Sukabumi 2017-Rev Global PDF

I.
UMUM
I.1. ADMINISTRASI RS
NO JENIS PELAYANAN TARIF
I.1.1. RAWAT JALAN

1 Pembuatan Kartu (sistem barcoding) 15,000
2 Buku Pasien 25,000
Jasa Sarana Klinik Umum 35,000
Jasa Sarana Klinik Obsgyn 44,000
Jasa Sarana Klinik Eksekutif 52,000
Jasa Sarana Klinik Eksekutif Obsgyn 61,000
I.1.2. RAWAT INAP

1 Uang muka Rawat Inap Sesuai Kelas Perawatan :
a. SUITE ROOM 14,820,000
b. SVIP 11,500,000
c. VIP 10,290,000
d. Kelas I, Perawatan isolasi 6,050,000
e. Kelas II 3,630,000
f. Kelas III 1,510,000
2 Uang Muka Rawat Intensif (ICU/NICU/PICU) 15,740,000
3 Uang Muka Rawat Perina L II, Intermediate Care Unit (IMCU) 6,660,000
4 Registrasi Rawat Inap 20,000
Keterangan :
- Biaya Umum (BUM) sudah termasuk dalam komponen Jasa Medis Konsultasi Medis (halaman 3)
(Tarif Biaya Umum (BUM) pada halaman ini hanya sebagai informasi, tidak duntuk ditagihkan terpisah).
TARIF TAHUN 2017 1 - REV

I.2 TARIF RUANGAN
KELAS
No. JENIS PELAYANAN
SUITE ROOM SVIP VIP I II III
1 KAMAR PERAWATAN 1,482,000 1,150,000 1,029,000 605,000 363,000 151,000
2 KAMAR BERSALIN :
a. Untuk Persalinan
- Dengan Dokter 3,037,000 2,430,000 2,126,000 1,518,000 1,367,000 1,139,000
- Dengan Bidan 2,126,000 1,518,000 1,367,000 1,139,000
- ILA 3,037,000 2,430,000 2,126,000 1,518,000 1,367,000 1,139,000
b. Untuk Observasi 1,029,000 363,000
3 KAMAR OPERASI :
a. Untuk Tindakan One Day Care (ODC) Mengikuti tarif ODC
b. Tindakan Medis Operatif : kebidanan & bedah
- Operasi Kecil 3,827,000 3,280,000 3,144,000 2,733,000 2,187,000 1,640,000
- Operasi Sedang 4,975,000 4,264,000 4,087,000 3,553,000 2,843,000 2,132,000
- Operasi Besar & SC 5,549,000 4,756,000 4,559,000 3,963,000 3,171,000 2,378,000
- Operasi Besar Khusus 8,611,000 7,380,000 7,074,000 6,149,000 4,921,000 3,690,000
c. Ruang Pemulihan / RR ( untuk observasi > 6 jam ) 605,000
4 PERAWATAN PERINA
a. Level I (KBBL) 889,000 690,000 617,000 363,000 218,000 112,000
b. Rujukan Untuk Blue Light (Blue Light di Perina Level II) 514,000 + Blue Light
5 INTERMEDIATE CARE UNIT (IMCU) 666,000
6 INTENSIVE CARE UNIT (ICU/PICU/NICU) 787,000
7 RUANG ISOLASI 605,000

II JASA MEDIS
II 1. JASA MEDIS KONSULTASI MEDIS
KLINIK UMUM KLINIK EKSEKUTIF

NO JENIS PELAYANAN
Jasa Jasa
Jasa Sarana TARIF Jasa Sarana TARIF
Pelayanan Pelayanan
1 Dokter Umum 45,000 35,000 80,000
2 Dokter Spesialis 132,000 35,000 167,000 180,000 52,000 232,000
3 Dokter Spesialis Obsgyn 132,000 44,000 176,000 180,000 61,000 241,000
4 Dokter Sub Spesialis/ Konsultan 155,000 35,000 190,000 225,000 52,000 277,000
5 Dokter Subspesialis/ Konsultan Obsgyn 155,000 44,000 199,000 225,000 61,000 286,000
6 Profesor 185,000 35,000 220,000 289,000 52,000 341,000
7 Profesor Obsgyn 185,000 44,000 229,000 289,000 61,000 350,000
8 Psikiater 146,000 35,000 181,000
9 Dokter Spesialis Gizi Klinik 146,000 35,000 181,000
10 Psikolog 126,000 35,000 161,000
11 Bidan 30,000 35,000 65,000
12 Klinik Tumbuh Kembang :
a. Dokter Spesialis Anak 150,000 35,000 185,000
b. Dokter Rehabilitasi Medik 150,000 35,000 185,000
c. Psikolog 128,000 35,000 163,000
d. Psikiater 150,000 35,000 185,000
e. Terapi Wicara
- Anak 100,000
- Dewasa 122,000
f. Terapi Okupasi
- Anak 100,000
- Dewasa 122,000
g. Sensori Integrasi 110,000
h. Snoezellen 110,000
i. Sensor Terapi Behaviour 110,000
j. Art Terapi 110,000
k. Fisioterapi
- Anak 100,000
- Dewasa 122,000
l. Neuromusculoskletal 122,000
13 Konsultasi Laktasi / Edukator Diabetes
a. Konselor Dokter Subspesialis 208,000 35,000 243,000 210,000 52,000 262,000
b. Konselor Dokter Spesialis 146,000 35,000 181,000 182,000 52,000 234,000
c. Konselor Dokter Umum 46,000 35,000 81,000
d. Konselor Bidan / Perawat 30,000 35,000 65,000

Keterangan :
- Jasa medis konsultasi Psikiater, Spesialis Gizi Klinik, Psikolog yang tercantum diatas adalah konsultasi
sampai dengan 30 menit. Jika lebih dari 30 menit maka tarif ditambah sebesar 50% dari HD.
- Jasa Medis Konsultasi Medis sudah termasuk Biaya Umum (BUM)

II.2 JASA MEDIS VISITE
TARIF
NO JENIS PELAYANAN
A VISITE di R.PERAWATAN
1 Dokter Spesialis / Fellow 200,000 187,000 175,000 125,000 100,000 81,000
2 Dokter SubSpesialis / Konsulen / Profesor 250,000 234,000 219,000 156,000 125,000 102,000
3 Dokter Spesialis/Sub/Prof Anak Visite I Bayi Baru Lahir 300,000 281,000 262,000 187,000 150,000 122,000
4 Panggilan Emergency Tanpa Tindakan :
a. Dokter Spesialis 182,000
b. Dokter SubSpesialis 237,000
5 Panggilan Emergency Dengan Tindakan Jasa Medis No.4 (point. a atau b) + Jasa Tindakan
6 Visiting Doctor (Dokter Tamu) :
a. Panggilan Tidak Emergency
- Dokter Spesialis 158,000
- Dokter Spesialis/Sub Spesialis/Profesor/Konsulen 243,000
b. Panggilan Emergency
- Dokter Spesialis 236,000
- Dokter Sub Spesialis 269,000
B VISITE di R. PERAWATAN PERINA
1 Dokter Spesialis 178,600
2 Dokter Sub Spesialis/ Konsulen 225,000
C VISITE di R. PERAWATAN ICU/NICU/PICU
1 Dokter Spesialis 162,000
2 Dokter SubSpesialis/ Konsulen 204,000
3 Dokter Intensivis 285,000
4 Visiting Doctor 312,000
II. 3 JASA PARAMEDIS
TARIF
No. PELAYANAN
1 Perawatan Kelas 72,000 65,000
2 Perawatan Perina 65,000
3 Perawatan Isolasi 82,000
4 Perawatan Intermediate 82,000
5 Perawatan ICU / NICU/ PICU 98,000

C
III. TINDAKAN MEDIS A
T
III.1A IGD A
T
A
N
2
NO TINDAKAN JUMLAH (Rp)
0
1
5
1 Aff drain (angkat drain) 58,000
-
2 Anuskopi 78,000 2
3 Bilas lambung 117,000 0
4 Buka gips : 1
6
a. 1 sisi 122,000
b. 2 sisi 202,000
5 Sirkumsisi 543,000
6 Klisma/ lavemen, korek skibala 60,000
7 Pemakaian defibrilator/ DC shock 256,000
8 Perawatan combustio :
a. Ringan 169,000
b. Sedang 202,000
9 Debridement :
a. Ringan 117,000
b. Sedang 149,000
c. Berat 192,000
10 Dilatasi preputium 58,000
11 Eksplorasi vulnus punctum 50,000
12 Eksplorasi Luka / Woud Toilet
Sederhana (< 5mm) 55,000
Luka Berat (> 5mm) 116,000
13 Ekstirpasi lipoma / kista / clavus / nevus :
a. Kecil 89,000
b. Sedang 108,000
c. Besar 161,000
14 Ekstraksi/ angkat corpus alienum 89,000
15 Ekstraksi kuku/ Rozerplasty 109,000
16 Epikutaneus 354,000
17 Ganti verban
a. Kecil 46,000
b. Sedang 78,000
c. Besar 109,000
18 Hecting :
a. Jumlah jahitan 1 – 3 64,000
b. Jumlah jahitan 4 – 6 109,000

C
A
T
A
T
A
N
2
0
1
c. Jumlah jahitan 7 - 10 165,000 5
-
d. Jumlah jahitan 11 - 15 169,000
2
e. Jumlah jahitan 15 - 20 205,000 0
f. Jumlah jahitan > 20 239,000 1
6
19 Aff hecting :
c. Jumlah jahitan 7 - 10 77,000
e. Jumlah jahitan 15 - 20 95,000
f. Jumlah jahitan > 20 102,000
20 Insisi abses :
a. Jumlah abses 1, ukuran < 10 cm 58,000
b. Jumlah abses >1 atau ukuran > 10cm 122,000
21 Injeksi intralesi keloid 47,000
22 Intubasi/ pemasangan ETT 216,000
23 Irigasi telinga/ mata 43,000
24 Kompresi jantung paru (CPR) 103,000
25 Kauterisasi 37,000
26 Lavemen 31,000
27 Pemasangan mini WSD 231,000
28 Nekrotomi 185,000
29 Observasi IGD :
a. 1 s.d 3 jam 50,000
b. 4 s.d 6 jam 96,000
30 Pemasangan kateter 72,000
31 Pasang infus :
a. Vena perifer 23,000
b. Intra osseus 134,000
c. Vena jugularis 134,000
d. Vena sectie 339,000
e. Percutaneous catheter 340,000
d. Vena sentral (CVC)/ CVP 451,000
32 Pasang ETT RJP (Intubasi) + resusitasi 287,000
33 Pemasangan WSD 355,000

C
A
T
A
T
A
N
2
0
1
34 Pasang nasogastric tube (NGT) 118,000 5
-
35 Pasang NGT + bilas lambung 178,000 2
36 Pasang ransel verband 118,000 0
1
37 Pasang spalk / bidai 50,000
6
38 Pasang tampon hidung 31,000
39 Pasang tampon Belloque 178,000
40 Pasang umbilical catheter 238,000
41 Pasang foley catheter 87,000
42 Pungsi :
a. Supra pubis 77,000
b. Hematoma di superfisial 102,000
c. Lutut 169,000
d. Pleura 270,000
e. Pericardial 368,000
43 Reposisi luksasi mandibula 169,000
44 Suntik 24,000
45 Tindik :
a. Dengan jarum/ biasa 107,000
b. Dengan alat/ tembak 143,000
46 Tes Mantoux 50,000
47 Bouginasi 319,000
50% dari
Tindakan medis di luar tindakan di atas
48 JM Dokter
(termasuk pendampingan persalinan menggantikan dokter obgyn)
Spesialis

III.2. SPESIALIS KEBIDANAN & KANDUNGAN
1 Biopsi 310,000
2 Ganti verban 80,000
3 Implant / Norplant :
a. Pasang implant/ Norplant 202,000
b. Aff implant (Norplant) 202,000
c. Aff dan pasang implant (Norplant) 340,000
4 IUD :
a. Pasang IUD 164,000
b. Aff IUD 164,000
c. Aff dan pasang IUD 216,000
d. Tindakan Reposisi IUD 111,000
5 Kolposkopi :
a. Kolposkopi 405,000
b. Kolposkopi + biopsi 727,000
6 Papsmear
Papsmear (belum termasuk lab PA) 118,000
7 Papsmear Thin Prep 780,000
8 Papsmear biasa 174,000
9 Papsmear bethesda 407,000
10 Pasang laminaria 200,000
11 Pasang Ring 249,000
12 Pesarium :
a. Pasang pesarium 172,000
b. Angkat pesarium 172,000
c. Pasang angkat pesarium 178,000
13 Pungsi Douglash 347,000
14 Sono HSG 617,000
15 Suntik 34,000
16 Tampon vagina 202,000
17 Intubasi/ Pemasangan ETT 410,000
18 Vaginal Toilet 49,000
19 Amniosintesis 3,429,000

III.3. SPESIALIS ANAK

2 Pasang Infus :
a. Intra osseus 231,000
b. Vena jugularis 244,000
c. Vena sectie 675,000
d. Percutaneous catheter 675,000
e. Vena sentral (CVC)/ CVP 825,000
3 Pasang nasogastric tube (NGT) 178,000
5 Pemberian surfaktan :
a. Tanpa pemasangan ETT 501,000
b. Dengan pemasangan ETT 627,000
6 Pungsi lumbal 384,000
7 Suntik 34,000
8 Tindik :
a. Dengan jarum 118,000
b. Dengan alat 178,000
9 Transfusi tukar
a. Transfusi tukar I 1,243,000
b. Transfusi tukar II 806,000
c. Transfusi tukar III 602,000

III.4. SPESIALIS BEDAH
1 Aff drain (angkat drain) 81,000

2 Sirkumsisi (Anestesi Lokal) 993,000
3 Anuskopi 156,000
4 Angkat Corpus Alineum
a. Kecil 155,000
b. Sedang 234,000
c. Besar 653,000
5 Biopsi Rektum 621,000
6 Debridement :
a. Ringan 164,000
b. Sedang 192,000
c. Berat 238,000
7 Dilatasi preputium
a. Kecil 272,000
b. Sedang 318,000
c. Besar 443,000
8 Eksplorasi vulnus punctum 205,000
9 Ekstirpasi lipoma / kista / clavus / nevus 308,000
10 Ekstraksi corpus alienum 205,000
11 Ekstraksi kuku/ Rozerplasty 270,000
12 Epikutaneus 742,000
13 Ganti verban
a. Kecil 93,000
b. Sedang 156,000
c. Besar 218,000
14 Gips :
a. Pasang gips :
- Tanpa reposisi 759,000
- Dengan reposisi 1,152,000
b. Buka gips :
- 1 sisi 244,000
- 2 sisi 404,000
c. Pasang gips pada Bayi :
- 1 sisi 1,245,000
- 2 sisi 2,491,000

d.Pasang gips pada Bayi :

- Tanpa reposisi 948,000
- Dengan reposisi 1,186,000
15 Hecting :
b. Jumlah jahitan 4 - 6 226,000
g. Tambah per Jahitan 110,000
16 Aff hecting :
17 Insisi abses
a. Jumlah abses 1, ukuran < 10 cm 170,000
b. Jumlah abses >1 atau ukuran > 10cm 328,000
18 Injeksi intralesi keloid 173,000
19 Injeksi intratekal 410,000
20 Injeksi blok syaraf 355,000
21 Injeksi Intra Artikuler 190,000
22 Intubasi/ pemasangan ETT 410,000
24 Multiple cauter 534,000
25 Pasang Bougie/ Bouginasi 205,000
26 Pemasangan kateter urin 151,000
27 Pasang infus :
a. Intra osseus 231,000
b. Vena jugularis 244,000
c. Vena sectie 675,000
d. Percutaneous catheter 675,000

e. Vena sentral (CVC)/ CVP 825,000

f. Pasang long line 736,000
g. Vena Perifer 30,000
28 Pasang nasogastric tube (NGT) 178,000
29 Pasang ransel verband 178,000
30 Pasang skin traction 118,000
31 Pasang spalk / Bidai 108,000
33 Pasang ETT RJP (Intubasi) + Resusitasi 575,000
34 ETT + CVP 893,000
35 Perawatan combustio :
a. Ringan 202,000
b. Sedang 270,000
c. Berat 339,000
36 Pungsi :
a. Abdomen 270,000
b. Douglash 475,000
c. Hematoma 170,000
d. Lumbal 384,000
e. Lutut 205,000
f. Pleura 308,000
g.Supra pubic 103,000
h.Sternum (Bone Marrow) 475,000
i. Perikardial 486,000
37 Reposisi luksasi mandibula 270,000
38 Reposisi sendi tertutup 340,000
39 Suntik 34,000
41 Tindakan Bedah Minor 738,000
42 Tindakan Bedah Sederhana 489,000
43 Vena Dalam 622,000
44 Insisi drainase 1,152,000
45 Intra oeseus 504,000

III.5. SPESIALIS THT
A TELINGA
1 Aplikasi obat 81,000
2 Audiogram / Audiometri
a. Nada murni 103,000
b. Nada turur 134,000
c. Dengan protokol 178,000
3 Biopsi telinga 310,000
4 Tampon Belloque 238,000
5 Endoskopi 123,000
6 Ekstirpasi kista aurikuler 109,000
7 Ekstraksi serumen :
a. Satu telinga tanpa irigasi 103,000
b. Dua telinga tanpa irigasi 197,000
c. Satu telinga dengan irigasi – spooling 134,000
d. Dua telinga dengan Irigasi - spooling 231,000
9 Ekstirpasi :
a. Cholesteatoma sekunder 325,000
b. Cholesteatoma – lithiasis 270,000
c. Polip – granulasi 167,000
d. Granulasi CAE – dengan anestesi lokal 717,000
e. Granulasi CAE – dengan anestesi lokal + tampon tarivid 775,000
10 Epistaksis dengan kauterisasi 355,000
11 Epistaksis dengan tampon nasal 178,000
12 Aff Hecting telinga (paska operasi) :
13 Injeksi kenacort (pasca eksisi) 139,000
14 Insisi drainase abses subperiosteal (abses mastoid) :
a. Anak 436,000
b. Dewasa 372,000
15 Insisi drainase abses perikordium 122,000
16 Insisi drainase abses retroaurikuler 122,000
17 Insisi drainase abses peritonsil 143,000
18 Insisi abses mastoid 231,000

19 Insisi perikondritis aurikel 365,000

20 Kauterisasi telinga 129,000
21 Lithiasis extraction 196,000
22 Parasentesis telinga 378,000
23 Pompa Siegel 103,000
24 Pungsi drainase kista auriculair 75,000
25 Tampon telinga 81,000
26 Tes garputala 91,000
27 Oto acoustic emission (OAE) 77,000
28 Tes pendengaran dengan BERA 372,000
29 Timpanometri 231,000
30 Toilet telinga :
a. Dengan H2O2 – suction 75,000
b. Dengan tampon tarivid 155,000
c. Dengan tampon cynolon 155,000
31 Test fungsi tuba 134,000
32 Test kalori vestibuler 178,000
33 Spoeling H202 70,000
HIDUNG
1 Aplikasi adrenalin 96,000
2 Aplikasi illiacin 75,000
3 Biopsi :
a. Hidung/ cavum nasi 296,000
b. Nasofaring 360,000
5 Ekstraksi polip :
a. Unilateral 216,000
b. Bilateral 296,000
6 Injeksi kenakort 151,000
7 Insisi : 143,000
a. Insisi abses hidung 144,000
b. Insisi abses dengan tampon Kemicetin 263,000
c. Insisi septal abses hidung 433,000
d. Insisi submandibula cavis hidung 261,000
e. Insisi drainase abses hidung 178,000

8 Irigasi sinus maxillaris 178,000

9 Kauterisasi hidung 129,000
10 Tampon hidung :
a. Pasang tampon anterior 184,000
b. pasang tampon posterior 360,000
c. Pasang tampon anterior dan posterior 487,000
d. Aff tampon hidung 117,000
11 Pungsi drainase kista auriculair 178,000
12 Polip hidung :
Solitaire S 167,000
Solitaire M 180,000
Solitaire L 193,000
13 Toilet hidung :
a. Toilet hidung / Suction 81,000
b. Krosti 109,000
c. Post operasi 134,000
TENGGOROK
1 Aplikasi xylocain 81,000
2 Biopsi :
a. Tonsil 340,000
b. Tenggorok – nasofaring 340,000
c. Palatum 340,000
3 Corp. All Tenggorokan 104,000
4 Kauter :
a. Granulasi faring (elektrik) 639,000
b. Tenggorokan Kimiawi 151,000
6 Insisi abses peritonsiler 340,000
7 Laryngoscopy Indirect 96,000

III.6. SPESIALIS MATA
1 Anel Test / sondage 286,000

2 Biometri 134,000
3 Ductus lacrimalis dilatation / Sondage 298,000
4 Eksisi xanthelasma : 1-2 244,000
5 Ekstirpasi granuloma 270,000
6 Ekstirpasi lithiasis 244,000
7 Ekstraksi corpus alienum cornea / Palpebra 273,000
8 Epilasi 145,000
9 Epilasi & cauterisasi 200,000
10 Eye toilet :
a. Ringan 129,000
b. Sedang 197,000
c. Berat 238,000
11 Direct funduscopy 77,000
12 Indirect funcuscopy 107,000
13 Aff hecting:
a. Kornea 205,000
b. Palpebra 114,000
14 Hecting palpebra :
a. Hecting palpebra < 5 384,000
b. Hecting palpebra lebih > 5 475,000
15 Insisi hordeolum / khalazion / kista 576,000
16 Indirect Opthalmoscopy 65,000
17 Keratometri / autorefraktor 45,000
18 Kerokan + debridement Kornea 81,000
19 Lithiasis per kelopak 107,000
20 Probing therapeutic 405,000
21 Pterygium plasty 1,152,000
22 Pterygium CLG (Conjunctiva Lumbal Graft) 2,229,000
23 Refraktometri 80,000
24 Scraping conjungtiva 205,000
25 Suntik intravitreal 176,000
26 Suntik subkonjungtiva 69,000
27 Symblepharon plasty repair 1,152,000
28 Tarsotomy / operasi Weeler 1,152,000

29 Tonometri / tensi okuli 75,000

30 ROP 291,000
31 Streak Retinoscopy 41,000

III.7. SPESIALIS KULIT-KELAMIN
1 Bedah Minor 523,000

2 Biopsi Skalpel :
a. Tubuh (1 lesi) 296,000
b. Wajah (1 lesi) 507,000
3 Biopsi Plong 296,000
4 Bulektomi
a. Ringan 109,000
b. Berat 218,000
5 Chemical peeling
a. CP - 1 (AHA/AFA/JESNER) 360,000
b. CP - 2 436,000
c. TCA 711,000
6 Chorethyl spray untuk "creeping diseases"
a. Ringan 192,000
b. Sedang 256,000
c. Berat 360,000
7 Ekstirpasi :
a. Ringan 436,000
b. Berat 711,000
8 Ekstraksi kuku 144,000
9 Eksisi Komedo
Sederhana (Non Suntik) 128,000
Kompleks (+Suntik) 215,000
10 Elektrokauterisasi bedah listrik :
a. Ringan 360,000
b. Sedang 507,000
c. Berat 648,000
11 Enukleasi moluskum :
a. Ringan (1 - 5 lesi) 218,000
b. Sedang (6 - 10 lesi) 296,000
c. Berat (> 10 lesi) 429,000
12 Facial :
a. Reguler 192,000
b. Masker lilin 218,000
c. Lilin + Thalasso Gaze 397,000

d. Masker topeng 239,000

e. Masker karet 109,000
f. Masker mikrodermabrasi 238,000
g.Facial oxygen botanicals 360,000
h. Facial La Tulipe 72,000
i. Treatment aromatherapi 129,000
j. Treatment akupressure 72,000
k. Kompleks + Masker + Serum 204,000
NJADI Rp 60rb (JTN) l. Beautican 59,000
13 Galvanic / Iontophoresis 129,000
14 Injeksi keloid :
a. Ringan (1 - 3 suntikan) 144,000
b. Sedang (4 - 6 suntikan) 226,000
c. Berat (> 7 suntikan) 288,000
15 Injeksi kenacort intralesi :
a. Ringan (1 - 5 lesi) / (< 0,02 cc) 129,000
b. Sedang (6 - 10 lesi) / (0,02 – 0,05 cc) 160,000
c. Berat (> 10 lesi) / (0,05 cc) 178,000
16 Insisi abses (1 buah) 200,000
17 Injeksi whitening 512,000
18 Kauterisasi
Kecil 308,000
Sedang 489,000
Besar 745,000
19 Kuretase Eksisi / Echoliasi
Sederhana A 145,000
Sederhana B 181,000
Kompleks A 239,000
Kompleks B 268,000
20 Ekstraksi Komedo:
a. Ringan (1 - 5 lesi) 73,000
b. Sedang (6 - 10 lesi) 109,000
c. Berat (> 11 lesi) 144,000
21 Mikro dermabrasi 583,000
22 Nekrotomi :

a. Ringan 144,000
b. Sedang 218,000
23 Peeling 160,000
24 Peeling GA Neostrata 419,000
25 Peeling TCA 303,000
26 Tincture pedophilyn 118,000
27 Tindakan manual
a. Ringan 224,000
b. Sedang 308,000
c. Berat 519,000
28 Tutul CA 50%
Sederhana 169,000
Kompleks 244,000
29 Vitamin C ion treatment (sonophoresis+Iontophoresis) 184,000
30 Ekstirpasi veruka :
a. Ringan (1-10 lesi) 149,000
b. Sedang (11-20 lesi) 213,000
c. Berat (> 20 lesi) 285,000
31 Audiovisual/otoskopi 118,000
32 Biopsi app CWL 344,000
33 Biopsi Tumor 310,000
34 Buka tampon 118,000
35 Injeksi imunoterapi 164,000
36 Test kulit cungkit (SPT) 328,000
37 Cauther Lokasi Konka 990,000
38 Dekanulisasi 169,000
39 Endoskopi 227,000
40 Ext. Corpus All. Cea 81,000
41 NPC + Biopsi 296,000

III.8. REHABILITASI MEDIK
1 Electric stimulation (ES) :

a. 1 area 73,000
b. 2 area 91,000
2 Exercise (EXC) :
a. Postural drainage 47,000
b. Muskuloskeletal exercise 66,000
c. Neuromuskular exercise 71,000
3 General exercise 118,000
4 Inhalasi :
a. Inhalasi 73,000
b. Inhalasi + suction 122,000
c. Inhalasi + suction + MWD 169,000
5 Infra red radiating (IRR) :
a. IRR 1 area 50,000
b. IRR 2 area 91,000
c. IRR + Inhalasi 116,000
6 Massage chest therapy 59,000
7 Micro wave diathermy (MWD) :
a. MWD 1 area 73,000
b. MWD 2 area 80,000
c. MWD 3 area 91,000
d. MWD + Inhalasi 134,000
8 Oksigen untuk 10 menit s.d 30 menit 24,000
9 Postural drainage(PD) 45,000
10 Suction 45,000
11 Short Wave Diathermy (SWD) 80,000
12 Tens :
a. 1 area 73,000
b. 2 area 91,000
c. 3 area 96,000
13 Ultrasonic (US) :
a. US 1 area 73,000
b. US 2 area 91,000
c. US 3 area 96,000

14 Pijat
a. Pijat Bayi 53,000
b. Pijat Dewasa 76,000
15 Hipno + Imajinasi 539,000
III.9. HEMODIALISA
1 Baru 1,176,000
2 Lanjutan 967,000
3 CITO 1,470,000
III.10. PSIKOLOGI
1 Psiko Tes
a. Tes Kecerdasan 327,000
b. Tes Kesiapan Masuk Sekolah 331,000
c. Tes Penelusuran Minat dan Bakat 331,000
d. Evaluasi Kepribadian 331,000
e. Seleksi Pegawai
- Tingkat SMA dan D3 331,000
- Tingkat S1 dan Manager 435,000
2 Psikoterapi / Intervensi Psikologi
a. Family Theraphy 327,000
b. Relaxaxi Theraphy 327,000
c. Supertive Theraphy 327,000
d. Ratio Emotive Theraphy 327,000

III.11. AKUPUNTUR
1 Tarif Klinik Akupunktur+ Tindakan 1 Posisi + 10 Jarum 139,000

2 Posisi ( Tindakan Akupunktur Tambahan ) 70,000
2 Carlene + Suntik ( Aquapunktur I ) 92,000
3 Oxydermal + Suntik ( Aquapunktur II ) 157,000
4 Kolagen + Suntik ( Aquapunktur III ) 70,000
5 Tindakan
Tindakan Pertama 44,000
Tindakan Kedua 116,000
Tindakan Ketiga 191,000
Tindakan Keempat 257,000
5 Moxa 18,000
6 Meso PPC @ 5 CC 173,000
7 Whitening Inj 5 cc ( Tathlon ) 129,000
8 Laser
Laser Akupunktur I 70,000
Laser Akupunktur II 81,000
Laser Akupunktur III 99,000
9 TDP ( Pemanasan ) 18,000
Pemakaian Perjarum 2,000

III.9.A GIGI dan MULUT
NO JENIS TINDAKAN TARIF
KELOMPOK A
a Drg. Umum & Spesialis
1 Pemeriksaan Pada Kunjungan 1 (Tanpa Tindakan) 112,000
2 Perawatan Stomatis, Ulcus Per-Kunjungan 146,000
3 Occlusal Adjustment 217,000
4 Cetak 266,000
5 Cetak Double Impression 404,000

b Tindakan Bedah Mulut
1 Insisi Intra Oral 245,000
2 Operculectomi 295,000
3 Pencabutan Gigi Sulung non Injeksi 199,000
4 Pencabutan Gigi Sulung Dengan Injeksi 245,000
5 Pencabutan Gigi Permanen 419,000

c Tindakan Konservasi
1 Tambal Sementara 206,000
2 Tambal Composit Kecil 361,000
3 Tambal Composit Besar 429,000
4 Tambal Compomer Kecil 381,000
5 Tambal Compomer Besar 443,000
6 Tambal Glass Ionomer Kecil 245,000
7 Tambal Glass Ionomer Besar 288,000
8 Cementasi Crown/Onlay yang Lepas 252,000
9 Desensitisasi 1 Gigi/ Buka Kamar Pulpa 183,000
10 Bongkar Amalgam/Poles Tambalan 144,000
11 Perawatan SA Akar Gigi Tunggal 258,000
12 Pengisian SA Tunggal 332,000

d Tindakan Prostodonti
1 Gigi tiruan Lepas Acrilic 980,000
2 Tambahan Tiap Elemen 397,000
3 Reparasi dengan Cetak 566,000
4 Reparasi Tanpa Cetak 484,000
5 Flexi Unilateral 2,266,000
6 Flexi Bilateral 2,946,000

e Tindakan Orthodonti
1 Plat Orthodonti Lepas per Rahang 2,266,000
2 Plat Orthodonti Lepas Atas Bawah 3,777,000
3 Reparasi Plat ortho per-rahang dengan Cetak 680,000
4 Trainer 2,097,000
5 Aktivir Orthodonti Removable 280,000

f Tindakan Periodonti
1 Scalling per-Rahang 354,000

2. KELOMPOK B
a Konsultasi
1 Pemeriksaan Pada Kunjungan 1 (Tanpa Tindakan) 213,000

b Speialis Bedah Mulut
1 Pengobatan TMJ 1 Kali Kunjungan 220,000
2 Pencabutan 694,000
3 Odontectomi /Operasi 3,218,000
4 Odontectomi Kelas I Posisi A 1,810,000
5 Apex Reseksi Per-Akar Gigi 2,203,000
6 Operasi Kista 2,327,000
7 Alveolectomi Per-Kwadran 955,000
8 Bedah Jaringan Lunak 1,615,000
9 Kontrol Pasca Bedah 272,000
10 Insisi Extra Oral 860,000
11 Extirpasi Mucocele 1,448,000
12 Windowing 2,351,000
13 Excochleasi Fistula 3,157,000
14 Reposisi TMJ 1,248,000
15 Penjahitan Luka 1 – 3 Akibat Trauma / Rudapaksa 272,000
16 Penjahitan Luka 4 – 6 Akibat Trauma / Rudapaksa 390,000
17 Penjahitan luka 7 - 10 476,000
18 Frenektomy Labialis 1,972,000
19 Frenektomy Lingualis 1,836,000
20 Penutupan Oro Antral Fistula 3,673,000
21 Fixasi Gigi 2 gigi 1,102,000
22 Fixasi Gigi 4 gigi 2,203,000
c Spesialis Prostodonti
1 Pemasangan Pin 251,000
2 Core Bulid Up 581,000

d Spesialis Konservasi
1 Tambal Sementara 231,000
2 Perawatan SA Tunggal 361,000
3 Perawatan SA Tungal (Protaper) 408,000
4 Pengisian SA Tunggal (Endometason) 376,000
5 Pengisian SA Tunggal (AHA) 443,000
6 Perawatan SA gigi ganda 429,000
7 Perawatan SA gigi ganda (Protaper) 500,000
8 Pengisian SA Ganda (Endometason) 565,000
9 Pengisian SA Ganda (AHA) 646,000
10 Pelapisan / Labial Veneering 842,000
11 Bleaching per rahang 1,510,000
12 Bleaching per gigi/per rahang 416,000
13 Tambal Composit Kecil 429,000
14 Tambal Composit Besar 475,000
e Spesialis Pedodonti
1 Counseling Gigi Anak 234,000
2 Tambal Composite Kecil 345,000
3 Tambal Composite Besar 382,000


8 One Visite Endodontic 354,000
9 Perawatan SA Gigi Anak Tunggal 266,000
10 Perawatan SA Gigi Anak Ganda 300,000
11 Pengisian SA Gigi Anak Tunggal 295,000
12 Pengisian SA Gigi Anak Ganda 324,000
13 Pencabutan gigi anak CE 252,000
14 Pencabutan gigi anak Injeksi 332,000
15 Topical Aplikasi 1 Rahang 184,000
16 Topical Aplikasi + Oral Proplyayis 377,000
f. Spesialis Oral Medicine

1 Conseling Oral Medicine/Visite 265,000
2 Terapi Stomatis/Visite 273,000
3 Terapi Ulcus Traumacicus/Visite 355,000
4 Terapi Oral Herpes/Visite 393,000
5 Terapi Oral Candidiasi/Visite 408,000
6 Terapi Angularchelities/Visite 363,000
g. Spesialis Periodonti
1 Curret 800,000
2 Ginggivectomi per-regio 1,198,000
3 Free ginggival Graft 1,296,000
4 Frenectomi 1,599,000
5 Scalling per-rahang 379,000
6 Vestibulo Plasty 861,000
7 Flap Operasi 1,906,000
8 Bonegraft 2,592,000

h. Spesialis Orthodonti
1 Aktivir Plat Removable 348,000

3. KELOMPOK C
a. Tindakan Bedah Mulut

1 Obturator 1,133,000
2 Fiksasi Fraktur Rahang 2,567,000
3 Implant (Surgery & Abutment) 24,168,000
b. Tindakan Konservasi
1 Inlay / Onlay 1,836,000
2 Bleaching per rahang 1,836,000
3 Bleaching per gigi 485,000
4 Fiber Post 1,510,000
c. Tindakan Prosthodonti
1 Crown:
a. Metal 1,819,000
b. Porcelain 3,399,000
2 Copping 619,000
3 Sendok Cetak Perorang 404,000
4 Mahkota Sementara 416,000
5 Gigi tiruan lepas logam 1 Elemen 2,870,000
6 Gigi tiruan penuh / rahang 4,380,000
7 Gigi tiruan penuh rahang atas & bawah 7,024,000
8 Per-elemen berikutnya 571,000
9 Reparasi dengan cetak 619,000
10 Bridge Work dgn Precious mental per-elemen 1,481,000
11 Post Core 814,000
12 Porcelain Veneer (Facing) 1,359,000
13 Maryland Bridge / 1 gigi 2,470,000
14 Labiel Veneer / 1 gigi 829,000
15 Prothesa Obturator 1,709,000
16 Occlusal Splint 1,299,000
17 Rebase 1,738,000
18 Reline 885,000
19 Kontrol Prothesa 332,000
20 Flexi Unilateral 2,719,000

21 Flexi Bilateral 3,624,000
d. Tindakan Periodonti
1 Bruxism 1,284,000
2 Splinting Kawat / Wire 1,170,000
3 Splinting Plastik 1,435,000
4 Splinting Fiber 1,888,000
e. Tindakan Pedodonti
1 Space Maintainer 1,248,000
2 Crown Metal 1,102,000
3 Crown GIC / Composite 1,102,000
f. Tindakan Orthodonti
1 Fixed Appliance 14,756,000
2 Fixed Appliance Full Cheramic 23,777,000
3 Pengganti Plat Ortho retensi 2 rahang 2,562,000
4 Aktivir Orthodonti Fixed (tanpa penambahan alat) 458,000
5 Aktivir Orthodonti Fixed (dgn penambahan alat) 659,000
6 Aktivir Orthodonti Removeble (dgn penambahan alat) 449,000
7 Fixed Appliance 1 (Satu) Rahang 8,693,000
8 Plat Orthodonti Lepas Atas Bawah 4,491,000
9 Plat Orthodonti Lepas per Rahang 2,695,000
4. KELOMPOK D
Bahan Khusus
1 Bahan khusus Komposit / Compomer 39,000
2 Bahan khusus GIC 26,000
3 Bahan Khusus Ledermix 26,000
4 Bahan Khusus cetak 31,000
5 Bahan Khusus Tambal Sementara 26,000
6 Bahan khusus Perawatan Sal Akar 31,000
7 Bahan Khusus Pengisian Sal Akar 31,000
8 Rontgen Photo 76,000

IV. PERKIRAAN TARIF TINDAKAN MEDIS OPERATIF (PER – KELAS PERAWATAN)
IV.1. SPESIALIS KEBIDANAN DAN KANDUNGAN
RUMAH JASA DOKTER (Dr.Operator,

KELAS GOL. OPERASI PARAMEDIS OBAT JUMLAH
SAKIT Dr.Anestesi, Dr.Asisten)
Kecil 5,309,000 4,286,800 306,200 4,496,000 14,398,000
Sedang 6,457,000 9,175,650 556,100 4,496,000 20,684,750

SUITE ROOM
Besar 12,959,000 10,665,600 646,400 5,505,000 29,776,000
Besar Khusus 16,021,000 14,699,850 890,900 5,505,000 37,116,750
Kecil 4,430,000 3,942,400 281,600 4,496,000 13,150,000
Sedang 5,414,000 8,258,250 500,500 4,496,000 18,668,750

SVIP
Besar 10,506,000 10,063,350 609,900 5,505,000 26,684,250
Besar Khusus 13,130,000 13,815,450 837,300 5,505,000 33,287,750
Kecil 4,173,000 3,649,800 260,700 4,496,000 12,579,500
Sedang 5,116,000 7,623,000 462,000 4,496,000 17,697,000

VIP
Besar 9,704,000 8,977,650 544,100 5,505,000 24,730,750
Besar Khusus 12,219,000 12,016,950 728,300 5,505,000 30,469,250
Kecil 3,338,000 3,066,000 219,000 4,496,000 11,119,000
Sedang 4,158,000 6,002,700 363,800 4,496,000 15,020,500

I
Besar 6,988,000 7,139,550 432,700 5,505,000 20,065,250
Besar Khusus 9,174,000 9,528,750 577,500 5,505,000 24,785,250
Kecil 2,550,000 2,626,400 187,600 4,496,000 9,860,000
Sedang 3,206,000 5,730,450 347,300 4,496,000 13,779,750

II
Besar 4,986,000 6,685,800 405,200 5,505,000 17,582,000
Besar Khusus 6,736,000 7,639,500 463,000 5,505,000 20,343,500
Kecil 1,791,000 1,960,000 140,000 4,496,000 8,387,000
Sedang 2,283,000 3,758,700 227,800 4,496,000 10,765,500

III
Besar 3,133,000 4,816,350 291,900 5,505,000 13,746,250
Besar Khusus 4,445,000 5,775,000 350,000 5,505,000 16,075,000
* Tarif kamar perawatan dihitung dengan perkiraan lama perawatan sebagai berikut :
Gol. Operasi Kecil dan Sedang : 1 hari
Gol. Operasi Besar dan Besar Khusus : 5 hari
* Tarif yang tertera diatas berlaku dalam KEADAAN NORMAL / BIASA
* Tarif Yang Tertera diatas merupakan Tarif PERKIRAAN SEMENTARA dan TIDAK BERLAKU MUTLAK,
SEWAKTU-WAKTU DAPAT BERUBAH KARENA KONDISI/KEBUTUHAN PELAYANAN MEDIS PASIEN.
* Tarif yang tertera diatas BELUM termasuk :
1. BIAYA ADMINISTRASI 7% DARI TOTAL KUITANSI, MAKSIMUM S/D Rp 1.200.000,-
2. TARIF JASA MEDIS VISITE DOKTER
3. TARIF PEMERIKSAAN LABORATORIUM DAN PENUNJANG MEDIS LAINNYA
4. BIAYA OBAT-OBATAN YANG DIRESEPKAN
5. BIAYA JASA PARAMEDIS di kamar perawatan

IV.2. SPESIALIS BEDAH
IV.2.1. SPESIALIS BEDAH ANAK :

Kecil 5,309,000 6,020,000 430,000 4,496,000 16,255,000
Sedang 6,457,000 8,023,950 486,300 4,496,000 19,463,250
Besar 12,959,000 12,294,150 745,100 6,056,000 32,054,250
Besar Khusus
SUITE ROOM
I 16,021,000 16,044,600 972,400 6,056,000 39,094,000
II 16,021,000 18,719,250 1,134,500 6,056,000 41,930,750
III 16,021,000 24,068,550 1,458,700 6,056,000 47,604,250
IV 16,021,000 26,741,550 1,620,700 6,056,000 50,439,250
Kecil 4,430,000 5,185,600 370,400 4,496,000 14,482,000
Sedang 5,414,000 8,023,950 486,300 4,496,000 18,420,250
Besar 10,506,000 12,224,850 740,900 6,056,000 29,527,750
Besar Khusus
SVIP
I 13,130,000 16,005,000 970,000 6,056,000 36,161,000
II 13,130,000 18,651,600 1,130,400 6,056,000 38,968,000
III 13,130,000 24,007,500 1,455,000 6,056,000 44,648,500
IV 13,130,000 26,673,900 1,616,600 6,056,000 47,476,500
Kecil 4,173,000 4,373,600 312,400 4,496,000 13,355,000
Sedang 5,116,000 6,519,150 395,100 4,496,000 16,526,250
Besar 9,704,000 9,240,000 560,000 6,056,000 25,560,000
Besar Khusus
VIP
I 12,219,000 13,718,100 831,400 6,056,000 32,824,500
II 12,219,000 16,039,650 972,100 6,056,000 35,286,750
III 12,219,000 20,578,800 1,247,200 6,056,000 40,101,000
IV 12,219,000 22,864,050 1,385,700 6,056,000 42,524,750
Kecil 3,338,000 3,721,200 265,800 4,496,000 11,821,000
Sedang 4,158,000 5,717,250 346,500 4,496,000 14,717,750
Besar 6,988,000 8,292,900 502,600 6,056,000 21,839,500
Besar Khusus
I
I 9,174,000 11,431,200 692,800 6,056,000 27,354,000
II 9,174,000 13,338,600 808,400 6,056,000 29,377,000
III 9,174,000 17,148,450 1,039,300 6,056,000 33,417,750
IV 9,174,000 19,054,200 1,154,800 6,056,000 35,439,000

Kecil 2,550,000 2,892,400 206,600 4,496,000 10,145,000
Sedang 3,206,000 4,730,550 286,700 4,496,000 12,719,250
Besar 4,986,000 6,860,700 415,800 6,056,000 18,318,500
Besar Khusus
II
I 6,736,000 9,169,050 555,700 6,056,000 22,516,750
II 6,736,000 10,696,950 648,300 6,056,000 24,137,250
III 6,736,000 13,741,200 832,800 6,056,000 27,366,000
IV 6,736,000 15,242,700 923,800 6,056,000 28,958,500
Kecil 1,791,000 2,398,200 171,300 4,496,000 8,856,500
Sedang 2,283,000 3,811,500 231,000 4,496,000 10,821,500
Besar 3,133,000 5,717,250 346,500 6,056,000 15,252,750
Besar Khusus
III
I 4,445,000 7,623,000 462,000 6,056,000 18,586,000
II 4,445,000 9,527,100 577,400 6,056,000 20,605,500
III 4,445,000 11,431,200 692,800 6,056,000 22,625,000
IV 4,445,000 14,190,000 860,000 6,056,000 25,551,000
Keterangan :

IV. 2.2 SPESIALIS BEDAH UMUM

Kecil 5,309,000 4,433,800 316,700 4,331,000 14,390,500
Sedang 6,457,000 8,878,650 538,100 4,331,000 20,204,750

SUITE ROOM
Besar 12,959,000 10,444,500 633,000 5,303,000 29,339,500
Besar Khusus 16,021,000 13,470,600 816,400 5,303,000 35,611,000
Kecil 4,430,000 5,017,600 358,400 4,331,000 14,137,000
Sedang 5,414,000 8,632,800 523,200 4,331,000 18,901,000

SVIP
Besar 10,506,000 10,160,700 615,800 5,303,000 26,585,500
Besar Khusus 13,130,000 12,759,450 773,300 5,303,000 31,965,750
Kecil 4,173,000 4,013,800 286,700 4,331,000 12,804,500
Sedang 5,116,000 7,392,000 448,000 4,331,000 17,287,000

VIP
Besar 9,704,000 8,708,700 527,800 5,303,000 24,243,500
Besar Khusus 12,219,000 11,231,550 680,700 5,303,000 29,434,250
Kecil 3,338,000 3,080,000 220,000 4,331,000 10,969,000
Sedang 4,158,000 7,095,000 430,000 4,331,000 16,014,000

I
Besar 6,988,000 7,260,000 440,000 5,303,000 19,991,000
Besar Khusus 9,174,000 9,358,800 567,200 5,303,000 24,403,000
Kecil 2,550,000 2,464,000 176,000 4,331,000 9,521,000
Sedang 3,206,000 4,950,000 300,000 4,331,000 12,787,000

II
Besar 4,986,000 5,730,450 347,300 5,303,000 16,366,750
Besar Khusus 6,736,000 7,487,700 453,800 5,303,000 19,980,500
Kecil 1,791,000 1,995,000 142,500 4,331,000 8,259,500
Sedang 2,283,000 4,011,150 243,100 4,331,000 10,868,250

III
Besar 3,133,000 4,950,000 300,000 5,303,000 13,686,000
Besar Khusus 4,445,000 7,095,000 430,000 5,303,000 17,273,000
Keterangan :

IV. 2.2.B SPESIALIS BEDAH DIGESTIF

Kecil 5,309,000 6,020,000 430,000 4,331,000 16,090,000
Sedang 6,457,000 8,023,950 486,300 4,331,000 19,298,250
Besar 12,959,000 12,294,150 745,100 5,303,000 31,301,250
Besar Khusus
SUITE ROOM
I 16,021,000 16,044,600 972,400 5,303,000 38,341,000
II 16,021,000 18,719,250 1,134,500 5,303,000 41,177,750
III 16,021,000 24,068,550 1,458,700 5,303,000 46,851,250
IV 16,021,000 26,741,550 1,620,700 5,303,000 49,686,250
Kecil 4,430,000 5,185,600 370,400 4,331,000 14,317,000
Sedang 5,414,000 8,023,950 486,300 4,331,000 18,255,250
Besar 10,506,000 12,224,850 740,900 5,303,000 28,774,750
Besar Khusus
SVIP
I 13,130,000 16,005,000 970,000 5,303,000 35,408,000
II 13,130,000 18,651,600 1,130,400 5,303,000 38,215,000
III 13,130,000 24,007,500 1,455,000 5,303,000 43,895,500
IV 13,130,000 26,673,900 1,616,600 5,303,000 46,723,500
Kecil 4,173,000 4,373,600 312,400 4,331,000 13,190,000
Sedang 5,116,000 6,519,150 395,100 4,331,000 16,361,250
Besar 9,704,000 9,240,000 560,000 5,303,000 24,807,000
Besar Khusus
VIP
I 12,219,000 13,718,100 831,400 5,303,000 32,071,500
II 12,219,000 16,039,650 972,100 5,303,000 34,533,750
III 12,219,000 20,578,800 1,247,200 5,303,000 39,348,000
IV 12,219,000 22,864,050 1,385,700 5,303,000 41,771,750
Kecil 3,338,000 3,721,200 265,800 4,331,000 11,656,000
Sedang 4,158,000 5,717,250 346,500 4,331,000 14,552,750
Besar 6,988,000 8,292,900 502,600 5,303,000 21,086,500
Besar Khusus
I
I 9,174,000 11,431,200 692,800 5,303,000 26,601,000
II 9,174,000 13,338,600 808,400 5,303,000 28,624,000
III 9,174,000 17,148,450 1,039,300 5,303,000 32,664,750
IV 9,174,000 19,054,200 1,154,800 5,303,000 34,686,000

Kecil 2,550,000 2,892,400 206,600 4,331,000 9,980,000
Sedang 3,206,000 4,730,550 286,700 4,331,000 12,554,250
Besar 4,986,000 6,860,700 415,800 5,303,000 17,565,500
Besar Khusus
II
I 6,736,000 9,169,050 555,700 5,303,000 21,763,750
II 6,736,000 10,696,950 648,300 5,303,000 23,384,250
III 6,736,000 13,741,200 832,800 5,303,000 26,613,000
IV 6,736,000 15,242,700 923,800 5,303,000 28,205,500
Kecil 1,791,000 2,398,200 171,300 4,331,000 8,691,500
Sedang 2,283,000 3,811,500 231,000 4,331,000 10,656,500
Besar 3,133,000 5,717,250 346,500 5,303,000 14,499,750
Besar Khusus
III
I 4,445,000 7,623,000 462,000 5,303,000 17,833,000
II 4,445,000 9,527,100 577,400 5,303,000 19,852,500
III 4,445,000 11,431,200 692,800 5,303,000 21,872,000
IV 4,445,000 14,190,000 860,000 5,303,000 24,798,000
Keterangan :

IV. 2.2.C SPESIALIS BEDAH ONKOLOGI

Kecil 5,309,000 5,542,600 395,900 4,331,000 15,578,500
Sedang 6,457,000 11,097,900 672,600 4,331,000 22,558,500

SUITE ROOM
Besar 12,959,000 13,056,450 791,300 5,303,000 32,109,750
Besar Khusus 16,021,000 16,838,250 1,020,500 5,303,000 39,182,750
Kecil 4,430,000 6,272,000 448,000 4,331,000 15,481,000
Sedang 5,414,000 10,791,000 654,000 4,331,000 21,190,000

SVIP
Besar 10,506,000 12,701,700 769,800 5,303,000 29,280,500
Besar Khusus 13,130,000 15,948,900 966,600 5,303,000 35,348,500
Kecil 4,173,000 5,017,600 358,400 4,331,000 13,880,000
Sedang 5,116,000 9,240,000 560,000 4,331,000 19,247,000

VIP
Besar 9,704,000 10,886,700 659,800 5,303,000 26,553,500
Besar Khusus 12,219,000 14,039,850 850,900 5,303,000 32,412,750
Kecil 3,338,000 3,850,000 275,000 4,331,000 11,794,000
Sedang 4,158,000 8,868,750 537,500 4,331,000 17,895,250

I
Besar 6,988,000 9,075,000 550,000 5,303,000 21,916,000
Besar Khusus 9,174,000 11,698,500 709,000 5,303,000 26,884,500
Kecil 2,550,000 3,080,000 220,000 4,331,000 10,181,000
Sedang 3,206,000 6,187,500 375,000 4,331,000 14,099,500

II
Besar 4,986,000 7,162,650 434,100 5,303,000 17,885,750
Besar Khusus 6,736,000 9,360,450 567,300 5,303,000 21,966,750
Kecil 1,791,000 2,493,400 178,100 4,331,000 8,793,500
Sedang 2,283,000 5,014,350 303,900 4,331,000 11,932,250

III
Besar 3,133,000 6,187,500 375,000 5,303,000 14,998,500
Besar Khusus 4,445,000 8,868,750 537,500 5,303,000 19,154,250
Keterangan :

IV. 2.2.D SPESIALIS BEDAH UROLOGI

Kecil 5,309,000 5,320,000 380,000 4,331,000 15,340,000
Sedang 6,457,000 10,654,050 645,700 4,331,000 22,087,750

SUITE ROOM
Besar 12,959,000 12,533,400 759,600 5,303,000 31,555,000
Besar Khusus 16,021,000 16,165,050 979,700 5,303,000 38,468,750
Kecil 4,430,000 6,021,400 430,100 4,331,000 15,212,500
Sedang 5,414,000 10,358,700 627,800 4,331,000 20,731,500

SVIP
Besar 10,506,000 12,193,500 739,000 5,303,000 28,741,500
Besar Khusus 13,130,000 15,312,000 928,000 5,303,000 34,673,000
Kecil 4,173,000 4,816,000 344,000 4,331,000 13,664,000
Sedang 5,116,000 8,870,400 537,600 4,331,000 18,855,000

VIP
Besar 9,704,000 10,451,100 633,400 5,303,000 26,091,500
Besar Khusus 12,219,000 13,477,200 816,800 5,303,000 31,816,000
Kecil 3,338,000 3,696,000 264,000 4,331,000 11,629,000
Sedang 4,158,000 8,514,000 516,000 4,331,000 17,519,000

I
Besar 6,988,000 8,712,000 528,000 5,303,000 21,531,000
Besar Khusus 9,174,000 11,229,900 680,600 5,303,000 26,387,500
Kecil 2,550,000 2,956,800 211,200 4,331,000 10,049,000
Sedang 3,206,000 5,940,000 360,000 4,331,000 13,837,000

II
Besar 4,986,000 6,877,200 416,800 5,303,000 17,583,000
Besar Khusus 6,736,000 8,985,900 544,600 5,303,000 21,569,500
Kecil 1,791,000 2,394,000 171,000 4,331,000 8,687,000
Sedang 2,283,000 4,813,050 291,700 4,331,000 11,718,750

III
Besar 3,133,000 5,940,000 360,000 5,303,000 14,736,000
Besar Khusus 4,445,000 8,514,000 516,000 5,303,000 18,778,000
Keterangan :

IV. 2.2.E SPESIALIS BEDAH PLASTIK

Kecil 5,309,000 5,542,600 395,900 4,331,000 15,578,500
Sedang 6,457,000 11,097,900 672,600 4,331,000 22,558,500

SUITE ROOM
Besar 12,959,000 13,056,450 791,300 5,303,000 32,109,750
Besar Khusus 16,021,000 16,838,250 1,020,500 5,303,000 39,182,750
Kecil 4,430,000 6,272,000 448,000 4,331,000 15,481,000
Sedang 5,414,000 10,791,000 654,000 4,331,000 21,190,000

SVIP
Besar 10,506,000 12,701,700 769,800 5,303,000 29,280,500
Besar Khusus 13,130,000 15,948,900 966,600 5,303,000 35,348,500
Kecil 4,173,000 5,017,600 358,400 4,331,000 13,880,000
Sedang 5,116,000 9,240,000 560,000 4,331,000 19,247,000

VIP
Besar 9,704,000 10,886,700 659,800 5,303,000 26,553,500
Besar Khusus 12,219,000 14,039,850 850,900 5,303,000 32,412,750
Kecil 3,338,000 3,850,000 275,000 4,331,000 11,794,000
Sedang 4,158,000 8,868,750 537,500 4,331,000 17,895,250

I
Besar 6,988,000 9,075,000 550,000 5,303,000 21,916,000
Besar Khusus 9,174,000 11,698,500 709,000 5,303,000 26,884,500
Kecil 2,550,000 3,080,000 220,000 4,331,000 10,181,000
Sedang 3,206,000 6,187,500 375,000 4,331,000 14,099,500

II
Besar 4,986,000 7,162,650 434,100 5,303,000 17,885,750
Besar Khusus 6,736,000 9,360,450 567,300 5,303,000 21,966,750
Kecil 1,791,000 2,493,400 178,100 4,331,000 8,793,500
Sedang 2,283,000 5,014,350 303,900 4,331,000 11,932,250

III
Besar 3,133,000 6,187,500 375,000 5,303,000 14,998,500
Besar Khusus 4,445,000 8,868,750 537,500 5,303,000 19,154,250
Keterangan :

IV.2.3. SPESIALIS BEDAH ORTHOPEDI :

Kecil 5,309,000 4,466,000 319,000 4,496,000 14,590,000
Sedang :
I 6,457,000 14,325,300 868,200 4,496,000 26,146,500
II 6,457,000 19,100,400 1,157,600 4,496,000 31,211,000
III 6,457,000 21,011,100 1,273,400 4,496,000 33,237,500
Besar :
SUITE ROOM I 12,959,000 23,875,500 1,447,000 5,505,000 43,786,500
II 12,959,000 28,653,900 1,736,600 5,505,000 48,854,500
III 12,959,000 30,561,300 1,852,200 5,505,000 50,877,500
Besar Khusus :
I 16,021,000 34,922,250 2,116,500 5,505,000 58,564,750
II 16,021,000 42,022,200 2,546,800 5,505,000 66,095,000
III 16,021,000 47,752,650 2,894,100 5,505,000 72,172,750
Kecil 4,430,000 3,711,400 265,100 4,496,000 12,902,500
Sedang :
I 5,414,000 13,609,200 824,800 4,496,000 24,344,000
II 5,414,000 18,146,700 1,099,800 4,496,000 29,156,500
III 5,414,000 19,961,700 1,209,800 4,496,000 31,081,500
Besar :
SVIP I 10,506,000 22,682,550 1,374,700 5,505,000 40,068,250
II 10,506,000 27,220,050 1,649,700 5,505,000 44,880,750
III 10,506,000 29,033,400 1,759,600 5,505,000 46,804,000
Besar Khusus :
I 13,130,000 34,381,050 2,083,700 5,505,000 55,099,750
II 13,130,000 39,920,100 2,419,400 5,505,000 60,974,500
III 13,130,000 45,365,100 2,749,400 5,505,000 66,749,500
Kecil 4,173,000 3,151,400 225,100 4,496,000 12,045,500
Sedang :
I 5,116,000 8,165,850 494,900 4,496,000 18,272,750
II 5,116,000 10,886,700 659,800 4,496,000 21,158,500
III 5,116,000 13,609,200 824,800 4,496,000 24,046,000
Besar :
VIP I 9,704,000 16,905,900 1,024,600 5,505,000 33,139,500
II 9,704,000 18,146,700 1,099,800 5,505,000 34,455,500
III 9,704,000 22,284,900 1,350,600 5,505,000 38,844,500
Besar Khusus :
I 12,219,000 22,864,050 1,385,700 5,505,000 41,973,750
II 12,219,000 24,769,800 1,501,200 5,505,000 43,995,000
III 12,219,000 26,017,200 1,576,800 5,505,000 45,318,000

Kecil 3,338,000 2,809,800 200,700 4,496,000 10,844,500
Sedang :
I 4,158,000 6,350,850 384,900 4,496,000 15,389,750
II 4,158,000 9,075,000 550,000 4,496,000 18,279,000
III 4,158,000 10,890,000 660,000 4,496,000 20,204,000
Besar :
I I 6,988,000 13,609,200 824,800 5,505,000 26,927,000
II 6,988,000 15,424,200 934,800 5,505,000 28,852,000
III 6,988,000 18,146,700 1,099,800 5,505,000 31,739,500
Besar Khusus :
I 9,174,000 19,054,200 1,154,800 5,505,000 34,888,000
II 9,174,000 20,959,950 1,270,300 5,505,000 36,909,250
III 9,174,000 22,864,050 1,385,700 5,505,000 38,928,750
Kecil 2,550,000 2,109,800 150,700 4,496,000 9,306,500
Sedang :
I 3,206,000 4,537,500 275,000 4,496,000 12,514,500
II 3,206,000 6,350,850 384,900 4,496,000 14,437,750
III 3,206,000 9,073,350 549,900 4,496,000 17,325,250
Besar :
II I 4,986,000 10,886,700 659,800 5,505,000 22,037,500
II 4,986,000 12,703,350 769,900 5,505,000 23,964,250
III 4,986,000 14,516,700 879,800 5,505,000 25,887,500
Besar Khusus :
I 6,736,000 16,331,700 989,800 5,505,000 29,562,500
II 6,736,000 18,146,700 1,099,800 5,505,000 31,487,500
III 6,736,000 19,961,700 1,209,800 5,505,000 33,412,500

Kecil 1,791,000 2,009,000 143,500 4,496,000 8,439,500
Sedang :
I 2,283,000 4,620,000 280,000 4,496,000 11,679,000
II 2,283,000 6,350,850 384,900 4,496,000 13,514,750
III 2,283,000 9,073,350 549,900 4,496,000 16,402,250
Besar :
III I 3,133,000 10,886,700 659,800 5,505,000 20,184,500
II 3,133,000 12,703,350 769,900 5,505,000 22,111,250
III 3,133,000 14,516,700 879,800 5,505,000 24,034,500
Besar Khusus :
I 4,445,000 16,331,700 989,800 5,505,000 27,271,500
II 4,445,000 18,146,700 1,099,800 5,505,000 29,196,500
III 4,445,000 19,961,700 1,209,800 5,505,000 31,121,500
Keterangan :

IV.2.4. SPESIALIS BEDAH SYARAF :

Kecil 5,309,000 4,762,800 340,200 4,941,000 15,353,000
Sedang 6,457,000 17,369,550 1,052,700 4,941,000 29,820,250

SUITE ROOM
Besar 12,959,000 24,052,050 1,457,700 5,928,000 44,396,750
Besar Khusus 16,021,000 39,283,200 2,380,800 5,928,000 63,613,000
Kecil 4,430,000 3,175,200 226,800 4,941,000 12,773,000
Sedang 5,414,000 14,963,850 906,900 4,941,000 26,225,750

SVIP
Besar 10,506,000 22,270,050 1,349,700 5,928,000 40,053,750
Besar Khusus 13,130,000 35,631,750 2,159,500 5,928,000 56,849,250
Kecil 4,173,000 3,175,200 226,800 4,941,000 12,516,000
Sedang 5,116,000 13,363,350 809,900 4,941,000 24,230,250

VIP
Besar 9,704,000 19,598,700 1,187,800 5,928,000 36,418,500
Besar Khusus 12,219,000 26,725,050 1,619,700 5,928,000 46,491,750
Kecil 3,338,000 3,241,000 231,500 4,941,000 11,751,500
Sedang 4,158,000 12,290,850 744,900 4,941,000 22,134,750

I
Besar 6,988,000 18,022,950 1,092,300 5,928,000 32,031,250
Besar Khusus 9,174,000 24,576,750 1,489,500 5,928,000 41,168,250
Kecil 2,550,000 3,022,600 215,900 4,941,000 10,729,500
Sedang 3,206,000 7,425,000 450,000 4,941,000 16,022,000

II
Besar 4,986,000 14,746,050 893,700 5,928,000 26,553,750
Besar Khusus 6,736,000 17,820,000 1,080,000 5,928,000 31,564,000
Kecil 1,791,000 3,080,000 220,000 4,941,000 10,032,000
Sedang 2,283,000 5,346,000 324,000 4,941,000 12,894,000

III
Besar 3,133,000 8,908,350 539,900 5,928,000 18,509,250
Besar Khusus 4,445,000 12,470,700 755,800 5,928,000 23,599,500
Keterangan :

IV.3. SPESIALIS THT :

Kecil 5,309,000 4,233,600 302,400 4,291,000 14,136,000
Sedang 6,457,000 7,159,350 433,900 4,291,000 18,341,250

SUITE ROOM
Besar 12,959,000 8,570,100 519,400 5,255,000 27,303,500
Besar Khusus 16,021,000 12,927,750 783,500 5,255,000 34,987,250
Kecil 4,430,000 3,887,800 277,700 4,291,000 12,886,500
Sedang 5,414,000 5,971,350 361,900 4,291,000 16,038,250

SVIP
Besar 10,506,000 7,837,500 475,000 5,255,000 24,073,500
Besar Khusus 13,130,000 11,226,600 680,400 5,255,000 30,292,000
Kecil 4,173,000 3,253,600 232,400 4,291,000 11,950,000
Sedang 5,116,000 5,346,000 324,000 4,291,000 15,077,000

VIP
Besar 9,704,000 7,297,950 442,300 5,255,000 22,699,250
Besar Khusus 12,219,000 9,977,550 604,700 5,255,000 28,056,250
Kecil 3,338,000 2,723,000 194,500 4,291,000 10,546,500
Sedang 4,158,000 4,719,000 286,000 4,291,000 13,454,000

I
Besar 6,988,000 6,501,000 394,000 5,255,000 19,138,000
Besar Khusus 9,174,000 8,111,400 491,600 5,255,000 23,032,000
Kecil 2,550,000 2,006,200 143,300 4,291,000 8,990,500
Sedang 3,206,000 3,557,400 215,600 4,291,000 11,270,000

II
Besar 4,986,000 5,882,250 356,500 5,255,000 16,479,750
Besar Khusus 6,736,000 6,235,350 377,900 5,255,000 18,604,250
Kecil 1,791,000 1,815,800 129,700 4,291,000 8,027,500
Sedang 2,283,000 3,547,500 215,000 4,291,000 10,336,500

III
Besar 3,133,000 4,950,000 300,000 5,255,000 13,638,000
Besar Khusus 4,445,000 5,515,950 334,300 5,255,000 15,550,250
Keterangan :

IV.4. SPESIALIS MATA :

Kecil 5,309,000 4,457,600 318,400 4,496,000 14,581,000
Sedang 6,457,000 7,578,450 459,300 4,496,000 18,990,750

SUITE ROOM
Besar 12,959,000 9,353,850 566,900 5,505,000 28,384,750
Besar Khusus 16,021,000 12,414,600 752,400 5,505,000 34,693,000
Kecil 4,430,000 4,051,600 289,400 4,496,000 13,267,000
Sedang 5,414,000 6,839,250 414,500 4,496,000 17,163,750

SVIP
Besar 10,506,000 7,822,650 474,100 5,505,000 24,307,750
Besar Khusus 13,130,000 12,033,450 729,300 5,505,000 31,397,750
Kecil 4,173,000 3,403,400 243,100 4,496,000 12,315,500
Sedang 5,116,000 6,138,000 372,000 4,496,000 16,122,000

VIP
Besar 9,704,000 7,449,750 451,500 5,505,000 23,110,250
Besar Khusus 12,219,000 10,696,950 648,300 5,505,000 29,069,250
Kecil 3,338,000 2,879,800 205,700 4,496,000 10,919,500
Sedang 4,158,000 5,157,900 312,600 4,496,000 14,124,500

I
Besar 6,988,000 6,685,800 405,200 5,505,000 19,584,000
Besar Khusus 9,174,000 8,594,850 520,900 5,505,000 23,794,750
Kecil 2,550,000 2,262,400 161,600 4,496,000 9,470,000
Sedang 3,206,000 4,090,350 247,900 4,496,000 12,040,250

II
Besar 4,986,000 6,111,600 370,400 5,505,000 16,973,000
Besar Khusus 6,736,000 6,685,800 405,200 5,505,000 19,332,000
Kecil 1,791,000 1,967,000 140,500 4,496,000 8,394,500
Sedang 2,283,000 3,742,200 226,800 4,496,000 10,748,000

III
Besar 3,133,000 5,702,400 345,600 5,505,000 14,686,000
Besar Khusus 4,445,000 6,235,350 377,900 5,505,000 16,563,250
Keterangan :

IV.5. SPESIALIS GIGI DAN MULUT
1. ODONTECTOMI 1 GIGI CANINUS (PERAWATAN 1 HARI)
KELAS
KETERANGAN
Rumah Sakit 3,396,000 2,790,000 2,601,000 1,972,000 1,457,000 971,000
Jasa Dokter
4,723,600 4,050,200 3,511,200 2,956,800 2,374,400 1,885,800
(Drg.Bedah Mulut, Dr.Anestesi)
Paramedis 337,400 289,300 250,800 211,200 169,600 134,700
Obat - obatan 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000
Jumlah 11,761,000 10,433,500 9,667,000 8,444,000 7,305,000 6,295,500
2. ODONTECTOMI 1 GIGI MOLAR (PERAWATAN 1 HARI)
KELAS
KETERANGAN
Rumah Sakit 3,396,000 2,790,000 2,601,000 1,972,000 1,457,000 971,000
Jasa Dokter
4,044,600 3,084,200 2,956,800 2,699,200 2,221,800 1,747,200
Paramedis 288,900 220,300 211,200 192,800 158,700 124,800
Obat - obatan 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000
Jumlah 11,033,500 9,398,500 9,073,000 8,168,000 7,141,500 6,147,000

3. ODONTECTOMI 2 GIGI (PERAWATAN 2 HARI)
KELAS
KETERANGAN
Rumah Sakit 5,452,000 4,432,000 4,102,000 2,987,000 2,148,000 1,368,000
Jasa Dokter
5,391,400 4,625,600 3,985,800 3,603,600 3,089,800 1,747,200
Paramedis 385,100 330,400 284,700 257,400 220,700 124,800
Obat - obatan 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000
Jumlah 14,532,500 12,692,000 11,676,500 10,152,000 8,762,500 6,544,000
4. ODONTECTOMI 4 GIGI (PERAWATAN 2 HARI)
KELAS
KETERANGAN
Rumah Sakit 5,739,000 4,678,000 4,338,000 3,192,000 2,312,000 1,491,000
Jasa Dokter
7,901,600 7,036,400 6,609,400 5,930,400 5,521,600 4,881,800
Paramedis 564,400 502,600 472,100 423,600 394,400 348,700
Obat - obatan 3,334,000 3,334,000 3,334,000 3,334,000 3,334,000 3,334,000
Jumlah 17,539,000 15,551,000 14,753,500 12,880,000 11,562,000 10,055,500

5. TUMOR KISTA RAHANG KECIL (PERAWATAN 2 HARI)
KELAS
KETERANGAN
Rumah Sakit 4,878,000 3,940,000 3,630,000 2,577,000 1,820,000 1,122,000
Jasa Dokter
4,625,600 3,985,800 3,537,800 3,084,200 2,709,000 2,290,400
Paramedis 330,400 284,700 252,700 220,300 193,500 163,600
Obat - obatan 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000
Jumlah 13,138,000 11,514,500 10,724,500 9,185,500 8,026,500 6,880,000
6. TUMOR KISTA RAHANG BESAR (PERAWATAN 2 HARI)
KELAS
KETERANGAN
Rumah Sakit 5,739,000 4,678,000 4,338,000 3,192,000 2,312,000 1,491,000
Jasa Dokter
6,672,400 5,983,600 5,521,600 4,944,800 4,177,600 3,647,000
Paramedis 476,600 427,400 394,400 353,200 298,400 260,500
Obat - obatan 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000
Jumlah 16,192,000 14,393,000 13,558,000 11,794,000 10,092,000 8,702,500

7. FRAKTUR RAHANG 1 RAHANG BESAR (PERAWATAN 2 HARI)
KELAS
KETERANGAN
Rumah Sakit 4,878,000 3,940,000 3,630,000 2,577,000 1,820,000 1,122,000
Jasa Dokter
5,138,000 4,433,800 4,050,200 3,635,800 3,089,800 2,580,200
Paramedis 367,000 316,700 289,300 259,700 220,700 184,300
Obat - obatan 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000
Jumlah 13,687,000 11,994,500 11,273,500 9,776,500 8,434,500 7,190,500
8. TINDAKAN PERAWATAN GIGI DENGAN ANESTESI UMUM
GOLONGAN
KETERANGAN
KECIL SEDANG BESAR
Rumah Sakit 1,050,000 1,296,000 1,419,000
Jasa Dokter
1,918,000 2,879,800 1,968,400
Paramedis 137,000 205,700 140,600
BHP Poli Sesuai Dengan Tarif Alat + Consumable
Alat + Obat 2,823,000 2,823,000 2,823,000
Jumlah 5,928,000 7,204,500 6,351,000
Keterangan :
1. Golongan Kecil 1-3 Tindakan
2. Golongan Sedang 4-10 Tindakan
3. Golongan Besar >10 Tindakan
V. TARIF PERSALINAN
V.1. PERSALINAN NORMAL (3 hari)
KELAS
KOMPONEN
Rumah Sakit 10,150,000 7,950,000 7,064,000 4,422,000 3,110,000 1,928,000
Jasa Dokter
4,393,000 3,860,550 3,461,500 2,555,300 1,713,500 1,223,600
(dr.Obsgyn, dr.Anak)
Paramedis 382,000 335,700 301,000 222,200 149,000 106,400
Obat - obatan 2,779,000 2,779,000 2,779,000 2,779,000 2,669,000 2,669,000
JUMLAH 17,704,000 14,925,250 13,605,500 9,978,500 7,641,500 5,927,000
Keterangan :
* Tarif Yang Tertera diatas merupakan Tarif PERKIRAAN SEMENTARA dan TIDAK BERLAKU MUTLAK
SEWAKTU-WAKTU DAPAT BERUBAH KARENA KEBUTUHAN PELAYANAN MEDIS PASIEN.
1. BIAYA ADMINISTRASI 7 % DARI TOTAL KUITANSI, MAKSIMUM S/D Rp 1.200.000,-
* Pada Kasus khusus yang memerlukan kehadiran dokter anak subspesialis, maka jasa dokter anak
ditambah 20%
* BILA KONDISI TIDAK NORMAL/ TIDAK BIASA, DAPAT LEBIH TINGGI DARI JUMLAH TERSEBUT, ANTARA LAIN KONDISI :
a. GEMELI
Kembar Dua : Obsgyn ( G1: 100%, G2: + 50 %), dokter anak & visite + 100 %,
RS (sewa kamar bersalin, paramedis dan obat-obatan): + 20 %.
Kembar Tiga : Obsgyn ( G1: 100%, G2: + 50 %, G3: + 25 %), dokter anak & visite + 100 %,
b. INDUKSI : Sewa kamar bersalin, dokter obsgyn, paramedis, dan obat-obatan ditambah 10 %.
c. VACUM DAN LETAK SUNGSANG :
Sewa kamar bersalin, dokter obsgyn, paramedis dan obat-obatan ditambah 10 %.
Jika dokter anak hadir dalam tindakan, maka tarif dokter anak + visite sama dengan biaya pada SC.

V.2. PERSALINAN DENGAN ILA (4 hari)
KELAS
KOMPONEN
Rumah Sakit 12,521,000 9,790,000 8,710,000 5,390,000 3,691,000 2,191,000
Jasa Dokter
(dr.Obsgyn, dr.Anestesi, 6,155,050 5,130,500 4,650,000 3,526,250 2,666,000 1,796,450
dr.Anak)
Paramedis 397,100 331,000 300,000 227,500 172,000 115,900
Obat - obatan 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000 3,304,000
JUMLAH 22,377,150 18,555,500 16,964,000 12,447,750 9,833,000 7,407,350
Keterangan :
Rumah Sakit
ditambah 20%
a. GEMELI

V.3. SECTIO CAESARIA (5 hari)
KELAS
KOMPONEN
Rumah Sakit 17,404,000 13,956,000 12,789,000 8,803,000 6,076,000 3,693,000
Jasa Dokter(dr.Obsgyn,
dr.Asisten, dr.Anestesi, 7,306,200 6,679,800 5,567,400 4,879,800 4,260,600 3,063,600
Dr.Anak)
Paramedis 405,900 371,100 309,300 271,100 236,700 170,200
Obat - obatan 5,505,000 5,505,000 5,505,000 5,505,000 5,505,000 5,505,000
JUMLAH 30,621,100 26,511,900 24,170,700 19,458,900 16,078,300 12,431,800
Keterangan :
ditambah 20%
a. GEMELI

V.4. PERSALINAN OLEH BIDAN (3 hari)
KELAS
KOMPONEN
VIP I II III
Rumah Sakit 7,064,000 4,422,000 3,110,000 2,667,000 1,928,000
Jasa Bidan & Dokter Anak 1,108,000 856,000 630,000 630,000 523,000
Paramedis 305,000 222,000 156,000 156,000 111,000
Obat - obatan 2,935,000 2,935,000 2,935,000 2,935,000 2,935,000
JUMLAH 11,412,000 8,435,000 6,831,000 6,388,000 5,497,000
Keterangan :
ditambah 20%
a. GEMELI

VI. TARIF PEMERIKSAAN DENGAN ALAT DAN SEWA ALAT
No. ALAT 2017
1 Aeroneb (Filter Nebulizer) 130,000

2 Blue Light 162,000
3 Bubble C- Pap
a. Reusable 480,000
b. Disposable / diluar alat sirkuit 240,000
4 CTG :
a. CTG 1 kali 122,000
b. CTG 2 kali 240,000
c. CTG 3 kali 333,000
d.CTG > 3 kali/hari 367,000
5 Couve 123,000
6 Defibrilator 325,000
7 Echocardiography 825,000
8 EKG 122,000
9 Konsul baca EKG 56,000
10 EEG 443,000
11 Infuse Pump :
a. Infuse Pump per jam 65,000
b. Infuse Pump > 4 jam 162,000
12 Laparaskopi untuk tindakan medis :
a. Tindakan medis operatif Golongan I dan II 1,705,000
b. Tindakan medis operatif Golongan III dan IV 2,726,000
13 Inkubator 299,000
14 Laryngoscope Direct 257,000
15 Monitor 284,000
16 Monitor Perina (Level 2) 122,000
17 Nebulizer 129,000
18 Oksigen :
a. Oksigen (per-jam) 66,000
b. Oksigen (perhari/24 jam) 276,000
19 Pompa susu elektrik 41,000
20 Pulse oxymetri 138,000
21 Syringe pump 146,000
22 USG Non Kebidanan :
a. USG Kepala 2D + print (maks.3 lbr) 324,000

b. USG Leher 3D + print (maks.3 lbr) 486,000
c. USG Thorax 3D + print (maks.3 lbr) 486,000

No. ALAT 2017
d. USG Jantung + print (maks.3 lbr) 378,000

e. USG Mammae 3D + print (maks.3 lbr) 324,000
f. USG Abdomen + print (maks.3 lbr) 551,000
g. USG Testis 3D + print (maks.3 lbr) 486,000
h. USG Ekstremitas (3D) + print (maks.3 lbr) 549,000
i. USG Kulit + print (maks.3 lbr) 292,000
j. USG Ginjal/prostat 616,000
k. USG Hepatobiler 616,000
l. USG Tyroid 639,000
m. USG Appendix 616,000
n. USG Paraorta & Illiaca 616,000
o. USG Soft Tissue Abdomen 616,000
p. USG Soft Tissue Leher 616,000
q. USG Dopler 648,000
r. USG 2D (Alat 3D/4D) 216,000
23 USG Kebidanan :
a. USG 2 Dimensi (Alat 3D) + print (maks.3 lbr) 640,000
b. USG 3 Dimensi/ 4 Dimensi + print (maks.3 lbr) 914,000
c. USG Kebidanan (Alat 2 D) + print (maks.3 lbr) 270,000
d. USG 3 Dimensi Non Feto 487,000
e. USG Transvaginal (Alat 3D) + print (maks.3 lbr) 447,000
f. Penambahan Print USG / lembar 27,000
24 Ventilator + Compres 694,000
25 Matras Anti Decubitus 37,000
26 Set Umbilical 157,000
27 Set Long Line 157,000
28 Set Vena Sectie 191,000
29 Histereskopi 448,000
30 DC Shock 220,000

VII. TARIF LABORATORIUM
No. ALAT TARIF
A. HEMATOLOGI
1 Rutin 1 (Hb,Ht,Leko,Trombo) 104,000
2 Rutin 2 (Hb,Leko,LED,Diff) 133,000
3 Darah Tepi (Hb,Leko,Ht,Trombo,Diff) 133,000
4 Darah Lengkap (Rutin 2, Ht, Eri, Trombo, Nilai Eri) 167,000
5 Retikilosit 47,000
6 Hitung Eosinofil 47,000
7 Gambaran Darah Tepi / MDT 190,000
8 Ferritin 384,000
9 Hemoglobin 47,000
10 Lekosit 47,000
11 Trombosit 47,000
12 LED 47,000
13 MCV,MCH,MCHC 47,000
14 Golongan darah 61,000
15 Sel LE 110,000
16 LE Test 187,000
17 G6PD Neonatus 104,000
18 G6PD Ery / Serum 312,000
19 Serum Iron / SI 187,000
20 TIBC 181,000
21 Tranferin 390,000
22 Vit B12 1,165,000
23 Hematokrit 38,000
24 Eritrosit 38,000
25 Hitung Jenis 24,000
26 Asam Folat 962,000

No. ALAT TARIF
27 DNA Analisa 1,930,000

28 Hb Analisa / Elektroforesa 488,000
29 CD4 414,000
30 CD8 414,000
31 Comb's Test 189,000
32 Electroforesa HB 264,000
B. KOAGULASI
33 Masa Pembekuan 21,000
34 Masa Perdarahan 21,000
35 Masa Protrombin 167,000
36 APTT 167,000
37 Fibrinogen 252,000
38 D-dimer 451,000
39 INR 167,000
40 Masa Trombin 407,000
41 AT III 579,000
42 Trombotest Owren 300,000
43 Agregasi Trombosit 355,000
44 Viscositas Darah 301,000
45 Viscositas Plasma 301,000
46 Faktor VIII 677,000
47 Faktor IX 677,000
48 Faktor Von Wallerbrand 602,000
C. KIMIA 0
49 Protein/alb/globulin 125,000
50 Protein Total 60,000
51 Albumin 60,000

No. ALAT TARIF
52 Bilirubin total/direct 129,000

53 Bilirubin Total 68,000
54 Bilirubin direct 68,000
55 Bilirubin bayi 68,000
56 SGOT 68,000
57 SGPT 68,000
58 Alkal Fosfatase 98,000
59 Gamma GT 120,000
60 CHE 249,000
61 GLDH 669,000
62 HBA1C 207,000
63 C Peptide 511,000
64 Insulin 474,000
65 Insulin Antibodi 1,879,000
66 Fruktosamin 497,000
67 ICA 2,329,000
68 Ureum 68,000
69 Kreatinin 68,000
70 Asam Urat 68,000
71 Cholesterol total 68,000
72 HDL Cholesterol 76,000
73 LDL Cholesterol 135,000
74 LDL Direk 135,000
75 Triglyserida 76,000
76 Total Lipid 173,000
77 LP (a) 505,000
78 APO A1 421,000

No. ALAT TARIF
79 APO B 308,000
80 LDH 173,000
81 HBDH 120,000
82 CPK 240,000
83 CK-MB 278,000
84 hs-CRP 451,000
85 Fosfor 120,000
86 Magnesium 120,000
87 Calcium 120,000
88 Fosfatase Asam 173,000
89 Fosfatase Asam Frostatic 173,000
90 Amilase Darah 316,000
91 Lipase Darah 316,000
92 Amonia Darah 552,000
93 Lactat 347,000
94 Calcium ion 302,000
95 Paket Na,K,Cl 361,000
96 Astrup + NaKCl / Analisa Gas Darah 586,000
97 Globulin 54,000
98 Creatin Clearence 84,000
99 Fosfor Anorganik 78,000
100 Berat Jenis 18,000
101 Gula Darah Puasa 47,000
102 Gula Darah PP 2 Jam 47,000
103 Gula Darah Sewaktu 47,000
104 Tes Toleransi Glukosa 180,000
105 Kurva Harian Glukosa 102,000

No. ALAT TARIF
D. SEROLOGI IMUNOLOGI
106 HBsAg 181,000
107 Anti HBs 240,000
108 Anti HCV 602,000
109 Anti HBc Total 421,000
110 Anti HBc IgM 752,000
111 Anti Hbe 691,000
112 HBeAg 511,000
113 HBV DNA 2,268,000
114 Anti HCV IgM 1,354,000
115 Anti HAV 617,000
116 Anti HAV IgM 511,000
117 CRP Kwantitatif 256,000
118 ACA IgG 505,000
119 ACA IgM 505,000
120 Dengue IgG IgM 436,000
121 TB IgG 243,000
122 VDRL 158,000
123 TPHA 167,000
124 Widal 120,000
125 Anti Salmonella IgM 234,000
126 Procalcitonin 1,000,000
127 IgE Total 354,000
128 Toxoplasma IgG 316,000
129 Toxoplasma IgM 316,000
130 Rubella IgG 316,000
131 Rubella IgM 377,000

No. ALAT TARIF
132 CMV IgG 339,000

133 CMV IgM 377,000
134 Anti HSV 1 IgG 368,000
135 Anti HSV 1 IgM 368,000
136 Anti HSV 2 IgG 339,000
137 Anti HSV 2 IgM 339,000
138 Aviditas CMV IgG 548,000
139 Aviditas Toxoplasma IgG 548,000
140 Mikoplasma IgG 361,000
141 Mikoplasma IgM 361,000
142 Klamidia IgG 361,000
143 Klamidia IgM 361,000
144 RF 301,000
145 Helicobacter IgG 602,000
146 Helicobacter IgM 677,000
147 Anti HIV 511,000
148 Anti HIV konfirmasi 549,000
149 IgG 497,000
150 IgA 497,000
151 IgM 497,000
152 C3 Komplemen 625,000
153 C4 Komplemen 625,000
154 ANA 625,000
155 Anti Ds DNA 625,000
156 ACA IgA 1,900,000
157 PCR TB 550,000
158 PCR Salmonella 669,000

No. ALAT TARIF
159 IgE Atopy 1,600,000

160 IgE Rast Susu Sapi 602,000
161 IgE Rast Susu Soya 602,000
162 IgE Rast Daging Sapi 602,000
163 IgE Rast Daging Ayam 602,000
164 IgE Rast Daging Kambing 872,000
165 IgE Rast Kuning Telur 602,000
166 IgE Rast Putih Telur 602,000
167 IgE Rast Lobster 872,000
168 IgE Rast Kerang 602,000
169 Analisa Kromosom 2,376,000
170 Anti CCP IgG 948,000
171 Antibodi Leptospira 109,000
172 Anti HBc Total 402,000
173 Anti Klamidia lgG 689,000
174 Anti Klamidia lgM 689,000
E. HORMON
175 LH 399,000
176 FSH 399,000
177 Prolactin 399,000
178 Testosteron 481,000
179 Progesteron 511,000
180 TSHs 354,000
181 TSH Neonatus 109,000
182 T3 428,000
183 T4 428,000
184 FTI 436,000

No. ALAT TARIF
185 Ftee T4 436,000

186 Free T3 512,000
187 TSHs 354,000
188 Tiroglobulin 811,000
189 T3 Up Take 400,000
190 Grow Hormon 550,000
191 Cortisol 500,000
192 AMH (Anti Mullerian Hormone) 719,000
193 PTH intact 811,000
194 Tiroxin Binding Globulin 2,682,000
195 Beta HCG 579,000
F. PETANDA TUMOR
196 AFP 407,000
197 CEA 399,000
198 NSE 933,000
199 Ca 15 - 3 737,000
200 Ca 19 - 9 872,000
201 PSA 872,000
202 Free PSA 1,141,000
203 SCC 737,000
204 PAP 586,000
205 Ca72-4 1,264,000
206 ACTH 3,232,000
207 Ca 125 820,000
G. KULTUR RESISTENSI
208 Sekret Vagina 512,000
209 Darah 512,000

No. ALAT TARIF
210 Urine 512,000

211 Faeces 512,000
212 Sputum 512,000
213 Gal Cultur 512,000
214 Pus / Sekret 512,000
215 Resistensi Jamur 932,000
216 Pewarna Diphteri 43,000
H. URINALISA
217 Urine lengkap 68,000
218 Protein Kwantitatif 114,000
219 Natrium 130,000
220 Kalium 130,000
221 Chlorida 130,000
222 Magnesium 114,000
223 Kalsium 114,000
224 Fosfor 114,000
225 Micro Albumin 210,000
226 Barbiturat 200,000
227 Benzodiazepam 200,000
228 Coccain 200,000
229 Canabis 200,000
230 Amfetamin 200,000
231 Keton 16,000
232 Bilirubin 16,000
I. FAECES
233 Faeces lengkap 144,000
234 Faeces Analisa 198,000

No. ALAT TARIF
235 Darah samar 87,000

J. SPERMA
236 Sperma 256,000
237 Washing Sperma 505,000
238 Analisa Batu Ginjal 240,000
239 Analisa Batu Empedu 240,000
VII.2. Laboratorium Patologi Anatomi
No. ALAT TARIF
A. SITOLOGI
1 Papsmear 202,000
2 Papsmear LB Prep (Liquid) 456,000
3 Sitologi Cairan Tubuh 249,000
B. PATOLOGI ANATOMI
1 Golongan A 416,000
2 Golongan B 690,000
3 Golongan C 830,000
4 Patologi Anatomi VC (Potong Beku) 1,879,000
5 Pemeriksaan Hispatologi
a. PA Jaringan Kecil < 5 cm 324,000
b. PA Jaringan Besar > 5 cm 641,000
6 Pemeriksaan Sitologi Exvoliatif
a. Papsmears Konvensional/ Biasa 180,000
b. Papsmears Liquid Base/ Bethesda 420,000

No. ALAT TARIF
7 Pemeriksaan Sitologi Sputum/Pleura/Urine 324,000

8 Pemeriksaan Sitologi Aspirasi
a. FNAB + Tindakan 803,000
b. FNAB + Tindakan dgn Guilding 1,199,000
c. FNAB Kiriman Slide 402,000
VII.3. Pelayanan Darah
No. ALAT TARIF
1 Labu darah* 451,000

2 Screening darah 710,000
3 Labu darah NAT* 901,000
*Bila ada kenaikan di PMI, harga disesuaikan

VII.4. Lain – lain
No. ALAT TARIF
1 Tes Kehamilan 98,000

2 Cairan tubuh
a. Hitung jumlah sel 57,000
b. Hitung jenis sel 64,000
c. Lekosit Esterase (LEA) 22,000
3 Uji Silang
a. Alkali Foltase 61,000
b. Dangue Rapid Test 209,000
c. Dangue NS1 313,000
d. Estradiol 193,000

VIII. TARIF RADIOLOGI
VIII.1. Radiologi Diagnostik
TARIF
No. ALAT
NON CR CR
A. KEPALA
1 Cranium 220,000 250,000
2 Sella Tursica 222,000 252,000
3 Orbita 222,000 252,000
4 Os Nasal 222,000 252,000
5 SPN 1 Posisi 196,000 226,000
6 SPN 2 Posisi 233,000 263,000
7 SPN 3 Posisi 334,000 364,000
8 Mastoid 218,000 248,000
9 Mandibula 218,000 248,000
10 TMJ ( Temporo Mardibular Joint ) 218,000 248,000
11 TMJ Open & Close Mouth 422,000 452,000
12 Dental 118,000 148,000
13 Panoramic 218,000 248,000
14 Chepalo 195,000 225,000
B. THORAX
15 Thorax AP / PA 209,000 239,000
16 Thorax Lat 209,000 239,000
17 Thorax AP / Iat 310,000 340,000
18 Thorax RLD 218,000 248,000
19 Thorax Anak 218,000 248,000
20 Thorax Top Lordotik 218,000 248,000
21 Thoraco Abdomen 435,000 465,000
22 Cor Analisa 344,000 374,000
23 Sternum 250,000 280,000
24 Cor Analisa dgn Barium 194,000 224,000
25 Thorax Tes Kesehatan 194,000 224,000

TARIF
No. ALAT
NON CR CR
26 Costae 208,000 238,000

27 Shoulder 1 sisi 218,000 248,000
28 Shoulder Bilateral 293,000 323,000
29 Clavicula 1 sisi 202,000 232,000
30 Clavicula Bilateral 251,000 281,000
31 Scapula 1 sisi 201,000 231,000
32 Scapula Bilateral 294,000 324,000
C. COLUMNA VERTEBRAE
33 Vert. Cervical Ap/Lat 255,000 285,000
34 Vert. Cervical Ap/Lat/Obl 405,000 435,000
35 Vert. Thoraco Lumbal Ap/Lat 251,000 281,000
36 Vert. Thoraco Lumbal Ap/Lat/Obl 411,000 441,000
37 Vert. Lumbo Sacral Ap/Lat 251,000 281,000
38 Vert. Lumbo Sacral Ap/Lat/Obl 411,000 441,000
39 Vert. Thoracal AP/Lat 413,000 443,000
40 Vert. Thoracal AP/Lat/Obl 389,000 419,000
41 Vert. Thoracal AP/Lat (2 sisi) 389,000 419,000
42 Vert. Lumbo Sacral Ap/Lat (2 sisi) 389,000 419,000
43 Vert. Lumbo Sacral AP/Lat/Obl (2 sisi) 413,000 443,000
44 Lumbal AP/Lat 261,000 291,000
45 Lumbal AP/Lat/Obl 411,000 441,000
46 Sacral AP/Lat 251,000 281,000
47 Sacral AP/Lat/Obl 411,000 441,000
48 Cocygeus Ap/Lat 251,000 281,000
49 Coxae AP 218,000 248,000
50 Coxae AP/Lat 311,000 341,000
51 Coxae AP/Lat/Obl 411,000 441,000

TARIF
No. ALAT
NON CR CR
52 Pelvis AP 250,000 280,000

53 Pelvis AP/Lat 309,000 339,000
54 Pelvis AP/Lat/Obl 400,000 430,000
55 Pelvis dengan Sonde 584,000 614,000
D. EKSTERMITAS ATAS
56 Digiti AP/Iat 218,000 248,000
57 Digiti Bilateral 326,000 356,000
58 Manus AP/Iat 218,000 248,000
59 Manus Bilateral 326,000 356,000
60 BONE AGE 218,000 248,000
61 Wrist Joint AP/Iat 218,000 248,000
62 Wrist Joint Bilateral 326,000 356,000
63 Antebranchi AP/Iat 218,000 248,000
64 Antebranchi Bilateral 326,000 356,000
65 Humerus AP/Iat 218,000 248,000
66 Humerus Bilateral 326,000 356,000
67 Artic Cubiti AP/Iat 218,000 248,000
68 Artic Cubiti Bilateral 326,000 356,000
69 Clavicula 191,000 221,000
70 Clavicula Bilateral 238,000 268,000
71 Scapula 191,000 221,000
72 Scapula Bilateral 238,000 268,000
73 Shoulder 203,000 233,000
74 Shoulder Bilateral 271,000 301,000
75 Elbow 203,000 233,000
76 Elbow Bilateral 305,000 335,000

TARIF
No. ALAT
NON CR CR
E. EKSTERMITAS BAWAH
77 Femur AP/Iat 218,000 248,000
78 Femur Bilateral 385,000 415,000
79 Art Genu AP/Iat 218,000 248,000
80 Art Genu Bilateral 326,000 356,000
81 Cruris AP/Iat 218,000 248,000
82 Cruris Bilateral 326,000 356,000
83 Pedis AP/Iat 218,000 248,000
84 Pedis Bilateral 326,000 356,000
85 Ankle Ap/Iat 218,000 248,000
86 Ankle Bilateral 326,000 356,000
87 Calcaneus Ap/Lat 218,000 248,000
88 Calcaneus Bilateral 326,000 356,000
F. ABDOMEN
89 Abdomen / BNO 218,000 248,000
90 Abdomen 2 Posisi 376,000 406,000
91 Abdomen 3 Posisi 443,000 473,000
92 Atresiani 226,000 256,000
93 BNO - IVP 1,668,000 1,698,000
94 HSG 1,344,000 1,374,000
95 Cystogarafi 746,000 776,000
96 Urethrografi 746,000 776,000
97 Urethrocystografi 985,000 1,015,000
98 Fistulografi 746,000 776,000
99 Appendicogram 508,000 538,000
100 Oesophagografi 5,508,000 5,538,000
101 Barium Enema / Colon in Loop 1,043,000 1,073,000

TARIF
No. ALAT
NON CR CR
H. MOBILE X-RAY ( ICU )

102 Thorax AP 233,000 263,000
103 Thorax Lateral 233,000 263,000
104 Thorax AP/Lateral 326,000 356,000
105 Thorax RLD 243,000 273,000
106 Abdomen / BNO 251,000 281,000
107 Abdomen 2 Posisi 401,000 431,000
108 Abdomen 3 Posisi 443,000 473,000
109 Creanium 276,000 306,000
110 Thorak Top Lordotik 251,000 281,000
111 Thoraco Abdomen 443,000 473,000
112 Baby Gram 361,000 391,000
113 Penambahan film 84,000 114,000
114 Elbow joint mobil X-Ray 186,000 216,000
115 Baby Gram 366,000 396,000
I. CT SCAN
116 CT Brain 1,220,000 1,250,000
117 CT Brain Trauma 1,220,000 1,250,000
118 CT Sellatursica 1,652,000 1,682,000
119 CT Orbita 2,281,000 2,311,000
120 CT Mastoid 2,103,000 2,133,000
121 CT Sinus Paransalis Coronal 1,845,000 1,875,000
122 CT Nasopharynx 1,799,000 1,829,000
123 CT Larynx 1,799,000 1,829,000
124 CT Carnival Soft Tissue 1,799,000 1,829,000
125 CT Cervical Mielo CT 3,440,000 3,470,000
126 CT Thoracal Mielo CT 4,355,000 4,385,000

TARIF
No. ALAT
NON CR CR
127 CT Thorax 1,981,000 2,011,000

128 CT Partial V Thoracal 1,601,000 1,631,000
129 CT Upper Abdominal 1,981,000 2,011,000
130 CT Upper extremity 2,165,000 2,195,000
131 CT Lower Abdominal 1,981,000 2,011,000
132 Whole Abdominal 3,430,000 3,460,000
133 CT Whole V Cervical 2,180,000 2,210,000
134 CT Whole V Thoracal 2,180,000 2,210,000
135 CT Whole V Lumbal 2,180,000 2,210,000
136 CT Lumbal Mielo CT 3,195,000 3,225,000
137 CT Lower extremity 2,165,000 2,195,000
138 CT Thyroid 1,799,000 1,829,000
139 Maxfell Facial 1,799,000 1,829,000
140 Oesophagus 1,981,000 2,011,000
141 Orbyta 1,601,000 1,631,000
142 Orohypopharynx 1,799,000 1,829,000
143 V. Sacro Coccygeal 2,058,000 2,088,000
144 Partial V Cervical 1,502,000 1,532,000
145 Partial V Lumbal 1,502,000 1,532,000
146 Mandibula 1,799,000 1,829,000
147 Sella Turcia 1,601,000 1,631,000
J. USG
148 USG Abdomen 627,000 657,000
149 USG Ginjal 627,000 657,000
150 USG Mammo 650,000 680,000
151 USG Thyroid 650,000 680,000
152 USG Testis 455,000 485,000

TARIF
No. ALAT
NON CR CR
153 USG Doppler Vaskuler 672,000 702,000

154 USG Abdomen / Gyn Doppler 653,000 683,000
155 USG 4D Gemeli 1,131,000 1,161,000
K. LAIN - LAIN
Bone Survey I
156 1,160,000 1,190,000
(Cranium, Cervical, Thoraco Lumbal, Pelvis)
Bone Survey II
157 1,624,000 1,654,000
(Bone Survey 1 + Ekstrimitas Atas & Bawah)
158 Penambahan per-film 91,000 121,000
159 Kateter 359,000 389,000
160 Kontras Omnipaque 243,000 273,000
161 Tes Kesehatan 127,000 157,000
162 Ratio Adenoid 273,000 303,000
163 Pelvimetri 460,000 490,000
164 Sono-Histografi 639,000 669,000
165 OMD/Barium meal 1,064,000 1,094,000
166 Barium Follow Through 1,144,000 1,174,000
167 Cistogram 245,000 275,000
168 MDG 150,000 180,000
L. EKSPERTISE CITO

PERKIRAAN BIAYA TINDAKAN ONE DAY CARE
DI KAMAR OPERASI
NO KET GOL I GOL II GOL III GOL IV
- Corpus Alineum Hidung - Hecting Perineum grade 3-4 - Mc Donald - Insisi Abses
- Micro Curet - Corpus Alienum - Sirodkar - D&C
- Plasenta Manual - Pemasangan Belog Tampon - Reposisi tertutup tanpa & - Vasektomi
- Insisi Kista bartolini - Anuscopy dengan anestesi umum - Ganglion
- Condiloma Perinium - Paracentesis - Ekstirpasi Kista Bartolini - Polipectomi

JENIS
1 - Angkat Spiral - cauter Condiloma Sedang - Eksplorasi & Hemostasis - Eksterpasi Kista Bartholini/
TINDAKAN
- AFF IUD dengan Narkose - Re Hecting Vagina hingga Fornilus Hematome Sedang Insisi Abses
- Condiloma Vulva Perinium - Condiloma Vulva Perinium Banyak - FAM Mamae
- Marsupralisasi - Operasi Perineum
- Kista Bartholini - Curretase Post Partum
- Kondiloma Vulva Vagina
TOTAL BIAYA 2,164,000 2,742,200 3,157,000 3,896,200
A. Tarif yang tertera di atas BELUM termasuk :
1. BIAYA OBAT OBATAN
4. BIAYA ADMINISTRASI 3% DARI TOTAL KUITANSI MAKSIMUM S/D RP. 150.000,-
B. Tarif yang tertera di atas berlaku dalam KEADAAN NORMAL/BIASA
C. Tarif yang tertera di atas merupakan Tarif PERKIRAAN SEMENTARA dan TIDAK BERLAKU MUTLAK
SEWAKTU-WAKTU DAPAT BERUBAH KARENA KONDISI/KEBUTUHAN PELAYANAN MEDIS PASIEN

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I.

NO JENIS PELAYANAN TARIF

I.1.1. RAWAT JALAN

I.1.2. RAWAT INAP

TARIF TAHUN 2017 1 - REV

- Dengan Dokter 3,037,000 2,430,000 2,126,000 1,518,000 1,367,000 1,139,000

- Dengan Bidan 2,126,000 1,518,000 1,367,000 1,139,000

- ILA 3,037,000 2,430,000 2,126,000 1,518,000 1,367,000 1,139,000

b. Untuk Observasi 1,029,000 363,000

a. Untuk Tindakan One Day Care (ODC) Mengikuti tarif ODC

b. Tindakan Medis Operatif : kebidanan & bedah

- Operasi Kecil 3,827,000 3,280,000 3,144,000 2,733,000 2,187,000 1,640,000

- Operasi Sedang 4,975,000 4,264,000 4,087,000 3,553,000 2,843,000 2,132,000

- Operasi Besar & SC 5,549,000 4,756,000 4,559,000 3,963,000 3,171,000 2,378,000

- Operasi Besar Khusus 8,611,000 7,380,000 7,074,000 6,149,000 4,921,000 3,690,000

c. Ruang Pemulihan / RR ( untuk observasi > 6 jam ) 605,000

a. Level I (KBBL) 889,000 690,000 617,000 363,000 218,000 112,000

5 INTERMEDIATE CARE UNIT (IMCU) 666,000

6 INTENSIVE CARE UNIT (ICU/PICU/NICU) 787,000

7 RUANG ISOLASI 605,000

TARIF TAHUN 2017 2 - REV

II 1. JASA MEDIS KONSULTASI MEDIS

KLINIK UMUM KLINIK EKSEKUTIF

2 Dokter Spesialis 132,000 35,000 167,000 180,000 52,000 232,000

3 Dokter Spesialis Obsgyn 132,000 44,000 176,000 180,000 61,000 241,000

6 Profesor 185,000 35,000 220,000 289,000 52,000 341,000

7 Profesor Obsgyn 185,000 44,000 229,000 289,000 61,000 350,000

8 Psikiater 146,000 35,000 181,000

9 Dokter Spesialis Gizi Klinik 146,000 35,000 181,000

10 Psikolog 126,000 35,000 161,000

11 Bidan 30,000 35,000 65,000

12 Klinik Tumbuh Kembang :

a. Dokter Spesialis Anak 150,000 35,000 185,000

b. Dokter Rehabilitasi Medik 150,000 35,000 185,000

c. Psikolog 128,000 35,000 163,000

d. Psikiater 150,000 35,000 185,000

g. Sensori Integrasi 110,000

i. Sensor Terapi Behaviour 110,000

j. Art Terapi 110,000

13 Konsultasi Laktasi / Edukator Diabetes

a. Konselor Dokter Subspesialis 208,000 35,000 243,000 210,000 52,000 262,000

b. Konselor Dokter Spesialis 146,000 35,000 181,000 182,000 52,000 234,000

c. Konselor Dokter Umum 46,000 35,000 81,000

d. Konselor Bidan / Perawat 30,000 35,000 65,000

TARIF TAHUN 2017 3 - REV

1 Dokter Spesialis / Fellow 200,000 187,000 175,000 125,000 100,000 81,000

4 Panggilan Emergency Tanpa Tindakan :

a. Dokter Spesialis 182,000

b. Dokter SubSpesialis 237,000

6 Visiting Doctor (Dokter Tamu) :

a. Panggilan Tidak Emergency

- Dokter Spesialis 158,000

- Dokter Spesialis/Sub Spesialis/Profesor/Konsulen 243,000

- Dokter Spesialis 236,000

- Dokter Sub Spesialis 269,000

B VISITE di R. PERAWATAN PERINA

1 Dokter Spesialis 178,600

2 Dokter Sub Spesialis/ Konsulen 225,000

C VISITE di R. PERAWATAN ICU/NICU/PICU

1 Dokter Spesialis 162,000

2 Dokter SubSpesialis/ Konsulen 204,000

3 Dokter Intensivis 285,000