15 Tarif Dhabeda Contoh

TARIF RSUD DHABEDA
I TARIF IGD Created by dr Hanna Permana Subanegara,

II TARIF RAWAT JALAN
III TARIF FASILITAS PERAWATAN
IV TARIF HCU/ICU/ICCU/NICU/PICU
V TARIF BEDAH SENTRAL*
VI TARIF MCU
VII TARIF LABORATORIUM PATOLOGI KLINIK
VIII TARIF LABORATORIUM PATLOGI ANATOMI
IX TARIF RADIOLOGI
X TARIF REHABILITASI MEDIK
XI TARIF HEMODIALISA
XII TARIF TINDAKAN KEPERAWATAN
XIII TARIF TINDAKAN KEBIDANAN
XIV TARIF PELAYANAN GIGI & MULUT
XV TARIF PELAYANAN MEDIS THT
XVI TARIF PELAYANAN MEDIS MATA
XVII TARIF PELAYANAN FORENSIK
XVIII TARIF PELAYANAN SYARAF
XIX TARIF PELAYANAN PSIKOLOGI
XX TARIF TINDAKAN MEDIS NON INVASIF
XXI TARIF TINDAKAN MEDIS INVASIF
XXII TARIF TINDAKAN ANDROLOGI
XXIII TARIF SEWA ALAT
XXIV TARIF DIAGNOSTIK
XXV TARIF PELAYANAN VAKSINASI
XXVI TARIF PROMOSI DAN EDUKASI KESEHATAN
XXVII TARIF LAIN-LAIN
TARIF RUMAH SAKIT DHABEDA

I TARIF IGD
NO URAIAN JASA SARANA
1 Pemeriksaan oleh Dokter Umum IGD 30,000
2 Pemeriksaan, Konsultasi Dokter Spesialis 30,000

1 Pemeriksaan/ Konsultasi Dokter Umum di Poliklinik 20,000
2 Pemeriksaan/ Konsultasi Dokter Spesialis di Poliklinik 20,000

1 Ruang Rawat Inap Kelas (III) 60,000
2 Ruang Rawat Inap Kelas (II) 90,000
3 Ruang Rawat Inap Kelas (I) 150,000
4 Ruang Rawat Inap VIP 275,000
5 Ruang Rawat Inap Isolasi 150,000
6 Ruang VK 115,000
7 One Day Care (ODC) 115,000
8 Rawat Observasi Kegawatdaruratan 115,000
9 Ruang Perawatan Pasca Operasi 115,000
10 Ruang Perawatan Kesehatan Jiwa 175,000
11 Ruang Perinatologi 115,000
12 Pemeriksaaan Dokter Case Manager -
1 Perawatan Reguler 550,000
2 Perawatan Khusus * 650,000
* Perawatan Khusus = Perawatan ICU yang memerlukan tindakan khusus dan di ruang isolasi ICU

1 Operasi Kecil ** 750,000
2 Operasi Sedang ** 1,000,000
3 Operasi Besar ** 2,500,000
4 Operasi Khusus ** 4,000,000
* pada tindakan cito jasa pelayanan ditambah 25% dari jasa pelayanan elektif,
Pada tindakan medik operatif dengan 2 operator atau lebih dengan sub sepesialisasi berbeda, maka jasa pelaya
masing-masing 100 %, sedangkan Dokter Anastesi dan Penata Anastesi ditambah 50%.
** pelayanan terlampir
VI TARIF MCU
1 Pemeriksaan untuk surat keterangan sehat 5,000
2 Pemeriksaan Kesehatan Standard
Terdiri dari :
a. Pemeriksaan dr. Umum
b. Pemeriksaan Thorax Photo
c. LAB Sederhana (Urine Lengkap + Darah Lengkap)
3 MCU Paket I
Terdiri dari :
c. EKG
d. LAB Sederhana
Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,

SGPT) + GDS + Fungsi Ginjal + Kolesterol Total
4 MCU Paket II
Terdiri dari :
b. Pemeriksaan dr. Spesialis
c. Pemeriksaan Thorax Photo
d. USG Abdomen Lengkap
e. EKG
f. LAB Sederhana
Urine Lengkap + Darah Lengkap + Fungsi Hati
(SGOT,SGPT, Gamma GT)+ GDS, GDP + Fungsi
Ginjal (Ureum, Kreatinin) + Fungsi Lemak + (Kolesterol
Total, HDL, LDL, Trigliserida) + Hepatitis (HbsAG/strip)
5 MCU Paket III
Terdiri dari :
c. Pemeriksaan Mata
d. Pemeriksaan THT
e. EKG
f. Sprirometri
g. LAB :
(SGOT,SGPT, Gamma GT) + GDS, GDP + Fungsi
+ Anti HBS + Asam Urat
6 MCU Paket IV
Terdiri dari :
c. Pemeriksaan Mata
d. Pemeriksaan Ginekologi (Khusus Wanita)
e. Pemeriksaan THT
f. Pemeriksaan Thorax Photo
g. USG Abdomen Lengkap
h. Gizi
i. Sprirometri
j. EKG
k. LAB :
(SGOT,SGPT, Gamma GT) + GDS, GDP + Fungsi
+ Anti HBS + Asam Urat

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA
HEMATOLOGI
1 Asam Folat -
2 Darah Lengkap ( ABX Pentra) 40,500
3 Darah Rutin 21,000
4 Ferritin 96,000
5 G6PD 75,000
6 Gambaran Darah Tepi 18,000
7 Golongan Darah (ABO + Rhesus) 16,500
8 HAM’s Test 28,000
9 Hb F 21,000
10 Hitung Eosinofil 18,000
11 Hitung Jenis Leukosit 15,000
12 IT Rasio 15,000
13 LED 18,000
14 Malaria/Filaria 25,000
15 NAP 60,000
16 NSE 38,000
17 Perwarnaan Besi 127,200
18 Pewarnaan Acid Phosphatase 60,000
19 Pewarnaan Sumsum Tulang 116,000
20 Retikulosit 18,000
21 Sel LE 25,500
22 SI & TIBC 48,000
23 SIBC 60,000
24 Sudan Black B 48,000
25 Sugar Water Test 100,000
26 Transferrin 40,000
URINALISIS
1 Kalium urine 40,000
2 Kalsium Urine 56,000
3 Lipase urine 40,000
4 Phospate urine 40,000
5 Protein Bence Jones 18,000
6 Protein Kuantitatif 27,000
7 Reduksi Urin/Protein Urin (3 parameter) 12,000
8 Tes Kehamilan (25 mIU/mL) 8,000
9 Tes Kehamilan Device 14,000
10 Urin Lengkap (Rutin + Sedimen) 21,000
HEMOSTASIS
1 APTT 56,250
2 D-dimer 124,500
3 Fibrinogen 82,500
4 Masa Pembekuan 16,500
5 Masa Perdarahan 16,500
6 Masa protrombin (PT) 54,000
7 PT + INR 90,000
TINJA
1 Darah samar 30,000
2 Lengkap (Rutin + pH + Reduksi) 37,500
KIMIA DARAH
1 Amilase Darah 40,000
2 Amilase Urine 64,000
3 Albumin 21,000
4 ALP 25,500
5 Analisa batu ginjal 128,000
6 Analisa Gas Darah 106,500
7 Analisa Gas Darah + elektrolit 120,000
8 Asam empedu 22,400
9 Asam urat 21,000
10 Bilirubin direk 21,000
11 Bilirubin indirek 21,000
12 Bilirubin total 21,000
13 Calsium Ion 40,000
14 Cholinesterase 76,000
15 CK-MB 75,000
16 CK-total 72,000
17 CL Darah 40,000
18 CL Urine 40,000
19 CPK 88,000
20 Elektroforese ptotein 185,000
21 Fluktosamin 29,000
22 Fosfatase Alkali 26,250
23 Fosfatase asam 30,000
24 Gamma GT 24,000
25 GLDH 64,000
26 Glikolysis HB 37,500
27 Globulin 16,500
28 Glukosa darah 16,500
29 Glukosa darah stik 16,500
30 Glukosa Toleransi test 54,500
31 HBA1c 106,500
32 HBDH 30,000
33 Kalium darah 37,500
34 Kalsium (Ca) 37,500
35 Kalsium darah 40,000
36 Kolesterol HDL 25,500
37 Kolesterol LDL 25,500
38 Kolesterol total 25,500
39 Kreatinin 16,500
40 Kreatinin clearance 32,250
41 Lipase darah 48,000
42 Magnesium 24,000
43 Na, K, Cl (elektrolit darah) 82,500
44 Phosphat darah 42,000
45 Protein total 21,000
46 SGOT 19,500
47 SGPT 19,500
48 Trigliserida 21,000
49 TTGO (5x GDS) 80,250
50 Urea Clearance 54,500
51 Ureum 21,000
52 Urine 4 porsi/ kurve harian 34,000
IMUNOSEROLOGI
1 Anti CMV IgG 75,000
2 Anti CMV IgM 75,000
3 Anti Dengue IgM, IgG 112,500
4 Anti HBc IgM 37,500
5 Anti HBc Total 64,000
6 Anti HBe 90,000
7 Anti HBs 37,500
8 Anti HBs (elisa) 135,000
9 Anti HCV 75,000
10 Anti Helicobacter Pylori IgG 128,000
11 Anti Helicobacter Pylori IgMHS 128,000
12 Anti HIV (ELISA) 112,500
13 Anti HIV (rapid) 100,500
14 Anti HSV I IgG 40,000
15 Anti HSV I IgM 40,000
16 Anti HSV II IgG 42,000
17 Anti HSV II IgM 40,000
18 Anti Rubella IgG 75,000
19 Anti Rubella IgM 75,000
20 Anti TB 40,000
21 Anti Toxoplasma IgG 75,000
22 Anti Toxoplasma IgM 75,000
23 ASTO 52,500
24 CRP kualitatif 27,000
25 CRP kuantitatif 52,500
26 Dengue Blot IgG 60,000
27 Dengue Blot IgM 48,000
28 Faktor Rhematoid 48,000
29 Hbe Ag 67,500
30 HBs Ag 60,000
31 HBsAg Elisa 120,000
32 HBsAg Rapid 32,250
33 IgM anti Salmonella (Tubex) 100,500
34 NS1 142,500
35 PAP TB 52,500
36 RF ( Rheumatoid Factor) 45,000
37 TPHA 37,500
38 VDRL 27,000
39 Widal 37,500
MIKROBIOLOGI
1 Biakan Jamur 115,200
2 Biakan Mikroorganismen dengan Resistensi 144,000
3 Biakan Salmonella Shigela (SS) 107,000
4 Cultur dan Resistensi test 135,000
5 Pewarnaan BTA 24,000
6 Pewarnaan Gram 16,500
CAIRAN TUBUH
1 Analisa cairan otak 106,500
2 Analisa cairan sendi 56,250
3 Analisa cairan tubuh lain (pleura dll) 100,500
DRUG MONITORING
1 Aminophylin 41,000
2 Tes Narkoba 3 parameter 112,500
DIABETES
1 Glukosa Darah PP 16,500
2 Glukosa Darah Puasa 16,500
3 Glukosa Darah Sewaktu 16,500
4 Urine 4 Porsi/ Kurve Harian 33,750
HORMON
1 Estradiol 66,000
2 FSH 70,000
3 FT3 80,000
4 FT4 74,000
5 LH 70,000
6 Progesteron 125,000
7 Prolactin 150,000
8 T3 55,000
9 T4 55,000
10 Testosteron 72,000
11 TSH 50,000
TUMOR MARKER
1 AFP 76,000
2 B2 Microglobulin 165,000
3 CA 125 II 105,000
4 CA 19-9 157,000
5 CA15.3 152,000
6 CEA 120,000
7 Prostat Specific Antigen (PSA) 355,000
VIII TARIF LABORATORIUM PATOLOGI ANATOMI
1 Sederhana 66,000
2 Kecil 96,000
3 Sedang 135,000
4 Besar 165,000
5 Canggih 225,000
IX TARIF RADIOLOGI
1 Appendicogram 135,000
2 Arteriografi 224,000
3 BNO IVP 225,000
4 BNO IVP Bipolar 225,000
5 Bone age 60,000
6 Bone survey 240,000
7 Cervical 69,000
8 Cervical 4 posisi 124,500
9 Cholecystrografi 196,000
10 Colon Inloop 240,000
11 Cor analysis 135,000
12 Coxigeus 82,500
13 CT Scan abdomen Kontras 1,050,000
14 CT Scan Abdomen Non Kontras 525,000
15 CT Scan Kepala Kontras 720,000
16 CT Scan Kepala Non Kontras 426,000
17 CT Scan Thorax Kontras 960,000
18 CT Scan Thorax Non Kontras 480,000
19 Cystogram 225,000
20 Dental alveolar 24,000
21 Dental panoramic 60,000
22 ERCP 270,000
23 Fistulografi 210,000
24 Follow trough 210,000
25 Foto Abdomen 1 Posisi 84,000
26 Foto Abdomen 3 Posisi 135,000
27 Foto Abdomen polos 60,000
28 Foto Cranium 90,000
29 Foto Extrimitas atas 90,000
30 Foto Extrimitas atas bilateral 165,000
31 Foto Extrimitas bawah 90,000
32 Foto Extrimitas bawah bilateral 165,000
33 Foto Jaringan Lunak 84,000
34 Foto Kolumna Vertebralis 84,000
35 Foto Thorax 48,000
36 Foto Thorax AP/Lat 48,000
37 Guide Fluoroscophy 108,000
38 HSG 240,000
39 Mamografi 165,000
40 Mastoid 75,000
41 MRI 900,000
42 Oesophangusgrafi 112,000
43 OMD 165,000
44 Pelvis 1 Posisi 105,000
45 RPG 168,000
46 Scoliosis program 105,000
47 Sinus Paranasal 135,000
48 Sistografi 210,000
49 TMJ 90,000
50 TMJ 4 posisi 165,000
51 Tulang belakang 2 Posisi(Lumbal/Sakral/Servikal/Thorakal) 44,800
52 Urethrocyctogram 240,000
53 Usus Kecil/Besar 210,000
54 Vertebrae 4 posisi 165,000
55 Vertebrae AP/Lat 90,000

1 ES 15,000
2 Exercise 21,000
3 IR 21,000
4 Laser 45,000
5 MWD 21,000
6 Speech Therapy 19,600
7 SWD 12,000
8 Terapi Parapin 21,000
9 Traksi Lumbal 19,600
10 USD 9,000
1 Reused Reguler 240,000

2 Reguler 330,000
XII TARIF PELAYANAN KEPERAWATAN
JENIS PEMERIKSAAN DAN TINDAKAN JASA SARANA

1 Minimal care 15,000
Perawatan minimal yang memerlukan waktu 1 sd 2 jam per

hari rawat yang terdiri dari : Kebersihan diri, ganti pakaian,
dilakukan sendiri, makan dan minum dilakukan sendiri,
ambulasi dengan pengawasan, observasi tanda tanda vital
dilakukan setiap shift, pengobatan minimal status psychologis
stabil, persiapan prosedur memerlukan persiapan.
2 Partial care 25,000
perawatan Intermediate memerlukan waktu 3 sd 4 jam dalam

sehari yang teridir dari : Kebersihan diri dibantu makan
minum dibantu, Observasi tanda tanda vital tiap 4 jam,
ambulasi dibantu pengobatan lebih dari sekali sehari, volley
catheter/intake output dicatat, klien dengan pemasangan
infus persiapan pengobatan, memerlukan prosedur
3 Total care 45,000
perawatan maksimal/total yang memerlukan waktu 5 sd 6 jam

sehari yang terdiri dari : segela yang diberikan perlu antuan
perawat, Posisi yang diatur, pemantauan tana tanda vital
setiap 2 jam, makan mengunakan NGT atau menggunakan
intrvenous, penggunaan suction, dan pasien gelisah atau
disorientasi
4 Intensif care 60,000
perawatan pasien yangnmemerlukan peralatan khusus, dan
perawat khusus, bertujuan untuk menanggulangi pasien
gawat, karena penyakit, trauma atau komplikasi penyakit dan
memberikan pelayanan 24 jam yang bertujuan untuk
mencegah terjadinya kematian atau cacat, mencegah
penyulit pasien yang berupa penyakit atau gangguan akut,
pada organ vital, yang memerlukan terpai intensif dan agresif
misalnya : gangguan atau gagal nafas akut, gangguan atau
gagal sirkulasi, gangguan atau gagal ginjal, pasien yang
memerlukan observasi secara intensif atau eksklusif, atas
keadaan keadaan yang dapat menimbulkan ancaman
gangguan pada sistem organ vital seperti : observasi intensif
pasca bedah, post operasi trepanasi, post open heart, post
laparatomi, dengan komplikasi dll, observasi intensif pasca
henti jantung dalam keadaan stabil, observasi operasi pasca
bedah pada pasien dengan penyakit jantung
1 Tindakan Kecil 12,000

Supresi Laktasi, Perawatan Kuku, Irigasi Telinga,
Spoling NGT, Irigasi Mata, Oral Hygine, Suntik
Vaksinasi, Personal Hygine, Observasi PH,
Hyperglycemia, Hypo, Injeksi IV, IC SC, Management
Cardiac Shock, Pasang Infus, EKG
2 Tindakan Sedang 24,000
Pemberian Obat Intra Spinal, NGT, Dressing, Wound
Care, Parenteral Nutrisi, Enteral Nutrisi, Pemasangan
Spalk Bidai, Pengambilan Darah Arteri Dewasa,
Phlebotomy, Umbilical Line, Irigasi Bladder, Intubasi
Gastro, Intestinal, Bowel, Irigasi Luka, Prolap Recti,
Ransel Verban, Tindik, Penanganan Kejang,
3 Tindakan Besar Luka Bakar
Perawatan 45,000
Catheterisasi, Distraksi, Jahit Luka, Intravenous, Bilas
Lambung
4 Tindakan Khusus 120,000
Venasecsi, RJP, ETT, CVC, Manual Placenta, Hecting
Perineum, Tindakan DC Shock
XIII TARIF TINDAKAN KEBIDANAN
1 Biopsi 75,000
2 Couterisasi Condiloma Acuminata 52,500
3 Dopler 9,000
4 Douglas Punktio 75,000
5 Ekstirpasi Polip Servik 150,000
6 Gelang Identitas Pasien 5,000
7 Hydrotubasi 202,500
8 Incisi Kista Bartholini 54,000
9 Jahit Luka Khusus / Jahit Luka Portio 40,500
10 Jahit Luka Perinium 60,000
11 Lepas IUD 48,000
12 Lepas Pasang Susuk 52,500
13 Manual Aid Ekstraksi Kaki 132,000
14 Melepas Stent / drain 21,000
15 Melepas Tampon Vagina 25,500
16 Memasang Tampon Vagina 40,500
17 Memasukkan Obat Sitostatika 45,000
18 Merawat Luka Tanpa Hecting 25,500
19 Mikro Kuret 52,500
20 NST 15,000
21 Pap Smear 45,000
22 Partus dengan Penyulit 500,000
23 Partus Normal 350,000
24 Partus Presipitatus 300,000
25 Pasang / Lepas Lamineria 21,000
26 Pasang IUD 48,000
27 Pasang Pesarium 21,000
28 Pemakaian Slem Suction 10,500
29 Pemeriksaan Fisik Bayi 16,000
30 Penanganan Pasien dengan Eklamsi 75,000
31 Penanganan Pasien dengan HEG 110,000
32 Penanganan Pasien dengan Konservatif 150,000
33 Penanganan Pasien dengan PEB 150,000
34 Penanganan Pasien dengan Pendarahan 110,000
35 Perawatan Tali Pusat 18,000
36 Plasenta Manual oleh dokter spesialis 240,000
37 Repair Perineum 66,000
38 Resusitasi Bayi 60,000
39 Scurent 12,000
40 Slem Peumosuction 10,500
41 Stradle Injury 55,500
42 Vacum Extraksi 120,000
43 Vaginal Touche (VT) 12,000
44 Visum Perkosaan 60,000
XIV TARIF LAYANAN GIGI & MULUT
PENAMBALAN
1 Inlay/Uplay 200,000
2 Perawatan Saluran Akar/ Pengisian 51,600
3 Pulp caping 45,000
4 Tambal Amalgam Kompleks 30,000
5 Tambal Amalgam Simpleks 30,000
6 Tambal Light Curig 1 Permukaan Besar 100,000
7 Tambal Light Curig 1 Permukaan Kecil 75,000
8 Tambal Light Curig 2 Permukaan Besar 125,000
9 Tambal Sementara 30,000
10 Tambal Sementara Perawatan Endomanual/Eksterpasi 45,000
PENCABUTAN
1 Gigi Sulung dengan Suntik 30,000
2 Gigi Sulung Topikal 24,000
3 Gigi Tetap dengan Komplikasi 50,000
4 Gigi Tetap Tanpa Komplikasi 40,000
5 Molar 3 dengan Komplikasi 400,000
6 Molar 3 tanpa Komplikasi 50,000
7 Scalling/Pembersihan Karang Gigi (per-kuadran) 70,000
PERIODONTAL
1 Alvelectomy 170,000
2 Curetage per regio 100,000
3 Frenoktomi 150,000
4 Ginggivektomi per regio 280,000
5 Hecting per 1 jahitan 25,000
6 Insisi Abses Ekstra Oral 84,000
7 Insisi Abses Intra Oral 70,000
8 Operculectomy 150,000
9 Perawatan Periodontal 37,500
10 Splinting wire per gigi 50,000
REMOVABLE PROTHESE :
1 Full prothese satu rahang 700,000
2 Full/Prothese/Rahang Atas & Rahang Bawah 1,500,000
3 Protese Partial Gigi Berikutnya 56,000
4 Prothese Partial Gigi Pertama 240,000
5 Rebase Prothese Full Rahang Atas/Bawah 392,000
6 Reparasi Prothese 126,000
FIXED PROTHESE
1 Bridge Acrylic Metal Procelin per-Elemen 336,000
2 Full Post Crown 210,000
3 Gigi Implant + Crown PFM 8,000,000
4 Jacket Crown All Acrylic 300,000
5 Procelin Crown per-Gigi 616,000
BEDAH MULUT DENGAN ANASTESI LOKAL

1 Kecil 250,000
Apex Reseksi 1 Elemen
Eksisi Mucocel/ Epulis
Eksisi Biopsi
Insisi Biopsi
Debridement
Transplantasi
2 Sedang 480,000
Odontectomy
Alveolectomy
Reposisi Dislokasi TMJ
Enukleasi Kista
Insisi Abses EO
3 Besar 800,000
Marsupiliasasi
Fiksasi Fraktur
Tindakan medik di Ruang Operasi Bedah Sentral disesuaikan dengan tarif bedah sentral
ORTHO
1 Pencetakan Alginate Rahang Atas+ Bawah 168,000
Pemasangan
2 Alat Ortodonti Lepas RA+RB 1,400,000
3 Alat Ortodonti Lepas RA/RB 625,000
4 Alat Ortodonti Cekat RA+RB 3,640,000
5 Alat Ortodonti Cekat RA/RB 2,000,000
6 Alat Ortodonti Secsional 750,000
Kontrol
7 Kontrol Cekat 112,000
8 Kontrol Removeable 56,000
Pemasangan Alat Tambahan:
9 Alat ekstra oral - Face Mask 2,400,000
10 Alat ekstra oral - Head Gear 900,000
11 Bate Raiser Posterior/Anterior (Removible) 300,000
12 Chin Cap + Head 1,000,000
13 Lip Bumper 900,000
14 Plat Retensi RA/RB (Retainer) 420,000
15 Trans Palatal Acrch (RPE) 500,000
XV TARIF PELAYANAN MEDIS THT
1 Angkat Tampon Hidung 24,000

2 Audiometri 48,000
3 Audiometri Nada Murni 20,000
4 Bellog Tampon 69,000
5 Biopsi aproach CWL 55,000
6 Biopsi Cavum Nasi 45,000
7 Biopsi Cavum Nasi 55,000
8 Biopsi dan NPC 30,000
9 Biopsi Larynx 55,000
10 Biopsi Nasopharyng 45,000
11 Biopsi Nasopharynx 55,000
12 Biopsi Oropharyng 45,000
13 Biopsi Palatum 30,000
14 Biopsi Tonsil 30,000
15 Biopsi Tumor Colli 55,000
16 Biopsi Tumor Lidah 30,000
17 Buka tampon anterior hidung 20,000
18 Buka Tampon Posterior Hidung 55,000
19 Corpus Alienum CAE 30,000
20 Corpus Alienum Cavum Nasi 30,000
21 Cuci Sinus 66,000
22 Curpus Alienum Hidung/ Lubang Telinga 30,000
23 Curpus Alienum Hidung/ Lubang Telinga dgn Penyulit 48,000
24 Debridemen Luka 30,000
25 Dekanulasi 30,000
26 ECA Hypopharinx dgn Inderect Laryng 30,000
27 ECA Telinga 28,500
28 ECA Tenggorokan 18,000
29 Ekstraksi Corpal Cavum Nasi 30,000
30 Ekstraksi Corpus Alienum Tenggorokan 30,000
31 Evacuasi Chalesteatoma 18,000
32 Evoked Potensial:SSEP 20,000
33 Gips Telinga 18,000
34 Imunoterapi 20,000
35 Injeksi Imunoterapi 20,000
36 Insisi Abses Mastoid 30,000
37 Insisi Abses Peritonsil/Tonsil 24,000
38 Insisi Mastoid 60,000
39 Insisi Retropharyngeal 55,000
40 Insisi Septal Abses 30,000
41 Insisi Septum Nasi 60,000
42 Irigasi Peritonsiler Abses 30,000
43 Irigasi Sinus Maksilaris 55,000
44 Kauter Konkha Hidung 30,000
45 Kauter Pharyng 30,000
46 Kauter Veruka 55,000
47 Laringoscopy Fiber Optik Tanpa Gambar 55,000
48 Nasopharyngoscopy dengan biopsi 55,000
49 Nasopharyngoscopy tanpa biopsi 20,000
50 Oto Aksutik Emission 20,000
51 Parasentese Telinga 18,000
52 Pasang NGT 30,000
53 Pasang Tampon Anterior Hidung 20,000
54 Perawatan Epistaxis 30,000
55 Perawatan Telinga 18,000
56 Punchtie Perinchondritis 18,000
57 Rhinoscopy Posterior 18,000
58 Serumen Plug 20,000
59 Spooling Cerumen 36,000
60 Spooling H202 3% 20,000
61 Spooling Serumen 20,000
62 Spooling Sinus Maxillaris 36,000
63 Suction Telinga 36,000
64 Tampon Hidung 18,000
65 Test Alergi 30,000
66 Test Fungsi Tuba 20,000
67 Test Kalori 30,000
68 Tympanometri 20,000
XVI TARIF PELAYANAN MEDIS MATA

1 Amotio Corpal Ekstra Okuler 75,000
2 Amotio Corpus Aleneum Conjungtiva 60,000
3 Amotio Corpus Aleneum Kornea 114,000
4 Amotio Granuloma 135,000
5 Aneltest 60,000
6 Auto Refraktometer 12,000
7 Debridement/Spoolling/Irigasi 39,000
8 Ekstirpasi Lithiasis 60,000
9 Epilasi 39,000
10 Flouresin Test 36,000
11 Funduscopy Direk 15,000
12 Funduscopy Indirek 18,000
13 Injeksi Subconjungtiva 42,000
14 Insisi Abses Palpebra 76,500
15 Insisi Hodeoulum/Khlalazion 240,000
16 Irigasi Mata 39,000
17 Laserasi Palpebra/ Wing Toilet 195,000
18 Literasi (Lemak Mata) 195,000
19 Pemeriksaan Biometry 39,000
20 Pemeriksaan Keratometer 60,000
21 Penjahitan Konjungtiva 420,000
22 Refraksi 15,000
23 Schemeer Test 12,000
24 Slit Lamp 12,000
25 Strike Retinoscopy 105,000
26 Tes Buta Warna 12,000
27 Tonometri 18,000
XVII TARIF FORENSIK
1 Otopsi Jenazah Yang Telah Dikuburkan 750,000

2 Pemeriksaaan Histopologik Jenazah 75,000
3 Pemeriksaaan Toxicology Perjenis 200,000
4 Pemeriksaan Obat Kualitatif Perjenis 200,000
5 Pemulasaraan Jenazah Laki-laki 600,000
6 Pemulasaraan Jenazah Perempuan 700,000
7 Pengawetan Jenazah 200,000
8 Pengawetan Jenazah Pasca Otopsi 250,000
9 Perawat / Tenaga Medis Pendamping Pasien -
10 Perawatan jenazah 220,500
11 Periksaaan Kerangka 250,000
12 Periksaaan Obat Kuantitatif Perjenis 200,000
13 Rekontruksi Luas 100,000
14 Rekontruksi Menengah 75,000
15 Rekontruksi Sederhana 50,000
16 Visum Dalam Jenazah (Outopsi) 250,000
17 Visum Luar Jenazah 50,000
XVIII TARIF PELAYANAN SYARAF

1 Injeksi Carpal Tunnel Syndrome 30,000
2 Injeksi Dequarvain 30,000
3 Injeksi Epidural 30,000
Injeksi Neuro Vaskuler (Trigger Point)
4 a. 1 s/d 2 titik 30,000
5 b. > 2 titik 30,000
Injeksi Trigger Finger
6 a. 1 Sisi 30,000
7 b. 2 Sisi 30,000
Injeksi Trigger Thumb
8 a. 1 Sisi 30,000
9 b. 2 Sisi 30,000
10 Skrining Awal Fungsi Luhur (MMSE & CDT) 20,000
12 Skrining TOAB (Test Orientasi Amnesia Balvaston) pada 20,000
Pasien Pasca Cedera Kepala
XIX TARIF PELAYANAN PSYCHOLOGY

Psikoterapi
1 a. Kurang dari 30 menit 10,000
2 b. Lebih dari 30 menit 10,000
3 Surat Keterangan Bebas Narkoba (SBN) 10,000
4 Surat Keterangan Sehat Rohani 10,000
13 Surat Keterangan Bebas Tembakau 5,000
Test Psikometri
5 a. MMSE (Tes Memori Pada Manula) 12,500
6 b. ADL / IADL (Tes Fungsi Kahidupan Sehari-hari) 12,500
7 c. GDS (Tes Depresi Pada Manula) 12,500
8 d. MMPI 100,000
9 e. PANNS (Tes Monitoring Kemajuan Terapi AP) 12,500
10 f. SCL-90 10,000
11 g. Tes Minat Bakat 50,000
12 h. Tes IQ 30,000
14 Konseling Perkawinan 10,000
15 Konseling HIV AIDS 10,000
16 Surat Keterangan Visum et Repertum Phychiatricum 110,000
17 Saksi Ahli 380,000
XX TARIF TINDAKAN MEDIS NON INVASIF
1 Anuskopi 50,000
2 Atropinisasi 15,000
3 Back Slap 7,500
4 Bilas Lambung 30,000
5 Body Jacket - Dewasa 22,500
6 Bulectomy / Rawat Jalan 102,000
7 Corpus Alineum 18,000
8 DC Shock 52,500
9 Decompresi Anak 52,500
10 Defibrilasi 69,000
11 Dilatasi Phymosis 75,000
12 Ekstrasi komedo milium 37,500
13 Exterpasi 120,000
14 Ganti Balut 30,000
15 Gips Jari Tangan 37,500
16 Gips Sepatu - Dewasa 60,000
17 Huknah / Glyseril / Hari 30,000
18 Kumbah lambung ( Hm & Intoksikasi) 60,000
19 Lavement/ Sterilisasi Usus 60,000
20 Manipulasi & Reposisi Fraktur Tertutup 150,000
21 Mantoux Test 36,000
22 Memasang / Melepas Tampon 40,500
23 Memasang Dolles Verband 30,000
24 Memasang Gips Long Leg 150,000
25 Memasang Gips Nasal 12,000
26 Memasang Rek Verband 37,500
27 Memasang Sirculair Gips 60,000
28 Memasang Uslyp Verband 84,000
29 Memasang Vellpen Verband 30,000
30 Membuat & Memasang Gips Spalk 60,000
31 Mencabut Cystostomi 15,000
32 Monitor Bed side 8,000
33 Multiple Incisi 52,500
34 Nail Extraction 90,000
35 Nebulizer 18,000
36 O2 > 10 L per jam 65,000
37 O2 1-3L/M/jam 25,000
38 O2 4-6L/M/jam 35,000
39 O2 6-8L/M/jam 45,000
40 O2 8-10L/M/jam 55,000
41 Observasi Ketat Pasien oleh Perawat -
42 Observasi Pasien oleh Dokter Spesialis -
43 Pasang Bidai Besar 60,000
44 Pasang Bidai Sedang 52,500
45 Pasang dan Lepas ETT 180,000
46 Pasang dan Lepas NGT/OGT 21,000
47 Pasang dan Lepas NGT/OGT dengan Penyulit 42,000
48 Pasang dan Lepas Schoorsteen 28,500
49 Pasang Fowley Catheter 30,000
50 Pasang Kateter ( Ret Urine ) 42,000
51 Pasang Kateter Urine 25,500
52 Pasang Kateterisasi LA 88,500
53 Pasang Ransel Verband 60,000
54 Pasang Skin Traksi 90,000
55 Pasang Spalk LA 88,500
56 Pengambilan Benda Asing THT 45,000
57 Pengambilan Cerumen 21,000
58 Rectal Toucher 12,000
59 Regulasi Cepat 30,000
60 Rehidrasi Berat 9,000
61 Resusitasi - Anak/Bayi 45,000
62 Resusitasi - Dewasa 45,000
63 Resusitasi Cardio Pulmonal 82,500
64 Skin Test 12,000
65 Slem / Pneumo Suction 18,000
66 Sling / Bandage 22,500
67 Tampon Hidung Depan, LA 30,000
68 Transfusi Darah / Paket Bayi 15,000
69 Transfusi Darah / Paket Dewasa 12,000
70 Transfusion Exchange 150,000
71 U Sleb 10,500
72 Ultraviolet Terapi/ hari 20,000
XXI TARIF TINDAKAN MEDIS INVASIF
1 Amputasi sederhana 225,000

2 Biopsi Jarum Halus 50,000
3 Biopsi Kelenjar Leher 100,000
4 Biopsi Pleura 100,000
5 Close sistotomi 45,000
6 CVC (Central Venus Chateter) 100,000
7 Eksisi Dengan Anastesi lokal 100,000
8 Incisi Besar 60,000
9 Incisi Biasa 21,000
10 Incisi Sedang 40,500
11 Pleurodesis 100,000
12 Punctie Acites 54,000
13 Punctie Bulibuli 30,000
14 Punctie Cephal Hematome 54,000
15 Punctie Lumbal 90,000
16 Punctie Pleura 175,000
17 Punctie Sumsum Tulang 75,000
18 Sedasi Anastesi 30,000
19 Venasectie 150,000
20 WSD 134,000
21 Angkat Drain thorax 15,000
22 Angkat Jahitan > 10 sampul dst 24,000
23 Angkat Jahitan 1 s/d 5 sampul 9,000
24 Angkat Jahitan 6 s/d 10 sampul 15,000
25 Dilatasi Phymosis 75,000
26 Ekstrasi komedo milium 37,500
27 Exterpasi 120,000
28 Exterpasi - Kulit 120,000
29 Extirpasi Benda Asing di Cornea 30,000
30 Extremitas Atas Besar 300,000
31 Extremitas Atas Kecil - Sedang 120,000
32 Extremitas Bawah Besar 360,000
33 Extremitas Bawah Kecil - Sedang 180,000
34 Infus, Drip, Tranfusi 10,000
35 Infusion Pump Dewasa / Hari 6,000
36 Injeksi Intra Cutan, Subcutan, Intra Muskular, Intravena / Hari 3,750
37 Injeksi Intraartikular 50,000
38 Injeksi Keloid 20,000
39 Insis Abses (Loop) 60,000
40 Intubasi Endotracheal 37,500
41 Irigasi / Spooling Catheter 30,000
42 Irigasi Trauma Kimia,LA 30,000
43 Jahit Konjungtiva (Loop) LA 30,000
44 Jahit Luka < 5 cm 21,000
45 Jahit Luka > 10 cm 45,000
46 Jahit Luka 5 - 10 cm 36,000
47 Jahit Palpebra. LA 37,500
48 Kaustik Kimia Konka Nasal 1-2 60,000
49 Lepas Drain 12,000
50 Lepas Kateter Urine 12,000
51 Lepas Tampon Haemorhoid 15,000
52 Lepas WSD 52,500
53 Luka Khusus - Gangren Luas 90,000
54 Luka Khusus - Steven Johnson 130,500
55 Memasukkan Cytostatika per 1 18,000
56 Memasukkan Obat IV/IM/SC/SUPP 4,500
57 Memasukkan Obat Sitostatika 30,000
58 Nekrotomi Deridemen Besar 90,000
59 Nekrotomi Deridemen Kecil 30,000
60 Nekrotomi Deridemen Sedang 60,000
61 Pasang Drain 42,000
62 Pasang Tampon Haemorhoid 25,500
63 Pasang WSD Non Paru 102,000
64 Pemasangan Infus - Anak 9,000
65 Pemasangan Infus Sitostastika 45,000
66 Pemasangan Infus Standar 4,000
67 Pemasangan Infus Umbilikalis 40,000
68 Pengambilan Darah Arteri - Anak 30,000
69 Pengambilan Darah Arteri - Dewasa 25,000
70 Pengambilan Darah Vena - Anak 4,000
71 Pengambilan Darah Vena - Dewasa 4,000
72 Perawatan Luka ( Paket ) 21,000
73 Perawatan Luka Bakar < 20 % 82,500
74 Perawatan Luka Bakar > 30 % 255,000
75 Perawatan Luka Bakar 21-30 % 132,000
76 Perawatan Luka Besar diameter > 15 cm 42,000
77 Perawatan Luka Kecil diameter < 5 cm 21,000
78 Perawatan Luka Operasi 30,000
79 Perawatan Luka sedang diameter 5 - 15 cm 30,000
80 Perawatan Luka tracheostomi 25,500
XXII TARIF TINDAKAN ANDROLOGI
1 Analisa sperma 120,000

2 Injeksi therapi hormon 120,000
3 Paket IUI (intra uterine insemimation) persiapan 1,800,000
4 Test anilin + hiosin 150,000
5 Test fructosa + alpha glukosidase 150,000
6 Tindakan PLI (paternal leucocyte immunization) 540,000
7 Washing sperm 1,500,000
8 Bayi Tabung : 20,000,000
Ovum pick up
Embryo
Embryo ransfer
Frezzing sperma
Inseminasi
XXIII TARIF SEWA ALAT
1 Bed Side Monitor 30,000

2 Blanket Warmer 10,000
3 Blood Warmer 25,500
4 CPAP 55,000
5 Incubator 25,000
6 Infused Pump 45,000
7 Pulse Oxymetry 15,000
8 Respirator (Sewa) 45,000
9 Sewa Lemari Pendingin Jenazah per hari (Max 5 hari) 50,000
10 Syringe Pump 45,000
11 Ventilator 135,000
XXIV TARIF DIAGNOSTIK
1 Audiometri 30,000
2 BERA 30,000
3 Bronchoscopy 350,000
4 Colonoscopy 285,000
5 EEG 150,000
6 EKG 20,000
7 Echocardiography 250,000
8 EMG 30,000
9 Endoscopy 285,000
10 Spirometry 40,000
11 SSEP 30,000
12 USG Abdomen 135,000
13 USG Abdomen Lengkap 270,000
14 USG Carotis Doppler 180,000
15 USG Ginecology/TV/Prostast/Paru 165,000
16 USG Kandungan 165,000
17 USG Mamae 135,000
18 USG Neonatus 135,000
19 USG Testis/Scrotum 120,000
20 USG Transvaginal 90,000
21 USG Tyroid 135,000
22 USG Vascular 180,000
XXV TARIF PELAYANAN VAKSINASI
1 Vaksinasi 10,000
XXVI TARIF PROMOSI DAN EDUKASI KESEHATAN

1 KMC (Kanggoroo Mather Care) 20,000
2 Manajemen Laktasi 10,000
3 Home Care 100,000
4 Growth and Development 100,000
XXVII TARIF LAIN-LAIN
1 Biaya Sterilisasi Alat per set 12,000

2 Insenerator per kg 9,000
3 Kontrak Pemasangan ATM/ tahun 12,000,000
4 Loundry, Biaya pencucian per kg cucian kering 7,500
5 Pan Pendidikan dan Pelatihan dokter muda per orang per 400,000
periode
6 Pan Pendidikan dan Pelatihan Manajemen/Disiplin Ilmu Lain 250,000
per orang per periode
7 Pan Pendidikan dan Pelatihan Perawat dan setara per orang 250,000
per periode
8 Parkir Kendaraan Roda 2/ jam (Max 4 jam) 300
9 Parkir Kendaraan Roda 4/ jam (Max 4 jam) 900
10 Penerimaan Study Banding per orang 250,000
11 Penelitian di RS per Paket 500,000
12 Sewa Lahan/Kantor/Fasilitas Umum per m2 per tahun 900,000
14 Sewa Mobil Operational Pasien Dalam Kota * 80,000
15 Sewa Kamar Jenazah / Hari * 85,000
16 Sewa Ambulance Dalam Kota * 80,000
17 Sewa Kendaraan Jenazah Dalam Kota * 80,000
* Sewa Kendaraan Ambilans/Jenazah Luar Kota (Tarif Dalam Kota ditambah Rp. 7.000,-/KM)
DHABEDA
Created by dr Hanna Permana Subanegara, MARS.
JASA
TARIF BARU TARIF LAMA TARIF PESAING 1
PELAYANAN
40,000 70,000 30,000.00 40,000.00
40,000 70,000 15,000.00 35,000.00
JASA
TARIF NARU TARIF LAMA TARIF PESAING 1
PELAYANAN
40,000 60,000 20,000.00 30,000.00
40,000 60,000 15,000.00 35,000.00
JASA
PELAYANAN
60,000 120,000 75,000.00 60,000.00
60,000 150,000 125,000.00 130,000.00
60,000 210,000 250,000.00 160,000.00
60,000 335,000 275,000.00 200,000.00
60,000 210,000### - 210,000.00
60,000 175,000### - 160,000.00
60,000 175,000### -
60,000 175,000 -
60,000 175,000 -
60,000 235,000 -
60,000 175,000 -
40,000 40,000 -
JASA
PELAYANAN
100,000 650,000 150,000.00 300,000.00
150,000 800,000 150,000.00 400,000.00
an khusus dan di ruang isolasi ICU
JASA
PELAYANAN
800,000 1,550,000 1,100,000.00 1,440,000.00
2,500,000 3,500,000 1,500,000.00 3,600,000.00
4,500,000 7,000,000 2,200,000.00 7,200,000.00
8,000,000 12,000,000 14,850,000.00
gan sub sepesialisasi berbeda, maka jasa pelayanan operator

Anastesi ditambah 50%.
JASA
PELAYANAN
30,000 35,000 15,000.00
150,000
350,000
850,000
1,155,000
1,250,000
JASA
PELAYANAN
-
8,100 48,600 22,000.00 55,000.00
4,200 25,200 22,000.00 49,500.00
19,200 115,200
15,000 90,000
3,600 21,600 22,000.00 27,500.00
3,300 19,800 22,000.00 17,000.00
5,600 33,600
4,200 25,200
3,600 21,600 22,000.00 65,000.00
3,000 18,000 22,000.00 17,500.00
3,000 18,000 16,000.00
3,600 21,600 22,000.00 15,000.00
5,000 30,000 17,000.00 35,000.00
12,000 72,000
7,600 45,600
25,440 152,640
12,000 72,000
23,200 139,200
3,600 21,600 22,000.00 25,000.00
5,100 30,600 17,500.00
9,600 57,600
12,000 72,000
9,600 57,600
20,000 120,000
8,000 48,000
- -
- -
8,000 48,000
11,200 67,200
8,000 48,000
8,000 48,000
3,600 21,600
5,400 32,400 40,000.00
2,400 14,400 11,000.00 16,000.00
1,600 9,600 8,000.00 25,000.00
2,800 16,800
4,200 25,200 22,000.00 45,000.00
- -
- -
11,250 67,500 70,000.00
24,900 149,400 140,000.00
16,500 99,000 60,000.00
3,300 19,800 22,000.00 18,500.00
3,300 19,800 22,000.00 18,500.00
10,800 64,800 40,000.00
18,000 108,000 80,000.00
- -
- -
6,000 36,000 22,000.00 49,500.00
7,500 45,000 22,000.00 55,000.00
- -
- -
8,000 48,000
12,800 76,800
4,200 25,200 11,000.00 30,000.00
5,100 30,600 11,000.00 32,500.00
25,600 153,600
21,300 127,800 35,000.00 215,000.00
24,000 144,000 140,000.00
4,480 26,880
4,200 25,200 20,000.00 27,500.00
4,200 25,200 11,000.00 35,000.00
4,200 25,200 11,000.00 35,000.00
4,200 25,200 11,000.00 35,000.00
8,000 48,000
15,200 91,200
15,000 90,000 25,000.00 110,000.00
14,400 86,400 13,000.00 97,500.00
8,000 48,000
8,000 48,000
17,600 105,600
37,000 222,000
5,800 34,800
5,250 31,500
6,000 36,000
4,800 28,800 11,000.00 30,000.00
12,800 76,800
7,500 45,000
3,300 19,800 11,000.00 25,500.00
3,300 19,800 9,000.00 20,000.00
3,300 19,800 9,000.00
10,900 65,400
21,300 127,800 150,000.00
6,000 36,000
7,500 45,000
7,500 45,000 15,000.00 50,000.00
8,000 48,000
5,100 30,600 11,000.00 40,000.00
5,100 30,600 11,000.00 45,000.00
5,100 30,600 11,000.00 40,000.00
3,300 19,800 11,000.00 20,000.00
6,450 38,700 20,000.00 40,000.00
9,600 57,600
4,800 28,800 13,000.00 32,000.00
16,500 99,000 125,000.00
8,400 50,400
4,200 25,200 11,000.00 30,000.00
3,900 23,400 11,000.00 25,000.00
3,900 23,400 11,000.00 25,000.00
4,200 25,200 15,000.00 30,000.00
16,050 96,300 95,000.00
10,900 65,400
4,200 25,200 11,000.00 27,500.00
6,800 40,800
- -
- -
15,000 90,000
15,000 90,000
22,500 135,000 45,000.00 150,000.00
7,500 45,000
12,800 76,800
18,000 108,000
7,500 45,000 20,000.00
27,000 162,000 80,000.00
15,000 90,000 40,000.00 64,000.00
25,600 153,600
25,600 153,600
22,500 135,000 220,000.00
20,100 120,600 185,000.00
8,000 48,000
8,000 48,000
8,400 50,400
8,000 48,000
15,000 90,000
15,000 90,000
8,000 48,000
15,000 90,000
15,000 90,000
10,500 63,000 25,000.00 36,000.00
5,400 32,400 18,500.00 24,000.00
10,500 63,000 25,000.00 80,000.00
12,000 72,000
9,600 57,600
9,600 57,600
13,500 81,000
12,000 72,000
24,000 144,000 65,600.00
6,450 38,700 25,000.00 40,000.00
20,100 120,600 185,000.00
28,500 171,000 200,000.00
10,500 63,000 60,000.00
9,000 54,000 25,000.00 50,000.00
7,500 45,000 20,000.00 40,000.00
5,400 32,400 5,000.00 40,000.00
7,500 45,000 21,000.00 50,000.00
- -
- -
23,040 138,240
28,800 172,800
21,400 128,400
27,000 162,000 70,000.00 185,000.00
4,800 28,800 20,000.00 96,000.00
3,300 19,800 8,000.00 20,000.00
- -
- -
21,300 127,800 65,000.00
11,250 67,500 65,000.00 48,000.00
20,100 120,600 65,000.00 76,000.00
- -
- -
8,200 49,200
22,500 135,000 100,000.00 144,000.00
26,000 156,000
27,000 162,000 100,000.00
- -
- -
3,300 19,800
3,300 19,800
3,300 19,800
6,750 40,500
- -
- -
13,200 79,200
14,000 84,000
16,000 96,000
14,800 88,800
14,000 84,000
25,000 150,000
30,000 180,000
11,000 66,000
11,000 66,000
14,400 86,400
10,000 60,000
- -
- -
15,200 91,200
33,000 198,000
21,000 126,000
31,400 188,400
30,400 182,400
24,000 144,000
71,000 426,000
JASA
PELAYANAN
44,000 110,000 45,000.00
64,000 160,000 55,000.00 200,000.00
90,000 225,000 65,000.00 300,000.00
110,000 275,000 130,000.00 500,000.00
150,000 375,000 140,000.00
JASA
PELAYANAN
90,000 225,000 45,000.00 250,000.00
149,333 373,333
150,000 375,000 170,000.00 550,000.00
150,000 375,000
40,000 100,000 90,000.00
160,000 400,000 36,000.00 600,000.00
46,000 115,000 36,000.00 100,000.00
83,000 207,500 36,000.00 195,000.00
130,667 350,000
160,000 400,000 400,000.00
90,000 225,000 200,000.00
55,000 137,500 36,000.00 135,000.00
700,000 1,750,000 450,000.00 1,320,000.00
350,000 875,000 350,000.00 689,600.00
480,000 1,200,000 400,000.00 616,000.00
284,000 710,000 350,000.00 416,000.00
640,000 1,600,000 400,000.00 1,104,000.00
320,000 800,000 350,000.00 689,600.00
150,000 375,000 70,000.00 385,000.00
16,000 40,000 35,000.00
40,000 100,000 90,000.00
180,000 450,000 225,000.00
140,000 350,000 70,000.00 400,000.00
140,000 350,000 350,000.00
56,000 150,000
90,000 225,000 50,000.00 225,000.00
40,000 100,000 36,000.00 110,000.00
60,000 150,000 36,000.00 80,000.00
60,000 150,000 36,000.00 200,000.00
110,000 275,000 36,000.00
60,000 150,000 36,000.00 240,000.00
110,000 275,000 36,000.00
56,000 150,000
56,000 150,000
32,000 80,000 36,000.00 70,000.00
32,000 80,000 36,000.00 70,000.00
72,000 180,000 150,000.00
160,000 400,000 60,000.00 400,000.00
110,000 275,000 45,000.00 280,000.00
50,000 125,000 36,000.00
600,000 1,500,000
74,667 200,000
110,000 275,000 85,000.00
70,000 175,000 36,000.00 165,000.00
112,000 300,000
70,000 175,000 36,000.00
90,000 225,000 36,000.00 100,000.00
140,000 375,000
60,000 150,000 36,000.00 70,000.00
110,000 275,000 36,000.00 100,000.00
29,867 80,000
160,000 400,000 75,000.00 450,000.00
140,000 375,000
110,000 275,000 36,000.00 110,000.00
60,000 150,000 36,000.00 70,000.00
JASA
PELAYANAN
10,000 25,000 6,000.00 24,000.00
14,000 35,000 8,000.00 35,000.00
14,000 35,000 6,000.00 20,000.00
30,000 75,000 75,000.00
14,000 35,000 20,000.00
13,000 32,600
8,000 20,000
14,000 35,000
13,000 32,600
6,000 15,000 10,000.00
JASA
PELAYANAN
160,000 400,000
220,000 550,000
JASA PELAYANAN TARIF BARU TARIF LAMA TARIF PESAING 1

20,000 35,000 -
35,000 60,000 -
60,000 105,000 -
80,000 140,000 -
JASA
PELAYANAN
8,000 20,000 10,000.00 18,500.00
36,000 60,000 27,500.00 38,500.00
30,000 75,000 60,000.00 82,000.00
80,000 200,000 100,000.00 202,000.00
JASA
PELAYANAN
50,000 125,000 125,000.00
78,000 130,500
6,000 15,000
50,000 125,000 125,000.00
100,000 250,000
- 5,000
135,000 337,500 400,000.00
81,000 135,000
27,000 67,500
40,000 100,000
32,000 80,000 100,000.00
35,000 87,500
88,000 220,000
14,000 35,000
17,000 42,500
27,000 67,500
30,000 75,000
17,000 42,500
35,000 87,500
10,000 25,000
30,000 75,000
750,000 1,250,000 500,000.00
525,000 875,000 300,000.00
200,000 500,000 500,000.00
14,000 35,000
32,000 80,000 100,000.00
14,000 35,000
7,000 17,500
10,000 26,000
50,000 125,000
73,000 185,000
100,000 250,000
100,000 250,000
73,000 185,000
12,000 30,000
160,000 400,000 400,000.00
44,000 110,000
40,000 100,000
8,000 20,000
7,000 17,500
37,000 92,500
80,000 200,000
8,000 20,000
90,000 150,000
JASA
PELAYANAN
133,000 333,000 325,000.00

75,000 126,600 27,500.00 85,000.00
65,000 110,000 27,500.00 75,000.00
45,000 75,000 27,500.00 50,000.00
45,000 75,000 27,500.00 50,000.00
150,000 250,000 27,500.00 125,000.00
110,000 185,000 27,500.00 95,000.00
190,000 315,000 27,500.00 150,000.00
45,000 75,000 27,500.00 50,000.00
65,000 110,000 27,500.00 50,000.00
20,000 50,000 27,500.00 70,000.00

16,000 40,000 27,500.00 50,000.00
75,000 125,000 110,000.00
60,000 100,000 27,500.00 90,000.00
600,000 1,000,000 65,000.00 250,000.00
75,000 125,000 27,500.00 110,000.00
105,000 175,000 36,000.00 100,000.00
250,000 420,000 250,000.00

65,000 165,000 27,500.00 150,000.00
200,000 350,000 250,000.00 270,000.00
220,000 500,000 27,500.00 270,000.00
30,000 55,000 50,000.00
66,000 150,000 65,000.00 300,000.00
50,000 120,000 65,000.00 150,000.00
200,000 350,000 250,000.00
50,000 87,500 27,500.00
50,000 100,000 105,000.00
460,000 1,160,000 1,225,000.00

1,000,000 2,500,000 2,450,000.00
40,000 96,000 75,000.00
160,000 400,000 320,500.00
265,000 657,000 600,000.00
85,000 211,000 200,000.00
225,000 561,000 500,000.00

140,000 350,000 300,000.00
5,500,000 13,500,000 8,000,000.00
200,000 500,000 350,000.00
400,000 1,016,000 1,100,000.00
800,000 1,050,000
700,000.00
65,000.00
100,000.00
100,000.00
1,500,000.00 900,000.00
1,100,000.00
900,000 1,380,000
1,100,000.00
1,500,000.00
1,500,000.00
1,100,000.00 1,100,000.00
65,000.00
1,500,000 2,300,000
1,100,000.00
1,500,000.00 900,000.00
engan tarif bedah sentral
112,000 280,000 310,000.00
950,000 2,350,000 2,800,000.00

520,000 1,145,000 1,400,000.00
2,400,000 6,040,000 5,000,000.00 5,800,000.00
1,500,000 3,500,000 2,900,000.00
750,000 1,500,000
75,000 187,000
40,000 96,000
1,600,000 4,000,000 4,000,000.00

800,000 1,700,000 1,300,000.00
200,000 500,000 500,000.00
500,000 1,500,000
600,000 1,500,000
380,000 800,000 815,000.00
500,000 1,000,000 1,000,000.00
JASA
PELAYANAN
16,000 40,000 27,500.00 40,000.00
32,000 80,000 27,500.00 60,000.00
25,000 45,000
46,000 115,000 27,500.00 300,000.00
150,000 205,000
30,000 75,000 225,000.00
150,000 205,000
55,000 85,000
150,000 205,000
30,000 75,000 225,000.00
150,000 205,000
30,000 75,000 225,000.00
55,000 85,000
55,000 85,000
150,000 205,000
55,000 85,000
25,000 45,000
150,000 205,000
55,000 85,000
55,000 85,000
44,000 110,000
20,000 50,000
32,000 80,000
55,000 85,000
55,000 85,000
20,000 50,000
19,000 47,500
12,000 30,000
55,000 85,000
55,000 85,000
12,000 30,000
25,000 45,000
12,000 30,000
25,000 45,000
25,000 45,000
55,000 85,000
16,000 40,000 350,000.00
40,000 100,000 300,000.00
150,000 205,000
55,000 85,000
40,000 100,000 350,000.00
55,000 85,000
150,000 205,000
55,000 85,000
55,000 85,000
150,000 205,000
150,000 205,000
150,000 205,000
25,000 45,000
25,000 45,000
12,000 30,000
55,000 85,000
25,000 45,000
20,000 50,000 27,500.00
12,000 30,000 27,500.00
12,000 30,000
12,000 30,000
25,000 45,000
24,000 60,000 27,500.00
25,000 45,000
25,000 45,000
24,000 60,000 27,500.00
24,000 60,000 27,500.00
12,000 30,000 27,500.00
55,000 85,000
25,000 45,000
55,000 85,000
25,000 45,000
JASA
PELAYANAN
50,000 125,000 150,000.00
40,000 100,000 27,500.00 75,000.00
170,000 284,000
90,000 225,000
40,000 100,000 200,000.00
8,000 20,000
26,000 65,000 27,500.00 75,000.00
40,000 100,000 65,000.00
26,000 65,000 150,000.00
24,000 60,000 50,000.00
10,000 25,000 20,000.00
12,000 30,000 20,000.00
28,000 70,000 27,500.00 75,000.00
51,000 127,500
160,000 400,000 65,000.00 500,000.00
26,000 65,000
130,000 325,000 300,000.00
130,000 325,000 65,000.00 300,000.00
26,000 65,000
40,000 100,000 200,000.00
280,000 700,000 300,000.00
10,000 25,000
8,000 20,000
8,000 20,000 20,000.00
70,000 175,000 200,000.00
8,000 20,000
12,000 30,000 50,000.00
JASA
PELAYANAN
1,250,000 2,000,000
175,000 250,000
50,000 250,000
50,000 250,000
200,000 800,000 100,000.00 700,000.00
200,000 900,000 100,000.00 700,000.00
300,000 500,000 750,000.00
500,000 750,000 900,000.00
100,000 100,000
147,000 367,500
500,000 750,000 1,000,000.00
50,000 250,000
200,000 300,000 250,000.00
175,000 250,000 200,000.00
150,000 200,000 150,000.00
500,000 750,000 600,000.00
150,000 200,000 400,000.00
JASA
PELAYANAN
80,000 110,000
80,000 110,000
250,000 280,000
80,000 110,000
160,000 190,000
80,000 110,000
160,000 190,000
80,000 110,000
160,000 190,000
80,000 100,000
80,000 100,000
JASA
PELAYANAN
90,000 100,000
140,000 150,000
65,000 75,000
15,000 25,000
20,000 25,000
35,000 47,500
35,000 47,500
35,000 47,500
150,000 250,000
35,000 47,500
35,000 45,000
150,000 200,000
120,000 150,000
90,000 100,000
90,000 100,000
275,000 385,000
420,000 800,000
JASA
PELAYANAN
33,000 83,000
10,000 25,000
5,000 12,500
45,000 75,000 30,000.00
15,000 37,500
68,000 170,000
12,000 30,000 27,500.00
75,000 127,500
35,000 87,500
46,000 115,000
50,000 125,000 100,000.00
25,000 62,500
80,000 200,000 200,000.00
20,000 50,000
25,000 62,500
40,000 100,000
20,000 50,000 3,750.00
40,000 100,000
40,000 100,000
100,000 250,000
24,000 60,000 27,500.00
27,000 67,500
20,000 50,000
100,000 250,000
8,000 20,000
25,000 62,500
40,000 100,000
56,000 140,000
20,000 50,000
40,000 100,000
10,000 25,000
5,000 13,000 7,500.00
35,000 87,500
60,000 150,000 2,500.00 100,000.00
12,000 30,000 10,000.00 25,000.00
20,000 85,000
- 25,000
- 35,000
30,000 75,000
36,000 91,000
30,000 30,000 150,000.00 400,000.00
100,000 100,000 150,000.00 400,000.00
40,000 100,000
35,000 87,500
120,000 300,000
14,000 35,000 38,500.00 40,000.00
28,000 70,000
19,000 47,500
20,000 50,000
28,000 70,000 18,500.00 60,000.00
17,000 42,500 35,000.00
59,000 147,500
40,000 100,000
60,000 150,000
59,000 147,500
30,000 75,000
14,000 35,000
8,000 20,000
20,000 50,000
6,000 15,000
105,000 150,000
105,000 150,000
125,000 207,500 7,500.00
8,000 20,000
12,000 30,000
15,000 37,500
20,000 50,000
22,500 37,500
8,000 20,000
250,000 400,000
7,000 17,500
15,000 35,000
JASA
PELAYANAN
150,000 375,000 1,385,000.00
75,000 125,000 1,100,000.00 100,000.00
150,000 250,000
175,000 275,000
30,000 75,000
200,000 300,000
150,000 250,000 1,100,000.00
40,000 100,000
14,000 35,000
27,000 67,500
175,000 275,000
85,000 139,000
45,000 75,000
80,000 134,000
155,000 245,000
250,000 425,000
50,000 125,000
60,000 90,000
100,000 250,000 250,000.00
234,500 368,500 250,000.00
10,000 25,000
16,000 40,000
6,000 15,000
10,000 25,000 27,500.00
50,000 125,000 100,000.00
25,000 62,500
80,000 200,000 200,000.00
80,000 200,000 200,000.00
20,000 50,000 25,000.00
200,000 500,000
80,000 200,000
240,000 600,000
120,000 300,000
5,000 15,000 10,000.00
4,000 10,000 7,500.00
2,500 6,250 2,500.00 10,000.00
75,000 125,000
30,000 50,000
40,000 100,000 200,000.00
60,000 97,500
20,000 50,000
20,000 50,000
20,000 50,000
14,000 35,000
30,000 75,000
24,000 60,000
25,000 62,500
40,000 100,000
8,000 20,000
8,000 20,000 7,500.00 20,000.00
10,000 25,000
35,000 87,500
60,000 150,000
87,000 217,500
12,000 30,000
3,000 7,500
20,000 50,000
60,000 150,000
20,000 50,000
40,000 100,000
28,000 70,000
17,000 42,500
68,000 170,000
6,000 15,000
30,000 75,000 18,500.00
6,000 10,000 18,500.00
110,000 150,000 18,500.00
37,500 67,500
16,000 41,000
5,000 9,000
3,000 7,000
14,000 35,000
55,000 137,500
170,000 425,000
88,000 220,000
28,000 70,000 60,000.00
14,000 35,000 25,000.00
20,000 50,000 1,500.00
20,000 50,000
17,000 42,500
JASA
PELAYANAN
80,000 200,000
80,000 200,000
1,200,000 3,000,000
100,000 250,000
100,000 250,000
360,000 900,000
1,000,000 2,500,000
15,000,000 35,000,000
JASA
PELAYANAN
20,000 50,000
5,000 15,000
17,000 42,500 40,000.00
35,000 90,000
15,000 40,000 30,000.00
10,000 55,000 75,000.00
5,000 20,000 25,000.00
30,000 75,000
35,000 85,000
10,000 55,000 95,000.00
50,000 185,000 350,000.00
JASA
PELAYANAN
20,000 50,000 27,500.00 45,000.00
100,000 130,000
650,000 1,000,000 100,000.00 1,200,000.00
190,000 475,000 30,000.00
100,000 250,000
30,000 50,000
100,000 350,000 30,000.00
100,000 130,000
190,000 475,000
60,000 100,000 30,000.00 60,000.00
100,000 130,000
90,000 225,000 60,000.00 225,000.00
180,000 450,000 60,000.00 485,000.00
120,000 300,000
110,000 275,000 65,000.00 215,000.00
110,000 275,000 60,000.00 225,000.00
90,000 225,000 60,000.00 225,000.00
90,000 225,000 60,000.00 225,000.00
80,000 200,000 60,000.00 215,000.00
60,000 150,000 60,000.00 150,000.00
90,000 225,000 60,000.00 225,000.00
120,000 300,000 60,000.00 350,000.00
JASA
PELAYANAN
10,000 20,000
JASA
PELAYANAN
30,000 50,000
30,000 40,000
100,000 200,000
75,000 175,000
JASA
PELAYANAN
8,000 20,000
1,000 10,000
4,000,000 16,000,000
2,000 9,500
275,000 675,000
150,000 400,000
150,000 400,000
200 500
100 1,000
- 250,000
- 500,000
100,000 1,000,000
20,000 100,000
20,000 105,000 125,000.00
20,000 100,000
20,000 100,000
ota ditambah Rp. 7.000,-/KM)
TARIF PESAING 2 TARIF PESAING 3 SELISIH
30,000.00 - (40,000.00)
35,000.00 75,000.00 (55,000.00)

(40,000.00)
30,000.00 (45,000.00)

50,000.00 (45,000.00)
150,000.00 (25,000.00)
250,000.00 40,000.00
350,000.00 (60,000.00)
150,000.00 (210,000.00)
(175,000.00)
70,000.00 (175,000.00)
(175,000.00)
(175,000.00)
(235,000.00)
150,000.00 (175,000.00)
150,000.00 (40,000.00)

620,000.00 (500,000.00)
(650,000.00) Perbedaan Reguler dan Khusus

4,000,000.00 (450,000.00)
6,900,000.00 (2,000,000.00)
9,000,000.00 (4,800,000.00)
14,000,000.00 (12,000,000.00)

(20,000.00)
(150,000.00)
762,000.00 (350,000.00)
(850,000.00)
(1,155,000.00)
(1,250,000.00)

-
-
50,000.00 45,500.00 (26,600.00)
25,000.00 11,500.00 (3,200.00)
(115,200.00)
(90,000.00)
100,000.00 21,500.00 400.00
20,000.00 21,500.00 2,200.00
(33,600.00)
(25,200.00)
20,000.00 21,500.00 400.00
18,000.00 4,000.00
21,500.00 (18,000.00)
15,000.00 400.00
40,000.00 39,500.00 (13,000.00)
(72,000.00)
(45,600.00)
(152,640.00)
(72,000.00)
(139,200.00)
22,500.00 21,500.00 400.00
39,500.00 (30,600.00)
(57,600.00)
(72,000.00)
(57,600.00)
(120,000.00)
(48,000.00)
-
-
(48,000.00)
(67,200.00)
(48,000.00)
(48,000.00)
27,500.00 39,500.00 (21,600.00)
32,500.00 39,500.00 (32,400.00)
13,000.00 11,500.00 (3,400.00)
20,000.00 9,500.00 (1,600.00)
(16,800.00)
23,000.00 30,500.00 (3,200.00)
-
-
100,000.00 72,500.00 (67,500.00)
175,000.00 144,000.00 (149,400.00)
120,000.00 94,000.00 (99,000.00)
15,000.00 11,500.00 2,200.00
15,000.00 11,500.00 2,200.00
100,000.00 72,500.00 (64,800.00)
150,000.00 140,000.00 (108,000.00)
-
-
38,500.00 21,500.00 (14,000.00)
49,500.00 21,500.00 (23,000.00)
-
-
(48,000.00)
(76,800.00)
25,500.00 21,500.00 (14,200.00)
39,500.00 (19,600.00)
(153,600.00)
135,000.00 144,000.00 (92,800.00)
135,000.00 144,000.00 (144,000.00)
(26,880.00)
23,000.00 39,500.00 (5,200.00)
27,000.00 21,500.00 (14,200.00)
20,000.00 21,500.00 (14,200.00)
27,500.00 21,500.00 (14,200.00)
(48,000.00)
(91,200.00)
105,000.00 94,000.00 (65,000.00)
85,000.00 94,000.00 (73,400.00)
(48,000.00)
(48,000.00)
(105,600.00)
(222,000.00)
(34,800.00)
(31,500.00)
(36,000.00)
30,000.00 39,500.00 (17,800.00)
(76,800.00)
(45,000.00)
20,000.00 21,500.00 (8,800.00)
18,500.00 21,500.00 (10,800.00)
18,500.00 (10,800.00)
(65,400.00)
125,000.00 144,000.00 (127,800.00)
(36,000.00)
(45,000.00)
55,000.00 (30,000.00)
(48,000.00)
33,500.00 39,500.00 (19,600.00)
31,000.00 21,500.00 (19,600.00)
31,500.00 39,500.00 (19,600.00)
26,000.00 21,500.00 (8,800.00)
50,000.00 39,500.00 (18,700.00)
(57,600.00)
(15,800.00)
105,000.00 94,000.00 (99,000.00)
(50,400.00)
26,500.00 21,500.00 (14,200.00)
23,000.00 39,500.00 (12,400.00)
23,000.00 39,500.00 (12,400.00)
31,500.00 39,500.00 (10,200.00)
(96,300.00)
(65,400.00)
25,500.00 39,500.00 (14,200.00)
(40,800.00)
-
-
(90,000.00)
(90,000.00)
120,000.00 206,000.00 (90,000.00)
(45,000.00)
(76,800.00)
(108,000.00)
45,000.00 97,500.00 (25,000.00)
205,000.00 (162,000.00)
120,000.00 (50,000.00)
(153,600.00)
(153,600.00)
140,000.00 166,200.00 (135,000.00)
120,000.00 166,200.00 (120,600.00)
(48,000.00)
(48,000.00)
(50,400.00)
(48,000.00)
(90,000.00)
(90,000.00)
(48,000.00)
(90,000.00)
(90,000.00)
81,500.00 72,500.00 (38,000.00)
55,000.00 39,500.00 (13,900.00)
75,000.00 (38,000.00)
(72,000.00)
(57,600.00)
(57,600.00)
(81,000.00)
(72,000.00)
185,000.00 (144,000.00)
42,500.00 97,500.00 (13,700.00)
120,000.00 72,500.00 (120,600.00)
195,000.00 (171,000.00)
(3,000.00)
56,000.00 72,500.00 (29,000.00)
55,000.00 39,500.00 (25,000.00)
32,000.00 39,500.00 (27,400.00)
44,000.00 72,500.00 (24,000.00)
-
-
(138,240.00)
(172,800.00)
(128,400.00)
155,000.00 190,000.00 (92,000.00)
35,000.00 21,500.00 (8,800.00)
31,500.00 21,500.00 (11,800.00)
-
-
150,000.00 (62,800.00)
99,000.00 (2,500.00)
135,000.00 237,000.00 (55,600.00)
-
-
(49,200.00)
(35,000.00)
(156,000.00)
(62,000.00)
-
-
(19,800.00)
(19,800.00)
(19,800.00)
(40,500.00)
-
-
(79,200.00)
(84,000.00)
(96,000.00)
(88,800.00)
(84,000.00)
(150,000.00)
(180,000.00)
(66,000.00)
(66,000.00)
(86,400.00)
(60,000.00)
-
-
(91,200.00)
(198,000.00)
(126,000.00)
(188,400.00)
(182,400.00)
(144,000.00)
(426,000.00)
-
105,000.00 112,000.00 (65,000.00)

155,000.00 170,000.00 (105,000.00)
205,000.00 236,000.00 (160,000.00)
255,000.00 313,000.00 (145,000.00)
305,000.00 518,000.00 (235,000.00)
225,000.00 216,500.00 (180,000.00)

(373,333.33)
250,000.00 390,000.00 (205,000.00)
390,000.00 (375,000.00)
216,500.00 (100,000.00)
390,000.00 (364,000.00)
145,000.00 (79,000.00)
216,500.00 (171,500.00)
(350,000.00)
390,000.00 (400,000.00)
216,500.00 (225,000.00)
145,000.00 (101,500.00)
1,150,000.00 (1,300,000.00)
575,000.00 (525,000.00)
750,000.00 (800,000.00)
465,000.00 (360,000.00)
(1,200,000.00)
(450,000.00)
390,000.00 (305,000.00)
40,000.00 38,000.00 (40,000.00)
84,500.00 (100,000.00)
549,000.00 (225,000.00)
390,000.00 (280,000.00)
390,000.00 (350,000.00)
(150,000.00)
216,500.00 (175,000.00)
84,500.00 (64,000.00)
84,500.00 (114,000.00)
84,500.00 (114,000.00)
216,500.00 (239,000.00)
84,500.00 (114,000.00)
216,500.00 (239,000.00)
(150,000.00)
(150,000.00)
84,500.00 (44,000.00)
(44,000.00)
390,000.00 (180,000.00)
390,000.00 (340,000.00)
275,000.00 216,500.00 (230,000.00)
145,000.00 (89,000.00)
1,500,000.00 390,000.00 (1,500,000.00)
(200,000.00)
145,000.00 (275,000.00)
175,000.00 216,500.00 (139,000.00)
(300,000.00)
216,500.00 (139,000.00)
80,000.00 84,500.00 (189,000.00)
(375,000.00)
216,500.00 (114,000.00)
433,000.00 (239,000.00)
(80,000.00)
390,000.00 (325,000.00)
(375,000.00)
125,000.00 216,500.00 (239,000.00)
145,000.00 (114,000.00)
(19,000.00)
40,000.00 72,000.00 (27,000.00)
50,000.00 (29,000.00)
(75,000.00)
50,000.00 (35,000.00)
(32,600.00)
(20,000.00)
40,000.00 (35,000.00)
(32,600.00)
(5,000.00)
505,000.00 (400,000.00)
650,000.00 (550,000.00)

(10,000.00)
-
30,000.00 42,500.00 (32,500.00)
-
75,000.00 (15,000.00)
-
230,000.00 (100,000.00)
200,000.00 (125,000.00)
(130,500.00)
15,000.00 (15,000.00)
(125,000.00)
250,000.00 (250,000.00)
(5,000.00)
(337,500.00)
82,000.00 (135,000.00)
(67,500.00)
(100,000.00)
80,000.00 (80,000.00)
(87,500.00)
(220,000.00)
(35,000.00)
(42,500.00)
(67,500.00)
(75,000.00)
(42,500.00)
(87,500.00)
(25,000.00)
65,000.00 (75,000.00)
(750,000.00)
(575,000.00)
(500,000.00)
(35,000.00)
80,000.00 (80,000.00)
(35,000.00)
(17,500.00)
(26,000.00)
(125,000.00)
(185,000.00)
(250,000.00)
(250,000.00)
(185,000.00)
30,000.00 (30,000.00)
(400,000.00)
(110,000.00)
(100,000.00)
(20,000.00)
(17,500.00)
(92,500.00)
(200,000.00)
(20,000.00)
(150,000.00)
521,000.00 (333,000.00)
148,000.00 (99,100.00)
88,000.00 (82,500.00)
94,000.00 (47,500.00)
90,000.00 (47,500.00)
234,000.00 (222,500.00)
177,000.00 (157,500.00)
234,000.00 (287,500.00)
88,000.00 (47,500.00)
88,000.00 (82,500.00)
-
-
117,000.00 (22,500.00)
89,000.00 (12,500.00)
210,000.00 (125,000.00)
142,000.00 (72,500.00)
1,250,000.00 (935,000.00)
300,000.00 (97,500.00)
166,000.00 (139,000.00)
-
-
372,000.00 (170,000.00)
394,000.00 (137,500.00)
2,300,000.00 (100,000.00)
2,600,000.00 (472,500.00)
66,000.00 (55,000.00)
193,000.00 (85,000.00)
193,000.00 (55,000.00)
(100,000.00)
(60,000.00)
109,000.00 (100,000.00)
-
-
1,448,000.00 (1,160,000.00)
2,720,000.00 (2,500,000.00)
115,000.00 (96,000.00)
577,000.00 (400,000.00)
758,000.00 (657,000.00)
248,000.00 (211,000.00)
-
-
704,000.00 (561,000.00)
(350,000.00)
(5,500,000.00)
568,000.00 (500,000.00)
1,015,000.00 (1,016,000.00)
-
-
(1,050,000.00)
2,350,000.00 -
399,000.00 65,000.00
394,000.00 100,000.00
394,000.00 100,000.00
420,000.00 2,000,000.00 1,500,000.00
1,100,000.00
(1,380,000.00)
1,465,000.00 -
372,000.00 1,500,000.00
283,000.00 1,500,000.00
2,650,000.00 1,100,000.00
2,100,000.00 65,000.00
(2,300,000.00)
509,000.00 1,100,000.00
2,300,000.00 1,500,000.00
-
-
-
-
200,000.00 (280,000.00)
-
2,391,000.00 (2,350,000.00)
1,281,000.00 (1,145,000.00)
7,424,000.00 (1,040,000.00)
4,000,000.00 (3,500,000.00)
(1,500,000.00)
-
(187,000.00)
(96,000.00)
-
(4,000,000.00)
1,769,000.00 (1,700,000.00)
511,000.00 (500,000.00)
(1,500,000.00)
(1,500,000.00)
645,000.00 (800,000.00)
662,000.00 (1,000,000.00)
34,000.00 (12,500.00)
80,000.00 73,000.00 (52,500.00)
(45,000.00)
316,000.00 (87,500.00)
(205,000.00)
83,000.00 (75,000.00)
(205,000.00)
(85,000.00)
(205,000.00)
83,000.00 (75,000.00)
(205,000.00)
83,000.00 (75,000.00)
(85,000.00)
(85,000.00)
(205,000.00)
(85,000.00)
(45,000.00)
(205,000.00)
(85,000.00)
(85,000.00)
100,000.00 (110,000.00)
40,000.00 (50,000.00)
70,000.00 (80,000.00)
(85,000.00)
(85,000.00)
83,000.00 (50,000.00)
83,000.00 (47,500.00)
83,000.00 (30,000.00)
(85,000.00)
(85,000.00)
(30,000.00)
(45,000.00)
83,000.00 (30,000.00)
(45,000.00)
(45,000.00)
(85,000.00)
83,000.00 (40,000.00)
(100,000.00)
(205,000.00)
(85,000.00)
(100,000.00)
(85,000.00)
(205,000.00)
(85,000.00)
(85,000.00)
(205,000.00)
(205,000.00)
(205,000.00)
(45,000.00)
(45,000.00)
(30,000.00)
(85,000.00)
(45,000.00)
(22,500.00)
(2,500.00)
(30,000.00)
(30,000.00)
(45,000.00)
70,000.00 (32,500.00)
(45,000.00)
(45,000.00)
(32,500.00)
83,000.00 (32,500.00)
34,000.00 (2,500.00)
(85,000.00)
(45,000.00)
(85,000.00)
(45,000.00)

(125,000.00)
40,000.00 107,000.00 (72,500.00)
(284,000.00)
250,000.00 (225,000.00)
115,000.00 (100,000.00)
(20,000.00)
(37,500.00)
90,000.00 107,000.00 (35,000.00)
50,000.00 78,000.00 (65,000.00)
(60,000.00)
(25,000.00)
(30,000.00)
(42,500.00)
(127,500.00)
232,000.00 455,000.00 (335,000.00)
50,000.00 (65,000.00)
(325,000.00)
(260,000.00)
(65,000.00)
(100,000.00)
903,000.00 (700,000.00)
15,000.00 (25,000.00)
(20,000.00)
(20,000.00)
(175,000.00)
(20,000.00)
(30,000.00)
(2,000,000.00)
(250,000.00)
(250,000.00)
(250,000.00)
(700,000.00)
(800,000.00)
(500,000.00)
(750,000.00)
(100,000.00)
(367,500.00)
(750,000.00)
(250,000.00)
(300,000.00)
(250,000.00)
(200,000.00)
(750,000.00)
(200,000.00)

(110,000.00)
(110,000.00)
(280,000.00)
-
(110,000.00)
(190,000.00)
-
(110,000.00)
(190,000.00)
-
(110,000.00)
(190,000.00)
(100,000.00)
(100,000.00)

-
92,000.00 (100,000.00)
144,000.00 (150,000.00)
80,000.00 (75,000.00)
280,000.00 (25,000.00)
25,000.00 (25,000.00)
-
50,000.00 (47,500.00)
50,000.00 (47,500.00)
50,000.00 (47,500.00)
250,000.00 (250,000.00)
50,000.00 (47,500.00)
45,000.00 (45,000.00)
(200,000.00)
(150,000.00)
(100,000.00)
(100,000.00)
(385,000.00)
(800,000.00)
(83,000.00)
(25,000.00)
(12,500.00)
80,000.00 (45,000.00)
(37,500.00)
(170,000.00)
40,000.00 (2,500.00)
(127,500.00)
(87,500.00)
(115,000.00)
328,000.00 (125,000.00)
(62,500.00)
(200,000.00)
(50,000.00)
30,000.00 (62,500.00)
(100,000.00)
(46,250.00)
(100,000.00)
(100,000.00)
(250,000.00)
70,000.00 (32,500.00)
(67,500.00)
(50,000.00)
(250,000.00)
(20,000.00)
(62,500.00)
(100,000.00)
(140,000.00)
(50,000.00)
(100,000.00)
(25,000.00)
(5,500.00)
(87,500.00)
150,000.00 293,000.00 (147,500.00)
30,000.00 34,000.00 (20,000.00)
(85,000.00)
16,000.00 (25,000.00)
(35,000.00)
(75,000.00)
(91,000.00)
120,000.00 Perbedaan Reguler dan Khusus
50,000.00 Perbedaan Reguler dan Khusus
(100,000.00)
(87,500.00)
25,000.00 (300,000.00)
25,000.00 3,500.00
(70,000.00)
(47,500.00)
30,000.00 (50,000.00)
270,000.00 (51,500.00)
210,000.00 (42,500.00)
(147,500.00)
(100,000.00)
(150,000.00)
(147,500.00)
(75,000.00)
(35,000.00)
(20,000.00)
(50,000.00)
(15,000.00)
(150,000.00)
35,000.00 (150,000.00)
(200,000.00)
15,000.00 (20,000.00)
20,000.00 (30,000.00)
(37,500.00)
(50,000.00)
(37,500.00)
(20,000.00)
(400,000.00)
(17,500.00)
(35,000.00)
(375,000.00)
150,000.00 975,000.00
(250,000.00)
(275,000.00)
(75,000.00)
(300,000.00)
850,000.00
(100,000.00)
50,000.00 (35,000.00)
(67,500.00)
(275,000.00)
(139,000.00)
(75,000.00)
(134,000.00)
184,000.00 (245,000.00)
325,000.00 475,000.00 (425,000.00)
(125,000.00)
(90,000.00)
230,000.00 -
250,000.00 (118,500.00)
(25,000.00)
(40,000.00)
(15,000.00)
20,000.00 34,000.00 2,500.00
328,000.00 (125,000.00)
(62,500.00)
(200,000.00)
(200,000.00)
(50,000.00)
681,000.00 (500,000.00)
371,000.00 (200,000.00)
723,000.00 (600,000.00)
413,000.00 (300,000.00)
15,000.00 (5,000.00)
6,000.00 (2,500.00)
15,000.00 (3,750.00)
(125,000.00)
(50,000.00)
80,000.00 (100,000.00)
(97,500.00)
(50,000.00)
(50,000.00)
(50,000.00)
30,000.00 (35,000.00)
70,000.00 (75,000.00)
50,000.00 (60,000.00)
(62,500.00)
(100,000.00)
(20,000.00)
(12,500.00)
(25,000.00)
(87,500.00)
(150,000.00)
(217,500.00)
(30,000.00)
(7,500.00)
(50,000.00)
150,000.00 (150,000.00)
10,000.00 (50,000.00)
70,000.00 (100,000.00)
(70,000.00)
(42,500.00)
(170,000.00)
(15,000.00)
(56,500.00)
8,500.00
(131,500.00)
(67,500.00)
(41,000.00)
(9,000.00)
(7,000.00)
(35,000.00)
(137,500.00)
(425,000.00)
(220,000.00)
67,000.00 115,000.00 (10,000.00)
30,000.00 82,000.00 (10,000.00)
(48,500.00)
50,000.00 (50,000.00)
(42,500.00)
(200,000.00)
(200,000.00)
(3,000,000.00)
(250,000.00)
(250,000.00)
(900,000.00)
(2,500,000.00)
(35,000,000.00)
(15,000.00)
(42,500.00)
(90,000.00)
75,000.00 (40,000.00)
50,000.00 (55,000.00)
50,000.00 (20,000.00)
(75,000.00)
(85,000.00)
50,000.00 (55,000.00)
100,000.00 (185,000.00)
73,000.00 (22,500.00)
(130,000.00)
1,100,000.00 (900,000.00)
1,000,000.00 (445,000.00)
200,000.00 (250,000.00)
(50,000.00)
(320,000.00)
(130,000.00)
(475,000.00)
100,000.00 81,000.00 (70,000.00)
(130,000.00)
280,500.00 (165,000.00)
560,000.00 (390,000.00)
(300,000.00)
275,000.00 326,500.00 (210,000.00)
326,500.00 (215,000.00)
200,000.00 280,500.00 (165,000.00)
326,500.00 (165,000.00)
200,000.00 186,000.00 (140,000.00)
125,000.00 326,500.00 (90,000.00)
280,500.00 (165,000.00)
326,500.00 (240,000.00)
(20,000.00)

(50,000.00)
(40,000.00)
(200,000.00)
(175,000.00)
(20,000.00)
(10,000.00)
(16,000,000.00)
(9,500.00)
(675,000.00)
(400,000.00)
(400,000.00)
(500.00)
(1,000.00)
(250,000.00)
(500,000.00)
(1,000,000.00)
(100,000.00)
(105,000.00)
(100,000.00)
(100,000.00)
BESARAN RP YANG HARUS DISUBSIDI (197,130,493.33)

JIKA MASIH MENERAPKAN TARIF LAMA
bedaan Reguler dan Khusus
KATAGORI OPERASI PADA BEDAH SENTRAL
NO KATAGORI OPERASI
I Operasi Kecil
1 Antroscopy (AWO)
2 Beloq Tampon Hidung
3 Biopsi Nasopharyng (Narkose Umum)
4 Buka Tampon Belok
5 Curetage
6 CWL
7 Debridemant dan Nekrotomi Luka Minor
8 Debridemant Kecil
9 Dilatasi Anus
10 Drainase Abses
11 Eksisi Veruca, Clavus, Nevus
12 Eksterpasi Etheroma Palpebra
13 Eksterpasi Kista Koncungtiva
14 Ekstirpasi Bronchial Kista
15 Ekstirpasi Dermoid
16 Ekstirpasi Ganglion
17 Ekstirpasi Granulasi CAE
18 Ekstirpasi Keloid CAE
19 Ekstirpasi Kista Atheroma
20 Ekstirpasi Kista Bibir
21 Ekstirpasi lipoma
22 Ekstirpasi Polipektomi
23 Ekstirpasi Pterigyum tanpa Graff Conjungtiva
24 Ekstirpasi Veruka
25 Ekstirpasi Xantelasma Kecil
26 Ekstraksi Korpus Alienum Hidung
27 Esophagoscopy (corpus alienum)
28 Injeksi Intra Vitreal
29 Insisi Abses
30 Insisi Abses Mastoid
31 Insisi OtoHematoma
32 Irigasi Abses Retrofaringeal
33 Irigasi Hematoma Septum Nasi
34 Irigasi Sinus Maksilaris
35 Kauter Luxatio Konka
36 Laringoskopi Fiber Optik
37 Laringoskopi Laring
38 Orchidektomi dengan lokal
39 Pasang Skeletal Traksi
40 Pasang Skin Traksi
41 Pasang Tampon Posterior Hidung
42 Pasang WSD/ Chest tube
43 Phymosis dengan lokal
44 Reposisi Fraktur Hidung
45 Reposisi Fraktur Nasal Tertutup
46 Roserplasty
47 Rupture Palpebra Simlpey
48 SBL/ Tarsotomi
49 Sirkumsisi dengan lokal
50 Tumor < 2cm
51 Vasektomi dengan lokal
II Operasi Sedang
1 Adenoidektomi
2 Amputasi Phalang
3 Antrostomi
4 Appendiktomi Akut/ Kronis
5 Biopsi Tumor
6 Bone Open Biopsi
7 Cimino
8 Cryosurgery
9 Debridement dan Nekrotomi Luka Mayor
10 Debridement fraktur terbuka pada anak
11 Debridement Sedang
12 Eksisi Crinekomastia
13 Eksisi Ganglion/ Lipoma, Atheroma, Granuloma + narkose
14 Eksisi Hemangioma < 5cm
15 Eksisi Keloid Sedang
16 Eksisi Mammae aberan
17 Eksisi Multiple Veruka
18 Eksisi Tumor
19 Eksisi tumor jaringan lunak ukuran kecil
20 Eksisi tumor Punggung < 5 cm
21 Eksterpasi Corpal Cornea dengan Penjahitan
22 Ekstirpasi Bursitis
23 Ekstirpasi FAM
24 Ekstirpasi Funicocele
25 Ekstirpasi Poliprekti
26 Ekstirpasi Pterygium dengan Graff Conjungtiva
27 Ekstirpasi Tumor < 5 cm
28 Ekstirpasi Xantelasma Sedang
29 Ekstripasi Preaurikular Kista
30 Esktirpasi Lymphadenopati
31 Esktirpasi Lymphadenopati colli
32 FAM Sincole
33 Gips Body Jacket
34 Herniotomi Anak
35 Herniotomi Incruinal
36 Injeksi botoks pada kasus cerebral palsy
37 Insisi Sub Mandibula Abses
38 Iridektomi Perifer
39 Konkotomi
40 Laringoskopi Terapi
41 Mammae Aberans
42 Mayor Degloving, Wound debridement of the spine
43 Meatotomi
44 Orchidektomi + Narkose
45 Orchidektomi Bilateral
46 Palomo Prosedure
47 Parasentese Hyperma
48 Penjahitan Margo Palpebra tanpa Avulsi
49 Phymosis + Narkose
50 Polipektomi Nasal
51 Release Compartment Syndrome+debridement
52 Remove implant kwire dengan anestesi regional/ block
53 Remove implant kwire dengan narkose
54 Repair Palatum
55 Reposisi Fraktur Nasal Terbuka tidak Kompleks
56 Revisi Jaringan Parut
57 Rupture Kornea Simplex
58 Rupture Palpebra Multilpe
59 Simblevarektomi dan Graf Konyungtiva
60 Tonsilektomi
61 Tonsilektomi dan Adenoidektomi
62 Tracheostomy
63 Trakeostomi
64 Tumor Payudara < 5 cm
65 Vasektomi + Narkose
66 Vitrektomi Anterior
67 Vulvus Multiple + Narkose
III Operasi Besar

1 Amputasi Ekstremitas Atas
2 Amputasi/ repair stump finger
3 Appendiktomi Perforata
4 Bleparoplasti
5 Bronchoscopy Terapi
6 Cholesistektomi
7 Colostomy/ Ileostomi
8 Debridement + Gangren DM
9 Debridement + Luka Bakar
10 Debridement + Nekrotomi necrotic tissue > 1 kompartemen
11 Debridement + rekontruksi
12 Debridement finger injury
13 Debridement Luas
14 Debridement open reduction Fiksasi
15 Disekti Tumor Axila
16 Drainage deep infection finger
17 Drainage Infeksi Abses Leher Dalam
18 Drainage superficial infection
19 ECCE/ICCE/SICS
20 Eksisi Hemangioma > 5 cm
21 Eksisi Kelenjar Sub Maksilaris (Sub Lingualis)
22 Eksisi Keloid Multiple
23 Eksisi Kista Kongenital (Brachyal Cyst)
24 Eksisi Mammae Oberon Bilateral
25 Eksisi Polidactily
26 Eksisi Skar Multiple
27 Eksisi Tattoo tanpa skin graft
28 Eksisi tumor buli-buli
29 Eksisi Tumor Punggung > 5 cm
30 Eksisi wart/ corn/ Naevus di jari
31 Eksplorasi Luka tembak
32 Eksplorasi Luka tusuk + Narkose
33 Ekstirpasi Lipoma > 5 cm
34 Ekstripasi Xantelasma dan Skin Graff
35 Esophagoscopy Terapi
36 Ethmodiektomi Eksterna
37 Eviserassi Enukleasi
38 Excisi Tumor Colli
39 Facet Block 1 Level
40 FAM Bilateral
41 FAM Multiple
42 Fiksasi Rahang Atas reduksi termurup
43 Fistulektomi
44 Ganglion Poplitea
45 Glosektomi Partial
46 Haemorridektomy Konvensional
47 Herniotomi + MESS
48 Herniotomi inkarserata
49 Herniotomi Scrotalis
50 Herniotomi Umbilicalis
51 Hidroselectomy
52 Jahit Kornea dengan Reposisi/Gunting Iris
53 Jahit Margo dengan Avulsi Pelpebra
54 Jahit Palpebra dengan Reposisi Saluran Air Mata
55 Labio/Palatoskisis
56 Labioplasty
57 Labirintektomi
58 Laringoscopy Terapi
59 Limb Ablasi 1 jari
60 Lip Shave
61 Mandibulektromi Partial
62 Manipulation & Reduction of simple spine fracture and dislocation with GA
63 Mastoidektomi Simple
64 Mikro Laringoskopi
65 Multiple Vulnus Laceratum + Narkose
66 Operasi Cadwell Luc
67 Otoplasti
68 Penjahitan Sklera, Kornea
69 Percutaneous tendon tenotomy
70 Repar nail bed laceration
71 Reposisi Fraktur Blow Out Orbita
72 Reposisi Fraktur Le Fort I
73 Reposisi Fraktur Mandibula
74 Reposisi Fraktur Nasal Kompleks Terbuka
75 Reposisi Fraktur Nasal Malar Tanpa Dasar Orbita
76 Reposisi Ptosis Pelpebra
77 Reposisi tertutup + gips pada fraktur
78 Rinotomi Lateral
79 Rupture Globe
80 Rupture Palpebra multiple dengan Reposisi Saluran Air Mata
81 Rupture Tendon
82 SC + Air ketuban warna hijau
83 SC + bilateral
84 SC + MOW
85 SC + Salpingektomy
86 SC Cito
87 SC+IUD
88 Sectio Caesaria (SC)
89 Trabekulektomi
90 Trauma muka + Vulnus multiple
91 Triple Endoskopi Diagnostik
92 Tumor Payudara > 5 cm
93 Uretrotomi
94 Vesicolitotomi
95 Wedge Resection
IV Operasi Khusus
1 Abdominoplasty
2 ACL / PCL Rekontruksi
3 Amputasi Ekstremitas Bawah
4 Anastomosis Usus
5 Appendictomi Laparoskopi
6 Arthrocopy Diagnostic
7 Arthrodesis
8 Arthroscopy Debridement knee
9 Arthroscopy diagnostic shoulder
10 Arthroscopy remove loose body
11 Biopsi Vertebrae
12 Bone bridge release pada kasus tarsal coalition
13 Bone curetage + bone graft
14 Cholesistektomi per laparoskopi
15 Close reduction & pemasangan hemispica fraktur femur pada anak
16 Corrective Ostetomy Surgery
17 Craniotomi
18 Debrdement + Laminektomi + Stabilisasi Pasterior Spind
19 Debridement + Sinovektomy
20 Debridement + Skin graft
21 Debridement + Synevectomy
22 Dekompresi Laminektomy
23 Discektomy
24 Eksisi Hemangioma Besar + Skin Graft
25 Eksisi Tattoo + skin graft
26 Eksisi Tumor Colli Multiple
27 Eksisi tumor jinak
28 Excentrasi
29 FESS (Ethmoidektomi intranasal)
30 Fiksasi cannulated screw pada SCFE
31 Haemorridektomy + Stapler
32 Hemiarthroplasty
33 Hemicolektomi
34 Hemiglosektomi
35 Hernioraphy Bilateral
36 Hernioraphy per laparoskopi
37 Herniorapy + MESS
38 Herniotomi Inkarserata + reseksi Usus
39 Herniotomi Scrotalis Bilateral
40 IDET 1 level
41 Koneksi Syndactili / Polidactili
42 Kuretase + Bone graft
43 Labioplasty Bilateral
44 laparatomy + Peritonitis Difusa
45 Laparatomy Eksplorasi
46 Laparotomi + Trauma Abdomen
47 Maksilektomi Total Tanpa Ekstenterasi Orbita
48 Marginal margin Eksisi tumor tulang
49 Mastektomi
50 Mastoidektomi Modifikasi Radikal
51 Mentoplasti
52 Minimal invasive platting osteosinthesis
53 Miringoplasty
54 Open biopsy tumor in spine
55 Open disectomy 1 level
56 Open Prostatektomi
57 Open reduction + Internal Fiksasi (ORIF)
58 Operasi Katarak Peco
59 ORIF Fraktur
60 Osteotomi
61 Parotidektomi
62 Phaco Emulsifikasi
63 Posteromedial Release CTEV
64 Rekontruksi Malunion Fraktur
65 Release Carpal Tunnel Syndrome
66 Release Kontraktur
67 Release Trigger Finger (Multipel)
68 Remove Implant in spine
69 Repair Tendon Multipel
70 Reposisi dan Fiksasi Fraktur Mandibula/ Maksilla
71 Reposisi Fraktrur Le Fort II, III
72 Reposisi tertutup & percutaneous pinning pada fracture seputar sendi siku
73 Reposisi tertutup, arthogram & hemispica pada DDH
74 Reseksi Mandibula/ Maksilla
75 Rhinoplasty Augmentasi
76 Rupture Arteri, Vena dan Nervus
77 Rupture Tendon Multiple
78 Salpingho-ovarektomi Bilateral/ SOB laparoscopi
79 Salpingooverektomi Unilateral/ SOD/ SOS
80 Septoplasti
81 Sirkumsisi
82 Skin graft luas
83 Splenektomi/ Nefrektomi
84 Thoracotomy + Hemato Thorax
85 Thyroidektomi
86 Total Hip Replacement (THR)
87 Total Knee Replacement (TKR)
88 Total Patellectomy
89 Trauma rectum (stradel Injury)
90 Triple Procedure
91 Ureterolithotomi
92 Vitruetomi Postarior
93 Wide Excidion Tumor
REKAP TARIF RS RUJUKAN
1 Tarif IGD
2 Tarif Rawat Jalan
3 Tarif Rawat Inap
4 Tarif HCU/ICU/ICCU/NICU/PICU
5 Tarif Bedah Sentral
6 Ruang Bersalin (VK)
7 Tarif MCU
8 Tarif laboratorium Patologi Klinik
9 Tarif laboratorium Patologi Anatomi
10 Tarif Radiologi
11 Tarif Rehabilitasi Medik
12 Tarif Pemeriksaan Visum, Pemulasaraan Jenazah & Forensik
13 Tarif Tindakan Medis Non Operatif/Invasif
14 Tarif Tindakan Medis Operatif/Invasif
15 Tarif Sewa Alat Medis
16 Tarif Ambulance, Kendaran Jenazah & Kendaraan Lain
17 Tarif Diklat Dan Bimbingan Teknis
18 Tarif Sewa Fasilitas Rumah Sakit
19 Tarif Lain-lain
1 mohon urutkan tindakan berdasarkan abjad di setiap kelompok tindakan

2 tarif psikiater seperti tindakan psikometri, belum ada.
TARIF RUMAH SAKIT UMUM PROVINSI BANTEN
I TARIF IGD
JASA JASA
NO URAIAN
SARANA PELAYANAN
1 Pemeriksaan oleh Dokter Umum IGD 30,000 30,000
3 Pemeriksaan, Konsultasi Dokter Spesialis 30,000 50,000

JASA JASA
NO URAIAN
SARANA PELAYANAN
1 Pemeriksaan/ konsultasi di Poliklinik 20,000 30,000

JASA JASA
NO URAIAN
SARANA PELAYANAN
1 RUANG RAWAT INAP STANDAR (III) 42,000 30,000
2 RUANG RAWAT INAP DELUXE (II) 65,000 60,000
3 RUANG RAWAT INAP SUITE 115,000 60,000
4 RUANG RAWAT INAP MASTER 255,000 60,000
5 RUANG RAWAT INAP GRAND MASTER 350,000 60,000
6 RUANG RAWAT INAP ISOLASI 115,000 60,000
7 RUANG VK 115,000 60,000
8 ONE DAY CARE (ODC) 115,000 60,000
9 RAWAT OBSERVASI KEGAWATDARURATAN 115,000 60,000
10 RUANG PERAWATAN PASCA OPERASI 115,000 60,000
11 RUANG PERAWATAN KESEHATAN JIWA 175,000 60,000
12 RUANG PERINATOLOGI 115,000 60,000
JASA
NO URAIAN AKOMODAS
PELAYANAN
I
1 PERAWATAN REGULER 350,000 100,000
2 PERAWATAN KHUSUS 400,000 150,000
JASA
NO URAIAN AKOMODAS
PELAYANAN
I
1 OPERASI KECIL 550,000 600,000
2 OPERASI SEDANG 1,000,000 2,000,000
3 OPERASI BESAR 2,000,000 3,000,000
4 OPERASI KHUSUS 3,500,000 4,500,000
* pada tindakan cito jasa pelayanan ditambah 25% dari jasa pelayanan elektif
Pada tindakan medik operatif dengan 2 operator atau lebih dengan sub sepesialisasi berbeda, maka jasa
pelayanan operator masing-masing 100 %,
VI TARIF MCU
JASA
NO URAIAN AKOMODAS
PELAYANAN
I
1 Pemeriksaan untuk surat keterangan sehat 5,000 30,000
2 Pemeriksaan Kesehatan Standard
Terdiri dari :
c. LAB Sederhana (Urine Lengkap + Darah Lengkap)
3 MCU Paket I
Terdiri dari :
c. EKG
d. LAB Sederhana (Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT, SGPT) +
GDS + Fungsi Ginjal + Kolesterol Total)
4 MCU Paket II
Terdiri dari :
e. EKG
f. LAB Sederhana (Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,SGPT, Gamma GT)+
GDS, GDP + Fungsi Ginjal (Ureum, Kreatinin) + Fungsi Lemak
(Kolesterol Total, HDL, LDL, Trigliserida) + Hepatitis (HbsAG/strip)
5 MCU Paket III
Terdiri dari :
c. Pemeriksaan Mata
d. Pemeriksaan THT
e. EKG
f. LAB :
- LAB (Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,SGPT, Gamma GT)+
- Anti HBS
- Asam Urat
6 MCU Paket IV
Terdiri dari :
c. Pemeriksaan Mata
d. Pemeriksaan Ginekologi (Khusus Wanita)
e. Pemeriksaan THT
f. Pemeriksaan Thorax Photo
g. USG Abdomen Lengkap
h. Gizi
i. EKG
j. LAB :
- LAB (Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,SGPT, Gamma GT)+
- Anti HBS
- Asam Urat
JASA
NO JENIS PEMERIKSAAN / TINDAKAN AKOMODAS
PELAYANAN
I
1 Darah rutin (Micros) 20,000 6,667
2 Darah lengkap ( ABX Pentra) 30,000 10,000
3 Hitung jenis leukosit 15,000 5,000
4 LED 6,000 2,000
5 Golongan darah (ABO + Rhesus) 9,500 3,167
6 Retikulosit 9,000 3,000
7 Hitung eosinofil 19,000 6,333
8 Gambaran darah tepi 15,000 5,000
9 Malaria/filaria 15,000 5,000
10 Sel LE 25,000 8,333
11 IT Rasio 24,000 8,000
-
URINALISIS -
1 Urin lengkap (Rutin + Sedimen) 20,000 6,667
2 Reduksi urin/protein urin (3 parameter) 12,000 4,000
3 Protein kuantitatif 24,000 8,000
4 Protein Bence Jones 16,000 5,333
5 Tes Kehamilan (25 mIU/mL) 16,000 5,333
-
-
HEMOSTASIS -
1 Masa Perdarahan 8,000 2,667
2 Masa Pembekuan 8,000 2,667
3 Masa protrombin (PT) 48,000 16,000
4 PT + INR 48,000 16,000
5 APTT 56,000 18,667
6 Fibrinogen 80,000 26,667
7 D-dimer 152,000 50,667
-
TINJA -
1 Lengkap (Rutin + pH + Reduksi) 16,000 5,333
2 Darah samar 24,000 8,000
-
KIMIA DARAH -
1 SGOT 15,000 5,000
2 SGPT 15,000 5,000
3 Bilirubin total 15,000 5,000
4 Bilirubin direk 15,000 5,000
5 Bilirubin indirek 15,000 5,000
6 Gamma GT 24,000 8,000
7 ALP 20,000 6,667
8 Protein total 16,000 5,333
9 Albumin 16,000 5,333
10 Globulin 16,000 5,333
11 Ureum 16,000 5,333
12 Kreatinin 16,000 5,333
13 Kreatinin clearance 32,000 10,667
14 Asam urat 16,000 5,333
15 Kolesterol total 16,000 5,333
16 Trigliserida 16,000 5,333
17 Kolesterol HDL 20,000 6,667
18 Kolesterol LDL 20,000 6,667
19 Glukosa darah stik 16,000 5,333
20 Glukosa darah 16,000 5,333
21 TTGO (5x GDS) 80,000 26,667
22 CK-total 72,000 24,000
23 CK-MB 72,000 24,000
24 Na, K, Cl (elektrolit darah) 64,000 21,333
25 Kalsium (Ca) 24,000 8,000
26 Fosfor 20,000 6,667
27 Magnesium 24,000 8,000
28 Analisa Gas Darah 80,000 26,667
29 Analisa Gas Darah + elektrolit 160,000 53,333
30 HBA1c 80,000 26,667
-
-
IMUNOSEROLOGI -
1 HBsAg rapid 32,000 10,667
2 HBsAg Elisa 60,000 20,000
3 Anti HBs 32,000 10,667
4 Anti HBs (elisa) 68,000 22,667
5 Anti HCV 48,000 16,000
6 Widal 28,000 9,333
7 PAP TB 52,000 17,333
8 VDRL 24,000 8,000
9 RF ( Rheumatoid Factor) 24,000 8,000
10 Anti Dengue IgM, IgG 112,000 37,333
11 TPHA 24,000 8,000
12 Anti HIV (rapid) 100,000 33,333
13 Anti HIV (ELISA) 100,000 33,333
14 HIV Western Blot* 640,000 213,333
15 ASTO 24,000 8,000
16 CRP kualitatif 24,000 8,000
17 CRP kuantitatif 64,000 21,333
18 NS1 120,000 40,000
19 IgM anti Salmonella (Tubex) 100,000 33,333
-
MIKROBIOLOGI -
1 Pewarnaan Gram 14,400 4,800
2 Pewarnaan BTA 1x 14,400 4,800
3 Cultur dan Resistensi test 280,000 93,333
-
CAIRAN TUBUH -
1 Analisa cairan otak 80,000 26,667
2 Analisa sperma 56,000 18,667
3 Analisa cairan sendi 80,000 26,667
4 Analisa cairan tubuh lain (pleura dll) 80,000 26,667
-
NARKOBA -
1 Tes Narkoba 3 parameter 80,000 26,667
2 Tes Narkoba 6 parameter 160,000 53,333
VIII TARIF LABORATORIUM PATLOGI ANATOMI
JASA
PELAYANAN
I
1 KECIL 65,000 43,333.33
2 SEDERHANA 28,000 18,666.67
3 SEDANG 100,000 66,666.67
4 BESAR 130,000 86,666.67
5 CANGGIH 246,000 164,000.00
IX TARIF RADIOLOGI
JASA
PELAYANAN
I
1 Foto Thorax 48,000 32,000
2 Foto thorax AP/Lat 72,000 48,000
3 Foto Abdomen polos 54,000 36,000
4 Foto Abdomen 3 Posisi 102,000 68,000
5 Foto Cranium 69,000 46,000
6 Sinus Paranasal 66,000 44,000
7 Mastoid 69,000 46,000
8 TMJ 72,000 48,000
9 TMJ 4 posisi 105,000 70,000
10 Cervical 69,000 46,000
11 Cervical 4 posisi 102,000 68,000
12 Vertebrae AP/Lat 66,000 44,000
13 Vertebrae 4 posisi 105,000 70,000
14 Pelvis 60,000 40,000
15 Coxigeus 66,000 44,000
16 Extrimitas atas 60,000 40,000
17 Extrimitas atas bilateral 90,000 60,000
18 Extrimitas bawah 60,000 40,000
19 Extrimitas bawah bilateral 90,000 60,000
20 Bone survey 240,000 160,000
21 Scoliosis program 105,000 70,000
22 Bone age 60,000 40,000
23 Dental panoramic 72,000 48,000
24 Dental alveolar 30,000 20,000
25 mamografi 105,000 70,000
26 Thorax Mobile 72,000 48,000
27 BNO IVP 210,000 140,000
28 Cystogram 150,000 100,000
29 URETHROCYCTOGRAM 180,000 120,000
30 BNO IVP Bipolar 225,000 150,000
31 Appendicogram 135,000 90,000
32 Colon Inloop 240,000 160,000
33 HSG 240,000 160,000
34 Fistulografi 210,000 140,000
35 Cor analysis 150,000 100,000
36 OMD 180,000 120,000
37 ERCP 210,000 140,000
38 GUIDE FLUOROSCOPHY 108,000 72,000
39 USG Abdomen 85,000 56,667
40 USG Abdomen Lengkap 135,000 90,000
41 USG Tyroid 135,000 90,000
42 USG Mamae 135,000 90,000
43 USG Ginecology/TV/Prostast/Paru 67,500 45,000
44 USG Kandungan 66,000 44,000
45 USG Testis/Scrotum 66,000 44,000
46 USG Vascular 90,000 60,000
47 USG Transvaginal 90,000 60,000
48 USG Neonatus 90,000 60,000
49 Follow trough 210,000 140,000
50 CT Scan Abdomen Non Kontras 420,000 280,000
51 CT Scan Thorax Non Kontras 420,000 280,000
52 CT Scan Kepala Non Kontras 420,000 280,000
53 CT Scan abdomen Kontras 660,000 440,000
54 CT Scan Thorax Kontras 660,000 440,000
55 CT Scan Kepala Kontras 660,000 440,000
JASA
PELAYANAN
I
1 EXERCISE 20,000 13,333.33
2 SWD 11,000 7,333.33
3 MWD 10,000 6,666.67
4 IR 7,500 5,000.00
5 ES 9,000 6,000.00
6 USD 9,000 6,000.00
7 TENS 11,000 7,333.33
8 LASER 17,000 11,333.33
9 NEBULIZER 17,000 11,333.33
10 LUMBAL TRAKSI 15,000 10,000.00
1 REGULER 200,000 133,333
2 EXECUTIVE 600,000 400,000
3 REUSED REGULER 450,000 300,000
4 REUSED EXECUTIVE 450,000 300,000
XII TARIF TINDAKAN MEDIS
JASA
NO JENIS TINDAKAN AKOMODAS
PELAYANAN
I
A TINDAKAN KEPERAWATAN
1 TINDAKAN SEDERHANA 15,000 5,000
Supresi laktasi, perawatan kuku
irigasi telinga, spoling NGT, irigasi mata
oral hygine, suntik vaksinasi, personal
hygine, observasi PH, Hyperglycemia, Hypo
Injeksi IV, IC SC, Management cardiac shock
Pasang Infus
2 TINDAKAN KECIL 15,000 25,000
Pemberian obat intra spinal, NGT, dressing
wound care, parenteral nutrisi,
enteral nutrisi, pemasangan spalk bidai
Pengambilan darah arteri, phlebotomy
umbilical line, irigasi bladder, intubasi gastro
intestinal, bowel, irigasi luka, prolap recti,
Ransel Verban, tindik,penanganan kejang,
Perawatan luka bakar
3 TINDAKAN BESAR 33,000 30,000
Catheterisasi, Distraksi, jahit luka, Intravenous
Pengambilan darah arteri
Bilas lambung,
4 TINDAKAN KHUSUS 59,000 50,000
Venasecsi, RJP, ETT, CVC, manual placenta
hecting perineum.
Tindakan DC Shock
B TINDAKAN KEBIDANAN
1 Vaginal Touche (VT) 12,000 8,000
2 Dopler 9,000 6,000
3 Observasi /RR 8,000 5,333
4 Pasang Chateter 21,000 14,000
5 Lepas Chateter 12,000 8,000
6 Pasang Chateter ( Ret Urine ) 21,000 14,000
7 Gelang identitas pasien 5,000
8 Perawatan tali pusat 13,000 8,667
9 Slem Peumosuction 10,000 6,667
10 Rawat luka 26,000 17,333
11 Pasang infus dewasa 13,000 8,667
12 Pasang infus anak 13,000 8,667
13 Injeksi 10,000 6,667
14 Tranfusi darah 13,000 8,667
15 Rekam ECG 12,000 8,000
16 Pasang IUD 32,000 21,333
17 Lepas IUD 18,000 12,000
18 Scurent 12,000 8,000
19 Memasang tampon 26,000 17,333
20 Melepas tampon 12,000 8,000
21 Jahit luka < 5 28,000 18,667
22 Visum Kekerasan 55,000 36,667
23 Visum Perkosaan 60,000 40,000
24 Resusitasi bayi 60,000 40,000
25 Explorasi vagina 20,000 13,333
26 Jahit luka 5-15 LA 36,000 24,000
27 NST 15,000 10,000
28 Resusitasi dewasa 60,000 40,000
29 Pasang infus drip 13,000 8,667
30 Biopsi CA servik 29,000 19,333
31 Hydrotubasi 25,000 16,667
32 Jahit luka kusus / jahit luka portio 40,000 26,667
33 Incisi abses bartoli 54,000 36,000
34 Mikro kuret 29,000 19,333
35 Partus normal 105,000 70,000
36 Couterisasi 52,000 34,667
37 Presipitatus 80,000 53,333
38 Plasenta manual 34,000 22,667
39 Kuret late HPP 51,000 34,000
40 Kuret plasenta manual 51,000 34,000
41 Kuret abortus incomplet 51,000 34,000
42 Kuret mola 51,000 34,000
43 Incisi himen 34,000 22,667
44 Partus normal drip 120,000 80,000
45 Kuret menometorargi 30,000 20,000
46 Repair perineum 66,000 44,000
47 Exterpasi polip 50,000 33,333
48 Incisi LA 40,000 26,667
49 Kuret late HPP Anestasi 50,000 33,333
50 Partus gemeli spontan 138,000 92,000
51 Vacum Extraksi 120,000 80,000
52 Partus spontan bracht 130,000 86,667
53 Manual aid ekstraksi kaki 132,000 88,000
54 Douglas punksi 30,000 20,000
55 Biopsi servik 60,000 40,000
56 Incisi Marsupilisasi 30,000 20,000
57 Kuret abortus incomplet + anestesi 150,000 100,000
58 Kuret LA non operatif sederhana 250,000 166,667
59 Kuret LA operatif sedang 350,000 233,333
60 Angkat jahitan 35,000 23,333
61 O2 1-3L/M/jam 25,000
62 O2 4-6L/M/jam 35,000
63 O2 6-8L/M/jam 45,000
64 O2 8-10L/M/jam 55,000
65 O2 > 10 L per jam 65,000
66 OBS & operasi kecil LA 80,000 53,333
67 Pasang pesarium 20,000 13,333
68 Melepas Stent / drain 17,000 11,333
69 Memasukkan obat sitostatika 35,000 23,333
70 pap smir 60,000 40,000
71 Lepas pasang susuk 50,000 33,333
72 Hecting skunder PD : Labia 50,000 33,333
73 Pemakaian slem suction 10,000 6,667
74 Merawat luka tanpa hecting 25,000 16,667
75 Ambil darah arteri - anak 30,000 20,000
76 Ambil darah arteri - dewasa 25,000 16,667
77 Pasang / lepas Lamineria 20,000 13,333
78 Ekstirpasi tumor labia 70,000 46,667
79 Ekstirpasi polip servik 150,000 100,000
80 Stradle Injury 55,000 36,667
81 Jahit luka perinium 60,000 40,000
TINDAKAN MEDIS NON OPERATIF NON INVASIF

1 Perawatan Luka Kecil diameter < 5 cm 15,000 10,000
2 Perawatan Luka sedang diameter 5- 15 cm 20,000 13,333
3 Perawatan luka besar diameter > 15 cm 30,000 20,000
4 Perawatan Luka Bakar per hari
a. Luka Bakar < 20 % 80,000 53,333
b. Luka Bakar 21-30 % 130,000 86,667
c. Luka Bakar > 30 % 250,000 166,667
5 Luka Khusus per hari
a. Gangren luas 90,000 60,000
b. Steven johnson 130,000 86,667
6 Perawatan Luka tracheostomi 25,000 16,667
7 Pasang bidai fraktur
a. Sedang 50,000 33,333
b. Besar 60,000 40,000
8 Pasang ransel verband 70,000 46,667
9 Pasang skin traksi 90,000 60,000
10 Lepas Tampon Haemorhoid 15,000 10,000
11 Pasang Tampon Haemorhoid 25,000 16,667
12 Lepas Drain 12,000 8,000
13 Lepas WSD Non Paru 50,000 33,333
14 Pasang & lepas infus / hari
a. Infus Standar 3,750 2,500
b. Infus Umbilikalis 30,000 20,000
c. Infus sitostastika 45,000 30,000
15 Huknah/ glyseril/ hari 15,000 10,000
16 Incisi abses kecil 30,000 20,000
17 Injeksi IC, SC, IM / hari 3,750 2,500
18 Bilas Lambung 30,000 20,000
19 Irigasi / spoeling catheter 30,000 20,000
22 Pasang dan Lepas Schoorsteen 15,000 10,000
25 Pasang dan Lepas NGT 40,000 26,667
26 Pasang dan Lepas NGT dengan Penyulit 60,000 40,000
27 Pasang dan Lepas ETT 180,000 120,000
28 Venasectie 180,000 120,000
30 Exterpasi 30,000 20,000
C TINDAKAN KEGAWAT DARURATAN

1 Manipulasi & Reposisi fraktur 150,000 100,000
2 Memasang Gips Nasal 12,000 8,000
3 Memasang Uslyp Verband 84,000 56,000
4 Memasukkan cytostatika per 1 18,000 12,000
5 Pengambilan darah arteri 12,000 8,000
6 Rawat luka bakar : <15% 10,290 6,860
7 Rawat luka bakar : 15-30% 14,700 9,800
8 Slem / pneumo suction 4,410 2,940
9 Sling / bandage 20,580 13,720
10 Tampon hidung depan,LA 20,580 13,720
11 U sleb 7,350 4,900
12 Ambulance charge per km 7,350 4,900
13 Angkat Drain thorax 4,410 2,940
14 Baca Ecg 4,410 2,940
15 Circumcici 147,000 98,000
16 Memasang rek verband 36,750 24,500
17 Memasukkan obat sitostatika 29,400 19,600
18 Pasang NGT 44,100 29,400
19 Pemakaian oksigen / 1/2 tabung 3,000 2,000
20 Pengambilan Cerumen 22,000 14,667
21 Rawat luka ( paket ) 14,700 9,800
22 Spooling 9,000 6,000
23 Back slap 7,500 5,000
24 Ekstrasi komedo milium 36,750 24,500
25 Exterpasi - kulit 36,800 24,533
26 Incisi abscess.LA 58,800 39,200
27 Irigasi Trauma kimia,LA 29,400 19,600
28 Konsultasi 29,400 19,600
29 Lepas kateter urine 14,700 9,800
30 Memasang / melepas tampon 44,100 29,400
31 Memasang Vellpen Verband 29,400 19,600
32 Memasukkan Obat IV/IM/SC/SUPP 4,500 3,000
33 Rectal Toucher 8,000 5,333
34 Regulasi cepat 30,000 20,000
35 Reposisi Mandibula 30,000 20,000
36 Resusitasi - dewasa 45,000 30,000
37 Ambil darah arteri/vena - anak 30,000 20,000
38 Ambil darah arteri/vena - dewasa 24,000 16,000
39 Atropinisasi 15,000 10,000
40 bulectomy / rawat jalan 20,000 13,333
41 Foto terapi - 5 hari 22,000 14,667
42 incisi luka sedang 15,000 10,000
43 Infusion pump dewasa / hari 5,000 3,333
44 Injeksi Dexsa 7,500 5,000
45 Jahit konjungtiva (loop) LA 30,000 20,000
46 Jahitan palpebra. LA 37,000 24,667
47 Lavement/ Sterilisasi usus 30,000 20,000
48 Defibrilasi 70,000 46,667
49 Dilatasi Pymoris 22,000 14,667
50 Ekstrasi Kuku 37,000 24,667
51 Kateterisasi LA 88,000 58,667
52 Kaustik kimia konka nasal 1-2 29,500 19,667
53 Memasang dolles verband 30,000 20,000
54 Memasang Ransel verband 30,000 20,000
55 Mencabut cystotomi 15,000 10,000
56 Merawat luka bakar / rendam 30,000 20,000
57 Merawat luka tanpa hetting 22,000 14,667
58 Multiple Incisi 30,000 20,000
59 O2 4-8 l/menit per jam 3,000 2,000
60 Pasang fowley catheter 30,000 20,000
61 Pasang kateter ( ret urine ) 37,000 24,667
62 Pasang spalk LA 88,000 58,667
63 Visum tindakan kekerasan 44,000 29,333
64 Amputasi sederhana distal 220,000 146,667
65 Angkat jahitan : > 20 jahitan 30,000 20,000
66 Angkat jahitan : 01-05 jahitan 10,000 6,667
67 Angkat jahitan : 06-10 jahitan 22,000 14,667
68 Body jacket - dewasa 22,000 14,667
69 EGC rekam 30,000 20,000
70 Gips jari tangan 37,000 24,667
71 Infus , drip , tranfusi 24,000 16,000
72 Injeksi Aminopilin 22,000 14,667
73 Intubasi Endotracheal 30,000 20,000
74 Jahit luka kusus 44,000 29,333
75 Konsul poli tanpa rujukan 30,000 20,000
76 Kumbah lambung ( Hm & Intoksikasi) 44,000 29,333
77 O2 3 L/ menit per jam 2,000 1,333
78 Pasang Pasarium 15,000 10,000
79 Pemakaian oksigen / tabung 4,000 2,667
80 Pengambilan benda asing THT 44,000 29,333
81 Sirkumsisi LA 147,000 98,000
82 Vena seksi 44,000 29,333
83 Ambulance 118 dalam kota 60,000 40,000
84 Angkat jahitan :11-20 jahitan 15,000 10,000
85 Extirpasi benda asing di cornea 30,000 20,000
86 Incisi luka kecil 22,000 14,667
87 Insis Abses (loop) 37,000 24,667
88 Intubasi Endotracheal 37,000 24,667
89 jahit luka < 5 jahitan LA 15,000 10,000
90 Monitor Bed side 8,000 5,333
91 Pasang infus - anak 8,000 5,333
92 Pemasangan Bidai 15,000 10,000
93 Perawatan jenazah 220,500 147,000
94 Perawatan luka ganggren 30,000 20,000
95 Cross Incisi 37,000 24,667
96 Gips sepatu - dewasa 37,000 24,667
97 Memasang gips long leg 44,000 29,333
98 Memasang sirculair gips 44,000 29,333
99 Membuat & memasang gips palk 44,000 29,333
100 Nebulizer 18,000 12,000
101 Rawat luka bakar : > 30% 147,000 98,000
102 Rawat luka operasi 30,000 20,000
103 Resusitasi - anak/bayi 74,000 49,333
104 Resusitasi cardio Pulmonal 80,000 53,333
105 Transfusi darah / paket 8,000 5,333
106 Angkat jahitan palpera 22,000 14,667
107 Close sistotomi 44,000 29,333
108 Jahit luka > 15 jahitan LA 37,000 24,667
109 Katerisasi invasif monitor 59,000 39,333
110 Lepas / pasang IUD 37,000 24,667
111 Melakukan Nekritomi 30,000 20,000
112 Merawat luka bakar / rendam 30,000 20,000
113 OBS & operasi kecil , GA 10,000 6,667
114 Observasi-RR 15,000 10,000
115 Pasang infus - dewasa 8,000 5,333
116 Rehidrasi berat 8,000 5,333
117 Respirator 44,000 29,333
120 DC Shock 50,000 33,333
121 DECOMPRESI ANAK 50,000 33,333
122 Bilas Lambung 14,758 9,838
123 Suntik Insulin 2,233 1,489
124 Buka Jahitan < 5 40,806 27,204
125 Corpus Alineum 16,362 10,908
126 Cuci Luka Besar 49,804 33,202
127 Cuci Luka Kecil 31,635 21,090
128 Ekstraksi Kuku 74,904 49,936
129 Ganti Balut Banyak 23,903 15,935
130 Ganti Balut Sedikit 14,513 9,675
131 Inhalasi 11,726 7,817
132 Jahit Luka > 5 69,311 46,208
133 Jahit Luka < 5 54,879 36,586
134 Monitor EKG 63,558 42,372
135 Necrotomy 149,617 99,745
136 Observasi Ketat 44,153 29,436
137 Pasang infus 33,445 22,297
138 Pasang Kateter 38,809 25,872
139 Pasang NGT 19,503 13,002
140 Pemasangan EKG 36,583 24,389
141 Perawatan Luka 20,216 13,477
142 Skin Tes 59,651 39,767
143 Suction 49,424 32,949
144 Resusitasi Jantung Paru 19,422 12,948
145 Pasang Spalk 16,860 11,240
146 Transfusi 29,628 19,752
147 Asuhan Keperawatan 1,778 1,186
148 Buka Kateter 18,827 12,551
TINDAKAN ANDROLOGI
1 Analisa sperma 120,000 80,000
2 Test fructosa + alpha glukosidase 150,000 100,000
3 Test anilin + hiosin 150,000 100,000
4 Washing sperm 1,500,000 1,000,000
5 Injeksi therapi hormon 120,000 80,000
6 Tindakan PLI (paternal leucocyte immunization) 540,000 360,000
7 Paket IUI (intra uterine insemimation) persiapan 1,800,000 1,200,000
XV Bayi Tabung 20,000,000 15,000,000

Ovum pick up
Embryo
Embryo ransfer
Frezzing sperma
Inseminasi
TINDAKAN MEDIS PADA GIGI & MULUT
PENAMBALAN
1 Tambal sementara 21,000 14,000
2 tambal sementara perawatan endomanual/eksterpasi 27,000 18,000
3 pulp caping 30,000 20,000
4 Pengisian perawatan endo 34,200 22,800
5 Tambal amalgam simpleks 39,000 26,000
6 Tambal amalgam kompleks 55,800 37,200
7 Tambal light curig 1 permukaan besar 132,000 88,000
8 Tambal light curig 1 permukaan kecil 75,000 50,000
9 Tambal light curig 2 permukaan besar 168,600 112,400
10 Inlay/uplay 51,600 34,400
PENCABUTAN
1 Gigi sulung topikal 24,000 16,000
2 Gigi sulung dengan suntik 27,000 18,000
3 Gigi tetap tanpa komplikasi 33,000 22,000
4 Molar 3 tanpa komplikasi 60,000 40,000
5 Molar 3 dengan komplikasi 75,000 50,000
6 SCALLING/PEMBERSIHAN KARANG GIGI (per-rahang) 25,000 50,000
TINDAKAN LAINNYA
1 Alvelectomy 45,000 30,000
2 Operculectomy 45,000 30,000
3 Frenoktomi 45,000 30,000
4 Insisi Abses Intra Oral 45,000 30,000
5 Insisi Abses Ekstra Oral 45,000 30,000
Removable Prothese :
1 Prothese Partial gigi pertama 225,000 150,000
2 Protese Partial gigi berikutnya 45,000 30,000
3 Full/prothese/rahang atas & rahang bawah 1,800,000 1,200,000
4 rebase prothese full rahang atas/bawah 360,000 240,000
5 reparasi prothese 180,000 120,000
FIXED PROTHESE
1 jacket crown all acrylic 360,000 240,000
2 Bridge acrylic metal procelin per-elemen 720,000 480,000
3 Procelin crown per-gigi 720,000 480,000
4 Full cost crown 450,000 300,000
5 Dental X-Ray 27,000 18,000
6 Gigi implant 13,000,000 3,000,000
BEDAH MULUT DENGAN ANASTESI LOKAL

1 Kecil 210,000 140,000
2 Sedang 360,000 240,000
3 Besar 468,000 312,000
4 Khusus 564,000 376,000
Tindakan medik di Ruang Operasi Bedah Sentral disesuaikan

dengan tarif bedah sentral
ORTHO
1 Pencetakan 180,000 120,000
2 Pemasangan
alat ortodonti lepas RA + RB 540,000 360,000
Alat ortodonti lepas RA/RB 405,000 270,000
alat ortodonti cekat lepas RA+RB 1,260,000 840,000
alat ortondonti cekat RA/RB 630,000 420,000
alat ortodonti cekat RA+RB 2,070,000 1,380,000
alat ortodonti cekat RA/RB 1,350,000 900,000
alat ortodonti secsional 900,000 600,000
3 Kontrol
O Ring 18,000 12,000
Br ulang 1 7,800 5,200
Br ulang 2 15,000 10,000
Br ulang 3 22,200 14,800
Power chain 1 7,800 5,200
Power chain 2 15,000 10,000
Arch Wire 1 11,400 7,600
arch Wire 2 22,200 14,800
Spiral 1 7,800 5,200
spiral 2 15,000 10,000
4 Pemasangan alat tambahan

alat ekstra oral 900,000 600,000
bate raiser posterior/anterior (removible) 180,000 120,000
plat retensi RA/RB 180,000 120,000
trans palatal acrch 180,000 120,000
lip bumper 180,000 120,000
TINDAKAN MEDIS THT

1 Perawatan Epistaxis 30,000 20,000
2 Tampon hidung 36,000 24,000
3 Spooling Sinus Maxillaris 36,000 24,000
4 Ekstraksi Corpus Alienum hidung 30,000 20,000
5 Audiometri 30,000 20,000
6 Perawatan telinga 9,000 6,000
7 Spooling Cerumen 18,000 12,000
8 Punchtie Perinchondritis 18,000 12,000
9 Parasentese telinga 18,000 12,000
10 Gips telinga 18,000 12,000
11 ECA tenggorokan 18,000 12,000
12 ECA telinga 28,800 19,200
13 Bellog tampon 69,000 46,000
14 Suction telinga 9,000 6,000
15 Evacuasi Chalesteatoma 18,000 12,000
16 Rhinoscopy posterior 12,000 8,000
17 Insisi Mastoid 60,000 40,000
18 Insisis Septum nasi 60,000 40,000
19 Insisi Abses PERITONSIL/TONSIL 24,000 36,000
20 Biopsi Cavum Nasi 45,000 30,000
21 Biopsi Nasopharyng 45,000 30,000
22 Biopsi Oropharyng 45,000 30,000
23 Angkat tampon hidung 24,000 16,000
24 Angkat jahitan
1 s/d 5 sampul 9,000 6,000
6 s/d 10 sampul 15,000 10,000
> 10 sampul dst 24,000 16,000
25 ECA hypopharinx dg inderect laryng 30,000 20,000
TINDAKAN MEDIS MATA

TINDAKAN SEDERHANA
1 Slit lamp 6,000 4,000
2 strike retinoscopy 33,000 22,000
3 funduscopy direk 15,000 10,000
4 funduscopy indirek 42,000 28,000
5 auto refraktometer 11,000 7,000
6 pemeriksaan keratometer 38,000 24,000
7 pemeriksaan biometry 38,000 25,000
8 aneltest 20,000 12,000
9 refraksi 8,000 5,000
10 flouresin test 11,000 8,000
11 schemeer test 11,000 8,000
12 tes buta warna 8,000 5,000
13 tonometer 8,000 5,000
TINDAKAN KECIL
1 epilasi 19,000 13,000
2 debridement/spoolling 38,000 25,000
3 ekspolrasi 38,000 25,000
4 ekstirpasi corpal ekstra okuler 75,000 50,000
5 ekstirpasi lithiasis 113,000 75,000
6 ekstirpasi granuloma 128,000 85,000
7 ekstirpasi millium 114,000 75,000
8 ekstirpasi nevus conjungtiva kecil 188,000 125,000
9 eekstirpasi gram kornea 113,000 75,000
10 simblevarektomi 57,000 37,000
11 penjahitan konjungtiva 188,000 125,000
12 insisi hodeoulum/khlalazion 113,000 75,000
13 insisi abses palpebra 76,000 50,000
14 injeksi subconjungtiva 38,000 25,000
15 ekstrpasi xanthelesasma kecil 188,000 125,000
TINDAKAN SEDANG
1 eksterpasi corpal kornea dengan penjahitan 750,000 500,000
2 eksterpasi kista koncungtiva 600,000 400,000
3 eksterpasi etheroma palpebra 600,000 400,000
4 penjahitan margo palpebra tanpa avulsi 563,000 375,000
5 injeksi intra vitreal 563,000 375,000
6 ekstirpasi pterigyum tanpa graff conjungtiva 563,000 375,000
7 ekstirpasi pterygium dengan graff conjungtiva 1,125,000 750,000
8 SBL/tarrsotomi 750,000 500,000
9 ekstirpasi xantelasma sedang 750,000 500,000
10 simblevarektomi dan graf konyungtiva 1,125,000 750,000
TINDAKAN BESAR
1 jahitan margo dengan avulsi pelpebra 900,000 600,000
2 ECCE/ICCE/SICS 1,575,000 1,050,000
3 vitrektomi anterior 1,500,000 1,000,000
4 trabekulektomi 1,575,000 1,050,000
5 iridektomi perifer 1,500,000 1,000,000
6 parasentese hyperma 1,500,000 1,000,000
7 bleparoplasti 1,313,000 875,000
8 jahit kornea dengan reposisi/gunting iris 1,500,000 1,000,000
9 penjahitan sklera, kornea 1,500,000 1,000,000
10 reposisi ptosis pelpebra 1,650,000 1,100,000
11 ekstripasi xantelasma dan skin graff 1,500,000 1,000,000
12 jahit palpebra dengan reposisi saluran air mata 1,500,000 1,000,000
13 eviserassi enukleasi 1,500,000 1,000,000
TINDAKAN KHUSUS
1 operasi katarak peco 2,813,000 1,875,000
2 triple procedure 2,813,000 1,875,000
3 excentrasi 2,250,000 1,500,000
TINDAKAN MEDIS OPERATIF

1 WSD 180,000 170,000
2 PUNCTIE PLEURA 100,000 200,000
3 BIOPSI KELENJAR LEHER 100,000 150,000
4 PUNCTIE ASCITES 50,000 75,000
5 PUNCTIE LUMBAL 75,000 175,000
6 PUNCTIE SUMSUM TULANG 75,000 175,000
7 PUNCTIE BULIBULI 30,000 70,000
8 VENA SECTION 80,000 145,000
9 PUNCTIE CEPHAL HEMATOME 50,000 100,000
10 EKSISI DENGAN ANESTESI LOKAL 100,000 200,000
XIII
TARIF DIAGNOSTIK
14 ARTHROSCOPY 2,000,000 1,250,000
6 BRONCHOGRAPHY 200,000 115,000
5 BRONCHOSCOPY 250,000 200,000
13 C-ARM 200,000 120,000
9 COLONOSCOPY 250,000 200,000
11 CYSTOGRAPHY 80,000 100,000
ECHOCARDIOGRAPHY 250,000 100,000
2 EEG 150,000 100,000
1 EKG 16,000 30,000
12 ELECTROMYELOGRAPHY (EMG) 200,000 175,000
8 GASTROSCOPY 250,000 200,000
7 THORAXOSCOPY 200,000 115,000
10 TREADMILL 250,000 200,000
3 USG 50,000 40,000
4 USG 4 DIMENSI 200,000 150,000
XIV TARIF PELAYANAN PSYCHOLOGY

1 MMPI 100,000 150,000
2 INTELEGENCY TEST 20,000 30,000
3 TES KEPRIBADIAN 30,000 50,000
4 TES BAKAT 30,000 50,000
5 PSYCHOTHERAPHY 50,000 80,000
6 KONSELING PERKAWINAN 30,000 70,000
XV FORENSIK
1 PEMULASARAAN JENAZAH PEREMPUAN 700,000 200,000
2 PEMULASARAAN JENAZAH LAKI-LAKI 600,000 200,000
3 PEMERIKSAAN LUAR JENAZAH 50,000 150,000
4 PEMERIKSAAN DALAM JENAZAH (OUTOPSI) 250,000 500,000
5 PEMERIKSAAN HISTOPATOLOGIK JENAZAH 75,000 175,000
6 PEMERIKSAAN TOXICOLOGY PERJENIS 200,000 50,000
7 PEMERIKSAAN OBAT KUALITATIF PERJENIS 200,000 50,000
8 PEMERIKSAAN OBAT KUANTITATIF PERJENIS 200,000 50,000
9 PEMERIKSAAN KERANGKA 250,000 500,000
10 REKONSTRUKSI SEDERHANA 50,000 150,000
11 REKONSTRUKSI MENENGAH 75,000 175,000
12 REKONSTRUKSI LUAS 100,000 200,000
13 PENGAWETAN JENAZAH 200,000 300,000
14 PENGAWETAN JENAZAH PASCA OTOPSI 250,000 500,000
15 OTOPSI JENAZAH YANG TELAH DIKUBURKAN 750,000 1,250,000
16 SEWA KENDARAAN JENAZAH DALAM KOTA 100,000 100,000
SEWA KENDARAAN JENAZAH LUAR KOTA (TARIF DALAM
17 KOTA + Rp. 7000/KM)
18 AMBULANCE DALAM KOTA 100,000 100,000
SEWA KENDARAAN AMBULANCE LUAR KOTA (TARIF
19 DALAM KOTA + Rp. 7000/KM)
20 PERAWAT/ TENAGA MEDIS PENDAMPING PASIEN 100,000
21 SEWA KAMAR JENAZAH/ HARI 85,000 20,000
XVI LAIN-LAIN
1 JASA BIMBINGAN SISWA D3 ,S1,COAS DAN RESIDENT

DISESUAIKAN DENGAN NILAI KONTRAK KERJA SAMA
ANTARA RS DENGAN INSTITUSI PENDIDIKAN
2 SEWA AULA RS 1,000,000
3 SEWA RUANG-RUANG USAHA PER METER PERSEGI PERT 750,000
4 KUNJUNGAN STUDY BANDING PER ORANG 200,000
5 PENELITIAN DI RS PER PAKET 500,000
TARIF SEBAIKNYA TETAP SEPERTI INI MALAH JIKA MEMUNGKINKAN JASA MENJADI 30.000
60,000 Mohon verifikasi, perlu dinaikkan/diturunkan ?
80,000
TARIF MASIH LOGIS

50,000 hasil diskusi dewan
TARIF
72,000 kelas III diturunkan
125,000 kelas 2 - VVIP dinaikkan
175,000
315,000
410,000
175,000
175,000
175,000
175,000
175,000
235,000
175,000
TARIF PERAWATAN KHUSUS PERAWATAN icu YANG MEMERLUKAN TINDAKAN KHUSUS DAN DI RUANG ISO
450,000 apa perbedaan antara perawatan reguler dan khusus?
550,000 apakah harga ini sudah termasuk sewa alat atau belum (seperti pemakaian ventilator) ?
TARIF
1,150,000
3,000,000
5,000,000
8,000,000
si berbeda, maka jasa
TARIF KETERANGAN SEHAT UNTUK MELAMAR PEKERJAAN BUKAN KEREANGAN SAKIT

35,000 ditanyakan , mengapa keterangan sehat dikenakan biaya ?
150,000
350,000 PEMERIKSAAN TREADMILL TIDAK TERMASUK PAKET, DI CHARGE TERSENDIRI

apakah komponen ini sudah termasuk treatmill / audiometri ?
Jika blm termasuk treatmill, dan ada penambahan treatmill, apakah harganya akan naik lagi ?
850,000
amma GT)+
1,055,000
1,150,000
TARIF
26,667
40,000
20,000
8,000
12,667
12,000
25,333
20,000
20,000
33,333
32,000
26,667
16,000
32,000
21,333
21,333
10,667
10,667
64,000
64,000
74,667
106,667
202,667
21,333
32,000
20,000
20,000
20,000
20,000
20,000
32,000
26,667
21,333
21,333
21,333
21,333
21,333
42,667
21,333
21,333
21,333
26,667
26,667
21,333
21,333
106,667
96,000
96,000
85,333
32,000
26,667
32,000
106,667
213,333
106,667
-
42,667
80,000
42,667
90,667
64,000
37,333
69,333
32,000
32,000
149,333
32,000
133,333
133,333
853,333
32,000
32,000
85,333
160,000
133,333
19,200
19,200
373,333
106,667
74,667
106,667
106,667
106,667
213,333
TARIF
108,333
46,667
166,667
216,667
410,000
TARIF
80,000
120,000
90,000
170,000
115,000
110,000
115,000
120,000
175,000
115,000
170,000
110,000
175,000
100,000
110,000
100,000
150,000
100,000
150,000
400,000
175,000
100,000
120,000
50,000
175,000
120,000
350,000
250,000
300,000
375,000
225,000
400,000
400,000
350,000
250,000
300,000
350,000
180,000
141,667
225,000
225,000
225,000
112,500
110,000
110,000
150,000
150,000
150,000
350,000
700,000
700,000
700,000
1,100,000
1,100,000
1,100,000
TARIF
33,333
18,333
16,667
12,500
15,000
15,000
18,333
28,333
28,333
25,000
333,333
1,000,000
750,000
750,000
TARIF
20,000
40,000
63,000
109,000
20,000
15,000
13,333
35,000
20,000
35,000
5,000
21,667
16,667
43,333 apa yang dimaksud dengan PAKET ?
21,667 PAKET DIHILANGKAN
21,667
16,667
21,667 apa yang dimaksud dengan PAKET ?
20,000 PAKET DIHILANGKAN
53,333
30,000
20,000
43,333
20,000
46,667
91,667 apa perbedaannnya ?
100,000 VISUM PERKOSAAN PERLU PEMERIKSAAN SPESIALIS OBSGYN
100,000
33,333
60,000
25,000
100,000
21,667
48,333
41,667
66,667
90,000
48,333
175,000
86,667
133,333
56,667
85,000
85,000
85,000
85,000
56,667
200,000
50,000
110,000
83,333
66,667
83,333
230,000
200,000
216,667
220,000
50,000
100,000
50,000
250,000
416,667 kenapa harga nya sama ?
583,333
35,000
45,000
55,000
65,000
133,333
33,333
28,333
58,333
100,000
83,333
83,333
16,667
41,667
41,667 TINGKAT KESULITANNYA SAMA
33,333
116,667
250,000
91,667
100,000
25,000
33,333
50,000
133,333
216,667
416,667
150,000
216,667
41,667
83,333
100,000
116,667
150,000
25,000
41,667
20,000
83,333
-
6,250
50,000
75,000
25,000
50,000
6,250
50,000
50,000
25,000
66,667
100,000
300,000
300,000
50,000
250,000
20,000
140,000
30,000
20,000
17,150
24,500
7,350
34,300
34,300
12,250
12,250
7,350
7,350
245,000
61,250
49,000
73,500
5,000
36,667
24,500
15,000
12,500
61,250
61,333
98,000
49,000
49,000 apa yg dimaksud konsultasi di sini ?
24,500 bagaimana tarifnya jika pasien IGD harus dikonsulkan ke dokter spesialis ?
73,500 KONSULTASI DIHILANGKAN
49,000
7,500
13,333 NO 33 DIHILANGKAN
50,000
50,000
75,000
50,000
40,000
25,000
33,333
36,667
25,000
8,333
12,500
50,000
61,667
50,000
116,667
36,667
61,667
146,667
49,167
50,000
50,000
25,000
50,000
36,667
50,000
5,000 mengapa harga nya beda dengan no 66
50,000 DIHILANGKAN
61,667
146,667
73,333 bedanya apa dengan visum kekerasan pada kelompok tindakan kebidanan
366,667 perlu atau tidak : visum kecelakaan ?
50,000 DIHILANGKAN
16,667
36,667
36,667
50,000
61,667
40,000
36,667
50,000
73,333
50,000 maksudnya biaya apa ? Kan sudah ada rawat jalan
73,333 DIHILANGKAN
3,333
25,000
6,667
73,333
245,000
73,333
100,000
25,000
50,000
36,667
61,667
61,667
25,000
13,333
13,333 jika dalam kasus seperti anak kecil yang harus 3 kali dipasang infus (krn bengkak) , biayanya kena 1 x atau 3
25,000 jika dalam kasus seperti anak kecil yang harus 3 kali dipasang infus (krn bengkak) , biayanya kena 1 x atau 3
367,500 HANYA SATU KALI PEMBAYARAN
50,000
61,667
61,667
73,333
73,333
73,333
30,000
245,000
50,000
123,333
133,333
13,333
36,667
73,333
61,667
98,333
61,667
50,000
50,000
16,667
25,000
13,333
13,333
73,333
83,333
83,333
24,596
3,722
68,010
27,270
83,006
52,725
124,840
39,838
24,188
19,543
115,519
91,464
105,931
249,362
73,589
55,742
64,681
32,505
60,972
33,693
99,418
82,374
32,370
28,100
49,381
2,964
31,378
ini masukan dari dokter andrologi

200,000
250,000
250,000
2,500,000
200,000
900,000
3,000,000
35,000,000
apa perlu ada rincian tindakan atau tidak.
INI MERUPAKAN PAKET BAYI TABUNG
DI RS LAIN BIAYA SARANA PALING MURAH 40.000.000
35,000
45,000
50,000
57,000
65,000
93,000
220,000
125,000
281,000
86,000
40,000
45,000
55,000
100,000
125,000
75,000
75,000
75,000
75,000
75,000
75,000
375,000
75,000
3,000,000
600,000
300,000
600,000
1,200,000
1,200,000
750,000
45,000
16,000,000
350,000
600,000
780,000
940,000
300,000
900,000
675,000
2,100,000
1,050,000
3,450,000
2,250,000
1,500,000
30,000
13,000
25,000
37,000
13,000
25,000
19,000
37,000
13,000
25,000
1,500,000
300,000
300,000
300,000
300,000
Rp 50,000
Rp 60,000
Rp 60,000
Rp 50,000
Rp 50,000
Rp 15,000
Rp 30,000
Rp 30,000
Rp 30,000
Rp 30,000
Rp 30,000
Rp 48,000
Rp 115,000
Rp 15,000
Rp 30,000
Rp 20,000
Rp 100,000
Rp 100,000
Rp 60,000
Rp 75,000
Rp 75,000
Rp 75,000
Rp 40,000
Rp 15,000
Rp 25,000
Rp 40,000
Rp 50,000
10,000
55,000
25,000
70,000
18,000
62,000
63,000
32,000
13,000
19,000
19,000
13,000
13,000
32,000
63,000
63,000
125,000
188,000
213,000
189,000
313,000
188,000
94,000
313,000
188,000
126,000
63,000
313,000
1,250,000
1,000,000
1,000,000
938,000
938,000
938,000
1,875,000
1,250,000
1,250,000
1,875,000
1,500,000
2,625,000
2,500,000
2,625,000
2,500,000
2,500,000
2,188,000
2,500,000
2,500,000
2,750,000
2,500,000
2,500,000
2,500,000
4,688,000
4,688,000
3,750,000
350,000
300,000
250,000
125,000
250,000
250,000
100,000
225,000
150,000
300,000
3,250,000
315,000
450,000
320,000
450,000
180,000
350,000
250,000
46,000
375,000
450,000
315,000
450,000
90,000
350,000
-
-
250,000
50,000
80,000
80,000
130,000
100,000
-
-
900,000
800,000
200,000
750,000
250,000
250,000
250,000
250,000
750,000
200,000
250,000
300,000
500,000
750,000
2,000,000
200,000
200,000
-
100,000
105,000
HUSUS DAN DI RUANG ISOLASI ICU
an naik lagi ?
k) , biayanya kena 1 x atau 3 kali ?
k) , biayanya kena 1 x atau 3 kali ?

15 Tarif Dhabeda Contoh

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TARIF RSUD DHABEDA

I TARIF IGD Created by dr Hanna Permana Subanegara,

TARIF RUMAH SAKIT DHABEDA

II TARIF RAWAT JALAN

III TARIF FASILITAS PERAWATAN

V TARIF BEDAH SENTRAL*

Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,

VII TARIF LABORATORIUM PATOLOGI KLINIK

VIII TARIF LABORATORIUM PATOLOGI ANATOMI

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

X TARIF REHABILITASI MEDIK

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Reused Reguler 240,000

XII TARIF PELAYANAN KEPERAWATAN

JENIS PEMERIKSAAN DAN TINDAKAN JASA SARANA

Perawatan minimal yang memerlukan waktu 1 sd 2 jam per

perawatan Intermediate memerlukan waktu 3 sd 4 jam dalam

perawatan maksimal/total yang memerlukan waktu 5 sd 6 jam

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Tindakan Kecil 12,000

XIII TARIF TINDAKAN KEBIDANAN

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

XIV TARIF LAYANAN GIGI & MULUT

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

BEDAH MULUT DENGAN ANASTESI LOKAL

XV TARIF PELAYANAN MEDIS THT

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Angkat Tampon Hidung 24,000

XVI TARIF PELAYANAN MEDIS MATA

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

XVII TARIF FORENSIK

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Otopsi Jenazah Yang Telah Dikuburkan 750,000

XVIII TARIF PELAYANAN SYARAF

XIX TARIF PELAYANAN PSYCHOLOGY

XX TARIF TINDAKAN MEDIS NON INVASIF

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

XXI TARIF TINDAKAN MEDIS INVASIF

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Amputasi sederhana 225,000

XXII TARIF TINDAKAN ANDROLOGI

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Analisa sperma 120,000

XXIII TARIF SEWA ALAT

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Bed Side Monitor 30,000

XXIV TARIF DIAGNOSTIK

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

XXVI TARIF PROMOSI DAN EDUKASI KESEHATAN

XXVII TARIF LAIN-LAIN

NO JENIS PEMERIKSAAN / TINDAKAN JASA SARANA

1 Biaya Sterilisasi Alat per set 12,000

gan sub sepesialisasi berbeda, maka jasa pelayanan operator

JASA PELAYANAN TARIF BARU TARIF LAMA TARIF PESAING 1

36,000 60,000 27,500.00 38,500.00

30,000 75,000 60,000.00 82,000.00

80,000 200,000 100,000.00 202,000.00

133,000 333,000 325,000.00

20,000 50,000 27,500.00 70,000.00

250,000 420,000 250,000.00

460,000 1,160,000 1,225,000.00

225,000 561,000 500,000.00

engan tarif bedah sentral