Format Clinical Pathway

TARIF BPJS PEMERIKSAAN PENUNJANG TERAPI OBAT YANG DIBERIKAN
NO DIAGNOSA PENYAKIT
LAB RADIOLOGI HARGA
1 2 3 JENIS OBAT JMLH SATUAN
SATUAN
JENIS PEMERIKSAAN HARGA BHP YANG DIGUNAKAN JENIS PEMERIKSAAN HARGA BHP YG DIGUNAKAN
1 APENDISITIS ACUT Hematologi Rutin Rp71,244 THORAX AP Rp25,000

Rp3,907,100 Rp3,348,900 Rp2,790,800 BT Rp15,000 Film ukuran 20 x 25 cm
CT Rp15,000 Amplop Radiologi Kecil
Cefotaxime 2X1 gr 8
Cefixim Tablet 2x200 mg 10

Paracetamol 3 x 500mg 21
Ketorolax Inject 3x30 mg 12
Ranitidin Inject 2x1 ampul 8
inf RL 12
2 BENIGNA PROSTAT HYPERTROPHY Hematologi Rutin Rp71,244 Rontgen Thorax Rp25,000 RL

Rp4,685,400 Rp4,016,000 Rp3,346,700 BT Rp15,000 USG Buli-buli dan Prostat Rp40,000 Vit K 2 x 1 amp 14
CT Rp15,000 Film ukuran 20 x 25 cm Kainex inj 2 x 500 mg / iv 14
Ureum Rp50,770 Amplop Radiologi Kecil Paracetamol 3 x 500mg 21
Kreatinin Rp66,157 Kertas USG Ceftriaxon 2 x 1 gr 14
Jelly USG Cefixim Tablet 2x200 mg 10
Handscoen ketorolac 2x 30mg 14
Map hasil USG NaCL Irigasi 60
3 PERITONITIS DIFUS e.c APENDIK Hematologi Rutin Rp71,244 USG abdomen Rp40,000 IVFD RL
PERFORASI BT Rp15,000 Kertas USG cefotaxime 2x1gr 14
CT Rp15,000 Jelly USG PCT inf 3x1 gr 21
Handscoen Omeprazol 7
Map hasil USG Ranitidin 14
rongent thorax Ketorolac 14
4 CHOLELITHIASIS Hematologi Rutin Rp71,244 USG hepato billiare INF RL

BT Rp15,000 rongent thorax Ceftriaxon 2x1 gr 14
CT Rp15,000 Ondancetron 3x8 mg 21
SGOT Rp33,247 Ketorolac 2x30 mg 14
SGPT Rp33,247 ranitidin 3x1 amp 21

Bilirubin total, Rp41,952
5 STRUMA NODOSA NON TOKSIK Hematologi Rutin Rp71,244 rongent thorax ISTHMO LOBEKTOMI
BT Rp15,000 cefotaxime 2x1gr 8
CT Rp15,000 ketorolac supp 2x1 8
T3,T4,TSHS, dexamethasone 3x1 amp 12
INF RL 12
6 PERITONITIS DIFUSA ET CAUSA Hematologi Rutin Rp71,244 rongent polos abdomen 1 posisi O2
PERFORASI GASTER BT Rp15,000 Inf RL 21
CT Rp15,000 cefriaxone 2x1gr 14
ranitidin 3x1 amp 21
PCT 3x1 gr 21
7 HERNIA INKARSERATA Hematologi Rutin Rp71,244 rongent thorax INF RL

BT Rp15,000 Cefixim Tablet 2x200 mg 10
CT Rp15,000 Paracetamol 3 x 500mg 21
Ketorolax Inject 3x30 mg 12
Ranitidin Inject 2x1 ampul 8
Q Ceftriaxon 2 x 1 g 8
IKAN BMHP RUANG TINDAKAN BMHP RUANG RAWAT INAP KELAS PERAWATAN TOTAL
LAMA
TOTAL PERAWATAN
JENIS BARANG JMLH HARGA SATUAN HARGA JUAL TOTAL HARGA JENIS BARANG JMLH HARGA SATUAN HARGA JUAL TOTAL HARGA 1 2 3 1 2
HARGA
1 4
Bisturi No. 23 & 15 737 Rp848 Kasa Bersih 10 Rp0
Handscoon Steril No. 7 / 7,5 4 12500 Rp14,375 Kasa Steril 10 Rp0
Underpad 1 Rp0 Betadin 100 ML Rp0
Folley Catheter No. 16/18 1 Rp0 Spuit 5 cc 1 Rp0
Urine Bag 1 Rp0 RL 10 botol Rp0
Aqua Bidest 1 Rp0 Hipavix 1 Rp0
Spuit 10cc 1 Rp0 Plester 1 Rp0
NaCl 0,9% 500ml 2 Rp0 Spuit 3 cc 1 Rp0
T-Vio 2-0 1 Rp0 Sofratulle 1 Rp0
Silk 2-0 2 Rp0 Handscoon bersih 3 Pasang Rp0
Chromic 2-0 1 Rp0 Handscoon steril 3 Pasang Rp0
Kasa 30 Rp0 Rp0
Alkohol 30 ML Rp0 Rp0
Betadin 200 ML Rp0 Rp0
Bisturi No. 23/15 1 Rp0 Kasa Bersih 20 Rp0 7
Handscoon Steril No. 7 2 Rp0 Kasa Steril 20 Rp0
Handscoon Steril No. 7,5 2 Rp0 Betadin 200 ML Rp0
Underpad 1 Rp0 Spuit 50 cc 1 Rp0
NaCl 0,9% 500ml 15 Rp0 Spuit 10 cc 1 Rp0
Spuit 50 cc 1 Rp0 Nacl 60 botol Rp0
Spuit 10 cc 1 Rp0 Hipavix 1 Rp0
NGT No. 14/16 1 Rp0 Plester 1 Rp0
Folley Catheter No. 24 & 18 1 Rp0 Spuit 3 cc 1 Rp0
Urine Bag 1 Rp0 Sofratulle 1 Rp0
Blood Set 1 Rp0 Handscoon bersih 7 Pasang Rp0
Surgicryl 1 2 Rp0 Handscoon steril 7 Pasang Rp0
Chromic 2-0 2 Rp0 RL 15 botol Rp0
Silk 2-0 1 Rp0 Rp0
Daclon 2-0 1 Rp0 Rp0
Kasa 30 Rp0 Rp0
Bisturi No. 15 & 23 1 Rp0 Rp0 7
Handscoon Steril No. 7 2 Rp0 Rp0
Handscoon Steril No. 7,5 2 Rp0 Rp0
Underpad 1 Rp0 Rp0
NGT No. 16/18/24 2 Rp0 Rp0
Folley Catheter No 14/16/18 1 Rp0 Rp0
Urine Bag 1 Rp0 Rp0
Aqua Bidest 1 Rp0 Rp0
Spuit 10cc 1 Rp0 Rp0
NaCl 0,9% 500ml 5 Rp0 Rp0
Surgicryl 1 3 Rp0 Rp0
Chromic 2-0 2 Rp0 Rp0
Silk 2-0 2 Rp0 Rp0
Silk 3-0 1 Rp0 Rp0
Kasa 30 Rp0 Rp0
Bisturi No. 15/23 1 Rp0 Kasa Bersih 20 Rp0 7
Folley Cateter no 14/16 1 Rp0 RL 10 Rp0

Urine Bag 1 Rp0 Hipavix 1 Rp0
Spuit 10 cc 1 Rp0 Plester 1 Rp0
Aqua Bidest 1 Rp0 Spuit 3 cc 6 Rp0
NGT No. 14/16/18 1 Rp0 Sofratulle 1 Rp0
Surgicryl 1 2 Rp0 Handscoon bersih 7 Pasang Rp0
Chromic 2-0 2 Rp0 Handscoon steril 7 Pasang Rp0
Silk 2-0 2 Rp0 Rp0
Kasa 30 Rp0 Rp0
Bisturi No. 15/23 1 Rp0 Rp0 4
Handsoon Steril No. 7 2 Rp0 Rp0
Handsoon Steril No. 7,5 2 Rp0 Rp0
Underpad 1 Rp0 Rp0
NGT No. 14/16 1 Rp0 Rp0
Infus Set Macro 1 Rp0 Rp0
Silk 2-0 2 Rp0 Rp0
Kasa 30 Rp0 Rp0
Bisturi No. 15 & 23 1 Rp0 Rp0 7
Handscoon Steril No. 7 2 Rp0 Rp0
Handscoon Steril No. 7,5 2 Rp0 Rp0
Underpad 1 Rp0 Rp0
NGT No. 16/18/24 2 Rp0 Rp0
Folley Catheter No 14/16/18 1 Rp0 Rp0
Urine Bag 1 Rp0 Rp0
Aqua Bidest 1 Rp0 Rp0
Spuit 10cc 1 Rp0 Rp0
NaCl 0,9% 500ml 5 Rp0 Rp0
Surgicryl 1 3 Rp0 Rp0
Silk 2-0 2 Rp0 Rp0
Silk 3-0 1 Rp0 Rp0
Kasa 30 Rp0 Rp0
Bisturi No. 1 Rp0 Kasa Bersih 10 Rp0 4
Folley Cateter no 16/18 1 Rp0 RL 10 botol Rp0
Urine Bag 1 Rp0 Hipavix 1 Rp0
Aqua Bidest 1 Rp0 Plester 1 Rp0
Spuit 10 cc 1 Rp0 Spuit 3 cc 1 Rp0
NaCl 0.9% 500 cc 2 Rp0 Handscoon bersih 3 Pasang Rp0
Hernia Mesh 1 Rp0 Handscoon steril 3 Pasang Rp0
Surgicryl 1 1 Rp0 Alkohol Swab 3 Rp0
Silk 2-0 1 Rp0 Rp0
kasa 20 Rp0 Rp0
betadin 100 ML Rp0 Rp0
TOTAL
3
TARIF BPJS PEMERIKSAAN PENUNJANG
1 2 3 LAB RADIOLOGI
1 BAYI BARU LAHIR Rp6,985,400 Rp5,987,500 Rp4,989,600 DL (Hb, Lt, Leu, Plt) Ro Thorax AP/RLD Rp25,000
GDS Film ukuran 20 x 25 cm
Skirining TSH Rp73,000 Amplop Radiologi Kecil
2 BRONCHOPNEUMONIA PADA ANAK Rp4,665,600 Rp3,999,100 Rp3,332,600 HB Rp15,000 Thorax FOTO Rp25,000
HT Rp15,000 Film ukuran 20 x 25 cm
LEUKO Rp15,000 Amplop Radiologi Kecil
LED
DIFF COUNT
KULTUR DARAH
3 DBD ANAK Rp2,112,800 Rp1,811,000 Rp1,509,200 DL (Hb, Hl, Leu, Plt) Ro Thorax AP/RLD Rp50,000
Ns Antigen Film ukuran 28 x 35 cm
SGOT/SGPT Rp.26.000/Rp. 26.000 Amplop Radiologi Besar
GDS
ELEKTROLIT Rp110,000
AGD Rp330,000
IgG/IgM dengue
4 DEMAM TIFOID PADA ANAK Rp2,929,500 Rp2,511,000 Rp2,092,500 DL FOTO THORAKS Rp50,000
Tubex Rp250,000 FOTO ABDOMEN
Ig M Salmonella Rp150,000 Film ukuran 28 x 35 cm
Fungsi Hati (SGOT/SGPT) Rp.26.000/Rp. 26.000 Amplop Radiologi Besar
5 DIARE AKUT ANAK Rp1,968,700 Rp1,687,500 Rp1,406,200 DL (Hb, Ht, Leu, Plt), DC
Urine Lengkap Rp30,000
Feses Lengkap Rp25,000
Elektrolit Rp110,000
TERAPI OBAT YANG DIBERIKAN BMHP RAWAT INAP BMHP RUANGAN LAINNYA
HARGA TOTAL JENIS

JENIS OBAT JMLH SATUAN JENIS BARANG JMLH HARGA SATUAN HARGA JUAL TOTAL HARGA JMLH HARGA SATUAN TOTAL HARGA
SATUAN HARGA BARANG
IVFD Isotonik (RL, RA )

IM Vitamin K1 1 mg
IM HepB0 0,5cc
Salep Mata
Ampilin Inj 50mg/KBBB/6 jam Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

Cefotaxim inj 50 mg/KBB/5jam Spuit 5 cc 15 Rp968 Rp1,113 Rp16,698
Nebulasi β2 Agonis tiap 8 jam Spuit 3 cc 15 Rp880 Rp1,012 Rp15,180
Cairan maintenance (Kaen 3B/ NACL) Spuit 1 cc 15 Rp907 Rp1,043 Rp15,646
Paracetamol syrup 10 Sarung tangan non steril S/M/L 10 Rp159,500 Rp183,425 Rp1,834,250
ACTUAL Alkohol Swab 10 Rp272 Rp313 Rp3,128
Infusion Set Anak/Dewasa 2 Rp7,128 Rp8,197 Rp16,394
IV Canula Catheter No. 22/24/26 2 Rp4,818 Rp5,541 Rp11,081
Nasal Oxygen Anak 2 Rp7,400 Rp8,510 Rp17,020
IVFD Isotonik (RL, RA) Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

Paracetamol 10-15mg bila suhu > 38c Spuit 5 cc 15 Rp968 Rp1,113 Rp16,698
Spuit 3 cc 15 Rp880 Rp1,012 Rp15,180
Spuit 1 cc 15 Rp907 Rp1,043 Rp15,646
Sarung tangan non steril S/M/L 10 Rp159,500 Rp183,425 Rp1,834,250
Alkohol Swab 10 Rp272 Rp313 Rp3,128
Ciprofloxacin 2x20mg Spuit 10 cc 12 Rp1,287 Rp1,480 Rp17,761

Ceftriaxone 2-3 x 2-4 gr selama 3-5hr Spuit 5 cc 12 Rp968 Rp1,113 Rp13,358
Thiamfenicol 4 x 500mg Spuit 3 cc 12 Rp880 Rp1,012 Rp12,144
Kaen 3B/RL /Dextrosa 5% Spuit 1 cc 12 Rp907 Rp1,043 Rp12,517
Aminofluid Sarung tangan non steril S/M/L 8 Rp159,500 Rp183,425 Rp1,467,400
Ciprofloxacin 2x500mg Alkohol Swab 8 Rp272 Rp313 Rp2,502
cefixim 2x100 mg atau Infusion Set Anak/Dewasa 2 Rp7,128 Rp8,197 Rp16,394
Thiamfenicol 4 x 500mg IV Canula Catheter No. 22/24/26 2 Rp4,818 Rp5,541 Rp11,081
antipiretik / paracetamol bila demam
Anti emetik
Robotina
IVFD Isotonik (RL, RA, HSD) Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

Paracetamol 10 mg Spuit 5 cc 15 Rp968 Rp1,113 Rp16,698
Antibiotik rasional Spuit 3 cc 15 Rp880 Rp1,012 Rp15,180
Oralit Dosis Sesuai Usia Spuit 1 cc 15 Rp907 Rp1,043 Rp15,646
KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
1 2 3 Perina Pediatric ICU ICU HCU 1 2 3
153,000 119,000 81,606 238,000 238,000 238,000 204,000 5
153,000 119,000 81,606 238,000 238,000 238,000 204,000 5
153,000 119,000 81,606 238,000 238,000 238,000 204,000 7
153,000 119,000 81,606 238,000 238,000 238,000 204,000 4
153,000 119,000 81,606 238,000 238,000 238,000 204,000 5

6 KEJANG DEMAM Rp3,535,500 Rp3,030,400 Rp2,525,300 DL (Hb, Ht, Leu, Plt) RoThorax AP/RLD Rp50,000
Urine Lengkap Rp30,000 Film ukuran 28 x 35 cm
GDS Amplop Radiologi Besar
Elektrolit Rp110,000
AGD Sesuai indikasi Rp330,000
Lumbai pungsi
CT Scan Kepala dengan Kontras
7 PNEUMONIA Rp4,665,600 Rp3,999,100 Rp3,332,600 DL (Hb, Ht, Leu, Plt), DC Rp60,000 Ro Thorax AP/Lateral Rp50,000
AGD Rp330,000 Film ukuran 28 x 35 cm
Amplop Radiologi Besar
Zinc Dosis Sesuai Usia Sarung tangan non steril S/M/L 10 Rp159,500 Rp183,425 Rp1,834,250

Paracetamol 10 mg Spuit 5 cc 15 Rp968 Rp1,113 Rp16,698
Antibiotik Rasional Spuit 3 cc 15 Rp880 Rp1,012 Rp15,180
Diazepam 0.2-0.5 mg Spuit 1 cc 15 Rp907 Rp1,043 Rp15,646

Paracetamol 10-15 mg Spuit 5 cc 15 Rp968 Rp1,113 Rp16,698
Ampisilin 200mg Spuit 3 cc 15 Rp880 Rp1,012 Rp15,180
Gentamicin 7,5 mg Spuit 1 cc 15 Rp907 Rp1,043 Rp15,646
153,000 119,000 81,606 238,000 238,000 238,000 204,000 5
153,000 119,000 81,606 238,000 238,000 238,000 204,000 5

LAB RADIOLOGI
HARGA TOTAL
SATUAN HARGA
Sesuai Indikasi Sesuai Indikasi profol 2mg/kg Atrakurium/vekuronium 1

Rocuronium , fentanyl 3 mcg/kg 1
Deksametason 2
Fentanyl 1 mcg/kg / 1 Ampul (2 cc) 1
Anti-emetik : granisetron 1 mg
1 ANASTESI UMUM
Ondansetron 8 mg 1
Analgetik;NSAID (ketorolak/dexketoprofen) 1
Paracetamol iv, Oplod
(Fentanyl/Pethidin/Morphin/ Termadol)Durogesic
Patch 1
Ringer Lactat /Koloid 2
Anestesi lokal: Bupivakain heavy 1 Amp,

1
Sesuai indikasi Sesuai indikasi
Fentanyl 1 ampul 1
AntiGemetik:granisetron 1mg/ 1
Ondansetron 8 mg 1
ANESTESI REGIONAL
2 Analgetik; NSAID (ketorolak/dexketoprofen)/
SPINAL 1
Parasetamol iv, Opiod (Fentanyl/Pethidin/
Morphin/Tramadol),Durogesic patch
Sesuai indikasi Sesuai indikasi Anestesi lokal:Lidokain 1% 3 amp, Bupivakain 1

0,5% Isobarik/Ropivakain 0,75% 1vial, 1
Fentanyl 1 amp
Bupivakain 0,5%isobarik/Ropivakain 1
ANESTESI REGIONAL
3 Analgetik; NSAID (ketorolak/dexketoprofen)/ 1
EPIDURAL
Parasetamol iv, Opiod (Fentanyl/Pethidin/ 1
Morphin/Tramadol),Bupivakain 0,5% isobarik/ 1
Ropivakain 0,75%
Sesuai indikasi Sesuai indikasi Anestesi lokal:Lidokain 1% 3 amp, Bupivakain 1

Bupivakain hiperbarik 1 ampul 1
ANESTESI REGIONAL Analgetik; NSAID (ketorolak/dexketoprofen)/ 1
4 KOMBINASI Parasetamol iv, Opiod (Fentanyl/Pethidin/ 1
SPINAL- EPIDURAL Morphin/Tramadol),Bupivakain 0,5% isobarik/
Ropivakain 0,75%
Anestesi lokal:Lidokain 1% 3 amp, Bupivakain 1

COMBINE EPIDURAL- Propofol 2mg/kg, Atrakurium/vekuronium/ 1
GENERAL Rocuronium, Fentanyl 3 mcg/kg 1
5
ANESTHESIA Bupivakain 0,5%isobarik/Ropivakain 0,75 1
(CEGA) Atrakurium/vekuronium/Rocuronium 1
Fentanyl 1 mcg/kg
Analgetik; NSAID (ketorolak/dexketoprofen)/ 1
Morphin/Tramadol),Bupivakain 0,5% isobarik/ 1
Ropivakain 0,75%
Sesuai indikasi Sesuai indikasi Anestesi lokal: Bupivakain 0,5%/

Lidocain HCl 3
Ropivakain 0,75% 2 vial, Fentanyl 1 amp.
Anti-emetik:granisetron 1mg/
ANESTESI BLOK Ondansetron 8 mg 1
6 SARAF
TEPI Analgetik; NSAID (ketorolak/dexketoprofen)/ 1
ANESTESI BLOK
6 SARAF
TEPI
Morphin/Tramadol),Durogesic patch
Infus set, kateter iv, spuite 3,10 cc 1

Propofol/midazolam/ketamin/dexmedetomidin 1
inkremental
Fentanyl 2 mcg/kg 1
SEDASI SEDANG - Anti-emetik: Granisetron 1x1mg/Primperan 3x10mg,
7
DALAM
Obat emergensi: Adrenalin, noradrenalin,SA,efedrin
1
8 CLINICAL PATHWAY ACUTE - - -

RESPIRATORY DISTRESS
SYNDROME (ARDS)
CLINICAL PATHWAY
9 SEPSIS BERAT - - -
DAN SYOK SEPTIK
CLINICAL PATHWAY
10 SEPSIS BERAT DAN - - -
SYOK SEPTIK
Magnesium sulfat bolus intravena 4 g dalam 20 menit

CLINICAL PATHWAY PRE
11 EKLAMPSIA BERAT, - -
EKLAMPSI,
DAN SINDROM HELLP
Magnesium sulfat infusi 1 g/jam selama 24 jam
Nicardipine 0.15 mg/kgBB/jam titrasi dengan target penurunan TD 15W25%
Bila edema paru: Furosemide 1W2mg/kgBB iv bolus
Bila kejang lagi MgSO4 bolus intravena 2 g
Magnesium sulfat infusi 1 g/jam selama 24 jam
Nicardipine 0.15 mg/kgBB/jam titrasi dengan target TD 140/90 mmHg
Transfusi Trombosit bila Trombosit <20000/ul
Furosemide 1W2 mg/kgBB iv bolus
Nicardipine 0.15 mg/kgBB/jam titrasi dengan target TD 140/90 mmHg
Furosemide 1W2 mg/kgBB iv bolus
12 CLINICAL PATHWAY GAGAL - - -

NAPAS AKUT KARENA
PNEUMONIA BERAT
(ec. Bacterial)
ICD * 10:E.87.5 CLINICAL

13 PATHWAY GANGGUAN - - -
HIPERKALEMIA
14 ICD * 10:E.87.6 CLINICAL - - -

PATHWAY HIPOKALEMIA

15 PATHWAY - - -
HIPERNATREMIA
16 ICD * 10:E.87.1 CLINICAL - - -

PATHWAY HIPONATREMIA
17 - - -
PATHWAY HIPERKALSEMIA
18 - - -
PATHWAY HIPOKALSEMIA
19 CD * 10:E. 83.41 CLINICAL - - -

PATHWAY
HIPERMAGNESEMIA
20 ICD - 10:E.83.42 CLINICAL - - -

PATHWAY
HIPOMAGNESEMIA
ICD * 10 R 57.1 CLINICAL

21 PATHWAY SYOK - - -
HIPOVOLEMIK
Gula darah sewaktu
ICD210: G 46 CLINICAL
PATHWAY PASIEN
22 PERDARAHAN - -
INTRA SEREBRAL (PIS) DAN
PERDARAHAN
SUBARAKHNOID
(PSA)
Natrium, Kalium, Klorida,
Kalsium, Magnesium serum
4mcg/kgBB /jam, atau Morphine
CLINICAL PATHWAYS
23 INTRACRANIAL INJURY - -
(ICD 10: S.06)
1-2 mg/jam Midazolam 0,05-0,1mg/kgB B/jam
Amikasin 1 x 1g
Meropenem 3 x 1g
Omeprazole 2 x 40 mg
NaCl 0,9% nebul
Heparin 2 x 5000 Unit
Flucon azole 1x400 mg,
Mycaf ungin 2x50m
g/Anid in 1x100 mg
ICD 10. k92.2 : CLINICAL

24 PATHWAY PERDARAHAN - - -
SALURAN CERNA ATAS
ICD 10. k92.2 : CLINICAL

25 PATHWAY PERDARAHAN - - -
SALURAN CERNA BAWAH
BMHP RUANGAN LAINNYA BMHP RUANG RAWAT INAP KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
JENIS BARANG JMLH HARGA SATUAN HARGA JUAL TOTAL HARGA JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 Perina Pediatric ICU ICU HCU 1 2 3
ETT 7.0/7.5 1 Rp22,880 Rp26,312

catheter suction dewasa ( Hijau) 1 Rp7,260 Rp8,349
Spuit 3 cc 2 Rp880 Rp1,012
Spuit 10 cc 2 Rp1,287 Rp1,480
Mayo 9/10 1 Rp0
BMHP
SpinAL NEEDLE 26 dan 27 1 Rp15,000 Rp17,250
Handscon 7/7,5 1 Rp12,500 Rp14,375
Metoclopramid 1 Rp0
2
Spuit 3 cc
1
Spuit 5 cc
Spuit 10 cc 2
1
sarung tangan steril
LAB RADIOLOGI
HARGA TOTAL
SATUAN HARGA
Darah Rutin Rp71,244 USG OBSTETRI ceftriaxone 6
Golongan Darah Rp15,000 EKG bila perlu ranitidine 1
Pemeriksaan LAB lain bila ada Pemeriksaan lain bila ondansentron 1
indikasi ada indikasi asam traneksamat 2
adona 2
oxytoxin 5
methergin 2
misoprostol 4
cefixime 10
pct 10
DELEVERY BY CAESAREAN fe 10
1
SECTION, UNSPECIFIED ringer laktat
2 PREMATURE RUPTURE OF Darah Rutin Rp71,244 USG OBSTETRI ceftriaxone

MEMBRANES , UNSPECIFIED Golongan Darah Rp15,000 EKG bila perlu dexamethason
Pemeriksaan LAB lain bila ada Pemeriksaan lain bila ringer laktat
indikasi ada indikasi oxytoxin
methergin
misoprostol
cefixime
pct
fe
3 OTHER SPECIFIED ASSISTED Darah Rutin Rp71,244 USG OBSTETRI

SINGLE DELIVERY Golongan Darah Rp15,000 EKG bila perlu
Pemeriksaan LAB lain bila ada Pemeriksaan lain bila
indikasi ada indikasi
4 OTHER UTERINE INERTIA Darah Rutin Rp71,244 USG OBSTETRI

Golongan Darah Rp15,000 EKG bila perlu
5 LOBOUR AND DELIVERY Darah Rutin Rp71,244 USG OBSTETRI
COMPLICATED BY FETAL Golongan Darah Rp15,000 EKG bila perlu
STRESS, UNSPECIFIED
KTG
6 MATERNAL CARE DUE TO Darah Rutin Rp71,244 USG OBSTETRI

UTERINE SCAR FROM Golongan Darah Rp15,000 EKG bila perlu
PREVIOUS SURGERY
7 INCOMPLATE, WITHOUT Darah Rutin Rp71,244 USG OBSTETRI

COMPLICATION Golongan Darah Rp15,000 EKG bila perlu
8 SEVERE PRE-ECLAMPSIA Darah Rutin Rp71,244

Golongan Darah Rp15,000
Rp30,000
protein urin
Pemeriksaan LAB lain bila ada
indikasi
9 MATERNAL CARE FOR Darah Rutin Rp71,244
DISPROPORTION, Golongan Darah Rp15,000
UNSPECIFIED
indikasi
10 MATERNAL CARE FOR Darah Rutin Rp71,244

TRANSVERSE AND OBLIQUE Golongan Darah Rp15,000
LIE
indikasi
1 HIPEREMESIS GRAVIDARUM Rp2,799,800 Rp2,399,800 Rp1,999,800 Darah Rutin Rp71,244 USG Obseteri neurobion dalam 50 cc RL 1 ampul
Golongan Darah Rp15,000 Ondansetron 3x4 mg
Ketonuria Rp30,000 Ranitidine 3 x 25 mg
Pemeriksaan LAB lain bila ada RL
indikasi Pan Amin G
KA- EN MG3
Antasid Syr 3 x 1
2 KEHAMILAN DENGAN GAMELI Rp7,142,800 Rp6,122,400 Rp5,102,000 Darah Rutin Rp71,244 USG Obseteri Antibiotik spektrum luas
(Dengan tindakan SC) Golongan Darah Rp15,000 Dexametason
Pemeriksaan LAB lain bila ada RL
indikasi NaCL
3 ABORTUS Rp2,320,000 Rp1,988,600 Rp1,657,100 Darah Rutin Rp71,244 USG Obseteri Antibiotik Spektrum luas
(Dengan Kuret) Golongan Darah Rp15,000 RL
Pemeriksaan LAB lain bila ada NaCL
indikasi Misoprostol
Oksitosin 2 ampul dalam 500cc RL
4 PREEKLAMSIA BERAT Rp2,799,800 Rp2,399,800 Rp1,999,800 Darah Rutin Rp71,244 USG Obseteri MgSO4 40% 4 gram dalam 100 cc RL
Golongan Darah Rp15,000 MgSO4 40% 6 gram dalam 500 cc RL
protein urin Rp30,000 Antibiotik Spektrum Luas
Pemeriksaan LAB lain bila ada Dexametason
indikasi Furosemid
Ca Glukonas 10%
RL
NaCL
5 KETUBAN PECAH DINI Rp6,762,300 Rp5,796,300 Rp4,830,200 Darah Rutin Rp71,244 USG Obseteri Antibiotik Spektrum luas
(Dengan SC) Golongan Darah Rp15,000 Dexametason
Lakmus SC
indikasi
6 Rp6,762,300 Rp5,796,300 Rp4,830,200 Darah Rutin, Rp71,244 USG Cefazolin Inj 2-3 x1gr atau
PLASENTA PREVIA TOTALIS
BT/CT Rp.15.000/Rp.15.000 CTG Cefotaxim Inj 2 x 1 gr
PADA KEHAMILAN ATERM
GDS SGOT/PT 34.404 / 33.427 / 33.427 Tramadol/Ketorolak/ Kaltropen
Pemeriksaan LAB lain bila ada Cairan kristaloid / RL
indikasi Sulfas Ferosus 1 x 360mg PO
Cepadroxil 3 x 500
B Complex 2 x 1
Asam Mefenamat 3x 500 mg PO
B Complex 2 x 1
Sulfas Ferosus 1 x 360 mg PO
B Complex 2 x 1
Asam Mefenamat 3x 500 mg PO/ Tramadol PO
Cefadroxil 3 x 1 Tab Cefixim
7 ABORTUS IMMINENS Rp1,728,000 Rp1,481,200 Rp1,234,300 tes hamil Rp15,000

darah rutin Rp71,244
gol darah (bila belum pernah)
HBSAG (bila belum di PKM)
HIV (bila belum di PKM)
sifilis (bila belum di PKM)
BMHP RUANG TINDAKAN BMHP RUANG RAWAT INAP KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 Perina Pediatric ICU ICU HCU 1 2 3
infuseth kassa
transfusi set perban anti air
abocath bethadine
threeway spuit 5 ml
folley kateter spuit 10 ml
urin bag sarungtangan bersih
spuit 1 ml
spuit 3 ml
spuit 5 ml
spuit 10 ml
sarung tangan bersih
kassa
bethadine
alkohol
T-VIO 1
T-VIO 2
T-VIO 3
spinocain
bisturi
leukomed
underpad
infuseth kassa
leukomed perban anti air
abocath bethadine
threeway spuit 5 ml
folley kateter spuit 10 ml
urin bag sarungtangan bersih
spuit 1 ml
spuit 3 ml
spuit 5 ml
spuit 10 ml
sarung tangan bersih
kassa
bethadine
underpad
153,000 119,000 81,606 238,000 238,000 238,000 204,000 3
Sarung tangan steril 3 153,000 119,000 81,606 238,000 238,000 238,000 204,000 3
T-vio 1 2
T-vio 2 1
T-vio 3 1
PostoFik 1
Nurse Cup 3
Apron 3
Alkohol 100 ML
Betadin 300 ML
Bisturi 23/24 1
Under Pad 1
kasa 40
Sarung Tangan Steril 2 153,000 119,000 81,606 238,000 238,000 238,000 204,000 3
Betadin 100 ML
Kasa 10
Under Pad 1
T-vio 1 2
T-vio 2 1
T-vio 3 1
PostoFik 1
Nurse Cup 3
Apron 3
Alkohol 100 ML
Betadin 300 ML
Bisturi 23/24 1
Under Pad 1
kasa 40
T-vio 1 2
T-vio 2 1
T-vio 3 1
PostoFik 1
Nurse Cup 3
Apron 3
Alkohol 100 ML
Betadin 300 ML
Bisturi 23/24 1
Under Pad 1
kasa 40
T-vio 1 2
T-vio 2 1
T-vio 3 1
PostoFik 1
Nurse Cup 3
Apron 3
Alkohol 100 ML
Betadin 300 ML
Bisturi 23/24 1
Under Pad 1
kasa 40
Sarung Tangan Steril 2

Betadin 100 ML
Kasa 10
Under Pad 1
LAB RADIOLOGI
HARGA
SATUAN
1 ERITRODERMIA Rp3,060,600 Rp2,623,400 Rp2,186,200 Hematologi rutin Rp50,000 Thorax PA Rp25,000 IVFD / NaCL 3
SGOT Rp26,000 EKG O2 2 liter / Menit (Tentatif)
SGPT Rp26,000 Film ukuran 20 x 25 cm Kortikosteroid Topikal 1
Ureum Rp24,000 Amplop Radiologi Kecil Oleum olivarum / pelembab 29 gr
Kreatinin Kasa Steril 1 box
Elektrolit Na/K Rp110,000 NaCL 100ML 1
GD 2 Jam PP Rp21,500 Plester 10 cm
GD sewaktu Rp21,500
Albumin Rp24,000
Globulin Rp24,000
Protein total Rp24,000
Sel sezary
Urin Rutin Rp20,000
2 ERUPSI OBAT Rp3,060,600 Rp2,623,400 Rp2,186,200 Hematologi rutin Rp50,000 Thorax PA Rp25,000 Infus NaCl 1500cc /24 jam 3
EKSANTEMATOSA/ SGOT Rp26,000 Kortikosteroid topikal 1
MORBILIFORMIS SGPT Rp26,000 Soft tissue leher (bila ada amgioedema) Bedak Salisil 2% 10 gr
Ureum Rp24,000 EKG Ranitidin 2x50mg 1
Kreatinin Rp24,000 Film ukuran 20 x 25 cm
BJ Plasma Amplop Radiologi Kecil
Elektrolit Na/K Rp110,000
GD sewaktu Rp21,500
Kompres NaCl 0,9% (Bila Lesi

3 Rp3,613,100 Rp3,096,100 Rp2,580,100 Hematologi rutin Rp50,000 Bila usia > 50 tahun 100 ML
Kotor)
HERPES ZOSTER SGOT Rp26,000 Foto thorax Rp25,000 Pemeriksaan Tzank smear
OPTALMIKUS TANPA Bedak Salisilat 2% (bila lesi
SGPT Rp26,000 EKG 10 gr
KOMPLIKASI kering)
Ureum Rp24,000 Film ukuran 20 x 25 cm Krim Gentamisin sulfat 0,1% 2.5 gr
Kreatinin Rp24,000 Amplop Radiologi Kecil Asiklovir 5 x800mg atau 10 mg
GD 2 Jam PP Rp21,500 Kasa Steril 1 box
GD Sewaktu Rp21,500 Asam Mefenamat 3 x 500 mg 3
Metilpredinsolon 2 x 8mg (Bila
tidak ada Kontraindikasi) 2
Cendo lytrees (mata) 1
Plester 10 cm
LAMA
PERAWATAN
TOTAL
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 Perina Pediatric ICU ICU HCU 1 2 3
HARGA
Abocath 1 153,000 119,000 81,606 238,000 238,000 238,000 204,000 7 Hari

Infus Set 1
Alcohol Swab 1
Kassa Steril 1
Handscoon 1
Plester 25 cm
Abocath 1 9 Hari
Infus Set 1
Alkohol Swab 1
Kassa Steril 1
Plester 25 cm
7 Hari
LAB RADIOLOGI
HARGA TOTAL
SATUAN HARGA
hari rawat 1
1 KATARAK + MIOPIA GRAVIOR Rp3,612,100 Rp3,096,100 Rp2,580,100 LABORATORIUM MAC USG Tropicamide 1 % topikal
EKG Phenylefrine 2,5 %/10% topikal
Lovofloksasin topiKal
hari rawat 2
Prednisolon asetat topiKal 6x1 gtt
Levofloksasin topikal 6x1 gtt
Siprofloksasin oral 2x500 mg
Siloxan topikal 3x1 gtt
hari rawat 1
2 KATARAK SENILIS IMATUR + Rp3,612,100 Rp3,096,100 Rp2,580,100 LABORATORIUM KHUSUS : USG Tropicamide 1 % topikal
DIABETES MILTUS TIPE II
GD puasa Rp34,404 EKG Phenylefrine 2,5 %/10% topikal
GD 2jPP Rp34,404 Lovofloksasin topiKal
HbA1C Rp504,782 Ketorolac/nepavenac topikal
LABORATORIUM MAC : hari rawat 2
Hematologi Rutin Rp71,244 Prednisolon asetat topiKal 6x1 gtt
GDS Rp34,404 Levofloksasin topikal 6x1 gtt
BT- Rp15,000 Siprofloksasin oral 2x500 mg
CT Rp15,000
ur-kreat 50.770/66.157
SGOT- Rp33,247
SGPT Rp33,247
urin lengkap Rp30,000
hari rawat 1
KATARAK SENILIS IMATUR +
3 DIABETES MILTUS TIPE II LABORATORIUM KHUSUS : EKG Tropicamide 1 % topikal
GD puasa Rp21,500 Phenylefrine 2,5 %/10% topikal

GD 2jPP Lovofloksasin topiKal
HbA1C Rp94,000 Ketorolac/nepavenac topikal
LABORATORIUM MAC : hari rawat 2
Hematologi Rutin Rp71,244 Prednisolon asetat topiKal 6x1 gtt
GDS Rp34,404 Levofloksasin topikal 6x1 gtt
BT- Rp15,000 Ciprofloxacin oral 2x500mg
CT Rp15,000
ur-kreat 50.770/66.157
SGOT- Rp33,247
SGPT Rp33,247
urin lengkap Rp30,000
hari rawat 1
Tlmolol maleat 0,5% ed 2x1/
4 Primary Open Angie Glaucoma Pemeriksaan Laboratorium persiapan operasi betaksolol 0,5% ed 2x1/ Carteolol 1%
Uncontrolled Rp3,612,100 Rp3,096,100 Rp2,580,100 ed 2x1
Acetazolamide tab 3 x 250 mg
Kalium suplement tab 1x1
latanoprost 0,005% ed 1x1 / tavoprost
0,004% ed 1x1 / tafluprost 0,0015%
ed 1x1
Dorzolamide 2% ed 3x1 /
Brinzolamide 1% ed 3x1
Brimonidine ed 3x1
Tlmolol maleat 0,5% + latanoprost
0,005% ed 1x1
Tlmolol maleat 0,5% + tavoprost
0,004% ed 1x1
Tlmolol maleat 0,5% + brinzolamide
1% ed 2x1
Giserol 50% 50cc 1x1
hari rawat 2
manitol 20% 5ml/kgBB IV bila TIO pre

operasi > 30 mmHg dan tidak ada
kontraindikasi pemberian manitol
Terapi pascaoperasi :
- Predinisolone acetate ed 6x1
- Ofloxacyn ed 6x1 / levofloxacyn ed 6x1
- Ciprofloxacin 2x500 mg
- NSAID oral 2x50 mg
- Antibiotik + steroid eo 3x1
hari rawat 3
Predinisolone acetate ed 6x1
Ofloxacyn ed 6x1
Ciprofloxacin 2x500 mg
NSAID oral 2x50 mg
Antibiotik + steroid eo 3x1
bila TIO pascaoperasi (setelah
massage) antara 16 mmHg sampai 25
mmHg diberikan satu macam obat
hipotensive agent
mmHg diberikan dua macam obat
hipotensive agent
hari rawat 1
Primary Angle Closure/Chronic Tlmolol maleat 0,5% ed 2x1/

5 USG betaksolol 0,5% ed 2x1/ Carteolol 1%
Angle Closure Glaucoma
Rp3,612,100 Rp3,096,100 Rp2,580,100 ed 1x1
Acetazolamide tab 3 x 250 mg
Kalium suplement tab 1x1
latanoprost 0,005% ed 1x1 / tavoprost
0,004% ed 1x1 / tafluprost 0,0015%
ed 1x1
Dorzolamide 2% ed 3x1 /
Brinzolamide 1% ed 3x1
Brimonidine ed 3x1
Tlmolol maleat 0,5% + latanoprost
0,005% ed 1x1
Tlmolol maleat 0,5% + tavoprost
0,004% ed 1x1
Tlmolol maleat 0,5% + brinzolamide
1% ed 2x1
Giserol 50% 50cc 1x1
hari rawat 2
Manitol 20% 5ml/kgBB IV bila TIO pre

operasi > 35 mmHg dan tidak ada
kontraindikasi pemberian manitol
Terapi pascaoperasi :
- Predinisolone acetate ed 6x1
- Ofloxacyn ed 6x1 / levofloxacyn ed 6x1
- Ciprofloxacin 2x500 mg
- NSAID oral 2x50 mg
- Antibiotik + steroid eo 3x1
- Siloxan ed 3x1
hari rawat 3
Predinisolone acetate ed 6x1
Ofloxacyn ed 6x1
Ciprofloxacin 2x500 mg
NSAID oral 2x50 mg
Antibiotik + steroid eo 3x1
Siloxan ed 3x1
mmHg diberikan satu macam obat
hipotensive agent
mmHg diberikan dua macam obat
hipotensive agent
terapi pasca operasi hari rawat 2

Pemeriksaan Laboratorium persiapan operasi Kloramfenikol + Dexamethason tetes
6 Pterigium Grd. 3/4/ Double Head Rp3,612,100 Rp3,096,100 Rp2,580,100 EKG mata
Amoxicilin tablet 3x500 mg
Asam Mefenamat tablet 3x500 mg
hari rawat 1
Vulnus Laceratum Kornea
7 dengan tindakan penjahitan Rp9,006,300 Rp7,719,600 Rp6,433,000 Lab darah lengkap (skrining narkose umum) EKG Cefotaxim 2x1 gr IV (skintest dahulu)
primer
thorax 25000 Asam Mefenamat tablet 3x500 mg
USG mata injeksi ATS/TT
Film ukuran 20 x 25 cm hari rawat 2
Amplop Radiologi Kecil tetes mata antibiotik spektrum luas
tetes mata prednisolone acetate 6x1
tetes (apabila KOH-)
tetes mata cycloplegik 3x1 tetes
Analgetik oral (asam mefenamat),
sesuai klinis
Cefotaxim 2x1 gr IV
hari rawat 3
tetes mata antibiotik spektrum luas
tetes mata prednisolone acetate 6x1
tetes (apabila KOH-)
tetes mata cycloplegik 3x1 tetes
Analgetik oral (asam mefenamat),
sesuai klinis
hari rawat 1
8 Optic Neuritis Tipikal/Atipikal Rp3,063,700 Rp2,626,000 Rp2,188,400 GDS Rp34,404 Thorax 25000 Methylprednisolon 250 mg IV (per 6 jam)
Film ukuran 20 x 25 cm Ranitidin 1 amp IV (per 12 jam)
Amplop Radiologi Kecil Mecobalamin 1 amp IV
suplemen vit D dan kalsium
hari rawat 2
Methylprednisolon 250 mg IV (per 6 jam)
Ranitidin 1 amp IV (per 12 jam)
Mecobalamin 1 amp IV
hari rawat 3
hari rawat 4
Diberikan setelah IV selesai :
Methylprednisolon 1mg/Kg BB (p.o)
Ranitidin 2 x 150 mg (p.o)
Mecobalamin 1 x 250 mg (p.o)
hari rawat 1
Non Artheritic Ischemic Optic Methylprednisolon 250 mg IV (per 6
9 GDS Rp34,404
Neuropathy jam)
darah rutin Rp71,244 Ranitidin 1 amp IV (per 12 jam)
profil lipid (CHOL-TG) 48.741 / 52.377 Mecobalamin 1 amp IV
GDP Rp34,404 suplemen vit D dan kalsium
GD2PP Rp34,404 hari rawat 2
HbA1C Rp504,782 Methylprednisolon 250 mg IV (per 6 jam)
hari rawat 3
hari rawat 4
hari rawat 2
10 Entroplon Rp3,612,100 Rp3,096,100 Rp2,580,100 Laboratorium (umum) EKG pasca bedah :
Rontgen Thorax PA 25000 Antibiotik oral (tgt riw alergi)
Film ukuran 20 x 25 cm NSAID/steroid (tgt kondisi)
Amplop Radiologi Kecil AB salep mata 3x
hari rawat 1
11 AFAKIA Rp3,612,100 Rp3,096,100 Rp2,580,100 Tropicamide 1 % topikal
Phenylefrine 2,5 %/10% topikal
Lovofloksasin topiKal
hari rawat 2
Prednisolon asetat topiKal 6x1 gtt
Levofloksasin topikal 6x1 gtt
Siprofloksasin oral 2x500 mg
LAMA
PERAWATAN
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 1 2 3
MST 1
MSL 1
MSU 1
Bioflex 1
Io gel 1
Io Blue 1
Io Chol 1
Infusion Set 1
RL 1
Gentamicin 1
Dispo 5 cc 1
Dispo 1 cc 2
Dispo 10 cc 4
Dispo 3 cc 1
Adrenalin Amp 1
Lidocaen 1
Cefuroxime 1
sarung tangan steril 3
MST 1
1
MSL
MSU 1
Bioflex 1
Io gel 1
Io Blue 1
Io Chol 1
Infusion Set 1
RL 1
Gentamicin 1
Dispo 5 cc 1
Dispo 1 cc 2
Dispo 10 cc 4
Dispo 3 cc 1
Adrenalin Amp 1
Lidocaen 1
Cefuroxime 1
1
MST
MSL 1
MSU 1
Bioflex 1
Io gel 1
Io Blue 1
Io Chol 1
Infusion Set 1
RL 1
Gentamicin 1
Dispo 5 cc 1
Dispo 1 cc 2
Dispo 10 cc 4
Dispo 3 cc 1
Adrenalin Amp 1
Lidocaen 1
Cefuroxime 1
1
RL
Infus Set 1
Dispo 3cc 1
1
Dispo 10 cc
1
Cefuroxime
Lidocaen 1
1
MCU (cresent 26 )
1
MST ( Straigh 16 )
1
Ethylon 10.0
1
RL
Infus Set 1
Dispo 3cc 1
1
Dispo 10 cc
1
Cefuroxime
Lidocaen 1
1
MCU (cresent 26 )
1
MST ( Straigh 16 )
1
Ethylon 10.0
1
RL
INfusion Set 1
SArung Tangan steriil 1
Ethylon 10.0
lidocaen 1
dispo 1 cc 1
1
RL
INfusion Set 1
SArung Tangan steriil 1
lidocaen 1
dispo 1 cc 1
1
Nylon 10.0
dispo 10 cc 1
1
MCU
RL 1
Infus Set 1
Sarung Tangan steril 3
Lidocaen 1
Straight 1
Surgical blade no 11 1
Prolen 6.0 1
softpad 1
MST 1
MSL 1
MSU 1
Io gel 1
Io Blue 1
Io Chol 1
Infusion Set 1
RL 1
Gentamicin 1
Dispo 5 cc 1
Dispo 1 cc 2
Dispo 10 cc 4
Dispo 3 cc 1
Adrenalin Amp 1
Lidocaen 1
Cefuroxime 1
LAB RADIOLOGI
HARGA TOTAL
SATUAN HARGA
1 AFAKIA Hematologi Rutin Rp71,244 USG B Scan Ciprofloxacin tablet 10
Kadar Gula Darah Sewaktu (GDS) Rp34,404 USG Biometri Na diclofenac tablet 10
Ureum Rp50,770 Ro Thorax Rp 25,000 Dexamethasone+Neomycin 1

sulfat+Polimixin B sulfat tetes mata
Kreatinin Rp66,157 tropicamide tetes 1
Plasma Prothrombin Time (PTT) Rp75,000 tetracaine hcl tetes 1
Partial Thromboplastin Time with Kaolin Rp45,000
2 GLAUKOMA Hematologi Rutin Rp71,244 Tonometri Ciprofloxacin tablet 10
Kadar Gula Darah Sewaktu (GDS) Rp34,404

Ureum Rp50,770 Funduskopi Na diclofenac tablet 10
Dexamethasone+Neomycin
Kreatinin Rp66,157 Ro Thorax Rp 25,000 1
Plasma Prothrombin Time (PTT) Rp75,000 Timolol maleat 0.5% tetes mata 1
3 KATARAK SENILIS MATUR Hematologi Rutin Rp71,244 USG B Scan Ciprofloxacin tablet 10
Ureum Rp50,770 Ro Thorax Rp 25,000 1
4 KELAINAN REFRAKSI - Autorefraksi Artificial tears 1
tropicamide tetes 1
5 KERATITIS Hematologi Rutin Rp71,244 - levofloxacin tetes mata 1

Kadar Gula Darah Sewaktu (GDS) Rp34,404 acyclovir tablet 50
prednisolon acetat tts 1
6 KONJUNGTIVITAS Pemeriksaan mikro organisme dari kerokan Levofloxacin tetes mT 1

konjungtiva atau getah mata artificial tears 1
Pemeriksaan sel-sel eosinofil pada konjungtivitis alergi ceftriaxone iv 6
7 KATARAK SINILIS IMATUR Hematologi Rutin Rp71,244 USG B Scan Ciprofloxacin tablet 10
Ureum Rp50,770 Ro Thorax Rp 25,000 sulfat+Polimixin B sulfat tetes mata 1

8 PSEUDOKAFIA Hematologi Rutin Rp71,244 USG B Scan Ciprofloxacin tablet 10
Ureum Rp50,770 Ro Thorax Rp 25,000 Dexamethasone+Neomycin sulfat+Polimixin B 1
Kreatinin Rp66,157
Plasma Prothrombin Time (PTT) Rp75,000
9 PTERIGIUM Hematologi Rutin Rp71,244 Ro Thorax Rp 25,000 Ciprofloxacin tablet 10

Kadar Gula Darah Sewaktu (GDS) Rp34,404 Na diclofenac tablet 10
Dexamethasone+Neomycin 1
tetracaine hcl tetes 1
10 UVEITIS Darah Lengkap, LED, Rheumatoid Factor, Autoimun Rontgen thorax Rp 25,000 methylprednisolon tappering off tablet 30
Kadar Gula Darah Sewaktu (GDS) Rp34,404 USG Biomikroskop prednisolon acetat tetes mata 1
siklopentolat tetes mata 1
11 ULKUS KORNEA Pemeriksaan mikro organisme dari kerokan kornea USG biomikroskopi gatifloxacine tetes mata 1
Hematologi Rutin Rp71,244 Ro thorax Rp 25,000 natamisin tetes mata 1
Kadar Gula Darah Sewaktu (GDS) Rp34,404 siklopentolat tetes mata 1
ketokonazole 300mg tablet 10
ciprofloxacib 500 mg tablet 10
LAMA
PERAWATAN
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 1 2 3
Spuit 1 cc 5 infus set 1

Spuit 10 cc 7 RL 1
Spuit 3 cc 1
Spuit 5 cc 1
Infus RL 1
RL 1
Handscoon 3
Infus set dewasa 1
Pisau straight 15 stab 1
Pisau crescent 1
Pisau slit angled 1
Lidocain 1
Gentamycin 1
Adrenalin 1
Viscoelastic 1
Iontraokular lensa 1
io blue 1
io chol 1
cefuroxime 1
2
topi operasi
Spuit 10 cc 7 RL 1
Spuit 3 cc 1
Spuit 5 cc 1
Infus RL 1
RL 1
Handscoon 3
Infus set dewasa 1
Pisau crescent 1
Pisau slit angled 1
Lidocain 1
Gentamycin 1
Adrenalin 1
Viscoelastic 1
io blue 1
io chol 1
cefuroxime 1
topi operasi 2

Spuit 10 cc 7 RL 1
Spuit 3 cc 1
Spuit 5 cc 1
Infus RL 1
RL 1
Handscoon 3
Infus set dewasa 1
Pisau crescent 1
Pisau slit angled 1
Lidocain 1
Gentamycin 1
Adrenalin 1
Viscoelastic 1
io blue 1
io chol 1
cefuroxime 1
topi operasi 2
nacl 1 infus set 1

spuit 5cc 1 RL 1
kassa steril 1
kapas basah linting 1

Spuit 10 cc 7 RL 1
Spuit 3 cc 1
Spuit 5 cc 1
Infus RL 1
RL 1
Handscoon 3
Infus set dewasa 1
Pisau crescent 1
Pisau slit angled 1
Lidocain 1
Gentamycin 1
Adrenalin 1
Viscoelastic 1
io blue 1
io chol 1
cefuroxime 1
topi operasi 2
infus set 1
RL 1

Spuit 10 cc 7 RL 1
Lidocain ampul 1
Ethylon 10 1
Infus RL 1
RL 1
Handscoon 3
Infus set dewasa 1
Pisau MCU26 crescent bevel up 1
alcohol swab kertas 1 infus set 1
pisaustraight 15 1 RL 1
handscoon 2
kassa 1
TARIF BPJS
1 2 3
1 CEDERA KEPALA Rp30,618,800 Rp2,630,400 Rp2,192,000
2 Demensia (ICD X: F03) Rp5,699,400 Rp4,885,200 Rp4,071,000
3 Epilepsi (ICD X: G40.9) Rp3,535,500 Rp3,030,400 Rp2,525,300
CLINICAL PATHWAY
4 STATUS EPILEPTIKUS
& EPILEPSI
Nn. Triani Nurfaedah
No RM. 003831
26-30 Nov 2021
Diagnosa : Status Epileptikus
Dirujuk Ke RS Margono
5 Vertigo (ICD X: R42) Rp1,836,400 Rp1,574,000 Rp1,311,700
Nyeri Punggung Bawah

6 Rp3,833,900 Rp3,286,200 Rp2,738,500
(ICD X: M54.5)
Koma & Penurunan

7 Kesadaran (ICD X: R40) Rp2,798,800 Rp2,398,900 Rp1,999,100
Kapsulitis Adhesiva
8 Bahu (ICD X: M75) Rp3,069,500 Rp2,631,000 Rp2,192,500
Fibromialgia
9 (ICD X: M79.7) 3048400 2612900 2177400
CLINICAL PATHWAY
10 STROKE NON Rp5,211,700 Rp4,467,200 Rp3,722,700
PERDARAHAN
CLINICAL PATHWAY
11 STROKE PERDARAHAN Rp3,072,300 Rp2,633,400 Rp2,194,500
PEMERIKSAAN PENUNJANG
LAB RADIOLOGI
JENIS PEMERIKSAAN HARGA BHP YANG DIGUNAKAN JENIS PEMERIKSAAN

pemeriksaan darah
Foto Rontgen tengkorak (AP Lateral
perifer lengkap
ureum Rp24,000 CT Scan
elektrolit Rp110,000 Film ukuran 28 x 35 cm
glukosa Amplop Radiologi Besar
analisis gas darah
Rp80,000 Film ukuran 35 x 43 cm
arteri
(Hb, Hematokrit,
Leukosit,
Tes biokimiaTrombosit,
meliputi 71244+15000 -
Hitung jenis,
elektrolit, glukosa,
fungsi renaltiroid
Tes fungsi dan hepar
Kadar serum
vitamin B12
Darah Hematologi
Rontgen Thoraks
Lengkap
Ureum, kreatinin Rp. 24.000/Rp. 24.000 BMD
SGOT/SGOT Rp. 26.000/Rp. 26.000 MRI otak
Profil lipid Film ukuran 20 x 25 cm
GDP/GD2PP Rp. 21.500/ Amplop Radiologi Kecil
Faal hemostasis
Asam urat
Albumin (Natrium,
Elektrolit Rp24,000
Kalium, Kalsium, Rp110,000
Magnesium)
Lumbal Pungsi
EKG
Kadar Obat Anti
Epilepsi dalam darah
Kultur darah, rapid HIV HCTS non kontras
TORCH, IGRA
Ronsen Thorax
(pada imunokompromis)
ANA, ANCA, anti-ds
Film ukuran 35 x 43 cm
DNA, LED, CRP
Folat, CPK, Troponin,
Trigliserida serum,
Pungsi Lumbal Film ukuran 20 x 25 cm
Amplop Radiologi Kecil
elektrolit,
CT Scan atau MRI Brain
kadar gula darah
Laju endap darah Foto polos

Darah perifer lengkap Rp48,000 Mielografi
Ureum, creatinine Rp. 24.000, Rp. 24.000 CT-mielografi
Elektrolit Rp110,000 BMD
C – reaktif protein (CRP) Rp55,500 MRI
Faktor rematoid Film ukuran 28 x 35 cm
Urinalisa Amplop Radiologi Besar
LCS
Tumor marker (PSA, Film ukuran 35 x 43 cm
AFP, CEA, ALP, β-hCG, Amplop Radiologi Besar
thyroglobulin, calcitonin)
pemeriksaan elektrolit Rp110,000 CT-scan

EEG
glukosa Rp15,000
pemeriksaan likuor
kalsium Rp22,500
serebrospinalis
osmolaritas Film ukuran 35 x 43 cm
toksik obat-obatan
(NAPZA)
fungsi ginjal/ hati.
Rontgen articulatio
Darah rutin glenohumeral
GDS akromioklavikular
GDP Rp21,500 coracoacromial
- -
INR, albumin ,elektrolit,

creatinin, ureum HCTS non kontras
HbA1C Rp94,000 Ronsen Thorax
GDP Rp21,500 Film ukuran 35 x 43 cm
Profil lipid Amplop Radiologi Besar
AsamUrat Film ukuran 20 x 25 cm
INR, albumin ,elektrolit,

creatinin, ureum HCTS non kontras
HbA1C Ronsen Thorax
GDP Rp21,500 Film ukuran 35 x 43 cm
Profil lipid Amplop Radiologi Besar
AsamUrat Film ukuran 20 x 25 cm
TERAPI OBAT YANG DIBERIKAN
RADIOLOGI
HARGA TOTAL
JENIS OBAT JMLH SATUAN
SATUAN HARGA
HARGA BHP YG DIGUNAKAN
Rp50,000 diazepam 10 mg iv
Rp150,000 fenitoin 15 mg/KgBB iv
piritinol
piracetam
citicholine
Antikonvulsan
Fenitoin
Diazepam
Donepezil
Rivastigmin patch
Galantamin
Ekstrak Ginkgo
Biloba 761
Donepezil.
Antagonis reseptor
MNDA Memantin
Risperidon
Olanzepin
Antidepresan golongan
SSRI
Fenitoin 4-6 mg/kg
Rp25,000
BB bid
Carbamazepin XR
15-18
Asam valproate bid
mg/kgBB 20-60
od/bid
mg/kgBB bid
Topiramat
Lamotrigin 3-9 mg/kg
100-400
mg bid
Oxcarbazepin 300-900
mg bid
Zonisamid 100-300
mg tid
Clonazepam 2-8
mg bid
Clobazam 10-30
mg tid
Fenobarbital 2-4
mg/kgBB bid300-900
Gabapentin
mg tid
Pregabalin 150-600
mg b/tid
Rp150,000 Diazepam IV
Rp25,000 Midazolam IM
Fenobarbital IV
Fenitoin IV
Asam Valproat oral
Leviteracetam oral
Fenobarbital IV
OBAT ACTUAL
Omeprazol Serbuk Inj 40 mg 2
Dexamethasone 5 mg/ ml 21
Phenitoin 100 mg/ 2 ml 7
Ceftriaxone inj 14
NACL 0.9 & 500 ml 8
Asam folat 1 mg 5
Betahistin 6 mg 3
Diazepam Tab 5 mg 1
Diazepam inj 5 mg 3
Parasetamol Inf 3
(dimenhidrinat,
Rp150,000
difenhidramin, meksilin,
Kalsium Antagonis
Anti inflamasi (steroid,

Rp50,000
NSAID
Relaksan sesuai fornas)
otot (Esperison
Hcl, Diazepam,
Analgetik opioidTizanidin)
lemah
Rp250,000
(Codein)
Analgetik opioid kuat
(Carbamazepine,
(Morphine sulfate)
Gabapentin,
Anti depresant
Okscarbazepine,
Relaksan otot
(amitryptiline)
(Esperison Hcl,
Analgetik
Diazepam,opioid lemah
Tizanidin)
(Codein)
Analgetik opioid kuat
(Morphine sulfate)
Rp150,000 Obati infeksi
Rp50,000 -
-
Rp150,000 -
Rp25,000 Asering
Manitol 125cc
Omeprazole 1x40mg
PCT 3x1g
Amlodipin 1x10 mg
Asam folat 2x1 mg
B.Complex 1x1 mg
Aricept 2x0,5 tablet
Dexa per 6 jam
Irbersartan 1x300 mg
Gabapetin 1x300 mg
Piracetam 1x1200 mg
Citicolin 2x500 mg
Combivent per 8 jam
Flexotid per 8 jam
Nicardipine
Nacl
Aspilet 1 x 81 mg
Rp150,000 -
Rp25,000 Asering
Manitol 125cc
Omeprazole 1x40mg
PCT 3x1g
Amlodipin 1x10 mg
Asam folat 2x1 mg
B.Complex 1x1 mg
Aricept 2x0,5 tablet
Dexa per 6 jam
Irbersartan 1x300 mg
Gabapetin 1x300 mg
Piracetam 1x1200 mg
Citicolin 2x500 mg
Combivent per 8 jam
Flexotid per 8 jam
Nicardipine
Nacl
Aspilet 1 x 81 mg
BMHP RUANG TINDAKAN BMHP RUANG RA
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA JENIS BARANG
Syringe 5 ml 17
Syringe 3 ml 16
Recision Glide needle, 21 G 1-1/2 TW 1
Syringe 1 ml 10
Handscoon non steril 16
Syringe 10 ml 13
Nasal Oksigen Kanula dewasa 1
IV canula Catheter 20GX2INCH 1
IV canula Catheter 24GX2INCH 1
Stomach Tube FR 14 1
Folley Catheter NO.12 1
Urine Bag 3
Disposable Syringe 50 ml 1
Folley Catheter No.18 1
Guedel Airway 90 ml 1
Infus Set
Abocat
Hivavik
Plester
Alcohol Swab
Asering
Spuit 10 cc
Spuit 05 cc
Spuit 03 cc
NGT
DC
Urine bag
Spuit 50 cc bolong tengah
Nassal Canul
NRM
Simple mask
Sungkup Nebulizer
Ferfusor
Spuit 50 cc bolong pinggir
Kasa Bersih
Kasa Steril
Handscoon bersih
Handscoon steril
Infus Set 1
Abocat 1
Hivavik 1
Plester 10 cm
Alcohol Swab 3
Asering 10
Spuit 10 cc 3
Spuit 05 cc 3
Spuit 03 cc 3
NGT 1
DC 1
Urine bag 1
Spuit 50 cc bolong tengah 1
Nassal Canul 1
NRM 1
Simple mask 1
Sungkup Nebulizer 1
Ferfusor
Spuit 50 cc bolong pinggir 1
Kasa Bersih 10
Kasa Steril 1 box
Handscoon bersih 5 Pasang
Handscoon steril 5 Pasang
BMHP RUANG RAWAT INAP KELAS PERAWATAN
LAMA
PERAWATAN
JMLH HARGA SATUAN TOTAL HARGA 1 2 3
TOTAL
1 2 3
TARIF BPJS
1 2 3
1 STROKE, NOT SPECIFIED AS

HAEMORRHAGE OR
INFARCTION
2 CEREBRAL INFARCTION,
UNSPECIFIED
3 HEMIPLEGIA, UNSPECIFIED
4 LOW BACK PAIN
5 INTRACEREBRAL
HAEMORRHAGE, UNSPECIFIED
6 SEQUELAE OF STROKE, NOT

SPECIFIED AS HAEMORRHAGE
OR INFARCTION
SEQUELAE OF STROKE, NOT
SPECIFIED AS HAEMORRHAGE
OR INFARCTION
7 TENSION-TYPE HEADACHE
8 BRONCHOPNEUMONIA ,
UNSPECIFIED
9 EPILEPSY, UNSPECIFIED
10 BENIGN PAROXYSMAL VERTIGO

LAB RADIOLOGI

RADIOLOGI
HARGA TOTAL
SATUAN HARGA
BMHP RUANG TINDAKAN BMHP RUANG RAW
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA JENIS BARANG
Kasa Bersih 10
Kasa Steril 1 box
Handscoon bersih 5 Pasang
Handscoon steril 5 Pasang
topi operasi 2
topi operasi 2
topi operasi 2
topi operasi 2
topi operasi 2
topi operasi 2
topi operasi 2
topi operasi 2
topi operasi 2
BMHP RUANG RAWAT INAP KELAS PERAWATAN
LAMA
PERAWATAN
JMLH HARGA SATUAN TOTAL HARGA 1 2 3
TOTAL
1 2 3
TARIF BPJS PEMERIKSAAN PENUNJANG TERAPI OBAT YANG DIBERIKAN BMHP RUANG RAWAT I
LAB RADIOLOGI
HARGA TOTAL
1 2 3 JENIS OBAT JMLH SATUAN JENIS BARANG
SATUAN HARGA
1 DIABETIC FOOT (DENGAN TINDAKA Rp8,813,800.0 Rp7,554,700.0 Rp6,295,600.0 THORAX 25000 Cefazolin 2x1g iv Bisturi No.20
DL, PT/aPTT,
Ny. Nining Widaningsih, 44 Th SGOT/SGPT,Ur/CR/GD FOOT AP/Lateral 50000 Dibekacin 2x1 amp Bisturi No.24
1031 S, Na/K/Cl CRURIS AP/Lateral 50000 Metronidazole 3x500mg iv Bisturi No.11 Surgical Blade
DPJP : dr. M.F. Nanda P, Sp.OT SATURASI O2 EKG Ketorolac 3x30mg iv Bisturi No. 15
Swab Antigen / PCR Film ukuran 20 x 25 cm Ranitidin 2x1 amp iv Benang Daclon No. 2-0
COVID-19 Amplop
Film Radiologi
ukuran Kecil
28 x 35 cm Analtram 2x1
Ranitidin 3x1 tab
tab Handscoon60x90
Underpad Steril 7,5
Amplop Radiologi Sedang Multivitamin dan mineral Kassa Pembalut Alat 3,6 x 15 cm
Film ukuran 28 x 35 cm Kristalloid (NaCl 0,9% /RL /D5%) Infus Set dewasa
Amplop Radiologi Besar Blood Transfusion Triway
Handscoon Non Steril

OBAT ACTUAL Dispo 10 cc
RL 8 Dispo 3 cc
NACL 0,9% 5 ml 12 Dispo 5 cc
Ceptriaxone 1 gr 7 Dispo 50 cc
Aquades Inject 25 ml 12 IV Cateter 20
Asam Folat 6 IV Cateter 18
Natrium Bicarbonat 18 Blood Tranfusi Set
Lantus Insulin 1 Poly Cateter No.16
Novoravid 1 Urine Bag
Kalk 12 T.Vio No.2
Amlodipin 10 mg 6 Ganti Perban
Captopil 25 mg 20 Rawat Luka 10-20 cm
D 5% 100 ml 5
Nicardipin Inject 2
Quanocain 1
Spinocain No.27B 1
Dexketoprofen 1
Ketorolak 30 mg Inject 7
Ranitidin 50 gr 4
Pletal Capsule 100 mg 20
OMZ 40 mg Inject 3
Ondan Inject 4
OBAT PULANG ACTUAL

Pratal 15
Omz Tab 15
Captopil 25 mg 14
Natrium Bicarbonat 21
Asam Folat 7
Novorafid 1
Lansoprazol 7
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Calcitriol 1x0,5 mcg
Vit D3 2x1000 iu
2 FR. CLAVICLE (DENGAN TINDAKAN Rp8,745,100 Rp7,495,800 Rp6,246,500 DL (Hb, Ht, Tr, Leu) THORAX, 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, SHOULDER True AP 25000 Dibekacin 2x1 amp
Ur/Cr/ GDS, Na/K/Cl EKG Ketorolac 3x30mg iv
SATURASI O2 Film ukuran 20 x 25 cm Ranitidin 2x1 amp iv
Swab Antigen/ PCR Amplop Radiologi Kecil Analtram 3x1 tab
COVID-19 Film ukuran 20 x 25 cm Ranitidin 2x1 tab
Amplop Radiologi Kecil Multivitamin dan mineral
Kristalloid (NaCl 0,9% /RL /D5%)
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
3 FR. PELVIS Rp8,303,500 Rp7,117,300 Rp5,931,100 DL (Hb, Ht, Tr, Leu) THORAX 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, PELVIS AP 25000 Dibekacin 2x1 amp
Ur/Cr/ GDS, Na/K/Cl PELVIS INLET-OUTLET 50000 Ketorolac 3x30mg iv
SATURASI O2 PELVIS JUDET VIEW 25000 Ranitidin 2x1 amp iv
Swab Antigen/ PCR EKG Analtram 3x1 tab
Amplop Radiologi Kecil Multivitamin dan mineral
Film ukuran 20 x 25 cm Kristalloid (NaCl 0,9% /RL /D5%)
Amplop Radiologi Kecil Blood Transfusion
Film ukuran 28 x 35 cm OBAT PULANG
Amplop Radiologi Besar Cefixime 2x200mg
Film ukuran 20 x 25 cm Analtram 3x1 tab
Amplop Radiologi Kecil Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
4 FR. SHAFT FEMUR TERBUKA 12847700 11012300 9176900 DL (Hb, Ht, Tr, Leu) THORAX 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, FEMUR AP/LAT 50000 Dibekacin 2x1 amp
Ur/Cr/ GDS, Na/K/Cl Film ukuran 20 x 25 cm Ketorolac 3x30mg iv
SATURASI O2 Amplop Radiologi Kecil Ranitidin 2x1 amp iv
Swab Antigen/ PCR Film ukuran 28 x 35 cm Analtram 3x1 tab
COVID-19 Amplop Radiologi Besar Ranitidin 2x1 tab
Multivitamin dan mineral
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
5 FR. SHAFT FEMUR TERTUTUP (TAN Rp3,080,600 Rp2,640,500 Rp2,200,400 DL (Hb, Ht, Tr, Leu) THORAX 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, FEMUR AP/LAT 50000 Dibekacin 2x1 amp
Amplop Radiologi Besar Multivitamin dan mineral
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
6 FR. SHAFT HUMERUS TERBUKA (D Rp8,745,100 Rp7,495,800 Rp6,246,500 DL (Hb, Ht, Tr, Leu) THORAX, 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, HUMERUS AP/LAT 50000 Dibekacin 2x1 amp
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
7 FR. SHAFT HUMERUS TERTUTUP ( Rp3,064,100 Rp2,626,400 Rp2,188,700 DL (Hb, Ht, Tr, Leu) THORAX, 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, HUMERUS AP/LAT 50000 Dibekacin 2x1 amp
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
8 FR. SHAFT RADIUS ULNA TERBUKA Rp8,745,100.0 Rp7,495,800.0 Rp6,246,500.0 DL (Hb, Ht, Tr, Leu) THORAX, 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, ANTEBRACHI AP/LAT 50000 Dibekacin 2x1 amp
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
9 FR. SHAFT RADIUS ULNA TERTUTU Rp3,064,100 Rp2,626,400 Rp2,188,700 DL (Hb, Ht, Tr, Leu) THORAX, 25000 Cefazolin 2x1g iv
PT/aPTT, SGOT/SGPT, ANTEBRACHI AP/LAT 50000 Dibekacin 2x1 amp
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
10 FR. SHAFT TIBIA TERBUKA Rp15,383,800 Rp13,186,100 Rp10,988,400 DL (Hb, Ht, Tr, Leu) THORAX, 25000 Cefazolin 2x1g iv
(DENGAN TINDAKAN ORIF)
PT/aPTT, SGOT/SGPT, CRURIS AP/LAT 50000 Dibekacin 2x1 amp
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
11 FR. SHAFT TIBIA TERTUTUP Rp3,064,100 Rp2,626,400 Rp2,188,700 DL (Hb, Ht, Tr, Leu) THORAX, 25000 Cefazolin 2x1g iv
(TANPA TINDAKAN)
PT/aPTT, SGOT/SGPT, CRURIS AP/LAT 50000 Dibekacin 2x1 amp
Blood Transfusion
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
12 OSTEOMIELITIS
Ny. Ai Rosita, RM. 022927 Rp5,818,700 Rp4,987,500 Rp4,156,200 THORAX,
EXTREMITAS SESUAI LUKA 25000 Cefazolin 2x1g iv Intra Vena Catheter 20 g
DL PT/aPTT,
SGOT/SGPT, Ur/Cr/ 50000 Dibekacin 2x1 amp Intra Vena Catheter 18 g
Osteomyelitis Cronic GDS, Na/K/Cl EKG Ketorolac 3x30mg iv Infusion Set Dewasa
SATURASI O2 Film ukuran 20 x 25 cm Ranitidin 2x1 amp iv Dispo 10 cc
Swab Antigen/ PCR COVID-19 Amplop Radiologi Kecil Analtram 3x1 tab Dispo 3 cc
Film ukuran 28 x 35 cm Ranitidin 2x1 tab Dispo 5 cc
Amplop Radiologi Besar Multivitamin dan mineral Handscoon Non steril
Kristalloid (NaCl 0,9% /RL /D5%) Blood Tranfusi Set
Blood Transfusion Handscoon Steril No.7
Handscoon Steril No.7.5
OBAT ACTUAL Carbon Steel Blades Pagar 15/Pisau Bedah
RL 500 ml 8 Underpad 60x90
NACL 500 ml 12 Nurse Cap
Sefazolin Inj 1000 mg 6 Betadine
Ketorolak Inj 10 Alkohol 70 %
Ranitidin Inj 8 Spinocan No. 27b
Vit C 6 V16 polyglycolide 1, 90 cm Heavy Round Bod
Quinocain Inj 1 Daclon 3/0 DS 24 mm
Kaptropil 25 mg 9 Urine Bag
Amlodipin 10 mg 3 Foley Catheter No.16
Asam Folat 1
OBAT PULANG ACTUAL

Cefixime Tab 15
Ranitidine 15
VIt C Tab 15
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
13 RUPTUR
Tn. TENDON
Marsodin, RM. 024860 Rp5,376,500 Rp4,608,400 Rp3,840,300 THORAX,
EXTREMITAS SESUAI LUKA 25000 Cefazolin 2x1g iv Blood Set
DL PT/aPTT,
SGOT/SGPT, Ur/Cr/ 50000 Dibekacin 2x1 amp Kassa Steril 16x16 cm
Post Op Ruptur Tendon Ektensor GDS, Na/K/Cl EKG Ketorolac 3x30mg iv Dispo 3 cc
SATURASI O2 Film ukuran 20 x 25 cm Ranitidin 2x1 amp iv Dispo 10 cc
Swab Antigen/ PCR COVID-19 Amplop Radiologi Kecil Analtram 3x1 tab Dispo 1 cc
Film ukuran 28 x 35 cm Ranitidin 2x1 tab Carbon Steel Blades Pagar 15/ Pisau Bedah
Amplop Radiologi Besar Multivitamin dan mineral Handscoon No.7
Kristalloid (NaCl 0,9% /RL /D5%) Handscoon No.7.5
Blood Transfusion Underpad 60x90
T-Lane
OBAT ACTUAL Daclon 2-0
NACL 500 ml 3 Handscoon non steril
Ranitidin inject 7 Dispo 5 cc
Ketorolac inject 7
Sefazoline Inj 1000 mg 8
Ampodipin 10 mg 1
Kaptropil 25 mg 1
RL 9
OBAT PULANG ACTUAL

Cefixime Tab 200 mg 25
Ranitidin Tab 150 mg 25
Vit C 50 mg 25
OBAT PULANG
Cefixime 2x200mg
Analtram 3x1 tab
Ranitidin 2x1 tab
Calcium 2x1
Vit D3 2x1000 iu
14 Sharp
Tn. Wond
Nono Injury Muscle
Darsono, & Fascia
RM.022057 Rp5,376,500 Rp4,608,400 Rp3,840,300 Quanocain Inj 1 Nurse Cap
RL 500 ml 12 Betadine
Dexametason Inj 5 mg/ml 2 Alkohol 70 %
Metoklopramide inj 5 mg/ml 1 Spinocan No.27b
Sefazolin sern Inj 1000 mg 6 FM Crepe Pembalut Elastis 10 cm x 4,55 m
Keterolac Inj 30 mg 6 Polygyp 15 cm x 2,7 m
Ranitidin inj 50 mg/2 ml 6 Polyban 10 cm x 2,7 m
T-Lene 3-0
NGT No.16
OBAT PULANG ACTUAL Folley Catheter No.16
Cefixime Kaps 200 mg 15 urine Bag
Ranitidine Tab 150 mg 15 Dispo 10 cc
Asam Askorbat ( vit C ) tab 50 mg 15 Aquadest ( Air untuk Injeksi 25 ml )
Handscoon Non Steril
Dispo 3 cc
Dispo 5 cc
BMHP RUANG RAWAT INAP BMHP RUANG TINDAKAN KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
JMLH HARGA SATUAN TOTAL HARGA JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 Perina Pediatric ICU ICU HCU 1 2 3
1 Rp737.00 Rp737.00 Bisturi No.15 1 Rp737.00 Rp737.00 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
1 Rp737.00 Rp737.00 Handscoon Steril No. 7 2 Rp12,500.00 Rp25,000.00
1 Rp737.00 Rp737.00 Handscoon Steril No. 7,5 2 Rp12,500.00 Rp25,000.00
1 Rp737.00 Rp737.00 Underpad 1 Rp0.00
1 Rp22,853.00 Rp22,853.00 Nacl 0,9% 500ml 2 Rp0.00
4
1 Rp12,500.00 Rp50,000.00
Rp0.00 Kasa Gulung
Daclon Besar )
2-0 (cuting 3
1 Rp22,853.00 Rp68,559.00
Rp22,853.00
6 Rp3,975.00 Rp23,850.00 Folley Catheter No 14/16/18 1 Rp9,200.00 Rp9,200.00 6 Hari
1 Rp7,128.00 Rp7,128.00 Urine Bag 1 Rp6,800.00 Rp6,800.00
1 Rp21,208.00 Rp21,208.00 Aqua Bidest 1 Rp0.00
22 Rp3,190.00 Rp70,180.00 0
19 Rp1,287.00 Rp24,453.00 0
20 Rp880.00 Rp17,600.00 0
20 Rp968.00 Rp19,360.00 0
1 Rp3,780.00 Rp3,780.00 0
2 Rp4,818.00 Rp9,636.00 0
2 Rp4,818.00 Rp9,636.00 0
2 Rp10,240.00 Rp20,480.00 0
1 Rp9,200.00 Rp9,200.00 0
1 Rp6,800.00 Rp6,800.00 0
1 Rp79,420.00 Rp79,420.00 0
8 Rp0.00 0
8 Rp0.00 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 Spuit 10cc 1 1287 1287
0 Kasaa 20 0
0 T-VIO 2-0 (Tapper) 1 Rp79,420.00 Rp79,420.00
0 T-NYLON 2-0 (Cutting) 1 79520 79520
0 alkohol 50cc 202 #VALUE!
0 betadin 100 cc 7960 #VALUE!
0 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000
0 Handscoon Steril No. 7 2 12500 25000
0 Handscoon Steril No. 7,5 2 12500 25000
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Folley Catheter No 14/16/18 1 9200 9200 6 Hari
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 alkohol 50 cc 202 #VALUE!
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Folley Catheter No 14/16/18 1 9200 9200
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 44330 88660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
0 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0 6 Hari
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
0 Bisturi No. 15 & 23 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
0 Underpad 1 0
0 NGT No. 16/18/24 2 8640 17280
0 Urine Bag 1 6800 6800
0 Aqua Bidest 1 0
0 Spuit 10cc 1 1287 1287
0 NaCl 0,9% 500ml 5 0
0 T-VIO 1 (Tapper) 1 85910 85910
0 T-Silk 2-0 (Tapper) 1 46750 46750
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 2 55330 110660
0 SOFTBAND 4 IN 1 0
0 kassa 30 0
0 0
3 21208 63624 Bisturi No.15 1 737 737 153,000 119,000 81,606 238,000 238,000 238,000 204,000 6 Hari
3 21208 63624 Handscoon Steril No. 7 2 12500 25000
1 7128 7128 Handscoon Steril No. 7,5 2 12500 25000
12 1287 15444 Underpad 1 0
11 Rp880.00 Rp9,680.00 Nacl 0,9% 500ml 2 0
11 Rp968.00 Rp10,648.00 Kasa Gulung Besar 3 0
10 3190 31900 Daclon 2-0 (cuting ) 1 55330 55330
1 10240 10240 Folley Catheter No 14/16/18 1 9200 9200
2 12500 25000 Urine Bag 1 6800 6800
3 12500 37500 0
1 737 737 0
1 0 0
3 400 1200 0
1 81101 81101 0
1 41059 41059 0
1 15000 15000 Aqua Bidest 1 0
1 85910 85910 Spuit 10cc 1 1287 1287
1 15954 15954 Kasaa 20 0
1 6800 6800 0
1 9200 9200 0
0 0
0 T-VIO 2-0 (Tapper) 1 79420 79420
0 T-NYLON 2-0 (Cutting) 1 55330 55330
0 alkohol 50cc 202 #VALUE!
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 10240 10240 Bisturi No. 15 & 23 1 Rp737.00 Rp737.00 6 Hari
1 383.333333333 383.333333333333 Handscoon Steril No. 7 2 Rp12,500.00 Rp25,000.00
12 880 10560 Handscoon Steril No. 7,5 2 Rp12,500.00 Rp25,000.00
11 1287 14157 Underpad 1 Rp0.00
1 907 907 NGT No. 16/18/24 2 Rp8,640.00 Rp17,280.00
1 737 737 Folley Catheter No 14/16/18 1 Rp9,200.00 Rp9,200.00
2 12500 25000 Urine Bag 1 Rp6,800.00 Rp6,800.00
2 12500 25000 Aqua Bidest 1 Rp0.00
1 0 Spuit 10cc 1 Rp1,287.00 Rp1,287.00
1 127160 127160 NaCl 0,9% 500ml 5 Rp0.00
1 22583 22583 T-VIO 1 (Tapper) 1 Rp85,910.00 Rp85,910.00
9 3190 28710 T-Silk 2-0 (Tapper) 1 Rp46,750.00 Rp46,750.00
9 968 8712 T-VIO 2-0 (Tapper) 1 Rp79,420.00 Rp79,420.00
0 T-NYLON 2-0 (Cutting) 2 Rp55,330.00 Rp110,660.00
0 SOFTBAND 4 IN 1 Rp0.00
0 kassa 30 Rp0.00
0 alkohol 50 cc Rp202.00 #VALUE!
0 betadin 200 cc Rp7,960.00 #VALUE!
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
3 400 1200 0
1 81101 81101 0
1 41059 41059 0
1 15000 15000 0
1 28900 28900 0
1 28900 28900 0
1 25000 25000 0
1 80190 80190 0
1 8640 8640 0
1 9200 9200 0
1 6800 6800 0
17 1287 21879 0
1 0 0
8 3190 25520 0
3 880 2640 0
3 968 2904 0
TARIF BPJS
1 2 3
1 ARTHORIS, UNSPECIFIED
2 LOW BACK PAIN
3 TYPE 2 DIABETES MELLITUS

4 FRACTURE OF SHAFT OF HUMERUS
5 GONARTHROSIS (ARTHROSIS OF
KNEE)
6 FRACTURE OF SHAFTS OF BOTH
ULNA AND RADIUS
7 OSTEOMYELITIS, UNSPECIFIED
8 FRACTURE OF LOWER END OF TIBIA
9 FRACTURE OF CLAVICLE
10 PRIMARY GONORTHROSIS BILATERAL
LAB RADIOLOGI

RADIOLOGI
HARGA TOTAL
SATUAN HARGA
BMHP RUANG RAWAT INAP
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA
Dispo 5 cc 3 968 2904

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
BMHP RUANG TINDAKAN K
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
KELAS PERAWATAN
LAMA
PERAWATAN
2 3 Perina Pediatric ICU ICU HCU
TOTAL
1 2 3
TARIF BPJS
1 2 3
1 DEMAM TIFOID Rp2,929,500 Rp2,511,000 Rp2,092,500
2 PNEUMONIA 4665600 3999100 3332600

Ny. Dasinah
65 tahun
Kalipucang
00015120
LAB RADIOLOGI
DARAH LENGKAP THORAX PHOTO Rp25,000

(LED, DIFF COUNT) EKG
SATURASI O2 Film ukuran 20 x 25 cm
UREUM / KREATININ Rp. 24.000 / Rp. 24.000 Amplop Radiologi Kecil
AGD
KULTUR DARAH
DARAH LENGKAP THORAX PHOTO Rp25,000

(LED, DIFF COUNT) EKG
SATURASI O2 Film ukuran 20 x 25 cm
UREUM / KREATININ Rp. 24.000 / Rp. 24.000 Amplop Radiologi Kecil
AGD
KULTUR DARAH
TERAPI OBAT YANG DIBERIKAN BMHP RUANG RAW
HARGA TOTAL
JENIS OBAT JMLH SATUAN JENIS BARANG
SATUAN HARGA
Ciprofloxacin 2 x 200mg atau

Ceftriaxone 2-3m x 2-4gr selama
3-5 hari atau
Thiamfenicol 4 x 500 mg
Kaen 3B / RL 0,9% Dextrosa 5%
Aminofluid
Ciprofloxacin 2 x 500 mg
Cefixim 2 x 100 mg atau
Tiamfenicol 4 x 500 mg
Antipiretik / Paracetamol bila demam
antiemetik
Roborantia
Cefotaxim inj 1 gr 12 jam atau

Ceftiaxon 2gr/24 jam atau
Levofloxacin 750mg 1x/24 jam 4
Expectoran syr 3xc1
Paracetamol 3 x 500 mg
Mukolitik 3x1
Multivitamin
Kristaloid (NaCl 0.9% / RL/D5%)
Koloid Haes 6% flab/24 jam
Ciprofloxacin 2 x 500mg atau
Levofloxacin 500mg 1x1 atau
Cefixim 1 x 100mg
ceftriaxon 4 Sungkup Nebu

NAC 9 Nasal Kanul Dewasa
Nebu Combivent 15 Handscoon
Nebu Flexotid 15 Abocath No 20
Ranitidine IV 6 Dyspo 10
Nacl 5 Dyspo 5
Furosemide IV 10 Dyspo 3
KSR 5
Kodein 8
Mp 3
Retapyl 3
Alprazolam 1
Seretide Diskus 1
BMHP RUANG RAWAT INAP BMHP RUANG TINDAKAN
JENIS
JMLH HARGA SATUAN TOTAL HARGA JMLH HARGA SATUAN
TOTAL HARGA
BARANG
0 0
153,000 119,000 81,606 238,000
153,000 119,000 81,606 238,000
1
1
12
2
12
12
12
KELAS PERAWATAN
1 2 3 Perina Pediatric ICU ICU HCU
238,000 238,000 204,000 4 Hari
238,000 238,000 204,000 5 Hari

TOTAL
LAMA
PERAWATAN
1 2 3
TARIF BPJS
1 2 3
1 Stomatitis herpes
2 dry mouth
3 lesi oral dengan kelainan autoimun
4 lesi oral dengan kelainan darah
5 stomatitis aftosa rekuren
6acute necrotizing ulcerative gingivitis
5
LAB RADIOLOGI
TERAPI OBAT YANG DIBERIKAN BMHP
HARGA TOTAL
JENIS OBAT JMLH SATUAN JENIS BARANG JMLH
SATUAN HARGA
chlorhexidine gluconate 1 botol 50,000 handsune

BMHP KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
HARGA SATUAN TOTAL HARGA 1 2 3 1
TOTAL
2 3
LAB RADIOLOGI
HARGA
SATUAN
1 Fraktur foto polos 50000
2 Gangguan retensi sputum pada hospital aquired P Analisa Gas Darah Foto Thorax
CT Scan 25000
kultur dan spesifity sputum
3 Paraplegia pada Cedera Medula Spinalis Darah Rutin Foto Thorax 25000
Gula Darah Sewaktu
ECG
Protein/Albumin/Globulin
Ureum Creatinin
SGOT/SGPT
Urine Lengkap
Kultur Urine/Pus
Resistensi Tes
Gula Darah Puasa/2PP
Cholesterol
Asam Urat
LED
BTA TB
PCR
IWT
Creatinin Clearance/Cystatin C
4 Gangguan Mobilisasi pada Stroke Hemaglobin CT Scan/MRI 150000

EKG
5 Stroke Fase Akut Hemoglobin Foto Thorax 25000
CT Scan 150000
MRI
EKG
TERAPI OBAT YANG DIBERIKAN BMHP KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
TOTAL
JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 1 2 3
HARGA
Bandage 1
Korset Lumbal
atau Korset
Thoracolumbal 1
Bilateral
Crutches 1
Walker 1
Walker 1
Walker 1
LAB RADIOLOGI
HARGA TOTAL
1 2 3 JENIS OBAT JMLH SATUAN JENIS BARANG
SATUAN HARGA
1 Multiple caries Darah Rutin Dental panoramic Cefotaxim 2x1 gr atau 3 vial Steril gloves
Thorax AP Ceftriaxone 1gr/24 jam 3 vial Spuit 10 cc
Film ukuran 28 x 35 cm Anti nyeri Betadine
Amplop Radiologi Besar Keterolak tid atau 2 vial Kassa
Ketoprofen supp 2 supp Cotton roll
Anti muntah Dental needle
Ondancetron bid 1 botol Pehacain
Midazolam IV:0,14 mg/kg

Gas anastesi (N20, sevo, Iso Flu)
Bupivacain 0,5% hipernarik 12,5 mg
Ringer laktat 3 buah

NaCl 3 buah
Dextrose 5% 1 buah
Cefadroksil 2x1 1 botol

Roboransia 1x1 1 botol
Ranitidine 2x1 1 botol
Asam mefenamat 3x1 10 tab
2 Clef palate Thorax AP Midazolam IV:0,14 mg/kg Steril gloves

Film ukuran 28 x 35 cm Gas anastesi (N20, sevo, Iso Flu) dental wax
Amplop Radiologi Besar Bupivacain 0,5% hipernarik 12,5 mg alginate
gips stone
Ringer laktat 2
NaCl 2
3 Mucocele Darah Rutin Thorax AP Cefotaxim 2x1 gr atau 3 vial Pehacain

Film ukuran 28 x 35 cm Ceftriaxone 1gr/24 jam 3 vial Surgical blade
Amplop Radiologi Besar Anti nyeri Dental needle
Keterolak tid atau 2 vial Silk
Ketoprofen supp 2 supp Kassa
Anti muntah Saliva ejector
Ondancetron bid 1 botol Betadin
Steril gloves
Ringer laktat 3
NaCl 3
Dextrose 5% 3

4 Epulis Darah Rutin Thorax AP Cefotaxim 2x1 gr atau 3 vial Pehacain

Steril gloves
Ringer laktat 3
NaCl 3
Dextrose 5% 3

5 Periapical abses Dental panoramic Cefotaxim 2x1 gr atau 3 vial Pehacain


Ringer laktat 3
NaCl 3
Dextrose 5% 3

6 Perikoronitis Darah rutin Dental panoramic Cefotaxim 2x1 gr atau 3 vial Pehacain
Steril gloves
Midazolam IV:0,14 mg/kg Spuit 10 cc
Ringer laktat 3
NaCl 3
Dextrose 5% 3

7 Dental cyst Darah rutin Dental panoramic Cefotaxim 2x1 gr atau 3 vial Pehacain
Thorax AP Ceftriaxone 1gr/24 jam 3 vial Surgical blade
Film ukuran 28 x 35 cm Anti nyeri Dental needle
Amplop Radiologi Besar Keterolak tid atau 2 vial Silk
Steril gloves
Midazolam IV:0,14 mg/kg Spuit 10 cc
Ringer laktat 3
NaCl 3
Dextrose 5% 3
8 Compound odontoma Darah rutin Dental panoramic Cefotaxim 2x1 gr atau 3 vial Pehacain
Spuit 10 cc
Midazolam IV:0,14 mg/kg steril gloves
Ringer laktat 3
NaCl 3
Dextrose 5% 3

9 Natal teeth Darah rutin Thorax AP Cefotaxim 2x1 gr atau 3 vial Pehacain
Film ukuran 28 x 35 cm Ceftriaxone 1gr/24 jam 3 vial Dental needle
Amplop Radiologi Besar Anti nyeri Silk
Keterolak tid atau 2 vial Kassa
Ketoprofen supp 2 supp Saliva ejector
Anti muntah Betadin
Ondancetron bid 1 botol Steril gloves

Ringer laktat 3
NaCl 3
Dextrose 5% 3

10 Abses submandibula Darah rutin Dental panoramic Cefotaxim 2x1 gr atau 3 vial Pehacain
Spuit 10 cc
Midazolam IV:0,14 mg/kg Steril gloves
Ringer laktat 3
NaCl 3
Dextrose 5% 3

BMHP KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
JMLH HARGA SATUAN TOTAL HARGA 1 2 3 1 2 3
3 3 hari
2
1
1
10
1
2
3 3 hari
1
1
1
2 3 hari
1
1
1
1
1
1
3
2 3 hari
1
1
1
1
1
1
3
2 3 hari
1
1
1
1
1
1
1 3 hari
1
1
1
1
1
1
3
1
2 3 hari
1
1
1
1
1
1
3
1
2
1 3 hari
1
1
1
1
1
1
3
1 3 hari
1
1
1
1
1
3
1 3 hari
1
1
1
1
1
1
1
3
TARIF BPJS PEMERIKSAAN PENUNJANG TERAPI OBAT YANG
LAB RADIOLOGI
1 2 3 JENIS OBAT
1 Pulpitis reversible Dental panoramic Amoxicilin 3x1 500 mg/
Film ukuran 28 x 35 cm Clindamicin 3x1 300 mg/
Amplop Radiologi Besar Ciprofloxacin 3x1 500 mg
Paracetamol 3x1 500 mg
Asam mefenamat 3x1 500 mg/
Dexketoprofen 3x1 25 mg
Antasid 3x1 400mg
2 Pulpitis irreversible Dental panoramic Amoxicilin 3x1 500 mg/

Antasid 3x1 400mg
3 Necrosis pulpa Gula darah sewaktu Dental panoramic Amoxicilin 3x1 500 mg/
Antasid 3x1 400mg
4 Gingivitis marginalis kronis generalisata Gula darah sewaktu Chlorhexidine 0,2%

Darah rutin
5 Periodontitis apikalis kronis Gula darah sewaktu Dental panoramic Amoxicilin 3x1 500 mg/
Darah rutin Film ukuran 28 x 35 cm Clindamicin 3x1 300 mg/
Antasid 3x1 400mg
6 Abses periapikal Dental panoramic Amoxicilin 3x1 500 mg/

Antasid 3x1 400mg
7 Disturbances in tooth eruption Dental panoramic Paracetamol 3x1 syr/tab

8 Operkulitis Gula darah sewaktu Dental panoramic Amoxicilin 3x1 500 mg/
Antasid 3x1 400mg
9 Impacted teeth Gula darah sewaktu Dental panoramic Amoxicilin 3x1 500 mg/
Antasid 3x1 400mg
10 Ulkus dekubitus Dental panoramic Amoxicilin 3x1 syr/tab

Film ukuran 28 x 35 cm Paracetamol 3x1 syr/tab
TERAPI OBAT YANG DIBERIKAN BMHP KELAS PERAWATAN TOTAL
LAMA
PERAWATAN
HARGA TOTAL
JMLH SATUAN JENIS BARANG JMLH HARGA SATUAN TOTAL HARGA 1 2 3 1 2 3
SATUAN HARGA
10 Eugenol 1
10 Tambalan sementara/ 1
10 Glass ionomer 1
10 Cotton roll 4
10 saliva ejector 1
6 Microbrush 1
10
10 Eugenol/ 1
10 Dycal/ 1
10 Paramonoclorofenol/ 1
10 Formocresol 1
10 Tambalan sementara 1
6 Glass ionomer/ 1
10 Elite cement 1
Saliva ejector 1
Microbrush 1
Cotton roll 4
10 Pehacain/ 1
10 Chloretil spray 1
10 Dental needle 1
10 Kassa 2
10 Saliva ejector 1
6 Betadin 1
10
1 Saliva ejector 1
Betadin 1
10 Pehacain/ 1
10 Dental needle 1
10 Kassa 2
10 Saliva ejector 1
6 Betadin 1
10
10 Pehacain/ 1
10 Surgical blade 1
10 Dental needle 1
10 Silk 1
6 Kassa 1
10 Saliva ejector 1
Betadin 1
1 Pehacain/ 1
Chloretil spray 1
Dental needle 1
Kassa 1
Saliva ejector 1
Betadin 1
10 Pehacain 1
10 Surgical blade 1
10 Dental needle 1
10 Silk 1
10 Kassa 2
6 Saliva ejector 1
10 Betadin 1
10 Pehacain 1
10 Surgical blade 1
10 Dental needle 1
10 Silk 1
10 Kassa 2
6 Saliva ejector 1
10 Betadin 1
1 Pehacain/ 1
1 Chloretil spray 1
Dental needle 1
Kassa 2
Saliva ejector 1
Betadin 1

Format Clinical Pathway

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Format Clinical Pathway

Uploaded by

Copyright:

Available Formats

TARIF BPJS PEMERIKSAAN PENUNJANG TERAPI OBAT YANG DIBERIKAN

1 APENDISITIS ACUT Hematologi Rutin Rp71,244 THORAX AP Rp25,000

Cefixim Tablet 2x200 mg 10

2 BENIGNA PROSTAT HYPERTROPHY Hematologi Rutin Rp71,244 Rontgen Thorax Rp25,000 RL

4 CHOLELITHIASIS Hematologi Rutin Rp71,244 USG hepato billiare INF RL

SGPT Rp33,247 ranitidin 3x1 amp 21

7 HERNIA INKARSERATA Hematologi Rutin Rp71,244 rongent thorax INF RL

Folley Cateter no 14/16 1 Rp0 RL 10 Rp0

HARGA TOTAL JENIS

IVFD Isotonik (RL, RA )

Ampilin Inj 50mg/KBBB/6 jam Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

IVFD Isotonik (RL, RA) Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

Ciprofloxacin 2x20mg Spuit 10 cc 12 Rp1,287 Rp1,480 Rp17,761

IVFD Isotonik (RL, RA, HSD) Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

153,000 119,000 81,606 238,000 238,000 238,000 204,000 5

153,000 119,000 81,606 238,000 238,000 238,000 204,000 5

153,000 119,000 81,606 238,000 238,000 238,000 204,000 7

153,000 119,000 81,606 238,000 238,000 238,000 204,000 4

153,000 119,000 81,606 238,000 238,000 238,000 204,000 5

IVFD Isotonik (RL, RA) Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

IVFD Isotonik (RL, RA) Spuit 10 cc 15 Rp1,287 Rp1,480 Rp22,201

153,000 119,000 81,606 238,000 238,000 238,000 204,000 5

Sesuai Indikasi Sesuai Indikasi profol 2mg/kg Atrakurium/vekuronium 1

Anestesi lokal: Bupivakain heavy 1 Amp,

Sesuai indikasi Sesuai indikasi Anestesi lokal:Lidokain 1% 3 amp, Bupivakain 1

Sesuai indikasi Sesuai indikasi Anestesi lokal:Lidokain 1% 3 amp, Bupivakain 1

Anestesi lokal:Lidokain 1% 3 amp, Bupivakain 1

Sesuai indikasi Sesuai indikasi

Sesuai indikasi Sesuai indikasi Anestesi lokal: Bupivakain 0,5%/

Infus set, kateter iv, spuite 3,10 cc 1

8 CLINICAL PATHWAY ACUTE - - -

Magnesium sulfat bolus intravena 4 g dalam 20 menit

12 CLINICAL PATHWAY GAGAL - - -

ICD * 10:E.87.5 CLINICAL

14 ICD * 10:E.87.6 CLINICAL - - -

ICD * 10:E.87.0 CLINICAL

16 ICD * 10:E.87.1 CLINICAL - - -

19 CD * 10:E. 83.41 CLINICAL - - -

20 ICD - 10:E.83.42 CLINICAL - - -

ICD * 10 R 57.1 CLINICAL

Gula darah sewaktu

ICD 10. k92.2 : CLINICAL

ICD 10. k92.2 : CLINICAL

ETT 7.0/7.5 1 Rp22,880 Rp26,312

2 PREMATURE RUPTURE OF Darah Rutin Rp71,244 USG OBSTETRI ceftriaxone

3 OTHER SPECIFIED ASSISTED Darah Rutin Rp71,244 USG OBSTETRI

4 OTHER UTERINE INERTIA Darah Rutin Rp71,244 USG OBSTETRI

6 MATERNAL CARE DUE TO Darah Rutin Rp71,244 USG OBSTETRI

7 INCOMPLATE, WITHOUT Darah Rutin Rp71,244 USG OBSTETRI

8 SEVERE PRE-ECLAMPSIA Darah Rutin Rp71,244

10 MATERNAL CARE FOR Darah Rutin Rp71,244

7 ABORTUS IMMINENS Rp1,728,000 Rp1,481,200 Rp1,234,300 tes hamil Rp15,000

Sarung Tangan Steril 2

Kompres NaCl 0,9% (Bila Lesi

Abocath 1 153,000 119,000 81,606 238,000 238,000 238,000 204,000 7 Hari

GD puasa Rp21,500 Phenylefrine 2,5 %/10% topikal

manitol 20% 5ml/kgBB IV bila TIO pre

Primary Angle Closure/Chronic Tlmolol maleat 0,5% ed 2x1/

Manitol 20% 5ml/kgBB IV bila TIO pre

terapi pasca operasi hari rawat 2

Ureum Rp50,770 Ro Thorax Rp 25,000 Dexamethasone+Neomycin 1

2 GLAUKOMA Hematologi Rutin Rp71,244 Tonometri Ciprofloxacin tablet 10