'19
733't't2
10-01-2019
733485
11-O't-2019
733485
06-01-2019
73/-216
09-01-2019
73r'.216
10-01-2019
73r'216
11-O',t-2019
734216
I
734249
09-0'1 -20'1
iTM WIDA D5 - 1/4 NS /TM
ML OTSU NACL 0,9 7o INF 5O0 ML oTSU NACL 0,9 Yo INF 500 ML OTSU NACL 0,9 % INF 500
DO55
Do55
ML D055 PARACETAMOL INFUS 1 cR / 100 ML DO55 PARACETAMOL INFUS '1 GR / '100 ML OO5S PARACETAMOL INFUS I GR/ 100 ML DOsE MINOSEP GARGLE 0,2% 60 ML DO55 KEToROLAC INJ 30 MG/ML D055 KETOROLAC INJ 30 MG/ML DO55 RANITIDIN INJ 50 MG / 2 ML DO55 RANITIDIN INJ 50 MG / 2 I\,IL Do55 RANITIDIN INJ 50 MG / 2 ML D055 RANITIDIN INJ 50 MG / 2 ML D055 CEFTRIAXoNE INJ 1GR Do55 CEFTRIAXONE INJ 1 GR DO55 CEFTRIAXoNE INJ 1 GR D055 PHYToMENADION INJ 10 MG / ML Do55 CEFUROXIM INJ 750 MG DO55 CEFUROXIM INJ 750 MG DO55 AQUAPACK 340 HUDSON DO55 CUSTODIOL INF 1000 ML DO5S LASIX TAB 40 MG Do55 LASIX TAB 40 MG DO55 THROMBO ASPILETS TAB 80 MG DO55 THROMBOASPILETS TAB 80 MG DO55 SPIRONOLACTONE TAB 25 MG DO55 SPIRONOLACTONE TAB 25 MG DO55 SPIRONOLACTONE TAB 25 MG DOSs SPIRONOLACTONE TAB 25 MG DOS5 FUROSEMIDE TAB 40 MG Do55 PARACEIAMOL INFUS 1 GR / '100
1
8.013
8.0'i3
0
2
'14.513
29.026
0
3
14.513
43.539
0
3
'14.513
43.539
0
2
14.513
29.026
0
1
20.900
20.900
0
1
1.306
1.306
0
-1
1.306
-1.30,6
0
2
'1.444
2.888
0
2
't.444
2.888
0
2
1.444
2.888
0
1.444
-2.888
0
2
5-604
11.204
0
2
5.604
11.208
0
2
5.604
11.208
0
1
5.363
5.363
0
4
37.469
149.876
0
4
37-469
-'t49.876
0
56.513
56.513
0
,1
0
4
2.102.760
2
5.355
10.7'10
'1.040
0
6
5.355
32.130
0
8.4
,|
556
556
0
3
556
't.668
0
2
244
488
0
1
244
244
0
1
244
244
0
3
244
732
0
2
96
't92
0
,...\ / --.2
RS. Jantunq & Pemburuh Danh H.ED.n Xrt S. Parman K.v.07, sirpi. Jatarr. B.,dr tr42o Llp:(021) 553'll'tt 0ruoring, Far lo2i) 5€a4130
Jr L.licn
page 6 of 8 Print€d by LAPoRAN RS / Dare : 1201/2018 0s:32:5a
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
d.
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
0d,IO1DO'19 09,17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO. TAMAN MADIUN
No. Kunjungan
1901 04EE02R0027
Kota
:
MADIUN
Proses Masuk
RSCC
Jaminan
:01
Nama Doliter
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltem Layanan
PRIBADI
otv
Sp/CARYPaT/Analddll
Tarif
Subtotal
Diskon
Umum 09{1-2019
7U345 73/345
0{1-201s
07-o',-2019
CAPTOPRIL TAB 12,5 MG
D055
'100
900
0
D055
100
300
0
734345
CAPTOPRIL TAB 12,5 MG CAPTOPRIL TAB ,I2,5 MG
D055
3
100
300
0
11-01-2019
73{345
CAPTOPRIL TAB 12,5 MG
10
'100
I
D055
1.000
0
734727
FLEET ENEMA
D055
,|
44.688
44.688
0
04-01-2019
900091
REHAB FASE
1
o050
1
110.000
110.000
0
1
't
04-01 -20't
07-01-2019
900091
REHAB FASE
D050
1
1'10.000
110.000
0
08{1-2019
9000s8
FISIOTERAPI
D050
1
80.000
80.000
0
09-01-2019
900098
FISIOTERAPI
D050
,|
80.000
80.000
0
't0.01-2019
900098
FISIOTERAPI
D050
1
80.000
80.000
0
05{1-2019
900r/0
05{1-20'19
901021
Pemasangan dan Tata Laksana Ventilato. s061 WES Rasteily Prosedure + Contegta D099
05-01-2019
751149
06-01-2019
751149
CoMPLETE BLOOD CoUNT(CBC:Hb,Ht, D054 CoMPLETE BLOOD COUNT(CBC:Hb,Ht, D054
1 1
8.500.000 203_4sO.000
8.500.000
0
203.450.000
0
1
85-000
85.000
0
1
85.000
85.000
0 0
07-01-2019
751149
COMPLETE BLoOD COUNT(CBC:Hb,HI,
D054
1
85.000
85.000
0&01-2019
751150
CBC + Difi.Count (Hitung Jenis)
D054
1
100.000
100.000
0
05{1-2019
751205
PT
o054
1
60.000
60.000
0
06{1-2019
751205
PT
D054
1
60.000
60.000
0
07-01-2019
751205
PT
D054
1
60-000
60.000
0
10{1-2019
751205
PT
D054
,|
60-000
60.000
0
11-01-2019
751205
PT
D054
1
60.000
60.000
0 0
05-01-201S
751206
APTT
D054
1
65-000
65.000
06-01-2019
751206
APTT
D054
1
65.000
65_000
0
07{1-2019
751206
APTT
0054
1
65.000
65.000
0
09{1-2019
751206
APTT
D054
1
65.000
65.000
0
09-01-20't 9
751206
APTT
D054
,|
65.000
65.000
0
1G01-2019
75'1206
APTT
0054
I
65.000
65.000
0
11-01-2019
751206
APTT
0054
1
65.000
65.000
0
05-0't-2019
751207
TT
D054
,|
60.000
60.000
0
07-01-2019
751207
TT
D054
I
60.000
60.000
0
0$01-2019
751204
FIBRINOGEN
D054
I
100_000
100.000
0
06{'t-2019
75120A
FIBRINOGEN
D054
1
100.000
100.000
0
07-01-20',t9
751204
FIBRINOGEN
D054
1
100.000
't
00.000
0
0t0'1-2019
752102
ALBUMIN
DO
1
30.000
30.000
0
05-01-2019
752401
UREUM
D054
,|
25.000
25.000
0
05-01-2019
752402
CREATININ
D054
1
25.000
25.000
0
05-01-2019
752404
OSMOLALITAS SERUM
D054
1
50.000
50.000
0
10-01-2019
752621
GD Sowaktu POCT
D054
1
25.000
25.000
0
10-01-2019
752621
GD Sewaktu POCT
D054
1
25.000
25.000
0
'1041-2019
752621
GD Setlraktu POCT
D054
1
25.000
25.000
0
10{1-201S
752621
GD S6waktu POCT
,|
25.000
25.000
0
D054
,,-\ -,/ /
RS. Jantunq A Pembutuh OaEh HaEban Kira Jl. Le{en s. Pamah lGvl/, sttpt, JEt rt BaEr 1t4,au Ierp: {o2i) 5631111 thu.rlnqt Fu:1021t 56a.t130
pagc 7 of 8 Printed by LAPORAN RS / Dare : 12y01/20.19 09:32:58
RINCIAN BIAYA SEMENTARA
NoMR Nama
Pasien
:
132305
Pengi.im
dr Sp/CAR/ParuiAnaUdll
:
MUHAMMADANDRE AJ, TN.
Masuk
O4lO1t2O19 09:17.27
No.Kunjungan
190104EE02R0027
Proses Masuk
RSCC
Nama Dokter
POPPY S. ROEBIONO
Alamat : PERUM BUMI MAS U3 01/04 MOJOREJO, Kota : MADIUN Jaminan : 01 PRIBAD| Tanggal
TAMAN MADTUN
Kode Yan/ltem Layanan
otv
Tarif
Subtotal
Diskon
Umum 05-01-2019
752701
ANALISA GAS DARAH
D054
145.000
145.000
0
05-01-2019
752701
ANALISA GAS DARAH
D054
1
145.000
145.000
0
0s01-2019
752701
ANALISA GAS DARAH
D054
1
145.000
145.000
0
06-01-2019
752701
ANALISA GAS DARAH
D054
1
145.000
'145.000
0
06-01-2019
752701
ANALISA GAS DARAH
D054
1
'145.000
145-000
0
i-01-2019
752701
ANALISA GAS DARAH
D0g
1
145.000
'145.000
0
752701
ANALISA GAS DARAH
D054
1
'145.000
145-000
0
07-o1-20 t9
752701
ANALISA GAS DARAH
D054
,1
145.000
145.000
0
08-0't-2019
752701
ANALISA GAS DARAH
D054
1
'!45.000
145.000
0
08-01-2019
752704
CALSIUM TOTAL
D054
1
35.000
s5.000
0
'nt-o1-2019
,|
10-01-20'19
752704
CALSIUM TOTAL
D054
1
35.000
35.000
0
11-0'1-2019
752704
CALSIUM TOTAL
D054
1
35.000
3s.000
0
08-01-2019
752707
MAGNESIUM
D054
1
35.000
35.000
0
10-01-2019
752707
MAGNESIUIVI
D054
1
35.000
35.000
0
'11-01-2019
752707
MAGNESIUM
D054
1
35.000
35.000
0
05-01-2019
752718
Analisa Gas Darah
D0g
1
145.000
145.000
0
0H1-2019
752718
Analisa Gas Darah
D054
1
145.000
145.000
0
06-01-2019
752718
Analisa Gas Darah
D054
1
145.000
145_000
0
08-0'1-2019
752720
09,01-2019
752720
10-01-2019
752720
11-01-2019
752720
Cl Cl Na, K, Cl Na, K, Cl
01-2019
753602
CRP
E-01-2019
753629
PROCALCITONIN
09-01-2019
756101
URINE RUTIN
04-01-2019
758'130
Biaya pengolahan darah
04-01-2019
758130
Biaya pengolahan darah
04-01-2019
754134
PMI/ PRC
05-0'1-2019
758135
PA/llI/
FFP
D054
05-01-20'19
758136
PMI/AHF
04-01-2019
758138
PMI/TC
04-01-2019
758'138
PMI/TC
D054
05-01-20'19
900043
THORAX PAJAP
Na, K,
(Natrium, Kalium, Chlorida)
D054
1
75.000
75.000
0
Na, K,
(Natrium, Kalium, Chlorida)
D054
'l
75.000
75.000
0
(Natrium, Kalium, Chlorida)
D054
1
75.000
75.000
0
(Natrium, Kalium, Chlorida)
D054
1
75.000
75.000
0
D054
1
145.000
'145.000
0
D054
I
455.000
455-000
0
D054
'|
30.000
30.000
0
D054
3
70.000
210.000
0
D054
't5
70-000
1.050.000
0
D054
3
535.000
1.605.000
0
535.000
2.675.000
0
06-01-2019
900043
THORAX PA./AP
07-01-2019
900043
THORAX PA/AP
D054
4
535_000
2.140-000
0
D054
3
535.000
1.605.000
0
535.000
'1.605.000
0
1
160,000
'160.000
0
,|
160.000
160.000
0
'160.000
160.000
0
907S
1
,,-t / --,/
RS, J.nlu.o A P.mbuluh O.r.h H.ED.. Kit Jl. LctiGn S. Pirrnan Xav87, Stilr. J.klria AlEt 1la2o lerp: lo2l, s6atlt,t tHunfng, fu: tt 2t, !ir,r413r,
I
Pago 8 of Priflted by LAPOMN RS / Date : 1ZO1l2019 09:32:50
RINCIAN BIAYA SEMENTARA No MR
:
132305
Pengirim
dr. Sp/CAFYPatu/Analddll
Nama Pasien
:
MUHAMMAD ANDRE AJ, TN.
Masuk
O4lO1l2O19 09:17:27
Alamat
:
PERUM BUMI MAS U3 01/04 MOJOREJO, TAMAN MADIUN
No.Kunjungan
'190104EE02R0027
Kota
:
MADIUN
Proses Masuk
RSCC
Jaminan
:
O,I
Nama Dokter
POPPY S. ROEBIONO
Tanggal
Kode Yan/ltom Lat6nan
PRIBADI
atv
Tarif
Subtotal
Diskon
[Jmum
08{1-2019 12-01-2019
900043
THORAX PfuAP
1
Bill Umum
160.000
160.000
302.742.975
Bill Non Askes
0
Bill Tslpon
0
Jumlah Tarif
302.742.975
Diskon
0
t,rl fd
*
Total Tagihan
Deposit
302.742.975
{
Sisa Tagihan
CATATAN
0
PERINCIAN INI TIDAK BERLAKU SEBAGAI TANDA BUKTI PEMBAYARAN
&'t"'
302.742.975
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100.000
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100.000
60.000
0
60.000
J0.000
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25.000
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85.000
0
85.000
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u0.000
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110.000
165.000
0
165.000
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115.000
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SDR MUHAMMAD ANDRE AYESHA JOFIDAN
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