LAMPIRAN I : PERATURAN DAERAH KABUPATEN KULON PROGO

NOMOR 4 TAHUN 2012

TENTANG
RETRIBUSI PELAYANAN KESEHATAN PADA UNIT PELAKSANA TEKNIS
DINAS KESEHATAN KABUPATEN KULON PROGO

RETRIBUSI PELAYANAN KESEHATAN PADA UPTD PUSKESMAS

BIAYA LANGSUNG BIAYA TIDAK
LANGSUNG
(ADMINISTRASI
KANTOR, LISTRIK, JASA TARIP SUBSIDI TARIP
KARTU
BAHAN AIR TELEPON,
NO JENIS PELAYANAN PASIEN BAHAN BAKAR,
PELAYANAN RETRIBUSI WARGA RETRIBUSI
MEDIS
DAN OBAT AKOMODASI PEMELIHARAAN (Rp.) (Rp.) DAERAH (Rp.) WARGA (Rp.)
HABIS
REKAM PRASARANA DAN
PAKAI SARANA
MEDIS
KESEHATAN

1 2 3 4 5 6 7 8 9 10 11
A. PEMERIKSAAN DAN TINDAKAN DI KLINIK UMUM
DASAR
1 Rawat Jalan Umum 1,000.00 0.00 4,500.00 0.00 3,250.00 2,000.00 10,750.00 4,500.00 6,250.00
2 Keur Dokter 1,000.00 0.00 0.00 0.00 3,250.00 5,000.00 9,250.00 0.00 9,250.00
3 Pemeriksaan Caten 1,000.00 0.00 0.00 0.00 3,250.00 5,000.00 9,250.00 0.00 9,250.00
4 Perawatan luka sobek 1,000.00 3,900.00 4,500.00 0.00 3,250.00 5,000.00 17,650.00 4,500.00 13,150.00
5 Jahit luka 4 jahitan 1,000.00 17,950.00 4,500.00 0.00 3,250.00 10,000.00 36,700.00 4,500.00 32,200.00
6 Jahit luka 5-10 jahitan 1,000.00 29,450.00 4,500.00 0.00 3,250.00 15,000.00 53,200.00 4,500.00 48,700.00
7 Jahit luka >10 jahitan 1,000.00 43,550.00 4,500.00 0.00 3,250.00 20,000.00 72,300.00 4,500.00 67,800.00
8 Perawatan luka bakar < 10 % 1,000.00 28,200.00 4,500.00 0.00 3,250.00 10,000.00 46,950.00 4,500.00 42,450.00
9 Perawatan luka bakar 10-20% 1,000.00 75,600.00 4,500.00 0.00 3,250.00 15,000.00 99,350.00 4,500.00 94,850.00
10 Incisi/Eksisi 1,000.00 15,300.00 4,500.00 0.00 3,250.00 15,000.00 39,050.00 4,500.00 34,550.00
11 Gigitan Binatang 1,000.00 1,100.00 4,500.00 0.00 3,250.00 10,000.00 19,850.00 4,500.00 15,350.00
12 Exterpasi Nail 1,000.00 20,450.00 4,500.00 0.00 3,250.00 15,000.00 44,200.00 4,500.00 39,700.00
13 Dawir kanan/kiri 1,000.00 19,150.00 4,500.00 0.00 3,250.00 25,000.00 52,900.00 4,500.00 48,400.00
14 ATS 1,000.00 34,550.00 4,500.00 0.00 3,250.00 5,000.00 48,300.00 4,500.00 43,800.00
15 Hordeolum / Chalazion 1,000.00 11,150.00 4,500.00 0.00 3,250.00 10,000.00 29,900.00 4,500.00 25,400.00
16 Cerumen Prop 1,000.00 1,250.00 4,500.00 0.00 3,250.00 10,000.00 20,000.00 4,500.00 15,500.00
17 Ekstraksi Corpus Alienum Mata 1,000.00 12,100.00 4,500.00 0.00 3,250.00 10,000.00 30,850.00 4,500.00 26,350.00
18 Corpus Alienum pada Telinga 1,000.00 3,100.00 4,500.00 0.00 3,250.00 10,000.00 21,850.00 4,500.00 17,350.00
19 Corpus Alienum pada Hidung 1,000.00 3,100.00 4,500.00 0.00 3,250.00 10,000.00 21,850.00 4,500.00 17,350.00
20 Pasang Kateter 1,000.00 20,400.00 4,500.00 0.00 3,250.00 15,000.00 44,150.00 4,500.00 39,650.00
21 Lepas Jahitan 1,000.00 1,750.00 4,500.00 0.00 3,250.00 5,000.00 15,500.00 4,500.00 11,000.00
 1 2 3 4 5 6 7 8 9 10 11
22 Ganti Verban 1,000.00 3,300.00 4,500.00 0.00 3,250.00 5,000.00 17,050.00 4,500.00 12,550.00
23 Pasang Infus 1,000.00 34,900.00 4,500.00 0.00 3,250.00 10,000.00 53,650.00 4,500.00 49,150.00
24 Lepas infus 1,000.00 6,000.00 0.00 0.00 0.00 5,000.00 12,000.00 0.00 12,000.00
25 Perbaikan infus 1,000.00 5,000.00 0.00 0.00 3,250.00 5,000.00 14,250.00 0.00 14,250.00
26 Ganti cairan infus 0.00 0.00 7,000.00 0.00 0.00 1,000.00 8,000.00 7,000.00 1,000.00
27 Injeksi (tindakan terpisah) 1,000.00 2,500.00 3,000.00 0.00 0.00 1,500.00 8,000.00 3,000.00 5,000.00
28 Corpal di kulit 1,000.00 2,500.00 3,000.00 0.00 0.00 1,500.00 8,000.00 3,000.00 5,000.00
29 Pemberian oksigen / hari 1,000.00 17,500.00 14,400.00 0.00 3,250.00 5,000.00 41,150.00 14,400.00 26,750.00
30 Perawatan luka DM (nekrotik) 1,000.00 18,000.00 4,500.00 0.00 3,250.00 10,000.00 36,750.00 4,500.00 32,250.00
31 Semprot cutaneus larva 1,000.00 55,000.00 4,500.00 0.00 3,250.00 5,000.00 68,750.00 4,500.00 64,250.00
32 Lepas kateter 1,000.00 7,000.00 4,500.00 0.00 3,250.00 5,000.00 20,750.00 4,500.00 16,250.00
33 Pemasangan slang NGT 1,000.00 21,000.00 0.00 0.00 3,250.00 15,000.00 40,250.00 0.00 40,250.00
34 Bilas lambung 1,000.00 21,000.00 4,500.00 0.00 3,250.00 15,000.00 44,750.00 4,500.00 40,250.00
35 Lepas slang NGT 1,000.00 5,000.00 0.00 0.00 3,250.00 5,000.00 14,250.00 0.00 14,250.00
36 Injeksi ABU (Anti Bisa Ular) 1,000.00 5,000.00 49,500.00 0.00 3,250.00 5,000.00 63,750.00 49,500.00 14,250.00
37 Pemberian Nebulizer 1,000.00 15,000.00 4,500.00 0.00 3,250.00 5,000.00 28,750.00 4,500.00 24,250.00
38 Irigasi telinga 1,000.00 8,000.00 4,500.00 0.00 3,250.00 5,000.00 21,750.00 4,500.00 17,250.00
39 Irigasi mata 1,000.00 12,000.00 4,500.00 0.00 3,250.00 5,000.00 25,750.00 4,500.00 21,250.00
40 Tampon hidung 1,000.00 6,000.00 4,500.00 0.00 3,250.00 5,000.00 19,750.00 4,500.00 15,250.00
41 Pemasangan bidai 1,000.00 20,000.00 4,500.00 0.00 3,250.00 5,000.00 33,750.00 4,500.00 29,250.00
42 Pemasangan gipspalk 1,000.00 107,000.00 4,500.00 0.00 3,250.00 10,000.00 125,750.00 4,500.00 121,250.00
43 Pemberian obat melalui anus 1,000.00 4,000.00 39,500.00 0.00 3,250.00 5,000.00 52,750.00 39,500.00 13,250.00
44 Rectal Toucher 1,000.00 4,200.00 0.00 0.00 3,250.00 15,000.00 23,450.00 0.00 23,450.00
45 Operasi tumor jinak 1,000.00 33,350.00 4,500.00 0.00 3,250.00 20,000.00 62,100.00 4,500.00 57,600.00

PENGEMBANGAN
46 Imobilisasi Dislokasi Sederhana 1,000.00 62,400.00 0.00 0.00 3,250.00 20,000.00 86,650.00 0.00 86,650.00
47 Circumsisi 1,000.00 31,600.00 4,500.00 0.00 3,250.00 30,000.00 70,350.00 0.00 70,350.00
48 Visum luar di Puskesmas 1,000.00 3,700.00 0.00 0.00 3,250.00 15,000.00 22,950.00 0.00 22,950.00
49 Visum luar di TKP 1,000.00 3,700.00 0.00 0.00 3,250.00 30,000.00 37,950.00 0.00 37,950.00
50 Infra red (fisio therapy) 1,000.00 2,000.00 0.00 0.00 3,250.00 5,000.00 11,250.00 0.00 11,250.00
51 Treadmill 1,000.00 0.00 0.00 0.00 10,000.00 5,000.00 16,000.00 0.00 16,000.00
52 Pemeriksaan spirometri/spiroanalyzer 1,000.00 1,000.00 0.00 0.00 3,250.00 5,000.00 10,250.00 0.00 10,250.00

B. PEMERIKSAAN DAN TINDAKAN DI KLINIK IBU DAN ANAK

DASAR
53 Pemeriksaan KIA 1,000.00 550.00 4,500.00 0.00 3,250.00 2,000.00 11,300.00 4,500.00 6,800.00
54 KB Suntik 1,000.00 7,700.00 0.00 0.00 3,250.00 6,300.00 18,250.00 0.00 18,250.00
55 KB Pil 1,000.00 5,400.00 0.00 0.00 3,250.00 2,000.00 11,650.00 0.00 11,650.00
56 KB IUD 1,000.00 5,400.00 4,500.00 0.00 3,250.00 15,000.00 29,150.00 4,500.00 24,650.00
57 Pelepasan IUD 1,000.00 15,000.00 4,500.00 0.00 3,250.00 15,000.00 38,750.00 4,500.00 34,250.00
58 Pelepasan IUD dg penyulit 1,000.00 15,000.00 4,500.00 0.00 3,250.00 25,000.00 48,750.00 4,500.00 44,250.00
59 Pemasangan Implant 1,000.00 10,550.00 4,500.00 0.00 3,250.00 30,000.00 49,300.00 4,500.00 44,800.00
60 Pelepasan Implant 1,000.00 15,950.00 4,500.00 0.00 3,250.00 50,000.00 74,700.00 4,500.00 70,200.00
61 Jahit Luka Perineum 1,000.00 28,800.00 4,500.00 0.00 3,250.00 40,000.00 77,550.00 4,500.00 73,050.00
 1 2 3 4 5 6 7 8 9 10 11
62 Evakuasi Manual Placenta 1,000.00 43,550.00 4,500.00 0.00 3,250.00 50,000.00 102,300.00 4,500.00 97,800.00
63 Tindik Telinga 1,000.00 2,100.00 4,500.00 0.00 3,250.00 2,500.00 13,350.00 4,500.00 8,850.00
64 Kontrol nifas 1,000.00 1,000.00 4,500.00 0.00 3,250.00 3,000.00 12,750.00 4,500.00 8,250.00
65 Kontrol IUD 1,000.00 1,000.00 4,500.00 0.00 3,250.00 3,000.00 12,750.00 4,500.00 8,250.00
66 Kontrol implant 1,000.00 1,000.00 4,500.00 0.00 3,250.00 3,000.00 12,750.00 4,500.00 8,250.00
67 Pemeriksaan IVA 1,000.00 2,500.00 4,500.00 0.00 3,250.00 5,000.00 16,250.00 4,500.00 11,750.00
68 Kontrol MOW 1,000.00 4,000.00 4,500.00 0.00 3,250.00 5,000.00 17,750.00 4,500.00 13,250.00
69 Pemeriksaan gynaecology 1,000.00 5,000.00 0.00 0.00 3,250.00 7,500.00 16,750.00 0.00 16,750.00
70 Pemeriksaan doppler 1,000.00 2,000.00 4,500.00 0.00 3,250.00 2,000.00 12,750.00 4,500.00 8,250.00

PENGEMBANGAN
71 Kuretase aspirasi vaum manual 1,000.00 43,550.00 4,500.00 0.00 3,250.00 75,000.00 127,300.00 0.00 127,300.00
72 Fototherapy 1,000.00 5,000.00 0.00 0.00 10,000.00 10,000.00 26,000.00 0.00 26,000.00
73 Pemakaian inkubator 1,000.00 7,500.00 0.00 0.00 10,000.00 5,000.00 23,500.00 0.00 23,500.00

C. PEMERIKSAAN DAN TINDAKAN DI KLINIK GIGI

DASAR
74 Pemeriksaan Gigi 1,000.00 0.00 0.00 0.00 3,250.00 2,000.00 6,250.00 0.00 6,250.00
75 Premedikasi 1,000.00 1,200.00 4,500.00 0.00 3,250.00 2,000.00 11,950.00 4,500.00 7,450.00
76 Ekstraksi gigi anak 1,000.00 2,650.00 4,500.00 0.00 3,250.00 3,000.00 14,400.00 4,500.00 9,900.00
77 Ekstr. gigi anak dg komplikasi 1,000.00 3,250.00 4,500.00 0.00 3,250.00 5,000.00 17,000.00 4,500.00 12,500.00
78 Ekstraksi gigi dewasa 1,000.00 2,950.00 4,500.00 0.00 3,250.00 10,000.00 21,700.00 4,500.00 17,200.00
79 Ekstr. gigi dewasa dg komplikasi 1,000.00 7,250.00 4,500.00 0.00 3,250.00 20,000.00 36,000.00 4,500.00 31,500.00
80 Tambalan amalgam 1,000.00 10,200.00 0.00 0.00 3,250.00 5,000.00 19,450.00 0.00 19,450.00
81 Tambalan Glass Ionomer 1,000.00 11,050.00 0.00 0.00 3,250.00 5,000.00 20,300.00 0.00 20,300.00
82 Perawatan Pulpa Capping 1,000.00 2,150.00 0.00 0.00 3,250.00 6,000.00 12,400.00 0.00 12,400.00
83 Perawatan Syaraf A 1,000.00 5,750.00 0.00 0.00 3,250.00 5,000.00 15,000.00 0.00 15,000.00
84 Perawatan Syaraf B 1,000.00 4,450.00 0.00 0.00 3,250.00 5,000.00 13,700.00 0.00 13,700.00
85 Perawatan Syaraf C 1,000.00 6,100.00 0.00 0.00 3,250.00 7,000.00 17,350.00 0.00 17,350.00
86 Incisi Abses 1,000.00 9,600.00 4,500.00 0.00 3,250.00 10,000.00 28,350.00 4,500.00 23,850.00
87 Operculektomi 1,000.00 7,900.00 4,500.00 0.00 3,250.00 10,000.00 26,650.00 4,500.00 22,150.00
88 Koreksi Oklusi 1,000.00 3,850.00 0.00 0.00 3,250.00 5,000.00 13,100.00 0.00 13,100.00
89 Ekstrasi gigi dewasa dengan injeksi intra septal 1,000.00 10,500.00 4,500.00 0.00 3,250.00 10,000.00 29,250.00 4,500.00 24,750.00

PENGEMBANGAN
90 Scaling Karang Gigi/regio 1,000.00 4,000.00 0.00 0.00 3,250.00 7,500.00 15,750.00 0.00 15,750.00
91 Operasi Gigi 1,000.00 30,350.00 4,500.00 0.00 3,250.00 30,000.00 69,100.00 0.00 69,100.00
92 Tambalan sinar Light Curing 1,000.00 35,400.00 0.00 0.00 3,250.00 10,000.00 49,650.00 0.00 49,650.00
93 Scaling OHIS Ringan 1,000.00 10,900.00 0.00 0.00 3,250.00 7,500.00 22,650.00 0.00 22,650.00
94 Scaling OHIS Sedang 1,000.00 15,900.00 0.00 0.00 3,250.00 7,500.00 27,650.00 0.00 27,650.00
95 Scaling OHISBerat 1,000.00 20,900.00 0.00 0.00 3,250.00 7,500.00 32,650.00 0.00 32,650.00
96 Protesa gigi lepasan 1 gigi pertama 1,000.00 75,000.00 0.00 0.00 3,250.00 30,000.00 109,250.00 0.00 109,250.00
97 Tambahan 1 gigi berikutnya 1,000.00 30,000.00 0.00 0.00 3,250.00 10,000.00 44,250.00 0.00 44,250.00
 1 2 3 4 5 6 7 8 9 10 11

D. PELAYANAN DI KLINIK KONSULTASI

98 Konsultasi dokter/dokter gigi 1,000.00 0.00 0.00 0.00 0.00 2,000.00 3,000.00 0.00 3,000.00
99 Konsultasi sanitasi/gizi/KIA 1,000.00 0.00 0.00 0.00 0.00 1,500.00 2,500.00 0.00 2,500.00

E. PENUNJANG DIAGNOSTIK
DASAR
100 LED 1,000.00 2,650.00 0.00 0.00 3,250.00 2,000.00 8,900.00 0.00 8,900.00
101 HB 1,000.00 950.00 0.00 0.00 3,250.00 1,500.00 6,700.00 0.00 6,700.00
102 LEUKOSIT 1,000.00 1,200.00 0.00 0.00 3,250.00 2,500.00 7,950.00 0.00 7,950.00
103 ERITROSIT 1,000.00 1,100.00 0.00 0.00 3,250.00 2,500.00 7,850.00 0.00 7,850.00
104 HITUNG JENIS 1,000.00 2,350.00 0.00 0.00 3,250.00 2,500.00 9,100.00 0.00 9,100.00
105 TROMBOCIT 1,000.00 2,000.00 0.00 0.00 3,250.00 2,500.00 8,750.00 0.00 8,750.00
106 HEMATOKRIT 1,000.00 1,550.00 0.00 0.00 3,250.00 2,500.00 8,300.00 0.00 8,300.00
107 GOLONGAN DARAH 1,000.00 1,750.00 0.00 0.00 3,250.00 2,000.00 8,000.00 0.00 8,000.00
108 MALARIA 1,000.00 2,200.00 0.00 0.00 3,250.00 1,500.00 7,950.00 0.00 7,950.00
109 PH / BJ / Protein/Uro/Bilirubin 1,000.00 4,800.00 0.00 0.00 3,250.00 2,000.00 11,050.00 0.00 11,050.00
110 SEDIMEN URINE 1,000.00 850.00 0.00 0.00 3,250.00 2,000.00 7,100.00 0.00 7,100.00
111 FAECES LENGKAP 1,000.00 1,250.00 0.00 0.00 3,250.00 2,500.00 8,000.00 0.00 8,000.00
112 WIDAL 1,000.00 8,450.00 0.00 0.00 3,250.00 3,000.00 15,700.00 0.00 15,700.00
113 PP TES 1,000.00 7,600.00 0.00 0.00 3,250.00 2,500.00 14,350.00 0.00 14,350.00
114 GULA DARAH 1,000.00 7,900.00 0.00 0.00 3,250.00 2,500.00 14,650.00 0.00 14,650.00
115 BTA 1,000.00 2,500.00 0.00 0.00 3,250.00 2,000.00 8,750.00 0.00 8,750.00
116 NEISSERIA 1,000.00 4,150.00 0.00 0.00 3,250.00 2,000.00 10,400.00 0.00 10,400.00
117 CLOTING TIME 1,000.00 2,050.00 0.00 0.00 3,250.00 2,000.00 8,300.00 0.00 8,300.00
118 BLEEDING TIME 1,000.00 700.00 0.00 0.00 3,250.00 2,000.00 6,950.00 0.00 6,950.00
119 Darah Rutin Manual (5 parameter) 1,000.00 12,850.00 0.00 0.00 3,250.00 11,000.00 28,100.00 0.00 28,100.00
120 Darah lengkap Manual (17 parameter) 1,000.00 17,000.00 0.00 0.00 4,270.00 16,000.00 38,270.00 0.00 38,270.00
121 Darah lengkap Automatik 1,000.00 29,450.00 0.00 0.00 3,250.00 5,000.00 38,700.00 0.00 38,700.00
122 Kreatinin 1,000.00 12,300.00 0.00 0.00 3,250.00 2,500.00 19,050.00 0.00 19,050.00
123 Ureum 1,000.00 12,300.00 0.00 0.00 3,250.00 2,500.00 19,050.00 0.00 19,050.00
124 HDL Kholesterol 1,000.00 11,850.00 0.00 0.00 3,250.00 2,500.00 18,600.00 0.00 18,600.00
125 LDL Kholesterol 1,000.00 11,850.00 0.00 0.00 3,250.00 2,500.00 18,600.00 0.00 18,600.00
126 SGOT 1,000.00 12,650.00 0.00 0.00 3,250.00 2,500.00 19,400.00 0.00 19,400.00
127 SGPT 1,000.00 12,650.00 0.00 0.00 3,250.00 2,500.00 19,400.00 0.00 19,400.00
128 Bilirubin Total 1,000.00 12,250.00 0.00 0.00 3,250.00 2,500.00 19,000.00 0.00 19,000.00
129 Bilirubin Direct 1,000.00 12,250.00 0.00 0.00 3,250.00 2,500.00 19,000.00 0.00 19,000.00
130 AMPHETAMIN 1,000.00 22,350.00 0.00 0.00 3,250.00 3,000.00 29,600.00 0.00 29,600.00
131 BENZODIASEPHINE 1,000.00 22,350.00 0.00 0.00 3,250.00 3,000.00 29,600.00 0.00 29,600.00
132 Jamur 1,000.00 5,750.00 0.00 0.00 3,250.00 2,500.00 12,500.00 0.00 12,500.00
133 Protein Total 1,000.00 12,250.00 0.00 0.00 3,250.00 2,500.00 19,000.00 0.00 19,000.00
134 Albumin 1,000.00 12,250.00 0.00 0.00 3,250.00 2,500.00 19,000.00 0.00 19,000.00
 1 2 3 4 5 6 7 8 9 10 11
135 Globulin 1,000.00 12,250.00 0.00 0.00 3,250.00 2,500.00 19,000.00 0.00 19,000.00
136 Bilirubin Indirect 1,000.00 12,250.00 0.00 0.00 3,250.00 2,500.00 19,000.00 0.00 19,000.00
137 Gama GT 1,000.00 12,250.00 0.00 0.00 3,250.00 2,500.00 19,000.00 0.00 19,000.00
138 Urin lengkap 1,000.00 8,000.00 0.00 0.00 3,250.00 2,000.00 14,250.00 0.00 14,250.00
139 Pemeriksaan Gram 1,000.00 5,750.00 0.00 0.00 3,250.00 2,000.00 12,000.00 0.00 12,000.00
140 Filaria 1,000.00 4,500.00 0.00 0.00 3,250.00 2,000.00 10,750.00 0.00 10,750.00
141 Telur Cacing pada faeses 1,000.00 6,500.00 0.00 0.00 3,250.00 2,000.00 12,750.00 0.00 12,750.00
142 Telur Cacing pada tanah 1,000.00 8,000.00 0.00 0.00 3,250.00 2,000.00 14,250.00 0.00 14,250.00
143 Anti Hbs 1,000.00 10,500.00 0.00 0.00 3,250.00 1,500.00 16,250.00 0.00 16,250.00
144 Analisa Sperma 1,000.00 8,000.00 0.00 0.00 3,250.00 3,000.00 15,250.00 0.00 15,250.00
145 VDRL 1,000.00 9,000.00 0.00 0.00 3,250.00 3,000.00 16,250.00 0.00 16,250.00
146 Pengambilan papsmear 1,000.00 9,500.00 0.00 0.00 3,250.00 7,500.00 21,250.00 0.00 21,250.00

PENGEMBANGAN
147 ASAM URAT 1,000.00 12,650.00 0.00 0.00 3,250.00 2,500.00 19,400.00 0.00 19,400.00
148 KOLESTEROL 1,000.00 17,450.00 0.00 0.00 3,250.00 2,500.00 24,200.00 0.00 24,200.00
149 TRIGLISERID 1,000.00 20,450.00 0.00 0.00 3,250.00 2,500.00 27,200.00 0.00 27,200.00
150 HBS AG 1,000.00 14,050.00 0.00 0.00 3,250.00 2,500.00 20,800.00 0.00 20,800.00
151 EKG 1,000.00 14,650.00 0.00 0.00 3,250.00 10,000.00 28,900.00 0.00 28,900.00
152 USG 1,000.00 10,200.00 0.00 0.00 3,250.00 15,000.00 29,450.00 0.00 29,450.00
153 Rontgen Foto ukuran 30x40 1,000.00 25,000.00 0.00 0.00 4,500.00 12,000.00 42,500.00 0.00 42,500.00
ukuran 35x35 1,000.00 22,500.00 0.00 0.00 4,500.00 12,000.00 40,000.00 0.00 40,000.00
ukuran 24x30 1,000.00 18,500.00 0.00 0.00 4,500.00 12,000.00 36,000.00 0.00 36,000.00
ukuran 18x24 1,000.00 16,500.00 0.00 0.00 4,500.00 12,000.00 34,000.00 0.00 34,000.00
154 Rontgen Foto gigi 1,000.00 5,000.00 0.00 0.00 4,500.00 6,000.00 16,500.00 0.00 16,500.00

F. RAWAT INAP
155 Rawat Pasien Umum 2,000.00 0.00 21,900.00 17,700.00 10,000.00 32,500.00 84,100.00 21,900.00 62,200.00
156 Rawat Pasien Bersalin 2,000.00 0.00 21,900.00 19,200.00 15,000.00 217,500.00 275,600.00 21,900.00 253,700.00
157 Persalinan patologis 2,000.00 0.00 21,900.00 19,200.00 25,000.00 360,000.00 428,100.00 21,900.00 406,200.00
158 Rawat bayi 2,000.00 0.00 21,900.00 3,000.00 15,000.00 32,500.00 74,400.00 21,900.00 52,500.00
159 Rawat bayi patologis 2,000.00 0.00 21,900.00 23,400.00 30,000.00 35,000.00 112,300.00 21,900.00 90,400.00

G. LAIN-LAIN
G.1. OPERASI KATARAK
160 Operasi Katarak 2,000.00 45,000.00 4,500.00 100,000.00 10,000.00 1,200,000.00 1,361,500.00 0.00 1,361,500.00
 1 2 3 4 5 6 7 8 9 10 11

G.2. PENGOLAHAN LIMBAH

161 Incenerator setiap kg 0.00 350.00 0.00 0.00 4,150.00 3,000.00 7,500.00 0.00 7,500.00

G.3. PELAYANAN AMBULANCE DAN MOBIL JENAZAH

162 Pelayanan Ambulance / Mobil jenazah
- 5 kilometer pertama 0.00 22,500.00 0.00 0.00 3,250.00 25,000.00 50,750.00 0.00 50,750.00
- kelebihan jarak /km berikutnya 0.00 4,500.00 0.00 0.00 0.00 500.00 5,000.00 0.00 5,000.00

Keterangan : Untuk pelayanan di luar jam kerja , penambahan jasa pelayanan sebesar : dr Spesialis 20,000.00
dr umum 10,000.00
Paramedis 5,000.00

Wates, 9 April 2012

BUPATI KULON PROGO,

Cap/ttd

HASTO WARDOYO
 LAMPIRAN II : PERATURAN DAERAH KABUPATEN KULON PROGO
NOMOR 4 TAHUN 2012

TENTANG
RETRIBUSI PELAYANAN KESEHATAN PADA UNIT PELAKSANA TEKNIS
DINAS KESEHATAN KABUPATEN KULON PROGO

RETRIBUSI PELAYANAN KESEHATAN PADA UPTD LABORATORIUM KESEHATAN

BIAYA TIDAK LANGSUNG

BIAYA LANGSUNG
(ADMINISTRASI KANTOR,
LISTRIK, AIR TELEPON, JASA TARIP SUBSIDI TARIP
NO JENIS PELAYANAN BAHAN BAKAR, PELAYANAN RETRIBUSI WARGA RETRIBUSI
BAHAN HABIS PAKAI PEMELIHARAAN (Rp.) (Rp.) DAERAH (Rp.) WARGA (Rp.)
PRASARANA DAN
SARANA KESEHATAN

1 2 3 4 5 6 7 8
A.
A. 1 PEMERIKSAAN SAMPEL LINGKUNGAN
1 MPN Coliform (Air Bersih) 24,950.00 4,000.00 5,000.00 33,950.00 0.00 33,950.00
2 MPN Coli tinja (Air Minum) 43,550.00 4,000.00 5,000.00 52,550.00 0.00 52,550.00
3 Angka Kuman 24,300.00 4,000.00 5,000.00 33,300.00 0.00 33,300.00
4 Suhu 1,200.00 3,250.00 1,500.00 5,950.00 0.00 5,950.00
5 Rasa 0.00 0.00 1,500.00 1,500.00 0.00 1,500.00
6 Warna 0.00 0.00 1,500.00 1,500.00 0.00 1,500.00
7 TDS / Zat Padat Terlarut 1,200.00 3,250.00 1,500.00 5,950.00 0.00 5,950.00
8 Kekeruhan 1,200.00 3,250.00 1,500.00 5,950.00 0.00 5,950.00
9 PH / Derajat Keasaman 2,100.00 3,250.00 1,000.00 6,350.00 0.00 6,350.00
10 Chlorida 8,650.00 3,250.00 1,000.00 12,900.00 0.00 12,900.00
11 Kesadahan 11,400.00 3,250.00 1,000.00 15,650.00 0.00 15,650.00
12 Nitrat 7,000.00 3,250.00 1,500.00 11,750.00 0.00 11,750.00
13 Nitrit (Air) 6,100.00 3,250.00 1,500.00 10,850.00 0.00 10,850.00
14 Besi 17,400.00 3,250.00 1,500.00 22,150.00 0.00 22,150.00
15 Mangan 7,500.00 3,250.00 1,500.00 12,250.00 0.00 12,250.00
16 Fluorida 8,200.00 3,250.00 1,500.00 12,950.00 0.00 12,950.00
17 Sulfat 15,600.00 3,250.00 1,500.00 20,350.00 0.00 20,350.00
18 COD / Kebutuhan Kimia akan Oksigen 18,000.00 3,250.00 1,500.00 22,750.00 0.00 22,750.00
19 BOD / Kebutuhan Biologi akan Oksigen 15,250.00 3,250.00 1,500.00 20,000.00 0.00 20,000.00
20 Sisa Chlor 8,000.00 3,250.00 1,000.00 12,250.00 0.00 12,250.00
21 Kualitas Air Minum Terbatas 131,000.00 3,250.00 24,500.00 158,750.00 0.00 158,750.00
22 Kualitas Air Bersih Terbatas 112,450.00 3,250.00 24,500.00 140,200.00 0.00 140,200.00
 1 2 3 4 5 6 7 8

A.2. PEMERIKSAAN SAMPEL MAKANAN

23 Borax 8,500.00 3,250.00 1,500.00 13,250.00 0.00 13,250.00
24 Formalin 21,600.00 3,250.00 1,500.00 26,350.00 0.00 26,350.00
25 Nitrit (Pengawet) 11,700.00 4,000.00 1,500.00 17,200.00 0.00 17,200.00
26 Benzoat 17,850.00 4,000.00 1,500.00 23,350.00 0.00 23,350.00
27 Salisilat 18,750.00 4,000.00 1,500.00 24,250.00 0.00 24,250.00
28 Siklamat 18,750.00 4,000.00 1,500.00 24,250.00 0.00 24,250.00
29 Sakarin 18,750.00 4,000.00 1,500.00 24,250.00 0.00 24,250.00
30 Pewarna 22,100.00 4,000.00 1,500.00 27,600.00 0.00 27,600.00
31 Kadar Gula 15,000.00 4,000.00 4,500.00 23,500.00 0.00 23,500.00
32 Kadar Air 9,000.00 3,250.00 3,000.00 15,250.00 0.00 15,250.00
33 Kadar Abu 9,000.00 3,250.00 3,000.00 15,250.00 0.00 15,250.00
34 Logam Berat 25,000.00 6,000.00 7,500.00 38,500.00 0.00 38,500.00
35 Garam Beryodium 3,400.00 3,250.00 2,000.00 8,650.00 0.00 8,650.00

Wates, 9 April 2012

BUPATI KULON PROGO,

Cap/ttd

HASTO WARDOYO