No Kode Obat Nama Obat BPJS Swasta Satuan

1 A-001 ACETYLCYSTEINE 200 MG √

2 A-002 ACYCLOVIR 400 MG √
3 A-003 ALBUFORCE √
4 A-004 ALDOMER 5 √
5 A-005 ALKOHOL SWAB √
6 A-006 ALLOPURINOL 300 MG √
7 A-007 ALOVELL 75 MG √
8 A-008 AMBROXOL HYDROCHLORIDA 30 MG (ERRITA) √
9 A-009 AMBROXOL HYDROCHLORIDA 30 MG (ETERCON) √
10 A-010 AMLODIPINE 5 MG √
12 A-012 AMOXICILLIN SYR √
13 A-013 AMOXICILLIN TRIHYDRATE 500 MG √
14 A-014 ANALSIK √
15 A-015 ASPILETS √
16 A-016 ASTA PLUS √
17 A-017 ASTATIN 4 √
18 A-018 ATORVASTATIN CALCIUM 10 MG √
19 A-019 B6 √ MAX 10
20 A-020 BARZEPIN 300 √
21 A-021 BENOCETAM 1500 MG √
23 A-023 BENOSON G ZALF √
24 A-024 BERTHYCO 500 MCG √
25 A-025 BETAHISTINE MESYLATE NPL √
26 A-026 BISOPROLOL 2,5 MG √
27 A-027 BISOPROLOL 5 MG √
28 A-028 BODREX √
29 A-029 BRALIFEX PLUS EYE DROP 5 ML √
30 A-030 BRAZINE √
31 A-031 CAL-95 √
32 A-032 CANDESERTAN (INFION) √
33 A-033 CANDESERTAN (NOVEL) √
34 A-034 CAPTOPRIL 25 MG √
35 A-035 CARBIDU 0.75 MG √
37 A-037 CEFADROXIL SYR √
38 A-038 CEFILA SYR √
39 A-039 CEFIXIME 100 MG √
40 A-040 CEFIXIME 100 MG NOVELL √
41 A-045 CEFIXIME 200 MG NOVELL √
42 A-041 CENDO ASTHENOF ED 5 ML √
43 A-042 CENDO AUGENTONIC √
44 A-043 CENDO CARPINE √
45 A-044 CENDO CENFRESH EDMD √ MAX 3
46 A-046 CENDO EFRISEL √
47 A-047 CENDO EYEFRESH ED 5 ML √
48 A-048 CENDO EYEFRESH EDMD √ MAX 3
49 A-049 CENDO FLOXA EDMD √ MAX 3
50 A-050 CENDO HYALUB √ MAX 2
51 A-051 CENDO LFX EDMD √ MAX 2
52 A-052 CENDO LYTEERS ED 15 ML √
53 A-053 CENDO LYTEERS EDMD √ MAX 3
54 A-054 CENDO MYDRIATYL ED 0.5% 5 ML √
55 A-055 CENDO NATACEN √ MAX 2
56 A-056 CENDO OCULENTA GEL MATA 5 GRAM √
57 A-057 CENDO PANTOCAIN 2% 5 ML √
58 A-058 CENDO POLYDEX EDMD √ MAX 3 √
59 A-059 CENDO POLYGRAN EDMD √ MAX 3 √
60 A-060 CENDO POLYNEL √ MAX 3
61 A-061 CENDO POSOP √ MAX 2
62 A-062 CENDO P-PRED EDMD √ MAX 3
63 A-063 CENDO PROTAGENTA EDMD √ MAX 3
64 A-064 CENDO TIMOL 0.5% EDMD √ MAX 3
65 A-065 CENDO TOBRO EDMD √ MAX 3
66 A-066 CENDO TOBROSON EDMD √ MAX 3
67 A-067 CENDO TROPIN 1% ED 5 ML √
68 A-068 CENDO VASACON EDMD √ MAX 3
69 A-069 CENDO VITROLENTA ED 5 ML √
70 A-070 CENDO XYTROL SALEP MATA 3.5 GRAM √
71 A-071 CEPEZET 100 MG √
72 A-072 CERECOL SYR √
74 A-074 CETRIZINE HCL TABLET √
75 A-075 CHANNA √
76 A-193 CIPROFLOXACIN 500 MG NOVELL √
77 A-191 CITION 1000 MG √
78 A-076 CLOFRITIS TAB 10 MG √
79 A-077 CLOPIDOGREL BISULFATE 75 MG (INTERBAT) √
80 A-078 CLOPIDOGREL BISULFATE 75 MG (LANDSON) √
81 A-079 CTM √
82 A-080 CURCUMA √
83 A-081 DC 2 √
84 A-082 DEXKETOPROFEN 25 MG √
85 A-196 DICLOFENAC SODIUM 50 MG √
86 A-083 DIQUAS 5 ML √
87 A-084 DIVOLTAR 50 MG √
88 A-085 DOMPERIDONE √
89 A-086 DONACEPT √
90 A-087 DONEPEZIL HCl 5 MG √
91 A-088 DULOXTA 60 √
92 A-089 EPERISONE HCl 50 MG (ETERCONE) √
93 A-090 EPERISONE HCl 50 MG (LAPI) √
94 A-091 EPESONE 50 MG √
95 A-194 EPILEPSAN SYRUP √
96 A-092 EPISAN SUSPENSI √
97 A-093 ETORICOXIB 90 MG √
98 A-094 EYE BRIGHT √
100 A-096 FLUNARIZINE 5 MG √
101 A-097 FOLAVIT 400 MG √
102 A-098 FRIXITAS 0.5 MG √
103 A-099 GABAPENTIN 300 MG √ MAX 3
105 A-101 GLAUSETA 250 MG √ MAX 5
106 A-102 GLIBENCLAMIDE 5 MG √
108 A-103 GRATAZONE √
109 A-104 HANDSCOON NON STERIL UK S √
110 A-105 HERVIS ZALF √
111 A-106 HIALID EYE DROP5 ML √
112 A-107 HY-FOLIC √
113 A-108 IBUPROFEN 400 √
114 A-109 IFALMIN √
115 A-110 INFIMYCIN √
116 A-111 INFUSION SET √
117 A-112 IREMAX √
118 A-113 KASA GULUNG HYDROFIL √
119 A-114 KODC HBSAG √
120 A-115 LAMESON 4 MG √
121 A-116 LAMESON SYRUP √
122 A-117 LAPIFLOX 500 √
123 A-118 L-BIO √
124 A-119 LERGIO OPYH. SOLUTION √
125 A-120 LEVOBEN √
126 A-121 LEVOCIN EYE DROP 5 ML √
127 A-122 LITENSAN √
128 A-123 LODIA 2 MG √
129 A-124 LODOMER 2 MG √
130 A-125 LOPERAMIDE √
131 A-126 LOKEV √ MAX 5
132 A-127 LORATADINE 10 MG NOVELL √
133 A-128 LOVASK 10 MG √
134 A-129 LUBIRE √
135 A-130 LUBRAN √
136 A-132 MAGANOL 500 MG √
137 A-133 MAXSTAN √
138 A-134 MECOBALAMIN 0.25 MG √
139 A-192 MECOBALAMIN 500 MCG √
140 A-135 MECONEURO √
141 A-136 MEDIKA POVIDINE 10% 1 L √
142 A-137 MEGABAL √
143 A-138 MELOXICAM 15 MG √ MAX 5
144 A-139 MELOXICAM 15 MG √ MAX 5
145 A-140 MELOXICAM 7.5 MG √ MAX 7
146 A-141 MEMOREX √
147 A-142 METFORMIN 500 MG √
148 A-143 METHYLON 4 MG √
149 A-144 METHYLPREDNISOLONE 4 MG √
150 A-145 METHYLPREDNISOLONE 4 MG (OGB) √
151 A-146 METHYLPREDNISOLONE 4 MG NOVELL √
152 A-197 METHYLPREDNISOLONE 8 MG √
153 A-147 METHYLPREDNISOLONE 8 MG (INFION) √
154 A-148 METRA GLOVESLX EXAM POW. S √
155 A-149 METRONIDAZOLE √
156 A-150 MEVILOX 15 √
157 A-151 MIGRATOP 25 MG √
158 A-152 MOLCIN OPTH. SOLUTION √
159 A-153 NERVA 5000 MG √
160 A-154 NEUGAIN √
161 A-155 NEURODEX TAB √
162 A-198 NEUVIS PRO 1000 CHEW √
163 A-156 NEUVIS PRO SYR √
164 A-157 NORFLAM √
165 A-158 NOVEXIB 100 MG √
166 A-159 NOVEXIB 200 MG √
167 A-160 NUTRI B √
169 A-162 OMEPRAZOLE 20 MG NPL √
170 A-163 ONDANSETRON HCl DIHYDRATE 4 MG √
171 A-164 OPTALVIT PLUS TABLET √
172 A-165 OPTALVIT SYRUP √
173 A-166 OPTIHEALTH PLUS √ MAX 6
174 A-167 PARACETAMOL √
175 A-168 PARFIX 10 X 500 CM √
176 A-169 PERTAM √
177 A-170 PIRACETAM 1200 √
178 A-171 PIRACETAM 400 √
179 A-172 POLYGRAN ZALF √
180 A-173 PRAMIVEX 0.125 √
181 A-174 PREDNISONE √
182 A-175 PREGABALIN 150 MG √
183 A-176 PREGABALIN 75 MG √ MAX 5
184 A-177 PREGAMAX 75 MG √
185 A-178 PREGAMEP 50 √
186 A-179 PROFENAL √
188 A-181 PUMPITOR 20 MG √
190 A-183 RANITIDINE √
192 A-185 RAMIPRIL 5 MG √
193 A-186 RINGER LAKTAT √
194 A-187 RIZONAX 50 √
195 A-188 ROSUPID 20 MG √
196 A-189 RUBYSTA POWDER 5 GRAM
197 A-190 SAGALON CREAM √
198 A-199 SALBUTAMOL 2 MG √
199 A-200 SANMOL DROP √
200 A-201 SANMOL SYRUP 60 ML √
201 A-202 SANMOL TABLET √
202 A-203 SILOXAN √
203 A-204 SILUM 10 MG √
204 A-205 SILUM 5 MG √
205 A-206 SIMCITI 500 MG √
206 A-207 SIMDROL-4 MG √
207 A-208 SIMFLAMFAS √
208 A-209 SIMFIX 100 MG √
209 A-210 SIMOVATE ZALF √
210 A-211 SIMPROFEN 25 MG √ MAX 3
211 A-212 SIMTRAM √
212 A-213 SIMZEN ORAL DROP 20 ML √
213 A-214 SOLASIC √
214 A-215 SOLFION 4 MG √
215 A-216 SOLFION 8 MG √
216 A-217 SPOIT 1 CC √
217 A-218 SPOIT 3 CC √
218 A-219 SPOIT 5 CC √
219 A-220 STAZOL 100 MG √
220 A-221 STERILE GLOVE 6.0 √
221 A-222 STERILE GLOVE 7.5 √
222 A-223 STRIP NESCO ASAM URAT 25 √
223 A-224 STRIP NESCO GULA 25 √
224 A-225 STRIP NESCO KOLESTEROL 10 √
225 A-226 STROVIT 500 MG √
226 A-227 SUNTIK KB ANDALAN 1 BLN 0.5 ML √
227 A-228 SYALOX P 300 √
228 A-229 takelin 1000 √
229 A-230 TAKELIN TAB 500 MG √
230 A-231 TAXIME 100 MG √
231 A-232 TOFEDEX 25 MG √ MAX 3
232 A-233 TREMENZA √
233 A-234 TRICODAZOLE 500 MG √
234 A-235 TRILAC 4 MG √
235 A-236 TRILAC INJ 10 MG/ML √
236 A-237 TROGYIL 500 MG √
237 A-238 TROPINEURON √
238 A-239 TUBIFAST 2 WAY STRETCH RED 10 M
239 A-240 VALISANBE 2 MG √
240 A-241 VALPROIC ACID SYRUP 250 MG/ 5 ML √
241 A-242 VERSILON 6 MG √
243 A-244 VITAMIN B COMPLEX √ MAX 10
244 A-245 VITSAP √
245 A-246 VOSERA 125 MG √
246 A-247 ZEGREN 50 MG √
247 A-248 ZILTAPE PAPER TAPE 0.5 INCH
248 A-249 ZINC SULFATE SYR √
249 A-250 ZOLTA 10 MG √
HNA PER TABLET/BIJIHARGA BPJS HARGA UMUM HARGA RESEP
1,000 1,221 1,500 1,500
700 855 1,100 1,500
58,900 65,379 87,000 95,000
18,500 22,589 28,000 30,000
200 244 300 500
420 513 700 1,000
91,500 111,722 135,000 150,000
192 234 500 1,000
1,000 1,500
1,500 2,000
4,505 5,000 10,000 15,000
397 485 1,000 1,500
1,550 1,893 2,500 3,000
555 678 1,000 2,000
8,750 10,684 14,000 15,000
6,300 7,692 11,000 12,000
1,200 1,465 2,000 2,500
128 156 500 1,000
7,800 9,524 12,000 13,000
5,000 6,105 7,500 8,500
60,000 73,260 90,000 100,000
17,000 20,757 25,000 28,000
840 1,026 1,500 2,000
550 610 1,000 2,000
900 999 1,500 3,000
440 488 1,000 2,000
47,600 58,120 70,000 80,000
2,686 3,280 4,000 4,500
5,500 6,716 8,500 9,000
5,000 8,000
6,000 9,000
1,000 2,000
1,500 1,665 2,500 3,000
6,818 7,567 10,000 15,000
120,000 145,000
2,176 2,657 3,189 2,416
2,176 2,657 4,000 5,000
3,666 4,476 6,000 7,000
21,000 25,641 35,000 35,000
40,000 45,000
25,000 30,000
 23,000 28,083 40,000 45,000
25,000 30,000
28,875 35,256 45,000 50,000
23,125 28,236 40,000 45,000
26,750 32,662 40,000 45,000
57,000 69,597 85,000 95,000
69,000 84,249 105,000 115,000
22,500 27,473 32,967 24,975
19,250 23,504 28,204 21,367
28,875 35,256 45,000 50,000
41,625 50,824 65,000 75,000
63,875 77,991 95,000 105,000
13,250 16,178 20,000 25,000
40,000 45,000
17,500 21,368 25,641 40,000
17,875 21,825 30,000 30,000
52,500 64,103 80,000 90,000
38,250 46,703 60,000 65,000
35,875 43,803 55,000 60,000
25,750 31,441 40,000 45,000
19,125 23,352 30,000 35,000
29,000 35,409 45,000 50,000
12,500 15,263 20,000 25,000
13,875 16,941 25,000 30,000
32,750 39,988 50,000 60,000
35,875 43,803 55,000 65,000
472 576 2,000 4,000
240,000 260,000
100 122 500 1,000
6,715 8,199 10,000 12,000
606 740 1,000 2,000
15,000 18,315 22,000 29,000
1,500 1,832 2,500 3,000
2,000 3,000
909 1,110 1,500 2,000
500 1,000
3,500 4,000
7,500 9,158 11,000 15,000
2,500 3,053 4,000 5,000
310 379 500 1,000
107,244 130,945 160,000 175,000
360 440 600 1,000
1,000 1,500
 14,200 17,338 23,000 24,000
6,000 7,326 9,000 10,000
13,750 16,789 21,000 22,000
1,540 1,880 2,500 3,000
1,500 1,832 2,500 3,000
4,000 4,884 6,000 7,000
75,000 91,575 110,000 125,000
50,100 61,172 75,000 85,000
5,000 6,105 7,500 8,500
8,000 9,000
2,000 3,000
2,000 2,500
2,475 3,022 7,000 8,000
4,410 5,385 7,000 7,000
4,850 5,922 7,000 8,000
125 153 500 1,000
151 167 500 1,000
900 1,099 1,500 2,000
70,000 85,000
89,000 108,669 135,000 135,000
4,150 5,067 6,500 7,000
281 343 500 1,000
5,500 6,716 8,500 9,500
55,000 66,000
9,000 10,989 15,000 20,000
1,050 1,282 2,000 2,500
140,000 170,940 210,000 230,000
50,000 61,050 73,260 55,500
3,750 4,579 5,500 6,500
120,000 145,000
13,000 15,873 20,000 23,000
7,750 9,463 12,000 15,000
80,000 97,680 120,000 15,000
9,000 13,000
76,600 93,529 115,000 125,000
7,666 9,360 12,000 13,000
1,708 2,085 3,000 4,000
1,092 1,333 2,000 2,000
1,000 2,000
394 481 6,000 1,500
302 369 500 2,000
9,500 11,600 14,000 16,000
8,000 9,000
 60,000 73,260 90,000 100,000
450 549 700 2,000
2,500 3,500
600 733 1,000 2,000
1,000 1,221 1,500 3,000
2,000 2,442 3,000 4,000
93,000 113,553 140,000 150,000
3,000 4,000
1,090 1,331 2,000 3,000
1,090 1,331 2,000 3,000
629 768 1,000 2,000
6,533 7,977 10,000 12,000
188 230 500 2,000
2,500 3,053 4,000 4,500
350 427 500 1,000
500 1,000
400 488 700 2,000
531 648 1,000 3,000
1,000 3,000
1,935 2,363 3,000 5,000
1,500 3,000
8,000 9,768 12,000 13,000
3,000 3,663 5,000 6,000
90,000 109,890 140,000 150,000
3,000 3,663 4,500 5,000
10,500 12,821 16,000 22,000
550 672 1,000 2,000
13,333 16,280 20,000 22,000
100,000 122,100 150,000 165,000
6,105 7,454 9,000 10,000
5,500 6,716 8,500 9,000
8,500 10,379 13,000 14,000
9,980 12,186 15,000 17,000
371 453 600 1,500
560 684 1,000 2,000
6,000 7,326 9,000 9,000
96,000 100,000
4,000 4,884 6,000 7,000
500 1,000
70,500 86,081 105,000 115,000
15,540 18,974 23,000 26,000
1,176 1,436 3,000 6,000
1,000 2,000
18,500 20,535 30,000 40,000
3,500 4,274 5,500 6,000
1,000 1,500
8,000 9,768 13,000 14,000
4,833 5,901 8,000 9,000
8,000 9,768 12,000 13,000
6,000 7,326 9,000 10,000
3,000 6,000
13,875 16,941 21,000 23,000
500 1,000
1,000 1,500
7,003 8,551 11,000 15,000
3,000 3,500
11,000 13,431 17,000 18,000
22,916 27,980 35,000 40,000
36,650 44,750 55,000 60,000
102 125 500 1,000
16,600 20,269 25,000 30,000
13,200 16,117 20,000 25,000
363 443 600 1,000
80,000 85,000
8,000 8,500
5,000 5,500
10,000 12,210 15,000 17,000
3,250 3,968 5,000 5,500
37,500 41,625 55,000 65,000
20,000 22,200 30,000 35,000
35,000 38,500 55,000 60,000
7,000 8,547 11,000 12,000
8,500 10,379 13,000 14,000
65,000 79,365 96,000 105,000
4,500 5,000
3,000 3,663 5,000 5,500
5,000 6,105 7,500 8,500
900 1,099 1,500 3,000
800 977 1,500 3,000
900 1,099 1,500 3,000
12,000 14,652 18,000 20,000
10,900 13,309 20,000 20,000
10,900 13,309 20,000 20,000
4,400 5,372 7,000 10,000
4,200 5,128 7,000 10,000
20,000 24,420 30,000 35,000
 7,000 8,547 11,000 12,000
3,300 4,029 5,000 10,000
33,000 40,293 50,000 55,000
28,000 30,000
9,100 11,111 14,000 15,000
2,833 3,459 4,500 5,000
7,000 8,547 11,000 12,000
2,500 3,000
3,500 4,000
3,850 4,701 5,640 4,273
110,000 134,310 165,000 170,000
3,500 4,000
3,000 3,500
240,000 293,040 355,000 390,000
250 305 1,000 2,000
42,000 51,282 65,000 70,000
3,500 4,500
78 95 500 2,000
3,066 3,403 4,500 5,500
4,500 5,495 7,000 8,000
1,500 1,832 2,200 2,500
150,000 183,150 220,000 250,000
3,000 3,330 5,000 10,000
6,500 7,937 10,000 11,000
NO JENIS PELAYANAN TARIF

1 ADMINISTRASI Rp. 20.000

2 REKAM MEDIK Rp. 10.000
3 SARANA DAN PETUGAS Rp. 40.000

TINDAKAN DOKTER
1 KONSUL DOKTER SPESIALIS Rp. 100.000
2 KONSUL DOKTER UMUM Rp. 75.000
3 PEMERIKSAAN KERATOMETRI Rp. 50.000
4 PEMERIKSAAN FOTO FUNDUS Rp. 300.000
5 PEMERIKSAAN TONOMETRI Rp. 20.000
6 PEMERIKSAAN YAG LASER Rp. 1.500.000
7 IRIGASI MATA Rp. 50.000
8 PEMERIKSAAN TES BUTA WARNA Rp. 50.000
9 PEMERIKSAAN SLIT LAMP Rp. 40.000
10 PEMERIKSAAN AUTOREFRAKTOMETRI (ARK) Rp. 50.000
11 PEMERIKSAAN TES FLOURESENSI Rp. 10.000
12 PEMERIKSAAN TES SCHIMER Rp. 25.000
13 PEMERIKSAAN FUNDUS COPY LENSA 78 Rp. 50.000

14 EPILASI BULU MATA Rp. 50.000

15 CABUT JAHITAN DI MATA Rp. 25.000

TINDAKAN PERAWAT
1 PEMERIKSAAN VISUS Rp. 10.000
2 KOREKSI REFRAKSI Rp. 20.000
3 PEMERIKSAAN BIOMETRI Rp. 25.000
4 PERBAN MATA Rp. 10.000
5 PASANG DOP MATA Rp. 10.000
6 PEMERIKSAAN TEKANAN BOLA BATA Rp. 10.000
7 PEMERIKSAAN TEKANAN DARAH Rp. 10.000

1.1 DAFTAR TARIF TINDAKAN OPERASI

TINDAKAN OPERASI (MATA)
1 TINDAKAN OP LEVEL I Rp. 6.500.000
2 TINDAKAN OP LEVEL II Rp. 9.500.000
3 TINDAKAN OPERASI LEVEL III Rp. 10.500.000
4 TINDAKAN OPERASI LEVEL IV Rp. 16.500.000
5 TINDAKAN OP PETHIGIUM Rp. 3.000.000
5 TINDAKAN OP KALAZION / HORDEOLUM Rp. 2.000.000

1.2 DAFTAR TARIF IGD

NO JENIS PELAYANAN TARIF

TINDAKAN KECIL

1 FOLLOW UP PASIEN 2 KALI Rp. 50.000

TINDAKAN SEDANG
2 l CROSS INSISI Rp. 85.000
l HECTING 1-5 JAHITAN TINDAKAN BESAR
3 l EXTRAKSI CORPUS Rp. 125.000
TELINGA/MATA/HIDUNG/TENGGOROKAN
l EXTRAKSI KUKU TINDAKAN KHUSUS
l HECTING > 5 JAHITAN
4 l PERAWATAN LUKA BAKAR < 20% Rp. 150.000
l PERAWATAN LUKA BAKAR > 20%
l FOLLOW UP 6 KALI
l KUMBAH LAMBUNG RESUSITASI RINGAN
l SIRKUMSISI

5 l REHIDRASI CAIRAN + PENGAWASAN Rp. 50.000

l REHIDRASI CAIRAN + BALANCE CAIRAN SEDANG
RESUSITASI
l PEMBERIAN DEX 40% 1 KALI
6 l PENANGANAN KEJANG > 1 KALI Rp. 85.000
l REHIDRASI CAIRAN + BALANCE CAIRAN
l PEMBERIAN DEX 40% 1 KALI
l PENANGANAN KEJANG > 1 KAL

RESUSITASI BESAR
7 l PEMBERIAN DEX 40% > 1 KALI Rp. 125.000
l PENANGANAN KEJANG > 1 KALI

RESUSITASI KHUSUS
8 l PEMBARIAN DOPAMIN Rp. 150.000
l PENGGUNAAN DC-SHOCK
l INTUBASI
l RJP

1.3 DARTAR TARIF PEMERIKSAAN PENUNJANG

NO JENIS PELAYANAN TARIF

LAB UMUM

1 LAB (BPJS) Rp. 176.000

2 LAB (SWASTA) Rp. 176.000

HEMATOLOGI
1 DARAH RUTIN Rp. 85.000
2 LED Rp. 40.000
3 CT Rp. 14.000
4 BT Rp. 14.000
NO JENIS PELAYANAN TARIF
KIMIA DARAH
1 GDS Rp. 36.000
2 GULA DARAH PUASA Rp. 36.000
3 GULA DARAH 2 JAM PP Rp. 36.000
4 COLESTEROL TOTAL Rp. 44.000
5 TRIGLISERIDA Rp. 70.000
6 ASAM URAT Rp. 37.000
7 UREUM Rp. 37.000
8 KREATIN Rp. 37.000
9 SGOT Rp. 37.000
10 SGPT Rp. 37.000
URINALISIS
1 URINE RUTIN Rp. 40.000

2 TES KEHAMILAN Rp. 30.000

 IMMUNOSERELOGI
1 HBsAG Rp. 55.000
2 ANTI HCV Rp. 85.000
3 WIDAL Rp. 47.000
4 MALARIA Rp. 180.000
5 RAPID AG SARS COV 2 Rp. 130.000
6 ELEKTROLIT Rp. 400.000
7 FUNGSI TIROID Rp. 700.000

1.4 DAFTAR TARIF BHP

NO JENIS BHP TARIF
1 HANDSCOON RP. 3000/ PSG
2 HANDSCOON STERIL RP. 20.000/PSG
3 CAIRAN RL RP. 12.000
4 CAIRAN NACL RP. 15.000
5 INFUS SET RP. 16.500/SET
6 BETADINE RP. 93.000/LITER
7 ALKOHOL RP. 40.000/LITER

8 KASSA STERIL KASSA ROL RP. 15.000/B0X RP.

140.000/ROLL
9 ALKOHOL SWAB RP. 35.000/BOX
10 RP. 350/LMBR
11 MASKER RP. 1000/BJI
12 NURSE CUB RP. 2000/BJI
13 UNDER PED RP. 6.500/BJI
14 HEPAFIX RP. 170.000/BOX
15 ABOCCATH RP. 13.000/BJI
16 STRIP GLUKOSA (ISI 25) RP. 200.000/BTL
17 STRIP KOLESTEROL (ISI 10) RP. 335.00/BTL

18 STRIP ASAM URAT (ISI 25) RP. 210.000/BTL

19 SPOIT 5 ML RP. 2000/PCS

20 SPOIT 10 ML RP. 3000/PCS
21 ABBOCATH 20&22 RP. 15.000/PCS

22 SPOIT 1 CC RP. 90.000/B0X

23 SPOIT 3 CC RP. 80.000/BOX

24 SPOIT 5 CC RP. 90.000/ BOX
NO JENIS PELAYANAN TARIF
TINDAKAN PERAWAT
1 EKTSTAKSI KORPUS Rp. 100.000

2 REFRAKSI Rp. 50.000

3 BIOMETRI Rp. 50.000

4 FOTO FUNDUS Rp. 300.000

5 TONOMETRI Rp.25.000

6 YAG LASER Rp. 1.500.000

7 IRIGASI MATA Rp. 30.000

8 TES BUTA WARNA Rp. 50.000