Ruangan Perawatan

1.
2.
3.
5.
6.

VIP
Kelas I
Kelas II
Kelas III
ICU/NICU

7.

Perinatologi

Tarif Administrasi rawat jalan

NO.

KETERANGAN

1.
2.
3.

Pasien baru + Kartu baru

Pasien lama
Penggantian kartu hilang

4.
5.

Buku pasien ibu

Buku pasien anak

Jasa dokter,bidan & ahli gizi " rawat jalan "

NO
1.
2.
3.
4

5.
6.
7.

KETERANGAN
Dokter unit gawat darurat
Dokter poliklinik umum
Dokter poliklinik gigi
Poliklinik spesialis
4.1. Dokter anak
4.2. Dokter penyakit dalam
4.3 Dokter kebidanan dan kandungan
4.4 Dokter syaraf
4.5 Dokter bedah (umum/anak)
Konsultasi kandungan oleh bidan
Konsultasi gizi oleh ahli gizi
Konsultasi tim dokter spesialis luar RSIA

Tarif kamar perawatan umum / hari

3,250,000
2,600,000
1,950,000
1,300,000

30%
30%
30%
30%

6,500,000

30%

2,600,000

30%

No.
1.
2
3.
4.
6.

JENIS KAMAR dan FASILITAS

VIP
Kelas I
Kelas II
Kelas III
HCU/ICU/NICU

Tarif kamar perawatan Ibu dan Anak/hari

No.
1.
2
3.
4.
5.
6.
7.
8.

JENIS KAMAR dan FASILITAS

VIP
Kelas I
Kelas II
Kelas III
HCU/ICU/NICU
Perinatologi
VK
Ruanga Bayi Sehat

Tarif tambahan :
1.
Sinar lampu blue lift
2.
Inkubator
3.
Pasang CPAP
4.
Sewa CPAP
Tarif Visiting Rawat inap

No.

KETERANGAN

Visite
Dokter Spesialis
(Rp)

1
2
3
5
6
7

Kelas VIP
Kelas I
Kelas II
Kelas III
ICU/NICU
Perinatologi

150,000
135,000
110,000
90,000
120,000
100,000

Dokter Sub
Spesialis (Rp)
270,000
220,000
180,000
150,000
200,000
180,000

Tarif pemeriksaan diagnostik

No.
1
2
3
4
5
7
8

NO.
1.
2.
3.
4
5
6
7
8
9
10
15
16
18
19
20
21
22
23
29
30
31
32
33
34
35

PERIKSAAN
EKG
ISERTIA IUD
ANGKAT IMPLANT
HYDROTUBASI
A.I.H
DOPPLER BJJ/kali
RESPIRATOR

Tarif Poliklinik kebidanan

TINDAKAN
USG 2D (Tanpa print)
USG 2D (Print)
USG (Tanpa film)
USG Transvaginal
USG (Print) Transvaginal
USG 4D (Tanpa print)
USG 4D (Print)
Ekstraksi IUD
Hidrotubasi/Partubasi
Mikro Kuretase/ Biopsi Cervix
A.I.H
Kauterisasi
Vaginal Toilet
Pap Smear
Pasang IUD
Ekstraksi dan Insertie IUD
Kultur Uap Vagina
PCT/UPS (Uji Pasca Senggama)
Ganti Pesarium
Pasang Pesarium
Angkat Pesarium
Pasang Tampon
Angkat Tampon
Relaktasi
Kontrol Jahitan SC

II
(Rp)
80,000
135,000
200,000
135,000
135,000
50,000
55,000

I
(Rp)
85,000
140,000
205,000
140,000
140,000
55,000
60,000

Tarif persalinan
No.

TINDAKAN
1 Partus Normal
2 Partus Letak Sungsang
3 Partus Gemelly
4 Partus Placenta Manual
5 Partus Ekstraksi Vakum/Forceps
7 Partus ILA
9 Partus Induksi
10 Partus dengan Penyulit
11 Partus dengan Vaccum
12 Sectio Casaria (SC)

No.
1
2
3
4
5
6
7
8
10
11
12
13

Tindakan khusus kebidanan

TINDAKAN
Incisi Exterpasi
A.I.H (Inseminasi Buatan)
Ekstraksi IUD, Anestesi Umum
Angkat Implan
Her Hecting
Hecting Trauma
Kuretase
Kolpoperineorafi
Tubektomi/Steril
PPN
Histerektomi
Kistektomi & Miomektomi
Tarif home visit care
( Pasien yang melahirkan di RSIA Petukangan

No.
1.
2.
3.

KETERANGAN
Radius < 5 Km
Radius 6-10 Km
Radius > 11 Km

No.
A

Tarif Poliklinik Anak

NAMA VAKSIN
GENERIK

II (Rp)
5500000
3200000
3500000
3200000
3600000
4400000
3300000
5000000
6500000
7500000

I (Rp)
7500000
4200000
4500000
4200000
4600000
5400000
4300000
6000000
8500000
10000000

II (Rp)
2,700,000
2,560,000
2,950,000
2,950,000
2,040,000
2,240,000
1,750,000
2,500,000
6,250,000
5,725,000
7,400,000
10,000,000

I (Rp)
3,700,000
3,560,000
3,950,000
3,950,000
3,040,000
3,240,000
3,750,000
3,500,000
7,250,000
6,725,000
8,400,000
11,000,000

1.
2.
3.
4.
5.
6.
7.
B
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Polio (= Polio)
Campak (= Campak)
BCG (= BCG)
DTP dan HB (=DTP dan Hepatitis B)
Hepatitis Rekombinian 0.5 ml (= Hepatitis B)
PPD RT (2 TU), (= Mantoux)
TT (= Tetanus Toxoid)
PATEN
Hiberix (= Haemophilus Influenzae B)
Havrix 720 (= Hepatitis A)
Engerix - B 0.5 ml (= Hepatitis B)
Infanrix (= DPT)
Infanrix HiB (= DPT dan HiB)
Infanrix IPV HiB (= DPT dan HiB dan Polio)
Pediacel (= DPT dan HiB dan Polio)
Synflorix (= PVC/ Pneumococcus)
Vaxigrip 0.25 ml (= Influenzae)
Vaxigrip 0.5 ml (= Influenzae)
Pentabio 0.5 ml (= DPT dan HiB dan Hepatitis B)

No.
A
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Tarif poliklinik Gigi

JENIS TINDAKAN PERAWATAN
KONSERVASI GIGI
Konsultasi Gigi Umum/Kontrol
Tumpatan Sementara
Tumpatan Amalgram 1 Sisi
Tumpatan Amalgram 2 Sisi
Tumpatan GIC Kecil
Tumpatan GIC Sedang
Tumpatan GIC Besar
Tumpatan Komposit Kecil
Tumpatan Komposi Sedang
Tumpatan Komposi Besar
Bongkar Restorasi Amalgram/Komposit per Elemen

12.
13.
14.
15.
16.

Bongkar Crown/Imlay/Onlay per Elemen

Penutupan Pit & Fissure dengan Komposit
Inlay/Onlay Logam
Inlay/Onlay Logam Facing Porselain
Labial Veneering Komposit

17.
18.
19.
20.
21.
22.
23.
B
1.
2.
3.
4.
5.
6.
7.

Labial Veneering Porselain

Pin Stabilok/Post Screw per Buah
Pasak Skrup per Buah
Pasak Tuang per Buah
Cementasi Inlay/Onlay/Crown Lepas per Elemen
Cementasi Sementara per Elemen
Polishing per Elemen
ENDODONTIK
Pulp Capping Direk/Indirek
Endodontik One Visite Akar Tunggal
Endodontik One Visite Akar Ganda
Vital Pulpektomi & Eksterpasi Pulpa Akar Tunggal
Vital Pulpektomi & Eksterpasi Pulpa Akar Ganda
Preparasi Saluran Akar Nonvital Akar Tungga
Preparasi Saluran Akar Nonvital Akar Ganda
Sederhana

8.

Preparasi Saluran Akar Nonvital Akar Ganda

Kompleks

9.

Preparasi Saluran Akar Nonvital Akar Kondisi

Khusus

10.
11.
12.
13.
14.
15.
16.
17.
18.
C
1.
2.
3.
4.
5.
6.

Trepanasi/Ganti Obat/Medikasi
Open Bor/Devitalisasi Pulpa
Pengisian Saluran Akar Tunggal
Pengisian Saluran Akar Ganda Sederhana
Pengisian Saluran Akar Ganda Kompleks
Pengisian Saluran Akar Kondisi Khusus
Bleaching Gigi Nonvital per Gigi per Kunjungan
Bleaching Gigi Vital Paket 12 Elemen
Pulpotomi/Mumifikasi per Kunjungan
PERIODONTIK
Pembersihan Karang Gigi Kelas I per Rahang
Pembersihan Karang Gigi Kelas II per Rahang
Pembersihan Karang Gigi Kelas III per Rahang
Kuret/Root Planing per Kuadran
Kuret/Root Planing per Gigi
Kuret/Root Planing dengan Ties (Metronidazole) per
Gigi

7.
8.
9.
10.

Gingivektomi per Kuadran

Bedah Flap per Kuadran
Frenektomi
Splinting Ligature per Kuadran

11.
12.
13.
14.
15.
16.
17.
D
1.
2.

Splinting Ligature per Gigi

Splinting Ligature per Gigi dengan Komposit
Occulusal Adjustment per Kuadran
Pejahitan
Buka Jahitan
Gingival Pack per Kuadran
Kontrol/Premedikasi
PROSTODONTIK
Konsultasi
Mencetak Rahang Atas dan Rahang Bawah
MAHKOTA dan JEMBATAN (GIGI TIRUAN
CEKAT)

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Mahkota Sementara
Mahkota Metal Facing Akrylik
Mahkota Metal Facing Porcelain
Mahkota Maryland Bridge
Mahkota/Onlay/Inlay Logam Penuh
Onlay/Inlay Metal Porcelain
Pasak Sekrup
Pasak Tuang
Pin Stabilok per Buah
Cementasi Mahkota/Inlay/Omlay Lepas
Cementasi Sementara
Bongkar Crown/Inlay/Onlay
Kontrol Protesa
GIGI TIRUAN SEBAGIAN LEPAS
Plat Akrylik dengan Satu Gigi per
Atas/Bawah

16.

Rahang

17.

Plat Metal dengan Satu Gigi per Rahang Atas/Bawah

18.
19.

Valplast dengan Satu Gigi per Rahang Atas/Bawah

Plat Kombinasi Metal & Valplast per Rahang
Atas/Bawah

20.

Penambahan Gigi per Elemen

GIGI TIRUAN PENUH LEPAS
GTP Akrylik Rahang Atas/Bawah
GTP Akrylik Rahang Atas dan Bawah
LAIN-LAIN
Reparasi Gigi Tiruan Tanpa Cetak
Reparasi Gigi Tiruan Dengan Cetak
Tambahan Klammer per Buah

21.
22.
23.
24.
25.

26.
27.
E
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Rebase
Reline
BEDAH MULUT
Pencabutan Gigi Susu dengan Topikal Anestesi
Pencabutan Gigi Susu dengan Lokal Anestesi
Pencabutan Gigi Permanen
Pencabutan Gigi Permanen Komplikasi
Pencabutan Gigi M3 Erupsi Sempurna
Pencabutan Gigi Komplikasi dengan Flap
Alveolektomi
Apeks Reseksi dengan Pengisian
Operkulektomi
Odontektomi Kelas I

ARIF POLIKLINIK GIGI

No.
E
11.
12.
13.
14.
15.
F
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
G
1.
2.

JENIS TINDAKAN PERAWATAN

BEDAH MULUT
Odontektomi Kelas II
Odontektomi Kelas III
Buka Jahitan/Kontrol
Perawatan Dry Soket per Kunjungan
Enukleasi
ORTHODONTIK
Orthodonti Lepasan per Rahang dan Ekspansi
Kontrol Orthodonti Lepasan per Kunjungan
Orthodonti Fixed Metal Kasus Ringan
Orthodonti Fixed Metal Kasus Sedang
Orthodonti Fixed Metal Kasus Berat
Kontrol Orthodonti Fixed Metal per Kunjungan
Ganti Bracket, Kawat, Alat Lain
Orthodonti Fixed Ceramic Kasus Ringan
Orthodonti Fixed Ceramic Kasus Sedang
Orthodonti Fixed Ceramic Kasus Berat
Kontrol Orthodonti Fixed Ceramic per Kunjungan
Retensi Plat Akrylik per Rahang
Retensi Transparan per Rahang
Retensi Lingual Rahang Bawah
Pasang Bracket Lepas per Elemen
PEDODONTIK
Porcelain
Pontic Porcelain

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

All Metal Porcelain

Inlay/Onlay
Down/Pin
Full Crown/Akrylik
Tempron per Elemen
Crown Metal Facing Akrylik
Crown Metal Facing Porcelain
Pontic Metal Facing Akrylik
Pontic Metal Facing Porcelain
Pontic Metal
Frame Dental Full per Rahang
Frame Dental Partial per Rahang
Frame Dental Saddle per Unit
Partial Denture Akrylik Gigi Pertama (New Italdent)

17.
18.
19.

Penambahan/Elemen
Full Denture Akrylik (New Italdent)
Full Denture Akrylik Gigi Akrylik per Rahang
(Ortholux)

20.

Full Denture Akrylik Gigi Porcelain per Rahang per

Gigi

21.

Partial Denture Plat Akrylik dengan Gigi Akrylik

Pertama

22.

Partial Denture Plat Akrylik dengan Gigi Porcelain

Pertama

23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.

Tiap Penambahan Gigi Akrylik (Ortholux)

Tiap Penambahan Gigi Porcelain
Orthodonti Plat Tanpa Expansion Screw + Solder
Orthodonti Plat Dengan Expansion Screw + Solder
Knop Klammer
Rest
Nance Holder
Palatal/Lingual Arch
Solder Quad Helix
Solder per Point
Solder Rapid Palatal Expander
Inclined Plane
Lingual Crib
Expand Coffin
Oral Screen
Bionator

39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.

Bite Tracer
Space Retainer
Studi Model
Reparasi Retak/Patah
Occulusal Splint
Obturator
Prothesa Mata
Prothesa Hidung
Prothesa Telinga
Prothesa Jari
Rebasing/Relining
Sendok Pribadi/Rahang
Removable Retainer
Removable Orthodontie Appliance
Removable Orthodontie Appliance with Expnatie
Screw

H
1.
2.
3.
4.

LAIN-LAIN
Tambalan Sementara per Elemen
Semi Permanen per Elemen (tambalan sementara)
Pulp Capping per Elemen (tambalan sementara)
Pit dan Fissur Sealant per Elemen (tambalan
sementara)

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Amalgam (tambalan permanen)

GIC Cement per Elemen (tambalan permanen)
GIC Filling per Elemen (tambalan permanen)
Komposit Resin Kelas II/IV (tambalan permanen)
Simple Ligh Cure Filling (tambalan permanen)
Complex Ligh Cure Filling (tambalan permanen)
Ligh Cure Labial Veneering (tambalan permanen)
Scalling Kecil
Scalling Sedang
Scalling Besar
Pasang Tampon Gigi

STALASI GAWAT DARURAT (IGD)

No.
1.
2.

TINDAKAN
Konsul Dokter Umum
Konsul Dokter Spesialis

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.

Konsul via Telepon Dokter Spesialis

Pasang Bidai/Spalk
Pertolongan Luka Bakar Kecil
Pertolongan Luka Bakar Besar
Defibrilasi
Insisi/Cross Incision Benjolan
Ekstraksi Kuku per Jari
Dilatasi Phimosis
Suctioning per Hari
Jahitan Luka 1 s/d 5 Jahitan
Jahitan Luka 6 s/d 10 Jahitan
Jahitan Luka 11 Jahitan ke atas
Ekstraksi Corpus Alienum
Pasang Tampon Hidung
Pasang Ransel Verban
Surface Cooling
Reposisi Mandibula
Reposisi Sendi Bahu
Gliserin Spuit (Tanpa Penyulit)
Gliserin Spuit (Dengan Penyulit)
Pemasangan Nasopharingael Tube
Lavage Lambung
Pasang NGT Darurat
Sirkumsisi (Sunat) Darurat
Punctie Kandung Kemih
Punctie Pleura
Irigasi Mata (per Sisi)
Pemasangan/Pergantian Canula Trachea
Vena Sectie
Fiksasi/Spalk
Bilas Kandung Kemih
Bilas Lambung
Plebotomi (Sampel Laboratorium)
Pertologan Luka Robek Kecil/Sedang
Pertologan Luka Robek Multiple
Jahitan Permukaan Multiple
Pasang Infus Dewasa oleh Perawat
Pasang Infus Neonatus oleh Perawat
Pasang Blood Set Dewasa oleh Perawat
Pasang Infus Dewasa oleh Dokter Umum
Pasang Infus Neonatus oleh Dokter Umum

44.
45.
46.
47.
48.
49.

Pasang Blood Set Dewasa oleh Dokter Umum

Pasang Catheter oleh Perawat
Nebulizer oleh Perawat
Nebulizer (Ventolin) Anak
Nebulizer (Ventolin) Dewasa
Paket Suction Pump oleh Perawat

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

Tarif Instalasi Gawat Darurat (IGD)

LAIN-LAIN
Room Charge 2-4 jam pertama
Room Charge setiap 1 Jam berikutnya
Room Charge Kamar Tindakan
Instrumen Dasar
Instrumen Catheter
Instrumen Hecting Up
Instrumen Partus Set
Instrumen Vena Sectie
Instrumen Madrin
Observasi 1 s/d 8 jam
Observasi setiap 4 jam berikutnya
Pasang Gips (BackSlab)
Injeksi Intra Artikuler 2 Sendi Kecil
Injeksi Intra Artikuler 2 Sendi Besar
Injeksi Trigger Poin 4-8 Titik
Injeksi Trigger Poin > 8 Titik

ARIF TINDAKAN UMUM

No.
1.
2.
3.
4.
5.
6.
7.
8.

TINDAKAN
Pasang NGT
Pasang Dower Catheter
Pasang Kondom Catheter
Ganti Verban Kecil/Sedang
Ganti Verban Besar
Pasang Balut Elastis
Angkat Jahitan
Dressing

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.

Transfusi Darah per Kantong

Klisma
Suntik 1x
Suntik Berulang per Hari
Irigasi Kolostomi
Pemberian Kemoterapi
Sunat Bayi Perempuan
Tindik
Bilas Kandung Kemih
Suction Pump
Pasang Catheter Umbilical
Lepas Catheter Umbilical
Oral Hygine
Tindakan Efusipleura
Pasang NST/CTG
Pemeriksaan Echocardio ke luar
Debridement Tanpa Bius Umum
Sewa Monitor
Panoramic Rujukan Luar
Lumbal Punksi
Pemeriksaan Fungsi Luhur
Pemasangan Longline
Pemasangan CVP
USG Intip Abdomen (Tanpa Print)
USG Intip Abdomen (Dengan Print)

TARIF BEDAH
No
A
1
2
3
4
5
6
7

TINDAKAN

RJ/III (Rp)

II
(Rp)

OPERASI MINOR
Tumor Kulit < 1 cm
Angkat T. Tube
Insisi Abses < 1 cm
Insisi Biobsi
Pleurosintesis
Klavus < 1 cm
Core Biopsi

1,825,000
825,000
825,000
825,000
825,000
825,000
825,000

Tumor Kulit < 1 cm

825,000

9
10
11
12
B
1
2

Ekstirpasi Tumor Kulit < 3 cm

Angkat Kuku
Insisi Abses Hematoma
Vena Secti

825,000
825,000
825,000
825,000

Klavus 1-3 cm

1,320,000

Ekstirpasi Tumor Daerah Muka < 1 cm

1,320,000

Maetotomi

1,320,000

6
7
8
9
10
11
12
13
14
15
16
17
18
19
C
1
2
D
1
2
3
E
1
2
3
4
5
6
7

Jahitan Sekunder
Tumor Kulit/Asbes/Clavus > 3 cm
Biopsi Rectum
Rozer Plastry
Sirkumsisi (Sunat)
Explorasi Benda Asing
FAM < 3 cm
Labuloplastry
Operasi Tumor < 3 cm
Biopsi Tumor Rectum
Extirpasi Tumor Daerah Muka/Kulit
Sklerosing dan Rubber Band
Trakhestomi
Vasektomi

Tumor Kulit 1-3 cm

Insisi Abses 1-3 cm

Operasi tumor 3-5 cm

Explorasi Benda Asing
Nekrotomi
Biopsi KGB Colli/Inguinal/Aksila < 2 cm
Pleuridesis
Eksisi Ganglion
Explorasi Benda Asing Agak Dalam
Nekrotomi/Debridement 5-7 cm
Tumor Kulit 3-5 cm
FAM 3-5 cm
Biopsi KGB Colli/Inguinal/Aksila > 2 cm
Nekrotomi/Debridement 7-10 cm

OPERASI MODERATE 1
1,320,000
1,320,000

1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
1,320,000
OPERASI MODERATE 2
1,485,000
1,485,000
OPERASI MODERATE 3
1,815,000
1,815,000
1,815,000
OPERASI MAYOR 1.
2,145,000
2,145,000
2,145,000
2,145,000
2,145,000
2,145,000
2,145,000

8
9
10

12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
F
1
2
3
4
5
6
7
8
9
10
G
1
2
H
1
2
3
4
5

Tumor Kulit Jinak 5-7 cm

FAM 5-7 cm
Eksisi Hemangioma Superfisial < 5 cm

2,145,000
2,145,000
2,145,000

11 Tumor Kulit > 10 cm

Ganglion Poplitae
Eksisi Mammae Aberans
Debridement Luas
Nekrotomi Luas
Skin Graft
Apendiktomi
Herniotomi
Fistlektomi
Operasi BW
Operasi Palmo
Kolesistostomi
Haemoroidektomi
Tumor >7 cm
Sectio Alta
Orchidectomi
Extirpasi Ganglion Poplitae
Labioplasty

2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
OPERASI MAYOR 2

Apendiktomi dengan Perforasi Lokal/Inf

Herniotomi dan Reseksi Omentum
Gastrostomi
Jejunostomi
Reparasi Hernia Umbilikasi
Ileustomi
Multiple FAM
Continuos Ambulatory Peritonael Dealis
Kolostomi Lokal
Sub Cutaneus Mastectomi untuk Gynecon

3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
OPERASI MAYOR 3

Apendiktomi dengan Perforasi Umum

Herniotomi dengan Reseksi Anastosmasis
Repair Hernia Umbilikalis
Eksisi Kista Duktus Thyroglosus
Apendiktomi dengan Insisi para Rectal
Kolesistostomi
Hernia Umbilikaslis

4,455,000
4,455,000
OPERASI KHUSUS 1
4,620,000
4,620,000
4,620,000
4,620,000
4,620,000

5,4
5,4
5,4
5,4
5,4

6
7
8
9
10
11
12
13
14
15
16

Giant FAM
Tumor Piloides
Laparatomi Explorasi
Laparatomi + Apendiktomi
Open Cholecystomi
Laparatomi + Colostomi
Simple Mastectomi
Sub Total Lobectomi
Herniotomi + Mesh
Tutup Cholostomi
Palatoplasty

4,620,000
4,620,000
4,620,000
4,620,000
4,620,000
4,620,000
4,620,000
4,620,000
4,620,000
4,620,000
4,620,000

5,4
5,4
5,4
5,4
5,4
5,4
5,4
5,4
5,4
5,4
5,4

TARIF BEDAH
No
I
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
J
1
2
3
4
5
6
7
8
9

TINDAKAN
Eksisi Mammae Aberans Besar
Wide Eksisi
Herniotomi + Mesh (Residif)
Apendiktomi dengan Insisi Mediana
Laparatomi + Reaksi Anastomosis
Splenoktomi
Explorasi CDB + Tube
Simple Mastectomi + Skin Graft
Sub Total Tirodektomi
Total Labektomi
Pyelolitotomi
Cimino/Repair Cimino
Uretro Lithotomi
Nefrektomi
Laparatomi Explorasi + Pembebasan
Perlengkatan
Sub Cutaneus Mastetomi Tumor Jinak
Apendiktomi dengan Insisi Mediana
Laparaskopi Cholecystectomi
Laparaskopi Apendiktomi
Laparaskopi Herniotomi
Miles
Reseksi Anterior
Kristo Jejunostomi
Gastro Jejunostomi

RJ/III/III Utama
(Rp)
OPERASI KHUSUS 2
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
5,115,000
OPERASI KHUSUS 3
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000

II
(Rp)
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000

10
11
12
13
14
15
16
17
18
K
1
2
3
L
1
2
3
M
1
2

Bilio Digestif
Total Mastectomi
Total Paratidektomi
LAR
Gasterctomi
Reseksi Hepar
Reseksi Tumor Intra Abdomen
Anoplastry Definitif (DSA)
Hirch Definitif
Whipe
Total Gasterctomi
RND
Histerektomi Radikal
Surgical Staging
Wide Eksisi Vulva
Ektenterasi
Vulvektomi Radikal

6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
6,105,000
OPERASI KHUSUS 4
7,260,000
7,260,000
7,260,000
OPERASI KHUSUS 5
8,415,000
8,415,000
8,415,000
OPERASI KHUSUS 6
10,395,000
10,395,000

6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
6,600,000
7,920,000
7,920,000
7,920,000
9,075,000
9,075,000
9,075,000
12,210,000
12,210,000

TARIF BEDAH
No
N
1
2
3
4
5
6

TINDAKAN
Keloid
Kutis dan subkutis
Genitalia Externa
Anuskopi
Kauterisasi
Insisi Dokter Umum

II
(Rp)
OPERASI LAIN
4,500,000
1,000,000
1,000,000
1,000,000
1,000,000
273,000

I
(Rp)
5,000,000
1,150,000
1,150,000
1,150,000
1,150,000
283,500

RIF TINDAKAN ANAK/BAYI

No.
1
2
3
4
5
6
7
8
9

TINDAKAN
Pasang Infus Neonatus Anak/Bayi oleh Perawat
Pasang NGT
Lampu penghangat per Hari
Pompa ASI per Hari
Doppler BJJ per Hari
Sunat Bayi Perempuan
Tindik
Inhalasi Terapi (Tanpa Obat)
Inhalasi Terapi (Termasuk Obat)

10

Inhalasi Terapi (Termasuk Obat), Chest Physiotherapy

11
12

Pemasangan CPAP ke-1

Pasang Infus Umbilikal

TARIF TINDAKAN ICU

No.
1
2
3
4
5
6
7
8
9
10
11
12
13

TINDAKAN
Pemasangan CVP
Pemasangan CPAP ke-1
Sewa Ventilator per Hari
Intubasi Anak
Intubasi Dewasa
Pemasangan NGT
Pembelian Darah per Kantong
Oksigen/Tabung per Hari
Ventilator + Oksigen per Hari
Oral Hygine
Pemasangan Dower Catheter
Decubitor per Hari
Bed Side Monitor

TARIF SEWA ALAT

No.
1
2

TINDAKAN
Ventilator per Hari
Bed Side Monitor

3
4
5
6
7
8
9
10
11
12
13
;314
15
16

Keterang
an:

Khusus
Tarif
VENTI
LATOR
,
tambaha
n
Disposi
ble
Item,
dikenaka
n Tarif
Tersendi
ri dilihat
dari
pemakai
an.

Mesin Anestesi
Monitor Anestesi
Apnu Alarm
Suction Pump
Decubitor per Hari
Syringe Pump
Infus Pump
Blood Warmer per Hari
Capnometry per Hari
Jaundicemeter per Kali
Patient Warmer per Kali
Bilirubin Meter per Kali
Ekstaraktor Vacuum per Kali
ACT per Kali

ENUNJANG MEDIS RADIOLOGI

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

TINDAKAN
USG Abdomen Atas
USG Abdomen Bawah
USG Abdomen Atas-Bawah
USG Thyroid
USG Mammae
USG Tractus Urinarius
USG Obstetri
USG Kepala
Sewa Alat USG Umum
Sewa Alat USG Keliling
Pyelography I.V
Appendicogram (Kontras beli di Instalasi Farmasi)
Urethrography
Cystography
HSG
Creanium AP/LAT
Sinus Paranasal
Mastoid
Temporo Mandibular Joint
Mandibulla
Zygomaticum
Orbita
Os Nasal/Sella Tursica
Thorax
Thorax AP/LAT
Abdomen
Pelvis
Manus
Wrist Joint
Anetebrachi
Art. Cubiti
Humerus
Clavicula
Scapula

II
(Rp)
357,500
357,500
500,500
325,000
325,000
325,000
325,000
325,000
195,000
845,000
318,500
695,500
546,000
863,200
143,000
157,300
143,000
223,600
143,000
143,000
143,000
143,000
117,000
171,600
117,000
117,000
117,000
117,000
117,000
117,000
117,000
117,000
117,000

I
(Rp)
371,250
371,250
519,750
337,500
337,500
337,500
337,500
337,500
202,500
877,500
330,750
722,250
567,000
896,400
148500
163,350
148500
232,200
148,500
148,500
148,500
148,500
121,500
178,200
121,500
121,500
121,500
121,500
121,500
121,500
121,500
121,500
121,500

35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

Art. Humeri
Art. Humeri Exo/Endo
Pedis
Ankle Joint
Calcaneus
Cruris (1 sisi)
Art Genu ( 1 sisi)
Art Genu Skyline
Femur (1 sisi)
Art. Coxae
Cervical AP/LAT
Cervical AP/LAT/Oblique
Thoracolumbal AP/LAT
Thoracal AP/LAT
Thoracal AP/LAT/Oblique
Lumbosacral AP/LAT

117,000
228,800
117,000
117,000
117,000
143,000
143,000
117,000
143,000
117,000
143,000
228,800
143,000
171,600
243,100
171,600

121,500
237,600
121,500
121,500
121,500
148,500
148,500
121,500
148,500
121,500
148,500
237,600
148,500
121,500
252,450
121,500

243,100
157,300
858,000
1,430,000
117,000
71,500
117,000

I
(Rp)
252,450
163,350
891,000
1,485,000
121,500
74,250
121,500

ENUNJANG MEDIS RADIOLOGI

No
51
52
53
54
55
56
57

TINDAKAN
Lumbosacral AP/LAT/Oblique
Sacrum
Bone Survey (Tanpa Tulang Panjang)
Bone Survey (Dengan Tulang Panjang)
Top Lordotik
Dental Foto
Toplordotik

II
(Rp)

UNJANG MEDIS LABORATORIUM

No
A
1
2
3

TINDAKAN
Hema 1 (Hb, Ht, L, T)
Hema 2 (Hema 1, Diff, LED, E)
Hema 2 (Hema 2, Rt)

II
(Rp)
HEMATOLOGI

I
(Rp)
84,500
88,400
143,000

87,750
91,800
148,500

4
5
6
7
8
9
10
11
12
13
14
B
1

Hitung Jenis/Diff Count

Gambaran Darah Tepi (GDT)
Retikulosit (Rt)
Index Eritrosit: (MCV, MCH, MCHC)
Malaria
Mikrofilaria
Blooding Time (BT0/Chloting Time (CT)
Laju Endap Darah (LED)
Golongan Darah (Goldar)
Viskositas Darah
G-6PD

40,500
216,000
67,500
54,000
67,500
67,500
33,750
37,800
47,250
108,000
324,000

52,000
52,000
58,500
52,000

54,000
54,000
60,750
54,000

234,000

243,000

87,100

90,450

45,500
45,500
45,500
130,000
97,500

47,250
47,250
47,250
135,000
101,250

58,500
58,500
169,000
58,500
58,500
58,500
169,000
46,800
46,800
78,000
62,400
58,500

60,750
60,750
175,500
60,750
60,750
60,750
175,500
48,600
48,600
81,000
64,800
60,750

KIMIA DARAH
Lemak Darah:
a. Cholesterol Darah
b. Trigliserida
c. HDL Cholesterol
d. LDL Cholesterol
e. Lemak lengkap : cholesterol, trigliserida, HDL
Cholesterol, LDL Cholesterol

39,000
208,000
65,000
52,000
65,000
65,000
32,500
36,400
45,500
104,000
312,000

f. Total Lipid
Fungsi Ginjal:
a. Ureum
b. Creatinin
c. Asam Urat (Urid Acid)
d. Paket RFT : Ureum,Creatinin, Asam Urat
e. Creatinin Clearens Test (CCT)
Fungsi Hati:
a. Total Protein
b. Albumin
c. Paket Protein: total protein, albumin, globulin
d. Bilirubin Total
e. Bilirubin Total Bayi
f. Bilirubin Direk
g. Paket Bilirubin : Bilirubin Total, direk, indirek
h. SGOT
i. SGPT
j. Gamma GT
k. Alkali Phosfatase
l. Globulin

UNJANG MEDIS LABORATORIUM

No

TINDAKAN

RJ/III (Rp)

II (Rp)

B
4

C
1
2
3
4
5
6
D
1
2
3
4
5
6
7
E
1
2
3
4
5
6
7
8
9
10

KIMIA DARAH
Fungsi Jantung:
a. LDH
b. CK
c. CKMB
d. Paket Enzim Jantung : LDH, CK, CKMB
e. Troponin T
Diabetes (DM):
a. Glukosa Sewaktu
b. Glukosa Puasa
c. Glukosa 2 jam, PP
d. Glukosa Puasa & 2 Jam PP
e. Glukosa Toleransi Test Oral (GGTO)
f. HbA1C
g. Keton Darah
Analisa Gas Darah (AGD)/Astrup
Elektrolit (Na, K, Cl)
Calcium Total
Calsium Ion
Paket 1 (AGD, Elektrolit)
Paket 2 (AGD, Elektrolit, Calcium Ion)
PT
APTT
INR
Masa Trombin (TT)
D-Dimer
Fibrinogen
Agregasi Trombosit

HBsAg
Anti HBsAg
HbeAg
Anti Hbe
Anti HAVlgM
WIDAL
NSI Ag
Anti Dengue lgG/lgM
Paket (NSI Ag Anti Dengue lgG/M)
Anti Salmonella lgM (Tubex TF)
11 Asto Kualitatif
12
Asto Kuantitatif

90,000
130,000
250,000
470,000
325,000

117,000
169,000
325,000
611,000
422,500

28,000
36,400
28,000
36,400
28,000
36,400
28,000
36,400
99,000
128,700
195,000
253,500
40,000
52,000
ELEKTROLIT dan ANALISA GAS DARAH
193,000
250,900
220,000
286,000
61,000
79,300
198,000
257,400
352,000
457,600
462,000
600,600
HEMOSTATIS
176,000
228,800
110,000
143,000
165,000
214,500
154,000
200,200
451,000
586,300
176,000
228,800
264,000
343,200
IMUNOSEROLOGI
121,000
157,300
138,000
179,400
341,000
443,300
413,000
536,900
308,000
400,400
84,000
109,200
330,000
429,000
330,000
429,000
440,000
572,000
209,000
271,700
88,000
114,400
132,000
171,600

13
14
15
16

RF Kualitatif
Rf Kuantitatif
CRP Kualitatif
CRP Kuantitatif

88,000
132,000
99,000
215,000

114,400
171,600
128,700
279,500

UNJANG MEDIS LABORATORIUM

No
F
1
2
3
4
5
6
7
8
9
10
11
G
1
2
3
4
5
6
7
8
9
10
11
12
13
H
1
2
3
I
1
2
3

TINDAKAN

II (Rp)
TIROID

FT3
FT4
TSHs
T3 (Total)
T4 (Total)
AFP
CEA
CA 15-3 (Breast)
CA 19-9 (Pancreas) S
PSA Total
Free PSA
Urine Lengkap
Glukosa Urine/Reduksi Urine
Keton Urine
Bilirubin Urine
Protein Urine Kualitatif
Protein Urine Kuantitatif
Protein Bence Jones
Sedimen Urine
HCG Urine (Tes Kehamilan)
Paket Narkoba (A, M, THC)
Amphetamine (A)
Morphine (M)
THC

386,100
328,900
257,400
236,600
236,600
314,600
293,800
572,000
643,500
414,700
843,700
URINALISA
54,600
28,600
28,600
28,600
28,600
55,900
67,600
28,600
100,100
299,000
117,000
117,000
117,000
FEACES

Feaces Lengkap
Darah Samar
Paket Feaces (Feaces Lengkap, Darah Samar)

1
3
1
1
1
71,500
107,900
153,400

MIKROBIOLOGI
Darah
Urine
Feaces

393,900
371,800
429,000

4
5
6
7
J
1
2
3
4
K
1
2
3
4

Sputum
Secret
Swab
Pus
BAKTERIOLOGI
Pewarnaan BTA 3x
Pewarnaan Gram
Perapatan GO
Rectal Swab

8
B
1
2
3
4
5
6
7
8

71,500
71,500
71,500
65,000
TORCH

Anti Toxoplasma lgA

Anti Toxoplasma lgG
Anti Rubella lgG
Anti Rubella lgM

MEDICAL CHECK UP (MCU)

No.
A
1
2
3
4
5
6
7

429,000
429,000
429,000
429,000

PEMERIKSAAN
CALON
KARYAWAN/KARYAWAN/MAHASISWA
Darah lengkap/Hema 2
Urine rutin
SGOT
SGPT
Ureum
Creatinin
HCG Urine (Tes Kehamilan)
SUB TOTAL
Paket narkoba
TOTAL
LENGKAP
Darah lengkap/Hema 2
Urine rutin
SGOT
SGPT
Ureum
Creatinin
Faeces rutin
Cholesterol

286,000
286,000
386,100
293,800

9
10
11

Urin acid
Glukosa puasa
Glukosa 2 jam, PP
TOTAL

C
1
2
3

SEDERHANA
Darah lengkap/Hema 2
Urine rutin
Glukosa sewaktu
TOTAL

Keterang
an :

Tarif
dapat
berubah
sewaktuwaktu

OBIL (AMBULAN dan JENAZAH)

No
A
1
2
3
4
5
B
1

WILAYAH
II (Rp)
I (Rp)
EVAKUASI MEDIS (MOBIL AMBULAN IGD)
Zona 1 (1 s/d 5) Km
193700
201150
Zona 2 (Diatas 5 s/d 10) Km
228800
237600
Zona 3 (Diatas 10 s/d 15) Km
300300
311850
Zona 4 (Diatas 15 s/d 20) Km
429000
445500
Zona 5 (Diatas 20 Km)
536900
557550
MOBIL JENAZAH (Kerjasama Pihak Luar RSIA)
DKI JAKARTA
1. Jakarta Barat
2. Jakarta Utara
3. Jakarta Pusat
4. Jakarta Timur
5. Jakarta Selatan
BANTEN:
1. Depok
-

2. Curug
3. Tanggerang
4. Teluk Naga
5. Kresek
6. Cipondoh
7. Tiga Raksa
8. Rajeg
9. Mauk
10. Ciledug
11. Cisoka
12. Balaraja
13. Kronjo
14. Sapatan
15. Pasar Kemis
16. Cikupa
17. Pondok Aren
18. Pamulang
19. Ciputat
20. Batu Ceper
21. Legok
22. Jati Uwung
23. Serpong

Penentua
n Zona
dilihat
dari
informas
i
pada
website
Google
Maps.

TARIF LAIN
No
1
2.

KETERANGAN
Pengurusan Akta Lahir
Bea Materai Rp 6000 (Ranap/Rajal/Jual Bebas)

KHUSUS (CPAP Prorata di Perina)

a Pemakaian : Rp 3.500.000 per Hari

No
1
2
3
4

KETERANGAN
0-6 Jam
6-12 Jam
12-18 Jam
18-24 Jam

KHUSUS (CPAP Prorata di ICU)

a Pemakaian : Rp 3.800.000 per Hari

No.
1
2
3
4

KETERANGAN
0-6 Jam
6-12 Jam
12-18 Jam
18-24 Jam

KHUSUS (VENTILATOR Prorata)

a Pemakaian : Rp 1.000.000 per Hari

No.
1
2
3
4

KETERANGAN
0-6 Jam
6-12 Jam
12-18 Jam
18-24 Jam

TARIF KHUSUS (O2)

No.
1
2

KETERANGAN
1-3 Liter/menit
Diatas 3 liter/menit

3250000
2600000
1950000
1300000
6500000
2600000

VIP
(Rp)
90,000
145,000
210,000
145,000
145,000
60,000
65,000

VIP (Rp)
9500000
5200000
5500000
5200000
5600000
6400000
5300000
7000000
9500000
14000000

VIP (Rp)
4,700,000
4,560,000
4,950,000
4,950,000
4,040,000
4,240,000
4,750,000
4,500,000
8,250,000
7,725,000
8,400,000
12,000,000

II
(Rp)

I
(Rp)
1,907,500
907,500
907,500
907,500
907,500
907,500
907,500

1,072,500
1,072,500
1,072,500
1,072,500
1,072,500
1,072,500
1,072,500

VIP
(Rp)
1,237,500
1,237,500
1,237,500
1,237,500
1,237,500
1,237,500
1,237,500

907,500

1..072.500

1,237,500

907,500
907,500
907,500
907,500

1,072,500
1,072,500
1,072,500
1,072,500

1,237,500
1,237,500
1,237,500
1,237,500

1,650,000
1,650,000

1,980,000
1,980,000

2,475,000
2,475,000

1,650,000

1,980,000

2..475.000

1,650,000

1,980,000

2,475,000

1,650,000

1..980.000

2,475,000

1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000
1,650,000

1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000
1,980,000

2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000
2,475,000

1,815,000
1,815,000

2,310,000
2,310,000

2,805,000
2,805,000

2,310,000
2,310,000
2,310,000

2,805,000
2,805,000
2,805,000

3,465,000
3,465,000
3,465,000

2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000
2,640,000

3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000

3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000

2,640,000
2,640,000
2,640,000

3,300,000
3,300,000
3,300,000

3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000
3,300,000

3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000

3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000
3,960,000

4,785,000
4,785,000
4,785,000
4,785,000
4,785,000
4,785,000
4,785,000
4,785,000
4,785,000
4,785,000

5,445,000
5,445,000

6,600,000
6,600,000

5,445,000
5,445,000
5,445,000
5,445,000
5,445,000

7,095,000
7,095,000
7,095,000
7,095,000
7,095,000

3,960,000
3,960,000
3,960,000

5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000
5,445,000

I
(Rp)

7,095,000
7,095,000
7,095,000
7,095,000
7,095,000
7,095,000
7,095,000
7,095,000
7,095,000
7,095,000
7,095,000

VIP
(Rp)

6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000
6,270,000

7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000

7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000

9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000

I
(Rp)

7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000
7,920,000

9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000
9,570,000

9,570,000
9,570,000
9,570,000

11,220,000
11,220,000
11,220,000

9,570,000
9,570,000
9,570,000

14,025,000
14,025,000
14,025,000

13,695,000
13,695,000

17,325,000
17,325,000

VIP
(Rp)
5,500,000
1,300,000
1,300,000
1,300,000
1,300,000
294,000

VIP
(Rp)
385,000
385,000
539,000
350,000
350,000
350,000
350,000
350,000
210,000
910,000
343,000
749,000
588,000
929,600
154,000
169,400
154,000
240,800
154,000
154,000
154,000
154,000
126,000
184,800
126,000
126,000
126,000
126,000
126,000
126,000
126,000
126,000
126,000

126,000
246,400
126,000
126,000
126,000
154,000
154,000
126,000
154,000
126,000
154,000
246,400
154,000
184,800
261,800
184,800

VIP
(Rp)
261,800
169,400
924,000
1,540,000
126,000
77,000
126,000

VIP
(Rp)
91,000
95,200
154,000

42,000
224,000
70,000
56,000
70,000
70,000
35,000
39,200
49,000
112,000
336,000

56,000
56,000
63,000
56,000
252,000
93,800
49,000
49,000
49,000
140,000
105,000
63,000
63,000
182,000
63,000
63,000
63,000
182,000
50,400
50,400
84,000
67,200
63,000

I (Rp)

VIP (Rp)

121,500
175,500
337,500
634,500
438,750

126,000
182,000
350,000
658,000
455,000

37,800
37,800
37,800
37,800
133,650
263,250
54,000

39,200
39,200
39,200
39,200
138,600
273,000
56,000

260,550
297,000
82,350
267,300
475,200
623,700

270,200
308,000
85,400
277,200
492,800
646,800

237,600
148,500
222,750
207,900
608,850
237,600
356,400

246,400
154,000
231,000
215,600
631,400
246,400
369,600

163,350
186,300
460,350
557,550
415,800
113,400
445,500
445,500
594,000
282,150
118,800
178,200

169,400
193,200
477,400
578,200
431,200
117,600
462,000
462,000
616,000
292,600
123,200
184,800

RAH

118,800
178,200
133,650
290,250

I (Rp)

123,200
184,800
138,600
301,000

VIP (Rp)

400,950
341,550
267,300
245,700
245,700
326,700
305,100
594,000
668,250
430,650
876,150

415,800
354,200
277,200
254,800
254,800
338,800
316,400
616,000
693,000
446,600
908,600

56,700
29,700
29,700
29,700
29,700
58,050
70,200
29,700
103,950
310,500
121,500
121,500
121,500

58,800
30,800
30,800
30,800
30,800
60,200
72,800
30,800
107,800
322,000
126,000
126,000
126,000

74,250
112,050
159,300

77,000
116,200
165,200

409,050
386,100
445,500

424,200
400,400
462,000

445,500
445,500
445,500
445,500

462,000
462,000
462,000
462,000

74,250
74,250
74,250
67,500

77,000
77,000
77,000
70,000

297,000
297,000
400,950
305,100

308,000
300,008
415,800
316,400

VIP (Rp)
208600
246400
323400
462000
578200

A)
-