Alokasi SFO ID SFO Name KELAS III KELAS II

SFO00833 ADMIN RAWAT INAP PAKET HEMAT SC 150,000

SFO00832 ADMIN RAWAT JALAN PAKET HEMAT SC 10,000
SFO00859 ADMINISTRASI - PAKET MCU GOLD 50,000
SFO00860 ADMINISTRASI - PAKET MCU PLATINUM 50,000
SFO00852 ADMINISTRASI - PAKET MCU SILVER 50,000
SFO00844 ADMINISTRASI PAKET HEMAT KURET 150,000
SFO00849 ADMINISTRASI PAKET MCU DIAMOND 50,000
rawat inap SFO00351 ADMINISTRASI PASIEN RI DIBAWAH 12 JAM 25,000
rawat inap SFO00149 ADMINISTRASI RAWAT INAP 150,000 250,000
rawat inap SFO00752 ADMINISTRASI RAWAT INAP - PAKET BIDAN 100,000 125,000
rawat inap SFO00839 ADMINISTRASI RAWAT INAP PAKET HEMAT PN 150,000
SFO00150 ADMINISTRASI RAWAT JALAN 35,000
poli SFO00552 ADMINISTRASI RAWAT JALAN BPJS 10,000
rawat inap SFO00658 AKTIVE EXERCISE 50,000 55,000 60,000
rawat inap SFO00612 AKTIVE EXERCISE - BPJS 35,000 38,500 42,000
rawat inap SFO00659 AKTIVE EXERCISE HL 60,000 66,000 72,000
rawat inap SFO00613 AKTIVE EXERCISE HL - BPJS 42,000 46,200 50,400
SFO00913 AMBULATION AND GAIT TRAINING 35,000
SFO00947 AMBULATION AND GAIT TRAINING 35,000 38,500 42,000
SFO00881 ANASTHESI 50,000
SFO00829 ANESTHESI PAKET HEMAT SC 600,000
SFO00562 ANGKAT JAHITAN >15 JAHITAN 75,000
bedah SFO00007 ANGKAT JAHITAN 1-15 JAHITAN 50,000
SFO00484 ANGKAT SERUMEN JAMSOSTEK 75,000
gigi SFO00446 APEKS RESEKSI PER GIGI 1,600,000
SFO00504 APERESIS 100,000
SFO00416 APLIKASI TI-ES 75,000
SFO00453 ASISTEN 1 OPERASI 100,000 125,000
SFO00454 ASISTEN 2 OPERASI 100,000 125,000
SFO00352 ASISTEN OPERASI 32 JAM 200,000
SFO00328 ASISTEN OPERASI 48 JAM 600,000 600,000
SFO00329 ASISTEN OPERASI 72 JAM 1,000,000 1,200,000
SFO00330 ASISTEN VK 200,000 400,000
SFO00895 ASSISTING EXERCISE 35,000
SFO00937 ASSISTING EXERCISE 35,000 38,500 42,000
anak SFO00660 BABY MASSAGE 60,000 66,000 72,000
anak SFO00614 BABY MASSAGE- BPJS 50,000 55,000 60,000
SFO00661 BABY MASSAGE HL 72,000 79,200 86,400
SFO00615 BABY MASSAGE HL - BPJS 60,000 66,000 72,000
SFO00599 BHP ANESTESI ISOFLURAN 97,000
SFO00600 BHP ANESTESI SOJOURN 155,000
SFO00564 BHP ANGKAT JAHITAN >15 JAHITAN 50,000
bedah SFO00563 BHP ANGKAT JAHITAN 1-15 JAHITAN 30,000
SFO00589 BHP BAYI SEHAT BPJS 50,000 300,000 400,000
 SFO00815 BHP BAYI SEHAT UMUM 300,000 300,000
poli SFO00317 BHP CABUT INFUS RAWAT JALAN 10,000
bedah SFO00570 BHP CROSS LUKA TUSUK KECIL 25,000
bedah SFO00566 BHP EXTRAKSI TUMOR JINAK/PEMBERSIHAN LUKA 50,000
SFO00340 BHP GANTI VERBAN RI 20,000
obg,bedah SFO00339 BHP GANTI VERBAN/WT RJ 40,000

SFO00362 BHP HALOTHANE PER CC 6,300

SFO00348 BHP HECTING RI 40,000
poli SFO00561 BHP HECTING RJ ( > 15 JAHITAN) 100,000
obgyn SFO00347 BHP HECTING RJ (1-15 JAHITAN) 50,000
SFO00784 BHP INSEMINASI 60,000
SFO00367 BHP KASSA OK 1-10 LEMBAR 8,000
SFO00368 BHP KASSA OK 15-30 LEMBAR 24,000
SFO00365 BHP KASSA VK 1-10 LEMBAR 5,000
SFO00366 BHP KASSA VK 15-30 LEMBAR 15,000
SFO00363 BHP KETALAR PER STRIP 5,000
SFO00565 BHP KURAS LAMBUNG DEWASA & ANAK 50,000
SFO00862 BHP KURET 50,000
bedah SFO00567 BHP LUKA BAKAR 50,000
SFO00821 BHP MATERNITY RUANG IBU - UMUM 200,000
SFO00327 BHP MEMBERSIHKAN LUKA POST OPERASI RAWAT 10,000
INAP/VK/O
poli SFO00061 BHP Membersihkan luka rawat Jalan 20,000
SFO00823 BHP NON MATERNITY UMUM 25,000
SFO00353 BHP OPERASI PAKET 32 JAM 200,000
SFO00355 BHP OPERASI PASIEN KELAS 2 500,000
SFO00354 BHP OPEREASI PAKET 72 JAM 300,000
SFO00846 BHP PAKET HEMAT KURET 50,000
SFO00513 BHP PARTUS NORMAL 32,000
SPO00347 BHP PARTUS NORMAL IGD 32,000
SFO00320 BHP PASANG / CABUT CATETER RAWAT INAPVK/OK 10,000
poli SFO00319 BHP Pasang / cabut cateter rawat Jalan 10,000
SFO00324 BHP PASANG / CABUT ETT RAWAT INAP/VK/OK 10,000
poli SFO00323 BHP PASANG / CABUT ETT RAWAT JALAN 10,000
SFO00318 BHP PASANG / CABUT INFUS RAWAT INAP/VK/OK 20,000
SFO00326 BHP PASANG / CABUT JALUR TRANFUSI RAWAT 10,000
INAP/VK/OK
SFO00325 BHP Pasang / cabut jalur tranfusi rawat Jalan 10,000

SFO00322 BHP PASANG / CABUT NGT RAWAT INAP/VK/OK 10,000

poli SFO00321 BHP Pasang / cabut NGT rawat Jalan 10,000
SFO00359 BHP PASANG INFUS BAYI/ANAK NON SPALK RI 15,000
SFO00344 BHP PASANG INFUS DENGAN SPALK RI 40,000
poli SFO00343 BHP PASANG INFUS DENGAN SPALK RJ 50,000
poli SFO00360 BHP PASANG INFUS NON SPALK RJ 40,000
poli SFO00572 BHP SUNTIK IM / IV 25,000
 SFO00369 BHP TAMPON BOLA VK 5,000
SFO00370 BHP TAMPON ROL PANJANG 16,250
anak SFO00569 BHP TINDIK BAYI 30,000
anak,obgyn SFO00904 BIAYA ADM PAKET VAKSIN 10,000

SFO00493 BIAYA JASA DOKTER EMERGENSI, DI POLI UGD RUMAH 50,000

SAKIT JAMSOSTEK
SFO00447 BIAYA LAIN-LAIN 1
SFO00529 BIAYA PERAWATAN BAYI PERINA TERMASUK INCIBATOR 150,000
PER HARI JAMSOSTEK
SFO00935 BODY MEASURENMENT 35,000 38,500 42,000
SFO00411 BONGKAR TAMBALAN AMALGAM 150,000
gigi SFO00804 BRACKET CERAMIC PER GIGI 100,000
gigi SFO00805 BRACKET SAPPHIRE PER GIGI 250,000
obgyn SFO00101 BREAST CARE 25,000
SFO00902 BREATHING EXERCISE 35,000
SFO00944 BREATHING EXERCISE 35,000 38,500 42,000
gigi SFO00776 BRIDGE CROWN - METAL ARCYLIC + PROVISORIS 2,000,000
gigi SFO00777 BRIDGE CROWN - PORCELAIN + PROVISORIS 2,750,000
anak SFO00542 BUKU PASPOR ANAK 10,000
anak SFO00906 BUKU VAKSIN 35,000
obgyn SFO00530 CABUT SPIRAL JAMSOSTEK 150,000
SFO00957 CARDIAC RETRAINING 35,000 38,500 42,000
poli SFO00847 CEK FISIK DOKTER - PAKET DIAMOND 15,000
poli SFO00857 CEK FISIK DOKTER - PAKET MCU GOLD 15,000
poli SFO00858 CEK FISIK DOKTER - PAKET MCU PLATINUM 15,000
poli SFO00853 CEK FISIK DOKTER - PAKET MCU SILVER 15,000
gigi SFO00426 CETAK RAHANG ATAS DAN RAHANG BAWAH 200,000
SFO00806 CLITH BUTTON 50,000
SFO00959 COMBINED PHYSICAL THERAPY WITHOUT MENTION OF 35,000 38,500 42,000
THE COMPONEN
anak,int SFO00662 COMBIVENT 16,000 16,000 16,000
anak,int SFO00616 COMBIVENT - BPJS 16,000 17,000 17,000
bedah SFO00803 CONTROL CABUT / OD BUKA JAHITAN 200,000
SFO00442 CONTROL ORTHO 150,000
SFO00498 CORPUS 100,000
ALIENUM(GRAM/MATA,TELINGA,HIDUNG,TONSIL)
JAMSOSTEK

SFO00431 CROWN ALL AKRILIK 500,000

SFO00430 CROWN METAL AKRILIK 1,000,000
SFO00429 CROWN METAL PORCELEN 2,000,000
SFO00119 CTG DENGAN PRINT 80,000
SFO00466 CTG JAMSOSTEK 60,000
SFO00807 DENTAL GEL / GIGI 30,000
SFO00403 DESENTISITASI FLUOCAL, BIFLUORID, DURAPHANT 100,000

SFO00955 DIATHERMY 50,000 55,000 55,000

SFO00928 DILATASI PREPORTIUM 250,000
SFO00911 DRY NEEDLING 250,000
SFO00464 EKG JAMSOSTEK 65,000
SFO00122 Eksisi Veruka Vulgaris per buah 75,000
SFO00480 EKSTIRPASI / EKSISI : GANGLION <= 2 CM 250,000
JAMSOSTEK
SFO00477 EKSTIRPASI KISTA ATEROM <= 2 CM JAMSOSTEK 250,000
SFO00475 EKSTIRPASI KISTA ATEROM > 5 CM JAMSOSTEK 325,000
SFO00476 EKSTIRPASI KISTA ATEROM 2-5 CM JAMSOSTEK 325,000
SFO00479 EKSTIRPASI LIPOMA <= 2 CM JAMSOSTEK 250,000
SFO00478 EKSTIRPASI LIPOMA 2-5 CM JAMSOSTEK 325,000
SFO00496 EKSTRASI KUKU JAMSOSTEK 100,000
SFO00435 ELEMEN FLEKSI 150,000
SFO00433 ELEMEN GIGI AKRILIK 200,000
SFO00437 ELEMEN GTSKL 250,000
SFO00800 EMAX CERAMIC (PER GIGI) 2,700,000
SFO00378 EXERCISE BERAT 45,000
SFO00903 EXERCISE NOT ELSEWHERE CLASSIFIED 35,000
SFO00945 EXERCISE NOT ELSEWHERE CLASSIFIED 35,000 38,500 42,000
SFO00376 EXERCISE RINGAN 25,000
SFO00377 EXERCISE SEDANG 35,000
SFO00663 EXERCISE TUMBANG 100,000 110,000 120,000
SFO00617 EXERCISE TUMBANG - BPJS 90,000 99,000 108,000
SFO00664 EXERCISE TUMBANG HL 120,000 132,000 144,000
SFO00618 EXERCISE TUMBANG HL - BPJS 108,000 118,800 129,600
SFO00121 Explorasi perdarahan Post Partum 600,000
SFO00472 EXTIRPASI KISTA BARTHOLINI JAMSOSTEK 1,750,000
SFO00010 EXTRAKSI KUKU, PER KUKU 100,000
SFO00665 FARBIVENT 11,000 11,000 11,000
SFO00619 FARBIVENT - BPJS 11,000 12,100 13,200
SFO00763 FEE ANESTESI BEDAH BERAT - BPJS 600,000
SFO00764 FEE ANESTESI BEDAH BESAR KHUSUS - BPJS 600,000
SFO00762 FEE ANESTESI BEDAH SEDANG - BPJS 600,000
SFO00843 FEE ANESTESI PAKET HEMAT KURET 337,500
SFO00510 FEE ANESTESI PAKET JAMPERSAL 410,526
SFO00557 FEE ANESTESI PAKET KURET BPJS 337,500
SFO00554 FEE ANESTESI PAKET OPERASI BPJS 487,500
SFO00231 FEE ANESTESI PAKET SC 32 JAM KELAS 3 506,250
SFO00247 FEE ANESTESI PAKET SC 48 JAM KELAS 3 506,250
SFO00263 FEE ANESTESI PAKET SC 72 JAM KELAS 3 562,500
SFO00546 FEE ANESTESI PAKET SC BPJS 575,000
SFO00922 FEE ANESTESI PARTUS NORMAL DENGAN ILA - PASIEN 337,500 337,500
UMUM
SFO0589 FEE ANESTESI PASANG / LEPAS IUD DENGAN 337,500 337,500
PENYULIT DALAM NARKOSE BPJS
SPO00349 FEE ANESTESI TINDAKAN PASANG ETT 200,000
SFO00533 FEE ASISTEN OPERATOR 2 KURET JAMSOSTEK 75,000
SFO00287 Fee Bidan paket partus normal kelas 3 150,000
 SFO00785 FEE DR ANASTESI HECTING VAGINALIS TOTAL 250,000
SFO00297 FEE DR ANASTESI PAKET KURET 334,000 375,000 562,500
SFO00232 FEE DSA PAKET SC 32 JAM KELAS 3 247,500
SFO00248 FEE DSA PAKET SC 48 JAM KELAS 3 247,500
SFO00264 FEE DSA PAKET SC 72 JAM KELAS 3 247,500
SFO00511 FEE DSA PAKET JAMPERSAL 222,222
SFO00547 FEE DSA PAKET SC BPJS 285,000
SFO00769 FEE DSOG INSISI/EXSISI HEMATOM BPJS 667,000
SFO00842 FEE DSOG PAKET HEMAT KURET 731,250
SFO00828 FEE DSOG PAKET HEMAT SC 1,250,000
SFO00509 FEE DSOG PAKET JAMPERSAL 947,368
SFO00296 FEE DSOG PAKET KURET 667,000 675,000 860,625
SFO00556 FEE DSOG PAKET KURET BPJS 731,250
SFO00553 FEE DSOG PAKET OPERASI BPJS 1,250,000
SFO00278 FEE DSOG PAKET PARTUS NORMAL KELAS 3 731,250
SFO00230 FEE DSOG PAKET SC 32 JAM KELAS 3 1,237,500
SFO00246 FEE DSOG PAKET SC 48 JAM KELAS 3 1,462,500
SFO00262 FEE DSOG PAKET SC 72 JAM KELAS 3 1,687,500
SFO00545 FEE DSOG PAKET SC BPJS 947,368 1,190,000 1,315,000
SFO00528 FEE DSOG REPARASI VAGINA 1,200,000
SFO00220 FEE GENERAL DR ANESTESI 675,000 735,750
SFO00218 FEE OPERATOR BEDAH KASUS BERAT 2,000,000 2,333,750
SFO00767 FEE OPERATOR BEDAH KASUS BERAT - BPJS 1,400,000 1,633,625
SFO00768 FEE OPERATOR BEDAH KASUS BESAR KHUSUS - BPJS 1,750,000 2,042,031

SFO00216 FEE OPERATOR BEDAH KASUS RINGAN 889,000 1,115,000

SFO00765 FEE OPERATOR BEDAH KASUS RINGAN - BPJS 435,610 780,500
SFO00217 FEE OPERATOR BEDAH KASUS SEDANG 1,687,500 1,912,500
SFO00766 FEE OPERATOR BEDAH KASUS SEDANG - BPJS 1,181,250 1,338,750
SFO00595 FEE RESUSITASI ANAK BPJS 156,250
SFO00341 FEE RESUSITASI BAYI SC DR. UMUM 156,250 218,750
SFO00586 FEE RESUSITASI DR UMUM 99,000 157,500
SFO00824 FEE RESUSITASI PAKET HEMAT SC 300,000
SFO00221 FEE RESUSITASI SC DSA 247,500 393,750
SFO00219 FEE SPINAL DR ANESTESI 562,500 613,125
SFO00914 FITTING OF ORTHOTIC DEVICE 35,000
SFO00948 FITTING OF ORTHOTIC DEVICE 35,000 38,500 42,000
poli SFO00666 FLIXOTIDE 24,700 24,700 24,700
poli SFO00620 FLIXOTIDE - BPJS 24,700 27,170 29,640
SFO00423 FLUORIDASI TOPICAL PER RAHANG 150,000
SFO00916 FORCED EXTENSION OF LIMB 35,000
SFO00950 FORCED EXTENSION OF LIMB 35,000 38,500 42,000
SFO00929 FUNCTIONAL EVALUATION 35,000 38,500 42,000
SFO00471 GANGLION BESAR, LIPOMA MULTIPLE JAMSOSTEK 2,000,000
gigi SFO00434 GIGI TIRUAN FLEKSI + SATU GIGI PERTAMA 1,500,000
gigi SFO00436 GIGI TIRUAN KERANGGA LOGAM + SATU GIGI PERTAMA 1,250,000

gigi SFO00432 GIGI TIRUAN LEPAS AKRILIK + SATU GIGI PERTAMA 1,500,000

SFO00417 GINGIVEKTOMI PER REGIO 500,000

SFO00667 GLOBAL EXERCISE 120,000 132,000 144,000
SFO00621 GLOBAL EXERCISE - BPJS 100,000 110,000 120,000
SFO00668 GLOBAL EXERCISE HL 144,000 158,400 172,800
SFO00622 GLOBAL EXERCISE HL - BPJS 120,000 132,000 144,000
SFO00795 GTSL - ARCYLIC (PER GIGI) 225,000
SFO00794 GTSL - ARCYLIC + PLAT (PER GIGI) 1,500,000
SFO00797 GTSL - METAL FRAME + 1 PLAT (PER GIGI) 1,800,000
SFO00798 GTSL - METAL FRAME GIGI ARCYLIC (PER GIGI) 300,000
SFO00799 GTSL - METAL FRAME GIGI PORCELAIN (PER GIGI) 500,000

SFO00796 GTSL - THERMOSENS + PLAT (PER GIGI) 2,000,000

SFO00787 GTSL - VALPLAST FLEXI + 1 PLAT (PER GIGI) 1,800,000
BILATERAL
SFO00788 GTSL - VALPLAST GIGI ARCYLIC (PER GIGI) 200,000
SFO00789 GTSL - VALPLAST GIGI PORCELAIN (PER GIGI) 400,000
SFO00425 HOME BLEACHING/PEMUTIHAN GIGI PER RAHANG 1,500,000
SFO00420 INCISI ABSES / CAUTERISASI POLIP / GRANULOMA 250,000

SFO00316 Inhalasi Pasien Dewasa 55,000

SFO00427 INLAY / OLAY 1,200,000
SFO00814 INLAY / UPLAY / ONLAY COMPOSITE 1,000,000
SFO00497 INSISI ABSES JAMSOSTEK 100,000
SFO00609 INSPECULO 100,000
SFO00485 IRIGASI TELINGA / TELINGA / KLISMA JAMSOSTEK 75,000

SFO00669 IRR 50,000 55,000 60,000

SFO00623 IRR - BPJS 35,000 38,500 42,000
SFO00670 IRR HL 60,000 66,000 72,000
SFO00624 IRR HL - BPJS 42,000 46,200 50,400
SFO00672 IRR+NEB +PD HL 108,000 118,800 129,600
SFO00626 IRR+NEB +PD HL - BPJS 102,500 112,750 123,000
SFO00671 IRR+NEB+PD 90,000 99,000 108,000
SFO00625 IRR+NEB+PD - BPJS 85,000 93,500 102,000
SFO00774 JACKET CROWN - METAL ARCYLIC + PROVISORIS 1,500,000
SFO00775 JACKET CROWN - PORCELAIN + PROVISORIS 2,500,000
poli SFO00060 Jasa ANC Bidan Poli 10,000
SFO00519 JASA ASISTEN OPERATOR 2 48 jam 400,000
SFO00525 JASA ASISTEN OPERATOR 2 HECTING 150,000
SFO00874 JASA ASISTEN OPERATOR 2 HISTEREKTOMI 1,500,000
SFO00524 JASA ASISTEN OPERATOR 2 JAMKESDA 125,000
AFO00520 JASA ASISTEN OPERATOR 2 KURET 200,000
SFO00877 JASA ASISTEN OPERATOR 2 KURET 200,000
SFO00875 JASA ASISTEN OPERATOR 2 LAPAROTOMI 1,500,000
 SFO00521 JASA ASISTEN OPERATOR 2 MANUAL PLASENTA 150,000
SFO00544 JASA ASISTEN OPERATOR 2 MIOMEKTOMI JAMSOSTEK 100,000

SFO00526 JASA ASISTEN OPERATOR 2 NORMAL 200,000

SFO00534 JASA ASISTEN OPERATOR 2 NORMAL JAMSOSTEK 100,000
SFO00856 JASA ASISTEN OPERATOR 2 PAKET HEMAT KURET 200,000
SFO00855 JASA ASISTEN OPERATOR 2 PAKET HEMAT PN 400,000
SFO00854 JASA ASISTEN OPERATOR 2 PAKET HEMAT SC 1,500,000
SFO00522 JASA ASISTEN OPERATOR 2 PERAWATAN 150,000
SFO00527 JASA ASISTEN OPERATOR 2 PERAWATAN JAMSOSTEK 50,000

SFO00876 JASA ASISTEN OPERATOR 2 PN 400,000

SFO00873 JASA ASISTEN OPERATOR 2 SC 1,500,000
SFO00523 JASA ASISTEN OPERATOR 2 SC JAMSOSTEK 200,000
SFO00517 JASA ASISTEN OPERATOR 32 Jam 200,000
SFO00518 JASA ASISTEN OPERATOR 72 Jam 1,350,000
SFO00055 Jasa Asisten perawat sirkumsisi manual/laser 25,000

SPO00352 JASA ASISTENSI BIDAN VK DI IGD 50,000

SFO00905 JASA DOKTER (KONSUL + SUNTIK) PAKET VAKSIN 75,000
SFO00346 JASA DSOG HECTING VAGINA PARTIALIS 175,000
SPO00345 JASA DSOG HECTING VAGINA TOTALIS 250,000
poli SFO00095 Jasa Ganti Verban 40,000
SFO00045 JASA HOME CARE PERAWAT 60,000
bedah SFO00364 JASA KONSULTASI DOKTER BEDAH 125,000
SFO00783 JASA KONSULTASI DOKTER REHAB MEDIK 125,000
SFO00864 JASA KONSULTASI DOKTER SYARAF 125,000
SFO00885 JASA KONSULTASI DOKTER SYARAF BPJS 75,000
SFO00888 JASA KONSULTASI DR REHAB MEDIK - BPJS 75,000
SFO00304 Jasa konsultasi dr umum paket berobat 10,000
Rp.50.000
poli SFO00974 JASA KONSULTASI DRG KONSERVASI - P/UMUM 125,000
poli SFO00078 Jasa Konsultasi DSA Poli 125,000
poli SFO00067 Jasa Konsultasi DSOG Poli 125,000
poli SFO00080 Jasa Konsultasi DSPD 125,000
SFO00040 JASA KONSULTASI HOME VISIT 50,000
poli SFO00926 JASA LEPAS SPIRAL DENGAN PENYULIT 120,000
poli SFO00925 JASA LEPAS SPIRAL DENGAN PENYULIT - BPJS 100,000
SFO00602 JASA MASSAGE PAYUDARA RAWAT INAP 100,000
poli SFO00601 JASA MASSAGE PAYUDARA RAWAT JALAN 100,000
SFO00506 JASA MEDIS CURRETAGE MOLAHIDATIDOSA 1,234,560
SFO00505 JASA MEDIS PASANG LAMINARIA 247,000
poli SFO00073 Jasa Pap smear dg DSOG 300,000
poli SFO00058 Jasa Pap smear non Paket oleh bidan 85,000
poli SFO00310 Jasa pap smear paket bidan Rp.60.000 60,000
SFO00312 JASA PARA MEDIS HCU
SFO00967 JASA PARA MEDIS HCU - BPJS
 SFO00108 JASA PARA MEDIS RUANG BAYI 60,000 100,000
SFO00818 JASA PARA MEDIS RUANG BAYI - BPJS 250,000 400,000
SFO00749 JASA PARA MEDIS RUANG BAYI - PAKET BIDAN 30,000 50,000
SFO00827 JASA PARA MEDIS RUANG BAYI PAKET HEMAT 30,000
SFO00106 JASA PARA MEDIS RUANG OK 30,000 45,000
SFO00105 JASA PARA MEDIS RUANG PERAWATAN DEWASA / ANAK 50,000 60,000

SFO00107 JASA PARA MEDIS RUANG VK 30,000 45,000

poli SFO00059 Jasa Pasang spiral bidan non Paket 100,000
poli SFO00307 Jasa pasang spiral bidan paket Rp.75.000 50,000
poli SFO00887 JASA PASANG SPIRAL DENGAN PENYULIT 200,000
poli SFO00886 JASA PASANG SPIRAL DENGAN PENYULIT - BPJS 150,000
poli SFO00071 Jasa Pasang Spiral dg DSOG 110,000
SFO00516 JASA PEMASANGAN ENDOTRACHEAL TUBE DNG DR 185,000
SPESIALIS
SFO00782 JASA PEMASANGAN+MELEPAS PESSARIUM 250,000
SFO00361 JASA PEMBUATAN AKTE 160,000
SFO00514 JASA PEMBUATAN AKTE (TERLAMBAT) 350,000
SFO00044 JASA PERAWAT PENDAMPING HOME VISIT 25,000
poli SFO00309 Jasa periksa hamil paket ANC bidan Rp.15.000 5,000

SFO00313 Jasa resusitasi pasien UGD dewasa/anak/bayi 100,000

poli SFO00079 Jasa Suntik 17,000

poli SFO00063 Jasa Suntik Imunisasi dg bidan non paket 10,000
poli SFO00062 Jasa Suntik KB 1 & 3 Bulan Non paket 10,000
poli SFO00072 Jasa Suntik KB 1 & 3 Bulan Non paket oleh DSOG 10,000

poli SFO00305 Jasa suntik KB 1 bulan bidan paket KB 5,000

Rp.10.000
poli SFO00306 Jasa suntik KB 3 bulan bidan paket KB 5,000
Rp.10.000
poli SFO00308 Jasa suntik paket imunisasi dasar oleh bidan 5,000

SFO00148 Jasa Tindakan Endo Tracheal Tube 120,000

bayi/anak/dewasa
SFO00770 JASA TINDAKAN INSEMINASI 300,000
SFO00315 JASA TINDAKAN PAKET PROMO SIRKUMSISI LASER 200,000
SFO00314 JASA TINDAKAN PEMASANGAN ETT DI UGD 65,000
SFO00386 JASA TINDAKAN PEMASANGAN ETT RAWAT INAP/OK/VK 75,000

SFO00576 JASA TINDAKAN SIRKUMSISI DR SPESIALIS 500,000

SFO00515 JASA TINDAKAN SIRKUMSISI DSA 75,000
SPO00346 JASA TINDAKAN SUCTION 75,000
SFO00147 JASA TINDAKAN SUCTION BAYI / ANAK 75,000
obsgyn SFO00066 JASA USG PERUT DENGAN PRINT OLEH DSOG 65,000
obsgyn SFO00065 Jasa USG Perut Tanpa print oleh DSOG 40,000
obsgyn SFO00069 JASA USG TRANSVAGINAL OLEH DSOG, DG PRINT 85,000
obsgyn SFO00068 JASA USG TRANSVAGINAL OLEH DSOG, TANPA PRINT 50,000

SFO00831 KAMAR IBU PER HARI PAKET HEMAT SC 125,000

 SFO00151 KARTU BEROBAT PASIEN 15,000
SFO00500 KATETERISASI LAMBUNG/PASANG NGT + LAVAGE 100,000
JAMSOSTEK
SFO00491 KELEBIHAN HARI RAWAT BAYI PER HARI (JAMSOSTEK) 10,000

SFO00490 KELEBIHAN HARI RAWAT IBU PER HARI (JAMSOSTEK) 40,000

SFO00124 Kompresi Bimanual Externa 300,000

SFO00123 Kompresi Bimanual Interna 650,000
SFO00861 KONSUL DOKTER IGD PAKET HEMAT SC 40,000
SFO00744 KONSUL DOKTER UGD 40,000
SFO00001 Konsul Dokter Umum 30,000
SFO00848 KONSUL DR SPESALIS INTERNIS - PAKET MCU 125,000
DIAMOND
SPO00354 KONSUL DSOG DI IGD BPJS 70,000
SPO00355 KONSUL DSOG DI IGD PASIEN UMUM 125,000
SFO00598 KONSUL GIZI 30,000 50,000
poli SFO00596 KONSUL GIZI RAWAT JALAN 50,000
poli SFO00740 KONSUL LAKTASI DI POLI DOKTER SPESIALIS 75,000
poli SFO00597 KONSUL LAKTASI RAWAT JALAN 50,000
SFO00739 KONSUL LAKTASI VIA TELPON DOKTER SPESIALIS 37,500
SFO00489 KONSUL RAWAT INAP/VISITE SPESIALIS JAMSOSTEK 80,000

poli SFO00555 KONSUL RAWAT JALAN SPESIALIS DSA BPJS 75,000

poli SFO00577 KONSUL RAWAT JALAN SPESIALIS DSB BPJS 75,000
poli SFO00551 KONSUL RAWAT JALAN SPESIALIS DSOG BPJS 75,000
poli SFO00560 KONSUL RAWAT JALAN SPESIALIS INTERNIST BPJS 75,000

poli SFO00488 KONSUL RAWAT JALAN SPESIALIS JAMSOSTEK 80,000

SFO00541 KONSUL VIA TELPON DOKTER SPESIALIS 39,000 57,500
poli SFO00152 KONSULTASI DOKTER GIGI UMUM - BPJS 75,000
poli SFO00074 Kontrol bekas jahitan SC 20,000
poli SFO00444 KONTROL ONDONTEKTOMI / BEDAH 150,000
poli SFO00415 KURETASE PER GIGI 250,000
SFO00401 LABIAL VENEERING KOMPOSIT BESAR 700,000
SFO00399 LABIAL VENEERING KOMPOSIT KECIL 500,000
SFO00400 LABIAL VENEERING KOMPOSIT SEDANG 600,000
SFO00311 Labu Darah 550,000
SFO00923 LABU DARAH 1,000,000
SFO00487 LABU DARAH JAMSOSTEK 250,000
SFO00865 LANJUTAN PAKET ADNEXITIS 10X 1
SFO00866 LANJUTAN PAKET ADNEXITIS 20X 1
SFO00867 LANJUTAN PAKET ADNEXITIS 30X 1
SFO00869 LANJUTAN PAKET SAKIT BAHU 6X 1
SFO00868 LANJUTAN PAKET SAKIT PINGGANG 6X 1
SFO00927 LEPAS IUD DSOG DENGAN PENYULIT DALAM NARKOSE 831,250 960,625
BPJS
poli SFO00075 Lepas Spiral dg bidan 30,000
poli SFO00076 Lepas Spiral dg DSOG, tanpa penyulit 50,000
poli SFO00077 Lepas Spiral dg Penyulit, msh bisa tanpa 110,000
operasi
poli SFO00590 LEPAS SPIRAL DGN PENYULIT DI VK 375,000
poli SFO00026 LUKA BAKAR 5% - 10 % 200,000
SFO00882 MAHKOTA SEMENTARA PER GIGI 100,000
SFO00912 MANUAL AND MECHANICAL TRACTION 35,000
SFO00946 MANUAL AND MECHANICAL TRACTION 35,000 38,500 42,000
SFO00932 MANUAL MUSCLE TESTING OF MUSCLE FUNCTION 35,000 38,500 42,000
SFO00917 MANUAL RUPTURE OF JOINT ADHESION 35,000
SFO00951 MANUAL RUPTURE OF JOINT ADHESION 35,000 38,500 42,000
SFO00680 MASKER ANAK 25,000 25,000 25,000
SFO00634 MASKER ANAK - BPJS 25,000 25,000 25,000
SFO00681 MASKER DEWASA 30,000 30,000 30,000
SFO00635 MASKER DEWASA - BPJS 30,000 30,000 30,000
SFO00224 Materai 7,000
SFO00934 MEASURENMENT OF LIMB LENGTH 35,000 38,500 42,000
SFO00462 MELEPAS BRACKET (ORTHO) / RAHANG 300,000
SFO00682 MICROMIST ANAK 45,000 45,000 45,000
SFO00636 MICROMIST ANAK - BPJS 45,000 45,000 45,000
SFO00683 MICROMIST DEWASA 50,000 50,000 50,000
SFO00637 MICROMIST DEWASA - BPJS 50,000 50,000 50,000
SFO00684 MOBILISASI 50,000 55,000 60,000
SFO00638 MOBILISASI - BPJS 50,000 55,000 60,000
SFO00685 MOBILISASI HL 60,000 66,000 72,000
SFO00639 MOBILISASI HL - BPJS 60,000 66,000 72,000
SFO00942 MOBILIZATION OF OTHER JOINT 35,000 38,500 42,000
SFO00901 MOBILIZATION OF OTHER JOINTS 35,000
SFO00899 MOBILIZATION OF SPINE 35,000
SFO00941 MOBILIZATION OF SPINE 35,000 38,500 42,000
SFO00686 MWD 60,000 66,000 72,000
SFO00640 MWD - BPJS 50,000 55,000 60,000
SFO00688 MWD ,NEB,PD 85,000 93,500 102,000
SFO00642 MWD ,NEB,PD - BPJS 85,000 93,500 102,000
SFO00687 MWD HL 72,000 79,200 86,400
SFO00641 MWD HL - BPJS 60,000 66,000 72,000
SFO00689 MWD,NEB,PD,HL 102,000 112,200 122,400
SFO00643 MWD,NEB,PD,HL - BPJS 102,000 112,200 122,400
SFO00753 NEB, PD, VIB - BPJS PERINA 78,000
SFO00754 NEB, PD, VIB - UMUM PERINA 84,000
SFO00676 NEB,PD 60,000 66,000 72,000
SFO00630 NEB,PD - BPJS 55,000 60,500 66,000
SFO00677 NEB,PD HL 72,000 79,200 86,400
SFO00631 NEB,PD HL - BPJS 66,000 72,600 79,200
SFO00678 NEB,PD,VIB 70,000 77,000 84,000
SFO00632 NEB,PD,VIB - BPJS 65,000 71,500 78,000
SFO00679 NEB,PD,VIB, HL 84,000 92,400 100,800
 SFO00633 NEB,PD,VIB, HL - BPJS 78,000 85,800 93,600
poli SFO00966 NEBULASI 71,500 78,000 84,500
poli SFO00465 NEBULIZER (INCL OBAT) JAMSOSTEK 70,000
SFO00374 NEBULIZER + POSTURAL DRAINAGE 50,000
SFO00081 Obesrvasi pasien Di UGD 1 - 4 jam 50,000
SFO00863 OBSERVASI < 6 JAM DI VK 250,000
SFO00082 OBSERVASI PASIEN DI UGD < 6 JAM 200,000
SFO00571 OBSERVASI PASIEN DI UGD 6-12 JAM 400,000
SFO00419 OCCLUSAL ADJUSTMENT 100,000
SFO00439 OKLUSAL SPLINT 600,000
SFO00494 OKSIGEN PER JAM PASIEN JAMSOSTEK 10,000
SFO00455 ON LOOP 50,000 75,000
SFO00443 ONDONTEKTOMI KASUS MUDAH 1,650,000
SFO00421 OPERCULEKTOMY 500,000
SFO00936 ORTHER DIAGNOSTIC PHYSICAL TERAPHY PROSEDUR 35,000 38,500 42,000

SFO00441 ORTHO FIXED ( RA & RB ) BRACKET METAL SPECIAL 5,000,000

SFO00755 ORTHO FIXED (RA+RB) CERAMIC BRACKET 7,000,000

SFO00756 ORTHO FIXED (RA+RB) SAPPHIRE BRACKET 8,000,000
SFO00440 ORTHO REMOVABLE PER RAHANG 1,300,000
SFO00930 ORTHOTIC EVALUATION 35,000 38,500 42,000
SFO00961 OSTEOPATHIC MANIPULATIVE TREATMENT FOR GENERAL 35,000 38,500 42,000
MOBILIZATION
SFO00964 OSTEOPATIC MANIPULATIVE TREATMENT TO MOVE 38,500 42,000 45,500
TISSUE FLUIDS
SFO00963 OSTEOPATIC MANIPULATIVE TREATMENT USING 38,500 42,000 45,500
INDIRECT FORCES
SFO00962 OSTEOPATIC MANIPULATIVE TREATMENT USING 35,000 38,500 42,000
ISOTONIC,ISOMETRICT FORCES
SFO00896 OTHER ACTIVE MUSCULOKELETAL EXERCISE 35,000
SFO00938 OTHER ACTIVE MUSCULOSKELETAL EXERCISE 35,000 38,500 42,000
SFO00920 OTHER FORCIBLE CORRECTION OF DEFORMITY 35,000
SFO00954 OTHER FORCIBLE OF DEFORMITY 35,000 38,500 42,000
SFO00956 OTHER HEAT THERAPY 35,000 38,500 42,000
SFO00900 OTHER PASSIVE MUSCULOSKELETAL EXERCISE 35,000
SFO00943 OTHER PASSIVE MUSCULOSKELETAL EXERCISE 35,000 38,500 42,000
SFO00960 OTHER PHYSICAL THERAPY 35,000 38,500 42,000
SFO00965 OTHER SPECIFIED OSTEOPATHIC MANIPULATIVE 38,500 42,000 45,500
TREATMENT
SFO00724 PAKET 1 MODALITAS ,TAPPING 80,000 88,000 96,000
SFO00704 PAKET 1 MODALITAS ,TAPPING - BPJS 80,000 88,000 96,000
SFO00725 PAKET 2 MODALITAS,TAPPING HL 96,000 105,600 115,200
SFO00705 PAKET 2 MODALITAS,TAPPING HL - BPJS 96,000 105,600 115,200
SFO00726 PAKET 3 MODALITAS 130,000 143,000 156,000
SFO00706 PAKET 3 MODALITAS - BPJS 100,000 110,000 120,000
SFO00727 PAKET 3 MODALITAS HL 156,000 171,600 187,200
SFO00707 PAKET 3 MODALITAS HL - BPJS 120,000 132,000 144,000
SFO00729 PAKET 3 MODALITAS,TAPPING HL 180,000 165,000 180,000
 SFO00709 PAKET 3 MODALITAS,TAPPING HL - BPJS 180,000 198,000 216,000
SFO00728 PAKET 3MODALITAS, TAPPING 150,000 165,000 180,000
SFO00708 PAKET 3MODALITAS, TAPPING - BPJS 150,000 165,000 180,000
SFO00730 PAKET 4 MODALITAS 175,000 192,500 210,000
SFO00710 PAKET 4 MODALITAS - BPJS 175,000 192,500 210,000
, SFO00731 PAKET 4 MODALITAS HL 210,000 231,000 252,000
SFO00711 PAKET 4 MODALITAS HL - BPJS 210,000 231,000 252,000
SFO00732 PAKET ADNEXITIS 10X 540,000
SFO00733 PAKET ADNEXITIS 10X HL 648,000
SFO00734 PAKET ADNEXITIS 20X 1,000,000
SFO00735 PAKET ADNEXITIS 20X HL 1,200,000
SFO00736 PAKET ADNEXITIS 30X 1,500,000
SFO00737 PAKET ADNEXITIS 30X HL 1,800,000
obsgyn SFO00336 PAKET ANC BIDAN 20,000
SFO00332 PAKET BEROBAT DOKTER UMUM RP. 50,000 50,000
internis SFO00371 PAKET BEROBAT DR INTERNIS 75,000
SFO00781 PAKET DIAMOND - MEDICAL CHECK UP 700,000
SFO00379 PAKET FISIOTERAPI 2 MODALITAS 90,000
SFO00380 PAKET FISIOTERAPI 3 MODALITAS 100,000
SFO00381 PAKET FISIOTERAPI 4 MODALITAS 110,000
SFO00779 PAKET GOLD - MEDICAL CHECK UP 500,000
SFO00460 PAKET IMUNISASI BCG OLEH BIDAN 20,000
poli
SFO00459 PAKET IMUNISASI CAMPAK OLEH BIDAN 20,000
poli
SFO00457 PAKET IMUNISASI DPT COMBO OLEH BIDAN 20,000
poli
SFO00458 PAKET IMUNISASI POLIO OLEH BIDAN 20,000
poli
SFO00461 PAKET IMUNISASI TT OLEH NBIDAN 20,000
poli
SFO00712 PAKET MWD,NEB,PD (D)5X 530,000
SFO00713 PAKET MWD,NEB,PD (D)5X HL 636,000
SFO00714 PAKET MWD,NEB,PD(C) 5X 490,000
SFO00715 PAKET MWD,NEB,PD(C) 5X HL 588,000
SFO00716 PAKET NEB,PD (A) 5X 355,000
SFO00717 PAKET NEB,PD (A) 5X HL 426,000
SFO00718 PAKET NEB,PD(B) 5X 360,000
SFO00719 PAKET NEB,PD(B) 5X HL 432,000
obsgyn SFO00335 PAKET PAPSMEAR BIDAN 250,000
obsgyn SFO00338 PAKET PASANG SPIRAL 85,000
SFO00543 PAKET PENGOBATAN 25,000
SFO00780 PAKET PLATINUM - MEDICAL CHECK UP 600,000
SFO00720 PAKET SAKIT BAHU 6X 700,000
SFO00721 PAKET SAKIT BAHU6X HL 840,000
SFO00722 PAKET SAKIT PINGGANG 6X 700,000
SFO00723 PAKET SAKIT PINGGANG 6X HL 840,000
SFO00337 PAKET SUNAT LASER 400,000
poli SFO00333 PAKET SUNTIK KB BIDAN 1 BULAN 20,000
poli SFO00334 PAKET SUNTIK KB BIDAN 3 BULAN 25,000
poli SFO00486 PAP SMEAR JAMSOSTEK 90,000
SFO00584 PASANG GIPS BESAR 150,000
SFO00582 PASANG GIPS KECIL 60,000
SFO00583 PASANG GIPS SEDANG 100,000
SFO00030 PASANG INFUS ANAK DI UGD 100,000
SFO00031 PASANG INFUS BAYI DI UGD 150,000
SFO00358 PASANG INFUS DENGAN PENYULIT 40,000
SFO00029 PASANG INFUS DEWASA DI UGD 75,000
SFO00357 PASANG INFUS INTRA CRANIAL 50,000
SFO00592 PASANG INFUS VENA UMBILICAL 50,000
poli SFO0588 PASANG IUD DSOG DENGAN PENYULIT DALAM NARKOSE 731,250 860,625
BPJS
poli SFO00532 PASANG KAWAT GIGI RAHANG ATAS/BAWAH 2,000,000
poli SFO00531 PASANG SPIRAL (TERMASUK SPIRAL) JAMSOSTEK 150,000
SFO00673 PASIVE EXERCISE 50,000 55,000 60,000
SFO00627 PASIVE EXERCISE - BPJS 35,000 38,500 42,000
SFO00674 PASIVE EXERCISE HL 60,000 66,000 72,000
SFO00628 PASIVE EXERCISE HL - BPJS 42,000 46,200 50,400
SFO000763 PASSIVE EXERCISE CITO PERINA - BPJS 60,060

SFO000762 PASSIVE EXERCISE PERINA - BPJS 50,050

SPO00350 PATOLOGI ANATOMI 900,000

poli SFO00456 PEKET IMUNISASI HEPATITIS B OLEH BIDAN 20,000
SFO00039 Pemakaian Oksigen per jam 35,000
SFO00144 Pemakaian Oksigen per tabung besar 250,000
SFO00508 PEMAKAIAN SATURASI 125,000
SFO00145 Pemakain Oksigen per tabung kecil 175,000
poli SFO00422 PEMASANGAN PIN & PASAK GIGI 500,000
SFO00501 PEMBERIAN INFUS+ALKES, JASA MEDIS DAN 100,000
OBSERVASI (UGD) JAMSOSTEK S/D 6 JAM
gigi SFO00579 PEMBERSIHAN KARANG GIGI 150,000
gigi SFO00424 PEMUTIHAN GIGI DENGAN OCO PER RAHANG 50,000
gigi SFO00390 PENCABUTAN GIGI PERMANEN KASUS BIASA 200,000
gigi SFO00771 PENCABUTAN GIGI PERMANEN KASUS SEDANG 250,000
gigi SFO00389 PENCABUTAN GIGI SUSU DENGAN INJEKSI 150,000
gigi SFO00388 PENCABUTAN GIGI SUSU TANPA INJEKSI 100,000
gigi SFO00391 PENCABUTAN KASUS SULIT/EKSTRAKSI KOMPLIKASI 350,000

SFO00482 PENGANGKATAN CLAVUS JAMSOSTEK 200,000

SFO00481 PENGANGKATAN NEVUS JAMSOSTEK 200,000
SFO00483 PENGANGKATAN VERUCA JAMSOSTEK 200,000
poli SFO00808 PENGGANTI KAWAT GIGI PER RAHANG 80,000
poli SFO00605 PENGGANTIAN BRACKET METAL GIGI 80,000
poli SFO00606 PENGGANTIAN BUCCAL TUBE GIGI 80,000
poli SFO00604 PENGGANTIAN KAWAT 80,000
poli SFO00878 PENGISIAN SALURAN AKAR + FUJI 400,000
gigi SFO00880 PENGISIAN SALURAN AKAR + METODE SANDWICH 500,000
 gigi SFO00879 PENGISIAN SALURAN AKAR + SINAR 450,000
gigi SFO00409 PENGISIAN SALURAN AKAR > GANDA 300,000
gigi SFO00408 PENGISIAN SALURAN AKAR TUNGGAL & GANDA 200,000
bedah SFO00495 PENJAHITAN LUKA SAMPAI DENGAN 5 JAHITAN 100,000
JAMSOSTEK
SFO00499 PERAWATAN LUKA BAKAR DIBAWAH 25% JAMSOSTEK 175,000
gigi SFO00407 PERAWATAN SALURAN AKAR > GANDA 200,000
gigi SFO00406 PERAWATAN SALURAN AKAR GANDA 150,000
gigi SFO00405 PERAWATAN SALURAN AKAR TUNGGAL 125,000
poli SFO00064 Periksa Dalam dg Bidan inpartu poli 25,000
poli SFO00070 Periksa Dalam dg DSOG inpartu 30,000
anak ,bdh SFO00470 PHIMOSIS ANAK DIBAWAH 8 TAHUN JAMSOSTEK 1,100,000

SFO00402 PIT FISSURE SEALANT 150,000

SFO00473 PLACENTA MANUAL PASIEN JAMSOSTEK 750,000
SFO00428 PORSELEN VENEER / FACING AKRILIK 1,000,000
SFO00607 POWER CHAIN PER RAHANG 50,000
SFO00958 PRENATAL TRAINING 35,000 38,500 42,000
poli SFO00503 PRINT USG PROMO 25,000
poli SFO00507 PROMO IUD 50,000
poli SFO00449 PROMO KAWAT GIGI 4,000,000
gigi SFO00580 PROMO PENCABUTAN GIGI ANAK 75,000
gigi SFO00581 PROMO PENCABUTAN GIGI DEWASA 125,000
poli SFO00448 PROMO USG MURAH 115,000
poli SFO00931 PROSTHETIC EVALUATION 35,000 38,500 42,000
poli SFO00675 PULMICORT 20,000 20,000 20,000
poli SFO00629 PULMICORT - BPJS 20,000 22,800 22,800
poli SFO00463 PULP CAPPING 100,000
poli SFO00809 PULP CAPPING + FUJI 325,000
poli SFO00810 PULP CAPPING + SINAR 375,000
poli SFO00404 PULPEKTOMI, PEMBUKAAN KAMAR PULPA 120,000
poli SFO00933 RANGE OF MOTION TESTING 35,000 38,500 42,000
poli SF000603 REBOUNDING GIGI PER SATUAN 50,000
poli SFO00802 REMOVING CROWN 150,000
poli SFO00438 REPARASI RAHANG GTS 350,000
SFO00897 RESISTIVE EXERCISE 35,000
SFO00939 RESISTIVE EXERCISE 35,000 38,500 42,000
SFO00141 Resusitasi Anak / Bayi BPJS oleh dr. Umum 100,000
SFO00140 Resusitasi anak / bayi oleh perawat semua 75,000
kelas
SFO00142 RESUSITASI ANAK/BAYI OLEH DR SPESIALIS SEMUA 150,000
KELAS
SFO00131 Resusitasi pasien HCU dr spesialis 250,000
SFO00130 RESUSITASI PASIEN HCU DR UMUM 100,000
SFO00445 RETAINER ORTHO LEPASAN PER RAHANG 1,500,000
gigi SFO00973 RONTGEN GIGI 60,000
gigi SFO00414 SCALLING PER 2 RAHANG BERAT 350,000
gigi SFO00412 SCALLING PER 2 RAHANG RINGAN 200,000
gigi SFO00413 SCALLING PER 2 RAHANG SEDANG 300,000
gigi SFO00773 SCALLING RUTIN PASIEN ORTHO/KAWAT GIGI 100,000
SFO00410 SEMENTASI 150,000
SFO00907 SERTIFIKAT VAKSIN PAKET A 25,720
SFO00908 SERTIFIKAT VAKSIN PAKET B 54,130
SFO00909 SERTIFIKAT VAKSIN PAKET C 45,320
SFO00910 SERTIFIKAT VAKSIN PAKET D 37,630
SFO00751 SEWA ALAT + ASISTEN RESUSITASI 350,000
SFO00133 Sewa Alat Infus pump 50,000
SFO00057 Sewa Alat Laser 100,000
SFO00537 SEWA ALAT NEBULIZER 20,000
SFO00578 SEWA ALAT OKSIGEN MIXER 100,000
SFO00223 Sewa Alat Operasi 50,000 75,000
SFO00129 Sewa Alat Pasien Monitor 75,000
SFO00132 Sewa Alat syringe pump 50,000
SFO00128 SEWA ALAT VK 100,000
SPO00353 SEWA ALAT VK DI UGD 100,000
SFO00350 SEWA ALAT VK NON PARTUS 50,000
SFO00227 Sewa ambulance > 15km - 25 km 97,500
SFO00228 Sewa ambulance > 25 km - < 50km 130,000
SFO00229 Sewa ambulance > 50 km - 100 km 260,000
SFO00225 Sewa ambulance jarak < = 10km 32,500
SFO00226 Sewa ambulance jarak >10 - 15 km 65,000
SFO00492 SEWA BLUE LIGHT PER HARI UNTUK BAYI JAMSOSTEK 80,000

SFO00138 Sewa Bluelight double per hari 175,000

SFO00137 Sewa Bluelight single per hari 75,000
SPO00356 SEWA BUBBLE CPAP KELAS III 450,000 500,000
SFO00135 Sewa cuvis per hari 100,000
SFO00139 Sewa headbox 25,000
SFO00146 SEWA INFANT WARMER 350,000 200,000 250,000
SFO00890 SEWA INFANT WARMER - BPJS 400,000
SFO00851 SEWA INFANT WARMER - PAKET HEMAT 100,000
SFO00750 SEWA INFANT WARMER PER HARI - PAKET BIDAN 100,000
SFO00134 Sewa Inkubator per hari 200,000
SFO00588 SEWA INKUBATOR PER JAM 20,000
SFO00222 Sewa Mesin Anestesi 400,000 500,000
SFO00136 Sewa neopuff per hari 175,000
SFO00127 SEWA OK 450,000 500,000
SFO00233 Sewa OK paket SC 32 jam kelas 3 300,000
SFO00249 SEWA OK PAKET SC 48 JAM KELAS 3 300,000
SFO00834 SEWA OK PAKET HEMAT SC 300,000
SFO00611 SEWA PASIEN MONITOR IGD 75,000
SFO00143 Sewa Puls oximetri 40,000
SFO00349 SEWA VK NON PARTUS 100,000
 SFO00845 SEWA VK PAKET HEMAT KURET 100,000
SFO00836 SEWA VK PAKET HEMAT PN 200,000
SFO00125 Sewa VK partus Bidan 50,000 100,000
SFO00126 SEWA VK PARTUS DSOG 200,000 250,000
SFO00474 SIRKUMSISI ATAS INDIKASI MEDIS (PHIMOSIS) 300,000
ANESTESI LOKAL JAMSOSTEK
SFO00811 SPLINTING WIRE COMPOSITE / GIGI 75,000
SFO00812 SPLINTING WIRE COMPOSITE / REGIO 1,000,000
SFO00813 SPLINTING WIRE RIBBON / GIGI 150,000
SFO00738 SPUTUM BTA 55,000
SFO00953 STRETCHING OF FACIA 35,000 38,500 42,000
SFO00919 STRETCHING OF FASCIA 35,000
SFO00918 STRETCHING OF MUSCLE OR TENDON 35,000
SFO00952 STRETCHING OF MUSCLE OR TENDON 35,000 38,500 42,000
SFO0587 SURAT KETERANGAN LAHIR 50,000
SFO00418 TAMBAHAN INJEKSI PER AMPUL 50,000
gigi SFO00772 TAMBAHAN OCO PADA TINDAKAN SCALLING 50,000
gigi SFO00395 TAMBALAN GIC BESAR 200,000
gigi SFO00393 TAMBALAN GIC KECIL 150,000
gigi SFO00394 TAMBALAN GIC SEDANG 175,000
gigi SFO00396 TAMBALAN KOMPOSIT KECIL 200,000
gigi SFO00397 TAMBALAN KOMPOSIT SEDANG 250,000
gigi SFO00398 TAMBALAN KOMPSIT BESAR 300,000
gigi SFO00392 TAMBALAN SEMENTARA 125,000
SFO00690 TAPPING 1 REGIO 25,000 27,500 30,000
SFO00644 TAPPING 1 REGIO - BPJS 25,000 27,500 30,000
SFO00701 TAPPING 1 REGIO HL 27,500 30,250 33,000
SFO00655 TAPPING 1 REGIO HL - BPJS 27,500 30,250 33,000
SFO00691 TAPPING 2 REGIO 50,000 55,000 60,000
SFO00645 TAPPING 2 REGIO - BPJS 50,000 55,000 60,000
SFO00702 TAPPING 2 REGIO HL 60,000 66,000 72,000
SFO00656 TAPPING 2 REGIO HL - BPJS 60,000 66,000 72,000
SFO00703 TAPPING 3 REGIO HL 90,000 99,000 108,000
SFO00657 TAPPING 3 REGIO HL - BPJS 90,000 99,000 108,000
SFO00692 TAPPPING 3 REGIO 75,000 82,500 90,000
SFO00646 TAPPPING 3 REGIO - BPJS 75,000 82,500 90,000
SFO00104 TARIF KAMAR ANAK 125,000 225,000
SFO00103 TARIF KAMAR BAYI 150,000 200,000
SFO00841 TARIF KAMAR BAYI PAKET HEMAT PN 75,000
SFO00791 TARIF KAMAR BAYI - PN BPJS 75,000 100,000
SFO00816 TARIF KAMAR BAYI BPJS 300,000 400,000
SFO00748 TARIF KAMAR BAYI PAKET BIDAN 75,000 100,000
SFO00825 TARIF KAMAR BAYI PAKET HEMAT SC 75,000
SFO00819 TARIF KAMAR DEWASA - BPJS 125,000 225,000
SFO00820 TARIF KAMAR DEWASA - PAKET BIDAN 125,000
SFO00102 TARIF KAMAR DEWASA - PASIEN 150,000 250,000
 SFO00837 TARIF KAMAR DEWASA PAKET HEMAT PN 125,000
SFO00375 TDP / DIATHERMI 25,000
SFO00693 TENS 50,000 55,000 60,000
SFO00647 TENS - BPJS 35,000 38,500 42,000
SFO00694 TENS HL 60,000 66,000 72,000
SFO00648 TENS HL - BPJS 42,000 46,200 50,400
int,bdh SFO00036 TINDAKAN AFF FOLLEY CATETER 75,000
bedah SFO00502 TINDAKAN AFF HECTING DAN KONTROL LUKA 100,000
JAMSOSTEK
obsgyn SFO00385 TINDAKAN AFF INPLANT DGN BIDAN 50,000
obsgyn SFO00383 TINDAKAN AFF INPLANT DGN DOKTER 125,000
SFO00100 Tindakan cabut jalur tranfusi darah 10,000
SFO00018 TINDAKAN CLISMA / LAVEMENT 100,000
SFO00016 TINDAKAN CORPUS ALINEUM HIDUNG 150,000
SFO00568 TINDAKAN CORPUS MATA DI UGD 150,000
SFO00050 Tindakan Cross Luka tusuk kecil 100,000
internis SFO00038 TINDAKAN EKG 100,000
SPO00348 TINDAKAN EKG RANAP 100,000
bedah SFO00022 TINDAKAN EXTRAKSI KISTA ATEROM <= 2 CM 200,000
bedah SFO00023 TINDAKAN EXTRAKSI KISTA ATEROM >2 - 5 CM 350,000
bedah SFO00024 Tindakan extraksi Kista Aterom >5 cm 250,000
bedah SFO00019 TINDAKAN EXTRAKSI KUTIL / MATA IKAN 200,000
bedah SFO00020 TINDAKAN EXTRAKSI LIPOMA <= 2 CM 200,000
bedah SFO00021 TINDAKAN EXTRAKSI LIPOMA >2 - 5 CM 350,000
gigi SFO00972 TINDAKAN GIGI KONSERVASI - IMPLAN PER GIGI - 1,500,000 1,500,000
FEE ANESTHESI IMPLANT GIGI
gigi SFO00971 TINDAKAN GIGI KONSERVASI - IMPLAN PER GIGI - 17,000,000 17,000,000
OPERATOR UTAMA IMPLAN GIGI
gigi SFO00970 TINDAKAN GIGI KONSERVASI - PERAWATAN SALURAN 298,000
AKAR - BPJS
gigi SFO00969 TINDAKAN GIGI KONSERVASI - TAMBALAN SEMENTARA 298,000
- BPJS
gigi SFO00968 TINDAKAN GIGI KONSERVASI - TAMBALAN TETAP DG 298,000
SINAR - BPJS
bedah SFO00009 Tindakan Incici Abses Besar 105,000
bedah SFO00008 Tindakan Incici Abses Sedang 80,000
SFO00111 TINDAKAN INDUKSI PERSALINAN DSOG 731,250 1,062,500
SFO00558 TINDAKAN INDUKSI PERSALINAN DSOG BPJS 435,000
SFO00835 TINDAKAN INDUKSI PERSALINAN DSOG PAKET HEMAT 435,000
PN
anak SFO00048 TINDAKAN INHALASI ANAK-ANAK 75,000
anak SFO00047 TINDAKAN INHALASI BAYI 50,000
bedah SFO00575 TINDAKAN INSISI / EKSISI DR SPESIALIS 200,000
SFO00037 TINDAKAN IRIGASI MATA DI UGD 75,000
SFO00006 TINDAKAN JAHIT >15 JAHITAN 200,000
bedah SFO00002 TINDAKAN JAHIT 1 - 15 JAHITAN 100,000
SFO00017 TINDAKAN KURAS LAMBUNG DEWASA & ANAK 250,000
SFO00535 TINDAKAN KURET DG MOLAHIDATIDOSA 780,000
SFO00114 TINDAKAN KURET DSOG 600,000
internis SFO00894 TINDAKAN LEPAS NGT RAWAT JALAN 100,000
SFO00120 Tindakan Manual Placenta DSOG 500,000
SFO00091 TINDAKAN MELEPAS CATETER DI RUANG 30,000
PERAWATAN/VK/OK
SFO00092 TINDAKAN MELEPAS DRAINASE DI RUANG 20,000
PERAWATAN/VK/OK
SFO00094 TINDAKAN MELEPAS NGT ANAK & DEWASA DU R. 25,000
PERAWATAN
SFO00089 TINDAKAN MELEPAS PASANG INFUS DI RUANG 30,000
PERAWATAN/V
SFO00610 TINDAKAN MENOLONG PARTUS DI UGD 350,000
SFO00113 TINDAKAN MENOLONG PARTUS FORCEP EXTRAKSI DSOG 780,000 1,020,000

SFO00109 Tindakan menolong Partus Normal Bidan 200,000 350,000

SPO00351 TINDAKAN MENOLONG PARTUS NORMAL BPJS 200,000
SFO00110 TINDAKAN MENOLONG PARTUS NORMAL DSOG 650,000 850,000
SFO00116 TINDAKAN MENOLONG PARTUS NORMAL GMELI 975,000 1,275,000
SFO00115 TINDAKAN MENOLONG PARTUS SUNGSANG DSOG 780,000 1,020,000
SFO00559 TINDAKAN MENOLONG PARTUS VAKUM EKSTRASI DSOG 650,000
BPJS
SFO00112 TINDAKAN MENOLONG PARTUS VAKUM EXTRAKSI DSOG 780,000 1,020,000

SFO00512 TINDAKAN OLES MATA 60,000

SFO00817 TINDAKAN OLES MATA - BPJS 60,000
SFO00850 TINDAKAN OLES MATA - PAKET HEMAT 10,000
SFO00921 TINDAKAN PARTUS NORMAL DSOG DENGAN ILA - 850,000 1,050,000
PASIEN UMUM
SFO00117 Tindakan pasang balon induksi 20,000
SFO00090 TINDAKAN PASANG CATETER DI RUANG 40,000
PERAWATAN/VK/OK
SFO00035 TINDAKAN PASANG FOLLEY CATETER 100,000
SFO00088 TINDAKAN PASANG INFUS DI RUANG PERAWATAN/VK/OK 40,000

SFO00356 TINDAKAN PASANG INFUS INTRA OSTEUM 75,000

SFO00384 TINDAKAN PASANG INPLANT DGN BIDAN 75,000
SFO00382 TINDAKAN PASANG INPLANT DNG DOKTER 200,000
SFO00099 Tindakan pasang jalur tranfusi darah 25,000
SFO00743 TINDAKAN PASANG MASKER CPAP/ SELANG NEOPUFF 100,000

SFO00033 TINDAKAN PASANG NGT ANAK 100,000

SFO00093 TINDAKAN PASANG NGT ANAK & DEWASA DU R. 55,000
PERAWATAN/
SFO00032 TINDAKAN PASANG NGT BAYI 150,000
SFO00034 TINDAKAN PASANG NGT DEWASA 75,000
SPO00358 TINDAKAN PEMAKAIAN BUBBLE CPAP - BPJS 150,000 200,000
SPO00357 TINDAKAN PEMAKAIAN BUBBLE CPAP - UMUM 350,000 450,000
SFO00014 Tindakan Pembersihan Cerumen/Corpus Alineum 85,000
Telinga
SFO00011 TINDAKAN PEMBERSIHAN LUKA/GV/WT 50,000
SFO00049 TINDAKAN PENANGANAN KEJANG UGD 75,000
SFO00822 TINDAKAN PERAWATAN LUKA 50,000
SFO00098 TINDAKAN PERAWATAN LUKA POST OPERASI BERAT 75,000
 SFO00096 Tindakan perawatan luka post Operasi Ringan 20,000

SFO00097 TINDAKAN PERAWATAN LUKA POST OPERASI SEDANG 40,000

SFO00608 TINDAKAN PIJAT BAYI 50,000

SFO00118 Tindakan re-hecting DSOG 150,000
SFO00056 TINDAKAN SIRKUMSISI LASER DR UMUM 500,000
SFO00054 TINDAKAN SIRKUMSISI MANUAL DR UMUM 500,000
SFO00574 TINDAKAN SIRKUMSISI SMARTKLEM DR UMUM 750,000
SFO00052 TINDAKAN SUNTIK IM DR UMUM NON GO DILUAR OBAT 75,000

SFO00053 TINDAKAN SUNTIK IM DR UMUM GO DILUAR OBAT 400,000

SFO00889 TINDAKAN SUNTIK INTRA ARTIKULAR 250,000
SFO00883 TINDAKAN SUNTIK INTRAMUSCULAR PER INJEKSI - 75,000
NON BPJS
intenis SFO00573 TINDAKAN SUNTIK IV 50,000
SFO00924 TINDAKAN SUNTIK TRIGGER THUMB / FINGER 250,000
anak SFO00051 TINDAKAN TINDIK 100,000
SFO00758 TINDAKAN VENA SECTIE DOKTER BEDAH 2,000,000
SFO00757 TINDAKAN VENA SECTIE DOKTER BEDAH - BPJS 1,000,000
SFO00760 TINDAKAN VENA SECTIE DOKTER UMUM 600,000
SFO00759 TINDAKAN VENA SECTIE DOKTER UMUM - BPJS 350,000
SFO00940 TRAINING IN JOINT MOVEMENT 35,000 38,500 42,000
SFO00898 TRAINING IN JOINT MOVEMENTS 35,000
SFO00915 TRAINING IN USE OF PROSTHETIC OR ORTHOTIC 35,000
DEVICE
SFO00949 TRAINING IN USE OF PROSTHETIC OR ORTHOTIC 35,000 38,500 42,000
DEVICE
SFO00042 TRANSPORT HOM VISIT DR UMUM RADIUS>500 M TANPA 50,000
TOL
SFO00041 Transport home visit dr umum radius < 500 m 30,000

SFO00043 TRANSPORT HOME VISIT DR UMUM RADIUS>500 M DG 75,000

TOL
SFO00046 TRANSPORT PERAWAT HOME VISIT 10,000
SFO00373 UKG + NEBULIZER + POSTURAL DRAINAGE 60,000
SFO00695 US 50,000 55,000 60,000
SFO00649 US - BPJS 35,000 38,500 42,000
SFO00696 US HL 60,000 66,000 72,000
SFO00650 US HL - BPJS 42,000 46,200 50,400
SFO00745 USG 4D 200,000
SFO00468 USG INTIP PERUT JAMSOSTEK 60,000
SFO00884 USG PAYUDARA 350,000
SFO00872 USG SOFT TISSUE 524,000
SFO00467 USG TRANSVAGINAL JAMSOSTEK 70,000
SFO00697 VELUTINE 11,000 11,000 11,000
SFO00651 VELUTINE - BPJS 11,000 12,100 12,100
SFO00469 VENA SECTIE JAMSOSTEK 2,000,000
poli SFO00698 VENTOLIN 12,000 12,000 12,000
poli SFO00652 VENTOLIN - BPJS 12,000 13,200 13,200
SFO00591 VISIT DOKTER ANESTESI 50,000
SFO00289 VISIT DSA PAKET PARTUS NORMAL BIDAN KELAS 3 56,000

SFO00280 VISIT DSA PAKET PARTUS NORMAL DSOG KELAS 3 75,000

SFO00892 VISITE DOKTER REHAB MEDIK 78,750 112,500
SFO00893 VISITE DOKTER REHAB MEDIK - BPJS 69,375
SFO00870 VISITE DOKTER SYARAF 78,750 112,500
SFO00871 VISITE DOKTER SYARAF BPJS 69,375
SFO00830 VISITE DR OBGYN PAKET HEMAT SC 69,375
SFO00083 Visite Dr Umum 38,750 56,000
SFO00087 Visite Dr. Bedah 78,750 112,500
SFO00761 VISITE DR. BEDAH BPJS 69,375
SFO00786 VISITE DRG 78,750 112,500
SFO00790 VISITE DRG BPJS 69,375
SFO00085 VISITE DSA 78,750 112,500
SFO00840 VISITE DSA PAKET HEMAT PN 69,750
SFO00549 VISITE DSA BPJS 69,375
SFO00826 VISITE DSA PAKET HEMAT SC 69,375
SFO00260 VISITE DSA PAKET SC 48 JAM KELAS 3 78,750
SFO00276 VISITE DSA PAKET SC 72 JAM KELAS 3 78,750
SFO00548 VISITE DSOG BPJS 69,375
SFO00086 VISITE INTERNIST 78,750 112,500
SFO00550 VISITE INTERNIST BPJS 69,375
SFO00084 VISITE SPOG 78,750 112,500
SFO00838 VISITE SPOG PAKET HEMAT PN 69,375
SFO00699 WALKING EXERCISE 50,000 55,000 60,000
SFO00653 WALKING EXERCISE - BPJS 35,000 38,500 42,000
SFO00700 WALKING EXERCISE HL 60,000 66,000 72,000
SFO00654 WALKING EXERCISE HL - BPJS 42,000 46,200 50,400
SFO00801 ZIRCORIA (PER GIGI) 3,500,000
KELAS I VIP HCU PERINA RAWAT JALAN

300,000 350,000 200,000 200,000

150,000

65,000
45,500
78,000
54,600

45,500 45,500

150,000 175,000
150,000 175,000

700,000
1,400,000 1,750,000
500,000 750,000

45,500 45,500
78,000 100,000
65,000
93,600
78,000

400,000
300,000 300,000
45,500 45,500

45,500 45,500

45,500 45,500

45,500 45,500

16,000
17,000

60,000 60,000
 45,500 45,500

130,000
117,000
156,000
140,400

11,000
14,300

337,500

337,500
 843,750

1,100,000

1,440,000

945,000 1,215,000
2,778,000 3,334,000
1,944,600 2,333,800
2,430,750 2,917,250

1,335,000 1,556,000
934,500 1,089,200
2,250,000 2,778,000
1,575,000 1,944,600

281,250 343,125
225,000

562,500 731,250
787,500 1,000,000

45,500 45,500
24,700
32,110

45,500 45,500
45,500 45,500
156,000
130,000
187,200
156,000

65,000
45,500
78,000
54,600
140,400
133,250
117,000
110,500
200,000
60,000
150,000 350,000 200,000
500,000
75,000

60,000 75,000
75,000 75,000 200,000

60,000 75,000
 60,000

83,500 112,500 83,500 100,000

1,200,000
 45,500 45,500
45,500 45,500

45,500 45,500
25,000
25,000
30,000
30,000

45,500 45,500

45,000
45,000
50,000
50,000
65,000
65,000
78,000
78,000
45,500 45,500

45,500 45,500
78,000
65,000
110,500
110,500
93,600
78,000
132,600
132,600

78,000
71,500
93,600
85,800
91,000 84,000
84,500
109,200
101,400
84,500

100,000 125,000

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
45,500 45,500

45,500 45,500
45,500 45,500
45,500

104,000
104,000
124,800
124,800
169,000
130,000
202,800
156,000
195,000
234,000
195,000
195,000
227,500
227,500
273,000
273,000
1,100,000

65,000 65,000
45,500
78,000
54,600
45,500 45,500

45,500 45,500
20,000
22,800

45,500 45,500

45,500 45,500

60,000
100,000 125,000

550,000

300,000

750,000 1,000,000

600,000 750,000
150,000 200,000
300,000 350,000

45,500 45,500

45,500 45,500

32,500
32,500
35,750
35,750
65,000
65,000
78,000
78,000
117,000
117,000
97,500
97,500
325,000 425,000 300,000
250,000 300,000 300,000

125,000
500,000
125,000

325,000

350,000 400,000 350,000

 65,000
45,500
78,000
54,600

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

17,000,000 17,000,000 17,000,000 17,000,000 15,000,000

1,187,500 1,437,500
1,200,000 1,440,000

500,000 650,000

1,000,000 1,200,000
1,500,000 1,800,000
1,200,000 1,440,000

1,200,000 1,440,000

1,200,000

100,000

250,000
500,000
45,500 45,500

45,500 45,500

65,000
45,500
78,000
54,600

11,000
12,100

12,000
13,200
168,750

168,750 225,000

78,750 89,000 25,000

168,750 225,000 200,000

168,750

168,750 225,000 156,250

168,750 225,000 200,000

168,750 225,000 200,000

65,000
45,500
78,000
54,600