No. Form : FR/14.

1/01
No. Rev : 00

INVOICE
BIAYA PERAWATAN RAWAT INAP
COST OF INPATIENT SERVICES
No. Reg / No. RM : 510149 Dokter Utama : dr. Dwi Erike S, Sp.THT, KL
Tanggal Masuk : May 27, 2025 6:00 AM Spesialisasi : THT
Nama Pasien : DONNY SURYONO PERMADI Bangsal : GARDENIA 2301A
Tanggal Lahir : 10 Jul 1982 Kelas : Kelas 3
Penjamin Bayar : PRIBADI Ruang Rawat : GARDENIA
Nama Instansi : PRIBADI No. Tempat Tidur : GRD2301A

TRANSAKSI HARIAN

RAWAT JALAN EPISODE : 2

BIAYA LAYANAN / COST OF SERVICES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Jasa Dokter / Doctors Fee

UGD / UGD
J-UGD-202505007775 Jasa Konsultasi 27/05/2025 1 37,000.00 0.00 37,000.00 0.00
dr.Prayoga Putra Nugraha
Total Unit UGD / UGD 37,000.00 0.00 37,000.00 0.00
Subtotal Jasa Dokter / Doctors Fee 37,000.00 0.00 37,000.00 0.00
Jasa Rumah Sakit / Hospital Fee
UGD / UGD
J-UGD-202505007775 Jasa Sarana Rawat Jalan 27/05/2025 1 68,000.00 0.00 68,000.00 0.00
Total Unit UGD / UGD 68,000.00 0.00 68,000.00 0.00
Subtotal Jasa Rumah Sakit / Hospital Fee 68,000.00 0.00 68,000.00 0.00
Radiologi / Radiology
RAD / RADIOLOGI
J-RAD-202505001714 Jasa Dokter Radiologi Thorax PA C-R 27/05/2025 1 40,000.00 0.00 40,000.00 0.00
Thorax PA C-R 27/05/2025 1 211,000.00 0.00 211,000.00 0.00
Total Unit RAD / RADIOLOGI 251,000.00 0.00 251,000.00 0.00
Subtotal Radiologi / Radiology 251,000.00 0.00 251,000.00 0.00
Laboratorium / Laboratory
LAB / LABORATORIUM
J-LAB-202505003803 Darah Lengkap 27/05/2025 1 147,000.00 0.00 147,000.00 0.00
Glukosa Sewaktu 27/05/2025 1 49,000.00 0.00 49,000.00 0.00
Natrium - Kalium - Klorida 27/05/2025 1 394,000.00 0.00 394,000.00 0.00
Total Unit LAB / LABORATORIUM 590,000.00 0.00 590,000.00 0.00
Subtotal Laboratorium / Laboratory 590,000.00 0.00 590,000.00 0.00
Biaya Admin / Administration Fee
UGD / UGD
J-UGD-202505007775 Administrasi Pasien Rawat Jalan 27/05/2025 1 25,000.00 0.00 25,000.00 0.00
Total Unit UGD / UGD 25,000.00 0.00 25,000.00 0.00
Subtotal Biaya Admin / Administration Fee 25,000.00 0.00 25,000.00 0.00
BIAYA OBAT / ALKES COST OF MEDICINES / MEDICAL SUPPLIES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
UGD / UGD
J-UGD-202505007764 FARTISON INJ 27/05/2025 1 151,900.00 0.00 151,900.00 0.00

Page 1 of 6 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by NURITA at
30 May 2025, 09:14:47
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id
 TRANSAKSI HARIAN

RAWAT JALAN EPISODE : 2

BIAYA OBAT / ALKES COST OF MEDICINES / MEDICAL SUPPLIES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
UGD / UGD
OMEPRAZOLE INJ 27/05/2025 1 68,700.00 0.00 68,700.00 0.00
SPUIT 10 CC TERUMO (*MRL) 27/05/2025 2 26,800.00 0.00 26,800.00 0.00
E CARE FILM IV DRESSING 67P 27/05/2025 1 3,000.00 0.00 3,000.00 0.00
IV. CAT. TROGE PLUS NO.22 27/05/2025 1 37,500.00 0.00 37,500.00 0.00
G-2TRGIV022 (*MRL)
OXYGEN NASAL CANULA ADULT 27/05/2025 1 14,200.00 0.00 14,200.00 0.00
BESMED (*MRL)
Total Unit UGD / UGD 302,100.00 0.00 302,100.00 0.00
Subtotal Farmasi / Pharmacy 302,100.00 0.00 302,100.00 0.00
Total Biaya RAWAT JALAN 1,273,100.00 0.00 1,273,100.00 0.00

RAWAT INAP EPISODE : 3

BIAYA LAYANAN / COST OF SERVICES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Asuhan Keperawatan / Nursing Services

GRD / GARDENIA
I-GRD-202505000872 Jasa Injeksi IV - Kelas Kelas 3 27/05/2025 2 0.00 0.00 0.00 0.00
Perawat
Injeksi IV - - RS Kelas Kelas 3 27/05/2025 2 36,000.00 0.00 36,000.00 0.00
Maksimal Care - Kelas Kelas 3 27/05/2025 1 85,000.00 0.00 85,000.00 0.00
Perawat
I-GRD-202505000912 Pasang Infus - Kelas Kelas 3 27/05/2025 1 65,000.00 0.00 65,000.00 0.00
Perawat
Injeksi IV - RS Kelas Kelas 3 28/05/2025 2 36,000.00 0.00 36,000.00 0.00
I-GRD-202505000917 Jasa Injeksi IV - Kelas Kelas 3 28/05/2025 3 0.00 0.00 0.00 0.00
Perawat
Injeksi IV - - RS Kelas Kelas 3 28/05/2025 3 54,000.00 0.00 54,000.00 0.00
Maksimal Care - Kelas Kelas 3 28/05/2025 1 85,000.00 0.00 85,000.00 0.00
Perawat
I-GRD-202505000931 Jasa Injeksi IV Kelas Kelas 3 28/05/2025 3 0.00 0.00 0.00 0.00
Perawat
I-GRD-202505000955 Aff Infus Kelas Kelas 3 29/05/2025 1 24,000.00 0.00 24,000.00 0.00
Perawat
Pasang Infus - Kelas Kelas 3 29/05/2025 1 65,000.00 0.00 65,000.00 0.00
Perawat
I-GRD-202505000977 Maksimal Care - Kelas Kelas 3 30/05/2025 1 85,000.00 0.00 85,000.00 0.00
Perawat
Injeksi IV - - RS Kelas Kelas 3 30/05/2025 1 18,000.00 0.00 18,000.00 0.00
Aff Infus Kelas Kelas 3 30/05/2025 1 24,000.00 0.00 24,000.00 0.00
Perawat
Jasa Injeksi IV - Kelas Kelas 3 30/05/2025 1 0.00 0.00 0.00 0.00
Perawat
I-GRD-202505000967 Jasa Injeksi IV Kelas Kelas 3 30/05/2025 3 0.00 0.00 0.00 0.00
Perawat
Injeksi IV - RS Kelas Kelas 3 30/05/2025 3 54,000.00 0.00 54,000.00 0.00
Maksimal Care - Kelas Kelas 3 30/05/2025 1 85,000.00 0.00 85,000.00 0.00
Perawat
Total Unit GRD / GARDENIA 716,000.00 0.00 716,000.00 0.00
Subtotal Asuhan Keperawatan / Nursing Services 716,000.00 0.00 716,000.00 0.00
Tindakan Dokter / Measures of Doctor
GRD / GARDENIA
I-GRD-202505000888 Visite Dokter Umum Kelas Kelas 3 27/05/2025 1 100,000.00 0.00 100,000.00 0.00
dr. Prastika Dica Izwara
I-GRD-202505000890 Jasa Visit Kelas Kelas 3 27/05/2025 1 120,000.00 0.00 120,000.00 0.00
dr. Dwi Erike S Sp.THT, KL
Jasa Sarana Rawat Inap Kelas Kelas 3 27/05/2025 1 30,000.00 0.00 30,000.00 0.00
I-GRD-202505000924 Jasa Nasofaringoscopy Diagnostic 28/05/2025 1 276,000.00 0.00 276,000.00 0.00
Kelas Kelas 3
dr. Dwi Erike S Sp.THT, KL
Nasofaringoscopy Diagnostic - RS 28/05/2025 1 118,000.00 0.00 118,000.00 0.00
Kelas Kelas 3

Page 2 of 6 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by NURITA at
30 May 2025, 09:14:47
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id
 RAWAT INAP EPISODE : 3
BIAYA LAYANAN / COST OF SERVICES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Tindakan Dokter / Measures of Doctor

GRD / GARDENIA
Jasa Sarana Rawat Inap Kelas Kelas 3 28/05/2025 1 30,000.00 0.00 30,000.00 0.00
Jasa Visit Kelas Kelas 3 28/05/2025 1 120,000.00 0.00 120,000.00 0.00
dr. Dwi Erike S Sp.THT, KL
I-GRD-202505000947 Jasa Visit Kelas Kelas 3 29/05/2025 1 120,000.00 0.00 120,000.00 0.00
dr. Dwi Erike S Sp.THT, KL
Jasa Sarana Rawat Inap Kelas Kelas 3 29/05/2025 1 30,000.00 0.00 30,000.00 0.00
I-GRD-202505000980 Jasa Visit Kelas Kelas 3 30/05/2025 1 120,000.00 0.00 120,000.00 0.00
dr. Dwi Erike S Sp.THT, KL
Jasa Sarana Rawat Inap Kelas Kelas 3 30/05/2025 1 30,000.00 0.00 30,000.00 0.00
Total Unit GRD / GARDENIA 1,094,000.00 0.00 1,094,000.00 0.00
Subtotal Tindakan Dokter / Measures of Doctor 1,094,000.00 0.00 1,094,000.00 0.00
Pemakaian Alat / Involve Using of Instrumen
GRD / GARDENIA
I-GRD-202505000931 Jasa Infusion Pump - Kelas Kelas 3 28/05/2025 1 0.00 0.00 0.00 0.00
Perawat
Jasa Monitor EKG / Bed Side Monitor - 28/05/2025 1 0.00 0.00 0.00 0.00
Kelas Kelas 3
Perawat
Total Unit GRD / GARDENIA 0.00 0.00 0.00 0.00
Subtotal Pemakaian Alat / Involve Using of Instrumen 0.00 0.00 0.00 0.00
Laboratorium / Laboratory
LAB / LABORATORIUM
I-LAB-202505002189 Glukosa Stik Kelas Kelas 3 Glukosa Stik 27/05/2025 1 49,000.00 0.00 49,000.00 0.00
Total Unit LAB / LABORATORIUM 49,000.00 0.00 49,000.00 0.00
Subtotal Laboratorium / Laboratory 49,000.00 0.00 49,000.00 0.00
Lain - Lain / Others
GRD / GARDENIA
I-GRD-202505000931 Oksigen Sentral 4 Lt / Menit (per jam) 28/05/2025 23 207,000.00 0.00 207,000.00 0.00
Kelas Kelas 3
Perawat
I-GRD-202505000917 Oksigen Sentral 3 Lt / Menit (per jam) 28/05/2025 1 8,000.00 0.00 8,000.00 0.00
Kelas Kelas 3
Perawat
Total Unit GRD / GARDENIA 215,000.00 0.00 215,000.00 0.00
Subtotal Lain - Lain / Others 215,000.00 0.00 215,000.00 0.00
Kamar / Room
GRD / GARDENIA
I-GRD-202505000870 Kamar Kelas 3 Kelas Kelas 3 27/05/2025 1 130,000.00 0.00 130,000.00 0.00
dr. NONAME
I-GRD-202505000915 Kamar Kelas 3 Kelas Kelas 3 28/05/2025 1 130,000.00 0.00 130,000.00 0.00
I-GRD-202505000938 Kamar Kelas 3 Kelas Kelas 3 29/05/2025 1 130,000.00 0.00 130,000.00 0.00
Total Unit GRD / GARDENIA 390,000.00 0.00 390,000.00 0.00
Subtotal Kamar / Room 390,000.00 0.00 390,000.00 0.00
Farmasi / Pharmacy
DP6 / DEPO ASEPTIS
I-DP6-202505003698 Rekonstitusi Obat Injeksi Kelas Kelas 3 27/05/2025 1 25,000.00 0.00 25,000.00 0.00
I-DP6-202505003799 Rekonstitusi Obat Injeksi Kelas Kelas 3 28/05/2025 1 25,000.00 0.00 25,000.00 0.00
I-DP6-202505004063 Rekonstitusi Obat Injeksi Kelas Kelas 3 30/05/2025 1 25,000.00 0.00 25,000.00 0.00
Total Unit DP6 / DEPO ASEPTIS 75,000.00 0.00 75,000.00 0.00
Subtotal Farmasi / Pharmacy 75,000.00 0.00 75,000.00 0.00
BIAYA OBAT / ALKES COST OF MEDICINES / MEDICAL SUPPLIES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
DP3 / DEPO FARMASI RI LT 4
I-DP3-202505006967 FUTROLIT INF 27/05/2025 1 100,900.00 0.00 100,900.00 0.00
LAMESON 125 MG INJ 27/05/2025 1 191,800.00 0.00 191,800.00 0.00
PANTOPUMP INJEKSI 27/05/2025 1 328,900.00 0.00 328,900.00 0.00
SPUIT 10 CC TERUMO (*MRL) 27/05/2025 1 14,100.00 0.00 14,100.00 0.00
SPUIT 3 CC TERUMO (*MRL) 27/05/2025 1 9,200.00 0.00 9,200.00 0.00
Total Unit DP3 / DEPO FARMASI RI LT 4 644,900.00 0.00 644,900.00 0.00

Page 3 of 6 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by NURITA at
30 May 2025, 09:14:47
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id
 RAWAT INAP EPISODE : 3
BIAYA OBAT / ALKES COST OF MEDICINES / MEDICAL SUPPLIES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
DP4 / DEPO FARMASI RI
I-DP4-202505011910 FUTROLIT INF 27/05/2025 1 100,900.00 0.00 100,900.00 0.00
I-DP4-202505011911 FUTROLIT INF 27/05/2025 1 100,900.00 0.00 100,900.00 0.00
I-DP4-202505012131 IV. CAT. TROGE PLUS NO.22 27/05/2025 1 39,500.00 0.00 39,500.00 0.00
G-2TRGIV022 (*MRL)
I-DP4-202505012297 IV. CAT. TROGE PLUS NO.22 27/05/2025 1 39,500.00 0.00 39,500.00 0.00
G-2TRGIV022 (*MRL)
INFUSION SET ADULT TERUMO 27/05/2025 1 30,600.00 0.00 30,600.00 0.00
(TI*Q300WI)
PARACETAMOL INF 1000MG/100ML 27/05/2025 1 78,000.00 0.00 78,000.00 0.00
I-DP4-202505011974 BRAXIDIN TAB (P) 27/05/2025 1 2,100.00 0.00 2,100.00 0.00
I-DP4-202505011975 FUTROLIT INF 27/05/2025 1 100,900.00 0.00 100,900.00 0.00
SANMOL INFUS 27/05/2025 1 105,200.00 0.00 105,200.00 0.00
I-DP4-202505012024 BRAXIDIN TAB (P) 27/05/2025 1 2,100.00 0.00 2,100.00 0.00
I-DP4-202505012026 BRAXIDIN TAB (P) 27/05/2025 1 2,100.00 0.00 2,100.00 0.00
I-DP4-202505012107 PARACETAMOL INF 1000MG/100ML 27/05/2025 1 78,000.00 0.00 78,000.00 0.00
I-DP4-202505012492 LAPIBAL 500 MCG INJ 28/05/2025 1 54,600.00 0.00 54,600.00 0.00
SPUIT 3 CC TERUMO (*MRL) 28/05/2025 1 9,200.00 0.00 9,200.00 0.00
I-DP4-202505012530 BRAXIDIN TAB (P) 28/05/2025 2 4,200.00 0.00 4,200.00 0.00
I-DP4-202505012565 SANMOL INFUS 28/05/2025 1 105,200.00 0.00 105,200.00 0.00
I-DP4-202505012752 PANOREX 10 MG/ML INF 100 ML - 28/05/2025 1 92,000.00 0.00 92,000.00 0.00
PARACETAMOL (*SFRS)
I-DP4-202505012460 PARACETAMOL INF 1000MG/100ML 28/05/2025 1 78,000.00 0.00 78,000.00 0.00
I-DP4-202505012872 BRAXIDIN TAB (P) 29/05/2025 1 2,100.00 0.00 2,100.00 0.00
I-DP4-202505012896 PARACETAMOL INF 1000MG/100ML 29/05/2025 1 78,000.00 0.00 78,000.00 0.00
I-DP4-202505013005 SUKRALFATE SUSPENSI 500/ 5ML 29/05/2025 1 25,300.00 0.00 25,300.00 0.00
I-DP4-202505013006 MUCOSTA 100 MG.TAB 29/05/2025 1 7,100.00 0.00 7,100.00 0.00
I-DP4-202505013059 BRAXIDIN TAB (P) 29/05/2025 2 4,200.00 0.00 4,200.00 0.00
MUCOSTA 100 MG.TAB 29/05/2025 2 14,200.00 0.00 14,200.00 0.00
I-DP4-202505013073 FUTROLIT INF 29/05/2025 1 100,900.00 0.00 100,900.00 0.00
I-DP4-202505013176 RL 500 ML INFUSAN (SANBE) SINGLE 29/05/2025 1 31,100.00 0.00 31,100.00 0.00
POT (*MRL)
I-DP4-202505013192 IV. CAT. TROGE PLUS NO.22 29/05/2025 1 39,500.00 0.00 39,500.00 0.00
G-2TRGIV022 (*MRL)
RTI-DP4-202505002648 FUTROLIT INF 29/05/2025 1 -100,900.00 0.00 -100,900.00 0.00
RTI-DP4-202505002647 SANMOL INFUS 29/05/2025 1 -105,200.00 0.00 -105,200.00 0.00
RTI-DP4-202505002645 PANTOPUMP INJEKSI 29/05/2025 1 -328,900.00 0.00 -328,900.00 0.00
SPUIT 10 CC TERUMO (*MRL) 29/05/2025 1 -14,100.00 0.00 -14,100.00 0.00
RTI-DP4-202505002601 BRAXIDIN TAB (P) 29/05/2025 1 -2,100.00 0.00 -2,100.00 0.00
RTI-DP4-202505002580 PANOREX 10 MG/ML INF 100 ML - 29/05/2025 1 -92,000.00 0.00 -92,000.00 0.00
PARACETAMOL (*SFRS)
I-DP4-202505013268 RL 500 ML INFUSAN (SANBE) SINGLE 29/05/2025 1 31,100.00 0.00 31,100.00 0.00
POT (*MRL)
I-DP4-202505013477 MUCOSTA 100 MG.TAB 30/05/2025 1 7,100.00 0.00 7,100.00 0.00
LANSOPRAZOLE 30 MG CAPSUL 30/05/2025 10 20,000.00 0.00 20,000.00 0.00
CEFIXIME 200 MG TAB 30/05/2025 10 71,000.00 0.00 71,000.00 0.00
BRAXIDIN TAB (P) 30/05/2025 5 10,500.00 0.00 10,500.00 0.00
LAZOSTIN 24 ODT 30/05/2025 5 78,000.00 0.00 78,000.00 0.00
MUCOSTA 100 MG.TAB 30/05/2025 14 99,400.00 0.00 99,400.00 0.00
SINOCORT TABLET (TRIAMCINOLON 30/05/2025 10 59,000.00 0.00 59,000.00 0.00
4 MG) (*SFRS)
CODIKAF 20MG (N) (*HA) 30/05/2025 3 10,500.00 0.00 10,500.00 0.00
RYMONT 10 MG TAB 30/05/2025 5 61,500.00 0.00 61,500.00 0.00
DESLOTINE TAB 30/05/2025 5 58,500.00 0.00 58,500.00 0.00
I-DP4-202505013544 Embalase Ranap Kelas Kelas 3 30/05/2025 1 20,000.00 0.00 20,000.00 0.00
RTI-DP4-202505002715 RL 500 ML INFUSAN (SANBE) SINGLE 30/05/2025 1 -31,100.00 0.00 -31,100.00 0.00
POT (*MRL)
RTI-DP4-202505002714 MUCOSTA 100 MG.TAB 30/05/2025 1 -7,100.00 0.00 -7,100.00 0.00
RTI-DP4-202505002713 PARACETAMOL INF 1000MG/100ML 30/05/2025 1 -78,000.00 0.00 -78,000.00 0.00
RTI-DP4-202505002712 LANSOPRAZOLE 30 MG CAPSUL 30/05/2025 10 -20,000.00 0.00 -20,000.00 0.00
CEFIXIME 200 MG TAB 30/05/2025 10 -71,000.00 0.00 -71,000.00 0.00
BRAXIDIN TAB (P) 30/05/2025 5 -10,500.00 0.00 -10,500.00 0.00
LAZOSTIN 24 ODT 30/05/2025 5 -78,000.00 0.00 -78,000.00 0.00
MUCOSTA 100 MG.TAB 30/05/2025 14 -99,400.00 0.00 -99,400.00 0.00

Page 4 of 6 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by NURITA at
30 May 2025, 09:14:47
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id
 RAWAT INAP EPISODE : 3
BIAYA OBAT / ALKES COST OF MEDICINES / MEDICAL SUPPLIES

NO RINCIAN LAYANAN TGL QTY SUBTOTAL TUNAI PRIBADI PENJAMIN

Farmasi / Pharmacy
DP4 / DEPO FARMASI RI
SINOCORT TABLET (TRIAMCINOLON 30/05/2025 10 -59,000.00 0.00 -59,000.00 0.00
4 MG) (*SFRS)
CODIKAF 20MG (N) (*HA) 30/05/2025 3 -10,500.00 0.00 -10,500.00 0.00
RYMONT 10 MG TAB 30/05/2025 5 -61,500.00 0.00 -61,500.00 0.00
DESLOTINE TAB 30/05/2025 5 -58,500.00 0.00 -58,500.00 0.00
Total Unit DP4 / DEPO FARMASI RI 624,200.00 0.00 624,200.00 0.00
DP6 / DEPO ASEPTIS
I-DP6-202505003698 TERFACEF 1 GR INJ 27/05/2025 1 359,900.00 0.00 359,900.00 0.00
PANTOPUMP INJEKSI 27/05/2025 1 328,900.00 0.00 328,900.00 0.00
LAMESON 125 MG INJ 27/05/2025 1 191,800.00 0.00 191,800.00 0.00
NACL 0,9 % 100 ML ECOSOL B-BRAUN 27/05/2025 2 41,200.00 0.00 41,200.00 0.00
SPUIT 10 CC TERUMO (*MRL) 27/05/2025 2 28,200.00 0.00 28,200.00 0.00
COMBISTOPER RED B BRAUN 27/05/2025 1 12,700.00 0.00 12,700.00 0.00
I-DP6-202505003774 CEFTRIAXONE 1 GR INJ (*MRL) 27/05/2025 1 15,600.00 0.00 15,600.00 0.00
COMBISTOPER RED B BRAUN 27/05/2025 1 12,700.00 0.00 12,700.00 0.00
SPUIT 10 CC TERUMO (*MRL) 27/05/2025 1 14,100.00 0.00 14,100.00 0.00
I-DP6-202505003863 PANTOPRAZOLE INJ 28/05/2025 1 93,600.00 0.00 93,600.00 0.00
CEFTRIAXONE 1 GR INJ (*MRL) 28/05/2025 1 15,600.00 0.00 15,600.00 0.00
SPUIT 10 CC TERUMO (*MRL) 28/05/2025 2 28,200.00 0.00 28,200.00 0.00
COMBISTOPER RED B BRAUN 28/05/2025 2 25,400.00 0.00 25,400.00 0.00
I-DP6-202505003799 CEFTRIAXONE 1 GR INJ (*MRL) 28/05/2025 1 15,600.00 0.00 15,600.00 0.00
METHYLPREDNISOLONE INJ 125MG 28/05/2025 1 62,400.00 0.00 62,400.00 0.00
PANTOPRAZOLE INJ 28/05/2025 1 93,600.00 0.00 93,600.00 0.00
NACL 0,9 % 100 ML ECOSOL B-BRAUN 28/05/2025 1 20,600.00 0.00 20,600.00 0.00
SPUIT 10 CC TERUMO (*MRL) 28/05/2025 3 42,300.00 0.00 42,300.00 0.00
COMBISTOPER RED B BRAUN 28/05/2025 2 25,400.00 0.00 25,400.00 0.00
I-DP6-202505003930 METHYLPREDNISOLONE INJ 125MG 29/05/2025 1 62,400.00 0.00 62,400.00 0.00
PANTOPRAZOLE INJ 29/05/2025 1 93,600.00 0.00 93,600.00 0.00
CEFTRIAXONE 1 GR INJ (*MRL) 29/05/2025 1 15,600.00 0.00 15,600.00 0.00
NACL 0,9 % 100 ML ECOSOL B-BRAUN 29/05/2025 1 20,600.00 0.00 20,600.00 0.00
COMBISTOPER RED B BRAUN 29/05/2025 2 25,400.00 0.00 25,400.00 0.00
I-DP6-202505003990 CEFTRIAXONE 1 GR INJ (*MRL) 29/05/2025 1 15,600.00 0.00 15,600.00 0.00
PANTOPRAZOLE INJ 29/05/2025 1 93,600.00 0.00 93,600.00 0.00
SPUIT 10 CC TERUMO (*MRL) 29/05/2025 2 28,200.00 0.00 28,200.00 0.00
COMBISTOPER RED B BRAUN 29/05/2025 2 25,400.00 0.00 25,400.00 0.00
I-DP6-202505004104 NEEDLE 18 X 1 1/2 IN AGANI TERUMO 30/05/2025 1 2,700.00 0.00 2,700.00 0.00
I-DP6-202505004063 PANTOPRAZOLE INJ 30/05/2025 1 93,600.00 0.00 93,600.00 0.00
CEFTRIAXONE 1 GR INJ (*MRL) 30/05/2025 1 15,600.00 0.00 15,600.00 0.00
SPUIT 10 CC TERUMO (*MRL) 30/05/2025 2 28,200.00 0.00 28,200.00 0.00
COMBISTOPER RED B BRAUN 30/05/2025 2 25,400.00 0.00 25,400.00 0.00
Total Unit DP6 / DEPO ASEPTIS 1,973,700.00 0.00 1,973,700.00 0.00
UGD / UGD
I-UGD-202505000826 Embalase RJ R2 Kelas Kelas 3 27/05/2025 2 15,000.00 0.00 15,000.00 0.00
FUTROLIT INF 27/05/2025 1 100,900.00 0.00 100,900.00 0.00
SOLUTION ADM SET TERUMO 27/05/2025 1 69,500.00 0.00 69,500.00 0.00
(TI*PU300L MACROSET)
THREE WAY BUNTUT AMS 27/05/2025 1 28,800.00 0.00 28,800.00 0.00
Total Unit UGD / UGD 214,200.00 0.00 214,200.00 0.00
Subtotal Farmasi / Pharmacy 3,457,000.00 0.00 3,457,000.00 0.00
Total Biaya RAWAT INAP 5,996,000.00 0.00 5,996,000.00 0.00

Grand Total Rp. 7,269,100.00

SCAN UNTUK ISI SURVEY Administrasi Rp. 363,455.00
KEPUASAN PELANGGAN Grand Total (Round Up) Rp. 7,632,555.00
0.00
Uang Muka Rp. 0.00
Yang Sudah Dibayar Pasien Rp. 0.00
Tagihan Yang Harus Dibayar 7,632,555.00
Pasien Rp.

Terima Kasih Yogyakarta, 30 May 2025

Page 5 of 6 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by NURITA at
30 May 2025, 09:14:47
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id
 Thank You Manajer Keuangan

NB : Tagihan tersebut belum termasuk biaya Materai Yonida Danan Puthu Wikarta, S.E
This Bill Not Include Legal Stamp
Harga obat sudah termasuk PPN
Layanan non farmasi - PPN dibebaskan

Page 6 of 6 TIDAK BERLAKU SEBAGAI KWITANSI / NOT VALID AS RECEIPT Printed by NURITA at
30 May 2025, 09:14:47
JL.Ring road Utara No.160,Condong Catur, Depok, Sleman, Yogyakarta 55283
Telp: 0274 4463535 (Hunting), Fax 0274 4463444
Website: www.rs-jih.co.id, Email: info@rs-jih.co.id