Rujukan 2018

Jumlah
No Tanggal No. MR Nama Pemeriksaan Pemeriksaan

1 1/1/2018 02.70.32 Wulan Mranani Analisa Gas Darah 1
2 2/1/2018 00.34.66 Nazwa Aulia Kultur Aerob (Darah) 1
3 02.68.77 Arief M. Anti HIV 1
4 02.37.77 Heri K. FT4, TSH 2
7 02.62.29 Zuraida Biopsi Jar. Kecil 1
Gamma-GT, TSH, FT4, IgG Anti
8 3/1/2018 02.65.85 Elang Bagaskara 5
CMV, IgM Anti CMV
9 00.94.03 Holiyah Analisa Gas Darah 1
5 4/1/2018 00.94.03 Holiyah Analisa Gas Darah 1
6 02.58.25 Fatimah FT4, TSH 2
10 02.70.07 Misan Analisa Gas Darah 1
11 02.61.24 Alit Analisa Gas Darah 1
12 5/1/2018 02.71.29 Ardhan CRP 1
13 02.70.94 Moh. Hosain T4, T3, FT4 3
14 01.24.04 Meiske SI, TIBC 2
15 01.47.80 Tunah Analisa Gas Darah 1
16 6/1/2018 02.72.13 Fitri R. Analisa Gas Darah 1
17 7/1/2018 01.93.67 Eti Analisa Gas Darah 1
Gamma-GT, TSH, FT4, IgG Anti
18 8/1/2018 02.72.00 Putri Fatimah 5
CMV, IgM Anti CMV
19 02.71.92 Neneng M. Fibrinogen, D-Dimer 2
20 02.72.13 Fitri R. Analisa Gas Darah 1
21 02.70.94 Moh. Hosain TCM 1
22 01.68.17 Partilah TCM 1
23 00.70.79 Sait bin Nimin TCM 1
25 02.71.23 Hisar TCM 1
26 02.68.65 Trinah Analisa Gas Darah 1
27 9/1/2018 02.68.77 Arief M. TCM 1
28 02.58.31 Calief SI, TIBC 2
29 02.35.70 Rodiansyah FT4, TSH 2
30 02.69.08 Hasni Ahmad FT4, TSH 2
31 01.82.72 Galih Aditya Analisa Gas Darah 1
32 10/1/2018 02.66.15 Tintin TCM 1
33 02.39.81 Wati T. FT4, TSH 2
34 02.37.13 Winda W. FT4, TSH 2
35 01.68.27 Partilah Biopsi Jar. Kecil 1
36 11/1/2018 01.57.54 Siti Fatimah FT4, TSH 2
37 02.62.94 Inan Belit TCM 1
38 01.58.29 Mursidi TCM 1
39 02.22.17 Odi Rusyanto TCM 1
40 12/1/2018 01.46.45 Nouman Abdul M. SI, TIBC 2
41 00.74.48 Surinah FT4, TSH 2
42 15/1/2018 02.73.56 Harlan TCM 1
43 02.74.10 Sukiyati Analisa Gas Darah 1
44 16/1/2018 00.15.38 Togi F. TCM 1
45 02.73.17 Rahmawati TCM 1
46 01.12.10 Karolina S. FT4, TSH 2
47 01.95.52 Dian S. TCM 1
48 17/1/2018 00.14.26 Saparudin TCM 1
49 02.75.07 Hania A. Analisa Gas Darah 1
50 01.35.80 Amelia M. FT4, TSH 2
51 01.49.82 Nurul P. T3, TSH, FT4 3
52 02.73.07 Indira G. TCM 1
53 01.68.01 Royani TCM 1
54 02.74.51 Andika P. TCM 1
55 02.74.52 Nur Fatona TCM 1
56 18/1/2018 02.72.84 Ratna Ningsih TCM 1
57 01.07.90 Supriyantini TCM 1
58 02.74.81 Ali Paseh FT4, TSH 2
59 01.33.63 Andi Nur Ilham Kultur Aerob (Urin) 1
60 02.73.14 Triedi S. TCM 1
61 19/1/2018 02.60.31 By. Rafardhan Analisa Gas Darah 1
62 01.72.95 Nurwanti Biopsi Jar. Kecil 1
63 02.75.03 Suhaedah T3, TSH, FT4 3
64 02.75.35 Najwa N. TCM 1
65 20/1/2018 02.12.82 Nesah TIBC 1
66 02.39.81 Wati T. FT4 1
67 02.74.92 Mutia Riana Antibodi malaria 1
68 02.76.04 Supandi TCM 1
69 02.75.72 Nina Holilah TCM 1
70 02.75.12 Wiwi Widyarsih Biopsi Jar. Kecil 1
71 23/1/2018 02.75.77 Wenih TCM 1
72 02.72.54 Yapaq TCM 1
73 02.74.24 Rafif TIBC 1
74 00.36.70 M. Djunaidi TIBC 1
75 00.26.31 Filza Analisa Gas Darah 1
76 24/1/2018 02.74.60 Fatimah Analisa Gas Darah 1
77 25/1/2018 02.76.48 Rasyid Antibodi malaria 1
78 02.73.81 Kemy Enggal P. Biopsi Jar. Kecil 1
79 26/1/2018 00.78.05 Heman CH TCM 1
80 02.76.70 Ernawati M. T3, TSH, FT4 3
81 01.62.01 Ira Dewi FT4, TSH 2
82 02.77.32 Nureliyawati FT4, TSH 2
83 02.77.21 Ahmad FS TCM 1
84 02.76.31 Filza CRP 1
85 28/1/2018 02.77.87 M. Rizal Analisa Gas Darah 1
86 02.77.87 M. Rizal Analisa Gas Darah 1
87 29/1/2018 02.77.55 H. Solichin TCM 1
88 02.77.62 Maslih Hani TCM 1
89 30/1/2018 02.65.47 Z ABD Rohman FT4, TSH 2
90 31/1/2018 02.62.59 AR Soentono FT4, TSH 2
91 02.76.38 Sutarmi TCM 1
92 02.61.05 Maryati Analisa Gas Darah 1
93 01.50.40 Topan Analisa Gas Darah 1
94 01.50.40 Topan Analisa Gas Darah 1
Total 128
BPJS 9,805,000
UMUM 1,330,000
Nama Lab Harga Pembayaran
Rujukan
PASBO Rp 135,000 BPJS
PASBO Rp 490,000 Umum


PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
Rp 11,135,000
Jumlah Nama Lab
No Tanggal No. MR Nama Pemeriksaan Pemeriksaan Rujukan
1 1/2/2018 02.76.36 Sutarmi TCM 1 PKM
2 02.78.49 Habibati TCM 1 PKM
3 02.78.89 Minah TCM 1 PKM
4 02.79.25 Margaret Troponin I, Analisa Gas Darah 2 PASBO
5 2/2/2018 02.05.72 Muslikah TSH, FT4 2 PASBO
6 02.76.28 Sariningsih Biopsi Jar. Kecil 1 PASBO
7 02.72.49 Novi Ika R. Biopsi Jar. Kecil 1 PASBO
8 02.74.48 Kartinah Biopsi Jar. Kecil 1 PASBO
9 4/2/2018 00.89.68 Diah Eka Rini Troponin I 1 PASBO
10 02.31.11 Sulis Susilowati Troponin I 1 PASBO
11 02.79.76 M. Yusuf Usman TCM 1 PKM
12 00.74.21 Tolopan S. TCM 1 PKM
13 5/2/2018 02.79.32 Aman TCM 1 PKM
14 02.78.71 Wulandari TCM 1 PKM
15 7/2/2018 02.79.59 Galuh Kultur Aerob (Darah) 1 PASBO
16 02.80.05 Junaedi Sitologi (C.Sendi), Rivalta 2 PASBO
17 8/2/2018 02.80.12 M. Wasroy Sitologi (C.Pleura) 1 PASBO
18 02.20.85 Darmin Analisa Gas Darah 1 PASBO
19 02.35.10 Rury Sri R. Analisa Gas Darah 1 PASBO
20 9/2/2018 00.37.33 Solihin TIBC 1 PASBO
21 02.72.00 Putri Fatimah IgG Anti CMV, IgM Anti CMV 2 PASBO
22 01.83.44 Adinda S. TCM 1 PKM
23 02.80.37 Juni R. TCM 1 PKM
24 00.23.14 H. M. Daud D. Analisa Gas Darah 1 PASBO
26 02.35.10 Rury Sri R. Analisa Gas Darah 1 PASBO
25 10/2/2018 02.35.10 Rury Sri R. D-Dimer, Fibrinogen 2 PASBO
27 12/2/2018 02.77.12 Rafi Rizqi TIBC 1 PASBO
28 02.81.77 Tatiya Annisa Ca. ion 1 PASBO
29 13/2/2018 02.35.10 Rury Sri R. Anti HIV 1 PASBO
30 02.8.00 Hj. Yusra P.A. Jaringan Otak 1 RSCM FKUI
31 14/2/2018 02.79.99 Sahat Biopsi Jar. Kecil 1 PASBO
32 00.68.23 Luqmanul TIBC 1 PASBO
33 02.69.96 Afiya D.Z. SI, TIBC 2 PASBO
34 00.82.29 Susane Toxoplasma IgM 1 PASBO
35 15/2/2018 00.45.97 Gunawan Analisa Gas Darah 1 PASBO
36 01.66.25 Deby T. TCM 1 PKM
37 02.64.18 Taja TSH, FT4 2 PASBO
38 01.45.23 Marindu TCM 1 PKM
39 00.18.06 Andrew TCM 1 PKM
40 02.80.95 Rafif TCM 1 PKM
41 16/2/2018 00.74.21 Tolopan S. Analisa Gas Darah 1 PASBO
42 19/2/2018 00.71.48 Surinah T3, T4, TSH 3 PASBO
43 02.82.50 Fitri Handayani T3, T4, TSH 3 PASBO
44 00.40.48 Oeripto D-Dimer, Fibrinogen 2 PASBO
45 02.83.18 Aeni bt Idup Analisa Gas Darah 1 PASBO
46 20/2/2018 02.33.62 Diman Sandika FT4, T3, TSH 3 PASBO
47 21/2/2018 02.75.07 Hania S. TIBC 1 PASBO
48 02.39.81 Wati T. TSH, FT4 2 PASBO
49 02.76.09 Ali Anton HIV Rapid 1 PASBO
50 02.83.16 Khiar Salma Kultur Aerob (Urine) 1 PASBO
51 22/2/2018 02.83.90 Prascenda TCM 1 PKM
52 02.83.59 Sutarni TCM 1 PKM
53 02.82.53 Oman TCM 1 PKM
54 00.15.38 Togi F. TCM 1 PKM
55 01.03.09 Leni S. TSH, FT4 2 PASBO
56 01.71.56 Delisah TSH, FT4 2 PASBO
57 02.34.02 Rohana HIV Rapid 1 PASBO
58 23/2/2018 02.73.58 Harlan Y. HIV Rapid 1 PASBO
59 01.59.21 Darmawansyah Analisa Gas Darah 1 PASBO
60 25/2/2018 00.15.92 Darmawansyah Analisa Gas Darah 1 PASBO
61 26/2/2018 00.15.92 Darmawansyah CRP, Kultur Aerob (Darah) 2 PASBO
62 Teguh Wiyono TCM 1 PKM
63 27/2/2018 01.49.14 Yasin Analisa Gas Darah 1 PASBO
64 02.85.13 Ernawati TSH, FT4 2 PASBO
65 02.01.13 Siti Fatimah TIBC 1 PASBO
Total 84
BPJS 7,852,000
UMUM 465,000
Harga Pembayaran
-
-
-
Rp 290,000 BPJS
Rp 200,000 BPJS
Rp 350,000 BPJS
Rp 350,000 BPJS
Rp 350,000 BPJS
Rp 155,000 BPJS
Rp 155,000 BPJS
-
-
-
-
Rp 260,000 BPJS
Rp 292,000 BPJS
Rp 250,000 Umum
Rp 135,000 BPJS
Rp 135,000 BPJS
Rp 40,000 Umum
Rp 290,000 BPJS
-
-
Rp 135,000 BPJS
Rp 135,000 BPJS
Rp 250,000 BPJS
Rp 40,000 BPJS
Rp 135,000 Umum
Rp 90,000 BPJS
- Umum
Rp 350,000 BPJS
Rp 40,000 Umum
Rp 90,000 BPJS
Rp 115,000 BPJS
Rp 135,000 BPJS
-
Rp 200,000 BPJS
-
-
-
Rp 115,000 BPJS
Rp 265,000 BPJS
Rp 265,000 BPJS
Rp 250,000 BPJS
Rp 115,000 BPJS
Rp 290,000 BPJS
Rp 40,000 BPJS
Rp 200,000 BPJS
Rp 90,000 BPJS
Rp 260,000 BPJS
-
-
-
-
Rp 200,000 BPJS
Rp 200,000 BPJS
Rp 90,000 BPJS
Rp 90,000 BPJS
Rp 115,000 BPJS
Rp 115,000 BPJS
Rp 295,000 BPJS
-
Rp 115,000 BPJS
Rp 200,000 BPJS
Rp 40,000 BPJS
Rp 8,317,000
Jumlah
1 1/3/2018 02.86.04 Sukni TSH, FT4 2
2 02.85.98 Al-Husain TIBC 1
3 2/3/2018 02.29.02 Jihad Elbana Analisa Gas Darah 1
4 5/3/2018 02.86.27 Tanti Eka TCM 1
5 02.86.11 Poniajo TCM 1
6 02.71.87 Lies Hermasyah T3, TSH, FT4 3
7 7/3/2018 02.86.95 Agung TCM 1
8 02.86.66 Nandar TCM 1
9 00.71.48 Surinah FT4 1
10 8/3/2018 02.87.87 M. Soleh Analisa Gas Darah 1
11 01.74.58 Ferry D. TIBC 1
12 9/3/2018 02.87.94 Sri Dewi S. TIBC 1
13 02.86.37 Djoni T. TCM 1
14 01.56.75 M. Yahya TCM 1
15 02.85.78 Mulya Yati S. Anti HIV 1
16 02.73.14 Tri Edi Analisa Gas Darah 1
17 10/3/2018 02.88.25 M. Rifan Analisa Gas Darah 1
18 02.88.34 Marbun L. Analisa Gas Darah 1
19 11/3/2018 02.35.70 Rodiansyah TSH, FT4 1
20 02.88.50 Khubaib Analisa Gas Darah 1
21 13/3/2018 02.22.91 Jamaluddin TCM 1
22 01.74.47 H. M. Mukim TCM 1
23 02.19.95 Sri Sulastri TCM 1
24 02.86.95 Agung Triyani Anti HIV 1
25 02.85.56 Rully Yanvar Anti HIV 1
26 02.71.92 Neneng M. T3, TSH, FT4 3
27 14/3/2018 02.88.54 Misrianto TCM 1
28 02.84.22 Gusmawi TCM 1
29 15/3/2018 02.87.85 Zoya Maureen TCM 1
30 01.87.37 Jayadi TCM 1
31 02.87.53 Sri L. TCM 1
32 02.89.28 Faizal TCM 1
33 00.67.48 Kardi Analisa Gas Darah 1
34 16/3/2018 02.88.81 Widodo Gamma-GT 1
35 02.89.33 Muslim TSH, FT4 2
36 02.89.68 Kasiati Anti HIV 1
37 17/8/2018 02.90.21 Nani S. Analisa Gas Darah 1
38 18/3/2018 02.39.35 Ramnah Analisa Gas Darah 1
39 02.90.15 Haryati Analisa Gas Darah 1
40 00.34.92 Hermawati Analisa Gas Darah 1
41 19/8/2018 02.85.79 Marina Hana Biopsi Jar. Kecil 1
42 02.89.75 Anisa Nur Anti HIV 1
43 02.90.21 Nani S. Analisa Gas Darah 1
44 20/8/2018 02.89.75 Annisa Nur C. TCM 1
45 02.89.88 Chandra Rifki TCM 1
46 02.61.97 Ati Aminingsih Anti HIV 1
47 02.90.59 Hendra Gunawan TCM 1
48 01.73.89 Ahmad Sanusi TCM 1
49 00.34.92 Hermawati TCM 1
50 00.65.98 Magdalena Hapsah T3, TSH, FT4 3
51 02.90.52 Tugiarti TSH, FT4 2
52 00.66.29 Santi Anti HIV 1
53 01.26.85 Suryati Biopsi Jar. Kecil 1
54 02.90.78 Dede Suwanto Fibrinogen, D-Dimer 2
55 01.58.02 Fahreza Analisa Gas Darah 1
56 02.90.78 Dede Suwanto Analisa Gas Darah 1
57 21/3/2018 02.89.75 Annisa Nur C. Rivalta 1
58 01.33.47 Arwin Widodo TCM 1
59 02.90.61 Teuku M. Rafli TCM 1
60 01.47.46 Nasihyati TCM 1
61 02.87.52 Supardiyo TCM 1
62 02.60.60 Muh. Nur Ali TCM 1
63 01.08.47 Satijan Analisa Gas Darah 1
64 22/3/2018 00.51.20 Umi Sangadah TSH, FT4 2
66 02.76.14 Hainul Analisa Gas Darah 1
68 01.73.17 Rahmawati TCM 1
69 02.90.15 Harianti TCM 1
70 02.79.81 Ahmad TCM 1
71 02.91.48 Hari S. Biopsi Jar. Kecil 1
72 02.91.57 Junita T3, TSH, FT4 3
73 23/3/2018 02.90.88 Sholeman Biopsi Jar. Kecil 1
74 02.86.38 Nuraniati Biopsi Jar. Kecil 1
75 24/3/2018 02.76.24 Hainul Anti HIV 1
76 02.46.72 Tri Kurniastuti Anti HIV 1
77 02.92.07 Maya Maria Analisa Gas Darah 1
79 02.88.76 Asman Fibrinogen, D-Dimer 2
80 25/3/2018 02.76.24 Hainul Analisa Gas Darah 1
82 02.85.51 Nining P. T4, T3, TSH 3
83 27/3/2018 02.88.81 Widodo Biopsi Jar. Kecil 1
84 02.89.88 Chandra Anti HIV 1
86 02.93.11 Trianis Anti HIV 1
87 28/3/2018 02.87.34 Maat Sholeh Analisa Gas Darah 1
88 02.76.24 Hainul Analisa Gas Darah, Mg 2
89 02.24.55 Suwandi TCM 1
90 02.87.37 Retno I. TCM 1
91 02.92.46 Bonar S. TCM 1
92 02.92.66 M. Supardi TCM 1
93 01.95.01 P. Elisheva TIBC 1
94 01.91.54 P. Elisheba TIBC 1
96 00.19.71 Otih Analisa Gas Darah 1
98 02.93.40 Djaimun Analisa Gas Darah 1
Total
BPJS 9,302,000
UMUM 1,060,000
Rujukan
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
Rp 10,362,000
Jumlah
1 2/4/2018 02.93.76 Mumun TCM 1
2 00.64.11 Susanto TCM 1
3 01.39.42 Sularno TCM 1
4 3/4/2018 02.70.84 Ika Septi Biopsi Jar. Kecil 1
5 02.82.28 Supriyadi Biopsi Jar. Kecil 1
6 02.94.10 Anji TCM 1
7 02.88.42 Misti Sukaesih TCM 1
8 4/4/2018 01.67.00 Rohanih TCM 1
9 02.91.57 Junita Biopsi Jar. Kecil 1
10 02.74.81 Ali Pase TSH, FT4 2
11 5/4/2018 02.94.30 Nemot Ca-125 1
12 01.87.77 Halimah Anti HIV 1
13 6/4/2018 02.78.58 Ilchma Fauziah Anti HCV 1
14 02.29.52 Maria Suprihatin TSH, FT4 2
15 02.95.73 Andrian Herjanto Anti HCV 1
16 02.95.86 Dedi Junaidi Anti HCV 1
17 7/4/2018 02.95.74 Marlin D-Dimer, Fibrinogen 2
18 9/4/2018 02.95.88 Lasmin HBsAg, Anti HCV, Anti HIV 3
19 02.95.90 Sutianah TCM 1
20 02.95.88 Lasmin TCM 1
21 02.95.51 Jhonson Sianturi Anti HCV 1
22 02.95.68 Erry Syaban TCM 1
23 10/4/2018 02.95.88 Lasmin CD-4 1
24 11/4/2018 02.11.81 Bayu Darmawan TCM 1
25 02.95.58 Delon Ady TCM 1
26 02.65.96 Eben Ezer BR TCM 1
27 01.28.38 Jeani Santika TCM 1
28 02.95.82 Gani Aprianto Sitologi (C.Pleura), Rivalta 2
29 02.95.90 Sutinah bt Janos Anti HIV 1
30 02.95.21 Dewi Nurhayati Biopsi Jar. Kecil 1
31 13/4/2018 02.39.81 Watti Trisnawati TSH, FT4 2
32 02.97.00 Sofyan TCM 1
33 02.97.06 Sumbono Anti HCV 1
34 02.97.07 Fithriyyah TCM 1
35 16/04/2018 02.96.99 Yusup TCM 1
36 00.83.32 Sanih T3, TSH, FT4 3
37 18/04/2018 02.98.25 Rusliyanto TCM 1
38 19/04/2018 02.98.28 Purwati Biopsi Jar. Kecil 1
39 02.94.92 Ade Fatma Biopsi Jar. Kecil 1
40 02.99.00 Sunhaji TSH, FT4 2
41 20/04/2018 02.99.30 Annaya Eka P. T4, TSH, FT4 3
42 02.99.40 Iyah Asiyah TSH, FT4 2
43 02.84.04M. Simbolon D-Dimer 1
44 02.59.42Casriyah TSH, FT4 2
45 02.96.97Nimat TCM 1
46 23/04/2018 01.80.05Tini Maryani Anti HCV 1
47 24/04/2018 01.57.54Siti Fatimah TSH, FT4 2
48 25/04/2018 02.53.73Saipan TCM 1
49 26/04/2018 02.98.66Nyai bt Salehudin TCM 1
50 27/04/2018 03.00.02Syari Nartha Magnesium 1
51 03.00.69Rimin TCM 1
52 03.00.70Siti Mulyani TCM 1
53 03.01.07Nuri K. T3, TSH, FT4 3
54 30/04/2018 03.01.04Ratima TCM 1
Total
BPJS 6,004,000
UMUM 660,000
Rujukan
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
PKM -
Rp 6,664,000
Jumlah
1 2/5/2018 03.01.54 Rifqi Aditya Magnesium, TSH, FT4 3
2 00.68.81 Chairuddin TCM 1
3 3/5/2018 02.05.72 Muslikah TSH, FT4 2
4 03.01.50 M. Amon Jaringan Besar 1
5 03.02.21 Kartinah D-dimer, Fibrinogen 2
6 4/5/2018 03.01.07 Febri Nelda TCM 1
7 02.58.22 Baih TCM 1
8 7/5/2018 02.64.16 Ferdian Cahyadi TCM 1
9 02.21.59 Fia Anggraini TSH, FT4 2
10 8/5/2018 01.35.80 Amelia Maharani TSH, FT4 2
11 02.96.99 Yusup TCM 1
12 03.00.07 Linyah Jaringan Besar 1
13 9/5/2018 01.30.08 Rina Meity Ca-125 1
14 11/5/2018 01.71.56 Delisah TSH, FT4 2
15 03.01.26 Raffa Satria Kamil TIBC 1
16 03.02.26 Ratih Sumarto Rivalta 1
17 03.02.97 Sunenti Laktat 1
18 14/5/2018 03.02.98 Riski Maulana Anti HIV (ELISA) 1
19 03.03.95 Loveyta Magnesium 1
20 15/5/2018 03.03.63 Sugeng S. TSH 1
21 03.04.68 Maya Maretha Ca-125 1
22 03.02.98 Riski Maulana CD-4 1
23 16/5/2018 03.05.26 Sumarti Anti HBs 1
24 03.05.34 Tri Endah TSH, FT4 2
25 03.05.36 Mulyani TSH, FT4 2
26 02.29.29 Loveyta TIBC 1
27 01.92.93 Gava TIBC 1
28 17/5/2018 03.05.67 Antoro bin Sardi T3, T4, FT4, TSH 4
29 03.05.78 Rahmat Hidayat Analisa Gas Darah 1
30 18/5/2018 01.57.54 Siti Fatimah Biopsi Jar. Kecil 1
31 03.02.98 Riski Maulana Anti HIV (ELISA) 1
32 03.03.92 Idah Djubaedah TSH, FT4 2
33 03.04.16 Kalti Qalbiat TSH, FT4 2
34 21/5/2018 01.83.66 M. Agung Nugroho TIBC 1
35 03.05.88 M. Heryanto TCM 1
36 02.37.63 Juriah T4, T3, TSH 3
37 22/5/2018 03.06.49 Tawekal Anti HIV (RAPID) 1
38 03.06.16 Marina Ledysha Ca-125 1
39 02.11.42 Nini TSH, FT4 2
40 03.06.02 Aliemran Nasution TSH, FT4 2
41 01.43.93 Kusfebriani Anti HIV (RAPID) 1
42 23/5/2018 03.06.68 Oyok Maryati T4, T3, TSH 3
43 03.04.70 Sumirah Biopsi Jar. Kecil 1
44 24/5/2018 03.02.24 Parsini Anti HIV 1
45 00.04.20 Jeani Oktavia Anti HIV 1
46 03.05.84 Syahira Layla TIBC, TSH 2
47 03.05.93 Shera Eria TIBC 1
48 25/5/2018 02.25.74 Chodijah Anti HIV 1
49 28/5/2018 00.76.72 Nita VDRL 1
IgG Toxoplasma, IgM
50 00.85.29 Suzanne H. 2
Toxoplasma
51 31/5/2018 03.08.48 Zailani T3, T4, FT4, TSH 4
52 03.01.63 Misa bin Gole D-dimer 1
Total
BPJS 7,275,000
UMUM 570,000
Rujukan
PKM -
PKM -
PKM -
PKM -
PKM -
PASBO -

Rp 7,845,000
Jumlah Nama Lab
No Tanggal No. MR Nama Pemeriksaan Pemeriksaan Rujukan Harga Pembayaran
1 1/6/2018 02.29.21 Jamaluddin D-Dimer 1 PASBO Rp 135,000 BPJS
2 4/6/2018 03.06.71 Iswanto bin Kusdi Biopsi / Jar. Kecil 1 PASBO Rp 350,000 BPJS
3 02.45.86 Sab'ah Biopsi / Jar. Kecil 1 PASBO Rp 350,000 BPJS
4 03.08.00 Wandra Rivalta 1 PASBO Rp 42,000 BPJS
5 02.39.81 Wati Trisnawati TSH, FT4 2 PASBO Rp 200,000 BPJS
6 03.09.03 Wilkent Alberto Anti HIV 1 PASBO Rp 90,000 BPJS
7 02.59.30 Agustianah Anti HIV 1 PASBO Rp 90,000 Umum
8 01.21.23 Dalih PT / INR 1 PASBO Rp 115,000 BPJS
9 03.09.46 Murtia H. PT / INR, APTT, Anti HIV 3 PASBO Rp 320,000 BPJS
10 5/6/2018 03.09.18 Teguh Trisutama Anti HIV 1 PASBO Rp 90,000 BPJS
11 03.00.05 Ratna Sari Dewi Anti HIV 1 PASBO Rp 90,000 BPJS
12 03.01.52 Adiba Shakila CMV IgG, CMV IgM, TSH, FT4 4 PASBO Rp 490,000 BPJS
13 03.09.48 Ida Triastutik VDRL, TPHA, Anti HIV 3 PASBO Rp 170,000 BPJS
14 03.06.52 Wanih bt Wahab Biopsi / Jar. Kecil 1 PASBO Rp 350,000 BPJS
15 03.09.38 Eka Agustiawningsih PT / INR, APTT, Anti HIV 3 PASBO Rp 320,000 BPJS
16 03.09.24 Viktoria Perjinia Kultur Aerob (Darah) 1 PASBO Rp 260,000 BPJS
17 6/6/2018 03.09.68 Andi Rokhanda CEA 1 PASBO Rp 155,000 BPJS
18 01.35.80 Amelia Maharani FT4 1 PASBO Rp 115,000 Umum
19 02.90.54 Fika Wulansari Anti HIV 1 PASBO Rp 90,000 BPJS
Toxoplasma IgG, Toxoplasma
20 7/6/2018 03.10.04 Diah Fari Andini IgM, Rubella IgG, Rubella IgM 4 PASBO Rp 520,000 BPJS
21 8/6/2018 03.09.24 Viktoria Perjinia HSV1 IgG, HSV1 IgM, HSV2 4 PASBO Rp 780,000 BPJS
IgG, HSV2 IgM
22 03.09.38 Eka Agustiawningsih Biopsi / Jar. Kecil 1 PASBO Rp 350,000 BPJS
23 03.10.39 Ratika PT / INR, APTT 2 PASBO Rp 230,000 BPJS
24 9/6/2018 03.09.24 Viktoria Perjinia Anti HIV 1 PASBO Rp 90,000 BPJS
25 12/6/2018 03.10.95 Meilan Saraswati Anti HIV 1 PASBO Rp 90,000 BPJS
26 03.10.87 Sanih Asih TSH, FT4 2 PASBO Rp 200,000 BPJS
27 01.80.05 Tini Maryani T3, T4, TSH, FT4 4 PASBO Rp 380,000 Umum
28 13/6/2018 02.35.77 Donowasito Lipase 1 PASBO Rp 85,000 BPJS
29 17/6/2018 03.11.40 Nadih PT / INR, APTT, D-Dimer 3 PASBO Rp 365,000 BPJS
30 18/6/2018 03.11.40 Nadih Lipase 1 PASBO Rp 85,000 BPJS
31 19/6/2018 03.09.41 Sulistiyarni Anti HIV 1 PASBO Rp 90,000 BPJS
32 00.23.14 M. Daud Kultur Aerob (Feses) 1 PASBO Rp 260,000 BPJS
33 20/6/2018 03.11.07 Danang bin Hadi Kultur Aerob (Darah) 1 PASBO Rp 260,000 BPJS
34 25/6/2018 02.64.19 Taja bin Ciwong TSH, FT4 2 PASBO Rp 200,000 BPJS
35 26/6/2018 03.05.07 M. Azka Al Fatih TSH, FT4 2 PASBO Rp 200,000 BPJS
36 03.13.28 Peni Saraswati Anti HIV 1 PASBO Rp 90,000 BPJS
37 01.62.45 Irma Puspaningrum TSH, FT4 2 PASBO Rp 200,000 BPJS
38 02.76.21 Suci Indrawati Anti HIV 1 PASBO Rp 90,000 Umum
Total Rp 8,387,000
BPJS 7,712,000
UMUM 675,000
No Tanggal No. MR Nama Pemeriksaan Harga Pembayaran
1 5/7/2017 01.05.68 Hilma Maas T4, T3, TSH Rp 265,000 BPJS
2 02.14.36 Sri Lestari Biopsi Jaringan Kecil Rp 350,000 BPJS
3 7/7/2017 02.14.03 Sri Wahyuti FNAB dengan tindakan Rp 350,000 BPJS
4 02.09.16 Andri Priliana Biopsi Jaringan Kecil Rp 350,000 BPJS
5 10/7/2017 02.17.20 By.Ny. Tita R. SI, TIBC Rp 90,000 BPJS
6 02.19.62 Surginem Biopsi Jaringan Kecil Rp 350,000 BPJS
7 11/7/2017 02.16.66 Vincent Arman Fibrinogen Rp 115,000 BPJS
8 13/7/2017 02.18.66 Arman Saros Biopsi Jaringan Kecil Rp 350,000 BPJS
Sitologi Pleura, Rivalta, Kultur
9 00.61.97 Amat Rp 589,000 BPJS
Aerob (Pleura)
10 15/7/2017 02.01.13 Siti Fatimah SI, TIBC Rp 90,000 BPJS
11 17/7/2017 01.93.35 Mulyani TSH, FT4 Rp 200,000 BPJS
12 18/7/2017 02.21.59 Ria Anggraini T4, T3, TSH Rp 265,000 BPJS
13 02.21.86 Anna Ernawati Troponin I Rp 155,000 BPJS
14 02.22.67 Mat Sani Troponin I Rp 155,000 BPJS
15 21/7/2017 02.22.67 Matsani Troponin I Rp 155,000 BPJS
16 02.21.77 Siti Nur Asiah Biopsi Jaringan Kecil Rp 350,000 BPJS
17 02.21.72 Ahmad Susanto Biopsi Jaringan Kecil Rp 350,000 BPJS
18 02.21.72 Ahmad Susanto Kultur Aerob (Pus) Rp 260,000 BPJS
19 02.21.86 Anna Ernawati TSH, FT4 Rp 200,000 BPJS
20 02.22.65 Misar TSH, FT4 Rp 200,000 BPJS
21 22/7/2017 02.20.81 Abrurroh M. PT, APTT Rp 230,000 BPJS
22 23/7/2017 02.23.40 Wawan Troponin I Rp 155,000 BPJS
23 24/7/2017 01.63.53 Wardatun H. PT, APTT Rp 230,000 BPJS
24 25/7/2017 00.51.99 Radja Pandjaitan TSH, FT4 Rp 200,000 BPJS
25 00.18.73 Iis bt. Saban Biopsi Jaringan Kecil Rp 350,000 BPJS
26 01.48.54 Dian Haerani Biopsi Jaringan Kecil Rp 350,000 BPJS
27 26/7/2017 02.24.41 Widiarti SI, TIBC Rp 90,000 Umum
28 02.20.82 Nasrudin Sitologi Pleura, Rivalta Rp 329,000 BPJS
29 28/7/2017 02.20.94 By.Ny. Wulan IgG CMV, IgM CMV, TSH, FT4 Rp 590,000 BPJS
30 02.24.45 Zuhriah T3, T4, FT4 Rp 295,000 BPJS
31 02.24.98 Wibowo CD4 Rp 135,000 BPJS
Total Rp 8,143,000
BPJS #REF!
UMUM #REF!
No Tanggal No. MR Nama Pemeriksaan Harga
1 1/8/2017 02.24.36 Marminah Biopsi Jar. Kecil Rp 350,000
2 02.24.12 Dhifa Husein Biopsi Jar. Kecil Rp 350,000
3 2/8/2017 01.71.56 Delisah FT4, TSH Rp 200,000
4 01.75.18 M. Didy I. FT4, TSH Rp 200,000
5 01.95.04 Fiji Waradinah Anti HIV (Elisa) Rp 90,000
6 9/8/2017 02.22.61 Rofi'i CRP Rp 35,000
7 02.20.02 Danar A. FT4, TSH Rp 200,000
8 02.26.37 drg. Fadillah FT4, TSH Rp 200,000
9 10/8/2017 02.28.82 M. Reza HBsAg (ELISA), Anti HBsAg(ELISA) Rp 180,000
10 01.15.56 Riski HBsAg (ELISA), Anti HBsAg(ELISA) Rp 180,000
11 02.26.78 Irawati FT4, TSH Rp 200,000
12 12/8/2017 02.29.18 M. Syawal M. Kultur Aerob (Urin) Rp 260,000
13 01.48.75 M. Isro Sitologi Pleura, Rivalta Rp 329,000
14 14/8/2017 02.29.57 Syakila Naura FT4, TSH Rp 200,000
15 15/8/2017 02.29.52 Maria Suprihatin FT4, TSH Rp 200,000
Toxoplasma IgG, Toxoplasma IgM,
16 16/8/2017 - Sunidah Rubella IgG, Rubella Ig M, CMV IgG, Rp 810,000
CMV IgM
17 18/8/2017 00.22.03 Raka Ilham SI, TIBC Rp 90,000
18 21/8/2017 02.30.36 By. Ny. Rahmawati Kultur Aerob (Darah) Rp 260,000
19 23/8/2017 02.31.18 Sangkalata T. FT4, TSH Rp 200,000
20 01.57.54 Siti Fatimah FT4, TSH Rp 200,000
21 24/8/2017 02.28.11 Harsa Apriandy Biopsi Jar. Kecil Rp 350,000
22 25/8/2017 02.31.80 Novia Khoirizki SI, TIBC Rp 90,000
23 02.31.71 By.Ny. Isnawati CRP Rp 35,000
24 26/8/2017 02.32.54 Muhammad Ali Kultur Aerob Rp 260,000
25 28/8/2017 02.33.07 Santi Marlena CEA Rp 155,000
26 29/8/2017 02.08.73 Faizal Azis FT4, TSH Rp 200,000
27 02.06.90 Debby Farah FT4 Rp 115,000
28 02.29.14 Siti Nurlaela Biopsi Jar. Kecil Rp 350,000
HBsAg (ELISA), Anti HCV (ELISA),
29 31/8/2017 02.33.97 Maryati Rp 365,000
Anti HIV (ELISA)
Total Rp 6,654,000
BPJS 5,029,000
UMUM 1,625,000
Pembayaran
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
1 2/9/2017 02.32.87 Tri Lestari Biopsi Jar. Kecil Rp 350,000
2 4/9/2017 02.33.51 Nisah TSH Rp 85,000
3 02.32.83 Lia Rahmawati Biopsi Jar. Kecil Rp 350,000
4 01.71.56 Delisah S. FT4, TSH Rp 200,000
7 5/9/2017 02.34.84 Dewi Rahmawati FT4, TSH Rp 200,000
8 02.33.77 Gebot FT4, TSH Rp 200,000
9 6/9/2017 02.35.42 By. Ny. Wahyu P. Kultur Aerob (Darah) Rp 260,000
5 02.35.70 Rodiansyah T3, T4, TSH, FT4 Rp 380,000
6 7/9/2017 02.32.60 Amaraldo L. FT4, TSH Rp 200,000
10 8/9/2017 00.71.48 Surinah FT4, TSH Rp 200,000
11 01.92.93 By. Gava Putri Kultur Aerob (Urine) Rp 260,000
12 00.37.33 Solihin SI, TIBC Rp 90,000
13 02.35.42 Shiva Fachri CRP Rp 35,000
14 00.88.83 Lina Oktaviani CEA Rp 155,000
15 12/9/2017 02.37.13 Winda Wigati FT4, TSH Rp 200,000
16 00.44.45 Kezia Almira Kultur Aerob (Darah) Rp 260,000
17 02.10.17 Sondang Paulus FT4, TSH Rp 200,000
18 13/9/2017 02.35.65 Intel Pentium Biopsi Jar. Kecil Rp 350,000
19 01.83.44 Adinda Syifa Kultur Aerob (Urine) Rp 260,000
20 02.37.77 Heri Kusmayanti FT4, TSH Rp 200,000
21 14/9/2017 02.32.61 Suherman Biopsi Jar. Kecil Rp 350,000
22 15/9/2017 02.38.45 Hesty Cipta CRP Rp 35,000
23 16/9/2017 02.38.51 Djumhari Magnesium Rp 35,000
24 01.92.93 Gava Putri SI, TIBC Rp 90,000
25 01.72.78 H. Sukardi Sitologi Pleura, Rivalta Rp 329,000
26 18/9/2017 02.21.59 Ria A. FT4, TSH Rp 200,000
27 02.38.68 Yuniati TSH, T3, FT4 Rp 290,000
28 20/9/2017 02.19.59 Samuel Vande FT4, TSH Rp 200,000
29 23/9/2017 01.41.60 Atik S. Magnesium Rp 35,000
30 25/9/2017 01.77.99 Warsih CRP Rp 35,000
31 02.05.72 Muslikah T4, T3, TSH Rp 265,000
32 02.39.92 Bun Win Nio CEA Rp 155,000
33 00.71.53 Maryani CRP Rp 35,000
34 26/9/2017 02.37.04 Uliana BR. S. T4, T3, TSH Rp 265,000
35 02.40.20 Dadang Sitologi Pleura, Rivalta Rp 329,000
36 00.21.51 Sugeng Sitologi Pleura, Rivalta Rp 329,000
37 28/9/2017 00.59.15 Nizam CRP Rp 35,000
38 27/9/2017 01.69.85 Abdul Agus D-Dimer Rp 135,000
39 02.41.00 By. Ny. Maria CRP Rp 35,000
40 02.33.94 Dellamia CRP Rp 35,000
41 02.36.84 Raesha SI, TIBC, TSH, FT4 Rp 290,000
42 29/9/2017 01.85.56 Tuginem CK, CK-MB Rp 155,000
43 02.29.50 Rahmayatin Lipase Rp 85,000
Total Rp 8,182,000
BPJS 7,327,000
UMUM 855,000
Pembayaran
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
Umum
BPJS
BPJS
BPJS
1 2/10/2017 02.39.81 Wati Trisnawati TSH, FT4 Rp 200,000
2 3/10/2017 02.42.21 M. Azka Kultur Aerob (faeces) Rp 260,000
Kultur Aerob (pleura), Sitologi
3 02.42.05 Puspo R. Rp 589,000
Pleura, Rivalta
4 4/10/2017 02.40.95 Nenih Suryani Biopsi Jar. Kecil Rp 350,000
7 02.41.93 Lintang Syafi CRP Rp 35,000
8 00.71.78 Surinah TSH, FT4 Rp 200,000
9 01.69.85 Abdul Kultur Aerob (Pus) Rp 260,000
5 02.09.57 Edison CRP Rp 35,000
6 6/10/2017 01.83.54 Ranum Thana HbsAg, Anti HbsAg Rp 180,000
10 01.97.09 Harry K. TSH, FT4 Rp 200,000
11 10/10/2017 02.41.72 Sugiman Biopsi Jar. Kecil Rp 350,000
12 02.44.58 Haris Pratama Elektrolit Astrup Rp 135,000
HbsAg, Anti HbsAg, Anti HCV,
13 11/10/2017 01.24.04 Meiske Rp 455,000
Anti HIV
14 02.43.17 Muh. Azmi SI, TIBC Rp 90,000
15 02.42.97 Fabian Dhafa SI, TIBC Rp 90,000
16 02.35.70 Rodiansyah TSH, FT4 Rp 200,000
17 02.44.85 Nuraini TSH, FT4 Rp 200,000
18 00.61.97 Amat Biopsi Jar. Kecil Rp 350,000
19 12/10/2017 01.89.44 Rohidah T3, T4, TSH Rp 265,000
20 02.43.67 Anita Biopsi Jar. Kecil Rp 350,000
21 02.45.55 Sidi TSH, FT4 Rp 200,000
22 13/10/17 02.44.85 Nuraini Sitologi Plura, Rivalta Rp 329,000
23 02.45.60 By. Ny. Santi CRP Rp 35,000
24 02.42.21 M. Azka A. SI, TIBC Rp 90,000
25 02.44.55 Yulian Agung CRP Rp 35,000
26 02.45.26 Camila F. CRP Rp 35,000
27 14/10/17 02.45.07 Tarsah Sitologi Plura, Rivalta Rp 329,000
28 16/10/17 02.15.65 Syahal Q. SI, TIBC Rp 90,000
29 02.43.20 Muh. Hanan SI, TIBC Rp 90,000
30 02.42.70 Linda B. C. Sitologi Plura, Rivalta Rp 329,000
31 17/10/17 02.47.21 Alfarizi Gamma-GT Rp 40,000
32 02.46.11 Lilis D-Dimer Rp 135,000
33 19/10/17 02.46.11 Lilis Lisnawati D-Dimer Rp 135,000
34 20/10/17 02.45.72 Whyndy S. FT4, T3, T4, TSH Rp 380,000
35 24/10/17 02.46.44 Kemala Sari S. SI, TIBC Rp 90,000
36 02.21.19 Kirana Adzkia A. TSH, FT4 Rp 200,000
37 02.48.83 Deffina Mikhaela TSH, FT4 Rp 200,000
38 00.23.25 A. Parangol M. Magnesium, Ca. ion Rp 170,000
39 26/10/17 01.35.68 Cucu Rosidah PT, APTT Rp 230,000
40 02.47.13 Susilowati Biopsi Jar. Kecil Rp 350,000
41 02.38.68 Yuhiati Eka FT4 Rp 115,000
42 27/10/17 02.47.39 Posma Diasina A. Biopsi Jar. Kecil 2x Rp 700,000
43 02.50.06 Doddy Nugraha TSH, FT4 Rp 200,000
44 02.50.29 Salwa Putri Nabila PT, APTT Rp 230,000
45 00.62.34 DRA. Tieni D-Dimer, PT/INR Rp 250,000
46 29/10/17 02.48.79 Sumiyem D-Dimer Rp 135,000
47 30/10/17 02.44.33 Linda Astuti Biopsi Jar. Kecil Rp 350,000
48 02.46.74 Siti Rokhayah Biopsi Jar. Kecil Rp 350,000
49 02.43.47 Sarman T3, T4, TSH Rp 265,000
50 02.16.35 Ataraksa SI, TIBC Rp 90,000
51 02.51.04 Adinda SI, TIBC Rp 90,000
52 02.36.49 Siti Cholilah PT, APTT Rp 230,000
53 31/10/17 02.36.49 Siti Cholilah PT, APTT Rp 230,000
54 02.49.79 Sumiyem D-Dimer Rp 135,000
55 02.49.74 Ida Parida T3, T4, TSH Rp 265,000
56 02.51.04 Adinda Aprilia Kultur Aerob (faeces) Rp 260,000
Total Rp 12,181,000
BPJS 11,696,000
UMUM 485,000
Pembayaran
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
1 1/11/2017 01.32.18 Gati Mareta SI, TIBC Rp 90,000
2 02.51.41 Indah P. CEA Rp 155,000
3 4/11/2017 01.25.49 Annisa K. PT, APTT Rp 230,000
4 5/11/2017 01.39.52 Fitri AgustienAmilase, Lipase Rp 170,000
7 6/11/2017 02.53.13 Alma CRP Rp 35,000
8 7/11/2017 02.47.08 Kustini PT, APTT Rp 230,000
9 02.52.84 Salma Maria Biopsi Jar. Kecil Rp 350,000
5 8/11/2017 02.53.07 Kaylila CRP Rp 35,000
6 9/11/2017 02.54.31 Fitria LusandaTSH, FT4 Rp 200,000
10 02.09.38 Ahmad Alkali Fosfatse, Gamma GT Rp 70,000
11 14/11/2017 02.54.17 Retno Agus PT, APTT Rp 230,000
12 15/11/2017 02.41.73 Febi Liyanti Biopsi Jar. Kecil Rp 350,000
13 00.97.34
Yuni Amri Biopsi Jar. Kecil Rp 350,000
14 16/11/2017 02.54.87
Asnaini Antibodi Malaria Rp 70,000
15 00.39.95
Syahfitriani Biopsi Jar. Kecil Rp 350,000
16 17/11/2017 02.59.42
Casriyah T3, T4, TSH Rp 265,000
17 02.56.17
Jane Zhevanya Kultur Aerob (Darah) Rp 260,000
18 02.59.56
Arjuna Hakim TSH, FT4 Rp 200,000
19 20/11/2017 02.46.57
Bona P. PT Rp 115,000
20 02.59.82
Tardi APTT, PT, Fibrinogen Rp 230,000
21 02.56.17
Jane Zhevanya CRP Rp 35,000
22 21/11/2017 00.51.20
Umi S. TSH, FT4 Rp 200,000
23 22/11/2017 02.60.62
Edy Hidayat PT, APTT Rp 230,000
24 23/11/2017 02.60.69
Nirina Jelita SI, TIBC Rp 90,000
25 02.50.53
Dentua Sitohang PT, APTT Rp 230,000
26 24/11/2017 02.59.57
Hindun Biopsi Jar. Kecil Rp 350,000
27 01.57.54
Siti Fatimah TSH, FT4 Rp 200,000
28 02.58.55
Layyina D. Nafisa SI, TIBC Rp 90,000
29 25/11/2017 02.61.06
Maryani PT, APTT Rp 230,000
30 29/11/2017 01.75.18
M. Didy TSH, FT4 Rp 200,000
31 02.60.80
Eko Lestari Biopsi Jar. Kecil Rp 350,000
32 30/11/2017 02.60.52
Ryo Raditya CRP Rp 35,000
Total Rp 6,225,000
BPJS 5,285,000
UMUM 940,000
Pembayaran
Umum
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Umum
BPJS
BPJS
Umum
Umum
BPJS
BPJS
Umum
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
BPJS
Jumlah
1 4/12/2017 02.29.52 Maria S. TSH, FT4 2

2 6/12/2017 02.63.47 Fakhri CRP 1
3 00.22.69 Warsoen D-Dimer 1
4 9/12/2017 02.64.17 Sopiah TSH, FT4 2
7 02.64.23 Indah R. TSH, FT4 2
8 11/12/2017 02.64.00 Paino TCM 1
9 12/12/2017 02.25.22 Syarie O. ALP, Gamma-GT 2
5 02.3.69 M. Yusuf Daud Sitologi Pleura, Rivalta 2
6 02.61.08 Maryati PT 1
10 13/12/2017 02.35.10 Rury Sri R. TCM 1
11 01.64.73 Dewi F. TCM 1
12 02.65.04 Debby S. APTT, PT 2
13 14/12/2017 01.87.64 Ety S. TSH, FT4 2
14 15/12/2017 02.65.70 Rini S. T3, TSH, FT4 3
15 02.60.49 Lisna TCM 1
16 02.86.38 Rohanah GFR 2
17 02.20.02 Danar A. TSH, FT4 2
18 18/12/2017 02.65.73 Lina H. Biopsi Jar. Kecil 1
19 02.65.64 Nurwati TCM 1
20 02.64.19 Taja T3, TSH, FT4 3
21 02.60.53 Dentua S. TCM 1
22 19/12/2017 02.37.39 Mustofa TCM 1
23 02.63.34 Enit TCM 1
25 00.62.46 Romelah T4, T3, FT4 3
26 02.09.63 Cicih T4, T3, FT4 3
27 Hasnah CRP 1
28 20/12/2017 02.56.16 Supriono TCM 1
29 02.67.33 M. Tesar APTT, PT 2
30 02.67.63 Difa A. VDRL, TPHA 2
Fibrinogen, D-Dimer, PT, APTT,
31 02.32.17 Nilla S. 5
Magnesium
32 02.66.42 Suparni Amilase, Lipase 2
33 21/12/2017 00.23.98 Wati T. TSH, FT4 2
Kultur Aerob (Pus), Kultur
34 02.66.31 Nurjanah 2
Anaerob (Pus)
35 02.62.59 A.R. Soentono T4, T3, FT4 3
36 00.41.09 Mira K. TCM 1
37 00.71.83 Mardi S. TCM 1
38 02.08.73 Faizal Azis D-Dimer 1
39 22/12/2017 02.68.48 I Nengah S. TCM 1
40 00.40.04 Zeth Deswara PT 1
41 23/12/2017 02.14.53 Unggul T. R. Anti HIV 1
42 01.82.14 Indriyani Biopsi Jar. Kecil 1
43 12/25/2017 02.61.05 Maryati APTT, PT 2
44 12/27/2017 02.58.65 Hartono TCM 1
45 02.66.87 Noorany TCM 1
46 12/28/2017 02.21.59 Ria A. FT4, TSH, T3, T4 4
47 00.73.93 Haya S. FT4, TSH, T3, T4 4
48 12/29/2017 02.66.79 Ivan P. FT4, TSH, T3, T4 4
49 02.61.16 Asep FT4 1
50 02.69.56 Abraham Sitologi Pleura, Rivalta 2
51 12/30/2017 02.70.07 Misan bin Siman Analisa Gas Darah 1
52 02.61.05 Maryati APTT, PT 2
53 02.70.32 Wulan M. Analisa Gas Darah 1
54 12/31/2017 01.13.67 Junihot M. Analisa Gas Darah 1
55 02.70.21 Nurjanah Analisa Gas Darah 1
Total 94
BPJS 7,793,000
UMUM 985,000
Rujukan

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Rp 8,778,000

Rujukan 2018

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PASBO Rp 490,000 Umum

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PASBO Rp 490,000 BPJS

PASBO Rp 250,000 BPJS

PASBO Rp 230,000 BPJS

PASBO Rp 380,000 BPJS

1 4/12/2017 02.29.52 Maria S. TSH, FT4 2

PASBO Rp 200,000 BPJS

PASBO Rp 515,000 Umum

PASBO Rp 170,000 BPJS

PASBO Rp 545,000 BPJS

PASBO Rp 295,000 BPJS

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