Tarif Remunerasi Perbup 2015

PEMBAGIAN JASA PELAYANAN SESUAI TARIF LAYANAN PELAYANAN
I. TARIF PENDAFTARAN , PEMERIKSAAN , DAN AKOMODASI
NO URAIAN TARIF
1 2 3
A Pendaftaran
1 Administrasi sistem informasi 1,500
2 Berkas RM Rawat Jalan / Kartu Pasien 10,000
3 Berkas RM Rawat Inap 15,000
B Pemeriksaan Poliklinik
1 Pemeriksaan poliklinik oleh dokter umum 20,000
2 Pemeriksaan poliklinik oleh dokter spesialis 30,000
C Akomodasi
C1 Biaya Kamar
1 VIP 260,000
2 Kelas I 150,000
3 Kelas II 100,000
4 Kelas III 70,000
5 ICU 240,000
6 NICU 140,000
C2 Visite Dokter Spesialis
7 VIP 65,000
8 Kelas I 45,000
9 Kelas II 45,000
10 Kelas III 45,000
11 ICU 65,000
12 NICU 55,000
C3 Visite Dokter Umum
13 VIP 40,000
14 Kelas I 25,000
15 Kelas II 25,000
16 Kelas III 25,000
17 ICU 45,000
18 NICU 35,000
D Poli Eksekutif /Khusus
1 Servis Layanan 17,000
2 Pemeriksaan dan Konsultasi dokter 50,000
3 Konsultasi antar SMF 50,000
E GENERAL CHECK UP
Paket I (Pemeriksaan fisik,Darah lengkap,Urine
1 95,000
Lengkap)
Paket II (Pemeriksan Fisik,Darah lengkap,Urine
2 Paket III (Pemeriksan
Lengkap,Gula Fisik,Darah lengkap,Urine
darah sewaktu,kolesterol 151,000
Lengkap,Gula darah sewaktu,kolesterol
total,trigliserida)
3 273,000
total,trigliserida,pemeriksaan
F SURAT KETERANGAN DOKTER Thorax)
narkotika,EKG,Rontgen
1 Surat Keterangan sehat 25,000
Surat Keterangan untuk asuransi umum / non
2 25,000
BPJS
3 Surat Keterangan Kelahiran 0
4 Surat Keterangan Kematian 0
AN PELAYANAN KESEHATAN RSUD SUMBAWA
JASA DIREKSI SISA JASA

JASA SARANA
PELAYANAN PELAYANAN
5%
4 5 6 7
1,200 300 15 285

8,500 1,500 75 1,425
13,000 2,000 100 1,900
- -
5,000 15,000 750 14,250
5,000 25,000 1,250 23,750
- -
- -
260,000 - - -
150,000 - - -
100,000 - - -
70,000 - - -
240,000 - - -
140,000 - - -
- -
5,000 60,000 3,000 57,000
5,000 40,000 2,000 38,000
5000 40,000 2,000 38,000
5,000 40,000 2,000 38,000
5,000 60,000 3,000 57,000
5,000 50,000 2,500 47,500
- -
5,000 35,000 1,750 33,250
5,000 20,000 1,000 19,000
5,000 20,000 1,000 19,000
5,000 20,000 1,000 19,000
5,000 40,000 2,000 38,000
5,000 30,000 1,500 28,500
- -
12,000 5,000 250 4,750
20,000 30,000 1,500 28,500
20,000 30,000 1,500 28,500
- -
60,000 35,000 1,750 33,250
100,000 51,000 2,550 48,450
170,000 103,000 5,150 97,850
- -
5,000 20,000 1,000 19,000
5,000 20,000 1,000 19,000
- - - -
- - - -
COST CENTER INDEX KINERJA KELOMPOK
DOKTER
PERAWAT
15% 35% 50%
8 9 10 11 13
43 100 143
214 499 713
285 665 950
- - -
2,138 4,988 7,125 2,138 4,988
3,563 8,313 11,875 3,563 8,313
- -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
8,550 19,950 28,500 8,550 19,950
5,700 13,300 19,000 5,700 13,300
5,700 13,300 19,000 5,700 13,300
5,700 13,300 19,000 5,700 13,300
8,550 19,950 28,500 8,550 19,950
7,125 16,625 23,750 7,125 16,625
- -
4,988 11,638 16,625 4,988 11,638
2,850 6,650 9,500 2,850 6,650
2,850 6,650 9,500 2,850 6,650
2,850 6,650 9,500 2,850 6,650
5,700 13,300 19,000 5,700 13,300
4,275 9,975 14,250 4,275 9,975
- -
713 1,663 2,375 713 1,663
4,275 9,975 14,250 4,275 9,975
4,275 9,975 14,250 4,275 9,975
- - - - -
4,988 11,638 16,625 4,988 11,638
7,268 16,958 24,225 7,268 16,958
14,678 34,248 48,925 14,678 34,248
- -
2,850 6,650 9,500 6,650
2,850 6,650 9,500 6,650
- - - - -
- - - - -
KELOMPOK REVISI REVISI
ADMIN/LOKET
PERAWAT DOKTER 80% PERAWAT
12 dr. UMUM dr. SPESIALIS

(DPJP)
143
713
950
2,375 6,650 2,850

2,375 9,500 2,375
2,850
2,850
REVISI
DOKTER 80%
dr. PPSD DPJP
- -
6,175 2,328
TARIF PELAYANAN RAWAT JALAN
NO URAIAN TARIF
1 2 3
1 POLIKLINIK TUMBUH KEMBANG
A IMUNISASI DIWAJIBKAN (PPI)
1 BCG 14,000
2 DPT - Hb 14,000
3 Hepatitis B 14,000
4 Polio 14,000
5 TT 14,000
6 Campak 14,000
B IMUNISASI DIANJURKAN (Non PPI)
1 Infrantrik (DTAP) 400,000
2 Infrantrik - HiB 550,000
3 Hepatitis Engerik B 200,000
4 HiB 350,000
5 IPD 1,000,000
6 Hepatitis A 500,000
7 Valirix (cacar air) 500,000
8 Typim (Typoid) 250,000
9 MMR 250,000
10 Psikologi Test
- Tes Perkembangan Anak (DDST) pasien ba 50,000
- Tes Perkembangan Anak (DDST) pasien l 25,000
11 Screening
- Tes Lambat Belajar 17,500
- Tes Hiperaktif & Gangguan Konsentrasi 17,500
- Tes Autisme 20,000
12 Tes Intelegensi (IQ)
- Tes Intelegensia Anak 40,000
- Tes Intelegensia Remaja 50,000
13 Tes Kepribadian
- Tes Kepribadian Anak 40,000
- Tes Kepribadian Remaja 50,000
14 Tes Minat Bakat
- Tes Minat Bakat Dewasa/Anak 50,000
15 Psiko Tes 120,000
16 Konseling Psikologi (anak, remaja & dewasa) 75,000
17 Terapi Wicara 50,000
18 Terapi Edukasi 50,000
19 Terapi Okupasi 50,000
2. POLIKLINIK PENYAKIT ANAK

1 BMP(lumbal punksi) 70,000
2 Therapi Inhalasi tanpa obat / Nebulizer 20,000
3 EKG 50,000
4 RRO 20,000
5 Pemeriksaan pasien autisme 20,000
6 Pemasangan O2 / jam 20,000
3. POLIKLINIK BEDAH UMUM

1 Rawat Luka
a. Kecil (< 5 cm) 15,000
b. Sedang (5-10 cm) 20,000
c. Besar (10-20 cm) 50,000
d. Khusus (> 20 cm) 70,000
2 Jahit luka / Repair Jahitan
- Kecil (< 10 Jahitan) 50,000
- Sedang (10 s/d 20 Jahitan) 70,000
- Besar (>20 Jahitan) 100,000
3 Angkat Jahitan
4 Rectal Toucher 20,000
5 Anoskopi 25,200
6 Coller And Cup 20,000
7 Angkat Wire 25,000
8 Nail Ekstrasi 20,000
9 Rozer Plasty 140,000
10 Incisi Abses 85,000
11 Eksisi 85,000
12 Ekstirpasi 100,000
13 Circumsisi 150,000
14 Biopsi 150,000
15 Tindik 20,000
16 Lobulo Plasty 150,000
17 Explorasi Corpus alienum 100,000
18 Curetage 10,000
19 Aspirasi 20,000
20 Bouginasi 20,000
21 Ekstraksi Batu uretra anterior 100,000
22 Spoor dawer cateter 100,000
23 Spooling dawer cateter 20,000
24 Debridment Luka 75,000
25 Injeksi Keloid / Kenacord / (IC) 10,000
26 Necrotomy 100,000
27 Amputasi Jari 100,000
28 Vasektomi 250,000
1 Rawat Luka
a. Kecil (< 5 cm) 15,000
b. Sedang (5-10 cm) 20,000
c. Besar (10-20 cm) 50,000
d. Khusus (> 20 cm) 70,000
3 Angkat Jahitan
4 Gips Kecil Anak * 50,000
5 Gips Kecil Dewasa* 60,000
6 Gips Sedang Anak* 75,000
7 Gips Sedang Dewasa* 90,000
8 Gips Besar Anak* 120,000
9 Gips Besar Dewasa* 150,000
10 Buka Gips 40,000
11 Ransel verband Anak 100,000
12 Ransel verband Dewasa 150,000
13 Injeksi Arthtritis / articuler* 70,000
14 Body cast* 300,000
15 Hemi Spica* 300,000
16 Necrotomy Ex Op 30,000
5. POLIKLINIK UROLOGI
1 Pasang Fowley Cateter* 25,000
2 Pasang Cateter Logam* 40,000
3 Tindakan Blast Punctie 75,000
4 Tindakan Blast Pistel / Cytostom 100,000
5 Ekstraksi batu uretra dengn GA di OK 2,500,000
6 Ekstraksi batu uretra anterior 100,000
7 Rawat Luka
a. Kecil (< 5 cm) 15,000
b. Sedang (5-10 cm) 20,000
c. Besar (10-20 cm) 50,000
d. Khusus (> 20 cm) 70,000
9 Sitostomi 450,000
10 Buginasi / Dilatasi Uretra 100,000
6. POLIKLINIK GIGI DAN MULUT
A SPESIFIKASI TINDAKAN PENCABUTAN GIGI

1 Pencabutan Gigi Susu
- Chlor Etyl 55,000
- Injeksi 75,000
2 Pencabutan Gigi Susu Perforasi Akar 80,000
3 Pencabutan Gigi Mesiodens 125,000
4 Pencabutan Gigi Eksosterm 3 125,000
5 Pencabutan Gigi Permanen Dengan Akar Tunggal 125,000
6 Pencabutan Gigi Permanen Dengan Akar Ganda 125,000
7 Pencabutan Gigi Dengan Komplikasi 150,000
8 Pencabutan Sisa Akar Yang Tertinggal 125,000
B SPESIFIKASI TINDAKAN PENAMBALAN GIGI

1 Perawatan Pulpa 110,000
2 Perawatan Pulpektomy
a. Saluran Akar tunggal 85,000
b. Saluran akar ganda 130,000
c. One Visit Saluran Akar Tunggal 100,000
d. One Visit Saluran akar ganda 145,000
3 Pengisian Saluran Akar Tunggal 145,000
4 Pengisian Saluran Akar Ganda 175,000
5 Tambalan Sinar
a. Kecil 125,000
b. Sedang 140,000
c. Besar 155,000
d. Venneer direct / Besar Sekali 245,000
6 Penambalan Amalgam 125,000
7 Perawatan saluran akar Endo Intrakanal
a. Saluran akar tunggal 85,000
b. Saluran akar ganda 125,000
c. One Visit Saluran Akar Tunggal 100,000
d. One Visit Saluran akar ganda 150,000
8 Penambalan Glass Lonomer
a. Kecil 115,000
b. Sedang 130,000
c. Besar 145,000
9 Penambalan Eugenol, ChKM, depupil
a. Devitalisasi, sterilisasi SA, Pulp Capping 85,000
b. Open Bur / Eksterpatie dgn lokal anaeste 65,500
10 Penambalan Eugenol Cavit 85,000
11 Pin Screw + Sementasi 250,000
C SPESIFIKASI TINDAKAN PENGOBATAN / PERAWATAN JARINGAN PENYANGGA GIGI

1 Pembersihan karang gigi per regio 100,000
2 Perawatan Pocet Periodental 126,000
3 Gingivektomy per regio 125,000
4 Eksterpasi Mucocele / epulis 125,000
D SPESIFIKASI PEMBUATAN PROTESA / GIGI PALSU

1 Gigi Tiruan per rahang
a. Satu gigi pertama 580,000
b. Dua gigi 700,000
c. Tiga gigi 850,000
d. Empat gigi 950,000
e. Lima gigi 1,100,000
f. Full per rahang 1,500,000
2 Reparasi Plat Patah
a. Reparasi plat patah full 210,000
b. Reparasi plat patah parsial 175,000
3 Reparasi Penambahan gigi per Rahang
a. Satu gigi pertama 350,000
b. Penambahan gigi berikutna 460,000
4 Rebasing / relining per rahang 260,000
5 Orthodontic
a. Alat orthodontic 380,000
b. Aktivasi ortho lepasan 65,000
c. Reparasi clamer (kawatortho) / rahang 105,000
6 Orthodontic cekat RA / RB 1,300,000
7 Perawatan / kontrol Orthodentic ceat RA / RB 105,000
E SPESIFIKASI TINDAKAN BEDAH MULUT

1 Odontectomy 210,000
2 Operculectom 170,000
3 Inter dental wiring / rahang 250,000
4 Inter maxilla wiring / rahang 185,000
5 Replantasi gigi 185,000
6 Alveolectomy / debridement per regio 185,000
7 Enukleasi kista (lokal anestesi) 140,000
8 Incisi / Eksisi abses 125,000
9 Pemeriksaan komplikasi post op / kontrol 55,000
10 Pemeriksaan dan perbaikan posisi IDW / IMW 60,000
11 Pembukaan IDW / Rahang 60,000
12 Pembukaan IMW 60,000
13 Dry Socket / curetage per gigi 90,000
14 Extirpasi mucocelle / epulis 115,000
15 Aff heacting epulis / mucocelle 30,000
F SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dengan LOGAM

1 Jembatan Adoro porcelain fusi metal 900,000
2 Inlay porcelain fusi metal 600,000
3 Uplay porcelain fusi metal 600,000
G SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY tanpa LOGAM

1 Jembatan/bridge full porcelain 1,450,000
2 Inlay / Uplay full porcelain 1,080,000
7. POLIKLINIK PENYAKIT KULIT DAN KELAMIN
1 Elektro fulgurasi / Elektro Couter :

a. Seboroik Keratosis :
- Kecil 55,000
- Sedang 95,000
- Besar 150,000
b. Skin Tag ;
- Kecil 33,000
- Sedang 95,000
- Besar 150,000
c. Kondyloma Akuminata :
- Kecil 95,000
- Sedang 150,000
- Besar 250,000
2 Ekstraksi Komedo 45,000
3 Enukleasi 40,000
4 Solarium / Photo Therapi 16,000
5 Excisi Wajah 205,000
6 Excisi Non wajah 125,000
7 Test Tempel / Patch Test Standard 175,000
8 Test Tempel Standard Kosmetik 175,000
9 Dermabrasi / Microdemabrasi 155,000
10 Rekonstruki Kulit 250,000
11 Heating Aff 18,000
13 Swab : Vagina, Cervix, Fornik 22,000
14 Swab : Uretra 22,000
15 Swab discar lesi 22,000
16 Kerokan Kulit, Kuku, Rmbut 18,400
17 Kultur 42,500
18 Ganti Verband 20,000
19 Revisi Parut 87,500
20 Injeksi Kenacort 45,000
21 Punch Biopsi 135,000
22 Insisonal biopsi 135,000
23 Ekstirpasi 100,000
24 Kuretase Kulit 40,000
25 Radioton 95,000
26 Trichlor Acetic Acid 35,000
27 Chemical Peeling :
- GA Peeling 175,000
- Proopeel 350,000
- PHA 105,000
28 Facial Regula 608,000
29 Test Alergi Tusuk
- Tusuk 88,000
- Tempel 125,000
8. POLIKLINIK PENYAKIT PARU
1 Terapi Inhalasi tanpa obat / Nebulizer 26,000

2 Punctie Pleura 350,000
3 Spirometri komputer 80,000
4 Portable Spirometri 65,000
9. POLIKLINIK PENYAKIT DALAM
1 Punctie asctes 250,000

2 Aspirasi jarum halus 50,000
3 BMP 87,000
4 EKG 50,000
10. POLIKLINIK PENYAKIT JANTUNG
1 Defribilasi 310,000
2 EKG 50,000
3 Echocardiografi 120,000
4 Echocardiografi Dopler collor 410,000
5 FNAB 68,000
6 Phonocardiografi 78,000
7 Punksi pericard 400,000
8 Resusitasi jantung dengan DC Shock 172,000
9 Telemetri 78,000
10 Treadmill 200,000
11 Fowley Catheter 40,000
12 NGT / kali 20,000
13 Pacemaker temporer 875,000
14 Pemasangan SB Tube 105,000
15 Pemasangan Cardiac Monitor 25,500
16 Pemasangan CVP 1,200,000
17 Pemasangan Cardiac monitor / hari 45,000
11. POLIKLINIK SYARAF/NEUROLOGI
1 Injeksi Intramuskuler 4,500

2 Injeksi Intraartikuler 70,000
3 Assessment Neurobehaviour fit n proper test 750,000
4 Assessment Neurobehaviour 325,000
5 Pemeriksaan EEG 175,000
6 Baca EEG 75,000
7 Assessment Nyeri 15,000
8 Pemeriksaan EMNG 250,000
12. POLIKLINIK MATA
1 Pterigium 400,000
2 S B L ( Bleparoplasty ) 400,000
3 Campimetri / perimetri 1 mata dengan Humpray 300,000
4 Campimetri / perimetri 2 mata dengan Humpray 500,000
5 U S G Mata 125,000
6 Keratometri 60,000
7 Pemeriksaan fundus (indirec) 60,000
8 Tonometri Aplansi 60,000
9 Water Drinking 15,000
10 Retinoskopi 60,000
11 Gonioskopi 60,000
12 Synophtophor 125,000
13 Sondage 50,000
14 tonometri Aplansi 50,000
15 Angkat jahitan di palpebra dan konjungtiva 90,000
16 Angkat jahitan di kornea 170,000
17 Amotio corpus Alienum 90,000
18 Irigasi 25,000
19 Refraktometer 60,000
20 Ekstirpasi kista konjungtiva 400,000
21 Ekstarpasi nevus / granulotoma 250,000
22 Epilasi 40,000
23 Excochleasi / Amotio Lithiasis 130,000
24 Ekstirpasi tumor / kista di palpebra 400,000
25 Biopsi dai palpebra 400,000
26 Biopsi di konjungtiva 400,000
27 Tarsoraphy / Jahitan di palpebra 400,000
28 Reposisi iris 400,000
29 Paracentesis 400,000
30 Iridektomi Perifer 500,000
31 Transplantasi membran amnion 400,000
32 Excochleasi / Amotio Lithiasis 250,000
33 Pemeriksaan Refraksi 50,000
34 Pemeriksaan Slit Biomikroskop 60,000
35 Tonometri SCHIOTZ 60,000
36 Test Ishihara 25,000
13. POLIKLINIK KEBIDANAN DAN PENYAKIT KANDUNGAN (OBSGYN)
1 Biopsi Pervaginam 140,000

2 Pap Smear 40,000
3 Vaginal Swab 20,000
4 Kolposkopi 100,000
5 Kauter Elektrik 40,000
6 Pasang IUD 75,000
7 Angkat IUD tanpa penyulit 75,000
8 Angkat IUD dengan penyulit 95,000
9 Pasang Implant 75,000
10 Angkat implant tanpa penyulit 75,000
11 Angkat Implant dengan penyulit 95,000
12 Diathermi ( satu seri = 6 kali kunjungan ) 75,000
13 Ganti verband / Buka jahitan 17,500
14 Pasang / Ganti tampon 17,500
15 Kauter Albotyl 17,500
16 USG Sp.OG
- Tanpa Print Out 65,000
- Dengan Print Out 100,000
16 USG dr. UMUM
- Tanpa Print Out 65,000
- Dengan Print Out 100,000
17 Pasang Pessarium 50,000
18 Buka pessarium 50,000
19 CTG 80,000
20 Suntikan KB 30,000
21 Pemeriksaan Gnekologi 15,000
22 Tindakan pasang kateter 25,000
23 Tindakan pasang infus 10,000
24 USG Transvaginal tanpa print out
- Tanpa print out 95,000
- Dengan print out 120,000
25 Konseling KB 15,000
26 MOW / MOP / Mini Laparotomy 540,000
14. POLIKLINIK PENYAKIT THT
1 Biopsi 112,500
2 Spoelling 76,500
3 Corpal Alienum telinga 76,500
4 Corpal Alienum tenggorokan 76,500
5 Corpal Alienum hidung 76,500
6 Caustik 20,000
7 Extirpasi granuloma 137,500
8 Swab Nasal 25,000
9 Test Allergi 88,000
10 Ganti verband 56,000
11 Evakuasi Cerumen Ringan 65,000
12 Swab Nasopharing Endoscopy 27,500
13 Audiometri murni 100,000
14 Audiometri tutur 75,000
15 Schimer test 88,000
17 Myringobridge 75,000
18 Buka pessarium 75,000
15. REHABILITASI MEDIK
1 Micro Wave Diathermy 35,000

2 Electrical Stimulation 28,000
3 Ultrasound Diathermy 28,000
4 Traksi 35,000
5 InfraPhil 2 Lamp 21,000
6 Infra Phil 3 Lamp 25,000
7 Fibrator / Massage 21,000
8 Senam hamil 30,000
9 Senam Nifas 30,000
10 Postural drainage 30,000
11 Bladder Training 30,000
12 Fisioterapi Stroke 35,000
13 Fisioterapi Anak 50,000
14 Fisioterapi Dada/ Breathing Exc 30,000
15 Back Exercise 30,000
16 Latihan Sepeda Statis 21,000
17 Latihan Paralel Bars 21,000
18 Continous Pasive Movement 21,000
19 Latihan Gerak Sendi / Penguatan Otot 21,000
20 Pemasangan Spalk 30,000
21 Short Wave Diathermy 35,000
22 Parafin Bath 28,000
23 Nabulizer 28,000
24 Active Movement Exercise 21,000
16. POLIKLINIK BEDAH SYARAF
1 Rawat Luka 15,000

a. Kecil (< 5 cm) 15,000
b. Sedang (5-10 cm) 20,000
c. Besar (10-20 cm) 50,000
d. Khusus (> 20 cm) 70,000
2 Angkat Jahitan
3 Pungsi CSF Cranial 300,000

4 Pungsi Lumbal 125,000
5 Injeksi Spinal 300,000
6 Injeksi obat ( IV ) / Injeksi 5,000
7 Pasang Elastic Band 50,000
17. POLIKLINIK JIWA / PSIKIATRI
A Pemeriksaan Psikometri
1 House manHouse
t man tree test 15,000
2 Warteg test 15,000
3 HDRS 20,000
4 HARS 20,000
5 BDI 20,000
6 MMSE 20,000
7 MMPI 300,000
8 PANS score 20,000
9 GDS 20,000
B PSIKOTERAPI
1 Psikoterapi suportif 50,000
2 Cognitif Behaviour therapy 200,000
3 Hipnotherapi 500,000
SISA COST
JASA DIREKSI JASA INDEX KINERJA
JASA SARANA CENTER
PELAYANAN PELAYAN
AN
5% 15% 35% 50%
4 5 6 7 8
-
10,000 4,000 200 3,800 570 1,330 1,900
10,000 4,000 200 3,800 570 1,330 1,900
10,000 4,000 200 3,800 570 1,330 1,900
10,000 4,000 200 3,800 570 1,330 1,900
10,000 4,000 200 3,800 570 1,330 1,900
10,000 4,000 200 3,800 570 1,330 1,900
240,000 160,000 8,000 152,000 22,800 53,200 76,000

330,000 220,000 11,000 209,000 31,350 73,150 104,500
120,000 80,000 4,000 76,000 11,400 26,600 38,000
210,000 140,000 7,000 133,000 19,950 46,550 66,500
600,000 400,000 20,000 380,000 57,000 133,000 190,000
300,000 200,000 10,000 190,000 28,500 66,500 95,000
300,000 200,000 10,000 190,000 28,500 66,500 95,000
150,000 100,000 5,000 95,000 14,250 33,250 47,500
150,000 100,000 5,000 95,000 14,250 33,250 47,500
30,000 20,000 1,000 19,000 2,850 6,650 9,500

15,000 10,000 500 9,500 1,425 3,325 4,750
- - - - -
10,500 7,000 350 6,650 998 2,328 3,325
10,500 7,000 350 6,650 998 2,328 3,325
12,000 8,000 400 7,600 1,140 2,660 3,800
- - - - -
24,000 16,000 800 15,200 2,280 5,320 7,600
30,000 20,000 1,000 19,000 2,850 6,650 9,500
- - - - -
24,000 16,000 800 15,200 2,280 5,320 7,600
30,000 20,000 1,000 19,000 2,850 6,650 9,500
- - - - -
30,000 20,000 1,000 19,000 2,850 6,650 9,500
72,000 48,000 2,400 45,600 6,840 15,960 22,800
45,000 30,000 1,500 28,500 4,275 9,975 14,250
30,000 20,000 1,000 19,000 2,850 6,650 9,500
30,000 20,000 1,000 19,000 2,850 6,650 9,500
30,000 20,000 1,000 19,000 2,850 6,650 9,500
42,000 28,000 1,400 26,600 3,990 9,310 13,300

12,000 8,000 400 7,600 1,140 2,660 3,800
30,000 20,000 1,000 19,000 2,850 6,650 9,500
12,000 8,000 400 7,600 1,140 2,660 3,800
12,000 8,000 400 7,600 1,140 2,660 3,800
14,000 6,000 300 5,700 855 1,995 2,850
9,000 6,000 300 5,700 855 1,995 2,850

12,000 8,000 400 7,600 1,140 2,660 3,800
30,000 20,000 1,000 19,000 2,850 6,650 9,500
42,000 28,000 1,400 26,600 3,990 9,310 13,300
30,000 20,000 1,000 19,000 2,850 6,650 9,500

40,000 30,000 1,500 28,500 4,275 9,975 14,250
60,000 40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
9,000 6,000 300 5,700 855 1,995 2,850
15,000 10,000 500 9,500 1,425 3,325 4,750
24,000 16,000 800 15,200 2,280 5,320 7,600
12,000 8,000 400 7,600 1,140 2,660 3,800
15,120 10,080 504 9,576 1,436 3,352 4,788
12,000 8,000 400 7,600 1,140 2,660 3,800
15,000 10,000 500 9,500 1,425 3,325 4,750
12,000 8,000 400 7,600 1,140 2,660 3,800
84,000 56,000 2,800 53,200 7,980 18,620 26,600
51,000 34,000 1,700 32,300 4,845 11,305 16,150
51,000 34,000 1,700 32,300 4,845 11,305 16,150
60,000 40,000 2,000 38,000 5,700 13,300 19,000
90,000 60,000 3,000 57,000 8,550 19,950 28,500
90,000 60,000 3,000 57,000 8,550 19,950 28,500
12,000 8,000 400 7,600 1,140 2,660 3,800
90,000 60,000 3,000 57,000 8,550 19,950 28,500
60,000 40,000 2,000 38,000 5,700 13,300 19,000
6,000 4,000 200 3,800 570 1,330 1,900
12,000 8,000 400 7,600 1,140 2,660 3,800
12,000 8,000 400 7,600 1,140 2,660 3,800
60,000 40,000 2,000 38,000 5,700 13,300 19,000
60,000 40,000 2,000 38,000 5,700 13,300 19,000
12,000 8,000 400 7,600 1,140 2,660 3,800
45,000 30,000 1,500 28,500 4,275 9,975 14,250
6,000 4,000 200 3,800 570 1,330 1,900
60,000 40,000 2,000 38,000 5,700 13,300 19,000
60,000 40,000 2,000 38,000 5,700 13,300 19,000
150,000 100,000 5,000 95,000 14,250 33,250 47,500
- - - - -
9,000 6,000 300 5,700 855 1,995 2,850
12,000 8,000 400 7,600 1,140 2,660 3,800
30,000 20,000 1,000 19,000 2,850 6,650 9,500
42,000 28,000 1,400 26,600 3,990 9,310 13,300
- - - - -
30,000 20,000 1,000 19,000 2,850 6,650 9,500
40,000 30,000 1,500 28,500 4,275 9,975 14,250
60,000 40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
9,000 6,000 300 5,700 855 1,995 2,850
15,000 10,000 500 9,500 1,425 3,325 4,750
24,000 16,000 800 15,200 2,280 5,320 7,600
30,000 20,000 1,000 19,000 2,850 6,650 9,500
36,000 24,000 1,200 22,800 3,420 7,980 11,400
45,000 30,000 1,500 28,500 4,275 9,975 14,250
54,000 36,000 1,800 34,200 5,130 11,970 17,100
72,000 48,000 2,400 45,600 6,840 15,960 22,800
90,000 60,000 3,000 57,000 8,550 19,950 28,500
24,000 16,000 800 15,200 2,280 5,320 7,600
60,000 40,000 2,000 38,000 5,700 13,300 19,000
90,000 60,000 3,000 57,000 8,550 19,950 28,500
42,000 28,000 1,400 26,600 3,990 9,310 13,300
180,000 120,000 6,000 114,000 17,100 39,900 57,000
180,000 120,000 6,000 114,000 17,100 39,900 57,000
18,000 12,000 600 11,400 1,710 3,990 5,700
15,000 10,000 500 9,500 1,425 3,325 4,750
24,000 16,000 800 15,200 2,280 5,320 7,600
45,000 30,000 1,500 28,500 4,275 9,975 14,250
60,000 40,000 2,000 38,000 5,700 13,300 19,000
1,500,000 1,000,000 50,000 950,000 142,500 332,500 475,000
60,000 40,000 2,000 38,000 5,700 13,300 19,000
9,000 6,000 300 5,700 855 1,995 2,850

12,000 8,000 400 7,600 1,140 2,660 3,800
30,000 20,000 1,000 19,000 2,850 6,650 9,500
42,000 28,000 1,400 26,600 3,990 9,310 13,300
51,000 34,000 1,700 32,300 4,845 11,305 16,150
270,000 180,000 9,000 171,000 25,650 59,850 85,500
60,000 40,000 2,000 38,000 5,700 13,300 19,000
41,000 14,000 700 13,300 1,995 4,655 6,650

55,000 20,000 1,000 19,000 2,850 6,650 9,500
63,000 17,000 850 16,150 2,423 5,653 8,075
85,000 40,000 2,000 38,000 5,700 13,300 19,000
85,000 40,000 2,000 38,000 5,700 13,300 19,000
85,000 40,000 2,000 38,000 5,700 13,300 19,000
85,000 40,000 2,000 38,000 5,700 13,300 19,000
102,000 48,000 2,400 45,600 6,840 15,960 22,800
85,000 40,000 2,000 38,000 5,700 13,300 19,000
85,000 25,000 1,250 23,750 3,563 8,313 11,875
65,000 20,000 1,000 19,000 2,850 6,650 9,500

100,000 30,000 1,500 28,500 4,275 9,975 14,250
75,000 25,000 1,250 23,750 3,563 8,313 11,875
110,000 35,000 1,750 33,250 4,988 11,638 16,625
110,000 35,000 1,750 33,250 4,988 11,638 16,625
135,000 40,000 2,000 38,000 5,700 13,300 19,000
95,000 30,000 1,500 28,500 4,275 9,975 14,250

105,000 35,000 1,750 33,250 4,988 11,638 16,625
115,000 40,000 2,000 38,000 5,700 13,300 19,000
200,000 45,000 2,250 42,750 6,413 14,963 21,375
80,000 45,000 2,250 42,750 6,413 14,963 21,375
65,000 20,000 1,000 19,000 2,850 6,650 9,500

95,000 30,000 1,500 28,500 4,275 9,975 14,250
75,000 25,000 1,250 23,750 3,563 8,313 11,875
110,000 40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
85,000 30,000 1,500 28,500 4,275 9,975 14,250
95,000 35,000 1,750 33,250 4,988 11,638 16,625
105,000 40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
65,000 20,000 1,000 19,000 2,850 6,650 9,500
50,500 15,000 750 14,250 2,138 4,988 7,125
65,000 20,000 1,000 19,000 2,850 6,650 9,500
175,000 75,000 3,750 71,250 10,688 24,938 35,625
- - - - -
PENYANGGA GIGI - - - - -
80,000 20,000 1,000 19,000 2,850 6,650 9,500
96,000 30,000 1,500 28,500 4,275 9,975 14,250
85,000 40,000 2,000 38,000 5,700 13,300 19,000
85,000 40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
- - - - -
- - - - -
380,000 200,000 10,000 190,000 28,500 66,500 95,000
450,000 250,000 12,500 237,500 35,625 83,125 118,750
550,000 300,000 15,000 285,000 42,750 99,750 142,500
600,000 350,000 17,500 332,500 49,875 116,375 166,250
700,000 400,000 20,000 380,000 57,000 133,000 190,000
1,000,000 500,000 25,000 475,000 71,250 166,250 237,500
- - - - -
160,000 50,000 2,500 47,500 7,125 16,625 23,750
135,000 40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
260,000 90,000 4,500 85,500 12,825 29,925 42,750
335,000 125,000 6,250 118,750 17,813 41,563 59,375
200,000 60,000 3,000 57,000 8,550 19,950 28,500
- - - - -
290,000 90,000 4,500 85,500 12,825 29,925 42,750
45,000 20,000 1,000 19,000 2,850 6,650 9,500
75,000 30,000 1,500 28,500 4,275 9,975 14,250
1,050,000 250,000 12,500 237,500 35,625 83,125 118,750
75,000 30,000 1,500 28,500 4,275 9,975 14,250
- - - - -
- - - - -
150,000 60,000 3,000 57,000 8,550 19,950 28,500
120,000 50,000 2,500 47,500 7,125 16,625 23,750
180,000 70,000 3,500 66,500 9,975 23,275 33,250
130,000 55,000 2,750 52,250 7,838 18,288 26,125
130,000 55,000 2,750 52,250 7,838 18,288 26,125
130,000 55,000 2,750 52,250 7,838 18,288 26,125
100,000 40,000 2,000 38,000 5,700 13,300 19,000
90,000 35,000 1,750 33,250 4,988 11,638 16,625
40,000 15,000 750 14,250 2,138 4,988 7,125
40,000 20,000 1,000 19,000 2,850 6,650 9,500
40,000 20,000 1,000 19,000 2,850 6,650 9,500
40,000 20,000 1,000 19,000 2,850 6,650 9,500
65,000 25,000 1,250 23,750 3,563 8,313 11,875
80,000 35,000 1,750 33,250 4,988 11,638 16,625
20,000 10,000 500 9,500 1,425 3,325 4,750
- - - - -
engan LOGAM
650,000 250,000 12,500 237,500 35,625 83,125 118,750
450,000 150,000 7,500 142,500 21,375 49,875 71,250
450,000 150,000 7,500 142,500 21,375 49,875 71,250
- - - - -
npa LOGAM - - - - -
1,130,000 320,000 16,000 304,000 45,600 106,400 152,000
800,000 280,000 14,000 266,000 39,900 93,100 133,000
33,000 22,000 1,100 20,900 3,135 7,315 10,450

57,000 38,000 1,900 36,100 5,415 12,635 18,050
90,000 60,000 3,000 57,000 8,550 19,950 28,500
- - - - -
33,000 22,00 #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
57,000 38,000 1,900 36,100 5,415 12,635 18,050
90,000 60,000 3,000 57,000 8,550 19,950 28,500
- - - - -
57,000 38,000 1,900 36,100 5,415 12,635 18,050
90,000 60,000 3,000 57,000 8,550 19,950 28,500
150,000 100,000 5,000 95,000 14,250 33,250 47,500
27,000 18,000 900 17,100 2,565 5,985 8,550
24,000 16,000 800 15,200 2,280 5,320 7,600
9,600 6,400 320 6,080 912 2,128 3,040
123,000 82,000 4,100 77,900 11,685 27,265 38,950
75,000 50,000 2,500 47,500 7,125 16,625 23,750
105,000 70,000 3,500 66,500 9,975 23,275 33,250
105,000 70,000 3,500 66,500 9,975 23,275 33,250
93,000 62,000 3,100 58,900 8,835 20,615 29,450
150,000 100,000 5,000 95,000 14,250 33,250 47,500
10,800 7,200 360 6,840 1,026 2,394 3,420
51,000 34,000 1,700 32,300 4,845 11,305 16,150
13,200 8,800 440 8,360 1,254 2,926 4,180
13,200 8,800 440 8,360 1,254 2,926 4,180
13,200 8,800 440 8,360 1,254 2,926 4,180
11,000 7,400 370 7,030 1,055 2,461 3,515
25,500 17,000 850 16,150 2,423 5,653 8,075
12,000 8,000 400 7,600 1,140 2,660 3,800
52,500 35,000 1,750 33,250 4,988 11,638 16,625
27,000 18,000 900 17,100 2,565 5,985 8,550
81,000 54,000 2,700 51,300 7,695 17,955 25,650
81,000 54,000 2,700 51,300 7,695 17,955 25,650
60,000 40,000 2,000 38,000 5,700 13,300 19,000
24,000 16,000 800 15,200 2,280 5,320 7,600
57,000 38,000 1,900 36,100 5,415 12,635 18,050
21,000 14,000 700 13,300 1,995 4,655 6,650
105,000 70,000 3,500 66,500 9,975 23,275 33,250

210,000 140,000 7,000 133,000 19,950 46,550 66,500
63,000 42,000 2,100 39,900 5,985 13,965 19,950
570,000 38,000 1,900 36,100 5,415 12,635 18,050
- - - - -
52,800 35,200 1,760 33,440 5,016 11,704 16,720
75,000 50,000 2,500 47,500 7,125 16,625 23,750
- - - - -
- - - - -
- - - - -
- - - - -
15,600 10,400 520 9,880 1,482 3,458 4,940
200,000 150,000 7,500 142,500 21,375 49,875 71,250
48,000 32,000 1,600 30,400 4,560 10,640 15,200
39,000 26,000 1,300 24,700 3,705 8,645 12,350
150,000 100,000 5,000 95,000 14,250 33,250 47,500
30,000 20,000 1,000 19,000 2,850 6,650 9,500
52,200 34,800 1,740 33,060 4,959 11,571 16,530
30,000 20,000 1,000 19,000 2,850 6,650 9,500
- - - - -
- - - - -
- - - - -
- - - - -
186,000 124,000 6,200 117,800 17,670 41,230 58,900
30,000 20,000 1,000 19,000 2,850 6,650 9,500
72,000 48,000 2,400 45,600 6,840 15,960 22,800
246,000 164,000 8,200 155,800 23,370 54,530 77,900
40,800 27,200 1,360 25,840 3,876 9,044 12,920
46,800 31,200 1,560 29,640 4,446 10,374 14,820
240,000 160,000 8,000 152,000 22,800 53,200 76,000
103,200 68,800 3,440 65,360 9,804 22,876 32,680
46,800 31,200 1,560 29,640 4,446 10,374 14,820
120,000 80,000 4,000 76,000 11,400 26,600 38,000
24,000 16,000 800 15,200 2,280 5,320 7,600
12,000 8,000 400 7,600 1,140 2,660 3,800
525,000 350,000 17,500 332,500 49,875 116,375 166,250
63,000 42,000 2,100 39,900 5,985 13,965 19,950
15,300 10,200 510 9,690 1,454 3,392 4,845
500,000 700,000 35,000 665,000 99,750 232,750 332,500
27,000 18,000 900 17,100 2,565 5,985 8,550
- - - - -
- - - - -
- - - - -
- - - - -
2,700 1,800 90 1,710 257 599 855
42,000 28,000 1,400 26,600 3,990 9,310 13,300
450,000 300,000 15,000 285,000 42,750 99,750 142,500
195,000 130,000 6,500 123,500 18,525 43,225 61,750
105,000 70,000 3,500 66,500 9,975 23,275 33,250
45,000 30,000 1,500 28,500 4,275 9,975 14,250
9,000 6,000 300 5,700 855 1,995 2,850
150,000 100,000 5,000 95,000 14,250 33,250 47,500
- - - - -
- - - - -
- - - - -
240,000 160,000 8,000 152,000 22,800 53,200 76,000
240,000 160,000 8,000 152,000 22,800 53,200 76,000
180,000 120,000 6,000 114,000 17,100 39,900 57,000
300,000 200,000 10,000 190,000 28,500 66,500 95,000
75,000 50,000 2,500 47,500 7,125 16,625 23,750
36,000 24,000 1,200 22,800 3,420 7,980 11,400
36,000 24,000 1,200 22,800 3,420 7,980 11,400
36,000 24,000 1,200 22,800 3,420 7,980 11,400
9,000 6,000 300 5,700 855 1,995 2,850
36,000 24,000 1,200 22,800 3,420 7,980 11,400
36,000 24,000 1,200 22,800 3,420 7,980 11,400
75,000 50,000 2,500 47,500 7,125 16,625 23,750
30,000 20,000 1,000 19,000 2,850 6,650 9,500
30,000 20,000 1,000 19,000 2,850 6,650 9,500
54,000 36,000 1,800 34,200 5,130 11,970 17,100
102,000 68,000 3,400 64,600 9,690 22,610 32,300
54,000 36,000 1,800 34,200 5,130 11,970 17,100
15,000 10,000 500 9,500 1,425 3,325 4,750
36,000 24,000 1,200 22,800 3,420 7,980 11,400
240,000 160,000 8,000 152,000 22,800 53,200 76,000
150,000 100,000 5,000 95,000 14,250 33,250 47,500
24,000 16,000 800 15,200 2,280 5,320 7,600
78,000 52,000 2,600 49,400 7,410 17,290 24,700
240,000 160,000 8,000 152,000 22,800 53,200 76,000
240,000 160,000 8,000 152,000 22,800 53,200 76,000
240,000 160,000 8,000 152,000 22,800 53,200 76,000
240,000 160,000 8,000 152,000 22,800 53,200 76,000
240,000 160,000 8,000 152,000 22,800 53,200 76,000
240,000 160,000 8,000 152,000 22,800 53,200 76,000
300,000 200,000 10,000 190,000 28,500 66,500 95,000
240,000 160,000 8,000 152,000 22,800 53,200 76,000
150,000 100,000 5,000 95,000 14,250 33,250 47,500
30,000 20,000 1,000 19,000 2,850 6,650 9,500
36,000 24,000 1,200 22,800 3,420 7,980 11,400
36,000 24,000 1,200 22,800 3,420 7,980 11,400
15,000 10,000 500 9,500 1,425 3,325 4,750
OBSGYN)
84,000 56,000 2,800 53,200 7,980 18,620 26,600

24,000 16,000 800 15,200 2,280 5,320 7,600
12,000 8,000 400 7,600 1,140 2,660 3,800
60,000 40,000 2,000 38,000 5,700 13,300 19,000
24,000 16,000 800 15,200 2,280 5,320 7,600
45,000 30,000 1,500 28,500 4,275 9,975 14,250
45,000 30,000 1,500 28,500 4,275 9,975 14,250
45,000 50,000 2,500 47,500 7,125 16,625 23,750
45,000 30,000 1,500 28,500 4,275 9,975 14,250
45,000 30,000 1,500 28,500 4,275 9,975 14,250
45,000 50,000 2,500 47,500 7,125 16,625 23,750
45,000 30,000 1,500 28,500 4,275 9,975 14,250
10,500 7,000 350 6,650 998 2,328 3,325
10500 7,000 350 6,650 998 2,328 3,325
10,500 7,000 350 6,650 998 2,328 3,325
50,000 25,000 1,250 23,750 3,563 8,313 11,875

65,000 35,000 1,750 33,250 4,988 11,638 16,625
50,000 25,000 1,250 23,750 3,563 8,313 11,875

65,000 35,000 1,750 33,250 4,988 11,638 16,625
30,000 20,000 1,000 19,000 2,850 6,650 9,500
30,000 20,000 1,000 19,000 2,850 6,650 9,500
48,000 32,000 1,600 30,400 4,560 10,640 15,200
18,000 12,000 600 11,400 1,710 3,990 5,700
9,000 6,000 300 5,700 855 1,995 2,850
15,000 10,000 500 9,500 1,425 3,325 4,750
6,000 4,000 200 3,800 570 1,330 1,900
65,000 30,000 1,500 28,500 4,275 9,975 14,250

75000 45,000 2,250 42,750 6,413 14,963 21,375
9,000 6,000 300 5,700 855 1,995 2,850
324,000 216,000 10,800 205,200 30,780 71,820 102,600
- - - - -
- - - - -
67,500 45,000 2,250 42,750 6,413 14,963 21,375
45,900 30,600 1,530 29,070 4,361 10,175 14,535
45,900 30,600 1,530 29,070 4,361 10,175 14,535
45,900 30,600 1,530 29,070 4,361 10,175 14,535
45,900 30,600 1,530 29,070 4,361 10,175 14,535
12,000 8,000 400 7,600 1,140 2,660 3,800
82,500 55,000 2,750 52,250 7,838 18,288 26,125
15,000 10,000 500 9,500 1,425 3,325 4,750
52,800 35,200 1,760 33,440 5,016 11,704 16,720
33,600 22,400 1,120 21,280 3,192 7,448 10,640
39,000 26,000 1,300 24,700 3,705 8,645 12,350
16,500 11,000 550 10,450 1,568 3,658 5,225
60,000 40,000 2,000 38,000 5,700 13,300 19,000
45,000 30,000 1,500 28,500 4,275 9,975 14,250
52,800 35,200 1,760 33,440 5,016 11,704 16,720
51,000 34,000 1,700 32,300 4,845 11,305 16,150
45,000 30,000 1,500 28,500 4,275 9,975 14,250
45,000 30,000 1,500 28,500 4,275 9,975 14,250
25,000 10,000 500 9,500 1,425 3,325 4,750

20,000 8,000 400 7,600 1,140 2,660 3,800
20,000 8,000 400 7,600 1,140 2,660 3,800
25,000 10,000 500 9,500 1,425 3,325 4,750
15,000 6,000 300 5,700 855 1,995 2,850
18,000 7,000 350 6,650 998 2,328 3,325
15,000 6,000 300 5,700 855 1,995 2,850
10,000 20,000 1,000 19,000 2,850 6,650 9,500
10,000 20,000 1,000 19,000 2,850 6,650 9,500
10,000 20,000 1,000 19,000 2,850 6,650 9,500
10,000 20,000 1,000 19,000 2,850 6,650 9,500
15,000 20,000 1,000 19,000 2,850 6,650 9,500
15,000 35,000 1,750 33,250 4,988 11,638 16,625
10,000 20,000 1,000 19,000 2,850 6,650 9,500
10,000 20,000 1,000 19,000 2,850 6,650 9,500
15,000 6,000 300 5,700 855 1,995 2,850
15,000 6,000 300 5,700 855 1,995 2,850
6,000 15,000 750 14,250 2,138 4,988 7,125
6,000 15,000 750 14,250 2,138 4,988 7,125
10,000 20,000 1,000 19,000 2,850 6,650 9,500
25,000 10,000 500 9,500 1,425 3,325 4,750
20,000 8,000 400 7,600 1,140 2,660 3,800
20,000 8,000 400 7,600 1,140 2,660 3,800
6,000 15,000 750 14,250 2,138 4,988 7,125
9,000 6,000 300 5,700 855 1,995 2,850

9,000 6,000 300 5,700 855 1,995 2,850
12,000 8,000 400 7,600 1,140 2,660 3,800
30,000 20,000 1,000 19,000 2,850 6,650 9,500
42,000 28,000 1,400 26,600 3,990 9,310 13,300
- - - - -
9,000 6,000 300 5,700 855 1,995 2,850
15,000 10,000 500 9,500 1,425 3,325 4,750
24,000 16,000 800 15,200 2,280 5,320 7,600
- - - - -
180,000 120,000 6,000 114,000 17,100 39,900 57,000
75,000 50,000 2,500 47,500 7,125 16,625 23,750
180,000 120,000 6,000 114,000 17,100 39,900 57,000
3,000 2,000 100 1,900 285 665 950
30,000 20,000 1,000 19,000 2,850 6,650 9,500
- - - - -
- - - - -
- - - - -
- - - - -
9,000 6,000 300 5,700 855 1,995 2,850
9,000 6,000 300 5,700 855 1,995 2,850
12,000 8,000 400 7,600 1,140 2,660 3,800
12,000 8,000 400 7,600 1,140 2,660 3,800
12,000 8,000 400 7,600 1,140 2,660 3,800
12,000 8,000 400 7,600 1,140 2,660 3,800
180,000 120,000 6,000 114,000 17,100 39,900 57,000
12,000 8,000 400 7,600 1,140 2,660 3,800
12,000 8,000 400 7,600 1,140 2,660 3,800
30,000 20,000 1,000 19,000 2,850 6,650 9,500

120,000 80,000 4,000 76,000 11,400 26,600 38,000
300,000 200,000 10,000 190,000 28,500 66,500 95,000
DIKERJAKAN DOKTER DIKERJAKAN BIDAN PSIKOLOG/FI
DOKTER
KELOMPOK KELOMPOK SIOTERAFIST/
DOKTER DOKTER PENANGGUNG
BIDAN BIDAN PROFESI
JAWAB
LAIN LAIN
20% 80% 80% 20%
9 10 11 12 13 14
380 1,520 1,520 380

380 1,520 1,520 380
380 1,520 1,520 380
380 1,520 1,520 380
380 1,520 1,520 380
380 1,520 1,520 380
15,200 60,800 60,800 15,200

20,900 83,600 83,600 20,900
7,600 30,400 30,400 7,600
13,300 53,200 53,200 13,300
38,000 152,000 152,000 38,000
19,000 76,000 76,000 19,000
19,000 76,000 76,000 19,000
9,500 38,000 38,000 9,500
47,500
9,500
4,750
-
3,325
3,325
3,800
-
7,600
9,500
-
7,600
9,500
-
9,500
22,800
14,250
9,500
9,500
9,500
2,660 10,640
760 3,040 3,040 760
1,900 7,600 7,600 1,900
760 3,040 3,040 760
760 3,040 3,040 760
570 2,280 2,280 570
570 2,280 2,280 570

760 3,040 3,040 760
1,900 7,600 7,600 1,900
2,660 10,640 10,640 2,660
1,900 7,600 7,600 1,900

2,850 11,400 11,400 2,850
3,800 15,200 15,200 3,800
- - - -
570 2,280 2,280 570
950 3,800 3,800 950
1,520 6,080 6,080 1,520
760 3,040 3,040 760
958 3,830 3,830 958
760 3,040 3,040 760
950 3,800 3,800 950
760 3,040 3,040 760
5,320 21,280 21,280 5,320
3,230 12,920 12,920 3,230
3,230 12,920 12,920 3,230
3,800 15,200 15,200 3,800
5,700 22,800 22,800 5,700
5,700 22,800 22,800 5,700
760 3,040 3,040 760
5,700 22,800 22,800 5,700
3,800 15,200 15,200 3,800
380 1,520 1,520 380
760 3,040 3,040 760
760 3,040 3,040 760
3,800 15,200 15,200 3,800
3,800 15,200 15,200 3,800
760 3,040 3,040 760
2,850 11,400 11,400 2,850
380 1,520 1,520 380
3,800 15,200 15,200 3,800
3,800 15,200 15,200 3,800
9,500 38,000 38,000 9,500
570 2,280 2,280 570

760 3,040 3,040 760
1,900 7,600 7,600 1,900
2,660 10,640 10,640 2,660
- - - -
1,900 7,600 7,600 1,900
2,850 11,400 11,400 2,850
3,800 15,200 15,200 3,800
- - - -
570 2,280 2,280 570
950 3,800 3,800 950
1,520 6,080 6,080 1,520
1,900 7,600 7,600 1,900
2,280 9,120 9,120 2,280
2,850 11,400 11,400 2,850
3,420 13,680 13,680 3,420
4,560 18,240 18,240 4,560
5,700 22,800 22,800 5,700
1,520 6,080 6,080 1,520
3,800 15,200 15,200 3,800
5,700 22,800 22,800 5,700
2,660 10,640 10,640 2,660
11,400 45,600 45,600 11,400
11,400 45,600 45,600 11,400
1,140 4,560 4,560 1,140
950 3,800 3,800 950
1,520 6,080 6,080 1,520
2,850 11,400 11,400 2,850
3,800 15,200 15,200 3,800
95,000 380,000 380,000 95,000
3,800 15,200 15,200 3,800
570 2,280 2,280 570

760 3,040 3,040 760
1,900 7,600 7,600 1,900
2,660 10,640 10,640 2,660
3,230 12,920 12,920 3,230
17,100 68,400 68,400 17,100
3,800 15,200 15,200 3,800
- - - -
1,330 5,320 5,320 1,330
1,900 7,600 7,600 1,900
1,615 6,460 6,460 1,615
3,800 15,200 15,200 3,800
3,800 15,200 15,200 3,800
3,800 15,200 15,200 3,800
3,800 15,200 15,200 3,800
4,560 18,240 18,240 4,560
3,800 15,200 15,200 3,800
- - - -
- - - -
2,375 9,500 9,500 2,375
- - - -
1,900 7,600 7,600 1,900
2,850 11,400 11,400 2,850
2,375 9,500 9,500 2,375
3,325 13,300 13,300 3,325
3,325 13,300 13,300 3,325
3,800 15,200 15,200 3,800
- - - -
2,850 11,400 11,400 2,850
3,325 13,300 13,300 3,325
3,800 15,200 15,200 3,800
4,275 17,100 17,100 4,275
4,275 17,100 17,100 4,275
- - - -
1,900 7,600 7,600 1,900
2,850 11,400 11,400 2,850
2,375 9,500 9,500 2,375
3,800 15,200 15,200 3,800
- - - -
2,850 11,400 11,400 2,850
3,325 13,300 13,300 3,325
3,800 15,200 15,200 3,800
- - - -
1,900 7,600 7,600 1,900
1,425 5,700 5,700 1,425
1,900 7,600 7,600 1,900
7,125 28,500 28,500 7,125
- - - -
- - - -
1,900 7,600 7,600 1,900
2,850 11,400 11,400 2,850
3,800 15,200 15,200 3,800
3,800 15,200 15,200 3,800
- - - -
- - - -
- - - -
19,000 76,000 76,000 19,000
23,750 95,000 95,000 23,750
28,500 114,000 114,000 28,500
33,250 133,000 133,000 33,250
38,000 152,000 152,000 38,000
47,500 190,000 190,000 47,500
- - - -
4,750 19,000 19,000 4,750
3,800 15,200 15,200 3,800
- - - -
8,550 34,200 34,200 8,550
11,875 47,500 47,500 11,875
5,700 22,800 22,800 5,700
- - - -
8,550 34,200 34,200 8,550
1,900 7,600 7,600 1,900
2,850 11,400 11,400 2,850
23,750 95,000 95,000 23,750
2,850 11,400 11,400 2,850
- - - -
- - - -
5,700 22,800 22,800 5,700
4,750 19,000 19,000 4,750
6,650 26,600 26,600 6,650
5,225 20,900 20,900 5,225
5,225 20,900 20,900 5,225
5,225 20,900 20,900 5,225
3,800 15,200 15,200 3,800
3,325 13,300 13,300 3,325
1,425 5,700 5,700 1,425
1,900 7,600 7,600 1,900
1,900 7,600 7,600 1,900
1,900 7,600 7,600 1,900
2,375 9,500 9,500 2,375
3,325 13,300 13,300 3,325
950 3,800 3,800 950
- - - -
23,750 95,000 95,000 23,750

14,250 57,000 57,000 14,250
14,250 57,000 57,000 14,250
- - - -
- - - -
30,400 121,600 121,600 30,400
26,600 106,400 106,400 26,600
2,090 8,360 8,360 2,090

3,610 14,440 14,440 3,610
5,700 22,800 22,800 5,700
- - - -
#VALUE! #VALUE! #VALUE! #VALUE!
3,610 14,440 14,440 3,610
5,700 22,800 22,800 5,700
- - - -
3,610 14,440 14,440 3,610
5,700 22,800 22,800 5,700
9,500 38,000 38,000 9,500
1,710 6,840 6,840 1,710
1,520 6,080 6,080 1,520
608 2,432 2,432 608
7,790 31,160 31,160 7,790
4,750 19,000 19,000 4,750
6,650 26,600 26,600 6,650
6,650 26,600 26,600 6,650
5,890 23,560 23,560 5,890
9,500 38,000 38,000 9,500
684 2,736 2,736 684
3,230 12,920 12,920 3,230
836 3,344 3,344 836
836 3,344 3,344 836
836 3,344 3,344 836
703 2,812 2,812 703
1,615 6,460 6,460 1,615
760 3,040 3,040 760
3,325 13,300 13,300 3,325
1,710 6,840 6,840 1,710
5,130 20,520 20,520 5,130
5,130 20,520 20,520 5,130
3,800 15,200 15,200 3,800
1,520 6,080 6,080 1,520
3,610 14,440 14,440 3,610
1,330 5,320 5,320 1,330
6,650 26,600 26,600 6,650

13,300 53,200 53,200 13,300
3,990 15,960 15,960 3,990
3,610 14,440 14,440 3,610
- - - -
3,344 13,376 13,376 3,344
4,750 19,000 19,000 4,750
- - - -
- - - -
- - - -
- - - -
988 3,952 3,952 988
14,250 57,000 57,000 14,250
3,040 12,160 12,160 3,040
2,470 9,880 9,880 2,470
9,500 38,000 38,000 9,500
1,900 7,600 7,600 1,900
3,306 13,224 13,224 3,306
1,900 7,600 7,600 1,900
- - - -
- - - -
- - - -
- - - -
11,780 47,120 47,120 11,780
1,900 7,600 7,600 1,900
4,560 18,240 18,240 4,560
15,580 62,320 62,320 15,580
2,584 10,336 10,336 2,584
2,964 11,856 11,856 2,964
15,200 60,800 60,800 15,200
6,536 26,144 26,144 6,536
2,964 11,856 11,856 2,964
7,600 30,400 30,400 7,600
1,520 6,080 6,080 1,520
760 3,040 3,040 760
33,250 133,000 133,000 33,250
3,990 15,960 15,960 3,990
969 3,876 3,876 969
66,500 266,000 266,000 66,500
1,710 6,840 6,840 1,710
- - - -
- - - -
- - - -
- - - -
171 684 684 171
2,660 10,640 10,640 2,660
28,500 114,000 114,000 28,500
12,350 49,400 49,400 12,350
6,650 26,600 26,600 6,650
2,850 11,400 11,400 2,850
570 2,280 2,280 570
9,500 38,000 38,000 9,500
- - - -
- - - -
- - - -
15,200 60,800 60,800 15,200
15,200 60,800 60,800 15,200
11,400 45,600 45,600 11,400
19,000 76,000 76,000 19,000
4,750 19,000 19,000 4,750
2,280 9,120 9,120 2,280
2,280 9,120 9,120 2,280
2,280 9,120 9,120 2,280
570 2,280 2,280 570
2,280 9,120 9,120 2,280
2,280 9,120 9,120 2,280
4,750 19,000 19,000 4,750
1,900 7,600 7,600 1,900
1,900 7,600 7,600 1,900
3,420 13,680 13,680 3,420
6,460 25,840 25,840 6,460
3,420 13,680 13,680 3,420
950 3,800 3,800 950
2,280 9,120 9,120 2,280
15,200 60,800 60,800 15,200
9,500 38,000 38,000 9,500
1,520 6,080 6,080 1,520
4,940 19,760 19,760 4,940
15,200 60,800 60,800 15,200
15,200 60,800 60,800 15,200
15,200 60,800 60,800 15,200
15,200 60,800 60,800 15,200
15,200 60,800 60,800 15,200
15,200 60,800 60,800 15,200
19,000 76,000 76,000 19,000
15,200 60,800 60,800 15,200
9,500 38,000 38,000 9,500
1,900 7,600 7,600 1,900
2,280 9,120 9,120 2,280
2,280 9,120 9,120 2,280
950 3,800 3,800 950
5,320 21,280 21,280 5,320

1,520 6,080 6,080 1,520
760 3,040 3,040 760
3,800 15,200 15,200 3,800
1,520 6,080 6,080 1,520
2,850 11,400 11,400 2,850
2,850 11,400 11,400 2,850
4,750 19,000 19,000 4,750
2,850 11,400 11,400 2,850
2,850 11,400 11,400 2,850
4,750 19,000 19,000 4,750
2,850 11,400 11,400 2,850
665 2,660 2,660 665
665 2,660 2,660 665
665 2,660 2,660 665
-
2,375 9,500
3,325 13,300
-
2,375 6,650 2,850
3,325 9,310 3,990
1,900 7,600 7,600 1,900
1,900 7,600 7,600 1,900
3,040 12,160 12,160 3,040
1,140 4,560 4,560 1,140
570 2,280 2,280 570
950 3,800 3,800 950
380 1,520 1,520 380
-
2,850 11,400 11,400 2,850
4,275 17,100 17,100 4,275
570 2,280 2,280 570
20,520 82,080 82,080 20,520
4,275 17,100 17,100 4,275 13,680 3,420

2,907 11,628 11,628 2,907
2,907 11,628 11,628 2,907
2,907 11,628 11,628 2,907
2,907 11,628 11,628 2,907
760 3,040 3,040 760
5,225 20,900 20,900 5,225
950 3,800 3,800 950
3,344 13,376 13,376 3,344
2,128 8,512 8,512 2,128
2,470 9,880 9,880 2,470
1,045 4,180 4,180 1,045
3,800 15,200 15,200 3,800
2,850 11,400 11,400 2,850
3,344 13,376 13,376 3,344
3,230 12,920 12,920 3,230
2,850 11,400 11,400 2,850
2,850 11,400 11,400 2,850
1,188 3,563
950 2,850
950 2,850
1,188 3,563
713 2,138
831 2,494
713 2,138
2,375 7,125
2,375 7,125
2,375 7,125
2,375 7,125
2,375 7,125
4,156 12,469
2,375 7,125
2,375 7,125
713 2,138
713 2,138
1,781 5,344
1,781 5,344
2,375 7,125
1,188 3,563
950 2,850
950 2,850
1,781 5,344
570 2,280 2,280 570

570 2,280 2,280 570
760 3,040 3,040 760
1,900 7,600 7,600 1,900
2,660 10,640 10,640 2,660
- - - -
570 2,280 2,280 570
950 3,800 3,800 950
1,520 6,080 6,080 1,520
- - - -
11,400 45,600 45,600 11,400
4,750 19,000 19,000 4,750
11,400 45,600 45,600 11,400
190 760 760 190
1,900 7,600 7,600 1,900
570 2,280 2,280 570

570 2,280 2,280 570
760 3,040 3,040 760
760 3,040 3,040 760
760 3,040 3,040 760
760 3,040 3,040 760
11,400 45,600 45,600 11,400
760 3,040 3,040 760
760 3,040 3,040 760
1,900 7,600 7,600 1,900

7,600 30,400 30,400 7,600
19,000 76,000 76,000 19,000
IV PELAYANAN TINDAKAN MEDIK OPERATIF TIDAK TERENCANA / EMERGENCY / CYTO
NO URAIAN TINDAKAN
1 2
A OPERASI BEDAH DIGESTIF
1 Anastomosis of small intestine to rectal stump (pa
2 Laparoscopyt terapi
3 LAR and to end anastomose
4 LAR dengan colostomy (anterior resection of rectu
5 Ekstraksi Kuku
6 Penjahitan Luka 1-4 Jahitan
7 Ekstraksi Gigi Goyang Depan
5 Pungsi Pleura/Abdomen
5 Miles prosedur
6 Pancreatectomy roux n y
7 Ruptur gaster gastrojejunustomy + jejunustomy fe
8 Soave
9 Achlasia Aesophagus
14 Hordiulum (Mata)
15 Persalinan Normal
10 Arthroscopy diagnostic
11 Arthroscopy debridement
12 Bristow Procedure
13 Choledochojejunustomy roux n y
14 Cysto jejunostomy roux n y pada kista empedu
15 Cysto jejunostomy roux n y pada kista pankreas
16 Discectomy
17 Open and other left hemicolectomy
18 Open and other resection colon transfersum
19 Open and other sigmoidectomy
20 Open Drainage abses hepar
21 Other and unspecified partial excision of large inte
22 Repair recto vaginal fistula
23 Ruptur gaster jahit primer omental patch
24 Laparoscopy
25 Anastomosis other small-to-large intestinal
26 Anastomosis Smal-to-small intestinal
27 Appendiktomi and drainage appendikceal abses
28 Cholesistectomy
29 Debulking
30 Eviscerasi dengan GA
31 Exteriorization of small intestine
32 Hernia fomaralis bilateral dengan atau tanpa graft
33 Herniotomi hernioraphi anostomosis
34 HIL bilateral (other and open bilateral repair of di
35 HIM bilateral (other and open bilateral repair of in
36 Laparoscopic appendectomy
37 Laparotomy eksplorasi dengan stoma
38 Other and open bilateral repair of inguinal hernia,
39 Repair Sub total perianal rupture
40 Repair total perianal rupture
41 Suture of laceration of duodenum
42 Suture of laceration of small intestine
43 Appendiktomi pada apendicities akut/kronis
44 Hernia femoralis unilateral dg atau tanpa graft (unil
45 Herniotomi hernioraphi selain HIM atau HIL dngan
46 Herniotomi pada anak
47 Hernitomy hernioraphi HIL unilateral dg atau tanpa
48 Hernitomy hernioraphi HIM unilateral dg atau tanpa
49 Hidrocele komunikan
50 Hidrocele punikuli
51 Hidrocele testis (hidrocele/excision af hydrocele of
52 Laparascopic diagnostic
53 Penutupan stoma pada colostomy (closure of stoma o
54 Penutupan stoma pada ileustomy (closure of stoma o
55 Funikokelektomy
56 Hydrokelektomy per inguinal
57 Hydrokelektomy per scrotal
58 Anoplasty pada setriktural anus
59 Closed Drainage abses hepar dengan GA
60 Colostomi
61 Excision of varicocele and hydrocele of spermatic c
62 Exici polip recti dengan GA
63 Exteriorication of large intestine
64 Gastrostomy
65 Haemorroidectomi/procedur on hemorrhoids)
66 Perianal Fistulectomy
67 Preauricula Fistulectomy
68 Prolaps recti (repair)
69 Release constriction band
70 Repair anus
71 Repair old perineal ruphture
72 Repair uracus
73 Stepler haemorroidectomi
74 Reseksi urachus
75 Closed Drainage abses hepar dengan LA
76 Colonoscopi disertai extirpasi tumor
77 Exici polip recti dengan LA
78 Fistulectomy
79 Perianal fistulotomi
80 Colonoscopi
81 Lavage
82 Potong stoma pada soave
83 Gastroscopi
84 Gastroscopi disertai biopsi
85 Gastroscopi disertai ligasi varises esofagus (LVE)
86 Gastroscopi disertai sclero terapi endoskopi (STE)
87 Insisi absces perineum
88 Insisi ansces scrotum
89 Anuscopy biopsi dengan LA (Local anaesthesia)
90 Open biopsy of breast dengan LA
100 Bipolar resectoscopy
101 Ekstraksi ductus choledocy
102 Ekstraksi batu ductus choledocus
103 Histeroscopy diagnostic
104 Histeroscopy operative
105 Laparotomy + release adhesi
106 Re-open Laparotomy
107 Transanal Endorected pull through
108 Transanal swense eike
B OPERASI BEDAH ANAK
1 Anaplasty PSA (postero sagital anoplasty)
2 Ilizarov
3 Invaginasi
4 Eksisi ductus thyroglosus
5 Illeustomi pada anak
6 Laparatomi pada anak
7 Orchidectomy bilateral
8 Hirschprung's/colostomy pada hirsprung's
9 Anoplasty atresia ani letak rendah (cutback incisio
10 Anoplastyh + uretheroplasty
11 Postero sagictal anorected pull through
C OPERASI BEDAH ORTHOPEDI
1 Koreksi Scoliosis
2 Total elbow arthtoplasty
3 Total Hip arthtoplasty
4 Total knee arthtoplasty
5 Total shoulder arthtoplasty
6 Debridement TB tulang belakang
7 Hemiarthroplasty (AMP, bipolar) complicated
8 Internal fiksasi fraktur acetabulum complicated
9 Internal fiksasi fraktur collumn femur complicated
10 Internal fiksasi fraktur collumn femur dengan DHS
11 Internal fiksasi fraktur collumn femur dengan ABP
12 Internal fiksasi fraktur pelvis complicated
13 Internal fiksasi fraktur scapula complicated
14 Osteotomi korektif(HTO, freanch, dll)
15 Other reconstructive procedure of the shoulder
16 Rekonstruksi ACL/PCL
17 Koreksi horshoe kidney (ishmectomy)
18 Bone graft iliac/fibular/autograft lainnya
19 Disartikulasi Hip
20 Disartikulasi shoulder
21 Elevation of skull fracture fragments
23 Hemiarthroplasty (AMP, bipolar)
24 Internal fiksasi fraktur acetabulum
25 Internal fiksasi fraktur collumn femur
26 Internal fiksasi fraktur femur dengan ABP
27 Internal fiksasi fraktur femur dengan K wire compl
28 Internal fiksasi fraktur femur dengan plate & scre
29 Internal fiksasi fraktur femur dengan DHS
30 Internal fiksasi fraktur humerus complicated
31 Iinternal fiksasi fraktur pelvis
32 Iinternal fiksasi fraktur radius complicated
33 Iinternal fiksasi fraktur scapula
34 Iinternal fiksasi fraktur symphisis pubis/symphisio
35 Internal fiksasi fraktur tibia complicated
36 Open reduction dislocation
37 Operasi avulsi PCL/ACL
38 Patellar stabilization
39 Pengambilan implant tulang belakang
40 Phacoemulsifikasi
41 Rekonstruksi bunion
42 Arthroscopy other procedures
43 Internal fiksasi fraktur carpalia
44 Internal fiksasi fraktur clavikula complicated
45 Internal fiksasi fraktur femur dengan K wire
46 Internal fiksasi fraktur femur dengan nail
47 Internal fiksasi fraktur femur dengan plate & scre
48 Internal fiksasi fraktur fibula complicated
49 Internal fiksasi fraktur radius
50 Internal fiksasi fraktur radius ulna
51 Internal fiksasi fraktur tibia fibula
52 Internal fiksasi fraktur ulna complicated
53 Arhtrodesis Pantalar
54 Arhtrodesis shoulder
55 Arhtrodesis subtalar
56 Arhtrodesis elbow
57 Arhtrodesis genu
58 Arhtrodesis hip
59 Arhtrodesis talocrural
60 Arhtrodesis triple
61 Arhtrodesis wrist
62 Bone graft allograft/xenograft/hydroxyapatite
63 Debridement osteomyelitis
64 Eksternal fiksasi pelvis
65 Eksternal fiksasi wrist
66 Ekstirpasi tumor + rekonstruksi (diluar orthopedi)
67 Excisi bone tumor
68 Fraktur costae dg internal fiksasi (pasang shapp pla
69 Free skin graft not otherwise specified
70 Internal fiksasi fraktur clavikula
71 Internal fiksasi fraktur fibula
72 Internal fiksasi fraktur humerus
73 Internal fiksasi fraktur patella complicated
74 Internal fiksasi fraktur tibia
75 Internal fiksasi fraktur tibia plateau complicated
76 Internal fiksasi fraktur ulna
77 Osteotomy sederhana
78 Pengambilan implant ABP
79 Pengambilan implant DHS
80 Pengambilan nail/plate termasuk implant symphisi
81 Amputasi below knee
82 Amputasi above elbow
83 Amputasi chopart
84 Amputasi Lisfranc
85 Amputasi syme
86 Amputasi ankle
87 Arthrodesis phalang manus
88 Arthrodesis phalang metacarpal
89 Arthrodesis phalang metatarsal
90 Arthrodesis phalang pedis
91 Debridement open fracture
92 Disartikulasi ankle
93 Disartikulasi elbow
94 Disartikulasi knee
95 Disartikulasi wrist
96 Disisi Aspirasi katarak dengan LA
97 Eksternal fiksasi tulang panjang
98 Internal fiksasi fraktur metacarpal complicated
99 Internal fiksasi fraktur olecranon
100 Internal fiksasi fraktur patella
101 Internal fiksasi fraktur phalang complicated
102 Internal fiksasi manus multiple
103 Osteoclasis
104 Pengambilan nail/plate termasuk implant symphisi
105 Adductor tenotomy off the hip
106 Amputasi metacarpal
107 Amputasi phalang manus dengan GA (General Anae
108 Amputasi phalang pedis dengan GA (General Anaes
109 Closed tenotomy achiles (achilotenotomy)
110 Excision of the bone
111 Internal fiksasi fraktur metacarpal
112 Internal fiksasi faktur phalang
113 Internal fiksasi fraktur tibia plateau
114 Pasang skeletal traksi dg GA
115 Pengambilan intramedulary nail (femur, tibia)
116 Pengambilan K Wire dengan GA
117 Release de Quervain tenosynovitis GA
118 Amputasi phalang manus dengan LA (local Anaesth
119 Amputasi phalang pedis dengan LA (local anaesthes
120 Anuscopy biopsi dengan GA (general anaesthesia)
121 Ateroma ekstirpasi dengan LA
122 Biopsy of skin and subcutaneous tissue dengan LA
123 Bone marrow analisa (BMA)
124 Closed reduction fractur nasal
125 Pelepasan eksternal fiksasi dengan GA (General An
126 Sondage canaliculi lacrimalis
127 Release CTS dg LA
128 Reposisi fraktur/dislokasi dg GA
129 Reposisi tertutup fraktur dan imobilisasi plaster c
130 Pelepasan eksternal fiksasi dengan LA (local anaest
131 Release de Quervain tenosynovitis
132 Suture of laceration of lip dengan LA (local anaesth
133 Suture of laceration of other part of mount dengan
134 Suture of laceration of palate dengan LA (local ana
135 Triger finger
136 In growing nail (ekstraksi kuku) dg LA
137 Antrostomi dengan CWL
138 Arthroscopy rekonstruksi
139 Stabilisasi posterior
140 Ekstirpasi tumor + rekonstruksi (orthopedi)
D OPERASI BEDAH ONKOLOGI
1 Neck dissection radical bilateral
2 Deseksi kelenjar inguinal
3 Mestectomy subcutaneous unilateral
4 Mastectomy extended simple unilateral
5 Mastectomy simple unilateral
6 Mastectomy sub total
7 Mastectomy Unilateral
8 MRM (modified radical mastectomy)
9 Neck dissection radical unilateral
10 Parotidectomy total
11 Pedicle flaps (advanced)
12 Reseksi hemi mandibula (hemimandibulektomi)
13 Thyroidectomy total
14 Deseksi kelenjar leher
15 Glossectomy parrtial
16 Parotidectomy superfisial
17 Reseksi mandibula bilateral
18 Soft tissue tumor (kompartment reseksi)
19 Sub total unilateral isthmo lobectomy
20 Thyroidectomy subtotal
21 Enukleasi dg GA
22 Basalioma (excision or destruction of lesion or tis
23 Eksisi fibro sarcomamae mama
24 Eksisi ginecomasti/subcutoneus mastectomy
25 Eksisi kelenjar liur
26 Eksisi limfangioma luas
27 Eksisi tumor kelenjar leher
28 Excision or destruction of lesion or tissue of tongue
29 Kista radicular (eksisi)
30 Soft tissue tumor (muscle reseksi)
31 Tumor palatum (eksisi)
32 Basalioma (excision or destruction of lesion or tis
33 Eksisi kelenjar inguinal
34 Eksisi limfangioma
35 Eksisi mamae aberan
36 Epidermoid carsinoma (excision or destruction of l
37 Liposarcoma (eksisi)
38 Soft tissue tumor (eksisi)
39 Trabekulektomi
40 Eksisi fibroma
41 Eksisi fibro adenoma (fam) dengan GA
42 Eksisi tumor adneksa sedang
43 Eksisi tumor kel. Submandibula
44 Eksisi tumor multiple
45 Epidermoid carsinoma (excision or destruction of l
46 Eviscerasi
47 Excision of lesion of breast dengan GA
48 Ganglion Carpi/tarsa
49 Lipoma nochae (ekstirpasi)
50 Ateroma ekstirpasi dengan GA
51 Biopsy of skin and subcutaneous tissue dengan G
52 Chemical peeling
53 Eksisi fibro adenoma (fam) dengan LA
54 Eksisi tumor adneksa kecil
55 Eksisi tumor dengan GA
56 Ekstirpasi korpal dengan penyulit (LA)
57 Excision of lesion of breast dengan LA
58 Lipoma (ekstirpasi) dengan GA
59 Neurofibroma (eksisi) dengan GA
60 Open biopsy of breast dengan GA
61 Tofus (eksisi) dengan GA
64 Eksisi tumor dengan LA
65 Tofus (eksisi) dengan LA
66 Extirpasi geborn myoma
67 Lipoma (ekstirpasi) dengan LA
68 Extirpasi tumor jinak kulit dan bawah kulit
69 Neurofibroma (eksisi) dengan LA
70 Excisi non wajah
E OPERASI BEDAH SYARAF
1 Replantansi/revaskularisasi
2 Trepanasi
3 Laminectomy
4 Laminoplasty
5 Open reduction cervical
6 Spinal fusion (PLIF/ALIF)
8 Other craniectomy
9 Other craniotomy
10 Evakuasi bekuan darah (clot)
11 Parasentesa
12 Injeksi tulang belakang dengan C Arm
F OPERASI BEDAH UROLOGI

1 Nefrolithotomy bivalve
2 Open prostatectomy
3 Uretero litotomi batu ureter pasang stent
4 Bladder neck rekonstruksi
5 Boary flap
6 PNL/PCNL
7 Reimplantasi ureter bilateral
8 Repair fistel enterovesica
9 Repair vesicorectal
10 Repair vesicovagina
11 TUR buli
12 TURP/BNI
13 URS
14 Pielolithotomy
15 Repair urethra
16 Uretero litotomi batu ureter 1/3 distal tanpa neo
17 Uretroplasty pada hypospadias
18 Vaginal histerectomy
19 Anastomose ureter end to end
20 Anastomose urethra end to end
21 Divertikulektomy buli
22 Extended pielolithotomy
23 Internal urethrotomy (sache)
24 Johanson II
25 Lithotripsi
26 Nefroureterectomy
27 Nefropeksi
28 Pieloplasty
29 Radikal nefrectomy
30 Radikal orchidektomy
31 Railroading ruptur urethra
32 Repair fistel vesikokutan
33 Repair trauma buli
34 Sistectomy parsial
35 Ureterocutaneostomy
36 Uretero litotomi distal
37 Enukleasi dg GA
38 Nephrotomy and nephrostomy
39 Orchidectomi + orchidopexy contra lateral
40 Orchidectomi pada undescensus testis unilateral
41 Partial nefrektomi
42 Repair AC joint sclera dengan GA
43 Unilateral orchidectomy
44 Insisi posterior urethral valve
45 Johanson I
46 Koreksi priapismus alghorab
47 Open nefrostomy
48 Orchidopeksi (torsio testis)
49 Orchidopeksi (undescencus testis)
50 Palomo
51 PER (primary endoscopy realignment)
52 Uretero litotomi proksimal
53 Batu buli-buli (sectio alta)
54 Percutaneous nephrostomy without fragmentation
56 Repair of testis
57 Cordektomi
58 Drainase periureter
59 Eksis web penis
60 Epispadia
61 Nefrostomi percutan
62 Parsial penektomi
63 Rekonstruksi penis
64 RPG (retrograde pielografi)
65 Subcapsuler orchidectomi
66 Tailoring ureter
67 Total penektomi
68 Vasoepididimostomy
69 Vesikolithotomy
70 Open cistostomi dg GA
71 Other repair of urinary bladder
72 Sialo lithiasis (ekstraksi batu dan marsupiasisasi)
73 Urethro litotomi batu uretra anterior dengan ata
74 Cistectomy ginjal
75 Divertikulektomy urethra
76 Insersi DJ Stent
77 Insersi selang tenckhof CAPD
78 pungsi dan sklesrosing kista ginjal
79 Repair fistel urethra
80 Skrotoplasty
81 Urethrolithotomy (GA)
82 Percutaneous cystostomy (closed cystotomy)
83 Spermatocele
84 Urethro litotomi batu uretra anterior dengan atau
85 Vitrektomi
86 Spermatokelectomy
87 Dilantasi uretra/bouginasi caterisasi
88 Vasectomi LA
89 Biopsi testis
90 Circumsisi dengan LA (local anaesthesia)
91 Biopsi penis
92 Cabut DJ stent
93 Circumsisi dengan GA (general anaesthesia)
94 Meatotomy
95 Operasi priapismus winter's procedure
96 Panendoscopy
97 Sitoscopy
98 Vasectomy (narkose)
99 Casting
100 Transurethral prostatectomy
101 Uretero litotomi batu ureter 1/3 distal + neo impla
102 Nefrolithotomy
G OPERASI BEDAH THORAX KARDIO VASKULER( BTKV )

1 Sternotomy pada tumor mediastinum
2 Thorakotomy lobectomy tumor paru
3 Thorakotomy pada PDA (patent ductus ateriosus pe
4 Thoraktomy pada tamponade jantung
5 Internal fiksasi (pasang shapp plate) fraktur costae
6 Repair vascular dg graft
7 Tendon transfer
8 Thorakotomy pada emphiema
9 Thorakotomy pada hematothotax
10 Thorakotomy pada hematothotax dg lobectomy par
11 Thoraktomy pada tumor pleura
12 Anastomose vascular end to end
13 Fraktur costae dg internal fiksasi (pasang shapp pl
14 Repair vascular
15 Vasografi
16 Eksisi hemangioma
17 Skin graft flap sederhana
18 A-V Shunt (cimino)
19 Debridement excisional of wound
20 Debridement incisi & drainage septic arthritis
21 Nevus pigmentosus (eksisi) dengan GA
22 Incisi abces dengan GA (general anaesthesia)
23 Pasang WSD
24 Electro encephalography (EEG)
25 Incisi abces dengan LA (Local anaesthesia)
26 Pasang central venous presure (CVP/CVC)
27 Double lumen
H OPERASI BEDAH PLASTIK

1 Fraktur maxilla lefolt III (internal fiksasi)
2 Neo Implantasi boary flap
3 Labio genatopalatoschisis
4 Other operations on mouth and face
5 Other reconstruction of the toe
6 Rekonstruksi kelopak mata berat
7 Rekonstruksi sindaktili
8 Rekonstruksi digiti
9 Release kontraktur luas
10 Fraktur hemimaksila (internal fiksasi)
11 Fraktur mandibula simple (internal fiksasi)
12 Fraktur maxila lefolt I (internal fiksasi)
13 Other tendon lengthening
14 Palatoplasty
15 Partial Nefrektomi
16 Pedicle flaps sederhana
17 Reduksi macrodactili
18 Release chordae(release of chordae)
19 Repair ruptur palpebra transkanal dengan GA
20 Repair ruptur moderate
21 Tendon transfer for stabilization of patella
22 FTSG (full-thickness skin graft to other sites)
23 Labioplasti/repair of cleft lip
24 Rekonstruksi palpebra
25 Relese kontraktur sederhana
26 Skin graft (STSG)
27 STSG (skinn graf : free skin graft)
28 Debridement infection or burn
29 Fasciotomy
30 Fraktur alfeolaris (pasang archbar)
31 Couterisasi clavus/veruca dengan GA
32 Eksisi keloid dengan GA (general anaesthesia)
33 Fiksasi arch bar dengan GA
34 Finger tip injury (repair v-y flap) dg GA
35 In growing nail (ekstraksi kuku) dg GA
36 Re hechting dengan GA
37 Re hechting dengan GA pada burst abdomen
38 Rekonstruksi polidaktili
39 Couterisasi clavus/veruca dengan LA
40 Jahit luka diwajah dengan GA (general anasthesia)
41 Lobuloplasty bilateral
42 Lobuloplasty unilateral
43 Parasentesa BMD
44 Suture of laceration of other part of mounth denga
45 Explorasi corpus alienum simple dengan LA
46 Jahit luka diwajah dengan LA (local anasthesia)
47 Eksisi keloid dengan LA (local anaesthesia)
48 Incisi pada hidung
49 Injeksi sub konjungtiva
50 Jahit palpebra kecil
51 Nevus pigmentosus (eksisi) dengan LA
52 Re hechting dengan LA
53 Excisi wajah
54 Glossectomy total (complet)
I OPERASI BEDAH TRAUMA

1 Internal bleeding ruptur ginjal/hepar/lien/sebab l
2 Amputasi forequarter
3 Amputasi hindquarter
4 Fraktur mandibula complicated (internal fiksasi)
5 Fraktur mandibula simple (internal fiksasi + pasan
6 Fraktur maxilla lefolt II (internal fiksasi)
8 Repair tendon achiles complicated
9 Ekstirpasi korpal dengan penyulit (GA)
10 Repair tendon achiles
11 Repair tendon ekstersor pedis
12 Repair tendon fleksor pedis
13 Repair tendon patella
14 Tendon achiles lengthening
15 Repair tendon fleksor/ekstensor pedis
16 Repair tendon fleksor/ekstensor manus (1 tendon)
17 Tracheostomi permanent
18 Transfusi tukar
19 Explorasi corpus alienum dengan penyulit
20 Finger tip injury (repair v-y flap) dengan LA
21 Tracheostomi temporer
22 Repair tendon sederhana (1 tendon)
23 Extraksi corpus alienum sederhana (bedah)
J OPERASI OBSTETRI DAN GINEKOLOGI(OBSGIN)

1 Supra vaginal histeroctomy/total abdominal histe
2 Cystektomi/ovarektomi bilateral
3 Miomektomi
4 Repeated sectio caesaria
5 Salphingo oophorectomy bilateral
6 Salphingo oophorectomy unilateral
7 Sectio caesaria
8 Sectio caesaria + cystektomy/ovarektomy bilateral
9 Sectio caesaria + cystektomy/ovarektomy unilatera
10 Sectio caesaria + miomektomy
11 Sectio caesaria + salphingo oophorectomy bilateral
12 Sectio caesaria + salphingo oophorectomy unilatera
13 Sectio caesaria + tubektomy pomeroy
14 Sectio caesaria gemelly
16 Vaginal reconstruction
17 Cystektomi/ovarektomi unilateral
18 Vaginoplasty
19 Curettage abortus incipien (inkomplit)
20 Curettage HPP (late HPP)
21 Curettage meno (metorrhagia)
22 Curettage missed abortion (death conceptus, bligh
23 Curettage molla hydatidosa
24 Incisi hymen imperforate
25 Kista dermoid eksisi dengan GA
26 Repair perineum/vagina (perineoraphy)
27 Repair vagina/cerviks/portio
28 Seconderi repair ephisiotomi
29 Tubektomy laparoscopy
31 Tubektomy minilaparotomy
32 Eksterpasi cysta bartolin
33 Kista dermoid eksisi dengan LA
34 Extirpasi tumor jinak vagina
35 Dermaroller platellet rich plasma (PRP)
36 Insisi absces bartholini + marsupialisasi
37 Reposisi inversio uteri
38 Extirpasi polip cervik
39 Extraksi corpus alienum vagina
40 Salphingo/Oophorectomy
41 Total abdominal hysterektomy + bisalphingoo oop
K OPERASI MATA
1 Disisi aspirasi katarak dengan GA
2 Repair ruptur cornea sclera dengan GA
3 Ekstraksi katarak pasang IOL
4 Koreksi entropion
5 Koreksi extropion
6 Koreksi simblepharon
7 Repari ruptur cornea sclera
8 Saucerization
9 Sequestrectomy
10 Jahit lid mirgin
11 Kanalisasi lakrimal
12 Repair laserasi konjungtiva
13 Repair laserasi kornea
14 Repair laserasi sclera
15 Repair ruptur palpebra simple
16 Repair ruptur palpebra transkanal
17 Aspirasi katarak sekunder
18 Extirpasi pterygium
19 Flap konjungtiva
20 Hymenorapi
21 Repair ruptur cornea
22 Repair ruptur konjungtiva
23 Eksisi calazion
24 Eksisi hordiolum
25 Ekstirpasi granuloma
26 Ekstraksi lithiasis
27 Insisi cornea
28 Irigasi trauma kimia perdrip
30 Skarping cornea
31 Ekstrasi corpus alienum cornea
L OPERASI TELINGA HIDUNG TENGGOROKAN (THT)

1 Tonsilektomi
2 Exstraksi polip nasi
3 Irigasi sinus
4 Anastesi
5 Adenotonsilectomy
6 Ethmoidektomy
7 Faringectomy
IV. PELAYANAN TINDAKAN MEDIK OPERATIF TIDAK TERENCANA / EMERGENCY / CYTO

* tarif dikalikan 25% dari tindakan medik operatif pada III A
EMERGENCY / CYTO
JASA DIREKSI SISA JASA

TARIF JASA SARANA
PELAYANAN PELAYANAN
5%
3 4 5 6 7
- -
6,050,000 3,630,000 2,420,000 121,000 2,299,000
5,280,000 3,168,000 2,112,000 105,600 2,006,400
5,775,000 3,465,000 2,310,000 115,500 2,194,500
5,775,000 3,465,000 2,310,000 115,500 2,194,500
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
6,160,000 3,696,000 2,464,000 123,200 2,340,800
5,280,000 3,168,000 2,112,000 105,600 2,006,400
5,775,000 3,465,000 2,310,000 115,500 2,194,500
6,600,000 3,960,000 2,640,000 132,000 2,508,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
5,280,000 3,168,000 2,112,000 105,600 2,006,400
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
2,530,000 1,518,000 1,012,000 50,600 961,400
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
- -
6,050,000 3,630,000 2,420,000 121,000 2,299,000
6,050,000 3,630,000 2,420,000 121,000 2,299,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
2,530,000 1,518,000 1,012,000 50,600 961,400
1,430,000 858,000 572,000 28,600 543,400
6,050,000 3,630,000 2,420,000 121,000 2,299,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
- -
- -
6,050,000 3,630,000 2,420,000 121,000 2,299,000
6,050,000 3,630,000 2,420,000 121,000 2,299,000
6,050,000 3,630,000 2,420,000 121,000 2,299,000
6,050,000 3,630,000 2,420,000 121,000 2,299,000
6,050,000 3,630,000 2,420,000 121,000 2,299,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
330,000 198,000 132,000 6,600 125,400
3,850,000 2,310,000 1,540,000 77,000 1,463,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
6,050,000 3,630,000 2,420,000 121,000 2,299,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
- -
5,280,000 3,168,000 2,112,000 105,600 2,006,400
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
- -
6,050,000 3,630,000 2,420,000 121,000 2,299,000
6,050,000 3,630,000 2,420,000 121,000 2,299,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
1,917,000 1,188,000 729,000 36,450 692,550
330,000 198,000 132,000 6,600 125,400
- -
- -
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1430000 858000 572000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
- -
- -
- -
-
6,600,000 3,960,000 2,640,000 132,000 2,508,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
6,600,000 3,960,000 2,640,000 132,000 2,508,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
1,000,000 500,000 500,000 25,000 475,000
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
1,200,000 500,000 700,000 35,000 665,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
- -
- -
3,850,000 2,310,000 1,540,000 77,000 1,463,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
- -
- -
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
330,000 198,000 132,000 6,600 125,400
- -
- -
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
4,300,000 2,500,000 1,800,000 90,000 1,710,000
4,970,000 2,970,000 2,000,000 100,000 1,900,000
4,970,000 2,970,000 2,000,000 100,000 1,900,000
4,970,000 2,970,000 2,000,000 100,000 1,900,000
4,970,000 2,970,000 2,000,000 100,000 1,900,000
4,970,000 2,970,000 2,000,000 100,000 1,900,000
4,970,000 2,970,000 2,000,000 100,000 1,900,000
4,600,000 2,700,000 1,900,000 95,000 1,805,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
3,850,000 2,310,000 1,540,000 77,000 1,463,000
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
550,000 330,000 220,000 11,000 209,000
330,000 198,000 132,000 6,600 125,400
330,000 198,000 132,000 6,600 125,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
4,950,000 2,970,000 1,980,000 99,000 1,881,000
- -
- -
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,850,000 2,310,000 1,540,000 77,000 1,463,000
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
2,530,000 1,518,000 1,012,000 50,600 961,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
1,430,000 858,000 572,000 28,600 543,400
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
770,000 462,000 308,000 15,400 292,600
550,000 330,000 220,000 11,000 209,000
330,000 198,000 132,000 6,600 125,400
- -
- -
1,980,000 1,188,000 792,000 39,600 752,400
1,430,000 858,000 572,000 28,600 543,400
330,000 198,000 132,000 6,600 125,400
250,000 150,000 100,000 5,000 95,000
4,950,000 2,970,000 1,980,000 99,000 1,881,000
3,080,000 1,848,000 1,232,000 61,600 1,170,400
3,850,000 2,310,000 1,540,000 77,000 1,463,000
- -
- -
- -
EMERGENCY / CYTO - -
- -
- -
COST CENTER INDEX KINERJA TIM BEDAH TIM ANESTESI OPERATOR
15% 35% 50% 70% 30% 50%

8 9 10 11 12 13
- - -
344,850 804,650 1,149,500 804,650 344,850 402,325
300,960 702,240 1,003,200 702,240 300,960 351,120
329,175 768,075 1,097,250 768,075 329,175 384,038
329,175 768,075 1,097,250 768,075 329,175 384,038
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
376,200 877,800 1,254,000 877,800 376,200 438,900
351,120 819,280 1,170,400 819,280 351,120 409,640
300,960 702,240 1,003,200 702,240 300,960 351,120
329,175 768,075 1,097,250 768,075 329,175 384,038
376,200 877,800 1,254,000 877,800 376,200 438,900
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
300,960 702,240 1,003,200 702,240 300,960 351,120
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
- - -
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
282,150 658,350 940,500 658,350 282,150 329,175
144,210 336,490 480,700 336,490 144,210 168,245
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
376,200 877,800 1,254,000 877,800 376,200 438,900
376,200 877,800 1,254,000 877,800 376,200 438,900
- - - - - -
344,850 804,650 1,149,500 804,650 344,850 402,325
344,850 804,650 1,149,500 804,650 344,850 402,325
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
144,210 336,490 480,700 336,490 144,210 168,245
81,510 190,190 271,700 190,190 81,510 95,095
344,850 804,650 1,149,500 804,650 344,850 402,325
376,200 877,800 1,254,000 877,800 376,200 438,900
- - - - - -
- - - - - -
344,850 804,650 1,149,500 804,650 344,850 402,325
344,850 804,650 1,149,500 804,650 344,850 402,325
344,850 804,650 1,149,500 804,650 344,850 402,325
344,850 804,650 1,149,500 804,650 344,850 402,325
344,850 804,650 1,149,500 804,650 344,850 402,325
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
18,810 43,890 62,700 43,890 18,810 21,945
219,450 512,050 731,500 512,050 219,450 256,025
376,200 877,800 1,254,000 877,800 376,200 438,900
344,850 804,650 1,149,500 804,650 344,850 402,325
282,150 658,350 940,500 658,350 282,150 329,175
- - - - - -
300,960 702,240 1,003,200 702,240 300,960 351,120
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
- - - - - -
344,850 804,650 1,149,500 804,650 344,850 402,325
344,850 804,650 1,149,500 804,650 344,850 402,325
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
175,560 409,640 585,200 409,640 175,560 204,820
103,883 242,393 346,275 242,393 103,883 121,196
18,810 43,890 62,700 43,890 18,810 21,945
- - - - - -
- - - - - -
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
376,200 877,800 1,254,000 877,800 376,200 438,900
- - -
- - -
- - -
- - -
376,200 877,800 1,254,000 877,800 376,200 438,900
376,200 877,800 1,254,000 877,800 376,200 438,900
376,200 877,800 1,254,000 877,800 376,200 438,900
376,200 877,800 1,254,000 877,800 376,200 438,900
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
175,560 409,640 585,200 409,640 175,560 204,820
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
71,250 166,250 237,500 166,250 71,250 83,125
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
99,750 232,750 332,500 232,750 99,750 116,375
175,560 409,640 585,200 409,640 175,560 204,820
- - - - - -
- - - - - -
219,450 512,050 731,500 512,050 219,450 256,025
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
- - - - - -
- - - - - -
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
18,810 43,890 62,700 43,890 18,810 21,945
- - - - - -
- - - - - -
282,150 658,350 940,500 658,350 282,150 329,175
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 276,507
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
256,500 598,500 855,000 598,500 256,500 299,250
285,000 665,000 950,000 665,000 285,000 359,100
285,000 665,000 950,000 665,000 285,000 359,100
285,000 665,000 950,000 665,000 285,000 359,100
285,000 665,000 950,000 665,000 285,000 359,100
285,000 665,000 950,000 665,000 285,000 359,100
285,000 665,000 950,000 665,000 285,000 359,100
270,750 631,750 902,500 631,750 270,750 341,145
219,450 512,050 731,500 512,050 219,450 256,025
219,450 512,050 731,500 512,050 219,450 256,025
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
31,350 73,150 104,500 73,150 31,350 36,575
18,810 43,890 62,700 43,890 18,810 21,945
18,810 43,890 62,700 43,890 18,810 21,945
175,560 409,640 585,200 409,640 175,560 204,820
282,150 658,350 940,500 658,350 282,150 329,175
- - - - - -
- - - - - -
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
175,560 409,640 585,200 409,640 175,560 204,820
219,450 512,050 731,500 512,050 219,450 256,025
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
144,210 336,490 480,700 336,490 144,210 168,245
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
81,510 190,190 271,700 190,190 81,510 95,095
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
43,890 102,410 146,300 102,410 43,890 51,205
31,350 73,150 104,500 73,150 31,350 36,575
18,810 43,890 62,700 43,890 18,810 21,945
- - - - - -
- - - - - -
112,860 263,340 376,200 263,340 112,860 131,670
81,510 190,190 271,700 190,190 81,510 95,095
18,810 43,890 62,700 43,890 18,810 21,945
14,250 33,250 47,500 33,250 14,250 16,625
282,150 658,350 940,500 658,350 282,150 329,175
175,560 409,640 585,200 409,640 175,560 204,820
219,450 512,050 731,500 512,050 219,450 256,025
- - - - - -
- - - - - -
ANESTESI DOKTER
PERAWAT
PERAWAT OK DOKTER PENDAMPING
PERAWAT NICU
ANESTESI OPERASI
40% 50% 50%
14 15 16 17 18
402,325 172,425 172,425

351,120 150,480 150,480
384,038 164,588 164,588
384,038 164,588 164,588
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
438,900 188,100 188,100
409,640 175,560 175,560
351,120 150,480 150,480
384,038 164,588 164,588
438,900 188,100 188,100
256,025 109,725 109,725
256,025 109,725 109,725
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
351,120 150,480 150,480
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
- - -
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
36,575 15,675 15,675
21,945 9,405 9,405
21,945 9,405 9,405
329,175 141,075 141,075
256,025 109,725 109,725
329,175 141,075 141,075
168,245 72,105 72,105
329,175 141,075 141,075
329,175 141,075 141,075
256,025 109,725 109,725
438,900 188,100 188,100
438,900 188,100 188,100
- - -
402,325 172,425 172,425
402,325 172,425 172,425
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
168,245 72,105 72,105
95,095 40,755 40,755
402,325 172,425 172,425
438,900 188,100 188,100
- - -
- - -
402,325 172,425 172,425
402,325 172,425 172,425
402,325 172,425 172,425
402,325 172,425 172,425
402,325 172,425 172,425
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
36,575 15,675 15,675
36,575 15,675 15,675
36,575 15,675 15,675
36,575 15,675 15,675
36,575 15,675 15,675
21,945 9,405 9,405
256,025 109,725 109,725
438,900 188,100 188,100
402,325 172,425 172,425
329,175 141,075 141,075
- - -
351,120 150,480 150,480
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
51,205 21,945 21,945
51,205 21,945 21,945
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
36,575 15,675 15,675
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
- - -
402,325 172,425 172,425
402,325 172,425 172,425
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
256,025 109,725 109,725
204,820 87,780 87,780
121,196 51,941 51,941
21,945 9,405 9,405
- - -
- - -
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
329,175 141,075 141,075
329,175 141,075 141,075
256,025 109,725 109,725
438,900 188,100 188,100
- - -
- - -
- - -
- - -
438,900 188,100 188,100
438,900 188,100 188,100
438,900 188,100 188,100
438,900 188,100 188,100
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
204,820 87,780 87,780
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
95,095 40,755 40,755
51,205 21,945 21,945
83,125 35,625 35,625
21,945 9,405 9,405
21,945 9,405 9,405
116,375 49,875 49,875
204,820 87,780 87,780
- - -
- - -
256,025 109,725 109,725
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
36,575 15,675 15,675
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
21,945 9,405 9,405
- - -
- - -
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
256,025 109,725 109,725
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
21,945 9,405 9,405
- - -
- - -
329,175 141,075 141,075
256,025 109,725 109,725
256,025 109,725 109,725
204,820 109,725 109,725 21,506 9,217
256,025 109,725 109,725
256,025 109,725 109,725
239,400 128,250 128,250 41,895 17,955
266,000 142,500 142,500 27,930 11,970
266,000 142,500 142,500 27,930 11,970
266,000 142,500 142,500 27,930 11,970
266,000 142,500 142,500 27,930 11,970
266,000 142,500 142,500 27,930 11,970
266,000 142,500 142,500 27,930 11,970
252,700 135,375 135,375 26,534 11,372
256,025 109,725 109,725
256,025 109,725 109,725
168,245 72,105 72,105
168,245 72,105 72,105
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
36,575 15,675 15,675
36,575 15,675 15,675
36,575 15,675 15,675
21,945 9,405 9,405
21,945 9,405 9,405
204,820 87,780 87,780
329,175 141,075 141,075
- - -
- - -
204,820 87,780 87,780
204,820 87,780 87,780
204,820 87,780 87,780
256,025 109,725 109,725
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
168,245 72,105 72,105
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
131,670 56,430 56,430
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
95,095 40,755 40,755
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
51,205 21,945 21,945
36,575 15,675 15,675
21,945 9,405 9,405
- - -
- - -
131,670 56,430 56,430
95,095 40,755 40,755
21,945 9,405 9,405
16,625 7,125 7,125
329,175 141,075 141,075
204,820 87,780 87,780
109,725 109,725 109,725
- - -
- - -
V. PELAYANAN TINDAKAN MEDIK NON OPERATIF - -
- -
1 Peritonial Dialisis 490,000 294,000 196,000 9,800 186,200 27,930
2 Injeksi LP Intratekal 125,000 75,000 50,000 2,500 47,500 7,125
3 Injeksi LP Epidural 125,000 75,000 50,000 2,500 47,500 7,125
4 Injeksi Impletol 5,000 3,000 2,000 100 1,900 285
5 Etanol Terapi Tumor Hati 250,000 150,000 100,000 5,000 95,000 14,250
6 Pasang Sonde 5,000 3,000 2,000 100 1,900 285
7 Pasang Skin Traction 60,000 36,000 24,000 1,200 22,800 3,420
8 Skleroterapi 650,000 390,000 260,000 13,000 247,000 37,050
9 Injeksi Intranodul 30,000 18,000 12,000 600 11,400 1,710
10 Esofagogastroduodenoskopi 300,000 180,000 120,000 6,000 114,000 17,100
11 Esofagogastroduodenoskopi dengan biopsi 450,000 270,000 180,000 9,000 171,000 25,650
12 Kolonoskopi 500,000 300,000 200,000 10,000 190,000 28,500
13 Kolonoskopi dengan biopsi 700,000 420,000 280,000 14,000 266,000 39,900
14 Ligasi Varises 800,000 480,000 320,000 16,000 304,000 45,600
15 Polipektomi 900,000 540,000 360,000 18,000 342,000 51,300
16 Dilatasi Esofagus 800,000 480,000 320,000 16,000 304,000 45,600
17 Clip 900,000 540,000 360,000 18,000 342,000 51,300
18 Regulasi Hemostatis 800,000 480,000 320,000 16,000 304,000 45,600
19 Bronkoskopi dengan biopsi 400,000 240,000 160,000 8,000 152,000 22,800
20 Bronkoskopi dengan brushing 500,000 300,000 200,000 10,000 190,000 28,500
21 Bronkoskopi dengan washing 500,000 300,000 200,000 10,000 190,000 28,500
22 BAL 500,000 300,000 200,000 10,000 190,000 28,500
23 Bronkoskopi pengambilan benda asing 800,000 480,000 320,000 16,000 304,000 45,600
24 Aspirasi mucous 800,000 480,000 320,000 16,000 304,000 45,600
25 Pungsi Lever 500,000 300,000 200,000 10,000 190,000 28,500
26 Tindakan pemberian Sitostatika / Kemoterapi 200,000 120,000 80,000 4,000 76,000 11,400
27 Pemasangan Water Seal Drainage / WSD 1,000,000 500,000 500,000 25,000 475,000 71,250
65,170 93,100 18,620
16,625 23,750 4,750
16,625 23,750 4,750
665 950 190
33,250 47,500 9,500
665 950 190
7,980 11,400 2,280
86,450 123,500 24,700
3,990 5,700 1,140
39,900 57,000 11,400
59,850 85,500 17,100
66,500 95,000 19,000
93,100 133,000 26,600
106,400 152,000 30,400
119,700 171,000 34,200
106,400 152,000 30,400
119,700 171,000 34,200
106,400 152,000 30,400
53,200 76,000 15,200
66,500 95,000 19,000
66,500 95,000 19,000
66,500 95,000 19,000
106,400 152,000 30,400
106,400 152,000 30,400
66,500 95,000 19,000
26,600 38,000 7,600
166,250 237,500 47,500
VI. PELAYANAN KEGAWAT DARURATAN / INSTALASI GAWAT DARURAT (IGD)
NO URAIAN TINDAKAN TARIF JASA SARANA
1 2 3 4
A TINDAKAN UMUM
1 Injeksi im (intra muskular) per kali 5,000 3,000
2 Injeksi iv (intra vena) per kali 5,000 3,000
3 Injeksi ic (intra cutan)per kali 5,000 3,000
4 Injeksi sc (sub cutan)per kali 5,000 3,000
5 Pasang infus dewasa 10,000 6,000
6 Pasang infus anak / bayi 15,000 9,000
7 Ambil sampel darah vena 5,000 3,000
8 Ambil sampel darah arteri 10,000 6,000
9 Pasang NGT dewasa 50,000 30,000
10 Pasang NGT anak / bayi 50,000 30,000
11 Pasang folley cateter 20,000 12,000
12 EKG 50,000 30,000
13 Pemeriksaan glukotest 20,000 12,000
14 suppositoria 5,000 3,000
B TINDAKAN KHUSUS EMERGENCY

1 Pasang mayo / oropharengeal tube* 10,000 6,000
2 Suction aktif / slem suction* 10,000 6,000
3 Pasang ET 1,200,000 500,000
4 Needle cricothyroidectomy 200,000 100,000
5 Pasang neck collar 10,000 6,000
6 Punctie pleural 350,000 200,000
7 Punctie ascites 250,000 150,000
8 Punctie blast 200,000 120,000
9 Cytostomi 300,000 150,000
10 Pemasangan cateter vena central(CVC) 1,200,000 500,000
11 Pemasangan cateter intra osseus /umbilic 200,000 120,000
12 Pemasangan vena sectie 250,000 125,000
13 Needle chest 75,000 45,000
14 Cricothroidectomy 1,200,000 500,000
15 Pemasangan monitor vital sign/jam 30,000 18,000
16 Pemasangan syringe pump 15,000 9,000
17 Pemasangan infussion pump 15,000 9,000
18 Therapi inhalasi tanpa obat / Nebulizer per 20,000 12,000
19 Pemasangan ventilator 200,000 120,000
20 Pemasangan infus warmer 10,000 6,000
21 Pemasangan infant warmer 10,000 6,000
22 Resusitasi Jantung Paru 100,000
23 defribrilator / DC shock 200,000 120,000
24 Manual ventilasi / jam 10,000 6,000
C TINDAKAN KHUSUS SESUAI KASUS EMERGENCY
1 Rawat Luka
a. Kecil (< 5 cm) 15,000 9,000
b. Sedang (5-10 cm) 20,000 12,000
c. Besar (10-20 cm) 50,000 30,000
d. Khusus (> 20 cm) 70,000 42,000
2 Rawat luka bakar < 10 % 25,000 15,000
3 Rawat luka bakar 10 - 50 % 50,000 30,000
4 Rawat luka bakar > 50 % 100,000 60,000
5 Debridemant dan necrotomy
- Luka kecil 25,000 15,000
- Luka sedang 40,000 24,000
- Luka Luas 60,000 36,000
6 Amputasi sendi kecil 200,000 120,000
7 Cross incisi 40,000 24,000
8 Nail Ekstrasi 25,000 15,000
9 Gips 100,000 50,000
10 Ransel verband 50,000 30,000
11 Imobilisasi Fraktur dengan spalk 32,000 20,000
12 Immobilisasi fraktur dengan back slab 60,000 36,000
- Kecil (< 10 Jahitan) 50,000 30,000
- Sedang (10 s/d 20 Jahi 70,000 40,000
- Besar (>20 Jahitan) 100,000 60,000
14 Incisi abses 50,000 30,000
15 Ekstraksi korpus alienum THT/mata/kulit 30,000 18000
- Ringan 30,000 18,000
- Sedang 50,000 30,000
- Berat 75,000 45,000
16 Ekstraksi batu urethra antherior 75,000 45,000
17 Tindakan lavement/spoeling 30,000 18,000
18 Tindakan reposisi:
- kecil 50,000 30,000
- sedang 50,000 30,000
- besar 50,000 30,000
19 Pemasangan tampon* 20,000 12,000
20 Pelepasan tampon 10,000 6,000
21 Angkat Jahitan
- Kecil (< 10 Jahitan) 15,000 9,000
- Sedang (10 s/d 20 Jahi 25,000 15,000
- Besar (>20 Jahitan) 40,000 24,000
22 Aff infus / NGT / Cateter Urine 2,500 1,500
23 Ultrasonografi (USG) emergency 250,000 150,000
24 Pemasangan WSD 1,000,000 500,000
25 Transfusi darah per kali 30,000 18,000
D RAWAT SEHARI
1 Ruang observasi reguler/P3
- Akomodasi / hari 15,000 15,000
- Visite dokter umum 20,000 5,000
- Visite dokter / konsul s 25,000 5,000
2 Ruang High Care/P2

3 Ruang observasi intensive/P1

JASA DIREKSI SISA JASA COST CENTER INDEX KINERJA
PELAYANAN PELAYANAN
5% 15% 35% 50%
5 6 7 8 9 10
2,000 100 1,900 285 665 950

2,000 100 1,900 285 665 950
2,000 100 1,900 285 665 950
2,000 100 1,900 285 665 950
4,000 200 3,800 570 1,330 1,900
6,000 300 5,700 855 1,995 2,850
2,000 100 1,900 285 665 950
4,000 200 3,800 570 1,330 1,900
20,000 1,000 19,000 2,850 6,650 9,500
20,000 1,000 19,000 2,850 6,650 9,500
8,000 400 7,600 1,140 2,660 3,800
20,000 1,000 19,000 2,850 6,650 9,500
8,000 400 7,600 1,140 2,660 3,800
2,000 100 1,900 285 665 950
- - - - -
- - - - -
4,000 200 3,800 570 1,330 1,900
4,000 200 3,800 570 1,330 1,900
700,000 35,000 665,000 99,750 232,750 332,500
100,000 5,000 95,000 14,250 33,250 47,500
4,000 200 3,800 570 1,330 1,900
150,000 7,500 142,500 21,375 49,875 71,250
100,000 5,000 95,000 14,250 33,250 47,500
80,000 4,000 76,000 11,400 26,600 38,000
150,000 7,500 142,500 21,375 49,875 71,250
700,000 35,000 665,000 99,750 232,750 332,500
80,000 4,000 76,000 11,400 26,600 38,000
125,000 6,250 118,750 17,813 41,563 59,375
30,000 1,500 28,500 4,275 9,975 14,250
700,000 35,000 665,000 99,750 232,750 332,500
12,000 600 11,400 1,710 3,990 5,700
6,000 300 5,700 855 1,995 2,850
6,000 300 5,700 855 1,995 2,850
8,000 400 7,600 1,140 2,660 3,800
80,000 4,000 76,000 11,400 26,600 38,000
4,000 200 3,800 570 1,330 1,900
4,000 200 3,800 570 1,330 1,900
100,000 5,000 95,000 14,250 33,250 47,500
80,000 4,000 76,000 11,400 26,600 38,000
4,000 200 3,800 570 1,330 1,900
- - - - -
- - - - -
6,000 300 5,700 855 1,995 2,850
8,000 400 7,600 1,140 2,660 3,800
20,000 1,000 19,000 2,850 6,650 9,500
28,000 1,400 26,600 3,990 9,310 13,300
10,000 500 9,500 1,425 3,325 4,750
20,000 1,000 19,000 2,850 6,650 9,500
40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
10,000 500 9,500 1,425 3,325 4,750
16,000 800 15,200 2,280 5,320 7,600
24,000 1,200 22,800 3,420 7,980 11,400
80,000 4,000 76,000 11,400 26,600 38,000
16,000 800 15,200 2,280 5,320 7,600
10,000 500 9,500 1,425 3,325 4,750
50,000 2,500 47,500 7,125 16,625 23,750
20,000 1,000 19,000 2,850 6,650 9,500
12,000 600 11,400 1,710 3,990 5,700
24,000 1,200 22,800 3,420 7,980 11,400
- - - - -
20,000 1,000 19,000 2,850 6,650 9,500
30,000 1,500 28,500 4,275 9,975 14,250
40,000 2,000 38,000 5,700 13,300 19,000
20,000 1,000 19,000 2,850 6,650 9,500
12,000 600 11,400 1,710 3,990 5,700
12,000 600 11,400 1,710 3,990 5,700
20,000 1,000 19,000 2,850 6,650 9,500
30,000 1,500 28,500 4,275 9,975 14,250
30,000 1,500 28,500 4,275 9,975 14,250
12,000 600 11,400 1,710 3,990 5,700
- - - - -
20,000 1,000 19,000 2,850 6,650 9,500
20,000 1,000 19,000 2,850 6,650 9,500
20,000 1,000 19,000 2,850 6,650 9,500
8,000 400 7,600 1,140 2,660 3,800
4,000 200 3,800 570 1,330 1,900
- - - - -
6,000 300 5,700 855 1,995 2,850
10,000 500 9,500 1,425 3,325 4,750
16,000 800 15,200 2,280 5,320 7,600
1,000 50 950 143 333 475
100,000 5,000 95,000 14,250 33,250 47,500
500,000 25,000 475,000 71,250 166,250 237,500
12,000 600 11,400 1,710 3,990 5,700
- - - - -
- - - - -
- - - - -
- - - - - -
15,000 750 14,250 2,138 4,988 7,125
20,000 1,000 19,000 2,850 6,650 9,500
- - - - -
- - - - -
- - - - - -
20,000 1,000 19,000 2,850 6,650 9,500
40,000 2,000 38,000 5,700 13,300 19,000
- - - - -
- - - - -
- - - - - -
40,000 2,000 38,000 5,700 13,300 19,000
80,000 4,000 76,000 11,400 26,600 38,000
KELOMPOK KELOMPOK
PERAWAT DOKTER
50% 50%
11 12
475 475
475 475
475 475
475 475
950 950
1,425 1,425
475 475
950 950
4,750 4,750
4,750 4,750
1,900 1,900
4,750 4,750
1,900 1,900
475 475
- -
- -
950 950
950 950
166,250 166,250
23,750 23,750
950 950
35,625 35,625
23,750 23,750
19,000 19,000
35,625 35,625
166,250 166,250
19,000 19,000
29,688 29,688
7,125 7,125
166,250 166,250
2,850 2,850
1,425 1,425
1,425 1,425
1,900 1,900
19,000 19,000
950 950
950 950
23,750 23,750
19,000 19,000
950 950
- -
- -
1,425 1,425
1,900 1,900
4,750 4,750
6,650 6,650
2,375 2,375
4,750 4,750
9,500 9,500
- -
2,375 2,375
3,800 3,800
5,700 5,700
19,000 19,000
3,800 3,800
2,375 2,375
11,875 11,875
4,750 4,750
2,850 2,850
5,700 5,700
- -
4,750 4,750
7,125 7,125
9,500 9,500
4,750 4,750
2,850 2,850
2,850 2,850
4,750 4,750
7,125 7,125
7,125 7,125
2,850 2,850
- -
4,750 4,750
4,750 4,750
4,750 4,750
1,900 1,900
950 950
- -
1,425 1,425
2,375 2,375
3,800 3,800
238 238
23,750 23,750
118,750 118,750
2,850 2,850
- -
- -
- -
- -
3,563 3,563
4,750 4,750
- -
- -
- -
4,750 4,750
9,500 9,500
- -
- -
- -
9,500 9,500
19,000 19,000
VII. PELAYANAN RAWAT INAP DAN KEPERAWATAN
NO URAIAN TINDAKAN
1 2 3 4
A PELAYANAN TINDAKAN KEPERAWATAN
1 Minimal Care per hari
2 Moderate Care per hari
3 High Care per hari
4 Intensif Care per hari
B PELAYANAN TINDAKAN RAWAT INAP
1 Pemeriksaan oleh dokter jaga
2 Pemeriksaan pasien rawat inap gawat oleh dok
3 Pasang infus dewasa
4 Pasang infus anak / bayi
5 Rawat Lokasi infus per hari
6 Rawat Luka
a. Kecil (< 5 cm)
b. Sedang (5-10 cm)
c. Besar (10-20 cm)
d. Khusus (> 20 cm)
7 Rawat luka bakar/gangren < 10 %
8 Rawat luka bakar/gangren 10 - 50 %
9 Rawat luka bakar/gangren > 50 %
10 infus tali pusat
11 Necrotomy jaring ( kecil )
12 Angkat Jahitan
- Kecil (< 10 Jahitan)
- Sedang (10 s/d 20 Jahitan)
- Besar (>20 Jahitan)
13 Pasang tampon
14 Aff Tampon
15 Memandikan bayi/kali
16 Memandikan Pasien/kali
17 Keramas pasien/kali
18 Injeksi im (intra muskular) per kali
19 Injeksi iv (intra vena) per kali
20 Injeksi ic (intra cutan)per kali
21 Injeksi sc (sub cutan)per kali
22 Skin Test
23 Memberi Obat melalui Gastrotomy
24 Memberi Obat Supositoria
25 Penanganan Pre Operasi
26 Pasang Fowley Cateter*
27 Pasang Kondom Cateter*
28 Pasang Bidai*
29 Pasang Neck Collar *
30 Penanganan Keracunan
31 Perawatan Payudara
32 Perawatan WSD
33 Perawatan Kolostomy / Iliestomy
34 Resusitasi Jantung Paru
35 Pasang NGT Dewasa / Anak
36 Pasang ET
37 Pasang Mayo / Oroparingeal
38 Aff infus / NGT / Cateter urine
39 Perawatan Tracheostomy
40 Irigasi Mata
41 EKG
42 Ambil sampel darah vena
43 ambil sampel darah arteri
44 Penggunaan Oksigen ( O2)
a. Tiap 1 liter / menit
b. Pemakaian dan pemasangan O2 per kali ta
45 Suctioning*
46 Therapi Inhalasi tanpa obat / Nebuizer per kal
47 irigasi BPH/hari
48 Spoeling BPH/kali
49 Klisma / Huknah
50 Postural Drainase
JASA JASA DIREKSI SISA JASA
TARIF
SARANA PELAYANAN PELAYANAN
5%
5 6 7 8 (5% x 7) 9 (7 - 8)
10,000 10,000 500 9,500

15,000 15,000 750 14,250
20,000 20,000 1,000 19,000
30,000 30,000 1,500 28,500
- -
15,000 5,000 10,000 500 9,500
20,000 5,000 15,000 750 14,250
10,000 6,000 4,000 200 3,800
15,000 9,000 6,000 300 5,700
2,500 1,500 1,000 50 950
- -
15,000 9,000 6,000 300 5,700
20,000 12,000 8,000 400 7,600
50,000 30,000 20,000 1,000 19,000
70,000 42,000 28,000 1,400 26,600
25,000 15,000 10,000 500 9,500
50,000 30,000 20,000 1,000 19,000
100,000 60,000 40,000 2,000 38,000
150,000 90,000 60,000 3,000 57,000
25,000 15,000 10,000 500 9,500
- - -
15,000 9,000 6,000 300 5,700
25,000 15,000 10,000 500 9,500
40,000 24,000 16,000 800 15,200
10,000 6,000 4,000 200 3,800
10,000 6,000 4,000 200 3,800
25,000 15,000 10,000 500 9,500
25,000 15,000 10,000 500 9,500
15,000 8,000 7,000 350 6,650
5,000 3,000 2,000 100 1,900
5,000 3,000 2,000 100 1,900
5,000 3,000 2,000 100 1,900
5,000 3,000 2,000 100 1,900
5,000 3,000 2,000 100 1,900
5,000 3,000 2,000 100 1,900
5,000 3,000 2,000 100 1,900
10,000 6,000 4,000 200 3,800
20,000 12,000 8,000 400 7,600
5,000 3,000 2,000 100 1,900
10,000 6,000 4,000 200 3,800
10,000 6,000 4,000 200 3,800
35,000 15,000 20,000 1,000 19,000
10,000 6,000 4,000 200 3,800
25,000 15,000 10,000 500 9,500
10,000 6,000 4,000 200 3,800
100,000 50,000 50,000 2,500 47,500
50,000 30,000 20,000 1,000 19,000
1,200,000 500,000 700,000 35,000 665,000
10,000 6,000 4,000 200 3,800
2,500 1,500 1,000 50 950
10,000 6,000 4,000 200 3,800
10,000 6,000 4,000 200 3,800
50,000 30,000 20,000 1,000 19,000
5,000 3,000 2,000 100 1,900
10,000 6,000 4,000 200 3,800
- -
110 110 -
5,000 3,000 2,000 100 1,900
10,000 6,000 4,000 200 3,800
20,000 12,000 8,000 400 7,600
30,000 10,000 20,000 1,000 19,000
10,000 6,000 4,000 200 3,800
10,000 6,000 4,000 200 3,800
20,000 12,000 8,000 400 7,600
DIKERJAKAN DOKTER
COST CENTER INDEX KINERJA
KELOMPOK
DOKTER
PERAWAT
15% 35% 50%
10 (15% x 9) 11 (35% x 9) 12 (50% x 9) 9 10
1,425 3,325 4,750

2,138 4,988 7,125
2,850 6,650 9,500
4,275 9,975 14,250
1,425 3,325 4,750 950 3,800

2,138 4,988 7,125 1,425 5,700
570 1,330 1,900 380 1,520
855 1,995 2,850 570 2,280
143 333 475 95 380
855 1,995 2,850 570 2,280

1,140 2,660 3,800 760 3,040
2,850 6,650 9,500 1,900 7,600
3,990 9,310 13,300 2,660 10,640
1,425 3,325 4,750 950 3,800
2,850 6,650 9,500 1,900 7,600
5,700 13,300 19,000 3,800 15,200
8,550 19,950 28,500 5,700 22,800
1,425 3,325 4,750 950 3,800
855 1,995 2,850 570 2,280

1,425 3,325 4,750 950 3,800
2,280 5,320 7,600 1,520 6,080
570 1,330 1,900 380 1,520
570 1,330 1,900 380 1,520
1,425 3,325 4,750
1,425 3,325 4,750
998 2,328 3,325
285 665 950 190 760
285 665 950 190 760
285 665 950 190 760
285 665 950 190 760
285 665 950 190 760
285 665 950 190 760
285 665 950 190 760
570 1,330 1,900 380 1,520
1,140 2,660 3,800 760 3,040
285 665 950 190 760
570 1,330 1,900 380 1,520
570 1,330 1,900 380 1,520
2,850 6,650 9,500 1,900 7,600
570 1,330 1,900 380 1,520
1,425 3,325 4,750 950 3,800
570 1,330 1,900 380 1,520
7,125 16,625 23,750 4,750 19,000
2,850 6,650 9,500 1,900 7,600
99,750 232,750 332,500 66,500 266,000
570 1,330 1,900 380 1,520
143 333 475 95 380
570 1,330 1,900 380 1,520
570 1,330 1,900 380 1,520
2,850 6,650 9,500 1,900 7,600
285 665 950 190 760
570 1,330 1,900 380 1,520
285 665 950 190 760

570 1,330 1,900 380 1,520
1,140 2,660 3,800 760 3,040
2,850 6,650 9,500 1,900 7,600
570 1,330 1,900 380 1,520
570 1,330 1,900 380 1,520
1,140 2,660 3,800 760 3,040
DIKERJAKAN PERAWAT DIKERJAKAN PERAWAT
KELOMPOK KELOMPOK
DOKTER DOKTER
PERAWAT PERAWAT
11 12 11 12
4,750 -
7,125 -
9,500 -
14,250 -
1,330 570 456 114

1,995 855 684 171
333 143 114 29
- - -
1,995 855 684 171
2,660 1,140 912 228
6,650 2,850 2,280 570
9,310 3,990 3,192 798
3,325 1,425 1,140 285
6,650 2,850 2,280 570
13,300 5,700 4,560 1,140
19,950 8,550 6,840 1,710
3,325 1,425 1,140 285
- -
1,995 855 684 171
3,325 1,425 1,140 285
5,320 2,280 1,824 456
1,330 570 456 114
1,330 570 456 114
4,750 - -
4,750 - -
3,325 - -
665 285 228 57
665 285 228 57
665 285 228 57
665 285 228 57
665 285 228 57
665 285 228 57
665 285 228 57
1,330 570 456 114
2,660 1,140 912 228
665 285 228 57
1,330 570 456 114
1,330 570 456 114
6,650 2,850 2,280 570
1,330 570 456 114
3,325 1,425 1,140 285
1,330 570 456 114
16,625 7,125 5,700 1,425
6,650 2,850 2,280 570
232,750 99,750 79,800 19,950
1,330 570 456 114
333 143 114 29
1,330 570 456 114
1,330 570 456 114
6,650 2,850 2,280 570
665 285 228 57
1,330 570 456 114
- -
- -
665 285 228 57
1,330 570 456 114
2,660 1,140 912 228
6,650 2,850 2,280 570
1,330 570 456 114
1,330 570 456 114
2,660 1,140 912 228
VIII. PELAYANAN KEBIDANAN
1 2 5 6
1 Persalinan Normal 600,000 360,000
2 Curretage 600,000 360,000
3 Persalinan dengan penyulit ringan :
a. Oxytosin Drip 1,000,000 600,000
b. induksi misoprostol 1,000,000 600,000
4 Persalinan dengan penyulit sedang :
a. Ekstraksi Vacum 2,000,000 1,200,000
b. KBI(ksi bimanual internal) 2,000,000 1,200,000
c. Manual Placenta 1,500,000 900,000
d. Manual AID (tindakan partus s 2,000,000 1,200,000
e. Versi Ekstraksi 2,000,000 1,200,000
Persalinan dengan penyulit besar :
a. Embriotomi 3,200,000 1,920,000
DIKERJAKAN DOKTER
COST
JASA DIREKSI SISA JASA INDEX KINERJA KELOMPOK
CENTER DOKTER
PELAYANAN PELAYANAN BIDAN
5% 15% 35% 50% 20% 80%
7 8 (5% x 7) 9 (7 - 8) 10 (15% x11
9) (35% x12
9) (50% x 9) 9 10
240,000 12,000 228,000 34,200 79,800 114,000 22,800 91,200
240,000 12,000 228,000 34,200 79,800 114,000 22,800
400,000 20,000 380,000 57,000 133,000 ### 38,000 152,000

400,000 20,000 380,000 57,000 133,000 ### 38,000 152,000
800,000 40,000 760,000 114,000 266,000 ### 76,000 304,000

800,000 40,000 760,000 114,000 266,000 ### 76,000 304,000
600,000 30,000 570,000 85,500 199,500 ### 57,000 228,000
800,000 40,000 760,000 114,000 266,000 ### 76,000 304,000
800,000 40,000 760,000 114,000 266,000 ### 76,000 304,000
1,280,000 64,000 1,216,000 182,400 425,600 ### 121,600 486,400

DIKERJAKAN BIDAN DOKTER & DIKERJAKAN BIDAN
DOKTER PENATA
KELOMPOK TIM DOKTER ANESTESI
DOKTER ANESTESI ANESTESI ANESTESI KELOMPOK
BIDAN BIDAN
70% 30% 80% 60% 40% 50% 50%
11 12 13 14 14 (30% x 12) 11
79,800 34,200 91,200
91,200 54,720 36,480 18,240 18,240
-
133,000 57,000 152,000
133,000 57,000 152,000
-
266,000 114,000 304,000

199,500 85,500 228,000
266,000 114,000 304,000
266,000 114,000 304,000
-
486,400
DIKERJAKAN BIDAN
DOKTER
12
22,800
-
38,000
38,000
-
76,000
57,000
76,000
76,000
-
121,600
IX. PELAYANAN ICU
NO URAIAN TINDAKAN
1 2
A
1 Tarif visite dokter / Intensiv / Konsultasi antar SMF
2 Jasa Keperawatan ICU / hari
B TINDAKAN
1 Pemasangan monitor vital sign
Sewa alat dan monitoring per jam
2 Pemasangan syringe pump:
3 Pemasangan infussion pump:
4 Pemasangan ventilator
Setting ventilator
5 Sewa alat dan monitoring per jam
Pemasangan Feeding Pump
6 Pemasangan Warm air sheet
7 Pemasangan Blanket Roll
8 Pemasangan Alat anti Dekubitus
9 Bedside monitor / hari
10 Pasang Mayo
11 Pasang NGT
12 Aff NGT
13 Pasang ET
14 Needlle Thorakostomi
15 Pasang Cateter urine
16 Aff Cateter
20 Rawat Luka
a.
b.
c.
d.
23 Pasang infus anak
24 Pemasangan Cateter vena profunda
25 Pemasangan cateter arteri ( artery line )
26 Pemasangan cateter CVP
27 Pemasangan cateter HD
28 Intubasi
28 Cricothyroidotomy / Tracheostomy
29 Bronchial Washing dengan alat
30 Pleural Punction
31 Therapi Inhalasi tanpa obat / Nebuizer per kali
32 Debridement dan necrotomy
-
-
-
33 Pemasangan Cateter epidural
34 Fisioterapi
35 Tindakan Anasthesi ( GA atau RA ) di ICU
36 Resusitasi Kardiopulmoonal ( dengan DC Shock )
37 Pemasangan WSD
38 Asites Puction
39 suction di luar cup per kali
40 Penggunaan Oksigen ( O2 )
a.
b.
c.
URAIAN TINDAKAN TARIF
2 3
dokter / Intensiv / Konsultasi antar SMF 85,000

watan ICU / hari 30,000
-
n monitor vital sign 30,000
an monitoring per jam 1,500
n syringe pump: 15,000
n infussion pump: 15,000
n ventilator 200,000
120,000
n Feeding Pump 15,000
n Warm air sheet 10,000
n Blanket Roll 15,000
n Alat anti Dekubitus 10,000
nitor / hari 40,000
5,000
50,000
2,500
1,200,000
rakostomi 90,000
eter urine 20,000
2,500
bakar/gangren < 10 % 25,000
bakar/gangren 10 - 50 % 50,000
bakar/gangren > 50 % 100,000
-
Kecil (< 5 cm) 15,000
Sedang (5-10 cm) 20,000
Besar (10-20 cm) 50,000
Khusus (> 20 cm) 70,000
dom Cateter* 5,000
s dewasa 10,000
15,000
n Cateter vena profunda 50,000
n cateter arteri ( artery line ) 400,000
n cateter CVP 1,200,000
n cateter HD 200,000
125,000
dotomy / Tracheostomy 2,500,000
Washing dengan alat 500,000
150,000
alasi tanpa obat / Nebuizer per kali 20,000
t dan necrotomy -
Luka kecil 25,000
Luka sedang 40,000
Luka luas 100,000
n Cateter epidural 300,000
20,000
nasthesi ( GA atau RA ) di ICU 700,000
Kardiopulmoonal ( dengan DC Shock ) 200,000
1,000,000
125,000
uar cup per kali 10,000
n Oksigen ( O2 ) -
Tiap 1 liter / menit 110
Pemakaian dan pemasangan O2 per kali tanpa ventilator 5,000
Pemakaian dan pemasangan O2 per kali dengan ventilator 6,000
JASA DIREKSI SISA JASA COST CENTER
JASA SARANA
PELAYANAN PELAYANAN
5% 15%
4 5 6 7 8
5,000 80,000 4,000 76,000 11,400

0 30,000 1,500 28,500 4,275
- - -
18,000 12,000 600 11,400 1,710
900 600 30 570 86
9,000 6,000 300 5,700 855
1,200 800 40 760 114
9,000 6,000 300 5,700 855
1,200 800 40 760 114
120,000 80,000 4,000 76,000 11,400
20,000 100,000 5,000 95,000 14,250
1,800 1,200 60 1,140 171
9,000 6,000 300 5,700 855
600 400 20 380 57
6,000 4,000 200 3,800 570
600 400 20 380 57
9,000 6,000 300 5,700 855
900 600 30 570 86
6,000 4,000 200 3,800 570
900 600 30 570 86
24,000 16,000 800 15,200 2,280
3,000 2,000 100 1,900 285
30,000 20,000 1,000 19,000 2,850
1,500 1,000 50 950 143
500,000 700,000 35,000 665,000 99,750
54,000 36,000 1,800 34,200 5,130
12,000 8,000 400 7,600 1,140
1,500 1,000 50 950 143
15,000 10,000 500 9,500 1,425
30,000 20,000 1,000 19,000 2,850
60,000 40,000 2,000 38,000 5,700
- - -
9,000 6,000 300 5,700 855
12,000 8,000 400 7,600 1,140
30,000 20,000 1,000 19,000 2,850
42,000 28,000 1,400 26,600 3,990
3,000 2,000 100 1,900 285
6,000 4,000 200 3,800 570
9,000 6,000 300 5,700 855
30,000 20,000 1,000 19,000 2,850
200,000 200,000 10,000 190,000 28,500
500,000 700,000 35,000 665,000 99,750
100,000 100,000 5,000 95,000 14,250
75,000 50,000 2,500 47,500 7,125
1,500,000 1,000,000 50,000 950,000 142,500
300,000 200,000 10,000 190,000 28,500
90,000 60,000 3,000 57,000 8,550
12,000 8,000 400 7,600 1,140
- - - -
15,000 10,000 500 9,500 1,425
24,000 16,000 800 15,200 2,280
60,000 40,000 2,000 38,000 5,700
180,000 120,000 6,000 114,000 17,100
12,000 8,000 400 7,600 1,140
420,000 280,000 14,000 266,000 39,900
120,000 80,000 4,000 76,000 11,400
500,000 500,000 25,000 475,000 71,250
75,000 50,000 2,500 47,500 7,125
6,000 4,000 200 3,800 570
- - - -
110
3,000 2,000 100 1,900 285
3,600 2,400 120 2,280 342
DIKERJAKAN DOKTER DIKERJAKAN PERAWAT
INDEX KINERJA
KELOMPOK KELOMPOK
DOKTER
PERAWAT PERAWAT
35% 50%
9 10 11 12 13
26,600 38,000 11,400 26,600

9,975 14,250 14,250
- - -
3,990 5,700 1,140 4,560 4,560
200 285 57 228 228
1,995 2,850 570 2,280 2,280
266 380 76 304 304
1,995 2,850 570 2,280 2,280
266 380 76 304 304
26,600 38,000 7,600 30,400 30,400
33,250 47,500 9,500 38,000 38,000
399 570 114 456 456
1,995 2,850 570 2,280 2,280
133 190 38 152 152
1,330 1,900 380 1,520 1,520
133 190 38 152 152
1,995 2,850 570 2,280 2,280
200 285 57 228 228
1,330 1,900 380 1,520 1,520
200 285 57 228 228
5,320 7,600 1,520 6,080 6,080
665 950 190 760 760
6,650 9,500 1,900 7,600 7,600
333 475 95 380 380
232,750 332,500 66,500 266,000 266,000
11,970 17,100 3,420 13,680 13,680
2,660 3,800 760 3,040 3,040
333 475 95 380 380
3,325 4,750 950 3,800 3,800
6,650 9,500 1,900 7,600 7,600
13,300 19,000 3,800 15,200 15,200
- - - - -
1,995 2,850 570 2,280 2,280
2,660 3,800 760 3,040 3,040
6,650 9,500 1,900 7,600 7,600
9,310 13,300 2,660 10,640 10,640
665 950 190 760 760
1,330 1,900 380 1,520 1,520
1,995 2,850 570 2,280 2,280
6,650 9,500 1,900 7,600 7,600
66,500 95,000 19,000 76,000 76,000
232,750 332,500 66,500 266,000 266,000
33,250 47,500 9,500 38,000 38,000
16,625 23,750 4,750 19,000 19,000
332,500 475,000 95,000 380,000 380,000
66,500 95,000 19,000 76,000 76,000
19,950 28,500 5,700 22,800 22,800
2,660 3,800 760 3,040 3,040
- - - - -
3,325 4,750 950 3,800 3,800
5,320 7,600 1,520 6,080 6,080
13,300 19,000 3,800 15,200 15,200
39,900 57,000 11,400 45,600 45,600
2,660 3,800 760 3,040 3,040
93,100 133,000 26,600 106,400 106,400
26,600 38,000 7,600 30,400 30,400
166,250 237,500 47,500 190,000 190,000
16,625 23,750 4,750 19,000 19,000
1,330 1,900 380 1,520 1,520
- - - - -
-
665 950 190 760 760
798 1,140 228 912 912
IKERJAKAN PERAWAT
DOKTER
14
1,140
57
570
76
570
76
7,600
9,500
114
570
38
380
38
570
57
380
57
1,520
190
1,900
95
66,500
3,420
760
95
950
1,900
3,800
-
570
760
1,900
2,660
190
380
570
1,900
19,000
66,500
9,500
4,750
95,000
19,000
5,700
760
-
950
1,520
3,800
11,400
760
26,600
7,600
47,500
4,750
380
-
-
190
228
X. PELAYANAN NICU
1 2 3 4
1 Pemasangan Respirator / hari 20,000 12,000
Sewa alat dan monitoring per jam 3,000 1,800
2 Pemasangan monitor vital sign 20,000 12,000
Sewa alat dan monitoring per jam #VALUE! 9,00
3 Pemasangan syringe pump: 15,000 9,000
4 Pemasangan infussion pump: 15,000 9,000
5 Pemasangan Feeding Pump: 15,000 9,000
Sewa alat dan monitoring per jam 1,000 600
6 Pemasangan Radiant / Infant Warmer : 10,000 6,000
7 Vena seksi 250,000 125,000
8 Foto Theraphy / hari 40,000 24,000
9 Resusitasi bayi bermasalah / RKP 100,000 60,000
10 Portable pulse oximeter 30,000 18,000
11 Resusitasi bayi normal 100,000 60,000
12 Intubasi 125,000 75,000
13 Suction pump 10,000 6,000
14 Pasang NGT 50,000 30,000
15 Aff NGT 2,500 1,500
16 Pasang ET 800,000 300,000
17 Pasang Cateter 20,000 12,000
18 Aff Cateter 2,500 1,500
19 Lumbal Punctie 125,000 75,000
20 Tindakan transfusi 30,000 18,000
21 Massage bayi 15,000 9,000
22 Pasang ventilator / NCPAP 250,000 150,000
23 Observasi Ventilator / NCPAP / hari 50,000 30,000
24 Perawatan luka 15,000 9,000
25 Tindakan metode kangguru 25,000 15,000
26 Perawatan tali pusat 15,000 9,000
27 Transfusi Tukar 700,000 420,000
28 Pemberian Surfactan 700,000 420,000
29 Pemasangan WSD pada Neonatus 600,000 300,000
30 Pemasangan cateter umbilical 125,000 75,000
31 Sensor saturasi oksigen (BHP ) 50,000 30,000
32 Rawat luka bakar < 10 % 25,000 15,000
33 Rawat luka bakar 10 - 50 % 50,000 30,000
34 Rawat luka bakar > 50 % 75,000 45,000
35 Pemasangan cateter Arteri ( artery line ) 200,000 100,000
36 Bronchial Washing dengan alat 240,000 144,000
37 Therapi Inhalasi tanpa obat / Nebuizer per 26,000 15,600
38 Debridement dan necrotomy 25,000 15,000
39 Fisioterapi 20,000 12,000
40 Pemasangan infus bayi per kali 15,000 9,000
41 Injeksi im per kali 5,000 3,000
42 Injeksi iv per kali 5,000 3,000
43 Injeksi ic per kali 5,000 3,000
44 Injeksi sc per kali 5,000 3,000
45 Memberi obat Supositoria 5,000 3,000
46 Penanganan Pre Operasi 10,000 6,000
47 Melakukan sampling spesisemen Lab 5,000 3,000
48 Melakukan klisma / huknah rendah / Dru 10,000 6,000
49 Penggunaan Oksigen ( O2 ) -
a. Tiap 1 liter / menit / jam 110 110
b. Pemakaian dan pemasangan O2 per kal 5,000 3,000
c. Pemakaian dan pemasangan O2 per ka 6,000 3,600
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JASA DIREKSI SISA JASA COST CENTER INDEX
PELAYANAN PELAYANAN
5% 15% 35%
5 6 7 8 9
8,000 400 7,600 1,140 2,660
1,200 60 1,140 171 399
8,000 400 7,600 1,140 2,660
600 30 570 86 200
6,000 300 5,700 855 1,995
800 40 760 114 266
6,000 300 5,700 855 1,995
800 40 760 114 266
6,000 300 5,700 855 1,995
400 20 380 57 133
4,000 200 3,800 570 1,330
800 40 760 114 266
125,000 6,250 118,750 17,813 41,563
16,000 800 15,200 2,280 5,320
40,000 2,000 38,000 5,700 13,300
12,000 600 11,400 1,710 3,990
40,000 2,000 38,000 5,700 13,300
50,000 2,500 47,500 7,125 16,625
4,000 200 3,800 570 1,330
20,000 1,000 19,000 2,850 6,650
1,000 50 950 143 333
500,000 25,000 475,000 71,250 166,250
8,000 400 7,600 1,140 2,660
1,000 50 950 143 333
50,000 2,500 47,500 7,125 16,625
12,000 600 11,400 1,710 3,990
6,000 300 5,700 855 1,995
100,000 5,000 95,000 14,250 33,250
20,000 1,000 19,000 2,850 6,650
6,000 300 5,700 855 1,995
10,000 500 9,500 1,425 3,325
6,000 300 5,700 855 1,995
280,000 14,000 266,000 39,900 93,100
280,000 14,000 266,000 39,900 93,100
300,000 15,000 285,000 42,750 99,750
50,000 2,500 47,500 7,125 16,625
20,000 1,000 19,000 2,850 6,650
10,000 500 9,500 1,425 3,325
20,000 1,000 19,000 2,850 6,650
30,000 1,500 28,500 4,275 9,975
100,000 5,000 95,000 14,250 33,250
96,000 4,800 91,200 13,680 31,920
10,400 520 9,880 1,482 3,458
10,000 500 9,500 1,425 3,325
8,000 400 7,600 1,140 2,660
6,000 300 5,700 855 1,995
2,000 100 1,900 285 665
2,000 100 1,900 285 665
2,000 100 1,900 285 665
2,000 100 1,900 285 665
2,000 100 1,900 285 665
4,000 200 3,800 570 1,330
2,000 100 1,900 285 665
4,000 200 3,800 570 1,330
- - - - -
- - - - -
2,000 100 1,900 285 665
2,400 120 2,280 342 798
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115,720.00 2,198,680.00 329,802.00 769,538.00
DIKERJAKAN DOKTER DIKERJAKAN PERAWAT
KINERJA
KELOMPOK KELOMPOK
DOKTER DOKTER
PERAWAT PERAWAT
50%
10 11 12 13 14
3,800 760 3,040 2,660 1,140
570 114 456 399 171
3,800 760 3,040 2,660 1,140
285 57 228 200 86
2,850 570 2,280 1,995 855
380 76 304 266 114
2,850 570 2,280 1,995 855
380 76 304 266 114
2,850 570 2,280 1,995 855
190 38 152 133 57
1,900 380 1,520 1,330 570
380 76 304 266 114
59,375 11,875 47,500 41,563 17,813
7,600 1,520 6,080 5,320 2,280
19,000 3,800 15,200 13,300 5,700
5,700 1,140 4,560 3,990 1,710
19,000 3,800 15,200 13,300 5,700
23,750 4,750 19,000 16,625 7,125
1,900 380 1,520 1,330 570
9,500 1,900 7,600 6,650 2,850
475 95 380 333 143
237,500 47,500 190,000 166,250 71,250
3,800 760 3,040 2,660 1,140
475 95 380 333 143
23,750 4,750 19,000 16,625 7,125
5,700 1,140 4,560 3,990 1,710
2,850 570 2,280 1,995 855
47,500 9,500 38,000 33,250 14,250
9,500 1,900 7,600 6,650 2,850
2,850 570 2,280 1,995 855
4,750 950 3,800 3,325 1,425
2,850 570 2,280 1,995 855
133,000 26,600 106,400 93,100 39,900
133,000 26,600 106,400 93,100 39,900
142,500 28,500 114,000 99,750 42,750
23,750 4,750 19,000 16,625 7,125
9,500 1,900 7,600 6,650 2,850
4,750 950 3,800 3,325 1,425
9,500 1,900 7,600 6,650 2,850
14,250 2,850 11,400 9,975 4,275
47,500 9,500 38,000 33,250 14,250
45,600 9,120 36,480 31,920 13,680
4,940 988 3,952 3,458 1,482
4,750 950 3,800 3,325 1,425
3,800 760 3,040 2,660 1,140
2,850 570 2,280 1,995 855
950 190 760 665 285
950 190 760 665 285
950 190 760 665 285
950 190 760 665 285
950 190 760 665 285
1,900 380 1,520 1,330 570
950 190 760 665 285
1,900 380 1,520 1,330 570
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- - - - -
950 190 760 665 285
1,140 228 912 798 342
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1,099,340.00
REVISI
DIKERJAKAN PERAWAT
KELOMPOK
DOKTER
PERAWAT
15 16
3,040 760
456 114
3,040 760
228 57
2,280 570
304 76
2,280 570
304 76
2,280 570
152 38
1,520 380
304 76
47,500 11,875
6,080 1,520
15,200 3,800
4,560 1,140
15,200 3,800
19,000 4,750
1,520 380
7,600 1,900
380 95
190,000 47,500
3,040 760
380 95
19,000 4,750
4,560 1,140
2,280 570
38,000 9,500
7,600 1,900
2,280 570
3,800 950
2,280 570
106,400 26,600
106,400 26,600
114,000 28,500
19,000 4,750
7,600 1,900
3,800 950
7,600 1,900
11,400 2,850
38,000 9,500
36,480 9,120
3,952 988
3,800 950
3,040 760
2,280 570
760 190
760 190
760 190
760 190
760 190
1,520 380
760 190
1,520 380
- -
- -
760 190
912 228
- -
- -
- -
- -
- -
- -
TARIF LAYANAN PELAYANAN
I. PENDAFTARAN , PEMERIKSAAN , DAN AKOMODASI
NO URAIAN
(1) (2)
A Pendaftaran
1 Administrasi sistem informasi
2 Berkas RM Rawat Jalan / Kartu Pasien
3 Berkas RM Rawat Inap
B Pemeriksaan Poliklinik
1 Pemeriksaan poliklinik oleh dokter umum
2 Pemeriksaan poliklinik oleh dokter spesialis
C Akomodasi
C1 Biaya Kamar
1
2
3
4
5
6
C2 Visite Dokter Spesialis
7
8
9
10
11
12
C3 Visite Dokter Umum
13
14
15
16
17
18
D Poli Eksekutif /Khusus
1 Servis Layanan
2 Pemeriksaan dan Konsultasi dokter
3 Konsultasi antar SMF
E GENERAL CHECK UP
1 Paket I (Pemeriksaan fisik,Darah lengkap,Urine Lengkap)
Paket II (Pemeriksan Fisik,Darah lengkap,Urine Lengkap,Gula darah
2
sewaktu,kolesterol total,trigliserida)
Paket III (Pemeriksan Fisik,Darah lengkap,Urine Lengkap,Gula darah
3
sewaktu,kolesterol total,trigliserida,pemeriksaan narkotika,EKG,Rontgen Thorax)
F SURAT KETERANGAN DOKTER

1 Surat Keterangan sehat
2 Surat Keterangan untuk asuransi umum / non BPJS
3 Surat Keterangan Kelahiran
4 Surat Keterangan Kematian
II. PELAYANAN RAWAT JALAN

1. POLI KLINIK TUMBUH KEMBANG
NO URAIAN
(1) (2)
A IMUNISASI DIWAJIBKAN (PPI)
1 BCG
2 DPT - Hb
3 Hepatitis B
4 Polio
5 TT
6 Campak
B IMUNISASI DIANJURKAN (Non PPI)
1 Infrantrik (DTAP)
2 Infrantrik - HiB
3 Hepatitis Engerik B
4 HiB
5 IPD
6 Hepatitis A
7 Valirix (cacar air)
8 Typim (Typoid)
9 MMR
10 Psikologi Test
-
-
11 Screening
-
-
-
12 Tes Intelegensi (IQ)
-
-
13 Tes Kepribadian
-
-
14 Tes Minat Bakat
-
15 Psiko Tes
16 Konseling Psikologi (anak, remaja & dewasa)
17 Terapi Wicara
18 Terapi Edukasi
19 Terapi Okupasi
2. POLIKLINIK PENYAKIT ANAK
NO URAIAN
(1) (2)
1 BMP(lumbal punksi)
2 Therapi Inhalasi tanpa obat / Nebulizer
3 EKG
4 RRO
5 Pemeriksaan pasien autisme
6 Pemasangan O2 / jam
3. POLIKLINIK BEDAH UMUM
NO URAIAN
(1) (2)
1 Rawat Luka
a. Kecil (< 5 cm)
b. Sedang (5-10 cm)
c. Besar (10-20 cm)
d. Khusus (> 20 cm)
3 Angkat Jahitan
4 Rectal Toucher
5 Anoskopi
6 Coller And Cup
7 Angkat Wire
8 Nail Ekstrasi
9 Rozer Plasty
10 Incisi Abses
11 Eksisi
12 Ekstirpasi
13 Circumsisi
14 Biopsi
15 Tindik
16 Lobulo Plasty
17 Exploarasi Corpus alienum
18 Curetage
19 Aspirasi
20 Bouginasi
21 Ekstraksi Batu uretra anterior
22 Spoor dawer cateter
23 Spooling dawer cateter
24 Debridment Luka
25 Injeksi Keloid / Kenacord / (IC)
26 Necrotomy
27 Amputasi Jari
28 Vasektomi
4. POLIKLINIK ORTHOPEDI
NO URAIAN
(1) (2)
1 Rawat Luka
a. Kecil (< 5 cm)
b. Sedang (5-10 cm)
c. Besar (10-20 cm)
d. Khusus (> 20 cm)
3 Angkat Jahitan
4 Gips Kecil Anak *
5 Gips Kecil Dewasa*
6 Gips Sedang Anak*
7 Gips Sedang Dewasa*
8 Gips Besar Anak*
9 Gips Besar Dewasa*
10 Buka Gips
11 Ransel verband Anak
12 Ransel verband Dewasa
13 Injeksi Arthtritis / articuler*
14 Body cast*
15 Hemi Spica*
16 Necrotomy Ex Op
5. POLIKLINIK UROLOGI
NO URAIAN
(1) (2)
2 Pasang Cateter Logam*
3 Tindakan Blast Punctie
4 Tindakan Blast Pistel / Cytostom
5 Ekstraksi batu uretra dengn GA di OK
6 Ekstraksi batu uretra anterior
7 Rawat Luka
a. Kecil (< 5 cm)
b. Sedang (5-10 cm)
c. Besar (10-20 cm)
d. Khusus (> 20 cm)
8 Incisi Abses
9 Sitostomi
10 Buginasi / Dilatasi Uretra
6. POLIKLINIK GIGI DAN MULUT
NO URAIAN
(1) (2)
A SPESIFIKASI TINDAKAN PENCABUTAN GIGI
1 Pencabutan Gigi Susu
-
-
2 Pencabutan Gigi Susu Perforasi Akar
3 Pencabutan Gigi Mesiodens
4 Pencabutan Gigi Eksosterm 3
5 Pencabutan Gigi Permanen Dengan Akar Tunggal
6 Pencabutan Gigi Permanen Dengan Akar Ganda
7 Pencabutan Gigi Dengan Komplikasi
8 Pencabutan Sisa Akar Yang Tertinggal
B SPESIFIKASI TINDAKAN PENAMBALAN GIGI

1 Perawatan Pulpa
2 Perawatan Pulpektomy
a.
b.
c.
d.
3 Pengisian Saluran Akar Tunggal
4 Pengisian Saluran Akar Ganda
5 Tambalan Sinar
a.
b.
c.
d.
6 Penambalan Amalgam
7 Perawatan saluran akar Endo Intrakanal
a.
b.
c.
d.
8 Penambalan Glass Lonomer
a.
b.
c.
9 Penambalan Eugenol, ChKM, depupil
a.
b.
10 Penambalan Eugenol Cavit
11 Pin Screw + Sementasi
C SPESIFIKASI TINDAKAN PENGOBATAN / PERAWATAN JARINGAN PENYANGGA GIGI

1 Pembersihan karang gigi per regio
2 Perawatan Pocet Periodental
3 Gingivektomy per regio
4 Eksterpasi Mucocele / epulis
D SPESIFIKASI PEMBUATAN PROTESA / GIGI PALSU

1 Gigi Tiruan per rahang
a.
b.
c.
d.
e.
f.
2 Reparasi Plat Patah
a.
b.
3 Reparasi Penambahan gigi per Rahang
a.
b.
4 Rebasing / relining per rahang
5 Orthodontic
a.
b.
c.
6 Orthodontic cekat RA / RB
7 Perawatan / kontrol Orthodentic ceat RA / RB
E SPESIFIKASI TINDAKAN BEDAH MULUT

1 Odontectomy
2 Operculectom
3 Inter dental wiring / rahang
4 Inter maxilla wiring / rahang
5 Replantasi gigi
6 Alveolectomy / debridement per regio
7 Enukleasi kista (lokal anestesi)
8 Incisi / Eksisi abses
9 Pemeriksaan komplikasi post op / kontrol
10 Pemeriksaan dan perbaikan posisi IDW / IMW
11 Pembukaan IDW / Rahang
12 Pembukaan IMW
13 Dry Socket / curetage per gigi
14 Extirpasi mucocelle / epulis
15 Aff heacting epulis / mucocelle
F SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dengan LOGAM
1 Jembatan Adoro porcelain fusi metal
2 Inlay porcelain fusi metal

3 Uplay porcelain fusi metal
G SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY tanpa LOGAM

1 Jembatan/bridge full porcelain
2 Inlay / Uplay full porcelain
7. POLIKLINIK PENYAKIT KULIT DAN KELAMIN
NO URAIAN
(1) (2)
1 Elektro fulgurasi / Elektro Couter :
a. Seboroik Keratosis :
-
-
-
b. Skin Tag ;
-
-
-
c. Kondyloma Akuminata :
-
-
-
2 Ekstraksi Komedo
3 Enukleasi
4 Solarium / Photo Therapi
5 Excisi Wajah
6 Excisi Non wajah
7 Test Tempel / Patch Test Standard
8 Test Tempel Standard Kosmetik
9 Dermabrasi / Microdemabrasi
10 Rekonstruki Kulit
11 Heating Aff
12 Incisi Abses
13 Swab : Vagina, Cervix, Fornik
14 Swab : Uretra
15 Swab discar lesi
16 Kerokan Kulit, Kuku, Rmbut
17 Kultur
18 Ganti Verband
19 Revisi Parut
20 Injeksi Kenacort
21 Punch Biopsi
22 Insisonal biopsi
23 Ekstirpasi
24 Kuretase Kulit
25 Radioton
26 Trichlor Acetic Acid
27 Chemical Peeling :
- GA Peeling
- Proopeel
- PHA
28 Facial Regula
29 Test Alergi Tusuk
- Tusuk
- Tempel
8. POLIKLINIK PENYAKIT PARU
NO URAIAN
(1) (2)
1 Terapi Inhalasi tanpa obat / Nebulizer
2 Punctie Pleura
3 Spirometri komputer
4 Portable Spirometri
9. POLIKLINIK PENYAKIT DALAM
NO URAIAN
(1) (2)
1 Punctie asctes
2 Aspirasi jarum halus
3 BMP
4 EKG
10. POLIKLINIK PENYAKIT JANTUNG
NO URAIAN
(1) (2)
1 Defribilasi
2 EKG
3 Echocardiografi
4 Echocardiografi Dopler collor
5 FNAB
6 Phonocardiografi
7 Punksi pericard
8 Resusitasi jantung dengan DC Shock
9 Telemetri
10 Treadmill
11 Fowley Catheter
12 NGT / kali
13 Pacemaker temporer
14 Pemasangan SB Tube
15 Pemasangan Cardiac Monitor
16 Pemasangan CVP
17 Pemasangan Cardiac monitor / hari
11. POLIKLINIK SYARAF/NEUROLOGI
NO URAIAN
(1) (2)
1 Injeksi Intramuskuler
2 Injeksi Intraartikuler
3 Assessment Neurobehaviour fit n proper test
4 Assessment Neurobehaviour
5 Pemeriksaan EEG
6 Baca EEG
7 Assessment Nyeri
8 Pemeriksaan EMNG
12. POLIKLINIK MATA
NO URAIAN
(1) (2)
1 Pterigium
2 S B L ( Bleparoplasty )
3 Campimetri / perimetri 1 mata dengan Humpray
5 U S G Mata
6 Keratometri
7 Pemeriksaan fundus (indirec)
8 Tonometri Aplansi
9 Water Drinking
10 Retinoskopi
11 Gonioskopi
12 Synophtophor
13 Sondage
14 tonometri Aplansi
15 Angkat jahitan di palpebra dan konjungtiva
16 Angkat jahitan di kornea
17 Amotio corpus Alienum
18 Irigasi
19 Refraktometer
20 Ekstirpasi kista konjungtiva
21 Ekstarpasi nevus / granulotoma
22 Epilasi
23 Excochleasi / Amotio Lithiasis
24 Ekstirpasi tumor / kista di palpebra
25 Biopsi dai palpebra
26 Biopsi di konjungtiva
27 Tarsoraphy / Jahitan di palpebra
28 Reposisi iris
29 Paracentesis
30 Iridektomi Perifer
31 Transplantasi membran amnion
32 Excochleasi / Amotio Lithiasis
33 Pemeriksaan Refraksi
34 Pemeriksaan Slit Biomikroskop
35 Tonometri SCHIOTZ
36 Test Ishihara
13. POLIKLINIK KEBIDANAN DAN PENYAKIT KANDUNGAN (OBSGYN)
NO URAIAN
(1) (2)
1 Biopsi Pervaginam
2 Pap Smear
3 Vaginal Swab
4 Kolposkopi
5 Kauter Elektrik
6 Pasang IUD
7 Angkat IUD tanpa penyulit
8 Angkat IUD dengan penyulit
9 Pasang Implant
10 Angkat implant tanpa penyulit
11 Angkat Implant dengan penyulit
12 Diathermi ( satu seri = 6 kali kunjungan )
13 Ganti verband / Buka jahitan
14 Pasang / Ganti tampon
15 Kauter Albotyl
16 USG
- Tanpa Print Out
- Dengan Print Out
17 Pasang Pessarium
18 Buka pessarium
19 CTG
20 Suntikan KB
21 Pemeriksaan Gnekologi
22 Tindakan pasang kateter
23 Tindakan pasang infus
24 USG Transvaginal tanpa print out
- Tanpa print out
- Dengan print out
25 Konseling KB
26 MOW / MOP / Mini Laparotomy
14. POLIKLINIK PENYAKIT THT
NO URAIAN
(1) (2)
1 Biopsi
2 Spoelling
3 Corpal Alienum telinga
4 Corpal Alienum tenggorokan
5 Corpal Alienum hidung
6 Caustik
7 Extirpasi granuloma
8 Swab Nasal
9 Test Allergi
10 Ganti verband
11 Evakuasi Cerumen Ringan
12 Swab Nasopharing Endoscopy
13 Audiometri murni
14 Audiometri tutur
15 Schimer test
16 Incisi Abses
17 Myringobridge
18 Buka pessarium
15. REHABILITASI MEDIK
NO URAIAN
(1) (2)
1 Micro Wave Diathermy
2 Electrical Stimulation
3 Ultrasound Diathermy
4 Traksi
5 InfraPhil 2 Lamp
6 Infra Phil 3 Lamp
7 Fibrator / Massage
8 Senam hamil
9 Senam Nifas
10 Postural drainage
11 Bladder Training
12 Fisioterapi Stroke
13 Fisioterapi Anak
14 Fisioterapi Dada/ Breathing Exc
15 Back Exercise
16 Latihan Sepeda Statis
17 Latihan Paralel Bars
18 Continous Pasive Movement
19 Latihan Gerak Sendi / Penguatan Otot
20 Pemasangan Spalk
21 Short Wave Diathermy
22 Parafin Bath
23 Nabulizer
24 Active Movement Exercise
16. POLIKLINIK BEDAH SYARAF
NO URAIAN
NO URAIAN
(1) (2)
1 Rawat Luka
a. Kecil (< 5 cm)
b. Sedang (5-10 cm)
c. Besar (10-20 cm)
d. Khusus (> 20 cm)
2 Angkat Jahitan
3 Pungsi CSF Cranial

4 Pungsi Lumbal
5 Injeksi Spinal
6 Injeksi obat ( IV ) / Injeksi
7 Pasang Elastic Band
17. POLIKLINIK JIWA / PSIKIATRI
NO URAIAN
(1) (2)
A Pemeriksaan Psikometri
1 House
2 Warteg test
3 HDRS
4 HARS
5 BDI
6 MMSE
7 MMPI
8 PANS score
9 GDS
B PSIKOTERAPI
1 Psikoterapi suportif
2 Cognitif Behaviour therapy
3 Hipnotherapi
III. PELAYANAN TINDAKAN MEDIK OPERATIF DAN TERAPI TERENCANA

NO URAIAN
(1) (2)
A OPERASI BEDAH DIGESTIF
1 Anastomosis of small intestine to rectal stump (pancolestomy)
2 Laparoscopyt terapi
3 LAR and to end anastomose
4 LAR dengan colostomy (anterior resection of rectum with synchronous colostomy)
5 Ekstraksi Kuku
6 Penjahitan Luka 1-4 Jahitan
7 Ekstraksi Gigi Goyang Depan
5 Pungsi Pleura/Abdomen
5 Miles prosedur
6 Pancreatectomy roux n y
7 Ruptur gaster gastrojejunustomy + jejunustomy feeding
8 Soave
9 Achlasia Aesophagus
10 Arthroscopy diagnostic
11 Arthroscopy debridement
12 Bristow Procedure
13 Choledochojejunustomy roux n y
14 Cysto jejunostomy roux n y pada kista empedu
15 Cysto jejunostomy roux n y pada kista pankreas
16 Discectomy
17 Open and other left hemicolectomy
18 Open and other resection colon transfersum
19 Open and other sigmoidectomy
20 Open Drainage abses hepar
21 Other and unspecified partial excision of large intestine
22 Repair recto vaginal fistula
23 Ruptur gaster jahit primer omental patch
24 Laparoscopy
25 Anastomosis other small-to-large intestinal
26 Anastomosis Smal-to-small intestinal
27 Appendiktomi and drainage appendikceal abses
28 Cholesistectomy
29 Debulking
31 Exteriorization of small intestine
32 Hernia fomaralis bilateral dengan atau tanpa graft
33 Herniotomi hernioraphi anostomosis
34 HIL bilateral (other and open bilateral repair of direct inguinal hernia) dengan atau
35 HIM bilateral (other and open bilateral repair of indirect inguinal hernia) dengan a
36 Laparoscopic appendectomy
37 Laparotomy eksplorasi dengan stoma
38 Other and open bilateral repair of inguinal hernia, one direct and one indirect
39 Repair Sub total perianal rupture
40 Repair total perianal rupture
41 Suture of laceration of duodenum
42 Suture of laceration of small intestine
43 Appendiktomi pada apendicities akut/kronis
44 Hernia femoralis unilateral dg atau tanpa graft (unilateral repair of femoral hernia
45 Herniotomi hernioraphi selain HIM atau HIL dngan graft
46 Herniotomi pada anak
47 Hernitomy hernioraphi HIL unilateral dg atau tanpa graft (other and open repair o
48 Hernitomy hernioraphi HIM unilateral dg atau tanpa graft (other and open repair o
49 Hidrocele komunikan
50 Hidrocele punikuli
51 Hidrocele testis (hidrocele/excision af hydrocele of tunica vaginalis)
52 Laparascopic diagnostic
53 Penutupan stoma pada colostomy (closure of stoma of large intestine)
54 Penutupan stoma pada ileustomy (closure of stoma of small intestine)
55 Funikokelektomy
56 Hydrokelektomy per inguinal
57 Hydrokelektomy per scrotal
58 Anoplasty pada setriktural anus
59 Closed Drainage abses hepar dengan GA
60 Colostomi
61 Excision of varicocele and hydrocele of spermatic cord
62 Exici polip recti dengan GA
63 Exteriorication of large intestine
64 Gastrostomy
65 Haemorroidectomi/procedur on hemorrhoids)
66 Perianal Fistulectomy
67 Preauricula Fistulectomy
68 Prolaps recti (repair)
70 Repair anus
72 Repair uracus
73 Stepler haemorroidectomi
74 Reseksi urachus
75 Closed Drainage abses hepar dengan LA
76 Colonoscopi disertai extirpasi tumor
77 Exici polip recti dengan LA
78 Fistulectomy
79 Perianal fistulotomi
80 Colonoscopi
81 Lavage
82 Potong stoma pada soave
83 Gastroscopi
84 Gastroscopi disertai biopsi
85 Gastroscopi disertai ligasi varises esofagus (LVE)
86 Gastroscopi disertai sclero terapi endoskopi (STE)
87 Insisi absces perineum
88 Insisi ansces scrotum
89 Anuscopy biopsi dengan LA (Local anaesthesia)
90 Open biopsy of breast dengan LA
100 Bipolar resectoscopy
101 Ekstraksi ductus choledocy
102 Ekstraksi batu ductus choledocus
103 Histeroscopy diagnostic
104 Histeroscopy operative
105 Laparotomy + release adhesi
106 Re-open Laparotomy
107 Transanal Endorected pull through
108 Transanal swense eike
B OPERASI BEDAH ANAK
1 Anaplasty PSA (postero sagital anoplasty)
2 Ilizarov
3 Invaginasi
4 Eksisi ductus thyroglosus
5 Illeustomi pada anak
6 Laparatomi pada anak
7 Orchidectomy bilateral
8 Hirschprung's/colostomy pada hirsprung's
9 Anoplasty atresia ani letak rendah (cutback incision)
10 Anoplastyh + uretheroplasty
11 Postero sagictal anorected pull through
C OPERASI BEDAH ORTHOPEDI

1 Koreksi Scoliosis
2 Total elbow arthtoplasty
3 Total Hip arthtoplasty
4 Total knee arthtoplasty
5 Total shoulder arthtoplasty
6 Debridement TB tulang belakang
7 Hemiarthroplasty (AMP, bipolar) complicated
8 Internal fiksasi fraktur acetabulum complicated
9 Internal fiksasi fraktur collumn femur complicated
10 Internal fiksasi fraktur collumn femur dengan DHS complicated
11 Internal fiksasi fraktur collumn femur dengan ABP complicated
12 Internal fiksasi fraktur pelvis complicated
13 Internal fiksasi fraktur scapula complicated
14 Osteotomi korektif(HTO, freanch, dll)
15 Other reconstructive procedure of the shoulder
16 Rekonstruksi ACL/PCL
17 Koreksi horshoe kidney (ishmectomy)
18 Bone graft iliac/fibular/autograft lainnya
19 Disartikulasi Hip
20 Disartikulasi shoulder
21 Elevation of skull fracture fragments
23 Hemiarthroplasty (AMP, bipolar)
24 Internal fiksasi fraktur acetabulum
25 Internal fiksasi fraktur collumn femur
26 Internal fiksasi fraktur femur dengan ABP
27 Internal fiksasi fraktur femur dengan K wire complicated
28 Internal fiksasi fraktur femur dengan plate & screw complicated
29 Internal fiksasi fraktur femur dengan DHS
30 Internal fiksasi fraktur humerus complicated
31 Iinternal fiksasi fraktur pelvis
32 Iinternal fiksasi fraktur radius complicated
33 Iinternal fiksasi fraktur scapula
34 Iinternal fiksasi fraktur symphisis pubis/symphisiolisis complicated
35 Internal fiksasi fraktur tibia complicated
36 Open reduction dislocation
37 Operasi avulsi PCL/ACL
38 Patellar stabilization
39 Pengambilan implant tulang belakang
40 Phacoemulsifikasi
41 Rekonstruksi bunion
42 Arthroscopy other procedures
43 Internal fiksasi fraktur carpalia
44 Internal fiksasi fraktur clavikula complicated
45 Internal fiksasi fraktur femur dengan K wire
46 Internal fiksasi fraktur femur dengan nail
47 Internal fiksasi fraktur femur dengan plate & screw
48 Internal fiksasi fraktur fibula complicated
49 Internal fiksasi fraktur radius
50 Internal fiksasi fraktur radius ulna
51 Internal fiksasi fraktur tibia fibula
52 Internal fiksasi fraktur ulna complicated
53 Arhtrodesis Pantalar
54 Arhtrodesis shoulder
55 Arhtrodesis subtalar
56 Arhtrodesis elbow
57 Arhtrodesis genu
58 Arhtrodesis hip
59 Arhtrodesis talocrural
60 Arhtrodesis triple
61 Arhtrodesis wrist
62 Bone graft allograft/xenograft/hydroxyapatite
63 Debridement osteomyelitis
64 Eksternal fiksasi pelvis
65 Eksternal fiksasi wrist
66 Ekstirpasi tumor + rekonstruksi (diluar orthopedi)
67 Excisi bone tumor
68 Fraktur costae dg internal fiksasi (pasang shapp plate) singgle
69 Free skin graft not otherwise specified
70 Internal fiksasi fraktur clavikula
71 Internal fiksasi fraktur fibula
72 Internal fiksasi fraktur humerus
73 Internal fiksasi fraktur patella complicated
74 Internal fiksasi fraktur tibia
75 Internal fiksasi fraktur tibia plateau complicated
76 Internal fiksasi fraktur ulna
77 Osteotomy sederhana
78 Pengambilan implant ABP
79 Pengambilan implant DHS
80 Pengambilan nail/plate termasuk implant symphisis pubis complicated
81 Amputasi below knee
82 Amputasi above elbow
83 Amputasi chopart
84 Amputasi Lisfranc
85 Amputasi syme
86 Amputasi ankle
87 Arthrodesis phalang manus
88 Arthrodesis phalang metacarpal
89 Arthrodesis phalang metatarsal
90 Arthrodesis phalang pedis
91 Debridement open fracture
92 Disartikulasi ankle
93 Disartikulasi elbow
94 Disartikulasi knee
95 Disartikulasi wrist
96 Disisi Aspirasi katarak dengan LA
97 Eksternal fiksasi tulang panjang
98 Internal fiksasi fraktur metacarpal complicated
99 Internal fiksasi fraktur olecranon
100 Internal fiksasi fraktur patella
101 Internal fiksasi fraktur phalang complicated
102 Internal fiksasi manus multiple
103 Osteoclasis
104 Pengambilan nail/plate termasuk implant symphisis pubis
105 Adductor tenotomy off the hip
106 Amputasi metacarpal
107 Amputasi phalang manus dengan GA (General Anaesthesia)
108 Amputasi phalang pedis dengan GA (General Anaesthesia)
109 Closed tenotomy achiles (achilotenotomy)
110 Excision of the bone
111 Internal fiksasi fraktur metacarpal
112 Internal fiksasi faktur phalang
113 Internal fiksasi fraktur tibia plateau
114 Pasang skeletal traksi dg GA
115 Pengambilan intramedulary nail (femur, tibia)
116 Pengambilan K Wire dengan GA
117 Release de Quervain tenosynovitis GA
118 Amputasi phalang manus dengan LA (local Anaesthesia)
119 Amputasi phalang pedis dengan LA (local anaesthesia)
120 Anuscopy biopsi dengan GA (general anaesthesia)
123 Bone marrow analisa (BMA)
124 Closed reduction fractur nasal
125 Pelepasan eksternal fiksasi dengan GA (General Anaesthesia)
127 Release CTS dg LA
128 Reposisi fraktur/dislokasi dg GA
129 Reposisi tertutup fraktur dan imobilisasi plaster cast dengan GA (general anaesth
130 Pelepasan eksternal fiksasi dengan LA (local anaesthesia)
131 Release de Quervain tenosynovitis
132 Suture of laceration of lip dengan LA (local anaesthesia)
133 Suture of laceration of other part of mount dengan LA (local anaesthesia)
134 Suture of laceration of palate dengan LA (local anaesthesia)
135 Triger finger
136 In growing nail (ekstraksi kuku) dg LA
137 Antrostomi dengan CWL
138 Arthroscopy rekonstruksi
140 Ekstirpasi tumor + rekonstruksi (orthopedi)
D OPERASI BEDAH ONKOLOGI
1 Neck dissection radical bilateral
2 Deseksi kelenjar inguinal
3 Mestectomy subcutaneous unilateral
4 Mastectomy extended simple unilateral
5 Mastectomy simple unilateral
6 Mastectomy sub total
7 Mastectomy Unilateral
8 MRM (modified radical mastectomy)
9 Neck dissection radical unilateral
10 Parotidectomy total
11 Pedicle flaps (advanced)
12 Reseksi hemi mandibula (hemimandibulektomi)
13 Thyroidectomy total
14 Deseksi kelenjar leher
15 Glossectomy parrtial
16 Parotidectomy superfisial
17 Reseksi mandibula bilateral
18 Soft tissue tumor (kompartment reseksi)
19 Sub total unilateral isthmo lobectomy
20 Thyroidectomy subtotal
21 Enukleasi dg GA
22 Basalioma (excision or destruction of lesion or tissue of skin and subcutaneous tis
23 Eksisi fibro sarcomamae mama

24 Eksisi ginecomasti/subcutoneus mastectomy
25 Eksisi kelenjar liur
26 Eksisi limfangioma luas
27 Eksisi tumor kelenjar leher
28 Excision or destruction of lesion or tissue of tongue
29 Kista radicular (eksisi)
30 Soft tissue tumor (muscle reseksi)
31 Tumor palatum (eksisi)
32 Basalioma (excision or destruction of lesion or tissue of skin and subcutaneous tis
33 Eksisi kelenjar inguinal
34 Eksisi limfangioma
35 Eksisi mamae aberan
36 Epidermoid carsinoma (excision or destruction of lesion or skin and subcutaneous
37 Liposarcoma (eksisi)
38 Soft tissue tumor (eksisi)
39 Trabekulektomi
40 Eksisi fibroma
41 Eksisi fibro adenoma (fam) dengan GA
42 Eksisi tumor adneksa sedang
43 Eksisi tumor kel. Submandibula
44 Eksisi tumor multiple
45 Epidermoid carsinoma (excision or destruction of lesion or skin and subcutaneous
46 Eviscerasi
47 Excision of lesion of breast dengan GA
48 Ganglion Carpi/tarsa
49 Lipoma nochae (ekstirpasi)
50 Ateroma ekstirpasi dengan GA
51 Biopsy of skin and subcutaneous tissue dengan GA
52 Chemical peeling
53 Eksisi fibro adenoma (fam) dengan LA
54 Eksisi tumor adneksa kecil
55 Eksisi tumor dengan GA
56 Ekstirpasi korpal dengan penyulit (LA)
57 Excision of lesion of breast dengan LA
58 Lipoma (ekstirpasi) dengan GA
59 Neurofibroma (eksisi) dengan GA
60 Open biopsy of breast dengan GA
61 Tofus (eksisi) dengan GA
64 Eksisi tumor dengan LA
65 Tofus (eksisi) dengan LA
66 Extirpasi geborn myoma
67 Lipoma (ekstirpasi) dengan LA
68 Extirpasi tumor jinak kulit dan bawah kulit
69 Neurofibroma (eksisi) dengan LA
70 Excisi non wajah
E OPERASI BEDAH SYARAF
1 Replantansi/revaskularisasi
2 Trepanasi
3 Laminectomy
4 Laminoplasty
5 Open reduction cervical
6 Spinal fusion (PLIF/ALIF)
8 Other craniectomy
9 Other craniotomy
10 Evakuasi bekuan darah (clot)
11 Parasentesa
12 Injeksi tulang belakang dengan C Arm
F OPERASI BEDAH UROLOGI
1 Nefrolithotomy bivalve
2 Open prostatectomy
3 Uretero litotomi batu ureter pasang stent
4 Bladder neck rekonstruksi
5 Boary flap
6 PNL/PCNL
7 Reimplantasi ureter bilateral
8 Repair fistel enterovesica
9 Repair vesicorectal
10 Repair vesicovagina
11 TUR buli
12 TURP/BNI
13 URS
14 Pielolithotomy
15 Repair urethra
16 Uretero litotomi batu ureter 1/3 distal tanpa neo implantasi ureter
17 Uretroplasty pada hypospadias
19 Anastomose ureter end to end
20 Anastomose urethra end to end
21 Divertikulektomy buli
22 Extended pielolithotomy
23 Internal urethrotomy (sache)
24 Johanson II
25 Lithotripsi
26 Nefroureterectomy
27 Nefropeksi
28 Pieloplasty
29 Radikal nefrectomy
30 Radikal orchidektomy
31 Railroading ruptur urethra
32 Repair fistel vesikokutan
33 Repair trauma buli
34 Sistectomy parsial
35 Ureterocutaneostomy
36 Uretero litotomi distal
37 Enukleasi dg GA
38 Nephrotomy and nephrostomy
39 Orchidectomi + orchidopexy contra lateral
40 Orchidectomi pada undescensus testis unilateral
41 Partial nefrektomi
42 Repair AC joint sclera dengan GA
43 Unilateral orchidectomy
44 Insisi posterior urethral valve
45 Johanson I
46 Koreksi priapismus alghorab
47 Open nefrostomy
48 Orchidopeksi (torsio testis)
49 Orchidopeksi (undescencus testis)
50 Palomo
51 PER (primary endoscopy realignment)
52 Uretero litotomi proksimal
53 Batu buli-buli (sectio alta)
54 Percutaneous nephrostomy without fragmentation
56 Repair of testis
57 Cordektomi
58 Drainase periureter
59 Eksis web penis
60 Epispadia
61 Nefrostomi percutan
62 Parsial penektomi
63 Rekonstruksi penis
64 RPG (retrograde pielografi)
65 Subcapsuler orchidectomi
66 Tailoring ureter
67 Total penektomi
68 Vasoepididimostomy
69 Vesikolithotomy
70 Open cistostomi dg GA
71 Other repair of urinary bladder
72 Sialo lithiasis (ekstraksi batu dan marsupiasisasi)
73 Urethro litotomi batu uretra anterior dengan atau tanpa meatothomy (dengan GA)
74 Cistectomy ginjal
75 Divertikulektomy urethra
76 Insersi DJ Stent
77 Insersi selang tenckhof CAPD
78 pungsi dan sklesrosing kista ginjal
79 Repair fistel urethra
80 Skrotoplasty
81 Urethrolithotomy (GA)
82 Percutaneous cystostomy (closed cystotomy)
83 Spermatocele
84 Urethro litotomi batu uretra anterior dengan atau tanpa meatothomy (dengan LA)
85 Vitrektomi
86 Spermatokelectomy
87 Dilantasi uretra/bouginasi caterisasi
88 Vasectomi LA
89 Biopsi testis
90 Circumsisi dengan LA (local anaesthesia)
91 Biopsi penis
92 Cabut DJ stent
93 Circumsisi dengan GA (general anaesthesia)
94 Meatotomy
95 Operasi priapismus winter's procedure
96 Panendoscopy
97 Sitoscopy
98 Vasectomy (narkose)
99 Casting
100 Transurethral prostatectomy
101 Uretero litotomi batu ureter 1/3 distal + neo implantasi ureter
102 Nefrolithotomy
G OPERASI BEDAH THORAX KARDIO VASKULER( BTKV )

1 Sternotomy pada tumor mediastinum
2 Thorakotomy lobectomy tumor paru
3 Thorakotomy pada PDA (patent ductus ateriosus persistent)
4 Thoraktomy pada tamponade jantung
5 Internal fiksasi (pasang shapp plate) fraktur costae multiple
6 Repair vascular dg graft
7 Tendon transfer
8 Thorakotomy pada emphiema
9 Thorakotomy pada hematothotax
10 Thorakotomy pada hematothotax dg lobectomy paru
11 Thoraktomy pada tumor pleura
12 Anastomose vascular end to end
13 Fraktur costae dg internal fiksasi (pasang shapp plate) multiple
14 Repair vascular
15 Vasografi
16 Eksisi hemangioma
17 Skin graft flap sederhana
18 A-V Shunt (cimino)
19 Debridement excisional of wound
20 Debridement incisi & drainage septic arthritis
21 Nevus pigmentosus (eksisi) dengan GA
22 Incisi abces dengan GA (general anaesthesia)
23 Pasang WSD
24 Electro encephalography (EEG)
25 Incisi abces dengan LA (Local anaesthesia)
26 Pasang central venous presure (CVP/CVC)
27 Double lumen
H OPERASI BEDAH PLASTIK

1 Fraktur maxilla lefolt III (internal fiksasi)
2 Neo Implantasi boary flap
3 Labio genatopalatoschisis
4 Other operations on mouth and face
5 Other reconstruction of the toe
6 Rekonstruksi kelopak mata berat
7 Rekonstruksi sindaktili
8 Rekonstruksi digiti
9 Release kontraktur luas
10 Fraktur hemimaksila (internal fiksasi)
11 Fraktur mandibula simple (internal fiksasi)
12 Fraktur maxila lefolt I (internal fiksasi)
13 Other tendon lengthening
14 Palatoplasty
15 Partial Nefrektomi
16 Pedicle flaps sederhana
17 Reduksi macrodactili
18 Release chordae(release of chordae)
19 Repair ruptur palpebra transkanal dengan GA
20 Repair ruptur moderate
21 Tendon transfer for stabilization of patella
22 FTSG (full-thickness skin graft to other sites)
23 Labioplasti/repair of cleft lip
24 Rekonstruksi palpebra
25 Relese kontraktur sederhana
26 Skin graft (STSG)
27 STSG (skinn graf : free skin graft)
28 Debridement infection or burn
29 Fasciotomy
30 Fraktur alfeolaris (pasang archbar)
31 Couterisasi clavus/veruca dengan GA
32 Eksisi keloid dengan GA (general anaesthesia)
33 Fiksasi arch bar dengan GA
34 Finger tip injury (repair v-y flap) dg GA
35 In growing nail (ekstraksi kuku) dg GA
36 Re hechting dengan GA
37 Re hechting dengan GA pada burst abdomen
38 Rekonstruksi polidaktili
39 Couterisasi clavus/veruca dengan LA
40 Jahit luka diwajah dengan GA (general anasthesia)
41 Lobuloplasty bilateral
42 Lobuloplasty unilateral
43 Parasentesa BMD
44 Suture of laceration of other part of mounth dengan GA (general anaesthesia)
45 Explorasi corpus alienum simple dengan LA
46 Jahit luka diwajah dengan LA (local anasthesia)
47 Eksisi keloid dengan LA (local anaesthesia)

48 Incisi pada hidung
49 Injeksi sub konjungtiva
50 Jahit palpebra kecil
51 Nevus pigmentosus (eksisi) dengan LA
52 Re hechting dengan LA
53 Excisi wajah
54 Glossectomy total (complet)
I OPERASI BEDAH TRAUMA

1 Internal bleeding ruptur ginjal/hepar/lien/sebab lain
2 Amputasi forequarter
3 Amputasi hindquarter
4 Fraktur mandibula complicated (internal fiksasi)
5 Fraktur mandibula simple (internal fiksasi + pasang arch bar)
6 Fraktur maxilla lefolt II (internal fiksasi)
8 Repair tendon achiles complicated
9 Ekstirpasi korpal dengan penyulit (GA)
10 Repair tendon achiles
11 Repair tendon ekstersor pedis
12 Repair tendon fleksor pedis
13 Repair tendon patella
14 Tendon achiles lengthening
15 Repair tendon fleksor/ekstensor pedis
16 Repair tendon fleksor/ekstensor manus (1 tendon)
17 Tracheostomi permanent
18 Transfusi tukar
19 Explorasi corpus alienum dengan penyulit
20 Finger tip injury (repair v-y flap) dengan LA
21 Tracheostomi temporer
22 Repair tendon sederhana (1 tendon)
23 Extraksi corpus alienum sederhana (bedah)
J OPERASI OBSTETRI DAN GINEKOLOGI(OBSGIN)

1 Supra vaginal histeroctomy/total abdominal histerectomy
2 Cystektomi/ovarektomi bilateral
3 Miomektomi
4 Repeated sectio caesaria
5 Salphingo oophorectomy bilateral
6 Salphingo oophorectomy unilateral
7 Sectio caesaria
8 Sectio caesaria + cystektomy/ovarektomy bilateral
9 Sectio caesaria + cystektomy/ovarektomy unilateral
10 Sectio caesaria + miomektomy
11 Sectio caesaria + salphingo oophorectomy bilateral
12 Sectio caesaria + salphingo oophorectomy unilateral
13 Sectio caesaria + tubektomy pomeroy

14 Sectio caesaria gemelly
16 Vaginal reconstruction
17 Cystektomi/ovarektomi unilateral
18 Vaginoplasty
19 Curettage abortus incipien (inkomplit)
20 Curettage HPP (late HPP)
21 Curettage meno (metorrhagia)
22 Curettage missed abortion (death conceptus, blighted ovum)
23 Curettage molla hydatidosa
24 Incisi hymen imperforate
25 Kista dermoid eksisi dengan GA
26 Repair perineum/vagina (perineoraphy)
27 Repair vagina/cerviks/portio
28 Seconderi repair ephisiotomi
31 Tubektomy minilaparotomy
32 Eksterpasi cysta bartolin
33 Kista dermoid eksisi dengan LA
34 Extirpasi tumor jinak vagina
35 Dermaroller platellet rich plasma (PRP)
36 Insisi absces bartholini + marsupialisasi
37 Reposisi inversio uteri
38 Extirpasi polip cervik
39 Extraksi corpus alienum vagina
40 Salphingo/Oophorectomy
41 Total abdominal hysterektomy + bisalphingoo oophorectomy
K OPERASI MATA
1 Disisi aspirasi katarak dengan GA
2 Repair ruptur cornea sclera dengan GA
3 Ekstraksi katarak pasang IOL
4 Koreksi entropion
5 Koreksi extropion
6 Koreksi simblepharon
7 Repari ruptur cornea sclera
8 Saucerization
9 Sequestrectomy
10 Jahit lid mirgin
11 Kanalisasi lakrimal
12 Repair laserasi konjungtiva
13 Repair laserasi kornea
14 Repair laserasi sclera
15 Repair ruptur palpebra simple
16 Repair ruptur palpebra transkanal
17 Aspirasi katarak sekunder
18 Extirpasi pterygium
19 Flap konjungtiva
20 Hymenorapi
21 Repair ruptur cornea
22 Repair ruptur konjungtiva
23 Eksisi calazion
24 Eksisi hordiolum
25 Ekstirpasi granuloma
26 Ekstraksi lithiasis
27 Insisi cornea
28 Irigasi trauma kimia perdrip
30 Skarping cornea
31 Ekstrasi corpus alienum cornea
L OPERASI TELINGA HIDUNG TENGGOROKAN (THT)

1 Tonsilektomi
2 Exstraksi polip nasi
3 Irigasi sinus
4 Anastesi
5 Adenotonsilectomy
6 Ethmoidektomy
7 Faringectomy
IV. PELAYANAN TINDAKAN MEDIK OPERATIF TIDAK TERENCANA / EMERGENCY / CYTO
* tarif dikalikan 25% dari tindakan medik operatif pada III A
V. PELAYANAN TINDAKAN MEDIK NON OPERATIF
NO URAIAN
(1) (2)
1 Peritonial Dialisis
2 Injeksi LP Intratekal
3 Injeksi LP Epidural
4 Injeksi Impletol
5 Etanol Terapi Tumor Hati
6 Pasang Sonde
7 Pasang Skin Traction
8 Skleroterapi
9 Injeksi Intranodul
10 Esofagogastroduodenoskopi
11 Esofagogastroduodenoskopi dengan biopsi
12 Kolonoskopi
13 Kolonoskopi dengan biopsi
14 Ligasi Varises
15 Polipektomi
16 Dilatasi Esofagus
17 Clip
18 Regulasi Hemostatis
19 Bronkoskopi dengan biopsi
20 Bronkoskopi dengan brushing
21 Bronkoskopi dengan washing
22 BAL
23 Bronkoskopi pengambilan benda asing
24 Aspirasi mucous
25 Pungsi Lever
26 Tindakan pemberian Sitostatika / Kemoterapi
27 Pemasangan Water Seal Drainage / WSD
VI. PELAYANAN KEGAWAT DARURATAN / INSTALASI GAWAT DARURAT (IGD)
NO URAIAN
NO URAIAN
(1) (2)
A TINDAKAN UMUM
8 Ambil sampel darah arteri
9 Pasang NGT dewasa
10 Pasang NGT anak / bayi
11 Pasang folley cateter
12 EKG
13 Pemeriksaan glukotest
14 suppositoria
B TINDAKAN KHUSUS EMERGENCY

1 Pasang mayo / oropharengeal tube*
2 Suction aktif / slem suction*
3 Pasang ET
4 Needle cricothyroidectomy
5 Pasang neck collar
6 Punctie pleural
7 Punctie ascites
8 Punctie blast
9 Cytostomi
10 Pemasangan cateter vena central(CVC)
11 Pemasangan cateter intra osseus /umbilical,vena dalam
12 Pemasangan vena sectie
13 Needle chest
14 Cricothroidectomy
15 Pemasangan monitor vital sign/jam
16 Pemasangan syringe pump
17 Pemasangan infussion pump
18 Therapi inhalasi tanpa obat / Nebulizer per kali
20 Pemasangan infus warmer
21 Pemasangan infant warmer
23 defribrilator / DC shock
24 Manual ventilasi / jam
C TINDAKAN KHUSUS SESUAI KASUS EMERGENCY
1 Rawat Luka
a.
b.
c.
d.
2 Rawat luka bakar < 10 %
3 Rawat luka bakar 10 - 50 %
4 Rawat luka bakar > 50 %
5 Debridemant dan necrotomy
-
-
-
6 Amputasi sendi kecil
7 Cross incisi
8 Nail Ekstrasi
9 Gips
10 Ransel verband
11 Imobilisasi Fraktur dengan spalk
12 Immobilisasi fraktur dengan back slab
-
-
-
14 Incisi abses
15 Ekstraksi korpus alienum THT/mata/kulit
-
-
-
16 Ekstraksi batu urethra antherior
17 Tindakan lavement/spoeling
18 Tindakan reposisi:
-
-
-
19 Pemasangan tampon*
20 Pelepasan tampon
21 Angkat Jahitan
-
-
-
22 Aff infus / NGT / Cateter Urine
23 Ultrasonografi (USG) emergency
24 Pemasangan WSD
25 Transfusi darah per kali
D RAWAT SEHARI
1 Ruang observasi reguler/P3
-
-
-
2 Ruang High Care/P2

-
-
-
3 Ruang observasi intensive/P1

-
-
-
E PELAYANAN PREHOSPITAL DAN RUJUKAN

1 Sewa ambulance BLS ( Team )
-
-
2 Sewa ambulance ALS ( Team )
-
-
3 Dokter umum / 24 jam
4 Dokter spesialis / 24 jam
5 Perawat / 24 jam
VII. PELAYANAN RAWAT INAP DAN KEPERAWATAN
NO URAIAN
(1) (2)
A PELAYANAN TINDAKAN KEPERAWATAN
1 Minimal Care per hari
2 Moderate Care per hari
3 High Care per hari
4 Intensif Care per hari
B PELAYANAN TINDAKAN RAWAT INAP
1 Pemeriksaan oleh dokter jaga
2 Pemeriksaan pasien rawat inap gawat oleh dokter jaga
5 Rawat Lokasi infus per hari
6 Rawat Luka
a.
b.
c.
d.
10 infus tali pusat
11 Necrotomy jaring ( kecil )
12 Angkat Jahitan
-
-
-
13 Pasang tampon
14 Aff Tampon
15 Memandikan bayi/kali
16 Memandikan Pasien/kali
17 Keramas pasien/kali
22 Skin Test
23 Memberi Obat melalui Gastrotomy
24 Memberi Obat Supositoria
28 Pasang Bidai*
29 Pasang Neck Collar *
30 Penanganan Keracunan
31 Perawatan Payudara
32 Perawatan WSD
33 Perawatan Kolostomy / Iliestomy
35 Pasang NGT Dewasa / Anak
36 Pasang ET
37 Pasang Mayo / Oroparingeal
38 Aff infus / NGT / Cateter urine
39 Perawatan Tracheostomy
40 Irigasi Mata
41 EKG
43 ambil sampel darah arteri
44 Penggunaan Oksigen ( O2)
a.
b.
45 Suctioning*
47 irigasi BPH/hari
48 Spoeling BPH/kali
49 Klisma / Huknah
50 Postural Drainase
VIII. PELAYANAN KEBIDANAN
NO URAIAN
(1) (2)
1 Persalinan Normal
2 Curretage
3 Persalinan dengan penyulit ringan :
a. Oxytosin Drip
b. induksi misoprostol
4 Persalinan dengan penyulit sedang :
a. Ekstraksi Vacum
b. KBI(ksi bimanual internal)
c. Manual Placenta
d. Manual AID (tindakan partus sungsang)
e. Versi Ekstraksi
Persalinan dengan penyulit besar :
a. Embriotomi
b. Laparotomi
IX. PELAYANAN ICU
NO URAIAN
(1) (2)
A
1 Tarif visite dokter / Intensiv / Konsultasi antar SMF
2 Jasa Keperawatan ICU / hari
B TINDAKAN
Setting ventilator
5 Sewa alat dan monitoring per jam
6 Pemasangan Warm air sheet
7 Pemasangan Blanket Roll
8 Pemasangan Alat anti Dekubitus
9 Bedside monitor / hari
10 Pasang Mayo
11 Pasang NGT
12 Aff NGT
13 Pasang ET
14 Needlle Thorakostomi
15 Pasang Cateter urine
16 Aff Cateter
20 Rawat Luka
a.
b.
c.
d.
23 Pasang infus anak
24 Pemasangan Cateter vena profunda
25 Pemasangan cateter arteri ( artery line )
26 Pemasangan cateter CVP
27 Pemasangan cateter HD
28 Intubasi
30 Pleural Punction
-
-
-
33 Pemasangan Cateter epidural
34 Fisioterapi
35 Tindakan Anasthesi ( GA atau RA ) di ICU
36 Resusitasi Kardiopulmoonal ( dengan DC Shock )
37 Pemasangan WSD
38 Asites Puction
39 suction di luar cup per kali
a.
b.
c.
X. PELAYANAN NICU
NO URAIAN
(1) (2)
1 Pemasangan Respirator / hari
5 Pemasangan Feeding Pump:
6 Pemasangan Radiant / Infant Warmer :
7 Vena seksi
8 Foto Theraphy / hari
9 Resusitasi bayi bermasalah / RKP
10 Portable pulse oximeter
11 Resusitasi bayi normal
12 Intubasi
13 Suction pump
14 Pasang NGT
15 Aff NGT
16 Pasang ET
17 Pasang Cateter
18 Aff Cateter
19 Lumbal Punctie
20 Tindakan transfusi
21 Massage bayi
22 Pasang ventilator / NCPAP
23 Observasi Ventilator / NCPAP / hari
24 Perawatan luka
25 Tindakan metode kangguru
26 Perawatan tali pusat
27 Transfusi Tukar
28 Pemberian Surfactan
29 Pemasangan WSD pada Neonatus
30 Pemasangan cateter umbilical
31 Sensor saturasi oksigen (BHP )
32 Rawat luka bakar < 10 %
33 Rawat luka bakar 10 - 50 %
34 Rawat luka bakar > 50 %
35 Pemasangan cateter Arteri ( artery line )
37 Therapi Inhalasi tanpa obat / Nebuizer per shift
39 Fisioterapi
40 Pemasangan infus bayi per kali
41 Injeksi im per kali
42 Injeksi iv per kali
43 Injeksi ic per kali
44 Injeksi sc per kali
45 Memberi obat Supositoria
47 Melakukan sampling spesisemen Lab
48 Melakukan klisma / huknah rendah / Drumbuisa (Nacl Hangat)
a. Tiap 1 liter / menit / jam
b. Pemakaian dan pemasangan O2 per kali tanpa ventilator
c. Pemakaian dan pemasangan O2 per kali dengan ventilator
XI. PELAYANAN HEMODIALISIS

A. PELAYANAN HEMODIALISIS TERENCANA
NO URAIAN
(1) (2)
1 Penggantian transver set ( CAPD )
3 Pelayanan HD dengan Reuse
4 Pelayanan HD tanpa Reuse di bawa pasien sendiri
5 Pelayanan HD dengan Reuse di bawa pasien sendiri
B. PELAYANAN HEMODIALISIS CITO
NO URAIAN
(1) (2)
1 Penggantian Transfusi set
2 Pelayanan HD tanpa Reuse
3 Pelayanan HD dengan Reuse
4 Pelayanan HD tanpa Reuse di bawa pasien sendiri
5 Pelayanan HD dengan Reuse di bawa pasien sendiri
XII. PELAYANAN PENUNJANG MEDIK
A. PELAYANAN TINDAKAN MEDIK DIAGNOSTIK ELEKTROMEDIK DAN NON ELEKTR
NO URAIAN
(1) (2)
1 WSD Kontinu
2 Laparaskopi
3 Punctie Pluera / Lung Punctie
4 AJH ( Paru )
5 Portable spirometri
6 Pungsi Acites
7 Pungsi Pericard
8 Treadmile
9 Holter Monitoring
10 Ochocardiografi Dopler Color
11 EKG Simple
12 Biopsi Hati
13 Pungsi abses hati
14 Gastroscopy
15 Colonoscopy
16 Pungsi abses hati
17 BMP ( Basic Metabolic Panel )
18 BMP dengan General Anesthesi
19 Biopsi Ginjal
20 Supra Public Punctie
21 Suntikan / Injeksi Intra Arikuler
22 Lumbal Pungsi
23 Ganglion Pungsi
24 Biopsi Transtorakal
25 Dopler Kamar Operasi
26 FFA / Fluorescin Fundus Angio
27 Toracoskopi
28 Kolposkopi
29 Test Perspirasi
30 Biopsi THT
31 AJH THT
32 Pemeriksaan EEG
33 Baca EEG
34 Pemeriksaan ENMG
35 CTG
36 Audiometri murni
37 Audiometri tutur
38 Test Vestibuler
39 Foto Fundus Mata
40 Funduscopy Indirect
41 Sinopthor
42 Test Provokasi
43 Skin Test Allergi Elektro
44 Desensitisasi ( Paket )
45 Nasolaringokopi
46 Swab Nasofaring
49 Keratometri
50 Anal Test
51 Gonioskopi
52 Retinoskopi
53 Biopsi Adneksa Mata
54 USG Mata
55 Tonometri Aplanasi
56 Water Drinking
B. RADIOLOGI ( Untuk Tarip Penunjang Radio Diagnostik, Tidak Termasuk Bahan K
NO URAIAN
(1) (2)
A KECIL / TANPA KONTRAS
1 Kepala AP / Lat
2 Kepala 3 Posisi
3 SPN ( Sinus Para Nasal )
4 Nasal
5 Cervical AP / Lat ( 2 Film )
6 Cervical AP / Lat / Obl ( 4 Film )
7 Thoracal / AP / Lat ( 2 Film )
8 Thoracal / AP / Lat Obl ( 4 Film )
9 Thoraco Lumbal AP / Lat
10 Thoraco Lumbal AP / Lat / Obl
11 Lumbal AP / Lat ( 2 Film )
12 Lumbal AP / Lat / Obl ( 4 Film )
13 Lumbosakral AP / Lat
14 Pelvis ( 1 Film )
15 Femur AP / Lat Genu AP / Lat
16 Genu AP / Lat
17 Cruris AP / Lat
18 Pedis AP / Lat
19 Ankle Joint AP / Lat
20 Manus AP / Lat
21 Wrist Joint AP / Lat
22 Antebrachi AP / Lat
23 Elbow Joint AP / Lat
24 Humerus AP / Lat
25 Shoulder AP / Lat
26 Clavicula
27 Thorax PA Dewasa
28 Thorax Lat Dewasa
29 Thorax AP / Lat Dewasa
30 Thorax AP Anak
31 Thorax AP / Lat Anak
32 Abdomen / BNO Dewasa
33 Abdomen / BNO Anaka
34 Abdomen 3 Posisi Dewasa
35 Abdomen 3 Posisi Anak
36 Dental Regio
37 Panoramic gigi
B SEDANG / DENGAN KONTRAS
1 Mammografi
2 Pelvis dengan sonde
3 Pelvimeteri
4 Uretrografi
5 Cystografi
6 Uretro Cystografi
7 H S G dengan kontras
8 RPG / APG
9 OMD dengan kontras
10 Oesofagografi
11 Colon In Loop Dewasa
12 Colon In Loop Anak
13 Fluoroscopy
14 Intra Vena Pyelography ( IVP ) 5 Film
15 Intra Vena Pyelography ( IVP ) 6-7 Film
C CANGGIH
1 Myelografi Lumbal
2 Myelografi Thoracal / Cervical
3 Arthrografi
4 Phlebografi extr superior
5 Phlebografi extr inf
6 CT Scan kepala non kontras
7 CT Scan Kepala kontras
8 a. Whole Body CT Scan non kontras
9 b. Whole Body CT scan dengan kontras
10 CT Scan thorax nn kontras
11 CT scan thorax kontras
12 CT scan abdomen atas / bawah non kontras
13 CT scan abdomen atas / bawah dengan kontras
14 CT scan ekstrimitas non kontras
15 CT scan ekstrimitas kontras
16 C- Arm
17 USG Abdomen atas
18 USG Abdomen bawah
19 USG Abdomen atas bawah
20 USG Ginjal
21 USG Testis
22 USG Payudara
23 USG Musculoskeletal
24 USG Neonatus
25 USG Thorax
26 USG Dopler Color
C. PELAYANAN PEMERIKSAAN LABORATORIUM / PATOLOGI KLINIK
NO URAIAN
(1) (2)
A HEMATOLOGI
1 Darah rutin ( HMK ) :
5 Dift
3 Dift
2 Reticolusit
3 Angka Eosinofil
4 Limfosit Plasma Biru
5 Malaria Mikroskopis
6 Malaria Stix
7 Filaria
8 Golongan Darah + Rhesus
9 Coomb's Test
10 Morfologi Darah Tepi
11 B M P ( Pemeriksaan )
12 Aspirasi BMP
13 Ratio IM / IT
14 Hemosidirin
15 LE Cell
16 O F T
17 Alkali Denaturasi / HBF
18 HbA2
19 Angka Eritrosit
20 Angka Leukosit
21 Angka Trombosit
22 Differential count
23 LED
24 Retraksi Bekuan
25 Serum Iron ( SI )
26 Total Iron Binding Capacity ( TIBC )
27 INR
28 OFT ( Screaning )
29 OFT ( Semi Kuantitatif )
30 HbF
FAAL HEMOSTASIS
1 Masa Jendal ( CT )
2 Masa Pendarahan ( BT )
3 PPT
4 APTT
5 APTT Substitusi
6 Fibrinogen
7 Fibrinogen Degradition Product ( FDP ) / D Dimer
PEWARNAAN SITOKIMIA
1 PAS
2 SBB
3 Peroksidase ( MPO )
4 NSE
5 Pearl
B KIMIA KLINIK
FAAL GINJAL
1 Ureum
2 Kreatinin
3 Uric Acid
4 Urea Clearance
FAAL HATI
1 Bilirubin Direk
2 Bilirubin Total
3 Bilirubin Indirect
4 Bilirubin ( Urine )
5 Total Protein
6 Albumin
7 Globulin
8 SGOT
9 SGPT
10 GGT
11 Alakali Fosfatase
DIABETES
1 Gula Darah Puasa
2 Gula darah puasa 2 jam
3 Gula darah sewaktu
4 HbA1C ( AIC )
5 Glukosa Stick
LEMAK
1 Cholesterol Total
2 Cholesterol HDL
3 Cholesterol LDL
4 Trigilserida
5 HDL Direct
6 LDL Direct
ELEKTROLIT
1 Elektrolit Na +
2 Elektrolit K+
3 Elektrolit Cl-
LAIN-LAIN
1 CKMB
2 LDH
3 Analisa Gas Darah dan Elektrolit
4 CK ( Creatine Kinase )
5 Protein Elektroforesis
6 Mikro Albumin
C IMUNOLOGI
1 TORCH
2 Torch IgM Rapid
3 Toxoplasma IgG IgM
4 Toxoplasma IgG
5 Rubela Ig.M
6 Rubella Ig.G
7 CMV Ig.M
8 CMV Ig.G
HEPATITIS
1 HBsAg (ELFA )
2 HBsAg Rapid
3 HBsAg ( Elisa )
4 Anti HIV ( Elva )
5 Anti HIV ( Elisa )
6 Anti HIV ( Rapid )
7 Ferritin
9 Anti HBs Elisa
10 Anti HBs Rapid
11 Anti HCV Elisa
12 Anti HCV Rapid
INFEKSI LAIN
1 TPHA
2 VDRL
3 DHF IgG IgM
4 Anti TB Rapid
5 IgM Anti Leptospira
6 IgG Anti Leptospira
7 ICT Malaria
8 Widal
9 HIV Elisa
10 HIV Rapid
11 NSI
PETANDA TUMOR
1 AFP
2 CEA
3 PSA
4 CA 15.3
5 CA 125
6 CA 19.9
FUNGSI THYROID
1 Total Ig.E
2 T3 Total
3 FSH
4 T4 Total
5 Free T4
6 TSH
7 Free T3
LAIN-LAIN
1 RA / RF
2 ASTO
3 CRP
4 HBsAg ( Elisa )
5 HBsAg Rapid
6 Tubex TF
7 HIV Elisa
8 HIV Rapid
9 Progesteron
10 Testosteron
11 Anti HP
12 Anti HP IgG
a. Troponin I
b. Mantoux Test
D MIKROBIOLOGI KULTUR URINE
D1 KULTUR URINE
1
2
D2 KULTUR FAECES
1
2
D3 KULTUR DARAH
1
2
3
4
5
6
D4 SPUTUM
1
2
D5 USAPAN TENGGOROK
1
2
D6 USAPAN LUKA
1
2
D7 CAIRAN CEREBROSPINAL
1
2
D8 CAIRAN PLEURA
1
2
D9 CAIRAN PERITONIUM
1
2
D10 CAIRAN PERICARDIUM
1
2
D11 CAIRAN DRAIN
1
2
D12 CAIRAN ASCITES
1
2
D13 BIAKAN GALL
1
2
D14 BIAKAN AN AEROB
1
2
MIKROSKOPIK
1
2
3
4
5
6
7
E PEMERIKSAAN LAINNYA
URINALISIS
1 Urine Rutin
2 Urin Protein
3 Urin Bilirubin
4 Urine Reduksi
5 Urin Urobilin
6 Analisa Sperma
7 Urine keton
8 Sedimen
9 Urine Esbach
10 Urine Bence Jones
11 Uji kehamilan/PP test
12 Uji kehamilan ( titrasi )
ANALISIS FAECES
1 Faeces Rutin
2 Faeces Amoeba
3 Faeces Consentrasi
4 Faeces Benzidin
5 Faeces Stercobilin
NARKOBA
1 Urine Narkoba Amfetamin
2 Urine Narkoba THC
3 Urine Narkoba Morfine
4 Urine Narkoba Benzodiazefin
5 Urine Narkoba Meth Amphetamine
ANALISA CAIRAN TUBUH LAIN
1 Angka cell LCS
2 Diff Cell LCS
3 None
4 Pandy
5 Rivalta Test
6 Glukosa
7 Protein
8 Patologi Anatomi / Histopatologi Besar
9 Patologi Anatomi/Histopatologi sedang
10 Patologi Anatomi / Histopatologi kecil
11 Sitologi
D. PELAYANAN FARMASI
NO URAIAN
NO URAIAN
(1) (2)
A BIAYA FARMASI
A1 BIAYA OBAT NON RACIKAN
1
A2 BIAYA OBAT RACIKAN
2
3
B KONSELING FARMASI
1 Konseling obat resep/ obat bebas
2 Visite farmasi klinik
a.
b.
E. PELAYANAN BANK DARAH
NO URAIAN
(1) (2)
1 Crossmacth ( metode gel )
2 Golongan darah
3 Phlebotomy
F. PELAYANAN PEMULASARAN JENASAH / FORENSIK DAN MOBIL JENAZAH
NO URAIAN
(1) (2)
1 Pemeriksaan Jenasah
2 Konservasi / Pengawetan
3 Rekonstruksi Jenasah
4 Penitipan Jenasah tanpa pendingin / hari
5 Penitipan Jenasah dengan pendingin / hari
6 Perawatan Jenasah
a. Tanpa resiko
b. Dengan resiko
7 Visum Et Repertum
- Luar
- Dalam / Otopsi
8 Biaya mobil jenazah
a. dalam kota
b. luar kota/km
G. PELAYANAN STERILISASI DAN LOUNDRY
NO URAIAN
(1) (2)
1 Gaas Kecil
2 Gaas Besar
3 Buiq Gaas
4 Gaas waten tanpa kapas
5 Gaas waten dengan kapas
6 Gaas mata
7 Tampon Vagina
8 Papan Spalk ukuran 100 cm
9 Papan Spalk ukuran 50 cm
10 Ransel Verband
11 Deppers HD dan Tonsil
12 Tampon Gigi
13 Donat
14 Tampon tanpa Boorzalft
15 Tampon dengan Boorzalft
16 Lidi Kapas
17 Kapas Savlon
18 Kapas Alkohol
19 Kapas potong segi empat
20 Benang tali pusat
21 Sterilisasi Handscun
22 Sterilisasi Instrumen dari unit RS
23 Sterilisasi Instrumen dari luar RS / Kilo
24 Loundry / kg
H. PELAYANAN GIZI
NO URAIAN
(1) (2)
1 Konsultasi Gizi
Rawat jalan
Kelas III
Kelas II
Kelas I
VIP
ICU
I. PELAYANAN PENUNJANG MEDIK LAINNYA
NO URAIAN
(1) (2)
1 Incinerator
TARIF LAYANAN NON PELAYANAN

I. PENDIDIKAN DAN PELATIHAN
NO URAIAN
(1) (2)
1 Praktek Klinik dokter muda
2 Praktek Klinik keperawatan
3 Praktek Klinik kebidanan
4 Seminar
II. PENELITIAN
NO URAIAN
(1) (2)
1 Penerbitan Izin Penelitian/Pengambilan data Mahasiswa DIII/D IV
2 Penerbitan Izin Penelitian/Pengambilan data Mahasiswa S1
3 Penggunaan berkas untukpenelitian
III. KANTIN
NO URAIAN
(1) (2)
1 sewa kantin
IV. SEWA RUANG/AULA
NO URAIAN
(1) (2)
1 sewa ruang/aula
TARIF LAYANAN PELAYANAN KESEHATAN
NDAFTARAN , PEMERIKSAAN , DAN AKOMODASI
URAIAN
(2)
ndaftaran
Administrasi sistem informasi
Berkas RM Rawat Jalan / Kartu Pasien
Berkas RM Rawat Inap
meriksaan Poliklinik
Pemeriksaan poliklinik oleh dokter umum
Pemeriksaan poliklinik oleh dokter spesialis
omodasi
Biaya Kamar
VIP
Kelas I
Kelas II
Kelas III
ICU
NICU
Visite Dokter Spesialis
VIP
Kelas I
Kelas II
Kelas III
ICU
NICU
Visite Dokter Umum
VIP
Kelas I
Kelas II
Kelas III
ICU
NICU
i Eksekutif /Khusus
Servis Layanan
Pemeriksaan dan Konsultasi dokter
Konsultasi antar SMF
NERAL CHECK UP
Paket I (Pemeriksaan fisik,Darah lengkap,Urine Lengkap)
Paket II (Pemeriksan Fisik,Darah lengkap,Urine Lengkap,Gula darah
sewaktu,kolesterol total,trigliserida)
Paket III (Pemeriksan Fisik,Darah lengkap,Urine Lengkap,Gula darah
sewaktu,kolesterol total,trigliserida,pemeriksaan narkotika,EKG,Rontgen Thorax)
RAT KETERANGAN DOKTER

Surat Keterangan sehat
Surat Keterangan untuk asuransi umum / non BPJS
Surat Keterangan Kelahiran
Surat Keterangan Kematian
LAYANAN RAWAT JALAN

POLI KLINIK TUMBUH KEMBANG
URAIAN
(2)
UNISASI DIWAJIBKAN (PPI)
BCG
DPT - Hb
Hepatitis B
Polio
TT
Campak
UNISASI DIANJURKAN (Non PPI)
Infrantrik (DTAP)
Infrantrik - HiB
Hepatitis Engerik B
HiB
IPD
Hepatitis A
Valirix (cacar air)
Typim (Typoid)
MMR
Psikologi Test
Tes Perkembangan Anak (DDST) pasien baru
Tes Perkembangan Anak (DDST) pasien lama
Screening
Tes Lambat Belajar
Tes Hiperaktif & Gangguan Konsentrasi
Tes Autisme
Tes Intelegensi (IQ)
Tes Intelegensia Anak
Tes Intelegensia Remaja
Tes Kepribadian
Tes Kepribadian Anak
Tes Kepribadian Remaja
Tes Minat Bakat
Tes Minat Bakat Dewasa/Anak
Psiko Tes
Konseling Psikologi (anak, remaja & dewasa)
Terapi Wicara
Terapi Edukasi
Terapi Okupasi
POLIKLINIK PENYAKIT ANAK
URAIAN
(2)
MP(lumbal punksi)
erapi Inhalasi tanpa obat / Nebulizer
G
O
meriksaan pasien autisme
masangan O2 / jam
POLIKLINIK BEDAH UMUM
URAIAN
(2)
wat Luka
Kecil (< 5 cm)
Sedang (5-10 cm)
Besar (10-20 cm)
Khusus (> 20 cm)
hit luka / Repair Jahitan
Kecil (< 10 Jahitan)
Sedang (10 s/d 20 Jahitan)
Besar (>20 Jahitan)
gkat Jahitan
Besar (>20 Jahitan)
ctal Toucher
oskopi
ller And Cup
gkat Wire
il Ekstrasi
zer Plasty
isi Abses
sisi
stirpasi
cumsisi
opsi
ndik
bulo Plasty
ploarasi Corpus alienum
retage
pirasi
uginasi
straksi Batu uretra anterior
oor dawer cateter
ooling dawer cateter
bridment Luka
eksi Keloid / Kenacord / (IC)
crotomy
mputasi Jari
sektomi
POLIKLINIK ORTHOPEDI
URAIAN
(2)
wat Luka
Kecil (< 5 cm)
Sedang (5-10 cm)
Besar (10-20 cm)
Khusus (> 20 cm)
hit luka / Repair Jahitan
Besar (>20 Jahitan)
gkat Jahitan
Besar (>20 Jahitan)
ps Kecil Anak *
ps Kecil Dewasa*
ps Sedang Anak*
ps Sedang Dewasa*
ps Besar Anak*
ps Besar Dewasa*
nsel verband Anak
nsel verband Dewasa
eksi Arthtritis / articuler*
mi Spica*
crotomy Ex Op
POLIKLINIK UROLOGI
URAIAN
(2)
sang Fowley Cateter*
sang Cateter Logam*
ndakan Blast Punctie
ndakan Blast Pistel / Cytostom
straksi batu uretra dengn GA di OK
straksi batu uretra anterior
wat Luka
Kecil (< 5 cm)
Sedang (5-10 cm)
Besar (10-20 cm)
Khusus (> 20 cm)
isi Abses
ginasi / Dilatasi Uretra
POLIKLINIK GIGI DAN MULUT
URAIAN
(2)
ESIFIKASI TINDAKAN PENCABUTAN GIGI
Pencabutan Gigi Susu
Chlor Etyl
Injeksi
Pencabutan Gigi Susu Perforasi Akar
Pencabutan Gigi Mesiodens
Pencabutan Gigi Eksosterm 3
Pencabutan Gigi Permanen Dengan Akar Tunggal
Pencabutan Gigi Permanen Dengan Akar Ganda
Pencabutan Gigi Dengan Komplikasi
Pencabutan Sisa Akar Yang Tertinggal
ESIFIKASI TINDAKAN PENAMBALAN GIGI

Perawatan Pulpa
Perawatan Pulpektomy
Saluran Akar tunggal
Saluran akar ganda
One Visit Saluran Akar Tunggal
One Visit Saluran akar ganda
Pengisian Saluran Akar Tunggal
Pengisian Saluran Akar Ganda
Tambalan Sinar
Kecil
Sedang
Besar
Venneer direct / Besar Sekali
Penambalan Amalgam
Perawatan saluran akar Endo Intrakanal
Saluran akar tunggal
Saluran akar ganda
One Visit Saluran Akar Tunggal
One Visit Saluran akar ganda
Penambalan Glass Lonomer
Kecil
Sedang
Besar
Penambalan Eugenol, ChKM, depupil
Devitalisasi, sterilisasi SA, Pulp Capping
Open Bur / Eksterpatie dgn lokal anaestesi
Penambalan Eugenol Cavit
Pin Screw + Sementasi
ESIFIKASI TINDAKAN PENGOBATAN / PERAWATAN JARINGAN PENYANGGA GIGI

Pembersihan karang gigi per regio
Perawatan Pocet Periodental
Gingivektomy per regio
Eksterpasi Mucocele / epulis
ESIFIKASI PEMBUATAN PROTESA / GIGI PALSU

Gigi Tiruan per rahang
Satu gigi pertama
Dua gigi
Tiga gigi
Empat gigi
Lima gigi
Full per rahang
Reparasi Plat Patah
Reparasi plat patah full
Reparasi plat patah parsial
Reparasi Penambahan gigi per Rahang
Satu gigi pertama
Penambahan gigi berikutna
Rebasing / relining per rahang
Orthodontic
Alat orthodontic
Aktivasi ortho lepasan
Reparasi clamer (kawatortho) / rahang
Orthodontic cekat RA / RB
Perawatan / kontrol Orthodentic ceat RA / RB
ESIFIKASI TINDAKAN BEDAH MULUT

Odontectomy
Operculectom
Inter dental wiring / rahang
Inter maxilla wiring / rahang
Replantasi gigi
Alveolectomy / debridement per regio
Enukleasi kista (lokal anestesi)
Incisi / Eksisi abses
Pemeriksaan komplikasi post op / kontrol
Pemeriksaan dan perbaikan posisi IDW / IMW
Pembukaan IDW / Rahang
Pembukaan IMW
Dry Socket / curetage per gigi
Extirpasi mucocelle / epulis
Aff heacting epulis / mucocelle
ESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dengan LOGAM
Jembatan Adoro porcelain fusi metal
Inlay porcelain fusi metal

Uplay porcelain fusi metal
ESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY tanpa LOGAM

Jembatan/bridge full porcelain
Inlay / Uplay full porcelain
POLIKLINIK PENYAKIT KULIT DAN KELAMIN
URAIAN
(2)
ektro fulgurasi / Elektro Couter :
Seboroik Keratosis :
Kecil
Sedang
Besar
Skin Tag ;
Kecil
Sedang
Besar
Kondyloma Akuminata :
Kecil
Sedang
Besar
straksi Komedo
arium / Photo Therapi

cisi Wajah
cisi Non wajah
st Tempel / Patch Test Standard
st Tempel Standard Kosmetik
rmabrasi / Microdemabrasi
konstruki Kulit
isi Abses
ab : Vagina, Cervix, Fornik
ab : Uretra
ab discar lesi
rokan Kulit, Kuku, Rmbut
nti Verband
visi Parut
eksi Kenacort
nch Biopsi
isonal biopsi
retase Kulit
chlor Acetic Acid

emical Peeling :
GA Peeling
Proopeel
cial Regula
st Alergi Tusuk
Tusuk
Tempel
POLIKLINIK PENYAKIT PARU
URAIAN
(2)
rapi Inhalasi tanpa obat / Nebulizer
nctie Pleura
irometri komputer
rtable Spirometri
POLIKLINIK PENYAKIT DALAM
URAIAN
(2)
nctie asctes
pirasi jarum halus
POLIKLINIK PENYAKIT JANTUNG
URAIAN
(2)
hocardiografi
hocardiografi Dopler collor
onocardiografi
nksi pericard
susitasi jantung dengan DC Shock
wley Catheter
cemaker temporer
masangan SB Tube
masangan Cardiac Monitor
masangan CVP
masangan Cardiac monitor / hari
POLIKLINIK SYARAF/NEUROLOGI
URAIAN
(2)
eksi Intramuskuler
eksi Intraartikuler
sessment Neurobehaviour fit n proper test
sessment Neurobehaviour
meriksaan EEG
sessment Nyeri
meriksaan EMNG
POLIKLINIK MATA
URAIAN
(2)
B L ( Bleparoplasty )
mpimetri / perimetri 1 mata dengan Humpray
S G Mata
ratometri
meriksaan fundus (indirec)
nometri Aplansi
ater Drinking
tinoskopi
nophtophor
nometri Aplansi
gkat jahitan di palpebra dan konjungtiva
gkat jahitan di kornea
motio corpus Alienum
fraktometer
stirpasi kista konjungtiva
starpasi nevus / granulotoma
cochleasi / Amotio Lithiasis

stirpasi tumor / kista di palpebra
opsi dai palpebra
opsi di konjungtiva
rsoraphy / Jahitan di palpebra
posisi iris
racentesis
dektomi Perifer
ansplantasi membran amnion
cochleasi / Amotio Lithiasis
meriksaan Refraksi
meriksaan Slit Biomikroskop
nometri SCHIOTZ
st Ishihara
POLIKLINIK KEBIDANAN DAN PENYAKIT KANDUNGAN (OBSGYN)
URAIAN
(2)
opsi Pervaginam
ginal Swab
uter Elektrik
sang IUD
gkat IUD tanpa penyulit
gkat IUD dengan penyulit
sang Implant
gkat implant tanpa penyulit
gkat Implant dengan penyulit
athermi ( satu seri = 6 kali kunjungan )
nti verband / Buka jahitan
sang / Ganti tampon
uter Albotyl
Tanpa Print Out

Dengan Print Out
sang Pessarium
ka pessarium
ntikan KB
meriksaan Gnekologi
ndakan pasang kateter
ndakan pasang infus
G Transvaginal tanpa print out
Tanpa print out
Dengan print out
nseling KB
OW / MOP / Mini Laparotomy
POLIKLINIK PENYAKIT THT
URAIAN
(2)
rpal Alienum telinga

rpal Alienum tenggorokan
rpal Alienum hidung
tirpasi granuloma
ab Nasal
st Allergi
nti verband
akuasi Cerumen Ringan
ab Nasopharing Endoscopy
diometri murni
diometri tutur
himer test
isi Abses
ringobridge
ka pessarium
REHABILITASI MEDIK
URAIAN
(2)
cro Wave Diathermy
ectrical Stimulation
rasound Diathermy
raPhil 2 Lamp
ra Phil 3 Lamp
brator / Massage
nam hamil
nam Nifas
stural drainage
adder Training
ioterapi Stroke
ioterapi Anak
ioterapi Dada/ Breathing Exc
ck Exercise
tihan Sepeda Statis
tihan Paralel Bars
ntinous Pasive Movement
tihan Gerak Sendi / Penguatan Otot
masangan Spalk
ort Wave Diathermy
rafin Bath
tive Movement Exercise
POLIKLINIK BEDAH SYARAF
URAIAN
URAIAN
(2)
wat Luka
Kecil (< 5 cm)
Sedang (5-10 cm)
Besar (10-20 cm)
Khusus (> 20 cm)
gkat Jahitan
Besar (>20 Jahitan)
ngsi CSF Cranial

ngsi Lumbal
eksi Spinal
eksi obat ( IV ) / Injeksi
sang Elastic Band
POLIKLINIK JIWA / PSIKIATRI
URAIAN
(2)
meriksaan Psikometri
House man tree test
Warteg test
HDRS
HARS
MMSE
MMPI
PANS score
IKOTERAPI
Psikoterapi suportif
Cognitif Behaviour therapy
Hipnotherapi
LAYANAN TINDAKAN MEDIK OPERATIF DAN TERAPI TERENCANA

URAIAN
(2)
ERASI BEDAH DIGESTIF
Anastomosis of small intestine to rectal stump (pancolestomy)
Laparoscopyt terapi
LAR and to end anastomose
LAR dengan colostomy (anterior resection of rectum with synchronous colostomy)
Ekstraksi Kuku
Penjahitan Luka 1-4 Jahitan
Ekstraksi Gigi Goyang Depan
Pungsi Pleura/Abdomen
Miles prosedur
Pancreatectomy roux n y
Ruptur gaster gastrojejunustomy + jejunustomy feeding
Soave
Achlasia Aesophagus
Arthroscopy diagnostic
Arthroscopy debridement
Bristow Procedure
Choledochojejunustomy roux n y
Cysto jejunostomy roux n y pada kista empedu
Cysto jejunostomy roux n y pada kista pankreas
Discectomy
Open and other left hemicolectomy
Open and other resection colon transfersum
Open and other sigmoidectomy
Open Drainage abses hepar
Other and unspecified partial excision of large intestine
Repair recto vaginal fistula
Ruptur gaster jahit primer omental patch
Laparoscopy
Anastomosis other small-to-large intestinal
Anastomosis Smal-to-small intestinal
Appendiktomi and drainage appendikceal abses
Cholesistectomy
Debulking
Eviscerasi dengan GA
Exteriorization of small intestine
Hernia fomaralis bilateral dengan atau tanpa graft
Herniotomi hernioraphi anostomosis
HIL bilateral (other and open bilateral repair of direct inguinal hernia) dengan atau t
HIM bilateral (other and open bilateral repair of indirect inguinal hernia) dengan atau
Laparoscopic appendectomy
Laparotomy eksplorasi dengan stoma
Other and open bilateral repair of inguinal hernia, one direct and one indirect
Repair Sub total perianal rupture
Repair total perianal rupture
Suture of laceration of duodenum
Suture of laceration of small intestine
Appendiktomi pada apendicities akut/kronis
Hernia femoralis unilateral dg atau tanpa graft (unilateral repair of femoral hernia wit
Herniotomi hernioraphi selain HIM atau HIL dngan graft
Herniotomi pada anak
Hernitomy hernioraphi HIL unilateral dg atau tanpa graft (other and open repair of dir
Hernitomy hernioraphi HIM unilateral dg atau tanpa graft (other and open repair of in
Hidrocele komunikan
Hidrocele punikuli
Hidrocele testis (hidrocele/excision af hydrocele of tunica vaginalis)
Laparascopic diagnostic
Penutupan stoma pada colostomy (closure of stoma of large intestine)
Penutupan stoma pada ileustomy (closure of stoma of small intestine)
Funikokelektomy
Hydrokelektomy per inguinal
Hydrokelektomy per scrotal
Anoplasty pada setriktural anus
Closed Drainage abses hepar dengan GA
Colostomi
Excision of varicocele and hydrocele of spermatic cord
Exici polip recti dengan GA
Exteriorication of large intestine
Gastrostomy
Haemorroidectomi/procedur on hemorrhoids)
Perianal Fistulectomy
Preauricula Fistulectomy
Prolaps recti (repair)
Release constriction band
Repair anus
Repair old perineal ruphture
Repair uracus
Stepler haemorroidectomi
Reseksi urachus
Closed Drainage abses hepar dengan LA
Colonoscopi disertai extirpasi tumor
Exici polip recti dengan LA
Fistulectomy
Perianal fistulotomi
Colonoscopi
Lavage
Potong stoma pada soave
Gastroscopi
Gastroscopi disertai biopsi
Gastroscopi disertai ligasi varises esofagus (LVE)
Gastroscopi disertai sclero terapi endoskopi (STE)
Insisi absces perineum
Insisi ansces scrotum
Anuscopy biopsi dengan LA (Local anaesthesia)
Open biopsy of breast dengan LA
Bipolar resectoscopy
Ekstraksi ductus choledocy
Ekstraksi batu ductus choledocus
Histeroscopy diagnostic
Histeroscopy operative
Laparotomy + release adhesi
Re-open Laparotomy
Transanal Endorected pull through
Transanal swense eike
ERASI BEDAH ANAK
Anaplasty PSA (postero sagital anoplasty)
Ilizarov
Invaginasi
Eksisi ductus thyroglosus
Illeustomi pada anak
Laparatomi pada anak
Orchidectomy bilateral
Hirschprung's/colostomy pada hirsprung's
Anoplasty atresia ani letak rendah (cutback incision)
Anoplastyh + uretheroplasty
Postero sagictal anorected pull through
ERASI BEDAH ORTHOPEDI

Koreksi Scoliosis
Total elbow arthtoplasty
Total Hip arthtoplasty
Total knee arthtoplasty
Total shoulder arthtoplasty
Debridement TB tulang belakang
Hemiarthroplasty (AMP, bipolar) complicated
Internal fiksasi fraktur acetabulum complicated
Internal fiksasi fraktur collumn femur complicated
Internal fiksasi fraktur collumn femur dengan DHS complicated
Internal fiksasi fraktur collumn femur dengan ABP complicated
Internal fiksasi fraktur pelvis complicated
Internal fiksasi fraktur scapula complicated
Osteotomi korektif(HTO, freanch, dll)
Other reconstructive procedure of the shoulder
Rekonstruksi ACL/PCL
Koreksi horshoe kidney (ishmectomy)
Bone graft iliac/fibular/autograft lainnya
Disartikulasi Hip
Disartikulasi shoulder
Elevation of skull fracture fragments
Eviscerasi dengan GA
Hemiarthroplasty (AMP, bipolar)
Internal fiksasi fraktur acetabulum
Internal fiksasi fraktur collumn femur
Internal fiksasi fraktur femur dengan ABP
Internal fiksasi fraktur femur dengan K wire complicated
Internal fiksasi fraktur femur dengan plate & screw complicated
Internal fiksasi fraktur femur dengan DHS
Internal fiksasi fraktur humerus complicated
Iinternal fiksasi fraktur pelvis
Iinternal fiksasi fraktur radius complicated
Iinternal fiksasi fraktur scapula
Iinternal fiksasi fraktur symphisis pubis/symphisiolisis complicated
Internal fiksasi fraktur tibia complicated
Open reduction dislocation
Operasi avulsi PCL/ACL
Patellar stabilization
Pengambilan implant tulang belakang
Phacoemulsifikasi
Rekonstruksi bunion
Arthroscopy other procedures
Internal fiksasi fraktur carpalia
Internal fiksasi fraktur clavikula complicated
Internal fiksasi fraktur femur dengan K wire
Internal fiksasi fraktur femur dengan nail
Internal fiksasi fraktur femur dengan plate & screw
Internal fiksasi fraktur fibula complicated
Internal fiksasi fraktur radius
Internal fiksasi fraktur radius ulna
Internal fiksasi fraktur tibia fibula
Internal fiksasi fraktur ulna complicated
Arhtrodesis Pantalar
Arhtrodesis shoulder
Arhtrodesis subtalar
Arhtrodesis elbow
Arhtrodesis genu
Arhtrodesis hip
Arhtrodesis talocrural
Arhtrodesis triple
Arhtrodesis wrist
Bone graft allograft/xenograft/hydroxyapatite
Debridement osteomyelitis
Eksternal fiksasi pelvis
Eksternal fiksasi wrist
Ekstirpasi tumor + rekonstruksi (diluar orthopedi)
Excisi bone tumor
Fraktur costae dg internal fiksasi (pasang shapp plate) singgle
Free skin graft not otherwise specified
Internal fiksasi fraktur clavikula
Internal fiksasi fraktur fibula
Internal fiksasi fraktur humerus
Internal fiksasi fraktur patella complicated
Internal fiksasi fraktur tibia
Internal fiksasi fraktur tibia plateau complicated
Internal fiksasi fraktur ulna
Osteotomy sederhana
Pengambilan implant ABP
Pengambilan implant DHS
Pengambilan nail/plate termasuk implant symphisis pubis complicated
Amputasi below knee
Amputasi above elbow
Amputasi chopart
Amputasi Lisfranc
Amputasi syme
Amputasi ankle
Arthrodesis phalang manus
Arthrodesis phalang metacarpal
Arthrodesis phalang metatarsal
Arthrodesis phalang pedis
Debridement open fracture
Disartikulasi ankle
Disartikulasi elbow
Disartikulasi knee
Disartikulasi wrist
Disisi Aspirasi katarak dengan LA
Eksternal fiksasi tulang panjang
Internal fiksasi fraktur metacarpal complicated
Internal fiksasi fraktur olecranon
Internal fiksasi fraktur patella
Internal fiksasi fraktur phalang complicated
Internal fiksasi manus multiple
Osteoclasis
Pengambilan nail/plate termasuk implant symphisis pubis
Adductor tenotomy off the hip
Amputasi metacarpal
Amputasi phalang manus dengan GA (General Anaesthesia)
Amputasi phalang pedis dengan GA (General Anaesthesia)
Closed tenotomy achiles (achilotenotomy)
Excision of the bone
Internal fiksasi fraktur metacarpal
Internal fiksasi faktur phalang
Internal fiksasi fraktur tibia plateau
Pasang skeletal traksi dg GA
Pengambilan intramedulary nail (femur, tibia)
Pengambilan K Wire dengan GA
Release de Quervain tenosynovitis GA
Amputasi phalang manus dengan LA (local Anaesthesia)
Amputasi phalang pedis dengan LA (local anaesthesia)
Anuscopy biopsi dengan GA (general anaesthesia)
Ateroma ekstirpasi dengan LA
Biopsy of skin and subcutaneous tissue dengan LA
Bone marrow analisa (BMA)
Closed reduction fractur nasal
Pelepasan eksternal fiksasi dengan GA (General Anaesthesia)
Sondage canaliculi lacrimalis
Release CTS dg LA
Reposisi fraktur/dislokasi dg GA
Reposisi tertutup fraktur dan imobilisasi plaster cast dengan GA (general anaesthesi
Pelepasan eksternal fiksasi dengan LA (local anaesthesia)
Release de Quervain tenosynovitis
Suture of laceration of lip dengan LA (local anaesthesia)
Suture of laceration of other part of mount dengan LA (local anaesthesia)
Suture of laceration of palate dengan LA (local anaesthesia)
Triger finger
In growing nail (ekstraksi kuku) dg LA
Antrostomi dengan CWL
Arthroscopy rekonstruksi
Stabilisasi posterior
Ekstirpasi tumor + rekonstruksi (orthopedi)
ERASI BEDAH ONKOLOGI
Neck dissection radical bilateral
Deseksi kelenjar inguinal
Mestectomy subcutaneous unilateral
Mastectomy extended simple unilateral
Mastectomy simple unilateral
Mastectomy sub total
Mastectomy Unilateral
MRM (modified radical mastectomy)
Neck dissection radical unilateral
Parotidectomy total
Pedicle flaps (advanced)
Reseksi hemi mandibula (hemimandibulektomi)
Thyroidectomy total
Deseksi kelenjar leher
Glossectomy parrtial
Parotidectomy superfisial
Reseksi mandibula bilateral
Soft tissue tumor (kompartment reseksi)
Sub total unilateral isthmo lobectomy
Thyroidectomy subtotal
Enukleasi dg GA
Basalioma (excision or destruction of lesion or tissue of skin and subcutaneous tissu
Eksisi fibro sarcomamae mama

Eksisi ginecomasti/subcutoneus mastectomy
Eksisi kelenjar liur
Eksisi limfangioma luas
Eksisi tumor kelenjar leher
Excision or destruction of lesion or tissue of tongue
Kista radicular (eksisi)
Soft tissue tumor (muscle reseksi)
Tumor palatum (eksisi)
Basalioma (excision or destruction of lesion or tissue of skin and subcutaneous tissue
Eksisi kelenjar inguinal
Eksisi limfangioma
Eksisi mamae aberan
Epidermoid carsinoma (excision or destruction of lesion or skin and subcutaneous ti
Liposarcoma (eksisi)
Soft tissue tumor (eksisi)
Trabekulektomi
Eksisi fibroma
Eksisi fibro adenoma (fam) dengan GA
Eksisi tumor adneksa sedang
Eksisi tumor kel. Submandibula
Eksisi tumor multiple
Epidermoid carsinoma (excision or destruction of lesion or skin and subcutaneous tis
Eviscerasi
Excision of lesion of breast dengan GA
Ganglion Carpi/tarsa
Lipoma nochae (ekstirpasi)
Ateroma ekstirpasi dengan GA
Biopsy of skin and subcutaneous tissue dengan GA
Chemical peeling
Eksisi fibro adenoma (fam) dengan LA
Eksisi tumor adneksa kecil
Eksisi tumor dengan GA
Ekstirpasi korpal dengan penyulit (LA)
Excision of lesion of breast dengan LA
Lipoma (ekstirpasi) dengan GA
Neurofibroma (eksisi) dengan GA
Open biopsy of breast dengan GA
Tofus (eksisi) dengan GA
Ateroma ekstirpasi dengan LA
Biopsy of skin and subcutaneous tissue dengan LA
Eksisi tumor dengan LA
Tofus (eksisi) dengan LA
Extirpasi geborn myoma
Lipoma (ekstirpasi) dengan LA
Extirpasi tumor jinak kulit dan bawah kulit
Neurofibroma (eksisi) dengan LA
Excisi non wajah
ERASI BEDAH SYARAF
Replantansi/revaskularisasi
Trepanasi
Laminectomy
Laminoplasty
Open reduction cervical
Spinal fusion (PLIF/ALIF)
Stabilisasi posterior
Other craniectomy
Other craniotomy
Evakuasi bekuan darah (clot)
Parasentesa
Injeksi tulang belakang dengan C Arm
ERASI BEDAH UROLOGI
Nefrolithotomy bivalve
Open prostatectomy
Uretero litotomi batu ureter pasang stent
Bladder neck rekonstruksi
Boary flap
PNL/PCNL
Reimplantasi ureter bilateral
Repair fistel enterovesica
Repair vesicorectal
Repair vesicovagina
TUR buli
TURP/BNI
Pielolithotomy
Repair urethra
Uretero litotomi batu ureter 1/3 distal tanpa neo implantasi ureter
Uretroplasty pada hypospadias
Vaginal histerectomy
Anastomose ureter end to end
Anastomose urethra end to end
Divertikulektomy buli
Extended pielolithotomy
Internal urethrotomy (sache)
Johanson II
Lithotripsi
Nefroureterectomy
Nefropeksi
Pieloplasty
Radikal nefrectomy
Radikal orchidektomy
Railroading ruptur urethra
Repair fistel vesikokutan
Repair trauma buli
Sistectomy parsial
Ureterocutaneostomy
Uretero litotomi distal
Enukleasi dg GA
Nephrotomy and nephrostomy
Orchidectomi + orchidopexy contra lateral
Orchidectomi pada undescensus testis unilateral
Partial nefrektomi
Repair AC joint sclera dengan GA
Unilateral orchidectomy
Insisi posterior urethral valve
Johanson I
Koreksi priapismus alghorab
Open nefrostomy
Orchidopeksi (torsio testis)
Orchidopeksi (undescencus testis)
Palomo
PER (primary endoscopy realignment)
Uretero litotomi proksimal
Batu buli-buli (sectio alta)
Percutaneous nephrostomy without fragmentation
Release constriction band
Repair of testis
Cordektomi
Drainase periureter
Eksis web penis
Epispadia
Nefrostomi percutan
Parsial penektomi
Rekonstruksi penis
RPG (retrograde pielografi)
Subcapsuler orchidectomi
Tailoring ureter
Total penektomi
Vasoepididimostomy
Vesikolithotomy
Open cistostomi dg GA
Other repair of urinary bladder
Sialo lithiasis (ekstraksi batu dan marsupiasisasi)
Urethro litotomi batu uretra anterior dengan atau tanpa meatothomy (dengan GA)
Cistectomy ginjal
Divertikulektomy urethra
Insersi DJ Stent
Insersi selang tenckhof CAPD
pungsi dan sklesrosing kista ginjal
Repair fistel urethra
Skrotoplasty
Urethrolithotomy (GA)
Percutaneous cystostomy (closed cystotomy)
Spermatocele
Urethro litotomi batu uretra anterior dengan atau tanpa meatothomy (dengan LA)
Vitrektomi
Spermatokelectomy
Dilantasi uretra/bouginasi caterisasi
Vasectomi LA
Biopsi testis
Circumsisi dengan LA (local anaesthesia)
Biopsi penis
Cabut DJ stent
Circumsisi dengan GA (general anaesthesia)
Meatotomy
Operasi priapismus winter's procedure
Panendoscopy
Sitoscopy
Vasectomy (narkose)
Casting
Transurethral prostatectomy
Uretero litotomi batu ureter 1/3 distal + neo implantasi ureter
Nefrolithotomy
ERASI BEDAH THORAX KARDIO VASKULER( BTKV )

Sternotomy pada tumor mediastinum
Thorakotomy lobectomy tumor paru
Thorakotomy pada PDA (patent ductus ateriosus persistent)
Thoraktomy pada tamponade jantung
Internal fiksasi (pasang shapp plate) fraktur costae multiple
Repair vascular dg graft
Tendon transfer
Thorakotomy pada emphiema
Thorakotomy pada hematothotax
Thorakotomy pada hematothotax dg lobectomy paru
Thoraktomy pada tumor pleura
Anastomose vascular end to end
Fraktur costae dg internal fiksasi (pasang shapp plate) multiple
Repair vascular
Vasografi
Eksisi hemangioma
Skin graft flap sederhana
A-V Shunt (cimino)
Debridement excisional of wound
Debridement incisi & drainage septic arthritis
Nevus pigmentosus (eksisi) dengan GA
Incisi abces dengan GA (general anaesthesia)
Pasang WSD
Electro encephalography (EEG)
Incisi abces dengan LA (Local anaesthesia)
Pasang central venous presure (CVP/CVC)
Double lumen
ERASI BEDAH PLASTIK

Fraktur maxilla lefolt III (internal fiksasi)
Neo Implantasi boary flap
Labio genatopalatoschisis
Other operations on mouth and face
Other reconstruction of the toe
Rekonstruksi kelopak mata berat
Rekonstruksi sindaktili
Rekonstruksi digiti
Release kontraktur luas
Fraktur hemimaksila (internal fiksasi)
Fraktur mandibula simple (internal fiksasi)
Fraktur maxila lefolt I (internal fiksasi)
Other tendon lengthening
Palatoplasty
Partial Nefrektomi
Pedicle flaps sederhana
Reduksi macrodactili
Release chordae(release of chordae)
Repair ruptur palpebra transkanal dengan GA
Repair ruptur moderate
Tendon transfer for stabilization of patella
FTSG (full-thickness skin graft to other sites)
Labioplasti/repair of cleft lip
Rekonstruksi palpebra
Relese kontraktur sederhana
Skin graft (STSG)
STSG (skinn graf : free skin graft)
Debridement infection or burn
Fasciotomy
Fraktur alfeolaris (pasang archbar)
Couterisasi clavus/veruca dengan GA
Eksisi keloid dengan GA (general anaesthesia)
Fiksasi arch bar dengan GA
Finger tip injury (repair v-y flap) dg GA
In growing nail (ekstraksi kuku) dg GA
Re hechting dengan GA
Re hechting dengan GA pada burst abdomen
Rekonstruksi polidaktili
Couterisasi clavus/veruca dengan LA
Jahit luka diwajah dengan GA (general anasthesia)
Lobuloplasty bilateral
Lobuloplasty unilateral
Parasentesa BMD
Suture of laceration of other part of mounth dengan GA (general anaesthesia)
Explorasi corpus alienum simple dengan LA
Jahit luka diwajah dengan LA (local anasthesia)
Eksisi keloid dengan LA (local anaesthesia)

Incisi pada hidung
Injeksi sub konjungtiva
Jahit palpebra kecil
Nevus pigmentosus (eksisi) dengan LA
Re hechting dengan LA
Excisi wajah
Glossectomy total (complet)
ERASI BEDAH TRAUMA

Internal bleeding ruptur ginjal/hepar/lien/sebab lain
Amputasi forequarter
Amputasi hindquarter
Fraktur mandibula complicated (internal fiksasi)
Fraktur mandibula simple (internal fiksasi + pasang arch bar)
Fraktur maxilla lefolt II (internal fiksasi)
Repair old perineal ruphture
Repair tendon achiles complicated
Ekstirpasi korpal dengan penyulit (GA)
Repair tendon achiles
Repair tendon ekstersor pedis
Repair tendon fleksor pedis
Repair tendon patella
Tendon achiles lengthening
Repair tendon fleksor/ekstensor pedis
Repair tendon fleksor/ekstensor manus (1 tendon)
Tracheostomi permanent
Transfusi tukar
Explorasi corpus alienum dengan penyulit
Finger tip injury (repair v-y flap) dengan LA
Tracheostomi temporer
Repair tendon sederhana (1 tendon)
Extraksi corpus alienum sederhana (bedah)
ERASI OBSTETRI DAN GINEKOLOGI(OBSGIN)

Supra vaginal histeroctomy/total abdominal histerectomy
Cystektomi/ovarektomi bilateral
Miomektomi
Repeated sectio caesaria
Salphingo oophorectomy bilateral
Salphingo oophorectomy unilateral
Sectio caesaria
Sectio caesaria + cystektomy/ovarektomy bilateral
Sectio caesaria + cystektomy/ovarektomy unilateral
Sectio caesaria + miomektomy
Sectio caesaria + salphingo oophorectomy bilateral
Sectio caesaria + salphingo oophorectomy unilateral
Sectio caesaria + tubektomy pomeroy

Sectio caesaria gemelly
Vaginal histerectomy
Vaginal reconstruction
Cystektomi/ovarektomi unilateral
Vaginoplasty
Curettage abortus incipien (inkomplit)
Curettage HPP (late HPP)
Curettage meno (metorrhagia)
Curettage missed abortion (death conceptus, blighted ovum)
Curettage molla hydatidosa
Incisi hymen imperforate
Kista dermoid eksisi dengan GA
Repair perineum/vagina (perineoraphy)
Repair vagina/cerviks/portio
Seconderi repair ephisiotomi
Tubektomy laparoscopy
Tubektomy laparoscopy
Tubektomy minilaparotomy
Eksterpasi cysta bartolin
Kista dermoid eksisi dengan LA
Extirpasi tumor jinak vagina
Dermaroller platellet rich plasma (PRP)
Insisi absces bartholini + marsupialisasi
Reposisi inversio uteri
Extirpasi polip cervik
Extraksi corpus alienum vagina
Salphingo/Oophorectomy
Total abdominal hysterektomy + bisalphingoo oophorectomy
ERASI MATA
Disisi aspirasi katarak dengan GA
Repair ruptur cornea sclera dengan GA
Ekstraksi katarak pasang IOL
Koreksi entropion
Koreksi extropion
Koreksi simblepharon
Repari ruptur cornea sclera
Saucerization
Sequestrectomy
Jahit lid mirgin
Kanalisasi lakrimal
Repair laserasi konjungtiva
Repair laserasi kornea
Repair laserasi sclera
Repair ruptur palpebra simple
Repair ruptur palpebra transkanal
Aspirasi katarak sekunder
Extirpasi pterygium
Flap konjungtiva
Hymenorapi
Repair ruptur cornea
Repair ruptur konjungtiva
Eksisi calazion
Eksisi hordiolum
Ekstirpasi granuloma
Ekstraksi lithiasis
Insisi cornea
Irigasi trauma kimia perdrip
Sondage canaliculi lacrimalis
Skarping cornea
Ekstrasi corpus alienum cornea
ERASI TELINGA HIDUNG TENGGOROKAN (THT)

Tonsilektomi
Exstraksi polip nasi
Irigasi sinus
Anastesi
Adenotonsilectomy
Ethmoidektomy
Faringectomy
LAYANAN TINDAKAN MEDIK OPERATIF TIDAK TERENCANA / EMERGENCY / CYTO
arif dikalikan 25% dari tindakan medik operatif pada III A
LAYANAN TINDAKAN MEDIK NON OPERATIF
URAIAN
(2)
ritonial Dialisis
eksi LP Intratekal
eksi LP Epidural
eksi Impletol
anol Terapi Tumor Hati
sang Sonde
sang Skin Traction
leroterapi
eksi Intranodul
ofagogastroduodenoskopi
ofagogastroduodenoskopi dengan biopsi
lonoskopi
lonoskopi dengan biopsi
asi Varises
ipektomi
atasi Esofagus
gulasi Hemostatis
onkoskopi dengan biopsi
onkoskopi dengan brushing
onkoskopi dengan washing
onkoskopi pengambilan benda asing

pirasi mucous
ngsi Lever
ndakan pemberian Sitostatika / Kemoterapi
masangan Water Seal Drainage / WSD
LAYANAN KEGAWAT DARURATAN / INSTALASI GAWAT DARURAT (IGD)
URAIAN
URAIAN
(2)
NDAKAN UMUM
Injeksi im (intra muskular) per kali
Injeksi iv (intra vena) per kali
Injeksi ic (intra cutan)per kali
Injeksi sc (sub cutan)per kali
Pasang infus dewasa
Pasang infus anak / bayi
Ambil sampel darah vena
Ambil sampel darah arteri
Pasang NGT dewasa
Pasang NGT anak / bayi
Pasang folley cateter
Pemeriksaan glukotest
suppositoria
NDAKAN KHUSUS EMERGENCY

Pasang mayo / oropharengeal tube*
Suction aktif / slem suction*
Pasang ET
Needle cricothyroidectomy
Pasang neck collar
Punctie pleural
Punctie ascites
Punctie blast
Cytostomi
Pemasangan cateter vena central(CVC)
Pemasangan cateter intra osseus /umbilical,vena dalam
Pemasangan vena sectie
Needle chest
Cricothroidectomy
Pemasangan monitor vital sign/jam
Pemasangan syringe pump
Pemasangan infussion pump
Therapi inhalasi tanpa obat / Nebulizer per kali
Pemasangan ventilator
Pemasangan infus warmer
Pemasangan infant warmer
Resusitasi Jantung Paru
defribrilator / DC shock
Manual ventilasi / jam
NDAKAN KHUSUS SESUAI KASUS EMERGENCY
Rawat Luka
Kecil (< 5 cm)
Sedang (5-10 cm)
Besar (10-20 cm)
Khusus (> 20 cm)
Rawat luka bakar < 10 %
Rawat luka bakar 10 - 50 %
Rawat luka bakar > 50 %
Debridemant dan necrotomy
Luka kecil
Luka sedang
Luka Luas
Amputasi sendi kecil
Cross incisi
Nail Ekstrasi
Gips
Ransel verband
Imobilisasi Fraktur dengan spalk
Immobilisasi fraktur dengan back slab
Jahit luka / Repair Jahitan
Besar (>20 Jahitan)
Incisi abses
Ekstraksi korpus alienum THT/mata/kulit
Ringan
Sedang
Berat
Ekstraksi batu urethra antherior
Tindakan lavement/spoeling
Tindakan reposisi:
kecil
sedang
besar
Pemasangan tampon*
Pelepasan tampon
Angkat Jahitan
Besar (>20 Jahitan)
Aff infus / NGT / Cateter Urine
Ultrasonografi (USG) emergency
Pemasangan WSD
Transfusi darah per kali
WAT SEHARI
Ruang observasi reguler/P3
Akomodasi / hari
Visite dokter umum
Visite dokter / konsul spesialis on site
Ruang High Care/P2

Akomodasi / hari
Visite dokter umum
Ruang observasi intensive/P1

Akomodasi / hari
Visite dokter umum
LAYANAN PREHOSPITAL DAN RUJUKAN

Sewa ambulance BLS ( Team )
Antar / jemput dalam kota
Luar kota / kilometer
Sewa ambulance ALS ( Team )
Antar / jemput dalam kota /kilometer
Luar kota / kilometer
Dokter umum / 24 jam
Dokter spesialis / 24 jam
Perawat / 24 jam
LAYANAN RAWAT INAP DAN KEPERAWATAN
URAIAN
(2)
LAYANAN TINDAKAN KEPERAWATAN
Minimal Care per hari
Moderate Care per hari
High Care per hari
Intensif Care per hari
LAYANAN TINDAKAN RAWAT INAP
Pemeriksaan oleh dokter jaga
Pemeriksaan pasien rawat inap gawat oleh dokter jaga
Pasang infus dewasa
Pasang infus anak / bayi
Rawat Lokasi infus per hari
Rawat Luka
Kecil (< 5 cm)
Sedang (5-10 cm)
Besar (10-20 cm)
Khusus (> 20 cm)
Rawat luka bakar/gangren < 10 %
Rawat luka bakar/gangren 10 - 50 %
Rawat luka bakar/gangren > 50 %
infus tali pusat
Necrotomy jaring ( kecil )
Angkat Jahitan
Besar (>20 Jahitan)
Pasang tampon
Aff Tampon
Memandikan bayi/kali
Memandikan Pasien/kali
Keramas pasien/kali
Injeksi im (intra muskular) per kali
Injeksi iv (intra vena) per kali
Injeksi ic (intra cutan)per kali
Injeksi sc (sub cutan)per kali
Skin Test
Memberi Obat melalui Gastrotomy
Memberi Obat Supositoria
Penanganan Pre Operasi
Pasang Fowley Cateter*
Pasang Kondom Cateter*
Pasang Bidai*
Pasang Neck Collar *
Penanganan Keracunan
Perawatan Payudara
Perawatan WSD
Perawatan Kolostomy / Iliestomy
Resusitasi Jantung Paru
Pasang NGT Dewasa / Anak
Pasang ET
Pasang Mayo / Oroparingeal
Aff infus / NGT / Cateter urine
Perawatan Tracheostomy
Irigasi Mata
Ambil sampel darah vena

ambil sampel darah arteri
Penggunaan Oksigen ( O2)
Tiap 1 liter / menit
Pemakaian dan pemasangan O2 per kali tanpa ventilator
Suctioning*
Therapi Inhalasi tanpa obat / Nebuizer per kali
irigasi BPH/hari
Spoeling BPH/kali
Klisma / Huknah
Postural Drainase
LAYANAN KEBIDANAN
URAIAN
(2)
rsalinan Normal
rsalinan dengan penyulit ringan :

Oxytosin Drip
induksi misoprostol
rsalinan dengan penyulit sedang :
Ekstraksi Vacum
KBI(ksi bimanual internal)
Manual Placenta
Manual AID (tindakan partus sungsang)
Versi Ekstraksi
rsalinan dengan penyulit besar :
Embriotomi
Laparotomi
LAYANAN ICU
URAIAN
(2)
Tarif visite dokter / Intensiv / Konsultasi antar SMF
Jasa Keperawatan ICU / hari
Pemasangan monitor vital sign

Pemasangan syringe pump:
Pemasangan infussion pump:
Pemasangan ventilator
Setting ventilator
Pemasangan Warm air sheet
Pemasangan Blanket Roll
Pemasangan Alat anti Dekubitus
Bedside monitor / hari
Pasang Mayo
Pasang NGT
Aff NGT
Pasang ET
Needlle Thorakostomi
Pasang Cateter urine
Aff Cateter
Rawat luka bakar/gangren < 10 %
Rawat luka bakar/gangren 10 - 50 %
Rawat luka bakar/gangren > 50 %
Rawat Luka
Kecil (< 5 cm)
Sedang (5-10 cm)
Besar (10-20 cm)
Khusus (> 20 cm)
Pasang Kondom Cateter*
Pasang infus dewasa
Pasang infus anak
Pemasangan Cateter vena profunda
Pemasangan cateter arteri ( artery line )
Pemasangan cateter CVP
Pemasangan cateter HD
Intubasi
Bronchial Washing dengan alat
Pleural Punction
Therapi Inhalasi tanpa obat / Nebuizer per kali
Debridement dan necrotomy
Luka kecil
Luka sedang
Luka luas
Pemasangan Cateter epidural
Fisioterapi
Tindakan Anasthesi ( GA atau RA ) di ICU
Resusitasi Kardiopulmoonal ( dengan DC Shock )
Pemasangan WSD
Asites Puction
suction di luar cup per kali
Penggunaan Oksigen ( O2 )
Tiap 1 liter / menit
Pemakaian dan pemasangan O2 per kali dengan ventilator
LAYANAN NICU
URAIAN
(2)
masangan Respirator / hari
wa alat dan monitoring per jam
masangan monitor vital sign
masangan syringe pump:
masangan infussion pump:
masangan Feeding Pump:
masangan Radiant / Infant Warmer :
to Theraphy / hari
susitasi bayi bermasalah / RKP
rtable pulse oximeter
susitasi bayi normal
ction pump
sang NGT
sang Cateter
mbal Punctie
ndakan transfusi
ssage bayi
sang ventilator / NCPAP
servasi Ventilator / NCPAP / hari
rawatan luka
ndakan metode kangguru
rawatan tali pusat
ansfusi Tukar
mberian Surfactan
masangan WSD pada Neonatus
masangan cateter umbilical
nsor saturasi oksigen (BHP )
wat luka bakar < 10 %
wat luka bakar 10 - 50 %
wat luka bakar > 50 %
masangan cateter Arteri ( artery line )
onchial Washing dengan alat
erapi Inhalasi tanpa obat / Nebuizer per shift
bridement dan necrotomy
masangan infus bayi per kali

eksi im per kali
eksi iv per kali
eksi ic per kali
eksi sc per kali
mberi obat Supositoria
nanganan Pre Operasi
lakukan sampling spesisemen Lab
lakukan klisma / huknah rendah / Drumbuisa (Nacl Hangat)
nggunaan Oksigen ( O2 )
Tiap 1 liter / menit / jam
Pemakaian dan pemasangan O2 per kali dengan ventilator
LAYANAN HEMODIALISIS
PELAYANAN HEMODIALISIS TERENCANA
URAIAN
(2)
nggantian transver set ( CAPD )
ayanan HD dengan Reuse
ayanan HD tanpa Reuse di bawa pasien sendiri
ayanan HD dengan Reuse di bawa pasien sendiri
PELAYANAN HEMODIALISIS CITO
URAIAN
(2)
nggantian Transfusi set
ayanan HD tanpa Reuse
ayanan HD dengan Reuse
ayanan HD tanpa Reuse di bawa pasien sendiri
ayanan HD dengan Reuse di bawa pasien sendiri
LAYANAN PENUNJANG MEDIK
PELAYANAN TINDAKAN MEDIK DIAGNOSTIK ELEKTROMEDIK DAN NON ELEKTROMEDIK
URAIAN
(2)
SD Kontinu
paraskopi
nctie Pluera / Lung Punctie
H ( Paru )
rtable spirometri
ngsi Acites
ngsi Pericard
lter Monitoring
hocardiografi Dopler Color
G Simple
ngsi abses hati

stroscopy
lonoscopy
ngsi abses hati
MP ( Basic Metabolic Panel )
MP dengan General Anesthesi
opsi Ginjal
pra Public Punctie
ntikan / Injeksi Intra Arikuler
mbal Pungsi
nglion Pungsi
opsi Transtorakal
pler Kamar Operasi
A / Fluorescin Fundus Angio
racoskopi
st Perspirasi
meriksaan EEG
meriksaan ENMG
diometri murni
diometri tutur
st Vestibuler
to Fundus Mata
nduscopy Indirect
st Provokasi
in Test Allergi Elektro
sensitisasi ( Paket )
solaringokopi
ab Nasofaring
ratometri
tinoskopi
opsi Adneksa Mata
nometri Aplanasi
ater Drinking
RADIOLOGI ( Untuk Tarip Penunjang Radio Diagnostik, Tidak Termasuk Bahan Kontras )
URAIAN
(2)
CIL / TANPA KONTRAS
Kepala AP / Lat
Kepala 3 Posisi
SPN ( Sinus Para Nasal )
Nasal
Cervical AP / Lat ( 2 Film )
Cervical AP / Lat / Obl ( 4 Film )
Thoracal / AP / Lat ( 2 Film )
Thoracal / AP / Lat Obl ( 4 Film )
Thoraco Lumbal AP / Lat
Thoraco Lumbal AP / Lat / Obl
Lumbal AP / Lat ( 2 Film )
Lumbal AP / Lat / Obl ( 4 Film )
Lumbosakral AP / Lat
Pelvis ( 1 Film )
Femur AP / Lat Genu AP / Lat
Genu AP / Lat
Cruris AP / Lat
Pedis AP / Lat
Ankle Joint AP / Lat
Manus AP / Lat
Wrist Joint AP / Lat
Antebrachi AP / Lat
Elbow Joint AP / Lat
Humerus AP / Lat
Shoulder AP / Lat
Clavicula
Thorax PA Dewasa
Thorax Lat Dewasa
Thorax AP / Lat Dewasa
Thorax AP Anak
Thorax AP / Lat Anak
Abdomen / BNO Dewasa
Abdomen / BNO Anaka
Abdomen 3 Posisi Dewasa
Abdomen 3 Posisi Anak
Dental Regio
Panoramic gigi
DANG / DENGAN KONTRAS
Mammografi
Pelvis dengan sonde
Pelvimeteri
Uretrografi
Cystografi
Uretro Cystografi
H S G dengan kontras
RPG / APG
OMD dengan kontras
Oesofagografi
Colon In Loop Dewasa
Colon In Loop Anak
Fluoroscopy
Intra Vena Pyelography ( IVP ) 5 Film
Intra Vena Pyelography ( IVP ) 6-7 Film
Myelografi Lumbal
Myelografi Thoracal / Cervical
Arthrografi
Phlebografi extr superior
Phlebografi extr inf
CT Scan kepala non kontras
CT Scan Kepala kontras
a. Whole Body CT Scan non kontras
b. Whole Body CT scan dengan kontras
CT Scan thorax nn kontras
CT scan thorax kontras
CT scan abdomen atas / bawah non kontras
CT scan abdomen atas / bawah dengan kontras
CT scan ekstrimitas non kontras
CT scan ekstrimitas kontras
C- Arm
USG Abdomen atas
USG Abdomen bawah
USG Abdomen atas bawah
USG Ginjal
USG Testis
USG Payudara
USG Musculoskeletal
USG Neonatus
USG Thorax
USG Dopler Color
PELAYANAN PEMERIKSAAN LABORATORIUM / PATOLOGI KLINIK
URAIAN
(2)
MATOLOGI
Darah rutin ( HMK ) :
5 Dift
3 Dift
Reticolusit
Angka Eosinofil
Limfosit Plasma Biru
Malaria Mikroskopis
Malaria Stix
Filaria
Golongan Darah + Rhesus
Coomb's Test
Morfologi Darah Tepi
B M P ( Pemeriksaan )
Aspirasi BMP
Ratio IM / IT
Hemosidirin
LE Cell
OFT
Alkali Denaturasi / HBF
HbA2
Angka Eritrosit
Angka Leukosit
Angka Trombosit
Differential count
Retraksi Bekuan
Serum Iron ( SI )
Total Iron Binding Capacity ( TIBC )
OFT ( Screaning )
OFT ( Semi Kuantitatif )
AL HEMOSTASIS
Masa Jendal ( CT )
Masa Pendarahan ( BT )
APTT
APTT Substitusi
Fibrinogen
Fibrinogen Degradition Product ( FDP ) / D Dimer
WARNAAN SITOKIMIA
Peroksidase ( MPO )
MIA KLINIK
AL GINJAL
Ureum
Kreatinin
Uric Acid
Urea Clearance
Bilirubin Direk
Bilirubin Total
Bilirubin Indirect
Bilirubin ( Urine )
Total Protein
Albumin
Globulin
SGOT
SGPT
Alakali Fosfatase
Gula Darah Puasa

Gula darah puasa 2 jam
Gula darah sewaktu
HbA1C ( AIC )
Glukosa Stick
Cholesterol Total
Cholesterol HDL
Cholesterol LDL
Trigilserida
HDL Direct
LDL Direct
EKTROLIT
Elektrolit Na +
Elektrolit K+
Elektrolit Cl-
CKMB
Analisa Gas Darah dan Elektrolit

CK ( Creatine Kinase )
Protein Elektroforesis
Mikro Albumin
UNOLOGI
TORCH
Torch IgM Rapid
Toxoplasma IgG IgM
Toxoplasma IgG
Rubela Ig.M
Rubella Ig.G
CMV Ig.M
CMV Ig.G
HBsAg (ELFA )
HBsAg Rapid
HBsAg ( Elisa )
Anti HIV ( Elva )
Anti HIV ( Elisa )
Anti HIV ( Rapid )
Ferritin
Anti HBs Elisa
Anti HBs Rapid
Anti HCV Elisa
Anti HCV Rapid
FEKSI LAIN
TPHA
VDRL
DHF IgG IgM
Anti TB Rapid
IgM Anti Leptospira
IgG Anti Leptospira
ICT Malaria
Widal
HIV Elisa
HIV Rapid
TANDA TUMOR
CA 15.3
CA 125
CA 19.9
NGSI THYROID
Total Ig.E
T3 Total
T4 Total
Free T4
Free T3
RA / RF
ASTO
HBsAg ( Elisa )
HBsAg Rapid
Tubex TF
HIV Elisa
HIV Rapid
Progesteron
Testosteron
Anti HP
Anti HP IgG
Troponin I
Mantoux Test
KROBIOLOGI KULTUR URINE
KULTUR URINE
Kultur + sensi ( Manual )
Kultur + sensi ( Bactec )
KULTUR FAECES
KULTUR DARAH
Kultur Anaerob ( Manual )
Kultur Anaerob ( Alat)
SPUTUM
USAPAN TENGGOROK
USAPAN LUKA
CAIRAN CEREBROSPINAL
CAIRAN PLEURA
CAIRAN PERITONIUM
CAIRAN PERICARDIUM
CAIRAN DRAIN
CAIRAN ASCITES
BIAKAN GALL
BIAKAN AN AEROB
MIKROSKOPIK
Sperma Direct
Cat Gram
BTA Sputum
Jamur / Spora
Trichomonas
Leptospira
a. Secret
b. BTA Lepral
Cat Giemsa
MERIKSAAN LAINNYA
INALISIS
Urine Rutin
Urin Protein
Urin Bilirubin
Urine Reduksi
Urin Urobilin
Analisa Sperma
Urine keton
Sedimen
Urine Esbach
Urine Bence Jones
Uji kehamilan/PP test
Uji kehamilan ( titrasi )
ALISIS FAECES
Faeces Rutin
Faeces Amoeba
Faeces Consentrasi
Faeces Benzidin
Faeces Stercobilin
Urine Narkoba Amfetamin

Urine Narkoba THC
Urine Narkoba Morfine
Urine Narkoba Benzodiazefin
Urine Narkoba Meth Amphetamine
ALISA CAIRAN TUBUH LAIN
Angka cell LCS
Diff Cell LCS
Pandy
Rivalta Test
Glukosa
Protein
Patologi Anatomi / Histopatologi Besar
Patologi Anatomi/Histopatologi sedang
Patologi Anatomi / Histopatologi kecil
Sitologi
PELAYANAN FARMASI
URAIAN
URAIAN
(2)
AYA FARMASI
BIAYA OBAT NON RACIKAN
Harga obat= (HNA+PPN)+20% keuntungan
BIAYA OBAT RACIKAN
Harga obat racikan salep/krim/sirup = (HNA+PPN)+20% keuntungan+ 5.000 /pot/botol
Pelayanan obat pulveres/racikan kapsul=(HNA+PPN)+20% +1.000/kapsul/bungkus
NSELING FARMASI
Konseling obat resep/ obat bebas
Visite farmasi klinik
klas I,II,III
VIP
PELAYANAN BANK DARAH
URAIAN
(2)
ossmacth ( metode gel )
longan darah
lebotomy
PELAYANAN PEMULASARAN JENASAH / FORENSIK DAN MOBIL JENAZAH
URAIAN
(2)
meriksaan Jenasah
nservasi / Pengawetan
konstruksi Jenasah
nitipan Jenasah tanpa pendingin / hari
nitipan Jenasah dengan pendingin / hari
rawatan Jenasah
Tanpa resiko
Dengan resiko
um Et Repertum
Dalam / Otopsi
aya mobil jenazah
dalam kota
luar kota/km
PELAYANAN STERILISASI DAN LOUNDRY
URAIAN
(2)
as waten tanpa kapas

as waten dengan kapas
mpon Vagina
pan Spalk ukuran 100 cm
pan Spalk ukuran 50 cm
nsel Verband
ppers HD dan Tonsil
mpon Gigi
mpon tanpa Boorzalft

mpon dengan Boorzalft
pas Savlon
pas Alkohol
pas potong segi empat
nang tali pusat
erilisasi Handscun
erilisasi Instrumen dari unit RS
erilisasi Instrumen dari luar RS / Kilo
undry / kg
PELAYANAN GIZI
URAIAN
(2)
nsultasi Gizi
wat jalan
PELAYANAN PENUNJANG MEDIK LAINNYA
URAIAN
(2)
TARIF LAYANAN NON PELAYANAN KESEHATAN

NDIDIKAN DAN PELATIHAN
URAIAN
(2)
aktek Klinik dokter muda
aktek Klinik keperawatan
aktek Klinik kebidanan
NELITIAN
URAIAN
(2)
nerbitan Izin Penelitian/Pengambilan data Mahasiswa DIII/D IV
nerbitan Izin Penelitian/Pengambilan data Mahasiswa S1
nggunaan berkas untukpenelitian
URAIAN
(2)
wa kantin
WA RUANG/AULA
URAIAN
(2)
wa ruang/aula
ANAN KESEHATAN
JASA
JASA
PELAYANAN TARIF (Rp) KETERANGAN
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
300 1,200 1,500

1,500 8,500 10,000
2,000 13,000 15,000
15,000 5,000 20,000

25,000 5,000 30,000
- 260,000 260,000
- 150,000 150,000
- 100,000 100,000
- 70,000 70,000
- 240,000 240,000
- 140,000 140,000
60,000 5,000 65,000

40,000 5,000 45,000
40,000 5,000 45,000
40,000 5,000 45,000
60,000 5,000 65,000
50,000 5,000 55,000
35,000 5,000 40,000

20,000 5,000 25,000
20,000 5,000 25,000
20,000 5,000 25,000
40,000 5,000 45,000
30,000 5,000 35,000
5,000 12,000 17,000

30,000 20,000 50,000
30,000 20,000 50,000
35,000 60,000 95,000

51,000 100,000 151,000
103,000 170,000 273,000
20,000 5,000 25,000

20,000 5,000 25,000
- 0 0
- 0 0
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
4,000 10,000 14,000

4,000 10,000 14,000
4,000 10,000 14,000
4,000 10,000 14,000
4,000 10,000 14,000
4,000 10,000 14,000
160,000 240,000 400,000

220,000 330,000 550,000
80,000 120,000 200,000
140,000 210,000 350,000
400,000 600,000 1,000,000
200,000 300,000 500,000
200,000 300,000 500,000
100,000 150,000 250,000
100,000 150,000 250,000
20,000 30,000 50,000

10,000 15,000 25,000
7,000 10,500 17,500

7,000 10,500 17,500
8,000 12,000 20,000
16,000 24,000 40,000

20,000 30,000 50,000
16,000 24,000 40,000

20,000 30,000 50,000
20,000 30,000 50,000

48,000 72,000 120,000
30,000 45,000 75,000
20,000 30,000 50,000
20,000 30,000 50,000
20,000 30,000 50,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
28,000 42,000 70,000
8,000 12,000 20,000
20,000 30,000 50,000
8,000 12,000 20,000
8,000 12,000 20,000
6,000 14,000 20,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
6,000 9,000 15,000

8,000 12,000 20,000
20,000 30,000 50,000
28,000 42,000 70,000
20,000 30,000 50,000

30,000 40,000 70,000
40,000 60,000 100,000
6,000 9,000 15,000

10,000 15,000 25,000
16,000 24,000 40,000
8,000 12,000 20,000
10,080 15,120 25,200
8,000 12,000 20,000
10,000 15,000 25,000
8,000 12,000 20,000
56,000 84,000 140,000
34,000 51,000 85,000
34,000 51,000 85,000
40,000 60,000 100,000
60,000 90,000 150,000
60,000 90,000 150,000
8,000 12,000 20,000
60,000 90,000 150,000
40,000 60,000 100,000
4,000 6,000 10,000
8,000 12,000 20,000
8,000 12,000 20,000
40,000 60,000 100,000
40,000 60,000 100,000
8,000 12,000 20,000
30,000 45,000 75,000
4,000 6,000 10,000
40,000 60,000 100,000
40,000 60,000 100,000
100,000 150,000 250,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
6,000 9,000 15,000

8,000 12,000 20,000
20,000 30,000 50,000
28,000 42,000 70,000
20,000 30,000 50,000

30,000 40,000 70,000
40,000 60,000 100,000
6,000 9,000 15,000

10,000 15,000 25,000
16,000 24,000 40,000
20,000 30,000 50,000
24,000 36,000 60,000
30,000 45,000 75,000
36,000 54,000 90,000
48,000 72,000 120,000
60,000 90,000 150,000
16,000 24,000 40,000
40,000 60,000 100,000
60,000 90,000 150,000
28,000 42,000 70,000
120,000 180,000 300,000
120,000 180,000 300,000
12,000 18,000 30,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
10,000 15,000 25,000
16,000 24,000 40,000
30,000 45,000 75,000
40,000 60,000 100,000
1,000,000 1,500,000 2,500,000
40,000 60,000 100,000
6,000 9,000 15,000

8,000 12,000 20,000
20,000 30,000 50,000
28,000 42,000 70,000
34,000 51,000 85,000
180,000 270,000 450,000
40,000 60,000 100,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
14,000 41,000 55,000

20,000 55,000 75,000
17,000 63,000 80,000
40,000 85,000 125,000
40,000 85,000 125,000
40,000 85,000 125,000
40,000 85,000 125,000
48,000 102,000 150,000
40,000 85,000 125,000
25,000 85,000 110,000
20,000 65,000 85,000

30,000 100,000 130,000
25,000 75,000 100,000
35,000 110,000 145,000
35,000 110,000 145,000
40,000 135,000 175,000
30,000 95,000 125,000

35,000 105,000 140,000
40,000 115,000 155,000
45,000 200,000 245,000
45,000 80,000 125,000
20,000 65,000 85,000

30,000 95,000 125,000
25,000 75,000 100,000
40,000 110,000 150,000
30,000 85,000 115,000

35,000 95,000 130,000
40,000 105,000 145,000
20,000 65,000 85,000

15,000 50,500 65,500
20,000 65,000 85,000
75,000 175,000 250,000
20,000 80,000 100,000

30,000 96,000 126,000
40,000 85,000 125,000
40,000 85,000 125,000
200,000 380,000 580,000 biaya adalah paket dari pengukuran, pema

250,000 450,000 700,000
300,000 550,000 850,000
350,000 600,000 950,000
400,000 700,000 1,100,000
500,000 1,000,000 1,500,000
50,000 160,000 210,000

40,000 135,000 175,000
90,000 260,000 350,000

125,000 335,000 460,000
60,000 200,000 260,000
90,000 290,000 380,000 paket dari cetak sampai pemasangan

20,000 45,000 65,000
30,000 75,000 105,000
250,000 1,050,000 1,300,000
30,000 75,000 105,000
60,000 150,000 210,000

50,000 120,000 170,000
70,000 180,000 250,000
55,000 130,000 185,000
55,000 130,000 185,000
55,000 130,000 185,000
40,000 100,000 140,000
35,000 90,000 125,000
15,000 40,000 55,000
20,000 40,000 60,000
20,000 40,000 60,000
20,000 40,000 60,000
25,000 65,000 90,000
35,000 80,000 115,000
10,000 20,000 30,000
250,000 650,000 900,000 paket dari pencetakan, pemasangan,dan kontr
150,000 450,000 600,000

150,000 450,000 600,000
320,000 1,130,000 1,450,000

280,000 800,000 1,080,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
22,00 33,000 33,000

38,000 57,000 95,000
60,000 90,000 150,000
22,00 33,000 33,000

38,000 57,000 95,000
60,000 90,000 150,000
38,000 57,000 95,000

60,000 90,000 150,000
100,000 150,000 250,000
18,000 27,000 45,000
16,000 24,000 40,000
6,400 9,600 16,000
82,000 123,000 205,000
50,000 75,000 125,000
70,000 105,000 175,000
70,000 105,000 175,000
62,000 93,000 155,000
100,000 150,000 250,000
7,200 10,800 18,000
34,000 51,000 85,000
8,800 13,200 22,000
8,800 13,200 22,000
8,800 13,200 22,000
7,400 11,000 18,400
17,000 25,500 42,500
8,000 12,000 20,000
35,000 52,500 87,500
18,000 27,000 45,000
54,000 81,000 135,000
54,000 81,000 135,000
40,000 60,000 100,000
16,000 24,000 40,000
38,000 57,000 95,000
14,000 21,000 35,000
70,000 105,000 175,000
140,000 210,000 350,000
42,000 63,000 105,000
38,000 570,000 608,000
35,200 52,800 88,000

50,000 75,000 125,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
10,400 15,600 26,000
150,000 200,000 350,000 tidak termasuk selang,needle,botol,BMHP
32,000 48,000 80,000
26,000 39,000 65,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
20,000 30,000 50,000
34,800 52,200 87,000
20,000 30,000 50,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
124,000 186,000 310,000
20,000 30,000 50,000
48,000 72,000 120,000
164,000 246,000 410,000
27,200 40,800 68,000
31,200 46,800 78,000
160,000 240,000 400,000
68,800 103,200 172,000
31,200 46,800 78,000
80,000 120,000 200,000
16,000 24,000 40,000
8,000 12,000 20,000
350,000 525,000 875,000
42,000 63,000 105,000
10,200 15,300 25,500
700,000 500,000 1,200,000 tidak termasuk selang,needle,botol,BMHP
18,000 27,000 45,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
1,800 2,700 4,500
28,000 42,000 70,000
300,000 450,000 750,000
130,000 195,000 325,000
70,000 105,000 175,000
30,000 45,000 75,000
6,000 9,000 15,000
100,000 150,000 250,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
160,000 240,000 400,000
160,000 240,000 400,000
120,000 180,000 300,000
200,000 300,000 500,000
50,000 75,000 125,000
24,000 36,000 60,000
24,000 36,000 60,000
24,000 36,000 60,000
6,000 9,000 15,000
24,000 36,000 60,000
24,000 36,000 60,000
50,000 75,000 125,000
20,000 30,000 50,000
20,000 30,000 50,000
36,000 54,000 90,000
68,000 102,000 170,000
36,000 54,000 90,000
10,000 15,000 25,000
24,000 36,000 60,000
160,000 240,000 400,000
100,000 150,000 250,000
16,000 24,000 40,000
52,000 78,000 130,000
160,000 240,000 400,000
160,000 240,000 400,000
160,000 240,000 400,000
160,000 240,000 400,000
160,000 240,000 400,000
160,000 240,000 400,000
200,000 300,000 500,000
160,000 240,000 400,000
100,000 150,000 250,000
20,000 30,000 50,000
24,000 36,000 60,000
24,000 36,000 60,000
10,000 15,000 25,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
56,000 84,000 140,000
16,000 24,000 40,000
8,000 12,000 20,000
40,000 60,000 100,000
16,000 24,000 40,000
30,000 45,000 75,000
30,000 45,000 75,000
50,000 45,000 95,000
30,000 45,000 75,000
30,000 45,000 75,000
50,000 45,000 95,000
30,000 45,000 75,000
7,000 10,500 17,500
7,000 10500 17,500
7,000 10,500 17,500
25,000 50,000 65,000

35,000 65,000 100,000
20,000 30,000 50,000
20,000 30,000 50,000
32,000 48,000 80,000
12,000 18,000 30,000
6,000 9,000 15,000
10,000 15,000 25,000
4,000 6,000 10,000
30,000 65,000 95,000

45,000 75000 120,000
6,000 9,000 15,000
216,000 324,000 540,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
45,000 67,500 112,500
30,600 45,900 76,500
30,600 45,900 76,500
30,600 45,900 76,500
30,600 45,900 76,500
8,000 12,000 20,000
55,000 82,500 137,500
10,000 15,000 25,000
35,200 52,800 88,000
22,400 33,600 56,000
26,000 39,000 65,000
11,000 16,500 27,500
40,000 60,000 100,000
30,000 45,000 75,000
35,200 52,800 88,000
34,000 51,000 85,000
30,000 45,000 75,000
30,000 45,000 75,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
10,000 25,000 35,000
8,000 20,000 28,000
8,000 20,000 28,000
10,000 25,000 35,000
6,000 15,000 21,000
7,000 18,000 25,000
6,000 15,000 21,000
20,000 10,000 30,000
20,000 10,000 30,000
20,000 10,000 30,000
20,000 10,000 30,000
20,000 15,000 35,000
35,000 15,000 50,000
20,000 10,000 30,000
20,000 10,000 30,000
6,000 15,000 21,000
6,000 15,000 21,000
15,000 6,000 21,000
15,000 6,000 21,000
20,000 10,000 30,000
10,000 25,000 35,000
8,000 20,000 28,000
8,000 20,000 28,000
15,000 6,000 21,000
JASA
JASA
SARANA (Rp)
(Rp)
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
6,000 9,000 15,000
6,000 9,000 15,000
8,000 12,000 20,000
20,000 30,000 50,000
28,000 42,000 70,000
6,000 9,000 15,000

10,000 15,000 25,000
16,000 24,000 40,000
120,000 180,000 300,000

50,000 75,000 125,000
120,000 180,000 300,000
2,000 3,000 5,000
20,000 30,000 50,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
6,000 9,000 15,000

6,000 9,000 15,000
8,000 12,000 20,000
8,000 12,000 20,000
8,000 12,000 20,000
8,000 12,000 20,000
120,000 180,000 300,000
8,000 12,000 20,000
8,000 12,000 20,000
20,000 30,000 50,000

80,000 120,000 200,000
200,000 300,000 500,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
2,420,000 3,630,000 6,050,000

2,112,000 3,168,000 5,280,000
2,310,000 3,465,000 5,775,000
2,310,000 3,465,000 5,775,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000

2,640,000 3,960,000 6,600,000
2,464,000 3,696,000 6,160,000
2,112,000 3,168,000 5,280,000
2,310,000 3,465,000 5,775,000
2,640,000 3,960,000 6,600,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
2,112,000 3,168,000 5,280,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
220,000 330,000 550,000
132,000 198,000 330,000
132,000 198,000 330,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,980,000 2,970,000 4,950,000
1,012,000 1,518,000 2,530,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
2,640,000 3,960,000 6,600,000
2,640,000 3,960,000 6,600,000
2,420,000 3,630,000 6,050,000

2,420,000 3,630,000 6,050,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,012,000 1,518,000 2,530,000
572,000 858,000 1,430,000
2,420,000 3,630,000 6,050,000
2,640,000 3,960,000 6,600,000
2,420,000 3,630,000 6,050,000

2,420,000 3,630,000 6,050,000
2,420,000 3,630,000 6,050,000
2,420,000 3,630,000 6,050,000
2,420,000 3,630,000 6,050,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
220,000 330,000 550,000
220,000 330,000 550,000
220,000 330,000 550,000
220,000 330,000 550,000
220,000 330,000 550,000
132,000 198,000 330,000
1,540,000 2,310,000 3,850,000
2,640,000 3,960,000 6,600,000
2,420,000 3,630,000 6,050,000
1,980,000 2,970,000 4,950,000
2,112,000 3,168,000 5,280,000

1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000

1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000

1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
308,000 462,000 770,000
308,000 462,000 770,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
220,000 330,000 550,000
132,000 198,000 330,000
132,000 198,000 330,000
132,000 198,000 330,000
2,420,000 3,630,000 6,050,000

2,420,000 3,630,000 6,050,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,232,000 1,848,000 3,080,000
729,000 1,188,000 1,917,000
132,000 198,000 330,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
132,000 198,000 330,000
132,000 198,000 330,000
132,000 198,000 330,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
2,640,000 3,960,000 6,600,000
2,640,000 3,960,000 6,600,000

2,640,000 3,960,000 6,600,000
2,640,000 3,960,000 6,600,000
2,640,000 3,960,000 6,600,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,232,000 1,848,000 3,080,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
572,000 858,000 1,430,000
308,000 462,000 770,000
500,000 500,000 1,000,000
132,000 198,000 330,000
132,000 198,000 330,000
700,000 500,000 1,200,000 tidak termasuk selang,needle,botol,BMHP
1,232,000 1,848,000 3,080,000
1,540,000 2,310,000 3,850,000

1,980,000 2,970,000 4,950,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
220,000 330,000 550,000
132,000 198,000 330,000

132,000 198,000 330,000
132,000 198,000 330,000
132,000 198,000 330,000
132,000 198,000 330,000
132,000 198,000 330,000
132,000 198,000 330,000
132,000 198,000 330,000
1,980,000 2,970,000 4,950,000

1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
132,000 198,000 330,000
1,980,000 2,970,000 4,950,000

1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,800,000 2,500,000 4,300,000
2,000,000 2,970,000 4,970,000
2,000,000 2,970,000 4,970,000
2,000,000 2,970,000 4,970,000
2,000,000 2,970,000 4,970,000
2,000,000 2,970,000 4,970,000
2,000,000 2,970,000 4,970,000

1,900,000 2,700,000 4,600,000
1,540,000 2,310,000 3,850,000
1,540,000 2,310,000 3,850,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
220,000 330,000 550,000
220,000 330,000 550,000
220,000 330,000 550,000
132,000 198,000 330,000
132,000 198,000 330,000
1,232,000 1,848,000 3,080,000
1,980,000 2,970,000 4,950,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,232,000 1,848,000 3,080,000
1,540,000 2,310,000 3,850,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
1,012,000 1,518,000 2,530,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
792,000 1,188,000 1,980,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
572,000 858,000 1,430,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
308,000 462,000 770,000
220,000 330,000 550,000
132,000 198,000 330,000
792,000 1,188,000 1,980,000

572,000 858,000 1,430,000
132,000 198,000 330,000
100,000 150,000 250,000
1,980,000 2,970,000 4,950,000
1,232,000 1,848,000 3,080,000
1,540,000 2,310,000 3,850,000
(Pasal 26 ayat 10)
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
196,000 294,000 490,000
50,000 75,000 125,000
50,000 75,000 125,000
2,000 3,000 5,000
100,000 150,000 250,000
2,000 3,000 5,000
24,000 36,000 60,000
260,000 390,000 650,000
12,000 18,000 30,000
120,000 180,000 300,000
180,000 270,000 450,000
200,000 300,000 500,000
280,000 420,000 700,000
320,000 480,000 800,000
360,000 540,000 900,000
320,000 480,000 800,000
360,000 540,000 900,000
320,000 480,000 800,000
160,000 240,000 400,000
200,000 300,000 500,000
200,000 300,000 500,000
200,000 300,000 500,000
320,000 480,000 800,000
320,000 480,000 800,000
200,000 300,000 500,000
80,000 120,000 200,000
500,000 500,000 1,000,000
JASA
JASA
SARANA (Rp)
(Rp)
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
2,000 3,000 5,000 tidak termasuk spuit

4,000 6,000 10,000 tidak termasuk iv cateter dan infuset
6,000 9,000 15,000 tidak termasuk iv cateter dan infuset
2,000 3,000 5,000
4,000 6,000 10,000
20,000 30,000 50,000
20,000 30,000 50,000
8,000 12,000 20,000
20,000 30,000 50,000
8,000 12,000 20,000
2,000 3,000 5,000
4,000 6,000 10,000

4,000 6,000 10,000 tidak termasuk selang
700,000 500,000 1,200,000 tidak termasuk tube,oksigen
100,000 100,000 200,000 tidak termasuk needle
4,000 6,000 10,000 tidak termasuk collar
150,000 150,000 300,000 tidak sudah termasuk alat dan BMHP
700,000 500,000 1,200,000 tidak sudah termasuk cateter vena central,oks
80,000 120,000 200,000
125,000 125,000 250,000 sudah termasuk iv cateter,infus set
700,000 500,000 1,200,000 tidak termasuk tube,oksigen
12,000 18,000 30,000
6,000 9,000 15,000
6,000 9,000 15,000
8,000 12,000 20,000 sudah termasuk oksigen,tidak termasuk mask
80,000 120,000 200,000 sudah termasuk oksigen
4,000 6,000 10,000
4,000 6,000 10,000
100,000 100,000
80,000 120,000 200,000
4,000 6,000 10,000
6,000 9,000 15,000
8,000 12,000 20,000
20,000 30,000 50,000
28,000 42,000 70,000
10,000 15,000 25,000
20,000 30,000 50,000
40,000 60,000 100,000
10,000 15,000 25,000

16,000 24,000 40,000
24,000 36,000 60,000
80,000 120,000 200,000
16,000 24,000 40,000
10,000 15,000 25,000
50,000 50,000 100,000 tidak termasuk gips
20,000 30,000 50,000 tidak termasuk ransel verband
12,000 20,000 32,000 sudah termasuk spalk
24,000 36,000 60,000 tidak termasuk gips
20,000 30,000 50,000

30,000 40,000 70,000
40,000 60,000 100,000
20,000 30,000 50,000
12,000 18000 30,000
12,000 18,000 30,000
20,000 30,000 50,000
30,000 45,000 75,000
30,000 45,000 75,000
12,000 18,000 30,000
20,000 30,000 50,000

20,000 30,000 50,000
20,000 30,000 50,000
8,000 12,000 20,000
4,000 6,000 10,000
6,000 9,000 15,000

10,000 15,000 25,000
16,000 24,000 40,000
1,000 1,500 2,500
100,000 150,000 250,000
500,000 500,000 1,000,000
12,000 18,000 30,000
- 15,000 15,000
15,000 5,000 20,000
20,000 5,000 25,000
- 25,000 25,000
20,000 5,000 25,000
40,000 5,000 45,000
- 35,000 35,000
40,000 5,000 45,000
80,000 5,000 85,000
tidak termasuk biaya penyeberangan

50,000 50,000 100,000 prwt+sopir
1,000 5,000 6,000 sopir
tidak termasuk biaya penyeberangan
100,000 100,000 200,000 prwt+sopir
1,250 5,000 6,250 sopir
1,000,000 1,000,000 Sesuai indikasi medis
2,500,000 2,500,000 Sesuai indikasi medis
500,000 500,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
10,000 10,000
15,000 15,000
20,000 20,000
30,000 30,000
10,000 5,000 15,000

15,000 5,000 20,000
4,000 6,000 10,000
6,000 9,000 15,000
1,000 1,500 2,500
6,000 9,000 15,000

8,000 12,000 20,000
20,000 30,000 50,000
28,000 42,000 70,000
10,000 15,000 25,000
20,000 30,000 50,000
40,000 60,000 100,000
60,000 90,000 150,000
10,000 15,000 25,000
6,000 9,000 15,000

10,000 15,000 25,000
16,000 24,000 40,000
4,000 6,000 10,000
4,000 6,000 10,000
10,000 15,000 25,000
10,000 15,000 25,000 sesuai indikasi
7,000 8,000 15,000 sesuai indikasi
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
4,000 6,000 10,000
8,000 12,000 20,000
2,000 3,000 5,000
4,000 6,000 10,000
4,000 6,000 10,000
20,000 15,000 35,000
4,000 6,000 10,000
10,000 15,000 25,000
4,000 6,000 10,000
50,000 50,000 100,000
20,000 30,000 50,000
700,000 500,000 1,200,000 tidak termasuk tube oksigen
4,000 6,000 10,000
1,000 1,500 2,500
4,000 6,000 10,000
4,000 6,000 10,000
20,000 30,000 50,000
2,000 3,000 5,000
4,000 6,000 10,000
110 110 contoh: dosis 3L/mnt, dipakai 1 jam= 3x60x11

2,000 3,000 5,000
4,000 6,000 10,000
8,000 12,000 20,000
20,000 10,000 30,000
4,000 6,000 10,000
4,000 6,000 10,000
8,000 12,000 20,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
240,000 360,000 600,000
240,000 360,000 600,000
400,000 600,000 1,000,000

400,000 600,000 1,000,000
800,000 1,200,000 2,000,000

800,000 1,200,000 2,000,000
600,000 900,000 1,500,000
800,000 1,200,000 2,000,000
800,000 1,200,000 2,000,000
1,280,000 1,920,000 3,200,000

2,400,000 2,700,000 5,100,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
80,000 5,000 85,000
30,000 0 30,000
12,000 18,000 30,000

600 900 1,500
6,000 9,000 15,000
800 1,200 2,000
6,000 9,000 15,000
800 1,200 2,000
80,000 120,000 200,000
100,000 20,000 120,000
1,200 1,800 3,000
6,000 9,000 15,000
400 600 1,000
4,000 6,000 10,000
400 600 1,000
6,000 9,000 15,000
600 900 1,500
4,000 6,000 10,000
600 900 1,500
16,000 24,000 40,000
2,000 3,000 5,000
20,000 30,000 50,000
1,000 1,500 2,500
700,000 500,000 1,200,000 tidak termasuk tube ,oksigen
36,000 54,000 90,000
8,000 12,000 20,000
1,000 1,500 2,500
10,000 15,000 25,000
20,000 30,000 50,000
40,000 60,000 100,000
6,000 9,000 15,000

8,000 12,000 20,000
20,000 30,000 50,000
28,000 42,000 70,000
2,000 3,000 5,000
4,000 6,000 10000
6,000 9,000 15,000
20,000 30,000 50,000
200,000 200,000 400,000 tidak termasuk cateter
700,000 500,000 1,200,000 tidak termasuk cateter
100,000 100,000 200,000 tidak termasuk cateter
50,000 75,000 125,000
200,000 300,000 500,000
60,000 90,000 150,000
8,000 12,000 20,000
- 0
10,000 15,000 25,000
16,000 24,000 40,000
40,000 60,000 100,000
120,000 180,000 300,000
8,000 12,000 20,000
280,000 420,000 700,000 sdhtermasuk BHP,obat anestesi
80,000 120,000 200,000
500,000 500,000 1,000,000
50,000 75,000 125,000
4,000 6,000 10,000
-
- 110 110
2,000 3,000 5,000
2,400 3,600 6,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
8,000 12,000 20,000
1,200 1,800 3,000
8,000 12,000 20,000
600 9,00 600
6,000 9,000 15,000
800 1,200 2,000
6,000 9,000 15,000
800 1,200 2,000
6,000 9,000 15,000
400 600 1,000
4,000 6,000 10,000
800 1,200 2,000
125,000 125,000 250,000 tidak termasuk iv cateter,infus set
16,000 24,000 40,000
40,000 60,000 100,000
12,000 18,000 30,000
40,000 60,000 100,000
50,000 75,000 125,000
4,000 6,000 10,000
20,000 30,000 50,000
1,000 1,500 2,500
500,000 300,000 800,000 tidak termasuk tube oksigen
8,000 12,000 20,000
1,000 1,500 2,500
50,000 75,000 125,000
12,000 18,000 30,000
6,000 9,000 15,000
100,000 150,000 250,000
20,000 30,000 50,000
6,000 9,000 15,000
10,000 15,000 25,000
6,000 9,000 15,000
280,000 420,000 700,000
280,000 420,000 700,000
300,000 300,000 600,000
50,000 75,000 125,000
20,000 30,000 50,000
10,000 15,000 25,000
20,000 30,000 50,000
30,000 45,000 75,000
100,000 100,000 200,000
96,000 144,000 240,000
10,400 15,600 26,000
10,000 15,000 25,000
8,000 12,000 20,000
6,000 9,000 15,000
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
2,000 3,000 5,000
4,000 6,000 10,000
2,000 3,000 5,000
4,000 6,000 10,000
- 0
- 110 110
2,000 3,000 5,000
2,400 3,600 6,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
28,000 42,000 70,000
300,000 450,000 750,000
160,000 240,000 400,000
120,000 180,000 300,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
35,000 52,500 87,500
475,000 712,500 1,187,500
375,000 562,500 937,500
200,000 300,000 500,000
150,000 225,000 375000
ELEKTROMEDIK
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
500,000 500,000 1,000,000
48,000 72,000 120,000
40,000 60,000 100,000
26,000 39,000 65,000
50,000 75,000 125,000
160,000 240,000 400,000
80,000 120,000 200,000
80,000 120,000 200,000
164,000 246,000 410,000
20,000 30,000 50,000
160,000 240,000 400,000
30,000 45,000 75,000
148,000 222,000 370,000
148,000 222,000 370,000
50,000 75,000 125,000
50,000 75,000 125,000
100,000 150,000 250,000
160,000 240,000 400,000
30,000 45,000 75,000
28,000 42,000 70,000
50,000 75,000 125,000
20,000 30,000 50,000
50,000 75,000 125,000
8,000 12,000 20,000
52,000 78,000 130,000
100,000 150,000 250,000
20,000 30,000 50,000
10,000 15,000 25,000
45,000 67,500 112,500
20,000 30,000 50,000
70,000 105,000 175,000
30,000 0 30,000
100,000 150,000 250,000
32,000 48,000 80,000
40,000 60,000 100,000
30,000 45,000 75,000
10,000 15,000 25,000
20,000 30,000 50,000
24,000 36,000 60,000
10,000 15,000 25,000
20,000 30,000 50,000
40,000 60,000 100,000
36,000 54,000 90,000
24,000 36,000 60,000
11,000 16,500 27,500
120,000 180,000 300,000
200,000 300,000 500,000
24,000 36,000 60,000
20,000 30,000 50,000
24,000 36,000 60,000
24,000 36,000 60,000
10,000 15,000 25,000
50,000 75,000 125,000
24,000 36,000 60,000
6,000 9,000 15,000
ahan Kontras )
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
40,000 100,000 140,000

60,000 140,000 200,000
20,000 50,000 70,000
20,000 50,000 70,000
40,000 100,000 140,000
80,000 200,000 280,000
40,000 100,000 140,000
80,000 200,000 280,000
40,000 100,000 140,000
60,000 150,000 210,000
40,000 100,000 140,000
80,000 200,000 280,000
40,000 100,000 140,000
20,000 50,000 70,000
40,000 50,000 90,000
40,000 50,000 90,000
40,000 100,000 140,000
40,000 50,000 90,000
40,000 50,000 90,000
40,000 50,000 90,000
40,000 50,000 90,000
40,000 50,000 90,000
40,000 50,000 90,000
40,000 50,000 90,000
40,000 50,000 90,000
20,000 50,000 70,000
20,000 50,000 70,000
20,000 50,000 70,000
40,000 100,000 140,000
20,000 50,000 70,000
40,000 100,000 140,000
20,000 30,000 50,000
20,000 30,000 50,000
60,000 150,000 210,000
60,000 150,000 210,000
14,000 35,000 49,000
20,000 50,000 70,000
96,000 160,000 256,000

48,000 80,000 128,000
96,000 160,000 256,000
192,000 320,000 512,000
192,000 320,000 512,000
192,000 320,000 512,000
192,000 320,000 512,000
240,000 400,000 640,000
192,000 320,000 512,000
144,000 240,000 384,000
240,000 400,000 640,000
240,000 400,000 640,000
96,000 160,000 256,000
240,000 400,000 640,000
336,000 560,000 896,000
200,000 300,000 500,000

200,000 300,000 500,000
200,000 300,000 500,000
160,000 240,000 400,000
140,000 210,000 350,000
240,000 360,000 600,000
360,000 540,000 900,000
440,000 660,000 1,100,000
800,000 1,200,000 2,000,000
240,000 360,000 600,000
360,000 540,000 900,000
280,000 420,000 700,000
480,000 720,000 1,200,000
240,000 360,000 600,000
360,000 540,000 900,000
160,000 240,000 400,000
90,000 135,000 225,000
90,000 135,000 225,000
120,000 180,000 300,000
90,000 135,000 225,000
80,000 120,000 200,000
80,000 120,000 200,000
80,000 120,000 200,000
80,000 120,000 200,000
90,000 135,000 225,000
160,000 240,000 400,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
15,000 30,000 45,000

12,000 23,000 35,000
4,500 9,000 13,500
4,500 9,000 13,500
4,500 9,000 13,500
4,000 8,000 12,000
3,000 14,000 17,000
4,500 9,000 13,500
4,000 8,500 12,500
10,000 20,000 30,000
20,000 40,000 60,000
60,000 90,000 150,000
80,000 180,000 260,000
4,500 9,000 13,500
6,000 12,000 18,000
9,000 16,000 25,000
8,000 15,000 23,000
7,000 13,000 20,000
20,000 40,000 60,000
4,500 9,000 13,500
4,500 9,000 13,500
4,500 9,000 13,500
4,500 9,000 13,500
3,000 6,000 9,000
4,000 6,000 10,000
25,000 50,000 75,000
25,000 50,000 75,000
35,000 65,000 100,000
7,000 13,000 20,000
13,000 22,000 35,000
18,000 32,000 50,000
3,000 7,000 10,000

2,500 4,000 6,500
34,000 56,000 90,000
70,000 115,000 185,000
35,000 65,000 100,000
30,000 55,000 85,000
50,000 100,000 150,000
8,000 15,000 23,000

8,000 15,000 23,000
8,000 15,000 23,000
8,000 15,000 23,000
8,000 15,000 23,000
3,500 15,000 18,500

3,500 15,000 18,500
10,000 17,000 27,000
10,000 17,000 27,000
5,000 20,000 25,000

5,000 20,000 25,000
5,000 20,000 25,000
4,000 2,000 6,000
5,000 14,000 19,000
5,000 14,000 19,000
5,000 14,000 19,000
5,000 20,000 25,000
5,000 20,000 25,000
5,000 14,000 19,000
6,000 11,000 17,000
7,000 18,000 25,000

5,000 10,000 15,000
5,500 13,000 18,500
40,000 80,000 120,000
7,200 15,000 22,200
4,500 14,000 18,500

12,500 25,000 37,500
15,000 35,000 50,000
6,000 21,000 27,000
15,000 25,000 40,000
20,000 35,000 55,000
50,000 85,000 135,000
15,000 30,000 45,000
15,000 30,000 45,000
15,000 30,000 45,000
45,000 85,000 130,000

20,000 40,000 60,000
70,000 180,000 250,000
45,000 85,000 130,000
40,000 85,000 125,000
40,000 70,000 110,000
125,000 250,000 375,000

125,000 250,000 375,000
30,000 70,000 100,000
30,000 70,000 100,000
60,000 140,000 200,000
25,000 75,000 100,000
60,000 120,000 180,000
35,000 75,000 110,000
25,000 50,000 75,000

9,000 19,000 28,000
16,000 33,000 49,000
35,000 80,000 115,000
20,000 38,000 58,000
20,000 40,000 60,000
40,000 100,000 140,000
40,000 65,000 105,000
10,000 25,000 35,000
45,000 115,000 160,000
15,000 35,000 50,000
5,000 10,000 15,000

3,500 7,500 11,000
40,000 100,000 140,000
15,000 35,000 50,000
10,000 25,000 35,000
12,500 25,000 37,500
7,000 15,000 22,000
3,500 15,000 18,500
35,000 80,000 115,000
15,000 40,000 55,000
60,000 140,000 200,000
35,000 80,000 115,000

40,000 115,000 155,000
40,000 110,000 150,000
80,000 200,000 280,000
60,000 140,000 200,000
90,000 210,000 300,000
50,000 100,000 150,000

30,000 70,000 100,000
50,000 100,000 150,000
30,000 70,000 100,000
35,000 75,000 110,000
30,000 70,000 100,000
45,000 100,000 145,000
20,000 40,000 60,000

15,000 35,000 50,000
20,000 50,000 70,000
20,000 45,000 65,000
5,000 12,500 17,500
10,000 30,000 40,000
40,000 80,000 120,000
20,000 40,000 60,000
45,000 140,000 185,000
40,000 130,000 170,000
15,000 40,000 55,000
50,000 160,000 210,000

30,000 70,000 100,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
64,000 96,000 160,000

80,000 165,000 245,000
56,000 84,000 140,000
80,000 150,000 230,000
56,000 84,000 140,000
80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
56,000 84,000 140,000

80,000 150,000 230,000
2,000 3,000 5,000

4,000 8,000 12,000
4,000 7,000 11,000
4,800 7,200 12,000
6,000 9,000 15,000
6,000 9,000 15,000
4,800 7,200 12,000
16,000 24,000 40,000
2,500 6,500 9,000
5,000 12,500 17,500

2,000 4,000 6,000
2,000 4,000 6,000
2,000 4,000 6,000
2,000 4,000 6,000
15,000 27,000 42,000
2,000 4,000 6,000
2,000 4,000 6,000
2,000 4,000 6,000
2,000 4,000 6,000
4,500 14,000 18,500
12,800 19,200 32,000
5,000 10,000 15,000

6,000 9,000 15,000
5,400 8,100 13,500
5,400 8,100 13,500
5,400 8,100 13,500
12,000 23,000 35,000

12,000 23,000 35,000
12,000 23,000 35,000
12,000 23,000 35,000
12,000 23,000 35,000
7,200 10,800 18,000

5,400 8,100 13,500
3,600 5,400 9,000
3,600 5,400 9,000
3,600 5,400 9,000
5,600 8,400 14,000
5,600 8,400 14,000
100,000 240,000 340,000
80,000 222,000 302,000
70,000 198,000 268,000
74,000 111,000 185,000
JASA
JASA
SARANA (Rp)
(Rp)
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
+ 5.000 /pot/botol
psul/bungkus
15,000 5,000 20,000
10,000 5,000 15,000

15,000 5,000 20,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
10,000 30,000 40,000
4,000 8,500 12,500
35,000 60,000 95,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
10,000 15,000 25,000
160,000 240,000 400,000 sudah termasuk bahan
80,000 120,000 200,000
8,000 12,000 20,000
40,000 60,000 100,000
20,000 30,000 50,000

40,000 60,000 100,000
- 0
30,000 45,000 75,000
400,000 600,000 1,000,000
30,000 50,000 80,000

2,000 4,000 6,000 tidak termasuk penyeberangan
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
320 480 800
1,040 1,560 2,600
5,400 8,100 13,500
400 600 1,000
440 660 1,100
320 480 800
920 1,380 2,300
4,000 6,000 10,000
2,000 3,000 5,000
17,000 32,000 49,000
30,000 45,000 75,000
20,000 30,000 50,000
360 540 900
1,520 2,280 3,800
1,600 2,400 4,000
10,000 15,000 25,000
10,000 15,000 25,000
8,000 12,000 20,000
16,000 24,000 40000
35,000 90,000 125,000
20,000 30,000 50,000
600 900 1,500
6,000 9,000 15,000
2,800 4,200 7,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
10,000 10,000
12,000 12,000
14,000 14,000
16,000 16,000
20,000 20,000
20,000 20,000
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
2,000 3000 5,000 per kilogram
YANAN KESEHATAN
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
30,000 45,000 75,000 orang/minggu
24,000 36,000 60,000 orang/minggu
24,000 36,000 60,000 orang/minggu
100,000 20,000 120,000 kali/pembimbing
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
30,000 45,000 75,000 orang/judul
40,000 100,000 140,000 orang/judul
1,000 2,000 3,000 per berkas
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
75,000 75,000 per meter persegi/ bulan
JASA
JASA
SARANA (Rp)
(Rp)
(3) (4) (5) (6)
200,000 200,000 per hari
ri pengukuran, pemasangan,dan kontrol
ai pemasangan
, pemasangan,dan kontrol
,needle,botol,BMHP
,needle,botol,BMHP
,needle,botol,BMHP
,needle,botol,BMHP
ter dan infuset
ter dan infuset
,needle,botol,BMHP
,needle,botol,BMHP
alat dan BMHP

cateter vena central,oksigen
eter,infus set
en,tidak termasuk masker

penyeberangan
penyeberangan
dipakai 1 jam= 3x60x110= 19.800
t anestesi
eter,infus set
,needle,botol,BMHP
JASA JASA
NO URAIAN TINDAKAN TARIF
SARANA PELAYANAN
1 2 3 4 5
1 Crossmacth ( metode gel ) 40,000 30,000 10,000
2 Golongan darah 12,500 8,500 4,000
3 Phlebotomy 95,000 60,000 35,000
1 Konsultasi Gizi
Rawat jalan 13,000 3,000 10,000
Kelas III 15,000 3,000 12,000
Kelas II 17,000 3,000 14,000
Kelas I 19,000 3,000 16,000
VIP 23,000 3,000 20,000
ICU 23,000 3,000 20,000
DOKTER
KARYAWAN
PENANGGUNG
BDRS/AHLI GIZI
JAWAB
70% 30%
6 7
7,000 2,100
2,800 840
24,500 7,350
10,000
12,000
14,000
16,000
20,000
20,000
B. RADIOLOGI ( Untuk Tarip Penunjang Radio Diagnostik, Tidak Termasuk Bahan Kontras )
JASA JASA
SARANA PELAYANAN
1 2 3 4 5
A KECIL / TANPA KONTRAS
1 Kepala AP / Lat 140,000 100,000 40,000
2 Kepala 3 Posisi 200,000 140,000 60,000
3 SPN ( Sinus Para Nasal ) 70,000 50,000 20,000
4 Nasal 70,000 50,000 20,000
5 Cervical AP / Lat ( 2 Film ) 140,000 100,000 40,000
6 Cervical AP / Lat / Obl ( 4 Film 280,000 200,000 80,000
7 Thoracal / AP / Lat ( 2 Film ) 140,000 100,000 40,000
8 Thoracal / AP / Lat Obl ( 4 Fil 280,000 200,000 80,000
9 Thoraco Lumbal AP / Lat 140,000 100,000 40,000
10 Thoraco Lumbal AP / Lat / Obl 210,000 150,000 60,000
11 Lumbal AP / Lat ( 2 Film ) 140,000 100,000 40,000
12 Lumbal AP / Lat / Obl ( 4 Film 280,000 200,000 80,000
13 Lumbosakral AP / Lat 140,000 100,000 40,000
14 Pelvis ( 1 Film ) 70,000 50,000 20,000
15 Femur AP / Lat Genu AP / Lat 90,000 50,000 40,000
16 Genu AP / Lat 90,000 50,000 40,000
17 Cruris AP / Lat 140,000 100,000 40,000
18 Pedis AP / Lat 90,000 50,000 40,000
19 Ankle Joint AP / Lat 90,000 50,000 40,000
20 Manus AP / Lat 90,000 50,000 40,000
21 Wrist Joint AP / Lat 90,000 50,000 40,000
22 Antebrachi AP / Lat 90,000 50,000 40,000
23 Elbow Joint AP / Lat 90,000 50,000 40,000
24 Humerus AP / Lat 90,000 50,000 40,000
25 Shoulder AP / Lat 90,000 50,000 40,000
26 Clavicula 70,000 50,000 20,000
27 Thorax PA Dewasa 70,000 50,000 20,000
28 Thorax Lat Dewasa 70,000 50,000 20,000
29 Thorax AP / Lat Dewasa 140,000 100,000 40,000
30 Thorax AP Anak 70,000 50,000 20,000
31 Thorax AP / Lat Anak 140,000 100,000 40,000
32 Abdomen / BNO Dewasa 50,000 30,000 20,000
33 Abdomen / BNO Anaka 50,000 30,000 20,000
34 Abdomen 3 Posisi Dewasa 210,000 150,000 60,000
35 Abdomen 3 Posisi Anak 210,000 150,000 60,000
36 Dental Regio 49,000 35,000 14,000
37 Panoramic gigi 70,000 50,000 20,000
B SEDANG / DENGAN KONTRAS -
1 Mammografi 256,000 160,000 96,000
2 Pelvis dengan sonde 128,000 80,000 48,000
3 Pelvimeteri 256,000 160,000 96,000
4 Uretrografi 512,000 320,000 192,000
5 Cystografi 512,000 320,000 192,000
6 Uretro Cystografi 512,000 320,000 192,000
7 H S G dengan kontras 512,000 320,000 192,000
8 RPG / APG 640,000 400,000 240,000
9 OMD dengan kontras 512,000 320,000 192,000
10 Oesofagografi 384,000 240,000 144,000
11 Colon In Loop Dewasa 640,000 400,000 240,000
12 Colon In Loop Anak 640,000 400,000 240,000
13 Fluoroscopy 256,000 160,000 96,000
14 Intra Vena Pyelography ( IVP ) 640,000 400,000 240,000
15 Intra Vena Pyelography ( IVP ) 896,000 560,000 336,000
C CANGGIH -
1 Myelografi Lumbal 500,000 300,000 200,000
2 Myelografi Thoracal / Cervical 500,000 300,000 200,000
3 Arthrografi 500,000 300,000 200,000
4 Phlebografi extr superior 400,000 240,000 160,000
5 Phlebografi extr inf 350,000 210,000 140,000
6 CT Scan kepala non kontras 600,000 360,000 240,000
7 CT Scan Kepala kontras 900,000 540,000 360,000
8 a. Whole Body CT Scan non kon 1,100,000 660,000 440,000
9 b. Whole Body CT scan dengan 2,000,000 1,200,000 800,000
10 CT Scan thorax nn kontras 600,000 360,000 240,000
11 CT scan thorax kontras 900,000 540,000 360,000
12 CT scan abdomen atas / bawah 700,000 420,000 280,000
13 CT scan abdomen atas / bawah 1,200,000 720,000 480,000
14 CT scan ekstrimitas non kontra 600,000 360,000 240,000
15 CT scan ekstrimitas kontras 900,000 540,000 360,000
16 C- Arm 400,000 240,000 160,000
17 USG Abdomen atas 225,000 135,000 90,000
18 USG Abdomen bawah 225,000 135,000 90,000
19 USG Abdomen atas bawah 300,000 180,000 120,000
20 USG Ginjal 225,000 135,000 90,000
21 USG Testis 200,000 120,000 80,000
22 USG Payudara 200,000 120,000 80,000
23 USG Musculoskeletal 200,000 120,000 80,000
24 USG Neonatus 200,000 120,000 80,000
25 USG Thorax 225,000 135,000 90,000
26 USG Dopler Color 400,000 240,000 160,000
ermasuk Bahan Kontras )
BILA ADA DOKTER RADIOLOGI

COST
DIREKSI INDEX KINERJA PENATA
SISA JASA CENTER DOKTER
PELAYANAN RADIOLOGI
5% 15% 35% 50%
6 7 8 9 10 11 12
2,000 38,000 5,700 13,300 19,000 9,500 9,500

3,000 57,000 8,550 19,950 28,500 14,250 14,250
1,000 19,000 2,850 6,650 9,500 4,750 4,750
1,000 19,000 2,850 6,650 9,500 4,750 4,750
2,000 38,000 5,700 13,300 19,000 9,500 9,500
4,000 76,000 11,400 26,600 38,000 19,000 19,000
2,000 38,000 5,700 13,300 19,000 9,500 9,500
4,000 76,000 11,400 26,600 38,000 19,000 19,000
2,000 38,000 5,700 13,300 19,000 9,500 9,500
3,000 57,000 8,550 19,950 28,500 14,250 14,250
2,000 38,000 5,700 13,300 19,000 9,500 9,500
4,000 76,000 11,400 26,600 38,000 19,000 19,000
2,000 38,000 5,700 13,300 19,000 9,500 9,500
1,000 19,000 2,850 6,650 9,500 4,750 4,750
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
2,000 38,000 5,700 13,300 19,000 9,500 9,500
1,000 19,000 2,850 6,650 9,500 4,750 4,750
1,000 19,000 2,850 6,650 9,500 4,750 4,750
1,000 19,000 2,850 6,650 9,500 4,750 4,750
2,000 38,000 5,700 13,300 19,000 9,500 9,500
1,000 19,000 2,850 6,650 9,500 4,750 4,750
2,000 38,000 5,700 13,300 19,000 9,500 9,500
1,000 19,000 2,850 6,650 9,500 4,750 4,750
1,000 19,000 2,850 6,650 9,500 4,750 4,750
3,000 57,000 8,550 19,950 28,500 14,250 14,250
3,000 57,000 8,550 19,950 28,500 14,250 14,250
700 13,300 1,995 4,655 6,650 3,325 3,325
1,000 19,000 2,850 6,650 9,500 4,750 4,750
- - - - - -
4,800 91,200 13,680 31,920 45,600 27,360 22,800
2,400 45,600 6,840 15,960 22,800 13,680 11,400
4,800 91,200 13,680 31,920 45,600 27,360 22,800
9,600 182,400 27,360 63,840 91,200 54,720 45,600
9,600 182,400 27,360 63,840 91,200 54,720 45,600
9,600 182,400 27,360 63,840 91,200 54,720 45,600
9,600 182,400 27,360 63,840 91,200 54,720 45,600
12,000 228,000 34,200 79,800 114,000 68,400 57,000
9,600 182,400 27,360 63,840 91,200 54,720 45,600
7,200 136,800 20,520 47,880 68,400 41,040 34,200
12,000 228,000 34,200 79,800 114,000 68,400 57,000
12,000 228,000 34,200 79,800 114,000 68,400 57,000
4,800 91,200 13,680 31,920 45,600 27,360 22,800
12,000 228,000 34,200 79,800 114,000 68,400 57,000
16,800 319,200 47,880 111,720 ### 95,760 79,800
- - - - - - -
10,000 190,000 28,500 66,500 95,000 57,000 47,500
10,000 190,000 28,500 66,500 95,000 57,000 47,500
10,000 190,000 28,500 66,500 95,000 57,000 47,500
8,000 152,000 22,800 53,200 76,000 45,600 38,000
7,000 133,000 19,950 46,550 66,500 39,900 33,250
12,000 228,000 34,200 79,800 114,000 68,400 57,000
18,000 342,000 51,300 119,700 ### 102,600 85,500
22,000 418,000 62,700 146,300 ### 125,400 104,500
40,000 760,000 114,000 266,000 ### 228,000 190,000
12,000 228,000 34,200 79,800 114,000 68,400 57,000
18,000 342,000 51,300 119,700 ### 102,600 85,500
14,000 266,000 39,900 93,100 ### 79,800 66,500
24,000 456,000 68,400 159,600 ### 136,800 114,000
12,000 228,000 34,200 79,800 114,000 68,400 57,000
18,000 342,000 51,300 119,700 ### 102,600 85,500
8,000 152,000 22,800 53,200 76,000 45,600 38,000
4,500 85,500 12,825 29,925 42,750 25,650 21,375
4,500 85,500 12,825 29,925 42,750 25,650 21,375
6,000 114,000 17,100 39,900 57,000 34,200 28,500
4,500 85,500 12,825 29,925 42,750 25,650 21,375
4,000 76,000 11,400 26,600 38,000 22,800 19,000
4,000 76,000 11,400 26,600 38,000 22,800 19,000
4,000 76,000 11,400 26,600 38,000 22,800 19,000
4,000 76,000 11,400 26,600 38,000 22,800 19,000
4,500 85,500 12,825 29,925 42,750 25,650 21,375
8,000 152,000 22,800 53,200 76,000 45,600 38,000
BILA TIDAK ADA ADA DOKTER RADIOLOGI
DOKTER
PENATA RADIOLOGI
PENGIRIM
13 14
4,750 14,250
7,125 21,375
2,375 7,125
2,375 7,125
4,750 14,250
9,500 28,500
4,750 14,250
9,500 28,500
4,750 14,250
7,125 21,375
4,750 14,250
9,500 28,500
4,750 14,250
2,375 7,125
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
4,750 14,250
2,375 7,125
2,375 7,125
2,375 7,125
4,750 14,250
2,375 7,125
4,750 14,250
2,375 7,125
2,375 7,125
7,125 21,375
7,125 21,375
1,663 4,988
2,375 7,125
- -
11,400 34,200
5,700 17,100
11,400 34,200
22,800 68,400
22,800 68,400
22,800 68,400
22,800 68,400
28,500 85,500
22,800 68,400
17,100 51,300
28,500 85,500
28,500 85,500
11,400 34,200
28,500 85,500
39,900 119,700
- -
23,750 71,250
23,750 71,250
23,750 71,250
19,000 57,000
16,625 49,875
28,500 85,500
42,750 128,250
52,250 156,750
95,000 285,000
28,500 85,500
42,750 128,250
33,250 99,750
57,000 171,000
28,500 85,500
42,750 128,250
19,000 57,000
10,688 32,063
10,688 32,063
14,250 42,750
10,688 32,063
9,500 28,500
9,500 28,500
9,500 28,500
9,500 28,500
10,688 32,063
19,000 57,000
C. PELAYANAN PEMERIKSAAN LABORATORIUM / PATOLOGI KLINIK
SISA COST
JASA JASA DIREKSI JASA CENTER
SARANA PELAYANAN PELAYA
5% NAN 15%
1 2 3 4 5 6 7 8
HEMATOLOGI
1 Darah rutin ( HMK ) :
5 Dift 45,000 30,000 15,000 750 14,250 2,138
3 Dift 35,000 23,000 12,000 600 11,400 1,710
2 Reticolusit 13,500 9,000 4,500 225 4,275 641
3 Angka Eosinofil 13,500 9,000 4,500 225 4,275 641
4 Limfosit Plasma Biru 13,500 9,000 4,500 225 4,275 641
5 Malaria Mikroskopis 12,000 8,000 4,000 200 3,800 570
6 Malaria Stix 17,000 14,000 3,000 150 2,850 428
7 Filaria 13,500 9,000 4,500 225 4,275 641
8 Golongan Darah + Rhes 12,500 8,500 4,000 200 3,800 570
9 Coomb's Test 30,000 20,000 10,000 500 9,500 1,425
10 Morfologi Darah Tepi 60,000 40,000 20,000 1,000 19,000 2,850
11 B M P ( Pemeriksaan ) 150,000 90,000 60,000 3,000 57,000 8,550
12 Aspirasi BMP 260,000 ### 80,000 4,000 76,000 11,400
13 Ratio IM / IT 13,500 9,000 4,500 225 4,275 641
14 Hemosidirin 18,000 12,000 6,000 300 5,700 855
15 LE Cell 25,000 16,000 9,000 450 8,550 1,283
16 O F T 23,000 15,000 8,000 400 7,600 1,140
17 Alkali Denaturasi / HBF 20,000 13,000 7,000 350 6,650 998
18 HbA2 60,000 40,000 20,000 1,000 19,000 2,850
19 Angka Eritrosit 13,500 9,000 4,500 225 4,275 641
20 Angka Leukosit 13,500 9,000 4,500 225 4,275 641
21 Angka Trombosit 13,500 9,000 4,500 225 4,275 641
22 Differential count 13,500 9,000 4,500 225 4,275 641
23 LED 9,000 6,000 3,000 150 2,850 428
24 Retraksi Bekuan 10,000 6,000 4,000 200 3,800 570
25 Serum Iron ( SI ) 75,000 50,000 25,000 1,250 23,750 3,563
26 Total Iron Binding Capac 75,000 50,000 25,000 1,250 23,750 3,563
27 INR 100,000 65,000 35,000 1,750 33,250 4,988
28 OFT ( Screaning ) 20,000 13,000 7,000 350 6,650 998
29 OFT ( Semi Kuantitatif ) 35,000 22,000 13,000 650 12,350 1,853
30 HbF 50,000 32,000 18,000 900 17,100 2,565
FAAL HEMOSTASIS - - - -
1 Masa Jendal ( CT ) 10,000 7,000 3,000 150 2,850 428
2 Masa Pendarahan ( BT ) 6,500 4,000 2,500 125 2,375 356
3 PPT 90,000 56,000 34,000 1,700 32,300 4,845
4 APTT 185,000 ### 70,000 3,500 66,500 9,975
5 APTT Substitusi 100,000 65,000 35,000 1,750 33,250 4,988
6 Fibrinogen 85,000 55,000 30,000 1,500 28,500 4,275
7 Fibrinogen Degradition 150,000 ### 50,000 2,500 47,500 7,125
PEWARNAAN SITOKIMIA - - - -
1 PAS 23,000 15,000 8,000 400 7,600 1,140
2 SBB 23,000 15,000 8,000 400 7,600 1,140
3 Peroksidase ( MPO ) 23,000 15,000 8,000 400 7,600 1,140
4 NSE 23,000 15,000 8,000 400 7,600 1,140
5 Pearl 23,000 15,000 8,000 400 7,600 1,140
KIMIA KLINIK - - - -
FAAL GINJAL - - - -
1 Ureum 18,500 15,000 3,500 175 3,325 499
2 Kreatinin 18,500 15,000 3,500 175 3,325 499
3 Uric Acid 27,000 17,000 10,000 500 9,500 1,425
4 Urea Clearance 27,000 17,000 10,000 500 9,500 1,425
FAAL HATI - - - -
1 Bilirubin Direk 25,000 20,000 5,000 250 4,750 713
2 Bilirubin Total 25,000 20,000 5,000 250 4,750 713
3 Bilirubin Indirect 25,000 20,000 5,000 250 4,750 713
4 Bilirubin ( Urine ) 6,000 2,000 4,000 200 3,800 570
5 Total Protein 19,000 14,000 5,000 250 4,750 713
6 Albumin 19,000 14,000 5,000 250 4,750 713
7 Globulin 19,000 14,000 5,000 250 4,750 713
8 SGOT 25,000 20,000 5,000 250 4,750 713
9 SGPT 25,000 20,000 5,000 250 4,750 713
10 GGT 19,000 14,000 5,000 250 4,750 713
11 Alakali Fosfatase 17,000 11,000 6,000 300 5,700 855
DIABETES - - - -
1 Gula Darah Puasa 25,000 18,000 7,000 350 6,650 998
2 Gula darah puasa 2 jam 15,000 10,000 5,000 250 4,750 713
3 Gula darah sewaktu 18,500 13,000 5,500 275 5,225 784
4 HbA1C ( AIC ) 120,000 80,000 40,000 2,000 38,000 5,700
5 Glukosa Stick 22,200 15,000 7,200 360 6,840 1,026
LEMAK - - - -
1 Cholesterol Total 18,500 14,000 4,500 225 4,275 641
2 Cholesterol HDL 37,500 25,000 12,500 625 11,875 1,781
3 Cholesterol LDL 50,000 35,000 15,000 750 14,250 2,138
4 Trigilserida 27,000 21,000 6,000 300 5,700 855
5 HDL Direct 40,000 25,000 15,000 750 14,250 2,138
6 LDL Direct 55,000 35,000 20,000 1,000 19,000 2,850
ELEKTROLIT 135,000 85,000 50,000 2,500 47,500 7,125
1 Elektrolit Na + 45,000 30,000 15,000 750 14,250 2,138
2 Elektrolit K+ 45,000 30,000 15,000 750 14,250 2,138
3 Elektrolit Cl- 30,000 15,000 750 14,250 2,138
LAIN-LAIN - - -
1 CKMB 85,000 45,000 2,250 42,750 6,413
2 LDH 40,000 20,000 1,000 19,000 2,850
3 Analisa Gas Darah dan Elektroli ### 70,000 3,500 66,500 9,975
4 CK ( Creatine Kinase ) 85,000 45,000 2,250 42,750 6,413
5 Protein Elektroforesis 85,000 40,000 2,000 38,000 5,700
6 Mikro Albumin 70,000 40,000 2,000 38,000 5,700
IMUNOLOGI - - -
1 TORCH ### 125,000 6,250 118,750 17,813
2 Torch IgM Rapid ### 125,000 6,250 118,750 17,813
3 Toxoplasma IgG IgM 70,000 30,000 1,500 28,500 4,275
4 Toxoplasma IgG 70,000 30,000 1,500 28,500 4,275
5 Rubela Ig.M ### 60,000 3,000 57,000 8,550
6 Rubella Ig.G 75,000 25,000 1,250 23,750 3,563
7 CMV Ig.M ### 60,000 3,000 57,000 8,550
8 CMV Ig.G 75,000 35,000 1,750 33,250 4,988
HEPATITIS - - -
1 HBsAg (ELFA ) 50,000 25,000 1,250 23,750 3,563
2 HBsAg Rapid 19,000 9,000 450 8,550 1,283
3 HBsAg ( Elisa ) 33,000 16,000 800 15,200 2,280
4 Anti HIV ( Elva ) 80,000 35,000 1,750 33,250 4,988
5 Anti HIV ( Elisa ) 38,000 20,000 1,000 19,000 2,850
6 Anti HIV ( Rapid ) 40,000 20,000 1,000 19,000 2,850
7 Ferritin ### 40,000 2,000 38,000 5,700
9 Anti HBs Elisa 65,000 40,000 2,000 38,000 5,700
10 Anti HBs Rapid 25,000 10,000 500 9,500 1,425
11 Anti HCV Elisa ### 45,000 2,250 42,750 6,413
12 Anti HCV Rapid 35,000 15,000 750 14,250 2,138
INFEKSI LAIN - - -
1 TPHA 10,000 5,000 250 4,750 713
2 VDRL 7,500 3,500 175 3,325 499
3 DHF IgG IgM ### 40,000 2,000 38,000 5,700
4 Anti TB Rapid 35,000 15,000 750 14,250 2,138
5 IgM Anti Leptospira 25,000 10,000 500 9,500 1,425
6 IgG Anti Leptospira 25,000 12,500 625 11,875 1,781
7 ICT Malaria 15,000 7,000 350 6,650 998
8 Widal 15,000 3,500 175 3,325 499
9 HIV Elisa 80,000 35,000 1,750 33,250 4,988
10 HIV Rapid 40,000 15,000 750 14,250 2,138
11 NSI ### 60,000 3,000 57,000 8,550
PETANDA TUMOR - - -
1 AFP 80,000 35,000 1,750 33,250 4,988
2 CEA ### 40,000 2,000 38,000 5,700
3 PSA ### 40,000 2,000 38,000 5,700
4 CA 15.3 ### 80,000 4,000 76,000 11,400
5 CA 125 ### 60,000 3,000 57,000 8,550
6 CA 19.9 ### 90,000 4,500 85,500 12,825
FUNGSI THYROID - - -
1 Total Ig.E ### 50,000 2,500 47,500 7,125
2 T3 Total 70,000 30,000 1,500 28,500 4,275
3 FSH ### 50,000 2,500 47,500 7,125
4 T4 Total 70,000 30,000 1,500 28,500 4,275
5 Free T4 75,000 35,000 1,750 33,250 4,988
6 TSH 70,000 30,000 1,500 28,500 4,275
7 Free T3 ### 45,000 2,250 42,750 6,413
LAIN-LAIN - - -
1 RA / RF 40,000 20,000 1,000 19,000 2,850
2 ASTO 35,000 15,000 750 14,250 2,138
3 CRP 50,000 20,000 1,000 19,000 2,850
4 HBsAg ( Elisa ) 45,000 20,000 1,000 19,000 2,850
5 HBsAg Rapid 12,500 5,000 250 4,750 713
6 Tubex TF 30,000 10,000 500 9,500 1,425
7 HIV Elisa 80,000 40,000 2,000 38,000 5,700
8 HIV Rapid 40,000 20,000 1,000 19,000 2,850
9 Progesteron ### 45,000 2,250 42,750 6,413
10 Testosteron ### 40,000 2,000 38,000 5,700
11 Anti HP 40,000 15,000 750 14,250 2,138
12 Anti HP IgG - - -
a. Troponin I ### 50,000 2,500 47,500 7,125
b. Mantoux Test 70,000 30,000 1,500 28,500 4,275
MIKROBIOLOGI KULTUR URINE - - -
D1 KULTUR URINE - - -
1 Kultur + sensi ( Manual 84,000 56,000 2,800 53,200 7,980
2 Kultur + sensi ( Bactec ) ### 80,000 4,000 76,000 11,400
D2 KULTUR FAECES - - -
D3 KULTUR DARAH - - -
1 Kultur Anaerob ( Manual96,000 64,000 3,200 60,800 9,120
2 Kultur Anaerob ( Alat) ### 80,000 4,000 76,000 11,400
D4 SPUTUM - - -
D5 USAPAN TENGGOROK - - -
D6 USAPAN LUKA - - -
D7 CAIRAN CEREBROSPINAL - - -
D8 CAIRAN PLEURA - - -
D9 CAIRAN PERITONIUM - - -
D10 CAIRAN PERICARDIUM - - -
D11 CAIRAN DRAIN - - -
D12 CAIRAN ASCITES - - -
D13 BIAKAN GALL - - -
D14 BIAKAN AN AEROB - - -
MIKROSKOPIK - - -
1 Sperma Direct 3,000 2,000 100 1,900 285
2 Cat Gram 8,000 4,000 200 3,800 570
3 BTA Sputum 7,000 4,000 200 3,800 570
4 Jamur / Spora 7,200 4,800 240 4,560 684
5 Trichomonas 9,000 6,000 300 5,700 855
6 Leptospira 9,000 6,000 300 5,700 855
a. Secret 7,200 4,800 240 4,560 684
b. BTA Lepral 24,000 16,000 800 15,200 2,280
7 Cat Giemsa 6,500 2,500 125 2,375 356
PEMERIKSAAN LAINNYA - - -
URINALISIS - - -
1 Urine Rutin 12,500 5,000 250 4,750 713
2 Urin Protein 4,000 2,000 100 1,900 285
3 Urin Bilirubin 4,000 2,000 100 1,900 285
4 Urine Reduksi 4,000 2,000 100 1,900 285
5 Urin Urobilin 4,000 2,000 100 1,900 285
6 Analisa Sperma 27,000 15,000 750 14,250 2,138
7 Urine keton 4,000 2,000 100 1,900 285
8 Sedimen 4,000 2,000 100 1,900 285
9 Urine Esbach 4,000 2,000 100 1,900 285
10 Urine Bence Jones 4,000 2,000 100 1,900 285
11 Uji kehamilan/PP test 14,000 4,500 225 4,275 641
12 Uji kehamilan ( titrasi ) 19,200 12,800 640 12,160 1,824
ANALISIS FAECES - - -
1 Faeces Rutin 10,000 5,000 250 4,750 713
2 Faeces Amoeba 9,000 6,000 300 5,700 855
3 Faeces Consentrasi 8,100 5,400 270 5,130 770
4 Faeces Benzidin 8,100 5,400 270 5,130 770
5 Faeces Stercobilin 8,100 5,400 270 5,130 770
NARKOBA - - -
1 Urine Narkoba Amfetamin 23,000 12,000 600 11,400 1,710
2 Urine Narkoba THC 23,000 12,000 600 11,400 1,710
3 Urine Narkoba Morfine 23,000 12,000 600 11,400 1,710
4 Urine Narkoba Benzodiazefin 23,000 12,000 600 11,400 1,710
5 Urine Narkoba Meth Amphetami 23,000 12,000 600 11,400 1,710
ANALISA CAIRAN TUBUH LAIN - - -
1 Angka cell LCS 10,800 7,200 360 6,840 1,026
2 Diff Cell LCS 8,100 5,400 270 5,130 770
3 None 5,400 3,600 180 3,420 513
4 Pandy 5,400 3,600 180 3,420 513
5 Rivalta Test 5,400 3,600 180 3,420 513
6 Glukosa 8,400 5,600 280 5,320 798
7 Protein 8,400 5,600 280 5,320 798
8 Patologi Anatomi / Histopatologi ### 100,000 5,000 95,000 14,250
9 Patologi Anatomi/Histopatologi ### 80,000 4,000 76,000 11,400
10 Patologi Anatomi / Histopatologi ### 70,000 3,500 66,500 9,975
11 Sitologi ### 74,000 3,700 70,300 10,545
ADA DOKTER PATOLOGI KLINIK BILA TIDAK ADA ADA DOKTER PATOLOGI KLINIK
INDEX KINERJA DOKTER DOKTER PJ
DOKTER KELOMPOK ANALIS
PENGIRIM LAB
35% 50% 30% 70% 2.5% 7.5%
9 10 11 12 13
4,988 7,125 2,138 4,988 178 534

3,990 5,700 1,710 3,990 143 428
1,496 2,138 641 1,496 53 160
1,496 2,138 641 1,496 53 160
1,496 2,138 641 1,496 53 160
1,330 1,900 570 1,330 48 143
998 1,425 428 998 36 107
1,496 2,138 641 1,496 53 160
1,330 1,900 570 1,330 48 143
3,325 4,750 1,425 3,325 119 356
6,650 9,500 2,850 6,650 238 713
19,950 28,500 8,550 19,950 713 2,138
26,600 38,000 11,400 26,600 950 2,850
1,496 2,138 641 1,496 53 160
1,995 2,850 855 1,995 71 214
2,993 4,275 1,283 2,993 107 321
2,660 3,800 1,140 2,660 95 285
2,328 3,325 998 2,328 83 249
6,650 9,500 2,850 6,650 238 713
1,496 2,138 641 1,496 53 160
1,496 2,138 641 1,496 53 160
1,496 2,138 641 1,496 53 160
1,496 2,138 641 1,496 53 160
998 1,425 428 998 36 107
1,330 1,900 570 1,330 48 143
8,313 11,875 3,563 8,313 297 891
8,313 11,875 3,563 8,313 297 891
11,638 16,625 4,988 11,638 416 1,247
2,328 3,325 998 2,328 83 249
4,323 6,175 1,853 4,323 154 463
5,985 8,550 2,565 5,985 214 641
- - - - - -
998 1,425 428 998 36 107
831 1,188 356 831 30 89
11,305 16,150 4,845 11,305 404 1,211
23,275 33,250 9,975 23,275 831 2,494
11,638 16,625 4,988 11,638 416 1,247
9,975 14,250 4,275 9,975 356 1,069
16,625 23,750 7,125 16,625 594 1,781
- - - - - -
2,660 3,800 1,140 2,660 95 285
2,660 3,800 1,140 2,660 95 285
2,660 3,800 1,140 2,660 95 285
2,660 3,800 1,140 2,660 95 285
2,660 3,800 1,140 2,660 95 285
- - - - - -
- - - - - -
1,164 1,663 499 1,164 42 125
1,164 1,663 499 1,164 42 125
3,325 4,750 1,425 3,325 119 356
3,325 4,750 1,425 3,325 119 356
- - - - - -
1,663 2,375 713 1,663 59 178
1,663 2,375 713 1,663 59 178
1,663 2,375 713 1,663 59 178
1,330 1,900 570 1,330 48 143
1,663 2,375 713 1,663 59 178
1,663 2,375 713 1,663 59 178
1,663 2,375 713 1,663 59 178
1,663 2,375 713 1,663 59 178
1,663 2,375 713 1,663 59 178
1,663 2,375 713 1,663 59 178
1,995 2,850 855 1,995 71 214
- - - - - -
2,328 3,325 998 2,328 83 249
1,663 2,375 713 1,663 59 178
1,829 2,613 784 1,829 65 196
13,300 19,000 5,700 13,300 475 1,425
2,394 3,420 1,026 2,394 86 257
- - - - - -
1,496 2,138 641 1,496 53 160
4,156 5,938 1,781 4,156 148 445
4,988 7,125 2,138 4,988 178 534
1,995 2,850 855 1,995 71 214
4,988 7,125 2,138 4,988 178 534
6,650 9,500 2,850 6,650 238 713
16,625 23,750 7,125 16,625 594 1,781
4,988 7,125 2,138 4,988 178 534
4,988 7,125 2,138 4,988 178 534
4,988 7,125 2,138 4,988 178 534
- - - - - -
14,963 21,375 6,413 14,963 534 1,603
6,650 9,500 2,850 6,650 238 713
23,275 33,250 9,975 23,275 831 2,494
14,963 21,375 6,413 14,963 534 1,603
13,300 19,000 5,700 13,300 475 1,425
13,300 19,000 5,700 13,300 475 1,425
- - - - - -
41,563 59,375 17,813 41,563 1,484 4,453
41,563 59,375 17,813 41,563 1,484 4,453
9,975 14,250 4,275 9,975 356 1,069
9,975 14,250 4,275 9,975 356 1,069
19,950 28,500 8,550 19,950 713 2,138
8,313 11,875 3,563 8,313 297 891
19,950 28,500 8,550 19,950 713 2,138
11,638 16,625 4,988 11,638 416 1,247
- - - - - -
8,313 11,875 3,563 8,313 297 891
2,993 4,275 1,283 2,993 107 321
5,320 7,600 2,280 5,320 190 570
11,638 16,625 4,988 11,638 416 1,247
6,650 9,500 2,850 6,650 238 713
6,650 9,500 2,850 6,650 238 713
13,300 19,000 5,700 13,300 475 1,425
13,300 19,000 5,700 13,300 475 1,425
3,325 4,750 1,425 3,325 119 356
14,963 21,375 6,413 14,963 534 1,603
4,988 7,125 2,138 4,988 178 534
- - - - - -
1,663 2,375 713 1,663 59 178
1,164 1,663 499 1,164 42 125
13,300 19,000 5,700 13,300 475 1,425
4,988 7,125 2,138 4,988 178 534
3,325 4,750 1,425 3,325 119 356
4,156 5,938 1,781 4,156 148 445
2,328 3,325 998 2,328 83 249
1,164 1,663 499 1,164 42 125
11,638 16,625 4,988 11,638 416 1,247
4,988 7,125 2,138 4,988 178 534
19,950 28,500 8,550 19,950 713 2,138
- - - - - -
11,638 16,625 4,988 11,638 416 1,247
13,300 19,000 5,700 13,300 475 1,425
13,300 19,000 5,700 13,300 475 1,425
26,600 38,000 11,400 26,600 950 2,850
19,950 28,500 8,550 19,950 713 2,138
29,925 42,750 12,825 29,925 1,069 3,206
- - - - - -
16,625 23,750 7,125 16,625 594 1,781
9,975 14,250 4,275 9,975 356 1,069
16,625 23,750 7,125 16,625 594 1,781
9,975 14,250 4,275 9,975 356 1,069
11,638 16,625 4,988 11,638 416 1,247
9,975 14,250 4,275 9,975 356 1,069
14,963 21,375 6,413 14,963 534 1,603
- - - - - -
6,650 9,500 2,850 6,650 238 713
4,988 7,125 2,138 4,988 178 534
6,650 9,500 2,850 6,650 238 713
6,650 9,500 2,850 6,650 238 713
1,663 2,375 713 1,663 59 178
3,325 4,750 1,425 3,325 119 356
13,300 19,000 5,700 13,300 475 1,425
6,650 9,500 2,850 6,650 238 713
14,963 21,375 6,413 14,963 534 1,603
13,300 19,000 5,700 13,300 475 1,425
4,988 7,125 2,138 4,988 178 534
- - - - - -
16,625 23,750 7,125 16,625 594 1,781
9,975 14,250 4,275 9,975 356 1,069
- - - - - -
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
21,280 30,400 9,120 21,280 760 2,280
26,600 38,000 11,400 26,600 950 2,850
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
18,620 26,600 7,980 18,620 665 1,995
26,600 38,000 11,400 26,600 950 2,850
- - - - - -
665 950 285 665 24 71
1,330 1,900 570 1,330 48 143
1,330 1,900 570 1,330 48 143
1,596 2,280 684 1,596 57 171
1,995 2,850 855 1,995 71 214
1,995 2,850 855 1,995 71 214
1,596 2,280 684 1,596 57 171
5,320 7,600 2,280 5,320 190 570
831 1,188 356 831 30 89
- - - - - -
- - - - - -
1,663 2,375 713 1,663 59 178
665 950 285 665 24 71
665 950 285 665 24 71
665 950 285 665 24 71
665 950 285 665 24 71
4,988 7,125 2,138 4,988 178 534
665 950 285 665 24 71
665 950 285 665 24 71
665 950 285 665 24 71
665 950 285 665 24 71
1,496 2,138 641 1,496 53 160
4,256 6,080 1,824 4,256 152 456
- - - - - -
1,663 2,375 713 1,663 59 178
1,995 2,850 855 1,995 71 214
1,796 2,565 770 1,796 64 192
1,796 2,565 770 1,796 64 192
1,796 2,565 770 1,796 64 192
- - - - - -
3,990 5,700 1,710 3,990 143 428
3,990 5,700 1,710 3,990 143 428
3,990 5,700 1,710 3,990 143 428
3,990 5,700 1,710 3,990 143 428
3,990 5,700 1,710 3,990 143 428
- - - - - -
2,394 3,420 1,026 2,394 86 257
1,796 2,565 770 1,796 64 192
1,197 1,710 513 1,197 43 128
1,197 1,710 513 1,197 43 128
1,197 1,710 513 1,197 43 128
1,862 2,660 798 1,862 67 200
1,862 2,660 798 1,862 67 200
33,250 47,500 14,250 33,250 1,188 3,563
26,600 38,000 11,400 26,600 950 2,850
23,275 33,250 9,975 23,275 831 2,494
24,605 35,150 10,545 24,605 879 2,636
DA ADA DOKTER PATOLOGI KLINIK
KELOMPOK ANALIS
90%
14
6,413
5,130
1,924
1,924
1,924
1,710
1,283
1,924
1,710
4,275
8,550
25,650
34,200
1,924
2,565
3,848
3,420
2,993
8,550
1,924
1,924
1,924
1,924
1,283
1,710
10,688
10,688
14,963
2,993
5,558
7,695
-
1,283
1,069
14,535
29,925
14,963
12,825
21,375
-
3,420
3,420
3,420
3,420
3,420
-
-
1,496
1,496
4,275
4,275
-
2,138
2,138
2,138
1,710
2,138
2,138
2,138
2,138
2,138
2,138
2,565
-
2,993
2,138
2,351
17,100
3,078
-
1,924
5,344
6,413
2,565
6,413
8,550
21,375
6,413
6,413
6,413
-
19,238
8,550
29,925
19,238
17,100
17,100
-
53,438
53,438
12,825
12,825
25,650
10,688
25,650
14,963
-
10,688
3,848
6,840
14,963
8,550
8,550
17,100
17,100
4,275
19,238
6,413
-
2,138
1,496
17,100
6,413
4,275
5,344
2,993
1,496
14,963
6,413
25,650
-
14,963
17,100
17,100
34,200
25,650
38,475
-
21,375
12,825
21,375
12,825
14,963
12,825
19,238
-
8,550
6,413
8,550
8,550
2,138
4,275
17,100
8,550
19,238
17,100
6,413
-
21,375
12,825
-
-
23,940
34,200
-
23,940
34,200
-
27,360
34,200
23,940
34,200
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
23,940
34,200
-
855
1,710
1,710
2,052
2,565
2,565
2,052
6,840
1,069
-
-
2,138
855
855
855
855
6,413
855
855
855
855
1,924
5,472
-
2,138
2,565
2,309
2,309
2,309
-
5,130
5,130
5,130
5,130
5,130
-
3,078
2,309
1,539
1,539
1,539
2,394
2,394
42,750
34,200
29,925
31,635

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PEMBAGIAN JASA PELAYANAN SESUAI TARIF LAYANAN PELAYANAN

I. TARIF PENDAFTARAN , PEMERIKSAAN , DAN AKOMODASI

JASA DIREKSI SISA JASA

1,200 300 15 285

12 dr. UMUM dr. SPESIALIS

2,375 6,650 2,850

dr. PPSD DPJP

2. POLIKLINIK PENYAKIT ANAK

3. POLIKLINIK BEDAH UMUM

6. POLIKLINIK GIGI DAN MULUT

A SPESIFIKASI TINDAKAN PENCABUTAN GIGI

B SPESIFIKASI TINDAKAN PENAMBALAN GIGI

C SPESIFIKASI TINDAKAN PENGOBATAN / PERAWATAN JARINGAN PENYANGGA GIGI

D SPESIFIKASI PEMBUATAN PROTESA / GIGI PALSU

E SPESIFIKASI TINDAKAN BEDAH MULUT

F SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dengan LOGAM

G SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY tanpa LOGAM

7. POLIKLINIK PENYAKIT KULIT DAN KELAMIN

1 Elektro fulgurasi / Elektro Couter :

8. POLIKLINIK PENYAKIT PARU

1 Terapi Inhalasi tanpa obat / Nebulizer 26,000

1 Punctie asctes 250,000

10. POLIKLINIK PENYAKIT JANTUNG

11. POLIKLINIK SYARAF/NEUROLOGI

1 Injeksi Intramuskuler 4,500

13. POLIKLINIK KEBIDANAN DAN PENYAKIT KANDUNGAN (OBSGYN)

1 Biopsi Pervaginam 140,000

14. POLIKLINIK PENYAKIT THT

15. REHABILITASI MEDIK

1 Micro Wave Diathermy 35,000

16. POLIKLINIK BEDAH SYARAF

1 Rawat Luka 15,000

3 Pungsi CSF Cranial 300,000

17. POLIKLINIK JIWA / PSIKIATRI

240,000 160,000 8,000 152,000 22,800 53,200 76,000

30,000 20,000 1,000 19,000 2,850 6,650 9,500

42,000 28,000 1,400 26,600 3,990 9,310 13,300

9,000 6,000 300 5,700 855 1,995 2,850

30,000 20,000 1,000 19,000 2,850 6,650 9,500

9,000 6,000 300 5,700 855 1,995 2,850

41,000 14,000 700 13,300 1,995 4,655 6,650

85,000 25,000 1,250 23,750 3,563 8,313 11,875

65,000 20,000 1,000 19,000 2,850 6,650 9,500

95,000 30,000 1,500 28,500 4,275 9,975 14,250

65,000 20,000 1,000 19,000 2,850 6,650 9,500

33,000 22,000 1,100 20,900 3,135 7,315 10,450

105,000 70,000 3,500 66,500 9,975 23,275 33,250

84,000 56,000 2,800 53,200 7,980 18,620 26,600

50,000 25,000 1,250 23,750 3,563 8,313 11,875

50,000 25,000 1,250 23,750 3,563 8,313 11,875

65,000 30,000 1,500 28,500 4,275 9,975 14,250

25,000 10,000 500 9,500 1,425 3,325 4,750

9,000 6,000 300 5,700 855 1,995 2,850

30,000 20,000 1,000 19,000 2,850 6,650 9,500

380 1,520 1,520 380

15,200 60,800 60,800 15,200

570 2,280 2,280 570

1,900 7,600 7,600 1,900

570 2,280 2,280 570

570 2,280 2,280 570

23,750 95,000 95,000 23,750

2,090 8,360 8,360 2,090

6,650 26,600 26,600 6,650