PERKIRAAN BIAYA OPERASI

RS.USADA INSANI

Nama Pasien : TN. SHOLEH

Ruang : CENDRAWASI A
Kelas : III
No. Reg : 00-22-12-01
Dokter PJP : DR. ASEANE
Dokter Operator : DR. ASEANE
Nama Operasi :
Kriteria Operasi : KHUSUS I
Sifat Operasi : CYTO

Jasa Medik Operator : 6,835,000

Jasa Medik Anastessy : 2,735,000
Sewa Kamar Operasi : 2,590,000
Perkiraan BHP Obat & Medis : 5,500,000
TOTAL BIAYA DILUAR ALAT : 17,660,000
Sewa Alat RS :
Pasang Alat dokter :
Sewa Alat dokter :
PERKIRAAN BIAYA OPERASI : 17,660,000

Note:
* Perkiraan biaya tersebut hanya selama pasien dilakukan tindakan operasi yang tersebut diatas.
* Belum termasuk apabila ditemukan penyulit/kondisi diluar perkiraan selama operasi berlangsung.
* Perkiraan biaya ini tidak berarti menyetujui rencana tindakan operasi.
* Jika tindakan operasi di setujui, perkiraan biaya tersebut harus dibayarkan terlebih dahulu.
* Biaya operasi sesungguhnya akan di informasikan satu hari setelahnya
atau bersama informasi biaya rawat inap sementara.

Tangerang, 20 , 01 , 2018
Penanggung Jawab Pasien

( )
 TARIF SEWA KAMAR OPERASI

KELAS KECIL SEDANG I SEDANG II BESAR I BESAR II BESAR III KHUSUS I

VVIP 1,750,000 2,600,000 2,600,000 3,000,000 3,000,000 3,000,000 5,200,000

VIP 1,210,000 2,015,000 2,015,000 2,300,000 2,300,000 2,300,000 4,660,000

ICU-B 1,210,000 2,015,000 2,015,000 2,300,000 2,300,000 2,300,000 4,660,000

ICU-C 1,210,000 2,015,000 2,015,000 2,300,000 2,300,000 2,300,000 4,660,000

HCU 1,210,000 2,015,000 2,015,000 2,300,000 2,300,000 2,300,000 4,660,000

MINI VIP 980,000 1,560,000 1,560,000 1,955,000 1,955,000 1,955,000 2,820,000

UTAMA 980,000 1,560,000 1,560,000 1,955,000 1,955,000 1,955,000 2,820,000

I-A 980,000 1,560,000 1,560,000 1,955,000 1,955,000 1,955,000 2,820,000

I-B 980,000 1,560,000 1,560,000 1,955,000 1,955,000 1,955,000 2,820,000

ISOLASI 750,000 1,150,000 1,150,000 1,610,000 1,610,000 1,610,000 2,710,000

II-A 750,000 1,150,000 1,150,000 1,610,000 1,610,000 1,610,000 2,710,000

OBSERVASI 750,000 1,150,000 1,150,000 1,610,000 1,610,000 1,610,000 2,710,000

PERINATOLOGI 750,000 1,150,000 1,150,000 1,610,000 1,610,000 1,610,000 2,710,000

II-B 750,000 1,150,000 1,150,000 1,610,000 1,610,000 1,610,000 2,710,000

BAYI SEHAT 575,000 980,000 980,000 1,495,000 1,495,000 1,495,000 2,590,000

III 575,000 980,000 980,000 1,495,000 1,495,000 1,495,000 2,590,000

INTERMEDITE 575,000 980,000 980,000 1,495,000 1,495,000 1,495,000 2,590,000

RAWAT JALAN 575,000 980,000 980,000 1,495,000 1,495,000 1,495,000 2,590,000

TARIF SEWA KAMAR BERSALIN

NON
KELAS PARTUS
PARTUS

VVIP 1,815,000 400,000

VIP 1,315,000 400,000

ICU-B 1,315,000 400,000

ICU-C 1,315,000 400,000

HCU 1,315,000 400,000

I-A 945,000 400,000

I-B 945,000 400,000

ISOLASI 525,000 400,000

II-A 525,000 400,000

OBSERVASI 525,000 400,000

PERINATOLOGI 525,000 400,000

II-B 525,000 400,000

BAYI SEHAT 370,000 400,000

III 370,000 400,000

INTERMEDITE 370,000 400,000

JASA DOKTER OPERATOR

KRITERIA OPERASI
KELAS
KECIL SEDANG I SEDANG II BESAR I BESAR II BESAR III KHUSUS I
VVIP 1,395,000 2,360,000 3,385,000 4,170,000 5,680,000 7,970,000 11,110,000
VIP 1,325,000 2,245,000 3,220,000 3,970,000 5,405,000 7,590,000 10,850,000
ICU-B 1,095,000 1,725,000 2,415,000 3,050,000 4,140,000 5,865,000 8,050,000
ICU-C 1,095,000 1,725,000 2,415,000 3,050,000 4,140,000 5,865,000 8,050,000
HCU 1,095,000 1,725,000 2,415,000 3,050,000 4,140,000 5,865,000 8,050,000
MINI VIP 1,095,000 1,725,000 2,415,000 3,050,000 4,140,000 5,865,000 8,050,000
UTAMA 1,095,000 1,725,000 2,415,000 3,050,000 4,140,000 5,865,000 8,050,000
I-A 1,095,000 1,725,000 2,415,000 3,050,000 4,140,000 5,865,000 8,050,000
I-B 1,095,000 1,725,000 2,415,000 3,050,000 4,140,000 5,865,000 8,050,000
ISOLASI 920,000 1,325,000 2,130,000 2,645,000 3,335,000 4,890,000 6,615,000
II-A 920,000 1,325,000 2,130,000 2,645,000 3,335,000 4,890,000 6,615,000
OBSERVASI 920,000 1,325,000 2,130,000 2,645,000 3,335,000 4,890,000 6,615,000
PERINATOLOGI 920,000 1,325,000 2,130,000 2,645,000 3,335,000 4,890,000 6,615,000
II-B 920,000 1,325,000 2,130,000 2,645,000 3,335,000 4,890,000 6,615,000
BAYI SEHAT 805,000 1,210,000 1,725,000 2,130,000 2,820,000 3,970,000 5,465,000
III 805,000 1,210,000 1,725,000 2,130,000 2,820,000 3,970,000 5,465,000
INTERMEDITE 805,000 1,210,000 1,725,000 2,130,000 2,820,000 3,970,000 5,465,000
RAWAT JALAN 805,000 1,210,000 1,725,000 2,130,000 2,820,000 3,970,000 5,465,000

JIKA CYTO ATAU DITEMUKAN PENYULIT, MAKA TARIF DIATAS DITAMBAH 25%
JIKA CYTO DAN DITEMUKAN PENYULIT, MAKA TARIF DIATAS DITAMBAH 50%
UNTUK KASUS SC CYTO DAN PENYULIT ADA RUMUS TERSENDIRI.

NORMAL 1
PENYULIT 1.25
CYTO + PENYULIT 1.5
CYTO 1.25
DAFTAR PERKIRAAN BHP UNTUK OPERASI
JENIS OPERASI HARGA
KECIL 1,000,000
SEDANG I 2,000,000
SEDANG II 2,500,000
BESAR I 3,500,000
BESAR II 4,000,000
BESAR III 4,500,000
KHUSUS I 5,000,000
KHUSUS II 5,500,000
KHUSUS III 6,000,000
KHUSUS II KHUSUS III OK MINOR
5,200,000 5,200,000 405,000
4,660,000 4,660,000 405,000
4,660,000 4,660,000 405,000
4,660,000 4,660,000 405,000
4,660,000 4,660,000 405,000
2,820,000 2,820,000 405,000
2,820,000 2,820,000 405,000
2,820,000 2,820,000 405,000
2,820,000 2,820,000 405,000
2,710,000 2,710,000 405,000
2,710,000 2,710,000 405,000
2,710,000 2,710,000 405,000
2,710,000 2,710,000 405,000
2,710,000 2,710,000 405,000
2,590,000 2,590,000 405,000
2,590,000 2,590,000 405,000
2,590,000 2,590,000 405,000
2,590,000 2,590,000 405,000
KHUSUS II KHUSUS III
17,510,000 20,290,000
16,675,000 19,320,000
12,595,000 14,550,000
12,595,000 14,550,000
12,595,000 14,550,000
12,595,000 14,550,000
12,595,000 14,550,000
12,595,000 14,550,000
12,595,000 14,550,000
10,580,000 12,190,000
10,580,000 12,190,000
10,580,000 12,190,000
10,580,000 12,190,000
10,580,000 12,190,000
8,340,000 9,545,000
8,340,000 9,545,000
8,340,000 9,545,000
8,340,000 9,545,000
Jasa Medik Operator
Jasa Medik Anastessy
Sewa Kamar Operasi
Sewa Alat RS
Pasang Alat dokter
Sewa Alat dokter
Perkiraan BHP Obat & Medis
 PENERIMAAN HARIAN TGL……………..S/D …………….

MINGGU I MINGGU II
TGL INPUT CAPITAL PROVIT TGL INPUT CAPITAL PROVIT
SALDO PINDAHAN 500,000 SALDO PINDAHAN 1,700,000
28 991,000 641,000 350,000 5 -
29 1,050,000 700,000 350,000 6 -
30 1,125,000 625,000 500,000 7 -
1 - 8 -
2 - 9 -
3 - 10 -
4 - 11 -
TOTAL 1,700,000 TOTAL 1,700,000

MINGGU III MINGGU IV

TGL INPUT CAPITAL PROVIT TGL INPUT CAPITAL PROVIT
SALDO PINDAHAN SALDO PINDAHAN
12 19
13 20
14 21
15 22
16 23
17 24
18 25
TOTAL TOTAL

Tangerang,………………………..