LAMPIRAN : PERATURAN BUPATI TEMANGGUNG

NOMOR TAHUN 2018

TARIF PELAYANAN KESEHATAN

PADA BADAN LAYANAN UMUM DAERAH PUSKESMAS

A. TARIF PELAYANAN MEDIS PUSKESMAS.

NOJENIS PELAYANANTARIF1Pelayanan Administrasi /
Pendaftaran5.0002Persalinan normal 600.0003Persalinan dengan
tindakan emergensi dasar750.0004Tindakan Pelayanan Medis /
Perawatan :a. Suntikan /injeksi2.500b. Kuras lambung10.000c.
Pembersihan Discharge10.000d. Pengambilan serumen12.500e.
Pengambilan benda asing telinga15.000f. Tampon telinga10.000g.
Pengambilan benda asing hidung15.000h. Tampon hidung
anterior15.000i. Tampon hidung posterior45.000j.
Repossisi25.000k. Spalk kecil8.000l. Spalk sedang14.000m.
Spalk besar25.000n. Ganti balut kecil5.000o. Ganti balut
sedang7.500p. Ganti balut besar15.000 q. Tindik telinga8.000r.
Pasang cateter10.000s. Ransel perban7.000t. Perawatan luka
bakar kecil5.000u. Perawatan luka bakar sedang10.000v.
Perawatan luka bakar besar20.000w. Schoortein4.000x. Pasang
infuse5.000y. Lavement (glycerin)5.000z. Circumsisi
(khitan)100.000aa. Incisi15.000ab. Exterpasi tumor
kecil/sedang30.000ac. Fiksasi dengan Gibs50.000ad. Jahit luka
:Kurang dari 6 jahitan15.0006 - 10 jahitan20.000Di atas 10
jahitan50.000ae. Hecting off 1 – 105.000af. Hecting off 10 –
3010.000ag. Pasang Sonde10.000ah. Extraksi korpus alienium
termasuk serumen ditelinga , hidung12.000ai. Penyiapan obat non
racikan
(per lembar resep)5.000aj. Penyiapan obat racikan al : caps,
unguentum atau pulveres (per lembar resep)7.000ak. Penyiapan racikan
jamu ter Scientifikasi10.000al. Pelayanan VCT15.0005Tindakan Pelayanan
GigiScalling gigi rahang atas / region10.000Scalling gigi rahang bawah /
region10.000Konservasi/penambalan/kunjunganSementara5.000Tetap
satu lubang10.000Tetap dua lubang atau lebih15.000Devitalisasi
pulpa8.000Perawatan syaraf10.000Extraksi/pencabutan gigiGigi susu
tanpa injeksi8.000Gigi susu dengan injeksi10.000Gigi tetap tanpa
penyulit/kompli kasi15.000Gigi tetap dengan penyulit/ kompli
kasi20.000Operasi gigi miring75.000Incissi abses dengan
injeksi15.0006Tindakan Pelayanan KhususOne day care120.000Home care
(dlm wilayah PKM)50.000Pelayanan visum hidup25.000Pemeriksaan luar
jenazah25.000

Pemeriksaan kesehatan/Kiur umum

10.000

Pemeriksaan kesehatan/Kiur anak sekolah

5.000
Pemeriksaan kesehatan calon mempelai / orang

10.000

Pemeriksaan kesehatan /Kiur calon haji

Pemeriksaan tahap I

20.000

Pemeriksaan tahap II

35.000

Electro Kardio Grafi (EKG)

15.000

Ultrasonografi (USG)

15.000

Nebulizer

20.000
Oksigen konsentrator (1 jam pertama)

20.000

Oksigen konsentrator penambahan tiap jam

5.000

Tindakan Pelayanan KB

Injeksi Kontrasepsi

10.000

Pasang susuk

50.000

Bongkar susuk

50.000

Pasang IUD

30.000

Bongkar IUD

30.000
8

Tarif rawat inap perhari, termasuk layanan gizi.

120.000

Pelayanan Transportasi Rujukan dengan Mobil Ambulan Puskesmas /Pusling

(biaya sudah meliputi ; Perawat pendamping, Sopir dan BBM).

Menyesuaikan jarak, dengan index perhitungan biaya maksimal Rp. 8.000,-

per kilometer jarak.

Pembayaran minimal Rp. 50.000,-

10

Pelayanan Transportasi Jenazah dengan Mobil Jenazah Puskesmas (jika ada)

atau Mobil Ambulance Puskesmas.

Menyesuaikan jarak, dengan index perhitungan biaya maksimal Rp. 8.000,-

per kilometer jarak.

Pembayaran minimal Rp. 50.000,-

TARIF PELAYANAN PENUNJANG / LABORATORIUM

NO

PARAMETER

TARIF

HAEMATOLOGI RUTIN

Hemoglobin

5.000
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