LAMPIRAN PERDA NO 4 TH 2013 TTG PERUB KEDUA PERDA 16 Klas III - PERUB KEDUA - Setalah TGL 10 - 9

1 TINDAKAN SEDERHANA
a. Pelayanan Medik Dasar

1 Arsen/eugeneol fletser 10,000
2 Bongkar filling (amg composit) 25,000
3 Caliun/Tkt.fletser 10,000
4 Pencabutan gigi sulung 15,000
5 Pencabutan gigi tetap 20,000
6 Pengisian cavum pulpa 25,000
7 Pengobatan keradangan 12,000
8 Pulp chapping 20,000
9 Trepanasi/preparasi 25,000
10 Tumpatan amalgam Kl I 30,000
b. Orthodonsi
1 Aktiver alat ortho lepasan 50,000
2 Konsultasi 15,000
3 Pencabutan gigi sulung :
- dengan CE 25,000
- dengan anestesi 30,000
c. Radiologi
1 Dental X Ray / Film 30,000
2 TINDAKAN KECIL
1 Pencegahan / Peningkatan O.H
Scalling / rahang 40,000
2 Currettage / regio 40,000
3 Tumpatan amalgam Kl. II 35,000
4 Bongkar chrom & bridge/gigi 40,000
5 Resementasi crown/gigi 40,000
6 Tumpatan composit/glass ionmer Kl. I kecil , III, IV 40,000
7 GTS lepasan gigi berikutnya per satu gigi (gigi beli sendiri/ 150,000
perrahang)
8 GTS pergigi 50,000
b. Pelayanan Medik Specialist
1) Orthodonsi
a Pasang alat lepasan RA dan RB 1,250,000
b Pasang braket metal :
- RA/RB tehnik straight wire 4,000,000
- RA/RB Teknik begg 3,000,000
c Kontrol (braket metal) :
- RA/RB tehnik straight wire 90,000
- RA/RB Teknik begg 90,000
d Kontrol (braket Ceramic) 200,000
e Kontrol alat lepasan 50,000
3 TINDAKAN SEDANG
1 Bongkar chrom & bridge/gigi 40,000
2 Curretase total 180,000
3 Currettage / regio 40,000
4 Endro intra canal
- satu akar 32,000
- akar ganda 54,000
5 Gingivectomy / regio 60,000
6 Gingivoclast / regio 60,000
7 GTS lepasan gigi berikutnya per satu gigi (gigi beli sendiri/ per 150,000
rahang)
8 GTS lepasan plat acrylic + gigi (gigi beli) 80,000
9 GTS pergigi 50,000
10 Mahkota sementara 60,000
11 Reparasi protesa patah 150,000
15 Tumpatan glass ion composit (Kl. I, Bsr, Kl.II) 50,000
16 Venaer/jacket composit/T. Limpont 70,000
17 Vital Pulpectomy
- satu akar 38,000
- akar ganda 64,000
1) Orthodonsi
a Control alat cekat/kunjungan implant orthodontik 50,000
b Bedah minor pemasangan skrup mini 1,500,000
c Pasang Retainer RA & RB akrilik 1,100,000
d Pasang Retainer invisible RA & RB 1,300,000
e Ganti kawat per rahang (archwire) 100,000
f Penambahan setiap 1 spring (auxiliary spring) :
- alat cekat 80,000
- alat lepasan 60,000
4 TINDAKAN BESAR
a Rebasing prothesa full denture 300,000
b Rebasing prothesa & menambah gigi (gigi beli sendiri) 75,000
c Jacket acrylic (gigi beli sendiri) 300,000
d Bridge acrylic (gigi beli sendiri) 300,000
1) Orthodonsi
a Cetak gigi 50,000
b Ganti braket hilang / gigi :
- braket metal straight wire 80,000
- braket metal begg 70,000
- braket ceramik 190,000
c Lepas braket 200,000
d Pasang band / gigi 180,000
e Pasang band lepas / gigi 70,000
f Pasang braket lepas / gigi 100,000
g Pembersihan karang gigi /kalkulus gigi/rahang:
- Sedikit 350,000
- Sedang 500,000
- banyak 650,000
h Reparasi akrilik 100,000
5. TINDAKAN CANGGIH
1 Alat ortho lepasan /rahang 400,000
2 Alat ortho lanjutan /rahang 300,000
3 Pasak dengan komposit (pasak beli sendiri) 300,000
4 Pasak +inti dengan crown (pasak beli sendiri) 500,000
5 Menyambung gigi fraktur (pasak beli sendiri) 160,000
1) Orthodonsi
a Bite plane/bite raiser 700,000
b Face mask 350,000
c Gigi tiruan lepas per rahang
- Bahan akrilik, gigi pertama+basis 500,000
- Gigi selanjutnya per gigi 150,000
- Bahan valplas, gigi pertama + basis 650,000
- Gigi selanjutnya per gigi 200,000
d Head Gear 350,000
6 TINDAKAN KHUSUS
GTL lepasan/full denture RA/RB 1,000,000

1) Orthodonsi
a Alat ortho cekat RA/RB 4,000,000
b Space regainer per rahang 500,000
c Space maintainer per rahang 500,000
d Oklusal adjusment 500,000
kecil sedang besar canggih khusus
100-500 600-1000 1000-1500 >15000 >20000
LAMPIRAN I : PERATURAN DAERAH KABUPATEN BONDOWOSO
Nomor : 4 TAHUN 2013
Tanggal :
TARIF PELAYANAN KESEHATAN KELAS III

DI RUMAH SAKIT UMUM Dr. H. KOESNADI KABUPATEN BONDOWOSO
I. INSTALASI GAWAT DARURAT

KOMPONEN JASA
TARIF
No. JENIS PELAYANAN SARANA PELAYANAN KETERANGAN
(Rp) (Rp) (Rp)
60% 40%
1. Pemeriksaan Kesehatan Umum:
a. Tanpa Rujukan 18,000 12,000 30,000 per kali
b. Dengan Rujukan Pelayanan Dasar 12,000 8,000 20,000 per kali
2. Observasi < 6 jam :
a. Sarana IGD 30,000 30,000
b. Dokter Umum 15,000 15,000
c. Asuhan Keperawatan 10,000 10,000
3. Jasa Konsultasi dokter spesialis
a. On Site 60,000 60,000 per kali
b. On Call 30,000 30,000 per kali
II. INSTALASI RAWAT JALAN

1. Pemeriksaan Kesehatan Umum: 60% 40%
a. Poli Umum
1)Tanpa Rujukan dari pelayanan dasar/RS Swasta 9,000 6,000 15,000 per kali
2) Dengan Rujukan Pelayanan Dasar 6,000 4,000 10,000 per kali
b. Poli Spesialis
1)Tanpa Rujukan dari pelayanan dasar/RS Swasta 12,000 8,000 20,000 per kali
2) Dengan Rujukan Pelayanan Dasar 9,000 6,000 15,000 per kali
2 Pelayanan Konsultasi
a. Jasa Konsultasi Dokter Spesialis (Konsultasi Antar Poliklinik) 12,000 12,000 per kali
b. Konsultasi Gizi 4,200 2,800 7,000 per kali
c. Konsultasi Obat 4,200 2,800 7,000 per kali
d. Tumbuh Kembang 36,000 24,000 60,000 per kali
e. Oxymetri 3,900 2,600 6,500 per kali
3 Pemeriksaan Psikiatri :
a. Kepribadian (MMPI) 90,000 60,000 150,000 per kali
b. Perawatan Psikiatri 36,000 24,000 60,000 per kali
c. Psikoterapi 30,000 20,000 50,000 per kali
4 Konsultasi Psikologi :
a. Konsultasi Psikologi 4,200 2,800 7,000 per jam
b. Test Psikologi 18,750 12,500 31,250 per kali
Hal 5 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
5 VCT (Voluntary Counseling and Testing) HIV
a. Konseling pra dan pasca test 18,000 12,000 30,000
b. Paket Testing HIV (3 pemeriksaan) 126,000 84,000 210,000
Hal 6 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
6 Konsultasi :
a. Geriatri 12,000 8,000 20,000 per kali
b. Paliatif 12,000 8,000 20,000 per kali
III. INSTALASI RAWAT INAP, RAWAT INTERMEDIATE, RAWAT INTENSIF, RAWAT ISOLASI DAN RAWAT SEHARI (ONE DAY CARE)
A. RAWAT INAP
1 Tarif Kamar
a. Biaya Sarana dan makan minum pasien 50,000 - 50,000 per hari
b. Jasa Pelayanan Asuhan Keperawatan 20,000 20,000 per hari
2. Visite
a. Dokter Umum 20,000 20,000 per hari
b. Dokter Spesialis 30,000 30,000 per hari
3. Konsultasi dokter Specialis
B. TARIF PELAYANAN INTERMEDIATE (termasuk stroke corner )

1. Jasa Akomodasi :
a. Sarana dan makan minum pasien 120,000 - 120,000 per hari
2. Visite
3. Konsultasi dokter Specialis
C. TARIF PELAYANAN RUANG BAYI

1. Jasa Akomodasi :
a. Sarana dan fasilitas Bayi Normal 50,000 50,000 per hari
b. Sarana dan fasilitas Bayi Resiko Tinggi 120,000 120,000 per hari
c. Jasa Pelayanan Asuhan Keperawatan Bayi Normal 30,000 30,000 per hari
d. Jasa Pelayanan Asuhan Keperawatan Bayi Resiko Tinggi 40,000 40,000 per hari
2. Visite
3. Jasa Konsultasi dokter Specialis
D. TARIF RAWAT INTENSIF (ICU, ICCU, PICU, NICU)

1. Jasa Akomodasi :
a. Sarana dan makan minum pasien 140,000 140,000 per hari
2. Visite
Hal 7 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
E. TARIF RAWAT ISOLASI

1. Jasa Akomodasi :
a. Sarana dan makan minum pasien 120,000 - 120,000 per hari
2. Visite
F. TARIF RAWAT SEHARI

1. Jasa Akomodasi :
a. Sarana dan makan minum pasien 90,000 90,000 per hari
2. Visite
II. TARIF PELAYANAN MEDIK

A. TINDAKAN MEDIK OPERATIF
1. KATEGORI OPERASI KECIL
a. Operasi Kecil I
1 Biopsi insisi tumor 306,000 204,000 510,000
2 Debridement dan soft tissue release pada infeksi sendi 306,000 204,000 510,000
3 Debridement dan tutup defek pada gangren diabetik 306,000 204,000 510,000
4 Eksisi tumor adneksa kecil 306,000 204,000 510,000
5 Eksterpasi Kista Ateroma / Lipoma / Ganglion > 2 cm 306,000 204,000 510,000
6 Ekstraksi corpus alienum tanpa komplikasi 306,000 204,000 510,000
7 Excisi clavus 306,000 204,000 510,000
8 Fiksasi Externa Sederhana 306,000 204,000 510,000
9 Fiksasi Interna Sederhana 306,000 204,000 510,000
10 Foto Koagulasi Laser 306,000 204,000 510,000
11 Frenectomi 306,000 204,000 510,000
12 Gingivectomy 306,000 204,000 510,000
13 Gonioplasty 306,000 204,000 510,000
14 Granuloma 306,000 204,000 510,000
15 Hordeolum 306,000 204,000 510,000
16 Incisi abses labia 306,000 204,000 510,000
Hal 8 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
17 Incisi bartholinitis dengan anestesi 306,000 204,000 510,000
18 Incisi Othaematomea 306,000 204,000 510,000
19 Jahit luka kecil (palp) 306,000 204,000 510,000
20 Jahit luka perineum derajat I dan II 306,000 204,000 510,000
21 Jahit luka3 -5 306,000 204,000 510,000
22 Kalazion 306,000 204,000 510,000
23 Laparoscopy Operatif - Histeroscopy 306,000 204,000 510,000
24 Odontectomy Kls. I 306,000 204,000 510,000
25 Pemasangan Flocare 306,000 204,000 510,000
26 Pinguicula 306,000 204,000 510,000
27 Probing ductus nasolakrimalis 306,000 204,000 510,000
28 Repair Muscle/ Tendon 306,000 204,000 510,000
29 Repair ruptur palpebra simple 306,000 204,000 510,000
30 Reposisi fraktur sederhana os nassal 306,000 204,000 510,000
31 Reposisi IOL 306,000 204,000 510,000
32 Reposisi tertutup, Arthrogram, dan Hemispica pada DDH 306,000 204,000 510,000
33 Savary Baougie 306,000 204,000 510,000
34 Sirklase 306,000 204,000 510,000
35 Skin Graft Orthopedi 306,000 204,000 510,000
36 Skleroterapi Varises Esofagus 306,000 204,000 510,000
37 Synovectomy arthroscopy 306,000 204,000 510,000
38 Tenolysis (multiple) Temdon-flexor (ekstremitas atas) 306,000 204,000 510,000
39 Tenotomy Tendon (ekstremitas atas) , contracture 306,000 204,000 510,000
40 Terapi Sklerosing 306,000 204,000 510,000
41 Terminalisation Jari, Trauma 306,000 204,000 510,000
42 Trauma jaringan lunak wajah sederhana 306,000 204,000 510,000
b. Operasi Kecil II
1 Angkat Arch Bar 346,800 231,200 578,000
2 Arthoplasty Sendi (jari), various lesions 346,800 231,200 578,000
3 Arthrodesis sendi 346,800 231,200 578,000
4 Biopsi adneksa 346,800 231,200 578,000
5 Biopsi Eksisional dalam narkose 346,800 231,200 578,000
6 Biopsy Nerve, Various Lesions 346,800 231,200 578,000
7 Blok saraf tepi 346,800 231,200 578,000
8 Bony bridge release pada kasus Tarsal Coalition 346,800 231,200 578,000
9 Debridement Nekrotik Tissue 346,800 231,200 578,000
10 Debridement Jari 346,800 231,200 578,000
Debridement, Nekrotomy, dan Saucerization pada Chronic
11 346,800 231,200 578,000
Osteomyelits
12 Debulking Jari (macrodactyly) 346,800 231,200 578,000
13 Defect grafting (single) Tendon-flexor (ekstremitas atas) 346,800 231,200 578,000
14 Drainage Jaringan lunak (palmar space), abscess 346,800 231,200 578,000
15 Drainase Pus pada Tuboovarial Abses Dengan Punksi Doglasi 92,480 231,200 578,000
16 Eksisi Fibroma 346,800 231,200 578,000
17 Eksisi Fistel Preauricular 346,800 231,200 578,000
18 Ekstraksi benda asing di Saluran Cerna Bagian Atas / Bawah 346,800 231,200 578,000
19 Excochliasi 346,800 231,200 578,000
Hal 9 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
20 Hemostasis Saluran Cerna Bagian Atas / Bawah 346,800 231,200 578,000
21 Incisi abses peritonsil 346,800 231,200 578,000
22 Jahit luka 6-8 346,800 231,200 578,000
23 Koreksi syndactyly kaki 346,800 231,200 578,000
24 Koreksi curly toe 346,800 231,200 578,000
25 Koreksi overriding toe polidactily 346,800 231,200 578,000
26 Laser iridotomi Perifer 346,800 231,200 578,000
27 Lengthening Open Achilles Tendon 346,800 231,200 578,000
Limb ablation: above/below knee amputation Soft Tissue
28 346,800 231,200 578,000
Tumor/sarcoma/ Bone Tumor
29 Local Flap Kulit dan jaringan subkutis, defect (multiple digits) 346,800 231,200 578,000
30 Open Knee Debridement 346,800 231,200 578,000
31 Operasi manual plasenta 346,800 231,200 578,000
32 Polipektomi Saluran Cerna Bagian Atas / Bawah 346,800 231,200 578,000
33 Proctoscopy biopsi 346,800 231,200 578,000
34 Pterigium + CLG 346,800 231,200 578,000
35 Punksi cairan otak dengan narkose 346,800 231,200 578,000
Release (unilateral) Nerve (Ekstremitas atas), Guyon's Tunnel
36 346,800 231,200 578,000
Syndrome
37 Release Jari, deformity, instrinsic muscle 346,800 231,200 578,000
38 Release Kompartemen Otot 346,800 231,200 578,000
39 Release Soft tissue 346,800 231,200 578,000
40 Release Synechia vulva 346,800 231,200 578,000
41 Release Tendon Sheath (ekstremitas atas) 346,800 231,200 578,000
42 Release Tongue Tie 346,800 231,200 578,000
43 Relokasi Jari, deformity, instrinsic muscle extensor 346,800 231,200 578,000
44 Removal Sendi (Extremitas Atas) Rush Rods / Wires / Screw 346,800 231,200 578,000
45 Repair suture Nerve various lesions 346,800 231,200 578,000
46 Reposisi joint dislocation 346,800 231,200 578,000
47 Reposisi tertutup dan gips pada fraktur anak kecuali fraktur femur 346,800 231,200 578,000
Reposisi tertutup dan Percutaneous Pinning pada fraktur seputar
48 346,800 231,200 578,000
sendi siku pada anak
49 Transposisi Nerve ulnar, entrapment 346,800 231,200 578,000
50 Tuba Plasty 346,800 231,200 578,000
51 Yag Laser 346,800 231,200 578,000
c. Operasi Kecil III

1 Apek Reseksi (gigi) 387,600 258,400 646,000
2 Belloque tampon dalam narkose 387,600 258,400 646,000
3 Biopsi rectum full thickness 387,600 258,400 646,000
4 Biopsi saraf kutaneus/otot 387,600 258,400 646,000
5 Biopsi Telinga 387,600 258,400 646,000
6 Biopsi/eksisi KGB, Lipoma, Ganglion, Atheroma 387,600 258,400 646,000
7 Cabut DJ Stent 387,600 258,400 646,000
8 Capsulectomy/ capsulotomy Sendi (jari), contracture 387,600 258,400 646,000
9 Circumcisi non GA 387,600 258,400 646,000
10 Closed Reduction dan pemasangan gips fraktur femur pada anak 387,600 258,400 646,000
11 Dawir 387,600 258,400 646,000
Hal 10 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
Debridement Ulang Vaskuler / Debridement dengan amputasi
12 387,600 258,400 646,000
mayor/minor
13 Debridement AVM 387,600 258,400 646,000
14 Debridement fraktur terbuka 387,600 258,400 646,000
15 Debridement luka 387,600 258,400 646,000
16 Dekompresi (unilateral/ bilateral) ekstremitas atas 387,600 258,400 646,000
17 Drainage Jari, superficial / deep infection 387,600 258,400 646,000
Drainage Tendon sheath (ekstremitas atas), tenosynovitis (single /
18 387,600 258,400 646,000
multiple)
19 Eksisi + Diseksi of neurovasculer bundle (Jari, tumors) 387,600 258,400 646,000
20 Eksisi bony fragment , Elbow (medical epicondyle), fracture 387,600 258,400 646,000
21 Eksisi Jari, jaringan lunak tumor/wart/com/naevus 387,600 258,400 646,000
22 Excisi keloid 387,600 258,400 646,000
Eksisi Tendon sheath (extremitas atas) & jaringan Subkutis ganglion
23 387,600 258,400 646,000
/ villo nodular synovitis
24 Eksisi Xantelasma 387,600 258,400 646,000
25 Eksterpasi atheroma 387,600 258,400 646,000
26 Eksterpasi ganglion 387,600 258,400 646,000
27 Eksterpasi Lipoma 387,600 258,400 646,000
28 Eksterpasi Polip 387,600 258,400 646,000
29 Eksterpasi tumor jinak kulit Ø < 3cm (lipoma, atheroma,dll) 387,600 258,400 646,000
30 Ekstraksi kondiloma 387,600 258,400 646,000
31 Ekstraksi polip telinga dengan LA 387,600 258,400 646,000
32 Enucleatie Kista 387,600 258,400 646,000
33 Fiksasi Cannualted Screw pada SCFE 387,600 258,400 646,000
34 Flap kunjungtiva 387,600 258,400 646,000
Fraktur Tulang Panjang - MIPO/ORIF & Implat Removal (Long
35 387,600 258,400 646,000
Bone)
Free full thickness graft Kulit dan jaringan subkultis, Defect (single
36 387,600 258,400 646,000
digit)
Graft Nerve defect/ peripheral /Tendon-flexor (ekstremitas atas)
37 387,600 258,400 646,000
injury
38 Incisi abses Retroaurikular 387,600 258,400 646,000
39 Insisi drainase/debridemen abses 387,600 258,400 646,000
40 Insisional biopsi kelenjar leher 387,600 258,400 646,000
41 Irigasi Sinus/ DAWO 387,600 258,400 646,000
42 Jahit luka 9 – 12 387,600 258,400 646,000
43 Jahit robekan portio 387,600 258,400 646,000
44 Kista 387,600 258,400 646,000
45 Lobulaplasti (1 telinga/2 Telinga ) 387,600 258,400 646,000
46 Odontectomy Kls. II 387,600 258,400 646,000
47 Open Biopsy Bone Tumor 387,600 258,400 646,000
Operasi Flap (Defect (deep) staged distant flap (division) (Kulit dan
48 387,600 258,400 646,000
jaringan subkus))
49 ORIF Closed Fraktur shaft femur/radius/ulna/humerus/tibia 387,600 258,400 646,000
50 ORIF Open Fr i 387,600 258,400 646,000
51 Pemasangan grommet dg Narkose (Diluar Alkes Gromet ) 387,600 258,400 646,000
52 Pemasangan Pilar Implant/Somnoplasty 387,600 258,400 646,000
53 Penutupan Oroantral Fistula 387,600 258,400 646,000
Hal 11 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
54 Pterygium Eksterpasi 387,600 258,400 646,000
55 Rekonstruksi Vaskuler Sederhana 387,600 258,400 646,000
56 Release (bilateral with endoneurolysis) Nerve (ekstremitas atas) 387,600 258,400 646,000
57 Repair fistel urethra pascauretroplasti 387,600 258,400 646,000
58 Repair Komplikasi AV Shunt 387,600 258,400 646,000
59 Reposisi Iris 387,600 258,400 646,000
60 Reshaping untuk Torus / Tumor Tulang 387,600 258,400 646,000
61 RetCam+Narkose 387,600 258,400 646,000
62 Revisi parut THT 387,600 258,400 646,000
63 Sequesterectomy dengan narkose 387,600 258,400 646,000
64 Sinuskopi/Sinoskopi Dengan Operasi 387,600 258,400 646,000
65 Somnoplasty 387,600 258,400 646,000
66 Trombektomi/lysis dengan catheter for vein 387,600 258,400 646,000
67 Tumor kecil jinak 387,600 258,400 646,000
68 Turbinektomi 387,600 258,400 646,000
69 Turbinoplasty 387,600 258,400 646,000
70 Vasektomy 387,600 258,400 646,000
71 Vena Seksi 387,600 258,400 646,000
2. KATEGORI OPERASI SEDANG

a. Operasi Sedang I
1 Abses dengan GA 510,000 340,000 850,000
2 Alveolectomi dengan GA 510,000 340,000 850,000
3 Biopsi Testis 510,000 340,000 850,000
4 Circumcisi dengan GA 510,000 340,000 850,000
5 Closed Reduksi dengan anastesi umum 510,000 340,000 850,000
6 Curatege death comceptus 510,000 340,000 850,000
7 Curetage post abortus 510,000 340,000 850,000
8 Curetage post retentio plasentae 510,000 340,000 850,000
9 Discograph (1 level/ multilevel) 510,000 340,000 850,000
10 Eksisi Baker Cyst/ ganglion 510,000 340,000 850,000
11 Eksisi FAM <5cm 510,000 340,000 850,000
12 Eksisi Tragus Acsesories 510,000 340,000 850,000
13 Ekstraksi corpus alienum 510,000 340,000 850,000
14 Eksterpasi Poly Dactili 510,000 340,000 850,000
15 Inredectomy basal – perifir sektoral (kdectomy) 510,000 340,000 850,000
16 Koreksi Extropion / Entropion 510,000 340,000 850,000
17 Koreksi Symblepharon 510,000 340,000 850,000
18 Kuretase/dilatasi kuretase dengan narkose 510,000 340,000 850,000
19 Laparatomy percobaan 510,000 340,000 850,000
20 Liberation Joint Stiffness 510,000 340,000 850,000
21 Meatotomi 510,000 340,000 850,000
22 Nekrotomy 510,000 340,000 850,000
23 Neurofibroma 510,000 340,000 850,000
24 Odontectomy Kls. III 510,000 340,000 850,000
25 Operasi Congenital Fornix Plastik 510,000 340,000 850,000
26 ORIF shaft tibia/femur/radius/ulna/humerus grade 3 510,000 340,000 850,000
Hal 12 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
27 Osteomyelitis 510,000 340,000 850,000
28 Osteotomy Jari, deformities 510,000 340,000 850,000
29 Paracenthese 510,000 340,000 850,000
30 Partus normal 510,000 340,000 850,000
31 Partus sungsang bracht 510,000 340,000 850,000
32 Pemasangan traksi servikal 510,000 340,000 850,000
33 Pemasangan WSD 510,000 340,000 850,000
34 Plaster application of extremity & spine 510,000 340,000 850,000
35 Potong colostomy 510,000 340,000 850,000
36 Potong Flap 510,000 340,000 850,000
37 Pthisis bulbi (Graft Mukosa Bibir) 510,000 340,000 850,000
38 Ray Amputation Jari 510,000 340,000 850,000
Reconstruction Anterior Cruciate Ligament
39 510,000 340,000 850,000
(anterior/Posterior/Lateral/Medial)
40 Recurrent Shoulder Dislocation Repair TUBS and AMBRI 510,000 340,000 850,000
41 Reduksi terbuka dan fiksasi interna Jari, Carpus, fracture/dislocation 510,000 340,000 850,000
42 Rekontruksi Instability Joint Infection 510,000 340,000 850,000
Rekontruksi Pulley Tendon (ekstremitas atas),
43 510,000 340,000 850,000
Bowstringing/entrapment
44 Removal of implants (Plate, Nail, Screw) 510,000 340,000 850,000
45 Repair Ruptur Palpebra Transkanal 510,000 340,000 850,000
46 Segmentektomi 510,000 340,000 850,000
47 Sirkumsisi pada Phymosis dengan narkose 510,000 340,000 850,000
48 Skin graft 510,000 340,000 850,000
49 Tampon belloque 510,000 340,000 850,000
50 Total Joint Arthroplasty 510,000 340,000 850,000
51 Vasektomi dengan Narkose 510,000 340,000 850,000
b. Operasi Sedang II
1 Amputasi jari extra digit( single) 612,000 408,000 1,020,000
2 Biopsi Ginjal Perkutan 612,000 408,000 1,020,000
3 Biopsi ginjal terbuka 612,000 408,000 1,020,000
4 Biopsi Incisional dalam narkose 612,000 408,000 1,020,000
5 Biopsi Prostat 612,000 408,000 1,020,000
6 Biopsi tumor hidung,lidah, Nasofaring THT 612,000 408,000 1,020,000
7 Cone Biopsi/Konisasi/LETZ 612,000 408,000 1,020,000
8 Curetage mised bortion 612,000 408,000 1,020,000
9 Debridement dengan skingrafting kecil 612,000 408,000 1,020,000
10 Drainage Kista Pankreas 612,000 408,000 1,020,000
11 Drainage Periureter 612,000 408,000 1,020,000
12 Eksisi FAM>5cm 612,000 408,000 1,020,000
13 Eksisi Hygroma/Lymphagioma simple 612,000 408,000 1,020,000
14 Eksisi Kista Brachialis 612,000 408,000 1,020,000
15 Eksplorasi Abses Multiple 612,000 408,000 1,020,000
16 Eksplorasi nasofaring 612,000 408,000 1,020,000
17 Eksterpasi Kista Bronchialis 612,000 408,000 1,020,000
18 Ekterpasi Geborn myoma +kuretase 612,000 408,000 1,020,000
19 Eksterpasi tumor jinak kulit Ø > 3cm (lipoma, atheroma,dll) 612,000 408,000 1,020,000
Hal 13 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
20 Eksterpasi tumor jinak lain > 5 cm 612,000 408,000 1,020,000
21 Ekstraksi corpus alienum dengan GA 612,000 408,000 1,020,000
22 Ekstraksi polip dengan GA 612,000 408,000 1,020,000
23 Forceps 612,000 408,000 1,020,000
24 Fraktur neck humerus pada orang tua (>60) 612,000 408,000 1,020,000
25 Heacting repair 612,000 408,000 1,020,000
26 hemiarthroplasty Fraktur collum femur pada orang tua (>60) 612,000 408,000 1,020,000
27 Hemiartroplasty : Metastatic Bone Disease 612,000 408,000 1,020,000
28 Induksi persalinan spontan 612,000 408,000 1,020,000
29 Jahit perineum derajat III dan IV 612,000 408,000 1,020,000
30 Keratosis telinga dengan GA 612,000 408,000 1,020,000
31 Koreksi Disartikulasi 612,000 408,000 1,020,000
32 Laringofisure 612,000 408,000 1,020,000
33 Meatoplasti 612,000 408,000 1,020,000
34 Minilaparatomie (Extractie IUD) 612,000 408,000 1,020,000
35 Operasi Blok Resectie 612,000 408,000 1,020,000
36 Operasi Cyclodia Termi 612,000 408,000 1,020,000
37 Operasi Laringoscopi biopsi 612,000 408,000 1,020,000
38 Partus Conduplicatio 612,000 408,000 1,020,000
39 Partus dengan distosia bahu 612,000 408,000 1,020,000
40 Partus HPP 612,000 408,000 1,020,000
41 Partus sungsang extractie kaki 612,000 408,000 1,020,000
42 Partus sungsang manual aid 612,000 408,000 1,020,000
43 Pemasangan Pipa Shepard 612,000 408,000 1,020,000
44 Polypectomy rectum 612,000 408,000 1,020,000
45 Potong Stump (Rectum) 612,000 408,000 1,020,000
46 Prosedur Thiersch (Prolaps anus) 612,000 408,000 1,020,000
47 Quretage molahidatidosa 612,000 408,000 1,020,000
48 Rekons defek/kelainan tubuh yg simple 612,000 408,000 1,020,000
49 Rekonstruksi Jari, Defect/contracture (single/multiple) 612,000 408,000 1,020,000
50 Rekontruksi Limb Leg Inequality - Bone Lengthening Transport 612,000 408,000 1,020,000
51 Rekontruksi Neglected Case - Bone 612,000 408,000 1,020,000
52 Repair luka robek sederhana pada wajah 612,000 408,000 1,020,000
53 Reposisi dislokasi Temporo Mandibula Joint (TMJ) 612,000 408,000 1,020,000
54 Septectomy (Potong Septum) 612,000 408,000 1,020,000
55 Sphyngterotomy 612,000 408,000 1,020,000
56 Trabekulektomi 612,000 408,000 1,020,000
57 Tracheostomy 612,000 408,000 1,020,000
58 Vacum extractie 612,000 408,000 1,020,000
c. Operasi Sedang III

1 Amputasi + rekonstruksi jari polydactil 765,000 510,000 1,275,000
2 Adenoidektomi 765,000 510,000 1,275,000
3 Amputasi Transmedular 765,000 510,000 1,275,000
4 Anterior / Posterior Sklerotomi 765,000 510,000 1,275,000
5 Antrostomi sinus maksilaris dengan GA 765,000 510,000 1,275,000
6 Biopsi tumor orbita 765,000 510,000 1,275,000
Hal 14 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
7 Biopsy Vertebra (1 level) 765,000 510,000 1,275,000
8 Caldwell Luc Anthrostomi 765,000 510,000 1,275,000
9 Cystostomy 765,000 510,000 1,275,000
10 Decapitasi 765,000 510,000 1,275,000
11 Double Osteotomy pelvis posterior pada exstrophy bladder 765,000 510,000 1,275,000
12 Eksisi Ca Laring dengan Laser 765,000 510,000 1,275,000
13 Eksisi Granuloma Umbilikal 765,000 510,000 1,275,000
14 Eksterpasi Hemangioma kecil 765,000 510,000 1,275,000
15 Eksisi tumor adneksa sedang 765,000 510,000 1,275,000
16 Eksplorasi Abses Mandibula 765,000 510,000 1,275,000
17 Eksplorasi Abses Parafaringeal 765,000 510,000 1,275,000
18 Eksplorasi Kista Branchial 765,000 510,000 1,275,000
19 Ekterpasi Kista Bartholin 765,000 510,000 1,275,000
20 Eksterpasi Papiloma 765,000 510,000 1,275,000
21 Eksterpasi Plunging Ranula 765,000 510,000 1,275,000
22 Eksterpasi tumor jinak sinonasal,oral cavity 765,000 510,000 1,275,000
23 Eksterpasi tumor vagina kecil 765,000 510,000 1,275,000
24 Ethmoidektomi (Intranasal) 765,000 510,000 1,275,000
25 Facet Block (1 level /Multilevel) 765,000 510,000 1,275,000
26 Fiksasi Interna Yang Kompleks 765,000 510,000 1,275,000
27 Foraminal Block (1 level /Multilevel) 765,000 510,000 1,275,000
28 Fracture Acetabulum 1 Collum - ORIF 765,000 510,000 1,275,000
29 Fracture Artikuler - > MIPO/ ORIF Artikuler 765,000 510,000 1,275,000
30 Fraktur Acetabulum & Pelvic -ORIF Acetabulum & Pelvic 765,000 510,000 1,275,000
31 Fraktur subtrochanter femur pada orang tua (>60) 765,000 510,000 1,275,000
32 Gastroduodenoskopi 765,000 510,000 1,275,000
33 Goniotomi 765,000 510,000 1,275,000
34 Hemiarthroplasty bahu 765,000 510,000 1,275,000
35 Incisi abses leher dalam 765,000 510,000 1,275,000
36 Intradiscal Electrothermic Therapy (IDET) Multilevel 765,000 510,000 1,275,000
37 Koreksi Jari/ ring construction (single/multiple) / deformitas 765,000 510,000 1,275,000
38 Ligasi Tinggi unilateral 765,000 510,000 1,275,000
39 Limb salvage Surgery 765,000 510,000 1,275,000
40 Marsupialisasi Abses Bartholin 765,000 510,000 1,275,000
41 Marsupialisasi Ranula 765,000 510,000 1,275,000
Multiple Fracture Tulang Panjang - MIPO/ORIF dan Removal
42 765,000 510,000 1,275,000
Implant > 1
43 Multiple Papilona 765,000 510,000 1,275,000
Open Reduction dislokasi panggul dengan Acetabuloplasty dan
44 765,000 510,000 1,275,000
Femoral Osteomy
45 Operasi ECCE tanpa pemasangan IOL 765,000 510,000 1,275,000
46 Operasi Manchester Fortegil 765,000 510,000 1,275,000
47 Operasi priapismus (prosedur Winter) 765,000 510,000 1,275,000
48 Operasi rekonstruksi ibu jari kaki pada Hallux Valgus 765,000 510,000 1,275,000
49 Oppnens plasty Thumb, paralysis 765,000 510,000 1,275,000
50 Orchidectomy/orchidopexy unilateral 765,000 510,000 1,275,000
51 Orchidektomi/Orchidektomi Subkapsuler 765,000 510,000 1,275,000
52 ORIF : MBD 765,000 510,000 1,275,000
Hal 15 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
53 ORIF Fracture Pelvic Simple 765,000 510,000 1,275,000
54 Partus gemellie 765,000 510,000 1,275,000
55 Pasang Kateter Tenckhoff untuk CAPD 765,000 510,000 1,275,000
56 Pemasangan T Tube 765,000 510,000 1,275,000
57 Pembukaan lubang hidung THT 765,000 510,000 1,275,000
58 Perparasi cranioclasi 765,000 510,000 1,275,000
59 Regional Flap 765,000 510,000 1,275,000
60 Rekonstruksi kelainan jari (polidaktili simpel) 765,000 510,000 1,275,000
61 Repair Nerve-digital, injury, (microsurgical) 765,000 510,000 1,275,000
62 Repair Perinium Grade III-IV Pasca persalinan 765,000 510,000 1,275,000
63 Repair Tendon-extensor (extremitas atas) /nail bed/nerve digital 765,000 510,000 1,275,000
64 Reposisi Fixatie (Compucate) 765,000 510,000 1,275,000
65 Reposisi fr. nasal tertutup 765,000 510,000 1,275,000
66 Reposisi Fraktur / Dislokasi Dalam Narkose 765,000 510,000 1,275,000
Reposisi terbuka & Fiksasi Interna pada kasus fraktur Salter Harris
67 765,000 510,000 1,275,000
III - IV
Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada
68 765,000 510,000 1,275,000
anak
Reposisi terbuka dan fiksasi interna kasus fraktur intra Artikular
69 765,000 510,000 1,275,000
pada anak
70 Revisi Jari/Digit, Stump, Osteotomy 765,000 510,000 1,275,000
71 Revisi Total Knee/ Shoulder replacement 765,000 510,000 1,275,000
72 Rewiring Sternum 765,000 510,000 1,275,000
73 Septum Reseksi 765,000 510,000 1,275,000
74 Sistoskopi 765,000 510,000 1,275,000
75 Sistoskopi ODS 765,000 510,000 1,275,000
76 Sistostomi perkutan 765,000 510,000 1,275,000
77 Sistostomi Terbuka 765,000 510,000 1,275,000
78 Skingrafting tidak luas THT 765,000 510,000 1,275,000
79 Skleroterapi dengan anestesi 765,000 510,000 1,275,000
Tendon transfer ekstremitas bawah pada kasus Neuromuskular
80 765,000 510,000 1,275,000
anak
81 Tonsilektomi dengan LA/Sluder 765,000 510,000 1,275,000
82 Total Knee/ Shoulder Replacement 765,000 510,000 1,275,000
83 Total Patellectomy dan rekonstruksi 765,000 510,000 1,275,000
84 Trakestomi dengan penyulit 765,000 510,000 1,275,000
85 Transfer Jari, deformity, instrinsic muscle 765,000 510,000 1,275,000
86 Tumor jinak genetalia 765,000 510,000 1,275,000
87 Uretroskopi/ uretrosistoskopi 765,000 510,000 1,275,000
88 Vasografi 765,000 510,000 1,275,000
2. KATEGORI OPERASI BESAR

a. Operasi Besar I
1 Abses parafaring 1,530,000 1,020,000 2,550,000
2 Abses retrofaring dengan penyulit 1,530,000 1,020,000 2,550,000
3 Amputasi Jari (Multiple) 1,530,000 1,020,000 2,550,000
4 Angkat K-Wire dengan Hekting 1,530,000 1,020,000 2,550,000
5 Biopsi incisi tumor 1,530,000 1,020,000 2,550,000
Hal 16 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
6 BSEF/FESS 1 : Mini 1,530,000 1,020,000 2,550,000
7 Closed Fraktur intercondylar femur 1,530,000 1,020,000 2,550,000
8 Closed Fraktur proksimal tibia involve intraartikular 1,530,000 1,020,000 2,550,000
9 Closed Fraktur supracondylar femur 1,530,000 1,020,000 2,550,000
10 Colostomi 1,530,000 1,020,000 2,550,000
11 Cryptor Chismus 1,530,000 1,020,000 2,550,000
12 Curettage + bonegraft Tumor jinak tulang 1,530,000 1,020,000 2,550,000
13 Debridement Combustia 75 % - GA 1,530,000 1,020,000 2,550,000
14 Debridement dengan skin grafting luas 1,530,000 1,020,000 2,550,000
15 Debridement dgn flap 1,530,000 1,020,000 2,550,000
16 Debridement Mayor desloughing 1,530,000 1,020,000 2,550,000
17 Double osteotomy pelvis anterior pada Bladder Ekstrophy 1,530,000 1,020,000 2,550,000
18 Eksisi Kista Ductus Thyroglosus 1,530,000 1,020,000 2,550,000
19 Eksisi / Reduksi Neurofibroma kompleks 1,530,000 1,020,000 2,550,000
20 Eksisi Chordae Hyspospadia 1,530,000 1,020,000 2,550,000
21 Eksisi hemangioma 1,530,000 1,020,000 2,550,000
22 Eksisi Limfedema + skin graft ( Charles Prosedur) 1,530,000 1,020,000 2,550,000
23 Eksisi webbed penis 1,530,000 1,020,000 2,550,000
24 Eksplorasi Duktus Koledokus 1,530,000 1,020,000 2,550,000
25 Ekterpasi Geborn myoma 1,530,000 1,020,000 2,550,000
26 Eksterpasi tumor nasal 1,530,000 1,020,000 2,550,000
27 Eksterpasi Mucocel 1,530,000 1,020,000 2,550,000
28 Ekstraksi batu 1,530,000 1,020,000 2,550,000
29 Ekstrasi corpus sclerotomy 1,530,000 1,020,000 2,550,000
30 Ekstraksi polip nasi unilateral 1,530,000 1,020,000 2,550,000
31 Evakuasi bekuan darah (clot) 1,530,000 1,020,000 2,550,000
32 Evisceratium 1,530,000 1,020,000 2,550,000
33 Fistulektomy perianal 1,530,000 1,020,000 2,550,000
34 Fistulektomi/Repair Fistel Uretra 1,530,000 1,020,000 2,550,000
35 Frontoethmoidektomi (Ekstranasal) 1,530,000 1,020,000 2,550,000
36 Hemiglosektomi THT 1,530,000 1,020,000 2,550,000
37 Herniotomi 1,530,000 1,020,000 2,550,000
38 Herniotomy Anak 1,530,000 1,020,000 2,550,000
39 Hemoroidektomi 1,530,000 1,020,000 2,550,000
40 Hidrokel per Inguinal/Ligasi Tinggi 1,530,000 1,020,000 2,550,000
41 Hidrokel per skrotal 1,530,000 1,020,000 2,550,000
42 Insersi DJ stent 1,530,000 1,020,000 2,550,000
43 Insisi Mucocele/epulis 1,530,000 1,020,000 2,550,000
44 Incisi hymen inperforata 1,530,000 1,020,000 2,550,000
45 Johanson 1,530,000 1,020,000 2,550,000
46 Keratoplastik 1,530,000 1,020,000 2,550,000
47 Koreksi CTEV (congenital talipes equino varus) 1,530,000 1,020,000 2,550,000
48 Laminectomy (1 Level) pada simple spine stenosis 1,530,000 1,020,000 2,550,000
49 Laparatomi VC 1,530,000 1,020,000 2,550,000
50 Laparoscopy sterilisasi 1,530,000 1,020,000 2,550,000
51 Laparotomie kista ovari 1,530,000 1,020,000 2,550,000
Limb Lengthening atau operasi rekonstruksi pada anak yang
52 1,530,000 1,020,000 2,550,000
menggunakan alat khusus
Hal 17 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
53 Mastoidektomi sederhana 1,530,000 1,020,000 2,550,000
54 Minilaparatomie (sterilisasi) 1,530,000 1,020,000 2,550,000
55 Micro endoscopic Disectomy 1,530,000 1,020,000 2,550,000
56 Nefropeksi/Renopeksi 1,530,000 1,020,000 2,550,000
57 Nefrostomi terbuka/Permanen 1,530,000 1,020,000 2,550,000
58 Nevus 1,530,000 1,020,000 2,550,000
59 Open Biopsy : Soft Tissue 1,530,000 1,020,000 2,550,000
60 Operasi Hydrokel 1,530,000 1,020,000 2,550,000
61 Operasi Tumor Pembuluh Darah 1,530,000 1,020,000 2,550,000
62 Orkhidektomi extended 1,530,000 1,020,000 2,550,000
63 Orkhidektomi Ligasi Tinggi 1,530,000 1,020,000 2,550,000
64 Pengangkatan Ganglion Poplitea dengan narkose 1,530,000 1,020,000 2,550,000
65 Pembedahan Kompartemental 1,530,000 1,020,000 2,550,000
66 Penektomi Parsial 1,530,000 1,020,000 2,550,000
67 Pielolitotomi 1,530,000 1,020,000 2,550,000
68 Polip multiple dengan GA 1,530,000 1,020,000 2,550,000
69 Prostatektomi Retropubik 1,530,000 1,020,000 2,550,000
70 Prostatektomi terbuka 1,530,000 1,020,000 2,550,000
71 Prostatektomi terbuka dan Sectio Alta 1,530,000 1,020,000 2,550,000
72 Rekonstruksi sedang(STSG, FTSG,Flap lokal) 1,530,000 1,020,000 2,550,000
73 Repair fistel vesikokutan 1,530,000 1,020,000 2,550,000
74 Repair ruptur korneosklera 1,530,000 1,020,000 2,550,000
75 Reseksi Anastomosis 1,530,000 1,020,000 2,550,000
76 Ruptur palpebra Moderate 1,530,000 1,020,000 2,550,000
77 Scleral Buckling 1,530,000 1,020,000 2,550,000
78 Skin Laser Treatment 1,530,000 1,020,000 2,550,000
79 Skrotoplasti 1,530,000 1,020,000 2,550,000
80 Spermatokelektomi 1,530,000 1,020,000 2,550,000
81 Splenektomi 1,530,000 1,020,000 2,550,000
82 Tendon release 1,530,000 1,020,000 2,550,000
83 Tram Flap 1,530,000 1,020,000 2,550,000
84 Trauma kompleks jaringan lunak wajah 1,530,000 1,020,000 2,550,000
85 Trombektomi dengan atau tanpa debridement 1,530,000 1,020,000 2,550,000
86 Tubektomi 1,530,000 1,020,000 2,550,000
87 Urethrektomi 1,530,000 1,020,000 2,550,000
88 Uretroplasti 1,530,000 1,020,000 2,550,000
89 Varikokelektomi (Palomo) 1,530,000 1,020,000 2,550,000
90 Vesicolithotom 1,530,000 1,020,000 2,550,000
91 Vesicolithotomi /Sectio Alta 1,530,000 1,020,000 2,550,000
b. Operasi Besar II
1 Anastomosis end to end ureter 1,650,000 1,100,000 2,750,000
2 Angkat plate / Screw 1,650,000 1,100,000 2,750,000
3 Anterior Cervical Corpectomy + Fusion ( ACCF ) 1,650,000 1,100,000 2,750,000
4 Appendiotomy akut 1,650,000 1,100,000 2,750,000
5 Appendiotomy & Peri Appendicular In filtrat (PAI) 1,650,000 1,100,000 2,750,000
6 Arthrodesis sendi ( panggul , wrist, ankle , triple arthrodesis ) 1,650,000 1,100,000 2,750,000
Hal 18 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
7 Arthroscopy Therapeutik 1,650,000 1,100,000 2,750,000
8 Arthrotomy/Synovectomi 1,650,000 1,100,000 2,750,000
9 Batu uretra 1,650,000 1,100,000 2,750,000
Bony Reconstruction pada ekstremitas atas anak ( Misalnya
10 1,650,000 1,100,000 2,750,000
malunion fraktur supracondylar, lateral condyle)
Bony Reconstruction pada ekstremitas bawah anak (Misalnya
11 1,650,000 1,100,000 2,750,000
CTEV, Blount disease, kelainan kongenital , malunion fraktur)
12 BSEF/ FESS 2 :Mini+Maksila/ etmoid 1,650,000 1,100,000 2,750,000
13 Caldwell WC 1,650,000 1,100,000 2,750,000
14 Debridement and anterior fusion in TB Spine 1,650,000 1,100,000 2,750,000
15 Deroofing/ unroofing kista 1,650,000 1,100,000 2,750,000
16 Divertikulum uretra 1,650,000 1,100,000 2,750,000
17 Ekscisi hemangioma kompleks 1,650,000 1,100,000 2,750,000
18 Eksplorasi Abses Multiple THT 1,650,000 1,100,000 2,750,000
19 Ekstipasi Adenomiosis 1,650,000 1,100,000 2,750,000
20 Ekstirpasi Preaurikuler Fistel THT 1,650,000 1,100,000 2,750,000
21 Ekstirpasi tumor jinak kel liur THT 1,650,000 1,100,000 2,750,000
22 Ektropion sikatriks/entropion dengan laser 1,650,000 1,100,000 2,750,000
23 Fare Head Flap 1,650,000 1,100,000 2,750,000
24 Faringotomi 1,650,000 1,100,000 2,750,000
25 Fore head flap 1,650,000 1,100,000 2,750,000
26 Forehead Flap THT 1,650,000 1,100,000 2,750,000
27 Herniotomy + Circumcici 1,650,000 1,100,000 2,750,000
28 Hidrocelectomy + Circumcici 1,650,000 1,100,000 2,750,000
29 Histerektomi Total + Kistektomi Bilateral 1,650,000 1,100,000 2,750,000
Histerektomi Total dan Salpingo Ooforektomi Bilateral / Histerektomi
30 1,650,000 1,100,000 2,750,000
Total dan Salpingo Ooforektomi Sinistra
Histerektomi Total dan Salpingo Ooforektomi Sinistra +Kistektomi
31 1,650,000 1,100,000 2,750,000
unilateral
32 Isthmolobektomi 1,650,000 1,100,000 2,750,000
33 Johanson I 1,650,000 1,100,000 2,750,000
34 Kapsulektomi posterior 1,650,000 1,100,000 2,750,000
35 Keratoplastie lamelar 1,650,000 1,100,000 2,750,000
36 Koreksi + rekonstruksi Ptosis 1,650,000 1,100,000 2,750,000
37 Koreksi Strabismus 1 - 2 otot 1,650,000 1,100,000 2,750,000
38 Laparatomy pada perforasi usus pada anak 1,650,000 1,100,000 2,750,000
39 Latisimus Dorsi Flap 1,650,000 1,100,000 2,750,000
40 Ligasi A.Karotis Eksterna 1,650,000 1,100,000 2,750,000
41 Microscopic Disectomy 1,650,000 1,100,000 2,750,000
42 Operasi ICCE / ECCE dengan pemasangan IOL 1,650,000 1,100,000 2,750,000
43 Operasi Pharyngeal Flap 1,650,000 1,100,000 2,750,000
44 Orbitotomi anterior 1,650,000 1,100,000 2,750,000
45 Orkhidopeksi (Torsio testis) 1,650,000 1,100,000 2,750,000
46 Posterior Lumbar Interbody Fusion (FLIF) + Posterior stabilisation 1,650,000 1,100,000 2,750,000
47 Posterolateral Fusion 1,650,000 1,100,000 2,750,000
48 Regional Flap tidak luas THT 1,650,000 1,100,000 2,750,000
49 Rekonstruksi avulsi kulit 1,650,000 1,100,000 2,750,000
50 Rekonstruksi Club hand 1,650,000 1,100,000 2,750,000
Hal 19 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
51 Rekonstruksi Craniosinostosis 1,650,000 1,100,000 2,750,000
52 Rekonstruksi defek dengan flap jauh 1,650,000 1,100,000 2,750,000
53 Rekonstruksi Ring Avulsion 1,650,000 1,100,000 2,750,000
54 Rekonstruksi Ulkus decubitus dengan flap 1,650,000 1,100,000 2,750,000
55 Replantasi 1,650,000 1,100,000 2,750,000
56 RF Dasar Lidah THT 1,650,000 1,100,000 2,750,000
57 Rinoplasty THT 1,650,000 1,100,000 2,750,000
58 Salvaging operasi mikro 1,650,000 1,100,000 2,750,000
59 Septoplasti 1,650,000 1,100,000 2,750,000
60 SeptoPlasty ec trauma hidung 1,650,000 1,100,000 2,750,000
61 Tiroidektomi THT 1,650,000 1,100,000 2,750,000
62 Tonsilo Adenoidectomi 1,650,000 1,100,000 2,750,000
63 Tonsilektomi 1,650,000 1,100,000 2,750,000
64 Total Disc Replacement (Multilevel) (SP.23) 1,650,000 1,100,000 2,750,000
65 TVP/ TMP 1,650,000 1,100,000 2,750,000
66 Ureterolisis 1,650,000 1,100,000 2,750,000
67 Ureterolithotomi 1,650,000 1,100,000 2,750,000
68 Ureterolithotomi proksimal 1,650,000 1,100,000 2,750,000
69 Ureterostomi 1,650,000 1,100,000 2,750,000
70 Wide eksisi tumor tonsil,orofaring 1,650,000 1,100,000 2,750,000
71 Hernia dengan penyulit 1,650,000 1,100,000 2,750,000
c. Operasi Besar III

Acetabuloplasty (Salter Innominate, Pemberton, Dega) pada kasus
1 1,740,000 1,160,000 2,900,000
panggul
2 Alar transverse fusion 1,740,000 1,160,000 2,900,000
3 Amputasi Eksisi Kista 1,740,000 1,160,000 2,900,000
4 Anoplasti sederhana (Cut Back) 1,740,000 1,160,000 2,900,000
5 Antrokoanal polip 1,740,000 1,160,000 2,900,000
6 Apendektomi Perforata 1,740,000 1,160,000 2,900,000
7 Appendiktomi dengan penyulit 1,740,000 1,160,000 2,900,000
8 Arthrosplasty 1,740,000 1,160,000 2,900,000
9 Biopsi/ Proof laparatomy 1,740,000 1,160,000 2,900,000
10 Breast Conserving Surgery 1,740,000 1,160,000 2,900,000
11 Dakriorinostomy 1,740,000 1,160,000 2,900,000
12 Detorsi Testis dengan Orchidopexi 1,740,000 1,160,000 2,900,000
13 Eksisi giant nevus + skin graft 1,740,000 1,160,000 2,900,000
14 Eksisi Giant Nevus (tanpa skin graft) 1,740,000 1,160,000 2,900,000
15 Eksisi Higroma 1,740,000 1,160,000 2,900,000
16 Eksisi hemangioma komplek 1,740,000 1,160,000 2,900,000
17 Eksisi Kista Urachus 1,740,000 1,160,000 2,900,000
18 Eksisi luas local 1,740,000 1,160,000 2,900,000
19 Eksisi Mamma Aberran 1,740,000 1,160,000 2,900,000
20 Eksplorasi Kista Tiroid 1,740,000 1,160,000 2,900,000
21 Eksterpasi tumor 1,740,000 1,160,000 2,900,000
22 Enucleatie Kista D 42 1,740,000 1,160,000 2,900,000
23 FAM 1,740,000 1,160,000 2,900,000
24 FAM Anosplasty 1,740,000 1,160,000 2,900,000
Hal 20 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
25 FAM duplex/multiple 1,740,000 1,160,000 2,900,000
26 Histerektomi Total dan Salpingo Ooforektomi Bilateral + Apendiktomi + 1,740,000 1,160,000 2,900,000
27 Histerektomi Total Subtotal + Salpingo Ooforektomi Dextra 1,740,000 1,160,000 2,900,000
28 Isthobektomi 1,740,000 1,160,000 2,900,000
29 Khordektomy pada hyspopadia 1,740,000 1,160,000 2,900,000
30 Kistektomi : 1,740,000 1,160,000 2,900,000
a). Kistektomi Bilateral 1,740,000 1,160,000 2,900,000
b). Kistektomi+Miomektomi+Kromotubasi 1,740,000 1,160,000 2,900,000
c). Kistektomi+Kromotubasi 1,740,000 1,160,000 2,900,000
d). Kistektomi+Miomektomi 1,740,000 1,160,000 2,900,000
31 Kolostomi / ileostomy 1,740,000 1,160,000 2,900,000
32 Laparotomi eksplorasi 1,740,000 1,160,000 2,900,000
33 Laparotomi haematocell 1,740,000 1,160,000 2,900,000
34 Laparotomie KET 1,740,000 1,160,000 2,900,000
35 Laparatomy pada trauma abdomen 1,740,000 1,160,000 2,900,000
36 Miringoplasti 1,740,000 1,160,000 2,900,000
37 Miomektomi : 1,740,000 1,160,000 2,900,000
a). Miomektomi Multiple 1,740,000 1,160,000 2,900,000
b). Miomektomi+Kromotubasi 1,740,000 1,160,000 2,900,000
38 MMK/ sling uretra 1,740,000 1,160,000 2,900,000
39 Myringoplasty 1,740,000 1,160,000 2,900,000
40 Nailing femur 1,740,000 1,160,000 2,900,000
41 Open Disectomy 1,740,000 1,160,000 2,900,000
42 Open Disectomy Multilevel 1,740,000 1,160,000 2,900,000
43 Open Reduction dan stabilisation of Spinal Fracture 1,740,000 1,160,000 2,900,000
44 Open Reduction dislokasi panggul tanpa Acetabuloplasty 1,740,000 1,160,000 2,900,000
45 Operasi Tumor Jinak Ovarium 1,740,000 1,160,000 2,900,000
46 Operasi vesica felea 1,740,000 1,160,000 2,900,000
47 Otoplasty THT 1,740,000 1,160,000 2,900,000
48 Posterior Cervical Fusion 1,740,000 1,160,000 2,900,000
49 Punctie Pericardium 1,740,000 1,160,000 2,900,000
50 Rekonstruksi defek dengan flap lokal 1,740,000 1,160,000 2,900,000
51 Rekonstruksi Degloving Injury 1,740,000 1,160,000 2,900,000
52 Rekonstruksi Duktus lacrimalis / stenosis sederhana 1,740,000 1,160,000 2,900,000
53 Rekonstruksi fraktur rahang 1,740,000 1,160,000 2,900,000
54 Rekonstruksi Gigantomastia 1,740,000 1,160,000 2,900,000
55 Rekonstruksi kelaiann Craniofacial Congenila 1,740,000 1,160,000 2,900,000
56 Rekonstruksi kelainan jari kompleks (sindaktili, constriction band 1,740,000 1,160,000 2,900,000
57 Rekonstruksi kelopak mata/ kontraktur palpebra 1,740,000 1,160,000 2,900,000
58 Rekonstruksi Kontraktur Difus 1,740,000 1,160,000 2,900,000
59 Rekonstruksi koreksi Camplodactyl/Clinodactyl 1,740,000 1,160,000 2,900,000
60 Rekonstruksi Koreksi Makrodactyl 1,740,000 1,160,000 2,900,000
61 Rekonstruksi mammae dengan miocutaneus 1,740,000 1,160,000 2,900,000
62 Rekonstruksi Meningo Encephalocele Anterior (MEA) 1,740,000 1,160,000 2,900,000
63 Rekonstruksi Repair tendon Complikata 1,740,000 1,160,000 2,900,000
64 Rekonstruksi Vagina 1,740,000 1,160,000 2,900,000
65 Rekontruksi Defek / Kelainan Tubuh yang kompleks 1,740,000 1,160,000 2,900,000
66 Release Syndactil kompleks 1,740,000 1,160,000 2,900,000
Hal 21 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
67 Repair luka pada wajah melibatkan saraf ductus lakrimal / Kelenjar liur 1,740,000 1,160,000 2,900,000
68 Reposisi fr. Nasal terbuka 1,740,000 1,160,000 2,900,000
69 Salphingo oophorektomi unilateral 1,740,000 1,160,000 2,900,000
70 Salphingo oophorektomi bilateral 1,740,000 1,160,000 2,900,000
71 Scrotoplasty pada hyspopadia 1,740,000 1,160,000 2,900,000
72 Sectio Caesaria sterilisasi 1,740,000 1,160,000 2,900,000
73 Sectio Caesaria 1,740,000 1,160,000 2,900,000
74 Septum lkoreksi 1,740,000 1,160,000 2,900,000
75 Splenectomy pada trauma 1,740,000 1,160,000 2,900,000
76 Sub total lobectomy thiroid 1,740,000 1,160,000 2,900,000
77 Tiroidektomi subtotal 1,740,000 1,160,000 2,900,000
78 Tonsilektomideseksi 1,740,000 1,160,000 2,900,000
79 Transeksi Esofagus 1,740,000 1,160,000 2,900,000
80 Tumor Ganas / Adneksa luas dengan rekonstruksi 1,740,000 1,160,000 2,900,000
81 Tumor ganas lainnya 1,740,000 1,160,000 2,900,000
82 Hernia dengan penyulit+Circumsisi 1,740,000 1,160,000 2,900,000
4. KATEGORI OPERASI KHUSUS

a. Operasi Khusus I
1 Batu Buli-buli dengan penyulit (B3) 2,700,000 1,800,000 4,500,000
2 Cat ekstraksi linier (Mata) 2,700,000 1,800,000 4,500,000
3 Cross Leg flap 2,700,000 1,800,000 4,500,000
4 Deroofing Kista Ginjal per laparoskopi 2,700,000 1,800,000 4,500,000
5 Divertikulektomi Buli 2,700,000 1,800,000 4,500,000
6 Eksisi dan rekonstruksi limfedema dan reduksi massa 2,700,000 1,800,000 4,500,000
7 Ekstrofi buli rekonstruksi 2,700,000 1,800,000 4,500,000
8 Eksplorasi Kista Ductus Tiroglosus 2,700,000 1,800,000 4,500,000
9 Explorasi testis mikro surgery 2,700,000 1,800,000 4,500,000
10 Free Flap 2,700,000 1,800,000 4,500,000
11 Histrectomi Trans Vaginal / Trans Abdominal et SOB 2,700,000 1,800,000 4,500,000
12 Laparatomy dan Appendectomy (Perforasi) 2,700,000 1,800,000 4,500,000
13 Limfadenektomi Ileoinguinal 2,700,000 1,800,000 4,500,000
14 Lithotripsi 2,700,000 1,800,000 4,500,000
15 Lobektomi tiroid 2,700,000 1,800,000 4,500,000
16 Lumbal simpatektomi bilateral 2,700,000 1,800,000 4,500,000
17 Mikrosurgeri Ligasi Vena Sprematika 2,700,000 1,800,000 4,500,000
18 Nefrektomi Donor Transplant 2,700,000 1,800,000 4,500,000
19 Nefrektomi Partial 2,700,000 1,800,000 4,500,000
20 Nefrektomi Radikal 2,700,000 1,800,000 4,500,000
21 Nefro Ureterektomi 2,700,000 1,800,000 4,500,000
22 Nefrostomi Per Kutan/Temporer 2,700,000 1,800,000 4,500,000
23 Neobladder 2,700,000 1,800,000 4,500,000
24 Open prostatectomi (BPH) 2,700,000 1,800,000 4,500,000
25 Operasi Arteri Carotis 2,250,000 1,500,000 3,750,000
26 Operasi Arteri Renalis Stenosis 2,250,000 1,500,000 3,750,000
27 Operasi Ileal Conduit (Bricker) 2,250,000 1,500,000 3,750,000
28 Operasi repair buli trauma 2,700,000 1,800,000 4,500,000
29 Orkhidopeksi (UDT) 2,700,000 1,800,000 4,500,000
Hal 22 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
30 Orkhidopeksi per laparoskopi 2,700,000 1,800,000 4,500,000
31 Pasang akses port celsite 2,700,000 1,800,000 4,500,000
32 Rekonstruksi Kontraktur Kompleks 2,700,000 1,800,000 4,500,000
33 Rekonstruksi vaskuler aneurisma perifer 2,700,000 1,800,000 4,500,000
Rekonstruksi vaskuler arteri tungkai/lengan pada Chronic Critical
34 2,700,000 1,800,000 4,500,000
Limb Ischemic
35 Rekonstruksi vaskuler pada AAA dan arteri tungkai 2,700,000 1,800,000 4,500,000
36 Rekonstruksi vaskuler pada AAA/arteri iliaka per laparotomi 2,700,000 1,800,000 4,500,000
37 Release Kontraktur 2,700,000 1,800,000 4,500,000
38 Sectio + uterus ruptur 2,700,000 1,800,000 4,500,000
39 Simple Mastectomi 2,700,000 1,800,000 4,500,000
40 Soft tissue tumor 2,700,000 1,800,000 4,500,000
41 Total hysterectomy 2,700,000 1,800,000 4,500,000
b. Operasi Khusus II
1 Ablasio retina 3,240,000 2,160,000 5,400,000
2 Alveolar Bone Graft 3,240,000 2,160,000 5,400,000
3 Augmentasi buli 5,184,000 3,456,000 8,640,000
4 AV Shunt radial/cubiti dengan pasang double lumen 3,240,000 2,160,000 5,400,000
5 Bladder Neck Rekonstruksi 5,184,000 3,456,000 8,640,000
6 Bronkoskopi ekstraksi 3,132,000 2,088,000 5,220,000
7 Condylectomy Mandibula 4,800,000 3,200,000 8,000,000
8 Diseksi kelenjar getah bening Inguinal 4,320,000 2,880,000 7,200,000
9 Diseksi kelenjar getah bening pelvis per laparoskopi 4,320,000 2,880,000 7,200,000
10 Eksisi Chordae/Chordektomi 4,644,000 3,096,000 7,740,000
11 Eksisi dan rekonstruksi vaskuler pada malformasi vaskuler 3,969,000 2,646,000 6,615,000
12 Eksisi fibroma/ rekonstruksi penis 4,860,000 3,240,000 8,100,000
13 Eksisi Gynaecomasti 4,800,000 3,200,000 8,000,000
14 Eksisi ligasi dan rekonstruksi malformasi vaskuler sederhana 4,968,000 3,312,000 8,280,000
15 Eksisi plaque (Peyronie disease) 4,320,000 2,880,000 7,200,000
16 Eksplorasi dan rekonstruksi vaskuler pada trauma vaskuler akut 5,130,000 3,420,000 8,550,000
17 Extracorporeal Shock Wave Lithotripsy (ESWL) tembakan I 4,200,000 2,800,000 7,000,000
18 Extracorporeal Shock Wave Lithotripsy (ESWL) tembakan II 2,700,000 1,800,000 4,500,000
19 Extracorporeal Shock Wave Lithotripsy (ESWL) tembakan III 1,500,000 1,000,000 2,500,000
20 Extended Pyelolithotomy 3,510,000 2,340,000 5,850,000
21 Hemiglosektomi 3,510,000 2,340,000 5,850,000
22 Hemimandibulektomi 4,800,000 3,200,000 8,000,000
23 Hipospadia subkoronal 3,132,000 2,088,000 5,220,000
24 Horseshoe Kidney Koreksi 3,132,000 2,088,000 5,220,000
25 Ilevs Obstruktif 4,320,000 2,880,000 7,200,000
26 Internal Bleeding 4,320,000 2,880,000 7,200,000
27 Karotis endarterektomi 3,132,000 2,088,000 5,220,000
28 Labioplasti Bilateral 4,800,000 3,200,000 8,000,000
29 Labioplasti Unilateral 3,600,000 2,400,000 6,000,000
30 Laparoskopi Adrenalektomi 4,320,000 2,880,000 7,200,000
31 Laparotomi HPP histeractomi 3,132,000 2,088,000 5,220,000
32 Laparotomie myoma uteri THA – BSO 3,132,000 2,088,000 5,220,000
33 Laparotomie prolaps histerectomy 3,132,000 2,088,000 5,220,000
Hal 23 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
34 Lefort Advancement / Set back maksilektomy I 3,600,000 2,400,000 6,000,000
35 Lefort Advancement / Set back maksilektomy II 4,200,000 2,800,000 7,000,000
36 Lefort Advancement / Set back maksilektomy III 4,800,000 3,200,000 8,000,000
37 Litholapaksi 4,860,000 3,240,000 8,100,000
38 Lumbal simpatektomi unilateral 4,050,000 2,700,000 6,750,000
39 Mandibulektomi Marginalis 3,600,000 2,400,000 6,000,000
40 Maksilektomi Partialis 4,800,000 3,200,000 8,000,000
41 Mandibulektomi parsial 4,800,000 3,200,000 8,000,000
42 Mastektomi Subkutaneus 4,800,000 3,200,000 8,000,000
43 Operasi Shunting Splenorenal 5,130,000 3,420,000 8,550,000
44 Palatoplasti 4,200,000 2,800,000 7,000,000
45 Pharingoplasty 4,200,000 2,800,000 7,000,000
46 Penektomi total/ amputasi penis 4,590,000 3,060,000 7,650,000
47 PER (primary endoscopic realignment) 4,590,000 3,060,000 7,650,000
48 Pieloplasti Per Laparoskopi 3,240,000 2,160,000 5,400,000
49 Psoas Hitch/ Boari flap 3,780,000 2,520,000 6,300,000
50 Punksi dan sklerosing kista ginjal 3,240,000 2,160,000 5,400,000
51 Pyeloplasty 3,240,000 2,160,000 5,400,000
52 Radical mastectomy/MRM 3,240,000 2,160,000 5,400,000
53 Railroading ruptur uretra 3,240,000 2,160,000 5,400,000
54 Reimplantasi ureter bilateral 3,240,000 2,160,000 5,400,000
55 Reimplantasi ureter Unilateral/Ureteroneosistostomi 3,240,000 2,160,000 5,400,000
56 Rekonstruksi kerusakan katup vena dalam tungkai pada DVT Kronik 3,780,000 2,520,000 6,300,000
atau CVI
57 Rekonstruksi komplikasi AV Shunt (pseudoaneurisma) 3,240,000 2,160,000 5,400,000
58 Rekonstruksi komplikasi pasca trauma (AV fistula/ 3,240,000 2,160,000 5,400,000
pseudoaneurisma)
59 Rekonstruksi telinga 3,240,000 2,160,000 5,400,000
60 Repair tendon jari 5,130,000 3,420,000 8,550,000
61 Reposisi & fiksasi fraktur tunggal tulang wajah 4,800,000 3,200,000 8,000,000
62 Reposisi Fraktur maksila / Zygoma 3,000,000 2,000,000 5,000,000
63 Reposisi Fraktur Mandibula Multiple / Kompleks 3,600,000 2,400,000 6,000,000
64 Resectic Hepar 5,130,000 3,420,000 8,550,000
65 Resectie Rahang 4,800,000 3,200,000 8,000,000
66 Simpatektomi 5,130,000 3,420,000 8,550,000
67 Simpatektomi per laparoskopi/thorakoskopi unilateral 5,130,000 3,420,000 8,550,000
68 Sistektomi parsial/ sistoplasti reduksi 4,320,000 2,880,000 7,200,000
69 Sistektomi Total/Radikal 5,130,000 3,420,000 8,550,000
70 Splenektomi ec. Hipertensi Portal/kelainan hematologi lain 5,130,000 3,420,000 8,550,000
71 Strabismus 1 - 2 otot 3,024,000 2,016,000 5,040,000
72 Stripping varises 2 tungkai dengan multipel flebektomi 4,860,000 3,240,000 8,100,000
73 Tailoring ureter 3,024,000 2,016,000 5,040,000
74 Trans Urethral Resection (TUR) Tumor Buli-buli 4,860,000 3,240,000 8,100,000
75 Trans Urethral Resection (TUR) Prostat 4,320,000 2,880,000 7,200,000
76 Transuretero-ureterostomi 4,687,200 3,124,800 7,812,000
77 Ureterokutaneostomi 3,024,000 2,016,000 5,040,000
78 Ureterolithotomi distal 4,320,000 2,880,000 7,200,000
79 Ureterorenoscopy (URS) 4,687,200 3,124,800 7,812,000
Hal 24 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
80 Ureterouretostomi 4,320,000 2,880,000 7,200,000
81 Uretroplasti hipospadia 4,320,000 2,880,000 7,200,000
82 Uretrotomi interna (Sachse) 4,320,000 2,880,000 7,200,000
83 Vasovasostomi 4,320,000 2,880,000 7,200,000
c. Operasi Khusus III

1 Adrenalektomi (Abdominotorakal) 5,400,000 3,600,000 9,000,000
2 AV Shunt cubiti 5,400,000 3,600,000 9,000,000
3 AV Shunt dengan graft vena/sintetis 5,400,000 3,600,000 9,000,000
4 Complicated Functional Neuro Percuteneus Kordotomi 7,560,000 5,040,000 12,600,000
5 Eksisi luas malformasi vaskuler 5,940,000 3,960,000 9,900,000
6 Endovenous Laser Treatment 5,400,000 3,600,000 9,000,000
7 Endovenous Laser Treatment dengan multipel flebektomi 5,400,000 3,600,000 9,000,000
8 Epispadia 5,670,000 3,780,000 9,450,000
9 Fraktur tulang wajah multipel atau segmental 5,400,000 3,600,000 9,000,000
10 Graf Vena membuat A Fistula 5,670,000 3,780,000 9,450,000
11 Grafting pada Arterial Insufisiensi 6,750,000 4,500,000 11,250,000
12 Insisi posterior urethral valve 5,940,000 3,960,000 9,900,000
13 Invaginasi dengan Reseksi 5,100,000 3,400,000 8,500,000
14 Johanson II 6,480,000 4,320,000 10,800,000
15 Koreksi Priapismus 5,400,000 3,600,000 9,000,000
16 Laparostomie tumor ganas 5,400,000 3,600,000 9,000,000
17 Laparostomie reseksi 5,400,000 3,600,000 9,000,000
18 Near total tiroidektomi 6,000,000 4,000,000 10,000,000
19 Nefrektomi Per Laparoskopi 6,739,200 4,492,800 11,232,000
20 Nefrostomi Percutan 7,020,000 4,680,000 11,700,000
21 Oesophaguscopy (THT) 5,940,000 3,960,000 9,900,000
22 Operasi Aneurisma Aorta 5,940,000 3,960,000 9,900,000
23 Operasi Fronto-orbital advancement pada craniosynostosis 7,830,000 5,220,000 13,050,000
24 Operasi Shunting Femoralis 5,670,000 3,780,000 9,450,000
25 Operasi Shunting Poplitea / Tibialis 5,940,000 3,960,000 9,900,000
26 Operasi sistokel 5,940,000 3,960,000 9,900,000
27 Operasi trauma ginjal 5,940,000 3,960,000 9,900,000
28 Operasi urakhus/ reseksi urakhus 5,940,000 3,960,000 9,900,000
29 Operasi Vaskuler yang memerlukan Tehnik Operasi Khusus 5,940,000 3,960,000 9,900,000
30 Parotidektomi Partialis 5,400,000 3,600,000 9,000,000
31 Percutaneous Nephrolithostripsy (PCNL) 7,290,000 4,860,000 12,150,000
32 Pielokalikotomi 5,940,000 3,960,000 9,900,000
33 Radikal Mastectomy Skin grafs 6,739,200 4,492,800 11,232,000
34 Rekonstruksi Renovaskuler 7,290,000 4,860,000 12,150,000
35 Rekonstruksi Ca mamae 6,000,000 4,000,000 10,000,000
36 Rekonstruksi vena-vena abdomen pelvis 5,778,000 3,852,000 9,630,000
37 Repair fistel enterovesika 7,290,000 4,860,000 12,150,000
38 Repair fistel vesikorektal 6,879,600 4,586,400 11,466,000
39 Reposisi / fiksasi Fr. orbita 7,020,000 4,680,000 11,700,000
40 Reposisi/fiksasi Fr maksilla &mandibula 6,750,000 4,500,000 11,250,000
41 Reposisi/fiksasi Fr. Naso Orbita Edmoe (NOE) 7,020,000 4,680,000 11,700,000
Hal 25 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
42 Reseksi-anastomosis uretra 6,750,000 4,500,000 11,250,000
43 Retro Peritoneal Lymp Node Dissection (RPLND) 6,750,000 4,500,000 11,250,000
44 Rhinotomy lateral 6,912,000 4,608,000 11,520,000
45 Sistektomi per laparoskopi 5,940,000 3,960,000 9,900,000
46 Stripping varises 1 tungkai dengan flebektomi 5,940,000 3,960,000 9,900,000
47 Stripping varises 1 tungkai, debridement ligasi vena 5,940,000 3,960,000 9,900,000
48 perforantes/penyulit
Vaginal Plasty 7,020,000 4,680,000 11,700,000
49 Total tiroidektomi 5,940,000 3,960,000 9,900,000
50 Tumor parotis 5,940,000 3,960,000 9,900,000
d. Operasi Khusus IV
1 Complicated Functional Neuro Percuteneus Paraverteb / Visceral 8,100,000 5,400,000 13,500,000
block
2 Repair fistel vesikovagina 8,100,000 5,400,000 13,500,000
3 Repair fraktur penis 8,100,000 5,400,000 13,500,000
4 AV Shunt radial (Brescia-Cimino) 8,154,000 5,436,000 13,590,000
5 Eksplorasi dan rekonstruksi vaskuler pada trauma vaskuler akut 8,640,000 5,760,000 14,400,000
6 Complicated Functional Neuro Stereotaxy sederhana 8,910,000 5,940,000 14,850,000
7 Mandibulektomi 9,180,000 6,120,000 15,300,000
8 Excisi Teratoma Retroperitoneal 9,180,000 6,120,000 15,300,000
9 Postero Sagital anorekto vagino uretra plasty (PSARVUP) 9,180,000 6,120,000 15,300,000
10 Complicated Functional Neuro Stereotaxy kompleks 9,720,000 6,480,000 16,200,000
11 Esofageal Replacement Procedure 9,720,000 6,480,000 16,200,000
12 Koreksi Scoliosis 9,720,000 6,480,000 16,200,000
13 Koreksi Spondilitis 9,720,000 6,480,000 16,200,000
14 Kraniotomi+Endoskopi 9,720,000 6,480,000 16,200,000
15 Vitrektomi + Endo Laser+ SB+Silikon Oil/Gas 10,260,000 6,840,000 17,100,000
16 Rekonstruksi vaskuler pada AAA dan arteri tungkai 10,584,000 7,056,000 17,640,000
17 PSARP + Abdomino perineal (Laparotomy) 11,340,000 7,560,000 18,900,000
B. TINDAKAN MEDIK NON OPERATIF

1. TINDAKAN SEDERHANA
a. Tindakan Sederhana I
1 Ambil darah arteri atau Vena 29,700 19,800 49,500
2 Angkat Drainage 29,700 19,800 49,500
3 Angkat jahitan bedah, kandungan, kulit 29,700 19,800 49,500
4 Antenatal care 29,700 19,800 49,500
5 APGAR score 29,700 19,800 49,500
6 Continues Suction 29,700 19,800 49,500
7 Chestphsioterapi 29,700 19,800 49,500
8 Creepin - Eruption 29,700 19,800 49,500
9 Cross incisi 29,700 19,800 49,500
10 Dilatasi Pimosis 29,700 19,800 49,500
11 Druk verban sprain lutut 29,700 19,800 49,500
12 Druk verban sprain siku 29,700 19,800 49,500
13 Explorasi luka 29,700 19,800 49,500
14 Fiksasi chemis injeksi 29,700 19,800 49,500
15 Fiksasi Mekanik dengan flanel/hari 29,700 19,800 49,500
Hal 26 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
16 Gastric cooling/Kumah lambung 29,700 19,800 49,500
17 Imobilisasi Luxatio mandibula 29,700 19,800 49,500
18 Imunisasi ibu dan anak 29,700 19,800 49,500
19 Injeksi intravena/intramussculer/intracutan 29,700 19,800 49,500 per hari
20 Injeksi Keloid 29,700 19,800 49,500
21 Injeksi Kenacort Intrademal 29,700 19,800 49,500
22 Keratometer 29,700 19,800 49,500
23 Koreksi Visus 29,700 19,800 49,500
24 Nagel ekstraksi 29,700 19,800 49,500
25 Oor toilet 29,700 19,800 49,500
26 Pemasangan Kateter 29,700 19,800 49,500
27 Pemasangan NG Tube 29,700 19,800 49,500
28 Psikoterapi anak 29,700 19,800 49,500
29 Psikoterapi kelompok 29,700 19,800 49,500
30 Psikoterapi lanjutan 29,700 19,800 49,500
31 Punctie abses bartholini 29,700 19,800 49,500
32 Punctie bedah 29,700 19,800 49,500
33 Punctie seroma 29,700 19,800 49,500
34 Rectal swab 29,700 19,800 49,500
35 Rectal Toucher 29,700 19,800 49,500
36 Slit Lambiomicroscopi 29,700 19,800 49,500
37 Surat keterangan bebas narkoba (pemeriksaan) 29,700 19,800 49,500
38 Tampon telinga dengan obat 29,700 19,800 49,500
39 Terapi dgn TCA / T. Podoplli 29,700 19,800 49,500
40 Terapi ESO 29,700 19,800 49,500
41 Test APM 29,700 19,800 49,500
42 Test Buta Warna 15,000 10,000 25,000
43 Test Fluorrescein 29,700 19,800 49,500
44 Test Perpirasi 29,700 19,800 49,500
45 Test Schimmer 29,700 19,800 49,500
46 Test sikloplegi 29,700 19,800 49,500
47 Tindik telinga 29,700 19,800 49,500
48 Tone decay / sisi test 29,700 19,800 49,500
49 Vaginal swab 29,700 19,800 49,500
50 Vagina toucher 29,700 19,800 49,500
b. Tindakan Sederhana II per tindakan

1 Foetal phone 46,800 31,200 78,000
2 Irigasi serumen /vaginal 46,800 31,200 78,000
3 Pasang/lepas pesarium 46,800 31,200 78,000
4 Pers sekresi dari trachea pd klien trakheostomi 46,800 31,200 78,000
5 Rectoscopi 46,800 31,200 78,000
6 Test bisik 46,800 31,200 78,000
7 Test Kalori 46,800 31,200 78,000
8 Test Mantoux 46,800 31,200 78,000 per hari
9 Tonometer schiotz 46,800 31,200 78,000
10 Transfusi darah bayi/anak 46,800 31,200 78,000
Hal 27 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
c. Tindakan Sederhana III per tindakan
1 Ekstraksi serumen obturan 60,000 40,000 100,000
2 Granulasi faring 60,000 40,000 100,000
3 Hapusan Hidung 60,000 40,000 100,000
4 Hapusan hidung & Tenggorokan 60,000 40,000 100,000
5 Hapusan Telinga 60,000 40,000 100,000
6 Hapusan Tenggorok 60,000 40,000 100,000
7 Kaustik : konkanasi 60,000 40,000 100,000
8 Kaustik telinga 60,000 40,000 100,000
9 Kaustik konka granulasi faring 60,000 40,000 100,000
10 Merawat omphalokel 60,000 40,000 100,000
11 Observasi < 6 jam (tindakan emergency ketat tiap 15 menti) 60,000 40,000 100,000
12 Pemasangan Oksigen dengan CPAP 60,000 40,000 100,000
13 Pasang IUD 60,000 40,000 100,000
14 Pengambilan corpus alienum 60,000 40,000 100,000
15 Tampon Effedrin 60,000 40,000 100,000
16 Test fungsi tuba 60,000 40,000 100,000
17 Tranfusi darah 60,000 40,000 100,000
18 Tympanometri 60,000 40,000 100,000
19 Unstepen 60,000 40,000 100,000
20 USG Poli Kandungan 60,000 40,000 100,000
d. Tindakan Sederhana IV per tindakan

1 Audiogram 78,300 52,200 130,500
2 Ekstraksi corpus alienum dengan penyulit 78,300 52,200 130,500
3 Ektraksi kuku 78,300 52,200 130,500
4 Funduscopy 78,300 52,200 130,500
5 Injeksi alergi 78,300 52,200 130,500
6 Reposisi tulang 78,300 52,200 130,500
e. Tindakan Sederhana V per tindakan

1 Autoref (Mata) 85,500 57,000 142,500
2 Fototherapi 24 jam 85,500 57,000 142,500
2 TINDAKAN KECIL per tindakan

a. Tindakan Kecil I
1 Af Gips Body Jacket 96,000 64,000 160,000
2 Af Gips Hemispika 96,000 64,000 160,000
3 Af plastik bandage 96,000 64,000 160,000
4 Angkat jahitan luka operasi 1-5 cm 96,000 64,000 160,000
5 Aspirasi sumsum tulang 96,000 64,000 160,000
6 BC 96,000 64,000 160,000
7 Cairan operasi SDG 96,000 64,000 160,000
8 Cauter electric 96,000 64,000 160,000
9 Chemical peeling 96,000 64,000 160,000
10 Digital vaginal 96,000 64,000 160,000
11 ECT / TEK 96,000 64,000 160,000
Hal 28 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
12 Eksterpasi Veruca 96,000 64,000 160,000
13 Faetal auto cardiograf 96,000 64,000 160,000
14 Feak Flow Meter 96,000 64,000 160,000
15 Fungsi Gips telinga pada fungsi percobaan 96,000 64,000 160,000
16 Goldman 3 cermin 96,000 64,000 160,000
17 Hess Screen 96,000 64,000 160,000
18 Hidrotubasi 96,000 64,000 160,000
19 Incisi Membrane Timpani 96,000 64,000 160,000
20 Incisi bartholinitis tanpa anestesi 96,000 64,000 160,000
21 Inseminasi 96,000 64,000 160,000
22 K/N Wache 96,000 64,000 160,000
23 Luka jahitan 1 – 5 96,000 64,000 160,000
24 Masupilasi 96,000 64,000 160,000
25 Paket Pemberian Metadon 96,000 64,000 160,000
26 Pemasangan C. Klem 96,000 64,000 160,000
27 Pemasangan SB Tube 96,000 64,000 160,000
28 Pemasangan susuk 96,000 64,000 160,000
29 Pemeriksaan dengan Microscop telinga 96,000 64,000 160,000
30 Pencabutan susuk 96,000 64,000 160,000
31 Pengelolaan Dry Socket 96,000 64,000 160,000
32 Psikoterapi Suportif 96,000 64,000 160,000
33 Psikoterapi Wawancara 96,000 64,000 160,000
34 Punctie sendi 96,000 64,000 160,000
35 SH test / Post coital test 96,000 64,000 160,000
36 Subdural Tap 96,000 64,000 160,000
37 Infus pump 96,000 64,000 160,000
38 Tangent Screen 96,000 64,000 160,000
39 Terapi okupasi olah raga 96,000 64,000 160,000
40 Test alergi 96,000 64,000 160,000
41 Test Alergi tempel 96,000 64,000 160,000
42 Test Allergi Tusuk 96,000 64,000 160,000
43 Test BCG 96,000 64,000 160,000
44 Tindakan emergency operasi BSR,KHS 96,000 64,000 160,000
45 Vena punksi 96,000 64,000 160,000
46 Ekstraksi IUD dengan penyulit 96,000 64,000 160,000
47 Ekstraksi susuk dengan penyulit 96,000 64,000 160,000
b. Tindakan Kecil II per tindakan

1 Angkat Kateter gastrotomi 102,000 68,000 170,000
2 Angkat pining 102,000 68,000 170,000
3 Bebat Panas Kering 102,000 68,000 170,000
4 Immunisasi BCG 102,000 68,000 170,000
5 Immunisasi campak 102,000 68,000 170,000
6 Immunisasi DPT+Polio 102,000 68,000 170,000
7 Imunologi Terapi Alergi 102,000 68,000 170,000
8 Injeksi Intratekal 102,000 68,000 170,000
9 Injeksi Retro bulbi 102,000 68,000 170,000
Hal 29 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
10 Injeksi Sub conjunctiva 102,000 68,000 170,000
11 Inspeculo 102,000 68,000 170,000
12 Irigasi mata 102,000 68,000 170,000
13 KOH 102,000 68,000 170,000
14 Lensometer 102,000 68,000 170,000
15 Lepas Agrafe 102,000 68,000 170,000
16 Lepas IMW 102,000 68,000 170,000
17 Doppler test (Andrologi) 102,000 68,000 170,000
18 Repossisi Tali pusat 102,000 68,000 170,000
19 Resusitasi napas 102,000 68,000 170,000
20 Tensi okuli 102,000 68,000 170,000
c. Tindakan Kecil III per tindakan

1 Automatic Refracto Keratometer (ARK) 108,000 72,000 180,000
2 Back slab / fore slab 108,000 72,000 180,000
3 Besredka tanpa ADS 108,000 72,000 180,000
4 Businasi anal 108,000 72,000 180,000
5 Pemeriksaan test HIV 108,000 72,000 180,000
6 Ekstraksi kuku 108,000 72,000 180,000
7 Excoliasi 108,000 72,000 180,000
8 Fruktosa 108,000 72,000 180,000
9 Ganti Kanul/dekanulasi 108,000 72,000 180,000
10 Hertel Exophthalmometer 108,000 72,000 180,000
11 LLC / BEC / C&C 108,000 72,000 180,000
12 Luka dalam kecil 108,000 72,000 180,000
13 Maddox Rod 108,000 72,000 180,000
14 Pacu Jantung Temporer/hari (generator) 108,000 72,000 180,000
15 Pemasangan Pacu Jantung Temporer 108,000 72,000 180,000
16 Perawatan Tampon/aff tampon hidung 108,000 72,000 180,000
17 Peritonial Punksi 108,000 72,000 180,000
18 Refraksi 108,000 72,000 180,000
19 Refraktometer 108,000 72,000 180,000
20 Remedial teaching 108,000 72,000 180,000
21 Synophtopor 108,000 72,000 180,000
22 Terapi sindroma lepas zat 108,000 72,000 180,000
23 Zuig aparat 108,000 72,000 180,000
d. Tindakan Kecil IV per tindakan

1 Bronchial Toilet 114,000 76,000 190,000
2 Fiksasi fractura cotae 114,000 76,000 190,000
3 Injeksi Intra Cavernosal 114,000 76,000 190,000
4 Intra Uterine Inseminasi (IUI) 114,000 76,000 190,000
5 Irigasi GO 114,000 76,000 190,000
6 Luka dalam sedang 114,000 76,000 190,000
7 Lumbal punsi 114,000 76,000 190,000
8 Pengobatan dengan TCA 114,000 76,000 190,000
9 Pneumo Peritonium 114,000 76,000 190,000
Hal 30 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
10 Post coital test (PCT) 114,000 76,000 190,000
11 Pra injeksi im perhari/pasien (pasien gaduh gelisah) 114,000 76,000 190,000
12 Punctie abses kulit 114,000 76,000 190,000
13 Reposisi toraks drain 114,000 76,000 190,000
14 Speech audiometri 114,000 76,000 190,000
15 Tampon perdarahan telinga 114,000 76,000 190,000
16 Test bakat minat 114,000 76,000 190,000
17 Test tondecay/SISI 114,000 76,000 190,000
18 Test vestibular 114,000 76,000 190,000
19 Wawancara awal dan psikoterapi 114,000 76,000 190,000
e. Tindakan Kecil V per tindakan

1 Businasi Esofagus 120,000 80,000 200,000
2 Faal paru rutin 120,000 80,000 200,000
3 Fixasi Fractur Costae 120,000 80,000 200,000
4 Funduscopi + midriatikum 120,000 80,000 200,000
5 Gonioskopi 120,000 80,000 200,000
6 Incisi drainage hemato 120,000 80,000 200,000
7 Injeksi intraarticular 120,000 80,000 200,000
8 Long leg cast 120,000 80,000 200,000
9 Luka jahitan 6 – 10 120,000 80,000 200,000
10 Pra injeksi iv perhari/pasien (pasien gaduh gelisah) 120,000 80,000 200,000
11 PTB cast 120,000 80,000 200,000
12 Punctie & gips Hemato 120,000 80,000 200,000
13 Punctie+gips telinga 120,000 80,000 200,000
14 Test IQ + kepribadian 120,000 80,000 200,000
15 Test IQ + kepribadian + bender gestalt 120,000 80,000 200,000
16 Tonometer aplanasi 120,000 80,000 200,000
3. TINDAKAN SEDANG
a. Tindakan Sedang I per tindakan
1 Bulectomi 132,000 88,000 220,000
2 Duadenal aspiration tes (DAT) 132,000 88,000 220,000
3 Ekstraksi corpus alienum hipofaring 132,000 88,000 220,000
4 Fitting Lensa Kontak 132,000 88,000 220,000
5 Funduscopi indirect 132,000 88,000 220,000
6 Gliserin Klisma 132,000 88,000 220,000
7 Hecting grade III-IV perineum di ruang VK 132,000 88,000 220,000
8 Hipnoterapi 132,000 88,000 220,000
9 Incisi Osthematom 132,000 88,000 220,000
10 Multiple incisi 132,000 88,000 220,000
11 Pelepasan tampon belloque 132,000 88,000 220,000
12 Punctie asites 132,000 88,000 220,000
13 Reposisi sendi mandibula dan humerus 132,000 88,000 220,000
14 Resusitasi bayi (pediatri) 132,000 88,000 220,000
15 Streak Ratinoskopi 132,000 88,000 220,000
16 Tampon epistaksis ringan 132,000 88,000 220,000
Hal 31 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
b. Tindakan Sedang II per tindakan
1 9 Tes assesment psikogeriatri 138,000 92,000 230,000
2 Angkat archbar 138,000 92,000 230,000
3 DC Shock/Defibrilasi 138,000 92,000 230,000
4 Esofaguskopi 138,000 92,000 230,000
5 Fluoroscopy (tanpa film) 138,000 92,000 230,000
6 Foto Fundus 138,000 92,000 230,000
7 Hecting grade III-IV perineum di ruang VK 138,000 92,000 230,000
8 Hefrycauter 138,000 92,000 230,000
9 Hyprecator 138,000 92,000 230,000
10 Intubasi Endotracheal 138,000 92,000 230,000
11 Micro curet di IRD 138,000 92,000 230,000
12 MMPI Anak 138,000 92,000 230,000
13 NST Kandungan / Obgyn 138,000 92,000 230,000
14 Pemasangan gromet 138,000 92,000 230,000
15 Pleurodesis 138,000 92,000 230,000
16 Punctie hemartros genu 138,000 92,000 230,000
17 Punctie pleura dengan jarum sayap 138,000 92,000 230,000
18 Radiotom 138,000 92,000 230,000
19 Respirator 138,000 92,000 230,000
20 Test Methelin blue 138,000 92,000 230,000
21 Trakeoskopi 138,000 92,000 230,000
c. Tindakan Sedang III per tindakan

1 Af Wayer 144,000 96,000 240,000
2 Biometri 144,000 96,000 240,000
3 BMD (Bone mass density) 144,000 96,000 240,000
4 Dermabasi pengambilan darah pasien HIV positif 144,000 96,000 240,000
5 EMG 144,000 96,000 240,000
6 Exterpasi Geborn Myoma/polip Servic tanpa anestesi 144,000 96,000 240,000
7 Exterpasi Atheroma
8 Faal paru + helium 144,000 96,000 240,000
9 Foto Video Printing 144,000 96,000 240,000
10 Ganti Gips/Buka 144,000 96,000 240,000
11 Incisi Abses fistel 144,000 96,000 240,000
12 Injeksi sitostatika/hari 144,000 96,000 240,000
13 Mikrodermabrasi 144,000 96,000 240,000
14 Oortel plasty 144,000 96,000 240,000
15 Oxytosin drip 144,000 96,000 240,000
16 Proktoskopi+Skleroterapi 144,000 96,000 240,000
17 PUVA 144,000 96,000 240,000
18 Repair stoma 144,000 96,000 240,000
19 Sinuskopi 144,000 96,000 240,000
20 Terapi elektrokonvulsi/hari 144,000 96,000 240,000
21 Test exercise paru 144,000 96,000 240,000
22 Transfusi tukar 144,000 96,000 240,000
d. Tindakan Sedang IV per tindakan
Hal 32 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
1 Incisi abses telinga 150,000 100,000 250,000
2 Luka jahitan 10 – 25 150,000 100,000 250,000
3 Perawatan perdarahan dengan tindakan bedah 150,000 100,000 250,000
4 Perawatan Trauma Jaringan Lunak Sedang (per kwadran rahang) 150,000 100,000 250,000
5 Vena seksi 150,000 100,000 250,000
e. Tindakan Sedang V per tindakan

1 Sirkumsisi 156,000 104,000 260,000
f. Tindakan Sedang VI per tindakan

1 Ekstraksi polip telinga 162,000 108,000 270,000
2 Ekstrasi batu uretra 162,000 108,000 270,000
3 Epistaksis sedang 162,000 108,000 270,000
4 Luka dalam besar 162,000 108,000 270,000
5 Luka jahitan > 25 162,000 108,000 270,000
6 Sirkumsisi / Femosis dengan penyulit 162,000 108,000 270,000
3. TINDAKAN BESAR
a. Tindakan Besar I per tindakan
1 EEG 168,000 112,000 280,000
2 Foto therapi 168,000 112,000 280,000
Perawatan Komplikasi Pencabutan Gigi dengan Pembedahan (per
3 168,000 112,000 280,000
regio)
4 Proktoskopi+Legasi Hemorhoid 168,000 112,000 280,000
5 Punctie Hemato Thorax 168,000 112,000 280,000
b. Tindakan Besar II per tindakan

1 Af External fixasi tanpa lokal anastesi 174,000 116,000 290,000
2 Ambulatory Blood Pressure Monitoring 174,000 116,000 290,000
3 Drainage Abses Hepar 174,000 116,000 290,000
4 EEG Digital 174,000 116,000 290,000
5 Eksisi Clavus 174,000 116,000 290,000
6 Eksisi Granuloma 174,000 116,000 290,000
7 Eksisi Nevus 174,000 116,000 290,000
8 FEES 174,000 116,000 290,000
9 Gastroduodenoskopi 174,000 116,000 290,000
10 MAR Test direct (Andrologi) 174,000 116,000 290,000
11 Mylography/Caudiography 174,000 116,000 290,000
12 Non Invasive Cardiac Closed Monitoring 174,000 116,000 290,000
13 Pasang Laminaria 174,000 116,000 290,000
14 Pemasangan katheter dengan GA 174,000 116,000 290,000
15 Punctie pleura dengan 3 waystock 174,000 116,000 290,000
16 Terapi Surfactan 174,000 116,000 290,000
c. Tindakan Besar III per tindakan

1 Angkat suspensi wire 180,000 120,000 300,000
2 Colposcopy 180,000 120,000 300,000
Hal 33 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
3 Eksisi Dermoid Cyst 180,000 120,000 300,000
4 Eksisi Keloid 180,000 120,000 300,000
5 Eksisi Polidaktil 180,000 120,000 300,000
6 Eksisi Tatto 180,000 120,000 300,000
7 Eksterpasi Ganglion 180,000 120,000 300,000
8 Esofagogastroduodenoskopi 180,000 120,000 300,000
9 Exterpasi Atheroma Besar 180,000 120,000 300,000
10 Exterpasi Lipoma Besar 180,000 120,000 300,000
11 Lobulo Plasty (Dawir) 180,000 120,000 300,000
12 Perawatan Trauma Jaringan Lunak berat (per rahang) 180,000 120,000 300,000
13 Punctie sinus maksila 180,000 120,000 300,000
14 Tandur kulit 180,000 120,000 300,000
15 Thoracoscopy 180,000 120,000 300,000
d. Tindakan Besar IV per tindakan

1 Perawatan Trauma Jaringan Lunak ringan (per regio) 186,000 124,000 310,000
e. Tindakan Besar V per tindakan

1 Epistaksis Berat 192,000 128,000 320,000
2 Pasang CVP 192,000 128,000 320,000
3 Pemberian Sitosthatika 192,000 128,000 320,000
f. Tindakan Besar VI
1 Pemasanan Body Jacket 198,000 132,000 330,000
2 Xanthelasma 198,000 132,000 330,000
4. TINDAKAN KHUSUS
a. Tindakan Khusus I per tindakan
1 Aplikasi Radium 255,000 170,000 425,000
2 Clinitron bed 255,000 170,000 425,000
3 Clonoscopi 255,000 170,000 425,000
4 Dilatasi (SG) 255,000 170,000 425,000
5 FFA 255,000 170,000 425,000
6 Fiber optic laryngoscope 255,000 170,000 425,000
7 Induksi operasi SDG,BSR,KHS 255,000 170,000 425,000
8 Irigasi sinus maxilaris 255,000 170,000 425,000
9 Kauterisasi 255,000 170,000 425,000
10 Kolposcopi 255,000 170,000 425,000
11 Laser fotoagulasi 255,000 170,000 425,000
12 Laser Trabekuloplasti 255,000 170,000 425,000
13 Humphrey Field Analyzer (HFA) 255,000 170,000 425,000
14 Pemasangan Minerva Jacket 255,000 170,000 425,000
b. Tindakan Khusus II per tindakan

1 Astrostomi Sinus Maxilaris 285,600 190,400 476,000
2 Dobutamin stress echocardiography 285,600 190,400 476,000
Hal 34 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
3 Eksisi 285,600 190,400 476,000
4 Empat Dimension Intraoperative 285,600 190,400 476,000
5 ERCP diagnostik 285,600 190,400 476,000
6 Extraksi batu biller 285,600 190,400 476,000
7 Fibroscan 285,600 190,400 476,000
8 FOB 285,600 190,400 476,000
9 Fundal Fluoresin Angiografi (FFA) 285,600 190,400 476,000
10 Holter Monitoring 285,600 190,400 476,000
11 Humphrey Field Analyzer (HFA) 285,600 190,400 476,000
12 Kalmoscopy 285,600 190,400 476,000
13 Laser argon 285,600 190,400 476,000
14 Laser YAG 285,600 190,400 476,000
15 LVE 285,600 190,400 476,000
16 Optical Coherent Tomography (OCT) 285,600 190,400 476,000
17 Preparasi sperma 285,600 190,400 476,000
18 Skleroterapi varises esophagus (termasuk obat) 285,600 190,400 476,000
19 Tampon belloque 285,600 190,400 476,000
20 Test Bera (KSO) 285,600 190,400 476,000
21 Trans eosophagus ecocardiographi (TEE) 285,600 190,400 476,000
22 Transthorax Echocardiography 285,600 190,400 476,000
6 TINDAKAN CANGGIH
a. Tindakan Canggih I per tindakan
1 Operating Microscop tanpa Biom 816,000 544,000 1,360,000
2 Polipektomi 816,000 544,000 1,360,000
3 Vascular Ultrasonography carotis 816,000 544,000 1,360,000
4 Vascular Ultrasonography extremitas ka/ki 816,000 544,000 1,360,000
b. Tindakan Canggih II per tindakan

1 Blepharosplasty 918,000 612,000 1,530,000
2 ERCP+Springterotomi 918,000 612,000 1,530,000
3 Monitoring TEE/Intra Operative 918,000 612,000 1,530,000
4 Operating Microscop dengan Biom 918,000 612,000 1,530,000
c. Tindakan Canggih III per tindakan

1 Eksterpasi tumor nasal 1,020,000 680,000 1,700,000
2 ERCP+Springterotomi+pemasangan NDB/Stent 1,020,000 680,000 1,700,000
d. TindakanCanggih IV per tindakan

1 Ekstraksi polipnasi 1,224,000 816,000 2,040,000
2 Faal paru dengan provokasi 1,224,000 816,000 2,040,000
3 Reposisi praktur nasal tertutup 1,224,000 816,000 2,040,000 per kali
7. TINDAKAN KEPERAWATAN
a. Tindakan kecil
Hal 35 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
1 Distraksi dengan teknik pernafasan 3,000 2,000 5,000 per tindakan
2 Distraksi relaksasi progresif 3,000 2,000 5,000 per tindakan
3 Distraksi visual, dengar dan kinestetik taktil 3,000 2,000 5,000 per tindakan
4 Ganti verban 3,000 2,000 5,000 per tindakan
5 Kompres mata 3,000 2,000 5,000 per tindakan
6 Lepas dower catheter 3,000 2,000 5,000 per tindakan
7 Melaksanakan pemeriksaan BMR 3,000 2,000 5,000 per tindakan
8 Melepas Resleting pd ujung penis 3,000 2,000 5,000 per tindakan
9 Memandikan Pasien 3,000 2,000 5,000 per hari
10 Memasukkan obat suppositoria 3,000 2,000 5,000 per hari
11 Memberikan huknah rendah 3,000 2,000 5,000 per tindakan
12 Memberikan kirbat es gantung 3,000 2,000 5,000 per hari
13 Memberikan kirbat es leher 3,000 2,000 5,000 per hari
14 Memberikan kompres dingin 3,000 2,000 5,000 per hari
15 Memberikan kompres panas 3,000 2,000 5,000 per hari
16 Memberikan makan klien 3,000 2,000 5,000 per hari
17 Memberikan minum bayi dengan sendok 3,000 2,000 5,000 per hari
18 Memberikan Nutrisi/Sonde 3,000 2,000 5,000 per hari
19 Memberikan obat lewat vagina 3,000 2,000 5,000 per hari
20 Membersihkan dan memotong kuku 3,000 2,000 5,000 per tindakan
21 Mencuci rambut 3,000 2,000 5,000 per tindakan
22 Mencukur daerah operasi 3,000 2,000 5,000 per tindakan
23 Mencukur rambut retro aurikuler 3,000 2,000 5,000 per hari
24 Mengajarkan cara batuk efektif 3,000 2,000 5,000 per hari
25 Mengajarkan klien cara nafas dalam efektif 3,000 2,000 5,000 per hari
26 Menyisir rambut 3,000 2,000 5,000 per hari
27 Mobilisasi log rolling 3,000 2,000 5,000 per hari
28 Pasang backlap kaki kiri 3,000 2,000 5,000 per tindakan
29 Pasang backlap tangan seluruh 3,000 2,000 5,000 per tindakan
30 Pemasangan bantal pasir klien dgn cidera cervical 3,000 2,000 5,000 per tindakan
31 Pemasangan infus 3,000 2,000 5,000 per hari
32 Pemasangan O2 3,000 2,000 5,000 per hari
33 Pemasangan spalk 3,000 2,000 5,000 per tindakan
34 Pemasangan Venflon 3,000 2,000 5,000 per tindakan
35 Pemasangan verban elastis 3,000 2,000 5,000 per tindakan
36 Pemasangan/lepas Pessarium 3,000 2,000 5,000 per tindakan
37 Pemeriksaan bebas narkoba 3,000 2,000 5,000 per tindakan
38 Pemeriksaan pendengaran dengan garputala 3,000 2,000 5,000 per tindakan
39 Pengambilan sampel darah 3,000 2,000 5,000 per tindakan
40 Pengobatan dengan tintura padopili 3,000 2,000 5,000 per tindakan
41 Perawatan gigi dan mulut (oral hygiene) 3,000 2,000 5,000 per tindakan
42 Perawatan klien akan meninggal 3,000 2,000 5,000 per tindakan
43 Perawatan Luka Bersih kecil (diameter <10cm2) 3,000 2,000 5,000 per tindakan
44 Perawatan Luka Bersih Sedang (diameter 10cm2-20cm2) 3,000 2,000 5,000 per tindakan
45 Perawatan luka kotor kecil (diameter <10cm2) 3,000 2,000 5,000 per tindakan
Hal 36 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
46 Perawatan tali pusat 3,000 2,000 5,000 per tindakan
47 Perawatan tube gastrostomi dgn pemberian diit 3,000 2,000 5,000 per tindakan
48 Psikoterapi anak 3,000 2,000 5,000 per tindakan
49 Psikoterapi kelompok 3,000 2,000 5,000 per tindakan
50 Psikoterapi lanjutan 3,000 2,000 5,000 per tindakan
51 Skin test 3,000 2,000 5,000 per tindakan
52 Spalk 3,000 2,000 5,000 per tindakan
53 Stimulasi kutaneus 3,000 2,000 5,000 per tindakan
b. Tindakan sedang
1 Inhalasi menggunakan baskom dan air panas 6,000 4,000 10,000 per hari
2 Irigasi kandung kemih 6,000 4,000 10,000 per tindakan
3 Melakukan huknah minyak 6,000 4,000 10,000 per tindakan
4 Melakukan lavas 6,000 4,000 10,000 per tindakan
5 Melatih berjalan 6,000 4,000 10,000 per hari
6 Memandikan bayi 6,000 4,000 10,000 per hari
7 Memandikan klien luka bakar 6,000 4,000 10,000 per hari
8 Membantu klien BAB dengan pispot 6,000 4,000 10,000 per hari
9 Membantu klien BAK dengan urinal 6,000 4,000 10,000 per hari
10 Membantu latihan otot 6,000 4,000 10,000 per hari
11 Memberikan huknak tinggi 6,000 4,000 10,000 per hari
12 Merawat bayi dengan foto terapi 6,000 4,000 10,000 per hari
13 Merawat luka 6,000 4,000 10,000 per hari
14 Minum perspen 6,000 4,000 10,000 per hari
15 Pemasangan infuse (bayi dan anak) 6,000 4,000 10,000 per tindakan
16 Pemasangan kap kutu 6,000 4,000 10,000 per tindakan
17 Pemasangan servical colar 6,000 4,000 10,000 per tindakan
18 Perawatan luka bakar kecil (<5%)/kali 6,000 4,000 10,000 per hari
19 Perawatan payudara ibu hamil 6,000 4,000 10,000 per hari
20 Perawatan payudara ibu meneteki 6,000 4,000 10,000 per hari
21 Perkusi vibrasi posisi secret (postural drainage) 6,000 4,000 10,000 per hari
22 Vulva hygiene 6,000 4,000 10,000 per hari
23 Merawat luka gangren 6,000 4,000 10,000 per tindakan
24 Nebulizer & Suction 6,000 4,000 10,000 per hari
25 Pemasangan infus perifer 6,000 4,000 10,000 per tindakan
26 Perawatan Luka bakar grade II 6-9% 6,000 4,000 10,000 per hari
27 Perawatan luka WSD 6,000 4,000 10,000 per hari
28 Pemasangan ransel verband 6,000 4,000 10,000 per tindakan
29 Perawatan luka bakar sedang (10-30%)/kali 6,000 4,000 10,000 per tindakan
30 Buka gips 6,000 4,000 10,000 per tindakan
31 Ekstraksi serumen obturan 6,000 4,000 10,000 per tindakan
32 Syringe pump 6,000 4,000 10,000 per hari
33 Jahitan situasi 6,000 4,000 10,000 per tindakan
34 Perawatan dekubitus grade I, II 6,000 4,000 10,000 per tindakan
35 Nebuliser sekali pakai 6,000 4,000 10,000 per tindakan
Hal 37 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
36 Oral Higyne 6,000 4,000 10,000 per tindakan
37 Perawatan luka bakar luas (>30%)/kali 6,000 4,000 10,000 per tindakan
38 Angkat jahitan luka operasi (+/_ 30 cm) 6,000 4,000 10,000 per tindakan
39 Pengelolaan + perawatan pasca Bedah 6,000 4,000 10,000 per hari
40 Perawatan dekubitus grade III, IV 6,000 4,000 10,000 per hari
41 Perawatan Luka Bersih luas (diameter>20cm2) 6,000 4,000 10,000 per hari
42 Perawatan luka kotor sedang (diameter 10 cm2-20cm2) 6,000 4,000 10,000 per hari
c. Tindakan Besar
1 Darm buis 9,000 6,000 15,000 per tindakan
2 Pemasangan skin traksi 9,000 6,000 15,000 per tindakan
3 Pemasangan skletel traksi 9,000 6,000 15,000 per tindakan
4 Pemasangan tampon vagina 9,000 6,000 15,000 per tindakan
5 Terapi okupasi menyulam 9,000 6,000 15,000 per hari
6 Perawatan suction pada tracheostomy 9,000 6,000 15,000 per hari
7 Terapi kelompok 9,000 6,000 15,000 per tindakan
8 Terapi keluarga 9,000 6,000 15,000 per tindakan
9 Terapi Kerja 9,000 6,000 15,000 per tindakan
10 Terapi okupasi anak 9,000 6,000 15,000 per tindakan
11 Terapi okupasi kerajinan 9,000 6,000 15,000 per tindakan
12 Terapi okupasi menjahit 9,000 6,000 15,000 per tindakan
13 Terapi okupasi merajut 9,000 6,000 15,000 per tindakan
14 Terapi perilaku anak 9,000 6,000 15,000 per tindakan
15 Terapi sindroma lepas zat 9,000 6,000 15,000 per tindakan
16 Day Care Jiwa Dewasa 9,000 6,000 15,000 per hari
17 Day Care Paliatif 9,000 6,000 15,000 per hari
18 Debridemen luka gangren 9,000 6,000 15,000 per tindakan
19 Latihan bicara 9,000 6,000 15,000 per tindakan
20 Lavement 9,000 6,000 15,000 per tindakan
21 Lepas Tampon 9,000 6,000 15,000 per tindakan
22 Luka bakar Grade II > 10 % 9,000 6,000 15,000 per tindakan
23 Pasang gips kupu-kupu 9,000 6,000 15,000 per tindakan
24 Pemasangan gips long arm 9,000 6,000 15,000 per tindakan
25 Perawatan Colostomy 9,000 6,000 15,000 per tindakan
26 Perawatan jenasah 9,000 6,000 15,000 per tindakan
27 Perawatan Tracheostomy/hari 9,000 6,000 15,000 per hari
28 Pemasangan gips long knee 9,000 6,000 15,000 per tindakan
29 Pemeriksaan dan wawancara 9,000 6,000 15,000 per tindakan
30 Nebulizer berkala 9,000 6,000 15,000 per hari
31 Pasang gips 9,000 6,000 15,000 per tindakan
32 Tindakan gliserin klisma 9,000 6,000 15,000 per tindakan
33 Perawatan jenasah HIV di ruangan 9,000 6,000 15,000 per tindakan
34 Perawatan luka kotor luas (diameter >20cm2) 9,000 6,000 15,000 per tindakan
III. TINDAKAN MEDIS MULUT DAN GIGI

1. TINDAKAN SEDERHANA
a. Pelayanan Medik Dasar per tindakan
Hal 38 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
1 Arsen/eugeneol fletser 12,000 8,000 20,000
2 Bongkar chrom & bridge/gigi 30,000 20,000 50,000
3 Bongkar chrom & bridge/gigi 24,000 16,000 40,000
4 Bongkar filling (amg composit) 18,000 12,000 30,000
5 Caliun/Tkt.fletser 12,000 8,000 20,000
6 Currettage / regio 24,000 16,000 40,000
7 Currettage / regio 24,000 16,000 40,000
8 Endro intra canal : akar ganda 96,000 64,000 160,000
9 Endro intra canal : satu akar 48,000 32,000 80,000
10 Gingivectomy / regio 60,000 40,000 100,000
11 Gingivoclast / regio 60,000 40,000 100,000
12 GTS lepasan plat acrylic + gigi (gigi beli) 120,000 80,000 200,000
13 GTS pergigi 45,000 30,000 75,000
14 Mahkota sementara 48,000 32,000 80,000
15 Pencabutan gigi tetap 24,000 16,000 40,000
16 Pencegahan / Peningkatan O.H : Scalling / rahang 45,000 30,000 75,000
17 Pengisian cavum pulpa 24,000 16,000 40,000
18 Pengobatan keradangan 9,000 6,000 15,000
19 Pulp chapping 24,000 16,000 40,000
20 Rebasing prothesa & menambah gigi (gigi beli sendiri) 60,000 40,000 100,000
21 Resementasi crown/gigi 36,000 24,000 60,000
22 Scallv/rahang 45,000 30,000 75,000
23 Trepanasi/preparasi 24,000 16,000 40,000
24 Tumpatan amalgam Kl I 24,000 16,000 40,000
25 Tumpatan amalgam Kl. II 30,000 20,000 50,000
26 Tumpatan composit/glass ionmer Kl. I kecil , III, IV 36,000 24,000 60,000
27 Tumpatan glass ion composit (Kl. I, Bsr, Kl.II) 42,000 28,000 70,000
28 Ulcus decubitus 9,000 6,000 15,000
29 Venaer/jacket composit/T. Limpont 60,000 40,000 100,000
30 Vital Pulpectomy : akar ganda 48,000 32,000 80,000
31 Vital Pulpectomy : satu akar 24,000 16,000 40,000
b. Pelayanan Medik Specialist (Orthodonsi) per tindakan

1 Aktiver alat ortho lepasan 30,000 20,000 50,000
2 Cetak gigi 30,000 20,000 50,000
3 Control alat cekat/kunjungan implant orthodontik 30,000 20,000 50,000
4 Ganti braket hilang / gigi : braket metal begg 42,000 28,000 70,000
5 Ganti braket hilang / gigi : braket metal straight wire 48,000 32,000 80,000
6 Konsultasi 30,000 30,000
7 Kontrol (braket metal) : RA/RB tehnik straight wire 54,000 36,000 90,000
8 Kontrol (braket metal) : RA/RB Teknik begg 54,000 36,000 90,000
9 Kontrol alat lepasan 30,000 20,000 50,000
10 Pasang band lepas / gigi 42,000 28,000 70,000
11 Penambahan setiap 1 spring (auxiliary spring) : alat cekat 48,000 32,000 80,000
12 Penambahan setiap 1 spring (auxiliary spring): alat lepasan 36,000 24,000 60,000
Hal 39 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
13 Pencabutan gigi permanen orthodontik 60,000 40,000 100,000
14 Pencabutan gigi sulung : dengan CE 15,000 10,000 25,000
c. Pelayanan Medik Specialist (Bedah Mulut)

1 Ambil jahitan/ Hecting aff 24,000 16,000 40,000
2 Kontrol pasca bedah 48,000 32,000 80,000
3 Pengelolaan Dry Socket 36,000 24,000 60,000
d. Radiologi per tindakan

1 Dental X Ray / Film 18,000 12,000 30,000
2. TINDAKAN KECIL
1 GTS lepasan gigi berikutnya per satu gigi (gigi beli sendiri/ 90,000 60,000 150,000
2 perrahang)
Curretase total 108,000 72,000 180,000
3 Reparasi protesa patah 90,000 60,000 150,000
4 Rebasing prothesa full denture 180,000 120,000 300,000
5 Jacket acrylic (gigi beli sendiri) 180,000 120,000 300,000
6 Bridge acrylic (gigi beli sendiri) 180,000 120,000 300,000
7 Pasak dengan komposit (pasak beli sendiri) 180,000 120,000 300,000
8 Pasak +inti dengan crown (pasak beli sendiri) 300,000 200,000 500,000
9 Menyambung gigi fraktur (pasak beli sendiri) 96,000 64,000 160,000
b. Pelayanan Medik Specialist (Orthodonsi) - - - per tindakan

1 Alat ortho lanjutan/rahang 240,000 160,000 400,000
2 Ganti kawat per rahang (archwire) 60,000 40,000 100,000
3 Face mask 210,000 140,000 350,000
4 Ganti braket hilang / gigi : braket ceramik 114,000 76,000 190,000
5 Gigi tiruan lepas per rahang : Bahan valplas Gigi selanjutnya per 120,000 80,000 200,000
gigi
6 Gigi tiruan lepas per rahang: Bahan akrilik, Gigi selanjutnya per gigi 90,000 60,000 150,000
7 Head Gear 210,000 140,000 350,000

8 Kontrol (braket Ceramic) 120,000 80,000 200,000
9 Lepas braket 120,000 80,000 200,000
10 Pasang band / gigi 108,000 72,000 180,000
11 Pasang braket lepas / gigi 60,000 40,000 100,000
12 Pembersihan karang gigi /kalkulus gigi/rahang: Sedikit 210,000 140,000 350,000
13 Reparasi akrilik 60,000 40,000 100,000
c. Pelayanan Medik Specialist (Bedah Mulut) per tindakan

1 Incisi abses IO 60,000 40,000 100,000
2 Lepas IMW 180,000 120,000 300,000
3 Operasi ektirpasi epolis kecil 90,000 60,000 150,000
4 Operasi mecocele 180,000 120,000 300,000
5 Pencabu 102,000 68,000 170,000
6 tan gigi
Pengelol 108,000 72,000 180,000
7 dengan
aan + Kista 180,000 120,000
Punksi 300,000
komplika
perawat
si
an
pasca
Bedah Hal 40 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
8 Uper cholectomy 180,000 120,000 300,000
3. TINDAKAN SEDANG
a. Pelayanan Medik Dasar - - - per tindakan

1 Bite plane/bite raiser 420,000 280,000 700,000
2 Gigi tiruan lepas per rahang: Bahan akrilik, gigi pertama+basis 300,000 200,000 500,000
3 Gigi tiruan lepas per rahang: Bahan valplas Gigi selanjutnya per gigi 390,000 260,000 650,000
4 Oklusal adjusment 300,000 200,000 500,000
5 Pembersihan karang gigi /kalkulus gigi/rahang: banyak 390,000 260,000 650,000
6 Pembersihan karang gigi /kalkulus gigi/rahang: Sedang 300,000 200,000 500,000
7 Space maintainer per rahang 300,000 200,000 500,000
8 Space regainer per rahang 300,000 200,000 500,000

1 Odontectomi / Partial Impected Kecil (alat habis pakai tidak 300,000 200,000 500,000
termasuk)
Odontectomi / Partial Impected Sedang (alat habis pakai tidak
2 360,000 240,000 600,000
termasuk)
3 Odontectomi / Full Impected Besar (alat habis pakai tidak termasuk) 450,000 300,000 750,000
4 Reposisi + Fiksasi Fraktur Mandibula dgn Arch Bar 324,000 216,000 540,000
5 Reposisi + Fiksasi Fraktur Dento alveolar IDW dgn Arch Bar 324,000 216,000 540,000
6 Enukleasi Kista Besar 324,000 216,000 540,000
7 Marsupialisasi Kista 324,000 216,000 540,000
8 Squstrectomi 180,000 120,000 300,000
9 Alveolectomi 180,000 120,000 300,000
10 Replantasi + Transplantasi Gigi 300,000 200,000 500,000
11 Apikoektomi 186,000 124,000 310,000
4. TINDAKAN BESAR
1 GTL lepasan/full denture RA/RB 600,000 400,000 1,000,000

1 Bedah minor pemasangan skrup mini 900,000 600,000 1,500,000
2 Pasang alat lepasan RA dan RB 750,000 500,000 1,250,000
3 Pasang Retainer invisible RA & RB 780,000 520,000 1,300,000
4 Pasang Retainer RA & RB akrilik 660,000 440,000 1,100,000
c. Pelayanan Medik Specialist (Bedah Mulut)

1 Incisi abses EO / regio 60,000 40,000 100,000 per tindakan
2 Operasi epulis sedang 180,000 120,000 300,000
3 Biopsi Tumor 90,000 60,000 150,000
4 Enukleasi Kista kecil 180,000 120,000 300,000
5 Lepas IDW 102,000 68,000 170,000
6 Debridgement 108,000 72,000 180,000
7 Ektirpasi Mucocele 180,000 120,000 300,000
8 Ektirpasi Papiloma 180,000 120,000 300,000
9 Fistulektomi/Squestrectomi 180,000 120,000 300,000
Hal 41 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
10 Frenectomi 150,000 100,000 250,000
11 Reposisi + Fiksasi Fraktur Dento alveolar IDW dgn Wire Ligature 300,000 200,000 500,000
12 Reposisi Dislokasi mandibula 108,000 72,000 180,000
13 Vestibuloplasti 240,000 160,000 400,000
14 Penutupan Oro Antral Fistula 180,000 120,000 300,000
15 Curretase 108,000 72,000 180,000
16 Gingivoplasti 180,000 120,000 300,000
5. TINDAKAN KHUSUS
a. Pelayanan Medik Dasar - - - per tindakan

1 Alat ortho cekat RA/RB 3,000,000 2,000,000 5,000,000
2 Pasang braket metal : RA/RB tehnik straight wire 3,000,000 2,000,000 5,000,000
3 Pasang braket metal : RA/RB Teknik begg 2,400,000 1,600,000 4,000,000

1 Implant gigi 4,800,000 3,200,000 8,000,000
2 Sialolitomi 300,000 200,000 500,000
3 Perawatan Bedah dengan Bone Graft 2,400,000 1,600,000 4,000,000
IV. TARIF PELAYANAN REHABILITASI MEDIK

1 Abduction Splint Besar 7,800 5,200 13,000
2 Abduction Splint Kecil 7,800 5,200 13,000
3 Ankle Foot Orthose Besar Double 7,800 5,200 13,000
4 Ankle Foot Orthose Besar Single 12,600 8,400 21,000
5 Ankle Foot Orthose Kecil Double 12,600 8,400 21,000
6 Ankle Foot Orthose Kecil Single 12,600 8,400 21,000
7 Arch Sole 13,800 9,200 23,000
8 B M D Test 13,800 9,200 23,000
9 Boston Brace 13,800 9,200 23,000
10 CTO 13,800 9,200 23,000
11 Cervical Collar 13,800 9,200 23,000
12 Chest Physical Theraphy 13,800 9,200 23,000
13 Continuous Passive Movement 13,800 9,200 23,000
14 Dennis Brown Splint Kecil 13,800 9,200 23,000
15 Dennis Brown Splint Sedang 13,800 9,200 23,000
16 Donat Heel 13,800 9,200 23,000
17 Elbow Splint 13,800 9,200 23,000
18 Emg Biofeedback 13,800 9,200 23,000
19 Ergocycle 13,800 9,200 23,000
20 Hand Splint Anak Alumunium 13,800 9,200 23,000
21 Hand Splint Anak Plastik 13,800 9,200 23,000
22 Hand Splint Dewasa Alumunium 13,800 9,200 23,000
23 Hand Splint Dewasa Plastik 13,800 9,200 23,000
24 Hip Knee Ankle Foot Orthose 13,800 9,200 23,000
Hal 42 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
25 Hip Knee Ankle Foot Orthose Double Besar 13,800 9,200 23,000
26 Hip Knee Ankle Foot Orthose Double Kecil 13,800 9,200 23,000
27 Hip Knee Ankle Foot Orthose Single Kecil 13,800 9,200 23,000
28 Hotpack 13,800 9,200 23,000
29 Icing/Cryojet 13,800 9,200 23,000
30 Infrared 13,800 9,200 23,000
31 Injeksi Intraartikular 13,800 9,200 23,000
32 Jewwet Extention Brace 13,800 9,200 23,000
33 Kinetizer 13,800 9,200 23,000
34 Knee Ankle Foot Orthose Double Kecil 13,800 9,200 23,000
35 Knee Ankle Foot Orthose Double Besar 13,800 9,200 23,000
36 Knee Ankle Foot Orthose Single Besar 13,800 9,200 23,000
37 Knee Ankle Foot Orthose Single Kecil 13,800 9,200 23,000
38 Knee Brace 13,800 9,200 23,000
39 Kruk Alumunium 13,800 9,200 23,000
40 L S O Brace Plastik 13,800 9,200 23,000
41 L S O Corset 13,800 9,200 23,000
42 Laser Therapy Unit 13,800 9,200 23,000
43 Latihan A D L 13,800 9,200 23,000
44 Latihan Ambulasi 13,800 9,200 23,000
45 Latihan Cerebral Palsy 13,800 9,200 23,000
46 Latihan Endurance 13,800 9,200 23,000
47 Latihan Feeding/Oral Stimulasi 13,800 9,200 23,000
48 Latihan Fungsi Tangan 17,400 11,600 29,000
49 Latihan Keseimbangan 18,000 12,000 30,000
50 Latihan Ketangkasan/Agility 18,000 12,000 30,000
51 Latihan Koordinasi 18,000 12,000 30,000
52 Latihan Lbp (William Flexion) 18,000 12,000 30,000
53 Latihan Luas Gerak Sendi 18,000 12,000 30,000
54 Latihan Neck Calliet 18,000 12,000 30,000
55 Latihan Osteoporosis 22,200 14,800 37,000
56 Latihan Pada Bayi 22,200 14,800 37,000
57 Latihan Parkinson 22,200 14,800 37,000
58 Latihan Penguatan 22,200 14,800 37,000
59 Latihan Peregangan 22,200 14,800 37,000
60 Latihan Skoliosis 22,200 14,800 37,000
61 Latihan Stroke 22,200 14,800 37,000
62 Latihan Vertigo 27,000 18,000 45,000
63 Latihan Vokasional 25,800 17,200 43,000
64 Long Leg Brace Besar Double 25,800 17,200 43,000
65 Long Leg Brace Besar Single 29,400 19,600 49,000
66 Long Leg Brace Kecil Double 33,000 22,000 55,000
67 Long Leg Brace Kecil Single 34,800 23,200 58,000
68 MSO 34,800 23,200 58,000
69 MWD 24,000 16,000 40,000
Hal 43 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
70 Magneto Therapy Unit 48,000 32,000 80,000
71 Manual Manipulasi 42,000 28,000 70,000
72 Manual Muscle Test 30,000 20,000 50,000
73 Masage 21,000 14,000 35,000
74 Milwaukee Brace 30,000 20,000 50,000
75 Nebulizer Ultrasonic Mobile 48,000 32,000 80,000
76 Overhead Pulley 42,000 28,000 70,000
77 Parafine Bath 60,000 40,000 100,000
78 Peak Flow Meter 42,000 28,000 70,000
79 Petugas Sosial Medis 36,000 24,000 60,000
80 Philadelphia Brace 42,000 28,000 70,000
81 Postural Drainage 48,000 32,000 80,000
82 Presso/Compressi Extremiter 42,000 28,000 70,000
83 Prothese Atas Lutut 54,000 36,000 90,000
84 Prothese Atas Siku 54,000 36,000 90,000
85 Prothese Bawah Lutut 54,000 36,000 90,000
86 Prothese Bawah Siku 54,000 36,000 90,000
87 Prothese Pergelangan Tangan (Wrist) 54,000 36,000 90,000
88 Prothese Telapak Kaki (Chopart) 54,000 36,000 90,000
89 Prothese Tepat Ankle ( Syme ) 54,000 36,000 90,000
90 Prothese Tepat Bahu 54,000 36,000 90,000
91 Prothese Tepat Lutut 54,000 36,000 90,000
92 Prothese Tepat Panggul ( Telting Table ) 54,000 36,000 90,000
93 Prothese Tepat Siku 54,000 36,000 90,000
94 Quadricep Exercise 48,000 32,000 80,000
95 Rehabilitasi Psikologi Individu 54,000 36,000 90,000
96 Rehabilitasi Psikologi Klompok 54,000 36,000 90,000
97 Rehabilitasi Psikologi Sosial 54,000 36,000 90,000
98 SWD 24,000 16,000 40,000
99 Sacro Iliac Corset 30,000 20,000 50,000
100 Senam Asma 36,000 24,000 60,000
101 Senam Bedah Caesar 21,000 14,000 35,000
102 Senam Hamil 21,000 14,000 35,000
103 Senam Nifas 18,000 12,000 30,000
104 Sepatu Boot Koreksi Uk 14-17 24,000 16,000 40,000
111 Sepatu Koreksi Diabetes 48,000 32,000 80,000
112 Sepatu Lars Koreksi Uk 14-17 36,000 24,000 60,000
Hal 44 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
119 Short Leg Brace Besar Double 42,000 28,000 70,000
120 Short Leg Brace Besar Single 42,000 28,000 70,000
121 Short Leg Brace Kecil Double 42,000 28,000 70,000
122 Short Leg Brace Kecil Single 42,000 28,000 70,000
123 Shoulder Sling 48,000 32,000 80,000
124 Shoulder Wheel 48,000 32,000 80,000
125 Snoozellen Room Theraphy 60,000 40,000 100,000
126 Step Ladder 36,000 24,000 60,000
127 T L S O Brace Plastik 24,000 16,000 40,000
128 T L S O Corset 24,000 16,000 40,000
129 Tens/Es/Faradisasi 24,000 16,000 40,000
130 Terapi Okupasi 30,000 20,000 50,000
131 Terapi Wicara 30,000 20,000 50,000
132 Test Kecerdasan/Perilaku 48,000 32,000 80,000
133 Tilt Table 18,000 12,000 30,000
134 Traksi Cervical Listrik 48,000 32,000 80,000
135 Traksi Pelvis Listrik 48,000 32,000 80,000
136 Tripod 30,000 20,000 50,000
137 USD 24,000 16,000 40,000
138 Walker 30,000 20,000 50,000
139 Whirl Poll 90,000 60,000 150,000
V. PENUNJANG MEDIS
1. PEMERIKSAAN LABORATORIUM
a. Hematologi
1) Sederhana / Sedang
a ) diffcount 6,300 2,700 9,000
b ) eritrosit 6,300 2,700 9,000
c ) Evaluasi hapusan darah 35,000 15,000 50,000
d ) Golongan Darah 8,750 3,750 12,500
e ) Haemoglobin 10,500 4,500 15,000
f ) HCT 7,000 3,000 10,000
g ) laju endap darah 6,300 2,700 9,000
h ) leukosit 6,300 2,700 9,000
i ) Malaria 9,450 4,050 13,500
j ) Masa pembekuan 14,000 6,000 20,000
k ) Masa perdarahan 14,000 6,000 20,000
l ) MCH 5,950 2,550 8,500
m ) MCHC 5,950 2,550 8,500
n ) MCV 5,950 2,550 8,500
o ) retikulosit 14,000 6,000 20,000
Hal 45 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
p ) trombosit 10,500 4,500 15,000
2) Canggih
a ) Darah lengkap automatic 24,500 10,500 35,000
b ) PT 49,000 21,000 70,000
c ) APTT 21,000 9,000 30,000
b. Kimia Klinik
1) Sederhana
2) Sedang
a ) Diabetes
(1) glukosa darah puasa 9,100 3,900 13,000
(2) glukosa darah 2 jam PP 9,100 3,900 13,000
(3) glukosa sewaktu 9,100 3,900 13,000
b ) Fungsi hati
(1) Albumin 10,500 4,500 15,000
(2) Alkali Fosfatase 10,500 4,500 15,000
(3) Billirubin Direk / Indirek 9,100 3,900 13,000
(4) Billirubin total 10,500 4,500 15,000
(5) Gama GT 11,900 5,100 17,000
(6) Globulin 10,500 4,500 15,000
(7) SGOT 10,500 4,500 15,000
(8) SGPT 10,500 4,500 15,000
(9) Total protein 10,500 4,500 15,000
c ) Fungsi ginjal
(1) Asam urat 10,500 4,500 15,000
(2) Creatinin 10,500 4,500 15,000
(3) Ureum/BUN 10,500 4,500 15,000
d ) Analisa lemak
(1) Cholesterol HDL 10,500 4,500 15,000
(2) Cholesterol LDL 10,500 4,500 15,000
(3) Cholesterol total 10,500 4,500 15,000
(4) Trigliserida 14,000 6,000 20,000
3) Canggih - - -
Kimia Darah :
(1) Calsium 35,000 15,000 50,000
(2) Kalium 28,000 12,000 40,000
(3) Klorida 28,000 12,000 40,000
(4) Natrium 31,500 13,500 45,000
c. Serologi
1) Sederhana
2) Sedang
a ) Anti HAV 98,000 42,000 140,000
b ) Anti Hbs 24,500 10,500 35,000
c ) Anti HCV 28,000 12,000 40,000
d ) Anti TB 70,000 30,000 100,000
Hal 46 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
e ) Dengue Blood lg G 49,000 21,000 70,000
f ) Dengue Blood lg M 49,000 21,000 70,000
g ) Hbs Ag 28,000 12,000 40,000
h ) HIV 49,000 21,000 70,000
i ) Rematoid 42,000 18,000 60,000
j ) Scrining Tes Narkoba 105,000 45,000 150,000
k ) TPHA 19,950 8,550 28,500
l ) VDRL 14,000 6,000 20,000
m ) Widal 17,500 7,500 25,000
n ) NS 1 122,500 52,500 175,000
3) Canggih
a ) CKMB 87,500 37,500 125,000
b ) CRP 38,500 16,500 55,000
c ) HBA 1C 108,500 46,500 155,000
d ) Troponin 49,000 21,000 70,000
e ) Tubek TF / I GM Salmonella/ Ag Salmonella 108,500 46,500 155,000
f ) Analisa Gas Darah 220,500 94,500 315,000
d. Imunologi
1) Sederhana
Tes kehamilan 10,500 4,500 15,000
2) Sedang
a ) Toxoplasma Ig G 87,500 37,500 125,000
b ) Toxoplasma Ig M 87,500 37,500 125,000
c ) T3 94,500 40,500 135,000
d ) T4 94,500 40,500 135,000
e ) TSHS 94,500 40,500 135,000
3) Canggih
FT4 98,000 42,000 140,000
e. Mikrobiologi
1) Sederhana
2) Sedang
a ) Jamur 13,300 5,700 19,000
b ) Parasit Tanah 21,700 9,300 31,000
c ) Pewarnaan BTA 15,750 6,750 22,500
d ) Pewarnaan Gram 14,000 6,000 20,000
3) Canggih
a ) Bakteriologi Air 87,500 37,500 125,000
b ) Blood Cultur dan Sensitivity Test Obat 87,500 37,500 125,000
c ) Cairan Tubuh Cultur dan Sensitivity Test Obat 87,500 37,500 125,000
e ) Gall Cultur dan Sensitivity Test Obat 87,500 37,500 125,000
f ) Pus Cultur dan Sensitivity Test Obat 87,500 37,500 125,000
g ) Sensitivity Test Obat 87,500 37,500 125,000
h ) Urin Cultur dan Sensitivity Test Obat 87,500 37,500 125,000
Hal 47 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
f. Cairan Tubuh
1) Sederhana
a ) Faeces lengkap 10,500 4,500 15,000
b ) Sedimen 6,300 2,700 9,000
c ) Urin lengkap 10,500 4,500 15,000
2) Sedang
a ) Analisa Sperma 52,500 22,500 75,000
b ) Cairan Otak 52,500 22,500 75,000
c ) Cairan Pleura / asilat 52,500 22,500 75,000
d ) Cairan Sendi 52,500 22,500 75,000
3) Canggih
a ) Batu ginjal 101,500 43,500 145,000
g. Patologi Anatomi
1 ) FNAB (Fine Needle Aspiration Biopsi) 108,000 72,000 180,000
2 ) Histopatologi :
a) Besar 270,000 180,000 450,000
b) Sedang 150,000 100,000 250,000
c) Kecil 60,000 40,000 100,000
3 ) Papsmear 45,000 30,000 75,000
4 ) Sitologi Cairan 60,000 40,000 100,000
2. PEMERIKSAAN RADIODIAGNOSTIK
a. Sederhana : 18/24 = 1, 30/40 = 1
1) Anak :
a ) Bone Age 56,000 24,000 80,000
b ) Pelvis 56,000 24,000 80,000
c ) Thorax, BOF 56,000 24,000 80,000
2) Dewasa :
a ) Basic Cranii 56,000 24,000 80,000
b ) Cadwell 56,000 24,000 80,000
c ) Extremitas 56,000 24,000 80,000
d ) OS Nasal 56,000 24,000 80,000
e ) Sella Khusus 56,000 24,000 80,000
f ) Skull Lat 56,000 24,000 80,000
g ) Towne 56,000 24,000 80,000
h ) Waters 56,000 24,000 80,000
b. Kecil : 18/24 = 1, 24/30 = 2

1) Anak :
a ) Thorax AP+Lat 60,000 40,000 100,000
b ) V. Th/LS AP+Lat 60,000 40,000 100,000
60,000 40,000 100,000
Hal 48 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
2) Dewasa :
a ) Bahu R + L 60,000 40,000 100,000
b ) BOF, Pelvis, AP + Lateral (dws) 60,000 40,000 100,000
c ) Cervical AP + Lat 60,000 40,000 100,000
d ) Extremitas AP 60,000 40,000 100,000
e ) Long Bone 60,000 40,000 100,000
f ) Mandibula R + L 60,000 40,000 100,000
g ) Mastoid R + L 60,000 40,000 100,000
h ) Orbita AP + Lat 60,000 40,000 100,000
i ) Rhese AP + Lat 60,000 40,000 100,000
j ) Skull AP + Lat 60,000 40,000 100,000
k ) Stenvers R + L 60,000 40,000 100,000
l ) Thorax 60,000 40,000 100,000
c. Sedang:18/24=4, 24x30 = 4,35/35=2,30/40=2

1 ) Cervical 60,000 40,000 100,000
2 ) COR Study 60,000 40,000 100,000
3 ) Cystrogram 141,000 94,000 235,000
4 ) Darecyografi 120,000 80,000 200,000
5 ) Fistulografi 120,000 80,000 200,000
6 ) Laryngogram 114,000 76,000 190,000
7 ) Oesophagogram 114,000 76,000 190,000
8 ) Sialografi 114,000 76,000 190,000
9 ) Thorax 2 posisi 48,000 32,000 80,000
10 ) Uretrographi 141,000 94,000 235,000
11 ) Vertebrae 60,000 40,000 100,000
d. Besar : 30/40 = 4, 35/43=3, 35/35=4

1 ) APG 180,000 120,000 300,000
2 ) Arthografi 300,000 200,000 500,000
3 ) Bipolar voilding 132,000 88,000 220,000
4 ) Bone Survey 120,000 80,000 200,000
5 ) Caudografi 132,000 88,000 220,000
6 ) Colon in loop 132,000 88,000 220,000
7 ) COR Study 90,000 60,000 150,000
8 ) Follow Trough 168,000 112,000 280,000
9 ) HSG 168,000 112,000 280,000
10 ) Infusion 168,000 112,000 280,000
11 ) IVP 180,000 120,000 300,000
12 ) Myolografi 132,000 88,000 220,000
13 ) Mamografy 132,000 88,000 220,000
14 ) RPG 180,000 120,000 300,000
15 ) Splingtografi 132,000 88,000 220,000
16 ) Th/LS 4 Posisi 90,000 60,000 150,000
17 ) Tomogram 132,000 88,000 220,000
Hal 49 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
18 ) UGI 90,000 60,000 150,000
e. Canggih :
1 ) FNAB Guider CT 420,000 280,000 700,000
2 ) FNAB Guider USG 300,000 200,000 500,000
3 ) Lower Abdoment 120,000 80,000 200,000
4 ) Pungksi Abses Guider USG 120,000 80,000 200,000
5 ) Upper & Lower Abdoment 195,000 130,000 325,000
6 ) USG Dopler Upper Abdoment 270,000 180,000 450,000
7 ) USG Upper Abdoment 129,000 86,000 215,000
8 ) USG Bahu 75,000 50,000 125,000
9 ) USG Kandungan 90,000 60,000 150,000
10 ) USG Bayi/Kepala 90,000 60,000 150,000
11 ) USG Mammae/Tyroid 120,000 80,000 200,000
12 ) USG Mata/Paru 120,000 80,000 200,000
13 ) USG Lengan 78,000 52,000 130,000
14 ) USG Lengan Bilateral 96,000 64,000 160,000
15 ) USG Appendix 108,000 72,000 180,000
16 ) USG Colour Doppler 3D 60,000 40,000 100,000
17 ) USG Prostat transrectal 96,000 64,000 160,000
18 ) USG Musculoskeletal bilateral 96,000 64,000 160,000
19 ) USG Extremitas 78,000 52,000 130,000
3. PEMERIKSAAN DIAGNOSTIK ELEKTROMEDIK

a. Rest ECG 36,000 24,000 60,000
b. Treadmill/Exercise Echocardiography 204,000 136,000 340,000
VI. PEMERIKSAAN INVASIF

1 Biopsi 300,000 200,000 500,000
2 Biopsi adneksa 306,000 204,000 510,000
3 Biopsi colon 306,000 204,000 510,000
4 Biopsi ginjal 306,000 204,000 510,000
5 Biopsi hati 306,000 204,000 510,000
6 Biopsi kulit 306,000 204,000 510,000
7 Biopsi nasofaring 306,000 204,000 510,000
8 Biopsi pleura 306,000 204,000 510,000
9 Biopsi tumor (THT- KL) 306,000 204,000 510,000
10 Biopsi tumor THT 346,800 231,200 578,000
11 Biopsi/Eklipasi jaringan 346,800 231,200 578,000
12 Bronchuscopy (Fyber) 346,800 231,200 578,000
13 Colonoscopy :
a. Colonoscopy Ebiopsi 900,000 600,000 1,500,000
b. Endoscopy Ebiopsi 690,000 460,000 1,150,000
c. Endoscopy + Ligasi Varices Esofagus 690,000 460,000 1,150,000
14 FOL/ NE (endoscopy diagnostic) 540,000 360,000 900,000
Hal 50 dari 41
KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
15 Laringoscopy direct 132,600 88,400 221,000
16 Laringoscopy indirect 46,800 31,200 78,000
17 Nasofaringoscopy 142,800 95,200 238,000
18 Rinoskopi posterior 46,800 31,200 78,000
VII. TINDAKAN HEMODIALISA (HD)

1 HD baru 465,000 310,000 775,000
2 HD lama 405,000 270,000 675,000
3 HD Cito baru 600,000 400,000 1,000,000
4 HD Cito Lama 510,000 340,000 850,000
VIII. PEMULASARAN JENAZAH/PERAWATAN JENAZAH

1 Perawatan Jenazah 150,000 100,000 250,000 per tindakan
2 Otopsi Jenazah 450,000 300,000 750,000 per tindakan
3 Pemakaian Kamar Jenazah 60,000 40,000 100,000 per tindakan
4 Pengawetan Jenazah 900,000 600,000 1,500,000 per tindakan
5 Bedah Jenazah (yang digali dari kubur) 1,200,000 800,000 2,000,000 per tindakan
6 Penyimpanan Jenazah 120,000 80,000 200,000 perhari
IX. TARIF PELAYANAN MEDICAL/GENERAL CHECK UP

1. PAKET I
a. Pemeriksaan Kesehatan Umum 9,000 6,000 15,000
b. Rongent (Thorax Foto) 48,000 32,000 80,000
c. Laboratorium : DL, UL 96,000 64,000 160,000
d. Pemeriksaan Mata : Visus 37,200 24,800 62,000
Jumlaah Paket I 317,000
2. PAKET II (PAKET I DITAMBAH)

a. Laboratorium : LFT (Liver Fungsi Test) dan GDA 107,600 26,900 134,500
b. Pemeriksaan Mata : Test Buta Warna 41,400 27,600 69,000
Jumlah Paket II (+Paket I) 520,500
3. PAKET III (PAKET II DITAMBAH)

a. Laboratorium : RFT (Renal Fungsi Test) dan Analisa Lemak 76,000 19,000 95,000
Jumlah Paket III (+Paket II) 615,500
X. TARIF PELAYANAN FARMASI RUMAH SAKIT

1 Pencampuran obat sitostatika
a. Pasien RSU Dr. Koesnadi 39,000 26,000 65,000
b. Pasien luar RSU Dr. Koesnadi 60,000 40,000 100,000
2 Pengkajian Pengobatan 6,000 4,000 10,000
3 Konseling Pasien KRS (persetujuan Pasien) 4,500 3,000 7,500
4 Konseling Pasif (Persetujuaan Pasien) 3,000 2,000 5,000
Hal 51 dari 41
XI. TARIF GAS MEDIK
angka WAKTU PENGGUNAAN DALAM JAM
pada skala 1 2 3 4 5 6 7 8
flowmeter (Rp.) (Rp.) (Rp.) (Rp.) (Rp.) (Rp.) (Rp.) (Rp.)
1 1,900 3,800 5,700 7,600 9,500 11,400 13,300 15,200
2 3,800 7,600 11,400 15,200 19,000 22,800 26,600 30,400
3 5,700 11,400 17,100 22,800 28,500 34,200 39,900 45,600
4 7,600 15,200 22,800 30,400 38,000 45,600 53,200 60,800
5 9,500 19,000 28,500 38,000 47,500 57,000 66,500 76,000
6 11,400 22,800 34,200 45,600 57,000 68,400 79,800 91,200
7 13,300 26,600 39,900 53,200 66,500 79,800 93,100 106,400
8 15,200 30,400 45,600 60,800 76,000 91,200 106,400 121,600
9 17,100 34,200 51,300 68,400 85,500 102,600 119,700 136,800
10 19,000 38,000 57,000 76,000 95,000 114,000 133,000 152,000
11 20,900 41,800 62,700 83,600 104,500 125,400 146,300 167,200

pada skala 9 10 11 12 13 14 15 16
1 17,100 19,000 20,900 22,800 24,700 26,600 28,500 30,400
2 34,200 38,000 41,800 45,600 49,400 53,200 57,000 60,800
3 51,300 57,000 62,700 68,400 74,100 79,800 85,500 91,200
4 68,400 76,000 83,600 91,200 98,800 106,400 114,000 121,600
5 85,500 95,000 104,500 114,000 123,500 133,000 142,500 152,000
6 102,600 114,000 125,400 136,800 148,200 159,600 171,000 182,400
7 119,700 133,000 146,300 159,600 172,900 186,200 199,500 212,800
8 136,800 152,000 167,200 182,400 197,600 212,800 228,000 243,200
9 153,900 171,000 188,100 205,200 222,300 239,400 256,500 273,600
10 171,000 190,000 209,000 228,000 247,000 266,000 285,000 304,000
11 188,100 209,000 229,900 250,800 271,700 292,600 313,500 334,400

pada skala 17 18 19 20 21 22 23 24
1 32,300 34200 36,100 38000 39,900 41,800 43700 45,600
2 64,600 68,400 72,200 76,000 79,800 83,600 87,400 91,200
3 96,900 102,600 108,300 114,000 119,700 125,400 131,100 136,800
4 129,200 136,800 144,400 152,000 159,600 167,200 174,800 182,400
5 161,500 171,000 180,500 190,000 199,500 209,000 218,500 228,000
6 193,800 205,200 216,600 228,000 239,400 250,800 262,200 273,600
7 226,100 239,400 252,700 266,000 279,300 292,600 305,900 319,200
8 258,400 273,600 288,800 304,000 319,200 334,400 349,600 364,800
9 290,700 307,800 324,900 342,000 359,100 376,200 393,300 410,400
10 323,000 342,000 361,000 380,000 399,000 418,000 437,000 456,000
11 355,300 376,200 397,100 418,000 438,900 459,800 480,700 501,600
Hal 40 dari 41
XII. PELAYANAN TRANSPORTASI PASIEN DAN TRANSPORTASI JENAZAH
NO JENIS RETRIBUSI KETERANGAN
1. Pemakaian Mobil Ambulance a. Jarak tempuh untuk 0-5 km pertama sebesar Rp. 80.000,- (delapan
(diatur/dihitung pergi pulang) puluh ribu rupiah) dan tiap Km selebihnya ada penambahan sebesar
Rp. 5.000,- (lima ribu rupiah) tidak termasuk penggunaan alat dan obat
b. Biaya BBM, Tol, parkir dan penyebrangan Kapal Laut ditanggung oleh
Pemakai Mobil Ambulance
2. Pemakaian Mobil Jenazah a. Jarak tempuh untuk 0-5 km pertama sebesar Rp. 120.000,- (seratus
(diatur/dihitung pergi pulang) dua puluh ribu rupiah) dan tiap Km selebihnya ada penambahan
sebesar Km Rp. 6.000,- (enam ribu rupiah)
b. Biaya BBM Tol, parkir dan penyebrangan Kapal Laut ditanggung oleh
Pemakai Mobil Ambulance
Hal 40 dari 41
XIV. PELAYANAN STERILISASI DAN LAUNDRY (BINATU)
KOMPONEN JASA
TARIF
No. JENIS PELAYANAN SARANA PELAYANAN KET
(Rp) (Rp) (Rp)
60% 40%
1 Linen Paket Operasi (OK) 105,000 70,000 175000 per paket
2 Hecting Set (IGD) 12,000 8,000 20,000 operasi
per set
3 Kasa steril per pak 600 400 1,000 per pak
4 Handschoen 1,800 1,200 3,000 per pasang
5 Partus Set (Seruni) 12,000 8,000 20,000 per set
6 Curettage Set (Mawar) 39,000 26,000 65,000 per set
7 Alat Operasi Mata 39,000 26,000 65,000 per set
8 Kontrasepsi Set (KIA) 6,000 4,000 10,000 per set
9 Alat Operasi THT 39,000 26,000 65,000 per set
10 Set Rawat Luka (Dahlia dan Bougenvil) 12,000 8,000 20,000 per set
11 Steril dual ukuran 7,5 cm 1,200 800 2,000 Per 30 cm
12 Steril dual ukuran 15 cm 2,100 1,400 3,500 Per 30 cm
13 Steril dual ukuran 25 cm 3,600 2,400 6,000 Per 30 cm
14 Steril dual ukuran 10 cm x 5 cm 2,100 1,400 3,500 Per 30 cm
18 Cuci pakaian/linen 1,200 800 2,000 Per potong
19 Cuci pakaian/linen 1,800 1,200 3,000 per kilogram
XV PELAYANAN PEMBAKARAN SAMPAH MEDIK

KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
1 Klinik/RS Swasta 270,000 180,000 450,000
2 UTD 75,000 50,000 125,000
3 Praktek Dokter Bersama 30,000 20,000 50,000
4 Laboratorium Kesehatan swasta 36,000 24,000 60,000
5 Pukesmas dengan rawat inap 45,000 30,000 75,000
6 Puskesmas tanpa rawat inap 30,000 20,000 50,000
7 Praktek Dokter Pribadi 21,000 14,000 35,000
XVI. PELAYANAN LAIN-LAIN

KOMPONEN JASA
TARIF
(Rp) (Rp) (Rp)
1 Sewa Aula Rumah Sakit Per 1 x pakai 90,000 60,000 150,000
Dikecualikan untuk Kepentingan:
1. Internal RS
2. Mahasiswa Praktek
Hal 41 dari 41
BUPATI BNDOWOSO,
AMIN SAID HUSNI
Hal 41 dari 41
0-72-36-01 12 235 1304 914 0 0 3 8 4
17022016- 0-72-24-52 3 18 206 9 17 ###

4 ISLAMIYAHBAYU KARI BWS ### MENGOK RT30 RW6 PUJER 0 0
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0 1
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LAMPIRAN PERDA NO 4 TH 2013 TTG PERUB KEDUA PERDA 16 Klas III - PERUB KEDUA - Setalah TGL 10 - 9

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LAMPIRAN PERDA NO 4 TH 2013 TTG PERUB KEDUA PERDA 16 Klas III - PERUB KEDUA - Setalah TGL 10 - 9

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1 TINDAKAN SEDERHANA

a. Pelayanan Medik Dasar

b. Pelayanan Medik Specialist

TARIF PELAYANAN KESEHATAN KELAS III

I. INSTALASI GAWAT DARURAT

II. INSTALASI RAWAT JALAN

B. TARIF PELAYANAN INTERMEDIATE (termasuk stroke corner )

C. TARIF PELAYANAN RUANG BAYI

D. TARIF RAWAT INTENSIF (ICU, ICCU, PICU, NICU)

E. TARIF RAWAT ISOLASI

F. TARIF RAWAT SEHARI

II. TARIF PELAYANAN MEDIK

c. Operasi Kecil III

2. KATEGORI OPERASI SEDANG

c. Operasi Sedang III

2. KATEGORI OPERASI BESAR

c. Operasi Besar III

4. KATEGORI OPERASI KHUSUS

c. Operasi Khusus III

B. TINDAKAN MEDIK NON OPERATIF

b. Tindakan Sederhana II per tindakan

d. Tindakan Sederhana IV per tindakan

e. Tindakan Sederhana V per tindakan

2 TINDAKAN KECIL per tindakan

b. Tindakan Kecil II per tindakan

c. Tindakan Kecil III per tindakan

d. Tindakan Kecil IV per tindakan

e. Tindakan Kecil V per tindakan

c. Tindakan Sedang III per tindakan

d. Tindakan Sedang IV per tindakan

e. Tindakan Sedang V per tindakan

f. Tindakan Sedang VI per tindakan

b. Tindakan Besar II per tindakan

c. Tindakan Besar III per tindakan

d. Tindakan Besar IV per tindakan

e. Tindakan Besar V per tindakan

b. Tindakan Khusus II per tindakan

b. Tindakan Canggih II per tindakan

c. Tindakan Canggih III per tindakan

d. TindakanCanggih IV per tindakan

III. TINDAKAN MEDIS MULUT DAN GIGI

b. Pelayanan Medik Specialist (Orthodonsi) per tindakan

c. Pelayanan Medik Specialist (Bedah Mulut)

d. Radiologi per tindakan

b. Pelayanan Medik Specialist (Orthodonsi) - - - per tindakan

7 Head Gear 210,000 140,000 350,000

c. Pelayanan Medik Specialist (Bedah Mulut) per tindakan

b. Pelayanan Medik Specialist (Orthodonsi) per tindakan

c. Pelayanan Medik Specialist (Bedah Mulut) per tindakan

b. Pelayanan Medik Specialist (Orthodonsi) per tindakan

c. Pelayanan Medik Specialist (Bedah Mulut)

b. Pelayanan Medik Specialist (Orthodonsi) per tindakan

c. Pelayanan Medik Specialist (Bedah Mulut) per tindakan

IV. TARIF PELAYANAN REHABILITASI MEDIK

b. Kecil : 18/24 = 1, 24/30 = 2

c. Sedang:18/24=4, 24x30 = 4,35/35=2,30/40=2

d. Besar : 30/40 = 4, 35/43=3, 35/35=4

3. PEMERIKSAAN DIAGNOSTIK ELEKTROMEDIK

VI. PEMERIKSAAN INVASIF

VII. TINDAKAN HEMODIALISA (HD)

VIII. PEMULASARAN JENAZAH/PERAWATAN JENAZAH

IX. TARIF PELAYANAN MEDICAL/GENERAL CHECK UP