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<html>
<head>
</head>
<body>
<table width="100%" border="0" align="left" cellpadding="3px" cellspacing="0" class="tbl_form">
<tr class="isi">
<td valign="middle" bgcolor="#FFFAF8" align="center" width="30px" rowspan="3">
NO.
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="300px" rowspan="3">
CARA BAYAR
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="600px" colspan="6">
TRANSAKSI
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="380px" colspan="2">
TOTAL
</td>
</tr>
<tr class="isi">
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
RAWAT JALAN
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
MCU
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" colspan="2">
RAWAT INAP
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2">
CASH
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" rowspan="2">
PENJAMIN
</td>
</tr>
<tr class="isi">
<td valign="middle" bgcolor="#FFFAF8" align="center" width="150px">
NILAI
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="50px">
QTY
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="150px">
NILAI
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="50px">
QTY
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="150px">
NILAI
</td>
<td valign="middle" bgcolor="#FFFAF8" align="center" width="50px">
QTY
</td>
</tr>
<tr class="isi">
<td>
1
</td>
<td>
-
</td>
<td align="right">
153,500
</td>
<td align="center">
2
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
14,925,500
</td>
<td align="center">
2
</td>
<td align="right">
8,243,500
</td>
<td align="right">
6,835,500
</td>
</tr>
<tr class="isi">
<td>
2
</td>
<td>
Asuransi / Pihak ke - III
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
3
</td>
<td>
Asuransi ABDA
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
4
</td>
<td>
Asuransi Adira ( Medicillin )
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
5
</td>
<td>
Asuransi AIA
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
6
</td>
<td>
Asuransi Allianz
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
7
</td>
<td>
Asuransi Astra Aviva Life
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
8
</td>
<td>
Asuransi Avrist
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
9
</td>
<td>
Asuransi Axa Financial
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
10
</td>
<td>
Asuransi Axa Services/Mandiri
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
11
</td>
<td>
Asuransi BNI Life
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
12
</td>
<td>
Asuransi FWD
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
13
</td>
<td>
Asuransi Garda Medika
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
14
</td>
<td>
Asuransi Lippo
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
15
</td>
<td>
Asuransi Manulife
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
16
</td>
<td>
Asuransi Mega
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
17
</td>
<td>
Asuransi Sinarmas
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
18
</td>
<td>
Asuransi Tugu Mandiri
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
19
</td>
<td>
BPJS
</td>
<td align="right">
370,000
</td>
<td align="center">
1
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
370,000
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
20
</td>
<td>
BPJS
</td>
<td align="right">
264,538
</td>
<td align="center">
1
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
264,538
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
21
</td>
<td>
Cynergy Care
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
22
</td>
<td>
JAMINAN BOGOR
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
23
</td>
<td>
Mandiri Inhealth
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
24
</td>
<td>
PT. PLN ADMEDIKA
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
25
</td>
<td>
TMS Healthcare
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
26
</td>
<td>
UMUM
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
0
</td>
<td align="right">
0
</td>
</tr>
<tr class="isi">
<td>
</td>
<td>
TOTAL :
</td>
<td align="right">
788,038
</td>
<td align="center">
4
</td>
<td align="right">
0
</td>
<td align="center">
0
</td>
<td align="right">
14,925,500
</td>
<td align="center">
2
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<td align="right">
8,878,038
</td>
<td align="right">
6,835,500
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</tr>
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