TARIF TINDAKAN POLIKLINIK MATA

No

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Jenis Tindakan

TINDAKAN SPESIALIS MATA

Anel test
Angkat jahitan palpebra
Angkat jahitan kornea
Autorefraksi
Biometri 1 mata
Eksisi granuloma palpebra/konjungtiva
Ekstraksi korpus alienum kornea
Ekstraksi korpus alienum konjungtiva
Ekstraksi lithiasis
Epilasi bulu mata
ERG ( Elektro Retinografi )
FFA ( Fundus Fluorescent Angiografi )
Fitting lensa kontak
Fluorescent test
Foto fundus
Funduskopi
Funduskopi ROP ( Retinopathi of Prematurity )
Ganti verban
Gonioskopi
Incisi hordeolum / chalazion
Kampimetri
Keratometri
Laser YAG
Laser fotokoagulasi
Patching mata
Retinometri

Jasa Medik 2011 (Rp)

30,000
30,000
40,000
25,000
60,000
50,000
40,000
25,000
60,000
30,000
60,000
250,000
50,000
25,000
200,000
25,000
75,000
20,000
40,000
60,000
75,000
25,000
200,000
250,000
20,000
50,000

27
28
29
30
31
32
33
34
35

Schirmer test
Slit lamp
Sondage canaliculi
Spooling bola mata
Streak retinoskopi
Test buta warna
Tonometri non contact
Tonometri schiotz
USG mata
*Usulan dr. Sukirman, Sp.M

25,000
20,000
50,000
30,000
40,000
20,000
25,000
20,000
150,000

Jasa Medik Usulan

30,000
30,000
40,000
25,000
60,000
50,000
50,000
40,000
60,000
30,000
60,000
250,000
50,000
25,000
200,000
40,000
75,000
20,000
40,000
60,000
90,000
35,000
250,000
300,000
20,000
50,000

Selisih lebih /
(kurang)

10,000
15,000
15,000
15,000
10,000
50,000
50,000
-

Persentase
Kenaikan (%)

25
60
60
20
40
25
20
-

Tarif Kesepakatan

Paraf

25,000
25,000
50,000
35,000
40,000
20,000
25,000
25,000
200,000

5,000
5,000
5,000
50,000

25
17
25
33

TARIF TINDAKAN POLIKLINIK THT

No

Jenis Tindakan

Jasa Medik 2011 (Rp)

TINDAKAN SPESIALIS THT

1 Tindakan Sederhana
- Ekstraksi serumen
- Cuci telinga
- Tampon telinga
- Test vstblm kobrak
- Audiometri
- Speech Audiometri

11,000
11,000
11,000
12,500
19,000
19,000

2 Hidung
- Nasal Toilet
- Belog Tampon
- Th/Epistaksis

11,000
11,000
17,000

3 Tenggorok
- Apus tenggorok
- Corpus alineum

11,000
19,000

4 Tes Alergi (Prick test )

- Tes Tempel
- ekstrak makanan
- Sekaligus ad.1 & 2

17,500
25,000
41,000

5 Tindakan Kecil
a. Punksi Hematom tlg
b. Ekstrp jar gran Tlg
c. Ins.perikondt telinga
d. Pasang tampon ant hdg
e. Cabut tampon ad.
f. Pasang tampon int hdg

11,000
17,500
17,500
11,000
11,000
17,500

g. Cabut tampon ad.

h. Ins + drain abses spt hdg
i. Biopsi Tumor superfsl
j. Elektrokauter bipolar

11,000
41,000
19,000
17,500

6
7
8
9
10
11
12
13
14

15
16
17
18
19
20
21
22
23
24
25
26

k. Nasofaringoskopi/endos
l. Ins+drain abs peritonsl
m. ad.m + biopsi
n. Parasentesa gendang tlg
o. Tes keseimbangan
p. Pasang tampon post hdg
q. Cabut tampon ad.
r. Tonodecay
s. Tonografi
t. Tonometri
u. Telemetri
Kemokaustik konka
Kemokaustik faring
Aspirasi abses septum
Aspirasi ot hematoma /perikondritis
Transluminasi
Audiogram nada murni
Timpanometri
Impedan audiometric
Nasoendoskopi
termasuk :
(A. Nasofaringoskopi)
(B. Laringoskopi)
(C. Otoskopi telinga)
Biopsi hidung
Biopsi nasofaringoskopi
Parasintesis Membran Timpani
OAE
Toilet Telinga
Toilet Hidung
Pasang tampon Anterior
Buka tampon anterior
Pasang tampon steril Telinga
Tes Vestibulum kobrak
Tes Alergi ( Prick Test)
Tes temple
Elektero Kauter

41,000
41,000
41,000
17,500
19,000
11,000
11,000
19,000
19,000
19,000
19,000
5,000
5,000
10,000
10,000
2,500
10,000
10,000
10,000
20,000

20,000
20,000
20,000
10,000
5,000
5,000
10,000
5,000
5,000
10,000
5,000
20,000

27
28
29
30

Tono Grafi
Tondecay
Tes Berbisik
Tes Garpu Penala

5,000
10,000
2,500
2,500

Jasa Medik Usulan

Selisih lebih /
(kurang)

Presentasi
Kenaikan (%)

Tarif Kesepakatan

19,000
19,000
19,000
37,500
31,000
31,000

8,000
8,000
8,000
25,000
12,000
12,000

73
73
73
200
63
63

19,000

8,000

73

17,000

19,000
31,000

8,000
12,000

73
63

32,000
25,000
41,000

14,500
-

83

31,000
32,000
32,000
31,000
19,000

20,000
14,500
14,500
20,000
8,000

182
83
83
182
73

Paraf

19,000

8,000

73

31,000
31,000

12,000
13,500

63
77

41,000

41,000
31,000
19,000

13,500
-

77
-

19,000
31,000
19,000
19,000
19,000
31,000
35,000
20,000
20,000
20,000
31,000
31,000
31,000

8,000
12,000
26,000
30,000
10,000
10,000
17,500
21,000
21,000
21,000

73
63
520
600
100
100
700
210
210
210

30,000
30,000
30,000
10,000
20,000
20,000
30,000
20,000
20,000
20,000

10,000
10,000
10,000
15,000
15,000
20,000
15,000
15,000
10,000

50
50
50
300
300
200
300
300
100

5,000
20,000

150,000

5,000
10,000
2,500
2,500

NO

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

JENIS OPERASI

DIGESTIVE
Afresia Duodenum
Apendektomi
Apendektomi dgn penyulit
Apendektomi perforasi laparatomi
Choledocho jejunostomi
Cholesistektomi
Debridement Luka
Ekplorasi koledokus
Fistulektomi
Gatrektomi (Bilroth 1:2)
Gastrotomy
Granuloma Umbilikalis laparatomi
Hemorhoidektomi
Herniotomi+Bassiniplasty
Herniotomi+surgi mesh
Herniotomi dgn komplikasi
Laparaskopik surgery
Laparatomi Colostomi
Laparatomi dengan Multiple Injury
Laparatomi dengan penyambungan khusus
Laparatomi Eksplorasi
Megacolon hirschsprung
Operasi Miles pada carcinomma recti
Pankreatektomi
Reseksi Anastomose
Reseksi Hepar
Speleenektomi
Transeksi Oesophagus
TUMOR
Amputasi Eksisi Kiste Brankiogenic
Biopsi dlm Narkose umum
Deseksi kelenjar
Eksisi kelenjar liur sub mandibula
Eksisi kista tiroglosus
Eksisi mamae aberans dua sisi/bilateral
Eksisi mamae aberans/unilateral
Eksplorasi Corpus Alineum
Fibro adenoma mame
Fibro adenoma mamae bilateral
Fibro adenoma mamae multiple
Hemiglosektomi
Isthmobacktomi
Mandibulektomi marginal
Mandibulektomi partial dengan rekontuksi

44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93

Mastektomi radikal
Mastektomi simple
Maxilektomi partial
Mailektomi radikal
Parotidektomi
Pembedah forequarter
Radical neck dissection
Segmentektomi
Thyroidektomi
Tracheostomi
Wide Eksisi Tumor + Jahit primer
Wide Eksisi Tumor luas
SOFT TISSUE TUMOR/MINOR SURGERY
Cauterisasi veruka/clavus
Ganglion, Kiste Atherome, Lipoma, Veruma
Naevus,clavus,roserplasty, pungsi hemarthros
Papiloma, Mucocele, insisi, kista delmoid, fibroma
Roserplasty
Sirkumsisi
Sirkumsisi dgn phimosis
Venaseksi
UROLOGI
Batu ureter di U.V. Junction
Batu Ginjal Stagharn
Biopsi Testis
Bladerneck insisition
Divertukulektomi
Enukleasi kista ginjal
Extended Pyelolitotomi
Fistula entero vesika
Hidrocelectomi B/W
Meatotomi
Nepherectomi
Nepherectomi partial
Nepherectomi radikal
Nephrostomi open
Open Prostatectomy
Orchidektomi ligasi tinggi
Orchidektomi sub kapsuler
Penectomi
Pyelolithotomi
Pyelonephrolithotomy
Pyeloplasti
Repair Urethra
Reparasi vistula vesiko vaginal
Reseksi partial vesiko
Sectio Alta vesicolithotomi
Sistostomi
Torsio Testis
Total cystectomi
Trans Urinal resection
Tumor testis
Ureterolithotomi

94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142

Uretoreneo cystostomi
Ureteroplasti
Urethero sigmoid dostomi
Urethotomi internal
Urethtretomi
Varikokelectomi/palamo
Vasektomi
PLASTIK
Angkat keloid luas
Chordectomi (eksisi chordee)
Debridement luka bakar
Fraktur rahang kompleks
Fraktur rahang sederhana
Free Flap surgery
Kelainan jari/ektrimitas (polidaktili,sindaktili)
Kontraktur komples
Kontraktur sederhana
Labioplasti Bilateral
Labioplasti unilateral
Microsurgery
Palatoplasty
Repair fistel urethra pasca uretoplasti
Repair luka robek kompleks pada wajah
Repair luka robek sederhana pada wajah
Skin grafting (STSG) tidak luas
STSG Luas
Terapi skelerosing
Urethroplasty hypospadi
THORAX/VASKULER
A-V Fiatel/cimino
Eksisi hemangioma komplek
Eksisi hemangioma simple
Lobektomi
Penyakit pembuluh darah perifer
Repair arteri/vena
Stripping Varises
Thoracotomy
WSD
ANAK
Apendektomi dengan penyulit
Appendektomi
Atresia Ani
CTEV & Kelainan ortopedi lain
Duhamel
Herniotomi dgn komplikasi
Herniotomi tanpa komplikasi
Hidrokel
Laparatomi Appendektomi Perforasi
Laparatomi colostomy
Orchidopexi
Polip Rekti
TULANG
Amputasi Cruiris,antebrachii

143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177

Amputasi Forequarter
Amputasi Hindquarter
Amputasi Jari komplek
Amputasi jari sederhana
Amputasi Transmeduler femur
Angkat plate cruris
Angkat plate screw: femur,humerus
Angkat screw yang tertinggal
Angkat wire pada fraktur
Debriment fraktur terbuka
Disarkulasi
Fiksasi interna yang sederhana
Fraksasi interna yang kompleks
Fingertip Injury,Flap
Fraktur colum femur
Fraktur kompresi tulang belakang
Fraltur pelvis acetabulun
Ganglion poplitea
Microsurgery
Multiple Fraktur dgn komplikasi
Open reduksi faktur
Operasi ruptule tendon kompleks
Osteosynthesa plate screw : antebrachii
Osteosynthesa plate screw : cruris
Osteosynthesa plate screw : femur
Osteosynthesa plate screw : humerus
Osteosynthesa supracondilare femur
Osteosynthesa supracondilare humerus
Osteosynthesa wire : olecranon, patella, dll
Repair repture tendon komplek
Repair repture tendon sederhana
Reposisi fraktur tertutup/dislokasi dlm narkose
Skeletal traksi
Traumatic Amputasi + STSG
Hipreplacemen

178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194

Meatostomi
Ateroma Multipe
Kista Ateroma Sedang
Debridement Sedang
Limpangioma
Lipoma Multiple
Rektoskopi Biopsi
Revisi Jahitan Muka
Skin Graft Sedang
Gigitan Binatang dengan Operasi
Sitoskopi
Soft Tissue Tumor Sedang
Limpadenophati 1
Abcess Perianal Fistel Simple
Debridoment Besar
Colostomi
Eks duct omphoplo + resect

195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227

Fraktur Nasal
Hernia
Hernia Umbilikalis
IDW
IDW + IMW
Multiple Ekcisi
Primary cleft palate unilat
Revisi kontraktur
Sinus Umbilikalis
Undesended testis/ UDT = 1
Tumor poplitea
Soft Tissue Tumor Besar
Multiple Linfadenophati
Sistostomi GA
Varicectomy
Wiring
A-V Fistel/Pseudoaneurasia
Anaplasti
Abses perianal fistle komplet
Thoraktomi Lobektomi
Hemoroidektomi + stapling
Laparatomi resektomi
Reseksi Khusus
Hernia raseksi
Hernia + Mesh
Hernia Umbilikalis penyulit
Primary cleft plate bilateral
Undensended Testis Bilateral
Cholosistectomi Laparascopi
Refair Hipospadi
Hernia Residif
Eksplorasi CBD
By Pass GI track

* Usulan Ka SMF bedah RSUD EF

Dr Asmoji SpB FINACS

TINDAKAN

Sarana/Jasa RS
(RP)

Alkes & OBHP

(Rp)

Jasa Medik
(Rp)
KELAS III

Sedang
Besar
Khusus
Khusus
Sedang
Besar
Besar
Besar
Khusus
Khusus
Besar
Khusus
Khusus

Besar

Kecil

Besar
Sedang

100,000
25,000
30,000
45,000
125,000
60,000
25,000
60,000
25,000
125,000
30,000
60,000
30,000
30,000
45,000
60,000
225,000
30,000
100,000
60,000
60,000
100,000
125,000
125,000
60,000
125,000
100,000
60,000

400,000
100,000
120,000
180,000
500,000
240,000
100,000
240,000
100,000
500,000
120,000
240,000
120,000
120,000
180,000
240,000
900,000
120,000
400,000
240,000
240,000
400,000
500,000
500,000
240,000
500,000
400,000
240,000

1,500,000
375,000
450,000
675,000
1,875,000
900,000
375,000
900,000
375,000
1,875,000
450,000
900,000
450,000
450,000
675,000
900,000
3,375,000
450,000
1,500,000
900,000
900,000
1,500,000
1,875,000
1,875,000
900,000
1,875,000
1,500,000
900,000

65,000
25,000
30,000
60,000
45,000
60,000
30,000
30,000
30,000
60,000
45,000
60,000
60,000
60,000
125,000

260,000
100,000
120,000
240,000
180,000
240,000
120,000
120,000
120,000
240,000
180,000
240,000
240,000
240,000
500,000

975,000
375,000
450,000
900,000
675,000
900,000
450,000
450,000
450,000
900,000
675,000
900,000
900,000
900,000
1,875,000

Khusus
Khusus

Khusus

Khusus
Besar
Besar
Kecil
Kecil
Kecil
Kecil
Sedang
Sedang

Khusus

Sedang
Khusus

Khusus
Besar
Besar

Khusus

Besar
Sedang

Besar

100,000
60,000
75,000
100,000
60,000
100,000
100,000
45,000
60,000
30,000
25,000
30,000

400,000
240,000
300,000
400,000
240,000
400,000
400,000
180,000
240,000
120,000
100,000
120,000

1,500,000
900,000
1,125,000
1,500,000
900,000
1,500,000
1,500,000
675,000
900,000
450,000
375,000
450,000

7,500
7,500
7,500
7,500
17,000
14,800
25,000
7,500

30,000
30,000
30,000
30,000
68,000
59,200
100,000
30,000

112,500
112,500
112,500
112,500
255,000
222,000
375,000
112,500

125,000
125,000
25,000
100,000
60,000
60,000
100,000
60,000
30,000
30,000
60,000
100,000
125,000
60,000
60,000
60,000
30,000
30,000
60,000
60,000
60,000
30,000
60,000
60,000
30,000
25,000
30,000
125,000
225,000
30,000
60,000

500,000
500,000
100,000
400,000
240,000
240,000
400,000
240,000
120,000
120,000
240,000
400,000
500,000
240,000
240,000
240,000
120,000
120,000
240,000
240,000
240,000
120,000
240,000
240,000
120,000
100,000
120,000
500,000
900,000
120,000
240,000

1,875,000
1,875,000
375,000
1,500,000
900,000
900,000
1,500,000
900,000
450,000
450,000
900,000
1,500,000
1,875,000
900,000
900,000
900,000
450,000
450,000
900,000
900,000
900,000
450,000
900,000
900,000
450,000
375,000
450,000
1,875,000
3,375,000
450,000
900,000

Besar
Sedang

Besar

Kecil
Besar

Khusus
Besar
Besar
Besar
Besar
Khusus
Khusus
Besar

Besar
Besar
Besar

125,000
100,000
60,000
60,000
60,000
30,000
30,000

500,000
400,000
240,000
240,000
240,000
120,000
120,000

1,875,000
1,500,000
900,000
900,000
900,000
450,000
450,000

30,000
45,000
30,000
60,000
30,000
225,000
30,000
60,000
45,000
45,000
30,000
225,000
45,000
30,000
45,000
30,000
30,000
60,000
30,000
60,000

120,000
180,000
120,000
240,000
120,000
900,000
120,000
240,000
180,000
180,000
120,000
900,000
180,000
120,000
180,000
120,000
120,000
240,000
120,000
240,000

450,000
675,000
450,000
900,000
450,000
3,375,000
450,000
900,000
675,000
675,000
450,000
3,375,000
675,000
450,000
675,000
450,000
450,000
900,000
450,000
900,000

60,000
60,000
30,000
125,000
45,000
60,000
45,000
125,000
25,000

240,000
240,000
120,000
500,000
180,000
240,000
180,000
500,000
100,000

900,000
900,000
450,000
1,875,000
675,000
900,000
675,000
1,875,000
375,000

30,000
25,000
60,000
60,000
100,000
60,000
30,000
30,000
45,000
30,000
75,000
30,000

90,000
75,000
180,000
180,000
300,000
180,000
90,000
90,000
135,000
90,000
225,000
90,000

480,000
400,000
960,000
960,000
1,600,000
960,000
480,000
480,000
720,000
480,000
1,200,000
480,000

45,000

135,000

720,000

Besar
Sedang
Sedang

Besar
Besar
Besar
Besar
Besar
Khusus

Kecil
Sedang
Sedang
Sedang
Sedang
Sedang
Sedang
Sedang
Sedang
Sedang
Sedang
Sedang
Sedang
Besar
Besar
Besar
Besar

125,000
125,000
45,000
25,000
60,000
30,000
45,000
125,000
30,000
30,000
45,000
60,000
125,000
30,000
125,000
200,000
200,000
30,000
225,000
125,000
125,000
60,000
45,000
45,000
100,000
100,000
125,000
125,000
45,000
60,000
45,000
45,000
30,000
30,000
225,000

375,000
375,000
135,000
75,000
180,000
90,000
135,000
375,000
90,000
90,000
135,000
180,000
375,000
90,000
375,000
600,000
600,000
90,000
675,000
375,000
375,000
180,000
135,000
135,000
300,000
300,000
375,000
375,000
135,000
180,000
135,000
135,000
90,000
90,000
675,000

2,000,000
2,000,000
720,000
400,000
960,000
480,000
720,000
2,000,000
480,000
480,000
720,000
960,000
2,000,000
480,000
2,000,000
3,200,000
3,200,000
480,000
3,600,000
2,000,000
2,000,000
960,000
720,000
720,000
1,600,000
1,600,000
2,000,000
2,000,000
720,000
960,000
720,000
720,000
480,000
480,000
3,600,000

Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Besar
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus
Khusus

U. TARIF JASA TINDAKAN OPERASI BED

Jasa Medik (Rp) PERDA 2007 Usulan Jasa Medik (Rp)

Tarif
(Rp)

Sarana/Jasa RS
(RP)

KELAS III

430,000
648,000
864,000

750,000
3,750,000
6,750,000

864,000
430,000

6,750,000
750,000

648,000

3,750,000

648,000

3,750,000

648,000

3,750,000

864,000

6,750,000

864,000
648,000

6,750,000
3,750,000

864,000
864,000

6,750,000
6,750,000

648,000

3,750,000

270,000

500,000

648,000
430,000

3,750,000
750,000

2,000,000
500,000
600,000
900,000
2,500,000
1,200,000
500,000
1,200,000
500,000
2,500,000
600,000
1,200,000
600,000
600,000
900,000
1,200,000
4,500,000
600,000
2,000,000
1,200,000
1,200,000
2,000,000
2,500,000
2,500,000
1,200,000
2,500,000
2,000,000
1,200,000

125,000
37,500
42,500
65,000
150,000
85,000
37,500
85,000
37,500
150,000
42,500
85,000
42,500
42,500
65,000
85,000
250,000
42,500
125,000
85,000
85,000
175,000
150,000
150,000
85,000
150,000
125,000
85,000

1,300,000
500,000
600,000
1,200,000
900,000
1,200,000
600,000
600,000
600,000
1,200,000
900,000
1,200,000
1,200,000
1,200,000
2,500,000

85,000
37,500
42,500
85,000
65,000
85,000
42,500
42,500
42,500
85,000
65,000
85,000
85,000
85,000
150,000

864,000
864,000

6,750,000
6,750,000

864,000

6,750,000

864,000
648,000

6,750,000
3,750,000

648,000

3,750,000

270,000
270,000
270,000
270,000
430,000
430,000

500,000
500,000
500,000
500,000
750,000
750,000

864,000

6,750,000

430,000

750,000

864,000

6,750,000

864,000
648,000
648,000

6,750,000
3,750,000
3,750,000

864,000

6,750,000

648,000
430,000

3,750,000
750,000

648,000

3,750,000

2,000,000
1,200,000
1,500,000
2,000,000
1,200,000
2,000,000
2,000,000
900,000
1,200,000
600,000
500,000
600,000

125,000
85,000
100,000
125,000
85,000
125,000
125,000
65,000
85,000
42,500
37,500
42,500

150,000
150,000
150,000
150,000
340,000
296,000
500,000
150,000

12,000
12,000
12,000
12,000
21,500
19,300
37,500
12,000

2,500,000
2,500,000
500,000
2,000,000
1,200,000
1,200,000
2,000,000
1,200,000
600,000
600,000
1,200,000
2,000,000
2,500,000
1,200,000
1,200,000
1,200,000
600,000
600,000
1,200,000
1,200,000
1,200,000
600,000
1,200,000
1,200,000
600,000
500,000
600,000
2,500,000
4,500,000
600,000
1,200,000

150,000
150,000
37,500
125,000
85,000
85,000
125,000
85,000
42,500
42,500
85,000
125,000
150,000
85,000
85,000
85,000
42,500
42,500
85,000
85,000
85,000
42,500
85,000
85,000
42,500
37,500
42,500
150,000
250,000
42,500
85,000

648,000
430,000

3,750,000
750,000

648,000

3,750,000

270,000
648,000

500,000
3,750,000

864,000
648,000
648,000

6,750,000
3,750,000
3,750,000

648,000
864,000
864,000
648,000

3,750,000
6,750,000
6,750,000
3,750,000

648,000
648,000

3,750,000
3,750,000

648,000

3,750,000

2,500,000
2,000,000
1,200,000
1,200,000
1,200,000
600,000
600,000

150,000
175,000
85,000
85,000
85,000
42,500
42,500

600,000
900,000
600,000
1,200,000
600,000
4,500,000
600,000
1,200,000
900,000
900,000
600,000
4,500,000
900,000
600,000
900,000
600,000
600,000
1,200,000
600,000
1,200,000

42,500
65,000
42,500
85,000
42,500
250,000
42,500
85,000
65,000
65,000
42,500
250,000
65,000
42,500
65,000
42,500
42,500
85,000
42,500
85,000

1,200,000
1,200,000
600,000
2,500,000
900,000
1,200,000
900,000
2,500,000
500,000

85,000
85,000
42,500
150,000
65,000
85,000
65,000
150,000
37,500

600,000
500,000
1,200,000
1,200,000
2,000,000
1,200,000
600,000
600,000
900,000
600,000
1,500,000
600,000

42,500
37,500
85,000
85,000
125,000
85,000
42,500
42,500
6,500
42,500
100,000
42,500

900,000

65,000

648,000

3,750,000

430,000
430,000

750,000
750,000

648,000

3,750,000

648,000
648,000
648,000
648,000

3,750,000
3,750,000
3,750,000
3,750,000

864,000

6,750,000

270,000
430,000
430,000
430,000
430,000
430,000
430,000
430,000
430,000
430,000
430,000
430,000
430,000
648,000
648,000
648,000
648,000

500,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
3,750,000
3,750,000
3,750,000
3,750,000

2,500,000
2,500,000
900,000
500,000
1,200,000
600,000
900,000
2,500,000
600,000
600,000
900,000
1,200,000
2,500,000
600,000
2,500,000
4,000,000
4,000,000
600,000
4,500,000
2,500,000
2,500,000
1,200,000
900,000
900,000
2,000,000
2,000,000
2,500,000
2,500,000
900,000
1,200,000
900,000
900,000
600,000
600,000
4,500,000

150,000
150,000
6,500
37,500
85,000
42,500
6,500
150,000
42,500
42,500
6,500
85,000
150,000
42,500
150,000
250,000
250,000
42,500
250,000
150,000
150,000
85,000
6,500
6,500
125,000
125,000
150,000
150,000
65,000
85,000
6,500
65,000
42,500
42,500
250,000

648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
648,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000
864,000

3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
3,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000
6,750,000

A TINDAKAN OPERASI BEDAH

Alkes & OBHP

(Rp)

Jasa Medik
(Rp)

Jasa Medik (Rp) PERDA 2007 Usulan Jasa Medik (Rp)

KELAS II

500,000
150,000
170,000
260,000
600,000
340,000
150,000
340,000
150,000
600,000
170,000
340,000
170,000
170,000
260,000
340,000
1,000,000
170,000
500,000
340,000
340,000
700,000
600,000
600,000
340,000
600,000
500,000
340,000

1,875,000
562,500
637,500
975,000
2,250,000
1,275,000
562,500
1,275,000
562,500
2,250,000
637,500
1,275,000
637,500
637,500
975,000
1,275,000
3,750,000
637,500
1,875,000
1,275,000
1,275,000
2,625,000
2,250,000
2,250,000
1,275,000
2,250,000
1,875,000
1,275,000

340,000
150,000
170,000
340,000
260,000
340,000
170,000
170,000
170,000
340,000
260,000
340,000
340,000
340,000
600,000

1,275,000
562,500
637,500
1,275,000
975,000
1,275,000
637,500
637,500
637,500
1,275,000
975,000
1,275,000
1,275,000
1,275,000
2,250,000

750,000
1,080,000
1,350,000

1,750,000
4,750,000
7,250,000

1,350,000
750,000

7,250,000
1,750,000

1,080,000

4,750,000

1,080,000

4,750,000

1,080,000

4,750,000

1,350,000

7,250,000

1,350,000
1,080,000

7,250,000
4,750,000

1,350,000
1,350,000

7,250,000
7,250,000

1,080,000

4,750,000

450,000

500,000

1,080,000
750,000

4,750,000
1,750,000

500,000
340,000
400,000
500,000
340,000
500,000
500,000
260,000
340,000
170,000
150,000
170,000

1,875,000
1,275,000
1,500,000
1,875,000
1,275,000
1,875,000
1,875,000
975,000
1,275,000
637,500
562,500
637,500

1,350,000
1,350,000

7,250,000
7,250,000

1,350,000

7,250,000

1,350,000
1,080,000

7,250,000
4,750,000

1,080,000

4,750,000

48,000
48,000
48,000
48,000
86,000
77,200
150,000
48,000

180,000
180,000
180,000
180,000
322,500
289,500
562,500
180,000

450,000
450,000
450,000
450,000
750,000
750,000

500,000
500,000
500,000
500,000
1,750,000
1,750,000

600,000
600,000
150,000
500,000
340,000
340,000
500,000
340,000
170,000
170,000
340,000
500,000
600,000
340,000
340,000
340,000
170,000
170,000
340,000
340,000
340,000
170,000
340,000
340,000
170,000
150,000
170,000
600,000
1,000,000
170,000
340,000

2,250,000
2,250,000
562,500
1,875,000
1,275,000
1,275,000
1,875,000
1,275,000
637,500
637,500
1,275,000
1,875,000
2,250,000
1,275,000
1,275,000
1,275,000
637,500
637,500
1,275,000
1,275,000
1,275,000
637,500
1,275,000
1,275,000
637,500
562,500
637,500
2,250,000
3,750,000
637,500
1,275,000

1,350,000

7,250,000

750,000

1,750,000

1,350,000

7,250,000

1,350,000
1,080,000
1,080,000

7,250,000
4,750,000
4,750,000

1,350,000

7,250,000

1,080,000
750,000

4,750,000
1,750,000

1,080,000

4,750,000

600,000
700,000
340,000
340,000
340,000
170,000
170,000

2,250,000
2,625,000
1,275,000
1,275,000
1,275,000
637,500
637,500

170,000
260,000
170,000
340,000
170,000
1,000,000
170,000
340,000
260,000
260,000
170,000
1,000,000
260,000
170,000
260,000
170,000
170,000
340,000
170,000
340,000

637,500
975,000
637,500
1,275,000
637,500
3,750,000
637,500
1,275,000
975,000
975,000
637,500
3,750,000
975,000
637,500
975,000
637,500
637,500
1,275,000
637,500
1,275,000

340,000
340,000
170,000
600,000
260,000
340,000
260,000
600,000
150,000

1,275,000
1,275,000
637,500
2,250,000
975,000
1,275,000
975,000
2,250,000
562,500

127,500
112,500
255,000
255,000
375,000
255,000
127,500
127,500
19,500
127,500
300,000
127,500

680,000
600,000
1,360,000
1,360,000
2,000,000
1,360,000
680,000
680,000
104,000
680,000
1,600,000
680,000

195,000

1,040,000

1,080,000
750,000

4,750,000
1,750,000

1,080,000

4,750,000

450,000
1,080,000

500,000
4,750,000

1,350,000
1,080,000
1,080,000

7,250,000
4,750,000
4,750,000

1,080,000
1,350,000
1,350,000
1,080,000

4,750,000
7,250,000
7,250,000
4,750,000

1,080,000
1,080,000

4,750,000
4,750,000

1,080,000

4,750,000

450,000
450,000
19,500
112,500
255,000
127,500
19,500
450,000
127,500
127,500
19,500
255,000
450,000
127,500
450,000
750,000
750,000
127,500
750,000
450,000
450,000
255,000
19,500
19,500
375,000
375,000
450,000
450,000
195,000
255,000
19,500
195,000
127,500
127,500
750,000

2,400,000
2,400,000
104,000
600,000
1,360,000
680,000
104,000
2,400,000
680,000
680,000
104,000
1,360,000
2,400,000
680,000
2,400,000
4,000,000
4,000,000
680,000
4,000,000
2,400,000
2,400,000
1,360,000
104,000
104,000
2,000,000
2,000,000
2,400,000
2,400,000
1,040,000
1,360,000
104,000
1,040,000
680,000
680,000
4,000,000

1,080,000

4,750,000

750,000
750,000

1,750,000
1,750,000

1,080,000

4,750,000

1,080,000
1,080,000
1,080,000
1,080,000

4,750,000
4,750,000
4,750,000
4,750,000

1,350,000

7,250,000

450,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
1,080,000
1,080,000
1,080,000
1,080,000

500,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
1,750,000
4,750,000
4,750,000
4,750,000
4,750,000

1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000
1,350,000

4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
4,750,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000
7,250,000

Tarif
(Rp)

Sarana/Jasa RS
(RP)

Alkes & OBHP

(Rp)

Jasa Medik
(Rp)
KELAS I

2,500,000
750,000
850,000
1,300,000
3,000,000
1,700,000
750,000
1,700,000
750,000
3,000,000
850,000
1,700,000
850,000
850,000
1,300,000
1,700,000
5,000,000
850,000
2,500,000
1,700,000
1,700,000
3,500,000
3,000,000
3,000,000
1,700,000
3,000,000
2,500,000
1,700,000

175,000
50,000
60,000
90,000
200,000
120,000
50,000
120,000
50,000
200,000
60,000
120,000
60,000
60,000
90,000
120,000
300,000
60,000
175,000
120,000
120,000
175,000
200,000
200,000
120,000
200,000
150,000
120,000

700,000
200,000
240,000
360,000
800,000
480,000
200,000
480,000
200,000
800,000
240,000
480,000
240,000
240,000
360,000
480,000
1,200,000
240,000
700,000
480,000
480,000
700,000
800,000
800,000
480,000
800,000
600,000
480,000

2,625,000
750,000
900,000
1,350,000
3,000,000
1,800,000
750,000
1,800,000
750,000
3,000,000
900,000
1,800,000
900,000
900,000
1,350,000
1,800,000
4,500,000
900,000
2,625,000
1,800,000
1,800,000
2,625,000
3,000,000
3,000,000
1,800,000
3,000,000
2,250,000
1,800,000

1,700,000
750,000
850,000
1,700,000
1,300,000
1,700,000
850,000
850,000
850,000
1,700,000
1,300,000
1,700,000
1,700,000
1,700,000
3,000,000

120,000
50,000
60,000
120,000
90,000
120,000
60,000
60,000
60,000
120,000
90,000
120,000
120,000
120,000
200,000

480,000
200,000
240,000
480,000
360,000
480,000
240,000
240,000
240,000
480,000
360,000
480,000
480,000
480,000
800,000

1,800,000
750,000
900,000
1,800,000
1,350,000
1,800,000
900,000
900,000
900,000
1,800,000
1,350,000
1,800,000
1,800,000
1,800,000
3,000,000

2,500,000
1,700,000
2,000,000
2,500,000
1,700,000
2,500,000
2,500,000
1,300,000
1,700,000
850,000
750,000
850,000

175,000
120,000
125,000
175,000
120,000
175,000
175,000
90,000
120,000
60,000
50,000
60,000

700,000
480,000
500,000
700,000
480,000
700,000
700,000
360,000
480,000
240,000
200,000
240,000

2,625,000
1,800,000
1,875,000
2,625,000
1,800,000
2,625,000
2,625,000
1,350,000
1,800,000
900,000
750,000
900,000

240,000
240,000
240,000
240,000
430,000
386,000
750,000
240,000

21,000
21,000
21,000
21,000
30,500
28,300
50,000
21,000

84,000
84,000
84,000
84,000
122,000
113,200
200,000
84,000

315,000
315,000
315,000
315,000
457,500
424,500
750,000
315,000

3,000,000
3,000,000
750,000
2,500,000
1,700,000
1,700,000
2,500,000
1,700,000
850,000
850,000
1,700,000
2,500,000
3,000,000
1,700,000
1,700,000
1,700,000
850,000
850,000
1,700,000
1,700,000
1,700,000
850,000
1,700,000
1,700,000
850,000
750,000
850,000
3,000,000
5,000,000
850,000
1,700,000

200,000
200,000
50,000
175,000
120,000
120,000
175,000
120,000
60,000
60,000
120,000
175,000
200,000
120,000
120,000
120,000
60,000
60,000
120,000
120,000
120,000
60,000
120,000
120,000
60,000
50,000
60,000
200,000
300,000
60,000
120,000

800,000
800,000
200,000
700,000
480,000
480,000
700,000
480,000
240,000
240,000
480,000
700,000
800,000
480,000
480,000
480,000
240,000
240,000
480,000
480,000
480,000
240,000
480,000
480,000
240,000
200,000
240,000
800,000
1,200,000
240,000
480,000

3,000,000
3,000,000
750,000
2,625,000
1,800,000
1,800,000
2,625,000
1,800,000
900,000
900,000
1,800,000
2,625,000
3,000,000
1,800,000
1,800,000
1,800,000
900,000
900,000
1,800,000
1,800,000
1,800,000
900,000
1,800,000
1,800,000
900,000
750,000
900,000
3,000,000
4,500,000
900,000
1,800,000

3,000,000
3,500,000
1,700,000
1,700,000
1,700,000
850,000
850,000

200,000
175,000
120,000
120,000
120,000
60,000
60,000

800,000
700,000
480,000
480,000
480,000
240,000
240,000

3,000,000
2,625,000
1,800,000
1,800,000
1,800,000
900,000
900,000

850,000
1,300,000
850,000
1,700,000
850,000
5,000,000
850,000
1,700,000
1,300,000
1,300,000
850,000
5,000,000
1,300,000
850,000
1,300,000
850,000
850,000
1,700,000
850,000
1,700,000

60,000
90,000
60,000
120,000
60,000
300,000
60,000
120,000
90,000
90,000
60,000
300,000
90,000
60,000
90,000
60,000
60,000
120,000
60,000
120,000

240,000
360,000
240,000
480,000
240,000
1,200,000
240,000
480,000
360,000
360,000
240,000
1,200,000
360,000
240,000
360,000
240,000
240,000
480,000
240,000
480,000

900,000
1,350,000
900,000
1,800,000
900,000
4,500,000
900,000
1,800,000
1,350,000
1,350,000
900,000
4,500,000
1,350,000
900,000
1,350,000
900,000
900,000
1,800,000
900,000
1,800,000

1,700,000
1,700,000
850,000
3,000,000
1,300,000
1,700,000
1,300,000
3,000,000
750,000

120,000
120,000
60,000
200,000
90,000
120,000
90,000
200,000
50,000

480,000
480,000
240,000
800,000
360,000
480,000
360,000
800,000
200,000

1,800,000
1,800,000
900,000
3,000,000
1,350,000
1,800,000
1,350,000
3,000,000
750,000

850,000
750,000
1,700,000
1,700,000
2,500,000
1,700,000
850,000
850,000
130,000
850,000
2,000,000
850,000

60,000
50,000
120,000
120,000
175,000
120,000
60,000
60,000
90,000
60,000
125,000
60,000

180,000
150,000
360,000
360,000
525,000
360,000
180,000
180,000
270,000
180,000
375,000
180,000

960,000
800,000
1,920,000
1,920,000
2,800,000
1,920,000
960,000
960,000
1,440,000
960,000
2,000,000
960,000

1,300,000

90,000

270,000

1,440,000

3,000,000
3,000,000
130,000
750,000
1,700,000
850,000
130,000
3,000,000
850,000
850,000
130,000
1,700,000
3,000,000
850,000
3,000,000
5,000,000
5,000,000
850,000
5,000,000
3,000,000
3,000,000
1,700,000
130,000
130,000
2,500,000
2,500,000
3,000,000
3,000,000
1,300,000
1,700,000
130,000
1,300,000
850,000
850,000
5,000,000

200,000
200,000
90,000
50,000
120,000
60,000
90,000
200,000
60,000
60,000
90,000
120,000
200,000
60,000
200,000
300,000
300,000
60,000
300,000
200,000
200,000
120,000
90,000
90,000
175,000
175,000
200,000
200,000
90,000
120,000
90,000
90,000
60,000
60,000
300,000

600,000
600,000
270,000
150,000
360,000
180,000
270,000
600,000
180,000
180,000
270,000
360,000
600,000
180,000
600,000
900,000
900,000
180,000
900,000
600,000
600,000
360,000
270,000
270,000
525,000
525,000
600,000
600,000
270,000
360,000
270,000
270,000
180,000
180,000
900,000

3,200,000
3,200,000
1,440,000
800,000
1,920,000
960,000
1,440,000
3,200,000
960,000
960,000
1,440,000
1,920,000
3,200,000
960,000
3,200,000
4,800,000
4,800,000
960,000
4,800,000
3,200,000
3,200,000
1,920,000
1,440,000
1,440,000
2,800,000
2,800,000
3,200,000
3,200,000
1,440,000
1,920,000
1,440,000
1,440,000
960,000
960,000
4,800,000

Jasa Medik (Rp) PERDA 2007

Usulan Jasa Medik (Rp)

Tarif
(Rp)

KELAS I

918,000
1,240,000
1,512,000

2,750,000
5,750,000
7,750,000

1,512,000
918,000

7,750,000
2,750,000

1,240,000

5,750,000

1,240,000

5,750,000

1,240,000

5,750,000

1,512,000

7,750,000

1,512,000
1,240,000

7,750,000
5,750,000

1,512,000
1,512,000

7,750,000
7,750,000

1,240,000

5,750,000

540,000

500,000

1,240,000
918,000

5,750,000
2,750,000

3,500,000
1,000,000
1,200,000
1,800,000
4,000,000
2,400,000
1,000,000
2,400,000
1,000,000
4,000,000
1,200,000
2,400,000
1,200,000
1,200,000
1,800,000
2,400,000
6,000,000
1,200,000
3,500,000
2,400,000
2,400,000
3,500,000
4,000,000
4,000,000
2,400,000
4,000,000
3,000,000
2,400,000
2,400,000
1,000,000
1,200,000
2,400,000
1,800,000
2,400,000
1,200,000
1,200,000
1,200,000
2,400,000
1,800,000
2,400,000
2,400,000
2,400,000
4,000,000

1,512,000
1,512,000

7,750,000
7,750,000

1,512,000

7,750,000

1,512,000
1,240,000

7,750,000
5,750,000

1,240,000

5,750,000

540,000
540,000
540,000
540,000
918,000
918,000

500,000
500,000
500,000
500,000
2,750,000
2,750,000

1,512,000

7,750,000

918,000

2,750,000

1,512,000

7,750,000

1,512,000
1,240,000
1,240,000

7,750,000
5,750,000
5,750,000

1,512,000

7,750,000

1,240,000
918,000

5,750,000
2,750,000

1,240,000

5,750,000

3,500,000
2,400,000
2,500,000
3,500,000
2,400,000
3,500,000
3,500,000
1,800,000
2,400,000
1,200,000
1,000,000
1,200,000
420,000
420,000
420,000
420,000
610,000
566,000
1,000,000
420,000
4,000,000
4,000,000
1,000,000
3,500,000
2,400,000
2,400,000
3,500,000
2,400,000
1,200,000
1,200,000
2,400,000
3,500,000
4,000,000
2,400,000
2,400,000
2,400,000
1,200,000
1,200,000
2,400,000
2,400,000
2,400,000
1,200,000
2,400,000
2,400,000
1,200,000
1,000,000
1,200,000
4,000,000
6,000,000
1,200,000
2,400,000

1,240,000
918,000

5,750,000
2,750,000

1,240,000

5,750,000

540,000
1,240,000

500,000
5,750,000

1,512,000
1,240,000
1,240,000

7,750,000
5,750,000
5,750,000

1,240,000
1,512,000
1,512,000
1,240,000

5,750,000
7,750,000
7,750,000
5,750,000

1,240,000
1,240,000

5,750,000
5,750,000

1,240,000

5,750,000

4,000,000
3,500,000
2,400,000
2,400,000
2,400,000
1,200,000
1,200,000
1,200,000
1,800,000
1,200,000
2,400,000
1,200,000
6,000,000
1,200,000
2,400,000
1,800,000
1,800,000
1,200,000
6,000,000
1,800,000
1,200,000
1,800,000
1,200,000
1,200,000
2,400,000
1,200,000
2,400,000
2,400,000
2,400,000
1,200,000
4,000,000
1,800,000
2,400,000
1,800,000
4,000,000
1,000,000
1,200,000
1,000,000
2,400,000
2,400,000
3,500,000
2,400,000
1,200,000
1,200,000
1,800,000
1,200,000
2,500,000
1,200,000
1,800,000

1,240,000

5,750,000

918,000
918,000

2,750,000
2,750,000

1,240,000

5,750,000

1,240,000
1,240,000
1,240,000
1,240,000

5,750,000
5,750,000
5,750,000
5,750,000

1,512,000

7,750,000

540,000
918,000
918,000
918,000
918,000
918,000
918,000
918,000
918,000
918,000
918,000
918,000
918,000
1,240,000
1,240,000
1,240,000
1,240,000

500,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
2,750,000
5,750,000
5,750,000
5,750,000
5,750,000

4,000,000
4,000,000
1,800,000
1,000,000
2,400,000
1,200,000
1,800,000
4,000,000
1,200,000
1,200,000
1,800,000
2,400,000
4,000,000
1,200,000
4,000,000
6,000,000
6,000,000
1,200,000
6,000,000
4,000,000
4,000,000
2,400,000
1,800,000
1,800,000
3,500,000
3,500,000
4,000,000
4,000,000
1,800,000
2,400,000
1,800,000
1,800,000
1,200,000
1,200,000
6,000,000

1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,240,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000
1,512,000

5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000
7,750,000

Jasa Medik (Rp) PERDA 2007

Usulan Jasa Medik (Rp)

VIP

1,080,000
1,404,000
1,674,000

5,750,000
9,750,000
14,750,000

1,674,000
1,080,000

14,750,000
5,750,000

1,404,000

9,750,000

1,404,000

9,750,000

1,404,000

9,750,000

1,674,000

14,750,000

1,674,000
1,404,000

14,750,000
9,750,000

1,674,000
1,674,000

14,750,000
14,750,000

1,404,000

9,750,000

675,000

500,000

1,404,000
1,080,000

9,750,000
5,750,000

1,674,000
1,674,000

14,750,000
14,750,000

1,674,000

14,750,000

1,674,000
1,404,000

14,750,000
9,750,000

1,404,000

9,750,000

675,000
675,000
675,000
675,000
1,080,000
1,080,000

500,000
500,000
500,000
500,000
5,750,000
5,750,000

1,674,000

14,750,000

1,080,000

5,750,000

1,674,000

14,750,000

1,674,000
1,404,000
1,404,000

14,750,000
9,750,000
9,750,000

1,674,000

14,750,000

1,404,000
1,080,000

9,750,000
5,750,000

1,404,000

9,750,000

1,080,000

9,750,000
5,750,000

1,404,000

9,750,000

675,000
1,404,000

500,000
9,750,000

1,674,000
1,404,000
1,404,000

14,750,000
9,750,000
9,750,000

1,404,000
1,674,000
1,674,000
1,404,000

9,750,000
14,750,000
14,750,000
9,750,000

1,404,000
1,404,000

9,750,000
9,750,000

1,404,000

9,750,000

1,404,000

9,750,000

1,080,000
1,080,000

5,750,000
5,750,000

1,404,000

9,750,000

1,404,000
1,404,000
1,404,000
1,404,000

9,750,000
9,750,000
9,750,000
9,750,000

1,674,000

14,750,000

675,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,080,000
1,404,000
1,404,000
1,404,000
1,404,000

500,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
5,750,000
9,750,000
9,750,000
9,750,000
9,750,000

1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,404,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000
1,674,000

9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
9,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000
14,750,000

Z. TARIF JASA

NO

JENIS OPERASI

Sarana/Jasa RS
(RP)

Alkes & OBHP

(Rp)

Jasa Medik
(Rp)

Tarif
(Rp)

KELAS III

1
2
3
4
5

OPERASI KECIL
Incisi Hordeolum / Chalazion
Ekstraksi Korpus Alienum Kornea / Konjungtiva
Eksisi Granuloma Konjungtiva / Palpebra
Repair Ruptur Palpebra / Konjungtiva Simple
Ekstraksi Lithiasis 1 sampai 5 buah

12,500
12,500
12,500
12,500
12,500

62,500
62,500
62,500
62,500
62,500

175,000
175,000
175,000
175,000
175,000

250,000
250,000
250,000
250,000
250,000

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

OPERASI SEDANG
Flap Konjungtiva
Repair Ruptur Konjungtiva dgn Komplikasi
Repair Ruptur Palpebra dgn Komplikasi
Avulsi Pterigium dgn CLG 1 mata
ALR (Anterior Lamellar Reposition) 1 mata
Everting Suture 1 mata
Eksisi Xanthelasma 1 mata
Eksisi Tumor Konjungtiva Simple
Eksisi Tumor Palpebra Simple
Tarsoraphi 1 mata
Injeksi Obat Intravitreal
Tab cairan Aquos / Vitreus
Ekstraksi Korpus Alienum Kornea Multiple
Ekstraksi Lithiasis > 5 buah
Release Simblepharon Simple
Tatooage Kornea

25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000

100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000
100,000

375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000

500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000
500,000

22
23
24

OPERASI BESAR
Repair Ruptur Kornea
Repair Ruptur Sklera
Repair Ruptur Palpebra Luas

45,000
45,000
45,000

135,000
135,000
135,000

720,000
720,000
720,000

900,000
900,000
900,000

25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

Repair Ruptur Konjungtiva Complex

ALR 2 mata
Everting Suture 2 mata
Eksisi Xanthelasma 2 mata
ECCE + IOL
ECCE
Trabekulektomi
Blepharoplasti
Parasentesis Hifema
Iridektomi
Release Simblepharon Luas
Avulsi Pterigium + CLG 2 mata
Implantasi IOL sekunder
Repair Socket Simple
Kriosiklodialisis

45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000
45,000

135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000
135,000

720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000
720,000

900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000
900,000

40
41
42
43
44
45
46
47
48
49
50
51
52
53
54

OPERASI KHUSUS
Repair Ruptur Korneosklera
Eviserasi + DFG
Enukleasi + DFG
Eksentrasi Orbita
Triple Procedure
Scleral Buckle
Repair Ptosis
Operasi Strabismus
DCR (Dacryo Cysto Rhinostomy)
Keratoplasti
ECCE + IOL dgn Penyulit
Repair Socket Complex
Fotokoagulasi Laser
Orbitotomy Lateral
PDT (Photodynamic Therapi)

125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000
125,000

375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000
375,000

2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000
2,000,000

2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000

55
56

OPERASI CANGGIH
Fakoemulsifikasi + IOL
Vitrektomi

225,000
225,000

675,000
675,000

3,600,000
3,600,000

4,500,000
4,500,000

57

Lasik

225,000

675,000

3,600,000

4,500,000

F JASA TINDAKAN OPERASI MATA

Usulan

Sarana/Jasa RS
(RP)

Alkes & OBHP

(Rp)

Jasa Medik
(Rp)

Tarif
(Rp)

Usulan

Sarana/Jasa
RS
(RP)

KELAS II

Alkes & OBHP

(Rp)
KELAS I

725,000
725,000
725,000
725,000
725,000

17,000
17,000
17,000
17,000
17,000

85,000
85,000
85,000
85,000
85,000

238,000
238,000
238,000
238,000
238,000

340,000
340,000
340,000
340,000
340,000

975,000
975,000
975,000
975,000
975,000

26,000
26,000
26,000
26,000
26,000

130,000
130,000
130,000
130,000
130,000

1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000
1,375,000

37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500
37,500

150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000

562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500
562,500

750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000

1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000
1,725,000

50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000
50,000

200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000

1,850,000
1,850,000
1,850,000

65,000
65,000
65,000

195,000
195,000
195,000

1,040,000
1,040,000
1,040,000

1,300,000
1,300,000
1,300,000

2,100,000
2,100,000
2,100,000

90,000
90,000
90,000

270,000
270,000
270,000

1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000
1,850,000

65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000
65,000

195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000
195,000

1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000
1,040,000

1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000
1,300,000

2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000
2,100,000

90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000
90,000

270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000
270,000

2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000
2,500,000

150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000
150,000

450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000
450,000

2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000
2,400,000

3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000

3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000
3,000,000

200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000
200,000

600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000
600,000

4,500,000
4,500,000

250,000
250,000

750,000
750,000

4,000,000
4,000,000

5,000,000
5,000,000

5,000,000
5,000,000

300,000
300,000

900,000
900,000

4,500,000

250,000

750,000

4,000,000

5,000,000

5,000,000

300,000

900,000

Jasa Medik
(Rp)

Tarif
(Rp)

Usulan

KELAS I

364,000
364,000
364,000
364,000
364,000

520,000
520,000
520,000
520,000
520,000

1,225,000
1,225,000
1,225,000
1,225,000
1,225,000

750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000
750,000

1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000
1,000,000

1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000
1,975,000

1,440,000
1,440,000
1,440,000

1,800,000
1,800,000
1,800,000

2,450,000
2,450,000
2,450,000

1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000
1,440,000

1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000
1,800,000

2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000
2,450,000

3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000
3,200,000

4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000

4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000
4,000,000

4,800,000
4,800,000

6,000,000
6,000,000

6,000,000
6,000,000

4,800,000

6,000,000

6,000,000