Penerimaan Januari 2024 PKM

REKAPITULASI LAPORAN PER
DI INSTALAS
JEMBER KIDUL PATRANG BANJAR SILO I SILO II ARJASA JELBUK UMBULSAR TEMBOK BANGSAL KLATAKAN ANDONGS CURAH SEMBORO TANGGUL MUMBUL TEMPUREJ SUKORAM PANTI
(1) (2) SENGON (4) (5) (6) (7) I REJO SARI (11) ARI NONGKO (14) (15) SARI O (17) BI (18) (19)
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
OBAT APBD/ DAK/ DAU

1 Acyclovir krim 2,764.00 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
2 Acyclovir tablet 400 mg 650.00 200 400 200 300 200 150 200 200 200 200 200 200 200 200 200 200 200 200 200
3 Alopurinol Tablet 100 mg 110.00 - - - - - - - 200 - - 200 200 - - 100 100 200 - 200
4 Alpara tablet 888.00
Alpara 750.00 300 300 300 300 450 300 300 300 300 300 300 300 300 300 300 300 300 300 300
6 Ambroxol tablet 30 mg 130.00 1,000 1,000 500 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000
7 Aminophylin injeksi 24mg/ml tablet 2,604.00
8 Amitriptilina HCL tablet 25 mg tablet 175.94 - - - - - - - 100 - - - - - - - - - - -
9 Amlodipin 10 mg 94.00 900 1,500 600 1,200 600 100
Amlodipin 10 mg 119.00 1,220 1,100 510 510 2,010 900 1,200 900 2,010 900 600 900 600 3,000
10 Amlodipin 5 mg tablet 53.48
11 Amoxicillin kaplet 500 mg kaplet 201.00
Amoxicillin kaplet 500 mg 525.00 3,000 2,500 3,000 1,000 3,000 2,000 2,000 2,000 2,000 2,000 3,000 1,000 1,000 1,600 600 1,000 1,000 1,000 2,000
Amoxicillin kaplet 500 mg 491.00
12 Amoxicillin sirup kering 125ml/5ml botol 2,050.00 100 100 100 50 50 100 100 50 - - - - - 100 100 100 50 50
13 Antasida Doen tablet tablet 58.00
Antasida Doen tablet 105.00 2,000 2,000 - 3,000 3,000 2,000 4,000 4,000 3,000 2,000 2,000 - 2,000 2,500 3,000 2,000 2,500 3,000 2,000
14 Anti Hemmoroid Suppositoria 3,250.00
15 Aqua pro injeksi steril - 20 ml ampul 2,860.00
Aqua Pro Injeksi Steril 20 ml 2,955.00 20 20 10 20 20 20 20 20 20 10 10 20 20 10 10 10 10 10 10
16 Asam Askorbat (vit C) tablet 250 mg tablet 119.00
Asam Askorbat (vit C) tablet 250 mg 141.00 3,000 3,000 3,000 3,000 5,000 3,000 3,000 3,000 3,000 1,000 1,000 3,000 3,000 3,000 3,000 3,000 3,000 3,000 3,000
17 Asam Askorbat (Vit C) tablet 50 mg 67.00 200 200 200 200 200 - - - - - - - - - - - - - -
18 Asam Mefenamat kaplet 500 mg kaplet 111.00
Asam Mefenamat kaplet 500 mg 190.00 1,000 1,000 500 1,500 1,500 1,000 1,000 1,000 1,000 500 1,500 500 500 1,500 1,500 1,000 1,500 1,000 1,000
Asam Mefenamat kaplet 500 mg 180.00
19 Asetosal tablet 80 mg 216.00
Asetosal tablet 80 mg 522.00
20 Attapulgit 630 mg (700 mg) 500.00
Attapulgit 630 mg (700 mg) 450.00 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150
21 Bahan tumpatan sementara (Orafil) 67,600.00
22 Becefort tablet 1,484.00 - - - - - 300 300 300 300 500 500 500 500 500 500 500 500 500 500
23 Bedak Salisil 2% 1,765.00
24 Benzatin Bensil Pen.inj 2,4 juta IU tablet 14,500.00
Benzatin Benzil Penicillin injeksi 31,419.00 10
25 Betahistin Mesilat 6 mg tablet 89.00
Betahistin Mesilat 6 mg tablet 190.00
26 Betametason krim tube 1,554.00
Betametason krim 2,000.00 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
27 Bisakodil Suppo 10 mg supp 4,325.00 - - - 5 - - - - - - - - - - - - - - -
28 Bonding Liquid 311,800.00
29 bur carbide highspeed round Pak 200,110.00
30 Caladin lotion 60ml 13,662.00 5 5 5 10 - - - 10 10 5 5 - - 4 - - - - -
31 Captopril tablet 25 mg 182.00 500 1,000 - 500 500 500 500 500 500 500 500 1,000 1,000 500 500 500 500 500 500
32 Catridge TCM pcs 253,137.10
Page 1 of 38
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NO. SATUAN
NAMA OBAT
HARGA SATUAN
33 Caviplek tablet tablet 832.50
Caviplek tablet tablet 754.80
34 Cefadroxil kapsul 500 mg 741.00
Cefadroxil kapsul 500 mg 820.00 500 500 500 500 500 500 500 500 300 500 500 500 300 500 500 500 500 300 300
35 Cetirizine tablet 10mg 74.00
Cetirizine tablet 10mg 130.00 500 500 500 500 500 200 200 200 200 300 300 500 300 500 - - 300 300 500
36 Chloramphenicol kapsul 250 mg 587.00 - - - 200 - - - - - - - 100 100 300 300 200 200 200 200
37 Chloramphenicol sirup -125 mg/ml-60ml botol 11,043.00
38 Chloramphenicol tetes mata 0,5% - 5 ml 7,000.00 20 20 20 20 20 10 10 10 10 10 10 10 10 10 10 10 10 10 10
39 Chlorpromazin injeksi 25mg/ml VIAL 7,850.00 - - - - - - - - - - - - - - - - - - -
40 Chlorpromazin tablet 100 mg 525.00 - - - - - - 300 - - - - - - - - - - - -
41 Ciprofloxacin kapsul 500 mg kapsul 248.00
Ciprofloxacin kapsul 500 mg 360.00 500 500 500 200 500 500 500 500 500 500 500 200 500 500 500 200 200 400
Ciprofloxacin kapsul 500 mg 448.00 500
42 Clindamycin kapsul 150 mg 708.00 100 - - 100 100 100 100 - - 100 100 100 100 - - - - 100 100
43 Clindamycin kapsul 300 mg 950.00 100 - - - - - - 100 100 - - - - - - 100 100 - -
44 Clozapin 25 mg tablet 477.00
Clozapin 25 mg tablet 473.00
45 Combipak (Azithromycin-Cefixime) tablet 31,231.00 - - - - - - - - - - - - - - - 10 - - -
46 Cotrimoxazol sirup botol 2,190.00 - 50 - 100 50 - 50 - - 100 - 50 - 50 50 100 50 100 100
47 Cotrimoxazol tablet tablet 126.00
Cotrimoxazol tablet 228.00 1,000 500 100 - -
Cotrimoxazol tablet tablet 133.00
Cotrimoxazol tablet 240.00 900 1,000 200 1,500 1,500 500 - - - 500 2,000 1,000 1,500 800 200
48 Cotrimoxazol tablet Forte 570.00 500 - - 300 - - - 300 - - - - - - 500 - - - -
49 Cyanocobalamin ( vit B12 ) injeksi ampul 1,104.00
Cyanocobalamin ( vit B12 ) injeksi 2,104.00 100 - - 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
50 Daryan Tulle : Tramisetin Sulfat 10 x 10 cm 10,455.00 10 10 - 10 10 10 10 - - 10 10 10 10 10 10 10 10 10 10
51 Deksametason Injeksi 5mg/ml 999.00
Deksametason Injeksi 5mg/ml 1,776.00 - - - 30 30 50 50 50 50 30 30 - 30 50 - 50 50 - -
52 Deksametason tablet 0,5 mg 57.00 1,000 1,000 - 1,000 500 500 500 500 500 500 1,500 1,000 - - 1,000 500 1,500 - 1,500
Deksametason tablet 0,5 mg 66.00
53 Dermazin salep kulit 25 gram 21,276.00 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
54 Diazepam enema 10 mg/2,5 ml (Stesolid) 47,725.00 - - - 5 - - - - - - 5 - - - - - - - -
55 Diazepam enema 5 mg/2,5 ml (Stesolid) 31,965.00 - - - 5 - - 5 - - - 5 - - - - - - - -
56 Diazepam tablet 5 mg tablet 275.00 - - - - 200 - - - - 500 300 - - - - - -
57 Digoksina tablet 0,25 mg 130.00 200 200 - - - 100 100 100 100 300 - 100 100 300 300 100 100 100 100
58 Dimenhidrinate 50 mg tablet 210.90 - - - - - 200 200 200 200 300 300 300 300 300 300 300 300 300 300
59 Diphenhidramina injeksi 10 mg 1,110.00
Diphenhidramina injeksi 10 mg 2,220.00 60 30 - 60 30 30 30 60 60 60 60 - 60 60 60 30 30 30 30
60 Domperidon tablet 10 mg 150.00
Domperidon tablet 10 mg 155.00 1,000 500 500 500 500 300 300 300 300 300 300 500 500 500 500 500 500 300 300
61 Epinephrina HCL/Bitart injeksi 0.1% - l ml ampul 1,408.00
Epinephrina HCL/Bitart injeksi 0.1% - l ml 3,885.00 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30
62 Erithromicin kaplet 500 mg 4,306.80
63 Erithromicin kapsul 200 mg 2,697.30 10 10 - - - - - - - - - - - - - - 10 - -
64 Erithromicin sirup - 60 ml Kering botol 6,462.00
Erithromicin sirup - 60 ml Kering botol 12,100.00
65 Etil Klorida semprot 187,000.00
66 Eugenol Cairan - 10 ml 20,150.00
67 Fenitoin kapsul 100 mg 170.00
68 Fenitoina Natrium kapsul 100 mg tablet 168.00
69 Fitomenadion (Vit K) tablet 10 mg 750.00
Fitomenadion (Vit K) tablet 10 mg 1,055.00 - - - 200 100 - - 100 100 300 - - 100 100 - - - - 100
70 Fluconazole 150 mg tablet 18,727.18
Page 2 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
71 Fluconazole 150 mg 11,250.00 50 - - 100 - - - 30 - - - - - - 90 - - - -
Fluconazole 150 mg 11,300.00 10
72 Furosemida tablet 40 mg tablet 98.00
Furosemida tablet 40 mg 263.00 - 200 - 200 100 - - 200 200 200 200 - 200 - 100 - - - -
73 Furosemide 10mg/ml injeksi ampul 931.00
74 Glibenklamida tablet 5 mg tablet 82.00 - 400 - - 500 - 2,000 500 500 500 500 2,000 1,000 - 200 500 1,000 300 1,000
75 Glimepiride 2 mg 180.00 500 500 300 500 200 500 500 500 500 1,000 1,000 500 500 500 500 500 500 500 500
76 Glukosa lar. infus 10% steril botol 8,003.00
Glukosa lar. infus 10% steril 8,350.00 20 - - 20 20 - - - - - - - - - 20 - - - -
78 Griseofulvin tablet 125 mg 293.00 200 - - 100 - - - - - - - - - - - - - - -
79 Haloperidol tablet 0.5 mg tablet 47.00 - - - - - - - - - - - - - - - - - - -
80 Haloperidol tablet 5 mg 190.00 - - - - - - 200 - - - - 300 - - - - -
Halopuridol tablet 5 mg tablet 54.00
81 Herbakof sirup 16,563.00 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 - -
82 Hidrokortison Krim 2,5% 2,800.00 48 - 13 24 24 24 24 24 24 24 24 24 24 24 24 24 24 48
83 Ibuprofen suspensi 100 mg/5ml 4,100.00
84 Ibuprofen tablet 400 mg 190.00 1,000 1,000 1,000 2,000 2,000 1,000 1,000 500 500 1,000 1,000 1,000 1,000 1,000 1,000 500 500 1,000 -
85 Infusion set anak set 8,400.00
86 Infusion set dewasa pcs 3,100.00
87 KA-EN 3B infus - 500 ml botol 10,696.00
88 Kalsium Laktat tablet 500mg. 85.00
Kalsium Laktat tablet 500mg. 84.00 5,000 5,000 5,000 8,000 5,000 5,000 5,000 1,000 2,000 5,000 5,000 5,000 5,000 5,000 5,000 3,000 2,000 4,000 3,000
89 Ketoconazol krim 2% 2,349.00 50 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
90 Ketokonazol tablet 380.00
Ketokonazol tablet 380.00 300 300 - 200 200 200 200 200 200 200 200 - - - 200 - 200 200 -
91 Kodeina tablet. 10mg tablet 600.00 - 100 - 100 - - - - - - - - - - - - - - -
92 Laktulosa sirup 3,335g/5 ml 12,533.00
93 Lanzoprazol kapsul 30 mg 500.00 200 - - 100 100 - 200 200 200 100 100 200 200 - - 100 100 - 200
94 Levofloxacin tablet 500 mg tablet 373.00 100 - 100 100 - - - - - - - - 100 - 200 - 200 200 -
95 Lexavit kaplet 750.00 100 - - - - - - - - - - - - - - - - - -
96 Lidocain Compositum + Epinephrine Injeksi 1,848.00 50 50 - 50 50 50 50 50 50 50 50 - - 50 50 50 50 50 -
97 Lidocain injeksi 2% 1,166.00 - - 100 - 50 100 100 50 50 100 - 100 - - 50 50 50 50 -
98 Loperamide tablet 2 mg 74.00 200 200 200 300 - 200 200 200 200 200 200 300 300 300 300 300 300 300 300
99 Magnesium Sulfat injeksi 20% ampul 3,580.00
Magnesium Sulfat injeksi 20% 4,973.00 12 12 12 12 6 6 6 6 6 12 6 6 12 12 12 12 12 12 12
Magnesium Sulfat injeksi 40% 5,661.00 12 10 12 12 6 6 6 6 6 12 6 6 12 12 12 - 6 6 24
101 Metamizol (Antrain) Injeksi 500mg/ml 2,789.00
Metamizol (Antrain) Injeksi 500mg/ml 3,020.00 30 30 - 30 30 30 30 30 30 50 50 50 50 50 50 50 50 50 50
102 Metformin H Cl tablet 500 mg 180.00 600 600 400 400 600 400 400 400 400 1,000 1,000 600 400 400 800 600 400 400 1,000
103 Metilergometrina injeksi 0,2 mg/ml -1 ml ampul 2,959.00
104 Metilergometrina Maleat tablet tablet 214.00
Metilergometrina Maleat tablet 257.00 - - - 100 100 - - - - - - - 100 100 100 - - - -
105 Metronidazol tablet 500 mg 211.00 100 100 200 100 100 100 100 - - - - 100 - 200 - - - - -
106 MOLEXFLU 450.00 300 300 300 300 150 300 300 300 300 150 150 - - 300 300 300 300 300 150
107 Monoklorkamfer Mentol cairan/Paramono Chlorophenol
68,266.67
108 N- Asetil Sistein tablet 716.00
N- Asetil Sistein tablet 373.00 1,000 1,000 - - - 500 200 500 500 500 - 1,000 500 500 500 300 300 1,300 500
109 N2O Nitrous Oxide tablet 2,488,750.00
110 Natrium Diklofenak 50 mg tablet 100.00 - 200 - 200 100 100 100 100 100 100 100 100 100 100 100 100 100 - -
111 Natrium Klorida 0.9% larutan infus 100 ml botol 15,180.00
Page 3 of 38
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NO. SATUAN
NAMA OBAT
HARGA SATUAN
Natrium Klorida 0.9% larutan infus 500 ml 7,205.00 - 100 - 100 100 200 100 200 200 100 200 200 100 200 200 100 100 100 200
Natrium Klorida 0.9% larutan infus 500 ml 7,205.00
113 Nifedipin tablet 10 mg 149.00 200 200 - 100 - 100 100 100 100 100 100 - - 200 200 100 100 100 100
114 Nifedipin tablet 30 mg (Adalat) 4,022.00 30 - - - - - - - - - - - - - - - - - -
115 Nystatin 100.000 IU/g tablet vaginal tablet 598.00
Nystatin ovula 100.000 IU/g 1,610.00 - 10 10 - - - - 10 10 10 - 10 10 10 - 10 10 10 -
116 Omeprazol kapsul Kapsul 129.00
Omeprazol kapsul 231.00 - - - - 300 200 800 300 300 300 300 300 600 200 500 200 300 - 300
117 Ondansetron injeksi 2,g/ml 1,500.00 20 20 10 60 - 30 30 30 30 50 - 90 60 80 50 50 50 50 50
118 Ondansetron tablet 4 mg 244.00 200 200 200 500 - 200 200 200 200 - - - - 400 400 400 400 500 500
119 Oseltamivir 75 mg tablet 14,300.00
120 Paracetamol tablet 500 mg tablet 170.00
Paracetamol tablet 500 mg 158.00 5,000 3,000 2,000 - 6,000 1,000 3,000 3,000 3,000 2,000 2,000 3,000 2,000 3,000 3,000 2,000 3,000 6,000 6,000
Paracetamol tablet 500 mg 139.00
121 Parasetamol sirup 120 mg/5ml botol 1,160.00
Parasetamol sirup 120 mg/5ml botol 1,181.00 - 100 - - 50 - - 100 100 150 - 100 200 - 100 100 50 100 100
Parasetamol sirup 120 mg/ml botol 1,181.00
122 Pehacain Injeksi tablet 3,663.00 - - 20 20 - - 40 - - - - 40 - - - 20 - 60 -
123 Permetrin (Scabimite) Krim 5% 6,660.00 10 10 10 10 5 5 5 5 5 5 - - - - - 5 5 10 -
124 Pirantel Pamoat tablet 125 mg tablet 306.00
125 Piridoksin (Vit B6) tablet 25 mg 255.00 100 - - 100 - - - 100 - - - - - - - - - - -
126 Plastic Apron pcs 2,959.00
127 Prednison tablet 5 mg tablet 68.00
Prednison tablet 5 mg 102.00 200 200 200 200 200 100 100 100 100 100 200 200 200 - 200 100 100 100 100
128 Ranitidin injeksi 50mg/2ml 1,276.99
Ranitidin injeksi 50mg/2ml 1,340.00 30 30 20 30 30 30 30 50 50 30 30 50 50 50 50 50 50 50 50
129 Ranitidin tablet 150 mg 172.00 300 300 200 500 500 300 300 300 300 300 300 300 300 500 500 500 300 300 300
130 Rapid Test Syphilis Biocare test 13,900.00
131 RDT DBD Dengue Combo Verotec pcs 68,112.00
132 Rifampisin kapsul 450 mg tablet 934.00
133 Rifampisin kapsul 600 mg tablet 1,233.00
134 Ringer Asetat ( Asering ) infus botol 9,646.00
Ringer Asetat ( Asering ) infus 8,400.00
Ringer Asetat (Asering) infus 8,400.00
135 Ringer Laktat infus 7,700.00 100 100 - 100 100 100 200 200 200 100 200 200 100
Ringer Laktat infus 7,699.00 200 200 200 200 100 100
Ringer Laktat Larutan infus - 500 ml botol 7,630.00
136 Risperidone 2 mg tablet 123.00
Risperidone 2 mg 209.00 500 - - 300 600 - - 400 500 - 1,000 500 - 500 - 1,000 - 1,000 1,000
137 Salbutamol tablet 4 mg 75.00 300 200 300 500 300 200 200 500 500 300 300 500 200 500 500 200 500 300 300
Salbutamol tablet 4 mg 180.00
138 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%)

3,820.00 10 - 5 5 - - 3 3 - 5 - 5 5 - 5 5 - 5 -
139 Serum Anti Bisa Ular injeksi (ABU I) / SABU 688,819.00 - - - - - - - - - - - - - - - - - - -
140 Sikzonoate injeksi 25 mg /ml ampul 63,800.00
Sikzonoate injeksi 25 mg /ml 80,586.00 20 - - - - - - - - - - - - - - - 30
Sikzonoate injeksi 25 mg /ml 80,586.00
141 Simvastatin tablet 10 mg tablet 68.00
142 Simvastatin tablet 20 mg 220.00 200 200 - 1,000 1,000 200 200 200 200 300 300 - - 200 500 300 300 500 500
143 Spasminal tablet tablet 1,110.00
144 Spironolactone 25 mg tablet 192.00
145 TETAGAM / ATS 250 IU 177,000.00 - - - - - - - - - - - - - - - - - - -
146 Trifluoperazin 5 mg tablet 220.00 - - - - - - - 600 - - - 500 100 - - - - - -
147 Triheksifenidil HCl tablet - 2 mg tablet 63.00
Page 4 of 38
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NO. SATUAN
NAMA OBAT
HARGA SATUAN
148 Vaksin HBIG VIAL 1,325,000.00
149 Yodium Povidon 10% - 30 ml botol 3,049.00
150 Yodium Povidon 1000 ml 86,854.00 - - - - 2 - - - - - - - - - - - 2 - -
151 ZINC tablet 20 mg tablet 524.00
REKLAS BELNJA MODAL -
152 Safe-T Pro Uno (DBHCT) 640.00 400 1,000 600 1,000 - - 2,000 - - - - 800 - - - 1,000 - - 600
LABKESDA -
153 Alat suntik sekali pakai 1 ml 950.00
155 Colour Test SPQ 114421.0001 4,136,000.00
156 indicator strips pH 0 -14 Universal indicator 1,408.00
157 PCA SPQ 1,353,000.00
158 Stericide 5 liter 752,400.00
159 Viorex liquid 4% (500 ml) 74,250.00
TOTAL BELANJA OBAT - OBATAN 2023 -
BELANJA BAHAN - BAHAN KIMIA -
Belanja Bahan - Bahan Kimia -
1 Golongan Darah Anti-A 48,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
2 Golongan Darah Anti-AB 62,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
3 Golongan Darah Anti-B 48,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
4 Golongan Darah Anti-D 62,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
5 PCA 3,145,740.00
6 PCR Reagen 138,748.18
7 Acon HB Hemoglobin Strip 50 test mission 8,039.50
8 ALAT (GPT) FS (IFCCMOD) 499,500.00
9 Alkohol Swab 164.80
Alkohol Swab 88.80
10 Ambroxol HCI 30 mg 102.00
11 Amies Transport Swab 1,236,646.00
12 Amoxicillin kapsul 250 mg tablet 415.14 - - - - - - - - - - - - - - - - - - -
13 Antasida Doen Tablet 54.40
15 Articulating papper 219,600.00
16 ASAT (GOT) FS (IFCCMOD) 499,500.00
17 Biokimia TSI/TSIA 1,834,830.00
19 BORAX Test 1,554,000.00
20 Buffer pH 10 1,665,000.00
21 Buffer pH 4 480,630.00
22 Buffer pH 7 466,200.00
23 Cadmium (cd ) 3,918,300.00
24 Calcium Gluconas infus 5,775.00
25 Carrez 560,550.00
26 Carry & Blair Amies Agar 1,998,000.00
27 Catridge TCM 253,300.00
Catridge TCM 254,400.00
28 Cell pack DCL 2,363,911.50
29 Cellclean auto ( CCA-500 ) 1,950,535.29
30 Cell-Dyn Emerald Reagent Cleaner 3,131,865.00
31 Cell-Dyn Emerald Reagent Diluent 4,695,744.00
32 Cell-Dyn Emerald Reagent Lyse 5,087,463.00
33 Chloride Test 3,793,425.00
34 Chlorpheniramin Maleat ( CTM ) tablet 4 mg 86.00 4,000 500 2,000 3,000 3,000 4,500 2,000 2,000 2,000 3,000 - 1,000 1,000 1,500 1,000 2,000 2,000 2,000 1,500
35 Chromate test 4,317,900.00
36 Coliformagar for microbiology 10,772,000.00
Page 5 of 38
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NO. SATUAN
NAMA OBAT
HARGA SATUAN
37 Complete Blood Count CBC Normal Abacus 1,485,180.00
38 Complete Blood Count CBC Normal Dirrui 1,485,180.00
39 Composit light curing A2 ( Master fill ) 1,051,840.66
40 Composit light curing A3 147,834.78
41 Copper test 4,723,050.00
42 CYBOW Strip 100"S 1,334.88
43 D.Piece 68,041.67
44 Deterjen 2,775,000.00
45 Diatro Reagen cleaner ( ABACUS ) 1,415,871.60
46 Diatro Reagen Diluent ( ABACUS ) 373,358.49
47 Diatro Reagen Lyse ( ABACUS ) 373,358.49
48 Diazepam enema 10mg/ 2,5 ml( Stesolid ) sub 19,693.00
50 Dirrui Reagent Cleanser( 500 L ) 1,110,000.00
51 Dirrui Reagent Diluent (20 L ) 1,221,000.00
52 Dirrui Reagent Lyse ( 500ml) 1,210,000.00
53 Eight Check 3 HP 1,237,650.00
54 Eosin Methylen Blue 387,836.00
55 Etanol 70% 23,595.00
56 Etchant/ Etsa Asam Liquid 78,304.35
57 Fitomenadion ( Vit K ) injeksi 2 mg/ml 1,386.00
58 Fluoride test 3,050,280.00
59 Fluoride Test Merck 4,320,000.00
60 fluorocell WDF 4,454,302.35
61 Formaldehyd test strip 1,665,000.00
62 Gentamycin tetes mata sub 4,520.00
63 Glass Ionomer Cement/GC Fuji IX kotak 1,097,790.00
64 Gluco Protein 1,045.00
65 Glukosa lar. infus 40% steril 7,000.00 - - - 10 10 - - 10 - - 20 - - 36 - - - 40 40
67 HCV Viral Load Xpert HIV 1 394,500.00
68 Herbakof sirup 14,402.00
69 Humasens Glucose Strip strip 3,800.00
70 Humasens Uric Acid Strip strip 14,146.25
71 Ibuprofen tablet 400 mg 191.00
72 Immersion Oil 756,000.00
73 Iron test 2,282,160.00
74 Isoniazid 100 mg tablet 147.63
75 Isoniazid 300 mg tablet 77.70 41
76 Isosorbid Dinitrat tablet 5 mg tablet 86.78
77 Kalsium Hidroksida pasta 180,300.00
78 Kalsium Laktat tablet 500mg 60.49
79 Kaolin Pektin ( Neo Kaominal ) sirup botol 8,369.40
80 Kesadahan test 3,219,000.00
81 Labiosis HDL Cholestrol 1,000,509.94
82 Lactosa broth 2,571,000.00
Lactose Broth 943,500.00
83 Laktulosa Sirup 3,335g/5 ml 12,420.00
84 Lidocain Compositum + Epinephrine injeksi 803.00
Lidocain Compositum + Epinephrine injeksi 802.99
85 Lysercall WDF 2,138,659.20
86 Lytacur sirup 60 ml 10,656.00 48 48 48 - 24 24 - 24 24 24 24 24 24 - - 24 24 24 24
87 Mangan 4,500,000.00
88 Media Mac Conkey Agar Merck 2,510,000.00
89 Merc Cyanida Test 4,325,000.00
Page 6 of 38
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NO. SATUAN
NAMA OBAT
HARGA SATUAN
90 Merc Zinc 8,330,000.00
91 Monoklorkamfer Mentol cairan/Paramono 51,100.00
92 Mouth Piece 4,800.00
93 Nitrat test 6,607,830.00
Nitrite test 2,997,000.00
94 Norma Reagent Cleaner idil3 1,957,375.11
95 Norma Reagent Diluent idil3 1,628,404.41
96 Norma Reagent Lyse idil3 2,423,417.40
97 Noza 805.00
98 Oksigen Gas dalam tabung - 6m3 tabung 54,867.30 - - 4 - 15 - 10 15 10 - - - - 15 - 15 - 10 -
99 Oxytocin injeksi 10 IU/ml 1,126.00 - - - 50 100 - - - - - - 50 50 50 50 50 - - 100
100 Paket Bahan Habis Pakai IVA 8,700,000.00
101 PCR tube baru 399.60 - - - - - - - - - - - - - - - - - - -
102 Pewarna Ziehl Nellsen 164,280.00
103 Ph test Strip 99,900.00
104 Phospate Buffer saline 1,998,000.00
106 PPD (Purified Protein Derivative)/ Mantoux test 854,700.00 2 - 1 - - 1 - - - 3 - 1 - - 1 1
107 Proline Creatinine FS 344,100.00
108 Proline Triglycerides FS 865,800.00
109 Proline Triglycerides FS 1,230,596.63
110 Proline Urea FS 510,600.00
111 Pulp X 205,923.08 - - - - 1 - - 1 - - - - - - - 1 - - -
112 RDT ANTIGEN COVID - 19 35,960.00
113 RDT Malaria (10 test / ktk) 13,983.96
114 Reagen I Intec One Step Anti HIV Tri Line Tes Card 15,665.93
115 Reagen I SD Bioline HIV 1/2 ( Syphilis Duo) test 17,723.52
116 Rhodamin B test 1,776,000.00
117 Rightest Glucose Strip test 4,600.00
118 Ringer Asetat ( Asering ) infus 8,800.00
119 Ringer Laktat + Glucose 5% infus-500ml 9,580.00
120 RPR Test Syphilis ( FOKUS Diagnostic ) 2,654.67 - - - - - - - 100 - - - - - - - - - - -
121 Salmonella Sigella Agar 473,849.86
122 Salmonella Thypi H 105,249.00
123 Salmonella Thypi H Antigen A 105,249.00
124 Salmonella Thypi H Antigen B 105,249.00
125 Salmonella Thypi H Antigen C 105,249.00
126 Salmonella Thypi O 105,249.00
127 Salmonella Thypi O Antigen A 105,249.00
128 Salmonella Thypi O Antigen B 105,249.00
129 Salmonella Thypi O Antigen C 105,249.00
130 Serum Anti Bisa Ular injeksi (ABU I)/SABU 521,833.00
131 Serum Anti Tetanus injeksi 1.500 IU 140,188.00
Serum Antitetanus ( ATS ) inj 1500 IU 140,188.00
132 Spectra Fresh Mint 145,862.07 - - - - - - - 1 - - - - - - - 1 - - -
133 Standart CRM FE 1,193,250.00
134 Sulfate test 3,576,000.00
135 Sulfolyser ( SLS-210A ) 826,750.20
136 Sysmex Reagent Cleanser 1,237,650.00
137 Sysmex Reagent Diluent 1,237,650.00
138 Sysmex Reagent Lyse 1,423,297.50
139 TCBS Agar 416,707.00
140 TCBS Agar 1.10263.0500 9 ( P+MI ) 4,184,700.00
141 Tes HIV II 15,330.56 - - - - - - - - - - 20 - - - - - - - -
142 Tetracyclin kapsul 500 mg tablet 219.78 200 - - - - - - - - - - - - - - - - - -
Page 7 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
143 Tiamina (Vit B1) tablet 50 mg tablet 95.46
144 Tube EDTA ungu 1,497.00
145 Ultra One Test Hamil 2,109.00
146 Urit Reagen Dilent 373,358.49
147 Urit Reagent Cleanser 2,149,798.05
148 Urit Reagent Lyse 999,000.00
149 Vitamin B Komplek 57.00 5,000 1,000 3,000 5,000 3,000 3,000 1,600
150 Vitamin B Kompleks tablet 57.00 1,400 3,000 3,000 - 2,000 5,000 2,000 2,000 2,000 2,000 2,000 1,000 6,000
151 Water one 20 L 102,500.00
152 XN CAL 2,575,549.65
153 XN -L Check ( L1, L2, L3 ) 3,465,422.22
154 Zinc F + ( Zinc Phosphate Cement ) 141,200.00
LABKESDA -
156 Cholesterol 583,200.00
157 Creatinin 408,100.00
158 Eosin 2% 1x100ml 182,000.00
159 FOKUS Amphetamine Check Test 312,386.00
160 FOKUS Cocain Rapid Test 378,035.00
161 FOKUS Device Benzodiazepine s (BZD) Rapid Test 321,184.00
162 FOKUS Marijuana (THC) Rapid Test 420,000.00
163 FOKUS Morphine (Opiates) Rapid Test 403,841.00
164 Glucose 288,600.00
165 Golongan Darah Anti A 56,785.71
166 Golongan Darah Anti AB 62,500.00
167 Golongan Darah Anti B 48,500.00
168 Golongan Darah Anti D 62,500.00
169 Immersion Oil 1 x 50ml 407,000.00
170 IMMUNOQUICK Contact Malaria +4 353,182.00
171 Methamphetamine 373,353.00
172 Multi-Drug One Step Multilin 1,914,166.67
173 PCR TUBE FLASH 20 13,898.09
174 Pewarna Giemsa 1 X 100ml 555,600.00
175 Pewarna Gram 3 x 100ml 293,500.00
176 Pewarna MDT 3 x 100 ml 161,500.00
177 Pewarna Ziehl Neelsen 5 X 100 ml 231,000.00
178 Rapid Test SD Bioline HBsAg 241,185.00
179 Rapid Test SD Bioline HIV 1/2 3.0 443,088.00
188 SGOT 519,500.00
189 SGPT 519,500.00
190 syphilis (RB-TS50:50 Test) 8,682.00
191 Trigliserida 955,800.00
192 Tru Cal N 6x3 ml 2,238,100.00
193 Tru Cal U 6x3 ml 1,561,000.00
194 Tru Lab P 6x5 ml 2,304,700.00
195 Turk 1x100ml 23,240.00
196 Uric Acid 704,900.00
Page 8 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
TOTAL BELANJA BAHAN-BAHAN KIMIA -
BELANJA
BARAN SUKU CADANG
HABIS PAKAI KEDOKTERAN
/ Belanja Suku Cadang - Suku -
Cadang Alat Kedokteran -
1 Acon Hb Hemoglobin Strip 50 test mission 8,046.14 100 100 100 - 50 100 100 100 100 - - 50 - - 100 - - - -
2 Alat Suntik 10 ml 976.80
3 Alkohol Swab pcs 90.00
4 Ams Blood Collection Tube Plain pet 1,751.15
5 Ams BT LDL Chol Direct 2x32 ml 5,994,112.00
6 Blue Tips 84.40
7 Chlorhexidine gluconat 0,5 W/V70 % 5 liter 395,000.00
9 Control Urine 2 Level 810,300.00
10 Cover Glass 9,657.00
11 Cup sample microtube 385,000.00
12 FOKUS HCG Strip 3,700.00
14 Glucosa Ams strip 3,980.00
15 HBA1C Hipro 2,136,626.00
16 IV Catether No.20 7,018.75
18 Kontrol Chem 3x 5ml Normal Ams 2,250,000.00
19 Masker Disposable (N95) 9,240.00
20 Microalbumin Hipro 2,000,000.00
21 Object Glass 14,208.00
Object Glass 16,428.00
22 Paket Reagen XN-L Series_Basis_CBC BASIC 19,096,995.00
23 Plester Flexible non woven 5 x 5 pcs 23,760.00
Plester Flexible non woven 5 x 5 22,000.00 2
Plester Flexible non woven 5 x 5 24,198.00 8 10 10 5 5 5 5 5 5 5 10 10 5 10 10 10 10 5 -
24 Plesterin Bulat Soft 170.94 - - - - - 50 - - 200 - 200 200 400 200 200 200 -
25 Safe Glove Exam L 690.80
26 Safe Glove Exam M 1,250.00
Safe Glove Exam M 1,243.44
27 Safe Glove Exam S 690.80
28 Sarung Tangan Obgyn steril 15,318.00 50 50 -
29 Sputum Pot 3,000.00 - 200 - - - - - - - 1,000 - - - - - 300 - - -
30 Surgical Glove No. 7,5 5,940.00
31 Transfusion set 5,328.00
32 Uji Fosfat test 3,436,560.00
33 Ultra Once Test Hamil 1,900.00
34 Urine Bag 5,280.00
35 Urinetest Insight 10U 2,142.30
36 Water one 20 L 102,500.00
37 XN cal 5,455,589.00
38 XN-L Check( L3,L2,L1 3.0ML ) 2,447,550.00
39 Yellow Tip 32.37
LABKESDA -
41 Kapas pembalut abs 250 gram 29,900.00
42 Plesterin Roll 175.00
TOTAL BELANJA SUKU CADANG ALAT KEDOKTERAN
Belanja Bahan - Isi Tabung Gas -
1 Oksigen Gas dalam tabung - 1m3 41,250.00
TOTAL BELANJA BAHAN ISI TABUNG GAS
Page 9 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
BELANJA BAHAN - BAHAN PERLENGKAPAN KANTOR -

1 APD ( Hasmat/Coverall ) XL 115,000.00 20 20 - 20 20 20 20 20 20 20 20 20 20 20 20 20 20 - -
2 Coverall Seam Tape Putih L 115,000.00 20 20 - 20 20 20 20 20 20 20 20 20 20 20 20 20 20 - -
3 Hazmat 99,000.00 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 - - - -
LABKESDA -
4 Coverall Seam Tape Putih XL 115,000.00
TOTAL BELANJA BAHAN-BAHAN PERLENGKAPAN KANT -
BELANJA BAHAN - BAHAN LAINNYA -
1 Alat Suntik 10 ml 976.00 - - - 200 200 - 200 - - - - 100 - 100 - - 200 - 100
Alat suntik sekali pakai 1 ml 577.00 100 300 100 100 - - 200 300 200 200 200 300 100 200
Alat suntik sekali pakai 1 ml 1,317.31 300 100 200 200 - 200
3 Alat suntik sekali pakai 2,5 ml 577.00 300 - 300 500 500 200 200 200 200 200 200 - 200 300 300 300 300 300 300
Alat suntik sekali pakai 2,5 ml 577.50
Alat suntik sekali pakai 3 ml 1,220.00 200 600 - 500 - 200 200 1,000 1,000 - 300 300 300 2,000 2,500 500 1,000 300 -
4 Alat suntik sekali pakai 3 ml 900.00 1,700
Alat suntik sekali pakai 5 ml 674.00 200 100 - 200 - 200 200 100 100 - 300 200 - 100 - 100 200 200 -
5 Alcohol Swab DBHCT 85.00 1,400 1,000 1,500 1,000 - 1,000 5,000 2,000 3,000 - 1,000 800 - 2,000 2,500 3,000 - 2,000 500
Alkohol Swab 120.00
Alkohol Swab 175.00
Alkohol Swab KESMAS 190.00 - - - - - - - - - - - - - - - - - - -
6 APD ( Hasmat/Coverall ) L 85,000.00
7 APD ( Hasmat/Coverall ) XL 85,000.00
APD ( Hasmat/Coverall ) XL 113,000.00
8 APD ( Hasmat/Coverall ) XXL 85,000.00
9 ARM SLING ( M ) 18,500.00
10 Arm Sling L 18,500.00
11 Auto Destruct Syringe (Pfizer) 0,3 ml 1,287.98
Auto Destruct Syringe (Pfizer) 0,3 ml 1,300.32
12 Autodisposable Syringe 0,5 ml (Soloshot) 1,206.00
13 Blood Lancet 143.77
Blood lanchet OM KESMAS 240.00 - - - - - - - - - - - - - - - - - - -
14 box Spesimen 17,900.00 - - - - - - - - - - - - - - - - - - -
15 Brilla broth 500 G 2,600,000.00
16 Catgut Chromic 2/0 + jarum 4,995.00 - - - 24 24 - - 24 24 24 - 24 - - 24 24 24 24 24
17 Catgut Chromic 3/0 + jarum 4,995.00 - - 24 24 24 - - 24 24 - - 24 24 - 24 - 24 24 24
Catgut Chromic 3/0 + jarum 22,489.83
18 Catgut Plain 2/0 + jarum 4,995.00 24 - - 24 24 - - 24 24 24 - 24 - - - 24 24 24 24
19 Catgut Plain 3/0 + jarum 4,995.00 24 - - 24 24 - - 24 24 24 - 24 - - - - 24 24 24
Catgut Plain 3/0 + jarum 22,310.42
20 Cell-Dyn Emerald Reagent Cleanser 3,130,000.00
21 Cervical Colar 108,700.00 - - - - - - - - - - - - - - - - - - -
CERVICAL COLAR 116,160.00
22 EKG Gel 48,000.00 - - - - - - - - 1 - - - - - - - - - -
23 Etanol 70% - 1000 ml botol 23,595.00 - - - - - 5 5 5 5 5 5 5 5 5 5 10 - 5 5
24 Etil Klorida semprot 187,500.00 - - - - - - - - - - - - - 1 - - - - -
25 FAST CLEAR Q SYPHILIS COMBO 15,500.00 - - 200 - - - - - 200 - - - - 200 - 200 - 200 -
26 Folley Catheter No. 14 9,900.00 4 - - - - - - - - - - - - - - - - - -
27 Folley Catheter No. 16 9,900.00 10 10 - 10 10 10 - 10 10 - - 10 - - 10 - - 10 10
Folley Catheter No. 16 9,990.00
28 Folley Catheter No. 18 9,900.00 10 - - 10 10 - - 10 10 - - 10 - - 10 - - - 10
29 GP CARE ANTISEPTEK (HAND SANITISER) 500 ML 31,000.00
30 GP CARE ANTISEPTEK (HAND WASH) 500 ML 33,000.00
31 Infusion set anak 6,600.00 - 50 - - 50 50 50 - 50 - 50 50 50 100 50 50 50 - 50
32 Infusion set dewasa 6,600.00 150 50 100 100 50 50 50 100 100 - 100 100 100 100 100 100 100 50 50
Page 10 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
33 IV Catether No.18 3,902.00 50 50 50 50 - 50 50 - - - 100 50 50 100 50
IV Catether No.18 6,900.00 100 100 - 100
34 IV Catether No.20 3,902.00 100 50 50 100 - 50 50 50 50 - 100 50 50 100 100 50 50 50 100
IV Catether No.20 6,900.00
35 IV Catether No.22 3,902.00 - 50 - 50 - - - 50 50 50 50 50 50 50 50 50 50 50 50
37 Kapas pembalut 40/80 125,000.00 2 - - - - 2 2 2 2 2 2 - 2 - 1 - - - -
Kapas pembalut 40/80 174,200.00
38 Kapas Pembalut 250 gram 16,000.00 10 10 10 10 - 10 10 10 10 10 10 10 10 10 10 10 10 10 10
39 Kasa Hidrofil 16 X 16 3,541.00
Kasa Hidrofil 16x16cm 6,000.00 5 5 5 - 5 - - 2 2 - - 3 - 5 5 - 5 - 5
40 Kasa Hidrofil 4mx10 cm 2,300.00 50 50 50 100 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50
41 Kasa Hidrofil 4mx15cm 3,300.00 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50
42 Kasa kompres steril 40cm/40cm 1,460.00
43 Kasa pembalut 2 m x 80 cm 10,452.00
44 Kertas EKG 106mmx 20 m 120,000.00 - - - - - - - - - - - 1 - - - - - - -
45 Kertas EKG 215mmx 25 m 120,000.00 1 - 1 - - - - - 1 - - - - - - 2 - - -
46 Kertas EKG 50mmx 20 m 120,000.00 - - - - - - - - - - - - - - - - - - -
47 Masker bedah 4 ply Supersoft 750.36
48 Masker Duckbill Ufo ( p2p) 1,200.00 - - - - - - - - - - - - - - - - - - -
49 Masker KN-95 2,886.00 50 50 50 50 50 50 50 50 50 50 50 50 - 50 50 50 50 50 -
50 Masker Nebulizer Anak 19,500.00
51 Masker Nebulizer Dewasa 19,500.00 - - - - - - - - - 3 - 3 - 5 3 2 2 - 3
52 Masker Oksigen Anak 12,700.00 5 - - 2 2 5 - - - - - 2 - - 2 - 2 - -
53 Masker Oksigen Bayi 12,700.00 5 - - 2 2 5 - - - - - 2 - - 2 - 2 - -
54 Masker Oksigen Dewasa 12,700.00
Masker Oksigen Dewasa 12,700.00 - - - 5 5 5 5 5 5 - - 4 4 - 5 - 5 - 5
55 Masker Surgical 3 Ply Headloop (Hijab) 328.50
56 Medicrepe 4'' 10,725.00
Medicrepe 4" ( 10 cm* 4,5 m ) 8,991.00 - 1 - - - - - - - - - - - - - - - - -
57 Microfill 5,500,000.00
58 Object Glass pcs 17,604.00
59 Oksigen Gas dalam tabung - 1m3 tabung 44,400.00 - - 10 - 5 - 10 15 - - 10 - 10 - - - 20 6 -
60 Oxyflow Nasal Oxygen Anak 7,800.00 - - - 2 - 2 2 2 2 - - - 5 2 2 2 2 - 2
Oxyflow Nasal Oxygen Anak 13,500.00
61 Oxyflow Nasal Oxygen Bayi 7,800.00 - - - 2 - 2 2 2 2 - - 5 - 2 2 2 2 - 2
62 Oxyflow Nasal Oxygen Dewasa 7,800.00 - - - 5 - 5 5 5 5 - 6 5 5 5 5 5 5 - 5
Oxyflow Nasal Oxygen Dewasa 13,500.00
63 Plester Flexible non woven 5 x 5 23,760.00
64 Plester Kain Roll 1,25cm x 4,5m 9,400.00
Plester Kain Roll 2,5cm x 4,5m 18,900.00 - 5 - 5 5 3 3 3 3 5 5 - - 5 5 5 5 5 -
66 Plester Kain Roll 7,5cm x 4,5m 52,100.00 - 2 - 2 2 2 2 2 2 - 2 2 - 2 2 - 2 2 2
67 Plesterin Bulat Soft 170.50
Plesterin Bulat Soft 1,300.00 - - - - - 150 - - 200 400
68 RDT Malaria 10,558.05
69 Reagen SKAMRT 20,482,000.00
70 Rightest Glucose Strip 4,600.00 400 1,000 - 1,000 - - 1,000 - 800 - - 300 - - - 1,000 - - 500
71 Safe Glove Exam L 816.96 300 - 200 100 100 - - - - - 200 100 - 100 - - 100 - -
Safe Glove Exam L 518.13
72 Safe Glove Exam M 816.96 300 - - 100 100 - - - - - 200 100 - 300 - - 100 200 -
Safe Glove Exam M 518.13
Safe Glove Exam S 518.13
Page 11 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
Safe Glove Exam S 382.95 300 200 - 100 100 - - 100 100 - 200 100 - - - - 100 - 300
74 Sarung Tangan Obgyn steril 15,318.00 - - - 50 - - 50 50 50 - - - - - - 50
75 SASKLIN Spray 250 ml (Hand Sanitiser) 14,388.00
76 Silk no 3/0 + jarum 15,562.33
Silk no 3/0 + jarum 3,630.56 36 36 36 - 36 36 36 36 36 - - - 36 - 36 36 36 36 36
77 SPALK 52,000.00 - - - - 2 - - - - - 3 3 - - 5 - - 1 -
78 Strip HB Sejoy KESMAS 8,800.00 - - - - - - - - - - - - - - - - - - -
79 Surgical Glove 7 4,424.40
Surgical Glove 7 12,600.00 - - - -
Surgical Glove No. 7 6,500.00 - 50 - - - 50 - 100 100 100 100 - 100 100 50
80 Surgical Glove 7,5 4,424.40
Surgical Glove 7,5 12,600.00
Surgical Glove No. 7,5 6,500.00 - - - - - 50 - 100 100 100 - - - - - 50 - - -
Surgical Glove No. 7,5 6,500.00
Surgical Glove No. 6,5 12,600.00 - 50 100 - - - - - - - 100 - - 100 - 50 - - -
82 Transfusion set 5,300.00 - - - 5 5 5 5 5 5 - - 10 10 10 - 10 10 10 10
83 Ultra Once Test Hamil 2,174.00 - 50 - - - 50 - - - - 50 - - - - 50 - - -
84 Umbilical Cord Clamp 1,798.00 - - - - 50 - - - - 50 50 - - 50 - - 50 50 50
85 Under Pad 3,552.00
Under Pad 3,800.00 50 100 100 100 50 30 30 30 30 100 100 50 50 50 100 100 100 50 50
86 Urine Bag 5,000.00
Urine Bag 5,200.00 20 20 - - 10 20 20 20 20 10 10 20 20 - 10 10 10 10 10
Urine Bag 4,235.00
87 USG Gel 5 liter 137,000.00
USG Gel 5 liter 220,000.00 - - - - - - - - - - - - - - - - - - -
88 Vacum Tube Clot activator 2,378.73 - 100 - - - - - - - - - - - - - - - - -
89 Viorex no rinse (500 ml) botol 65,934.00 2 2 2 5 5 5 5 5 5 5 - 10 - 5 5 5 5 5 5
90 XPER GLUCOSE STRIP 4,993.67
91 Yellow Tip 70.00
92 Yodium Povidon 10% - 30 ml 4,809.00 5 - - - 5 5 5 5 5 3 - - - - 5 - - - -
93 Yodium Povidon 10% - 300 ml 26,602.00 - 3 3 5 5 10 10 10 10 10 - - - 5 5 10 10 10 10
TOTAL BALANJA BAHAN-BAHAN LAINNYA -
OBAT PROGRAM APBD PROPINSI / APBN -
1 3HP ( Isoniazid + Rifapentin ) tablet 6,501.00
3HP ( Isoniazid + Rifapentin ) tablet 6,730.00
3HP ( Isoniazid + Rifapentin ) 6,776.00
3HP ( Isoniazid + Rifapentin ) 6,987.00 - - - - - - 108
3HP (Isoniazid + Rifapentin) tablet 7,613.10
3HP (Isoniazid + Rifapentin) tablet 6,776.00 - 72 - - - - - - - - 72 252 72
2 3HR (Isoniazid + Rifampicin) tablet 799.00
3HR (Isoniazid + Rifampicin) tablet 1,087.00 - - - - - - - - - - 672 - - - - - - - 252
3HR (Isoniazid + Rifampicin) tablet 1,062.60
3 Abate peal 71,500.00
Abate peal 73,500.00
4 Acyclovir tablet 400 mg tablet 407.00 50
5 Albendazol suspensi 200 mg/5ml botol 4,300.00
6 Albendazol tablet 400 mg tablet 390.00
Albendazol tablet 400 mg tablet 457.00
7 Alcohol Swab 88.00
Page 12 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
ALKOHOL SWAB 79.00 - - - - - - - - - - - - - - - - - - -
8 Alopurinol Tablet 100 mg tablet 87.00
10 Amoxicillin kaplet 500 mg tablet 201.00
Amoxicillin kaplet 500 mg tablet 471.00
11 Amoxicillin sirup kering 125ml/5ml 3,330.00 100
12 Ampicillin Injeksi 1 gram 8,616.63
13 Antasida DOEN Tablet 54.00
14 Antifungi DOEN (As Benzoat 3%+As Salisilat 6%) pot 3,477.00
15 APD Vaksin Covid -19(BA-BUN) 98,450.00
APD BNPB PMK - - - - - - - - - - - - - 3 3 3 3 3 3
16 Artesunate 60 mg inj ampul 88,989.00
17 Asam Askorbat (Vit C) tablet 500 mg tablet 225.00
Asam Askorbat (Vit C) tablet 500 mg 42.00
18 Attapulgit 600 mg tablet 227.00
19 Auto Destruct Syringe (PFIZER) 0,3 ML set 1,255.00
20 Auto Destruct Syringe (PFIZER) 3 ML 569.00
Auto Destruct Syringe (PFIZER) 3 ML 395.92
21 Autodisposable Syringe 0,05 ml (Soloshot) set 1,460.00
Autodisposable Syringe 0,05 ml (Soloshot) set 1,465.00
Autodisposable Syringe 0,05 ml (Soloshot) set 1,665.00 - 100 - - 100 100 - - - - - - - - - - 100 300 100
22 Autodisposable Syringe 0,5 ml 1,190.00
Autodisposable Syringe 0,5 ml 1,220.00 - 1,600 1,000 1,000 500 1,200 1,000 - - - 500 200 300 1,600 500 200 300 1,000 1,000
23 Autodisposable Syringe 5 ml (Soloshot) set 1,439.00
Autodisposable Syringe 5 ml (Soloshot) set 1,460.00 - - 100 - - - - - - - 100 - - - - - 100 100 100
24 Bedaqullin tablet 100 mg 34,611.00 - - - - - - - - - - - - - - - - - - -
25 Benzatin Benzil Penicillin injeksi vial 14,430.00 - - - - - - - 3 - - - - - 1 6 - - -
26 Berlinger & Co Freeze Tag Green 1,334.00
27 Berlinger & Co Fridge Tag WHO Type 9,662.24
28 Betametason krim 2,500.00
Betametason krim 2,000.00
29 Booklet pcs -
30 Box slide 77,690.00
31 Brosur pcs -
32 BTI Larvasida Mosnon 64,691.00
33 Buku Kontak pcs 12,100.00
34 Buku Peraturan per UU Covid pcs 85,250.00
35 Buku PVC -
36 Chloroquin tablet 150 mg tablet 850.00
37 Ciprofloxacin kapsul 500 mg tablet 248.00
39 Cotrimoxazol tablet 126.00
40 Cotrimoxazol tablet Forte tablet 357.50
Cotrimoxazol tablet Forte tablet 325.00 200
Cotrimoxazol tablet Forte tablet 499.00
Container box with lockabel lid 15 ltr - - - - - - - - - - - - - - - - - - -
41 DETEKSI Rapidan Tester anti HIV 1/2 test ( triline ) 7,454.44
42 Diazepam Injeksi 5mg/ml-2ml ampul 1,545.00 - - - 30 - - - - - - - 5 - - - - - - -
43 Diazepam tablet 5 mg tablet 108.00 100
Diazepam tablet 5 mg tablet 1,080.00
Diazepam tablet 5 mg tablet 54.00 200
44 Diphenhidramina injeksi 10 mg ampul 781.00
45 Etambutol (E) tablet 100mg tablet 670.00
Etambutol (E) tablet 100mg tablet 688.00 - - - - - - - - - - - - - - - - - - 56
46 Ethambutol 400mg 507.00
Page 13 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
47 FDC :TDF 300 mg+3TC 300mg +DTG 50mg 3,499.00
FDC :TDF 300 mg+3TC 300mg +DTG 50mg -
FDC :TDF 300 mg+3TC 300mg +DTG 50mg 2,609.00
FDC :TDF 300 mg+3TC 300mg +DTG 50mg 2,850.00 10,770 - - 630 - - - 360 - - - - - - 1,980 - - - 90
48 Fenobarbital Injeksi 50mg/ml-2ml 1,715.45
49 Fitomenadion (Vit K) injeksi 2 mg/ml ampul 1,399.00
Fitomenadion (Vit K) injeksi 2 mg/ml 3,400.00
Fluconazole 150 mg tablet 18,890.00
51 Fridge - Tag -
52 Fridge - Tag 2 -
53 Garam Oralit untuk 200 ml air kantong 257.00
Garam Oralit untuk 200 ml air kantong 280.00 500 500 - - 500 - - 500 500 2,000 - 300 - 500 500 - 500 500 1,000
54 Gentamycin injeksi 80 mg/2 ml 3,385.50
55 Goggle / Kaca Mata Pelindung 27,600.00
56 Haloperidol Decanoate lar Injeksi 50mg/ml 101,300.00
Haloperidol Decanoate lar Injeksi 50mg/ml 109,000.00 - - - - - - - - - - - - - - - - - - -
57 Haloperidol injeksi 5 mg/ ml vial 1,190.00
58 Haloperidol tablet 5 mg 54.00 600 500
59 Hidroklorotiazida tablet 25 mg 149.35
60 Hidrokortison Krim 2,5% tube 2,325.00 48 11
61 Ibuprofen tablet 400 mg tablet 1,910.00
62 Immersion Oil -
63 Insektisida sipermetrin 200,000.00
Insektisida sipermetrin 451,000.00 - - - - - - - 5 - - - - - - - - - - -
64 INSEKTISIDA SIPERMETRIN ZETA 15 UL (1 liter) 215,600.00
Isoniazid 300 mg tablet 309.00
Isoniazid 300 mg tablet 400.00 - - - - - - 300 - - - - - - - - - - 190 159
66 Kalsium Glukonat injeksi 10,450.00
67 Kapas pembalut 100g 7,205.00
68 Kartu Vaksin pcs 770.00
69 Kasa Pembalut Hidrofil 4m X 5cm 949.00
70 Levofloxacin 100mg TB tablet 1,952.00 - - - - - - - - - - - - - - - - - - -
Levofloxacin 100mg TB tablet 2,488.00
71 Levofloxacin tablet 250 mg tablet 405.00
72 Linezolid tablet 600 mg 2,933.00 - - - - - - - - - - - - - - - - - - -
73 Loperamide tablet 2 mg tablet 77.00
74 Magnesium Sulfat injeksi 20% 3,579.75
Magnesium Sulfat injeksi 20% 4,724.00
76 Maltodextrin tablet / TABURIA tablet 605.00
Maltodextrin tablet / TABURIA tablet - - - - 9,000 - - - - - - - - - - - - - - -
77 Masker 3 Ply Disposable (HIV-AIDS) pcs 2,290.00
78 Masker 3 Ply Earloop ( APBN-TB ) pcs 706.00
Masker 3 Ply Earloop ( APBN-TB ) pcs 706.42
79 Masker Bedah TB KALMED @50 706.42
80 Masker KN-95 Covid -
81 Masker N95 (1860 s) Program - TB pcs 19,900.00
Page 14 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
82 Masker N95 aero pcs 20,000.00
83 Masker N95 Wegen @20 12,000.00
84 Masker TB PLUS Conector 328.56
Masker Kain - - - - - - - - - - - - - 50 50 50 50 50 50
85 Metformin H Cl tablet 500 mg tablet 77.00
86 Metilergometrin Maleat injeksi 0,2 mg/ml 2,050.00
87 Metronidazol infus vial 5,938.50
88 Mineral mix 2,981.00
Mineral mix 3,008.10
89 Moxiflocaxin table 400 mg 3,401.00 - - - - - - - - - - - - - - - - - - -
90 Nystatin ovula 100.000 IU/g tablet 550.00
91 Obat Anti Malaria (DHP) tablet 1,900.00
Obat Anti Malaria DHP (Dihidroartemisin + Primaquin) tablet

1,917.00

2,851.00 - - - - - - - - - - - - - - - - - - -
92 Obat Antituberkulosis (OAT) KDT Dosis Harian 511,609.00
Obat Antituberkulosis dosis Harian paket 548,865.00
Obat Antituberkulosis dosis Harian paket 530,025.00 10 10 10 - 16 10 5 - - 25 10 5 5 10 10 10 - 10 6
93 Obat Antituberkulosis kat - Anak paket -
Obat Antituberkulosis kat - Anak paket 250,264.00
Obat Antituberkulosis kat - Anak paket 314,241.00 3 2 2 - - - - - - - 1 6 - 4 2 - - - 2
94 Obat Antituberkulosis kat - I paket 418,971.00
95 OBAT KUSTA M B anak strip 31,928.00
OBAT KUSTA M B anak strip 25,354.00
OBAT KUSTA M B anak strip 33,282.00 - - - - - - - - - 2 - - - - - - - - -
96 OBAT KUSTA M B dewasa strip 49,748.00
OBAT KUSTA M B dewasa strip 51,858.00
OBAT KUSTA M B dewasa strip 50,401.00 - - 2 - 3 - - 7 - 6 - - - - - 3 - - 2
97 OBAT KUSTA P B anak strip 18,562.00 - - - - 1 - - - - - - - - - - - - - -
98 OBAT KUSTA P B dewasa strip 15,304.00
OBAT KUSTA P B dewasa strip 15,014.00
100 Oxytetracylin salep mata 1% 3,531.82 10 - - 5 - - - 5 5 5 - - - 5 5 5 - - -
101 Oxytocin injeksi 10 IU/ml ampul 1,136.24
102 Paket APD lengkap 53,296.00
104 Pelarut BCG ampul - 5 - 20 - 50 - - - - 50 30 - - 10 20 - - 40 20
105 Pelarut NACL 0,9% 3,280.00
Pelarut NACL 0,9% -
106 Pen Maker -
107 Pewarna Ziehl Nellsen ( PROGRAM ) set 176,760.00
Pewarna Ziehl Nellsen ( PROGRAM ) set 174,000.00
Pewarna Ziehl Nellsen ( PROGRAM ) set 178,500.00 - - - - - - - - - - - 1 - - - - - - -
108 Piridoksin (Vit B6) tablet 10 mg 65.00 100 100 - 100 100 - - - - - - - - - - - - - -
109 Piridoksina ( Vit B6) tablet 25mg tablet 222.00
110 PPD ( Purified Protein Derivative )/ Mantoux vial 608,280.00 - - 2
111 Prednison tablet 5 mg 88.00
112 Pretomanid 32,576.00 - - - - - - - - - - - - - - - - - - -
Page 15 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
113 Primaquin 15 mg tablet 235.00 - - - - - - - - - - - - - - - - - - -
114 Pyrimetamin 25mg tablet 1,320.00
115 Rapid Test Anti Hbs 3,985.90 50 40 40 75 75 - 45 45 40 40
Rapid Test Anti Hbs 3,875.00 35 40 40 40 60 75 50 50 50 75
116 Rapid Test Anti HCV 10,088.00
Rapid Test Anti HCV 6,332.00
117 RDT ANTIGEN COVID - 19 -
118 RDT CHIKUNGUNYA 65,000.00 - 25 - - - - - - - - - - - - - - - - -
119 RDT DBD COMBO 453,660.00
RDT DBD COMBO 376,700.00 - - 1 - - 1 - 1 - - - - - - - - - - -
120 RDT LEPTOSPIROSIS 195,000.00
121 Retinol kap. lunak 100.000 IU ( Biru ) kapsul - - 400 300 450 700 - - 250 200 600 - 300 - 350 - - - - -
Retinol kap. lunak 100.000 IU ( Biru ) kapsul 305.00
122 Retinol kap. lunak 200.000 IU ( Merah ) kapsul 552.00
Retinol kap. lunak 200.000 IU ( Merah ) kapsul - - 7,400 2,600 3,100 3,900 - 1,150 1,700 2,100 4,300 - 1,400 - 2,450 - 4,400 - - -
123 Rifampisin kapsul 450 mg kapsul 921.00
124 Rifampisin Kapsul 600 mg kapsul 1,182.00
125 RIFAPENTIN 150 MG tablet 5,525.00
Rifapentin 150 mg tablet 5,525.00
Risperidone 2 mg tablet 210.00 100
127 Roll Banner Imunisasi Ganda -
128 Roll Banner PCV -
129 Rompi Vasinator pcs 148,000.00
130 Safety box 5 lt 16,500.00
Safety box 5 lt 14,717.00
Safety box 5 lt 16,451.36 - 25 - 25 - 25 - 25 - - 25 25 - - - - - 25 -
131 Salbutamol tablet 2 mg tablet 103.00
132 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%) tube

1,410.00
133 Sarung Tangan ( Handscoon ) Latex pcs 64,700.00
134 Serum Anti Dipteri injeksi 10.000 IU -
135 Serum Anti Rabies 153,000.00
Serum Anti Rabies 154,790.00 - - - - - - - - - - - - - - - - - - -
136 Serum Anti Rabies(Rabivax) -
137 Sikzonoate injeksi 25 mg /ml 62,000.00 10 15
Simvastatin tablet 10 mg tablet 112.00 90 90 - 120 120 90 90 90 90 150 90 120 120 90 120 150 90 150 90
139 Sputum Pot buah 2,275.00
Sputum Pot buah 2,200.00
Sputum Pot buah -
140 Tablet Tambah Darah (ferro Sulfat + as. Folat ) tablet 226.00
Tablet Tambah Darah (ferro Sulfat + as. Folat ) tablet - 28,000 28,000 11,200 5,600 22,400 11,200 11,200 11,200 11,200 - - 11,200 5,600 11,200 28,000 11,200 11,200 28,000 -
Tablet Tambah Darah (ferro Sulfat + as. Folat ) tablet 232.60
141 Trifluoperazin 5 mg tablet 287.00
142 Triheksifenidil Hcl tablet - 2 mg tablet 63.00
Triheksifenidil Hcl tablet - 2 mg tablet 120.99
143 Vaksin BCG ampul 97,780.10
Vaksin BCG ampul -
Vaksin BCG ampul 97,999.68
Vaksin BCG 98,000.00
Vaksin BCG ampul 202,107.63 5 - 20 - 50 - - - - 50 30 - - 10 20 - - 40 20
Page 16 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
144 Vaksin DPT Hb - Hib / PENTABIO vial 85,103.00
Vaksin DPT Hb - Hib / PENTABIO vial 77,366.36
Vaksin DPT Hb - Hib / PENTABIO vial -
Vaksin DPT Hb - Hib / PENTABIO 47,032.43
Vaksin DPT Hb - Hib / PENTABIO 10 ds 210,000.00 - - 16 21 - - 16 20 13 33 14 14 14 22 27 30 - 19 29
145 Vaksin DT vial 33,063.06
Vaksin DT vial 36,700.00
146 Vaksin HB Unijeck vial 23,490.00
Vaksin HB Unijeck vial 26,073.90
Vaksin HB Unijeck vial -
Vaksin HB Unijeck vial 28,695.00 10 20 - 30 - 60 - 20 - 100 20 - - 10 100 - 30 - 75
Vaksin Hb-0 (Unijeck) vial 25,851.35
147 Vaksin Hb-0 (Unijeck) Dewasa 51,351.35 - 33 - - - - - - 34 - - - - - - - 39 - -
148 Vaksin HBIG vial 1,325,000.00
Vaksin HBIG vial 1,375,000.00 3 - 6 - - 2 - 1 - 4 1 - - - - 2 1 - -
149 Vaksin HPV 161,036.04 - - - - - - - - - - - - - - - - - - -
150 VAKSIN INAVAC vial 464,225.00 6 2 2 2
VAKSIN INAVAC vial 515,289.75 3 5 2 11 2 5 4 - 7 2 1 10 2 3 4 3
151 VAKSIN INDOVAC vial -
152 Vaksin Meningitis vial 60,332.56
Vaksin Meningitis vial 122,000.00
153 vaksin MR set 152,600.00
vaksin MR set 169,386.00 5 50 30 - - 35 50 15 10 50 20 5 - 30 25 50 - 50 40
vaksin MR set 194,386.00
154 Vaksin PCV -
Vaksin PCV 190,657.00 - 100 50 50 50 80 80 30 20 100 30 20 - 60 25 100 20 100 70
155 Vaksin PFIZER BILATERAL SHIPMENT 6 Dosis -
Vaksin Polio 50 Dosis ampul - 111 173 102 122 167 106 83 107 80 189 89 76 78 116 173 172 140 111 183
156 Vaksin Polio bOPV 10 Dosis ampul 21,689.40
Vaksin Polio bOPV 10 Dosis ampul -
Vaksin Polio bOPV 10 Dosis ampul 158,500.00
Vaksin Polio bOPV 10 Dosis ampul 21,810.81 30 50 50 50 50 80 50 20 - 100 20 10 20 30 60 50 20 80 50
157 Vaksin Polio IPV 5 Dosis ampul 158,500.23
Vaksin Polio IPV 5 Dosis ampul -
Vaksin Polio IPV 5 Dosis ampul 158,500.00
Vaksin Polio IPV 5 Dosis ampul 172,000.05 10 40 40 30 40 50 40 - 20 50 - 10 50 30 30 - 30 60 50
158 Vaksin ROTAVAC 249,750.00 25 80 60 50 50 90 80 30 15 50 50 - 30 30 - 70 30 100 40
Vaksin ROTAVAC 225,000.00
159 Vaksin Td vial 20,721.00
Vaksin Td 23,000.31 - - - 20 40 - - - - - - - - - - - - - -
Vaksin Td 29,279.28
160 VAKSIN ZIFIVAX vial -
161 ZINC tablet 20 mg tablet 208.00 200 200 200 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
OBAT PROGRAM HIV AIDS/ APBD PROPINSI -
1 3HP HIV tablet 6,536.64 360 - - - - - - - - - - - - - - - - - -
2 Abacavir (ABC) 300 mg tablet 2,031.42
Abacavir (ABC) 300 mg tablet 2,161.35
Page 17 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
Catridge TCM 167,000.00 - - - - - - - 200 - 200 - - - - 100
Catridge TCM 129,039.00 50 - - - -
4 Cepheid Xpert HIV-1 VL Assay ( Catridge HIV Viral 397,215.00
Load ) Xpert HIV-1 VL Assay ( Catridge HIV Viral
Cepheid 397,215.39
5 Load )
Combipak (Azithromycin-Cefixime) 31,231.00
6 DBS Collection Kit ( kotak/ 20 pcs ) 26,980.00
DBS Collection Kit ( kotak/ 20 pcs ) 46,694.00 - - - - - - - - - - - - - - - - - - -
7 Dolutegravir (DTG) 10 mg tablet 771.93
8 Dolutegravir (DTG) 50 mg tablet 4,855.00
Dolutegravir (DTG) 50 mg tablet 4,995.00 - - - - - - - - - - - - - - 150 - - - 30
Dolutegravir (DTG) 50 mg tablet 4,440.00
9 Efavirenz (EFV) 600mg 7,050.00
Efavirenz (EFV) 600mg 7,000.00 60 - - - - - - - - - - - - - - - - - -
10 FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

mg 6,800.00
FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600 tablet
mg 3,260.00
FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

mg 3,011.00 7,110 - - 840 - - - 330 - - - - - - 960 - - - 90
12 INDEN HIV 1/2 COMBO 17,497.52
INDEN HIV 1/2 COMBO 17,499.00 - - - 100 - - - - - - - - - - - - - - 200
13 Kodom Artika 448.00
Kodom Artika 740.62 1,440 - - - - - - - - - - - - - - - - - -
14 Kodom Lubrikan/Pelicin 331.00 500 - - - - - - - - - - - - - - - - - -
15 Lamivudine (3TC)150 mg tablet tablet 1,640.00 180 - - - - - - - - - - - - - 60 - - - -
Lamivudine (3TC)150 mg tablet tablet 1,560.00
16 Lopinavir/ritonavir (LPV / r) 200/150 mg tablet 5,196.82
Lopinavir/ritonavir (LPV / r) 200/150 mg 5,196.82
18 Masker FFP 2NR (Prop) pcs -
19 Nevirapine ( NVP ) 200mg tablet 2,415.00 - - - - - - - - - - - - - - - - - - 60
Nevirapine ( NVP ) 200mg tablet 3,058.00
20 Rapid Test Syphilis ( Trepocheck Syphilis ) test 9,300.00
Rapid Test Syphilis ( Trepocheck Syphilis ) test 8,096.00 - - - - - - - - - - - - - - - - - - -
Rapid Test Syphilis ( Trepocheck Syphilis ) test 9,639.00
21 RAPIDAN TESTER ANTI HIV 1/2 TEST (R3)(50) 11,440.00 - - - - - - - - - - - - - - - - - - -
22 Reagen Penghitung CD 4 Control 971,152.00
23 Reagen Penghitung CD 4 MOBIL 137,792.00
24 RHZE (rifampicin+inh+pza+etham) 1,423.00 - - - - - - - - - - - - - - - - - - -
25 SD HBsAg WB ( Multi + Diloper ) 7,419.00
SD HBsAg WB ( Multi + Diloper ) 7,120.00
SD HBsAg WB ( Multi + Diloper ) 3,190.28 - - - - - - - - 50 - - - - - - - - - 975
26 STANDART Q HIV 1/2 AB 3 LINE (R2)(25) 10,500.00 - - - - - - - - - - - - - - - - - - -
27 Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg tablet

3,750.00
Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg

2,271.76
28 Tenofovir 300 mg tablet 2,240.00
Tenofovir 300 mg tablet 3,280.00
29 Virocheck HIV 1/2 (25 test ) test 8,024.00
Page 18 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
Virocheck HIV 1/2 (25 test ) test 8,391.00 - - - - 200 - - 50 - - - - 100 50 100 - - - -
30 Zidofudine ( ZDV ) 300mg + Lamivudine ( 3TC ) 150mg tablet 3,848.00 - - - - - - - - - - - - - - - - - - 60
31 Zidofudine (ZDV ) 100 mg tablet tablet 1,768.00 - - - - - - - - - - - - - - - - - - -
32 Zidovudin 60 mg dan Lamivudin 30 mg tablet 430.73 60 - - - - - - - - - - - - - - - - - -
TOTAL APBD PROVINSI/ APBN -
BANTUAN BPBD PROVINSI JAWA TIMUR -
1 Face Shield Kacamata pcs -
2 Hand Sanitizer 1 Liter botol -
3 Helm Face Shield (Pendopo) pcs -
4 Thermometer Gun Nikita(Bantuan BPBD) unit -
OBAT BANTUAN Tingkat Sektor -
1 Cryotube 2ml - - - - - - - - - - - - - - - - - - - -
Cryotube 2ml 2,057.94
2 Flashback Needle 22G - - - - - - - - - - - - - - - - - - - -
Flashback Needle 22G 2,420.91
3 Ice Gel - - - - - - - - - - - - - - - - - - - -
Ice Gel 3,108.00
4 Ice Pack - - - - - - - - - - - - - - - - - - - -
Ice Pack 13,431.00
5 Lakban - - - - - - - - - - - - - - - - - - - -
Lakban 17,205.00
6 NMicrotrainer EDTA -
NMicrotrainer EDTA 5,200.35 - - - - - - - - - - - - - - - - - - -
7 Parafilm -
Parafilm 20,238.08 - - - - - - - - - - - - - - - - - - -
8 Plastik Clip 16 x 24 cm - - - - - - - - - - - - - - - - - - - -
Plastik Clip 16 x 24 cm 57,165.00
9 Plastik Clip 5x7 cm - - - - - - - - - - - - - - - - - - - -
Plastik Clip 5x7 cm 5,772.00
10 Styrofoam (37,5 cm x 24 cmx 16 cm ) - - - - - - - - - - - - - - - - - - - -
Styrofoam (37,5 cm x 24 cmx 16 cm ) 15,717.60
11 Tip Pipet 1ml (sterile) - - - - - - - - - - - - - - - - - - - -
Tip Pipet 1ml (sterile) 120,625.92
12 Tube EDTA plh 13x75 3,0 blblce lav (HIV)
- - - - - - - - - - - - - - - - - - - -
Tube EDTA plh 13x75 3,0 blblce lav (HIV) 251,193.00
13 Wing Needle no.27 - - - - - - - - - - - - - - - - - - - -
14 Wing Needle no.27 13,213.44
15 Yellow Holder - - - - - - - - - - - - - - - - - - - -
Yellow Holder 1,149.96
LABKESDA -
16 Safety box 5 lt 14,717.00
TOTAL PROGRAM OBAT-OBATAN
BAHAN LAINNYA -
1 PMT BALITA Sak 30,250.00
2 PMT BUMIL Sak 32,750.00
TOTAL PROGRAM BAHAN LAINNYA
TOTAL BANTUAN PROGRAM - 142,199
TOTAL APBD DAERAH -
TOTAL PERSEDIAAN (APBD DAERAH DAN HIBAH) -
-
Page 19 of 38
REKAPITULASI LAPORAN PER
DI INSTALAS
JEMBER KIDUL PATRANG BANJAR SILO I SILO II ARJASA JELBUK UMBULSAR TEMBOK BANGSAL KLATAKAN ANDONGS CURAH SEMBORO TANGGUL MUMBUL TEMPUREJ SUKORAM PANTI NOGO
(1) (2) SENGON (4) (5) (6) (7) I REJO SARI (11) ARI NONGKO (14) (15) SARI O (17) BI (18) (19) (2
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
OBAT APBD/ DAK/ DAU

1 Acyclovir krim 2,764.00 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
2 Acyclovir tablet 400 mg 650.00 200 400 200 300 200 150 200 200 200 200 200 200 200 200 200 200 200 200 200
3 Alopurinol Tablet 100 mg 110.00 - - - - - - - 200 - - 200 200 - - 100 100 200 - 200
Alpara 750.00 300 300 300 300 450 300 300 300 300 300 300 300 300 300 300 300 300 300 300
6 Ambroxol tablet 30 mg 130.00 1,000 1,000 500 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1
7 Aminophylin injeksi 24mg/ml tablet 2,604.00
8 Amitriptilina HCL tablet 25 mg tablet 175.94 - - - - - - - 100 - - - - - - - - - - -
9 Amlodipin 10 mg 94.00 900 1,500 600 1,200 600 100
Amlodipin 10 mg 119.00 1,220 1,100 510 510 2,010 900 1,200 900 2,010 900 600 900 600 3,000
11 Amoxicillin kaplet 500 mg kaplet 201.00
Amoxicillin kaplet 500 mg 525.00 3,000 2,500 3,000 1,000 3,000 2,000 2,000 2,000 2,000 2,000 3,000 1,000 1,000 1,600 600 1,000 1,000 1,000 2,000 2
Amoxicillin kaplet 500 mg 491.00
12 Amoxicillin sirup kering 125ml/5ml botol 2,050.00 100 100 100 50 50 100 100 50 - - - - - 100 100 100 50 50
13 Antasida Doen tablet tablet 58.00
Antasida Doen tablet 105.00 2,000 2,000 - 3,000 3,000 2,000 4,000 4,000 3,000 2,000 2,000 - 2,000 2,500 3,000 2,000 2,500 3,000 2,000
15 Aqua pro injeksi steril - 20 ml ampul 2,860.00
Aqua Pro Injeksi Steril 20 ml 2,955.00 20 20 10 20 20 20 20 20 20 10 10 20 20 10 10 10 10 10 10
16 Asam Askorbat (vit C) tablet 250 mg tablet 119.00
Asam Askorbat (vit C) tablet 250 mg 141.00 3,000 3,000 3,000 3,000 5,000 3,000 3,000 3,000 3,000 1,000 1,000 3,000 3,000 3,000 3,000 3,000 3,000 3,000 3,000 3
17 Asam Askorbat (Vit C) tablet 50 mg 67.00 200 200 200 200 200 - - - - - - - - - - - - - -
18 Asam Mefenamat kaplet 500 mg kaplet 111.00
Asam Mefenamat kaplet 500 mg 190.00 1,000 1,000 500 1,500 1,500 1,000 1,000 1,000 1,000 500 1,500 500 500 1,500 1,500 1,000 1,500 1,000 1,000 1
Asam Mefenamat kaplet 500 mg 180.00
19 Asetosal tablet 80 mg 216.00
20 Attapulgit 630 mg (700 mg) 500.00
Attapulgit 630 mg (700 mg) 450.00 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150 150
21 Bahan tumpatan sementara (Orafil) 67,600.00
22 Becefort tablet 1,484.00 - - - - - 300 300 300 300 500 500 500 500 500 500 500 500 500 500
23 Bedak Salisil 2% 1,765.00
24 Benzatin Bensil Pen.inj 2,4 juta IU tablet 14,500.00
Benzatin Benzil Penicillin injeksi 31,419.00 10
25 Betahistin Mesilat 6 mg tablet 89.00
Betahistin Mesilat 6 mg tablet 190.00
26 Betametason krim tube 1,554.00
Betametason krim 2,000.00 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
27 Bisakodil Suppo 10 mg supp 4,325.00 - - - 5 - - - - - - - - - - - - - - -
29 bur carbide highspeed round Pak 200,110.00
30 Caladin lotion 60ml 13,662.00 5 5 5 10 - - - 10 10 5 5 - - 4 - - - - -
31 Captopril tablet 25 mg 182.00 500 1,000 - 500 500 500 500 500 500 500 500 1,000 1,000 500 500 500 500 500 500
32 Catridge TCM pcs 253,137.10
Page 20 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
33 Caviplek tablet tablet 832.50
Caviplek tablet tablet 754.80
34 Cefadroxil kapsul 500 mg 741.00
Cefadroxil kapsul 500 mg 820.00 500 500 500 500 500 500 500 500 300 500 500 500 300 500 500 500 500 300 300
35 Cetirizine tablet 10mg 74.00
Cetirizine tablet 10mg 130.00 500 500 500 500 500 200 200 200 200 300 300 500 300 500 - - 300 300 500
36 Chloramphenicol kapsul 250 mg 587.00 - - - 200 - - - - - - - 100 100 300 300 200 200 200 200
37 Chloramphenicol sirup -125 mg/ml-60ml botol 11,043.00
38 Chloramphenicol tetes mata 0,5% - 5 ml 7,000.00 20 20 20 20 20 10 10 10 10 10 10 10 10 10 10 10 10 10 10
39 Chlorpromazin injeksi 25mg/ml VIAL 7,850.00 - - - - - - - - - - - - - - - - - - -
40 Chlorpromazin tablet 100 mg 525.00 - - - - - - 300 - - - - - - - - - - - -
41 Ciprofloxacin kapsul 500 mg kapsul 248.00
Ciprofloxacin kapsul 500 mg 360.00 500 500 500 200 500 500 500 500 500 500 500 200 500 500 500 200 200 400
Ciprofloxacin kapsul 500 mg 448.00 500
42 Clindamycin kapsul 150 mg 708.00 100 - - 100 100 100 100 - - 100 100 100 100 - - - - 100 100
43 Clindamycin kapsul 300 mg 950.00 100 - - - - - - 100 100 - - - - - - 100 100 - -
Clozapin 25 mg tablet 473.00
45 Combipak (Azithromycin-Cefixime) tablet 31,231.00 - - - - - - - - - - - - - - - 10 - - -
46 Cotrimoxazol sirup botol 2,190.00 - 50 - 100 50 - 50 - - 100 - 50 - 50 50 100 50 100 100
47 Cotrimoxazol tablet tablet 126.00
Cotrimoxazol tablet 228.00 1,000 500 100 - -
Cotrimoxazol tablet tablet 133.00
Cotrimoxazol tablet 240.00 900 1,000 200 1,500 1,500 500 - - - 500 2,000 1,000 1,500 800 200
48 Cotrimoxazol tablet Forte 570.00 500 - - 300 - - - 300 - - - - - - 500 - - - -
49 Cyanocobalamin ( vit B12 ) injeksi ampul 1,104.00
Cyanocobalamin ( vit B12 ) injeksi 2,104.00 100 - - 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
50 Daryan Tulle : Tramisetin Sulfat 10 x 10 cm 10,455.00 10 10 - 10 10 10 10 - - 10 10 10 10 10 10 10 10 10 10
51 Deksametason Injeksi 5mg/ml 999.00
Deksametason Injeksi 5mg/ml 1,776.00 - - - 30 30 50 50 50 50 30 30 - 30 50 - 50 50 - -
52 Deksametason tablet 0,5 mg 57.00 1,000 1,000 - 1,000 500 500 500 500 500 500 1,500 1,000 - - 1,000 500 1,500 - 1,500
Deksametason tablet 0,5 mg 66.00
53 Dermazin salep kulit 25 gram 21,276.00 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
54 Diazepam enema 10 mg/2,5 ml (Stesolid) 47,725.00 - - - 5 - - - - - - 5 - - - - - - - -
55 Diazepam enema 5 mg/2,5 ml (Stesolid) 31,965.00 - - - 5 - - 5 - - - 5 - - - - - - - -
56 Diazepam tablet 5 mg tablet 275.00 - - - - 200 - - - - 500 300 - - - - - -
57 Digoksina tablet 0,25 mg 130.00 200 200 - - - 100 100 100 100 300 - 100 100 300 300 100 100 100 100
58 Dimenhidrinate 50 mg tablet 210.90 - - - - - 200 200 200 200 300 300 300 300 300 300 300 300 300 300
59 Diphenhidramina injeksi 10 mg 1,110.00
Diphenhidramina injeksi 10 mg 2,220.00 60 30 - 60 30 30 30 60 60 60 60 - 60 60 60 30 30 30 30
60 Domperidon tablet 10 mg 150.00
Domperidon tablet 10 mg 155.00 1,000 500 500 500 500 300 300 300 300 300 300 500 500 500 500 500 500 300 300
61 Epinephrina HCL/Bitart injeksi 0.1% - l ml ampul 1,408.00
Epinephrina HCL/Bitart injeksi 0.1% - l ml 3,885.00 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30
62 Erithromicin kaplet 500 mg 4,306.80
63 Erithromicin kapsul 200 mg 2,697.30 10 10 - - - - - - - - - - - - - - 10 - -
64 Erithromicin sirup - 60 ml Kering botol 6,462.00
Erithromicin sirup - 60 ml Kering botol 12,100.00
65 Etil Klorida semprot 187,000.00
66 Eugenol Cairan - 10 ml 20,150.00
67 Fenitoin kapsul 100 mg 170.00
68 Fenitoina Natrium kapsul 100 mg tablet 168.00
69 Fitomenadion (Vit K) tablet 10 mg 750.00
Fitomenadion (Vit K) tablet 10 mg 1,055.00 - - - 200 100 - - 100 100 300 - - 100 100 - - - - 100
Page 21 of 38
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NO. SATUAN
NAMA OBAT
HARGA SATUAN
71 Fluconazole 150 mg 11,250.00 50 - - 100 - - - 30 - - - - - - 90 - - - -
Fluconazole 150 mg 11,300.00 10
72 Furosemida tablet 40 mg tablet 98.00
Furosemida tablet 40 mg 263.00 - 200 - 200 100 - - 200 200 200 200 - 200 - 100 - - - -
73 Furosemide 10mg/ml injeksi ampul 931.00
74 Glibenklamida tablet 5 mg tablet 82.00 - 400 - - 500 - 2,000 500 500 500 500 2,000 1,000 - 200 500 1,000 300 1,000 2
75 Glimepiride 2 mg 180.00 500 500 300 500 200 500 500 500 500 1,000 1,000 500 500 500 500 500 500 500 500
Glukosa lar. infus 10% steril 8,350.00 20 - - 20 20 - - - - - - - - - 20 - - - -
78 Griseofulvin tablet 125 mg 293.00 200 - - 100 - - - - - - - - - - - - - - -
79 Haloperidol tablet 0.5 mg tablet 47.00 - - - - - - - - - - - - - - - - - - -
80 Haloperidol tablet 5 mg 190.00 - - - - - - 200 - - - - 300 - - - - -
81 Herbakof sirup 16,563.00 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 - -
82 Hidrokortison Krim 2,5% 2,800.00 48 - 13 24 24 24 24 24 24 24 24 24 24 24 24 24 24 48
83 Ibuprofen suspensi 100 mg/5ml 4,100.00
84 Ibuprofen tablet 400 mg 190.00 1,000 1,000 1,000 2,000 2,000 1,000 1,000 500 500 1,000 1,000 1,000 1,000 1,000 1,000 500 500 1,000 -
85 Infusion set anak set 8,400.00
86 Infusion set dewasa pcs 3,100.00
87 KA-EN 3B infus - 500 ml botol 10,696.00
88 Kalsium Laktat tablet 500mg. 85.00
Kalsium Laktat tablet 500mg. 84.00 5,000 5,000 5,000 8,000 5,000 5,000 5,000 1,000 2,000 5,000 5,000 5,000 5,000 5,000 5,000 3,000 2,000 4,000 3,000 5
89 Ketoconazol krim 2% 2,349.00 50 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25
90 Ketokonazol tablet 380.00
Ketokonazol tablet 380.00 300 300 - 200 200 200 200 200 200 200 200 - - - 200 - 200 200 -
91 Kodeina tablet. 10mg tablet 600.00 - 100 - 100 - - - - - - - - - - - - - - -
92 Laktulosa sirup 3,335g/5 ml 12,533.00
93 Lanzoprazol kapsul 30 mg 500.00 200 - - 100 100 - 200 200 200 100 100 200 200 - - 100 100 - 200
94 Levofloxacin tablet 500 mg tablet 373.00 100 - 100 100 - - - - - - - - 100 - 200 - 200 200 -
95 Lexavit kaplet 750.00 100 - - - - - - - - - - - - - - - - - -
96 Lidocain Compositum + Epinephrine Injeksi 1,848.00 50 50 - 50 50 50 50 50 50 50 50 - - 50 50 50 50 50 -
97 Lidocain injeksi 2% 1,166.00 - - 100 - 50 100 100 50 50 100 - 100 - - 50 50 50 50 -
98 Loperamide tablet 2 mg 74.00 200 200 200 300 - 200 200 200 200 200 200 300 300 300 300 300 300 300 300
Magnesium Sulfat injeksi 20% 4,973.00 12 12 12 12 6 6 6 6 6 12 6 6 12 12 12 12 12 12 12
Magnesium Sulfat injeksi 40% 5,661.00 12 10 12 12 6 6 6 6 6 12 6 6 12 12 12 - 6 6 24
101 Metamizol (Antrain) Injeksi 500mg/ml 2,789.00
Metamizol (Antrain) Injeksi 500mg/ml 3,020.00 30 30 - 30 30 30 30 30 30 50 50 50 50 50 50 50 50 50 50
102 Metformin H Cl tablet 500 mg 180.00 600 600 400 400 600 400 400 400 400 1,000 1,000 600 400 400 800 600 400 400 1,000
103 Metilergometrina injeksi 0,2 mg/ml -1 ml ampul 2,959.00
104 Metilergometrina Maleat tablet tablet 214.00
Metilergometrina Maleat tablet 257.00 - - - 100 100 - - - - - - - 100 100 100 - - - -
105 Metronidazol tablet 500 mg 211.00 100 100 200 100 100 100 100 - - - - 100 - 200 - - - - -
106 MOLEXFLU 450.00 300 300 300 300 150 300 300 300 300 150 150 - - 300 300 300 300 300 150
107 Monoklorkamfer Mentol cairan/Paramono Chlorophenol
68,266.67
108 N- Asetil Sistein tablet 716.00
N- Asetil Sistein tablet 373.00 1,000 1,000 - - - 500 200 500 500 500 - 1,000 500 500 500 300 300 1,300 500
109 N2O Nitrous Oxide tablet 2,488,750.00
110 Natrium Diklofenak 50 mg tablet 100.00 - 200 - 200 100 100 100 100 100 100 100 100 100 100 100 100 100 - -
Page 22 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
Natrium Klorida 0.9% larutan infus 500 ml 7,205.00 - 100 - 100 100 200 100 200 200 100 200 200 100 200 200 100 100 100 200
Natrium Klorida 0.9% larutan infus 500 ml 7,205.00
113 Nifedipin tablet 10 mg 149.00 200 200 - 100 - 100 100 100 100 100 100 - - 200 200 100 100 100 100
114 Nifedipin tablet 30 mg (Adalat) 4,022.00 30 - - - - - - - - - - - - - - - - - -
115 Nystatin 100.000 IU/g tablet vaginal tablet 598.00
Nystatin ovula 100.000 IU/g 1,610.00 - 10 10 - - - - 10 10 10 - 10 10 10 - 10 10 10 -
116 Omeprazol kapsul Kapsul 129.00
Omeprazol kapsul 231.00 - - - - 300 200 800 300 300 300 300 300 600 200 500 200 300 - 300
117 Ondansetron injeksi 2,g/ml 1,500.00 20 20 10 60 - 30 30 30 30 50 - 90 60 80 50 50 50 50 50
118 Ondansetron tablet 4 mg 244.00 200 200 200 500 - 200 200 200 200 - - - - 400 400 400 400 500 500
119 Oseltamivir 75 mg tablet 14,300.00
Paracetamol tablet 500 mg 158.00 5,000 3,000 2,000 - 6,000 1,000 3,000 3,000 3,000 2,000 2,000 3,000 2,000 3,000 3,000 2,000 3,000 6,000 6,000 3
Paracetamol tablet 500 mg 139.00
121 Parasetamol sirup 120 mg/5ml botol 1,160.00
Parasetamol sirup 120 mg/5ml botol 1,181.00 - 100 - - 50 - - 100 100 150 - 100 200 - 100 100 50 100 100
Parasetamol sirup 120 mg/ml botol 1,181.00
122 Pehacain Injeksi tablet 3,663.00 - - 20 20 - - 40 - - - - 40 - - - 20 - 60 -
123 Permetrin (Scabimite) Krim 5% 6,660.00 10 10 10 10 5 5 5 5 5 5 - - - - - 5 5 10 -
125 Piridoksin (Vit B6) tablet 25 mg 255.00 100 - - 100 - - - 100 - - - - - - - - - - -
126 Plastic Apron pcs 2,959.00
127 Prednison tablet 5 mg tablet 68.00
Prednison tablet 5 mg 102.00 200 200 200 200 200 100 100 100 100 100 200 200 200 - 200 100 100 100 100
128 Ranitidin injeksi 50mg/2ml 1,276.99
Ranitidin injeksi 50mg/2ml 1,340.00 30 30 20 30 30 30 30 50 50 30 30 50 50 50 50 50 50 50 50
129 Ranitidin tablet 150 mg 172.00 300 300 200 500 500 300 300 300 300 300 300 300 300 500 500 500 300 300 300
130 Rapid Test Syphilis Biocare test 13,900.00
131 RDT DBD Dengue Combo Verotec pcs 68,112.00
132 Rifampisin kapsul 450 mg tablet 934.00
133 Rifampisin kapsul 600 mg tablet 1,233.00
134 Ringer Asetat ( Asering ) infus botol 9,646.00
Ringer Asetat ( Asering ) infus 8,400.00
Ringer Asetat (Asering) infus 8,400.00
135 Ringer Laktat infus 7,700.00 100 100 - 100 100 100 200 200 200 100 200 200 100
Ringer Laktat infus 7,699.00 200 200 200 200 100 100
Ringer Laktat Larutan infus - 500 ml botol 7,630.00
Risperidone 2 mg 209.00 500 - - 300 600 - - 400 500 - 1,000 500 - 500 - 1,000 - 1,000 1,000
137 Salbutamol tablet 4 mg 75.00 300 200 300 500 300 200 200 500 500 300 300 500 200 500 500 200 500 300 300
Salbutamol tablet 4 mg 180.00
138 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%)

3,820.00 10 - 5 5 - - 3 3 - 5 - 5 5 - 5 5 - 5 -
139 Serum Anti Bisa Ular injeksi (ABU I) / SABU 688,819.00 - - - - - - - - - - - - - - - - - - -
140 Sikzonoate injeksi 25 mg /ml ampul 63,800.00
Sikzonoate injeksi 25 mg /ml 80,586.00 20 - - - - - - - - - - - - - - - 30
Sikzonoate injeksi 25 mg /ml 80,586.00
142 Simvastatin tablet 20 mg 220.00 200 200 - 1,000 1,000 200 200 200 200 300 300 - - 200 500 300 300 500 500
143 Spasminal tablet tablet 1,110.00
144 Spironolactone 25 mg tablet 192.00
145 TETAGAM / ATS 250 IU 177,000.00 - - - - - - - - - - - - - - - - - - -
146 Trifluoperazin 5 mg tablet 220.00 - - - - - - - 600 - - - 500 100 - - - - - -
147 Triheksifenidil HCl tablet - 2 mg tablet 63.00
Page 23 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
148 Vaksin HBIG VIAL 1,325,000.00
149 Yodium Povidon 10% - 30 ml botol 3,049.00
150 Yodium Povidon 1000 ml 86,854.00 - - - - 2 - - - - - - - - - - - 2 - -
151 ZINC tablet 20 mg tablet 524.00
REKLAS BELNJA MODAL -
152 Safe-T Pro Uno (DBHCT) 640.00 400 1,000 600 1,000 - - 2,000 - - - - 800 - - - 1,000 - - 600
LABKESDA -
155 Colour Test SPQ 114421.0001 4,136,000.00
156 indicator strips pH 0 -14 Universal indicator 1,408.00
157 PCA SPQ 1,353,000.00
158 Stericide 5 liter 752,400.00
159 Viorex liquid 4% (500 ml) 74,250.00
TOTAL BELANJA OBAT - OBATAN 2023 -
BELANJA BAHAN - BAHAN KIMIA -
Belanja Bahan - Bahan Kimia -
1 Golongan Darah Anti-A 48,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
2 Golongan Darah Anti-AB 62,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
3 Golongan Darah Anti-B 48,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
4 Golongan Darah Anti-D 62,500.00 - - - 1 2 - - 10 1 1 1 4 1 1 2 1 1 - -
5 PCA 3,145,740.00
6 PCR Reagen 138,748.18
7 Acon HB Hemoglobin Strip 50 test mission 8,039.50
8 ALAT (GPT) FS (IFCCMOD) 499,500.00
Alkohol Swab 88.80
10 Ambroxol HCI 30 mg 102.00
11 Amies Transport Swab 1,236,646.00
12 Amoxicillin kapsul 250 mg tablet 415.14 - - - - - - - - - - - - - - - - - - -
13 Antasida Doen Tablet 54.40
15 Articulating papper 219,600.00
16 ASAT (GOT) FS (IFCCMOD) 499,500.00
17 Biokimia TSI/TSIA 1,834,830.00
19 BORAX Test 1,554,000.00
20 Buffer pH 10 1,665,000.00
21 Buffer pH 4 480,630.00
22 Buffer pH 7 466,200.00
23 Cadmium (cd ) 3,918,300.00
24 Calcium Gluconas infus 5,775.00
25 Carrez 560,550.00
26 Carry & Blair Amies Agar 1,998,000.00
28 Cell pack DCL 2,363,911.50
29 Cellclean auto ( CCA-500 ) 1,950,535.29
30 Cell-Dyn Emerald Reagent Cleaner 3,131,865.00
31 Cell-Dyn Emerald Reagent Diluent 4,695,744.00
32 Cell-Dyn Emerald Reagent Lyse 5,087,463.00
33 Chloride Test 3,793,425.00
34 Chlorpheniramin Maleat ( CTM ) tablet 4 mg 86.00 4,000 500 2,000 3,000 3,000 4,500 2,000 2,000 2,000 3,000 - 1,000 1,000 1,500 1,000 2,000 2,000 2,000 1,500 2
35 Chromate test 4,317,900.00
36 Coliformagar for microbiology 10,772,000.00
Page 24 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
37 Complete Blood Count CBC Normal Abacus 1,485,180.00
38 Complete Blood Count CBC Normal Dirrui 1,485,180.00
39 Composit light curing A2 ( Master fill ) 1,051,840.66
40 Composit light curing A3 147,834.78
41 Copper test 4,723,050.00
42 CYBOW Strip 100"S 1,334.88
43 D.Piece 68,041.67
44 Deterjen 2,775,000.00
45 Diatro Reagen cleaner ( ABACUS ) 1,415,871.60
46 Diatro Reagen Diluent ( ABACUS ) 373,358.49
47 Diatro Reagen Lyse ( ABACUS ) 373,358.49
50 Dirrui Reagent Cleanser( 500 L ) 1,110,000.00
51 Dirrui Reagent Diluent (20 L ) 1,221,000.00
52 Dirrui Reagent Lyse ( 500ml) 1,210,000.00
53 Eight Check 3 HP 1,237,650.00
54 Eosin Methylen Blue 387,836.00
55 Etanol 70% 23,595.00
56 Etchant/ Etsa Asam Liquid 78,304.35
57 Fitomenadion ( Vit K ) injeksi 2 mg/ml 1,386.00
58 Fluoride test 3,050,280.00
59 Fluoride Test Merck 4,320,000.00
60 fluorocell WDF 4,454,302.35
61 Formaldehyd test strip 1,665,000.00
62 Gentamycin tetes mata sub 4,520.00
63 Glass Ionomer Cement/GC Fuji IX kotak 1,097,790.00
65 Glukosa lar. infus 40% steril 7,000.00 - - - 10 10 - - 10 - - 20 - - 36 - - - 40 40
68 Herbakof sirup 14,402.00
69 Humasens Glucose Strip strip 3,800.00
70 Humasens Uric Acid Strip strip 14,146.25
71 Ibuprofen tablet 400 mg 191.00
72 Immersion Oil 756,000.00
73 Iron test 2,282,160.00
75 Isoniazid 300 mg tablet 77.70 41
76 Isosorbid Dinitrat tablet 5 mg tablet 86.78
77 Kalsium Hidroksida pasta 180,300.00
78 Kalsium Laktat tablet 500mg 60.49
79 Kaolin Pektin ( Neo Kaominal ) sirup botol 8,369.40
80 Kesadahan test 3,219,000.00
81 Labiosis HDL Cholestrol 1,000,509.94
82 Lactosa broth 2,571,000.00
Lactose Broth 943,500.00
83 Laktulosa Sirup 3,335g/5 ml 12,420.00
84 Lidocain Compositum + Epinephrine injeksi 803.00
Lidocain Compositum + Epinephrine injeksi 802.99
85 Lysercall WDF 2,138,659.20
86 Lytacur sirup 60 ml 10,656.00 48 48 48 - 24 24 - 24 24 24 24 24 24 - - 24 24 24 24
87 Mangan 4,500,000.00
88 Media Mac Conkey Agar Merck 2,510,000.00
89 Merc Cyanida Test 4,325,000.00
Page 25 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
90 Merc Zinc 8,330,000.00
91 Monoklorkamfer Mentol cairan/Paramono 51,100.00
92 Mouth Piece 4,800.00
93 Nitrat test 6,607,830.00
Nitrite test 2,997,000.00
94 Norma Reagent Cleaner idil3 1,957,375.11
95 Norma Reagent Diluent idil3 1,628,404.41
96 Norma Reagent Lyse idil3 2,423,417.40
97 Noza 805.00
98 Oksigen Gas dalam tabung - 6m3 tabung 54,867.30 - - 4 - 15 - 10 15 10 - - - - 15 - 15 - 10 -
99 Oxytocin injeksi 10 IU/ml 1,126.00 - - - 50 100 - - - - - - 50 50 50 50 50 - - 100
100 Paket Bahan Habis Pakai IVA 8,700,000.00
101 PCR tube baru 399.60 - - - - - - - - - - - - - - - - - - -
102 Pewarna Ziehl Nellsen 164,280.00
103 Ph test Strip 99,900.00
104 Phospate Buffer saline 1,998,000.00
106 PPD (Purified Protein Derivative)/ Mantoux test 854,700.00 2 - 1 - - 1 - - - 3 - 1 - - 1 1
107 Proline Creatinine FS 344,100.00
108 Proline Triglycerides FS 865,800.00
109 Proline Triglycerides FS 1,230,596.63
110 Proline Urea FS 510,600.00
111 Pulp X 205,923.08 - - - - 1 - - 1 - - - - - - - 1 - - -
112 RDT ANTIGEN COVID - 19 35,960.00
113 RDT Malaria (10 test / ktk) 13,983.96
114 Reagen I Intec One Step Anti HIV Tri Line Tes Card 15,665.93
115 Reagen I SD Bioline HIV 1/2 ( Syphilis Duo) test 17,723.52
116 Rhodamin B test 1,776,000.00
117 Rightest Glucose Strip test 4,600.00
118 Ringer Asetat ( Asering ) infus 8,800.00
119 Ringer Laktat + Glucose 5% infus-500ml 9,580.00
120 RPR Test Syphilis ( FOKUS Diagnostic ) 2,654.67 - - - - - - - 100 - - - - - - - - - - -
121 Salmonella Sigella Agar 473,849.86
130 Serum Anti Bisa Ular injeksi (ABU I)/SABU 521,833.00
131 Serum Anti Tetanus injeksi 1.500 IU 140,188.00
Serum Antitetanus ( ATS ) inj 1500 IU 140,188.00
132 Spectra Fresh Mint 145,862.07 - - - - - - - 1 - - - - - - - 1 - - -
133 Standart CRM FE 1,193,250.00
134 Sulfate test 3,576,000.00
135 Sulfolyser ( SLS-210A ) 826,750.20
136 Sysmex Reagent Cleanser 1,237,650.00
137 Sysmex Reagent Diluent 1,237,650.00
138 Sysmex Reagent Lyse 1,423,297.50
139 TCBS Agar 416,707.00
140 TCBS Agar 1.10263.0500 9 ( P+MI ) 4,184,700.00
141 Tes HIV II 15,330.56 - - - - - - - - - - 20 - - - - - - - -
142 Tetracyclin kapsul 500 mg tablet 219.78 200 - - - - - - - - - - - - - - - - - -
Page 26 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
143 Tiamina (Vit B1) tablet 50 mg tablet 95.46
144 Tube EDTA ungu 1,497.00
145 Ultra One Test Hamil 2,109.00
146 Urit Reagen Dilent 373,358.49
147 Urit Reagent Cleanser 2,149,798.05
148 Urit Reagent Lyse 999,000.00
149 Vitamin B Komplek 57.00 5,000 1,000 3,000 5,000 3,000 3,000 1,600
150 Vitamin B Kompleks tablet 57.00 1,400 3,000 3,000 - 2,000 5,000 2,000 2,000 2,000 2,000 2,000 1,000 6,000 3
151 Water one 20 L 102,500.00
152 XN CAL 2,575,549.65
153 XN -L Check ( L1, L2, L3 ) 3,465,422.22
154 Zinc F + ( Zinc Phosphate Cement ) 141,200.00
LABKESDA -
157 Creatinin 408,100.00
158 Eosin 2% 1x100ml 182,000.00
159 FOKUS Amphetamine Check Test 312,386.00
160 FOKUS Cocain Rapid Test 378,035.00
161 FOKUS Device Benzodiazepine s (BZD) Rapid Test 321,184.00
162 FOKUS Marijuana (THC) Rapid Test 420,000.00
163 FOKUS Morphine (Opiates) Rapid Test 403,841.00
164 Glucose 288,600.00
165 Golongan Darah Anti A 56,785.71
166 Golongan Darah Anti AB 62,500.00
167 Golongan Darah Anti B 48,500.00
168 Golongan Darah Anti D 62,500.00
169 Immersion Oil 1 x 50ml 407,000.00
170 IMMUNOQUICK Contact Malaria +4 353,182.00
171 Methamphetamine 373,353.00
172 Multi-Drug One Step Multilin 1,914,166.67
173 PCR TUBE FLASH 20 13,898.09
174 Pewarna Giemsa 1 X 100ml 555,600.00
175 Pewarna Gram 3 x 100ml 293,500.00
176 Pewarna MDT 3 x 100 ml 161,500.00
177 Pewarna Ziehl Neelsen 5 X 100 ml 231,000.00
178 Rapid Test SD Bioline HBsAg 241,185.00
179 Rapid Test SD Bioline HIV 1/2 3.0 443,088.00
188 SGOT 519,500.00
189 SGPT 519,500.00
190 syphilis (RB-TS50:50 Test) 8,682.00
191 Trigliserida 955,800.00
192 Tru Cal N 6x3 ml 2,238,100.00
193 Tru Cal U 6x3 ml 1,561,000.00
194 Tru Lab P 6x5 ml 2,304,700.00
195 Turk 1x100ml 23,240.00
196 Uric Acid 704,900.00
Page 27 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
TOTAL BELANJA BAHAN-BAHAN KIMIA -
BELANJA
BARAN SUKU CADANG
HABIS PAKAI KEDOKTERAN
/ Belanja Suku Cadang - Suku -
Cadang Alat Kedokteran -
1 Acon Hb Hemoglobin Strip 50 test mission 8,046.14 100 100 100 - 50 100 100 100 100 - - 50 - - 100 - - - -
2 Alat Suntik 10 ml 976.80
3 Alkohol Swab pcs 90.00
4 Ams Blood Collection Tube Plain pet 1,751.15
5 Ams BT LDL Chol Direct 2x32 ml 5,994,112.00
6 Blue Tips 84.40
9 Control Urine 2 Level 810,300.00
10 Cover Glass 9,657.00
11 Cup sample microtube 385,000.00
12 FOKUS HCG Strip 3,700.00
14 Glucosa Ams strip 3,980.00
15 HBA1C Hipro 2,136,626.00
18 Kontrol Chem 3x 5ml Normal Ams 2,250,000.00
19 Masker Disposable (N95) 9,240.00
20 Microalbumin Hipro 2,000,000.00
Object Glass 16,428.00
22 Paket Reagen XN-L Series_Basis_CBC BASIC 19,096,995.00
23 Plester Flexible non woven 5 x 5 pcs 23,760.00
Plester Flexible non woven 5 x 5 22,000.00 2
Plester Flexible non woven 5 x 5 24,198.00 8 10 10 5 5 5 5 5 5 5 10 10 5 10 10 10 10 5 -
24 Plesterin Bulat Soft 170.94 - - - - - 50 - - 200 - 200 200 400 200 200 200 -
25 Safe Glove Exam L 690.80
26 Safe Glove Exam M 1,250.00
Safe Glove Exam M 1,243.44
28 Sarung Tangan Obgyn steril 15,318.00 50 50 -
29 Sputum Pot 3,000.00 - 200 - - - - - - - 1,000 - - - - - 300 - - -
31 Transfusion set 5,328.00
32 Uji Fosfat test 3,436,560.00
33 Ultra Once Test Hamil 1,900.00
34 Urine Bag 5,280.00
35 Urinetest Insight 10U 2,142.30
36 Water one 20 L 102,500.00
37 XN cal 5,455,589.00
38 XN-L Check( L3,L2,L1 3.0ML ) 2,447,550.00
39 Yellow Tip 32.37
LABKESDA -
41 Kapas pembalut abs 250 gram 29,900.00
42 Plesterin Roll 175.00
TOTAL BELANJA SUKU CADANG ALAT KEDOKTERAN
Belanja Bahan - Isi Tabung Gas -
TOTAL BELANJA BAHAN ISI TABUNG GAS
Page 28 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
BELANJA BAHAN - BAHAN PERLENGKAPAN KANTOR -

1 APD ( Hasmat/Coverall ) XL 115,000.00 20 20 - 20 20 20 20 20 20 20 20 20 20 20 20 20 20 - -
2 Coverall Seam Tape Putih L 115,000.00 20 20 - 20 20 20 20 20 20 20 20 20 20 20 20 20 20 - -
3 Hazmat 99,000.00 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 - - - -
LABKESDA -
4 Coverall Seam Tape Putih XL 115,000.00
TOTAL BELANJA BAHAN-BAHAN PERLENGKAPAN KANT -
BELANJA BAHAN - BAHAN LAINNYA -
1 Alat Suntik 10 ml 976.00 - - - 200 200 - 200 - - - - 100 - 100 - - 200 - 100
Alat suntik sekali pakai 1 ml 577.00 100 300 100 100 - - 200 300 200 200 200 300 100 200
Alat suntik sekali pakai 1 ml 1,317.31 300 100 200 200 - 200
3 Alat suntik sekali pakai 2,5 ml 577.00 300 - 300 500 500 200 200 200 200 200 200 - 200 300 300 300 300 300 300
Alat suntik sekali pakai 2,5 ml 577.50
Alat suntik sekali pakai 3 ml 1,220.00 200 600 - 500 - 200 200 1,000 1,000 - 300 300 300 2,000 2,500 500 1,000 300 -
4 Alat suntik sekali pakai 3 ml 900.00 1,700
Alat suntik sekali pakai 5 ml 674.00 200 100 - 200 - 200 200 100 100 - 300 200 - 100 - 100 200 200 -
5 Alcohol Swab DBHCT 85.00 1,400 1,000 1,500 1,000 - 1,000 5,000 2,000 3,000 - 1,000 800 - 2,000 2,500 3,000 - 2,000 500
Alkohol Swab 120.00
Alkohol Swab 175.00
Alkohol Swab KESMAS 190.00 - - - - - - - - - - - - - - - - - - -
6 APD ( Hasmat/Coverall ) L 85,000.00
7 APD ( Hasmat/Coverall ) XL 85,000.00
APD ( Hasmat/Coverall ) XL 113,000.00
8 APD ( Hasmat/Coverall ) XXL 85,000.00
9 ARM SLING ( M ) 18,500.00
10 Arm Sling L 18,500.00
11 Auto Destruct Syringe (Pfizer) 0,3 ml 1,287.98
Auto Destruct Syringe (Pfizer) 0,3 ml 1,300.32
12 Autodisposable Syringe 0,5 ml (Soloshot) 1,206.00
13 Blood Lancet 143.77
Blood lanchet OM KESMAS 240.00 - - - - - - - - - - - - - - - - - - -
14 box Spesimen 17,900.00 - - - - - - - - - - - - - - - - - - -
15 Brilla broth 500 G 2,600,000.00
16 Catgut Chromic 2/0 + jarum 4,995.00 - - - 24 24 - - 24 24 24 - 24 - - 24 24 24 24 24
17 Catgut Chromic 3/0 + jarum 4,995.00 - - 24 24 24 - - 24 24 - - 24 24 - 24 - 24 24 24
Catgut Chromic 3/0 + jarum 22,489.83
18 Catgut Plain 2/0 + jarum 4,995.00 24 - - 24 24 - - 24 24 24 - 24 - - - 24 24 24 24
19 Catgut Plain 3/0 + jarum 4,995.00 24 - - 24 24 - - 24 24 24 - 24 - - - - 24 24 24
Catgut Plain 3/0 + jarum 22,310.42
20 Cell-Dyn Emerald Reagent Cleanser 3,130,000.00
21 Cervical Colar 108,700.00 - - - - - - - - - - - - - - - - - - -
CERVICAL COLAR 116,160.00
22 EKG Gel 48,000.00 - - - - - - - - 1 - - - - - - - - - -
23 Etanol 70% - 1000 ml botol 23,595.00 - - - - - 5 5 5 5 5 5 5 5 5 5 10 - 5 5
24 Etil Klorida semprot 187,500.00 - - - - - - - - - - - - - 1 - - - - -
25 FAST CLEAR Q SYPHILIS COMBO 15,500.00 - - 200 - - - - - 200 - - - - 200 - 200 - 200 -
26 Folley Catheter No. 14 9,900.00 4 - - - - - - - - - - - - - - - - - -
27 Folley Catheter No. 16 9,900.00 10 10 - 10 10 10 - 10 10 - - 10 - - 10 - - 10 10
Folley Catheter No. 16 9,990.00
28 Folley Catheter No. 18 9,900.00 10 - - 10 10 - - 10 10 - - 10 - - 10 - - - 10
29 GP CARE ANTISEPTEK (HAND SANITISER) 500 ML 31,000.00
30 GP CARE ANTISEPTEK (HAND WASH) 500 ML 33,000.00
31 Infusion set anak 6,600.00 - 50 - - 50 50 50 - 50 - 50 50 50 100 50 50 50 - 50
32 Infusion set dewasa 6,600.00 150 50 100 100 50 50 50 100 100 - 100 100 100 100 100 100 100 50 50
Page 29 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
33 IV Catether No.18 3,902.00 50 50 50 50 - 50 50 - - - 100 50 50 100 50
IV Catether No.18 6,900.00 100 100 - 100
34 IV Catether No.20 3,902.00 100 50 50 100 - 50 50 50 50 - 100 50 50 100 100 50 50 50 100
IV Catether No.20 6,900.00
35 IV Catether No.22 3,902.00 - 50 - 50 - - - 50 50 50 50 50 50 50 50 50 50 50 50
37 Kapas pembalut 40/80 125,000.00 2 - - - - 2 2 2 2 2 2 - 2 - 1 - - - -
Kapas pembalut 40/80 174,200.00
38 Kapas Pembalut 250 gram 16,000.00 10 10 10 10 - 10 10 10 10 10 10 10 10 10 10 10 10 10 10
39 Kasa Hidrofil 16 X 16 3,541.00
Kasa Hidrofil 16x16cm 6,000.00 5 5 5 - 5 - - 2 2 - - 3 - 5 5 - 5 - 5
40 Kasa Hidrofil 4mx10 cm 2,300.00 50 50 50 100 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50
41 Kasa Hidrofil 4mx15cm 3,300.00 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50
42 Kasa kompres steril 40cm/40cm 1,460.00
43 Kasa pembalut 2 m x 80 cm 10,452.00
44 Kertas EKG 106mmx 20 m 120,000.00 - - - - - - - - - - - 1 - - - - - - -
45 Kertas EKG 215mmx 25 m 120,000.00 1 - 1 - - - - - 1 - - - - - - 2 - - -
46 Kertas EKG 50mmx 20 m 120,000.00 - - - - - - - - - - - - - - - - - - -
47 Masker bedah 4 ply Supersoft 750.36
48 Masker Duckbill Ufo ( p2p) 1,200.00 - - - - - - - - - - - - - - - - - - -
49 Masker KN-95 2,886.00 50 50 50 50 50 50 50 50 50 50 50 50 - 50 50 50 50 50 -
50 Masker Nebulizer Anak 19,500.00
51 Masker Nebulizer Dewasa 19,500.00 - - - - - - - - - 3 - 3 - 5 3 2 2 - 3
52 Masker Oksigen Anak 12,700.00 5 - - 2 2 5 - - - - - 2 - - 2 - 2 - -
53 Masker Oksigen Bayi 12,700.00 5 - - 2 2 5 - - - - - 2 - - 2 - 2 - -
54 Masker Oksigen Dewasa 12,700.00
Masker Oksigen Dewasa 12,700.00 - - - 5 5 5 5 5 5 - - 4 4 - 5 - 5 - 5
55 Masker Surgical 3 Ply Headloop (Hijab) 328.50
56 Medicrepe 4'' 10,725.00
Medicrepe 4" ( 10 cm* 4,5 m ) 8,991.00 - 1 - - - - - - - - - - - - - - - - -
57 Microfill 5,500,000.00
58 Object Glass pcs 17,604.00
59 Oksigen Gas dalam tabung - 1m3 tabung 44,400.00 - - 10 - 5 - 10 15 - - 10 - 10 - - - 20 6 -
60 Oxyflow Nasal Oxygen Anak 7,800.00 - - - 2 - 2 2 2 2 - - - 5 2 2 2 2 - 2
Oxyflow Nasal Oxygen Anak 13,500.00
61 Oxyflow Nasal Oxygen Bayi 7,800.00 - - - 2 - 2 2 2 2 - - 5 - 2 2 2 2 - 2
62 Oxyflow Nasal Oxygen Dewasa 7,800.00 - - - 5 - 5 5 5 5 - 6 5 5 5 5 5 5 - 5
Oxyflow Nasal Oxygen Dewasa 13,500.00
63 Plester Flexible non woven 5 x 5 23,760.00
Plester Kain Roll 2,5cm x 4,5m 18,900.00 - 5 - 5 5 3 3 3 3 5 5 - - 5 5 5 5 5 -
66 Plester Kain Roll 7,5cm x 4,5m 52,100.00 - 2 - 2 2 2 2 2 2 - 2 2 - 2 2 - 2 2 2
67 Plesterin Bulat Soft 170.50
Plesterin Bulat Soft 1,300.00 - - - - - 150 - - 200 400
68 RDT Malaria 10,558.05
69 Reagen SKAMRT 20,482,000.00
70 Rightest Glucose Strip 4,600.00 400 1,000 - 1,000 - - 1,000 - 800 - - 300 - - - 1,000 - - 500
71 Safe Glove Exam L 816.96 300 - 200 100 100 - - - - - 200 100 - 100 - - 100 - -
Safe Glove Exam L 518.13
72 Safe Glove Exam M 816.96 300 - - 100 100 - - - - - 200 100 - 300 - - 100 200 -
Safe Glove Exam S 518.13
Page 30 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
Safe Glove Exam S 382.95 300 200 - 100 100 - - 100 100 - 200 100 - - - - 100 - 300
74 Sarung Tangan Obgyn steril 15,318.00 - - - 50 - - 50 50 50 - - - - - - 50
75 SASKLIN Spray 250 ml (Hand Sanitiser) 14,388.00
76 Silk no 3/0 + jarum 15,562.33
Silk no 3/0 + jarum 3,630.56 36 36 36 - 36 36 36 36 36 - - - 36 - 36 36 36 36 36
77 SPALK 52,000.00 - - - - 2 - - - - - 3 3 - - 5 - - 1 -
78 Strip HB Sejoy KESMAS 8,800.00 - - - - - - - - - - - - - - - - - - -
79 Surgical Glove 7 4,424.40
Surgical Glove 7 12,600.00 - - - -
Surgical Glove No. 7 6,500.00 - 50 - - - 50 - 100 100 100 100 - 100 100 50
80 Surgical Glove 7,5 4,424.40
Surgical Glove 7,5 12,600.00
Surgical Glove No. 7,5 6,500.00 - - - - - 50 - 100 100 100 - - - - - 50 - - -
Surgical Glove No. 6,5 12,600.00 - 50 100 - - - - - - - 100 - - 100 - 50 - - -
82 Transfusion set 5,300.00 - - - 5 5 5 5 5 5 - - 10 10 10 - 10 10 10 10
83 Ultra Once Test Hamil 2,174.00 - 50 - - - 50 - - - - 50 - - - - 50 - - -
84 Umbilical Cord Clamp 1,798.00 - - - - 50 - - - - 50 50 - - 50 - - 50 50 50
85 Under Pad 3,552.00
Under Pad 3,800.00 50 100 100 100 50 30 30 30 30 100 100 50 50 50 100 100 100 50 50
86 Urine Bag 5,000.00
Urine Bag 5,200.00 20 20 - - 10 20 20 20 20 10 10 20 20 - 10 10 10 10 10
Urine Bag 4,235.00
87 USG Gel 5 liter 137,000.00
USG Gel 5 liter 220,000.00 - - - - - - - - - - - - - - - - - - -
88 Vacum Tube Clot activator 2,378.73 - 100 - - - - - - - - - - - - - - - - -
89 Viorex no rinse (500 ml) botol 65,934.00 2 2 2 5 5 5 5 5 5 5 - 10 - 5 5 5 5 5 5
90 XPER GLUCOSE STRIP 4,993.67
91 Yellow Tip 70.00
92 Yodium Povidon 10% - 30 ml 4,809.00 5 - - - 5 5 5 5 5 3 - - - - 5 - - - -
93 Yodium Povidon 10% - 300 ml 26,602.00 - 3 3 5 5 10 10 10 10 10 - - - 5 5 10 10 10 10
TOTAL BALANJA BAHAN-BAHAN LAINNYA -
OBAT PROGRAM APBD PROPINSI / APBN -
1 3HP ( Isoniazid + Rifapentin ) tablet 6,501.00
3HP ( Isoniazid + Rifapentin ) tablet 6,730.00
3HP ( Isoniazid + Rifapentin ) 6,776.00
3HP ( Isoniazid + Rifapentin ) 6,987.00 - - - - - - 108
3HP (Isoniazid + Rifapentin) tablet 6,776.00 - 72 - - - - - - - - 72 252 72
2 3HR (Isoniazid + Rifampicin) tablet 799.00
3HR (Isoniazid + Rifampicin) tablet 1,087.00 - - - - - - - - - - 672 - - - - - - - 252
3 Abate peal 71,500.00
Abate peal 73,500.00
4 Acyclovir tablet 400 mg tablet 407.00 50
5 Albendazol suspensi 200 mg/5ml botol 4,300.00
6 Albendazol tablet 400 mg tablet 390.00
Albendazol tablet 400 mg tablet 457.00
7 Alcohol Swab 88.00
Page 31 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
ALKOHOL SWAB 79.00 - - - - - - - - - - - - - - - - - - -
8 Alopurinol Tablet 100 mg tablet 87.00
10 Amoxicillin kaplet 500 mg tablet 201.00
Amoxicillin kaplet 500 mg tablet 471.00
11 Amoxicillin sirup kering 125ml/5ml 3,330.00 100
12 Ampicillin Injeksi 1 gram 8,616.63
13 Antasida DOEN Tablet 54.00
14 Antifungi DOEN (As Benzoat 3%+As Salisilat 6%) pot 3,477.00
15 APD Vaksin Covid -19(BA-BUN) 98,450.00
APD BNPB PMK - - - - - - - - - - - - - 3 3 3 3 3 3
16 Artesunate 60 mg inj ampul 88,989.00
17 Asam Askorbat (Vit C) tablet 500 mg tablet 225.00
Asam Askorbat (Vit C) tablet 500 mg 42.00
18 Attapulgit 600 mg tablet 227.00
19 Auto Destruct Syringe (PFIZER) 0,3 ML set 1,255.00
20 Auto Destruct Syringe (PFIZER) 3 ML 569.00
Auto Destruct Syringe (PFIZER) 3 ML 395.92
21 Autodisposable Syringe 0,05 ml (Soloshot) set 1,460.00
Autodisposable Syringe 0,05 ml (Soloshot) set 1,465.00
Autodisposable Syringe 0,05 ml (Soloshot) set 1,665.00 - 100 - - 100 100 - - - - - - - - - - 100 300 100
22 Autodisposable Syringe 0,5 ml 1,190.00
Autodisposable Syringe 0,5 ml 1,220.00 - 1,600 1,000 1,000 500 1,200 1,000 - - - 500 200 300 1,600 500 200 300 1,000 1,000
23 Autodisposable Syringe 5 ml (Soloshot) set 1,439.00
Autodisposable Syringe 5 ml (Soloshot) set 1,460.00 - - 100 - - - - - - - 100 - - - - - 100 100 100
24 Bedaqullin tablet 100 mg 34,611.00 - - - - - - - - - - - - - - - - - - -
25 Benzatin Benzil Penicillin injeksi vial 14,430.00 - - - - - - - 3 - - - - - 1 6 - - -
26 Berlinger & Co Freeze Tag Green 1,334.00
27 Berlinger & Co Fridge Tag WHO Type 9,662.24
28 Betametason krim 2,500.00
Betametason krim 2,000.00
29 Booklet pcs -
30 Box slide 77,690.00
31 Brosur pcs -
32 BTI Larvasida Mosnon 64,691.00
33 Buku Kontak pcs 12,100.00
34 Buku Peraturan per UU Covid pcs 85,250.00
35 Buku PVC -
36 Chloroquin tablet 150 mg tablet 850.00
37 Ciprofloxacin kapsul 500 mg tablet 248.00
39 Cotrimoxazol tablet 126.00
40 Cotrimoxazol tablet Forte tablet 357.50
Cotrimoxazol tablet Forte tablet 325.00 200
Cotrimoxazol tablet Forte tablet 499.00
Container box with lockabel lid 15 ltr - - - - - - - - - - - - - - - - - - -
41 DETEKSI Rapidan Tester anti HIV 1/2 test ( triline ) 7,454.44
42 Diazepam Injeksi 5mg/ml-2ml ampul 1,545.00 - - - 30 - - - - - - - 5 - - - - - - -
43 Diazepam tablet 5 mg tablet 108.00 100
Diazepam tablet 5 mg tablet 1,080.00
Diazepam tablet 5 mg tablet 54.00 200
44 Diphenhidramina injeksi 10 mg ampul 781.00
45 Etambutol (E) tablet 100mg tablet 670.00
Etambutol (E) tablet 100mg tablet 688.00 - - - - - - - - - - - - - - - - - - 56
46 Ethambutol 400mg 507.00
Page 32 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
47 FDC :TDF 300 mg+3TC 300mg +DTG 50mg 3,499.00
FDC :TDF 300 mg+3TC 300mg +DTG 50mg -
FDC :TDF 300 mg+3TC 300mg +DTG 50mg 2,850.00 10,770 - - 630 - - - 360 - - - - - - 1,980 - - - 90
48 Fenobarbital Injeksi 50mg/ml-2ml 1,715.45
49 Fitomenadion (Vit K) injeksi 2 mg/ml ampul 1,399.00
Fitomenadion (Vit K) injeksi 2 mg/ml 3,400.00
51 Fridge - Tag -
52 Fridge - Tag 2 -
53 Garam Oralit untuk 200 ml air kantong 257.00
Garam Oralit untuk 200 ml air kantong 280.00 500 500 - - 500 - - 500 500 2,000 - 300 - 500 500 - 500 500 1,000
54 Gentamycin injeksi 80 mg/2 ml 3,385.50
55 Goggle / Kaca Mata Pelindung 27,600.00
56 Haloperidol Decanoate lar Injeksi 50mg/ml 101,300.00
Haloperidol Decanoate lar Injeksi 50mg/ml 109,000.00 - - - - - - - - - - - - - - - - - - -
57 Haloperidol injeksi 5 mg/ ml vial 1,190.00
58 Haloperidol tablet 5 mg 54.00 600 500
59 Hidroklorotiazida tablet 25 mg 149.35
60 Hidrokortison Krim 2,5% tube 2,325.00 48 11
61 Ibuprofen tablet 400 mg tablet 1,910.00
62 Immersion Oil -
63 Insektisida sipermetrin 200,000.00
Insektisida sipermetrin 451,000.00 - - - - - - - 5 - - - - - - - - - - -
64 INSEKTISIDA SIPERMETRIN ZETA 15 UL (1 liter) 215,600.00
Isoniazid 300 mg tablet 400.00 - - - - - - 300 - - - - - - - - - - 190 159
66 Kalsium Glukonat injeksi 10,450.00
67 Kapas pembalut 100g 7,205.00
68 Kartu Vaksin pcs 770.00
69 Kasa Pembalut Hidrofil 4m X 5cm 949.00
70 Levofloxacin 100mg TB tablet 1,952.00 - - - - - - - - - - - - - - - - - - -
Levofloxacin 100mg TB tablet 2,488.00
71 Levofloxacin tablet 250 mg tablet 405.00
72 Linezolid tablet 600 mg 2,933.00 - - - - - - - - - - - - - - - - - - -
73 Loperamide tablet 2 mg tablet 77.00
76 Maltodextrin tablet / TABURIA tablet 605.00
Maltodextrin tablet / TABURIA tablet - - - - 9,000 - - - - - - - - - - - - - - -
77 Masker 3 Ply Disposable (HIV-AIDS) pcs 2,290.00
78 Masker 3 Ply Earloop ( APBN-TB ) pcs 706.00
Masker 3 Ply Earloop ( APBN-TB ) pcs 706.42
79 Masker Bedah TB KALMED @50 706.42
80 Masker KN-95 Covid -
81 Masker N95 (1860 s) Program - TB pcs 19,900.00
Page 33 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
82 Masker N95 aero pcs 20,000.00
83 Masker N95 Wegen @20 12,000.00
84 Masker TB PLUS Conector 328.56
Masker Kain - - - - - - - - - - - - - 50 50 50 50 50 50
85 Metformin H Cl tablet 500 mg tablet 77.00
86 Metilergometrin Maleat injeksi 0,2 mg/ml 2,050.00
87 Metronidazol infus vial 5,938.50
88 Mineral mix 2,981.00
Mineral mix 3,008.10
89 Moxiflocaxin table 400 mg 3,401.00 - - - - - - - - - - - - - - - - - - -
90 Nystatin ovula 100.000 IU/g tablet 550.00
91 Obat Anti Malaria (DHP) tablet 1,900.00

1,917.00

2,851.00 - - - - - - - - - - - - - - - - - - -
92 Obat Antituberkulosis (OAT) KDT Dosis Harian 511,609.00
Obat Antituberkulosis dosis Harian paket 548,865.00
Obat Antituberkulosis dosis Harian paket 530,025.00 10 10 10 - 16 10 5 - - 25 10 5 5 10 10 10 - 10 6
93 Obat Antituberkulosis kat - Anak paket -
Obat Antituberkulosis kat - Anak paket 314,241.00 3 2 2 - - - - - - - 1 6 - 4 2 - - - 2
94 Obat Antituberkulosis kat - I paket 418,971.00
95 OBAT KUSTA M B anak strip 31,928.00
OBAT KUSTA M B anak strip 25,354.00
OBAT KUSTA M B anak strip 33,282.00 - - - - - - - - - 2 - - - - - - - - -
96 OBAT KUSTA M B dewasa strip 49,748.00
OBAT KUSTA M B dewasa strip 51,858.00
OBAT KUSTA M B dewasa strip 50,401.00 - - 2 - 3 - - 7 - 6 - - - - - 3 - - 2
97 OBAT KUSTA P B anak strip 18,562.00 - - - - 1 - - - - - - - - - - - - - -
98 OBAT KUSTA P B dewasa strip 15,304.00
100 Oxytetracylin salep mata 1% 3,531.82 10 - - 5 - - - 5 5 5 - - - 5 5 5 - - -
101 Oxytocin injeksi 10 IU/ml ampul 1,136.24
102 Paket APD lengkap 53,296.00
104 Pelarut BCG ampul - 5 - 20 - 50 - - - - 50 30 - - 10 20 - - 40 20
105 Pelarut NACL 0,9% 3,280.00
Pelarut NACL 0,9% -
106 Pen Maker -
107 Pewarna Ziehl Nellsen ( PROGRAM ) set 176,760.00
Pewarna Ziehl Nellsen ( PROGRAM ) set 178,500.00 - - - - - - - - - - - 1 - - - - - - -
108 Piridoksin (Vit B6) tablet 10 mg 65.00 100 100 - 100 100 - - - - - - - - - - - - - -
109 Piridoksina ( Vit B6) tablet 25mg tablet 222.00
110 PPD ( Purified Protein Derivative )/ Mantoux vial 608,280.00 - - 2
111 Prednison tablet 5 mg 88.00
112 Pretomanid 32,576.00 - - - - - - - - - - - - - - - - - - -
Page 34 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
113 Primaquin 15 mg tablet 235.00 - - - - - - - - - - - - - - - - - - -
114 Pyrimetamin 25mg tablet 1,320.00
115 Rapid Test Anti Hbs 3,985.90 50 40 40 75 75 - 45 45 40 40
Rapid Test Anti Hbs 3,875.00 35 40 40 40 60 75 50 50 50 75
116 Rapid Test Anti HCV 10,088.00
Rapid Test Anti HCV 6,332.00
117 RDT ANTIGEN COVID - 19 -
118 RDT CHIKUNGUNYA 65,000.00 - 25 - - - - - - - - - - - - - - - - -
119 RDT DBD COMBO 453,660.00
RDT DBD COMBO 376,700.00 - - 1 - - 1 - 1 - - - - - - - - - - -
120 RDT LEPTOSPIROSIS 195,000.00
121 Retinol kap. lunak 100.000 IU ( Biru ) kapsul - - 400 300 450 700 - - 250 200 600 - 300 - 350 - - - - -
Retinol kap. lunak 100.000 IU ( Biru ) kapsul 305.00
122 Retinol kap. lunak 200.000 IU ( Merah ) kapsul 552.00
Retinol kap. lunak 200.000 IU ( Merah ) kapsul - - 7,400 2,600 3,100 3,900 - 1,150 1,700 2,100 4,300 - 1,400 - 2,450 - 4,400 - - -
123 Rifampisin kapsul 450 mg kapsul 921.00
124 Rifampisin Kapsul 600 mg kapsul 1,182.00
125 RIFAPENTIN 150 MG tablet 5,525.00
Rifapentin 150 mg tablet 5,525.00
Risperidone 2 mg tablet 210.00 100
127 Roll Banner Imunisasi Ganda -
128 Roll Banner PCV -
129 Rompi Vasinator pcs 148,000.00
130 Safety box 5 lt 16,500.00
Safety box 5 lt 16,451.36 - 25 - 25 - 25 - 25 - - 25 25 - - - - - 25 -
131 Salbutamol tablet 2 mg tablet 103.00
132 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%) tube

1,410.00
133 Sarung Tangan ( Handscoon ) Latex pcs 64,700.00
134 Serum Anti Dipteri injeksi 10.000 IU -
135 Serum Anti Rabies 153,000.00
Serum Anti Rabies 154,790.00 - - - - - - - - - - - - - - - - - - -
136 Serum Anti Rabies(Rabivax) -
137 Sikzonoate injeksi 25 mg /ml 62,000.00 10 15
Simvastatin tablet 10 mg tablet 112.00 90 90 - 120 120 90 90 90 90 150 90 120 120 90 120 150 90 150 90
139 Sputum Pot buah 2,275.00
Sputum Pot buah 2,200.00
Sputum Pot buah -
140 Tablet Tambah Darah (ferro Sulfat + as. Folat ) tablet 226.00
Tablet Tambah Darah (ferro Sulfat + as. Folat ) tablet - 28,000 28,000 11,200 5,600 22,400 11,200 11,200 11,200 11,200 - - 11,200 5,600 11,200 28,000 11,200 11,200 28,000 - 16
Tablet Tambah Darah (ferro Sulfat + as. Folat ) tablet 232.60
141 Trifluoperazin 5 mg tablet 287.00
142 Triheksifenidil Hcl tablet - 2 mg tablet 63.00
Triheksifenidil Hcl tablet - 2 mg tablet 120.99
143 Vaksin BCG ampul 97,780.10
Vaksin BCG ampul -
Vaksin BCG 98,000.00
Vaksin BCG ampul 202,107.63 5 - 20 - 50 - - - - 50 30 - - 10 20 - - 40 20
Page 35 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
144 Vaksin DPT Hb - Hib / PENTABIO vial 85,103.00
Vaksin DPT Hb - Hib / PENTABIO vial -
Vaksin DPT Hb - Hib / PENTABIO 47,032.43
Vaksin DPT Hb - Hib / PENTABIO 10 ds 210,000.00 - - 16 21 - - 16 20 13 33 14 14 14 22 27 30 - 19 29
145 Vaksin DT vial 33,063.06
Vaksin DT vial 36,700.00
146 Vaksin HB Unijeck vial 23,490.00
Vaksin HB Unijeck vial 26,073.90
Vaksin HB Unijeck vial -
Vaksin HB Unijeck vial 28,695.00 10 20 - 30 - 60 - 20 - 100 20 - - 10 100 - 30 - 75
Vaksin Hb-0 (Unijeck) vial 25,851.35
147 Vaksin Hb-0 (Unijeck) Dewasa 51,351.35 - 33 - - - - - - 34 - - - - - - - 39 - -
148 Vaksin HBIG vial 1,325,000.00
Vaksin HBIG vial 1,375,000.00 3 - 6 - - 2 - 1 - 4 1 - - - - 2 1 - -
149 Vaksin HPV 161,036.04 - - - - - - - - - - - - - - - - - - -
150 VAKSIN INAVAC vial 464,225.00 6 2 2 2
VAKSIN INAVAC vial 515,289.75 3 5 2 11 2 5 4 - 7 2 1 10 2 3 4 3
151 VAKSIN INDOVAC vial -
152 Vaksin Meningitis vial 60,332.56
Vaksin Meningitis vial 122,000.00
153 vaksin MR set 152,600.00
vaksin MR set 169,386.00 5 50 30 - - 35 50 15 10 50 20 5 - 30 25 50 - 50 40
vaksin MR set 194,386.00
154 Vaksin PCV -
Vaksin PCV 190,657.00 - 100 50 50 50 80 80 30 20 100 30 20 - 60 25 100 20 100 70
155 Vaksin PFIZER BILATERAL SHIPMENT 6 Dosis -
Vaksin Polio 50 Dosis ampul - 111 173 102 122 167 106 83 107 80 189 89 76 78 116 173 172 140 111 183
156 Vaksin Polio bOPV 10 Dosis ampul 21,689.40
Vaksin Polio bOPV 10 Dosis ampul -
Vaksin Polio bOPV 10 Dosis ampul 158,500.00
Vaksin Polio bOPV 10 Dosis ampul 21,810.81 30 50 50 50 50 80 50 20 - 100 20 10 20 30 60 50 20 80 50
157 Vaksin Polio IPV 5 Dosis ampul 158,500.23
Vaksin Polio IPV 5 Dosis ampul -
Vaksin Polio IPV 5 Dosis ampul 158,500.00
Vaksin Polio IPV 5 Dosis ampul 172,000.05 10 40 40 30 40 50 40 - 20 50 - 10 50 30 30 - 30 60 50
158 Vaksin ROTAVAC 249,750.00 25 80 60 50 50 90 80 30 15 50 50 - 30 30 - 70 30 100 40
Vaksin ROTAVAC 225,000.00
159 Vaksin Td vial 20,721.00
Vaksin Td 23,000.31 - - - 20 40 - - - - - - - - - - - - - -
Vaksin Td 29,279.28
160 VAKSIN ZIFIVAX vial -
161 ZINC tablet 20 mg tablet 208.00 200 200 200 200 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
OBAT PROGRAM HIV AIDS/ APBD PROPINSI -
1 3HP HIV tablet 6,536.64 360 - - - - - - - - - - - - - - - - - -
2 Abacavir (ABC) 300 mg tablet 2,031.42
Page 36 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
Catridge TCM 167,000.00 - - - - - - - 200 - 200 - - - - 100
Catridge TCM 129,039.00 50 - - - -
4 Cepheid Xpert HIV-1 VL Assay ( Catridge HIV Viral 397,215.00
Load ) Xpert HIV-1 VL Assay ( Catridge HIV Viral
Cepheid 397,215.39
5 Load )
Combipak (Azithromycin-Cefixime) 31,231.00
6 DBS Collection Kit ( kotak/ 20 pcs ) 26,980.00
DBS Collection Kit ( kotak/ 20 pcs ) 46,694.00 - - - - - - - - - - - - - - - - - - -
7 Dolutegravir (DTG) 10 mg tablet 771.93
8 Dolutegravir (DTG) 50 mg tablet 4,855.00
Dolutegravir (DTG) 50 mg tablet 4,995.00 - - - - - - - - - - - - - - 150 - - - 30
Dolutegravir (DTG) 50 mg tablet 4,440.00
9 Efavirenz (EFV) 600mg 7,050.00
Efavirenz (EFV) 600mg 7,000.00 60 - - - - - - - - - - - - - - - - - -
10 FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

mg 6,800.00
FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600 tablet
mg 3,260.00
FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

mg 3,011.00 7,110 - - 840 - - - 330 - - - - - - 960 - - - 90
12 INDEN HIV 1/2 COMBO 17,497.52
INDEN HIV 1/2 COMBO 17,499.00 - - - 100 - - - - - - - - - - - - - - 200
13 Kodom Artika 448.00
Kodom Artika 740.62 1,440 - - - - - - - - - - - - - - - - - -
14 Kodom Lubrikan/Pelicin 331.00 500 - - - - - - - - - - - - - - - - - -
15 Lamivudine (3TC)150 mg tablet tablet 1,640.00 180 - - - - - - - - - - - - - 60 - - - -
Lamivudine (3TC)150 mg tablet tablet 1,560.00
Lopinavir/ritonavir (LPV / r) 200/150 mg 5,196.82
18 Masker FFP 2NR (Prop) pcs -
19 Nevirapine ( NVP ) 200mg tablet 2,415.00 - - - - - - - - - - - - - - - - - - 60
20 Rapid Test Syphilis ( Trepocheck Syphilis ) test 9,300.00
Rapid Test Syphilis ( Trepocheck Syphilis ) test 8,096.00 - - - - - - - - - - - - - - - - - - -
Rapid Test Syphilis ( Trepocheck Syphilis ) test 9,639.00
21 RAPIDAN TESTER ANTI HIV 1/2 TEST (R3)(50) 11,440.00 - - - - - - - - - - - - - - - - - - -
22 Reagen Penghitung CD 4 Control 971,152.00
23 Reagen Penghitung CD 4 MOBIL 137,792.00
24 RHZE (rifampicin+inh+pza+etham) 1,423.00 - - - - - - - - - - - - - - - - - - -
25 SD HBsAg WB ( Multi + Diloper ) 7,419.00
SD HBsAg WB ( Multi + Diloper ) 7,120.00
SD HBsAg WB ( Multi + Diloper ) 3,190.28 - - - - - - - - 50 - - - - - - - - - 975
26 STANDART Q HIV 1/2 AB 3 LINE (R2)(25) 10,500.00 - - - - - - - - - - - - - - - - - - -
27 Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg tablet

3,750.00
Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg

2,271.76
28 Tenofovir 300 mg tablet 2,240.00
Tenofovir 300 mg tablet 3,280.00
29 Virocheck HIV 1/2 (25 test ) test 8,024.00
Page 37 of 38
(3) (8) (9) ( 10 ) (12) (13) (16)
NO. SATUAN
NAMA OBAT
HARGA SATUAN
Virocheck HIV 1/2 (25 test ) test 8,391.00 - - - - 200 - - 50 - - - - 100 50 100 - - - -
30 Zidofudine ( ZDV ) 300mg + Lamivudine ( 3TC ) 150mg tablet 3,848.00 - - - - - - - - - - - - - - - - - - 60
31 Zidofudine (ZDV ) 100 mg tablet tablet 1,768.00 - - - - - - - - - - - - - - - - - - -
32 Zidovudin 60 mg dan Lamivudin 30 mg tablet 430.73 60 - - - - - - - - - - - - - - - - - -
TOTAL APBD PROVINSI/ APBN -
BANTUAN BPBD PROVINSI JAWA TIMUR -
1 Face Shield Kacamata pcs -
2 Hand Sanitizer 1 Liter botol -
3 Helm Face Shield (Pendopo) pcs -
4 Thermometer Gun Nikita(Bantuan BPBD) unit -
OBAT BANTUAN Tingkat Sektor -
1 Cryotube 2ml - - - - - - - - - - - - - - - - - - - -
Cryotube 2ml 2,057.94
2 Flashback Needle 22G - - - - - - - - - - - - - - - - - - - -
Flashback Needle 22G 2,420.91
3 Ice Gel - - - - - - - - - - - - - - - - - - - -
Ice Gel 3,108.00
4 Ice Pack - - - - - - - - - - - - - - - - - - - -
Ice Pack 13,431.00
5 Lakban - - - - - - - - - - - - - - - - - - - -
Lakban 17,205.00
6 NMicrotrainer EDTA -
NMicrotrainer EDTA 5,200.35 - - - - - - - - - - - - - - - - - - -
7 Parafilm -
Parafilm 20,238.08 - - - - - - - - - - - - - - - - - - -
8 Plastik Clip 16 x 24 cm - - - - - - - - - - - - - - - - - - - -
Plastik Clip 16 x 24 cm 57,165.00
9 Plastik Clip 5x7 cm - - - - - - - - - - - - - - - - - - - -
Plastik Clip 5x7 cm 5,772.00
10 Styrofoam (37,5 cm x 24 cmx 16 cm ) - - - - - - - - - - - - - - - - - - - -
Styrofoam (37,5 cm x 24 cmx 16 cm ) 15,717.60
11 Tip Pipet 1ml (sterile) - - - - - - - - - - - - - - - - - - - -
Tip Pipet 1ml (sterile) 120,625.92
12 Tube EDTA plh 13x75 3,0 blblce lav (HIV)
- - - - - - - - - - - - - - - - - - - -
Tube EDTA plh 13x75 3,0 blblce lav (HIV) 251,193.00
13 Wing Needle no.27 - - - - - - - - - - - - - - - - - - - -
14 Wing Needle no.27 13,213.44
15 Yellow Holder - - - - - - - - - - - - - - - - - - - -
Yellow Holder 1,149.96
LABKESDA -
16 Safety box 5 lt 14,717.00
TOTAL PROGRAM OBAT-OBATAN
BAHAN LAINNYA -
1 PMT BALITA Sak 30,250.00
2 PMT BUMIL Sak 32,750.00
TOTAL PROGRAM BAHAN LAINNYA
TOTAL BANTUAN PROGRAM - 142,199
TOTAL APBD DAERAH -
TOTAL PERSEDIAAN (APBD DAERAH DAN HIBAH) -
-
Page 38 of 38

Penerimaan Januari 2024 PKM

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REKAPITULASI LAPORAN PER

OBAT APBD/ DAK/ DAU

138 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%)

BELANJA BAHAN - BAHAN PERLENGKAPAN KANTOR -

Obat Anti Malaria DHP (Dihidroartemisin + Primaquin) tablet

Obat Anti Malaria DHP (Dihidroartemisin + Primaquin) tablet

132 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%) tube

10 FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

27 Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg tablet

Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg

OBAT APBD/ DAK/ DAU

138 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%)

BELANJA BAHAN - BAHAN PERLENGKAPAN KANTOR -

Obat Anti Malaria DHP (Dihidroartemisin + Primaquin) tablet

Obat Anti Malaria DHP (Dihidroartemisin + Primaquin) tablet

132 Salep 2-4 DOEN (As.Salisilat 2%+Belerang Endap 4%) tube

10 FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

FDC Dewasa : TDF 300 mg + 3TC300mg + EFV 600

27 Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg tablet

Tenofovir (TDF) 300 mg + Emcitritabine (FCT) 200 mg

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