LAMPIRAN: PERATURAN BUPATI NOMOR: TAHUN :

TENTANG TARIF PELAYANAN KESEHATAN

DI RUMAH SAKIT UMUM DAERAH KABUPATEN GRESIK

USULAN TARIF PELAYANAN KESEHATAN

DI RUMAH SAKIT UMUM DAERAH IBNU SINA KABUPATEN GRESIK

A. PELAYANAN MEDIS

1 TARIF RAWAT JALAN

2 TARIF TINDAKAN DI INSTALASI GAWAT DARURAT
3 TARIF KAMAR INSTALASI RAWAT INAP
4 TARIF TINDAKAN MEDIS OPERATIF
4.1 TARIF TINDAKAN MEDIS OPERATIF SMF BEDAH
A. TARIF TINDAKAN MEDIS OPERATIF BEDAH UMUM
B. TARIF TINDAKAN MEDIS OPERATIF BEDAH UROLOGI
C. TARIF TINDAKAN MEDIS OPERATIF BEDAH ORTHOPEDI
D. TARIF TINDAKAN MEDIS OPERATIF BEDAH SARAF
4.2 TARIF TINDAKAN MEDIS OPERATIF SMF THT
4.3 TARIF TINDAKAN MEDIS OPERATIF SMF MATA
4.4 TARIF TINDAKAN MEDIS OPERATIF SMF KANDUNGAN
4.5 TARIF TINDAKAN MEDIS OPERATIF SMF KULIT DAN KELAMIN
4.6 TARIF TINDAKAN MEDIS OPERATIF SMF GIGI
5 TARIF TINDAKAN MEDIS NON OPERATIF DI RAWAT JALAN DAN RAWAT INAP
5.1 TARIF TINDAKAN MEDIS NON OPERATIF SMF BEDAH
5.2 TARIF TINDAKAN MEDIS NON OPERATIF SMF KULIT DAN KELAMIN
5.3 TARIF TINDAKAN MEDIS NON OPERATIF SMF PARU
5.4 TARIF TINDAKAN MEDIS NON OPERATIF SMF THT
5.5 TARIF TINDAKAN MEDIS NON OPERATIF SMF MATA
5.6 TARIF TINDAKAN MEDIS NON OPERATIF SMF PENYAKIT DALAM
5.7 TARIF TINDAKAN MEDIS NON OPERATIF SMF SYARAF
5.8 TARIF TINDAKAN MEDIS NON OPERATIF SMF GIGI
5.9 TARIF TINDAKAN MEDIS NON OPERATIF SMF JANTUNG
5.10 TARIF TINDAKAN MEDIS NON OPERATIF SMF KANDUNGAN
5.11 TARIF TINDAKAN MEDIS NON OPERATIF SMF REHABILITASI MEDIK
5.12 TARIF TINDAKAN MEDIS NON OPERATIF SMF GIZI
5.13 TARIF TINDAKAN MEDIS NON OPERATIF SMF ANAK
5.14 TARIF TINDAKAN MEDIS NON OPERATIF SMF ICU

B. PELAYANAN PENUNJANG MEDIS

1 TARIF PEMERIKSAAN RADIOLOGI
2 TARIF PEMERIKSAAN LABORATORIUM PATOLOGI KLINIK
3 TARIF PEMERIKSAAN LABORATORIUM PATOLOGI ANATOMI
4 TARIF PELAYANAN AMBULANCE
5 TARIF PELAYANAN MOBIL JENAZAH
6 TARIF PEMULASARAN JENAZAH
7 CATATAN

C. PELAYANAN NON MEDIS

1 TARIF DIKLAT/PENELITIAN/SURVEY
2 TARIF PELAYANAN LAINNYA

D. TARIF TINDAKAN UMUM

A. PELAYANAN MEDIS

1 TARIF PELAYANAN RAWAT JALAN

NO JENIS PELAYANAN TARIF LAMA (Rp) USULAN TARIF BARU

1 Poli Umum / Gigi / Askes 9,000
2 Poli Spesialis 18,000
3 Konsul Spesialis 15,000
4 Konsul Gigi 6,000
5 Konsultasi tenaga gizi 10,000
6 Poli VIP 50,000 80,000
7 Poli CheckUP 25,000
8 Poli CheckUP Haji 25,000

2 TARIF INSTALASI GAWAT DARURAT

NO JENIS PELAYANAN TARIF LAMA (Rp)

1 Pelayanan oleh dokter jaga IGD 25,000
2 Pemeriksaan Dokter spesialis 40,000

NO JENIS TINDAKAN TARIF LAMA (Rp)

1 Amputasi 1 jari kaki/tangan 121,000
2 amputasi 2 jari kaki/tangan 163,000
3 amputasi >3 jari kaki/tangan 203,000
4 Observasi intoksikasi + antropinisasi/hari 118,000
5 Cross insisi 22,000
6 Circumisi 550,000
7 Konsul dokter Spesialis :
1. Datang dalam jam kerja 40,000
2. Datang diluar jam kerja 100,000
8 Dokter pendamping pasien/amb 100,000
Luar kota ditambah/jam 25,000
9 Perawat pendamping pasien/amb 75,000
Luar kota ditambah/jam 20,000
10 ECG 52,000
11 Ektraksi kuku 45,000
12 Ektraksi benda asing pada mata 50,000
13 Incisi Absces kecil 40,000
14 Incisi Absces besar 56,000
15 Injeksi IV/IM/SC > 3x 13,000
16 Kumbah lambung 130,000
17 Lepas gips 38,000
18 masukkan obat rectal 8,500
19 Nebulaizer 66,000
20 Necrotomy kecil/sedang 125,000
21 Oksigen/jam 10,000
22 Resusitasi berhasil 100,000
23 Oksigen/tabung 70,000
24 Pemasangan fiksasi dada 32,000
25 Pungsi kandung kemih 150,000
26 pasang infus 15,000
27 Pasang NGT 29,000
28 Pasang cateter tanpa penyulit 66,000
29 Pasang cateter dengan penyulit 156,000
30 Pasang condom khateter 22,000
31 Pasang ransel verbad 35,000
32 Pasang elastic bandage 15,000
33 Pasang spalk 50,000
34 Pasang Gips 100,000
35 Rawat luka kecil 33,000
36 Rawat luka sedang 45,500
37 Rawat luka besar 65,000
38 Rawat luka bakar 0-10 % 65,000
39 Rawat luka bakar 10-20 % 85,000
40 Rawat luka bakar 20-40 % 98,000
41 Rawat luka bakar > 40 % 118,000
42 Rectal toucher 21,000
43 Repair tendon 150,000
44 Reposisi hernia & fiksasi 100,000
45 Reposisi luksasio mandibulla 100,000
46 Suction/ hari 26,000
47 Tindakan heacthing kecil 33,000
48 Tindakan heacthing sedang 67,000
49 Tindakan heacthing besar 77,000
50 Tindakan heacthing > 25 170,000
51 Vena seksi 125,000
52 Observasi tanpa monitor :
1. 1 - 12 jam 30,000
2. 12 - 24 jam 40,000
 53 Observasi dengan monitor :
1. 1 - 12 jam 87,500
2. 12 - 24 jam 175,000
54 Pengambilan sample darah 4,000
55 Ektraksi benda asing 67,000
56 Thoracosintesis 100,000
57 Pasang LMA 75,000
58 Pasang ETT 150,000
59 imcomed 1,600
60 Pemberian obat lewat syring phump 100,000
61 Infus Phump 75,000
62 DC shoeck 150,000
63 Pungsi Pleura 180,000

Catatan:
Semua jenis tindakan yang dilakukan di Instalasi Gawat Darurat
dikenakan tarif sesuai tarif tindakan di IGD
Bila belum ada tarif tindakan tertentu, maka tarif disetarakan dengan tarif tindakan kelas II
3 TARIF PELAYANAN RAWAT INAP

3.1 Tarif Kamar Perawatan

TARIF LAMA (Rp) USULAN TARIF BARU
NO JENIS PELAYANAN
III II I VIP VVIP III
1 Sarana :
- Catering 20,000 25,000 30,000 35,000 80,000
- Kamar/Akomodasi 20,000 41,000 64,000 175,000 200,000
TOTAL SARANA 40,000 66,000 94,000 210,000 280,000
2 Jasa Visite :
Dokter Umum 20,000 30,000 40,000 60,000 75,000
Dokter Spesialis 30,000 40,000 60,000 100,000 100,000
TOTAL JASA VISITE 50,000 70,000 100,000 160,000 175,000
3 Extra bed dewasa :
Sarana - - 164,500 - 448,000
Jasa Visite :
Dokter Umum - - 40,000 - 75,000
Dokter Spesialis - - 60,000 - 100,000
4 Pemasangan CPAP 250,000
5 Sewa CPAP 250,000
6 Douglas punksi 600,000 700,000 900,000 1,500,000 1,750,000
7 Heacting situasi 600,000 700,000 900,000 1,500,000 1,750,000
8 Pasang laminaria 165,000 205,000 247,000 330,000 346,000
9 Puls oxymetri tanpa CPAP/ 20,000
hari
10 Pompa ASI /hari 5,000
4.1 TARIF TINDAKAN MEDIS OPERATIF SMF BEDAH
A TARIF TINDAKAN MEDIS OPERATIF BEDAH UMUM

TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
A TINDAKAN KHUSUS :
1 Mastectomy Radical 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
2 Parotidectomy 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
3 Radical Nect Dissection 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
4 Minimal Invasive Surgery (Laparoscopy Surgery) 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
5 Abdomino Perineal Resection 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
6 Low Anterior Resection 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
7 Hernia Diafragmatica 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
8 Biliair Disgestive Anastomose 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
9 Repair Atresia Ani (Anoplasty) 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
10 Repair Megacolon 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000

B TINDAKAN BESAR :
11 Mastectomy / Sub Cutan Mastectomy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
12 Cheilonaphi dengan Anestesi Umum 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
13 Strumectomy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
14 Laparostomy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
15 Hernia Incarcerata 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
16 Palatoraphy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
17 Cystaductus Thyrogrossus 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
18 Cholecystectomy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
19 Amputasi Extremitas 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
20 Plating / IOID Mandibula + Suspension 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
21 Flap + Reconstruction 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
22 Colostomy, Tutup Colostomy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
23 Ileus Obstruksi 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
24 Invaginasi, Volvulus 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
25 Reseksi Usus, Hemicolectomi, Anastomose 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
26 Peri Appendicular Infiltrat 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
27 Gastrostomy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
28 Tracheostomy 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
29 Hernia Cicatrialis 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
30 Hernia Umbillicalis 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
31 Corpus Alienum Dalam Sistem Organ 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
32 Lapaorscopy Diagnostic 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
33 Hernia dengan perlekatan 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
34 Hernia Permagna 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
35 Skin Graft 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
36 Batu buli-buli ukuran > besar 2,640,000 3,300,000 3,960,000 5,016,000 5,280,000
 TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
C TINDAKAN SEDANG :
37 Hernia Inguinalis Reponible 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
38 Hernia Femoralis Reponible 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
39 Hydrocele 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
40 Biopsi 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
41 Bursiris 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
42 Ganglion Poplitea 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
43 Fribro Adenoma Mamma 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
44 Mamma Aberrans 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
45 Epulis 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
46 Radicular Cyst 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
47 Reposisi Nasal 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
48 Reposisi Zygoma 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
49 Torus Palatinum 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
50 Ranula 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
51 Appendisitis 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
52 Amputasi Jari 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
53 Hemorrhoid 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
54 Perianal Fistulla 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
55 Perianal Abscos 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
56 Cheiloraphy dengan Lokal Anesthesi 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
57 Cimino Shunt 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
58 Diagnostic Peritoneal Lavage (DPL) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
59 Ganglion Carpi (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
60 Corpus Alienum Dangral (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
61 Cysta Dermoid (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
62 Lipoma (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
63 Atheroma (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
64 Clavus (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
65 Hemangioma (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
66 Furuncle (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
67 Neurofibroma (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
68 Granuloma (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
69 Fibroma (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
70 Phlegmon (Absces) (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
71 Veruca (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
72 Papilloma (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
73 Mucocele (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000
74 Keloid (GA) 1,650,000 2,062,000 2,475,000 3,135,000 3,300,000

D TINDAKAN KECIL (LOKAL ANASTESI) :

75 Ganglion Carpi 528,000 660,000 792,000 1,003,000 1,056,000
76 Corpus Alienum Dangral 528,000 660,000 792,000 1,003,000 1,056,000
 TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
77 Cysta Dermoid 528,000 660,000 792,000 1,003,000 1,056,000
78 Lipoma 528,000 660,000 792,000 1,003,000 1,056,000
79 Atheroma 528,000 660,000 792,000 1,003,000 1,056,000
80 Clavus 528,000 660,000 792,000 1,003,000 1,056,000
81 Hemangioma 528,000 660,000 792,000 1,003,000 1,056,000
82 Furuncle 528,000 660,000 792,000 1,003,000 1,056,000
83 Neurofibroma 528,000 660,000 792,000 1,003,000 1,056,000
84 Granuloma 528,000 660,000 792,000 1,003,000 1,056,000
85 Fibroma 528,000 660,000 792,000 1,003,000 1,056,000
86 Phlegmon (Absces) 528,000 660,000 792,000 1,003,000 1,056,000
87 Veruca 528,000 660,000 792,000 1,003,000 1,056,000
88 Papilloma 528,000 660,000 792,000 1,003,000 1,056,000
89 Mucocele 528,000 660,000 792,000 1,003,000 1,056,000
90 Keloid 528,000 660,000 792,000 1,003,000 1,056,000
91 Pasang CVP 528,000 660,000 792,000 1,003,000 1,056,000
92 Vena seksi 528,000 660,000 792,000 1,003,000 1,056,000

E TINDAKAN MEDIS OPERATIF RAWAT JALAN :

Insisi Abses:
93 Kecil 40,000 50,000 60,000 76,000 80,000
94 Besar 56,000 70,000 84,000 106,000 112,000
95 Ekstraksi Kuku 45,000 56,000 67,000 85,000 90,000
96 Amputasi Jari 121,000 151,000 181,000 229,000 242,000
97 Amputasi ringan/kecil 163,000 203,000 244,000 309,000 326,000
98 Amputasi sedang 203,000 253,000 304,000 385,000 406,000
99 Circumsisi 170,000 212,000 255,000 323,000 340,000
100 Cross Incisi 22,000 27,000 33,000 41,000 44,000
101 Dorsumcisi Phimosis 30,000 37,000 45,000 57,000 60,000
102 Repair tendon 150,000 187,000 225,000 285,000 300,000
103 Reposisi hernia 100,000 125,000 150,000 190,000 200,000
104 Necrotomi kecil/sedang 125,000 156,000 187,000 237,000 250,000
105 reposisi luksasi mandibulae 100,000 125,000 150,000 190,000 200,000
106 Reposisi haemorhoid 31,000 38,000 46,000 58,000 62,000
4 TARIF TINDAKAN MEDIS OPERATIF

D. TARIF TINDAKAN MEDIS OPERATIF BEDAH SYARAF

TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
A TINDAKAN BESAR:
1 External Ventricular drainase 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
2 Eksisi Ensefalokel 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
3 Revisi Drain VP Shunt 3,234,000 4,042,000 4,851,000 6,144,000 6,468,000
B TINDAKAN KHUSUS:
1 Trepanasi Trauma 4,042,000 5,052,000 6,063,000 7,679,000 8,084,000
2 Trepanasi Tumor 4,042,000 5,052,000 6,063,000 7,679,000 8,084,000
3 Laminektomi 4,042,000 5,052,000 6,063,000 7,679,000 8,084,000
4 VP Shunt 4,042,000 5,052,000 6,063,000 7,679,000 8,084,000
5 Eksisi Myelokel 4,042,000 5,052,000 6,063,000 7,679,000 8,084,000

4.2 TARIF TINDAKAN MEDIS OPERATIF THT

TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
A OPERASI BESAR :
1 Adenoidektomi + tonsilektomi 1,600,000 2,000,000 2,600,000 3,500,000 3,800,000
2 Polip ekstraksi + etmoidektomi 1,600,000 2,000,000 2,600,000 3,500,000 3,800,000
3 Polip ekstraksi + etmoidektomi dengan tuntunan endoscopy 2,100,000 2,550,000 3,200,000 4,150,000 4,500,000

` 4 Polip ekstraksi + irigasi sinus maksilaris 1,600,000 2,000,000 2,600,000 3,500,000 3,800,000
5 Polip ekstraksi + irigasi sinus maksilaris dengan tuntunan 2,100,000 2,550,000 3,200,000 4,150,000 4,500,000
endoscopy
6 Tonsilektomi + Irigasi sinus maksilaris 1,600,000 2,000,000 2,600,000 3,500,000 3,800,000
7 Tonsilektomi + Irigasi sinus maksilaris dengan tuntunan 2,100,000 2,550,000 3,200,000 4,150,000 4,500,000
endoscopy
8 Insisi abses besar 1,600,001 2,000,000 2,600,000 3,500,000 3,800,000
9 Chaldwell - Luc 2,000,000 2,500,000 3,000,000 4,000,000 4,500,000
10 Trakeotomi 1,600,000 2,000,000 2,720,000 3,840,000 4,000,000
B OPERASI SEDANG :
11 Adenoidektomi 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
12 Adenoidektomi dengan tuntunan endoscopy 1,700,000 2,050,000 2,600,000 3,150,000 3,450,000
13 Tonsilektomi tanpa Thermal welding 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
14 Tonsilektomi + Thermal welding 1,800,000 2,100,000 2,600,000 3,100,000 3,350,000
15 Irigasi sinus maksilaris 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
16 Polip ekstraksi 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
17 Polip ekstraksi dengan tuntunan endoscopy 1,700,000 2,050,000 2,600,000 3,150,000 3,450,000
18 Ekstirpasi fistel preaurikularis 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
19 Reposisi fraktur os nasalis 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
20 Ekstraksi korpus alienum (sulit) 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
Ekstraksi korpus alienum (sulit) dengan endoscopy 1,600,000 2,000,000 2,600,000 3,500,000 4,000,000
21 (General Anesthesi)
22 Insisi abses 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
23 Ekstraksi oorpolip (polip telinga) 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
24 Konka reduksi dengan thermal welding (General anesthesi) 1,600,000 2,000,000 2,500,000 3,000,000 3,500,000
25 Konka reduksi dengan thermal welding (Lokal anesthesi) 1,500,000
26 Biopsi tumor nasal/nasofaring sulit (General anesthesi) 1,200,000 1,500,000 2,000,000 2,500,000 2,750,000
C OPERASI KECIL :
27 Ekstirpasi atheroma telinga 500,000 600,000 800,000 1,100,000 1,250,000
28 Repair lobullus 500,000 600,000 800,000 1,100,000 1,250,000
29 Ekstraksi corpus alienum 500,000 600,000 800,000 1,100,000 1,250,000
30 Ekstirpasi fistel pre aurikularis dengan lokal anestesi 500,000 600,000 800,000 1,100,000 1,250,000
31 Laringoscopy directa (lokal anesthesi) 300,000 350,000 400,000 500,000 600,000
32 laringoscopy directa + Biopsi (lokal anesthesi) 500,000 600,000 800,000 1,000,000 1,250,000

4.3 TARIF TINDAKAN MEDIS OPERATIF MATA

TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
A OPERASI KHUSUS 1,500,000 1,725,000 2,000,000 2,250,000 2,500,000
1 Cataract dgn Phacoemulsifikasi 1,500,000 1,725,000 2,000,000 2,250,000 2,500,000
2 Tumor adnexa dgn Rekronstruksi 1,500,000 1,725,000 2,000,000 2,250,000 2,500,000
3 Rekonstruksi Symblefaron 1,500,000 1,725,000 2,000,000 2,250,000 2,500,000
4 Trauma dgn Pigtail dan Rekonstruksi adnexa 1,500,000 1,725,000 2,000,000 2,250,000 2,500,000
5 Exerterasi 1,500,000 1,725,000 2,000,000 2,250,000 2,500,000
B OPERASI BESAR :
6 Katarak
7 Trabekulektomi
8 Enukleasi
9 Eviserasi 1,100,000 1,375,000 1,650,000 2,090,000 2,200,000
10 Ruptur bola mata
11 Tarsotomi
12 Disisi Aspirasi
13 Parasintesa dan Ekstraksi Koagulm
14 One Day Care Katarak 825,000
15 Operasi katarak dengan Pacho 1,325,000 1,600,000 1,875,000 2,315,000 2,425,000
C OPERASI SEDANG :
16 Flap Konjungtiva
17 Parasintesa 578,000 722,000 867,000 1,098,000 1,156,000
18 Hechting Konjungtiva Palpebra tanpa pigtail/rekonstruksi
19 Tindakan kecil dgn General Anasthesi
D OPERASI KECIL
20 Pterygeum 350,000 420,000 504,000 604,000 724,000
21 Papilloma 350,000 420,000 504,000 604,000 724,000
22 Nevus Konjungtiva 350,000 420,000 504,000 604,000 724,000
23 Hordeolum 150,000 180,000 216,000 259,000 310,000
24 Chalazion 150,000 180,000 216,000 259,000 310,000
25 Granuloma 150,000 180,000 216,000 259,000 310,000
26 Lithiasis 150,000 180,000 216,000 259,000 310,000
Catatan :
Jasa Anesthesi Operasi Mata adalah 1/3 dari Tarif Jasa Operator
Operasi kecil poli yg dikerjakan di OK dg GA tarifnya menjadi operasi sedang
4.4 TARIF TINDAKAN MEDIS OPERATIF KANDUNGAN

TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
A. TARIF TINDAKAN MEDIS OPERATIF KANDUNGAN
1 Histeriktomi tanpa Komplikasi 3,000,000 3,500,000 4,000,000 5,000,000 5,750,000
2 Histeriktomi dengan Komplikasi 3,500,000 4,000,000 4,500,000 5,500,000 6,000,000
3 Operasi Kista tanpa Penyulit 3,000,000 3,500,000 4,000,000 5,000,000 5,750,000
4 Operasi Kista dengan Penyulit 3,500,000 4,000,000 4,500,000 5,500,000 6,000,000
5 HT - SOB tanpa Penyulit 3,000,000 3,500,000 4,000,000 5,000,000 5,750,000
6 HT - SOB dengan Penyulit 3,500,000 4,000,000 4,500,000 5,500,000 6,250,000
7 SC tanpa Penyulit 2,500,000 3,000,000 3,500,000 4,500,000 4,750,000
8 SC dengan Penyulit 3,000,000 3,500,000 4,000,000 5,000,000 5,750,000
9 Sterilisasi ( Mini+Lap ) 750,000 1,000,000 1,200,000 1,700,000 2,000,000
10 Rekrontruksi Jalan Lahir ( Perineum ), Antero Posterior
3,000,000 3,500,000 4,000,000 5,000,000 5,750,000
Repair
Keterangan :
Cito 50%
Penyulit
TARIF LAMA
B. TINDAKAN MEDIS OPERATIF DI VK BERSALIN III II I VIP VVIP
1 Persalinan Spontan oleh Bidan 247,000 309,000 370,000 495,000 519,000
2 Persalinan Spontan Oleh Dokter 500,000 600,000 700,000 900,000 1,500,000
3 Persalinan Pathol VE / SU / Eksplorasi HPP 750,000 1,000,000 1,200,000 1,700,000 2,000,000
4 Curretage 600,000 700,000 900,000 1,500,000 1,750,000
5 Marsupialisasi Bartholin 600,000 700,000 900,000 1,500,000 1,750,000
6 Repair Jalan lahir 600,000 700,000 900,000 1,500,000 1,750,000
7 Placenta Manual 600,000 700,000 900,000 1,500,000 1,750,000
8 Aff. IUD sulit 600,000 700,000 900,000 1,500,000 1,750,000
9 Biopsi Sedang 165,000 205,000 247,000 330,000 346,000
10 Aff. Implant 300,000 350,000 400,000 550,000 750,000
11 Vacum 750,000 1,000,000 1,200,000 1,750,000 2,000,000
12 Curetase Mola 1,000,000 1,500,000 2,000,000 3,000,000 3,500,000
13 Curetase Abortus 600,000 700,000 900,000 1,200,000 1,750,000
14 Curetase Retensio Placenta 1,200,000 1,500,000 1,750,000 2,250,000 2,750,000
15 Curetase Rest Placenta 750,000 800,000 900,000 1,500,000 1,750,000
16 Kistektomi Bartholini 750,000 900,000 1,200,000 1,750,000 2,000,000

4.5 TARIF TINDAKAN MEDIS OPERATIF SMF KULIT DAN KELAMIN

TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
1 Extirpasi 150,000 175,000 200,000 250,000 300,000
2 Biopsi 150,000 175,000 200,000 250,000 300,000
3 Incisi Abses 150,000 175,000 200,000 250,000 300,000
4 Marsupialisasi 325,000 350,000 375,000 400,000 450,000
5 Extirpasi Tumor Jinak 200,000 215,000 225,000 250,000 300,000
6 Tindakan Bedah Listrik 200,000 215,000 225,000 250,000 300,000
7 Incici Furancle 60,000 70,000 80,000 85,000 100,000

4.6 TARIF TINDAKAN MEDIS OPERATIF SMF GIGI

TARIF LAMA
NO JENIS PELAYANAN
III II I VIP VVIP
1 Odontectomy 500,000 1,100,000 1,320,000 1,584,000 1,900,800
2 Ginggivectomy Tiap Regio 300,000 650,000 780,000 936,000 1,123,200
3 Kuret Tiap Regio 300,000 650,000 780,000 936,000 1,123,200
4 Extraksi Ditunda 13,000 14,000 15,000 16,000 18,000
5 Cabut Gigi Permanen ( > 1 Akar ) 65,000 100,000 120,000 159,000 190,800
6 Cabut Gigi Sulung ( > 1 Akar ) 40,000 50,000 60,000 87,000 104,400
7 Cabut Gigi Permanen ( Akar Tunggal ) 50,000 100,000 120,000 159,000 190,800
8 Cabut Gigi Sulung ( Akar Tunggal ) 25,000 50,000 60,000 72,000 86,400
9 Cabut Gigi Permanen denganTopikal Anaestesi 40,000 50,000 60,000 87,000 104,400
10 Cabut Gigi Anaestesi Topikal (Sulung) 40,000 50,000 60,000 87,000 104,400
11 Cabut Gigi Komplikasi 115,000 200,000 240,000 303,000 363,600
12 Pulpectomy 45,000 46,500 48,000 50,000 60,000
13 Tumpatan Sementara + Pengobatan Pulpa 121,000 221,000 254,000 75,000 86,000
14 Uperculectomy 275,000 400,000 480,000 576,000 691,200
15 Incisi Abses Intra Oval 50,000 100,000 120,000 144,000 172,800
16 Alveolectomy 400,000 600,000 720,000 864,000 1,036,800
17 Splinting 500,000 1,000,000 1,200,000 1,440,000 1,728,000
18 Tumpatan tuang inlay 350000 400,000
19 Tumpatan tuang uplay 350000 400,000
20 Tumpatan tuang mahkota selubung porcelain 600000 650,000
21 Mahkota sementara akrilik 75000 100,000
22 Gigi tiruan lepasan sebagian :
- Akrilik gigi pertama 350000 400,000
- Akrilik gigi berikutnya 40000 50,000
23 Gigi tiruan lepasan metal :
- Per Gigi 75,000 100,000
- Plat 700,000 750,000
24 Full Denture per rahang :
- Gigi Akrilik 1,200,000 1,250,000
- Gigi Porcelain 1,400,000 1,500,000
5.6 TARIF TINDAKAN MEDIS NON OPERATIF SMF PENYAKIT DALAM
TARIF LAMA
KELAS
NO JENIS PELAYANAN
III II I VIP VVIP
1 Fungsi Asites 234,000 281,000 337,000 405,000 486,000
2 Sitostatika (paket/hari) 234,000 281,000 337,000 405,000 486,000
3 Fungsi Genu 156,000 188,000 225,000 270,000 324,000
4 Plebotomi 234,000 281,000 337,000 405,000 486,000
5 Endoscopy 390,000 468,000 562,000 674,000 809,000
6 LVE / STE 546,000 656,000 787,000 944,000 1,133,000
7 Biopsi Gastroscopy 116,400 140,000 168,000 202,000 242,000
8 Biopsi Colonoscopy 156,000 188,000 225,000 270,000 324,000
9 Colonoscopy 780,000 936,000 1,124,000 1,348,000 1,618,000
10 Injeksi Intra artikuler 156,000 188,000 225,000 270,000 324,000
11 Fungsi abces hepar 390,000 468,000 562,000 674,000 809,000
12 VCT rawat inap 30,000 40,000 60,000 100,000 100,000
13 VCT rawat inap (perawat) 23,000 30,000 45,000 60,000 60,000
14 Hemodialisa:
Ket : Hemodialisa 0 - 30 menit 500,000
Hemodialisa 30 - 60 menit 550,000
Hemodialisa > 1 jam Tarif penuh
2 PEMERIKSAAN LABORATORIUM PATOLOGI KLINIK

TARIF
NO JENIS PELAYANAN
III II I VIP VVIP
A PEMERIKSAAN URINE
1 UL Analiser 19,500 21,500 23,500 26,500 27,500
2 Bilirubin / Urobilin 19,500 21,500 23,500 26,500 27,500
3 Albumin / Sedimen 19,500 21,500 23,500 26,500 27,500
4 Reduksi 19,500 21,500 23,500 26,500 27,500
5 BJ Urine 19,500 21,500 23,500 26,500 27,500
6 Esbach 13,000 14,500 16,000 19,000 20,000
7 Ph 11,000 12,000 13,000 15,000 16,000
8 Aceton 13,000 14,500 16,000 19,000 20,000
9 Urine Bencejones 13,000 14,500 16,000 19,000 20,000
B PEMERIKSAAN DARAH
10 Darah Lengkap Analizer 50,000 55,000 60,000 65,000 70,000
11 Hb 20,000 22,000 25,000 27,000 29,000
12 PCV 11,000 12,000 13,000 15,000 16,000
13 Leucocyte 13,000 14,500 16,000 19,000 20,000
14 LED 20,000 22,000 24,000 26,000 29,000
15 Hb, PCV, Thrombo 45,000 49,000 53,000 55,000 60,000
16 Hapusan Darah 40,000 45,000 50,000 55,000 60,000
17 Darah Malaria 50,000 55,000 60,000 65,000 70,000
18 Gol. Darah 13,500 14,000 15,000 19,000 20,000
19 BT / CT 11,000 12,000 13,000 15,000 16,000
20 EOS 20,000 22,000 24,000 27,000 28,000
21 Reticulocyte 20,000 22,000 24,000 27,000 28,000
22 Rhesus 13,000 14,500 16,000 19,000 20,000
23 Hb A1C 160,000 165,000 170,000 175,000 180,000
24 Whoole Blood 200,000 240,000 260,000 280,000 300,000
C FAAL HAEMOTASIS
25 APTT 40,000 44,000 46,500 53,000 59,000
26 Fibronogen 45,000 49,500 54,000 60,000 66,000
27 Trombin Time (TT) 40,000 44,000 46,500 53,000 59,000
28 Protombin Time (PT) 45,000 49,500 54,000 60,000 66,000
29 D. Dimer 210,000 220,000 225,000 230,000 235,000
D FAECES
30 Faeces Lengkap 11,000 12,000 13,000 15,000 16,000
31 Bensidin Lengkap 25,000 30,000 35,000 40,000 45,000
E SEROLOGY / IMUNOLOGI
32 Widal Slide 25,000 27,500 30,000 35,000 40,000
33 VDRL 30,000 35,000 40,000 45,000 47,500
34 Tes Kehamilan ( Stick ) 27,000 30,000 32,500 36,500 38,000
35 HBs Ag ( Stick ) 41,000 45,000 49,000 55,000 57,000
36 HBs Ab ( Stick ) 41,000 45,000 49,000 55,000 57,000
37 Dbt 61,000 67,000 73,000 82,000 86,000
38 Micodot 74,000 81,000 89,000 101,000 106,000
39 HIV Stik 97,000 106,000 116,000 133,000 139,000
41 Rematoid Factor 35,000 40,000 45,000 50,000 55,000
42 HCV Stik 78,000 85,000 93,000 106,000 111,000
43 Narkoba ( tiap parameter ) 45,000 49,000 53,000 59,000 61,000
 TARIF
NO JENIS PELAYANAN
III II I VIP VVIP
44 Mikro Albumin 125,000 130,000 135,000 140,000 145,000
45 CRP Kwantitatif 110,000 115,000 120,000 125,000 127,000
F BACTERIOLOGI
46 GO Preparat 25,000 27,500 30,000 32,500 35,000
47 MH 25,000 27,500 30,000 32,500 35,000
48 Sputum ( BTA ) 25,000 27,500 30,000 32,500 35,000
49 Difteri 25,000 27,500 30,000 32,500 35,000
50 Pemeriksaan Air 76,000 83,500 91,000 102,500 106,500
G KIMIA DARAH
51 Bili Dir / Tot 17,000 18,000 20,000 22,000 24,000
52 SGOT 17,000 18,000 20,000 22,000 24,000
53 SGPT 17,000 18,000 20,000 22,000 24,000
54 Alkali Fosfatase 25,000 27,000 29,000 32,500 33,500
55 GMGT 60,000 65,000 67,500 71,000 74,000
56 Albumin 17,000 18,000 20,000 22,000 24,000
57 Total Protein 17,000 18,000 20,000 22,000 24,000
58 Globulin 17,000 18,000 20,000 22,000 24,000
59 BUN 16,000 18,000 20,000 22,000 24,000
60 Serum Creatinin 18,000 20,000 22,000 24,000 26,000
61 Uric Acid 18,000 20,000 22,000 24,000 26,000
62 Urea Clearrence 48,000 52,000 57,000 64,000 67,000
63 Creatin CL 48,000 52,000 57,000 64,000 67,000
64 Cholesterol 21,000 22,500 25,000 27,000 30,000
65 Trigleseride 21,000 22,500 25,000 27,000 30,000
66 HDL Cholesterol 25,000 27,500 30,000 33,000 36,500
67 LDL Colesterol 25,000 27,500 30,000 33,000 36,500
68 Total Lipid 25,000 27,500 30,000 33,000 36,500
69 Kalium 35,000 37,000 39,000 41,000 43,000
70 Natrium 35,000 37,000 39,000 41,000 43,000
71 Calcium 35,000 37,000 39,000 41,000 43,000
72 Chlorida 35,000 37,000 39,000 41,000 43,000
73 Gula Darah Acak 14,000 15,000 16,000 19,000 20,000
74 BSN 2 jam PP 13,000 14,000 15,000 16,500 17,000
75 SI 50,000 55,000 57,000 60,000 62,000
76 TIBC 50,000 55,000 57,000 60,000 62,000
H LIQUOR
77 Liquor Lengkap 90,000 100,000 110,000 120,000 130,000
I CAIRAN PLEURA
78 Analisa Sperma 50,000 55,000 60,000 69,000 72,000
79 Analisa Gas darah 350,000 385,000 423,000 489,000 513,000
J TAMBAHAN
80 Leptospira 125,000 135,000 145,000 155,000 165,000
81 IgG Dengue Stick 70,000 77,000 85,000 93,000 102,000
82 IgM Dengue Stick 70,000 77,000 85,000 93,000 102,000
83 IgG Denghe Ellisa 102,000 110,000 120,000 130,000 140,000
84 IgM Dengue Ellisa 102,000 110,000 120,000 130,000 140,000
85 T3 Ellisa 85,000 93,500 103,000 113,000 124,500
86 T4 Ellisa 85,000 93,500 103,000 113,000 124,500
87 TSHS Ellisa 110,000 121,000 133,000 146,000 160,000
 TARIF
NO JENIS PELAYANAN
III II I VIP VVIP
88 HBsAg Ellisa 80,500 85,000 90,000 92,000 95,000
89 HBsAb Ellisa 88,000 90,000 92,000 95,000 97,000
90 Anti HBC Ellisa 120,000 132,000 145,000 160,000 175,000
91 Anti HCV Ellisa 130,000 145,000 150,000 155,000 160,000
K PARAMETER
92 LDH 55,000 57,500 60,000 65,000 70,000
93 CK-MB 85,000 87,500 90,000 95,000 100,000
94 IgG IgM Salmonela 110,000 115,000 120,000 125,000 130,000
95 Troponin I 80,000 88,000 97,000 106,500 117,500
96 FT 4 140,000 155,000 170,500 188,000 206,000
97 AFP 140,000 155,000 170,500 188,000 206,000
98 CEA 140,000 155,000 170,500 188,000 206,000
99 PSA 140,000 155,000 170,500 188,000 206,000
100 ASO 35,000 40,000 45,000 50,000 55,000
101 Kultur dan Sensitivity (3 hari)
- Urine 200,000 210,000 230,000 240,000 250,000
- Darah 200,000 210,000 230,000 240,000 250,000
- Pus 200,000 210,000 230,000 240,000 250,000
102 Jamur/KOH 35,000 38,500 42,500 47,000 52,000

Usulan
103 IgM Anti HAV 170,000 175,000 180,000 185,000 190,000
104 Phospor 35,000 37,000 39,000 41,000 43,000
105 β HCG 170,000 175,000 180,000 185,000 190,000

Cito : Tarif umum ditambah 25 %

TARIF PEMULASARAN JENAZAH

NO JENIS PELAYANAN TARIF

1 Surat Visum et Repertum :
1. Visum et Repertum Hidup 50,000 235%
2. Visum et Repertum Meninggal 50,000 150%
3. Surat Pemeriksaan Jenazah (Surat Kematian) 25,000 40%
Asuransi Korban Meninggal

2 Tindakan Otopsi Jenazah ( Pemeriksaan Dalam )

1. Otopsi pada Jam Kerja 250,000 10%
2. Optopsi di luar Jam Kerja 375,000 0.3%

Tindakan Otopsi Jenazah ( Pemeriksaan Luar )

1. Otopsi pada Jam Kerja
2. Optopsi di luar Jam Kerja

3 Perawatan Jenazah :
a. Perawatan Jenazah 50,000 0%
. Perawatan Jenazah dengan Penyakit Menular
b. Penyimpanan Jenazah per jam 10,000 35%
c. Penyimpanan jenazah per hari 275,000 0%
d. Pengawetan Jenazah (Embalming) 1,700,000 25%
e. Kain Kafan 100,000 35%
 TARIF TINDAKAN UMUM

TARIF LAMA USULAN TARIF BARU

NO TINDAKAN
III II I VIP VVP III II I VIP
Rawat luka :
2 Kecil 25,000 33,000 43,000 55,000 72,000
3 Sedang 35,000 45,500 60,000 77,000 100,000
4 Besar 50,000 65,000 85,000 110,000 143,000
Rawat Luka Bakar:
5 0 - 10 % 50,000 65,000 84,500 109,850 142,805
6 10 - 20 % 65,000 85,000 110,000 143,000 186,000
7 20 - 40 % 75,000 98,000 127,000 165,000 215,000
> 40 % 90,000 118,000 153,000 198,000 258,000
Rawat Luka Gangren:
8 Stadium 0 - 2 (Kecil) 35,000 46,000 60,000 77,000 10,000
9 Stadium 4 - 4 (Sedang) 50,000 65,000 85,000 110,000 143,000
10 Stadium > 4 (Besar) 60,000 78,000 102,000 132,000 172,000
Angkat Jahitan:
11 1-6 20,000 26,000 34,000 44,000 58,000
12 7 - 12 25,000 33,000 43,000 55,000 72,000
13 > 12 35,000 46,000 60,000 77,000 100,000

14 Pasang Infus 11,000 15,000 19,000 25,000 32,000

15 Pasang NGT 22,000 29,000 38,000 49,000 63,000
16 Kumbah Lambung per hari 100,000 130,000 169,000 220,000 286,000
17 Pasang DC (Kateter) 22,000 29,000 38,000 49,000 63,000
18 Lavement per Hari 70,000 91,000 118,000 153,000 198,000
19 Rectal Toucher 16,000 21,000 28,000 36,000 46,000
20 Atropinisasi per hari 100,000 130,000 169,000 220,000 286,000
21 Periksa Hb Ruangan 10,000 13,000 16,000 20,000 26,000
22 Ambil Sampel Darah Ruangan 3,000 4,000 5,000 6,000 7,000
23 GDA Ruangan(stick tdk termasuk) 18,000 23,000 29,000 37,000 48,000
24 Vena Seksi 91,000 125,000 162,000 210,000 273,000
25 Observasi Intoksikasi / hari 90,000 118,000 153,000 198,000 258,000
26 Injeksi IV / IM per hari per pasien 9,500 13,000 17,000 21,000 28,000
27 Memasukkan obat per rectal 8,500 12,000 15,000 19,000 25,000
28 Pasang cateter tanpa penyulit 50,000 66,000 85,000 110,000 143,000
29 Pasang cateter dengan penyulit 150,000 196,000 254,000 330,000 429,000
30 Pemeriksaan Dr. spesialis jam kerja 40,000 52,000 68,000 88,000 115,000
31 Pemeriksaan Dr. spesialis di luar jam kerja 90,000 117,000 152,000 197,000 256,000
32 Blass punksi 54,000 60,000 75,000 146,000 146,000
33 Pasang collar brisch(fixasi leher) 35,000 47,500 59,000 116,000 116,000
34 ECG Emergency 40,000 52,000 68,000 88,000 115,000
36 Suction/hari 27,000 36,000 46,000 60,000 78,000
 37 RJPO berhasil hidup 150,000 195,000 254,000 330,000 429,000
38 RJPO (resusitasi jant.pulm.otak) gagal hidup 150,000 195,000 254,000 330,000 429,000
39 Skiren Kepala 13,000 16,000 20,000 39,000 49,000
40 RR 72,000 81,000 85,000 99,000 104,000
41 Tarif Anesthesi CT-Scan 65,000 68,000 71,000 83,000 87,000
42 Tarif Anesthesi Operasi Kecil 162,000 170,000 179,000 208,000 217,000
43 Oksigen per liter 6,000
44 Oksigen per tabung 70,000
45 N2O per jam 84,000
46 Ambil sampel darah arteri (ICU) 10,000 13,000 16,000 20,000 26,000
47 Sewa Alat LMA 75,000
48 Plat Mandibula - - - - -
49 Plat Orthopedi - - - - -
50 Lensa / IOL - - - - -
51 Vaksinasi 42,000 50,000 60,000 72,000 86,000
52 Mantoux test 42,000 50,000 60,000 72,000 86,000

Keterangan:
GDA, Hb : ada 2 perlakuan: 1. Lab : diberi kode untuk Lab
2. Ruangan : diberi kode untuk ruangan,
jasa sarana untuk Lab jasa layanannya untuk Ruangan
3. Sampel kecuali untuk sampel laboratorium

1. Plat Mandibula Tarif berdasar pembelian

2. Plat Orthopedi Tarif berdasar pembelian
3. Lensa/IOL Tarif berdasar pembelian
USULAN TARIF BARU
VVP
5 BANK DARAH

NO JENIS PELAYANAN TARIF LAMA USULAN TARIF BARU

Pelayanan Darah Pasien Umum ( Non VIP ) I VIP VVIP
1 Pasien dari Kabupaten Gresik 241,000 241,000
2 Pasien dari Luar Kabupaten Gresik 260,000 260,000

Pelayanan Darah Pasien Umum ( VIP / Paviliun )

1 Pasien dari Kabupaten Gresik 307,500 307,500
2 Pasien dari Luar Kabupaten Gresik 331,500 331,500
 TARIF TINDAKAN UNIT ENDOSKOPI GASTROINTESTINAL

NO JENIS TINDAKAN TARIF

USULAN
01 Gastroskopi Rp 1,100,000
02 Kolonoskopi Rp 1,850,000
03 Gastroskopi dengan STE / LVE Rp 1,500,000
04 Biopsy Gastroskopi Rp 140,000
05 Biopsy Kolonoskopi Rp 188,000
06 Pungsi Acites Rp 280,000
07 Drainase Abses Hepar Rp 1,500,000
08 Gastroskopi Pengambilan Benda Asing Rp 2,400,000
09 Gastroskopi Endoklip Rp 2,500,000
10 Gastroskopi Transnasal Rp 1,500,000
11 Polipectomy Gastroskopi Rp 1,750,000
12 Polipectomy Kolonoskopi Rp 2,500,000
13 Gastroskopi dengan Anestesi Rp 1,740,000
14 Kolonoskopi dengan Anestesi Rp 2,890,000
15 Gastroskopi STE / LVE dengan Anestesi Rp 2,300,000