No JENIS PELAYANAN TARIF

POLI CITRA
Konsultasi Pasien Baru (termasuk pemeriksaan autoref dan
1 250,000
non kontak)
Konsultasi Pasien Lama (termasuk pemeriksaan autoref dan
2 220,000
non kontak)
3 Low Vision 478,000
4 Konsultasi Lanjutan Poli Mata 139,000
5 Konsultasi Pasien Post Op 129,000
6 DBR / BIOMETRI (1 mata) 140,000
7 Dermabrasi / Corpus Alineum 520,000
8 Epilasi Bulu Mata 82,000
9 ERG 416,000
10 ERG dan VEP + Multifocal 750,000
11 FFA 1,248,000
12 Fitting Lensa Kontak 120,000
13 Foto Fundus (1 Mata) 104,000
14 Foto Fundus non midriatikum 104,000
15 Humphrey 158,000
16 ICG Fundus Angiography 2,748,000
17 Kampimetri Goldmann (ODS) 138,000
18 Keratometri Javal (2 Mata) 104,000
19 Laser Multispot 2,500,000
20 Laser Multiwave 3,000,000
21 Non Con Robo (1 Mata) 50,000
22 Octopus (1 Mata) 158,000
23 Retinometri (1 Mata) 164,000
24 Selective Laser Trabeculoplasty 1,600,000
25 Spooling / Irigasi bola mata 66,000
26 Streak retinoscopy ( 1 mata ) 102,000
27 Suntik Botox 2,496,000
28 Synoptophore 104,000
29 Tes Schirmer /BUT 12,000
30 UBM 200,000
31 OCT (1 MATA)/Visante 300,000
32 USG (1 Mata) 522,000
33 VEP 416,000
34 Yag Laser ( Kapsul Posterior ) 1,000,000
35 Argon Laser ( Laser Retina ) 1,900,000
36 Iridektomi perifer laser 1,328,000
37 Angkat Jahitan palpebra / DFG 118,000
38 Angkat Jahitan kornea ( 1 mata ) 118,000
39 Pterygium 2,016,000
40 Ekstraksi Lithiasis 310,000
41 Hordeolum / Incisi 644,000
42 Abses / Insisi 644,000
43 Biopsi / Insisi Tumor 2,066,000
44 Nekrotomi 320,000
45 Jahit Palpebra ringan 2,066,000
46 Xanthelasma 3,118,000
47 Eksisi - Granuloma ( 1 mata ) 4,160,000
48 Eksterpasi Papiloma/Kista 2,066,000
49 Eksisi Nevus 3,120,000

10. Departemen Mata/ 2015

No JENIS PELAYANAN TARIF
50 Eksterpasi Tumor Jinak (Kecil) 3,072,000
51 Parasentese 406,000
52 Anel Lakrimalis 104,000
53 Dermalipoma 1,596,000
54 Screening ROP 296,000
55 Tonometri tonopen ( 2 mata ) 48,000
56 Funduskopi indirec ( 2 mata / ods ) 138,000
57 Funduskopi direc ( 2 mata / ods ) 138,000
58 Ganti Balutan (Verband) / Fitting Protesa (1 mata) 132,000
59 Topolyzer (1 Mata) / Corneal Topografi 160,000
60 Occulyzer (1Mata) 160,000
61 Analyzer (1 Mata) 161,000
62 IOL Master (1Mata) 265,000
63 Paket Pra Lasik (2 Mata) 600,000
64 Injeksi Subtenon / Flamincort (BMHP diresepkan) 180,000
65 Injeksi Subtenon / Flamincort (BMHP Paket) 305,000
66 Injeksi 5FU 264,000

10. Departemen Mata/ 2015