RAWAT JALAN

DAN NON KELAS

I BIAYA PENGGANTI ID CARD DAN MAP

II PELAYANAN RAWAT JALAN

Rawat Jalan dan

No JENIS PELAYANAN
Non Kelas

1 PELAYANAN RAWAT JALAN 25,000

2 KONSULTASI ANTAR POLI 10,000
3 PELAYANAN RAWAT JALAN DOKTER SPESIALIS 75,000
4 PELAYANAN RAWAT JALAN SPESIALIS KONSULTAN 100,000
5 PELAYANAN RAWAT JALAN (KUSTA) 25,000
6 CHARTING 15,000
7 PERAWATAN LUKA
8 PERAWATAN LUKA BESAR 100,000
9 a. PERALATAN DAN OBAT BAHAN HABIS PAKAI 50,000
10 b. JASA PERAWATAN 50,000
11 PERAWATAN LUKA SEDANG 50,000
12 a. PERALATAN DAN OBAT BAHAN HABIS PAKAI 25,000
13 b. JASA PERAWATAN 25,000
14 PERAWATAN LUKA KECIL 30,000
15 a. PERALATAN DAN OBAT BAHAN HABIS PAKAI 15,000
16 b. JASA PERAWATAN 15,000
17 KONSULTASI GIZI 25,000

III PELAYANAN RAWAT DARURAT

Rawat Jalan dan

No JENIS PELAYANAN
Non Kelas

1 JASA PELAYANAN IGD dr. SPESIALIS 40,000

2 JASA PELAYANAN IGD dr. UMUM 15,000
3 JASA PELAYANAN IGD PERAWAT 10,000
4 JASA CERVICAL COLOOR 45,000
5 JASA INJEKSI (PER KALI) IM 10,000
6 JASA INJEKSI (PER KALI) SC 10,000
7 JASA INJEKSI (PER KALI) IV 10,000
8 JASA PEMASANGAN INFUS 30,000
9 JASA LEPAS INFUS 10,000
10 JASA LEPAS NGT 10,000
11 JASA PASANG NGT 30,000
12 JASA PEMASANGAN CATETER 30,000
13 JASA LEPAS CATETER 15,000
14 JASA PASANG KONDOM CATETER 10,000
15 JASA KUMBAH LAMBUNG 30,000
16 JASA VENA SEKSI 100,000
17 JASA PEMBERIAN SUPOSITORIA 5,000
18 RAWAT LUKA BESAR 60,000
19 RAWAT LUKA SEDANG 50,000
20 RAWAT LUKA KECIL 35,000
21 CHARTING 15,000
22 NEBULIZER 25,000
23 SEWA BED SET MONITOR ADA EKG 75,000
24 PELAYANAN ONE DAY CARE 175,000
25 PEMAKAIAN SUCTION 30,000
26 JASA RJP (TANPA DC SHOCK) 100,000
27 02/LITER/JAM 5,000
28 DC SHOCK 200,000
29 PASANG SPALK 30,000
30 EKSTRAKSI KUKU 75,000
31 MENJAHIT LUKA (1-5 JAHITAN) 50,000
32 MENJAHIT LUKA (6-10 JAHITAN) 75,000
33 MENJAHIT LUKA >JAHITAN 100,000
34 JASA REGULASI INSULIN (1-5 X INJEKSI) 10,000
35 JASA REGULASI INSULIN (6-10 X INJEKSI) 20,000
36 JASA REGULASI INSULIN (>10 X INJEKSI) 30,000
37 ANGKAT JAHITAN 1-5 20,000
38 ANGKAT JAHITAN 6-10 30,000
39 EKG 30,000
40 SEWA AMBULAN JARAK JAUH TEMPUH AWAL 0-25 KM 150,000
41 SEWA AMBULAN >25 KM DIKARENAKAN TAMBAH PER KM 10,000
42 GDA STIK 15,000
43 RECTAL TOUSE 20,000
44 PEMAKAIAN SYRENGE PUMP (PER HARI) 50,000
45 JASA TRANSFUSI 15,000
IV PELAYANAN RAWAT INAP

Rawat Jalan dan

No JENIS PELAYANAN
Non Kelas

1 ASUHAN GIZI
2 VISITE DOKTER SPESIALIS
3 Rawat Inap Sehari (terdiri dari) :
a. Pemeriksaan Dokter Umum
b. Akomodasi
c. Perawatan
d. Konsumsi

4 Rawat Intensif
a. Pemeriksaan Dokter Umum
b. Akomodasi
c. Perawatan
d. Konsumsi

5 Perawatan Luka Besar

a. Peralatan dan Obat Bahan Pakai Habis (OBPH)
b. Jasa Perawatan

6 Perawatan Luka Sedang

a. Peralatan dan Obat Bahan Pakai Habis (OBPH)
b. Jasa Perawatan

7 Perawatan Luka Kecil

a. Peralatan dan Obat Bahan Pakai Habis (OBPH)
b. Jasa Perawatan

8 Perawatan Luka Dokter Spesialis

a. Jasa Dokter
b. OBPH
c. Jasa Asistensi

9 Pemeriksaan EKG
a. Jasa Sarana
b. Jasa Tindakan

10 Nebulizer tanpa obat

a. Jasa Sarana
b. Jasa Tindakan

11 Pemakaian Infus Pump (perhari)

a. Jasa Sarana/sewa
b. Jasa pemberian Drip Dopamin, dsb

12 Pemakaian Suction (perhari)

a. Jasa sarana/sewa
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

b. Jasa Suction

13 Bed Sed Monitor

a. Jasa Sarana/sewa
b. Jasa Pemasangan Bed sed Monitor

14 Konsultasi Gizi
15 Perawatan Puluh Sadar
16 Jasa Pasang Infus
17 Jasa Lepas Infus
18 Jasa Injeksi per-macam obat
19 Jasa Tranfusi
20 Pasang Cateter
21 Lepas Cateter
22 Pasang kondom cateter
23 Lepas kondom cateter
24 Pasang Maag Slang
25 Lepas Maag Slang
26 Pemakaian Oxymetri
27 Pemakaian Oksigen Concentrase
28 RJP (tanpa DC shock)
29 Jasa regulasi insulin (1- 5 x injeksi)
30 Jasa regulasi insulin (5 - 10 x injeksi)
31 Jasa regulasi insulin (> 10 injeksi)
32 Jasa Vena Sectie
33 Jasa Lavement
34 Jasa Kumbah Kandung Kemih
35 Pasang Drambuis
36 Jasa Huknah rendah/tinggi
37 Jasa skintest antibotika
38 Jasa pemberian suppositoria
39 Jasa Pasang NGT
40 Jasa Lepas NGT
41 Jasa Pemberian Obat tetes Telinga
42 Jasa Pemberian Obat Tetes Mata
43 Jasa Pemberian Obat Tetets Hidung
44 Jasa Irigasi telinga
45 Jasa Irigasi Mata
46 Jasa Kumbah Vagina
47 Oksigen/Liter/Jam
48 Jasa Heacting 1-5
49 Jasa Heacting 5-10
50 Jasa Heacting > 10
51 Jasa Lepas Jahitan 1-5
52 Jasa Lepas Jahitan 5-10
53 Jasa Lepas Jahitan > 10
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

54 Jasa Pemeriksaan GDA Stik Rawat Inap

 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

VI TINDAKAN NON OPERATIF

NO JENIS PELAYANAN Rawat Jalan dan

Non Kelas
1. UMUM
1 ANGKAT DRAIN
2 ANGKAT JAHITAN 1-5
3 ANGKAT JAHITAN 6-10
4 INKUBATOR ( PER HARI )
5 INKUBATOR SEDERHANA/INFANT WARM (PER HARI)
6 IRIGASI KHUSUS (STOSEL) POST BPH (PER KALI)
7 IRIGASI MAINTENANCE POST BPH (PER HARI)
8 JASA KHEMOTERAPI ( PER KALI )
9 JASA LAVEMENT
10 JASA PASANG SPALK
11 JASA PELAYANAN SKIREN
12 JASA PEMASANGAN GIBS
13 JASA PENGAMBILAN SPESIMEN FNAB
14 JASA PUNCTIE ACITES
15 JASA PUNCTIE ACITES SPECIALIS
16 JASA RECTAL TOUCHE
17 JASA SPOLLING ABSES HEPAR
18 JASA SYRENGE PUMP (PER KALI)
19 JASA TREADMILL W / STRESS TEST ECG
20 OKSIGEN 2-5 LITER/JAM (PER JAM)
21 OKSIGEN 5-10 LITER/JAM (PER JAM)
22 PEMAKAIAN INFUS PUMP (PER HARI)
23 PEMAKAIAN OXYMETRI (PER KALI)
24 PEMASANGAN RANSEL VERBAND
25 RAWAT LUKA (SEPTIC) DR. SPECIALIS
26 REGULASI INSULIN (>10X INJEKSI)
27 REGULASI INSULIN (1-5X INJEKSI)
28 REGULASI INSULIN (6-10X INJEKSI)
29 TINDAKAN DEFIBRILASI / DC SYOCK
30 TINDAKAN EKSTRAKSI KORPUS ALINEUM
31 TINDAKAN EKSTRAKSI KUKU
32 TINDAKAN IMUNISASI BCG
33 TINDAKAN IMUNISASI CAMPAK
34 TINDAKAN IMUNISASI DPT
35 TINDAKAN IMUNISASI HEPATITIS
36 TINDAKAN IMUNISASI POLIO
37 TINDAKAN IMUNISASI TT
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

38 TINDAKAN INJEKSI AVASTIN INTRA VITREAL

39 TINDAKAN INJEKSI DEXAMETASONE RETROBULBER
40 TINDAKAN INJEKSI VARISES
41 TINDAKAN MANTOUX TEST
42 TINDAKAN SUCTION (PER KALI)
43 VISUM LUAR
44 CLAVUS
45 EKSTRAKSI KORPUS ALINEUM
46 JASA INJEKSI (PER KALI)
47 MELEPAS INFUS/ TRANFUSI
48 MELEPAS NGT
49 MENJAHIT LUKA (1-5 JAHITAN)
50 MENJAHIT LUKA (6-10 JAHITAN)
51 MENJAHIT LUKA (> 10 JAHITAN)
52 MENJAHIT TENDON (1-5 JAHITAN)
53 MENJAHIT TENDON (6-10 JAHITAN)
54 PEMBERIAN OBAT SUPPOSITORIA
55 RJP (TANPA DC SHOCK)
56 SKIREN

NO
Rawat Jalan dan
2. PARU
Non Kelas

1 BRONKOSKOPI SEDERHANA
2 BRONKOSKOPI DENGAN BIOPSI
3 BRONKOSKOPI DENGAN BIOPSO DAN AUTO LORSEN
4 MELEPAS WSD
5 MINI WSD
8 PEAK FLOW METER
9 PEMASANGAN WSD / TORAK CATETER
10 PERAWATAN LUKA WSD
11 PERAWATAN WSD PER 5 HARI (+ SEWA CONTINUES SUCTION)
12 PERAWATAN WSD PER HARI (+ SEWA CONTINUES SUCTION)
13 PLEURODESIS
14 PROOF PUNCTIE
15 PUNCTIE PLEURA SPECIALIS
16 PUNGTIE PLEURA
17 REPOSISI WSD
18 SPIROMETRI

Rawat Jalan dan

NO 3. KEBIDANAN
Non Kelas
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

1 OFF IMPLANT
2 DOUGLAS PUNGTIE
3 INCISI BARTOLINI + MARSUPIALISASI
4 INVERSIO UTERI (REPOSISI)
5 MANUAL PLASENTA
6 MELEPAS IUD
7 MENJAHIT PERINEUM (DERAJAT I, Ii)
8 METHODE KANGURU (PAKET)
9 PASANG IMPLANT (KEBIDANAN)
10 PASANG IMPLANT OLEH DOKTER
11 PASANG IUD OLEH BIDAN
12 PASANG IUD OLEH DOKTER
13 PEMASANGAN PRESARIUM
14 PERAWATAN BAYI BARU LAHIR
15 PERSALINAN NORMAL :
16 v      PERTOLONGAN OLEH BIDAN :
17 v      PERTOLONGAN OLEH OBGYN :
18 PERSALINAN DENGAN PENYULIT
19 v      PERTOLONGAN OLEH BIDAN
20 v      PERTOLONGAN OLEH OBGYN
21 PIJAT BAYI
22 REPAIR PERINEUM DERAJAT Iii
23 REPAIR PERINEUM TOTALIS
24 RESUSITASI BAYI (PARTUS DENGAN PENYULIT)
25 SENAM IBU HAMIL, YOGA,
26 SEWA VK
27 TINDIK
28 SUNTIK KB
29 USG KANDUNGAN
30 USG TRANSVAGINAL
31 PAP SMEAR

Rawat Jalan dan

NO 4. MATA
Non Kelas

1 ANEL TES
- PAGI
- SORE
2 CORPUS ALINEUM/ DI MATA
- PAGI
- SORE
3 DEBRIDEMEN KORNEA
4 EPILASI BULU MATA
- PAGI
- SORE
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

5 EXTRAKSI GRAM
6 INCISI HORDEOLUM
7 INCISI KALAZION
8 IRIDEKTOMI PERIFER
9 IRIGASI MATA
10 JAHIT KELOPAK MATA
11 JAHIT KONJUNGTIVA (TRAUMA)
12 PEMERIKSAAN FLUARESCENT
13 PEMERIKSAAN OFTOLEOSKOP
14 PEMERIKSAAN VISUS
15 SONDAGE CANALICULI LACRIMALIS
- PAGI
- SORE
16 SPOOLING BOLA MATA
- PAGI
- SORE
17 TARSORAPHY
18 TEST BUTA WARNA
19 VERUKA VULGARIS
20 AUTO REFRAKTO METER
21 BIOMETRI
22 USG MATA
23 NON CONTACT TONOMETRI
24 LASER MATA
25 FOTO FUNDAL

NO
Rawat Jalan dan
5. THT
Non Kelas

1 BIOPSI THT DERAJAT 1

2 BIOPSI THT DERAJAT 2
3 EAR SPOELLING (IRIGASI TELINGA)
4 EKSTRAKSI CORPUS ALIENUM THT DERAJAT 1
5 EKSTRAKSI CORPUS ALIENUM THT DERAJAT 2
6 EKSTRAKSI CORPUS ALIENUM THT DERAJAT 3
7 EKTERPASI POLIP TANPA CURETASI/ E.POLIP
8 INSISI ABSES THT / OTHEMATOMA
9 IRIGASI SINUS MAKSILARIS LA
10 IRIGASI TELINGA
11 LARINGOSKOPI DIREKTA (LD) / LA
12 NASOENDOSKOPI LA
13 PENGAMBILAN BENDA ASING DI DAERAH THT
14 SYRINGOMA
15 TAMPON BELOG /LA
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

16 TAMPON HIDUNG
17 TAMPON HIDUNG ANTERIOR / LA

Rawat Jalan dan

NO 6. ORTHOPEADI
Non Kelas

1 ANGKAT K-WIRE DENGAN HEKTING

2 OFF WIRE
3 MELEPAS GIBS
4 REPOSISI DENGAN ANESTESI LOKAL

NO
Rawat Jalan dan
7. KULIT DAN KELAMIN
Non Kelas

1 ALERGI TEST
2 BIOPSI KELENJAR EKSISI
3 CAUTERISASI CONDILOMA ACCUMINATA
a. Ringan
b. Sedang
c. Berat
4 CHEMICAL PEELING
6 DERMABRASI
7 EKSTERPASI DAN JAHIT
9 HEFRICOUTER
10 INJEKSI
11 INJEKSI KENACORT DENGAN OBAT
12 INSISI FURUNKEL / ABSES
13 KARATOSIS SEBOROIKA
a. Ringan
b. Sedang
c. Berat
14 KAUSTIK
15 LASER KULIT DAN KELAMIN
16 NEKROTOMI
17 NEURO FIBROMA
18 NEVUS
a. Ringan
b. Sedang
c. Berat
19 PENGAMBILAN SEDIAN
20 PENGOBATAN TCA / TINCTURA POPOPHILI
21 PUNGSI / INSISI / EKSOKLEASI
22 RADIOTOMI / HEFRICAUTER
23 ROSER PLASTY
24 SKIN TAG
a. Ringan
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

b. Sedang
c. Berat
25 SKIN TEST
26 SYRINGOMA/ KELOID
a. Ringan
b. Sedang
c. Berat
27 TCA
28 VERUCA VULGARIS
29 EKSTRAKSI COMEDO
30 FACIAL
31 SIRKUMSISI DENGAN COUTER
32 SIRKUMSISI MANUAL
33 SIRKUMSISI SMART CLAMP
34 PAPIPLOMA/PIOGENICGRANULOMA
a. Ringan
b. Sedang
c. Berat
35 MOLUSKUM KONTAGIOSUM
a. Ringan
b. Sedang
c. Berat
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

Rawat Jalan dan

NO 8. GIGI
Non Kelas

1 KONSULTASI/ PEMERIKSAAN 25,000

2 INSISI EKSTRA/ INTRA ORAL 150,000
3 PENABUTAN GIGI SULUNG/ TOPIKAL 100,000
4 PENCABUTAN TANPA KOMPLIKASI 200,000
5 PENCABUTAN DENGAN KOMPLIKASI 250,000
6 ODONTEKTOMI SEDERHANA 1,000,000
7 ALVEOLEKTOMI TIAP REGIO 250,000
8 PEMBERSIHAN KARANG GIGI (PER KUADRAN) 75,000
9 OPERCULECTOMI 150,000
10 KURET (PER REGIO) 250,000
11 FISSURE SEALANT 100,000
12 TUMPANG GIC 150,000
13 TUMPATAN KOMPOSIT KECIL 150,000
14 TUMPATAN KOMPOSIT SEDANG 200,000
15 TUMPATAN KOMPOSIT BESAR 250,000
16 PULP CAPPING/ TUMPATAN SEMENTARA 50,000
17 DEVITALISASI 50,000
18 STERILISASI 50,000
19 PENGISIAN SALURAN AKAR 100,000
20 MAHKOTA AKRILIK 150,000
21 MAHKOTA PORCELAIN FUSED METAL 400,000
22 MAHKOTA FULL PORCELAIN 500,000
23 MAHKOTA SEMENTARA 100,000
24 GTL RA-RB 1,500,000
25 GTS AKRILIK 200,000
26 GTS VARPLAST 400,000
27 GIGI BERIKUTNYA 75,000
28 REPARASI 100,000
29 REBASING 200,000
30 BRIDGE AKRILIK (PER UNIT) 300,000
31 BRIDGE PORCELAIN (PER UNIT) 750,000
32 ORTODONSI CEKAT 4,000,000
33 KONTROL/ AKTIVASI 150,000
34 ANGKAT JAHITAN 25,000
35 CETAK (PER RAHANG) 30,000
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

NO
Rawat Jalan dan
9. UROLOGI
Non Kelas

1 BLASS PUNCTIE
2 BUSINASI

Rawat Jalan dan

NO 10. PLASTIK
Non Kelas

1 REPOSISI FRAKTUR NASI, LA

VI TINDAKAN OPERATIF
JENIS PELAYANAN
Rawat Jalan dan
NO
1. UMUM Non Kelas

1 AMPUTASI BESAR
2 ANUS PLASTY
3 APPENDICITIS ACUTA
4 APPENDICITIS INFILTRAT / KRONIS
5 APPENDICITIS PERFORASI
6 ATHEROM KISTA KECIL
7 ATHEROMA
8 BASALIOMA
9 BASALIOMA SKIN GRAFT
10 BATU EMPEDU
11 BIOPSI
12 BPH (PROTECTOMY TERBOKU)
13 BULEKTOMI < 20%
14 BULEKTOMI > 20%
15 C.ALIENUM JARUM
16 CA MAMAE ( MASTEKTOMIE )
17 CA MAMAE SKIN GRAF
18 CALDWEL LUC / GA
19 CHOLELITHIASIS
20 CLAVUS
21 CLAVUS (DOKTER SPESIALIS)
22 COLOSTOMI
23 CONGENITA FORNIX PLASTIK
24 CONTRA VENTILE
25 CROS INSISI
26 CROSS INSISI
27 CYSTA ATHEROM
28 CYSTA STHEROM
29 DEBRIDEMENT PADA LUKA BAKAR
30 DEKOMPRESI
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

31 DESEKSI KELENJAR
32 EKSISI HEMANGIONA KOMPLEKS
33 EKSTERPASI FIBROMA
34 EKSTERPASI TUMOR KECIL
35 EKSTERPASI VERUKA VULGARIS
36 ENUKLEASIS (GA)
37 FAM
38 FIBROMA PEDIS
39 FRAKTUR MANDIBULA
40 GANGLION POPLITEA
41 HEMOROIDECTOMI
42 HERNIA
43 HERNIA BILATERAL
44 HERNIA INCARSERATA
45 HERNIA UNILATERAL
46 HIDROCELE
47 INSISI EKOLOZIOR / LORDEOLUSEA + JAHITAN
48 JAHIT TENDON < 3
49 JAHIT TENDON > 3
50 LAPARATOMY
51 LIPOMA DENGAN (GA)
52 MENJAHIT LUKA < 5 JAHITAN
53 MENJAHIT LUKA > 10 JAHITAN
54 MENJAHIT LUKA > 6-10 JAHITAN
55 MILES PROSEDUR
56 OPERASI STROMA
57 POLIP RECTI
58 PUNCTIE ABSES HEPAR DR. SPECIALIS
59 REPAIR FISTEL
60 REPAIR HISPRUNG
61 SIRKUMSISI DENGAN PHYMOSIS
62 TINDAKAN CIRKUMSISI DG SISI DG COUTER (DOKTER UMUM)
63 TINDAKAN CIRKUMSISI DG SISI DG COUTER (PARA MEDIS)
64 TINDAKAN INSISI ABSES
65 TINDAKAN INSISI KELOID
66 TINDAKAN SIRCUMSISI NORMAL
67 TINDAKAN VENASEKSI
68 TUMOR PAROTIS
69 VARICOCEL

NO
Rawat Jalan dan
2. KEBIDANAN
Non Kelas

1 CURETASE ABORTUS RINGAN

2 CURETASE ABORTUS SEDANG
3 CURETASE ABORTUS BERAT
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

4 CURETASE ABORTUS MOLA II

5 CYSTOMA OVARII
6 HIDROTUBASI
7 HYSTERECTOMY PERABDOMINAL
8 HYSTERECTOMY PERVAGINAM
9 KET
10 KISTA OVARII
11 MENJAHIT PORTIO
12 MYOMA UTERI
13 PAP SMEAR
14 SECTIO CAESARIA
15 SECUNDER IMPLANT
16 TUBECTOMI
17 VAGINO PLASTY

Rawat Jalan dan

NO 3. MATA
Non Kelas

1 ABLATIO RETINA
2 ANTERIOR/POSTERIOR SKLEROTOMI
3 ARGON LASER/KENON
4 ARTHROSCOPY
5 ASPIRASI AFTER CATARACT
6 BLEPHAROPLASTY
7 CORPUS ALINEUM INTRAOCULAR
8 CYCLODIA TERMI
9 CYCLODIALYSA
10 EKSISI PTERIGIUM DENGAN BARE SCLERA
11 EKSISI PTERIGIUM DG GRAFT KONJUNGTIVA
12 EKSTERPASI CALAZION+C37
13 EKSTERPASI GRANULOMA
15 ENUKLEASI / EVISERASI
- PAGI
- SORE
16 EXTRAKSI LINEAR
17 FLAP KONJUNGTIVA
18 FOTO KOAGULASI
19 FRAKTUR TRIPODO/MULTIPLE
20 GONIOTOMI
21 GLUKOMA DENGAN TRABECTOMI
- PAGI
- SORE
22 SICS
a. DOKTER SPESIALIS
- PAGI (TANPA IOL)
- PAGI (DENGAN IOL)
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

- SORE (TANPA IOL)

- SORE (DENGAN IOL)
b. DOKTER KONSULTAN AHLI
- TANPA IOL
- DENGAN IOL
23 INJEKSI AVASTIN INTRA VITREAL
24 INJEKSI DEXAMETASONE RETROBULBER
25 JAHIT PERFORASI CORNEA / SLERA
- PAGI
- SORE
26 JAHIT PALPEBRA
- PAGI
- SORE
27 KATARAK DENGAN MESIN PHACHO
a. DOKTER SPESIALIS
- PAGI DAN SORE (TANPA IOL)
- PAGI DAN SORE (DENGAN IOL)
b. DOKTER KONSULTAN AHLI
- TANPA IOL
- DENGAN IOL
28 KATARAK MANUAL (ECCE)
29 KERATOPLASTIE LAMERAL
30 KOREKSI EXTROPION/ENTROPION
- PAGI
- SORE
31 OPERASI EVISCERORI (LA)
32 OPERASI EVISCEROSI (GA)
33 ORBITOTOMI LATERAL
34 REKANALISASI RUPTURA/TRANSKANAL
35 REKONSTRUKSI KELOPAK BERAT
36 REKONSTRUKSI ORBITAL CONGENITAL
37 REKONSTRUKSI SAKET BERAT
38 REKONSTRUKSI TRAUMA PALPEBRA
39 REPOSISI IRIS POLAPS
40 STRABISMUS
41 TRIPLE PRODUSER KERATIPLASTI DENGAN GLAUKOMA
42 TUMOR GANAS/ADNESA LUAS DENGAN REKKONTRUKSI
43 VIREKTOMI

Rawat Jalan dan

NO 4. THT
Non Kelas

1 ADENOTONSILEKTOMI / GA
2 ADENOIDEKTOMI/GA
3 ADENOTONSILEKTOMI/GA
4 ANGKAT DRAIN, LA
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

5 ANGKAT JAHITAN THT,LA

6 ATIKOANTROTOMI/GA
7 ATIKOANTROTOMI MIRINGOPLASTI/GA
8 BEDAH LARING MIKROSKOPIK DERAJAT 1/GA
9 BEDAH LARING MIKROSKOPIK DERAJAT 2/GA
10 BIOPSI KAVUM NASI/NASOFARING/LA
11 BIOPSI LIDAH/LA
12 BIOPSI TELINGA/HIDUNG/TENGGOROK DERAJAT 1/ GA
13 BIOPSI TELINGA/HIDUNG/TENGGOROK DERAJAT 2/ GA
14 BIOPSI TELINGA/HIDUNG/TENGGOROK DERAJAT 1/ LA
15 BIOPSI TELINGA/HIDUNG/TENGGOROK DERAJAT 2/ LA
16 BRONKOSKOPI/GA
17 BRONKOSKOPI DERAJAT 1 / LA
18 BRONKOSKOPI DERAJAT 2 / LA
19 BRONKOSKOPI EKSTRAKSI/BIOPSI/GA
20 CALDWEL LUC/GA
21 DAKRIOSISTORINOTOMI (DCR)/GA
22 DEBRIDEMAN PERIKONDRITIS /GA
23 DEBRIDEMAN PERIKONDRITIS /LA
24 DEKANULASI DERAJAT 1/LA
25 DEKANULASI DERAJAT 2/LA
26 DEKOMPRESI NERVUS VASIALIS /GA
27 DESEKSI LEHER FUNGSIONAL/GA
28 DESEKSI LEHER RADIKAL/GA
29 EKSISI/EKSTIRPASI KELAINAN THT DERAJAT 1 /LA
30 EKSISI/EKSTIRPASI KELAINAN THT DERAJAT 1 /GA
31 EKSISI/EKSTIRPASI KELAINAN THT DERAJAT 2 /LA
32 EKSISI/EKSTIRPASI KELAINAN THT DERAJAT 2 /GA
33 EKSTRAKSI DUKTUS TIROGLOSUS GA
34 EKSTRAKSI KISTA MAKSILA/MANDIBULA/GA
35 EKSTRAKSI KISTA MAKSILA/MANDIBULA LUAS/GA
36 EKSTRAKSI TUMOR LIDAH/OROFARING/GA
37 EKSTRAKSI TUMOR RONGGA MULUT GA
38 EKSTRAKSI ANGIOFIBROMA JUVENILE/GA
39 EKSTRAKSI GRANULASI LIANG TELINGA/KOLESTEATOSIS GA
40 EKSTRAKSI GRANULASI LIANG TELINGA/KOLESTEATOSIS LA
41 EKSTRAKSI KORPUS ALIENUM THT /GA
42 EKSTRAKSI KORPUS ALIENUM THT DERAJAT I/LA
43 EKSTRAKSI KORPUS ALIENUM THT DERAJAT 2/LA
44 EKSTRAKSI TRANSPALATAL ANGIOFIBROMA JUVENILE/GA
45 ESOFAGOSCOPY EKSPLORASI/GA
46 ESOFAGOSCOPY EKSPLORAS DERAJAT 1/LA
47 ESOFAGOSCOPY EKSPLORAS DERAJAT 2/LA
48 ESOFAGOSCOPY EKSTRAKSI / BIOPSI/ GA
49 FESS/BSEF (BEDAH SINUS ENDOSKOPI FUNGSIONAL) DERAJAT 1/GA
50 FESS/BSEF (BEDAH SINUS ENDOSKOPI FUNGSIONAL) DERAJAT 2/GA
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

51 FISTULEKTOMI DERAJAT 1/LA

52 FISTULEKTOMI DERAJAT 1/GA
53 FISTULEKTOMI DERAJAT 2/GA
54 FISTULEKTOMI DERAJAT 2/LA
55 GANTI KANUL LA
56 GLOSEKTOMI GA
57 IMPLANTASI KOKLEA / GA
58 INCISI ABSES TELINGA/HIDUNG/TENGGOROK DERAJAT 1 / GA
59 INCISI ABSES TELINGA/HIDUNG/TENGGOROK DERAJAT 2 / GA
60 INCISI ABSES TELINGA/HIDUNG/TENGGOROK DERAJAT 1 / LA
61 INCISI ABSES TELINGA/HIDUNG/TENGGOROK DERAJAT 2 / LA
62 IRIGASI SINUS MAKSILARIS / GA
63 IRIGASI SINUS MAKSILARIS / LA
64 KAUSTIK KIMIA KONKA NASAL 1-2 SISI, LA
65 KILLIAN GA
66 KONKOTOMI GA
67 KONKOTOMI LA
68 KOREKSI KOANAL MEMBRANEUS (DERAJAT 1) / GA
69 KOREKSI TRANSEPTAL ATRESIA KOANAL BONY (DERAJAT 2) / GA
70 KOREKSI TRANSEPTAL ATRESIA KOANAL BONY (DERAJAT 3) / GA
71 LARINGEKTOMI TOTAL GA
72 LARINGEKTOMI TATAL + DISEKSI LEHER RADIKAL / GA
73 LARINGOSKOPI DIREKTA (LD) / LA
74 LARINGOSKOPI DIREKTA (LD) / GA
75 LARINGOSKOPI DIREKTA (LD) DENGAN BIOPSI / LA
76 LARINGOSKOPI DIREKTA (LD) DENGAN/TANPA BIOPSI / GA
77 MAKSILEKTOMI PARSIAL/GA
78 MAKSILEKTOMI TOTAL/GA
79 MARSUPIALISASI KISTA / GA
80 MASTOIDEKTOMI RADIKAL / GA
81 MASTOIDEKTOMI RADIKAL + REKONSTRUKSI / GA
82 MEATOPLASTI DERAJAT 1 / GA
83 MEATOPLASTI DERAJAT 2 / GA
84 MIRINGOPLASTI / GA
85 MIRINGOPLASTI / LA
86 MULTIPLE INCISI LA
87 NASOENDOSKOPI GA
88 NASOENDOSKOPI LA
89 NASOENDOSKOPI + BIOPSI / GA
90 NASOENDOSKOPI + BIOPSI / LA
91 NEKROTOMI GA
92 NEKROTOMI LA
93 OPERASI KELENJAR & SALURAN AIR LIUR DERAJAT 1 / GA
94 OPERASI KELENJAR & SALURAN AIR LIUR DERAJAT 2 / GA
95 OPERASI PADA FARING 1 / GA (FARINGEKTOMI)
96 OPERASI PADA FARING 2 / GA (FARINGEKTOMI)
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

97 OPERASI SINUS EDMOID (EDMOIDEKTOMI EKSTRANASAL )/GA

98 OPERASI SINUS EDMOID (EDMOIDEKTOMI INTRANASAL )/GA
99 OPERASI SINUS FRONTALIS PENDEKATAN KILLIAN / GA
100 OPERASI SINUS FRONTALIS PENDEKATAN OSTEOPLASTI / GA
101 OPERASI SINUS SFENOID / GA (SFENOIDEKTOMI)
102 OPERASI UVULA 1/ LA (UVULORAFI / UVULEKTOMI)
103 OPERASI UVULA 2/ GA (UVULORAFI / UVULEKTOMI)
104 PALATOPLASTI / GA
105 PARACENTESE / GA
106 PARACENTESE / LA
107 PASANGA GROMET / GA
108 PASANGA GROMET DERAJAT 1/ LA
109 POLIP EKSTRAKSI 2 / LA
110 POLIP EKSTRAKSI GA
111 POLIP EKSTRAKSI + ETMOIDEKTOMI / GA
112 POLIP EKSTRAKSI + IRIGASI SINUS MAKSILARIS / GA
113 REPAIR FISTEL PALATUM / GA
114 REPAIR STOMA / GA
115 REPAIR STOMA / LA
116 REPAIR TELINGA DAWIR / LA
117 REPOSISI FRAKTUR NASI / GA
118 REPOSISI FRAKTUR NASI / LA
119 RINOPLASTI DERAJAT 1 / GA
120 RINOPLASTI DERAJAT 2 / GA
121 RINOTOMI LATERAL DERAJAT 1 / GA
122 RINOTOMI LATERAL DERAJAT 2 / GA
123 SEPTOPLASTI GA
124 STAPEDEKTOMI GA
125 TAMPON BELOG GA
126 TAMPON BELOG LA
127 TAMPON HIDUNG ANTERIOR LA
128 TAMPON TELINGA LUAR LA
129 TIMPANOPLASTI TIPE 1 / GA
130 TIMPANOPLASTI TIPE 2 / GA
131 TIROIDEKTOMI DAN ATAU PARATIROIDEKTOMI 1 GA
132 TIROIDEKTOMI DAN ATAU PARATIROIDEKTOMI 2 GA
133 TONSILEKTOMI GA
134 TRAKEOSKOPI GA
135 TRAKEOSKOPI LA
136 TRAKEOTOMI LA
137 TRAKEOTOMI 1 GA
138 TRAKEKOTOMI 2 GA
139 TRIPLE ENDOSKOPI (LD +TRAKEOSKOPI+ESOFAGOSKOPI) GA
140 ANGKAT DRAIN, LA
141 ANGKAT JAHITAN : 1-5 JAHITAN
142 ANGKAT JAHITAN : 1-10 JAHITAN
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

143 ANGKAT JAHITAN : 1-20 JAHITAN

144 PERAWATAN LUKA TRAKEOSTOMY
145 PERAWATAN LUKA MININGAPLASTI
146 PERAWATAN LUKA POST INSISI ABSES
147 MEMASANG NGT
148 SKIN PRICK TEST
149 PERAWATAN TRAKEOTOMI/HARI
150 Audiologi Nada Murni
151 Timpanometri
152 BERA
153 Test Sisi/ Decay
154 Audiometri Tutur
155 Posturografi
156 Tes Keseimbangan dengan Frezels
157 Audiometri Tes gliserol
158 Terapi Reposisi Otolot
159 OAE
160 Tes Keseimbangan Sederhana
161 Irigasi Liang Telinga
162 Ekstrasi Benda Asing Telinga
163 Ekstraksi jaringan granulasi
164 Otomikroskopi Diagnostik
165 Ear toilet
166 Ambil bahan kultur
167 Patch Test Diagnostik
168 Angkat Tampon Anterior
169 Angkat Tampon Posterior

Rawat Jalan dan

NO 5. ORTHOPEADI
Non Kelas

1 AFF PLATE CRURIS,TIBIA, PATELA

2 AMPUTASI FOREQUARTER
3 AMPUTASI HIND QUARTER
4 AMPUTASI JARI
5 AMPUTASI KAKI
6 AMPUTASI KECIL
7 AMPUTASI TRANSMEDULAR
8 ANGKAT PEN / SCREW
9 AP HUMERUS / FEMUR
10 CONTRUCTION HAND SEDERHANA
11 CTEV
12 DEBRIDEMENT FRAKTUR TERBUKA
13 DISARTIKULASI
14 DISLOKASI COLLUM FEMUR
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

15 FIKSASI INTERNA SEDERHANA / EKSTERNA

16 FIKSASI INTERNA YANG KOMPLEK (TIDAK TERMASUK ALAT)
17 FR. ANTEBRACHII ( GIPS)
18 FR. COLLUM FEMUR NON PATOLOGIS
19 FR. HUMERUS
20 FR. METATARSAL
21 FR.ANTEBRACHII
22 FR.CLAVICULA
23 FR.CRURIS/TIBIA
24 FR.FEMUR
25 FR.PATELA
26 FRAKTUR PELVIS
27 FRAKTUR PHALANG
28 GANTI SENDI (TIDAK TERMASUK ALAT)
29 LAT ( KONTRAKTUR )
30 LUMBRICALIS REPLACEMENT ( EF4T + EE4T )
31 MICROSURGERY
32 OPEN REDUKSI FRAKTUR / DISLOKASI LAMA
33 OPPONEN REPLACEMENT
34 REKONTRUKSI KELAINAN JARI/EKSTERMITAS (POLIDAKTILI, SINDATILI,
35 REKONTRUKSI TENDONTRANSFER TANGAN
36 REKONTRUKSI TENDONTRANSFER KAKI
37 REPAIR TENDON JARI
38 REPOSISI FRAKTUR/DISLOKASI DALAM NARKOSE
39 REPOSISI MANDIBULA
40 RUPTUR TENDON
41 SCOLIOSIS
42 SYMBLEPHARON
43 TEMPORALIS MUSCULUS TRANSFER
44 TIBIALIS POSTERIOR TRANSFER
45 TRIDENELISIS
46 ULCUS PEDIS (DEPRIDEMENT FRAKTUR TERBUKA)
47 ULCUS PLANTAR SEPTIK (DEPRIDEMENT FRAKTUR TERBUKA)

NO
Rawat Jalan dan
6. KULIT DAN KELAMIN
Non Kelas

1 SKINGRAFTING YANG LUAS

2 SKINGRAFTING YANG TIDAK LUAS

Rawat Jalan dan

NO 7. UROLOGI
Non Kelas

1 AFF DJ STAND
2 BATU BULI-BULI OPEN
3 BATU BULI-BULI/LITROTIPSI
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

4 BATU GINJAL
5 BATU URETER OPEN
6 BATU URETER URS
7 BPH TURP
8 CA BULI(TURB)
9 EXTRAKSI BATU URETRA
10 HYPOSPADIA
11 STICTURE URETRA (SACHZE)

NO
Rawat Jalan dan
8. PLASTIK
Non Kelas

1 FRAKTUR MAKSILA /ZYGOMA

2 FRAKTUR MUKA MULTIPLE (TANPA MINIPLATE SCREW)
3 FRAKTUR RAHANG SEDERHANA
4 FRAKTUR SEDERHANA OS NASAL
5 FREE FLAP SURGERY
6 FRONTO-ORBITAL ADVANCEMENT PADA CRANIOSYNOSTOSIS
7 OPERASI MIKROTIA
8 ORTHOGNATIC SURGERY
9 PALATO SCHIZIS / LABIO SCHIZIS
10 REKONSTRUKSI DEFEK / KELAINAN TUBUH YANG KOMPLEKS
11 REKONTRUKSI LABIO PALATO SCHIZIS
12 RELEASE N. ULNARIS (DIOPSI SARAF KUTANEUS / OTOT)
13 REPAIR LUKA PADA WAJAH KOMPLEKS
14 REPAIR LUKA ROBEK SEDERHANA PADA WAJAH
15 REPLANTASI
16 REPOSISI FRAKTUR NASI, GA
17 SALVAGING OPERASI MIKRO

VII PENUNJANG
JENIS PELAYANAN
Rawat Jalan dan
NO
1. FISIOTERAPHI Non Kelas

1 FISIOTERAPI DENGAN ALAT SINAR INFRA MERAH/INFRA RED

2 FISIOTERAPI DENGAN ALAT HOT COLLATOR PACK
3 FISIOTERAPI DENGAN ALAT LASER THERAPY
4 FISIOTERAPI DENGAN ALAT LATIHAN DAN SENAM
5 FISIOTERAPI DENGAN ALAT MASSAGER
6 FISIOTERAPI DENGAN ALAT MWD (MICRO WAVE DIATHERMY)
7 FISIOTERAPI DENGAN ALAT PARRAFIN BATH
8 FISIOTERAPI DENGAN ALAT STIMULASI LISTRIK ( E.S )
9 FISIOTERAPI DENGAN ALAT SWD (SHORT WAVE DIATHERMY)
10 FISIOTERAPI DENGAN ALAT TRAKSI
11 FISIOTERAPI DENGAN ALAT ULTRA SOUND THERAPY
12 FISIOTERAPI DENGAN ALAT WHIRLPOOL
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

13 PEMERIKSAAN MMT/MANUAL MUSCLE TEST DAN SENSORIS TEST

14 TERAPI WICARA
15 FISIOTERAPI DENGAN ALAT LATIHAN DAN SENAM

Rawat Jalan dan

NO 2. ORTHESA DAN PROTESA
Non Kelas

1 Above elbow Prosthesis / Prostesis Atas Siku

2 Above Knee Prosthesis / Prostesis Atas Lutut
3 Above Knee Prosthesis / Prostesis Atas Lutut (Komponen Import)
4 Bellow Elbow Prosthesis / Prostesis Bawah Siku
5 Bellow Knee Prosthesis / Prostesis Bawah Lutut
6 Bellow Knee Prosthesis / Prostesis Bawah Lutut (Komponen Import)
7 Syme Prosthesis Foot Karet
8 Syme Prosthesis Foot Spon
9 True Knee Prosthesis / Prostesis Bawah Lutut
10 True Knee Prosthesis / Prostesis Bawah Lutut (Komponen Import)
11 True Elbow Prosthesis / Prostesis tepat Siku
12 AFO (Ankle Foot Orthosis)
13 AFO (Ankle Foot Orthosis) With Joint
14 AFO (Ankle Foot Orthosis) Anak - anak
15 Boston Brace
16 Cock Up Splint
17 Dennis Brown Splint
18 Finger Splint
19 FO (Foot Orthosis) plastic (1 pasang)
20 FO (Foot Orthosis) Spon (1 Pasang)
21 KAFO (Knee Ankle Foot Orthosis) Dewasa
22 KAFO (Knee Ankle Foot Orthosis) Anak – anak
23 LSO Korset / Lumbo Sacral Orthosis Korset
24 PTB Brace / Patella Tendon Bearing
25 Scoliosis Brace
26 Sandal MCR
27 Sandal MCR Kulit
28 TLSO Korset / Toraco Lumbo Sacral Orthosis Korset
29 TLSO Rigid / Toraco Lumbo Sacral Orthosis Rigid
30 Axial Cructh / Kruk
31 Perbaikan Pengantian Hand Glove
32 Perbaikan Penggantian SACH Foot
33 Perbaikan Penggantian Sabuk Atas Lutut
34 Perbaikan Penggantian Sabuk Bawah Lutut
35 Perbaikan Penggantian Strap Orthosis
36 Perbaikan Prosthesis
37 Perbaikan KAFO (Knee Ankle Foot Orthosis)
38 Perbaikan AFO (Ankle Foot Orthosis)
39 Perbaikan PTB Brace / Patella Tendon Bearing
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

40 Perbaikan Axial Cructh / Kruk

Rawat Jalan dan

NO 3. OKUPASI TERAPI
Non Kelas

1 ADL/ACTIVITY OF DAILY LIVING

2 LATIHAN PRE DAN POST OP
3 LATIHAN ROM NON OPERATIF
4 PEMASANGAN SPALK GIBS
5 PEMBERIAN ALAT PELINDUNG MATA / TOPI
6 PEMBERIAN ALAT PELINDUNG MATA /KACA MATA
7 PEMBERIAN ALAT PENGAIT KANCING BAJU
8 PEMBERIAN ALAT PENJEPIT SAYURAN
9 PEMBERIAN PENGIKAT SENDOK DAN SIKAT GIGI
10 PEMBERIAN SARUNG TANGAN JAMPEL
11 PEMBERIAN SARUNG TANGAN JARI-JARI
12 PEMBERIAN WASHLAP KANTONG
13 PERAWATAN DIRI
14 PRE VOCATIONAL THERAPY
15 SENAM RELAKSASI
16 TERAPI REKREASI
17 FOLLOW UP KE RUANGAN

Rawat Jalan dan

NO 4. AKUPUNTUR
Non Kelas

1 AKUPUNTUR 1 SISI / 1 DIAGNOSA 40,000

2 AKUPUNTUR 2 SISI / 2 DIAGNOSA 70,000
3 AKUPUNTUR PAKET 110,000
4 PASANG PRESNEDLE 30,000
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

Rawat Jalan dan

NO 5. LABORATORIUM
Non Kelas

1 ALBUMIN 17,000
2 ALKALI PHOSPHAT 24,000
3 AMILASE 35,000
4 ANALISA GAS DARAH 288,000
5 ANTHEBRACII 58,000
6 ANTI HBS AG 52,000
7 ANTI DHF RAPID TEST 155,000
8 ANTI TB RAPID TEST 72,000
9 APTT 58,000
10 ASAM URAT / URIC ACID 21,000
11 ASTO 25,000
12 BILIRUBIN DIREK 14,000
13 BILIRUBIN INDIREK 14,000
14 BILIRUBIN TOTAL 14,000
15 BLEEDING TIME 150,000
16 BTA Z-N ( PAKET ) 25,000
17 CEA 127,000
18 CHOLESTEROL 21,000
19 CLOTING TIME 15,000
20 CREATININ 18,000
21 DARAH LENGKAP (OTOMATIS) 58,000
22 GAMMA GT 46,000
23 GLOBULIN 17,000
24 GOLONGAN DARAH 15,000
25 GULA DARAH STIK 15,000
26 GULA DARAH VENA 15,000
27 HAPUSAN DARAH TEPI 52,000
28 HBSAG 45,000
29 HDL CHOLESTEROL 21,000
30 HIV TEST 45,000
31 HSG * 230,000
32 KALIUM 48,000
33 KALSIUM 48,000
34 KULTUR BTA 250,000
35 ANALISA CAIRAN LAMBUNG 58,000
36 LDL CHOLESTEROL 21,000
37 LED 15,000
38 MORFOLOGI HAPUSAN 35,000
39 NATRIUM 48,000
40 PCV / HEMATOCRIT 17,000
41 PENGAMBILAN DARAH VENA 10,000
42 PLANO 17,000
43 PPT 35,000
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

44 RETIKULOSIT 25,000
45 SGOT 20,000
46 SGPT 20,000
47 SKIN SMAER 45,000
48 T3 99,000
49 T4 99,000
50 TETES TEBAL (MALARIA) 25,000
51 TOTAL PROTEIN 21,000
52 TRIGLISERIDA 24,000
53 TSHS 113,000
54 UREUM / BUN 20,000
55 URINE LENGKAP (OTOMATIS) 25,000
56 WIDAL 25,000
57 IGM SALMONELA 207,000
58 VDRL 40,000
59 TPHA 40,000
60 IGM ANTI DHF 316,000
61 SERUM IRON 86,000
62 TIBC 121,000
63 HBA1C 180,000
64 PEWARNAAN KOH 20,000
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

Rawat Jalan dan

NO 6. RADIOLOGI
Non Kelas

1 ANKLE AP/LAT
2 ANTEBRAHI AP/LAT
3 APENDKOGRAM
4 BARIUM OESOPHAGUS
5 BNO/BOF
7 C-ARM
8 CALCANIUS AP/LAT
9 CLAVICULA AP
10 COLON IN LOOP
11 CRURIS AP/LAT
12 CUBITI AP/LAT
13 CUBITI/ELBOW
14 CYSTOGRAM
15 DENTAL
16 EISLER (KA, KI)
17 FEMUR AP/LAT
18 FISTULUGRAFI
19 GENU AP/LAT
20 HUMERUS AP / LAT
21 I.V.P *
22 KEPALA AP/LAT
23 LOPOGRAFI
24 MANDIBULA AP
25 MANUS
26 MANUS AP/LAT
27 MASTOID KA/KI
28 PATELA SKY LINE
29 PEDIS AP/LAT
30 PELVIS AP
31 PELVIS AP/LAT
32 R.P G
33 SACRUM AP/LAT
34 SHOULDER 2 PSS (EKSO, ENDO)
35 SHOULDER AP
36 SKULL 2 POSISI
37 THORAX AP/LAT
38 TMJ (OPEN, CLOSE)
39 UGI
40 ULTRASONIC DIATERMY (USD)
41 URETROGRAFI
42 USG DOPPLER
43 USG KANDUNGAN
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

44 USG LOWER ABD

45 USG MARKER
46 USG UPPER ABD
47 USG WHOLE BODY
48 VERT CERVICAL 2 POSISI
49 VERT CERVICAL 4 POSISI
50 VERT LUMBAL 2 POSISI
51 VERT LUMBAL 4 POSISI
52 VERT LUMBOSACRAL 2 POSISI
53 VERT LUMBOSACRAL 4 POSISI
54 VERT THORACAL 2 POSISI
55 VERT THORACAL 4 POSISI
56 VERT THORACOLUMBAL 2 POSISI
57 VERT THORACOLUMBAL 4 POSISI
58 WRISE JOINT AP/LAT
59 ABDOMEN
60 ABDOMEN 3 POSISI
61 CERVICAL AP/LAT
62 CERVICAL OBLIQUE
63 CLACICULA D-S
64 COXAE
65 COXIGEUS AP/LAT
66 KUB
67 LUMBAL AP/LAT
68 LUMBAL OBLIQUE
69 LUMBOSACRUM AP/LAT
70 LUMBOSACRUM OBLIQUE
71 MASTOID ESHELER D-S
72 MASTOID SCHULER D-S
73 SCAPULA
74 SKULL CRANIUM AP
75 SKULL CRANIUM AP-LAT
76 SKUL CRANIUM LAT
77 STANDART SCOLISIS
78 THORAK OBLIQUE
79 THORAKOLUMBAL AP/LAT
80 THORAKOLUMBAL OBLIQUE
81 USG ABDOMEN ATAS
82 USG ABDOMEN BAWAH
83 USG ABDOMEN TOTAL
84 USG GINJAL
85 USG HEPAR
86 USG MAMAE
87 USG MAMAE KANAN-KIRI
88 USG THORAK
89 USG THORAK KANAN-KIRI
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

90 USG THYROID
91 USG UROLOGI
92 WATERS

NO
Rawat Jalan dan
7. PSIKOLOGI
Non Kelas

1 KONSULTASI/PEMERIKSAAN UMUM
2 KONSELING/PEMERIKSAAN UMUM
3 PEMERIKSAAN DETEKSI GANGGUAN PERKEMBANGAN SOSIAL
4 PEMERIKSAAN DETEKSI GG. PERKEMBANGAN INTELEKTUAL/IQ
5 PEMERIKSAAN DETEKSI GG. PERKEMBANGAN KEPRIBADIAN
6 PEMERIKSAAN DETEKSI GG.PERKEMBANGAN BAHASA
7 PEMR. DETEKSI GG.PERKEMBANGAN MOTORIS KASAR-HALUS
8 SELEKSI KARYAWAN
9 TERAPI INDIVIDU
10 TERAPI KELOMPOK(3-6 ORANG)
11 TERAPI RELIGI(6-10 ORANG)

Rawat Jalan dan

NO 8. LAINNYA
Non Kelas

1 ABDOMEN 3 POSISI
2 AKUPUNKTUR (4 X TINDAKAN)
3 AKUPUNTUR PER KALI
4 CVA
5 EKG
6 HIPERBARIK PAKET
7 HIPEREBARIK MONOPLACE TANPA OKSIGEN
8 HIPEREBARIK MULTYPLACE
10 PEMULASARAAN JENAZAH LENGKAP
11 PEMAKAMAN JENAZAH
12 SEWA AMBULANCE JARAK TEMPUH AWAL 0 S/D 25 KM
13 SEWA AMBULANCE LEBIH DARI 25 KM DIKENAKAN TAMBAHAN PER KM

14 SEWA PENDINGINAN JENAZAH (PER HARI)

15 LOUNDRY (PER KG)
16 FOGGING STERILISASI RUANGAN (PER M3)
17 PEMBAKARAN SAMPAH MEDIS (PER KG)

Rawat Jalan
dan Non Kelas

1 Administrasi Pengambilan Data ( per orang per bulan )

2 Pembimbing ( per orang per bulan )
3 Penelitian
 Rawat Jalan dan
No JENIS PELAYANAN
Non Kelas

4 PKL
 RAWAT INAP KET

KELAS 3 KELAS 2 KELAS 1 VIP

10,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP

PERUBAHAN TARIF
PERUBAHAN TARIF
PERUBAHAN TARIF
PERUBAHAN TARIF
PERUBAHAN TARIF
PERUBAHAN TARIF
PERUBAHAN TARIF
PERUBAHAN TARIF
PERUBAHAN TARIF
TARIF BARU

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
45,000 45,000 45,000 45,000
17,000 17,000 17,000 17,000
12,000 12,000 12,000 12,000
45,000 45,000 45,000 45,000
10,000 10,000 10,000 10,000
10,000 10,000 10,000 10,000
10,000 10,000 10,000 10,000
30,000 30,000 30,000 30,000
10,000 10,000 10,000 10,000
10,000 10,000 10,000 10,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
15,000 15,000 15,000 15,000
10,000 10,000 10,000 10,000
30,000 30,000 30,000 30,000
100,000 100,000 100,000 100,000
5,000 5,000 5,000 5,000 PERUBAHAN TARIF
 PERUBAHAN TARIF
60,000 60,000 60,000 60,000
50,000 50,000 50,000 50,000
35,000 35,000 35,000 35,000
15,000 15,000 15,000 15,000
25,000 25,000 25,000 25,000
75,000 75,000 75,000 75,000
175,000 175,000 175,000 175,000
30,000 30,000 30,000 30,000
100,000 100,000 100,000 100,000
5,000 5,000 5,000 5,000
200,000 200,000 200,000 200,000
30,000 30,000 30,000 30,000
75,000 75,000 75,000 75,000
50,000 50,000 50,000 50,000
75,000 75,000 75,000 75,000
100,000 100,000 100,000 100,000
10,000 10,000 10,000 10,000
20,000 20,000 20,000 20,000
30,000 30,000 30,000 30,000
20,000 20,000 20,000 20,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
150,000 150,000 150,000 150,000
10,000 10,000 10,000 10,000
15,000 15,000 15,000 15,000
20,000 20,000 20,000 20,000
50,000 50,000 50,000 50,000
15,000 15,000 15,000 15,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
3,000 5,000 5,000 7,500
50,000 60,000 70,000 100,000
147,000 171,000 210,000 265,000
30,000 37,000 49,000 65,000
60,000 65,000 75,000 90,000
23,000 30,000 35,000 50,000
34,000 39,000 51,000 60,000

250,000 250,000 250,000 250,000

50,000 50,000 50,000 50,000
100,000 100,000 100,000 100,000
40,000 40,000 40,000 40,000
60,000 60,000 60,000 60,000

100,000 125,000 125,000 172,800

50,000 50,000 50,000 60,000
50,000 75,000 75,000 86,400

50,000 75,000 75,000 86,400

25,000 25,000 25,000 30,000
25,000 50,000 50,000 60,000

30,000 55,000 55,000 73,000

15,000 15,000 15,000 25,000
15,000 40,000 40,000 48,000

275,000 325,000 355,000 416,000

150,000 175,000 175,000 200,000
75,000 90,000 108,000 129,600
50,000 60,000 72,000 86,400 TARIF BARU

30,000 32,500 32,500 35,000 TARIF BARU

15,000 15,000 15,000 15,000 TARIF BARU
15,000 17,500 17,500 20,000 TARIF BARU

25,000 27,500 27,500 30,000 TARIF BARU

15,000 15,000 15,000 15,000 TARIF BARU
10,000 12,500 12,000 15,000 TARIF BARU

67,000 80,000 80,000 97,000 PERUBAHAN TARIF

50,000 60,000 60,000 72,000 PERUBAHAN TARIF
17,500 20,000 20,000 25,000 PERUBAHAN TARIF

47,500 56,000 56,000 68,200 PERUBAHAN TARIF

30,000 36,000 36,000 43,200 PERUBAHAN TARIF
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
17,500 20,000 20,000 25,000 PERUBAHAN TARIF

115,000 137,500 137,500 160,000 TARIF BARU

100,000 120,000 120,000 140,000 TARIF BARU
15,000 17,500 17,500 20,000 TARIF BARU

25,000 30,000 36,000 43,200

250,000 250,000 250,000 250,000
30,000 36,000 36,000 43,200
15,000 18,000 18,000 21,600
10,000 12,000 12,000 14,400
15,000 18,000 18,000 21,600
30,000 36,000 36,000 43,200
10,000 12,000 12,000 14,400
10,000 12,000 12,000 14,400
5,000 6,000 6,000 7,200 TARIF BARU
30,000 36,000 36,000 43,200
10,000 12,000 12,000 14,400
20,000 24,000 24,000 28,800
50,000 60,000 60,000 72,000 TARIF BARU
100,000 120,000 120,000 144,000
30,000 40,000 40,000 50,000
50,000 60,000 60,000 80,000
70,000 80,000 80,000 100,000
100,000 120,000 120,000 144,000
30,000 36,000 36,000 43,200
30,000 36,000 36,000 43,200
20,000 24,000 24,000 28,800
20,000 24,000 24,000 28,800
10,000 12,000 12,000 14,400
5,000 6,000 6,000 7,200
40,000 45,000 45,000 50,000
10,000 12,500 12,500 15,000 TARIF BARU
7,500 10,000 10,000 15,000 TARIF BARU
7,500 10,000 10,000 15,000 TARIF BARU
7,500 10,000 10,000 15,000 TARIF BARU
7,500 10,000 10,000 15,000 TARIF BARU
7,500 10,000 10,000 15,000 TARIF BARU
7,500 10,000 10,000 15,000 TARIF BARU
5,000 6,000 6,000 7,200
50,000 60,000 60,000 72,000 TARIF BARU
100,000 125,000 125,000 150,000 TARIF BARU
150,000 185,000 185,000 200,000 TARIF BARU
20,000 24,000 28,800 34,560 TARIF BARU
30,000 36,000 43,200 51,840 TARIF BARU
40,000 46,000 46,000 60,000 TARIF BARU
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
3,000 3,600 3,600 4,320 TARIF BARU
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
20,000 24,000 28,800 34,560
20,000 24,000 28,800 34,560
30,000 36,000 43,200 51,840
200,000 240,000 288,000 345,600
50,000 60,000 72,000 86,400
50,000 60,000 72,000 86,400
25,000 30,000 36,000 43,200
225,000 270,000 324,000 388,800
30,000 36,000 43,200 51,840
20,000 24,000 28,800 34,560
10,000 12,000 14,400 17,280
20,000 24,000 28,800 34,560
75,000 90,000 108,000 129,600
65,000 78,000 93,600 112,320
165,000 198,000 237,600 285,120
20,000 24,000 28,800 34,560
50,000 60,000 72,000 86,400
25,000 30,000 36,000 43,200
48,000 57,600 69,120 82,944
20,000 24,000 28,800 34,560
40,000 48,000 57,600 69,120
50,000 60,000 72,000 86,400
20,000 24,000 28,800 34,560
50,000 60,000 72,000 86,400
600,000 720,000 864,000 1,036,800
75,000 90,000 108,000 129,600
20,000 24,000 28,800 34,560
50,000 60,000 72,000 86,400
200,000 240,000 288,000 345,600
75,000 90,000 108,000 129,600
75,000 90,000 108,000 129,600
42,000 50,400 60,480 72,576
42,000 50,400 60,480 72,576
42,000 50,400 60,480 72,576
42,000 50,400 60,480 72,576
42,000 50,400 60,480 72,576
42,000 50,400 60,480 72,576
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
3,600,000 4,320,000 5,184,000 6,220,800
1,500,000 1,800,000 2,160,000 2,592,000
100,000 120,000 144,000 172,800
80,000 96,000 115,200 138,240
30,000 36,000 43,200 51,840
55,000 55,000 55,000 55,000
100,000 120,000 144,000 172,800
100,000 120,000 144,000 172,800
10,000 12,000 14,400 17,280
10,000 12,000 14,400 17,280
10,000 12,000 14,400 17,280
50,000 60,000 72,000 86,400
100,000 120,000 144,000 172,800
150,000 180,000 216,000 259,200
75,000 90,000 108,000 129,600
200,000 240,000 288,000 345,600
10,000 12,000 14,400 17,280
100,000 120,000 144,000 172,800
10,000 12,000 14,400 17,280

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
350,000 420,000 504,000 604,800
425,000 510,000 612,000 734,400
500,000 600,000 720,000 864,000
50,000 60,000 72,000 86,400
120,000 144,000 172,800 207,360
20,000 24,000 28,800 34,560
350,000 420,000 504,000 604,800
30,000 36,000 43,200 51,840
100,000 120,000 144,000 172,800
25,000 30,000 36,000 43,200
50,000 60,000 72,000 86,400
20,000 24,000 28,800 34,560
250,000 300,000 360,000 432,000
100,000 120,000 144,000 172,800
50,000 60,000 72,000 86,400
80,000 96,000 115,200 138,240

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
100,000
100,000 120,000 144,000 172,800
200,000 240,000 288,000 345,600
250,000 300,000 360,000 432,000
250,000 300,000 360,000 432,000
100,000
250,000 300,000 360,000 432,000
10,000 12,000 14,400 17,280
350,000
500,000
350,000 420,000 504,000 604,800
600,000
50,000 60,000 72,000 86,400
20,000 24,000 28,800 34,560

700,000 840,000 1,008,000 1,209,600

1,225,000 1,470,000 1,764,000 2,116,800

950,000 1,140,000 1,368,000 1,641,600

1,600,000 1,920,000 2,304,000 2,764,800
35,000
300,000 360,000 432,000 518,400
450,000 540,000 648,000 777,600
150,000 180,000 216,000 259,200
10,000
100,000 120,000 144,000 172,800
30,000
30,000
100,000 110,000 125,000 140,000
200,000 215,000 225,000 240,000
100,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP

100,000 120,000 144,000 172,800

150,000 180,000 216,000 259,200

200,000 240,000 288,000 345,600

400,000 480,000 576,000 691,200
100,000 120,000 144,000 172,800

100,000 120,000 144,000 172,800

200,000 240,000 288,000 345,600
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
200,000 240,000 288,000 345,600
625,000 625,000 625,000 625,000 Perubahan Tarif
625,000 625,000 625,000 625,000 Perubahan Tarif
1,000,000 1,200,000 1,440,000 1,728,000
200,000 240,000 288,000 345,600
1,000,000 1,200,000 1,440,000 1,728,000
1,000,000 1,200,000 1,440,000 1,728,000
40,000 48,000 57,600 69,120
15,000 18,000 21,600 25,920
15,000 18,000 21,600 25,920

150,000 180,000 216,000 259,200

250,000 300,000 360,000 432,000

150,000 180,000 216,000 259,200

200,000 240,000 288,000 345,600
750,000 900,000 1,080,000 1,296,000
30,000 36,000 43,200 51,840
150,000
15,000 18,000 21,600 25,920
50,000 60,000 72,000 86,400
200,000 220,000 240,000 288,000
15,000 18,000 21,600 25,920
950,000 950,000 950,000 950,000
500,000 500,000 500,000 500,000 Perubahan Tarif

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
122,500 147,000 176,400 211,680
233,000 279,600 335,520 402,624
30,000 36,000 43,200 51,840
75,000 90,000 108,000 129,600
139,000 166,800 200,160 240,192
234,000 280,800 336,960 404,352
75,000 90,000 108,000 129,600
339,000 406,800 488,160 585,792
170,000 204,000 244,800 293,760
30,000 36,000 43,200 51,840
234,000 280,800 336,960 404,352
234,000 280,800 336,960 404,352
100,000 120,000 144,000 172,800
30,000 36,000 43,200 51,840
139,000 166,800 200,160 240,192
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
50,000 60,000 72,000 86,400
85,000 102,000 122,400 146,880

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
75,000 90,000 108,000 129,600
60,000 72,000 86,400 103,680
100,000 120,000 144,000 172,800
350,000 420,000 504,000 604,800

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
93,600 112,320 134,784 161,741
160,000 192,000 230,400 276,480

400,000 400,000 400,000 400,000

Perubahan Tarif
600,000 600,000 600,000 600,000
850,000 850,000 850,000 850,000
120,000 144,000 172,800 207,360
300,000 360,000 432,000 518,400
55,000 66,000 79,200 95,040
110,000 132,000 158,400 190,080
16,000 19,200 23,040 27,648
40,000 48,000 57,600 69,120
162,000 194,400 233,280 279,936

150,000 150,000 150,000 150,000

250,000 250,000 250,000 250,000 Perubahan Tarif
450,000 450,000 450,000 450,000
30,000 36,000 43,200 51,840
360,000 432,000 518,400 622,080
162,000 194,400 233,280 279,936
75,000 90,000 108,000 129,600

200,000 200,000 200,000 200,000

Perubahan Tarif
250,000 250,000 250,000 250,000
300,000 300,000 300,000 300,000
12,000 14,400 17,280 20,736
22,400 26,880 32,256 38,707
24,000 28,800 34,560 41,472
96,000 115,200 138,240 165,888
30,000 36,000 43,200 51,840

200,000 200,000 200,000 200,000

Perubahan Tarif
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
Perubahan Tarif
250,000 250,000 250,000 250,000
300,000 300,000 300,000 300,000
15,000 18,000 21,600 25,920

150,000 150,000 150,000 150,000

Perubahan Tarif
200,000 200,000 200,000 200,000
250,000 250,000 250,000 250,000
30,000 36,000 43,200 51,840
162,000 194,400 233,280 279,936
35,000 42,000 50,400 60,480
75,000 90,000 108,000 129,600
350,000 420,000 504,000 604,800
250,000 300,000 360,000 432,000
550,000 660,000 792,000 950,400

150,000 150,000 150,000 150,000

TARIF BARU
150,000 150,000 150,000 150,000
250,000 250,000 250,000 250,000

150,000 150,000 150,000 150,000

TARIF BARU
150,000 150,000 150,000 150,000
250,000 250,000 250,000 250,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
100,000 120,000 144,000 172,800
27,500 33,000 39,600 47,520

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
234,000 280,800 336,960 404,352

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
4,719,000 5,219,000 5,719,000 6,219,000
4,250,125 4,750,125 5,250,125 5,750,125
4,235,000 4,735,000 5,235,000 5,735,000
4,840,000 5,340,000 5,840,000 6,340,000
5,445,000 5,945,000 6,445,000 6,945,000
181,500 272,250 408,375 612,563
1,452,000 1,952,000 2,452,000 2,952,000
3,267,000 3,767,000 4,267,000 4,767,000
4,023,250 4,523,250 5,023,250 5,523,250
4,598,000 5,098,000 5,598,000 6,098,000
90,750 136,125 204,188 306,281
5,082,000 5,582,000 6,082,000 6,582,000
90,750 136,125 204,188 306,281
181,500 272,250 408,375 612,563
1,919,363 2,419,363 2,919,363 3,419,363
3,097,600 3,597,600 4,097,600 4,597,600
3,747,975 4,247,975 4,747,975 5,247,975
3,188,350 3,688,350 4,188,350 4,688,350
3,569,500 4,069,500 4,569,500 5,069,500
181,500 272,250 408,375 612,563
196,020 294,030 441,045 661,568
4,174,500 4,674,500 5,174,500 5,674,500
2,117,500 2,617,500 3,117,500 3,617,500
60,500 90,750 136,125 204,188
121,000 181,500 272,250 408,375
121,000 181,500 272,250 408,375
181,500 272,250 408,375 612,563
181,500 272,250 408,375 612,563
2,117,500 2,617,500 3,117,500 3,617,500
5,445,000 5,945,000 6,445,000 6,945,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
4,395,325 4,895,325 5,395,325 5,895,325
3,025,000 3,525,000 4,025,000 4,525,000
605,000 907,500 1,361,250 2,041,875
423,500 635,250 952,875 1,429,313
423,500 635,250 952,875 1,429,313
3,630,000 4,130,000 4,630,000 5,130,000
1,633,500 2,133,500 2,633,500 3,133,500
1,512,500 2,012,500 2,512,500 3,012,500
6,110,500 6,610,500 7,110,500 7,610,500
1,573,000 2,073,000 2,573,000 3,073,000
4,235,000 4,735,000 5,235,000 5,735,000
3,630,000 4,130,000 4,630,000 5,130,000
4,840,000 5,340,000 5,840,000 6,340,000
4,840,000 5,340,000 5,840,000 6,340,000
4,235,000 4,735,000 5,235,000 5,735,000
2,147,750 2,647,750 3,147,750 3,647,750
605,000 907,500 1,361,250 2,041,875
605,000 907,500 1,361,250 2,041,875
1,210,000 1,710,000 2,210,000 2,710,000
3,630,000 4,130,000 4,630,000 5,130,000
1,573,000 2,073,000 2,573,000 3,073,000
84,700 127,050 190,575 285,863
181,500 272,250 408,375 612,563
121,000 181,500 272,250 408,375
5,762,625 6,262,625 6,762,625 7,262,625
4,719,000 5,219,000 5,719,000 6,219,000
1,512,500 2,012,500 2,512,500 3,012,500
1,936,000 2,436,000 2,936,000 3,436,000
1,512,500 2,012,500 2,512,500 3,012,500
4,915,625 5,415,625 5,915,625 6,415,625
1,452,000 1,952,000 2,452,000 2,952,000
484,000 726,000 1,089,000 1,633,500
363,000 544,500 816,750 1,225,125
151,250 226,875 340,313 510,469
617,100 925,650 1,388,475 2,082,713
363,000 544,500 816,750 1,225,125
605,000 907,500 1,361,250 2,041,875
4,235,000 4,735,000 5,235,000 5,735,000
2,208,250 2,708,250 3,208,250 3,708,250

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
900,000 1,100,000 1,300,000 1,500,000
1,200,000 1,400,000 1,600,000 1,800,000
1,500,000 1,700,000 1,900,000 2,100,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
400,000 480,000 576,000 691,200
2,630,000 3,156,000 3,787,200 4,544,640
400,000 480,000 576,000 691,200
4,200,000 5,040,000 6,048,000 7,257,600
5,200,000 6,240,000 7,488,000 8,985,600
2,630,000 3,156,000 3,787,200 4,544,640
3,300,000 3,960,000 4,752,000 5,702,400
400,000 480,000 576,000 691,200
2,650,000 3,180,000 3,816,000 4,579,200
100,000 120,000 144,000 172,800
2,850,000 3,420,000 4,104,000 4,924,800
2,500,000 3,000,000 3,600,000 4,320,000
1,350,000 1,620,000 1,944,000 2,332,800
2,350,000 2,820,000 3,384,000 4,060,800

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
3,250,000 3,900,000 4,680,000 5,616,000
2,500,000 3,000,000 3,600,000 4,320,000
700,000 700,000 700,000 700,000
3,250,000 3,900,000 4,680,000 5,616,000
2,000,000 2,400,000 2,880,000 3,456,000
1,500,000 1,800,000 2,160,000 2,592,000
2,500,000 3,000,000 3,600,000 4,320,000
1,750,000 2,100,000 2,520,000 3,024,000
2,500,000 3,000,000 3,600,000 4,320,000
1,000,000 1,000,000 1,000,000 1,000,000 Perubahan Tarif
1,500,000 1,500,000 1,500,000 1,500,000 Perubahan Tarif
625,000 750,000 900,000 1,080,000
625,000 750,000 900,000 1,080,000

3,000,000 3,600,000 4,320,000 5,184,000

4,000,000 4,800,000 5,760,000 6,912,000
2,500,000 3,000,000 3,600,000 4,320,000
750,000 900,000 1,080,000 1,296,000
1,200,000 1,440,000 1,728,000 2,073,600
4,500,000 5,400,000 6,480,000 7,776,000
2,500,000 3,000,000 3,600,000 4,320,000

3,000,000 3,600,000 4,320,000 5,184,000

3,500,000 4,200,000 5,040,000 6,048,000
3,500,000 4,200,000 5,040,000 6,048,000

3,500,000 4,200,000 5,040,000 6,048,000

4,000,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
4,500,000 5,400,000 6,480,000 7,776,000
5,000,000

5,100,000 6,120,000 7,344,000 8,812,800

6,000,000 7,200,000 8,640,000 10,368,000
3,600,000 4,320,000 5,184,000 6,220,800
1,500,000 1,800,000 2,160,000 2,592,000

2,500,000 3,000,000 3,600,000 4,320,000

3,000,000 3,600,000 4,320,000 5,184,000

2,000,000 2,400,000 2,880,000 3,456,000

3,000,000 3,600,000 4,320,000 5,184,000

5,500,000 6,600,000 7,920,000 9,504,000 Perubahan Tarif

8,000,000 9,600,000 11,520,000 13,824,000 Perubahan Tarif

6,700,000 8,040,000 9,648,000 11,577,600

9,000,000 10,800,000 12,960,000 15,552,000
2,500,000 3,000,000 3,600,000 4,320,000
2,500,000 3,000,000 3,600,000 4,320,000

2,500,000 3,000,000 3,600,000 4,320,000

3,500,000 4,200,000 5,040,000 6,048,000
3,000,000 3,600,000 4,320,000 5,184,000
3,000,000 3,600,000 4,320,000 5,184,000
4,500,000 5,400,000 6,480,000 7,776,000
1,750,000 2,100,000 2,520,000 3,024,000
4,500,000 5,400,000 6,480,000 7,776,000
4,500,000 5,400,000 6,480,000 7,776,000
4,500,000 5,400,000 6,480,000 7,776,000
1,000,000 1,200,000 1,440,000 1,728,000
2,500,000 3,000,000 3,600,000 4,320,000
2,500,000 3,000,000 3,600,000 4,320,000
4,500,000 5,400,000 6,480,000 7,776,000
2,500,000 3,000,000 3,600,000 4,320,000
3,250,000 3,900,000 4,680,000 5,616,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
3,000,000 3,500,000 4,000,000 4,700,000 Perubahan Tarif
3,000,000 3,500,000 4,000,000 4,700,000
3,250,000 3,750,000 4,250,000 5,500,000
250,000 275,000 300,000 350,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
50,000 60,000 70,000 80,000
5,250,000 5,500,000 6,000,000 6,500,000
6,250,000 6,500,000 7,000,000 7,500,000
5,250,000 5,500,000 6,000,000 6,500,000
6,250,000 6,500,000 7,000,000 7,500,000
500,000 550,000 600,000 800,000
500,000 550,000 600,000 800,000
1,500,000 1,750,000 2,000,000 2,500,000
1,750,000 2,000,000 2,500,000 3,000,000
500,000 550,000 600,000 800,000
750,000 850,000 900,000 1,000,000
6,250,000 6,500,000 7,000,000 7,500,000
6,250,000 6,500,000 6,750,000 7,500,000
6,500,000 6,750,000 7,000,000 7,750,000
6,500,000 6,750,000 7,000,000 7,750,000
3,250,000 3,750,000 4,250,000 5,500,000
2,327,000 3,676,000 1,472,000 7,475,000
3,000,000 3,500,000 4,000,000 4,700,000
500,000 550,000 600,000 800,000
500,000 550,000 600,000 800,000
750,000 850,000 900,000 1,000,000
500,000 550,000 600,000 800,000
6,250,000 6,500,000 7,000,000 7,500,000
6,500,000 6,750,000 7,000,000 7,500,000
500,000 550,000 600,000 800,000
1,500,000 1,750,000 2,000,000 2,500,000
750,000 850,000 900,000 1,000,000
Tarif Baru
1,750,000 2,000,000 2,500,000 3,000,000
3,250,000 3,750,000 4,250,000 5,500,000
3,000,000 3,500,000 4,000,000 4,700,000
3,250,000 3,750,000 4,250,000 5,500,000
3,250,000 3,750,000 4,250,000 5,500,000
3,250,000 3,750,000 4,250,000 5,500,000
3,250,000 3,750,000 4,250,000 5,500,000
3,000,000 3,500,000 4,000,000 4,700,000
500,000 550,000 600,000 800,000
1,750,000 2,000,000 2,500,000 3,000,000
500,000 550,000 600,000 800,000
750,000 850,000 900,000 1,000,000
3,250,000 3,750,000 4,250,000 5,500,000
5,250,000 5,500,000 6,000,000 6,500,000
5,250,000 5,500,000 6,000,000 6,500,000
6,250,000 6,500,000 7,000,000 7,500,000
6,250,000 6,500,000 7,000,000 7,500,000
5,250,000 5,500,000 6,000,000 6,500,000
6,500,000 6,750,000 7,000,000 7,500,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
500,000 550,000 600,000 800,000
1,500,000 1,750,000 2,000,000 2,500,000
750,000 850,000 900,000 1,000,000
1,750,000 2,000,000 2,500,000 3,000,000
500,000 550,000 600,000 800,000
3,250,000 3,750,000 4,250,000 5,500,000
10,000,000 12,000,000 14,000,000 18,000,000
1,750,000 2,000,000 2,500,000 3,000,000
3,000,000 3,500,000 4,000,000 4,700,000
750,000 850,000 900,000 1,000,000
1,221,000 1,680,000 664,000 3,565,000
1,500,000 1,750,000 2,000,000 2,500,000 Perubahan Tarif
750,000 850,000 900,000 1,000,000
150,000 175,000 180,000 200,000
3,250,000 3,750,000 4,250,000 5,500,000
1,750,000 2,000,000 2,500,000 3,000,000
750,000 850,000 900,000 1,000,000
Tarif Baru
3,250,000 3,750,000 4,250,000 5,500,000
5,250,000 5,500,000 6,000,000 6,500,000
6,250,000 6,500,000 7,000,000 7,500,000
8,500,000 9,000,000 10,000,000 12,000,000
10,000,000 12,000,000 14,000,000 17,000,000
500,000 550,000 600,000 800,000 Perubahan Tarif
1,221,000 1,680,000 664,000 3,565,000
1,500,000 1,750,000 2,000,000 2,500,000
3,000,000 3,500,000 4,000,000 4,700,000
Tarif Baru
5,250,000 5,500,000 6,000,000 6,500,000
6,250,000 6,500,000 7,000,000 7,500,000
3,000,000 3,500,000 4,000,000 4,700,000
6,250,000 6,500,000 7,000,000 7,500,000 Perubahan Tarif
6,500,000 6,750,000 7,000,000 7,500,000
3,000,000 3,500,000 4,000,000 4,700,000
3,250,000 3,750,000 4,250,000 5,500,000
3,250,000 3,750,000 4,250,000 5,500,000
1,500,000 1,750,000 2,000,000 2,500,000
1,500,000 1,750,000 2,000,000 2,500,000
1,221,000 1,680,000 664,000 3,565,000
500,000 550,000 600,000 800,000
1,500,000 1,750,000 2,000,000 2,500,000
500,000 550,000 600,000 800,000
1,500,000 1,750,000 2,000,000 2,500,000
500,000 550,000 600,000 800,000
3,250,000 3,750,000 4,250,000 5,500,000
3,500,000 3,750,000 4,000,000 4,500,000
3,250,000 3,750,000 4,250,000 5,500,000
6,500,000 6,750,000 7,000,000 7,250,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
5,250,000 5,500,000 6,000,000 6,500,000
3,250,000 3,750,000 4,250,000 5,500,000
3,500,000 3,750,000 4,000,000 4,500,000
5,250,000 5,500,000 6,000,000 6,500,000
Tarif Baru
7,000,000 7,250,000 7,500,000 8,000,000
1,221,000 1,680,000 664,000 3,565,000
3,250,000 3,750,000 4,250,000 5,500,000
3,250,000 3,750,000 4,250,000 5,500,000
1,221,000 1,680,000 664,000 3,565,000
500,000 550,000 600,000 800,000
1,500,000 1,750,000 2,000,000 2,500,000
1,221,000 1,680,000 664,000 3,565,000
1,500,000 1,750,000 2,000,000 2,500,000
3,250,000 3,750,000 4,250,000 5,500,000
3,500,000 3,750,000 4,000,000 4,500,000
3,500,000 3,750,000 4,000,000 4,500,000
3,000,000 3,500,000 4,000,000 4,700,000
1,500,000 1,750,000 2,000,000 2,500,000
1,221,000 1,680,000 664,000 3,565,000
500,000 550,000 600,000 800,000
3,000,000 3,500,000 4,000,000 4,700,000
1,221,000 1,680,000 664,000 3,565,000
6,500,000 6,750,000 7,000,000 7,250,000
7,500,000 7,750,000 8,000,000 8,250,000
3,000,000 3,500,000 4,000,000 4,700,000 Perubahan Tarif
3,500,000 3,750,000 4,000,000 4,500,000
6,500,000 6,750,000 7,000,000 7,250,000
7,500,000 7,750,000 8,000,000 8,250,000
1,221,000 1,680,000 664,000 3,565,000
500,000 550,000 600,000 800,000
200,000 225,000 250,000 300,000 Perubahan Tarif
150,000 170,000 180,000 200,000
6,500,000 6,750,000 7,000,000 7,250,000
7,500,000 7,750,000 8,000,000 8,250,000
6,500,000 6,750,000 7,000,000 7,250,000
7,500,000 7,750,000 8,000,000 8,250,000
3,250,000 3,750,000 4,250,000 5,500,000 Perubahan Tarif
1,500,000 1,750,000 2,000,000 2,500,000
1,221,000 1,680,000 664,000 3,565,000
750,000 850,000 900,000 1,000,000
1,500,000 1,750,000 2,000,000 2,500,000
1,750,000 2,000,000 2,500,000 3,000,000
1,750,000 2,000,000 2,500,000 3,000,000
150,000 170,000 180,000 200,000
110,000 120,000 130,000 150,000
150,000 170,000 180,000 200,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
175,000 185,000 195,000 220,000
110,000 120,000 130,000 150,000
110,000 120,000 130,000 150,000
110,000 120,000 130,000 150,000
110,000 120,000 130,000 150,000
300,000 325,000 350,000 400,000
110,000 120,000 130,000 150,000
200,000 225,000 250,000 300,000
200,000 225,000 250,000 300,000
Tarif Baru
600,000 625,000 650,000 700,000
200,000 225,000 250,000 300,000
200,000 225,000 250,000 300,000
200,000 225,000 250,000 300,000
200,000 225,000 250,000 300,000
200,000 225,000 250,000 300,000
200,000 225,000 250,000 300,000
300,000 325,000 350,000 400,000
200,000 225,000 250,000 300,000
150,000 160,000 170,000 200,000
150,000 160,000 170,000 200,000
750,000 850,000 900,000 1,000,000
150,000 160,000 170,000 200,000
150,000 160,000 170,000 200,000
150,000 160,000 170,000 200,000
300,000 325,000 350,000 400,000
110,000 120,000 130,000 150,000
110,000 120,000 130,000 150,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
2,048,750 2,548,750 3,048,750 3,548,750
3,575,000 4,075,000 4,575,000 5,075,000
3,575,000 4,075,000 4,575,000 5,075,000
825,000 1,325,000 1,825,000 2,325,000
4,730,000 5,230,000 5,730,000 6,230,000
2,750,000 3,250,000 3,750,000 4,250,000
2,640,000 3,140,000 3,640,000 4,140,000
1,430,000 1,930,000 2,430,000 2,930,000
2,048,750 2,548,750 3,048,750 3,548,750
1,650,000 2,150,000 2,650,000 3,150,000
2,750,000 3,250,000 3,750,000 4,250,000
1,430,000 1,930,000 2,430,000 2,930,000
1,650,000 2,150,000 2,650,000 3,150,000
1,567,500 2,067,500 2,567,500 3,067,500
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
1,430,000 1,930,000 2,430,000 2,930,000
2,200,000 2,700,000 3,200,000 3,700,000
2,145,000 2,645,000 3,145,000 3,645,000
2,585,000 3,085,000 3,585,000 4,085,000
3,410,000 3,910,000 4,410,000 4,910,000
1,744,875 2,244,875 2,744,875 3,244,875
2,585,000 3,085,000 3,585,000 4,085,000
2,585,000 3,085,000 3,585,000 4,085,000
2,365,000 2,865,000 3,365,000 3,865,000
2,750,000 3,250,000 3,750,000 4,250,000
2,585,000 3,085,000 3,585,000 4,085,000
4,950,000 5,450,000 5,950,000 6,450,000
1,689,875 2,189,875 2,689,875 3,189,875
3,575,000 4,075,000 4,575,000 5,075,000
1,925,000 2,425,000 2,925,000 3,425,000
2,750,000 3,250,000 3,750,000 4,250,000
4,950,000 5,450,000 5,950,000 6,450,000
2,750,000 3,250,000 3,750,000 4,250,000
2,241,250 2,741,250 3,241,250 3,741,250
1,760,000 2,260,000 2,760,000 3,260,000
3,630,000 4,130,000 4,630,000 5,130,000
3,850,000 4,350,000 4,850,000 5,350,000
1,925,000 2,425,000 2,925,000 3,425,000
1,650,000 2,150,000 2,650,000 3,150,000
605,000 907,500 1,361,250 2,041,875
1,567,500 2,067,500 2,567,500 3,067,500
4,950,000 5,450,000 5,950,000 6,450,000
1,925,000 2,425,000 2,925,000 3,425,000
2,475,000 2,975,000 3,475,000 3,975,000
1,993,750 2,493,750 2,993,750 3,493,750
2,750,000 3,250,000 3,750,000 4,250,000
1,375,000 1,875,000 2,375,000 2,875,000
1,375,000 1,875,000 2,375,000 2,875,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
2,500,000 3,000,000 3,600,000 4,320,000
1,750,000 2,100,000 2,520,000 3,024,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
1,056,000 1,556,000 2,056,000 2,556,000
1,540,000 2,040,000 2,540,000 3,040,000
3,740,000 4,240,000 4,740,000 5,240,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
6,160,000 6,660,000 7,160,000 7,660,000
3,465,000 3,965,000 4,465,000 4,965,000
3,905,000 4,405,000 4,905,000 5,405,000
3,300,000 3,800,000 4,300,000 4,800,000
4,730,000 5,230,000 5,730,000 6,230,000
907,500 1,407,500 1,907,500 2,407,500
4,215,750 4,715,750 5,215,750 5,715,750
3,300,000 3,800,000 4,300,000 4,800,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
2,750,000 3,250,000 3,750,000 4,250,000
4,950,000 5,450,000 5,950,000 6,450,000
1,925,000 2,425,000 2,925,000 3,425,000
1,650,000 2,150,000 2,650,000 3,150,000
8,250,000 8,750,000 9,250,000 9,750,000
4,950,000 5,450,000 5,950,000 6,450,000
1,925,000 2,425,000 2,925,000 3,425,000
4,950,000 5,450,000 5,950,000 6,450,000
2,475,000 2,975,000 3,475,000 3,975,000
2,750,000 3,250,000 3,750,000 4,250,000
2,475,000 2,975,000 3,475,000 3,975,000
1,952,500 2,452,500 2,952,500 3,452,500
2,200,000 2,700,000 3,200,000 3,700,000
1,650,000 2,150,000 2,650,000 3,150,000
8,250,000 8,750,000 9,250,000 9,750,000
701,250 1,201,250 1,701,250 2,201,250
2,750,000 3,250,000 3,750,000 4,250,000

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
26,000 26,000 26,000 26,000
26,000 26,000 26,000 26,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
26,000 26,000 26,000 26,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
16,000 16,000 16,000 16,000
30,000 30,000 30,000 30,000
30,000 30,000 30,000 30,000 TARIF BARU

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
2,500,000 2,500,000 2,500,000 2,500,000 PERUBAHAN TARIF
5,000,000 5,000,000 5,000,000 5,000,000 TARIF BARU
15,000,000 15,000,000 15,000,000 15,000,000 PERUBAHAN TARIF
1,700,000 1,700,000 1,700,000 1,700,000 PERUBAHAN TARIF
2,500,000 2,500,000 2,500,000 2,500,000 PERUBAHAN TARIF
7,500,000 7,500,000 7,500,000 7,500,000 PERUBAHAN TARIF
1,900,000 1,900,000 1,900,000 1,900,000
1,000,000 1,000,000 1,000,000 1,000,000 PERUBAHAN TARIF
5,000,000 5,000,000 5,000,000 5,000,000 TARIF BARU
15,000,000 15,000,000 15,000,000 15,000,000 TARIF BARU
2,500,000 2,500,000 2,500,000 2,500,000 TARIF BARU
700,000 700,000 700,000 700,000 TARIF BARU
800,000 800,000 800,000 800,000 PERUBAHAN TARIF
500,000 500,000 500,000 500,000 PERUBAHAN TARIF
3,750,000 3,750,000 3,750,000 3,750,000 TARIF BARU
700,000 700,000 700,000 700,000
700,000 700,000 700,000 700,000
25,000 25,000 25,000 25,000 TARIF BARU
500,000 500,000 500,000 500,000 TARIF BARU
250,000 250,000 250,000 250,000 TARIF BARU
3,500,000 3,500,000 3,500,000 3,500,000 PERUBAHAN TARIF
2,750,000 2,750,000 2,750,000 2,750,000 PERUBAHAN TARIF
250,000 250,000 250,000 250,000
2,500,000 2,500,000 2,500,000 2,500,000 TARIF BARU
3,750,000 3,750,000 3,750,000 3,750,000 TARIF BARU
75,000 75,000 75,000 75,000 PERUBAHAN TARIF
165,000 165,000 165,000 165,000 TARIF BARU
650,000 650,000 650,000 650,000 PERUBAHAN TARIF
750,000 750,000 750,000 750,000 PERUBAHAN TARIF
300,000 300,000 300,000 300,000
800,000 800,000 800,000 800,000 TARIF BARU
950,000 950,000 950,000 950,000 TARIF BARU
200,000 200,000 200,000 200,000 TARIF BARU
75,000 75,000 75,000 75,000 TARIF BARU
75,000 75,000 75,000 75,000 TARIF BARU
100,000 100,000 100,000 100,000 TARIF BARU
100,000 100,000 100,000 100,000 TARIF BARU
75,000 75,000 75,000 75,000 TARIF BARU
100,000 100,000 100,000 100,000 TARIF BARU
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
30,000 30,000 30,000 30,000 PERUBAHAN TARIF

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
7,500 20,000 27,500 35,000 PERUBAHAN TARIF
10,000 10,000 10,000 10,000 PERUBAHAN TARIF
10,000 10,000 10,000 10,000 PERUBAHAN TARIF
25,000 25,000 25,000 25,000
25,000 25,000 25,000 25,000 PERUBAHAN TARIF
25,000 25,000 25,000 25,000 PERUBAHAN TARIF
12,000 12,000 12,000 12,000 PERUBAHAN TARIF
25,500 25,500 25,500 25,500
17,000 17,000 17,000 17,000 PERUBAHAN TARIF
20,000 20,000 20,000 20,000
10,000 10,000 10,000 10,000
10,000 10,000 10,000 10,000
10,000 10,000 10,000 10,000 PERUBAHAN TARIF
10,000 10,000 10,000 10,000 PERUBAHAN TARIF
10,000 10,000 10,000 10,000 PERUBAHAN TARIF
10,000 10,000 15,000 20,000 PERUBAHAN TARIF
10,000 10,000 10,000 10,000 TARIF BARU

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
17,000 17,000 17,000 17,000
24,000 24,000 24,000 24,000
35,000 35,000 35,000 35,000
288,000 288,000 288,000 288,000
58,000 58,000 58,000 58,000
52,000 52,000 52,000 52,000
155,000 155,000 155,000 155,000
72,000 72,000 72,000 72,000
58,000 58,000 58,000 58,000
21,000 21,000 21,000 21,000
25,000 25,000 25,000 25,000
14,000 14,000 14,000 14,000
14,000 14,000 14,000 14,000
14,000 14,000 14,000 14,000
150,000 150,000 150,000 150,000
25,000 25,000 25,000 25,000
127,000 127,000 127,000 127,000
21,000 21,000 21,000 21,000
15,000 15,000 15,000 15,000
18,000 18,000 18,000 18,000
58,000 58,000 58,000 58,000
46,000 46,000 46,000 46,000
17,000 17,000 17,000 17,000
15,000 15,000 15,000 15,000
15,000 15,000 15,000 15,000
15,000 15,000 15,000 15,000
52,000 52,000 52,000 52,000
45,000 45,000 45,000 45,000
21,000 21,000 21,000 21,000
45,000 45,000 45,000 45,000
230,000 230,000 230,000 230,000
48,000 48,000 48,000 48,000 PERUBAHAN TARIF
48,000 48,000 48,000 48,000
250,000 250,000 250,000 250,000
58,000 58,000 58,000 58,000
21,000 21,000 21,000 21,000
15,000 15,000 15,000 15,000
35,000 35,000 35,000 35,000
48,000 48,000 48,000 48,000
17,000 17,000 17,000 17,000
10,000 10,000 10,000 10,000
17,000 17,000 17,000 17,000
35,000 35,000 35,000 35,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
25,000 25,000 25,000 25,000
20,000 20,000 20,000 20,000
20,000 20,000 20,000 20,000
45,000 45,000 45,000 45,000
99,000 99,000 99,000 99,000
99,000 99,000 99,000 99,000
25,000 25,000 25,000 25,000
21,000 21,000 21,000 21,000
24,000 24,000 24,000 24,000
113,000 113,000 113,000 113,000
20,000 20,000 20,000 20,000
25,000 25,000 25,000 25,000
25,000 25,000 25,000 25,000
207,000 207,000 207,000 207,000
40,000 40,000 40,000 40,000
40,000 40,000 40,000 40,000
316,000 316,000 316,000 316,000
86,000 86,000 86,000 86,000
121,000 121,000 121,000 121,000
180,000 180,000 180,000 180,000
20,000 20,000 20,000 20,000 TARIF BARU
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
200,000 200,000 200,000 200,000
300,000 300,000 300,000 300,000
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
500,000 500,000 500,000 500,000
90,000 90,000 90,000 90,000
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
750,000 750,000 750,000 750,000
100,000 100,000 100,000 100,000
90,000 90,000 90,000 90,000
100,000 100,000 100,000 100,000
500,000 500,000 500,000 500,000
75,000 75,000 75,000 75,000
100,000 100,000 100,000 100,000
250,000 250,000 250,000 250,000 PERUBAHAN TARIF
700,000 700,000 700,000 700,000
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
120,000 100,000 100,000 100,000 PERUBAHAN TARIF
550,000 550,000 550,000 550,000
90,000 90,000 90,000 90,000
400,000 400,000 400,000 400,000
95,000 95,000 95,000 95,000
70,000 70,000 70,000 70,000
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
80,000 80,000 80,000 80,000
90,000 90,000 90,000 90,000
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
90,000 90,000 90,000 90,000
100,000 100,000 100,000 100,000
175,000 175,000 175,000 175,000
100,000 100,000 100,000 100,000
150,000 150,000 150,000 150,000
100,000 100,000 100,000 100,000
75,000 75,000 75,000 75,000
125,000 125,000 125,000 125,000
150,000 150,000 150,000 150,000
400,000 400,000 400,000 400,000
60,000 60,000 60,000 60,000
500,000 500,000 500,000 500,000
375,000 375,000 375,000 375,000
200,000 200,000 200,000 200,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
250,000 250,000 250,000 250,000 PERUBAHAN TARIF
200,000 200,000 200,000 200,000
250,000 250,000 250,000 250,000 PERUBAHAN TARIF
300,000 300,000 300,000 300,000
90,000 90,000 90,000 90,000
160,000 160,000 160,000 160,000
90,000 90,000 90,000 90,000
160,000 160,000 160,000 160,000
90,000 90,000 90,000 90,000
160,000 160,000 160,000 160,000
90,000 90,000 90,000 90,000
160,000 160,000 160,000 160,000
90,000 90,000 90,000 90,000
160,000 160,000 160,000 160,000
100,000 100,000 100,000 100,000
100,000 100,000 100,000 100,000
250,000 250,000 250,000 250,000
100,000 100,000 100,000 100,000
225,000 225,000 225,000 225,000
150,000 150,000 150,000 150,000
100,000 100,000 100,000 100,000
100,000 100,000 100,000 100,000
100,000 100,000 100,000 100,000
100,000 100,000 100,000 100,000
225,000 225,000 225,000 225,000
225,000 225,000 225,000 225,000 PERUBAHAN TARIF
225,000 225,000 225,000 225,000
150,000 150,000 150,000 150,000
150,000 150,000 150,000 150,000
100,000 100,000 100,000 100,000
120,000 120,000 120,000 120,000 PERUBAHAN TARIF
200,000 200,000 200,000 200,000 PERUBAHAN TARIF
100,000 100,000 100,000 100,000
125,000 125,000 125,000 125,000
125,000 125,000 125,000 125,000
225,000 225,000 225,000 225,000 PERUBAHAN TARIF
225,000 225,000 225,000 225,000
300,000 300,000 300,000 300,000
300,000 300,000 300,000 300,000
400,000 400,000 400,000 400,000
300,000 300,000 300,000 300,000
300,000 300,000 300,000 300,000
300,000 300,000 300,000 300,000
400,000 400,000 400,000 400,000
300,000 300,000 300,000 300,000
400,000 400,000 400,000 400,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
300,000 300,000 300,000 300,000
300,000 300,000 300,000 300,000
120,000 120,000 120,000 120,000 PERUBAHAN TARIF

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
30,000 36,000 43,200 51,840
30,000 36,000 43,200 51,840
100,000 120,000 144,000 172,800
100,000 120,000 144,000 172,800
100,000 120,000 144,000 172,800
100,000 120,000 144,000 172,800
100,000 120,000 144,000 172,800
150,000 180,000 216,000 259,200
30,000 36,000 43,200 51,840
30,000 36,000 43,200 51,840
30,000 36,000 43,200 51,840

RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
140,000 140,000 140,000 140,000
150,000 180,000 216,000 259,200
40,000 48,000 57,600 69,120
75,000 75,000 75,000 75,000
30,000 30,000 30,000 30,000
1,200,000 1,440,000 1,728,000 2,073,600
350,000 420,000 504,000 604,800
200,000 240,000 288,000 345,600
300,000 300,000 300,000 300,000
500,000 500,000 500,000 500,000
260,000 260,000 260,000 260,000
10,000 10,000 10,000 10,000
100,000 100,000 100,000 100,000
15,000 15,000 15,000 15,000
6,000 6,000 6,000 6,000
15,000 15,000 15,000 15,000

TARIF BARU (Rp)

SMA DIPLOMA S1 S2 S3
50,000 100,000 150,000 200,000 300,000
50,000 150,000 150,000 150,000 150,000
- 150,000 200,000 250,000 350,000
 RAWAT INAP
KET
KELAS 3 KELAS 2 KELAS 1 VIP
100,000 150,000 200,000 250,000 350,000