TINDAKAN ESWL

4 HARI RAWAT
KELAS 3
RINCIAN PELAYANAN

NO

BIAYA ESWL

BIAYA OBAT DAN ALKES PERAWATAN

BIAYA PEMERIKSAAN PENUNJANG

JUML
AH

BREAKDOWN
BPJS LEVEL 1

KELAS 2

BREAKDOWN
BPJS LEVEL 2

BREAKDOWN
BPJS LEVEL 3

BREAKDOWN
BPJS LEVEL 1

KELAS 1

BREAKDOWN
BPJS LEVEL 2

BREAKDOWN
BPJS LEVEL 3

BREAKDOWN
BPJS LEVEL 1

BREAKDOWN
BPJS LEVEL 2

BREAKDOWN
BPJS LEVEL 3

7,475,000

7,475,000

7,475,000

8,625,000

8,625,000

8,625,000

9,775,000

9,775,000

9,775,000

BNO - IVP

990,000

990,000

990,000

1,090,000

1,090,000

1,090,000

1,200,000

1,200,000

1,200,000

USG ABDOMEN

420,000

420,000

420,000

470,000

470,000

470,000

520,000

520,000

520,000

UREUM

40,000

40,000

40,000

50,000

50,000

50,000

60,000

60,000

60,000

CREATININ

40,000

40,000

40,000

50,000

50,000

50,000

60,000

60,000

60,000

DARAH LENGKAP

70,000

70,000

70,000

80,000

80,000

80,000

90,000

90,000

90,000

BIAYA AMBULANCE K AWAL BROS

770,000

770,000

770,000

770,000

770,000

770,000

770,000

770,000

770,000

BIAYA KAMAR INAP

BIAYA KAMAR

330,000

330,000

330,000

600,000

600,000

600,000

1,320,000

1,320,000

1,320,000

VISITE DR BEDAH

102,000

102,000

102,000

135,000

135,000

135,000

195,000

195,000

195,000

JASA DOKTER RUANGAN

21,000

21,000

21,000

24,000

24,000

24,000

27,000

27,000

27,000

JASA PARAMEDIS

33,000

33,000

33,000

40,000

40,000

40,000

88,000

88,000

88,000

PASANG INFUS

M1

30,000

30,000

30,000

30,000

30,000

30,000

30,000

30,000

30,000

10,321,000

10,321,000

10,321,000

11,964,000

11,964,000

11,964,000

14,135,000

14,135,000

14,135,000

516,050

516,050

516,050

598,200

598,200

598,200

706,750

706,750

706,750

SUB TOTAL
ADMINISTRASI 5 %

PERKIRAAN TOTAL

10,837,050

10,837,050

10,837,050

KODE & TARIF INA CBGs / BPJS

N-1-20-I

N-1-20-II

N-1-20-III

12,562,200
N-1-20-I

12,562,200
N-1-20-II

12,562,200
N-1-20-III

14,841,750
N-1-20-I

14,841,750
N-1-20-II

14,841,750
N-1-20-III

PEMAKAIAN OBAT DAN ALKES RUANG PERAWATAN ESWL

ESWL
NO
1
2
3
4
5
6
7
8
9
10
11
12
13

NAMA ALKES
CEFTRIAXON 1 GR INJEKSI (DEXA)
VASOFIX SERENITY NO 18
TRANSFUSI SET (*)
RL INFUS 500 *
SARUNG TANGAN WIN GLOVE
OMNIPAC
SPUIT 20 CC
WING NEEDLE
AQUABIDEST 25 ML
MASKER
NACL 500 ML 0,9 %
CEFIXIM 100 MG
PASTIK
JUMLAH

JUMLAH
4
1
1
8
3
1
1
1
2
3
1
6
6
38

HARGA
Rp
Rp
Rp
Rp

11,172.16
12,993.75
37,867.50
17,160.00

Rp 3,430.35
Rp 16,632.00
Rp 3,712.50

Rp102,968.26

JUMLAH
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp

44,688.64
12,993.75
37,867.50
137,280.00
3,430.35
16,632.00
7,425.00
260,317.24