Tarif GT III - 2019 (Draft)

BUKU TARIF RS HERMINA
TAHUN 2019
DAFTAR ISI BUKU TARIF 2019
NO. PERIHAL HALAMAN
1 DAFTAR ISI
2 SURAT KEBIJAKAN
ii.a KEBIJAKAN DIREKTUR RS HERMINA
ii.b KEBIJAKAN POLA TARIF
3 ISI BUKU TARIF
I. UMUM
I.1. ADMINISTRASI RS 1
I.1.1. RAWAT JALAN 1
I.1.2. RAWAT INAP 1
I.2 TARIF RUANGAN 2
II. JASA MEDIS 3
II 1. JASA MEDIS KONSULTASI MEDIS 3
II.2 JASA MEDIS VISITE 4
III.A TINDAKAN MEDIS NON OPERATIF 5
III.A.1 IGD 5
III.A.2 SPESIALIS KEBIDANAN & KANDUNGAN 7
III.A.3 SPESIALIS ANAK 8
III.A.4 SPESIALIS BEDAH 9
III.A.5 SPESIALIS THT 11
III.A.6 SPESIALIS MATA 14
III.A.7 SPESIALIS KULIT-KELAMIN 15
III.A.8 REHABILITASI MEDIK 18
III.A.9 HEMODIALISA 19
III.A.10 PSIKOLOGI 19
III.A.11 AKUPUNTUR 20
III.A.12 VASKULER 20
III.A.13 PARU 21
III.A.14 GIGI dan MULUT 22
1. KELOMPOK A 22
2. KELOMPOK B 23
3. KELOMPOK C 25
4. KELOMPOK D 26
III.A.15 GIGI DAN MULUT KLINIK EKSEKUTIF 27
1. KELOMPOK A 27
2. KELOMPOK B 28
3. KELOMPOK C 31
4. KELOMPOK D 33
III.B TINDAKAN MEDIS NON OPERATIF DI RAWAT INAP 34
III.B.1 IGD 34
III.B.2 SPESIALIS KEBIDANAN & KANDUNGAN 35
III.B.3 SPESIALIS ANAK 35
III.B.4 SPESIALIS BEDAH 36
III.B.5 VASKULER 36
PERKIRAAN TARIF TINDAKAN MEDIS OPERATIF
IV (PER – KELAS PERAWATAN) 37
IV.1. SPESIALIS KEBIDANAN DAN KANDUNGAN 37
IV.2. SPESIALIS BEDAH 38
IV.2.A SPESIALIS BEDAH ANAK 38
IV. 2.B SPESIALIS BEDAH UMUM 40
IV. 2.C SPESIALIS BEDAH DIGESTIF 41
IV. 2.D SPESIALIS BEDAH ONKOLOGI 43
IV. 2.E SPESIALIS BEDAH UROLOGI 44
IV. 2.F SPESIALIS BEDAH PLASTIK 45
IV.2.G SPESIALIS BEDAH ORTHOPEDI 46
IV.2.H SPESIALIS BEDAH SYARAF 49
IV.3. SPESIALIS THT 50
IV.4. SPESIALIS MATA 51
IV.5. SPESIALIS BEDAH VASKULER 52
NO. PERIHAL HALAMAN
IV.6. SPESIALIS GIGI DAN MULUT 54
1. ODONTECTOMI 1 GIGI CANINUS (PERAWATAN 1 HARI) 54
2. ODONTECTOMI 1 GIGI MOLAR (PERAWATAN 1 HARI) 54
3. ODONTECTOMI 2 GIGI (PERAWATAN 2 HARI) 55
4. ODONTECTOMI 4 GIGI (PERAWATAN 2 HARI) 56
5. TUMOR KISTA RAHANG KECIL (PERAWATAN 2 HARI) 56
6. TUMOR KISTA RAHANG BESAR (PERAWATAN 2 HARI) 56
7. FRAKTUR RAHANG 1 RAHANG BESAR (PERAWATAN 2 HARI) 57
8. TINDAKAN PERAWATAN GIGI DENGAN ANESTESI UMUM 57
V. PERKIRAAN TARIF PERSALINAN 58
V.1. PERSALINAN NORMAL (3 hari) 58
V.2. PERSALINAN DENGAN ILA (4 hari) 59
V.3. SECTIO CAESARIA (5 hari) 60
V.4. PERSALINAN OLEH BIDAN (3 hari) 61
VI. VI.A TARIF PEMERIKSAAN DENGAN ALAT DAN SEWA ALAT 62
VI.B TARIF INSTRUMEN ALAT (TINDAKAN) 64
VII. TARIF LABORATORIUM 66
VII.1. LABORATORIUM PATOLOGI KLINIK 66
A. HEMATOLOGI 66
B. KOAGULASI 67
C. KIMIA 67
D. SEROLOGI IMUNOLOGI 68
E. HORMON 71
F. PETANDA TUMOR 72
G. KULTUR RESISTENSI 72
H. URINALISA 72
I. FAECES 73
J.SPERMA 73
VII.2. LABORATORIUM PATOLOGI ANATOMI 73
A. SITOLOGI 73
B. PATOLOGI ANATOMI 73
VII.3. PELAYANAN DARAH 74
VII.4. LAIN-LAIN 74
VIII. TARIF RADIOLOGI 78
VIII.1. RADIOLOGI DIAGNOSTIK 78
A. KEPALA 78
B. THORAX 78
C. COLUMNA VERTEBRAE 79
D. EKSTERMITAS ATAS 79
E. EKSTERMITAS BAWAH 80
F. ABDOMEN 80
G. MOBILE X-RAY ( ICU ) 81
H. CT SCAN 81
I. USG 83
J. MRI 83
J. LAIN – LAIN 85
IX. PERKIRAAN TARIF TINDAKAN ONE DAY CARE (ODC) di KAMAR OPERASI 87
1. OBSGYN, ANAK & UMUM 87
2. KEMOTERAPI 88
3. CIMINO (ANESTESI LOKAL) 88
4. HEMATOLOGI 88
5. MATA 88
6. ORTHOPEDI 88
X LAIN-LAIN 89
A. PELAYANAN CATH LAB 89
B. MCU RS HERMINA 90
C. LAMPIRAN LAIN 91
I. UMUM
I.1. ADMINISTRASI RS
NO JENIS PELAYANAN TARIF
I.1.1. RAWAT JALAN

1 Pembuatan Kartu (sistem barcoding) 25,000
2 Buku Pasien 25,000
3 Jasa Sarana
a. Jasa Sarana Klinik Umum 40,000
b. Jasa Sarana Klinik Obsgyn 49,000
c. Jasa Sarana Klinik Eksekutif 59,000
d. Jasa Sarana Klinik Eksekutif Obsgyn 68,000
I.1.2. RAWAT INAP

1 Uang muka Rawat Inap Sesuai Kelas Perawatan :
a. SUITE ROOM 16,880,000
b. EKSEKUTIF 13,090,000
c. DELUXE 11,710,000
d. ANGGREK, Perawatan isolasi 6,500,000
e. MAWAR 4,250,000
f. MELATI 1,720,000
2 Uang Muka Rawat Intensif (ICU/NICU/PICU) 16,900,000
3 Uang Muka Rawat Perina L II, Intermediate Care Unit (IMCU) 7,150,000
4 Registrasi Rawat Inap 25,000
Keterangan :
- Biaya Administrasi adalah biaya-biaya yang bersifat dukungan administrasi berupa surat menyurat,
status,formulir, beban computer/ billing system, sampul, materi dan lain-lain yang ditimbulkan akibat
- Jasa Sarana sudah termasuk dalam komponen Jasa Medis Konsultasi Medis (halaman 3)
(Tarif Jasa Sarana pada halaman ini hanya sebagai informasi, tidak untuk ditagihkan terpisah).
pelayanan jasa kesehatan.
- Besaran Biaya Administrasi RI adalah 7% maksimal Rp 1.200.000,- (dari total kuitansi)
I.2 TARIF RUANGAN
KELAS PERAWATAN
No. JENIS PELAYANAN
SUITE ROOM EKSEKUTIF DELUXE ANGGREK MAWAR MELATI
1 KAMAR PERAWATAN 1,688,000 1,309,000 1,171,000 650,000 425,000 172,000
2 KAMAR BERSALIN :
a. Untuk Persalinan
- Dengan Dokter 3,188,000 2,550,000 2,231,000 1,594,000 1,435,000 1,195,000
- Dengan Bidan 2,231,000 1,594,000 1,435,000 1,195,000
- ILA 3,188,000 2,550,000 2,231,000 1,594,000 1,435,000 1,195,000
b. Untuk Observasi 1,080,000 425,000
3 KAMAR OPERASI :
a. Untuk Tindakan One Day Care (ODC) Mengikuti tarif ODC
b. Tindakan Medis Operatif : kebidanan & bedah
- Operasi Kecil 4,018,000 3,444,000 3,300,000 2,870,000 2,296,000 1,722,000
- Operasi Sedang 5,223,000 4,477,000 4,290,000 3,731,000 2,985,000 2,239,000
- Operasi Besar & SC 5,826,000 4,994,000 4,785,000 4,162,000 3,329,000 2,497,000
- Operasi Besar Khusus 9,041,000 7,749,000 7,425,000 6,458,000 5,166,000 3,875,000
c. Ruang Pemulihan / RR ( untuk observasi > 6 jam ) 650,000
4 PERAWATAN PERINA
a. Level I (KBBL) 956,000 741,000 663,000 390,000 234,000 112,000
b. Rujukan Untuk Blue Light (Blue Light di Perina Level II) 553,000 + Blue Light
c. Level II 650,000
5 INTERMEDIATE CARE UNIT (IMCU) 715,000
6 INTENSIVE CARE UNIT (ICU/PICU/NICU) 845,000
7 RUANG ISOLASI 650,000

II. JASA MEDIS
II 1. JASA MEDIS KONSULTASI MEDIS
KLINIK SPESIALIS KLINIK EKSEKUTIF
JM DOKTER Biaya Sarana JM DOKTER Biaya Sarana
NO JENIS PELAYANAN TARIF TARIF
HD Pot. & Prasarana HD Pot. & Prasarana
HD (Rp) HD (Rp)
BRUTO RS 5% (BUM) BRUTO RS 5% (BUM)
1 Dokter Umum 49,000 2,450 46,550 40,000 89,000
2 Dokter Spesialis 146,000 7,300 138,700 40,000 186,000 198,000 9,900 188,100 59,000 257,000
Dokter Spesialis
3 146,000 7,300 138,700 49,000 195,000 198,000 9,900 188,100 68,000 266,000
Obsgyn
Dokter Sub Spesialis
4 174,000 8,700 165,300 40,000 214,000 248,000 12,400 235,600 59,000 307,000
/ Konsultan
Dokter Subspesialis
5 174,000 8,700 165,300 49,000 223,000 248,000 12,400 235,600 68,000 316,000
/ Konsultan Obsgyn
6 Profesor 204,000 10,200 193,800 40,000 244,000 318,000 15,900 302,100 59,000 377,000
7 Profesor Obsgyn 204,000 10,200 193,800 49,000 253,000 318,000 15,900 302,100 68,000 386,000
8 Psikiater 161,000 8,050 152,950 40,000 201,000

Dokter Spesialis
9 161,000 8,050 152,950 40,000 201,000
Gizi Klinik
10 Psikolog 139,000 6,950 132,050 40,000 179,000
11 Bidan 34,000 1,700 32,300 40,000 74,000
12 Klinik Tumbuh Kembang :
a. Dokter Spesialis Anak 166,000 8,300 157,700 40,000 206,000
b. Dokter Rehabilitasi Medik 166,000 8,300 157,700 40,000 206,000
c. Psikolog 141,000 7,050 133,950 40,000 181,000
d. Psikiater 166,000 8,300 157,700 40,000 206,000
e. Terapi Wicara
- Anak 110,000
- Dewasa 134,000
f. Terapi Okupasi
- Anak 110,000
- Dewasa 134,000
g. Sensori Integrasi 122,000
h. Snoezellen 122,000
i. Sensor Terapi Behaviour 122,000
j. Art Terapi 122,000
k. Fisioterapi
- Anak 110,000
- Dewasa 134,000
l. Neuromusculoskletal 134,000
Konsultasi Laktasi
13
/ Edukator Diabetes
a. Konselor Dokter
229,000 11,450 217,550 40,000 269,000 232,000 11,600 220,400 59,000 291,000
Subspesialis
b. Konselor Dokter Spesialis 161,000 8,050 152,950 40,000 201,000 201,000 10,050 190,950 59,000 260,000
c. Konselor Dokter Umum 50,000 2,500 47,500 40,000 90,000
d. Konselor Bidan / Perawat 34,000 1,700 32,300 40,000 74,000
Keterangan :
- Jasa medis konsultasi Psikiater, Spesialis Gizi Klinik, Psikolog yang tercantum diatas adalah konsultasi
sampai dengan 30 menit. Jika lebih dari 30 menit maka tarif ditambah sebesar 50% dari HD.
- Jasa Medis Konsultasi Medis sudah termasuk Biaya Jasa Sarana
II.2 JASA MEDIS VISITE
KELAS PERAWATAN
NO JENIS PELAYANAN
A VISITE di R.PERAWATAN
1 Dokter Spesialis / Fellow 281,000 263,000 245,000 175,000 140,000 114,000
2 Dokter SubSpesialis / Konsulen / Profesor 351,000 329,000 307,000 219,000 175,000 142,000
3 Dokter Spesialis/Sub/Prof Anak Visite I Bayi Baru Lahir 421,000 395,000 368,000 263,000 210,000 171,000
4 Panggilan Emergency Tanpa Tindakan :
a. Dokter Spesialis 294,000
b. Dokter SubSpesialis 357,000
5 Panggilan Emergency Dengan Tindakan Jasa Medis No.4 (point. a atau b) + Jasa Tindakan
6 Visiting Doctor (Dokter Tamu) :
a. Panggilan Tidak Emergency
- Dokter Spesialis 294,000
- Dokter Spesialis/Sub Spesialis/Profesor/Konsulen 357,000
b. Panggilan Emergency
- Dokter Spesialis 331,000
- Dokter Sub Spesialis 394,000
B VISITE di R. PERAWATAN PERINA

1 Dokter Spesialis 208,000
2 Dokter Sub Spesialis/ Konsulen 232,000
C VISITE di R. PERAWATAN ICU/NICU/PICU

2 Dokter SubSpesialis/ Konsulen 285,000
3 Dokter Intensivis 340,000
4 Visiting Doctor 438,000
II. 3 JASA PARAMEDIS

KELAS PERAWATAN
NO JENIS PELAYANAN
1 Perawatan Kelas 91,000 83,000
2 Perawatan Perina 83,000
3 Perawatan Isolasi 104,000
4 Perawatan Intermediate 104,000
5 Perawatan ICU / NICU/ PICU 124,000
III.A TINDAKAN MEDIS
III.A.1. IGD
NO TINDAKAN TARIF (Rp)
1 Aff drain (angkat drain) 66,000

2 Anuskopi 89,000
3 Bilas lambung 133,000
4 Buka gips :
a. 1 sisi 138,000
b. 2 sisi 229,000
5 Sirkumsisi 616,000
6 Klisma/ lavemen, korek skibala 68,000
7 Pemakaian defibrilator/ DC shock 291,000
8 Perawatan combustio :
a. Ringan 191,000
b. Sedang 229,000
9 Debridement :
a. Ringan 133,000
b. Sedang 168,000
c. Berat 218,000
10 Dilatasi preputium 66,000
11 Eksplorasi vulnus punctum 57,000
12 Eksplorasi Luka / Woud Toilet
Sederhana (< 5mm) 63,000
Luka Berat (> 5mm) 132,000
13 Ekstirpasi lipoma / kista / clavus / nevus :
a. Kecil 100,000
b. Sedang 122,000
c. Besar 183,000
14 Ekstraksi/ angkat corpus alienum 100,000
15 Ekstraksi kuku/ Rozerplasty 123,000
16 Epikutaneus 402,000
17 Ganti verban
a. Kecil 52,000
b. Sedang 89,000
c. Besar 123,000
18 Hecting :
a. Jumlah jahitan 1 – 3 72,000
b. Jumlah jahitan 4 – 6 123,000
c. Jumlah jahitan 7 - 10 187,000
d. Jumlah jahitan 11 - 15 191,000
e. Jumlah jahitan 15 - 20 232,000
f. Jumlah jahitan > 20 271,000
19 Aff hecting :
20 Insisi abses :
a. Jumlah abses 1, ukuran < 10 cm 66,000
b. Jumlah abses >1 atau ukuran > 10cm 138,000
21 Injeksi intralesi keloid 53,000
22 Intubasi/ pemasangan ETT 245,000
23 Irigasi telinga/ mata 49,000
24 Kompresi jantung paru (CPR) 117,000
25 Kauterisasi 42,000
26 Lavemen 36,000
27 Pemasangan mini WSD 262,000
28 Nekrotomi 210,000
29 Observasi IGD :
a. 1 s.d 3 jam 57,000
b. 4 s.d 6 jam 109,000
30 Pemasangan kateter 82,000
31 Pasang infus :
a. Vena perifer 26,000
b. Intra osseus 152,000
c. Vena jugularis 152,000
d. Vena sectie 384,000
e. Percutaneous catheter 386,000
d. Vena sentral (CVC)/ CVP 512,000
32 Pasang ETT RJP (Intubasi) + resusitasi 325,000
33 Pemasangan WSD 403,000
34 Pasang nasogastric tube (NGT) 134,000
35 Pasang NGT + bilas lambung 202,000
36 Pasang ransel verband 134,000
37 Pasang spalk / bidai 57,000
38 Pasang tampon hidung 36,000
39 Pasang tampon Belloque 202,000
40 Pasang umbilical catheter 270,000
41 Pasang foley catheter 98,000
42 Pungsi :
a. Supra pubis 87,000
b. Hematoma di superfisial 116,000
c. Lutut 191,000
d. Pleura 307,000
e. Pericardial 417,000
43 Reposisi luksasi mandibula 191,000
44 Suntik 27,000
45 Tindik :
a. Dengan jarum/ biasa 121,000
b. Dengan alat/ tembak 162,000
46 Tes Mantoux 57,000
47 Bouginasi 362,000
50% dari
Tindakan medis di luar tindakan di atas
48 JM Dokter
(termasuk pendampingan persalinan menggantikan dokter obgyn)
Spesialis
III.A.2. SPESIALIS KEBIDANAN & KANDUNGAN
1 Biopsi 352,000
2 Ganti verban 91,000
3 Implant / Norplant :
a. Pasang implant/ Norplant 229,000
b. Aff implant (Norplant) 229,000
c. Aff dan pasang implant (Norplant) 386,000
4 IUD :
a. Pasang IUD 186,000
b. Aff IUD 186,000
c. Aff dan pasang IUD 245,000
d. Tindakan Reposisi IUD 126,000
5 Kolposkopi :
a. Kolposkopi 459,000
b. Kolposkopi + biopsi 824,000
6 Papsmear
a. Papsmear Thin Prep 825,000
b. Papsmear biasa 185,000
10 Pasang laminaria 227,000

11 Pasang Ring 282,000
12 Pesarium :
a. Pasang pesarium 195,000
b. Angkat pesarium 195,000
c. Pasang angkat pesarium 202,000
13 Pungsi Douglash 393,000
14 Sono HSG 700,000
15 Suntik 39,000
16 Tampon vagina 229,000
17 Intubasi/ Pemasangan ETT 465,000
18 Vaginal Toilet 55,000
19 Amniosintesis 3,888,000
III.A.3. SPESIALIS ANAK

2 Pasang Infus :
a. Intra osseus 262,000
b. Vena jugularis 276,000
c. Vena sectie 766,000
d. Percutaneous catheter 766,000
e. Vena sentral (CVC)/ CVP 935,000
5 Pemberian surfaktan :
a. Tanpa pemasangan ETT 568,000
b. Dengan pemasangan ETT 711,000
6 Pungsi lumbal 435,000
7 Suntik 39,000
8 Tindik :
a. Dengan jarum 134,000
b. Dengan alat 202,000
9 Transfusi tukar
a. Transfusi tukar I 1,409,000
b. Transfusi tukar II 914,000
c. Transfusi tukar III 683,000
III.A.4. SPESIALIS BEDAH

2 Sirkumsisi (Anestesi Lokal) 1,126,000
3 Anuskopi 177,000
4 Angkat Corpus Alineum
a. Kecil 176,000
b. Sedang 266,000
c. Besar 741,000
5 Biopsi Rektum 704,000
6 Debridement :
a. Ringan 186,000
b. Sedang 218,000
c. Berat 270,000
7 Dilatasi preputium
a. Kecil 309,000
b. Sedang 361,000
c. Besar 502,000
8 Eksplorasi vulnus punctum 232,000
9 Ekstirpasi lipoma / kista / clavus / nevus 349,000
10 Ekstraksi corpus alienum 232,000
11 Ekstraksi kuku/ Rozerplasty 307,000
12 Epikutaneus 841,000
13 Ganti verban
a. Kecil 106,000
b. Sedang 177,000
c. Besar 247,000
14 Gips :
a. Pasang gips :
- Tanpa reposisi 861,000
- Dengan reposisi 1,307,000
b. Buka gips :
- 1 sisi 276,000
- 2 sisi 458,000
c. Pasang gips pada Bayi :
- 1 sisi 1,412,000
- 2 sisi 2,825,000
d.Pasang gips pada Bayi :
- Tanpa reposisi 1,075,000
15 Hecting :
b. Jumlah jahitan 4 - 6 256,000

g. Tambah per Jahitan 125,000
16 Aff hecting :
17 Insisi abses
a. Jumlah abses 1, ukuran < 10 cm 193,000
b. Jumlah abses >1 atau ukuran > 10cm 372,000
18 Injeksi intralesi keloid 197,000
19 Injeksi intratekal 465,000
20 Injeksi blok syaraf 403,000
21 Injeksi Intra Artikuler 216,000
24 Multiple cauter 606,000
25 Pasang Bougie/ Bouginasi 232,000
26 Pemasangan kateter urin 172,000
27 Pasang infus :
f. Pasang long line 835,000
g. Vena Perifer 35,000
29 Pasang ransel verband 202,000
30 Pasang skin traction 134,000
31 Pasang spalk / Bidai 122,000
33 Pasang ETT RJP (Intubasi) + Resusitasi 652,000
34 ETT + CVP 1,013,000
35 Perawatan combustio :
a. Ringan 229,000
b. Sedang 307,000
c. Berat 384,000
36 Pungsi :
a. Abdomen 307,000
b. Douglash 539,000
c. Hematoma 193,000
d. Lumbal 435,000
e. Lutut 232,000
f. Pleura 349,000
g.Supra pubic 117,000
h.Sternum (Bone Marrow) 539,000
i. Perikardial 551,000
37 Reposisi luksasi mandibula 307,000
38 Reposisi sendi tertutup 386,000
39 Suntik 39,000
41 Tindakan Bedah Minor 837,000
42 Tindakan Bedah Sederhana 554,000
43 Vena Dalam 705,000
44 Insisi drainase 1,307,000
45 Intra oeseus 571,000
46 Wash Out 275,000
III.A.5. SPESIALIS THT
A TELINGA
1 Aplikasi obat 92,000
2 Audiogram / Audiometri
a. Nada murni 117,000
b. Nada turur 152,000
c. Dengan protokol 202,000
3 Biopsi telinga 352,000
4 Tampon Belloque 270,000
5 Endoskopi 139,000
6 Ekstirpasi kista aurikuler 123,000
7 Ekstraksi serumen :
a. Satu telinga tanpa irigasi 117,000
b. Dua telinga tanpa irigasi 224,000
c. Satu telinga dengan irigasi – spooling 152,000
d. Dua telinga dengan Irigasi - spooling 262,000

9 Ekstirpasi :
a. Cholesteatoma sekunder 368,000
b. Cholesteatoma – lithiasis 307,000
c. Polip – granulasi 189,000
d. Granulasi CAE – dengan anestesi lokal 813,000
e. Granulasi CAE – dengan anestesi lokal + tampon tarivid 879,000
10 Epistaksis dengan kauterisasi 403,000
11 Epistaksis dengan tampon nasal 202,000
12 Aff Hecting telinga (paska operasi) :
13 Injeksi kenacort (pasca eksisi) 158,000
14 Insisi drainase abses subperiosteal (abses mastoid) :
a. Anak 495,000
b. Dewasa 422,000
15 Insisi drainase abses perikordium 138,000
16 Insisi drainase abses retroaurikuler 138,000
17 Insisi drainase abses peritonsil 162,000
18 Insisi abses mastoid 262,000
19 Insisi perikondritis aurikel 414,000
20 Kauterisasi telinga 146,000
21 Lithiasis extraction 222,000
22 Parasentesis telinga 429,000
23 Pompa Siegel 117,000
24 Pungsi drainase kista auriculair 85,000
25 Tampon telinga 92,000
26 Tes garputala 104,000
27 Oto acoustic emission (OAE) 87,000
28 Tes pendengaran dengan BERA 422,000
29 Timpanometri 262,000
30 Toilet telinga :
a. Dengan H2O2 – suction 85,000
b. Dengan tampon tarivid 176,000
c. Dengan tampon cynolon 176,000
31 Test fungsi tuba 152,000
32 Test kalori vestibuler 202,000
33 Spoeling H202 80,000
HIDUNG
1 Aplikasi adrenalin 109,000
2 Aplikasi illiacin 85,000
3 Biopsi :
a. Hidung/ cavum nasi 336,000
b. Nasofaring 408,000
5 Ekstraksi polip :
a. Unilateral 245,000
b. Bilateral 336,000
6 Injeksi kenakort 172,000
7 Insisi : 162,000
a. Insisi abses hidung 163,000
b. Insisi abses dengan tampon Kemicetin 298,000
c. Insisi septal abses hidung 491,000
d. Insisi submandibula cavis hidung 296,000
e. Insisi drainase abses hidung 202,000
8 Irigasi sinus maxillaris 202,000
9 Kauterisasi hidung 146,000
10 Tampon hidung :
a. Pasang tampon anterior 208,000
b. pasang tampon posterior 408,000
c. Pasang tampon anterior dan posterior 552,000
d. Aff tampon hidung 133,000
11 Pungsi drainase kista auriculair 202,000
12 Polip hidung :
Solitaire S 189,000
Solitaire M 204,000
Solitaire L 219,000
13 Toilet hidung :
a. Toilet hidung / Suction 92,000
b. Krosti 123,000
c. Post operasi 152,000
TENGGOROK
1 Aplikasi xylocain 92,000
2 Biopsi :
a. Tonsil 386,000
b. Tenggorok – nasofaring 386,000
c. Palatum 386,000
3 Corp. All Tenggorokan 118,000
4 Kauter :
a. Granulasi faring (elektrik) 725,000
b. Tenggorokan Kimiawi 172,000
6 Insisi abses peritonsiler 386,000
7 Laryngoscopy Indirect 109,000
LAIN-LAIN
1 Imunoterapi 125,000
2 Prick Tes 660,000
III.A.6. SPESIALIS MATA
1 Anel Test / sondage 324,000

2 Biometri 152,000
3 Ductus lacrimalis dilatation / Sondage 338,000
4 Eksisi xanthelasma : 1-2 276,000
5 Ekstirpasi granuloma 307,000
6 Ekstirpasi lithiasis 276,000
7 Ekstraksi corpus alienum cornea / Palpebra 310,000
8 Epilasi 164,000
9 Epilasi & cauterisasi 227,000
10 Eye toilet :
a. Ringan 146,000
b. Sedang 224,000
c. Berat 270,000
11 Direct funduscopy 87,000
12 Indirect funcuscopy 121,000
13 Aff hecting:
a. Kornea 232,000
b. Palpebra 130,000
14 Hecting palpebra :
a. Hecting palpebra < 5 435,000
b. Hecting palpebra lebih > 5 539,000
15 Insisi hordeolum / khalazion / kista 653,000
16 Indirect Opthalmoscopy 73,000
17 Keratometri / autorefraktor 51,000
18 Kerokan + debridement Kornea 92,000
19 Lithiasis per kelopak 121,000
20 Probing therapeutic 459,000
21 Pterygium plasty 1,307,000
22 Pterygium CLG (Conjunctiva Lumbal Graft) 2,527,000
23 Refraktometri 91,000
24 Scraping conjungtiva 232,000
25 Suntik intravitreal 200,000
26 Suntik subkonjungtiva 78,000
27 Symblepharon plasty repair 1,307,000
28 Tarsotomy / operasi Weeler 1,307,000
29 Tonometri / tensi okuli 85,000
30 ROP 330,000
31 Streak Retinoscopy 46,000
32 Eksisi khalazion 350,000
III.A.7. SPESIALIS KULIT-KELAMIN
1 Bedah Minor 593,000

2 Biopsi Skalpel :
a. Tubuh (1 lesi) 336,000
b. Wajah (1 lesi) 575,000
3 Biopsi Plong 336,000
4 Bulektomi
a. Ringan 123,000
b. Berat 247,000
5 Chemical peeling
a. CP - 1 (AHA/AFA/JESNER) 408,000
b. CP - 2 495,000
c. TCA 807,000
6 Chorethyl spray untuk "creeping diseases"
a. Ringan 218,000
b. Sedang 291,000
c. Berat 408,000
7 Ekstirpasi :
a. Ringan 495,000
b. Berat 807,000
8 Ekstraksi kuku 163,000
9 Eksisi Komedo
Sederhana (Non Suntik) 145,000
Kompleks (+Suntik) 244,000
10 Elektrokauterisasi bedah listrik :
a. Ringan 408,000
b. Sedang 575,000
c. Berat 734,000
11 Enukleasi moluskum :
a. Ringan (1 - 5 lesi) 247,000
b. Sedang (6 - 10 lesi) 336,000
c. Berat (> 10 lesi) 486,000
12 Facial :
a. Reguler 218,000
b. Masker lilin 247,000
c. Lilin + Thalasso Gaze 450,000
d. Masker topeng 271,000
e. Masker karet 123,000
f. Masker mikrodermabrasi 270,000
g.Facial oxygen botanicals 408,000
h. Facial La Tulipe 82,000
i. Treatment aromatherapi 146,000
j. Treatment akupressure 82,000
k. Kompleks + Masker + Serum 231,000
l. Beautican 67,000
13 Galvanic / Iontophoresis 146,000
14 Injeksi keloid :
a. Ringan (1 - 3 suntikan) 163,000
b. Sedang (4 - 6 suntikan) 256,000
c. Berat (> 7 suntikan) 326,000
15 Injeksi kenacort intralesi :
a. Ringan (1 - 5 lesi) / (< 0,02 cc) 146,000
b. Sedang (6 - 10 lesi) / (0,02 – 0,05 cc) 181,000
c. Berat (> 10 lesi) / (0,05 cc) 202,000
16 Insisi abses (1 buah) 227,000
17 Injeksi whitening 581,000
18 Kauterisasi
Kecil 349,000
Sedang 554,000
Besar 845,000
19 Kuretase Eksisi / Echoliasi
Sederhana A 164,000
Sederhana B 205,000
Kompleks A 271,000
Kompleks B 303,000
20 Ekstraksi Komedo:
a. Ringan (1 - 5 lesi) 83,000
b. Sedang (6 - 10 lesi) 123,000
c. Berat (> 11 lesi) 163,000
21 Mikro dermabrasi 661,000

22 Nekrotomi :
a. Ringan 163,000
b. Sedang 247,000
23 Peeling 181,000
24 Peeling GA Neostrata 475,000
25 Peeling TCA 343,000
26 Tincture pedophilyn 134,000
27 Tindakan manual
a. Ringan 254,000
b. Sedang 349,000
c. Berat 589,000
28 Tutul CA 50%
Sederhana 191,000
Kompleks 276,000
29 Vitamin C ion treatment (sonophoresis+Iontophoresis) 208,000
30 Ekstirpasi veruka :
a. Ringan (1-10 lesi) 168,000
b. Sedang (11-20 lesi) 242,000
c. Berat (> 20 lesi) 323,000
31 Audiovisual/otoskopi 134,000
32 Biopsi app CWL 390,000
33 Biopsi Tumor 352,000
34 Buka tampon 134,000
35 Injeksi imunoterapi 186,000
36 Test kulit cungkit (SPT) 372,000
37 Cauther Lokasi Konka 1,123,000
38 Dekanulisasi 191,000
39 Endoskopi 257,000
40 Ext. Corpus All. Cea 92,000
41 NPC + Biopsi 336,000
42 Oxygeneo
a. Tindakan Oxygeneo 208,000
b. Tindakan Tripolar RF 208,000
c. US 78,000
43 PRP (Platelet Rich Plasma) 2,400,000
44 Botox
a. Full Face 5,000,000
b. Upper Face 2,600,000
c. Lower Face 3,500,000
III.8. REHABILITASI MEDIK
1 Electric stimulation (ES) :

a. 1 area 83,000
b. 2 area 104,000
2 Exercise (EXC) :
a. Postural drainage 53,000
b. Muskuloskeletal exercise 75,000
c. Neuromuskular exercise 81,000
3 General exercise 134,000
4 Inhalasi :
a. Inhalasi 83,000
b. Inhalasi + suction 138,000
c. Inhalasi + suction + MWD 191,000
5 Infra red radiating (IRR) :
a. IRR 1 area 57,000
b. IRR 2 area 104,000
c. IRR + Inhalasi 132,000
6 Massage chest therapy 67,000
7 Micro wave diathermy (MWD) :
a. MWD 1 area 83,000
b. MWD 2 area 91,000
c. MWD 3 area 104,000
d. MWD + Inhalasi 152,000
8 Oksigen untuk 10 menit s.d 30 menit 27,000
9 Postural drainage(PD) 51,000
10 Suction 51,000
11 Short Wave Diathermy (SWD) 91,000
12 Tens :
a. 1 area 83,000
b. 2 area 104,000
c. 3 area 109,000
13 Ultrasonic (US) :
a. US 1 area 83,000
b. US 2 area 104,000
c. US 3 area 109,000
14 Pijat
a. Pijat Bayi 60,000
b. Pijat Dewasa 86,000
15 Hipno + Imajinasi 611,000
III.9. HEMODIALISA
1 Baru 1,334,000
2 Lanjutan 1,096,000
3 CITO 1,668,000
III.10. PSIKOLOGI
1 Psiko Tes
a. Tes Kecerdasan 370,000
b. Tes Kesiapan Masuk Sekolah 376,000
c. Tes Penelusuran Minat dan Bakat 376,000
d. Evaluasi Kepribadian 376,000
e. Seleksi Pegawai
- Tingkat SMA dan D3 376,000
- Tingkat S1 dan Manager 494,000
2 Psikoterapi / Intervensi Psikologi
a. Family Theraphy 370,000
b. Relaxaxi Theraphy 370,000
c. Supertive Theraphy 370,000
d. Ratio Emotive Theraphy 370,000
III.11. AKUPUNTUR
1 Tarif Klinik Akupunktur+ Tindakan 1 Posisi + 10 Jarum 158,000

2 Posisi ( Tindakan Akupunktur Tambahan ) 80,000
2 Carlene + Suntik ( Aquapunktur I ) 105,000
3 Oxydermal + Suntik ( Aquapunktur II ) 178,000
4 Kolagen + Suntik ( Aquapunktur III ) 80,000
5 Tindakan
Tindakan Pertama 50,000
Tindakan Kedua 132,000
Tindakan Ketiga 217,000
Tindakan Keempat 292,000
5 Moxa 21,000
6 Meso PPC @ 5 CC 197,000
7 Whitening Inj 5 cc ( Tathlon ) 146,000
8 Laser
Laser Akupunktur I 80,000
Laser Akupunktur II 92,000
Laser Akupunktur III 112,000
9 TDP ( Pemanasan ) 21,000
Pemakaian Perjarum 2,000
III.12. VASKULER

2 Nekrotomi 376,000
3 Hand Doppler portable 141,000
4 Mapping vaskuler 470,000
III.A.13. PARU
1 PFR 25,000
2 Spirometri 85,000
3 Uji Bronkodilator 85,000
4 Oksimetri 50,000
5 AGD (Analisis Gas Darah) 85,000
6 Step Test 85,000
7 6 Minutes Walking Test 85,000
8 CPX (Cardio Pulmonary Exercise)/ Uji Latih Jantung Paru 124,000
9 Kapasiti Difusi 124,000
10 Pemeriksaan Volume Statik Paru 124,000
11 Uji Provokasi Bronkis 124,000
12 Body Pletysmography 134,000
13 Bronkospirometri 4,968,000
14 Sleep Study 497,000
15 Fungsi Cairan Pleura 1,242,000
16 WSD (Water Sealed Drainage) 3,279,000
17 Spoeling Rongga Pleura 1,242,000
18 Pleurodesis 1,590,000
19 Biopsi Pleura 1,590,000
20 TTNA (Trans Thoracal Needle Aspiration) 1,590,000
21 TTNA dengan fluoroskopi 1,590,000
22 TTNA dengan tuntutan CT (CT Guided) 1,590,000
23 TTNA dengan Tuntutan USG (USG Guided) 1,590,000
24 Torakoskopi Medik 9,936,000
25 Pemasangan Pig Tail Catheter untuk fungsi pleura 1,639,000
26 Bronkial Toilet 4,968,000
27 Uji Methilen Blue 4,968,000
28 Bronkoskopi Perioperatif 4,968,000
29 Injeksi Intrabronkus 4,968,000
30 Bilasan Bronkus 4,968,000
31 Sikatan Bronkus 4,968,000
32 Biopsi Forcep 4,968,000
III.A.14 GIGI dan MULUT
1. KELOMPOK A
Alat + Consumable
NO JENIS TINDAKAN JM DOKTER RS TARIF
PIHAK II RS
a Drg. Umum & Spesialis 55% 15% 25% 5%

1 Konsultasi & Pemeriksaan 69,850 19,050 31,750 6,350 127,000
2 Perawatan Stomatis, Ulcus Per-Kunjungan 90,750 24,750 41,250 8,250 165,000
3 Occlusal Adjustment 135,300 36,900 61,500 12,300 246,000
4 Cetak 165,550 45,150 75,250 15,050 301,000
5 Cetak Double Impression 251,900 68,700 114,500 22,900 458,000

b Tindakan Bedah Mulut 55% 15% 25% 5%
1 Insisi Intra Oral 152,900 41,700 69,500 13,900 278,000
2 Operculectomi 184,250 50,250 83,750 16,750 335,000
3 Pencabutan Gigi Sulung non Injeksi 124,300 33,900 56,500 11,300 226,000
4 Pencabutan Gigi Sulung Dengan Injeksi 152,900 41,700 69,500 13,900 278,000
5 Pencabutan Gigi Permanen 261,250 71,250 118,750 23,750 475,000

c Tindakan Konservasi 55% 15% 25% 5%
1 Tambal Sementara 128,150 34,950 58,250 11,650 233,000
2 Tambal Composit Kecil 224,950 61,350 102,250 20,450 409,000
3 Tambal Composit Besar 267,300 72,900 121,500 24,300 486,000
4 Tambal Compomer Kecil 237,600 64,800 108,000 21,600 432,000
5 Tambal Compomer Besar 276,100 75,300 125,500 25,100 502,000
6 Tambal Glass Ionomer Kecil 152,900 41,700 69,500 13,900 278,000
7 Tambal Glass Ionomer Besar 179,300 48,900 81,500 16,300 326,000
8 Cementasi Crown/Onlay yang Lepas 157,300 42,900 71,500 14,300 286,000
9 Desensitisasi 1 Gigi/ Buka Kamar Pulpa 113,850 31,050 51,750 10,350 207,000
10 Bongkar Amalgam/Poles Tambalan 89,650 24,450 40,750 8,150 163,000
11 Perawatan SA Akar Gigi Tunggal 161,150 43,950 73,250 14,650 293,000
12 Pengisian SA Tunggal 207,350 56,550 94,250 18,850 377,000

d Tindakan Prostodonti 70% 10% 15% 5%
1 Gigi tiruan Lepas Acrilic 777,700 111,100 166,650 55,550 1,111,000
2 Tambahan Tiap Elemen 315,000 45,000 67,500 22,500 450,000
3 Reparasi dengan Cetak 449,400 64,200 96,300 32,100 642,000
4 Reparasi Tanpa Cetak 384,300 54,900 82,350 27,450 549,000
5 Flexi Unilateral 1,798,300 256,900 385,350 128,450 2,569,000
6 Flexi Bilateral 2,338,000 334,000 501,000 167,000 3,340,000
e Tindakan Orthodonti 70% 10% 15% 5%
1 Plat Orthodonti Lepas per Rahang 1,798,300 256,900 385,350 128,450 2,569,000
2 Plat Orthodonti Lepas Atas Bawah 2,998,100 428,300 642,450 214,150 4,283,000
3 Reparasi Plat ortho per-rahang dengan Cetak 539,700 77,100 115,650 38,550 771,000
4 Trainer 1,664,600 237,800 356,700 118,900 2,378,000
5 Aktivir Orthodonti Removable 222,600 31,800 47,700 15,900 318,000

f Tindakan Periodonti 55% 15% 25% 5%
1 Scalling per-Rahang 221,100 60,300 100,500 20,100 402,000
2. KELOMPOK B
Alat + Consumable
PIHAK II RS
a Konsultasi 60% 15% 20% 5%

b Speialis Bedah Mulut 60% 15% 20% 5%
1 Pengobatan TMJ 1 Kali Kunjungan 149,400 37,350 49,800 12,450 249,000
2 Pencabutan 472,200 118,050 157,400 39,350 787,000
3 Odontectomi /Operasi 2,189,400 547,350 729,800 182,450 3,649,000
4 Odontectomi Kelas I Posisi A 1,231,800 307,950 410,600 102,650 2,053,000
5 Apex Reseksi Per-Akar Gigi 1,498,800 374,700 499,600 124,900 2,498,000
6 Operasi Kista 1,582,800 395,700 527,600 131,900 2,638,000
7 Alveolectomi Per-Kwadran 649,800 162,450 216,600 54,150 1,083,000
8 Bedah Jaringan Lunak 1,099,200 274,800 366,400 91,600 1,832,000
9 Kontrol Pasca Bedah 185,400 46,350 61,800 15,450 309,000
10 Insisi Extra Oral 585,000 146,250 195,000 48,750 975,000
11 Extirpasi Mucocele 985,200 246,300 328,400 82,100 1,642,000
12 Windowing 1,600,200 400,050 533,400 133,350 2,667,000
13 Excochleasi Fistula 2,148,000 537,000 716,000 179,000 3,580,000
14 Reposisi TMJ 849,000 212,250 283,000 70,750 1,415,000
15 Penjahitan Luka 1 – 3 Akibat Trauma / Rudapaksa 185,400 46,350 61,800 15,450 309,000
16 Penjahitan Luka 4 – 6 Akibat Trauma / Rudapaksa 265,800 66,450 88,600 22,150 443,000
17 Penjahitan luka 7 - 10 324,000 81,000 108,000 27,000 540,000
18 Frenektomy Labialis 1,342,200 335,550 447,400 111,850 2,237,000
19 Frenektomy Lingualis 1,249,200 312,300 416,400 104,100 2,082,000
20 Penutupan Oro Antral Fistula 2,499,600 624,900 833,200 208,300 4,166,000
21 Fixasi Gigi 2 gigi 750,000 187,500 250,000 62,500 1,250,000
22 Fixasi Gigi 4 gigi 1,498,800 374,700 499,600 124,900 2,498,000
c Spesialis Prostodonti 60% 15% 20% 5%

1 Pemasangan Pin 171,000 42,750 57,000 14,250 285,000
2 Core Bulid Up 395,400 98,850 131,800 32,950 659,000
d Spesialis Konservasi 55% 15% 25% 5%

2 Perawatan SA Tunggal 224,950 61,350 102,250 20,450 409,000
3 Perawatan SA Tungal (Protaper) 254,100 69,300 115,500 23,100 462,000
4 Pengisian SA Tunggal (Endometason) 234,850 64,050 106,750 21,350 427,000
5 Pengisian SA Tunggal (AHA) 276,100 75,300 125,500 25,100 502,000
6 Perawatan SA gigi ganda 267,300 72,900 121,500 24,300 486,000
7 Perawatan SA gigi ganda (Protaper) 311,850 85,050 141,750 28,350 567,000
8 Pengisian SA Ganda (Endometason) 352,000 96,000 160,000 32,000 640,000
9 Pengisian SA Ganda (AHA) 402,600 109,800 183,000 36,600 732,000
10 Pelapisan / Labial Veneering 525,250 143,250 238,750 47,750 955,000
11 Bleaching per rahang 942,150 256,950 428,250 85,650 1,713,000
12 Bleaching per gigi/per rahang 259,600 70,800 118,000 23,600 472,000
Alat + Consumable
PIHAK II RS
e Spesialis Pedodonti 60% 15% 20% 5%

1 Counseling Gigi Anak 159,600 39,900 53,200 13,300 266,000
2 Tambal Composite Kecil 234,600 58,650 78,200 19,550 391,000
3 Tambal Composite Besar 259,800 64,950 86,600 21,650 433,000
8 One Visite Endodontic 241,200 60,300 80,400 20,100 402,000
9 Perawatan SA Gigi Anak Tunggal 180,600 45,150 60,200 15,050 301,000
10 Perawatan SA Gigi Anak Ganda 204,000 51,000 68,000 17,000 340,000
11 Pengisian SA Gigi Anak Tunggal 201,000 50,250 67,000 16,750 335,000
12 Pengisian SA Gigi Anak Ganda 220,200 55,050 73,400 18,350 367,000
13 Pencabutan gigi anak CE 171,600 42,900 57,200 14,300 286,000
14 Pencabutan gigi anak Injeksi 226,200 56,550 75,400 18,850 377,000
15 Topical Aplikasi 1 Rahang 124,800 31,200 41,600 10,400 208,000
16 Topical Aplikasi + Oral Proplyayis 256,800 64,200 85,600 21,400 428,000
f. Spesialis Oral Medicine 60% 15% 20% 5%

1 Conseling Oral Medicine/Visite 180,000 45,000 60,000 15,000 300,000
2 Terapi Stomatis/Visite 186,000 46,500 62,000 15,500 310,000
3 Terapi Ulcus Traumacicus/Visite 241,800 60,450 80,600 20,150 403,000
4 Terapi Oral Herpes/Visite 267,600 66,900 89,200 22,300 446,000
5 Terapi Oral Candidiasi/Visite 277,200 69,300 92,400 23,100 462,000
6 Terapi Angularchelities/Visite 246,600 61,650 82,200 20,550 411,000
g. Spesialis Periodonti 60% 15% 20% 5%

1 Curret 544,200 136,050 181,400 45,350 907,000
2 Ginggivectomi per-regio 815,400 203,850 271,800 67,950 1,359,000
3 Free ginggival Graft 882,000 220,500 294,000 73,500 1,470,000
4 Frenectomi 1,087,800 271,950 362,600 90,650 1,813,000
5 Scalling per-rahang 258,000 64,500 86,000 21,500 430,000
6 Vestibulo Plasty 585,600 146,400 195,200 48,800 976,000
7 Flap Operasi 1,296,600 324,150 432,200 108,050 2,161,000
8 Bonegraft 1,764,000 441,000 588,000 147,000 2,940,000
h. Spesialis Orthodonti 60% 15% 20% 5%

1 Aktivir Plat Removable 236,400 59,100 78,800 19,700 394,000
3. KELOMPOK C
Alat + Consumable
PIHAK II RS
a. Tindakan Bedah Mulut 70% 10% 15% 5%
1 Obturator 899,500 128,500 192,750 64,250 1,285,000
2 Fiksasi Fraktur Rahang 2,037,700 291,100 436,650 145,550 2,911,000
3 Implant (Surgery & Abutment) 19,184,200 2,740,600 4,110,900 1,370,300 27,406,000
b. Tindakan Konservasi 70% 10% 15% 5%

1 Inlay / Onlay 1,457,400 208,200 312,300 104,100 2,082,000
2 Bleaching per rahang 1,457,400 208,200 312,300 104,100 2,082,000
3 Bleaching per gigi 385,000 55,000 82,500 27,500 550,000
4 Fiber Post 1,199,100 171,300 256,950 85,650 1,713,000
c. Tindakan Prosthodonti 70% 10% 15% 5%

1 Crown:
a. Metal 1,444,100 206,300 309,450 103,150 2,063,000
b. Porcelain 2,698,500 385,500 578,250 192,750 3,855,000
2 Copping 491,400 70,200 105,300 35,100 702,000
3 Sendok Cetak Perorang 320,600 45,800 68,700 22,900 458,000
4 Mahkota Sementara 330,400 47,200 70,800 23,600 472,000
5 Gigi tiruan lepas logam 1 Elemen 2,278,500 325,500 488,250 162,750 3,255,000
6 Gigi tiruan penuh / rahang 3,476,900 496,700 745,050 248,350 4,967,000
7 Gigi tiruan penuh rahang atas & bawah 5,575,500 796,500 1,194,750 398,250 7,965,000
8 Per-elemen berikutnya 453,600 64,800 97,200 32,400 648,000
9 Reparasi dengan cetak 491,400 70,200 105,300 35,100 702,000
10 Bridge Work dgn Precious mental per-elemen 1,175,300 167,900 251,850 83,950 1,679,000
11 Post Core 646,100 92,300 138,450 46,150 923,000
12 Porcelain Veneer (Facing) 1,078,700 154,100 231,150 77,050 1,541,000
13 Maryland Bridge / 1 gigi 1,961,400 280,200 420,300 140,100 2,802,000
14 Labiel Veneer / 1 gigi 658,000 94,000 141,000 47,000 940,000
15 Prothesa Obturator 1,356,600 193,800 290,700 96,900 1,938,000
16 Occlusal Splint 1,031,100 147,300 220,950 73,650 1,473,000
17 Rebase 1,379,700 197,100 295,650 98,550 1,971,000
18 Reline 702,100 100,300 150,450 50,150 1,003,000
19 Kontrol Prothesa 263,900 37,700 56,550 18,850 377,000
21 Flexi Bilateral 2,876,300 410,900 616,350 205,450 4,109,000
22 Crown all porcelain emax 2,619,400 374,200 561,300 187,100 3,742,000
23 Crown all porcelain zirconia 2,977,100 425,300 637,950 212,650 4,253,000
24 Partial denture trame valplast 2,797,900 399,700 599,550 199,850 3,997,000
25 Set up per elemen berikutnya pd frame val 419,300 59,900 89,850 29,950 599,000
26 Set up per elemen pd precision attachment 419,300 59,900 89,850 29,950 599,000
27 Partial denure precision attachment 5,358,500 765,500 1,148,250 382,750 7,655,000
28 Full denture valplast /rahang 3,750,600 535,800 803,700 267,900 5,358,000
29 Full debture frame – akrilik /rahang 3,334,100 476,300 714,450 238,150 4,763,000
30 Reparasi valplast 793,800 113,400 170,100 56,700 1,134,000
31 Reparasi akrilik (lab) 436,800 62,400 93,600 31,200 624,000
32 Reparasi akrilik (one visite) 595,700 85,100 127,650 42,550 851,000
33 Crown implant zirconia 3,076,500 439,500 659,250 219,750 4,395,000
34 Mini dental implant 4,961,600 708,800 1,063,200 354,400 7,088,000
35 Overdenture magnet, 3,393,600 484,800 727,200 242,400 4,848,000
Alat + Consumable
PIHAK II RS
36 Immediate denture 257,600 36,800 55,200 18,400 368,000
37 Partial denture thermoplast 2,004,100 286,300 429,450 143,150 2,863,000
38 Metal housing 1,504,300 214,900 322,350 107,450 2,149,000
d. Tindakan Periodonti 70% 10% 15% 5%

1 Bruxism 1,019,200 145,600 218,400 72,800 1,456,000
2 Splinting Kawat / Wire 928,900 132,700 199,050 66,350 1,327,000
3 Splinting Plastik 1,139,600 162,800 244,200 81,400 1,628,000
4 Splinting Fiber 1,498,700 214,100 321,150 107,050 2,141,000
e. Tindakan Pedodonti 70% 10% 15% 5%

1 Space Maintainer 990,500 141,500 212,250 70,750 1,415,000
2 Crown Metal 875,000 125,000 187,500 62,500 1,250,000
3 Crown GIC / Composite 875,000 125,000 187,500 62,500 1,250,000
f. Tindakan Orthodonti 70% 10% 15% 5%
1 Fixed Appliance 11,713,800 1,673,400 2,510,100 836,700 16,734,000
2 Fixed Appliance Full Cheramic 18,874,100 2,696,300 4,044,450 1,348,150 26,963,000
3 Pengganti Plat Ortho retensi 2 rahang 2,033,500 290,500 435,750 145,250 2,905,000
4 Aktivir Orthodonti Fixed (tanpa penambahan alat) 363,300 51,900 77,850 25,950 519,000
5 Aktivir Orthodonti Fixed (dgn penambahan alat) 522,900 74,700 112,050 37,350 747,000
6 Aktivir Orthodonti Removeble (dgn penambahan alat) 356,300 50,900 76,350 25,450 509,000
7 Fixed Appliance 1 (Satu) Rahang 6,900,600 985,800 1,478,700 492,900 9,858,000
4. KELOMPOK D
Alat + Consumable
PIHAK II RS
Bahan Khusus 5% 15% 70% 10%
1 Bahan khusus Komposit / Compomer 2,200 6,600 30,800 4,400 44,000
2 Bahan khusus GIC 1,450 4,350 20,300 2,900 29,000
3 Bahan Khusus Ledermix 1,450 4,350 20,300 2,900 29,000
4 Bahan Khusus cetak 1,800 5,400 25,200 3,600 36,000
5 Bahan Khusus Tambal Sementara 1,450 4,350 20,300 2,900 29,000
6 Bahan khusus Perawatan Sal Akar 1,800 5,400 25,200 3,600 36,000
7 Bahan Khusus Pengisian Sal Akar 1,800 5,400 25,200 3,600 36,000
8 Rontgen Photo 4,300 12,900 60,200 8,600 86,000
III.A.15 GIGI DAN MULUT KLINIK EKSEKUTIF
1. KELOMPOK A
Alat + Consumable
PIHAK II RS
50% 20% 26% 4%
a Drg. Umum & Spesialis
2 Rontgen photo 60,000 24,000 31,200 4,800 120,000
3 Perawatan Stomatis, Ulcus per-kunjungan 117,500 47,000 61,100 9,400 235,000
4 Occlusal adjustment 174,000 69,600 90,480 13,920 348,000
###
b Tindakan Bedah Mulut 50% 20% 26% 4% ###
1 Insisi Intra Oral 196,000 78,400 101,920 15,680 392,000
2 Operculectomi 235,500 94,200 122,460 18,840 471,000
3 Pencabutan gigi sulung non injeksi 168,500 67,400 87,620 13,480 337,000
4 Pencabutan gigi sulung (injeksi) 201,500 80,600 104,780 16,120 403,000
5 Pencabutan gigi permanen 336,500 134,600 174,980 26,920 673,000
###
c Tindakan Konservasi 50% 20% 26% 4% ###
2 Tambal Composit kecil 297,000 118,800 154,440 23,760 594,000
3 Tambal Composit besar 353,000 141,200 183,560 28,240 706,000
8 Cementasi Ulang Crown/Onlay 201,500 80,600 104,780 16,120 403,000
9 Desensitisasi 1 Gigi/ Buka Kamar Pulpa 146,000 58,400 75,920 11,680 292,000
10 Bongkar Amalgam/Poles Tambalan 114,000 45,600 59,280 9,120 228,000
11 Perawatan SA Akar Gigi Tunggal 205,500 82,200 106,860 16,440 411,000
12 Pengisian SA Tunggal 267,500 107,000 139,100 21,400 535,000
###
d Tindakan Prostodonti 50% 20% 26% 4% ###
1 Gigi tiruan Lepas Acrilic 784,000 313,600 407,680 62,720 1,568,000
2 Tambahan Tiap Elemen 336,500 134,600 174,980 26,920 673,000

Alat + Consumable
PIHAK II RS
4 Reparasi tanpa cetak 388,500 155,400 202,020 31,080 777,000
5 Cetak 217,500 87,000 113,100 17,400 435,000
7 Flexi Bilateral 2,359,500 943,800 1,226,940 188,760 4,719,000
e Tindakan Orthodonti 50% 20% 26% 4% ###
1 Plat Orthodonti Lepas per rahang 1,815,500 726,200 944,060 145,240 3,631,000
2 Plat Orthodonti Lepas Atas Bawah 3,025,000 1,210,000 1,573,000 242,000 6,050,000
3 Reparasi plat ortho per-rahang dengan cetak 544,000 217,600 282,880 43,520 1,088,000
4 Trainer 1,681,000 672,400 874,120 134,480 3,362,000
###
5 Aktivir Orthodonti removable 224,000 89,600 116,480 17,920 448,000
###
f Tindakan Periodonti 50% 20% 26% 4% ###
###
2. KELOMPOK B ###
Alat + Consumable
PIHAK II RS
KELOMPOK B ###
55% 19% 22% 4% ###
a Konsultasi ###
###
b Speialis Bedah Mulut 55% 19% 22% 4% ###
1 Pengobatan TMJ 1 kali kunjungan 200,750 69,350 80,300 14,600 365,000
2 Pencabutan 628,650 217,170 251,460 45,720 1,143,000
3 Odontectomi /Operasi 2,957,900 1,021,820 1,183,160 215,120 5,378,000
4 Odontectomi kelas I posisi A 1,663,750 574,750 665,500 121,000 3,025,000
5 Apex reseksi per-akar gigi 1,997,050 689,890 798,820 145,240 3,631,000
6 Operasi kista 1,997,050 689,890 798,820 145,240 3,631,000
7 Alveolectomi per-kwadran 864,600 298,680 345,840 62,880 1,572,000
8 Bedah jaringan lunak 1,464,650 505,970 585,860 106,520 2,663,000
9 Kontrol Pasca Bedah 246,400 85,120 98,560 17,920 448,000
10 Insisi Extra Oral 778,250 268,850 311,300 56,600 1,415,000
11 Extirpasi Mucocele 1,311,200 452,960 524,480 95,360 2,384,000

Alat + Consumable
PIHAK II RS
12 Windowing 2,129,600 735,680 851,840 154,880 3,872,000
13 Excochleasi Fistula 2,861,100 988,380 1,144,440 208,080 5,202,000
14 Reposisi TMJ 1,131,350 390,830 452,540 82,280 2,057,000
15 Penjahitan luka 1 - 3 246,400 85,120 98,560 17,920 448,000
16 Penjahitan luka 4 - 6 353,650 122,170 141,460 25,720 643,000
17 Penjahitan luka 7 - 10 432,300 149,340 172,920 31,440 786,000
18 Frenektomy Labialis 1,786,950 617,310 714,780 129,960 3,249,000
19 Frenektomy Lingualis 1,663,750 574,750 665,500 121,000 3,025,000
20 Penutupan Oro Antral Fistula 3,327,500 1,149,500 1,331,000 242,000 6,050,000
21 Fixasi Gigi 2 gigi 997,150 344,470 398,860 72,520 1,813,000
22 Fixasi Gigi 4 gigi 1,997,050 689,890 798,820 145,240 3,631,000
###
c Spesialis Prostodonti 55% 19% 22% 4% ###
1 Pemasangan Pin 220,550 76,190 88,220 16,040 401,000
###
d Spesialis Konservasi 55% 19% 22% 4% ###
2 Perawatan SA Tunggal 326,700 112,860 130,680 23,760 594,000
3 Perawatan SA Tungal (Protaper) 370,150 127,870 148,060 26,920 673,000
4 Pengisian SA Tunggal (Endometason) 339,900 117,420 135,960 24,720 618,000
5 Pengisian SA Ganda (AH) 400,400 138,320 160,160 29,120 728,000
6 Perawatan SA gigi ganda 388,300 134,140 155,320 28,240 706,000
7 Perawatan SA gigi ganda (Protaper) 453,200 156,560 181,280 32,960 824,000
8 Pengisian SA Ganda (Endometason) 512,050 176,890 204,820 37,240 931,000
9 Pengisian SA Ganda (AH) 585,750 202,350 234,300 42,600 1,065,000
10 Pelapisan / Labial Veneering 764,500 264,100 305,800 55,600 1,390,000

Alat + Consumable
PIHAK II RS
e Spesialis Pedodonti 55% 19% 22% 4% ###
1 Counseling Gigi Anak 212,850 73,530 85,140 15,480 387,000

55% 19% 22% 4% ###
2 Tambal Composite Kecil 312,400 107,920 124,960 22,720 568,000
3 Tambal Composite Besar 346,500 119,700 138,600 25,200 630,000

55% 19% 22% 4% ###
8 One Visite Endodontic 320,100 110,580 128,040 23,280 582,000
9 Perawatan SA Gigi Anak Tunggal 239,250 82,650 95,700 17,400 435,000
10 Perawatan SA Gigi Anak Ganda 279,950 96,710 111,980 20,360 509,000
11 Pengisian SA Gigi Anak Tunggal 266,750 92,150 106,700 19,400 485,000
12 Pengisian SA Gigi Anak Ganda 293,700 101,460 117,480 21,360 534,000
13 Pencabutan gigi anak CE 234,300 80,940 93,720 17,040 426,000
14 Pencabutan gigi anak Injeksi 293,700 101,460 117,480 21,360 534,000
15 Topical Aplikasi 1 Rahang 161,700 55,860 64,680 11,760 294,000
16 Topical Aplikasi + Oral Prophilaxis 332,200 114,760 132,880 24,160 604,000
###
f. Spesialis Oral Medicine 55% 19% 22% 4% ###
1 Conseling Oral Medicine/Visite 233,200 80,560 93,280 16,960 424,000
2 Terapi Stomatis/Visite 239,250 82,650 95,700 17,400 435,000
3 Terapi Ulcus Traumacicus/Visite 312,400 107,920 124,960 22,720 568,000
4 Terapi Oral Herpes/Visite 346,500 119,700 138,600 25,200 630,000
5 Terapi Oral Candidiasi/Visite 360,800 124,640 144,320 26,240 656,000
6 Terapi Angularchelities/Visite 320,100 110,580 128,040 23,280 582,000
###
g. Spesialis Periodonti 55% 19% 22% 4% ###
1 Curret 699,050 241,490 279,620 50,840 1,271,000
2 Ginggivectomi per-regio 1,044,450 360,810 417,780 75,960 1,899,000
3 Free ginggival Graft 1,130,800 390,640 452,320 82,240 2,056,000
4 Frenectomi 1,397,000 482,600 558,800 101,600 2,540,000

Alat + Consumable
PIHAK II RS
6 Vestibulo Plasty 751,300 259,540 300,520 54,640 1,366,000
7 Flap Operasi 1,663,750 574,750 665,500 121,000 3,025,000
8 Bonegraft 2,262,150 781,470 904,860 164,520 4,113,000
###
h. Spesialis Orthodonti 55% 19% 22% 4% ###
1 Aktivir Plat Removable 306,350 105,830 122,540 22,280 557,000
###
3. KELOMPOK C ###
Alat + Consumable
PIHAK II RS
KELOMPOK C ###
65% 14% 17% 4% ###
a. Tindakan Bedah Mulut ###
1 Obturator 1,178,450 253,820 308,210 72,520 1,813,000
2 Fiksasi Fraktur Rahang 2,673,450 575,820 699,210 164,520 4,113,000
3 Implant (Surgery & Abutment) 25,168,650 5,420,940 6,582,570 1,548,840 38,721,000
###
b. Tindakan Konservasi 65% 14% 17% 4% ###
1 Inlay / Onlay 1,966,250 423,500 514,250 121,000 3,025,000
4 Fiber Post 1,573,000 338,800 411,400 96,800 2,420,000
###
c. Tindakan Prosthodonti 65% 14% 17% 4% ###
1 Crown: - Metal 1,891,500 407,400 494,700 116,400 2,910,000
2 - Porcelain 3,547,050 763,980 927,690 218,280 5,457,000
3 Core Bulid Up 605,800 130,480 158,440 37,280 932,000
4 Copping 360,100 77,560 94,180 22,160 554,000
5 Sendok Cetak Perorangan 431,600 92,960 112,880 26,560 664,000
6 Mahkota Sementara 431,600 92,960 112,880 26,560 664,000
7 Gigi tiruan lepas logam 1 Elemen 2,988,700 643,720 781,660 183,920 4,598,000
8 Gigi tiruan penuh / rahang 4,561,050 982,380 1,192,890 280,680 7,017,000
9 Gigi tiruan penuh rahang atas & bawah 7,315,100 1,575,560 1,913,180 450,160 11,254,000
10 Per-elemen berikutnya 622,700 134,120 162,860 38,320 958,000

Alat + Consumable
PIHAK II RS
12 Bridge Work dgn Precious mental per-elemen 1,542,450 332,220 403,410 94,920 2,373,000
13 Post Core 739,050 159,180 193,290 45,480 1,137,000
14 Porcelain Veneer (Facing) 1,415,700 304,920 370,260 87,120 2,178,000
15 Maryland Bridge / 1 gigi 2,595,450 559,020 678,810 159,720 3,993,000
16 Labiel Veneer / 1 gigi 865,800 186,480 226,440 53,280 1,332,000
17 Prothesa Obturator 1,730,950 372,820 452,710 106,520 2,663,000
18 Occlusal Splint 1,178,450 253,820 308,210 72,520 1,813,000
19 Rebase 1,808,950 389,620 473,110 111,320 2,783,000
20 Reline 919,750 198,100 240,550 56,600 1,415,000
21 Kontrol Prothesa 347,100 74,760 90,780 21,360 534,000
23 Flexi Bilateral 3,775,200 813,120 987,360 232,320 5,808,000
d. Tindakan Periodonti 65% 14% 17% 4% ###
1 Bruxism 1,337,050 287,980 349,690 82,280 2,057,000
2 Splinting Kawat / Wire 1,218,100 262,360 318,580 74,960 1,874,000
3 Splinting Plastik 1,493,700 321,720 390,660 91,920 2,298,000
4 Splinting Fiber 1,966,250 423,500 514,250 121,000 3,025,000
e. Tindakan Pedodonti 65% 14% 17% 4% ###
1 Space Maintainer 1,337,050 287,980 349,690 82,280 2,057,000
2 Crown Metal 1,178,450 253,820 308,210 72,520 1,813,000
3 Crown GIC / Composite 1,178,450 253,820 308,210 72,520 1,813,000
###
f. Tindakan Orthodonti 65% 14% 17% 4% ###
1 Fixed Appliance 13,902,850 2,994,460 3,636,130 855,560 21,389,000
2 Fixed Appliance Full Cheramic 22,510,150 4,848,340 5,887,270 1,385,240 34,631,000
3 Pengganti Plat Ortho retensi 2 rahang 2,359,500 508,200 617,100 145,200 3,630,000
4 Aktivir Orthodonti Fixed (tanpa penambahan alat) 488,150 105,140 127,670 30,040 751,000
5 Aktivir Orthodonti Fixed (dgn penambahan alat) 607,100 130,760 158,780 37,360 934,000
6 Fixed Appliance 1 Rahang 8,008,650 1,724,940 2,094,570 492,840 12,321,000

Alat + Consumable
PIHAK II RS
9 Aktivir Orthodonti Lepasan 378,300 81,480 98,940 23,280 582,000
Keterangan: Precious Metal tergantung

Dengan berat/gram dan harganya
###
4. KELOMPOK D ###
Alat + Consumable
PIHAK II RS
Bahan Khusus 5% 15% 70% 10% ###
1 Bahan Komposit / Compomer 2,400 7,200 33,600 4,800 48,000
2 Bahan GIC 1,550 4,650 21,700 3,100 31,000
3 Bahan Ledermix 1,550 4,650 21,700 3,100 31,000
4 Bahan cetak 2,000 6,000 28,000 4,000 40,000
5 Bahan Tambal Sementara 1,550 4,650 21,700 3,100 31,000
6 Bahan Perawatan Sal Akar 2,000 6,000 28,000 4,000 40,000
7 Bahan Pengisian Sal Akar 2,000 6,000 28,000 4,000 40,000
8 Rontgen Photo 4,700 14,100 65,800 9,400 94,000

III.B TINDAKAN MEDIS DI RAWAT INAP
III.B.1 IGD

2 Bilas lambung 133,000
3 Ganti verban
a. Kecil 52,000
b. Sedang 89,000
c. Besar 123,000
4 Hecting :
5 Aff hecting :
9 Observasi IGD :
a. 1 s.d 3 jam 57,000
b. 4 s.d 6 jam 109,000
10 Pasang infus :
a. Vena perifer 26,000
b. Intra osseus 152,000
c. Vena jugularis 152,000
d. Vena sectie 384,000
e. Percutaneous catheter 386,000
d. Vena sentral (CVC)/ CVP 512,000
50% dari
Tindakan medis di luar tindakan di atas
JM Dokter
(termasuk pendampingan persalinan menggantikan dokter obgyn)
Spesialis
III.B.2 SPESIALIS KEBIDANAN & KANDUNGAN
1 Biopsi 352,000
3 IUD :
a. Pasang IUD 186,000
b. Aff IUD 186,000
c. Aff dan pasang IUD 245,000
d. Tindakan Reposisi IUD 126,000
4 Pasang laminaria 227,000
5 Suntik 39,000
6 Intubasi/ Pemasangan ETT
III.B.3 SPESIALIS ANAK


2 Pasang Infus :
5 Pemberian surfaktan :
a. Tanpa pemasangan ETT 568,000
b. Dengan pemasangan ETT 711,000
6 Pungsi lumbal 435,000
7 Suntik 39,000
8 Tindik :
a. Dengan jarum 134,000
b. Dengan alat 202,000
9 Transfusi tukar
a. Transfusi tukar I 1,409,000
b. Transfusi tukar II 914,000
c. Transfusi tukar III 683,000
III.B.4 SPESIALIS BEDAH
1 Ganti verban
a. Kecil 106,000
b. Sedang 177,000
c. Besar 247,000
2 Gips :
a. Pasang gips :
- Tanpa reposisi 861,000
b. Buka gips :
- 1 sisi 276,000
- 2 sisi 458,000
III.B.5 VASKULER

IV. PERKIRAAN TARIF TINDAKAN MEDIS OPERATIF (PER – KELAS PERAWATAN)
IV.1. SPESIALIS KEBIDANAN DAN KANDUNGAN
KAMAR KAMAR DOKTER DOKTER DOKTER

KELAS GOL. OPERASI PARAMEDIS OBAT JUMLAH
PERAWATAN OPERASI OPERATOR ASISTEN ANESTESI
Kecil 1,688,000 4,018,000 3,215,000 1,286,000 321,500 4,554,000 15,082,500
Sedang 1,688,000 5,223,000 5,839,000 1,459,750 2,335,600 583,900 4,554,000 21,683,250

SUITE ROOM
Besar 8,440,000 5,826,000 6,787,000 1,696,750 2,714,800 678,700 5,577,000 31,720,250
Besar Khusus 8,440,000 9,041,000 9,354,000 2,338,500 3,741,600 935,400 5,577,000 39,427,500
Kecil 1,309,000 3,444,000 2,957,000 1,182,800 295,700 4,554,000 13,742,500
Sedang 1,309,000 4,477,000 5,255,000 1,313,750 2,102,000 525,500 4,554,000 19,536,250

EKSEKUTIF
Besar 6,545,000 4,994,000 6,404,000 1,601,000 2,561,600 640,400 5,577,000 28,323,000
Besar Khusus 6,545,000 7,749,000 8,792,000 2,198,000 3,516,800 879,200 5,577,000 35,257,000
Kecil 1,171,000 3,300,000 2,737,000 1,094,800 273,700 4,554,000 13,130,500
Sedang 1,171,000 4,290,000 4,851,000 1,212,750 1,940,400 485,100 4,554,000 18,504,250

DELUXE
Besar 5,855,000 4,785,000 5,713,000 1,428,250 2,285,200 571,300 5,577,000 26,214,750
Besar Khusus 5,855,000 7,425,000 7,647,000 1,911,750 3,058,800 764,700 5,577,000 32,239,250
Kecil 650,000 2,870,000 2,300,000 920,000 230,000 4,554,000 11,524,000
Sedang 650,000 3,731,000 3,820,000 955,000 1,528,000 382,000 4,554,000 15,620,000

ANGGREK
Besar 3,250,000 4,162,000 4,543,000 1,135,750 1,817,200 454,300 5,577,000 20,939,250
Besar Khusus 3,250,000 6,458,000 6,064,000 1,516,000 2,425,600 606,400 5,577,000 25,897,000
Kecil 425,000 2,296,000 1,970,000 788,000 197,000 4,554,000 10,230,000
Sedang 425,000 2,985,000 3,647,000 911,750 1,458,800 364,700 4,554,000 14,346,250

MAWAR
Besar 2,125,000 3,329,000 4,255,000 1,063,750 1,702,000 425,500 5,577,000 18,477,250
Besar Khusus 2,125,000 5,166,000 4,862,000 1,215,500 1,944,800 486,200 5,577,000 21,376,500
Kecil 172,000 1,722,000 1,470,000 588,000 147,000 4,554,000 8,653,000
Sedang 172,000 2,239,000 2,392,000 598,000 956,800 239,200 4,554,000 11,151,000

MELATI
Besar 860,000 2,497,000 3,065,000 766,250 1,226,000 306,500 5,577,000 14,297,750
Besar Khusus 860,000 3,875,000 3,675,000 918,750 1,470,000 367,500 5,577,000 16,743,250
* Tarif kamar perawatan dihitung dengan perkiraan lama perawatan sebagai berikut :
Gol. Operasi Kecil dan Sedang : 1 hari
Gol. Operasi Besar dan Besar Khusus : 5 hari
* Tarif yang tertera diatas berlaku dalam KEADAAN NORMAL / BIASA
* Tarif Yang Tertera diatas merupakan Tarif PERKIRAAN SEMENTARA dan TIDAK BERLAKU MUTLAK,
SEWAKTU-WAKTU DAPAT BERUBAH KARENA KONDISI/KEBUTUHAN PELAYANAN MEDIS PASIEN.
* Tarif yang tertera diatas BELUM termasuk :
1. BIAYA ADMINISTRASI 7% DARI TOTAL KUITANSI, MAKSIMUM S/D Rp 1.200.000,-
2. TARIF JASA MEDIS VISITE DOKTER
3. TARIF PEMERIKSAAN LABORATORIUM DAN PENUNJANG MEDIS LAINNYA
4. BIAYA OBAT-OBATAN YANG DIRESEPKAN
5. BIAYA JASA PARAMEDIS di kamar perawatan
IV.2. SPESIALIS BEDAH
IV.2.A SPESIALIS BEDAH ANAK :

Kecil 1,688,000 4,018,000 4,515,000 1,806,000 451,500 5,099,000 17,577,500

Sedang 1,688,000 5,223,000 5,106,000 1,276,500 2,042,400 510,600 5,099,000 20,945,500
Besar 8,440,000 5,826,000 7,824,000 1,956,000 3,129,600 782,400 6,868,000 34,826,000
Besar Khusus
SUITE ROOM
I 8,440,000 9,041,000 10,210,000 2,552,500 4,084,000 1,021,000 6,868,000 42,216,500
II 8,440,000 9,041,000 11,912,000 2,978,000 4,764,800 1,191,200 6,868,000 45,195,000
III 8,440,000 9,041,000 15,316,000 3,829,000 6,126,400 1,531,600 6,868,000 51,152,000
IV 8,440,000 9,041,000 17,017,000 4,254,250 6,806,800 1,701,700 6,868,000 54,128,750
Kecil 1,309,000 3,444,000 3,889,000 1,555,600 388,900 5,099,000 15,685,500
Sedang 1,309,000 4,477,000 5,106,000 1,276,500 2,042,400 510,600 5,099,000 19,820,500
Besar 6,545,000 4,994,000 7,779,000 1,944,750 3,111,600 777,900 6,868,000 32,020,250
Besar Khusus
EKSEKUTIF
I 6,545,000 7,749,000 10,185,000 2,546,250 4,074,000 1,018,500 6,868,000 38,985,750
II 6,545,000 7,749,000 11,869,000 2,967,250 4,747,600 1,186,900 6,868,000 41,932,750
III 6,545,000 7,749,000 15,278,000 3,819,500 6,111,200 1,527,800 6,868,000 47,898,500
IV 6,545,000 7,749,000 16,974,000 4,243,500 6,789,600 1,697,400 6,868,000 50,866,500
Kecil 1,171,000 3,300,000 3,280,000 1,312,000 328,000 5,099,000 14,490,000
Sedang 1,171,000 4,290,000 4,149,000 1,037,250 1,659,600 414,900 5,099,000 17,820,750
Besar 5,855,000 4,785,000 5,880,000 1,470,000 2,352,000 588,000 6,868,000 27,798,000
Besar Khusus
DELUXE
I 5,855,000 7,425,000 8,730,000 2,182,500 3,492,000 873,000 6,868,000 35,425,500
II 5,855,000 7,425,000 10,207,000 2,551,750 4,082,800 1,020,700 6,868,000 38,010,250
III 5,855,000 7,425,000 13,096,000 3,274,000 5,238,400 1,309,600 6,868,000 43,066,000
IV 5,855,000 7,425,000 14,550,000 3,637,500 5,820,000 1,455,000 6,868,000 45,610,500
Kecil 650,000 2,870,000 2,791,000 1,116,400 279,100 5,099,000 12,805,500
Sedang 650,000 3,731,000 3,638,000 909,500 1,455,200 363,800 5,099,000 15,846,500
Besar 3,250,000 4,162,000 5,277,000 1,319,250 2,110,800 527,700 6,868,000 23,514,750
Besar Khusus
ANGGREK
I 3,250,000 6,458,000 7,274,000 1,818,500 2,909,600 727,400 6,868,000 29,305,500
II 3,250,000 6,458,000 8,488,000 2,122,000 3,395,200 848,800 6,868,000 31,430,000
III 3,250,000 6,458,000 10,913,000 2,728,250 4,365,200 1,091,300 6,868,000 35,673,750
IV 3,250,000 6,458,000 12,125,000 3,031,250 4,850,000 1,212,500 6,868,000 37,794,750

KELAS KAMAR KAMAR DOKTER DOKTER DOKTER
GOL. OPERASI PARAMEDIS OBAT JUMLAH
PERAWATAN PERAWATAN OPERASI OPERATOR ASISTEN ANESTESI
Kecil 425,000 2,296,000 2,169,000 867,600 216,900 5,099,000 11,073,500
Sedang 425,000 2,985,000 3,010,000 752,500 1,204,000 301,000 5,099,000 13,776,500
Besar 2,125,000 3,329,000 4,366,000 1,091,500 1,746,400 436,600 6,868,000 19,962,500
Besar Khusus
MAWAR
I 2,125,000 5,166,000 5,835,000 1,458,750 2,334,000 583,500 6,868,000 24,370,250
II 2,125,000 5,166,000 6,807,000 1,701,750 2,722,800 680,700 6,868,000 26,071,250
III 2,125,000 5,166,000 8,744,000 2,186,000 3,497,600 874,400 6,868,000 29,461,000
IV 2,125,000 5,166,000 9,700,000 2,425,000 3,880,000 970,000 6,868,000 31,134,000
Kecil 172,000 1,722,000 1,799,000 719,600 179,900 5,099,000 9,691,500
Sedang 172,000 2,239,000 2,426,000 606,500 970,400 242,600 5,099,000 11,755,500
Besar 860,000 2,497,000 3,638,000 909,500 1,455,200 363,800 6,868,000 16,591,500
Besar Khusus
MELATI
I 860,000 3,875,000 4,851,000 1,212,750 1,940,400 485,100 6,868,000 20,092,250
II 860,000 3,875,000 6,063,000 1,515,750 2,425,200 606,300 6,868,000 22,213,250
III 860,000 3,875,000 7,274,000 1,818,500 2,909,600 727,400 6,868,000 24,332,500
IV 860,000 3,875,000 9,030,000 2,257,500 3,612,000 903,000 6,868,000 27,405,500
IV. 2.B SPESIALIS BEDAH UMUM
Kecil 1,688,000 4,018,000 3,325,000 1,330,000 332,500 4,912,000 15,605,500
Sedang 1,688,000 5,223,000 5,650,000 1,412,500 2,260,000 565,000 4,912,000 21,710,500

SUITE ROOM
Besar 8,440,000 5,826,000 6,647,000 1,661,750 2,658,800 664,700 6,013,000 31,911,250
Besar Khusus 8,440,000 9,041,000 8,572,000 2,143,000 3,428,800 857,200 6,013,000 38,495,000
Kecil 1,309,000 3,444,000 3,234,000 1,293,600 323,400 4,912,000 14,516,000
Sedang 1,309,000 4,477,000 5,494,000 1,373,500 2,197,600 549,400 4,912,000 20,312,500

EKSEKUTIF
Besar 6,545,000 4,994,000 6,466,000 1,616,500 2,586,400 646,600 6,013,000 28,867,500
Besar Khusus 6,545,000 7,749,000 8,120,000 2,030,000 3,248,000 812,000 6,013,000 34,517,000
Kecil 1,171,000 3,300,000 3,010,000 1,204,000 301,000 4,912,000 13,898,000
Sedang 1,171,000 4,290,000 4,704,000 1,176,000 1,881,600 470,400 4,912,000 18,605,000

DELUXE
Besar 5,855,000 4,785,000 5,542,000 1,385,500 2,216,800 554,200 6,013,000 26,351,500
Besar Khusus 5,855,000 7,425,000 7,147,000 1,786,750 2,858,800 714,700 6,013,000 31,800,250
Kecil 650,000 2,870,000 2,310,000 924,000 231,000 4,912,000 11,897,000
Sedang 650,000 3,731,000 4,515,000 1,128,750 1,806,000 451,500 4,912,000 17,194,250

ANGGREK
Besar 3,250,000 4,162,000 4,620,000 1,155,000 1,848,000 462,000 6,013,000 21,510,000
Besar Khusus 3,250,000 6,458,000 5,956,000 1,489,000 2,382,400 595,600 6,013,000 26,144,000
Kecil 425,000 2,296,000 1,848,000 739,200 184,800 4,912,000 10,405,000
Sedang 425,000 2,985,000 3,150,000 787,500 1,260,000 315,000 4,912,000 13,834,500

MAWAR
Besar 2,125,000 3,329,000 3,647,000 911,750 1,458,800 364,700 6,013,000 17,849,250
Besar Khusus 2,125,000 5,166,000 4,765,000 1,191,250 1,906,000 476,500 6,013,000 21,642,750
Kecil 172,000 1,722,000 1,496,000 598,400 149,600 4,912,000 9,050,000
Sedang 172,000 2,239,000 2,553,000 638,250 1,021,200 255,300 4,912,000 11,790,750

MELATI
Besar 860,000 2,497,000 3,150,000 787,500 1,260,000 315,000 6,013,000 14,882,500
Besar Khusus 860,000 3,875,000 4,515,000 1,128,750 1,806,000 451,500 6,013,000 18,649,250
IV. 2.C SPESIALIS BEDAH DIGESTIF

Kecil 1,688,000 4,018,000 4,515,000 1,806,000 451,500 4,912,000 17,390,500
Sedang 1,688,000 5,223,000 5,106,000 1,276,500 2,042,400 510,600 4,912,000 20,758,500
Besar 8,440,000 5,826,000 7,824,000 1,956,000 3,129,600 782,400 6,013,000 33,971,000
Besar Khusus
SUITE ROOM
I 8,440,000 9,041,000 10,210,000 2,552,500 4,084,000 1,021,000 6,013,000 41,361,500
II 8,440,000 9,041,000 11,912,000 2,978,000 4,764,800 1,191,200 6,013,000 44,340,000
III 8,440,000 9,041,000 15,316,000 3,829,000 6,126,400 1,531,600 6,013,000 50,297,000
IV 8,440,000 9,041,000 17,017,000 4,254,250 6,806,800 1,701,700 6,013,000 53,273,750
Kecil 1,309,000 3,444,000 3,889,000 1,555,600 388,900 4,912,000 15,498,500
Sedang 1,309,000 4,477,000 5,106,000 1,276,500 2,042,400 510,600 4,912,000 19,633,500
Besar 6,545,000 4,994,000 7,779,000 1,944,750 3,111,600 777,900 6,013,000 31,165,250
Besar Khusus
EKSEKUTIF
I 6,545,000 7,749,000 10,185,000 2,546,250 4,074,000 1,018,500 6,013,000 38,130,750
II 6,545,000 7,749,000 11,869,000 2,967,250 4,747,600 1,186,900 6,013,000 41,077,750
III 6,545,000 7,749,000 15,278,000 3,819,500 6,111,200 1,527,800 6,013,000 47,043,500
IV 6,545,000 7,749,000 16,974,000 4,243,500 6,789,600 1,697,400 6,013,000 50,011,500
Kecil 1,171,000 3,300,000 3,280,000 1,312,000 328,000 4,912,000 14,303,000
Sedang 1,171,000 4,290,000 4,149,000 1,037,250 1,659,600 414,900 4,912,000 17,633,750
Besar 5,855,000 4,785,000 5,880,000 1,470,000 2,352,000 588,000 6,013,000 26,943,000
Besar Khusus
DELUXE
I 5,855,000 7,425,000 8,730,000 2,182,500 3,492,000 873,000 6,013,000 34,570,500
II 5,855,000 7,425,000 10,207,000 2,551,750 4,082,800 1,020,700 6,013,000 37,155,250
III 5,855,000 7,425,000 13,096,000 3,274,000 5,238,400 1,309,600 6,013,000 42,211,000
IV 5,855,000 7,425,000 14,550,000 3,637,500 5,820,000 1,455,000 6,013,000 44,755,500
Kecil 650,000 2,870,000 2,791,000 1,116,400 279,100 4,912,000 12,618,500
Sedang 650,000 3,731,000 3,638,000 909,500 1,455,200 363,800 4,912,000 15,659,500
Besar 3,250,000 4,162,000 5,277,000 1,319,250 2,110,800 527,700 6,013,000 22,659,750
Besar Khusus
ANGGREK
I 3,250,000 6,458,000 7,274,000 1,818,500 2,909,600 727,400 6,013,000 28,450,500
II 3,250,000 6,458,000 8,488,000 2,122,000 3,395,200 848,800 6,013,000 30,575,000
III 3,250,000 6,458,000 10,913,000 2,728,250 4,365,200 1,091,300 6,013,000 34,818,750
IV 3,250,000 6,458,000 12,125,000 3,031,250 4,850,000 1,212,500 6,013,000 36,939,750

Kecil 425,000 2,296,000 2,169,000 867,600 216,900 4,912,000 10,886,500
Sedang 425,000 2,985,000 3,010,000 752,500 1,204,000 301,000 4,912,000 13,589,500
Besar 2,125,000 3,329,000 4,366,000 1,091,500 1,746,400 436,600 6,013,000 19,107,500
Besar Khusus
MAWAR
I 2,125,000 5,166,000 5,835,000 1,458,750 2,334,000 583,500 6,013,000 23,515,250
II 2,125,000 5,166,000 6,807,000 1,701,750 2,722,800 680,700 6,013,000 25,216,250
III 2,125,000 5,166,000 8,744,000 2,186,000 3,497,600 874,400 6,013,000 28,606,000
IV 2,125,000 5,166,000 9,700,000 2,425,000 3,880,000 970,000 6,013,000 30,279,000
Kecil 172,000 1,722,000 1,799,000 719,600 179,900 4,912,000 9,504,500
Sedang 172,000 2,239,000 2,426,000 606,500 970,400 242,600 4,912,000 11,568,500
Besar 860,000 2,497,000 3,638,000 909,500 1,455,200 363,800 6,013,000 15,736,500
Besar Khusus
MELATI
I 860,000 3,875,000 4,851,000 1,212,750 1,940,400 485,100 6,013,000 19,237,250
II 860,000 3,875,000 6,063,000 1,515,750 2,425,200 606,300 6,013,000 21,358,250
III 860,000 3,875,000 7,274,000 1,818,500 2,909,600 727,400 6,013,000 23,477,500
IV 860,000 3,875,000 9,030,000 2,257,500 3,612,000 903,000 6,013,000 26,550,500
IV. 2.D SPESIALIS BEDAH ONKOLOGI
Kecil 1,688,000 4,018,000 4,156,000 1,662,400 415,600 4,912,000 16,852,000
Sedang 1,688,000 5,223,000 7,063,000 1,765,750 2,825,200 706,300 4,912,000 24,183,250

SUITE ROOM
Besar 8,440,000 5,826,000 8,309,000 2,077,250 3,323,600 830,900 6,013,000 34,819,750
Besar Khusus 8,440,000 9,041,000 10,715,000 2,678,750 4,286,000 1,071,500 6,013,000 42,245,250
Kecil 1,309,000 3,444,000 4,043,000 1,617,200 404,300 4,912,000 15,729,500
Sedang 1,309,000 4,477,000 6,868,000 1,717,000 2,747,200 686,800 4,912,000 22,717,000

EKSEKUTIF
Besar 6,545,000 4,994,000 8,083,000 2,020,750 3,233,200 808,300 6,013,000 31,697,250
Besar Khusus 6,545,000 7,749,000 10,150,000 2,537,500 4,060,000 1,015,000 6,013,000 38,069,500
Kecil 1,171,000 3,300,000 3,763,000 1,505,200 376,300 4,912,000 15,027,500
Sedang 1,171,000 4,290,000 5,880,000 1,470,000 2,352,000 588,000 4,912,000 20,663,000

DELUXE
Besar 5,855,000 4,785,000 6,928,000 1,732,000 2,771,200 692,800 6,013,000 28,777,000
Besar Khusus 5,855,000 7,425,000 8,934,000 2,233,500 3,573,600 893,400 6,013,000 34,927,500
Kecil 650,000 2,870,000 2,888,000 1,155,200 288,800 4,912,000 12,764,000
Sedang 650,000 3,731,000 5,644,000 1,411,000 2,257,600 564,400 4,912,000 19,170,000

ANGGREK
Besar 3,250,000 4,162,000 5,775,000 1,443,750 2,310,000 577,500 6,013,000 23,531,250
Besar Khusus 3,250,000 6,458,000 7,445,000 1,861,250 2,978,000 744,500 6,013,000 28,749,750
Kecil 425,000 2,296,000 2,310,000 924,000 231,000 4,912,000 11,098,000
Sedang 425,000 2,985,000 3,938,000 984,500 1,575,200 393,800 4,912,000 15,213,500

MAWAR
Besar 2,125,000 3,329,000 4,559,000 1,139,750 1,823,600 455,900 6,013,000 19,445,250
Besar Khusus 2,125,000 5,166,000 5,956,000 1,489,000 2,382,400 595,600 6,013,000 23,727,000
Kecil 172,000 1,722,000 1,870,000 748,000 187,000 4,912,000 9,611,000
Sedang 172,000 2,239,000 3,191,000 797,750 1,276,400 319,100 4,912,000 12,907,250

MELATI
Besar 860,000 2,497,000 3,938,000 984,500 1,575,200 393,800 6,013,000 16,261,500
Besar Khusus 860,000 3,875,000 5,644,000 1,411,000 2,257,600 564,400 6,013,000 20,625,000
IV. 2.E SPESIALIS BEDAH UROLOGI
Kecil 1,688,000 4,018,000 3,990,000 1,596,000 399,000 4,912,000 16,603,000
Sedang 1,688,000 5,223,000 6,780,000 1,695,000 2,712,000 678,000 4,912,000 23,688,000

SUITE ROOM
Besar 8,440,000 5,826,000 7,976,000 1,994,000 3,190,400 797,600 6,013,000 34,237,000
Besar Khusus 8,440,000 9,041,000 10,286,000 2,571,500 4,114,400 1,028,600 6,013,000 41,494,500
Kecil 1,309,000 3,444,000 3,881,000 1,552,400 388,100 4,912,000 15,486,500
Sedang 1,309,000 4,477,000 6,593,000 1,648,250 2,637,200 659,300 4,912,000 22,235,750

EKSEKUTIF
Besar 6,545,000 4,994,000 7,759,000 1,939,750 3,103,600 775,900 6,013,000 31,130,250
Besar Khusus 6,545,000 7,749,000 9,744,000 2,436,000 3,897,600 974,400 6,013,000 37,359,000
Kecil 1,171,000 3,300,000 3,612,000 1,444,800 361,200 4,912,000 14,801,000
Sedang 1,171,000 4,290,000 5,645,000 1,411,250 2,258,000 564,500 4,912,000 20,251,750

DELUXE
Besar 5,855,000 4,785,000 6,650,000 1,662,500 2,660,000 665,000 6,013,000 28,290,500
Besar Khusus 5,855,000 7,425,000 8,576,000 2,144,000 3,430,400 857,600 6,013,000 34,301,000
Kecil 650,000 2,870,000 2,772,000 1,108,800 277,200 4,912,000 12,590,000
Sedang 650,000 3,731,000 5,418,000 1,354,500 2,167,200 541,800 4,912,000 18,774,500

ANGGREK
Besar 3,250,000 4,162,000 5,544,000 1,386,000 2,217,600 554,400 6,013,000 23,127,000
Besar Khusus 3,250,000 6,458,000 7,147,000 1,786,750 2,858,800 714,700 6,013,000 28,228,250
Kecil 425,000 2,296,000 2,218,000 887,200 221,800 4,912,000 10,960,000
Sedang 425,000 2,985,000 3,780,000 945,000 1,512,000 378,000 4,912,000 14,937,000

MAWAR
Besar 2,125,000 3,329,000 4,376,000 1,094,000 1,750,400 437,600 6,013,000 19,125,000
Besar Khusus 2,125,000 5,166,000 5,718,000 1,429,500 2,287,200 571,800 6,013,000 23,310,500
Kecil 172,000 1,722,000 1,795,000 718,000 179,500 4,912,000 9,498,500
Sedang 172,000 2,239,000 3,064,000 766,000 1,225,600 306,400 4,912,000 12,685,000

MELATI
Besar 860,000 2,497,000 3,780,000 945,000 1,512,000 378,000 6,013,000 15,985,000
Besar Khusus 860,000 3,875,000 5,418,000 1,354,500 2,167,200 541,800 6,013,000 20,229,500
IV. 2.F SPESIALIS BEDAH PLASTIK
Kecil 1,688,000 4,018,000 4,156,000 1,662,400 415,600 4,912,000 16,852,000
Sedang 1,688,000 5,223,000 7,063,000 1,765,750 2,825,200 706,300 4,912,000 24,183,250

SUITE ROOM
Besar 8,440,000 5,826,000 8,309,000 2,077,250 3,323,600 830,900 6,013,000 34,819,750
Besar Khusus 8,440,000 9,041,000 10,715,000 2,678,750 4,286,000 1,071,500 6,013,000 42,245,250
Kecil 1,309,000 3,444,000 4,043,000 1,617,200 404,300 4,912,000 15,729,500
Sedang 1,309,000 4,477,000 6,868,000 1,717,000 2,747,200 686,800 4,912,000 22,717,000

EKSEKUTIF
Besar 6,545,000 4,994,000 8,083,000 2,020,750 3,233,200 808,300 6,013,000 31,697,250
Besar Khusus 6,545,000 7,749,000 10,150,000 2,537,500 4,060,000 1,015,000 6,013,000 38,069,500
Kecil 1,171,000 3,300,000 3,763,000 1,505,200 376,300 4,912,000 15,027,500
Sedang 1,171,000 4,290,000 5,880,000 1,470,000 2,352,000 588,000 4,912,000 20,663,000

DELUXE
Besar 5,855,000 4,785,000 6,928,000 1,732,000 2,771,200 692,800 6,013,000 28,777,000
Besar Khusus 5,855,000 7,425,000 8,934,000 2,233,500 3,573,600 893,400 6,013,000 34,927,500
Kecil 650,000 2,870,000 2,888,000 1,155,200 288,800 4,912,000 12,764,000
Sedang 650,000 3,731,000 5,644,000 1,411,000 2,257,600 564,400 4,912,000 19,170,000

ANGGREK
Besar 3,250,000 4,162,000 5,775,000 1,443,750 2,310,000 577,500 6,013,000 23,531,250
Besar Khusus 3,250,000 6,458,000 7,445,000 1,861,250 2,978,000 744,500 6,013,000 28,749,750
Kecil 425,000 2,296,000 2,310,000 924,000 231,000 4,912,000 11,098,000
Sedang 425,000 2,985,000 3,938,000 984,500 1,575,200 393,800 4,912,000 15,213,500

MAWAR
Besar 2,125,000 3,329,000 4,559,000 1,139,750 1,823,600 455,900 6,013,000 19,445,250
Besar Khusus 2,125,000 5,166,000 5,956,000 1,489,000 2,382,400 595,600 6,013,000 23,727,000
Kecil 172,000 1,722,000 1,870,000 748,000 187,000 4,912,000 9,611,000
Sedang 172,000 2,239,000 3,191,000 797,750 1,276,400 319,100 4,912,000 12,907,250

MELATI
Besar 860,000 2,497,000 3,938,000 984,500 1,575,200 393,800 6,013,000 16,261,500
Besar Khusus 860,000 3,875,000 5,644,000 1,411,000 2,257,600 564,400 6,013,000 20,625,000
IV.2.G SPESIALIS BEDAH ORTHOPEDI :

Kecil 1,688,000 4,018,000 3,350,000 1,340,000 335,000 5,099,000 15,830,000
Sedang :
I 1,688,000 5,223,000 9,116,000 2,279,000 3,646,400 911,600 5,099,000 27,963,000
II 1,688,000 5,223,000 12,155,000 3,038,750 4,862,000 1,215,500 5,099,000 33,281,250
III 1,688,000 5,223,000 13,371,000 3,342,750 5,348,400 1,337,100 5,099,000 35,409,250
Besar :
SUITE ROOM I 8,440,000 5,826,000 15,194,000 3,798,500 6,077,600 1,519,400 6,242,000 47,097,500
II 8,440,000 5,826,000 18,234,000 4,558,500 7,293,600 1,823,400 6,242,000 52,417,500
III 8,440,000 5,826,000 19,448,000 4,862,000 7,779,200 1,944,800 6,242,000 54,542,000
Besar Khusus :
I 8,440,000 9,041,000 22,223,000 5,555,750 8,889,200 2,222,300 6,242,000 62,613,250
II 8,440,000 9,041,000 26,741,000 6,685,250 10,696,400 2,674,100 6,242,000 70,519,750
III 8,440,000 9,041,000 30,388,000 7,597,000 12,155,200 3,038,800 6,242,000 76,902,000
Kecil 1,309,000 3,444,000 2,784,000 1,113,600 278,400 5,099,000 14,028,000
Sedang :
I 1,309,000 4,477,000 8,660,000 2,165,000 3,464,000 866,000 5,099,000 26,040,000
II 1,309,000 4,477,000 11,548,000 2,887,000 4,619,200 1,154,800 5,099,000 31,094,000
III 1,309,000 4,477,000 12,703,000 3,175,750 5,081,200 1,270,300 5,099,000 33,115,250
Besar :
EKSEKUTIF I 6,545,000 4,994,000 14,434,000 3,608,500 5,773,600 1,443,400 6,242,000 43,040,500
II 6,545,000 4,994,000 17,322,000 4,330,500 6,928,800 1,732,200 6,242,000 48,094,500
III 6,545,000 4,994,000 18,476,000 4,619,000 7,390,400 1,847,600 6,242,000 50,114,000
Besar Khusus :
I 6,545,000 7,749,000 21,879,000 5,469,750 8,751,600 2,187,900 6,242,000 58,824,250
II 6,545,000 7,749,000 25,404,000 6,351,000 10,161,600 2,540,400 6,242,000 64,993,000
III 6,545,000 7,749,000 28,869,000 7,217,250 11,547,600 2,886,900 6,242,000 71,056,750
Kecil 1,171,000 3,300,000 2,364,000 945,600 236,400 5,099,000 13,116,000
Sedang :
I 1,171,000 4,290,000 5,196,000 1,299,000 2,078,400 519,600 5,099,000 19,653,000
II 1,171,000 4,290,000 6,928,000 1,732,000 2,771,200 692,800 5,099,000 22,684,000
III 1,171,000 4,290,000 8,660,000 2,165,000 3,464,000 866,000 5,099,000 25,715,000
Besar :
DELUXE I 5,855,000 4,785,000 10,758,000 2,689,500 4,303,200 1,075,800 6,242,000 35,708,500
II 5,855,000 4,785,000 11,548,000 2,887,000 4,619,200 1,154,800 6,242,000 37,091,000
III 5,855,000 4,785,000 14,181,000 3,545,250 5,672,400 1,418,100 6,242,000 41,698,750
Besar Khusus :
I 5,855,000 7,425,000 14,550,000 3,637,500 5,820,000 1,455,000 6,242,000 44,984,500
II 5,855,000 7,425,000 15,763,000 3,940,750 6,305,200 1,576,300 6,242,000 47,107,250
III 5,855,000 7,425,000 16,556,000 4,139,000 6,622,400 1,655,600 6,242,000 48,495,000

Kecil 650,000 2,870,000 2,107,000 842,800 210,700 5,099,000 11,779,500
Sedang :
I 650,000 3,731,000 4,041,000 1,010,250 1,616,400 404,100 5,099,000 16,551,750
II 650,000 3,731,000 5,775,000 1,443,750 2,310,000 577,500 5,099,000 19,586,250
III 650,000 3,731,000 6,930,000 1,732,500 2,772,000 693,000 5,099,000 21,607,500
Besar :
ANGGREK I 3,250,000 4,162,000 8,660,000 2,165,000 3,464,000 866,000 6,242,000 28,809,000
II 3,250,000 4,162,000 9,815,000 2,453,750 3,926,000 981,500 6,242,000 30,830,250
III 3,250,000 4,162,000 11,548,000 2,887,000 4,619,200 1,154,800 6,242,000 33,863,000
Besar Khusus :
I 3,250,000 6,458,000 12,125,000 3,031,250 4,850,000 1,212,500 6,242,000 37,168,750
II 3,250,000 6,458,000 13,338,000 3,334,500 5,335,200 1,333,800 6,242,000 39,291,500
III 3,250,000 6,458,000 14,550,000 3,637,500 5,820,000 1,455,000 6,242,000 41,412,500
Kecil 425,000 2,296,000 1,582,000 632,800 158,200 5,099,000 10,193,000
Sedang :
I 425,000 2,985,000 2,888,000 722,000 1,155,200 288,800 5,099,000 13,563,000
II 425,000 2,985,000 4,041,000 1,010,250 1,616,400 404,100 5,099,000 15,580,750
III 425,000 2,985,000 5,774,000 1,443,500 2,309,600 577,400 5,099,000 18,613,500
Besar :
MAWAR I 2,125,000 3,329,000 6,928,000 1,732,000 2,771,200 692,800 6,242,000 23,820,000
II 2,125,000 3,329,000 8,084,000 2,021,000 3,233,600 808,400 6,242,000 25,843,000
III 2,125,000 3,329,000 9,238,000 2,309,500 3,695,200 923,800 6,242,000 27,862,500
Besar Khusus :
I 2,125,000 5,166,000 10,393,000 2,598,250 4,157,200 1,039,300 6,242,000 31,720,750
II 2,125,000 5,166,000 11,548,000 2,887,000 4,619,200 1,154,800 6,242,000 33,742,000
III 2,125,000 5,166,000 12,703,000 3,175,750 5,081,200 1,270,300 6,242,000 35,763,250

Kecil 172,000 1,722,000 1,507,000 602,800 150,700 5,099,000 9,253,500
Sedang :
I 172,000 2,239,000 2,888,000 722,000 1,155,200 288,800 5,099,000 12,564,000
II 172,000 2,239,000 4,041,000 1,010,250 1,616,400 404,100 5,099,000 14,581,750
III 172,000 2,239,000 5,774,000 1,443,500 2,309,600 577,400 5,099,000 17,614,500
Besar :
MELATI I 860,000 2,497,000 6,928,000 1,732,000 2,771,200 692,800 6,242,000 21,723,000
II 860,000 2,497,000 8,084,000 2,021,000 3,233,600 808,400 6,242,000 23,746,000
III 860,000 2,497,000 9,238,000 2,309,500 3,695,200 923,800 6,242,000 25,765,500
Besar Khusus :
I 860,000 3,875,000 10,393,000 2,598,250 4,157,200 1,039,300 6,242,000 29,164,750
II 860,000 3,875,000 11,548,000 2,887,000 4,619,200 1,154,800 6,242,000 31,186,000
III 860,000 3,875,000 12,703,000 3,175,750 5,081,200 1,270,300 6,242,000 33,207,250
IV.2.H SPESIALIS BEDAH SYARAF :

Kecil 1,688,000 4,018,000 3,572,000 1,428,800 357,200 5,603,000 16,667,000
Sedang 1,688,000 5,223,000 11,053,000 2,763,250 4,421,200 1,105,300 5,603,000 31,856,750

SUITE ROOM
Besar 8,440,000 5,826,000 15,306,000 3,826,500 6,122,400 1,530,600 6,722,000 47,773,500
Besar Khusus 8,440,000 9,041,000 24,998,000 6,249,500 9,999,200 2,499,800 6,722,000 67,949,500
Kecil 1,309,000 3,444,000 2,835,000 1,134,000 283,500 5,603,000 14,608,500
Sedang 1,309,000 4,477,000 9,522,000 2,380,500 3,808,800 952,200 5,603,000 28,052,500

EKSEKUTIF
Besar 6,545,000 4,994,000 14,172,000 3,543,000 5,668,800 1,417,200 6,722,000 43,062,000
Besar Khusus 6,545,000 7,749,000 22,675,000 5,668,750 9,070,000 2,267,500 6,722,000 60,697,250
Kecil 1,171,000 3,300,000 2,625,000 1,050,000 262,500 5,603,000 14,011,500
Sedang 1,171,000 4,290,000 8,504,000 2,126,000 3,401,600 850,400 5,603,000 25,946,000

DELUXE
Besar 5,855,000 4,785,000 12,472,000 3,118,000 4,988,800 1,247,200 6,722,000 39,188,000
Besar Khusus 5,855,000 7,425,000 17,007,000 4,251,750 6,802,800 1,700,700 6,722,000 49,764,250
Kecil 650,000 2,870,000 2,431,000 972,400 243,100 5,603,000 12,769,500
Sedang 650,000 3,731,000 7,821,000 1,955,250 3,128,400 782,100 5,603,000 23,670,750

ANGGREK
Besar 3,250,000 4,162,000 11,469,000 2,867,250 4,587,600 1,146,900 6,722,000 34,204,750
Besar Khusus 3,250,000 6,458,000 15,640,000 3,910,000 6,256,000 1,564,000 6,722,000 43,800,000
Kecil 425,000 2,296,000 2,267,000 906,800 226,700 5,603,000 11,724,500
Sedang 425,000 2,985,000 6,778,000 1,694,500 2,711,200 677,800 5,603,000 20,874,500

MAWAR
Besar 2,125,000 3,329,000 9,384,000 2,346,000 3,753,600 938,400 6,722,000 28,598,000
Besar Khusus 2,125,000 5,166,000 13,554,000 3,388,500 5,421,600 1,355,400 6,722,000 37,732,500
Kecil 172,000 1,722,000 2,267,000 906,800 226,700 5,603,000 10,897,500
Sedang 172,000 2,239,000 3,402,000 850,500 1,360,800 340,200 5,603,000 13,967,500

MELATI
Besar 860,000 2,497,000 5,669,000 1,417,250 2,267,600 566,900 6,722,000 19,999,750
Besar Khusus 860,000 3,875,000 7,936,000 1,984,000 3,174,400 793,600 6,722,000 25,345,000
IV.3.SPESIALIS THT :

Kecil 1,688,000 4,018,000 3,175,000 1,270,000 317,500 4,866,000 15,334,500
Sedang 1,688,000 5,223,000 4,556,000 1,139,000 1,822,400 455,600 4,866,000 19,750,000

SUITE ROOM
Besar 8,440,000 5,826,000 5,454,000 1,363,500 2,181,600 545,400 5,959,000 29,769,500
Besar Khusus 8,440,000 9,041,000 8,227,000 2,056,750 3,290,800 822,700 5,959,000 37,837,250
Kecil 1,309,000 3,444,000 2,916,000 1,166,400 291,600 4,866,000 13,993,000
Sedang 1,309,000 4,477,000 3,800,000 950,000 1,520,000 380,000 4,866,000 17,302,000

EKSEKUTIF
Besar 6,545,000 4,994,000 4,988,000 1,247,000 1,995,200 498,800 5,959,000 26,227,000
Besar Khusus 6,545,000 7,749,000 7,144,000 1,786,000 2,857,600 714,400 5,959,000 32,755,000
Kecil 1,171,000 3,300,000 2,440,000 976,000 244,000 4,866,000 12,997,000
Sedang 1,171,000 4,290,000 3,402,000 850,500 1,360,800 340,200 4,866,000 16,280,500

DELUXE
Besar 5,855,000 4,785,000 4,644,000 1,161,000 1,857,600 464,400 5,959,000 24,726,000
Besar Khusus 5,855,000 7,425,000 6,349,000 1,587,250 2,539,600 634,900 5,959,000 30,349,750
Kecil 650,000 2,870,000 2,042,000 816,800 204,200 4,866,000 11,449,000
Sedang 650,000 3,731,000 3,003,000 750,750 1,201,200 300,300 4,866,000 14,502,250

ANGGREK
Besar 3,250,000 4,162,000 4,137,000 1,034,250 1,654,800 413,700 5,959,000 20,610,750
Besar Khusus 3,250,000 6,458,000 5,162,000 1,290,500 2,064,800 516,200 5,959,000 24,700,500
Kecil 425,000 2,296,000 1,505,000 602,000 150,500 4,866,000 9,844,500
Sedang 425,000 2,985,000 2,264,000 566,000 905,600 226,400 4,866,000 12,238,000

MAWAR
Besar 2,125,000 3,329,000 3,743,000 935,750 1,497,200 374,300 5,959,000 17,963,250
Besar Khusus 2,125,000 5,166,000 3,968,000 992,000 1,587,200 396,800 5,959,000 20,194,000
Kecil 172,000 1,722,000 1,362,000 544,800 136,200 4,866,000 8,803,000
Sedang 172,000 2,239,000 2,258,000 564,500 903,200 225,800 4,866,000 11,228,500

MELATI
Besar 860,000 2,497,000 3,150,000 787,500 1,260,000 315,000 5,959,000 14,828,500
Besar Khusus 860,000 3,875,000 3,510,000 877,500 1,404,000 351,000 5,959,000 16,836,500
IV.4.SPESIALIS MATA :

Kecil 1,688,000 4,018,000 3,343,000 1,337,200 334,300 5,099,000 15,819,500
Sedang 1,688,000 5,223,000 4,823,000 1,205,750 1,929,200 482,300 5,099,000 20,450,250

SUITE ROOM
Besar 8,440,000 5,826,000 5,952,000 1,488,000 2,380,800 595,200 6,242,000 30,924,000
Besar Khusus 8,440,000 9,041,000 7,900,000 1,975,000 3,160,000 790,000 6,242,000 37,548,000
Kecil 1,309,000 3,444,000 3,039,000 1,215,600 303,900 5,099,000 14,410,500
Sedang 1,309,000 4,477,000 4,352,000 1,088,000 1,740,800 435,200 5,099,000 18,501,000

EKSEKUTIF
Besar 6,545,000 4,994,000 4,978,000 1,244,500 1,991,200 497,800 6,242,000 26,492,500
Besar Khusus 6,545,000 7,749,000 7,658,000 1,914,500 3,063,200 765,800 6,242,000 33,937,500
Kecil 1,171,000 3,300,000 2,553,000 1,021,200 255,300 5,099,000 13,399,500
Sedang 1,171,000 4,290,000 3,906,000 976,500 1,562,400 390,600 5,099,000 17,395,500

DELUXE
Besar 5,855,000 4,785,000 4,741,000 1,185,250 1,896,400 474,100 6,242,000 25,178,750
Besar Khusus 5,855,000 7,425,000 6,807,000 1,701,750 2,722,800 680,700 6,242,000 31,434,250
Kecil 650,000 2,870,000 2,160,000 864,000 216,000 5,099,000 11,859,000
Sedang 650,000 3,731,000 3,282,000 820,500 1,312,800 328,200 5,099,000 15,223,500

ANGGREK
Besar 3,250,000 4,162,000 4,255,000 1,063,750 1,702,000 425,500 6,242,000 21,100,250
Besar Khusus 3,250,000 6,458,000 5,469,000 1,367,250 2,187,600 546,900 6,242,000 25,520,750
Kecil 425,000 2,296,000 1,697,000 678,800 169,700 5,099,000 10,365,500
Sedang 425,000 2,985,000 2,603,000 650,750 1,041,200 260,300 5,099,000 13,064,250

MAWAR
Besar 2,125,000 3,329,000 3,889,000 972,250 1,555,600 388,900 6,242,000 18,501,750
Besar Khusus 2,125,000 5,166,000 4,255,000 1,063,750 1,702,000 425,500 6,242,000 20,979,250
Kecil 172,000 1,722,000 1,475,000 590,000 147,500 5,099,000 9,205,500
Sedang 172,000 2,239,000 2,381,000 595,250 952,400 238,100 5,099,000 11,676,750

MELATI
Besar 860,000 2,497,000 3,629,000 907,250 1,451,600 362,900 6,242,000 15,949,750
Besar Khusus 860,000 3,875,000 3,968,000 992,000 1,587,200 396,800 6,242,000 17,921,000
IV.5. SPESIALIS BEDAH VASKULER
Kecil
I 1,688,000 4,018,000 4,869,000 1,947,600 486,900 4,912,000 17,921,500
II 1,688,000 4,018,000 5,951,000 2,380,400 595,100 4,912,000 19,544,500
Sedang
I 1,688,000 5,223,000 8,114,000 2,028,500 3,245,600 811,400 4,912,000 26,022,500
II 1,688,000 5,223,000 10,819,000 2,704,750 4,327,600 1,081,900 4,912,000 30,756,250
SUITE ROOM Besar
I 8,440,000 5,826,000 14,065,000 3,516,250 5,626,000 1,406,500 6,013,000 44,892,750
II 8,440,000 5,826,000 17,311,000 4,327,750 6,924,400 1,731,100 6,013,000 50,573,250
Besar Khusus
I 8,440,000 9,041,000 27,048,000 6,762,000 10,819,200 2,704,800 6,013,000 70,828,000
II 8,440,000 9,041,000 37,867,000 9,466,750 15,146,800 3,786,700 6,013,000 89,761,250
III 8,440,000 9,041,000 81,144,000 20,286,000 32,457,600 8,114,400 6,013,000 165,496,000
Kecil
I 1,309,000 3,444,000 3,787,000 1,514,800 378,700 4,912,000 15,345,500
II 1,309,000 3,444,000 4,598,000 1,839,200 459,800 4,912,000 16,562,000
Sedang
I 1,309,000 4,477,000 7,032,000 1,758,000 2,812,800 703,200 4,912,000 23,004,000
II 1,309,000 4,477,000 8,655,000 2,163,750 3,462,000 865,500 4,912,000 25,844,250
EKSEKUTIF Besar
I 6,545,000 4,994,000 11,901,000 2,975,250 4,760,400 1,190,100 6,013,000 38,378,750
II 6,545,000 4,994,000 15,147,000 3,786,750 6,058,800 1,514,700 6,013,000 44,059,250
Besar Khusus
I 6,545,000 9,041,000 21,638,000 5,409,500 8,655,200 2,163,800 6,013,000 59,465,500
II 6,545,000 9,041,000 32,458,000 8,114,500 12,983,200 3,245,800 6,013,000 78,400,500
III 6,545,000 9,041,000 70,325,000 17,581,250 28,130,000 7,032,500 6,013,000 144,667,750
Kecil
I 1,171,000 3,300,000 2,705,000 1,082,000 270,500 4,912,000 13,440,500
II 1,171,000 3,300,000 3,516,000 1,406,400 351,600 4,912,000 14,657,000
Sedang
I 1,171,000 4,290,000 5,951,000 1,487,750 2,380,400 595,100 4,912,000 20,787,250
II 1,171,000 4,290,000 7,032,000 1,758,000 2,812,800 703,200 4,912,000 22,679,000
DELUXE Besar
I 5,855,000 4,785,000 9,737,000 2,434,250 3,894,800 973,700 6,013,000 33,692,750
II 5,855,000 4,785,000 12,983,000 3,245,750 5,193,200 1,298,300 6,013,000 39,373,250
Besar Khusus
I 5,855,000 7,425,000 18,393,000 4,598,250 7,357,200 1,839,300 6,013,000 51,480,750
II 5,855,000 7,425,000 28,671,000 7,167,750 11,468,400 2,867,100 6,013,000 69,467,250
III 5,855,000 7,425,000 59,506,000 14,876,500 23,802,400 5,950,600 6,013,000 123,428,500
Kecil
I 650,000 2,870,000 2,164,000 865,600 216,400 4,912,000 11,678,000
II 650,000 2,870,000 2,705,000 1,082,000 270,500 4,912,000 12,489,500
Sedang
I 650,000 3,731,000 4,328,000 1,082,000 1,731,200 432,800 4,912,000 16,867,000
II 650,000 3,731,000 5,951,000 1,487,750 2,380,400 595,100 4,912,000 19,707,250
ANGGREK Besar
I 3,250,000 4,162,000 8,114,000 2,028,500 3,245,600 811,400 6,013,000 27,624,500
II 3,250,000 4,162,000 11,360,000 2,840,000 4,544,000 1,136,000 6,013,000 33,305,000
Besar Khusus
I 3,250,000 6,458,000 15,147,000 3,786,750 6,058,800 1,514,700 6,013,000 42,228,250
II 3,250,000 6,458,000 24,343,000 6,085,750 9,737,200 2,434,300 6,013,000 58,321,250
III 3,250,000 6,458,000 48,686,000 12,171,500 19,474,400 4,868,600 6,013,000 100,921,500
Kecil
I 425,000 2,296,000 1,623,000 649,200 162,300 4,912,000 10,067,500
II 425,000 2,296,000 2,164,000 865,600 216,400 4,912,000 10,879,000
Sedang
I 425,000 2,985,000 3,246,000 811,500 1,298,400 324,600 4,912,000 14,002,500
II 425,000 2,985,000 4,869,000 1,217,250 1,947,600 486,900 4,912,000 16,842,750
MAWAR Besar
I 2,125,000 3,329,000 6,492,000 1,623,000 2,596,800 649,200 6,013,000 22,828,000
II 2,125,000 3,329,000 9,737,000 2,434,250 3,894,800 973,700 6,013,000 28,506,750
Besar Khusus
I 2,125,000 5,166,000 12,983,000 3,245,750 5,193,200 1,298,300 6,013,000 36,024,250
II 2,125,000 5,166,000 20,016,000 5,004,000 8,006,400 2,001,600 6,013,000 48,332,000
III 2,125,000 5,166,000 37,867,000 9,466,750 15,146,800 3,786,700 6,013,000 79,571,250
Kecil
I 172,000 1,722,000 1,082,000 432,800 108,200 4,912,000 8,429,000
II 172,000 1,722,000 1,623,000 649,200 162,300 4,912,000 9,240,500
Sedang
I 172,000 2,239,000 2,705,000 676,250 1,082,000 270,500 4,912,000 12,056,750
II 172,000 2,239,000 3,787,000 946,750 1,514,800 378,700 4,912,000 13,950,250
MELATI Besar
I 860,000 2,497,000 5,410,000 1,352,500 2,164,000 541,000 6,013,000 18,837,500
II 860,000 2,497,000 8,114,000 2,028,500 3,245,600 811,400 6,013,000 23,569,500
Besar Khusus
I 860,000 3,875,000 10,819,000 2,704,750 4,327,600 1,081,900 6,013,000 29,681,250
II 860,000 3,875,000 16,229,000 4,057,250 6,491,600 1,622,900 6,013,000 39,148,750
III 860,000 3,875,000 27,048,000 6,762,000 10,819,200 2,704,800 6,013,000 58,082,000
IV.6. SPESIALIS GIGI DAN MULUT
1. ODONTECTOMI 1 GIGI CANINUS (PERAWATAN 1 HARI)
KELAS PERAWATAN
KETERANGAN
Kamar Perawatan 1,688,000 1,309,000 1,171,000 650,000 425,000 172,000
Kamar Operasi 2,009,000 1,722,000 1,650,000 1,435,000 1,148,000 861,000
Dokter Bedah Mulut 3,956,000 3,319,000 3,083,000 2,409,000 1,936,000 1,659,000
Dokter Anestesi 1,582,400 1,327,600 1,233,200 963,600 774,400 663,600
Paramedis 395,600 331,900 308,300 240,900 193,600 165,900
Obat - obatan 3,747,000 3,747,000 3,747,000 3,747,000 3,747,000 3,747,000
Jumlah 13,378,000 11,756,500 11,192,500 9,445,500 8,224,000 7,268,500
2. ODONTECTOMI 1 GIGI MOLAR (PERAWATAN 1 HARI)
KELAS PERAWATAN
KETERANGAN
Kamar Perawatan 1,688,000 1,309,000 1,171,000 650,000 425,000 172,000
Kamar Operasi 2,009,000 1,722,000 1,650,000 1,435,000 1,148,000 861,000
Dokter Anestesi 1,582,400 1,327,600 963,600 880,400 766,000 663,600
Paramedis 395,600 331,900 240,900 220,100 191,500 165,900
Obat - obatan 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000
Jumlah 13,564,000 11,942,500 10,367,500 9,319,500 8,378,500 7,454,500

3. ODONTECTOMI 2 GIGI (PERAWATAN 2 HARI)
KELAS PERAWATAN
KETERANGAN
Kamar Perawatan 3,376,000 2,618,000 2,342,000 1,300,000 850,000 344,000
Kamar Operasi 2,612,000 2,239,000 2,145,000 1,866,000 1,493,000 1,120,000
Dokter Anestesi 1,787,200 1,633,200 1,531,600 1,378,400 1,276,400 918,800
Paramedis 446,800 408,300 382,900 344,600 319,100 229,700
Obat - obatan 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000
Jumlah 16,623,000 14,914,500 14,163,500 12,268,000 11,062,500 8,842,500
4. ODONTECTOMI 4 GIGI (PERAWATAN 2 HARI)
KELAS PERAWATAN
KETERANGAN
Kamar Perawatan 3,376,000 2,618,000 2,342,000 1,300,000 850,000 344,000
Kamar Operasi 2,913,000 2,497,000 2,393,000 2,081,000 1,665,000 1,249,000
Dokter Anestesi 2,575,600 2,294,000 2,154,800 1,933,200 1,799,200 1,591,200
Paramedis 643,900 573,500 538,700 483,300 449,800 397,800
Obat - obatan 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000
Jumlah 19,880,500 17,650,500 16,748,500 14,563,500 13,195,000 11,493,000

5. TUMOR KISTA RAHANG KECIL (PERAWATAN 2 HARI)
KELAS PERAWATAN
KETERANGAN
Kamar Perawatan 3,376,000 2,618,000 2,342,000 1,300,000 850,000 344,000
Kamar Operasi 2,009,000 1,722,000 1,650,000 1,435,000 1,148,000 861,000
Dokter Anestesi 1,531,600 1,299,200 1,153,600 1,005,200 882,000 747,200
Paramedis 382,900 324,800 288,400 251,300 220,500 186,800
Obat - obatan 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000
Jumlah 15,061,500 13,145,000 12,251,000 10,437,500 9,238,500 7,940,000
6. TUMOR KISTA RAHANG BESAR (PERAWATAN 2 HARI)
KELAS PERAWATAN
KETERANGAN
Kamar Perawatan 3,376,000 2,618,000 2,342,000 1,300,000 850,000 344,000
Kamar Operasi 2,913,000 2,497,000 2,393,000 2,081,000 1,665,000 1,249,000
Dokter Anestesi 2,175,600 1,950,400 1,799,200 1,612,400 1,361,600 1,188,800
Paramedis 543,900 487,600 449,800 403,100 340,400 297,200
Obat - obatan 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000
Jumlah 18,380,500 16,362,000 15,415,000 13,360,500 11,554,000 9,984,000

7. FRAKTUR RAHANG 1 RAHANG BESAR (PERAWATAN 2 HARI)
KELAS PERAWATAN
KETERANGAN
Kamar Perawatan 3,376,000 2,618,000 2,342,000 1,300,000 850,000 344,000
Kamar Operasi 2,009,000 1,722,000 1,650,000 1,435,000 1,148,000 861,000
Dokter Anestesi 1,674,400 1,445,600 1,320,400 1,184,400 1,007,600 840,400
Paramedis 418,600 361,400 330,100 296,100 251,900 210,100
Obat - obatan 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000 3,933,000
Jumlah 15,597,000 13,694,000 12,876,500 11,109,500 9,709,500 8,289,500
8. TINDAKAN PERAWATAN GIGI DENGAN ANESTESI UMUM
GOLONGAN
KETERANGAN
KECIL SEDANG BESAR
Dokter Gigi 1,565,000 2,347,000 3,129,000
Dokter Anestesi 626,000 938,800 1,251,600
Sewa Kamar Operasi 861,000 1,120,000 1,249,000
Paramedis 156,500 234,700 312,900
Ruang Pulih 252,000 252,000 259,000
BHP Poli Sesuai Dengan Tarif Alat + Consumable
Alat + Obat 2,964,000 2,964,000 2,964,000
Jumlah 6,424,500 7,856,500 9,165,500
Keterangan :
1. Golongan Kecil 1-3 Tindakan
2. Golongan Sedang 4-10 Tindakan
3. Golongan Besar >10 Tindakan
V. PERKIRAAN TARIF PERSALINAN
V.1. PERSALINAN NORMAL (3 hari)

KELAS PERAWATAN
KOMPONEN
Perawatan Ibu 5,064,000 3,927,000 3,513,000 1,950,000 1,275,000 516,000
Perawatan Bayi 2,868,000 2,223,000 1,989,000 1,170,000 702,000 336,000
Kamar Bersalin 3,188,000 2,550,000 2,231,000 1,594,000 1,435,000 1,195,000
Dokter Obsgyn 4,680,000 4,194,000 3,768,000 2,796,000 1,958,000 1,320,000
Dokter Anak 702,000 629,100 565,200 419,400 293,700 198,000
Paramedis 468,000 419,400 376,800 279,600 195,800 132,000
Obat - obatan 3,151,000 3,151,000 3,151,000 3,151,000 3,026,000 3,026,000
JUMLAH 20,121,000 17,093,500 15,594,000 11,360,000 8,885,500 6,723,000
Keterangan :
* Tarif Yang Tertera diatas merupakan Tarif PERKIRAAN SEMENTARA dan TIDAK BERLAKU MUTLAK
SEWAKTU-WAKTU DAPAT BERUBAH KARENA KEBUTUHAN PELAYANAN MEDIS PASIEN.
1. BIAYA ADMINISTRASI 7 % DARI TOTAL KUITANSI, MAKSIMUM S/D Rp 1.200.000,-
* Pada Kasus khusus yang memerlukan kehadiran dokter anak subspesialis, maka jasa dokter anak
ditambah 20%
* BILA KONDISI TIDAK NORMAL/ TIDAK BIASA, DAPAT LEBIH TINGGI DARI JUMLAH TERSEBUT, ANTARA LAIN KONDISI :
a. GEMELI
Kembar Dua : Obsgyn ( G1: 100%, G2: + 50 %), dokter anak & visite + 100 %,
RS (sewa kamar bersalin, paramedis dan obat-obatan): + 20 %.
Kembar Tiga : Obsgyn ( G1: 100%, G2: + 50 %, G3: + 25 %), dokter anak & visite + 100 %,
b. INDUKSI : Sewa kamar bersalin, dokter obsgyn, paramedis, dan obat-obatan ditambah 10 %.
c. VACUM DAN LETAK SUNGSANG :
Sewa kamar bersalin, dokter obsgyn, paramedis dan obat-obatan ditambah 10 %.
Jika dokter anak hadir dalam tindakan, maka tarif dokter anak + visite sama dengan biaya pada SC.
V.2. PERSALINAN DENGAN ILA (4 hari)
KELAS PERAWATAN
KOMPONEN
Perawatan Ibu 6,752,000 5,236,000 4,684,000 2,600,000 1,700,000 688,000
Perawatan Bayi 3,824,000 2,964,000 2,652,000 1,560,000 936,000 448,000
Kamar Bersalin 3,188,000 2,550,000 2,231,000 1,594,000 1,435,000 1,195,000
Dokter Obsgyn 4,786,000 4,263,000 3,872,000 2,945,000 2,177,000 1,567,000
Dokter Anestesi 1,914,400 1,705,200 1,548,800 1,178,000 870,800 626,800
Dokter Anak 717,900 639,450 580,800 441,750 326,550 235,050
Paramedis 478,600 426,300 387,200 294,500 217,700 156,700
Obat - obatan 3,747,000 3,747,000 3,747,000 3,747,000 3,747,000 3,747,000
JUMLAH 25,407,900 21,530,950 19,702,800 14,360,250 11,410,050 8,663,550
Keterangan :
ditambah 20%
a. GEMELI
V.3. SECTIO CAESARIA (5 hari)
KELAS PERAWATAN
KOMPONEN
Perawatan Ibu 8,440,000 6,545,000 5,855,000 3,250,000 2,125,000 860,000
Perawatan Bayi 4,780,000 3,705,000 3,315,000 1,950,000 1,170,000 560,000
Kamar Operasi 5,826,000 4,994,000 4,785,000 4,162,000 3,329,000 2,497,000
Dokter Obsgyn 5,299,000 4,889,000 4,408,000 3,929,000 3,153,000 2,240,000
Dokter Asisten 1,324,750 1,222,250 1,102,000 982,250 788,250 560,000
Dokter Anestesi 2,119,600 1,955,600 1,763,200 1,571,600 1,261,200 896,000
Dokter Anak 794,850 733,350 661,200 589,350 472,950 336,000
Paramedis 529,900 488,900 440,800 392,900 315,300 224,000
Obat - obatan 6,242,000 6,242,000 6,242,000 6,242,000 6,242,000 6,242,000
JUMLAH 35,356,100 30,775,100 28,572,200 23,069,100 18,856,700 14,415,000
Keterangan :
ditambah 20%
a. GEMELI
V.4. PERSALINAN OLEH BIDAN (3 hari)
KELAS PERAWATAN
KOMPONEN
DELUXE ANGGREK MAWAR MELATI
Perawatan Ibu 3,513,000 1,950,000 1,275,000 930,000 516,000
Perawatan Bayi 1,989,000 1,170,000 702,000 528,000 336,000
Kamar Bersalin 2,231,000 1,594,000 1,435,000 1,266,000 1,195,000
Bidan 732,000 641,000 572,000 572,000 511,000
Dokter Anak 566,000 465,000 460,000 460,000 377,000
Paramedis 377,000 281,000 205,000 205,000 139,000
Obat - obatan 3,329,000 3,329,000 3,329,000 3,329,000 3,329,000
JUMLAH 12,737,000 9,430,000 7,978,000 7,290,000 6,403,000
Keterangan :
ditambah 20%
a. GEMELI
VI.A TARIF PEMERIKSAAN DENGAN ALAT DAN SEWA ALAT
No. ALAT TARIF
1 Aeroneb (Filter Nebulizer) 140,000

2 Blue Light 180,000
3 Bubble C- Pap
a. Reusable 550,000
b. Disposable / diluar alat sirkuit 270,000
4 CTG :
a. CTG 1 kali 130,000
b. CTG 2 kali 260,000
c. CTG 3 kali 390,000
d.CTG > 3 kali/hari 410,000
5 Couve 140,000
6 Defibrilator 345,000
7 Echocardiography 900,000
8 EKG 150,000
9 Konsul baca EKG 60,000
10 EEG 660,000
11 Infuse Pump :
a. Infuse Pump per jam 70,000
b. Infuse Pump > 4 jam 250,000
12 Laparaskopi untuk tindakan medis :
a. Tindakan medis operatif Golongan I dan II 1,925,000
b. Tindakan medis operatif Golongan III dan IV 3,850,000
13 Inkubator 320,000
14 Laryngoscope Direct 290,000
15 Monitor 675,000
16 Monitor Perina (Level 2) 130,000
17 Nebulizer 140,000
18 Oksigen (O2) :
a. Oksigen (per-jam) 75,000
b. Oksigen (perhari/24 jam) 300,000
19 Pompa susu elektrik 45,000
20 Pulse oxymetri 157,000
21 Syringe pump 168,000
22 USG SIS 800,000
23 EMG 550,000
24 USG Non Kebidanan :
a. USG Kepala 3D + print (maks.3 lbr) 350,000
b. USG Leher 3D + print (maks.3 lbr) 525,000
No. ALAT TARIF
c. USG Thorax 3D + print (maks.3 lbr) 525,000

d. USG Jantung + print (maks.3 lbr) 400,000
e. USG Mammae 3D + print (maks.3 lbr) 350,000
f. USG Abdomen + print (maks.3 lbr) 700,000
g. USG Testis 3D + print (maks.3 lbr) 550,000
h. USG Ekstremitas (3D) + print (maks.3 lbr) 600,000
i. USG Kulit + print (maks.3 lbr) 310,000
j. USG Ginjal/prostat 700,000
k. USG Hepatobiler 650,000
l. USG Tyroid 715,000
m. USG Appendix 650,000
n. USG Paraorta & Illiaca 650,000
o. USG Soft Tissue Abdomen 650,000
p. USG Soft Tissue Leher 650,000
q. USG Dopler 750,000
r. USG 2D (Alat 3D/4D) 250,000
s. USG 2D (Alat 2D) 200,000
25 USG Kebidanan :
a. USG 2D (Alat 3D) + print (maks.3 lbr) 675,000
b. USG 3D/ 4D + print (maks.3 lbr) 965,000
c. USG Kebidanan (Alat 2D) + print (maks.3 lbr) 285,000
d. USG 3D Non Feto 525,000
e. USG Transvaginal (Alat 3D) + print (maks.3 lbr) 480,000
f. Penambahan Print USG / lembar 30,000
h. USG Transvaginal (Alat 2D) + print (maks.3 lbr) 430,000
26 Ventilator + Compres 840,000
27 Matras Anti Decubitus 135,000
28 Set Umbilical 178,000
29 Set Long Line 178,000
30 Set Vena Sectie 217,000
31 Histereskopi 508,000
32 DC Shock 250,000
LAIN-LAIN
1 N2O 234,000
2 Udara Tekan
a. Penggunaan (per jam) 82,000
b. Penggunaan (per hari/ 24 jam) 971,000
3 Fess 715,000
4 THT (septoplasty, TA) 429,000
5 URS & Lithoclast 1,947,000
No. ALAT TARIF
6 Spirometri 120,000
7 BMI Scale 90,000
8 Ergocycle 148,000
9 Disposable / diluar alat sirkuit 324,000
10 Saw 261,000
11 N2O (Per Jam) 234,000
12 Capnograph 200,000
13 AV Shunt 216,000
14 Treadmill
- Tanpa EKG 756,000
- Dengan EKG 867,000
15 OAE/ Alat Skrining Pendengaran 120,000
16 Musculoskletal 75,000
17 Radio Frekuensi 2,600,000
VI.B TARIF INSTRUMEN ALAT (TINDAKAN)

(*Tarif dapat berubah sewaktu-waktu dalam 1 tahun berjalan)
No. ALAT TARIF
1 BEDAH ONKOLOGI
Instrumen Onkologi 1,000,000
2 BEDAH UROLOGI
a. Instrumen Urologi 4,000,000
b. Instrumen ESWL 8,000,000
3 BEDAH PLASTIK
Instrumen Plastik 2,500,000
4 BEDAH ORTHOPEDI
a. Instrumen Orthopedi 3,500,000
b. Paket TKR/THR 33,000,000
5 BEDAH SYARAF
Instrumen Craniotomy 6,250,000
6 BEDAH THT
Instrumen THT 3,000,000
7 BEDAH MATA
a. Instrumen Mata PACO 3,500,000
b. Instrumen Mata ECCE 1,500,000
8 BEDAH VASUKULER
Instrumen AV Shunt/ CDL 800,000
No. ALAT TARIF
9 BEDAH JANTUNG
a. - PCA (Mini Cath Lab) 7,500,000
- PCA (Fix Cath Lab) 17,500,000
b. - CORANGIOGRAFI (instrumen tipe 1) 2,000,000
- CORANGIOGRAFI (instrumen tipe 2) 5,500,000
10 BEDAH LAIN-LAIN
A. LO
a. APP 8,000,000
b. CHOLE 12,000,000
c. - HEMOLOG (instrumen tipe 1) 613,000
- HEMOLOG (instrumen tipe 2) 10,000,000
d. COLON 10,000,000
e. KEBIDANAN 10,000,000
B. Tur-Prostat (Paket Instrumenr Light Source) 1,521,000
C. Uretroscopy (Instrument + Light Source) 662,000
D. Cytoscopy (Instrument + Light Source) 662,000
E. Light Source Non Paket 199,000
VII. TARIF LABORATORIUM
(*Tarif dapat berubah sewaktu-waktu dalam 1 tahun berjalan)
VII.1. Laboratorium Patologi Klinik

No. ALAT TARIF
A. HEMATOLOGI
1 Rutin 1 (Hb,Ht,Leko,Trombo) 125,000
2 Rutin 2 (Hb,Leko,LED,Diff) 140,000
3 Darah Tepi (Hb,Leko,Ht,Trombo,Diff) 140,000
4 Darah Lengkap (Rutin 2, Ht, Eri, Trombo, Nilai Eri) 180,000
5 Retikilosit 135,000
6 Hitung Eosinofil 140,000
7 Morfologi Darah Tepi 250,000
8 Ferritin 410,000
9 Hemoglobin 85,000
10 Lekosit 85,000
11 Trombosit 85,000
12 LED 85,000
13 MCV,MCH,MCHC 85,000
14 Golongan darah 85,000
15 Sel LE 172,000
16 LE Test 200,000
17 G6PD Neonatus 160,000
18 G6PD Ery / Serum 330,000
19 Serum Iron / SI 200,000
20 TIBC 310,000
21 Tranferin 425,000
22 Vit B12 1,225,000
23 Hematokrit 65,000
24 Eritrosit 65,000
25 Hitung Jenis 65,000
26 Asam Folat 1,050,000
27 DNA Analisa 2,050,000
28 Hb Analisa / Elektroforesa 570,000
29 CD4 450,000
30 CD8 450,000
31 Comb's Test 550,000
B. KOAGULASI
No. ALAT TARIF
33 Masa Pembekuan 65,000

34 Masa Perdarahan 65,000
35 Masa Protrombin 180,000
36 APTT 180,000
37 Fibrinogen 350,000
38 D-dimer 500,000
39 INR 180,000
40 Masa Trombin 450,000
41 AT III 610,000
42 Trombotest Owren 320,000
43 Agregasi Trombosit 450,000
44 Viscositas Darah 330,000
45 Viscositas Plasma 330,000
46 Faktor VIII 720,000
47 Faktor IX 720,000
48 Faktor Von Wallerbrand 1,930,000
C. KIMIA
49 Protein/alb/globulin 135,000
50 Protein Total 95,000
51 Albumin 95,000
52 Bilirubin total/direct 175,000
53 Bilirubin Total 95,000
54 Bilirubin direct 95,000
55 Bilirubin bayi 95,000
56 SGOT 95,000
57 SGPT 95,000
58 Alkali Fosfatase 105,000
59 Gamma GT 135,000
60 CHE 270,000
61 GLDH 710,000
62 HBA1C 320,000
63 C Peptide 550,000
64 Insulin 520,000
65 Insulin Antibodi 1,975,000
66 Fruktosamin 955,000
67 ICA 2,445,000
68 Ureum 95,000
69 Kreatinin 95,000
No. ALAT TARIF
70 Asam Urat 95,000

71 Cholesterol total 95,000
72 HDL Cholesterol 85,000
73 LDL Cholesterol 145,000
74 LDL Direk 145,000
75 Triglyserida 95,000
76 Total Lipid 185,000
77 LP (a) 530,000
78 APO A1 445,000
79 APO B 339,000
80 LDH 185,000
81 HBDH 130,000
82 CPK 260,000
83 CK-MB 310,000
84 hs-CRP 475,000
85 Fosfor 130,000
86 Magnesium 130,000
87 Calcium 130,000
88 Fosfatase Asam 185,000
89 Fosfatase Asam Frostatic 185,000
90 Amilase Darah 335,000
91 Lipase Darah 335,000
92 Amonia Darah 605,000
93 Lactat 365,000
94 Calcium ion 700,000
95 Paket Na,K,Cl 380,000
*96 Astrup + NaKCl / Analisa Gas Darah 410,000
97 Globulin 68,000
98 Creatin Clearence 95,000
99 Fosfor Anorganik 95,000
100 Berat Jenis 68,000
101 Gula Darah Puasa 68,000
102 Gula Darah PP 2 Jam 68,000
103 Gula Darah Sewaktu 68,000
104 Tes Toleransi Glukosa 250,000
105 Kurva Harian Glukosa 200,000
D. SEROLOGI IMUNOLOGI
106 HBsAg 200,000
No. ALAT TARIF
107 Anti HBs 255,000

108 Anti HCV 635,000
109 Anti HCV Total Rapid 335,000
110 Anti HBc Total 450,000
111 Anti HBc IgM 795,000
112 Anti Hbe 755,000
113 HBeAg 550,000
*114 HBV DNA 2,500,000
115 Anti HCV IgM 1,450,000
116 Anti HAV 650,000
117 Anti HAV IgM 550,000
118 CRP Kwantitatif 280,000
119 ACA IgG 650,000
120 ACA IgM 650,000
121 Dengue IgG IgM 550,000
122 TB IgG 265,000
123 Anti TB IgG 265,000
*124 VDRL 170,000
125 TPHA 200,000
126 Widal 200,000
127 Anti Salmonella IgM 360,000
128 Procalcitonin 1,150,000
129 IgE Total 470,000
130 Toxoplasma IgG 350,000
131 Anti Toxoplasma IgG 350,000
132 Toxoplasma IgM 350,000
133 Anti Toxoplasma IgM 350,000
134 Rubella IgG 350,000
135 Anti Rubella IgG 350,000
136 Rubella IgM 450,000
137 Anti Rubella IgM 450,000
138 CMV IgG 370,000
139 CMV IgM 450,000
140 Anti HSV 1 IgG 427,000
141 Anti HSV 1 IgM 427,000
142 Anti HSV 2 IgG 427,000
143 Anti HSV 2 IgM 427,000
*144 Aviditas CMV IgG 689,000
No. ALAT TARIF
*145 Aviditas Toxoplasma IgG 689,000

146 Mikoplasma IgG 1,600,000
147 Mikoplasma IgM 1,600,000
148 Klamidia IgG 689,000
149 Klamidia IgM 689,000
150 RF 320,000
151 Helicobacter IgG 650,000
152 Helicobacter IgM 720,000
153 Anti HIV 550,000
154 Anti HIV konfirmasi 950,000
155 IgG 675,000
156 IgA 675,000
157 IgM 656,000
158 C3 Komplemen 656,000
159 C4 Komplemen 656,000
160 ANA 775,000
161 Anti Ds DNA Ncx 656,000
162 ACA IgA 1,995,000
163 PCR TB 745,000
164 PAP TB 300,000
165 PCR Salmonella 725,000
166 IgE Atopy 1,900,000
167 IgE Rast Susu Sapi 656,000
168 IgE Rast Susu Soya 656,000
169 IgE Rast Susu 656,000
170 IgE Rast Daging Sapi 656,000
171 IgE Rast Daging Ayam 656,000
172 IgE Rast Daging Kambing 916,000
173 IgE Rast Kuning Telur 656,000
174 IgE Rast Putih Telur 656,000
175 IgE Rast Lobster 920,000
176 IgE Rast Kerang 656,000
177 IgE Rast Debu Rumah 656,000
178 IgE Rast Bulu Ayam 664,000
179 IgE Rast Kapuk 656,000
180 IgE Rast Epitel Anjing 664,000
181 IgE Rast Epitel Kucing 664,000
182 IgE Rast Epitel Tikus 664,000
No. ALAT TARIF
183 IgE Rast Kecoa 656,000

184 IgE Rast Coklat 656,000
185 IgE Rast Ikan 656,000
186 IgE Rast Jamur 664,000
187 IgE Rast Kacang 656,000
188 IgE Rast Udang 656,000
189 IgE Rast Kepiting 656,000
190 IgE Rast Gandum 656,000
191 IgE Rast Mucor 656,000
192 IgE Rast Kotoran Burung 656,000
*193 Analisa Kromosom 2,620,000
194 Anti CCP IgG 1,045,000
195 Antibodi Leptospira 120,000
196 Anti HBc Total 425,000
197 Anti Klamidia lgG 725,000
198 Anti Klamidia lgM 725,000
E. HORMON
199 LH 425,000
200 FSH 425,000
201 Prolactin 425,000
202 Testosteron 530,000
203 Free Testosteron Index 1,965,000
204 Free Testosteron 1,965,000
205 Progesteron 556,000
206 17 – OH Progesteron (LC-MS/MS) 1,020,000
207 TSHs 375,000
208 TSH Neonatus 180,000
209 T3 449,000
210 T4 449,000
211 FTI 459,000
212 Ftee T4 459,000
213 Free T3 549,000
214 TSHs 375,000
215 Tiroglobulin 852,000
216 Anti Tiroglobulin 625,000
217 T3 Up Take 701,000
218 Grow Hormon 601,000
219 Cortisol 550,000
No. ALAT TARIF
220 Cortisol Free 4,350,000

221 AMH (Anti Mullerian Hormone) 760,000
222 PTH intact 895,000
223 Tiroxin Binding Globulin 2,850,000
224 Beta HCG 630,000
F. PETANDA TUMOR
225 AFP 430,000
226 MS AFP 450,000
227 CEA 420,000
228 NSE 1,000,000
229 Ca 15 - 3 800,000
230 Ca 19 - 9 920,000
231 Ca 72 – 4 1,020,000
232 PSA 920,000
233 Free PSA 1,198,000
234 SCC 800,000
235 PAP 620,000
236 Ca72-4 1,330,000
237 ACTH 3,395,000
238 Ca 125 865,000
G. KULTUR RESISTENSI
239 Sekret Vagina 538,000
240 Darah 735,000
241 Urine 596,000
242 Faeces 596,000
243 Sputum 596,000
244 Gal Cultur 538,000
245 Pus / Sekret 596,000
246 Resistensi Jamur 1,000,000
247 Pewarna Diphteri 45,000
248 Diphteri 125,000
H. URINALISA
249 Urine lengkap 75,000
250 Urine Rutin 75,000
251 Urine Rutin Flow Cytometri 75,000
252 Protein Kwantitatif 235,000
253 Protein Total 235,000
254 Natrium 148,000
No. ALAT TARIF
255 Kalium 148,000

256 Chlorida 148,000
257 Magnesium 138,000
258 Kalsium 138,000
259 Fosfor 138,000
260 Micro Albumin 225,000
261 Barbiturat 215,000
262 Benzodiazepam 215,000
263 Coccain 215,000
264 Canabis 215,000
265 Amfetamin 215,000
266 Keton 25,000
267 Bilirubin 25,000
268 PH Urine 25,000
269 Glukosa Urine 25,000
I. FAECES
270 Faeces lengkap 155,000
271 Faeces Analisa 285,000
272 Faeces Rutin 100,000
273 Darah samar 155,000
274 APT Test 150,000
J. SPERMA
275 Sperma 430,000
276 Washing Sperma 530,000
277 Analisa Batu Ginjal 265,000
278 Analisa Batu Empedu 265,000
279 Rotavirus Antigen 330,000
280 Analisa Sperma 430,000
VII.2. Laboratorium Patologi Anatomi
No. ALAT TARIF
A. SITOLOGI
1 Papsmear 220,000
2 Papsmear LB Prep (Liquid) 480,000
3 Sitologi Cairan Tubuh 450,000
No. ALAT TARIF
B. PATOLOGI ANATOMI
1 Golongan A 450,000
2 Golongan B 750,000
3 Golongan C 900,000
4 Patologi Anatomi VC (Potong Beku) 2,000,000
5 Pemeriksaan Hispatologi
a. PA Jaringan Kecil < 5 cm 380,000
b. PA Jaringan Besar > 5 cm 680,000
6 Pemeriksaan Sitologi Exvoliatif
a. Papsmears Konvensional/ Biasa 200,000
b. Papsmears Liquid Base/ Bethesda 450,000
7 Pemeriksaan Sitologi Sputum/Pleura/Urine 350,000
8 Pemeriksaan Sitologi Aspirasi
a. FNAB + Tindakan 850,000
b. FNAB + Tindakan dgn Guilding 1,300,000
c. FNAB Kiriman Slide 450,000
VII.3. Pelayanan Darah
No. ALAT TARIF
1 Labu darah* 480,000

2 Screening darah 780,000
3 Labu darah NAT* 950,000
*Tarif dapat berubah sewaktu-waktu dalam 1 tahun berjalan
*Bila ada kenaikan di PMI, harga disesuaikan
VII.4. Lain – lain
No. ALAT TARIF
1 Tes Kehamilan 138,000

2 Cairan tubuh
a. Hitung jumlah sel 60,000
b. Hitung jenis sel 70,000
c. Lekosit Esterase (LEA) 30,000
No. ALAT TARIF
3 Uji Silang
a. Alkali Foltase 65,000
b. Dangue Rapid Test 225,000
c. Dangue NS1 335,000
d. Estradiol 445,000
4 Protein 25,000
5 Pewarnaan BTA 1,2,3 185,000
6 Pewarnaan Gram 85,000
7 Limfosit Plasma Biru 100,000
8 Crosstmach 190,000
9 Tubex TF 285,000
10 Osmolalitas Darah 285,000
11 Osmolalitas Urine 285,000
12 ASTO 285,000
13 BMP 435,000
14 Limfosit Subset 665,000
15 Kultur + Resist Cairan 665,000
16 KTR LCS 665,000
17 KTR Pleura 665,000
18 RTR Swab 665,000
19 KTR Jaringan 665,000
20 KTR Alat 665,000
21 Kultur Aerob 755,000
22 Kultur An Aeob 755,000
23 KTR BTR 755,000
24 BCR ABL 1,902,000
25 HCV RNA 6,262,000
26 Lupus Antikoagulan 781,000
27 Vitamin D25 OH Total 825,000
28 Anti TPO 1,109,000
29 Immunofenotypme 1,223,000
30 Ana Profile 1,680,000
31 Jak-2 1,766,000
32 Retikulosit 125,000
*33 Troponin I 485,000
34 Troponin T 485,000
35 Vitamin D 385,000
36 Vitamin A & E 585,000
No. ALAT TARIF
37 IgM Salmonella (Tubex) 275,000

38 B2GPI IgG 795,000
39 Helicobacter Antigen 375,000
40 Protein Elektroforesa 295,000
41 IGRA 985,000
42 leukimia Phenotyping 1,015,000
43 IT Ratio 65,000
44 Malaria (Mikroskopik) 115,000
45 Tromboelastografi 795,000
46 Anti Chikungunya IgM 335,000
47 IPF 135,000
48 Bone Marrow 385,000
49 Rhematoid Faktor 385,000
50 Sekret Mata 85,000
51 Sputum BTA 85,000
52 Imunohistokimia 685,000
53 BTA (Mikroskopik) 115,000
54 Eosinofil Absolut 115,000
55 Adenosin Diaminase (ADA) 630,000
56 Albumin Creatinine Ratio (ACR) 343,000
57 Analisa Cairan Acites 470,000
58 Analisa Cairan LCS 568,000
59 Anti Trombin III (ATIII) 921,000
60 Antibodi Trombosit 487,000
61 Cholesterase 261,000
62 Cystatin C 334,000
63 Filaria Slide 172,000
64 Gall Cultur 538,000
65 HE4 580,000
66 ICT Malaria 200,000
67 ICU Lenkap 1,010,000
68 K&R LCS 512,000
69 K&R Secret 512,000
70 Kultur BTA (Cairan Pleura) 649,000
71 Lactat Darah 75,000
72 Masa Protombin 175,000
73 Metamphetamin 200,000
74 Nilai MC 48,000
No. ALAT TARIF
75 Nitrit 25,000
76 Nonne 40,000
77 Pandy 40,000
78 RH Faktor 25,000
79 Rumpel Leede 25,000
80 Transferin 445,000
81 Urobilinogen 25,000
82 RDW 40,000
83 Prenatal Baru 650,000
84 N2O 350,000
VIII. TARIF RADIOLOGI
VIII.1. Radiologi Diagnostik

TARIF
No. 0.79 "
NON CR CR
A. KEPALA
1 Cranium 262,000 292,000
2 Sella Tursica 265,000 295,000
3 Orbita 265,000 295,000
4 Os Nasal 265,000 295,000
5 SPN 1 Posisi 233,000 263,000
6 SPN 2 Posisi 278,000 308,000
7 SPN 3 Posisi 399,000 429,000
8 Mastoid 259,000 289,000
9 Mandibula 259,000 289,000
10 TMJ ( Temporo Mardibular Joint ) 259,000 289,000
11 TMJ Open & Close Mouth 502,000 532,000
12 Dental 140,000 170,000
13 Panoramic 259,000 289,000
14 Chepalo 232,000 262,000
B. THORAX
15 Thorax AP / PA 248,000 278,000
16 Thorax Lat 248,000 278,000
17 Thorax AP / Iat 369,000 399,000
18 Thorax RLD 259,000 289,000
19 Thorax Anak 259,000 289,000
20 Thorax Top Lordotik 259,000 289,000
21 Thoraco Abdomen 518,000 548,000
22 Cor Analisa 409,000 439,000
24 Cor Analisa dgn Barium 231,000 261,000
25 Thorax Tes Kesehatan 231,000 261,000
26 Costae 247,000 277,000
27 Shoulder 1 sisi 259,000 289,000
28 Shoulder Bilateral 349,000 379,000
29 Clavicula 1 sisi 241,000 271,000
30 Clavicula Bilateral 299,000 329,000
31 Scapula 1 sisi 240,000 270,000
32 Scapula Bilateral 350,000 380,000
TARIF
No. 0.79 "
NON CR CR
C. COLUMNA VERTEBRAE
33 Vert. Cervical Ap/Lat 303,000 333,000
34 Vert. Cervical Ap/Lat/Obl 482,000 512,000
35 Vert. Thoraco Lumbal Ap/Lat 299,000 329,000
36 Vert. Thoraco Lumbal Ap/Lat/Obl 490,000 520,000
37 Vert. Lumbo Sacral Ap/Lat 299,000 329,000
38 Vert. Lumbo Sacral Ap/Lat/Obl 490,000 520,000
39 Vert. Thoracal AP/Lat 492,000 522,000
40 Vert. Thoracal AP/Lat/Obl 462,000 492,000
41 Vert. Thoracal AP/Lat (2 sisi) 462,000 492,000
42 Vert. Lumbo Sacral Ap/Lat (2 sisi) 462,000 492,000
43 Vert. Lumbo Sacral AP/Lat/Obl (2 sisi) 492,000 522,000
44 Lumbal AP/Lat 311,000 341,000
45 Lumbal AP/Lat/Obl 490,000 520,000
46 Sacral AP/Lat 299,000 329,000
47 Sacral AP/Lat/Obl 490,000 520,000
48 Cocygeus Ap/Lat 299,000 329,000
49 Coxae AP 259,000 289,000
50 Coxae AP/Lat 370,000 400,000
51 Coxae AP/Lat/Obl 490,000 520,000
52 Pelvis AP 298,000 328,000
53 Pelvis AP/Lat 367,000 397,000
54 Pelvis AP/Lat/Obl 476,000 506,000
55 Pelvis dengan Sonde 696,000 726,000
D. EKSTERMITAS ATAS
56 Digiti AP/Iat 259,000 289,000
57 Digiti Bilateral 388,000 418,000
58 Manus AP/Iat 259,000 289,000
59 Manus Bilateral 388,000 418,000
60 BONE AGE 259,000 289,000
61 Wrist Joint AP/Iat 259,000 289,000
62 Wrist Joint Bilateral 388,000 418,000
63 Antebranchi AP/Iat 259,000 289,000
64 Antebranchi Bilateral 388,000 418,000
65 Humerus AP/Iat 259,000 289,000
66 Humerus Bilateral 388,000 418,000
TARIF
No. 0.79 "
NON CR CR
67 Artic Cubiti AP/Iat 259,000 289,000
68 Artic Cubiti Bilateral 388,000 418,000
69 Clavicula 228,000 258,000
70 Clavicula Bilateral 284,000 314,000
71 Scapula 228,000 258,000
72 Scapula Bilateral 284,000 314,000
73 Shoulder 242,000 272,000
74 Shoulder Bilateral 323,000 353,000
75 Elbow 242,000 272,000
76 Elbow Bilateral 363,000 393,000
E. EKSTERMITAS BAWAH
77 Femur AP/Iat 259,000 289,000
78 Femur Bilateral 458,000 488,000
79 Art Genu AP/Iat 259,000 289,000
80 Art Genu Bilateral 388,000 418,000
81 Cruris AP/Iat 259,000 289,000
82 Cruris Bilateral 388,000 418,000
83 Pedis AP/Iat 259,000 289,000
84 Pedis Bilateral 388,000 418,000
85 Ankle Ap/Iat 259,000 289,000
86 Ankle Bilateral 388,000 418,000
87 Calcaneus Ap/Lat 259,000 289,000
88 Calcaneus Bilateral 388,000 418,000
F. ABDOMEN
89 Abdomen / BNO 259,000 289,000
90 Abdomen 2 Posisi 448,000 478,000
91 Abdomen 3 Posisi 527,000 557,000
92 Atresiani 269,000 299,000
93 BNO - IVP 1,986,000 2,016,000
94 HSG 1,601,000 1,631,000
95 Cystogarafi 888,000 918,000
96 Urethrografi 888,000 918,000
97 Urethrocystografi 1,173,000 1,203,000
98 Fistulografi 888,000 918,000
99 Appendicogram 605,000 635,000
100 Oesophagografi 605,000 635,000
TARIF
No. 0.79 "
NON CR CR
101 Barium Enema / Colon in Loop 1,242,000 1,272,000
G. MOBILE X-RAY ( ICU )
102 Thorax AP 278,000 308,000
103 Thorax Lateral 278,000 308,000
104 Thorax AP/Lateral 388,000 418,000
105 Thorax RLD 289,000 319,000
106 Abdomen / BNO 299,000 329,000
107 Abdomen 2 Posisi 477,000 507,000
108 Abdomen 3 Posisi 527,000 557,000
109 Creanium 329,000 359,000
110 Thorak Top Lordotik 299,000 329,000
111 Thoraco Abdomen 527,000 557,000
112 Penambahan film 99,000 129,000
113 Elbow joint mobil X-Ray 221,000 251,000
114 Baby Gram 435,000 465,000
H. CT SCAN
116 CT Brain 1,620,000
117 CT Brain Trauma 1,750,000
118 CT Brain Kontras 2,858,000
119 CT Sellatursica 2,527,000
120 CT Sellatursica Kontras 3,358,000
121 CT Orbita 2,372,000
122 CT Orbita Kontras 4,044,000
123 CT Mastoid 2,696,000
124 CT Mastoid Kontras 4,129,000
125 CT Sinus Paransalis Coronal 2,197,000
126 CT Nasopharynx 2,696,000
127 CT Nasopharynx Kontras 3,785,000
128 CT Larynx 2,696,000
129 CT Larynx Kontras 3,958,000
130 CT Carnival Soft Tissue 2,142,000
131 CT Cervical Mielo CT 4,096,000
132 CT Thoracal Mielo CT 5,186,000
133 CT Thorax 2,592,000
134 CT Thorax Kontras 4,215,000
135 CT Partial V Thoracal 1,906,000
TARIF
No. 0.79 "
NON CR CR
136 CT Upper Abdominal 2,376,000
137 CT Upper Abdominal Kontras 3,990,000
138 CT Upper extremity 2,592,000
139 CT Upper extremity Kontras 3,990,000
140 CT Lower Abdominal 2,376,000
141 CT Lower Abdominal Kontras 3,990,000
142 CT Whole Abdominal 4,347,000
143 CT Whole Abdominal Kontras 5,537,000
144 CT Whole V Cervical 2,372,000
145 CT Whole V Cervical Kontras 4,044,000
146 CT Whole V Thoracal 2,866,000
147 CT Whole V Thoracal Kontras 5,001,000
148 CT Whole V Lumbal 2,595,000
149 CT Lumbal Mielo CT 3,805,000
150 CT Lower extremity 2,592,000
151 CT Lower extremity Kontras 3,990,000
152 CT Thyroid 2,696,000
153 CT Thyroid Kontras 3,785,000
154 CT Maxfell Facial 2,696,000
155 CT Maxfell Facial Kontras 3,785,000
156 CT Oesophagus 2,359,000
157 CT Orohypopharynx 2,696,000
158 CT Orohypopharynx Kontras 3,958,000
159 CT V. Sacro Coccygeal 2,451,000
160 CT Partial V Cervical 1,788,000
161 CT Partial V Lumbal 1,788,000
162 CT Mandibula 2,436,000
163 CT Mandibula Kontras 3,510,000
164 CT Sella Turcia 1,906,000
165 CT Sinus Paranasal 2,216,000
166 CT Sinus Paranasal Kontras 2,864,000
167 CT Whole Lumbal 2,866,000
168 CT Whole Lumbal Kontras 3,668,000
169 CT Abdomen 3 Fase 5,022,000
170 CT 3D Facial 3,564,000
171 CT Urologi 2,592,000
TARIF
No. 0.79 "
NON CR CR
172 CT Urologi Kontras 3,888,000
173 CT Angio Aorta Abdominalis 4,752,000
174 CT Angio Aorta Thoracalis 3,505,000
175 CT 3D Extrimitas 3,505,000
176 CT Whole Spine 3D 6,178,000
177 CT Soft Tissue Leher Kontras 5,589,000
178 CT Thorax + Abdomen 7,290,000
179 CT Thoracal 3D 5,119,000
180 CT Angio Runn Off (Tungkai) 5,925,000
181 CT Angio Aorta Abdominalis + Tungkai 6,739,000
182 CT Angio Kepala + Leher 5,589,000
183 CTA Kepala 4,752,000
I. USG
184 USG Abdomen 700,000
185 USG Ginjal 700,000
186 USG Mammo 715,000
187 USG Thyroid 715,000
188 USG Testis 550,000
189 USG Doppler Vaskuler 750,000
190 USG Abdomen / Gyn Doppler 750,000
191 USG 4D Gemeli 1,250,000
192 USG Jaringan Lunak 900,000
193 USG Muculoskeletal 900,000
194 USG Thorax 900,000
195 USG Prostat 900,000
J. MRI
192 MRI Brain 3,819,000
193 MRI+MRA Brain (VASKULER) 4,779,000
194 MRI Brain Kontras 4,779,000
195 MRI+MRA Brain (VASKULER) Kontras 5,741,000
196 MRI Brain Spektroskopy 4,011,000
197 MRI Upper Abdominal 3,780,000
198 MRI Upper Abdominal Kontras 4,942,000
199 MRI Whole Abdomen 3,780,000
200 MRI Whole Abdomen Kontras 5,308,000
201 MRI Shoulder 3,819,000
TARIF
No. 0.79 "
NON CR CR
202 MRI Shoulder Kontras 5,162,000
203 MRI Elbow 3,819,000
204 MRI Elbow Kontras 5,162,000
205 MRI Mandibula 3,819,000
206 MRI Mandibula Kontras 5,162,000
207 MRI Wirst Joint 3,819,000
208 MRI Wirst Joint Kontras 5,162,000
209 MRI HIP 3,819,000
210 MRI HIP KONTRAS 5,162,000
211 MRI Nasopharynx 3,819,000
212 MRI Nasopharynx Kontras 5,343,000
213 MRI Sella Tursica 3,819,000
214 MRI Sella Tursica Kontras 4,779,000
215 MRI Sinus Paranasal 3,819,000
216 MRI Sinus Paranasal Kontras 5,162,000
217 MRI Thorax 3,819,000
218 MRI Thorax Kontras 5,162,000
219 MRI Thyroid 3,819,000
220 MRI Thyroid Kontras 5,162,000
221 MRI Cervical 3,819,000
222 MRI Cervical Kontras 5,162,000
223 MRI Lidah 3,819,000
224 MRI Lidah Kontras 5,162,000
225 MRI Pelvis 3,819,000
226 MRI Pelvis Kontras 5,162,000
227 MRI Thoracal 3,819,000
228 MRI Thoracal Kontras 5,162,000
229 MRI Lumbal 3,819,000
230 MRI Lumbal Kontras 5,162,000
231 MRI Larynx 3,819,000
232 MRI Larynx Kontras 5,162,000
233 MRI Orbita 3,819,000
234 MRI Orbita Kontras 5,162,000
235 MRI Oropharyinx 3,819,000
236 MRI Oropharyinx Kontras 5,162,000
237 MRI Lumbosacral 3,819,000
TARIF
No. 0.79 "
NON CR CR
238 MRI Lumbosacral Kontras 5,162,000
239 MRI Urologi/ Urografy 3,658,000
240 MRI Urologi/ Urografy Kontras 4,942,000
241 MRI Soft Tissue Leher Kontras 5,162,000
242 MRI Soft Tissue Leher 3,819,000
243 MRI Extrimitas 3,819,000
244 MRI Extrimitas Kontras 5,162,000
245 MRI Knee/ Genu 3,819,000
246 MRI Knee/ Genu Kontras 5,162,000
247 MRI Ankle 3,819,000
248 MRI Ankle Kontras 5,162,000
249 MRI Whole Spine 4,108,000
250 MRI Whole Spine Kontras 5,162,000
251 MRI Myelografi 3,819,000
252 MRCP Tanpa Kontras 3,658,000
253 MRCP Kontras 4,942,000
254 MR Aorta Abdominalis 5,308,000
255 MR Aorta Abdominalis Toracalis 5,162,000
256 MRI Mediastinum 3,819,000
257 MRI Mediastinum Kontras 5,162,000
258 MRI Mammae Kontras 4,203,000
259 MRI Mammae 3,564,000
K. LAIN - LAIN
Bone Survey I
260 1,381,000 1,411,000
(Cranium, Cervical, Thoraco Lumbal, Pelvis)
Bone Survey II
261 1,933,000 1,963,000
(Bone Survey 1 + Ekstrimitas Atas & Bawah)
262 Penambahan per-film 109,000 139,000
263 Kateter 428,000 458,000
264 Kontras Omnipaque 289,000 319,000
265 Ratio Adenoid 325,000 355,000
266 Pelvimetri 548,000 578,000
267 Sono-Histografi 761,000 791,000
268 OMD/Barium meal 1,267,000 1,297,000
269 Barium Follow Through 1,362,000 1,392,000
270 Cistogram 292,000 322,000
271 MDG 179,000 209,000
TARIF
No. 0.79 "
NON CR CR
272 USG Jantung 1,740,000 1,770,000
273 MRI 4,500,000 4,530,000
IX. PERKIRAAN TARIF TINDAKAN ONE DAY CARE (ODC) di KAMAR OPERASI
1. OBSGYN
PELAYANAN OBSGYN
NO KOMPONEN GOL I GOL II GOL III GOL IV
- Marsupialisasi Kista Bartholini - Repair Dehicense - Kolpoperineorafi - D&C
- Eksplorasi Perdarahan - Insisi Hymen - Kuretase Pos Partum - Vasektomi
- Angkat Spiral dengan komplikasi - Laserasi Polyp Serviks - Ekstirpasi Myoma Geburt - Eksterpasi Kista Bartholini/
- Sinklasi - Konisasi - Kuretase Bertingkat Insisi Abses (Besar)
- Insisi Labia/ Insisi Abses - Inseminasi - Repair Partio - Curretase Post Partum
- Pasang Implan - Hecting Partio - Perineorafi - Condiloma Vulva Perinium (Banyak)
- Pasang susuk - Kaurerisasi Servistis Kronis - Plasenta Manual
- Micro Curet - Rehecting Perineum - MOW/ Steril/ Tibektomi
1 PELAYANAN
- Cauter Candiloma - Rehecting Vagina hingga Fornilus - Histeroscopy Diagnostic
- Placenta Manual - Kauterisasi Condyloma (Sedang) - Hidrotubasi
- Angkat Spiral (dengan Pembiusan) - Kauterisasi Condyloma (Banyak) - D/C a/i Kematian Mudigah
- Reposisi Jahitan - Condiloma Vulva Perinium - D/C a/i abortus Inkomplet
- Insisi Kista bartolini - Insisi Abses Bartolini - D/C a/i Insipiens
- Condiloma Perinium - Eksplorasi Perdarahan Post Partum
- AFF IUD dengan Narkose - Khusus Ca Endometriosis
- Kista Bartholini
2 KAMAR OPERASI 861,000 1,248,000 1,414,000 1,663,000
3 DR. OPERATOR 1,150,000 2,250,000 2,550,000 2,950,000
4 DR. ANESTESI 460,000 900,000 1,020,000 1,180,000

5 PARAMEDIS 115,000 225,000 255,000 295,000
TOTAL BIAYA 2,586,000 4,623,000 5,239,000 6,088,000
2. ANAK
PELAYANAN ANAK
NO KOMPONEN GOL I GOL II
- Biopsi Insisi Tumor/ Biopsi Eksisi KG - Eksisi Kista Branchial (pre auricular)
- Eksisi Lipoma, Ateroma, Ganglion - Eksisi Higroma/ Limfangioma Simple
1 PELAYANAN - Eksisi Granuloma Umbilikal - Herniotomi
- Eksisi Hemangioma Kecil - Ligas TInggi
- Eksisi Tie Tongue
2 KAMAR OPERASI 861,000 1,248,000
3 DR. OPERATOR 2,800,000 5,000,000
4 DR. ANESTESI 1,120,000 2,000,000

5 PARAMEDIS 198,000 265,000
TOTAL BIAYA 4,979,000 8,513,000
3. UMUM
PELAYANAN UMUM
NO KOMPONEN GOL I GOL II GOL III GOL IV
- Ganglion - Eksisi besar - Eksterpasi Bronchial Kista - Insisi Abses (Besar)
- Skin graft flap lokal - Skin graft - Reposisi Fraktur Os Nasal - Ganglion
- Eksisi Kecil/ Sedang - FAM Mammae - Polipektomi - Polipectomi
- Insisi Abses (diameter < 2cm) - Mioma Geburt - Trakheostomi - FAM Mamae
- Circumsisi - FAM Mammae - Mc Donald - Operasi Perineum
- Antrostomi (AWO) - Mioma Geburt - Sirodkar
- Cryo - Exterpasi Kista Bibir - Reposisi tertutup tanpa &
- Clavus 1 buah - Reposisi Terrtutup dengan anestesi umum

- Kista Ateroma (diameter < 2cm 1 buah) - Kemoterapi - Ekstirpasi Kista Bartolini
1 PELAYANAN - Veruca 1 buah - Pasang susuk - Eksplorasi & Hemostasis
- Exterpasi granuli CAE - Angkat susuk Hematome Sedang
- Angkat susuk - Extrpasi kista bibir - Marsupralisasi
- Reposisi Jahitan - Hecting Perineum grade 3-4

- Hidrotubasi - Corpus Alienum
- Reposisi Jahitan - Pemasangan Belog Tampon
- Inseminasi - Anuscopy
- Eksisi kecil - Paracentesis
- Eksisi Sedang
- Corpus Alineum Hidung
2 KAMAR OPERASI 861,000 1,248,000 1,414,000 1,663,000
3 DR. OPERATOR 1,350,000 1,750,000 2,250,000 2,750,000
4 DR. ANESTESI 540,000 700,000 900,000 1,100,000

5 PARAMEDIS 198,000 265,000 331,000 353,000
TOTAL BIAYA 2,949,000 3,963,000 4,895,000 5,866,000
4. KEMOTERAPI
PELAYANAN KEMOTERAPI
NO KOMPONEN TARIF
1 KAMAR OPERASI 861,000
2 DR. OPERATOR 750,000
3 DR. ANESTESI 300,000

4 PARAMEDIS 75,000
TOTAL BIAYA 1,986,000
5. CIMINO (ANESTESI LOKAL)

PELAYANAN CIMINO (ANESTESI LOKAL)
NO KOMPONEN TARIF
DR. OPERATOR
2 4,800,000
+ Set Minor
3 DR. ANESTESI 1,920,000

4 PARAMEDIS 480,000
6. HEMATOLOGI
PELAYANAN HEMATOLOGI
NO KOMPONEN TARIF
2 DR. OPERATOR 950,000
3 DR. ANESTESI 380,000

4 PARAMEDIS 95,000
7. MATA
- Katarak
PELAYANAN MATA
NO KOMPONEN GOL I GOL II
1 KAMAR OPERASI 2,145,000 4,290,000
2 DR. OPERATOR 1,450,000 3,500,000
3 DR. ANESTESI 580,000 1,400,000

4 PARAMEDIS 145,000 350,000
TOTAL BIAYA 4,320,000 9,540,000
8. ORTHOPEDI
PELAYANAN ORTHOPEDI
NO KOMPONEN GOL I GOL II GOL III
1 KAMAR OPERASI 861,000 1,248,000 1,414,000
2 DR. OPERATOR 2,350,000 4,350,000 5,550,000
3 DR. ANESTESI 940,000 1,740,000 2,220,000

4 PARAMEDIS 235,000 435,000 555,000
TOTAL BIAYA 4,386,000 7,773,000 9,739,000
A. Tarif yang tertera di atas BELUM termasuk :

1. BIAYA OBAT OBATAN
4. BIAYA ADMINISTRASI
5. TARIF KAMAR PERAWATAN (*Jika dibutuhkan)
B. Tarif yang tertera di atas berlaku dalam KEADAAN NORMAL/BIASA
C. Tarif yang tertera di atas merupakan Tarif PERKIRAAN SEMENTARA dan TIDAK BERLAKU MUTLAK
SEWAKTU-WAKTU DAPAT BERUBAH KARENA KONDISI/KEBUTUHAN PELAYANAN MEDIS PASIEN
D. Bila terdapat penyulit, maka biaya dapat bertambah 10 s/d 50%
XI. PELAYANAN LAIN
A. PELAYANAN CATH LAB RS HERMINA
1. Precutaneus Transluminal Coronary Angioplasty (PTCA)/ Permanent Pace Maker (PPM)
KELAS PERAWATAN
NO KOMPONEN
1 Kamar Perawatan 3,376,000 2,618,000 2,342,000 1,300,000 850,000 344,000
2 Kamar Operasi 9,041,000 7,749,000 7,425,000 6,458,000 5,166,000 3,875,000
3 Dokter Operator 14,065,000 11,901,000 9,737,000 8,114,000 6,492,000 5,410,000
4 Dokter Asisten 3,516,250 2,975,250 2,434,250 2,028,500 1,623,000 1,352,500
5 Paramedis 1,406,500 1,190,100 973,700 811,400 649,200 541,000
6 Obat-obatan 8,364,000 8,364,000 8,364,000 8,364,000 8,364,000 8,364,000
7 Sewa Alat Cath Lab (*Perkiraan) 7,500,000 7,500,000 7,500,000 7,500,000 7,500,000 7,500,000
JUMLAH 47,268,750 42,297,350 38,775,950 34,575,900 30,644,200 27,386,500
2. Core Angio Graphy (CAG) Diagnostik

KELAS PERAWATAN
NO KOMPONEN
1 Kamar Perawatan 3,376,000 2,618,000 2,342,000 1,300,000 850,000 344,000
2 Kamar Operasi 9,041,000 7,749,000 7,425,000 6,458,000 5,166,000 3,875,000
3 Dokter Operator 10,819,000 8,655,000 7,032,000 5,951,000 4,869,000 3,787,000
4 Dokter Asisten 2,704,750 2,163,750 1,758,000 1,487,750 1,217,250 946,750
5 Paramedis 1,081,900 865,500 703,200 595,100 486,900 378,700
6 Obat-obatan 4,618,000 4,618,000 4,618,000 4,618,000 4,618,000 4,618,000
7 Sewa Alat Cath Lab (*Perkiraan) 5,500,000 5,500,000 5,500,000 5,500,000 5,500,000 5,500,000
JUMLAH 37,140,650 32,169,250 29,378,200 25,909,850 22,707,150 19,449,450
* Tarif kamar perawatan dihitung dengan perkiraan lama perawatan 2 hari.

* Bila terdapat penyulit, maka biaya dapat bertambah 10 s/d 50%
B. PELAYANAN MCU RS HERMINA – TAHUN 2019
PAKET SIMPLE
NO PELAYANAN TARIF (Rp)
1 Dokter umum 89,000

2 Laboratorium : ###
- Darah Rutin 140,000
- Gula Darah Puasa 68,000
- Gula Darah 2 Jam PP 68,000
- Asam Urat 95,000
- Cholesterol Total 95,000
TOTAL 555,000
PAKET BASIC
1 Dokter umum 89,000

2 Rontgen thorax 525,000
3 EKG 150,000
- Darah lengkap 180,000
- Urine lengkap 75,000
- Ureum 95,000
- Kreatinin 95,000
- SGOT 95,000
- SGPT 95,000
- HBsAg 200,000
TOTAL 1,599,000
PAKET SILVER
1 Dokter Spesialis Penyakit Dalam 213,000

3 EKG 150,000
Fungsi Hati: ###
- SGOT 95,000
- SGPT 95,000
Fungsi Ginjal : ###
- Ureum 95,000
- Kreatinin 95,000
- Asam Urat 95,000
Fungsi Lemak : ###
- HDL 85,000
- LDL 145,000
- Triglyserida 95,000
- GDP 68,000
- GDPP 68,000
- HBsAg 200,000
- Anti HbS 255,000
- VDRL 170,000
TOTAL 2,799,000
PAKET GOLD
1 Dokter Spesialis Penyakit Dalam 186,000

2 Dokter spesialis mata 186,000
3 Dokter Gigi 127,000
4 Dokter spesialis kandungan (wanita) 195,000
6 EKG 150,000
7 USG Abodemen 700,000
Fungsi Hati: ###
- SGOT 95,000
- SGPT 95,000
Fungsi Ginjal : ###
- Ureum 95,000
- Creatinin 95,000
- Asam Urat 95,000
Fungsi Lemak : ###
- HDL 85,000
- LDL 145,000
- GDP 68,000
- GDPP 68,000
- HBsAg 200,000
- Anti HbS 255,000
- VDRL 170,000
- Pertanda Tumor CEA ###
*Tambahan : papsmear (untuk wanita) ###
TOTAL 3,980,000
PAKET DIAMOND
1 Dokter spesialis penyakit dalam 186,000

3 Dokter gigi 127,000
4 Dokter spesialis THT 186,000

5 Dokter spesialis jantung 186,000
8 EKG 150,000
10 Mammografi / USG mammae 350,000
11 Treadmill 756,000
12 Audiometri 202,000
Fungsi Hati: ###
- SGOT 95,000
- SGPT 95,000
Fungsi Ginjal : ###
- Ureum 95,000
- Creatinin 95,000
- Asam Urat 95,000
Fungsi Lemak : ###
- HDL 85,000
- LDL 145,000
- GDP 68,000
- GDPP 68,000
- HBsAg 200,000
- Anti HbS 255,000
- Anti HCV 635,000
- VDRL 170,000
- Tumor marker Ca-125 (wanita); PSA (laki-laki) 920,000
- Thin prep pap test 825,000
*Tambahan : papsmear (untuk wanita)
TOTAL 8,160,000
PLATINUM
1 Dokter spesialis penyakit dalam 186,000

3 Dokter gigi 127,000
4 Dokter spesialis THT 186,000
5 Dokter spesialis jantung 186,000
7 Dokter spesialis saraf 186,000
8 Dokter spesialis bedah 186,000
10 EKG 150,000
12 USG kebidanan (wanita) 285,000
13 Echocardiography 900,000
14 Mammografi / USG mammae 350,000
15 Treadmil 756,000
16 Audiometri 202,000
18 Brain MRI (non kontras) 4,779,000
Fungsi Hati : ###
- SGOT 95,000
- SGPT 95,000
Fungsi Ginjal : ###
- Ureum 95,000
- Creatinin 95,000
- Asam Urat 95,000
Fungsi Lemak : ###
- GDP 68,000
- GDPP 68,000
- HBsAg 200,000
- Anti HbS 255,000
- Anti HCV 635,000
- VDRL 170,000
- Tumor marker Ca-125 (wanita); PSA (laki-laki) 920,000
- Tumor marker : Ca. 15-3 (wanita) 800,000
- Thyroid : Free T4 & TSH, FSH 459,000
20 Thin prep pap test 825,000
*Tambahan : papsmear (untuk wanita)
TOTAL 15,335,000
* Tarif yang tertera diatas adalah TARIF NORMAL

* Tarif Yang Tertera diatas merupakan Tarif PERKIRAAN SEMENTARA
dan TIDAK BERLAKU MUTLAK, SEWAKTU-WAKTU DAPAT BERUBAH KARENA
KONDISI/KEBUTUHAN PELAYANAN MEDIS PASIEN.
1. BIAYA ADMINISTRASI
2. Fasilitas lain seperti SNACK
Lampiran :
I. PELAKSANAAN PELAYANAN MEDIS RS HERMINA
1 Biaya yang dijelaskan belum termasuk :

a. Biaya administrasi (sesuai dengan RS Hermina masing-masing)
- Administrasi RI 7% dari total kuitansi, maksimum Rp 1.200.000,-
b. Visite dokter
c. Pemeriksaan Laboratorium dan Penunjang Medis lainnya serta Obat-obat yang diresepkan
d. Bila terdapat penyulit, maka biaya dapat bertambah 10 s/d 50%
Tarif yang dijelaskan adalah tarif perkiraan sementara, tidak berlaku mutlak sewaktu-waktu dapat berubah karena
2
kebutuhan pelayanan medis pasien
3 Tarif berlaku dalam keadaan normal/ biasa
4 Bila tidak normal/ biasa dapat lebih tinggi dari jumlah tersebut.
A. Gameli
Kembar dua :
a. Obsgyn (G1 = 100%, G2 = + 50%)
b. Dokter anak & visite + 100%
c. RS (sewa kamar bersalin, paramedis dan obat-obatan) + 20%
Kembar tiga :
a. Obsgyn (G1 = 100%, G2 = + 50%, G3 = + 25%)
b. Dokter anak & visite + 100%
c. RS (sewa kamar bersalin, paramedis dan obat-obatan) + 50%
B. Induksi : Sewa kamar bersalin, dokter obsgyn, paramedis dan obat-obatan + 10%
C. Vacum dan letak sungsang
a. Sewa kamar bersalin, dokter obsgyn, paramedis dan obat-obatan + 10%
b. Jika dokter anak hadir dalam tindakan, maka tarif dokter anak + visite = biaya pada SC
5 Tindakan dengan dua operasi sekaligus

A. Dalam bidang ilmu yang sama :
a. Jasa medis (JM) Dokter tindakan operasi terbesar + maksimal 50% dari operasi yang terkecil
b. Jasa dokter Anestesi diambil 40% dari JM dokter Operator
c. Sewa kamar operasi + 50% tergantung kelasnya
A. Dalam bidang ilmu yang berbeda :
a. JM Dokter tindakan operasi ke-2 + maksimal 100% dari tindakan operasi yang terbesar
b. Jasa dokter Anestesi diambil 40% dari JM dokter Operator
c. Sewa kamar operasi + 100% tergantung kelasnya
6 Perhitungan hari perawatan berdasarkan waktu mulai masuk dan waktu pulang
1. Waktu masuk pasien (check in)
a. Pukul 00.00 – 18.00, dihitung 1 (satu) hari biaya kamar perawatan
b. Pukul 18.00 – 00.00, dihitung ½ (setengah) hari biaya kamar perawatan
2. Waktu pulang pasien (check out)
a. Maksimal pukul 14.00, dengan batas toleransi 2 (dua) jam, dihitung 1 (satu) hari biaya kamar perawatan
b. Bila pasien pulang > 2 (dua) jam setelah pukul 14.00 atau melebihi batas toleransi, dikenakan tambahan ½
(setengah) hari biaya kamar perawatan
II. JUKNIS PELAYANAN KESEHATAN GIGI dan MULUT RS HERMINA
KELOMPOK PELAYANAN GIGI

1 KELOMPOK A
adalah tarif untuk tindakan yang dikerjakan oleh dokter gigi umum dan dokter gigi spesialis yang bukan bidang spesialisnya
2 KELOMPOK B
adalah tarif untuk tindakan yang dikerjakan oleh dokter gigi spesialis sesuai dengan bidang spesialisnya
3 KELOMPOK C
adalah tarif untuk tindakan yang memerlukan biaya tambahan (biaya tekniker, biaya alat kedokteran gigi khusus, dll)
4 KELOMPOK D
adalah tarif bahan khusus untuk melengkapi pengkodean tarif tindakan di kelompok Adan kelompok Bsesuai dengan tindakan
yang terkait
Kode tarif Dditambahkan pada kode tarif tindakan kelompok A dan B
Contoh ;
a. Tindakan penambahan Composit Kecil
Pengkodean tarif : Kode kelompok A tambal komposit + kode kelompok D bahan khusus komposit
b. Tindakan Cetak
Pengkodean tarif : Kode kelompok A cetak + kode kelompok D bahan khusus cetak
c. Tindakan Tambal Sementara (dengan Ledermix)
Pengkodean tarif : Kode kelompok B tambal sementara + kode kelompok D bahan khsusus Ledermix
d. Tindakan Perawatan Saluran Akar
Pengkodean tarif : Kode kelompok B perawatan SA Gigi Ganda + kode Kelompok D Bahan Khusus Saluran Akar
PERKIRAAN TARIF RS HERMINA – TAHUN 2019
TARIF KONSULTASI

1 Dokter Umum 89,000
3 Dokter Spesialis Obsgyn 195,000
4 Dokter Sub Spesialis/ Konsultan 214,000
5 Dokter Subspesialis/ Konsultan Obsgyn 223,000
6 Bidan 74,000
TARIF KAMAR PERAWATAN

& UANG MUKA RAWAT INAP SESUAI KAMAR PERAWATAN
TARIF KAMAR UANG MUKA

NO KAMAR PERAWATAN
PERAWATAN RAWAT INAP
1 KAMAR PERAWATAN
a. SUITE ROOM 1,688,000 16,880,000
b. EKSEKUTIF 1,309,000 13,090,000
c. DELUXE 1,171,000 11,710,000
d. KELAS I 650,000 6,500,000
e. KELAS II 425,000 4,250,000
f. KELAS III 172,000 1,720,000
2 INTERMEDIATE CARE UNIT (IMCU) 715,000 7,150,000
3 INTENSIVE CARE UNIT (ICU/PICU/NICU) 845,000 16,900,000
TARIF PERSALINAN
TARIF (Rp)
NO PELAYANAN NORMAL ILA SC
(3 HARI) (4 HARI) (5 HARI)
1 SUITE ROOM 20,121,000 25,407,900 35,356,100
2 EKSEKUTIF 17,093,500 21,530,950 30,775,100
3 DELUXE 15,594,000 19,702,800 28,572,200
4 KELAS I 11,360,000 14,360,250 23,069,100
5 KELAS II 8,885,500 11,410,050 18,856,700
6 KELAS III 6,723,000 8,663,550 14,415,000
Keterangan :
* Tarif Yang Tertera diatas merupakan Tarif PERKIRAAN SEMENTARA
* Tarif yang tertera diatas BELUM termasuk BIAYA ADMINISTRASI 7 % MAKSIMAL Rp 1.200.000,-,
TARIF JASA MEDIS VISITE DOKTER, LABORATORIUM DAN PENUNJANG MEDIS LAINNYA, OBAT-OBATAN

Tarif GT III - 2019 (Draft)

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BUKU TARIF RS HERMINA

NO JENIS PELAYANAN TARIF

I.1.1. RAWAT JALAN

I.1.2. RAWAT INAP

- Dengan Dokter 3,188,000 2,550,000 2,231,000 1,594,000 1,435,000 1,195,000

- Dengan Bidan 2,231,000 1,594,000 1,435,000 1,195,000

- ILA 3,188,000 2,550,000 2,231,000 1,594,000 1,435,000 1,195,000

b. Untuk Observasi 1,080,000 425,000

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

b. Tindakan Medis Operatif : kebidanan & bedah

- Operasi Kecil 4,018,000 3,444,000 3,300,000 2,870,000 2,296,000 1,722,000

- Operasi Sedang 5,223,000 4,477,000 4,290,000 3,731,000 2,985,000 2,239,000

- Operasi Besar & SC 5,826,000 4,994,000 4,785,000 4,162,000 3,329,000 2,497,000

- Operasi Besar Khusus 9,041,000 7,749,000 7,425,000 6,458,000 5,166,000 3,875,000

c. Ruang Pemulihan / RR ( untuk observasi > 6 jam ) 650,000

a. Level I (KBBL) 956,000 741,000 663,000 390,000 234,000 112,000

5 INTERMEDIATE CARE UNIT (IMCU) 715,000

6 INTENSIVE CARE UNIT (ICU/PICU/NICU) 845,000

7 RUANG ISOLASI 650,000

1 Dokter Umum 49,000 2,450 46,550 40,000 89,000

8 Psikiater 161,000 8,050 152,950 40,000 201,000

11 Bidan 34,000 1,700 32,300 40,000 74,000

12 Klinik Tumbuh Kembang :

a. Dokter Spesialis Anak 166,000 8,300 157,700 40,000 206,000

b. Dokter Rehabilitasi Medik 166,000 8,300 157,700 40,000 206,000

c. Psikolog 141,000 7,050 133,950 40,000 181,000

d. Psikiater 166,000 8,300 157,700 40,000 206,000

g. Sensori Integrasi 122,000

i. Sensor Terapi Behaviour 122,000

j. Art Terapi 122,000

c. Konselor Dokter Umum 50,000 2,500 47,500 40,000 90,000

d. Konselor Bidan / Perawat 34,000 1,700 32,300 40,000 74,000

B VISITE di R. PERAWATAN PERINA

C VISITE di R. PERAWATAN ICU/NICU/PICU

II. 3 JASA PARAMEDIS

NO TINDAKAN TARIF (Rp)

1 Aff drain (angkat drain) 66,000

III.A.2. SPESIALIS KEBIDANAN & KANDUNGAN

NO TINDAKAN TARIF (Rp)

10 Pasang laminaria 227,000

III.A.3. SPESIALIS ANAK

NO TINDAKAN TARIF (Rp)

1 Kompresi jantung paru (CPR) 785,000

NO TINDAKAN TARIF (Rp)

1 Aff drain (angkat drain) 92,000

c. Jumlah jahitan 7 - 10 378,000

III.A.5. SPESIALIS THT

NO TINDAKAN TARIF (Rp)

d. Dua telinga dengan Irigasi - spooling 262,000

III.A.6. SPESIALIS MATA

NO TINDAKAN TARIF (Rp)

1 Anel Test / sondage 324,000

III.A.7. SPESIALIS KULIT-KELAMIN

NO TINDAKAN TARIF (Rp)

1 Bedah Minor 593,000

21 Mikro dermabrasi 661,000

NO TINDAKAN TARIF (Rp)

1 Electric stimulation (ES) :

NO TINDAKAN TARIF (Rp)

NO TINDAKAN TARIF (Rp)

NO TINDAKAN TARIF (Rp)

1 Tarif Klinik Akupunktur+ Tindakan 1 Posisi + 10 Jarum 158,000