Tarif SPB R. Inap

No Diagnosa lama rawat tarif disetujui tarif awal jamsostek selisih
(hari)
1 Astma pada anak 3 1,302,803 1,327,803 (25,000)
2 Bronchopneumonia Anak 5 1,810,879 2,171,341 (360,462)
3 Bronchopneumonia Dewasa 5 2,149,228 2,174,228 (25,000)
5 Observasi febris 3 920,159 931,104 (10,945)
6 Paket Harian ICU 5 1,217,097 1,233,041 (15,944)
7 Tarif Paket Harian 7 274,116 309,116 (35,000)
8 Tarif Paket Harian Isolasi 7 278,412 309,116 (30,704)
9 Partus dengan Induksi 2 2,316,579 2,341,579 (25,000)
10 Sectio Saecaria ai gagal drip 8,328,662 8,353,662 (25,000)
12 appendisitis akut tanpa perforas 4 5,206,527 5,231,527 (25,000)
13 Pterigium 1 1,003,815 1,028,815 (25,000)
14 Tarif Paket Operasi Kecil 1 2,233,374 2,258,374 (25,000)
RAWAT INAP JAMSOSTEK SP3
No Diagnosa lama rawat Rupiah

(hari)
1 Astma pada anak 3 1,327,803
2 Bronchopneumonia Anak 5 2,171,341
3 Bronchopneumonia Dewasa 5 2,174,228
4 Demam Thypoid Anak 5 1,724,742
5 Demam Thypoid Dewasa 5 1,850,837
6 DHF grade I-II Anak 4 1,728,968
7 DHF grade I-II Dewasa 4 1,595,105
8 GEA anak 3 1,145,554
9 GEA dewasa 3 1,172,934
10 Kejang Demam 3 1,245,638
11 Observasi febris 3 931,104 per hari
12 Paket Harian ICU 5 6,165,206 1,233,041
13 Tarif Paket Harian 7 2,163,815 309,116
14 Tarif Paket Harian Isolasi 7 2,163,815 309,116
15 Abortus dengan kuretase pada Blighted ovum 2 1,761,026
16 Abortus inkomplit dengan kuretase 2 1,796,989
17 Partus dengan Induksi 2 2,341,579
18 Partus dengan risiko tinggi 3 2,342,086
19 Partus dengan vakum ekstraksi, forceps 3 2,717,548
20 Sectio Saecaria ai gagal drip 4 8,353,662
21 Sectio Saecaria elektif (CPD, KPD, oligohidramnion) 5 6,962,854
22 Sectio Saecaria emergensi (gawa janin, Perdarahan antepartum) 5 7,190,959
23 Histerektomi 4 6,260,286
24 appendisitis akut tanpa perforasi 4 5,231,527
25 FAM 2 3,550,000
26 Ganglion 2 3,550,000
27 Lipoma Multipel 2 3,550,000
28 Haemorroid disertai tindakan operasi 4 5,090,740
29 Katarak 1 4,185,203
30 Pterigium 1 1,028,815
31 Tonsilitis hipertropi anak 2 4,066,863
32 Tonsilitis hipertropi dewasa 2 3,995,647
33 Tarif Paket Operasi Kecil 1 2,258,374
34 Tarif Paket Operasi Sedang 3 4,820,737
35 Tarif Paket Operasi Besar 5 6,659,969
50,000
40,000
10,000
25,000
10,000
1,196,755
376,034
550,899
192,515
77,307
2,156,000
662,200
1,018,641
339,022
136,137
2,835,000
870,750
1,339,448
445,791
179,011
3,060,000
939,857
1,445,753
481,172
193,218
3,625,000
1,113,393
1,712,697
570,016
228,894
Biaya Operasional
Operator
Anestesi
Asisten, BHP, lain2
Biaya Operasional
50 Operator
20 Anestesi
5 Asisten, BHP, lain2
Biaya Operasional
Operator
Anestesi
Asisten, BHP, lain2
Biaya Operasional
Operator
Anestesi
Asisten, BHP, lain2
Tindakan Operasi kecil 1,000,000 2,100,000
aya Operasional 31% Biaya Operasional 307,143 645,000
47% Operator 472,468 992,183
16% Anestesi 157,246 330,216
isten, BHP, lain2 6% Asisten, BHP, lain2 63,143 132,601
Tindakan operasi sedang 1,700,000 3,300,000
aya Operasional 31% Biaya Operasional 522,143 1,013,572
47% Operator 803,196 1,559,145
16% Anestesi 267,318 518,911
Tindakan operasi besar 2,500,000 4,750,000
aya Operasional 31% Biaya Operasional 767,857 1,458,929
47% Operator 1,181,170 2,244,224
16% Anestesi 393,114 746,917
Tindakan operasi khusus 4,350,000 8,100,000

aya Operasional 31% Biaya Operasional 1,336,072 2,487,858
47% Operator 2,055,236 3,826,992
16% Anestesi 684,019 1,273,690
Mondok makan 70,000 120,000
Visite dr spesialis 35,000 65,000
Asuhan keperawatan 30,000 30,000
Tindakan keperawatan 25,000 25,000
Rawat Jalan Lanjutan
No Diagnosa Dokter Penunjang Diag
Obat-obatan
Spesialis Rontgen
1 Astma pada anak #REF! #REF! #REF!
2 Bronchopneumonia Anak #REF! #REF! #REF!
3 Bronchopneumonia Dewasa #REF! #REF! #REF!
4 Demam Thypoid Anak #REF! #REF! #REF!
5 Demam Thypoid Dewasa #REF! #REF! #REF!
6 DHF grade I-II Anak #REF! #REF! #REF!
7 DHF grade I-II Dewasa #REF! #REF! #REF!
8 GEA anak #REF! #REF! #REF!
9 GEA dewasa #REF! #REF! #REF!
10 Kejang Demam #REF! #REF! #REF!
11 Observasi febris #REF! #REF! #REF!
12 Paket Harian ICU #REF! #REF! #REF!
13 Tarif Paket Harian #REF! #REF! #REF!
14 Tarif Paket Harian Isolasi #REF! #REF! #REF!
15 Abortus dengan kuretase pada Blighted ovum #REF! #REF! #REF!
16 Abortus inkomplit dengan kuretase #REF! #REF! #REF!
17 Partus dengan Induksi #REF! #REF! #REF!
18 Partus dengan risiko tinggi #REF! #REF! #REF!
19 Partus dengan vakum ekstraksi, forceps #REF! #REF! #REF!
20 Sectio Saecaria ai gagal drip #REF! #REF! #REF!
21 Sectio Saecaria elektif (CPD, KPD, oligohidramnion) #REF! #REF! #REF!
22 Sectio Saecaria emergensi (gawa janin, Perdarahan antep #REF! #REF! #REF!
23 Histerektomi #REF! #REF! #REF!
24 appendisitis akut tanpa perforasi #REF! #REF! #REF!
25 FAM #REF! #REF! #REF!
26 Ganglion Err:509 Err:509 Err:509
27 Lipoma Multipel Err:509 Err:509 Err:509
28 Haemorroid disertai tindakan operasi #REF! #REF! #REF!
29 Katarak #REF! #REF! #REF!
30 Pterigium #REF! #REF! #REF!
31 Tonsilitis hipertropi anak #REF! #REF! #REF!
32 Tonsilitis hipertropi dewasa #REF! #REF! #REF!
33 Tarif Paket Operasi Kecil Err:509 Err:509 Err:509
34 Tarif Paket Operasi Sedang Err:509 Err:509 Err:509
35 Tarif Paket Operasi Besar Err:509 Err:509 Err:509
Rawat Inap
Penunjang Diagnostik Tindakan
Phisiotera Emergency Rawat Inap Obat-obatan
Lab Pem Khusus PA Khusus
pi
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
Err:509 Err:509 Err:509 Err:509 Err:509 Err:509 310,000 49,570
Err:509 Err:509 Err:509 Err:509 Err:509 Err:509 - -
Err:509 Err:509 Err:509 Err:509 Err:509 Err:509 775,000 1,503,886
Perawatan Persalinan Penunjang Diagnostik Tindakan Lain-lain :
Operasi Pem Labu
Khusus Patologis Rontgen Lab PA Khusus
Khusus Darah
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
2,753,209 Err:509 Err:509 70,000 197,000 Err:509 Err:509 Err:509 Err:509
2,753,209 Err:509 Err:509 70,000 197,000 Err:509 Err:509 Err:509 Err:509
1,813,192 Err:509 Err:509 - 127,000 Err:509 #REF! Err:509 Err:509
4,950 Err:509 Err:509 - 217,000 Err:509 Err:509 Err:509 Err:509
3,445,031 Err:509 Err:509 - 217,000 Err:509 Err:509 Err:509 Err:509
BAWAH ATAS Rawat Jalan Lanjutan
Lain-lain : SELISIH Dokter
Transfusi Pin, Plate, Physiotera TOTAL TOTAL
pi ATAS-BAWAH Spesialis
Darah Screw
#REF! #REF! #REF! #REF! #REF! -
#REF! #REF! -
#REF! #REF! -
Err:509 Err:509 Err:509 Err:509 Err:509 -
#REF! #REF! #REF! #REF! #REF!
Rawat Jalan Lanjutan
Penunjang Diagnostik Tindakan
Obat-obatan Phisiotera Emergency
Rontgen Lab Pem Khusus PA Khusus
pi
Rawat Inap
Perawatan Persalinan Penunjang Diagnostik
Rawat Inap Obat-obatan Operasi
Khusus Patologis Rontgen
Penunjang Diagnostik Tindakan Lain-lain :
Labu Transfusi Pin, Plate, Physioterapi
Lab Pem Khusus PA Khusus
Darah Darah Screw
Kertas Kerja Perhitungan Tarif Paket Rawat Inap
KASUS : GANGLION
USIA : DEWASA
Hari 1
Sediaan Harga Satuan Jumlah
RAWAT INAP
Komponen Rawat Inap

Mondok makan 60,000 1
Visite dokter spesialis 40,000 1
Asuhan keperawatan 15,000 1
Tindakan keperawatan 20,000 1
visite dokter umum 20,000 1
Obat-obatan
Analgesik, Antipiretik ASAM MEFENAMAT 500 MG GKF TAB 138 15

Antibiotik gol sefalosporiCEFADROXIL CAP 500MG GIF CAP 1,600 10
Ceftriaxon 1 gr VIAL 15,750 2
Operasi
Operasi sedang 1,775,000 1

Biaya Operasional 350,000
Operator 950,000
Anestesi 332,500
Asisten, BHP, lain2 142,500
Materi dan bahan habis pRECOFOL AMP IV 10MG/ML 20ML AMP 101,200 1
Materi dan bahan habis pFENTANYL CITRATE INJ 10 ML VIA 71,610 1
RANITIDINE INJ GHEX 4,125 2
Anestetik Umum Isoflurane cc 8,107 50
KETOROLAC 3% INJ@10 GDX 18,563 1
AQUABIDEST 50 ML IKA FLS 7,150 1
INFUS SET DEWASA TRM 15,125 1
RINGER LACTAT 500ML OTS 15,476 3
ETT 100,958 1
ABBOCATH T 20G 24,420 1
LEUKOMED 72380-01 8 X 10 5,431 1
DISP SYRINGE 1 ML TERUMO TB BH 2,612 1
DISP SYRINGE 3 ML TERUMO BH 1,375 2
IODINE POVIDON SOL 10% 30ML BTL 2,500 2
FAM/GANGLION/LIPOMA
Halaman 14 dari 59
Hari 1
HIBISCRUB 100 ml 24,070 0.25
SURGICAL GLOVE NO 7.5 BH 4,400 4
SURGICAL BLADE 15 BH 3,438 1
CARESA KAPAS BOLA 50 GR BH 6,504 0.25
CAT GUT CHROMIC 2-0 BH 66,206 1
CHROMIC 2-0 (W-448) BH 68,475 1
Penunjang Diagnostik
Rontgen
Thoraks PA 70,000 1
Laboratorium
Darah Lengkap (Darah Rutin, Diff count, LED) 55,000 1

BT (Bleedding Time) / Masa Perdarahan 10,000 1
CT (Cloting Time) / Masa Pembekuan 10,000 1
Gula Darah Puasa 22,000 1
HbsAg 90,000 1
golongan darah 10,000 1
Total Biaya
FAM/GANGLION/LIPOMA
Halaman 15 dari 59
-
Hari 1 Hari 2 Hari 3 Total

Harga Jumlah Harga Jumlah Harga Jumlah Harga
- -
- -
155,000 155,000 - - 310,000
60,000 1 60,000 - 1 100,000
40,000 1 40,000 - 1 40,000
15,000 1 15,000 - 1 20,000
20,000 1 20,000 - 1 20,000
20,000 1 20,000 - 2 40,000
49,570 - - - 49,570
- - - - -
2,070 - - 15 2,070
16,000 - - 10 16,000
31,500 - - 2 31,500
- - - - -
2,753,209 - - - 2,753,209
- - - - -
1,775,000 - - 1 1,775,000
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
101,200 - - 1 101,200
71,610 - - 1 71,610
8,250 - - 2 8,250
405,350 - - 50 405,350
18,563 - - 1 18,563
7,150 - - 1 7,150
15,125 - - 1 15,125
46,428 - - 3 46,428
100,958 - - 1 100,958
24,420 - - 1 24,420
5,431 - - 1 5,431
2,612 - - 1 2,612
2,750 - - 2 2,750
5,000 - - 2 5,000
FAM/GANGLION/LIPOMA
Halaman 16 dari 59
6,018 - - 0 6,018
17,600 - - 4 17,600
3,438 - - 1 3,438
1,626 - - 0 1,626
66,206 - - 1 66,206
68,475 - - 1 68,475
- - - - -
- - - - -
- -
70,000 - - - 70,000
- - - - -
70,000 - - 1 70,000
- - - - -
197,000 - - - 197,000
- - - - -
55,000 - - 1 55,000
10,000 - - 1 10,000
10,000 - - 1 10,000
22,000 - - 1 22,000
90,000 - - 1 90,000
10,000 - - 1 10,000
3,224,779 155,000 - - 3,379,779
FAM/GANGLION/LIPOMA
Halaman 17 dari 59
KASUS : LIPOMA MULTIPLE
USIA : DEWASA
Hari 1
RAWAT INAP
Komponen Rawat Inap

Visite dokter umum 20,000 1
Obat-obatan

Ceftriaxon 1 gr VIAL 15,750 2
Operasi

Operator 950,000
Anestesi 332,500
Materi dan bahan habis pRECOFOL AMP IV 10MG/ML 20ML AMP 101,200 1
Materi dan bahan habis pFENTANYL CITRATE INJ 10 ML VIA 71,610 1
RANITIDINE INJ GHEX 4,125 2
INFUS SET DEWASA TRM 15,125 1
ETT 100,958 1
LEUKOMED 72380-01 8 X 10 5,431 1
FAM/GANGLION/LIPOMA
Halaman 18 dari 59
Hari 1
HIBISCRUB 100 ml 24,070 0.25
CARESA KAPAS BOLA 50 GR BH 6,504 0.25
CHROMIC 2-0 (W-448) BH 68,475 1
Rontgen
Thoraks PA 70,000 1
Laboratorium

Gula Darah Puasa 22,000 1
HbsAg 90,000 1
golongan darah 10,000 1
Total Biaya
Keterangan:
*) Tarif paket untuk kasus lipoma yang dimaksud adalah pada kasus Lipoma dengan:
ü ukuran > 8cm, atau
ü Letak pada tengkuk (nuche), jumlah
ü Jumlah ≥ 3 buah yang dioperasi pada saat bersamaan
FAM/GANGLION/LIPOMA
Halaman 19 dari 59
- -
- -
155,000 155,000 - - 310,000
60,000 1 60,000 - 1 100,000
40,000 1 40,000 - 1 40,000
15,000 1 15,000 - 1 20,000
20,000 1 20,000 - 1 20,000
20,000 1 20,000 - 2 40,000
49,570 - - - 49,570
- - - - -
2,070 - - 15 2,070
16,000 - - 10 16,000
31,500 - - 2 31,500
-
2,753,209 - - - 2,753,209
- - - - -
1,775,000 - - 1 1,775,000
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
101,200 - - 1 101,200
71,610 - - 1 71,610
8,250 - - 2 8,250
405,350 - - 50 405,350
18,563 - - 1 18,563
7,150 - - 1 7,150
15,125 - - 1 15,125
46,428 - - 3 46,428
100,958 - - 1 100,958
24,420 - - 1 24,420
5,431 - - 1 5,431
2,612 - - 1 2,612
2,750 - - 2 2,750
5,000 - - 2 5,000
FAM/GANGLION/LIPOMA
Halaman 20 dari 59
6,018 - - 0 6,018
17,600 - - 4 17,600
3,438 - - 1 3,438
1,626 - - 0 1,626
66,206 - - 1 66,206
68,475 - - 1 68,475
- - - - -
- - - - -
- -
70,000 - - - 70,000
- - - - -
70,000 - - 1 70,000
- - - - -
197,000 - - - 197,000
- - - - -
55,000 - - 1 55,000
10,000 - - 1 10,000
10,000 - - 1 10,000
22,000 - - 1 22,000
90,000 - - 1 90,000
10,000 - - 1 10,000
3,224,779 155,000 - - 3,379,779
FAM/GANGLION/LIPOMA
Halaman 21 dari 59
KASUS : OPERASI KECIL
Har
RAWAT INAP
Komponen Rawat Inap

Obat-obatan
Antibiotik gol sefalosporiCEFTRIAXONE VIAL DRY 1G GHEX@2 VIA 13,262 1
Antiamoeba & AntigiardiaMETRONIDAZOL INFUS GFIMA BH 23,375 1
Cairan Mineral RINGER LACTATE 500ML OTS FLS 10,476 1
Bahan Habis Pakai AQUABIDEST 50 ML IKA FLS 7,150 1
Bahan Habis Pakai BLOOD TRANFUSION SET TRM 39,126 1
Bahan Habis Pakai ABBOCATH T 20G 24,420 1
Bahan Habis Pakai DISP SYRINGE 1 ML TERUMO TB BH 2,612 1
Bahan Habis Pakai DISP SYRINGE 5 ML TRM BH 1,650 1
Bahan Habis Pakai THREE WAY STOP COCK BH 23,292 1
Bahan Habis Pakai HANSAPLAST STD STRIPS @ 10 BH 438 1
Operasi
Operasi Kecil 1,250,000 1

Operator 600,000
Anestesi 210,000
BHP B Plain 2/0 HR 26 buah 82,200 1

BHP Handschoen 6,5 Steril psg 12,375 2
BHP Handschoen 7 Steril buah 12,375 2
BHP Handschoen 7,5 Steril buah 5,844 1
BHP Pisau insisi 20 (Pisau bisturi) buah 3,100 1
BHP B Soflilk 3-0 GS-832 v.20 buah 70,800 1
BHP Hansaplas buah 750 1
Operasi Kecil
Halaman 22 dari 59
Har
BHP Kasa Hidrofil citra x-ray lbr 1,170 20
BHP Cerplast aerofilm 50 x 50 mm lbr 73,200 1
BHP Spuit 10 cc (Terumo) buah 6,400 1
BHP spuit 5 cc (Terumo) buah 4,900 2
BHP B. Surgycal 910 No. 2/0 HR 26 mm buah 86,000 1
Obat OK NaCl 0.9% 1000ml buah 10,470 1

Obat OK RL 500 ml buah 11,719 2
Obat OK Pethidin amp inj 50MG mg 14,990 1
Obat OK Primperan inj amp 11,688 1
Obat OK Fentanyl 2ml 50MG mcg 38,500 1
Obat OK Miloz 15mg inj mcg 18,113 1
Obat OK Extradine 10 % @ 1 galon 4,600 2
Obat OK Tramadol 100mg inj amp 8,600 3
Rontgen
Laboratorium
Glukosa Sewaktu 22,000 1
Cross Match (Vena) 20,000 1
Golongan darah 10,000 1
Total Biaya
Operasi Kecil
Halaman 23 dari 59
Hari 1 Total
Harga Jumlah Harga Jumlah Harga
- -
- -
155,000 - - 155,000
60,000 - 1 60,000
40,000 - 1 40,000
15,000 - 1 15,000
20,000 - 1 20,000
20,000 - 1 20,000
163,181 - - 163,181
13,262 - 1 13,262
23,375 - 1 23,375
10,476 - 1 10,476
7,150 - 1 7,150
39,126 - 1 39,126
24,420 - 1 24,420
2,612 - 1 2,612
1,650 - 1 1,650
23,292 - 1 23,292
438 - 1 438
1,380 - 10 1,380
16,000 - 10 16,000
- - - -
- - - -
1,813,192 - - 1,813,192
- - - -
1,250,000 - 1 1,250,000
- - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
82,200 - 1 82,200
24,750 - 2 24,750
24,750 - 2 24,750
5,844 - 1 5,844
3,100 - 1 3,100
70,800 - 1 70,800
750 - 1 750
Operasi Kecil
Halaman 24 dari 59
Hari 1 Total
23,400 - 20 23,400
73,200 - 1 73,200
6,400 - 1 6,400
9,800 - 2 9,800
86,000 - 1 86,000
- - - -
10,470 - 1 10,470
23,438 - 2 23,438
14,990 - 1 14,990
11,688 - 1 11,688
38,500 - 1 38,500
18,113 - 1 18,113
9,200 - 2 9,200
25,800 - 3 25,800
- - - -
- - - -
- -
- - - -
- - - -
- - - -
- - - -
127,000 - - 127,000
55,000 - 1 55,000
10,000 - 1 10,000
10,000 - 1 10,000
22,000 - 1 22,000
20,000 - 1 20,000
10,000 - 1 10,000
- - - -
2,258,374 - - 2,258,374
Operasi Kecil
Halaman 25 dari 59
KASUS : HAEMORRHOID gr II-III (dengan tindakan staples)
USIA : DEWASA
Hari 1 Hari 2 Hari 3
Sediaan Harga Satuan Jumlah Harga Jumlah Harga Jumlah Harga
RAWAT INAP
Komponen Rawat Inap 155,000 155,000 155,000

Mondok makan 60,000 1 60,000 1 60,000 1 60,000
Visite dokter spesialis 40,000 1 40,000 1 40,000 1 40,000
Asuhan keperawatan 15,000 1 15,000 1 15,000 1 15,000
Tindakan keperawatan 20,000 1 20,000 1 20,000 1 20,000
Visite dokter umum 20,000 1 20,000 1 20,000 1 20,000
Obat-obatan 295,117 158,085 189,655
- - -
Bahan Habis Pakai BLOOD TRANFUSION SET TRM 39,126 1 39,126 - -
Bahan Habis Pakai ABBOCATH T 20G 24,420 1 24,420 - 1 24,420
Bahan Habis Pakai INFUS SET DEWASA TRM 15,125 1 15,125 - -
Bahan Habis Pakai DISP SYRINGE 1 ML TERUMO TB BH 2,612 1 2,612 - -
Bahan Habis Pakai DISP SYRINGE 5 ML TRM BH 1,650 1 1,650 - -
Bahan Habis Pakai THREE WAY STOP COCK BH 23,292 1 23,292 - -
Bahan Habis Pakai HANSAPLAST STD STRIPS @ 10 BH 750 1 750 - -
Analgesik Narkotik TRAMADOL 50MG INJ @5 GIF AMP 8,644 3 25,932 - -
Analgesik, Antipiretik KETOPROFEN 100 MG TAB TAB 1,535 2 3,070 2 3,070 2 3,070
Antibiotik gol sefalosporiCEFTAZIDIME 1GR VIAL@2 GD AMP 47,025 2 94,050 2 94,050 2 94,050
Katartik DULCOLAX TAB 5MG @200 TAB 904 2 1,808 2 1,808 2 1,808
Bahan Habis Pakai AQUABIDEST 50 ML IKA FLS 7,150 1 7,150 - 1 7,150
Antibiotik gol sefalosporiCEFIXIME 100mg cap 3,000 - - -
Antasid dan antitukak OMEPRAZOLE 20 MG CAP DX CAP 976 1 976 1 976 1 976
Cairan Mineral DEXT 5% 500 ML OTS FLS 8,728 1 8,728 1 8,728 1 8,728
Cairan Mineral RINGER LACTATE 500ML OTS FLS 15,476 3 46,428 3 46,428 3 46,428
Topikal Kulit Antibakteri SOFRATULLE LBR 15,110 - - -
Bahan Habis Pakai DISP SYRINGE 3 ML TERUMO BH 1,375 - 1 1,375 1 1,375
Bahan Habis Pakai DISP SYRINGE 5 ML TRM BH 1,650 - 1 1,650 1 1,650
- - -
- - -
Operasi 2,798,120 - -
- - -
Operasi sedang 1,775,000 1 1,775,000 - -
Biaya Operasional 350,000 - - -
Operator 950,000 - - -
Anestesi 332,500 - - -
Asisten, BHP, lain2 142,500 - - -
- - -
- - -
- - -
Materi dan BHP RECOFOL AMP IV 10MG/ML 20ML AMP 101,200 1 101,200 - -
Materi dan BHP FENTANYL CITRATE INJ 10 ML VIA 71,610 1 71,610 - -
KETOROLAC 3% INJ@10 GDX 18,563 2 37,125 - -
Anestetik Umum Isoflurane cc 8,107 50 405,350 - -
ETT 100,958 1 100,958 - -
AQUABIDEST 50 ML IKA FLS 7,150 1 7,150 - -
BLOOD TRANFUSION SET TRM 39,126 1 39,126 - -
RINGER LACTAT 500ML OTS 15,476 4 61,904 - -
ABBOCATH T 22G 24,420 1 24,420 - -
LEUKOMED 72380-01 8 X 10 5,431 1 5,431 - -
DISP SYRINGE 1 ML TERUMO TB BH 2,612 1 2,612 - -
DISP SYRINGE 3 ML TERUMO BH 1,375 1 1,375 - -
DISP SYRINGE 5 ML TRM BH 1,650 1 1,650 - -
DISP SYRINGE 10 ML TRM BH 2,338 1 2,338 - -
IODINE POVIDON SOL 10% 30ML BTL 2,500 1 2,500 - -
ALKOHOL 70 % 100 ML ANMAK FLS 3,587 1 3,587 - -
HIBISCRUB 100 ml 24,070 0.25 6,018 - -
KASA HYDR.STERIL 24DR 16/16 BH 7,622 1 7,622 - -
SURGICAL GLOVE NO 7.5 BH 4,400 5 22,000 - -
SURGICAL BLADE 15 BH 3,438 1 3,438 - -
MICROPORE 0,5" X 10 BH 6,875 0.2 1,375 - -
CAT GUT CHROMIC 2-0 BH 66,206 1 66,206 - -
CAT GUT MERSILK 3-O BH 48,125 1 48,125 - -
- - -
- - -
- - -
Rontgen 300,000 - -
- - -
Colon In Loop 300,000 1 300,000 - -
- - -
- - -
Laboratorium 217,000 - -
- - -
Darah Lengkap (Darah Rutin, Diff count, LED) 55,000 1 55,000 - -
BT (Bleedding Time) / Masa Perdarahan 10,000 1 10,000 - -
CT (Cloting Time) / Masa Pembekuan 10,000 1 10,000 - -
Glukosa Sewaktu 22,000 1 22,000 - -
Cross Match (Vena) 20,000 1 20,000 - -
Golongan darah 10,000 1 10,000 - -
HBSAg 90,000 1 90,000 - -
Hari 4 Kontrol Total
Jumlah Harga Jumlah Harga Jumlah Harga
- -
- -
155,000 - - 620,000
1 60,000 - 4 240,000
1 40,000 - 4 160,000
1 15,000 - 4 60,000
1 20,000 - 4 80,000
1 20,000 - 4 80,000
210,345 - - 853,202
- - - -
- - 1 39,126
- - 2 48,840
- - 1 15,125
- - 1 2,612
- - 1 1,650
- - 1 23,292
- - 1 750
- - 3 25,932
2 3,070 - 8 12,280
2 94,050 - 8 376,200
2 1,808 - 8 7,232
1 7,150 - 3 21,450
10 30,000 - 10 30,000
1 976 - 4 3,904
1 8,728 - 4 34,912
3 46,428 - 12 185,712
1 15,110 - 1 15,110
1 1,375 - 3 4,125
1 1,650 - 3 4,950
- - - -
- - - -
- - - 2,798,120
- - - -
- - 1 1,775,000
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - 1 101,200
- - 1 71,610
- - 2 37,125
- - 50 405,350
- - 1 100,958
- - 1 7,150
- - 1 39,126
- - 4 61,904
- - 1 24,420
- - 1 5,431
- - 1 2,612
- - 1 1,375
- - 1 1,650
- - 1 2,338
- - 1 2,500
- - 1 3,587
- - 0 6,018
- - 1 7,622
- - 5 22,000
- - 1 3,438
- - 0 1,375
- - 1 66,206
- - 1 48,125
- - - -
- - - -
- - - -
- -
- - - 300,000
- - - -
- - 1 300,000
- - - -
- - - -
- - - 217,000
- - - -
- - 1 55,000
- - 1 10,000
- - 1 10,000
- - 1 22,000
- - 1 20,000
- - 1 10,000
- - 1 90,000
KASUS : OPERASI BESAR
USIA : DEWASA
Hari 1 Hari 2 Hari 3 Ha
Sediaan Harga Satuan Jumlah Harga Jumlah Harga Jumlah Harga Jumlah
RAWAT INAP
Komponen Rawat Inap 155,000 155,000 155,000

Mondok makan 60,000 1 60,000 1 60,000 1 60,000 1
Visite dokter spesialis 40,000 1 40,000 1 40,000 1 40,000 1
Asuhan keperawatan 15,000 1 15,000 1 15,000 1 15,000 1
Tindakan keperawatan 20,000 1 20,000 1 20,000 1 20,000 1
visite dokter umum 20,000 1 20,000 1 20,000 1 20,000 1
Obat-obatan 346,878 254,926 254,926
- - -
Antibiotik gol sefalosporiCEFTAZIDIME 1GR VI VIAL 47,025 1 47,025 - -
Antiamoeba & AntigiardiaMETRONIDAZOL INFUBH 23,375 1 23,375 - -
Cairan Mineral RINGER LACTATE 500 FLS 15,476 1 15,476 - -
Bahan Habis Pakai AQUABIDEST 50 ML IKFLS 7,150 1 7,150 - -
Bahan Habis Pakai BLOOD TRANFUSION SET TRM 39,126 1 39,126 - -
Bahan Habis Pakai ABBOCATH T 20G 24,420 1 24,420 - - 1
Bahan Habis Pakai DISP SYRINGE 1 ML BH 2,612 1 2,612 - -
Bahan Habis Pakai DISP SYRINGE 5 ML BH 1,650 1 1,650 - -
Bahan Habis Pakai THREE WAY STOP COCBH 23,292 1 23,292 - -
Bahan Habis Pakai HANSAPLAST STD STRIBH 750 1 750 - -
Analgesik, Antipiretik KETOPROFEN 100 MGTAB 1,535 - - -
Antasid dan antitukak OMEPRAZOLE 20 MG CAP 976 - - -
Analgesik Narkotik TRAMADOL 50MG INJAMP 8,644 - 3 25,932 3 25,932 3
Analgesik, Antipiretik KETOPROFEN 100 MGTAB 1,535 - - -
Antibiotik gol sefalosporiCEFTAZIDIME 1GR VI VIAL 47,025 2 94,050 2 94,050 2 94,050 2
Antasid dan antitukak RANITIDIN AMP 50M AMP 3,215 2 6,430 2 6,430 2 6,430 2
Antasid dan antitukak OMEPRAZOLE 20 MG CAP 976 - - -
Antasid dan antitukak NECIBLOK SUSP 100 MSYRP 48,125 - 1 48,125 1 48,125 1
Antiemetik PRIMPERAN INJ AMP 10,312 3 30,936 3 30,936 3 30,936 3
Cairan Mineral DEXT 5% 500 ML OTS FLS 15,476 1 15,476 1 15,476 1 15,476 1
Cairan Mineral RINGER LACTATE 500 FLS 15,476 - 2 30,952 2 30,952 2
Topikal Kulit Antibakteri SOFRATULLE LBR 15,110 1 15,110 - -
Bahan Habis Pakai DISP SYRINGE 3 ML BH 1,375 - 1 1,375 1 1,375 1
Bahan Habis Pakai DISP SYRINGE 5 ML BH 1,650 - 1 1,650 1 1,650 1
- - -
- - -
Operasi 3,445,031 - -
- - -
Operasi Besar 2,300,000 1 2,300,000 - -
Biaya Operasional 350,000 - - -
Operator 1,300,000 - - -
Anestesi 455,000 - - -
Asisten 195,000 - - -
- - -
- - -
Ruang pemulihan 139,000 1 139,000 - -
- - -
BHP B Plain 2/0 HR 26 buah 82,200 1 82,200 - -
BHP Handschoen 6,5 Sterilpsg 12,375 2 24,750 - -
BHP Urinebag royal (non ste buah 5,600 1 5,600 - -
BHP Foleycatteter 20 2 wa buah 24,600 1 24,600 - -
BHP Handschoen 7 Steril buah 12,375 2 24,750 - -
BHP Handschoen 7,5 Sterilbuah 5,844 1 5,844 - -
BHP Pisau insisi 20 (Pisau bbuah 3,100 1 3,100 - -
BHP B Biosyn 3-0 sm 693 cbuah 146,300 1 146,300 - -
BHP B Soflilk 3-0 GS-832 v. buah 70,800 1 70,800 - -
BHP Hansaplas buah 300 1 300 - -
BHP Kasa Hidrofil citra x-ralbr 1,170 20 23,400 - -
BHP Jarum Disp 27 Spinal (buah 38,500 1 38,500 - -
BHP Cerplast aerofilm 50 lbr 73,200 1 73,200 - -
BHP Spuit 10 cc (Terumo) buah 6,400 1 6,400 - -
BHP spuit 5 cc (Terumo) buah 4,900 2 9,800 - -
BHP Hand Peace electro cou buah 69,300 2 138,600 - -
BHP B. Surgycal 910 No. 2 buah 86,000 1 86,000 - -
- - -
Obat OK NaCl 0.9% 1000ml buah 10,470 1 10,470 - -
Obat OK RL 500 ml buah 11,719 2 23,438 - -
Obat OK Pethidin amp inj 50M mg 14,990 1 14,990 - -
Obat OK Primperan inj amp 11,688 1 11,688 - -
Obat OK Marcain spinal heavy 0amp 56,789 1 56,789 - -
Obat OK Fentanyl 2ml 50MG mcg 38,500 1 38,500 - -
Obat OK Miloz 15mg inj mcg 18,113 1 18,113 - -
Obat OK Extradine 10 % @ 1 galon 4,600 2 9,200 - -
Obat OK Ketorolac 3% inj amp 16,700 3 50,100 - -
Obat OK Tramadol 100mg inj amp 8,600 1 8,600 - -
- - -
- - -
Rontgen - - -
- - -
- - -
- - -
Laboratorium 217,000 - -
Darah Lengkap (Darah Rutin, Diff count, LED) 55,000 1 55,000 - -
BT (Bleedding Time) / Masa Perdarahan 10,000 1 10,000 - -
CT (Cloting Time) / Masa Pembekuan 10,000 1 10,000 - -
Glukosa Sewaktu 22,000 1 22,000 - -
Cross Match (Vena) 20,000 1 20,000 - -
Golongan darah 10,000 1 10,000 - -
HBSAg 90,000 1 90,000 - -
Total Biaya 4,163,909 409,926 409,926
ari 4 Hari 5 Total
Harga Jumla Harga Jumlah Harga Jumlah Harga
- -
- -
155,000 155,000 - - 775,000
60,000 1 60,000 - 5 300,000
40,000 1 40,000 - 5 200,000
15,000 1 15,000 - 5 75,000
20,000 1 20,000 - 5 100,000
20,000 1 20,000 - 5 100,000
279,346 367,810 - - 1,503,886
- - - - -
- - - 1 47,025
- - - 1 23,375
- - - 1 15,476
- - - 1 7,150
- - - 1 39,126
24,420 - - 2 48,840
- - - 1 2,612
- - - 1 1,650
- - - 1 23,292
- - - 1 750
- 10 15,350 - 10 15,350
- 15 45,000 - 15 45,000
- 10 9,760 - 10 9,760
25,932 15 129,660 - 24 207,456
- 2 3,070 - 2 3,070
94,050 2 94,050 - 10 470,250
- 10 30,000 - 10 30,000
6,430 2 6,430 - 10 32,150
- 4 3,904 - 4 3,904
48,125 - - 3 144,375
30,936 - - 12 123,744
15,476 1 15,476 - 5 77,380
30,952 - - 6 92,856
- 1 15,110 - 2 30,220
1,375 - - 3 4,125
ari 4 Hari 5 Total
1,650 - - 3 4,950
- - - - -
- - - - -
- - - - 3,445,031
- - - - -
- - - 1 2,300,000
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - 1 139,000
- - - - -
- - - 1 82,200
- - - 2 24,750
- - - 1 5,600
- - - 1 24,600
- - - 2 24,750
- - - 1 5,844
- - - 1 3,100
- - - 1 146,300
- - - 1 70,800
- - - 1 300
- - - 20 23,400
- - - 1 38,500
- - - 1 73,200
- - - 1 6,400
- - - 2 9,800
- - - 2 138,600
- - - 1 86,000
- - - - -
- - - 1 10,470
- - - 2 23,438
- - - 1 14,990
- - - 1 11,688
- - - 1 56,789
- - - 1 38,500
ari 4 Hari 5 Total
- - - 1 18,113
- - - 2 9,200
- - - 3 50,100
- - - 1 8,600
- - - - -
- - - - -
- -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - 217,000
- - - 1 55,000
- - - 1 10,000
- - - 1 10,000
- - - 1 22,000
- - - 1 20,000
- - - 1 10,000
- - - 1 90,000
434,346 522,810 - - 5,940,917
KASUS : OPERASI BESAR
USIA : DEWASA
KRITERIA DIAGNOSIS
- Nyeri (bisa mendadak) yang dimulai dari perut kanan atas
atau disekitar pusat. Setelah beberapa jam, nyeri berpindah
ke perut bagian kanan bawah (Mc Burney Sign)
- Mual dan muntah
- Pada colok dubur, nyeri tekan daerah lingkar rektum jam
9-12
ASPEK MEDIS
Hari 1
RAWAT INAP
Komponen Rawat Inap

Obat-obatan
Antibiotik gol sefalosporiCEFTAZIDIME 1GR VI VIAL 47,025 1

Antiamoeba & AntigiardiaMETRONIDAZOL INFUBH 23,375 1
Cairan Mineral RINGER LACTATE 500 FLS 15,476 1
Bahan Habis Pakai AQUABIDEST 50 ML IKFLS 7,150 1
Bahan Habis Pakai DISP SYRINGE 1 ML BH 2,612 1
Bahan Habis Pakai DISP SYRINGE 5 ML BH 1,650 1
Bahan Habis Pakai THREE WAY STOP COCBH 23,292 1
Bahan Habis Pakai HANSAPLAST STD STRIBH 750 1
Analgesik, Antipiretik KETOPROFEN 100 MGTAB 1,535
Antibiotik gol sefalosporiCEFIXIME 100mg cap 3,000
Antasid dan antitukak OMEPRAZOLE 20 MG CAP 976
Analgesik Narkotik TRAMADOL 50MG INJAMP 8,644
Analgesik, Antipiretik KETOPROFEN 100 MGTAB 1,535
Antibiotik gol sefalosporiCEFTAZIDIME 1GR VI VIAL 47,025 2
Antasid dan antitukak RANITIDIN AMP 50M AMP 3,215 2
Antasid dan antitukak OMEPRAZOLE 20 MG CAP 976
Antasid dan antitukak NECIBLOK SUSP 100 MSYRP 48,125
Antiemetik PRIMPERAN INJ AMP 10,312 3
Cairan Mineral DEXT 5% 500 ML OTS FLS 15,476 1
Cairan Mineral RINGER LACTATE 500 FLS 15,476
Topikal Kulit Antibakteri SOFRATULLE LBR 15,110 1
Bahan Habis Pakai DISP SYRINGE 3 ML BH 1,375
Bahan Habis Pakai DISP SYRINGE 5 ML BH 1,650
Operasi
Operasi Besar 2,300,000 1

Operator 1,300,000
Anestesi 455,000
Asisten 195,000
Ruang pemulihan 139,000 1
BHP B Plain 2/0 HR 26 buah 82,200 1

BHP Handschoen 6,5 Sterilpsg 12,375 2
BHP Urinebag royal (non ste buah 5,600 1
BHP Foleycatteter 20 2 wa buah 24,600 1
BHP Handschoen 7 Steril buah 12,375 2
BHP Handschoen 7,5 Sterilbuah 5,844 1
BHP Pisau insisi 20 (Pisau bbuah 3,100 1
BHP B Biosyn 3-0 sm 693 cbuah 146,300 1
BHP B Soflilk 3-0 GS-832 v. buah 70,800 1
BHP Hansaplas buah 300 1
BHP Kasa Hidrofil citra x-ralbr 1,170 20
BHP Jarum Disp 27 Spinal (buah 38,500 1
BHP Cerplast aerofilm 50 lbr 73,200 1
BHP Spuit 10 cc (Terumo) buah 6,400 1
BHP spuit 5 cc (Terumo) buah 4,900 2
BHP Hand Peace electro cou buah 69,300 2
BHP B. Surgycal 910 No. 2 buah 86,000 1
Obat OK NaCl 0.9% 1000ml buah 10,470 1

Obat OK RL 500 ml buah 11,719 2
Obat OK Pethidin amp inj 50M mg 14,990 1
Obat OK Primperan inj amp 11,688 1
Obat OK Marcain spinal heavy 0amp 56,789 1
Obat OK Fentanyl 2ml 50MG mcg 38,500 1
Obat OK Miloz 15mg inj mcg 18,113 1
Obat OK Extradine 10 % @ 1 galon 4,600 2
Obat OK Ketorolac 3% inj amp 16,700 3
Obat OK Tramadol 100mg inj amp 8,600 1
Rontgen
Laboratorium
HBSAg 90,000 1
Total Biaya
PENUNJANG DIAGNOSTIK TINDAKAN YANG DIPERLUKAN INDIKASI RAWAT INAP
- Leukositosis (darah lengkap) - Operasi pengangkatan umbai cacing Rawat inap untuk pembedahan
(appendictomy) segera pada apedisitis akut
- Appendictomy elektif pada apendisitis kronis
ADMINISTRASI
- F6c1
- Hasil Laboratorium (darah lengkap)
Hari 1 Hari 2 Hari 3 Hari 4 Hari 5

Harga Jumlah Harga Jumlah Harga Jumlah Harga Jumla Harga
155,000 155,000 155,000 155,000 155,000

60,000 1 60,000 1 60,000 1 60,000 1 60,000
40,000 1 40,000 1 40,000 1 40,000 1 40,000
15,000 1 15,000 1 15,000 1 15,000 1 15,000
20,000 1 20,000 1 20,000 1 20,000 1 20,000
20,000 1 20,000 1 20,000 1 20,000 1 20,000
346,878 254,926 254,926 279,346 367,810
- - - - -
47,025 - - - -
23,375 - - - -
15,476 - - - -
7,150 - - - -
39,126 - - - -
24,420 - - 1 24,420 -
2,612 - - - -
1,650 - - - -
23,292 - - - -
750 - - - -
- - - - 10 15,350
- - - - 15 45,000
- - - - 10 9,760
- 3 25,932 3 25,932 3 25,932 15 129,660
- - - - 2 3,070
94,050 2 94,050 2 94,050 2 94,050 2 94,050
- - - - 10 30,000
6,430 2 6,430 2 6,430 2 6,430 2 6,430
- - - - 4 3,904
- 1 48,125 1 48,125 1 48,125 -
30,936 3 30,936 3 30,936 3 30,936 -
15,476 1 15,476 1 15,476 1 15,476 1 15,476
- 2 30,952 2 30,952 2 30,952 -
15,110 - - - 1 15,110
- 1 1,375 1 1,375 1 1,375 -
- 1 1,650 1 1,650 1 1,650 -
- - - - -
- - - - -
3,445,031 - - - -
- - - - -
2,300,000 - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
139,000 - - - -
- - - - -
82,200 - - - -
24,750 - - - -
5,600 - - - -
24,600 - - - -
24,750 - - - -
5,844 - - - -
3,100 - - - -
146,300 - - - -
70,800 - - - -
300 - - - -
23,400 - - - -
38,500 - - - -
73,200 - - - -
6,400 - - - -
9,800 - - - -
138,600 - - - -
86,000 - - - -
- - - - -
10,470 - - - -
23,438 - - - -
14,990 - - - -
11,688 - - - -
56,789 - - - -
38,500 - - - -
18,113 - - - -
9,200 - - - -
50,100 - - - -
8,600 - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
217,000 - - - -
55,000 - - - -
10,000 - - - -
10,000 - - - -
22,000 - - - -
20,000 - - - -
10,000 - - - -
90,000 - - - -
4,163,909 409,926 409,926 434,346 522,810
Total
Jumlah Harga Jumlah Harga
- -
- -
- - 775,000
- 5 300,000
- 5 200,000
- 5 75,000
- 5 100,000
- 5 100,000
- - 1,503,886
- - -
- 1 47,025
- 1 23,375
- 1 15,476
- 1 7,150
- 1 39,126
- 2 48,840
- 1 2,612
- 1 1,650
- 1 23,292
- 1 750
- 10 15,350
- 15 45,000
- 10 9,760
- 24 207,456
- 2 3,070
- 10 470,250
- 10 30,000
- 10 32,150
- 4 3,904
- 3 144,375
- 12 123,744
- 5 77,380
- 6 92,856
- 2 30,220
- 3 4,125
- 3 4,950
- - -
- - -
- - 3,445,031
- - -
- 1 2,300,000
- - -
- - -
- - -
- - -
- - -
- - -
- 1 139,000
- - -
- 1 82,200
- 2 24,750
- 1 5,600
- 1 24,600
- 2 24,750
- 1 5,844
- 1 3,100
- 1 146,300
- 1 70,800
- 1 300
- 20 23,400
- 1 38,500
- 1 73,200
- 1 6,400
- 2 9,800
- 2 138,600
- 1 86,000
- - -
- 1 10,470
- 2 23,438
- 1 14,990
- 1 11,688
- 1 56,789
- 1 38,500
- 1 18,113
- 2 9,200
- 3 50,100
- 1 8,600
- - -
- - -
- -
- - -
- - -
- - -
- - -
- - 217,000
- 1 55,000
- 1 10,000
- 1 10,000
- 1 22,000
- 1 20,000
- 1 10,000
- 1 90,000
- - 5,940,917
KASUS : FAM (FIBROADENOMA MAMMAE)
USIA : DEWASA
Hari 1 Hari 2
Sediaan Harga Satuan Jumlah Harga Jumlah
RAWAT INAP
Komponen Rawat Inap 155,000

Mondok makan 60,000 1 60,000 1
Visite dokter spesialis 40,000 1 40,000 1
Asuhan keperawatan 15,000 1 15,000 1
Tindakan keperawatan 20,000 1 20,000 1
visite dokter umum 20,000 1 20,000 1
Obat-obatan 49,570
-
Analgesik, Antipiretik ASAM MEFENAMAT TAB 138 15 2,070
Antibiotik gol sefalosporiCEFADROXIL CAP CAP 1,600 10 16,000
Ceftriaxon 1 gr VIAL 15,750 2 31,500
Operasi 2,753,209
-
Operasi sedang 1,775,000 1 1,775,000
Biaya Operasional 350,000 -
Operator 950,000 -
Anestesi 332,500 -
Asisten, BHP, lain2 142,500 -
-
-
-
-
Materi dan bahan habis pRECOFOL AMP IV AMP 101,200 1 101,200
Materi dan bahan habis pFENTANYL CITRATEVIA 71,610 1 71,610
RANITIDINE INJ GHEX 4,125 2 8,250
Anestetik Umum Isoflurane cc 8,107 50 405,350
KETOROLAC 3% INJ@10 GDX 18,563 1 18,563
AQUABIDEST 50 MFLS 7,150 1 7,150
INFUS SET DEWASA TRM 15,125 1 15,125
RINGER LACTAT 500ML OTS 15,476 3 46,428
ETT 100,958 1 100,958
ABBOCATH T 20G 24,420 1 24,420
LEUKOMED 72380-01 8 X 10 5,431 1 5,431
DISP SYRINGE 1 BH 2,612 1 2,612
DISP SYRINGE 3 BH 1,375 2 2,750
IODINE POVIDON BTL 2,500 2 5,000
HIBISCRUB 100 ml 24,070 0.25 6,018
SURGICAL GLOVE BH 4,400 4 17,600
SURGICAL BLADE BH 3,438 1 3,438
CARESA KAPAS BOBH 6,504 0.25 1,626
CAT GUT CHROMICBH 66,206 1 66,206
CHROMIC 2-0 (W-BH 68,475 1 68,475
-
-
Rontgen 70,000
-
Thoraks PA 70,000 1 70,000
-
Laboratorium 197,000
-
Darah Lengkap (Darah Rutin, Diff count, LED) 55,000 1 55,000
BT (Bleedding Time) / Masa Perdarahan 10,000 1 10,000
CT (Cloting Time) / Masa Pembekuan 10,000 1 10,000
Gula Darah Puasa 22,000 1 22,000
HbsAg 90,000 1 90,000
golongan darah 10,000 1 10,000
Total Biaya 3,224,779
Hari 2 Hari 3 Total
- -
- -
155,000 - - 310,000
60,000 - 1 120,000
40,000 - 1 80,000
15,000 - 1 30,000
20,000 - 1 40,000
20,000 - 2 40,000
- - - 49,570
- - - -
- - 15 2,070
- - 10 16,000
- - 2 31,500
- - - 2,753,209
- - - -
- - 1 1,775,000
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - 1 101,200
- - 1 71,610
- - 2 8,250
- - 50 405,350
- - 1 18,563
- - 1 7,150
- - 1 15,125
- - 3 46,428
- - 1 100,958
- - 1 24,420
- - 1 5,431
- - 1 2,612
- - 2 2,750
- - 2 5,000
- - 0 6,018
- - 4 17,600
- - 1 3,438
- - 0 1,626
- - 1 66,206
- - 1 68,475
- - - -
- - - -
- -
- - - 70,000
- - - -
- - 1 70,000
- - - -
- - - 197,000
- - - -
- - 1 55,000
- - 1 10,000
- - 1 10,000
- - 1 22,000
- - 1 90,000
- - 1 10,000
155,000 - - 3,379,779
KASUS : HAEMORRHOID gr II-III (dengan tindakan staples)
USIA : DEWASA
KRITERIA DIAGNOSIS
- Buang air besar berdarah segar tanpa nyeri/lendir
- Darah tidak bercampur dengan feces (darah menetes)
- Terdapat tonjolan yang besar dari anus saat buang air
besar yang dapat masuk sendiri, dimasukkan secara manual
atau tidak dapat dimasukkan.
- Pemeriksaan colok dubur, tidak ada kelainan
- Pada hemoroid eksternal sering timbul nyeri hebat akibat
inflamasi dan edema yang disebabkan oleh trombosis
sehingga dapat menimbulkan iskemia dan nekrosis pada
area tersebut.
Hari 1
RAWAT INAP
Komponen Rawat Inap

Visite dokter umum 20,000 1
Obat-obatan

Bahan Habis Pakai INFUS SET DEWASA TRM 15,125 1
Bahan Habis Pakai DISP SYRINGE 1 ML TERUMO TB BH 2,612 1
Bahan Habis Pakai DISP SYRINGE 5 ML TRM BH 1,650 1
Bahan Habis Pakai THREE WAY STOP COCK BH 23,292 1
Bahan Habis Pakai HANSAPLAST STD STRIPS @ 10 BH 750 1
Analgesik Narkotik TRAMADOL 50MG INJ @5 GIF AMP 8,644 3
Analgesik, Antipiretik KETOPROFEN 100 MG TAB TAB 1,535 2
Antibiotik gol sefalosporiCEFTAZIDIME 1GR VIAL@2 GD AMP 47,025 2
Katartik DULCOLAX TAB 5MG @200 TAB 904 2
Bahan Habis Pakai AQUABIDEST 50 ML IKA FLS 7,150 1
Antasid dan antitukak OMEPRAZOLE 20 MG CAP DX CAP 976 1
Cairan Mineral DEXT 5% 500 ML OTS FLS 8,728 1
Cairan Mineral RINGER LACTATE 500ML OTS FLS 15,476 3
Topikal Kulit Antibakteri SOFRATULLE LBR 15,110
Bahan Habis Pakai DISP SYRINGE 3 ML TERUMO BH 1,375
Bahan Habis Pakai DISP SYRINGE 5 ML TRM BH 1,650
Operasi

Operator 950,000
Anestesi 332,500
Materi dan BHP RECOFOL AMP IV 10MG/ML 20ML AMP 101,200 1

Materi dan BHP FENTANYL CITRATE INJ 10 ML VIA 71,610 1
ETT 100,958 1
BLOOD TRANFUSION SET TRM 39,126 1
LEUKOMED 72380-01 8 X 10 5,431 1
DISP SYRINGE 5 ML TRM BH 1,650 1
DISP SYRINGE 10 ML TRM BH 2,338 1
ALKOHOL 70 % 100 ML ANMAK FLS 3,587 1
HIBISCRUB 100 ml 24,070 0.25
KASA HYDR.STERIL 24DR 16/16 BH 7,622 1
MICROPORE 0,5" X 10 BH 6,875 0.2
CAT GUT MERSILK 3-O BH 48,125 1
Rontgen
Colon In Loop 300,000 1
Laboratorium
HBSAg 90,000 1
Tindakan Khusus
Rectal Taucher 40,000 1
Total Biaya
PENUNJANG DIAGNOSTIK TINDAKAN YANG DIPERLUKAN INDIKASI RAWAT INAP
- Anuskopi atau kolonoskopi - Terapi konservatif pada rawat jalan untuk - Rawatan elektif untuk derajat 3 dan cito
- Pemeriksaan laboratorium untuk persiapan hemoroid derajat 1 dan 2: untuk derajat 4.
operasi > Diet tinggi serat - Persiapan operasi pada hemoroid derajat 3
> Laksansia ringan bila ada riwayat obsyip dan 4
- Pada derajat 3 dan 4:

> Hemoroidektomi
> terapi konservatif
Hari 1 Hari 2 Hari 3 Hari 4 Kontrol

Harga Jumlah Harga Jumlah Harga Jumlah Harga Jumlah Harga
155,000 155,000 155,000 155,000 -

60,000 1 60,000 1 60,000 1 60,000 -
40,000 1 40,000 1 40,000 1 40,000 -
15,000 1 15,000 1 15,000 1 15,000 -
20,000 1 20,000 1 20,000 1 20,000 -
20,000 1 20,000 1 20,000 1 20,000 -
295,117 158,085 189,655 210,345 -
- - - - -
39,126 - - - -
24,420 - 1 24,420 - -
15,125 - - - -
2,612 - - - -
1,650 - - - -
23,292 - - - -
750 - - - -
25,932 - - - -
3,070 2 3,070 2 3,070 2 3,070 -
94,050 2 94,050 2 94,050 2 94,050 -
1,808 2 1,808 2 1,808 2 1,808 -
7,150 - 1 7,150 1 7,150 -
- - - 10 30,000 -
976 1 976 1 976 1 976 -
8,728 1 8,728 1 8,728 1 8,728 -
46,428 3 46,428 3 46,428 3 46,428 -
- - - 1 15,110 -
- 1 1,375 1 1,375 1 1,375 -
- 1 1,650 1 1,650 1 1,650 -
- - - - -
- - - - -
2,798,120 - - - -
- - - - -
1,775,000 - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
101,200 - - - -
71,610 - - - -
37,125 - - - -
405,350 - - - -
100,958 - - - -
7,150 - - - -
39,126 - - - -
61,904 - - - -
24,420 - - - -
5,431 - - - -
2,612 - - - -
1,375 - - - -
1,650 - - - -
2,338 - - - -
2,500 - - - -
3,587 - - - -
6,018 - - - -
7,622 - - - -
22,000 - - - -
3,438 - - - -
1,375 - - - -
66,206 - - - -
48,125 - - - -
- - - - -
- - - - -
- - - - -
300,000 - - - -
- - - - -
300,000 - - - -
- - - - -
- - - - -
217,000 - - - -
- - - - -
55,000 - - - -
10,000 - - - -
10,000 - - - -
22,000 - - - -
20,000 - - - -
10,000 - - - -
90,000 - - - -
- - - - -
40,000 - - - -
- - - - -
40,000 - - - -
- - - - -
- - - - -
3,805,237 313,085 344,655 365,345 -
Total
Jumlah Harga
- -
- -
- 620,000
4 240,000
4 160,000
4 60,000
4 80,000
4 80,000
- 853,202
- -
1 39,126
2 48,840
1 15,125
1 2,612
1 1,650
1 23,292
1 750
3 25,932
8 12,280
8 376,200
8 7,232
3 21,450
10 30,000
4 3,904
4 34,912
12 185,712
1 15,110
3 4,125
3 4,950
- -
- -
- 2,798,120
- -
1 1,775,000
- -
- -
- -
- -
- -
- -
- -
1 101,200
1 71,610
2 37,125
50 405,350
1 100,958
1 7,150
1 39,126
4 61,904
1 24,420
1 5,431
1 2,612
1 1,375
1 1,650
1 2,338
1 2,500
1 3,587
0 6,018
1 7,622
5 22,000
1 3,438
0 1,375
1 66,206
1 48,125
- -
- -
- -
- -
- 300,000
- -
1 300,000
- -
- -
- 217,000
- -
1 55,000
1 10,000
1 10,000
1 22,000
1 20,000
1 10,000
1 90,000
- -
- 40,000
- -
1 40,000
- -
- -
- 4,828,322

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No Diagnosa lama rawat tarif disetujui tarif awal jamsostek selisih

No Diagnosa lama rawat Rupiah

Tindakan operasi khusus 4,350,000 8,100,000

Komponen Rawat Inap

Analgesik, Antipiretik ASAM MEFENAMAT 500 MG GKF TAB 138 15

Operasi sedang 1,775,000 1

Darah Lengkap (Darah Rutin, Diff count, LED) 55,000 1

Hari 1 Hari 2 Hari 3 Total

Komponen Rawat Inap

Analgesik, Antipiretik ASAM MEFENAMAT 500 MG GKF TAB 138 15

Operasi sedang 1,775,000 1

Darah Lengkap (Darah Rutin, Diff count, LED) 55,000 1

Komponen Rawat Inap

Operasi Kecil 1,250,000 1

BHP B Plain 2/0 HR 26 buah 82,200 1

Obat OK NaCl 0.9% 1000ml buah 10,470 1

Komponen Rawat Inap 155,000 155,000 155,000

Komponen Rawat Inap 155,000 155,000 155,000

Komponen Rawat Inap

Antibiotik gol sefalosporiCEFTAZIDIME 1GR VI VIAL 47,025 1

Operasi Besar 2,300,000 1

Ruang pemulihan 139,000 1

BHP B Plain 2/0 HR 26 buah 82,200 1

Obat OK NaCl 0.9% 1000ml buah 10,470 1

Hari 1 Hari 2 Hari 3 Hari 4 Hari 5

155,000 155,000 155,000 155,000 155,000

Komponen Rawat Inap 155,000

Komponen Rawat Inap

Bahan Habis Pakai BLOOD TRANFUSION SET TRM 39,126 1

Operasi sedang 1,775,000 1

Materi dan BHP RECOFOL AMP IV 10MG/ML 20ML AMP 101,200 1

Colon In Loop 300,000 1

Rectal Taucher 40,000 1

- Pada derajat 3 dan 4:

Hari 1 Hari 2 Hari 3 Hari 4 Kontrol

155,000 155,000 155,000 155,000 -

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