Daftar bahan habis pakai di Kamar Operasi

operasi sedang
No

Nama barang
Kemasan

1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Petidin
Atracium
Progstigmin
Ketamin
Succinil cholin
Sulfas Atropin
Halotan
Recofol

10 ampul
5 ampul
5 ampul
1 vial
Vial
100 ampul
Btl 100 ml
1 ampul

Kassa
alkohol
Hipapic
plane 2/0
plane 1
crom 2/0
bisturi
hand scoon
hibiscraff
masker
Nald No.3
Nald No.10
Nald kulit
rinso
bayclin
kantong plasti

1 gulung
1 liter
1 gulung
1 kotak
1 kotak
1 kotak
1 ltr

1 btl

Harga per
Kemasan
149,903.00
506,000.00
79,062.00
154,000.00
173,368.00
288,000.00
1,393,325.00
99,000.00

Pemakaian
rata-rata / pasien

ampul
1 ampul
3 ampul
1/5 vial
vial
4 ampul
1,5 ml
1 ampul

7,500.00
101,120.00
47,500.00
30,800.00
86,684.00
1,150.00
20,803.00
99,000.00

3 ikat

29,400.00

50 ml

1,500.00

10 x 25

6,000.00

100 cm

17,900.00

100 cm

17,900.00

80 cm

17,300.00

1 buah

2,600.00

5 psg

12,650.00

100 ml

29,800.00

7 buah

7,700.00

1 buah

4,100.00

1 buah

4,100.00

1 buah

4,100.00

1 bgks

500.00

50 ml

500.00

1 buah
Total

1,600,000.00
560,000.00

Total biaya

JASA MANAGEMEN
JASA YANMED
180,000.00

500.00
551,107.00

IX

REHABILITASI MEDIS
T
Kelas III
NO.

JENIS PELAYANAN
unit cost

1
2
3

Sedehana
Sedang
Latihan Di Tempat (Zaal)

6,000
12,500
2,500

pos
Jasa
remuneras
Pelayanan
i
4

10,000
34,000
10,000

tarif
5

2,000
8,500
2,500

19,000
55,000
15,000

Kelas II
Jasa
pos
unit cost Pelayana remuner
n
asi
6

7,800
16,250
3,250

13,000
44,200
13,000

tarif
8

2,600
11,050
3,250

24,700
12,000
12,000

(Rp)

(Rp)

Kelas I
pos
Jasa
unit cost
remuneras
Pelayanan
i
9

8,700
18,125
3,625

10

14,500
49,300
14,500

2,900
12,325
3,625

VIP
tarif

unit cost

11

12

27,550
16,000
15,000

9,900
20,625
4,125

pos
Jasa
remuneras
Pelayanan
i
13

tarif
14

16,500
56,100
16,500

3,300
14,025
4,125

31,350
22,000
22,000

VII. MEDICAL INTERVENTION

T
Kelas III
NO.

JENIS PELAYANAN
unit cost

Kelas II

Jasa
pos
Pelayanan remunerasi
4

Jumlah

unit cost

Jasa
Pelayanan

a
b
c
d
e
f
g
h
i

Kecil I
Tindik Kuping Wanita
Sunat Wanita
Uf Drainage
Suntik
Buka Jahitan
Combotio < 5%
Pasang Oksigen
Shosten (Drumbest)
Suction

5,000
5,000
5,000
5,000
5,000
5,000
7,500
5,000
7,500

15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000

2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250

22,250
22,250
22,250
22,250
22,250
22,250
24,750
22,250
24,750

6,500
6,500
6,500
6,500
6,500
6,500
9,750
6,500
9,750

19,500
19,500
19,500
19,500
19,500
19,500
19,500
19,500
19,500

a
b
c
d
e
f
g
h
i
j
k
l
m

Kecil II
Skin Tractor
GV pada Ulnus DM
Pasang Cytosstatika
Spoel WSD
Af WSD
Necrotomi
Debridement Ringan
Combotio 5 - 10%
Irigasi Telinga
Irigasi Mata
Angkat Clopus
Pasang Gip Tanpa Narcose
Robet Jones Bandage

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000

4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500

37,000
37,000
37,000
37,000
37,000
37,000
37,000
37,000
37,000
37,000
37,000
37,000
37,000

9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750

32,500
32,500
32,500
32,500
32,500
32,500
32,500
32,500
32,500
32,500
32,500
32,500
32,500

a
b
c
d
c
d
e
f
g
h
i
j
k
l
m
n

Sedang
Pasang kateter
Pasang infus
Pasang Mag Slang
SPP
Pro Fungsi
Geric Surgery
Hidroturbasi
Pemasangan T Pice
Thest Fistel Metyline Blue
Pasang/angkat Susuk KB
Catheter dengan Mandrin
Catheter dgn Cytostomi
Silaktasi
Tampon
Aspirasi Sendi
Peturbasi

50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000

25,000
25,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000
35,000

3,750
3,750
5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250

78,750
78,750
90,250
90,250
90,250
90,250
90,250
90,250
90,250
90,250
90,250
90,250
90,250
90,250
90,250
90,250

50,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000

30,000
45,500
45,500
45,500
45,500
45,500
45,500
45,500
45,500
45,500
45,500
45,500
45,500
45,500
45,500

Transfusi Vena Sectie

Fototherapi
Long Armplaster
Diet per NGT/ hari
Resusitasi Cardiopulmonal
Pasang infus tranfusi
Terafi Nebulizer
Hukna/ klisma

50,000
50,000
50,000
5,000
5,000
65,000
5,000
5,000

35,000
35,000
35,000
35,000
50,000
25,000
25,000
25,000

5,250
5,250
5,250
5,250
7,500
3,750
3,750
3,750

90,250
90,250
90,250
45,250
62,500
93,750
33,750
33,750

65,000
65,000
65,000
6,500
6,500
84500
6500
6500

45,500
45,500
45,500
45,500
65,000

a
b
c
d
e
f
g
h
i
j

Besar
Cuci Lambung/Cooling,Spol
Pasang body gast
Exchange Tranfusi
Sholder Spice
Balance Traktion
Pelvic/Lumbal Traction
Pasang Endhotracheal Tube
Infusion Pump
Vena Seksi
Body Jacket

50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000

50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000

7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500
7,500

107,500
107,500
107,500
107,500
107,500
107,500
107,500
107,500
107,500
107,500

65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000

65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000

a
b
c
e

Khusus
Minerve Jacket
Scoliosis (EDF)
Perawatan Intensive Bayi Patologis
Brancial Wosing

50,000
50,000
50,000
50,000

50,000
50,000
50,000
50,000

7,500
7,500
7,500
7,500

107,500
107,500
107,500
107,500

65,000
65,000
65,000
65,000

65,000
65,000
65,000
65,000

o
p
q
r
d
e
f
g
h
D

(Rp)

Kelas II

Kelas I

pos
remunerasi

Jumlah

unit cost

VIP

Jasa
pos
Pelayanan remunerasi
10

Jumlah

unit cost

11

12

pos
Jasa
remunera
Pelayanan
si
13

Jumlah
14

2,925
2,925
2,925
2,925
2,925
2,925
2,925
2,925
2,925

28,925
28,925
28,925
28,925
28,925
28,925
32,175
28,925
32,175

7,250
7,250
7,250
7,250
7,250
7,250
10,875
7,250
10,875

21,750
21,750
21,750
21,750
21,750
21,750
21,750
21,750
21,750

3,263
3,263
3,263
3,263
3,263
3,263
3,263
3,263
3,263

32,263
32,263
32,263
32,263
32,263
32,263
35,888
32,263
35,888

8,700
8,700
8,700
8,700
8,700
8,700
13,050
8,700
13,050

26,100
26,100
26,100
26,100
26,100
26,100
26,100
26,100
26,100

3,915
3,915
3,915
3,915
3,915
3,915
3,915
3,915
3,915

38,715
38,715
38,715
38,715
38,715
38,715
43,065
38,715
43,065

5,850
5,850
5,850
5,850
5,850
5,850
5,850
5,850
5,850
5,850
5,850
5,850
5,850

48,100
48,100
48,100
48,100
48,100
48,100
48,100
48,100
48,100
48,100
48,100
48,100
48,100

11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213

37,375
37,375
37,375
37,375
37,375
37,375
37,375
37,375
37,375
37,375
37,375
37,375
37,375

6,728
6,728
6,728
6,728
6,728
6,728
6,728
6,728
6,728
6,728
6,728
6,728
6,728

55,315
55,315
55,315
55,315
55,315
55,315
55,315
55,315
55,315
55,315
55,315
55,315
55,315

13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455

44,850
44,850
44,850
44,850
44,850
44,850
44,850
44,850
44,850
44,850
44,850
44,850
44,850

8,073
8,073
8,073
8,073
8,073
8,073
8,073
8,073
8,073
8,073
8,073
8,073
8,073

66,378
66,378
66,378
66,378
66,378
66,378
66,378
66,378
66,378
66,378
66,378
66,378
66,378

4,500
6,825
6,825
6,825
6,825
6,825
6,825
6,825
6,825
6,825
6,825
6,825
6,825
6,825
6,825

84,500
117,325
117,325
117,325
117,325
117,325
117,325
117,325
117,325
117,325
117,325
117,325
117,325
117,325
117,325

57,500
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750

34,500
52,325
52,325
52,325
52,325
52,325
52,325
52,325
52,325
52,325
52,325
52,325
52,325
52,325
52,325

5,175
7,849
7,849
7,849
7,849
7,849
7,849
7,849
7,849
7,849
7,849
7,849
7,849
7,849
7,849

97,175
134,924
134,924
134,924
134,924
134,924
134,924
134,924
134,924
134,924
134,924
134,924
134,924
134,924
134,924

69,000
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700

41,400
62,790
62,790
62,790
62,790
62,790
62,790
62,790
62,790
62,790
62,790
62,790
62,790
62,790
62,790

6,210
9,419
9,419
9,419
9,419
9,419
9,419
9,419
9,419
9,419
9,419
9,419
9,419
9,419
9,419

116,610
161,909
161,909
161,909
161,909
161,909
161,909
161,909
161,909
161,909
161,909
161,909
161,909
161,909
161,909

6,825
6,825
6,825
6,825
9,750

117,325
117,325
117,325
58,825
81,250

74,750
74,750
74,750
7,475
7,475
97175
7475
7475

52,325
52,325
52,325
52,325
74,750

7,849
7,849
7,849
7,849
11,213

134,924
134,924
134,924
67,649
93,438

89,700
89,700
89,700
8,970
8,970
116610
8970
8970

62,790
62,790
62,790
62,790
89,700

9,419
9,419
9,419
9,419
13,455

161,909
161,909
161,909
81,179
112,125

9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750
9,750

139,750
139,750
139,750
139,750
139,750
139,750
139,750
139,750
139,750
139,750

74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750

74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750
74,750

11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213
11,213

160,713
160,713
160,713
160,713
160,713
160,713
160,713
160,713
160,713
160,713

89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700

89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700
89,700

13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455
13,455

192,855
192,855
192,855
192,855
192,855
192,855
192,855
192,855
192,855
192,855

9,750
9,750
9,750
9,750

139,750
139,750
139,750
139,750

74,750
74,750
74,750
74,750

74,750
74,750
74,750
74,750

11,213
11,213
11,213
11,213

160,713
160,713
160,713
160,713

89,700
89,700
89,700
89,700

89,700
89,700
89,700
89,700

13,455
13,455
13,455
13,455

192,855
192,855
192,855
192,855

IV. PEMERIKSAAN LABORATORIUM

T
NO.

Kelas III

JENIS PELAYANAN
unit cost

A
1
a
b
c
d
e
f
g
h
i
j
k
2
a
b
c
d
3
a
b
4
a
b
c

SEDERHANA
Hematologi
LED
Thrombocyt
Erythrocyt
Haematokrit
Hitung Jenis Leokocyt
Retyculocyt
Waktu Pendarahan
Waktu Penjendalan
Golongan Darah
Haemoglobin
Sel LE
Urine
Protein
Reduksi
Bilirubin
Sedimen
Tinja
Tl. Cacing
Amuba
Parasitologi
Malaria
Filaria
Jamur

4 Darah Rutin
5 Urine Rutin

(Rp)

Kelas II

Jasa
pos
Pelayanan remunerasi
4

tarif

unit cost

Kelas I

Jasa
pos
Pelayanan remunerasi
7

tarif

unit cost

VIP

Jasa
pos
Pelayanan remunerasi
10

tarif

unit cost

11

12

jasa
pos
pelayanan remunerasi

tarif
14

2,730
2,730
2,730
2,730
2,730
2,730
2,730
2,730
2,730
2,730
2,730

995
995
995
995
995
995
995
995
995
995
995

176
176
176
176
176
176
176
176
176
176
176

3,900
3,900
3,900
3,900
3,900
3,900
3,900
3,900
3,900
3,900
3,900

3,640
3,640
3,640
3,640
3,640
3,640
3,640
3,640
3,640
3,640
3,640

1,326
1,326
1,326
1,326
1,326
1,326
1,326
1,326
1,326
1,326
1,326

234
234
234
234
234
234
234
234
234
234
234

5,200
5,200
5,200
5,200
5,200
5,200
5,200
5,200
5,200
5,200
5,200

3,850
3,850
3,850
3,850
3,850
3,850
3,850
3,850
3,850
3,850
3,850

1,403
1,403
1,403
1,403
1,403
1,403
1,403
1,403
1,403
1,403
1,403

248
248
248
248
248
248
248
248
248
248
248

5,500
5,500
5,500
5,500
5,500
5,500
5,500
5,500
5,500
5,500
5,500

4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550

6,500
6,500
6,500
6,500
6,500
6,500
6,500
6,500
6,500
6,500
6,500

2,730
2,730
2,730
2,730

995
995
995
995

176
176
176
176

3,900
3,900
3,900
3,900

3,640
3,640
3,640
3,640

1,326
1,326
1,326
1,326

234
234
234
234

5,200
5,200
5,200
5,200

3,850
3,850
3,850
3,850

1,403
1,403
1,403
1,403

248
248
248
248

5,500
5,500
5,500
5,500

4,550
4,550
4,550
4,550

6,500
6,500
6,500
6,500

2,730
2,730

995
995

176
176

3,900
3,900

3,640
3,640

1,326
1,326

234
234

5,200
5,200

3,850
3,850

1,403
1,403

248
248

5,500
5,500

4,550
4,550

6,500
6,500

2,730
2,730
2,730

995
995
995

176
176
176

3,900
3,900
3,900

3,640
3,640
3,640

1,326
1,326
1,326

234
234
234

5,200
5,200
5,200

3,850
3,850
3,850

1,403
1,403
1,403

248
248
248

5,500
5,500
5,500

4,550
4,550
4,550

6,500
6,500
6,500

4,200
4,200

1,530
1,530

270
270

6,000
6,000

5,250
5,250

1,913
1,913

338
338

7,500
7,500

5,600
5,600

2,040
2,040

360
360

8,000
8,000

6,300
6,300

9,000
9,000

6 Faeces Rutin

4,200

1,530

270

6,000

5,250

1,913

338

7,500

5,600

2,040

360

8,000

6,300
-

9,000

SEDANG I
1 Hematologi
Gambaran darah Tepi

8,050

2,933

518

11,500

9,450

3,443

608

13,500

10,500

3,825

675

15,000

11,900

17,000

2 Tinja
Darah Samar

8,050

2,933

518

11,500

9,450

3,443

608

13,500

10,500

3,825

675

15,000

11,900

17,000

3
a
b
c
d

Sp/Bakterio Sld
BTA
Nesseria
Mikroorganisme lain
Analisa Sperma

8,050
8,050
8,050
8,050

2,933
2,933
2,933
2,933

518
518
518
518

11,500
11,500
11,500
11,500

9,450
9,450
9,450
9,450

3,443
3,443
3,443
3,443

608
608
608
608

13,500
13,500
13,500
13,500

10,500
10,500
10,500
10,500

3,825
3,825
3,825
3,825

675
675
675
675

15,000
15,000
15,000
15,000

11,900
11,900
11,900
11,900

17,000
17,000
17,000
17,000

4
a
b
c
d
e
f
g
h
i
j
k

Kimia Darah
Ureum
Creatinin Darah
Creatinin Urine
Gula Darah
Albumin
Uric Acid
Protein Total
Bilirubin Total
Lipase Darah
Fosfatassa Asam
Fosfatassa Basa

8,050
8,050
8,050
8,050
8,050
8,050
8,050
8,050
8,050
8,050
8,050

2,933
2,933
2,933
2,933
2,933
2,933
2,933
2,933
2,933
2,933
2,933

518
518
518
518
518
518
518
518
518
518
518

11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500

9,450
9,450
9,450
9,450
9,450
9,450
9,450
9,450
9,450
9,450
9,450

3,443
3,443
3,443
3,443
3,443
3,443
3,443
3,443
3,443
3,443
3,443

608
608
608
608
608
608
608
608
608
608
608

13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500

10,500
10,500
10,500
10,500
10,500
10,500
10,500
10,500
10,500
10,500
10,500

3,825
3,825
3,825
3,825
3,825
3,825
3,825
3,825
3,825
3,825
3,825

675
675
675
675
675
675
675
675
675
675
675

15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000

11,900
11,900
11,900
11,900
11,900
11,900
11,900
11,900
11,900
11,900
11,900

17,000
17,000
17,000
17,000
17,000
17,000
17,000
17,000
17,000
17,000
17,000

1
a
b
c
d
e
f

SEDANG II
Kimia Darah
Kholesterol
Total Lipid
L DL
SGPT
SGOT
HDL

10,150
10,150
10,150
10,150
10,150
10,150

3,698
3,698
3,698
3,698
3,698
3,698

653
653
653
653
653
653

14,500
14,500
14,500
14,500
14,500
14,500

11,900
11,900
11,900
11,900
11,900
11,900

4,335
4,335
4,335
4,335
4,335
4,335

765
765
765
765
765
765

17,000
17,000
17,000
17,000
17,000
17,000

13,650
13,650
13,650
13,650
13,650
13,650

4,973
4,973
4,973
4,973
4,973
4,973

878
878
878
878
878
878

19,500
19,500
19,500
19,500
19,500
19,500

15,750
15,750
15,750
15,750
15,750
15,750

22,500
22,500
22,500
22,500
22,500
22,500

10,150

3,698

653

14,500

11,900

4,335

765

17,000

13,650

4,973

878

19,500

15,750

22,500

2 Immunologi/Serologi
a Plano Test Kehamilan

b Widal
c Papsmear
d HbsAg

10,150
10,150
10,150

3,698
3,698
3,698

653
653
653

14,500
14,500
14,500

11,900
11,900
11,900

4,335
4,335
4,335

765
765
765

17,000
17,000
17,000

13,650
13,650
13,650

4,973
4,973
4,973

878
878
878

19,500
19,500
19,500

15,750
15,750
15,750

22,500
22,500
22,500

V. PEMERIKSAAN DIAGNOSTIK
T
NO.

Kelas III

JENIS PELAYANAN
unit cost

(Rp)

Kelas II

Jasa
pos
Pelayanan remunerasi

Kelas I

Jasa
pos
Pelayanan remunerasi

tarif

unit cost

tarif

unit cost

VIP

Jasa
pos
Pelayanan remunerasi
10

tarif

unit cost

tarif

11

12

14

1.
a
b
c
d
e

PEMERIKSAAN RADIOLOGI
Sederhana
Os Orbita
Os. Nasale
Os. Zigomatikum
Finger
Os. Mandibula

17,250
17,250
17,250
17,250
17,250

15,094
15,094
15,094
15,094
15,094

2,156
2,156
2,156
2,156
2,156

34,500
34,500
34,500
34,500
34,500

19,250
19,250
19,250
19,250
19,250

16,844
16,844
16,844
16,844
16,844

2,406
2,406
2,406
2,406
2,406

38,500
38,500
38,500
38,500
38,500

22,500
22,500
22,500
22,500
22,500

19,688
19,688
19,688
19,688
19,688

2,813
2,813
2,813
2,813
2,813

45,000
45,000
45,000
45,000
45,000

24,500
24,500
24,500
24,500
24,500

49,000
49,000
49,000
49,000
49,000

2
a
b
c
d
e
f

Sederhana I
Thorax
BNO/Abdomen
Tulang Belakang
Pelvis
Schedal
Cewrvicel

19,250
19,250
19,250
19,250
19,250
19,250

16,844
16,844
16,844
16,844
16,844
16,844

2,406
2,406
2,406
2,406
2,406
2,406

38,500
38,500
38,500
38,500
38,500
38,500

21,000
21,000
21,000
21,000
21,000
21,000

18,375
18,375
18,375
18,375
18,375
18,375

2,625
2,625
2,625
2,625
2,625
2,625

42,000
42,000
42,000
42,000
42,000
42,000

25,500
25,500
25,500
25,500
25,500
25,500

22,313
22,313
22,313
22,313
22,313
22,313

3,188
3,188
3,188
3,188
3,188
3,188

51,000
51,000
51,000
51,000
51,000
51,000

28,500
28,500
28,500
28,500
28,500
28,500

57,000
57,000
57,000
57,000
57,000
57,000

3
a
b
c
d

Sedang
Barium Meal
Pelvimetri
Panoramic
Bone Survey

73,250
73,250
73,250
73,250

64,094
64,094
64,094
64,094

9,156
9,156
9,156
9,156

146,500
146,500
146,500
146,500

82,500
82,500
82,500
82,500

72,188
72,188
72,188
72,188

10,313
10,313
10,313
10,313

165,000
165,000
165,000
165,000

88,250
88,250
88,250
88,250

77,219
77,219
77,219
77,219

11,031
11,031
11,031
11,031

176,500
176,500
176,500
176,500

92,500
92,500
92,500
92,500

185,000
185,000
185,000
185,000

4
a
b
c
d
e

Canggih
IVP
OMD
Cystografi
Colon Inlop
Urethografi

130,750
130,750
130,750
130,750
130,750

114,406
114,406
114,406
114,406
114,406

16,344
16,344
16,344
16,344
16,344

261,500
261,500
261,500
261,500
261,500

142,750
142,750
142,750
142,750
142,750

124,906
124,906
124,906
124,906
124,906

17,844
17,844
17,844
17,844
17,844

285,500
285,500
285,500
285,500
285,500

148,250
148,250
148,250
148,250
148,250

129,719
129,719
129,719
129,719
129,719

18,531
18,531
18,531
18,531
18,531

296,500
296,500
296,500
296,500
296,500

152,500
152,500
152,500
152,500
152,500

305,000
305,000
305,000
305,000
305,000

2 Elektro Medik
a Elektrocardiografi (ECG)
b USG

8,000

10,000

2,000

20,000

12,000

15,000

3,000

30,000

14,000

17,500

3,500

35,000

16,000

40,000

16,000

20,000

4,000

40,000

20,000

25,000

5,000

50,000

22,000

27,500

5,500

55,000

24,000

60,000

VI. TINDAKAN MEDIK/THERAPI

T
NO.

Kelas III

JENIS PELAYANAN
unit cost

(Rp)

Kelas II

Jasa
pos
Pelayanan remunerasi

Kelas I

Jasa
pos
Pelayanan remunerasi

Jumlah

unit cost

VIP

Jasa
pos
Pelayanan remunerasi

Jumlah

unit cost

10

Jumlah

unit cost

11

12

jasa
pos
pelayanan remunerasi

Jumlah

15,625
31,000
38,000

37,500
46,500
57,000

9,375
11,625
14,250

62,500
77,500
95,000

22,500
42,000
50,000

54,000
63,000
75,000

13,500
15,750
18,750

90,000
105,000
125,000

33,750
64,000
80,000

81,000
96,000
120,000

20,250
24,000
30,000

135,000
160,000
200,000

33,750
92,000
110,000

135,000
230,000
275,000

2 Partus dgn Patologi (Spontan)

- Episiotomi

42,500

102,000

25,500

170,000

53,750

129,000

32,250

215,000

62,500

150,000

37,500

250,000

75,000

300,000

3
a
b
c
d
e
f

Partus dgn Patologi Tindakan

Vakumektrasi/Eks Forcep
Embriotomi
Letak Sungsang
Manual Plasenta
Eksplorasi Sisa Plasenta
Robekan Cervik

80,313
80,313
80,313
75,000
80,313
75,000

192,750
192,750
192,750
180,000
192,750
180,000

48,188
48,188
48,188
45,000
48,188
45,000

321,250
321,250
321,250
300,000
321,250
300,000

97,813
97,813
97,813
87,500
97,813
87,500

234,750
234,750
234,750
210,000
234,750
210,000

58,688
58,688
58,688
52,500
58,688
52,500

391,250
391,250
391,250
350,000
391,250
350,000

124,063
124,063
124,063
100,000
124,063
100,000

297,750
297,750
297,750
240,000
297,750
240,000

74,438
74,438
74,438
60,000
74,438
60,000

496,250
496,250
496,250
400,000
496,250
400,000

164,063
164,063
164,063
137,500
164,063
137,500

656,250
656,250
656,250
550,000
656,250
550,000

a
b
c
d
e
f
g
h
i
j

TINDAKAN MEDIK LAIN NON OPERATIF

Punksi Sumsum Tulang
19,875
Pemasangan SB Tube
20,000
Punksi Pangkard
19,625
Biopsi
18,788
Punksi Sendi
18,375
CVP
22,500
Pungsi Thyroid
23,375
Cardio Versislektif
22,500
Lumbal Punksi
17,125
Pleura Punksi
17,125

47,700
48,000
47,100
45,090
44,100
54,000
56,100
54,000
41,100
41,100

11,925
12,000
11,775
11,273
11,025
13,500
14,025
13,500
10,275
10,275

79,500
80,000
78,500
75,150
73,500
90,000
93,500
90,000
68,500
68,500

26,125
26,250
28,375
24,413
25,875
30,000
30,875
30,000
20,250
20,250

62,700
63,000
68,100
58,590
62,100
72,000
74,100
72,000
48,600
48,600

15,675
15,750
17,025
14,648
15,525
18,000
18,525
18,000
12,150
12,150

104,500
105,000
113,500
97,650
103,500
120,000
123,500
120,000
81,000
81,000

33,625
33,750
38,375
31,913
33,375
33,750
34,625
33,750
25,875
25,875

80,700
81,000
92,100
76,590
80,100
81,000
83,100
81,000
62,100
62,100

20,175
20,250
23,025
19,148
20,025
20,250
20,775
20,250
15,525
15,525

134,500
135,000
153,500
127,650
133,500
135,000
138,500
135,000
103,500
103,500

44,875
47,500
47,125
45,663
44,625
45,000
48,375
47,500
3,338
3,338

179,500
190,000
188,500
182,650
178,500
180,000
193,500
190,000
13,350
13,350

A
1
a
b
d

KEBIDANAN DAN KANDUNGAN

Partus Normal
Oleh Bidan
Oleh Dokter Umum
Oleh Dokter Spesialis

14

k WSD
l Punksi Ascites
m Subdural Punksi
n Intratekal Therapi
o Supra Pubik Punksi
p Resusitasi Ringan
q Resusitasi Sedang
r Resusitasi Berat

12,500
17,125
17,125

30,000
41,100
41,100

7,500
10,275
10,275

50,000
68,500
68,500

18,750
20,250
20,250

45,000
48,600
48,600

11,250
12,150
12,150

75,000
81,000
81,000

22,500
25,875
25,875

54,000
62,100
62,100

13,500
15,525
15,525

90,000
103,500
103,500

2,875
3,338
3,338

11,500
13,350
13,350

12,500
17,125
4,125
7,000
10,500

30,000
41,100
9,900
16,800
25,200

7,500
10,275
2,475
4,200
6,300

50,000
68,500
16,500
28,000
42,000

15,625
20,250
5,375
10,125
13,625

37,500
48,600
12,900
24,300
32,700

9,375
12,150
3,225
6,075
8,175

62,500
81,000
21,500
40,500
54,500

21,250
25,875
8,500
14,500
19,250

51,000
62,100
20,400
34,800
46,200

12,750
15,525
5,100
8,700
11,550

85,000
103,500
34,000
58,000
77,000

33,375
3,338
10,375
19,500
26,750

133,500
13,350
41,500
78,000
107,000

VII. MEDICAL INTERVENTION

T
NO.

JENIS PELAYANAN

Kelas III
pos
Jasa
unit cost
remunera
Pelayanan
si
3

(Rp)

Kelas II

Kelas I

pos
Jasa
remunera Jumlah
Pelayanan
si

Jumlah

unit cost

unit cost
9

VIP

pos
Jasa
remuneras
Pelayanan
i
10

Jumlah

unit cost

Jumlah

11

12

14

a
b
c
d
e
f
g
h

Kecil I
Tindik Kuping Wanita
Sunat Wanita
Af Drainage
Suntik
Buka Jahitan
Combotio < 5%
Pasang Oksigen
Shosten (Drumbest)

2,625
2,625
2,625
2,625
2,625
2,625
2,625
2,625

6,300
6,300
6,300
6,300
6,300
6,300
6,300
6,300

1,575
1,575
1,575
1,575
1,575
1,575
1,575
1,575

10,500
10,500
10,500
10,500
10,500
10,500
10,500
10,500

3,000
3,000
3,000
3,000
3,000
3,000
3,000
3,000

7,200
7,200
7,200
7,200
7,200
7,200
7,200
7,200

1,800
1,800
1,800
1,800
1,800
1,800
1,800
1,800

12,000
12,000
12,000
12,000
12,000
12,000
12,000
12,000

3,875
3,875
3,875
3,875
3,875
3,875
3,875
3,875

9,300
9,300
9,300
9,300
9,300
9,300
9,300
9,300

2,325
2,325
2,325
2,325
2,325
2,325
2,325
2,325

15,500
15,500
15,500
15,500
15,500
15,500
15,500
15,500

5,250
5,250
5,250
5,250
5,250
5,250
5,250
5,250

21,000
21,000
21,000
21,000
21,000
21,000
21,000
21,000

a
b
c
d
e
f
g
h
i
j
k
l
m

Kecil II
Skin Tractor
GV pada Ulnus DM
Pasang Cytosstatika
Spoel WSD
Af WSD
Necrotomi
Debridement Ringan
Combotio 5 - 10%
Irigasi Telinga
Irigasi Mata
Angkat Clopus
Pasang Gip Tanpa Narcose
Robet Jones Bandage

3,750
3,750
3,750
3,750
3,750
3,750
3,750
3,750
3,750
3,750
3,750
3,750
3,750

9,000
9,000
9,000
9,000
9,000
9,000
9,000
9,000
9,000
9,000
9,000
9,000
9,000

2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250
2,250

15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000
15,000

4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500
4,500

10,800
10,800
10,800
10,800
10,800
10,800
10,800
10,800
10,800
10,800
10,800
10,800
10,800

2,700
2,700
2,700
2,700
2,700
2,700
2,700
2,700
2,700
2,700
2,700
2,700
2,700

18,000
18,000
18,000
18,000
18,000
18,000
18,000
18,000
18,000
18,000
18,000
18,000
18,000

5,625
5,625
5,625
5,625
5,625
5,625
5,625
5,625
5,625
5,625
5,625
5,625
5,625

13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500
13,500

3,375
3,375
3,375
3,375
3,375
3,375
3,375
3,375
3,375
3,375
3,375
3,375
3,375

22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500

8,500
8,500
8,500
8,500
8,500
8,500
8,500
8,500
8,500
8,500
8,500
8,500
8,500

34,000
34,000
34,000
34,000
34,000
34,000
34,000
34,000
34,000
34,000
34,000
34,000
34,000

a
b
c
d

Sedang
Pasang Mag Slang
SPP
Pro Fungsi
Geric Surgery

5,875
5,875
5,875
5,875

14,100
14,100
14,100
14,100

3,525
3,525
3,525
3,525

23,500
23,500
23,500
23,500

6,625
6,625
6,625
6,625

15,900
15,900
15,900
15,900

3,975
3,975
3,975
3,975

26,500
26,500
26,500
26,500

8,000
8,000
8,000
8,000

19,200
19,200
19,200
19,200

4,800
4,800
4,800
4,800

32,000
32,000
32,000
32,000

11,750
11,750
11,750
11,750

47,000
47,000
47,000
47,000

e
f
g
h
i
j
k
l
m
n
o
p
q

Hyndroturbasi
Pemasangan T Pice
Thest Ustel Metylim Blue
Pasang/angkat Susuk KB
Catheter dengan Mandrin
Catheter dgn Cytatomi
Silaktasi
Tampon
Aspirasi Sendi
Peturbasi
Transfusi Vena Sectie
Fototherapi
Long Armplaster

5,875
5,875
5,875
5,875
5,875
5,875
5,875
5,875
5,875
5,875
5,875
5,875
5,875

14,100
14,100
14,100
14,100
14,100
14,100
14,100
14,100
14,100
14,100
14,100
14,100
14,100

3,525
3,525
3,525
3,525
3,525
3,525
3,525
3,525
3,525
3,525
3,525
3,525
3,525

23,500
23,500
23,500
23,500
23,500
23,500
23,500
23,500
23,500
23,500
23,500
23,500
23,500

6,625
6,625
6,625
6,625
6,625
6,625
6,625
6,625
6,625
6,625
6,625
6,625
6,625

15,900
15,900
15,900
15,900
15,900
15,900
15,900
15,900
15,900
15,900
15,900
15,900
15,900

3,975
3,975
3,975
3,975
3,975
3,975
3,975
3,975
3,975
3,975
3,975
3,975
3,975

26,500
26,500
26,500
26,500
26,500
26,500
26,500
26,500
26,500
26,500
26,500
26,500
26,500

8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000
8,000

19,200
19,200
19,200
19,200
19,200
19,200
19,200
19,200
19,200
19,200
19,200
19,200
19,200

4,800
4,800
4,800
4,800
4,800
4,800
4,800
4,800
4,800
4,800
4,800
4,800
4,800

32,000
32,000
32,000
32,000
32,000
32,000
32,000
32,000
32,000
32,000
32,000
32,000
32,000

11,750
11,750
11,750
11,750
11,750
11,750
11,750
11,750
11,750
11,750
11,750
11,750
11,750

47,000
47,000
47,000
47,000
47,000
47,000
47,000
47,000
47,000
47,000
47,000
47,000
47,000

a
b
c
d
e
f
g
h
i
j

Besar
Cuci Lambung/Cooling,Spol
Pasang body gast
Exchange Tranfusi
Sholder Spice
Balance Traktion
Pelvic/Lumbal Traction
Pasang Endhotracheal Tube
Infusion Pump
Vena Seksi
Body Jacket

7,875
7,875
7,875
7,875
7,875
7,875
7,875
7,875
7,875
7,875

18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900
18,900

4,725
4,725
4,725
4,725
4,725
4,725
4,725
4,725
4,725
4,725

31,500
31,500
31,500
31,500
31,500
31,500
31,500
31,500
31,500
31,500

8,625
8,625
8,625
8,625
8,625
8,625
8,625
8,625
8,625
8,625

20,700
20,700
20,700
20,700
20,700
20,700
20,700
20,700
20,700
20,700

5,175
5,175
5,175
5,175
5,175
5,175
5,175
5,175
5,175
5,175

34,500
34,500
34,500
34,500
34,500
34,500
34,500
34,500
34,500
34,500

11,125
11,125
11,125
11,125
11,125
11,125
11,125
11,125
11,125
11,125

26,700
26,700
26,700
26,700
26,700
26,700
26,700
26,700
26,700
26,700

6,675
6,675
6,675
6,675
6,675
6,675
6,675
6,675
6,675
6,675

44,500
44,500
44,500
44,500
44,500
44,500
44,500
44,500
44,500
44,500

15,500
15,500
15,500
15,500
15,500
15,500
15,500
15,500
15,500
15,500

62,000
62,000
62,000
62,000
62,000
62,000
62,000
62,000
62,000
62,000

a
b
c
d
e

Khusus
Minerve Jacket
Scoliosis (EDF)
Perawatan Intensive Bayi Patolog
Resusitasi Cardiopulmonal
Brancial Wosing

9,625
9,625
9,625
9,625
9,625

23,100
23,100
23,100
23,100
23,100

5,775
5,775
5,775
5,775
5,775

38,500
38,500
38,500
38,500
38,500

10,500
10,500
10,500
10,500
10,500

25,200
25,200
25,200
25,200
25,200

6,300
6,300
6,300
6,300
6,300

42,000
42,000
42,000
42,000
42,000

14,000
14,000
14,000
14,000
14,000

33,600
33,600
33,600
33,600
33,600

8,400
8,400
8,400
8,400
8,400

56,000
56,000
56,000
56,000
56,000

19,000
19,000
19,000
19,000
19,000

76,000
76,000
76,000
76,000
76,000

VIII. TINDAKAN OPERASI/BEDAH

T
NO.

JENIS PELAYANAN

Kelas III

Kelas II

(Rp)
Kelas I

VIP

NO.

JENIS PELAYANAN
unit cost

Jasa
pos
Pelayanan remunerasi
4

Jumlah

unit cost

Jasa
pos
Pelayanan remunerasi

Jumlah

unit cost

Jasa
po
Pelayanan remunerasi
10

Jumlah

unit cost

11

12

jasa
pos
pelayanan remunerasi

Jumlah
14

KECIL

164,750

395,400

98,850

659,000

214,175

514,020

128,505

856,700

246,301

591,123

147,781

985,205

295,573

709,375

177,344

1,182,291

SEDANG
1. Nercoleptik
2. Spinal Anestesi
3. Anestesi Umum

262,500
250,000
281,250

630,000
600,000
675,000

157,500
150,000
168,750

1,050,000
1,000,000
1,125,000

341,250
325,000
365,625

819,000
780,000
877,500

204,750
195,000
219,375

1,365,000
1,300,000
1,462,500

392,438
372,500
420,469
-

941,850
894,000
1,009,125
-

235,463
223,500
252,281

1,569,750
1,490,000
1,681,875

470,925
448,500
504,563

1,130,220
1,076,400
1,210,950

282,555
269,100
302,738

1,883,700
1,794,000
2,018,250

BESAR
1. Spinal Anestesi
2. Anestesi Umum
3.Jasa dokter Anak pada SC
KHUSUS

525,000
860,300
112,500
779,250

1,260,000
1,229,000
270,000
1,870,200

315,000
368,700
67,500
467,550

2,100,000
2,458,000
450,000
3,117,000

682,500
1,118,390
146,250
1,013,025

1,638,000
1,597,700
351,000
2,431,260

409,500
479,310
87,750
607,815

2,730,000
3,195,400
585,000
4,052,100

784,875
1,273,549
168,188
1,164,979

1,883,700
1,819,355
324,000
2,795,949

470,925
545,807
100,913
698,987

3,139,500
3,638,710
672,750
4,659,915

941,850
1,528,258
925,000
1,397,973

2,260,440
2,183,226
484,380
3,355,136

941,850
1,528,258
201,825
1,397,973

3,767,400
4,366,452
807,300
5,591,893

IX

REHABILITASI MEDIS
T

NO.

Kelas III

JENIS PELAYANAN
unit cost

1 Sedehana
2 Sedang
3 Latihan Di Tempat (Zaal)

1,875
1,875
1,875

4,500
4,500
4,500

(Rp)

Kelas II

pos
Jasa
remunera
Pelayanan
si

1,125
1,125
1,125

Kelas I

pos
Jasa
remunera
Pelayanan
si

tarif

unit cost

7,500
7,500
7,500

2,500
3,000
3,000

6,000
7,200
7,200

1,500
1,800
1,800

tarif

unit cost

10,000
12,000
12,000

VIP

pos
Jasa
remuneras
Pelayanan
i
10

3,750
4,000
3,750

9,000
9,600
9,000

2,250
2,400
2,250

tarif

unit cost

11

12

15,000
16,000
15,000

5,000
5,500
5,500

pos
jasa
remuneras
pelayanan
i

14

12,000
13,200

X. INSTALASI GIZI
T
NO.

JENIS PELAYANAN

Kelas III

Kelas II

(Rp)
Kelas I

tarif

VIP

3,000

20,000
22,000
22,000

NO.

JENIS PELAYANAN
unit cost

Konsultasi Gizi

pos
Jasa
remunera
Pelayanan
si

1,200

1,500

300

pos
Jasa
remunera
Pelayanan
si

tarif

unit cost

3,000

2,000

2,500

tarif

unit cost

5,000

3,000

500

pos
Jasa
remuneras
Pelayanan
i
10

3,750

750

tarif

unit cost

tarif

11

12

14

6,000

15,000

7,500

XI. INSTALASI FARMASI

T
NO.

Kelas III

JENIS PELAYANAN
unit cost

Resep
(Dihitung per Jumlah Resep
yang dilayani diluar obat)

1,000

1,250

(Rp)

Kelas II

pos
Jasa
remunera
Pelayanan
si

250

Kelas I

pos
Jasa
remunera
Pelayanan
si

tarif

unit cost

2,500

1,000

1,250

250

tarif

unit cost

2,500

1,000

VIP

pos
Jasa
remuneras
Pelayanan
i
10

1,250

250

tarif

unit cost

tarif

11

12

14

2,500

1,000

2,500

VIII. TINDAKAN OPERASI/BEDAH

T
Kelas III
NO.

JENIS PELAYANAN
unit cost

Kelas II

Jasa
pos
Pelayanan remunerasi
4

Jumlah

unit cost

Jasa
pos
Pelayanan remunerasi
7

Jumlah
8

KECIL

150,000

450,000

67,500

667,500

195,000

585,000

87,750

867,750

SEDANG
1. Nercoleptik
2. Spinal Anestesi
3. Anestesi Umum

500,000
550,000
850,000

750,000
750,000
750,000

112,500
112,500
112,500

1,362,500
1,412,500
1,712,500

650,000
715,000
1,105,000

975,000
975,000
975,000

146,250
146,250
146,250

1,365,000
1,300,000
1,462,500

550,000
950,000
50,000
1,700,000

1,500,000
1,500,000
250,000
2,000,000

225,000
225,000
37,500
300,000

2,275,000
2,675,000
337,500
4,000,000

715,000
1,235,000
65,000
2,210,000

1,950,000
1,950,000
325,000
2,600,000

292,500
292,500
48,750
390,000

2,730,000
3,195,400
585,000
4,052,100

BESAR
1. Spinal Anestesi
2. Anestesi Umum
3.Jasa dokter Anak pada SC
KHUSUS

(Rp)

(Rp)
Kelas I

unit cost

Jasa
Pelayanan

10

VIP

po
remunerasi

Jumlah

unit cost

11

12

Jasa
pos
Pelayanan remunerasi
13

Jumlah
14

217,500

652,500

97,875

967,875

247,500

742,500

111,375

1,101,375

725,000
797,500
1,232,500
-

1,087,500
1,087,500
1,087,500
-

163,125
163,125
163,125

825,000
907,500
1,402,500

1,237,500
1,237,500
1,237,500

185,625
185,625
185,625

2,248,125
2,330,625
2,825,625

797,500
1,377,500
72,500
2,465,000

2,175,000
2,175,000
362,500
2,900,000

326,250
326,250
54,375
435,000

1,975,625
2,048,125
2,483,125
3,298,750
3,878,750
489,375
5,800,000

907,500
1,567,500
82,500
2,805,000

2,475,000
2,475,000
412,500
3,300,000

371,250
371,250
61,875
495,000

3,753,750
4,413,750
556,875
6,600,000

VI. TINDAKAN MEDIK/THERAPI

T
Kelas III
NO.

JENIS PELAYANAN
unit cost

A
1
a
b
d
2

Jasa
pos
Pelayanan remunerasi
4

Jumlah

unit cost

Jasa
Pelayanan

KEBIDANAN DAN KANDUNGAN

Partus Normal
Oleh Bidan
Oleh Dokter Umum
Oleh Dokter Spesialis

100,000
100,000
100,000

250,000
300,000
400,000

37,500
45,000
60,000

387,500
445,000
560,000

130,000
130,000
130,000

325,000
390,000
520,000

Partus dgn episotomi oleh spesialis

- Episiotomi

150,000

450,000

67,500

667,500

195,000

585,000

150,000
150,000
150,000
150,000
150,000
150,000

500,000
500,000
500,000
350,000
350,000
350,000

75,000
75,000
75,000
52,500
52,500
52,500

725,000
725,000
725,000
552,500
552,500
552,500

195,000
195,000
195,000
195,000
195,000
195,000

650,000
650,000
650,000
455,000
455,000
455,000

150,000
150,000
150,000
100,000
75,000
50,000
50,000
20,000
100,000
5,000

350,000
500,000
450,000
250,000
100,000
250,000
100,000
35,000
350,000
14,000

52,500
75,000
67,500
37,500
15,000
37,500
15,000
5,250
52,000
1,000

552,500
725,000
667,500
387,500
190,000
337,500
165,000
60,250
502,000
20,000

195,000
195,000
195,000
130,000
97,500
65,000
65,000
26,000
130,000
6,500

455,000
650,000
585,000
325,000
130,000
325,000
130,000
45,500
455,000
18,200

75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000

75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000
75,000

11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500
11,500

161,500
161,500
161,500
161,500
161,500
161,500
161,500
161,500
161,500
161,500
161,500

90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000

90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000

3
a
b
c
d
e
f
g
4
g
h
i
j
k
l
m
n
o
p

Partus dgn Patologi Tindakan

Vakumektrasi/Eks Forcep
Embriotomi
Letak Sungsang
Manual Plasenta
Eksplorasi Sisa Plasenta
Robekan Cervik
Resusitasi bayi patologis 1/3 JM
Tindakan lain di Kebidanan
Amnion Infution
Curetage
Marsupialisasi tanpa anestesi
Insisi abses bartolin
biopsi
Pungsi Cavum Dougles
Pasang / lepas IUD
Doppler
Amnion reduktion
Perawatan bayi gabung

a
b
c
d
e
f
g
h
i
j
k

TINDAKAN MEDIK LAIN NON OPERATIF

Punksi Sumsum Tulang
Pemasangan SB Tube
Punksi Pangkard
Biopsi
Punksi Sendi
CVP
Pungsi Thyroid
Cardio Versislektif
Lumbal Punksi
Pleura Punksi
WSD

Kelas II

l
m
n
o
p
q
r

Punksi Ascites
Subdural Punksi
Intratekal Therapi
Supra Pubik Punksi
Resusitasi Ringan
Resusitasi Sedang
Resusitasi Berat

75,000
75,000
75,000
75,000

75,000
75,000
75,000
75,000

11,500
11,500
11,500
11,500

161,500
161,500
161,500
161,500

7,500

25,000

4,500

37,000

15,000

35,000

5,250

20,000

40,000

6,000

55,250
66,000

90,000
90,000
90,000
90,000
9,000
18,000
24,000

90,000
90,000
90,000
90,000
30,000
42,000
48,000

(Rp)

Kelas II

Kelas I

pos
remunerasi

Jumlah

unit cost

VIP

Jasa
pos
Pelayanan remunerasi
10

Jumlah

unit cost

11

12

Jasa
pos
Pelayanan remunerasi
13

Jumlah
14

48,750
58,500
78,000

503,750
578,500
728,000

145,000
145,000
145,000

362,500
435,000
580,000

54,375
65,250
87,000

561,875
645,250
812,000

174,000
174,000
174,000

435,000
522,000
696,000

65,250
78,300
104,400

674,250
774,300
974,400

87,750

867,750

217,500

652,500

97,875

967,875

261,000

783,000

117,450

1,161,450

97,500
97,500
97,500
68,250
68,250
68,250

942,500
942,500
942,500
718,250
718,250
718,250

217,500
217,500
217,500
217,500
217,500
217,500

725,000
725,000
725,000
507,500
507,500
507,500

108,750
108,750
108,750
76,125
76,125
76,125

1,051,250
1,051,250
1,051,250
801,125
801,125
801,125

261,000
261,000
261,000
261,000
261,000
261,000

870,000
870,000
870,000
609,000
609,000
609,000

130,500
130,500
130,500
91,350
91,350
91,350

1,261,500
1,261,500
1,261,500
961,350
961,350
961,350

68,250
97,500
87,750
48,750
19,500
48,750
19,500
6,825
67,600
1,300

718,250
942,500
867,750
503,750
247,000
438,750
214,500
78,325
652,600
26,000

217,500
217,500
217,500
145,000
108,750
72,500
72,500
29,000
145,000
7,250

507,500
725,000
652,500
362,500
145,000
362,500
145,000
50,750
507,500
20,300

76,125
108,750
97,875
54,375
21,750
54,375
21,750
7,613
75,400
1,450

801,125
1,051,250
967,875
561,875
275,500
489,375
239,250
87,363
727,900
29,000

261,000
261,000
261,000
174,000
130,500
87,000
87,000
34,800
174,000
8700

609,000
870,000
783,000
435,000
174,000
435,000
174,000
60,900
609,000
24360

91,350
130,500
117,450
65,250
26,100
65,250
26,100
9,135
90,480
1740

961,350
1,261,500
1,161,450
674,250
330,600
587,250
287,100
104,835
873,480
34800

13,800
13,800
13,800
13,800
13,800
13,800
13,800
13,800
13,800
13,800
13,800

193,800
193,800
193,800
193,800
193,800
193,800
193,800
193,800
193,800
193,800
193,800

103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500

103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500

15,870
15,870
15,870
15,870
15,870
15,870
15,870
15,870
15,870
15,870
15,870

222,870
222,870
222,870
222,870
222,870
222,870
222,870
222,870
222,870
222,870
222,870

103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500
103,500

124,200
124,200
124,200
124,200
124,200
124,200
124,200
124,200
124,200
124,200
124,200

19,044
19,044
19,044
19,044
19,044
19,044
19,044
19,044
19,044
19,044
19,044

246,744
246,744
246,744
246,744
246,744
246,744
246,744
246,744
246,744
246,744
246,744

13,800
13,800
13,800
13,800
5,400
6,300
7,200

193,800
193,800
193,800
193,800
44,400
66,300
79,200

103,500
103,500
103,500
103,500
10,350
20,700
27,600

103,500
103,500
103,500
103,500
34,500
48,300
55,200

15,870
15,870
15,870
15,870
6,210
7,245
8,280

222,870
222,870
222,870
222,870
51,060
76,245
91,080

103,500
103,500
103,500
103,500
10,350
20,700
27,600

124,200
124,200
124,200
124,200
41,400
57,960
66,240

19,044
19,044
19,044
19,044
7,452
8,694
9,936

246,744
246,744
246,744
246,744
59,202
87,354
103,776

XII. INSTALASI GAWAT DARURAT (IGD)

No

Jenis Pelayanan

T A R I F
Jasa
pos
Pelayanan remunerasi

unit cost

tarif

Intermediet Care

Konsultasi/Pemeriksaan Dokter Spesialis

20,000

Konsultasi/Pemeriksaan Dokter Umum

5,000

5,000
10,000
1,000
5,000

10,000
15,000
6,000
20,000

2,250
1,500
900
3,000

17,250
26,500
7,900
28,000

50,000

a
b
c
d

Tindakan IGD :
1 Ringan
ap heating
Perawatan Luka
Supositoria
uf WSD

a
b
c
d
e
e
f
g
h
i
j
k

2 Sedang
Combotio Sedang (5 - 15%)
Spoeling/Negle Extraksi/Eksplorasi
Immobilisasi External
Pasang Gips Tanpa Narkose ( Dr.UMUM)
Pasang Gips Tanpa Narkose ( Dr.Spesialis)
Pasang Ransel
Resusitasi Anak/Dewasa
Pasang Infus
Pasang Guedel
Pasang Spalak pada fraktur
Pasang Neck Coller
Pasang Scortein

50,000
50,000
50,000
100,000
100,000
50,000
50,000
50,000
5,000
50,000
50,000
15,000

30,000
30,000
30,000
30,000
200,000
30,000
30,000
30,000
15,000
30,000
30,000
15,000

4,500
4,500
4,500
4,500
30,000
4,500
4,500
4,500
2,250
4,500
4,500
2,750

84,500
84,500
84,500
134,500
330,000
84,500
84,500
84,500
22,250
84,500
84,500
32,750

a
b
c
d
f
g
h

3 Berat
Combotio Berat (> 15%)
Cuci Lambung
Amputasi Jari
Pemasangan Edotrakeal Tube
Vena Sectie
Resusitasi Anak/Dewasa
RJP dengan De Shock

75,000
50,000
50,000
100,000
150,000
50,000
50,000

50,000
50,000
50,000
30,000
150,000
50,000
50,000

15,000
7,500
7,500
4,500
22,500
7,500
7,500

140,000
107,500
107,500
134,500
322,500
107,500
107,500

5,000
50,000
50,000
50,000

20,000
30,000
45,000
50,000

3,000
4,500
4,500
7,500

28,000
84,500
99,500
107,500

F
a
b
c
d

Jahitan (heacting)
15
5 10
10 15
> 15

XIII PELAYANAN PSIKOLOGI

No

Jenis Pelayanan

unit cost

T A R I F
Jasa
pos
Pelayanan remunerasi

tarif

A
B
C
D

Test Kecerdasan
Test Kepribadian
Test Minat dan Bakat
Evaluasi Psykologi

5,000
5,000
5,000
5,000

12,500
12,500
12,500
12,500

2,500
2,500
2,500
2,500

20,000
20,000
20,000
20,000

IV. PEMERIKSAAN LABORATORIUM

T
Kelas III
NO.

JENIS PELAYANAN
unit cost

A
1
a
b
c
d
e
f
g
h
i
j
k
2
a
b
c
d
3
a
b
4
a
b
c

SEDERHANA
Hematologi
LED
Thrombocyt
Erythrocyt
Haematokrit
Hitung Jenis Leokocyt
Retyculocyt
Waktu Pendarahan
Waktu Penjendalan
Golongan Darah
Haemoglobin
Sel LE
Urine
Protein
Reduksi
Bilirubin
Sedimen
Tinja
Tl. Cacing
Amuba
Parasitologi
Malaria
Filaria
Jamur

4
5

Darah Rutin
Urine Rutin

(Rp)

Kelas II

Jasa
pos
Pelayanan remunerasi

Kelas I

Jasa
pos
Pelayanan remunerasi

tarif

unit cost

tarif

unit cost

VIP

pos
Jasa
remunera
Pelayanan
si
10

pos
Jasa
remunera
Pelayanan
si

tarif

unit cost

11

12

13

tarif

14

3,500
3,500
3,500
3,500
3,500
3,500
3,500
3,500
3,500
3,500
3,500

1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500

750
750
750
750
750
750
750
750
750
750
750

5,750
5,750
5,750
5,750
5,750
5,750
5,750
5,750
5,750
5,750
5,750

4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550
4,550

1,950
1,950
1,950
1,950
1,950
1,950
1,950
1,950
1,950
1,950
1,950

975
975
975
975
975
975
975
975
975
975
975

7,475
7,475
7,475
7,475
7,475
7,475
7,475
7,475
7,475
7,475
7,475

5,233
5,233
5,233
5,233
5,233
5,233
5,233
5,233
5,233
5,233
5,233

2,243
2,243
2,243
2,243
2,243
2,243
2,243
2,243
2,243
2,243
2,243

1,121
1,121
1,121
1,121
1,121
1,121
1,121
1,121
1,121
1,121
1,121

8,596
8,596
8,596
8,596
8,596
8,596
8,596
8,596
8,596
8,596
8,596

6,279
6,279
6,279
6,279
6,279
6,279
6,279
6,279
6,279
6,279
6,279

2,691
2,691
2,691
2,691
2,691
2,691
2,691
2,691
2,691
2,691
2,691

1,346
1,346
1,346
1,346
1,346
1,346
1,346
1,346
1,346
1,346
1,346

10,316
10,316
10,316
10,316
10,316
10,316
10,316
10,316
10,316
10,316
10,316

3,500
3,500
3,500
3,500

1,500
1,500
1,500
1,500

750
750
750
750

5,750
5,750
5,750
5,750

4,550
4,550
4,550
4,550

1,950
1,950
1,950
1,950

975
975
975
975

7,475
7,475
7,475
7,475

5,233
5,233
5,233
5,233

2,243
2,243
2,243
2,243

1,121
1,121
1,121
1,121

8,596
8,596
8,596
8,596

6,279
6,279
6,279
6,279

2,691
2,691
2,691
2,691

1,346
1,346
1,346
1,346

10,316
10,316
10,316
10,316

3,500
3,500

1,500
1,500

750
750

5,750
5,750

4,550
4,550

1,950
1,950

975
975

7,475
7,475

5,233
5,233

2,243
2,243

1,121
1,121

8,596
8,596

6,279
6,279

2,691
2,691

1,346
1,346

10,316
10,316

3,500
3,500
3,500

1,500
1,500
1,500

750
750
750

5,750
5,750
5,750

4,550
4,550
4,550

1,950
1,950
1,950

975
975
975

7,475
7,475
7,475

5,233
5,233
5,233

2,243
2,243
2,243

1,121
1,121
1,121

8,596
8,596
8,596

6,279
6,279
6,279

2,691
2,691
2,691

1,346
1,346
1,346

10,316
10,316
10,316

5,500

4,600

700

10,800

7,150

5,980

910

14,040

8,223

6,877

1,047

16,146

9,867

8,252

1,256

19,375

Faeces Rutin

5,500

4,600

700

10,800

7,150

5,980

910

14,040

8,223

6,877

1,047

16,146

9,867
-

8,252
-

1,256

19,375

SEDANG I
Hematologi
Gambaran darah Tepi

7,000

9,500

1,425

17,925

8,400

11,400

1,853

21,653

9,660

13,680

2,223

25,563

12,558

16,416

2,668

31,642

Tinja
Darah Samar

7,000

9,500

1,425

17,925

8,400

11,400

1,853

21,653

9,660

13,680

2,223

25,563

12,558

16,416

2,668

31,642

3
a
b
c
d

Sp/Bakterio Sld
BTA
Nesseria
Mikroorganisme lain
Analisa Sperma

7,000
7,000
7,000
10,000

9,500
9,500
9,500
35,000

1,425
1,425
1,425
5,000

17,925
17,925
17,925
50,000

8,400
8,400
8,400
12,000

11,400
11,400
11,400
42,000

1,853
1,853
1,853
6,500

21,653
21,653
21,653
60,500

9,660
9,660
9,660
13,800

13,680
13,680
13,680
50,400

2,223
2,223
2,223
7,800

25,563
25,563
25,563
72,000

12,558
12,558
12,558
17,940

16,416
16,416
16,416
60,480

2,668
2,668
2,668
9,360

31,642
31,642
31,642
87,780

4
a
b
c
d
e
f
g
h
i
j
k

Kimia Darah
Ureum
Creatinin Darah
Creatinin Urine
Gula Darah
Albumin
Uric Acid
Protein Total
Bilirubin Total
Lipase Darah
Fosfatassa Asam
Fosfatassa Basa

22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500

5,000
5,000
5,000
5,000
5,000
5,000
5,000
5,000
5,000
5,000
5,000

1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500
1,500

29,000
29,000
29,000
29,000
29,000
29,000
29,000
29,000
29,000
29,000
29,000

22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500

6,000
6,000
6,000
6,000
6,000
6,000
6,000
6,000
6,000
6,000
6,000

1,800
1,800
1,800
1,800
1,800
1,800
1,800
1,800
1,800
1,800
1,800

30,300
30,300
30,300
30,300
30,300
30,300
30,300
30,300
30,300
30,300
30,300

22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500

7,000
7,000
7,000
7,000
7,000
7,000
7,000
7,000
7,000
7,000
7,000

2,000
2,000
2,000
2,000
2,000
2,000
2,000
2,000
2,000
2,000
2,000

31,500
31,500
31,500
31,500
31,500
31,500
31,500
31,500
31,500
31,500
31,500

22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500
22,500

8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400
8,400

2,400
2,400
2,400
2,400
2,400
2,400
2,400
2,400
2,400
2,400
2,400

33,300
33,300
33,300
33,300
33,300
33,300
33,300
33,300
33,300
33,300
33,300

1
a
b
c
d
e
f

SEDANG II
Kimia Darah
Kholesterol
Total Lipid
L DL
SGPT
SGOT
HDL

26,500
26,500
26,500
26,500
26,500
26,500

17,500
17,500
17,500
17,500
17,500
17,500

8,500
8,500
8,500
8,500
8,500
8,500

2,400
2,400
2,400
2,400
2,400
2,400

28,400
28,400
28,400
28,400
28,400
28,400

17,500
17,500
17,500
17,500
17,500
17,500

5,000
5,000
5,000
5,000
5,000
5,000

1,500
1,500
1,500
1,500
1,500
1,500

24,000
24,000
24,000
24,000
24,000
24,000

17,500
17,500
17,500
17,500
17,500
17,500

6,000
6,000
6,000
6,000
6,000
6,000

1,800
1,800
1,800
1,800
1,800
1,800

25,300
25,300
25,300
25,300
25,300
25,300

17,500
17,500
17,500
17,500
17,500
17,500

7,000
7,000
7,000
7,000
7,000
7,000

2,000
2,000
2,000
2,000
2,000
2,000

Test Narkoba

80,000

70,000

10,000

160,000

3
a
b
c
d

Immunologi/Serologi
Plano Test Kehamilan
Widal
Papsmear
HbsAg

9,000
17,500
17,500
17,500

3,000
10,000
10,000
10,000

1,000
1,000
1,000
1,000

13,000
28,500
28,500
28,500

10,800
17,500
17,500
17,500

3,600
12,000
12,000
12,000

1,000
1,000
1,000
1,000

15,400
30,500
30,500
30,500

10,800
17,500
17,500
17,500

4,140
13,800
13,800
13,800

1,150
1,150
1,150
1,150

16,090
32,450
32,450
32,450

12,960
21,000
21,000
21,000

4,968
16,560
16,560
16,560

1,380
1,380
1,380
1,380

19,308
38,940
38,940
38,940

V. PEMERIKSAAN DIAGNOSTIK
T
Kelas III
NO.

JENIS PELAYANAN
unit cost

pos
Jasa
remunera
Pelayanan
si
4

(Rp)

Kelas II
tarif

unit cost

Kelas I

Jasa
pos
Pelayanan remunerasi
7

tarif

unit cost

VIP

Jasa
pos
Pelayanan remunerasi
10

pos
Jasa
remunera
Pelayanan
si

tarif

unit cost

11

12

13

tarif
14

1.
a
b
c
d
e

PEMERIKSAAN RADIOLOGI
Sederhana
Os Orbita
Os. Nasale
Os. Zigomatikum
Finger
Os. Mandibula

25,000
25,000
25,000
25,000
25,000

###
###
###
###
###

3,750
3,750
3,750
3,750
3,750

53,750
53,750
53,750
53,750
53,750

25,000
25,000
25,000
25,000
25,000

30,000
30,000
30,000
30,000
30,000

4,500
4,500
4,500
4,500
4,500

59,500
59,500
59,500
59,500
59,500

25,000
25,000
25,000
25,000
25,000

34,500
34,500
34,500
34,500
34,500

5,175
5,175
5,175
5,175
5,175

64,675
64,675
64,675
64,675
64,675

30,000
30,000
30,000
30,000
30,000

41,400
41,400
41,400
41,400
41,400

36,000
36,000
36,000
36,000
36,000

107,400
107,400
107,400
107,400
107,400

2
a
b
c
d
e
f

Sederhana I
Thorax
BNO/Abdomen
Tulang Belakang
Pelvis
Schedal
Cewrvicel

30,000
30,000
30,000
30,000
30,000
30,000

###
###
###
###
###
###

4,500
4,500
4,500
4,500
4,500
4,500

64,500
64,500
64,500
64,500
64,500
64,500

30,000
30,000
30,000
30,000
30,000
30,000

36,000
36,000
36,000
36,000
36,000
36,000

5,400
5,400
5,400
5,400
5,400
5,400

71,400
71,400
71,400
71,400
71,400
71,400

30,000
30,000
30,000
30,000
30,000
30,000

41,400
41,400
41,400
41,400
41,400
41,400

6,210
6,210
6,210
6,210
6,210
6,210

77,610
77,610
77,610
77,610
77,610
77,610

30,000
30,000
30,000
30,000
30,000
30,000

49,680
49,680
49,680
49,680
49,680
49,680

36,000
36,000
36,000
36,000
36,000
36,000

115,680
115,680
115,680
115,680
115,680
115,680

3
a
b
c
d

Sedang
Barium Meal
Pelvimetri
Panoramic
Bone Survey

160,000
160,000
160,000
160,000

205,000
205,000
205,000
205,000

37,050
37,050
37,050
37,050

402,050
402,050
402,050
402,050

160,000
160,000
160,000
160,000

160,000
246,000
246,000
246,000

44,460
44,460
44,460
44,460

364,460
450,460
450,460
450,460

160,000
160,000
160,000
160,000

184,000
282,900
282,900
282,900

51,129
51,129
51,129
51,129

395,129
494,029
494,029
494,029

160,000
160,000
160,000
160,000

220,800
339,480
339,480
339,480

192,000
192,000
192,000
192,000

572,800
691,480
691,480
691,480

4
a
b
c
d
e

Canggih
IVP
OMD
Cystografi
Colon Inlop
Urethografi

205,000
205,000
205,000
205,000
205,000

###
###
###
###
###

37,500
37,500
37,500
37,500
37,500

447,500
447,500
447,500
447,500
447,500

205,000
205,000
205,000
205,000
205,000

246,000
246,000
246,000
246,000
246,000

45,000
45,000
45,000
45,000
45,000

496,000
496,000
496,000
496,000
496,000

205,000
205,000
205,000
205,000
205,000

205,000
205,000
205,000
205,000
205,000

51,750
51,750
51,750
51,750
51,750

461,750
461,750
461,750
461,750
461,750

205,000
205,000
205,000
205,000
205,000

246,000
246,000
246,000
246,000
246,000

246,000
246,000
246,000
246,000
246,000

697,000
697,000
697,000
697,000
697,000

IVP Non Ionik

2
a
b
c

Elektro Medik
Elektrocardiografi (ECG)
Monitor ECG / hari
USG

420,000.00

350,000

52,500

822,500.00

420,000

420,000

63,000

903,000

205,000

205,000

72,450

482,450

205,000

246,000

246,000

697,000

12,500
50,000
15,000

17,500
35,000
35,000

2,500
5,250
10,000

32,500
90,250
60,000

12,500
50,000
15,000

21,000
42,000
42,000

3,000
6,300
12,000

36,500
98,300
69,000

12,500
50,000
15,000

24,150
48,300
48,300

3,450
7,245
13,800

40,100
105,545
77,100

12,500
50,000
15,000

28,980
57,960
57,960

15,000
60,000
18,000

56,480
167,960
90,960

No

Jenis Pelayanan
unit cost

II

PENDAFTARAN
Rawat Jalan
a Karcis Rawat Jalan baru
b Karcis Rawat jalan lama
Tarif adminitrasi
a Rawat Jalan umum
b Rawat jalan spesialis
A
a
b
c
d
e
f
g

III
A
I
b
c
d
e

Pemeriksaan, Konsul Dokter

Pemeriksaan Dokter Umum/Gigi
Pemeriksaan Dokter Spesialis
Konsul Dokter Spesialis
Konsul Dokter Umum
Konsul Dokter Gigi
Konsul Farmasi
Konsul Gizi / Visite
RAWAT INAP
AKOMODASI RUANGAN DAN ASKEP
VVIP
VIP
Kelas I
Kelas II
Kelas III

II Askep
a Askep VVIP
b ASKEP VIP
c Askep Kelas I
d Askep Kelas II
e Askep Kelas III
B

T A R I F
Jasa Pelayanan
tidak
langsung
langsung

4,000
3,000

4,000
3,000

4,500
4,500

7,000
15,000

1,000
1,875

12,500
21,375

4,500
4,500
1,000
-

7,000
15,000
15,000
-

1,000
2,000
2,250

12,500
21,500
18,250
10,000
10,000
5,000
5,000

225,000
125,000
60,000
45,000
35,000

2,500
2,500
1,500
1,500
1,500

16,000
14,000
12,500
10,000
7,500

225,000
125,000
60,000
45,000
35,000

1,500
1,000
1,000
1,000
1,000

30,000
20,000
15,000
12,500
10,000

10,000
8,500
7,000
6,500

a
b
c
d

ADIMINISTRASI RAWAT INAP

Ruang VIP
Kelas I
Kelas II
Kelas III

5,000

1,500

a
b
c
d
e

VISITE DAN KONSUL

1 Visite Dokter Spesialis Klas VIP
Ruang V.VIP
Kelas VIP
Kelas I
Kelas II
Kelas III

2,000
1,500
1,500
1,250
1,250

50,000
40,000
30,000
25,000
15,000

7,500
6,000
4,500
3,750
2,250

2 Visite Dokter Umum

Jumlah

59,500
47,500
36,000
30,000
18,500
-

a
b
c
d
e
`

Ruang V.VIP
Kelas VIP
Kelas I
Kelas II
Kelas III

5,450
2,750
50
800
600

17,000
15,000
13,000
8,000
6,000

2,550
2,250
1,950
1,200
900

25,000
20,000
15,000
10,000
7,500

4
a
b
c
d
e

Konsul Dokter Spesialis

Ruang V.VIP
Kelas VIP
Kelas I
Kelas II
Kelas III

2,000
1,500
1,500
1,250
1,250

50,000
40,000
30,000
25,000
15,000

7,500
6,000
4,500
3,750
2,250

59,500
47,500
36,000
30,000
18,500
-

XIV. PEMERIKSAAN KESEHATAN

T A R I F
No

Jenis Pelayanan
unit cost

A
B
C
D
F
G

Visum et Refertum
Surat Keterangan bebas narkoba
Surat Keterangan Kesehatan sederhana
Surat Keterangan Kesehatan Lengkap
Surat Keterangan Kematian
Surat Keterangan Kelahiran

langsung

5,000
80,000
5,000
86,500
5,000
5,000

tak langsung

75,000
70,000
15,000
45,000
15,000
15,000

6,750
10,500
2,500
6,750
2,500
2,500

tarif
86,750
177,500
22,500
138,250
22,500
22,500

XV. PERAWATAN JENAZAH

No

A
B
D
E

Jenis Pelayanan

Pemulazaran (Pengawetan Mayat) Dewasa

Pemulazaran bayi (s/d umur 3 tahun)
Penyimpanan Jenazah/hari
Ruangan/hari

T A R I F
Jasa
pos
Pelayanan remunerasi

unit cost
200,000
150,000
-

250,000
250,000
-

50,000
31,500
-

tarif
500,000
381,500
10,000
10,000

XVI. PEMAKAIAN OKSIGEN (O2)

No

Jenis Pelayanan

1 Pemakaian Oksigen Liter/Jam

2 Pemakaian Oksigen diatas 200 liter dihitung
1 (satu) tabung

XVII. SEWA MOBIL JENAZAH/AMBULANCE

T A R I F
Jasa Sarana
Jasa
pos
dan
Pelayanan remunerasi
Prasarana
-

250

tarif

20,000
250,000

No

Jenis Pelayanan

1 Dalam Kota (Jauh/Dekat)

2 Referal ke Rumah Sakit M. Yunus
3 Luar Kota / Km

unit cost
20,000
150,000
-

T A R I F
Jasa
pos
Pelayanan remunerasi
40,000
180,000
-

1,140
20,000

tarif
61,140
350,000
5,000

XVIII. SEWA PEMBAKARAN LIMBAH MEDIS/ PADAT DI IPSRS

No

Jenis Pelayanan

1 Pembakaran Limbah medis golongan A/ kg

2 Pembakaran Limbah medis golongan B
3 Pembakaran Limbah medis golongan C

unit cost
15,000
20,000
25,000

T A R I F
Jasa
pos
Pelayanan remunerasi
12,500
17,000
21,000

2,500
3,000
4,000

tarif
30,000
40,000
50,000

Tarif Pelayanan Rawat jalan.

Sarana
A BEDAH MULUT
I SEDERHANA
1. Cabut gigi / ekstraksi
- Biasa
- Citojeck
2. Cabut gigi anak (chlorethil)

Jasa Pelayanan

Remunerasi

Tarif

24,000
20,000
15,000

16,000
15,000
7,500

2,400
2,250
1,125

42,400
37,250
23,625

30,000
50,000
20,000
20,000
10,000

25,000
40,000
12,500
12,500
8,000

3,750
6,000
1,875
1,875
1,200

58,750
96,000
34,375
34,375
19,200

6,000
20,000
20,000
20,000
20,000

4,000
14,000
14,000
14,000
14,000

600
2,100
2,100
2,100
2,100

10,600
36,100
36,100
36,100
36,100

20,000
20,000
30,000
36,000

14,000
14,000
20,000
24,000

2,100
2,100
3,000
3,600

36,100
36,100
53,000
63,600

12,000
36,000
15,000
40,000

8,000
24,000
10,000
30,000

1,200
3,600
1,500
4,500

21,200
63,600
26,500
74,500

24,000
90,000
42,000
45,000

16,000
60,000
28,000
30,000

2,400
9,000
4,200
4,500

42,400
159,000
74,200
79,500

B ORTHODONTIA
I KECIL
1. Mencetak Rahang
2. Kontrol ortho lepasan
3. Kontrol alat cekat
4. Braket lepas / gigi
5. Buccal tube hilang / gigi

36,000
30,000
30,000
18,000
48,000

24,000
20,000
20,000
12,000
32,000

3,600
3,000
3,000
1,800
4,800

63,600
53,000
53,000
31,800
84,800

SEDANG
Alat Lepas
1. Space maintener
2. Plat aktif 1 rahang
3. Plat aktif 2 rahang

180,000
240,000
480,000

120,000
160,000
320,000

18,000
24,000
48,000

318,000
424,000
848,000

II

SEDANG
1. Cabut gigi / ekstraksi dengan komplikasi
2. Cabut gigi tertanam / impected
3. Incisi abses
4. Eksterpasi mukokel
5. Perawatan abses

III KONSERVASI UMUM

1. Tindakan premedikasi
2. Sterilisasi saluran akar
3. Sterilisasi saluran akar dengan Ca (OH) 2
4. Pulpektomi gigi anterior
5. Pulpotomi gigi posterior
6. Tumpatan permanen
* Fuji IX
* Fuji II (GIC)
* Resin Komposit (LC) kecil
* Resin Komposit (LC) besar
IV PERIODONTI UMUM
1. Pengobatan Gingivitis (radang gusi)
2. Scalling / pembersihan karang gigi
3. Trepanasi / grinding
4. Kuretase / frenektomi
V

II

PROSTODONTI UMUM
1. Cetak rahang
2. Protesa gigi pertama
3. Menambah 1 gigi akrilik
4. Reparasi gigi palsu / protesa

4. Plat ekspansi
5. Plat dengan biteraizer
6. Aktifator
7. Ortho trainer TMJ

300,000
180,000
480,000
480,000

200,000
120,000
320,000
320,000

30,000
18,000
48,000
48,000

530,000
318,000
848,000
848,000

III BESAR
Alat Cekat
1. 2 (dua) rahang
a. Kunjungan I
b. Kunjungan II
c. Kunjungan IIII

1,200,000
750,000
750,000

800,000
500,000
500,000

120,000
75,000
75,000

2,120,000
1,325,000
1,325,000

2. 1 (satu)rahang
a. Kunjungan I
b. Kunjungan II

825,000
825,000

550,000
550,000

82,500
82,500

1,457,500
1,457,500

3. Tarif Pasien Lanjutan

1,200,000

800,000

120,000

2,120,000

4. 2 (dua) rahang braket estetika

a. Kunjungan I
b. Kunjungan II
c. Kunjungan III

1,800,000
900,000
900,000

1,200,000
600,000
600,000

180,000
90,000
90,000

3,180,000
1,590,000
1,590,000

300,000
240,000

200,000
160,000

30,000
24,000

530,000
424,000

5. Retainer
a. Retainer estetik (transparan)
b. Retainer ekrilik

ix

tarif DIKLAT dan SDM

E
A
a
b
c
d

Tarif mahasiswa magang/pendidikan/ penelitian

praktek lapangan /hari
Siswa Departemen Kesehatan RI
Siswa Non Departemen Kesehatan RI
mahasiswa Departemen Kesehatan
mahasiswa Non Departemen Kesehatan

B
a
b
c
d

ujian praktek/ orang untuk satu kali diluar honor

Siswa Departemen Kesehatan RI
Siswa Non Departemen Kesehatan RI
mahasiswa Departemen Kesehatan
mahasiswa Non Departemen Kesehatan

C
a
b
c
j

On the job training/orang/bulan

lembaga pendidikan Depkes RI
lembaga pendidikan Non Depkes RI
Instansi/ Rumah Sakit Pemerintah
Instansi/ Rumah Sakit Swasta

D
a
b
c
d
E
a
b
c
d

unit cost

jasa pelayanan remunerasi

tarif

1,000
1,000
1,000
1,500

1,000
1,000
3,000
3,500

500
150
450
525

2,500
2,150
4,450
5,525

5,000
5,000
5,000
10,000

5,000
10,000
15,000
20,000

750
1,500
2,250
3,000

10,750
16,500
22,250
33,000

20,000
25,000
200,000
250,000

20,000
30,000
200,000
250,000

3,000
4,500
30,000
37,500

43,000
59,500
430,000
537,500

penelitian / orang dengan 3 bulan

Siswa Departemen Kesehatan RI
Siswa Non Departemen Kesehatan RI
mahasiswa Departemen Kesehatan
mahasiswa Non Departemen Kesehatan

15,000
20,000
25,000
30,000

15,000
20,000
25,000
30,000

2,250
3,000
3,750
4,500

32,250
43,000
53,750
64,500

penelitian / orang dengan 3 - 6 bulan

Siswa Departemen Kesehatan RI
Siswa Non Departemen Kesehatan RI
mahasiswa Departemen Kesehatan
mahasiswa Non Departemen Kesehatan

17,500
20,000
22,500
25,000

17,500
20,000
22,500
25,000

2,625
3,000
3,375
3,750

37,625
43,000
48,375
53,750

modal
50%
keuntungan
50%
remunerasi

100%
modal
sisa
JP
remunerasi
direksi dkk
strukutr/sta
taktis

50%
50%
100%
50%
35%
5%
5%
5%

100%
50%