LAMPIRAN 01 Pelayanan Kesehatan

LAMPIRAN I
PERATURAN DAERAH KABUPATEN PEKALONGAN

NOMOR 1 TAHUN 2012
TENTANG RETRIBUSI DAERAH
BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN

PUSKESMAS DAN JARINGANYA DI KABUPATEN PEKALONGAN
TARIF
NO JENIS PELAYANAN
Jasa Sarana Jasa Pelayanan Jumlah
I Rawat Jalan Puskesmas
Biaya Pelayanan Rawat Jalan 1,500 1,500 3,000
( Administrasi, pemeriksaan dan obat)
II Biaya Rawat Inap
a. Sewa kamar / hari kelas III 10,000 5,000 15,000
Sewa kamar / hari kelas II 15,000 7,500 22,500
Sewa kamar / hari kelas I 20,000 10,000 30,000
b. Bangsal UGD 10,000 5,000 15,000
d. Asuhan Keperawatan 10,000 10,000
III TINDAKAN
1. Pertolongan Pertama
a. Debridemen luka 5,000 5,000 10,000
b. Jahitan kurang dari 5 7,500 7,500 15,000
c. Jahitan 5 sampai 10 10,000 10,000 20,000
d. Jahitan lebih dari 10 ( d tambah perjahitan Rp 1000,-)
f. Cross Insisi 7,500 7,500 15,000
i. Ransel verband 10,000 10,000 20,000
j. Spalk 6,000 6,000 12,000
k.Gigitan Binatang 6,250 6,250 12,500
l. Luka Bakar 11,750 11,750 23,500
m. Lain-lain yang termasuk ringan 5,000 5,000 10,000
n. RJP 5,000 5,000 10,000
2. Tindakan Umum
a. Perawatan Luka lama 5,000 5,000 10,000
b. Insisi dengan anestesi lokal 10,000 10,000 20,000
c. Insisi tanpa anestesi 6,250 6,250 12,500
d. Exterpasi Corpus Allenium 5,000 5,000 10,000
e. Lepas jahitan per kegiatan 5,000 5,000 10,000
f. Pasang Kateter 5,000 5,000 10,000
g. Lavement 5,000 5,000 10,000
h. Skorstain 5,000 5,000 10,000
i. Resusitasi 10,000 10,000 20,000
j. Sirkumsisi ( Khitan ) 50,000 50,000 100,000
k. Ektraksi kuku 7,500 7,500 15,000
l. Operasi kecil ( lipoma aeteroma ) 25,000 25,000 50,000
m. Operasi Katarak 150,000 150,000 300,000
n. Pasang Infus 5,000 5,000 10,000
o. Tindik telinga sepasang 5,000 5,000 10,000
p. Penggunaan Oksigen Per Liter 5,000 5,000 10,000
q. Nabulezer 5,000 5,000 10,000
r. EKG (elektrokardiograf) 7,500 7,500 15,000
s. Radiologi
a. Thorax / AP 10,000 15,000 25,000
b. Thorax AP/LAT 20,000 25,000 45,000
c. BNO tanpa kontas 10,000 15,000 25,000
d. Ekstremitas 10,000 15,000 25,000
3. Tindakan Kebidanan dan KB
a. Persalinan Normal 125,000 125,000 250,000
b. Persalinan dengan penyulit 175,000 175,000 350,000
c. Manual Placenta 25,000 25,000 50,000
d. Tindakan ringan kebidanan 5,000 5,000 10,000
e. Pasang implant 7,500 7,500 15,000
f. Cabut Impalnt 10,000 10,000 20,000
g. Pasang IUD/ Spiral 10,000 10,000 20,000
h. Cabut IUD/Spiral 12,500 12,500 25,000
i. Curetase/Abourtus 50,000 50,000 100,000
j. Papssmear 12,500 12,500 25,000
k. Vasektomi 25,000 25,000 50,000
l. Suntik KB Mandiri 6,000 6,000 12,000
m. Tindakan pengalolaan bayi baru lahir 12,500 12,500 25,000
n. Persalinan dengan resiko tinggi yang ditangani
Puskesmas PONED 175,000 175,000 350,000
o. Deteksi Dini kamker rahim 7,500 7,500 15,000
p. Tindakan Creoterapi 25,000 25,000 50,000
q. Konsultasi Dokter Spesialis 5,000 10,000 15,000
IV TINDAKAN GIGI
A. Penambalan Gigi Permanen
- Amalgam 10,000 10,000 20,000
- Glass ionomer 15,000 15,000 30,000
- Komposit / laser 20,000 20,000 40,000
b. Penambalan gigi susu
- Amalgam 7,500 7,500 15,000
- Glass ionomer 10,000 10,000 20,000
- Komposit / laser 15,000 15,000 30,000
c. Perawatan syaraf gigi
- Perawatan syaraf gigi vital tiap tahap 5,000 5,000 10,000
- Perawatan syaraf gigi non vital tiap tahap 6,250 6,250 12,500
d. Penambalan gigi sementara
- gigi permanen 6,250 6,250 12,500
- gigi susu 5,000 5,000 10,000
e. Pencabutan gigi susu
- dengan injeksi anestesi 7,500 7,500 15,000
- dengan topikal anestesi 6,250 6,250 12,500
f. Pencabutan gigi permanen
- tanpa penyulit 12,500 12,500 25,000
- dengan penyulit 25,000 25,000 50,000
g. Tindakan lain
- Pembersihan karang gigi per rahang 10,000 10,000 20,000
- Grinding 5,000 5,000 10,000
- Jahit operasi kurang dari 5 7,500 7,500 15,000
- Jahit operasi 5 sampai 10 10,000 10,000 20,000
- Lepas jahitan operasi 5,000 5,000 10,000
- Incisi abses intra oral 7,500 7,500 15,000
- Incisi abses extra oral 25,000 25,000 50,000
- Perawatan pasca incisi 5,000 5,000 10,000
- Operasi Impected Mesio Angular 100,000 100,000 200,000
- Overculectomy 100,000 100,000 200,000
- Operasi epulis 25,000 25,000 50,000
- Kuretase dry socket 12,500 12,500 25,000
- Perawatan gigi abses 5,000 5,000 10,000
V Pemeriksaan Laboratorium
A Hematologi ( Darah )
1 Darah Lengkap Rp 1,750 Rp 1,500 Rp 3,250
2 Hb Sahli Rp 1,750 Rp 6,500 Rp 8,250
3 Hb. Hemoque Rp 1,750 Rp 1,500 Rp 3,250
4 Leukosit Rp 1,750 Rp 1,500 Rp 3,250
5 Eritrosit Rp 1,750 Rp 1,500 Rp 3,250
6 LED Rp 1,750 Rp 1,500 Rp 3,250
7 Hitung jenis / Diffcount Rp 2,250 Rp 2,000 Rp 4,250
8 Trombosit Rp 1,750 Rp 2,000 Rp 3,750
9 Hematokrit Rp 750 Rp 1,250 Rp 2,000
10 Retikulosit Rp 750 Rp 1,250 Rp 2,000
11 Hitung Eosinofil Rp 750 Rp 1,250 Rp 2,000
12 Golongan Darah Rp 2,000 Rp 1,500 Rp 3,500
13 Waktu perdarahan ( BT ) Rp 2,000 Rp 1,350 Rp 3,350
14 Waktu pembekuan ( CT ) Rp 2,000 Rp 1,350 Rp 3,350
B Urine
1 Reduksi I Rp 1,000 Rp 1,000 Rp 2,000
2 Reduksi II Rp 1,000 Rp 1,000 Rp 2,000
3 Reduksi sewaktu Rp 1,000 Rp 1,000 Rp 2,000
4 PH Rp 1,000 Rp 1,000 Rp 2,000
5 Protein Rp 1,000 Rp 1,000 Rp 2,000
6 Bilirubin Rp 1,000 Rp 1,000 Rp 2,000
7 Urobilin Rp 1,000 Rp 1,000 Rp 2,000
8 Urin Combur Rp 1,000 Rp 3,500 Rp 4,500
9 Urin Sedimen Rp 1,000 Rp 1,000 Rp 2,000
C Kimia Klinik
1 Gula Darah Rp 2,500 Rp 3,000 Rp 5,500
- Terumo
- Cair
2 Gula darah Stik Rp 2,500 Rp 3,900 Rp 6,400
Accuntrend
3 Cholesterol ( Stik ) Rp 500 Rp 5,500 Rp 6,000
4 Cholesterol ( Cair ) Rp 500 Rp 3,600 Rp 4,100
5 Trigliseride ( Stik ) Rp 500 Rp 6,600 Rp 7,100
6 Trigliseride ( Cair ) Rp 500 Rp 4,800 Rp 5,300
7 SGOT Rp 750 Rp 3,250 Rp 4,000
8 SGPT Rp 750 Rp 3,375 Rp 4,125
9 Asam Urat Rp 500 Rp 4,200 Rp 4,700
10 Ureum Rp 750 Rp 3,375 Rp 4,125
11 Creatinin Rp 750 Rp 3,375 Rp 4,125
12 Albumin Rp 750 Rp 2,750 Rp 3,500
13 Total Protein Rp 750 Rp 2,250 Rp 3,000
14 Bilirubin D / T Rp 750 Rp 5,750 Rp 6,500
15 HDL - LDL Rp 750 Rp 5,750 Rp 6,500
D Serologi
1 Dengue Blood Rp 750 Rp 32,750 Rp 33,500
Ig G dan Ig M
2 Test Kehamilan Rp 1,300 Rp 2,200 Rp 3,500
3 Widal ( 3 Jenis ) Rp 3,500 Rp 4,500 Rp 8,000
4 Narkoba ( 6 Parameter ) Rp 1,000 Rp 30,000 Rp 31,000
5 HBSAg Rp 1,750 Rp 5,250 Rp 7,000
6 Anti HBsAg Rp 1,000 Rp 10,250 Rp 11,250
7 ASTO Rp 1,000 Rp 10,250 Rp 11,250
VI LAIN-LAIN
A. Pembuatan Visum et Repertum
a. Visum luar hidup 3,750 3,750 7,500
b. Visum luar mati 7,500 7,500 15,000
B. Pengujian Kesehatan
a. Kir Pelajar/ Mahasiswa 2,000 2,000 4,000
b. Kir melamar pekerjaan/ pekerjaan lain 7,500 7,500 15,000
c. Kir calon pengantin 10,000 10,000 20,000
d. Kir Calon Haji tahap I 5,000 10,000 15,000
e. Kir Calon Haji tahap II 25,000 25,000 50,000
C. Surat Keterangan Kematian 2,500 2,500 5,000
D. Sewa Ambulance
- kurang dari 30 km 25,000 25,000 50,000
- 31-50 km 35,000 35,000 70,000
- selebihnya per 1 km 1,000 1,000 2,000
Keterangan
- Tarif retribusi untuk tindakan pada bayi barulahir
sebesar 50 % dari tindakan Dokter atau Bidan yang
melaksanakan
- Jasa konsul Dokter sesuai dengan jasa dokter
- Tarif tindakan untuk penderita dibangsal rawat inap ditentukan
sama dengan yang lainnya
- Jasa pemeriksaan laboratorium untuk penderita rawat inap
sama dengan yang lain
- Tarif tersebut belum termasuk bahan habis pakai

UPT LABORATORIUM KESEHATAN DAERAH KABUPATEN PEKALONGAN
JASA
JENIS PELAYANAN TARIF ( Rp )
PRASARANA PELAYANAN
I. PELAYANAN PEMERIKSAAN
LABORATORIUM
1 Darah Rutin Rp 1,750 Rp 5,000 Rp 6,750
3 Hb Sahli Rp 1,750 Rp 6,500 Rp 8,250
Hb. Hemoque Rp 1,750 Rp 1,500 Rp 3,250
4 Leukosit Rp 1,750 Rp 1,500 Rp 3,250
6 LED Rp 1,750 Rp 1,500 Rp 3,250
B Urine
1 Urine rutin Rp 1,000 Rp 2,700 Rp 3,700
2 Reduksi I Rp 1,000 Rp 1,000 Rp 2,000
5 PH Rp 1,000 Rp 1,000 Rp 2,000
6 Protein Rp 1,000 Rp 1,000 Rp 2,000
8 Urobilin Rp 1,000 Rp 1,000 Rp 2,000
C Kimia Klinik
- Terumo
- Cair
Accuntrend
7 SGOT Rp 750 Rp 3,250 Rp 4,000
8 SGPT Rp 750 Rp 3,375 Rp 4,125
9 Asam Urat Rp 500 Rp 4,200 Rp 4,700
10 Ureum Rp 750 Rp 3,375 Rp 4,125
12 Albumin Rp 750 Rp 2,750 Rp 3,500
15 HDL - LDL Rp 750 Rp 5,750 Rp 6,500
D Serologi
Ig G dan Ig M
5 HBSAg Rp 1,750 Rp 5,250 Rp 7,000
7 ASTO Rp 1,000 Rp 10,250 Rp 11,250
E Mikrobiologi
1 BTA Paru Rp 2,300 Rp 1,700 Rp 4,000
2 BTA Kusta Rp 1,300 Rp 1,700 Rp 3,000
3 Malaria Rp 1,300 Rp 1,700 Rp 3,000
4 Faeces ( Telur cacing ) Rp 1,300 Rp 1,700 Rp 3,000
5 Mikrofilaria Rp 1,300 Rp 1,700 Rp 3,000
F Pemeriksaan Air
1 Fisik Rp 2,500 Rp 5,000 Rp 7,500
Bau, Rasa, Suhu, Warna, Kekeruhan
2 Bakteriologi Rp 2,500 Rp 8,500 Rp 11,000
3 Secara Kimiawi
a Total Hardnes Rp 2,500 Rp 21,000 Rp 23,500
b Chlorine Rp 2,500 Rp 2,000 Rp 4,500
c Chloride Rp 2,500 Rp 6,000 Rp 8,500
d Mangan Rp 2,500 Rp 2,500 Rp 5,000
e Flour Rp 2,500 Rp 6,000 Rp 8,500
f Fe Rp 2,500 Rp 4,000 Rp 6,500
g NO 2 sebagai Nitrit Rp 2,500 Rp 2,000 Rp 4,500
h NO 3 sebagai Nitrat Rp 2,500 Rp 7,000 Rp 9,500
i NH 4 Rp 2,500 Rp 8,000 Rp 10,500
j Cyanida Rp 2,500 Rp 6,000 Rp 8,500
k PH Rp 2,500 Rp 1,000 Rp 3,500
G Pemeriksaan Makmin
1 Borak Rp 1,500 Rp 3,500 Rp 5,000
2 Formalin Rp 1,500 Rp 3,500 Rp 5,000
3 Pewarna Rp 1,500 Rp 3,500 Rp 5,000
4 Pemanis ( Sakarin ) Rp 1,500 Rp 3,500 Rp 5,000
II. PELAYANAN MOBILE LABORATORIUM
A KIMIA AIR
d Mangan Rp 5,000 Rp 5,000 Rp 10,000
e Flour Rp 5,000 Rp 8,500 Rp 13,500
f Fe Rp 5,000 Rp 6,500 Rp 11,500
i NH 4 Rp 5,000 Rp 10,500 Rp 15,500
j Cyanida Rp 5,000 Rp 8,500 Rp 13,500
k PH Rp 5,000 Rp 3,500 Rp 8,500
B PEMERIKSAAN MAKMIN
1 Borak Rp 6,500 Rp 8,500 Rp 15,000
2 Formalin Rp 6,500 Rp 8,500 Rp 15,000
3 Pewarna Rp 6,500 Rp 8,500 Rp 15,000
NB : Tarif tersebut belum Reagent dan bahan habis pakai.

RUMAH SAKIT PEMERINTAHAN TIPE C DAN D
A. Pemeriksaan.
No. Katagori Jasa Jasa Tarif
Pelayanan Sarana Pelayanan ( Rp. )
1 2 3 4 5
1 Poli Umum 5,000 10,000 15,000
2 Poli Spesialis 5,000 15,000 20,000
3 Poli Gigi 5,000 10,000 15,000
Keterangan :
1 Tarif tersebut untuk 1 (satu) kali Pemeriksaan.
2 Tarif tersebut belum termasuk Tindakan Medis, Pemeriksaan Penunjang, Obat & Bahan Habis Pakai.
3 Tarif Konsultasi Paviliun 3 kali lipat tarif dasar
B. Tindakan Rawat Jalan

1. Tarif tindakan di Poliklinik Spesialis
1 2 3 4 5
1 Sederhana 5,000 20,000 25,000
2 Kecil 10,000 45,000 55,000
3 Sedang 20,000 100,000 120,000
2. Tarif tindakan di poliklinik gigi dan mulut

1 2 3 4 5
1 Sederhana 6,000 11,000 17,000
2 Kecil 1 10,000 20,000 30,000
3 Kecil 2 20,000 30,000 50,000
4 Sedang 30,000 50,000 80,000
Catatan :
1. Tarif pelayanan tindakan medis tersebut diatas adalah untuk satu kali tindakan.
2. Besarnya tarif pelayanan Tindakan Medis di Poliklinik yang bersifat amat segera/ Cito ditambah
25 % dari tarif masing-masing katagori pelayanan.
3. Tarif tindakan paviliun 2 kali tarif dasar
3. Tarif Hemodialisa
Pelayanan Sarana Pelayanan (Rp.)
1 2 3 4 5
1. Non VIP 140,000 200,000 340,000
2. VIP 140,000 260,000 400,000
3. VVIP 140,000 300,000 440,000
Catatan :
1. Tarif tersebut diatas adalah untuk satu kali tindakan.
2 Tarif tersebut belum termasuk bahan habis pakai.
3. Besarnya tarif pelayanan Tindakan Medis yang bersifat amat segera ditambah
25 % dari tarif masing-masing katagori pelayanan dan kelas perawatannya.
4. Tarif pelayanan tindakan medis pasien rawat inap menyesuaikan kelas perawatannya.
5. Obat dan bahan habis pakai untuk tindakan operatif akan diresepkan.
4. Tarif tindakan medis non operatif.

1 2 3 4 5
1 Sederhana 3,000 7,000 10,000

2 Kecil 4,000 9,000 13,000
3 Sedang 9,000 20,000 29,000
Catatan :
1. Tarif pelayanan tindakan medis non operatif tersebut diatas adalah untuk satu kali tindakan.
2. Besarnya tarif pelayanan Tindakan Medis operatif non operatif yang bersifat amat segera
ditambah 25 % dari tarif masing-masing katagori pelayanan.
II. Rawat Darurat.
1. Pemeriksaan.
1 2 3 4 5
1 Dokter Umum 5,000 15,000 20,000
2 Dokter Spesialis 5,000 25,000 30,000
3 Dokter Gigi dan Mulut 5,000 15,000 20,000
2. Tindakan Medis di IGD.

1 2 3 4 5
1 Sederhana 5,000 10,000 15,000
3 Kecil 10,000 15,000 25,000
4 Sedang 30,000 40,000 70,000
Catatan :
1. Tarif pelayanan tindakan medis operatif tersebut diatas adalah untuk satu kali tindakan.
2. Tarif pelayanan tindakan medis rawat inap menyesuaikan kelas perawatannya
4 Tarif tindakan medis non operatif di IGD disesuakan dengan tarif tindakan medis non operatif rawat jalan
III. Akomodasi Rawat Inap

No. Kelas Tarif
( Rp. )
1 2 3
1 III 10,000
2 II. 20,000
3 I. 40,000
5 VIP. 120,000
6 VVIP. 150,000 150,000
Catatan :
1. Tarif tersebut diatas belum termasuk biaya makan / gizi.
2. Setiap pasien rawat inap dikenakan biaya adminsitrasi kelas III s/d kelas II : Rp. 5.000,- Kelas I
sebesar Rp. 10.000,- untuk pasien ruang Intensif dan untuk VIP sebesasr Rp. 15.000,-
3. Khusus bagi penderita rawat inap kleas I, dan VIP terlebih dahulu diwajibkan membayar dimuka
biaya perawatan yang diperhitungkan selama 5 ( lima ) hari perawatan.
4. Apabila waktu 5 ( lima ) hari sebagaimana dimaksud pada point 2 berakhir dan rawat inap diteruskan,
penderita diwajibkan membayar perawatan untuk 5 (lima) hari berikutnya dan demikian seterusnya.
5. Jumlah hari rawat inap dihitung mulai penderita masuk rawat inap sampai dengan penderita keluar dari RSU
6. Bayi normal dan sehat yang dilahirkan di RSUD dikenakan tarif rawat inap sebesar 50 % ( lima puluh
persen ) dari tarif kelas perawatan yang ditempati ibunya.
7. Untuk bayi bermasalah yang memerlukan perawatan khusus dikenakan biaya rawat inap sebesar tarif
kelas perawatan yang ditempati ibunya.
8. Penunggu pasien dikenakan biaya akomodasi sebesasr Rp. 5.000,- setiap hari.
9. biaya akomodasi belum termasuk biaya loundry
IV. Loundry
No. Katagori Jasa Sarana Jasa Pelayanan Tarif
Pelayanan ( Rp. )
1 2 3 4 5
A. Paket pelayanan loundry 1 x pelayanan 1500 2500 4000
Catatan
1. Biaya paket pelayanan londry meliputi pelayanan loundry rawat inap dan atau pelayanan loundry
kamar operasi/ VK bila pasien mendapatkan tindakan operasi/persalinan
2. Biaya loundry dihitung sesuai jumlah paket pelayanan loundry
Visite / Konsul.
Pelayanan ( Rp. )
1 2 3 4 5
A. Dokter Spesialis.
III 10,000 15,000 25,000
II. 10,000 20,000 30,000
I. 10,000 30,000 40,000
VIP 10,000 40,000 50,000
VVIP 10,000 55,000 65,000
B. Dokter Sub Spesialis
III 10,000 30,000 40,000
II. 10,000 40,000 50,000
I. 10,000 55,000 65,000
VIP 10,000 80,000 90,000
VVIP 10,000 100,000 110,000
C. Dokter Umum/Gigi.
III 10,000 8,000 18,000
II. 10,000 11,000 21,000
I. 10,000 15,000 25,000
VIP 10,000 22,000 32,000
VVIP 10,000 30,000 40,000
Catatan :
1. Tarif tersebut diatas adalah tarif untuk satu kali pemeriksaan/konsultasi.
2. Konsultasi medis per telpon dihitung sama dengan satu kali konsultasi/visite dan maksimal dipungut
satu kali dalam 24 jam sejak konsultasi terakhir.
Pelayanan Makanan Pasien

Pelayanan ( Rp. )
1 2 3 4 5
1 III 3,000 5,000 8,000
2 II 3,000 7,000 10,000
3 I 3,000 9,000 12,000
4 VIP 3,000 13,000 16,000
5 VVIP 3,000 17,000 20,000
Keterangan :
- Tarif tersebut untuk satu hari pelayanan gizi
IV. Tarif Asuhan Keperawatan

Jasa Sarana Jasa Tarif
No. Uraian Kelas Pelayanan ( Rp. )
1 2 3 4 5 6
1 TINGGI III 9,000 15,000 24,000
II 9,000 19,000 28,000
I 9,000 24,000 33,000
VIP 9,000 30,000 39,000
VVIP 9,000 38,000 47,000
2 SEDANG III 7,000 10,000 17,000
II 7,000 13,000 20,000
I 7,000 16,000 23,000
VIP 7,000 20,000 27,000
VVIP 7,000 25,000 32,000
3 RENDAH III 5,000 7,000 12,000
II 5,000 10,000 15,000
I 5,000 11,000 16,000
VIP 5,000 14,000 19,000
VVIP 5,000 18,000 23,000
4 ICU III 15,000 25,000 40,000
II 15,000 32,000 47,000
I 15,000 40,000 55,000
VIP 15,000 50,000 65,000
VVIP 15,000 62,000 77,000
Catatan :
1. Kriteria Asuhan Keperawatan Ketergantungan Rendah :
* Kebersihan diri, mandi, ganti pakaian, makan minum dilakukan sendiri
* Ambulasi dengan pengawasan minimal
* Observasi tanda - tanda vital dilakukan setiap shief
* Pengobatan minimal, status psikologis stabil
* Persiapan prosedur memerlukan pengobatan
2. Kriteria Asuhan Keperawatan Ketergantungan Sedang :
* Kebersihan diri dibantu, makan minum dibantu
* Ambulasi dibantu, pengobatan lebih dari sekali
* Volly chateter, nake out put dicatat.
* Klien dengan terpasang infus, persiapan pengobatan memerukan prosedur
3. Kriteria Asuhan Keperawatan Ketergantungan Tinggi :
* Segala diberikan / dibantu
* Makan minum memerukan NGT, terapi intravena.
* Pemakaian suction
* Gelisah / disorientasi
4. Asuhan Keperawatan ICU : Asuhan Keperawatan di ICU
V. TARIF RAWAT INTENSIF PELAYANAN DI RUANG ICU
Katagori Jasa Jasa Tarif
No.
1 2 3 4 5
1 Pasien dari Kelas III 110,000 40,000 150,000
2 Pasien dari Kelas II 180,000 46,000 226,000
3 Pasien dari Kelas I 250,000 50,000 300,000
4 Pasien dari Kelas VIP 275,000 60,000 335,000
5 Pasien dari Kelas VVIP 330,000 70,000 400,000
Keterangan :
1 Tarif tersebut untuk satu hari perawatan
2 Tarif tersebut tidak termasuk makan/minum, asuhan keperawatan,
penggunaan paket instrumentasi ICU, kecuali untuk ventilator diberi tarif khusus
Penderita IGD / Ruangan kelas III yg dimasukkan ke ICU ,
tarif disesuaikan dg tarif kls II
4 tarif tersebut belum termasuk obat, oksigen, tindakan medis, penunjang medis, bahan habis pakai
5 Bila diperlukan rawat bersama,maka besaran jasa dokter tersebut masing-masing sebesar jasa medis
VI. PENGGUNAAN ALAT VENTILATOR

No.
1 2 3 4 5
1 kelas 2 100,000 30,000 130,000
2 kelas 1 120,000 35,000 155,000
3 kelas VIP 130,000 50,000 180,000
4 kelas VVIP 150,000 60,000 210,000
VII. Tindakan Medis.

a. Tindakan Medis Operatif Umum
Kelas
No. Pelayanan Sarana Pelayanan ( Rp. )
1 2 3 4 5 6
1 Kecil III 25,000 130,000 155,000
II 35,000 165,000 200,000
I 45,000 195,000 240,000
VIP 50,000 245,000 295,000
VVIP 55,000 300,000 355,000
2 Sedang III 100,000 490,000 590,000
II 125,000 540,000 665,000
I 150,000 580,000 730,000
VIP 175,000 630,000 805,000
VVIP 200,000 700,000 900,000
3 Besar III 150,000 650,000 800,000
II 175,000 700,000 875,000
I 200,000 800,000 1,000,000
VIP 350,000 930,000 1,280,000
VVIP 400,000 1,000,000 1,400,000
4 Khusus III 200,000 930,000 1,130,000
II 300,000 1,000,000 1,300,000
I 350,000 1,200,000 1,550,000
VIP 600,000 1,400,000 2,000,000
VVIP 650,000 1,500,000 2,150,000
Keterangan
1 Tarif tersebut untuk satu kali Pelayanan.
2 Tarif tersebut belum termasuk Obat & Bahan Habis Pakai.
3 Tarif Tindakan Operatif Cito (amat Segera), Jasa Pelayanan ditambah 25 %
4 Bila Pasien Pindah Kelas, Tindakan Medis diperhitungkan dari Kelas Tertinggi yang ditempati.
5 Tindakan minimal infasif masuk tindakan khusus kelas II
b. Tindakan Medis Non Operatif

No. Kelas
1 2 3 4 5 5
1 Sederhana III 3,000 11,000 14,000
II 3,000 13,000 16,000
I 4,000 16,000 20,000
VIP 5,000 18,000 23,000
VVIP 6,000 25,000 31,000
2 Kecil III 5,000 27,000 32,000
II 6,000 35,000 41,000
I 7,000 50,000 57,000
VIP 12,000 60,000 72,000
VVIP 15,000 70,000 85,000
3 Sedang III 7,000 40,000 47,000
II 9,000 50,000 59,000
I 11,000 60,000 71,000
VIP 14,000 70,000 84,000
VVIP 20,000 75,000 95,000
4 Besar III 14,000 85,000 99,000
II 22,000 90,000 112,000
I 27,000 108,000 135,000
VIP 32,000 125,000 157,000
VVIP 45,000 135,000 180,000
Keterangan :
1 Tindakan Medis Non Operatif tersebut belum termasuk Obat & Bahan Habis Pakai.
2 Bila dilaksanakan dengan Anestesi maka dikenakan tambahan Tarif sesuai Tindakan Medis Operatif
dengan Kategori sama.
VIII. PELAYANAN KEBIDANAN

A PELAYANAN TINDAKAN KEBIDANAN
No. Kelas
1 2 3 4 5 6
1 Kecil III 25,000 130,000 155,000
II 30,000 150,000 180,000
I 35,000 170,000 205,000
VIP 40,000 200,000 240,000
VVIP 55,000 300,000 355,000
2 Sedang III 100,000 440,000 540,000
II 125,000 450,000 575,000
I 150,000 500,000 650,000
VIP 175,000 600,000 775,000
VVIP 200,000 700,000 900,000
3 Besar III 150,000 600,000 750,000
II 175,000 700,000 875,000
I 200,000 800,000 1,000,000
VIP 350,000 930,000 1,280,000
VVIP 400,000 1,000,000 1,400,000
4 Khusus III 200,000 880,000 1,080,000
II 300,000 1,000,000 1,300,000
I 350,000 1,200,000 1,550,000
VIP 600,000 1,400,000 2,000,000
VVIP 650,000 1,500,000 2,150,000
Keterangan :
2 Tarif tersebut belum termasuk Obat, & Bahan Habis Pakai.
3 Tarif Tindakan Operatif Cito (amat Segera), Jasa Pelayanan ditambah 25 %
4 Bila Pasien Pindah Kelas, Tindakan Medis diperhitungkan dari Kelas Tertinggi yang ditempati.
5 Jasa medis operatif anak hanya pada tindakan sectio caesaria
B PELAYANAN PERSALINAN
Kelas
No. Pelayanan Sarana Pelayanan ( Rp. )
1 2 3 4 5 6
1 Persalinan Normal III 92,000 138,000 230,000
II 128,000 192,000 320,000
I 168,000 252,000 420,000
VIP 228,000 342,000 570,000
VVIP 312,000 468,000 780,000
2 Persalinan dengan III 112,000 168,000 280,000
Penyulit Sedang II 156,000 234,000 390,000
I 200,000 300,000 500,000
VIP 270,000 405,000 675,000
VVIP 360,000 540,000 900,000
3 Persalinan dengan III 140,000 210,000 350,000
Penyulit Berat II 196,000 294,000 490,000
I 252,000 378,000 630,000
VIP 342,000 513,000 855,000
VVIP 456,000 684,000 1,140,000
Keterangan :
1 Tarif tersebut belum termasuk Obat & Bahan Habis Pakai.
2 Bila dilaksanakan dengan Anestesi, maka dikenakan tambahan Tarif sesuai Tindakan Medis Operatif
dengan Kategori yang Sama.
3 Bila Pasien Pindah Kelas, maka Tindakan Medis diperhitungkan dari Kelas Tertinggi yang ditempati.
IX. PENUNJANG MEDIK
A. PEMERIKSAAN LABORATORIUM
Jenis Jasa Jasa Tarif
No Kelas
Pemeriksaan Sarana Pelayanan ( Rp. )
1 2 3 4 5 6
1 Hematologi III 500 1,500 2,000
per parameter II 600 1,900 2,500
I 700 2,300 3,000
VIP 1,000 3,000 4,000
VVIP 2,000 4,000 6,000
2 Hb Cyanmeth III 2,000 4,000 6,000
II 2,100 5,900 8,000
I 2,500 7,500 10,000
VIP 3,000 10,000 13,000
VVIP 4,000 12,000 16,000
3 Darah Lengkap III 2,000 6,000 8,000
Auto Analizer II 2,000 8,000 10,000
I 2,500 9,500 12,000
VIP 3,000 12,000 15,000
VVIP 3,500 14,500 18,000
4 Golongan Darah III 500 1,500 2,000
II 500 2,000 2,500
I 700 2,300 3,000
VIP 1,000 3,000 4,000
VVIP 1,500 3,500 5,000
5 Tes Kehamilan III 2,000 3,000 5,000
II 2,000 5,000 7,000
I 2,500 6,000 8,500
VIP 3,000 7,000 10,000
VVIP 3,600 8,400 12,000
6 Preparat dengan III 2,000 5,000 7,000
Pengecatan II 2,300 5,700 8,000
( Malaria, BTA, Kusta, I 2,500 6,500 9,000
Jamur ) VIP 3,000 8,000 11,000
VVIP 3,500 10,000 13,500
7 Serologi III 2,000 7,000 9,000
( VDRL, Widal, ASTO, II 2,100 8,900 11,000
CRP, RF ) I 2,500 10,500 13,000
VIP 3,000 12,000 15,000
VVIP 3,600 14,400 18,000
8 Kimia Klinik Sedang III 2,000 5,000 7,000
( Gula, OT, PT, Chol, UA, II 2,100 5,900 8,000
TP, Alb, Ur, Cre ) I 2,500 6,500 9,000
VIP 3,000 8,000 11,000
VVIP 3,500 10,000 13,500
9 Kimia Klinik Canggih III 2,000 5,500 7,500
( Tg, ALP, GGT, Bil T, II 2,100 6,400 8,500
Bil D, HDL LDL, CKMB ) I 2,500 7,000 9,500
VIP 3,000 8,500 11,500
VVIP 3,500 10,000 13,500
10 Imunologi - Serologi III 3,000 10,000 13,000
( HBS-Ag, Anti HBS, HIV, II 3,500 12,500 16,000
DB Ig G Ig M, Ig G Anti TB ) I 4,000 15,000 19,000
VIP 5,000 17,000 22,000
VVIP 6,000 20,000 26,000
11 Urin Lengkap III 2,000 6,000 8,000
II 2,100 7,900 10,000
I 2,500 9,500 12,000
VIP 3,000 12,000 15,000
VVIP 3,600 14,400 18,000
12 Feses Lengkap III 2,000 6,000 8,000
II 2,100 7,900 10,000
I 2,500 9,500 12,000
VIP 3,000 12,000 15,000
VVIP 3,600 14,400 18,000
13 Elektrolit III 3,000 15,000 18,000
II 3,500 16,500 20,000
I 4,000 18,000 22,000
VIP 5,000 20,000 25,000
VVIP 6,000 24,000 30,000
14 Narkoba III 3,000 15,000 18,000
II 3,500 16,500 20,000
I 4,000 18,000 22,000
VIP 5,000 20,000 25,000
VVIP 6,000 24,000 30,000
Keterangan :
1. Tarif tersebut untuk satu kali pemeriksaan.
2. Pasien rawat jalan disesuaikan dengan tarif kelas II.
3. Bila ada tambahan jenis pemeriksaan baru, tarif akan di tentukan kemudian.
4. Tarif belum termasuk bahan habis pakai.
B. PEMERIKSAAN RADIO DIAGNOSTIK

No Kelas
1 2 3 4 5 6
III 9,000 15,000 24,000
II 9,000 16,500 25,500
1 THORAX
I 9,000 18,000 27,000
VIP 9,000 19,500 28,500
VVIP 9,000 25,000 34,000
III 18,000 30,000 48,000
THORAX II 18,000 33,000 51,000
2
AP/LAT I 18,000 36,000 54,000
VIP 18,000 39,000 57,000
VVIP 18,000 47,000 65,000
III 9,000 15,000 24,000
II 9,000 16,500 25,500
3 BNO
I 9,000 18,000 27,000
VIP 9,000 19,500 28,500
VVIP 9,000 23,500 32,500
III 18,000 30,000 48,000
BNO II 18,000 33,000 51,000
4
2 POSISI I 18,000 36,000 54,000
VIP 18,000 39,000 57,000
VVIP 18,000 47,000 65,000
III 9,000 15,000 24,000
II 9,000 16,500 25,500
5 PELVIS
I 9,000 18,000 27,000
VIP 9,000 19,500 28,500
VVIP 9,000 24,000 33,000
III 18,000 30,000 48,000
PELVIS II 18,000 33,000 51,000
6 AP/LAT I 18,000 36,000 54,000
VIP 18,000 39,000 57,000
VVIP 18,000 47,000 65,000
III 9,000 15,000 24,000
EXTRIMITAS II 9,000 16,500 25,500
7
1 POSISI I 9,000 18,000 27,000
VIP 9,000 19,500 28,500
VVIP 9,000 23,500 32,500
III 18,000 30,000 48,000
EXTRIMITAS II 18,000 33,000 51,000
8 2 POSISI I 18,000 36,000 54,000
VIP 18,000 39,000 57,000
VVIP 18,000 47,000 65,000
III 18,000 30,000 48,000
COLUMNA VERTEBRA II 18,000 33,000 51,000
9 2 POSISI I 18,000 36,000 54,000
VIP 18,000 39,000 57,000
VVIP 18,000 47,000 65,000
III 36,000 50,000 86,000
COLUMNA VERTEBRA II 36,000 55,000 91,000
10
4 POSISI I 36,000 60,000 96,000
VIP 36,000 65,000 101,000
VVIP 36,000 78,000 114,000
III 18,000 30,000 48,000
CRANIUM / II 18,000 33,000 51,000
11
SPN I 18,000 36,000 54,000
VIP 18,000 39,000 57,000
VVIP 18,000 47,000 65,000
III 27,000 45,000 72,000
MASTOID / TMJ / II 27,000 49,500 76,500
12 ORBITA I 27,000 54,000 81,000
VIP 27,000 58,500 85,500
VVIP 27,000 70,000 97,000
III 36,000 75,000 111,000
OSEFAGUS / II 36,000 82,500 118,500
13 OMD I 36,000 90,000 126,000
VIP 36,000 97,500 133,500
VVIP 36,000 117,000 153,000
III 45,000 75,000 120,000
COLON IN LOOP / II 45,000 82,500 127,500
14
FOLLOW THROUGH I 45,000 90,000 135,000
VIP 45,000 97,500 142,500
VVIP 45,000 117,000 162,000
III 45,000 75,000 120,000
CYSTOGRAFI / II 45,000 82,500 127,500
15
URETRCYSTOGRAFI I 45,000 90,000 135,000
VIP 45,000 97,500 142,500
VVIP 45,000 117,000 162,000
III 45,000 75,000 120,000
FISTULOGRAFI / II 45,000 82,500 127,500
16
GENITOGRAFI I 45,000 90,000 135,000
VIP 45,000 97,500 142,500
VVIP 45,000 117,000 162,000
III 45,000 75,000 120,000
II 45,000 82,500 127,500
17 BNO-IVP
I 45,000 90,000 135,000
VIP 45,000 97,500 142,500
VVIP 45,000 117,000 162,000
18 BONE SURVEY III 90,000 150,000 240,000
II 90,000 165,000 255,000
I 90,000 180,000 270,000
VIP 90,000 195,000 285,000
VVIP 90,000 234,000 324,000
Keterangan :
1 Tarif tersebut untuk satu kali Pemeriksaan.
2 Tarif tersebut belum termasuk Bahan Habis Pakai.
3 Bila ada tambahan Jenis Pemeriksan Baru, Tarif akan ditentukan kemudian.
4 Tarif Cito ditambah 1 (satu) kali Jasa Pelayanan.
C. Tarif Pelayanan Diagnostik & Tindakan Khusus.

No Kelas
1 2 3 4 5 6
1 USG III 34,000 26,000 60,000
II 34,000 33,500 67,500
I 34,000 43,000 77,000
VIP 34,000 46,000 80,000
VVIP 34,000 56,000 90,000
2 EKG III 10,500 24,500 35,000
II 12,000 28,000 40,000
I 13,500 31,500 45,000
VIP 15,000 35,000 50,000
VVIP 16,500 38,500 55,000
3 Vasculer doppler / TCD III 48,000 112,000 160,000
( Transcranial Doppler ) II 54,000 126,000 180,000
USG Mata I 60,000 140,000 200,000
VIP 66,000 154,000 220,000
VVIP 72,000 168,000 240,000
4 Doppler ( Kandungan ) III 67,500 50,000 117,500
II 67,500 100,000 167,500
I 67,500 150,000 217,500
VIP 67,500 200,000 267,500
VVIP 67,500 250,000 317,500
5 EEG dan Brain - III 32,000 128,000 160,000
Mapping II 36,000 144,000 180,000
I 40,000 160,000 200,000
VIP 44,000 176,000 220,000
VVIP 48,000 192,000 240,000
6 AUDIOMETRI III 10,000 9,500 19,500
II 15,000 15,000 30,000
I 20,000 21,000 41,000
VIP 29,000 27,000 56,000
VVIP 35,000 35,000 70,000
7 Slit Lamp & Opthal Moskope III 8,000 32,000 40,000
II 10,000 40,000 50,000
I 12,000 48,000 60,000
VIP 14,000 56,000 70,000
VVIP 16,000 64,000 80,000
8 Cauter Dermatologi III 6,000 8,000 14,000
II 8,000 12,000 20,000
I 15,000 16,000 31,000
VIP 27,000 31,000 58,000
VVIP 32,000 37,000 69,000
9 CTG III 10,000 17,500 27,500
II 12,500 22,500 35,000
I 17,500 32,500 50,000
VIP 28,000 52,000 80,000
VVIP 33,600 62,400 96,000
10 ENMG III 32,000 128,000 160,000
( Elektro Neuro Myografi) II 36,000 144,000 180,000
I 40,000 160,000 200,000
VIP 44,000 176,000 220,000
VVIP 48,000 192,000 240,000
11 Infant Warmer - III 10,000 7,500 17,500
Incubator II 14,000 11,000 25,000
I 15,000 15,500 30,500
VIP 20,000 20,000 40,000
VVIP 24,000 24,000 48,000
12 Blue Light III 10,000 7,500 17,500
II 14,000 11,000 25,000
I 15,000 15,500 30,500
VIP 20,000 20,000 40,000
VVIP 24,000 24,000 48,000
Keterangan :
1 Tarif tersebut untuk satu kali Pemeriksaan.
3 Bila ada tambahan Jenis Pemeriksan Baru, Tarif akan ditentukan kemudian.
4 Tarif Cito ditambah 1 (satu) kali Jasa Pelayanan.
D. Tarif Tindakan Spesialis Rehab Medik dan Fisioterapi.
No Kelas
1 2 3 4 5 6
I SEDERHANA
1 Latihan Lokal III 3,000 6,000 9,000
II 5,000 7,500 12,500
I 7,000 10,000 17,000
VIP 9,500 17,000 26,500
VVIP 11,500 20,500 32,000
2 Latihan General III 5,000 7,500 12,500
II 7,000 10,500 17,500
I 9,000 17,500 26,500
VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
3 Latihan Gymnasium III 3,000 6,000 9,000
II 5,000 7,500 12,500
I 7,000 10,000 17,000
VIP 9,500 17,000 26,500
VVIP 11,500 20,500 32,000
4 Massage III 3,000 6,000 9,000
II 5,000 7,500 12,500
I 7,000 10,000 17,000
VIP 9,500 17,000 26,500
VVIP 11,500 20,500 32,000
5 Infra Red III 3,000 6,000 9,000
Microwave Diathermi II 5,000 7,500 12,500
I 7,000 10,000 17,000
VIP 9,500 17,000 26,500
VVIP 11,500 20,500 32,000
6 Chest Vibrator III 3,000 6,000 9,000
II 5,000 7,500 12,500
I 7,000 10,000 17,000
VIP 9,500 17,000 26,500
VVIP 11,500 20,500 32,000
II SEDANG
7 Cervical Traction III 5,000 7,500 12,500
II 7,000 10,500 17,500
I 9,000 17,500 26,500
VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
8 Lumbal Traction III 5,000 7,500 12,500
II 7,000 10,500 17,500
I 9,000 17,500 26,500
VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
9 Electrical Stimulation III 5,000 7,500 12,500
II 7,000 10,500 17,500
I 9,000 17,500 26,500
VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
10 TENS III 5,000 7,500 12,500
(Transcutaneus II 7,000 10,500 17,500
Electrical Nerve I 9,000 17,500 26,500
Stimulation ) VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
11 USD III 5,000 7,500 12,500
(Ultrasound Therapi) II 7,000 10,500 17,500
I 9,000 17,500 26,500
VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
12 SWD III 5,000 7,500 12,500
(Short Wave II 7,000 10,500 17,500
Diathermy) I 9,000 17,500 26,500
VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
13 MWD III 5,000 7,500 12,500
(Micro Wave II 7,000 10,500 17,500
Diathermy) I 9,000 17,500 26,500
VIP 11,500 23,500 35,000
VVIP 13,800 28,200 42,000
Keterangan :
1 Tarif tersebut untuk satu kali tindakan
X. Pelayanan Lain-lain.
A Konsultasi Remaja, Keluarga, Pelayanan Psikologi dan Tumbuh kembang Anak
No
1 2 3 4 5
1. Pemeriksaan Awal.
- Intake interview 5,500 10,000 15,500
- Psikhologi dasar. 5,500 17,000 22,500
- Psikhiatri dasar. 5,500 17,000 22,500
2. Konsultasi
- Psikhiatri/Psykholog 5,500 20,000 25,500
lanjutan 45 menit.
- Dokter ahli. 5,500 20,000 25,500
3. Tes/Pemeriksaan Lanjutan
- Tes Bendergestali 11,500 34,000 45,500
- Tes Rochaach 11,500 34,000 45,500
- Tes WAIS 11,500 34,000 45,500
- Test Tumbuh Kembang anak 11,500 45,000 56,500
4. Terapi.
- Gestalt Terapi/ 45 menit. 11,500 34,000 45,500
- Suport Terapi/ 45 menit. 11,500 34,000 45,500
- Terapi perilaku/45 menit 11,500 34,000 45,500
- Terapi Kelompok/45 menit 11,500 34,000 45,500
- Marital Terapi/45 menit 11,500 34,000 45,500
- Famili Terapi 45 menit. 11,500 34,000 45,500
5. Psichotest.
- Seleksi/Promosi Karyawan. 11,500 34,000 45,500
- Untuk penjurusan/minat/bakat 11,500 34,000 45,500
- Test Intelegensi 11,500 34,000 45,500
- Konsultasi tanpa tes penunjang 11,500 34,000 45,500
- Konsultasi dengan test psycho penunjang 11,500 34,000 45,500
B. Konsultasi Gizi.
No. Katagori Pelayanan Jasa Jasa Tarif
Kelas. Sarana Pelayanan ( Rp. )
1 2 3 4 5
1 Pasien Rawat Jalan. 2,500 5,000 7,500

2 Pasien Rawat Inap.
III 2,500 6,500 9,000
II. 2,500 8,500 11,000
I. 2,500 9,000 11,500
VIP. 2,500 12,500 15,000
VVIP 2,500 16,000 18,500
C. Pelayanan Pemulasaraan Jenazah
Katagori Pelayanan Jasa Sarana Jasa Pelayanan Tarif
No.
Kelas. (Rp.) (Rp.) (Rp.)
1 2 3 4 5
1 Perawatan Jenazah.
III 50,000 135,000 185,000
II. 50,000 150,000 200,000
I. 50,000 160,000 210,000
VIP. 50,000 225,000 275,000
VVIP. 50,000 250,000 300,000
2 Konservasi/Pengawetan
Jenazah.
III 100,000 130,000 230,000
II. 100,000 135,000 235,000
I. 100,000 140,000 240,000
VIP. 100,000 145,000 245,000
VVIP. 100,000 160,000 260,000
3 Rekontruksi Jenazah.
III 150,000 100,000 250,000
II. 150,000 105,000 255,000
I. 150,000 110,000 260,000
VIP. 150,000 120,000 270,000
VVIP. 150,000 130,000 280,000
4 Penitipan Jenazah
dari RSUD per hari.
III 100,000 60,000 160,000
II. 100,000 65,000 165,000
I. 100,000 70,000 170,000
VIP. 100,000 80,000 180,000
VVIP. 100,000 85,000 185,000
5 Penitipan Jenazah dari
luar RSUD per hari.
III 100,000 60,000 160,000
II. 100,000 65,000 165,000
I. 100,000 70,000 170,000
VIP. 100,000 80,000 180,000
VVIP. 100,000 85,000 185,000
6 Pembongkaran Jenazah 200,000 250,000 450,000
7 Pemakaman Jenazah.
III 198,000 225,000 423,000
II. 198,000 234,000 432,000
I. 198,000 243,000 441,000
VIP. 198,000 270,000 468,000
VVIP. 198,000 315,000 513,000
8 Otopsi 1,800,000 1,800,000
9 Visum Jenazah.
III 13,500 31,500 45,000
II. 13,500 36,000 49,500
I. 13,500 40,500 54,000
VIP. 13,500 49,500 63,000
VVIP. 13,500 58,500 72,000
D. Pelayanan Ambulance/Mobil Jenazah.

Tarif Tarif
No. Katagori Pelayanan
( Rp. ) Keraton
1 2 3
1 Sampai dengan jarak 10 Km. 75,000
2 Lebih dari 10 km dihitung 1km x harga bensin
E. Pelayanan Mediko Legal.

Jasa Sarana Jasa Pelayanan Tarif
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Pembongkaran Jenazah.
- Jarak sampai dengan 10 Km. 150,000 250,000 400,000
- Jarak 10 Km s/d 30 Km. 250,000 300,000 550,000
- Jarak lebih dari 30 Km ditambah Rp. 4500,-
setiap 1 Km.
2 Surat Keterangan Rumah Sakit. 5,000 10,000 15,000
3 Permintaan Visum et Repertum.
III 9,000 9,000 18,000
II. 9,000 15,000 24,000
I. 9,000 20,000 29,000
VIP. 9,000 30,000 39,000
F. PELAYANAN FARMASI
No. U r a i a n Jasa Jasa Tarif
Sarana Pelayanan ( Rp. )
1 2 3 4 5
1 RAWAT JALAN Rx1,125 R x 0, 150 R x 1,275
2 RAWAT INAP R x 1,125 R x 0,125 R x 1,250
Keterangan :
- Harga Obat / Bahan sesuai Faktur Terakhir.
G. Pemeriksaan Kesehatan untuk Pemberian Surat Keterangan Kesehatan
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Orang Sakit dan Hamil/Bersalin/Masa Nifas 2,500 2,500 5,000
2 Malanjutkan Sekolah 2,500 2,500 5,000
3 Malamar Pekerjaan 2,500 2,500 5,000
4 Mengikuti Kursus 2,500 2,500 5,000
5 Keluar Negeri 11,250 11,250 22,500
6 Keperluan Asuransi 13,500 13,500 27,000
7 Test CPNS 5,400 8,100 13,500
8 Tes Buta Warna 10,000 15,000 25,000
Pelayanan Penunjang Medik.

A. Pemeriksaan Laboratorium.
Jasa Sarana Jasa Pelayanan TARIF
No. JENIS PEMERIKSAAN
(Rp.) (Rp.) (Rp.)
1 2 3 4 5
I. SEDERHANA I
1. III. 1,600.00 1,100.00 2,700.00
II 1,600.00 1,500.00 3,100.00
I 1,600.00 2,000.00 3,600.00
VIP 1,600.00 2,400.00 4,000.00
VVIP 1,600.00 2,900.00 4,500.00
II. SEDERHANA II.
2. III. 2,000.00 2,500.00 4,500.00
II 2,000.00 3,000.00 5,000.00
I 2,000.00 3,500.00 5,500.00
VIP 2,000.00 4,000.00 6,000.00
VVIP 2,000.00 4,500.00 6,500.00
3. SEDANG I.
III. 2,800.00 3,000.00 5,800.00
II 2,800.00 3,500.00 6,300.00
I 2,800.00 4,000.00 6,800.00
VIP 2,800.00 5,000.00 7,800.00
VVIP 2,800.00 5,700.00 8,500.00
4. SEDANG II.
III. 6,500.00 6,000.00 12,500.00
II 6,500.00 9,000.00 15,500.00
I 6,500.00 11,000.00 17,500.00
VIP 6,500.00 14,000.00 20,500.00
VVIP 6,500.00 18,500.00 25,000.00
5. CANGGIH
III. 16,000.00 16,000.00 32,000.00
II 16,000.00 21,000.00 37,000.00
I 16,000.00 25,000.00 41,000.00
VIP 16,000.00 35,000.00 51,000.00
VVIP 16,000.00 39,000.00 55,000.00
6. Dengue Blot IgG + IgM
III. 9,000.00 9,000.00 18,000.00
II 12,000.00 12,000.00 24,000.00
I 15,000.00 15,000.00 30,000.00
VIP 18,000.00 18,000.00 36,000.00
VVIP 21,000.00 21,000.00 42,000.00
7. Hematologi
(Autoanalyzer)
III. 4,200.00 4,200.00 8,400.00
II 5,900.00 5,900.00 11,800.00
I 7,000.00 7,000.00 14,000.00
VIP 8,400.00 8,400.00 168,000.00
VVIP 9,800.00 9,800.00 19,600.00
8. Blood Gaz Analyzer (BGA)
III. 9,000.00 9,000.00 18,000.00
II 12,000.00 12,000.00 24,000.00
I 15,000.00 15,000.00 30,000.00
VIP 18,000.00 18,000.00 42,000.00
VVIP 21,000.00 21,000.00 45,000.00
Catatan :
1. Tarif pemeriksaan tersebut belum termasuk bahan habis pakai / reagen
2. Tarif pemeriksaan laboratorium pasien dari poliklinik RSUD, Puskesmas dan RSUD Pemerintah lainnya sesuai
tarif kelas III.
3. Tarif pemeriksaan loboratorium untuk pemeriksaan kesehatan pegawai Negeri/TNI POLRI
untuk melanjutkan Sekolah, Tenaga Kerja Keluar Neger sesuai tarif kelas III.
4. Tarif pemeriksaan loboratorium pasien dari praktek swasta, RSU Swasta, pemeriksaan
kesehatan Pegawai Swasta dan General Check Up sesuai tarif kelas II.
5. Pemeriksaan laboratorium yang bersifat amat segera ( Cito ) dikenakan tambahan sebesar
25 % dari jasa pelayanan masing-masing katagori pelayanan dan kelas perawatannya.
B. Pemeriksaan Radiodiagnostik
No. JENIS PEMERIKSAAN JASA
Sarana Pelayanan TARIF
(Rp.) (Rp.) (Rp.)
1 2 3 4 5
I. SEDERHANA
III. 22,500.00 10,000.00 32,500.00
II 22,500.00 16,000.00 38,500.00
I 22,500.00 20,000.00 42,500.00
VIP 22,500.00 22,500.00 47,500.00
VVIP 22,500.00 25,000.00 57,500.00
II. SEDANG
III. 43,500.00 22,000.00 56,500.00
II 43,500.00 23,500.00 58,000.00
I 43,500.00 25,000.00 59,500.00
VIP 43,500.00 26,500.00 62,500.00
VVIP 43,500.00 28,000.00 70,000.00
III. CANGGIH.
III. 40,500.00 40,500.00 81,000.00
II 40,500.00 44,500.00 85,000.00
I 40,500.00 46,000.00 86,500.00
VIP 40,500.00 48,000.00 90,500.00
VVIP 40,500.00 50,000.00 95,000.00
Catatan :
1. Tarif pemeriksaan tersebut belum termasuk bahan habis pakai.
2. Tarif pemeriksaan Radiodiagnostik tersebut sudah termasuk jasa pembacaan hasil
3. Tarif pemeriksaan Radiodiagnostik pasien dari poliklinik RSUD, IGD, Puskesmas dan RSUD
Pemerintah lainnya sesuai tarif kelas III.
4. Tarif pemeriksaan Radiodiagnostik untuk pemeriksaan kesehatan pegawai Negeri/TNI POLRI
5. Tarif pemeriksaan Radiodiagnostik pasien dari praktek swasta, RSU Swasta, pemeriksaan
6. Pemeriksaan Radiodiagnostik yang bersifat amat segera ( Cito ) dikenakan tambahan sebesar
7. Pemeriksaan Radiodiagnostik bersifat amat segera ( Cito ) apabila dikerjakan setelah jam 13.
/setelah jam kerja.
C. Tarif Pelayanan Diagnostik & Tindakan Khusus.

No. Katagori Pelayanan Jasa Sarana Jasa Pelayanan Tarif Baru
Kelas. (Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 EKG.
III 30,000.00 25,000.00 55,000.00
II. 30,000.00 35,000.00 65,000.00
I. 30,000.00 45,000.00 75,000.00
VIP. 30,000.00 55,000.00 85,000.00
VVIP. 30,000.00 70,000.00 100,000.00
2 ECHOCARDIOGRAFI.
III 90,000.00 115,000.00 205,000.00
II. 90,000.00 175,000.00 265,000.00
I. 90,000.00 225,000.00 315,000.00
VIP. 90,000.00 240,000.00 330,000.00
VVIP. 90,000.00 260,000.00 350,000.00
3 ULTRASONOGRAFI (USG)
III 51,500.00 23,500.00 75,000.00
II. 51,500.00 29,500.00 81,000.00
I. 51,500.00 44,500.00 96,000.00
VIP. 51,500.00 59,500.00 111,000.00
VVIP. 51,500.00 69,500.00 121,000.00
D. Tarif pemakaian alat.
No. Katagori Pelayanan Tarif
( Rp. )
1 2 3
1. Infant Warmer (per jam) 5,500.00
2. Blue Light (per jam) 6,800.00
3. Incubator per hari 13,500.00
4. Bedside Monitor per hari 78,000.00
5. Syringe Pump per hari 77,200.00
6. Infusion Pump per hari 77,500.00
7. Ventilator per hari 150,000.00
E. Tarif Tindakan Spesialis Rehab Medik dan Fisioterapi.

No. Katagori Pelayanan Jasa Sarana Jasa Pelayanan Tarif
1 2 3 4 5
1 Sederhana.
III 5,000.00 7,500.00 12,500.00
II. 5,000.00 10,000.00 15,000.00
I. 5,000.00 15,000.00 20,000.00
VIP. 5,000.00 20,000.00 25,000.00
VVIP. 5,000.00 25,000.00 30,000.00
2 Sedang.
III 9,000.00 13,000.00 22,000.00
II. 9,000.00 16,000.00 25,000.00
I. 9,000.00 21,000.00 30,000.00
VIP. 9,000.00 31,000.00 40,000.00
VVIP. 9,000.00 41,000.00 50,000.00
Pelayanan Lain-lain.
A. Konsultasi Remaja & Keluarga Pelayanan Psikologi.
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
- Intake interview 3,750.00 11,250.00 15,000.00
- Psikhologi dasar. 6,250.00 18,750.00 25,000.00
- Psikhiatri dasar. 6,250.00 18,750.00 25,000.00
2. Konsultasi
- Psikhiatri/Psykholog 7,500.00 22,500.00 30,000.00
lanjutan 45 menit.
- Dokter ahli. 7,500.00 22,500.00 30,000.00
- Tes Bendergestali 12,500.00 37,500.00 50,000.00
- Tes Rochaach 12,500.00 37,500.00 50,000.00
- Tes WAIS 12,500.00 37,500.00 50,000.00
4. Terapi.
- Gestalt Terapi/ 45 menit. 12,500.00 37,500.00 50,000.00
- Suport Terapi/ 45 menit. 12,500.00 37,500.00 50,000.00
- Terapi perilaku/45 menit 12,500.00 37,500.00 50,000.00
- Terapi Kelompok/45 menit 12,500.00 37,500.00 50,000.00
- Marital Terapi/45 menit 12,500.00 37,500.00 50,000.00
- Famili Terapi 45 menit. 12,500.00 37,500.00 50,000.00
5. Psichotest.
- Seleksi/Promosi Karyawan. 12,500.00 37,500.00 50,000.00
- Untuk penjurusan/minat/bakat 12,500.00 37,500.00 50,000.00
- Test Intelegensi 12,500.00 37,500.00 50,000.00
- Konsultasi tanpa tes penunjang 12,500.00 37,500.00 50,000.00
- Konsultasi dengan test psycho penunjang 12,500.00 37,500.00 50,000.00
B. Konsultasi Gizi.
No.
1 2 3 4 5
1 Pasien Rawat Jalan. 2,250.00 5,250.00 7,500.00
III 2,250.00 5,250.00 7,500.00
II. 2,250.00 7,250.00 9,500.00
I. 2,250.00 9,250.00 11,500.00
VIP. 2,250.00 13,750.00 16,000.00
VVIP. 2,250.00 17,750.00 20,000.00
C. Pelayanan CSSD ( Strerilitasi ).
Autoclave ( Steam ).
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Pelayanan Biasa.
- Linen s/d 5 Kg. 7,500.00 7,500.00 15,000.00
- Linen diatas 5 kg tambahan per Kg. 1,750.00 1,750.00 3,500.00
- Iinstrumen umum s/d 5 kg 7,500.00 7,500.00 15,000.00
- Diatas 5 kg tambahan per Kg. 2,500.00 2,500.00 5,000.00
- Iinstrumen khusus s/d 5 kg 12,500.00 12,500.00 25,000.00
2. Pelayanan Cito dalam jam kerja.
- Linen s/d 5 Kg. 10,000.00 10,000.00 20,000.00
3. Pelayanan Cito diluar jam kerja.
- Linen s/d 50 Kg. 75,000.00 75,000.00 150,000.00
- Diatas 5 0kg tambahan per Kg. 3,500.00 3,500.00 7,000.00
Autoclave ( Formaline ).
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Pelayanan Biasa.
- Linen s/d 5 Kg. 4,500.00 4,500.00 9,000.00
- Linen s/d 5 Kg. 7,500.00 7,500.00 15,000.00
- Lenin s/d 50 Kg. 75,000.00 75,000.00 150,000.00
Catatan :
1. Biaya dikenakan untuk :
Titipan alat, bahan milik pribadi institusi diluar RSUD yang diseterilkan, yang digunakan diluar RSUD
2. Sifat Pelayanan.
a. Biaya : Alat/Bahan siap steril, setelah 3 (tiga) jam ( dalam jam kerja ).
b. Cito : Dalam Jam kerja : alat/bahan siap steril setelah 1 (satu) jam
Diluar jam kerja : alat/bahan siap steril setelah 1 (satu) jam
3. Jenis alat :
a. Linen
b. Instrumen umum : Instrumen bukan disposibel.
c. Instrumen khusus : Instrumen disposibel.
d. Plastik dan karet : Alat Medis habis pakai, sarung tangan.
4. Jenis Sterilisasi :
a. Autoclave - steam : Untuk linen, instrumen, kaca, plastik tahan panas, karet.
b. Autoclave-Formaline : Untuk kaca, plastik tidak tahan panas tinggi.
D. Pemulasaraan Jenazah.
Katagori Pelayanan Bahan habis Jasa Sarana Jasa Pelayanan Tarif
No.
Kelas. pakai (Rp.) (Rp.) ( Rp. )
1 2 3 4 5 6
III 139,000.00 52,000.00 150,000.00 341,000.00
II. 139,000.00 52,000.00 165,000.00 356,000.00
I. 139,000.00 52,000.00 180,000.00 371,000.00
VIP. 139,000.00 52,000.00 250,000.00 441,000.00
VVIP. 139,000.00 52,000.00 250,000.00 441,000.00
Jenazah.
III 85,500.00 96,000.00 142,500.00 324,000.00
II. 85,500.00 96,000.00 147,500.00 329,000.00
I. 85,500.00 96,000.00 152,500.00 334,000.00
VIP. 85,500.00 96,000.00 162,500.00 344,000.00
VVIP. 85,500.00 96,000.00 178,500.00 360,000.00
III 12,000.00 37,500.00 112,500.00 162,000.00
II. 12,000.00 37,500.00 117,500.00 167,000.00
I. 12,000.00 37,500.00 122,500.00 172,000.00
VIP. 12,000.00 37,500.00 132,500.00 182,000.00
VVIP. 12,000.00 37,500.00 142,500.00 192,000.00
4 Penitipan Jenazah
dari RSUD per hari.
III 12,000.00 83,000.00 65,000.00 160,000.00
II. 12,000.00 83,000.00 70,000.00 165,000.00
I. 12,000.00 83,000.00 75,000.00 170,000.00
VIP. 12,000.00 83,000.00 85,000.00 180,000.00
VVIP. 12,000.00 83,000.00 95,000.00 190,000.00
5 Penitipan Jenazah dari
luar RSUD per hari.
III 12,000.00 83,000.00 70,000.00 165,000.00
II. 12,000.00 83,000.00 75,000.00 170,000.00
I. 12,000.00 83,000.00 80,000.00 175,000.00
VIP. 12,000.00 83,000.00 90,000.00 185,000.00
VVIP. 12,000.00 83,000.00 95,000.00 190,000.00
6 Pembongkaran Jenazah 39,000.00 120,000.00 239,000.00 398,000.00
III 100,000.00 220,000.00 250,000.00 570,000.00
II. 100,000.00 220,000.00 260,000.00 580,000.00
I. 100,000.00 220,000.00 270,000.00 590,000.00
VIP. 100,000.00 220,000.00 300,000.00 620,000.00
VVIP. 100,000.00 220,000.00 350,000.00 670,000.00
8 Visum Jenazah.
III 13,000.00 15,000.00 35,000.00 63,000.00
II. 13,000.00 15,000.00 40,000.00 68,000.00
I. 13,000.00 15,000.00 45,000.00 73,000.00
VIP. 13,000.00 15,000.00 55,000.00 83,000.00
VVIP. 13,000.00 15,000.00 65,000.00 93,000.00
E. Pelayanan Ambulance/Mobil Jenazah.

Tarif
( Rp. )
1 2 3
1 Sampai dengan jarak 10 Km. 60,000.00
2 Jarak lebih dari 10 Km, ditambah Rp.6000,-
setiap 1 Km.
F. Pelayanan Mediko Legal.

(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
- Jarak sampai dengan 10 Km. 159,000.00 239,000.00 398,000.00
- Jarak 10 Km s/d 30 Km. 249,000.00 239,000.00 488,000.00
setiap 1 Km.
2 Surat Keterangan Rumah Sakit. 2,500.00 2,500.00 5,000.00
III 10,000.00 10,000.00 20,000.00
II. 10,000.00 12,500.00 22,500.00
I. 10,000.00 15,000.00 25,000.00
UTAMA 10,000.00 17,500.00 27,500.00
VIP. 10,000.00 20,000.00 30,000.00
G. Pemeriksaan Kesehatan untuk Pemberian Surat Keterangan Kesehatan.
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Orang Sakit dan Hamil/Bersalin/Masa Nifas 2,500.00 2,500.00 5,000.00
2 Malanjutkan Sekolah 2,500.00 2,500.00 5,000.00
3 Malamar Pekerjaan 2,500.00 2,500.00 5,000.00
4 Mengikuti Kursus 2,500.00 2,500.00 5,000.00
5 Keluar Negeri 12,500.00 12,500.00 25,000.00
6 Keperluan Asuransi 15,000.00 15,000.00 30,000.00
PEMERIKSAAN RADIO DIAGNOSTIK CITO.

A. Dewasa.
No. JENIS PEMERIKSAAN BA JASA
KLAS RS MEDIS
1 2 3 4 5 6
I. SEDERHANA
1. Thorax 35,000.00 III. B 0.00 0.00
35,000.00 III. A 4,375.00 4,375.00
35,000.00 II 8,750.00 8,750.00
35,000.00 I 10,625.00 10,625.00
35,000.00 Utama 12,500.00 12,500.00
35,000.00 VIP 15,000.00 15,000.00
2. BNO 35,000.00 III. B 0.00 0.00
35,000.00 III. A 4,375.00 4,375.00
35,000.00 II 8,750.00 8,750.00
35,000.00 I 10,625.00 10,625.00
35,000.00 Utama 12,500.00 12,500.00
35,000.00 VIP 15,000.00 15,000.00
3. Clauicula 25,000.00 III. B 0.00 0.00
25,000.00 III. A 4,375.00 4,375.00
25,000.00 II 8,750.00 8,750.00
25,000.00 I 10,625.00 10,625.00
25,000.00 Utama 12,500.00 12,500.00
25,000.00 VIP 15,000.00 15,000.00
4. Scapula 25,000.00 III. B 0.00 0.00
25,000.00 III. A 4,375.00 4,375.00
25,000.00 II 8,750.00 8,750.00
25,000.00 I 10,625.00 10,625.00
25,000.00 Utama 12,500.00 12,500.00
25,000.00 VIP 15,000.00 15,000.00
5. Pelvis 35,000.00 III. B 0.00 0.00
35,000.00 III. A 4,375.00 4,375.00
35,000.00 II 8,750.00 8,750.00
35,000.00 I 10,625.00 10,625.00
35,000.00 Utama 12,500.00 12,500.00
35,000.00 VIP 15,000.00 15,000.00
6. Manus 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
7. Amtebrachi 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
8. Humerus 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
9. Wrist 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
10. Cubiti 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
11. Shoulder 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
12. Pedis 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
13. Cruris 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
14. Angkle 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
15. Genu 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
16. Femur 35,000.00 III. B 0.00 0.00
35,000.00 III. A 8,750.00 8,750.00
35,000.00 II 17,500.00 17,500.00
35,000.00 I 21,250.00 21,250.00
35,000.00 Utama 25,000.00 25,000.00
35,000.00 VIP 30,000.00 30,000.00
17. Patella 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
18. Hip Joint 35,000.00 III. B 0.00 0.00
35,000.00 III. A 8,750.00 8,750.00
35,000.00 II 17,500.00 17,500.00
35,000.00 I 21,250.00 21,250.00
35,000.00 Utama 25,000.00 25,000.00
35,000.00 VIP 30,000.00 30,000.00
II. SEDANG
1. VC 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
2. VL 70,000.00 III. B 0.00 0.00
70,000.00 III. A 7,187.50 7,187.50
70,000.00 II 14,375.00 14,375.00
70,000.00 I 17,812.50 17,812.50
70,000.00 Utama 21,250.00 21,250.00
70,000.00 VIP 25,000.00 25,000.00
3. VT 70,000.00 III. B 0.00 0.00
70,000.00 III. A 7,187.50 7,187.50
70,000.00 II 14,375.00 14,375.00
70,000.00 I 17,812.50 17,812.50
70,000.00 Utama 21,250.00 21,250.00
70,000.00 VIP 25,000.00 25,000.00
4. VL - S 70,000.00 III. B 0.00 0.00
70,000.00 III. A 7,187.50 7,187.50
70,000.00 II 14,375.00 14,375.00
70,000.00 I 17,812.50 17,812.50
70,000.00 Utama 21,250.00 21,250.00
70,000.00 VIP 25,000.00 25,000.00
5. VL - L 70,000.00 III. B 0.00 0.00
70,000.00 III. A 7,187.50 7,187.50
70,000.00 II 14,375.00 14,375.00
70,000.00 I 17,812.50 17,812.50
70,000.00 Utama 21,250.00 21,250.00
70,000.00 VIP 25,000.00 25,000.00
6. Thorax AP/LAT. 70,000.00 III. B 0.00 0.00
70,000.00 III. A 7,187.50 7,187.50
70,000.00 II 14,375.00 14,375.00
70,000.00 I 17,812.50 17,812.50
70,000.00 Utama 21,250.00 21,250.00
70,000.00 VIP 25,000.00 25,000.00
7. BNO 2 Posisi 70,000.00 III. B 0.00 0.00
70,000.00 III. A 7,187.50 7,187.50
70,000.00 II 14,375.00 14,375.00
70,000.00 I 17,812.50 17,812.50
70,000.00 Utama 21,250.00 21,250.00
70,000.00 VIP 25,000.00 25,000.00
8. Cranium 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
9. SPN 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
10. OPG 40,000.00 III. B 0.00 0.00
40,000.00 III. A 7,187.50 7,187.50
40,000.00 II 14,375.00 14,375.00
40,000.00 I 17,812.50 17,812.50
40,000.00 Utama 21,250.00 21,250.00
40,000.00 VIP 25,000.00 25,000.00
11. USG 40,000.00 III. B 0.00 0.00
40,000.00 III. A 15,000.00 15,000.00
40,000.00 II 30,000.00 30,000.00
40,000.00 I 35,625.00 35,625.00
40,000.00 Utama 41,875.00 41,875.00
40,000.00 VIP 50,000.00 50,000.00
III. CANGGIH.
1. Mastoid 100,000.00 III. B 0.00 0.00
100,000.00 III. A 14,375.00 14,375.00
100,000.00 II 29,375.00 29,375.00
100,000.00 I 36,250.00 36,250.00
100,000.00 Utama 43,125.00 43,125.00
100,000.00 VIP 50,625.00 50,625.00
2. Orbita 100,000.00 III. B 0.00 0.00
100,000.00 III. A 14,375.00 14,375.00
100,000.00 II 29,375.00 29,375.00
100,000.00 I 36,250.00 36,250.00
100,000.00 Utama 43,125.00 43,125.00
100,000.00 VIP 50,625.00 50,625.00
3. Oesophagus 197,000.00 III. B 0.00 0.00
197,000.00 III. A 28,750.00 28,750.00
197,000.00 II 57,500.00 57,500.00
197,000.00 I 70,937.50 70,937.50
197,000.00 Utama 86,250.00 86,250.00
197,000.00 VIP 100,625.00 100,625.00
4. Cystogram 235,000.00 III. B 0.00 0.00
235,000.00 III. A 28,750.00 28,750.00
235,000.00 II 57,500.00 57,500.00
235,000.00 I 70,937.50 70,937.50
235,000.00 Utama 86,250.00 86,250.00
235,000.00 VIP 100,625.00 100,625.00
5. Uretro Cystogram 235,000.00 III. B 0.00 0.00
235,000.00 III. A 28,750.00 28,750.00
235,000.00 II 57,500.00 57,500.00
235,000.00 I 70,937.50 70,937.50
235,000.00 Utama 86,250.00 86,250.00
235,000.00 VIP 100,625.00 100,625.00
6. Colon in Loop 250,000.00 III. B 0.00 0.00
250,000.00 III. A 28,750.00 28,750.00
250,000.00 II 57,500.00 57,500.00
250,000.00 I 70,937.50 70,937.50
250,000.00 Utama 86,250.00 86,250.00
250,000.00 VIP 100,625.00 100,625.00
7. BNO IUP 315,000.00 III. B 0.00 0.00
315,000.00 III. A 28,750.00 28,750.00
315,000.00 II 57,500.00 57,500.00
315,000.00 I 70,937.50 70,937.50
315,000.00 Utama 86,250.00 86,250.00
315,000.00 VIP 100,625.00 100,625.00
8. Bone Survey 640,000.00 III. B 0.00 0.00
640,000.00 III. A 28,750.00 28,750.00
640,000.00 II 57,500.00 57,500.00
640,000.00 I 70,937.50 70,937.50
640,000.00 Utama 86,250.00 86,250.00
640,000.00 VIP 100,625.00 100,625.00
B. Anak-anak
No. JENIS PEMERIKSAAN BA JASA
KLAS RS MEDIS
1 2 3 4 5 6
I. SEDERHANA
1. Thorax 25,000.00 III. B 0.00 0.00
25,000.00 III. A 4,375.00 4,375.00
25,000.00 II 8,750.00 8,750.00
25,000.00 I 10,625.00 10,625.00
25,000.00 Utama 12,500.00 12,500.00
25,000.00 VIP 15,000.00 15,000.00
2. BNO 25,000.00 III. B 0.00 0.00
25,000.00 III. A 4,375.00 4,375.00
25,000.00 II 8,750.00 8,750.00
25,000.00 I 10,625.00 10,625.00
25,000.00 Utama 12,500.00 12,500.00
25,000.00 VIP 15,000.00 15,000.00
3. Clauicula 25,000.00 III. B 0.00 0.00
25,000.00 III. A 4,375.00 4,375.00
25,000.00 II 8,750.00 8,750.00
25,000.00 I 10,625.00 10,625.00
25,000.00 Utama 12,500.00 12,500.00
25,000.00 VIP 15,000.00 15,000.00
4. Scapula 25,000.00 III. B 0.00 0.00
25,000.00 III. A 4,375.00 4,375.00
25,000.00 II 8,750.00 8,750.00
25,000.00 I 10,625.00 10,625.00
25,000.00 Utama 12,500.00 12,500.00
25,000.00 VIP 15,000.00 15,000.00
5. Pelvis 25,000.00 III. B 0.00 0.00
25,000.00 III. A 4,375.00 4,375.00
25,000.00 II 8,750.00 8,750.00
25,000.00 I 10,625.00 10,625.00
25,000.00 Utama 12,500.00 12,500.00
25,000.00 VIP 15,000.00 15,000.00
6. Manus 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
7. Amtebrachi 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
8. Humerus 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
9. Wrist 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
10. Cubiti 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
11. Shoulder 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
12. Pedis 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
13. Cruris 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
14. Angkle 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
15. Genu 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
16. Femur 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
17. Patella 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
18. Hip Joint 25,000.00 III. B 0.00 0.00
25,000.00 III. A 8,750.00 8,750.00
25,000.00 II 17,500.00 17,500.00
25,000.00 I 21,250.00 21,250.00
25,000.00 Utama 25,000.00 25,000.00
25,000.00 VIP 30,000.00 30,000.00
II. SEDANG
1. VC 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
2. VL 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
3. VT 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
4. VL - S 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
5. VL - L 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
6. Thorax AP/LAT. 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
7. BNO 2 Posisi 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
8. Cranium 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
9. SPN 50,000.00 III. B 0.00 0.00
50,000.00 III. A 7,187.50 7,187.50
50,000.00 II 14,375.00 14,375.00
50,000.00 I 17,812.50 17,812.50
50,000.00 Utama 21,250.00 21,250.00
50,000.00 VIP 25,000.00 25,000.00
10. OPG 40,000.00 III. B 0.00 0.00
40,000.00 III. A 7,187.50 7,187.50
40,000.00 II 14,375.00 14,375.00
40,000.00 I 17,812.50 17,812.50
40,000.00 Utama 21,250.00 21,250.00
40,000.00 VIP 25,000.00 25,000.00
11. Atresia Ani 50,000.00 III. B 0.00 0.00
50,000.00 III. A 15,000.00 15,000.00
50,000.00 II 30,000.00 30,000.00
50,000.00 I 35,625.00 35,625.00
50,000.00 Utama 41,875.00 41,875.00
50,000.00 VIP 50,000.00 50,000.00
12. USG 40,000.00 III. B 0.00 0.00
40,000.00 III. A 15,000.00 15,000.00
40,000.00 II 30,000.00 30,000.00
40,000.00 I 35,625.00 35,625.00
40,000.00 Utama 41,875.00 41,875.00
40,000.00 VIP 50,000.00 50,000.00
III. CANGGIH.
1. Mastoid 100,000.00 III. B 0.00 0.00
100,000.00 III. A 14,375.00 14,375.00
100,000.00 II 29,375.00 29,375.00
100,000.00 I 36,250.00 36,250.00
100,000.00 Utama 43,125.00 43,125.00
100,000.00 VIP 50,625.00 50,625.00
2. Orbita 100,000.00 III. B 0.00 0.00
100,000.00 III. A 14,375.00 14,375.00
100,000.00 II 29,375.00 29,375.00
100,000.00 I 36,250.00 36,250.00
100,000.00 Utama 43,125.00 43,125.00
100,000.00 VIP 50,625.00 50,625.00
3. Oesophagus 215,000.00 III. B 0.00 0.00
215,000.00 III. A 28,750.00 28,750.00
215,000.00 II 57,500.00 57,500.00
215,000.00 I 70,937.50 70,937.50
215,000.00 Utama 86,250.00 86,250.00
215,000.00 VIP 100,625.00 100,625.00
4. Cystogram 215,000.00 III. B 0.00 0.00
215,000.00 III. A 28,750.00 28,750.00
215,000.00 II 57,500.00 57,500.00
215,000.00 I 70,937.50 70,937.50
215,000.00 Utama 86,250.00 86,250.00
215,000.00 VIP 100,625.00 100,625.00
5. Uretro Cystogram 215,000.00 III. B 0.00 0.00
215,000.00 III. A 28,750.00 28,750.00
215,000.00 II 57,500.00 57,500.00
215,000.00 I 70,937.50 70,937.50
215,000.00 Utama 86,250.00 86,250.00
215,000.00 VIP 100,625.00 100,625.00
6. Colon in Loop 225,000.00 III. B 0.00 0.00
225,000.00 III. A 28,750.00 28,750.00
225,000.00 II 57,500.00 57,500.00
225,000.00 I 70,937.50 70,937.50
225,000.00 Utama 86,250.00 86,250.00
225,000.00 VIP 100,625.00 100,625.00
7. BNO IUP 265,000.00 III. B 0.00 0.00
265,000.00 III. A 28,750.00 28,750.00
265,000.00 II 57,500.00 57,500.00
265,000.00 I 70,937.50 70,937.50
265,000.00 Utama 86,250.00 86,250.00
265,000.00 VIP 100,625.00 100,625.00
8. Bone Survey 440,000.00 III. B 0.00 0.00
440,000.00 III. A 28,750.00 28,750.00
440,000.00 II 57,500.00 57,500.00
440,000.00 I 70,937.50 70,937.50
440,000.00 Utama 86,250.00 86,250.00
440,000.00 VIP 100,625.00 100,625.00
Catatan :
Pemerintah lainnya sesuai tarif kelas III.A
untuk melanjutkan Sekolah, Tenaga Kerja Keluar Neger sesuai tarif kelas III.A
25 % ( dua puluh lima persen ) dari tarif.

JASA
PRASARANA PELAYANAN
I. PELAYANAN PEMERIKSAAN LABORATORIUM
3 Hb Sahli Rp 1,750 Rp 6,500 Rp 8,250
4 Leukosit Rp 1,750 Rp 1,500 Rp 3,250
6 LED Rp 1,750 Rp 1,500 Rp 3,250
B Urine
2 Reduksi I Rp 1,000 Rp 1,000 Rp 2,000
5 PH Rp 1,000 Rp 1,000 Rp 2,000
6 Protein Rp 1,000 Rp 1,000 Rp 2,000
8 Urobilin Rp 1,000 Rp 1,000 Rp 2,000
C Kimia Klinik
- Terumo
- Cair
Accuntrend
7 SGOT Rp 750 Rp 3,250 Rp 4,000
8 SGPT Rp 750 Rp 3,375 Rp 4,125
9 Asam Urat Rp 500 Rp 4,200 Rp 4,700
10 Ureum Rp 750 Rp 3,375 Rp 4,125
12 Albumin Rp 750 Rp 2,750 Rp 3,500
15 HDL - LDL Rp 750 Rp 5,750 Rp 6,500
D Serologi
Ig G dan Ig M
5 HBSAg Rp 1,750 Rp 5,250 Rp 7,000
7 ASTO Rp 1,000 Rp 10,250 Rp 11,250
E Mikrobiologi
1 BTA Paru Rp 2,300 Rp 1,700 Rp 4,000
2 BTA Kusta Rp 1,300 Rp 1,700 Rp 3,000
3 Malaria Rp 1,300 Rp 1,700 Rp 3,000
F Pemeriksaan Air
1 Fisik Rp 2,500 Rp 5,000 Rp 7,500
3 Secara Kimiawi
d Mangan Rp 2,500 Rp 2,500 Rp 5,000
e Flour Rp 2,500 Rp 6,000 Rp 8,500
f Fe Rp 2,500 Rp 4,000 Rp 6,500
i NH 4 Rp 2,500 Rp 8,000 Rp 10,500
j Cyanida Rp 2,500 Rp 6,000 Rp 8,500
k PH Rp 2,500 Rp 1,000 Rp 3,500
1 Borak Rp 1,500 Rp 3,500 Rp 5,000
2 Formalin Rp 1,500 Rp 3,500 Rp 5,000
3 Pewarna Rp 1,500 Rp 3,500 Rp 5,000
A KIMIA AIR
d Mangan Rp 5,000 Rp 5,000 Rp 10,000
e Flour Rp 5,000 Rp 8,500 Rp 13,500
f Fe Rp 5,000 Rp 6,500 Rp 11,500
i NH 4 Rp 5,000 Rp 10,500 Rp 15,500
j Cyanida Rp 5,000 Rp 8,500 Rp 13,500
k PH Rp 5,000 Rp 3,500 Rp 8,500
1 Borak Rp 6,500 Rp 8,500 Rp 15,000
2 Formalin Rp 6,500 Rp 8,500 Rp 15,000
3 Pewarna Rp 6,500 Rp 8,500 Rp 15,000

RUMAH SAKIT PEMERINTAHAN TIPE A DAN B
I. Rawat Jalan
A. Rawat Jalan
1. Pemeriksaan.
Pelayanan ( Rp. )
1 2 3 4 5
1 Doker Umum 10,000.00 12,500.00 22,500.00
2 Dokter Spesialis 10,000.00 20,000.00 30,000.00
3 Dokter SubSpesialis 10,000.00 35,000.00 45,000.00
4 Dokter Gigi 10,000.00 12,500.00 22,500.00
2. Tarif Tindakan di Poliklinik Spesialis Mata.

Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 5,000.00 13,000.00 18,000.00
2 Kecil 10,000.00 34,000.00 44,000.00
3. Tarif Tindakan di Poliklinik Spesialis THT.

Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 4,500.00 13,500.00 18,000.00
2 Kecil 10,000.00 34,000.00 44,000.00
4. Tarif Tindakan di Poliklinik Spesialis Bedah.

Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 6,000.00 26,000.00 32,000.00
2 Kecil 13,000.00 60,000.00 73,000.00
3 Sedang 24,500.00 117,100.00 141,600.00
5. Tarif Tindakan di Poliklinik Spesialis Obgyns.

Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 7,000.00 25,000.00 32,000.00
2 Kecil 11,000.00 50,000.00 61,000.00
3 Sedang 11,000.00 100,000.00 111,000.00
6. Tarif Tindakan di Poliklinik Spesialis Jantung.

Pelayanan ( Rp. )
1 2 3 4 5
1 EKG 29,000.00 36,000.00 65,000.00
2 Treadmill 75,000.00 90,000.00 165,000.00
3 ECHO 90,000.00 114,000.00 204,000.00
7. Tarif Tindakan di Poliklinik Spesialis Syaraf.
Pelayanan ( Rp. )
1 2 3 4 5
1 EEG 138,800.00 91,200.00 230,000.00
8. Tarif Tindakan di Poliklinik Spesialis Rehab Medik dan Fisioterapi.

Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 5,000.00 7,500.00 12,500.00
2 Sedang 9,000.00 13,000.00 22,000.00
9. Tarif Tindakan di Poliklinik Kulit Kelamin.

Pelayanan ( Rp. )
1 2 3 4 5
1 Cauter 7,500.00 67,000.00 74,500.00
10. Tarif Tindakan di Poliklinik Spesialis Bedah Orthopedi.
Pelayanan ( Rp. )
1 2 3 4 5
1 Perawatan Luka 10,500.00 58,500.00 69,000.00
2 Buka Gips 8,000.00 58,500.00 64,500.00
3 Fiksasi Plester 15,000.00 185,000.00 200,000.00
4 Pasang Gips 10,000.00 250,000.00 260,000.00
11. Tarif Tindakan di Poliklinik Gigi dan Mulut.

Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 15,000.00 15,000.00 30,000.00
2 Kecil 1 20,000.00 25,000.00 45,000.00
3 Kecil 2 25,000.00 40,000.00 65,000.00
4 Sedang 63,000.00 97,000.00 160,000.00
5 Besar 126,000.00 194,000.00 320,000.00
6 Khusus 139,000.00 291,000.00 430,000.00
7 Canggih 198,000.00 387,000.00 585,000.00
Catatan :
2. Besarnya tarif pelayanan Tindakan Medis di Poliklinik yang bersifat amat segera ditambah
25 % dari tarif masing-masing katagori pelayanan.
3. Besarnya tarif pelayanan tindakan medis pasien dari sarana kesehatan swasta dan sarana pelayanan
kesehatan spesialis pemerintah lainnya ditetapkan sama dengan tarif kelas II dari masing-masing
katagori pelayanan.
12. Tarif Pelayanan Hemodialisa.

Pelayanan (Rp.)
1 2 3 4 5
1 Non VIP 140,500.00 225,000.00 365,500.00
VIP 140,500.00 295,000.00 435,500.00
VVIP 140,500.00 350,000.00 490,500.00
Catatan :
13. Tarif Tindakan Endoskopi.

Pelayanan (Rp.)
1 2 3 4 5
1 Esofago Gastro Duodenoskopi
III 123,500.00 301,500.00 425,000.00
II. 123,500.00 326,500.00 450,000.00
I. 123,500.00 351,500.00 475,000.00
VIP 123,500.00 376,500.00 500,000.00
VVIP 123,500.00 401,500.00 525,000.00
2. Esofago Gastro Duodenoskopi + Biopsi
III 123,500.00 351,500.00 475,000.00
II. 123,500.00 376,500.00 500,000.00
I. 123,500.00 401,500.00 525,000.00
VIP 123,500.00 426,500.00 550,000.00
VVIP 123,500.00 451,500.00 575,000.00
3. Kolonoskopi
III 202,500.00 362,500.00 565,000.00
II. 202,500.00 412,500.00 615,000.00
I. 202,500.00 462,500.00 665,000.00
VIP 202,500.00 512,500.00 715,000.00
VVIP 202,500.00 562,500.00 765,000.00
4. Kolonoskopi + Biopsi
III 202,500.00 397,500.00 600,000.00
II. 202,500.00 447,500.00 650,000.00
I. 202,500.00 497,500.00 700,000.00
VIP 202,500.00 547,500.00 750,000.00
VVIP 202,500.00 622,500.00 825,000.00
5. STE Hemoroid
III 93,500.00 106,500.00 200,000.00
II. 93,500.00 121,500.00 215,000.00
I. 93,500.00 136,500.00 230,000.00
VIP 93,500.00 151,500.00 245,000.00
VVIP 93,500.00 166,500.00 260,000.00
6. Ligasi Varices Esofagus (LVE)
III 132,200.00 467,800.00 600,000.00
II. 132,200.00 517,800.00 650,000.00
I. 132,200.00 567,800.00 700,000.00
VIP 132,200.00 617,800.00 750,000.00
VVIP 132,200.00 667,800.00 800,000.00
7. Recto Sigmoid
III 75,000.00 175,000.00 250,000.00
II. 90,000.00 210,000.00 300,000.00
I. 105,000.00 245,000.00 350,000.00
VIP 120,000.00 280,000.00 400,000.00
VVIP 135,000.00 315,000.00 450,000.00
8. Recto Sigmoid + Biopsi
III 93,500.00 210,000.00 300,000.00
II. 93,500.00 245,000.00 350,000.00
I. 93,500.00 280,000.00 400,000.00
VIP 93,500.00 315,000.00 450,000.00
VVIP 93,500.00 350,000.00 500,000.00
9. STE Fundus/ Gaster/ Histoakril
III 176,200.00 373,800.00 550,000.00
II. 176,200.00 423,800.00 600,000.00
I. 176,200.00 473,800.00 650,000.00
VIP 176,200.00 523,800.00 700,000.00
VVIP 176,200.00 573,800.00 750,000.00
10. Pungsi Ascites Guiding
III 135,000.00 315,000.00 450,000.00
II. 150,000.00 350,000.00 500,000.00
I. 195,000.00 455,000.00 650,000.00
VIP 210,000.00 490,000.00 700,000.00
VVIP 225,000.00 525,000.00 750,000.00
11. Pungsi Abces Hepar
III 135,000.00 315,000.00 450,000.00
II. 150,000.00 350,000.00 500,000.00
I. 195,000.00 455,000.00 650,000.00
VIP 210,000.00 490,000.00 700,000.00
VVIP 225,000.00 525,000.00 750,000.00
12. Biopsi Hepar
III 135,000.00 315,000.00 450,000.00
II. 150,000.00 350,000.00 500,000.00
I. 195,000.00 455,000.00 650,000.00
VIP 210,000.00 490,000.00 700,000.00
VVIP 225,000.00 525,000.00 750,000.00
13. Biopsi Hepatoma/NCC/Nodul
III 165,000.00 385,000.00 550,000.00
II. 180,000.00 420,000.00 600,000.00
I. 210,000.00 490,000.00 700,000.00
VIP 225,000.00 525,000.00 750,000.00
VVIP 255,000.00 595,000.00 850,000.00
14. PTE/Terapi
III 135,000.00 315,000.00 450,000.00
II. 150,000.00 350,000.00 500,000.00
I. 195,000.00 455,000.00 650,000.00
VIP 210,000.00 490,000.00 700,000.00
VVIP 225,000.00 525,000.00 750,000.00
Catatan :
14. Tarif tindakan medis non operatif.

Katagori Jasa Sarana Jasa Pelayanan Tarif
No.
Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 3,500.00 7,500.00 7,500.00
2 Kecil 5,000.00 9,500.00 14,500.00
3 Sedang 9,500.00 22,000.00 31,500.00
Catatan :
1. Tarif pelayanan tindakan medis non operatif tersebut diatas adalah untuk satu kali tindakan.
2. Besarnya tarif pelayanan Tindakan Medis operatif non operatif yang bersifat amat segera
ditambah 25 % dari tarif masing-masing katagori pelayanan.
3. Besarnya tarif pelayanan tindakan medis non operatif pasien dari sarana kesehatan swasta
dan sarana pelayanan kesehatan spesialis pemerintah lainnya ditetapkan sama dengan tarif
kelas II dari masing-masing katagori pelayanan.
4. Tarif pelayanan tindakan medis & non operatif pasien rawat inap menyesuaikan kelas perawatannya.
II. Rawat Darurat.

1. Pemeriksaan.
No.
Pelayanan ( Rp. )
1 2 3 4 5
1 Dokter Umum 10,000.00 16,000.00 26,000.00
2 Dokter Spesialis 10,000.00 30,000.00 40,000.00
3 Dokter Sub Spesialis 10,000.00 70,000.00 80,000.00
4 Dokter Gigi 10,000.00 16,000.00 26,000.00
2. Tindakan Medis di IGD.
No.
Pelayanan ( Rp. )
1 2 3 4 5
1 Sederhana 8,500.00 6,500.00 15,000.00
2 Kecil I 12,000.00 9,500.00 21,500.00
3 Kecil II 15,000.00 11,500.00 26,500.00
4 Sedang I 28,000.00 22,000.00 50,000.00
5 Sedang II 48,000.00 37,500.00 85,500.00
Catatan :
1. Tarif pelayanan tindakan medis operatif tersebut diatas adalah untuk satu kali tindakan.
2. Besarnya tarif pelayanan tindakan medis pasien dari sarana kesehatan swasta
dan sarana pelayanan kesehatan spesialis pemerintah lainnya ditetapkan sama dengan tarif kelas II dari
masing-masing katagori pelayanan.
3. Tarif pelayanan tindakan medis rawat inap menyesuaikan kelas perawatannya
III. Rawat Inap.

1. Akomodasi Rawat Inap
Tarif
No. Kelas
( Rp. )
1 2 3
1 III 10,500.00
2 II. 21,000.00
3 I. 42,000.00
4 VIP. 126,000.00
5 VVIP. 150,000.00
Catatan :
1. Tarif tersebut diatas belum termasuk biaya makan / gizi.
2. Setiap pasien rawat inap dikenakan biaya adminsitrasi kelas III s/d kelas II : Rp. 5.000,- Kelas I
sebesar Rp. 10.000,- untuk pasien ruang Intensif dan untuk VIP sebesasr Rp. 15.000,-
3. Khusus bagi penderita rawat inap kleas I, dan VIP terlebih dahulu diwajibkan membayar dimuka
biaya perawatan yang diperhitungkan selama 5 ( lima ) hari perawatan.
4. Apabila waktu 5 ( lima ) hari sebagaimana dimaksud pada point 2 berakhir dan rawat inap diteruskan,
penderita diwajibkan membayar perawatan untuk 5 (lima) hari berikutnya dan demikian seterusnya.
5. Jumlah hari rawat inap dihitung mulai penderita masuk rawat inap sampai dengan penderita keluar dari RSU
6. Bayi normal dan sehat yang dilahirkan di RSUD dikenakan tarif rawat inap sebesar 50 % ( lima puluh
persen ) dari tarif kelas perawatan yang ditempati ibunya.
7. Untuk bayi bermasalah yang memerlukan perawatan khusus dikenakan biaya rawat inap sebesar tarif
kelas perawatan yang ditempati ibunya.
8. Penunggu pasien dkenakan biaya akomodasi sebesasr Rp. 5.000,- setiap hari.
2. Visite / Konsul.
No.
Pelayanan ( Rp. )
1 2 3 4 5
A. Dokter Spesialis.
III 10,000.00 15,000.00 25,000.00
II. 10,000.00 22,500.00 32,500.00
I. 10,000.00 30,000.00 40,000.00
VIP 10,000.00 45,000.00 55,000.00
VVIP 10,000.00 60,000.00 70,000.00
B. Dokter Sub Spesialis
III 10,000.00 30,000.00 40,000.00
II. 10,000.00 45,000.00 55,000.00
I. 10,000.00 60,000.00 70,000.00
VIP 10,000.00 90,000.00 100,000.00
VVIP 10,000.00 120,000.00 130,000.00
C. Dokter Umum/Gigi.
III 10,000.00 8,000.00 18,000.00
II. 10,000.00 12,000.00 22,000.00
I. 10,000.00 16,000.00 26,000.00
VIP 10,000.00 24,000.00 34,000.00
VVIP 10,000.00 32,000.00 42,000.00
Catatan :
1. Tarif tersebut diatas adalah tarif untuk satu kali pemeriksaan/konsultasi.
2. Konsultasi medis per telpon dihitung sama dengan satu kali konsultasi/visite dan maksimal dipungut
satu kali dalam 24 jam sejak konsultasi terakhir.
3. Tarif Asuhan Keperawatan

No. Jenis Pelayanan
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Ketergantungan Rendah
III 14,800.00 10,000.00 24,800.00
II 14,800.00 12,500.00 27,300.00
I 14,800.00 15,000.00 29,800.00
VIP 14,800.00 20,000.00 34,800.00
VVIP 14,800.00 25,000.00 39,800.00
2 Ketergantungan Sedang
III 20,700.00 12,500.00 33,200.00
II 20,700.00 15,000.00 35,700.00
I 20,700.00 20,000.00 40,700.00
VIP 20,700.00 25,000.00 45,700.00
VVIP 20,700.00 30,000.00 50,700.00
3 Ketergantungan Tinggi
III 24,500.00 15,000.00 39,500.00
II 24,500.00 20,000.00 44,500.00
I 24,500.00 25,000.00 49,500.00
VIP 24,500.00 30,000.00 54,500.00
VVIP 24,500.00 35,000.00 59,500.00
4 Asuhan Keperawatan di ICU
III 32,000.00 20,000.00 52,000.00
II 32,000.00 25,000.00 57,000.00
I 32,000.00 30,000.00 62,000.00
VIP 32,000.00 35,000.00 67,000.00
VVIP 32,000.00 40,000.00 72,000.00
Catatan :
1. Kriteria Asuhan Keperawatan Ketergantungan Rendah :
* Kebersihan diri, mandi, ganti pakaian, makan minum dilakukan sendiri
* Ambulasi dengan pengawasan minimal
* Pengobatan minimal, status psikologis stabil
* Persiapan prosedur memerlukan pengobatan
2. Kriteria Asuhan Keperawatan Ketergantungan Sedang :
* Kebersihan diri dibantu, makan minum dibantu
* Ambulasi dibantu, pengobatan lebih dari sekali
* Volly chateter, nake out put dicatat.
* Klien dengan terpasang infus, persiapan pengobatan memerukan prosedur
3. Kriteria Asuhan Keperawatan Ketergantungan Tinggi :
* Segala diberikan / dibantu
* Makan minum memerukan NGT, terapi intravena.
* Pemakaian suction
* Gelisah / disorientasi
4. Asuhan Keperawatan ICU : Asuhan Keperawatan di ICU
4. Akomodasi Rawat Intensif

Tarif
No. Kelas
( Rp. )
1 2 3
1 III 45,000.00
2 II. 90,000.00
3 I. 112,500.00
4 VIP. 225,000.00
5 VVIP 250,000.00
Catatan :
1. Tarip tersebut belum termasuk biaya makan/Gizi.
2. Setiap pasien di rawat di ruang Intensif dikenakan biaya administrasi Rp. 15.000
3. Penderita dari luar RSUD yang langsung masuk dan belum menentukan kelas perawtan kemudian
pulang atau meninggal, dikenakan biaya perhari sebesar 2 (dua) kali biaya rawat inap kelas II.
4. Bagi pasien Askes dikenakan tarif 3 (tiga) kali kelas asal yang ditempati.
5. Penderita yang berasal dari rawat inap baik dari RSUD maupun dari luar RSUD dikenakan biaya perhari
sebesar 3 (tiga) kali besarnya tarif kelas perawatan yang ditempati.
6. Rujukan dari pelayanan kesehatan dasar swasta atau RS Pemerintah yang lain ditetapkan 3 (tiga ) kali
tarif kelas yang akn ditempati dengan minimal kelas II.
5. Akomodasi Rawat HCU

Tarif
No. Kelas
( Rp. )
1 2 3
1 III 30,000.00
2 II. 50,000.00
3 I. 90,000.00
4. VIP. 130,000.00
5. VVIP. 150,000.00
Keterangan :
1. Tarip tersebut belum termasuk biaya makan/Gizi.
2. Setiap pasien di rawat di ruang HCU dikenakan biaya administrasi Rp. 7.000
3. Penderita dari luar RSUD yang langsung masuk dan belum menentukan kelas perawatan kemudian
pulang atau meninggal, dikenakan biaya perhari sebesar 2 (dua) kali biaya rawat inap kelas II.
4. Bagi pasien Askes dikenakan tarif 3 (tiga) kali kelas asal yang ditempati.
5. Penderita yang berasal dari rawat inap baik dari RSUD maupun dari luar RSUD dikenakan biaya perhari
sebesar 3 (tiga) kali besarnya tarif kelas perawatan yang ditempati.
6. Rujukan dari pelayanan kesehatan dasar swasta atau RS Pemerintah yang lain ditetapkan 3 (tiga ) kali
tarif kelas yang akn ditempati dengan minimal kelas II.
6. Pelayanan dan tindakan di ruang intensif

No.
Kelas (Rp.) (Rp.) ( Rp. )
1 2 3 4 5
Visite / Konsul
a. Dokter Spesialis
III 10,000.00 70,000.00 80,000.00
II. 10,000.00 100,000.00 110,000.00
I. 10,000.00 140,000.00 150,000.00
VIP. 10,000.00 200,000.00 210,000.00
VVIP. 10,000.00 250,000.00 260,000.00
b. Dokter Gigi
III 10,000.00 35,000.00 45,000.00
II. 10,000.00 50,000.00 60,000.00
I. 10,000.00 70,000.00 80,000.00
VIP. 10,000.00 100,000.00 110,000.00
VVIP. 10,000.00 130,000.00 140,000.00
IV. Tindakan Medis.

A. Tindakan Medis Operatif.
No. Kelas
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Sederhana
III 7,500.00 26,000.00 33,500.00
II. 13,000.00 30,000.00 43,000.00
I. 17,000.00 35,000.00 52,000.00
VIP. 37,500.00 49,000.00 86,500.00
VVIP. 37,500.00 64,000.00 101,500.00
ODC 13,000.00 30,000.00 43,000.00
2 Kecil.
III 30,000.00 150,000.00 180,000.00
II. 50,000.00 175,000.00 225,000.00
I. 75,000.00 200,000.00 275,000.00
VIP. 122,500.00 250,000.00 372,500.00
VVIP. 122,500.00 350,000.00 472,500.00
ODC 50,000.00 175,000.00 225,000.00
3 Sedang.
III 300,000.00 500,000.00 800,000.00
II. 300,000.00 550,000.00 850,000.00
I. 300,000.00 600,000.00 900,000.00
VIP. 300,000.00 750,000.00 1,050,000.00
VVIP. 300,000.00 800,000.00 1,100,000.00
ODC 300,000.00 550,000.00 850,000.00
4 Besar.
III 582,000.00 750,000.00 1,332,000.00
II. 582,000.00 850,000.00 1,432,000.00
I. 582,000.00 950,000.00 1,532,000.00
VIP. 582,000.00 1,000,000.00 1,582,000.00
VVIP. 582,000.00 1,250,000.00 1,832,000.00
ODC 582,000.00 850,000.00 1,432,000.00
5 Khusus.
III 891,000.00 1,000,000.00 1,891,000.00
II. 891,000.00 1,250,000.00 2,141,000.00
I. 891,000.00 1,500,000.00 2,391,000.00
VIP. 891,000.00 1,750,000.00 2,641,000.00
VVIP. 891,000.00 2,000,000.00 2,891,000.00
ODC 891,000.00 1,250,000.00 2,141,000.00
6 Canggih
III 1,136,000.00 1,250,000.00 2,386,000.00
II. 1,136,000.00 1,500,000.00 2,636,000.00
I. 1,136,000.00 1,750,000.00 2,886,000.00
VIP. 1,136,000.00 2,000,000.00 3,136,000.00
VVIP. 1,136,000.00 2,500,000.00 3,636,000.00
ODC 1,136,000.00 1,500,000.00 2,636,000.00
Catatan :
4. Untuk tindakan medis operatif kecil dikenakan Jasa anastesi apabila dokter anastesi terlibat
5 Obat dan bahan habis pakai untuk tindakan operatif akan diresepkan.
6 Besarnya jasa medis anastesi sama dengan 50% jasa tindakan medis operator.
7 Tindakan medis operatif dengan resiko anastesi tinggi jasa anastesinya ditambah 25 % ( 75%)
dari Jasa Medis Operator.
B. Tindakan Medis Operatif Subspesialis

No. Kelas
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Sedang I.
III 315,000.00 735,000.00 1,050,000.00
II. 345,000.00 805,000.00 1,150,000.00
I. 450,000.00 1,050,000.00 1,500,000.00
VIP. 525,000.00 1,225,000.00 1,750,000.00
VVIP. 525,000.00 1,500,000.00 2,025,000.00
ICU 390,000.00 910,000.00 1,300,000.00
ODC 315,000.00 735,000.00 1,050,000.00
2 Sedang II.
III 375,000.00 875,000.00 1,250,000.00
II. 420,000.00 980,000.00 1,400,000.00
I. 555,000.00 1,295,000.00 1,850,000.00
VIP. 675,000.00 1,575,000.00 2,250,000.00
VVIP. 675,000.00 1,650,000.00 2,325,000.00
ICU 465,000.00 1,085,000.00 1,550,000.00
ODC 375,000.00 875,000.00 1,250,000.00
3 Besar I
III 435,000.00 1,015,000.00 1,450,000.00
II. 495,000.00 1,155,000.00 1,650,000.00
I. 660,000.00 1,540,000.00 2,200,000.00
VIP. 825,000.00 1,925,000.00 2,750,000.00
VVIP. 825,000.00 2,075,000.00 2,900,000.00
ICU 540,000.00 1,260,000.00 1,800,000.00
4 Besar II
III 495,000.00 1,155,000.00 1,650,000.00
II. 615,000.00 1,435,000.00 2,050,000.00
I. 765,000.00 1,785,000.00 2,550,000.00
VIP. 975,000.00 2,275,000.00 3,250,000.00
VVIP. 975,000.00 2,475,000.00 3,450,000.00
ICU 615,000.00 1,435,000.00 2,050,000.00
5 Khusus I
III 595,000.00 1,305,000.00 1,900,000.00
II. 670,000.00 1,420,000.00 2,090,000.00
I. 865,000.00 1,875,000.00 2,740,000.00
VIP. 1,075,000.00 2,590,000.00 3,665,000.00
VVIP. 1,175,000.00 2,890,000.00 4,065,000.00
ICU 715,000.00 1,525,000.00 2,240,000.00
6 Khusus II
III 595,000.00 1,505,000.00 2,100,000.00
II. 670,000.00 1,620,000.00 2,290,000.00
I. 865,000.00 2,075,000.00 2,940,000.00
VIP. 1,075,000.00 2,790,000.00 3,865,000.00
VVIP. 1,175,000.00 3,090,000.00 4,265,000.00
ICU 715,000.00 1,725,000.00 2,440,000.00
Catatan :
6 Besarnya jasa medis anastesi sama dengan 50% jasa tindakan medis operator.
7 Tindakan medis operatif dengan resiko anastesi tinggi jasa anastesinya ditambah 25 % ( 75%)
C. Tindakan Medis Non Operatif.

No. Kelas
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Sederhana
III 2,500.00 12,000.00 14,500.00
II. 2,500.00 14,000.00 16,500.00
I. 4,000.00 17,000.00 21,000.00
VIP. 5,000.00 20,000.00 25,000.00
VVIP. 6,000.00 25,000.00 31,000.00
2 Kecil
III 5,000.00 30,000.00 35,000.00
II. 7,000.00 40,000.00 47,000.00
I. 8,500.00 55,000.00 63,500.00
VIP. 12,500.00 65,000.00 77,500.00
VVIP. 17,000.00 75,000.00 92,000.00
3 Sedang
III 8,000.00 43,000.00 51,000.00
II. 10,000.00 55,000.00 65,000.00
I. 12,500.00 65,000.00 77,500.00
VIP. 15,000.00 75,000.00 90,000.00
VVIP. 21,000.00 85,000.00 106,000.00
4 Besar
III 15,000.00 95,000.00 110,000.00
II. 25,000.00 100,000.00 125,000.00
I. 30,000.00 120,000.00 150,000.00
VIP. 35,000.00 135,000.00 170,000.00
VVIP. 50,000.00 150,000.00 200,000.00
5 Khusus
III 20,000.00 100,000.00 120,000.00
II. 30,000.00 105,000.00 135,000.00
I. 50,000.00 125,000.00 175,000.00
VIP. 75,000.00 150,000.00 225,000.00
VVIP. 100,000.00 160,000.00 260,000.00
6 Canggih
III 25,000.00 100,000.00 125,000.00
II. 35,000.00 105,000.00 140,000.00
I. 60,000.00 125,000.00 185,000.00
VIP. 100,000.00 150,000.00 250,000.00
VVIP. 125,000.00 160,000.00 285,000.00
Catatan :
1. Tarif pelayanan tindakan tersebut diatas adalah untuk satu kali tindakan.
2. Tarif tersebut diatas adalah tarif tindakan oleh para medis.
3. Apabila dilakukan oleh Dokter, tarif tersebut ditambah jasa tindakan Dokter sebesar 2 (dua ) kali
jasa tindakan oleh para medis.
4. Apabila dilakukan tindakan anestesi, dikenakan tarif tindakan anestesi sebesar 1/3 ( sepertiga)
dari tarif tindakan Dokter.
5. Untuk kasus-kasus yang memerlukan waktu perawatan yang lama, dapat dilakukan dengan
kebijaksanaan pejabat bidang keperawatan.
6. Tarif pelayanan tindakan medis non operatif pasien rawat inap menyesuaikan kelas perawatannya.
D. Pelayanan Kebidanan & Kandungan.

No. Katgori Pelayanan Jasa Sarana Jasa Pelayanan Tarif
1 2 3 4 5
1 Sederhana
III 6,000.00 26,000.00 32,000.00
II. 6,000.00 30,000.00 36,000.00
I. 6,000.00 35,000.00 41,000.00
VIP. 6,000.00 49,000.00 55,000.00
VVIP. 6,000.00 64,000.00 70,000.00
ODC. 6,000.00 30,000.00 36,000.00
2 Kecil.
III 13,000.00 150,000.00 163,000.00
II. 13,000.00 175,000.00 188,000.00
I. 13,000.00 200,000.00 213,000.00
VIP. 13,000.00 250,000.00 263,000.00
VVIP. 13,000.00 350,000.00 363,000.00
ODC 13,000.00 175,000.00 188,000.00
3 Sedang.
III 300,000.00 300,000.00 600,000.00
II. 300,000.00 350,000.00 650,000.00
I. 300,000.00 450,000.00 750,000.00
VIP. 300,000.00 600,000.00 900,000.00
VVIP. 300,000.00 800,000.00 1,100,000.00
ODC 300,000.00 300,000.00 600,000.00
4 Besar.
III 582,000.00 660,000.00 1,242,000.00
II. 582,000.00 775,000.00 1,357,000.00
I. 582,000.00 900,000.00 1,482,000.00
VIP. 582,000.00 1,200,000.00 1,782,000.00
VVIP. 582,000.00 1,500,000.00 2,082,000.00
5 Khusus.
III 891,000.00 860,000.00 1,751,000.00
II. 891,000.00 975,000.00 1,866,000.00
I. 891,000.00 1,100,000.00 1,991,000.00
VIP. 891,000.00 1,400,000.00 2,291,000.00
VVIP. 891,000.00 1,700,000.00 2,591,000.00
6. Canggih
III 1,136,000.00 960,000.00 2,096,000.00
II. 1,136,000.00 1,075,000.00 2,211,000.00
I. 1,136,000.00 1,200,000.00 2,336,000.00
VIP. 1,136,000.00 1,500,000.00 2,636,000.00
VVIP. 1,136,000.00 1,800,000.00 2,936,000.00
D. Pelayanan Persalinan
1 2 3 4 5
1. Persalinan Normal.
Oleh Dokter Ahli.
III 25,000.00 300,000.00 325,000.00
II. 25,000.00 350,000.00 375,000.00
I. 25,000.00 500,000.00 525,000.00
VIP. 25,000.00 700,000.00 725,000.00
VVIP. 25,000.00 1,000,000.00 1,025,000.00
2. Persalinan Patologis.
Oleh Dokter Ahli.
III 50,000.00 500,000.00 550,000.00
II. 50,000.00 600,000.00 650,000.00
I. 50,000.00 750,000.00 800,000.00
VIP. 50,000.00 1,000,000.00 1,050,000.00
VVIP. 50,000.00 1,200,000.00 1,250,000.00
Catatan :
1. Tarif pelayanan tindakan tersebut diatas adalah untuk satu kali tindakan.
2. Besarnya tarif pelayanan Tindakan Medis operatif kebidanan yang bersifat amat segera ditambah
3. Tarif pelayanan tindakan medis operatif kebidanan pasien rawat inap menyesuaikan kelas perawatannya.
4. Obat dan bahan habis pakai untuk tindakan operatif kebidanan akan diresepkan.
5. Besarnya jasa medis anastesi sama dengan 50% dari jasa tindakan medis operatior.
6. Tindakan medis operatif dengan resiko anastesi tinggi jasa anastesinya ditambah 25 % ( 75%)
7. Persalinan patologis, bayi harus memperoleh pengawasan dokter spesialis anak dan dikenakan
jasa medis sebesar 1/3 ( sepertiga ) dari jasa medis spesialis obsgyn.
8. Apabila persalinan normal dilakukan oleh bidan, maka jasa pelayannya sebesar 1/3 jasa dokter spesialis
E. TINDAKAN GIGI DAN MULUT PASIEN RAWAT INAP.

No. Katagori Pelayanan / Jasa Sarana Jasa Pelayanan Tarif
1 2 3 4 5
1 Tind. Sederhana
III 15,000.00 15,000.00 30,000.00
II. 15,000.00 20,000.00 35,000.00
I. 15,000.00 25,000.00 40,000.00
VIP. 15,000.00 45,000.00 60,000.00
VVIP. 15,000.00 60,000.00 75,000.00
2 Tindakan Kecil 1
III 20,000.00 25,000.00 45,000.00
II. 20,000.00 35,000.00 55,000.00
I. 20,000.00 45,000.00 65,000.00
VIP. 20,000.00 70,000.00 90,000.00
VVIP. 20,000.00 100,000.00 120,000.00
3 Tindakan Kecil 2
III 25,000.00 40,000.00 65,000.00
II. 25,000.00 50,000.00 75,000.00
I. 25,000.00 60,000.00 85,000.00
VIP. 25,000.00 85,000.00 110,000.00
VVIP. 25,000.00 125,000.00 150,000.00
4 Tindakan Sedang
III 63,000.00 97,000.00 160,000.00
II. 63,000.00 122,000.00 185,000.00
I. 63,000.00 147,000.00 210,000.00
VIP. 63,000.00 292,000.00 355,000.00
VVIP. 63,000.00 312,000.00 375,000.00
5 Tindakan Besar.
III 126,000.00 194,000.00 320,000.00
II. 126,000.00 244,000.00 370,000.00
I. 126,000.00 294,000.00 420,000.00
VIP. 126,000.00 389,000.00 515,000.00
VVIP. 126,000.00 424,000.00 550,000.00
6 Tindakan Khusus.
III 139,000.00 291,000.00 430,000.00
II. 139,000.00 356,000.00 495,000.00
I. 139,000.00 436,000.00 575,000.00
VIP. 139,000.00 656,000.00 795,000.00
VVIP. 139,000.00 711,000.00 850,000.00
7 Tindakan Canggih
III 198,000.00 387,000.00 585,000.00
II. 198,000.00 467,000.00 665,000.00
I. 198,000.00 582,000.00 780,000.00
VIP. 198,000.00 792,000.00 990,000.00
VVIP. 198,000.00 902,000.00 1,100,000.00
Catatan :
5. Besarnya jasa medis anastesi sama dengan 50% jasa tindakan medis operator.
6. Tidakan medis operatif dengan resiko anastesi tinggi jasa anastesinya ditambah 25 % (75%)
dari jasa medis operator.
V. Pelayanan Tindakan Sitostatika

1 2 3 4 5
1. Sitostatika Golongan I 70,000.00 155,000.00 225,000.00

2. Sitostatika Golongan II 70,000.00 100,000.00 170,000.00
3. Sitostatika Golongan III 35,000.00 46,000.00 81,000.00
Catatan :
1. Tarif pelayanan tindakan sitostatika tersebut diatas adalah untuk satu kali tindakan.
2. Tarif pelayanan tindakan sitostatika tersebut diatas tidak termasuk biaya pemeriksaan laboratorium,
obat-obatan, alat kesehatan.
3. Apabila pasien memerlukan rawat inap, tarip ruang perawatan dihitung tersendiri sesuai kelas perawatan
yang ditempati.
VI. Pelayanan Penunjang Medik.

A. Pemeriksaan Laboratorium.
1 2 3 4 5
I. SEDERHANA I
1. III. 1,600.00 1,100.00 2,700.00
II 1,600.00 1,500.00 3,100.00
I 1,600.00 2,000.00 3,600.00
VIP 1,600.00 2,400.00 4,000.00
VVIP 1,600.00 2,900.00 4,500.00
II. SEDERHANA II.
2. III. 2,000.00 2,500.00 4,500.00
II 2,000.00 3,000.00 5,000.00
I 2,000.00 3,500.00 5,500.00
VIP 2,000.00 4,000.00 6,000.00
VVIP 2,000.00 4,500.00 6,500.00
3. SEDANG I.
III. 2,800.00 3,000.00 5,800.00
II 2,800.00 3,500.00 6,300.00
I 2,800.00 4,000.00 6,800.00
VIP 2,800.00 5,000.00 7,800.00
VVIP 2,800.00 5,700.00 8,500.00
4. SEDANG II.
III. 6,500.00 6,000.00 12,500.00
II 6,500.00 9,000.00 15,500.00
I 6,500.00 11,000.00 17,500.00
VIP 6,500.00 14,000.00 20,500.00
VVIP 6,500.00 18,500.00 25,000.00
5. CANGGIH
III. 16,000.00 16,000.00 32,000.00
II 16,000.00 21,000.00 37,000.00
I 16,000.00 25,000.00 41,000.00
VIP 16,000.00 35,000.00 51,000.00
VVIP 16,000.00 39,000.00 55,000.00
6. Dengue Blot IgG + IgM
III. 9,000.00 9,000.00 18,000.00
II 12,000.00 12,000.00 24,000.00
I 15,000.00 15,000.00 30,000.00
VIP 18,000.00 18,000.00 36,000.00
VVIP 21,000.00 21,000.00 42,000.00
7. Hematologi
(Autoanalyzer)
III. 4,200.00 4,200.00 8,400.00
II 5,900.00 5,900.00 11,800.00
I 7,000.00 7,000.00 14,000.00
VIP 8,400.00 8,400.00 168,000.00
VVIP 9,800.00 9,800.00 19,600.00
8. Blood Gaz Analyzer (BGA)
III. 9,000.00 9,000.00 18,000.00
II 12,000.00 12,000.00 24,000.00
I 15,000.00 15,000.00 30,000.00
VIP 18,000.00 18,000.00 42,000.00
VVIP 21,000.00 21,000.00 45,000.00
Catatan :
1. Tarif pemeriksaan tersebut belum termasuk bahan habis pakai / reagen
2. Tarif pemeriksaan laboratorium pasien dari poliklinik RSUD, Puskesmas dan RSUD Pemerintah lainnya sesuai
tarif kelas III.
3. Tarif pemeriksaan loboratorium untuk pemeriksaan kesehatan pegawai Negeri/TNI POLRI
4. Tarif pemeriksaan loboratorium pasien dari praktek swasta, RSU Swasta, pemeriksaan
5. Pemeriksaan laboratorium yang bersifat amat segera ( Cito ) dikenakan tambahan sebesar
25 % ( dua puluh lima persen ) dari tarif.
VII. PEMERIKSAAN RADIO DIAGNOSTIK DAN TINDAKAN KHUSUS.

A. Tarif Pelayanan Radiodiagnostik
1 2 3 4 5
I. SEDERHANA
III. 22,500.00 10,000.00 32,500.00
II 22,500.00 16,000.00 38,500.00
I 22,500.00 20,000.00 42,500.00
VIP 22,500.00 22,500.00 47,500.00
VVIP 22,500.00 25,000.00 57,500.00
II. SEDANG
III. 43,500.00 22,000.00 56,500.00
II 43,500.00 23,500.00 58,000.00
I 43,500.00 25,000.00 59,500.00
VIP 43,500.00 26,500.00 62,500.00
VVIP 43,500.00 28,000.00 70,000.00
III. BESAR
Bone Survey
III. 170,000.00 100,000.00 270,000.00
II 170,000.00 108,000.00 278,000.00
I 170,000.00 116,500.00 286,500.00
VIP 170,000.00 126,000.00 296,000.00
VVIP 170,000.00 136,000.00 306,000.00
Abdomen 3
III. 50,000.00 55,000.00 105,000.00
II 50,000.00 59,400.00 109,400.00
I 50,000.00 64,000.00 114,000.00
VIP 50,000.00 69,000.00 119,000.00
VVIP 50,000.00 74,500.00 124,500.00
Scoliosis Pr
III. 150,000.00 75,000.00 225,000.00
II 150,000.00 81,000.00 231,000.00
I 150,000.00 87,500.00 237,500.00
VIP 150,000.00 94,500.00 244,500.00
VVIP 150,000.00 102,000.00 252,000.00
VC 4 ps
III. 50,000.00 50,000.00 100,000.00
II 50,000.00 54,000.00 104,000.00
I 50,000.00 58,000.00 108,000.00
VIP 50,000.00 63,000.00 113,000.00
VVIP 50,000.00 68,000.00 118,000.00
VL 4 ps
III. 75,000.00 75,000.00 150,000.00
II 75,000.00 81,000.00 156,000.00
I 75,000.00 87,500.00 162,500.00
VIP 75,000.00 94,500.00 169,500.00
VVIP 75,000.00 102,000.00 177,000.00
Pelvis 3 ps
III 60,000.00 50,000.00 110,000.00
II 60,000.00 54,000.00 114,000.00
I 60,000.00 58,300.00 118,300.00
VIP 60,000.00 63,000.00 123,000.00
VVIP 60,000.00 68,000.00 128,000.00
IV KONTRAS
Esofagografi A
III 50,000.00 65,000.00 115,000.00
II 50,000.00 69,500.00 119,500.00
I 50,000.00 74,500.00 124,500.00
VIP 50,000.00 79,000.00 129,000.00
VVIP 50,000.00 85,000.00 135,000.00
Esofagografi D
III 50,000.00 70,000.00 120,000.00
II 50,000.00 75,000.00 125,000.00
I 50,000.00 80,000.00 130,000.00
VIP 50,000.00 85,000.00 135,000.00
VVIP 50,000.00 90,000.00 140,000.00
OMD Anak
III 70,000.00 80,000.00 150,000.00
II 70,000.00 85,000.00 155,000.00
I 70,000.00 90,000.00 160,000.00
VIP 70,000.00 95,000.00 165,000.00
VVIP 70,000.00 100,000.00 170,000.00
OMD Dewasa
III 70,000.00 90,000.00 160,000.00
II 70,000.00 96,000.00 166,000.00
I 70,000.00 102,000.00 172,000.00
VIP 70,000.00 109,000.00 179,000.00
VVIP 70,000.00 116,000.00 186,000.00
Colom / Loop A
III 65,000.00 65,000.00 130,000.00
II 65,000.00 69,500.00 134,500.00
I 65,000.00 74,300.00 139,300.00
VIP 65,000.00 79,500.00 144,500.00
VVIP 65,000.00 85,000.00 150,000.00
Colon / Loop D
III 65,000.00 75,000.00 140,000.00
II 65,000.00 80,000.00 145,000.00
I 65,000.00 85,000.00 150,000.00
VIP 65,000.00 90,000.00 155,000.00
VVIP 65,000.00 95,000.00 160,000.00
IVP Anak
III 80,000.00 80,000.00 160,000.00
II 80,000.00 85,000.00 165,000.00
I 80,000.00 90,000.00 170,000.00
VIP 80,000.00 95,000.00 175,000.00
VVIP 80,000.00 100,000.00 180,000.00
IVP Dewasa
III 80,000.00 90,000.00 170,000.00
II 80,000.00 96,000.00 176,000.00
I 80,000.00 102,000.00 182,000.00
VIP 80,000.00 109,000.00 189,000.00
VVIP 80,000.00 116,000.00 196,000.00
Sistografi
III 50,000.00 80,000.00 130,000.00
II 50,000.00 85,000.00 135,000.00
I 50,000.00 90,000.00 140,000.00
VIP 50,000.00 95,000.00 145,000.00
VVIP 50,000.00 100,000.00 150,000.00
Uretrosistografi
III 70,000.00 80,000.00 150,000.00
II 70,000.00 85,000.00 155,000.00
I 70,000.00 90,000.00 160,000.00
VIP 70,000.00 95,000.00 165,000.00
VVIP 70,000.00 100,000.00 170,000.00
Fistulografi
III 70,000.00 90,000.00 160,000.00
II 70,000.00 96,000.00 166,000.00
I 70,000.00 102,000.00 172,000.00
VIP 70,000.00 109,000.00 179,000.00
VVIP 70,000.00 116,000.00 186,000.00
Appendicografi
III 50,000.00 65,000.00 115,000.00
II 50,000.00 69,500.00 119,500.00
I 50,000.00 74,300.00 124,300.00
VIP 50,000.00 79,500.00 129,500.00
VVIP 50,000.00 85,000.00 135,000.00
Mylografi
III 80,000.00 90,000.00 170,000.00
II 80,000.00 96,000.00 176,000.00
I 80,000.00 102,000.00 182,000.00
VIP 80,000.00 109,000.00 189,000.00
VVIP 80,000.00 116,000.00 196,000.00
IV CANGGIH
A. Pemeriksaan CT Scan Non Kontras
1. Head, Temporal, Orbita, Colli
III. 270,000.00 130,000.00 400,000.00
II 270,000.00 165,000.00 435,000.00
I 270,000.00 20,000.00 290,000.00
VIP 270,000.00 255,000.00 525,000.00
VVIP 270,000.00 315,000.00 585,000.00
2. Vertebrae, Osteo
III. 300,000.00 150,000.00 450,000.00
II 300,000.00 187,500.00 487,500.00
I 300,000.00 225,000.00 525,000.00
VIP 300,000.00 280,000.00 580,000.00
VVIP 300,000.00 345,000.00 645,000.00
3. SPN
III. 345,000.00 155,000.00 500,000.00
II 345,000.00 195,000.00 540,000.00
I 345,000.00 245,000.00 590,000.00
VIP 345,000.00 310,000.00 655,000.00
VVIP 345,000.00 380,000.00 725,000.00
4. Upper Abdomen
III. 405,000.00 220,000.00 625,000.00
II 405,000.00 270,000.00 675,000.00
I 405,000.00 325,000.00 730,000.00
VIP 405,000.00 400,000.00 805,000.00
VVIP 405,000.00 490,000.00 895,000.00
5. Thorax
III. 420,000.00 230,000.00 650,000.00
II 420,000.00 280,000.00 700,000.00
I 420,000.00 330,000.00 750,000.00
VIP 420,000.00 420,000.00 840,000.00
VVIP 420,000.00 505,000.00 925,000.00
6. Lower Abdomen
III. 465,000.00 260,000.00 725,000.00
II 465,000.00 315,000.00 780,000.00
I 465,000.00 380,000.00 845,000.00
VIP 465,000.00 470,000.00 935,000.00
VVIP 465,000.00 485,000.00 950,000.00
7. Nasopharyng
III. 510,000.00 290,000.00 800,000.00
II 510,000.00 353,000.00 863,000.00
I 510,000.00 422,000.00 932,000.00
VIP 510,000.00 520,000.00 1,030,000.00
VVIP 510,000.00 560,000.00 1,070,000.00
8. Whole Abdomen
III. 840,000.00 510,000.00 1,350,000.00
II 840,000.00 610,000.00 1,450,000.00
I 840,000.00 710,000.00 1,550,000.00
VIP 840,000.00 870,000.00 1,710,000.00
VVIP 840,000.00 1,010,000.00 1,850,000.00
B. Pemeriksaan CT Scan Kontras
1. Head, Temporal, Orbita, Colli
III. 360,000.00 140,000.00 500,000.00
II 360,000.00 203,000.00 563,000.00
I 360,000.00 270,000.00 630,000.00
VIP 360,000.00 342,500.00 702,500.00
VVIP 360,000.00 420,000.00 780,000.00
2. Vertebrae, Osteo
III. 420,000.00 180,000.00 600,000.00
II 420,000.00 250,000.00 670,000.00
I 420,000.00 325,000.00 745,000.00
VIP 420,000.00 405,000.00 825,000.00
VVIP 420,000.00 490,000.00 910,000.00
3. SPN
III. 480,000.00 170,000.00 650,000.00
II 480,000.00 247,000.00 727,000.00
I 480,000.00 330,000.00 810,000.00
VIP 480,000.00 420,000.00 900,000.00
VVIP 480,000.00 520,000.00 1,000,000.00
4. Upper Abdomen
III. 510,000.00 190,000.00 700,000.00
II 510,000.00 295,000.00 805,000.00
I 510,000.00 400,000.00 910,000.00
VIP 510,000.00 520,000.00 1,030,000.00
VVIP 510,000.00 640,000.00 1,150,000.00
5. Thorax
III. 720,000.00 330,000.00 1,050,000.00
II 720,000.00 435,000.00 1,155,000.00
I 720,000.00 550,000.00 1,270,000.00
VIP 720,000.00 680,000.00 1,400,000.00
VVIP 720,000.00 805,000.00 1,525,000.00
6. Lower Abdomen
III. 600,000.00 250,000.00 850,000.00
II 600,000.00 362,000.00 962,000.00
I 600,000.00 480,000.00 1,080,000.00
VIP 600,000.00 610,000.00 1,210,000.00
VVIP 780,000.00 750,000.00 1,530,000.00
7. Nasopharyng
III. 780,000.00 370,000.00 1,150,000.00
II 780,000.00 485,000.00 1,265,000.00
I 780,000.00 600,000.00 1,380,000.00
VIP 780,000.00 730,000.00 1,510,000.00
VVIP 780,000.00 870,000.00 1,650,000.00
8. Whole Abdomen
III. 1,200,000.00 600,000.00 1,800,000.00
II 1,200,000.00 756,000.00 1,956,000.00
I 1,200,000.00 921,000.00 2,121,000.00
VIP 1,200,000.00 1,096,000.00 2,296,000.00
VVIP 1,200,000.00 1,280,000.00 2,480,000.00
C. Pemeriksaan Ultrasonografi (USG)
1 Abdomen, Colli, Head, Ginekologi
III 30,000.00 45,000.00 75,000.00
II. 30,000.00 70,000.00 100,000.00
I. 30,000.00 95,000.00 125,000.00
VIP. 30,000.00 120,000.00 150,000.00
VVIP. 30,000.00 170,000.00 200,000.00
2 Tiroid, Mamae,Testis, Obstetri
III 40,000.00 60,000.00 100,000.00
II 40,000.00 85,000.00 125,000.00
I. 40,000.00 110,000.00 150,000.00
VIP. 40,000.00 135,000.00 175,000.00
VVIP. 40,000.00 185,000.00 225,000.00
3. Doppler
III 75,000.00 50,000.00 125,000.00
II. 75,000.00 100,000.00 175,000.00
I. 75,000.00 150,000.00 225,000.00
VIP. 75,000.00 200,000.00 275,000.00
VVIP. 75,000.00 250,000.00 325,000.00
4. Echocardiografi
III 75,000.00 50,000.00 125,000.00
II. 75,000.00 100,000.00 175,000.00
I. 75,000.00 175,000.00 250,000.00
VIP. 75,000.00 275,000.00 350,000.00
VVIP. 75,000.00 375,000.00 450,000.00
5 EKG
III 30,000.00 25,000.00 55,000.00
II. 30,000.00 35,000.00 65,000.00
I. 30,000.00 45,000.00 75,000.00
VIP. 30,000.00 55,000.00 85,000.00
VVIP. 30,000.00 70,000.00 100,000.00
Catatan :
1. Tarif pemeriksaan tersebut belum termasuk bahan habis pakai.
2. Tarif pemeriksaan Radiodiagnostik tersebut sudah termasuk jasa pembacaan hasil
Pemerintah lainnya sesuai tarif kelas III.
25 % ( dua puluh lima persen ) dari jasa pelayanan.
7. Pemeriksaan Radiodiagnostik bersifat amat segera ( Cito ) apabila dikerjakan setelah jam 13.
/setelah jam kerja.
E. Tarif pemakaian alat.

Tarif
( Rp. )
1 2 3
1. Infant Warmer (per jam) 5,500.00
2. Blue Light (per jam) 6,800.00
3. Incubator per hari 13,500.00
4. Bedside Monitor per hari 78,000.00
5. Syringe Pump per hari 77,200.00
6. Infusion Pump per hari 77,500.00
7. Ventilator per hari 150,000.00
D. Tarif Tindakan Spesialis Rehab Medik dan Fisioterapi.

No.
1 2 3 4 5
1 Sederhana.
III 5,000.00 10,000.00 20,000.00
II. 5,000.00 15,000.00 20,000.00
I. 5,000.00 20,000.00 25,000.00
VIP. 5,000.00 25,000.00 30,000.00
VVIP. 5,000.00 30,000.00 35,000.00
2 Sedang.
III 9,000.00 13,000.00 22,000.00
II. 9,000.00 21,000.00 30,000.00
I. 9,000.00 26,000.00 35,000.00
VIP. 9,000.00 31,000.00 40,000.00
VVIP. 9,000.00 41,000.00 50,000.00
VIII. Pelayanan Lain-lain.
A. Konsultasi Remaja & Keluarga Pelayanan Psikologi.
No.
1 2 3 4 5
- Intake interview 3,750.00 11,250.00 15,000.00
- Psikhologi dasar. 6,250.00 18,750.00 25,000.00
- Psikhiatri dasar. 6,250.00 18,750.00 25,000.00
2. Konsultasi
- Psikhiatri/Psykholog 7,500.00 22,500.00 30,000.00
lanjutan 45 menit.
- Dokter ahli. 7,500.00 22,500.00 30,000.00
- Tes Bendergestali 12,500.00 37,500.00 50,000.00
- Tes Rochaach 12,500.00 37,500.00 50,000.00
- Tes WAIS 12,500.00 37,500.00 50,000.00
4. Terapi.
- Gestalt Terapi/ 45 menit. 12,500.00 37,500.00 50,000.00
- Suport Terapi/ 45 menit. 12,500.00 37,500.00 50,000.00
- Terapi perilaku/45 menit 12,500.00 37,500.00 50,000.00
- Terapi Kelompok/45 menit 12,500.00 37,500.00 50,000.00
- Marital Terapi/45 menit 12,500.00 37,500.00 50,000.00
- Famili Terapi 45 menit. 12,500.00 37,500.00 50,000.00
5. Psichotest.
- Seleksi/Promosi Karyawan. 12,500.00 37,500.00 50,000.00
- Untuk penjurusan/minat/bakat 12,500.00 37,500.00 50,000.00
- Test Intelegensi 12,500.00 37,500.00 50,000.00
- Konsultasi tanpa tes penunjang 12,500.00 37,500.00 50,000.00
- Konsultasi dengan test psycho penunjang 12,500.00 37,500.00 50,000.00
B. Konsultasi Gizi.
No.
1 2 3 4 5
1 Pasien Rawat Jalan. 2,250.00 5,250.00 7,500.00
III 2,250.00 5,250.00 7,500.00
II. 2,250.00 7,250.00 9,500.00
I. 2,250.00 9,250.00 11,500.00
VIP. 2,250.00 13,750.00 16,000.00
VVIP. 2,250.00 17,750.00 20,000.00
C. Pelayanan CSSD ( Strerilitasi ).

Autoclave ( Steam ).
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Pelayanan Biasa.
- Linen s/d 5 Kg. 7,500.00 7,500.00 15,000.00
- Iinstrmen umum s/d 5 kg 7,500.00 7,500.00 15,000.00
- Iinstrmen khusus s/d 5 kg 12,500.00 12,500.00 25,000.00

- Linen s/d 5 Kg. 10,000.00 10,000.00 20,000.00

- Lenin s/d 50 Kg. 75,000.00 75,000.00 150,000.00
Autoclave ( Formaline ).
(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Pelayanan Biasa.
- Lenin s/d 5 Kg. 4,500.00 4,500.00 9,000.00
2. Pelayanan Cito dalam jam kerja. 0.00
- Lenin s/d 5 Kg. 7,500.00 7,500.00 15,000.00
- Lenin diatas 5 kg tambahan per Kg. 2,250.00 2,250.00 4,500.00
3. Pelayanan Cito diluar jam kerja. 0.00
- Lenin s/d 50 Kg. 75,000.00 75,000.00 150,000.00
Catatan :
1. Biaya dikenakan untuk :
a. Titipan alat, bahan milik pribadi institusi diluar RSUD yang diseterilkan, yang digunakan diluar
RSUD.
2. Sifat Pelayanan.
a. Biaya : Alat/Bahan siap steril, setelah 3 (tiga) jam ( dalam jam kerja ).
b. Cito : Dalam Jam kerja : alat/bahan siap steril setelah 1 (satu) jam
Diluar jam kerja : alat/bahan siap steril setelah 1 (satu) jam
3. Jenis alat :
a. Linen
b. Instrumen umum : Instrumen bukan disposibel.
c. Instrumen khusus : Instrumen disposibel.
d. Plastik dan karet : Alat Medis habis pakai, sarung tangan.
4. Jenis Sterilisasi :
a. Autoclave - steam : Untuk lenin, instrumen, kaca, plastik tahan panas, karet.
b. Autoclave-Formaline : Untuk kaca, plastik tidak tahan panas tinggi.
D. Pemulasaraan Jenazah.
Katagori Pelayanan Bahan habis Jasa Sarana Jasa Pelayanan Tarif
No.
Kelas. pakai (Rp.) (Rp.) (Rp.)
1 2 3 4 5 6
III 139,000.00 52,000.00 150,000.00 341,000.00
II. 139,000.00 52,000.00 165,000.00 356,000.00
I. 139,000.00 52,000.00 180,000.00 371,000.00
VIP. 139,000.00 52,000.00 250,000.00 441,000.00
VVIP. 139,000.00 52,000.00 250,000.00 441,000.00
Jenazah.
III 85,500.00 96,000.00 142,500.00 324,000.00
II. 85,500.00 96,000.00 147,500.00 329,000.00
I. 85,500.00 96,000.00 152,500.00 334,000.00
VIP. 85,500.00 96,000.00 162,500.00 344,000.00
VVIP. 85,500.00 96,000.00 178,500.00 360,000.00
III 12,000.00 37,500.00 112,500.00 162,000.00
II. 12,000.00 37,500.00 117,500.00 167,000.00
I. 12,000.00 37,500.00 122,500.00 172,000.00
VIP. 12,000.00 37,500.00 132,500.00 182,000.00
VVIP. 12,000.00 37,500.00 142,500.00 192,000.00
4 Penitipan Jenazah
dari RSUD per hari.
III 12,000.00 83,000.00 65,000.00 160,000.00
II. 12,000.00 83,000.00 70,000.00 165,000.00
I. 12,000.00 83,000.00 75,000.00 170,000.00
VIP. 12,000.00 83,000.00 85,000.00 180,000.00
VVIP. 12,000.00 83,000.00 95,000.00 190,000.00
5 Penitipan Jenazah dari Luar RSUD per hari
III 12,000.00 83,000.00 70,000.00 165,000.00
II. 12,000.00 83,000.00 75,000.00 170,000.00
I. 12,000.00 83,000.00 80,000.00 175,000.00
VIP. 12,000.00 83,000.00 90,000.00 185,000.00
VVIP. 12,000.00 83,000.00 95,000.00 185,000.00
6 Pembongkaran Jenazah
III 100,000.00 220,000.00 250,000.00 570,000.00
II. 100,000.00 220,000.00 260,000.00 580,000.00
I. 100,000.00 220,000.00 270,000.00 590,000.00
VIP. 100,000.00 220,000.00 300,000.00 620,000.00
VVIP. 100,000.00 220,000.00 350,000.00 670,000.00
8 Visum Jenazah.
III 13,000.00 15,000.00 35,000.00 63,000.00
II. 13,000.00 15,000.00 40,000.00 68,000.00
I. 13,000.00 15,000.00 45,000.00 73,000.00
VIP. 13,000.00 15,000.00 55,000.00 83,000.00
VVIP. 13,000.00 15,000.00 65,000.00 93,000.00
E. Pelayanan Ambulance/Mobil Jenazah.

Tarif
( Rp. )
1 2 3
1 Sampai dengan jarak 10 Km. 75,000.00
2 Jarak lebih dari 10 Km, dihitung 1 Km kali harga
BBM
F. Pelayanan Mediko Legal.

(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
- Jarak sampai dengan 10 Km. 159,000.00 239,000.00 398,000.00
- Jarak 10 Km s/d 30 Km. 249,000.00 239,000.00 488,000.00
setiap 1 Km.
2 Surat Keterangan Rumah Sakit. 2,500.00 2,500.00 5,000.00
III 10,000.00 10,000.00 20,000.00
II. 10,000.00 12,500.00 22,500.00
I. 10,000.00 15,000.00 25,000.00
VIP. 10,000.00 20,000.00 30,000.00
G. Pemeriksaan Kesehatan untuk Pemberian Surat Keterangan Kesehatan.

(Rp.) (Rp.) ( Rp. )
1 2 3 4 5
1 Orang Sakit dan Hamil/Bersalin/Masa Nifas 2,500.00 2,500.00 5,000.00
2 Malanjutkan Sekolah 2,500.00 2,500.00 5,000.00
3 Malamar Pekerjaan 2,500.00 2,500.00 5,000.00
4 Mengikuti Kursus 2,500.00 2,500.00 5,000.00
5 Keluar Negeri 12,500.00 12,500.00 25,000.00
6 Keperluan Asuransi 15,000.00 15,000.00 30,000.00

JASA
PRASARANA PELAYANAN
I. PELAYANAN PEMERIKSAAN
LABORATORIUM
3 Hb Sahli Rp 1,750 Rp 6,500 Rp 8,250
4 Leukosit Rp 1,750 Rp 1,500 Rp 3,250
6 LED Rp 1,750 Rp 1,500 Rp 3,250
B Urine
2 Reduksi I Rp 1,000 Rp 1,000 Rp 2,000
5 PH Rp 1,000 Rp 1,000 Rp 2,000
6 Protein Rp 1,000 Rp 1,000 Rp 2,000
8 Urobilin Rp 1,000 Rp 1,000 Rp 2,000
C Kimia Klinik
- Terumo
- Cair
Accuntrend
7 SGOT Rp 750 Rp 3,250 Rp 4,000
8 SGPT Rp 750 Rp 3,375 Rp 4,125
9 Asam Urat Rp 500 Rp 4,200 Rp 4,700
10 Ureum Rp 750 Rp 3,375 Rp 4,125
12 Albumin Rp 750 Rp 2,750 Rp 3,500
15 HDL - LDL Rp 750 Rp 5,750 Rp 6,500
D Serologi
Ig G dan Ig M
5 HBSAg Rp 1,750 Rp 5,250 Rp 7,000
7 ASTO Rp 1,000 Rp 10,250 Rp 11,250
E Mikrobiologi
1 BTA Paru Rp 2,300 Rp 1,700 Rp 4,000
2 BTA Kusta Rp 1,300 Rp 1,700 Rp 3,000
3 Malaria Rp 1,300 Rp 1,700 Rp 3,000
F Pemeriksaan Air
1 Fisik Rp 2,500 Rp 5,000 Rp 7,500
3 Secara Kimiawi
d Mangan Rp 2,500 Rp 2,500 Rp 5,000
e Flour Rp 2,500 Rp 6,000 Rp 8,500
f Fe Rp 2,500 Rp 4,000 Rp 6,500
i NH 4 Rp 2,500 Rp 8,000 Rp 10,500
j Cyanida Rp 2,500 Rp 6,000 Rp 8,500
k PH Rp 2,500 Rp 1,000 Rp 3,500
1 Borak Rp 1,500 Rp 3,500 Rp 5,000
2 Formalin Rp 1,500 Rp 3,500 Rp 5,000
3 Pewarna Rp 1,500 Rp 3,500 Rp 5,000
A KIMIA AIR
d Mangan Rp 5,000 Rp 5,000 Rp 10,000
e Flour Rp 5,000 Rp 8,500 Rp 13,500
f Fe Rp 5,000 Rp 6,500 Rp 11,500
i NH 4 Rp 5,000 Rp 10,500 Rp 15,500
j Cyanida Rp 5,000 Rp 8,500 Rp 13,500
k PH Rp 5,000 Rp 3,500 Rp 8,500
1 Borak Rp 6,500 Rp 8,500 Rp 15,000
2 Formalin Rp 6,500 Rp 8,500 Rp 15,000
3 Pewarna Rp 6,500 Rp 8,500 Rp 15,000
BUPATI PEKALONGAN
TTD
A. ANTONO
Diundangkan di Kajen
Pada Tanggal 8 Februari 2012
SEKRETARIS DAERAH KABUPATEN PEKALONGAN
TTD
SUSIYANTO
LEMBARAN DAERAH KABUPATEN PEKALONGAN TAHUN 2012
NOMOR 1

LAMPIRAN 01 Pelayanan Kesehatan

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LAMPIRAN 01 Pelayanan Kesehatan

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LAMPIRAN I

PERATURAN DAERAH KABUPATEN PEKALONGAN

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN

B. Tindakan Rawat Jalan

2. Tarif tindakan di poliklinik gigi dan mulut

4. Tarif tindakan medis non operatif.

1 Sederhana 3,000 7,000 10,000

2. Tindakan Medis di IGD.

III. Akomodasi Rawat Inap

Pelayanan Makanan Pasien

IV. Tarif Asuhan Keperawatan

VI. PENGGUNAAN ALAT VENTILATOR

VII. Tindakan Medis.

b. Tindakan Medis Non Operatif

VIII. PELAYANAN KEBIDANAN

B. PEMERIKSAAN RADIO DIAGNOSTIK

C. Tarif Pelayanan Diagnostik & Tindakan Khusus.

1 Pasien Rawat Jalan. 2,500 5,000 7,500

D. Pelayanan Ambulance/Mobil Jenazah.

E. Pelayanan Mediko Legal.

Pelayanan Penunjang Medik.

C. Tarif Pelayanan Diagnostik & Tindakan Khusus.

E. Tarif Tindakan Spesialis Rehab Medik dan Fisioterapi.

E. Pelayanan Ambulance/Mobil Jenazah.

F. Pelayanan Mediko Legal.

PEMERIKSAAN RADIO DIAGNOSTIK CITO.

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN

2. Tarif Tindakan di Poliklinik Spesialis Mata.

3. Tarif Tindakan di Poliklinik Spesialis THT.

4. Tarif Tindakan di Poliklinik Spesialis Bedah.

5. Tarif Tindakan di Poliklinik Spesialis Obgyns.

6. Tarif Tindakan di Poliklinik Spesialis Jantung.

8. Tarif Tindakan di Poliklinik Spesialis Rehab Medik dan Fisioterapi.

9. Tarif Tindakan di Poliklinik Kulit Kelamin.

11. Tarif Tindakan di Poliklinik Gigi dan Mulut.

12. Tarif Pelayanan Hemodialisa.

13. Tarif Tindakan Endoskopi.

14. Tarif tindakan medis non operatif.

II. Rawat Darurat.

III. Rawat Inap.

3. Tarif Asuhan Keperawatan

4. Akomodasi Rawat Intensif

5. Akomodasi Rawat HCU

6. Pelayanan dan tindakan di ruang intensif

IV. Tindakan Medis.

B. Tindakan Medis Operatif Subspesialis

C. Tindakan Medis Non Operatif.

D. Pelayanan Kebidanan & Kandungan.

E. TINDAKAN GIGI DAN MULUT PASIEN RAWAT INAP.

V. Pelayanan Tindakan Sitostatika

1. Sitostatika Golongan I 70,000.00 155,000.00 225,000.00

VI. Pelayanan Penunjang Medik.

VII. PEMERIKSAAN RADIO DIAGNOSTIK DAN TINDAKAN KHUSUS.

E. Tarif pemakaian alat.

D. Tarif Tindakan Spesialis Rehab Medik dan Fisioterapi.

C. Pelayanan CSSD ( Strerilitasi ).

2. Pelayanan Cito dalam jam kerja.

3. Pelayanan Cito diluar jam kerja.

E. Pelayanan Ambulance/Mobil Jenazah.

F. Pelayanan Mediko Legal.

G. Pemeriksaan Kesehatan untuk Pemberian Surat Keterangan Kesehatan.