LAMPIRAN NOTA DINAS

NOMOR BPen/046/XII/2021

USULAN STANDAR SATUAN HARGA TAHUN 2022 - 2025

PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
Kenaikan (2%)
PPN (10%) PPH 22 (1,5%) kenaikan)

Generator High Frequency

DC, Tube Voltage 57-85 kV,
Tube Current 2-16 mA, 4
Patient Positioning lights, 9
Image Programs, Automatic
Spine Compensation,
ORTHOCEPH Imaging
1 Automatic Facial Contour, 5- 658,581,728 include 9,878,726 13,171,635 10,500,000 692,132,088 692,200,000 PT. Andini Sarana E-Catalog
System - OC 200D
20 s Expose time, Automatic
Dose recording, SmartPad,
sensor pixel 48x48 ?m, image
pixel 96x96 ?m, Komputer
dan printer set, Apron dan
film paper

Constant potential Generator,

kV 60 & 70 (selectable), 7mA,
focal spot 0,7mm, Exposure
time 0,02-3,2 second, Sudah
termasuk Image Plate, Higine
Focus + Scan Exam One
Paper, Cover IP, Paper Film,
2 Digital Imaging Plate 211,283,233 21,128,323 3,169,248 4,225,665 10,500,000 250,306,469 250,400,000 PT. Andini Sarana E-Catalog
Komputer, Printer set, Apron,
Scanner
dan Stabilizer. Sudah
termasuk Scanner Image
Plate Digital, Uji fungsi dan
uji kesesuaian, Garansi 1
Tahun

NSK VOLVERE i7 - Unit Kontrol Volvere

Micromotor System with - E Type Motor PT. Thomasong
3 9,740,000 974,000 146,100 194,800 510,000 11,564,900 11,600,000 E-Catalog
NSK Straight Handpiece - Straight Handpiece Nirmala
FX65 FX65
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Fully Automatic, user friendly

PC based system, uses PC's
USB Port for communication
DigiFlow Uroflowmetry PT. Endo
4 with the hardware, real time 70,000,000 7,000,000 1,050,000 1,400,000 4,481,500 83,931,500 84,000,000 E-Catalog
System (4W) Indonesia
cloured display, long test
duration up to 30 minutes,
include PC Set.

Monitor Stand, basic monitor

stand, tiltable, rotation +/-
30, disinfectable, color white,
31 4K MONITOR TM342 PT. Advance
5 VESA 100 adaptor, for use 12,010,916 1,201,092 180,164 240,218 300,273 13,932,663 14,000,000 E-Catalog
9826SF Medicare Corpora
with all monitors with VESA
100 Adaptor and a max.
weight of 12kg

"24"" KARL STORZ Touch

Screen, Resolution: 1920 x
1080 Format: 16:9 FULL HD
Power supply: 100 – 240
VAC, 50/60 Hz IP protection
class IPX2 Touch control with
latex gloves VESA 100
adaptor Video inputs: 1x DVI-
I, 1x DVI-D, 1x Display Port
1.2 compliant, 1x VGA 1x
USB-B Touch Connector
(called “USB touch” on I/O
label) 1x RS232 (D-Sub)
AIDA COMPACT NEO PT. Advance
6 Touch Connector (called 72,799,202 7,279,920 1,091,988 1,455,984 1,819,980 84,447,074 84,500,000 E-Catalog
ADVANCED WM101 Medicare Corpora
“RS232 touch” on I/O label)
1x RJ45 Serial
Communication Connector
Includes: 1x External 24 VDC
Power Supply 1x Mains Cord
1x Potential Equalization Bolt
1x Cable Cover 1x Instruction
Manual, print version in
English as well as other
languages on USB flash drive
Dimensions in mm (w x h x
d): 587 x 367,5 x 59.50
Weight in kg: 6.80"
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Equipment Cart, narrow,

small, rides on 4 antistatic
dual wheels equipped with
locking brakes, mains switch
on cover, energy beam with
integrated electrical
subdistributors with 6
sockets, grounding plugs,
Dimensions in mm (w x h x
d): Equipment cart: 660 x
1265 x 730, Shelf: 450 x 25 x
510, Caster diameter: 150 PT. Advance
7 AIDA MINI UG110 69,862,229 6,986,223 1,047,933 1,397,245 1,746,556 81,040,186 81,100,000 E-Catalog
consisting of: UG 010 Base Medicare Corpora
Module, equipment cart,
small UG 020 Cover,
equipment cart, small UG
041 Beam Package,
equipment cart, small 2x UG
603 Shelf, narrow UG 601
Drawer Unit with Lock,
narrow 2x UG 608
Equipment Rail, long 2x UG
700 Mains Cord, length 100
cm

BIPOLAR
RESECTOSCOPE
SYSTEM INSTRUMENT PT. Advance
8 Punch-Working Element 37,186,135 3,718,614 557,792 743,723 929,653 43,135,917 43,200,000 E-Catalog
SET (THE REVOLUTION Medicare Corpora
IN TRANSURETHRA
RESECTION) 27077A

Punch Sheath, with central

Bipolar Resectoscope
valve, 25 Fr., straight beak
System Instrument Set
consisting of: 27077 BZ PT. Advance
9 (The Revolution In 15,568,614 1,556,861 233,529 311,372 389,215 18,059,592 18,100,000 E-Catalog
Punch Sheath 27077 DO Medicare Corpora
Transurethra Resection)
Obturator Connecting Tube
27077BZK
for In- and Outflow
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Uretero-Renoscope, 7 Fr., 6°,

length 43 cm, distal tip 6.5
Fr., instrument sheath 7 Fr.,
one-step, 9.9 Fr.,
autoclavable, with angled
eyepiece, fiber optic light
transmission incorporated, 2
lateral irrigation ports and 1
working channel 4.8 Fr., for
use with instruments up to 4
The New Generation
Fr. The following accessories
Uretero-Renoscope and PT. Advance
10 are included in delivery: 129,670,942 12,967,094 1,945,064 2,593,419 3,241,774 150,418,293 150,500,000 E-Catalog
Accessories Instrument Medicare Corpora
27000 L Uretero-Renoscope
Set 27000LK
27001 E Insertion Aid 27001
G Instrument Port with
Sealing System and Quick
Release Lock 27500 LUER-
Lock Tube Connector, male
27502 LUER-Lock Tube
Connector, with stopcock
27550 N Seal, package of 10
27504 Flow Control Stopcock
39501 X Wire Tray

Adaptor, autoclavable, for

KARL STORZ uretero-
renoscopes, new generation,
PT. Advance
11 CALCUSPLIT 27630136 for use with CALCUSPLIT®, 4,014,908 401,491 60,224 80,298 100,373 4,657,293 4,700,000 E-Catalog
Medicare Corpora
in conjunction with
Instrument Port 27001 G and
Handpiece 27630038

Instrument Port with Sealing

HF Endomat LC SCB System and Quick Release PT. Advance
12 6,125,046 612,505 91,876 122,501 153,126 7,105,053 7,200,000 E-Catalog
27001GH Lock 2 channels, 1 straight Medicare Corpora
channel, 1 lateral channel
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

PEREZ CASTRO Forceps,

long jaws for Steinstraße,
Uretero-Renoscope PT. Advance
13 rigid, double action jaws, 4 12,138,215 1,213,822 182,073 242,764 303,455 14,080,329 14,100,000 E-Catalog
27424R Medicare Corpora
Fr., length 60 cm, color code:
blue

Biopsy Forceps, rigid, double

Uretero-Renoscope PT. Advance
14 action jaws, 4 Fr., length 60 12,138,215 1,213,822 182,073 242,764 303,455 14,080,329 14,100,000 E-Catalog
27424Z Medicare Corpora
cm, color code: blue

IMAGE1 S CONNECT,
connect module, for use with
up to 3 link modules,
resolution 1920 x 1080
pixels, with integrated KARL
STORZ-SCB and digital
Image Processing Module,
power supply 100 - 120
VAC/200 - 240 VAC, 50/60
PT. Advance
15 Image Spies TC200EN Hz including: 400 A Mains 188,418,479 18,841,848 2,826,277 3,768,370 4,710,462 218,565,436 218,600,000 E-Catalog
Medicare Corpora
Cord, length 300 cm
20040089 DVI-D Connecting
Cable, length 300 cm
20090170 SCB Connecting
Cable, length 100 cm
20040282 USB Flash Drive,
32 GB 20040240US USB
Silicone Keyboard, with
touchpad, US
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

IMAGE1 S X-LINK, link

module, for use with flexible
video endoscopes and one-
chip camera heads (up to
FULL HD), power supply 100
- 120 VAC/200 - 240 VAC,
PT. Advance
16 Image Spies TC301 50/60 Hz, including: 400 A 143,331,236 14,333,124 2,149,969 2,866,625 3,583,281 166,264,234 166,300,000 E-Catalog
Medicare Corpora
Mains Cord, length 300 cm
TC 011 Link Cable, length 20
cm for use with IMAGE1 S
CONNECT TC 200EN or
IMAGE1 S CONNECT II TC
201EN

IMAGE1 S HX One-Chip
FULL HD Camera Head,
50/60 Hz, fixed focus,
progressive scan, soakable,
IMAGE1 HX TH110 PT. Advance
17 gas- and plasma-sterilizable, 169,165,329 16,916,533 2,537,480 3,383,307 4,229,133 196,231,782 196,300,000 E-Catalog
TH110 Medicare Corpora
focal length f = 16 mm, 2
freely programmable camera
head buttons, for use with
IMAGE1 S

Cold Light Fountain Power

LED 175 SCB, with
integrated KARL STORZ-SCB,
STORZ Cold Light high-performance LED and
PT. Advance
18 Fountain Power LED 175 one KARL STORZ light outlet, 122,191,267 12,219,127 1,832,869 2,443,825 3,054,782 141,741,870 141,800,000 E-Catalog
Medicare Corpora
SCB 20161401-1 power supply 110 - 240 VAC,
50/60 Hz including: 400 A
Mains Cord 20090170 SCB
Connecting Cable

Fiber Optic Light Cable, with

Cold Light Fountain PT. Advance
19 straight connector, diameter 8,730,641 873,064 130,960 174,613 218,266 10,127,544 10,200,000 E-Catalog
Xenon 100 SCB 495NA Medicare Corpora
3.5 mm, length 230 cm
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

CALCUSPLIT® System, for

pneumatic lithotripsy, power
supply: 100/120/230/240
VAC, 50/60 Hz, consisting of:
27630020 CALCUSPLIT® 400
A Mains Cord 20014230 One-
Pedal Footswitch, digital, two-
stage 27630021 Fabric Tube,
for connecting CALCUSPLIT®
27630020 to the central
compressed air supply, length
400 cm 27630038
CALCUSPLIT® Handpiece,
autoclavable, for use with
CALCUSPLIT® 27630020
PT. Advance
20 CALCUSPLIT 27630003 27630180 Sealing Rings, for 261,732,720 26,173,272 3,925,991 5,234,654 6,543,318 303,609,955 303,700,000 E-Catalog
Medicare Corpora
use with CALCUSPLIT®
Handpiece 27630038,
package of 5 27630035 Spare
Damping Unit, autoclavable,
for use with CALCUSPLIT®
lithotripsy probes, package of
20 27630040 Silicone Tube,
autoclavable, length 200 cm,
for connecting Handpiece
27630038 to CALCUSPLIT®
27630020 27650 C Cleaning
Brush, outer diameter 2.5
mm, length 35 cm 27656 B
Instrument Oil, bottle of 50
ml

Air Compressor, 0 - 8 bar,

power supply 230 VAC,
50/60 Hz, Dimensions (w x d
x h): appr. 500 x 320 x 340
mm, weight appr. 22 kg
consisting of: 20031020 PT. Advance
21 CALCUSPLIT 20031001 47,505,731 4,750,573 712,586 950,115 1,187,643 55,106,648 55,200,000 E-Catalog
Compressor 27630022 Fabric Medicare Corpora
Reinforced Tube, for
connecting CALCUSPLIT®
27630020 and HYDROMAT®
26311020 to Air Compressor
20031020
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Adaptor, autoclavable, for

KARL STORZ uretero-
renoscopes, new generation,
PT. Advance
22 CALCUSPLIT 27630136 for use with CALCUSPLIT®, 4,014,908 401,491 60,224 80,298 100,373 4,657,293 4,700,000 E-Catalog
Medicare Corpora
in conjunction with
Instrument Port 27001 G and
Handpiece 27630038

CALCUSPLIT® Lithotripsy
Wire Probe, diameter 0.8 mm,
working length 57.5 cm, for
The New Generation
use with Uretero-Renoscopes
Uretero-Renoscope and PT. Advance
23 27000 L, 27001 L, 27002 L, 1,690,597 169,060 25,359 33,812 42,265 1,961,093 2,000,000 E-Catalog
Accessories Instrument Medicare Corpora
27003 L, 27014 L in
Set 27632634
conjunction with Instrument
Port 27001 G and Handpiece
27630038

CALCUSPLIT® Lithotripsy
Wire Probe, diameter 1 mm,
working length 57.5 cm, for
The New Generation
use with Uretero-Renoscopes
Uretero-Renoscope and PT. Advance
24 27000 L, 27001 L, 27002 L, 1,690,597 169,060 25,359 33,812 42,265 1,961,093 2,000,000 E-Catalog
Accessories Instrument Medicare Corpora
27003 L, 27014 L in
Set 27632635
conjunction with Instrument
Port 27001 G and Handpiece
27630038

Bipolar Resectoscope
System Instrument Set
PT. Advance
25 (The Revolution In ELLIK Evacuator 1,957,860 195,786 29,368 39,157 48,947 2,271,118 2,300,000 E-Catalog
Medicare Corpora
Transurethra Resection)
27224

Bipolar Resectoscope
Telescope Bridge, with 1
System Instrument Set
lockable channel, for use with PT. Advance
26 (The Revolution In 5,062,467 506,247 75,937 101,249 126,562 5,872,462 5,900,000 E-Catalog
Cystoscope Sheaths 27026 Medicare Corpora
Transurethra Resection)
A/AB/B/BB/C/CB/D/DB/U
27025G
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
27 (The Revolution In without channel, curved, 19.5 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573H

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
28 (The Revolution In without channel, curved, 18 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573G

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
29 (The Revolution In without channel, curved, 16.5 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573F

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
30 (The Revolution In without channel, curved, 15 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573E

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
31 (The Revolution In without channel, curved, 13.5 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573D

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
32 (The Revolution In without channel, curved, 12 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573C

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
33 (The Revolution In without channel, curved, 10.5 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573B

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
34 (The Revolution In without channel, curved, 9 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573A
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Bipolar Resectoscope
Cold Knife round, not to be
System Instrument Set
used with HF current This PT. Advance
35 The Revolution In 1,632,845 163,285 24,493 32,657 40,821 1,894,100 1,900,000 E-Catalog
article is only available in Medicare Corpora
Transurethra Resection)
units of 6
27069L

Bipolar Resectoscope
SACHSE Cold Knife straight,
System Instrument Set
not to be used with HF PT. Advance
36 (The Revolution In 1,632,845 163,285 24,493 32,657 40,821 1,894,100 1,900,000 E-Catalog
current This article is only Medicare Corpora
Transurethra Resection)
available in units of 6
27069K

SACHSE Urethrotome
Bipolar Resectoscope
Sheath, 21 Fr., with channel
System Instrument Set
for FILIFORM bougies PT. Advance
37 (The Revolution In 12,473,848 1,247,385 187,108 249,477 311,846 14,469,664 14,500,000 E-Catalog
consisting of: 27068 D Medicare Corpora
Transurethra Resection)
SACHSE Urethrotome Sheath
27068DK
and 2 LUER-Lock cones

Bipolar Resectoscope
System Instrument Set
Obturator, for urethrotome PT. Advance
38 (The Revolution In 2,880,851 288,085 43,213 57,617 72,021 3,341,787 3,400,000 E-Catalog
sheath, 21 Fr., 27068 D Medicare Corpora
Transurethra Resection)
27068DO

Bipolar Resectoscope Coagulating Electrode ball-

System Instrument Set shaped, diameter 3 mm,
PT. Advance
39 (The Revolution In 24/26 Fr., color code: yellow 1,022,179 102,218 15,333 20,444 25,554 1,185,728 1,200,000 E-Catalog
Medicare Corpora
Transurethra Resection) This article is only available
27050N in units of 6

Cutting Loop angled, 24/26

SUPRALOOP Unipolar Fr., color code: yellow This PT. Advance
40 1,022,179 102,218 15,333 20,444 25,554 1,185,728 1,200,000 E-Catalog
Loop 27050G article is only available in Medicare Corpora
units of 6

Resectoscope Sheath, 26 Fr.,

oblique beak, rotating inner
Bipolar Resectoscope sheath with ceramic
System Instrument Set insulation, quick-release lock,
PT. Advance
41 (The Revolution In color code: yellow consisting 15,524,588 1,552,459 232,869 310,492 388,115 18,008,522 18,100,000 E-Catalog
Medicare Corpora
Transurethra Resection) of: 27050 SC Resectoscope
27050SCK Sheath 27050 CA Inner
Sheath Connecting Tube for
In- and Outflow
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Working Element (also for use

Bipolar Resectoscope
with optical Urethrotome)
System Instrument Set
Motion by means of a spring. PT. Advance
42 (The Revolution In 30,904,667 3,090,467 463,570 618,093 772,617 35,849,414 35,900,000 E-Catalog
The thumb support is Medicare Corpora
Transurethra Resection)
movable. In rest position the
27050E
electrode is inside the sheath.

Cystoscope-Urethroscope
Sheath, 22 Fr., with
Pediatric Cysto- additional slot, color code: PT. Advance
43 12,893,390 1,289,339 193,401 257,868 322,335 14,956,332 15,000,000 E-Catalog
Urethroscope 27026BBK blue consisting of: 27026 BB Medicare Corpora
Sheath 27026 BO Obturator
and 2 LUER-Lock cones

Bipolar Resectoscope
Catheter Deflecting
System Instrument Set
Mechanism with 2 lockable PT. Advance
44 (The Revolution In 15,885,860 1,588,586 238,288 317,717 397,146 18,427,598 18,500,000 E-Catalog
channels, with ratchet, filling Medicare Corpora
Transurethra Resection)
rod 27021O included
27026EF

Bipolar Resectoscope
System Instrument Set
Optical Biopsy Forceps, PT. Advance
45 (The Revolution In 17,172,453 1,717,245 257,587 343,449 429,311 19,920,045 20,000,000 E-Catalog
double action jaws Medicare Corpora
Transurethra Resection)
27072A

HOPKINS® Straight forward

telescope 0°, enlarged view, 4
Hopkins Telescope II mm, autoclavable, fiber optic PT. Advance
46 73,306,583 7,330,658 1,099,599 1,466,132 1,832,665 85,035,636 85,100,000 E-Catalog
27005AA light transmission Medicare Corpora
incorporated, Color code:
green

Bipolar Resectoscope
System Instrument Set
Insertion Mandrin, for PT. Advance
47 (The Revolution In 1,127,064 112,706 16,906 22,541 28,177 1,307,394 1,400,000 E-Catalog
Catheters Medicare Corpora
Transurethra Resection)
27618

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
48 (The Revolution In without channel, curved, 28.5 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573O
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
49 (The Revolution In without channel, curved, 27 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573N

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
50 (The Revolution In without channel, curved, 25.5 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573M

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
51 (The Revolution In without channel, curved, 24 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573L

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
52 (The Revolution In without channel, curved, 22.5 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573K

Bipolar Resectoscope
System Instrument Set BENIQUE Urethral Bougie,
PT. Advance
53 (The Revolution In without channel, curved, 21 1,706,135 170,614 25,592 34,123 42,653 1,979,117 2,000,000 E-Catalog
Medicare Corpora
Transurethra Resection) Fr.
27573J

Bipolar Resectoscope Standard Obturator, for

System Instrument Set 24/26 Fr. Sheaths 27040 BO,
PT. Advance
54 (The Revolution In 27241 BO, 27240 BO, 27040 2,328,714 232,871 34,931 46,574 58,218 2,701,308 2,800,000 E-Catalog
Medicare Corpora
Transurethra Resection) SD/SL, 27050 SL/SC, color
27040OC code: yellow

Unipolar High Frequency

Cord, with 4 mm plug, length
Pediatric Cysto- PT. Advance
55 300 cm, For usage with HF 872,750 87,275 13,091 17,455 21,819 1,012,390 1,100,000 E-Catalog
Urethroscope 277 Medicare Corpora
units, models KARL STORZ
and Erbe type T, older models
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

HOPKINS® Forward-Oblique
Telescope 30°, diameter 4
Hopkins Telescope II mm, length 30 cm, PT. Advance
56 76,420,254 7,642,025 1,146,304 1,528,405 1,910,506 88,647,495 88,700,000 E-Catalog
27005BA autoclavable, fiber optic light Medicare Corpora
transmission incorporated,
color code: red

TOTAL 2,917,400,000
 PAJAK
HARGA SATUAN
Perkiraan
NO NAMA ALAT SPESIFIKASI HARGA SATUAN Unit ONGKIR (ongkir+pajak+ Pembulatan DISTRIBUTOR KETERANGAN
PPN (10%) PPH 22 (1,5%) Kenaikan (2%) kenaikan)

Purworejo, 2021
Direktur RSUD R.A.A. Tjokronegoro Purworejo

dr. Tolkha Amaruddin,Sp.THT-KL., M.Kes

NIP. 19750307 200902 1 002
 USULAN STANDAR SATUAN HARGA TAHUN 2022 -2025
NON E-CATALOG

Harga Satuan
HARGA SURVEY SURVEY SURVEY Perkiraan
NO NAMA ITEM/ BARANG SPESIFIKASI SATUAN PPN (10%) PPH Ongkir (Pajak+Ongkir+K Pembulatan
USULAN HARGA 1 HARGA 2 HARGA 3 Kenaikan (2%)
enaikan)
1 2 3 4 5 6 7 8 9 10 11 12 13 14

1 Vital Signs Simulator Prosim 8 unit 303,006,000 303,006,000 308,840,000 310,450,000 30,300,600 4,545,090 6,060,120 9,090,180 353,001,990 353,100,000

2 Lampu Downlight 5 Watt LED Downlight 5 W, Phillips buah 70,990 70,990 75,905 79,863 7,099 1,065 1,420 2,130 82,703 83,000

3 Lampu Downlight 7 Watt LED Downlight 7 W, Phillips buah 87,694 87,694 95,001 98,655 8,769 1,315 1,754 2,631 102,164 103,000

4 Lampu Kotak LED 36S/865 PSU W60L60 buah 987,600 987,600 1,069,900 1,111,050 98,760 14,814 19,752 29,628 1,150,554 1,200,000

5 Hand Pallet Hand Pallet 3 Ton 685X1220MM unit 5,090,800 5,090,800 5,490,000 5,822,000 509,080 76,362 101,816 152,724 5,930,782 6,000,000

6 Pallet Plastic Single, 1.5 Ton buah 970,189 970,189 1,135,640 1,600,000 97,019 14,553 19,404 29,106 1,130,270 1,140,000

Body SS 201, Tungku & Burner

7 Gas Range 4 Burner Freestanding unit 16,390,000 16,390,000 16,610,000 16,753,000 1,639,000 245,850 327,800 491,700 19,094,350 19,100,000
Cast Iron

Dimensi (mm) 1500x700x850,

8 Meja Persiapan Dapur unit 3,357,500 3,357,500 3,463,000 4,597,000 335,750 50,363 67,150 100,725 3,911,488 4,000,000
Stainless steel

Cocktail Shaker Stainless Steel

9 Shaker buah 115,000 115,000 125,000 196,000 11,500 1,725 2,300 3,450 133,975 134,000
750ml

10 Shaker Shaker Stainless Steel 550ml buah 135,000 135,000 167,000 184,000 13,500 2,025 2,700 4,050 157,275 158,000

Food model 4 sehat 5 sempurna isi

11 Food Model set 700,000 700,000 725,000 848,000 70,000 10,500 14,000 21,000 815,500 816,000
50 item

Body SS 201, Dilengkapi dengan

12 Electric Bain Marie unit 16,594,600 16,594,600 18,425,000 19,250,000 1,659,460 248,919 331,892 497,838 19,332,709 19,400,000
roda/castor 4 buah
 Harga Satuan
HARGA SURVEY SURVEY SURVEY Perkiraan
NO NAMA ITEM/ BARANG SPESIFIKASI SATUAN PPN (10%) PPH Ongkir (Pajak+Ongkir+K Pembulatan
USULAN HARGA 1 HARGA 2 HARGA 3 Kenaikan (2%)
enaikan)
1 2 3 4 5 6 7 8 9 10 11 12 13 14

Hanger SS 201, Panjang 1,00 meter

13 Plastic Curtain Anti Insect set 1,625,000 1,625,000 1,850,000 1,900,000 162,500 24,375 32,500 48,750 1,893,125 1,900,000
(termasuk clip)

Hanger SS 201, Panjang 2,00 meter

14 Plastic Curtain Anti Insect set 3,138,000 3,138,000 3,500,000 3,800,000 313,800 47,070 62,760 94,140 3,655,770 3,700,000
(termasuk clip)

15 Isi Ulang N2O Gas Nitrous Oxide (N2O) kap 20kg tabung 3,000,000 3,000,000 3,300,000 3,500,000 300,000 45,000 60,000 90,000 3,495,000 3,500,000

- SOMATOM go Now kegiatan 193,380,000 193,380,000 534,600,000 710,000,000 19,338,000 3,867,600 3,867,600 0 220,453,200 220,500,000
16 Pemeliharaan CT Scan
- Ysio Max kegiatan 81,950,000 81,950,000 374,000,000 475,000,000 8,195,000 1,639,000 1,639,000 0 93,423,000 93,500,000

+Perbaikan Instalasi Gas R Jalak Lt

1, +Perbaikan Instalasi Gas Ruang
Pemeliharaan Instalasi Gas
17 Lt 2, +Perbaikan Instalasi Gas kegiatan 25,372,500 25,372,500 27,000,000 27,500,000 2,537,250 507,450 507,450 0 28,924,650 29,000,000
Medis
Ruang Lt 3, +Regulator AR 60 10
EB

Double Pot Washing With

unit 6,929,000 6,929,000 7,235,000 7,140,000 692,900 103,935 138,580 207,870 8,072,285 8,100,000
Scraphole & Splashback
Cold Water Faucet - Deck
unit 757,000 757,000 825,000 837,000 75,700 11,355 15,140 22,710 881,905 900,000
Mounted
18 Alat Cuci Masak
Portable Grease Trap - 4 Section unit 1,513,000 1,513,000 1,615,000 1,575,000 151,300 22,695 30,260 45,390 1,762,645 1,800,000

Pekerjaan Sipil Area Dishwashing lot 2,000,000 2,000,000 2,500,000 2,500,000 200,000 40,000 40,000 0 2,280,000 2,300,000

770,434,014
 84,000,000 84,000,000
14,000,000 14,000,000
84,500,000 84,500,000
81,100,000 8,110,000 72,990,000
43,200,000 43,200,000
18,100,000 18,100,000
150,500,000 150,500,000
4,700,000 4,700,000
7,200,000 7,200,000
14,100,000 14,100,000
14,100,000 14,100,000
218,600,000 218,600,000
166,300,000 166,300,000
196,300,000 196,300,000
141,800,000 141,800,000
10,200,000 10,127,544
303,700,000
303,700,000
55,200,000 55,200,000
4,700,000 4,700,000
2,000,000 2,000,000
2,000,000 2,000,000
2,300,000 2,300,000
5,900,000 5,900,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
1,900,000 1,900,000
1,900,000 1,900,000
14,500,000 14,500,000
3,400,000 3,400,000
1,200,000 1,200,000
1,200,000 1,200,000
18,100,000 18,100,000
35,900,000 35,900,000
15,000,000 15,000,000
18,500,000 18,500,000
20,000,000 20,000,000
85,100,000 85,100,000
1,400,000 1,400,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,000,000 2,000,000
2,800,000 2,800,000
1,100,000 1,100,000
88,700,000 88,700,000
1,963,200,000 1,890,137,544

73,062,456
2,612,000 2,525,000
2,612,000 2,525,000
2,612,000 2,525,000
437,000 424,000
221,000 215,000
221,000 215,000
198,000 193,000
130,000 127,000
130,000 127,000
130,000 127,000
130,000 127,000
437,000 424,000
1,769,000 1,711,000
1,792,000 1,733,000
585,000 567,000
585,000 567,000
585,000 567,000
631,000 611,000
5,754,000 5,561,000
1,041,000 1,007,000
22,612,000 21,878,000