TARIF RETRIBUSI PELAYANAN KESEHATAN

PUSKESMAS MEKAR BARU

TAHUN 2014
NO JENIS PELAYANAN TARIF (Rp)
1 Pemeriksaan Dasar + Obat (P.Umum ,KIA & MTBS) Rp 7,000
2 Pemeriksaan Dasar + Obat + SKS Rp 10,000
3 Pemeriksaan GIGI + Obat (P.Gigi) Rp 10,000
4 Imunisasi TT Caten Rp 10,000
5 Tindik Bayi Rp 20,000
6 Sunat Bayi Perempuan Rp 15,000
7 Suntik KB 1 bln Rp 25,000
8 Suntik KB 3 bln Rp 15,000
9 Injeksi IV Rp 10,000
10 Injeksi IM/ SC/ IC Rp 3,000
11 Pasang Implant Rp 225,000
12 Cabut Implant Rp 60,000
13 Pasang IUD Rp 60,000
14 Cabut IUD Rp 30,000
15 Debridement Luka / Ganti Verban / Aff Hecting Rp 10,000
16 Perawatan Luka Bakar Kecil Rp 20,000
17 Perawatan Luka Bakar Sedang Rp 25,000
18 Pembersihan Luka Bakar 10-15% Rp 20,000
19 Heacting Luka Robek 1-5 Rp 20,000
20 Heacting Luka Robek 6-10 Rp 40,000
21 Benda Asing Mata/ Hidung/ Telinga Rp 20,000
22 Nebulizer Rp 40,000
23 Pemakaian Oksigen /Jam Rp 25,000
24 Eksplorasi Benda Asing Rp 25,000
25 Cross Insisi Rp 20,000
26 Ektraksi Kuku Rp 20,000
27 Ekstraksi Serumen / Benda Asing Rp 10,000
28 Circumsisi Rp 150,000
29 Pemasangan Infus Rp 50,000
30 Surat Keterangan Sehat Rp 10,000
 Pelayanan Laboratorium
1 Darah Rutin :
2 - Haemoglobin Rp 15,000
3 - Leukosit Rp 6,000
4 - Trombosit Rp 8,000
5 LED / PVC Rp 5,000
6 Golongan Darah Rp 6,000
7 Urine Lengkap Rp 15,000
8 Protein Urine Rp 15,000
9 Pregnancy Test Rp 15,000
10 Malaria Rp 10,000
11 Gula Darah Sewaktu Rp 25,000
12 Asam Urat Rp 25,000
13 Cholesterol Total Rp 28,000
14 HIV Rp 55,000

Pelayanan Gigi
Pemeriksaan GIGI + Obat (P.Gigi) Rp 10,000
Pencabutan Gigi + Obat sbb ;
A Rp 1,000
B Rp 2,000
C Rp 3,000
D Rp 4,000
E Rp 5,000
F Rp 6,000
G Rp 7,000
H Rp 8,000
I Rp 9,000
J (gigi susu) Rp 10,000
JE (gigi tetap) Rp 15,000
JJ Rp 20,000
DIAGNOSA ICD-X

PENYAKIT INFEKSI & PARASIT PENYAKIT INFEKSI & PARASIT PENYAKIT ENDOKRIN NUTRISI & METABOLIK
A39 Meningococcal Infekction B001 Herpesviral Vesicular Dermatitis A39 Meningococcal Infekction
A39.0+ Meningococcal Meningitis B01 Varicella A39.0+ Meningococcal Meningitis
Respiratory Tuberculosis, Bacterriologically and Respiratory Tuberculosis, Bacterriologically and
A15 B05 Measles A15
Histologically Confirmed Histologically Confirmed
A06 Amoebiasis B07 Viral Warts / Verucca A06 Amoebiasis
A01 Typhoid and Paratyphoid fevers B15.9 Acute Hepatitis A A01 Typhoid and Paratyphoid fevers
A01.0 Typhoid fever B16 Acute Hepatitis B A01.0 Typhoid fever
Diarhoea and Gastroenteritis of presumed infectios Diarhoea and Gastroenteritis of presumed infectios
A09 B18.1 Chronic Viral Hepatitis A09
origin origin
A05 Other Bacterial Foodborn intoxications B77 Ascariasis A05 Other Bacterial Foodborn intoxications
A15 Respiratory Tuberculosis B80 Oxyurisiasis A15 Respiratory Tuberculosis
A30 Leprosy [Hansen's disease] B20 HIV A30 Leprosy [Hansen's disease]
B15 Acute Hepatitis A B86 Scabies B15 Acute Hepatitis A
B16 Acute Hepatitis B B37.3 Candidiasis of Vulva and Vagina B16 Acute Hepatitis B
B50 Plasmodium Falciparum Malaria B26 Mumps B50 Plasmodium Falciparum Malaria
B51 Plasmodium Vivax Malaria B85 Pediculosis and Phthiriasis B51 Plasmodium Vivax Malaria
B52 Plasmodium Malariae Malaria B30 Viral Conjunctivitis B52 Plasmodium Malariae Malaria
Human Immunodeficiency Virus [hiv] disease Human Immunodeficiency Virus [hiv] disease
B20 B20
Resulting in infectiousand Parasitic disease Resulting in infectiousand Parasitic disease
B35.3 Tinea Pedis PENYAKIT NEOPLASMA
B35.4 Tinea Corporis C20 Malignant Neoplasm of Rectum
B35.6 Tinea Cruris C50 Malignant Neoplasm of Breast
B36.0 Pityriasis Versicolor C53 Malignant Neoplasm of Cervix Uteri
B37.0 Candidal Stomatitis C54 Malignant Neoplasm of Corpus Uteri
B37.2 Candidiasis of Skin and Nail [Diapers] C61 Malignant Neoplasm of Prostate
 DIAGNOSA PENYAKIT
PUSKESMAS MEKAR BARU

KODE
NO PENYAKIT DIAGNOSA PENYAKIT

1 A 09 Diarhoea (GE)
2 A 153 Tuberculosis of lung
3 E 041 Nontoxic single thyroid nodule (syndroma nnodusa toxic)
4 E 119 Non Insulin Diabetic Mellitus without complication
5 E 780 Pure Hypercholesterol
6 H 259 Senile Cataract, unspecified
7 H 521 Myopia
8 H 660 Acute Suppurativa Otitis Media
9 I 10 Essential Hypertension
10 J 039 Acut Tonsillitis
11 J 180 Pneumonia
12 J 189 Bronchopneumonia
13 J 209 Acute Bronchitis
14 J 350 Chronic Tonsillitis
15 K 029 Dental Caries, unspecified
16 K 297 Gastritis, unspecified
17 M 791 Myalgia
18 M 792 Neuralgia & Neuritis
19 N 801 Endrometriosis of Ovary
20 S 009 Vulnus Head ( Kepala )
21 S 224 Multiple fractures of ribs (Patah tulang Iga/Rusuk)
22 S 608 Vulnus ( Telapak tangan s/d tangan )
23 S 909 Vulnus ( Lutut & kaki)

KB - General counselling and advice on contraception (consultasi

24 Z 300 alat Kontrasepsi)
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 DIAGNOSA PENYAKIT
PUSKESMAS MEKAR BARU

KODE
NO DIAGNOSA PENYAKIT
PENYAKIT

1 Asam Urat/gout M109

2 Batu Ginjal / Urolithiasis / Calculus of Kidney N 200
3 Batuk Pilek / ISPA / Commond Cold J 00
4 Biduran/Urtikaria L 509
5 Bronchitis J 209
6 Bronchopneumonia J 180
7 Cacingan B 769
8 Cataract H 259
9 Cephalgia/Headache/Sakit Kepala R 51
10 CHD I 251
11 Cholelithiasis K 808
12 Chronic Tonsillitis J 350
13 Demam Dengue A 90
14 Demam / Fever, Unspecified R 509
15 Dental Caries, unspecified K 029
16 DHF A 919
17 Dislocation of Elbow/Humerus S 531
18 DM tanpa Komplikasi E 149
19 Dysentery A 060
20 Dysmenorrhoea N 946
21 Dyspepsia K 309
22 Ekstraksi Kuku L 989
23 Embryonic cyst of Cervix Q 516
24 Endometriosis of Ovary / Kista Ovarium N 801
25 Epistaxsis R 040
26 Essential Hypertension I 10
27 Facial Asymmetrys D 670
28 Fatigue/Malaise R 53
29 FAM N 602
30 Fibro Adenosis N 602
31 Gagal Ginjal Akut N 179
32 Gagal Ginjal Kronik N 189
33 Gastritis Acute K 297
34 Gastritis Chronic K 295
35 Gastritis Kronik K 295
 DIAGNOSA PENYAKIT
PUSKESMAS MEKAR BARU

KODE
NO DIAGNOSA PENYAKIT
PENYAKIT
36 Gastritis, unspecified K 297
37 Gastroenteritis A 09
38 Haemorrhoid Masa Kehamilan O 224
39 Haemorrhoids Dalam tanpa Komplikasi I 841
40 Haemorrhoids Luar tanpa Komplikasi I 845
41 Haemorrhoids Setelah Persalinan / Puerperium O 872
42 Hemaptoe/ Batuk Darah R 042
43 Hematoma T 140
44 Hamil z 321
45 Herpes Simplex P 352
46 HyperCholesterol E 780
47 Hypermetropia H520
48 Infeksi Saluran Kemih N 390
49 Insect Bite T 140
50 Insomnia G 470
51 IVA Z 124
52 KB / Konsultasi alat Kontrasepsi Z 309
53 Kehamilan Normal Z 349
54 Kena Setrum T 754
55 Keputihan B 373
56 Keracunan Kehamilan / Pre-Eclampsia O 149
57 Keracunan Kehamilan + Kejang / Eclampsia in Pregnancy O 150
58 Kista Ovarium N 801
59 Konstipasi K 590
60 Lemah / Malaise dan Fatigue R 53
61 Melena K 921
62 Morbili B 059
63 Multiple fractures of ribs (Patah tulang Iga/Rusuk) S 224
64 Myalgia M 791
65 Myopia / Rabun Jauh H 521
66 Neuralgia & Neuritis M 792
67 Obserfasi Febris R 509
68 Nontoxic single thyroid nodule (syndroma nodosa toxic) E 041
69 Osteoarthritis M 150
70 Otitis Media Acute H 660
 DIAGNOSA PENYAKIT
PUSKESMAS MEKAR BARU

KODE
NO DIAGNOSA PENYAKIT
PENYAKIT
71 Periksa Hami Z 349
72 Pemasangan Kacamata Z 460
73 Pharingitis J 029
74 Pneumonia J 189
75 Pterygium H 110
76 PPOK J 449
77 Rheumoatoid Athritis/RA M 069
78 Sakit Jantung / Heart disease I 519
79 Sakit Kepala + Tegang Otot / Tension-Type Headache G 442
80 Sakit Kepala Berat/Tension-type headache G 442
81 Sakit Kepala Biasa / Pusing / Headache R 51
82 Schizophrenia F 209
83 Sectio (SC) / Delivery by elective Caesarean section O 820
84 Sectio (SC) Riwayat Aborsi Z 351
85 Serumen Prop H 619
86 Sirkumsisi Z 412
87 Stomatitis B 370
88 Syndrom Nodusa Toksik E 051
89 Thalasemia D 569
90 Tinea Cruris B 356
91 Tonsillitis Acute J 039
92 Tonsiloparingitis j 068
93 Tuberculosis of lung A 153
94 Tumor Rahim/Leiomyoma Uteri D 259
95 Vulnus ( Lutut & kaki) S 909
96 Vulnus ( Telapak tangan s/d tangan ) S 608
97 Vulnus Head ( Kepala ) S 009
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