Антон

PEMERINTAHAN PROVINSI BALI
RSUD BALI MANDARA
Jl. Bypass Ngurah Rai No.548, Sanur Kauh, Denpasar Selatan, Kota Denpasar, Bali (0361) 4490566
Email : [відкрити контакти](див. вище в блоці «контактна інформація») Website : https://rsbm.baliprov.go.id/

RINCIAN BIAYA
No. Registrasi : 2603120784 Unit : Instalasi Rawat Inap
No. RM / Umur : 20.88.22 / 34 thn 10 Bulan 01 hr Ruang : KASUARI
Nama Pasien : ANTON CHYRVA (Laki-laki) Tgl Masuk : 12/03/2026
: dr. PUTU AGUNG WIRAHADI SANJAYA,
DPJP Tgl Pulang : 14/03/2026
Sp.OT
No SEP : Type : UMUM/PRIBADI
No Kartu :- Penjamin : Diri Sendiri

No Deskripsi Tarif Qty Sub Total
OBAT
1 2 WAY FOLEY CATHETER FR 16 24,185 x1 24,185
2 ADVANTIME (POLYGLECAPRONE) 3/0 3/8 24 MM 70 CM ( CUT- EXCUT) 214,834 x1 214,834
3 ANALTRAM (PARASETAMOL 325+ TRAMADOL 37.5) TABLET 22,154 x3 66,462
4 APRON PLASTIK LENGAN PENDEK 6,155 x3 18,465
5 BACTIGRAS (TULLE) 10 X 10 CM 16,411 x1 16,411
6 BFLUID INF 500 ML 238,814 x3 716,442
7 BLOOD SET WITH AIR VENT 17,741 x1 17,741
8 CANWELL 4.5MM LOCKING COMPRESSION PLATE (NARROW, LC-LCP) 8,055,936 x1 8,055,936
9 CANWELL CORTEX SCREW 4.5 X 36 447,552 x2 895,104
10 CANWELL CORTEX SCREW 4.5 X 38 447,552 x2 895,104
11 CANWELL LOCKING SCREW 5.0 X 36 1,300,032 x3 3,900,096
12 CANWELL LOCKING SCREW 5.0 X 38 1,300,032 x1 1,300,032
13 CEFAZOLIN 1000 MG INJ 24,000 x1 24,000
14 CEPTIK (CEFIXIME) 200 MG KAPSUL 96,689 x3 290,067
15 DECAMED I.V FILM 6,221 x1 6,221
16 DEKSAMETASON 5 MG/ML INJ 4,666 x2 9,332
17 DIPHENHYDRAMINE 10 MG/ML INJ 6,394 x1 6,394
18 DOCARE WASH GLOVES 11,869 x6 71,214
19 ELASTIC BANDAGE 10 CM 109,544 x1 109,544
20 ELASTIC BANDAGE 15 CM 134,266 x1 134,266
21 ELECTRODA 11,040 x5 55,200
22 ENOXRIN (ENOXAPARIN) 0.4 ML 190,210 x1 190,210
23 EXTENTION TUBE 100 CM (ONEMED) 11,722 x1 11,722
24 FENTANIL 0,05 MG/ML INJ 62,043 x4 248,172
25 GELANG DEWASA BIRU 3,410 x1 3,410
26 GELANG DEWASA KUNING 3,410 x1 3,410
27 GENTAMICIN 40 MG/ML INJ 8,170 x2 16,340
28 IV CANNULA UK. 20 G 10,656 x1 10,656
29 KASA DARM CSSD 23,536 x2 47,072
30 KASA STERIL CSSD 10 X 10 CM 35,904 x8 287,232
31 KETAMINE 100 MG/ML INJ 6,822 x2 13,644
32 KETOROLAK 30 MG/ML INJ 4,416 x3 13,248
33 KILLBAC WOUND IRIGATION 97,920 x1 97,920
34 LIDOCAINE COMPOSITUM (LIDOCAIN+EPINEFRIN) INJ 4,224 x2 8,448
35 LINA PEN 92,196 x1 92,196
36 LINA TIP CLEANER 48,737 x1 48,737
37 LORAZEPAM 2 MG TAB 2,324 x3 6,972
38 MARCAIN (BUPIVACAINE) PDF 0.5% INJ 161,569 x1 161,569
39 MESS AESCULAP NO 15 11,521 x1 11,521
No Deskripsi Tarif Qty Sub Total
40 MESS AESCULAP NO 20 11,521 x2 23,042
41 MY JELLY 5 GR 4,828 x1 4,828
42 NACL 0.9% INF 1000 ML 35,880 x2 71,760
43 NACL 0.9% INF 100 ML 13,681 x7 95,767
44 NACL 0.9% INF 500 ML 14,733 x2 29,466
45 NASAL OKSIGEN DEWASA (OXYFLOW) 17,050 x1 17,050
46 NEEDLE 18 G X 38 MM 605 x1 605
47 NICE CARE UNDERPAD 60 X 90 CM 8,631 x2 17,262
48 OMEPRAZOLE 40 MG INJ 18,528 x4 74,112
49 ONDANSETRON 4 MG/2 ML INJ 3,725 x1 3,725
50 OPTIME (POLYGLYCOLIDE) 1/0 1/2 TP 40 MM 90 CM 185,671 x3 557,013
51 OPTIME (POLYGLYCOLIDE) 2/0 1/2 TP 26 MM 75 CM 164,764 x1 164,764
52 PARACETAMOL 500 MG TAB 363 x4 1,452
53 PARACETAMOL 500 MG TAB 363 x1 363
54 PEINLOS (IBUPROFEN) 100 MG /ML INJ 4 ML 122,758 x3 368,274
55 POVIDONE IODINE 60 ML 17,212 x4 68,848
56 REGIVELL (BUPIVACAINE) 0.5% INJ 4 ML 105,665 x1 105,665
57 RINGER LACTATE (RL) INF 500 ML 16,223 x4 64,892
58 SOFTSKIN SKIN PREP 100 ML 31,484 x1 31,484
59 STARDEC LATEX SURGICAL GLOVES POWDER 7.0 5,761 x4 23,044
60 SUCTION CATHETER NO 14 10,656 x1 10,656
61 SUCTION CONNECTING TUBE 3M 47,121 x1 47,121
62 SURGICAL GLOVES STERIL PRE PWD 7.5 19,435 x5 97,175
63 SURGICAL GLOVES STERIL PRE PWD 8 19,435 x4 77,740
64 SYRINGE 10 ML 2,771 x9 24,939
65 SYRINGE 1 ML 2,132 x1 2,132
66 SYRINGE 3 ML 1,919 x13 24,947
67 SYRINGE 50 ML 8,738 x1 8,738
68 SYRINGE 5 ML 2,132 x13 27,716
69 THREE WAY EKOR (POLYMED) 22,378 x1 22,378
70 TOFEDEX (DEXKETOPROFEN) 50 MG/2 ML INJ 105,495 x3 316,485
71 TONGKAT KETIAK M 316,801 x1 316,801
72 TRAMADOL 100 MG/2 ML INJ 8,525 x3 25,575
73 TRANEXAMIC ACID 500MG/5 ML INJ 8,160 x2 16,320
74 TRANSOFIX, BBRAUN 8,915 x1 8,915
75 URINE DRAINAGE BAG T VALVE WITH HANGER 13,853 x1 13,853
76 VAC WOUND DRAIN UK. 14 176,730 x1 176,730
21,041,166
TINDAKAN
77 Aff Folley Catheter 40,500 x1 40,500
78 Biaya Registrasi Pasien 10,000 x1 10,000
79 Gawat Darurat Umum/Gigi 135,000 x1 135,000
80 Memberi Obat Injeksi (IGD) 37,500 x1 37,500
81 Observasi Lebih dari 2 Jam 79,500 x1 79,500
82 Pasang Foley Kateter 93,000 x1 93,000
83 Pasang Infus Dewasa (IGD) 37,500 x1 37,500
84 Pemasangan Syring Pump 30,000 x1 30,000
85 Persiapan Pasien Pre Op 37,500 x1 37,500
86 Tindakan Asuhan Gizi Rawat Inap 45,000 x1 45,000
87 Tindakan Asuhan Keperawatan/Kebidanan di ruang IGD 75,000 x1 75,000
88 Tindakan Asuhan Keperawatan/Kebidanan Kompleks 364,500 x3 1,093,500
89 Tindakan Medik Canggih 1 24,937,500 x1 24,937,500
26,651,500
RADIOLOGI
90 C-Arm 540,000 x1 540,000
91 Femur AP/Lateral 210,000 x1 210,000
750,000
LABORATORIUM
92 Darah lengkap 5 diff 105,000 x2 210,000
No Deskripsi Tarif Qty Sub Total
93 Golongan darah (ABO + Rhesus) 45,000 x1 45,000
94 Masa Pembekuan (CT) 22,500 x1 22,500
95 Masa Perdarahan (BT) 22,500 x1 22,500
96 Pengambilan Spesimen Darah Dewasa 22,500 x2 45,000
345,000
KONSULTASI
97 Konsultasi Dokter Gigi / Dokter Umum 37,500 x1 37,500
98 Konsultasi Dokter Spesialis di IRD 45,000 x2 90,000
127,500
SEWA KAMAR
99 Pelayanan Rawat Inap VIP 1,125,000 x2 2,250,000
2,250,000
LAIN-LAIN
100 Rekonsiliasi Obat 7,500 x1 7,500
7,500
VISITE DOKTER
101 Visite Dokter Spesialis 225,000 x2 450,000
450,000

TOTAL TAGIHAN : 51,622,666
DEPOSIT - UANG
: 20,000,000
MUKA
TOTAL BAYAR : 0
TOTAL DIKLAIM : 0
SISA HARUS BAYAR : 31,622,666

TERBILANG :
# LIMA PULUH SATU JUTA ENAM RATUS DUA PULUH DUA RIBU ENAM RATUS ENAM PULUH ENAM RUPIAH #

Denpasar, 14/03/2026
Penanggung Biaya Kasir

ANTON CHYRVA