Sigompul

Nomor : 440/ /UPTD K-05/ VIII /2021 Kepada Yth:

Kepala Dinas Kesehatan Kab. Humbang
Sifat : Penting Hasundutan
Lampiran di
Perihal : Usulan Rincian Belanja Kapitasi JKN TA 2021 Doloksanggul

Sesuai dengan Permenkes 21 Tahun 2016 dan Keputusan Bupati Humbang Hasundutan Nomor 123 Tahun 2021 tentang
Alokasi Dana Kapitasi JKN Pada Puskesmas dan untuk memenuhi Kebutuhan Puskesmas bonandolok dalam menunjang Pelayanan
JKN pada Puskesmas Sigompul Kec.Lintongnihuta , Kab Humbang Hasundutan bersama ini kami mengajukan Usulan Rincian
Belanja Kapitasi JKN sesuai dengan Analisis Sarana dan Prasarana Puskesmas Bonandolok Tahun 2021 dan Perkiraan Dana JKN
yang masuk di Tahun 2021 dengan perincian sebagai berikut :

No Kegiatan Harga Jumlah Total

A Jasa 60 % 853,950,631 180,000,000
Jumlah 180,000,000
B Operasional Pelayanan 25 % 75,000,000

Belanja Alat Kesehatan 45,000,000

1 45,000,000
2 Belanja Bahan Medis Habis Pakai (BMHP) 30,000,000 30,000,000
Jumlah 75,000,000
C Dukungan Operasional 15 % 45,000,000
3 PEMELIHARAAN PUSKESMAS 1,700,000
6 kulkas 3,500,000 1 3,500,000
9 gorden biasa 88,900 21 1,866,900
12 Tangga Lipat 5 Meter 2,500,000 1 2,500,000
13 RUNING TEX 5,000,000 1 5,000,000
14 Honorarium Pejabat Pegadaan Kegiatan 3,900,000 1 3,900,000
15 Tempat sampah pedal 124,500.00 8 996,000
16 plastik sampah 40,000 32 1,280,000
17 Fotocopi 400 3,600 1,440,000
18 Paket Internet 105,000 12 1,260,000
19 Materai 10000 10,000 30 300,000
20 Biaya cetak gambar 3,000 12 36,000
21 Alat Tulis Kantor (ATK) 2,452,400 1 2,452,400
22 Pengganti transport petugas 80,000 24 1,920,000
23 sppd eselon IV 150,000 12 1,800,000
24 SPPD gol 3 150,000 40 6,000,000
25 SPPD GOL 2 150,000 12 1,800,000
26 mesin cuci 4,500,000 1 4,500,000
27 Bantal 60,000 10 600,000
42,851,300

85,702,600
45,000,000

Jumlah 28,151,300
TOTAL 283,151,300
-999,000,062
Diketahui / Disetujui
Kepala Puskesmas Sigompul
Kecamatan Lintong Nihuta

dr. Mey Merry Sidauruk

NIP. 19930522 201903 2 019
rencana pembelian alkes

no nama jumlah Harga Satuan ongkir Jumlah

1 bor intan untuk jet handpiece 1 set Menunggu Kabar Dari Penyedia
2 light curing 1 set
WOODPECKER WOODPECKER CURING
1,262,000 126,200 1,388,200
LIGHT
WOODPECKER WOODPECKER CURING 2,203,000
LIGHT O-LIGHT 220,300 2,423,300

WOODPECKER WOODPECKER CURING

2,442,000 244,200 2,686,200
LIGHT LED-F
MONITEX MONITEX BLUELEX LED
CURING LIGHT 4,592,000 459,200 5,051,200

MONITEX MONITEX BLUELEX CORDLESS

4,020,000 402,000 4,422,000
LED CURING LIGHT
3 sendok cetak dewasa 1 set

PRIMAMED SCHWERT IMPRESSION

TRAY PERFORATED SET - IMPRESSION
TRAY PERFORATED SET , FULL JAW / 2,546,500 254,650 2,801,150
SET SENDOK CETAK GIGI , RAHANG
PENUH

OTTO-LEIBINGER IMPRESSION TRAYS

188,000 18,800 206,800
UPPER NO. 1
OTTO-LEIBINGER IMPRESSION TRAYS
188,000 18,800 206,800
UPPER NO. 2
CHUGATA DENTAL SURGICAL
INSTRUMENTS-IMPRESSION TRAYS TIPE 440,000 44,000 484,000
ECO - SET - 1930
4 rubber bowl 1bh Tidak ditemukan dalam Ekatalog

5 jarum k-file (15-40) 1 Set

SVENSKA DENTORAMA SVENSKA -
173,000 17,300 190,300
DENTORAMA K FILE 15-40

6 jarum k-file (45-80) 1 set

SVENSKA DENTORAMA SVENSKA -
173,000 17,300 190,300
DENTORAMA K FILE 45-80

7 polishing bor 1 set Menunggu Kabar Dari Penyedia

8 skeler ultrasonik 1 set
BONART BONART PIEZO ELECTRIC
5,800,000 580,000 6,380,000
ULTRASONIC SCALLER

9 stetoskop dewasa 3
ONEMED STETHOSCOPE DUPLEX
39,564 3,956 43,520
DELUXE SERIES DEWASA

SPECTRA Stethoscope 128,760 12,876 141,636

ABN Sprague Rappaport Stethoscope 130,900 13,090 143,990

10 stetoskop bayi 1
ONEMED STETHOSCOPE DUPLEX
39,564 3,956 43,520
DELUXE SERIES BAYI

11 saturasi bayi 1
ELITECH - INDONESIA PULSE OXIMETER
3,300,000
FOX-BABY

12 tensimeter 10
 Onemed Digital Tensimeter 352,550 35,255 387,805
Carstensz Platinum Tensimeter Aneroid
(Newborn, Child, Infant, Adult, Large, 200,000 20,000 220,000
Thigh)
Accurate Tensimeter Aneroid
(Newborn, Child, Infant, Adult, Large, 170,000 17,000 187,000
Thigh)
Elitech - Indonesia Blood Pressure
4,290,000 429,000 4,719,000
Monitor Tensione
RGB Medical Blood Pressure Monitor/
Tensimeter Digital Powerbank Plus 1,685,200 168,520 1,853,720
Adaptor
RGB Medical - Blood Pressure
Monitor/ Tensimeter Digital Plus 1,636,800 163,680 1,800,480
Adaptor

RGB Medical Blood Pressure Monitor/

Tensimeter Digital Powerbank dengan 3,527,700 352,770 3,880,470
Tiang Powder Coating Beroda

RGB Medical Blood Pressure Monitor/

Tensimeter Digital dengan Tiang 3,624,500 362,450 3,986,950
Stainless Steel Beroda

RGB Medical Blood Pressure Monitor/

Tensimeter Digital Powerbank dengan 3,671,800 367,180 4,038,980
Tiang Stainless Steel Beroda

A & D Tensimeter Digital UA-711 1,700,000 170,000 1,870,000

A & D Tensimeter Digital UA-651 1,750,000 175,000 1,925,000
A & D Tensimeter Digital Adaptor
1,755,000 175,500 1,930,500
UM-777
A & D Tensimeter Digital Powerbank
2,300,000 230,000 2,530,000
UM-888
A & D Tensimeter Digital UA-711
3,350,000 335,000 3,685,000
Tiang PC Beroda

A & D Tensimeter Digital Powerbank

3,930,000 393,000 4,323,000
UM-888 Tiang PC Beroda

A & D Tensimeter Digital Powerbank

3,980,000 398,000 4,378,000
UM-888 Tiang SS Beroda

A & D Tensimeter Digital UA-651

3,400,000 340,000 3,740,000
Tiang PC Beroda
A & D Tensimeter Digital UA-711
3,400,000 340,000 3,740,000
Tiang SS Beroda

13 timbangan obat digital Tidak Ada Dalam Ekatalog

14 gunting bedah 5
ASTRA SURGICAL OPERATING
SCISSORS STRAIGHT FIG 3 Pcs 1,107,653 110,765 1,218,418
14.5CM - 5 3/4 SH/SH

HOHLKORPEL SCISSORS
INSTRUMENT STAINLESS STEEL Pcs 137,445 13,745 151,190
OPERATING SCISSORS, 14,5CM

FRIMED SURGICAL SCISSORS

SH/SH STRAIGHT 14,5 CM - 012- Pcs 246,000 24,600 270,600
104-145
 FRIMED SURGICAL SCISSORS
SH/BL STRAIGHT 14,5 CM - 012- Pcs 242,000 24,200 266,200
102-145
FRIMED SURGICAL SCISSORS
SH/SH STRAIGHT 15,5 CM - 012- Pcs 286,000 28,600 314,600
104-155
FRIMED SURGICAL SCISSORS
SH/BL STRAIGHT 15,5 CM - 012- Pcs 286,000 28,600 314,600
102-155

15 pen light 2
Heilemed Penlight Zeagr Morgn 93,183 9,318 102,501
Hope Penligth (Minimum pembelian 50
20,000 2,000 22,000
buah)
Hope Penligth Stainles Stell (1 Dus isi
1,750,000 175,000 1,925,000
50 pcs)
16 periksa kgd , kolesterol, asam urat 2

INEZCO MULTI PARAMETER 6 IN 1

MONITORING SYSTEM CONNECT
(BLOOD GLUCOSE, B KETON, TOTAL 1,400,000 140,000 1,540,000
CHOLESTEROL, URIC ACID,
HEMATROCIT, HEMOGLOBIN)

INEZCO TEST N GO VITA VOICE MULTI

PARAMETER 6 IN 1 MONITORING
SYSTEM ADVANCED VOICE (BLOOD 1,700,000 170,000 1,870,000
GLUCOSE, B -KETONE, TOTAL
CHOLESTEROL, URIC ACID,
HEMATROCIT, HEMOGLOBIN)

AUTOCHECK 3 IN 1 MULTI -
MONITORING SYSTEM ( CHOL, 220,000 22,000 242,000
GLUCOSE, URIC ACID)
Benecheck plus Multi-monitoring
193,000 19,300 212,300
Systim 3 in 1
Benecheck Supreme Multi-Monitoring
275,000 27,500 302,500
Meter

BHP
no nama jumlah
1 stik gula 20 kotak
INEZCO BLOOD GLUCOSE TEST STRIP 25
182,500 18,250 200,750
S
INEZCO BLOOD GLUCOSE TEST STRIP 50
270,000 27,000 297,000
S
INEZCO BLOOD GLUCOSE /
HEMATOCRIT / HEMOGLOBIN TEST 325,000 32,500 357,500
STRIP 50 S

INEZCO BLOOD GLUCOSE /

HEMATOCRIT / HEMOGLOBIN TEST 212,847 21,285 234,132
STRIP 25 S
BeneCheck Plus Blood Glucose Test 160,000 16,000 176,000
Strip 50s
AUTOCHECK BLOOD GLUCOSE TEST
123,000 12,300 135,300
STRIP

stik kolesterol 30 kotak

INEZCO TOTAL CHOLESTEROL TEST
960,000 96,000 1,056,000
STRIP 25 S
BeneCheck Plus Total Cholesterol Test 250,000 25,000 275,000
Strip 10s
AUTOCHECK TOTAL CHOLESTEROL TEST 367,000
STRIP 25s 36,700 403,700

stik asam urat 15 kotak

AUTOCHECK URIC ACID TEST STRIP 184,000 18,400 202,400
BENECHECK BENECHECK PLUS URIC 150,000
ACID TEST STRIP 25S 15,000 165,000
INEZCO URIC ACID TEST STRIP 25 S 524,370 52,437 576,807
INEZCO URIC ACID TEST STRIP 10 S 295,000 29,500 324,500

kassa steril
Cuplik Kasa Hidrofil uk. 16 x 16 Kotak isi 16 2,885 289 3,174

sufratulle Tidak Ada Dalam Ekatalog

 peyedia
u Kabar Dari Penyedia

PT. Cobra Dental

PT. Cobra Dental

PT. Cobra Dental

PT. Thomasong Nirmala

PT. Thomasong Nirmala

Daya Prima Mandiri Jaya PT

PT. Andini Sarana

PT. Andini Sarana

PT. Cobra Dental

mukan dalam Ekatalog

PT. Cobra Dental

PT. Cobra Dental

u Kabar Dari Penyedia

PT. Cobra Dental

PT. Jayamas Medica

PT. Trimitra Garmedindo

Interbuana

PT. Abadinusa Usahasemesta

PT. Jayamas Medica

PT. SINKO PRIMA ALLOY

 PT. Jayamas Medica Industri

PT. Dharma Medipro

PT. Dharma Medipro

PT. Sinko Prima Alloy

PT. Emiindo Jaya Bersama

PT. Emiindo Jaya Bersama

PT. Emiindo Jaya Bersama

PT. Emiindo Jaya Bersama

PT. Emiindo Jaya Bersama

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

PT. Pradana Sirona Persada

m Ekatalog

PT. Mitra Medika Utama

PT. Anugrah Mitra Selaras

PT. Karya Pratama

PT. Karya Pratama

PT. Karya Pratama

PT. Karya Pratama

PT. Multiguna Ciptasentosa

PT. Graha Megatama Indonesia

PT. Graha Megatama Indonesia

PT. Sekarguna Medica

PT. Sekarguna Medica

PT. Mega Pratama

PT. Mitra Asa Pratama

PT. Mitra Asa Pratama

peyedia

PT. Sekarguna Medica

PT. Sekarguna Medica

PT. Sekarguna Medica

PT. Sekarguna Medica

PT. Mitra Asa Pratama

PT. Mega Pratama

PT. Sekarguna Medica

 PT. Mitra Asa Pratama

PT. Mega Pratama

PT. Mega Pratama

PT. Mitra Asa Pratama

PT. Sekarguna Medica

PT. Sekarguna Medica

PT. Likuid Pharmalab

m Ekatalog
OBAT NAMA JUMLAH
1 DIAZEPAM SUPP 5MG 10

2 B12 INJEKSI 500

3 DIAZEPAM INJ 5
4 VENTOLIN NEBU 10
5 BISOLVON SOLUTION BOTOL 3

6 SALBUTAMOL TAB 4MG 5000

7 RESIN COMPOSITE 1
8 VITAMIN D 1000IU 30000
9 SANBE PLEKS DROP 1000
10 KENALOG ORABASE 12
11 TRIMIX MP 1
12 ALGINATE 1
13 DENTAL STONE 1
14 PEHACAIN INJEKSI 1
 Satuan Harga Satuan
GENERIK DIAZEPAM TABLET/KAPSUL/KAPLET 5 MG Tab 108 1,080

GENERIK FITOMENADION/ PHYTOMENADIONE/

Ampul 1,452 726,000
PHYTOMENADION (VITAMIN K1) INJEKSI 2 MG/ML (I.M.)

GENERIK DIAZEPAM INJEKSI 5 MG/ML Ampul 1,545 7,725

Tidak ada dalam ekatalog -
Tidak ada dalam ekatalog -
GENERIK SALBUTAMOL SULFATE/ SALBUTAMOL
Tab 65 325,000
TABLET/KAPSUL/KAPLET 4 MG
Tidak ada dalam ekatalog
Tidak ada dalam ekatalog
Tidak ada dalam ekatalog
TUBE
SET
BUNGKUS

KOTAK
PT. Mersifarma Tirmaku Mercusana

PT. Phapros

PT. MEPROFARM

PT.Imfarmind Farmasi Industri

rencana pembelian alkes

no nama jumlah Harga Satuan ongkir Jumlah

1 bor intan untuk jet handpiece 1 set

WOODPECKER WOODPECKER CURING
2 1 2,442,000 244,200 2,442,000
LIGHT LED-F

PRIMAMED SCHWERT IMPRESSION

TRAY PERFORATED SET - IMPRESSION
3 TRAY PERFORATED SET , FULL JAW / 1 2,546,500 254,650 2,546,500
SET SENDOK CETAK GIGI , RAHANG
PENUH

4 rubber bowl 1bh Tidak ditemukan

dalam Ekatalog
SVENSKA DENTORAMA SVENSKA -
5 DENTORAMA K FILE 15-40 1 173,000 17,300 173,000
6 jarum k-file (45-80) 1 set
SVENSKA DENTORAMA SVENSKA -
7 1 173,000 17,300 173,000
DENTORAMA K FILE 45-80
8 polishing bor 1 set
BONART BONART PIEZO ELECTRIC
9 1 5,800,000 580,000 5,800,000
ULTRASONIC SCALLER

10 ABN Sprague Rappaport Stethoscope 10 130,900 13,090 1,309,000

ONEMED STETHOSCOPE DUPLEX

11 2 39,564 3,956 79,128
DELUXE SERIES BAYI
ELITECH - INDONESIA PULSE OXIMETER
12 1 3,300,000 330,000 3,300,000
FOX-BABY

13 SERENITIY TENSIMETER KOMPAS 10

14 timbangan obat digital

FRIMED SURGICAL SCISSORS
16 SH/BL STRAIGHT 14,5 CM - 012- 2 242,000 24,200 266,200
102-145
FRIMED SURGICAL SCISSORS
17 SH/SH STRAIGHT 15,5 CM - 012- 2 286,000 28,600 314,600
104-155
18 Heilemed Penlight Zeagr Morgn 15 93,183 9,318 102,501
INEZCO MULTI PARAMETER 6 IN 1
MONITORING SYSTEM CONNECT
19 (BLOOD GLUCOSE, B KETON, TOTAL 2 1,400,000 140,000 1,540,000
CHOLESTEROL, URIC ACID,
HEMATROCIT, HEMOGLOBIN)

20 PHANTOM GIGI ANAK 1

21 PHANTOM GIGI DEWASA 1

22 STERILISATOR KERING 1 9,570,000 957,000 9,570,000

Alat ukur panjang badan bayi 10 1,490,124 1,490,124.00 14,901,240

BHP
no nama jumlah
INEZCO BLOOD GLUCOSE TEST STRIP 25
1 10 182,500 18,250 200,750
S
INEZCO BLOOD GLUCOSE /
2 HEMATOCRIT / HEMOGLOBIN TEST 2 325,000 32,500 357,500
STRIP 50 S

3 BeneCheck Plus Blood Glucose Test 1 160,000 16,000 176,000

Strip 50s
 INEZCO TOTAL CHOLESTEROL TEST
4 10 960,000 96,000 1,056,000
STRIP 25 S

5 BeneCheck Plus Total Cholesterol Test 4 250,000 25,000 275,000

Strip 10s
BENECHECK BENECHECK PLUS URIC
6 4 150,000 15,000 165,000
ACID TEST STRIP 25S
7 INEZCO URIC ACID TEST STRIP 25 S 4 524,370 52,437 576,807
8 KASA STERIL
sufratulle
JLMH+ONGKIR peyedia

2,686,200 PT. Cobra Dental

2,801,150 Daya Prima Mandiri Jaya PT

190,300 PT. Cobra Dental

190,300 PT. Cobra Dental

6,380,000 PT. Cobra Dental

1,322,090 PT. Abadinusa Usahasemesta

83,084 PT. Jayamas Medica

3,630,000 PT. SINKO PRIMA ALLOY

- PT. SERENITIY

290,400 PT. Karya Pratama

343,200 PT. Karya Pratama

111,820 PT. Multiguna Ciptasentosa

1,680,000 PT. Sekarguna Medica

ELITECH - INDONESIA MEDICAL

10,527,000 STERILIZER / STERILISATOR
ZTP80AS-UPGRADE
16,391,364

46,626,908
peyedia

2,007,500 PT. Sekarguna Medica

715,000 PT. Sekarguna Medica

176,000 PT. Mitra Asa Pratama

10,560,000 PT. Sekarguna Medica

1,100,000 PT. Mitra Asa Pratama

660,000 PT. Mitra Asa Pratama

2,307,228 PT. Sekarguna Medica

17,525,728