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LAMPIRAN IPERATURAN GUBERNUR NUSA TENGGARA BARATNOMOR 31 TAHUN 2018

TARIF LAYANAN PELAYANAN KESEHATAN BLUD RSMA

NO URAIAN TARIF KET

(1) (2) (3) (4) (5) (6)

I. PENDAFTARAN, PEMERIKSAAN, TINDAKAN DAN AKOMODASI

A PENDAFTARAN 1 Administrasi sistem informasi 1,000 9,000 10,000 2 Berkas RM Rawat Jalan / Kartu Pasien 2,000 10,000 12,000 3 Berkas RM Rawat Inap 2,000 15,000 17,000

B PEMERIKSAAN POLIKLINIK1 Pemeriksaan poliklinik oleh dokter umum 15,000 5,000 20,000 2 Pemeriksaan poliklinik oleh dokter spesialis 25,000 10,000 35,000

C AKOMODASIBiaya Kamar

1 VVIP 55,000 375,000 430,000 2 VIP A 42,500 232,500 275,000 3 VIP B 42,500 207,500 250,000 3 Kelas I 35,000 145,000 180,000 4 Kelas II 28,000 72,000 100,000 5 Kelas III 12,000 43,000 55,000 6 ICU/NICU 42,500 200,000 242,500 7 Ruang Isolasi 30,000 120,000 150,000

D VISITE DOKTER SPESIALIS1 VVIP 60,000 10,000 70,000 2 VIP 50,000 8,000 58,000 3 Kelas I, Kelas II, Kelas III 40,000 10,000 50,000

E VISITE DOKTER UMUM1 VVIP 35,000 10,000 45,000 2 VIP 30,000 8,000 38,000 3 Kelas I, Kelas II, Kelas III 20,000 5,000 25,000

TENTANG TARIF PELAYANAN KESEHATAN PADA RUMAH SAKIT H.L. MANAMBAI ABDUL KADIR PROVINSI NUSA TENGGARA BARAT

Jasa Pelayanan

Jasa Sarana

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NO URAIAN TARIF KETJasa Pelayanan

Jasa Sarana

F POLI EKSEKUTIF/KHUSUS1 - Servis Layanan 12,500 7,500 20,000 2 - Pemeriksaan dan Konsultasi dokter 35,000 12,500 47,500 3 - Konsultasi antar SMF 22,500 12,500 35,000

G GENERAL CHECK UP

H SURAT KETERANGAN DOKTER1 Surat Keterangan sehat 10,000 15,000 25,000 2 Surat Keterangan untuk asuransi umum 10,000 15,000 25,000 3 10,000 15,000 25,000

4 Visum Et Refertum 10,000 15,000 25,000

II. PELAYANAN RAWAT JALAN

1 POLI KLINIK TUMBUH KEMBANG

A IMUNISASI DIWAJIBKAN (PPI)1 BCG 5,000 11,500 16,500 2 DPT - Hb 5,000 11,500 16,500 3 Hepatitis B 5,000 11,500 16,500 4 Polio 5,000 11,500 16,500 5 TT 5,000 11,500 16,500 6 Campak 5,000 11,500 16,500 7 Pengukuran Vital Sign 2,000 1,000 3,000

B PSIKOLOGI TEST1 - Tes Perkembangan Anak (DDST) pasien baru 20,000 15,000 35,000 2 - Tes Perkembangan Anak (DDST) pasien lama 15,000 15,000 30,000

C SCREENING1 - Tes Lambat Belajar 10,000 13,000 23,000 2 - Tes Hiperaktif & Gangguan Konsentrasi 10,000 13,000 23,000 3 - Tes Autisme 15,000 13,000 28,000

D TES INTELEGENSI (IQ)1 - Tes Intelegensia Anak 15,000 20,000 35,000 2 - Tes Intelegensia Remaja 20,000 20,000 40,000

E TES KEPRIBADIAN1 - Tes Kepribadian Anak 20,000 20,000 40,000 2 - Tes Kepribadian Remaja 25,000 20,000 45,000

F TES MINAT BAKAT- Tes Minat Bakat Dewasa / Anak 25,000 20,000 45,000

Untuk tarif layanan pemeriksaan General check up disesuaikan dengan permintaan klien/ pihak yang mengajukan permintaan Medical Check up dan diperhitungkan tarif layanan berdasarkan jenis, ketegori dan tindakan layanan yang dipilih ;

Surat Keterangan Formalin dengan Masa Pengawetan/Liter

Semua item Imunisasi , tidak termasuk biaya

Vaksin

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Jasa Sarana

G 20,000 25,000 45,000

H TERAPI WICARA 20,000 25,000 45,000

I TERAPI EDUKASI 20,000 25,000 45,000

J TERAPI OKUPASI 20,000 25,000 45,000

2. POLIKLINIK PENYAKIT ANAK 1 BMP(lumbal punksi) 35,000 49,000 84,000 2 Therapi Inhalasi tanpa obat / Nebulizer 14,000 10,000 24,000 3 ECG 25,000 35,000 60,000 4 RRO 10,000 14,000 24,000 5 Pemeriksaan pasien autisme 15,000 13,000 28,000 6 Pemeriksaan Vital Sign 2,000 1,000 3,000

3. POLIKLINIK BEDAH UMUM1 Rawat Luka

a. Kecil (< 5 cm) 7,000 11,000 18,000 b. Sedang (5-10 cm) 10,000 15,000 25,000 c. Besar (10-20 cm) 17,500 40,000 57,500 d. Khusus (> 20 cm) 35,000 45,000 80,000

2 Jahit luka / Repair Jahitan - Kecil (< 5 Jahitan) 25,000 35,000 60,000 - Sedang (5 s/d 10 Jahitan) 35,000 45,000 80,000 - Besar (10 -20 Jahitan) 40,000 55,000 95,000 - Khusus (>20 Jahitan) 50,000 70,000 120,000

3 Angkat Jahitan - Kecil (< 5Jahitan) 8,000 12,000 20,000 - Sedang (5s/d 10 Jahitan) 10,000 15,000 25,000 - Besar (10 - 20 Jahitan) 20,000 25,000 45,000 - Khusus >20 25,000 35,000 60,000 - Pemasangan Volley Cateter 10,000 25,000 35,000 - GFF NGT / Cateter Urin 30,000 30,000 60,000 Debbridement dan Neorotomy - Rawat Luka Kecil 10,000 15,000 25,000 - Rawat Luka Sedang 24,000 26,000 50,000 Rawat Luka Besar 60,000 40,000 100,000

4 Rectal Toucher 10,000 17,000 27,000 5 Anoskopi 12,000 20,000 32,000 6 Coller And Cup 10,000 17,000 27,000 7 Angkat Wire 12,000 20,000 32,000 8 Nail Ekstrasi 17,000 13,000 30,000 9 Rozer Plasty 65,000 100,000 165,000 10 Incisi Abses 50,000 47,500 97,500 11 Eksisi 40,000 60,000 100,000 12 Ekstirpasi 50,000 70,000 120,000 13 Circumsisi 250,000 150,000 400,000 14 Biopsi 70,000 105,000 175,000 15 Tindik 5,000 5,000 10,000 16 Lobulo Plasty 70,000 115,000 185,000 17 Exploarasi Corpus alienum 50,000 70,000 120,000

KONSELING PSIKOLOGI (ANAK, REMAJA & DEWASA)

Tidak termasuk spuit

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Jasa Sarana

18 Aspirasi 10,000 15,000 25,000 19 Bouginasi 10,000 15,000 25,000 20 Spooling dawer cateter 10,000 14,000 24,000 21 Debridment Luka 35,000 55,000 90,000 22 Injeksi Keloid / Kenacord / (IC) 5,000 15,000 20,000

23 Necrotomy 50,000 70,000 120,000 24 Amputasi 1 Jari 50,000 70,000 120,000 25 Pemeriksaan Vital Sign 2,000 1,000 3,000

4. POLIKLINIK ORTHOPEDI

1 Rawat Luka a. Kecil (< 5 cm) 7,000 11,000 18,000 b. Sedang (5-10 cm) 10,000 15,000 25,000 c. Besar (10-20 cm) 17,500 40,000 57,500 d. Khusus (> 20 cm) 35,000 45,000 80,000

2 Jahit luka / Repair Jahitan - Kecil (< 5 Jahitan) 25,000 35,000 60,000 - Sedang (5 s/d 10 Jahitan) 35,000 45,000 80,000 - Besar (10 - 20 jahitan) 40,000 55,000 95,000 - Khusus (>20 Jahitan) 50,000 70,000 120,000

3 Angkat Jahitan - Kecil (< 5 Jahitan) 8,000 12,000 20,000 - Sedang (5 s/d 10 Jahitan) 10,000 15,000 25,000 - Besar (10 - 20 Jahitan) 20,000 25,000 45,000 - Khusus > 20 25,000 35,000 60,000

4 Gips Kecil Anak * 25,000 15,000 40,000 5 Gips Kecil Dewasa* 30,000 42,000 72,000 6 Gips Sedang Anak* 35,000 52,000 87,000 7 Gips Sedang Dewasa* 42,000 83,000 125,000 8 Gips Besar Anak* 56,000 83,000 139,000 9 Gips Besar Dewasa* 70,000 104,000 174,000 10 Buka Gips 20,000 28,000 48,000 11 Ransel verband Anak 50,000 69,000 119,000 12 Ransel verband Dewasa 70,000 104,000 174,000 13 Injeksi Arthtritis / articuler* 33,000 15,000 48,000

14 Body cast* 140,000 207,000 347,000 15 Hemi Spica* 140,000 207,000 347,000 16 Necrotomy Ex Op 14,000 21,000 35,000 17 Pemeriksaan Vital Sign 2,000 1,000 3,000

5. POLIKLINIK UROLOGI 1 Pasang Fowley Cateter* 10,000 25,000 35,000 2 Pasang Cateter Logam* 20,000 28,000 48,000 3 Tindakan Blast Punctie 60,000 50,000 110,000 4 Tindakan Blast Pistel / Cytostom 50,000 70,000 120,000 5 Ekstraksi batu uretra dengn GA di OK 1,150,000 1,725,000 2,875,000 6 Ekstraksi batu uretra anterior 50,000 70,000 120,000 7 Rawat Luka -

a. Kecil (< 5 cm) 7,000 11,000 18,000

Tidak biaya termasuk Obat

Tidak termasuk biaya Gipsona


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Jasa Sarana

b. Sedang (5-10 cm) 10,000 15,000 25,000 c. Besar (10-20 cm) 17,500 40,000 57,500 d. Khusus (> 20 cm) 35,000 45,000 80,000

8 Incisi Abses 50,000 47,500 97,500 9 Sitostomi 210,000 315,000 525,000 10 Buginasi / Dilatasi Uretra 50,000 70,000 120,000 11 Pemeriksaan Vital Sign 2,000 1,000 3,000

6. POLIKLINIK GIGI DAN MULUTA TINDAKAN PENCABUTAN GIGI1 Pencabutan Gigi Susu

- Chlor Etyl 15,500 48,000 63,500 - Injeksi 25,000 64,000 89,000

2 Pencabutan Gigi Susu Perforasi Akar 20,000 73,000 93,000 3 Pencabutan Gigi Mesiodens 48,000 98,000 146,000 4 Pencabutan Gigi Eksosterm 3 48,000 98,000 146,000 5 Pencabutan Gigi Permanen Dengan Akar Tunggal 46,000 98,000 144,000 6 Pencabutan Gigi Permanen Dengan Akar Ganda 52,000 105,000 157,000 7 Pencabutan Gigi Dengan Komplikasi 55,000 120,000 175,000 8 Pencabutan Sisa Akar Yang Tertinggal 46,000 98,000 144,000

B TINDAKAN PENAMBALAN GIGI1 Perawatan Pulpa 30,000 98,000 128,000 2 Perawatan Pulpektomy

a. Saluran Akar tunggal 25,000 75,000 100,000 b. Saluran akar ganda 35,000 110,000 145,000 c. One Visit Saluran Akar Tunggal 30,000 87,000 117,000 d. One Visit Saluran akar ganda 41,000 127,000 168,000

3 Pengisian Saluran Akar Tunggal 41,000 127,000 168,000 4 Pengisian Saluran Akar Ganda 46,000 150,000 196,000 5 Tambalan Sinar

a. Kecil 35,000 110,000 145,000 b. Sedang 40,000 120,000 160,000 c. Besar 50,000 133,000 183,000 d. Venneer direct / Besar Sekali 52,000 230,000 282,000

6 Penambalan Amalgam 52,000 92,000 144,000 7 Perawatan saluran akar Endo Intrakanal

a. Saluran akar tunggal 25,000 75,000 100,000 b. Saluran akar ganda 35,000 110,000 145,000 c. One Visit Saluran Akar Tunggal 30,000 87,000 117,000 d. One Visit Saluran akar ganda 50,000 127,000 177,000

8 Penambalan Glass Lonomera. Kecil 35,000 98,000 133,000 b. Sedang 41,000 110,000 151,000 c. Besar 50,000 121,000 171,000

9 Penambalan Eugenol, ChKM, depupila. Devitalisasi, sterilisasi SA, Pulp Capping 25,000 75,000 100,000 b. Open Bur / Eksterpatie dgn lokal anaestesi 20,000 25,000 45,000

10 Penambalan Eugenol Cavit 25,000 75,000 100,000 11 Pin Screw + Sementasi 87,000 202,000 289,000

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C TINDAKAN PENGOBATAN / PERAWATAN JARINGAN PENYANGGA GIGI1 Pembersihan karang gigi per regio 25,000 95,000 120,000 2 Perawatan Pocet Periodental 35,000 111,000 146,000 3 Gingivektomy per regio 50,000 98,000 148,000 4 Eksterpasi Mucocele / epulis 50,000 98,000 148,000

D PEMBUATAN PROTESA / GIGI PALSU1 Gigi Tiruan per rahang

a. Satu gigi pertama 230,000 437,000 667,000 b. Dua gigi 290,000 518,000 808,000 c. Tiga gigi 345,000 633,000 978,000 d. Empat gigi 403,000 690,000 1,093,000 e. Lima gigi 460,000 805,000 1,265,000 f. Full per rahang 575,000 1,150,000 1,725,000

2 Reparasi Plat Pataha. Reparasi plat patah full 58,000 184,000 242,000 b. Reparasi plat patah parsial 50,000 156,000 206,000

3 Reparasi Penambahan gigi per Rahanga. Satu gigi pertama 104,000 299,000 403,000 b. Penambahan gigi berikutna 144,000 386,000 530,000

4 Rebasing / relining per rahang 70,000 230,000 300,000 5 Orthodontic

a. Alat orthodontic 104,000 334,000 438,000 b. Aktivasi ortho lepasan 25,000 52,000 77,000 c. Reparasi clamer (kawatortho) / rahang 35,000 87,000 122,000

6 Orthodontic cekat RA / RB 290,000 1,208,000 1,498,000 7 Perawatan / kontrol Orthodentic ceat RA / RB 30,000 75,000 105,000

E TINDAKAN BEDAH MULUT 1 Odontectomy 100,000 190,000 290,000 2 Operculectom 58,000 138,000 196,000 3 Inter dental wiring / rahang 81,000 207,000 288,000 4 Inter maxilla wiring / rahang 64,000 150,000 214,000 5 Replantasi gigi 64,000 150,000 214,000 6 Alveolectomy / debridement per regio 64,000 150,000 214,000 7 Enukleasi kista (lokal anestesi) 50,000 115,000 165,000 8 Incisi / Eksisi abses 50,000 47,500 97,500 9 Pemeriksaan komplikasi post op / kontrol 18,000 46,000 64,000 10 Pemeriksaan dan perbaikan posisi IDW / IMW 23,000 46,000 69,000 11 Pembukaan IDW / Rahang 23,000 46,000 69,000 12 Pembukaan IMW 23,000 46,000 69,000 13 Dry Socket / curetage per gigi 29,000 75,000 104,000 14 Extirpasi mucocelle / epulis 41,000 92,000 133,000 15 Aff heacting epulis / mucocelle 12,000 23,000 35,000 16 Grinding 12,000 23,000 35,000

F PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dengan LOGAM1 Jembatan Adoro porcelain fusi metal 288,000 748,000 1,036,000 2 Inlay porcelain fusi metal 173,000 518,000 691,000 3 Uplay porcelain fusi metal 173,000 518,000 691,000

G PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY tanpa LOGAM1 Jembatan/bridge full porcelain 368,000 1,300,000 1,668,000 2 Inlay / Uplay full porcelain 322,000 920,000 1,242,000

biaya adalah paket dari pengukuran, pemasangan,dan

kontrol

paket dari cetak sampai

pemasangan

paket dari pencetakan,

pemasangan,dan kontrol

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Jasa Sarana

7. POLIKLINIK PENYAKIT KULIT DAN KELAMIN1 Elektro fulgurasi / Elektro Couter :

a. Seboroik Keratosis : - Kecil 26,000 38,000 64,000 - Sedang 38,000 57,000 95,000 - Besar 60,000 90,000 150,000 b. Skin Tag ;- Kecil 25,000 38,000 63,000 - Sedang 26,000 66,000 92,000 - Besar 69,000 104,000 173,000 c. Kondyloma Akuminata :- Kecil 44,000 66,000 110,000 - Sedang 69,000 104,000 173,000 - Besar 115,000 173,000 288,000

2 Ekstraksi Komedo 21,000 32,000 53,000 3 Enukleasi 19,000 28,000 47,000 4 Solarium / Photo Therapi 8,000 12,000 20,000 5 Excisi Wajah 95,000 142,000 237,000 6 Excisi Non wajah 58,000 87,000 145,000 7 Test Tempel / Patch Test Standard 81,000 121,000 202,000 8 Test Tempel Standard Kosmetik 81,000 121,000 202,000 9 Dermabrasi / Microdemabrasi 72,000 107,000 179,000 10 Rekonstruki Kulit 115,000 10,000 125,000 11 Heating Aff 15,000 10,000 25,000 12 Incisi Abses 50,000 47,500 97,500 13 Swab : Vagina, Cervix, Fornik 11,000 16,000 27,000 14 Swab : Uretra 11,000 16,000 27,000 15 Swab discar lesi 11,000 16,000 27,000 16 Kerokan Kulit, Kuku, Rmbut 9,000 13,000 22,000 17 Kultur 20,000 30,000 50,000 18 Ganti Verband 10,000 14,000 24,000 19 Revisi Parut 41,000 61,000 102,000 20 Injeksi Kenacort 21,000 32,000 53,000 21 Punch Biopsi 63,000 94,000 157,000 22 Insisonal biopsi 63,000 94,000 157,000 23 Ekstirpasi 46,000 70,000 116,000 24 Kuretase Kulit 19,000 28,000 47,000 25 Radioton 44,000 66,000 110,000 26 Trichlor Acetic Acid 17,000 25,000 42,000 27 Chemical Peeling :

- GA Peeling 81,000 121,000 202,000 - Proopeel 161,000 242,000 403,000 - PHA 49,000 73,000 122,000

28 Facial Regula 44,000 656,000 700,000 29 Test Allergi Tusuk

- Tusuk 41,000 61,000 102,000 - Tempel 58,000 87,000 145,000

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Jasa Sarana

8. POLIKLINIK PENYAKIT PARU1 Terapi Inhalasi tanpa obat / Nebulizer 12,000 18,000 30,000 2 Punctie Pleura 173,000 230,000 403,000 3 Spirometri komputer 37,000 56,000 93,000 4 Portable Spirometri 30,000 45,000 75,000 5 Pemeriksaan Vital Sign 2,000 1,000 3,000

9. POLIKLINIK PENYAKIT DALAM1 Punctie asctes 115,000 173,000 288,000 2 Aspirasi jarum halus 23,000 35,000 58,000 3 BMP 41,000 61,000 102,000 4 ECG 25,000 35,000 60,000 5 Pemeriksaan Vital Sign 2,000 1,000 3,000

10. POLIKLINIK PENYAKIT JANTUNG1 Defribilasi 143,000 214,000 357,000 2 ECG 25,000 35,000 60,000 3 Echocardiografi Dopler collor (Transtorakal) 160,000 200,000 360,000 4 Punksi pericard 184,000 276,000 460,000 5 Resusitasi jantung dengan DC Shock 80,000 119,000 199,000 6 Telemetri 36,000 54,000 90,000 7 Treadmill 92,000 138,000 230,000 8 Fowley Catheter 19,000 28,000 47,000 9 NGT / kali 30,000 30,000 60,000 10 Pacemaker temporer 300,000 700,000 1,000,000 11 Pemasangan SB Tube 49,000 73,000 122,000 12 Pemasangan Cardiac Monitor 12,000 18,000 30,000 13 Pemasangan CVP 805,000 575,000 1,380,000 14 Pemasangan Cardiac monitor / hari 21,000 32,000 53,000 15 Dopler Vascular Pembuluh Darah 220,000 252,000 472,000 16 Transesofageal Echocardiografi 300,000 400,000 700,000 17 Pemasangan Holter 1 x 24 Jam 200,000 150,000 350,000 18 Pemasangan Holter 2 x 24 Jam 320,000 180,000 500,000 19 Pemeriksaan Vital Sign 2,000 1,000 3,000

11. POLIKLINIK SYARAF/NEUROLOGI1 Injeksi Intramuskuler 3,000 4,000 7,000 2 Injeksi Intraartikuler 33,000 49,000 82,000 3 Assessment Neurobehaviour fit n proper test 345,000 518,000 863,000 4 Assessment Neurobehaviour 150,000 225,000 375,000 5 Pemeriksaan EEG 81,000 121,000 202,000 6 Baca EEG 35,000 52,000 87,000 7 Assessment Nyeri 7,000 11,000 18,000 8 Pemeriksaan EMNG 115,000 173,000 288,000 9 Pemeriksaan Vital Sign 2,000 1,000 3,000

tidak termasuk selang,needle,botol

, BMHP


, BMHP


, BMHP

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Jasa Sarana

12. POLIKLINIK MATA1 Pterigium (Bale Sclera) 300,000 400,000 700,000 2 S B L ( Bleparoplasty ) 184,000 276,000 460,000 3 Campimetri / perimetri 1 mata dengan Humpray 138,000 207,000 345,000 4 Campimetri / perimetri 2 mata dengan Humpray 230,000 345,000 575,000 5 U S G Mata 100,000 150,000 250,000 6 Keratometri 28,000 42,000 70,000 7 Pemeriksaan fundus (indirec) 28,000 42,000 70,000 8 Tonometri Aplansi(schiutz) 28,000 42,000 70,000 9 Water Drinking 7,000 11,000 18,000 10 Retinoskopi 28,000 42,000 70,000 11 Gonioskopi 28,000 42,000 70,000 12 Synophtophor 58,000 87,000 145,000 13 Sondage 23,000 35,000 58,000 14 Anel test 23,000 35,000 58,000 15 Angkat jahitan di palpebra dan konjungtiva 42,000 63,000 105,000 16 Angkat jahitan di kornea 79,000 118,000 197,000 17 Amotio corpus Alienum 42,000 63,000 105,000 18 Irigasi 12,000 18,000 30,000 19 Refraktometer 28,000 42,000 70,000 20 Ekstirpasi kista konjungtiva 184,000 276,000 460,000 21 Ekstarpasi nevus / granulotoma 115,000 173,000 288,000 22 Epilasi 19,000 28,000 47,000 23 Excochleasi / Amotio Lithiasis 60,000 90,000 150,000 24 Ekstirpasi tumor / kista di palpebra 184,000 276,000 460,000 25 Biopsi dai palpebra 184,000 276,000 460,000 26 Refraksi 30,000 30,000 60,000 27 Biopsi di Konjungtiva 300,000 160,000 460,000 28 Jahitan di Palpebra 400,000 600,000 1,000,000 29 Reposisi iris 1,500,000 1,500,000 3,000,000 30 Paracentesis 300,000 400,000 700,000 31 Transplantasi Memberan Amnion 2,000,000 1,000,000 3,000,000 32 Biopsi di konjungtiva 184,000 276,000 460,000 33 Tarsoraphy / Jahitan di palpebra 184,000 276,000 460,000 34 Paracentesis 184,000 276,000 460,000 35 Iridektomi Perifer 230,000 345,000 575,000 36 Transplantasi membran amnion 184,000 276,000 460,000 37 Excochleasi / Amotio Lithiasis 115,000 173,000 288,000 38 Pemeriksaan Refraksi 23,000 35,000 58,000 39 Pemeriksaan Slit Biomikroskop 28,000 42,000 70,000 40 Tonometri SCHIOTZ 28,000 42,000 70,000 41 Test Ishihara 12,000 18,000 30,000

13. POLIKLINIK KEBIDANAN DAN PENYAKIT KANDUNGAN ( OBSGYN )

1 Biopsi Pervaginam 65,000 97,000 162,000 2 Pap Smear 30,000 50,000 80,000 3 Vaginal Swab 10,000 14,000 24,000 4 Kolposkopi 46,000 70,000 116,000 5 Kauter Elektrik 19,000 28,000 47,000 6 Pasang IUD 35,000 52,000 87,000 7 Angkat IUD tanpa penyulit 35,000 52,000 87,000 8 Angkat IUD dengan penyulit 58,000 52,000 110,000

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9 Pasang Implant 35,000 52,000 87,000 10 Angkat implant tanpa penyulit 35,000 52,000 87,000 11 Angkat Implant dengan penyulit 58,000 52,000 110,000 12 Diathermi ( satu seri = 6 kali kunjungan ) 35,000 52,000 87,000 13 Ganti verband / Buka jahitan / Rawat Luka 25,000 30,000 55,000 14 Pasang / Ganti tampon 10,000 14,000 24,000 15 Kauter Albotyl 9,000 15,000 24,000 16 USG

- Tanpa Print Out 50,000 30,000 80,000 - Dengan Print Out 80,000 70,000 150,000

17 Pasang Pessarium 23,000 50,000 73,000 18 Buka pessarium 23,000 35,000 58,000 19 CTG 50,000 30,000 80,000 20 Suntikan KB 14,000 21,000 35,000 21 Pemeriksaan Gnekologi 15,000 10,000 25,000 22 Pemeriksaan Obstetri 15,000 10,000 25,000 23 Tindakan pasang kateter 12,000 20,000 32,000 24 Tindakan pasang infus Dewasa 9,000 6,000 15,000 25 USG Transvaginal tanpa print out

- Tanpa print out 35,000 75,000 110,000 - Dengan print out 52,000 87,000 139,000

26 Konseling KB 7,000 11,000 18,000 27 MOW / MOP / Mini Laparotomy 249,000 373,000 622,000 28 Pelayanan ANC 15,000 10,000 25,000 29 IUD/Implant 250,000 150,000 400,000 30 Pemeriksaan Vital Sign 2,000 1,000 3,000

14. POLIKLINIK PENYAKIT THT1 Biopsi 70,000 105,000 175,000 2 Spoelling 36,000 53,000 89,000 3 Corpal Alienum telinga 36,000 53,000 89,000 4 Corpal Alienum tenggorokan 36,000 53,000 89,000 5 Corpal Alienum hidung 36,000 53,000 89,000 6 Caustik 10,000 20,000 30,000 7 Extirpasi granuloma 64,000 95,000 159,000 8 Swab Nasal 12,000 20,000 32,000 9 Test Allergi 41,000 61,000 102,000 10 Ganti verband 26,000 39,000 65,000 11 Evakuasi Cerumen Ringan 30,000 45,000 75,000 12 Swab Nasopharing Endoscopy 13,000 19,000 32,000 13 Audiometri murni 46,000 69,000 115,000 14 Audiometri tutur 35,000 52,000 87,000 15 Schimer test 41,000 61,000 102,000 16 Incisi Abses 50,000 47,500 97,500 17 Myringobridge 35,000 52,000 87,000 18 Buka pessarium 35,000 52,000 87,000

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15. REHABILITASI MEDIK1 Micro Wave Diathermy 12,000 30,000 42,000 2 Electrical Stimulation 10,000 23,000 33,000 3 Ultrasound Diathermy 10,000 23,000 33,000 4 Traksi 12,000 29,000 41,000 5 InfraPhil 2 Lamp 7,000 10,000 17,000 6 Infra Phil 3 Lamp 9,000 21,000 30,000 7 Fibrator / Massage 7,000 18,000 25,000 8 Senam hamil 23,000 12,000 35,000 9 Senam Nifas 23,000 12,000 35,000 10 Postural drainage 10,000 14,000 24,000 11 Bladder Training 23,000 13,000 36,000 12 Fisioterapi Stroke 23,000 18,000 41,000 13 Fisioterapi Anak 41,000 18,000 59,000 14 Fisioterapi Dada/ Breathing Exc 23,000 12,000 35,000 15 Back Exercise 23,000 12,000 35,000 16 Latihan Sepeda Statis 7,000 18,000 25,000 17 Latihan Paralel Bars 7,000 18,000 25,000 18 Continous Pasive Movement 18,000 10,000 28,000 19 Latihan Gerak Sendi / Penguatan Otot 18,000 7,000 25,000 20 Pemasangan Spalk 23,000 20,000 43,000 21 Short Wave Diathermy 12,000 29,000 41,000 22 Parafin Bath 10,000 25,000 35,000 23 Nebulizer 12,000 18,000 30,000 24 Active Movement Exercise 18,000 10,000 28,000

16. POLIKLINIK BEDAH SYARAF1 Rawat Luka


2 Angkat Jahitan - Kecil (< 5 Jahitan) 8,000 12,000 20,000 - Sedang (5-10 Jahitan) 10,000 15,000 25,000 - Besar (10-20Jahitan) 20,000 25,000 45,000 - Khusus > 20 Jahitan 25,000 35,000 60,000

3 Pungsi CSF Cranial 138,000 207,000 345,000 4 Pungsi Lumbal 58,000 87,000 145,000 5 Injeksi Spinal 138,000 207,000 345,000 6 Injeksi obat ( IV ) / Injeksi 3,000 4,000 7,000 7 Pasang Elastic Band 23,000 35,000 58,000 8 Pemeriksaan Vital Sign 2,000 1,000 3,000

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17. POLIKLINIK JIWA / PSIKIATRIA PEMERIKAAN PSIKOMETRI1 HHouse man tree test 7,000 11,000 18,000 2 Warteg test 7,000 11,000 18,000 3 HDRS 10,000 14,000 24,000 4 HARS 10,000 14,000 24,000 5 BDI 10,000 14,000 24,000 6 MMSE 10,000 14,000 24,000 7 MMPI 138,000 207,000 345,000 8 PANS score 10,000 14,000 24,000 9 GDS 10,000 14,000 24,000

B PSIKOTERAPI1 Psikoterapi suportif 23,000 35,000 58,000 2 Cognitif Behaviour therapy 92,000 138,000 230,000 3 Hipnotherapi 230,000 345,000 575,000

III. PELAYANAN TINDAKAN MEDIK OPERATIF DAN TERAPI TERENCANAA OPERASI BEDAH DIGESTIF

1 2,783,000 4,200,000 6,983,000

2 Laparoscopyt terapi 2,429,000 3,700,000 6,129,000 3 LAR and to end anastomose 2,656,500 4,000,000 6,656,500

4 2,657,000 4,000,000 6,657,000

5 Pungsi Pleura/Abdomen 2,500,000 1,555,000 4,055,000 6 Miles prosedur 3,036,000 4,555,000 7,591,000 7 Pancreatectomy roux n y 2,834,000 4,255,000 7,089,000

8 2,429,000 3,650,000 6,079,000

9 Soave 2,657,000 3,985,000 6,642,000 10 Achlasia Aesophagus 3,036,000 4,555,000 7,591,000 11 Hordiulum (Mata) 2,500,000 1,555,000 4,055,000 12 Arthroscopy diagnostic 2,277,000 3,416,000 5,693,000 13 Arthroscopy debridement 2,277,000 3,416,000 5,693,000 14 Bristow Procedure 2,277,000 3,416,000 5,693,000 15 Choledochojejunustomy roux n y 2,277,000 3,416,000 5,693,000 16 Cysto jejunostomy roux n y pada kista empedu 2,277,000 3,416,000 5,693,000

17 Cysto jejunostomy roux n y pada kista pankreas 2,277,000 3,416,000 5,693,000

18 Discectomy 2,277,000 3,416,000 5,693,000 19 Open and other left hemicolectomy 2,277,000 3,416,000 5,693,000 20 Open and other resection colon transfersum 2,277,000 3,416,000 5,693,000 21 Open and other sigmoidectomy 2,277,000 3,416,000 5,693,000 22 Open Drainage abses hepar 2,277,000 3,416,000 5,693,000

23 2,277,000 3,416,000 5,693,000

24 Repair recto vaginal fistula 2,277,000 3,416,000 5,693,000 25 Ruptur gaster jahit primer omental patch 2,277,000 3,416,000 5,693,000 26 Laparoscopy 2,429,000 3,416,000 5,845,000

Anastomosis of small intestine to rectal stump (pancolestomy)

LAR dengan colostomy (anterior resection of rectum with synchronous colostomy)

Ruptur gaster gastrojejunustomy + jejunustomy feeding

Other and unspecified partial excision of large intestine

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27 Anastomosis other small-to-large intestinal 1,771,000 3,416,000 5,187,000 28 Anastomosis Smal-to-small intestinal 1,771,000 3,416,000 5,187,000

29 Appendiktomi and drainage appendikceal abses 1,771,000 3,416,000 5,187,000

30 Cholesistectomy 1,771,000 3,416,000 5,187,000 31 Debulking 1,771,000 3,416,000 5,187,000 32 Eviscerasi dengan GA 1,771,000 3,416,000 5,187,000 33 Exteriorization of small intestine 1,771,000 3,416,000 5,187,000

34 Hernia fomaralis bilateral dengan atau tanpa graft 1,771,000 3,416,000 5,187,000

35 Herniotomi hernioraphi anostomosis 1,771,000 3,416,000 5,187,000

36 1,771,000 3,416,000 5,187,000

37 1,771,000 3,416,000 5,187,000

38 Laparoscopic appendectomy 1,771,000 3,416,000 5,187,000 39 Laparotomy eksplorasi dengan stoma 1,771,000 3,416,000 5,187,000

40 1,771,000 3,416,000 5,187,000

41 Repair Sub total perianal rupture 1,771,000 3,416,000 5,187,000 42 Repair total perianal rupture 1,771,000 3,416,000 5,187,000 43 Suture of laceration of duodenum 1,771,000 3,416,000 5,187,000 44 Suture of laceration of small intestine 1,771,000 3,416,000 5,187,000 45 Appendiktomi pada apendicities akut/kronis 1,771,000 2,126,000 3,897,000

46 1,771,000 2,657,000 4,428,000

47 1,771,000 2,657,000 4,428,000

48 Herniotomi pada anak 1,771,000 2,657,000 4,428,000

49 1,771,000 2,657,000 4,428,000

50 1,771,000 2,657,000 4,428,000

51 Hidrocele komunikan 1,771,000 2,657,000 4,428,000 52 Hidrocele punikuli 1,771,000 2,657,000 4,428,000

53 1,771,000 2,657,000 4,428,000

54 Laparascopic diagnostic 1,771,000 2,657,000 4,428,000

55 1,771,000 2,657,000 4,428,000

56 1,771,000 2,657,000 4,428,000

57 Funikokelektomy 1,771,000 2,657,000 4,428,000 58 Hydrokelektomy per inguinal 1,771,000 2,657,000 4,428,000 59 Hydrokelektomy per scrotal 1,771,000 2,657,000 4,428,000 60 Anoplasty pada setriktural anus 1,164,000 1,746,000 2,910,000 61 Closed Drainage abses hepar dengan GA 1,164,000 1,746,000 2,910,000 62 Colostomi 1,164,000 1,746,000 2,910,000 63 1,164,000 1,746,000 2,910,000 64 Exici polip recti dengan GA 1,164,000 1,746,000 2,910,000

HIL bilateral (other and open bilateral repair of direct inguinal hernia) dengan atau tanpa graft

HIM bilateral (other and open bilateral repair of indirect inguinal hernia) dengan atau tanpa graft

Other and open bilateral repair of inguinal hernia, one direct and one indirect

Hernia femoralis unilateral dg atau tanpa graft (unilateral repair of femoral hernia with graft or prosthesis)Herniotomi hernioraphi selain HIM atau HIL dngan graft

Hernitomy hernioraphi HIL unilateral dg atau tanpa graft (other and open repair of direct inguinal hernia with graft or prosthesis)Hernitomy hernioraphi HIM unilateral dg atau tanpa graft (other and open repair of indirect inguinal hernia with graft or prosthesis)

Hidrocele testis (hidrocele/excision af hydrocele of tunica vaginalis)

Penutupan stoma pada colostomy (closure of stoma of large intestine)Penutupan stoma pada ileustomy (closure of stoma of small intestine)

Excision of varicocele and hydrocele of spermatic cord

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65 Exteriorication of large intestine 1,164,000 1,746,000 2,910,000 66 Gastrostomy 1,164,000 1,746,000 2,910,000 67 Haemorroidectomi/procedur on hemorrhoids) 1,164,000 1,746,000 2,910,000 68 Perianal Fistulectomy 1,164,000 1,746,000 2,910,000 69 Preauricula Fistulectomy 1,164,000 1,746,000 2,910,000 70 Prolaps recti (repair) 1,164,000 1,746,000 2,910,000 71 Release constriction band 1,164,000 1,746,000 2,910,000 72 Repair anus 1,164,000 1,746,000 2,910,000 73 Repair old perineal ruphture 1,164,000 1,746,000 2,910,000 74 Repair uracus 1,164,000 1,746,000 2,910,000 75 Stepler haemorroidectomi 1,164,000 1,746,000 2,910,000 76 Reseksi urachus 1,164,000 1,746,000 2,910,000 77 Closed Drainage abses hepar dengan LA 911,000 1,367,000 2,278,000 78 Colonoscopi disertai extirpasi tumor 911,000 1,367,000 2,278,000 79 Exici polip recti dengan LA 911,000 1,367,000 2,278,000 80 Fistulectomy 911,000 1,367,000 2,278,000 81 Perianal fistulotomi 911,000 1,367,000 2,278,000 82 Colonoscopi 658,000 987,000 1,645,000 83 Lavage 658,000 987,000 1,645,000 84 Potong stoma pada soave 658,000 987,000 1,645,000 85 Gastroscopi 355,000 532,000 887,000 86 Gastroscopi disertai biopsi 355,000 532,000 887,000 87 Gastroscopi disertai ligasi varises esofagus (LVE) 355,000 532,000 887,000 88 Gastroscopi disertai sclero terapi endoskopi (STE) 355,000 532,000 887,000 89 Insisi absces perineum 253,000 380,000 633,000 90 Insisi ansces scrotum 253,000 380,000 633,000 91 Anuscopy biopsi dengan LA (Local anaesthesia) 152,000 300,000 452,000 92 Open biopsy of breast dengan LA 152,000 250,000 402,000 93 Bipolar resectoscopy 2,277,000 3,416,000 5,693,000 94 Ekstraksi ductus choledocy 1,771,000 2,657,000 4,428,000 95 Ekstraksi batu ductus choledocus 2,277,000 3,416,000 5,693,000 96 Histeroscopy diagnostic 1,164,000 1,746,000 2,910,000 97 Histeroscopy operative 2,277,000 3,416,000 5,693,000 98 Laparotomy + release adhesi 2,277,000 3,416,000 5,693,000 99 Re-open Laparotomy 1,771,000 2,657,000 4,428,000

100 Transanal Endorected pull through 3,036,000 4,554,000 7,590,000 101 Transanal swense eike 3,036,000 4,554,000 7,590,000

B OPERASI BEDAH ANAK1 Anaplasty PSA (postero sagital anoplasty) 2,783,000 4,175,000 6,958,000 2 Ilizarov 2,783,000 4,175,000 6,958,000 3 Invaginasi 2,277,000 3,416,000 5,693,000 4 Eksisi ductus thyroglosus 1,771,000 2,657,000 4,428,000 5 Illeustomi pada anak 1,771,000 2,657,000 4,428,000 6 Laparatomi pada anak 1,771,000 2,657,000 4,428,000 7 Orchidectomy bilateral 1,771,000 2,657,000 4,428,000 8 Hirschprung's/colostomy pada hirsprung's 1,164,000 1,746,000 2,910,000 9 658,000 1,000,000 1,658,000 10 Anoplastyh + uretheroplasty 2,783,000 4,175,000 6,958,000

Anoplasty atresia ani letak rendah (cutback incision)

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11 Postero sagictal anorected pull through 3,036,000 4,555,000 7,591,000

C OPERASI BEDAH ORTHOPEDI1 Koreksi Scoliosis 2,783,000 4,175,000 6,958,000 2 Total elbow arthtoplasty 2,783,000 4,175,000 6,958,000 3 Total Hip arthtoplasty 2,783,000 4,175,000 6,958,000 4 Total knee arthtoplasty 2,783,000 4,175,000 6,958,000 5 Total shoulder arthtoplasty 2,783,000 4,175,000 6,958,000 6 Debridement TB tulang belakang 2,277,000 3,416,000 5,693,000 7 Hemiarthroplasty (AMP, bipolar) complicated 2,277,000 3,416,000 5,693,000 8 Internal fiksasi fraktur acetabulum complicated 2,277,000 3,416,000 5,693,000 9 Internal fiksasi fraktur collumn femur complicated 2,277,000 3,416,000 5,693,000 10 2,277,000 3,416,000 5,693,000

11 2,277,000 3,416,000 5,693,000

12 Internal fiksasi fraktur pelvis complicated 2,277,000 3,416,000 5,693,000 13 Internal fiksasi fraktur scapula complicated 2,277,000 3,416,000 5,693,000 14 Osteotomi korektif(HTO, freanch, dll) 2,277,000 3,416,000 5,693,000 15 Other reconstructive procedure of the shoulder 2,277,000 3,416,000 5,693,000 16 Rekonstruksi ACL/PCL 2,277,000 3,416,000 5,693,000 17 Koreksi horshoe kidney (ishmectomy) 2,277,000 3,416,000 5,693,000 18 Bone graft iliac/fibular/autograft lainnya 1,771,000 2,657,000 4,428,000 19 Disartikulasi Hip 1,771,000 2,657,000 4,428,000 20 Disartikulasi shoulder 1,771,000 2,657,000 4,428,000 21 Elevation of skull fracture fragments 1,771,000 2,657,000 4,428,000 22 Eviscerasi dengan GA 1,771,000 2,657,000 4,428,000 23 Hemiarthroplasty (AMP, bipolar) 1,771,000 2,657,000 4,428,000 24 Internal fiksasi fraktur acetabulum 1,771,000 2,657,000 4,428,000 25 Internal fiksasi fraktur collumn femur 1,771,000 2,657,000 4,428,000 26 Internal fiksasi fraktur femur dengan ABP 1,771,000 2,657,000 4,428,000

27 1,771,000 2,657,000 4,428,000

28 1,771,000 2,657,000 4,428,000

29 Internal fiksasi fraktur femur dengan DHS 1,771,000 2,657,000 4,428,000 30 Internal fiksasi fraktur humerus complicated 1,771,000 2,657,000 4,428,000 31 Iinternal fiksasi fraktur pelvis 1,771,000 2,657,000 4,428,000 32 Iinternal fiksasi fraktur radius complicated 1,771,000 2,657,000 4,428,000 33 Iinternal fiksasi fraktur scapula 1,771,000 2,657,000 4,428,000

34 1,771,000 2,657,000 4,428,000

35 Internal fiksasi fraktur tibia complicated 1,771,000 2,657,000 4,428,000 36 Open reduction dislocation 1,771,000 2,657,000 4,428,000 37 Operasi avulsi PCL/ACL 1,771,000 2,657,000 4,428,000 38 Patellar stabilization 1,771,000 2,657,000 4,428,000 39 Pengambilan implant tulang belakang 1,771,000 2,657,000 4,428,000 40 Phacoemulsifikasi 1,771,000 2,657,000 4,428,000 41 Rekonstruksi bunion 1,771,000 2,657,000 4,428,000 42 Arthroscopy other procedures 1,417,000 2,126,000 3,543,000 43 Internal fiksasi fraktur carpalia 1,417,000 2,126,000 3,543,000 44 Internal fiksasi fraktur clavikula complicated 1,417,000 2,126,000 3,543,000

Internal fiksasi fraktur collumn femur dengan DHS complicatedInternal fiksasi fraktur collumn femur dengan ABP complicated

Internal fiksasi fraktur femur dengan K wire complicatedInternal fiksasi fraktur femur dengan plate & screw complicated

Iinternal fiksasi fraktur symphisis pubis/symphisiolisis complicated

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45 Internal fiksasi fraktur femur dengan K wire 1,417,000 2,126,000 3,543,000 46 Internal fiksasi fraktur femur dengan nail 1,417,000 2,126,000 3,543,000 47 Internal fiksasi fraktur femur dengan plate & screw 1,417,000 2,126,000 3,543,000 48 Internal fiksasi fraktur fibula complicated 1,417,000 2,126,000 3,543,000 49 Internal fiksasi fraktur radius 1,417,000 2,126,000 3,543,000 50 Internal fiksasi fraktur radius ulna 1,417,000 2,126,000 3,543,000 51 Internal fiksasi fraktur tibia fibula 1,417,000 2,126,000 3,543,000 52 Internal fiksasi fraktur ulna complicated 1,417,000 2,126,000 3,543,000 53 Arhtrodesis Pantalar 1,164,000 1,746,000 2,910,000 54 Arhtrodesis shoulder 1,164,000 1,746,000 2,910,000 55 Arhtrodesis subtalar 1,164,000 1,746,000 2,910,000 56 Arhtrodesis elbow 1,164,000 1,746,000 2,910,000 57 Arhtrodesis genu 1,164,000 1,746,000 2,910,000 58 Arhtrodesis hip 1,164,000 1,746,000 2,910,000 59 Arhtrodesis talocrural 1,164,000 1,746,000 2,910,000 60 Arhtrodesis triple 1,164,000 1,746,000 2,910,000 61 Arhtrodesis wrist 1,164,000 1,746,000 2,910,000 62 Bone graft allograft/xenograft/hydroxyapatite 1,164,000 1,746,000 2,910,000 63 Debridement osteomyelitis 1,164,000 1,746,000 2,910,000 64 Eksternal fiksasi pelvis 1,164,000 1,746,000 2,910,000 65 Eksternal fiksasi wrist 1,164,000 1,746,000 2,910,000 66 Ekstirpasi tumor + rekonstruksi (diluar orthopedi) 1,164,000 1,746,000 2,910,000 67 Excisi bone tumor 1,164,000 1,746,000 2,910,000 68 1,164,000 1,746,000 2,910,000

69 Free skin graft not otherwise specified 1,164,000 1,746,000 2,910,000 70 Internal fiksasi fraktur clavikula 1,164,000 1,746,000 2,910,000 71 Internal fiksasi fraktur fibula 1,164,000 1,746,000 2,910,000 72 Internal fiksasi fraktur humerus 1,164,000 1,746,000 2,910,000 73 Internal fiksasi fraktur patella complicated 1,164,000 1,746,000 2,910,000 74 Internal fiksasi fraktur tibia 1,164,000 1,746,000 2,910,000 75 Internal fiksasi fraktur tibia plateau complicated 1,164,000 1,746,000 2,910,000 76 Internal fiksasi fraktur ulna 1,164,000 1,746,000 2,910,000 77 Osteotomy sederhana 1,164,000 1,746,000 2,910,000 78 Pengambilan implant ABP 1,164,000 1,746,000 2,910,000 79 Pengambilan implant DHS 1,164,000 1,746,000 2,910,000

80 1,164,000 1,746,000 2,910,000

81 Amputasi below knee 911,000 1,367,000 2,278,000 82 Amputasi above elbow 911,000 1,367,000 2,278,000 83 Amputasi chopart 911,000 1,367,000 2,278,000 84 Amputasi Lisfranc 911,000 1,367,000 2,278,000 85 Amputasi syme 911,000 1,367,000 2,278,000 86 Amputasi ankle 911,000 1,367,000 2,278,000 87 Arthrodesis phalang manus 911,000 1,367,000 2,278,000 88 Arthrodesis phalang metacarpal 911,000 1,367,000 2,278,000 89 Arthrodesis phalang metatarsal 911,000 1,367,000 2,278,000 90 Arthrodesis phalang pedis 911,000 1,367,000 2,278,000 91 Debridement open fracture 911,000 1,367,000 2,278,000 92 Disartikulasi ankle 911,000 1,367,000 2,278,000 93 Disartikulasi elbow 911,000 1,367,000 2,278,000

Fraktur costae dg internal fiksasi (pasang shapp plate) singgle

Pengambilan nail/plate termasuk implant symphisis pubis complicated

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94 Disartikulasi knee 911,000 1,367,000 2,278,000 95 Disartikulasi wrist 911,000 1,367,000 2,278,000 96 Disisi Aspirasi katarak dengan LA 911,000 1,367,000 2,278,000 97 Eksternal fiksasi tulang panjang 911,000 1,367,000 2,278,000 98 Internal fiksasi fraktur metacarpal complicated 911,000 1,367,000 2,278,000 99 Internal fiksasi fraktur olecranon 911,000 1,367,000 2,278,000

100 Internal fiksasi fraktur patella 911,000 1,367,000 2,278,000 101 Internal fiksasi fraktur phalang complicated 911,000 1,367,000 2,278,000 102 Internal fiksasi manus multiple 911,000 1,367,000 2,278,000 103 Osteoclasis 911,000 1,367,000 2,278,000

104 911,000 1,367,000 2,278,000

105 Adductor tenotomy off the hip 658,000 987,000 1,645,000 106 Amputasi metacarpal 658,000 987,000 1,645,000

107 658,000 987,000 1,645,000

108 658,000 987,000 1,645,000

109 Closed tenotomy achiles (achilotenotomy) 658,000 987,000 1,645,000 110 Excision of the bone 658,000 987,000 1,645,000 111 Internal fiksasi fraktur metacarpal 658,000 987,000 1,645,000 112 Internal fiksasi faktur phalang 658,000 987,000 1,645,000 113 Internal fiksasi fraktur tibia plateau 658,000 987,000 1,645,000 114 Pasang skeletal traksi dg GA 658,000 987,000 1,645,000 115 Pengambilan intramedulary nail (femur, tibia) 658,000 987,000 1,645,000 116 Pengambilan K Wire dengan GA 658,000 987,000 1,645,000 117 Release de Quervain tenosynovitis GA 658,000 987,000 1,645,000 118 355,000 532,000 887,000 119 355,000 532,000 887,000 120 Anuscopy biopsi dengan GA (general anaesthesia) 355,000 532,000 887,000 121 Ateroma ekstirpasi dengan LA 355,000 532,000 887,000 122 Biopsy of skin and subcutaneous tissue dengan LA 355,000 532,000 887,000 123 Bone marrow analisa (BMA) 355,000 532,000 887,000 124 Closed reduction fractur nasal 355,000 532,000 887,000

125 355,000 532,000 887,000

126 Sondage canaliculi lacrimalis 355,000 532,000 887,000 127 Release CTS dg LA 355,000 532,000 887,000 128 Reposisi fraktur/dislokasi dg GA 355,000 532,000 887,000

129 355,000 532,000 887,000

130 253,000 380,000 633,000

131 Release de Quervain tenosynovitis 253,000 380,000 633,000

132 253,000 380,000 633,000

133 253,000 380,000 633,000

134 253,000 380,000 633,000

135 Triger finger 253,000 380,000 633,000 136 In growing nail (ekstraksi kuku) dg LA 152,000 228,000 380,000 137 Antrostomi dengan CWL 1,771,000 2,657,000 4,428,000 138 Arthroscopy rekonstruksi 3,036,000 4,554,000 7,590,000

Pengambilan nail/plate termasuk implant symphisis pubis

Amputasi phalang manus dengan GA (General Anaesthesia)Amputasi phalang pedis dengan GA (General Anaesthesia)

Amputasi phalang manus dengan LA (local Anaesthesia)Amputasi phalang pedis dengan LA (local anaesthesia)

Pelepasan eksternal fiksasi dengan GA (General Anaesthesia)

Reposisi tertutup fraktur dan imobilisasi plaster cast dengan GA (general anaesthesia)Pelepasan eksternal fiksasi dengan LA (local anaesthesia)

Suture of laceration of lip dengan LA (local anaesthesia)Suture of laceration of other part of mount dengan LA (local anaesthesia)Suture of laceration of palate dengan LA (local anaesthesia)

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139 Stabilisasi posterior 2,783,000 4,175,000 6,958,000 140 Ekstirpasi tumor + rekonstruksi (orthopedi) 2,277,000 3,416,000 5,693,000

D OPERASI BEDAH ONKOLOGI - - - 1 Neck dissection radical bilateral 2,429,000 3,644,000 6,073,000 2 Deseksi kelenjar inguinal 2,277,000 3,416,000 5,693,000 3 Mestectomy subcutaneous unilateral 2,277,000 3,416,000 5,693,000 4 Mastectomy extended simple unilateral 2,277,000 3,416,000 5,693,000 5 Mastectomy simple unilateral 2,277,000 3,416,000 5,693,000 6 Mastectomy sub total 2,277,000 3,416,000 5,693,000 7 Mastectomy Unilateral 2,277,000 3,416,000 5,693,000 8 MRM (modified radical mastectomy) 2,277,000 3,416,000 5,693,000 9 Neck dissection radical unilateral 2,277,000 3,416,000 5,693,000 10 Parotidectomy total 2,277,000 3,416,000 5,693,000 11 Pedicle flaps (advanced) 2,277,000 3,416,000 5,693,000 12 Reseksi hemi mandibula (hemimandibulektomi) 2,277,000 3,416,000 5,693,000 13 Thyroidectomy total 2,277,000 3,416,000 5,693,000 14 Deseksi kelenjar leher 1,771,000 2,657,000 4,428,000 15 Glossectomy parrtial 1,771,000 2,657,000 4,428,000 16 Parotidectomy superfisial 1,771,000 2,657,000 4,428,000 17 Reseksi mandibula bilateral 1,771,000 2,657,000 4,428,000 18 Soft tissue tumor (kompartment reseksi) 1,771,000 2,657,000 4,428,000 19 Sub total unilateral isthmo lobectomy 1,771,000 2,657,000 4,428,000 20 Thyroidectomy subtotal 1,771,000 2,657,000 4,428,000 21 Enukleasi dg GA 1,771,000 2,657,000 4,428,000

22 1,417,000 2,126,000 3,543,000

23 Eksisi fibro sarcomamae mama 1,417,000 2,126,000 3,543,000 24 Eksisi ginecomasti/subcutoneus mastectomy 1,417,000 2,126,000 3,543,000 25 Eksisi kelenjar liur 1,417,000 2,126,000 3,543,000 26 Eksisi limfangioma luas 1,417,000 2,126,000 3,543,000 27 Eksisi tumor kelenjar leher 1,417,000 2,126,000 3,543,000 28 Excision or destruction of lesion or tissue of tongue 1,417,000 2,126,000 3,543,000 29 Kista radicular (eksisi) 1,417,000 2,126,000 3,543,000 30 Soft tissue tumor (muscle reseksi) 1,417,000 2,126,000 3,543,000 31 Tumor palatum (eksisi) 1,417,000 2,126,000 3,543,000

32 1,164,000 1,746,000 2,910,000

33 Eksisi kelenjar inguinal 1,164,000 1,746,000 2,910,000 34 Eksisi limfangioma 1,164,000 1,746,000 2,910,000 35 Eksisi mamae aberan 1,164,000 1,746,000 2,910,000

36 1,164,000 1,746,000 2,910,000

37 Liposarcoma (eksisi) 1,164,000 1,746,000 2,910,000 38 Soft tissue tumor (eksisi) 1,164,000 1,746,000 2,910,000 39 Trabekulektomi 1,164,000 1,746,000 2,910,000 40 Eksisi fibroma 1,164,000 1,746,000 2,910,000 41 Eksisi fibro adenoma (fam) dengan GA 911,000 1,367,000 2,278,000 42 Eksisi tumor adneksa sedang 911,000 1,367,000 2,278,000 43 Eksisi tumor kel. Submandibula 911,000 1,367,000 2,278,000

Basalioma (excision or destruction of lesion or tissue of skin and subcutaneous tissue) dengan graft

Basalioma (excision or destruction of lesion or tissue of skin and subcutaneous tissue) tanpa graft

Epidermoid carsinoma (excision or destruction of lesion or skin and subcutaneous tissue) dengan graft

C824

DELL:

Page 19 of 53


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44 Eksisi tumor multiple 911,000 1,367,000 2,278,000

45 911,000 1,367,000 2,278,000

46 Eviscerasi 911,000 1,367,000 2,278,000 47 Excision of lesion of breast dengan GA 911,000 1,367,000 2,278,000 48 Ganglion Carpi/tarsa 911,000 1,367,000 2,278,000 49 Lipoma nochae (ekstirpasi) 911,000 1,367,000 2,278,000 50 Ateroma ekstirpasi dengan GA 355,000 550,000 905,000 51 Biopsy of skin and subcutaneous tissue dengan GA 355,000 550,000 905,000 52 Chemical peeling 658,000 1,000,000 1,658,000 53 Eksisi fibro adenoma (fam) dengan LA 658,000 1,000,000 1,658,000 54 Eksisi tumor adneksa kecil 658,000 1,000,000 1,658,000 55 Eksisi tumor dengan GA 658,000 1,000,000 1,658,000 56 Ekstirpasi korpal dengan penyulit (LA) 658,000 1,000,000 1,658,000 57 Excision of lesion of breast dengan LA 658,000 1,000,000 1,658,000 58 Lipoma (ekstirpasi) dengan GA 658,000 1,000,000 1,658,000 59 Neurofibroma (eksisi) dengan GA 658,000 1,000,000 1,658,000 60 Open biopsy of breast dengan GA 658,000 1,000,000 1,658,000 61 Tofus (eksisi) dengan GA 658,000 1,000,000 1,658,000 62 Ateroma ekstirpasi dengan LA 658,000 1,000,000 1,658,000 63 Biopsy of skin and subcutaneous tissue dengan LA 658,000 1,000,000 1,658,000 64 Eksisi tumor dengan LA 355,000 550,000 905,000 65 Tofus (eksisi) dengan LA 355,000 550,000 905,000 66 Extirpasi geborn myoma 253,000 400,000 653,000 67 Lipoma (ekstirpasi) dengan LA 253,000 400,000 653,000 68 Extirpasi tumor jinak kulit dan bawah kulit 152,000 250,000 402,000 69 Neurofibroma (eksisi) dengan LA 152,000 250,000 402,000 70 Excisi non wajah 152,000 250,000 402,000

E OPERASI BEDAH SYARAF1 Replantansi/revaskularisasi 2,783,000 4,500,000 7,283,000 2###Trepanasi 2,783,000 4,500,000 7,283,000 3 Laminectomy 2,277,000 3,500,000 5,777,000 4 Laminoplasty 2,277,000 3,500,000 5,777,000 5 Open reduction cervical 2,277,000 3,500,000 5,777,000 6 Spinal fusion (PLIF/ALIF) 2,277,000 3,500,000 5,777,000 7 Stabilisasi posterior 2,277,000 3,500,000 5,777,000 8 Other craniectomy 2,277,000 3,500,000 5,777,000 9 Other craniotomy 1,771,000 3,500,000 5,271,000 10 Evakuasi bekuan darah (clot) 1,417,000 2,500,000 3,917,000 11 Parasentesa 839,000 1,500,000 2,339,000 12 Injeksi tulang belakang dengan C Arm 152,000 300,000 452,000

F OPERASI BEDAH UROLOGI1###Nefrolithotomy bivalve 2,277,000 3,500,000 5,777,000 2 Open prostatectomy 2,277,000 3,500,000 5,777,000 3 Uretero litotomi batu ureter pasang stent 2,277,000 3,500,000 5,777,000 4 Bladder neck rekonstruksi 2,277,000 3,500,000 5,777,000 5 Boary flap 2,277,000 3,500,000 5,777,000 6 PNL/PCNL 2,277,000 3,500,000 5,777,000

Epidermoid carsinoma (excision or destruction of lesion or skin and subcutaneous tissue) tanpa graft

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7 Reimplantasi ureter bilateral 2,277,000 3,500,000 5,777,000 8 Repair fistel enterovesica 2,277,000 3,500,000 5,777,000 9 Repair vesicorectal 2,277,000 3,500,000 5,777,000 10 Repair vesicovagina 2,277,000 3,500,000 5,777,000 11 TUR buli 2,277,000 3,500,000 5,777,000 12 TURP/BNI 2,277,000 3,500,000 5,777,000 13 URS 2,277,000 3,500,000 5,777,000 14 Pielolithotomy 1,771,000 3,000,000 4,771,000 15 Repair urethra 1,771,000 3,000,000 4,771,000

16 1,771,000 3,000,000 4,771,000

17 Uretroplasty pada hypospadias 1,771,000 3,000,000 4,771,000 18 Vaginal histerectomy 1,771,000 3,000,000 4,771,000 19 Anastomose ureter end to end 1,771,000 3,000,000 4,771,000 20 Anastomose urethra end to end 1,771,000 3,000,000 4,771,000 21 Divertikulektomy buli 1,771,000 3,000,000 4,771,000 22 Extended pielolithotomy 1,771,000 3,000,000 4,771,000 23 Internal urethrotomy (sache) 1,771,000 3,000,000 4,771,000 24 Johanson II 1,771,000 3,000,000 4,771,000 25 Lithotripsi 1,771,000 3,000,000 4,771,000 26 Nefroureterectomy 1,771,000 3,000,000 4,771,000 27 Nefropeksi 1,771,000 3,000,000 4,771,000 28 Pieloplasty 1,771,000 3,000,000 4,771,000 29 Radikal nefrectomy 1,771,000 3,000,000 4,771,000 30 Radikal orchidektomy 1,771,000 3,000,000 4,771,000 31 Railroading ruptur urethra 1,771,000 3,000,000 4,771,000 32 Repair fistel vesikokutan 1,771,000 3,000,000 4,771,000 33 Repair trauma buli 1,771,000 3,000,000 4,771,000 34 Sistectomy parsial 1,771,000 3,000,000 4,771,000 35 Ureterocutaneostomy 1,771,000 3,000,000 4,771,000 36 Uretero litotomi distal 1,771,000 3,000,000 4,771,000 37 Enukleasi dg GA 1,771,000 3,000,000 4,771,000 38 Nephrotomy and nephrostomy 1,417,000 2,500,000 3,917,000 39 Orchidectomi + orchidopexy contra lateral 1,417,000 2,500,000 3,917,000 40 Orchidectomi pada undescensus testis unilateral 1,417,000 2,500,000 3,917,000 41 Partial nefrektomi 1,417,000 2,500,000 3,917,000 42 Repair AC joint sclera dengan GA 1,417,000 2,500,000 3,917,000 43 Unilateral orchidectomy 1,417,000 2,500,000 3,917,000 44 Insisi posterior urethral valve 1,417,000 2,500,000 3,917,000 45 Johanson I 1,417,000 2,500,000 3,917,000 46 Koreksi priapismus alghorab 1,417,000 2,500,000 3,917,000 47 Open nefrostomy 1,417,000 2,500,000 3,917,000 48 Orchidopeksi (torsio testis) 1,417,000 2,500,000 3,917,000 49 Orchidopeksi (undescencus testis) 1,417,000 2,500,000 3,917,000 50 Palomo 1,417,000 2,500,000 3,917,000 51 PER (primary endoscopy realignment) 1,417,000 2,500,000 3,917,000 52 Uretero litotomi proksimal 1,417,000 2,500,000 3,917,000 53 Batu buli-buli (sectio alta) 1,164,000 2,000,000 3,164,000 54 Percutaneous nephrostomy without fragmentation 1,164,000 2,000,000 3,164,000 55 Release constriction band 1,164,000 2,000,000 3,164,000

Uretero litotomi batu ureter 1/3 distal tanpa neo implantasi ureter

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56 Repair of testis 1,164,000 2,000,000 3,164,000 57 Cordektomi 1,164,000 2,000,000 3,164,000 58 Drainase periureter 1,164,000 2,000,000 3,164,000 59 Eksis web penis 1,164,000 2,000,000 3,164,000 60 Epispadia 1,164,000 2,000,000 3,164,000 61 Nefrostomi percutan 1,164,000 2,000,000 3,164,000 62 Parsial penektomi 1,164,000 2,000,000 3,164,000 63 Rekonstruksi penis 1,164,000 2,000,000 3,164,000 64 RPG (retrograde pielografi) 1,164,000 2,000,000 3,164,000 65 Subcapsuler orchidectomi 1,164,000 2,000,000 3,164,000 66 Tailoring ureter 1,164,000 2,000,000 3,164,000 67 Total penektomi 1,164,000 2,000,000 3,164,000 68 Vasoepididimostomy 1,164,000 2,000,000 3,164,000 69 Vesikolithotomy 1,164,000 2,000,000 3,164,000 70 Open cistostomi dg GA 911,000 1,500,000 2,411,000 71 Other repair of urinary bladder 911,000 1,500,000 2,411,000 72 Sialo lithiasis (ekstraksi batu dan marsupiasisasi) 911,000 1,500,000 2,411,000 73 911,000 1,500,000 2,411,000

74 Cistectomy ginjal 911,000 1,500,000 2,411,000 75 Divertikulektomy urethra 911,000 1,500,000 2,411,000 76 Insersi DJ Stent 911,000 1,500,000 2,411,000 77 Insersi selang tenckhof CAPD 911,000 1,500,000 2,411,000 78 pungsi dan sklesrosing kista ginjal 911,000 1,500,000 2,411,000 79 Repair fistel urethra 911,000 1,500,000 2,411,000 80 Skrotoplasty 911,000 1,500,000 2,411,000 81 Urethrolithotomy (GA) 911,000 1,500,000 2,411,000 82 Percutaneous cystostomy (closed cystotomy) 658,000 1,000,000 1,658,000 83 Spermatocele 658,000 1,000,000 1,658,000

84 658,000 1,000,000 1,658,000

85 Vitrektomi 658,000 1,000,000 1,658,000 86 Spermatokelectomy 658,000 1,000,000 1,658,000 87 Dilantasi uretra/bouginasi caterisasi 355,000 600,000 955,000 88 Vasectomi LA 355,000 600,000 955,000 89 Biopsi testis 152,000 300,000 452,000 90 Circumsisi dengan LA (local anaesthesia) 152,000 300,000 452,000 91 Biopsi penis 152,000 300,000 452,000 92 Cabut DJ stent 355,000 600,000 955,000 93 Circumsisi dengan GA (general anaesthesia) 355,000 600,000 955,000 94 Meatotomy 355,000 600,000 955,000 95 Operasi priapismus winter's procedure 355,000 600,000 955,000 96 Panendoscopy 355,000 600,000 955,000 97 Sitoscopy 355,000 600,000 955,000 98 Vasectomy (narkose) 355,000 600,000 955,000 99 Casting 253,000 500,000 753,000

100 Transurethral prostatectomy 2,277,000 3,500,000 5,777,000 101 2,277,000 3,500,000 5,777,000

102 Nefrolithotomy 1,771,000 3,000,000 4,771,000

Urethro litotomi batu uretra anterior dengan atau tanpa meatothomy (dengan GA)

Urethro litotomi batu uretra anterior dengan atau tanpa meatothomy (dengan LA)

Uretero litotomi batu ureter 1/3 distal + neo implantasi ureter

C962

DELL:

Page 22 of 53


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G OPERASI BEDAH THORAX KARDIO VASKULER( BTKV )1 Sternotomy pada tumor mediastinum 3,036,000 4,554,000 7,590,000 2 Thorakotomy lobectomy tumor paru 3,036,000 4,554,000 7,590,000

3 3,036,000 4,554,000 7,590,000 4 Thoraktomy pada tamponade jantung 3,036,000 4,554,000 7,590,000 5 2,277,000 3,416,000 5,693,000

6 Repair vascular dg graft 2,277,000 3,416,000 5,693,000 7 Tendon transfer 2,277,000 3,416,000 5,693,000 8 Thorakotomy pada emphiema 2,277,000 3,416,000 5,693,000 9 Thorakotomy pada hematothotax 2,277,000 3,416,000 5,693,000

10 2,277,000 3,416,000 5,693,000

11 Thoraktomy pada tumor pleura 2,277,000 3,416,000 5,693,000 12 Anastomose vascular end to end 1,771,000 3,000,000 4,771,000

13 1,771,000 3,000,000 4,771,000

14 Repair vascular 1,771,000 3,000,000 4,771,000 15 Vasografi 1,417,000 2,500,000 3,917,000 16 Eksisi hemangioma 1,164,000 2,000,000 3,164,000 17 Skin graft flap sederhana 1,164,000 2,000,000 3,164,000 18 A-V Shunt (cimino) 911,000 1,500,000 2,411,000 19 Debridement excisional of wound 911,000 1,500,000 2,411,000 20 Debridement incisi & drainage septic arthritis 911,000 1,500,000 2,411,000 21 Nevus pigmentosus (eksisi) dengan GA 658,000 1,000,000 1,658,000 22 Incisi abces dengan GA (general anaesthesia) 355,000 600,000 955,000 23 Pasang WSD 550,000 150,000 700,000 24 Electro encephalography (EEG) 152,000 300,000 452,000 25 Incisi abces dengan LA (Local anaesthesia) 152,000 300,000 452,000 26 Pasang central venous presure (CVP/CVC) 600,000 100,000 700,000 27 Double lumen 1,417,000 2,500,000 3,917,000

H OPERASI BEDAH PLASTIK1 Fraktur maxilla lefolt III (internal fiksasi) 1,771,000 3,000,000 4,771,000 2 Neo Implantasi boary flap 2,277,000 4,000,000 6,277,000 3 Labio genatopalatoschisis 1,771,000 3,000,000 4,771,000 4 Other operations on mouth and face 1,771,000 3,000,000 4,771,000 5 Other reconstruction of the toe 1,771,000 3,000,000 4,771,000 6 Rekonstruksi kelopak mata berat 1,771,000 3,000,000 4,771,000 7 Rekonstruksi sindaktili 1,771,000 3,000,000 4,771,000 8 Rekonstruksi digiti 1,771,000 3,000,000 4,771,000 9 Release kontraktur luas 1,771,000 3,000,000 4,771,000 10 Fraktur hemimaksila (internal fiksasi) 1,417,000 2,500,000 3,917,000 11 Fraktur mandibula simple (internal fiksasi) 1,417,000 2,500,000 3,917,000 12 Fraktur maxila lefolt I (internal fiksasi) 1,417,000 2,500,000 3,917,000 13 Other tendon lengthening 1,417,000 2,500,000 3,917,000 14 Palatoplasty 1,417,000 2,500,000 3,917,000 15 Partial Nefrektomi 1,417,000 2,500,000 3,917,000 16 Pedicle flaps sederhana 1,417,000 2,500,000 3,917,000 17 Reduksi macrodactili 1,417,000 2,500,000 3,917,000

Thorakotomy pada PDA (patent ductus ateriosus persistent)

Internal fiksasi (pasang shapp plate) fraktur costae multiple

Thorakotomy pada hematothotax dg lobectomy paru

Fraktur costae dg internal fiksasi (pasang shapp plate) multiple


, BMHP

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18 Release chordae(release of chordae) 1,417,000 2,500,000 3,917,000 19 Repair ruptur palpebra transkanal dengan GA 1,417,000 2,500,000 3,917,000 20 Repair ruptur moderate 1,417,000 2,500,000 3,917,000 21 Tendon transfer for stabilization of patella 1,417,000 2,500,000 3,917,000 22 FTSG (full-thickness skin graft to other sites) 1,164,000 2,000,000 3,164,000 23 Labioplasti/repair of cleft lip 1,164,000 2,000,000 3,164,000 24 Rekonstruksi palpebra 1,164,000 2,000,000 3,164,000 25 Relese kontraktur sederhana 1,164,000 2,000,000 3,164,000 26 Skin graft (STSG) 1,164,000 2,000,000 3,164,000 27 STSG (skinn graf : free skin graft) 1,164,000 2,000,000 3,164,000 28 Debridement infection or burn 910,800 1,500,000 2,410,800 29 Fasciotomy 911,000 1,500,000 2,411,000 30 Fraktur alfeolaris (pasang archbar) 911,000 1,500,000 2,411,000 31 Couterisasi clavus/veruca dengan GA 658,000 1,000,000 1,658,000 32 Eksisi keloid dengan GA (general anaesthesia) 658,000 1,000,000 1,658,000 33 Fiksasi arch bar dengan GA 658,000 1,000,000 1,658,000 34 Finger tip injury (repair v-y flap) dg GA 658,000 1,000,000 1,658,000 35 In growing nail (ekstraksi kuku) dg GA 658,000 1,000,000 1,658,000 36 Re hechting dengan GA 658,000 1,000,000 1,658,000 37 Re hechting dengan GA pada burst abdomen 658,000 1,000,000 1,658,000 38 Rekonstruksi polidaktili 658,000 1,000,000 1,658,000 39 Couterisasi clavus/veruca dengan LA 355,000 700,000 1,055,000 40 Jahit luka diwajah dengan GA (general anasthesia) 355,000 700,000 1,055,000 41 Lobuloplasty bilateral 355,000 700,000 1,055,000 42 Lobuloplasty unilateral 355,000 700,000 1,055,000 43 Parasentesa BMD 355,000 700,000 1,055,000 44 355,000 700,000 1,055,000 45 Explorasi corpus alienum simple dengan LA 253,000 500,000 753,000 46 Jahit luka diwajah dengan LA (local anasthesia) 253,000 500,000 753,000 47 Eksisi keloid dengan LA (local anaesthesia) 152,000 300,000 452,000 48 Incisi pada hidung 152,000 300,000 452,000 49 Injeksi sub konjungtiva 152,000 300,000 452,000 50 Jahit palpebra kecil 152,000 300,000 452,000 51 Nevus pigmentosus (eksisi) dengan LA 152,000 300,000 452,000 52 Re hechting dengan LA 152,000 300,000 452,000 53 Excisi wajah 152,000 300,000 452,000 54 Glossectomy total (complet) 152,000 300,000 452,000

I OPERASI BEDAH TRAUMA1 Internal bleeding ruptur ginjal/hepar/lien/sebab lain 2,277,000 3,500,000 5,777,000 2 Amputasi forequarter 1,771,000 3,000,000 4,771,000 3 Amputasi hindquarter 1,771,000 3,000,000 4,771,000 4 Fraktur mandibula complicated (internal fiksasi) 1,771,000 3,000,000 4,771,000

5 1,771,000 3,000,000 4,771,000

6 Fraktur maxilla lefolt II (internal fiksasi) 1,771,000 2,657,000 4,428,000 7 Repair old perineal ruphture 1,164,000 2,000,000 3,164,000 8 Repair tendon achiles complicated 1,164,000 2,000,000 3,164,000 9 Ekstirpasi korpal dengan penyulit (GA) 911,000 1,367,000 2,278,000 10 Repair tendon achiles 911,000 1,367,000 2,278,000

Suture of laceration of other part of mounth dengan GA (general anaesthesia)

Fraktur mandibula simple (internal fiksasi + pasang arch bar)

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11 Repair tendon ekstersor pedis 911,000 1,367,000 2,278,000 12 Repair tendon fleksor pedis 911,000 1,367,000 2,278,000 13 Repair tendon patella 911,000 1,367,000 2,278,000 14 Tendon achiles lengthening 911,000 1,367,000 2,278,000 15 Repair tendon fleksor/ekstensor pedis 658,000 987,000 1,645,000 16 Repair tendon fleksor/ekstensor manus (1 tendon) 658,000 987,000 1,645,000 17 Tracheostomi permanent 658,000 987,000 1,645,000 18 Transfusi tukar 658,000 987,000 1,645,000 19 Explorasi corpus alienum dengan penyulit 355,000 550,000 905,000 20 Finger tip injury (repair v-y flap) dengan LA 355,000 550,000 905,000 21 Tracheostomi temporer 355,000 550,000 905,000 22 Repair tendon sederhana (1 tendon) 253,000 550,000 803,000 23 Extraksi corpus alienum sederhana (bedah) 152,000 550,000 702,000

J OPERASI OBSTETRI DAN GINEKOLOGI(OBSGIN)1 2,277,000 3,416,000 5,693,000

2 Cystektomi/ovarektomi bilateral 1,771,000 2,657,000 4,428,000 3 Miomektomi 1,771,000 2,657,000 4,428,000 4 Repeated sectio caesaria 1,771,000 2,657,000 4,428,000 5 Salphingo oophorectomy bilateral 1,771,000 2,657,000 4,428,000 6 Salphingo oophorectomy unilateral 1,771,000 2,657,000 4,428,000 7 Sectio caesaria 2,070,000 2,875,000 4,945,000

8 Sectio caesaria + cystektomy/ovarektomy bilateral 2,300,000 3,416,000 5,716,000

9 2,300,000 3,416,000 5,716,000

10 Sectio caesaria + miomektomy 2,300,000 3,416,000 5,716,000

11 Sectio caesaria + salphingo oophorectomy bilateral 2,300,000 3,416,000 5,716,000

12 2,300,000 3,416,000 5,716,000 13 Sectio caesaria + tubektomy pomeroy 2,300,000 3,416,000 5,716,000 14 Sectio caesaria gemelly 2,185,000 3,105,000 5,290,000 15 Vaginal histerectomy 1,771,000 2,657,000 4,428,000 16 Vaginal reconstruction 1,771,000 2,657,000 4,428,000 17 Cystektomi/ovarektomi unilateral 1,164,000 1,746,000 2,910,000 18 Vaginoplasty 1,164,000 1,746,000 2,910,000 19 Curettage abortus incipien (inkomplit) 658,000 1,100,000 1,758,000 20 Curettage HPP (late HPP) 658,000 1,100,000 1,758,000 21 Curettage meno (metorrhagia) 658,000 1,100,000 1,758,000

22 658,000 1,100,000 1,758,000

23 Curettage molla hydatidosa 658,000 1,100,000 1,758,000 24 Incisi hymen imperforate 658,000 1,100,000 1,758,000 25 Kista dermoid eksisi dengan GA 658,000 1,100,000 1,758,000 26 Repair perineum/vagina (perineoraphy) 658,000 1,100,000 1,758,000 27 Repair vagina/cerviks/portio 658,000 1,100,000 1,758,000 28 Seconderi repair ephisiotomi 658,000 1,100,000 1,758,000 29 Tubektomy laparoscopy 658,000 1,100,000 1,758,000 30 Tubektomy laparoscopy 658,000 1,100,000 1,758,000 31 Tubektomy minilaparotomy 658,000 1,100,000 1,758,000

Supra vaginal histeroctomy/total abdominal histerectomy

Sectio caesaria + cystektomy/ovarektomy unilateral

Sectio caesaria + salphingo oophorectomy unilateral

Curettage missed abortion (death conceptus, blighted ovum)

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32 Eksterpasi cysta bartolin 355,000 550,000 905,000 33 Kista dermoid eksisi dengan LA 355,000 550,000 905,000 34 Extirpasi tumor jinak vagina 253,000 380,000 633,000 35 Dermaroller platellet rich plasma (PRP) 253,000 380,000 633,000 36 Insisi absces bartholini + marsupialisasi 253,000 380,000 633,000 37 Reposisi inversio uteri 253,000 380,000 633,000 38 Extirpasi polip cervik 152,000 300,000 452,000 39 Extraksi corpus alienum vagina 152,000 250,000 402,000 40 Salphingo/Oophorectomy 1,417,000 2,126,000 3,543,000

41 2,277,000 3,416,000 5,693,000

K OPERASI MATA1 Disisi aspirasi katarak dengan GA 1,417,000 2,126,000 3,543,000 2 Repair ruptur cornea sclera dengan GA 1,417,000 2,126,000 3,543,000 3 Ekstraksi katarak pasang IOL 1,417,000 2,126,000 3,543,000 4 Koreksi entropion 1,540,000 2,310,000 3,850,000 5 Koreksi extropion 1,164,000 1,746,000 2,910,000 6 Koreksi simblepharon 1,164,000 1,746,000 2,910,000 7 Repari ruptur cornea sclera 1,164,000 1,746,000 2,910,000 8 Saucerization 1,164,000 1,746,000 2,910,000 9 Sequestrectomy 1,164,000 1,746,000 2,910,000 10 Jahit lid mirgin 911,000 1,467,000 2,378,000 11 Kanalisasi lakrimal 911,000 1,467,000 2,378,000 12 Repair laserasi konjungtiva 911,000 1,467,000 2,378,000 13 Repair laserasi kornea 911,000 1,467,000 2,378,000 14 Repair laserasi sclera 911,000 1,467,000 2,378,000 15 Repair ruptur palpebra simple 911,000 1,467,000 2,378,000 16 Repair ruptur palpebra transkanal 911,000 1,467,000 2,378,000 17 Aspirasi katarak sekunder 658,000 987,000 1,645,000 18 Extirpasi pterygium 658,000 987,000 1,645,000 19 Flap konjungtiva 658,000 987,000 1,645,000 20 Hymenorapi 658,000 987,000 1,645,000 21 Repair ruptur cornea 658,000 987,000 1,645,000 22 Repair ruptur konjungtiva 658,000 987,000 1,645,000 23 Eksisi calazion 355,000 532,000 887,000 24 Eksisi hordiolum 355,000 532,000 887,000 25 Ekstirpasi granuloma 355,000 532,000 887,000 26 Ekstraksi lithiasis 355,000 532,000 887,000 27 Insisi cornea 355,000 532,000 887,000 28 Irigasi trauma kimia perdrip 355,000 532,000 887,000 29 Sondage canaliculi lacrimalis 355,000 532,000 887,000 30 Skarping cornea 253,000 380,000 633,000 31 Ekstrasi corpus alienum cornea 152,000 228,000 380,000

L OPERASI TELINGA HIDUNG TENGGOROKAN (THT)1 Tonsilektomi 911,000 1,367,000 2,278,000 2 Exstraksi polip nasi 658,000 987,000 1,645,000 3 Irigasi sinus 152,000 228,000 380,000

Total abdominal hysterektomy + bisalphingoo oophorectomy

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4 Anastesi 115,000 300,000 415,000 5 Adenotonsilectomy 2,277,000 3,416,000 5,693,000 6 Ethmoidektomy 1,417,000 2,126,000 3,543,000 7 Faringectomy 1,771,000 2,657,000 4,428,000

IV.

V. PELAYANAN TINDAKAN MEDIK NON OPERATIF1 Peritonial Dialisis 226,000 338,000 564,000 2 Injeksi LP Intratekal 58,000 90,000 148,000 3 Injeksi LP Epidural 58,000 90,000 148,000 4 Injeksi Impletol 3,000 5,000 8,000 5 Etanol Terapi Tumor Hati 115,000 173,000 288,000 6 Pasang Sonde 3,000 4,000 7,000 7 Pasang Skin Traction 28,000 42,000 70,000 8 Skleroterapi 299,000 449,000 748,000 9 Injeksi Intranodul 14,000 30,000 44,000 10 Esofagogastroduodenoskopi 138,000 207,000 345,000 11 Esofagogastroduodenoskopi dengan biopsi 207,000 311,000 518,000 12 Kolonoskopi 230,000 345,000 575,000 13 Kolonoskopi dengan biopsi 322,000 483,000 805,000 14 Ligasi Varises 368,000 552,000 920,000 15 Polipektomi 414,000 621,000 1,035,000 16 Dilatasi Esofagus 368,000 552,000 920,000 17 Clip 414,000 621,000 1,035,000 18 Regulasi Hemostatis 368,000 552,000 920,000 19 Bronkoskopi dengan biopsi 184,000 276,000 460,000 20 Bronkoskopi dengan brushing 230,000 345,000 575,000 21 Bronkoskopi dengan washing 230,000 345,000 575,000 22 B A L 230,000 345,000 575,000 23 Bronkoskopi pengambilan benda asing 368,000 552,000 920,000 24 Aspirasi mucous 368,000 552,000 920,000 25 Pungsi Lever 230,000 345,000 575,000 26 Tindakan pemberian Sitostatika / Kemoterapi 92,000 138,000 230,000 27 Pemasangan Water Seal Drainage / WSD 550,000 150,000 700,000

VI. PELAYANAN KEGAWAT DARURATAN / INSTALASI GAWAT DARURAT (IGD)A RUANG RAWAT DARURAT1 Ruang Observasi Reguler/P3

- Akomodasi / Jam 2,500 2,500 - Visite Dokter Umum 18,000 6,000 24,000 - Visite Dokter / Konsul Spesialis On Site 23,000 6,000 29,000 - Jasa Keperawatan 25,000 25,000

2 Ruang High Care/P2- Akomodasi / Jam - 3,000 3,000 - Visite dokter umum 23,000 6,000 29,000

PELAYANAN TINDAKAN MEDIK OPERATIF TIDAK TERENCANA/ EMERGENCY/ CYTO

* tarif dikalikan 25% dari tindakan medik operatif pada tarif pada masing masing item (JP + JS)

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- Visite dokter / konsul spesialis on site 46,000 6,000 52,000 - Jasa Keperawatan 35,000 35,000

3 Ruang observasi intensive/P1- Akomodasi / Jam - 4,500 4,500 - Visite dokter umum 46,000 20,000 66,000 - Visite dokter / konsul spesialis on site 92,000 25,000 117,000 - Jasa Keperawatan 45,000

B TINDAKAN UMUM1 Injeksi im (intra muskular) per kali 2,500 7,500 10,000 2 Injeksi iv (intra vena) per kali 2,500 7,500 10,000 3 Injeksi ic (intra cutan)per kali 2,500 7,500 10,000 4 Injeksi sc (sub cutan)per kali 2,500 7,500 10,000 5 Pasang infus dewasa 9,000 6,000 15,000

6 Pasang infus anak / bayi 12,000 8,000 20,000

7 Ambil sampel darah vena 3,000 4,000 7,000

8 Ambil sampel darah arteri 15,000 5,000 20,000

9 Pasang NGT dewasa 30,000 30,000 60,000 10###Pasang NGT anak / bayi 30,000 30,000 60,000 11 Pasang folley cateter 10,000 25,000 35,000 12 ECG 25,000 35,000 60,000 13 Pemeriksaan glukotest 10,000 15,000 25,000 14 suppositoria 5,000 5,000 10,000 15 Pemasangan Kondom Cateter 15,000 5,000 20,000 16 Ambil Sample Urine 1,000 2,000 3,000 17 Aff Infus/NGT/Urine/Catether 2,000 2,000 4,000 18 Persiapan Pre Operasi 6,000 9,000 15,000 19 Pengukuran Vital Sign 2,000 1,000 3,000

tidak termasuk spuit

tidak termasuk iv cateter dan infuset

Tidak Termasuk Biaya Spuid

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C TINDAKAN KHUSUS EMERGENCY1 Pasang mayo / oropharengeal tube* 7,500 7,500 15,000

2 Suction aktif / slem suction* 5,000 10,000 15,000

3 Pasang ETT + RSI 710,000 150,000 860,000 4 Pasang ETT tanpa RSI 360,000 100,000 460,000 5 Needle cricothyroidectomy 115,000 115,000 230,000

6 Pasang neck collar 5,000 15,000 20,000

7 Punctie pleural 173,000 230,000 403,000

8 Punctie ascites 115,000 173,000 288,000

9 Punctie blast 92,000 138,000 230,000

10 Cytostomi 173,000 173,000 346,000

11 Pemasangan cateter vena central(CVC) 600,000 100,000 700,000

12 92,000 138,000 230,000

13 Pemasangan vena sectie 144,000 144,000 288,000

14 Needle chest 35,000 52,000 87,000 tidak tmsk needle

15 Cricothroidectomy 805,000 575,000 1,380,000

16 Pemasangan monitor vital sign/jam 21,000 14,000 35,000 17 sewa monitor vital sign/ jam 3,000 7,000 10,000 18 Pemasangan syringe pump 7,000 11,000 18,000 19 Sewa syringe pump 1,500 2,000 3,500 20 Pemasangan infussion pump 7,000 11,000 18,000 21 Sewa infussion pump 1,500 2,000 3,500

22 Therapi inhalasi tanpa obat / Nebulizer per kali 10,000 14,000 24,000

23 Pemasangan ventilator 92,000 138,000 230,000 24 Sewa Ventilator 2,000 10,000 12,000 25 Pemasangan infus warmer 5,000 7,000 12,000 26 Pemasangan infant warmer 5,000 10,000 15,000 27 Resusitasi Jantung Paru 115,000 - 115,000 28 defribrilator / DC shock 92,000 138,000 230,000 29 Manual ventilasi / jam 5,000 7,000 12,000 30 kardioversi 100,000 75,000 175,000 31 Slim Suction/kali 7,500 7,500 15,000 32 RJP tanpa defibilator 50,000 70,000 120,000 33 RJP dengan Defibilator 100,000 130,000 230,000 34 Pasang SPO2 10,000 13,000 23,000 35 Pemasangan Oksigen 3,000 - 3,000 36 Penggunaan Oksigen per liter/menit - 200 200 37 Nebulizer perkali dengan obat 12,000 18,000 30,000 38 pemasangan Monitor Vital sign perjam 21,000 14,000 35,000 39 sewa monitor vital sign/ jam 3,000 7,000 10,000 40 Ekstraksi Corpus Alienum

tidak termasuk selang

tidak termasuk tube, oksigen

tidak termasuk needle

tidak termasuk collar


, BMHPtidak termasuk

selang,needle,botol, BMHP

tidak termasuk needle

tidak sudah termasuk alat dan

BMHPtidak sudah

termasuk cateter vena central,

oksigenPemasangan cateter intra osseus /umbilical,vena dalam

sudah termasuk iv cateter, infus set

tidak termasuk tube,oksigen

sudah termasuk oksigen,tidak

termasuk masker

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- Ringan 15,000 20,000 35,000 - Sedang 30,000 30,000 60,000 - Berat 40,000 50,000 90,000

41 Irigasi Lambung 100,000 75,000 175,000 42 USG Dopler Colour (3D/ 4D) 150,000 300,000 450,000 43 Usg Emergency 130,000 160,000 290,000 44 Pemasangan Pacemaker Temporer 300,000 700,000 1,000,000 45 sewa alat monitor / jam 3,000 7,000 10,000 46 Rawat Luka


47 Rawat luka bakar < 10 % 12,000 25,000 37,000 48 Rawat luka bakar 10 - 50 % 23,000 50,000 73,000 49 Rawat luka bakar > 50 % 46,000 80,000 126,000 50 Debridemant dan necrotomy

- Luka kecil 12,000 25,000 37,000 - Luka sedang 19,000 35,000 54,000 - Luka Luas 28,000 50,000 78,000

51 Amputasi sendi kecil 92,000 300,000 392,000 52 Cross incisi 19,000 250,000 269,000 53 Nail Ekstrasi 17,000 13,000 30,000 54 Gips 58,000 300,000 358,000 tidak termasuk gips

55 Ransel verband 23,000 35,000 58,000

56 Imobilisasi Fraktur dengan spalkkecil 10,000 35,000 45,000 sedang 15,000 45,000 60,000 besar 20,000 55,000 75,000

57 Immobilisasi fraktur dengan back slab 28,000 42,000 70,000 tidak termasuk gips58 imobilisasi fraktur dengan verban

kecil 7,500 17,500 25,000

sedang 10,000 20,000 30,000 besar 15,000 40,000 55,000

59 Jahit luka / Repair Jahitan - Kecil (< 5 Jahitan) 25,000 35,000 60,000 - Sedang (5 s/d 10 Jahitan) 35,000 45,000 80,000 - Besar (10 - 20 jahitan) 40,000 55,000 95,000 - Khusus (>20 Jahitan) 50,000 70,000 120,000

60 Incisi abses 50,000 47,500 97,500

tidak termasuk ransel verband

sudah termasuk spalk

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61 Ekstraksi korpus alienum THT/mata/kulit 14,000 21,000 35,000 - Ringan 14,000 21,000 35,000 - Sedang 23,000 35,000 58,000 - Berat 35,000 52,000 87,000

62 Ekstraksi batu urethra antherior 35,000 52,000 87,000 63 Tindakan lavement/spoeling 14,000 21,000 35,000 64 Tindakan reposisi:

- kecil 23,000 35,000 58,000 - sedang 23,000 35,000 58,000 - besar 23,000 35,000 58,000

65 Pemasangan tampon* 10,000 14,000 24,000 66 Pelepasan tampon 5,000 7,000 12,000 67 Angkat Jahitan

- Kecil (< 5 Jahitan) 8,000 12,000 20,000 - Sedang (5 s/d 10 Jahitan) 10,000 15,000 25,000 - Besar (10 - 20 Jahitan) 20,000 25,000 45,000 - khusus 25,000 35,000 60,000

68 Aff infus / NGT / Cateter Urine 2,000 2,000 4,000 69 Pemasangan WSD 550,000 150,000 700,000 70 pemasangan Transfusi darah per kali 15,000 5,000 20,000

71 Jahit luka di wajah dengan LA (Kosmetik) 350,000 225,000 575,000

72 jahit telinga 70,000 50,000 120,000

C PELAYANAN KANDUNGAN dan KEBIDANAN1 USG Obgyn tanpa Print 50,000 30,000 80,000 2 USG Obgyn dengan Print 50,000 50,000 100,000 3 Pemeriksaan Ginekologi 15,000 10,000 25,000 4 pemeriksaan Obstetri 15,000 10,000 25,000 5 persalinan Normal 600,000 150,000 750,000

E PELAYANAN PREHOSPITAL DAN RUJUKAN

1 Sewa ambulance BLS ( Team )- Antar / jemput dalam kota 80,000 120,000 200,000 prwt+sopir- Luar kota / kilometer 2,000 3,000 5,000 Tarif PP, Sopir

2 Sewa ambulance ALS ( Team )

- Antar / jemput dalam kota / 100,000 150,000 250,000 prwt+sopir- Luar kota / kilometer 2,000 3,500 5,500 sopir

3 Dokter umum / 24 jam 1,150,000 - 1,150,000

4 Dokter spesialis / 24 jam 2,875,000 - 2,875,000 5 Perawat / 24 jam 400,000 - 400,000 6 Sopir 300,000 - 300,000

VII. PELAYANAN RAWAT INAP DAN KEPERAWATANA PELAYANAN TINDAKAN KEPERAWATAN1 Minimal Care per hari 20,000 20,000 2 Moderate Care per hari 25,000 25,000 3 High Care per hari 30,000 30,000 4 Intensif Care per hari 50,000 50,000

Tidak termasuk BMHP

Tidak termasuk BMHP

tidak termasuk biaya

penyeberangan

tidak termasuk biaya

penyeberangan

Sesuai indikasi medis

Sesuai indikasi medis

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B PELAYANAN TINDAKAN RAWAT INAP1 Pemeriksaan oleh dokter jaga 7,500 12,500 20,000 2 15,000 10,000 25,000 3 Pasang infus dewasa 9,000 6,000 15,000 4 Pasang infus anak / bayi 12,000 8,000 20,000 5 Rawat Lokasi infus per hari / Shift 2,000 5,000 7,000 6 Rawat Luka

a. Kecil (< 5 cm) 7,000 11,000 18,000 b. Sedang (5-10 cm) 10,000 15,000 25,000 c. Besar (10-20 cm) 17,500 40,000 57,500

d. Khusus (> 20 cm) 30,000 50,000 80,000

7 Rawat luka bakar < 10 % 12,000 25,000 37,000 8 Rawat luka bakar 10 - 50 % 23,000 50,000 73,000 9 Rawat luka bakar > 50 % 46,000 80,000 126,000 10 infus tali pusat 69,000 104,000 173,000 11 Necrotomy jaring ( kecil ) 10,000 15,000 25,000 12 Angkat Jahitan

- Kecil (< 5 Jahitan) 8,000 12,000 20,000 - Sedang (5 s/d 10 Jahitan) 10,000 15,000 25,000 - Besar (10 - 20 Jahitan) 20,000 25,000 45,000 - khusus > 20 25,000 35,000 60,000

13 Pasang tampon 10,000 14,000 24,000 14 Aff Tampon 8,000 4,000 12,000 15 Memandikan bayi/kali 12,000 18,000 30,000 16 Memandikan Pasien/kali 12,000 18,000 30,000 sesuai indikasi17 Keramas pasien/kali 10,000 10,000 20,000 sesuai indikasi18 Injeksi im (intra muskular) per kali 2,500 7,500 10,000 19 Injeksi iv (intra vena) per kali 2,500 7,500 10,000 20 Injeksi ic (intra cutan)per kali 2,500 7,500 10,000 21 Injeksi sc (sub cutan)per kali 2,500 7,500 10,000 22 Skin Test 3,000 4,000 7,000 23 Memberi Obat melalui Gastrotomy 3,000 4,000 7,000 24 Memberi Obat Supositoria 4,000 6,000 10,000 25 Penanganan Pre Operasi 10,000 1,000 11,000 26 Pasang Fowley Cateter* 10,000 25,000 35,000 27 Pasang Kondom Cateter* 15,000 5,000 20,000 28 Pasang Bidai* 5,000 7,000 12,000 29 Pasang Neck Collar * 5,000 15,000 20,000 30 Penanganan Keracunan 23,000 18,000 41,000 31 Perawatan Payudara 5,000 7,000 12,000 32 Perawatan WSD 12,000 18,000 30,000 33 Perawatan Kolostomy / Iliestomy 5,000 7,000 12,000 34 Resusitasi Jantung Paru 58,000 58,000 116,000 35 Pasang NGT Dewasa / Anak 30,000 30,000 60,000

36 Pasang ETT 805,000 575,000 1,380,000

37 Pasang Mayo / Oroparingeal 7,500 7,500 15,000

Pemeriksaan pasien rawat inap gawat oleh dokter jaga

tidak termasuk tube oksigen

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38 Aff infus 2,000 2,000 4,000 39 Aff NGT 2,000 2,000 4,000 40 Aff Cateter Urine 2,000 2,000 4,000 41 Perawatan Tracheostomy 5,000 7,000 12,000 42 Irigasi Mata 12,500 12,500 25,000 43 ECG 25,000 35,000 60,000 44 Ambil sampel darah vena 3,000 4,000 7,000 45 ambil sampel darah arteri 5,000 15,000 20,000 46 SAMPEL URINE 1,000 2,000 3,000 47 Irigasi Lambung 100,000 75,000 175,000 48 Irigasi Telinga 30,000 30,000 60,000 49 Pemasangan WSD ? Sama seperti poli dan IGD 550,000 150,000 700,000 50 RJP dengan Defib 100,000 130,000 230,000 51 Penggunaan Oksigen ( O2)

- Pemakaian O2 1 Ltr/Mnt 130 130 - pemasangan O2 per kali tanpa ventilator 3,000 3,000

52 Suctioning* 5,000 7,000 12,000 53 Therapi Inhalasi tanpa obat / Nebuizer per kali 10,000 14,000 24,000 54 irigasi BPH/hari 23,000 12,000 35,000 55 Spoeling BPH/kali 5,000 7,000 12,000 56 Klisma / Huknah 5,000 7,000 12,000 57 Postural Drainase 10,000 14,000 24,000 58 Rawat lokasi iv /kali 2,000 3,000 5,000 59 Pemasangan Sonde 7,500 7,500 15,000 60 Pengukuran Vital Sign 2,000 1,000 3,000

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VIII. PELAYANAN KEBIDANANA PERSALINAN PERVAGINAM1 Partus Spontan 600,000 150,000 750,000 2 Partus Vacum Ekstraksi 1,000,000 300,000 1,300,000 3 Kelainan Letak ( Sungsang/ lintang / Oblique) 1,000,000 300,000 1,300,000 4 Persalian Gemeli 1,000,000 300,000 1,300,000

B PENYULIT PENYERTA - 1 Embriotomi 2,000,000 1,500,000 3,500,000 2 Laparotomi 3,800,000 2,000,000 5,800,000 3 Versi Ekstraksi 400,000 100,000 500,000 4 Induksi ( Drip Oksitoksin/Ripening Misoprostol) 400,000 100,000 500,000 5 Manual Plasenta 400,000 100,000 500,000 6 Rehidrasi 75,000 15,000 90,000 7 HPP 250,000 100,000 350,000 8 Perineorhaphy ( Drajad 3 dan 4 ) 200,000 250,000 450,000 9 Atonia Uteri ( KBI / KBE ) 200000 150,000 350,000 10 Insersi IUD 100,000 25,000 125,000

C ABORTUS - 1 Spontan 400,000 200,000 600,000 2 Induksi 600,000 200,000 800,000 3 Curettage 1,050,000 150,000 1,200,000

D NEONATAL CARE - 1 Pemasangan Infant Warmer 5,000 10,000 15,000 2 Resusitasi Bayi baru Lahir ( VTP / Komprensi Dada) 90,000 60,000 150,000 3 Suctioning 10,000 15,000 25,000 4 Perawatan Tali pusat 5,000 5,000 10,000 5 Pasang Infus Bayi / Mikro 12,000 8,000 20,000 6 Pemasangan SPO2 10,000 13,000 23,000

E TINDAKAN - 1 VT 10,000 5,000 15,000 2 DJJ 5,000 5,000 10,000 3 USG Tanpa Print 50,000 30,000 80,000 4 USG Dengan Print 50,000 50,000 100,000 5 CTG 50,000 30,000 80,000 6 Injeksi ( IM/IV/IC/SC ) 2,500 7,500 10,000 7 Pasang Infus Makro 9,000 6,000 15,000 8 Pasang Folley Cateter 10,000 25,000 35,000 9 Pasang Tampon 10,000 14,000 24,000 10 Pasang NGT 30,000 30,000 60,000 11 Pasang O2 dengan / tanpa Ventilator 8,000 15,000 23,000 12 Ambil Sampel Darah 1,000 2,000 3,000 13 Ambil Sample Urine 1,000 2,000 3,000 14 Ambil Sample Sputum 1,000 2,000 3,000

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15 Pemakainan O2/ liter/ jam 110 110 16 AFF Cateter 2,000 2,000 4,000 17 Aff Infus 2,000 2,000 4,000 18 Aff Tampon 2,000 2,000 4,000 19 Aff NGT 2,000 2,000 4,000 20 Aff O2 2,000 2,000 4,000 21 Persiapan Operasi 10,000 1,000 11,000 22 Perawatan Jenazah BBL 150,000 50,000 200,000 23 Pengukuran Vital Sign 2,000 1,000 3,000

F TINDAKAN NIFAS - 1 Skin Test 3,000 4,000 7,000 2 pemeriksaan ginekologi 15,000 10,000 25,000 3 memandikan bayi 15,000 15,000 30,000 4 Perawatan Tali Pusat 5,000 5,000 10,000 5 Massage Bayi 15,000 10,000 25,000 6 Perawatan Payudara 5,000 7,000 12,000 7 rawat lokasi iv / kali 2,000 3,000 5,000 8 Pengukuran Vital Sign 2,000 1,000 3,000

IX. PELAYANAN ICU/NICU1 Tarif visite dokter / Intensiv / Konsultasi antar SMF 90,000 90,000 2 Visite Dokter Umum/Kali 40,000 40,000 3 Jasa Keperawatan ICU / hari 60,000 - 60,000

TINDAKAN1 Pemasangan monitor vital sign 21,000 14,000 35,000 2 Sewa alat dan monitoring per jam 3,000 7,000 10,000 3 Bedside monitor / hari 40,000 7,000 47,000 4 Pasang Syring pump/kali 7,000 11,000 18,000 5 Sewa syring pump/jam 1,500 2,000 3,500 6 Pasang infusion pump/ kali 8,000 12,000 20,000 7 Sewa Infusion pump / jam 1,500 2,000 3,500 8 pasang Ventilator / kali 92,000 138,000 230,000 9 setting Ventilator / kali 115,000 23,000 138,000 10 Observasi Ventilator / hari 100,000 50,000 150,000 11 Sewa Ventilator / jam 2,000 10,000 12,000 12 Pasang Feeding pump / kali 7,000 11,000 18,000 13 Sewa alat Feeding pump / jam 3,000 8,000 11,000 14 Nebulizer dengan obat / kali 12,000 18,000 30,000 15 Nebulizer tanpa obat / kali 14,000 10,000 24,000 16 Pemasangan collarneck / kali 5,000 15,000 20,000 17 Pemasangan LMA / kali 100,000 100,000 200,000 18 Pasang Mayo/ PA per kali 7,500 7,500 15,000 19 Pemasangan warm air set / kali 5,000 7,000 12,000 20 sewa Warm air set / jam 2,000 3,000 5,000 21 pemasangan blanket roll / kali 8,000 10,000 18,000 22 sewa blanket roll / jam 2,000 3,000 5,000 23 pemasangan bed decubal / kali 5,000 7,000 12,000 24 pasang infusion warmer / kali 5,000 7,000 12,000

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25 sewa alat decubal / jam 2,000 4,000 6,000 26 Pasang O2 tanpa Ventilator / kali 8,000 15,000 23,000 27 pasang O2 dengan Ventilator / kali 18,000 12,000 30,000 28 Sewa O2 /liter / jam 110 110 29 pasang SPO2 10,000 13,000 23,000 30 Pasang NGT / kali 30,000 30,000 60,000 31 AFF NGT / Kali 2,000 2,000 4,000 32 Irigasi lambung / kali 100,000 75,000 175,000 33 Irigasi mata / kali 12,500 12,500 25,000 34 Pasang ETT + RSI / Kali 710,000 150,000 860,000 35 Pasang ETT Tanpa RSI / Kali 360,000 100,000 460,000 36 Perawatan ETT / kali 5,000 7,000 12,000 37 Ekstubasi 60,000 45,000 105,000 38 tindakan anastesi GA/RA per kali 422,000 500,000 922,000 39 Pasang Kondom Cateter / kali 15,000 5,000 20,000 40 AFF kondom Cateter 2,000 2,000 4,000 41 Pasang Cateter / kali 20,000 15,000 35,000 42 AFF cateter / kali 2,000 2,000 4,000 43 Irigasi BPH / kali 23,000 12,000 35,000 44 Spooling dawer cateter / kali 10,000 14,000 24,000 45 blast Punction / kali 60,000 50,000 110,000 46 Acites puntion / kali 115,000 173,000 288,000 47 Transfusi / kali 15,000 30,000 45,000 48 Injeksi IC / kali 2,500 7,500 10,000 49 Injeksi SC / kali 2,500 7,500 10,000 50 Injeksi IM / kali 2,500 7,500 10,000 51 Injeksi IV / kali 2,500 7,500 10,000 52 Skintest / kali 3,000 4,000 7,000 53 pemberian obat Supositoria / kali 4,000 6,000 10,000 54 Pemberian obat oral / kali 5,000 5,000 55 memberikan obat via sonde / kali 5,000 5,000 56 Huknah / kali 5,000 7,000 12,000 57 GLUkOTEST 10,000 15,000 25,000 58 Pemberian TROMBOLITIK / kali 200,000 50,000 250,000 59 Pasang Infus Dewasa / kali 9,000 6,000 15,000 60 Pasang Infus Anak / Kali 12,000 8,000 20,000 61 AFF Infus 2,000 2,000 4,000 62 Rawat lokasi IV / kali 2,000 3,000 5,000 63 ECG 25,000 35,000 60,000 64 Pemasangan alat pacemaker temporer 300,000 700,000 1,000,000 65 USG Biasa dengan print out / kali 80,000 70,000 150,000 66 USG Biasa tanpa print out / kali 50,000 30,000 80,000 67 USG Emergency / kali 130,000 160,000 290,000 68 Suction / kali 10,000 5,000 15,000 69 Bronchial washing dengan alat / kali 111,000 200,000 311,000 70 Fisioterapi dada / kali 23,000 12,000 35,000 71 Postural drainase / kali 10,000 14,000 24,000 72 Pemasangan WSD / kali 550,000 150,000 700,000

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73 Perawatan WSD / kali 12,000 18,000 30,000 74 Needle thoracostomi / kali 42,000 63,000 105,000 75 PLEURAL punction / kali 173,000 230,000 403,000 76 AFF Tampon 8,000 4,000 12,000 77 Pemasangan tampon / kali 10,000 14,000 24,000 78 Personal Hygien ( memandikan ) / kali 12,000 18,000 30,000 79 Oral hygiene / kali 15,000 10,000 25,000 80 Perianal Hygiene / kali 15,000 10,000 25,000 81 Vulava Hygien / kali 15,000 10,000 25,000 82 Keramas Pasien / kali 10,000 10,000 20,000 83 Perawatan Payudara / kali 5,000 7,000 12,000 84 Manual Ventilation / bagging/kali 5,000 7,000 12,000 85 RJP tanpa Defib. / siklus 50,000 70,000 120,000 86 RJP Dengan Defib. / kali 100,000 130,000 230,000 87 Kardioversi / kali 75,000 100,000 175,000 88 Perawatan Jenazah tak beresiko / kali 200,000 75,000 275,000 89 Perawatan Jenazah beresiko / kali 225,000 75,000 300,000 90 Pengambilan sampel vena / kali 3,000 4,000 7,000 91 Pengambian Sampel Arteri / kali 10,000 10,000 20,000 92 pengambilan Sampel urine / kali 1,000 2,000 3,000 93 ambil Spesimen Lab. Sputum / kali 3,000 15,000 18,000 94 Pengembilan Sampel kultur / kali 20,000 30,000 50,000 95 Insisi Abses 20,000 77,500 97,500 96 Pasang cateter CVC / kali 600,000 100,000 700,000 97 AFF CVC 20,000 15,000 35,000 98 Pasang Cateter Vena provunda 23,000 35,000 58,000 99 Pasang cateter arteri / arteri line / kali 230,000 230,000 460,000

100 AFF arteri line / kali 20,000 15,000 35,000 101 Pasang Cateter HD / kali 115,000 115,000 230,000 102 Pasang kateter ntraoseus / intra umbilical / kali 92,000 138,000 230,000 103 Vena Sectie / kali 144,000 144,000 288,000 104 Balance Cairan per kali 10,000 10,000 20,000 105 TRAKEOSTOMI, cricothiroitdectomi/kali 900,000 350,000 1,250,000 106 Perawatan trakeostomi/kali 5,000 7,000 12,000 107 cictotomy/kali 173,000 170,000 343,000 108 Penanganan keracunan /kali 23,000 18,000 41,000 109 Penanganan Pre-operasi/kali 6,000 9,000 15,000 110 25,000 35,000 60,000 111 Jahit luka sedang (5-10 Jahitan) 35,000 45,000 80,000 112 Jahit luka besar (>10 jahitan) 40,000 55,000 95,000 113 Rawat luka kecil (< 5cm) 7,000 11,000 18,000 114 Rawat luka sedang (5-10cm) 10,000 15,000 25,000 115 Rawat luka besar (10-20cm) 17,500 40,000 57,500 116 Rawat luka khusus (> 20cm) 35,000 45,000 80,000

Jahit luka kecil (< 5 jahitan)

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117 Rawat luka ganggren/bakar <10% 12,000 25,000 37,000 118 Rawat luka bakar/ganggren 10-50% 23,000 50,000 73,000 119 Rawat luka ganggren/bakar 50% 46,000 80,000 126,000 120 debribment dan nekrotomi kecil 12,000 25,000 37,000 121 debridment dan nekrotomi sedang 19,000 35,000 54,000 122 debridment dan nekrotomi luas 28,000 50,000 78,000 123 Amputasi sendi kecil 192,000 200,000 392,000 124 Nail ekstraksi 17,000 13,000 30,000 125 Cross insisi/kali 19,000 250,000 269,000 126 Pemasangan spalk/kali -

a. Kecil 15,000 30,000 45,000 b. Sedang 20,000 40,000 60,000 c. Besar 30,000 45,000 75,000

127 Pemasangan gips/kali 70,000 104,000 174,000

128 Pemasangan kateter epidural/kali 138,000 207,000 345,000

129 Drainase cairan pleura/kali 120,000 30,000 150,000

130 Drainase cairan abdomen / kali 120,000 30,000 150,000

131 pengangkatan corpusalieneum - Ringan 15,000 20,000 35,000 - sedang 25,000 35,000 60,000 - Berat 35,000 55,000 90,000

132 Pengukuran Vital Sign 2,000 1,000 3,000

X. PELAYANAN NICU

1 Pemasangan Respirator / hari 10,000 20,000 30,000

2 Sewa alat dan monitoring per jam 3,000 7,000 10,000 3 Pemasangan monitor vital sign 21,000 14,000 35,000 4 Pemasangan syringe pump: 7,000 11,000 18,000 5 Sewa Syringe Pump 1,500 2,000 3,500 6 Pemasangan infussion pump: 8,000 12,000 20,000 7 Sewa infussion pump 1,500 2,000 3,500 8 Pemasangan Feeding Pump: 7,000 11,000 18,000 9 Sewa Feeding pump 3,000 8,000 11,000 10 Pemasangan Radiant / Infant Warmer : 5,000 10,000 15,000

11 Vena seksi 144,000 180,000 324,000

12 Foto Theraphy / hari 19,000 30,000 49,000 13 Resusitasi bayi bermasalah / RKP 46,000 69,000 115,000 14 Portable pulse oximeter 14,000 21,000 35,000 15 Resusitasi bayi normal 46,000 69,000 115,000 16 Intubasi 87,000 58,000 145,000 17 Suction pump 5,000 30,000 35,000 18 Pasang NGT 30,000 30,000 60,000

19 Aff NGT 2,000 2,000 4,000


Tidak termasuk obat dan BMHP Tidak termasuk obat dan BMHP

tidak termasuk iv cateter,infus set

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20 Pasang ET 575,000 400,000 975,000

21 Pasang Cateter 20,000 15,000 35,000 22 Aff Cateter 2,000 2,000 4,000 23 Lumbal Punctie 58,000 100,000 158,000 24 pemasangan transfusi / kali 15,000 5,000 20,000 25 Massage bayi 15,000 10,000 25,000 26 Pasang ventilator / NCPAP 92,000 138,000 230,000 27 Observasi Ventilator / NCPAP / hari 100,000 50,000 150,000 28 Perawatan luka 7,000 11,000 18,000 29 Tindakan metode kangguru 12,000 18,000 30,000 30 Perawatan tali pusat 5,000 5,000 10,000 31 Transfusi Tukar 322,000 500,000 822,000 32 Pemberian Surfactan 322,000 550,000 872,000 33 Pemasangan WSD pada Neonatus 550,000 150,000 700,000 34 Pemasangan cateter umbilical 58,000 100,000 158,000 35 Sensor saturasi oksigen (BHP ) 23,000 35,000 58,000 36 Rawat luka bakar < 10 % 12,000 25,000 37,000 37 Rawat luka bakar 10 - 50 % 23,000 50,000 73,000 38 Rawat luka bakar > 50 % 46,000 80,000 126,000 39 Pemasangan cateter Arteri ( artery line ) 115,000 150,000 265,000 40 Bronchial Washing dengan alat 111,000 200,000 311,000 41 Therapi Inhalasi tanpa obat / Nebuizer per shift 12,000 25,000 37,000 42 Debridement dan necrotomy 12,000 30,000 42,000 43 Pemasangan infus bayi per kali 12,000 8,000 20,000 44 Injeksi im per kali 2,500 7,500 10,000 45 Injeksi iv per kali 2,500 7,500 10,000 46 Injeksi ic per kali 2,500 7,500 10,000 47 Injeksi sc per kali 2,500 7,500 10,000 48 Memberi obat Supositoria 4,000 6,000 10,000 49 Penanganan Pre Operasi 6,000 9,000 15,000 50 Mengambil sample darah vena 3,000 4,000 7,000

51 5,000 20,000 25,000

52 Pemasangan dan penggunaan Oksigen ( O2 ) a. Penggunaan Tiap 1 liter / menit / jam 130 130 b. pemasangan O2 per kali tanpa ventilator 3,000 3,000 c. pemasangan O2 per kali dengan ventilator 3,000 5,000 8,000

53 Pengukuran Vital Sign 2,000 1,000 3,000

XI. PELAYANAN HEMODIALISISA PELAYANAN HEMODIALISIS TERENCANA

1 Penggantian transver set ( CAPD ) 33,000 49,000 82,000

2 Pelayanan HD tanpa Reuse 437,000 656,000 1,093,000 3 Pelayanan HD dengan Reuse 345,000 518,000 863,000 4 Pelayanan HD tanpa Reuse di bawa pasien sendiri 184,000 276,000 460,000 5 138,000 207,000 345,000

tidak termasuk tube oksigen

Melakukan klisma / huknah rendah / Drumbuisa (Nacl Hangat)

Pelayanan HD dengan Reuse di bawa pasien sendiri

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B PELAYANAN HEMODIALISIS CITO1 Penggantian Transfusi set 41,000 61,000 102,000 2 Pelayanan HD tanpa Reuse 547,000 820,000 1,367,000 3 Pelayanan HD dengan Reuse 432,000 647,000 1,079,000 4 Pelayanan HD tanpa Reuse di bawa pasien sendiri 230,000 345,000 575,000 5 173,000 259,000 432,000

XII. PELAYANAN PENUNJANG MEDIK A APELAYANAN TINDAKAN MEDIK DIAGNOSTIK ELEKTROMEDIK DAN NON ELEKTROMEDIK

1 WSD Kontinu 575,000 575,000 1,150,000 2 Laringoscopi 56,000 83,000 139,000

3 Punctie Pluera / Lung Punctie 173,000 230,000 403,000

4 AJH ( Paru ) 46,000 69,000 115,000 5 Portable spirometri 30,000 45,000 75,000 6 Pungsi Acites 115,000 173,000 288,000 7 Pungsi Pericard 184,000 276,000 460,000 8 Treadmile 92,000 138,000 230,000 9 Holter Monitoring 92,000 138,000 230,000 10 Ochocardiografi Dopler Color 189,000 283,000 472,000 11 ECG Simple 25,000 35,000 60,000 12 Biopsi Hati 184,000 400,000 584,000 13 Pungsi abses hati 35,000 100,000 135,000 14 Gastroscopy 171,000 256,000 427,000 15 Colonoscopy 171,000 256,000 427,000 16 Pungsi abses hati 58,000 87,000 145,000 17 BMP ( Basic Metabolic Panel ) 58,000 87,000 145,000 18 BMP dengan General Anesthesi 115,000 173,000 288,000 19 Biopsi Ginjal 184,000 276,000 460,000 20 Supra Public Punctie 35,000 52,000 87,000 21 Suntikan / Injeksi Intra Arikuler 33,000 49,000 82,000 22 Lumbal Pungsi 58,000 87,000 145,000 23 Ganglion Pungsi 23,000 35,000 58,000 24 Biopsi Transtorakal 58,000 87,000 145,000 25 Dopler Kamar Operasi 10,000 14,000 24,000 26 FFA / Fluorescin Fundus Angio 60,000 90,000 150,000 27 Toracoskopi 115,000 173,000 288,000 28 Kolposkopi 23,000 35,000 58,000 29 Test Perspirasi 12,000 17,000 29,000 30 Biopsi THT 52,000 78,000 130,000 31 AJH THT 23,000 35,000 58,000 32 Pemeriksaan EEG 81,000 121,000 202,000 33 Baca EEG 35,000 - 35,000 34 Pemeriksaan ENMG 115,000 173,000 288,000 35 CTG 50,000 30,000 80,000 36 Audiometri murni 46,000 69,000 115,000 37 Audiometri tutur 35,000 52,000 87,000

Pelayanan HD dengan Reuse di bawa pasien sendiri

tidak termasuk selang,needle,

botol, BMHP

C1756

DELL:

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38 Test Vestibuler 12,000 18,000 30,000 39 Foto Fundus Mata 23,000 35,000 58,000 40 Funduscopy Indirect 28,000 42,000 70,000 41 Sinopthor 12,000 18,000 30,000 42 Test Provokasi 23,000 35,000 58,000 43 Skin Test Allergi Elektro 46,000 69,000 115,000 44 Desensitisasi ( Paket ) 42,000 63,000 105,000 45 Nasolaringokopi 28,000 42,000 70,000 46 Swab Nasofaring 13,000 19,000 32,000 47 Campimetri / perimetri 1 mata dengan Humpray 138,000 207,000 345,000 48 Campimetri / perimetri 2 mata dengan Humpray 230,000 345,000 575,000 49 Keratometri 28,000 42,000 70,000 50 Anal Test 23,000 35,000 58,000 51 Gonioskopi 28,000 42,000 70,000 52 Retinoskopi 28,000 42,000 70,000 53 Biopsi Adneksa Mata 12,000 18,000 30,000 54 USG Mata 58,000 87,000 145,000 55 Tonometri Aplanasi 28,000 42,000 70,000 56 Water Drinking 7,000 11,000 18,000

B. RADIOLOGI ( Untuk Tarip Penunjang Radio Diagnostik, Tidak Termasuk Bahan Kontras )KECIL (Tidak Menggunakan Kontras)

1 Kepala AP / Lat 46,000 115,000 161,000 2 Kepala 3 Posisi 69,000 161,000 230,000 3 SPN ( Sinus Para Nasal ) 70,000 50,000 120,000 4 Nasal 70,000 50,000 120,000 5 Cervical AP / Lat ( 2 Film ) 46,000 115,000 161,000 6 Cervical AP / Lat / Obl ( 4 Film ) 92,000 230,000 322,000 7 Thoracal / AP / Lat ( 2 Film ) 46,000 115,000 161,000 8 Thoracal / AP / Lat Obl ( 4 Film ) 92,000 230,000 322,000 9 Thoraco Lumbal AP / Lat 46,000 115,000 161,000 10 Thoraco Lumbal AP / Lat / Obl 69,000 173,000 242,000 11 Lumbal AP / Lat ( 2 Film ) 46,000 115,000 161,000 12 Lumbal AP / Lat / Obl ( 4 Film ) 92,000 230,000 322,000 13 Lumbosakral AP / Lat 46,000 115,000 161,000 14 Pelvis ( 1 Film ) 30,000 50,000 80,000 15 Femur AP / Lat Genu AP / Lat 46,000 100,000 146,000 16 Genu AP / Lat 46,000 100,000 146,000 17 Cruris AP / Lat 46,000 100,000 146,000 18 Pedis AP / Lat 46,000 100,000 146,000 19 Ankle Joint AP / Lat 46,000 100,000 146,000 20 Manus AP / Lat 46,000 100,000 146,000 21 Wrist Joint AP / Lat 46,000 100,000 146,000 22 Antebrachi AP / Lat 46,000 100,000 146,000 23 Elbow Joint AP / Lat 46,000 100,000 146,000 24 Humerus AP / Lat 46,000 100,000 146,000 25 Shoulder AP / Lat 46,000 100,000 146,000 26 Clavicula 30,000 50,000 80,000

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27 Thorax PA Dewasa 30,000 50,000 80,000 28 Thorax Lat Dewasa 30,000 50,000 80,000 29 Thorax AP / Lat Dewasa 30,000 50,000 80,000 30 Thorax AP Anak 30,000 50,000 80,000 31 Thorax AP / Lat Anak 30,000 50,000 80,000 32 Abdomen / BNO Dewasa 30,000 50,000 80,000 33 Abdomen / BNO Anaka 30,000 50,000 80,000 34 Abdomen 3 Posisi Dewasa 69,000 173,000 242,000 35 Abdomen 3 Posisi Anak 69,000 173,000 242,000 36 Panoramic gigi 30,000 60,000 90,000

SEDANG (Menggunakan Kontras)1 Mammografi 111,000 250,000 361,000 2 Pelvis dengan sonde 56,000 92,000 148,000 3 Pelvimeteri 111,000 184,000 295,000 4 Uretrografi 275,000 250,000 525,000 5 Cystografi 275,000 250,000 525,000 6 Uretro Cystografi 221,000 450,000 671,000 7 H S G dengan kontras 221,000 450,000 671,000 8 RPG / APG 276,000 460,000 736,000 9 OMD dengan kontras 221,000 368,000 589,000 10 Oesofagografi 166,000 276,000 442,000 11 Colon In Loop Dewasa 276,000 500,000 776,000 12 Colon In Loop Anak 276,000 500,000 776,000 13 Fluoroscopy 111,000 250,000 361,000 14 Intra Vena Pyelography ( IVP ) 5 Film 276,000 460,000 736,000 15 Intra Vena Pyelography ( IVP ) 6-7 Film 387,000 644,000 1,031,000

CANGGIH1 Myelografi Lumbal 230,000 345,000 575,000 2 Myelografi Thoracal / Cervical 230,000 345,000 575,000 3 Arthrografi 230,000 345,000 575,000 4 Phlebografi extr superior 184,000 276,000 460,000 5 Phlebografi extr inf 161,000 241,500 402,500 6 CT Scan kepala non kontras 276,000 414,000 690,000 7 CT Scan Kepala kontras 414,000 650,000 1,064,000 8 a. Whole Body CT Scan non kontras 506,000 759,000 1,265,000 9 b. Whole Body CT scan dengan kontras 920,000 1,380,000 2,300,000 10 CT Scan thorax nn kontras 300,000 505,000 805,000 11 CT scan thorax kontras 400,000 1,100,000 1,500,000 12 CT scan abdomen atas / bawah non kontras 322,000 1,000,000 1,322,000 13 CT scan abdomen atas / bawah dengan kontras 552,000 1,000,000 1,552,000 14 CT scan ekstrimitas non kontras 276,000 800,000 1,076,000 15 CT scan ekstrimitas kontras 414,000 800,000 1,214,000 16 C- Arm 184,000 500,000 684,000 17 USG Abdomen atas 138,000 300,000 438,000 18 USG Abdomen bawah 138,000 300,000 438,000 19 USG Abdomen atas bawah 104,000 400,000 504,000 20 USG Ginjal 104,000 300,000 404,000

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21 USG Testis 92,000 200,000 292,000 22 USG Payudara 92,000 200,000 292,000 23 USG Musculoskeletal 92,000 200,000 292,000 24 USG Neonatus 92,000 200,000 292,000 25 USG Thorax 104,000 200,000 304,000 26 USG Dopler Color 184,000 276,000 460,000

C PELAYANAN PEMERIKSAAN LABORATORIUM / PATOLOGI KLINIKI HAEMATOLOGY1 Darah rutin ( HMK ) :

5 Dift 18,000 35,000 53,000 3 Dift 14,000 27,000 41,000

2 Reticolusit 6,000 11,000 17,000 3 Angka Eosinofil 6,000 11,000 17,000 4 Limfosit Plasma Biru 6,000 11,000 17,000 5 Malaria Mikroskopis 5,000 10,000 15,000 6 Malaria Stik 10,000 22,000 32,000 7 Filaria 6,000 11,000 17,000 8 Golongan Darah + Rhesus 5,000 10,000 15,000 9 Coomb's Test 12,000 23,000 35,000 10 Morfologi Darah Tepi 23,000 46,000 69,000 11 B M P ( Pemeriksaan ) 69,000 104,000 173,000 12 Aspirasi BMP 92,000 207,000 299,000 13 Ratio IM / IT 6,000 11,000 17,000 14 Hemosidirin 7,000 14,000 21,000 15 LE Cell 11,000 19,000 30,000 16 O F T 10,000 18,000 28,000 17 Alkali Denaturasi / HBF 9,000 15,000 24,000 18 HbA2 23,000 46,000 69,000 19 Angka Eritrosit 6,000 11,000 17,000 20 Angka Leukosit 6,000 11,000 17,000 21 Angka Trombosit 6,000 11,000 17,000 22 Differential count 6,000 11,000 17,000 23 LED 4,000 7,000 11,000 24 Retraksi Bekuan 5,000 7,000 12,000 25 Serum Iron ( SI ) 29,000 58,000 87,000 26 Total Iron Binding Capacity ( TIBC ) 29,000 58,000 87,000 27 INR 13,000 32,000 45,000 28 OFT ( Screaning ) 9,000 15,000 24,000 29 OFT ( Semi Kuantitatif ) 15,000 26,000 41,000 30 HbF 21,000 37,000 58,000

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Faal Hemostasis1 Masa Jendal ( CT ) 4,000 9,000 13,000 2 Masa Pendarahan ( BT ) 3,000 5,000 8,000 3 PPT 40,000 65,000 105,000 4 APTT 70,000 130,000 200,000 5 APTT Substitusi 41,000 75,000 116,000 6 Fibrinogen 35,000 63,000 98,000 7 Fibrinogen Degradition Product ( FDP ) / D Dimer 58,000 115,000 173,000

Pewarnaan Sitokimia1 PAS 10,000 18,000 28,000 2 SBB 10,000 18,000 28,000 3 Peroksidase ( MPO ) 10,000 18,000 28,000 4 NSE 10,000 18,000 28,000 5 Pearl 10,000 18,000 28,000

II KIMIA KLINIKFaal Ginjal

1 Ureum 5,000 18,000 23,000 2 Kreatinin 5,000 18,000 23,000 3 Uric Acid 12,000 20,000 32,000 4 Urea Clearance 12,000 20,000 32,000

Faal Hati1 Bilirubin Direk 6,000 23,000 29,000 2 Bilirubin Total 6,000 23,000 29,000 3 Bilirubin Indirect 6,000 23,000 29,000 4 Bilirubin ( Urine ) 5,000 3,000 8,000 5 Total Protein 6,000 17,000 23,000 6 Albumin 6,000 17,000 23,000 7 Globulin 6,000 17,000 23,000 8 SGOT 6,000 23,000 29,000 9 SGPT 6,000 23,000 29,000 10 GGT 6,000 17,000 23,000 11 Alakali Fosfatase 7,000 17,000 24,000

Diabetes1 Gula Darah Puasa 9,000 16,000 25,000 2 Gula darah puasa 2 jam 9,000 16,000 25,000 3 Gula darah sewaktu 9,000 16,000 25,000 4 HbA1C ( AIC ) 46,000 92,000 138,000 5 Glukosa Stick 9,000 18,000 27,000

Lemak1 Cholesterol Total 6,000 17,000 23,000 2 Cholesterol HDL 15,000 29,000 44,000 3 Cholesterol LDL 18,000 41,000 59,000

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4 Trigilserida 7,000 25,000 32,000 5 HDL Direct 18,000 39,000 57,000 6 LDL Direct 23,000 41,000 64,000

ELEKTROLIT 58,000 98,000 156,000 1 Elektrolit Na + 18,000 35,000 53,000 2 Elektrolit K+ 18,000 35,000 53,000 3 Elektrolit Cl- 18,000 35,000 53,000

Lain - lain1 CKMB 52,000 98,000 150,000 2 LDH 23,000 46,000 69,000 3 Analisa Gas Darah dan Elektrolit 81,000 207,000 288,000 4 CK ( Creatine Kinase ) 52,000 98,000 150,000 5 Protein Elektroforesis 46,000 98,000 144,000 6 Mikro Albumin 46,000 81,000 127,000

III IMUNOLOGI1 TORCH 144,000 288,000 432,000 2 Torch IgM Rapid 144,000 288,000 432,000 3 Toxoplasma IgG IgM 35,000 81,000 116,000 4 Toxoplasma IgG 35,000 81,000 116,000 5 Rubela Ig.M 69,000 162,000 231,000 6 Rubella Ig.G 29,000 87,000 116,000 7 CMV Ig.M 69,000 138,000 207,000 8 CMV Ig.G 41,000 87,000 128,000

IV HEPATITIS1 HBsAg (ELFA ) 29,000 58,000 87,000 2 HBsAg Rapid 11,000 22,000 33,000 3 HBsAg ( Elisa ) 19,000 38,000 57,000 4 Anti HIV ( Elva ) 51,000 102,000 153,000 5 Anti HIV ( Elisa ) 23,000 44,000 67,000 6 Anti HIV ( Rapid ) 23,000 46,000 69,000 7 Ferritin 46,000 115,000 161,000 9 Anti HBs Elisa 46,000 75,000 121,000 10 Anti HBs Rapid 12,000 29,000 41,000

Anti HBS ( ELVA ) 45,000 109,000 154,000 11 Anti HCV Elisa 52,000 133,000 185,000 12 Anti HCV Rapid 18,000 41,000 59,000

Anti HCV ( ELVA ) 70,000 150,000 220,000 HBE/ Anti HBE 50,000 150,000 200,000

V INFEKSI LAIN1 TPHA 6,000 12,000 18,000 2 VDRL 5,000 9,000 14,000 3 DHF IgG IgM 46,000 115,000 161,000 4 Anti TB Rapid 18,000 41,000 59,000

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5 IgM Anti Leptospira 12,000 29,000 41,000 6 IgG Anti Leptospira 15,000 29,000 44,000 7 ICT Malaria 9,000 18,000 27,000 8 Widal 5,000 18,000 23,000 9 HIV Elisa 41,000 92,000 133,000 10 HIV Rapid 18,000 46,000 64,000

ß HCG ( ELVA ) 120,000 230,000 350,000 11 NSI 69,000 161,000 230,000

VI PETANDA TUMOR1 AFP 41,000 92,000 133,000 2 CEA 46,000 133,000 179,000 3 PSA 46,000 127,000 173,000 4 CA 15.3 92,000 230,000 322,000 5 CA 125 69,000 161,000 230,000 6 CA 19.9 104,000 242,000 346,000

VII FUNGSI THYROID1 Total Ig.E 58,000 115,000 173,000 2 T3 Total 35,000 81,000 116,000 3 FSH 58,000 115,000 173,000 4 T4 Total 35,000 81,000 116,000 5 Free T4 41,000 87,000 128,000

Free T4 (ELVA) 94,000 139,000 233,000 6 TSH 35,000 81,000 116,000

TSH ( ELVA ) 64,000 110,000 174,000 7 Free T3 52,000 115,000 167,000

VIII LAIN-LAIN1 RA / RF 23,000 46,000 69,000 2 ASTO 18,000 41,000 59,000 3 CRP 23,000 58,000 81,000 4 HBsAg ( Elisa ) 23,000 52,000 75,000 5 HBsAg Rapid 6,000 15,000 21,000 6 Tubex TF 12,000 35,000 47,000 7 HIV Elisa 46,000 92,000 138,000 8 HIV Rapid 23,000 46,000 69,000 9 Progesteron 52,000 161,000 213,000 10 Testosteron 46,000 150,000 196,000 11 Anti HP 18,000 47,000 65,000 12 Anti HP IgG

a. Troponin I 58,000 185,000 243,000 b. Mantoux Test 35,000 81,000 116,000

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IX MIKROBIOLOGI KULTUR URINEA KULTUR URINE1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

B KULTUR FAECES1 Kultur + sensi ( Manual ) 64,000 97,000 161,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

C KULTUR DARAH1 Kultur Anaerob ( Manual ) 74,000 110,400 184,400 2 Kultur Anaerob ( Alat) 92,000 190,000 282,000 3 Kultur + sensi ( Manual ) 65,000 97,000 162,000 4 Kultur + sensi ( Bactec ) 92,000 173,000 265,000 5 Kultur + sensi ( Manual ) 65,000 97,000 162,000 6 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

D SPUTUM1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

E USAPAN TENGGOROK1 Kultur + sensi ( Manual ) 39,000 27,000 66,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

F USAPAN LUKA1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

G CAIRAN CEREBROSPINAL1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

H CAIRAN PLEURA1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

I CAIRAN PERITONIUM1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

J CAIRAN PERICARDIUM1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

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K CAIRAN DRAIN1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

L CAIRAN ASCITES1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

M BIAKAN GALL1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

N BIAKAN AN AEROB1 Kultur + sensi ( Manual ) 65,000 97,000 162,000 2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000

X MIKROSKOPIK1 Sperma Direct 3,000 4,000 7,000 2 Cat Gram 5,000 10,000 15,000 3 BTA Sputum 6,000 9,000 15,000 4 Jamur / Spora 6,000 9,000 15,000 5 Trichomonas 7,000 11,000 18,000 6 Leptospira 7,000 11,000 18,000

a. Secret 6,000 9,000 15,000 b. BTA Lepral 19,000 28,000 47,000

7 Cat Giemsa 3,000 8,000 11,000

XI PEMERIKSAAN LAINNYAURINALISIS

1 Urine Rutin 6,000 15,000 21,000 2 Urin Protein 3,000 5,000 8,000 3 Urin Bilirubin 3,000 5,000 8,000 4 Urine Reduksi 3,000 5,000 8,000 5 Urin Urobilin 3,000 5,000 8,000 6 Analisa Sperma 18,000 32,000 50,000 7 Urine keton 3,000 5,000 8,000 8 Sedimen 3,000 5,000 8,000 9 Urine Bence Jones 3,000 5,000 8,000 10 Uji kehamilan/PP test 6,000 17,000 23,000 11 Uji kehamilan ( titrasi ) 15,000 23,000 38,000

XII ANALISIS FAECES1 Faeces Rutin 6,000 12,000 18,000 2 Faeces Amoeba 7,000 10,000 17,000 3 Faeces Consentrasi 7,000 10,000 17,000 4 Faeces Benzidin 7,000 10,000 17,000 5 Faeces Stercobilin 7,000 10,000 17,000

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XIII NARKOBA1 Urine Narkoba Amfetamin 13,000 27,000 40,000 2 Urine Narkoba THC 13,000 27,000 40,000 3 Urine Narkoba Morfine 13,000 27,000 40,000 4 Urine Narkoba Benzodiazefin 13,000 27,000 40,000 5 Urine Narkoba Meth Amphetamine 13,000 27,000 40,000

XIV ANALISA CAIRAN TUBUH LAIN1 Angka cell LCS 9,000 13,000 22,000 2 Diff Cell LCS 7,000 10,000 17,000 3 Pandy 5,000 7,000 12,000 4 Rivalta Test 5,000 7,000 12,000 5 Glukosa 7,000 10,000 17,000 6 Protein 7,000 10,000 17,000 7 Patologi Anatomi / Histopatologi Besar 182,000 343,000 525,000 8 Patologi Anatomi/Histopatologi sedang 106,000 269,000 375,000 9 Patologi Anatomi / Histopatologi kecil 81,000 228,000 309,000 10 Sitologi 86,000 128,000 214,000

XV PATOLOGI ANATOMIA Pemeriksaan Histopatologi1 Sedang

Pemeriksaan PA kecil (1-4 blok) 212,500 318,500 531,000 Biopsi endoscopy 1-2 blok 231,000 346,500 577,500 Bone marrow aspirasi atau biopsi 404,000 606,000 1,010,000 Bone marrow aspirasi dan biopsi 404,000 606,000 1,010,000 Kulit (1-4 blok) 350,000 525,000 875,000

2 CanggihBiopsi endoscopy 3 blok 404,000 606,000 1,010,000 Pemeriksaan PA sedang (5-8 blok) 572,500 858,500 1,431,000 Ca. Cervic stadium IB keatas 577,500 866,000 1,443,500 Pemeriksaan PA besar (>8 blok) 717,000 1,075,500 1,792,500 Ca. Cervic stadium IA, insitu 751,000 1,072,500 1,823,500

B Pemeriksaan SitologiKonsultasi dokter (tidak jadi FNAB) 15,000 - 15,000 Pap smear - kiriman slide 147,000 220,500 367,500 Pap smear - diambil di Lab PA 200,000 300,000 500,000

141,000 211,500 352,500

FNAB - kiriman slide 115,000 172,500 287,500 Cell Block 216,000 324,000 540,000 FNAB - diambil do Lab PA & di ruangan (superfisial) 230,000 345,000 575,000 Urine dan sputum seri 3 kali 224,000 336,000 560,000

600,000 900,000 1,500,000

C Frozen Zection

Urine, sputum dan sitologi eksfoliatif lainnya (bronkoskopi, broncial washing

FNAB - FNAB Deep (diluar Lab PA, Tuntunan USG / CT-Scan)

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Frozen Zection (FZ) pemeriksaan 1-2 blok 385,000 577,500 962,500 Frozen Zection (FZ) pemeriksaan >2 blok 462,000 639,000 1,101,000

1,425,000 2,137,500 3,562,500

2,310,000 3,465,000 5,775,000

D Histokimia1 Kecil

- 1 jenis pemeriksaan 65,000 97,500 162,500 - 2 jenis pemeriksaan 70,000 105,000 175,000 - 3 jenis pemeriksaan 90,000 135,000 225,000

2 SedangBone marrow aspirasi dan biopsi 180,000 162,000 342,000

E imunohistokimiaimunohistokimia 1 jenis pemeriksaan 200,000 300,000 500,000 imunohistokimia 2 jenis pemeriksaan 400,000 600,000 1,000,000 imunohistokimia 3 jenis pemeriksaan 450,000 675,000 1,125,000 imunohistokimia lebih dari 3 jenis pemeriksaan 1,000,000 1,500,000 2,500,000

F OtopsiOtopsi bahan kecil (1 organ) 650,000 975,000 1,625,000 Otopsi bahan sedang (2-3 organ) 1,400,000 2,100,000 3,500,000 Otopsi bahan besar (>3 organ) 2,100,000 3,150,000 5,250,000

II

A HistopatologiPemeriksaan PA kecil (1-4 blok) 145,000 217,500 362,500 Pemeriksaan Pa sedang (5-8 blok) 230,000 345,000 575,000 Pemeriksaan PA besar (>8 blok) 350,000 525,000 875,000 Ca. Cervic stadium IB keatas 300,000 450,000 750,000 Ca. Cervic stadium IA, insitu 350,000 525,000 875,000 kulit 145,000 217,500 362,500 Biopsi endoscopy 1-2 blok 145,000 217,500 362,500 Biopsi endoscopi 3 blok 170,000 255,000 425,000

B SitologiPap smear kiriman - 1 slide 40,000 60,000 100,000 Pap smear kiriman - 2 slide 50,000 75,000 125,000 Urine,sputum dan sitologi eksfoliatif lain 60,000 90,000 150,000 Bronkoskopi, bronchial washing 60,000 90,000 150,000 FNAB kiriman slide 40,000 60,000 100,000

Frozen Zection (FZ) dari Rumah Sakit Swasta pemeriksaan 1-2 blokFrozen Zection (FZ) dari Rumah Sakit Swasta pemeriksaan >2 blok

Tarif Prosesing tanpa pembacaan oleh spesialis patologi anatomi

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C Histokimia1 jenis pemeriksaan 40,000 60,000 100,000 2 jenis pemeriksaan 45,000 67,500 112,500 3 jenis pemeriksaan 55,000 82,500 137,500

D Imunohistokimiaimunohistokimia 1 jenis pemeriksaan 100,000 250,000 350,000 imunohistokimia 2 jenis pemeriksaan 150,000 400,000 550,000 imunohistokimia 3 jenis pemeriksaan 200,000 600,000 800,000 imunohistokimia lebih dari 3 jenis pemeriksaan 250,000 800,000 1,050,000

III Pemeriksaan yang disetarakan dengan PA kecila 110,000 165,000 275,000 b Papsmear / Vaginal Smear 110,000 165,000 275,000 c 110,000 165,000 275,000 d Sitologi scrapping 110,000 165,000 275,000

IV Pemeriksaan yang di setarakan dengan PA sedang 222,000 333,000 555,000 a FNA dengan tuntunan USG 222,000 333,000 555,000 b 222,000 333,000 555,000

V Pemeriksaan yangn disetarakan dengan PA besara FNA tumor paru dengan tuntunan CT-Scan 240,000 360,000 600,000 b 240,000 360,000 600,000

PELAYANAN FARMASIA BIAYA FARMASI

I

II BIAYA OBAT NON RACIKANHarga obat= (HNA+PPN)+25% keuntungan

III BIAYA OBAT RACIKAN

IV EMBALASE 1500/R

V Tuslah

- Obat Racikan 5000/R - Obat jadi 500/R

Catatan

E. PELAYANAN BANK DARAH

Sitologi tanpa histokimia (FNA tanpa tuntunan USG/CT-Scan)

Semua sitologi lain dengan pengecatan giemsa / papacicoulaon / Diff Quick

Sitologi Sputum dengan pengecatan Ziehl-nielsen(Histokimia)

FNA tumor jaringan lunak dan tulang dengan tuntunan CT-Scan

Untuk tarif layanan pelayanan kesehatan tidak termasuk obat-obatan

Harga obat racikan salep/krim/sirup = (HNA+PPN)+25% keuntungan+ 5.000 /pot/botolPelayanan obat pulveres/racikan kapsul=(HNA+PPN)+25% +1.000/kapsul/bungkus

Penggunaan bahan pakai habis di perhitungkan berdasaekan jumlaj bahan pakai habis yang dipakai termasuk spuit, maag selang, infus set, dll sesuai daftar bahan alat pakai habis kesehatan terlampi dalam lampiran IV

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1 Crossmacth ( metode gel ) 12,000 78,000 90,000 2 Golongan darah 5,000 10,000 15,000 3 Phlebotomy 25,000 150,000 175,000

F. PELAYANAN PEMULASARAN JENASAH / FORENSIK DAN MOBIL JENAZAH1 Pemeriksaan Jenasah 12,000 18,000 30,000 2 Konservasi / Pengawetan 350,000 275,000 625,000 3 Rekonstruksi Jenasah 92,000 138,000 230,000 4 Penitipan Jenasah tanpa pendingin / hari 15,000 100,000 115,000 5 Penitipan Jenasah dengan pendingin / hari 20,000 200,000 220,000 6 Perawatan Jenasah

a. Tanpa resiko 25,000 40,000 65,000 b. Dengan resiko 50,000 70,000 120,000

7 Visum Et Repertum - Luar 40,000 55,000 95,000 - Dalam / Otopsi 470,000 680,000 1,150,000

8 Biaya mobil jenazaha. Dalam kota 80,000 120,000 200,000

b. Luar kota/km 2,000 3,000 5,000

1 Gaas Kecil 250 250 500 2 Gaas Besar 250 500 750 3 Buiq Gaas (bungkus) 2,000 8,000 10,000 4 Gaas waten tanpa kapas 1,000 1,000 2,000 5 Gaas waten dengan kapas 1,000 1,000 2,000 6 Gaas mata 1,000 1,000 2,000 7 Tampon Vagina 500 2,000 2,500 8 Papan Spalk ukuran 100 cm 5,000 25,000 30,000 9 Papan Spalk ukuran 50 cm 3,000 15,000 18,000 10 Ransel Verband 10,000 37,000 47,000 11 Deppers HD dan Tonsil 20,000 50,000 70,000 12 Tampon Gigi 23,000 35,000 58,000 13 Donat 2,000 13,000 15,000 14 Tampon tanpa Boorzalft (bungkus) 1,000 3,000 4,000 15 Tampon dengan Boorzalft (bungkus) 2,000 5,000 7,000 16 Lidi Kapas (bungkus) 12,000 18,000 30,000 17 Kapas Savlon (bungkus) 5,000 15,000 20,000 18 Kapas Alkohol (Bungkus) 5,000 10,000 15,000 19 Kapas potong segi empat 5,000 20,000 25,000 20 Benang tali pusat 5,000 20,000 25,000 21 Sterilisasi Handscun 2,000 5,000 7,000 22 Sterilisasi Instrumen dari unit RS 1,000 5,000 6,000 23 Sterilisasi Instrumen dari luar RS / Kilo 5,000 10,000 15,000 24 Loundry / kg 1,000 3,000 4,000

H. PELAYANAN GIZI1 Konsultasi Gizi

a. VVIP 20,000 10,000 30,000

tidak termasuk penyeberangan

G. PELAYANAN STERILISASI DAN LOUNDRY

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b. VIP 15,000 8,000 23,000 c. Kelas I, Kelas II, Kelas III, ICU 10,000 7,000 17,000 d. PICU/ NICU 10,000 7,000 17,000 Jika ada diit

I. PELAYANAN PENUNJANG MEDIK LAINNYA

1 Incinerator 20,000 287,000 307,000

2 1,000 3,000 4,000 per kilogram

GUBERNUR NUSA TENGGARA BARAT,

ttd.

H. M. ZAINUL MAJDI

Per kali operasional/ 150

KgPenambahan biaya per kg setelah berat 150 Kg per satuan kg sampai dengan berat maksimal 200 kg

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LAMPIRAN IIPERATURAN GUBERNUR NUSA TENGGARA BARATNOMOR TAHUN 2018

TARIF LAYANAN NON PELAYANAN KESEHATAN

I. PENDIDIKAN DAN PELATIHAN

NO URAIAN TARIF (Rp) KETERANGAN(1) (2) (3) (4) (5) (6)1 Praktek Klinik dokter muda 35,000 55,000 90,000 orang/minggu2 Praktek Klinik keperawatan 25,000 45,000 70,000 orang/minggu3 Praktek Klinik kebidanan 25,000 45,000 70,000 orang/minggu4 Seminar 150,000 50,000 200,000 kali/pembimbing/Org5 Narasumber 250,000 250,000 kali/Pertemuan

II. PENELITIAN

NO URAIAN TARIF (Rp) KETERANGAN(1) (2) (3) (4) (5) (6)

1 30,000 50,000 80,000 orang/judul

2 50,000 100,000 150,000 orang/judul

3 4,000 6,000 10,000 per berkas

III. KANTIN

NO URAIAN TARIF (Rp) KETERANGAN(1) (2) (3) (4) (5) (6)1 sewa kantin 10,000 50,000 60,000

IV. SEWA RUANG/AULA dan PERLENGKAPAN

NO URAIAN TARIF (Rp) KETERANGAN(1) (2) (3) (4) (5) (6)1 sewa ruang/aula 15,000 250,000 265,000 per hari2 Sewa alat/ peralatan presentasi 10,000 20,000 Audio Video

GUBERNUR NUSA TENGGARA BARAT,

ttd.

H. M. ZAINUL MAJDI

TENTANG TARIF PELAYANAN KESEHATAN PADA RUMAH SAKIT H.L. MANAMBAI ABDUL KADIR PROVINSI NUSA TENGGARA BARAT

JASA PELAYANAN

(Rp)

JASA SARANA

(Rp)

JASA PELAYANAN

(Rp)

JASA SARANA

(Rp)

Penerbitan Izin Penelitian/Pengambilan data Mahasiswa DIII/D IVPenerbitan Izin Penelitian/Pengambilan data Mahasiswa S1Penggunaan berkas untuk penelitian

JASA PELAYANAN

(Rp)

JASA SARANA

(Rp)

per meter persegi/ bulan

JASA PELAYANAN

(Rp)

JASA SARANA

(Rp)

Documents

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