BAB IV INFORMASI YANG DISAMPAIKAN SAAT ADMISI

DAFTAR HARGA PERAWATAN

TARIF OPERASI SEDANG (odontektomi 2 gigi)

RUMAH SAKIT GIGI DAN MULUT

UNIVERSITAS AIRLANGGA
JUMLAH HARGA TARIF
No JENIS PELAYANAN RINCIAN SATUAN
KEPERLUAN SATUAN KELAS 3 KELAS 2 KELAS 1 ODC

I. SARANA & PRASARANA

1. Mesin Anestesi, Syringe Pump, Monitor

2. Instrumen Bedah & Anestesi

1 Sewa Kamar Operasi (OK) 3. Listrik & Pendingin Ruangan 3,500,000

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

4. CSSD + Linen + Laundry

5. Maintenance

2 Sewa Ruang Pulih Sadar (RR) 100,000

150,000
200,000 500,000

3 Sewa Ruang Perawatan Intensif (HCU)

JUMLAH I 3,600,000 7,700,000 6,000,000

5,650,000
II. BAHAN HABIS PAKAI

Isofluran / Dexofluran / Cevofluran 1 Jam 300,000

300,000
300,000 300,000

Gas Medis 2 Jam 7,000 14,000

14,000
14,000 14,000

Propofol 1 amp 76,000 76,000

76,000
76,000 76,000

1 Anestesi & Reanimasi Muscle Relaxant 2 amp 30,000 60,000

60,000
60,000 60,000

ETT 1 pcs 250,000 250,000

250,000
250,000 250,000

Narkotik 1 amp 45,000 45,000

45,000
45,000 45,000

Infus Set 1 pcs 20,000 20,000

20,000
20,000 20,000
 Jarum Infus 1 pcs 10,000 10,000
10,000
10,000 10,000

Cairan Infus 500 cc 5 flush 15,000 75,000

75,000
75,000 75,000

Tampon Pita 1 pcs 2,000 2,000

2,000
2,000 2,000

ECG Electrode 3 pcs 3,000 9,000

9,000
9,000 9,000

Mayo 1 pcs 15,000 15,000

15,000
15,000 15,000

Suction Catheter 1 pcs 10,000 10,000

10,000
10,000 10,000

Handscoon Non Steril 12 pcs 500 6,000

6,000
6,000 6,000

Atrophin / Sulfas Atrophin 1 amp 6,000 6,000

6,000
6,000 6,000

Ephedrine 1 amp 50,000 50,000

50,000
50,000 50,000

Lidocaine 1 amp 2,500 2,500

2,500
2,500 2,500

Adrenaline 1 amp 10,000 10,000

10,000
10,000 10,000

Prostigmine 1 amp 50,000 50,000

50,000
50,000 50,000

Spuit 3 cc 2 pcs 2,500 5,000

5,000
5,000 5,000

Spuit 5 cc 2 pcs 4,000 8,000

8,000
8,000 8,000

Spuit 10 cc 2 pcs 6,000 12,000

12,000
12,000 12,000

Spuit 20 cc 1 pcs 12,000 12,000

12,000
12,000 12,000

2 Operator RSGM (salah satu) Povidon Iodine 10 % 100 ml 1 btl 55,000 55,000
55,000
55,000 55,000

☐ Bedah Mulut dan Maksilofasial Alkohol 70 % 100 ml 1 btl 70,000 70,000

70,000
70,000 70,000

☐ Ortodonsia Spuit 3 cc

☐ Konservasi Gigi Spuit 5 cc

☐ Ilmu Kedokteran Gigi Anak Spuit 10 cc 2 pcs 6,000 12,000

12,000
12,000 12,000

☐ Prostodonsia Spuit 20 cc

☐ Periodonsia Spuit 50 cc 1 pcs 20,000 20,000

20,000
20,000 20,000

☐ Ilmu Penyakit Mulut Surgical Blade #11

Surgical Blade #15 2 pcs 2,500 5,000

5,000
5,000 5,000
 Needle 24G 2 pcs 5,000 10,000
10,000
10,000 10,000

Needle 27G

Lidocaine 4 amp 2,000 8,000

8,000
8,000 8,000

Pehacaine 4 amp 7,500 30,000

30,000
30,000 30,000

Handscoon Non Steril 10 pcs 500 5,000

5,000
5,000 5,000

Handscoon Gamex 3 pasang 20,000 60,000

60,000
60,000 60,000

Masker 5 pcs 500 2,500

2,500
2,500 2,500

Surgical Cap 5 pcs 500 2,500

2,500
2,500 2,500

Apron Plastik 4 pcs 5,000 20,000

20,000
20,000 20,000

Underpad 2 pcs 5,000 10,000

10,000
10,000 10,000

Kasa Tampon / Kasa Steril 20 pcs 175 3,500

3,500
3,500 3,500

Pz / NaCl 500 cc 4 flush 15,000 60,000

60,000
60,000 60,000

Gentamycin Salep 2 tube 15,000 30,000

30,000
30,000 30,000

Vicryl 3.0 3 pcs 125,000 375,000

375,000
375,000 375,000

Vicryl 4.0

Silk 2.0

Silk 3.0

Nylon 5.0

Round Bur 2 pcs 50,000 100,000

100,000
100,000 100,000

Fissure Bur 2 pcs 50,000 100,000

100,000
100,000 100,000

Plastik Handstook 3 pcs 500 1,500

1,500
1,500 1,500

Suction Tip Plastik 1 pcs 10,000 10,000

10,000
10,000 10,000

Folley Catheter

Urine Bag

NGT
 Radon Drain

Plester / Hypafix

3 Operator Non RSGM (salah satu)

☐ Bedah Umum

☐ Lain-lain, …………………………

Jumlah II 2,037,500
2,037,500
2,037,500 2,037,500

Jumlah I + II 5,637,500
7,687,500
9,737,500 8,037,500

III. TIM

1 Dokter Operator RSGM 40 % Jumlah I + II 2,255,000

3,075,000
3,895,000 3,215,000

2 Dokter Anestesi & Reanimasi 40 % Operator 902,000

1,230,000
1,558,000 1,286,000

3 Dokter Operator Non RSGM 25 % Operator

4 Perawat Anestesi & Reanimasi 4 % Operator 90,200

123,000
155,800 128,600

5 Perawat OK / Bedah / Instrumen 4 % Operator 90,200

123,000
155,800 128,600

6 Dokter HCU

Jumlah III 3,337,400

4,551,000
5,764,600 4,758,200

Jumlah I + II + III 8,974,900

12,238,500
15,502,100 12,795,700

Pembulatan Jumlah I + II + III 9,200,000

12,400,000
15,600,000 13,000,000

IV. ADMINISTRASI

1 Administrasi Rumah Sakit 10 % Jumlah I + II + III 920,000

1,240,000
1,560,000 1,300,000

2 Lain-lain 12.5 % Jumlah I + II + III 1,150,000

1,550,000
1,950,000 1,625,000

Jumlah IV 2,070,000
2,790,000
3,510,000 2,925,000

JUMLAH TOTAL 11,270,000 19,110,000 15,925,000

15,190,000
 TARIF OPERASI BESAR (enukleasi kista, osteomyelitis)

RUMAH SAKIT GIGI DAN MULUT

UNIVERSITAS AIRLANGGA

JUMLAH HARGA TARIF

No JENIS PELAYANAN RINCIAN SATUAN
KEPERLUAN SATUAN KELAS 3 KELAS 2 KELAS 1

I. SARANA & PRASARANA

1. Mesin Anestesi, Syringe Pump, Monitor

2. Instrumen Bedah & Anestesi

1 Sewa Kamar Operasi (OK) 3. Listrik & Pendingin Ruangan 3,500,000 5,500,000
7,500,000
4. CSSD + Linen + Laundry

5. Maintenance

2 Sewa Ruang Pulih Sadar (RR) 100,000 150,000

200,000
3 Sewa Ruang Perawatan Intensif (HCU)

JUMLAH I 3,600,000 5,650,000

7,700,000
II. BAHAN HABIS PAKAI

Isofluran / Dexofluran / Cevofluran 1 Jam 300,000 300,000

300,000
Gas Medis 3 Jam 7,000 21,000 21,000
21,000
Propofol 1 amp 76,000 76,000 76,000
76,000
Muscle Relaxant 2 amp 30,000 60,000 60,000
60,000
1 Anestesi & Reanimasi
ETT 1 pcs 250,000 250,000 250,000
250,000
Narkotik 1 amp 45,000 45,000 45,000
45,000
Infus Set 1 pcs 20,000 20,000 20,000
20,000
Jarum Infus 1 pcs 10,000 10,000 10,000
10,000
 Cairan Infus 500 cc 5 flush 15,000 75,000 75,000
75,000
Tampon Pita 1 pcs 2,000 2,000 2,000
2,000
ECG Electrode 3 pcs 3,000 9,000 9,000
9,000
Mayo 1 pcs 15,000 15,000 15,000
15,000
Suction Catheter 1 pcs 10,000 10,000 10,000
10,000
Handscoon Non Steril 12 pcs 500 6,000 6,000
6,000
Atrophin / Sulfas Atrophin 1 amp 6,000 6,000 6,000
6,000
Ephedrine 1 amp 50,000 50,000 50,000
50,000
Lidocaine 1 amp 2,500 2,500 2,500
2,500
Adrenaline 1 amp 10,000 10,000 10,000
10,000
Prostigmine 1 amp 50,000 50,000 50,000
50,000
Spuit 3 cc 2 pcs 2,500 5,000 5,000
5,000
Spuit 5 cc 2 pcs 4,000 8,000 8,000
8,000
Spuit 10 cc 2 pcs 6,000 12,000 12,000
12,000
Spuit 20 cc 1 pcs 12,000 12,000 12,000
12,000
2 Operator RSGM (salah satu) Povidon Iodine 10 % 100 ml 1 btl 55,000 55,000 55,000
55,000
☐ Bedah Mulut dan Maksilofasial Alkohol 70 % 100 ml 1 btl 70,000 70,000 70,000
70,000
☐ Ortodonsia Spuit 3 cc

☐ Konservasi Gigi Spuit 5 cc

☐ Ilmu Kedokteran Gigi Anak Spuit 10 cc 2 pcs 6,000 12,000 12,000

12,000
☐ Prostodonsia Spuit 20 cc 1 pcs 12,000 12,000 12,000
12,000
☐ Periodonsia Spuit 50 cc 1 pcs 20,000 20,000 20,000
20,000
☐ Ilmu Penyakit Mulut Surgical Blade #11

Surgical Blade #15 2 pcs 2,500 5,000 5,000

5,000
 Needle 24G 2 pcs 5,000 10,000 10,000
10,000
Needle 27G 2 pcs 7,500 15,000 15,000
15,000
Lidocaine 4 amp 2,000 8,000 8,000
8,000
Pehacaine 4 amp 7,500 30,000 30,000
30,000
Handscoon Non Steril 10 pcs 500 5,000 5,000
5,000
Handscoon Gamex 3 pasang 20,000 60,000 60,000
60,000
Masker 5 pcs 500 2,500 2,500
2,500
Surgical Cap 5 pcs 500 2,500 2,500
2,500
Apron Plastik 4 pcs 5,000 20,000 20,000
20,000
Underpad 2 pcs 5,000 10,000 10,000
10,000
Kasa Tampon / Kasa Steril 20 pcs 175 3,500 3,500
3,500
Pz / NaCl 500 cc 4 flush 15,000 60,000 60,000
60,000
Gentamycin Salep 2 tube 15,000 30,000 30,000
30,000
Vicryl 3.0 2 pcs 125,000 250,000 250,000
250,000
Vicryl 4.0

Silk 2.0

Silk 3.0 2 pcs 50,000 100,000 100,000

100,000
Nylon 5.0

Round Bur 2 pcs 50,000 100,000 100,000

100,000
Fissure Bur 2 pcs 50,000 100,000 100,000
100,000
Plastik Handstook 3 pcs 500 1,500 1,500
1,500
Suction Tip Plastik 1 pcs 10,000 10,000 10,000
10,000
Folley Catheter

Urine Bag
 NGT

Radon Drain

Plester / Hypafix 1 roll 35,000 35,000 35,000

35,000
Spongostan 2 pcs 100,000 200,000 200,000
200,000
Kasa Pita 2 pcs 20,000 40,000 40,000
40,000
Kalmycetin Salep 2 tube 20,000 40,000 40,000
40,000
Carnoy Solution 1 btl 75,000 75,000 75,000
75,000
3 Operator Non RSGM (salah satu)

☐ Bedah Umum

☐ Lain-lain, …………………………

Jumlah II 2,436,500 2,436,500

2,436,500
Jumlah I + II 6,036,500 8,086,500
10,136,500
III. TIM

1 Dokter Operator RSGM 40 % Jumlah I + II 2,414,600 3,234,600

4,054,600
2 Dokter Anestesi & Reanimasi 40 % Operator 965,840 1,293,840
1,621,840
3 Dokter Operator Non RSGM 25 % Operator

4 Perawat Anestesi & Reanimasi 4 % Operator 96,584 129,384

162,184
5 Perawat OK / Bedah / Instrumen 4 % Operator 96,584 129,384
162,184
6 Dokter HCU

Jumlah III 3,573,608 4,787,208

6,000,808
Jumlah I + II + III 9,610,108 12,873,708
16,137,308
Pembulatan Jumlah I + II + III 9,800,000 13,000,000
16,200,000
IV. ADMINISTRASI

1 Administrasi Rumah Sakit 10 % Jumlah I + II + III 980,000 1,300,000

1,620,000
 2 Lain-lain 12.5 % Jumlah I + II + III 1,225,000 1,625,000
2,025,000
Jumlah IV 2,205,000 2,925,000
3,645,000
JUMLAH TOTAL 12,005,000 15,925,000 19,845,000

TARIF OPERASI CANGGIH (bedah ortognatik)

RUMAH SAKIT GIGI DAN MULUT

UNIVERSITAS AIRLANGGA

JUMLAH HARGA TARIF

No JENIS PELAYANAN RINCIAN SATUAN
KEPERLUAN SATUAN KELAS 3 KELAS 2 KELAS 1

I. SARANA & PRASARANA

1. Mesin Anestesi, Syringe Pump, Monitor

2. Instrumen Bedah & Anestesi

1 Sewa Kamar Operasi (OK) 3. Listrik & Pendingin Ruangan 3,500,000 5,500,000 7,500,000

4. CSSD + Linen + Laundry

5. Maintenance

2 Sewa Ruang Pulih Sadar (RR) 100,000 150,000 200,000

3 Sewa Ruang Perawatan Intensif (HCU) 500,000 550,000 600,000

JUMLAH I 4,100,000 6,200,000 8,300,000

II. BAHAN HABIS PAKAI

Isofluran / Dexofluran / Cevofluran 1 Jam 300,000 300,000 300,000

Gas Medis 6 Jam 7,000 42,000 42,000 42,000

1 Anestesi & Reanimasi
Propofol 1 amp 76,000 76,000 76,000 76,000

Muscle Relaxant 2 amp 30,000 60,000 60,000 60,000

 ETT 1 pcs 250,000 250,000 250,000 250,000

Narkotik 1 amp 45,000 45,000 45,000 45,000

Infus Set 1 pcs 20,000 20,000 20,000 20,000

Jarum Infus 1 pcs 10,000 10,000 10,000 10,000

Cairan Infus 500 cc 5 flush 15,000 75,000 75,000 75,000

Tampon Pita 1 pcs 2,000 2,000 2,000 2,000

ECG Electrode 3 pcs 3,000 9,000 9,000 9,000

Mayo 1 pcs 15,000 15,000 15,000 15,000

Suction Catheter 1 pcs 10,000 10,000 10,000 10,000

Handscoon Non Steril 12 pcs 500 6,000 6,000 6,000

Atrophin / Sulfas Atrophin 1 amp 6,000 6,000 6,000 6,000

Ephedrine 1 amp 50,000 50,000 50,000 50,000

Lidocaine 1 amp 2,500 2,500 2,500 2,500

Adrenaline 1 amp 10,000 10,000 10,000 10,000

Prostigmine 1 amp 50,000 50,000 50,000 50,000

Spuit 3 cc 2 pcs 2,500 5,000 5,000 5,000

Spuit 5 cc 2 pcs 4,000 8,000 8,000 8,000

Spuit 10 cc 2 pcs 6,000 12,000 12,000 12,000

Spuit 20 cc 1 pcs 12,000 12,000 12,000 12,000

2 Operator RSGM (salah satu) Povidon Iodine 10 % 100 ml 1 btl 55,000 55,000 55,000 55,000

☐ Bedah Mulut dan Maksilofasial Alkohol 70 % 100 ml 1 btl 70,000 70,000 70,000 70,000

☐ Ortodonsia Spuit 3 cc

☐ Konservasi Gigi Spuit 5 cc 2 pcs 4,000 8,000 8,000 8,000

☐ Ilmu Kedokteran Gigi Anak Spuit 10 cc 2 pcs 6,000 12,000 12,000 12,000

☐ Prostodonsia Spuit 20 cc
☐ Periodonsia Spuit 50 cc 1 pcs 20,000 20,000 20,000 20,000

☐ Ilmu Penyakit Mulut Surgical Blade #11

Surgical Blade #15 2 pcs 2,500 5,000 5,000 5,000

Needle 24G

Needle 27G 2 pcs 7,500 15,000 15,000 15,000

Lidocaine 4 amp 2,000 8,000 8,000 8,000

Pehacaine 4 amp 7,500 30,000 30,000 30,000

Handscoon Non Steril 10 pcs 500 5,000 5,000 5,000

Handscoon Gamex 3 pasang 20,000 60,000 60,000 60,000

Masker 5 pcs 500 2,500 2,500 2,500

Surgical Cap 5 pcs 500 2,500 2,500 2,500

Apron Plastik 4 pcs 5,000 20,000 20,000 20,000

Underpad 2 pcs 5,000 10,000 10,000 10,000

Kasa Tampon / Kasa Steril 20 pcs 175 3,500 3,500 3,500

Pz / NaCl 500 cc 4 flush 15,000 60,000 60,000 60,000

Gentamycin Salep 2 tube 15,000 30,000 30,000 30,000

Vicryl 3.0 4 pcs 125,000 500,000 500,000 500,000

Vicryl 4.0

Silk 2.0

Silk 3.0

Nylon 5.0

Round Bur 2 pcs 50,000 100,000 100,000 100,000

Fissure Bur 2 pcs 50,000 100,000 100,000 100,000

Plastik Handstook 3 pcs 500 1,500 1,500 1,500

Suction Tip Plastik 1 pcs 10,000 10,000 10,000 10,000

 Folley Catheter 1 pcs 125,000 125,000 125,000 125,000

Urine Bag 1 pcs 80,000 80,000 80,000 80,000

NGT 1 pcs 25,000 25,000 25,000 25,000

Radon Drain 2 pcs 200,000 400,000 400,000 400,000

Plester / Hypafix 1 roll 35,000 35,000 35,000 35,000

Linderman Bur Pendek 1 pcs 900,000 900,000 900,000 900,000

Linderman Bur Panjang 1 pcs 900,000 900,000 900,000 900,000

Alginat 1 15,000 15,000 15,000 15,000

Gips 1 15,000 15,000 15,000 15,000

Wafer 1 pcs 250,000 250,000 250,000 250,000

Wire ⌀ 0.4 mm 1 m 30,000 30,000 30,000 30,000

Screw 2 mm 32 pcs 172,000 5,504,000 5,504,000 5,504,000

Plate L Shape 4 Hole 2.0 mm 4 pcs 559,000 2,236,000 2,236,000 2,236,000

Plate 4 Hole w/ Stem 1.7 mm 1 pcs 1,805,000 1,805,000 1,805,000 1,805,000

3 Operator Non RSGM (salah satu)

☐ Bedah Umum

☐ Lain-lain, …………………………

Jumlah II 14,523,500 14,523,500 14,523,500

Jumlah I + II 18,623,500 20,723,500 22,823,500

III. TIM

1 Dokter Operator RSGM 40 % Jumlah I + II 7,449,400 8,289,400 9,129,400

2 Dokter Anestesi & Reanimasi 40 % Operator 2,979,760 3,315,760 3,651,760

3 Dokter Operator Non RSGM 25 % Operator

4 Perawat Anestesi & Reanimasi 4 % Operator 297,976 331,576 365,176

5 Perawat OK / Bedah / Instrumen 4 % Operator 297,976 331,576 365,176

6 Dokter HCU 150,000 200,000 250,000

Jumlah III 11,175,112 12,468,312 13,761,512

Jumlah I + II + III 29,798,612 33,191,812 36,585,012

Pembulatan Jumlah I + II + III 30,000,000 33,400,000 36,800,000

IV. ADMINISTRASI

1 Administrasi Rumah Sakit 10 % Jumlah I + II + III 3,000,000 3,340,000 3,680,000

2 Lain-lain 12.5 % Jumlah I + II + III 3,750,000 4,175,000 4,600,000

Jumlah IV 6,750,000 7,515,000 8,280,000

JUMLAH TOTAL 36,750,000 40,915,000 45,080,000

DIREKTUR

Prof. Coen Pramono D, drg.,SU.,SpBM(K)

NIP.19540210.1979011.001