REKAP SETOR RETRIBUSI DARI UNIT BULAN AGUSTUS TAHUN 2019

KOMPONEN TARIF
JML
NO NAMA BENDA BERHARGA JML JML NOMINAL
jasa KELUAR
Jasa Sarana
pelayanan
I UGD

1 Pmrksn kesehatan umum 10,000 10,000 20,000 44 880,000

2 pelayanana observasi(maksimum 6 jam) 30,000 30,000 60,000 2 120,000

3 UGD
4 Tarif plyanan Rekam Medik di poli Umum Gigi dan KIA 6,000 4,000 10,000 91 910,000
II RAWAT JALN 0
1 pelyanan konsultasi 80,000 12,000 92,000
2 Pemriksaan plyn umum sore hari 6,000 4,000 10,000 0
3 Tarif plyn RM Baru UGD 10,000 5,000 15,000
4 RANAP 0
III Pelyanan Rawat inap
1 tarif atminitrasi RANAP 10,000 5,000 15,000 41 615,000
2 ASKEP/GIZI/PERHARI 30,000 30,000 118 3,540,000
3 AKOMODASI 70,000 70,000 118 8,260,000
4 VISITE 30000 118 3,540,000
PERSALINAN
1 Persalinan dg penyulit 250,000 500,000 750,000 0
Persalinan Normal 200,000 400,000 600,000
A TINDAKAN MEDIS RINGAN, terdiri dari
1 luka lecet 4,000 6,000 10,000
1 Jht luka s/d 3 8,000 12,000 20,000
2 perwatan luka / tidik 8,000 12,000 20,000 1 20,000
3 pmsngan bidai 8,000 12,000 20,000 0
C TINDAKAN MEDIS SEDANG,terdiri dari 0
1 luka bkr sedang 10,000 15,000 25,000 0
2 Jht luka 4 s/d 7 10,000 15,000 25,000 0
3 incisi abses 10,000 15,000 25,000 0
4 ekstraksi kuku 10,000 15,000 25,000 0
5 pngambilan benda asing 10,000 15,000 25,000 0
6 psng / buka kateter 10,000 15,000 25,000 0
7 pmasangan infus 10,000 15,000 25,000 43 1,075,000
D TINDAKAN MEDIS BESAR,terdiri dari 0
1 luka bkr berat 15,000 20,000 35,000 0
2 Jht luka lebih dr 7 15,000 20,000 35,000 2 70,000
3 pngambilan tumor kecil 15,000 20,000 35,000 1 35,000
E TINDAKAN MEDIS KHUSUS 0
1 khitan 50,000 100,000 150,000 0
2 nebul 40,000 20,000 60,000 0
3 pngambilan pap smear 10,000 15,000 25,000 0
4 cpw 6,000 8,000 14,000 32 448,000
5 HIV 0 0
6 HBS AG 0 0
7 TINDIK 5,000 5,000 10,000 1 10,000
VI TINDAKAN MEDIS di POLI GIGI 0
1 Pncbtn gigi sulung dg chlor ethyl 10,000 15,000 25,000 5 125,000
2 pmbrsihn karang gigi 20,000 30,000 50,000 0
3 Pncbtn gigi anterior 10,000 20,000 30,000 0
4 Pncbtn gigi posterior 10,000 40,000 50,000 1 50,000
5 tumpatan gigi sementara 10,000 15,000 25,000 0
6 tumpatan gigi dg glass ionomer 20,000 30,000 50,000 0
7 open bur/ bongkar tumpatan 10,000 15,000 25,000 0
Pncbtn gigi sulung(anak)dgn anastesis lokal
8 10,000 30,000
preijneksi 40,000 0
9 Tumpatan gigi dgn komposit 40,000 40,000 80,000 0
10 pengobatan perdarahan dgn tindakan 10,000 15,000 25,000 0
VII PELAYANAN PENUNJANG MEDIK 0
I. LABORATORIUM KLINIK 0
A. HEMATOLOGI 0
1 Darah lengkap metode hematologi analyer (DL) 23,000 12,000 35,000 1 35,000
2 GOLDA 9,000 6,000 15,000 26 390,000
3 haemoglobin 6,000 4,000 10,000 47 470,000
B URINALISA 0
1 reduksi dan protein urine 6,000 4,000 10,000 4 40,000
2 pregnoction plano test 7,000 5,000 12,000 0
glukosa Darah 0
1 Glukosw BSN/ 2 Jam PP/ Random (GDA) 6,000 4,000 10,000 6 60,000
E Lemak Darah 0
1 cholestherolmeter 9,000 6,000 15,000 0
C faal ginjal 0
1 Urid acidmeter AU 9,000 6,000 15,000 3 45,000
F IMUNOLOGI - SEROLOGI 0
1 WIDAL 8,000 9,000 17,000 1 17,000
G PEMERIKSAAN KESEHATAN 0
1 KEUR 4,000 6,000 10,000 11 110,000
H PEMERIKASAAN 0
1 KORBAN HIDUP (VER) 15,000 30,000 45,000 0
JUMLAH 1,178,000 1,757,000 2,905,000 20,865,000
 REKAP SETOR RETRIBUSI DARI UNIT BULAN SEPTEMBER TAHUN 2019

KOMPONEN TARIF
JML
NO NAMA BENDA BERHARGA JML JML NOMINAL
jasa KELUAR
Jasa Sarana
pelayanan
I UGD

1 Pmrksn kesehatan umum 10,000 10,000 20,000 40 800,000

2 pelayanana observasi(maksimum 6 jam) 30,000 30,000 60,000 0

3 UGD
4 Tarif plyanan Rekam Medik di poli Umum Gigi dan KIA 6,000 4,000 10,000 105 1,050,000
II RAWAT JALN 0
1 pelyanan konsultasi 80,000 12,000 92,000
2 Pemriksaan plyn umum sore hari 6,000 4,000 10,000 0
3 Tarif plyn RM Baru UGD 10,000 5,000 15,000
4 RANAP 0
III Pelyanan Rawat inap
1 tarif atminitrasi RANAP 10,000 5,000 15,000 38 570,000
2 ASKEP/GIZI/PERHARI 30,000 30,000 102 3,060,000
3 AKOMODASI 70,000 70,000 102 7,140,000
4 VISITE 30000 102 3,060,000
PERSALINAN
1 Persalinan dg penyulit 250,000 500,000 750,000 3 2,250,000
Persalinan Normal 200,000 400,000 600,000 1 600,000
A TINDAKAN MEDIS RINGAN, terdiri dari
1 luka lecet 4,000 6,000 10,000 4 40,000
1 Jht luka s/d 3 8,000 12,000 20,000 2 40,000
2 perwatan luka / tidik 8,000 12,000 20,000 1 20,000
3 pmsngan bidai 8,000 12,000 20,000 0
C TINDAKAN MEDIS SEDANG,terdiri dari 0
1 luka bkr sedang 10,000 15,000 25,000 0
2 Jht luka 4 s/d 7 10,000 15,000 25,000 1 25,000
3 incisi abses 10,000 15,000 25,000 0
4 ekstraksi kuku 10,000 15,000 25,000 1 25,000
5 pngambilan benda asing 10,000 15,000 25,000 0
6 psng / buka kateter 10,000 15,000 25,000 0
7 pmasangan infus 10,000 15,000 25,000 38 950,000
D TINDAKAN MEDIS BESAR,terdiri dari 0
1 luka bkr berat 15,000 20,000 35,000 0
2 Jht luka lebih dr 7 15,000 20,000 35,000 0
3 pngambilan tumor kecil 15,000 20,000 35,000 0
E TINDAKAN MEDIS KHUSUS 0
1 khitan 50,000 100,000 150,000 1 150,000
2 nebul 40,000 20,000 60,000 2 120,000
3 pngambilan pap smear 10,000 15,000 25,000 0
4 cpw 6,000 8,000 14,000 10 140,000
5 HIV 0 0
6 HBS AG 0 0
7 TINDIK 5,000 5,000 10,000 2 20,000
VI TINDAKAN MEDIS di POLI GIGI 0
1 Pncbtn gigi sulung dg chlor ethyl 10,000 15,000 25,000 18 450,000
2 pmbrsihn karang gigi 20,000 30,000 50,000 0
3 Pncbtn gigi anterior 10,000 20,000 30,000 0
4 Pncbtn gigi posterior 10,000 40,000 50,000 0
5 tumpatan gigi sementara 10,000 15,000 25,000 0
6 tumpatan gigi dg glass ionomer 20,000 30,000 50,000 1 50,000
7 open bur/ bongkar tumpatan 10,000 15,000 25,000 0
Pncbtn gigi sulung(anak)dgn anastesis lokal
8 10,000 30,000
preijneksi 40,000 0
9 Tumpatan gigi dgn komposit 40,000 40,000 80,000 0
10 pengobatan perdarahan dgn tindakan 10,000 15,000 25,000 0
VII PELAYANAN PENUNJANG MEDIK 0
I. LABORATORIUM KLINIK 0
A. HEMATOLOGI 0
1 Darah lengkap metode hematologi analyer (DL) 23,000 12,000 35,000 4 140,000
2 GOLDA 9,000 6,000 15,000 27 405,000
3 haemoglobin 6,000 4,000 10,000 26 260,000
B URINALISA 0
1 reduksi dan protein urine 6,000 4,000 10,000 3 30,000
2 pregnoction plano test 7,000 5,000 12,000 0
glukosa Darah 0
1 Glukosw BSN/ 2 Jam PP/ Random (GDA) 6,000 4,000 10,000 10 100,000
E Lemak Darah 0
1 cholestherolmeter 9,000 6,000 15,000 0
C faal ginjal 0
1 Urid acidmeter AU 9,000 6,000 15,000 4 60,000
F IMUNOLOGI - SEROLOGI 0
1 WIDAL 8,000 9,000 17,000 3 51,000
G PEMERIKSAAN KESEHATAN 0
1 KEUR 4,000 6,000 10,000 33 330,000
H PEMERIKASAAN 0
1 KORBAN HIDUP (VER) 15,000 30,000 45,000 0
JUMLAH 1,178,000 1,757,000 2,905,000 21,936,000
 REKAP SETOR RETRIBUSI DARI UNIT BULAN OKTOBER TAHUN 2019

KOMPONEN TARIF
JML
NO NAMA BENDA BERHARGA JML JML NOMINAL
jasa KELUAR
Jasa Sarana
pelayanan
I UGD

1 Pmrksn kesehatan umum 10,000 10,000 20,000 48 960,000

2 pelayanana observasi(maksimum 6 jam) 30,000 30,000 60,000 0

3 UGD
4 Tarif plyanan Rekam Medik di poli Umum Gigi dan KIA 6,000 4,000 10,000 94 940,000
II RAWAT JALN 0
1 pelyanan konsultasi 80,000 12,000 92,000
2 Pemriksaan plyn umum sore hari 6,000 4,000 10,000 0
3 Tarif plyn RM Baru UGD 10,000 5,000 15,000
4 RANAP 0
III Pelyanan Rawat inap
1 tarif atminitrasi RANAP 10,000 5,000 15,000 48 720,000
2 ASKEP/GIZI/PERHARI 30,000 30,000 147 4,410,000
3 AKOMODASI 70,000 70,000 147 10,290,000
4 VISITE 30000 147 4,410,000
PERSALINAN
1 Persalinan dg penyulit 250,000 500,000 750,000 1 750,000
Persalinan Normal 200,000 400,000 600,000 1 600,000
A TINDAKAN MEDIS RINGAN, terdiri dari
1 luka lecet 4,000 6,000 10,000 0
1 Jht luka s/d 3 8,000 12,000 20,000 0
2 perwatan luka / tidik 8,000 12,000 20,000 0
3 pmsngan bidai 8,000 12,000 20,000 0
C TINDAKAN MEDIS SEDANG,terdiri dari 0
1 luka bkr sedang 10,000 15,000 25,000 0
2 Jht luka 4 s/d 7 10,000 15,000 25,000 0
3 incisi abses 10,000 15,000 25,000 0
4 ekstraksi kuku 10,000 15,000 25,000 0
5 pngambilan benda asing 10,000 15,000 25,000 0
6 psng / buka kateter 10,000 15,000 25,000 0
7 pmasangan infus 10,000 15,000 25,000 48 1,200,000
D TINDAKAN MEDIS BESAR,terdiri dari 0
1 luka bkr berat 15,000 20,000 35,000 0
2 Jht luka lebih dr 7 15,000 20,000 35,000 0
3 pngambilan tumor kecil 15,000 20,000 35,000 0
E TINDAKAN MEDIS KHUSUS 0
1 khitan 50,000 100,000 150,000 0
2 nebul 40,000 20,000 60,000 1 60,000
Pemasangan implan 10,000 50,000 60,000 1 60,000
3 pngambilan pap smear 10,000 15,000 25,000 0
4 cpw 6,000 8,000 14,000 28 392,000
5 HIV 0 0
6 HBS AG 0 0
7 TINDIK 5,000 5,000 10,000 1 10,000
TINDIK 2 6,000 6,000 12,000 3 36,000
VI TINDAKAN MEDIS di POLI GIGI 0
1 Pncbtn gigi sulung dg chlor ethyl 10,000 15,000 25,000 17 425,000
2 pmbrsihn karang gigi 20,000 30,000 50,000 0
3 Pncbtn gigi anterior 10,000 20,000 30,000 1 30,000
4 Pncbtn gigi posterior 10,000 40,000 50,000 0
5 tumpatan gigi sementara 10,000 15,000 25,000 8 200,000
6 tumpatan gigi dg glass ionomer 20,000 30,000 50,000 0
7 open bur/ bongkar tumpatan 10,000 15,000 25,000 0
Pncbtn gigi sulung(anak)dgn anastesis lokal
8 10,000 30,000
preijneksi 40,000 0
9 Tumpatan gigi dgn komposit 40,000 40,000 80,000 0
10 pengobatan perdarahan dgn tindakan 10,000 15,000 25,000 0
VII PELAYANAN PENUNJANG MEDIK 0
I. LABORATORIUM KLINIK 0
A. HEMATOLOGI 0
1 Darah lengkap metode hematologi analyer (DL) 23,000 12,000 35,000 3 105,000
2 GOLDA 9,000 6,000 15,000 36 540,000
3 haemoglobin 6,000 4,000 10,000 43 430,000
B URINALISA 0
1 reduksi dan protein urine 6,000 4,000 10,000 0
2 pregnoction plano test 7,000 5,000 12,000 1 12,000
glukosa Darah 0
1 Glukosw BSN/ 2 Jam PP/ Random (GDA) 6,000 4,000 10,000 13 130,000
E Lemak Darah 0
1 cholestherolmeter 9,000 6,000 15,000 0
C faal ginjal 0
1 Urid acidmeter AU 9,000 6,000 15,000 8 120,000
F IMUNOLOGI - SEROLOGI 0
1 WIDAL 8,000 9,000 17,000 3 51,000
G PEMERIKSAAN KESEHATAN 0
1 KEUR 4,000 6,000 10,000 12 120,000
H PEMERIKASAAN 0
1 KORBAN HIDUP (VER) 15,000 30,000 45,000 0
JUMLAH 1,194,000 1,813,000 2,977,000 27,001,000
 REKAP SETOR RETRIBUSI DARI UNIT BULAN NOVEMBER TAHUN 2019

KOMPONEN TARIF
JML
NO NAMA BENDA BERHARGA JML JML NOMINAL
jasa KELUAR
Jasa Sarana
pelayanan
I UGD

1 Pmrksn kesehatan umum 10,000 10,000 20,000 42 840,000

2 pelayanana observasi(maksimum 6 jam) 30,000 30,000 60,000 0

3 UGD
4 Tarif plyanan Rekam Medik di poli Umum Gigi dan KIA 6,000 4,000 10,000 86 860,000
II RAWAT JALN 0
1 pelyanan konsultasi 80,000 12,000 92,000
2 Pemriksaan plyn umum sore hari 6,000 4,000 10,000 0
3 Tarif plyn RM Baru UGD 10,000 5,000 15,000
4 RANAP 0
III Pelyanan Rawat inap
1 tarif atminitrasi RANAP 10,000 5,000 15,000 41 615,000
2 ASKEP/GIZI/PERHARI 30,000 30,000 123 3,690,000
3 AKOMODASI 70,000 70,000 123 8,610,000
4 VISITE 30000 123 3,690,000
PERSALINAN
1 Persalinan dg penyulit 250,000 500,000 750,000 0
Persalinan Normal 200,000 400,000 600,000 2 1,200,000
A TINDAKAN MEDIS RINGAN, terdiri dari
1 luka lecet 4,000 6,000 10,000 0
1 Jht luka s/d 3 8,000 12,000 20,000 2 40,000
2 perwatan luka / tidik 8,000 12,000 20,000 3 60,000
3 pmsngan bidai 8,000 12,000 20,000 0
C TINDAKAN MEDIS SEDANG,terdiri dari 0
1 luka bkr sedang 10,000 15,000 25,000 0
2 Jht luka 4 s/d 7 10,000 15,000 25,000 1 25,000
3 incisi abses 10,000 15,000 25,000 0
4 ekstraksi kuku 10,000 15,000 25,000 0
5 pngambilan benda asing 10,000 15,000 25,000 0
6 psng / buka kateter 10,000 15,000 25,000 0
7 pmasangan infus 10,000 15,000 25,000 41 1,025,000
D TINDAKAN MEDIS BESAR,terdiri dari 0
1 luka bkr berat 15,000 20,000 35,000 0
2 Jht luka lebih dr 7 15,000 20,000 35,000 0
3 pngambilan tumor kecil 15,000 20,000 35,000 0
E TINDAKAN MEDIS KHUSUS 0
1 khitan 50,000 100,000 150,000 1 150,000
2 nebul 40,000 20,000 60,000 1 60,000
Pemasangan implan 10,000 50,000 60,000 0
Pencabutan implan 10,000 50,000 60,000 1 60,000
3 pngambilan pap smear 10,000 15,000 25,000 0
4 cpw 6,000 8,000 14,000 23 322,000
5 HIV 0 0
6 HBS AG 0 0
7 TINDIK 5,000 5,000 10,000 0
TINDIK 2 6,000 6,000 12,000 0
VI TINDAKAN MEDIS di POLI GIGI 0
1 Pncbtn gigi sulung dg chlor ethyl 10,000 15,000 25,000 16 400,000
2 pmbrsihn karang gigi 20,000 30,000 50,000 0
3 Pncbtn gigi anterior 10,000 20,000 30,000 1 30,000
4 Pncbtn gigi posterior 10,000 40,000 50,000 2 100,000
5 tumpatan gigi sementara 10,000 15,000 25,000 3 75,000
6 tumpatan gigi dg glass ionomer 20,000 30,000 50,000 2 100,000
7 open bur/ bongkar tumpatan 10,000 15,000 25,000 0
Pncbtn gigi sulung(anak)dgn anastesis lokal
8 preijneksi 10,000 30,000
40,000 0
9 Tumpatan gigi dgn komposit 40,000 40,000 80,000 0
10 pengobatan perdarahan dgn tindakan 10,000 15,000 25,000 0
VII PELAYANAN PENUNJANG MEDIK 0
I. LABORATORIUM KLINIK 0
A. HEMATOLOGI 0
1 Darah lengkap metode hematologi analyer (DL) 23,000 12,000 35,000 4 140,000
2 GOLDA 9,000 6,000 15,000 36 540,000
3 haemoglobin 6,000 4,000 10,000 34 340,000
B URINALISA 0
1 reduksi dan protein urine 6,000 4,000 10,000 3 30,000
2 pregnoction plano test 7,000 5,000 12,000 0
glukosa Darah 0
1 Glukosw BSN/ 2 Jam PP/ Random (GDA) 6,000 4,000 10,000 8 80,000
E Lemak Darah 0
1 cholestherolmeter 9,000 6,000 15,000 0
C faal ginjal 0
1 Urid acidmeter AU 9,000 6,000 15,000 6 90,000
F IMUNOLOGI - SEROLOGI 0
1 WIDAL 8,000 9,000 17,000 4 68,000
G PEMERIKSAAN KESEHATAN 0
1 KEUR 4,000 6,000 10,000 19 190,000
H PEMERIKASAAN 0
1 KORBAN HIDUP (VER) 15,000 30,000 45,000 0
JUMLAH 1,204,000 1,863,000 3,037,000 23,430,000
 REKAP SETOR RETRIBUSI DARI UNIT BULAN DESEMBER TAHUN 2019

KOMPONEN TARIF
JML
NO NAMA BENDA BERHARGA JML JML NOMINAL
jasa KELUAR
Jasa Sarana
pelayanan
I UGD

1 Pmrksn kesehatan umum 10,000 10,000 20,000 47 940,000

2 pelayanana observasi(maksimum 6 jam) 30,000 30,000 60,000 2 120,000

3 UGD
4 Tarif plyanan Rekam Medik di poli Umum Gigi dan KIA 6,000 4,000 10,000 82 820,000
II RAWAT JALN 0
1 pelyanan konsultasi 80,000 12,000 92,000
2 Pemriksaan plyn umum sore hari 6,000 4,000 10,000 0
3 Tarif plyn RM Baru UGD 10,000 5,000 15,000
4 RANAP 0
III Pelyanan Rawat inap
1 tarif atminitrasi RANAP 10,000 5,000 15,000 39 585,000
2 ASKEP/GIZI/PERHARI 30,000 30,000 100 3,000,000
3 AKOMODASI 70,000 70,000 100 7,000,000
4 VISITE 30000 100 3,000,000
PERSALINAN
1 Persalinan dg penyulit 250,000 500,000 750,000 0
Persalinan Normal 200,000 400,000 600,000 2 1,200,000
A TINDAKAN MEDIS RINGAN, terdiri dari
1 luka lecet 4,000 6,000 10,000 0
1 Jht luka s/d 3 8,000 12,000 20,000 3 60,000
2 perwatan luka / tidik 8,000 12,000 20,000 3 60,000
3 pmsngan bidai 8,000 12,000 20,000 0
C TINDAKAN MEDIS SEDANG,terdiri dari 0
1 luka bkr sedang 10,000 15,000 25,000 0
2 Jht luka 4 s/d 7 10,000 15,000 25,000 0
3 incisi abses 10,000 15,000 25,000 0
4 ekstraksi kuku 10,000 15,000 25,000 1 25,000
5 pngambilan benda asing 10,000 15,000 25,000 0
6 psng / buka kateter 10,000 15,000 25,000 1 25000
7 pmasangan infus 10,000 15,000 25,000 41 1,025,000
D TINDAKAN MEDIS BESAR,terdiri dari 0
1 luka bkr berat 15,000 20,000 35,000 0
2 Jht luka lebih dr 7 15,000 20,000 35,000 0
3 pngambilan tumor kecil 15,000 20,000 35,000 0
E TINDAKAN MEDIS KHUSUS 0
1 khitan 50,000 100,000 150,000 1 150,000
2 nebul 40,000 20,000 60,000 1 60,000
Pemasangan implan 10,000 50,000 60,000 0
Pencabutan implan 10,000 50,000 60,000 0
pmasangan iud 10,000 50,000 60,000 1 60,000
3 pngambilan pap smear 10,000 15,000 25,000 0
4 cpw 6,000 8,000 14,000 9 126,000
5 HIV 0 0
6 HBS AG 0 0
7 TINDIK 5,000 5,000 10,000 1 10,000
TINDIK 2 6,000 6,000 12,000 0
VI TINDAKAN MEDIS di POLI GIGI 0
1 Pncbtn gigi sulung dg chlor ethyl 10,000 15,000 25,000 17 425,000
2 pmbrsihn karang gigi 20,000 30,000 50,000 0
3 Pncbtn gigi anterior 10,000 20,000 30,000 1 30,000
4 Pncbtn gigi posterior 10,000 40,000 50,000 0
5 tumpatan gigi sementara 10,000 15,000 25,000 1 25,000
6 tumpatan gigi dg glass ionomer 20,000 30,000 50,000 1 50,000
7 open bur/ bongkar tumpatan 10,000 15,000 25,000 0
Pncbtn gigi sulung(anak)dgn anastesis lokal
8 preijneksi 10,000 30,000
40,000 0
9 Tumpatan gigi dgn komposit 40,000 40,000 80,000 0
10 pengobatan perdarahan dgn tindakan 10,000 15,000 25,000 0
VII PELAYANAN PENUNJANG MEDIK 0
I. LABORATORIUM KLINIK 0
A. HEMATOLOGI 0
1 Darah lengkap metode hematologi analyer (DL) 23,000 12,000 35,000 4 140,000
2 GOLDA 9,000 6,000 15,000 30 450,000
3 haemoglobin 6,000 4,000 10,000 27 270,000
B URINALISA 0
1 reduksi dan protein urine 6,000 4,000 10,000 2 20,000
2 pregnoction plano test 7,000 5,000 12,000 2 24,000
glukosa Darah 0
1 Glukosw BSN/ 2 Jam PP/ Random (GDA) 6,000 4,000 10,000 12 120,000
E Lemak Darah 0
1 cholestherolmeter 9,000 6,000 15,000 0
C faal ginjal 0
1 Urid acidmeter AU 9,000 6,000 15,000 8 120,000
F IMUNOLOGI - SEROLOGI 0
1 WIDAL 8,000 9,000 17,000 0
G PEMERIKSAAN KESEHATAN 0
1 KEUR 4,000 6,000 10,000 23 230,000
pmeriksaan haji thp 1 110,000 40,000 150,000 14 2,100,000
H PEMERIKASAAN 0
1 KORBAN HIDUP (VER) 15,000 30,000 45,000 0
JUMLAH 1,324,000 1,953,000 3,247,000 22,270,000
 REKAP SETOR RETRIBUSI DARI UNIT BULAN JANUARI TAHUN 2020

KOMPONEN TARIF
JML
NO NAMA BENDA BERHARGA JML JML NOMINAL
jasa KELUAR
Jasa Sarana
pelayanan
I UGD

1 Pmrksn kesehatan umum 10,000 10,000 20,000 54 1,080,000

2 pelayanana observasi(maksimum 6 jam) 30,000 30,000 60,000 2 120,000

3 UGD
4 Tarif plyanan Rekam Medik di poli Umum Gigi dan KIA 6,000 4,000 10,000 97 970,000
II RAWAT JALN 0
1 pelyanan konsultasi 80,000 12,000 92,000
2 Pemriksaan plyn umum sore hari 6,000 4,000 10,000 0
3 Tarif plyn RM Baru UGD 10,000 5,000 15,000
4 RANAP 0
III Pelyanan Rawat inap
1 tarif atminitrasi RANAP 10,000 5,000 15,000 51 765,000
2 ASKEP/GIZI/PERHARI 30,000 30,000 129 3,870,000
3 AKOMODASI 70,000 70,000 129 9,030,000
4 VISITE 30000 129 3,870,000
PERSALINAN
1 Persalinan dg penyulit 250,000 500,000 750,000 0
Persalinan Normal 200,000 400,000 600,000 1 600,000
A TINDAKAN MEDIS RINGAN, terdiri dari
1 luka lecet 4,000 6,000 10,000 0
1 Jht luka s/d 3 8,000 12,000 20,000 0
2 perwatan luka / tidik 8,000 12,000 20,000 0
3 pmsngan bidai 8,000 12,000 20,000 0
C TINDAKAN MEDIS SEDANG,terdiri dari 0
1 luka bkr sedang 10,000 15,000 25,000 0
2 Jht luka 4 s/d 7 10,000 15,000 25,000 1 25,000
3 incisi abses 10,000 15,000 25,000 0
4 ekstraksi kuku 10,000 15,000 25,000 0
5 pngambilan benda asing 10,000 15,000 25,000 0
6 psng / buka kateter 10,000 15,000 25,000 1 25000
7 pmasangan infus 10,000 15,000 25,000 53 1,325,000
D TINDAKAN MEDIS BESAR,terdiri dari 0
1 luka bkr berat 15,000 20,000 35,000 0
2 Jht luka lebih dr 7 15,000 20,000 35,000 0
3 pngambilan tumor kecil 15,000 20,000 35,000 0
E TINDAKAN MEDIS KHUSUS 0
1 khitan 50,000 100,000 150,000 0
2 nebul 40,000 20,000 60,000 2 120,000
Pemasangan implan 10,000 50,000 60,000 0
Pencabutan implan 10,000 50,000 60,000 0
pmasangan iud 10,000 50,000 60,000 0
3 pngambilan pap smear 10,000 15,000 25,000 0
4 cpw 6,000 8,000 14,000 9 126,000
5 HIV 0 0
6 HBS AG 0 0
7 TINDIK 5,000 5,000 10,000 2 20,000
TINDIK 2 6,000 6,000 12,000 0
VI TINDAKAN MEDIS di POLI GIGI 0
1 Pncbtn gigi sulung dg chlor ethyl 10,000 15,000 25,000 27 675,000
2 pmbrsihn karang gigi 20,000 30,000 50,000 0
3 Pncbtn gigi anterior 10,000 20,000 30,000 2 60,000
4 Pncbtn gigi posterior 10,000 40,000 50,000 0
5 tumpatan gigi sementara 10,000 15,000 25,000 6 150,000
6 tumpatan gigi dg glass ionomer 20,000 30,000 50,000 2 100,000
7 open bur/ bongkar tumpatan 10,000 15,000 25,000 0
Pncbtn gigi sulung(anak)dgn anastesis lokal
8 preijneksi 10,000 30,000
40,000 0
9 Tumpatan gigi dgn komposit 40,000 40,000 80,000 0
10 pengobatan perdarahan dgn tindakan 10,000 15,000 25,000 0
VII PELAYANAN PENUNJANG MEDIK 0
I. LABORATORIUM KLINIK 0
A. HEMATOLOGI 0
1 Darah lengkap metode hematologi analyer (DL) 23,000 12,000 35,000 3 105,000
2 GOLDA 9,000 6,000 15,000 26 390,000
3 haemoglobin 6,000 4,000 10,000 27 270,000
B URINALISA 0
1 reduksi dan protein urine 6,000 4,000 10,000 4 40,000
2 pregnoction plano test 7,000 5,000 12,000 0
glukosa Darah 0
1 Glukosw BSN/ 2 Jam PP/ Random (GDA) 6,000 4,000 10,000 16 160,000
E Lemak Darah 0
1 cholestherolmeter 11,000 9,000 20,000 2 40,000
C faal ginjal 0
1 Urid acidmeter AU 9,000 6,000 15,000 9 135,000
F IMUNOLOGI - SEROLOGI 0
1 WIDAL 8,000 9,000 17,000 3 51,000
G PEMERIKSAAN KESEHATAN 0
1 KEUR 4,000 6,000 10,000 23 230,000
pmeriksaan haji thp 1 110,000 40,000 150,000 0
H PEMERIKASAAN 0
1 KORBAN HIDUP (VER) 15,000 30,000 45,000 0
JUMLAH 1,326,000 1,956,000 3,252,000 24,352,000

Probolinggo 31 Januari 2020

Bendahara Pembantu Kusus Penerimaan

RENGGO JAJANG SAKSONO

NIP. 198102 32 016011 0001
 REKAP SETOR RETRIBUSI DARI UNIT BULAN FEBRUARI TAHUN 2020

KOMPONEN TARIF
JML
NO NAMA BENDA BERHARGA JML JML NOMINAL
jasa KELUAR
Jasa Sarana
pelayanan
I UGD

1 Pmrksn kesehatan umum 10,000 10,000 20,000 9 180,000

2 pelayanana observasi(maksimum 6 jam) 30,000 30,000 60,000 0

3 UGD
4 Tarif plyanan Rekam Medik di poli Umum Gigi dan KIA 6,000 4,000 10,000 15 150,000
II RAWAT JALN 0
1 pelyanan konsultasi 80,000 12,000 92,000
2 Pemriksaan plyn umum sore hari 6,000 4,000 10,000 0
3 Tarif plyn RM Baru UGD 10,000 5,000 15,000
4 RANAP 0
III Pelyanan Rawat inap
1 tarif atminitrasi RANAP 10,000 5,000 15,000 9 135,000
2 ASKEP/GIZI/PERHARI 30,000 30,000 25 750,000
3 AKOMODASI 70,000 70,000 25 1,750,000
4 VISITE 30000 25 750,000
PERSALINAN
1 Persalinan dg penyulit 250,000 500,000 750,000 0
Persalinan Normal 200,000 400,000 600,000 0
A TINDAKAN MEDIS RINGAN, terdiri dari
1 luka lecet 4,000 6,000 10,000 0
1 Jht luka s/d 3 8,000 12,000 20,000 0
2 perwatan luka / tidik 8,000 12,000 20,000 0
3 pmsngan bidai 8,000 12,000 20,000 0
C TINDAKAN MEDIS SEDANG,terdiri dari 0
1 luka bkr sedang 10,000 15,000 25,000 0
2 Jht luka 4 s/d 7 10,000 15,000 25,000 0
3 incisi abses 10,000 15,000 25,000 0
4 ekstraksi kuku 10,000 15,000 25,000 0
5 pngambilan benda asing 10,000 15,000 25,000 0
6 psng / buka kateter 10,000 15,000 25,000 9 225,000
7 pmasangan infus 10,000 15,000 25,000 0
D TINDAKAN MEDIS BESAR,terdiri dari 0
1 luka bkr berat 15,000 20,000 35,000 0
2 Jht luka lebih dr 7 15,000 20,000 35,000 0
3 pngambilan tumor kecil 15,000 20,000 35,000 0
E TINDAKAN MEDIS KHUSUS 0
1 khitan 50,000 100,000 150,000 0
2 nebul 40,000 20,000 60,000 1 60,000
Pemasangan implan 10,000 50,000 60,000 0
Pencabutan implan 10,000 50,000 60,000 0
pmasangan iud 10,000 50,000 60,000 0
3 pngambilan pap smear 10,000 15,000 25,000 0
4 cpw 6,000 8,000 14,000 5 70,000
5 HIV 0 0
6 HBS AG 0 0
7 TINDIK 5,000 5,000 10,000 0
TINDIK 2 6,000 6,000 12,000 0
VI TINDAKAN MEDIS di POLI GIGI 0
1 Pncbtn gigi sulung dg chlor ethyl 10,000 15,000 25,000 1 25,000
2 pmbrsihn karang gigi 20,000 30,000 50,000 0
3 Pncbtn gigi anterior 10,000 20,000 30,000 1 30,000
4 Pncbtn gigi posterior 10,000 40,000 50,000 0
5 tumpatan gigi sementara 10,000 15,000 25,000 1 25,000
6 tumpatan gigi dg glass ionomer 20,000 30,000 50,000 0
7 open bur/ bongkar tumpatan 10,000 15,000 25,000 0
Pncbtn gigi sulung(anak)dgn anastesis lokal
8 preijneksi 10,000 30,000
40,000 0
9 Tumpatan gigi dgn komposit 40,000 40,000 80,000 0
10 pengobatan perdarahan dgn tindakan 10,000 15,000 25,000 0
VII PELAYANAN PENUNJANG MEDIK 0
I. LABORATORIUM KLINIK 0
A. HEMATOLOGI 0
1 Darah lengkap metode hematologi analyer (DL) 23,000 12,000 35,000 1 35,000
2 GOLDA 9,000 6,000 15,000 2 30,000
3 haemoglobin 6,000 4,000 10,000 4 40,000
B URINALISA 0
1 reduksi dan protein urine 6,000 4,000 10,000 1 10,000
2 pregnoction plano test 7,000 5,000 12,000 0
glukosa Darah 0
1 Glukosw BSN/ 2 Jam PP/ Random (GDA) 6,000 4,000 10,000 1 10,000
E Lemak Darah 0
1 cholestherolmeter 11,000 9,000 20,000 0
C faal ginjal 0
1 Urid acidmeter AU 9,000 6,000 15,000 0
F IMUNOLOGI - SEROLOGI 0
1 WIDAL 8,000 9,000 17,000 1 17,000
G PEMERIKSAAN KESEHATAN 0
1 KEUR 4,000 6,000 10,000 1 10,000
pmeriksaan haji thp 1 110,000 40,000 150,000 0
H PEMERIKASAAN 0
1 KORBAN HIDUP (VER) 15,000 30,000 45,000 0
JUMLAH 1,326,000 1,956,000 3,252,000 4,302,000