BCP Januari 2018

Lampiran : Peraturan Gubernur Provinsi Daerah Khusus Ibukota Jakarta
Nomor :
Tanggal :
TARIF LAYANAN RUMAH SAKIT UMUM DAERAH KELAS C DAN D
USULAN TARIF
NO NAMA LAYANAN BARU
A PEMERIKSAAN DAN KONSULTASI
1 Konsultasi Spesialis by Phone (di luar jam praktek) 20,000

2 Konsultasi Gizi di Instalasi Rawat Inap 25,000
3 Konsultasi Gizi di Instalasi Rawat Jalan 25,000
4 Konsultasi Dokter Umum di Ruang Rawat Inap Isolasi dan Intensif 30,000
5 Konsultasi Emergency Spesialis by Phone (Jam 23.00 - 07.00 WIB) 30,000
6 Konsultasi Psikolog Klinis di Instalasi Rawat Jalan 30,000

7 Konsultasi Psikologi Klinis di Instalasi Rawat Inap 30,000
8 Pemeriksaan / konsultasi Dokter Umum/ Dokter Gigi 30,000
9 Konsultasi Dokter Spesialis di Ruang Rawat Inap Isolasi dan Intensif 40,000
10 Pemeriksaan / konsultasi Spesialis Internal (non DPJP) 40,000

11 Pemeriksaan / konsultasi Spesialis Perioperatif 40,000
12 Pemeriksaan / konsultasi Spesialis Rawat Inap 40,000
13 Pemeriksaan IGD 40,000
14 Pemeriksaan / konsultasi Spesialis Rawat Jalan 60,000
B INSTALASI GAWAT DARURAT
1 Injeksi 20,000
2 Injeksi TT 20,000
3 Klisma 20,000
4 Oksigen 1 - 3 Liter / Jam 20,000
5 Pasang Infus 20,000
6 Pemasangan Oropharingeal Gastric Tube 20,000
7 Aff Kateter 25,000

8 Irigasi Telinga 25,000
9 Wound Toilet Kecil 25,000
10 Observasi < 8 Jam 30,000

11 Pasang Kateter Urine 30,000
12 Pasang Spalk 30,000
13 Pemasangan Nasopharingeal Gastric Tube 30,000
14 Cabut Jahitan 0-10 Jahitan 35,000

15 Inhalasi 35,000
17 Hecting 1-5 40,000

18 Infus Pump 40,000
19 Irigasi Mata 40,000
20 Syringe Pump 40,000
21 Toilet Hidung 40,000
22 Visum Luar 40,000
23 Cabut Jahitan > 10 Jahitan 45,000

24 Insisi Cross 45,000
25 Monitor 45,000
26 EKG 50,000
27 Ekstraksi Corpus Alienum 50,000
28 Hecting >5 50,000
29 Observasi ≥ 8 Jam 50,000
30 Pemasangan jalur intraosseseus 50,000
31 Suction 50,000
32 Wound Toilet Sedang 50,000
33 Oksigen > 7 Liter / Jam 60,000

34 Pasang Tampon Hidung 60,000
35 Pasang Tampon Telinga 60,000
36 Intubasi Endotracheal 65,000

37 Krikotiroidektomi 65,000
38 WT Combustio ≤ 30 % 65,000
39 Aspirasi Cairan 80,000

40 Ekstraksi Kuku 80,000
41 Kumbah Lambung 80,000
42 Wound Toilet Besar 80,000
43 WT Combustio > 30 % 80,000
44 Punksi Vesica Urinaria 150,000

45 Resusitasi 150,000
46 Oksigen 1 - 3 Liter / Hari 200,000

48 Pasang Chest Tube 250,000
49 Punksi Pleura 300,000

50 Oksigen > 7 Liter / Hari 300,000
51 Pasang CVC 300,000
52 Vena Secti 300,000
53 Pasang CPAP 350,000
54 Pasang Ventilator 500,000
C INSTALASI RAWAT JALAN
1 Aff Contact Lens 20,000

2 Edukasi Kelompok per Orang 20,000
3 Injeksi (ic, sc, iv, im) 20,000
4 Injeksi TT 20,000
5 Ischiara Test 20,000
6 Klisma 20,000
7 Memory/MMSE 20,000
8 MMT 20,000
11 Patching 20,000
13 Pemeriksaan Garpu Tala 20,000
14 Pemeriksaan Posture 20,000
15 Penilaian MMT 20,000
16 ROM 20,000
17 Senam Hamil 20,000
18 Vaksinasi dasar 20,000

20 Auditory Retraining 25,000
21 Ingatan Bahasa 25,000
22 Irigasi Telinga 25,000
23 Klinik Memori 25,000
24 Sensor-Motory Retraining 25,000
25 Train The Brain 25,000
26 Visual Retraining 25,000
28 Aff Tampon Nasal 30,000

29 Chiropraksi 30,000
30 Daya Tahan 30,000
31 Ekstraksi Clavus 30,000
32 Ekstraksi Corpus Alienum Palpebra 30,000
33 Ekstraksi Kolesteatom 30,000
34 Ekstraksi Serumen 30,000
35 Fitting Bandange Lens (1 Eye) 30,000
36 IVA Test 30,000
37 Kaustik Tenggorok 30,000
38 Keseimbangan Dan Koordinasi 30,000
39 Observasi < 8 Jam 30,000
42 Pedagogic 30,000
43 Pelatihan Posture 30,000
45 Pernafasan Dan Relaksasi 30,000
46 Probing 30,000
47 Refraksi Anak 30,000
48 Refraksi Dewasa 30,000
49 Terapi Kerja 30,000
50 Terapi Wicara 30,000
52 Vitalisasi Otak (Ikhtisar) 30,000

54 Inhalasi 35,000
56 Vaginal Hygiene 35,000
57 Ekstraksi Corpus Alienum Kornea 40,000

58 Epilasi 40,000
59 Hecting 1-5 40,000
60 Hecting Palpebra 40,000
62 Irigasi Mata 40,000
63 Stimulasi - Terapi Behavior 40,000
64 Stimulasi - Terapi Fisioterapi 40,000
65 Stimulasi - Terapi Occupational 40,000
66 Stimulasi - Terapi Speech 40,000
69 Visum 40,000

71 Insisi Cross 45,000
72 Kaustik Telinga 45,000
73 Tindik 45,000
74 Aff susuk KB 50,000
75 Baby Gym 50,000
76 Baby Massage 50,000
77 Baby Spa 50,000
78 Benda Asing Hidung Tanpa Anastesi 50,000
79 Benda Asing Telinga Tanpa Anastesi 50,000
80 Chloretyl Spray 50,000
81 Dis Hallpike Manuver 50,000
82 Ekstraksi Corpus Alienum 50,000
83 Hecting >5 50,000
84 Imobilisasi Dengan Elastic Verban 50,000
85 Observasi ≥ 8 Jam 50,000
87 Slit Lamp 50,000
88 Snozelen/Sensory-Integrasi, Stimulasi-Terapi 50,000
89 Suction 50,000
91 Drainage Abses 55,000

92 Akupunktur Penyakit 60,000
93 Audiometri Nada Murni 60,000
94 Benda Asing Tenggorokan 60,000
95 Ekstraksi Komedo 60,000
96 Elektroakupunktur 60,000
97 Facial 60,000
98 Infus Vitamin C Per Kunjungan 60,000
99 KIL 60,000
101 Pasang Tampon Hidung 60,000
102 Pasang Tampon Telinga 60,000
103 Podofilin 60,000

105 WT Combustio ≤ 30 % 65,000
106 Endoskopi Hidung 70,000

107 Endoskopi Telinga 70,000
108 Endoskopi Tenggorok 70,000
109 Mantoux Test 70,000
110 Paresentase/Miringotomi 70,000
111 Aff IUD 75,000
112 Cek Permanen Pace Maker 75,000
113 Aquapunktur 80,000

115 Debridement 80,000
116 Ekstraksi Kuku 80,000
117 Elektrokauter 80,000
118 Eustachius Tube Function 80,000
119 Injeksi Intra Artikuler 80,000
121 Pasang Implan 80,000
122 Pasang IUD 80,000
123 Refleks Akustik 80,000
125 WT Combustio > 30 % 80,000
126 Akupunktur Estetika 100,000

127 Audiometri Tutur 100,000
128 Insisi 100,000
129 Insisi Abses Peritonsil 100,000
130 Pap Smear 100,000
131 Pasang susuk KB dengan anastesi lokal 100,000
132 Peeling 100,000
133 Psiko test 100,000
134 Biopsi 120,000

135 Brand Daroft Manuver 120,000
136 Laserpunktur 120,000
137 Reposisi 120,000
138 Buka Gips Sesisi 125,000
139 Aff Implan 150,000

140 Insisi Hordoleum/Khalazion/Abses 150,000
141 MMPI 150,000
142 Punksi Asites 150,000
146 Sensory Aqustic Level 150,000
147 Buka Gips Sirkular 175,000

148 Buka Gips Tabung 175,000
149 Oto Acustic Emission 175,000
150 Cryo 180,000

151 Mikrodermabrasi 180,000
152 Pleurodesis 180,000
153 BERA tanpa sedasi 200,000

154 Biopsi Jarum Halus (FNAB) 200,000
155 Ekstirpasi 200,000
156 FNAB guided USG 200,000
157 Insisi Bartolin 200,000
158 Pelayanan Hiperbarik Per Pelayanan 200,000
159 Pungsi Asites/Pleura/Vesica guided USG 200,000
160 Akupunktur Tanam Benang 250,000

161 Eksisi 250,000
162 Ekstirpasi Pterygium 250,000
163 Holler Monitoring 250,000
164 Kauter Condyloma 250,000
165 Pasang Chest Tube 250,000
166 Stress Echo Treadmill 250,000
167 Tinitus Retaining Theraphy 250,000
168 Pasang Gips Sesisi 300,000

169 Pasang Gips Sirkular 300,000
170 Pasang Gips Tabung 300,000
171 Pasang WSD 300,000
172 Sirkumsisi 300,000
174 Carotid Duplex Doppler 400,000

175 Dermaroller 400,000
176 Vasektomi 400,000
177 Stress Echo Dobutamin (DSE) 500,000

178 Vascular Tungkai Doppler 500,000
179 Laser IPL 700,000
D TINDAKAN GIGI DAN MULUT
1 Ekstraksi Gigi Sulung (Chlorethyl) 35,000

2 Open Bur 35,000
3 Bongkar Amalgam Filling 40,000

4 Penambalan Sementara 40,000
5 Terapi: Stomatitis, Ulkus/Kunjungan 40,000
6 Ekstraksi Gigi Sulung dengan Injeksi 50,000

7 Grinding 50,000
8 Lepas bracket 75,000

9 Penambahan open coil 75,000
10 Penggantian wire 75,000
11 Activier Ortho Removable 80,000

12 Amalgam Filling Per Gigi 80,000
13 Cementasi Per Gigi 80,000
14 Cetak Per Rahang 80,000
15 Composite Filling Per Gigi 80,000
16 Debridement Gigi 80,000
17 Flouridasi 80,000
18 Insisi Abses Intra Oral 80,000
19 Oclusal Adjusment Per Gigi 80,000
20 Operculectomy Per Gigi 80,000
21 Oral Profilaksis 80,000
22 Pasang Pin Per Gigi 80,000
23 Penambalan Composite 80,000
24 Penambalan Glass Ionomer 80,000
25 Perawatan Penyakit Mulut 80,000
26 Perawatan Saluran Akar 80,000
27 Pit Dan Fissur Sealant 80,000
28 Terapi: Temporo Mandibular Junction / Kunjungan 80,000
29 Trepanasi 80,000
30 Activier Ortho Appliance 90,000

31 Activier Ortho Dengan Penambahan Alat 90,000
32 Apeksifikasi 90,000
33 Ekstraksi Gigi Tetap 90,000
34 Kuretase Gigi 90,000
35 Scalling Per Rahang 90,000
36 Penggantian bracket / pcs 100,000

37 Gigi Tiruan Per Gigi 150,000
38 Pengisian Saluran Akar (2 akar) 150,000
39 Composite Crown 170,000

40 Tambah Gigi Berikutnya 170,000
41 Bleaching gigi non vital (per gigi) 200,000

42 Core Build Up 200,000
43 Ekstraksi Gigi Dengan Penyulit 200,000
44 Insisi Abses Extra Oral 200,000
45 Mahkota Sementara 200,000
46 Reparasi Plat Ortho Dan Cetak 200,000
47 Copping 250,000
48 Gingivectomy Per Regio 250,000
49 Labial Veneering Per Gigi 250,000
50 Post Core 250,000
51 Reline 250,000
52 Reparasi Dan Cetak 250,000
53 Alveolectomy 300,000
54 Crown And Bridge Pfm Per Gigi 300,000
55 Frenektomy 300,000
56 Lingual Arct 300,000
57 Occlusal Splint Per Gigi 300,000
58 Palatal Arct 300,000
59 Pengisian Saluran Akar 300,000
60 Pengisian Saluran Akar Multiple (>3) 300,000
61 Skin Prick Test 300,000
62 Space Maintainer 300,000
63 Bruxism 400,000
64 Obturator Tanpa Gigi 400,000
65 Plat Ortho Lepasan Per Rahang 400,000
66 Rebase 400,000
67 Bridge Work Dan Precious Metal Per Gigi 450,000

68 Fiksasi Fraktur Rahang 450,000
69 Free Gingival Graft 450,000
70 Palatal Crib 450,000
71 Porcelin Veneer (Facing) 450,000
72 Crown Metal 500,000

73 Gigi Tiruan Flexi 500,000
74 Gigi Tiruan Sebagian 500,000
75 Inlay/Outlay 500,000
76 Maryland Bridge Per Gigi 500,000
77 Retainer ortho per Rahang 500,000
78 Odontectomy 800,000
79 Crown Porcelin 1,300,000
80 Gigi Tiruan Lengkap Logam 1 Elemen 1,300,000
81 Gigi Tiruan Logam 1,300,000
82 Gigi Tiruan Penuh 1 Rahang 1,300,000
83 Fixed Appliance Gigi Standar Per Rahang 2,300,000
84 Fixed Appliance Gigi Transparan Per Rahang 2,300,000
E KAMAR RAWAT INAP
1 Tarif Kamar Bayi / Perawatan Bayi Sehat Per Hari 100,000

2 Tarif Kamar ICU/ICCU 1,000,000
3 Tarif Kamar Intermediate / HCU Per Hari 200,000
4 Tarif Kamar Kelas I per Hari 300,000
5 Tarif Kamar Kelas II per Hari 200,000
6 Tarif Kamar Kelas III Per Hari 100,000
7 Tarif Kamar NICU Per Hari 800,000
8 Tarif Kamar Perinatologi / Perawatan Bayi Sakit Per Hari 200,000
9 Tarif Kamar VIP 500,000
10 Tarif Rawat Gabung Per Hari 150,000
F TINDAKAN RAWAT INAP
1 Aff Infus 15,000

3 Aff Nasogastric tube 20,000

4 Kasur Dekubitus 20,000
5 Klisma 20,000
6 Oksigen 1 - 3 Liter / jam 20,000

9 Penis Hygiene 25,000
11 Aff Tampon Nasal 30,000

12 Ekstraksi Corpus Alienum Palpebra 30,000
13 Minimal Care 30,000

18 Inhalasi 35,000
19 Oksigen 4 - 6 Liter / jam 35,000

24 Injeksi Intra Artikuler 45,000
25 Partial Care 45,000
26 Imobilisasi Dengan Elastic Verban 50,000

28 Suction 50,000
30 Drainage Abses 55,000

32 WT Combustio ≤ 30 % 65,000

36 Pasang Iud 80,000
38 WT Combustio > 30 % 80,000
39 Aff WSD 100,000

40 Arthrocentresis 100,000
41 Biopsi Jarum Halus (FNAB) 100,000
42 Insisi 100,000
43 Lumbal Pungsi 150,000

44 Punksi Asites 150,000
48 Tindakan Pemasangan Transfusi 170,000

49 Oto Acustic Emission 175,000
50 Eksisi 180,000
51 Ekstirpasi 180,000


G RAWAT INAP ISOLASI DAN INTENSIF
1 Warmer Blanket Per Jam 10,000

4 Kasur Dekubitus 25,000
5 Oral Hygine 25,000
6 Perawatan Bayi Baru Lahir 25,000
7 Penis Hygiene 30,000

12 Single Nasal Pronge 35,000
13 Surface Cooling 35,000
14 Inhalasi 40,000
16 Monitor 45,000
17 Pasang Inkubator Transport 45,000
18 Ekstubasi 50,000
20 Suction 50,000
22 Aff CPAP 60,000

23 Oksigen > 7 Liter / jam 60,000
24 Total Care 60,000

27 Blue Light Per Hari 75,000

28 WT Combustio < 30 % 75,000
29 WT Combustio > 30 % 85,000

33 Resusitasi Neonatus 150,000
34 Warmer Blanket per Hari 150,000

37 Pasang Kateter Umbilikal 200,000
41 Pasang Arteri Line 350,000

42 Pasang CPAP 350,000
43 CPAP hari berikutnya 200,000
44 Pasang CVP 350,000
46 Pasang Ventilator 500,000

47 Ventilator hari berikutnya 350,000
H PERSALINAN
1 Inspekulo 20,000
3 Perawatan Tali Pusat 20,000
4 Induksi Dengan Folley Catether 30,000

5 Pemeriksaan Air Ketuban 30,000
8 Douglas Pungsi 50,000

10 Induksi/Akselerasi Persalinan 70,000
11 Aff IUD 80,000

12 Pasang IUD 80,000
13 Eksplorasi Placenta 100,000

14 Kompresi Bimanual Eksternal 100,000
15 Kompresi Bimanual internal 100,000
16 Doppler 150,000
17 Forceps 150,000
18 Vacuum 150,000
20 Hidrotubasi 200,000
22 Kuret Dengan AVM 200,000
24 Pasang Laminaria 200,000
26 Hecting Perineum 270,000
27 Hecting Portio 300,000

29 Manual Plasenta 400,000

30 Manual Plasenta dengan narkose 500,000
31 Kauter Condyloma 750,000
32 Circlage 850,000
33 Kuretase 900,000
34 Persalinan Normal 1,000,000
35 Persalinan Dengan Penyulit 1,350,000
36 Persalinan Dengan Penyulit II 1,700,000
37 Persalinan Dengan Penyulit III 2,100,000
I HAEMODIALISA
1 Aff Double Lumen 200,000

2 Pasang Double Lumen 350,000
3 Haemodialisa Re-Use 600,000
4 Haemodialisa 800,000
5 Haemodialisa Emergency 900,000
J RADIOLOGI
1 Dental 60,000
2 Abdomen Polos 90,000
3 Ankle Joint 90,000
4 Clavicula 90,000
5 Hip Joint 90,000
6 Humerus 90,000
7 Mandibula 90,000
8 Manus 90,000
9 Mastoid (Schuller) 90,000
10 Pedis 90,000
11 Pelvis 90,000
12 Scapula 90,000
13 Shoulder Joint 90,000
14 Sinus Paranasal Water'S-Lateral 90,000
15 Temporomandibular Joint 90,000
16 Vertebrae Coccygeus 90,000
17 Wrist Joint 90,000
18 Anklejoint AP-Lateral 100,000
19 Antebrachi AP-Lateral 100,000
20 Cruris AP-Lateral 100,000
21 Cubiti AP-Lateral 100,000
22 Femur AP-Lateral 100,000
23 Genu AP- Lateral 100,000
24 Humerus AP-Lateral 100,000
25 Manus AP-Oblique 100,000
26 Nasal AP-Lateral 100,000
27 Pedis AP-Oblique 100,000
28 Thorax AP/Lateral 100,000
29 Thorax Top Lordotic 100,000
30 Vertebrae Cervikal 2 Posisi 100,000
31 Wrist Joint AP-Lateral 100,000
32 Schedell AP-Lateral 110,000

33 Vertebrae Lumbal 110,000
34 Vertebrae Lumbosacral 110,000
35 Abdomen 2 Posisi 120,000

36 Appedicogram 120,000
37 Cephalometri 120,000
38 Vertebrae Thoracal 120,000
39 Vertebrae Thoracolumbal 120,000
40 Babygram 140,000
41 Abdomen 3 Posisi 150,000
42 Sinus Paranasalis 3 Posisi 150,000
43 Cephalometri 170,000
44 Panoramic 170,000
45 USG Abdomen 200,000

46 USG Buli Buli 200,000
47 USG Ginjal 200,000
48 USG Kebidanan 200,000
49 USG Kepala Bayi 200,000
50 USG Liver Dan Kandung Empedu 200,000
51 USG Mammae 200,000
52 USG Mata 200,000
53 USG Muskuloskeletal 200,000
54 USG Prostat 200,000
55 USG Testis 200,000
56 USG Thorax 200,000
57 USG Thyroid 200,000
58 USG Vascular Dopler 200,000
59 Vertebrae Cervikal 4 Posisi 200,000
60 Oesofagografi 250,000
61 RPG 250,000
62 HSG 300,000
63 BNO/IVP 400,000
K LABORATORIUM KLINIK
1 Pemeriksaan cross check (Rujukan Uji Silang) 10,000

2 Eosinofil 15,000
3 Feses Rutin 15,000
4 Filaria 15,000
5 LED 15,000
6 Retikulosit 15,000
7 Sediaan Jamur (KOH) 15,000
8 Sedimen Urine 15,000
9 Waktu Pembekuan 15,000
10 Waktu Perdarahan 15,000
11 Glukosa 2 Jam PP 25,000

12 Glukosa Puasa 25,000
13 Glukosa Sewaktu 25,000
14 Golongan Darah + Rhesus 25,000
15 Beta hCG Urine 30,000

16 Sediaan BTA MH 30,000
17 SGOT 30,000
18 SGPT 30,000
19 Sputum BTA 3X 30,000
20 Urine Lengkap 30,000
21 Albumin 35,000
22 Asam Urat 35,000
23 Asam Urat Urine 24 Jam 35,000
24 Biliribin Indirect 35,000
25 Bilirubin Direct 35,000
26 Bilirubin Total 35,000
27 Globulin 35,000
28 Kolesterol Total 35,000
29 Kreatinin 35,000
30 Kreatinin Urine 24 Jam 35,000
31 Malaria 35,000
32 Pewarnaan Gram 35,000
33 Protein Total 35,000
34 Trigliserida 35,000
35 Ureum 35,000
36 Ureum Urine 24 Jam 35,000
37 Darah Rutin (Hb+Ht+Leuko+Trombo) 40,000

38 Feses Lengkap 40,000
39 Alkali Fosfatase 45,000
40 Calcium Total 45,000
41 Gamma GT 45,000
42 Magnesium 45,000
43 RPR 45,000
44 Amphetamine 50,000
45 ASTO 50,000
46 Benzodiazepin 50,000
47 Calcium Urine 50,000
48 Darah Lengkap (Darah Rutin+Hitung Jenis+E+NER+LED) 50,000
49 HDL 50,000
50 IT-Ratio 50,000
51 LDH 50,000
52 LDL 50,000
53 Magnesium Urine 50,000
54 Mariyuana 50,000
55 Morfin/Opiat 50,000
56 Phospor 50,000
57 Phospor Urine 50,000
58 Rheumatoid Faktor 50,000
59 Tes Cepat Molekuler tanpa Cartridge (subsidi / hibah) 50,000
60 TTGO 50,000
61 VDRL 50,000
62 Widal 50,000
63 Bersihan Kreatinin Urine 24 Jam 60,000

64 CK-MB 75,000
65 Gambaran Darah Tepi 75,000
66 Amylase 80,000
67 Analisa Sperma 80,000
68 Chlorida 80,000
69 Kalium 80,000
70 Kolinesterase 80,000
71 Leptospira IgM 80,000
72 Natrium 80,000
73 TPHA 80,000
74 APTT 90,000
75 CRP 90,000
76 PT 90,000
77 Anti HBs 100,000

78 Anti HCV (ELISA) 100,000
79 Elektrolit (Na, K, Cl) 100,000
80 Fibrinogen 100,000
81 HbsAg 100,000
82 Salmonella IgM Typhi (Tubex) 100,000
83 Serum Iron 100,000
84 TIBC 100,000
85 Trombin Time 100,000
86 Agregasi Trombosit 120,000

87 Analisa Gas Darah 120,000
88 D Dimer 120,000
89 HbsAg (ELISA) 120,000
90 Mikro Albumin Urin 24 Jam 120,000
91 T3 120,000
92 T4 120,000
93 TSH 120,000
94 CD4 130,000
95 CD8 130,000
96 AFP 140,000
97 Anti HbsAg (ELISA) 140,000
98 Anti HIV 140,000
99 Apo B 140,000
100 CEA 140,000
101 G6PD 140,000
102 Dengue Antigen NS1 150,000

103 Dengue IgG IgM 150,000
104 Analisa Batu 160,000

105 Feritin 160,000
106 Hba1C 160,000
107 Peroksidase 160,000
108 Anti CMV IgG 180,000

109 Anti HIV 1-2 (ELISA) 180,000
110 Anti HSV 1 IgG 180,000
111 Anti HSV 1 IgM 180,000
112 Anti HSV 2 IgG 180,000
113 Anti HSV 2 IgM 180,000
114 Anti Toksoplasma IgG (ELISA) 180,000
115 Anti Toxoplasma IgM (Elisa) 180,000
116 Apo A 180,000
117 Elektrolit Urine (Na, K, Cl) 180,000
118 Free T4 180,000
119 Troponin T 180,000
120 Anti Rubella IgG 200,000

121 Anti Rubella IgM 200,000
122 CRP Kuantitatif 200,000
123 ANA 225,000

124 Anti CMV IgM 225,000
125 Anti HAV IgM 225,000
126 Anti HAV Total 225,000
127 Anti TB IgG Titer 225,000
128 FSH 225,000
129 IDT, ICT (Amoeba) 225,000
130 IgE Total 225,000
131 LH 225,000
132 MCA (Payudara) 225,000
133 Prolactin 225,000
134 Sudan Black B 225,000
135 Transferin 225,000
136 Analisa Hb 250,000

137 Anti ds-DNA 250,000
138 Beta hCG Serum 250,000
139 Calcium Ion 250,000
140 Cortisol 250,000
141 C-Peptide 250,000
142 Estradiol 250,000
143 Faktor VIII 250,000
144 LP (a) 250,000
145 Progesteron 250,000
146 PSA (total) 250,000
147 Salmonella IgG Typhi 250,000
148 Tes Cepat Molekuler dengan Cartridge (TBRO, Hepatitis) 250,000
149 Testosteron 250,000
150 C3 Komplemen 300,000

151 C4 Komplemen 300,000
152 Ca 15-3 (Payudara) 300,000
153 Comb Test 300,000
154 Cyfra 21-1 (Paru) 300,000
155 Kultur MO + Resistensi Anaerob 300,000
156 ACA IgG 350,000

157 ACA IgM 350,000
158 Ca-125 (Ovarium) 350,000
159 Ca-19-9 (Pankreas) 350,000
160 Tes EID RNA DNA 400,000

161 Asam Folat 450,000
162 Ca 724 (Lambung) 450,000
163 Protein C 500,000

164 Protein S 500,000
165 Measles IgG 700,000

166 Measles IgM 700,000
167 Viral Load (HIV) 1,000,000

168 Western Blood 1,000,000
L LABORATORIUM PATOLOGI ANATOMI
1 Pulasan Khusus: BTA, H.Pylori 50,000

2 Serviks/Vagina/Sputum 1 x 100,000
3 Bilasan Bronkus 250,000
4 Cairan Pleura 250,000
5 FNAB 250,000
6 Serviks Thin Prep 250,000
7 Sikatan Bronkus 250,000
8 Sputum 3 x 250,000
9 Urine 250,000
10 Biopsi/Jaringan Kecil (Apendiks, Kuret, KGB, Kulit) 350,000
11 FNAB (tindakan oleh DSPA) 350,000
12 Jaringan Besar (Mastektomi, Histerektomi, Usus) 500,000
13 Imunohistokimia 800,000
14 Potong Beku 1,000,000
15 Imuhistokimia 1,500,000
M BANK DARAH
1 Biaya Darah Titip 30,000

2 Ice Packed 30,000
3 Pemeriksaan Golongan Darah Metode Slide 30,000
4 Cool Box Lengkap 50,000
5 Biaya Cross Match 70,000
6 Buku Formulir Permintaan Darah Rangkap 4 70,000
7 Pemeriksaan Golongan Darah Metode Tabung 70,000
8 Sel Panel Kecil untuk Skrining Antibodi 90,000
9 Fresh Frozen Plasma (FFP) 250,000
10 Packed Red Blood Cell (PRC) 250,000
11 Trombocyt Concentrate (TC) 250,000
12 Wash Eritrocyt (WE) 250,000
13 Whole Blood (WB) 250,000
14 Pemeriksaan Rhesus Typing 350,000
15 Pemeriksaan Comb Test 400,000
16 Pemeriksaan Incompatible 400,000
17 Sel Panel Besar untuk Identifikasi Antibodi 550,000
18 Sel Panel Lengkap yaitu Sel Panel Besar dan Kecil 600,000
19 Darah NAT 800,000
N KAMAR OPERASI
1 Operasi Kecil 2,000,000

2 Operasi Aulvulsi Pterygium 2,000,000
3 Operasi Eksisi Granulasi Telinga 2,000,000
4 Operasi Sirkumsisi 2,000,000
5 Operasi Sedang 3,000,000

6 Operasi Abses Submandibula 3,000,000
7 Operasi Adheliolisis 3,000,000
8 Operasi Aff Implan 3,000,000
9 Operasi Alveolectomy 3,000,000
10 Operasi Anoplastik 3,000,000
11 Operasi Antrostomi Unilateral 3,000,000
12 Operasi Biopsi Dalam Tubuh (Berbagai Jenis) 3,000,000
13 Operasi Biopsi Saraf Kutaneus/Otot 3,000,000
14 Operasi Blok Saraf Tepi 3,000,000
15 Operasi Dilatasi Dan Kuretase Untuk Biopsi 3,000,000
16 Operasi Drainase (Insisi Abses Ekstra Oral) 3,000,000
17 Operasi Drainase Abses Pada Otot 3,000,000
18 Operasi Duktus Thyroglosus Simple 3,000,000
19 Operasi Eksisi Arthoplasti Sendi Kecil 3,000,000
20 Operasi Eksisi Dengan Penyulit 3,000,000
21 Operasi Eksisi FAM 3,000,000
22 Operasi Eksisi Fibroma 3,000,000
23 Operasi Eksisi Ginekomasti 3,000,000
24 Operasi Eksisi Hemangioma 3,000,000
25 Operasi Eksisi Mamae Aberans 3,000,000
26 Operasi Eksisi Tumor < 1 cm Konjunctiva Lokal 3,000,000
27 Operasi Eksisi Tumor > 1cm Konjunctiva Lokal 3,000,000
28 Operasi Eksplorasi Plexus Cervical/Branchialis 3,000,000
29 Operasi Eksplorasi Vagina 3,000,000
30 Operasi Ekstirpasi (Leher) 3,000,000
31 Operasi Ekstirpasi Kista Bartholin 3,000,000
32 Operasi Ekstirpasi Mioma Geburt 3,000,000
33 Operasi Ekstraksi Gigi Dan Komplikasi 3,000,000
34 Operasi Excochleatie & Ekstraksi Gigi 3,000,000
35 Operasi Fistulektomi 3,000,000
36 Operasi Ganglion 3,000,000
37 Operasi Gastrostomi Paliatif 3,000,000
38 Operasi Glosectomi 3,000,000
39 Operasi Hernia Umbilical 3,000,000
40 Operasi Hidrocelectomi 3,000,000
41 Operasi Katarak SICS +IOL (ECCE) 3,000,000
42 Operasi Keloid Multipel > 5 3,000,000
43 Operasi Konisasi 3,000,000
44 Operasi Koreksi Osteotomi Simpel 3,000,000
45 Operasi Laparoscopy Diagnostic 3,000,000
46 Operasi Lipoma > 3 3,000,000
47 Operasi Mc. Donald/Shirodcar 3,000,000
48 Operasi Odontektomi 2 Gigi 3,000,000
49 Operasi Pasang Gips Telinga & Hidung 3,000,000
50 Operasi Pengambilan Dislokasi IUD 3,000,000
51 Operasi Penutupan Oaf 3,000,000
52 Operasi Perineum 3,000,000
53 Operasi Polip Rekti 3,000,000
54 Operasi Pungsi Cairan Otak 3,000,000
55 Operasi Repair Otot 3,000,000
56 Operasi Reparasi Burst Abdomen 3,000,000
57 Operasi Replantasi Gigi 3,000,000
58 Operasi Reposisi Uterus Pada Inversio Uteri 3,000,000
59 Operasi Reseksi Apex Gigi Belakang (>1 Akar) 3,000,000
60 Operasi Sirklase 3,000,000
61 Operasi Tonsilektomi tanpa Adenoidektomi 3,000,000
62 Operasi Tubektomi Post Partum 3,000,000
63 Operasi Tumor Lid Margin < 1/3 Palpebra Lokal 3,000,000
64 Operasi Tumor Lid Margin > 1/3 Palpebra Lokal 3,000,000
65 Operasi WSD Kasus Trauma 3,000,000
66 Operasi Tonsilektomi dengan Adenoidektomi 3,500,000
67 Operasi Bone Graft 4,000,000

68 Operasi Eksisi + Graft 4,000,000
69 Operasi Eksternal Drainage 4,000,000
70 Operasi Fiksasi Rahang 4,000,000
71 Operasi Kistektomy 4,000,000
72 Operasi Necrotomi/Debridement 4,000,000
73 Operasi Pungsi Kista Bedah Mulut 4,000,000
74 Operasi Sectio Caesarea 4,000,000
75 Operasi Sequestrektomi 4,000,000
76 Operasi Eksisi Tumor Jaringan Lunak 4,000,000
77 Operasi Tumor Mammae 4,000,000
78 Operasi Varicocelektomi 4,000,000
79 Operasi Besar 4,500,000

80 Operasi Anastomosis Ileum Desenden 4,500,000
81 Operasi Antrostomi Bilateral 4,500,000
82 Operasi Appendiktomi 4,500,000
83 Operasi CAPD 4,500,000
84 Operasi Colostomi 4,500,000
85 Operasi Colosystectomi 4,500,000
86 Operasi Diseksi KGB Retroperitoneal 4,500,000
87 Operasi Drainage Abses Liver 4,500,000
88 Operasi Eksisi Tumor < 1cm Konjungtiva 4,500,000
89 Operasi Eksisi Tumor > 1 cm Konjungtiva 4,500,000
90 Operasi Eksisi Tumor Kistik 4,500,000
91 Operasi Ekstirpasi Tumor < 1cm Palpebra Superior/Inferior Lokal 4,500,000
92 Operasi Ekstirpasi Tumor > 1cm Palpebra Superior/Inferior Lokal 4,500,000
93 Operasi Enukleasi (Ekstirpasi) Kompleks Bedah Mulut 4,500,000

94 Operasi Eviserasi 4,500,000
95 Operasi Fistulektomi Bedah Mulut 4,500,000
96 Operasi Hemoroidektomi Interna 4,500,000
97 Operasi Hernia Incarcerata 4,500,000
98 Operasi Herniatomi 4,500,000
99 Operasi Herniatomi Bilateral 4,500,000
100 Operasi Herniatomi Residif 4,500,000
101 Operasi Impaksi Sisi Khusus Bedah Mulut 4,500,000
102 Operasi Kista Duktus Thyroglosus 4,500,000
103 Operasi Kista Ovarium 4,500,000
104 Operasi Kolesistektomi 4,500,000
105 Operasi Kolpodeksis 4,500,000
106 Operasi Kontraktur Released 4,500,000
107 Operasi Laparascopy MOW 4,500,000
108 Operasi Laparatomi KET 4,500,000
109 Operasi Lateral Sphinterotomi 4,500,000
110 Operasi Manchester Fortegil 4,500,000
111 Operasi Mastektomi 4,500,000
112 Operasi Mastektomi Simple 4,500,000
113 Operasi Medistinoscopy 4,500,000
114 Operasi Obstruksi Usus/Invaginasi 4,500,000
115 Operasi Pembuluh Darah Simple 4,500,000
116 Operasi Pengangkatan Tumor Ovarium 4,500,000
117 Operasi Perineoraphi Kasus Lama / Penyulit 4,500,000
118 Operasi Quandrantektomy Mammae 4,500,000
119 Operasi Released Interdigiti 4,500,000
120 Operasi Repair Arteri 4,500,000
121 Operasi Repair Pembulur Darah Besar 4,500,000
122 Operasi Repair Ruptur Kornea Lokal 4,500,000
123 Operasi Repair Tendon + Debridement 4,500,000
124 Operasi Repair Tendon > 1 Jari 4,500,000
125 Operasi Reposisi Nasal 4,500,000
126 Operasi Reseksi Adenomiosis 4,500,000
127 Operasi Reseksi Gaster 4,500,000
128 Operasi Rotational Flap 4,500,000
129 Operasi RPG 4,500,000
130 Operasi Skin Graft 4,500,000
131 Operasi Splenectomi 4,500,000
132 Operasi Stripping 4,500,000
133 Operasi Struma 4,500,000
134 Operasi STSG (Skin Graft Luas) 4,500,000
135 Operasi Superfisial Paratiroidektomi 4,500,000
Operasi Thyroidektomi Subtotal/Lobectomi/Strumektomi
136 4,500,000
/Ismuslobektomi
137 Operasi Tubektomi 4,500,000
138 Operasi Tumor Lid Margin < 1/3 Palpebra 4,500,000
139 Operasi Khusus

140 Operasai Total Disc Replacement Bedah Mulut 6,000,000
141 Operasi Close Reduction Complex Bedah Mulut 5,000,000
142 Operasi Debulking 5,000,000
143 Operasi Diseksi Leher Radikal 5,000,000
144 Operasi Duhamel 5,000,000
145 Operasi Eksenterasi Pelvis 5,000,000
146 Operasi Eksenterasi Tumor 5,000,000
147 Operasi Eksplorasi Duktus Kholedokus 5,000,000
148 Operasi end to End Anastomosis 5,000,000
149 Operasi Fore Quater Amputation 5,000,000
150 Operasi Gastrectomi 5,000,000
151 Operasi Gastrokisis Repair 5,000,000
152 Operasi Gnatoplasty 5,000,000
153 Operasi Hemikolektomi 5,000,000
154 Operasi Hemimandibulektomi (Hemimaksilektomi) 5,000,000
155 Operasi Hemoroidektomi 5,000,000
156 Operasi Histerektomi 8,000,000
157 Operasi Histerektomi Radikal (dengan lympadenektomi regional) 5,000,000
158 Operasi Histerektomi Supravaginal / Subtotal 5,000,000

159 Operasi Histerektomi Total dan SOB/TAH + BSO 5,000,000
160 Operasi Interposisi Kolon 5,000,000
161 Operasi Jugular, Subclavia, Femoral 5,000,000
162 Operasi Katarak Fakoemulsifikasi 6,000,000
163 Operasi Kholedoku Jejunostomi 5,000,000
164 Operasi Kholedokuduodenostomi 5,000,000
165 Operasi Kolesistektomi + Eksplorasi CBD 5,000,000
166 Operasi Komando 5,000,000
167 Operasi Laparatomi Explorasi 8,000,000
168 Operasi Laparoscopy Operatif 5,000,000
169 Operasi Laparotomi + Drainage Abses Hepar 5,000,000
170 Operasi Laparotomi + Herniotomi dengan komplikasi (reseksi usus) 5,000,000
171 Operasi Laparotomi Eksplorasi (staging) 5,000,000

172 Operasi Lithotripsi 5,000,000
173 Operasi Low Anterior Resection 5,000,000
174 Operasi Mastoidektomi 5,000,000
175 Operasi Mega Kolon Hisrchprung 5,000,000
176 Operasi Miles Operation 5,000,000
177 Operasi Miomektomi 5,000,000
178 Operasi Miomektomi/Kistektomi dengan Laparoscopy 5,000,000
179 Operasi Mrm + STSG/Flap 5,000,000
180 Operasi Odontektomi 4 Gigi 5,000,000
181 Operasi Open Reduction Internal Fixation 6,000,000
182 Operasi Operasi Nonunion & Delayed Union 6,000,000
183 Operasi Orif.Fraktur Patella 5,000,000
184 Operasi Pankreatektomi 5,000,000
185 Operasi Pemasangan Arteri/Vena Access 5,000,000
186 Operasi Prolaps Rekti 5,000,000
187 Operasi Prosedur Bypass/Hemicolectomy 5,000,000
188 Operasi Radikal Mastektomi/MRM 5,000,000
189 Operasi Rebola 5,000,000
190 Operasi Reduksi Terbuka & Eksternal Fiksasi Bedah Mulut 4,500,000
191 Operasi Reduksi Terbuka & Eksternal Fiksasi Dengan Plate & Screw 4,500,000
192 Operasi Reduksi Terbuka & Eksternal Fiksasi Dengan Wire & Screw 4,500,000
193 Operasi Reimplantasi Satu Gigi 6,000,000

194 Operasi Rekonstruksi Arteri/Vena Besar 5,000,000
195 Operasi Repair Cleft Lip Bilateral 6,000,000
196 Operasi Repair Cleft Lip Unilateral 5,000,000
197 Operasi Repair Cleft Palate Complete 6,000,000
198 Operasi Repair Cleft Palate Incomplete 5,000,000
199 Operasi Repair Ruptur Kornea 5,000,000
200 Operasi Repair Tendon 1 Jari 5,000,000
201 Operasi Reparasi Fistal 5,000,000
202 Operasi Reseksi Anterior 5,000,000
203 Operasi Reseksi Esofagus dengan Interposisi Kolon/Gaster 5,000,000
204 Operasi Reseksi Hepar (Penyulit) 5,000,000
205 Operasi Reseksi Iga 5,000,000
206 Operasi Reseksi Sebagian Mandibula (Maksila) 5,000,000
207 Operasi Reseksi Segmental 5,000,000
208 Operasi Reseksi Usus - Anastomosis 5,000,000
209 Operasi Reseksi Usus Radikal 5,000,000
210 Operasi Ripstein Procedure 5,000,000
211 Operasi Salpingektomi 8,000,000
212 Operasi SC + Histerektomi Total 5,000,000
213 Operasi Surgical Staging 5,000,000
214 Operasi Swenson 5,000,000
215 Operasi Thoracotomy 5,000,000
216 Operasi Thorak Abdominal 5,000,000
217 Operasi Timpanoplasti 5,000,000
218 Operasi Total Glosektomi 5,000,000
219 Operasi Transeksi Esofagus 5,000,000
220 Operasi Tromboembolektomi 5,000,000
221 Operasi Tubaplasti 5,000,000
222 Operasi Tumor Ganas Ovarium 5,000,000
223 Operasi Tumor Lid Margin > 1/3 Palpebra 5,000,000
224 Operasi Uretroskopi (litotripsi/biopsi) 5,000,000
225 Operasi URS - Lithoclast 5,000,000
226 Operasi Vaginal Histerektomi 5,000,000
227 Operasi Vaginoplasty (Kolporafi ant/post) 5,000,000
228 Operasi Vulvektomi 5,000,000
229 Operasi Whipple (Pankreatiko Duedenoktomi) 5,000,000
230 Operasio Bilio Digestive 5,000,000
O AMBULANCE
1 Ambulance Darat 450,000

2 Ambulance Laut 17,500,000
P ELEKTROMEDIK
1 Doppler 40,000
2 Tonometri Schiotz 45,000
3 EKG 50,000
4 Funduscopy Direct 50,000
5 Funduscopy Indirect 50,000
6 Tonometri Non Contact 50,000
7 Tympanometri + Interpretasi 50,000
8 Audiometri Anak 60,000

9 Audiometri Interpretasi 60,000
10 Biometri 60,000
11 CTG 60,000
12 Anel test 80,000

13 Spirometri 80,000
14 Anuscopy 100,000
15 Monitor EKG 150,000

16 Treadmill 150,000
17 Echo Cardiography Doppler 200,000

18 EEG tanpa Warna 200,000
19 EMG 200,000
20 Kecepatan Hantar Syaraf 200,000
21 Somato Sensory Evoked Potential 200,000
22 Spasmofili 200,000
23 Visual Evoked Potential 200,000
24 Blink Refleks + EMG 250,000

25 EEG Berwarna 250,000
26 Kecepatan Hantar Syaraf + EMG 250,000
27 Brain Mapping 300,000

28 Brain Mapping tanpa EEG 300,000
Q REHABILITASI MEDIK
1 Infra Red 30,000

2 Massage 30,000
3 MWD Kecil / Diathermy 30,000
4 SWD 30,000
5 Electrical Stimulasi/TENS 35,000

6 Electrical Traction 35,000
7 Exercise Aktif 35,000
8 Exercise Terapi Ringan 35,000
9 MWD Sedang 35,000
10 Ultrasound Therapy 35,000
11 Exercise Terapi Sedang 40,000

12 Inhalasi/Nebulizer 40,000
13 Manual Therapy 40,000
14 Exercise Pasif 50,000

15 Exercise Terapi Berat 50,000
16 Exercise Terapi Khusus 50,000
R KAMAR JENAZAH
1 Pemulasaran Jenazah Anak 400,000

2 Pemulasaran Jenazah Dewasa 500,000
3 Penyimpanan Jenazah Ruangan Cool Storage per 24 Jam 100,000
4 Penyimpanan Jenazah/Ruangan Biasa 2 Jam Pertama 30,000
5 Perawatan Jenazah dan Kain Laken Anak 50,000
6 Perawatan Jenazah dan Kain Laken Bayi 30,000
7 Perawatan Jenazah dan Kain Laken Dewasa 60,000
8 Perawatan Jenazah/Ruangan Biasa per 24 Jam 60,000
9 Tambahan per Sampel 60,000
10 Tindakan Formalin Jenazah Anak 700,000
11 Tindakan Formalin Jenazah Dewasa 900,000
S LAIN-LAIN
1 Kantin dll (per area/ hari) 15,000

2 Magang, per orang/hari 15,000
3 Pengambilan Data, per orang/siklus, maksimal 2 bulan 150,000
4 Homecare (diluar tindakan) 200,000
5 Penelitian, per orang/siklus, maksimal 2 bulan 250,000
6 Bank per m2 area/ bulan 300,000
7 Sewa Aula per Hari 350,000
8 Biaya Kaji Etik 1,500,000
9 Anjungan Tunai Mandiri (per area/ bulan) 4,000,000
10 Bank (per area/ bulan) 10,000,000
maksimal 120%
11 Layanan Obat dan Farmasi Lainnya dari harga beli
Lampiran : Peraturan Gubernur Provinsi Daerah Khusus Ibukota Jakarta
Nomor :
Tanggal :
TARIF LAYANAN RUMAH SAKIT UMUM DAERAH KELAS C DAN D
% TARIF
USULAN TARIF DENGAN
NO NAMA LAYANAN TARIF LAMA UNIT COST BARU UC
A PEMERIKSAAN DAN KONSULTASI
1 Konsultasi Spesialis by Phone (di luar jam praktek) 30,000 95,847 20,000 20.87%
2 Konsultasi Gizi di Instalasi Rawat Inap 20,000 48,273 25,000 51.79%
3 Konsultasi Gizi di Instalasi Rawat Jalan 20,000 48,273 25,000 51.79%
4 Konsultasi Dokter Umum di Ruang Rawat Inap Isolasi dan Intensif 38,633 30,000 77.65%
5 Konsultasi Emergency Spesialis by Phone (Jam 23.00 - 07.00 WIB) 30,000 95,847 30,000 31.30%
6 Konsultasi Psikolog Klinis di Instalasi Rawat Jalan 50,374 30,000 59.55%

7 Konsultasi Psikologi Klinis di Instalasi Rawat Inap 48,372 30,000 62.02%
8 Pemeriksaan / konsultasi Dokter Umum/ Dokter Gigi 20,000 51,827 30,000 57.88%
9 Konsultasi Dokter Spesialis di Ruang Rawat Inap Isolasi dan Intensif 20,000 56,355 40,000 70.98%
10 Pemeriksaan / konsultasi Spesialis Internal (non DPJP) 30,000 95,847 40,000 41.73%
11 Pemeriksaan / konsultasi Spesialis Perioperatif 30,000 95,847 40,000 41.73%
12 Pemeriksaan / konsultasi Spesialis Rawat Inap 30,000 95,847 40,000 41.73%
13 Pemeriksaan IGD 35,000 57,143 40,000 70.00%
14 Pemeriksaan / konsultasi Spesialis Rawat Jalan 30,000 95,847 60,000 62.60%
B INSTALASI GAWAT DARURAT

1 Injeksi 31,237 20,000 64.03%
2 Injeksi TT 32,758 20,000 64.03%
3 Klisma 20,000 26,337 20,000 75.94%
4 Oksigen 1 - 3 Liter / Jam 31,287 20,000 63.92%
5 Pasang Infus 10,000 26,361 20,000 75.87%
6 Pemasangan Oropharingeal Gastric Tube 28,377 20,000 70.48%
7 Aff Kateter 25,000 42,938 25,000 58.22%

8 Irigasi Telinga 20,000 39,283 25,000 63.64%
9 Wound Toilet Kecil 20,000 43,768 25,000 57.12%
10 Observasi < 8 Jam 20,000 53,928 30,000 55.63%

11 Pasang Kateter Urine 25,000 46,253 30,000 64.86%
12 Pasang Spalk 20,000 47,174 30,000 63.59%
13 Pemasangan Nasopharingeal Gastric Tube 50,451 30,000 59.46%
14 Cabut Jahitan 0-10 Jahitan 25,000 62,355 35,000 56.13%

15 Inhalasi 20,000 57,068 35,000 61.33%
17 Hecting 1-5 20,000 70,181 40,000 57.00%

18 Infus Pump 20,000 65,342 40,000 61.22%
19 Irigasi Mata 30,000 68,273 40,000 58.59%
20 Syringe Pump 20,000 67,263 40,000 59.47%
21 Toilet Hidung 30,000 70,128 40,000 57.04%
22 Visum Luar 70,803 40,000 56.49%
23 Cabut Jahitan > 10 Jahitan 92,044 45,000 48.89%

24 Insisi Cross 40,000 76,283 45,000 58.99%
25 Monitor 45,000 75,243 45,000 59.81%
26 EKG 50,000 80,655 50,000 61.99%
27 Ekstraksi Corpus Alienum 25,000 87,362 50,000 57.23%
28 Hecting >5 30,000 82,837 50,000 60.36%
29 Observasi ≥ 8 Jam 45,000 82,716 50,000 60.45%
30 Pemasangan jalur intraosseseus 86,729 50,000 57.65%
31 Suction 50,000 80,602 50,000 62.03%
32 Wound Toilet Sedang 30,000 81,547 50,000 61.31%
33 Oksigen > 7 Liter / Jam 101,372 60,000 59.19%

34 Pasang Tampon Hidung 50,000 101,827 60,000 58.92%
35 Pasang Tampon Telinga 100,293 60,000 59.82%
36 Intubasi Endotracheal 45,000 95,675 65,000 67.94%

37 Krikotiroidektomi 45,000 95,675 65,000 67.94%
38 WT Combustio ≤ 30 % 50,000 111,030 65,000 58.54%
39 Aspirasi Cairan 40,000 132,837 80,000 60.22%

40 Ekstraksi Kuku 50,000 136,452 80,000 58.63%
41 Kumbah Lambung 45,000 132,736 80,000 60.27%
42 Wound Toilet Besar 40,000 116,206 80,000 68.84%
43 WT Combustio > 30 % 80,000 106,679 80,000 74.99%
44 Punksi Vesica Urinaria 246,735 150,000 60.79%

45 Resusitasi 50,000 245,468 150,000 61.11%
46 Oksigen 1 - 3 Liter / Hari 330,847 200,000 60.45%

48 Pasang Chest Tube 100,000 413,515 250,000 60.46%
49 Punksi Pleura 150,000 497,694 300,000 60.28%

50 Oksigen > 7 Liter / Hari 499,208 300,000 60.10%
51 Pasang CVC 502,937 300,000 59.65%
52 Vena Secti 498,372 300,000 60.20%
53 Pasang CPAP 548,203 350,000 63.84%
54 Pasang Ventilator 834,283 500,000 59.93%
C INSTALASI RAWAT JALAN
1 Aff Contact Lens 20,000 32,938 20,000 60.72%

2 Edukasi Kelompok per Orang 20,000 31,827 20,000 62.84%
3 Injeksi (ic, sc, iv, im) 33,429 20,000 59.83%
4 Injeksi TT 32,758 20,000 64.03%
5 Ischiara Test 20,000 31,928 20,000 62.64%
6 Klisma 20,000 26,337 20,000 75.94%
7 Memory/MMSE 20,000 33,826 20,000 59.13%
8 MMT 20,000 34,821 20,000 57.44%
10 Pasang Infus 10,000 26,361 20,000 75.87%
11 Patching 10,000 31,405 20,000 63.68%
13 Pemeriksaan Garpu Tala 30,293 20,000 66.02%
14 Pemeriksaan Posture 20,000 34,827 20,000 57.43%
15 Penilaian MMT 20,000 30,294 20,000 66.02%
16 ROM 20,000 35,213 20,000 56.80%
17 Senam Hamil 20,000 33,928 20,000 58.95%
18 Vaksinasi dasar 31,237 20,000 64.03%
19 Aff Kateter 25,000 42,938 25,000 58.22%

20 Auditory Retraining 20,000 39,281 25,000 63.64%
21 Ingatan Bahasa 20,000 40,192 25,000 62.20%
22 Irigasi Telinga 20,000 39,283 25,000 63.64%
23 Klinik Memori 20,000 40,928 25,000 61.08%
24 Sensor-Motory Retraining 20,000 38,928 25,000 64.22%
25 Train The Brain 20,000 39,201 25,000 63.77%
26 Visual Retraining 20,000 40,163 25,000 62.25%
28 Aff Tampon Nasal 30,000 48,291 30,000 62.12%

29 Chiropraksi 53,948 30,000 55.61%
30 Daya Tahan 49,583 30,000 60.50%
31 Ekstraksi Clavus 48,394 30,000 61.99%
32 Ekstraksi Corpus Alienum Palpebra 30,000 48,923 30,000 61.32%
33 Ekstraksi Kolesteatom 51,827 30,000 57.88%
34 Ekstraksi Serumen 20,000 50,768 30,000 59.09%
35 Fitting Bandange Lens (1 Eye) 30,000 49,382 30,000 60.75%
36 IVA Test 39,500 30,000 75.95%
37 Kaustik Tenggorok 20,000 47,261 30,000 63.48%
38 Keseimbangan Dan Koordinasi 47,152 30,000 63.62%
39 Observasi < 8 Jam 20,000 53,928 30,000 55.63%
41 Pasang Spalk 20,000 47,174 30,000 63.59%
42 Pedagogic 30,000 48,372 30,000 62.02%
43 Pelatihan Posture 20,000 46,251 30,000 64.86%
45 Pernafasan Dan Relaksasi 20,000 49,281 30,000 60.88%
46 Probing 20,000 49,837 30,000 60.20%
47 Refraksi Anak 30,000 50,291 30,000 59.65%
48 Refraksi Dewasa 30,000 48,271 30,000 62.15%
49 Terapi Kerja 30,000 49,328 30,000 60.82%
50 Terapi Wicara 30,000 52,039 30,000 57.65%
51 Toilet Hidung 30,000 49,281 30,000 60.88%
52 Vitalisasi Otak (Ikhtisar) 20,000 48,653 30,000 61.66%

54 Inhalasi 20,000 57,068 35,000 61.33%
56 Vaginal Hygiene 10,000 56,692 35,000 61.74%
57 Ekstraksi Corpus Alienum Kornea 40,000 62,695 40,000 63.80%

58 Epilasi 30,000 62,938 40,000 63.55%
59 Hecting 1-5 20,000 70,181 40,000 57.00%
60 Hecting Palpebra 30,000 63,708 40,000 62.79%
61 Infus Pump 20,000 65,342 40,000 61.22%
62 Irigasi Mata 30,000 68,273 40,000 58.59%
63 Stimulasi - Terapi Behavior 71,203 40,000 56.18%
64 Stimulasi - Terapi Fisioterapi 70,845 40,000 56.46%
65 Stimulasi - Terapi Occupational 71,392 40,000 56.03%
66 Stimulasi - Terapi Speech 71,352 40,000 56.06%
67 Syringe Pump 20,000 67,263 40,000 59.47%
68 Toilet Hidung 30,000 70,128 40,000 57.04%
69 Visum 70,803 40,000 56.49%

71 Insisi Cross 40,000 76,283 45,000 58.99%
72 Kaustik Telinga 30,000 74,726 45,000 60.22%
73 Tindik 10,000 77,109 45,000 58.36%
74 Aff susuk KB 75,726 50,000 66.03%

75 Baby Gym 81,928 50,000 61.03%
76 Baby Massage 84,625 50,000 59.08%
77 Baby Spa 83,620 50,000 59.79%
78 Benda Asing Hidung Tanpa Anastesi 78,376 50,000 63.80%
79 Benda Asing Telinga Tanpa Anastesi 77,463 50,000 64.55%
80 Chloretyl Spray 40,000 81,928 50,000 61.03%
81 Dis Hallpike Manuver 75,625 50,000 66.12%
82 Ekstraksi Corpus Alienum 25,000 87,362 50,000 57.23%
83 Hecting >5 30,000 82,837 50,000 60.36%
84 Imobilisasi Dengan Elastic Verban 40,000 80,192 50,000 62.35%
85 Observasi ≥ 8 Jam 45,000 82,716 50,000 60.45%
87 Slit Lamp 10,000 82,039 50,000 60.95%
88 Snozelen/Sensory-Integrasi, Stimulasi-Terapi 40,000 79,203 50,000 63.13%
89 Suction 50,000 80,602 50,000 62.03%
91 Drainage Abses 40,000 91,764 55,000 59.94%

92 Akupunktur Penyakit 98,372 60,000 60.99%
93 Audiometri Nada Murni 98,307 60,000 61.03%
94 Benda Asing Tenggorokan 97,382 60,000 61.61%
95 Ekstraksi Komedo 50,000 97,483 60,000 61.55%
96 Elektroakupunktur 98,372 60,000 60.99%
97 Facial 102,938 60,000 58.29%
98 Infus Vitamin C Per Kunjungan 50,000 98,309 60,000 61.03%
99 KIL 50,000 99,483 60,000 60.31%
101 Pasang Tampon Hidung 50,000 101,827 60,000 58.92%
102 Pasang Tampon Telinga 100,293 60,000 59.82%
103 Podofilin 40,000 98,394 60,000 60.98%

105 WT Combustio ≤ 30 % 50,000 111,030 65,000 58.54%
106 Endoskopi Hidung 119,209 70,000 58.72%

107 Endoskopi Telinga 120,495 70,000 58.09%
108 Endoskopi Tenggorok 119,287 70,000 58.68%
109 Mantoux Test 30,000 75,372 70,000 92.87%
110 Paresentase/Miringotomi 40,000 82,394 70,000 84.96%
111 Aff IUD 50,000 128,502 75,000 58.37%
112 Cek Permanen Pace Maker 127,384 75,000 58.88%
113 Aquapunktur 110,293 80,000 72.53%
114 Aspirasi Cairan 40,000 132,837 80,000 60.22%
115 Debridement 40,000 137,362 80,000 58.24%
116 Ekstraksi Kuku 50,000 136,452 80,000 58.63%
117 Elektrokauter 50,000 135,029 80,000 59.25%
118 Eustachius Tube Function 120,394 80,000 66.45%
119 Injeksi Intra Artikuler 30,000 132,643 80,000 60.31%
120 Kumbah Lambung 45,000 132,736 80,000 60.27%
121 Pasang Implan 80,000 130,293 80,000 61.40%
122 Pasang IUD 80,000 132,049 80,000 60.58%
123 Refleks Akustik 121,298 80,000 65.95%
125 WT Combustio > 30 % 80,000 106,679 80,000 74.99%
126 Akupunktur Estetika 162,933 100,000 61.37%

127 Audiometri Tutur 158,403 100,000 63.13%
128 Insisi 40,000 167,416 100,000 59.73%
129 Insisi Abses Peritonsil 100,000 168,372 100,000 59.39%
130 Pap Smear 165,049 100,000 60.59%
131 Pasang susuk KB dengan anastesi lokal 153,827 100,000 65.01%
132 Peeling 156,203 100,000 64.02%
133 Psiko test 167,362 100,000 59.75%
134 Biopsi 50,000 201,939 120,000 59.42%

135 Brand Daroft Manuver 172,394 120,000 69.61%
136 Laserpunktur 246,397 120,000 48.70%
137 Reposisi 80,000 203,948 120,000 58.84%
138 Buka Gips Sesisi 208,376 125,000 59.99%
139 Aff Implan 150,000 252,938 150,000 59.30%

140 Insisi Hordoleum/Khalazion/Abses 150,000 247,298 150,000 60.66%
141 MMPI 252,838 150,000 59.33%
142 Punksi Asites 150,000 248,372 150,000 60.39%
143 Punksi Pleura 150,000 251,736 150,000 59.59%
145 Resusitasi 50,000 245,468 150,000 61.11%
146 Sensory Aqustic Level 245,459 150,000 61.11%
147 Buka Gips Sirkular 295,382 175,000 59.25%

148 Buka Gips Tabung 293,645 175,000 59.60%
149 Oto Acustic Emission 285,295 175,000 61.34%
150 Cryo 275,000 180,000 65.45%

151 Mikrodermabrasi 302,738 180,000 59.46%
152 Pleurodesis 302,839 180,000 59.44%
153 BERA tanpa sedasi 308,596 200,000 64.81%

154 Biopsi Jarum Halus (FNAB) 100,000 269,382 200,000 74.24%
155 Ekstirpasi 150,000 301,293 200,000 66.38%
156 FNAB guided USG 330,273 200,000 60.56%
157 Insisi Bartolin 150,000 300,000 200,000 66.67%
158 Pelayanan Hiperbarik Per Pelayanan 320,799 200,000 62.34%
159 Pungsi Asites/Pleura/Vesica guided USG 331,928 200,000 60.25%
160 Akupunktur Tanam Benang 400,000 250,000 62.50%

161 Eksisi 150,000 301,938 250,000 82.80%
162 Ekstirpasi Pterygium 250,000 420,394 250,000 59.47%
163 Holler Monitoring 412,736 250,000 60.57%
164 Kauter Condyloma 250,000 413,029 250,000 60.53%
165 Pasang Chest Tube 100,000 413,515 250,000 60.46%
166 Stress Echo Treadmill 413,263 250,000 60.49%
167 Tinitus Retaining Theraphy 428172 250,000 58.39%
168 Pasang Gips Sesisi 150,000 498,645 300,000 60.16%

169 Pasang Gips Sirkular 150,000 499,827 300,000 60.02%
170 Pasang Gips Tabung 150,000 501,827 300,000 59.78%
171 Pasang WSD 250,000 498,293 300,000 60.21%
172 Sirkumsisi 250,000 497,850 300,000 60.26%
173 Vena Secti 330,183 300,000 90.86%
174 Carotid Duplex Doppler 613,827 400,000 65.16%

175 Dermaroller 614,283 400,000 65.12%
176 Vasektomi 625,344 400,000 63.96%
177 Stress Echo Dobutamin (DSE) 726,354 500,000 68.84%

178 Vascular Tungkai Doppler 724,364 500,000 69.03%
179 Laser IPL 1,229,384 700,000 56.94%
D TINDAKAN GIGI DAN MULUT
1 Ekstraksi Gigi Sulung (Chlorethyl) 30,000 115,331 35,000 30.35%

2 Open Bur 30,000 63,548 35,000 55.08%
3 Bongkar Amalgam Filling 30,000 78,271 40,000 51.10%

4 Penambalan Sementara 30,000 76,253 40,000 52.46%
5 Terapi: Stomatitis, Ulkus/Kunjungan 30,000 76,272 40,000 52.44%
6 Ekstraksi Gigi Sulung dengan Injeksi 95,607 50,000 52.30%

7 Grinding 95,607 50,000 52.30%
8 Lepas bracket 173,625 75,000 43.20%

9 Penambahan open coil 161,535 75,000 46.43%
10 Penggantian wire 149,220 75,000 50.26%
11 Activier Ortho Removable 75,000 131,373 80,000 60.90%

12 Amalgam Filling Per Gigi 75,000 147,938 80,000 54.08%
13 Cementasi Per Gigi 75,000 148,273 80,000 53.95%
14 Cetak Per Rahang 75,000 151,884 80,000 52.67%
15 Composite Filling Per Gigi 75,000 149,203 80,000 53.62%
16 Debridement Gigi 75,000 151,029 80,000 52.97%
17 Flouridasi 75,000 151,928 80,000 52.66%
18 Insisi Abses Intra Oral 75,000 147,263 80,000 54.32%
19 Oclusal Adjusment Per Gigi 75,000 148,273 80,000 53.95%
20 Operculectomy Per Gigi 75,000 149,281 80,000 53.59%
21 Oral Profilaksis 75,000 148,923 80,000 53.72%
22 Pasang Pin Per Gigi 75,000 147,283 80,000 54.32%
23 Penambalan Composite 75,000 147,263 80,000 54.32%
24 Penambalan Glass Ionomer 75,000 148,273 80,000 53.95%
25 Perawatan Penyakit Mulut 75,000 149,823 80,000 53.40%
26 Perawatan Saluran Akar 75,000 150,296 80,000 53.23%
27 Pit Dan Fissur Sealant 75,000 148,539 80,000 53.86%
28 Terapi: Temporo Mandibular Junction / Kunjungan 75,000 150,753 80,000 53.07%
29 Trepanasi 132,602 80,000 60.33%
30 Activier Ortho Appliance 75,000 173,625 90,000 51.84%

31 Activier Ortho Dengan Penambahan Alat 75,000 245,142 90,000 36.71%
32 Apeksifikasi 75,000 164,897 90,000 54.58%
33 Ekstraksi Gigi Tetap 75,000 164,251 90,000 54.79%
34 Kuretase Gigi 75,000 233,453 90,000 38.55%
35 Scalling Per Rahang 75,000 161,424 90,000 55.75%
36 Penggantian bracket / pcs 203,262 100,000 49.20%

37 Gigi Tiruan Per Gigi 100,000 292,922 150,000 51.21%
38 Pengisian Saluran Akar (2 akar) 189,151 150,000 79.30%
39 Composite Crown 150,000 283,726 170,000 59.92%

40 Tambah Gigi Berikutnya 150,000 280,291 170,000 60.65%
41 Bleaching gigi non vital (per gigi) 250,000 200,000 80.00%
42 Core Build Up 150,000 332,883 200,000 60.08%
43 Ekstraksi Gigi Dengan Penyulit 200,000 344,945 200,000 57.98%
44 Insisi Abses Extra Oral 150,000 347,085 200,000 57.62%
45 Mahkota Sementara 200,000 331,928 200,000 60.25%
46 Reparasi Plat Ortho Dan Cetak 150,000 338,754 200,000 59.04%
47 Copping 250,000 415,827 250,000 60.12%

48 Gingivectomy Per Regio 250,000 462,193 250,000 54.09%
49 Labial Veneering Per Gigi 250,000 420,991 250,000 59.38%
50 Post Core 250,000 419,844 250,000 59.55%
51 Reline 250,000 422,939 250,000 59.11%
52 Reparasi Dan Cetak 250,000 417,090 250,000 59.94%
53 Alveolectomy 591,726 300,000 50.70%

54 Crown And Bridge Pfm Per Gigi 590,803 300,000 50.78%
55 Frenektomy 300,000 595,333 300,000 50.39%
56 Lingual Arct 300,000 502,329 300,000 59.72%
57 Occlusal Splint Per Gigi 300,000 501,233 300,000 59.85%
58 Palatal Arct 300,000 498,293 300,000 60.21%
59 Pengisian Saluran Akar 300,000 499,872 300,000 60.02%
60 Pengisian Saluran Akar Multiple (>3) 300,000 499,872 300,000 60.02%
61 Skin Prick Test 512,330 300,000 58.56%
62 Space Maintainer 300,000 497,992 300,000 60.24%
63 Bruxism 350,000 659,687 400,000 60.63%

64 Obturator Tanpa Gigi 350,000 668,374 400,000 59.85%
65 Plat Ortho Lepasan Per Rahang 300,000 659,384 400,000 60.66%
66 Rebase 350,000 658,849 400,000 60.71%
67 Bridge Work Dan Precious Metal Per Gigi 400,000 825,739 450,000 54.50%
68 Fiksasi Fraktur Rahang 400,000 840,920 450,000 53.51%
69 Free Gingival Graft 400,000 841,299 450,000 53.49%
70 Palatal Crib 400,000 827,463 450,000 54.38%
71 Porcelin Veneer (Facing) 400,000 831,448 450,000 54.12%
72 Crown Metal 500,000 998,509 500,000 50.07%

73 Gigi Tiruan Flexi 500,000 1,005,367 500,000 49.73%
74 Gigi Tiruan Sebagian 500,000 1,001,283 500,000 49.94%
75 Inlay/Outlay 500,000 1,002,938 500,000 49.85%
76 Maryland Bridge Per Gigi 500,000 994,837 500,000 50.26%
77 Retainer ortho per Rahang 415,724 500,000 120.27%
78 Odontectomy 500,000 1,325,348 800,000 60.36%

79 Crown Porcelin 1,200,000 2,165,384 1,300,000 60.04%
80 Gigi Tiruan Lengkap Logam 1 Elemen 1,200,000 2,166,739 1,300,000 60.00%
81 Gigi Tiruan Logam 1,200,000 2,163,829 1,300,000 60.08%
82 Gigi Tiruan Penuh 1 Rahang 1,200,000 2,168,729 1,300,000 59.94%
83 Fixed Appliance Gigi Standar Per Rahang 2,000,000 3,666,305 2,300,000 62.73%
84 Fixed Appliance Gigi Transparan Per Rahang 2,000,000 3,666,305 2,300,000 62.73%
E KAMAR RAWAT INAP
1 Tarif Kamar Bayi / Perawatan Bayi Sehat Per Hari 50,000 165,994 100,000 60.24%
2 Tarif Kamar ICU/ICCU 1,000,000 1,664,374 1,000,000 60.08%
3 Tarif Kamar Intermediate / HCU Per Hari 150,000 254,834 200,000 78.48%
4 Tarif Kamar Kelas I per Hari 499,378 300,000 60.07%
5 Tarif Kamar Kelas II per Hari 330,928 200,000 60.44%
6 Tarif Kamar Kelas III Per Hari 50,000 165,972 100,000 60.25%
7 Tarif Kamar NICU Per Hari 150,000 1,421,928 800,000 56.26%
8 Tarif Kamar Perinatologi / Perawatan Bayi Sakit Per Hari 150,000 254,364 200,000 78.63%
9 Tarif Kamar VIP 400,000 831,268 500,000 60.15%
10 Tarif Rawat Gabung Per Hari 255,283 150,000 58.76%
F TINDAKAN RAWAT INAP
1 Aff Infus 28,552 15,000 52.54%

3 Aff Nasogastric tube 30,000 20,000 66.67%

4 Kasur Dekubitus 20,000 34,629 20,000 57.76%
5 Klisma 20,000 26,337 20,000 75.94%
6 Oksigen 1 - 3 Liter / jam 31,287 20,000 63.92%
7 Pasang Infus 10,000 26,361 20,000 75.87%
8 Aff Kateter 25,000 42,938 25,000 58.22%

9 Penis Hygiene 41,209 25,000 60.67%
11 Aff Tampon Nasal 30,000 48,291 30,000 62.12%

12 Ekstraksi Corpus Alienum Palpebra 30,000 48,923 30,000 61.32%
13 Minimal Care 20,000 51,434 30,000 58.33%
15 Pasang Spalk 20,000 47,174 30,000 63.59%

18 Inhalasi 20,000 57,068 35,000 61.33%
19 Oksigen 4 - 6 Liter / jam 54,916 35,000 63.73%
20 Vaginal Hygiene 10,000 56,692 35,000 61.74%
21 Infus Pump 20,000 65,342 40,000 61.22%

22 Syringe Pump 20,000 67,263 40,000 59.47%
24 Injeksi Intra Artikuler 30,000 74,631 45,000 60.30%
25 Partial Care 73,968 45,000 60.84%
26 Imobilisasi Dengan Elastic Verban 40,000 80,192 50,000 62.35%
28 Suction 50,000 80,602 50,000 62.03%
30 Drainage Abses 40,000 91,764 55,000 59.94%

32 WT Combustio ≤ 30 % 50,000 111,030 65,000 58.54%
33 Aspirasi Cairan 40,000 132,837 80,000 60.22%

34 Debridement 40,000 137,362 80,000 58.24%
35 Kumbah Lambung 45,000 132,736 80,000 60.27%
36 Pasang Iud 80,000 132,049 80,000 60.58%
38 WT Combustio > 30 % 80,000 106,679 80,000 74.99%
39 Aff WSD 162,416 100,000 61.57%

40 Arthrocentresis 100,000 167,263 100,000 59.79%
41 Biopsi Jarum Halus (FNAB) 100,000 169,382 100,000 59.04%
42 Insisi 40,000 167,416 100,000 59.73%
43 Lumbal Pungsi 80,000 249,574 150,000 60.10%

44 Punksi Asites 150,000 248,372 150,000 60.39%
45 Punksi Pleura 150,000 251,736 150,000 59.59%
47 Resusitasi 50,000 245,468 150,000 61.11%
48 Tindakan Pemasangan Transfusi 287,352 170,000 59.16%

49 Oto Acustic Emission 285,295 175,000 61.34%
50 Eksisi 150,000 301,938 180,000 59.61%
51 Ekstirpasi 150,000 301,293 180,000 59.74%
52 Insisi Bartolin 150,000 300,000 200,000 66.67%

56 Pasang WSD 498,293 300,000 60.21%
57 Vena Secti 330,183 300,000 90.86%
G RAWAT INAP ISOLASI DAN INTENSIF
1 Warmer Blanket Per Jam 16,253 10,000 61.53%

4 Kasur Dekubitus 20,000 34,629 25,000 72.19%

5 Oral Hygine 39,787 25,000 62.83%
6 Perawatan Bayi Baru Lahir 37,866 25,000 66.02%
7 Penis Hygiene 41,209 30,000 72.80%

9 Pasang Infus 10,000 56,688 35,000 61.74%
12 Single Nasal Pronge 57,542 35,000 60.82%
13 Surface Cooling 55,260 35,000 63.34%
14 Inhalasi 20,000 57,068 40,000 70.09%

15 Vaginal Hygiene 10,000 56,692 40,000 70.56%
16 Monitor 45,000 75,243 45,000 59.81%

17 Pasang Inkubator Transport 73,029 45,000 61.62%
18 Ekstubasi 66,352 50,000 75.36%

19 Infus Pump 20,000 65,342 50,000 76.52%
20 Suction 50,000 66,374 50,000 75.33%
21 Syringe Pump 20,000 67,263 50,000 74.34%
22 Aff CPAP 100,000 60,000 60.00%

23 Oksigen > 7 Liter / jam 101,372 60,000 59.19%
24 Total Care 102,244 60,000 58.68%

27 Blue Light Per Hari 45,000 121,039 75,000 61.96%

28 WT Combustio < 30 % 50,000 120,948 75,000 62.01%
29 WT Combustio > 30 % 80,000 106,679 85,000 79.68%

30 Aspirasi Cairan 40,000 132,837 90,000 67.75%
31 Debridement 40,000 137,362 90,000 65.52%
32 Resusitasi 50,000 245,468 150,000 61.11%

33 Resusitasi Neonatus 245,468 150,000 61.11%
34 Warmer Blanket per Hari 251,827 150,000 59.56%

37 Pasang Kateter Umbilikal 60,000 286,739 200,000 69.75%

40 Vena Secti 330,183 300,000 90.86%
41 Pasang Arteri Line 534,262 350,000 65.51%
42 Pasang CPAP 640,684 350,000 54.63%
43 CPAP hari berikutnya 350,000 200,000 57.14%
44 Pasang CVP 647,362 350,000 54.07%
45 Pasang WSD 498,293 350,000 70.24%
46 Pasang Ventilator 834,283 500,000 59.93%

47 Ventilator hari berikutnya 498,293 350,000 70.24%
H PERSALINAN
1 Inspekulo 30,000 20,000 66.67%

3 Perawatan Tali Pusat 29,856 20,000 66.99%
4 Induksi Dengan Folley Catether 20,000 52,933 30,000 56.68%

5 Pemeriksaan Air Ketuban 10,000 46,547 30,000 64.45%
6 Vaginal Hygiene 10,000 56,692 30,000 52.92%
8 Douglas Pungsi 50,000 70,000 50,000 71.43%

10 Induksi/Akselerasi Persalinan 97,273 70,000 71.96%
11 Aff IUD 50,000 124,502 80,000 64.26%

12 Pasang IUD 80,000 132,049 80,000 60.58%
13 Eksplorasi Placenta 100,000 138,715 100,000 72.09%

14 Kompresi Bimanual Eksternal 140,024 100,000 71.42%
15 Kompresi Bimanual internal 140,024 100,000 71.42%
16 Doppler 150,000 212,870 150,000 70.47%
17 Forceps 202,220 150,000 74.18%
18 Vacuum 202,220 150,000 74.18%
20 Hidrotubasi 200,000 289,384 200,000 69.11%

21 Insisi Bartolin 150,000 300,000 200,000 66.67%
22 Kuret Dengan AVM 20,000 247,824 200,000 80.70%
24 Pasang Laminaria 200,000 279,280 200,000 71.61%

26 Hecting Perineum 100,000 386,751 270,000 69.81%
27 Hecting Portio 425,783 300,000 70.46%

29 Manual Plasenta 601,827 400,000 66.46%

30 Manual Plasenta dengan narkose 754,625 500,000 66.26%
31 Kauter Condyloma 974,639 750,000 76.95%
32 Circlage 1,029,384 850,000 82.57%
33 Kuretase 500,000 1,485,073 900,000 60.60%
34 Persalinan Normal 600,000 1,512,495 1,000,000 66.12%
35 Persalinan Dengan Penyulit 1,000,000 2,257,445 1,350,000 59.80%
36 Persalinan Dengan Penyulit II 1,200,000 2,808,934 1,700,000 60.52%
37 Persalinan Dengan Penyulit III 1,500,000 3,470,721 2,100,000 60.51%
I HAEMODIALISA
1 Aff Double Lumen 251,827 200,000 79.42%

2 Pasang Double Lumen 335,102 350,000 104.45%
3 Haemodialisa Re-Use 837,018 600,000 71.68%
4 Haemodialisa 1,018,273 800,000 78.56%
5 Haemodialisa Emergency 1,186,394 900,000 75.86%
J RADIOLOGI
1 Dental 50,000 87,272 60,000 68.75%

2 Abdomen Polos 75,000 139,371 90,000 64.58%
3 Ankle Joint 75,000 156,089 90,000 57.66%
4 Clavicula 75,000 156,222 90,000 57.61%
5 Hip Joint 75,000 149,958 90,000 60.02%
6 Humerus 75,000 141,285 90,000 63.70%
7 Mandibula 75,000 154,827 90,000 58.13%
8 Manus 75,000 155,439 90,000 57.90%
9 Mastoid (Schuller) 75,000 141,300 90,000 63.69%
10 Pedis 75,000 156,178 90,000 57.63%
11 Pelvis 75,000 157,862 90,000 57.01%
12 Scapula 75,000 141,161 90,000 63.76%
13 Shoulder Joint 75,000 155,484 90,000 57.88%
14 Sinus Paranasal Water'S-Lateral 75,000 156,439 90,000 57.53%
15 Temporomandibular Joint 75,000 147,894 90,000 60.85%
16 Vertebrae Coccygeus 75,000 147,376 90,000 61.07%
17 Wrist Joint 75,000 140,625 90,000 64.00%
18 Anklejoint AP-Lateral 75,000 134,543 100,000 74.33%

19 Antebrachi AP-Lateral 75,000 157,645 100,000 63.43%
20 Cruris AP-Lateral 75,000 156,043 100,000 64.08%
21 Cubiti AP-Lateral 75,000 146,903 100,000 68.07%
22 Femur AP-Lateral 75,000 157,917 100,000 63.32%
23 Genu AP- Lateral 75,000 156,024 100,000 64.09%
24 Humerus AP-Lateral 75,000 141,292 100,000 70.78%
25 Manus AP-Oblique 75,000 157,643 100,000 63.43%
26 Nasal AP-Lateral 75,000 144,461 100,000 69.22%
27 Pedis AP-Oblique 75,000 141,292 100,000 70.78%
28 Thorax AP/Lateral 75,000 161,520 100,000 61.91%
29 Thorax Top Lordotic 75,000 136,329 100,000 73.35%
30 Vertebrae Cervikal 2 Posisi 75,000 173,625 100,000 57.60%
31 Wrist Joint AP-Lateral 75,000 141,271 100,000 70.79%
32 Schedell AP-Lateral 75,000 178,561 110,000 61.60%

33 Vertebrae Lumbal 100,000 185,779 110,000 59.21%
34 Vertebrae Lumbosacral 100,000 185,078 110,000 59.43%
35 Abdomen 2 Posisi 75,000 155,161 120,000 77.34%

36 Appedicogram 156,358 120,000 76.75%
37 Cephalometri 100,000 194,036 120,000 61.84%
38 Vertebrae Thoracal 100,000 195,256 120,000 61.46%
39 Vertebrae Thoracolumbal 100,000 193,689 120,000 61.96%
40 Babygram 236,890 140,000 59.10%

41 Abdomen 3 Posisi 100,000 156,543 150,000 95.82%
42 Sinus Paranasalis 3 Posisi 75,000 156,246 150,000 96.00%
43 Cephalometri 150,000 284,362 170,000 59.78%
44 Panoramic 150,000 283,945 170,000 59.87%
45 USG Abdomen 150,000 251,693 200,000 79.46%

46 USG Buli Buli 251,928 200,000 79.39%
47 USG Ginjal 100,000 249,834 200,000 80.05%
48 USG Kebidanan 100,000 250,934 200,000 79.70%
49 USG Kepala Bayi 252,837 200,000 79.10%
50 USG Liver Dan Kandung Empedu 100,000 251,632 200,000 79.48%
51 USG Mammae 100,000 250,395 200,000 79.87%
52 USG Mata 250,395 200,000 79.87%
53 USG Muskuloskeletal 100,000 251,623 200,000 79.48%
54 USG Prostat 252,394 200,000 79.24%
55 USG Testis 248,374 200,000 80.52%
56 USG Thorax 100,000 249,691 200,000 80.10%
57 USG Thyroid 100,000 249,285 200,000 80.23%
58 USG Vascular Dopler 250,394 200,000 79.87%
59 Vertebrae Cervikal 4 Posisi 100,000 206,135 200,000 97.02%
60 Oesofagografi 200,000 410,483 250,000 60.90%
61 RPG 200,000 413,283 250,000 60.49%
62 HSG 200,000 493,920 300,000 60.74%
63 BNO/IVP 250,000 665,243 400,000 60.13%
K LABORATORIUM KLINIK
1 Pemeriksaan cross check (Rujukan Uji Silang) 8,000 15,121 10,000 66.13%
2 Eosinofil 15,000 25,483 15,000 58.86%
3 Feses Rutin 15,000 26,374 15,000 56.87%
4 Filaria 15,000 24,734 15,000 60.65%
5 LED 15,000 25,365 15,000 59.14%
6 Retikulosit 15,000 24,885 15,000 60.28%
7 Sediaan Jamur (KOH) 15,000 26,354 15,000 56.92%
8 Sedimen Urine 15,000 24,958 15,000 60.10%
9 Waktu Pembekuan 15,000 24,499 15,000 61.23%
10 Waktu Perdarahan 15,000 24,979 15,000 60.05%
11 Glukosa 2 Jam PP 25,000 40,721 25,000 61.39%

12 Glukosa Puasa 25,000 40,721 25,000 61.39%
13 Glukosa Sewaktu 25,000 40,721 25,000 61.39%
14 Golongan Darah + Rhesus 25,000 45,743 25,000 54.65%
15 Beta hCG Urine 30,000 49,282 30,000 60.87%

16 Sediaan BTA MH 30,000 52,384 30,000 57.27%
17 SGOT 30,000 51,293 30,000 58.49%
18 SGPT 30,000 51,293 30,000 58.49%
19 Sputum BTA 3X 30,000 49,837 30,000 60.20%
20 Urine Lengkap 48,106 30,000 62.36%
21 Albumin 30,000 58,200 35,000 60.14%

22 Asam Urat 30,000 62,328 35,000 56.15%
23 Asam Urat Urine 24 Jam 30,000 58,475 35,000 59.85%
24 Biliribin Indirect 35,000 58,717 35,000 59.61%
25 Bilirubin Direct 35,000 56,391 35,000 62.07%
26 Bilirubin Total 35,000 55,851 35,000 62.67%
27 Globulin 30,000 59,827 35,000 58.50%
28 Kolesterol Total 30,000 59,409 35,000 58.91%
29 Kreatinin 30,000 60,372 35,000 57.97%
30 Kreatinin Urine 24 Jam 30,000 58,374 35,000 59.96%
31 Malaria 15,000 60,948 35,000 57.43%
32 Pewarnaan Gram 30,000 56,352 35,000 62.11%
33 Protein Total 30,000 58,473 35,000 59.86%
34 Trigliserida 30,000 59,837 35,000 58.49%
35 Ureum 30,000 60,449 35,000 57.90%
36 Ureum Urine 24 Jam 30,000 59,845 35,000 58.48%
37 Darah Rutin (Hb+Ht+Leuko+Trombo) 40,000 70,498 40,000 56.74%

38 Feses Lengkap 35,000 67,876 40,000 58.93%
39 Alkali Fosfatase 40,000 75,645 45,000 59.49%
40 Calcium Total 35,000 75,392 45,000 59.69%
41 Gamma GT 40,000 74,625 45,000 60.30%
42 Magnesium 35,000 76,635 45,000 58.72%
43 RPR 77,010 45,000 58.43%
44 Amphetamine 50,000 80,257 50,000 62.30%

45 ASTO 35,000 84,921 50,000 58.88%
46 Benzodiazepin 50,000 80,257 50,000 62.30%
47 Calcium Urine 50,000 82,364 50,000 60.71%
48 Darah Lengkap (Darah Rutin+Hitung Jenis+E+NER+LED) 50,000 80,127 50,000 62.40%
49 HDL 40,000 81,724 50,000 61.18%
50 IT-Ratio 40,000 83,726 50,000 59.72%
51 LDH 35,000 83,129 50,000 60.15%
52 LDL 40,000 82,635 50,000 60.51%
53 Magnesium Urine 50,000 82,304 50,000 60.75%
54 Mariyuana 50,000 81,726 50,000 61.18%
55 Morfin/Opiat 50,000 82,763 50,000 60.41%
56 Phospor 50,000 83,462 50,000 59.91%
57 Phospor Urine 50,000 84,210 50,000 59.38%
58 Rheumatoid Faktor 30,000 84,625 50,000 59.08%
59 Tes Cepat Molekuler tanpa Cartridge (subsidi / hibah) 516,293 50,000 9.68%
60 TTGO 50,000 83,746 50,000 59.70%
61 VDRL 30,000 69,485 50,000 71.96%
62 Widal 40,000 85,886 50,000 58.22%
63 Bersihan Kreatinin Urine 24 Jam 60,000 100,127 60,000 59.92%

64 CK-MB 70,000 127,870 75,000 58.65%
65 Gambaran Darah Tepi 70,000 121,841 75,000 61.56%
66 Amylase 70,000 133,023 80,000 60.14%

67 Analisa Sperma 70,000 133,129 80,000 60.09%
68 Chlorida 80,000 132,248 80,000 60.49%
69 Kalium 80,000 131,284 80,000 60.94%
70 Kolinesterase 80,000 132,945 80,000 60.18%
71 Leptospira IgM 60,000 132,435 80,000 60.41%
72 Natrium 80,000 132,938 80,000 60.18%
73 TPHA 80,000 133,423 80,000 59.96%
74 APTT 70,000 152,436 90,000 59.04%

75 CRP 80,000 150,885 90,000 59.65%
76 PT 60,000 153,762 90,000 58.53%
77 Anti HBs 100,000 165,616 100,000 60.38%
78 Anti HCV (ELISA) 100,000 166,804 100,000 59.95%
79 Elektrolit (Na, K, Cl) 80,000 165,971 100,000 60.25%
80 Fibrinogen 60,000 165,329 100,000 60.49%
81 HbsAg 100,000 167,263 100,000 59.79%
82 Salmonella IgM Typhi (Tubex) 164,392 100,000 60.83%
83 Serum Iron 80,000 167,342 100,000 59.76%
84 TIBC 80,000 166,985 100,000 59.89%
85 Trombin Time 80,000 164,295 100,000 60.87%
86 Agregasi Trombosit 100,000 201,843 120,000 59.45%

87 Analisa Gas Darah 201,729 120,000 59.49%
88 D Dimer 100,000 199,827 120,000 60.05%
89 HbsAg (ELISA) 100,000 198,235 120,000 60.53%
90 Mikro Albumin Urin 24 Jam 100,000 199,382 120,000 60.19%
91 T3 100,000 200,837 120,000 59.75%
92 T4 100,000 201,746 120,000 59.48%
93 TSH 100,000 200,264 120,000 59.92%
94 CD4 120,000 218,413 130,000 59.52%

95 CD8 120,000 217,817 130,000 59.68%
96 AFP 120,000 235,273 140,000 59.51%

97 Anti HbsAg (ELISA) 120,000 237,362 140,000 58.98%
98 Anti HIV 140,000 232,319 140,000 60.26%
99 Apo B 120,000 235,918 140,000 59.34%
100 CEA 120,000 234,183 140,000 59.78%
101 G6PD 120,000 236,354 140,000 59.23%
102 Dengue Antigen NS1 249,586 150,000 60.10%

103 Dengue IgG IgM 140,000 250,398 150,000 59.90%
104 Analisa Batu 120,000 265,932 160,000 60.17%
105 Feritin 160,000 267,463 160,000 59.82%
106 Hba1C 140,000 249,837 160,000 64.04%
107 Peroksidase 140,000 266,986 160,000 59.93%
108 Anti CMV IgG 140,000 300,120 180,000 59.98%

109 Anti HIV 1-2 (ELISA) 140,000 299,083 180,000 60.18%
110 Anti HSV 1 IgG 160,000 299,473 180,000 60.11%
111 Anti HSV 1 IgM 160,000 299,374 180,000 60.13%
112 Anti HSV 2 IgG 160,000 301,635 180,000 59.67%
113 Anti HSV 2 IgM 160,000 301,738 180,000 59.65%
114 Anti Toksoplasma IgG (ELISA) 140,000 297,490 180,000 60.51%
115 Anti Toxoplasma IgM (Elisa) 160,000 301,265 180,000 59.75%
116 Apo A 140,000 299,857 180,000 60.03%
117 Elektrolit Urine (Na, K, Cl) 140,000 298,938 180,000 60.21%
118 Free T4 160,000 298,465 180,000 60.31%
119 Troponin T 160,000 297,463 180,000 60.51%
120 Anti Rubella IgG 200,000 331,746 200,000 60.29%

121 Anti Rubella IgM 200,000 331,837 200,000 60.27%
122 CRP Kuantitatif 351,237 200,000 56.94%
123 ANA 160,000 376,192 225,000 59.81%

124 Anti CMV IgM 225,000 376,298 225,000 59.79%
125 Anti HAV IgM 225,000 372,438 225,000 60.41%
126 Anti HAV Total 377,923 225,000 59.54%
127 Anti TB IgG Titer 160,000 373,482 225,000 60.24%
128 FSH 160,000 374,927 225,000 60.01%
129 IDT, ICT (Amoeba) 225,000 371,948 225,000 60.49%
130 IgE Total 200,000 374,274 225,000 60.12%
131 LH 160,000 375,019 225,000 60.00%
132 MCA (Payudara) 225,000 374,659 225,000 60.05%
133 Prolactin 225,000 375,298 225,000 59.95%
134 Sudan Black B 140,000 375,629 225,000 59.90%
135 Transferin 160,000 376,291 225,000 59.79%
136 Analisa Hb 225,000 416,231 250,000 60.06%

137 Anti ds-DNA 225,000 416,932 250,000 59.96%
138 Beta hCG Serum 225,000 418,236 250,000 59.77%
139 Calcium Ion 225,000 416,254 250,000 60.06%
140 Cortisol 225,000 418,032 250,000 59.80%
141 C-Peptide 225,000 417,029 250,000 59.95%
142 Estradiol 225,000 416,893 250,000 59.97%
143 Faktor VIII 225,000 418,746 250,000 59.70%
144 LP (a) 225,000 417,645 250,000 59.86%
145 Progesteron 225,000 417,362 250,000 59.90%
146 PSA (total) 225,000 417,364 250,000 59.90%
147 Salmonella IgG Typhi 225,000 417,364 250,000 59.90%
148 Tes Cepat Molekuler dengan Cartridge (TBRO, Hepatitis) 355,723 250,000 70.28%
149 Testosteron 225,000 415,980 250,000 60.10%
150 C3 Komplemen 225,000 499,247 300,000 60.09%

151 C4 Komplemen 225,000 500,129 300,000 59.98%
152 Ca 15-3 (Payudara) 225,000 498,277 300,000 60.21%
153 Comb Test 225,000 498,273 300,000 60.21%
154 Cyfra 21-1 (Paru) 250,000 501,823 300,000 59.78%
155 Kultur MO + Resistensi Anaerob 200,000 499,382 300,000 60.07%
156 ACA IgG 225,000 581,354 350,000 60.20%

157 ACA IgM 225,000 582,645 350,000 60.07%
158 Ca-125 (Ovarium) 225,000 584,625 350,000 59.87%
159 Ca-19-9 (Pankreas) 225,000 584,137 350,000 59.92%
160 Tes EID RNA DNA 572,297 400,000 69.89%
161 Asam Folat 400,000 751,723 450,000 59.86%
162 Ca 724 (Lambung) 250,000 750,387 450,000 59.97%
163 Protein C 400,000 837,264 500,000 59.72%

164 Protein S 400,000 835,473 500,000 59.85%
165 Measles IgG 400,000 1,163,754 700,000 60.15%

166 Measles IgM 400,000 1,164,827 700,000 60.09%
167 Viral Load (HIV) 400,000 1,667,018 1,000,000 59.99%

168 Western Blood 400,000 1,665,374 1,000,000 60.05%
L LABORATORIUM PATOLOGI ANATOMI
1 Pulasan Khusus: BTA, H.Pylori 40,000 74,635 50,000 66.99%

2 Serviks/Vagina/Sputum 1 x 65,000 137,462 100,000 72.75%
3 Bilasan Bronkus 100,000 334,928 250,000 74.64%
4 Cairan Pleura 100,000 332,948 250,000 75.09%
5 FNAB 100,000 332,904 250,000 75.10%
6 Serviks Thin Prep 150,000 333,857 250,000 74.88%
7 Sikatan Bronkus 100,000 331,615 250,000 75.39%
8 Sputum 3 x 100,000 331,982 250,000 75.31%
9 Urine 100,000 334,019 250,000 74.85%
10 Biopsi/Jaringan Kecil (Apendiks, Kuret, KGB, Kulit) 210,000 499,283 350,000 70.10%
11 FNAB (tindakan oleh DSPA) 275,000 500,192 350,000 69.97%
12 Jaringan Besar (Mastektomi, Histerektomi, Usus) 275,000 583,746 500,000 85.65%
13 Imunohistokimia 600,000 1,165,028 800,000 68.67%
14 Potong Beku 750,000 1,332,374 1,000,000 75.05%
15 Imuhistokimia 1,400,000 1,865,374 1,500,000 80.41%
M BANK DARAH
1 Biaya Darah Titip 49,958 30,000 60.05%
2 Ice Packed 49,857 30,000 60.17%
3 Pemeriksaan Golongan Darah Metode Slide 50,384 30,000 59.54%
4 Cool Box Lengkap 66,684 50,000 74.98%
5 Biaya Cross Match 103,746 70,000 67.47%
6 Buku Formulir Permintaan Darah Rangkap 4 102,847 70,000 68.06%
7 Pemeriksaan Golongan Darah Metode Tabung 102,374 70,000 68.38%
8 Sel Panel Kecil untuk Skrining Antibodi 133,283 90,000 67.53%
9 Fresh Frozen Plasma (FFP) 332,903 250,000 75.10%
10 Packed Red Blood Cell (PRC) 335,283 250,000 74.56%
11 Trombocyt Concentrate (TC) 336,283 250,000 74.34%
12 Wash Eritrocyt (WE) 334,928 250,000 74.64%
13 Whole Blood (WB) 335,241 250,000 74.57%
14 Pemeriksaan Rhesus Typing 499,273 350,000 70.10%
15 Pemeriksaan Comb Test 582,109 400,000 68.72%
16 Pemeriksaan Incompatible 583,225 400,000 68.58%
17 Sel Panel Besar untuk Identifikasi Antibodi 751,420 550,000 73.19%
18 Sel Panel Lengkap yaitu Sel Panel Besar dan Kecil 836,792 600,000 71.70%
19 Darah NAT 835,241 800,000 95.78%
N KAMAR OPERASI
1 Operasi Kecil 3,172,638 2,000,000 63.04%

2 Operasi Aulvulsi Pterygium 8,178,840 2,000,000 24.45%
3 Operasi Eksisi Granulasi Telinga 3,172,638 2,000,000 63.04%
4 Operasi Sirkumsisi 1,800,000 3,047,585 2,000,000 65.63%
5 Operasi Sedang 5,647,362 3,000,000 70.83%

6 Operasi Abses Submandibula 4,029,384 3,000,000 74.45%
7 Operasi Adheliolisis 2,250,000 3,784,736 3,000,000 79.27%
8 Operasi Aff Implan 3,000,000 4,962,639 3,000,000 60.45%
9 Operasi Alveolectomy 4,029,384 3,000,000 74.45%
10 Operasi Anoplastik 2,250,000 3,774,653 3,000,000 79.48%
11 Operasi Antrostomi Unilateral 3,798,273 3,000,000 78.98%
12 Operasi Biopsi Dalam Tubuh (Berbagai Jenis) 3,784,625 3,000,000 79.27%
13 Operasi Biopsi Saraf Kutaneus/Otot 2,250,000 3,788,675 3,000,000 79.18%
14 Operasi Blok Saraf Tepi 2,250,000 3,783,754 3,000,000 79.29%
15 Operasi Dilatasi Dan Kuretase Untuk Biopsi 2,250,000 3,777,465 3,000,000 79.42%
16 Operasi Drainase (Insisi Abses Ekstra Oral) 3,782,716 3,000,000 79.31%
17 Operasi Drainase Abses Pada Otot 3,692,837 3,000,000 81.24%
18 Operasi Duktus Thyroglosus Simple 2,250,000 4,575,934 3,000,000 65.56%
19 Operasi Eksisi Arthoplasti Sendi Kecil 5,001,928 3,000,000 59.98%
20 Operasi Eksisi Dengan Penyulit 2,400,000 4,400,873 3,000,000 68.17%
21 Operasi Eksisi FAM 3,000,000 4,991,547 3,000,000 60.10%
22 Operasi Eksisi Fibroma 4,587,697 3,000,000 65.39%
23 Operasi Eksisi Ginekomasti 3,000,000 5,023,764 3,000,000 59.72%
24 Operasi Eksisi Hemangioma 2,250,000 4,547,293 3,000,000 65.97%
25 Operasi Eksisi Mamae Aberans 2,250,000 4,556,748 3,000,000 65.84%
26 Operasi Eksisi Tumor < 1 cm Konjunctiva Lokal 2,400,000 4,998,374 3,000,000 60.02%
27 Operasi Eksisi Tumor > 1cm Konjunctiva Lokal 2,400,000 5,002,837 3,000,000 59.97%
28 Operasi Eksplorasi Plexus Cervical/Branchialis 2,250,000 4,549,856 3,000,000 65.94%
29 Operasi Eksplorasi Vagina 2,250,000 4,550,493 3,000,000 65.93%
30 Operasi Ekstirpasi (Leher) 2,250,000 3,713,856 3,000,000 80.78%
31 Operasi Ekstirpasi Kista Bartholin 2,250,000 4,559,847 3,000,000 65.79%
32 Operasi Ekstirpasi Mioma Geburt 2,250,000 4,609,384 3,000,000 65.08%
33 Operasi Ekstraksi Gigi Dan Komplikasi 3,928,371 3,000,000 76.37%
34 Operasi Excochleatie & Ekstraksi Gigi 4,182,736 3,000,000 71.72%
35 Operasi Fistulektomi 2,250,000 4,559,833 3,000,000 65.79%
36 Operasi Ganglion 2,250,000 4,560,934 3,000,000 65.78%
37 Operasi Gastrostomi Paliatif 2,250,000 4,565,938 3,000,000 65.70%
38 Operasi Glosectomi 2,250,000 4,568,395 3,000,000 65.67%
39 Operasi Hernia Umbilical 2,250,000 4,570,943 3,000,000 65.63%
40 Operasi Hidrocelectomi 2,250,000 3,750,015 3,000,000 80.00%
41 Operasi Katarak SICS +IOL (ECCE) 3,000,000 5,013,466 3,000,000 59.84%
42 Operasi Keloid Multipel > 5 2,250,000 4,572,465 3,000,000 65.61%
43 Operasi Konisasi 2,250,000 4,573,948 3,000,000 65.59%
44 Operasi Koreksi Osteotomi Simpel 3,791,827 3,000,000 79.12%
45 Operasi Laparoscopy Diagnostic 4,574,823 3,000,000 65.58%
46 Operasi Lipoma > 3 2,250,000 4,574,946 3,000,000 65.57%
47 Operasi Mc. Donald/Shirodcar 2,250,000 4,575,867 3,000,000 65.56%
48 Operasi Odontektomi 2 Gigi 5,142,736 3,000,000 58.33%
49 Operasi Pasang Gips Telinga & Hidung 4,603,654 3,000,000 65.17%
50 Operasi Pengambilan Dislokasi IUD 2,250,000 3,750,300 3,000,000 79.99%
51 Operasi Penutupan Oaf 5,119,283 3,000,000 58.60%
52 Operasi Perineum 2,250,000 4,963,764 3,000,000 60.44%
53 Operasi Polip Rekti 2,250,000 4,580,294 3,000,000 65.50%
54 Operasi Pungsi Cairan Otak 2,250,000 4,590,384 3,000,000 65.35%
55 Operasi Repair Otot 2,250,000 4,585,867 3,000,000 65.42%
56 Operasi Reparasi Burst Abdomen 2,250,000 4,562,847 3,000,000 65.75%
57 Operasi Replantasi Gigi 4,928,374 3,000,000 60.87%
58 Operasi Reposisi Uterus Pada Inversio Uteri 2,250,000 4,590,298 3,000,000 65.36%
59 Operasi Reseksi Apex Gigi Belakang (>1 Akar) 4,992,837 3,000,000 60.09%
60 Operasi Sirklase 2,250,000 4,586,947 3,000,000 65.40%
61 Operasi Tonsilektomi tanpa Adenoidektomi 4,726,354 3,000,000 63.47%
62 Operasi Tubektomi Post Partum 2,250,000 4,593,840 3,000,000 65.30%
63 Operasi Tumor Lid Margin < 1/3 Palpebra Lokal 2,250,000 3,768,475 3,000,000 79.61%
64 Operasi Tumor Lid Margin > 1/3 Palpebra Lokal 2,400,000 4,974,657 3,000,000 60.31%
65 Operasi WSD Kasus Trauma 2,250,000 4,601,864 3,000,000 65.19%
66 Operasi Tonsilektomi dengan Adenoidektomi 5,237,465 3,500,000 66.83%
67 Operasi Bone Graft 3,000,000 5,832,746 4,000,000 68.58%

68 Operasi Eksisi + Graft 3,500,000 5,802,558 4,000,000 68.94%
69 Operasi Eksternal Drainage 3,500,000 5,599,698 4,000,000 71.43%
70 Operasi Fiksasi Rahang 5,850,293 4,000,000 68.37%
71 Operasi Kistektomy 3,500,000 5,867,364 4,000,000 68.17%
72 Operasi Necrotomi/Debridement 3,000,000 5,601,544 4,000,000 71.41%
73 Operasi Pungsi Kista Bedah Mulut 5,482,734 4,000,000 72.96%
74 Operasi Sectio Caesarea 3,500,000 5,605,939 4,000,000 71.35%
75 Operasi Sequestrektomi 5,437,293 4,000,000 73.57%
76 Operasi Eksisi Tumor Jaringan Lunak 3,000,000 5,852,823 4,000,000 68.34%
77 Operasi Tumor Mammae 3,000,000 5,841,823 4,000,000 68.47%
78 Operasi Varicocelektomi 3,000,000 5,835,263 4,000,000 68.55%
79 Operasi Besar 7,352,638 4,500,000 61.20%

80 Operasi Anastomosis Ileum Desenden 3,500,000 7,251,827 4,500,000 62.05%
81 Operasi Antrostomi Bilateral 7,362,537 4,500,000 61.12%
82 Operasi Appendiktomi 3,500,000 7,249,412 4,500,000 62.07%
83 Operasi CAPD 3,500,000 7,249,342 4,500,000 62.07%
84 Operasi Colostomi 3,500,000 7,252,315 4,500,000 62.05%
85 Operasi Colosystectomi 3,500,000 7,250,374 4,500,000 62.07%
86 Operasi Diseksi KGB Retroperitoneal 3,500,000 7,248,907 4,500,000 62.08%
87 Operasi Drainage Abses Liver 3,500,000 7,249,830 4,500,000 62.07%
88 Operasi Eksisi Tumor < 1cm Konjungtiva 3,750,000 7,082,537 4,500,000 63.54%
89 Operasi Eksisi Tumor > 1 cm Konjungtiva 3,750,000 7,083,746 4,500,000 63.53%
90 Operasi Eksisi Tumor Kistik 3,500,000 7,248,783 4,500,000 62.08%
91 Operasi Ekstirpasi Tumor < 1cm Palpebra Superior/Inferior Lokal 3,750,000 6,676,253 4,500,000 67.40%
92 Operasi Ekstirpasi Tumor > 1cm Palpebra Superior/Inferior Lokal 3,750,000 6,665,342 4,500,000 67.51%
93 Operasi Enukleasi (Ekstirpasi) Kompleks Bedah Mulut 7,263,847 4,500,000 61.95%

94 Operasi Eviserasi 3,500,000 7,251,920 4,500,000 62.05%
95 Operasi Fistulektomi Bedah Mulut 7,735,465 4,500,000 58.17%
96 Operasi Hemoroidektomi Interna 3,500,000 7,253,865 4,500,000 62.04%
97 Operasi Hernia Incarcerata 3,500,000 7,250,990 4,500,000 62.06%
98 Operasi Herniatomi 3,000,000 7,081,283 4,500,000 63.55%
99 Operasi Herniatomi Bilateral 3,500,000 7,251,341 4,500,000 62.06%
100 Operasi Herniatomi Residif 3,500,000 7,249,089 4,500,000 62.08%
101 Operasi Impaksi Sisi Khusus Bedah Mulut 7,263,547 4,500,000 61.95%
102 Operasi Kista Duktus Thyroglosus 3,500,000 7,250,897 4,500,000 62.06%
103 Operasi Kista Ovarium 3,750,000 7,252,012 4,500,000 62.05%
104 Operasi Kolesistektomi 3,500,000 7,248,989 4,500,000 62.08%
105 Operasi Kolpodeksis 3,500,000 7,248,210 4,500,000 62.08%
106 Operasi Kontraktur Released 3,500,000 7,250,901 4,500,000 62.06%
107 Operasi Laparascopy MOW 3,750,000 6,642,824 4,500,000 67.74%
108 Operasi Laparatomi KET 3,750,000 7,249,934 4,500,000 62.07%
109 Operasi Lateral Sphinterotomi 3,500,000 7,248,965 4,500,000 62.08%
110 Operasi Manchester Fortegil 3,500,000 7,249,403 4,500,000 62.07%
111 Operasi Mastektomi 3,750,000 7,085,014 4,500,000 63.51%
112 Operasi Mastektomi Simple 3,500,000 7,248,091 4,500,000 62.09%
113 Operasi Medistinoscopy 3,500,000 7,248,796 4,500,000 62.08%
114 Operasi Obstruksi Usus/Invaginasi 3,500,000 7,250,132 4,500,000 62.07%
115 Operasi Pembuluh Darah Simple 3,750,000 7,285,890 4,500,000 61.76%
116 Operasi Pengangkatan Tumor Ovarium 3,500,000 7,250,893 4,500,000 62.06%
117 Operasi Perineoraphi Kasus Lama / Penyulit 3,500,000 7,251,037 4,500,000 62.06%
118 Operasi Quandrantektomy Mammae 3,500,000 7,251,016 4,500,000 62.06%
119 Operasi Released Interdigiti 3,500,000 7,250,782 4,500,000 62.06%
120 Operasi Repair Arteri 3,750,000 7,253,472 4,500,000 62.04%
121 Operasi Repair Pembulur Darah Besar 3,500,000 7,252,013 4,500,000 62.05%
122 Operasi Repair Ruptur Kornea Lokal 3,750,000 7,081,906 4,500,000 63.54%
123 Operasi Repair Tendon + Debridement 3,500,000 7,249,781 4,500,000 62.07%
124 Operasi Repair Tendon > 1 Jari 3,500,000 7,249,089 4,500,000 62.08%
125 Operasi Reposisi Nasal 3,500,000 7,248,102 4,500,000 62.09%
126 Operasi Reseksi Adenomiosis 3,500,000 7,252,031 4,500,000 62.05%
127 Operasi Reseksi Gaster 3,500,000 7,249,029 4,500,000 62.08%
128 Operasi Rotational Flap 3,500,000 7,234,763 4,500,000 62.20%
129 Operasi RPG 3,500,000 7,252,907 4,500,000 62.04%
130 Operasi Skin Graft 3,500,000 7,252,804 4,500,000 62.04%
131 Operasi Splenectomi 3,500,000 7,253,079 4,500,000 62.04%
132 Operasi Stripping 3,500,000 7,253,754 4,500,000 62.04%
133 Operasi Struma 3,750,000 7,253,805 4,500,000 62.04%
134 Operasi STSG (Skin Graft Luas) 3,750,000 7,082,593 4,500,000 63.54%
135 Operasi Superfisial Paratiroidektomi 3,500,000 7,254,018 4,500,000 62.03%
Operasi Thyroidektomi Subtotal/Lobectomi/Strumektomi
136 3,500,000 7,253,217 4,500,000 62.04%
/Ismuslobektomi
137 Operasi Tubektomi 3,500,000 7,000,824 4,500,000 64.28%
138 Operasi Tumor Lid Margin < 1/3 Palpebra 3,750,000 7,082,734 4,500,000 63.53%
139 Operasi Khusus

140 Operasai Total Disc Replacement Bedah Mulut 9,938,374 6,000,000 60.37%
141 Operasi Close Reduction Complex Bedah Mulut 7,948,576 5,000,000 62.90%
142 Operasi Debulking 7,498,203 5,000,000 66.68%
143 Operasi Diseksi Leher Radikal 7,498,274 5,000,000 66.68%
144 Operasi Duhamel 7,499,756 5,000,000 66.67%
145 Operasi Eksenterasi Pelvis 7,499,807 5,000,000 66.67%
146 Operasi Eksenterasi Tumor 7,500,264 5,000,000 66.66%
147 Operasi Eksplorasi Duktus Kholedokus 7,500,372 5,000,000 66.66%
148 Operasi end to End Anastomosis 7,501,892 5,000,000 66.65%
149 Operasi Fore Quater Amputation 7,501,472 5,000,000 66.65%
150 Operasi Gastrectomi 7,502,847 5,000,000 66.64%
151 Operasi Gastrokisis Repair 7,502,937 5,000,000 66.64%
152 Operasi Gnatoplasty 7,563,545 5,000,000 66.11%
153 Operasi Hemikolektomi 7,503,829 5,000,000 66.63%
154 Operasi Hemimandibulektomi (Hemimaksilektomi) 8,475,635 5,000,000 58.99%
155 Operasi Hemoroidektomi 3,500,000 9,000,000 5,000,000 55.56%
156 Operasi Histerektomi 3,500,000 12,280,222 8,000,000 65.15%
157 Operasi Histerektomi Radikal (dengan lympadenektomi regional) 7,504,893 5,000,000 66.62%
158 Operasi Histerektomi Supravaginal / Subtotal 8,332,536 5,000,000 60.01%

159 Operasi Histerektomi Total dan SOB/TAH + BSO 8,333,756 5,000,000 60.00%
160 Operasi Interposisi Kolon 8,331,903 5,000,000 60.01%
161 Operasi Jugular, Subclavia, Femoral 8,332,863 5,000,000 60.00%
162 Operasi Katarak Fakoemulsifikasi 10,008,161 6,000,000 59.95%
163 Operasi Kholedoku Jejunostomi 8,332,817 5,000,000 60.00%
164 Operasi Kholedokuduodenostomi 8,333,906 5,000,000 60.00%
165 Operasi Kolesistektomi + Eksplorasi CBD 7,500,278 5,000,000 66.66%
166 Operasi Komando 8,336,489 5,000,000 59.98%
167 Operasi Laparatomi Explorasi 3,750,000 12,518,757 8,000,000 63.90%
168 Operasi Laparoscopy Operatif 8,335,243 5,000,000 59.99%
169 Operasi Laparotomi + Drainage Abses Hepar 8,336,290 5,000,000 59.98%
170 Operasi Laparotomi + Herniotomi dengan komplikasi (reseksi usus) 8,341,273 5,000,000 59.94%
171 Operasi Laparotomi Eksplorasi (staging) 8,339,283 5,000,000 59.96%

172 Operasi Lithotripsi 8,328,595 5,000,000 60.03%
173 Operasi Low Anterior Resection 8,337,263 5,000,000 59.97%
174 Operasi Mastoidektomi 8,336,253 5,000,000 59.98%
175 Operasi Mega Kolon Hisrchprung 8,337,261 5,000,000 59.97%
176 Operasi Miles Operation 8,341,928 5,000,000 59.94%
177 Operasi Miomektomi 2,250,000 9,030,294 5,000,000 55.37%
178 Operasi Miomektomi/Kistektomi dengan Laparoscopy 8,336,738 5,000,000 59.98%
179 Operasi Mrm + STSG/Flap 8,337,263 5,000,000 59.97%
180 Operasi Odontektomi 4 Gigi 7,463,547 5,000,000 66.99%
181 Operasi Open Reduction Internal Fixation 11,827,364 6,000,000 50.73%
182 Operasi Operasi Nonunion & Delayed Union 12,938,474 6,000,000 46.37%
183 Operasi Orif.Fraktur Patella 8,328,407 5,000,000 60.04%
184 Operasi Pankreatektomi 8,335,243 5,000,000 59.99%
185 Operasi Pemasangan Arteri/Vena Access 8,334,809 5,000,000 59.99%
186 Operasi Prolaps Rekti 8,331,723 5,000,000 60.01%
187 Operasi Prosedur Bypass/Hemicolectomy 8,331,760 5,000,000 60.01%
188 Operasi Radikal Mastektomi/MRM 8,335,263 5,000,000 59.99%
189 Operasi Rebola 8,337,807 5,000,000 59.97%
190 Operasi Reduksi Terbuka & Eksternal Fiksasi Bedah Mulut 7,562,536 4,500,000 59.50%
191 Operasi Reduksi Terbuka & Eksternal Fiksasi Dengan Plate & Screw 7,645,242 4,500,000 58.86%
192 Operasi Reduksi Terbuka & Eksternal Fiksasi Dengan Wire & Screw 7,563,849 4,500,000 59.49%
193 Operasi Reimplantasi Satu Gigi 10,293,746 6,000,000 58.29%

194 Operasi Rekonstruksi Arteri/Vena Besar 8,338,928 5,000,000 59.96%
195 Operasi Repair Cleft Lip Bilateral 9,928,374 6,000,000 60.43%
196 Operasi Repair Cleft Lip Unilateral 7,534,231 5,000,000 66.36%
197 Operasi Repair Cleft Palate Complete 10,293,847 6,000,000 58.29%
198 Operasi Repair Cleft Palate Incomplete 7,529,182 5,000,000 66.41%
199 Operasi Repair Ruptur Kornea 8,331,238 5,000,000 60.02%
200 Operasi Repair Tendon 1 Jari 3,500,000 7,498,426 5,000,000 66.68%
201 Operasi Reparasi Fistal 8,339,254 5,000,000 59.96%
202 Operasi Reseksi Anterior 8,333,237 5,000,000 60.00%
203 Operasi Reseksi Esofagus dengan Interposisi Kolon/Gaster 8,331,760 5,000,000 60.01%
204 Operasi Reseksi Hepar (Penyulit) 8,332,331 5,000,000 60.01%
205 Operasi Reseksi Iga 8,332,096 5,000,000 60.01%
206 Operasi Reseksi Sebagian Mandibula (Maksila) 7,849,283 5,000,000 63.70%
207 Operasi Reseksi Segmental 7,746,352 5,000,000 64.55%
208 Operasi Reseksi Usus - Anastomosis 8,329,708 5,000,000 60.03%
209 Operasi Reseksi Usus Radikal 8,330,799 5,000,000 60.02%
210 Operasi Ripstein Procedure 8,331,151 5,000,000 60.02%
211 Operasi Salpingektomi 3,500,000 12,175,385 8,000,000 65.71%
212 Operasi SC + Histerektomi Total 8,329,686 5,000,000 60.03%
213 Operasi Surgical Staging 8,329,412 5,000,000 60.03%
214 Operasi Swenson 8,331,799 5,000,000 60.01%
215 Operasi Thoracotomy 8,331,496 5,000,000 60.01%
216 Operasi Thorak Abdominal 8,330,436 5,000,000 60.02%
217 Operasi Timpanoplasti 8,331,151 5,000,000 60.02%
218 Operasi Total Glosektomi 8,328,821 5,000,000 60.03%
219 Operasi Transeksi Esofagus 8,330,432 5,000,000 60.02%
220 Operasi Tromboembolektomi 8,329,413 5,000,000 60.03%
221 Operasi Tubaplasti 8,329,809 5,000,000 60.03%
222 Operasi Tumor Ganas Ovarium 8,331,405 5,000,000 60.01%
223 Operasi Tumor Lid Margin > 1/3 Palpebra 4,500,000 7,499,384 5,000,000 66.67%
224 Operasi Uretroskopi (litotripsi/biopsi) 8,330,204 5,000,000 60.02%
225 Operasi URS - Lithoclast 8,329,413 5,000,000 60.03%
226 Operasi Vaginal Histerektomi 8,330,799 5,000,000 60.02%
227 Operasi Vaginoplasty (Kolporafi ant/post) 8,331,171 5,000,000 60.02%
228 Operasi Vulvektomi 8,329,405 5,000,000 60.03%
229 Operasi Whipple (Pankreatiko Duedenoktomi) 8,328,496 5,000,000 60.03%
230 Operasio Bilio Digestive 7,501,895 5,000,000 66.65%
O AMBULANCE
1 Ambulance Darat 650,000 499,726 450,000 90.05%

2 Ambulance Laut 26,804,800 17,500,000 65.29%
P ELEKTROMEDIK
1 Doppler 40,000 66,483 40,000 60.17%

2 Tonometri Schiotz 15,000 72,210 45,000 62.32%
3 EKG 40,000 80,655 50,000 61.99%

4 Funduscopy Direct 25,000 86,577 50,000 57.75%
5 Funduscopy Indirect 40,000 86,540 50,000 57.78%
6 Tonometri Non Contact 85,473 50,000 58.50%
7 Tympanometri + Interpretasi 25,000 86,574 50,000 57.75%
8 Audiometri Anak 40,000 96,748 60,000 62.02%

9 Audiometri Interpretasi 40,000 97,485 60,000 61.55%
10 Biometri 40,000 98,355 60,000 61.00%
11 CTG 40,000 103,696 60,000 57.86%
12 Anel test 40,000 133,827 80,000 59.78%
13 Spirometri 70,000 132,847 80,000 60.22%
14 Anuscopy 70,000 164,524 100,000 60.78%
15 Monitor EKG 100,000 249,835 150,000 60.04%

16 Treadmill 100,000 251,834 150,000 59.56%
17 Echo Cardiography Doppler 150,000 334,827 200,000 59.73%

18 EEG tanpa Warna 70,000 250,241 200,000 79.92%
19 EMG 334,132 200,000 59.86%
20 Kecepatan Hantar Syaraf 332,894 200,000 60.08%
21 Somato Sensory Evoked Potential 334,019 200,000 59.88%
22 Spasmofili 333,947 200,000 59.89%
23 Visual Evoked Potential 332,847 200,000 60.09%
24 Blink Refleks + EMG 416,293 250,000 60.05%

25 EEG Berwarna 100,000 417,362 250,000 59.90%
26 Kecepatan Hantar Syaraf + EMG 416,234 250,000 60.06%
27 Brain Mapping 150,000 498,372 300,000 60.20%

28 Brain Mapping tanpa EEG 150,000 498,362 300,000 60.20%
Q REHABILITASI MEDIK
1 Infra Red 48,734 30,000 61.56%

2 Massage 30,000 49,372 30,000 60.76%
3 MWD Kecil / Diathermy 25,000 48,745 30,000 61.54%
4 SWD 47,309 30,000 63.41%
5 Electrical Stimulasi/TENS 25,000 60,950 35,000 57.42%

6 Electrical Traction 35,000 57,462 35,000 60.91%
7 Exercise Aktif 35,000 58,463 35,000 59.87%
8 Exercise Terapi Ringan 58,018 35,000 60.33%
9 MWD Sedang 35,000 57,298 35,000 61.08%
10 Ultrasound Therapy 35,000 56,131 35,000 62.35%
11 Exercise Terapi Sedang 35,000 68,263 40,000 58.60%

12 Inhalasi/Nebulizer 40,000 67,068 40,000 59.64%
13 Manual Therapy 30,000 67,872 40,000 58.93%
14 Exercise Pasif 40,000 82,734 50,000 60.43%

15 Exercise Terapi Berat 40,000 83,625 50,000 59.79%
16 Exercise Terapi Khusus 40,000 82,514 50,000 60.60%
R KAMAR JENAZAH
1 Pemulasaran Jenazah Anak 400,000 663,928 400,000 60.25%

2 Pemulasaran Jenazah Dewasa 500,000 836,923 500,000 59.74%
3 Penyimpanan Jenazah Ruangan Cool Storage per 24 Jam 75,000 165,342 100,000 60.48%
4 Penyimpanan Jenazah/Ruangan Biasa 2 Jam Pertama 30,000 48,623 30,000 61.70%
5 Perawatan Jenazah dan Kain Laken Anak 50,000 82,635 50,000 60.51%
6 Perawatan Jenazah dan Kain Laken Bayi 30,000 49,837 30,000 60.20%
7 Perawatan Jenazah dan Kain Laken Dewasa 50,000 98,465 60,000 60.94%
8 Perawatan Jenazah/Ruangan Biasa per 24 Jam 50,000 97,845 60,000 61.32%
9 Tambahan per Sampel 50,000 98,248 60,000 61.07%
10 Tindakan Formalin Jenazah Anak 700,000 1,164,352 700,000 60.12%
11 Tindakan Formalin Jenazah Dewasa 900,000 1,502,437 900,000 59.90%
S LAIN-LAIN
1 Kantin dll (per area/ hari) 15,000

2 Magang, per orang/hari 25,000 15,000 60.00%
3 Pengambilan Data, per orang/siklus, maksimal 2 bulan 249,583 150,000 60.10%
4 Homecare (diluar tindakan) 330,273 200,000 60.56%
5 Penelitian, per orang/siklus, maksimal 2 bulan 417,284 250,000 59.91%
6 Bank per m2 area/ bulan 300,000
7 Sewa Aula per Hari 350,000
8 Biaya Kaji Etik 1,500,000
9 Anjungan Tunai Mandiri (per area/ bulan) 4,000,000
10 Bank (per area/ bulan) 10,000,000
maksimal
11 Layanan Obat dan Farmasi Lainnya 120% dari
harga beli
USULAN TARIF KHUSUS RSUD ADHYAKSA
TARIF USULAN
NO NAMA LAYANAN UNIT COST
LAMA TARIF BARU
A 1 Pembacaan Foto CT - Scan 884,526 600,000

2 CT-Scan Guide Non-Kontras 1,000,293 700,000
3 CT-Scan Brain Non-Kontras 1,110,293 750,000
4 CT-Scan Extermitas Atas Non-Kontras 1,218,372 750,000
5 CT-Scan Temporal Non-Kontras 1,273,645 750,000
6 CT-Scan Vert. Cervical Non-Kontras 1,263,542 750,000
7 CT-Scan Extermitas Bawah Non-Kontras 1,317,263 800,000
8 CT-Scan Leher Non-Kontras 1,342,538 800,000
9 CT-Scan Mastoid Non-Kontras 1,326,392 800,000
10 CT-Scan Nasopharyng Non-Kontras 1,362,837 800,000
11 CT-Scan Orbita Non-Kontras 1,352,384 800,000
12 CT-Scan Sella Tursica Non-Kontras 1,357,263 800,000
13 CT-Scan Sinus Paranasal Non-Kontras 1,358,473 800,000
14 CT-Scan Abdomen Atas Non-Kontras 1,562,539 950,000
15 CT-Scan Abdomen Bawah Non-Kontras 1,585,736 950,000
16 CT-Scan Thorax Non-Kontras 1,585,283 950,000
17 CT-Scan Vert. Lumbosacral Non-Kontras 1,594,723 950,000
18 CT-Scan Vert. Thoracal Non-Kontras 1,625,374 950,000
19 CT-Scan Whole Abdomen Non-Kontras 2,263,549 1,500,000
20 CT-Scan Mastoid Kontras 2,394,857 1,500,000
21 CT-Scan Brain Kontras 2,473,948 1,500,000
22 CT-Scan Extermitas Atas Kontras 2,635,421 1,500,000
23 CT-Scan Extermitas Bawah Kontras 2,837,465 1,500,000
24 CT-Scan Leher Kontras 2,837,465 1,500,000
25 CT-Scan Nasopharyng Kontras 2,746,593 1,500,000
26 CT-Scan Orbita Kontras 2,635,142 1,500,000
27 CT-Scan Sella Tursica Kontras 2,514,233 1,500,000
28 CT-Scan Sinus Paranasal Kontras 2,417,263 1,500,000
29 CT-Scan Temporal Kontras 2,416,273 1,500,000
30 CT-Scan Vert. Cervical Kontras 2,392,837 1,500,000
31 CT-Scan Abdomen Atas Kontras 2,534,261 1,750,000
32 CT-Scan Abdomen Bawah/Pelvis Kontras 2,537,463 1,750,000
33 CT-Scan Thorax Kontras 2,438,172 1,750,000

34 CT-Scan Vert. Lurnbosacral Kontras 2,533,748 1,750,000
35 CT-Scan Vert, Thoracal Kontras 2,645,374 1,750,000
36 CT-Scan Whole Abdomen Kontras 3,783,645 2,500,000
B Bedah Saraf
1 Operasi Pungsi Cairan Otak 4,550,694 3.000.000
2 Operasi Bedah Saraf 20,394,857 10.000.000
3 Operasi Dekompresi_saraf tepi 19283746 10.000.000
4 Operasi Neuroktomi/ Neurolise 20,394,857 10.000.000
5 Operasi Simple Fung_sional Neurosurgery
a. Percutaneus Rhizotomi/PRGR 20,192,837 10.000.000

b. Perc Facet Denervation dll 18,273,645 9.000.000
Operasi Pemasangan Pintasan VA
6 20,192,837 14.000.000
Shunt/VPShunt
Operasi Kraniotomi/Trepanasi konvensional
7 25,483,746 15.000.000
kurang dari 4 jam
8 Operasi Kraniotomi/Trepanasi konvensional 27,364,514 17.000.000

lebih dari 4 jam
9 Operasi Kraniotomi dgn Endoskopi 28,374,658 17.000.000
10 Operasi Kraniotomi + Bedah mikro kurang 30,293,847 20.000.000

dari 4 jam
Operasi Kraniotomi + Bedah mikro lebih dad
11 35,263,748 25.000.000
4 jam
12 Operasi Kranial (anterior/posterior) 22,716,254 12.500.000
13 Operasi Spina bifida 23,827,364 13.000.000
14 Operasi Tulang punggung
a. Fusi corpus vertebra
Anterior approach 28,374,658 17.000.000
Posterior approach 20,193,847 12.500.000
b. Laminektomi
Sederhana 22,837,465 12.500.000
Kompleks 27,364,558 16.000.000
15 Operasi Daerah kraniospinal 29,384,756 17.000.000
16 Operasi Daerah cervikal 29,948,573 15.000.000
17 Operasi Daerah torakolumbal 21,827,465 12.500.000
18 Operasi Neuroplasty/anastamosis/eksplorasi
19 a. Bedah mikro
20 1. Plexus Brachialis/Lb sacralis 31,928,374 20.000.000
21 2. N.cranialislSpinalis perifer 32,837,465 21.000.000
22 b. Bedah konpensional 24,837,465 14,000,000
C Bedah Orthopedi
1 ORIF KE 705,948 500,000
2 Amputasi kaki SE 948,576 700,000
3 Angkat plate lengan bawah SE 938,476 700,000
4 Close Reduction SE 927,364 700,000
5 Fiksasi Eksternal SE 980,394 700,000
6 Open Reduction SE 973,827 700,000
7 ORIF SE 976,847 700,000
8 Pasang gips SE 958,375 700,000
9 ORIF KC 1,068,273 800,000
10 Amputasi 1 lengan BE 1,382,746 1,100,000
11 Amputasi 1 tangan BE 1,283,746 1,100,000
12 ORIF SC 1,372,635 1,100,000
13 Aff Wire 1,527,364 1,200,000
14 Amputasi kaki BE 1,635,273 1,200,000
15 Amputasi tungkai atas BE 1,682,736 1,200,000
16 Amputasi tungkai bawah BE 1,728,374 1,200,000
17 Angkat plate femur BE 1,782,736 1,200,000
18 Angkat plate lengan atas BE 1,728,374 1,200,000
19 Angkat plate lengan bawah SC 1,827,645 1,200,000
20 Closed Reduction SC 1,862,736 1,200,000
21 Fiksasi Eksternal SC 1,872,938 1,200,000
22 Fiksasi Internal BE 1,927,364 1,200,000
23 Fiksasi Internal SC 1,982,039 1,200,000
24 ORIF BE 1,983,746 1,200,000
25 Pasang gips SC 2,019,283 1,200,000
26 Ruptur tendon achilles SC 2,192,837 1,200,000
27 Amputasi KHE 2,182,736 1,400,000
28 Amputasi tungkai atas KHE 2,273,645 1,400,000
29 Closed Reduction KHE 1,928,374 1,400,000
30 Open Reduction KHE 2,283,746 1,400,000
31 ORIF KHE 2,374,658 1,400,000
32 Ruptur tendon KHE 2,102,938 1,400,000
33 Angkat k wire 2,563,746 1,800,000
34 Amputasi 1 lengan BC 2,837,465 2,000,000
35 Amputasi 1 tangan BC 2,983,846 2,000,000
36 Amputasi kaki BC 2,998,403 2,000,000
37 Amputasi tungkai atas BC 3,019,283 2,000,000
38 Amputasi tungkai bawah BC 3,182,736 2,000,000
39 Angkat late femur BC 3,282,736 2,000,000
40 Angkat palte lengan atas BC 3,172,837 2,000,000
41 Close Reduction BC 2,993,847 2,000,000
42 Fiksasi Internal BC 2,998,263 2,000,000
43 ORIF BC 3,029,384 2,000,000
44 Ruptur tendon achilles BC 3,017,263 2,000,000
45 Angkat k wire cito 3,382,736 2,300,000
46 ORIF KHC 3,492,837 2,400,000
47 Amputasi satu jari 3,782,736 2,600,000
48 Biopsi Orthopedi 3,726,354 2,600,000
49 Repair single ekstennsor tendon 3,872,636 2,600,000
50 Amputasi dari tangan, lengan dan lutut 4,231,723 3,000,000
51 Arthrodesis sendi kecil 4,398,219 3,000,000
52 Repair tendon ekstensor multiple 4,412,837 3,000,000
53 Amputasi satu jari cito 4,827,465 3,400,000
54 Biopsi Orthopedi Cito 4,928,374 3,400,000
55 Repair single ekstennsor tendon cito 4,928,377 3,400,000
56 Arthroplasti reseksi dan interposisi 5,189,874 3,500,000
57 Reduksi Terbuka dan Eksternal Fiksasi 5,241,328 3,500,000
58 Amputasi dari tangan, lengan dan lutut cito 5,629,381 3,900,000
59 Arthrodesis sendi kecil cito 5,612,039 3,900,000

60 Repair tendon ekstensor multiple cito 5,712,394 3,900,000
61 Closed Reduction Complex 5,938,475 4,000,000
62 CTS Orthopedi 5,902,957 4,000,000
63 Operasi Koreksi Kelainan dan Kontraktur 5,945,342 4,000,000

Tulang dan Sendi
Operasi Release Jaringan lunak, otot dan
64 6,029,182 4,000,000
tendon
65 Arthrodesis sendi besar 6,532,635 4,500,000
66 Arthroskopik diagnostik 6,635,498 4,500,000
67 ORIF 6,736,548 4,500,000
68 Operasi Nonunion dan Delayed Union 6,854,362 4,500,000
69 Arthroplasti reseksi dan interposisi cito 6,938,273 4,600,000
70 Reduksi Terbuka dan Eksternal Fiksasi cito 7,019,283 4,600,000
Anterior (posterior) cruciate Ligament

71 7,598,364 5,000,000
Rekonstruksi
72 Arthroskopik dengan tindakan lain 7,512,938 5,000,000
73 Closed Reduction Complex Cito 7,725,342 5,200,000
74 CTS Orthopedi cito 7,820,398 5,200,000
Operasi Koreksi Kelainan dan Kontraktur
75 7,921,284 5,200,000
Tulang dan Sendi cito
Operasi Release Jaringan lunak, otot dan
76 7,983,645 5,200,000
tendon cito
77 Arthrodesis sendi besar cito 8,790,293 5,900,000
78 Arthroskopik diagnostik cito 8,721,274 5,900,000
79 ORIF Cito 8,801,928 5,900,000
80 Operasi Nonunion dan Delayed Union cito 8,937,846 5,900,000
Anterior (posterior) cruciate Ligament

81 9,783,746 6,500,000
Rekonstruksi cito
82 Arthroskopik dengan tindakan lain cito 9,837,465 6,500,000
D Forensik Klinik
1 Autopsi Klinik WNI 8,473,645 6,000,000
2 Autopsi Klinik WNA 11,293,847 8,000,000
3 Formalin infeksi > 2 Minggu 6,938,274 4,500,000
E Layanan Farmasi
Racikan sirup , salep, krim, lotion (per item) 5,000

10,000
Pengemasan Kembali (Per Kemasan) 2,000 1,000
Racikan Pulvers / Kapsul (Per bungkus / 250
kapsul) 500
Distribusi dan pelayanan obat atas resep 5,000
dokter (per pasien) 11,000
Konseling Obat Resep (Per pasien) 35,000 20,000
Konseling obat bebas / swamedikasi (per 10,000
pasien) 17,000
Visite/HomeCare/MESO (Per Kunjungan) 25,000
50,000
F Sewa lahan / Konsesi

Lapangan Tenis per jam 150,000
Kolam Renang per orang 20,000
Kolam Renang Per Group (5 - 10 orang) 150,000
Aula per hari 3 jam dengan kapasitas 150
orang 1,500,000
% TARIF
DENGAN
UC
67.83%
69.98%
67.55%
61.56%
58.89%
59.36%
60.73%
59.59%
60.31%
58.70%
59.15%
58.94%
58.89%
60.80%
59.91%
59.93%
59.57%
58.45%
66.27%
62.63%
60.63%
56.92%
52.86%
52.86%
54.61%
56.92%
59.66%
62.05%
62.08%
62.69%
69.05%
68.97%
71.78%
69.07%
66.15%
66.07%
#VALUE!
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56.37%
70.83%
73.79%
74.59%
75.48%
71.40%
71.88%
71.66%
73.04%
74.89%
79.55%
85.69%
80.14%
78.57%
73.38%
71.31%
69.43%
67.31%
69.43%
65.66%
64.42%
64.07%
62.26%
60.54%
60.49%
59.43%
54.72%
64.14%
61.58%
72.60%
61.30%
58.96%
66.57%
70.21%
70.49%
67.03%
66.70%
66.24%
62.84%
60.92%
63.04%
66.80%
66.71%
66.02%
66.29%
67.99%
68.71%
68.73%
69.77%
67.14%
70.89%
68.21%
67.98%
70.43%
68.99%
68.99%
67.44%
66.78%
69.28%
69.49%
68.27%
67.36%
67.76%
67.28%
66.34%
68.88%
67.82%
66.80%
65.65%
66.30%
65.53%
65.80%
66.55%
67.31%
66.49%
65.65%
65.13%
67.12%
67.65%
67.03%
66.01%
66.44%
66.07%
70.81%
70.84%
64.86%
50.00%
50.00%
50.00%
45.45%
57.14%
58.82%
50.00%

BCP Januari 2018

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Lampiran : Peraturan Gubernur Provinsi Daerah Khusus Ibukota Jakarta

TARIF LAYANAN RUMAH SAKIT UMUM DAERAH KELAS C DAN D

1 Konsultasi Spesialis by Phone (di luar jam praktek) 20,000

5 Konsultasi Emergency Spesialis by Phone (Jam 23.00 - 07.00 WIB) 30,000

6 Konsultasi Psikolog Klinis di Instalasi Rawat Jalan 30,000

10 Pemeriksaan / konsultasi Spesialis Internal (non DPJP) 40,000

B INSTALASI GAWAT DARURAT

7 Aff Kateter 25,000

10 Observasi < 8 Jam 30,000

14 Cabut Jahitan 0-10 Jahitan 35,000

17 Hecting 1-5 40,000

23 Cabut Jahitan > 10 Jahitan 45,000

33 Oksigen > 7 Liter / Jam 60,000

36 Intubasi Endotracheal 65,000

39 Aspirasi Cairan 80,000

44 Punksi Vesica Urinaria 150,000

46 Oksigen 1 - 3 Liter / Hari 200,000

49 Punksi Pleura 300,000

C INSTALASI RAWAT JALAN

1 Aff Contact Lens 20,000

19 Aff Kateter 25,000

28 Aff Tampon Nasal 30,000

53 Cabut Jahitan 0-10 Jahitan 35,000

57 Ekstraksi Corpus Alienum Kornea 40,000

70 Cabut Jahitan > 10 Jahitan 45,000

91 Drainage Abses 55,000

104 Intubasi Endotracheal 65,000

106 Endoskopi Hidung 70,000

113 Aquapunktur 80,000

126 Akupunktur Estetika 100,000

134 Biopsi 120,000

139 Aff Implan 150,000

147 Buka Gips Sirkular 175,000

150 Cryo 180,000

153 BERA tanpa sedasi 200,000

160 Akupunktur Tanam Benang 250,000

168 Pasang Gips Sesisi 300,000

174 Carotid Duplex Doppler 400,000

177 Stress Echo Dobutamin (DSE) 500,000

D TINDAKAN GIGI DAN MULUT

1 Ekstraksi Gigi Sulung (Chlorethyl) 35,000

3 Bongkar Amalgam Filling 40,000

6 Ekstraksi Gigi Sulung dengan Injeksi 50,000

8 Lepas bracket 75,000

11 Activier Ortho Removable 80,000

30 Activier Ortho Appliance 90,000

36 Penggantian bracket / pcs 100,000

39 Composite Crown 170,000

41 Bleaching gigi non vital (per gigi) 200,000

67 Bridge Work Dan Precious Metal Per Gigi 450,000

72 Crown Metal 500,000

E KAMAR RAWAT INAP

1 Tarif Kamar Bayi / Perawatan Bayi Sehat Per Hari 100,000

F TINDAKAN RAWAT INAP

1 Aff Infus 15,000

3 Aff Nasogastric tube 20,000

8 Aff Kateter 25,000

11 Aff Tampon Nasal 30,000

17 Cabut Jahitan 0-10 Jahitan 35,000

21 Infus Pump 40,000

26 Imobilisasi Dengan Elastic Verban 50,000

31 Intubasi Endotracheal 65,000

33 Aspirasi Cairan 80,000