TAGIHAN KLAIM RAWAT JALAN PASIEN PKMS DI PELAYANAN DASAR

PUSKESMAS : NUSUKAN BULAN : Maret

KOTA : SURAKARTA TAHUN : 2015
PROPINSI : JAWA TENGAH

Kepada Yth :
Kepala Dinas Kesehatan Kota Surakarta
di tempat

Bersama ini kami ajukan rincian Klaim Pelayanan Kesehatan Umum Rawat Jalan Peserta PKMS :
Pelayanan Kesehatan& Besaran Tarif sesuai Perd
Jenis Jenis Tahun/B
No Tgl Nama No. Peserta L/P Kode Diagnosis
Pasien PKMS ulan Retribusi BP Umum Gigi

1 '23/03 ADELIA DWI '05.03.04.089608 PKMS GOLD P '13 / 11 Dermatitis Kontak Alergi 7,500 - -
Influensa bukan karena
2 '23/03 ALIKA KIRANA 05.02.03.228340 PKMS GOLD P '3 / 8 Virus 7,500 - -
3 '23/03 ANANINGTYAS TITI P '01.01.05.137985 PKMS SILVER P '10 / Conjunctivities 7,500 - -
Influensa bukan karena
4 '23/03 ANASTASYA '04.10.05.175247 PKMS SILVER P '5 / 5 Virus 7,500 - -
5 '23/03 ANIK SUTAMPI '04.10.02.103243 PKMS SILVER P '32 / 11 Gastritis 7,500 - -
6 '23/03 ARWANTO SLAMET R '05.02.01.230200 PKMS SILVER L '54 / 2 Gastritis 7,500 - -
Influensa bukan karena
7 '23/03 ASHIFA FAEIZA '05.02.06.276538 PKMS SILVER P '0 / 9 Virus 7,500 - -
8 '23/03 DEWI AYU LESTARI '05.02.04.030163 PKMS SILVER P '7 / 9 Diare infeksi/ + antibiotika 7,500 - -
9 '23/03 DEWI R '05.02.01.236274 PKMS SILVER P '57 / 4 Vertigo 7,500 - -
10 '23/03 DWI NURYANTI '05.01.02.152663 PKMS SILVER P '47 / 11 Gastritis 7,500 - -
Pelayanan Kontrasespsi /
11 '23/03 EKA ANDRIYANI '05.02.02.240145 PKMS GOLD P '33 / KB 7,500 - -
12 '23/03 EKA NOVI ARUM '05.02.03.000553 PKMS GOLD P '17 / 3 Obs. Febris 7,500 - -
Kontrol kesehatan dengan
13 '23/03 FARHAN '05.02.03.246272 PKMS SILVER L '3 / 8 keluhan 7,500 - -
Influensa bukan karena
14 '23/03 FEBRIAN ARDI '04.10.04.213375 PKMS SILVER L '4 / 1 Virus 7,500 - -
15 '23/03 H.SUMINTO '05.01.01.283787 PKMS SILVER L '61 / 10 Diare infeksi/ + antibiotika 7,500 - -
16 '23/03 HANI JIHAN '05.01.05.283097 PKMS SILVER P '1 / 1 Gastritis 7,500 - -
17 '23/03 HAURA '05.02.04.268120 PKMS SILVER P '1 / 4 Influensa karena Virus 7,500 - -
 Influensa bukan karena
18 '23/03 JUFRI G '05.02.04.270103 PKMS SILVER L '9 / 10 Virus 7,500 - -
19 '23/03 KEMAT 05.02.01.243163 PKMS GOLD L '55 / 7 Cough / batuk 7,500 - -
20 '23/03 KEVIN PUTRA WIJAYA 05.02.03.283578 PKMS SILVER L '/4 Obs. Febris 7,500 - -
Influensa bukan karena
21 '23/03 KIRANA MISWA H '05.01.04.282007 PKMS SILVER P '0 / 3 Virus 7,500 - -
Influensa bukan karena
22 '23/03 M REVAN '05.02.06.264768 PKMS SILVER L '1 / 7 Virus 7,500 - -
23 '23/03 MARYATI '05.01.01.040535 PKMS GOLD P '64 / 2 Penyakit Jantung Iskemik 7,500 - -
24 '23/03 MAYMUNA RACHMAD '05.01.01.097879 PKMS SILVER L '32 / 10 Pharingitis 7,500 - -
Pelayanan Kontrasespsi /
25 '23/03 NUR MARYATI '05.01.02.112261 PKMS SILVER P '43 / 3 KB 7,500 - -
26 '23/03 PURWADI '05.02.01.030149 PKMS SILVER L '42 / Ginggivitis 7,500 - -
27 '23/03 RAFAEL '05.01.03.251456 PKMS SILVER L '4 / 4 Cough / batuk 7,500 - -
28 '23/03 REVALIA '05.02.03.273389 PKMS SILVER P '7 / 6 Supernumerary teeth 7,500 - 7,500
29 '23/03 RIDWAN '05.01.05.260983 PKMS SILVER L '4 / 2 Influensa bukan karena Virus 7,500 - -
Influensa bukan karena
30 '23/03 SARTINI '05.01.03.156522 PKMS SILVER P '53 / 9 Virus 7,500 - -
31 '23/03 SRI SUMARNI '05.02.02.057342 PKMS SILVER P '51 / 10 Hipertensi Essensial 7,500 - -
32 '23/03 SUPRIYADI '05.02.01.182748 PKMS SILVER L '59 / 11 Stroke 7,500 - -
33 '23/03 SUWARNO '04.10.01.103242 PKMS SILVER L '40 / 7 Infeksi non spesifik 7,500 - -
34 '23/03 TOTO S. '05.02.01.026958 PKMS SILVER L '47 / Bronchitis 7,500 - -
35 '23/03 TRIYADI '05.01.01.112896 PKMS SILVER L '40 / 3 Hipotensi 7,500 - -
Influensa bukan karena
36 '23/03 TUKIYEM '05.02.02.022045 PKMS SILVER P '68 / 11 Virus 7,500 - -
Influensa bukan karena
37 '23/03 YOAN OKTA WIJAYA '05.02.03.245954 PKMS GOLD L '3 / 5 Virus 7,500 - -
38 '23/03 YOHANES ARDRA C '05.02.05.267180 PKMS SILVER L '10 / 11 Pharingitis 7,500 - -
39 '23/03 BALQIS '05.02,04.235593 PKMS GOLD P '5 / 2 Influensa karena Virus 7,500 - -
Influensa bukan karena
40 '23/03 DADEO MANUNGGAL '05.02.03.277091 PKMS SILVER L '0 / 11 Virus 7,500 - -
41 '23/03 ERLINDA 05.02.02.220476 PKMS GOLD P '26 / 6 Influensa karena Virus 7,500 - -
42 '23/03 HASANAH 05.02.01.280698 PKMS SILVER P '51 / 2 Myalgia (keju kemeng) 7,500 - -
Influensa bukan karena
43 '23/03 IKSAN '05.02,03.235592 PKMS GOLD L '8 / 6 Virus 7,500 - -
Kontrol kesehatan dengan
44 '23/03 SALSABILA AVIA '05.02.04.282594 PKMS SILVER P '0 / 1 keluhan 7,500 - -
45 '23/03 SANTI ASIH,NY 05.02.02.235590 PKMS GOLD P '28 / 11 Influensa karena Virus 7,500 - -
 Pelayanan Kontrasespsi /
46 '23/03 SRI RAHAYU 05.02.02.275746 PKMS SILVER P '24 / 2 KB 7,500 - -
47 '23/03 SUIMAH,NY '05.13.02.087318 PKMS GOLD P '63 / 3 Hipertensi Essensial 7,500 - -
48 '23/03 SUMADI 05.02.01.067336 PKMS SILVER L '49 / 8 Gastritis 7,500 - -
49 '23/03 YUNA CITRA '05.02.03,274345 PKMS SILVER P '2 / 9 Influensa karena Virus 7,500 - -
Pelayanan Kontrasespsi /
50 '23/03 APRILIA ROS '01.07.02.265088 PKMS SILVER P '29 / 11 KB 7,500 - -
51 '23/03 DEVAN 01.07.03.229375 PKMS SILVER L '3 / 10 Influensa karena Virus 7,500 - -
Influensa bukan karena
52 '23/03 FELISIA T '05.02.04.278145 PKMS SILVER P '2 / 9 Virus 7,500 - -
53 '23/03 KUKUH WIJAYA '05.02.01.143556 PKMS SILVER L '36 / 7 Influensa karena Virus 7,500 - -
54 '23/03 SRI SABARSIH '05.02.02.074294 PKMS SILVER P '52 / 1 Influensa karena Virus 7,500 - -
55 '23/03 SUKINAH 05.02.01.009705 PKMS GOLD P '71 / 10 Hipertensi Essensial 7,500 - -
56 '23/03 SUKINAH 05.02.02.071411 PKMS SILVER P '74 / 2 Artritis yang lain 7,500 - -
57 '23/03 SULIYEM '05.02.02.074300 PKMS GOLD P '56 / 11 Hipertensi Essensial 7,500 - -
Influensa bukan karena
58 '23/03 WELLANKE A.C '05.02.05.231358 PKMS SILVER P '3 / 2 Virus 7,500 - -
59 '24/03 AGUNG SANTOSO '05.02.01.226019 PKMS GOLD L '31 / 4 Embedded teeth 7,500 - -
Influensa bukan karena
60 '24/03 ALIP VIA '05.02.03.279816 PKMS SILVER L '1 / 10 Virus 7,500 - -
61 '24/03 ANGELIN '05.02.04.158589 PKMS GOLD P '5 / 11 Supernumerary teeth 7,500 - 7,500
Influensa bukan karena
62 '24/03 ANISA MUR F '05.02.03.264981 PKMS SILVER P '2 / 7 Virus 7,500 - -
63 '24/03 ASHIFA FAEIZA '05.02.06.276538 PKMS SILVER P '/9 Obs. Febris 7,500 - -
Influensa bukan karena
64 '24/03 CARISA 05.02.03.281166 PKMS SILVER P '1 / 4 Virus 7,500 - -
Influensa bukan karena
65 '24/03 DAVIN '05.01.05.242349 PKMS SILVER L '3 / 10 Virus 7,500 - -
66 '24/03 DEA PUTRI '05.02.03.011204 PKMS SILVER P '11 / Pulpitis 7,500 - -
67 '24/03 DELVI ANUNG '05.02.02.006184 PKMS GOLD P '59 / Hipertensi Essensial 7,500 - -
68 '24/03 ELI EVARIANTI '05.02.02.248204 PKMS SILVER P '30 / 3 Pulpitis 7,500 - -
69 '24/03 ENDANG HERMININGSIH '05.02.01.251139 PKMS GOLD P '60 / Obs. Febris 7,500 - -
70 '24/03 F ASISI SURONO 05.02.01.238414 PKMS SILVER P '66 / 6 Dermatophytosis / jamur 7,500 - -
71 '24/03 KARTO SEMITO '05.02.01.245287 PKMS GOLD L '87 / 8 Hipertensi Essensial 7,500 - -
Pengawasan kehamilan
72 '24/03 LISDARLINA '05.02.02.271928 PKMS SILVER P '32 / 1 normal 7,500 - -
Influensa bukan karena
73 '24/03 MUQUFA '04.02.03.240369 PKMS SILVER L '18 / 1 Virus 7,500 - -
74 '24/03 NAJWA NAPISAH '05.03.03.000058 PKMS SILVER P '34 / 10 Pulpitis 7,500 - -
 Influensa bukan karena
75 '24/03 NAYLA '05.02.03.271436 PKMS SILVER P '1 / 4 Virus 7,500 - -
76 '24/03 PARIYEM '05.01.02.113283 PKMS SILVER P '50 / Myalgia (keju kemeng) 7,500 - -
Influensa bukan karena
77 '24/03 SITI SUSWATUN '05.02.02.273051 PKMS SILVER P '40 / 10 Virus 7,500 - -
78 '24/03 SRI WAHYUNI '05.02.02.274859 PKMS SILVER P '55 / 9 Cephalgia non spesifik 7,500 - -
Pengawasan kehamilan
79 '24/03 SUDARTI '05.01.02.066227 PKMS SILVER P '33 / 9 Risti 7,500 - -
80 '24/03 SUSI WATI 05.02.01.274639 PKMS SILVER P '50 / 2 Influensa karena Virus 7,500 - -
81 '24/03 SUZANA '05.02.02.057616 PKMS SILVER P '41 / 9 Mens tdk teratur 7,500 - -
82 '24/03 TUMINI '05.01.02.051785 PKMS SILVER P '58 / Influensa karena Virus 7,500 - -
83 '24/03 ENI YULIARTI '05.02.02.065388 PKMS SILVER P '42 / 2 Karies gigi 7,500 - -
84 '24/03 ESTER SUPRIYANA 05.02.02.149214 PKMS SILVER P '32 / 11 Gastritis 7,500 - -
85 '24/03 MANAH RAHAYU '05.02.04.279144 PKMS SILVER P '0 / 6 Diare non infeksi 7,500 - -
Influensa bukan karena
86 '24/03 NOVI HAPSARI 05.02.03.230930 PKMS GOLD L '3 / 5 Virus 7,500 - -
87 '24/03 SARJIMAN '05.02.01.128785 PKMS SILVER L '46 / 1 Pharingitis 7,500 - -
88 '24/03 SUKARTI 05.02.02.006189 PKMS SILVER P '51 / 0 Hipertensi Essensial 7,500 - -
89 '24/03 ALWI '04.09.01.278020 PKMS SILVER L '73 / 2 Dermatitis Kontak Alergi 7,500 - -
Influensa bukan karena
90 '24/03 CANDRA BUDI SAPUTRA '05.02.34.057135 PKMS SILVER L '7 / 10 Virus 7,500 - -
91 '24/03 CLARISTA RAHMADANI '05.02.03.212923 PKMS SILVER P '7 / 6 Influensa karena Virus 7,500 - -
Influensa bukan karena
92 '24/03 DIMAS BAGUS ANGGORO '05.02.03.223037 PKMS SILVER L '20 / 7 Virus 7,500 - -
Influensa bukan karena
93 '24/03 DINAR ANGGRAENI '05.02.04.228548 PKMS SILVER P '3 / 3 Virus 7,500 - -
Pengawasan kehamilan
94 '24/03 NITA SUNARNI '05.01.02.177787 PKMS SILVER P '35 / 6 Risti 7,500 - -
95 '24/03 RETNO RANTI S,NY '05.02.34.057132 PKMS SILVER P '29 / 9 Influensa karena Virus 7,500 - -
96 '24/03 SAMIONO '05.02.01.091746 PKMS SILVER L '56 / 2 Conjunctivities 7,500 - -
97 '24/03 SEFANYA '05.02.03.282241 PKMS SILVER P '0 / 6 Gastritis 7,500 - -
98 '24/03 SRI PURWANINGSIH '05 02 02 014090 PKMS SILVER P '52 / 10 Diare non infeksi 7,500 - -
99 '24/03 SURIP,NY 05.02.34.206739 PKMS SILVER P '67 / 3 Hipertensi Essensial 7,500 - -
100 '24/03 TARMINI '04.09.02.133120 PKMS SILVER P '63 / 1 Angina Pektoris 7,500 - -
Hordeolum & Chalazion
101 '25/03 ALIFA 05.02.03.161958 PKMS SILVER P '5 / 11 (timbil) 7,500 - -
Influensa bukan karena
102 '25/03 ALMERIA 05.02.05.277314 PKMS SILVER P '3 / 7 Virus 7,500 - -
 Pengawasan kehamilan
103 '25/03 ANITA SARI '05.02.05.031586 PKMS SILVER P '25 / 1 normal 7,500 - -
104 '25/03 ATIK SARTIKAH '05.02.01.257138 PKMS GOLD P '65 / 8 Myalgia (keju kemeng) 7,500 - -
Influensa bukan karena
105 '25/03 ANGELINA YASMINE 05.01.04.273607 PKMS SILVER P 2/1 Virus 7,500
106 '25/03 CINTA KHALIDA 05.02.04.227931 PKMS SILVER P '3 / 4 Dermatitis Kontak Alergi 7,500 - -
Pengawasan kehamilan
107 '25/03 DWI SAPUTRI '05.02.02.272153 PKMS SILVER P '28 / 2 normal 7,500 - -
Pengawasan kehamilan
108 '25/03 FITRIA '05.01.02.283005 PKMS SILVER P '25 / 10 normal 7,500 - -
109 '25/03 JENI FRANSISKA '05.02.05.107784 PKMS SILVER P '22 / 2 Dermatophytosis / jamur 7,500 - -
110 '25/03 JOHAN ADITYA '05.01.03.224604 PKMS SILVER L '6 / 8 Pharingitis 7,500 - -
Pengawasan kehamilan
111 '25/03 LISDARLINA '05.02.02.271928 PKMS SILVER P '32 / 1 normal 7,500 - -
Influensa bukan karena
112 '25/03 M ARDA H '05.01.03.279239 PKMS SILVER P '/7 Virus 7,500 - -
113 '25/03 OKI SUSILOWATI '05.02.05.198097 PKMS SILVER P '19 / 4 Embedded teeth 7,500 - -
Influensa bukan karena
114 '25/03 PANJI '05.02.03.283845 PKMS SILVER L ' / 10 Virus 7,500 - -
115 '25/03 RENOVAL ZANETI '05.02.04.282770 PKMS SILVER L '/4 Dermatitis Kontak Alergi 7,500 - -
116 '25/03 SADIYEM 05.01.31.177687 PKMS SILVER P '68 / 2 Dermatitis Kontak Alergi 7,500 - -
117 '25/03 SRI NINGSIH R '05.02.02.009384 PKMS SILVER P '44 / 10 Abdominal pain 7,500 - -
118 '25/03 SRI SUMARNI '05.02.02.057342 PKMS SILVER P '51 / 10 Myalgia (keju kemeng) 7,500 - -
Gangguan Refraksi &
119 '25/03 SRI WAHYUNI '05.02.02.274859 PKMS SILVER P '55 / 9 Akomodasi 7,500 - -
Influensa bukan karena
120 '25/03 SUDIYATI '05.01.02.054085 PKMS SILVER P '61 / 3 Virus 7,500 - -
121 '25/03 SUMARDI '05.02.01.253961 PKMS GOLD L '49 / 9 Ginggivitis 7,500 - -
122 '25/03 SUTRISNO 05.02.01.057617 PKMS SILVER L '49 / 7 Obs. Febris 7,500 - -
123 '25/03 TARMINI 05.02.02.020886 PKMS SILVER P '59 / 10 NIDDM (tdk tgt insulin) 7,500 - -
124 '25/03 WIDYASTUTI 05.01.01.052114 PKMS GOLD P '60 / Myalgia (keju kemeng) 7,500 - -
Pengawasan kehamilan
125 '25/03 WINARTI,NY '05.02.02.196367 PKMS SILVER P '31 / 9 normal 7,500 - -
126 '25/03 ANAS NASUTION 05.02.34.150437 PKMS GOLD P '8 / 2 Influensa karena Virus 7,500 - -
Pengawasan kehamilan
127 '25/03 ETIK '05.02.02.271490 PKMS GOLD P '34 / 8 normal 7,500 - -
Pengawasan kehamilan
128 '25/03 JANAR WIDANINGRUM 05.02.03.246724 PKMS GOLD P '22 / 1 normal 7,500 - -
129 '25/03 MARJUKI '05.02.01.283839 PKMS SILVER L '46 / 5 Gastritis 7,500 - -
130 '25/03 PAINAH 05.02.02.062058 PKMS SILVER P '49 / 6 Asma 7,500 - -
131 '25/03 PARMI '05.02.02.009417 PKMS GOLD P '56 / 2 Gastritis 7,500 - -
132 '25/03 RIMA PURWANTI 05.02.01.239032 PKMS SILVER P '38 / 9 Myalgia (keju kemeng) 7,500 - -
133 '25/03 ABNER 04.11.03.261462 PKMS SILVER L '2 / 4 Dermatophytosis / jamur 7,500 - -
134 '25/03 SUPARNO '05.02.01.021325 PKMS SILVER L '56 / 10 Asma 7,500 - -
135 '25/03 TITIN SUMARNI,NY 04.11.02.006859 PKMS SILVER P '35 / 4 Dermatitis Kontak Alergi 7,500 - -
136 '26/03 AGUS SARI '05.02.01.129150 PKMS SILVER L '45 / 6 Myalgia (keju kemeng) 7,500 - -
Influensa bukan karena
137 '26/03 ALAM SAMUDRA 05.01.03.097497 PKMS SILVER L '12 / 2 Virus 7,500 - -
Gangguan Refraksi &
138 '26/03 BAMBANG MARSONO '05.01.03.033906 PKMS SILVER L '40 / 8 Akomodasi 7,500 - -
Influensa bukan karena
139 '26/03 DIPANGGA ATMAJA 05.02.04.213617 PKMS GOLD L '8 / Virus 7,500 - -
140 '26/03 EDY SURYONO '05.02.01.192780 PKMS SILVER L '57 / 11 Otitis Media 7,500 - -
141 '26/03 ESTIRA I '02.02.02.199578 PKMS SILVER P '32 / 6 Gastritis 7,500 - -
Influensa bukan karena
142 '26/03 FATA ALFIN 05.01.04.097502 PKMS SILVER L '10 / 11 Virus 7,500 - -
Influensa bukan karena
143 '26/03 YEHESKIEL '05.02.04.222792 PKMS SILVER L '4 / 3 Virus 7,500 - -
144 '26/03 M RAJAH AJI GUSTI F '05.01.03.174117 PKMS SILVER L '6 / 9 Dermatitis Kontak Alergi 7,500 - -
145 '26/03 MARGARETA IKA W '05.01.03.107681 PKMS GOLD P '13 / Herpes simplek 7,500 - -
Influensa bukan karena
146 '26/03 MUH ASIP '05.01.03.260170 PKMS SILVER L '3 / 2 Virus 7,500 - -
Influensa bukan karena
147 '26/03 MUH.SAFAAT AZRO 05.01.04.240710 PKMS SILVER L '2 / 7 Virus 7,500 - -
148 '26/03 PRATIWI 05.01.05.219986 PKMS SILVER P '10 / 8 Asma 7,500 - -
149 '26/03 PURWANTO '05.02.01.283888 PKMS SILVER L '42 / 5 Infeksi non spesifik 7,500 15,000 -
Influensa bukan karena
150 '26/03 RAHYAN Z '05.02.05.129154 PKMS SILVER L '8 / 8 Virus 7,500 - -
151 '26/03 RISTIWATI JUMAIDAH 05.01.02.174116 PKMS SILVER P '46 / 2 Myalgia (keju kemeng) 7,500 - -
Influensa bukan karena
152 '26/03 RIZA PERDANA '05.02.03.231773 PKMS SILVER P '13 / 5 Virus 7,500 - -
153 '26/03 SAMIKEM '05.01.31.103923 PKMS SILVER P '67 / 2 Artritis yang lain 7,500 - -
Influensa bukan karena
154 '26/03 SETIA NURCAHYANI '05.01.02.020642 PKMS SILVER P '43 / 5 Virus 7,500 - -
Influensa bukan karena
155 '26/03 SITI SUSWATUN '05.02.02.273051 PKMS SILVER P '40 / 10 Virus 7,500 - -
156 '26/03 SRI EKOWATI '05.02.03.026803 PKMS SILVER P '32 / 9 Polineuropati (kesemutan) 7,500 - -
157 '26/03 SRININGSIH '05.01.02.107679 PKMS GOLD P '45 / 7 Myalgia (keju kemeng) 7,500 - -
158 '26/03 SUPRIYADI '05.02.01.182748 PKMS SILVER L '60 / Hipertensi Essensial 7,500 - -
159 '26/03 SYAHLAN SUPRAPTO 05.02.01.045321 PKMS SILVER L '67 / 2 Myalgia (keju kemeng) 7,500 - -
160 '26/03 TUGINEM '05.02.31.110779 PKMS SILVER P '76 / 7 Myalgia (keju kemeng) 7,500 - -
Hordeolum & Chalazion
161 '26/03 VANIA '05.02.03.282749 PKMS SILVER P '1 / (timbil) 7,500 - -
162 '26/03 YASINTA FISYA. I 05.01.06.020646 PKMS SILVER P '15 / 9 Dermatitis Kontak Alergi 7,500 - -
Influensa bukan karena
163 '26/03 ZHAFRAN '05.01.05.275747 PKMS SILVER P '1 / Virus 7,500 - -
Influensa bukan karena
164 '26/03 AYYANNA '05.02.05.275824 PKMS SILVER P '1 / 5 Virus 7,500 - -
165 '26/03 DARMI 05.02.01.260373 PKMS GOLD P '48 / 11 Myalgia (keju kemeng) 7,500 - -
166 '26/03 DESVITA 05.02.03.269712 PKMS SILVER P '1 / 3 Influensa karena Virus 7,500 - -
167 '26/03 DWI WALUYO '05,02.01.189245 PKMS SILVER L '37 / 2 Pruritus (gatal) 7,500 - -
168 '26/03 NGATINI '05.02.02.260108 PKMS GOLD P '46 / 11 Dermatitis Kontak Alergi 7,500 - -
Influensa bukan karena
169 '26/03 NGATMINI 05.02.02.017083 PKMS SILVER P '51 / 2 Virus 7,500 - -
Influensa bukan karena
170 '26/03 RINA 05.02.03.062067 PKMS SILVER P '31 / 5 Virus 7,500 - -
171 '26/03 SRI SUTIYANI 05.02.02.054565 PKMS GOLD P '50 / 2 Diare infeksi/ + antibiotika 7,500 - -
172 '26/03 JOYO KARTONO 05.01.01.126260 PKMS GOLD P '81 / 8 Angina Pektoris 7,500 - -
173 '26/03 SIHMADI '05.02.01.071443 PKMS SILVER L '57 / 10 Hipertensi Essensial 7,500 - -
Pengawasan kehamilan
174 '26/03 SLAMET WIJIASTUTI 05.02.02.254390 PKMS GOLD P '38 / 0 Risti 7,500 - -
175 '26/03 SUKINAH,NY 05.02.02.071411 PKMS SILVER P '74 / 2 Luka lecet di pedis 7,500 - -
176 '26/03 SURANTI '05.02.02.157621 PKMS SILVER P '43 / 6 Cough / batuk 7,500 - -
177 '26/03 WARNO 05.02.01.000096 PKMS SILVER L '74 / 9 NIDDM (tdk tgt insulin) 7,500 - -
178 '26/03 WIRYANI '05.02.02.071454 PKMS SILVER P '57 / 1 Myalgia (keju kemeng) 7,500 - -
Pengawasan kehamilan
179 '27/03 ANIK PAMILIH '05.01.02.263235 PKMS SILVER P '27 / 11 Risti 7,500 - -
180 '27/03 BANON LESTARI '05.02.03.236375 PKMS SILVER P '33 / 4 Myalgia (keju kemeng) 7,500 - -
181 '27/03 DEWI R 05.02.01.236374 PKMS SILVER P '57 / 4 Hipertensi Essensial 7,500 - -
182 '27/03 DWI HARTINI '05.02.02.059401 PKMS SILVER P '48 / 10 NIDDM (tdk tgt insulin) 7,500 - -
183 '27/03 ENDANG '05.01.02.206537 PKMS SILVER P '35 / 9 Gastritis 7,500 - -
Influensa bukan karena
184 '27/03 EUNIKE BELVANIA '05.01.05.283954 PKMS SILVER P ' / 10 Virus 7,500 - -
Influensa bukan karena
185 '27/03 FAUZAN F '05.01.05.270219 PKMS GOLD L '1 / 7 Virus 7,500 - -
186 '27/03 GADIS APRILIA '05.01.04.016858 PKMS SILVER P '17 / 11 Gastritis 7,500 - -
Kontrol kesehatan dengan
187 '27/03 HALIMAH PUSPA '05.02.03.111934 PKMS SILVER P '11 / keluhan 7,500 - -
188 '27/03 HARTANTI '05.01.02.236393 PKMS SILVER P '48 / 4 Influensa karena Virus 7,500 - -
Influensa bukan karena
189 '27/03 IFAT A '05.01.04.244335 PKMS GOLD L '2 / 8 Virus 7,500 - -
Influensa bukan karena
190 '27/03 JONY SURAAWAN '05.01.01.281453 PKMS SILVER L '40 / 2 Virus 7,500 - -
191 '27/03 NANANG SANUTRA '05.02.04.026880 PKMS SILVER L '28 / 4 Other anxiety disorders 7,500 - -
192 '27/03 NGATIYEM 05.01.31.174027 PKMS SILVER P '65 / 2 TBC Paru BTA (neg) 7,500 - -
Influensa bukan karena
193 '27/03 NIPUTU D '05.02.03.244072 PKMS SILVER P '2 / 8 Virus 7,500 - -
194 '27/03 RAFLI HANIF 05.01.01.059223 PKMS SILVER L '8 / 2 Luka lecet kepala 7,500 - -
195 '27/03 RARA MUSTIKA '05.02.03.278884 PKMS SILVER P ' / 10 Influensa karena Virus 7,500 - -
196 '27/03 SATRI ARJUN '05.02.05.263088 PKMS SILVER L '1 / 9 Influensa karena Virus 7,500 - -
197 '27/03 SILFISTER BAGUS CONDR '05.02.04.178821 PKMS GOLD L '6 / 5 Supernumerary teeth 7,500 - 7,500
Influensa bukan karena
198 '27/03 SRI SUWITO '05.02.01.224710 PKMS SILVER L '73 / 2 Virus 7,500 - -
199 '27/03 SUPIYAH '05.01.02.060186 PKMS SILVER P '70 / 2 Hipertensi Essensial 7,500 - -
200 '27/03 SUPRIYADI '05.02.01.182748 PKMS SILVER L '60 / Myalgia (keju kemeng) 7,500 - -
Influensa bukan karena
201 '27/03 TABINA WIDYA '05.02.04.111935 PKMS SILVER P '7 / 11 Virus 7,500 - -
202 '27/03 TATIK WINARTI '05.02.01.021491 PKMS SILVER P '52 / 3 Gastritis 7,500 - -
203 '27/03 VENI KURNIA '05.01.02.138920 PKMS SILVER P '36 / 1 Cough / batuk 7,500 - -
Influensa bukan karena
204 '27/03 VERLITA 05.02.03.136757 PKMS SILVER P '7 / 1 Virus 7,500 - -
205 '27/03 WINARNI 05.01.02.016852 PKMS SILVER P '51 / 2 Pharingitis 7,500 - -
Influensa bukan karena
206 '27/03 ALBI LUTFI F '05.02.03.278378 PKMS SILVER L '0 / 10 Virus 7,500 - -
207 '27/03 AURELIA A 05.02.04.271874 PKMS GOLD P '1 / 6 Influensa karena Virus 7,500 - -
Influensa bukan karena
208 '27/03 BAMBANG HARTONO 05.02.01.058724 PKMS SILVER L '57 / 2 Virus 7,500 - -
Influensa bukan karena
209 '27/03 ERLINDA '05.02.02.220476 PKMS GOLD P '26 / 7 Virus 7,500 - -
210 '27/03 MUH ARDANU 05.02.04.241047 PKMS SILVER L '2 / 8 Diare infeksi/ + antibiotika 7,500 - -
Influensa bukan karena
211 '27/03 MUH KEVIN DWI P 05.02.04.240104 PKMS GOLD L '2 / 8 Virus 7,500 - -
Influensa bukan karena
212 '27/03 RIFAN '05.02.05.280042 PKMS SILVER L '0 / 9 Virus 7,500 - -
Influensa bukan karena
213 '27/03 RINO KURNIAWAN 05.02.03.030227 PKMS SILVER L '21 / 2 Virus 7,500 - -
214 '27/03 SAMIYEM 05.02.01.021965 PKMS GOLD P '61 / 7 Hipertensi Essensial 7,500 - -
215 '27/03 AKBAR DWI 05.02.04.191842 PKMS SILVER L '4 / 5 Gastritis 7,500 - -
 Influensa bukan karena
216 '27/03 BUDI PUTRA '05.02.04.143559 PKMS SILVER L '10 / 1 Virus 7,500 - -
217 '27/03 ROSA DIAH '05.02.02.264714 PKMS GOLD P '42 / 0 Dermatophytosis / jamur 7,500 - -
218 '27/03 RINI SARWOSRI,NY 05.01.02.063677 PKMS SILVER P '49 / 9 Dermatitis Kontak Alergi 7,500 - -
Influensa bukan karena
219 '27/03 SITI SULASTRI '05.02.02.265572 PKMS SILVER P '56 / 6 Virus 7,500 - -
Influensa bukan karena
220 '27/03 SUNDARI '05.02.02.143557 PKMS SILVER P '28 / 3 Virus 7,500 - -
Influensa bukan karena
221 '28/03 ALDEVANO R '05.01.05.276470 PKMS SILVER L '2 / 3 Virus 7,500 - -
Pengawasan kehamilan
222 '28/03 ANIK NURYANI '04.02.02.261620 PKMS SILVER P '32 / 1 Risti 7,500 - -
223 '28/03 ATIKAH PUTRI '05.02.03.113018 PKMS SILVER P '7 / Pulpitis 7,500 - 15,000
Influensa bukan karena
224 '28/03 ARIES HERNAWAN '05.02.04.280242 PKMS SILVER L '0 / 5 Virus 7,500 - -
Pengawasan kehamilan
225 '28/03 DEVY PURI '05.02.05.042772 PKMS SILVER P '26 / 4 normal 7,500 - -
226 '28/03 DEWI HAMAYASARI '05.02.02.098736 PKMS SILVER P '43 / 4 Influensa karena Virus 7,500 - -
Pengawasan kehamilan
227 '28/03 ENDANG '05.01.03.155954 PKMS SILVER P '37 / 10 normal 7,500 - -
228 '28/03 FITRIAH DIAN 05.02.03.000896 PKMS SILVER P '33 / 8 Diare non infeksi 7,500 - -
229 '28/03 HARMINI '05.01.02.040099 PKMS SILVER P '60 / 6 Excessive attrition of teeth 7,500 - -
230 '28/03 HARSIH '05.02.02.106844 PKMS SILVER P '36 / 2 Cephalgia non spesifik 7,500 - -
231 '28/03 INDAR SULISTIYANI '05.01.02.155119 PKMS SILVER P '46 / 7 Karies gigi 7,500 - -
232 '28/03 JOSHI '05.02.04.106848 PKMS SILVER L '8 / 8 Fraktur antebrachii 7,500 28,000 -
233 '28/03 MARGARETA IKA W '05.01.03.107681 PKMS GOLD P '13 / Pulpitis 7,500 - 7,500
Influensa bukan karena
234 '28/03 MUH DZAKI P 05.12.03.281383 PKMS SILVER L 0/4 Virus 7,500
235 '28/03 NATASYA ' 05.01.03.167840 PKMS SILVER P '5 / 10 Influensa karena Virus 7,500 - -
236 '28/03 PURWANTO '05.02.01.283888 PKMS SILVER L '42 / 5 Infeksi non spesifik 7,500 15,000 -
Influensa bukan karena
237 '28/03 RAFAEL '05.01.03.251456 PKMS SILVER L '4 / 4 Virus 7,500 - -
238 '28/03 RUMINTO 05.01.01.053727 PKMS SILVER L 57 / 2 Influensa karena Virus 7,500 - -
239 '28/03 RIADI '05.01.01.145258 PKMS SILVER L '45 / 8 Hepatitis B 7,500 - -
Pengawasan kehamilan
240 '28/03 SLAMET WIJIASTUTI '05.02.02.254390 PKMS GOLD P '38 / normal 7,500 - -
241 '28/03 SUDARNO '05.02.01.245039 PKMS GOLD L '69 / 2 Myalgia (keju kemeng) 7,500 - -
242 '28/03 SUMARNI '05.02.02.042758 PKMS SILVER P '59 / 7 Hipertensi Essensial 7,500 - -
Influensa bukan karena
243 '28/03 SUTRISNO '05.02.01.057617 PKMS SILVER L '49 / 7 Virus 7,500 - -
244 '28/03 TRIYADI '05.01.01.112896 PKMS SILVER L '40 / 4 Gastritis 7,500 - -
245 '28/03 TUPON TRI SEPTI H '05.01.01.045292 PKMS GOLD L '49 / 6 Influensa karena Virus 7,500 - -
246 '28/03 ERNA W. 05.02.02.004382 PKMS GOLD P '32 / 5 Myalgia (keju kemeng) 7,500 - -
247 '28/03 FAUSAN '05.03.03.113923 PKMS SILVER L '7 / 7 Dermatitis Kontak Alergi 7,500 - -
248 '28/03 MIA RISKIANDA PUTRI 05.02.04.265890 PKMS SILVER P '1 / 6 Dermatitis Kontak Alergi 7,500 - -
249 '28/03 PUJI ASTUTI '05.03.02.113922 PKMS SILVER P '38 / 5 Myalgia (keju kemeng) 7,500 - -
250 '28/03 SRI RAHAYU 05.02.02.030167 PKMS SILVER P '48 / 6 Gastritis 7,500 - -
251 '28/03 SUROSO 05.02.01.009415 PKMS GOLD L '65 / 2 Gastritis 7,500 - -
252 '28/03 SUWARNI 05.02.02.003029 PKMS SILVER P '47 / 4 NIDDM (tdk tgt insulin) 7,500 - -
253 '28/03 OKTAVIANI 05.02.02.266623 PKMS SILVER P '30 / 5 Herpes Zoster 7,500 - -
Influensa bukan karena
254 '28/03 RAHEL STEFANI 05.02.05.283499 PKMS SILVER P '0 / 7 Virus 7,500 - -
255 '28/03 SUKINAH,NY 05.02.02.071411 PKMS SILVER P '74 / 2 Dermatitis Kontak Alergi 7,500 - -
256 '28/03 KASMIYATI 05.02.02.029086 PKMS GOLD P 54/3 Hipertensi Essensial 7,500
Influensa bukan karena
257 '28/03 MAMIK 05.02.02.187800 PKMS SILVER P '55 / 2 Virus 7,500 - -
258 '28/03 SULASIH,NY 05.02.02.216754 PKMS SILVER P '69 / 3 Hipertensi Essensial 7,500 - -
259 '28/03 SUNARSI 05.02.02.057202 PKMS SILVER P '76 / 4 Hipertensi Essensial 7,500 - -
260 '28/03 WAGIYEM 05.02.01.266182 PKMS SILVER P '62 / 2 Hipertensi Essensial 7,500 - -
261 '30/03 AAT NINGSIH '05.01.02.137923 PKMS SILVER P '35 / 4 TBC Paru BTA (neg) 7,500 - -
262 '30/03 ARWANTO SLAMET R '05.02.01.230200 PKMS SILVER L '54 / 2 Gastritis 7,500 - -
263 '30/03 BAMBANG ARI '05.02.01.019120 PKMS SILVER L '60 / 9 Hipertensi Essensial 7,500 - -
Influensa bukan karena
264 '30/03 BAYU DIRGA 05.02.03.274569 PKMS SILVER L '1 / 7 Virus 7,500 - -
265 '30/03 BIRGITTA KRISYA P '05.02.04.238841 PKMS SILVER P '20 / 11 Pelayanan Kontrasespsi / KB 7,500 - -
Influensa bukan karena
266 '30/03 CARISA 05.02.03.281166 PKMS SILVER P '1 / 5 Virus 7,500 - -
267 '30/03 DEA PUTRI '05.02.03.011204 PKMS GOLD P '11 / Pulpitis 7,500 - -
268 '30/03 EMILIA DEWI '05.02.04.166558 PKMS SILVER P '16 / 2 Myalgia (keju kemeng) 7,500 - -
269 '30/03 EVAN ZIGY 05.02.03.380503 PKMS SILVER L '1 / 1 Obs. Febris 7,500 - -
270 '30/03 FERIANANIGSIH '05.02.04.148184 PKMS SILVER P '20 / 1 Dermatitis Kontak Alergi 7,500 - -
271 '30/03 HERI SARTONO '05.02.01.038263 PKMS SILVER L '52 / 9 Gastritis 7,500 - -
272 '30/03 HOLY 05.01.03.276337 PKMS SILVER P '2 / 4 Dermatitis Kontak Alergi 7,500 - -
Gangguan Refraksi &
273 '30/03 ISTIATI '05.02.02.193680 PKMS SILVER P '33 / 4 Akomodasi 7,500 - -
Kontrol kesehatan dengan
274 '30/03 IZHYCHA 05.02.03.284015 PKMS SILVER L '0 / 0 keluhan 7,500 - -
275 '30/03 KAYLA R '05.02.04.231280 PKMS GOLD P '3 / 3 Dermatitis Kontak Alergi 7,500 - -
 Influensa bukan karena
276 '30/03 M RAJAH AJI GUSTI F '05.01.03.174117 PKMS SILVER L '6 / 9 Virus 7,500 - -
277 '30/03 MARSONO '05.02.01.000762 PKMS SILVER L '65 / 11 Dermatitis Kontak Alergi 7,500 - -
278 '30/03 MULYANI 05.01.02.224861 PKMS SILVER P 46/11 Myalgia (keju kemeng) 7,500
Influensa bukan karena
279 '30/03 NOVIA ANDARI KUSUMA 05.02.03.167947 PKMS SILVER P '27 / 6 Virus 7,500 - -
280 '30/03 PRATIWI 05.01.05.219986 PKMS SILVER P '10 / 8 Obs. Febris 7,500 - -
281 '30/03 PURWANTO '05.02.01.283888 PKMS SILVER L '42 / 5 Infeksi non spesifik 7,500 15,000 -
282 '30/03 RAMADHANA 05.01.03.259450 PKMS SILVER L '3 / 7 Obs. Febris 7,500 - -
283 '30/03 RISTIWATI JUMAIDAH,NY 05.01.02.174116 PKMS SILVER P '46 / 2 Dermatitis Kontak Alergi 7,500 - -
Influensa bukan karena
284 '30/03 RUBIYEM, NY 05.01.01.049151 PKMS SILVER P '73 / 2 Virus 7,500 - -
285 '30/03 SAINI 05.02.02.070399 PKMS SILVER P '77 / 5 Gastritis 7,500 - -
Influensa bukan karena
286 '30/03 SHAQINA MIKAELA 05.02.03.274640 PKMS SILVER P '1 / 4 Virus 7,500 - -
287 '30/03 SRI NINGSIH R '05.02.02.009384 PKMS SILVER P '44 / 10 Abdominal pain 7,500 - -
288 '30/03 SRI WIYANTI 05.02.02.247379 PKMS GOLD P '44 / 11 Obs. Febris 7,500 - -
289 '30/03 SUNARTO '05.02.01.077349 PKMS SILVER L '46 / 6 Hipertensi Essensial 7,500 - -
290 '30/03 SUPRIYADI '05.02.01.182748 PKMS SILVER L '60 / Hipertensi Essensial 7,500 - -
291 '30/03 SYIFA '05.02.04.224284 PKMS SILVER P '7 / 8 Pharingitis 7,500 - -
292 '30/03 WAHYUDI '05.02.01.275398 PKMS SILVER L '0 / 0 Ginggivitis 7,500 - 30,000
293 '30/03 ZEA AVISA '05.02.03.193681 PKMS SILVER P '8 / 10 Dermatitis Kontak Alergi 7,500 - -
294 '30/03 BUDIYARTI 05.02.02.009359 PKMS GOLD P '45 / 6 Gastritis 7,500 - -
Pelayanan Kontrasespsi /
295 '30/03 DENY W '05.02.03.160417 PKMS SILVER P '27 / 3 KB 7,500 - -
Influensa bukan karena
296 '30/03 KANSA TRI SULA 05.02.05.273223 PKMS SILVER P '2 / 1 Virus 7,500 - -
297 '30/03 KERTO SEMITO '05.02.01.245287 PKMS GOLD L '87 / 6 Hipertensi Essensial 7,500 - -
298 '30/03 PUJI ASTUTI '05.03,02.113922 PKMS SILVER P '38 / 5 Cough / batuk 7,500 - -
299 '30/03 RAFI EKA PRATAMA 05.02.03.281037 PKMS SILVER L '4 / 7 Diare infeksi/ + antibiotika 7,500 - -
Pelayanan Kontrasespsi /
300 '30/03 SRI MARTANTI 05.02.02.074638 PKMS SILVER P '44 / 0 KB 7,500 - -
301 '30/03 SUGENG KUSTANTO '05.02.01.213614 PKMS GOLD L '42 / 11 Stomatitis 7,500 - -
302 '30/03 SUTINI 05.02.02.239265 PKMS SILVER P '38 / 0 Gastritis 7,500 - -
303 '30/03 AMAIRA HELENA 05.02.05.264291 PKMS SILVER P '2 / 10 Influensa karena Virus 7,500 - -
304 '30/03 DARTINI '05.02.02.081005 PKMS SILVER P '42 / 9 Dermatophytosis / jamur 7,500 - -
Pelayanan Kontrasespsi /
305 '30/03 ENY BUDI HARIYANTI 05.02.02.276348 PKMS SILVER P '42 / 8 KB 7,500 - -
306 '30/03 GISELA DEVIA 05.02.05.275619 PKMS SILVER P '3 / 8 Diare non infeksi 7,500 - -
Pelayanan Kontrasespsi /
307 '30/03 MAULIANA 05.02.02.020537 PKMS SILVER P '40 / 0 KB 7,500 - -
Influensa bukan karena
308 '30/03 SABIAN 05.02.03.222418 PKMS SILVER L '4 / 9 Virus 7,500 - -
Pelayanan Kontrasespsi /
309 '30/03 SRIYATI '05.02.02.188035 PKMS SILVER P '38 / 11 KB 7,500 - -
310 '30/03 SUKINAH,NY 05.02.02.071411 PKMS SILVER P '74 / 2 Luka lecet di pedis 7,500 - -
311 '30/03 TEGUH YUONO 05.02.01.231301 PKMS SILVER L '39 / 9 Pulpitis 7,500 - -
Pelayanan Kontrasespsi /
312 '30/03 TITIN SUMARNI,NY 04.11.02.006859 PKMS SILVER P '35 / 5 KB 7,500 - -
313 '30/03 WIRYANI 05.02.02.071454 PKMS SILVER P '57 / 1 Hipertensi Essensial 7,500 - -
Influensa bukan karena
314 '31/03 ABIZAR KUSUMA '05.08.05.269164 PKMS SILVER L '1 / 5 Virus 7,500 - -
315 '31/03 AFIKA LARASATI '05.01.04.233317 PKMS SILVER P '3 / 1 Influensa karena Virus 7,500 - -
316 '31/03 AGUS SARI '05.02.01.129150 PKMS SILVER L '45 / 7 Myalgia (keju kemeng) 7,500 - -
317 '31/03 AQILA '05.02.03.282259 PKMS SILVER P '/5 Herpes Zoster 7,500 - -
318 '31/03 DALIMIN '05.02.01.209317 PKMS SILVER L '57 / 9 NIDDM (tdk tgt insulin) 7,500 - -
319 '31/03 DIRGA ODI S 05.02.04.263369 PKMS SILVER L '1 / 9 Influensa karena Virus 7,500 - -
320 '31/03 ENDANG '05.01.02.206537 PKMS SILVER P '35 / 9 Gastritis 7,500 - -
Influensa bukan karena
321 '31/03 ENI SUSILOWATI 05.01.02.180109 PKMS GOLD P '33 / 9 Virus 7,500 - -
322 '31/03 MICHAEL ANGELINA M '05.02.03.235805 PKMS GOLD P '2 / 10 Obs. Febris 7,500 - -
323 '31/03 NGATINEM '05.01.02.054501 PKMS SILVER P '40 / 11 NIDDM (tdk tgt insulin) 7,500 - -
324 '31/03 PURWANTI '05.02.02.115714 PKMS SILVER P '41 / 6 Gastritis 7,500 - -
325 '31/03 RAHYAN Z '05.02.05.129154 PKMS SILVER L '8 / 8 Dermatitis Kontak Alergi 7,500 - -
Kontrol kesehatan dengan
326 '31/03 SARI P '05.02.02.128327 PKMS GOLD P '30 / 0 keluhan 7,500 - -
327 '31/03 SATRI ARJUN '05.02.05.263088 PKMS SILVER L '1 / 9 Diare infeksi/ + antibiotika 7,500 - -
328 '31/03 SODIMUN 05.01.01.049206 PKMS SILVER L '50 / Pulpitis 7,500 - -
329 '31/03 SUDIYATI '05.01.02.054085 PKMS SILVER P '61 / 3 Pulpitis 7,500 - -
330 '31/03 SUGENG PRAYITNO '05.01.01.198815 PKMS GOLD L '59 / 3 Diare non infeksi 7,500 - -
331 '31/03 SUPARTI '05.01.34.283902 PKMS SILVER P '59 / 3 Abdominal pain 7,500 - -
332 '31/03 SURIP '05.02.01.026865 PKMS SILVER P '67 / 8 Stroke 7,500 - -
333 '31/03 WHORO MNP. '05.02.04.033876 PKMS GOLD P '7 / Otitis Media 7,500 - -
Influensa bukan karena
334 '31/03 WILUJENG '05.01.06.232935 PKMS SILVER P '3 / 2 Virus 7,500 - -
335 '31/03 YOHANES IMANUEL '05.02.03.232164 PKMS GOLD L '15 / 11 Cough / batuk 7,500 - -
 Influensa bukan karena
336 '31/03 AFRIZAL 05.02.03.260213 PKMS SILVER L '12 / 2 Virus 7,500 - -
337 '31/03 ERLINDA '05.02.02.220476 PKMS GOLD P '26 / 7 Diare non infeksi 7,500 - -
338 '31/03 ESTER SUPRIYANA 05.02.02.149214 PKMS SILVER P '32 / 11 Myalgia (keju kemeng) 7,500 - -
Influensa bukan karena
339 '31/03 NOVI HAPSARI 05.02.03.230930 PKMS GOLD L '3 / 5 Virus 7,500 - -
340 '31/03 PURWANDARI 05.02.02.039337 PKMS SILVER P '45 / 10 Cough / batuk 7,500 - -
341 '31/03 RIMA PURWANTI 05.02.01.239032 PKMS SILVER P '38 / 10 Myalgia (keju kemeng) 7,500 - -
342 '31/03 SUKARTI 05.02.02.006189 PKMS SILVER P '51 / 0 Hipertensi Essensial 7,500 - -
Influensa bukan karena
343 '31/03 ADITYA MUH ALDIANSYAH 05.02.03.283412 PKMS SILVER L '0 / 11 Virus 7,500 - -
Pengawasan kehamilan
344 '31/03 ANTIKA 05.02.02.267210 PKMS SILVER P '24 / 8 normal 7,500 - -
345 '31/03 APRILIYA '01.07.02.265088 PKMS SILVER P '29 / 11 Conjunctivities 7,500 - -
346 '31/03 ENDANG 05.02.02.009696 PKMS SILVER P '53 / 5 Hipertensi Essensial 7,500 - -
Pengawasan kehamilan
347 '31/03 FUZI SOFIA '05.02.02.218163 PKMS SILVER P '28 / 7 normal 7,500 - -
Influensa bukan karena
348 '31/03 JOSHUA GRACE 05.02.03.170544 PKMS SILVER L '6 / 2 Virus 7,500 - -
349 '31/03 KASWADI '05.02.01.095369 PKMS SILVER L '48 / 6 Cough / batuk 7,500 - -
350 '31/03 LILIK SURYANI 05.02.02.095382 PKMS SILVER P '46 / 7 Gastritis 7,500 - -
351 '31/03 M MAGDALENA SUNARTI 05.02.02.076657 PKMS GOLD P '50 / 6 Urtikaria (biduren) 7,500 - -
352 '31/03 ROFIK,BP '05.02.03.217212 PKMS GOLD L '29 / 11 Dermatitis Kontak Alergi 7,500 - -
353 '31/03 SUPARNO '05.02.01.005512 PKMS SILVER L '77 / 5 Conjunctivities 7,500 - -
354 '31/03 SURIP 05.02.34.206739 PKMS SILVER P '67 / 3 Hipertensi Essensial 7,500 - -
355 '31/03 SUTARNI 05.02.02.005516 PKMS SILVER P '71 / 4 Hipertensi Essensial 7,500 - -
356 '31/03 SAMSUL MA'ARF 05.03.01.089566 PKMS GOLD L 39/4 Karies gigi 7,500 7,500
357 '31/03 WAGINEM,NY 05.01.01.261859 PKMS SILVER P '82 / 3 Myalgia (keju kemeng) 7,500 - -
JUMLAH 2,677,500 73,000 82,500

Surakarta, 27 April 2015

Kepala UPTD Puskesmas Nusu

Dinas Kesehatan
Kota Surakarta
anan Kesehatan& Besaran Tarif sesuai Perda
Total
KIA Laborat

- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
 - - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 15,000
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500

11,000 - 18,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 15,000

- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 22,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 15,000

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500

- - 7,500

- - 7,500
- - 22,500

- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 35,500
- - 15,000

7,500
- - 7,500
- - 22,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- 12,000 19,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
7,500

- - 7,500
- - 7,500
- - 22,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 37,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
 - - 7,500
- - 7,500
- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500

- - 7,500

- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
- - 7,500
15,000
- - 7,500
11,000 12,000 2,856,000

Surakarta, 27 April 2015

Kepala UPTD Puskesmas Nusukan

Dinas Kesehatan
Kota Surakarta
 drg. Agus Susanto,MM
NIP.19590823 198311 1 001