B.

TINDAKAN MEDIK OPERATIF

NO. JENIS TINDAKAN
KODE
KECIL
1 OPERAK1 Subkonjungtival injeksi
2 TMOK2 Ekstraksi corpal magnetik kornea
3 TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 TMOS1 Repair laserasi konjungtiva
2 TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 TMOS3 Skraping korneal
4 TMOS4 Biopsi
5 TMOS5 Eksisi pterygium
6 TMOS6 Repair jahitan post operasi kornea
7 TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 TMOB1 Repair simblefaron
2 TMOB2 Jahit laserasi kornea
3 TMOB3 Repair laserasi kornea + flap konjungtiva
4 TMOB4 Trabekulektomi
5 TMOB5 Siklodialisis
6 TMOB6 Sklerotomi + iriodektomi
7 TMOB7 Jahit laserasi sklera
8 TMOB8 Operasi lain pada iris
9 TMOB9 Paracenthesa
10 TMOB10 ECCE dengan simple aspirasi
11 TMOB11 Kapsulektomi
12 TMOB12 Insersi implant IOL durante operasi katarak
13 TMOB13 Sekunder implant IOL
14 TMOB14 Aff implant IOL
15 TMOB15 Repair luka orbita
16 TMOB16 Disisi lentis

KHUSUS A
1 TMOKA1 Goniosinekiolisis
2 TMOKA2 Sinekiolisis anterior
3 TMOKA3 ECCE dengan linear ekstraksi
4 TMOKA4 Disisi membran katarak sekunder
5 TMOKA5 Vitrektomi anterior durante ECCE
6 TMOKA6 X-Ray orbita
7 TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 TMOKB1 Sinekiolisis posterior
2 TMOKB2 Insersi sekunder implant okuler
3 TMOKB3 Ekstraksi lensa jernih
4 TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 TMOKC1 Fakoemulsifikasi

KHUSUS D
1 TMOKD1 Coreoplasty
 STANDARD

JASA
JASA PELAYANAN JUMLAH
SARANA

Rp. JasMed Dokter Jasa Lainnya Anasthesi Rp.

TARIF

542,000 406,500 406,500 - 1,355,000

542,000 406,500 406,500 - 1,355,000
542,000 406,500 406,500 - 1,355,000

1,200,000 900,000 900,000 - 3,000,000

1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000

1,800,000 1,350,000 1,350,000 - 4,500,000

1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000

2,400,000 1,800,000 1,800,000 - 6,000,000

2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000

3,000,000 2,250,000 2,250,000 - 7,500,000

3,000,000 2,250,000 2,250,000 - 7,500,000
3,000,000 2,250,000 2,250,000 - 7,500,000
3,000,000 2,250,000 2,250,000 - 7,500,000

3,640,000 2,730,000 2,730,000 - 9,100,000

4,264,000 3,198,000 3,198,000 - 10,660,000

 ASA 1 AS

JASA JASA
JASA PELAYANAN JUMLAH
SARANA SARANA

Rp. JasMed Dokter Jasa Lainnya Anasthesi Rp. Rp.

542,000 406,500 406,500 121,950 1,476,950 542,000

542,000 406,500 406,500 121,950 1,476,950 542,000
542,000 406,500 406,500 121,950 1,476,950 542,000

1,200,000 900,000 900,000 270,000 3,270,000 1,200,000

1,200,000 900,000 900,000 270,000 3,270,000 1,200,000
1,200,000 900,000 900,000 270,000 3,270,000 1,200,000
1,200,000 900,000 900,000 270,000 3,270,000 1,200,000
1,200,000 900,000 900,000 270,000 3,270,000 1,200,000
1,200,000 900,000 900,000 270,000 3,270,000 1,200,000
1,200,000 900,000 900,000 270,000 3,270,000 1,200,000

1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000

1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000
1,800,000 1,350,000 1,350,000 405,000 4,905,000 1,800,000

2,400,000 1,800,000 1,800,000 540,000 6,540,000 2,400,000

2,400,000 1,800,000 1,800,000 540,000 6,540,000 2,400,000
2,400,000 1,800,000 1,800,000 540,000 6,540,000 2,400,000
2,400,000 1,800,000 1,800,000 540,000 6,540,000 2,400,000
2,400,000 1,800,000 1,800,000 540,000 6,540,000 2,400,000
2,400,000 1,800,000 1,800,000 540,000 6,540,000 2,400,000
2,400,000 1,800,000 1,800,000 540,000 6,540,000 2,400,000

3,000,000 2,250,000 2,250,000 675,000 8,175,000 3,000,000

3,000,000 2,250,000 2,250,000 675,000 8,175,000 3,000,000
3,000,000 2,250,000 2,250,000 675,000 8,175,000 3,000,000
3,000,000 2,250,000 2,250,000 675,000 8,175,000 3,000,000

3,640,000 2,730,000 2,730,000 819,000 9,919,000 3,640,000

4,264,000 3,198,000 3,198,000 959,400 11,619,400 4,264,000

 ASA 2 ASA 3

JASA
JASA PELAYANAN JUMLAH JASA PELAYANAN
SARANA
JasMed Dokter Jasa Lainnya Anasthesi Rp. Rp. JasMed Dokter

406,500 406,500 142,275 1,497,275 542,000 406,500

406,500 406,500 142,275 1,497,275 542,000 406,500
406,500 406,500 142,275 1,497,275 542,000 406,500

900,000 900,000 315,000 3,315,000 1,200,000 900,000

900,000 900,000 315,000 3,315,000 1,200,000 900,000
900,000 900,000 315,000 3,315,000 1,200,000 900,000
900,000 900,000 315,000 3,315,000 1,200,000 900,000
900,000 900,000 315,000 3,315,000 1,200,000 900,000
900,000 900,000 315,000 3,315,000 1,200,000 900,000
900,000 900,000 315,000 3,315,000 1,200,000 900,000

1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000

1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000
1,350,000 1,350,000 472,500 4,972,500 1,800,000 1,350,000

1,800,000 1,800,000 630,000 6,630,000 2,400,000 1,800,000

1,800,000 1,800,000 630,000 6,630,000 2,400,000 1,800,000
1,800,000 1,800,000 630,000 6,630,000 2,400,000 1,800,000
1,800,000 1,800,000 630,000 6,630,000 2,400,000 1,800,000
1,800,000 1,800,000 630,000 6,630,000 2,400,000 1,800,000
1,800,000 1,800,000 630,000 6,630,000 2,400,000 1,800,000
1,800,000 1,800,000 630,000 6,630,000 2,400,000 1,800,000

2,250,000 2,250,000 787,500 8,287,500 3,000,000 2,250,000

2,250,000 2,250,000 787,500 8,287,500 3,000,000 2,250,000
2,250,000 2,250,000 787,500 8,287,500 3,000,000 2,250,000
2,250,000 2,250,000 787,500 8,287,500 3,000,000 2,250,000

2,730,000 2,730,000 955,500 10,055,500 3,640,000 2,730,000

3,198,000 3,198,000 1,119,300 11,779,300 4,264,000 3,198,000

 ASA 3 ASA 4

JASA
JASA PELAYANAN JUMLAH JASA PELAYANAN
SARANA
Jasa Lainnya Anasthesi Rp. Rp. JasMed Dokter Jasa Lainnya

406,500 162,600 1,517,600 542,000 406,500 406,500

406,500 162,600 1,517,600 542,000 406,500 406,500
406,500 162,600 1,517,600 542,000 406,500 406,500

900,000 360,000 3,360,000 1,200,000 900,000 900,000

900,000 360,000 3,360,000 1,200,000 900,000 900,000
900,000 360,000 3,360,000 1,200,000 900,000 900,000
900,000 360,000 3,360,000 1,200,000 900,000 900,000
900,000 360,000 3,360,000 1,200,000 900,000 900,000
900,000 360,000 3,360,000 1,200,000 900,000 900,000
900,000 360,000 3,360,000 1,200,000 900,000 900,000

1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000

1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000
1,350,000 540,000 5,040,000 1,800,000 1,350,000 1,350,000

1,800,000 720,000 6,720,000 2,400,000 1,800,000 1,800,000

1,800,000 720,000 6,720,000 2,400,000 1,800,000 1,800,000
1,800,000 720,000 6,720,000 2,400,000 1,800,000 1,800,000
1,800,000 720,000 6,720,000 2,400,000 1,800,000 1,800,000
1,800,000 720,000 6,720,000 2,400,000 1,800,000 1,800,000
1,800,000 720,000 6,720,000 2,400,000 1,800,000 1,800,000
1,800,000 720,000 6,720,000 2,400,000 1,800,000 1,800,000

2,250,000 900,000 8,400,000 3,000,000 2,250,000 2,250,000

2,250,000 900,000 8,400,000 3,000,000 2,250,000 2,250,000
2,250,000 900,000 8,400,000 3,000,000 2,250,000 2,250,000
2,250,000 900,000 8,400,000 3,000,000 2,250,000 2,250,000

2,730,000 1,092,000 10,192,000 3,640,000 2,730,000 2,730,000

3,198,000 1,279,200 11,939,200 4,264,000 3,198,000 3,198,000

ASA 4 ASA 5

JASA
ELAYANAN JUMLAH JASA PELAYANAN
SARANA
Anasthesi Rp. Rp. JasMed Dokter Jasa Lainnya Anasthesi

182,925 1,537,925 542,000 406,500 406,500 203,250

182,925 1,537,925 542,000 406,500 406,500 203,250
182,925 1,537,925 542,000 406,500 406,500 203,250

405,000 3,405,000 1,200,000 900,000 900,000 450,000

405,000 3,405,000 1,200,000 900,000 900,000 450,000
405,000 3,405,000 1,200,000 900,000 900,000 450,000
405,000 3,405,000 1,200,000 900,000 900,000 450,000
405,000 3,405,000 1,200,000 900,000 900,000 450,000
405,000 3,405,000 1,200,000 900,000 900,000 450,000
405,000 3,405,000 1,200,000 900,000 900,000 450,000

607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000

607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000
607,500 5,107,500 1,800,000 1,350,000 1,350,000 675,000

810,000 6,810,000 2,400,000 1,800,000 1,800,000 900,000

810,000 6,810,000 2,400,000 1,800,000 1,800,000 900,000
810,000 6,810,000 2,400,000 1,800,000 1,800,000 900,000
810,000 6,810,000 2,400,000 1,800,000 1,800,000 900,000
810,000 6,810,000 2,400,000 1,800,000 1,800,000 900,000
 810,000 6,810,000 2,400,000 1,800,000 1,800,000 900,000
810,000 6,810,000 2,400,000 1,800,000 1,800,000 900,000

1,012,500 8,512,500 3,000,000 2,250,000 2,250,000 1,125,000

1,012,500 8,512,500 3,000,000 2,250,000 2,250,000 1,125,000
1,012,500 8,512,500 3,000,000 2,250,000 2,250,000 1,125,000
1,012,500 8,512,500 3,000,000 2,250,000 2,250,000 1,125,000

1,228,500 10,328,500 3,640,000 2,730,000 2,730,000 1,365,000

1,439,100 12,099,100 4,264,000 3,198,000 3,198,000 1,599,000

 ASA 1 CYTO

JASA
JUMLAH JASA PELAYANAN JUMLAH
SARANA

Rp. Rp. JasMed Dokter Jasa Lainnya Anasthesi Rp.

1,558,250 542,000 508,125 406,500 152,438 1,609,063

1,558,250 542,000 508,125 406,500 152,438 1,609,063
1,558,250 542,000 508,125 406,500 152,438 1,609,063

3,450,000 1,200,000 1,125,000 900,000 337,500 3,562,500

3,450,000 1,200,000 1,125,000 900,000 337,500 3,562,500
3,450,000 1,200,000 1,125,000 900,000 337,500 3,562,500
3,450,000 1,200,000 1,125,000 900,000 337,500 3,562,500
3,450,000 1,200,000 1,125,000 900,000 337,500 3,562,500
3,450,000 1,200,000 1,125,000 900,000 337,500 3,562,500
3,450,000 1,200,000 1,125,000 900,000 337,500 3,562,500

5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750

5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750
5,175,000 1,800,000 1,687,500 1,350,000 506,250 5,343,750

6,900,000 2,400,000 2,250,000 1,800,000 675,000 7,125,000

6,900,000 2,400,000 2,250,000 1,800,000 675,000 7,125,000
6,900,000 2,400,000 2,250,000 1,800,000 675,000 7,125,000
6,900,000 2,400,000 2,250,000 1,800,000 675,000 7,125,000
6,900,000 2,400,000 2,250,000 1,800,000 675,000 7,125,000
 6,900,000 2,400,000 2,250,000 1,800,000 675,000 7,125,000
6,900,000 2,400,000 2,250,000 1,800,000 675,000 7,125,000

8,625,000 3,000,000 2,812,500 2,250,000 843,750 8,906,250

8,625,000 3,000,000 2,812,500 2,250,000 843,750 8,906,250
8,625,000 3,000,000 2,812,500 2,250,000 843,750 8,906,250
8,625,000 3,000,000 2,812,500 2,250,000 843,750 8,906,250

10,465,000 3,640,000 3,412,500 2,730,000 1,023,750 10,806,250

12,259,000 4,264,000 3,997,500 3,198,000 1,199,250 12,658,750

 ASA 2 CYTO ASA

JASA JASA
JASA PELAYANAN JUMLAH
SARANA SARANA

Rp. JasMed Dokter Jasa Lainnya Anasthesi Rp. Rp.

542,000 508,125 406,500 177,844 1,634,469 542,000

542,000 508,125 406,500 177,844 1,634,469 542,000
542,000 508,125 406,500 177,844 1,634,469 542,000

1,200,000 1,125,000 900,000 393,750 3,618,750 1,200,000

1,200,000 1,125,000 900,000 393,750 3,618,750 1,200,000
1,200,000 1,125,000 900,000 393,750 3,618,750 1,200,000
1,200,000 1,125,000 900,000 393,750 3,618,750 1,200,000
1,200,000 1,125,000 900,000 393,750 3,618,750 1,200,000
1,200,000 1,125,000 900,000 393,750 3,618,750 1,200,000
1,200,000 1,125,000 900,000 393,750 3,618,750 1,200,000

1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000

1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000
1,800,000 1,687,500 1,350,000 590,625 5,428,125 1,800,000

2,400,000 2,250,000 1,800,000 787,500 7,237,500 2,400,000

2,400,000 2,250,000 1,800,000 787,500 7,237,500 2,400,000
2,400,000 2,250,000 1,800,000 787,500 7,237,500 2,400,000
2,400,000 2,250,000 1,800,000 787,500 7,237,500 2,400,000
2,400,000 2,250,000 1,800,000 787,500 7,237,500 2,400,000
2,400,000 2,250,000 1,800,000 787,500 7,237,500 2,400,000
2,400,000 2,250,000 1,800,000 787,500 7,237,500 2,400,000

3,000,000 2,812,500 2,250,000 984,375 9,046,875 3,000,000

3,000,000 2,812,500 2,250,000 984,375 9,046,875 3,000,000
3,000,000 2,812,500 2,250,000 984,375 9,046,875 3,000,000
3,000,000 2,812,500 2,250,000 984,375 9,046,875 3,000,000

3,640,000 3,412,500 2,730,000 1,194,375 10,976,875 3,640,000

4,264,000 3,997,500 3,198,000 1,399,125 12,858,625 4,264,000

 ASA 3 CYTO ASA 4 CYTO

JASA
JASA PELAYANAN JUMLAH JASA PELAYANAN
SARANA
JasMed Dokter Jasa Lainnya Anasthesi Rp. Rp. JasMed Dokter

508,125 406,500 203,250 1,659,875 542,000 508,125

508,125 406,500 203,250 1,659,875 542,000 508,125
508,125 406,500 203,250 1,659,875 542,000 508,125

1,125,000 900,000 450,000 3,675,000 1,200,000 1,125,000

1,125,000 900,000 450,000 3,675,000 1,200,000 1,125,000
1,125,000 900,000 450,000 3,675,000 1,200,000 1,125,000
1,125,000 900,000 450,000 3,675,000 1,200,000 1,125,000
1,125,000 900,000 450,000 3,675,000 1,200,000 1,125,000
1,125,000 900,000 450,000 3,675,000 1,200,000 1,125,000
1,125,000 900,000 450,000 3,675,000 1,200,000 1,125,000

1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500

1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500
1,687,500 1,350,000 675,000 5,512,500 1,800,000 1,687,500

2,250,000 1,800,000 900,000 7,350,000 2,400,000 2,250,000

2,250,000 1,800,000 900,000 7,350,000 2,400,000 2,250,000
2,250,000 1,800,000 900,000 7,350,000 2,400,000 2,250,000
2,250,000 1,800,000 900,000 7,350,000 2,400,000 2,250,000
2,250,000 1,800,000 900,000 7,350,000 2,400,000 2,250,000
2,250,000 1,800,000 900,000 7,350,000 2,400,000 2,250,000
2,250,000 1,800,000 900,000 7,350,000 2,400,000 2,250,000

2,812,500 2,250,000 1,125,000 9,187,500 3,000,000 2,812,500

2,812,500 2,250,000 1,125,000 9,187,500 3,000,000 2,812,500
2,812,500 2,250,000 1,125,000 9,187,500 3,000,000 2,812,500
2,812,500 2,250,000 1,125,000 9,187,500 3,000,000 2,812,500

3,412,500 2,730,000 1,365,000 11,147,500 3,640,000 3,412,500

3,997,500 3,198,000 1,599,000 13,058,500 4,264,000 3,997,500

 ASA 4 CYTO ASA 5 CYTO

JASA
JASA PELAYANAN JUMLAH JASA PELAYANAN
SARANA
Jasa Lainnya Anasthesi Rp. Rp. JasMed Dokter Jasa Lainnya

406,500 228,656 1,685,281 542,000 508,125 406,500

406,500 228,656 1,685,281 542,000 508,125 406,500
406,500 228,656 1,685,281 542,000 508,125 406,500

900,000 506,250 3,731,250 1,200,000 1,125,000 900,000

900,000 506,250 3,731,250 1,200,000 1,125,000 900,000
900,000 506,250 3,731,250 1,200,000 1,125,000 900,000
900,000 506,250 3,731,250 1,200,000 1,125,000 900,000
900,000 506,250 3,731,250 1,200,000 1,125,000 900,000
900,000 506,250 3,731,250 1,200,000 1,125,000 900,000
900,000 506,250 3,731,250 1,200,000 1,125,000 900,000

1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000

1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000
1,350,000 759,375 5,596,875 1,800,000 1,687,500 1,350,000

1,800,000 1,012,500 7,462,500 2,400,000 2,250,000 1,800,000

1,800,000 1,012,500 7,462,500 2,400,000 2,250,000 1,800,000
1,800,000 1,012,500 7,462,500 2,400,000 2,250,000 1,800,000
1,800,000 1,012,500 7,462,500 2,400,000 2,250,000 1,800,000
1,800,000 1,012,500 7,462,500 2,400,000 2,250,000 1,800,000
1,800,000 1,012,500 7,462,500 2,400,000 2,250,000 1,800,000
1,800,000 1,012,500 7,462,500 2,400,000 2,250,000 1,800,000

2,250,000 1,265,625 9,328,125 3,000,000 2,812,500 2,250,000

2,250,000 1,265,625 9,328,125 3,000,000 2,812,500 2,250,000
2,250,000 1,265,625 9,328,125 3,000,000 2,812,500 2,250,000
2,250,000 1,265,625 9,328,125 3,000,000 2,812,500 2,250,000

2,730,000 1,535,625 11,318,125 3,640,000 3,412,500 2,730,000

3,198,000 1,798,875 13,258,375 4,264,000 3,997,500 3,198,000

A 5 CYTO

ELAYANAN JUMLAH

Anasthesi Rp.

254,063 1,710,688
254,063 1,710,688
254,063 1,710,688

562,500 3,787,500
562,500 3,787,500
562,500 3,787,500
562,500 3,787,500
562,500 3,787,500
562,500 3,787,500
562,500 3,787,500

843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250
843,750 5,681,250

1,125,000 7,575,000
1,125,000 7,575,000
1,125,000 7,575,000
1,125,000 7,575,000
1,125,000 7,575,000
1,125,000 7,575,000
1,125,000 7,575,000

1,406,250 9,468,750
1,406,250 9,468,750
1,406,250 9,468,750
1,406,250 9,468,750

1,706,250 11,488,750

1,998,750 13,458,250
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 OPERAK1 Subkonjungtival injeksi
2 TMOK2 Ekstraksi corpal magnetik kornea
3 TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 TMOS1 Repair laserasi konjungtiva
2 TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 TMOS3 Skraping korneal
4 TMOS4 Biopsi
5 TMOS5 Eksisi pterygium
6 TMOS6 Repair jahitan post operasi kornea
7 TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 TMOB1 Repair simblefaron
2 TMOB2 Jahit laserasi kornea
3 TMOB3 Repair laserasi kornea + flap konjungtiva
4 TMOB4 Trabekulektomi
5 TMOB5 Siklodialisis
6 TMOB6 Sklerotomi + iriodektomi
7 TMOB7 Jahit laserasi sklera
8 TMOB8 Operasi lain pada iris
9 TMOB9 Paracenthesa
10 TMOB10 ECCE dengan simple aspirasi
11 TMOB11 Kapsulektomi
12 TMOB12 Insersi implant IOL durante operasi katarak
13 TMOB13 Sekunder implant IOL
14 TMOB14 Aff implant IOL
15 TMOB15 Repair luka orbita
16 TMOB16 Disisi lentis

KHUSUS A
1 TMOKA1 Goniosinekiolisis
2 TMOKA2 Sinekiolisis anterior
3 TMOKA3 ECCE dengan linear ekstraksi
4 TMOKA4 Disisi membran katarak sekunder
5 TMOKA5 Vitrektomi anterior durante ECCE
6 TMOKA6 X-Ray orbita
7 TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 TMOKB1 Sinekiolisis posterior
2 TMOKB2 Insersi sekunder implant okuler
3 TMOKB3 Ekstraksi lensa jernih
4 TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 TMOKC1 Fakoemulsifikasi

KHUSUS D
1 TMOKD1 Coreoplasty
 STANDARD

JASA
JASA PELAYANAN JUMLAH
SARANA

Rp. JasMed Dokter Jasa Lainnya Anasthesi Rp.

TARIF

542,000 406,500 406,500 - 1,355,000

542,000 406,500 406,500 - 1,355,000
542,000 406,500 406,500 - 1,355,000

1,200,000 900,000 900,000 - 3,000,000

1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000
1,200,000 900,000 900,000 - 3,000,000

1,800,000 1,350,000 1,350,000 - 4,500,000

1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000
1,800,000 1,350,000 1,350,000 - 4,500,000

2,400,000 1,800,000 1,800,000 - 6,000,000

2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000
2,400,000 1,800,000 1,800,000 - 6,000,000

3,000,000 2,250,000 2,250,000 - 7,500,000

3,000,000 2,250,000 2,250,000 - 7,500,000
3,000,000 2,250,000 2,250,000 - 7,500,000
3,000,000 2,250,000 2,250,000 - 7,500,000

3,640,000 2,730,000 2,730,000 - 9,100,000

4,264,000 3,198,000 3,198,000 - 10,660,000

 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA1-OPERAK1 Subkonjungtival injeksi
2 ASA1-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA1-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA1-TMOS1 Repair laserasi konjungtiva
2 ASA1-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA1-TMOS3 Skraping korneal
4 ASA1-TMOS4 Biopsi
5 ASA1-TMOS5 Eksisi pterygium
6 ASA1-TMOS6 Repair jahitan post operasi kornea
7 ASA1-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA1-TMOB1 Repair simblefaron
2 ASA1-TMOB2 Jahit laserasi kornea
3 ASA1-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA1-TMOB4 Trabekulektomi
5 ASA1-TMOB5 Siklodialisis
6 ASA1-TMOB6 Sklerotomi + iriodektomi
7 ASA1-TMOB7 Jahit laserasi sklera
8 ASA1-TMOB8 Operasi lain pada iris
9 ASA1-TMOB9 Paracenthesa
10 ASA1-TMOB10 ECCE dengan simple aspirasi
11 ASA1-TMOB11 Kapsulektomi
12 ASA1-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA1-TMOB13 Sekunder implant IOL
14 ASA1-TMOB14 Aff implant IOL
15 ASA1-TMOB15 Repair luka orbita
16 ASA1-TMOB16 Disisi lentis

KHUSUS A
1 ASA1-TMOKA1 Goniosinekiolisis
2 ASA1-TMOKA2 Sinekiolisis anterior
3 ASA1-TMOKA3 ECCE dengan linear ekstraksi
4 ASA1-TMOKA4 Disisi membran katarak sekunder
5 ASA1-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA1-TMOKA6 X-Ray orbita
7 ASA1-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA1-TMOKB1 Sinekiolisis posterior
2 ASA1-TMOKB2 Insersi sekunder implant okuler
3 ASA1-TMOKB3 Ekstraksi lensa jernih
4 ASA1-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA1-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA1-TMOKD1 Coreoplasty
 ASA 1
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 406,500 406,500 121,950

542,000 406,500 406,500 121,950
/abses 542,000 406,500 406,500 121,950

1,200,000 900,000 900,000 270,000

1,200,000 900,000 900,000 270,000
1,200,000 900,000 900,000 270,000
1,200,000 900,000 900,000 270,000
1,200,000 900,000 900,000 270,000
1,200,000 900,000 900,000 270,000
1,200,000 900,000 900,000 270,000

1,800,000 1,350,000 1,350,000 405,000

1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000
1,800,000 1,350,000 1,350,000 405,000

2,400,000 1,800,000 1,800,000 540,000

2,400,000 1,800,000 1,800,000 540,000
2,400,000 1,800,000 1,800,000 540,000
2,400,000 1,800,000 1,800,000 540,000
2,400,000 1,800,000 1,800,000 540,000
2,400,000 1,800,000 1,800,000 540,000
2,400,000 1,800,000 1,800,000 540,000
3,000,000 2,250,000 2,250,000 675,000
3,000,000 2,250,000 2,250,000 675,000
3,000,000 2,250,000 2,250,000 675,000
3,000,000 2,250,000 2,250,000 675,000

3,640,000 2,730,000 2,730,000 819,000

4,264,000 3,198,000 3,198,000 959,400

JUMLAH
Rp.

1,476,950
1,476,950
1,476,950

3,270,000
3,270,000
3,270,000
3,270,000
3,270,000
3,270,000
3,270,000

4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000
4,905,000

6,540,000
6,540,000
6,540,000
6,540,000
6,540,000
6,540,000
6,540,000
 8,175,000
8,175,000
8,175,000
8,175,000

9,919,000

11,619,400
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA2-OPERAK1 Subkonjungtival injeksi
2 ASA2-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA2-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA2-TMOS1 Repair laserasi konjungtiva
2 ASA2-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA2-TMOS3 Skraping korneal
4 ASA2-TMOS4 Biopsi
5 ASA2-TMOS5 Eksisi pterygium
6 ASA2-TMOS6 Repair jahitan post operasi kornea
7 ASA2-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA2-TMOB1 Repair simblefaron
2 ASA2-TMOB2 Jahit laserasi kornea
3 ASA2-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA2-TMOB4 Trabekulektomi
5 ASA2-TMOB5 Siklodialisis
6 ASA2-TMOB6 Sklerotomi + iriodektomi
7 ASA2-TMOB7 Jahit laserasi sklera
8 ASA2-TMOB8 Operasi lain pada iris
9 ASA2-TMOB9 Paracenthesa
10 ASA2-TMOB10 ECCE dengan simple aspirasi
11 ASA2-TMOB11 Kapsulektomi
12 ASA2-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA2-TMOB13 Sekunder implant IOL
14 ASA2-TMOB14 Aff implant IOL
15 ASA2-TMOB15 Repair luka orbita
16 ASA2-TMOB16 Disisi lentis

KHUSUS A
1 ASA2-TMOKA1 Goniosinekiolisis
2 ASA2-TMOKA2 Sinekiolisis anterior
3 ASA2-TMOKA3 ECCE dengan linear ekstraksi
4 ASA2-TMOKA4 Disisi membran katarak sekunder
5 ASA2-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA2-TMOKA6 X-Ray orbita
7 ASA2-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA2-TMOKB1 Sinekiolisis posterior
2 ASA2-TMOKB2 Insersi sekunder implant okuler
3 ASA2-TMOKB3 Ekstraksi lensa jernih
4 ASA2-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA2-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA2-TMOKD1 Coreoplasty
 ASA 2
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 406,500 406,500 142,275

542,000 406,500 406,500 142,275
/abses 542,000 406,500 406,500 142,275

1,200,000 900,000 900,000 315,000

1,200,000 900,000 900,000 315,000
1,200,000 900,000 900,000 315,000
1,200,000 900,000 900,000 315,000
1,200,000 900,000 900,000 315,000
1,200,000 900,000 900,000 315,000
1,200,000 900,000 900,000 315,000

1,800,000 1,350,000 1,350,000 472,500

1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500
1,800,000 1,350,000 1,350,000 472,500

2,400,000 1,800,000 1,800,000 630,000

2,400,000 1,800,000 1,800,000 630,000
2,400,000 1,800,000 1,800,000 630,000
2,400,000 1,800,000 1,800,000 630,000
2,400,000 1,800,000 1,800,000 630,000
2,400,000 1,800,000 1,800,000 630,000
2,400,000 1,800,000 1,800,000 630,000

3,000,000 2,250,000 2,250,000 787,500

3,000,000 2,250,000 2,250,000 787,500
3,000,000 2,250,000 2,250,000 787,500
3,000,000 2,250,000 2,250,000 787,500

3,640,000 2,730,000 2,730,000 955,500

4,264,000 3,198,000 3,198,000 1,119,300

JUMLAH
Rp.

1,497,275
1,497,275
1,497,275

3,315,000
3,315,000
3,315,000
3,315,000
3,315,000
3,315,000
3,315,000

4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500
4,972,500

6,630,000
6,630,000
6,630,000
6,630,000
6,630,000
6,630,000
 6,630,000

8,287,500
8,287,500
8,287,500
8,287,500

10,055,500

11,779,300
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA3-OPERAK1 Subkonjungtival injeksi
2 ASA3-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA3-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA3-TMOS1 Repair laserasi konjungtiva
2 ASA3-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA3-TMOS3 Skraping korneal
4 ASA3-TMOS4 Biopsi
5 ASA3-TMOS5 Eksisi pterygium
6 ASA3-TMOS6 Repair jahitan post operasi kornea
7 ASA3-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA3-TMOB1 Repair simblefaron
2 ASA3-TMOB2 Jahit laserasi kornea
3 ASA3-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA3-TMOB4 Trabekulektomi
5 ASA3-TMOB5 Siklodialisis
6 ASA3-TMOB6 Sklerotomi + iriodektomi
7 ASA3-TMOB7 Jahit laserasi sklera
8 ASA3-TMOB8 Operasi lain pada iris
9 ASA3-TMOB9 Paracenthesa
10 ASA3-TMOB10 ECCE dengan simple aspirasi
11 ASA3-TMOB11 Kapsulektomi
12 ASA3-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA3-TMOB13 Sekunder implant IOL
14 ASA3-TMOB14 Aff implant IOL
15 ASA3-TMOB15 Repair luka orbita
16 ASA3-TMOB16 Disisi lentis

KHUSUS A
1 ASA3-TMOKA1 Goniosinekiolisis
2 ASA3-TMOKA2 Sinekiolisis anterior
3 ASA3-TMOKA3 ECCE dengan linear ekstraksi
4 ASA3-TMOKA4 Disisi membran katarak sekunder
5 ASA3-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA3-TMOKA6 X-Ray orbita
7 ASA3-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA3-TMOKB1 Sinekiolisis posterior
2 ASA3-TMOKB2 Insersi sekunder implant okuler
3 ASA3-TMOKB3 Ekstraksi lensa jernih
4 ASA3-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA3-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA3-TMOKD1 Coreoplasty
 ASA 3
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 406,500 406,500 162,600

542,000 406,500 406,500 162,600
/abses 542,000 406,500 406,500 162,600

1,200,000 900,000 900,000 360,000

1,200,000 900,000 900,000 360,000
1,200,000 900,000 900,000 360,000
1,200,000 900,000 900,000 360,000
1,200,000 900,000 900,000 360,000
1,200,000 900,000 900,000 360,000
1,200,000 900,000 900,000 360,000

1,800,000 1,350,000 1,350,000 540,000

1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000
1,800,000 1,350,000 1,350,000 540,000

2,400,000 1,800,000 1,800,000 720,000

2,400,000 1,800,000 1,800,000 720,000
2,400,000 1,800,000 1,800,000 720,000
2,400,000 1,800,000 1,800,000 720,000
2,400,000 1,800,000 1,800,000 720,000
2,400,000 1,800,000 1,800,000 720,000
2,400,000 1,800,000 1,800,000 720,000

3,000,000 2,250,000 2,250,000 900,000

3,000,000 2,250,000 2,250,000 900,000
3,000,000 2,250,000 2,250,000 900,000
3,000,000 2,250,000 2,250,000 900,000

3,640,000 2,730,000 2,730,000 1,092,000

4,264,000 3,198,000 3,198,000 1,279,200

JUMLAH
Rp.

1,517,600
1,517,600
1,517,600

3,360,000
3,360,000
3,360,000
3,360,000
3,360,000
3,360,000
3,360,000

5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000
5,040,000

6,720,000
6,720,000
6,720,000
6,720,000
6,720,000
6,720,000
 6,720,000

8,400,000
8,400,000
8,400,000
8,400,000

10,192,000

11,939,200
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA4-OPERAK1 Subkonjungtival injeksi
2 ASA4-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA4-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA4-TMOS1 Repair laserasi konjungtiva
2 ASA4-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA4-TMOS3 Skraping korneal
4 ASA4-TMOS4 Biopsi
5 ASA4-TMOS5 Eksisi pterygium
6 ASA4-TMOS6 Repair jahitan post operasi kornea
7 ASA4-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA4-TMOB1 Repair simblefaron
2 ASA4-TMOB2 Jahit laserasi kornea
3 ASA4-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA4-TMOB4 Trabekulektomi
5 ASA4-TMOB5 Siklodialisis
6 ASA4-TMOB6 Sklerotomi + iriodektomi
7 ASA4-TMOB7 Jahit laserasi sklera
8 ASA4-TMOB8 Operasi lain pada iris
9 ASA4-TMOB9 Paracenthesa
10 ASA4-TMOB10 ECCE dengan simple aspirasi
11 ASA4-TMOB11 Kapsulektomi
12 ASA4-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA4-TMOB13 Sekunder implant IOL
14 ASA4-TMOB14 Aff implant IOL
15 ASA4-TMOB15 Repair luka orbita
16 ASA4-TMOB16 Disisi lentis

KHUSUS A
1 ASA4-TMOKA1 Goniosinekiolisis
2 ASA4-TMOKA2 Sinekiolisis anterior
3 ASA4-TMOKA3 ECCE dengan linear ekstraksi
4 ASA4-TMOKA4 Disisi membran katarak sekunder
5 ASA4-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA4-TMOKA6 X-Ray orbita
7 ASA4-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA4-TMOKB1 Sinekiolisis posterior
2 ASA4-TMOKB2 Insersi sekunder implant okuler
3 ASA4-TMOKB3 Ekstraksi lensa jernih
4 ASA4-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA4-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA4-TMOKD1 Coreoplasty
 ASA 4
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 406,500 406,500 182,925

542,000 406,500 406,500 182,925
/abses 542,000 406,500 406,500 182,925

1,200,000 900,000 900,000 405,000

1,200,000 900,000 900,000 405,000
1,200,000 900,000 900,000 405,000
1,200,000 900,000 900,000 405,000
1,200,000 900,000 900,000 405,000
1,200,000 900,000 900,000 405,000
1,200,000 900,000 900,000 405,000

1,800,000 1,350,000 1,350,000 607,500

1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500
1,800,000 1,350,000 1,350,000 607,500

2,400,000 1,800,000 1,800,000 810,000

2,400,000 1,800,000 1,800,000 810,000
2,400,000 1,800,000 1,800,000 810,000
2,400,000 1,800,000 1,800,000 810,000
2,400,000 1,800,000 1,800,000 810,000
2,400,000 1,800,000 1,800,000 810,000
2,400,000 1,800,000 1,800,000 810,000

3,000,000 2,250,000 2,250,000 1,012,500

3,000,000 2,250,000 2,250,000 1,012,500
3,000,000 2,250,000 2,250,000 1,012,500
3,000,000 2,250,000 2,250,000 1,012,500

3,640,000 2,730,000 2,730,000 1,228,500

4,264,000 3,198,000 3,198,000 1,439,100

JUMLAH
Rp.

1,537,925
1,537,925
1,537,925

3,405,000
3,405,000
3,405,000
3,405,000
3,405,000
3,405,000
3,405,000

5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500
5,107,500

6,810,000
6,810,000
6,810,000
6,810,000
6,810,000
6,810,000
 6,810,000

8,512,500
8,512,500
8,512,500
8,512,500

10,328,500

12,099,100
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA5-OPERAK1 Subkonjungtival injeksi
2 ASA5-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA5-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA5-TMOS1 Repair laserasi konjungtiva
2 ASA5-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA5-TMOS3 Skraping korneal
4 ASA5-TMOS4 Biopsi
5 ASA5-TMOS5 Eksisi pterygium
6 ASA5-TMOS6 Repair jahitan post operasi kornea
7 ASA5-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA5-TMOB1 Repair simblefaron
2 ASA5-TMOB2 Jahit laserasi kornea
3 ASA5-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA5-TMOB4 Trabekulektomi
5 ASA5-TMOB5 Siklodialisis
6 ASA5-TMOB6 Sklerotomi + iriodektomi
7 ASA5-TMOB7 Jahit laserasi sklera
8 ASA5-TMOB8 Operasi lain pada iris
9 ASA5-TMOB9 Paracenthesa
10 ASA5-TMOB10 ECCE dengan simple aspirasi
11 ASA5-TMOB11 Kapsulektomi
12 ASA5-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA5-TMOB13 Sekunder implant IOL
14 ASA5-TMOB14 Aff implant IOL
15 ASA5-TMOB15 Repair luka orbita
16 ASA5-TMOB16 Disisi lentis

KHUSUS A
1 ASA5-TMOKA1 Goniosinekiolisis
2 ASA5-TMOKA2 Sinekiolisis anterior
3 ASA5-TMOKA3 ECCE dengan linear ekstraksi
4 ASA5-TMOKA4 Disisi membran katarak sekunder
5 ASA5-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA5-TMOKA6 X-Ray orbita
7 ASA5-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA5-TMOKB1 Sinekiolisis posterior
2 ASA5-TMOKB2 Insersi sekunder implant okuler
3 ASA5-TMOKB3 Ekstraksi lensa jernih
4 ASA5-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA5-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA5-TMOKD1 Coreoplasty
 ASA 5
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 406,500 406,500 203,250

542,000 406,500 406,500 203,250
/abses 542,000 406,500 406,500 203,250

1,200,000 900,000 900,000 450,000

1,200,000 900,000 900,000 450,000
1,200,000 900,000 900,000 450,000
1,200,000 900,000 900,000 450,000
1,200,000 900,000 900,000 450,000
1,200,000 900,000 900,000 450,000
1,200,000 900,000 900,000 450,000

1,800,000 1,350,000 1,350,000 675,000

1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000
1,800,000 1,350,000 1,350,000 675,000

2,400,000 1,800,000 1,800,000 900,000

2,400,000 1,800,000 1,800,000 900,000
2,400,000 1,800,000 1,800,000 900,000
2,400,000 1,800,000 1,800,000 900,000
2,400,000 1,800,000 1,800,000 900,000
2,400,000 1,800,000 1,800,000 900,000
2,400,000 1,800,000 1,800,000 900,000

3,000,000 2,250,000 2,250,000 1,125,000

3,000,000 2,250,000 2,250,000 1,125,000
3,000,000 2,250,000 2,250,000 1,125,000
3,000,000 2,250,000 2,250,000 1,125,000

3,640,000 2,730,000 2,730,000 1,365,000

4,264,000 3,198,000 3,198,000 1,599,000

JUMLAH
Rp.

1,558,250
1,558,250
1,558,250

3,450,000
3,450,000
3,450,000
3,450,000
3,450,000
3,450,000
3,450,000

5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000
5,175,000

6,900,000
6,900,000
6,900,000
6,900,000
6,900,000
6,900,000
 6,900,000

8,625,000
8,625,000
8,625,000
8,625,000

10,465,000

12,259,000
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA1CYTO-OPERAK1 Subkonjungtival injeksi
2 ASA1CYTO-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA1CYTO-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA1CYTO-TMOS1 Repair laserasi konjungtiva
2 ASA1CYTO-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA1CYTO-TMOS3 Skraping korneal
4 ASA1CYTO-TMOS4 Biopsi
5 ASA1CYTO-TMOS5 Eksisi pterygium
6 ASA1CYTO-TMOS6 Repair jahitan post operasi kornea
7 ASA1CYTO-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA1CYTO-TMOB1 Repair simblefaron
2 ASA1CYTO-TMOB2 Jahit laserasi kornea
3 ASA1CYTO-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA1CYTO-TMOB4 Trabekulektomi
5 ASA1CYTO-TMOB5 Siklodialisis
6 ASA1CYTO-TMOB6 Sklerotomi + iriodektomi
7 ASA1CYTO-TMOB7 Jahit laserasi sklera
8 ASA1CYTO-TMOB8 Operasi lain pada iris
9 ASA1CYTO-TMOB9 Paracenthesa
10 ASA1CYTO-TMOB10 ECCE dengan simple aspirasi
11 ASA1CYTO-TMOB11 Kapsulektomi
12 ASA1CYTO-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA1CYTO-TMOB13 Sekunder implant IOL
14 ASA1CYTO-TMOB14 Aff implant IOL
15 ASA1CYTO-TMOB15 Repair luka orbita
16 ASA1CYTO-TMOB16 Disisi lentis

KHUSUS A
1 ASA1CYTO-TMOKA1 Goniosinekiolisis
2 ASA1CYTO-TMOKA2 Sinekiolisis anterior
3 ASA1CYTO-TMOKA3 ECCE dengan linear ekstraksi
4 ASA1CYTO-TMOKA4 Disisi membran katarak sekunder
5 ASA1CYTO-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA1CYTO-TMOKA6 X-Ray orbita
7 ASA1CYTO-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA1CYTO-TMOKB1 Sinekiolisis posterior
2 ASA1CYTO-TMOKB2 Insersi sekunder implant okuler
3 ASA1CYTO-TMOKB3 Ekstraksi lensa jernih
4 ASA1CYTO-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA1CYTO-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA1CYTO-TMOKD1 Coreoplasty
 ASA 1 CYTO
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 508,125 406,500 152,438

542,000 508,125 406,500 152,438
/abses 542,000 508,125 406,500 152,438

1,200,000 1,125,000 900,000 337,500

1,200,000 1,125,000 900,000 337,500
1,200,000 1,125,000 900,000 337,500
1,200,000 1,125,000 900,000 337,500
1,200,000 1,125,000 900,000 337,500
1,200,000 1,125,000 900,000 337,500
1,200,000 1,125,000 900,000 337,500

1,800,000 1,687,500 1,350,000 506,250

1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250
1,800,000 1,687,500 1,350,000 506,250

2,400,000 2,250,000 1,800,000 675,000

2,400,000 2,250,000 1,800,000 675,000
2,400,000 2,250,000 1,800,000 675,000
2,400,000 2,250,000 1,800,000 675,000
2,400,000 2,250,000 1,800,000 675,000
2,400,000 2,250,000 1,800,000 675,000
2,400,000 2,250,000 1,800,000 675,000

3,000,000 2,812,500 2,250,000 843,750

3,000,000 2,812,500 2,250,000 843,750
3,000,000 2,812,500 2,250,000 843,750
3,000,000 2,812,500 2,250,000 843,750

3,640,000 3,412,500 2,730,000 1,023,750

4,264,000 3,997,500 3,198,000 1,199,250

JUMLAH
Rp.

1,609,063
1,609,063
1,609,063

3,562,500
3,562,500
3,562,500
3,562,500
3,562,500
3,562,500
3,562,500

5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750
5,343,750

7,125,000
7,125,000
7,125,000
7,125,000
7,125,000
7,125,000
 7,125,000

8,906,250
8,906,250
8,906,250
8,906,250

10,806,250

12,658,750
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA2CYTO-OPERAK1 Subkonjungtival injeksi
2 ASA2CYTO-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA2CYTO-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA2CYTO-TMOS1 Repair laserasi konjungtiva
2 ASA2CYTO-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA2CYTO-TMOS3 Skraping korneal
4 ASA2CYTO-TMOS4 Biopsi
5 ASA2CYTO-TMOS5 Eksisi pterygium
6 ASA2CYTO-TMOS6 Repair jahitan post operasi kornea
7 ASA2CYTO-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA2CYTO-TMOB1 Repair simblefaron
2 ASA2CYTO-TMOB2 Jahit laserasi kornea
3 ASA2CYTO-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA2CYTO-TMOB4 Trabekulektomi
5 ASA2CYTO-TMOB5 Siklodialisis
6 ASA2CYTO-TMOB6 Sklerotomi + iriodektomi
7 ASA2CYTO-TMOB7 Jahit laserasi sklera
8 ASA2CYTO-TMOB8 Operasi lain pada iris
9 ASA2CYTO-TMOB9 Paracenthesa
10 ASA2CYTO-TMOB10 ECCE dengan simple aspirasi
11 ASA2CYTO-TMOB11 Kapsulektomi
12 ASA2CYTO-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA2CYTO-TMOB13 Sekunder implant IOL
14 ASA2CYTO-TMOB14 Aff implant IOL
15 ASA2CYTO-TMOB15 Repair luka orbita
16 ASA2CYTO-TMOB16 Disisi lentis

KHUSUS A
1 ASA2CYTO-TMOKA1 Goniosinekiolisis
2 ASA2CYTO-TMOKA2 Sinekiolisis anterior
3 ASA2CYTO-TMOKA3 ECCE dengan linear ekstraksi
4 ASA2CYTO-TMOKA4 Disisi membran katarak sekunder
5 ASA2CYTO-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA2CYTO-TMOKA6 X-Ray orbita
7 ASA2CYTO-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA2CYTO-TMOKB1 Sinekiolisis posterior
2 ASA2CYTO-TMOKB2 Insersi sekunder implant okuler
3 ASA2CYTO-TMOKB3 Ekstraksi lensa jernih
4 ASA2CYTO-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA2CYTO-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA2CYTO-TMOKD1 Coreoplasty
 ASA 2 CYTO
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 508,125 406,500 177,844

542,000 508,125 406,500 177,844
/abses 542,000 508,125 406,500 177,844

1,200,000 1,125,000 900,000 393,750

1,200,000 1,125,000 900,000 393,750
1,200,000 1,125,000 900,000 393,750
1,200,000 1,125,000 900,000 393,750
1,200,000 1,125,000 900,000 393,750
1,200,000 1,125,000 900,000 393,750
1,200,000 1,125,000 900,000 393,750

1,800,000 1,687,500 1,350,000 590,625

1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625
1,800,000 1,687,500 1,350,000 590,625

2,400,000 2,250,000 1,800,000 787,500

2,400,000 2,250,000 1,800,000 787,500
2,400,000 2,250,000 1,800,000 787,500
2,400,000 2,250,000 1,800,000 787,500
2,400,000 2,250,000 1,800,000 787,500
2,400,000 2,250,000 1,800,000 787,500
2,400,000 2,250,000 1,800,000 787,500

3,000,000 2,812,500 2,250,000 984,375

3,000,000 2,812,500 2,250,000 984,375
3,000,000 2,812,500 2,250,000 984,375
3,000,000 2,812,500 2,250,000 984,375

3,640,000 3,412,500 2,730,000 1,194,375

4,264,000 3,997,500 3,198,000 1,399,125

JUMLAH
Rp.

1,634,469
1,634,469
1,634,469

3,618,750
3,618,750
3,618,750
3,618,750
3,618,750
3,618,750
3,618,750

5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125
5,428,125

7,237,500
7,237,500
7,237,500
7,237,500
7,237,500
7,237,500
 7,237,500

9,046,875
9,046,875
9,046,875
9,046,875

10,976,875

12,858,625
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1ASA3CYTO-OPERAK1
Subkonjungtival injeksi
2 ASA3CYTO-TMOK2
Ekstraksi corpal magnetik kornea
3 ASA3CYTO-TMOK3
Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA3CYTO-TMOS1
Repair laserasi konjungtiva
2 ASA3CYTO-TMOS2
Ekstraksi corpal magnetik kornea dengan insisi
3 ASA3CYTO-TMOS3
Skraping korneal
4 ASA3CYTO-TMOS4
Biopsi
5 ASA3CYTO-TMOS5
Eksisi pterygium
6 ASA3CYTO-TMOS6
Repair jahitan post operasi kornea
7 ASA3CYTO-TMOS7
Injeksi intra kameral --> udara/obat

BESAR
1 ASA3CYTO-TMOB1
Repair simblefaron
2 ASA3CYTO-TMOB2
Jahit laserasi kornea
3 ASA3CYTO-TMOB3
Repair laserasi kornea + flap konjungtiva
4 ASA3CYTO-TMOB4
Trabekulektomi
5 ASA3CYTO-TMOB5
Siklodialisis
6 ASA3CYTO-TMOB6
Sklerotomi + iriodektomi
7 ASA3CYTO-TMOB7
Jahit laserasi sklera
8 ASA3CYTO-TMOB8
Operasi lain pada iris
9 ASA3CYTO-TMOB9
Paracenthesa
10ASA3CYTO-TMOB10
ECCE dengan simple aspirasi
11ASA3CYTO-TMOB11
Kapsulektomi
12ASA3CYTO-TMOB12
Insersi implant IOL durante operasi katarak
13ASA3CYTO-TMOB13
Sekunder implant IOL
14ASA3CYTO-TMOB14
Aff implant IOL
15ASA3CYTO-TMOB15
Repair luka orbita
16ASA3CYTO-TMOB16
Disisi lentis

KHUSUS A
1ASA3CYTO-TMOKA1
Goniosinekiolisis
2ASA3CYTO-TMOKA2
Sinekiolisis anterior
3ASA3CYTO-TMOKA3
ECCE dengan linear ekstraksi
4ASA3CYTO-TMOKA4
Disisi membran katarak sekunder
5ASA3CYTO-TMOKA5
Vitrektomi anterior durante ECCE
6ASA3CYTO-TMOKA6
X-Ray orbita
7ASA3CYTO-TMOKA7
ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1ASA3CYTO-TMOKB1
Sinekiolisis posterior
2ASA3CYTO-TMOKB2
Insersi sekunder implant okuler
3ASA3CYTO-TMOKB3
Ekstraksi lensa jernih
4ASA3CYTO-TMOKB4
Ekstraksi lensa ekstra linier

KHUSUS C
1ASA3CYTO-TMOKC1
Fakoemulsifikasi

KHUSUS D
1ASA3CYTO-TMOKD1
Coreoplasty
 ASA 3 CYTO
JASA
JASA PELAYANAN JUMLAH
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi Rp.

TARIF

542,000 508,125 406,500 203,250 1,659,875

542,000 508,125 406,500 203,250 1,659,875
542,000 508,125 406,500 203,250 1,659,875

1,200,000 1,125,000 900,000 450,000 3,675,000

1,200,000 1,125,000 900,000 450,000 3,675,000
1,200,000 1,125,000 900,000 450,000 3,675,000
1,200,000 1,125,000 900,000 450,000 3,675,000
1,200,000 1,125,000 900,000 450,000 3,675,000
1,200,000 1,125,000 900,000 450,000 3,675,000
1,200,000 1,125,000 900,000 450,000 3,675,000

1,800,000 1,687,500 1,350,000 675,000 5,512,500

1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500
1,800,000 1,687,500 1,350,000 675,000 5,512,500

2,400,000 2,250,000 1,800,000 900,000 7,350,000

2,400,000 2,250,000 1,800,000 900,000 7,350,000
2,400,000 2,250,000 1,800,000 900,000 7,350,000
2,400,000 2,250,000 1,800,000 900,000 7,350,000
2,400,000 2,250,000 1,800,000 900,000 7,350,000
2,400,000 2,250,000 1,800,000 900,000 7,350,000
2,400,000 2,250,000 1,800,000 900,000 7,350,000

3,000,000 2,812,500 2,250,000 1,125,000 9,187,500

3,000,000 2,812,500 2,250,000 1,125,000 9,187,500
3,000,000 2,812,500 2,250,000 1,125,000 9,187,500
3,000,000 2,812,500 2,250,000 1,125,000 9,187,500

3,640,000 3,412,500 2,730,000 1,365,000 11,147,500

4,264,000 3,997,500 3,198,000 1,599,000 13,058,500

 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA4CYTO-OPERAK1 Subkonjungtival injeksi
2 ASA4CYTO-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA4CYTO-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA4CYTO-TMOS1 Repair laserasi konjungtiva
2 ASA4CYTO-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA4CYTO-TMOS3 Skraping korneal
4 ASA4CYTO-TMOS4 Biopsi
5 ASA4CYTO-TMOS5 Eksisi pterygium
6 ASA4CYTO-TMOS6 Repair jahitan post operasi kornea
7 ASA4CYTO-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA4CYTO-TMOB1 Repair simblefaron
2 ASA4CYTO-TMOB2 Jahit laserasi kornea
3 ASA4CYTO-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA4CYTO-TMOB4 Trabekulektomi
5 ASA4CYTO-TMOB5 Siklodialisis
6 ASA4CYTO-TMOB6 Sklerotomi + iriodektomi
7 ASA4CYTO-TMOB7 Jahit laserasi sklera
8 ASA4CYTO-TMOB8 Operasi lain pada iris
9 ASA4CYTO-TMOB9 Paracenthesa
10 ASA4CYTO-TMOB10 ECCE dengan simple aspirasi
11 ASA4CYTO-TMOB11 Kapsulektomi
12 ASA4CYTO-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA4CYTO-TMOB13 Sekunder implant IOL
14 ASA4CYTO-TMOB14 Aff implant IOL
15 ASA4CYTO-TMOB15 Repair luka orbita
16 ASA4CYTO-TMOB16 Disisi lentis

KHUSUS A
1 ASA4CYTO-TMOKA1 Goniosinekiolisis
2 ASA4CYTO-TMOKA2 Sinekiolisis anterior
3 ASA4CYTO-TMOKA3 ECCE dengan linear ekstraksi
4 ASA4CYTO-TMOKA4 Disisi membran katarak sekunder
5 ASA4CYTO-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA4CYTO-TMOKA6 X-Ray orbita
7 ASA4CYTO-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA4CYTO-TMOKB1 Sinekiolisis posterior
2 ASA4CYTO-TMOKB2 Insersi sekunder implant okuler
3 ASA4CYTO-TMOKB3 Ekstraksi lensa jernih
4 ASA4CYTO-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA4CYTO-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA4CYTO-TMOKD1 Coreoplasty
 ASA 4 CYTO
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 508,125 406,500 228,656

542,000 508,125 406,500 228,656
/abses 542,000 508,125 406,500 228,656

1,200,000 1,125,000 900,000 506,250

1,200,000 1,125,000 900,000 506,250
1,200,000 1,125,000 900,000 506,250
1,200,000 1,125,000 900,000 506,250
1,200,000 1,125,000 900,000 506,250
1,200,000 1,125,000 900,000 506,250
1,200,000 1,125,000 900,000 506,250

1,800,000 1,687,500 1,350,000 759,375

1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375
1,800,000 1,687,500 1,350,000 759,375

2,400,000 2,250,000 1,800,000 1,012,500

2,400,000 2,250,000 1,800,000 1,012,500
2,400,000 2,250,000 1,800,000 1,012,500
2,400,000 2,250,000 1,800,000 1,012,500
2,400,000 2,250,000 1,800,000 1,012,500
2,400,000 2,250,000 1,800,000 1,012,500
 2,400,000 2,250,000 1,800,000 1,012,500

3,000,000 2,812,500 2,250,000 1,265,625

3,000,000 2,812,500 2,250,000 1,265,625
3,000,000 2,812,500 2,250,000 1,265,625
3,000,000 2,812,500 2,250,000 1,265,625

3,640,000 3,412,500 2,730,000 1,535,625

4,264,000.0 3,997,500.0 3,198,000.0 1,798,875.0

JUMLAH
Rp.

1,685,281
1,685,281
1,685,281

3,731,250
3,731,250
3,731,250
3,731,250
3,731,250
3,731,250
3,731,250

5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875
5,596,875

7,462,500
7,462,500
7,462,500
7,462,500
7,462,500
7,462,500
 7,462,500

9,328,125
9,328,125
9,328,125
9,328,125

11,318,125

13,258,375.0
 B. TINDAKAN MEDIK OPERATIF
NO. JENIS TINDAKAN
KODE
KECIL
1 ASA5CYTO-OPERAK1 Subkonjungtival injeksi
2 ASA5CYTO-TMOK2 Ekstraksi corpal magnetik kornea
3 ASA5CYTO-TMOK3 Insisi/eksisi : Hordeolum/kalazion, granuloma/papiloma, nevus/abses

SEDANG
1 ASA5CYTO-TMOS1 Repair laserasi konjungtiva
2 ASA5CYTO-TMOS2 Ekstraksi corpal magnetik kornea dengan insisi
3 ASA5CYTO-TMOS3 Skraping korneal
4 ASA5CYTO-TMOS4 Biopsi
5 ASA5CYTO-TMOS5 Eksisi pterygium
6 ASA5CYTO-TMOS6 Repair jahitan post operasi kornea
7 ASA5CYTO-TMOS7 Injeksi intra kameral --> udara/obat

BESAR
1 ASA5CYTO-TMOB1 Repair simblefaron
2 ASA5CYTO-TMOB2 Jahit laserasi kornea
3 ASA5CYTO-TMOB3 Repair laserasi kornea + flap konjungtiva
4 ASA5CYTO-TMOB4 Trabekulektomi
5 ASA5CYTO-TMOB5 Siklodialisis
6 ASA5CYTO-TMOB6 Sklerotomi + iriodektomi
7 ASA5CYTO-TMOB7 Jahit laserasi sklera
8 ASA5CYTO-TMOB8 Operasi lain pada iris
9 ASA5CYTO-TMOB9 Paracenthesa
10 ASA5CYTO-TMOB10 ECCE dengan simple aspirasi
11 ASA5CYTO-TMOB11 Kapsulektomi
12 ASA5CYTO-TMOB12 Insersi implant IOL durante operasi katarak
13 ASA5CYTO-TMOB13 Sekunder implant IOL
14 ASA5CYTO-TMOB14 Aff implant IOL
15 ASA5CYTO-TMOB15 Repair luka orbita
16 ASA5CYTO-TMOB16 Disisi lentis

KHUSUS A
1 ASA5CYTO-TMOKA1 Goniosinekiolisis
2 ASA5CYTO-TMOKA2 Sinekiolisis anterior
3 ASA5CYTO-TMOKA3 ECCE dengan linear ekstraksi
4 ASA5CYTO-TMOKA4 Disisi membran katarak sekunder
5 ASA5CYTO-TMOKA5 Vitrektomi anterior durante ECCE
6 ASA5CYTO-TMOKA6 X-Ray orbita
7 ASA5CYTO-TMOKA7 ECCE W/O implant IOL pengelompokkan tindakan medis rawat

KHUSUS B
1 ASA5CYTO-TMOKB1 Sinekiolisis posterior
2 ASA5CYTO-TMOKB2 Insersi sekunder implant okuler
3 ASA5CYTO-TMOKB3 Ekstraksi lensa jernih
4 ASA5CYTO-TMOKB4 Ekstraksi lensa ekstra linier

KHUSUS C
1 ASA5CYTO-TMOKC1 Fakoemulsifikasi

KHUSUS D
1 ASA5CYTO-TMOKD1 Coreoplasty
 ASA 5 CYTO
JASA
JASA PELAYANAN
SARANA
Rp. JasMed Dokter Jasa Lainnya Anasthesi

TARIF

542,000 508,125 406,500 254,063

542,000 508,125 406,500 254,063
/abses 542,000 508,125 406,500 254,063

1,200,000 1,125,000 900,000 562,500

1,200,000 1,125,000 900,000 562,500
1,200,000 1,125,000 900,000 562,500
1,200,000 1,125,000 900,000 562,500
1,200,000 1,125,000 900,000 562,500
1,200,000 1,125,000 900,000 562,500
1,200,000 1,125,000 900,000 562,500

1,800,000 1,687,500 1,350,000 843,750

1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750
1,800,000 1,687,500 1,350,000 843,750

2,400,000 2,250,000 1,800,000 1,125,000

2,400,000 2,250,000 1,800,000 1,125,000
2,400,000 2,250,000 1,800,000 1,125,000
2,400,000 2,250,000 1,800,000 1,125,000
2,400,000 2,250,000 1,800,000 1,125,000
2,400,000 2,250,000 1,800,000 1,125,000
2,400,000 2,250,000 1,800,000 1,125,000

3,000,000 2,812,500 2,250,000 1,406,250

3,000,000 2,812,500 2,250,000 1,406,250
3,000,000 2,812,500 2,250,000 1,406,250
3,000,000 2,812,500 2,250,000 1,406,250

3,640,000 3,412,500 2,730,000 1,706,250

4,264,000 3,997,500 3,198,000 1,998,750

JUMLAH
Rp.

1,710,688
1,710,688
1,710,688

3,787,500
3,787,500
3,787,500
3,787,500
3,787,500
3,787,500
3,787,500

5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250
5,681,250

7,575,000
7,575,000
7,575,000
7,575,000
7,575,000
7,575,000
 7,575,000

9,468,750
9,468,750
9,468,750
9,468,750

11,488,750

13,458,250