Lampiran Negosiasi

Nama Kegiatan : KEGIATAN BELANJA MAKANAN DAN MINUMAN PASIEN DI PELAYANAN INSTALASI GIZI RUMAH SAKIT
Pekerjaan : Belanja Makanan dan Minuman Pasien di Pelayanan Instalasi Gizi Rumah Sakit
Lokasi : Jl. Dr Wahidin Sudirohusodo, 243-B Gresik
Tahun Anggaran : 2021

TOTAL HARGA TOTAL HARGA

NO NAMA BARANG / JASA VOL SATUAN HPS SATUAN PENAWARAN NEGOSIASI TOTAL HPS
PENAWARAN NEGOSIASI
I. Makanan Padat :
1. VVIP 44 porsi Rp 30,000.00 Rp 30,000.00 Rp 30,000.00 Rp 1,320,000.00 Rp 1,320,000.00 Rp 1,320,000.00
2. VIP 30 porsi Rp 25,000.00 Rp 25,000.00 Rp 25,000.00 Rp 750,000.00 Rp 750,000.00 Rp 750,000.00
3. Kelas I 984 porsi Rp 20,000.00 Rp 20,000.00 Rp 20,000.00 Rp 19,680,000.00 Rp 19,680,000.00 Rp 19,680,000.00
4. Kelas II/Penunggu Pasien 101 porsi Rp 18,000.00 Rp 18,000.00 Rp 18,000.00 Rp 1,818,000.00 Rp 1,818,000.00 Rp 1,818,000.00
5. Kelas III 440 porsi Rp 17,500.00 Rp 17,500.00 Rp 17,500.00 Rp 7,700,000.00 Rp 7,700,000.00 Rp 7,700,000.00
II.  Makanan Khusus :
1. Diet Bubur Halus 260 porsi Rp 12,500.00 Rp 12,500.00 Rp 12,500.00 Rp 3,250,000.00 Rp 3,250,000.00 Rp 3,250,000.00
2. Diet TKTP 153 porsi Rp 12,500.00 Rp 12,500.00 Rp 12,500.00 Rp 1,912,500.00 Rp 1,912,500.00 Rp 1,912,500.00
3. Diet DM TP 36 porsi Rp 17,500.00 Rp 17,500.00 Rp 17,500.00 Rp 630,000.00 Rp 630,000.00 Rp 630,000.00
4. Diet Makanan Cair DM :
a. BC DM 1 84 porsi Rp 10,000.00 Rp 10,000.00 Rp 10,000.00 Rp 840,000.00 Rp 840,000.00 Rp 840,000.00
b. BC DM 2 0 porsi Rp 12,500.00 Rp 12,500.00 Rp 12,500.00
5. Diet Makanan Cair RP :
a. BC RP 1 42 porsi Rp 10,000.00 Rp 10,000.00 Rp 10,000.00 Rp 420,000.00 Rp 420,000.00 Rp 420,000.00
b. BC RP 2 10 porsi Rp 12,500.00 Rp 12,500.00 Rp 12,500.00 Rp 125,000.00 Rp 125,000.00 Rp 125,000.00
6. Diet Makanan Cair Medis Khusus A :
a. BC MKA 1 4 porsi Rp 10,000.00 Rp 10,000.00 Rp 10,000.00 Rp 40,000.00 Rp 40,000.00 Rp 40,000.00
b. BC MKA 2 18 porsi Rp 12,500.00 Rp 12,500.00 Rp 12,500.00 Rp 225,000.00 Rp 225,000.00 Rp 225,000.00
7. Diet Makanan Cair Hati :
a. BC H 1 0 porsi Rp 12,500.00 Rp 12,500.00 Rp 12,500.00
b. BC H 2 0 porsi Rp 15,000.00 Rp 15,000.00 Rp 15,000.00
8. Diet Makanan Cair Medis Khusus B :
a. BC MKB 1 66 porsi Rp 15,000.00 Rp 15,000.00 Rp 15,000.00 Rp 990,000.00 Rp 990,000.00 Rp 990,000.00
b. BC MKB 2 14 porsi Rp 17,500.00 Rp 17,500.00 Rp 17,500.00 Rp 245,000.00 Rp 245,000.00 Rp 245,000.00
9. Diet Makanan Cair Biasa :
a. BC B 1 88 porsi Rp 11,000.00 Rp 11,000.00 Rp 11,000.00 Rp 968,000.00 Rp 968,000.00 Rp 968,000.00
b. BC B 2 4 porsi Rp 12,500.00 Rp 12,500.00 Rp 12,500.00 Rp 50,000.00 Rp 50,000.00 Rp 50,000.00
10. Susu Formula Bayi :
a. Susu Bayi Premature 94 porsi Rp 13,500.00 Rp 13,500.00 Rp 13,500.00 Rp 1,269,000.00 Rp 1,269,000.00 Rp 1,269,000.00
b. Susu Bayi 0-6 Bulan 58 porsi Rp 13,500.00 Rp 13,500.00 Rp 13,500.00 Rp 783,000.00 Rp 783,000.00 Rp 783,000.00
c. Susu Bayi BBLR 0 porsi Rp 13,500.00
d. Susu Bayi Rendah Laktosa 0 porsi Rp 13,500.00
e. Susu Bayi Alergi 0 porsi Rp 13,500.00
f. Susu Bayi Resiko Alergi 0 porsi Rp 13,500.00
Total Sebelum PPN Rp 43,015,500.00 Rp 43,015,500.00 Rp 43,015,500.00
PPN 10% Rp 4,301,550.00 Rp 4,301,550.00 Rp 4,301,550.00
Total Sesudah PPN Rp 47,317,050.00 Rp 47,317,050.00 Rp 47,317,050.00
Terbilang : Empat Puluh Tujuh Juta Tiga Ratus Tujuh Belas Ribu Lima Puluh Rupiah
Gresik, 04 Januari 2021
Pejabat Pengadaan Barang / Jasa
PT. BANIARA NOVITA RSUD Ibnu Sina Kabupaten Gresik

Mengetahui,
Chahyadi Angka Widjaya
Direktur Pejabat Pembuat Komitmen Arifudin, Amd.Kom
RSUD Ibnu Sina Kabupaten Gresik NIP. 19781025 200604 1 011

Akhmad Munif, S.Sos

NIP. 19630416 198712 1 001
 NO PRODUK JML SATUAN TOTAL TOTAL HARGA
1 Face Shield 500 Buah Rp 19,000 Rp 9,500,000
2 Kain Kafan 50 Roll Rp 170,000 Rp 8,500,000
3 Plastik Pembungkus Jenazah 10 Roll Rp 175,000 Rp 1,750,000
Total Sebelum PPN Rp 19,750,000
PPN 10% 10% Rp 1,975,000
Total Sesudah PPN Rp 21,725,000
 HARGA
NO NAMA BARANG / JASA VOL SATUAN TOTAL HARGA
SATUAN
I. Makanan Padat :
1. VVIP 44 porsi Rp 30,000.00 Rp 1,320,000.00
2. VIP 30 porsi Rp 25,000.00 Rp 750,000.00
3. Kelas I 984 porsi Rp 20,000.00 Rp 19,680,000.00
4. Kelas II/Penunggu Pasien 101 porsi Rp 18,000.00 Rp 1,818,000.00
5. Kelas III 440 porsi Rp 17,500.00 Rp 7,700,000.00
II.  Makanan Khusus :
1. Diet Bubur Halus 260 porsi Rp 12,500.00 Rp 3,250,000.00
2. Diet TKTP 153 porsi Rp 12,500.00 Rp 1,912,500.00
3. Diet DM TP 36 porsi Rp 17,500.00 Rp 630,000.00
4. Diet Makanan Cair DM :
a. BC DM 1 84 porsi Rp 10,000.00 Rp 840,000.00
b. BC DM 2 0 porsi Rp 12,500.00
5. Diet Makanan Cair RP :
a. BC RP 1 42 porsi Rp 10,000.00 Rp 420,000.00
b. BC RP 2 10 porsi Rp 12,500.00 Rp 125,000.00

6. Diet Makanan Cair Medis Khusus A :

a. BC MKA 1 4 porsi Rp 10,000.00 Rp 40,000.00
b. BC MKA 2 18 porsi Rp 12,500.00 Rp 225,000.00
7. Diet Makanan Cair Hati :
a. BC H 1 0 porsi Rp 12,500.00
b. BC H 2 0 porsi Rp 15,000.00
8. Diet Makanan Cair Medis Khusus B :
a. BC MKB 1 66 porsi Rp 15,000.00 Rp 990,000.00
b. BC MKB 2 14 porsi Rp 17,500.00 Rp 245,000.00
9. Diet Makanan Cair Biasa :
a. BC B 1 88 porsi Rp 11,000.00 Rp 968,000.00
b. BC B 2 4 porsi Rp 12,500.00 Rp 50,000.00
10. Susu Formula Bayi :
a. Susu Bayi Premature 94 porsi Rp 13,500.00 Rp 1,269,000.00
b. Susu Bayi 0-6 Bulan 58 porsi Rp 13,500.00 Rp 783,000.00
c. Susu Bayi BBLR 0 porsi Rp 13,500.00
d. Susu Bayi Rendah Laktosa 0 porsi Rp 13,500.00
e. Susu Bayi Alergi 0 porsi Rp 13,500.00
f. Susu Bayi Resiko Alergi 0 porsi Rp 13,500.00
Total Sebelum PPN Rp 43,015,500.00
PPN 10% 10% Rp 4,301,550.00
Total Sesudah PPN Rp 47,317,050.00