1 2 3 4 5 6
A. OBAT ESSENSIAL
1 AMOKSISILLIN SERBUK INJEKSI 1000 MG KTK 10 VIAL 75,000 150 11,250,000
2 AMBROKSOL TABLET KTK 10 X 10 TABLET 20,000 500 10,000,000
3 ANTI HEMOROID SUPP SUPP 11,000 1,000 11,000,000
4 ANTI SCABIES KRIM 10 GRAM TUB 10 GRAM 24,000 1,000 24,000,000
5 ANTI INFEKSI KRIM TUBE 15 G 14,000 1,000 14,000,000
6 AQUA PRO INJEKSI SERIL BEBAS PIROGEN KTK 10 VIAL @ 20 ML 55,000 500 27,500,000
7 ASAM ASKORBAT ( VIT. C ) TABLET 250 MG BTL 250 TABLET 32,000 400 12,800,000
8 ASIKLOVIR KRIM 5 % TUBE 5 g 3,150 20,000 63,000,000
9 BETAHISTIN MESILAT TABLET 6 MG KTK 3 X 10 TABLET 27,720 1,000 27,720,000
10 DEXTRAN 70 % BTL 500 ML 35,526 100 3,552,600
11 DIAZEPAM RECTAL TUBE 36,300 200 7,260,000
12 FITOMENADION INJ. 10 MG / ML- 1 ML KTK 30 AMPUL @ 1ML 52,200 2,060 107,532,000
13 GENTAMYCIN SALEP KULIT 0,1 % KTK 10 TUBE @ 5 g 18,370 500 9,185,000
14 GENTIAN VIOLET LARUTAN 1 % BTL 10 ML 1,320 5,000 6,600,000
15 GLISERIL GUAIAKOLAT TABLET 100 MG btl 1000 27,900 800 22,320,000
16 HYOSCINE-N-BUTILBROMIDA 10 MG KTK 10 X 10 TABLET 30,000 400 12,000,000
17 KALSIUM LAKTAT TABLET 500 MG BTL 1000 TABLET 52,000 300 15,600,000
18 KOTRIMOKZASOL DOEN ( PEDIATRIK ) KTK 10 X 10 TABLET 7,590 500 3,795,000
19 KLORAMPHENICOL INJ EKSI KTK 10 VIAL 120,000 50 6,000,000
20 KLORAMFENIKOL TETES TELINGA 3 % BTL 5 ML 1,200 5,000 6,000,000
HARGA KEMASAN KUANTUM JUMLAH HARGA
No. NAMA OBAT SATUAN KEMASAN
(Rp) KEMASAN ( RP )
1 2 3 4 5 6
21 KLORFENIRAMIN MALEAT / CTM TABLET 4 MG BTL 1000 TABLET 24,000 510 12,240,000
22 MAGNESIUM SULFAT / IV 40 % - 25 ML KTK 10 VIAL 60,500 75 4,537,500
23 MAGNESIUM SULFAT / IV 20 % - 25 ML KTK 10 VIAL 60,500 75 4,537,500
24 MELOKSIKAM TABLET 15 MG KTK 5 X 10 TABLET 59,950 500 29,975,000
25 METIL ERGOMETRIN MALEAT INJEKSI 0,200 - 1 ML KTK 10 AMP 49,500 1,000 49,500,000
26 METOCLOPRAMID INJ KTK 6 AMP @ 2 ML 30,000 350 10,500,000
27 OKSITETRASIKLIN HCL SALEP KULIT 3 % TUBE 5 g 1,675 3,000 5,025,000
28 OKSITETRASIKLIN HCL INJ IM 50 MG/ML- 10 ML KTK 10 VIAL 31,000 100 3,100,000
29 OKSITOSIN INJ 10 IU/ML - 1 ML KTK 10 AMP 68,750 2,800 192,500,000
30 PIRACETAM 400 MG KTK 10 X 10 TABLET 45,100 30 1,353,000
31 PIRACETAM INJEKSI 1 GRAM/5 ML KTK 10 AMPUL 55,000 20 1,100,000
32 PIRIDOKSIN tablet 10 mg ( HCl ) btl 1000 tab 17,000 150 2,550,000
33 PROPILTIOURASIL 100 MG BTL 100 TABLET 29,957 50 1,497,850
34 SIMETIDIN 200 MG KTK 10 X 10 TABLET 11,490 3,000 34,470,000
35 SULFASETAMID NARIUM TETES MATA 15 % KTK 24 BTL @ 5 ML 82,686 100 8,268,600
36 TIAMIN HCL / VIT. B1 INJEKSI 1.000 MCG / ML - 1 ML KTK 30 AMP@1 ML 23,000 200 4,600,000
37 TIAMIN HCL MONONITRAT / VIT. B1 TABLET 50 MG BTL 1000 TAB 37,800 1,000 37,800,000
JUMLAH A 804,669,050
B OBAT GIGI
38 ETIL KLORIDA SEMPROT AEROSOL 100 ML / VIAL 105,000 1,000 105,000,000
39 SEMEN SENG PHOSPHAT SET/ BTL 93,400 70 6,538,000
40 SPON GELATIN BIJI 13,000 1,000 13,000,000
41 GLASS LONOMER CEMENT SET / BTL 395,000 100 39,500,000
42 TUMPATAN SEMENTARA SET / BTL 129,000 100 12,900,000
43 TRIKRESOLFORMALIN / TKF CAIRAN BTL 10 ML 90,900 70 6,363,000
JUMLAH B 183,301,000
HARGA KEMASAN KUANTUM JUMLAH HARGA
No. NAMA OBAT SATUAN KEMASAN
(Rp) KEMASAN ( RP )
1 2 3 4 5 6
C BAHAN KIMIA
44 AQUADES STERIL BTL 1000 ML 16,000 1,500 24,000,000
45 DEVELOPER GALON 1,221,000 6 7,326,000
46 ETAKRIDIN LARUTAN 0,1 % BTL 300 ML 1,800 1,000 1,800,000
47 ETANOL 96 % BTL 1000 ML 60,000 50 3,000,000
48 FIXER GALON 753,500 6 4,521,000
49 KALIUM PERMANGANAT SERBUK POT 5 GRAM 3,000 150 450,000
50 LARUTAN DESINFEKTAN 250 ML BOTOL 250 ML 7,500 2,000 15,000,000
51 METANOL BTL 100 ML 34,100 20 682,000
52 PERHIDROL ( H2O2) 3 % BTL 100 ML 3,170 250 792,500
53 FOOD SECURITY KIT PAKET 88,000,000 1 88,000,000
JUMLAH C 145,571,500
D BAHAN MEDIS PAKAI HABIS
54 BIST MESS KTK 100 BUAH 77,000 200 15,400,000
55 KAPAS PEMBALUT / ABSORBEN 250 GRAM BKS 7,500 2,000 15,000,000
56 KASA KOMPRES 40/40 STERIL BKS 1,390 20,000 27,800,000
57 PH INDIKATOR PAK 181,500 66 11,979,000
58 SARUNG TANGAN KEBIDANAN PASANG 19,800 20,600 407,880,000
59 MASKER OKSIGEN BUAH 14,850 100 1,485,000
60 NASAL KANULA DEWASA BUAH 18,700 200 3,740,000
61 NASAL KANULA ANAK BUAH 18,700 200 3,740,000
62 TES HIV 50 TES/KIT 2,500,000 35 87,500,000
63 TES HAMIL URINE /HCG TEST TEST 2,500 1,750 4,375,000
64 URINE BAG STERIL PCS 3,636 500 1,818,000
65 PLESTER ROLL 7,000 2,500 17,500,000
66 YELLOW TIP 1000 PCS/KANTONG 55,000 10 550,000
HARGA KEMASAN KUANTUM JUMLAH HARGA
No. NAMA OBAT SATUAN KEMASAN
(Rp) KEMASAN ( RP )
1 2 3 4 5 6
67 BLUE TIP 500 PCS/KANTONG 66,000 10 660,000
68 WHITE TIP 1000 PCS/KANTONG 55,000 10 550,000
69 BLOOD LANCET KOTAK 110,000 200 22,000,000
70 DISPOSIBLE TEST STRIP GLUKOSA BTL 25 TEST 137,500 180 24,750,000
71 DISPOSIBLE TEST STRIP CHOLESTEROL BTL 10 TEST 220,000 180 39,600,000
72 DISPOSIBLE TEST STRIP URIC ACID BTL 25 TEST 154,000 180 27,720,000
73 DISPOSIBLE TEST STRIP HB BTL 25 TEST 412,500 40 16,500,000
74 X RAY FILM FUJI KOTAK 100 PCS 3,494,700 6 20,968,200
75 X RAY FILM FUJI KOTAK 100 PCS 2,197,800 6 13,186,800
76 X RAY FILM FUJI KOTAK 100 PCS 3,795,000 6 22,770,000
77 KASET WITH SCREEN GREEN PAKET 6,031,300 5 30,156,500
78 JARUM JAHIT SAC ISI 12 27,000 240 6,480,000
JUMLAH D 824,108,500
E PERBEKALAN KESEHATAN
79 BOX SLIDE KOTAK 66,000 200 13,200,000
80 OBYEK GLASS BOX ISI 72 16,500 500 8,250,000
81 COVER GLASS 24 X 24 MM BOX ISI 100 16,500 100 1,650,000
82 POT SPUTUM POT 1,060 20,000 21,200,000
83 UNDERPAD KTK 10 BIJI 75,900 4,000 303,600,000
84 MEDICINE PACKET & EQUIPMENT PAKET 9,405,000 4 37,620,000
JUMLAH E 385,520,000
JUMLAH TOTAL ( A+B+C+D + E ) 2,343,170,050
PEMBULATAN 2,343,170,000
1 2 3 4 5 6
Harga sudah termasuk PPN 10 %
SHODIKIN,SKM
NIP. 19631203 198703 1 009
444,950
22
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PEMBUAT KOMITMEN
KET
KUANTUM
No. NAMA OBAT SATUAN KEMASAN SPESIFIKASI
KEMASAN
1 2 3 4 5
A. OBAT ESSENSIAL
1 AMOKSISILLIN SERBUK INJEKSI 1000 MG KTK 10 VIAL Obat Generik Berlogo, CPOB 150
6 AQUA PRO INJEKSI SERIL BEBAS PIROGEN KTK 10 VIAL @ 20 ML CPOB 500
7 ASAM ASKORBAT ( VIT. C ) TABLET 250 MG BTL 250 TABLET Obat Generik Berlogo, CPOB 400
8 ASIKLOVIR KRIM 5 % TUBE 5 g Obat Generik Berlogo, CPOB 20,000
9 BETAHISTIN MESILAT TABLET 6 MG KTK 3 X 10 TABLET Obat Generik Berlogo, CPOB 1,000
10 DEXTRAN 70 % BTL 500 ML CPOB 100
11 DIAZEPAM RECTAL TUBE Branded Name ( Komposisi Di azepam 5 mg/ 2,5 ml dalam tube ), CPOB 200
12 FITOMENADION INJ. 10 MG / ML- 1 ML KTK 30 AMPUL @ 1ML Obat Generik Berlogo, CPOB 2,060
13 GENTAMYCIN SALEP KULIT 0,1 % KTK 10 TUBE @ 5 g Obat Generik Berlogo, CPOB 500
14 GENTIAN VIOLET LARUTAN 1 % BTL 10 ML Obat Generik , CPOB 5,000
15 GLISERIL GUAIAKOLAT TABLET 100 MG btl 1000 Obat Generik , CPOB 800
19 KLORAMPHENICOL INJ EKSI KTK 10 VIAL Branded Name ( Komposisi Kloramphenicol Na suksinat) 1 g /vial, CPOB 50
20 KLORAMFENIKOL TETES TELINGA 3 % BTL 5 ML Obat Generik Berlogo, CPOB 5,000
21 KLORFENIRAMIN MALEAT / CTM TABLET 4 MG BTL 1000 TABLET Obat Generik Berlogo, CPOB 510
KUANTUM
No. NAMA OBAT SATUAN KEMASAN SPESIFIKASI
KEMASAN
1 2 3 4 5
22 MAGNESIUM SULFAT / IV 40 % - 25 ML KTK 10 VIAL Obat Generik Berlogo, CPOB 75
23 MAGNESIUM SULFAT / IV 20 % - 25 ML KTK 10 VIAL Obat Generik Berlogo, CPOB 75
29 OKSITOSIN INJ 10 IU/ML - 1 ML KTK 10 AMP Brended name ( Komposisi Oktitosin Sintetik 10 IU/ ml), CPOB 2,800
30 PIRACETAM 400 MG KTK 10 X 10 TABLET Obat Generik , CPOB 30
31 PIRACETAM INJEKSI 1 GRAM/5 ML KTK 10 AMPUL Obat Generik , CPOB 20
32 PIRIDOKSIN tablet 10 mg ( HCl ) btl 1000 tab Obat Generik, CPOB 150
33 PROPILTIOURASIL 100 MG BTL 100 TABLET Obat Generik , CPOB 50
38 ETIL KLORIDA SEMPROT AEROSOL 100 ML / VIAL Komposisi Etil Klorida 1,000
39 SEMEN SENG PHOSPHAT SET/ BTL Komposisi : Semen Seng Phosfat serbuk dan cairan 70
40 SPON GELATIN BIJI Komposisi ; Spons Gelatin 1,000
41 GLASS LONOMER CEMENT SET / BTL Komposisi; Glass Lonomer cement 100
42 TUMPATAN SEMENTARA SET / BTL Komposisi : Bahan tambal sementara (caviton) 100
1 2 3 4 5
48 FIXER GALON Fixer Automatic Fuji 20 lt 6
49 KALIUM PERMANGANAT SERBUK POT 5 GRAM Komposisi Kalium Permanganat Serbuk Pot 5 gram , CPOB 150
54 BIST MESS KTK 100 BUAH Sterilisasi menggunakan gamma radiasi 200
55 KAPAS PEMBALUT / ABSORBEN 250 GRAM BKS Berat 250 gram 2,000
56 KASA KOMPRES 40/40 STERIL BKS Ukuran 40 cm x 40 cm 20,000
57 PH INDIKATOR PAK PH Indikator 66
58 SARUNG TANGAN KEBIDANAN PASANG Bahan natural, rubber latex, pro powder dan hypo alergenik 20,600
64 URINE BAG STERIL PCS Volume minimal 2000 ml, pembuangan T type ,steril 500
65 PLESTER ROLL Leukoplast 3 x 5 cm 2,500
66 YELLOW TIP 1000 PCS/KANTONG YELLOW TIP ISI 1000 10
67 BLUE TIP 500 PCS/KANTONG BLUE TIP ISI 500 10
68 WHITE TIP 1000 PCS/KANTONG WHITE TIP ISI 1000 10
72 DISPOSIBLE TEST STRIP URIC ACID BTL 25 TEST NESCO TEST STRIP 180
73 DISPOSIBLE TEST STRIP HB BTL 25 TEST AKON TEST STRIP 40
1 2 3 4 5
75 X RAY FILM FUJI KOTAK 100 PCS Green Ukuran 24 x 30 cm 6
76 X RAY FILM FUJI KOTAK 100 PCS Green Ukuran 35 x 35 cm 6
81 COVER GLASS 24 X 24 MM BOX ISI 100 COVER GLASS 24 x 24 mm' 100 100
82 POT SPUTUM POT Diameter Wadah bagian bawah 6 cm Diameter Penutup 5 cm 20,000
Tinggi 5 cm, wadah transparant
83 UNDERPAD KTK 10 BIJI Ukuran 60 cm x 90 cm 4,000
84 MEDICINE PACKET & EQUIPMENT PAKET Medicine Packet SI-20-S , Sealing Equipment-S, Pulverizer-S, Plastic Spoon-S 4
Keterangan :
1 Nomor Registrasi yang masih berlaku yang dikeluarkan oleh pihak yang berwenang ( dikecualikan obat gigi, bahan kimia, bahan medis ............., ............. 2014
pakai habis dan perbekalan kesehatan ) PT/CV/Fa......................
2 Sertifikat CPOB atau sejenis yang masih berlaku ( dikecualikan obat gigi, bahan kimia, bahan medis pakai habis dan perbekalan kesehatan)
Nama Jelas
SHODIKIN,SKM Direktur
KET
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Bulan I Bulan II
No Uraian Pekerjaan Minggu Ke Minggu Ke
1 2 3 4 1 2 3 4
1 Persiapan
2 Pengadaan Barang
3 Pengiriman Barang dan Uji Fungsi
4 Penerimaan/Pemeriksaan
SEHATAN NON KATALOG
( DAK. 2.398.210.000 )
Bulan III
Minggu Ke Ket
1 2 3 4
Nama Jelas
Direktur