LPLPO 2019 APBD SD 31 Des 2019

LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT
(LPLPO)
KODE PUSKESMAS : 63710203 BULAN 0 1 LB2

PUSKESMAS : BANJARMASIN INDAH TAHUN 2 0 1 9
KECAMATAN : BANJARMASIN BARAT
KAB/KODYA : BANJARMASIN
SATU HARGA STOK PENERI PERSE PEMAKAIAN RUSAK / E.D/REALOKASI SISA STOK STOK PERMIN PEMBERIAN
KODE NAMA OBAT
AN PER SATUAN AWAL MAAN DIAAN JUMLAH Rp JUMLAH Rp JUMLAH Rp OPT TAAN APBD PROGRAM KET
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000000983 Albendazol tablet 400 mg tablet Rp 323.0 - 0 - - - - - - -
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 1,014 0 1,014 20 1,980 - 994 98,406 (946)
DRG000001666 Aminofilin injeksi 24 mg/ml-10 ml ampul Rp 4,204.0 - 0 - - - - - - -
Aminofilin tablet 200 mg tablet Rp 86.0 400 300 700 10 860 - 690 59,340 (666)
DRG000001769 Amitriptilin Hcl tablet salut 25 mg tablet Rp 168.0 110 0 110 - - - 110 18,480 (110)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 6,280 0 6,280 1,460 110,960 - 4,820 366,320 (1,316) 1600
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 252 1500 1,752 1,616 400,768 - 136 33,728 3,742 1500
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 314 0 314 137 595,265 - 177 769,065 152 100
Ampisilin serbuk injeksi i.m.i.v 1000 mg/ml vial Rp 9,524.0 - 0 - - - - - - -
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 3,548 1300 4,848 810 45,360 - 4,038 226,128 (2,094) 1000
DRG000002883 Antasida sirup botol Rp 2,098.0 64 0 64 26 54,548 - 38 79,724 24 100
DRG000002996 Antifungi doen kombinasi tube Rp 5,170.0 24 0 24 - - - 24 124,080 (24)
Artemether injeksi 80 Mg ampul Rp 29,925.0 - 0 - - - - - - -
Artesunate cairan injeksi 60 mg ampul Rp 33,835.0 - 0 - - - - - - -
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 1,339 700 2,039 1,353 162,360 - 686 82,320 2,561 1300
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 - 0 - - - - - - - 500
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 - 0 - - - - - - - 1000
DRG000003731 Asiklovir 200 mg tablet tablet Rp 236.0 2,374 0 2,374 97 22,892 - 2,277 537,372 (2,044)
DRG000003947 Atropin Sulfat tablet 0,5 mg tablet Rp 26.2 - 0 - - - - - - -
DRG000004829 Benzatin Benzil Penisilin inj 1,2 juta iu/vial vial Rp 10,780.0 - 0 - - - - - - -
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 47 50 97 49 67,277 - 48 65,904 70 50
Clindamisin kapsul 300 mg kapsul Rp 1,017.0 - 0 - - - - - - -
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 2,287 500 2,787 163 5,542 - 2,624 89,216 (2,233)
DRG000011634 Deksametason inj 5 mg/ml-1 ml ampul Rp 1,805.0 22 0 22 - - - 22 39,710 (22)
1
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DHP / Darplex / D-Artepp (Dehidro artemisin -

Piperaquin) tab tablet Rp 2,160.0 100 0 100 - - 100 216,000 (100)
Diazepam inj 5 mg/ml-2 ml ampul Rp 1,913.0 5 0 5 - - - 5 9,565 (5)
DRG000012224 Diazepam tablet 2 mg tablet Rp 220.0 183 0 183 - - - 183 40,260 (183)
Diazepam tablet 5 mg tablet Rp 109.0 - 0 - - - - - - -
Dietilkarbamazin sitrat tablet 100 mg tablet Rp 180.0 - 0 - - - - - - -
DRG000012294 Difenhidramin Hcl inj 10 mg/ml-1 ml ampul Rp 1,262.0 - 0 - - - - - - -
DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 400 0 400 - - - 400 41,200 (400)
DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 884 0 884 256 30,976 - 628 75,988 (14) 300
DRG000012885 Doksisiklin 100 mg kapsul kapsul Rp 299.0 - 0 - - - - - - -
DRG000012719 Domperidon 10 mg tablet Rp 90.0 402 100 502 25 2,250 - 477 42,930 (417) 100
DRG000013853 Epinefrin Hcl/Bitartrat(adrenalin)inj 0,1 %-1 ml ampul Rp 1,518.0 17 0 17 - - - 17 25,806 (17)
DRG000014229 Erytromisin sirup botol Rp 6,390.0 - 0 - - - - - - -
DRG000014234 Erytromisin 500 mg kaplet tablet Rp 781.0 - 0 - - - - - - -
DRG000046712 Etambutol 500 mg tablet tablet Rp 466.0 - 0 - - - - - - -
DRG000027466 Fenitoin kapsul 50 mg kapsul Rp 1.0 - 0 - - - - - - - 100
DRG000015393 Fenobarbital inj 50 mg / ml - 2 ml ampul Rp 2,135.0 - 0 - - - - - - -
DRG000032549 Fenobarbital tablet 30 mg tablet Rp 197.0 192 0 192 - - - 192 37,824 (192)
Ferrous sulphate tab selaput 300 mg tablet Rp 1.0 - 0 - - - - - - -
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 8,475 0 8,475 875 48,125 - 7,600 418,000 (5,500)
DRG000015698 Fitomenadion ( vit k 1 ) tablet salut 10 mg tablet Rp 818.0 601 0 601 70 57,260 - 531 434,358 (363)
DRG000032665 Fitomenadion ( vit k 1 ) inj 10 mg / ml - 1 ml ampul Rp 5,516.5 12 0 12 - - - 12 66,198 (12)
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 770 0 770 10 790 - 760 60,040 (736)
Furosemid Cairan Injeksi 10 mg/ml ampul Rp 2,781.1 - 0 - - - - - - -
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 739 0 739 167 69,806 - 572 239,096 (171) 200
DRG000017209 Gentamisin inj 40 mg/2 ml ampul Rp 4,989.6 - 0 - - - - - - -
DRG000017398 Glibenklamid tablet 5 mg tablet Rp 137.0 3,015 0 3,015 10 1,370 - 3,005 411,685 (2,981)
DRG000017435 Glimepirid tab 1 mg tablet Rp 194.0 280 0 280 20 3,880 - 260 50,440 (212)
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 - 0 - - - - - - -
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 505 200 705 190 10,450 - 515 28,325 (59) 200
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 390 0 390 30 1,680 - 360 20,160 (288) 100
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 757 0 757 - - - 757 123,391 (757)
DRG000019279 Hidrokortison krim 2,5 % tube Rp 2,533.0 - 0 - - - - - - -
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 1,000 1000 2,000 400 44,800 - 1,600 179,200 (640) 500
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 - 1000 1,000 100 29,200 - 900 262,800 (660)
DRG000020665 Isoniazid tablet 100 mg tablet Rp 79.0 100 0 100 - - - 100 7,900 (100)
2
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020671 Isoniazid tablet 300 mg tablet Rp 173.0 - 0 - - - - - - -
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 200 0 200 10 890 - 190 16,910 (166)
DRG46597 Kalsium Gluconas inj ampul Rp 1.0 - 0 - - - - - - -
Kalsium Karbonat tablet 500 mg tablet Rp 1.0 - 0 - - - - - - -
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 867 300 1,167 200 22,000 - 967 106,370 (487) 600
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 300 0 300 - - - 300 70,200 (300)
DRG000021678 Ketokenazol 200 mg tablet tablet Rp 286.0 193 0 193 - - - 193 55,198 (193) 200
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 685 0 685 45 12,375 - 640 176,000 (532)
Kloramfenikol salep 2 % tube Rp 1.0 - 0 - - - - - - -
Kloramfenikol salep mata 1 % tube Rp 1,925.0 48 0 48 1 1,925 - 47 90,475 (45)
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 66 0 66 5 24,910 - 61 303,902 (49)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 7,015 0 7,015 2,095 50,280 - 4,920 118,080 108 2000
Klorpromazin Hcl inj 5 mg / ml - 2 ml ampul Rp 376.0 - 0 - - - - - - -
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 100 0 100 30 4,440 - 70 10,360 2 300
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 340 0 340 30 19,710 - 310 203,670 (238)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 1,055 200 1,255 130 16,250 - 1,125 140,625 (813)
DRG000010167 Kotrimoksazol suspensi botol Rp 2,052.0 9 0 9 9 18,468 - - - 22 200
DRG000021836 Kuinine tablet salut selaput 200 mg tablet Rp 310.7 - 0 - - - - - - -
Kuinine Dihydrochloride cairan inj 25%-2 ml ampul Rp 2,616.1 - 0 - - - - - - -
DRG000023410 Lidocain injeksi 2 % ampul Rp 1,319.0 5 0 5 - - - 5 6,595 (5)
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 56 30 86 30 39,510 - 56 73,752 16 30
DRG000023922 Loratadin tablet tablet Rp 127.0 1,835 0 1,835 - - - 1,835 233,045 (1,835)
DRG000024327 Magnesium sulfat inj ( 1V ) 20 % - 25 ml vial Rp 3,200.0 2 0 2 - - - 2 6,400 (2)
DRG000043759 Mebendazol tablet 100 mg (vermox) tablet Rp 7,854.0 - 0 - - - - - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 1,002 0 1,002 270 27,540 - 732 74,664 (84) 100
DRG000025481 Metformin tab 850 mg tablet Rp 165.0 140 0 140 - - - 140 23,100 (140)
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 90 0 90 10 2,738 - 80 21,904 (56)
DRG000025567 Metilergometrin maleat inj 0,200 mg - 1 ml ampul Rp 3,399.0 9 0 9 - - - 9 30,591 (9)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 2,516 300 2,816 230 37,950 - 2,586 426,690 (2,034)
DRG000025667 Metilprednisolon 16 mg tablet tablet Rp 875.0 - 0 - - - - - - -
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 - 0 - - - - - - - 500
DRG000025793 Metronidazol tablet 250 mg tablet Rp 94.0 - 0 - - - - - - - 300
Metronidazol suspension 125 mg/ml botol Rp 3,800.0 - 0 - - - - - - -
DRG000025979 Miconazol krim tube Rp 2,577.0 - 0 - - - - - - - 50
DRG000026103 Mineral mix serbuk 8 gr sachet Rp 3,055.0 - 40 40 - - - 40 122,200 (40)
3
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038915 Natrium Bikarbonat tablet 500 mg tablet Rp 9.8 - 0 - - - - - - -
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 1,585 0 1,585 540 76,680 - 1,045 148,390 251 500
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,000 500 2,500 - - - 2,500 340,000 (2,500)
Natrium Tiroksin (Levotiroksin) tablet 100 mg -
(Euthyrox) tablet Rp 850.0 - 0 - - - - - -
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 190 100 290 60 10,800 - 230 41,398 (86)
Nicotinamida tablet 20 mg tablet Rp 1.0 - 0 - - - - - - -
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 91 0 91 10 6,450 - 81 52,245 (57)
Obat antituberkolusis katagori 1 paket Rp 395,900.0 - 0 - - - - - - -
Obat antituberkolusis katagori 2 paket Rp 1,379,984.0 - 0 - - - - - - -
Obat antituberkulosis anak paket Rp 267,400.0 - 0 - - - - - - -
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 - 0 - - - - - - -
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 - 0 - - - - - - -
DRG000031217 Oksitetrasiklin Hcl salep mata 1 % tube Rp 2,600.0 - 0 - - - - - - -
DRG000031235 Oksitosin injeksi 10 iu / ml ampul Rp 1,232.0 15 0 15 - - - 15 18,480 (15)
DRG000030245 Omeprazol inj 40 mg/10 ml ampul Rp 18,537.0 - 0 - - - - - - -
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 1,553 0 1,553 200 27,600 - 1,353 186,714 (873)
DRG000031912 Parasetamol sirup 120 mg / 5 ml botol Rp 1,160.0 309 100 409 237 274,920 - 172 199,520 397 300
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 2,264 2000 4,264 4,264 255,840 - - - 10,234 4000
DRG000034958 Pirantel pamoat 125 mg tablet tablet Rp 318.0 - 0 - - - - - - -
DRG000034959 Pirantel suspensi 5 mg/ml botol Rp 9,100.0 - 0 - - - - - - -
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 1,475 0 1,475 150 21,150 - 1,325 186,825 (965)
DRG000032952 Piridoksin Hcl tablet 25 mg tablet Rp 40.5 - 0 - - - - - - -
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 922 0 922 - - - 922 167,343 (922) 300
DRG000033915 Primakuin tablet 15 mg tablet Rp 258.0 - 0 - - - - - - -
DRG000034345 Prokain benzil penisilin 3 juta iu / vial injeksi vial Rp 1.0 - 0 - - - - - - -
DRG000034487 Propanolol Hcl tablet 40 mg tablet Rp 300.0 100 100 200 - - - 200 59,998 (200)
DRG000034502 Propiltiourasil tablet 100 mg tablet Rp 500.0 100 0 100 - - - 100 50,001 (100)
DRG000035403 Ranitidin tablet tablet Rp 122.0 2,100 0 2,100 1,160 141,520 - 940 114,680 1,844 1200
DRG000044394 Retinol ( Vit A ) 100.000 IU kapsul kapsul Rp 585.0 - 200 200 200 117,000 - - - 480
DRG000044395 Retinol ( Vit A ) 200.000 IU kapsul kapsul Rp 519.2 100 1400 1,500 1,500 778,800 - - - 3,600
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 243 100 343 98 6,272 - 245 15,680 (10) 100
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,146 0 1,146 60 4,620 - 1,086 83,622 (942)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 75 0 75 4 12,068 - 71 214,207 (61)
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 1,720 0 1,720 50 24,600 - 1,670 821,640 (1,550)
DRG000007256 Sefadroxil syp kering 125 ml / 5 ml botol Rp 4,086.0 231 0 231 26 106,236 - 205 837,630 (143)
Sianokobalamin ( Vit.B.12 ) inj 500 mcg / ml ampul Rp 1,067.0 - 0 - - - - - - -
4
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 2,210 300 2,510 420 46,200 - 2,090 229,900 (1,082) 500
DRG000008829 Siprofloksasin 500 mg tablet tablet Rp 281.0 1,705 0 1,705 40 11,240 - 1,665 467,865 (1,569)
Tetrasiklin Hcl kapsul 250 mg kapsul Rp 73.0 - 0 - - - - - - -
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 2,280 0 2,280 330 29,040 - 1,950 171,600 (1,158)
DRG000042321 Triheksilfenidil hidroklorida tablet 2 mg tablet Rp 95.0 260 200 460 265 25,175 - 195 18,525 441 300
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 2,120 2500 4,620 2,251 303,885 - 2,369 319,815 3,033 2500
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 1,230 0 1,230 80 48,320 - 1,150 694,600 (958)
DRG000043194 Vaksin BCG vial Rp 59,950.0 - 0 - - - - - - -
Vaksin Jerap D T vial Rp 17,798.0 - 0 - - - - - - -
Vaksin CAMPAK 10 Dosis vial Rp 28,204.0 5 0 5 - - - 5 141,020 (5)
Vaksin POLIO 10 Dosis vial Rp 19,954.0 15 0 15 - - - 15 299,310 (15)
Vaksin HEPATITIS B 0,5 ml ADS vial Rp 20,900.0 - 0 - - - - - - -
DRG000043208 Pentabio Vaksin DTP-HB-HIB inj vial Rp 76,285.0 - 0 - - - - - - -
DRG000043266 Vaksin Td vial Rp 16,500.0 - 0 - - - - - - -
Vaksin IPV (Poliomyelitis Vaccine inj (ShanIPV vial Rp 152,900.0 - 0 - - - - - - -
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - -
Acdat salep tube Rp 6,241.0 4 0 4 4 24,964 - - - 10 50
DRG000000325 Air untuk irigasi lar infus 1000 ml botol Rp 22,000.0 - 0 - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 0 200 - - - 200 175,600 (200)
DRG000001441 Albendazol suspensi 200mg/5 ml botol Rp 4,600.0 - 0 - - - - - - -
DRG000001442 Alprazolam 0,5 mg tablet Rp 88.0 - 0 - - - - - - -
Alprazolam 1 mg tablet Rp 120.0 552 0 552 - - - 552 66,240 (552)
DRG000001592 Alvit drops botol Rp 12,500.0 - 0 - - - - - - -
DRG000001574 Ambroxol sirup botol Rp 3,300.0 476 0 476 107 353,100 - 369 1,217,700 (112)
DRG000001791 Ambroxol tablet tablet Rp 100.0 1,899 0 1,899 510 51,000 - 1,389 138,900 (165)
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 4,188 0 4,188 335 31,825 - 3,853 366,035 (3,049)
Amoksisilin 250 mg tablet Rp 196.0 - 0 - - - - - - -
Anemolat 1 mg tablet tablet Rp 77.0 - 0 - - - - - - -
DRG000002721 Antalgin (Metampiron) tablet 500 mg tablet Rp 67.0 - 0 - - - - - - -
DRG000002981 Antalgin injeksi 250 mg/5 ml ampul Rp 407.8 - 0 - - - - - - -
DRG000003002 Anti bakteri doen salep kombinasi tube Rp 3,490.0 - 0 - - - - - - -
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 82 0 82 13 47,346 - 69 251,298 (38)
DRG000023225 Antimigrain doen kombinasi tablet Rp 149.0 - 0 - - - - - - -
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 230 100 330 70 72,450 - 260 269,100 (92)
Antrain inj ampul Rp 11,999.2 - 0 - - - - - - -
DRG000003089 Apialis Drops botol Rp 21,175.0 - 0 - - - - - - -
5
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 86 0 86 28 924,000 - 58 1,914,000 9
DRG000003393 Aqua proinjeksi steril,bebas pirogen vial Rp 2,860.0 28 0 28 - - - 28 80,080 (28)
DRG000003466 Arkavit tablet Rp 320.0 2,290 200 2,490 865 276,800 - 1,625 520,000 451
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 58 0 58 - - - 58 8,932 (58)
DRG000003564 Asam Asetilsalisilat tablet 500 mg (Asetosal) tablet Rp 99.6 - 0 - - - - - - -
Asam askorbat(vit C) tablet 250 mg tablet Rp 150.0 - 0 - - - - - - -
DRG000003595 Asam Folat 5 mg tablet tablet Rp 63.5 - 0 - - - - - - -
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 580 0 580 - - - 580 903,930 (580)
DRG000000595 Asam Traneksamat injeksi 5 % 250 mg/ 5 ml ampul Rp 1,813.0 - 0 - - - - - - -
Asiklovir salep kulit tube Rp 3,699.3 83 0 83 23 85,084 - 60 221,958 (5)
DRG000003950 Atropin Sulfat injeksi 0,25 mg/ml-1 ml ampul Rp 1,540.0 - 0 - - - - - - -
DRG000003956 Atropin Sulfat tetes mata 0,5 % botol Rp 2,800.7 - 0 - - - - - - -
DRG000004142 Atrovent HFA kotak Rp 83,500.0 7 0 7 7 584,500 - - - 17 10
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 409 0 409 110 195,580 - 299 531,622 (35)
Baby Cough sirup botol Rp 3,999.6 245 0 245 34 135,986 - 211 843,916 (129)
Betahistin mesilat tablet 6 mg tablet Rp 119.0 - 0 - - - - - - -
DRG000005736 Bioplacenton Cream tube Rp 18,499.8 21 0 21 1 18,500 - 20 369,996 (18)
Bisoprolol tablet 5 mg tablet Rp 248.0 200 0 200 - - - 200 49,600 (200)
Buscopan tablet tablet Rp 3,100.0 190 0 190 20 62,000 - 170 527,000 (122)
Cendo Augentonic tetes mata botol Rp 30,990.0 - 0 - - - - - - -
Cendo Catarlent tetes mata botol Rp 33,699.6 - 0 - - - - - - -
DRG000015887 Cendo Edta tetes mata botol Rp 37,500.0 - 0 - - - - - - -
Cendo Floxa tetes mata botol Rp 33,599.5 - 0 - - - - - - -
Cendo fungicide tetes mata botol Rp 18,500.0 - 0 - - - - - - -
DRG000007801 Cendo Homatrol tetes mata botol Rp 43,785.0 - 0 - - - - - - -
Cendo Lyteers tetes mata botol Rp 25,999.6 31 0 31 1 26,000 - 30 779,988 (28)
Cendo mydriatil tetes mata botol Rp 27,845.4 - 0 - - - - - - -
Cendo Tobroson tetes mata botol Rp 53,999.0 - 0 - - - - - - -
DRG000007849 Cendo tropin tetes mata botol Rp 13,875.0 - 0 - - - - - - -
Cendo Xytrol tetes mata botol Rp 33,000.0 - 0 - - - - - - -
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 160 0 160 133 339,150 - 27 68,850 292 200
DRG000010471 Clopidogrel 75 mg tablet tablet Rp 1,469.0 240 0 240 - - - 240 352,560 (240)
Curcuma tablet tablet Rp 990.0 - 0 - - - - - - -
DRG000011354 Dekstran 70 larutan infus 6 % steril botol Rp 35,526.0 - 0 - - - - - - -
DRG000011365 Depakene sirup botol Rp 17,789.0 6 0 6 - - - 6 106,734 (6)
DRG000011337 Depakote tablet tablet Rp 1,200.0 390 0 390 - - - 390 468,000 (390)
DRG000011848 Desoksimetason 0,25 mg (Denomix) tube Rp 11,500.0 - 0 - - - - - - -
6
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Dextamine tablet tablet Rp 1,815.0 - 0 - - - - - - -
DRG000012127 Dextrofen sirup botol Rp 12,499.3 - 0 - - - - - - -
Diamicron MR 30 mg tablet tablet Rp 638.0 - 0 - - - - - - -
DRG000012720 Diltiazem tablet tablet Rp 143.0 - 0 - - - - - - -
DRG000012774 Domperidon Suspensi 5 mg/5 ml botol Rp 2,862.0 337 0 337 23 65,826 - 314 898,668 (259)
DRG000012960 Dopamet (metildopa) tablet Rp 880.0 - 0 - - - - - - -
DRG000012963 Dulcolax 10 mg supp supp Rp 5,900.0 - 0 - - - - - - -
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 90 90 180 - - - 180 56,880 (180)
DRG000013350 Efedrin Hcl tablet 25 mg tablet Rp 197.8 - 0 - - - - - - -
DRG000014440 Erytromisin 250 mg kapsul kapsul Rp 636.0 - 0 - - - - - - -
Etakridin ( Rivanol ) larutan 0,1 % botol Rp 4,999.5 - 0 - - - - - - -
DRG000015045 Etambutol Hcl tablet 250 mg tablet Rp 186.3 - 0 - - - - - - -
DRG000027495 Famotidin 40 mg tablet tablet Rp 192.0 900 0 900 - - - 900 172,800 (900)
DRG000027467 Fenitoin natrium inj 50 mg / ml ampul Rp 48,368.0 - 0 - - - - - - -
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 100 0 100 - - - 100 15,800 (100)
DRG000015398 Fenobarbital tablet 100 mg tablet Rp 127.2 - 0 - - - - - - -
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 235 0 235 60 64,380 - 175 187,775 (31)
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 93 0 93 6 15,540 - 87 225,330 (73)
Flukonazol tab 150 mg tablet Rp 24,200.0 60 0 60 35 847,000 - 25 605,000 59 200
DRG000016599 Fluor tablet 0,5 mg tablet Rp 32.9 - 0 - - - - - - -
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 19 0 19 - - - 19 92,891 (19) 20
Fungasol 2 % botol Rp 24,200.0 - 0 - - - - - -
DRG000016864 Fuson ointment tube Rp 7,500.0 - 0 - - - - - - -
Gemfibrozil 300 mg tablet Rp 428.0 720 0 720 10 4,280 - 710 303,880 (686)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 83 24 107 29 72,477 - 78 194,938 (8)
DRG000017167 Gentamisin salep mata tube Rp 3,075.0 - 0 - - - - - - -
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 - 0 - - - - - - -
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 51 0 51 5 17,496 - 46 160,959 (34)
Glimepirid tab 2 mg tablet Rp 207.0 460 0 460 10 2,070 - 450 93,150 (426)
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 889 2000 2,889 1,599 143,910 - 1,290 116,100 2,548 1600
DRG000017683 Gliserin larutan 50% botol Rp 5,867.0 - 0 - - - - - - -
DRG000017692 Glukosa larutan infus 10 % steril botol Rp 7,500.0 - 0 - - - - - - -
DRG000017682 Glukosa larutan infus 40 % steril botol Rp 988.0 - 0 - - - - - - -
DRG000030867 Glukosa larutan infus 5 % steril botol Rp 5,720.0 1 0 1 - - - 1 5,720 (1)
Glukosamin 250 mg tablet (osmin) tablet Rp 1,000.0 - 0 - - - - - - -
DRG000018288 H.Booster sirup botol Rp 14,168.0 - 0 - - - - - - -
DRG000018443 Haloperidol tablet 1,5 mg tablet Rp 59.0 100 0 100 - - - 100 5,900 (100)
7
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 261 600 861 80 67,999 - 781 663,842 (589)
DRG000019256 HEXADOL (Larutan Hexetidine) botol Rp 12,650.0 - 0 - - - - - - -
Hidrokortison krim 1% tube Rp 5,723.3 43 0 43 9 51,510 - 34 194,592 (12)
Hyorex 10 mg tablet tablet Rp 405.0 - 0 - - - - - - -
DRG000019430 Hyoscine N Butilbromida 10 mg tablet tablet Rp 1,625.8 - 0 - - - - - - -
DRG000019495 Ibuprofen syr 100 mg/5ml botol Rp 2,560.0 164 0 164 3 7,680 - 161 412,160 (154)
Ichtyol salep tube Rp 6,200.0 54 0 54 1 6,200 - 53 328,600 (51)
Inhitril 10 mg tablet Rp 385.0 - 0 - - - - - - -
Interhistin tablet tablet Rp 880.0 198 0 198 198 174,240 - - - 475 200
DRG000006615 Irbesartan tab 150 mg tablet Rp 425.0 - 0 - - - - - - -
DRG000006804 Kalsium laktat ( Kalk ) tablet 500 mg tablet Rp 59.0 7,603 0 7,603 430 25,370 - 7,173 423,207 (6,141)
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 1,815 0 1,815 340 203,660 - 1,475 883,525 (659)
DRG000007735 Kandesartan 16 mg tablet tablet Rp 6,225.0 - 0 - - - - - - -
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 232 0 232 17 450,483 - 215 5,697,285 (174)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 335 0 335 335 41,872 - - - 804 500
DRG000021651 Kaptopril 50 mg tablet tablet Rp 135.0 - 0 - - - - - - -
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 59 0 59 9 23,193 - 50 128,850 (28)
DRG000009233 Ketoprofen 100 mg tablet tablet Rp 1,366.2 - 0 - - - - - - -
DRG000009302 Klindamisin 150 mg tablet tablet Rp 754.0 - 0 - - - - - - -
DRG000009337 Klobazam 10 mg tablet tablet Rp 872.0 445 0 445 5 4,360 - 440 383,680 (428)
DRG000021912 Klonidin 0,15 mg tablet tablet Rp 224.0 - 0 - - - - - - -
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 - 0 - - - - - - -
DRG000008615 Klorpromazin Hcl inj 25 mg / ml - 12 ml ampul Rp 418.3 - 0 - - - - - - -
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 110 0 110 - - - 110 123,310 (110)
DRG000021974 Kodein tablet 15 mg tablet Rp 728.0 - 0 - - - - - - -
DRG000003009 Kodein tablet 20 mg tablet Rp 1,494.0 - 0 - - - - - - -
DRG000022061 Kombinasi pirimetamin 25 mg / sulfadoksin 50 tablet Rp 379.6 - 0 - - - - - - -
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - 0 - - - - - - -
DRG000022701 Kotrimoksazol DOEN II (pedriatik) tablet tablet Rp 79.0 - 0 - - - - - - -
Lanzoprazol tablet Rp 330.0 775 200 975 250 82,500 - 725 239,250 (125)
DRG000022980 Lapalos Cream tube Rp 16,500.0 - 0 - - - - - - -
Laxadine emulsi botol Rp 7,700.0 - 0 - - - - - - -
DRG000023225 L-Bio sachet sachet Rp 4,033.3 448 0 448 18 72,599 - 430 1,734,319 (387)
DRG000023291 Levofloksasin tab 500 mg tablet Rp 449.0 - 0 - - - - - - -
DRG000045684 Lexapram sirup botol Rp 2,900.0 - 0 - - - - - - -
8
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023536 Lidocain jeli 2 % (Xylocaine Jelly 2%) syringe Rp 40,000.0 - 0 - - - - - - -
DRG000023691 Lincomisin 500 mg tablet Rp 1,319.6 200 0 200 - - - 200 263,920 (200)
DRG000023692 Lisinopril 10 mg tablet tablet Rp 323.0 - 0 - - - - - - -
Lisinopril 5 mg tablet tablet Rp 238.0 - 0 - - - - - - -
DRG000026266 Lisol botol Rp 45,100.0 1 0 1 - - - 1 45,100 (1)
DRG000023860 Livertran salep tube Rp 4,600.0 119 0 119 - - - 119 547,400 (119)
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 1,337 0 1,337 80 215,512 - 1,257 3,386,232 (1,065)
DRG000023935 Loperamida tablet tablet Rp 85.0 300 0 300 - - - 300 25,500 (300)
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 - 0 - - - - - - -
DRG000024571 MDT Combi paket Rp 31,570.0 - 0 - - - - - - -
DRG000024987 Mebendazol sirup 100 mg / 5 ml botol Rp 2,035.0 - 0 - - - - - - -
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 710 0 710 80 64,000 - 630 504,000 (438)
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 1,965 0 1,965 160 104,000 - 1,805 1,173,250 (1,421)
Mersibion injeksi ampul Rp 6,000.0 - 0 - - - - - - -
DRG000025750 Metoklorpropamid sirup botol Rp 1,919.0 - 0 - - - - - - -
DRG000015762 Metronidazol infus 500 mg/100 ml botol Rp 25,300.0 - 0 - - - - - - -
DRG000026108 Metronidazol supp 500 mg (Flagyl supp) supp Rp 3,655.0 - 0 - - - - - - -
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 639 0 639 - - - 639 63,261 (639)
DRG000026643 Misoprostol 200 mg (gastrul) tablet Rp 12,300.0 - 0 - - - - - - -
DRG000044042 Mixaria sachet Rp 1,260.0 - 0 - - - - - - -
DRG000026742 Moksifloksasin tetes mata 0,5% (Vigamox) botol Rp 81,000.0 - 0 - - - - - - -
DRG000027470 Mometason furoat krim 0,1 % tube Rp 7,912.0 5 0 5 5 39,560 - - - 12
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 10 0 10 - - - 10 51,700 (10)
DRG000028214 Neo Diaform tablet Rp 253.0 - 0 - - - - - - -
DRG000028376 Neurodex tablet tablet Rp 591.4 330 0 330 - - - 330 195,162 (330)
DRG000028619 New Diatabs tablet Rp 560.0 - 0 - - - - - - -
DRG000028637 Nistatin 500.000 iu /g tablet salut tablet Rp 910.0 - 0 - - - - - - -
Nitral (gliseril trinitras sublingual 0.5 mg) tablet Rp 1,650.1 - 0 - - - - - - -
DRG000029080 Nopres 20 mg tablet tablet Rp 883.3 150 90 240 10 8,833 - 230 203,159 (206)
Norages Injeksi ampul Rp 9,999.9 - 0 - - - - - - -
novadium tablet Rp 200.0 - 0 - - - - - - -
Novastan sirup botol Rp 12,650.0 48 0 48 1 12,650 - 47 594,550 (45)
Noza tablet tablet Rp 797.5 100 500 600 40 31,900 - 560 446,600 (464)
Obat antituberkulosis kat.3 paket Rp 154,000.0 - 0 - - - - - - -
DRG000029617 Obat antituberkulosis kat.sisipan paket Rp 160,000.0 - 0 - - - - - - -
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 - 100 100 10 49,995 - 90 449,955 (66)
DRG000039980 Obat suntik KB I (3 bulan) ampul Rp 7,175.0 - 0 - - - - - - -
9
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030101 Obat suntik KB II (1 bulan) ampul Rp 5,885.0 - 0 - - - - - - -
DRG000019683 Ofloksasin tab 400 mg tablet Rp 700.0 295 0 295 - - - 295 206,500 (295)
DRG000031218 Oksimetazolin tts hidung 0,025% (Iliadin drops) botol Rp 37,433.0 - 0 - - - - - - -
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 - 0 - - - - - - -
DRG000030419 Ondansetron inj 4 mg/2ml ampul Rp 1,198.0 - 0 - - - - - - -
DRG000030584 Ondansetron tab 4 mg tablet Rp 406.0 - 0 - - - - - - -
Optiflox tetes mata botol Rp 14,005.0 - 0 - - - - - - -
Pamol supp supp Rp 18,999.2 - 0 - - - - - - -
DRG000031557 Pantocain 0,5 % TM botol Rp 17,499.9 5 0 5 - - - 5 87,500 (5)
DRG000031585 Papaverin 40 mg tablet tablet Rp 170.0 - 0 - - - - - - -
DRG000031608 Parasetamol Drop 100 mg/ml botol Rp 6,938.8 - 0 - - - - - - -
DRG000032133 Pedialyte botol Rp 31,999.0 94 0 94 - - - 94 3,007,906 (94)
DRG000032718 Pehacain injeksi ampul Rp 3,580.0 - 0 - - - - - - -
DRG000002552 Pil KB I tablet Rp 1,350.0 310 0 310 40 54,000 - 270 364,500 (174)
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - 0 - - - - - - -
Pim-Tra-Kol sirup botol Rp 9,999.0 - 0 - - - - - - -
DRG000032996 Pirazinamid tab 500 mg tablet Rp 238.0 - 0 - - - - - - -
DRG000032977 Piroksikam 10 mg tablet tablet Rp 112.2 - 0 - - - - - - -
DRG000033456 Polikresulen botol Rp 43,975.8 - 0 - - - - - - -
DRG000020429 Povidon Iodida larutan 10 % 30 ml botol Rp 3,190.0 11 0 11 - - - 11 35,090 (11)
Povidon Iodida Larutan 1000 ml botol Rp 42,000.0 1 0 1 - - - 1 42,000 (1)
PP Isoniazide 100 mg tablet Rp 79.0 - 0 - - - - - - -
Prazikuantel tablet 600 mg tablet Rp 2,295.0 - 0 - - - - - - -
Prenatin DF tablet tablet Rp 3,258.3 10 0 10 10 32,583 - - - 24 500
DRG000034697 Primolut N tablet Rp 2,618.0 20 0 20 - 20 52,360 - - - 100
Protofen supp supp Rp 2,790.0 - 0 - - - - - - -
DRG000034797 Protofen tablet tablet Rp 880.0 - 0 - - - - - - -
Pularex tablet tablet Rp 175.0 990 0 990 220 38,500 - 770 134,750 (242)
DRG000034808 Pulmicort respules ampul Rp 9,725.0 - 0 - - - - - - -
Pulmicort turbuhaler kotak Rp 101,000.0 - 0 - - - - - - -
Ramabion tab tablet Rp 6,490.0 - 0 - - - - - - -
DRG000035650 Ranitidin inj 25mg/2ml ampul Rp 1,155.0 - 0 - - - - - - -
DRG000035955 Recovit sirup botol Rp 8,650.0 - 0 - - - - - - -
Reserpin tablet 0,25 mg tablet Rp 114.0 - 0 - - - - - - -
10
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Rifampisin kaplet 600 mg tablet Rp 1,209.0 - 0 - - - - - - -
DRG000036344 Rifampisin kapsul 300 mg tablet Rp 670.0 - 0 - - - - - - -
DRG000036698 Ringer laktat larutan infus steril botol Rp 7,150.0 5 0 5 - - - 5 35,750 (5)
DRG000037347 Risperidon 2 mg tab tablet Rp 273.0 560 0 560 - - - 560 152,880 (560)
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 224 0 224 34 204,989 - 190 1,145,529 (108) 100
Sandepril 50 mg tablet Rp 8,900.0 - 0 - - - - - - -
Sangobion kids drop botol Rp 34,999.8 - 0 - - - - - - -
Sangobion Kids Sirup botol Rp 24,515.7 - 0 - - - - - - -
DRG000037725 Scabicid cream 10 gram tube Rp 11,475.0 - 0 - - - - - - -
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 61 0 61 1 11,475 - 60 688,500 (58)
Scopma tablet tablet Rp 750.0 - 0 - - - - - - -
DRG000007425 Sefaleksin kapsul 500 mg kapsul Rp 717.0 - 0 - - - - - - -
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 684 0 684 10 22,990 - 674 1,549,526 (650)
DRG000038259 Sefiksim syr kering 100mg/5ml botol Rp 5,710.0 97 10 107 3 17,130 - 104 593,840 (97)
DRG000038315 Seretide Inhaler 50 mcg kotak Rp 58,000.0 - 0 - - - - - - -
Serum anti bisa ular polivalen inj 5 ml ( ABU I ) vial Rp 479,996.0 - 0 - - - - - - -
Serum anti bisa ular polivalen inj 50 ml ( ABU II vial Rp 28,468,086.0 - 0 - - - - - - -
DRG000038321 Serum anti defteri inj 1000 mg / vial vial Rp 2,200,000.0 - 0 - - - - - - -
Serum anti tetanus inj 1.500 IU / ampul ( ATS ) ampul Rp 130,999.0 - 0 - - - - - - -
DRG000008166 Serum anti tetanus inj 20.000 IU / ampul ( ATS ampul Rp 604,670.0 - 0 - - - - - - -
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 60 100 160 80 239,440 - 80 239,440 112 100
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 216 500 716 410 39,770 - 306 29,682 678 500
DRG000008751 Simetidin tablet tablet Rp 250.0 - 0 - - - - - - -
DRG000038671 Simpastatin 20 mg tablet tablet Rp 225.0 560 0 560 13 2,925 - 547 123,075 (516)
Sohobion tablet tablet Rp 1,043.6 - 0 - - - - - - -
Spiramisin 500 mg tablet tablet Rp 1,223.2 - 0 - - - - - - -
DRG000039298 Spironolakton tab 25 mg tablet Rp 212.0 - 0 - - - - - - -
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 4 10 14 - - - 14 202,426 (14)
Stimuno Forte tablet tablet Rp 2,504.7 - 0 - - - - - - -
Stimuno Sirup botol Rp 18,500.0 53 0 53 - - - 53 980,500 (53)
Sucralfate 500 mg/5 ml suspensi botol Rp 7,338.0 - 0 - - - - - -
DRG000039932 Sulfasetamid natrium tetes mata 15 % botol Rp 8,499.7 - 0 - - - - - - -
DRG000040124 Susuk KB II set Rp 213,936.8 - 0 - - - - - - -
DRG000040178 Symbicort turbuhaler 160/4.5 mg kotak Rp 134,500.0 - 0 - - - - - - -
DRG000040195 Synarcus krim tube Rp 2,534.0 - 0 - - - - - - - 50
11
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Taburia sachet Rp 1,000.0 - 240 240 240 240,000 - - - 576
DRG000040442 Tanapress 5 mg (imidapril ) tablet Rp 2,333.0 - 0 - - - - - - -
Tensigard tablet tablet Rp 1,063.3 - 0 - - - - - - -
Terra Flu tablet tablet Rp 807.1 - 0 - - - - - - -
DRG000041013 Tetagam ampul Rp 176,800.0 - 0 - - - - - - -
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 100 0 100 30 26,700 - 70 62,300 2 100
DRG000041258 Thiamin Hcl ( Vit B1 ) inj.100 mg / ml - 1 ml ampul Rp 730.0 - 0 - - - - - - -
DRG000041358 Thrombophob gel tube Rp 54,450.0 7 0 7 - - - 7 381,150 (7)
DRG000041532 Timolol tetes mata 0,5% botol Rp 10,286.0 - 0 - - - - - - -
DRG000041922 Tramadol 50 mg kapsul kapsul Rp 580.0 - 0 - - - - - - -
DRG000041920 Tramadol inj 50 mg/ml ampul Rp 2,680.0 - 0 - - - - - - -
DRG000042315 Triflouperazin 5mg tablet tablet Rp 309.0 - 0 - - - - - - -
DRG000042713 Truvit drops botol Rp 36,499.1 263 0 263 139 5,073,375 - 124 4,525,888 210 150
Truvit sirup botol Rp 11,400.0 - 0 - - - - - - -
DRG000042887 Ulsafate sirup botol Rp 9,192.0 69 0 69 5 45,960 - 64 588,288 (52)
DRG000042899 Ulsidex tablet tablet Rp 296.0 - 0 - - - - - - -
Urea krim (Soft U derm) botol Rp 7,040.0 - 0 - - - - - - -
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 330 0 330 30 54,450 - 300 544,500 (228)
DRG000043188 Vagizol ovula (metronidazol ovula) ovula Rp 4,235.0 - 0 - - - - - - -
valisanbe 2 mg tablet Rp 236.0 - 0 - - - - - - -
DRG000043324 Valsartan tab 80 mg (Diovan 80mg) tablet Rp 3,900.0 - 0 - - - - - - -
Vastral tablet Rp 605.0 - 0 - - - - - - -
DRG000043683 Ventolin inhaler kotak Rp 70,125.0 - 0 - - - - - - -
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 10 0 10 6 66,000 - 4 44,000 10 10
Vitamin A6000IU tablet Rp 237.0 - 0 - - - - - - -
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 3,810 500 4,310 800 39,200 - 3,510 171,990 (1,590)
Vitonorm tablet tablet Rp 4,107.2 - 0 - - - - - - -
DRG000045683 Xylocain spray kotak Rp 344,570.0 - 0 - - - - - - -
Yodium Test botol Rp 1.0 - 0 - - - - - - -
DRG000046219 Zincpro drops botol Rp 31,999.9 - 0 - - - - - - -
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 75 0 75 34 111,690 - 41 134,685 41 100
DRG000046382 Zoloral SS (ketokonazol scalp sol 2 %) botol Rp 24,200.0 6 0 6 - - - 6 145,200 (6)
- 0 - - - - - - -
II.OBAT GIGI - 0 - - - - - - -
MDVx000864 Achatit/Fuji II kotak Rp 939,400.0 - 0 - - - - - - -
0 acid etching kotak Rp 376,035.0 - 0 - - - - - - -
0 Air raksa dental use botol Rp 437,500.0 - 0 - - - - - - -
12
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Alveogyl kotak Rp 789,800.0 2 0 2 - - - 2 1,579,600 (2)
0 Aplicator kotak Rp 95,000.0 1 0 1 - - - 1 95,000 (1)
0 Arsenic Pasta 10 gr/pot Rp 942,040.0 3 0 3 - - - 3 2,826,120 (3)
MDVx002393 Articulating paper kotak Rp 195,800.0 6 0 6 - - - 6 1,174,800 (6)
0 Bond strenght kotak Rp 330,000.0 - 0 - - - - - - -
0 Caviton kotak Rp 252,950.0 - 1 1 - - - 1 252,950 (1)
MDVx022575 Citodur (Bahan tambalan sementara) kotak Rp 200,200.0 - 0 - - - - - - -
0 Cotton pelet pack Rp 247,500.0 5 0 5 - - - 5 1,237,500 (5)
MDVx009212 Cotton roll pack Rp 75,000.0 3 0 3 - - - 3 225,000 (3)
0 Cresofen / endoseptone pack Rp 473,000.0 6 0 6 - - - 6 2,838,000 (6)
MDVx024268 Dental floss kotak Rp 30,250.0 - 0 - - - - - - -
0 Dentin conditioning kotak Rp 366,465.0 - 0 - - - - - - -
0 Devitalisasi pasta (non arsen) / D.Pulp botol Rp 752,400.0 - 0 - - - - - - -
0 Devitalisasi pasta (non arsen) / Devitec kotak Rp 698,500.0 - 0 - - - - - - -
0 Dysclosing agent / Disclosing gel (GC tri plaqu botol Rp 345,950.0 - 0 - - - - - - -
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 0 1 - - - 1 164,950 (1)
DRG000014675 Eugenol cairan botol Rp 136,400.0 4 0 4 1 136,400 - 3 409,200 (1)
0 Flour sediaan topical botol Rp 170,000.0 - 0 - - - - - - -
0 Formokresol botol Rp 60,000.0 - 0 - - - - - - -
0 G aenial bond kotak Rp 875,578.0 - 0 - - - - - - - 1
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 3 0 3 - - - 3 1,930,500 (3)
0 Glass Ionomer cemen / ketakmolar kotak Rp 880,000.0 - 0 - - - - - - -
MDVx019949 Glass Ionomer Light cured Universal restorativ kotak Rp 412,500.0 - 0 - - - - - - -
MDVx000028 Gutta perchha point 15-40 mm kotak Rp 51,700.0 - 0 - - - - - - -
0 Jarum Dental cytoject pcs Rp 2,662.0 - 0 - - - - - - - 200
SBx148 Kalsium hidroksida pasta kotak Rp 187,000.0 - 0 - - - - - - -
0 Marbalet/neocones botol Rp 750,000.0 - 0 - - - - - - -
0 Monoklorkamfer mentol cairan (camphenol) kotak Rp 55,000.0 - 0 - - - - - - -
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 4 0 4 - - - 4 300,960 (4)
SBx147 Mummifying pasta kotak Rp 451,000.0 - 0 - - - - - - -
0 Oco Tooth Clensing botol Rp 191,999.0 1 0 1 - - - 1 191,999 (1) 2
MDVx012595 Paper point 15-40 mm kotak Rp 47,300.0 - 0 - - - - - - -
0 Pasta pengisi saluran akar kotak Rp 506,000.0 - 0 - - - - - - -
0 Rockless kotak Rp 1,135,200.0 - 0 - - - - - - -
DRG001BJM Scandonest pcs Rp 17,622.0 - 0 - - - - - - - 2
13
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx000992 selang saliva eyector pack Rp 157,300.0 10 0 10 - - - 10 1,573,000 (10)
DRG000038085 Semen seng fosfat serbuk dan cairan kotak Rp 225,500.0 3 0 3 - - - 3 676,500 (3)
0 Silver amalgam serbuk 65 - 75 % kotak Rp 937,500.0 - 0 - - - - - - -
MDVx000870 Surgical ginggival pack (Coe Pak) kotak Rp 669,350.0 1 0 1 - - - 1 669,350 (1)
SBx139 Tambalan sinar solare A2 kotak Rp 256,731.0 3 0 3 - - - 3 770,193 (3) 1
0 Tambalan sinar solare A3,5 kotak Rp 420,200.0 - 0 - - - - - - - 1
0 Tampon pack Rp 300,000.0 8 0 8 2 600,000 - 6 1,800,000 (1)
0 Temporary stopping fletcher serbuk dan cairan set Rp 62,150.0 - 0 - - - - - - -
0 Topical anastesi pasta kotak Rp 302,500.0 4 0 4 - - - 4 1,210,000 (4)
DRG000042250 Trikesol Formalin ( TKF ) cairan botol Rp 82,720.0 - 0 - - - - - - -
MDVx020416 Varnish box Rp 165,440.0 - 0 - - - - - - -
- 0 - - - - - - -
III. BMHP - 0 - - - - - - -
MDVx001727 Alat suntik sekali pakai 1 ml pcs Rp 1,614.0 185 0 185 13 20,982 - 172 277,608 (141) 100
0 Alat suntik sekali pakai 2,5 ml pcs Rp 605.0 62 0 62 - - - 62 37,510 (62)
MDVx001732 Alat suntik sekali pakai 3 ml pcs Rp 1,138.0 766 0 766 6 6,828 - 760 864,880 (746)
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 570 0 570 3 4,953 - 567 936,117 (560)
MDVx001793 Alat suntik sekali pakai 10 ml pcs Rp 1,095.3 100 0 100 - - - 100 109,529 (100)
DRG000000999 Albothyl botol Rp 45,000.0 - 0 - - - - - - -
DRG000001226 Alkohol Swab lembar Rp 105.0 1,100 0 1,100 100 10,500 - 1,000 105,000 (760)
0 Bioplacenton tulle pcs Rp 10,920.0 36 30 66 1 10,920 - 65 709,800 (63)
MDVx000796 Bistruri/scalpel balde No 10 pcs Rp 3,300.0 80 0 80 - - - 80 264,000 (80)
0 Bistruri/scalpel balde No 11 pcs Rp 3,450.0 - 0 - - - - - - -
0 Bisturi/scalpel balde No 15 pcs Rp 850.0 - 0 - - - - - - -
MDVx002305 Blood Lancet pcs Rp 176.0 750 0 750 100 17,600 - 650 114,400 (410)
0 Blood transfusion set pcs Rp 4,698.0 - 0 - - - - - - -
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - 2 279,000 (2)
Box slide TB kotak Rp 36,000.0 - 0 - - - - - - -
0 canula dewasa pcs Rp 1.0 - 0 - - - - - - -
0 Cat Gut chromic No 1 pcs Rp 1.0 - 0 - - - - - - -
MDVx001331 Catgut/benang bedah no 2/0 chronic pcs Rp 5,862.5 - 0 - - - - - - -
MDVx001331 Catgut/benang bedah no 2/0 plain pcs Rp 5,862.5 - 0 - - - - - - -
0 Celulid strip pcs Rp 73,700.0 - 0 - - - - - - -
Cetride 5 Liter galon Rp 774,972.0 - 0 - - - - - - -
14
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Clorheksidin 2,5 % botol Rp 618,750.0 - 0 - - - - - - -
MDVx023244 Coverplast pcs Rp 470.0 2 0 2 - - - 2 940 (2)
0 Deck glass / objek glass 20 x 20 mm pack Rp 48,000.0 - 0 - - - - - - -
Deck glass / objek glass 22 x 22 mm pack Rp 52,300.0 - 0 - - - - - - -
0 Deck gelas / objek glass 24 x 24 mm pack Rp 48,000.0 - 0 - - - - - - -
MDVx018887 Disposibel vagina speculum pcs Rp 7,500.0 - 0 - - - - - - -
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - -
ECG 112 mm x 30 mm x 16 mm roll Rp 141,400.0 - 0 - - - - - - -
MDVx011444 Film Rontgen 24 x 30 cm lembar Rp 21,970.0 - 0 - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - -
MDVx000971 Foley cateter no 16 pcs Rp 13,688.0 - 0 - - - - - - -
MDVx001175 Fukuda M.E.ECG Paper pcs Rp 56,566.7 - 0 - - - - - - -
MDVx002014 handiplast pcs Rp 385.0 - 0 - - - - - - -
Holder tube vacutainer pcs Rp 6,940.0 - 0 - - - - - - -
0 Hypafix uk. Kecil 5 cm x 5 m pcs Rp 98,900.0 8 0 8 - - - 8 791,200 (8)
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - -
0 Infusiun set anak pcs Rp 2,970.0 2 0 2 - - - 2 5,940 (2)
MDVx026876 Infusiun set dewasa pcs Rp 4,176.0 4 0 4 - - - 4 16,704 (4)
MDVx002098 IV Catheter no 18 G pcs Rp 4,959.0 2 0 2 - - - 2 9,918 (2)
MDVx001125 IV Catheter no 20 G pcs Rp 8,566.0 - 0 - - - - - - -
MDVx001152 Jarum (Needle) no 23 pcs Rp 400.0 100 0 100 - - - 100 40,000 (100)
MDVx001154 Jarum (Needle) no 25 pcs Rp 604.0 - 0 - - - - - - -
Jarum Jahit kulit no 10 GT pack Rp 38,000.0 - 0 - - - - - - -
0 Jarum Jahit Kulit No 11 GT pack Rp 32,500.0 - 0 - - - - - - -
0 jarum K-File no 15-40 kotak Rp 150,700.0 - 0 - - - - - - -
MDVx022261 Jelly (Aquagel) botol Rp 31,027.3 2 0 2 1 31,027 - 1 31,027 1 2
15
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 0 80 - - - 80 200,000 (80)
0 Kapas berlemak 500 mg roll Rp 21,532.5 3 0 3 - - - 3 64,598 (3)
DRG000021388 Kapas pembalut / absorben 250 mg roll Rp 13,000.0 1 0 1 - - - 1 13,000 (1)
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 26 0 26 - - - 26 51,007 (26)
0 Kasa pembalut 2 m x80 cm pcs Rp 9,347.0 8 0 8 - - - 8 74,776 (8)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 15 0 15 - - - 15 36,855 (15)
SBx134 Kasa pembalut hidrofil 4m x 3 cm pcs Rp 613.5 29 0 29 - - - 29 17,792 (29)
Kasa steril 16 cm x 16 cm box Rp 8,685.7 - 0 - - - - - - -
MDVx001191 Kertas EKG (uk 80 x 90 x 280) lembar Rp 106,250.0 - 0 - - - - - - -
0 Kertas Puyer lembar Rp 91.6 - 0 - - - - - - -
MDVx013360 Kertas Thermal roll Rp 94,500.0 - 0 - - - - - - -
kertas thermal 50 mm x 57 mm roll Rp 18,200.0 - 0 - - - - - - -
Kertas thermal mindray 50mm x 50 mm roll Rp 76,500.0 - 0 - - - - - - -
Kertas thermal mindray 80 x 50 roll Rp 24,250.0 - 0 - - - - - - -
0 Klorin botol Rp 15,970.0 3 52 55 3 47,910 - 52 830,440 (45)
0 Kondom pcs Rp 716.7 240 0 240 90 64,503 - 150 107,505 66 200
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 24 0 24 - - - 24 910,800 (24)
MDVx022456 Lidi Kapas/cotton swab pcs Rp 1,000.0 412 0 412 - - - 412 412,000 (412)
Markerpen pcs Rp 1.0 70 0 - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 - 0 - - - - - - -
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - -
0 masker nebule dewasa pcs Rp 28,300.0 - 0 - - - - - - -
0 masker oksigen anak pcs Rp 19,800.0 - 0 - - - - - - -
0 masker oksigen dewasa pcs Rp 19,800.0 - 0 - - - - - - -
0 Mata Bor high speed pack Rp 154,000.0 1 0 1 - - - 1 154,000 (1)
0 Microtube 1,5 cc pack Rp 245,000.0 - 0 - - - - - - -
0 Minyak handpiece 500 ml botol Rp 561,000.0 - 0 - - - - - - -
Mouthpiece sterilbreath 250s box Rp 4,527.6 - 0 - - - - - - -
0 NaOcl 2,5 % untuk sal irigasi botol Rp 123,200.0 - 0 - - - - - - -
0 Needle flashback pcs Rp 3,170.0 - 0 - - - - - - -
MDVx000733 Obyek glass* biasa pack Rp 37,446.0 - 0 - - - - - - -
0 Open akses bur pcs Rp 135,300.0 - 0 - - - - - - -
0 Pembalut gips pcs Rp 55,000.0 - 0 - - - - - - -
0 Penjepit tali pusat pcs Rp 3,025.0 2 0 2 - - - 2 6,050 (2)
0 Pharmafix pcs Rp 27,000.0 8 0 8 - - - 8 216,000 (8)
16
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
pipet ESR citotes pcs Rp 7,675.0 - 0 - - - - - - -
Plastik klip sedang pack/100sRp 3,950.0 - 0 - - - - - - -
0 Plastik Obat kecil (uk. 8 cm x 5 cm) pack Rp 17,000.0 15 0 15 - - - 15 255,000 (15)
0 Plastik Obat pembungkus puyer (uk. Besar) pack Rp 5,950.0 10 0 10 - - - 10 59,500 (10)
MDVx041848 Plester (hansaplast 5 cm x 4,5 m) pcs Rp 12,000.0 - 0 - - - - - - -
Plesterin pcs Rp 161.7 - 0 - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - 0 - - - - - - -
0 safety box* pcs Rp 16,500.0 91 0 91 - - - 91 1,501,500 (91)
sealing wax pcs Rp 164,000.0 - 0 - - - - - - -
0 Serum gel tes tube 5 ml / tabung gel & cloat act pcs Rp 2,650.0 - 0 - - - - - - -
0 Silk ( benang bedah sutra ) no.3/0 pcs Rp 4,766.7 36 0 36 - - - 36 171,601 (36)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - -
0 Spon gelatin cubicle 1 x 1 x 1 cm pcs Rp 1,850.0 - 0 - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 0 300 - - - 300 495,000 (300)
MDVx001722 Spuit 0,5 ml pcs Rp 1,240.0 400 0 400 - - - 400 496,000 (400)
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - 0 - - - - - - -
0 Suction tips pack Rp 73,700.0 - 0 - - - - - - -
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 5 0 5 - - - 5 41,775 (5)
MDVx002389 Surgical Glove No 6,5 pcs Rp 20,006.7 100 0 100 - - - 100 2,000,670 (100)
0 Surgical Glove No 8 pcs Rp 5,000.0 93 0 93 - - - 93 465,000 (93)
MDVx019415 Surgical Glove obsgyn / gynecolog No 6,5 pcs Rp 20,006.7 - 0 - - - - - - -
Surgical Glove obsgyn / gynecolog No 7 pcs Rp 20,010.0 - 0 - - - - - - -
0 Surgical Gloves non steril uk L pcs Rp 462.0 1,000 0 1,000 - - - 1,000 462,000 (1,000)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 1,000 0 1,000 200 74,800 - 800 299,200 (320) 200
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 1,200 0 1,200 400 184,800 - 800 369,600 160 200
MDVx003948 Surgical mask 3 ply tie on pcs Rp 462.0 253 0 253 - - - 253 116,886 (253)
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,600 0 2,600 550 254,100 - 2,050 947,100 (730)
MDVx010039 Surgikal Gloves No 7 pcs Rp 5,000.0 12 0 12 - - - 12 60,000 (12)
MDVx010040 Surgikal Gloves No 7.5 pcs Rp 4,600.0 164 0 164 - - - 164 754,400 (164)
MDVx000518 Tabung EDTA K-3 pcs Rp 1,690.9 - 0 - - - - - - -
0 Tabung EdtA K-3 micro 0,5 cc pcs Rp 2,445.0 - 0 - - - - - - -
Tabung hematokrit pack Rp 180,500.0 - 0 - - - - - - -
0 Tabung reaksi / Test tube 75 x 100 dia 1 cm pcs Rp 5,500.0 - 0 - - - - - - -
Tabung reaksi kaca uk.12 x 75 mm pcs Rp 10,900.0 - 0 - - - - - - -
17
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000043003 Underpad pcs Rp 4,370.5 186 0 186 - - - 186 812,913 (186)
MDVx013451 Urine bag pcs Rp 3,120.0 - 0 - - - - - - -
USG paper 110 HG (110 mm x 18m_SONY) roll Rp 268,500.0 - 0 - - - - - - -
Viorex liquid 4 % 500 ml botol Rp 76,477.5 - 0 - - - - - - -
0 Wing needle no 21 pcs Rp 2,450.0 - 0 - - - - - - -
0 Yellow Tip pack Rp 139,500.0 - 0 - - - - - - -
- 0 - - - - - - -
IV. REAGEN - 0 - - - - - - -
0 Abate/temephos botol Rp 2,197,800.0 - 0 - - - - - - -
0 ACS level I (control serum) botol Rp 4,160,000.0 - 0 - - - - - - -
0 Aquadest steril botol Rp 22,000.0 11 0 11 - - - 11 242,000 (11)
DRG000046738 Asam klorida 0,1 N botol Rp 24,200.0 2 0 2 - - - 2 48,400 (2)
MDVx041607 Asam sulfosalisilat 20 % botol Rp 531,000.0 2 0 2 - - - 2 1,062,000 (2)
bactive SL botol Rp 30,700.0 - 0 - - - - - - -
MDVx040425 Blood Analisir Clianac Detergen (Nihon kohden botol Rp 8,050,000.0 - 0 - - - - - - -
MDVx041543 Blood Analisir Hemolinac 3N Lysing (nihon koh botol Rp 3,850,000.0 - 0 - - - - - - -
MDVx041531 Blood Analisir Isotonac 3 Diluent (nihon kohden botol Rp 4,290,000.0 - 0 - - - - - - -
0 Blood Analisir Clianac Detergen (norma clean botol Rp 2,112,000.0 - 0 - - - - - - -
0 Blood Analisir Hemolinac 3N Lysing (norma lys botol Rp 5,240,000.0 - 0 - - - - - - -
0 Blood Analisir Isotonac 3 Diluent (norma diluen botol Rp 3,696,000.0 - 0 - - - - - - -
0 Carbol gentian violet botol Rp 64,900.0 - 0 - - - - - - -
0 Cynoff 25 UL botol Rp 1,124,500.0 - 0 - - - - - - -
DRG000046731 Edta kering botol Rp 121,000.0 - 0 - - - - - - -
DRG000014470 Etanol 70 % 1 Liter botol Rp 41,800.0 23 0 23 - - - 23 961,400 (23)
DRG000001161 Etanol 70 % 100 ml botol Rp 5,500.0 - 0 - - - - - - -
0 K-Othrine 20 EW / Cyflutrin botol Rp 1,000,000.0 - 0 - - - - - - -
Kontrol darah botol Rp 1,358,500.0 1 0 1 - - - 1 1,358,500 (1)
Kontrol norma low botol Rp 596,000.0 - 0 - - - - - - -
Kontrol norma normal botol Rp 596,000.0 - 0 - - - - - - -
kontrol norma high botol Rp 596,000.0 - 0 - - - - - - -
MDVx343BJM Lab Pro reagen botol Rp 203,500.0 - 0 - - - - - - -
0 Larutan Air Fuchsin botol Rp 32,500.0 - 0 - - - - - - -
DRG000001165 Larutan Alkohol 95 % botol Rp 91,300.0 - 0 - - - - - - -
0 Larutan Alkohol 96 % botol Rp 48,500.0 - 0 - - - - - - -
18
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Larutan alkohol aseton botol Rp 31,000.0 - 0 - - - - - - -
MDVx103BJM Larutan amonium oksalat botol Rp 48,400.0 - 0 - - - - - - -
MDVx104BJM Larutan Anisol botol Rp 231,000.0 - 0 - - - - - - -
DRG000046732 Larutan Asam asetat 5% botol Rp 19,500.0 3 0 3 1 19,500 - 2 39,000 0
MDVx041776 Larutan Barium Klorida botol Rp 26,400.0 - 0 - - - - - - -
MDVx041604 Larutan Benedict botol Rp 84,700.0 - 0 - - - - - - -
MDVx105BJM Larutan Buffer Fosfat botol Rp 36,300.0 - 0 - - - - - - -
MDVx018552 Larutan Developer botol Rp 1,183,000.0 - 0 - - - - - - -
MDVx041584 Larutan Edta 10% botol Rp 151,250.0 - 0 - - - - - - -
MDVx041581 Larutan Eosin 2 % botol Rp 447,700.0 1 0 1 - - - 1 447,700 (1)
DRG000046739 Larutan Etanol Asam botol Rp 62,700.0 2 0 2 - - - 2 125,400 (2)
MDVx106BJM Larutan Eter alkohol botol Rp 68,200.0 - 0 - - - - - - -
MDVx018554 Larutan Fixer botol Rp 801,900.0 - 0 - - - - - - -
MDVx041704 Larutan Foucet botol Rp 176,000.0 - 0 - - - - - - -
MDVx041602 Larutan Giemsa Sain botol Rp 378,125.0 - 0 - - - - - - -
MDVx041700 Larutan hayem botol Rp 122,100.0 1 0 1 - - - 1 122,100 (1)
DRG000018188 Larutan Hidrogen Peroksida (H2O2) botol Rp 60,500.0 - 0 - - - - - - -
0 Larutan Iodium 1 % botol Rp 27,500.0 - 0 - - - - - - -
DRG000046764 Larutan Karbol Fuksin botol Rp 165,000.0 2 0 2 - - - 2 330,000 (2)
MDVx041583 Larutan KOH 10 % botol Rp 29,700.0 - 0 - - - - - - -
MDVx109BJM Larutan KOH 20 % botol Rp 40,700.0 - 0 - - - - - - -
MDVx041673 Larutan Lugol 1 % botol Rp 44,000.0 - 0 - - - - - - -
MDVx012323 Larutan Metilen Biru botol Rp 84,700.0 2 0 2 - - - 2 169,400 (2)
MDVx110BJM Larutan Natrium Citrat 3,8 % botol Rp 44,000.0 - 0 - - - - - - -
MDVx111BJM larutan safranin botol Rp 157,300.0 - 0 - - - - - - -
MDVx108BJM Larutan sodium hipoklorid 1 L botol Rp 110,000.0 - 0 - - - - - - -
0 Larutan sodium hipoklorid 100 ML botol Rp 18,634.0 5 0 5 - - - 5 93,170 (5)
MDVx041790 Larutan Turk botol Rp 39,600.0 1 0 1 - - - 1 39,600 (1)
DRG000046736 Larutan Xylol botol Rp 30,800.0 - 0 - - - - - - -
DRG000025457 Lipid Panel cardiocheck PA kotak Rp 1,721,516.9 - 0 - - - - - - -
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - -
0 M-30 CFL LYSE 500 ML Mindray botol Rp 2,100,000.0 - 0 - - - - - - -
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 - 1 1 - - - 1 2,050,000 (1)
0 M-30 E-Z Cleanser Mindray botol Rp 1,500,000.0 1 1 2 1 1,500,000 - 1 1,500,000 1
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 1 0 1 1 130,000 - - - 2 1
0 M-30 RINSE Mindray botol Rp 2,050,000.0 - 1 1 - - - 1 2,050,000 (1)
0 B30 Control Hematology Analyzer Mindray botol Rp 1,336,500.0 - 0 - - - - - - -
19
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Medonic Diluent 20 L botol Rp 3,400,100.0 - 0 - - - - - - -
0 Medonic Lyse 5 L botol Rp 5,550,600.0 - 0 - - - - - - -
DRG000025457 Metanol botol Rp 24,645.0 - 0 - - - - - - -
0 Norma cleaner botol Rp 1,910,000.0 - 0 - - - - - - -
0 Norma diluent diff botol Rp 1,910,000.0 - 0 - - - - - - -
0 Norma lyse diff botol Rp 2,625,000.0 - 0 - - - - - - -
MDVx112BJM Oil Imersi botol Rp 580,000.0 1 0 1 - - - 1 580,000 (1)
0 Pewarnaan Gram 1 % botol Rp 518,100.0 - 0 - - - - - - -
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 - 0 - - - - - - -
0 Rapid 2 Intec HIV stik Rp 40,800.0 - 0 - - - - - - -
0 Rapid 3 oncoprobe stik Rp 64,280.0 - 0 - - - - - - -
0 Rapid 4 right sign HIV stik Rp 35,120.0 1 0 1 - - - 1 35,120 (1)
0 Rapid 5 CTK Bioteck HIV stik Rp 30,250.0 1 0 1 - - - 1 30,250 (1)
0 Rapid 6 HIV Vikia stik Rp 21,818.0 - 0 - - - - - - -
0 Rapid 7 HIV Card Vcare stik Rp 30,250.0 - 0 - - - - - - -
Rapid 8 Fokus HIV stik Rp 4,179.0 - 0 - - - - - - -
0 Reagen Albumin biosystem kit Rp 800,000.0 - 0 - - - - - - -
Reagen albumin agappe / mindray kit Rp 1,400,000.0 - 0 - - - - - - -
0 Reagen Albumin randox kit Rp 917,250.0 - 0 - - - - - - -
MDVx114BJM Reagen Asam Urat biosystem kit Rp 2,805,000.0 - 0 - - - - - - -
0 Reagen Asam Urat agappe / mindray kit Rp 1,150,000.0 2 0 2 2 2,300,000 - - - 5
MDVx034902 Reagen Asam Urat randox kit Rp 1,225,700.0 - 0 - - - - - - -
0 Reagen Bilirubin Direct biosystem kit Rp 2,090,000.0 - 0 - - - - - - -
Reagen Bilirubin Direct agappe / mindray kit Rp 900,000.0 - 0 - - - - - - -
0 Reagen Bilirubin Direct randox kit Rp 970,000.0 - 0 - - - - - - -
0 Reagen Bilirubin Total biosystem kit Rp 2,090,000.0 - 0 - - - - - - -
Reagen Bilirubin Total agappe / mindray kit Rp 1,450,000.0 - 0 - - - - - - -
0 Reagen Bilirubin Total randox kit Rp 897,000.0 - 0 - - - - - - -
MDVx117BJM Reagen Cholesterol biosystem kit Rp 759,000.0 - 0 - - - - - - -
0 Reagen Cholesterol agappe / mindray kit Rp 1,150,000.0 2 0 2 2 2,300,000 - - - 5
MDVx034903 Reagen Cholesterol randox kit Rp 1,586,500.0 - 0 - - - - - - -
MDVx118BJM Reagen Cholesterol HDL biosystem kit Rp 2,040,000.0 - 0 - - - - - - -
Reagen Cholesterol HDL agappe / mindray kit Rp 8,225,000.0 - 0 - - - - - - -
0 Reagen Cholesterol HDL randox kit Rp 1,924,750.0 - 0 - - - - - - -
MDVx119BJM Reagen Creatinin biosystem kit Rp 1,572,725.0 - 0 - - - - - - -
Reagen Creatinin agappe / mindray kit Rp 850,000.0 - 0 - - - - - - -
0 Reagen Creatinin randox kit Rp 937,750.0 - 0 - - - - - - -
20
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx120BJM Reagen Glucose biosystem kit Rp 495,000.0 - 0 - - - - - - -
0 Reagen Glucose agappe / mindray kit Rp 1,450,000.0 2 0 2 2 2,900,000 - - - 5
MDVx034905 Reagen Glucose PAP randox kit Rp 1,803,400.0 - 0 - - - - - - -
0 Reagen golongan darah set-2 Rp 142,650.0 3 0 3 - - - 3 427,950 (3)
0 Reagen golongan darah set-4 Rp 355,480.0 - 0 - - - - - - -
MDVx344bjm Reagen HB Cyanida kit Rp 165,000.0 - 0 - - - - - - -
0 Reagen HB konsentrat biosystem kit Rp 308,000.0 - 0 - - - - - - -
0 Reagen HB konsentrat randox kit Rp 1,498,700.0 - 0 - - - - - - -
0 Reagen Protein Total biosystem kit Rp 545,000.0 - 0 - - - - - - -
Reagen Protein Total agappe / mindray kit Rp 700,000 - 0 - - - - - - -
0 Reagen Protein Total randox kit Rp 880,000 - 0 - - - - - - -
MDVx123BJM Reagen SGOT / AST biosystem kit Rp 715,000 - 0 - - - - - - -
0 Reagen SGOT / AST Mindray kit Rp 1,625,000 - 0 - - - - - - -
0 Reagen SGOT / AST randox kit Rp 1,435,700 - 0 - - - - - - -
MDVx124 Reagen SGPT / ALT biosystem kit Rp 715,000 - 0 - - - - - - -
0 Reagen SGPT / ALT mindray kit Rp 1,625,000 - 0 - - - - - - -
0 Reagen SGPT / ALT randox kit Rp 1,200,000 - 0 - - - - - - -
MDVx125BJM Reagen Trigliseride biosystem kit Rp 3,768,792 - 0 - - - - - - -
0 Reagen Trigliseride mindray kit Rp 1,950,000 2 0 2 2 3,900,000 - - - 5
0 Reagen Trigliseride randox kit Rp 1,879,650 - 0 - - - - - - -
MDVx126BJM Reagen Ureum biosystem kit Rp 1,550,000 - 0 - - - - - - -
0 Reagen Urea Mindray kit Rp 1,150,000 - 0 - - - - - - -
MDVx034850 Reagen Ureum randox kit Rp 2,380,150 - 0 - - - - - - -
MDVx041577 Reagen Wright Stain kit Rp 290,400 - 0 - - - - - - -
MDVx037823 reagent cholesterol pap sl (microlab/elitech) kit Rp 3,088,800 - 0 - - - - - - -
MDVx002BJM reagent cholesterol standar 200 mg/dl (microlab kit Rp 633,600 - 0 - - - - - - -
MDVx037816 reagent glucose pap sl (microlab/elitech) kit Rp 1,584,000 - 0 - - - - - - -
MDVx001BJM reagent glucose standar 100 mg/dl (microlab/el kit Rp 448,800 - 0 - - - - - - -
MDVx037822 reagent trigliserid mono sl (microlab/elitech) kit Rp 4,752,000 - 0 - - - - - - -
MDVx037603 reagent trigliserid standar 200 mg/dl (microlab/e kit Rp 475,200 - 0 - - - - - - -
MDVx037819 reagent uric acid mono sl (microlab/elitech) kit Rp 3,168,000 - 0 - - - - - - -
MDVx037604 reagent uric acid standar (microlab/elitech) kit Rp 580,800 - 0 - - - - - - -
0 Reagen Elitrol 1 Normal 1 x 5 ml (elitech) kit Rp 924,000 - 0 - - - - - - -
MDVx041674 Res eker botol Rp 144,100 1 0 1 - - - 1 144,100 (1)
0 RPR syfilis randox botol Rp 1,555,920 - 0 - - - - - - -
0 RPR syfilis Fokus Diagnostik botol Rp 4,250 - 0 - - - - - - -
RPR syfilis "Human" botol Rp 5,684 - 0 - - - - - - -
21
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Serum kontrol mindray (Qualichek normal mind botol Rp 1,200,000 - 0 - - - - - - -
DRG000046730 Spiritus 1 L botol Rp 53,900 6 0 6 - - - 6 323,400 (6)
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 50 0 50 25 119,900 - 25 119,900 35 50
0 Stik asam urat Nesco stik Rp 5,258 - 0 - - - - - - -
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 53 0 53 13 284,570 - 40 875,600 (9) 20
0 Stik Cholesterol Nesco stik Rp 24,090 - 0 - - - - - - -
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 0 15 - - - 15 108,570 (15)
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - 0 - - - - - - -
MDVx041511 Stik Gula Darah Accu cek stik Rp 8,327 - 0 - - - - - - -
0 Stik HB BeneCheck stik Rp 7,955 - 0 - - - - - - -
MDVx133BJM Stik HB Easy touch stik Rp 6,688 - 100 100 - - - 100 668,800 (100)
0 Stik HBSAb merek Intec stik Rp 27,478 - 0 - - - - - - -
0 Stik HBSAg merek SD stik Rp 9,870 - 0 - - - - - - -
Stik HBSAg merek Intec stik Rp 9,850 200 100 300 - - - 300 2,955,000 (300)
0 Stik Kehamilan stik Rp 1,947 150 0 150 - - - 150 292,050 (150)
0 Stik syphilis 'SD' stik Rp 35,429 - 0 - - - - - - -
Stik syphilis 'Monotest' stik Rp 10,758 - 0 - - - - - - -
Stik syphilis 'Human hexagonal' stik Rp 26,744 - 0 - - - - - - -
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - 0 - - - - - - -
MDVx138BJM Stik urinalisa 10 parameter (Lab U 11) stik Rp 2,274 - 0 - - - - - - -
0 Stik urinalisa 10 parameter Akray stik Rp 6,050 - 0 - - - - - - -
0 Stik urinalisa 10 prm (mission) stik Rp 2,700 - 0 - - - - - - -
0 Stik urinalisa 3 parameter stik Rp 5,720 - 0 - - - - - - -
0 Swelab alfa diluent 20 L botol Rp 6,500,000 - 0 - - - - - - -
0 Swelab alfa lyse 5 L botol Rp 8,500,000 - 0 - - - - - - -
0 Widal tes 4 set 4 set Rp 291,640 1 0 1 - - - 1 291,640 (1)
0 Widal tes 6 set 6 set Rp 279,140 - 0 - - - - - - -
0 Ziehl Nielseen Stain paket Rp 273,978 2 1 3 1 273,978 - 2 547,956 0
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
22
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 32,261,628 118,845,424
UMUM
JUMLAH
JUMLAH KUNJUNGAN RESEP BAYAR TDK BYR JKN
1146 324 1470
Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

Plt. Kepala Dinas Kesehatan Kab/Kota Kepala UPTD Instalasi Farmasi Kepala Puskesmas Petugas Puskesmas
H. Lukman Hakim,SKM,M.AP Yohana Rusnayuda,S.Si.,Apt. Rusmadi, SKM, MA M. Ary Aprian Noor, S.Far,Apt
NIP.19610409 198511 1 001 NIP. 19790311 200501 2 015 NIP.19680616 198911 1 001 NIP.19840410 200803 1 002
23
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 994 0 994 50 4,950 - 944 93,456 (824)
Aminofilin tablet 200 mg tablet Rp 86.0 690 0 690 - - - 690 59,340 (690)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 4,820 0 4,820 1,510 114,760 - 3,310 251,560 314 1600
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 177 100 277 86 373,670 - 191 829,895 15 100
Ampisilin serbuk injeksi i.m.i.v 1000 mg/ml vial Rp 9,524.0 - 10 10 10 95,240 - - - 24
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 4,038 1000 5,038 1,110 62,160 - 3,928 219,968 (1,264) 1000
DRG000002883 Antasida sirup botol Rp 2,098.0 38 100 138 21 44,058 - 117 245,466 (67) 100
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 686 1300 1,986 1,570 188,400 - 416 49,920 3,352 1300
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 - 0 - - - - - - - 500
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 48 50 98 23 31,579 - 75 102,975 (20) 50
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 2,624 0 2,624 183 6,222 - 2,441 82,994 (2,002)
24
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 400 0 400 - - - 400 41,200 (400)
DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 628 300 928 362 43,802 - 566 68,486 303 300
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 7,600 0 7,600 630 34,650 - 6,970 383,350 (5,458)
DRG000032665 Fitomenadion ( vit k 1 ) inj 10 mg / ml - 1 ml ampul Rp 5,516.5 12 270 282 270 1,489,455 - 12 66,198 636
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 760 0 760 20 1,580 - 740 58,460 (692)
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 572 200 772 95 39,710 - 677 282,986 (449)
DRG000017209 Gentamisin inj 40 mg/2 ml ampul Rp 4,989.6 - 15 15 15 74,844 - - - 36
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 - 0 - - - - - - -
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 515 0 515 180 9,900 - 335 18,425 97 200
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 360 0 360 - - - 360 20,160 (360) 100
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 757 0 757 - - - 757 123,391 (757)
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 1,600 500 2,100 640 71,680 - 1,460 163,520 76 500
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 900 0 900 - - - 900 262,800 (900)
DRG000020665 Isoniazid tablet 100 mg tablet Rp 79.0 100 0 100 - - - 100 7,900 (100)
25
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 190 0 190 - - - 190 16,910 (190)
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 967 200 1,167 210 23,100 - 957 105,270 (453) 600
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 300 0 300 60 14,040 - 240 56,160 (96)
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 193 0 193 193 55,198 - - - 463 300
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 640 0 640 - - - 640 176,000 (640)
Kloramfenikol salep mata 1 % tube Rp 1,925.0 47 0 47 47 90,475 - - - 113 100
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 61 0 61 2 9,964 - 59 293,938 (54)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 4,920 2000 6,920 1,857 44,568 - 5,063 121,512 (606) 1000
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 70 0 70 - - - 70 10,360 (70) 300
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 310 0 310 20 13,140 - 290 190,530 (242)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 1,125 0 1,125 72 9,000 - 1,053 131,625 (880)
DRG000010167 Kotrimoksazol suspensi botol Rp 2,052.0 - 200 200 12 24,624 - 188 385,776 (159) 200
DRG000023410 Lidocain injeksi 2 % ampul Rp 1,319.0 5 0 5 5 6,595 - - - 12 50
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 56 30 86 - - - 86 113,262 (86) 30
DRG000023922 Loratadin tablet tablet Rp 127.0 1,835 0 1,835 120 15,240 - 1,715 217,805 (1,427)
DRG000024328 Magnesium sulfat inj ( 1V ) 40 % - 25 ml vial Rp 3,796.0 10 15 25 15 56,940 - 10 37,960 26
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 732 0 732 290 29,580 - 442 45,084 254 100
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 80 0 80 20 5,476 - 60 16,428 (12)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 2,586 0 2,586 230 37,950 - 2,356 388,740 (1,804)
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 - 0 - - - - - - - 500
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 - 300 300 - - - 300 60,900 (300) 500
DRG000025979 Miconazol krim tube Rp 2,577.0 - 48 48 2 5,154 - 46 118,542 (41) 50
DRG000026103 Mineral mix serbuk 8 gr sachet Rp 3,055.0 40 0 40 - - - 40 122,200 (40)
26
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 1,045 0 1,045 640 90,880 - 405 57,510 1,131 500
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,500 0 2,500 - - - 2,500 340,000 (2,500)
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 81 0 81 7 4,515 74 47,730 - - 17 50
Obat antituberkulosis anak paket Rp 267,400.0 - 0 - - - - - - -
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 - 0 - - - - - - -
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 - 0 - - - - - - -
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 1,353 0 1,353 280 38,640 - 1,073 148,074 (401)
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 - 8000 8,000 5,063 303,780 - 2,937 176,220 9,214 4000
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 1,325 0 1,325 200 28,200 - 1,125 158,625 (645)
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 922 0 922 - - - 922 167,343 (922) 300
DRG000034345 Prokain benzil penisilin 3 juta iu / vial injeksi vial Rp 1.0 - 30 30 30 30 - - - 72
DRG000035403 Ranitidin tablet tablet Rp 122.0 940 1200 2,140 710 86,620 - 1,430 174,460 274 700
DRG000044394 Retinol ( Vit A ) 100.000 IU kapsul kapsul Rp 585.0 - 0 - - - - - - -
DRG000044395 Retinol ( Vit A ) 200.000 IU kapsul kapsul Rp 519.2 - 0 - - - - - - -
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 245 100 345 87 5,568 - 258 16,512 (49)
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,086 0 1,086 40 3,080 - 1,046 80,542 (950)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 71 0 71 - - - 71 214,207 (71)
27
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 2,090 0 2,090 390 42,900 - 1,700 187,000 (764) 500
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 1,950 0 1,950 190 16,720 - 1,760 154,880 (1,304)
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 1,150 0 1,150 40 24,160 - 1,110 670,440 (1,014)
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - -
Acdat salep tube Rp 6,241.0 - 0 - - - - - - - 50
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 0 200 - - 200 175,600 - - - 100
Alprazolam 1 mg tablet Rp 120.0 552 0 552 - - - 552 66,240 (552)
DRG000001574 Ambroxol sirup botol Rp 3,300.0 369 0 369 131 432,300 - 238 785,400 76 100
DRG000001791 Ambroxol tablet tablet Rp 100.0 1,389 0 1,389 426 42,600 - 963 96,300 59 300
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 3,853 0 3,853 1,030 97,850 - 2,823 268,185 (351) 600
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 69 0 69 8 29,136 - 61 222,162 (42)
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 260 0 260 30 31,050 - 230 238,050 (158)
DRG000003089 Apialis Drops botol Rp 21,175.0 - 0 - - - - - - -
28
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 58 0 58 24 792,000 - 34 1,122,000 24 100
DRG000003393 Aqua proinjeksi steril,bebas pirogen vial Rp 2,860.0 28 0 28 7 20,020 - 21 60,060 (4)
DRG000003466 Arkavit tablet Rp 320.0 1,625 0 1,625 535 171,200 - 1,090 348,800 194
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 580 0 580 50 77,925 - 530 826,005 (410)
DRG000004142 Atrovent HFA kotak Rp 83,500.0 - 0 - - - - - - - 10
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 299 0 299 50 88,900 - 249 442,722 (129)
Baby Cough sirup botol Rp 3,999.6 211 0 211 26 103,990 - 185 739,926 (123)
DRG000005736 Bioplacenton Cream tube Rp 18,499.8 20 0 20 - - - 20 369,996 (20)
Buscopan tablet tablet Rp 3,100.0 170 0 170 60 186,000 - 110 341,000 34
Cendo Lyteers tetes mata botol Rp 25,999.6 30 0 30 2 51,999 - 28 727,989 (23)
DRG000011365 Depakene sirup botol Rp 17,789.0 6 0 6 - - - 6 106,734 (6)
29
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 180 0 180 20 6,320 - 160 50,560 (112)
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 100 100 200 100 15,800 - 100 15,800 140 100
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 175 0 175 60 64,380 - 115 123,395 29 120
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 87 0 87 - - - 87 225,330 (87)
Flukonazol tab 150 mg tablet Rp 24,200.0 25 0 25 25 605,000 - - - 60 200
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 19 0 19 1 4,889 - 18 88,002 (16) 20
Gemfibrozil 300 mg tablet Rp 428.0 710 0 710 - - - 710 303,880 (710)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 78 0 78 14 34,989 - 64 159,949 (30)
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 - 48 48 2 9,770 - 46 224,710 (41)
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 46 0 46 - - - 46 160,959 (46)
Glimepirid tab 2 mg tablet Rp 207.0 450 0 450 20 4,140 - 430 89,010 (382)
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 1,290 1600 2,890 1,763 158,670 - 1,127 101,430 3,104 1600
30
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 781 0 781 255 216,747 - 526 447,095 86 300
Hidrokortison krim 1% tube Rp 5,723.3 34 0 34 4 22,893 - 30 171,699 (20)
Interhistin tablet tablet Rp 880.0 - 0 - - - - - - - 200
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 1,475 0 1,475 390 233,610 - 1,085 649,915 (149)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 - 500 500 20 2,500 - 480 59,995 (432) 500
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 50 0 50 5 12,885 - 45 115,965 (33)
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 - 0 - - - - - - -
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 110 0 110 - - - 110 123,310 (110)
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - 0 - - - - - - -
Lanzoprazol tablet Rp 330.0 725 0 725 230 75,900 - 495 163,350 57
DRG000023225 L-Bio sachet sachet Rp 4,033.3 430 0 430 18 72,599 - 412 1,661,720 (369)
31
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023860 Livertran salep tube Rp 4,600.0 119 0 119 12 55,200 - 107 492,200 (78)
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 1,257 0 1,257 140 377,146 - 1,117 3,009,086 (781)
DRG000023935 Loperamida tablet tablet Rp 85.0 300 0 300 - - - 300 25,500 (300)
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 - 0 - - - - - - -
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 630 0 630 - - - 630 504,000 (630)
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 1,805 0 1,805 470 305,500 - 1,335 867,750 (207)
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 639 0 639 - - - 639 63,261 (639)
DRG000027470 Mometason furoat krim 0,1 % tube Rp 7,912.0 - 0 - - - - - - -
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 10 0 10 10 51,700 - - - 24 3
DRG000029080 Nopres 20 mg tablet tablet Rp 883.3 230 0 230 - - - 230 203,159 (230)
Novastan sirup botol Rp 12,650.0 47 0 47 1 12,650 - 46 581,900 (44)
Noza tablet tablet Rp 797.5 560 0 560 184 146,740 - 376 299,860 66 200
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 90 0 90 24 119,988 - 66 329,967 (8) 100
32
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 - 0 - - - - - - -
DRG000002552 Pil KB I tablet Rp 1,350.0 270 0 270 57 76,950 - 213 287,550 (76)
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - 0 - - - - - - -
Pim-Tra-Kol sirup botol Rp 9,999.0 - 0 - - - - - - -
PP Isoniazide 100 mg tablet Rp 79.0 - 0 - - - - - - -
Prenatin DF tablet tablet Rp 3,258.3 - 480 480 - - - 480 1,563,984 (480) 500
DRG000034697 Primolut N tablet Rp 2,618.0 - 0 - - - - - - - 100
Pularex tablet tablet Rp 175.0 770 0 770 80 14,000 - 690 120,750 (498)
33
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 190 0 190 36 217,048 - 154 928,481 (68) 100
Sangobion Kids Sirup botol Rp 24,515.7 - 0 - - - - - - -
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 60 0 60 - - - 60 688,500 (60)
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 674 0 674 10 22,990 - 664 1,526,536 (640)
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 306 500 806 230 22,310 - 576 55,872 (24) 300
Stimuno Sirup botol Rp 18,500.0 53 0 53 - - - 53 980,500 (53)
DRG000040195 Synarcus krim tube Rp 2,534.0 - 50 50 5 12,670 - 45 114,030 (33) 50
34
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Taburia sachet Rp 1,000.0 - 0 - - - - - - -
DRG000041013 Tetagam ampul Rp 176,800.0 - 0 - - - - - - -
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 70 100 170 10 8,900 - 160 142,400 (136) 100
DRG000042713 Truvit drops botol Rp 36,499.1 124 0 124 52 1,897,953 - 72 2,627,935 53 100
Truvit sirup botol Rp 11,400.0 - 150 150 19 216,600 - 131 1,493,400 (85)
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 300 0 300 20 36,300 - 280 508,200 (232)
Vastral tablet Rp 605.0 - 0 - - - - - - -
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 4 20 24 - - - 24 264,000 (24) 10
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 3,510 0 3,510 610 29,890 - 2,900 142,100 (1,436)
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 41 0 41 20 65,700 - 21 68,985 27 100
- 0 - - - - - - -
II.OBAT GIGI - 0 - - - - - - -
35
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 1 0 1 - - - 1 252,950 (1)
0 Cotton pelet pack Rp 247,500.0 5 0 5 1 247,500 - 4 990,000 (2)
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 0 1 - - - 1 164,950 (1)
DRG000014675 Eugenol cairan botol Rp 136,400.0 3 0 3 - - - 3 409,200 (3)
0 G aenial bond kotak Rp 875,578.0 - 1 1 1 875,578 - - - 2 1
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 3 0 3 - - - 3 1,930,500 (3)
0 Jarum Dental cytoject pcs Rp 2,662.0 - 200 200 200 532,400 - - - 480
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 4 0 4 - - - 4 300,960 (4)
0 Oco Tooth Clensing botol Rp 191,999.0 1 2 3 - - - 3 575,997 (3) 1
36
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Tampon pack Rp 300,000.0 6 0 6 - - - 6 1,800,000 (6)
0 Topical anastesi pasta kotak Rp 302,500.0 4 0 4 - - - 4 1,210,000 (4)
- 0 - - - - - - -
III. BMHP - 0 - - - - - - -
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 567 0 567 - - - 567 936,117 (567)
DRG000001226 Alkohol Swab lembar Rp 105.0 1,000 0 1,000 - - - 1,000 105,000 (1,000)
0 Bioplacenton tulle pcs Rp 10,920.0 65 0 65 - - - 65 709,800 (65)
MDVx002305 Blood Lancet pcs Rp 176.0 650 0 650 - - - 650 114,400 (650)
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - 2 279,000 (2)
37
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx023244 Coverplast pcs Rp 470.0 2 0 2 - - - 2 940 (2)
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - -
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - -
MDVx026876 Infusiun set dewasa pcs Rp 4,176.0 4 0 4 1 4,176 - 3 12,528 (1)
MDVx022261 Jelly (Aquagel) botol Rp 31,027.3 1 2 3 - - - 3 93,082 (3) 2
38
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 0 80 - - - 80 200,000 (80)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 15 0 15 - - - 15 36,855 (15)
MDVx013360 Kertas Thermal roll Rp 94,500.0 - 0 - - - - - - -
0 Klorin botol Rp 15,970.0 52 0 52 - - - 52 830,440 (52)
0 Kondom pcs Rp 716.7 150 288 438 174 124,706 - 264 189,209 154 200
Markerpen pcs Rp 1.0 70 0 - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 - 0 - - - - - - -
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - -
0 Pharmafix pcs Rp 27,000.0 8 0 8 - - - 8 216,000 (8)
39
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - 0 - - - - - - -
0 safety box* pcs Rp 16,500.0 91 0 91 - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 0 300 - - - 300 495,000 (300)
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - 0 - - - - - - -
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 5 0 5 - - - 5 41,775 (5)
0 Surgical Gloves non steril uk L pcs Rp 462.0 1,000 0 1,000 200 92,400 - 800 369,600 (320)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 800 200 1,000 200 74,800 - 800 299,200 (320)
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 800 200 1,000 200 92,400 - 800 369,600 (320) 300
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,050 0 2,050 750 346,500 - 1,300 600,600 500 1000
40
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - -
IV. REAGEN - 0 - - - - - - -
DRG000014470 Etanol 70 % 1 Liter botol Rp 41,800.0 23 0 23 1 41,800 - 22 919,600 (20)
41
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000046732 Larutan Asam asetat 5% botol Rp 19,500.0 2 0 2 - - - 2 39,000 (2)
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - -
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 1 0 1 - - - 1 2,050,000 (1)
0 M-30 E-Z Cleanser Mindray botol Rp 1,500,000.0 1 0 1 - - - 1 1,500,000 (1)
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 - 0 - - - - - - - 1
0 M-30 RINSE Mindray botol Rp 2,050,000.0 1 0 1 - - - 1 2,050,000 (1)
42
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 - 0 - - - - - - -
0 Rapid 2 Intec HIV stik Rp 40,800.0 - 0 - - - - - - - 30
0 Rapid 3 oncoprobe stik Rp 64,280.0 - 0 - - - - - - - 30
0 Reagen Asam Urat agappe / mindray kit Rp 1,150,000.0 - 0 - - - - - - -
0 Reagen Cholesterol agappe / mindray kit Rp 1,150,000.0 - 0 - - - - - - -
43
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Reagen Glucose agappe / mindray kit Rp 1,450,000.0 - 0 - - - - - - -
0 Reagen golongan darah set-2 Rp 142,650.0 3 0 3 1 142,650 - 2 285,300 0
0 Reagen Trigliseride mindray kit Rp 1,950,000 - 0 - - - - - - -
RPR syfilis "Human" botol Rp 5,684 - 0 - - - - - - -
44
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 25 0 25 - - - 25 119,900 (25) 50
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 40 0 40 20 437,800 - 20 437,800 28 40
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 0 15 - - - 15 108,570 (15)
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - 0 - - - - - - -
MDVx041511 Stik Gula Darah Accu cek stik Rp 8,327 - 0 - - - - - - -
MDVx133BJM Stik HB Easy touch stik Rp 6,688 100 0 100 50 334,400 - 50 334,400 70 50
0 Stik HBSAg merek SD stik Rp 9,870 - 0 - - - - - - -
0 Stik syphilis 'SD' stik Rp 35,429 - 0 - - - - - - -
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - 0 - - - - - - -
0 Widal tes 4 set 4 set Rp 291,640 1 0 1 - - - 1 291,640 (1)
0 Ziehl Nielseen Stain paket Rp 273,978 2 0 2 - - - 2 547,956 (2)
45
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
TOTAL 17,039,106 114,320,952
UMUM
JUMLAH
1021 346 1367

NIP.19610409 198511 1 001 NIP. 19790311 200501 2 015 NIP.19680616 198911 1 001 NIP.19840410 200803 1 002
46
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000000983 Albendazol tablet 400 mg tablet Rp 323.0 - - - - - - - -
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 944 944 10 990 - 934 92,466 (910)
DRG000001666 Aminofilin injeksi 24 mg/ml-10 ml ampul Rp 4,204.0 - - - - - - - -
Aminofilin tablet 200 mg tablet Rp 86.0 690 690 - - - 690 59,340 (690)
DRG000001769 Amitriptilin Hcl tablet salut 25 mg tablet Rp 168.0 110 110 - - - 110 18,480 (110)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 3,310 300 3,610 1,445 109,820 - 2,165 164,540 1,303 2000
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 191 100 291 131 569,195 - 160 695,200 154
Ampisilin serbuk injeksi i.m.i.v 1000 mg/ml vial Rp 9,524.0 - - - - - - - -
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 3,928 1000 4,928 1,420 79,520 - 3,508 196,448 (100) 2000
DRG000002883 Antasida sirup botol Rp 2,098.0 117 100 217 23 48,254 - 194 407,012 (139)
DRG000002996 Antifungi doen kombinasi tube Rp 5,170.0 24 24 - - - 24 124,080 (24)
Artemether injeksi 80 Mg ampul Rp 29,925.0 - - - - - - - -
Artesunate cairan injeksi 60 mg ampul Rp 33,835.0 - - - - - - - -
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 416 1300 1,716 988 118,560 - 728 87,360 1,643 1600
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 - - - - - - - - 500
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 - - - - - - - - 2000
DRG000003731 Asiklovir 200 mg tablet tablet Rp 236.0 2,187 2,187 10 2,360 - 2,177 513,772 (2,153)
DRG000000605 Asiklovir 400 mg tablet tablet Rp 425.0 2,100 2,100 60 25,500 - 2,040 867,000 (1,896)
DRG000003947 Atropin Sulfat tablet 0,5 mg tablet Rp 26.2 - - - - - - - -
DRG000004829 Benzatin Benzil Penisilin inj 1,2 juta iu/vial vial Rp 10,780.0 - - - - - - - -
DRG000004830 Benzatin Benzil Penisilin inj 1,4 juta iu/vial vial Rp 14,740.0 - - - - - - - -
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 75 50 125 26 35,698 - 99 135,927 (37) 50
Clindamisin kapsul 300 mg kapsul Rp 1,017.0 - - - - - - - -
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 2,441 2,441 342 11,628 - 2,099 71,366 (1,278)
DRG000011634 Deksametason inj 5 mg/ml-1 ml ampul Rp 1,805.0 22 22 - - - 22 39,710 (22)
47
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

Piperaquin) tab tablet Rp 2,160.0 100 100 - - 100 216,000 (100)
Diazepam inj 5 mg/ml-2 ml ampul Rp 1,913.0 5 5 - - - 5 9,565 (5)
DRG000012224 Diazepam tablet 2 mg tablet Rp 220.0 183 183 5 1,100 - 178 39,160 (166)
Diazepam tablet 5 mg tablet Rp 109.0 - - - - - - - -
Dietilkarbamazin sitrat tablet 100 mg tablet Rp 180.0 - - - - - - - -
DRG000012294 Difenhidramin Hcl inj 10 mg/ml-1 ml ampul Rp 1,262.0 - - - - - - - -
DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 400 400 - - - 400 41,200 (400)
DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 566 300 866 180 21,780 - 686 83,006 (254) 400
DRG000012885 Doksisiklin 100 mg kapsul kapsul Rp 299.0 - - - - - - - -
DRG000013853 Epinefrin Hcl/Bitartrat(adrenalin)inj 0,1 %-1 ml ampul Rp 1,518.0 17 17 - - - 17 25,806 (17)
DRG000014229 Erytromisin sirup botol Rp 6,390.0 - - - - - - - -
DRG000014234 Erytromisin 500 mg kaplet tablet Rp 781.0 - - - - - - - -
DRG000046712 Etambutol 500 mg tablet tablet Rp 466.0 - - - - - - - -
DRG000027466 Fenitoin kapsul 50 mg kapsul Rp 1.0 - - - - - - - - 100
DRG000015393 Fenobarbital inj 50 mg / ml - 2 ml ampul Rp 2,135.0 - - - - - - - -
DRG000032549 Fenobarbital tablet 30 mg tablet Rp 197.0 192 192 - - 192 37,824 - - -
Ferrous sulphate tab selaput 300 mg tablet Rp 1.0 - - - - - - - -
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 6,970 6,970 850 46,750 - 6,120 336,600 (4,080)
DRG000015698 Fitomenadion ( vit k 1 ) tablet salut 10 mg tablet Rp 818.0 471 471 130 106,340 - 341 278,938 (29) 200
DRG000032665 Fitomenadion ( vit k 1 ) inj 10 mg / ml - 1 ml ampul Rp 5,516.5 12 12 - - - 12 66,198 (12)
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 740 740 30 2,370 - 710 56,090 (638)
Furosemid Cairan Injeksi 10 mg/ml ampul Rp 2,781.1 - - - - - - - -
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 677 677 88 36,784 - 589 246,202 (378)
DRG000017209 Gentamisin inj 40 mg/2 ml ampul Rp 4,989.6 - - - - - - - -
DRG000017209 Gentamisin inj 80 mg/2 ml ampul Rp 2,750.0 - - - - - - - -
DRG000017398 Glibenklamid tablet 5 mg tablet Rp 137.0 2,975 2,975 60 8,220 - 2,915 399,355 (2,771)
DRG000017435 Glimepirid tab 1 mg tablet Rp 194.0 220 220 60 11,640 - 160 31,040 (16)
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 - - - - - - - -
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 360 100 460 45 2,520 - 415 23,240 (307) 100
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 757 757 30 4,890 - 727 118,501 (655)
DRG000019279 Hidrokortison krim 2,5 % tube Rp 2,533.0 - - - - - - - -
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 1,460 500 1,960 180 20,160 - 1,780 199,360 (1,348) 500
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 900 900 10 2,920 - 890 259,880 (866)
DRG000020665 Isoniazid tablet 100 mg tablet Rp 79.0 100 100 - - - 100 7,900 (100)
48
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020671 Isoniazid tablet 300 mg tablet Rp 173.0 - - - - - - - -
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 190 190 - - - 190 16,910 (190)
DRG46597 Kalsium Gluconas inj ampul Rp 1.0 - - - - - - - -
Kalsium Karbonat tablet 500 mg tablet Rp 1.0 - - - - - - - -
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 957 600 1,557 120 13,200 - 1,437 158,070 (1,149) 600
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 240 240 70 16,380 - 170 39,780 (2)
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 - - - - - - - - 300
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 640 640 - - - 640 176,000 (640)
Kloramfenikol salep 2 % tube Rp 1.0 - - - - - - - -
Kloramfenikol salep mata 1 % tube Rp 1,925.0 - 100 100 5 9,625 - 95 182,875 (83) 100
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 59 59 - - - 59 293,938 (59)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 5,063 1000 6,063 1,448 34,752 - 4,615 110,760 (1,140) 2000
Klorpromazin Hcl inj 5 mg / ml - 2 ml ampul Rp 376.0 - - - - - - - -
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 70 70 70 10,360 - - - 168 400
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 290 290 50 32,850 - 240 157,680 (120)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 1,053 1,053 100 12,500 - 953 119,125 (713)
DRG000010167 Kotrimoksazol suspensi botol Rp 2,052.0 188 200 388 33 67,716 - 355 728,460 (276)
DRG000021836 Kuinine tablet salut selaput 200 mg tablet Rp 310.7 - - - - - - - -
Kuinine Dihydrochloride cairan inj 25%-2 ml ampul Rp 2,616.1 - - - - - - - -
DRG000023410 Lidocain injeksi 2 % ampul Rp 1,319.0 - - - - - - - -
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 86 30 116 30 39,510 - 86 113,262 (14) 30
DRG000023922 Loratadin tablet tablet Rp 127.0 1,715 1,715 190 24,130 - 1,525 193,675 (1,069)
DRG000024327 Magnesium sulfat inj ( 1V ) 20 % - 25 ml vial Rp 3,200.0 2 2 - - - 2 6,400 (2)
DRG000024328 Magnesium sulfat inj ( 1V ) 40 % - 25 ml vial Rp 3,796.0 10 10 - - - 10 37,960 (10)
DRG000043759 Mebendazol tablet 100 mg (vermox) tablet Rp 7,854.0 - - - - - - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 442 100 542 90 9,180 - 452 46,104 (236) 100
DRG000025481 Metformin tab 850 mg tablet Rp 165.0 140 140 - - - 140 23,100 (140)
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 60 60 10 2,738 - 50 13,690 (26) 100
DRG000025567 Metilergometrin maleat inj 0,200 mg - 1 ml ampul Rp 3,399.0 9 9 - - - 9 30,591 (9)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 2,356 2,356 353 58,245 - 2,003 330,495 (1,156)
DRG000025667 Metilprednisolon 16 mg tablet tablet Rp 875.0 - - - - - - - -
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 - 300 300 16 1,328 - 284 23,572 (246) 500
DRG000025793 Metronidazol tablet 250 mg tablet Rp 94.0 - - - - - - - - 300
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 300 500 800 40 8,120 - 760 154,280 (664) 500
Metronidazol suspension 125 mg/ml botol Rp 3,800.0 - - - - - - - -
DRG000025979 Miconazol krim tube Rp 2,577.0 46 50 96 5 12,885 - 91 234,507 (79) 50
DRG000026103 Mineral mix serbuk 8 gr sachet Rp 3,055.0 40 40 - - - 40 122,200 (40)
49
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038915 Natrium Bikarbonat tablet 500 mg tablet Rp 9.8 - - - - - - - -
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 405 405 220 31,240 - 185 26,270 343 500
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,500 2,500 380 51,680 - 2,120 288,320 (1,208)
(Euthyrox) tablet Rp 850.0 - - - - - - -
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 210 210 10 1,800 200 35,999 - - 24 300
Nicotinamida tablet 20 mg tablet Rp 1.0 - - - - - - - - -
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 74 50 124 5 3,225 - - 119 76,755 (107)
Obat antituberkolusis katagori 1 paket Rp 395,900.0 - - - - - - - - -
Obat antituberkolusis katagori 2 paket Rp 1,379,984.0 - - - - - - - - -
Obat antituberkulosis anak paket Rp 267,400.0 - - - - - - - - - 1
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 - - - - - - - - - 3
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 - - - - - - - - - 1
DRG000031217 Oksitetrasiklin Hcl salep mata 1 % tube Rp 2,600.0 - - - - - - - - -
DRG000031235 Oksitosin injeksi 10 iu / ml ampul Rp 1,232.0 15 15 - - - - 15 18,480 (15)
DRG000030245 Omeprazol inj 40 mg/10 ml ampul Rp 18,537.0 - - - - - - - - -
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 1,073 1,073 200 27,600 - - 873 120,474 (393)
DRG000031912 Parasetamol sirup 120 mg / 5 ml botol Rp 1,160.0 230 300 530 185 214,600 - - 345 400,200 99 300
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 2,937 4000 6,937 3,220 193,200 - - 3,717 223,020 4,011 5000
DRG000034958 Pirantel pamoat 125 mg tablet tablet Rp 318.0 - - - - - - - - -
DRG000034959 Pirantel suspensi 5 mg/ml botol Rp 9,100.0 - - - - - - - - -
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 1,125 1,125 350 49,350 - - 775 109,275 65 400
DRG000032952 Piridoksin Hcl tablet 25 mg tablet Rp 40.5 - - - - - - - - -
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 922 100 1,022 10 1,815 - - 1,012 183,678 (988)
DRG000033915 Primakuin tablet 15 mg tablet Rp 258.0 - - - - - - - - -
DRG000034345 Prokain benzil penisilin 3 juta iu / vial injeksi vial Rp 1.0 - - - - - - - - -
DRG000034487 Propanolol Hcl tablet 40 mg tablet Rp 300.0 200 200 - - 200 59,998 - - - 100
DRG000034502 Propiltiourasil tablet 100 mg tablet Rp 500.0 100 100 - - - - 100 50,001 (100)
DRG000035403 Ranitidin tablet tablet Rp 122.0 1,430 700 2,130 630 76,860 - - 1,500 183,000 12 1000
DRG000044394 Retinol ( Vit A ) 100.000 IU kapsul kapsul Rp 585.0 - - - - - - - - -
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 258 258 74 4,736 - - 184 11,776 (6) 200
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,046 1,046 10 770 - - 1,036 79,772 (1,012)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 71 71 - - - - 71 214,207 (71)
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 1,630 1,630 70 34,440 - - 1,560 767,520 (1,392)
DRG000007256 Sefadroxil syp kering 125 ml / 5 ml botol Rp 4,086.0 193 193 10 40,860 - - 183 747,738 (159)
Sianokobalamin ( Vit.B.12 ) inj 500 mcg / ml ampul Rp 1,067.0 - - - - - - - - -
50
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 1,700 510 2,210 290 31,900 - - 1,920 211,200 (1,224) 500
DRG000008829 Siprofloksasin 500 mg tablet tablet Rp 281.0 1,615 1,615 30 8,430 - - 1,585 445,385 (1,513)
Tetrasiklin Hcl kapsul 250 mg kapsul Rp 73.0 - - - - - - - - -
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 1,760 1,760 770 67,760 - - 990 87,120 858
DRG000042321 Triheksilfenidil hidroklorida tablet 2 mg tablet Rp 95.0 295 300 595 230 21,850 - - 365 34,675 187 600
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 1,902 2500 4,402 1,677 226,395 - - 2,725 367,875 1,300 3000
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 1,110 1,110 260 157,040 - - 850 513,400 (226) 300
DRG000043194 Vaksin BCG vial Rp 59,950.0 - - - - - - - - -
Vaksin Jerap D T vial Rp 17,798.0 - - - - - - - - -
Vaksin CAMPAK 10 Dosis vial Rp 28,204.0 5 5 - - - - 5 141,020 (5)
Vaksin POLIO 10 Dosis vial Rp 19,954.0 15 15 - - - - 15 299,310 (15)
Vaksin HEPATITIS B 0,5 ml ADS vial Rp 20,900.0 - - - - - - - - -
DRG000043208 Pentabio Vaksin DTP-HB-HIB inj vial Rp 76,285.0 - - - - - - - - -
DRG000043266 Vaksin Td vial Rp 16,500.0 - - - - - - - - -
Vaksin IPV (Poliomyelitis Vaccine inj (ShanIPV vial Rp 152,900.0 - - - - - - - - -
Vaksin MR vial Rp 141,648.0 - - - - - - - - -
Acdat salep tube Rp 6,241.0 - - - - - - - - - 50
DRG000000325 Air untuk irigasi lar infus 1000 ml botol Rp 22,000.0 - - - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 200 - - - - 200 175,600 (200) 100
DRG000001441 Albendazol suspensi 200mg/5 ml botol Rp 4,600.0 - - - - - - - - -
DRG000001442 Alprazolam 0,5 mg tablet Rp 88.0 - - - - - - - - -
Alprazolam 1 mg tablet Rp 120.0 552 552 - - 552 66,240 - - -
DRG000001592 Alvit drops botol Rp 12,500.0 - - - - - - - - -
DRG000001574 Ambroxol sirup botol Rp 3,300.0 238 100 338 58 191,400 - - 280 924,000 (141)
DRG000001791 Ambroxol tablet tablet Rp 100.0 963 300 1,263 470 47,000 - - 793 79,300 335 500
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 2,823 2,823 620 58,900 - - 2,203 209,285 (715) 1000
Amoksisilin 250 mg tablet Rp 196.0 - - - - - - - - -
Anemolat 1 mg tablet tablet Rp 77.0 - - - - - - - - -
DRG000002721 Antalgin (Metampiron) tablet 500 mg tablet Rp 67.0 - - - - - - - - -
DRG000002981 Antalgin injeksi 250 mg/5 ml ampul Rp 407.8 - - - - - - - - -
DRG000003002 Anti bakteri doen salep kombinasi tube Rp 3,490.0 - - - - - - - - -
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 61 61 12 43,704 - - 49 178,458 (20)
DRG000023225 Antimigrain doen kombinasi tablet Rp 149.0 - - - - - - - - -
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 230 230 50 51,750 - - 180 186,300 (60)
Antrain inj ampul Rp 11,999.2 - - - - - - - - -
DRG000003089 Apialis Drops botol Rp 21,175.0 - - - - - - - - -
51
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 34 34 - - - - 34 1,122,000 (34) 100
DRG000003393 Aqua proinjeksi steril,bebas pirogen vial Rp 2,860.0 21 21 - - - - 21 60,060 (21)
DRG000003466 Arkavit tablet Rp 320.0 1,090 1,090 1,005 321,600 - - 85 27,200 2,327 2000
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 58 58 - - - - 58 8,932 (58)
DRG000003564 Asam Asetilsalisilat tablet 500 mg (Asetosal) tablet Rp 99.6 - - - - - - - - -
Asam askorbat(vit C) tablet 250 mg tablet Rp 150.0 - - - - - - - - -
DRG000003595 Asam Folat 5 mg tablet tablet Rp 63.5 - - - - - - - - -
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 530 530 20 31,170 - - 510 794,835 (462)
DRG000000595 Asam Traneksamat injeksi 5 % 250 mg/ 5 ml ampul Rp 1,813.0 - - - - - - - - -
Asiklovir salep kulit tube Rp 3,699.3 54 54 7 25,895 - - 47 173,867 (30)
DRG000003950 Atropin Sulfat injeksi 0,25 mg/ml-1 ml ampul Rp 1,540.0 - - - - - - - - -
DRG000003956 Atropin Sulfat tetes mata 0,5 % botol Rp 2,800.7 - - - - - - - - -
DRG000004142 Atrovent HFA kotak Rp 83,500.0 - - - - - - - - - 10
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 249 249 175 311,150 - - 74 131,572 346 400
Baby Cough sirup botol Rp 3,999.6 185 185 39 155,984 - - 146 583,942 (52) 100
Betahistin mesilat tablet 6 mg tablet Rp 119.0 - - - - - - - - -
DRG000005736 Bioplacenton Cream tube Rp 18,499.8 20 20 - - - - 20 369,996 (20)
Bisoprolol tablet 5 mg tablet Rp 248.0 200 200 10 2,480 - - 190 47,120 (166)
Buscopan tablet tablet Rp 3,100.0 110 110 70 217,000 - - 40 124,000 128 200
Cendo Augentonic tetes mata botol Rp 30,990.0 - - - - - - - - -
Cendo Catarlent tetes mata botol Rp 33,699.6 - - - - - - - - -
DRG000015887 Cendo Edta tetes mata botol Rp 37,500.0 - - - - - - - - -
Cendo Floxa tetes mata botol Rp 33,599.5 - - - - - - - - -
Cendo fungicide tetes mata botol Rp 18,500.0 - - - - - - - - -
DRG000007801 Cendo Homatrol tetes mata botol Rp 43,785.0 - - - - - - - - -
Cendo Lyteers tetes mata botol Rp 25,999.6 28 28 1 26,000 - - 27 701,989 (25)
Cendo mydriatil tetes mata botol Rp 27,845.4 - - - - - - - - -
Cendo Tobroson tetes mata botol Rp 53,999.0 - - - - - - - - -
DRG000007849 Cendo tropin tetes mata botol Rp 13,875.0 - - - - - - - - -
Cendo Xytrol tetes mata botol Rp 33,000.0 - - - - - - - - -
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 119 119 119 303,450 - - - - 286 400
DRG000010471 Clopidogrel 75 mg tablet tablet Rp 1,469.0 240 240 - - - - 240 352,560 (240)
Curcuma tablet tablet Rp 990.0 - - - - - - - - -
DRG000011354 Dekstran 70 larutan infus 6 % steril botol Rp 35,526.0 - - - - - - - - -
DRG000011365 Depakene sirup botol Rp 17,789.0 6 6 1 17,789 - - 5 88,945 (3)
DRG000011337 Depakote tablet tablet Rp 1,200.0 390 390 - - - - 390 468,000 (390)
DRG000011848 Desoksimetason 0,25 mg (Denomix) tube Rp 11,500.0 - - - - - - - - -
52
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Dextamine tablet tablet Rp 1,815.0 - - - - - - - - -
DRG000012127 Dextrofen sirup botol Rp 12,499.3 - - - - - - - - -
Diamicron MR 30 mg tablet tablet Rp 638.0 - - - - - - - - -
DRG000012720 Diltiazem tablet tablet Rp 143.0 - - - - - - - - -
DRG000012774 Domperidon Suspensi 5 mg/5 ml botol Rp 2,862.0 223 223 40 114,480 - - 183 523,746 (87)
DRG000012960 Dopamet (metildopa) tablet Rp 880.0 - - - - - - - - -
DRG000012963 Dulcolax 10 mg supp supp Rp 5,900.0 - - - - - - - - -
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 160 160 30 9,480 - - 130 41,080 (58)
DRG000013350 Efedrin Hcl tablet 25 mg tablet Rp 197.8 - - - - - - - - -
DRG000014440 Erytromisin 250 mg kapsul kapsul Rp 636.0 - - - - - - - - -
Etakridin ( Rivanol ) larutan 0,1 % botol Rp 4,999.5 - - - - - - - - -
DRG000015045 Etambutol Hcl tablet 250 mg tablet Rp 186.3 - - - - - - - - -
DRG000027495 Famotidin 40 mg tablet tablet Rp 192.0 900 900 - - - - 900 172,800 (900)
DRG000027467 Fenitoin natrium inj 50 mg / ml ampul Rp 48,368.0 - - - - - - - - -
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 100 100 200 100 15,800 - - 100 15,800 140 100
DRG000015398 Fenobarbital tablet 100 mg tablet Rp 127.2 - - - - - - - - -
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 115 115 20 21,460 - - 95 101,935 (47) 120
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 87 87 14 36,260 - - 73 189,070 (39)
Flukonazol tab 150 mg tablet Rp 24,200.0 - - - - - - - - - 200
DRG000016599 Fluor tablet 0,5 mg tablet Rp 32.9 - - - - - - - - -
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 18 18 2 9,778 - - 16 78,224 (11) 20
Fungasol 2 % botol Rp 24,200.0 - - - - - - - -
DRG000016864 Fuson ointment tube Rp 7,500.0 - - - - - - - - -
Gemfibrozil 300 mg tablet Rp 428.0 710 710 - - - - 710 303,880 (710)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 64 64 7 17,494 - - 57 142,454 (40)
DRG000017167 Gentamisin salep mata tube Rp 3,075.0 - - - - - - - - -
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 46 46 17 83,045 - - 29 141,665 12 50
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 46 46 3 10,497 - - 43 150,461 (36)
Glimepirid tab 2 mg tablet Rp 207.0 430 430 - - - - 430 89,010 (430)
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 1,127 1600 2,727 1,270 114,300 - - 1,457 131,130 1,591 2000
DRG000017683 Gliserin larutan 50% botol Rp 5,867.0 - - - - - - - - -
DRG000017692 Glukosa larutan infus 10 % steril botol Rp 7,500.0 - - - - - - - - -
DRG000017682 Glukosa larutan infus 40 % steril botol Rp 988.0 - - - - - - - - -
DRG000030867 Glukosa larutan infus 5 % steril botol Rp 5,720.0 1 1 - - - - 1 5,720 (1)
Glukosamin 250 mg tablet (osmin) tablet Rp 1,000.0 - - - - - - - - -
DRG000018288 H.Booster sirup botol Rp 14,168.0 - - - - - - - - -
DRG000018443 Haloperidol tablet 1,5 mg tablet Rp 59.0 100 100 - - - - 100 5,900 (100)
53
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 526 300 826 285 242,247 - - 541 459,845 143 600
DRG000019256 HEXADOL (Larutan Hexetidine) botol Rp 12,650.0 - - - - - - - - -
Hidrokortison krim 1% tube Rp 5,723.3 30 30 4 22,893 - - 26 148,806 (16)
Hyorex 10 mg tablet tablet Rp 405.0 - - - - - - - - -
DRG000019430 Hyoscine N Butilbromida 10 mg tablet tablet Rp 1,625.8 - - - - - - - - -
DRG000019495 Ibuprofen syr 100 mg/5ml botol Rp 2,560.0 159 159 1 2,560 - - 158 404,480 (156)
Ichtyol salep tube Rp 6,200.0 50 50 5 31,000 - - 45 279,000 (33)
Inhitril 10 mg tablet Rp 385.0 - - - - - - - - -
Interhistin tablet tablet Rp 880.0 - 200 200 20 17,600 - - 180 158,400 (132) 200
DRG000006615 Irbesartan tab 150 mg tablet Rp 425.0 - - - - - - - - -
DRG000006804 Kalsium laktat ( Kalk ) tablet 500 mg tablet Rp 59.0 6,943 6,943 266 15,694 - - 6,677 393,943 (6,039)
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 1,085 1,085 435 260,565 - - 650 389,350 394 400
DRG000007735 Kandesartan 16 mg tablet tablet Rp 6,225.0 - - - - - - - - -
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 201 201 9 238,491 - - 192 5,087,808 (170)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 480 500 980 120 14,999 - - 860 107,491 (572)
DRG000021651 Kaptopril 50 mg tablet tablet Rp 135.0 - - - - - - - - -
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 45 45 10 25,770 - - 35 90,195 (11) 25
DRG000009233 Ketoprofen 100 mg tablet tablet Rp 1,366.2 - - - - - - - - -
DRG000009302 Klindamisin 150 mg tablet tablet Rp 754.0 - - - - - - - - -
DRG000009337 Klobazam 10 mg tablet tablet Rp 872.0 435 435 58 50,576 - - 377 328,744 (238)
DRG000021912 Klonidin 0,15 mg tablet tablet Rp 224.0 - - - - - - - - -
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 - - - - - - - - -
DRG000008615 Klorpromazin Hcl inj 25 mg / ml - 12 ml ampul Rp 418.3 - - - - - - - - -
DRG000009409 Klorpromazin Hcl tablet salut 25 mg tablet Rp 250.0 190 190 190 47,500 - - - - 456 400
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 110 110 - - - - 110 123,310 (110)
DRG000021974 Kodein tablet 15 mg tablet Rp 728.0 - - - - - - - - -
DRG000003009 Kodein tablet 20 mg tablet Rp 1,494.0 - - - - - - - - -
DRG000022061 Kombinasi pirimetamin 25 mg / sulfadoksin 50 tablet Rp 379.6 - - - - - - - - -
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - - - - - - - - - 100
DRG000022701 Kotrimoksazol DOEN II (pedriatik) tablet tablet Rp 79.0 - - - - - - - - -
Lanzoprazol tablet Rp 330.0 495 495 425 140,250 - - 70 23,100 950 800
DRG000022980 Lapalos Cream tube Rp 16,500.0 - - - - - - - - -
Laxadine emulsi botol Rp 7,700.0 - - - - - - - - -
DRG000023225 L-Bio sachet sachet Rp 4,033.3 412 412 31 125,032 - - 381 1,536,687 (307)
DRG000023291 Levofloksasin tab 500 mg tablet Rp 449.0 - - - - - - - - -
DRG000045684 Lexapram sirup botol Rp 2,900.0 - - - - - - - - -
54
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023536 Lidocain jeli 2 % (Xylocaine Jelly 2%) syringe Rp 40,000.0 - - - - - - - - -
DRG000023691 Lincomisin 500 mg tablet Rp 1,319.6 200 200 - - - - 200 263,920 (200)
DRG000023692 Lisinopril 10 mg tablet tablet Rp 323.0 - - - - - - - - -
Lisinopril 5 mg tablet tablet Rp 238.0 - - - - - - - - -
DRG000026266 Lisol botol Rp 45,100.0 1 1 - - - - 1 45,100 (1)
DRG000023860 Livertran salep tube Rp 4,600.0 107 107 4 18,400 - - 103 473,800 (93)
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 1,117 1,117 40 107,756 - - 1,077 2,901,330 (981)
DRG000023935 Loperamida tablet tablet Rp 85.0 300 300 - - - - 300 25,500 (300)
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 - - - - - - - - -
DRG000024571 MDT Combi paket Rp 31,570.0 - - - - - - - - -
DRG000024987 Mebendazol sirup 100 mg / 5 ml botol Rp 2,035.0 - - - - - - - - -
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 630 630 40 32,000 - - 590 472,000 (494)
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 1,335 1,335 170 110,500 - - 1,165 757,250 (757)
Mersibion injeksi ampul Rp 6,000.0 - - - - - - - - -
DRG000025750 Metoklorpropamid sirup botol Rp 1,919.0 - - - - - - - - -
DRG000015762 Metronidazol infus 500 mg/100 ml botol Rp 25,300.0 - - - - - - - - -
DRG000026108 Metronidazol supp 500 mg (Flagyl supp) supp Rp 3,655.0 - - - - - - - - -
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 639 639 - - - - 639 63,261 (639)
DRG000026643 Misoprostol 200 mg (gastrul) tablet Rp 12,300.0 - - - - - - - - -
DRG000044042 Mixaria sachet Rp 1,260.0 - - - - - - - - -
DRG000026742 Moksifloksasin tetes mata 0,5% (Vigamox) botol Rp 81,000.0 - - - - - - - - -
DRG000027470 Mometason furoat krim 0,1 % tube Rp 7,912.0 - - - - - - - - -
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 - - - - - - - - - 3
DRG000028214 Neo Diaform tablet Rp 253.0 - - - - - - - - -
DRG000028376 Neurodex tablet tablet Rp 591.4 330 330 - - - - 330 195,162 (330)
DRG000028619 New Diatabs tablet Rp 560.0 - - - - - - - - -
DRG000028637 Nistatin 500.000 iu /g tablet salut tablet Rp 910.0 - - - - - - - - -
Nitral (gliseril trinitras sublingual 0.5 mg) tablet Rp 1,650.1 - - - - - - - - -
DRG000029080 Nopres 20 mg tablet tablet Rp 883.3 230 230 45 39,749 - - 185 163,411 (77) 200
Norages Injeksi ampul Rp 9,999.9 - - - - - - - - -
novadium tablet Rp 200.0 - - - - - - - - -
Novastan sirup botol Rp 12,650.0 46 46 4 50,600 - - 42 531,300 (32)
Noza tablet tablet Rp 797.5 376 200 576 179 142,753 - - 397 316,608 33 400
Obat antituberkulosis kat.3 paket Rp 154,000.0 - - - - - - - - -
DRG000029617 Obat antituberkulosis kat.sisipan paket Rp 160,000.0 - - - - - - - - -
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 66 100 166 3 14,999 - - 163 814,919 (156) 100
DRG000039980 Obat suntik KB I (3 bulan) ampul Rp 7,175.0 - - - - - - - - -
55
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030101 Obat suntik KB II (1 bulan) ampul Rp 5,885.0 - - - - - - - - -
DRG000019683 Ofloksasin tab 400 mg tablet Rp 700.0 295 295 - - - - 295 206,500 (295)
DRG000031218 Oksimetazolin tts hidung 0,025% (Iliadin drops) botol Rp 37,433.0 - - - - - - - - -
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 - - - - - - - - -
DRG000030419 Ondansetron inj 4 mg/2ml ampul Rp 1,198.0 - - - - - - - - -
DRG000030584 Ondansetron tab 4 mg tablet Rp 406.0 - - - - - - - - -
Optiflox tetes mata botol Rp 14,005.0 - - - - - - - - -
Pamol supp supp Rp 18,999.2 - - - - - - - - -
DRG000031557 Pantocain 0,5 % TM botol Rp 17,499.9 5 5 - - - - 5 87,500 (5)
DRG000031585 Papaverin 40 mg tablet tablet Rp 170.0 - - - - - - - - -
DRG000031608 Parasetamol Drop 100 mg/ml botol Rp 6,938.8 - - - - - - - - -
DRG000032133 Pedialyte botol Rp 31,999.0 94 94 - - - - 94 3,007,906 (94)
DRG000032718 Pehacain injeksi ampul Rp 3,580.0 - - - - - - - - -
DRG000002552 Pil KB I tablet Rp 1,350.0 213 213 21 28,350 - - 192 259,200 (142) 50
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - - - - - - - - -
Pim-Tra-Kol sirup botol Rp 9,999.0 - - - - - - - - - 100
DRG000032996 Pirazinamid tab 500 mg tablet Rp 238.0 - - - - - - - - -
DRG000032977 Piroksikam 10 mg tablet tablet Rp 112.2 - - - - - - - - -
DRG000033456 Polikresulen botol Rp 43,975.8 - - - - - - - - -
DRG000020429 Povidon Iodida larutan 10 % 30 ml botol Rp 3,190.0 11 11 - - - - 11 35,090 (11)
Povidon Iodida Larutan 1000 ml botol Rp 42,000.0 1 1 - - - - 1 42,000 (1)
PP Isoniazide 100 mg tablet Rp 79.0 - - - - - - - - - 200
Prazikuantel tablet 600 mg tablet Rp 2,295.0 - - - - - - - - -
Prenatin DF tablet tablet Rp 3,258.3 480 120 600 - - - - 600 1,954,980 (600) 500
DRG000034697 Primolut N tablet Rp 2,618.0 - - - - - - - - - 100
Protofen supp supp Rp 2,790.0 - - - - - - - - -
DRG000034797 Protofen tablet tablet Rp 880.0 - - - - - - - - -
Pularex tablet tablet Rp 175.0 690 690 100 17,500 - - 590 103,250 (350)
DRG000034808 Pulmicort respules ampul Rp 9,725.0 - - - - - - - - -
Pulmicort turbuhaler kotak Rp 101,000.0 - - - - - - - - -
Ramabion tab tablet Rp 6,490.0 - - - - - - - - -
DRG000035650 Ranitidin inj 25mg/2ml ampul Rp 1,155.0 - - - - - - - - -
DRG000035955 Recovit sirup botol Rp 8,650.0 - - - - - - - - -
Reserpin tablet 0,25 mg tablet Rp 114.0 - - - - - - - - -
56
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Rifampisin kaplet 600 mg tablet Rp 1,209.0 - - - - - - - - -
DRG000036344 Rifampisin kapsul 300 mg tablet Rp 670.0 - - - - - - - - -
DRG000036698 Ringer laktat larutan infus steril botol Rp 7,150.0 5 5 1 7,150 - - 4 28,600 (2)
DRG000037347 Risperidon 2 mg tab tablet Rp 273.0 560 560 10 2,730 550 150,150 - - 24
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 154 100 254 27 162,786 - - 227 1,368,606 (162) 100
Sandepril 50 mg tablet Rp 8,900.0 - - - - - - - - -
Sangobion kids drop botol Rp 34,999.8 - - - - - - - - -
Sangobion Kids Sirup botol Rp 24,515.7 - - - - - - - - -
DRG000037725 Scabicid cream 10 gram tube Rp 11,475.0 - - - - - - - - -
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 60 60 9 103,275 - - 51 585,225 (29)
Scopma tablet tablet Rp 750.0 - - - - - - - - -
DRG000007425 Sefaleksin kapsul 500 mg kapsul Rp 717.0 - - - - - - - - -
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 664 664 70 160,930 - - 594 1,365,606 (426)
DRG000038259 Sefiksim syr kering 100mg/5ml botol Rp 5,710.0 103 103 - - - - 103 588,130 (103)
DRG000038315 Seretide Inhaler 50 mcg kotak Rp 58,000.0 - - - - - - - - -
Serum anti bisa ular polivalen inj 5 ml ( ABU I ) vial Rp 479,996.0 - - - - - - - - -
Serum anti bisa ular polivalen inj 50 ml ( ABU II vial Rp 28,468,086.0 - - - - - - - - -
DRG000038321 Serum anti defteri inj 1000 mg / vial vial Rp 2,200,000.0 - - - - - - - - -
Serum anti tetanus inj 1.500 IU / ampul ( ATS ) ampul Rp 130,999.0 - - - - - - - - -
DRG000008166 Serum anti tetanus inj 20.000 IU / ampul ( ATS ampul Rp 604,670.0 - - - - - - - - -
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 103 100 203 56 167,608 - - 147 439,971 (13)
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 576 300 876 235 22,795 - - 641 62,177 (77) 500
DRG000008751 Simetidin tablet tablet Rp 250.0 - - - - - - - - -
DRG000038671 Simpastatin 20 mg tablet tablet Rp 225.0 537 537 30 6,750 - - 507 114,075 (435)
Sohobion tablet tablet Rp 1,043.6 - - - - - - - - -
Spiramisin 500 mg tablet tablet Rp 1,223.2 - - - - - - - - -
DRG000039298 Spironolakton tab 25 mg tablet Rp 212.0 - - - - - - - - -
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 14 14 2 28,918 - - 12 173,508 (7)
Stimuno Forte tablet tablet Rp 2,504.7 - - - - - - - - -
Stimuno Sirup botol Rp 18,500.0 53 53 53 980,500 - - - - 127
Sucralfate 500 mg/5 ml suspensi botol Rp 7,338.0 - - - - - - - -
DRG000039932 Sulfasetamid natrium tetes mata 15 % botol Rp 8,499.7 - - - - - - - - -
DRG000040124 Susuk KB II set Rp 213,936.8 - - - - - - - - -
DRG000040178 Symbicort turbuhaler 160/4.5 mg kotak Rp 134,500.0 - - - - - - - - -
DRG000040195 Synarcus krim tube Rp 2,534.0 45 50 95 18 45,612 - - 77 195,118 (34) 50
57
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Taburia sachet Rp 1,000.0 - - - - - - - - -
DRG000040442 Tanapress 5 mg (imidapril ) tablet Rp 2,333.0 - - - - - - - - -
Tensigard tablet tablet Rp 1,063.3 - - - - - - - - -
Terra Flu tablet tablet Rp 807.1 - - - - - - - - -
DRG000041013 Tetagam ampul Rp 176,800.0 - - - - - - - - -
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 160 100 260 20 17,800 - - 240 213,600 (192) 100
DRG000041258 Thiamin Hcl ( Vit B1 ) inj.100 mg / ml - 1 ml ampul Rp 730.0 - - - - - - - - -
DRG000041358 Thrombophob gel tube Rp 54,450.0 7 7 1 54,450 - - 6 326,700 (4)
DRG000041532 Timolol tetes mata 0,5% botol Rp 10,286.0 - - - - - - - - -
DRG000041922 Tramadol 50 mg kapsul kapsul Rp 580.0 - - - - - - - - -
DRG000041920 Tramadol inj 50 mg/ml ampul Rp 2,680.0 - - - - - - - - -
DRG000042315 Triflouperazin 5mg tablet tablet Rp 309.0 - - - - - - - - -
DRG000042713 Truvit drops botol Rp 36,499.1 72 72 21 766,481 - - 51 1,861,454 (1) 100
Truvit sirup botol Rp 11,400.0 131 131 37 421,800 - - 94 1,071,600 (5) 100
DRG000042887 Ulsafate sirup botol Rp 9,192.0 60 60 9 82,728 - - 51 468,792 (29) 50
DRG000042899 Ulsidex tablet tablet Rp 296.0 - - - - - - - - -
Urea krim (Soft U derm) botol Rp 7,040.0 - - - - - - - - -
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 280 280 30 54,450 - - 250 453,750 (178)
DRG000043188 Vagizol ovula (metronidazol ovula) ovula Rp 4,235.0 - - - - - - - - -
valisanbe 2 mg tablet Rp 236.0 - - - - - - - - -
DRG000043324 Valsartan tab 80 mg (Diovan 80mg) tablet Rp 3,900.0 - - - - - - - - -
Vastral tablet Rp 605.0 - - - - - - - - -
DRG000043683 Ventolin inhaler kotak Rp 70,125.0 - - - - - - - - -
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 24 10 34 7 77,000 - - 27 297,000 (10) 10
Vitamin A6000IU tablet Rp 237.0 - - - - - - - - -
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 2,900 2,900 980 48,020 - - 1,920 94,080 432 1000
Vitonorm tablet tablet Rp 4,107.2 - - - - - - - - -
DRG000045683 Xylocain spray kotak Rp 344,570.0 - - - - - - - - -
Yodium Test botol Rp 1.0 - - - - - - - - -
DRG000046219 Zincpro drops botol Rp 31,999.9 - - - - - - - - -
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 21 21 - - 21 68,985 - - - 100
DRG000046382 Zoloral SS (ketokonazol scalp sol 2 %) botol Rp 24,200.0 6 6 - - - - 6 145,200 (6)
- - - - - - - - -
II.OBAT GIGI - - - - - - - - -
MDVx000864 Achatit/Fuji II kotak Rp 939,400.0 - - - - - - - - -
0 acid etching kotak Rp 376,035.0 - - - - - - - - -
0 Air raksa dental use botol Rp 437,500.0 - - - - - - - - -
58
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Alveogyl kotak Rp 789,800.0 2 2 - - - - 2 1,579,600 (2)
0 Aplicator kotak Rp 95,000.0 1 1 - - - - 1 95,000 (1)
0 Arsenic Pasta 10 gr/pot Rp 942,040.0 3 3 - - - - 3 2,826,120 (3)
MDVx002393 Articulating paper kotak Rp 195,800.0 6 6 - - - - 6 1,174,800 (6)
0 Bond strenght kotak Rp 330,000.0 - - - - - - - - -
0 Caviton kotak Rp 252,950.0 1 1 1 252,950 - - - - 2 1
MDVx022575 Citodur (Bahan tambalan sementara) kotak Rp 200,200.0 - - - - - - - - -
0 Cotton pelet pack Rp 247,500.0 4 4 - - - - 4 990,000 (4)
MDVx009212 Cotton roll pack Rp 75,000.0 3 3 - - - - 3 225,000 (3)
0 Cresofen / endoseptone pack Rp 473,000.0 6 6 - - - - 6 2,838,000 (6)
MDVx024268 Dental floss kotak Rp 30,250.0 - - - - - - - - -
0 Dentin conditioning kotak Rp 366,465.0 - - - - - - - - -
0 Devitalisasi pasta (non arsen) / D.Pulp botol Rp 752,400.0 - - - - - - - - -
0 Devitalisasi pasta (non arsen) / Devitec kotak Rp 698,500.0 - - - - - - - - -
0 Dysclosing agent / Disclosing gel (GC tri plaqu botol Rp 345,950.0 - - - - - - - - -
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 1 - - - - 1 164,950 (1)
DRG000014675 Eugenol cairan botol Rp 136,400.0 3 3 - - - - 3 409,200 (3)
0 Flour sediaan topical botol Rp 170,000.0 - - - - - - - - -
0 Formokresol botol Rp 60,000.0 - - - - - - - - -
0 G aenial bond kotak Rp 875,578.0 - 1 1 - - - - 1 875,578 (1)
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 3 3 1 643,500 - - 2 1,287,000 0
0 Glass Ionomer cemen / ketakmolar kotak Rp 880,000.0 - - - - - - - - -
MDVx019949 Glass Ionomer Light cured Universal restorativ kotak Rp 412,500.0 - - - - - - - - -
MDVx000028 Gutta perchha point 15-40 mm kotak Rp 51,700.0 - - - - - - - - -
0 Jarum Dental cytoject pcs Rp 2,662.0 - - - - - - - - -
SBx148 Kalsium hidroksida pasta kotak Rp 187,000.0 - - - - - - - - -
0 Marbalet/neocones botol Rp 750,000.0 - - - - - - - - -
0 Monoklorkamfer mentol cairan (camphenol) kotak Rp 55,000.0 - - - - - - - - -
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 4 4 - - - - 4 300,960 (4)
SBx147 Mummifying pasta kotak Rp 451,000.0 - - - - - - - - -
0 Oco Tooth Clensing botol Rp 191,999.0 3 3 - - - - 3 575,997 (3) 1
MDVx012595 Paper point 15-40 mm kotak Rp 47,300.0 - - - - - - - - -
0 Pasta pengisi saluran akar kotak Rp 506,000.0 - - - - - - - - -
0 Rockless kotak Rp 1,135,200.0 - - - - - - - - -
DRG001BJM Scandonest pcs Rp 17,622.0 - - - - - - - - - 2
59
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx000992 selang saliva eyector pack Rp 157,300.0 10 10 - - - - 10 1,573,000 (10)
DRG000038085 Semen seng fosfat serbuk dan cairan kotak Rp 225,500.0 3 3 - - - - 3 676,500 (3)
0 Silver amalgam serbuk 65 - 75 % kotak Rp 937,500.0 - - - - - - - - -
MDVx000870 Surgical ginggival pack (Coe Pak) kotak Rp 669,350.0 1 1 - - - - 1 669,350 (1)
SBx139 Tambalan sinar solare A2 kotak Rp 256,731.0 3 3 - - - - 3 770,193 (3) 1
0 Tambalan sinar solare A3,5 kotak Rp 420,200.0 - - - - - - - - - 1
0 Tampon pack Rp 300,000.0 6 6 - - - - 6 1,800,000 (6)
0 Temporary stopping fletcher serbuk dan cairan set Rp 62,150.0 - - - - - - - - -
0 Topical anastesi pasta kotak Rp 302,500.0 4 4 - - - - 4 1,210,000 (4)
DRG000042250 Trikesol Formalin ( TKF ) cairan botol Rp 82,720.0 - - - - - - - - -
MDVx020416 Varnish box Rp 165,440.0 - - - - - - - - -
- - - - - - - - -
III. BMHP - - - - - - - - -
MDVx001727 Alat suntik sekali pakai 1 ml pcs Rp 1,614.0 262 262 101 163,014 - - 161 259,854 81 100
0 Alat suntik sekali pakai 2,5 ml pcs Rp 605.0 62 62 - - - - 62 37,510 (62)
MDVx001732 Alat suntik sekali pakai 3 ml pcs Rp 1,138.0 749 749 503 572,414 - - 246 279,948 961 200
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 567 567 100 165,100 - - 467 771,017 (227)
MDVx001793 Alat suntik sekali pakai 10 ml pcs Rp 1,095.3 100 100 - - - - 100 109,529 (100)
DRG000000999 Albothyl botol Rp 45,000.0 - - - - - - - - -
DRG000001226 Alkohol Swab lembar Rp 105.0 1,000 1,000 - - - - 1,000 105,000 (1,000)
0 Bioplacenton tulle pcs Rp 10,920.0 65 65 - - - - 65 709,800 (65)
MDVx000796 Bistruri/scalpel balde No 10 pcs Rp 3,300.0 80 80 - - - - 80 264,000 (80)
0 Bistruri/scalpel balde No 11 pcs Rp 3,450.0 - - - - - - - - -
0 Bisturi/scalpel balde No 15 pcs Rp 850.0 - - - - - - - - -
MDVx002305 Blood Lancet pcs Rp 176.0 650 650 - - - - 650 114,400 (650)
0 Blood transfusion set pcs Rp 4,698.0 - - - - - - - - -
0 Blue Tip pack Rp 139,500.0 2 2 - - - - 2 279,000 (2)
Box slide TB kotak Rp 36,000.0 - - - - - - - - -
0 canula dewasa pcs Rp 1.0 - - - - - - - - -
0 Cat Gut chromic No 1 pcs Rp 1.0 - - - - - - - - -
MDVx001331 Catgut/benang bedah no 2/0 chronic pcs Rp 5,862.5 - - - - - - - - -
MDVx001331 Catgut/benang bedah no 2/0 plain pcs Rp 5,862.5 - - - - - - - - -
0 Celulid strip pcs Rp 73,700.0 - - - - - - - - -
Cetride 5 Liter galon Rp 774,972.0 - - - - - - - - -
60
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Clorheksidin 2,5 % botol Rp 618,750.0 - - - - - - - - -
MDVx023244 Coverplast pcs Rp 470.0 2 2 - - - - 2 940 (2)
0 Deck glass / objek glass 20 x 20 mm pack Rp 48,000.0 - - - - - - - - -
Deck glass / objek glass 22 x 22 mm pack Rp 52,300.0 - - - - - - - - -
0 Deck gelas / objek glass 24 x 24 mm pack Rp 48,000.0 - - - - - - - - -
MDVx018887 Disposibel vagina speculum pcs Rp 7,500.0 - - - - - - - - -
D-Pierce X12 box Rp 817,450.0 - - - - - - - - -
ECG 112 mm x 30 mm x 16 mm roll Rp 141,400.0 - - - - - - - - -
MDVx011444 Film Rontgen 24 x 30 cm lembar Rp 21,970.0 - - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - - - - - - - - -
MDVx000971 Foley cateter no 16 pcs Rp 13,688.0 - - - - - - - - -
MDVx001175 Fukuda M.E.ECG Paper pcs Rp 56,566.7 - - - - - - - - -
MDVx002014 handiplast pcs Rp 385.0 - - - - - - - - -
Holder tube vacutainer pcs Rp 6,940.0 - - - - - - - - -
0 Hypafix uk. Kecil 5 cm x 5 m pcs Rp 98,900.0 8 8 - - - - 8 791,200 (8)
MDVx003549 IUD set Rp 11,800.0 - - - - - - - - -
0 Infusiun set anak pcs Rp 2,970.0 2 2 - - - - 2 5,940 (2)
MDVx026876 Infusiun set dewasa pcs Rp 4,176.0 3 3 - - - - 3 12,528 (3)
MDVx002098 IV Catheter no 18 G pcs Rp 4,959.0 2 2 - - - - 2 9,918 (2)
MDVx001125 IV Catheter no 20 G pcs Rp 8,566.0 - - - - - - - - -
MDVx001152 Jarum (Needle) no 23 pcs Rp 400.0 100 100 - - - - 100 40,000 (100)
MDVx001154 Jarum (Needle) no 25 pcs Rp 604.0 - - - - - - - - -
Jarum Jahit kulit no 10 GT pack Rp 38,000.0 - - - - - - - - -
0 Jarum Jahit Kulit No 11 GT pack Rp 32,500.0 - - - - - - - - -
0 jarum K-File no 15-40 kotak Rp 150,700.0 - - - - - - - - -
MDVx022261 Jelly (Aquagel) botol Rp 31,027.3 3 2 5 - - - - 5 155,137 (5)
61
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 80 - - - - 80 200,000 (80)
0 Kapas berlemak 500 mg roll Rp 21,532.5 3 3 - - - - 3 64,598 (3)
DRG000021388 Kapas pembalut / absorben 250 mg roll Rp 13,000.0 1 1 - - - - 1 13,000 (1)
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 26 26 1 1,962 - - 25 49,045 (23)
0 Kasa pembalut 2 m x80 cm pcs Rp 9,347.0 8 8 - - - - 8 74,776 (8)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 15 15 15 36,855 - - - - 36 30
SBx134 Kasa pembalut hidrofil 4m x 3 cm pcs Rp 613.5 29 29 - - - - 29 17,792 (29)
Kasa steril 16 cm x 16 cm box Rp 8,685.7 - - - - - - - - -
MDVx001191 Kertas EKG (uk 80 x 90 x 280) lembar Rp 106,250.0 - - - - - - - - -
0 Kertas Puyer lembar Rp 91.6 - - - - - - - - -
MDVx013360 Kertas Thermal roll Rp 94,500.0 - - - - - - - - -
kertas thermal 50 mm x 57 mm roll Rp 18,200.0 - - - - - - - - -
Kertas thermal mindray 50mm x 50 mm roll Rp 76,500.0 - - - - - - - - -
Kertas thermal mindray 80 x 50 roll Rp 24,250.0 - - - - - - - - -
0 Klorin botol Rp 15,970.0 52 52 4 63,880 - - 48 766,560 (38)
0 Kondom pcs Rp 716.7 264 288 552 18 12,901 - - 534 382,718 (491) 288
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 24 24 1 37,950 - - 23 872,850 (21)
MDVx022456 Lidi Kapas/cotton swab pcs Rp 1,000.0 412 412 - - - - 412 412,000 (412)
Markerpen pcs Rp 1.0 70 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 - - - - - - - - -
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - - - - - - - - -
0 masker nebule dewasa pcs Rp 28,300.0 - - - - - - - - -
0 masker oksigen anak pcs Rp 19,800.0 - - - - - - - - -
0 masker oksigen dewasa pcs Rp 19,800.0 - - - - - - - - -
0 Mata Bor high speed pack Rp 154,000.0 1 1 - - - - 1 154,000 (1)
0 Microtube 1,5 cc pack Rp 245,000.0 - - - - - - - - -
0 Minyak handpiece 500 ml botol Rp 561,000.0 - - - - - - - - -
Mouthpiece sterilbreath 250s box Rp 4,527.6 - - - - - - - - -
0 NaOcl 2,5 % untuk sal irigasi botol Rp 123,200.0 - - - - - - - - -
0 Needle flashback pcs Rp 3,170.0 - - - - - - - - -
MDVx000733 Obyek glass* biasa pack Rp 37,446.0 - - - - - - - - -
0 Open akses bur pcs Rp 135,300.0 - - - - - - - - -
0 Pembalut gips pcs Rp 55,000.0 - - - - - - - - -
0 Penjepit tali pusat pcs Rp 3,025.0 2 2 - - - - 2 6,050 (2)
0 Pharmafix pcs Rp 27,000.0 8 8 - - - - 8 216,000 (8)
62
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
pipet ESR citotes pcs Rp 7,675.0 - - - - - - - - -
Plastik klip sedang pack/100sRp 3,950.0 - - - - - - - - -
0 Plastik Obat kecil (uk. 8 cm x 5 cm) pack Rp 17,000.0 15 15 - - - - 15 255,000 (15)
0 Plastik Obat pembungkus puyer (uk. Besar) pack Rp 5,950.0 10 10 - - - - 10 59,500 (10)
MDVx041848 Plester (hansaplast 5 cm x 4,5 m) pcs Rp 12,000.0 - - - - - - - - -
Plesterin pcs Rp 161.7 - - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - - - - - - - - -
0 safety box* pcs Rp 16,500.0 91 91 - - - - 91 1,501,500 (91)
sealing wax pcs Rp 164,000.0 - - - - - - - - -
0 Serum gel tes tube 5 ml / tabung gel & cloat act pcs Rp 2,650.0 - - - - - - - - -
0 Silk ( benang bedah sutra ) no.3/0 pcs Rp 4,766.7 36 36 - - - - 36 171,601 (36)
silk no 2/0 pcs Rp 3,208.3 - - - - - - - - -
0 Spon gelatin cubicle 1 x 1 x 1 cm pcs Rp 1,850.0 - - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 300 - - - - 300 495,000 (300)
MDVx001722 Spuit 0,5 ml pcs Rp 1,240.0 400 400 - - - - 400 496,000 (400)
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - - - - - - - - - 5
0 Suction tips pack Rp 73,700.0 - - - - - - - - -
0 Surflo No 18 pcs Rp 8,355.0 6 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 5 5 - - - - 5 41,775 (5)
MDVx002389 Surgical Glove No 6,5 pcs Rp 20,006.7 100 100 15 300,101 - - 85 1,700,570 (49)
0 Surgical Glove No 8 pcs Rp 5,000.0 93 93 - - - - 93 465,000 (93)
MDVx019415 Surgical Glove obsgyn / gynecolog No 6,5 pcs Rp 20,006.7 - - - - - - - - -
Surgical Glove obsgyn / gynecolog No 7 pcs Rp 20,010.0 - - - - - - - - -
0 Surgical Gloves non steril uk L pcs Rp 462.0 800 800 - - - - 800 369,600 (800)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 800 800 200 74,800 - - 600 224,400 (120) 200
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 800 300 1,100 300 138,600 - - 800 369,600 (80) 300
MDVx003948 Surgical mask 3 ply tie on pcs Rp 462.0 253 253 - - - - 253 116,886 (253)
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 1,300 1000 2,300 550 254,100 - - 1,750 808,500 (430) 1000
MDVx010039 Surgikal Gloves No 7 pcs Rp 5,000.0 12 12 - - - - 12 60,000 (12)
MDVx010040 Surgikal Gloves No 7.5 pcs Rp 4,600.0 164 164 - - - - 164 754,400 (164)
MDVx000518 Tabung EDTA K-3 pcs Rp 1,690.9 - - - - - - - - -
0 Tabung EdtA K-3 micro 0,5 cc pcs Rp 2,445.0 - - - - - - - - -
Tabung hematokrit pack Rp 180,500.0 - - - - - - - - -
0 Tabung reaksi / Test tube 75 x 100 dia 1 cm pcs Rp 5,500.0 - - - - - - - - -
Tabung reaksi kaca uk.12 x 75 mm pcs Rp 10,900.0 - - - - - - - - -
63
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000043003 Underpad pcs Rp 4,370.5 186 186 - - - - 186 812,913 (186)
MDVx013451 Urine bag pcs Rp 3,120.0 - - - - - - - - -
USG paper 110 HG (110 mm x 18m_SONY) roll Rp 268,500.0 - - - - - - - - -
Viorex liquid 4 % 500 ml botol Rp 76,477.5 - - - - - - - - -
0 Wing needle no 21 pcs Rp 2,450.0 - - - - - - - - -
0 Yellow Tip pack Rp 139,500.0 - - - - - - - - -
- - - - - - - - -
IV. REAGEN - - - - - - - - -
0 Abate/temephos botol Rp 2,197,800.0 - - - - - - - - -
0 ACS level I (control serum) botol Rp 4,160,000.0 - - - - - - - - -
0 Aquadest steril botol Rp 22,000.0 11 11 - - - - 11 242,000 (11)
DRG000046738 Asam klorida 0,1 N botol Rp 24,200.0 2 2 - - - - 2 48,400 (2)
MDVx041607 Asam sulfosalisilat 20 % botol Rp 531,000.0 2 2 - - - - 2 1,062,000 (2)
bactive SL botol Rp 30,700.0 - - - - - - - - -
MDVx040425 Blood Analisir Clianac Detergen (Nihon kohden botol Rp 8,050,000.0 - - - - - - - - -
MDVx041543 Blood Analisir Hemolinac 3N Lysing (nihon koh botol Rp 3,850,000.0 - - - - - - - - -
MDVx041531 Blood Analisir Isotonac 3 Diluent (nihon kohden botol Rp 4,290,000.0 - - - - - - - - -
0 Blood Analisir Clianac Detergen (norma clean botol Rp 2,112,000.0 - - - - - - - - -
0 Blood Analisir Hemolinac 3N Lysing (norma lys botol Rp 5,240,000.0 - - - - - - - - -
0 Blood Analisir Isotonac 3 Diluent (norma diluen botol Rp 3,696,000.0 - - - - - - - - -
0 Carbol gentian violet botol Rp 64,900.0 - - - - - - - - -
0 Cynoff 25 UL botol Rp 1,124,500.0 - - - - - - - - -
DRG000046731 Edta kering botol Rp 121,000.0 - - - - - - - - -
DRG000014470 Etanol 70 % 1 Liter botol Rp 41,800.0 22 22 - - - - 22 919,600 (22)
DRG000001161 Etanol 70 % 100 ml botol Rp 5,500.0 - - - - - - - - -
0 K-Othrine 20 EW / Cyflutrin botol Rp 1,000,000.0 - - - - - - - - -
Kontrol darah botol Rp 1,358,500.0 1 1 - - - - 1 1,358,500 (1)
Kontrol norma low botol Rp 596,000.0 - - - - - - - - -
Kontrol norma normal botol Rp 596,000.0 - - - - - - - - -
kontrol norma high botol Rp 596,000.0 - - - - - - - - -
MDVx343BJM Lab Pro reagen botol Rp 203,500.0 - - - - - - - - -
0 Larutan Air Fuchsin botol Rp 32,500.0 - - - - - - - - -
DRG000001165 Larutan Alkohol 95 % botol Rp 91,300.0 - - - - - - - - -
0 Larutan Alkohol 96 % botol Rp 48,500.0 - - - - - - - - -
64
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Larutan alkohol aseton botol Rp 31,000.0 - - - - - - - - -
MDVx103BJM Larutan amonium oksalat botol Rp 48,400.0 - - - - - - - - -
MDVx104BJM Larutan Anisol botol Rp 231,000.0 - - - - - - - - -
DRG000046732 Larutan Asam asetat 5% botol Rp 19,500.0 2 2 - - - - 2 39,000 (2)
MDVx041776 Larutan Barium Klorida botol Rp 26,400.0 - - - - - - - - -
MDVx041604 Larutan Benedict botol Rp 84,700.0 - - - - - - - - -
MDVx105BJM Larutan Buffer Fosfat botol Rp 36,300.0 - - - - - - - - -
MDVx018552 Larutan Developer botol Rp 1,183,000.0 - - - - - - - - -
MDVx041584 Larutan Edta 10% botol Rp 151,250.0 - - - - - - - - -
MDVx041581 Larutan Eosin 2 % botol Rp 447,700.0 1 1 - - - - 1 447,700 (1)
DRG000046739 Larutan Etanol Asam botol Rp 62,700.0 2 2 - - - - 2 125,400 (2)
MDVx106BJM Larutan Eter alkohol botol Rp 68,200.0 - - - - - - - - -
MDVx018554 Larutan Fixer botol Rp 801,900.0 - - - - - - - - -
MDVx041704 Larutan Foucet botol Rp 176,000.0 - - - - - - - - -
MDVx041602 Larutan Giemsa Sain botol Rp 378,125.0 - - - - - - - - -
MDVx041700 Larutan hayem botol Rp 122,100.0 1 1 - - - - 1 122,100 (1)
DRG000018188 Larutan Hidrogen Peroksida (H2O2) botol Rp 60,500.0 - - - - - - - - -
0 Larutan Iodium 1 % botol Rp 27,500.0 - - - - - - - - -
DRG000046764 Larutan Karbol Fuksin botol Rp 165,000.0 2 2 - - - - 2 330,000 (2)
MDVx041583 Larutan KOH 10 % botol Rp 29,700.0 - - - - - - - - -
MDVx109BJM Larutan KOH 20 % botol Rp 40,700.0 - - - - - - - - -
MDVx041673 Larutan Lugol 1 % botol Rp 44,000.0 - - - - - - - - -
MDVx012323 Larutan Metilen Biru botol Rp 84,700.0 2 2 - - - - 2 169,400 (2)
MDVx110BJM Larutan Natrium Citrat 3,8 % botol Rp 44,000.0 - - - - - - - - -
MDVx111BJM larutan safranin botol Rp 157,300.0 - - - - - - - - -
MDVx108BJM Larutan sodium hipoklorid 1 L botol Rp 110,000.0 - - - - - - - - -
0 Larutan sodium hipoklorid 100 ML botol Rp 18,634.0 5 5 - - - - 5 93,170 (5)
MDVx041790 Larutan Turk botol Rp 39,600.0 1 1 - - - - 1 39,600 (1)
DRG000046736 Larutan Xylol botol Rp 30,800.0 - - - - - - - - -
DRG000025457 Lipid Panel cardiocheck PA kotak Rp 1,721,516.9 - - - - - - - - -
0 Lipid Pro pcs Rp 836,000.0 - - - - - - - - -
0 M-30 CFL LYSE 500 ML Mindray botol Rp 2,100,000.0 - - - - - - - - -
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 1 1 - - - - 1 2,050,000 (1)
0 M-30 E-Z Cleanser Mindray botol Rp 1,500,000.0 1 1 - - - - 1 1,500,000 (1)
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 - - - - - - - - - 1
0 M-30 RINSE Mindray botol Rp 2,050,000.0 1 1 - - - - 1 2,050,000 (1)
0 B30 Control Hematology Analyzer Mindray botol Rp 1,336,500.0 - - - - - - - - -
65
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Medonic Diluent 20 L botol Rp 3,400,100.0 - - - - - - - - -
0 Medonic Lyse 5 L botol Rp 5,550,600.0 - - - - - - - - -
DRG000025457 Metanol botol Rp 24,645.0 - - - - - - - - -
0 Norma cleaner botol Rp 1,910,000.0 - - - - - - - - -
0 Norma diluent diff botol Rp 1,910,000.0 - - - - - - - - -
0 Norma lyse diff botol Rp 2,625,000.0 - - - - - - - - -
MDVx112BJM Oil Imersi botol Rp 580,000.0 1 1 - - - - 1 580,000 (1)
0 Pewarnaan Gram 1 % botol Rp 518,100.0 - - - - - - - - -
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 - - - - - - - - -
0 Rapid 2 Intec HIV stik Rp 40,800.0 - 50 50 50 2,040,000 - - - - 120 50
0 Rapid 3 oncoprobe stik Rp 64,280.0 - 25 25 25 1,607,000 - - - - 60 25
0 Rapid 4 right sign HIV stik Rp 35,120.0 1 1 - - - - 1 35,120 (1)
0 Rapid 5 CTK Bioteck HIV stik Rp 30,250.0 1 1 - - - - 1 30,250 (1)
0 Rapid 6 HIV Vikia stik Rp 21,818.0 - - - - - - - - -
0 Rapid 7 HIV Card Vcare stik Rp 30,250.0 - - - - - - - - -
Rapid 8 Fokus HIV stik Rp 4,179.0 - - - - - - - - -
0 Reagen Albumin biosystem kit Rp 800,000.0 - - - - - - - - -
Reagen albumin agappe / mindray kit Rp 1,400,000.0 - - - - - - - - -
0 Reagen Albumin randox kit Rp 917,250.0 - - - - - - - - -
MDVx114BJM Reagen Asam Urat biosystem kit Rp 2,805,000.0 - - - - - - - - -
0 Reagen Asam Urat agappe / mindray kit Rp 1,150,000.0 - - - - - - - - -
MDVx034902 Reagen Asam Urat randox kit Rp 1,225,700.0 - - - - - - - - -
0 Reagen Bilirubin Direct biosystem kit Rp 2,090,000.0 - - - - - - - - -
Reagen Bilirubin Direct agappe / mindray kit Rp 900,000.0 - - - - - - - - -
0 Reagen Bilirubin Direct randox kit Rp 970,000.0 - - - - - - - - -
0 Reagen Bilirubin Total biosystem kit Rp 2,090,000.0 - - - - - - - - -
Reagen Bilirubin Total agappe / mindray kit Rp 1,450,000.0 - - - - - - - - -
0 Reagen Bilirubin Total randox kit Rp 897,000.0 - - - - - - - - -
MDVx117BJM Reagen Cholesterol biosystem kit Rp 759,000.0 - - - - - - - - -
0 Reagen Cholesterol agappe / mindray kit Rp 1,150,000.0 - - - - - - - - -
MDVx034903 Reagen Cholesterol randox kit Rp 1,586,500.0 - - - - - - - - -
MDVx118BJM Reagen Cholesterol HDL biosystem kit Rp 2,040,000.0 - - - - - - - - -
Reagen Cholesterol HDL agappe / mindray kit Rp 8,225,000.0 - - - - - - - - -
0 Reagen Cholesterol HDL randox kit Rp 1,924,750.0 - - - - - - - - -
MDVx119BJM Reagen Creatinin biosystem kit Rp 1,572,725.0 - - - - - - - - -
Reagen Creatinin agappe / mindray kit Rp 850,000.0 - - - - - - - - -
0 Reagen Creatinin randox kit Rp 937,750.0 - - - - - - - - -
66
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx120BJM Reagen Glucose biosystem kit Rp 495,000.0 - - - - - - - - -
0 Reagen Glucose agappe / mindray kit Rp 1,450,000.0 - - - - - - - - -
MDVx034905 Reagen Glucose PAP randox kit Rp 1,803,400.0 - - - - - - - - -
0 Reagen golongan darah set-2 Rp 142,650.0 2 2 - - - - 2 285,300 (2)
0 Reagen golongan darah set-4 Rp 355,480.0 - - - - - - - - -
MDVx344bjm Reagen HB Cyanida kit Rp 165,000.0 - - - - - - - - -
0 Reagen HB konsentrat biosystem kit Rp 308,000.0 - - - - - - - - -
0 Reagen HB konsentrat randox kit Rp 1,498,700.0 - - - - - - - - -
0 Reagen Protein Total biosystem kit Rp 545,000.0 - - - - - - - - -
Reagen Protein Total agappe / mindray kit Rp 700,000 - - - - - - - - -
0 Reagen Protein Total randox kit Rp 880,000 - - - - - - - - -
MDVx123BJM Reagen SGOT / AST biosystem kit Rp 715,000 - - - - - - - - -
0 Reagen SGOT / AST Mindray kit Rp 1,625,000 - - - - - - - - -
0 Reagen SGOT / AST randox kit Rp 1,435,700 - - - - - - - - -
MDVx124 Reagen SGPT / ALT biosystem kit Rp 715,000 - - - - - - - - -
0 Reagen SGPT / ALT mindray kit Rp 1,625,000 - - - - - - - - -
0 Reagen SGPT / ALT randox kit Rp 1,200,000 - - - - - - - - -
MDVx125BJM Reagen Trigliseride biosystem kit Rp 3,768,792 - - - - - - - - -
0 Reagen Trigliseride mindray kit Rp 1,950,000 - - - - - - - - -
0 Reagen Trigliseride randox kit Rp 1,879,650 - - - - - - - - -
MDVx126BJM Reagen Ureum biosystem kit Rp 1,550,000 - - - - - - - - -
0 Reagen Urea Mindray kit Rp 1,150,000 - - - - - - - - -
MDVx034850 Reagen Ureum randox kit Rp 2,380,150 - - - - - - - - -
MDVx041577 Reagen Wright Stain kit Rp 290,400 - - - - - - - - -
MDVx037823 reagent cholesterol pap sl (microlab/elitech) kit Rp 3,088,800 - - - - - - - - -
MDVx002BJM reagent cholesterol standar 200 mg/dl (microlab kit Rp 633,600 - - - - - - - - -
MDVx037816 reagent glucose pap sl (microlab/elitech) kit Rp 1,584,000 - - - - - - - - -
MDVx001BJM reagent glucose standar 100 mg/dl (microlab/el kit Rp 448,800 - - - - - - - - -
MDVx037822 reagent trigliserid mono sl (microlab/elitech) kit Rp 4,752,000 - - - - - - - - -
MDVx037603 reagent trigliserid standar 200 mg/dl (microlab/e kit Rp 475,200 - - - - - - - - -
MDVx037819 reagent uric acid mono sl (microlab/elitech) kit Rp 3,168,000 - 0 - - - - - - - -
MDVx037604 reagent uric acid standar (microlab/elitech) kit Rp 580,800 - - - - - - - - -
0 Reagen Elitrol 1 Normal 1 x 5 ml (elitech) kit Rp 924,000 - - - - - - - - -
MDVx041674 Res eker botol Rp 144,100 1 1 - - - - 1 144,100 (1)
0 RPR syfilis randox botol Rp 1,555,920 - - - - - - - - - 1
0 RPR syfilis Fokus Diagnostik botol Rp 4,250 - - - - - - - - - 1
RPR syfilis "Human" botol Rp 5,684 - - - - - - - - - 1
67
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Serum kontrol mindray (Qualichek normal mind botol Rp 1,200,000 - - - - - - - - -
DRG000046730 Spiritus 1 L botol Rp 53,900 6 6 - - - - 6 323,400 (6)
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 25 25 25 119,900 - - - - 60 50
0 Stik asam urat Nesco stik Rp 5,258 - - - - - - - - -
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 20 20 - - - - 20 437,800 (20) 40
0 Stik Cholesterol Nesco stik Rp 24,090 - - - - - - - - -
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 15 - - - - 15 108,570 (15)
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - - - - - - - - -
MDVx041511 Stik Gula Darah Accu cek stik Rp 8,327 - - - - - - - - -
0 Stik HB BeneCheck stik Rp 7,955 - - - - - - - - -
MDVx133BJM Stik HB Easy touch stik Rp 6,688 50 50 100 - - - - 100 668,800 (100) 50
0 Stik HBSAb merek Intec stik Rp 27,478 - - - - - - - - -
0 Stik HBSAg merek SD stik Rp 9,870 - - - - - - - - -
Stik HBSAg merek Intec stik Rp 9,850 300 300 - - - - 300 2,955,000 (300)
0 Stik Kehamilan stik Rp 1,947 150 150 - - - - 150 292,050 (150)
0 Stik syphilis 'SD' stik Rp 35,429 - - - - - - - - -
Stik syphilis 'Monotest' stik Rp 10,758 - - - - - - - - -
Stik syphilis 'Human hexagonal' stik Rp 26,744 - - - - - - - - -
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - - - - - - - - -
MDVx138BJM Stik urinalisa 10 parameter (Lab U 11) stik Rp 2,274 - - - - - - - - -
0 Stik urinalisa 10 parameter Akray stik Rp 6,050 - - - - - - - - -
0 Stik urinalisa 10 prm (mission) stik Rp 2,700 - - - - - - - - -
0 Stik urinalisa 3 parameter stik Rp 5,720 - - - - - - - - -
0 Swelab alfa diluent 20 L botol Rp 6,500,000 - - - - - - - - -
0 Swelab alfa lyse 5 L botol Rp 8,500,000 - - - - - - - - -
0 Widal tes 4 set 4 set Rp 291,640 1 1 - - - - 1 291,640 (1)
0 Widal tes 6 set 6 set Rp 279,140 - - - - - - - - -
0 Ziehl Nielseen Stain paket Rp 273,978 2 2 1 273,978 - - 1 273,978 1
68
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
TOTAL 17,183,281 109,570,005
UMUM
JUMLAH
876 334 1210

NIP.19610409 198511 1 001 NIP. 19790311 200501 2 015 NIP.19680616 198911 1 001 NIP.19840410 200803 1 002
69
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000000983 Albendazol tablet 400 mg tablet Rp 323.0 - 0 - - - - - - - -
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 934 0 934 90 8,910 - - 844 83,556 (628)
DRG000001666 Aminofilin injeksi 24 mg/ml-10 ml ampul Rp 4,204.0 - 0 - - - - - - - -
Aminofilin tablet 200 mg tablet Rp 86.0 690 0 690 10 860 - - 680 58,480 (656)
DRG000001769 Amitriptilin Hcl tablet salut 25 mg tablet Rp 168.0 110 0 110 - - - - 110 18,480 (110)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 2,165 300 2,465 955 72,580 - - 1,510 114,760 782
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 631 2000 2,631 1,239 307,272 - - 1,392 345,216 1,582
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 160 0 160 132 573,540 - - 28 121,660 289
Ampisilin serbuk injeksi i.m.i.v 1000 mg/ml vial Rp 9,524.0 - 0 - - - - - - - -
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 3,508 2000 5,508 1,296 72,576 - - 4,212 235,872 (1,102)
DRG000002883 Antasida sirup botol Rp 2,098.0 194 0 194 28 58,744 - - 166 348,268 (99)
DRG000002996 Antifungi doen kombinasi tube Rp 5,170.0 24 0 24 - - - - 24 124,080 (24)
Artemether injeksi 80 Mg ampul Rp 29,925.0 - 0 - - - - - - - -
Artesunate cairan injeksi 60 mg ampul Rp 33,835.0 - 0 - - - - - - - -
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 728 1600 2,328 1,052 126,240 - - 1,276 153,120 1,249
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 - 0 - - - - - - - -
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 - 0 - - - - - - - -
DRG000003731 Asiklovir 200 mg tablet tablet Rp 236.0 2,177 0 2,177 10 2,360 - - 2,167 511,412 (2,143)
DRG000003947 Atropin Sulfat tablet 0,5 mg tablet Rp 26.2 - 0 - - - - - - - -
DRG000004829 Benzatin Benzil Penisilin inj 1,2 juta iu/vial vial Rp 10,780.0 - 0 - - - - - - - -
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 99 50 149 19 26,087 - - 130 178,490 (84)
Clindamisin kapsul 300 mg kapsul Rp 1,017.0 - 0 - - - - - - - -
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 2,099 0 2,099 363 12,342 - - 1,736 59,024 (865)
DRG000011634 Deksametason inj 5 mg/ml-1 ml ampul Rp 1,805.0 22 0 22 - - - - 22 39,710 (22)
70
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DHP / Darplex / D-Artepp (Dehidro artemisin - -

Diazepam inj 5 mg/ml-2 ml ampul Rp 1,913.0 5 0 5 - - - - 5 9,565 (5)
DRG000012224 Diazepam tablet 2 mg tablet Rp 220.0 178 0 178 - - - - 178 39,160 (178)
Diazepam tablet 5 mg tablet Rp 109.0 - 0 - - - - - - - -
Dietilkarbamazin sitrat tablet 100 mg tablet Rp 180.0 - 0 - - - - - - - -
DRG000012294 Difenhidramin Hcl inj 10 mg/ml-1 ml ampul Rp 1,262.0 - 0 - - - - - - - -
DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 400 0 400 - - 400 41,200 - - -
DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 686 400 1,086 140 16,940 - - 946 114,466 (610)
DRG000012885 Doksisiklin 100 mg kapsul kapsul Rp 299.0 - 0 - - - - - - - -
DRG000012719 Domperidon 10 mg tablet Rp 90.0 537 0 537 30 2,700 - - 507 45,630 (435)
DRG000013853 Epinefrin Hcl/Bitartrat(adrenalin)inj 0,1 %-1 ml ampul Rp 1,518.0 17 0 17 - - - - 17 25,806 (17)
DRG000014229 Erytromisin sirup botol Rp 6,390.0 - 0 - - - - - - - -
DRG000014234 Erytromisin 500 mg kaplet tablet Rp 781.0 - 0 - - - - - - - -
DRG000046712 Etambutol 500 mg tablet tablet Rp 466.0 - 0 - - - - - - - -
DRG000027466 Fenitoin kapsul 50 mg kapsul Rp 1.0 - 0 - - - - - - - -
DRG000015393 Fenobarbital inj 50 mg / ml - 2 ml ampul Rp 2,135.0 - 0 - - - - - - - -
DRG000032549 Fenobarbital tablet 30 mg tablet Rp 197.0 - 0 - - - - - - - -
Ferrous sulphate tab selaput 300 mg tablet Rp 1.0 - 0 - - - - - - - -
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 6,120 0 6,120 622 34,210 - - 5,498 302,390 (4,005)
DRG000015698 Fitomenadion ( vit k 1 ) tablet salut 10 mg tablet Rp 818.0 341 200 541 110 89,980 - - 431 352,558 (167)
DRG000032665 Fitomenadion ( vit k 1 ) inj 10 mg / ml - 1 ml ampul Rp 5,516.5 12 0 12 - - - - 12 66,198 (12)
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 710 0 710 10 790 - - 700 55,300 (676)
Furosemid Cairan Injeksi 10 mg/ml ampul Rp 2,781.1 - 0 - - - - - - - -
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 589 0 589 54 22,572 - - 535 223,630 (405)
DRG000017209 Gentamisin inj 40 mg/2 ml ampul Rp 4,989.6 - 0 - - - - - - - -
DRG000017398 Glibenklamid tablet 5 mg tablet Rp 137.0 2,915 0 2,915 50 6,850 - - 2,865 392,505 (2,745)
DRG000017435 Glimepirid tab 1 mg tablet Rp 194.0 160 0 160 100 19,400 - - 60 11,640 180
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 - 0 - - - - - - - -
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 335 400 735 110 6,050 - - 625 34,375 (361)
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 415 0 415 - - - - 415 23,240 (415)
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 727 0 727 10 1,630 - - 717 116,871 (693)
DRG000019279 Hidrokortison krim 2,5 % tube Rp 2,533.0 - 0 - - - - - - - -
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 1,780 500 2,280 70 7,840 - - 2,210 247,520 (2,042)
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 890 0 890 30 8,760 - - 860 251,120 (788)
DRG000020665 Isoniazid tablet 100 mg tablet Rp 79.0 100 0 100 - - - - 100 7,900 (100)
71
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020671 Isoniazid tablet 300 mg tablet Rp 173.0 - 0 - - - - - - - -
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 190 0 190 - - - - 190 16,910 (190)
DRG46597 Kalsium Gluconas inj ampul Rp 1.0 - 0 - - - - - - - -
Kalsium Karbonat tablet 500 mg tablet Rp 1.0 - 0 - - - - - - - -
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 1,437 600 2,037 121 13,310 - - 1,916 210,760 (1,626)
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 170 0 170 30 7,020 - - 140 32,760 (68)
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 - 0 - - - - - - - -
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 640 0 640 - - - - 640 176,000 (640)
Kloramfenikol salep 2 % tube Rp 1.0 - 0 - - - - - - - -
Kloramfenikol salep mata 1 % tube Rp 1,925.0 95 100 195 12 23,100 - - 183 352,275 (154)
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 59 0 59 - - - - 59 293,938 (59)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 4,615 2000 6,615 1,077 25,848 - - 5,538 132,912 (2,953)
Klorpromazin Hcl inj 5 mg / ml - 2 ml ampul Rp 376.0 - 0 - - - - - - - -
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 - 0 - - - - - - - -
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 240 0 240 40 26,280 - - 200 131,400 (104)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 953 0 953 58 7,250 - - 895 111,875 (756)
DRG000010167 Kotrimoksazol suspensi botol Rp 2,052.0 355 0 355 23 47,196 - - 332 681,264 (277)
DRG000021836 Kuinine tablet salut selaput 200 mg tablet Rp 310.7 - 0 - - - - - - - -
Kuinine Dihydrochloride cairan inj 25%-2 ml ampul Rp 2,616.1 - 0 - - - - - - - -
DRG000023410 Lidocain injeksi 2 % ampul Rp 1,319.0 - 0 - - - - - - - -
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 86 30 116 - - - - 116 152,772 (116)
DRG000023922 Loratadin tablet tablet Rp 127.0 1,525 0 1,525 120 15,240 - - 1,405 178,435 (1,117)
DRG000024327 Magnesium sulfat inj ( 1V ) 20 % - 25 ml vial Rp 3,200.0 2 0 2 - - - - 2 6,400 (2)
DRG000043759 Mebendazol tablet 100 mg (vermox) tablet Rp 7,854.0 - 0 - - - - - - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 452 0 452 150 15,300 - - 302 30,804 58
DRG000025481 Metformin tab 850 mg tablet Rp 165.0 140 0 140 - - - - 140 23,100 (140)
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 50 100 150 20 5,476 - - 130 35,594 (82)
DRG000025567 Metilergometrin maleat inj 0,200 mg - 1 ml ampul Rp 3,399.0 9 0 9 - - - - 9 30,591 (9)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 2,003 0 2,003 429 70,785 - - 1,574 259,710 (544)
DRG000025667 Metilprednisolon 16 mg tablet tablet Rp 875.0 - 0 - - - - - - - -
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 284 500 784 14 1,162 - - 770 63,910 (736)
DRG000025793 Metronidazol tablet 250 mg tablet Rp 94.0 - 0 - - - - - - - -
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 760 500 1,260 85 17,255 - - 1,175 238,525 (971)
Metronidazol suspension 125 mg/ml botol Rp 3,800.0 - 0 - - - - - - - -
DRG000025979 Miconazol krim tube Rp 2,577.0 91 50 141 5 12,885 - - 136 350,472 (124)
DRG000026103 Mineral mix serbuk 8 gr sachet Rp 3,055.0 40 0 40 - - - - 40 122,200 (40)
72
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038915 Natrium Bikarbonat tablet 500 mg tablet Rp 9.8 - 0 - - - - - - - -
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 185 0 185 170 24,140 - - 15 2,130 393
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,120 0 2,120 490 66,640 - - 1,630 221,680 (454)
Natrium Tiroksin (Levotiroksin) tablet 100 mg - -
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 - 300 300 - - - - 300 53,998 (300)
Nicotinamida tablet 20 mg tablet Rp 1.0 - 0 - - - - - - - -
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 119 0 119 - - - - 119 76,755 (119)
Obat antituberkolusis katagori 1 paket Rp 395,900.0 - 0 - - - - - - - -
Obat antituberkolusis katagori 2 paket Rp 1,379,984.0 - 0 - - - - - - - -
Obat antituberkulosis anak paket Rp 267,400.0 - 1 1 - - - - 1 267,400 (1)
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 - 3 3 - - - - 3 1,241,937 (3)
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 - 1 1 - - - - 1 1,492,574 (1)
DRG000031217 Oksitetrasiklin Hcl salep mata 1 % tube Rp 2,600.0 - 0 - - - - - - - -
DRG000031235 Oksitosin injeksi 10 iu / ml ampul Rp 1,232.0 15 0 15 - - - - 15 18,480 (15)
DRG000030245 Omeprazol inj 40 mg/10 ml ampul Rp 18,537.0 - 0 - - - - - - - -
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 873 0 873 75 10,350 - - 798 110,124 (618)
DRG000031912 Parasetamol sirup 120 mg / 5 ml botol Rp 1,160.0 345 300 645 152 176,320 - - 493 571,880 (128)
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 3,717 5000 8,717 4,255 255,300 - - 4,462 267,720 5,750
DRG000034958 Pirantel pamoat 125 mg tablet tablet Rp 318.0 - 0 - - - - - - - -
DRG000034959 Pirantel suspensi 5 mg/ml botol Rp 9,100.0 - 0 - - - - - - - -
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 775 400 1,175 259 36,519 - - 916 129,156 (294)
DRG000032952 Piridoksin Hcl tablet 25 mg tablet Rp 40.5 - 0 - - - - - - - -
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 1,012 0 1,012 - - - - 1,012 183,678 (1,012)
DRG000033915 Primakuin tablet 15 mg tablet Rp 258.0 - 0 - - - - - - - -
DRG000034345 Prokain benzil penisilin 3 juta iu / vial injeksi vial Rp 1.0 - 0 - - - - - - - -
DRG000034487 Propanolol Hcl tablet 40 mg tablet Rp 300.0 - 100 100 - - - - 100 29,999 (100)
DRG000034502 Propiltiourasil tablet 100 mg tablet Rp 500.0 100 0 100 - - - - 100 50,001 (100)
DRG000035403 Ranitidin tablet tablet Rp 122.0 1,500 1000 2,500 550 67,100 - - 1,950 237,900 (630)
DRG000044394 Retinol ( Vit A ) 100.000 IU kapsul kapsul Rp 585.0 - 0 - - - - - - - -
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 184 200 384 113 7,232 - - 271 17,344 0
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,036 0 1,036 45 3,465 - - 991 76,307 (883)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 71 0 71 2 6,034 - - 69 208,173 (64)
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 1,560 0 1,560 140 68,880 - - 1,420 698,640 (1,084)
DRG000007256 Sefadroxil syp kering 125 ml / 5 ml botol Rp 4,086.0 183 0 183 25 102,150 - - 158 645,588 (98)
Sianokobalamin ( Vit.B.12 ) inj 500 mcg / ml ampul Rp 1,067.0 - 0 - - - - - - - -
73
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 1,920 510 2,430 190 20,900 - - 2,240 246,400 (1,784)
DRG000008829 Siprofloksasin 500 mg tablet tablet Rp 281.0 1,585 0 1,585 10 2,810 - - 1,575 442,575 (1,551)
Tetrasiklin Hcl kapsul 250 mg kapsul Rp 73.0 - 0 - - - - - - - -
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 990 0 990 630 55,440 - - 360 31,680 1,152
DRG000042321 Triheksilfenidil hidroklorida tablet 2 mg tablet Rp 95.0 365 600 965 150 14,250 - - 815 77,425 (455)
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 2,725 3000 5,725 1,174 158,490 - - 4,551 614,385 (1,733)
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 850 300 1,150 361 218,044 - - 789 476,556 77
DRG000043194 Vaksin BCG vial Rp 59,950.0 - 0 - - - - - - - -
Vaksin Jerap D T vial Rp 17,798.0 - 0 - - - - - - - -
Vaksin CAMPAK 10 Dosis vial Rp 28,204.0 5 0 5 - - - - 5 141,020 (5)
Vaksin POLIO 10 Dosis vial Rp 19,954.0 15 0 15 - - - - 15 299,310 (15)
Vaksin HEPATITIS B 0,5 ml ADS vial Rp 20,900.0 - 0 - - - - - - - -
DRG000043208 Pentabio Vaksin DTP-HB-HIB inj vial Rp 76,285.0 - 0 - - - - - - - -
DRG000043266 Vaksin Td vial Rp 16,500.0 - 0 - - - - - - - -
Vaksin IPV (Poliomyelitis Vaccine inj (ShanIPV vial Rp 152,900.0 - 0 - - - - - - - -
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - - -
Acdat salep tube Rp 6,241.0 - 0 - - - - - - - -
DRG000000325 Air untuk irigasi lar infus 1000 ml botol Rp 22,000.0 - 0 - - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 0 200 - - - - 200 175,600 (200)
DRG000001441 Albendazol suspensi 200mg/5 ml botol Rp 4,600.0 - 0 - - - - - - - -
DRG000001442 Alprazolam 0,5 mg tablet Rp 88.0 - 0 - - - - - - - -
Alprazolam 1 mg tablet Rp 120.0 - 0 - - - - - - - -
DRG000001592 Alvit drops botol Rp 12,500.0 - 0 - - - - - - - -
DRG000001574 Ambroxol sirup botol Rp 3,300.0 280 0 280 88 290,400 - - 192 633,600 19
DRG000001791 Ambroxol tablet tablet Rp 100.0 793 500 1,293 670 67,000 - - 623 62,300 985
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 2,203 0 2,203 790 75,050 - - 1,413 134,235 483
Amoksisilin 250 mg tablet Rp 196.0 - 0 - - - - - - - -
Anemolat 1 mg tablet tablet Rp 77.0 - 0 - - - - - - - -
DRG000002721 Antalgin (Metampiron) tablet 500 mg tablet Rp 67.0 - 0 - - - - - - - -
DRG000002981 Antalgin injeksi 250 mg/5 ml ampul Rp 407.8 - 0 - - - - - - - -
DRG000003002 Anti bakteri doen salep kombinasi tube Rp 3,490.0 - 0 - - - - - - - -
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 49 0 49 11 40,062 - - 38 138,396 (12)
DRG000023225 Antimigrain doen kombinasi tablet Rp 149.0 - 0 - - - - - - - -
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 180 0 180 30 31,050 - - 150 155,250 (78)
Antrain inj ampul Rp 11,999.2 - 0 - - - - - - - -
DRG000003089 Apialis Drops botol Rp 21,175.0 - 0 - - - - - - - -
74
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 34 0 34 - - - - 34 1,122,000 (34)
DRG000003393 Aqua proinjeksi steril,bebas pirogen vial Rp 2,860.0 21 0 21 - - - - 21 60,060 (21)
DRG000003466 Arkavit tablet Rp 320.0 85 0 85 85 27,200 - - - - 204
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 58 0 58 - - - - 58 8,932 (58)
DRG000003564 Asam Asetilsalisilat tablet 500 mg (Asetosal) tablet Rp 99.6 - 0 - - - - - - - -
Asam askorbat(vit C) tablet 250 mg tablet Rp 150.0 - 0 - - - - - - - -
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 510 0 510 - - - - 510 794,835 (510)
DRG000000595 Asam Traneksamat injeksi 5 % 250 mg/ 5 ml ampul Rp 1,813.0 - 0 - - - - - - - -
Asiklovir salep kulit tube Rp 3,699.3 47 0 47 8 29,594 - - 39 144,273 (20)
DRG000003950 Atropin Sulfat injeksi 0,25 mg/ml-1 ml ampul Rp 1,540.0 - 0 - - - - - - - -
DRG000003956 Atropin Sulfat tetes mata 0,5 % botol Rp 2,800.7 - 0 - - - - - - - -
DRG000004142 Atrovent HFA kotak Rp 83,500.0 - 0 - - - - - - - -
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 74 0 74 74 131,572 - - - - 178
Baby Cough sirup botol Rp 3,999.6 146 0 146 37 147,985 - - 109 435,956 (20)
Betahistin mesilat tablet 6 mg tablet Rp 119.0 - 0 - - - - - - - -
DRG000005736 Bioplacenton Cream tube Rp 18,499.8 20 0 20 - - - - 20 369,996 (20)
Bisoprolol tablet 5 mg tablet Rp 248.0 190 0 190 - - - - 190 47,120 (190)
Buscopan tablet tablet Rp 3,100.0 40 200 240 30 93,000 - - 210 651,000 (138)
Cendo Augentonic tetes mata botol Rp 30,990.0 - 0 - - - - - - - -
Cendo Catarlent tetes mata botol Rp 33,699.6 - 0 - - - - - - - -
DRG000015887 Cendo Edta tetes mata botol Rp 37,500.0 - 0 - - - - - - - -
Cendo Floxa tetes mata botol Rp 33,599.5 - 0 - - - - - - - -
Cendo fungicide tetes mata botol Rp 18,500.0 - 0 - - - - - - - -
DRG000007801 Cendo Homatrol tetes mata botol Rp 43,785.0 - 0 - - - - - - - -
Cendo Lyteers tetes mata botol Rp 25,999.6 27 0 27 10 259,996 - - 17 441,993 7
Cendo mydriatil tetes mata botol Rp 27,845.4 - 0 - - - - - - - -
Cendo Tobroson tetes mata botol Rp 53,999.0 - 0 - - - - - - - -
DRG000007849 Cendo tropin tetes mata botol Rp 13,875.0 - 0 - - - - - - - -
Cendo Xytrol tetes mata botol Rp 33,000.0 - 0 - - - - - - - -
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 - 0 - - - - - - - -
DRG000010471 Clopidogrel 75 mg tablet tablet Rp 1,469.0 240 0 240 1 1,469 - - 239 351,091 (237)
Curcuma tablet tablet Rp 990.0 - 0 - - - - - - - -
DRG000011354 Dekstran 70 larutan infus 6 % steril botol Rp 35,526.0 - 0 - - - - - - - -
DRG000011365 Depakene sirup botol Rp 17,789.0 5 0 5 - - 5 88,945 - - -
DRG000011337 Depakote tablet tablet Rp 1,200.0 390 0 390 - - - - 390 468,000 (390)
DRG000011848 Desoksimetason 0,25 mg (Denomix) tube Rp 11,500.0 - 0 - - - - - - - -
75
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Dextamine tablet tablet Rp 1,815.0 - 0 - - - - - - - -
DRG000012127 Dextrofen sirup botol Rp 12,499.3 - 0 - - - - - - - -
Diamicron MR 30 mg tablet tablet Rp 638.0 - 0 - - - - - - - -
DRG000012720 Diltiazem tablet tablet Rp 143.0 - 0 - - - - - - - -
DRG000012774 Domperidon Suspensi 5 mg/5 ml botol Rp 2,862.0 183 0 183 6 17,172 - - 177 506,574 (163)
DRG000012960 Dopamet (metildopa) tablet Rp 880.0 - 0 - - - - - - - -
DRG000012963 Dulcolax 10 mg supp supp Rp 5,900.0 - 0 - - - - - - - -
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 130 0 130 1 316 - - 129 40,764 (127)
DRG000013350 Efedrin Hcl tablet 25 mg tablet Rp 197.8 - 0 - - - - - - - -
DRG000014440 Erytromisin 250 mg kapsul kapsul Rp 636.0 - 0 - - - - - - - -
Etakridin ( Rivanol ) larutan 0,1 % botol Rp 4,999.5 - 0 - - - - - - - -
DRG000015045 Etambutol Hcl tablet 250 mg tablet Rp 186.3 - 0 - - - - - - - -
DRG000027495 Famotidin 40 mg tablet tablet Rp 192.0 900 0 900 - - - - 900 172,800 (900)
DRG000027467 Fenitoin natrium inj 50 mg / ml ampul Rp 48,368.0 - 0 - - - - - - - -
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 100 100 200 - - - - 200 31,600 (200)
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 95 0 95 10 10,730 - - 85 91,205 (61)
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 73 0 73 6 15,540 - - 67 173,530 (53)
Flukonazol tab 150 mg tablet Rp 24,200.0 - 0 - - - - - - - -
DRG000016599 Fluor tablet 0,5 mg tablet Rp 32.9 - 0 - - - - - - - -
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 16 0 16 10 48,890 - - 6 29,334 18
Fungasol 2 % botol Rp 24,200.0 - 0 - - - - - - -
DRG000016864 Fuson ointment tube Rp 7,500.0 - 0 - - - - - - - -
Gemfibrozil 300 mg tablet Rp 428.0 710 0 710 86 36,808 - - 624 267,072 (418)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 57 0 57 8 19,994 - - 49 122,461 (30)
DRG000017167 Gentamisin salep mata tube Rp 3,075.0 - 0 - - - - - - - -
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 29 50 79 9 43,965 - - 70 341,950 (48)
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 43 0 43 3 10,497 - - 40 139,964 (33)
Glimepirid tab 2 mg tablet Rp 207.0 430 0 430 10 2,070 - - 420 86,940 (396)
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 1,457 2000 3,457 1,160 104,400 - - 2,297 206,730 487
DRG000017683 Gliserin larutan 50% botol Rp 5,867.0 - 0 - - - - - - - -
DRG000017692 Glukosa larutan infus 10 % steril botol Rp 7,500.0 - 0 - - - - - - - -
DRG000017682 Glukosa larutan infus 40 % steril botol Rp 988.0 - 0 - - - - - - - -
DRG000030867 Glukosa larutan infus 5 % steril botol Rp 5,720.0 1 0 1 - - - - 1 5,720 (1)
Glukosamin 250 mg tablet (osmin) tablet Rp 1,000.0 - 0 - - - - - - - -
DRG000018288 H.Booster sirup botol Rp 14,168.0 - 0 - - - - - - - -
DRG000018443 Haloperidol tablet 1,5 mg tablet Rp 59.0 100 0 100 - - - - 100 5,900 (100)
76
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 541 600 1,141 495 420,745 - - 646 549,094 542
DRG000019256 HEXADOL (Larutan Hexetidine) botol Rp 12,650.0 - 0 - - - - - - - -
Hidrokortison krim 1% tube Rp 5,723.3 26 0 26 3 17,170 - - 23 131,636 (16)
Hyorex 10 mg tablet tablet Rp 405.0 - 0 - - - - - - - -
DRG000019430 Hyoscine N Butilbromida 10 mg tablet tablet Rp 1,625.8 - 0 - - - - - - - -
DRG000019495 Ibuprofen syr 100 mg/5ml botol Rp 2,560.0 158 0 158 3 7,680 - - 155 396,800 (148)
Ichtyol salep tube Rp 6,200.0 45 0 45 1 6,200 - - 44 272,800 (42)
Inhitril 10 mg tablet Rp 385.0 - 0 - - - - - - - -
Interhistin tablet tablet Rp 880.0 180 200 380 90 79,200 - - 290 255,200 (74)
DRG000006615 Irbesartan tab 150 mg tablet Rp 425.0 - 0 - - - - - - - -
DRG000006804 Kalsium laktat ( Kalk ) tablet 500 mg tablet Rp 59.0 6,677 0 6,677 440 25,960 - - 6,237 367,983 (5,181)
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 650 420 1,070 320 191,680 - - 750 449,250 18
DRG000007735 Kandesartan 16 mg tablet tablet Rp 6,225.0 - 0 - - - - - - - -
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 192 0 192 28 741,972 - - 164 4,345,836 (97)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 860 0 860 20 2,500 - - 840 104,992 (792)
DRG000021651 Kaptopril 50 mg tablet tablet Rp 135.0 - 0 - - - - - - - -
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 35 0 35 3 7,731 - - 32 82,464 (25)
DRG000009233 Ketoprofen 100 mg tablet tablet Rp 1,366.2 - 0 - - - - - - - -
DRG000009302 Klindamisin 150 mg tablet tablet Rp 754.0 - 0 - - - - - - - -
DRG000009337 Klobazam 10 mg tablet tablet Rp 872.0 377 0 377 63 54,936 - - 314 273,808 (163)
DRG000021912 Klonidin 0,15 mg tablet tablet Rp 224.0 - 0 - - - - - - - -
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 - 0 - - - - - - - -
DRG000008615 Klorpromazin Hcl inj 25 mg / ml - 12 ml ampul Rp 418.3 - 0 - - - - - - - -
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 110 0 110 10 11,210 - - 100 112,100 (76)
DRG000021974 Kodein tablet 15 mg tablet Rp 728.0 - 0 - - - - - - - -
DRG000003009 Kodein tablet 20 mg tablet Rp 1,494.0 - 0 - - - - - - - -
DRG000022061 Kombinasi pirimetamin 25 mg / sulfadoksin 50 tablet Rp 379.6 - 0 - - - - - - - -
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - 0 - - - - - - - -
DRG000022701 Kotrimoksazol DOEN II (pedriatik) tablet tablet Rp 79.0 - 0 - - - - - - - -
Lanzoprazol tablet Rp 330.0 70 800 870 345 113,850 - - 525 173,250 303
DRG000022980 Lapalos Cream tube Rp 16,500.0 - 0 - - - - - - - -
Laxadine emulsi botol Rp 7,700.0 - 0 - - - - - - - -
DRG000023225 L-Bio sachet sachet Rp 4,033.3 381 0 381 9 36,300 - - 372 1,500,388 (350)
DRG000023291 Levofloksasin tab 500 mg tablet Rp 449.0 - 0 - - - - - - - -
DRG000045684 Lexapram sirup botol Rp 2,900.0 - 0 - - - - - - - -
77
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023536 Lidocain jeli 2 % (Xylocaine Jelly 2%) syringe Rp 40,000.0 - 0 - - - - - - - -
DRG000023691 Lincomisin 500 mg tablet Rp 1,319.6 200 0 200 - - - - 200 263,920 (200)
DRG000023692 Lisinopril 10 mg tablet tablet Rp 323.0 - 0 - - - - - - - -
Lisinopril 5 mg tablet tablet Rp 238.0 - 0 - - - - - - - -
DRG000026266 Lisol botol Rp 45,100.0 1 0 1 - - - - 1 45,100 (1)
DRG000023860 Livertran salep tube Rp 4,600.0 103 0 103 - - - - 103 473,800 (103)
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 1,077 0 1,077 36 96,980 - - 1,041 2,804,350 (955)
DRG000023935 Loperamida tablet tablet Rp 85.0 300 0 300 - - - - 300 25,500 (300)
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 - 0 - - - - - - - -
DRG000024571 MDT Combi paket Rp 31,570.0 - 0 - - - - - - - -
DRG000024987 Mebendazol sirup 100 mg / 5 ml botol Rp 2,035.0 - 0 - - - - - - - -
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 590 0 590 70 56,000 - - 520 416,000 (352)
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 1,165 0 1,165 430 279,500 - - 735 477,750 297
Mersibion injeksi ampul Rp 6,000.0 - 0 - - - - - - - -
DRG000025750 Metoklorpropamid sirup botol Rp 1,919.0 - 0 - - - - - - - -
DRG000015762 Metronidazol infus 500 mg/100 ml botol Rp 25,300.0 - 0 - - - - - - - -
DRG000026108 Metronidazol supp 500 mg (Flagyl supp) supp Rp 3,655.0 - 0 - - - - - - - -
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 639 0 639 - - - - 639 63,261 (639)
DRG000026643 Misoprostol 200 mg (gastrul) tablet Rp 12,300.0 - 0 - - - - - - - -
DRG000044042 Mixaria sachet Rp 1,260.0 - 0 - - - - - - - -
DRG000026742 Moksifloksasin tetes mata 0,5% (Vigamox) botol Rp 81,000.0 - 0 - - - - - - - -
DRG000027470 Mometason furoat krim 0,1 % tube Rp 7,912.0 - 0 - - - - - - - -
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 - 3 3 1 5,170 - - 2 10,340 0
DRG000028214 Neo Diaform tablet Rp 253.0 - 0 - - - - - - - -
DRG000028376 Neurodex tablet tablet Rp 591.4 330 0 330 - - - - 330 195,162 (330)
DRG000028619 New Diatabs tablet Rp 560.0 - 0 - - - - - - - -
DRG000028637 Nistatin 500.000 iu /g tablet salut tablet Rp 910.0 - 0 - - - - - - - -
Nitral (gliseril trinitras sublingual 0.5 mg) tablet Rp 1,650.1 - 0 - - - - - - - -
DRG000029080 Nopres 20 mg tablet tablet Rp 883.3 185 210 395 - - - - 395 348,904 (395)
Norages Injeksi ampul Rp 9,999.9 - 0 - - - - - - - -
novadium tablet Rp 200.0 - 0 - - - - - - - -
Novastan sirup botol Rp 12,650.0 42 0 42 7 88,550 - - 35 442,750 (18)
Noza tablet tablet Rp 797.5 397 400 797 150 119,625 - - 647 515,983 (287)
Obat antituberkulosis kat.3 paket Rp 154,000.0 - 0 - - - - - - - -
DRG000029617 Obat antituberkulosis kat.sisipan paket Rp 160,000.0 - 0 - - - - - - - -
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 163 100 263 10 49,995 - - 253 1,264,874 (229)
DRG000039980 Obat suntik KB I (3 bulan) ampul Rp 7,175.0 - 0 - - - - - - - -
78
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030101 Obat suntik KB II (1 bulan) ampul Rp 5,885.0 - 0 - - - - - - - -
DRG000019683 Ofloksasin tab 400 mg tablet Rp 700.0 295 0 295 - - - - 295 206,500 (295)
DRG000031218 Oksimetazolin tts hidung 0,025% (Iliadin drops) botol Rp 37,433.0 - 0 - - - - - - - -
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 - 0 - - - - - - - -
DRG000030419 Ondansetron inj 4 mg/2ml ampul Rp 1,198.0 - 0 - - - - - - - -
DRG000030584 Ondansetron tab 4 mg tablet Rp 406.0 - 0 - - - - - - - -
Optiflox tetes mata botol Rp 14,005.0 - 0 - - - - - - - -
Pamol supp supp Rp 18,999.2 - 0 - - - - - - - -
DRG000031557 Pantocain 0,5 % TM botol Rp 17,499.9 5 0 5 - - - - 5 87,500 (5)
DRG000031585 Papaverin 40 mg tablet tablet Rp 170.0 - 0 - - - - - - - -
DRG000031608 Parasetamol Drop 100 mg/ml botol Rp 6,938.8 - 0 - - - - - - - -
DRG000032133 Pedialyte botol Rp 31,999.0 94 0 94 - - - - 94 3,007,906 (94)
DRG000032718 Pehacain injeksi ampul Rp 3,580.0 - 0 - - - - - - - -
DRG000002552 Pil KB I tablet Rp 1,350.0 192 100 292 110 148,500 - - 182 245,700 82
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - 0 - - - - - - - -
Pim-Tra-Kol sirup botol Rp 9,999.0 - 0 - - - - - - - -
DRG000032996 Pirazinamid tab 500 mg tablet Rp 238.0 - 0 - - - - - - - -
DRG000032977 Piroksikam 10 mg tablet tablet Rp 112.2 - 0 - - - - - - - -
DRG000033456 Polikresulen botol Rp 43,975.8 - 0 - - - - - - - -
DRG000020429 Povidon Iodida larutan 10 % 30 ml botol Rp 3,190.0 11 0 11 - - - - 11 35,090 (11)
Povidon Iodida Larutan 1000 ml botol Rp 42,000.0 1 0 1 - - - - 1 42,000 (1)
PP Isoniazide 100 mg tablet Rp 79.0 - 0 - - - - - - - -
Prazikuantel tablet 600 mg tablet Rp 2,295.0 - 0 - - - - - - - -
Prenatin DF tablet tablet Rp 3,258.3 600 0 600 60 195,498 - - 540 1,759,482 (396)
DRG000034697 Primolut N tablet Rp 2,618.0 - 0 - - - - - - - -
Protofen supp supp Rp 2,790.0 - 0 - - - - - - - -
DRG000034797 Protofen tablet tablet Rp 880.0 - 0 - - - - - - - -
Pularex tablet tablet Rp 175.0 590 0 590 94 16,450 - - 496 86,800 (270)
DRG000034808 Pulmicort respules ampul Rp 9,725.0 - 0 - - - - - - - -
Pulmicort turbuhaler kotak Rp 101,000.0 - 0 - - - - - - - -
Ramabion tab tablet Rp 6,490.0 - 0 - - - - - - - -
DRG000035650 Ranitidin inj 25mg/2ml ampul Rp 1,155.0 - 0 - - - - - - - -
DRG000035955 Recovit sirup botol Rp 8,650.0 - 0 - - - - - - - -
Reserpin tablet 0,25 mg tablet Rp 114.0 - 0 - - - - - - - -
79
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Rifampisin kaplet 600 mg tablet Rp 1,209.0 - 0 - - - - - - - -
DRG000036344 Rifampisin kapsul 300 mg tablet Rp 670.0 - 0 - - - - - - - -
DRG000036698 Ringer laktat larutan infus steril botol Rp 7,150.0 4 0 4 - - - - 4 28,600 (4)
DRG000037347 Risperidon 2 mg tab tablet Rp 273.0 - 0 - - - - - - - -
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 227 100 327 33 198,960 - - 294 1,772,555 (215)
Sandepril 50 mg tablet Rp 8,900.0 - 0 - - - - - - - -
Sangobion kids drop botol Rp 34,999.8 - 0 - - - - - - - -
Sangobion Kids Sirup botol Rp 24,515.7 - 0 - - - - - - - -
DRG000037725 Scabicid cream 10 gram tube Rp 11,475.0 - 0 - - - - - - - -
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 51 0 51 7 80,325 - - 44 504,900 (27)
Scopma tablet tablet Rp 750.0 - 0 - - - - - - - -
DRG000007425 Sefaleksin kapsul 500 mg kapsul Rp 717.0 - 0 - - - - - - - -
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 594 0 594 60 137,940 - - 534 1,227,666 (390)
DRG000038259 Sefiksim syr kering 100mg/5ml botol Rp 5,710.0 103 0 103 - - - - 103 588,130 (103)
DRG000038315 Seretide Inhaler 50 mcg kotak Rp 58,000.0 - 0 - - - - - - - -
Serum anti bisa ular polivalen inj 5 ml ( ABU I ) vial Rp 479,996.0 - 0 - - - - - - - -
Serum anti bisa ular polivalen inj 50 ml ( ABU II vial Rp 28,468,086.0 - 0 - - - - - - - -
DRG000038321 Serum anti defteri inj 1000 mg / vial vial Rp 2,200,000.0 - 0 - - - - - - - -
Serum anti tetanus inj 1.500 IU / ampul ( ATS ) ampul Rp 130,999.0 - 0 - - - - - - - -
DRG000008166 Serum anti tetanus inj 20.000 IU / ampul ( ATS ampul Rp 604,670.0 - 0 - - - - - - - -
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 147 0 147 62 185,566 - - 85 254,405 64
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 641 500 1,141 836 81,092 - - 305 29,585 1,701
DRG000008751 Simetidin tablet tablet Rp 250.0 - 0 - - - - - - - -
DRG000038671 Simpastatin 20 mg tablet tablet Rp 225.0 507 0 507 90 20,250 - - 417 93,825 (201)
Sohobion tablet tablet Rp 1,043.6 - 0 - - - - - - - -
Spiramisin 500 mg tablet tablet Rp 1,223.2 - 0 - - - - - - - -
DRG000039298 Spironolakton tab 25 mg tablet Rp 212.0 - 0 - - - - - - - -
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 12 0 12 - - - - 12 173,508 (12)
Stimuno Forte tablet tablet Rp 2,504.7 - 0 - - - - - - - -
Stimuno Sirup botol Rp 18,500.0 - 0 - - - - - - - -
Sucralfate 500 mg/5 ml suspensi botol Rp 7,338.0 - 0 - - - - - - -
DRG000039932 Sulfasetamid natrium tetes mata 15 % botol Rp 8,499.7 - 0 - - - - - - - -
DRG000040124 Susuk KB II set Rp 213,936.8 - 0 - - - - - - - -
DRG000040178 Symbicort turbuhaler 160/4.5 mg kotak Rp 134,500.0 - 0 - - - - - - - -
DRG000040195 Synarcus krim tube Rp 2,534.0 77 50 127 10 25,340 - - 117 296,478 (93)
80
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Taburia sachet Rp 1,000.0 - 0 - - - - - - - -
DRG000040442 Tanapress 5 mg (imidapril ) tablet Rp 2,333.0 - 0 - - - - - - - -
Tensigard tablet tablet Rp 1,063.3 - 0 - - - - - - - -
Terra Flu tablet tablet Rp 807.1 - 0 - - - - - - - -
DRG000041013 Tetagam ampul Rp 176,800.0 - 0 - - - - - - - -
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 240 100 340 - - - - 340 302,600 (340)
DRG000041258 Thiamin Hcl ( Vit B1 ) inj.100 mg / ml - 1 ml ampul Rp 730.0 - 0 - - - - - - - -
DRG000041358 Thrombophob gel tube Rp 54,450.0 6 0 6 - - - - 6 326,700 (6)
DRG000041532 Timolol tetes mata 0,5% botol Rp 10,286.0 - 0 - - - - - - - -
DRG000041922 Tramadol 50 mg kapsul kapsul Rp 580.0 - 0 - - - - - - - -
DRG000041920 Tramadol inj 50 mg/ml ampul Rp 2,680.0 - 0 - - - - - - - -
DRG000042315 Triflouperazin 5mg tablet tablet Rp 309.0 - 0 - - - - - - - -
DRG000042713 Truvit drops botol Rp 36,499.1 51 0 51 51 1,861,454 - - - - 122
Truvit sirup botol Rp 11,400.0 94 0 94 12 136,800 - - 82 934,800 (53)
DRG000042887 Ulsafate sirup botol Rp 9,192.0 51 0 51 12 110,304 - - 39 358,488 (10)
DRG000042899 Ulsidex tablet tablet Rp 296.0 - 0 - - - - - - - -
Urea krim (Soft U derm) botol Rp 7,040.0 - 0 - - - - - - - -
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 250 0 250 50 90,750 - - 200 363,000 (80)
DRG000043188 Vagizol ovula (metronidazol ovula) ovula Rp 4,235.0 - 0 - - - - - - - -
valisanbe 2 mg tablet Rp 236.0 - 0 - - - - - - - -
DRG000043324 Valsartan tab 80 mg (Diovan 80mg) tablet Rp 3,900.0 - 0 - - - - - - - -
Vastral tablet Rp 605.0 - 0 - - - - - - - -
DRG000043683 Ventolin inhaler kotak Rp 70,125.0 - 0 - - - - - - - -
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 27 10 37 2 22,000 - - 35 385,000 (30)
Vitamin A6000IU tablet Rp 237.0 - 0 - - - - - - - -
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,920 1000 2,920 720 35,280 - - 2,200 107,800 (472)
Vitonorm tablet tablet Rp 4,107.2 - 0 - - - - - - - -
DRG000045683 Xylocain spray kotak Rp 344,570.0 - 0 - - - - - - - -
Yodium Test botol Rp 1.0 - 0 - - - - - - - -
DRG000046219 Zincpro drops botol Rp 31,999.9 - 0 - - - - - - - -
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 - 0 - - - - - - - -
DRG000046382 Zoloral SS (ketokonazol scalp sol 2 %) botol Rp 24,200.0 6 0 6 - - - - 6 145,200 (6)
- 0 - - - - - - - -
II.OBAT GIGI - 0 - - - - - - - -
MDVx000864 Achatit/Fuji II kotak Rp 939,400.0 - 0 - - - - - - - -
0 acid etching kotak Rp 376,035.0 - 0 - - - - - - - -
0 Air raksa dental use botol Rp 437,500.0 - 0 - - - - - - - -
81
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Alveogyl kotak Rp 789,800.0 2 0 2 - - - - 2 1,579,600 (2)
0 Aplicator kotak Rp 95,000.0 1 0 1 - - - - 1 95,000 (1)
0 Arsenic Pasta 10 gr/pot Rp 942,040.0 3 0 3 - - - - 3 2,826,120 (3)
MDVx002393 Articulating paper kotak Rp 195,800.0 6 0 6 - - - - 6 1,174,800 (6)
0 Bond strenght kotak Rp 330,000.0 - 0 - - - - - - - -
0 Caviton kotak Rp 252,950.0 - 1 1 - - - - 1 252,950 (1)
MDVx022575 Citodur (Bahan tambalan sementara) kotak Rp 200,200.0 - 0 - - - - - - - -
0 Cotton pelet pack Rp 247,500.0 4 0 4 - - - - 4 990,000 (4)
MDVx009212 Cotton roll pack Rp 75,000.0 3 0 3 1 75,000 - - 2 150,000 0
0 Cresofen / endoseptone pack Rp 473,000.0 6 0 6 - - - - 6 2,838,000 (6)
MDVx024268 Dental floss kotak Rp 30,250.0 - 0 - - - - - - - -
0 Dentin conditioning kotak Rp 366,465.0 - 0 - - - - - - - -
0 Devitalisasi pasta (non arsen) / D.Pulp botol Rp 752,400.0 - 0 - - - - - - - -
0 Devitalisasi pasta (non arsen) / Devitec kotak Rp 698,500.0 - 0 - - - - - - - -
0 Dysclosing agent / Disclosing gel (GC tri plaqu botol Rp 345,950.0 - 0 - - - - - - - -
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 0 1 - - - - 1 164,950 (1)
DRG000014675 Eugenol cairan botol Rp 136,400.0 3 0 3 - - - - 3 409,200 (3)
0 Flour sediaan topical botol Rp 170,000.0 - 0 - - - - - - - -
0 Formokresol botol Rp 60,000.0 - 0 - - - - - - - -
0 G aenial bond kotak Rp 875,578.0 1 0 1 - - - - 1 875,578 (1)
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 2 0 2 - - - - 2 1,287,000 (2)
0 Glass Ionomer cemen / ketakmolar kotak Rp 880,000.0 - 0 - - - - - - - -
MDVx019949 Glass Ionomer Light cured Universal restorativ kotak Rp 412,500.0 - 0 - - - - - - - -
MDVx000028 Gutta perchha point 15-40 mm kotak Rp 51,700.0 - 0 - - - - - - - -
0 Jarum Dental cytoject pcs Rp 2,662.0 - 0 - - - - - - - -
SBx148 Kalsium hidroksida pasta kotak Rp 187,000.0 - 0 - - - - - - - -
0 Marbalet/neocones botol Rp 750,000.0 - 0 - - - - - - - -
0 Monoklorkamfer mentol cairan (camphenol) kotak Rp 55,000.0 - 0 - - - - - - - -
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 4 0 4 - - - - 4 300,960 (4)
SBx147 Mummifying pasta kotak Rp 451,000.0 - 0 - - - - - - - -
0 Oco Tooth Clensing botol Rp 191,999.0 3 1 4 - - - - 4 767,996 (4)
MDVx012595 Paper point 15-40 mm kotak Rp 47,300.0 - 0 - - - - - - - -
0 Pasta pengisi saluran akar kotak Rp 506,000.0 - 0 - - - - - - - -
0 Rockless kotak Rp 1,135,200.0 - 0 - - - - - - - -
DRG001BJM Scandonest pcs Rp 17,622.0 - 0 - - - - - - - -
82
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx000992 selang saliva eyector pack Rp 157,300.0 10 0 10 - - - - 10 1,573,000 (10)
DRG000038085 Semen seng fosfat serbuk dan cairan kotak Rp 225,500.0 3 0 3 - - - - 3 676,500 (3)
0 Silver amalgam serbuk 65 - 75 % kotak Rp 937,500.0 - 0 - - - - - - - -
MDVx000870 Surgical ginggival pack (Coe Pak) kotak Rp 669,350.0 1 0 1 - - - - 1 669,350 (1)
SBx139 Tambalan sinar solare A2 kotak Rp 256,731.0 3 0 3 - - - - 3 770,193 (3)
0 Tambalan sinar solare A3,5 kotak Rp 420,200.0 - 0 - - - - - - - -
0 Tampon pack Rp 300,000.0 6 0 6 2 600,000 - - 4 1,200,000 1
0 Temporary stopping fletcher serbuk dan cairan set Rp 62,150.0 - 0 - - - - - - - -
0 Topical anastesi pasta kotak Rp 302,500.0 4 0 4 - - - - 4 1,210,000 (4)
DRG000042250 Trikesol Formalin ( TKF ) cairan botol Rp 82,720.0 - 0 - - - - - - - -
MDVx020416 Varnish box Rp 165,440.0 - 0 - - - - - - - -
- 0 - - - - - - - -
III. BMHP - 0 - - - - - - - -
MDVx001727 Alat suntik sekali pakai 1 ml pcs Rp 1,614.0 161 100 261 10 16,140 - - 251 405,114 (227)
0 Alat suntik sekali pakai 2,5 ml pcs Rp 605.0 62 0 62 - - - - 62 37,510 (62)
MDVx001732 Alat suntik sekali pakai 3 ml pcs Rp 1,138.0 246 200 446 141 160,458 - - 305 347,090 33
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 467 0 467 - - - - 467 771,017 (467)
MDVx001793 Alat suntik sekali pakai 10 ml pcs Rp 1,095.3 100 0 100 - - - - 100 109,529 (100)
DRG000000999 Albothyl botol Rp 45,000.0 - 0 - - - - - - - -
DRG000001226 Alkohol Swab lembar Rp 105.0 1,000 0 1,000 - - - - 1,000 105,000 (1,000)
0 Bioplacenton tulle pcs Rp 10,920.0 65 0 65 2 21,840 - - 63 687,960 (58)
MDVx000796 Bistruri/scalpel balde No 10 pcs Rp 3,300.0 80 0 80 - - - - 80 264,000 (80)
0 Bistruri/scalpel balde No 11 pcs Rp 3,450.0 - 0 - - - - - - - -
0 Bisturi/scalpel balde No 15 pcs Rp 850.0 - 0 - - - - - - - -
MDVx002305 Blood Lancet pcs Rp 176.0 650 0 650 100 17,600 - - 550 96,800 (310)
0 Blood transfusion set pcs Rp 4,698.0 - 0 - - - - - - - -
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - - 2 279,000 (2)
Box slide TB kotak Rp 36,000.0 - 0 - - - - - - - -
0 canula dewasa pcs Rp 1.0 - 0 - - - - - - - -
0 Cat Gut chromic No 1 pcs Rp 1.0 - 0 - - - - - - - -
MDVx001331 Catgut/benang bedah no 2/0 chronic pcs Rp 5,862.5 - 0 - - - - - - - -
MDVx001331 Catgut/benang bedah no 2/0 plain pcs Rp 5,862.5 - 0 - - - - - - - -
0 Celulid strip pcs Rp 73,700.0 - 0 - - - - - - - -
Cetride 5 Liter galon Rp 774,972.0 - 0 - - - - - - - -
83
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Clorheksidin 2,5 % botol Rp 618,750.0 - 0 - - - - - - - -
MDVx023244 Coverplast pcs Rp 470.0 2 0 2 - - - - 2 940 (2) 4
0 Deck glass / objek glass 20 x 20 mm pack Rp 48,000.0 - 0 - - - - - - - -
Deck glass / objek glass 22 x 22 mm pack Rp 52,300.0 - 0 - - - - - - - -
0 Deck gelas / objek glass 24 x 24 mm pack Rp 48,000.0 - 0 - - - - - - - -
MDVx018887 Disposibel vagina speculum pcs Rp 7,500.0 - 0 - - - - - - - -
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - - -
ECG 112 mm x 30 mm x 16 mm roll Rp 141,400.0 - 0 - - - - - - - -
MDVx011444 Film Rontgen 24 x 30 cm lembar Rp 21,970.0 - 0 - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - - -
MDVx000971 Foley cateter no 16 pcs Rp 13,688.0 - 0 - - - - - - - -
MDVx001175 Fukuda M.E.ECG Paper pcs Rp 56,566.7 - 0 - - - - - - - -
MDVx002014 handiplast pcs Rp 385.0 - 0 - - - - - - - -
Holder tube vacutainer pcs Rp 6,940.0 - 0 - - - - - - - -
0 Hypafix uk. Kecil 5 cm x 5 m pcs Rp 98,900.0 8 0 8 - - - - 8 791,200 (8)
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - - -
0 Infusiun set anak pcs Rp 2,970.0 2 0 2 - - - - 2 5,940 (2)
MDVx026876 Infusiun set dewasa pcs Rp 4,176.0 3 0 3 - - - - 3 12,528 (3)
MDVx002098 IV Catheter no 18 G pcs Rp 4,959.0 2 0 2 - - - - 2 9,918 (2)
MDVx001125 IV Catheter no 20 G pcs Rp 8,566.0 - 0 - - - - - - - -
MDVx001152 Jarum (Needle) no 23 pcs Rp 400.0 100 0 100 - - - - 100 40,000 (100)
MDVx001154 Jarum (Needle) no 25 pcs Rp 604.0 - 0 - - - - - - - -
Jarum Jahit kulit no 10 GT pack Rp 38,000.0 - 0 - - - - - - - -
0 Jarum Jahit Kulit No 11 GT pack Rp 32,500.0 - 0 - - - - - - - -
0 jarum K-File no 15-40 kotak Rp 150,700.0 - 0 - - - - - - - -
84
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 0 80 - - - - 80 200,000 (80)
0 Kapas berlemak 500 mg roll Rp 21,532.5 3 0 3 - - - - 3 64,598 (3)
DRG000021388 Kapas pembalut / absorben 250 mg roll Rp 13,000.0 1 0 1 - - - - 1 13,000 (1)
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 25 0 25 2 3,924 - - 23 45,121 (18)
0 Kasa pembalut 2 m x80 cm pcs Rp 9,347.0 8 0 8 - - - - 8 74,776 (8)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 - 30 30 30 73,710 - - - - 72
SBx134 Kasa pembalut hidrofil 4m x 3 cm pcs Rp 613.5 29 0 29 - - - - 29 17,792 (29)
Kasa steril 16 cm x 16 cm box Rp 8,685.7 - 0 - - - - - - - -
MDVx001191 Kertas EKG (uk 80 x 90 x 280) lembar Rp 106,250.0 - 0 - - - - - - - -
0 Kertas Puyer lembar Rp 91.6 - 0 - - - - - - - -
MDVx013360 Kertas Thermal roll Rp 94,500.0 - 0 - - - - - - - -
kertas thermal 50 mm x 57 mm roll Rp 18,200.0 - 0 - - - - - - - -
Kertas thermal mindray 50mm x 50 mm roll Rp 76,500.0 - 0 - - - - - - - -
Kertas thermal mindray 80 x 50 roll Rp 24,250.0 - 0 - - - - - - - -
0 Klorin botol Rp 15,970.0 48 0 48 - - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 534 288 822 74 53,036 - - 748 536,092 (570)
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 23 0 23 - - - - 23 872,850 (23)
MDVx022456 Lidi Kapas/cotton swab pcs Rp 1,000.0 412 0 412 - - - - 412 412,000 (412)
Markerpen pcs Rp 1.0 70 0 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 - 0 - - - - - - - -
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - - -
0 masker nebule dewasa pcs Rp 28,300.0 - 0 - - - - - - - -
0 masker oksigen anak pcs Rp 19,800.0 - 0 - - - - - - - -
0 masker oksigen dewasa pcs Rp 19,800.0 - 0 - - - - - - - -
0 Mata Bor high speed pack Rp 154,000.0 1 0 1 - - - - 1 154,000 (1)
0 Microtube 1,5 cc pack Rp 245,000.0 - 0 - - - - - - - -
0 Minyak handpiece 500 ml botol Rp 561,000.0 - 0 - - - - - - - -
Mouthpiece sterilbreath 250s box Rp 4,527.6 - 0 - - - - - - - -
0 NaOcl 2,5 % untuk sal irigasi botol Rp 123,200.0 - 0 - - - - - - - -
0 Needle flashback pcs Rp 3,170.0 - 0 - - - - - - - -
MDVx000733 Obyek glass* biasa pack Rp 37,446.0 - 0 - - - - - - - - 100
0 Open akses bur pcs Rp 135,300.0 - 0 - - - - - - - -
0 Pembalut gips pcs Rp 55,000.0 - 0 - - - - - - - -
0 Penjepit tali pusat pcs Rp 3,025.0 2 0 2 - - - - 2 6,050 (2)
0 Pharmafix pcs Rp 27,000.0 8 0 8 - - - - 8 216,000 (8)
85
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
pipet ESR citotes pcs Rp 7,675.0 - 0 - - - - - - - -
Plastik klip sedang pack/100sRp 3,950.0 - 0 - - - - - - - -
0 Plastik Obat kecil (uk. 8 cm x 5 cm) pack Rp 17,000.0 15 0 15 - - - - 15 255,000 (15)
0 Plastik Obat pembungkus puyer (uk. Besar) pack Rp 5,950.0 10 0 10 - - - - 10 59,500 (10)
MDVx041848 Plester (hansaplast 5 cm x 4,5 m) pcs Rp 12,000.0 - 0 - - - - - - - -
Plesterin pcs Rp 161.7 - 0 - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - 0 - - - - - - - -
0 safety box* pcs Rp 16,500.0 91 0 91 - - - - 91 1,501,500 (91)
sealing wax pcs Rp 164,000.0 - 0 - - - - - - - -
0 Serum gel tes tube 5 ml / tabung gel & cloat act pcs Rp 2,650.0 - 0 - - - - - - - -
0 Silk ( benang bedah sutra ) no.3/0 pcs Rp 4,766.7 36 0 36 - - - - 36 171,601 (36)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - - -
0 Spon gelatin cubicle 1 x 1 x 1 cm pcs Rp 1,850.0 - 0 - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 0 300 - - - - 300 495,000 (300)
MDVx001722 Spuit 0,5 ml pcs Rp 1,240.0 400 0 400 - - - - 400 496,000 (400)
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - 0 - - - - - - - -
0 Suction tips pack Rp 73,700.0 - 0 - - - - - - - -
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 5 0 5 - - - - 5 41,775 (5)
MDVx002389 Surgical Glove No 6,5 pcs Rp 20,006.7 85 0 85 - - - - 85 1,700,570 (85)
0 Surgical Glove No 8 pcs Rp 5,000.0 93 0 93 - - - - 93 465,000 (93)
MDVx019415 Surgical Glove obsgyn / gynecolog No 6,5 pcs Rp 20,006.7 - 0 - - - - - - - -
Surgical Glove obsgyn / gynecolog No 7 pcs Rp 20,010.0 - 0 - - - - - - - -
0 Surgical Gloves non steril uk L pcs Rp 462.0 800 0 800 100 46,200 - - 700 323,400 (460)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 600 200 800 200 74,800 - - 600 224,400 (120)
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 800 300 1,100 300 138,600 - - 800 369,600 (80)
MDVx003948 Surgical mask 3 ply tie on pcs Rp 462.0 253 0 253 - - - - 253 116,886 (253)
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 1,750 1000 2,750 450 207,900 - - 2,300 1,062,600 (1,220)
MDVx010039 Surgikal Gloves No 7 pcs Rp 5,000.0 12 0 12 - - - - 12 60,000 (12)
MDVx010040 Surgikal Gloves No 7.5 pcs Rp 4,600.0 164 0 164 - - - - 164 754,400 (164)
MDVx000518 Tabung EDTA K-3 pcs Rp 1,690.9 - 0 - - - - - - - - 100
0 Tabung EdtA K-3 micro 0,5 cc pcs Rp 2,445.0 - 0 - - - - - - - - 100
Tabung hematokrit pack Rp 180,500.0 - 0 - - - - - - - -
0 Tabung reaksi / Test tube 75 x 100 dia 1 cm pcs Rp 5,500.0 - 0 - - - - - - - -
Tabung reaksi kaca uk.12 x 75 mm pcs Rp 10,900.0 - 0 - - - - - - - -
86
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000043003 Underpad pcs Rp 4,370.5 186 0 186 - - - - 186 812,913 (186)
MDVx013451 Urine bag pcs Rp 3,120.0 - 0 - - - - - - - -
USG paper 110 HG (110 mm x 18m_SONY) roll Rp 268,500.0 - 0 - - - - - - - -
Viorex liquid 4 % 500 ml botol Rp 76,477.5 - 0 - - - - - - - -
0 Wing needle no 21 pcs Rp 2,450.0 - 0 - - - - - - - -
0 Yellow Tip pack Rp 139,500.0 - 0 - - - - - - - -
- 0 - - - - - - - -
IV. REAGEN - 0 - - - - - - - -
0 Abate/temephos botol Rp 2,197,800.0 - 0 - - - - - - - -
0 ACS level I (control serum) botol Rp 4,160,000.0 - 0 - - - - - - - -
0 Aquadest steril botol Rp 22,000.0 11 0 11 10 220,000 - - 1 22,000 23
DRG000046738 Asam klorida 0,1 N botol Rp 24,200.0 2 0 2 - - - - 2 48,400 (2)
MDVx041607 Asam sulfosalisilat 20 % botol Rp 531,000.0 2 0 2 - - - - 2 1,062,000 (2)
bactive SL botol Rp 30,700.0 - 0 - - - - - - - -
MDVx040425 Blood Analisir Clianac Detergen (Nihon kohden botol Rp 8,050,000.0 - 0 - - - - - - - -
MDVx041543 Blood Analisir Hemolinac 3N Lysing (nihon koh botol Rp 3,850,000.0 - 0 - - - - - - - -
MDVx041531 Blood Analisir Isotonac 3 Diluent (nihon kohden botol Rp 4,290,000.0 - 0 - - - - - - - -
0 Blood Analisir Clianac Detergen (norma clean botol Rp 2,112,000.0 - 0 - - - - - - - -
0 Blood Analisir Hemolinac 3N Lysing (norma lys botol Rp 5,240,000.0 - 0 - - - - - - - -
0 Blood Analisir Isotonac 3 Diluent (norma diluen botol Rp 3,696,000.0 - 0 - - - - - - - -
0 Carbol gentian violet botol Rp 64,900.0 - 0 - - - - - - - -
0 Cynoff 25 UL botol Rp 1,124,500.0 - 0 - - - - - - - -
DRG000046731 Edta kering botol Rp 121,000.0 - 0 - - - - - - - -
DRG000014470 Etanol 70 % 1 Liter botol Rp 41,800.0 22 0 22 - - - - 22 919,600 (22)
DRG000001161 Etanol 70 % 100 ml botol Rp 5,500.0 - 0 - - - - - - - -
0 K-Othrine 20 EW / Cyflutrin botol Rp 1,000,000.0 - 0 - - - - - - - -
Kontrol darah botol Rp 1,358,500.0 1 0 1 - - - - 1 1,358,500 (1)
Kontrol norma low botol Rp 596,000.0 - 0 - - - - - - - -
Kontrol norma normal botol Rp 596,000.0 - 0 - - - - - - - -
kontrol norma high botol Rp 596,000.0 - 0 - - - - - - - -
MDVx343BJM Lab Pro reagen botol Rp 203,500.0 - 0 - - - - - - - -
0 Larutan Air Fuchsin botol Rp 32,500.0 - 0 - - - - - - - -
DRG000001165 Larutan Alkohol 95 % botol Rp 91,300.0 - 0 - - - - - - - -
0 Larutan Alkohol 96 % botol Rp 48,500.0 - 0 - - - - - - - -
87
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Larutan alkohol aseton botol Rp 31,000.0 - 0 - - - - - - - -
MDVx103BJM Larutan amonium oksalat botol Rp 48,400.0 - 0 - - - - - - - -
MDVx104BJM Larutan Anisol botol Rp 231,000.0 - 0 - - - - - - - -
DRG000046732 Larutan Asam asetat 5% botol Rp 19,500.0 2 0 2 - - - - 2 39,000 (2)
MDVx041776 Larutan Barium Klorida botol Rp 26,400.0 - 0 - - - - - - - -
MDVx041604 Larutan Benedict botol Rp 84,700.0 - 0 - - - - - - - -
MDVx105BJM Larutan Buffer Fosfat botol Rp 36,300.0 - 0 - - - - - - - -
MDVx018552 Larutan Developer botol Rp 1,183,000.0 - 0 - - - - - - - -
MDVx041584 Larutan Edta 10% botol Rp 151,250.0 - 0 - - - - - - - -
MDVx041581 Larutan Eosin 2 % botol Rp 447,700.0 1 0 1 - - - - 1 447,700 (1)
DRG000046739 Larutan Etanol Asam botol Rp 62,700.0 2 0 2 - - - - 2 125,400 (2)
MDVx106BJM Larutan Eter alkohol botol Rp 68,200.0 - 0 - - - - - - - -
MDVx018554 Larutan Fixer botol Rp 801,900.0 - 0 - - - - - - - -
MDVx041704 Larutan Foucet botol Rp 176,000.0 - 0 - - - - - - - -
MDVx041602 Larutan Giemsa Sain botol Rp 378,125.0 - 0 - - - - - - - -
MDVx041700 Larutan hayem botol Rp 122,100.0 1 0 1 - - - - 1 122,100 (1)
DRG000018188 Larutan Hidrogen Peroksida (H2O2) botol Rp 60,500.0 - 0 - - - - - - - -
0 Larutan Iodium 1 % botol Rp 27,500.0 - 0 - - - - - - - -
DRG000046764 Larutan Karbol Fuksin botol Rp 165,000.0 2 0 2 - - - - 2 330,000 (2)
MDVx041583 Larutan KOH 10 % botol Rp 29,700.0 - 0 - - - - - - - -
MDVx109BJM Larutan KOH 20 % botol Rp 40,700.0 - 0 - - - - - - - -
MDVx041673 Larutan Lugol 1 % botol Rp 44,000.0 - 0 - - - - - - - -
MDVx012323 Larutan Metilen Biru botol Rp 84,700.0 2 0 2 - - - - 2 169,400 (2)
MDVx110BJM Larutan Natrium Citrat 3,8 % botol Rp 44,000.0 - 0 - - - - - - - -
MDVx111BJM larutan safranin botol Rp 157,300.0 - 0 - - - - - - - -
MDVx108BJM Larutan sodium hipoklorid 1 L botol Rp 110,000.0 - 0 - - - - - - - -
0 Larutan sodium hipoklorid 100 ML botol Rp 18,634.0 5 0 5 - - - - 5 93,170 (5)
MDVx041790 Larutan Turk botol Rp 39,600.0 1 0 1 - - - - 1 39,600 (1)
DRG000046736 Larutan Xylol botol Rp 30,800.0 - 0 - - - - - - - -
DRG000025457 Lipid Panel cardiocheck PA kotak Rp 1,721,516.9 - 0 - - - - - - - -
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - - -
0 M-30 CFL LYSE 500 ML Mindray botol Rp 2,100,000.0 - 0 - - - - - - - -
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 1 0 1 - - - - 1 2,050,000 (1)
0 M-30 E-Z Cleanser Mindray botol Rp 1,500,000.0 1 0 1 - - - - 1 1,500,000 (1)
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 - 0 - - - - - - - -
0 M-30 RINSE Mindray botol Rp 2,050,000.0 1 0 1 - - - - 1 2,050,000 (1)
0 B30 Control Hematology Analyzer Mindray botol Rp 1,336,500.0 - 0 - - - - - - - -
88
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Medonic Diluent 20 L botol Rp 3,400,100.0 - 0 - - - - - - - -
0 Medonic Lyse 5 L botol Rp 5,550,600.0 - 0 - - - - - - - -
DRG000025457 Metanol botol Rp 24,645.0 - 0 - - - - - - - -
0 Norma cleaner botol Rp 1,910,000.0 - 0 - - - - - - - -
0 Norma diluent diff botol Rp 1,910,000.0 - 0 - - - - - - - -
0 Norma lyse diff botol Rp 2,625,000.0 - 0 - - - - - - - -
MDVx112BJM Oil Imersi botol Rp 580,000.0 1 0 1 - - - - 1 580,000 (1)
0 Pewarnaan Gram 1 % botol Rp 518,100.0 - 0 - - - - - - - -
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 - 100 100 - - - - 100 1,434,400 (100)
0 Rapid 2 Intec HIV stik Rp 40,800.0 - 0 - - - - - - - -
0 Rapid 3 oncoprobe stik Rp 64,280.0 - 0 - - - - - - - -
0 Rapid 4 right sign HIV stik Rp 35,120.0 1 0 1 - - - - 1 35,120 (1)
0 Rapid 5 CTK Bioteck HIV stik Rp 30,250.0 1 0 1 - - - - 1 30,250 (1)
0 Rapid 6 HIV Vikia stik Rp 21,818.0 - 0 - - - - - - - -
0 Rapid 7 HIV Card Vcare stik Rp 30,250.0 - 0 - - - - - - - -
Rapid 8 Fokus HIV stik Rp 4,179.0 - 0 - - - - - - - -
0 Reagen Albumin biosystem kit Rp 800,000.0 - 0 - - - - - - - -
Reagen albumin agappe / mindray kit Rp 1,400,000.0 - 0 - - - - - - - -
0 Reagen Albumin randox kit Rp 917,250.0 - 0 - - - - - - - -
MDVx114BJM Reagen Asam Urat biosystem kit Rp 2,805,000.0 - 0 - - - - - - - -
0 Reagen Asam Urat agappe / mindray kit Rp 1,150,000.0 - 0 - - - - - - - -
MDVx034902 Reagen Asam Urat randox kit Rp 1,225,700.0 - 0 - - - - - - - -
0 Reagen Bilirubin Direct biosystem kit Rp 2,090,000.0 - 0 - - - - - - - -
Reagen Bilirubin Direct agappe / mindray kit Rp 900,000.0 - 0 - - - - - - - -
0 Reagen Bilirubin Direct randox kit Rp 970,000.0 - 0 - - - - - - - -
0 Reagen Bilirubin Total biosystem kit Rp 2,090,000.0 - 0 - - - - - - - -
Reagen Bilirubin Total agappe / mindray kit Rp 1,450,000.0 - 0 - - - - - - - -
0 Reagen Bilirubin Total randox kit Rp 897,000.0 - 0 - - - - - - - -
MDVx117BJM Reagen Cholesterol biosystem kit Rp 759,000.0 - 0 - - - - - - - -
0 Reagen Cholesterol agappe / mindray kit Rp 1,150,000.0 - 0 - - - - - - - -
MDVx034903 Reagen Cholesterol randox kit Rp 1,586,500.0 - 0 - - - - - - - -
MDVx118BJM Reagen Cholesterol HDL biosystem kit Rp 2,040,000.0 - 0 - - - - - - - -
Reagen Cholesterol HDL agappe / mindray kit Rp 8,225,000.0 - 0 - - - - - - - -
0 Reagen Cholesterol HDL randox kit Rp 1,924,750.0 - 0 - - - - - - - -
MDVx119BJM Reagen Creatinin biosystem kit Rp 1,572,725.0 - 0 - - - - - - - -
Reagen Creatinin agappe / mindray kit Rp 850,000.0 - 0 - - - - - - - -
0 Reagen Creatinin randox kit Rp 937,750.0 - 0 - - - - - - - -
89
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx120BJM Reagen Glucose biosystem kit Rp 495,000.0 - 0 - - - - - - - -
0 Reagen Glucose agappe / mindray kit Rp 1,450,000.0 - 0 - - - - - - - -
MDVx034905 Reagen Glucose PAP randox kit Rp 1,803,400.0 - 0 - - - - - - - -
0 Reagen golongan darah set-2 Rp 142,650.0 2 0 2 - - - - 2 285,300 (2)
0 Reagen golongan darah set-4 Rp 355,480.0 - 0 - - - - - - - -
MDVx344bjm Reagen HB Cyanida kit Rp 165,000.0 - 0 - - - - - - - -
0 Reagen HB konsentrat biosystem kit Rp 308,000.0 - 0 - - - - - - - -
0 Reagen HB konsentrat randox kit Rp 1,498,700.0 - 0 - - - - - - - -
0 Reagen Protein Total biosystem kit Rp 545,000.0 - 0 - - - - - - - -
Reagen Protein Total agappe / mindray kit Rp 700,000 - 0 - - - - - - - -
0 Reagen Protein Total randox kit Rp 880,000 - 0 - - - - - - - -
MDVx123BJM Reagen SGOT / AST biosystem kit Rp 715,000 - 0 - - - - - - - -
0 Reagen SGOT / AST Mindray kit Rp 1,625,000 - 0 - - - - - - - -
0 Reagen SGOT / AST randox kit Rp 1,435,700 - 0 - - - - - - - -
MDVx124 Reagen SGPT / ALT biosystem kit Rp 715,000 - 0 - - - - - - - -
0 Reagen SGPT / ALT mindray kit Rp 1,625,000 - 0 - - - - - - - -
0 Reagen SGPT / ALT randox kit Rp 1,200,000 - 0 - - - - - - - -
MDVx125BJM Reagen Trigliseride biosystem kit Rp 3,768,792 - 0 - - - - - - - -
0 Reagen Trigliseride mindray kit Rp 1,950,000 - 0 - - - - - - - -
0 Reagen Trigliseride randox kit Rp 1,879,650 - 0 - - - - - - - -
MDVx126BJM Reagen Ureum biosystem kit Rp 1,550,000 - 0 - - - - - - - -
0 Reagen Urea Mindray kit Rp 1,150,000 - 0 - - - - - - - -
MDVx034850 Reagen Ureum randox kit Rp 2,380,150 - 0 - - - - - - - -
MDVx041577 Reagen Wright Stain kit Rp 290,400 - 0 - - - - - - - -
MDVx037823 reagent cholesterol pap sl (microlab/elitech) kit Rp 3,088,800 - 0 - - - - - - - -
MDVx002BJM reagent cholesterol standar 200 mg/dl (microlab kit Rp 633,600 - 0 - - - - - - - -
MDVx037816 reagent glucose pap sl (microlab/elitech) kit Rp 1,584,000 - 0 - - - - - - - -
MDVx001BJM reagent glucose standar 100 mg/dl (microlab/el kit Rp 448,800 - 0 - - - - - - - -
MDVx037822 reagent trigliserid mono sl (microlab/elitech) kit Rp 4,752,000 - 0 - - - - - - - -
MDVx037603 reagent trigliserid standar 200 mg/dl (microlab/e kit Rp 475,200 - 0 - - - - - - - -
MDVx037604 reagent uric acid standar (microlab/elitech) kit Rp 580,800 - 0 - - - - - - - -
0 Reagen Elitrol 1 Normal 1 x 5 ml (elitech) kit Rp 924,000 - 0 - - - - - - - -
MDVx041674 Res eker botol Rp 144,100 1 0 1 - - - - 1 144,100 (1)
0 RPR syfilis randox botol Rp 1,555,920 - 0 - - - - - - - -
0 RPR syfilis Fokus Diagnostik botol Rp 4,250 - 1 1 - - - - 1 4,250 (1)
RPR syfilis "Human" botol Rp 5,684 - 1 1 - - - - 1 5,684 (1)
90
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Serum kontrol mindray (Qualichek normal mind botol Rp 1,200,000 - 0 - - - - - - - -
DRG000046730 Spiritus 1 L botol Rp 53,900 6 0 6 - - - - 6 323,400 (6)
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 - 0 - - - - - - - -
0 Stik asam urat Nesco stik Rp 5,258 - 0 - - - - - - - -
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 20 0 20 - - - - 20 437,800 (20)
0 Stik Cholesterol Nesco stik Rp 24,090 - 0 - - - - - - - -
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 0 15 - - - - 15 108,570 (15)
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - 0 - - - - - - - -
MDVx041511 Stik Gula Darah Accu cek stik Rp 8,327 - 0 - - - - - - - - 200
0 Stik HB BeneCheck stik Rp 7,955 - 0 - - - - - - - -
MDVx133BJM Stik HB Easy touch stik Rp 6,688 100 50 150 - - - - 150 1,003,200 (150)
0 Stik HBSAb merek Intec stik Rp 27,478 - 0 - - - - - - - -
0 Stik HBSAg merek SD stik Rp 9,870 - 0 - - - - - - - -
Stik HBSAg merek Intec stik Rp 9,850 300 0 300 - - - - 300 2,955,000 (300) 200
0 Stik Kehamilan stik Rp 1,947 150 0 150 - - - - 150 292,050 (150)
0 Stik syphilis 'SD' stik Rp 35,429 - 0 - - - - - - - - 100
Stik syphilis 'Monotest' stik Rp 10,758 - 0 - - - - - - - - 100
Stik syphilis 'Human hexagonal' stik Rp 26,744 - 0 - - - - - - - -
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - 0 - - - - - - - -
MDVx138BJM Stik urinalisa 10 parameter (Lab U 11) stik Rp 2,274 - 0 - - - - - - - -
0 Stik urinalisa 10 parameter Akray stik Rp 6,050 - 0 - - - - - - - -
0 Stik urinalisa 10 prm (mission) stik Rp 2,700 - 0 - - - - - - - -
0 Stik urinalisa 3 parameter stik Rp 5,720 - 0 - - - - - - - -
0 Swelab alfa diluent 20 L botol Rp 6,500,000 - 0 - - - - - - - -
0 Swelab alfa lyse 5 L botol Rp 8,500,000 - 0 - - - - - - - -
0 Widal tes 4 set 4 set Rp 291,640 1 0 1 - - - - 1 291,640 (1) 1
0 Widal tes 6 set 6 set Rp 279,140 - 0 - - - - - - - -
0 Ziehl Nielseen Stain paket Rp 273,978 1 0 1 1 273,978 - - - - 2
Pil KB BKKBN 736 0 736 - - - - 736 - (736)
Suntik KB 3 bulan BKKBN 84 0 84 27 - - - 57 - 8
Kondom BKKBN 4 0 4 - - - - 4 - (4)
IUD Copper T BKKBN 5 0 5 - - - - 5 - (5)
Susuk dengan inserter (implan) BKKBN 5 0 5 - - - - 5 - (5)
Spuit 3cc BKKBN 84 0 84 27 - - - 57 - (57)
calcetin pasta (gigi) 1 0 1 - - - - 1 - (1)
- - - - - -
- - - - - -
91
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 12,330,063 111,621,785
UMUM
JUMLAH
943 361 1304

NIP.19610409 198511 1 001 NIP. 19790311 200501 2 015 NIP.19680616 198911 1 001 NIP.19840410 200803 1 002
92
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000000983 Albendazol tablet 400 mg tablet Rp 323.0 - - - - - - - - -
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 844 844 115 11,385 - - 729 72,171 (453)
DRG000001666 Aminofilin injeksi 24 mg/ml-10 ml ampul Rp 4,204.0 - - - - - - - - -
Aminofilin tablet 200 mg tablet Rp 86.0 680 680 20 1,720 - - 660 56,760 (612)
DRG000001769 Amitriptilin Hcl tablet salut 25 mg tablet Rp 168.0 110 110 - - - - 110 18,480 (110)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 1,510 1,510 1,055 80,180 - - 455 34,580 2,077 3000
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 1,392 1,392 780 193,440 - - 612 151,776 1,260
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 28 28 28 121,660 - - - - 67
Ampisilin serbuk injeksi i.m.i.v 1000 mg/ml vial Rp 9,524.0 - - - - - - - - -
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 4,212 4,212 710 39,760 - - 3,502 196,112 (1,798)
DRG000002883 Antasida sirup botol Rp 2,098.0 166 166 128 268,544 - - 38 79,724 269
DRG000002996 Antifungi doen kombinasi tube Rp 5,170.0 24 24 - - - - 24 124,080 (24)
Artemether injeksi 80 Mg ampul Rp 29,925.0 - - - - - - - - -
Artesunate cairan injeksi 60 mg ampul Rp 33,835.0 - - - - - - - - -
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 1,276 1,276 1,058 126,960 - - 218 26,160 2,321 500
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 - - - - - - - - - 500
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 - - - - - - - - - 2000
DRG000003731 Asiklovir 200 mg tablet tablet Rp 236.0 2,167 2,167 - - - - 2,167 511,412 (2,167)
DRG000000605 Asiklovir 400 mg tablet tablet Rp 425.0 1,990 1,990 90 38,250 - - 1,900 807,500 (1,684)
DRG000003947 Atropin Sulfat tablet 0,5 mg tablet Rp 26.2 - - - - - - - - -
DRG000004829 Benzatin Benzil Penisilin inj 1,2 juta iu/vial vial Rp 10,780.0 - - - - - - - - -
DRG000004830 Benzatin Benzil Penisilin inj 1,4 juta iu/vial vial Rp 14,740.0 - - - - - - - - -
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 130 130 21 28,833 - - 109 149,657 (59)
Clindamisin kapsul 300 mg kapsul Rp 1,017.0 - - - - - - - - -
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 1,736 1,736 150 5,100 - - 1,586 53,924 (1,226)
DRG000011634 Deksametason inj 5 mg/ml-1 ml ampul Rp 1,805.0 22 22 - - - - 22 39,710 (22)
93
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

Piperaquin) tab tablet Rp 2,160.0 100 100 - - 100 216,000 (100)
Diazepam inj 5 mg/ml-2 ml ampul Rp 1,913.0 5 5 - - - - 5 9,565 (5)
DRG000012224 Diazepam tablet 2 mg tablet Rp 220.0 178 178 - - - - 178 39,160 (178)
Diazepam tablet 5 mg tablet Rp 109.0 - - - - - - - - -
Dietilkarbamazin sitrat tablet 100 mg tablet Rp 180.0 - - - - - - - - -
DRG000012294 Difenhidramin Hcl inj 10 mg/ml-1 ml ampul Rp 1,262.0 - - - - - - - - -
DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 - - - - - - - - -
DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 946 946 160 19,360 - - 786 95,106 (402)
DRG000012885 Doksisiklin 100 mg kapsul kapsul Rp 299.0 - - - - - - - - -
DRG000012719 Domperidon 10 mg tablet Rp 90.0 507 507 80 7,200 - - 427 38,430 (235)
DRG000013853 Epinefrin Hcl/Bitartrat(adrenalin)inj 0,1 %-1 ml ampul Rp 1,518.0 17 17 3 4,554 14 21,252 - - 7 10
DRG000014229 Erytromisin sirup botol Rp 6,390.0 - - - - - - - - -
DRG000014234 Erytromisin 500 mg kaplet tablet Rp 781.0 - - - - - - - - -
DRG000046712 Etambutol 500 mg tablet tablet Rp 466.0 - - - - - - - - -
DRG000027466 Fenitoin kapsul 50 mg kapsul Rp 1.0 - - - - - - - - - 100
DRG000015393 Fenobarbital inj 50 mg / ml - 2 ml ampul Rp 2,135.0 - - - - - - - - -
Ferrous sulphate tab selaput 300 mg tablet Rp 1.0 - - - - - - - - -
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 5,498 5,498 4,323 237,765 - - 1,175 64,625 9,200 1000
DRG000015698 Fitomenadion ( vit k 1 ) tablet salut 10 mg tablet Rp 818.0 431 431 55 44,990 - - 376 307,568 (244) 200
DRG000032665 Fitomenadion ( vit k 1 ) inj 10 mg / ml - 1 ml ampul Rp 5,516.5 12 12 - - 12 66,198 - - - 10
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 700 700 10 790 - - 690 54,510 (666)
Furosemid Cairan Injeksi 10 mg/ml ampul Rp 2,781.1 - - - - - - - - -
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 535 535 176 73,568 - - 359 150,062 63
DRG000017209 Gentamisin inj 40 mg/2 ml ampul Rp 4,989.6 - - - - - - - - -
DRG000017209 Gentamisin inj 80 mg/2 ml ampul Rp 2,750.0 - - - - - - - - -
DRG000017398 Glibenklamid tablet 5 mg tablet Rp 137.0 2,865 2,865 30 4,110 - - 2,835 388,395 (2,763)
DRG000017435 Glimepirid tab 1 mg tablet Rp 194.0 60 60 10 1,940 - - 50 9,700 (26)
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 - - - - - - - - - 200
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 625 625 155 8,525 - - 470 25,850 (98) 200
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 415 415 10 560 - - 405 22,680 (381)
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 717 717 110 17,930 - - 607 98,941 (343)
DRG000019279 Hidrokortison krim 2,5 % tube Rp 2,533.0 - - - - - - - - -
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 2,210 2,210 175 19,600 - - 2,035 227,920 (1,615)
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 860 860 300 87,600 - - 560 163,520 160
DRG000020665 Isoniazid tablet 100 mg tablet Rp 79.0 100 100 - - - - 100 7,900 (100)
94
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020671 Isoniazid tablet 300 mg tablet Rp 173.0 - - - - - - - - -
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 190 190 20 1,780 - - 170 15,130 (122)
DRG46597 Kalsium Gluconas inj ampul Rp 1.0 - - - - - - - - -
Kalsium Karbonat tablet 500 mg tablet Rp 1.0 - - - - - - - - -
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 1,916 1,916 145 15,950 - - 1,771 194,810 (1,423)
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 140 140 50 11,700 - - 90 21,060 30 300
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 - - - - - - - - - 300
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 640 640 10 2,750 - - 630 173,250 (606)
Kloramfenikol salep 2 % tube Rp 1.0 - - - - - - - - -
Kloramfenikol salep mata 1 % tube Rp 1,925.0 183 183 5 9,625 - - 178 342,650 (166)
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 59 59 - - - - 59 293,938 (59)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 5,538 5,538 733 17,592 - - 4,805 115,320 (3,046)
Klorpromazin Hcl inj 5 mg / ml - 2 ml ampul Rp 376.0 - - - - - - - - -
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 - - - - - - - - - 400
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 200 200 30 19,710 - - 170 111,690 (98)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 895 895 - - 444 55,500 451 56,375 (451) 500
DRG000010167 Kotrimoksazol suspensi botol Rp 2,052.0 332 332 19 38,988 - - 313 642,276 (267)
DRG000021836 Kuinine tablet salut selaput 200 mg tablet Rp 310.7 - - - - - - - - -
Kuinine Dihydrochloride cairan inj 25%-2 ml ampul Rp 2,616.1 - - - - - - - - -
DRG000023410 Lidocain injeksi 2 % ampul Rp 1,319.0 - - - - - - - - -
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 116 116 30 39,510 - - 86 113,262 (14)
DRG000023922 Loratadin tablet tablet Rp 127.0 1,405 1,405 100 12,700 - - 1,305 165,735 (1,065)
DRG000024327 Magnesium sulfat inj ( 1V ) 20 % - 25 ml vial Rp 3,200.0 2 2 - - - - 2 6,400 (2)
DRG000024328 Magnesium sulfat inj ( 1V ) 40 % - 25 ml vial Rp 3,796.0 10 10 - - - - 10 37,960 (10)
DRG000043759 Mebendazol tablet 100 mg (vermox) tablet Rp 7,854.0 - - - - - - - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 302 302 50 5,100 - - 252 25,704 (132) 200
DRG000025481 Metformin tab 850 mg tablet Rp 165.0 140 140 - - - - 140 23,100 (140)
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 130 130 - - - - 130 35,594 (130)
DRG000025567 Metilergometrin maleat inj 0,200 mg - 1 ml ampul Rp 3,399.0 9 9 - - - - 9 30,591 (9)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 1,574 1,574 220 36,300 - - 1,354 223,410 (826)
DRG000025667 Metilprednisolon 16 mg tablet tablet Rp 875.0 - - - - - - - - -
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 770 770 - - - - 770 63,910 (770)
DRG000025793 Metronidazol tablet 250 mg tablet Rp 94.0 - - - - - - - - -
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 1,175 1,175 30 6,090 - - 1,145 232,435 (1,073)
Metronidazol suspension 125 mg/ml botol Rp 3,800.0 - - - - - - - - -
DRG000025979 Miconazol krim tube Rp 2,577.0 136 136 4 10,308 - - 132 340,164 (122)
DRG000026103 Mineral mix serbuk 8 gr sachet Rp 3,055.0 40 40 - - - - 40 122,200 (40)
95
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038915 Natrium Bikarbonat tablet 500 mg tablet Rp 9.8 - - - - - - - - -
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 15 15 - - - - 15 2,130 (15) 500
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 1,630 1,630 480 65,280 - - 1,150 156,400 2 1000
(Euthyrox) tablet Rp 850.0 - - - - - - -
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 300 300 15 2,700 - - 285 51,298 (249)
Nicotinamida tablet 20 mg tablet Rp 1.0 - - - - - - - - -
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 119 119 - - - - 119 76,755 (119)
Obat antituberkolusis katagori 1 paket Rp 395,900.0 - - - - - - - - -
Obat antituberkolusis katagori 2 paket Rp 1,379,984.0 - - - - - - - - -
Obat antituberkulosis anak paket Rp 267,400.0 1 1 - - - - 1 267,400 (1)
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 3 3 1 413,979 - - 2 827,958 0 2
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 1 1 - - - - 1 1,492,574 (1)
DRG000031217 Oksitetrasiklin Hcl salep mata 1 % tube Rp 2,600.0 - - - - - - - - -
DRG000031235 Oksitosin injeksi 10 iu / ml ampul Rp 1,232.0 15 15 - - - - 15 18,480 (15)
DRG000030245 Omeprazol inj 40 mg/10 ml ampul Rp 18,537.0 - - - - - - - - -
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 798 798 345 47,610 - - 453 62,514 375
DRG000031912 Parasetamol sirup 120 mg / 5 ml botol Rp 1,160.0 493 493 147 170,520 - - 346 401,360 7 200
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 4,462 4,462 3,455 207,300 - - 1,007 60,420 7,285 1000
DRG000034958 Pirantel pamoat 125 mg tablet tablet Rp 318.0 - - - - - - - - -
DRG000034959 Pirantel suspensi 5 mg/ml botol Rp 9,100.0 - - - - - - - - -
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 916 916 195 27,495 - - 721 101,661 (253)
DRG000032952 Piridoksin Hcl tablet 25 mg tablet Rp 40.5 - - - - - - - - -
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 1,012 1,012 - - - - 1,012 183,678 (1,012)
DRG000033915 Primakuin tablet 15 mg tablet Rp 258.0 - - - - - - - - -
DRG000034345 Prokain benzil penisilin 3 juta iu / vial injeksi vial Rp 1.0 - - - - - - - - -
DRG000034487 Propanolol Hcl tablet 40 mg tablet Rp 300.0 100 100 - - - - 100 29,999 (100)
DRG000034502 Propiltiourasil tablet 100 mg tablet Rp 500.0 100 100 - - - - 100 50,001 (100)
DRG000035403 Ranitidin tablet tablet Rp 122.0 950 950 526 64,172 - - 424 51,728 838 500
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 271 271 52 3,328 - - 219 14,016 (94)
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 991 991 21 1,617 - - 970 74,690 (920)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 69 69 5 15,085 - - 64 193,088 (52)
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 1,420 1,420 130 63,960 - - 1,290 634,680 (978)
DRG000007256 Sefadroxil syp kering 125 ml / 5 ml botol Rp 4,086.0 158 158 12 49,032 - - 146 596,556 (117)
Sianokobalamin ( Vit.B.12 ) inj 500 mcg / ml ampul Rp 1,067.0 - - - - - - - - -
96
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 2,240 2,240 420 46,200 - - 1,820 200,200 (812)
DRG000008829 Siprofloksasin 500 mg tablet tablet Rp 281.0 1,575 1,575 30 8,430 - - 1,545 434,145 (1,473)
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 360 360 180 15,840 - - 180 15,840 252
DRG000042321 Triheksilfenidil hidroklorida tablet 2 mg tablet Rp 95.0 815 815 205 19,475 - - 610 57,950 (118) 200
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 4,551 4,551 2,191 295,785 - - 2,360 318,600 2,898
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 789 789 290 175,160 - - 499 301,396 197 300
DRG000043194 Vaksin BCG vial Rp 59,950.0 - - - - - - - - -
Vaksin Jerap D T vial Rp 17,798.0 - - - - - - - - -
Vaksin CAMPAK 10 Dosis vial Rp 28,204.0 5 5 - - - - 5 141,020 (5)
Vaksin POLIO 10 Dosis vial Rp 19,954.0 15 15 - - - - 15 299,310 (15)
Vaksin HEPATITIS B 0,5 ml ADS vial Rp 20,900.0 - - - - - - - - -
DRG000043208 Pentabio Vaksin DTP-HB-HIB inj vial Rp 76,285.0 - - - - - - - - -
DRG000043266 Vaksin Td vial Rp 16,500.0 - - - - - - - - -
Vaksin IPV (Poliomyelitis Vaccine inj (ShanIPV vial Rp 152,900.0 - - - - - - - - -
Vaksin MR vial Rp 141,648.0 - - - - - - - - -
Acdat salep tube Rp 6,241.0 - - - - - - - - - 50
DRG000000325 Air untuk irigasi lar infus 1000 ml botol Rp 22,000.0 - - - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 200 - - - - 200 175,600 (200)
DRG000001441 Albendazol suspensi 200mg/5 ml botol Rp 4,600.0 - - - - - - - - -
DRG000001442 Alprazolam 0,5 mg tablet Rp 88.0 - - - - - - - - -
Alprazolam 1 mg tablet Rp 120.0 - - - - - - - - -
DRG000001592 Alvit drops botol Rp 12,500.0 - - - - - - - - -
DRG000001574 Ambroxol sirup botol Rp 3,300.0 192 192 53 174,900 - - 139 458,700 (12) 100
DRG000001791 Ambroxol tablet tablet Rp 100.0 623 623 550 55,000 - - 73 7,300 1,247 700
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 1,413 1,413 640 60,800 - - 773 73,435 763 600
Amoksisilin 250 mg tablet Rp 196.0 - - - - - - - - -
Anemolat 1 mg tablet tablet Rp 77.0 - - - - - - - - -
DRG000002721 Antalgin (Metampiron) tablet 500 mg tablet Rp 67.0 - - - - - - - - -
DRG000002981 Antalgin injeksi 250 mg/5 ml ampul Rp 407.8 - - - - - - - - -
DRG000003002 Anti bakteri doen salep kombinasi tube Rp 3,490.0 - - - - - - - - -
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 38 38 15 54,630 - - 23 83,766 13 20
DRG000023225 Antimigrain doen kombinasi tablet Rp 149.0 - - - - - - - - -
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 150 150 50 51,750 - - 100 103,500 20 100
Antrain inj ampul Rp 11,999.2 - - - - - - - - -
DRG000003089 Apialis Drops botol Rp 21,175.0 - - - - - - - - - 100
97
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 34 34 - - - - 34 1,122,000 (34) 100
DRG000003393 Aqua proinjeksi steril,bebas pirogen vial Rp 2,860.0 21 21 - - - - 21 60,060 (21)
DRG000003466 Arkavit tablet Rp 320.0 - - - - - - - - - 2000
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 58 58 - - - - 58 8,932 (58)
DRG000003564 Asam Asetilsalisilat tablet 500 mg (Asetosal) tablet Rp 99.6 - - - - - - - - -
Asam askorbat(vit C) tablet 250 mg tablet Rp 150.0 - - - - - - - - -
DRG000003595 Asam Folat 5 mg tablet tablet Rp 63.5 - - - - - - - - -
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 510 510 - - 465 724,703 45 70,133 (45) 100
DRG000000595 Asam Traneksamat injeksi 5 % 250 mg/ 5 ml ampul Rp 1,813.0 - - - - - - - - -
Asiklovir salep kulit tube Rp 3,699.3 39 39 4 14,797 - - 35 129,476 (25)
DRG000003950 Atropin Sulfat injeksi 0,25 mg/ml-1 ml ampul Rp 1,540.0 - - - - - - - - -
DRG000003956 Atropin Sulfat tetes mata 0,5 % botol Rp 2,800.7 - - - - - - - - -
DRG000004142 Atrovent HFA kotak Rp 83,500.0 - - - - - - - - - 10
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 - - - - - - - - - 400
Baby Cough sirup botol Rp 3,999.6 109 109 41 163,984 - - 68 271,973 30 100
Betahistin mesilat tablet 6 mg tablet Rp 119.0 - - - - - - - - -
DRG000005736 Bioplacenton Cream tube Rp 18,499.8 20 20 2 37,000 - - 18 332,996 (13)
Bisoprolol tablet 5 mg tablet Rp 248.0 190 190 10 2,480 - - 180 44,640 (156)
Buscopan tablet tablet Rp 3,100.0 210 210 10 31,000 - - 200 620,000 (176) 200
Cendo Augentonic tetes mata botol Rp 30,990.0 - - - - - - - - -
Cendo Catarlent tetes mata botol Rp 33,699.6 - - - - - - - - -
DRG000015887 Cendo Edta tetes mata botol Rp 37,500.0 - - - - - - - - -
Cendo Floxa tetes mata botol Rp 33,599.5 - - - - - - - - -
Cendo fungicide tetes mata botol Rp 18,500.0 - - - - - - - - -
DRG000007801 Cendo Homatrol tetes mata botol Rp 43,785.0 - - - - - - - - -
Cendo Lyteers tetes mata botol Rp 25,999.6 17 17 7 181,997 - - 10 259,996 7
Cendo mydriatil tetes mata botol Rp 27,845.4 - - - - - - - - -
Cendo Tobroson tetes mata botol Rp 53,999.0 - - - - - - - - -
DRG000007849 Cendo tropin tetes mata botol Rp 13,875.0 - - - - - - - - -
Cendo Xytrol tetes mata botol Rp 33,000.0 - - - - - - - - -
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 - - - - - - - - - 400
DRG000010471 Clopidogrel 75 mg tablet tablet Rp 1,469.0 239 239 36 52,884 - - 203 298,207 (117) 100
Curcuma tablet tablet Rp 990.0 - - - - - - - - -
DRG000011354 Dekstran 70 larutan infus 6 % steril botol Rp 35,526.0 - - - - - - - - -
DRG000011365 Depakene sirup botol Rp 17,789.0 - - - - - - - - -
DRG000011337 Depakote tablet tablet Rp 1,200.0 390 390 30 36,000 - - 360 432,000 (288)
DRG000011848 Desoksimetason 0,25 mg (Denomix) tube Rp 11,500.0 - - - - - - - - -
98
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Dextamine tablet tablet Rp 1,815.0 - - - - - - - - -
DRG000012127 Dextrofen sirup botol Rp 12,499.3 - - - - - - - - -
Diamicron MR 30 mg tablet tablet Rp 638.0 - - - - - - - - -
DRG000012720 Diltiazem tablet tablet Rp 143.0 - - - - - - - - -
DRG000012774 Domperidon Suspensi 5 mg/5 ml botol Rp 2,862.0 177 177 16 45,792 - - 161 460,782 (123)
DRG000012960 Dopamet (metildopa) tablet Rp 880.0 - - - - - - - - -
DRG000012963 Dulcolax 10 mg supp supp Rp 5,900.0 - - - - - - - - -
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 129 129 20 6,320 - - 109 34,444 (61) 100
DRG000013350 Efedrin Hcl tablet 25 mg tablet Rp 197.8 - - - - - - - - -
DRG000014440 Erytromisin 250 mg kapsul kapsul Rp 636.0 - - - - - - - - -
Etakridin ( Rivanol ) larutan 0,1 % botol Rp 4,999.5 - - - - - - - - -
DRG000015045 Etambutol Hcl tablet 250 mg tablet Rp 186.3 - - - - - - - - -
DRG000027495 Famotidin 40 mg tablet tablet Rp 192.0 900 900 - - - - 900 172,800 (900)
DRG000027467 Fenitoin natrium inj 50 mg / ml ampul Rp 48,368.0 - - - - - - - - -
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 200 200 50 7,900 - - 150 23,700 (30) 100
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 85 85 30 32,190 - - 55 59,015 17 200
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 67 67 8 20,720 - - 59 152,810 (40)
Flukonazol tab 150 mg tablet Rp 24,200.0 - - - - - - - - - 200
DRG000016599 Fluor tablet 0,5 mg tablet Rp 32.9 - - - - - - - - -
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 6 6 1 4,889 - - 5 24,445 (3) 20
Fungasol 2 % botol Rp 24,200.0 - - - - - - - -
DRG000016864 Fuson ointment tube Rp 7,500.0 - - - - - - - - -
Gemfibrozil 300 mg tablet Rp 428.0 624 624 24 10,272 - - 600 256,800 (542)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 49 49 28 69,978 - - 21 52,483 46
DRG000017167 Gentamisin salep mata tube Rp 3,075.0 - - - - - - - - -
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 70 70 12 58,620 - - 58 283,330 (29) 50
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 40 40 5 17,496 - - 35 122,469 (23)
Glimepirid tab 2 mg tablet Rp 207.0 420 420 - - - - 420 86,940 (420)
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 2,297 2,297 805 72,450 - - 1,492 134,280 440 1000
DRG000017683 Gliserin larutan 50% botol Rp 5,867.0 - - - - - - - - -
DRG000017692 Glukosa larutan infus 10 % steril botol Rp 7,500.0 - - - - - - - - -
DRG000017682 Glukosa larutan infus 40 % steril botol Rp 988.0 - - - - - - - - -
DRG000030867 Glukosa larutan infus 5 % steril botol Rp 5,720.0 1 1 - - - - 1 5,720 (1)
Glukosamin 250 mg tablet (osmin) tablet Rp 1,000.0 - - - - - - - - -
DRG000018288 H.Booster sirup botol Rp 14,168.0 - - - - - - - - -
DRG000018443 Haloperidol tablet 1,5 mg tablet Rp 59.0 100 100 - - - - 100 5,900 (100)
99
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 646 646 276 234,597 - - 370 314,496 292 300
DRG000019256 HEXADOL (Larutan Hexetidine) botol Rp 12,650.0 - - - - - - - - -
Hidrokortison krim 1% tube Rp 5,723.3 23 23 5 28,617 - - 18 103,019 (6)
Hyorex 10 mg tablet tablet Rp 405.0 - - - - - - - - -
DRG000019430 Hyoscine N Butilbromida 10 mg tablet tablet Rp 1,625.8 - - - - - - - - -
DRG000019495 Ibuprofen syr 100 mg/5ml botol Rp 2,560.0 155 155 6 15,360 33 84,480 116 296,960 (102)
Ichtyol salep tube Rp 6,200.0 44 44 1 6,200 - - 43 266,600 (41)
Interhistin tablet tablet Rp 880.0 290 290 130 114,400 - - 160 140,800 152 200
DRG000006615 Irbesartan tab 150 mg tablet Rp 425.0 - - - - - - - - -
DRG000006804 Kalsium laktat ( Kalk ) tablet 500 mg tablet Rp 59.0 6,237 6,237 540 31,860 - - 5,697 336,123 (4,401)
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 750 750 155 92,845 - - 595 356,405 (223) 200
DRG000007735 Kandesartan 16 mg tablet tablet Rp 6,225.0 - - - - - - - - -
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 164 164 12 317,988 - - 152 4,027,848 (123)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 840 840 40 5,000 - - 800 99,992 (704)
DRG000021651 Kaptopril 50 mg tablet tablet Rp 135.0 - - - - - - - - -
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 32 32 6 15,462 - - 26 67,002 (12) 25
DRG000009233 Ketoprofen 100 mg tablet tablet Rp 1,366.2 - - - - - - - - -
DRG000009302 Klindamisin 150 mg tablet tablet Rp 754.0 - - - - - - - - -
DRG000009337 Klobazam 10 mg tablet tablet Rp 872.0 314 314 23 20,056 - - 291 253,752 (236)
DRG000021912 Klonidin 0,15 mg tablet tablet Rp 224.0 - - - - - - - - -
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 - - - - - - - - - 50
DRG000008615 Klorpromazin Hcl inj 25 mg / ml - 12 ml ampul Rp 418.3 - - - - - - - - -
DRG000009409 Klorpromazin Hcl tablet salut 25 mg tablet Rp 250.0 - - - - - - - - - 500
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 100 100 - - - - 100 112,100 (100) 100
DRG000021974 Kodein tablet 15 mg tablet Rp 728.0 - - - - - - - - -
DRG000003009 Kodein tablet 20 mg tablet Rp 1,494.0 - - - - - - - - -
DRG000022061 Kombinasi pirimetamin 25 mg / sulfadoksin 50 tablet Rp 379.6 - - - - - - - - -
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - - - - - - - - - 100
DRG000022701 Kotrimoksazol DOEN II (pedriatik) tablet tablet Rp 79.0 - - - - - - - - -
Lanzoprazol tablet Rp 330.0 525 525 90 29,700 - - 435 143,550 (219) 800
DRG000022980 Lapalos Cream tube Rp 16,500.0 - - - - - - - - -
Laxadine emulsi botol Rp 7,700.0 - - - - - - - - -
DRG000023225 L-Bio sachet sachet Rp 4,033.3 372 372 - - - - 372 1,500,388 (372)
DRG000023291 Levofloksasin tab 500 mg tablet Rp 449.0 - - - - - - - - -
DRG000045684 Lexapram sirup botol Rp 2,900.0 - - - - - - - - -
100
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023536 Lidocain jeli 2 % (Xylocaine Jelly 2%) syringe Rp 40,000.0 - - - - - - - - -
DRG000023691 Lincomisin 500 mg tablet Rp 1,319.6 200 200 - - - - 200 263,920 (200)
DRG000023692 Lisinopril 10 mg tablet tablet Rp 323.0 - - - - - - - - -
Lisinopril 5 mg tablet tablet Rp 238.0 - - - - - - - - -
DRG000026266 Lisol botol Rp 45,100.0 1 1 - - - - 1 45,100 (1)
DRG000023860 Livertran salep tube Rp 4,600.0 103 103 1 4,600 - - 102 469,200 (100)
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 1,041 1,041 56 150,858 - - 985 2,653,492 (851)
DRG000023935 Loperamida tablet tablet Rp 85.0 300 300 - - - - 300 25,500 (300)
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 - - - - - - - - - 100
DRG000024571 MDT Combi paket Rp 31,570.0 - - - - - - - - -
DRG000024987 Mebendazol sirup 100 mg / 5 ml botol Rp 2,035.0 - - - - - - - - -
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 520 520 110 88,000 - - 410 328,000 (146)
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 735 735 430 279,500 - - 305 198,250 727 500
Mersibion injeksi ampul Rp 6,000.0 - - - - - - - - -
DRG000025750 Metoklorpropamid sirup botol Rp 1,919.0 - - - - - - - - -
DRG000015762 Metronidazol infus 500 mg/100 ml botol Rp 25,300.0 - - - - - - - - -
DRG000026108 Metronidazol supp 500 mg (Flagyl supp) supp Rp 3,655.0 - - - - - - - - -
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 639 639 6 594 - - 633 62,667 (619)
DRG000026643 Misoprostol 200 mg (gastrul) tablet Rp 12,300.0 - - - - - - - - -
DRG000044042 Mixaria sachet Rp 1,260.0 - - - - - - - - -
DRG000026742 Moksifloksasin tetes mata 0,5% (Vigamox) botol Rp 81,000.0 - - - - - - - - -
DRG000027470 Mometason furoat krim 0,1 % tube Rp 7,912.0 - - - - - - - - -
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 2 2 1 5,170 - - 1 5,170 1 3
DRG000028214 Neo Diaform tablet Rp 253.0 - - - - - - - - -
DRG000028376 Neurodex tablet tablet Rp 591.4 330 330 40 23,656 - - 290 171,506 (194)
DRG000028619 New Diatabs tablet Rp 560.0 - - - - - - - - -
DRG000028637 Nistatin 500.000 iu /g tablet salut tablet Rp 910.0 - - - - - - - - -
Nitral (gliseril trinitras sublingual 0.5 mg) tablet Rp 1,650.1 - - - - - - - - -
DRG000029080 Nopres 20 mg tablet tablet Rp 883.3 395 395 10 8,833 - - 385 340,071 (361)
Norages Injeksi ampul Rp 9,999.9 - - - - - - - - -
novadium tablet Rp 200.0 - - - - - - - - -
Novastan sirup botol Rp 12,650.0 35 35 3 37,950 - - 32 404,800 (25)
Noza tablet tablet Rp 797.5 647 647 8 6,380 - - 639 509,603 (620)
Obat antituberkulosis kat.3 paket Rp 154,000.0 - - - - - - - - -
DRG000029617 Obat antituberkulosis kat.sisipan paket Rp 160,000.0 - - - - - - - - -
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 253 253 7 34,997 - - 246 1,229,877 (229)
DRG000039980 Obat suntik KB I (3 bulan) ampul Rp 7,175.0 - - - - - - - - -
101
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030101 Obat suntik KB II (1 bulan) ampul Rp 5,885.0 - - - - - - - - -
DRG000019683 Ofloksasin tab 400 mg tablet Rp 700.0 295 295 - - - - 295 206,500 (295)
DRG000031218 Oksimetazolin tts hidung 0,025% (Iliadin drops) botol Rp 37,433.0 - - - - - - - - -
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 - - - - - - - - -
DRG000030419 Ondansetron inj 4 mg/2ml ampul Rp 1,198.0 - - - - - - - - -
DRG000030584 Ondansetron tab 4 mg tablet Rp 406.0 - - - - - - - - -
Optiflox tetes mata botol Rp 14,005.0 - - - - - - - - -
Pamol supp supp Rp 18,999.2 - - - - - - - - -
DRG000031557 Pantocain 0,5 % TM botol Rp 17,499.9 5 5 - - - - 5 87,500 (5)
DRG000031585 Papaverin 40 mg tablet tablet Rp 170.0 - - - - - - - - -
DRG000031608 Parasetamol Drop 100 mg/ml botol Rp 6,938.8 - - - - - - - - -
DRG000032133 Pedialyte botol Rp 31,999.0 94 94 - - - - 94 3,007,906 (94)
DRG000032718 Pehacain injeksi ampul Rp 3,580.0 - - - - - - - - -
DRG000002552 Pil KB I tablet Rp 1,350.0 182 182 - - - - 182 245,700 (182) 50
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - - - - - - - - -
Pim-Tra-Kol sirup botol Rp 9,999.0 - - - - - - - - - 100
DRG000032996 Pirazinamid tab 500 mg tablet Rp 238.0 - - - - - - - - -
DRG000033456 Polikresulen botol Rp 43,975.8 - - - - - - - - -
PP Isoniazide 100 mg tablet Rp 79.0 - - - - - - - - - 100
Prazikuantel tablet 600 mg tablet Rp 2,295.0 - - - - - - - - -
Prenatin DF tablet tablet Rp 3,258.3 540 540 40 130,332 - - 500 1,629,150 (404)
DRG000034697 Primolut N tablet Rp 2,618.0 - - - - - - - - - 100
Protofen supp supp Rp 2,790.0 - - - - - - - - -
DRG000034797 Protofen tablet tablet Rp 880.0 - - - - - - - - -
Pularex tablet tablet Rp 175.0 496 496 88 15,400 - - 408 71,400 (197)
DRG000034808 Pulmicort respules ampul Rp 9,725.0 - - - - - - - - -
Pulmicort turbuhaler kotak Rp 101,000.0 - - - - - - - - -
Ramabion tab tablet Rp 6,490.0 - - - - - - - - -
DRG000035650 Ranitidin inj 25mg/2ml ampul Rp 1,155.0 - - - - - - - - -
DRG000035955 Recovit sirup botol Rp 8,650.0 - - - - - - - - -
Reserpin tablet 0,25 mg tablet Rp 114.0 - - - - - - - - -
102
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Rifampisin kaplet 600 mg tablet Rp 1,209.0 - - - - - - - - -
DRG000036698 Ringer laktat larutan infus steril botol Rp 7,150.0 4 4 - - - - 4 28,600 (4)
DRG000037347 Risperidon 2 mg tab tablet Rp 273.0 - - - - - - - - - 100
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 294 294 33 198,960 - - 261 1,573,595 (182)
Sandepril 50 mg tablet Rp 8,900.0 - - - - - - - - -
Sangobion kids drop botol Rp 34,999.8 - - - - - - - - -
Sangobion Kids Sirup botol Rp 24,515.7 - - - - - - - - - 100
DRG000037725 Scabicid cream 10 gram tube Rp 11,475.0 - - - - - - - - -
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 44 44 3 34,425 - - 41 470,475 (34)
Scopma tablet tablet Rp 750.0 - - - - - - - - -
DRG000007425 Sefaleksin kapsul 500 mg kapsul Rp 717.0 - - - - - - - - -
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 534 534 82 188,518 - - 452 1,039,148 (255)
DRG000038259 Sefiksim syr kering 100mg/5ml botol Rp 5,710.0 103 103 3 17,130 - - 100 571,000 (93)
DRG000038315 Seretide Inhaler 50 mcg kotak Rp 58,000.0 - - - - - - - - -
Serum anti bisa ular polivalen inj 5 ml ( ABU I ) vial Rp 479,996.0 - - - - - - - - -
Serum anti bisa ular polivalen inj 50 ml ( ABU II vial Rp 28,468,086.0 - - - - - - - - -
DRG000038321 Serum anti defteri inj 1000 mg / vial vial Rp 2,200,000.0 - - - - - - - - -
Serum anti tetanus inj 1.500 IU / ampul ( ATS ) ampul Rp 130,999.0 - - - - - - - - -
DRG000008166 Serum anti tetanus inj 20.000 IU / ampul ( ATS ampul Rp 604,670.0 - - - - - - - - -
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 85 85 50 149,650 - - 35 104,755 85 50
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 305 305 305 29,585 - - - - 732 300
DRG000008751 Simetidin tablet tablet Rp 250.0 - - - - - - - - -
DRG000038671 Simpastatin 20 mg tablet tablet Rp 225.0 417 417 55 12,375 - - 362 81,450 (230)
Sohobion tablet tablet Rp 1,043.6 - - - - - - - - -
Spiramisin 500 mg tablet tablet Rp 1,223.2 - - - - - - - - -
DRG000039298 Spironolakton tab 25 mg tablet Rp 212.0 - - - - - - - - -
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 12 12 - - - - 12 173,508 (12)
Stimuno Forte tablet tablet Rp 2,504.7 - - - - - - - - -
Stimuno Sirup botol Rp 18,500.0 - - - - - - - - - 100
Sucralfate 500 mg/5 ml suspensi botol Rp 7,338.0 - - - - - - - -
DRG000039932 Sulfasetamid natrium tetes mata 15 % botol Rp 8,499.7 - - - - - - - - -
DRG000040124 Susuk KB II set Rp 213,936.8 - - - - - - - - -
DRG000040195 Synarcus krim tube Rp 2,534.0 117 117 3 7,602 - - 114 288,876 (107)
103
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Taburia sachet Rp 1,000.0 - - - - - - - - -
DRG000040442 Tanapress 5 mg (imidapril ) tablet Rp 2,333.0 - - - - - - - - -
Tensigard tablet tablet Rp 1,063.3 - - - - - - - - -
Terra Flu tablet tablet Rp 807.1 - - - - - - - - -
DRG000041013 Tetagam ampul Rp 176,800.0 - - - - - - - - - 5
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 340 340 - - - - 340 302,600 (340) 100
DRG000041258 Thiamin Hcl ( Vit B1 ) inj.100 mg / ml - 1 ml ampul Rp 730.0 - - - - - - - - -
DRG000041358 Thrombophob gel tube Rp 54,450.0 6 6 - - - - 6 326,700 (6)
DRG000041532 Timolol tetes mata 0,5% botol Rp 10,286.0 - - - - - - - - -
DRG000041922 Tramadol 50 mg kapsul kapsul Rp 580.0 - - - - - - - - -
DRG000041920 Tramadol inj 50 mg/ml ampul Rp 2,680.0 - - - - - - - - -
DRG000042315 Triflouperazin 5mg tablet tablet Rp 309.0 - - - - - - - - -
DRG000042713 Truvit drops botol Rp 36,499.1 - - - - - - - - - 100
Truvit sirup botol Rp 11,400.0 82 82 82 934,800 - - - - 197 100
DRG000042887 Ulsafate sirup botol Rp 9,192.0 39 39 - - - - 39 358,488 (39)
DRG000042899 Ulsidex tablet tablet Rp 296.0 - - - - - - - - -
Urea krim (Soft U derm) botol Rp 7,040.0 - - - - - - - - -
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 200 200 30 54,450 - - 170 308,550 (98) 100
DRG000043188 Vagizol ovula (metronidazol ovula) ovula Rp 4,235.0 - - - - - - - - -
valisanbe 2 mg tablet Rp 236.0 - - - - - - - - -
DRG000043324 Valsartan tab 80 mg (Diovan 80mg) tablet Rp 3,900.0 - - - - - - - - -
Vastral tablet Rp 605.0 - - - - - - - - - 300
DRG000043683 Ventolin inhaler kotak Rp 70,125.0 - - - - - - - - -
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 35 35 1 11,000 - - 34 374,000 (32) 10
Vitamin A6000IU tablet Rp 237.0 - - - - - - - - -
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 2,200 2,200 715 35,035 - - 1,485 72,765 231 700
Vitonorm tablet tablet Rp 4,107.2 - - - - - - - - -
DRG000045683 Xylocain spray kotak Rp 344,570.0 - - - - - - - - -
Yodium Test botol Rp 1.0 - - - - - - - - -
DRG000046219 Zincpro drops botol Rp 31,999.9 - - - - - - - - -
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 - - - - - - - - - 100
DRG000046382 Zoloral SS (ketokonazol scalp sol 2 %) botol Rp 24,200.0 6 6 - - - - 6 145,200 (6)
- - - - - - - - -
II.OBAT GIGI - - - - - - - - -
MDVx000864 Achatit/Fuji II kotak Rp 939,400.0 - - - - - - - - -
0 acid etching kotak Rp 376,035.0 - - - - - - - - -
0 Air raksa dental use botol Rp 437,500.0 - - - - - - - - -
104
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Alveogyl kotak Rp 789,800.0 2 2 - - - - 2 1,579,600 (2)
0 Aplicator kotak Rp 95,000.0 1 1 - - - - 1 95,000 (1)
0 Arsenic Pasta 10 gr/pot Rp 942,040.0 3 3 - - - - 3 2,826,120 (3)
MDVx002393 Articulating paper kotak Rp 195,800.0 6 6 - - - - 6 1,174,800 (6)
0 Bond strenght kotak Rp 330,000.0 - - - - - - - - -
0 Caviton kotak Rp 252,950.0 1 1 - - - - 1 252,950 (1) 1
MDVx022575 Citodur (Bahan tambalan sementara) kotak Rp 200,200.0 - - - - - - - - -
0 Cotton pelet pack Rp 247,500.0 4 4 - - - - 4 990,000 (4)
MDVx009212 Cotton roll pack Rp 75,000.0 2 2 - - - - 2 150,000 (2)
0 Cresofen / endoseptone pack Rp 473,000.0 6 6 - - - - 6 2,838,000 (6)
MDVx024268 Dental floss kotak Rp 30,250.0 - - - - - - - - -
0 Dentin conditioning kotak Rp 366,465.0 - - - - - - - - -
0 Devitalisasi pasta (non arsen) / D.Pulp botol Rp 752,400.0 - - - - - - - - -
0 Devitalisasi pasta (non arsen) / Devitec kotak Rp 698,500.0 - - - - - - - - -
0 Dysclosing agent / Disclosing gel (GC tri plaqu botol Rp 345,950.0 - - - - - - - - -
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 1 - - - - 1 164,950 (1)
DRG000014675 Eugenol cairan botol Rp 136,400.0 3 3 - - - - 3 409,200 (3)
0 Flour sediaan topical botol Rp 170,000.0 - - - - - - - - -
0 Formokresol botol Rp 60,000.0 - - - - - - - - -
0 G aenial bond kotak Rp 875,578.0 1 1 - - - - 1 875,578 (1)
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 2 2 - - - - 2 1,287,000 (2)
0 Glass Ionomer cemen / ketakmolar kotak Rp 880,000.0 - - - - - - - - -
MDVx019949 Glass Ionomer Light cured Universal restorativ kotak Rp 412,500.0 - - - - - - - - -
0 Jarum Dental cytoject pcs Rp 2,662.0 - - - - - - - - -
SBx148 Kalsium hidroksida pasta kotak Rp 187,000.0 - - - - - - - - -
0 Marbalet/neocones botol Rp 750,000.0 - - - - - - - - -
0 Monoklorkamfer mentol cairan (camphenol) kotak Rp 55,000.0 - - - - - - - - -
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 4 4 4 300,960 - - - - 10 1
SBx147 Mummifying pasta kotak Rp 451,000.0 - - - - - - - - -
0 Oco Tooth Clensing botol Rp 191,999.0 4 4 - - - - 4 767,996 (4)
0 Pasta pengisi saluran akar kotak Rp 506,000.0 - - - - - - - - -
0 Rockless kotak Rp 1,135,200.0 - - - - - - - - -
DRG001BJM Scandonest pcs Rp 17,622.0 - - - - - - - - - 2
105
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx000992 selang saliva eyector pack Rp 157,300.0 10 10 - - - - 10 1,573,000 (10)
DRG000038085 Semen seng fosfat serbuk dan cairan kotak Rp 225,500.0 3 3 - - - - 3 676,500 (3)
0 Silver amalgam serbuk 65 - 75 % kotak Rp 937,500.0 - - - - - - - - -
MDVx000870 Surgical ginggival pack (Coe Pak) kotak Rp 669,350.0 1 1 - - - - 1 669,350 (1)
SBx139 Tambalan sinar solare A2 kotak Rp 256,731.0 3 3 - - - - 3 770,193 (3)
0 Tambalan sinar solare A3,5 kotak Rp 420,200.0 - - - - - - - - - 1
0 Tampon pack Rp 300,000.0 4 4 - - - - 4 1,200,000 (4)
0 Temporary stopping fletcher serbuk dan cairan set Rp 62,150.0 - - - - - - - - -
0 Topical anastesi pasta kotak Rp 302,500.0 4 4 - - - - 4 1,210,000 (4)
DRG000042250 Trikesol Formalin ( TKF ) cairan botol Rp 82,720.0 - - - - - - - - -
MDVx020416 Varnish box Rp 165,440.0 - - - - - - - - -
- - - - - - - - -
III. BMHP - - - - - - - - -
MDVx001727 Alat suntik sekali pakai 1 ml pcs Rp 1,614.0 251 251 10 16,140 - - 241 388,974 (217)
0 Alat suntik sekali pakai 2,5 ml pcs Rp 605.0 62 62 - - - - 62 37,510 (62)
MDVx001732 Alat suntik sekali pakai 3 ml pcs Rp 1,138.0 305 305 23 26,174 - - 282 320,916 (227)
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 467 467 - - - - 467 771,017 (467)
MDVx001793 Alat suntik sekali pakai 10 ml pcs Rp 1,095.3 100 100 - - - - 100 109,529 (100)
DRG000000999 Albothyl botol Rp 45,000.0 - - - - - - - - -
DRG000001226 Alkohol Swab lembar Rp 105.0 1,000 1,000 - - - - 1,000 105,000 (1,000)
0 Bioplacenton tulle pcs Rp 10,920.0 63 63 1 10,920 - - 62 677,040 (60)
MDVx000796 Bistruri/scalpel balde No 10 pcs Rp 3,300.0 80 80 - - - - 80 264,000 (80)
0 Bistruri/scalpel balde No 11 pcs Rp 3,450.0 - - - - - - - - -
0 Bisturi/scalpel balde No 15 pcs Rp 850.0 - - - - - - - - -
MDVx002305 Blood Lancet pcs Rp 176.0 550 550 - - - - 550 96,800 (550)
0 Blood transfusion set pcs Rp 4,698.0 - - - - - - - - -
0 Blue Tip pack Rp 139,500.0 2 2 - - - - 2 279,000 (2)
Box slide TB kotak Rp 36,000.0 - - - - - - - - -
0 canula dewasa pcs Rp 1.0 - - - - - - - - -
0 Cat Gut chromic No 1 pcs Rp 1.0 - - - - - - - - -
0 Celulid strip pcs Rp 73,700.0 - - - - - - - - -
Cetride 5 Liter galon Rp 774,972.0 - - - - - - - - -
106
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Clorheksidin 2,5 % botol Rp 618,750.0 - - - - - - - - -
MDVx023244 Coverplast pcs Rp 470.0 2 2 - - - - 2 940 (2) 2
0 Deck glass / objek glass 20 x 20 mm pack Rp 48,000.0 - - - - - - - - -
Deck glass / objek glass 22 x 22 mm pack Rp 52,300.0 - - - - - - - - - 2
0 Deck gelas / objek glass 24 x 24 mm pack Rp 48,000.0 - - - - - - - - -
MDVx018887 Disposibel vagina speculum pcs Rp 7,500.0 - - - - - - - - -
D-Pierce X12 box Rp 817,450.0 - - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - - - - - - - - -
MDVx001175 Fukuda M.E.ECG Paper pcs Rp 56,566.7 - - - - - - - - -
MDVx002014 handiplast pcs Rp 385.0 - - - - - - - - -
Holder tube vacutainer pcs Rp 6,940.0 - - - - - - - - -
0 Hypafix uk. Kecil 5 cm x 5 m pcs Rp 98,900.0 8 8 - - - - 8 791,200 (8)
MDVx003549 IUD set Rp 11,800.0 - - - - - - - - -
0 Infusiun set anak pcs Rp 2,970.0 2 2 - - - - 2 5,940 (2)
MDVx026876 Infusiun set dewasa pcs Rp 4,176.0 3 3 - - - - 3 12,528 (3)
MDVx001152 Jarum (Needle) no 23 pcs Rp 400.0 100 100 - - - - 100 40,000 (100)
MDVx001154 Jarum (Needle) no 25 pcs Rp 604.0 - - - - - - - - -
MDVx022261 Jelly (Aquagel) botol Rp 31,027.3 5 5 - - - - 5 155,137 (5)
107
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 80 - - - - 80 200,000 (80)
0 Kapas berlemak 500 mg roll Rp 21,532.5 3 3 - - - - 3 64,598 (3)
DRG000021388 Kapas pembalut / absorben 250 mg roll Rp 13,000.0 1 1 - - - - 1 13,000 (1)
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 23 23 - - - - 23 45,121 (23)
0 Kasa pembalut 2 m x80 cm pcs Rp 9,347.0 8 8 - - - - 8 74,776 (8)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 - - - - - - - - - 30
SBx134 Kasa pembalut hidrofil 4m x 3 cm pcs Rp 613.5 29 29 - - - - 29 17,792 (29)
Kasa steril 16 cm x 16 cm box Rp 8,685.7 - - - - - - - - -
MDVx001191 Kertas EKG (uk 80 x 90 x 280) lembar Rp 106,250.0 - - - - - - - - -
0 Kertas Puyer lembar Rp 91.6 - - - - - - - - -
MDVx013360 Kertas Thermal roll Rp 94,500.0 - - - - - - - - - 1
kertas thermal 50 mm x 57 mm roll Rp 18,200.0 - - - - - - - - -
Kertas thermal mindray 50mm x 50 mm roll Rp 76,500.0 - - - - - - - - -
0 Klorin botol Rp 15,970.0 48 48 - - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 748 748 12 8,600 - - 736 527,491 (707)
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 23 23 - - - - 23 872,850 (23)
MDVx022456 Lidi Kapas/cotton swab pcs Rp 1,000.0 412 412 - - - - 412 412,000 (412)
Markerpen pcs Rp 1.0 70 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 - - - - - - - - - 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - - - - - - - - -
0 masker nebule dewasa pcs Rp 28,300.0 - - - - - - - - -
0 masker oksigen anak pcs Rp 19,800.0 - - - - - - - - -
0 masker oksigen dewasa pcs Rp 19,800.0 - - - - - - - - -
0 Mata Bor high speed pack Rp 154,000.0 1 1 - - - - 1 154,000 (1)
0 Microtube 1,5 cc pack Rp 245,000.0 - - - - - - - - -
0 Minyak handpiece 500 ml botol Rp 561,000.0 - - - - - - - - -
Mouthpiece sterilbreath 250s box Rp 4,527.6 - - - - - - - - -
0 NaOcl 2,5 % untuk sal irigasi botol Rp 123,200.0 - - - - - - - - -
0 Needle flashback pcs Rp 3,170.0 - - - - - - - - -
MDVx000733 Obyek glass* biasa pack Rp 37,446.0 - - - - - - - - - 2
0 Open akses bur pcs Rp 135,300.0 - - - - - - - - -
0 Pembalut gips pcs Rp 55,000.0 - - - - - - - - -
0 Penjepit tali pusat pcs Rp 3,025.0 2 2 - - - - 2 6,050 (2)
0 Pharmafix pcs Rp 27,000.0 8 8 1 27,000 - - 7 189,000 (5)
108
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
pipet ESR citotes pcs Rp 7,675.0 - - - - - - - - -
Plastik klip sedang pack/100sRp 3,950.0 - - - - - - - - -
0 Plastik Obat kecil (uk. 8 cm x 5 cm) pack Rp 17,000.0 15 15 - - - - 15 255,000 (15)
0 Plastik Obat pembungkus puyer (uk. Besar) pack Rp 5,950.0 10 10 - - - - 10 59,500 (10)
MDVx041848 Plester (hansaplast 5 cm x 4,5 m) pcs Rp 12,000.0 - - - - - - - - -
Plesterin pcs Rp 161.7 - - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - - - - - - - - - 50
0 safety box* pcs Rp 16,500.0 91 91 - - - - 91 1,501,500 (91)
sealing wax pcs Rp 164,000.0 - - - - - - - - -
0 Serum gel tes tube 5 ml / tabung gel & cloat act pcs Rp 2,650.0 - - - - - - - - -
0 Silk ( benang bedah sutra ) no.3/0 pcs Rp 4,766.7 36 36 - - - - 36 171,601 (36)
silk no 2/0 pcs Rp 3,208.3 - - - - - - - - -
0 Spon gelatin cubicle 1 x 1 x 1 cm pcs Rp 1,850.0 - - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 300 - - - - 300 495,000 (300)
MDVx001722 Spuit 0,5 ml pcs Rp 1,240.0 400 400 100 124,000 - - 300 372,000 (60)
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - - - - - - - - - 3
0 Suction tips pack Rp 73,700.0 - - - - - - - - -
0 Surflo No 18 pcs Rp 8,355.0 6 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 5 5 - - - - 5 41,775 (5)
MDVx002389 Surgical Glove No 6,5 pcs Rp 20,006.7 85 85 - - - - 85 1,700,570 (85)
0 Surgical Glove No 8 pcs Rp 5,000.0 93 93 - - - - 93 465,000 (93)
MDVx019415 Surgical Glove obsgyn / gynecolog No 6,5 pcs Rp 20,006.7 - - - - - - - - -
Surgical Glove obsgyn / gynecolog No 7 pcs Rp 20,010.0 - - - - - - - - -
0 Surgical Gloves non steril uk L pcs Rp 462.0 700 700 - - - - 700 323,400 (700)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 600 600 200 74,800 - - 400 149,600 80 200
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 800 800 100 46,200 - - 700 323,400 (460) 200
MDVx003948 Surgical mask 3 ply tie on pcs Rp 462.0 253 253 - - - - 253 116,886 (253)
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,300 2,300 450 207,900 - - 1,850 854,700 (770) 500
MDVx010039 Surgikal Gloves No 7 pcs Rp 5,000.0 12 12 - - - - 12 60,000 (12)
MDVx010040 Surgikal Gloves No 7.5 pcs Rp 4,600.0 164 164 - - - - 164 754,400 (164)
MDVx000518 Tabung EDTA K-3 pcs Rp 1,690.9 - - - - - - - - - 100
0 Tabung EdtA K-3 micro 0,5 cc pcs Rp 2,445.0 - - - - - - - - - 100
Tabung hematokrit pack Rp 180,500.0 - - - - - - - - -
0 Tabung reaksi / Test tube 75 x 100 dia 1 cm pcs Rp 5,500.0 - - - - - - - - -
Tabung reaksi kaca uk.12 x 75 mm pcs Rp 10,900.0 - - - - - - - - -
109
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000043003 Underpad pcs Rp 4,370.5 186 186 - - - - 186 812,913 (186)
MDVx013451 Urine bag pcs Rp 3,120.0 - - - - - - - - -
USG paper 110 HG (110 mm x 18m_SONY) roll Rp 268,500.0 - - - - - - - - -
Viorex liquid 4 % 500 ml botol Rp 76,477.5 - - - - - - - - -
0 Yellow Tip pack Rp 139,500.0 - - - - - - - - -
- - - - - - - - -
IV. REAGEN - - - - - - - - -
0 Abate/temephos botol Rp 2,197,800.0 - - - - - - - - -
0 ACS level I (control serum) botol Rp 4,160,000.0 - - - - - - - - -
0 Aquadest steril botol Rp 22,000.0 1 1 - - - - 1 22,000 (1)
DRG000046738 Asam klorida 0,1 N botol Rp 24,200.0 2 2 - - - - 2 48,400 (2)
MDVx041607 Asam sulfosalisilat 20 % botol Rp 531,000.0 2 2 - - - - 2 1,062,000 (2)
bactive SL botol Rp 30,700.0 - - - - - - - - -
MDVx040425 Blood Analisir Clianac Detergen (Nihon kohden botol Rp 8,050,000.0 - - - - - - - - -
MDVx041543 Blood Analisir Hemolinac 3N Lysing (nihon koh botol Rp 3,850,000.0 - - - - - - - - -
MDVx041531 Blood Analisir Isotonac 3 Diluent (nihon kohden botol Rp 4,290,000.0 - - - - - - - - -
0 Blood Analisir Clianac Detergen (norma clean botol Rp 2,112,000.0 - - - - - - - - -
0 Blood Analisir Hemolinac 3N Lysing (norma lys botol Rp 5,240,000.0 - - - - - - - - -
0 Blood Analisir Isotonac 3 Diluent (norma diluen botol Rp 3,696,000.0 - - - - - - - - -
0 Carbol gentian violet botol Rp 64,900.0 - - - - - - - - -
0 Cynoff 25 UL botol Rp 1,124,500.0 - - - - - - - - -
DRG000046731 Edta kering botol Rp 121,000.0 - - - - - - - - -
DRG000014470 Etanol 70 % 1 Liter botol Rp 41,800.0 22 22 - - - - 22 919,600 (22)
DRG000001161 Etanol 70 % 100 ml botol Rp 5,500.0 - - - - - - - - -
0 K-Othrine 20 EW / Cyflutrin botol Rp 1,000,000.0 - - - - - - - - -
Kontrol darah botol Rp 1,358,500.0 1 1 - - - - 1 1,358,500 (1)
Kontrol norma low botol Rp 596,000.0 - - - - - - - - -
Kontrol norma normal botol Rp 596,000.0 - - - - - - - - -
kontrol norma high botol Rp 596,000.0 - - - - - - - - -
MDVx343BJM Lab Pro reagen botol Rp 203,500.0 - - - - - - - - -
0 Larutan Air Fuchsin botol Rp 32,500.0 - - - - - - - - -
DRG000001165 Larutan Alkohol 95 % botol Rp 91,300.0 - - - - - - - - -
0 Larutan Alkohol 96 % botol Rp 48,500.0 - - - - - - - - -
110
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Larutan alkohol aseton botol Rp 31,000.0 - - - - - - - - -
MDVx103BJM Larutan amonium oksalat botol Rp 48,400.0 - - - - - - - - -
MDVx104BJM Larutan Anisol botol Rp 231,000.0 - - - - - - - - -
DRG000046732 Larutan Asam asetat 5% botol Rp 19,500.0 2 2 - - - - 2 39,000 (2)
MDVx041776 Larutan Barium Klorida botol Rp 26,400.0 - - - - - - - - -
MDVx041604 Larutan Benedict botol Rp 84,700.0 - - - - - - - - -
MDVx105BJM Larutan Buffer Fosfat botol Rp 36,300.0 - - - - - - - - -
MDVx018552 Larutan Developer botol Rp 1,183,000.0 - - - - - - - - -
MDVx041584 Larutan Edta 10% botol Rp 151,250.0 - - - - - - - - -
MDVx041581 Larutan Eosin 2 % botol Rp 447,700.0 1 1 - - - - 1 447,700 (1)
DRG000046739 Larutan Etanol Asam botol Rp 62,700.0 2 2 - - - - 2 125,400 (2)
MDVx106BJM Larutan Eter alkohol botol Rp 68,200.0 - - - - - - - - -
MDVx018554 Larutan Fixer botol Rp 801,900.0 - - - - - - - - -
MDVx041704 Larutan Foucet botol Rp 176,000.0 - - - - - - - - -
MDVx041602 Larutan Giemsa Sain botol Rp 378,125.0 - - - - - - - - -
MDVx041700 Larutan hayem botol Rp 122,100.0 1 1 - - - - 1 122,100 (1)
DRG000018188 Larutan Hidrogen Peroksida (H2O2) botol Rp 60,500.0 - - - - - - - - -
0 Larutan Iodium 1 % botol Rp 27,500.0 - - - - - - - - -
DRG000046764 Larutan Karbol Fuksin botol Rp 165,000.0 2 2 - - - - 2 330,000 (2)
MDVx041583 Larutan KOH 10 % botol Rp 29,700.0 - - - - - - - - -
MDVx109BJM Larutan KOH 20 % botol Rp 40,700.0 - - - - - - - - -
MDVx041673 Larutan Lugol 1 % botol Rp 44,000.0 - - - - - - - - -
MDVx012323 Larutan Metilen Biru botol Rp 84,700.0 2 2 - - - - 2 169,400 (2)
MDVx110BJM Larutan Natrium Citrat 3,8 % botol Rp 44,000.0 - - - - - - - - -
MDVx111BJM larutan safranin botol Rp 157,300.0 - - - - - - - - -
MDVx108BJM Larutan sodium hipoklorid 1 L botol Rp 110,000.0 - - - - - - - - -
0 Larutan sodium hipoklorid 100 ML botol Rp 18,634.0 5 5 - - - - 5 93,170 (5)
MDVx041790 Larutan Turk botol Rp 39,600.0 1 1 - - - - 1 39,600 (1)
DRG000046736 Larutan Xylol botol Rp 30,800.0 - - - - - - - - -
DRG000025457 Lipid Panel cardiocheck PA kotak Rp 1,721,516.9 - - - - - - - - -
0 Lipid Pro pcs Rp 836,000.0 - - - - - - - - -
0 M-30 CFL LYSE 500 ML Mindray botol Rp 2,100,000.0 - - - - - - - - -
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 1 1 - - - - 1 2,050,000 (1) 1
0 M-30 E-Z Cleanser Mindray botol Rp 1,500,000.0 1 1 - - - - 1 1,500,000 (1)
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 - - - - - - - - - 1
0 M-30 RINSE Mindray botol Rp 2,050,000.0 1 1 - - - - 1 2,050,000 (1)
0 B30 Control Hematology Analyzer Mindray botol Rp 1,336,500.0 - - - - - - - - -
111
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Medonic Diluent 20 L botol Rp 3,400,100.0 - - - - - - - - -
0 Medonic Lyse 5 L botol Rp 5,550,600.0 - - - - - - - - -
DRG000025457 Metanol botol Rp 24,645.0 - - - - - - - - -
0 Norma cleaner botol Rp 1,910,000.0 - - - - - - - - -
0 Norma diluent diff botol Rp 1,910,000.0 - - - - - - - - -
0 Norma lyse diff botol Rp 2,625,000.0 - - - - - - - - -
MDVx112BJM Oil Imersi botol Rp 580,000.0 1 1 - - - - 1 580,000 (1)
0 Pewarnaan Gram 1 % botol Rp 518,100.0 - - - - - - - - -
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 100 100 - - - - 100 1,434,400 (100)
0 Rapid 2 Intec HIV stik Rp 40,800.0 - - - - - - - - -
0 Rapid 3 oncoprobe stik Rp 64,280.0 - - - - - - - - -
0 Rapid 4 right sign HIV stik Rp 35,120.0 1 1 - - - - 1 35,120 (1)
0 Rapid 5 CTK Bioteck HIV stik Rp 30,250.0 1 1 - - - - 1 30,250 (1)
0 Rapid 6 HIV Vikia stik Rp 21,818.0 - - - - - - - - -
0 Rapid 7 HIV Card Vcare stik Rp 30,250.0 - - - - - - - - -
Rapid 8 Fokus HIV stik Rp 4,179.0 - - - - - - - - -
0 Reagen Albumin biosystem kit Rp 800,000.0 - - - - - - - - -
Reagen albumin agappe / mindray kit Rp 1,400,000.0 - - - - - - - - -
0 Reagen Albumin randox kit Rp 917,250.0 - - - - - - - - -
MDVx114BJM Reagen Asam Urat biosystem kit Rp 2,805,000.0 - - - - - - - - -
0 Reagen Asam Urat agappe / mindray kit Rp 1,150,000.0 - - - - - - - - -
MDVx034902 Reagen Asam Urat randox kit Rp 1,225,700.0 - - - - - - - - -
0 Reagen Bilirubin Direct biosystem kit Rp 2,090,000.0 - - - - - - - - -
Reagen Bilirubin Direct agappe / mindray kit Rp 900,000.0 - - - - - - - - -
0 Reagen Bilirubin Direct randox kit Rp 970,000.0 - - - - - - - - -
0 Reagen Bilirubin Total biosystem kit Rp 2,090,000.0 - - - - - - - - -
Reagen Bilirubin Total agappe / mindray kit Rp 1,450,000.0 - - - - - - - - -
0 Reagen Bilirubin Total randox kit Rp 897,000.0 - - - - - - - - -
MDVx117BJM Reagen Cholesterol biosystem kit Rp 759,000.0 - - - - - - - - -
0 Reagen Cholesterol agappe / mindray kit Rp 1,150,000.0 - - - - - - - - -
MDVx034903 Reagen Cholesterol randox kit Rp 1,586,500.0 - - - - - - - - -
MDVx118BJM Reagen Cholesterol HDL biosystem kit Rp 2,040,000.0 - - - - - - - - -
Reagen Cholesterol HDL agappe / mindray kit Rp 8,225,000.0 - - - - - - - - -
0 Reagen Cholesterol HDL randox kit Rp 1,924,750.0 - - - - - - - - -
MDVx119BJM Reagen Creatinin biosystem kit Rp 1,572,725.0 - - - - - - - - -
Reagen Creatinin agappe / mindray kit Rp 850,000.0 - - - - - - - - -
0 Reagen Creatinin randox kit Rp 937,750.0 - - - - - - - - -
112
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx120BJM Reagen Glucose biosystem kit Rp 495,000.0 - - - - - - - - -
0 Reagen Glucose agappe / mindray kit Rp 1,450,000.0 - - - - - - - - -
MDVx034905 Reagen Glucose PAP randox kit Rp 1,803,400.0 - - - - - - - - -
0 Reagen golongan darah set-2 Rp 142,650.0 2 2 - - - - 2 285,300 (2)
0 Reagen golongan darah set-4 Rp 355,480.0 - - - - - - - - -
MDVx344bjm Reagen HB Cyanida kit Rp 165,000.0 - - - - - - - - -
0 Reagen HB konsentrat biosystem kit Rp 308,000.0 - - - - - - - - -
0 Reagen HB konsentrat randox kit Rp 1,498,700.0 - - - - - - - - -
0 Reagen Protein Total biosystem kit Rp 545,000.0 - - - - - - - - -
Reagen Protein Total agappe / mindray kit Rp 700,000 - - - - - - - - -
0 Reagen Protein Total randox kit Rp 880,000 - - - - - - - - -
MDVx123BJM Reagen SGOT / AST biosystem kit Rp 715,000 - - - - - - - - -
0 Reagen SGOT / AST Mindray kit Rp 1,625,000 - - - - - - - - -
0 Reagen SGOT / AST randox kit Rp 1,435,700 - - - - - - - - -
MDVx124 Reagen SGPT / ALT biosystem kit Rp 715,000 - - - - - - - - -
0 Reagen SGPT / ALT mindray kit Rp 1,625,000 - - - - - - - - -
0 Reagen SGPT / ALT randox kit Rp 1,200,000 - - - - - - - - -
MDVx125BJM Reagen Trigliseride biosystem kit Rp 3,768,792 - - - - - - - - -
0 Reagen Trigliseride mindray kit Rp 1,950,000 - - - - - - - - -
0 Reagen Trigliseride randox kit Rp 1,879,650 - - - - - - - - -
MDVx126BJM Reagen Ureum biosystem kit Rp 1,550,000 - - - - - - - - -
0 Reagen Urea Mindray kit Rp 1,150,000 - - - - - - - - -
MDVx034850 Reagen Ureum randox kit Rp 2,380,150 - - - - - - - - -
MDVx041577 Reagen Wright Stain kit Rp 290,400 - - - - - - - - -
MDVx037823 reagent cholesterol pap sl (microlab/elitech) kit Rp 3,088,800 - - - - - - - - -
MDVx002BJM reagent cholesterol standar 200 mg/dl (microlab kit Rp 633,600 - - - - - - - - -
MDVx037816 reagent glucose pap sl (microlab/elitech) kit Rp 1,584,000 - - - - - - - - -
MDVx001BJM reagent glucose standar 100 mg/dl (microlab/el kit Rp 448,800 - - - - - - - - -
MDVx037822 reagent trigliserid mono sl (microlab/elitech) kit Rp 4,752,000 - - - - - - - - -
MDVx037603 reagent trigliserid standar 200 mg/dl (microlab/e kit Rp 475,200 - - - - - - - - -
MDVx037819 reagent uric acid mono sl (microlab/elitech) kit Rp 3,168,000 - - - - - - - - -
MDVx037604 reagent uric acid standar (microlab/elitech) kit Rp 580,800 - - - - - - - - -
0 Reagen Elitrol 1 Normal 1 x 5 ml (elitech) kit Rp 924,000 - - - - - - - - -
MDVx041674 Res eker botol Rp 144,100 1 1 - - - - 1 144,100 (1)
0 RPR syfilis randox botol Rp 1,555,920 - - - - - - - - -
0 RPR syfilis Fokus Diagnostik botol Rp 4,250 1 1 1 4,250 - - - - 2 1
RPR syfilis "Human" botol Rp 5,684 1 1 - - - - 1 5,684 (1)
113
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Serum kontrol mindray (Qualichek normal mind botol Rp 1,200,000 - - - - - - - - -
DRG000046730 Spiritus 1 L botol Rp 53,900 6 6 - - - - 6 323,400 (6)
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 - - - - - - - - - 50
0 Stik asam urat Nesco stik Rp 5,258 - - - - - - - - -
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 20 20 - - - - 20 437,800 (20) 40
0 Stik Cholesterol Nesco stik Rp 24,090 - - - - - - - - -
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 15 - - - - 15 108,570 (15)
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - - - - - - - - -
MDVx041511 Stik Gula Darah Accu cek stik Rp 8,327 - - - - - - - - - 200
0 Stik HB BeneCheck stik Rp 7,955 - - - - - - - - -
MDVx133BJM Stik HB Easy touch stik Rp 6,688 150 150 - - - - 150 1,003,200 (150) 50
0 Stik HBSAb merek Intec stik Rp 27,478 - - - - - - - - -
0 Stik HBSAg merek SD stik Rp 9,870 - - - - - - - - -
Stik HBSAg merek Intec stik Rp 9,850 300 300 - - - - 300 2,955,000 (300) 100
0 Stik Kehamilan stik Rp 1,947 150 150 - - - - 150 292,050 (150)
0 Stik syphilis 'SD' stik Rp 35,429 - - - - - - - - - 100
Stik syphilis 'Monotest' stik Rp 10,758 - - - - - - - - -
Stik syphilis 'Human hexagonal' stik Rp 26,744 - - - - - - - - -
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - - - - - - - - -
MDVx138BJM Stik urinalisa 10 parameter (Lab U 11) stik Rp 2,274 - - - - - - - - -
0 Stik urinalisa 10 parameter Akray stik Rp 6,050 - - - - - - - - -
0 Stik urinalisa 10 prm (mission) stik Rp 2,700 - - - - - - - - -
0 Stik urinalisa 3 parameter stik Rp 5,720 - - - - - - - - -
0 Swelab alfa diluent 20 L botol Rp 6,500,000 - - - - - - - - -
0 Swelab alfa lyse 5 L botol Rp 8,500,000 - - - - - - - - -
0 Widal tes 4 set 4 set Rp 291,640 1 1 - - - - 1 291,640 (1) 1
0 Widal tes 6 set 6 set Rp 279,140 - - - - - - - - -
0 Ziehl Nielseen Stain paket Rp 273,978 - - - - - - - - - 1
Pil KB BKKBN 736 736 19 - - - 717 - (671)
Suntik KB 3 bulan BKKBN 57 57 22 - - - 35 - 18
Kondom BKKBN 4 4 - - - - 4 - (4)
IUD Copper T BKKBN 5 5 - - - - 5 - (5)
Susuk dengan inserter (implan) BKKBN 5 5 - - - - 5 - (5)
Spuit 3cc BKKBN 57 57 22 - - - 35 - (35)
calcetin pasta (gigi) 1 1 - - - - 1 - (1)
- - - - - -
- - - - - -
114
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 8,848,072 101,699,581
UMUM
JUMLAH
843 282 1125

Kepala Dinas Kesehatan Kab/Kota Kepala UPTD Instalasi Farmasi Kepala Puskesmas Petugas Puskesmas
Dr. Machli Riyadi, S.H., M.H. Yohana Rusnayuda, S.Si., Apt. Rusmadi, SKM., MA. M. Ary Aprian Noor, S.Far., Apt.
NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19680616 198911 1 001 NIP.19840410 200803 1 002
115
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000000983 Albendazol tablet 400 mg tablet Rp 323.0 - 0 - - - - - - - - 3900
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 729 0 729 90 8,910 - - 639 63,261 (423)
Aminofilin tablet 200 mg tablet Rp 86.0 660 0 660 20 1,720 - - 640 55,040 (592)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 455 3000 3,455 1,325 100,700 - - 2,130 161,880 1,050 3000
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 612 1700 2,312 544 134,912 - - 1,768 438,464 (462)
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 - 0 - - - - - - - -
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 3,502 0 3,502 880 49,280 - - 2,622 146,832 (510)
DRG000002883 Antasida sirup botol Rp 2,098.0 38 0 38 12 25,176 - - 26 54,548 3
DRG000002996 Antifungi doen kombinasi tube Rp 5,170.0 24 0 24 10 51,700 - - 14 72,380 10
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 218 500 718 718 86,160 - - - - 1,723 500
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 - 500 500 30 2,430 - - 470 38,070 (398) 500
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 - 0 - - - - - - - - 2000
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 109 0 109 18 24,714 - - 91 124,943 (48)
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 1,586 0 1,586 138 4,692 - - 1,448 49,232 (1,117)
116
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 - 0 - - - - - - - -
DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 786 0 786 210 25,410 - - 576 69,696 (72)
DRG000012719 Domperidon 10 mg tablet Rp 90.0 427 0 427 10 900 - - 417 37,530 (393)
DRG000013853 Epinefrin Hcl/Bitartrat(adrenalin)inj 0,1 %-1 ml ampul Rp 1,518.0 - 10 10 - - - - 10 15,180 (10)
DRG000027466 Fenitoin kapsul 50 mg kapsul Rp 1.0 - 0 - - - - - - - - 100
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 1,175 3000 4,175 740 40,700 - - 3,435 188,925 (1,659) 3000
DRG000015698 Fitomenadion ( vit k 1 ) tablet salut 10 mg tablet Rp 818.0 376 200 576 20 16,360 - - 556 454,808 (508) 200
DRG000032665 Fitomenadion ( vit k 1 ) inj 10 mg / ml - 1 ml ampul Rp 5,516.5 - 10 10 - - - - 10 55,165 (10)
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 690 0 690 20 1,580 - - 670 52,930 (622)
DRG000017435 Glimepirid tab 1 mg tablet Rp 194.0 50 0 50 10 1,940 - - 40 7,760 (16) 500
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 - 0 - - - - - - - - 200
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 470 200 670 125 6,875 - - 545 29,975 (245) 100
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 405 0 405 10 560 - - 395 22,120 (371)
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 2,035 0 2,035 180 20,160 - - 1,855 207,760 (1,423)
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 560 0 560 120 35,040 - - 440 128,480 (152)
DRG000020665 Isoniazid tablet 100 mg tablet Rp 79.0 100 0 100 - - 100 7,900 - - -
117
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 170 0 170 20 1,780 - - 150 13,350 (102)
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 1,771 0 1,771 250 27,500 - - 1,521 167,310 (921)
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 90 200 290 50 11,700 - - 240 56,160 (120) 300
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 - 0 - - - - - - - - 300
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 630 0 630 10 2,750 - - 620 170,500 (596)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 4,805 0 4,805 1,022 24,528 - - 3,783 90,792 (1,330)
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 - 0 - - - - - - - - 400
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 170 0 170 - - - - 170 111,690 (170)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 451 0 451 - - - - 451 56,375 (451) 500
DRG000023922 Loratadin tablet tablet Rp 127.0 1,305 0 1,305 - - 1,305 165,735 - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 252 200 452 265 27,030 - - 187 19,074 449 300
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 130 0 130 - - - - 130 35,594 (130)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 1,354 0 1,354 310 51,150 - - 1,044 172,260 (300) 300
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 770 0 770 - - - - 770 63,910 (770)
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 1,145 0 1,145 16 3,248 - - 1,129 229,187 (1,091)
118
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 15 0 15 - - - - 15 2,130 (15) 500
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 1,150 1000 2,150 255 34,680 - - 1,895 257,720 (1,283) 1000
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 285 0 285 90 16,199 - - 195 35,099 21
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 119 0 119 - - - - 119 76,755 (119)
Obat antituberkulosis anak paket Rp 267,400.0 1 0 1 - - - - 1 267,400 (1)
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 2 2 4 - - - - 4 1,655,916 (4) 4
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 1 0 1 - - - - 1 1,492,574 (1)
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 453 0 453 453 62,514 - - - - 1,087 900
DRG000031912 Parasetamol sirup 120 mg / 5 ml botol Rp 1,160.0 346 200 546 119 138,040 - - 427 495,320 (141) 200
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 1,007 2300 3,307 7 420 - - 3,300 198,000 (3,283) 1000
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 721 0 721 621 87,561 - - 100 14,100 1,390 700
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 1,012 0 1,012 132 23,958 - - 880 159,720 (563)
DRG000034487 Propanolol Hcl tablet 40 mg tablet Rp 300.0 100 0 100 - - - - 100 29,999 (100)
DRG000035403 Ranitidin tablet tablet Rp 122.0 974 0 974 400 48,800 - - 574 70,028 386 500
DRG000044394 Retinol ( Vit A ) 100.000 IU kapsul kapsul Rp 585.0 - 0 - - - - - - - - 350 (7 btl)
DRG000044395 Retinol ( Vit A ) 200.000 IU kapsul kapsul Rp 519.2 - 0 - - - - - - - - 2075 (41 btl)
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 219 0 219 30 1,920 - - 189 12,096 (117)
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 970 0 970 10 770 - - 960 73,920 (936)
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 1,290 0 1,290 50 24,600 - - 1,240 610,080 (1,120)
DRG000007256 Sefadroxil syp kering 125 ml / 5 ml botol Rp 4,086.0 146 0 146 - - - - 146 596,556 (146)
119
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 1,820 0 1,820 270 29,700 - - 1,550 170,500 (902)
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 180 800 980 180 15,840 - - 800 70,400 (368)
DRG000042321 Triheksilfenidil hidroklorida tablet 2 mg tablet Rp 95.0 610 200 810 155 14,725 - - 655 62,225 (283) 200
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 2,360 0 2,360 1,461 197,235 - - 899 121,365 2,607 1500
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 499 300 799 220 132,880 - - 579 349,716 (51) 300
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - - -
Acdat salep tube Rp 6,241.0 - 0 - - - - - - - - 50
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 0 200 - - - - 200 175,600 (200)
DRG000001574 Ambroxol sirup botol Rp 3,300.0 139 0 139 56 184,800 - - 83 273,900 51 400
DRG000001791 Ambroxol tablet tablet Rp 100.0 73 700 773 230 23,000 - - 543 54,300 9 1800
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 773 0 773 320 30,400 - - 453 43,035 315 600
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 23 20 43 3 10,926 - - 40 145,680 (33) 20
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 100 100 200 50 51,750 - - 150 155,250 (30) 100
DRG000003089 Apialis Drops botol Rp 21,175.0 - 0 - - - - - - - - 100
120
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 34 0 34 - - - - 34 1,122,000 (34) 100
DRG000003466 Arkavit tablet Rp 320.0 - 0 - - - - - - - - 2000
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 58 0 58 - - - - 58 8,932 (58)
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 45 100 145 - - - - 145 225,983 (145) 100
Asiklovir salep kulit tube Rp 3,699.3 35 0 35 5 18,497 - - 30 110,979 (18) 50
DRG000004142 Atrovent HFA kotak Rp 83,500.0 - 0 - - - - - - - - 10
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 - 0 - - - - - - - - 400
Baby Cough sirup botol Rp 3,999.6 68 0 68 20 79,992 - - 48 191,981 - 300
Buscopan tablet tablet Rp 3,100.0 200 200 400 10 31,000 - - 390 1,209,000 (366) 200
Cendo Lyteers tetes mata botol Rp 25,999.6 10 0 10 10 259,996 - - - - 24 20
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 - 200 200 110 280,500 - - 90 229,500 174 400
DRG000010471 Clopidogrel 75 mg tablet tablet Rp 1,469.0 203 90 293 - - - - 293 430,417 (293)
DRG000011365 Depakene sirup botol Rp 17,789.0 - 0 - - - - - - - -
DRG000011337 Depakote tablet tablet Rp 1,200.0 360 0 360 30 36,000 - - 330 396,000 (258)
121
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 109 90 199 20 6,320 - - 179 56,564 (131) 100
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 55 0 55 - - - - 55 59,015 (55) 200
Flukonazol tab 150 mg tablet Rp 24,200.0 - 0 - - - - - - - - 200
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 5 0 5 5 24,445 - - - - 12 50
Gemfibrozil 300 mg tablet Rp 428.0 600 0 600 - - - - 600 256,800 (600)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 21 0 21 12 29,990 - - 9 22,493 20 50
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 58 0 58 11 53,735 - - 47 229,595 (21) 50
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 35 0 35 4 13,996 - - 31 108,472 (21)
Glimepirid tab 2 mg tablet Rp 207.0 420 0 420 30 6,210 - - 390 80,730 (318)
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 1,492 0 1,492 470 42,300 - - 1,022 91,980 106 1000
122
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 370 300 670 90 76,499 - - 580 492,994 (364) 300
Hidrokortison krim 1% tube Rp 5,723.3 18 0 18 - - - - 18 103,019 (18)
Ichtyol salep tube Rp 6,200.0 43 0 43 - - - - 43 266,600 (43)
Interhistin tablet tablet Rp 880.0 160 200 360 - - - - 360 316,800 (360) 200
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 595 210 805 190 113,810 - - 615 368,385 (159)
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 152 0 152 3 79,497 - - 149 3,948,351 (142)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 800 0 800 - - - - 800 99,992 (800)
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 26 0 26 11 28,347 - - 15 38,655 11 25
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 - 50 50 - - - - 50 330,000 (50)
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 100 100 200 10 11,210 - - 190 212,990 (166) 100
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - 0 - - - - - - - - 100
Lanzoprazol tablet Rp 330.0 435 800 1,235 110 36,300 - - 1,125 371,250 (861) 800
DRG000023225 L-Bio sachet sachet Rp 4,033.3 372 0 372 - - - - 372 1,500,388 (372)
123
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023860 Livertran salep tube Rp 4,600.0 102 0 102 1 4,600 - - 101 464,600 (99)
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 985 0 985 64 172,410 - - 921 2,481,082 (767)
DRG000023935 Loperamida tablet tablet Rp 85.0 300 0 300 10 850 - - 290 24,650 (266)
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 - 100 100 - - - - 100 93,200 (100)
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 410 0 410 4 3,200 - - 406 324,800 (396)
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 305 0 305 305 198,250 - - - - 732 500
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 633 0 633 - - - - 633 62,667 (633)
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 1 3 4 - - - - 4 20,680 (4) 2
DRG000029080 Nopres 20 mg tablet tablet Rp 883.3 385 0 385 20 17,666 - - 365 322,405 (317)
Novastan sirup botol Rp 12,650.0 32 0 32 - - - - 32 404,800 (32)
Noza tablet tablet Rp 797.5 639 0 639 16 12,760 - - 623 496,843 (585)
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 246 0 246 16 79,992 - - 230 1,149,885 (192)
124
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 - 0 - - - - - - - - 50
DRG000032133 Pedialyte botol Rp 31,999.0 94 0 94 1 31,999 - - 93 2,975,907 (91)
DRG000002552 Pil KB I tablet Rp 1,350.0 182 100 282 137 184,950 - - 145 195,750 184 100
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - 0 - - - - - - - - 100
Pim-Tra-Kol sirup botol Rp 9,999.0 - 0 - - - - - - - - 100
PP Isoniazide 100 mg tablet Rp 79.0 - 0 - - - - - - - - 100
Prenatin DF tablet tablet Rp 3,258.3 500 0 500 - - - - 500 1,629,150 (500)
DRG000034697 Primolut N tablet Rp 2,618.0 - 0 - - - - - - - - 100
Pularex tablet tablet Rp 175.0 408 0 408 65 11,375 - - 343 60,025 (187) 500
125
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000036698 Ringer laktat larutan infus steril botol Rp 7,150.0 4 0 4 1 7,150 3 21,450 - - 2 5
DRG000037347 Risperidon 2 mg tab tablet Rp 273.0 - 100 100 - - - - 100 27,300 (100)
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 261 0 261 21 126,611 - - 240 1,446,984 (190)
Sangobion Kids Sirup botol Rp 24,515.7 - 0 - - - - - - - - 100
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 41 0 41 2 22,950 - - 39 447,525 (34)
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 452 0 452 282 648,318 170 390,830 - - 677
DRG000038259 Sefiksim syr kering 100mg/5ml botol Rp 5,710.0 100 0 100 1 5,710 - - 99 565,290 (97)
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 35 50 85 67 200,531 - - 18 53,874 143 100
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 - 300 300 270 26,190 - - 30 2,910 618 300
Stimuno Sirup botol Rp 18,500.0 - 0 - - - - - - - - 100
DRG000040195 Synarcus krim tube Rp 2,534.0 114 0 114 1 2,534 - - 113 286,342 (111)
126
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Tensigard tablet tablet Rp 1,063.3 - 0 - - - - - - - -
DRG000041013 Tetagam ampul Rp 176,800.0 - 1 1 - - - - 1 176,800 (1)
DRG000042713 Truvit drops botol Rp 36,499.1 - 0 - - - - - - - - 200
Truvit sirup botol Rp 11,400.0 - 0 - - - - - - - - 100
DRG000042887 Ulsafate sirup botol Rp 9,192.0 39 0 39 - - - - 39 358,488 (39)
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 170 0 170 10 18,150 - - 160 290,400 (136) 100
Vastral tablet Rp 605.0 - 300 300 - - - - 300 181,500 (300) 1000
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,485 700 2,185 500 24,500 - - 1,685 82,565 (485) 700
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 - 100 100 - - - - 100 328,500 (100) 100
- 0 - - - - - - - -
II.OBAT GIGI - 0 - - - - - - - -
127
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 1 1 2 2 505,900 - - - - 5 1
MDVx009212 Cotton roll pack Rp 75,000.0 2 0 2 - - - - 2 150,000 (2)
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 0 1 - - - - 1 164,950 (1)
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 2 0 2 - - - - 2 1,287,000 (2)
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 - 1 1 1 75,240 - - - - 2 1
DRG001BJM Scandonest pcs Rp 17,622.0 - 0 - - - - - - - - 2
128
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
SBx140 Tambalan sinar solare A3 kotak Rp 256,731.0 1 0 1 - - - - 1 256,731 (1) 1
0 Tambalan sinar solare A3,5 kotak Rp 420,200.0 - 0 - - - - - - - - 1
0 Tampon pack Rp 300,000.0 4 0 4 1 300,000 - - 3 900,000 (1)
0 Topical anastesi pasta kotak Rp 302,500.0 4 0 4 1 302,500 - - 3 907,500 (1)
- 0 - - - - - - - -
III. BMHP - 0 - - - - - - - -
MDVx002305 Blood Lancet pcs Rp 176.0 550 0 550 100 17,600 - - 450 79,200 (210) 100
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - - 2 279,000 (2)
129
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Deck glass / objek glass 22 x 22 mm pack Rp 52,300.0 - 2 2 2 104,600 - - - - 5
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - - -
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - - -
MDVx026876 Infusiun set dewasa pcs Rp 4,176.0 3 0 3 1 4,176 - - 2 8,352 0
MDVx022261 Jelly (Aquagel) botol Rp 31,027.3 5 0 5 1 31,027 - - 4 124,109 (2)
130
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 0 80 - - - - 80 200,000 (80)
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 23 0 23 - - - - 23 45,121 (23)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 - 0 - - - - - - - -
MDVx013360 Kertas Thermal roll Rp 94,500.0 - 1 1 - - - - 1 94,500 (1)
0 Klorin botol Rp 15,970.0 48 0 48 - - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 736 0 736 36 25,801 - - 700 501,690 (614)
Markerpen pcs Rp 1.0 70 0 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 - 20 20 - - - - 20 390,000 (20) 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - - -
MDVx000733 Obyek glass* biasa pack Rp 37,446.0 - 2 2 2 74,892 - - - - 5
0 Pharmafix pcs Rp 27,000.0 7 0 7 - - - - 7 189,000 (7)
131
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - 50 50 - - - - 50 134,220 (50)
0 safety box* pcs Rp 16,500.0 91 0 91 - - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 0 300 - - - - 300 495,000 (300)
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - 0 - - - - - - - - 3
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 5 0 5 1 8,355 - - 4 33,420 (2)
0 Surgical Gloves non steril uk L pcs Rp 462.0 700 0 700 - - - - 700 323,400 (700)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 400 200 600 200 74,800 - - 400 149,600 80 200
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 700 200 900 200 92,400 - - 700 323,400 (220) 200
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 1,850 500 2,350 400 184,800 - - 1,950 900,900 (990) 500
MDVx000518 Tabung EDTA K-3 pcs Rp 1,690.9 - 100 100 100 169,090 - - - - 240
0 Tabung EdtA K-3 micro 0,5 cc pcs Rp 2,445.0 - 100 100 100 244,500 - - - - 240
132
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - - -
IV. REAGEN - 0 - - - - - - - -
0 Aquadest steril botol Rp 22,000.0 1 0 1 - - - - 1 22,000 (1)
133
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - - -
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 1 0 1 - - - - 1 2,050,000 (1) 1
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 - 0 - - - - - - - - 1
134
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 100 0 100 - - - - 100 1,434,400 (100)
135
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 RPR syfilis Fokus Diagnostik botol Rp 4,250 - 1 1 1 4,250 - - - - 2
RPR syfilis "Human" botol Rp 5,684 1 0 1 - - - - 1 5,684 (1)
136
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 - 0 - - - - - - - - 50
0 Stik asam urat Nesco stik Rp 5,258 - 0 - - - - - - - -
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 20 0 20 - - - - 20 437,800 (20) 50
0 Stik Cholesterol Nesco stik Rp 24,090 - 0 - - - - - - - -
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 0 15 - - - - 15 108,570 (15)
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - 0 - - - - - - - -
MDVx133BJM Stik HB Easy touch stik Rp 6,688 150 0 150 - - - - 150 1,003,200 (150) 50
0 Stik HBSAg merek SD stik Rp 9,870 - 100 100 - - - - 100 987,000 (100)
Stik HBSAg merek Intec stik Rp 9,850 300 0 300 - - - - 300 2,955,000 (300)
0 Stik syphilis 'SD' stik Rp 35,429 - 0 - - - - - - - -
Stik syphilis 'Monotest' stik Rp 10,758 - 0 - - - - - - - -
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - 0 - - - - - - - -
0 Ziehl Nielseen Stain paket Rp 273,978 - 1 1 - - - - 1 273,978 (1) 1
Pil KB BKKBN 717 0 717 - - - - 717 - (717)
Suntik KB 3 bulan BKKBN 35 100 135 17 - - - 118 - (77)
Kondom BKKBN 4 200 204 - - - - 204 - (204)
Spuit 3cc BKKBN 35 100 135 33 - - - 102 - (102)
Stik sifilis AB - 1 1 1 - - - - - -
Bacitracin Salep Kulit - 25 25 6 - - - 19 - (19)
137
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 7,525,307 104,050,474
UMUM
JUMLAH
887 259 1146

NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19680616 198911 1 001 NIP.19840410 200803 1 002
138
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000000983 Albendazol tablet 400 mg tablet Rp 323.0 - 3900 3,900 3,900 1,259,700 - - - 9,360
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 639 0 639 70 6,930 - 569 56,331 (401)
Aminofilin tablet 200 mg tablet Rp 86.0 640 0 640 20 1,720 - 620 53,320 (572)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 2,130 3000 5,130 1,972 149,872 - 3,158 240,008 1,575 3000
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 1,768 0 1,768 731 181,288 - 1,037 257,176 717
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 - 0 - - - - - - -
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 2,622 0 2,622 1,410 78,960 - 1,212 67,872 2,172 1500
DRG000002883 Antasida sirup botol Rp 2,098.0 26 0 26 12 25,176 - 14 29,372 15 50
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 - 500 500 500 60,000 - - - 1,200 1000
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 470 500 970 130 10,530 - 840 68,040 (528)
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 91 0 91 17 23,341 - 74 101,602 (33)
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 1,448 0 1,448 139 4,726 - 1,309 44,506 (975)
139
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 - 0 - - - - - - -
DRG000012719 Domperidon 10 mg tablet Rp 90.0 417 0 417 60 5,400 - 357 32,130 (213)
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 3,435 3000 6,435 1,285 70,675 - 5,150 283,250 (2,066) 3000
DRG000015698 Fitomenadion ( vit k 1 ) tablet salut 10 mg tablet Rp 818.0 556 200 756 30 24,540 - 726 593,868 (654) 200
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 670 0 670 - - - 670 52,930 (670)
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 264 0 264 175 73,150 - 89 37,202 331 200
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 - 200 200 - - - 200 44,600 (200)
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 395 0 395 30 1,680 - 365 20,440 (293)
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 597 0 597 10 1,630 - 587 95,681 (563)
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 1,855 0 1,855 140 15,680 - 1,715 192,080 (1,379)
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 440 0 440 250 73,000 - 190 55,480 410
140
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 1,521 0 1,521 30 3,300 - 1,491 164,010 (1,419)
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 240 300 540 60 14,040 - 480 112,320 (336) 300
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 - 300 300 - - - 300 85,800 (300) 300
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 620 0 620 10 2,750 - 610 167,750 (586)
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 59 0 59 - - - 59 293,938 (59)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 3,783 0 3,783 712 17,088 - 3,071 73,704 (1,362)
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 - 0 - - - - - - - 400
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 170 0 170 - - - 170 111,690 (170)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 451 0 451 - - - 451 56,375 (451) 500
DRG000023410 Lidocain injeksi 2 % ampul Rp 1,319.0 - 0 - - - - - - -
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 86 0 86 2 2,634 - 84 110,628 (79)
DRG000023922 Loratadin tablet tablet Rp 127.0 - 0 - - - - - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 187 300 487 145 14,790 - 342 34,884 6 300
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 130 0 130 - - - 130 35,594 (130)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 1,044 0 1,044 170 28,050 - 874 144,210 (466) 300
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 770 0 770 35 2,905 - 735 61,005 (651)
DRG000025793 Metronidazol tablet 250 mg tablet Rp 94.0 - 0 - - - - - - -
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 1,129 0 1,129 50 10,150 - 1,079 219,037 (959)
DRG000025979 Miconazol krim tube Rp 2,577.0 126 0 126 2 5,154 - 124 319,548 (119)
141
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 15 500 515 - - - 515 73,130 (515) 500
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 1,895 1000 2,895 720 97,920 - 2,175 295,800 (447) 1000
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 119 0 119 - - - 119 76,755 (119)
Obat antituberkulosis anak paket Rp 267,400.0 1 0 1 - - - 1 267,400 (1)
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 4 0 4 - - - 4 1,655,916 (4) 4
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 1 0 1 - - - 1 1,492,574 (1) 3
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 - 900 900 655 90,390 - 245 33,810 1,327 600
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 3,300 1000 4,300 4,096 245,760 - 204 12,240 9,626 4500
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 100 700 800 370 52,170 - 430 60,630 458 400
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 880 0 880 203 36,845 - 677 122,876 (190)
DRG000035403 Ranitidin tablet tablet Rp 122.0 1,100 0 1,100 580 70,760 - 520 63,440 872 600
DRG000044395 Retinol ( Vit A ) 200.000 IU kapsul kapsul Rp 519.2 - 2100 2,100 2,100 1,090,320 - - - 5,040
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 189 0 189 70 4,480 - 119 7,616 49
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 960 0 960 20 1,540 - 940 72,380 (892)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 59 0 59 10 30,170 - 49 147,833 (25)
142
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 1,550 0 1,550 490 53,900 - 1,060 116,600 116
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 800 0 800 470 41,360 - 330 29,040 798 500
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 899 1500 2,399 1,199 161,865 - 1,200 162,000 1,678 1200
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 579 0 579 280 169,120 - 299 180,596 373 300
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 0 200 - - - 200 175,600 (200)
Alprazolam 1 mg tablet Rp 120.0 - 0 - - - - - - -
DRG000001574 Ambroxol sirup botol Rp 3,300.0 83 0 83 14 46,200 - 69 227,700 (35) 400
DRG000001791 Ambroxol tablet tablet Rp 100.0 543 0 543 543 54,300 - - - 1,303 1800
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 453 0 453 402 38,190 - 51 4,845 914 600
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 40 20 60 21 76,482 - 39 142,038 11 20
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 150 100 250 40 41,400 - 210 217,350 (114) 100
DRG000003089 Apialis Drops botol Rp 21,175.0 - 0 - - - - - - - 100
143
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 34 0 34 - - - 34 1,122,000 (34) 100
DRG000003393 Aqua proinjeksi steril,bebas pirogen vial Rp 2,860.0 21 0 21 1 2,860 - 20 57,200 (18)
DRG000003466 Arkavit tablet Rp 320.0 - 0 - - - - - - - 2000
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 145 100 245 36 56,106 - 209 325,727 (123) 100
Asiklovir salep kulit tube Rp 3,699.3 30 50 80 4 14,797 - 76 281,147 (66) 50
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 - 0 - - - - - - - 400
Baby Cough sirup botol Rp 3,999.6 48 0 48 4 15,998 - 44 175,982 (34) 300
Buscopan tablet tablet Rp 3,100.0 390 0 390 40 124,000 - 350 1,085,000 (254) 200
Cendo Lyteers tetes mata botol Rp 25,999.6 - 0 - - - - - - - 20
DRG000011365 Depakene sirup botol Rp 17,789.0 - 0 - - - - - - -
DRG000011337 Depakote tablet tablet Rp 1,200.0 330 0 330 20 24,000 - 310 372,000 (262)
144
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 179 90 269 - - - 269 85,004 (269) 100
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 175 100 275 120 18,960 - 155 24,490 133 100
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 55 0 55 20 21,460 - 35 37,555 13 200
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 57 0 57 4 10,360 - 53 137,270 (43)
Flukonazol tab 150 mg tablet Rp 24,200.0 - 0 - - - - - - - 200
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 - 50 50 - - - 50 244,450 (50) 50
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 9 50 59 1 2,499 - 58 144,954 (56) 50
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 47 0 47 11 53,735 - 36 175,860 (10) 50
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 31 0 31 5 17,496 - 26 90,977 (14) 25
Glimepirid tab 2 mg tablet Rp 207.0 390 0 390 - - - 390 80,730 (390)
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 1,022 0 1,022 928 83,520 - 94 8,460 2,133 1000
145
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 580 300 880 435 369,746 - 445 378,246 599 500
Hidrokortison krim 1% tube Rp 5,723.3 18 0 18 - - - 18 103,019 (18)
Ichtyol salep tube Rp 6,200.0 43 0 43 - - - 43 266,600 (43) 25
Interhistin tablet tablet Rp 880.0 360 200 560 21 18,480 - 539 474,320 (489) 200
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 615 0 615 265 158,735 - 350 209,650 286
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 800 0 800 20 2,500 - 780 97,492 (732)
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 15 0 15 10 25,770 - 5 12,885 19 25
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 50 0 50 - - - 50 330,000 (50)
DRG000009409 Klorpromazin Hcl tablet salut 25 mg tablet Rp 250.0 - 0 - - - - - - - 500
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 190 100 290 10 11,210 - 280 313,880 (256)
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - 0 - - - - - - - 100
Lanzoprazol tablet Rp 330.0 1,125 800 1,925 145 47,850 - 1,780 587,400 (1,432)
DRG000023225 L-Bio sachet sachet Rp 4,033.3 372 0 372 78 314,597 174 701,794 120 483,996 67
146
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 921 0 921 102 274,778 - 819 2,206,304 (574)
DRG000023935 Loperamida tablet tablet Rp 85.0 290 0 290 80 6,800 - 210 17,850 (18)
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 100 0 100 - - - 100 93,200 (100)
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 406 0 406 335 268,000 - 71 56,800 733 300
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 - 0 - - - - - - - 500
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 633 0 633 10 990 - 623 61,677 (599)
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 4 2 6 3 15,510 - 3 15,510 4 3
Novastan sirup botol Rp 12,650.0 32 0 32 - - - 32 404,800 (32)
Noza tablet tablet Rp 797.5 623 0 623 18 14,355 - 605 482,488 (562)
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 230 0 230 17 84,992 - 213 1,064,894 (172)
147
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 - 50 50 - - - 50 110,000 (50) 50
DRG000002552 Pil KB I tablet Rp 1,350.0 145 100 245 166 224,100 - 79 106,650 319 100
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - 0 - - - - - - - 100
Pim-Tra-Kol sirup botol Rp 9,999.0 - 0 - - - - - - - 100
DRG000020429 Povidon Iodida larutan 10 % 30 ml botol Rp 3,190.0 11 0 11 1 3,190 - 10 31,900 (8)
PP Isoniazide 100 mg tablet Rp 79.0 - 0 - - - - - - - 100
Prenatin DF tablet tablet Rp 3,258.3 500 0 500 20 65,166 - 480 1,563,984 (432)
Pularex tablet tablet Rp 175.0 343 0 343 132 23,100 - 211 36,925 106 500
148
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000036698 Ringer laktat larutan infus steril botol Rp 7,150.0 - 5 5 - - - 5 35,750 (5) 5
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 240 0 240 72 434,095 - 168 1,012,889 5
Sangobion kids drop botol Rp 34,999.8 - 0 - - - - - - - 10
Sangobion Kids Sirup botol Rp 24,515.7 - 0 - - - - - - - 10
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 39 0 39 31 355,725 - 8 91,800 66 30
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 - 0 - - - - - - -
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 30 300 330 330 32,010 - - - 792 500
DRG000038671 Simpastatin 20 mg tablet tablet Rp 225.0 352 0 352 - - - 352 79,200 (352)
Stimuno Sirup botol Rp 18,500.0 - 0 - - - - - - - 100
DRG000040195 Synarcus krim tube Rp 2,534.0 113 0 113 2 5,068 - 111 281,274 (106)
149
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000041013 Tetagam ampul Rp 176,800.0 1 0 1 - - - 1 176,800 (1)
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 440 0 440 20 17,800 - 420 373,800 (372)
DRG000042713 Truvit drops botol Rp 36,499.1 - 0 - - - - - - - 200
Truvit sirup botol Rp 11,400.0 - 0 - - - - - - - 100
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 160 0 160 30 54,450 - 130 235,950 (58) 100
Vastral tablet Rp 605.0 300 0 300 90 54,450 - 210 127,050 6 1000
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 42 0 42 15 165,000 - 27 297,000 9
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,685 700 2,385 590 28,910 - 1,795 87,955 (379) 700
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 100 100 200 - - - 200 657,000 (200) 100
- 0 - - - - - - -
II.OBAT GIGI - 0 - - - - - - -
150
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 - 1 1 - - - 1 252,950 (1) 1
0 Cotton pelet pack Rp 247,500.0 4 0 4 - - - 4 990,000 (4)
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 0 1 - - - 1 164,950 (1) 3
0 G aenial bond kotak Rp 875,578.0 1 0 1 - - - 1 875,578 (1)
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 2 0 2 1 643,500 - 1 643,500 1 1
0 Jarum Dental cytoject pcs Rp 2,662.0 - 0 - - - - - - -
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 - 0 - - - - - - - 1
0 Oco Tooth Clensing botol Rp 191,999.0 4 0 4 - - - 4 767,996 (4)
151
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
SBx139 Tambalan sinar solare A2 kotak Rp 256,731.0 3 0 3 - - - 3 770,193 (3)
0 Tampon pack Rp 300,000.0 3 0 3 - - - 3 900,000 (3)
0 Topical anastesi pasta kotak Rp 302,500.0 3 0 3 1 302,500 - 2 605,000 0
- 0 - - - - - - -
III. BMHP - 0 - - - - - - -
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 467 0 467 100 165,100 - 367 605,917 (127)
DRG000001226 Alkohol Swab lembar Rp 105.0 1,000 0 1,000 - - - 1,000 105,000 (1,000)
0 Bioplacenton tulle pcs Rp 10,920.0 61 0 61 3 32,760 - 58 633,360 (51)
MDVx002305 Blood Lancet pcs Rp 176.0 450 100 550 100 17,600 - 450 79,200 (210) 100
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - 2 279,000 (2)
152
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx023244 Coverplast pcs Rp 470.0 2 0 2 - - - 2 940 (2) 3
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - -
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - -
MDVx022261 Jelly (Aquagel) botol Rp 31,027.3 4 0 4 - - - 4 124,109 (4)
153
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 0 80 - - - 80 200,000 (80) 50
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 23 0 23 23 45,121 - - - 55 20
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 - 0 - - - - - - -
SBx134 Kasa pembalut hidrofil 4m x 3 cm pcs Rp 613.5 59 0 59 1 614 - 58 35,583 (56)
MDVx013360 Kertas Thermal roll Rp 94,500.0 1 0 1 - - - 1 94,500 (1)
0 Klorin botol Rp 15,970.0 48 0 48 - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 700 0 700 132 94,604 - 568 407,086 (251) 200
Markerpen pcs Rp 1.0 70 0 - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 20 0 20 5 97,500 - 15 292,500 (3) 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - -
0 Pharmafix pcs Rp 27,000.0 7 0 7 - - - 7 189,000 (7)
154
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 50 0 50 - - - 50 134,220 (50)
0 safety box* pcs Rp 16,500.0 91 0 91 - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 0 300 - - - 300 495,000 (300)
MDVx001722 Spuit 0,5 ml pcs Rp 1,240.0 300 0 300 100 124,000 - 200 248,000 40
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - 0 - - - - - - - 3
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 4 0 4 - - - 4 33,420 (4)
0 Surgical Gloves non steril uk L pcs Rp 462.0 700 0 700 - - - 700 323,400 (700)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 400 200 600 300 112,200 - 300 112,200 420 300
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 700 200 900 500 231,000 - 400 184,800 800 500
MDVx003948 Surgical mask 3 ply tie on pcs Rp 462.0 253 0 253 200 92,400 - 53 24,486 427
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 1,950 500 2,450 350 161,700 - 2,100 970,200 (1,260) 500
155
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - -
IV. REAGEN - 0 - - - - - - -
156
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - -
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 1 0 1 - - - 1 2,050,000 (1) 1
0 M-30 E-Z Cleanser Mindray botol Rp 1,500,000.0 1 0 1 - - - 1 1,500,000 (1)
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 - 0 - - - - - - - 1
0 M-30 RINSE Mindray botol Rp 2,050,000.0 1 0 1 - - - 1 2,050,000 (1)
157
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 100 0 100 - - - 100 1,434,400 (100) 100
158
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
RPR syfilis "Human" botol Rp 5,684 1 0 1 - - - 1 5,684 (1)
159
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 - 0 - - - - - - - 75
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 20 0 20 - - - 20 437,800 (20) 100
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 0 15 - - - 15 108,570 (15) 100
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - 0 - - - - - - - 100
MDVx041511 Stik Gula Darah Accu cek stik Rp 8,327 - 0 - - - - - - - 200
MDVx133BJM Stik HB Easy touch stik Rp 6,688 150 0 150 - - - 150 1,003,200 (150) 50
0 Stik HBSAg merek SD stik Rp 9,870 100 0 100 - - - 100 987,000 (100)
0 Stik syphilis 'SD' stik Rp 35,429 - 0 - - - - - - - 100
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - 0 - - - - - - - 100
0 Widal tes 4 set 4 set Rp 291,640 1 0 1 - - - 1 291,640 (1) 1
0 Widal tes 6 set 6 set Rp 279,140 - 0 - - - - - - - 1
0 Ziehl Nielseen Stain paket Rp 273,978 1 1 2 1 273,978 - 1 273,978 1 1
Pil KB BKKBN 717 0 717 - - - 717 - (717)
Suntik KB 3 bulan BKKBN 118 0 118 35 - - 83 - 1
Kondom BKKBN 204 0 204 - - - 204 - (204)
IUD Copper T BKKBN 5 0 5 - - - 5 - (5)
Susuk dengan inserter (implan) BKKBN 5 0 5 - - - 5 - (5)
Spuit 3cc BKKBN 102 0 102 52 - - 50 - (50)
calcetin pasta (gigi) 1 0 1 - - - 1 - (1)
Stik sifilis AB - 0 - - - - - - - 100
Bacitracin Salep Kulit 19 0 19 12 - - 7 - (7)
160
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 12,150,395 99,298,346
UMUM
JUMLAH
975 354 1329

NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19680616 198911 1 001 NIP.19840410 200803 1 002
161
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 569 0 569 369 36,531 - - 200 19,800 686 400
Aminofilin tablet 200 mg tablet Rp 86.0 620 0 620 120 10,320 - - 500 43,000 (212)
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 3,158 1500 4,658 1,308 99,408 - - 3,350 254,600 (211) 4000
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 1,037 0 1,037 1,037 257,176 - - - - 2,489 3000
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 - 0 - - - - - - - -
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 1,212 1500 2,712 976 54,656 941 52,696 795 44,520 1,547 1500
DRG000002883 Antasida sirup botol Rp 2,098.0 14 0 14 14 29,372 - - - - 34 50
DRG000002996 Antifungi doen kombinasi tube Rp 5,170.0 14 0 14 10 51,700 - - 4 20,680 20
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 - 1000 1,000 210 25,200 - - 790 94,800 (286) 1000
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 840 0 840 340 27,540 - - 500 40,500 316 400
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 - 0 - - - - - - - - 2000
DRG000000605 Asiklovir 400 mg tablet tablet Rp 425.0 1,770 0 1,770 320 136,000 - - 1,450 616,250 (682)
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 74 0 74 74 101,602 - - - - 178 50
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 1,309 0 1,309 329 11,186 - - 980 33,320 (190) 500
162
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 370 100 470 125 15,125 - - 345 41,745 (45)
DRG000013853 Epinefrin Hcl/Bitartrat(adrenalin)inj 0,1 %-1 ml ampul Rp 1,518.0 10 0 10 2 3,036 - - 8 12,144 (3)
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 670 0 670 570 45,030 - - 100 7,900 1,268
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 89 200 289 240 100,320 - - 49 20,482 527 400
DRG000017435 Glimepirid tab 1 mg tablet Rp 194.0 530 0 530 230 44,620 - - 300 58,200 252 300
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 200 0 200 - - - - 200 44,600 (200)
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 380 200 580 180 9,900 - - 400 22,000 32 200
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 365 0 365 10 560 - - 355 19,880 (331)
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 587 0 587 187 30,481 - - 400 65,200 49
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 1,715 0 1,715 915 102,480 - - 800 89,600 1,396 1000
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 190 0 190 190 55,480 - - - - 456 1000
163
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 139 0 139 39 3,471 - - 100 8,900 (6)
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 1,491 0 1,491 491 54,010 - - 1,000 110,000 178
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 300 300 600 - - - - 600 171,600 (600)
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 59 0 59 1 4,982 20 99,640 38 189,316 (36)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 3,071 0 3,071 1,243 29,832 - - 1,828 43,872 1,155 1300
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 451 0 451 451 56,375 - - - - 1,082 500
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 84 0 84 2 2,634 - - 82 107,994 (77)
DRG000023922 Loratadin tablet tablet Rp 127.0 - 0 - - - - - - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 342 300 642 120 12,240 - - 522 53,244 (234) 200
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 130 0 130 30 8,214 - - 100 27,380 (28)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 874 300 1,174 274 45,210 - - 900 148,500 (242) 300
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 735 0 735 10 830 - - 725 60,175 (701)
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 1,079 0 1,079 179 36,337 - - 900 182,700 (470)
164
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 515 500 1,015 215 30,530 - - 800 113,600 (284) 300
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,175 1000 3,175 1,075 146,200 - - 2,100 285,600 480 1000
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 175 0 175 125 22,499 - - 50 9,000 250 300
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 119 0 119 69 44,505 - - 50 32,250 116
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 4 4 8 - - - - 8 3,311,832 (8)
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 245 600 845 300 41,400 - - 545 75,210 175
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 204 500 704 704 42,240 - - - - 1,690 5000
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 430 400 830 520 73,320 - - 310 43,710 938 500
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 677 0 677 51 9,257 500 90,750 126 22,869 (4)
DRG000035403 Ranitidin tablet tablet Rp 122.0 920 0 920 720 87,840 - - 200 24,400 1,528 1000
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 119 100 219 30 1,920 - - 189 12,096 (117)
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 940 700 1,640 140 10,780 - - 1,500 115,500 (1,164)
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 1,180 0 1,180 280 137,760 - - 900 442,800 (228)
DRG000007256 Sefadroxil syp kering 125 ml / 5 ml botol Rp 4,086.0 143 0 143 43 175,698 - - 100 408,600 3
165
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 1,060 0 1,060 120 13,200 - - 940 103,400 (652)
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 330 500 830 280 24,640 - - 550 48,400 122 300
DRG000042321 Triheksilfenidil hidroklorida tablet 2 mg tablet Rp 95.0 575 200 775 220 20,900 - - 555 52,725 (27) 300
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 1,200 1200 2,400 1,933 260,955 - - 467 63,045 4,172 2500
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 299 500 799 399 240,996 - - 400 241,600 558 400
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 0 200 200 175,600 - - - - 480 200
DRG000001574 Ambroxol sirup botol Rp 3,300.0 69 0 69 - - - - 69 227,700 (69) 400
DRG000001791 Ambroxol tablet tablet Rp 100.0 - 0 - - - - - - - - 1800
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 51 0 51 51 4,845 - - - - 122 3000
166
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 58 0 58 58 8,932 - - - - 139
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 209 100 309 109 169,877 - - 200 311,700 62 100
Baby Cough sirup botol Rp 3,999.6 44 0 44 44 175,982 - - - - 106 300
Bisoprolol tablet 5 mg tablet Rp 248.0 180 0 180 80 19,840 - - 100 24,800 92 200
Buscopan tablet tablet Rp 3,100.0 350 0 350 50 155,000 - - 300 930,000 (180) 200
Cendo Lyteers tetes mata botol Rp 25,999.6 - 0 - - - - - - - - 20
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 10 0 10 10 25,500 - - - - 24 400
167
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 269 0 269 19 6,004 - - 250 79,000 (204) 100
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 35 0 35 35 37,555 - - - - 84 200
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 50 50 100 - - - - 100 488,900 (100) 50
Gemfibrozil 300 mg tablet Rp 428.0 580 0 580 220 94,160 - - 360 154,080 168 300
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 58 0 58 1 2,499 - - 57 142,454 (55) 50
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 26 0 26 - - - - 26 90,977 (26) 25
Glimepirid tab 2 mg tablet Rp 207.0 390 0 390 - - - - 390 80,730 (390) 300
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 94 0 94 94 8,460 - - - - 226 1000
168
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Ichtyol salep tube Rp 6,200.0 43 25 68 7 43,400 24 148,800 37 229,400 (20)
DRG000006804 Kalsium laktat ( Kalk ) tablet 500 mg tablet Rp 59.0 4,912 0 4,912 1,212 71,508 - - 3,700 218,300 (791)
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 350 0 350 290 173,710 - - 60 35,940 636 500
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 139 0 139 7 185,493 90 2,384,910 42 1,112,958 (25)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 780 0 780 480 59,995 - - 300 37,497 852 500
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 5 25 30 2 5,154 - - 28 72,156 (23) 25
DRG000009337 Klobazam 10 mg tablet tablet Rp 872.0 178 0 178 65 56,680 - - 113 98,536 43
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 50 0 50 2 13,200 - - 48 316,800 (43)
Lanzoprazol tablet Rp 330.0 1,780 0 1,780 85 28,050 - - 1,695 559,350 (1,491)
DRG000023225 L-Bio sachet sachet Rp 4,033.3 120 0 120 - - 120 483,996 - - -
169
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023860 Livertran salep tube Rp 4,600.0 101 0 101 1 4,600 24 110,400 76 349,600 (74)
DRG000023935 Loperamida tablet tablet Rp 85.0 210 0 210 151 12,835 - - 59 5,015 303 500
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 100 0 100 - - - - 100 93,200 (100)
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 71 0 71 71 56,800 - - - - 170 300
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 - 0 - - - - - - - - 500
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 623 0 623 323 31,977 - - 300 29,700 475 300
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 3 3 6 1 5,170 - - 5 25,850 (3) 5
DRG000029080 Nopres 20 mg tablet tablet Rp 883.3 335 0 335 - - - - 335 295,906 (335)
Novastan sirup botol Rp 12,650.0 32 0 32 10 126,500 22 278,300 - - 24
Noza tablet tablet Rp 797.5 605 0 605 480 382,800 - - 125 99,688 1,027 500
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 213 0 213 93 464,954 - - 120 599,940 103 100
170
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 50 50 100 14 30,800 - - 86 189,200 (52) 50
DRG000002552 Pil KB I tablet Rp 1,350.0 79 0 79 19 25,650 - - 60 81,000 (14) 100
Pularex tablet tablet Rp 175.0 211 500 711 211 36,925 - - 500 87,500 6 500
171
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000036698 Ringer laktat larutan infus steril botol Rp 7,150.0 5 5 10 1 7,150 - - 9 64,350 (7) 5
DRG000037347 Risperidon 2 mg tab tablet Rp 273.0 100 0 100 - - - - 100 27,300 (100)
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 168 0 168 21 126,611 - - 147 886,278 (97)
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 - 0 - - - - - - - - 30
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 - 0 - - - - - - - -
DRG000038259 Sefiksim syr kering 100mg/5ml botol Rp 5,710.0 94 0 94 - - - - 94 536,740 (94)
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 23 200 223 61 182,573 - - 162 484,866 (16) 200
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 - 500 500 70 6,790 - - 430 41,710 (262) 500
DRG000038671 Simpastatin 20 mg tablet tablet Rp 225.0 352 0 352 - - - - 352 79,200 (352)
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 12 0 12 - - 12 173,508 - - - 5
DRG000040195 Synarcus krim tube Rp 2,534.0 111 0 111 - - - - 111 281,274 (111)
172
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Taburia sachet Rp 1,000.0 - 1170 1,170 1,170 1,170,000 - - - - 2,808
Tensigard tablet tablet Rp 1,063.3 - 0 - - - - - - - - 500
DRG000041013 Tetagam ampul Rp 176,800.0 1 0 1 - - - - 1 176,800 (1)
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 420 0 420 20 17,800 - - 400 356,000 (352)
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 130 0 130 10 18,150 120 217,800 - - 24 100
Vastral tablet Rp 605.0 210 0 210 210 127,050 - - - - 504 1000
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,795 700 2,495 1,110 54,390 - - 1,385 67,865 1,279 1000
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 200 100 300 50 164,250 - - 250 821,250 (130)
- 0 - - - - - - - -
II.OBAT GIGI - 0 - - - - - - - -
173
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 1 1 2 - - - - 2 505,900 (2) 1
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 1 0 1 1 164,950 - - - - 2
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 1 0 1 - - - - 1 643,500 (1) 1
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 - 0 - - - - - - - - 1
174
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Tampon pack Rp 300,000.0 3 0 3 - - - - 3 900,000 (3)
0 Topical anastesi pasta kotak Rp 302,500.0 2 0 2 - - - - 2 605,000 (2)
- 0 - - - - - - - -
III. BMHP - 0 - - - - - - - -
MDVx001732 Alat suntik sekali pakai 3 ml pcs Rp 1,138.0 274 0 274 106 120,628 - - 168 191,184 86
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 367 0 367 1 1,651 - - 366 604,266 (364)
MDVx001793 Alat suntik sekali pakai 10 ml pcs Rp 1,095.3 100 0 100 - - - - 100 109,529 (100) 10
MDVx000796 Bistruri/scalpel balde No 10 pcs Rp 3,300.0 80 0 80 1 3,300 - - 79 260,700 (77)
MDVx002305 Blood Lancet pcs Rp 176.0 450 100 550 100 17,600 - - 450 79,200 (210) 100
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - - 2 279,000 (2)
175
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - - -
0 Hypafix uk. Kecil 5 cm x 5 m pcs Rp 98,900.0 8 0 8 1 98,900 - - 7 692,300 (5)
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - - -
0 Infusiun set anak pcs Rp 2,970.0 2 0 2 1 2,970 - - 1 2,970 1
MDVx001152 Jarum (Needle) no 23 pcs Rp 400.0 100 0 100 2 800 - - 98 39,200 (93)
176
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 0 80 - - - - 80 200,000 (80) 50
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 - 20 20 3 5,885 - - 17 33,351 (10) 10
SBx134 Kasa pembalut hidrofil 4m x 3 cm pcs Rp 613.5 58 0 58 2 1,227 - - 56 34,356 (51)
MDVx013360 Kertas Thermal roll Rp 94,500.0 1 0 1 - - - - 1 94,500 (1)
0 Klorin botol Rp 15,970.0 48 0 48 - - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 568 288 856 132 94,604 - - 724 518,891 (407) 200
Markerpen pcs Rp 1.0 70 0 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 15 20 35 - - - - 35 682,500 (35) 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - - -
MDVx000733 Obyek glass* biasa pack Rp 37,446.0 - 0 - - - - - - - -
0 Pharmafix pcs Rp 27,000.0 7 0 7 - - - - 7 189,000 (7)
177
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 50 0 50 - - - - 50 134,220 (50)
0 safety box* pcs Rp 16,500.0 91 0 91 - - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 300 0 300 100 165,000 - - 200 330,000 40 200
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 4 0 4 - - - - 4 33,420 (4)
MDVx002389 Surgical Glove No 6,5 pcs Rp 20,006.7 85 0 85 1 20,007 - - 84 1,680,563 (82)
0 Surgical Glove No 8 pcs Rp 5,000.0 93 0 93 7 35,000 - - 86 430,000 (69)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 300 300 600 100 37,400 - - 500 187,000 (260) 300
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 400 500 900 300 138,600 - - 600 277,200 120 500
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,100 500 2,600 150 69,300 - - 2,450 1,131,900 (2,090) 500
MDVx010040 Surgikal Gloves No 7.5 pcs Rp 4,600.0 164 0 164 1 4,600 - - 163 749,800 (161)
MDVx000518 Tabung EDTA K-3 pcs Rp 1,690.9 - 0 - - - - - - - -
0 Tabung EdtA K-3 micro 0,5 cc pcs Rp 2,445.0 - 0 - - - - - - - -
178
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - - -
IV. REAGEN - 0 - - - - - - - -
179
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - - -
180
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 100 0 100 100 1,434,400 - - - - 240 100
181
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 RPR syfilis Fokus Diagnostik botol Rp 4,250 - 0 - - - - - - - -
182
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Stik asam urat Nesco stik Rp 5,258 - 0 - - - - - - - - 50
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 20 0 20 20 437,800 - - - - 48 100
0 Stik Cholesterol Nesco stik Rp 24,090 - 0 - - - - - - - - 100
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 15 0 15 15 108,570 - - - - 36 100
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - 0 - - - - - - - - 100
MDVx133BJM Stik HB Easy touch stik Rp 6,688 150 0 150 - - - - 150 1,003,200 (150) 50
0 Stik HBSAg merek SD stik Rp 9,870 100 0 100 - - - - 100 987,000 (100)
0 Stik syphilis 'SD' stik Rp 35,429 - 100 100 - - - - 100 3,542,900 (100)
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - 0 - - - - - - - - 100
0 Widal tes 6 set 6 set Rp 279,140 - 0 - - - - - - - - 1
0 Ziehl Nielseen Stain paket Rp 273,978 1 1 2 1 273,978 - - 1 273,978 1 1
Pil KB BKKBN 717 0 717 20 - - - 697 - (649)
Kondom BKKBN 204 0 204 - - - - 204 - (204)
Spuit 3cc BKKBN 50 0 50 36 - - - 14 - (14)
Stik sifilis AB - 100 100 100 - - - - - -
Bacitracin Salep Kulit 7 0 7 7 - - - - - -
183
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 12,759,919 100,146,007
UMUM
JUMLAH
938 341 1279

Dr. Machli Riyadi, S.H., M.H. Yohana Rusnayuda, S.Si., Apt. dr. Renate., M.Kes. M. Ary Aprian Noor, S.Far., Apt.
NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19790902 200903 2 006 NIP.19840410 200803 1 002
184
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 200 400 600 10 990 - - 590 58,410 (566) 400
Aminofilin tablet 200 mg tablet Rp 86.0 500 0 500 - - 500 43,000 - - -
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 3,350 0 3,350 1,720 130,720 - - 1,630 123,880 2,498 4000
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 - 3000 3,000 930 230,640 - - 2,070 513,360 162 3000
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 - 0 - - - - - - - - 300
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 795 1500 2,295 1,075 60,200 - - 1,220 68,320 1,360 1500
DRG000002883 Antasida sirup botol Rp 2,098.0 - 50 50 5 10,490 - - 45 94,410 (33) 50
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 790 1000 1,790 1,259 151,080 - - 531 63,720 2,491 1000
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 500 400 900 150 12,150 - - 750 60,750 (390) 400
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 - 2000 2,000 50 5,100 - - 1,950 198,900 (1,830) 2000
DRG000003731 Asiklovir 200 mg tablet tablet Rp 236.0 1,800 0 1,800 - - - - 1,800 424,800 (1,800)
DRG000000605 Asiklovir 400 mg tablet tablet Rp 425.0 1,450 0 1,450 - - - - 1,450 616,250 (1,450)
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 - 50 50 37 50,801 - - 13 17,849 76 50
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 980 500 1,480 326 11,084 - - 1,154 39,236 (372) 500
185
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 345 0 345 250 30,250 - - 95 11,495 505
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 100 0 100 - - - - 100 7,900 (100)
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 49 400 449 129 53,922 - - 320 133,760 (10) 400
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 355 0 355 120 6,720 - - 235 13,160 53
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 800 1000 1,800 1,267 141,904 - - 533 59,696 2,508 1000
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 - 0 - - - - - - - - 1000
186
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 100 0 100 10 890 - - 90 8,010 (66)
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 1,000 0 1,000 270 29,700 - - 730 80,300 (82)
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 600 0 600 40 11,440 - - 560 160,160 (464)
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 - 400 400 40 5,920 - - 360 53,280 (264) 400
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 - 500 500 - - - - 500 62,500 (500) 500
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 725 0 725 - - - - 725 60,175 (725)
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 900 0 900 10 2,030 - - 890 180,670 (866)
187
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 800 300 1,100 - - - - 1,100 156,200 (1,100) 1000
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,100 1000 3,100 270 36,720 - - 2,830 384,880 (2,182)
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 50 0 50 6 3,870 - - 44 28,380 (30)
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 8 0 8 - - - - 8 3,311,832 (8)
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 4 0 4 1 1,492,574 - - 3 4,477,722 (1)
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 545 0 545 160 22,080 - - 385 53,130 (1)
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 - 5000 5,000 - - - - 5,000 300,000 (5,000) 5000
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 310 500 810 195 27,495 - - 615 86,715 (147) 500
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 126 0 126 - - - - 126 22,869 (126)
DRG000035403 Ranitidin tablet tablet Rp 122.0 200 0 200 200 24,400 - - - - 480 1000
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 189 0 189 110 7,040 - - 79 5,056 185 1000
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,500 0 1,500 34 2,618 - - 1,466 112,882 (1,384)
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 900 0 900 100 49,200 - - 800 393,600 (560)
188
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 467 2500 2,967 2,018 272,430 - - 949 128,115 3,894 2500
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 400 400 800 70 42,280 - - 730 440,920 (562) 400
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 - 200 200 - - - - 200 175,600 (200) 200
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 - 0 - - - - - - - - 3000
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 51 20 71 - - - - 71 258,582 (71) 20
189
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 - 0 - - - - - - - - 300
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 200 100 300 55 85,718 - - 245 381,833 (113) 100
Baby Cough sirup botol Rp 3,999.6 - 0 - - - - - - - - 300
Bisoprolol tablet 5 mg tablet Rp 248.0 100 200 300 - - - - 300 74,400 (300) 200
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 - 0 - - - - - - - - 400
DRG000010471 Clopidogrel 75 mg tablet tablet Rp 1,469.0 240 0 240 - - - - 240 352,560 (240)
190
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 250 30 280 10 3,160 - - 270 85,320 (246)
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 - 0 - - - - - - - - 200
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 48 0 48 1 2,590 - - 47 121,730 (45) 50
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 100 50 150 - - - - 150 733,350 (150)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 57 0 57 - - - - 57 142,454 (57) 50
Glimepirid tab 2 mg tablet Rp 207.0 390 0 390 10 2,070 - - 380 78,660 (356) 300
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 - 0 - - - - - - - - 2000
191
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 600 0 600 545 463,245 - - 55 46,749 1,253 3000
Ichtyol salep tube Rp 6,200.0 37 0 37 - - 7 43,400 30 186,000 (30)
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 42 0 42 7 185,493 - - 35 927,465 (18)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 300 500 800 40 5,000 - - 760 94,992 (664) 500
DRG000009337 Klobazam 10 mg tablet tablet Rp 872.0 113 0 113 30 26,160 - - 83 72,376 (11) 200
DRG000023225 L-Bio sachet sachet Rp 4,033.3 - 0 - - - - - - - -
192
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023860 Livertran salep tube Rp 4,600.0 76 0 76 6 27,600 70 322,000 - - 14 25
DRG000023935 Loperamida tablet tablet Rp 85.0 59 0 59 59 5,015 - - - - 142 500
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 - 0 - - - - - - - - 300
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 300 0 300 - - - - 300 29,700 (300) 500
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 5 5 10 - - - - 10 51,700 (10)
DRG000028637 Nistatin 500.000 iu /g tablet salut tablet Rp 910.0 - 0 - - - - - - - - 50
novadium tablet Rp 200.0 - 500 500 - - - - 500 100,000 (500)
Novastan sirup botol Rp 12,650.0 - 0 - - - - - - - -
Noza tablet tablet Rp 797.5 125 0 125 8 6,380 - - 117 93,308 (98) 500
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 120 0 120 119 594,941 - - 1 5,000 285 100
193
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 86 50 136 15 33,000 - - 121 266,200 (85) 50
DRG000002552 Pil KB I tablet Rp 1,350.0 60 100 160 60 81,000 - - 100 135,000 44 100
Pularex tablet tablet Rp 175.0 500 500 1,000 12 2,100 - - 988 172,900 (959)
194
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 147 0 147 25 150,728 - - 122 735,550 (62)
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 162 200 362 44 131,692 - - 318 951,774 (212) 200
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 430 500 930 165 16,005 - - 765 74,205 (369) 500
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 - 5 5 - - - - 5 72,295 (5) 5
195
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 - 100 100 - - - - 100 181,500 (100) 100
Vastral tablet Rp 605.0 - 0 - - - - - - - - 1000
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 24 0 24 - - - - 24 264,000 (24)
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,385 1000 2,385 600 29,400 - - 1,785 87,465 (345) 1000
- 0 - - - - - - - -
II.OBAT GIGI - 0 - - - - - - - -
196
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 2 1 3 - - - - 3 758,850 (3) 1
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 - 0 - - - - - - - -
197
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Tampon pack Rp 300,000.0 3 0 3 - - - - 3 900,000 (3)
- 0 - - - - - - - -
III. BMHP - 0 - - - - - - - -
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 366 0 366 1 1,651 - - 365 602,615 (363)
0 Bioplacenton tulle pcs Rp 10,920.0 52 0 52 - - - - 52 567,840 (52)
MDVx002305 Blood Lancet pcs Rp 176.0 450 100 550 - - - - 550 96,800 (550) 100
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - - 2 279,000 (2)
198
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx023244 Coverplast pcs Rp 470.0 2 300 302 - - - - 302 141,940 (302) 3
MDVx018887 Disposibel vagina speculum pcs Rp 7,500.0 - 75 75 75 562,500 - - - - 180
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - - -
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - - -
199
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 17 10 27 - - - - 27 52,969 (27) 10
0 Klorin botol Rp 15,970.0 48 0 48 - - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 724 288 1,012 96 68,803 - - 916 656,497 (686) 200
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 23 0 23 2 75,900 - - 21 796,950 (16)
Markerpen pcs Rp 1.0 70 0 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 35 20 55 6 117,000 - - 49 955,500 (35) 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - - -
0 Pharmafix pcs Rp 27,000.0 7 0 7 - - - - 7 189,000 (7)
200
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 50 0 50 50 134,220 - - - - 120
0 safety box* pcs Rp 16,500.0 91 0 91 - - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 200 200 400 - - - - 400 660,000 (400) 200
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 4 0 4 - - - - 4 33,420 (4)
0 Surgical Gloves non steril uk L pcs Rp 462.0 500 0 500 - - - - 500 231,000 (500)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 500 300 800 100 37,400 - - 700 261,800 (460) 300
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 600 0 600 600 277,200 - - - - 1,440 500
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,450 500 2,950 600 277,200 - - 2,350 1,085,700 (910) 500
201
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - - -
IV. REAGEN - 0 - - - - - - - -
202
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - - -
203
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 - 0 - - - - - - - - 100
204
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
205
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000046730 Spiritus 1 L botol Rp 53,900 6 0 6 1 53,900 - - 5 269,500 (3)
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 - 0 - - - - - - - - 100
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 - 0 - - - - - - - - 100
MDVx133BJM Stik HB Easy touch stik Rp 6,688 150 0 150 100 668,800 - - 50 334,400 190 50
0 Stik syphilis 'SD' stik Rp 35,429 100 0 100 - - - - 100 3,542,900 (100) 100
0 Ziehl Nielseen Stain paket Rp 273,978 1 1 2 - - - - 2 547,956 (2) 1
Pil KB BKKBN 697 200 897 40 - - - 857 - (761)
Kondom BKKBN 204 0 204 - - - - 204 - (204)
Spuit 3cc BKKBN 14 80 94 51 - - - 43 - (43)
Stik sifilis AB - 0 - - - - - - - - 100
Bacitracin Salep Kulit - 0 - - - - - - - -
206
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 9,114,426 99,570,595
UMUM
JUMLAH
1009 386 1395

NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19790902 200903 2 006 NIP.19840410 200803 1 002
207
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 590 400 990 20 1,980 - - 970 96,030 (922) 400
Aminofilin tablet 200 mg tablet Rp 86.0 - 0 - - - - - - - -
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 1,630 3500 5,130 1,015 77,140 - - 4,115 312,740 (1,679) 3500
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 2,070 3000 5,070 1,030 255,440 - - 4,040 1,001,920 (1,568) 500
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 - 0 - - - - - - - - 300
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 1,220 1500 2,720 1,165 65,240 - - 1,555 87,080 1,241 1200
DRG000002883 Antasida sirup botol Rp 2,098.0 45 50 95 7 14,686 - - 88 184,624 (71) 50
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 531 1000 1,531 920 110,400 - - 611 73,320 1,597 2000
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 750 400 1,150 385 31,185 - - 765 61,965 159 400
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 1,950 2000 3,950 755 77,010 - - 3,195 325,890 (1,383) 100
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 13 50 63 28 38,444 - - 35 48,055 32 25
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 1,154 500 1,654 178 6,052 - - 1,476 50,184 (1,049) 200
208
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 95 0 95 95 11,495 - - - - 228 500
DRG000032549 Fenobarbital tablet 30 mg tablet Rp 197.0 - 0 - - - - - - - - 100
DRG000015698 Fitomenadion ( vit k 1 ) tablet salut 10 mg tablet Rp 818.0 655 0 655 - - - - 655 535,790 (655)
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 100 0 100 95 7,505 - - 5 395 223 100
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 447 200 647 240 13,200 - - 407 22,385 169 500
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 235 0 235 40 2,240 - - 195 10,920 (99)
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 533 500 1,033 565 63,280 - - 468 52,416 888 1000
209
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 90 0 90 10 890 - - 80 7,120 (56)
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 730 0 730 80 8,800 - - 650 71,500 (458)
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 560 0 560 30 8,580 - - 530 151,580 (458)
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 440 0 440 70 19,250 370 101,750 - - 168 100
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 360 400 760 190 28,120 - - 570 84,360 (114) 400
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 500 500 1,000 20 2,500 - - 980 122,500 (932)
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 725 0 725 10 830 - - 715 59,345 (691)
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 890 0 890 270 54,810 - - 620 125,860 28
210
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 1,100 1000 2,100 100 14,200 - - 2,000 284,000 (1,760) 1000
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,830 0 2,830 736 100,096 - - 2,094 284,784 (328)
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 44 0 44 18 11,610 - - 26 16,770 17 20
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 8 0 8 6 2,483,874 - - 2 827,958 12
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 385 0 385 330 45,540 - - 55 7,590 737
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 5,000 0 5,000 5,000 300,000 - - - - 12,000 5000
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 615 500 1,115 370 52,170 - - 745 105,045 143 500
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 126 0 126 92 16,698 - - 34 6,171 187 300
DRG000035403 Ranitidin tablet tablet Rp 122.0 - 0 - - - - - - - -
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 79 0 79 75 4,800 - - 4 256 176 600
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,466 0 1,466 20 1,540 - - 1,446 111,342 (1,398)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 33 0 33 33 99,561 - - - - 79 25
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 800 0 800 270 132,840 - - 530 260,760 118 300
211
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 949 2500 3,449 2,553 344,655 - - 896 120,960 5,231 2500
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 730 400 1,130 90 54,360 - - 1,040 628,160 (824)
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 0 200 - - - - 200 175,600 (200) 200
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 - 3000 3,000 460 43,700 - - 2,540 241,300 (1,436) 3000
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 250 100 350 - - - - 350 362,250 (350) 100
212
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 245 100 345 25 38,963 - - 320 498,720 (260)
Curcuma tablet tablet Rp 990.0 - 0 - - - - - - - - 100
213
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Dextamine tablet tablet Rp 1,815.0 - 0 - - - - - - - - 300
DRG000012127 Dextrofen sirup botol Rp 12,499.3 - 0 - - - - - - - - 50
DRG000012774 Domperidon Suspensi 5 mg/5 ml botol Rp 2,862.0 88 0 88 21 60,102 67 191,754 - - 50 50
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 270 0 270 - - - - 270 85,320 (270)
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 184 100 284 60 9,480 - - 224 35,392 (80)
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 47 50 97 1 2,590 - - 96 248,640 (94) 50
DRG000018443 Haloperidol tablet 1,5 mg tablet Rp 59.0 100 0 100 10 590 - - 90 5,310 (66)
214
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Ichtyol salep tube Rp 6,200.0 30 0 30 - - - - 30 186,000 (30)
Interhistin tablet tablet Rp 880.0 690 0 690 - - - - 690 607,200 (690)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 760 500 1,260 10 1,250 - - 1,250 156,238 (1,226)
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 52 25 77 - - - - 77 198,429 (77) 25
DRG000009337 Klobazam 10 mg tablet tablet Rp 872.0 83 200 283 - - - - 283 246,776 (283)
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 47 0 47 - - - - 47 310,200 (47)
215
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023860 Livertran salep tube Rp 4,600.0 - 25 25 - - - - 25 115,000 (25)
DRG000023935 Loperamida tablet tablet Rp 85.0 - 0 - - - - - - - -
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 300 0 300 - - - - 300 29,700 (300) 500
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 10 0 10 3 15,510 - - 7 36,190 0 5
Novadium tablet Rp 200.0 500 500 1,000 80 16,000 - - 920 184,000 (728)
Noza tablet tablet Rp 797.5 117 0 117 12 9,570 - - 105 83,738 (76) 500
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 1 0 1 - - - - 1 5,000 (1) 100
216
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 121 50 171 8 17,600 - - 163 358,600 (144)
DRG000031608 Parasetamol Drop 100 mg/ml botol Rp 6,938.8 - 0 - - - - - - - - 200
DRG000002552 Pil KB I tablet Rp 1,350.0 100 100 200 - - - - 200 270,000 (200)
DRG000033456 Polikresulen botol Rp 43,975.8 - 0 - - - - - - - - 10
Prenatin DF tablet tablet Rp 3,258.3 400 0 400 290 944,907 - - 110 358,413 586
217
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 122 0 122 26 156,757 - - 96 578,794 (34) 100
DRG000037725 Scabicid cream 10 gram tube Rp 11,475.0 - 0 - - - - - - - - 25
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 318 200 518 28 83,804 - - 490 1,466,570 (423) 50
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 765 500 1,265 200 19,400 - - 1,065 103,305 (585) 500
Stimuno Forte tablet tablet Rp 2,504.7 - 0 - - - - - - - - 100
218
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 100 100 200 10 18,150 - - 190 344,850 (166) 100
DRG000043683 Ventolin inhaler kotak Rp 70,125.0 - 0 - - - - - - - - 5
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 24 0 24 - - - - 24 264,000 (24) 10
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,785 1000 2,785 950 46,550 - - 1,835 89,915 445 1000
- 0 - - - - - - - -
II.OBAT GIGI - 0 - - - - - - - -
219
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 3 1 4 - - - - 4 1,011,800 (4) 1
MDVx009212 Cotton roll pack Rp 75,000.0 2 0 2 1 75,000 - - 1 75,000 1 1
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 - 0 - - - - - - - - 3
220
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Tampon pack Rp 300,000.0 3 0 3 - - - - 3 900,000 (3)
- 0 - - - - - - - -
III. BMHP - 0 - - - - - - - -
MDVx001793 Alat suntik sekali pakai 10 ml pcs Rp 1,095.3 110 0 110 10 10,953 - - 100 109,529 (76) 10
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - - 2 279,000 (2)
221
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - - -
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - - -
222
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 27 10 37 10 19,618 - - 27 52,969 (3)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 - 0 - - - - - - - - 20
0 Kertas Puyer lembar Rp 91.6 - 0 - - - - - - - - 500
0 Klorin botol Rp 15,970.0 48 0 48 - - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 916 288 1,204 204 146,207 - - 1,000 716,700 (510) 288
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 21 0 21 1 37,950 - - 20 759,000 (18) 10
Markerpen pcs Rp 1.0 70 0 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 49 20 69 40 780,000 - - 29 565,500 67 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - - -
0 Pharmafix pcs Rp 27,000.0 7 0 7 - - - - 7 189,000 (7)
223
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - 0 - - - - - - - -
0 safety box* pcs Rp 16,500.0 91 0 91 - - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 400 200 600 100 165,000 - - 500 825,000 (260) 200
MDVx001722 Spuit 0,5 ml pcs Rp 1,240.0 200 400 600 600 744,000 - - - - 1,440 100
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 4 0 4 - - - - 4 33,420 (4)
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 700 300 1,000 300 112,200 - - 700 261,800 20 1000
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 - 0 - - - - - - - - 600
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,350 500 2,850 500 231,000 - - 2,350 1,085,700 (1,150) 500
224
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - - -
IV. REAGEN - 0 - - - - - - - -
225
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - - -
226
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 - 100 100 100 1,434,400 - - - - 240 100
227
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
228
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx133BJM Stik HB Easy touch stik Rp 6,688 50 0 50 25 167,200 - - 25 167,200 35 50
0 Stik Kehamilan stik Rp 1,947 150 0 150 - - 150 292,050 - - - 50
0 Ziehl Nielseen Stain paket Rp 273,978 2 1 3 1 273,978 - - 2 547,956 0
Pil KB BKKBN 857 0 857 17 - - - 840 - (799)
Kondom BKKBN 204 0 204 - - - - 204 - (204)
Spuit 3cc BKKBN 43 20 63 35 - - - 28 - (28)
Stik sifilis AB - 0 - - - - - - - -
229
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 12,263,347 97,208,539
UMUM
JUMLAH
841 362 1203

NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19790902 200903 2 006 NIP.19840410 200803 1 002
230
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 970 400 1,370 170 16,830 - - 1,200 118,800 (792)
Aminofilin tablet 200 mg tablet Rp 86.0 - 0 - - - - - - - -
DRG000001807 Amlodipin 5 mg tablet Rp 76.0 4,115 3000 7,115 1,110 84,360 - - 6,005 456,380 (3,341) 2000
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 4,040 500 4,540 440 109,120 - - 4,100 1,016,800 (3,044) 500
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 - 300 300 4 17,380 - - 296 1,286,120 (286) 300
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 1,555 1200 2,755 995 55,720 - - 1,760 98,560 628 1200 jangan ed januari
DRG000002883 Antasida sirup botol Rp 2,098.0 88 50 138 4 8,392 - - 134 281,132 (124)
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 611 2000 2,611 411 49,320 - - 2,200 264,000 (1,214) 1000
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 765 400 1,165 200 16,200 - - 965 78,165 (485) 200
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 3,195 100 3,295 801 81,702 - - 2,494 254,388 (572) 1000
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 35 25 60 25 34,325 - - 35 48,055 25 25
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 1,476 200 1,676 231 7,854 - - 1,445 49,130 (891) 200
DRG000011634 Deksametason inj 5 mg/ml-1 ml ampul Rp 1,805.0 22 0 22 - - 22 39,710 - - -
231
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012413 Dimenhidrinate tablet tablet Rp 121.0 - 500 500 10 1,210 - - 490 59,290 (466)
DRG000012719 Domperidon 10 mg tablet Rp 90.0 210 0 210 210 18,900 - - - - 504
DRG000032549 Fenobarbital tablet 30 mg tablet Rp 197.0 - 100 100 - - - - 100 19,700 (100) 100
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 5 200 205 25 1,975 - - 180 14,220 (120) 100
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 200 0 200 60 13,380 - - 140 31,220 4 100
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 195 0 195 30 1,680 - - 165 9,240 (93) 100
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 468 1000 1,468 370 41,440 - - 1,098 122,976 (210)
232
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000020747 Isosorbit dinitrat tablet sublingual 5 mg tablet Rp 89.0 80 0 80 - - - - 80 7,120 (80)
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 650 0 650 100 11,000 - - 550 60,500 (310)
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 530 0 530 - - - - 530 151,580 (530)
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 - 0 - - - - - - - - 100
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 38 0 38 - - 1 4,982 37 184,334 (37)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 1,245 1200 2,445 674 16,176 - - 1,771 42,504 (153) 1000
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 570 400 970 180 26,640 - - 790 116,920 (358) 200
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 980 0 980 50 6,250 - - 930 116,250 (810)
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 547 200 747 275 28,050 - - 472 48,144 188 300
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 864 300 1,164 764 126,060 - - 400 66,000 1,434 1000
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 715 0 715 15 1,245 - - 700 58,100 (664)
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 620 0 620 25 5,075 - - 595 120,785 (535)
233
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 2,000 1000 3,000 100 14,200 - - 2,900 411,800 (2,660)
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 2,094 0 2,094 506 68,816 - - 1,588 215,968 (374) 1000
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 20 0 20 - - - - 20 3,600 (20) 300
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 26 20 46 5 3,225 - - 41 26,445 (29) 20
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 2 0 2 - - - - 2 827,958 (2)
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 55 0 55 55 7,590 - - - - 132 600
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 - 5000 5,000 580 34,800 - - 4,420 265,200 (3,028) 1000
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 745 500 1,245 483 68,103 - - 762 107,442 397 500
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 34 300 334 12 2,178 - - 322 58,443 (293) 300
DRG000035403 Ranitidin tablet tablet Rp 122.0 - 0 - - - - - - - -
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 4 0 4 2 128 - - 2 128 3 600
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,446 0 1,446 10 770 - - 1,436 110,572 (1,412)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 - 25 25 - - - - 25 75,425 (25) 25
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 530 300 830 430 211,560 40 19,680 360 177,120 672 1000
DRG000007256 Sefadroxil syp kering 125 ml / 5 ml botol Rp 4,086.0 96 0 96 - - - - 96 392,256 (96)
234
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000044426 Vitamin B komplek tablet tablet Rp 135.0 896 2500 3,396 1,453 196,155 - - 1,943 262,305 1,544 2000
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 1,040 0 1,040 240 144,960 - - 800 483,200 (224) 300
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 200 200 400 - - - - 400 351,200 (400) 200
DRG000001574 Ambroxol sirup botol Rp 3,300.0 69 400 469 70 231,000 - - 399 1,316,700 (231) 400
DRG000001791 Ambroxol tablet tablet Rp 100.0 - 1800 1,800 - - - - 1,800 180,000 (1,800) 1800
DRG000001949 Amlodipin 10 mg tablet Rp 95.0 2,540 3000 5,540 1,445 137,275 - - 4,095 389,025 (627) 3000
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 350 0 350 - - - - 350 362,250 (350) 100
235
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 320 0 320 - - - - 320 498,720 (320)
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 400 400 800 - - - - 800 1,422,400 (800) 400
Bisoprolol tablet 5 mg tablet Rp 248.0 300 0 300 10 2,480 - - 290 71,920 (266)
Curcuma tablet tablet Rp 990.0 - 0 - - - - - - - - 100
236
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Dextamine tablet tablet Rp 1,815.0 - 0 - - - - - - - - 300
DRG000012127 Dextrofen sirup botol Rp 12,499.3 - 0 - - - - - - - - 50
DRG000012774 Domperidon Suspensi 5 mg/5 ml botol Rp 2,862.0 - 0 - - - - - - - - 50
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 270 0 270 46 14,536 - - 224 70,784 (114)
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 224 100 324 33 5,214 - - 291 45,978 (212)
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 96 50 146 - - - - 146 378,140 (146) 50
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 26 0 26 1 3,499 - - 25 87,478 (23) 25
DRG000018443 Haloperidol tablet 1,5 mg tablet Rp 59.0 90 0 90 50 2,950 - - 40 2,360 80
237
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 380 3000 3,380 470 399,495 - - 2,910 2,473,471 (1,782) 2000
DRG000019495 Ibuprofen syr 100 mg/5ml botol Rp 2,560.0 98 0 98 - - - - 98 250,880 (98)
Ichtyol salep tube Rp 6,200.0 30 0 30 2 12,400 - - 28 173,600 (23)
DRG000006804 Kalsium laktat ( Kalk ) tablet 500 mg tablet Rp 59.0 2,480 0 2,480 880 51,920 - - 1,600 94,400 512
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 420 600 1,020 435 260,565 - - 585 350,415 459 600
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 1,250 0 1,250 - - - - 1,250 156,238 (1,250)
Lanzoprazol tablet Rp 330.0 1,630 0 1,630 190 62,700 - - 1,440 475,200 (984)
238
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023860 Livertran salep tube Rp 4,600.0 25 0 25 1 4,600 - - 24 110,400 (22)
DRG000023935 Loperamida tablet tablet Rp 85.0 - 0 - - - - - - - -
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 300 500 800 200 19,800 - - 600 59,400 (120) 500
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 7 5 12 - - - - 12 62,040 (12) 5
Novadium tablet Rp 200.0 920 0 920 50 10,000 - - 870 174,000 (750)
Noza tablet tablet Rp 797.5 105 0 105 105 83,738 - - - - 252 700
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 1 100 101 4 19,998 - - 97 484,952 (87) 100
239
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 163 0 163 13 28,600 - - 150 330,000 (119)
DRG000031608 Parasetamol Drop 100 mg/ml botol Rp 6,938.8 - 0 - - - - - - - - 200
DRG000002552 Pil KB I tablet Rp 1,350.0 200 0 200 - - - - 200 270,000 (200)
DRG000033456 Polikresulen botol Rp 43,975.8 - 0 - - - - - - - - 10
Prenatin DF tablet tablet Rp 3,258.3 110 0 110 110 358,413 - - - - 264
240
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 96 0 96 9 54,262 - - 87 524,532 (65) 100
DRG000037725 Scabicid cream 10 gram tube Rp 11,475.0 - 0 - - - - - - - - 25
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 490 50 540 22 65,846 - - 518 1,550,374 (465) 50
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 1,065 500 1,565 508 49,276 - - 1,057 102,529 162 500
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 10 0 10 - - 1 14,459 9 130,131 (9)
Stimuno Forte tablet tablet Rp 2,504.7 - 0 - - - - - - - - 100
241
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 190 100 290 - - - - 290 526,350 (290) 100
DRG000043683 Ventolin inhaler kotak Rp 70,125.0 - 0 - - - - - - - - 5
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 24 10 34 - - - - 34 374,000 (34) 10
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,835 1000 2,835 1,035 50,715 - - 1,800 88,200 684 1000
- 0 - - - - - - - -
II.OBAT GIGI - 0 - - - - - - - -
242
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 4 0 4 - - - - 4 1,011,800 (4) 1
MDVx009212 Cotton roll pack Rp 75,000.0 1 1 2 - - - - 2 150,000 (2) 1
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 - 3 3 - - - - 3 494,850 (3) 3
243
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Tampon pack Rp 300,000.0 3 0 3 - - - - 3 900,000 (3)
- 0 - - - - - - - -
III. BMHP - 0 - - - - - - - -
MDVx001732 Alat suntik sekali pakai 3 ml pcs Rp 1,138.0 155 0 155 10 11,380 - - 145 165,010 (121) 300
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - - 2 279,000 (2)
244
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - - -
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - - -
245
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx002273 Kasa kompres 40 / 40 steril pcs Rp 1,961.8 27 0 27 - - - - 27 52,969 (27)
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 - 20 20 - - - - 20 49,140 (20) 20
0 Kertas Puyer lembar Rp 91.6 - 0 - - - - - - - - 500
0 Klorin botol Rp 15,970.0 48 0 48 - - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 1,000 288 1,288 54 38,702 - - 1,234 884,408 (1,104) 288
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 20 0 20 - - - - 20 759,000 (20) 10
Markerpen pcs Rp 1.0 70 0 - - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 29 40 69 20 390,000 - - 49 955,500 (1) 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - - -
0 Pharmafix pcs Rp 27,000.0 7 0 7 - - - - 7 189,000 (7)
246
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - 0 - - - - - - - -
0 safety box* pcs Rp 16,500.0 91 0 91 - - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 500 200 700 - - - - 700 1,155,000 (700) 200
MDVx001722 Spuit 0,5 ml pcs Rp 1,240.0 - 100 100 - - - - 100 124,000 (100) 100
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 4 0 4 - - - - 4 33,420 (4)
0 Surgical Glove No 8 pcs Rp 5,000.0 86 0 86 10 50,000 - - 76 380,000 (52)
0 Surgical Gloves non steril uk L pcs Rp 462.0 400 0 400 200 92,400 - - 200 92,400 280 300
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 700 900 1,600 1,100 411,400 - - 500 187,000 2,140 1000
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 - 0 - - - - - - - - 600
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,350 1600 3,950 1,550 716,100 - - 2,400 1,108,800 1,320 1700
247
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - - -
IV. REAGEN - 0 - - - - - - - -
248
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - - -
249
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 - 100 100 - - - - 100 1,434,400 (100) 100
250
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
251
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Stik HB BeneCheck stik Rp 7,955 - 0 - - - - - - - - 100
MDVx133BJM Stik HB Easy touch stik Rp 6,688 25 0 25 25 167,200 - - - - 60 50
0 Stik HBSAg merek SD stik Rp 9,870 100 0 100 100 987,000 - - - - 240 100
0 Stik Kehamilan stik Rp 1,947 - 0 - - - - - - - -
0 Ziehl Nielseen Stain paket Rp 273,978 2 0 2 - - - - 2 547,956 (2)
Pil KB BKKBN 840 200 1,040 31 - - - 1,009 - (935)
Suntik KB 3 bulan BKKBN 64 100 164 28 - - - 136 - (69)
Kondom BKKBN 204 144 348 24 - - - 324 - (266)
Spuit 3cc BKKBN 28 100 128 42 - - - 86 - (86)
Stik sifilis AB - 0 - - - - - - - - 50
252
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
- - - - - -
TOTAL 7,567,841 106,040,330
UMUM
JUMLAH
851 371 1222

NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19790902 200903 2 006 NIP.19840410 200803 1 002
253
(LPLPO)

KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
I. OBAT
DRG000001271 Allopurinol tablet 100 mg tablet Rp 99.0 1,200 0 1,200 230 22,770 - 970 96,030 (418)
Aminofilin tablet 200 mg tablet Rp 86.0 - 0 - - - - - - -
DRG000001934 Amoksisilin 500 mg kaplet tablet Rp 248.0 4,100 500 4,600 965 239,320 - 3,635 901,480 (1,319) 200
DRG000001909 Amoksisilin Sirup kering 125 mg/5 ml botol Rp 4,345.0 296 300 596 39 169,455 - 557 2,420,165 (463) 100
DRG000002891 Antasida doen tablet kombinasi tablet Rp 56.0 1,760 1200 2,960 1,860 104,160 400 22,400 700 39,200 3,764 1700
DRG000002883 Antasida sirup botol Rp 2,098.0 134 0 134 14 29,372 - 120 251,760 (86)
DRG000003567 Asam Askorbat(vit C) tablet 50 mg tablet Rp 120.0 2,200 1000 3,200 2,278 273,360 - 922 110,640 4,545 2000
DRG000003569 Asam Folat 1 mg tablet tablet Rp 81.0 965 200 1,165 660 53,460 - 505 40,905 1,079 400
DRG000003606 Asam mefenamat 500 mg kaplet tablet Rp 102.0 2,494 1000 3,494 1,155 117,810 - 2,339 238,578 433 1000
DRG000003731 Asiklovir 200 mg tablet tablet Rp 236.0 1,600 0 1,600 1,400 330,400 200 47,200 - - 3,360 700
DRG000005108 Betametason krim 0,1 % tube Rp 1,373.0 35 25 60 36 49,428 - 24 32,952 62 25
DRG000011238 Deksametason tablet 0,5 mg tablet Rp 34.0 1,445 200 1,645 333 11,322 - 1,312 44,608 (513) 300
DRG000011634 Deksametason inj 5 mg/ml-1 ml ampul Rp 1,805.0 - 0 - - - - - - -
254
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18

DRG000012334 Digoksin tablet 0,25 mg tablet Rp 103.0 - 0 - - - - - - -
DRG000012719 Domperidon 10 mg tablet Rp 90.0 - 0 - - - - - - - 500
DRG000040321 Ferro folat tab sal selaput 200 mg + 0,25 mg ( tablet Rp 55.0 5,750 0 5,750 3,080 169,400 - 2,670 146,850 4,722
DRG000016705 Furosemid tablet 40 mg tablet Rp 79.0 180 200 380 - - - 380 30,020 (380)
DRG000030693 Garam oralit untuk 200 ml air sachet Rp 418.0 505 0 505 135 56,430 - 370 154,660 (46)
DRG000017435 Glimepirid tab 1 mg tablet Rp 194.0 640 0 640 - - - 640 124,160 (640)
DRG000018089 Griseofulvin tablet 125 mg micronized tablet Rp 223.0 140 0 140 - - - 140 31,220 (140) 100
DRG000018285 Haloperidol tablet 0,5 mg tablet Rp 55.0 757 100 857 115 6,325 - 742 40,810 (466) 200
DRG000018289 Haloperidol tablet 5 mg tablet Rp 56.0 165 200 365 120 6,720 - 245 13,720 43 200
DRG000018823 Hidroklortiazid ( Hct ) tablet 25 mg tablet Rp 163.0 355 100 455 50 8,150 - 405 66,015 (285)
DRG000019463 Ibuprofen tablet 200 mg tablet Rp 112.0 1,098 0 1,098 330 36,960 - 768 86,016 24
DRG000019444 Ibuprofen tablet 400 mg tablet Rp 292.0 - 1000 1,000 80 23,360 - 920 268,640 (728) 1000
255
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000006917 Kaptopril 25 mg tablet tablet Rp 110.0 550 0 550 110 12,100 - 440 48,400 (176)
DRG000006947 Karbamazepin tablet 200 mg tablet Rp 234.0 300 0 300 60 14,040 - 240 56,160 (96)
DRG000021678 Ketokonazol 200 mg tablet tablet Rp 286.0 530 0 530 - - - 530 151,580 (530)
DRG000021911 Kloramfenikol kapsul 250 mg kapsul Rp 275.0 - 0 - - - - - - - 100
DRG000021907 Kloramfenikol sirup botol Rp 4,982.0 37 0 37 - - - 37 184,334 (37)
DRG000010399 Klorfeniramin maleat ( CTM ) tablet 4 mg tablet Rp 24.0 1,771 1000 2,771 770 18,480 - 2,001 48,024 (153) 600
DRG000046756 Klorpromazin Hcl tablet salut 100 mg tablet Rp 148.0 790 200 990 200 29,600 - 790 116,920 (310) 200
DRG000009466 Kodein tablet 10 mg tablet Rp 657.0 110 0 110 - - - 110 72,270 (110)
DRG000022299 Kotrimoksazol DOEN I (dewasa) tablet tablet Rp 125.0 930 0 930 100 12,500 - 830 103,750 (590)
DRG000023410 Lidocain injeksi 2 % ampul Rp 1,319.0 - 0 - - - - - - -
DRG000023432 Lidokain kompositum injeksi ampul Rp 1,317.0 82 0 82 9 11,853 - 73 96,141 (51)
DRG000023922 Loratadin tablet tablet Rp 127.0 - 0 - - - - - - -
DRG000025499 Metformin tab 500 mg tablet Rp 102.0 472 300 772 225 22,950 - 547 55,794 (7) 300
DRG000025664 Metilergometrin maleat tablet salut 0,125 mg tablet Rp 273.8 100 0 100 - - - 100 27,380 (100)
DRG000025667 Metilprednisolon 4 mg tablet tablet Rp 165.0 400 1000 1,400 613 101,145 - 787 129,855 684 700
DRG000025705 Metoklorpropamid tablet tablet Rp 83.0 700 0 700 245 20,335 - 455 37,765 133 200
DRG000025793 Metronidazol tablet 250 mg tablet Rp 94.0 - 0 - - - - - - -
DRG000025795 Metronidazol tablet 500 mg tablet Rp 203.0 595 0 595 30 6,090 - 565 114,695 (493)
DRG000025979 Miconazol krim tube Rp 2,577.0 108 0 108 4 10,308 - 104 268,008 (94)
256
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000027443 Natrium Diklofenak tablet 25 mg tablet Rp 142.0 2,900 0 2,900 460 65,320 - 2,440 346,480 (1,336)
DRG000027445 Natrium Diklofenak tablet 50 mg tablet Rp 136.0 1,588 0 1,588 500 68,000 - 1,088 147,968 112 1000
DRG000028512 Nipedipin 10 mg tablet tablet Rp 180.0 20 300 320 5 900 - 315 56,698 (303) 300
DRG000028621 Nistatin 100.000 iu /g tablet vagina tablet Rp 645.0 41 20 61 5 3,225 - 56 36,120 (44) 20
Obat antituberkulosis anak paket Rp 267,400.0 1 0 1 - - - 1 267,400 (1)
DRG000029731 Obat FDC Kategori 1 paket Rp 413,979.0 2 0 2 2 827,958 - - - 5 5
DRG000029732 obat FDC KATEGORI 2 paket Rp 1,492,574.0 3 0 3 2 2,985,148 - 1 1,492,574 4
DRG000030251 Omeprazole 20 mg capsul kapsul Rp 138.0 - 600 600 320 44,160 - 280 38,640 488 300
DRG000031622 Parasetamol tablet 500 mg tablet Rp 60.0 4,420 1000 5,420 3,713 222,780 - 1,707 102,420 7,204 3000
DRG000032952 Piridoksin Hcl tablet 10 mg tablet Rp 141.0 762 500 1,262 273 38,493 - 989 139,449 (334) 500
DRG000033669 Prednison tablet 5 mg tablet Rp 181.5 322 300 622 25 4,538 - 597 108,356 (537) 100
DRG000035403 Ranitidin tablet tablet Rp 122.0 - 0 - - - - - - -
DRG000044395 Retinol ( Vit A ) 200.000 IU kapsul kapsul Rp 519.2 - 1150 1,150 1,150 597,080 - - - 2,760
DRG000037219 Salbutamol tablet 2 mg tablet Rp 64.0 2 600 602 53 3,392 - 549 35,136 (428) 600
DRG000037227 Salbutamol tablet 4 mg tablet Rp 77.0 1,436 0 1,436 30 2,310 - 1,406 108,262 (1,338)
DRG000000087 Salep 2 - 4 kombinasi tablet Rp 3,017.0 25 25 50 1 3,017 - 49 147,833 (47) 25
DRG000007260 Sefadroxil kapsul 500 mg tablet Rp 492.0 360 1000 1,360 360 177,120 - 1,000 492,000 (160) 1000
257
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000038679 Simpastatin 10 mg tablet tablet Rp 110.0 550 0 550 550 60,500 - - - 1,320 600
DRG000041259 Thiamin Hcl monohidrat ( Vit B1 ) 50 mg tablet Rp 88.0 300 1000 1,300 520 45,760 - 780 68,640 418 1000
DRG000042321 Triheksilfenidil hidroklorida tablet 2 mg tablet Rp 95.0 605 300 905 211 20,045 - 694 65,930 (218) 300
DRG000046201 Zink 20 mg tablet (generik) tablet Rp 604.0 800 300 1,100 185 111,740 - 915 552,660 (491) 300
Vaksin MR vial Rp 141,648.0 - 0 - - - - - - -
DRG000000986 Akarbose tablet 100 mg tablet Rp 878.0 400 200 600 - - - 600 526,800 (600) 200
Alprazolam 1 mg tablet Rp 120.0 - 0 - - - - - - -
DRG000001574 Ambroxol sirup botol Rp 3,300.0 399 150 549 27 89,100 - 522 1,722,600 (457) 400
DRG000001791 Ambroxol tablet tablet Rp 100.0 1,800 1000 2,800 376 37,600 - 2,424 242,400 (1,582) 1000
DRG000003010 Antihemaroid doen kombinasi supp Rp 3,642.0 99 10 109 37 134,754 - 72 262,224 13 30
Antiparkinson doen tablet kombinasi tablet Rp 1,035.0 350 0 350 - - - 350 362,250 (350) 100
DRG000003089 Apialis Drops botol Rp 21,175.0 - 0 - - - - - - - 100
258
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000003164 Apialys sirup botol Rp 33,000.0 34 0 34 - - - 34 1,122,000 (34) 100
DRG000003393 Aqua proinjeksi steril,bebas pirogen vial Rp 2,860.0 20 0 20 - - - 20 57,200 (20)
DRG000003466 Arkavit tablet Rp 320.0 - 1000 1,000 - - - 1,000 320,000 (1,000) 2000
DRG000003716 Asam Asetilsalisilat tablet 100 mg (Asetosal) tablet Rp 154.0 - 300 300 - - - 300 46,200 (300) 300
DRG000003651 Asam Traneksamat 500 mg kapsul kapsul Rp 1,558.5 320 0 320 - - - 320 498,720 (320)
DRG000005594 Azitromisin 500 mg tablet tablet Rp 1,778.0 800 0 800 - - - 800 1,422,400 (800) 400
Baby Cough sirup botol Rp 3,999.6 - 80 80 17 67,993 - 63 251,975 (26) 300
Buscopan tablet tablet Rp 3,100.0 220 100 320 40 124,000 - 280 868,000 (188) 100
Cendo Lyteers tetes mata botol Rp 25,999.6 - 20 20 - - - 20 519,992 (20) 20
DRG000009353 Cetop-zink kaplet tablet Rp 2,550.0 - 400 400 10 25,500 - 390 994,500 (366) 400
Curcuma tablet tablet Rp 990.0 - 100 100 - - - 100 99,000 (100) 100
DRG000011365 Depakene sirup botol Rp 17,789.0 - 0 - - - - - - -
259
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Dextamine tablet tablet Rp 1,815.0 - 0 - - - - - - - 300
DRG000012127 Dextrofen sirup botol Rp 12,499.3 - 50 50 - - - 50 624,965 (50) 50
DRG000012774 Domperidon Suspensi 5 mg/5 ml botol Rp 2,862.0 - 50 50 9 25,758 - 41 117,342 (19) 50
DRG000013291 Dulcolax 5 mg tablet tablet Rp 316.0 224 0 224 48 15,168 - 176 55,616 (61)
DRG000015398 Fenitoin natrium kapsul 100 mg kapsul Rp 158.0 291 0 291 60 9,480 - 231 36,498 (87)
DRG000015406 Fenofibrat kaps 100 mg tablet Rp 1,073.0 - 0 - - - - - - - 200
Fenol gliserol tetes telinga 10 % botol Rp 2,590.0 146 50 196 4 10,360 - 192 497,280 (182) 50
Flukonazol tab 150 mg tablet Rp 24,200.0 - 0 - - - - - - - 100
Fucilex ointment (natrium fusidat) tube Rp 4,889.0 150 0 150 - - - 150 733,350 (150)
DRG000017127 Gentamisin salep kulit tube Rp 2,499.2 57 25 82 2 4,998 - 80 199,936 (75) 50
DRG000017230 Gentamisin Tetes mata botol Rp 4,885.0 189 25 214 15 73,275 - 199 972,115 (163) 50
DRG000017444 Gentian violet larutan 1 % pot Rp 3,499.1 25 24 49 - - - 49 171,456 (49) 25
Glimepirid tab 2 mg tablet Rp 207.0 380 0 380 150 31,050 - 230 47,610 130 300
DRG000017509 Gliseril guayakolat tablet 100 mg tablet Rp 90.0 - 2000 2,000 230 20,700 - 1,770 159,300 (1,218) 2000
DRG000018443 Haloperidol tablet 1,5 mg tablet Rp 59.0 40 0 40 10 590 - 30 1,770 (6)
260
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000018721 Hemafort tablet tablet Rp 850.0 2,910 1000 3,910 690 586,493 - 3,220 2,736,968 (1,564) 2000
Hidrokortison krim 1% tube Rp 5,723.3 18 0 18 - - - 18 103,019 (18)
Interhistin tablet tablet Rp 880.0 680 0 680 20 17,600 - 660 580,800 (612)
DRG000006804 Kalsium laktat ( Kalk ) tablet 500 mg tablet Rp 59.0 1,600 0 1,600 1,015 59,885 - 585 34,515 1,763 1000
DRG000021334 Kandesartan 8 mg tablet tablet Rp 599.0 585 600 1,185 465 278,535 - 720 431,280 372 600
DRG000006909 Kandistatin drops (nistatin 100.000IU) botol Rp 26,499.0 26 0 26 1 26,499 - 25 662,475 (23)
DRG000006919 Kaptopril 12,5 mg tablet tablet Rp 125.0 1,250 0 1,250 40 5,000 - 1,210 151,238 (1,114)
DRG000021711 Ketokonazol Krim tube Rp 2,577.0 76 24 100 - - - 100 257,700 (100) 25
DRG000021939 Kloramfenikol tetes telinga 3 % botol Rp 6,600.0 45 0 45 4 26,400 - 41 270,600 (33)
DRG000009409 Klorpromazin Hcl tablet salut 25 mg tablet Rp 250.0 - 0 - - - - - - -
DRG000021973 Klozapin 25 mg tablet tablet Rp 1,121.0 190 0 190 17 19,057 - 173 193,933 (136)
DRG000022301 Kombipak Azitromycin-Cefixim paket Rp 44,550.0 - 1 1 - - - 1 44,550 (1) 100
Lanzoprazol tablet Rp 330.0 1,440 0 1,440 272 89,760 - 1,168 385,440 (543)
DRG000023225 L-Bio sachet sachet Rp 4,033.3 - 0 - - - - - - -
261
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000023879 Longatin 25 mg tablet Rp 2,693.9 423 0 423 - - - 423 1,139,520 (423)
DRG000023935 Loperamida tablet tablet Rp 85.0 - 0 - - - - - - -
DRG46583 Lorazepam (Merlopam) 2 mg tablet tablet Rp 932.0 100 0 100 - - - 100 93,200 (100)
DRG000025004 Meloxikam 15 mg tablet tablet Rp 800.0 - 300 300 - - - 300 240,000 (300) 300
DRG000025684 Meloxikam 7,5 mg tablet tablet Rp 650.0 - 500 500 10 6,500 - 490 318,500 (470) 500
DRG000026268 Miniaspi 80 mg tablet Rp 99.0 600 500 1,100 20 1,980 - 1,080 106,920 (1,040) 500
DRG000027500 Natrium klorida larutan infus 0,9 % steril botol Rp 5,170.0 12 5 17 - - - 17 87,890 (17) 5
DRG000028376 Neurodex tablet tablet Rp 591.4 290 0 290 90 53,226 - 200 118,280 (20)
DRG000028637 Nistatin 500.000 iu /g tablet salut tablet Rp 910.0 - 0 - - - - - - - 50
Novadium tablet Rp 200.0 870 0 870 - - - 870 174,000 (870)
Novastan sirup botol Rp 12,650.0 - 0 - - - - - - -
Noza tablet tablet Rp 797.5 - 0 - - - - - - - 700
DRG000029801 Obat Batuk Hitam ( OBH ) cairan botol Rp 4,999.5 97 100 197 12 59,994 - 185 924,908 (157) 100
262
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000030411 Oksitetrasiklin Hcl salep kulit 3 % tube Rp 2,200.0 150 0 150 - - - 150 330,000 (150)
DRG000031608 Parasetamol Drop 100 mg/ml botol Rp 6,938.8 - 224 224 2 13,878 - 222 1,540,414 (218) 200
DRG000002552 Pil KB I tablet Rp 1,350.0 200 0 200 - - - 200 270,000 (200)
DRG000032746 Pil KB II / Laktasi tablet Rp 10,500.0 - 0 - - - - - - - 100
Pim-Tra-Kol sirup botol Rp 9,999.0 - 147 147 8 79,992 - 139 1,389,861 (120) 200
DRG000033456 Polikresulen botol Rp 43,975.8 - 0 - - - - - - - 10
PP Isoniazide 100 mg tablet Rp 79.0 - 100 100 - - - 100 7,900 (100) 100
Prenatin DF tablet tablet Rp 3,258.3 - 0 - - - - - - -
Pularex tablet tablet Rp 175.0 800 0 800 - - - 800 140,000 (800)
263
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
DRG000037531 Salisil bedak 2 % kotak Rp 6,029.1 87 100 187 22 132,640 - 165 994,802 (115) 100
Sangobion Kids Sirup botol Rp 24,515.7 - 100 100 - - - 100 2,451,570 (100) 100
DRG000037725 Scabicid cream 10 gram tube Rp 11,475.0 - 0 - - - - - - - 25
DRG000037835 Scabimite cream 10 gram tube Rp 11,475.0 - 25 25 1 11,475 - 24 275,400 (22) 25
DRG000007424 Sefiksim kapsul 100 mg kapsul Rp 2,299.0 - 0 - - - - - - -
DRG000008160 Setirizin sirup 5 mg/ml botol Rp 2,993.0 518 50 568 31 92,783 - 537 1,607,241 (463) 50
DRG000038415 Setirizine tablet 10 mg tablet Rp 97.0 1,057 500 1,557 531 51,507 - 1,026 99,522 202 500
DRG000039594 Stesolid rectal 5 mg supp Rp 14,459.0 9 0 9 1 14,459 - 8 115,672 (6)
Stimuno Forte tablet tablet Rp 2,504.7 - 0 - - - - - - - 100
Stimuno Sirup botol Rp 18,500.0 - 0 - - - - - - - 100
DRG000040178 Symbicort turbuhaler 160/4.5 mg kotak Rp 134,500.0 - 5 5 - - - 5 672,500 (5)
DRG000040195 Synarcus krim tube Rp 2,534.0 111 0 111 - - - 111 281,274 (111)
264
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Tensigard tablet tablet Rp 1,063.3 - 0 - - - - - - - 500
DRG000041013 Tetagam ampul Rp 176,800.0 1 0 1 - - - 1 176,800 (1)
DRG000041252 Thiamfenicol 500 mg kapsul kapsul Rp 890.0 400 0 400 - - - 400 356,000 (400)
DRG000042713 Truvit drops botol Rp 36,499.1 - 0 - - - - - - - 200
Truvit sirup botol Rp 11,400.0 - 0 - - - - - - - 100
DRG000042887 Ulsafate sirup botol Rp 9,192.0 38 0 38 - - - 38 349,296 (38)
DRG000043145 Urotractin (asam pipemidat) 400 mg tablet Rp 1,815.0 290 100 390 - - - 390 707,850 (390) 100
Vastral tablet Rp 605.0 - 0 - - - - - - - 1000
DRG000043683 Ventolin inhaler kotak Rp 70,125.0 - 0 - - - - - - - 5
DRG000043686 Ventolin Nebulizer ampul Rp 11,000.0 34 10 44 5 55,000 - 39 429,000 (27) 10
DRG000044687 Vitamin B 12 tablet tablet Rp 49.0 1,800 1000 2,800 730 35,770 - 2,070 101,430 (318) 1000
DRG000046229 Zincum Kid sirup botol Rp 3,285.0 225 0 225 1 3,285 - 224 735,840 (222)
- 0 - - - - - - -
II.OBAT GIGI - 0 - - - - - - -
265
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Caviton kotak Rp 252,950.0 4 0 4 - - - 4 1,011,800 (4) 1
0 Cotton pelet pack Rp 247,500.0 4 0 4 - - - 4 990,000 (4)
MDVx009212 Cotton roll pack Rp 75,000.0 2 0 2 1 75,000 - 1 75,000 1 1
DRG000014635 Ethyl klorida semprot botol Rp 164,950.0 3 2 5 2 329,900 - 3 494,850 2 3
0 G aenial bond kotak Rp 875,578.0 1 0 1 - - - 1 875,578 (1)
SBx144 Glass Ionomer cemen ( GC IX ) kotak Rp 643,500.0 1 1 2 - - - 2 1,287,000 (2) 1
0 Jarum Dental cytoject pcs Rp 2,662.0 - 0 - - - - - - -
SBx149 Monoklorkamfer mentol cairan (CHKM) kotak Rp 75,240.0 - 0 - - - - - - - 1
0 Oco Tooth Clensing botol Rp 191,999.0 4 0 4 - - - 4 767,996 (4)
DRG001BJM Scandonest pcs Rp 17,622.0 - 100 100 - - - 100 1,762,200 (100) 2
266
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
SBx139 Tambalan sinar solare A2 kotak Rp 256,731.0 3 0 3 - - - 3 770,193 (3)
0 Tambalan sinar solare A3,5 kotak Rp 420,200.0 - 1 1 - - - 1 420,200 (1) 1
0 Tampon pack Rp 300,000.0 3 0 3 - - - 3 900,000 (3)
0 Topical anastesi pasta kotak Rp 302,500.0 2 0 2 - - - 2 605,000 (2)
- 0 - - - - - - -
III. BMHP - 0 - - - - - - -
MDVx001732 Alat suntik sekali pakai 3 ml pcs Rp 1,138.0 145 300 445 - - - 445 506,410 (445) 300
DRG000039348 Alat suntik sekali pakai 5 ml pcs Rp 1,651.0 365 0 365 - - - 365 602,615 (365)
MDVx001793 Alat suntik sekali pakai 10 ml pcs Rp 1,095.3 110 0 110 - - - 110 120,482 (110) 10
DRG000001226 Alkohol Swab lembar Rp 105.0 1,000 0 1,000 100 10,500 - 900 94,500 (660)
0 Bioplacenton tulle pcs Rp 10,920.0 52 0 52 - - - 52 567,840 (52)
MDVx002305 Blood Lancet pcs Rp 176.0 750 100 850 - - - 850 149,600 (850) 100
0 Blue Tip pack Rp 139,500.0 2 0 2 - - - 2 279,000 (2)
267
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx023244 Coverplast pcs Rp 470.0 302 0 302 - - - 302 141,940 (302) 3
D-Pierce X12 box Rp 817,450.0 - 0 - - - - - - -
0 Fixomull pcs Rp 37,440.0 - 0 - - - - - - -
MDVx003549 IUD set Rp 11,800.0 - 0 - - - - - - -
MDVx022261 Jelly (Aquagel) botol Rp 31,027.3 4 0 4 - - - 4 124,109 (4)
268
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 kantongan plastik pack Rp 2,500.0 80 0 80 - - - 80 200,000 (80) 60
SBx133 Kasa pembalut hidrofil 4m x 15 cm pcs Rp 2,457.0 20 20 40 - - - 40 98,280 (40) 20
0 Kertas Puyer lembar Rp 91.6 - 0 - - - - - - - 500
MDVx013360 Kertas Thermal roll Rp 94,500.0 1 0 1 - - - 1 94,500 (1)
0 Klorin botol Rp 15,970.0 48 0 48 - - - 48 766,560 (48)
0 Kondom pcs Rp 716.7 1,234 288 1,522 60 43,002 - 1,462 1,047,815 (1,342) 288
DRG000046745 Larutan antiseptik (Aseptan) botol Rp 37,950.0 20 10 30 - - - 30 1,138,500 (30) 10
Markerpen pcs Rp 1.0 70 0 - - - - - -
0 Masker N 95 3M 1860 pcs Rp 19,500.0 49 20 69 - - - 69 1,345,500 (69) 20
0 Masker N 95 3M 1860S pcs Rp 19,500.0 - 0 - - - - - - -
0 Masker N 95 3M 1870 pcs Rp 21,000.0 - 0 - - - - - - -
0 Pharmafix pcs Rp 27,000.0 7 0 7 - - - 7 189,000 (7)
269
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
Plesterin pcs Rp 161.7 - 0 - - - - - - -
0 Pot Sputum pcs Rp 2,684.4 - 0 - - - - - - -
0 safety box* pcs Rp 16,500.0 91 0 91 - - - 91 1,501,500 (91)
silk no 2/0 pcs Rp 3,208.3 - 0 - - - - - - -
0 Spuit 0,05 ml pcs Rp 1,650.0 700 200 900 - - - 900 1,485,000 (900)
Steril Pouch 9 x 26 cm kotak Rp 88,660.0 - 0 - - - - - - - 3
0 Surflo No 18 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 20 pcs Rp 8,355.0 6 0 6 - - - 6 50,130 (6)
0 Surflo No 22 pcs Rp 8,355.0 5 0 5 - - - 5 41,775 (5)
0 Surflo No 24 pcs Rp 8,355.0 4 0 4 - - - 4 33,420 (4)
MDVx002389 Surgical Glove No 6,5 pcs Rp 20,006.7 64 0 64 1 20,007 - 63 1,260,422 (61) 300
0 Surgical Gloves non steril uk L pcs Rp 462.0 200 300 500 100 46,200 - 400 184,800 (160) 300
MDVx005018 Surgical Gloves non steril uk M pcs Rp 374.0 500 0 500 500 187,000 - - - 1,200 800
MDVx023325 Surgical Gloves non steril uk S pcs Rp 462.0 - 0 - - - - - - - 1000
MDVx003BJM Surgical mask-plus 3 ply plus earloop (Jilbab) pcs Rp 462.0 2,400 0 2,400 300 138,600 - 2,100 970,200 (1,380) 1700
MDVx010039 Surgikal Gloves No 7 pcs Rp 5,000.0 12 0 12 - - - 12 60,000 (12) 300
270
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- 0 - - - - - - -
IV. REAGEN - 0 - - - - - - -
271
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Lipid Pro pcs Rp 836,000.0 - 0 - - - - - - -
0 M-30 CFL LYSE 500 ML Mindray botol Rp 2,100,000.0 - 1 1 1 2,100,000 - - - 2
0 M-30 DILUENT Mindray botol Rp 2,050,000.0 1 1 2 1 2,050,000 - 1 2,050,000 1 1
0 M-30 E-Z Cleanser Mindray botol Rp 1,500,000.0 1 1 2 1 1,500,000 - 1 1,500,000 1
0 M-30 PROBE CLEANSER Mindray botol Rp 130,000.0 - 1 1 1 130,000 - - - 2 1
0 M-30 RINSE Mindray botol Rp 2,050,000.0 1 1 2 1 2,050,000 - 1 2,050,000 1
272
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
0 Rapid 1 SD HIV 1/2 3.0 stik Rp 14,344.0 100 100 200 - - - 200 2,868,800 (200) 100
273
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
RPR syfilis "Human" botol Rp 5,684 1 0 1 - - - 1 5,684 (1)
274
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
MDVx127BJM Stik asam urat easy touch stik Rp 4,796 - 75 75 - - - 75 359,700 (75) 75
0 Stik asam urat Nesco stik Rp 5,258 - 50 50 - - - 50 262,900 (50) 50
MDVx129BJM Stik Cholesterol easy touch stik Rp 21,890 - 100 100 30 656,700 - 70 1,532,300 2 100
0 Stik Cholesterol Nesco stik Rp 24,090 - 100 100 - - - 100 2,409,000 (100) 100
MDVx131BJM Stik gula darah ( gluco dr autosensor) stik Rp 7,238 - 0 - - - - - - - 100
0 Stik Gula Darah (Gluko DR supersensor) stik Rp 6,800 - 0 - - - - - - - 100
MDVx041511 Stik Gula Darah Accu cek stik Rp 8,327 - 200 200 50 416,350 - 150 1,249,050 (30) 200
0 Stik HB BeneCheck stik Rp 7,955 - 0 - - - - - - - 100
MDVx133BJM Stik HB Easy touch stik Rp 6,688 - 50 50 25 167,200 - 25 167,200 35 50
0 Stik HBSAg merek SD stik Rp 9,870 - 100 100 - - - 100 987,000 (100) 100
0 Stik Kehamilan stik Rp 1,947 - 0 - - - - - - -
0 Stik syphilis 'SD' stik Rp 35,429 100 0 100 - - - 100 3,542,900 (100) 100
0 Stik urinalisa 10 parameter (Dirui) stik Rp 3,245 - 0 - - - - - - - 100
0 Widal tes 4 set 4 set Rp 291,640 1 0 1 - - - 1 291,640 (1) 1
0 Ziehl Nielseen Stain paket Rp 273,978 2 0 2 - - - 2 547,956 (2)
275
KODE NAMA OBAT
1 2 3 4 5 6 7=(5+6) 8 9 10 11 12=(7-8-10) 13 14 15 16 17 18
- - - - - -
TOTAL 20,778,387 127,718,287
UMUM
JUMLAH
1170 357 1527

NIP.19701124 199101 1 004 NIP. 19790311 200501 2 015 NIP.19790902 200903 2 006 NIP.19840410 200803 1 002
276

LPLPO 2019 APBD SD 31 Des 2019

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LPLPO 2019 APBD SD 31 Des 2019

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LAPORAN PEMAKAIAN DAN LEMBAR PERMINTAAN OBAT

KODE PUSKESMAS : 63710203 BULAN 0 1 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 2 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin -

TOTAL 17,039,106 114,320,952

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 3 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin -

TOTAL 17,183,281 109,570,005

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 4 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin - -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 5 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin - -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 6 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin - -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 7 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 8 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin - -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 0 9 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin - -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 1 0 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin - -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 1 1 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin - -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

KODE PUSKESMAS : 63710203 BULAN 1 2 LB2

DHP / Darplex / D-Artepp (Dehidro artemisin -

Mengetahui/Menyetujui Yang Menyerahkan Yang Menerima/Melapor Yang Menerima

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