Page ad RUMAH SAKIT UMUM ST. ANTONIUS. Jl K. H. Wahid Hasyim No. 249 Pontianak Telp. (0561) 732101 Fax (0561) 733623, (0561) 742242 PERINCIAN TAGIHAN PASIEN Periode: 07 - Oct - 2022 s/d 08 - Oct - 2022 No, Reg 1 REG/IP/221007-0019 No.MR 12-65-86 Noma MARGARETHA WILYANA To. Keluar 08-0¢t-2022 21:14 Alamat: JL, PEMBANGUNAN KOMP. DALISA PERMAI DS. Kiasifikasi Pasien © Tanggungan Karyawen . PONTIANAK PSSA Tol, Registrasi 07-Oct-2022 14:52 Kelas C I Unitykis/No.Kamar —: St, Maria 1 /1/263-2 tet Keterangan Kamar Ruang Perawatan Status Kamar | Tanggal Masuk | ‘Tanggal Keluar St Maria 1 Inap 07-Oct-2022 14:52 |oe-oct-2022 ttt Rincian Pelayanan & Jasa Dokter Deskripsi Kelas Harga Qty | Total Diskon| Total Pasien |Total fetenl Visite & Konsultasi Dokter ‘St. Maria 1 ‘ese Medik Visite (Or. Marcellinus T 150,000] 7 150,000] q ae Kowira, $p.06) Jasa Medik Visite (hari Minggu/Libur) I 150,000) 1 150,000] qj a {Dr. Marceliinus Kowira, $0.0G) SubTotal: 300,000 0 Q Total: 300,000 8 ¢ Tindaken Medik cere |Paket Tindeken Koret Biasa (Or. T 1,515,000] 7 963,750] 551,259] Marcellinus Kovéra, $9.06) - bee eae SubTotal: 963,750 $51,250 { Total : (963,750 551,250 Pelayanan Penunjang Medik [Test Rapid Antigen SARS COV-2 Paket C] BR. JALAN 6,000] T 76,500] FSH) \(Ranap IGO) (Or. Novita Prosaria Rohana Siahaan, Sp. PK., M.Kes.; Or. \Ady Jaya Dokta; Petugas Laboratorium) a SubTotal: 16,500 49,500 q es Total: 16,500 49,500 a Sewa KamarMaria 1 - Kelas 1 Page 1/3 599,009| fl 149,750] 449,280] q Sub Total : 149,750 449,250 Total : 149,750 449,250 a Pelayanan Non Medik 16D [Rdiministras! Rawat Jalan RJALAN | 35,000) 7 B75] «26,280 7 ‘Sub Total : 8,750 26,250 0) ‘St. Maria 1 [Administrasi Rawat Inap T 350,000] yf 87,500] 262,509] q SubTotal: 87,500 262,500 q Total: 96,250 (288,750 q Pelayanan Penunjang Medik Laboratorium . T 000] 7 17,250) 31,759 0] SubTotal: 17,250 51,750 9 Total: 17,250 51,750 a Bahan Habis Pakai = St. Maria [ATROPINE SULFAT INJ T 11,000] y 2,750) 8,250) q |BLEDSTOP IN} T 10,000! 1 2,500) 7,500] gi |Handscoen No. 7 Gamex: T 31,700) a 7,925] 23,775) 0} [INDUXIN IND T 14,700) 7] 3a75) 11,025] a SubTotal: 16,850 50,550 a { Total: 16,850 50,550 a} | Farmasi | Instalasi Farmasi [AQUA DEST TOME : 5,600] 7 2,800] ado, CSCS |BLEDSTOP TAB 125 MCG 900) 10) 2,250] 6,750| oO} |CEFAT S00 MG CAPS ' 13,800) 10) 34,500| 103,500} ae 0 RING AS INFUSAN: 30,200) q 7,550) 22,650} Oj IV Catheter No. 20 with port injection 2,100 ij 7,275} 21,825] 7 KETAMIN INI 721,200) 19) 33,000] 159,000) 7” IMEFINAL 500 MG TABLET > 7,900 iy) 4,750 14,259] 7” ONDANSETRON 4 MG IND “| 6,700) 1 1875| 5,035 7" PLASMINEX INT - 16,900) i 4228 12,673| "q RATIVOL INJ : 49,500) 1] 12,375| 37,125] ol ISpuit 5 Cc NP 1,700, 2 850) 2,550| ol (Spuit 3 Cc NP - 7,500 "3 113 3335 7 [Tranfosi Set Type V INS 65,600) 7] 17,400 352,200 7Page 23, |VALISANBE INJ Hee 24,400) 6,100| 18,309] 4 SubTotal: 178,825 536,475 Total: 178,825 536,475 | Lain-lain St. Maria 1 Pembalut Wanita (Monalisa Jumbo) @ T 30,500] T 7,65] 22875] q 10 pes/Bks Sub Total : 7,625 22,875 0} Total; 7,625 22,875 ao Grand Total: 1,746,800 2,000,400 z Total Tagihan =: Rp. 2,000,400 5 Petugas Administration + Rp. Q Total Pasien Rp 2,000,400 Total Instansi : Rp. 0 No.Interm Bill :18/221011/0026,18/221011/0027 Hironimus Rony, AMA tht os0:35