Distribusi Perdir Tentang Pemberlakuan Tarif Pelayanan

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PELAYANAN KESEHATAN

RSUP NASIONAL Dr. CIPTO MANGUNKUSUMO
Jalan Diponegoro No.71 Jakarta 10430 Kotak Pos 1086
Faksimile : (021) 3148991 Call Center : 1500135 Laman (Wesite) www.rscm.co.id
PERATURAN DIREKTUR UTAMA RSUP NASIONAL Dr. CIPTO MANGUNKUSUMO

NOMOR : HK.01.07/4.2/8320/2020
TENTANG
PEMBERLAKUAN TARIF PELAYANAN
RSUP NASIONAL Dr. CIPTO MANGUNKUSUMO
DENGAN RAHMAT TUHAN YANG MAHA ESA

DIREKTUR UTAMA RSUP NASIONAL Dr. CIPTO MANGUNKUSUMO,
Menimbang : a. bahwa berdasarkan Peraturan Pemerintah Republik

Indonesia Nomor 23 Tahun 2005 tentang Pengelolaan
Keuangan Badan Layanan Umum sebagaimana telah diubah
dengan Peraturan Pemerintah Republik Indonesia Nomor 74
tahun 2012 tentang Perubahan Peraturan Pemerintah
Nomor 23 Tahun 2005 tentang Pengelolaan Keuangan Badan
Layanan Umum perlu disusun besaran tarif yang digunakan
sebagai imbal jasa pemberian pelayanan kesehatan RSUP
Nasional Dr. Cipto Mangunkusumo;
b. bahwa perlu adanya Peraturan Direktur Utama RSUP
Nasional Dr. Cipto Mangunkusumo tentang Pemberlakuan
Tarif Pelayanan RSUP Nasional Dr. Cipto Mangunkusumo;
c. bahwa berdasarkan pertimbangan sebagaimana dimaksud
dalam huruf a dan b, maka perlu menetapkan Peraturan
Direktur Utama RSUP Nasional Dr. Cipto Mangunkusumo
tentang Pemberlakuan Tarif Pelayanan RSUP Nasional Dr.
Cipto Mangunkusumo;
Mengingat : 1. Undang Undang Republik Indonesia Nomor 17 Tahun 2003
tentang Keuangan Negara (Lembaran Negara Republik
Indonesia Tahun 2003 Nomor 47, Tambahan Lembaran
Negara Nomor 4286);
2. Undang Undang Republik Indonesia Nomor 1 Tahun 2004
tentang Perbendaharaan Negara (Lembaran Negara Republik
Indonesia Tahun 2004 Nomor 5, Tambahan Lembaran
Negara Nomor 4355);
3. Undang Undang Republik Indonesia Nomor 44 Tahun 2009
tentang Rumah Sakit (Lembaran Negara Republik Indonesia
Tahun 2009 Nomor 153, Tambahan Lembaran Negara Nomor
5072);
“ Menolong, memberikan yang terbaik”

JCI
CN 3494.1
-2-
4. Peraturan Pemerintah Republik Indonesia Nomor 23 Tahun

2005 tentang Pengelolaan Keuangan Badan Layanan Umum
sebagaimana telah diubah dengan Peraturan Pemerintah
Republik Indonesia Nomor 74 tahun 2012 tentang
Perubahan Peraturan Pemerintah Nomor 23 Tahun 2005
tentang Pengelolaan Keuangan Badan Layanan Umum
(Lembaran Negara Republik Indonesia Tahun 2012 Nomor
171, Tambahan Lembaran Negara Nomor 5340);
5. Peraturan Pemerintah Republik Indonesia Nomor 45 Tahun
2013 tentang Tata Cara Pelaksanaan Anggaran Pendapatan
dan Belanja Negara;
6. Peraturan Menteri Kesehatan Republik Indonesia Nomor
1672/Menkes/Per/XII/2005 tanggal 27 Desember 2005
tentang Organisasi dan Tata Kerja RSUP Nasional Dr. Cipto
Mangunkusumo;
7. Peraturan Menteri Keuangan Republik Indonesia Nomor 76
Tahun 2008 tentang Pedoman dan Pelaporan Keuangan
Badan Layanan Umum;
8. Keputusan Menteri Kesehatan Republik Indonesia Nomor
1243/Menkes/SK/VIII/2005 tentang Penetapan 13 (Tiga
Belas) Eks Rumah Sakit Perusahaan Jawatan (Perjan)
Menjadi Unit Pelaksana Teknis (UPT) Departemen Kesehatan
Dengan Menerapkan Pola Pengelolaan Keuangan Badan
Layanan Umum (BLU).
9. Keputusan Menteri Kesehatan Republik Indonesia Nomor
KP.03.03/Menkes/254/2018 tanggal 14 Mei 2018 tentang
Pemberhentian dan Pengangkatan Dari Dan Dalam Jabatan
Pimpinan Tinggi Pratama di Lingkungan Kementerian
Kesehatan Republik Indonesia;
10. Keputusan Kepala Badan Koordinator Penanaman Modal
Republik Indonesia Nomor 2/1/10/KES/PMDN/2017
tanggal 1 Maret 2017 tentang Izin Operasional Rumah Sakit
Umum Pusat Nasional Dr. Cipto Mangunkusumo Sebagai
Rumah Sakit Kelas A.
Memperhatikan : Rapat Pimpinan RSUP Nasional Dr. Cipto Mangunkusumo.
MEMUTUSKAN :
Menetapkan : PERATURAN DIREKTUR UTAMA RSUP NASIONAL

Dr. CIPTO MANGUNKUSUMO TENTANG PEMBERLAKUAN
TARIF PELAYANAN RSUP NASIONAL Dr. CIPTO
MANGUNKUSUMO
-3-
Pasal 1
Memberlakukan Tarif Pelayanan RSUP Nasional Dr. Cipto Mangunkusumo

sebagaimana tercantum dalam Lampiran I dan Lampiran II Peraturan ini.
Pasal 2
Pemberlakuan Tarif Pelayanan sebagaimana dimaksud dalam Pasal 1 adalah acuan

yang dijadikan dasar pemberian tarif pelayanan kesehatan tiap unit kerja di RSUP
Nasional Dr. Cipto Mangunkusumo.
Pasal 3
Ketentuan kebijakan sebagaimana dimaksud pada Pasal 1 tercantum dalam

Lampiran III yang merupakan bagian tidak terpisahkan dari Peraturan ini.
Pasal 4
Direktorat Keuangan bertanggungjawab terhadap sosialisasi dan pelaksanaan

pemberlakuan Tarif Pelayanan 2020 sebagaimana dimaksud pada Pasal 1.
Pasal 5
Dengan diberlakukanya Peraturan ini, maka Keputusan Direktur Utama RSUP
Nasional Dr. Cipto Mangunkusumo Nomor HK.01.07/3.3/19028/2020 tentang
Pemberlakuan Tarif Layanan RSUP Nasional Dr. Cipto Mangunkusumo, dinyatakan
dicabut dan tidak berlaku lagi.
Pasal 6
Peraturan ini berlaku terhitung sejak tanggal 1 Januari 2021.
Ditetapkan di Jakarta
Pada tanggal 22 Oktober 2020
DIREKTUR UTAMA,
Ttd.
LIES DINA LIASTUTI

Lampiran I Peraturan Direktur Utama
RSUP Nasional Dr. Cipto Mangunkusumo
Nomor : HK.01.07/4.2/8320/2020
Tanggal : 22 Oktober 2020
PELAYANAN MEDIS
1. KONSULTASI DAN VISITE
JASA
No NAMA KEGIATAN JASA SARANA TARIF
PELAYANAN
1 Konseling Gizi 100,000 10,000 110,000
2 Konseling Khusus 114,000 75,000 189,000
3 Konsultasi Dokter 86,000 56,000 142,000
4 Visite - HCU/ICU/PICU - 336,000 336,000
5 Visite - Intermediate ward - 176,000 176,000
6 Visite - Isolasi & NICU - 220,000 220,000
7 Visite - Kangaroo Mother - 176,000 176,000
8 Visite - Kelas I - 176,000 176,000
9 Visite - Kelas II - 110,000 110,000
10 Visite - Kelas III - 58,000 58,000
11 Visite - Kelas VIP - 220,000 220,000
12 Visite - Kelas VVIP - 220,000 220,000
13 Visite - Rawat Gabung - 58,000 58,000
14 Visite - RIIM - 220,000 220,000
15 Visite - Ruang Isolasi - 176,000 176,000
16 Visite - Ruang Plasmaferesis - 176,000 176,000
17 Visite - SCN 1/2/3/4 - 176,000 176,000
PELAYANAN MEDIS
2. INSTALASI GAWAT DARURAT
JASA
PELAYANAN
1 ADMINISTRASI PASIEN UGD* 27.000 - 27.000
2 KONSULTASI RAWAT BERSAMA 44.000 30.000 74.000
3 KASUS KEKERASAN PKT* 74.000 8.000 82.000
4 OBSERVASI PASIEN ≥8 JAM 153.000 170.000 323.000
5 RESUSITASI 286.000 129.000 415.000
6 RUANG HIJAU 105.000 41.000 146.000
7 RUANG KUNING** 221.000 241.000 462.000
8 RUANG MERAH** 431.000 374.000 805.000
9 TRIASE 50.000 35.000 85.000
10 SEWA BUBBLE CPAP* 225.000 23.000 248.000
PELAYANAN MEDIS
3. AKOMODASI
JASA
PELAYANAN
1 Pelayanan rawat inap - HCU/ICU/PICU 2,875,000 - 2,875,000
2 Pelayanan rawat inap - Intermediate Ward 538,000 - 538,000
3 Pelayanan rawat inap - Isolasi & NICU 970,000 - 970,000
4 Pelayanan rawat inap - Kangaroo Mother 538,000 - 538,000
5 Pelayanan rawat inap - Kelas I 538,000 - 538,000
6 Pelayanan rawat inap - Kelas II 353,000 - 353,000
7 Pelayanan rawat inap - Kelas III 302,000 - 302,000
8 Pelayanan rawat inap - Kelas VIP 970,000 - 970,000
9 Pelayanan rawat inap - Kelas VVIP 1,395,000 - 1,395,000
10 Pelayanan rawat inap - Rawat Gabung 302,000 - 302,000
11 Pelayanan rawat inap - RIIM 1,950,000 - 1,950,000
12 Pelayanan rawat inap - Ruang Isolasi 538,000 - 538,000
13 Pelayanan rawat inap - Ruang Plasmaferesis 538,000 - 538,000
14 Pelayanan rawat inap - SCN 1/2/3/4 538,000 - 538,000
PELAYANAN MEDIS
4. TINDAKAN KEPERAWATAN
JASA
PELAYANAN
1 Ambil drh astrup 115.000 12.000 127.000
2 Angkat drain 42.000 5.000 47.000
3 Bilas lambung dengan NGT 68.000 7.000 75.000
4 Bladder Training 141.000 66.000 207.000
5 Clisma 100.000 10.000 110.000
6 code blue 43.000 5.000 48.000
7 Cukur gundul 26.000 3.000 29.000
8 CVC/Long Line 226.000 23.000 249.000
9 D3an celside 98.000 10.000 108.000
10 D3an colostomi 99.000 10.000 109.000
11 D3an Kateter Suprapubik 24.000 3.000 27.000
12 D3an Neprostomi 28.000 3.000 31.000
13 D3an WSD 47.000 5.000 52.000
14 EKG record 25.000 3.000 28.000
15 Injeksi kenacort 138.000 14.000 152.000
16 Lung Maturation 42.000 5.000 47.000
17 Melakukan Penis / vulva Hygine 40.000 4.000 44.000
18 Melakukan perawatan WSD 108.000 11.000 119.000
19 Melakukan Suction 20.000 2.000 22.000
20 Melepas kateter 72.000 8.000 80.000
21 Memandikan pasien di tempat tidur 88.000 9.000 97.000
22 Memasang Kateter 160.000 16.000 176.000
23 Memasang NGT 206.000 15.000 221.000
24 Memberi obat melalui inhalasi 117.000 12.000 129.000
25 Memberi tranfusi 115.000 12.000 127.000
26 Memberika injeksi 8.000 1.000 9.000
27 Memberikan injeksi IM 113.000 12.000 125.000
28 Memberikan injeksi IV 114.000 12.000 126.000
29 Mengambil Darah AGD 14.000 2.000 16.000
30 Mengambil darah perifer 113.000 12.000 125.000
31 Mengganti Botol WSD 21.000 3.000 24.000
32 Mengganti Kolostomi 254.000 26.000 280.000
33 Neurorestorasi 213.000 22.000 235.000
34 Oral Hygiene 14.000 2.000 16.000
35 Pasang infus anak/bayi 207.000 21.000 228.000
36 Pasang Light Therapy 25.000 3.000 28.000
37 Pemasangan infus 82.000 9.000 91.000
38 Pemasangan Syringe Pump 100.000 10.000 110.000
39 Pemberian kemoterapi 104.000 11.000 115.000
40 Pemberian terapi inj sub cutan 26.000 3.000 29.000
41 Pemberian Terapi Parentral Nutrisi 51.000 6.000 57.000
42 Pemberian TPN 40.000 4.000 44.000
43 Perawatan colostomi 336.000 34.000 370.000
44 Perawatan fistel peri anal 62.000 7.000 69.000
45 Perawatan illiustomi 448.000 45.000 493.000
46 Perawatan Kateter 124.000 13.000 137.000
47 Perawatan Luka Besar (Luka Cancer) 431.000 44.000 475.000
48 Perawatan luka kecil 108.000 11.000 119.000
49 Perawatan Luka Ringan 168.000 17.000 185.000
50 Perawatan nefrostomi 95.000 10.000 105.000
51 Perawatan Payudara 21.000 3.000 24.000
52 Perawatan sistostomi 86.000 9.000 95.000
53 Perawatan Tali Pusat 23.000 3.000 26.000
JASA
PELAYANAN
54 Perawatan Tracheastomi 142.000 15.000 157.000
55 Perawatan urostomi 336.000 34.000 370.000
56 Roserplasty 258.000 26.000 284.000
57 Spulling Kateter 154.000 16.000 170.000
58 Staging 50.000 5.000 55.000
59 Tindakan Vena sektie 50.000 5.000 55.000
60 Transfusi Darah 93.000 10.000 103.000
61 Vulva Hygiene 47.000 5.000 52.000
PELAYANAN MEDIS
5. TINDAKAN RUANG INTENSIVE
JASA
PELAYANAN
1 Blok ganglion trigeminal 1.713.000 1.313.000 3.026.000
2 Blok Simpatis Craniofacial 1.713.000 1.313.000 3.026.000
3 Blok simpatis trunkus 1.713.000 1.313.000 3.026.000
4 Bronkoskopi 1.209.000 927.000 2.136.000
5 Cerebral Monitoring 993.000 258.000 1.251.000
6 Chemical Neurolytic 1.241.000 951.000 2.192.000
7 CVC 1.778.000 1.364.000 3.142.000
8 CVP Akses Vaskuler 1.290.000 989.000 2.279.000
9 CVP Akses Vaskuler dengan USG 1.304.000 999.000 2.303.000
10 CVVH/CVVHD/CVVHDF 16.075.000 8.039.000 24.114.000
11 CVVH/CVVHD/CVVHDF harian 3.894.000 2.985.000 6.879.000
12 CVVH/CVVHD/CVVHDF harian tanpa Prismasol 2.160.000 1.656.000 3.816.000
13 CVVH/CVVHD/CVVHDF tanpa Prismasol dan set 4.402.000 3.375.000 7.777.000
14 Dorsal root ganglion 1.469.000 1.126.000 2.595.000
15 ECMO 3.894.000 2.985.000 6.879.000
16 Epidural bolus hari 1 367.000 230.000 597.000
17 Epidural bolus hari 2 & 3 294.000 225.000 519.000
18 Epidural kontinyu 956.000 230.000 1.186.000
19 Epidural kontinyu hari 2 & 3 294.000 225.000 519.000
20 Extubasi 651.000 386.000 1.037.000
21 Facet joint injection 1.469.000 1.126.000 2.595.000
22 Ganti Balutan Besar ( > 11cm ) 238.000 87.000 325.000
23 Ganti Balutan Kecil (< 5 cm) 97.000 37.000 134.000
24 Ganti Balutan Sedang ( 6 cm - 10 cm ) 190.000 54.000 244.000
25 HD Sled 1.657.000 1.271.000 2.928.000
26 Hemodialisis 894.000 230.000 1.124.000
27 Hemodinamik Monitoring (PICCO) 9.615.000 1.771.000 11.386.000
28 HFO setting harian oleh DPJP 646.000 496.000 1.142.000
29 Injeksi Alkohol 1.241.000 951.000 2.192.000
30 Injeksi Phenol 1.241.000 951.000 2.192.000
31 Insersi chest tube + WSD 5.159.000 3.956.000 9.115.000
32 Intubasi 956.000 733.000 1.689.000
33 Intubasi ETT 651.000 386.000 1.037.000
34 IV kontinyu hari 1 719.000 230.000 949.000
35 IV kontinyu hari 2 dan 3 220.000 169.000 389.000
36 MARS 3.894.000 2.985.000 6.879.000
37 Medial branch injection 1.469.000 1.126.000 2.595.000
38 Medial branch RF 1.645.000 1.262.000 2.907.000
39 Monitoring End tidal CO2 Harian oleh DPJP 137.000 106.000 243.000
40 Monitoring Hemodinamik Non Invasive Harian oleh DPJP 372.000 285.000 657.000
41 Myofascial triggerpoint injection 1.137.000 872.000 2.009.000
42 Opioid pump implantation 1.529.000 1.172.000 2.701.000
43 Pasang Infus 132.000 101.000 233.000
44 Pasang O2 98.000 46.000 144.000
45 PCA Epidural hari 1 368.000 230.000 598.000
46 PCA Epidural hari 2&3 321.000 230.000 551.000
47 PCA IV hari 1 307.000 230.000 537.000
48 PCA IV hari 2 & 3 353.000 230.000 583.000
49 Pemasangan Akses Intraoseus 1.472.000 1.128.000 2.600.000
50 Pemasangan Arteri Line oleh DPJP 1.941.000 1.488.000 3.429.000
51 Pemasangan CDL Temporary 3.911.000 2.999.000 6.910.000
52 Pemasangan Defibrilator 511.000 392.000 903.000
53 Pemasangan Non-invasive respiratory support 4.971.000 1.382.000 6.353.000
JASA
PELAYANAN
54 Pencabutan kateter Lumen ganda Temporer 370.000 284.000 654.000
55 Perifer kontinyu hari 1 419.000 230.000 649.000
56 Perifer kontinyu hari 2 & 3 375.000 230.000 605.000
57 Peripheral nerve injection 1.137.000 872.000 2.009.000
58 PICC 3.417.000 2.620.000 6.037.000
59 Plasmaferesis 11.704.000 7.970.000 19.674.000
60 Pungsi Pleura / Torakosintesis 476.000 366.000 842.000
61 Radiofrekuensi neuraksial 1.645.000 1.262.000 2.907.000
62 Removal CVP 436.000 335.000 771.000
63 reposisi cdl 400.000 307.000 707.000
64 RESUSITASI 286.000 129.000 415.000
65 RJP 675.000 386.000 1.061.000
66 Sedasi sedang 107.000 83.000 190.000
67 Sedasi Tindakan Invasif oleh DPJP 628.000 482.000 1.110.000
68 SI joint injection 1.469.000 1.126.000 2.595.000
69 SI joint RF 1.645.000 1.262.000 2.907.000
70 Spinal bolus hari 1 431.000 230.000 661.000
71 spinal bolus hari 2 & 3 374.000 230.000 604.000
72 Spinal Cord Stimulation 1.529.000 1.172.000 2.701.000
73 Spinal kontinyu hr 1 319.000 230.000 549.000
74 Spinal kontinyu hari 2 & 3 281.000 216.000 497.000
75 Steroid Injection 1.469.000 1.126.000 2.595.000
76 Tracheostomi elektif 4.149.000 3.181.000 7.330.000
77 Trigeminal RF 1.645.000 1.262.000 2.907.000
78 VENTILATOR 900.000 80.000 980.000
79 Ventilator setting harian oleh DPJP 1.975.000 543.000 2.518.000
80 WSD chest tube konvensional 2.234.000 1.712.000 3.946.000
PELAYANAN MEDIS
6. NON OPERATIF
JASA
PELAYANAN
1. KEBIDANAN DAN PENYAKIT KANDUNGAN
1.1 KEBIDANAN DAN PENYAKIT KANDUNGAN
1 Abortus Spontan 259,000 199,000 458,000
2 Amnioinfusion, Pungsi 415,000 319,000 734,000
3 Amnioreduksi, Aspirasi 464,000 355,000 819,000
4 Aspirasi Vakum Manual 217,000 167,000 384,000
5 Businasi Penyakit Kebidanan 277,000 59,000 336,000
6 CTG 85,000 23,000 108,000
7 CVS 398,000 305,000 703,000
8 Hacting 698,000 184,000 882,000
9 Inspekulo VT 55,000 43,000 98,000
10 Kolposkopi & Biopsi 163,000 125,000 288,000
11 Kordosintesis 415,000 319,000 734,000
12 Lepas Pesarium 73,000 56,000 129,000
13 Manual Plasenta 690,000 529,000 1,219,000
14 Marsupialisasi Penyakit Kebidanan 3,311,000 2,539,000 5,850,000
15 Mikrokuret 107,000 40,000 147,000
16 NST/ CTG 61,000 36,000 97,000
17 Paket Evakuasi Hematom 2,751,000 2,109,000 4,860,000
18 Papsmear Konvesional 53,000 25,000 78,000
19 Papsmear Thinprep 120,000 92,000 212,000
20 Partus Forsep 1,421,000 1,089,000 2,510,000
21 Partus Normal 1,037,000 795,000 1,832,000
22 Partus Vakum 1,420,000 1,089,000 2,509,000
23 Pasang kateter 135,000 46,000 181,000
24 Pasang O2 98,000 46,000 144,000
25 Pasang pesarium 559,000 59,000 618,000
26 Pasang/angkat susuk 131,000 40,000 171,000
27 Pasang/Lepas Mold Vagina 67,000 52,000 119,000
28 Pemasangan Laminaria 562,000 431,000 993,000
29 Pemberian terapi oral / Injeksi 37,000 29,000 66,000
30 Pungsi Asites 239,000 46,000 285,000
31 Sistoskopi 695,000 534,000 1,229,000
32 Sistoskopi + Biopsi 753,000 577,000 1,330,000
33 Tes Busa 206,000 159,000 365,000
34 Test Metilium Blue 185,000 59,000 244,000
35 USG Abdomen + CTG/Transvaginal 180,000 138,000 318,000
36 USG Uroginekologi Skrining/ Sederhana 161,000 124,000 285,000
1.2 KEBIDANAN DAN PENYAKIT KANDUNGAN (KINTANI)
1 Analisa Sperma 400,000 307,000 707,000
2 Buka pasang susuk 197,000 135,000 332,000
3 Ekstirpasi Polip 191,000 147,000 338,000
4 Hidrotubasi 259,000 197,000 456,000
5 Hifosi 1,577,000 1,209,000 2,786,000
6 Histereskopi Office 1,037,000 849,000 1,886,000
7 Irigasi Vagina 136,000 105,000 241,000
8 IVA 103,000 79,000 182,000
9 Kolposkopi 535,000 411,000 946,000
10 Kolposkopi Cryotherapy 251,000 192,000 443,000
11 Kolposkopi LLETZ 303,000 232,000 535,000
12 Lepas pasang IUD 183,000 140,000 323,000
13 Pasang susuk 152,000 97,000 249,000
14 Pemeriksaan Dalam 101,000 78,000 179,000
15 Perineumetri (Perkali datang) 100,000 60,000 160,000
16 Sistoskopi+ Biopsi 753,000 577,000 1,330,000
17 USG GINEKOLOGI 234,000 152,000 386,000
18 USG Onkologi 347,000 267,000 614,000
19 USG Uroginekologi Patologis 287,000 220,000 507,000
2. BEDAH SYARAF
1 Angkat Jahitan besar ( > 15 jahitan) 244,000 97,000 341,000
2 Angkat Jahitan kecil (1-7 jahitan) 91,000 62,000 153,000
3 Angkat Jahitan sedang (8-15 jahitan) 190,000 74,000 264,000
4 Ganti Balutan Besar ( > 11cm ) 238,000 87,000 325,000
5 Ganti Balutan Kecil (< 5 cm) 97,000 37,000 134,000
JASA
PELAYANAN
6 Ganti Balutan Sedang ( 6 cm - 10 cm ) 190,000 54,000 244,000
7 Overhecting 465,000 112,000 577,000
8 PUNGSI SUB GALEAL 187,000 84,000 271,000
9 PUNGSI VENTRIKEL 235,000 181,000 416,000
3. UROLOGI
1 Biofeedback 978,000 575,000 1,553,000
2 BIOPSI PROSTAT 1,435,000 460,000 1,895,000
3 Businasi 419,000 131,000 550,000
4 CIC 1,085,000 345,000 1,430,000
5 ESWL 2,910,000 2,231,000 5,141,000
6 ESWL ULANG 2,490,000 1,909,000 4,399,000
7 Ganti verban Kecil 88,000 29,000 117,000
8 Instilasi obat 248,000 191,000 439,000
9 MASSAGE PROSTAT 79,000 61,000 140,000
10 METHYLENE BLUE TEST 198,000 152,000 350,000
11 Pasang kateter dengan mandrain 333,000 155,000 488,000
12 SISTOGRAFI 1,115,000 633,000 1,748,000
13 Sistouretrografi Bipolar 1,115,000 748,000 1,863,000
14 URODINAMIK 5,944,000 1,725,000 7,669,000
15 UROFLOWMETRI 84,000 64,000 148,000
16 USG PROSTAT/USG GINJAL 84,000 64,000 148,000
17 USG TESTIS 93,000 71,000 164,000
4. NEUROLOGI
1 Blink Refleks 351,000 269,000 620,000
2 Brainstem Auditory Evoked Potential 314,000 240,000 554,000
3 Carotid Duplex 210,000 161,000 371,000
4 Cognitive Event Related Potential (P300) 288,000 221,000 509,000
5 Doppler Perifer 210,000 161,000 371,000
6 EEG Challenge Diazepam 938,000 719,000 1,657,000
7 EEG Long Term Monitoring 1,428,000 1,095,000 2,523,000
8 EEG Premedikasi 780,000 598,000 1,378,000
9 EEG rutin 666,000 233,000 899,000
10 EMG dengan jarum 435,000 334,000 769,000
11 EMG tanpa jarum 218,000 167,000 385,000
12 Fisioterapi 126,000 97,000 223,000
13 Hemodilusi isotonik 321,000 246,000 567,000
14 Injeksi ekstraartikular <2 cc 146,000 113,000 259,000
15 Injeksi ekstraartikular <2 cc dengan guided USG 225,000 173,000 398,000
16 Injeksi ekstraartikular >2 cc 184,000 141,000 325,000
17 Injeksi ekstraartikular >2 cc guided USG 264,000 202,000 466,000
18 Injeksi Epidural USG Guided 848,000 651,000 1,499,000
19 Injeksi Facet Joint USG Guided 832,000 638,000 1,470,000
20 Injeksi intra muskular <2 cc 145,000 112,000 257,000
21 Injeksi Intraartikular <2 cc 146,000 113,000 259,000
22 Injeksi Intraartikular <2 cc dengan guided USG 225,000 173,000 398,000
23 Injeksi Intraartikular >2 cc 184,000 141,000 325,000
24 Injeksi Intraartikular >2 cc dengan guided USG 264,000 202,000 466,000
25 Injeksi intramuskular <2 cc dengan guided USG 225,000 173,000 398,000
26 Injeksi intramuskular >2 cc 184,000 141,000 325,000
27 Injeksi intramuskular >2 cc guided USG 264,000 202,000 466,000
28 Injeksi Intratekal USG Guided 860,000 659,000 1,519,000
29 Injeksi Neuromuskular guided USG 322,000 247,000 569,000
30 Injeksi Perineural 253,000 194,000 447,000
31 Injeksi Peripheral selective nerve block USG Guided 828,000 635,000 1,463,000
32 Injeksi Piriformis USG Guided 820,000 629,000 1,449,000
33 Injeksi Sacroiliac USG Guided 822,000 630,000 1,452,000
34 Injeksi Trigger Point 226,000 174,000 400,000
35 Injeksi Trigger Point USG Guided 216,000 166,000 382,000
36 IOM HNP Lumbal Sakral 5,450,000 4,179,000 9,629,000
37 IOM HNP Servikal 5,451,000 4,179,000 9,630,000
38 IOM Pleksus Brachialis/N. Fasialis 5,860,000 4,493,000 10,353,000
39 IOM Skoliosis 7,828,000 6,002,000 13,830,000
40 IOM Tumor Fosa anterior kortikal mapping 16,583,000 10,019,000 26,602,000
41 IOM Tumor Fosa Posterior 10,520,000 8,065,000 18,585,000
42 IOM Tumor Medula Spinalis 13,930,000 10,680,000 24,610,000
43 IVM 206,000 159,000 365,000
44 Kecepatan Hantar Saraf 243,000 186,000 429,000
45 Kecepatan Hantar Saraf dan F-wave/H-Refleks 293,000 225,000 518,000
46 Lumbal Pungsi Guided 688,000 528,000 1,216,000
47 Lumbal Pungsi non guided 686,000 527,000 1,213,000
JASA
PELAYANAN
48 monitoring trombolisis intravena 2,510,000 1,925,000 4,435,000
49 NOT 171,000 131,000 302,000
50 Okupasi Terapi 125,000 97,000 222,000
51 Pain intervensi injeksi dengan radiofrekuensi guided C-ARM 2,028,000 1,555,000 3,583,000
52 Pain intervensi injeksi guided C-ARM 2,028,000 1,555,000 3,583,000
53 Pemeriksaan NO 177,000 136,000 313,000
54 PSG 24 jam 3,349,000 1,337,000 4,686,000
55 PSG 8 jam 1,250,000 667,000 1,917,000
56 Repetitive Nerve Stimulation 303,000 232,000 535,000
57 skrining karotis 123,000 94,000 217,000
58 skrining TCD 118,000 67,000 185,000
59 Somatosensory Evoked Potential 314,000 240,000 554,000
60 Spasmofili 244,000 187,000 431,000
61 Speech Terapi 170,000 115,000 285,000
62 Sympathetic Skin Response 338,000 260,000 598,000
63 Tapping and straping 324,000 115,000 439,000
64 TCD Buble Contrast 307,000 236,000 543,000
65 terapi fungsi luhur 171,000 131,000 302,000
66 TMS 210,000 161,000 371,000
67 Trans Cranial Doppler 210,000 161,000 371,000
68 Trombolisis Intravena 9,290,000 4,676,000 13,966,000
69 Visual Evoked Potential 314,000 240,000 554,000
5. PSIKIATRI
1 Cognitive-Behavioral Therapy 80,000 62,000 142,000
2 Hipnoterapi 43,000 33,000 76,000
3 Intervensi Keluarga 232,000 178,000 410,000
Layanan Untuk Memberikan Kesaksian Sebagai Konsulatan Ahli
4 114,000 2,875,000 2,989,000
Psikiatri Forensik (Common Case)
5 114,000 11,500,000 11,614,000
Psikiatri Forensik (Kasus Berat dengan Penyulit)
6 114,000 5,750,000 5,864,000
Psikiatri Forensik (Kasus Berat)
7 Manajemen gaduh gelisah 165,000 127,000 292,000
8 Manajemen risiko bunuh diri 165,000 127,000 292,000
9 Melakukan Tindakan ECT 199,000 153,000 352,000
10 Melakukan tindakan pengambilan darah intra vena 18,000 14,000 32,000
11 Melakukan tindakan Terapi Aktivitas Kelompok (TAK) 179,000 138,000 317,000
12 Motivational enhancement therapy 77,000 60,000 137,000
13 Motivational Interviewing 80,000 62,000 142,000
14 Paket Tes Kepribadian 1 178,000 138,000 316,000
16 Pemeriksaan cognistat 480,000 368,000 848,000
17 Pemeriksaan psikiatrik pada orangtua 41,000 31,000 72,000
18 Pemeriksaan Psikologi Pada Kasus Psikiatri Forensik 290,000 224,000 514,000
19 Pemeriksaan Umum Psikiatri 45,000 35,000 80,000
20 Pengkajian fungsi kognitif (penapisan demensia) 48,000 37,000 85,000
21 Penjemputan pasien 298,000 229,000 527,000
22 Problem Solving Therapy (Individual) 80,000 62,000 142,000
23 Problem Solving Therapy (Kelompok) 128,000 98,000 226,000
24 Program Keterampilan Hidup Harian (Individual) 346,000 266,000 612,000
25 Program Keterampilan Hidup Harian (Kelompok) 468,000 359,000 827,000
26 Program Pemanfaatan Waktu Luang & Rekreasi (Kelompok) 357,000 274,000 631,000
27 Psikiatri Forensik 1 134,000 368,000 502,000
29 Psikiatri Forensik 3 276,000 1,380,000 1,656,000
31 Psikoterapi I (Suportif dan Edukasi) 43,000 33,000 76,000
32 Psikoterapi II (dengan konseling keluarga) 80,000 62,000 142,000
33 Psikoterapi Psikodinamik 80,000 62,000 142,000
34 Psikoterapi suportif pada anak 40,000 31,000 71,000
35 Psikoterapi suportif pada orangtua 20,000 16,000 36,000
36 Remediasi Kognitif berbasis Games 134,000 102,000 236,000
37 Skrining kognitif berbasis kertas 59,000 46,000 105,000
38 Skrining Narkoba 80,000 62,000 142,000
39 Social Skills Training (Individual) 235,000 181,000 416,000
40 Social Skills Training (Kelompok) 357,000 274,000 631,000
41 Terapi bermain pada anak (playtherapy) 60,000 46,000 106,000
42 Terapi Kejang Listrik (ECT) = tindakan: "Melakukan Tindakan ECT" 263,000 201,000 464,000
43 Terapi Kelompok 89,000 68,000 157,000
JASA
PELAYANAN
44 Terapi substitusi 40,000 31,000 71,000
45 Tes inteligensi (IQ) 142,000 109,000 251,000
46 Tes IQ 181,000 139,000 320,000
47 Tes Minat Bakat Anak dan Remaja 217,000 168,000 385,000
48 Tes Minat Bakat Dewasa (Tes IQ, Minat dan MMPI) 197,000 152,000 349,000
49 Tes MMPI, print grafik MMPI dan pembuatan hasil 85,000 66,000 151,000
50 Tes Neurocognitive (NCT) 63,000 48,000 111,000
51 Uji Kompetensi 1 (rekrutmen/ laik kerja) 320,000 246,000 566,000
52 Uji Kompetensi 2 (laik studi) 315,000 243,000 558,000
6. REHABILITASI MEDIK
1 Asesmen dengan Cardiopulmonary exercise testing 450,000 345,000 795,000
2 Asesmen dengan Motion and gait analyzer 578,000 444,000 1,022,000
3 Asesmen fungsi seksual 213,000 163,000 376,000
4 Dry Needling (5 titik) 167,000 129,000 296,000
Evaluasi Elektrodiagnostik (Elektromiografi, konduksi hantaran saraf,
5 283,000 217,000 500,000
evoked potential); Evaluasi Biofeedback (surface dan pressure)
Evaluasi kapasitas fungsional return to activities--> Manajemen
6 529,000 406,000 935,000
rehabilitasi interdisiplin
Evaluasi kapasitas fungsional return to work --> Manajemen
7 529,000 406,000 935,000
rehabilitasi interdisiplin ?
8 Evaluasi kemampuan intelektual (Tes IQ) 329,000 253,000 582,000
9 Evaluasi USG neuromuskuloskeletal 225,000 173,000 398,000
10 Functional check up 149,000 114,000 263,000
11 Layanan psikologis lainnya 329,000 253,000 582,000
12 Low level laser therapy 167,000 129,000 296,000
13 Pemeriksaan Kedokteran Fisik dan Rehabilitasi Komprehensif 150,000 115,000 265,000
14 Pengukuran, Fitting, Revisi Orthosis dan Sepatu 128,000 98,000 226,000
Peresepan dan Check Out Orthosis, alat bantu jalan, dan alat
15 128,000 98,000 226,000
imobilisasi sendi (casting, splinting)
16 Peresepan dan Check Out Prosthesis 128,000 98,000 226,000
Rehabilitasi psikososial, lingkungan, rumah, dan hambatan kerja;
17 140,000 107,000 247,000
Rehabilitasi paliatif; Tatalaksana perawat rehabilitasi
18 Rehabilitasi vokasional dan okupasi 128,000 99,000 227,000
19 Tatalaksana dengan Human Body Equilibrium 439,000 337,000 776,000
20 Tatalaksana dengan Virtual Reality 516,000 396,000 912,000
21 Tatalaksana dengan Work simulator 512,000 392,000 904,000
22 Tatalaksana gangguan berbahasa 151,000 116,000 267,000
23 Tatalaksana gangguan berbahasa tidak spesifik : disleksia, dispraksia 151,000 116,000 267,000
Tatalaksana gangguan proses bicara (fonasi, resonansi, artikulasi) dan
24 121,000 93,000 214,000
menelan
25 Tatalaksana gangguan proses bicara pada kelainan kraniofasial 121,000 93,000 214,000
Teknik Bersihan Jalan Napas (Postural drainage, positioning, tapping,
26 152,000 116,000 268,000
clapping, vibration, suction, cough assist)
27 Terapi edukasi & Home Program 106,000 82,000 188,000
28 Terapi Extracorporeal Shock Wave 177,000 136,000 313,000
29 Terapi imobilisasi sendi dengan casting dan splinting 129,000 99,000 228,000
30 Terapi inhalasi 83,000 64,000 147,000
31 Terapi injeksi Botulinum Toksin A dengan panduan USG 201,000 154,000 355,000
Terapi injeksi steroid dengan panduan USG Muskuloskeletal (pada
32 201,000 154,000 355,000
bursa, ligamen, tendon)
Terapi Injeksi substansi terapeutik dengan panduan USG
33 201,000 154,000 355,000
Muskuloskeletal (pada bursa tangan)
34 201,000 154,000 355,000
Muskuloskeletal (pada bursa)
35 274,000 210,000 484,000
Muskuloskeletal (pada sendi, ligamen)
36 201,000 154,000 355,000
Muskuloskeletal (pada tendon tangan)
Terapi Latihan Ambulasi (Keseimbangan dan Reaksi Proteksi, Pola
37 125,000 95,000 220,000
Jalan)
38 Terapi latihan bicara esofageal 121,000 93,000 214,000
39 Terapi latihan dengan Neuromuscular Activation System 242,000 185,000 427,000
40 Terapi latihan dengan robotic system 847,000 650,000 1,497,000
41 Terapi Latihan Kebugaran Kardiorespirasi 152,000 117,000 269,000
Terapi Latihan Lain: koordinasi dan keterampilan motorik,
neuromuscular facilitation (Proprioceptive Neuromuscular
42 135,000 104,000 239,000
Fascilitation, Bobath, Rood, Motor re-learning program), skoliosis,
osteoporosis, koreksi postur
43 Terapi Latihan Lingkup Gerak Sendi Ekstremitas 80,000 62,000 142,000
JASA
PELAYANAN
Terapi Latihan Lingkup Gerak Sendi Lainnya (Kraniofasial dan Otot
44 80,000 62,000 142,000
Dasar Panggul)
Terapi Latihan Lingkup Gerak Sendi Menggunakan Alat Continuous
45 119,000 92,000 211,000
Passive Movement (CPM)
46 Terapi Latihan Lingkup Gerak Sendi Tulang Belakang 80,000 62,000 142,000
47 Terapi Latihan menggunakan ortosis, prostesis, dan alat bantu jalan 75,000 58,000 133,000
48 Terapi Latihan Penguatan Otot 90,000 69,000 159,000
49 Terapi Latihan Peregangan 83,000 63,000 146,000
Terapi Latihan pernapasan dengan atau tanpa alat (incentive
50 spirometry, inspiratory muscle training, positive expiratory pressure, 151,000 116,000 267,000
air stacking exercise)
51 Terapi Manipulasi Sendi Ekstremitas 127,000 98,000 225,000
52 Terapi Manipulasi Sendi Kraniofasial dan Lainnya 127,000 98,000 225,000
53 Terapi Manipulasi Sendi Vertebra 127,000 98,000 225,000
54 Terapi Manual Limfatik, Fascia, dan Otot 148,000 114,000 262,000
55 Terapi Modalitas : TENS, ES, PTNS, NMES, Tapping Straping 167,000 128,000 295,000
56 Terapi Modalitas Diatermi: US, MWD, SWD 93,000 71,000 164,000
57 Terapi Modalitas Dingin (Ice Massage/ Vapocoolant spray) 93,000 71,000 164,000
58 Terapi Modalitas Panas Superfisial: Parafin Bath, IRR 80,000 62,000 142,000
59 Terapi Modalitas Traksi 105,000 81,000 186,000
60 Terapi musik 121,000 93,000 214,000
61 Terapi perilaku 121,000 93,000 214,000
62 Terapi rekreasi 92,000 71,000 163,000
Terapi sensasi somatosensori, sensori integrasi, persepsi kognisi, dan
63 133,000 102,000 235,000
adaptasi aktivitas kehidupan sehari-hari
64 Uji Fungsi Defekasi 131,000 101,000 232,000
65 Uji Fungsi Kekuatan Otot menggunakan alat 137,000 105,000 242,000
66 Uji Fungsi Persepsi, Uji Fungsi Kognisi 128,000 98,000 226,000
Uji Kemampuan Fungsional (Menelan, Sensori integrasi, Sensori taktil
67 dan proprioseptif, Komunikasi, Motorik halus anak, Fungsi tangan, 161,000 123,000 284,000
Kardiorespirasi, Spirometri, AKS, Vokasional, Uji Fungsi Berkemih)
Uji Kontrol Gerak (Fungsi Eksekusi/Praksis, Lokomotor,
68 131,000 101,000 232,000
Keseimbangan, Pola Jalan)
7. GIGI DAN MULUT
7.1 GIGI DAN MULUT
1 Ablatio 429,000 329,000 758,000
2 AKTIVATOR 585,000 449,000 1,034,000
3 ALAT CEKAT CERAMIC RA/ RB SAJA 5,052,000 3,873,000 8,925,000
4 ALAT CEKAT CERAMIK RA & RB 9,166,000 7,028,000 16,194,000
5 Alat Cekat Metal RA dan RB 4,942,000 3,789,000 8,731,000
6 Alat Cekat Metal RA dan RB komplek 5,457,000 4,184,000 9,641,000
7 Alat Cekat Metal RA/ RB saja 2,644,000 1,967,000 4,611,000
8 Alveolektomi Per Regio 480,000 265,000 745,000
9 ANALISA 139,000 107,000 246,000
10 Apeksreseksi 381,000 242,000 623,000
11 Band Gigi Fraktur 198,000 152,000 350,000
12 Bongkar Crown/pin per Unit 407,000 312,000 719,000
13 Bongkar Prothesa/ Unit 547,000 420,000 967,000
14 Buka Fiksasi /Archbar 218,000 167,000 385,000
15 Buka Jahitan 103,000 75,000 178,000
16 Cetak Alginate 117,000 90,000 207,000
17 Cetak Double Impression 186,000 143,000 329,000
18 CETAK ORTHO + MODEL KERJA 117,000 90,000 207,000
19 CETAK ORTHO DOUBLE IMPRESSION+ MODEL KERJA 290,000 115,000 405,000
20 CHIN CUP 187,000 144,000 331,000
21 Composite Besar 320,000 245,000 565,000
22 Composite Kecil 233,000 178,000 411,000
23 CRIMPABLE HOOK 152,000 115,000 267,000
24 Debonding pergigi 274,000 151,000 425,000
25 Dental Implant 5,185,000 3,976,000 9,161,000
26 Eksisi Mucocele 501,000 384,000 885,000
27 Eksisi Tumor Jinak 792,000 607,000 1,399,000
28 ELIMINASI TRAUMA LOKAL 375,000 268,000 643,000
29 Enukleasi Kista 578,000 443,000 1,021,000
30 FACEBOW TRANSFER 403,000 309,000 712,000
31 FACEMASK 2,485,000 633,000 3,118,000
32 Feeding plate 449,000 344,000 793,000
33 FIXED RETAINER RA & RB 1,788,000 1,371,000 3,159,000
JASA
PELAYANAN
34 FIXED RETAINER RA / RB SAJA 1,154,000 886,000 2,040,000
35 Flexi Denture * 688,000 528,000 1,216,000
36 FOTO SLIDE 81,000 62,000 143,000
37 Full Denture (RA dan RB) 1,645,000 1,262,000 2,907,000
38 GANTI BAND/bracket BARU 167,000 92,000 259,000
39 GIC besar 162,000 124,000 286,000
40 GIC kecil 103,000 79,000 182,000
41 Gingivextomy/ Frenectomy 433,000 332,000 765,000
42 GTS Frame 557,000 427,000 984,000
43 HEAD GEAR 1,658,000 805,000 2,463,000
44 Home Bleaching * 742,000 569,000 1,311,000
45 In Office Bleaching * 1,123,000 861,000 1,984,000
46 Incisi Abses 501,000 384,000 885,000
47 Incisi Biopsi 501,000 384,000 885,000
48 Incisi/cauterisasi 501,000 384,000 885,000
49 Inj Scleret Agent 257,000 197,000 454,000
50 InLay / OnLay * 957,000 734,000 1,691,000
51 KARET INTRA ORAL 67,000 23,000 90,000
52 Kontrol 218,000 75,000 293,000
53 Kuret per Gigi 333,000 161,000 494,000
54 Labial Veneer Direct 499,000 383,000 882,000
55 Labial Veneer In Direct * 1,255,000 963,000 2,218,000
56 Mahkota All Porcelain* 986,000 757,000 1,743,000
57 Mahkota Metal* 569,000 437,000 1,006,000
58 Mahkota Sementara Direct 279,000 214,000 493,000
59 Mahkota Sementara In Direct * 331,000 254,000 585,000
60 Mocking * 188,000 145,000 333,000
61 NASO ALVEOLAR MOLDING 1,080,000 828,000 1,908,000
62 NEKROPSI 390,000 275,000 665,000
63 Obturator * 571,000 438,000 1,009,000
64 OCCLUSAL ADJUSTMENT 186,000 106,000 292,000
65 Occlusal adjustment / coronoplasty 186,000 106,000 292,000
66 Occlusal Splint 412,000 316,000 728,000
67 OD M3 IMP Kls I 926,000 711,000 1,637,000
68 OD M3 IMP Kls II 1,027,000 788,000 1,815,000
69 OD M3 IMP Kls III 1,386,000 1,063,000 2,449,000
70 Open flap debridement perregio 453,000 347,000 800,000
71 Operkulektomi 723,000 398,000 1,121,000
72 Oral Profilaksis/DHE 214,000 164,000 378,000
73 Ortho Removable RA + RB * 766,000 588,000 1,354,000
74 PAPER SURGERY 218,000 168,000 386,000
75 PASANG BRACKET/ BAND LEPAS 95,000 74,000 169,000
76 Penambahan Elemen * 165,000 127,000 292,000
77 Penambahan Wing 372,000 285,000 657,000
78 Pencabutan dgn komplikasi 425,000 327,000 752,000
79 Pencabutan dgn suntik 266,000 204,000 470,000
80 Pencabutan Gigi 266,000 204,000 470,000
81 Pencabutan Gigi dengan komplikasi 425,000 327,000 752,000
82 Pencabutan tanpa suntik 164,000 125,000 289,000
83 Pengisian 1 Saluran Akar 157,000 121,000 278,000
85 Pengisian 3 Saluran Akar/Lebih 261,000 200,000 461,000
86 Pin Casting* 348,000 267,000 615,000
87 Pin Ready Made Fiber 706,000 542,000 1,248,000
88 Pin Ready Made Metal 675,000 518,000 1,193,000
89 Pit and Fissure Sealent 152,000 117,000 269,000
90 Plat Prothesa* 415,000 319,000 734,000
91 PLAT REMOVABLE AKTIF RINGAN RA / RB SAJA 909,000 697,000 1,606,000
92 PLAT REMOVABLE AKTIF SEDANG RA / RB SAJA 964,000 739,000 1,703,000
93 POSTERIOR BITE RISER DG TAMBALAN 93,000 71,000 164,000
94 POSTERIOR BITE RISER PLAT 472,000 362,000 834,000
95 PREMEDIKASI 148,000 90,000 238,000
96 PSA 1 Saluran Akar 142,000 109,000 251,000
97 PSA 2 Saluran Akar 193,000 147,000 340,000
98 PSA 3 Saluran Akar 239,000 184,000 423,000
99 PSA One Visit 1 SA 606,000 465,000 1,071,000
100 PSA One Visit 2 SA 738,000 566,000 1,304,000
101 PSA One Visit 3 atau lebih SA 1,001,000 767,000 1,768,000
102 Pulp capping 181,000 139,000 320,000
103 QUAD HELIX 837,000 642,000 1,479,000
JASA
PELAYANAN
104 RAPID PALATAL EXPANSION 983,000 753,000 1,736,000
105 Reline/Rebase : Soft Liner 415,000 319,000 734,000
106 REMOVABLE RETAINER RA & RB 766,000 588,000 1,354,000
107 REMOVABLE RETAINER RA / RB SAJA 500,000 384,000 884,000
108 Rep. Fix dgn Arcbar ( 1 rahang ) 741,000 568,000 1,309,000
109 Rep. Fix dgn Arcbar ( RA & RB ) 986,000 757,000 1,743,000
110 Reparasi Kompleks 324,000 248,000 572,000
111 Reparasi Ringan : Reparasi Kawat 288,000 221,000 509,000
112 Reparasi Ringan : Reparasi Patah 288,000 221,000 509,000
113 Reposisi Disi TMJ 849,000 651,000 1,500,000
114 RMGIC/MRGIC besar 243,000 186,000 429,000
115 RMGIC/MRGIC kecil 169,000 130,000 299,000
116 Scalling 1 kuadran 172,000 132,000 304,000
120 Sementasi Ulang 249,000 191,000 440,000
121 SEPARASI 161,000 92,000 253,000
122 SIALOMETRI 62,000 43,000 105,000
123 Single Denture 707,000 543,000 1,250,000
124 Space Maintainer Removable 1 Gigi 249,000 191,000 440,000
125 Splinting Per Gigi 433,000 184,000 617,000
126 SURGICAL WAFER SPLINT (1 splint) 1,019,000 781,000 1,800,000
127 Tambalan Sementara 120,000 92,000 212,000
128 TEMPORARY ANCHORAGE DEVICE 993,000 761,000 1,754,000
129 TOPICAL FLOUR APPLICATION RA / RB 182,000 139,000 321,000
130 TRANS PALATAL ARCH 961,000 690,000 1,651,000
131 Windowing Exposure 711,000 545,000 1,256,000
7.2 GIGI DAN MULUT (PKG ADITYAWARMAN)
1 Ablatio 429,000 329,000 758,000
2 AKTIVATOR 585,000 449,000 1,034,000
9 ANALISA 139,000 107,000 246,000
10 Apeksreseksi 381,000 242,000 623,000
13 Bongkar Prothesa/ Unit 547,000 420,000 967,000
15 Buka Jahitan 103,000 75,000 178,000
16 Cetak Alginate 117,000 90,000 207,000
20 CHIN CUP 187,000 144,000 331,000
21 Composite Besar 320,000 245,000 565,000
22 Composite Kecil 233,000 178,000 411,000
23 CRIMPABLE HOOK 152,000 115,000 267,000
25 Dental Implant 5,185,000 3,976,000 9,161,000
26 Eksisi Mucocele 501,000 384,000 885,000
29 Enukleasi Kista 578,000 443,000 1,021,000
31 FACEMASK 2,485,000 633,000 3,118,000
32 Feeding plate 449,000 344,000 793,000
34 FIXED RETAINER RA / RB SAJA 1,154,000 886,000 2,040,000
35 Flexi Denture * 688,000 528,000 1,216,000
36 FOTO SLIDE 81,000 62,000 143,000
39 GIC besar 162,000 124,000 286,000
40 GIC kecil 103,000 79,000 182,000
JASA
PELAYANAN
42 GTS Frame 557,000 427,000 984,000
43 HEAD GEAR 1,658,000 805,000 2,463,000
44 Home Bleaching * 742,000 569,000 1,311,000
45 In Office Bleaching * 1,123,000 861,000 1,984,000
46 Incisi Abses 501,000 384,000 885,000
47 Incisi Biopsi 501,000 384,000 885,000
48 Incisi/cauterisasi 501,000 384,000 885,000
50 InLay / OnLay * 957,000 734,000 1,691,000
51 KARET INTRA ORAL 67,000 23,000 90,000
52 Kontrol 218,000 75,000 293,000
53 Kuret per Gigi 333,000 161,000 494,000
54 Labial Veneer Direct 499,000 383,000 882,000
55 Labial Veneer In Direct * 1,255,000 963,000 2,218,000
56 Mahkota All Porcelain* 986,000 757,000 1,743,000
57 Mahkota Metal* 569,000 437,000 1,006,000
60 Mocking * 188,000 145,000 333,000
62 NEKROPSI 390,000 275,000 665,000
63 Obturator * 571,000 438,000 1,009,000
66 Occlusal Splint 412,000 316,000 728,000
67 OD M3 IMP Kls I 926,000 711,000 1,637,000
68 OD M3 IMP Kls II 1,027,000 788,000 1,815,000
69 OD M3 IMP Kls III 1,386,000 1,063,000 2,449,000
71 Operkulektomi 723,000 398,000 1,121,000
74 PAPER SURGERY 218,000 168,000 386,000
77 Penambahan Wing 372,000 285,000 657,000
80 Pencabutan Gigi 266,000 204,000 470,000
86 Pin Casting* 348,000 267,000 615,000
90 Plat Prothesa* 415,000 319,000 734,000
91 PLAT REMOVABLE AKTIF RINGAN RA / RB SAJA 909,000 697,000 1,606,000
92 PLAT REMOVABLE AKTIF SEDANG RA / RB SAJA 964,000 739,000 1,703,000
94 POSTERIOR BITE RISER PLAT 472,000 362,000 834,000
95 PREMEDIKASI 148,000 90,000 238,000
96 PSA 1 Saluran Akar 142,000 109,000 251,000
97 PSA 2 Saluran Akar 193,000 147,000 340,000
98 PSA 3 Saluran Akar 239,000 184,000 423,000
99 PSA One Visit 1 SA 606,000 465,000 1,071,000
100 PSA One Visit 2 SA 738,000 566,000 1,304,000
102 Pulp capping 181,000 139,000 320,000
103 QUAD HELIX 837,000 642,000 1,479,000
104 RAPID PALATAL EXPANSION 983,000 753,000 1,736,000
107 REMOVABLE RETAINER RA / RB SAJA 500,000 384,000 884,000
109 Rep. Fix dgn Arcbar ( RA & RB ) 986,000 757,000 1,743,000
JASA
PELAYANAN
113 Reposisi Disi TMJ 849,000 651,000 1,500,000
120 Sementasi Ulang 249,000 191,000 440,000
121 SEPARASI 161,000 92,000 253,000
122 SIALOMETRI 62,000 43,000 105,000
123 Single Denture 707,000 543,000 1,250,000
128 TEMPORARY ANCHORAGE DEVICE 993,000 761,000 1,754,000
130 TRANS PALATAL ARCH 961,000 690,000 1,651,000
8. MATA (KIRANA ANUGERAH)
1 Analyzer 180,000 35,000 215,000
2 Anel Lakrimalis / Anel Test 75,000 46,000 121,000
3 Angkat jahitan blefarorafi + Paha(PO) 200,000 92,000 292,000
4 Angkat jahitan kornea (PO) 200,000 69,000 269,000
5 Angkat Jahitan Kornea 200,000 69,000 269,000
6 Angkat Jahitan Palpebra 150,000 35,000 185,000
7 Bandage Lens 90,000 35,000 125,000
8 Corneal topography 50,000 41,000 91,000
9 DBR/Biometri/Synoptophore 100,000 35,000 135,000
10 Demodex 45,000 41,000 86,000
11 Dermabrasi / Ekstraksi corpus alenium 155,000 127,000 282,000
12 Dermolipoma 530,000 391,000 921,000
13 Eksisi/insisi Tumor Konjungtiva 550,000 288,000 838,000
14 Eksisi/insisi Tumor Palpebra 550,000 230,000 780,000
15 Ekstraksi Lithiasis 90,000 92,000 182,000
16 Epilasi bulu mata 75,000 35,000 110,000
17 FFA 707,000 58,000 765,000
18 Fitting Lensa Kontak RGP 100,000 69,000 169,000
19 HESS Screen 85,000 35,000 120,000
20 Humprey 80,000 41,000 121,000
21 Indocyanine Green Angiography (ICG) 1,240,000 25,000 1,265,000
22 Indocyanine Green Angiography (ICG) + FFA 1,275,000 80,000 1,355,000
23 Injeksi Intrakameral / COA / Bubble 300,000 501,000 801,000
24 Injeksi Intrastromal Kornea 300,000 501,000 801,000
25 Injeksi Intravitreal 300,000 501,000 801,000
26 Injeksi Subkonjungtiva/ Subkutis 300,000 345,000 645,000
27 Injeksi Subtenon/ Sclera 300,000 345,000 645,000
28 Insisi Hordeolum/Kalazion/Granuloma/ Abses 190,000 115,000 305,000
29 IOL Master 85,000 75,000 160,000
30 Jahit Palpebra Ringan 450,000 115,000 565,000
31 Keratometri 70,000 35,000 105,000
32 Laser Perifer Iridektomi (LPI) 365,000 305,000 670,000
33 Laser Photocoagulation (Argon Laser) 500,000 345,000 845,000
34 Low Vision 250,000 81,000 331,000
35 Membranektomi konjungtivitis (PO) 300,000 115,000 415,000
36 Nd Yag Laser 500,000 345,000 845,000
37 Nekrotomi 100,000 81,000 181,000
38 Non Con Robo 45,000 35,000 80,000
39 OCT Scan / Visante 85,000 52,000 137,000
40 Octopus 175,000 41,000 216,000
41 Parasentese ( I/A Koagulum / Aspirasi sisa korteks) 460,000 104,000 564,000
42 Pemeriksaan Calon PPDS 160,000 140,000 300,000
43 Pemeriksaan ERG Full field 380,000 35,000 415,000
44 Pemeriksaan ERG Multifokal 400,000 58,000 458,000
45 Pemeriksaan Foto Fundus Foto Fundus Midriatikum 50,000 41,000 91,000
46 Pemeriksaan VEP Full field 380,000 35,000 415,000
47 Pemeriksaan VEP Multifokal 400,000 58,000 458,000
48 Pentacam/ Oculyzer 180,000 35,000 215,000
49 Refraksi Objektif (Streak Retinoskopi) 50,000 58,000 108,000
JASA
PELAYANAN
50 RETINOMETRI 70,000 35,000 105,000
51 Screening ROP JAKROP (Pasien Luar) 1,010,000 506,000 1,516,000
52 Screening ROP/Retcam 150,000 92,000 242,000
53 Slitlamp Examination 35,000 35,000 70,000
54 Spooling / Irigasi bola mata 120,000 46,000 166,000
55 Suntik Botox (min 3 org) 2,400,000 460,000 2,860,000
56 Tes Schimer (BUT) 30,000 12,000 42,000
57 Tonometri tonopen 180,000 35,000 215,000
58 Toppolyzer 180,000 35,000 215,000
59 UBM (pemeriksaan bilik mata depan ) 600,000 58,000 658,000
60 USG mata 160,000 115,000 275,000
9. TELINGA, HIDUNG DAN TENGGOROKAN
1 ABR Bone Kom 221,000 170,000 391,000
2 ABR Click 222,000 170,000 392,000
3 ABR dengan Sedasi 558,000 428,000 986,000
4 ABR Skrining 160,000 123,000 283,000
5 Ambil Bahan Kultur 94,000 72,000 166,000
6 Ambil Sedian Spes Kultur 94,000 72,000 166,000
7 Analisis Suara 163,000 125,000 288,000
8 Angkat Tampon Hidung Anterior 393,000 90,000 483,000
9 Angkat Tampon Hidung Posterior 393,000 78,000 471,000
10 ASSR 425,000 327,000 752,000
11 Audiometri tes gliserol 320,000 181,000 501,000
12 Audometri Nada Murni 77,000 60,000 137,000
13 Audometri Tutur 124,000 95,000 219,000
14 Benda asing Dengan Penyulit 247,000 190,000 437,000
15 Bera 141,000 108,000 249,000
16 Biopsi Endoskopi 566,000 233,000 799,000
17 Biopsi Lidah Palatum 223,000 171,000 394,000
18 Biopsi Nasofaring Rigid 833,000 288,000 1,121,000
19 Biopsi Sinus Maksila 533,000 288,000 821,000
20 Biopsi tumor hipofaring LF 348,000 267,000 615,000
21 Biopsi Tumor Kavumnasi 724,000 156,000 880,000
22 Biopsi tumor oral cavity LF 287,000 221,000 508,000
23 BOA/VRA 160,000 123,000 283,000
24 Dekanulasi 303,000 232,000 535,000
25 Dokumentasi & Tata Laksana 91,000 70,000 161,000
26 DPOAE 11 Frekuensi Komp Double 188,000 145,000 333,000
27 DPOAE Diagnostic Kom 180,000 138,000 318,000
28 DPOAE Skrining Kom 123,000 94,000 217,000
29 Ear Toilet 106,000 82,000 188,000
30 Ekstirpasi Tumor Jinak 490,000 376,000 866,000
31 Ekstraksi Benda Asing Daerah Hidung 75,000 41,000 116,000
32 Ekstraksi Benda asing Dengan RFL 566,000 268,000 834,000
33 Ekstrasi jaringan Granulasi 120,000 92,000 212,000
34 Ekstrasi kolesteatom Eksterna 285,000 219,000 504,000
35 EKSTRASI SERUMEN DI NO 134,000 102,000 236,000
36 ENG Komp 227,000 174,000 401,000
37 Fasialis N VII 105,000 81,000 186,000
38 FEES 410,000 315,000 725,000
39 FEES dengan Rehab Medik 604,000 463,000 1,067,000
40 Fleksibel esophagoscopy 566,000 288,000 854,000
41 Free Field Test 163,000 125,000 288,000
42 Ganti Cuci Kanul 208,000 160,000 368,000
43 Ganti Provok 872,000 669,000 1,541,000
44 Ganti Verban besar 246,000 189,000 435,000
45 Inj Kenacort 218,000 167,000 385,000
46 Irigasi Liang Telinga 117,000 41,000 158,000
47 Irigasi Sinus 120,000 41,000 161,000
48 Kauterisasi Hidung 401,000 220,000 621,000
49 Mapping implant koklea 185,000 143,000 328,000
50 Nasalance 472,000 288,000 760,000
51 Nasoendoskopi 408,000 118,000 526,000
52 Nasoendoskopi dengan Fiber 507,000 173,000 680,000
53 Nasoendoskopi Polpektomi 430,000 220,000 650,000
54 Nasoendoskopi Rigid 727,000 115,000 842,000
55 Nasofaringoskopi BSO 741,000 115,000 856,000
56 Nasolaringoskopi 202,000 155,000 357,000
57 OAE dengan Sedasi 421,000 323,000 744,000
58 Otomikroskopi Diagnostik 141,000 108,000 249,000
JASA
PELAYANAN
59 P 300 218,000 168,000 386,000
60 Parasintesis 210,000 161,000 371,000
61 Pasang grommet 368,000 283,000 651,000
62 Pasang NGT 206,000 158,000 364,000
63 Pasang NGT dengan Guiding 576,000 67,000 643,000
64 Pasang Tampon 412,000 63,000 475,000
65 Pasang Tampon Hidung Anterior 756,000 47,000 803,000
66 Pasang Tampon Hidung Posterior 415,000 59,000 474,000
67 Patch Paper Therapi 385,000 296,000 681,000
68 Patch Test Diagnostik 188,000 144,000 332,000
69 PEAK NASAL INSPIRATORY FLOWMETRI ( PNIF) 131,000 101,000 232,000
70 Penatalaksanaan Epistaksis 742,000 220,000 962,000
71 Pengangkatan Jaringan (Debridement) 324,000 248,000 572,000
72 Posturografi NO 448,000 242,000 690,000
73 Pseudokista 507,000 389,000 896,000
74 Reposisi Hidung 756,000 575,000 1,331,000
75 Revisi jaringan Parut 428,000 328,000 756,000
76 Rinomanometri 1,109,000 575,000 1,684,000
77 Serumen dengan penyulit 335,000 258,000 593,000
78 Sinuskopi Diagnostik 564,000 118,000 682,000
79 Sleep Nasoendoskopi 597,000 336,000 933,000
80 Speech Assesment 130,000 100,000 230,000
81 Telelaringoskopi Fleksibel 178,000 137,000 315,000
82 Telelaringoskopi Rigid 118,000 91,000 209,000
83 Terapi Bicara 132,000 101,000 233,000
84 TERAPI REHABILITASI VESTIBULER(VRT) 207,000 159,000 366,000
85 Terapi reposisi otolit 123,000 94,000 217,000
86 TES ELEKTROFISIOLOGI N. FASIALIS 215,000 164,000 379,000
87 TES KESEIMBANGAN DENGAN VIDEOOCULOGRAFI 298,000 229,000 527,000
88 Tes Keseimbangan dg Frenzel 133,000 102,000 235,000
89 Tes keseimbangan sederhana 119,000 92,000 211,000
90 TES MOTORIK N. FASIALIS 131,000 100,000 231,000
91 TES OAE (OTO ACOUSTIK EMISSION) 136,000 105,000 241,000
92 TES PSIKOAKUSTIK TINITUS 233,000 178,000 411,000
93 Tes Psikolog 134,000 104,000 238,000
94 TES SAL (sensorineural acquity level) 194,000 150,000 344,000
95 TES TOPOGRAFI N. FASIALIS 173,000 132,000 305,000
96 TES VISUAL DINAMIC ACQUTY (VDA) 309,000 237,000 546,000
97 Test Alergi Quick Test 345,000 265,000 610,000
98 Test Alergi Skin Prick Test 336,000 230,000 566,000
99 Test Alergi Stellerpoint 360,000 276,000 636,000
100 Test Sisi Decay 117,000 90,000 207,000
101 Test Sniffin 421,000 323,000 744,000
102 Timpanometri 77,000 60,000 137,000
103 Timpanometri High Frequensi 131,000 100,000 231,000
104 Tone burst Kom 222,000 170,000 392,000
105 Transnasal Esoohagoskopi 1,104,000 288,000 1,392,000
106 Vibrasi 89,000 68,000 157,000
107 Wound Toilet THT 155,000 118,000 273,000
10. BEDAH
1 Aff Arch Bar + Wire 165,000 95,000 260,000
2 Aff Catheter 95,000 45,000 140,000
6 Anuskopi 205,000 125,000 330,000
7 Anuskopi biopsi 305,000 180,000 485,000
8 Anuskopi dan diagnostik fistel perianal 415,000 180,000 595,000
9 Anuskopi dan ligasi hemoroid 370,000 225,000 595,000
10 Aspirasi Effusi Pleura 295,000 130,000 425,000
11 Aspirasi Kista 231,000 177,000 408,000
12 Biopsi Eksisi < 3 cm 673,000 516,000 1,189,000
13 Biopsi Eksisi > 3 cm 781,000 599,000 1,380,000
15 Biopsi Insisi 574,000 440,000 1,014,000
16 Businasi 419,000 131,000 550,000
17 Cabut CDL Tunneling 435,000 205,000 640,000
18 Cathinefros + Catheter 315,000 70,000 385,000
19 Cathinefros Non Catheter Bilateral 185,000 75,000 260,000
20 Cathinefros Non Catheter Lateral 155,000 65,000 220,000
JASA
PELAYANAN
21 Core Biopsi ( New Biopsi Needle) 1,285,000 275,000 1,560,000
22 Core Biopsi ( Re - Use Biopsy needle) 935,000 295,000 1,230,000
23 Core Biopsi (CT guided) 1,246,000 773,000 2,019,000
24 CTV / Gips 2' 285,000 65,000 350,000
25 CTV / Gips 4' 495,000 105,000 600,000
26 CTV / Gips 6' 910,000 195,000 1,105,000
27 Debridement luka besar ( > 11 cm) 386,000 190,000 576,000
28 Debridement luka kecil (< 5 cm) 297,000 104,000 401,000
29 Debridement luka sedang (6 cm - 10 cm) 297,000 144,000 441,000
30 Ekstirpasi Tumor Jinak 490,000 376,000 866,000
31 Endoscopy Nasolaring 185,000 75,000 260,000
32 FNAB Mamma dengan USG 390,000 230,000 620,000
33 FNAB Tiroid dengan USG 390,000 230,000 620,000
37 Hemorhoid Kontrol (Anuskopi) 415,000 319,000 734,000
38 Inj Kenacort 218,000 167,000 385,000
39 Injeksi Bleomisin 640,000 140,000 780,000
40 Insisi Abses 418,000 321,000 739,000
41 Jahit < 10 simpul 508,000 390,000 898,000
42 Jahit > 10 simpul 687,000 527,000 1,214,000
43 Kontrol CDL 295,000 125,000 420,000
44 Kontrol Celsite 430,000 95,000 525,000
45 Lobulaplasty 540,000 315,000 855,000
46 Nekrotomi & Ganti Verband 450,000 240,000 690,000
47 Pasang kateter 135,000 46,000 181,000
48 Pencabutan kateter Lumen ganda Temporer 370,000 284,000 654,000
49 Perawatan colostomi 336,000 34,000 370,000
50 Perawatan stoma Dewasa 175,000 75,000 250,000
51 Potong Flap 315,000 185,000 500,000
52 Rawat luka terbuka besar (>11 cm) 380,000 121,000 501,000
53 Rawat luka terbuka kecil (< 5 cm) 293,000 87,000 380,000
54 Rawat luka terbuka sedang (6 cm - 10 cm) 293,000 104,000 397,000
55 Rozer plasty 574,000 440,000 1,014,000
56 Sinechia Vulva 140,000 85,000 225,000
57 Sirkumsisi 450,000 230,000 680,000
58 Sklerotapi 1 Tungkai Multiple 570,000 310,000 880,000
59 Sklerotapi 1 Tungkai Sederhana 350,000 150,000 500,000
60 Sklerotapi 2 Tungkai 740,000 390,000 1,130,000
61 STSG / Skin Graft 555,000 330,000 885,000
62 STSG tanpa benang 660,000 340,000 1,000,000
11. AKUPUNTUR
1 Akuapunktur 51,000 39,000 90,000
2 Akupunktur Cupping 43,000 33,000 76,000
3 Akupunktur Daerah Mata 53,000 41,000 94,000
4 Akupunktur Kecantikan 68,000 52,000 120,000
5 Akupunktur Kepala 65,000 49,000 114,000
6 Akupunktur Laser Multilead 62,000 48,000 110,000
7 Akupunktur Laser Portable 60,000 46,000 106,000
8 Akupunktur Obesitas 71,000 54,000 125,000
9 Akupunktur Tanam Benang 122,000 58,000 180,000
10 Akupunktur Telinga 53,000 41,000 94,000
11 Akupunktur Tubuh 1 posisi 60,000 46,000 106,000
13 Pencabutan jarum 12,000 2,000 14,000
14 Sonopunktur 59,000 45,000 104,000
12. KULIT DAN KELAMIN
2 Anoskopi 216,000 115,000 331,000
3 Aspirasi Abses 137,000 106,000 243,000
4 Bedah listrik Berat 735,000 564,000 1,299,000
5 Bedah listrik Ringan 407,000 313,000 720,000
6 Bedah listrik Sedang 627,000 481,000 1,108,000
7 Bedah Mohs 1 layer (Ringan) 1,890,000 1,449,000 3,339,000
8 Bedah Mohs 2-3 layer (sedang) 3,375,000 2,588,000 5,963,000
9 Bedah Mohs 4-5 layer (erat) 5,326,000 3,450,000 8,776,000
10 Bedah Skapel Berat 1,807,000 1,386,000 3,193,000
11 Bedah skapel Ringan 1,214,000 930,000 2,144,000
12 Bedah Skapel Sedang 1,489,000 1,142,000 2,631,000
JASA
PELAYANAN
13 Biopsi Besar 1,647,000 1,263,000 2,910,000
14 Biopsi Kuku I 1,444,000 1,107,000 2,551,000
15 Biopsi Kuku II 1,791,000 1,373,000 3,164,000
16 Biopsi Ringan 1,257,000 964,000 2,221,000
17 Biopsi Sedang 1,411,000 1,082,000 2,493,000
18 BTA MH 69,000 53,000 122,000
19 Dermoskopi 84,000 64,000 148,000
20 Ekstrasi Komedo Berat 218,000 168,000 386,000
21 Ekstrasi Komedo Ringan 109,000 84,000 193,000
22 Ekstrasi Komedo Sedang 158,000 121,000 279,000
23 ENUKLEASI > 5 lesi 208,000 160,000 368,000
24 ENUKLEASI 1 - 5 lesi 137,000 106,000 243,000
25 Fat Transfer 1,105,000 426,000 1,531,000
26 Fenolisasi 75,000 58,000 133,000
27 Flap/Graft 2,261,000 1,110,000 3,371,000
28 Ganti Verban Sedang 124,000 95,000 219,000
29 Gram ganda 84,000 58,000 142,000
30 Gram tunggal 63,000 45,000 108,000
31 High Resolution Anoskopi 346,000 266,000 612,000
32 Injeksi BotoX I 1,938,000 426,000 2,364,000
33 Injeksi Botox II 3,711,000 575,000 4,286,000
34 Injeksi Filler I 2,850,000 638,000 3,488,000
35 Injeksi Filler II 5,535,000 1,001,000 6,536,000
36 Injeksi Penisilin 99,000 76,000 175,000
37 Kil I 84,000 64,000 148,000
38 Kil II 117,000 90,000 207,000
39 Kil III 139,000 107,000 246,000
40 Kil Kuku I ≤ 3 kuku 242,000 185,000 427,000
41 Kil Kuku II › 3 kuku 261,000 200,000 461,000
42 KOH + WL 60,000 26,000 86,000
43 KOH Ganda 63,000 39,000 102,000
44 KOH Tunggal 46,000 26,000 72,000
45 Kredo 90,000 69,000 159,000
46 Laser CO2 Berat 827,000 635,000 1,462,000
47 Laser CO2 Ringan 492,000 377,000 869,000
48 Laser CO2 Sedang 688,000 528,000 1,216,000
49 Laser Diode 94,000 32,000 126,000
50 Laser NdYag A 332,000 255,000 587,000
51 Laser NdYag B 427,000 328,000 755,000
52 Laser NdYag C 515,000 394,000 909,000
53 Mikro Dermabrasi 375,000 288,000 663,000
54 Miniliposuction (per area) 991,000 760,000 1,751,000
55 Nitrogen cair berat 569,000 437,000 1,006,000
56 Nitrogen cair ringan 209,000 160,000 369,000
57 Nitrogen cair sedang 389,000 299,000 688,000
58 Paket Uji Urtikaria 1,310,000 460,000 1,770,000
59 Peeling Wajah & Leher AHA - TCA 188,000 145,000 333,000
60 Peeling Wajah AHA-TCA 147,000 113,000 260,000
61 Pengambilan Specimen Gram Wanita I tanpa Spekulum 86,000 66,000 152,000
62 Pengambilan Specimen Gram Wanita II dengan Spekulum 100,000 77,000 177,000
63 Pengambulan Specimen Gram Pria 69,000 53,000 122,000
64 Perawatan Ulkus > 5 lesi 190,000 146,000 336,000
65 Perawatan Ulkus 1-5 lesi 131,000 101,000 232,000
66 Pewarnaan Gram Pria 40,000 31,000 71,000
67 Pewarnaan Gram Wanita I tanpa Spekulum 52,000 40,000 92,000
68 Pewarnaan Gram wanita II dengan Spekulum 60,000 46,000 106,000
69 Ph Vagina 56,000 43,000 99,000
70 Podopilin > 5 lesi 138,000 106,000 244,000
71 Podopilin 1-5 lesi 98,000 75,000 173,000
72 PRF ( Platelet Rich Fibrim) 165,000 127,000 292,000
73 PRP (automated) 962,000 575,000 1,537,000
74 PRP (Manual) 548,000 420,000 968,000
75 Punch Grafting I < 5 lesi 1,460,000 1,119,000 2,579,000
76 Punch Grafting II > 5 lesi 1,596,000 1,224,000 2,820,000
77 Sedimen Urine 52,000 35,000 87,000
78 Subsicion Berat 359,000 275,000 634,000
79 Subsicion Ringan 1-2 lesi 246,000 189,000 435,000
80 Subsicion Sedang 317,000 242,000 559,000
81 TCA 6-10 lesi 135,000 104,000 239,000
82 TCA 90% > 10 lesi 178,000 137,000 315,000
JASA
PELAYANAN
83 TCA 90% 1-5 lesi 96,000 74,000 170,000
84 TCA 90%> 10 cm (Giant) 163,000 125,000 288,000
85 Tes Amin 57,000 44,000 101,000
86 Tes Asam Asetat 68,000 53,000 121,000
87 Tutul KOH 50,000 39,000 89,000
88 Uji Patergi 273,000 209,000 482,000
89 Uji Penisilin I 401,000 307,000 708,000
90 uji penisilin Ulang 321,000 246,000 567,000
91 Uji Provokasi Obat (per kedatangan) 656,000 115,000 771,000
92 Uji Serum Autolog 301,000 231,000 532,000
93 Uji Tempel Obat 434,000 334,000 768,000
94 Uji Tempel Standar 610,000 403,000 1,013,000
95 Uji Tusuk Obat 331,000 254,000 585,000
96 Uji Tusuk Standar 1,154,000 345,000 1,499,000
97 UV Localized I (1-2 lesi) 69,000 30,000 99,000
98 UV Localized II (= 3 lesi) 84,000 25,000 109,000
99 UV Whole Body 79,000 26,000 105,000
13. PENYAKIT DALAM
13.1 ALERGI IMUNOLOGI
1 Patch Test Obat* 133,000 102,000 235,000
2 Provokasi histamin 400,000 307,000 707,000
3 Provokasi Vaksin 280,000 215,000 495,000
4 Skin Prick Test 237,000 173,000 410,000
5 Tes Mantoux 206,000 81,000 287,000
6 Tes obat oral 255,000 196,000 451,000
7 Tes obat suntik 490,000 376,000 866,000
8 Vaksinasi 58,000 45,000 103,000
13.2 GERIATRI
1 FRAILTY 110,000 58,000 168,000
2 IMOBILISASI 87,000 58,000 145,000
3 INNANISI 116,000 58,000 174,000
4 INSTABILITAS 101,000 58,000 159,000
13.3 GINJAL HIPERTENSI
1 ABPM (Ambulatory Blood Pressure Machine) 450,000 345,000 795,000
2 BIA 651,000 499,000 1,150,000
3 Biopsi Ginjal 917,000 703,000 1,620,000
4 HD CITO 1,598,000 1,226,000 2,824,000
5 HD sled 1,657,000 1,271,000 2,928,000
6 Hemodialisis 894,000 230,000 1,124,000
7 Pemasangan CDL Semi Permanen 3,881,000 2,976,000 6,857,000
8 Pemasangan CDL Temporary 3,911,000 2,999,000 6,910,000
9 Pencabutan kateter Lumen ganda semi permanen 370,000 284,000 654,000
Perawatan CAPD (transfer set)* tanpa bmhp --> Penggantian transfer
11 122,000 93,000 215,000
set CAPD
12 Perawatan Cateter CAPD --> perawatan exit site capd 123,000 94,000 217,000
13 USG Ginjal 190,000 146,000 336,000
13.4 HEPATOLOGI
1 Artificial Ascites 470,000 361,000 831,000
2 Aspirasi abses hati 1,699,000 1,303,000 3,002,000
3 Aspirasi Kista hati 1,739,000 1,334,000 3,073,000
4 ASPIRASI LIMPA 1,785,000 1,369,000 3,154,000
5 Aspirasi Nodul (Tumor) 2,026,000 1,554,000 3,580,000
6 ASPIRASI PANKREAS 1,960,000 1,503,000 3,463,000
7 Band Ligation / Ligasi VE 1,754,000 736,000 2,490,000
8 Biopsi Core (Guide) Tuntunan USG 2,659,000 2,039,000 4,698,000
9 BIOPSI GASTER 8,343,000 2,092,000 10,435,000
10 Biopsi hati membuta 1,552,000 1,190,000 2,742,000
11 CABUT PTBD/PIGTAIL/ PIGTAIL ASITES 573,000 439,000 1,012,000
12 Drainage Abses dengan Pigtail (Cathether) 10,564,000 8,099,000 18,663,000
13 Drainage Asites dengan Pigtail (Cathether) 7,931,000 6,081,000 14,012,000
14 Endosonografi Diagnostik 21,283,000 4,409,000 25,692,000
15 Endosonografi Terapeutik 21,586,000 4,467,000 26,053,000
16 Fibroscan 963,000 738,000 1,701,000
17 Flicker Test 98,000 75,000 173,000
18 Gastroscopy / Esofagogastroduodenoscopy EGD 1,451,000 761,000 2,212,000
19 Injeksi etanol (PEIT) 1,666,000 725,000 2,391,000
20 Injeksi Histoacryl 7,015,000 3,493,000 10,508,000
21 Injeksi PegIFN 38,000 29,000 67,000
22 Kolangioskopi 6,170,000 4,375,000 10,545,000
JASA
PELAYANAN
23 Pasang Infus 132,000 101,000 233,000
24 peritoneoscopy 1,301,000 997,000 2,298,000
25 Peritoneoscopy + biopsi 1,300,000 997,000 2,297,000
26 PICC (Pripheralty inserted central catheher) 8,857,000 374,000 9,231,000
27 PTBD (Percutaneous trans hepatic billiary drainage) 11,344,000 4,390,000 15,734,000
28 PTGBD (Percutaneous Transhepatic Gallbladder Drainage) 60" 6,764,000 4,390,000 11,154,000
29 Pungsi asites membuta 531,000 407,000 938,000
30 Pungsi asites tuntunan usg (guided) 1,082,000 434,000 1,516,000
31 REPAIR PTBD 604,000 463,000 1,067,000
32 RFA (Radio Frequency Abblation) 11,743,000 3,618,000 15,361,000
33 Stroop Test 89,000 69,000 158,000
34 USG Abdomen 232,000 178,000 410,000
35 USG Dopller 278,000 214,000 492,000
36 USG Kontras 3,330,000 725,000 4,055,000
13.5 HEMATOLOGI ONKOLOGI MEDIK
1 BMP + Biopsi SUMSUM TULANG 1,161,000 890,000 2,051,000
2 BMP SUMSUM TULANG 782,000 599,000 1,381,000
3 Flushing cellsite 233,000 173,000 406,000
4 FNAB 213,000 163,000 376,000
5 Infus obat (drip) 350,000 173,000 523,000
6 Injeksi Obat anti hemofilia 130,000 100,000 230,000
7 Injeksi Obat kemo dan Th/Hormonal 251,000 193,000 444,000
8 Injeksi Obat Khusus GCSF 130,000 100,000 230,000
9 Injeksi Obat subkutan 109,000 84,000 193,000
10 Injeksi Obat Zoladex 115,000 89,000 204,000
11 Intratekal 764,000 585,000 1,349,000
12 Kemoterapi 635,000 486,000 1,121,000
13 Kemoterapi drip 2 Hari RINAP 514,000 394,000 908,000
14 Kemoterapi drip 3 Hari RINAP 1,338,000 1,026,000 2,364,000
16 Kemoterapi IM bolus 90,000 69,000 159,000
17 Kemoterapi IV drip < 3 jam (Hidrasi 1 jam) 1/ 2 regimen 764,000 575,000 1,339,000
18 Kemoterapi IV drip > 3 jam (Hidrasi 1 jam) 3 regimen 750,000 575,000 1,325,000
19 Leukoferesis 1,382,000 863,000 2,245,000
20 Pemeiksaan Sitogenetika 1,254,000 460,000 1,714,000
21 Plasmaferesis 1,644,000 863,000 2,507,000
22 Tapping/ Plebotomi (terapeutik dan diagnostik) 228,000 175,000 403,000
23 Terapi infus non kemoterapi 215,000 164,000 379,000
24 Transfusi darah dgn filter 547,000 173,000 720,000
25 Transfusi darah tanpa filter 282,000 173,000 455,000
26 Tromboferesis 1,382,000 863,000 2,245,000
13.6 METABOLIK ENDOKTRIN
1 Aspirasi + Injeksi Ethanol Tiroid dengan Panduan USG 721,000 553,000 1,274,000
2 Aspirasi Kista Tiroid 279,000 214,000 493,000
3 Aspirasi Kista Tiroid dengan Panduan USG 424,000 325,000 749,000
4 BAJAH Kista Tiroid 309,000 237,000 546,000
5 BAJAH Kista Tiroid dengan Panduan USG 475,000 365,000 840,000
6 BAJAH Nodul Tiroid 268,000 206,000 474,000
7 BAJAH Nodul Tiroid dengan Panduan USG 410,000 315,000 725,000
8 Core Biopsi Tiroid 894,000 685,000 1,579,000
9 Edukasi Diabetes 40,000 31,000 71,000
10 Foto Retina 112,000 86,000 198,000
11 Pemeriksaan Kaki (Deteksi Dini) 98,000 75,000 173,000
12 Perawatan Kaki Non Ulkus 157,000 121,000 278,000
13 Perawatan Luka Berat 325,000 250,000 575,000
14 Perawatan Luka Sedang 255,000 196,000 451,000
15 Radio Frequency Ablation (RFA) Tiroid 9,048,000 3,450,000 12,498,000
16 USG Tiroid 180,000 138,000 318,000
13.7 PSIKOSOMATIS
1 Pemeriksaan Otonom (HRV) 128,000 99,000 227,000
2 PSIKOTERAPI PSIKOSOMATIK 124,000 95,000 219,000
13.8 PULMONOLOGI
1 Aff or Repair pleural drain 352,000 270,000 622,000
2 Argon Plasma Coagulation 6,374,000 4,888,000 11,262,000
3 Argon Plasma Coagulation dengan sedasi 7,547,000 5,787,000 13,334,000
4 Aspirasi pneumotoraks / Lung 390,000 299,000 689,000
5 Balon dilatasi saluran nafas 12,718,000 9,751,000 22,469,000
6 Balon dilatasi saluran nafas dengan sedasi 13,873,000 10,636,000 24,509,000
7 Biopsi KGB 1,075,000 825,000 1,900,000
8 Biopsi pleura 492,000 377,000 869,000
JASA
PELAYANAN
9 BRONKOKOPI + TBLB guided EBUS Radial 11,061,000 8,480,000 19,541,000
10 BRONKOKOPI + TBLB guided EBUS Radial dengan sedasi 12,233,000 9,379,000 21,612,000
11 Bronkoskopi + BAL 1,201,000 921,000 2,122,000
12 Bronkoskopi + BAL dengan sedasi 2,356,000 1,807,000 4,163,000
13 Bronkoskopi + Brushing 2,187,000 1,677,000 3,864,000
14 Bronkoskopi + Brushing + Biopsi 3,577,000 2,743,000 6,320,000
15 Bronkoskopi + Brushing + Biopsi dengan sedasi 4,749,000 3,641,000 8,390,000
16 Bronkoskopi + Brushing dengan sedasi 3,360,000 2,576,000 5,936,000
17 Bronkoskopi + TBLB Blind 3,577,000 2,743,000 6,320,000
18 Bronkoskopi + TBLB Blind dengan sedasi 4,749,000 3,641,000 8,390,000
19 Bronkoskopi + TBLB guided Fluroskopi 3,697,000 2,835,000 6,532,000
20 Bronkoskopi + TBLB guided Fluroskopi dengan sedasi 4,870,000 3,734,000 8,604,000
21 Bronkoskopi+ TBNA Konvensional 6,000,000 4,600,000 10,600,000
22 Bronkoskopi+ TBNA Konvensional dengan sedasi 7,172,000 5,499,000 12,671,000
23 CRYOTHERAPY 7,931,000 6,080,000 14,011,000
24 CRYOTHERAPY dengan sedasi 9,104,000 6,979,000 16,083,000
25 CVC 1,778,000 1,364,000 3,142,000
26 EBUS Diagnostik 2,222,000 1,703,000 3,925,000
27 EBUS Diagnostik dengan sedasi 3,394,000 2,602,000 5,996,000
28 EBUS Linier + TBNA 13,289,000 10,188,000 23,477,000
29 EBUS Linier + TBNA dengan sedasi 14,461,000 11,087,000 25,548,000
30 Ekstraksi Benda Asing 10,393,000 7,968,000 18,361,000
31 Ekstraksi Benda Asing dengan sedasi 11,566,000 8,868,000 20,434,000
32 Fibrinolitik Intrapleura 451,000 346,000 797,000
33 Fibrinolitik Lanjutan 288,000 221,000 509,000
34 FNAB /Aspirasi jarum halus KGB 286,000 220,000 506,000
35 Induksi Sputum 219,000 168,000 387,000
36 Indwelling Pleural Catheter 8,071,000 6,188,000 14,259,000
37 Indwelling Pleural Catheter dengan sedasi 9,244,000 7,087,000 16,331,000
38 Intubasi 956,000 733,000 1,689,000
39 Mantuox Tes 105,000 81,000 186,000
40 Pemasangan stent metal saluran napas 17,440,000 13,371,000 30,811,000
41 Pemasangan stent metal saluran napas dengan sedasi 18,595,000 14,257,000 32,852,000
42 Pemasangan stent silikon saluran napas 24,675,000 18,918,000 43,593,000
43 Pemasangan stent silikon saluran napas dengan sedasi 25,866,000 19,831,000 45,697,000
44 PICC 3,417,000 2,620,000 6,037,000
45 Pleurodesis Bleomycin 384,000 294,000 678,000
46 Pleurodesis Doksisiklin 454,000 348,000 802,000
47 Pleurodesis Talc 384,000 294,000 678,000
48 Pungsi Pleura / Torakosintesis 476,000 366,000 842,000
49 Small Pleural Catheter 1,485,000 1,139,000 2,624,000
50 Spirometri 149,000 114,000 263,000
51 Spirometri dengan bronkodilator 153,000 117,000 270,000
52 Terapi Oksigen 53,000 40,000 93,000
53 TORAKOSKOPI MEDIS 5,412,000 4,149,000 9,561,000
54 TORAKOSKOPI MEDIS dengan sedasi 6,585,000 5,049,000 11,634,000
55 TTB 1,099,000 843,000 1,942,000
56 TTB guided CT Scan 1,868,000 1,433,000 3,301,000
57 TTNA 485,000 371,000 856,000
58 USG Thorax/Colli 149,000 114,000 263,000
59 WSD Chest Tube Konvensional 2,234,000 1,712,000 3,946,000
60 WSD Chest Tube Seldinger 4,270,000 3,274,000 7,544,000
13.9 REUMATOLOGI
1 Injeksi intraartikular sendi besar 248,000 152,000 400,000
2 Injeksi intraartikular sendi kecil 244,000 132,000 376,000
3 Injeksi periartikuler 244,000 152,000 396,000
4 Pungsi sendi besar 250,000 158,000 408,000
5 Pungsi sendi kecil 247,000 158,000 405,000
6 USG Guide Injeksi dan Pungsi 563,000 206,000 769,000
7 USG Muskuloskeletal 243,000 152,000 395,000
13.10 GASTROENTEROLOGI
1 Businasi Hurtz (Achalasia) 371,000 284,000 655,000
2 Drainase pancreas 11,731,000 5,153,000 16,884,000
3 Ekstraksi benda asing di SCBA 2,479,000 1,901,000 4,380,000
4 Ekstraksi benda asing di SCBB 1,576,000 1,209,000 2,785,000
5 Endoscopic Mucosal Resection (EMR) Saluran Cerna Bagian Atas 5,961,000 4,570,000 10,531,000
6 Endoscopic Mucosal Resection (EMR) Saluran Cerna Bagian Bawah 5,689,000 4,362,000 10,051,000
7 Endoscopic submucosal dissection (ESD) Saluran Cerna Bagian Atas 11,310,000 8,671,000 19,981,000
JASA
PELAYANAN
Endoscopic submucosal dissection (ESD) Saluran Cerna Bagian
8 11,616,000 8,906,000 20,522,000
Bawah
9 Endoscopic Ultrasound Diagnostik 2,582,000 1,980,000 4,562,000
10 Endoscopic Ultrasound FNA 3,486,000 2,673,000 6,159,000
11 Endoscopic Ultrasound Terapeutik 12,814,000 5,153,000 17,967,000
12 Endoscopic Ultrasound Terapeutik Billiary Drainage 3,335,000 2,556,000 5,891,000
13 Endoscopt Rectrograde Cholangio Pancreatography (ERCP) diagnostik 3,287,000 2,521,000 5,808,000
14 Enteroskopi double balloon 7,300,000 4,916,000 12,216,000
15 Enteroskopi single balloon 4,772,000 3,659,000 8,431,000
16 ERCP + Spingterotomi 4,341,000 3,328,000 7,669,000
17 ERCP+ekstraksi batu including litotriptor 13,823,000 10,598,000 24,421,000
18 ERCP+ekstraksi batu sederhana 10,165,000 7,794,000 17,959,000
19 ERCP+Spingterotomi+pemasangan stent 5,593,000 4,288,000 9,881,000
20 Esofagogastroduodenoskopi 982,000 753,000 1,735,000
22 Hemostasis SCBA 2,228,000 1,708,000 3,936,000
23 Hemostasis SCBB 2,686,000 2,060,000 4,746,000
24 KOLONOSKOPI GASTROENTEROLOGI 1,569,000 1,203,000 2,772,000
25 Ligasi Varises Esofagus 656,000 503,000 1,159,000
26 Manometri 2,074,000 1,076,000 3,150,000
27 Pemasangan flocare 2,270,000 1,741,000 4,011,000
28 Pemasangan NGT dengan wire 2,510,000 1,925,000 4,435,000
29 Pemasangan NJT 5,423,000 2,605,000 8,028,000
30 Per Endoskopi Gasterotomi (PEG) 4,458,000 3,418,000 7,876,000
31 Per Oral Endoscopic Myotomy (POEM) 23,610,000 18,101,000 41,711,000
32 pH metri impedance 2,091,000 1,603,000 3,694,000
33 Pneumatic bouginasi dilatation 7,873,000 3,094,000 10,967,000
34 POLIPEKTOMI SCBA 3,517,000 2,697,000 6,214,000
35 POLIPEKTOMI SCBB 4,061,000 3,114,000 7,175,000
36 REKTOSIGMOIDOSKOPI 917,000 703,000 1,620,000
37 Savari bougie 1,781,000 987,000 2,768,000
38 Skleroterapi VE 1,597,000 1,225,000 2,822,000
39 STE Hemoroid 405,000 311,000 716,000
40 STE Histoakril 1,488,000 1,141,000 2,629,000
14. ANAK
14.1 PEDIATRI SOSIAL
1 Terapi motivational counseling remaja 127,000 98,000 225,000
2 Terapi perilaku korban kekerasan anak 127,000 98,000 225,000
3 Tindakan imunisasi biasa 117,000 35,000 152,000
Tindakan imunisasi pada kondisi penyakit khusus (HIV, atresia bilier,
4 172,000 69,000 241,000
hemofilia, dll)
5 Uji depresi anak CDI 127,000 98,000 225,000
6 Uji gangguan perilaku autisme MCHATR/F 127,000 98,000 225,000
7 Uji gangguan perilaku hiperaktivitas Conners ASQ 127,000 98,000 225,000
8 Uji gangguan psikososial SDQ 127,000 98,000 225,000
9 Uji Kemampuan Bahasa Capute Scale 202,000 155,000 357,000
10 Uji kualitas hidup PedsQL 127,000 98,000 225,000
11 Uji Perkembangan Denver 187,000 144,000 331,000
12 Uji perkembangan khusus BSID III 307,000 236,000 543,000
13 Uji psikososial remaja HEEADSSS 157,000 121,000 278,000
14.2 KARDIOLOGI
1 Ekokardiogragi 313,000 240,000 553,000
2 Elektrokardiografi 128,000 98,000 226,000
3 Suntik BPG 170,000 115,000 285,000
1 Desensitasi obat level I (durasi 12 jam)-anak 375,000 288,000 663,000
2 Desensitasi obat level II (durasi 24 jam)-anak 514,000 394,000 908,000
3 Skin prick test-anak 599,000 230,000 829,000
4 Uji provokasi makanan/ obat level I (DURASI 4 JAM)-anak 259,000 199,000 458,000
5 Uji provokasi makanan/ obat level II (durasi 6 jam)-anak 319,000 245,000 564,000
14.4 GASTRO-HEPATOLOGI
JASA
PELAYANAN
8 11,616,000 8,906,000 20,522,000
Bawah
13 Endoscopt Rectrograde Cholangio Pancreatography (ERCP) diagnostik 3,287,000 2,521,000 5,808,000
20 Esofagogastroduodenoskopi 982,000 753,000 1,735,000
22 Hemostasis SCBA 2,228,000 1,708,000 3,936,000
23 Hemostasis SCBB 2,686,000 2,060,000 4,746,000
26 Manometri 2,074,000 1,076,000 3,150,000
29 Pemasangan NJT 5,423,000 2,605,000 8,028,000
36 REKTOSIGMOIDOSKOPI 917,000 703,000 1,620,000
37 Savari bougie 1,781,000 987,000 2,768,000
38 Skleroterapi VE 1,597,000 1,225,000 2,822,000
39 STE Hemoroid 405,000 311,000 716,000
40 STE Histoakril 1,488,000 1,141,000 2,629,000
14.5 NEUROLOGI
1 BERA-anak 174,000 133,000 307,000
2 BLINK 174,000 133,000 307,000
3 EEG BEDSIDE 256,000 196,000 452,000
4 EEG DIGITAL 267,000 161,000 428,000
5 EEG LONG TERM MONITORING-anak 339,000 260,000 599,000
6 EMG Jarum 371,000 253,000 624,000
7 EMG KHS 164,000 125,000 289,000
8 EMG SPASMOFILI 157,000 121,000 278,000
9 H. Reflex 136,000 105,000 241,000
10 Lumbal Pungsi 535,000 411,000 946,000
11 OAE 214,000 104,000 318,000
12 RNS 168,000 129,000 297,000
13 Single Fiber 345,000 253,000 598,000
14 SSEP 175,000 135,000 310,000
14.6 NEFROLOGI
1 biopsi ginjal tanpa needle 1,198,000 919,000 2,117,000
2 biopsi ginjal-anak 1,551,000 1,189,000 2,740,000
3 Bladder washout 269,000 207,000 476,000
4 CIC (Continuous Intermittent Catheterization) 209,000 161,000 370,000
5 Cook/Surmisil acute peritoneal dilysis cath removal 569,000 276,000 845,000
6 CVVH/CVVHD/CVVHDF 16,075,000 8,039,000 24,114,000
7 CVVH/CVVHD/CVVHDF harian 3,894,000 2,985,000 6,879,000
8 CVVH/CVVHD/CVVHDF harian tanpa Prismasol 2,160,000 1,656,000 3,816,000
9 CVVH/CVVHD/CVVHDF tanpa Prismasol dan set 4,402,000 3,375,000 7,777,000
10 Exit site checking 170,000 130,000 300,000
11 ganti tranfer set 539,000 413,000 952,000
12 ganti tranfer set tanpa alat 356,000 274,000 630,000
13 hemodialisa anak 775,000 395,000 1,170,000
14 Injeksi eriropoietin 703,000 483,000 1,186,000
15 Injeksi eriropoietin tanpa obat 320,000 246,000 566,000
16 Injeksi pre transplantasi 287,000 104,000 391,000
17 Injeksi pre transplantasi tanpa obat 120,000 92,000 212,000
18 Intradialytic parenteral nutrition 343,000 242,000 585,000
19 Intradialytic parenteral nutrition tanpa obat 204,000 156,000 360,000
JASA
PELAYANAN
20 Pemasangan Cook peritoneal dialisis 4,838,000 1,967,000 6,805,000
21 Pemasangan Cook peritoneal dialisis tanpa alat 1,704,000 1,306,000 3,010,000
22 Pemasangan surmisil silicone peritoneal dialisis akut 4,838,000 1,967,000 6,805,000
23 Pemasangan surmisil silicone peritoneal dialisis akut tanpa alat 1,704,000 1,306,000 3,010,000
24 pemasangan temporer hemodialysis catheter 2,126,000 1,518,000 3,644,000
25 pemasangan temporer hemodialysis catheter tanpa alat 938,000 719,000 1,657,000
26 perawatan CAPD baru 570,000 437,000 1,007,000
27 perawatan CAPD baru tanpa obat 428,000 329,000 757,000
28 perawatan CAPD kronik 1,019,000 690,000 1,709,000
29 perawatan CAPD kronik tanpa obat 556,000 427,000 983,000
30 peritoneal dialisis akut harian 396,000 276,000 672,000
31 peritoneal dialisis akut harian tanpa obat 241,000 185,000 426,000
32 peritoneal dialisis kronik harian 293,000 173,000 466,000
33 peritoneal dialisis kronik harian tanpa obat 159,000 122,000 281,000
34 Peritoneal permeability check 378,000 290,000 668,000
35 Peritoneal permeability check tanpa obat 237,000 182,000 419,000
36 PET Kt/V 410,000 315,000 725,000
37 PET Kt/V tanpa obat 372,000 285,000 657,000
38 Plasmaferesis tanpa alat, tanpa prismasol 4,324,000 3,315,000 7,639,000
39 plasmaferesis-anak 11,704,000 7,970,000 19,674,000
40 reposisi cdl 400,000 307,000 707,000
41 reposisi kateter peritoneal dialisis akut cook/surmisil 1,130,000 794,000 1,924,000
42 reposisi kateter peritoneal dialisis akut cook/surmisil tanpa obat 951,000 729,000 1,680,000
43 Sedasi Sedang Anak 493,000 378,000 871,000
44 Sedasi Sedang Anak tanpa obat 345,000 265,000 610,000
45 SLED 1,657,000 1,271,000 2,928,000
46 terapi besi intravena 358,000 275,000 633,000
47 terapi besi intravena tanpa obat 241,000 185,000 426,000
48 terapi obat khusus cyclophosphamide intravena 450,000 345,000 795,000
49 terapi obat khusus cyclophosphamide intravena tanpa obat 323,000 247,000 570,000
50 terapi obat khusus IV Ig immunoglobulin intravena 479,000 367,000 846,000
51 terapi obat khusus IV Ig immunoglobulin intravena tanpa obat 365,000 281,000 646,000
52 terapi obat khusus metilprednisolon pulse harian 367,000 282,000 649,000
53 terapi obat khusus metilprednisolon pulse harian tanpa obat 292,000 224,000 516,000
54 thrombolytics for dialysis catheter fibrin occlusion dengan heparin 542,000 416,000 958,000
55 thrombolytics for hemodialys catheter fibrin occlusion 828,000 635,000 1,463,000
56 thrombolytics for hemodialys catheter fibrin occlusion tanpa obat 499,000 383,000 882,000
57 thrombolytics for peritoneal dialysis catheter fibrin occlusion 666,000 276,000 942,000
thrombolytics for peritoneal dialysis catheter fibrin occlusion tanpa
58 317,000 244,000 561,000
obat
14.7 NUTRISI DAN METABOLIK
1 Asuhan nutrisi enteral dasar 126,000 97,000 223,000
2 Asuhan nutrisi enteral khusus 314,000 115,000 429,000
3 Asuhan nutrisi parenteral 1,363,000 230,000 1,593,000
4 Terapi sulih enzim 659,000 505,000 1,164,000
14.8 ENDOKTRINOLOGI
1 Desmopresin (DDAVP) test 353,000 230,000 583,000
2 Program inisiasi terapi insulin pada pasien baru DM Tipe-1 447,000 343,000 790,000
3 Protokol pemberian asam zoledronat pada Osteogenesis Imperfecta 402,000 308,000 710,000
4 Psikoterapi / psikoedukasi pada DM 191,000 146,000 337,000
5 Tindakan injeksi GnRH analog / Leuprorelin acetate (Tapros®) 698,000 173,000 871,000
6 Tindakan injeksi testosteron ester (Sustanon®) 192,000 147,000 339,000
7 Tindakan uji stimulasi GH 568,000 436,000 1,004,000
8 Tindakan uji stimulasi HCG 267,000 173,000 440,000
9 Uji haus (water deprivation test) - 15 jam 482,000 370,000 852,000
10 Uji haus (water deprivation test) - 8 jam 392,000 301,000 693,000
11 Uji stimulasi hormon pertumbuhan (clonidine test) 542,000 416,000 958,000
14.9 RESPIROLOGI
1 Argon Plasma Coagulation-anak 7,623,000 5,844,000 13,467,000
2 Bronkoskopi 1,209,000 927,000 2,136,000
3 Bronkoskopi dan biopsi 8,731,000 1,380,000 10,111,000
4 Bronkoskopi dan brush 2,003,000 1,380,000 3,383,000
5 Bronkoskopi dan transbronchial nodul aspiration 2,885,000 1,380,000 4,265,000
6 Cryotherapy-anak 3,646,000 2,796,000 6,442,000
7 Ekstraksi benda asing-anak 13,323,000 10,214,000 23,537,000
8 Induksi sputum-anak 180,000 115,000 295,000
9 Pemasangan mini-WSD certofix 1,065,000 817,000 1,882,000
10 Poligrafi 570,000 437,000 1,007,000
11 Polisomnografi 833,000 638,000 1,471,000
JASA
PELAYANAN
12 Pungsi cairan pleura 474,000 363,000 837,000
13 Rinofaringolaringoskopi 484,000 371,000 855,000
14 Uji fungsi paru / spirometri anak 646,000 173,000 819,000
15 Uji fungsi paru pre- dan post- bronkodilator anak 674,000 288,000 962,000
16 Uji keringat atau sweat test 1,830,000 288,000 2,118,000
14.10 HEMATOLOGI
1 Bone marrow puncture anak **** 744,000 570,000 1,314,000
Injeksi Obat Khusus Faktor Pembekuan (Koate/Octanine) IV tanpa
2 134,000 104,000 238,000
obat ***
3 Injeksi Obat Khusus GCSF ** 129,000 99,000 228,000
4 Kemoterapi drip 24 jam (durasi 24 jam) dan hidrasi 24 jam * 294,000 225,000 519,000
5 Kemoterapi Intratekal **** 473,000 362,000 835,000
6 Kemoterapi IV bolus * 155,000 120,000 275,000
7 Kemoterapi IV drip 12 jam (durasi 12 jam) dan hidrasi 6 jam * 235,000 181,000 416,000
8 Kemoterapi IV drip 4 jam (durasi 4 jam) * 192,000 147,000 339,000
9 Kemoterapi SC Leunase * 129,000 99,000 228,000
10 Leukoferesis anak (durasi 6 jam) 1,244,000 953,000 2,197,000
Perawatan celsite (chemo port) (tidak termasuk filter leukosit
11 331,000 173,000 504,000
IMUGARD III terumo dan labu darah)
12 Plasmaferesis anak (durasi 6 jam) 1,244,000 953,000 2,197,000
13 Sedasi sedang anak (untuk kemoterapi IT dan BMP) **** 384,000 294,000 678,000
Transfusi Darah di rawat jalan (tidak termasuk filter leukosit
14 270,000 115,000 385,000
15. INSTALASI PELAYANAN TERPADU ONKOLOGI
RADIASI
RAWAT JALAN - - -
1 Prosedur Radioterapi 1,636,000 808,000 2,444,000
RAWAT INAP - - -
1 Radioterapi Ringan 8,590,000 4,235,000 12,825,000
2 Radioterapi Sedang 11,083,000 5,463,000 16,546,000
3 Radioterapi Berat 13,518,000 6,663,000 20,181,000
16. ORTHOPEDI
3 Aspirasi Kista 231,000 177,000 408,000
4 Aspirasi Sendi 167,000 129,000 296,000
5 Biopsi Eksisi < 3 cm 673,000 516,000 1,189,000
6 Biopsi Eksisi > 3 cm 781,000 599,000 1,380,000
7 Biopsi Insisi 574,000 440,000 1,014,000
8 Bone Marrow Aspiration 1,735,000 524,000 2,259,000
9 Buka body jacket 225,000 173,000 398,000
10 Buka gips atas lutut 212,000 162,000 374,000
11 Buka Gips atas siku 212,000 162,000 374,000
12 Buka Gips bawah lutut 178,000 137,000 315,000
13 Buka Gips bawah siku 178,000 137,000 315,000
14 Buka hip spica 225,000 173,000 398,000
15 Cabut K-wire / pin dengan anestesi lokal 528,000 405,000 933,000
20 Ekstraksi corpus alienum 528,000 405,000 933,000
24 infus bisphosphonate 1,711,000 331,000 2,042,000
25 Injeksi Intraarticular 330,000 253,000 583,000
Injeksi intralesional (tendon sheath / tendon insertion / nerve
26 343,000 263,000 606,000
compression)
27 Insisi Abses 418,000 321,000 739,000
28 Jahit < 10 simpul 508,000 390,000 898,000
29 Jahit > 10 simpul 687,000 527,000 1,214,000
30 Pemasangan body jacket 493,000 378,000 871,000
31 Pemasangan Gips atas lutut tanpa reposisi 391,000 300,000 691,000
32 Pemasangan Gips atas siku tanpa reposisi 313,000 240,000 553,000
33 Pemasangan Gips bawah lutut tanpa reposisi 304,000 233,000 537,000
34 Pemasangan Gips bawah siku tanpa reposisi 409,000 314,000 723,000
35 Pemasangan hip spica 1,167,000 419,000 1,586,000
36 Pemasangan Slab 325,000 250,000 575,000
37 pemasangan total contact cast 388,000 298,000 686,000
JASA
PELAYANAN
41 Reposisi dan pemasangan gips atas lutut dengan lokal anestesi 609,000 467,000 1,076,000
42 Reposisi dan pemasangan gips atas siku dengan lokal anestesi 572,000 438,000 1,010,000
43 Reposisi dan pemasangan gips bawah lutut dengan lokal anestesi 519,000 398,000 917,000
44 Reposisi dan Pemasangan Gips bawah siku dengan lokal anestesi 481,000 369,000 850,000
45 Rozer plasty 574,000 440,000 1,014,000
46 Serial plaster / ponseti (<3bln) (Single) 277,000 213,000 490,000
47 Serial plaster / ponseti (>4th / relaps) (Single) 526,000 404,000 930,000
48 Serial plaster / ponseti (1th - 4th) (Single) 408,000 313,000 721,000
49 Serial plaster / ponseti (3bln - 1th) (Single) 349,000 268,000 617,000
50 Skin Traction 236,000 182,000 418,000
51 Strapping 336,000 258,000 594,000
17. INSTALASI PELAYANAN JANTUNG TERPADU
1 Doppler Vaskular 339,000 260,000 599,000
2 Doppler Vaskular 2 tungkai/carotis 632,000 484,000 1,116,000
3 Echocardiography 436,000 335,000 771,000
4 EKG 66,000 51,000 117,000
5 Holter Monitoring 24 jam 828,000 635,000 1,463,000
6 Holter Monitoring 48 jam 1,578,000 1,210,000 2,788,000
7 klinik gagal jantung 155,000 118,000 273,000
8 Programming PPM 115,000 89,000 204,000
9 Rehabilitasi Medik Fase II / Club Senam jantung 131,000 100,000 231,000
10 Stress Echo Debutamin 672,000 515,000 1,187,000
11 Trans Esofageale Echo (TEE) 414,000 317,000 731,000
12 Treadmill Test 223,000 171,000 394,000
18. UPT LUKA BAKAR
1 Pasang Folley Catheter 123,000 92,000 215,000
2 Perawatan Luka Bakar dengan sedasi 2,801,000 2,147,000 4,948,000
3 Perawatan Luka bakar di wajah 130,000 100,000 230,000
4 Perawatan Luka Bakar tanpa sedasi dengan atau tanpa STSG 557,000 427,000 984,000
5 Thakheostomy 662,000 508,000 1,170,000
6 WSD 564,000 432,000 996,000
19. UPT HIV
1 administrasi obat 27,000 - 27,000
2 Denda kartu hilang 36,000 - 36,000
3 Pemeriksaan Viral Load 578,000 135,000 713,000
4 Pemeriksaan Viral Load (Donasi) 165,000 143,000 308,000
5 Pengambilan Resep Obat pasien Luar RSCM 20,000 - 20,000
20. INSTALASI GIZI
Penyuluhan Gizi EDUKASI GIZI / SEMINAR PER ORANG PER
1 100,000 10,000 110,000
KEGIATAN
2 Pengkajian Awal Asuhan Gizi & Pengkajian Ulang Asuhan Gizi 57,000 6,000 63,000
21. GIZI KLINIK
1 Food Recall 24 H notes 46,000 36,000 82,000
2 Interpretasi bioelectric impedance 36,000 28,000 64,000
3 Interpretasi bioelectric impedance pada pasien bedridden 306,000 235,000 541,000
4 Kalorimetri indirek 278,000 213,000 491,000
5 Pengukuran knee height 43,000 33,000 76,000
6 Pengukuran lingkar pinggang/panggul 16,000 12,000 28,000
7 Pengukuran MUAC (Mid Upper Arm Circumference) 16,000 12,000 28,000
8 Status hidrasi (Urine Specific Gravity) 16,000 13,000 29,000
9 Uji Kekuatan Genggaman Tangan dengan Handgrip Dynamometer 42,000 32,000 74,000
PELAYANAN MEDIS
7. OPERATIF
JASA
PELAYANAN
1. KEBIDANAN DAN PENYAKIT KANDUNGAN
1 Amnio Reduksi 2,175,000 1,668,000 3,843,000
2 D/C (Diagnostic Curretage) 2,126,000 1,631,000 3,757,000
3 Debulking 11,899,000 9,123,000 21,022,000
4 Eksisi Septum 12,107,000 9,283,000 21,390,000
5 EXTERPASI KISTA BARTHOLIN 2,908,000 2,230,000 5,138,000
6 Extirpasi Polip 2,792,000 2,140,000 4,932,000
7 Fistuloraphy 12,541,000 9,615,000 22,156,000
8 Geburt, Bartholin, Gartner 8,908,000 4,025,000 12,933,000
9 Ginekologi Jinak (Miomektomi) 7,800,000 5,980,000 13,780,000
10 HEMATOM VAGINA 2,908,000 2,230,000 5,138,000
11 HEMATOM VULVA 2,908,000 2,230,000 5,138,000
12 Histerektomi Radikal 12,253,000 9,394,000 21,647,000
13 Histerektomi Total 7,800,000 5,980,000 13,780,000
14 INSISI LABIA 5,848,000 4,484,000 10,332,000
15 Kistektomi 7,800,000 5,980,000 13,780,000
16 Konisasi Serviks 6,707,000 4,025,000 10,732,000
17 Kromotubasi 6,876,000 5,272,000 12,148,000
18 Kuret Mola 1,725,000 1,323,000 3,048,000
19 Kuret Tajam / Kuret Missed abortion 1,876,000 1,439,000 3,315,000
20 Laparatomi eksplorasi 6,876,000 5,272,000 12,148,000
21 Laparoscopic Sacro Colposuspension 17,410,000 13,283,000 30,693,000
Laparoskopi Ginekologi Jinak / Salphingoovarektomi Unilateral
22 13,459,000 10,319,000 23,778,000
(SOU)
23 Laparoskopi Histerektomi/Kistektomi/ Miomektomi/Radikal 13,459,000 10,319,000 23,778,000
24 Laparoskopi KET (Kehamilan Ektopik Terganggu) 7,845,000 6,015,000 13,860,000
25 Laparotomi Histerektomi 7,800,000 5,980,000 13,780,000
26 Repair Ruptura Perineum Lama 12,955,000 9,933,000 22,888,000
27 Reseksi Adenomiosis 6,876,000 5,272,000 12,148,000
28 Salphingoovarektomi Bilateral 7,800,000 5,980,000 13,780,000
29 Salphingoovarektomi Dextra 7,800,000 5,980,000 13,780,000
30 Salphingoovarektomi Sinistra 7,800,000 5,980,000 13,780,000
31 Sectio Caesarea 7,986,000 6,123,000 14,109,000
32 Sectio Caesarea + Histerektomi Total 9,069,000 6,953,000 16,022,000
33 Surgical Staging 11,929,000 9,146,000 21,075,000
Total Vaginal Hysterectomy + Anterior Kolporaphy + Posterior
34 Kolpoperineuraphy + Sacro Spinosus Fiksasi + Kolpokleisis + Sacro 13,710,000 10,511,000 24,221,000
Spinosus Histeropexy, Manchester Fortegyl
35 Transvaginal Mesh 26,775,000 13,283,000 40,058,000
36 TVT (Trans Vaginal Tape), TOT (Trans Obturator Tape) 28,742,000 13,283,000 42,025,000
37 Vaginoplasty 12,519,000 9,598,000 22,117,000
38 Vulvektomi Radikal 11,398,000 8,739,000 20,137,000
1.2 KEBIDANAN DAN PENYAKIT KANDUNGAN (KINTANI)
1 Histereskopi diagnostik 1,045,000 802,000 1,847,000
2 Histereskopi operatif 2,097,000 1,608,000 3,705,000
3 Histeroskopi Biopsi Uterus 1,518,000 614,000 2,132,000
4 IBS Shaver 1,221,000 936,000 2,157,000
5 Insisi/Eksisi 2,133,000 1,335,000 3,468,000
6 Laparascopi Ouklusi Tuba Anestesi Lokal ( LOTAL ) 1,589,000 1,019,000 2,608,000
7 LAPARASKOPI 2,887,000 1,318,000 4,205,000
8 Mini Laparatomi 2,137,000 1,335,000 3,472,000
2. BEDAH SYARAF
1 Angiografi Diagnostik Craniospinal 6,515,000 4,994,000 11,509,000
2 Arterial occlusion - sacrifice 11,550,000 18,263,000 29,813,000
3 Ballon test occlusion 10,450,000 13,046,000 23,496,000
4 Biopsi Saraf Kutaneus / Otot 3,525,000 2,703,000 6,228,000
5 Blok Saraf Tepi 1,031,000 791,000 1,822,000
6 Carotid/Vertebral Arteri Stenting 12,650,000 15,813,000 28,463,000
7 Carotid/Vertebral Arteri Stenting dengan Anestesi 12,650,000 20,873,000 33,523,000
8 CCF kompleks - ballooning/coil 11,550,000 18,263,000 29,813,000
9 CCF simpel - ballooning 11,550,000 15,655,000 27,205,000
10 Coiling Aneurisma (stent-assisted atau balloon-asisted) 14,850,000 26,091,000 40,941,000
JASA
PELAYANAN
11 Coiling Aneurisma kompleks (>5 coil) 13,750,000 20,873,000 34,623,000
12 Coiling Aneurisma simpel (3-5 coil) 12,650,000 18,263,000 30,913,000
13 Complicated Functional Neuro P.Paraverteb / Visceral Block 10,595,000 8,124,000 18,719,000
14 Complicated Functional Neuro Percutaneus Kordotomi 13,742,000 10,536,000 24,278,000
15 Dekompresi Saraf Tepi 10,339,000 7,927,000 18,266,000
DSA ( DIGITAL SUBTRACTING ANGIOGRAM ) 4 vessel -
16 11,050,000 7,008,000 18,058,000
Craniocervical
17 11,700,000 9,251,000 20,951,000
Craniocervical dengan Anestesi
18 12,350,000 9,344,000 21,694,000
Craniocervical
19 13,000,000 12,334,000 25,334,000
20 DSA ( DIGITAL SUBTRACTING ANGIOGRAM ) Superselektif 12,350,000 9,344,000 21,694,000
21 DSA ( DIGITAL SUBTRACTING ANGIOGRAM )-Spinal 12,350,000 9,344,000 21,694,000
DSA ( DIGITAL SUBTRACTING ANGIOGRAM )-Spinal dengan
22 13,000,000 12,334,000 25,334,000
Anestesi
23 Eksterpasi Tumor Scalp / Cranium Ligasi Carotis Ext / Int 9,096,000 6,974,000 16,070,000
24 Eksterpasi Tumor Scalp / Cranium Saraf Tepi 8,451,000 6,479,000 14,930,000
25 Embolisasi brain AVM kompleks kombinasi transarterial-transvena 14,850,000 26,091,000 40,941,000
26 Embolisasi brain AVM kompleks transarterial 13,750,000 20,873,000 34,623,000
27 Embolisasi brain AVM simpel 11,550,000 15,655,000 27,205,000
28 Embolisasi Cerebral-Glue 11,550,000 15,655,000 27,205,000
29 Embolisasi perioperatif 11,550,000 15,655,000 27,205,000
30 Embolisasi spinal AVM/AVF 13,750,000 20,873,000 34,623,000
31 Flow Diverter Stent 15,950,000 31,309,000 47,259,000
32 Fusi Corpus Vertebra Anterior Approach 19,007,000 14,572,000 33,579,000
33 Fusi Corpus Vertebra Posterior Approach 14,089,000 10,802,000 24,891,000
34 Gamma Knife 125,017,000 12,000,000 137,017,000
35 Intrakranial angioplasti 13,750,000 20,873,000 34,623,000
36 Koreksi Impresi Fraktur < 1 jam 13,127,000 10,064,000 23,191,000
37 Koreksi Impresi Fraktur > 1 jam 14,489,000 11,109,000 25,598,000
38 Kranioplasti < 4 jam 11,666,000 8,945,000 20,611,000
39 Kranioplasti > 4 jam 16,493,000 12,645,000 29,138,000
40 Kraniotomi bedah mikro < 4 jam 13,772,000 10,559,000 24,331,000
41 Kraniotomi bedah mikro > 4 jam 16,533,000 12,675,000 29,208,000
42 Kraniotomi dengan Endoskopi 16,183,000 12,407,000 28,590,000
43 Kraniotomi/Trepanasi Konvensional < 240 mnt 13,658,000 10,472,000 24,130,000
44 Kraniotomi/Trepanasi Konvensional > 240 mnt 15,048,000 11,537,000 26,585,000
45 Laminektomi Kompleks 15,628,000 11,982,000 27,610,000
46 Laminektomi Sederhana 13,583,000 10,413,000 23,996,000
47 Neurektomi / Neurolise 11,313,000 8,673,000 19,986,000
48 Neuroplasty/Anastomosis/Explorasi Bedah mikro Bedah Konvensional 11,581,000 8,879,000 20,460,000
Neuroplasty/Anastomosis/Explorasi Bedah mikro N.Cranialis/Spinalis
49 17,645,000 13,529,000 31,174,000
Perifer
Neuroplasty/Anastomosis/Explorasi Bedah mikro Plexus
50 17,500,000 13,417,000 30,917,000
Brachialis/LbSacralis
51 Pemasangan Fiksasi Interna 12,726,000 9,757,000 22,483,000
52 Pemasangan Traksi Cervical / dan pemasangan HaloVest 7,847,000 6,016,000 13,863,000
53 Pemasangan VPS 12,705,000 9,741,000 22,446,000
54 Punksi Cairan Otak Boorhole 5,035,000 3,861,000 8,896,000
55 Rekonstruksi Menigokel Spina Bifida 13,888,000 10,648,000 24,536,000
56 Rekonstruksi Meningokel Kranial (arterior/Posterior) 11,571,000 8,871,000 20,442,000
57 Simple Functional Nsurgery Perc Facet Denervation dll 10,305,000 7,901,000 18,206,000
58 Simple Functional Nsurgery Percutaneus Rhizotomy / PRGR 9,436,000 7,235,000 16,671,000
59 Stenting Intrakranial-Sirkulasi anterior 14,850,000 26,091,000 40,941,000
60 Stenting Intrakranial-Sirkulasi posterior 14,850,000 26,091,000 40,941,000
61 Transarterial intracranial therapy 11,550,000 12,413,000 23,963,000
62 Trombektomi Stroke 12,650,000 20,873,000 33,523,000
63 Trombolisis Intraarteri 10,450,000 7,906,000 18,356,000
64 Tumor Spinal daerah Cervikal 16,443,000 12,606,000 29,049,000
65 Tumor Spinal daerah Kraniospinal 20,071,000 15,388,000 35,459,000
66 Tumor Spinal daerah Torakolumbal 14,933,000 11,449,000 26,382,000
67 Ventrikulostomi / VE Drainage 7,710,000 5,911,000 13,621,000
68 Wada test 10,450,000 10,436,000 20,886,000
3. UROLOGI
1 ADRENALEKTOMI 18,229,000 12,966,000 31,195,000
JASA
PELAYANAN
2 Aff DJ Local 1,282,000 983,000 2,265,000
3 Aff DJ Narkose 3,698,000 2,836,000 6,534,000
4 Aff Kateter Per Flouroskopi Lokal 1,416,000 942,000 2,358,000
5 Aff Kateter Per Flouroskopi Narkose 4,235,000 1,824,000 6,059,000
6 APG 1,186,000 910,000 2,096,000
7 APG Narkose 4,235,000 1,824,000 6,059,000
8 APG Perkutan Punksi Lokal 1,416,000 942,000 2,358,000
9 APG Perkutan Punksi Narkose 4,235,000 1,824,000 6,059,000
10 AUGMENTASI BULI 16,910,000 12,965,000 29,875,000
11 Biopsi Ginjal Perkutan 3,442,000 2,639,000 6,081,000
12 Biopsi Ginjal Terbuka 5,394,000 4,135,000 9,529,000
13 Biopsi Mukosa Buli Narkose 5,836,000 3,039,000 8,875,000
14 Biopsi Penis Lokal 1,931,000 1,447,000 3,378,000
15 Biopsi Penis Narkose 5,836,000 3,039,000 8,875,000
16 Biopsi Prostat (Narkose) 3,443,000 2,639,000 6,082,000
17 Biopsi Prostat Lokal 1,931,000 1,447,000 3,378,000
18 Biopsi Tepi Fistel Narkose 5,836,000 3,039,000 8,875,000
19 Biopsi Testis 3,391,000 2,600,000 5,991,000
20 BLADDER NECK REKONSTRUKSI 11,794,000 8,103,000 19,897,000
21 BNI (narkose) 6,376,000 4,889,000 11,265,000
22 Boari Flap 11,794,000 8,103,000 19,897,000
23 Buccal Mucosal Graft 6,242,000 1,403,000 7,645,000
24 CYTOREDUCTIVE NEFREKTOMI 18,229,000 12,966,000 31,195,000
25 Debridemen gangren Fournier 6,447,000 4,943,000 11,390,000
26 Dilatasi/ Kalibrasi Uretra Lokal 1,416,000 942,000 2,358,000
27 Dilatasi/ Kalibrasi Uretra Narkose 4,235,000 1,824,000 6,059,000
28 DISEKSI KELENJAR GETAH BENING INGUINAL 11,794,000 8,103,000 19,897,000
29 Divertikulektomi vesika narkose 7,297,000 5,595,000 12,892,000
30 DONOR GINJAL LLDN 32,582,000 43,131,000 75,713,000
31 Donor Transplant dengan operasi terbuka (Khusus III+khusus II) 40,574,000 31,586,000 72,160,000
32 Dorsumsisi Lokal 1,416,000 942,000 2,358,000
33 Dorsumsisi Narkose 4,235,000 1,824,000 6,059,000
34 Drainage periureter (narkose) 5,547,000 4,253,000 9,800,000
35 Drainase Abses Perinefrik/ Paranefrik Narkose 6,523,000 3,647,000 10,170,000
36 Drainase Urinoma Narkose 6,523,000 3,647,000 10,170,000
37 Eksisi condiloma komplek 11,079,000 7,091,000 18,170,000
38 Eksisi Divertikel Uretra 9,547,000 5,065,000 14,612,000
39 Eksisi Karunkula 3,323,000 2,547,000 5,870,000
40 Eksisi Karunkula Narkose 5,836,000 3,039,000 8,875,000
41 Eksisi pibrosis (narkose) 4,781,000 3,666,000 8,447,000
42 Eksisi Remant Duktus 18,229,000 12,966,000 31,195,000
43 Eksisi Webbed Penis 9,671,000 7,415,000 17,086,000
44 Eksplorasi testis (mikro surgery) narkose 6,285,000 4,819,000 11,104,000
45 Endopyelolitotomi interna 11,079,000 7,091,000 18,170,000
46 Epididimimovasostomi narkose 10,128,000 7,765,000 17,893,000
47 Evakuasi Hematom 10,548,000 6,077,000 16,625,000
48 Ext. Pyelolitotomi (narkose) 7,725,000 5,923,000 13,648,000
49 Fistula enterovesika (nakose) 4,336,000 3,325,000 7,661,000
50 Full Thickness Skin 9,547,000 5,065,000 14,612,000
51 Ganti Nefrostomi Lokal 3,289,000 2,171,000 5,460,000
52 Ganti nefrostomi perkutan 11,079,000 7,091,000 18,170,000
53 Glanduloplasty 9,547,000 5,065,000 14,612,000
54 HEMINEFREKTOMI 18,229,000 12,966,000 31,195,000
55 Hidrokel ligasi tinggi narkose 5,625,000 4,313,000 9,938,000
56 Hidrokelektomi (narkose) 3,786,000 2,903,000 6,689,000
57 Ileal Conduit 17,645,000 13,529,000 31,174,000
58 IMPLANT ARTIFICIAL SFINGTER 18,229,000 12,966,000 31,195,000
59 Insersi UK 10,548,000 6,077,000 16,625,000
60 Insisi Drainage Abses Lokal 1,416,000 942,000 2,358,000
61 Insisi Drainage Abses Narkose 4,235,000 1,824,000 6,059,000
62 Koreksi pria prismus (winter prosedur narkose) 5,142,000 3,942,000 9,084,000
63 Laparaskopi diagnostik 11,079,000 7,091,000 18,170,000
64 Laparatomi Eksplorasi 10,548,000 6,077,000 16,625,000
65 LAPAROSKOPI ADRENALEKTOMI 34,470,000 14,913,000 49,383,000
66 LAPAROSKOPI BIOPSI GONAD 16,994,000 8,103,000 25,097,000
67 LAPAROSKOPI DISEKSI KELENJAR GETAH BENING PELVIS 34,470,000 14,913,000 49,383,000
68 LAPAROSKOPI EKSISI REMNANT DUKTUS MULLERI 16,994,000 8,103,000 25,097,000
69 LAPAROSKOPI GONADEKTOMI 16,994,000 8,103,000 25,097,000
70 LAPAROSKOPI NEFROURETREKTOMI 34,470,000 14,913,000 49,383,000
JASA
PELAYANAN
71 LAPAROSKOPI ORCHIDOPEKSI 16,994,000 8,103,000 25,097,000
72 LAPAROSKOPI REPAIR FISTEL 34,470,000 14,913,000 49,383,000
73 LAPAROSKOPI SISTEKTOMI RADIKAL 34,470,000 14,913,000 49,383,000
74 Ligasi vena spermatika (mikro surgery narkose) 6,245,000 4,787,000 11,032,000
75 LITHOTRIPSI BATU BULI (narkose) 6,200,000 4,753,000 10,953,000
76 Longitudinal nefrolothotomi 4,248,000 3,257,000 7,505,000
77 Meatoplasty Lokal 1,416,000 942,000 2,358,000
78 Meatoplasty Narkose 4,235,000 1,824,000 6,059,000
79 Meatotomi Lokal 1,416,000 942,000 2,358,000
80 Meatotomy 4,001,000 2,697,000 6,698,000
81 MESA-TESA (narkose) 6,638,000 5,089,000 11,727,000
82 Mitrofanoff 14,345,000 10,997,000 25,342,000
83 Monti Procedure 14,351,000 11,002,000 25,353,000
84 Nefropeksi 10,548,000 6,077,000 16,625,000
85 Nefrostomi perkutan (bius) 6,418,000 4,921,000 11,339,000
86 Nefrostomi perkutan Lokal 3,192,000 2,447,000 5,639,000
87 Nefrostomi terbuka/ permanen 10,548,000 6,077,000 16,625,000
88 Nefroureterektomi 19,359,000 14,842,000 34,201,000
89 Nefrrektomi partial/Simple nefrektomi 12,706,000 9,742,000 22,448,000
90 NEOBLADDER 18,229,000 12,966,000 31,195,000
91 Open Radikal Nefrektomi 14,718,000 4,675,000 19,393,000
92 OPERASI KOREKSI STRESS INCONTINENCE 11,794,000 8,103,000 19,897,000
93 OPERASI PROSTHESIS PENIS 18,229,000 12,966,000 31,195,000
94 Operasi Sistokel 11,079,000 7,091,000 18,170,000
95 Orchidektomi ligasi tinggi/ hernia ligasi tinggi 9,547,000 5,065,000 14,612,000
96 Orchidektomi local 1,541,000 1,182,000 2,723,000
97 Orchidektomi narkose 4,791,000 3,673,000 8,464,000
98 Orchidopexy bilateral 3,960,000 3,036,000 6,996,000
99 Orchudopexy (narkose) 7,823,000 5,998,000 13,821,000
100 Orthoplasty 10,271,000 7,875,000 18,146,000
101 Otis (narkose) 1,398,000 1,072,000 2,470,000
102 Pasang DJ Local/Ganti DJ stent lokal 1,541,000 1,182,000 2,723,000
103 Pasang DJ Narkose/Ganti DJ Stent narkose 1,891,000 1,450,000 3,341,000
104 Pasang Kateter tenchoff untuk CAPD Narkose 6,523,000 3,647,000 10,170,000
105 PASANG/ REVISI KATETER TENCKHOFF PER LAPAROSKOPI 16,994,000 8,103,000 25,097,000
106 PCNL (narkose) 8,333,000 6,389,000 14,722,000
107 PCNL DENGAN LASER 18,229,000 12,966,000 31,195,000
108 Penektomi 10,548,000 6,077,000 16,625,000
109 Perasi Peyronie 7,186,000 5,510,000 12,696,000
110 Percutaneouscopy Vesikolithotripsi 11,079,000 7,091,000 18,170,000
111 Perineostomi 11,079,000 7,091,000 18,170,000
112 Pielokalikotomi 11,079,000 7,091,000 18,170,000
113 Primary Endoscopic Realignment urethra pasca trauma 11,079,000 7,091,000 18,170,000
114 Prosedur Winter (Priapismus) Narkose 6,523,000 3,647,000 10,170,000
115 Prostatektomi Retropubik 12,370,000 7,527,000 19,897,000
116 Psoas Hitch 11,794,000 8,103,000 19,897,000
117 Pubektomi 8,884,000 3,896,000 12,780,000
118 Punksi kista ginjal (bius) 6,055,000 4,643,000 10,698,000
119 Punksi Kista Ginjal Lokal 2,981,000 2,286,000 5,267,000
120 Pyelolitotomi 10,548,000 6,077,000 16,625,000
121 Pyeloplasty 20,265,000 15,537,000 35,802,000
122 Pyeloplasty per laparoskopi 22,700,000 17,403,000 40,103,000
123 Radikal Nefrektomi per laparoskopi 20,663,000 15,142,000 35,805,000
124 Radikal Prostatektomi 16,452,000 12,613,000 29,065,000
125 Radikal Prostatektomi per laparoskopi 23,009,000 15,142,000 38,151,000
126 Radikal Sistektomi Ileal Conduit 20,672,000 1,403,000 22,075,000
127 Rail Roding 11,079,000 7,091,000 18,170,000
128 Reimplantasi Ureter 20,319,000 15,578,000 35,897,000
129 Rekonstruksi Blassemeck narkose 4,489,000 3,442,000 7,931,000
130 REKONSTRUKSI EPISPADIA 11,794,000 8,103,000 19,897,000
131 REKONSTRUKSI HORSE-SHOE KIDNEY 11,794,000 8,103,000 19,897,000
132 REKONSTRUKSI RENOVASKULAR 18,229,000 12,966,000 31,195,000
133 Rekonstruksi Transposisi Penokrotal 9,547,000 5,065,000 14,612,000
134 Rekonstruksi Vesika narkose 4,336,000 3,325,000 7,661,000
135 Release cordeae (narkose)/eksisi chorde (narkose) 9,480,000 7,268,000 16,748,000
136 Repair fistel (nakose) 7,800,000 5,980,000 13,780,000
137 Repair fistel uretrokutan 10,548,000 6,077,000 16,625,000
138 Repair fistel vesico vagina (nakose) 8,265,000 6,337,000 14,602,000
139 Repair fistel vesiko vaginal komplek (narkose) 11,135,000 8,538,000 19,673,000
JASA
PELAYANAN
140 Repair Fistel Vesikokutan 9,547,000 5,065,000 14,612,000
141 REPAIR FISTEL VESIKOREKTAL 11,794,000 8,103,000 19,897,000
142 Repair fraktur penis 6,643,000 5,093,000 11,736,000
143 Repair Trauma Buli-buli 10,548,000 6,077,000 16,625,000
144 Repair trauma uretra 10,548,000 6,077,000 16,625,000
145 RESEKSI ANASTOMOSIS (RA) Urethra 9,019,000 6,915,000 15,934,000
146 Reseksi Anastomosis Urethra (narkose) 16,101,000 12,344,000 28,445,000
147 Reseksi dan Anastomosis Ureter 10,548,000 6,077,000 16,625,000
148 Reseksi partial vesika (narkose) 3,403,000 2,609,000 6,012,000
149 Reseksi Urachus (narkose) 6,616,000 5,073,000 11,689,000
150 Resipien Transplan Ginjal 31,800,000 46,123,000 77,923,000
151 Retroperitoneal Lymph Node Dissection 13,318,000 9,488,000 22,806,000
152 Retroperitoneoskopik Heminefrektomi 15,099,000 6,233,000 21,332,000
153 Revisi Nefrostomi Lokal 1,931,000 1,447,000 3,378,000
154 RIRS 11,794,000 8,103,000 19,897,000
155 Rotational Flap 7,922,000 6,074,000 13,996,000
156 RPG Local 1,063,000 815,000 1,878,000
157 RPG Narkose 3,810,000 2,921,000 6,731,000
158 Sachse (narkose) 5,415,000 4,152,000 9,567,000
159 Scrotoplasty 8,369,000 6,233,000 14,602,000
160 Sectio Alta (narkose) 4,043,000 3,100,000 7,143,000
161 Sekunder Hecting Lokal 1,416,000 942,000 2,358,000
162 Sekunder Hecting Narkose 4,235,000 1,824,000 6,059,000
163 Simple nefrektomi per laparoskopi 35,771,000 27,424,000 63,195,000
164 Sircumsisi local 1,106,000 848,000 1,954,000
165 Sircumsisi Narkose 2,934,000 2,249,000 5,183,000
166 Sistektomi Parsial 11,079,000 7,091,000 18,170,000
167 Sistoskopi - VCUG Narkose 3,465,000 2,657,000 6,122,000
168 Sistoskopi dan Evakuasi Clot/ Bekuan Darah 10,548,000 6,077,000 16,625,000
169 Sistoskopi Local 1,326,000 1,017,000 2,343,000
170 Sistoskopi Narkose 3,068,000 2,352,000 5,420,000
171 Sistostomi lokal 1,815,000 1,392,000 3,207,000
172 Sistostomi Narkose 3,484,000 2,671,000 6,155,000
173 Sistostomi Terbuka Narkose 5,836,000 3,039,000 8,875,000
174 Spermatokel narkose 3,301,000 2,531,000 5,832,000
175 Tailoring Ureter 11,794,000 8,103,000 19,897,000
176 Torsio testis (narkose) 5,176,000 3,969,000 9,145,000
177 Total Penektomi 7,282,000 5,583,000 12,865,000
178 Trauma Ginjal 11,079,000 7,091,000 18,170,000
179 TUR BULI (narkose) 6,914,000 5,302,000 12,216,000
180 TUR DENGAN LASER 11,794,000 8,103,000 19,897,000
181 TUR PROSTAT (narkose) 5,860,000 4,493,000 10,353,000
182 Tutup Defek Primer 7,071,000 5,421,000 12,492,000
183 Unroofing kista ginjal per laparoskopi 10,407,000 7,979,000 18,386,000
184 Unroofing/Deroofing Kista Ginjal 9,547,000 5,065,000 14,612,000
185 Uretero Uretrostomi narkose 3,547,000 2,720,000 6,267,000
186 Ureterolitotomi (narkose) 7,558,000 5,795,000 13,353,000
187 Ureterolitotomi Distal 11,079,000 7,091,000 18,170,000
188 Ureterolitotomi per laparoskopi 11,969,000 9,176,000 21,145,000
189 Ureterolysis 5,967,000 4,575,000 10,542,000
190 Ureteroneosistostomi narkose 3,547,000 2,720,000 6,267,000
191 Ureteroplasty (narkose) 8,113,000 3,896,000 12,009,000
192 Ureterostomi (narkose) 4,101,000 3,144,000 7,245,000
193 Urethroplasty 14,267,000 10,938,000 25,205,000
194 uretrokele 5,611,000 4,302,000 9,913,000
195 Uretrosistografi Narkose 4,235,000 1,824,000 6,059,000
196 Uretrosistoskopi Narkose 5,836,000 3,039,000 8,875,000
197 Uretroskopi Narkose 5,836,000 3,039,000 8,875,000
198 URS (narkose) 5,675,000 4,352,000 10,027,000
199 URS DENGAN LASER 11,794,000 8,103,000 19,897,000
200 Varikokelektomi (mikro surgery narkose) 3,347,000 2,566,000 5,913,000
201 Varikokelektomi (Palomo) Narkose 6,523,000 3,647,000 10,170,000
202 Vasektomi (local) 1,086,000 833,000 1,919,000
203 Vasektomi dlm narkose 2,157,000 1,654,000 3,811,000
204 Vasografi (narkose) 3,263,000 2,501,000 5,764,000
205 Vasografi Narkose 5,836,000 3,039,000 8,875,000
206 Vasovasostomi 10,128,000 7,765,000 17,893,000
207 VCUG (narcose) 4,555,000 3,493,000 8,048,000
208 VCUG local 3,413,000 2,616,000 6,029,000
209 Vulgurasi urethra (narkose) 4,624,000 3,545,000 8,169,000
JASA
PELAYANAN
210 WIDE EKSISI TUMOR 11,794,000 8,103,000 19,897,000
211 Laparoskopi Simple Prostatektomi 19,951,000 13,169,000 33,120,000
212 VIDEOURODINAMIK LOKAL 8,195,000 4,550,000 12,745,000
213 VIDIOURODINAMIK BIUS 9,513,000 6,280,000 15,793,000
4. GIGI DAN MULUT
4.1 GIGI DAN MULUT DEWASA
1 Operasi Gigi Ringan 5,776,000 3,220,000 8,996,000
2 Operasi Gigi Sedang 7,567,000 6,440,000 14,007,000
3 Operasi Gigi Berat 12,181,000 12,880,000 25,061,000
4.2 GIGI DAN MULUT ANAK
1 Paket OK Gigi Anak Ringan dengan sedasi Nitrous Oxide (1-5 gigi) 7,481,000 6,348,000 13,829,000
Perawatan Saluran Akar - - -
Pengisian Saluran Akar - - -
Penambalan Komposit - - -
Cetak Double Impression - - -
Pembuatan Feeding plate / obturator - - -
2 Paket OK Gigi Anak Ringan (1-5 gigi) 7,481,000 6,348,000 13,829,000
3 Paket OK Gigi Anak Sedang (1 - 10 gigi) 10,936,000 8,562,000 19,498,000
Pencabutan Gigi Susu - - -
Pit dan fissure sealant - - -
Eksisi Mucocele - - -
4 Paket OK Gigi Anak Berat (› 10 gigi) 15,594,000 10,734,000 26,328,000
5 Paket OK Gigi Anak Berat dengan penyulit 16,077,000 12,808,000 28,885,000
Pencabutan Gigi Permanen - - -
5. MATA ANUGERAH
1 Ahmed Implant Lokal 13,690,000 1,430,000 15,120,000
2 Ahmed Implant narkose 14,540,000 2,145,000 16,685,000
3 ALR+Spliting Tarsus Lokal 3,150,000 1,898,000 5,048,000
4 ALR+Spliting Tarsus Narkose 4,000,000 2,243,000 6,243,000
5 Amnion Membrane Transplant lokal 3,000,000 880,000 3,880,000
6 Amnion Membrane Transplant narkose 4,000,000 1,430,000 5,430,000
7 Angkat Jahitan lokal 850,000 440,000 1,290,000
8 Angkat Jahitan narkose 1,700,000 715,000 2,415,000
9 Aspirasi Hipopion + Injeksi Intracameral (Tanpa Obat) lokal 2,550,000 660,000 3,210,000
10 Aspirasi Hipopion + Injeksi Intracameral (Tanpa Obat) narkose 3,500,000 1,430,000 4,930,000
11 Aspirasi Sisa Korteks lokal 2,650,000 660,000 3,310,000
12 Aspirasi Sisa Korteks narkose 3,500,000 1,430,000 4,930,000
13 Beevelt Implant lokal 10,650,000 1,430,000 12,080,000
14 Beevelt Implant narkose 11,500,000 2,145,000 13,645,000
15 Biopsi insisi kelopak Lokal 2,850,000 748,000 3,598,000
16 Biopsi insisi kelopak Narkose 3,700,000 1,495,000 5,195,000
17 Biopsi insisi konjungtiva Lokal 3,000,000 748,000 3,748,000
18 Biopsi insisi konjungtiva Narkose 3,850,000 2,243,000 6,093,000
19 Biopsi insisi orbita Lokal 3,400,000 1,898,000 5,298,000
20 Biopsi insisi orbita Narkose 4,250,000 2,990,000 7,240,000
21 Blefaroplasti Lokal 6,150,000 1,898,000 8,048,000
22 Blefaroplasti Narkose 7,000,000 2,243,000 9,243,000
JASA
PELAYANAN
23 Cyclocrio/Tcp lokal 2,750,000 1,320,000 4,070,000
24 Cyclocrio/Tcp narkose 4,765,000 1,716,000 6,481,000
25 Eksenterasi 6,000,000 3,575,000 9,575,000
26 Eksenterasi kompleks 6,500,000 4,290,000 10,790,000
Eksisi/ Ekstirpasi luas tumor kelopak kecil (<5 mm) dan rekonstruksi
27 3,900,000 4,290,000 8,190,000
kelopak sederhana
Eksisi/ Ekstirpasi tumor kelopak besar (>5 mm) dan rekonstruksi
28 3,900,000 5,005,000 8,905,000
kelopak kompleks
29 Eksisi/ Ekstirpasi tumor kelopak besar (>5 mm) Lokal 3,150,000 748,000 3,898,000
30 Eksisi/ Ekstirpasi tumor kelopak besar (>5 mm) Narkose 4,000,000 2,243,000 6,243,000
31 Eksisi/ Ekstirpasi tumor kelopak kecil (<5 mm) Lokal 2,850,000 748,000 3,598,000
32 Eksisi/ Ekstirpasi tumor kelopak kecil (<5 mm) Narkose 3,700,000 1,495,000 5,195,000
Eksisi/ Ekstirpasi tumor konjungtiva besar (keterlibatan >1 clock hour)
33 4,250,000 978,000 5,228,000
Lokal
34 5,100,000 2,990,000 8,090,000
Narkose
Eksisi/ Ekstirpasi tumor konjungtiva kecil (keterlibatan < 1 clock hour)
35 4,150,000 863,000 5,013,000
Lokal
36 5,000,000 2,243,000 7,243,000
Narkose
37 Ekstraksi katarak+IOL+PPC+Vitrektomi anterior pars plana 9,800,000 5,005,000 14,805,000
38 Ekstraksi katarak+IOL+PPC+Vitrektomi anterior 9,600,000 5,005,000 14,605,000
39 Ekstraksi katarak+PPC+Vitrektomi anterior 7,800,000 4,290,000 12,090,000
40 Enukleasi DFG + Retcam 4,000,000 4,290,000 8,290,000
41 Enukleasi (PO) 3,500,000 3,575,000 7,075,000
42 Enukleasi/ Eviserasi 4,000,000 3,575,000 7,575,000
43 Enukleasi/ Eviserasi with Ball Orbital Implant 4,300,000 3,575,000 7,875,000
44 Enukleasi/ Eviserasi with DFG 4,550,000 4,290,000 8,840,000
45 Enukleasi/ Eviserasi with Orbital Implant 4,600,000 3,575,000 8,175,000
46 ERG Full field 1,700,000 429,000 2,129,000
47 ERG Multifokal 1,900,000 501,000 2,401,000
48 Evakuasi Silicon Oil + Endolaser Lokal 14,150,000 1,380,000 15,530,000
49 Evakuasi Silicon Oil + Endolaser Narkose 15,000,000 1,495,000 16,495,000
50 Examination under anesthesia 2,600,000 1,073,000 3,673,000
51 EXTERNAL DCR+SIL TUBE Lokal 3,650,000 3,048,000 6,698,000
52 EXTERNAL DCR+SIL TUBE Narkose 4,500,000 3,575,000 8,075,000
53 Fasalata Graft Lokal 4,950,000 1,898,000 6,848,000
54 Fasalata Graft Narkose 5,800,000 2,243,000 8,043,000
55 Flap Konjungtiva lokal 3,250,000 715,000 3,965,000
56 Flap Konjungtiva narkose 4,350,000 2,288,000 6,638,000
57 Gas-Fluid Exchange (GFX)/ Drainage subretinal Fluid Lokal 4,350,000 165,000 4,515,000
58 Gas-Fluid Exchange (GFX)/ Drainage subretinal Fluid Narkose 5,200,000 575,000 5,775,000
59 Glueing lokal 3,250,000 935,000 4,185,000
60 Glueing narkose 4,300,000 2,288,000 6,588,000
61 ICCE / ECCE / SICS / SCLERAL FIKSASI lokal 2,850,000 1,815,000 4,665,000
62 ICCE / ECCE / SICS / SCLERAL FIKSASI narkose 3,700,000 2,145,000 5,845,000
63 ICCE/ECCE/SICS/SEKUNDER IMPLANT lokal 2,650,000 1,485,000 4,135,000
64 ICCE/ECCE/SICS/SEKUNDER IMPLANT narkose 3,500,000 1,716,000 5,216,000
65 Injeksi Intrakameral / COA / Bubble Tanpa Obat Lokal 1,150,000 690,000 1,840,000
66 Injeksi Intrakameral / COA / Bubble Tanpa Obat Narkose 2,000,000 748,000 2,748,000
67 Injeksi Intrastromal Kornea Tanpa Obat Lokal 1,150,000 690,000 1,840,000
68 Injeksi Intrastromal Kornea Tanpa Obat Narkose 2,000,000 748,000 2,748,000
69 Injeksi Intravitreal Tanpa Obat Lokal 1,150,000 690,000 1,840,000
70 Injeksi Intravitreal Tanpa Obat Narkose 2,000,000 748,000 2,748,000
71 Injeksi Subkonjungtiva/ Subkutis Tanpa Obat Lokal 1,150,000 575,000 1,725,000
72 Injeksi Subkonjungtiva/ Subkutis Tanpa Obat Narkose 2,000,000 598,000 2,598,000
73 Injeksi Subtenon/ Sclera Tanpa Obat Lokal 1,150,000 575,000 1,725,000
74 Injeksi Subtenon/ Sclera Tanpa Obat Narkose 2,000,000 598,000 2,598,000
75 INSISI HORDEOLUM / KALAZION 3,300,000 715,000 4,015,000
76 Iridektomi Lokal 2,950,000 880,000 3,830,000
77 Iridektomi Narkose 3,800,000 1,430,000 5,230,000
78 Kantopeksi Lokal 3,150,000 1,898,000 5,048,000
79 Kantopeksi Narkose 4,000,000 2,243,000 6,243,000
80 Kapsulotomi posterior sekunder + vitrektomi anterior + sinekiolisis 7,800,000 3,575,000 11,375,000
81 KELOPAK BERAT Lokal 7,850,000 1,668,000 9,518,000
82 KELOPAK BERAT Narkose 8,700,000 1,944,000 10,644,000
83 KELOPAK RINGAN Lokal 1,650,000 1,093,000 2,743,000
84 KELOPAK RINGAN Narkose 2,500,000 1,196,000 3,696,000
85 KELOPAK SEDANG I Lokal 2,650,000 1,208,000 3,858,000
JASA
PELAYANAN
86 KELOPAK SEDANG I Narkose 3,500,000 1,346,000 4,846,000
87 KELOPAK SEDANG II Lokal 3,050,000 1,323,000 4,373,000
88 KELOPAK SEDANG II Narkose 3,900,000 1,495,000 5,395,000
89 Keratoplasty (Tanpa donor) lokal 13,150,000 3,575,000 16,725,000
90 Keratoplasty (Tanpa donor) narkose 14,000,000 3,933,000 17,933,000
91 Kornea Tattoo lokal 3,450,000 1,980,000 5,430,000
92 Kornea Tattoo narkose 4,300,000 2,288,000 6,588,000
93 Lateral Tarsal Strip Lokal 4,950,000 1,898,000 6,848,000
94 Lateral Tarsal Strip Narkose 5,800,000 2,243,000 8,043,000
95 Levator reseksi Lokal 4,950,000 2,473,000 7,423,000
96 Levator reseksi Narkose 5,800,000 2,990,000 8,790,000
97 limbal stem cell graft lokal 3,350,000 2,420,000 5,770,000
98 limbal stem cell graft narkose 4,200,000 5,005,000 9,205,000
99 Lip Mucosa Graft Lokal 3,150,000 1,725,000 4,875,000
100 Lip Mucosa Graft Narkose 4,000,000 3,575,000 7,575,000
101 LRI ( Limbal relaxing Incision ) lokal 2,650,000 1,265,000 3,915,000
102 LRI ( Limbal relaxing Incision ) narkose 3,500,000 1,716,000 5,216,000
103 Medial wall and orbital floor fracture/naso orbital fracture 7,000,000 4,290,000 11,290,000
104 Micropulse lokal 3,100,000 1,210,000 4,310,000
105 Micropulse narkose 4,200,000 1,716,000 5,916,000
106 Mild Soket reconstruction 6,000,000 2,990,000 8,990,000
107 Moderate soket rekonstruktion 6,500,000 3,575,000 10,075,000
108 Naso orbital fracture with complete rhinoplasty 10,200,000 4,290,000 14,490,000
109 Naso orbital fracture with DCR 12,200,000 4,290,000 16,490,000
110 Naso orbital fracture with Partial rhinoplasty 10,000,000 4,290,000 14,290,000
111 Nekrotomi lokal 3,350,000 935,000 4,285,000
112 Nekrotomi narkose 4,200,000 2,860,000 7,060,000
113 orbital floor fracture 9,000,000 3,575,000 12,575,000
114 Orbitotomi anterior dan eksisi tumor kompleks 5,000,000 4,290,000 9,290,000
115 Orbitotomi anterior dan ekstirpasi tumor 5,000,000 3,575,000 8,575,000
116 Orbitotomi lateral dan eksisi tumor 7,000,000 5,005,000 12,005,000
117 Orbitotomi lateral dan eksisi tumor kompleks 8,000,000 5,720,000 13,720,000
118 periosteal graft lokal 3,550,000 2,145,000 5,695,000
119 periosteal graft narkose 4,400,000 3,933,000 8,333,000
120 Phaco lokal 5,150,000 1,980,000 7,130,000
121 Phaco narkose 6,000,000 2,360,000 8,360,000
122 Pneumatic Retinopexy Lokal 5,150,000 2,185,000 7,335,000
123 Pneumatic Retinopexy Narkose 6,000,000 2,542,000 8,542,000
124 Probing with/ without Infracturing Concha Lokal 2,150,000 1,093,000 3,243,000
125 Probing with/ without Infracturing Concha Narkose 3,000,000 2,243,000 5,243,000
126 Probing with/ without Infracturing Concha with Endoscopy Lokal 3,150,000 1,093,000 4,243,000
127 Probing with/ without Infracturing Concha with Endoscopy Narkose 4,000,000 2,243,000 6,243,000
128 Pterigium Plasty lokal 2,950,000 1,045,000 3,995,000
129 Pterigium Plasty narkose 3,800,000 2,145,000 5,945,000
130 Punctum Atresia Lokal 1,150,000 978,000 2,128,000
131 Punctum Atresia Narkose 2,000,000 1,196,000 3,196,000
132 Reconstruction post tumor berat 9,000,000 4,290,000 13,290,000
133 Reconstruction post tumor sedang 5,000,000 2,990,000 7,990,000
134 Repair Cyclodialysis lokal 4,150,000 990,000 5,140,000
135 Repair Cyclodialysis narkose 5,000,000 1,716,000 6,716,000
136 Repair Kornea lokal 3,750,000 1,265,000 5,015,000
137 Repair Kornea narkose 4,600,000 2,431,000 7,031,000
138 Repair Sklera lokal 3,750,000 1,265,000 5,015,000
139 Repair Sklera narkose 4,600,000 2,145,000 6,745,000
140 Repair Tube lokal 2,550,000 880,000 3,430,000
141 Repair Tube narkose 3,400,000 1,716,000 5,116,000
142 Reposisi lokal 1,650,000 440,000 2,090,000
143 Reposisi narkose 2,500,000 2,145,000 4,645,000
144 RETCAM ODS 2,200,000 2,145,000 4,345,000
145 RetCam ODS + Cryotherapy OD/OS 2,800,000 2,431,000 5,231,000
146 RetCam ODS + Cryotherapy ODS 3,600,000 2,860,000 6,460,000
147 RetCam ODS + Injeksi Avastine ODS 3,600,000 2,860,000 6,460,000
148 RetCam ODS+ Injeksi Avastine OD/OS 3,200,000 2,431,000 5,631,000
149 RetCam ODS+ Injeksi carboplatin OD/OS 3,300,000 2,431,000 5,731,000
150 RetCam ODS+ Injeksi carboplatin ODS 3,800,000 2,860,000 6,660,000
151 RetCam ODS+LIO OD/OS 2,800,000 2,431,000 5,231,000
152 RetCam ODS+LIO ODS 3,600,000 2,860,000 6,460,000
153 RetCam+LIO+Cryotherapy 4,000,000 4,290,000 8,290,000
JASA
PELAYANAN
154 Revisi Iridektomi / Bleb lokal 1,700,000 880,000 2,580,000
155 Revisi Iridektomi / Bleb narkose 3,700,000 2,002,000 5,702,000
156 Revormasi COA lokal 2,350,000 550,000 2,900,000
157 Revormasi COA narkose 3,200,000 2,145,000 5,345,000
158 Schlera Buckle Lokal 4,150,000 1,955,000 6,105,000
159 Schlera Buckle Narkose 5,000,000 2,243,000 7,243,000
160 scleral patch lokal 3,500,000 2,420,000 5,920,000
161 scleral patch narkose 4,350,000 4,290,000 8,640,000
162 scrapping kornea / keratektomi superfisial lokal 3,250,000 935,000 4,185,000
163 scrapping kornea / keratektomi superfisial narkose 4,500,000 2,288,000 6,788,000
164 Sekunder Implant Dengan penyulit + Vitrektomi Anterior 7,500,000 2,145,000 9,645,000
165 Semi Eksentrasi /Eksenterasi + RetCam 4,500,000 3,861,000 8,361,000
166 Severe soket rekonstruktion 9,000,000 4,290,000 13,290,000
167 Sklerotomi posterior lokal 2,950,000 880,000 3,830,000
168 Sklerotomi posterior narkose 3,800,000 1,716,000 5,516,000
169 Strabismus 1 Lokal 3,950,000 2,243,000 6,193,000
170 Strabismus 1 Narkose 4,800,000 2,691,000 7,491,000
171 Strabismus 2 Lokal 4,650,000 2,473,000 7,123,000
172 Strabismus 2 Narkose 5,500,000 2,990,000 8,490,000
173 Strabismus 3 6,700,000 3,575,000 10,275,000
174 Strabismus 4 7,100,000 4,290,000 11,390,000
175 Tambah Jahitan lokal 950,000 440,000 1,390,000
176 Tambah Jahitan narkose 1,800,000 715,000 2,515,000
177 Tarsorapi Beban Emas (Goldweight) Lokal 3,650,000 1,898,000 5,548,000
178 Tarsorapi Beban Emas (Goldweight) Narkose 4,500,000 2,243,000 6,743,000
179 Trabekulo-Trabekulektomi + MMU lokal 4,400,000 1,650,000 6,050,000
180 Trabekulo-Trabekulektomi + MMU narkose 5,250,000 2,145,000 7,395,000
181 Tripod fraktur 12,500,000 5,720,000 18,220,000
182 VEP Full field 1,700,000 429,000 2,129,000
183 VEP Multifokal 1,900,000 501,000 2,401,000
184 Virna Implant lokal 6,400,000 1,430,000 7,830,000
185 Virna Implant narkose 7,250,000 2,145,000 9,395,000
186 Vitrektomi Anterior lokal 3,150,000 1,100,000 4,250,000
187 Vitrektomi Anterior narkose 4,000,000 1,430,000 5,430,000
188 Vitrektomi Complex Lokal 17,150,000 2,970,000 20,120,000
189 Vitrektomi Complex Narkose 18,000,000 3,575,000 21,575,000
190 Vitrektomi simple Lokal 14,450,000 2,970,000 17,420,000
191 Vitrektomi simple Narkose 15,300,000 3,575,000 18,875,000
192 Vitreus /Aqueous Tap lokal 1,000,000 660,000 1,660,000
193 Vitreus /Aqueous Tap narkose 3,000,000 1,430,000 4,430,000
194 GRAFT SKLERA lokal 3,930,000 1,265,000 5,195,000
195 GRAFT SKLERA narkose 4,760,000 2,145,000 6,905,000
6. TELINGA, HIDUNG DAN TENGGOROKAN
1 Aritenoidectomy 8,834,000 6,774,000 15,608,000
2 ASSR dengan Anestesi 1,451,000 1,113,000 2,564,000
3 Atresia Liang Telinga 13,387,000 10,264,000 23,651,000
4 Base Of Tongue ( BOT ) Surgery 9,138,000 7,006,000 16,144,000
5 Beloq Tampon dgn Narkosis 4,152,000 3,183,000 7,335,000
6 BERA dengan Anestesi 1,488,000 1,141,000 2,629,000
7 Biopsi Tumor Hidung Lidah dan Nasofaring 4,651,000 3,566,000 8,217,000
8 Bronkoskopi Diagnostik 4,369,000 3,350,000 7,719,000
9 Bronkoskopi Ekstraksi dengan Kesulitan 6,269,000 4,806,000 11,075,000
10 Bronkoskopi Ekstraksi tanpa Kesulitan 5,031,000 3,857,000 8,888,000
11 BSEF Lanjutan 27,053,000 20,740,000 47,793,000
12 BSEF Mini (I) 8,852,000 6,695,000 15,547,000
13 BSEF Mini (II) + maksila/etomoid 7,460,000 5,720,000 13,180,000
14 BSEF Mini (III) + frontal sfenoid 10,002,000 7,668,000 17,670,000
15 BSEF Mini (IV) + Maksila/Etmoid + Frontal/Sfenoid 18,612,000 14,269,000 32,881,000
16 Cauter Assisted Assisted Stiffning Operation (Capso) 8,834,000 6,774,000 15,608,000
17 Dekompresi Nervus Fasialis 14,513,000 11,127,000 25,640,000
18 Diseksi Leher Bilateral 19,311,000 14,805,000 34,116,000
19 Diseksi Leher Modified 11,250,000 8,625,000 19,875,000
20 Diseksi Leher Radikal 10,301,000 7,898,000 18,199,000
21 Eksisi Ca Laring dgn laser 7,994,000 6,130,000 14,124,000
22 Eksisi Stenosis Laring/ Sub Glotis 8,298,000 6,362,000 14,660,000
23 Eksisional Biopsi 4,321,000 3,313,000 7,634,000
24 Eksplorasi Abses Mandibula 7,702,000 5,905,000 13,607,000
25 Eksplorasi Abses Multipel 8,463,000 6,488,000 14,951,000
26 Eksplorasi Abses Parafaring 6,927,000 5,311,000 12,238,000
27 Eksplorasi Nasofaring 6,757,000 5,181,000 11,938,000
JASA
PELAYANAN
28 Ekstended Mastoidektomi Radikal 10,805,000 8,285,000 19,090,000
29 Eksterpasi Tumor Jinak Ke Liur 8,028,000 6,155,000 14,183,000
30 Eksterpasi Tumor jinak,sinonasal,oral cavity 6,496,000 4,981,000 11,477,000
31 Ekstirpasi angiofibroma 7,244,000 5,553,000 12,797,000
32 Ekstirpasi angiofibroma dengan Endoskopi 11,974,000 9,180,000 21,154,000
33 Ekstirpasi Kista Bronchialis 6,919,000 5,305,000 12,224,000
34 Ekstirpasi Nodul 5,297,000 4,061,000 9,358,000
35 Ekstirpasi Papiloma 5,393,000 4,135,000 9,528,000
36 Ekstirpasi Preaurikuler Fistel 9,332,000 7,155,000 16,487,000
37 Ekstraksi Benda Asing operatif 3,486,000 2,657,000 6,143,000
38 Esofagoskopi Benda Asing dengan kesulitan 6,438,000 4,936,000 11,374,000
39 Esofagoskopi Benda Asing tanpa kesulitan 3,906,000 2,995,000 6,901,000
40 Esofagoskopi Diagnostik 3,889,000 2,982,000 6,871,000
41 Esofagoskopi Dilatasi 4,797,000 3,678,000 8,475,000
42 Faringeal Flap 9,306,000 7,135,000 16,441,000
43 Forehead flap 15,755,000 12,078,000 27,833,000
44 Hemiglosektomi + Diseksi Leher 15,465,000 11,857,000 27,322,000
45 Hemiglosektomi THT 7,345,000 5,632,000 12,977,000
46 Implantasi Koklea 14,814,000 11,357,000 26,171,000
47 Injection Laringoplasty 8,834,000 6,774,000 15,608,000
48 Insisional Biopsi Kelenjar Leher 4,784,000 3,669,000 8,453,000
49 Intubasi dengan Fleksibel Bronkoskopi 3,619,000 2,775,000 6,394,000
50 Ismulobectomy Thiroid 8,834,000 6,774,000 15,608,000
51 Kanaloplasty 8,094,000 6,205,000 14,299,000
52 Konkoplasty/ konkotomi 6,390,000 4,899,000 11,289,000
53 Labioplasti bilateral 7,901,000 6,058,000 13,959,000
54 Labioplasti unilateral 7,031,000 5,390,000 12,421,000
55 Laringeal Botox Injection 8,834,000 6,774,000 15,608,000
56 Laringektomi 14,101,000 10,811,000 24,912,000
57 Laringektomi + RND 16,584,000 12,714,000 29,298,000
58 Laringektomi Total 10,670,000 8,181,000 18,851,000
59 Laringofisure 8,402,000 6,441,000 14,843,000
60 Laringoskopi dengan Ekstirpasi 5,641,000 4,325,000 9,966,000
61 Laringoskopi Diagnostik 4,671,000 3,581,000 8,252,000
62 Ligasi Arteri Profunda + Eksisi Biopsi 7,382,000 5,660,000 13,042,000
63 Ligasi Carotis Eksterna 8,944,000 6,857,000 15,801,000
64 Maksilektomi Parsial 9,051,000 6,939,000 15,990,000
65 Maksilektomi Total 11,663,000 8,941,000 20,604,000
66 Mandibulektomi Parsial 7,685,000 5,891,000 13,576,000
67 Mastoidektomi Radikal 9,270,000 7,107,000 16,377,000
68 Mastoidektomi Radikal dgn penyulit 15,223,000 11,671,000 26,894,000
69 Mastoidektomi Sederhana 12,395,000 8,050,000 20,445,000
70 Meatoplasty 6,629,000 5,082,000 11,711,000
71 Midline Glosectomy 8,834,000 6,774,000 15,608,000
72 Miringoplasty 7,204,000 5,523,000 12,727,000
73 Nasoendoskopi dengan tindakan 2,935,000 2,251,000 5,186,000
74 Nasofarinjektomi 8,891,000 6,817,000 15,708,000
75 NRI+ Impedance + E SRT 1,445,000 1,109,000 2,554,000
76 ORIF 9,502,000 7,285,000 16,787,000
77 Oscikuloplasty 13,387,000 10,264,000 23,651,000
78 Otoplasty 9,470,000 7,260,000 16,730,000
79 PAN Bronkoskopi 3,703,000 2,839,000 6,542,000
80 PAN Endoskopi 7,330,000 5,620,000 12,950,000
81 PAN Esofagoskopi 3,876,000 2,972,000 6,848,000
82 Parotidektomi 10,289,000 7,888,000 18,177,000
83 Pemasangan BAHA 15,268,000 11,706,000 26,974,000
84 Pemasangan Gromet 1 TELINGA 5,495,000 4,212,000 9,707,000
85 Pemasangan Gromet 2 TELINGA 7,158,000 5,488,000 12,646,000
86 Pemasangan T-Tube 8,407,000 6,446,000 14,853,000
87 Pilar Implant 2,170,000 1,664,000 3,834,000
88 Regional Flap tdk luas 9,302,000 7,131,000 16,433,000
89 Rekonstruksi Fraktur muka dg palte screw 15,345,000 11,765,000 27,110,000
90 Rekonstruksi Fraktur Rahang 8,755,000 6,713,000 15,468,000
91 Rekonstruksi hidung dengan defek 15,589,000 11,952,000 27,541,000
92 Rekonstruksi Mandibula 15,774,000 12,093,000 27,867,000
93 Rekonstruksi telinga (Mikrotia) tahap 2 15,836,000 12,142,000 27,978,000
94 Revisi Parut 6,245,000 4,789,000 11,034,000
95 RF Dasar Lidah 5,461,000 4,187,000 9,648,000
96 Rinoplasty 13,778,000 10,563,000 24,341,000
97 Rinoplasty dg Augmentasi tulang rawan 15,502,000 11,885,000 27,387,000
JASA
PELAYANAN
98 RND 11,440,000 8,771,000 20,211,000
99 Septo Plasty ec Trauma Hidung 9,320,000 7,145,000 16,465,000
100 Septoplasty 7,195,000 5,517,000 12,712,000
101 Septorinoplasty 14,274,000 10,943,000 25,217,000
102 Septum reseksi 7,538,000 5,780,000 13,318,000
103 Sialendoskopi Diagnostik dan Dilatasi 6,211,000 3,826,000 10,037,000
104 Sialendoskopi Diagnostik dan Teurapeutik 6,387,000 4,897,000 11,284,000
105 Sinuskopi/ Sinoskopi dengan tindakan 3,700,000 2,837,000 6,537,000
106 Skingrafting tdk luas 6,193,000 4,748,000 10,941,000
107 Sleep Nasoendoskopi operatif 4,379,000 2,551,000 6,930,000
108 Stapedektomi 8,851,000 6,786,000 15,637,000
109 Supraglotoplasty 8,834,000 6,774,000 15,608,000
110 TA/T 4,592,000 3,521,000 8,113,000
111 TA/T dgn Coblation Laser 6,007,000 4,606,000 10,613,000
112 Temporal Bone Resection 17,585,000 13,481,000 31,066,000
113 Tiroidektomi 14,247,000 10,923,000 25,170,000
114 Tongue Base Reduction 7,238,000 5,550,000 12,788,000
115 Trakestomi 5,398,000 4,139,000 9,537,000
116 Trakestomi dgn Penyulit 6,319,000 4,845,000 11,164,000
117 Turbinoplasty 2,592,000 1,987,000 4,579,000
118 Tympanoplasty 12,993,000 9,961,000 22,954,000
119 UPPP 9,965,000 7,641,000 17,606,000
120 Wide Eksisi Tumor Tonsil, Orofaring 7,721,000 5,920,000 13,641,000
7. BEDAH
1 Operasi Sedang I - Biopsi cubit (oral cancer) 2,759,000 2,115,000 4,874,000
2 Operasi Sedang I - Core biopsi 2,759,000 2,115,000 4,874,000
3 Operasi Sedang I - Eksisi Lokal > 3 cm 2,759,000 2,115,000 4,874,000
4 Operasi Sedang I - Eksisi Lokal ≤ 3 cm 2,759,000 2,115,000 4,874,000
5 Operasi Sedang I - Eksisi Mamaria Aberant ≤ 3cm 2,759,000 2,115,000 4,874,000
6 Operasi Sedang I - Insisional biopsi 2,759,000 2,115,000 4,874,000
Operasi Sedang I - Pemasangan double lumen kateter dengan lokal
7 2,759,000 2,115,000 4,874,000
anestesi
8 Operasi Sedang I - Vena seksi dan pasang akses vaskuler 2,759,000 2,115,000 4,874,000
9 Operasi Sedang II - Aff drain 4,149,000 3,181,000 7,330,000
10 Operasi Sedang II - Biopsi all layer 4,149,000 3,181,000 7,330,000
11 Operasi Sedang II - Biopsi eksisional dalam narkose 4,149,000 3,181,000 7,330,000
12 Operasi Sedang II - Biopsi insisional dalam narkose 4,149,000 3,181,000 7,330,000
13 Operasi Sedang II - Biopsi rektum "Full thickness" 4,149,000 3,181,000 7,330,000
14 Operasi Sedang II - Biopsi/Eksisi KGB, Lipoma. Ateroma, ganglion 4,149,000 3,181,000 7,330,000
15 Operasi Sedang II - Businasi 4,149,000 3,181,000 7,330,000
16 Operasi Sedang II - Debridement Gangren Diabetik 4,149,000 3,181,000 7,330,000
17 Operasi Sedang II - Eksisi FAM ( 1 FAM ) 4,149,000 3,181,000 7,330,000
18 Operasi Sedang II - Eksisi Ganglion 4,149,000 3,181,000 7,330,000
19 Operasi Sedang II - Eksisi granuloma umbilikal 4,149,000 3,181,000 7,330,000
20 Operasi Sedang II - Eksisi Hemangioma < 3 cm 4,149,000 3,181,000 7,330,000
21 Operasi Sedang II - Eksisi hemangioma kecil 4,149,000 3,181,000 7,330,000
22 Operasi Sedang II - Eksisi kista tiroglosus 4,149,000 3,181,000 7,330,000
23 Operasi Sedang II - Eksisi/Ekstirpasi 4,149,000 3,181,000 7,330,000
24 Operasi Sedang II - Ekstirpasi mucocele 4,149,000 3,181,000 7,330,000
Operasi Sedang II - Ekstirpasi tumor jinak kulit φ>3 cm (Limpoma,
25 4,149,000 3,181,000 7,330,000
atheroma, dll)
26 Operasi Sedang II - Fasciotomi dekompresi 4,149,000 3,181,000 7,330,000
27 Operasi Sedang II - Fistulektomi Sederhana 4,149,000 3,181,000 7,330,000
28 Operasi Sedang II - Flebektomi saja 4,149,000 3,181,000 7,330,000
29 Operasi Sedang II - Flobektomi 1 tungkai sederhana 4,149,000 3,181,000 7,330,000
30 Operasi Sedang II - Incisi drainage abses multiple/kompleks 4,149,000 3,181,000 7,330,000
31 Operasi Sedang II - Insisi Abses Perianal 4,149,000 3,181,000 7,330,000
32 Operasi Sedang II - Insisi drainase/debridement abses 4,149,000 3,181,000 7,330,000
33 Operasi Sedang II - Insisi tongue tie 4,149,000 3,181,000 7,330,000
34 Operasi Sedang II - Labioplasty unilateral 4,149,000 3,181,000 7,330,000
35 Operasi Sedang II - Laringoskopi 4,149,000 3,181,000 7,330,000
36 Operasi Sedang II - Ligasi cabang Draining Vein AV Shunt 4,149,000 3,181,000 7,330,000
37 Operasi Sedang II - Marsupialisasi 4,149,000 3,181,000 7,330,000
38 Operasi Sedang II - Pasang CDL temporer (+/- Radiografer) 4,149,000 3,181,000 7,330,000
Operasi Sedang II - Pasang double lumen kateter semi permanen
39 4,149,000 3,181,000 7,330,000
dengan lokal anestesi
40 Operasi Sedang II - Pencabutan CDL Semipermanen 4,149,000 3,181,000 7,330,000
41 Operasi Sedang II - Polipektomi rektum 4,149,000 3,181,000 7,330,000
42 Operasi Sedang II - Potong flap 4,149,000 3,181,000 7,330,000
JASA
PELAYANAN
43 Operasi Sedang II - Redebridement 4,149,000 3,181,000 7,330,000
44 Operasi Sedang II - Release sinekhia vulva 4,149,000 3,181,000 7,330,000
45 Operasi Sedang II - Sirkumsisi 4,149,000 3,181,000 7,330,000
46 Operasi Sedang II - Skleroterapi dengan anestesi 4,149,000 3,181,000 7,330,000
47 Operasi Sedang II - Spingterektomi lateral 4,149,000 3,181,000 7,330,000
48 Operasi Sedang II - Split thickness skin graft sederhana (10x20 cm) 4,149,000 3,181,000 7,330,000
49 Operasi Sedang II - Stimulasi otot 4,149,000 3,181,000 7,330,000
50 Operasi Sedang II - Suntik scleroting agent 4,149,000 3,181,000 7,330,000
51 Operasi Sedang II - Tracheostomi elektif 4,149,000 3,181,000 7,330,000
52 Operasi Sedang III - Appendektomi Terbuka 5,159,000 3,956,000 9,115,000
53 Operasi Sedang III - A-V Shunt radial (Brescia Cimino) 5,159,000 3,956,000 9,115,000
54 Operasi Sedang III - Biopsi Lokal 5,159,000 3,956,000 9,115,000
55 Operasi Sedang III - Bronchoscopy 5,159,000 3,956,000 9,115,000
56 Operasi Sedang III - Debridement dan evakuasi hematom 5,159,000 3,956,000 9,115,000
Operasi Sedang III - Debridement dan tutup defek kaki diabetik/CVI
57 5,159,000 3,956,000 9,115,000
sederhana
Operasi Sedang III - Debridement dengan amputasi minor/mayor tanpa
58 5,159,000 3,956,000 9,115,000
trombektomi
59 Operasi Sedang III - Debridement sederhana 5,159,000 3,956,000 9,115,000
Operasi Sedang III - Eksplorasi vaskuler ekstremitas tanpa
60 5,159,000 3,956,000 9,115,000
rekonstruksi
61 Operasi Sedang III - Flebektomi 1 tungkai kompleks 5,159,000 3,956,000 9,115,000
62 Operasi Sedang III - Flebektomi 2 tungkai 5,159,000 3,956,000 9,115,000
63 Operasi Sedang III - Gastrostromi 5,159,000 3,956,000 9,115,000
64 Operasi Sedang III - Haemoroidektomi Konvesional 5,159,000 3,956,000 9,115,000
65 Operasi Sedang III - Insersi chest tube + WSD 5,159,000 3,956,000 9,115,000
66 Operasi Sedang III - Insersi Heimlich Valve 5,159,000 3,956,000 9,115,000
67 Operasi Sedang III - Insersi Indweling Pleural Catheter (IPC) 5,159,000 3,956,000 9,115,000
68 Operasi Sedang III - Jejunostomi 5,159,000 3,956,000 9,115,000
69 Operasi Sedang III - Kolostomi 5,159,000 3,956,000 9,115,000
70 Operasi Sedang III - Mediastinostomi 5,159,000 3,956,000 9,115,000
71 Operasi Sedang III - Pasang akses port celsite 5,159,000 3,956,000 9,115,000
Operasi Sedang III - Pasang CDL semipermanen (+/-Radiografer) (+/-
72 5,159,000 3,956,000 9,115,000
Venografi)
73 Operasi Sedang III - Pleurodesis 5,159,000 3,956,000 9,115,000
74 Operasi Sedang III - Pleurofibrosis 5,159,000 3,956,000 9,115,000
75 Operasi Sedang III - Stripping varises 1 tungkai sederhana 5,159,000 3,956,000 9,115,000
76 Operasi Sedang III - Trakheostomi 5,159,000 3,956,000 9,115,000
77 Operasi Besar I - A-V shunt cubiti 6,552,000 5,023,000 11,575,000
78 Operasi Besar I - A-V shunt radial/cubiti dengan pasang double lumen 6,552,000 5,023,000 11,575,000
79 Operasi Besar I - Biopsi 6,552,000 5,023,000 11,575,000
80 Operasi Besar I - Biopsi Kanker Laring 6,552,000 5,023,000 11,575,000
81 Operasi Besar I - Caldwell LUC Anthrostomi 6,552,000 5,023,000 11,575,000
82 Operasi Besar I - Debridement 6,552,000 5,023,000 11,575,000
83 Operasi Besar I - Debridement angkat graft perifer 6,552,000 5,023,000 11,575,000
84 Operasi Besar I - Debridement dan tutup defek pada gangren diabetik 6,552,000 5,023,000 11,575,000
85 Operasi Besar I - Debridement dan tutup defek trauma 6,552,000 5,023,000 11,575,000
86 Operasi Besar I - Debridement dengan amputasi minor kaki diabetik 6,552,000 5,023,000 11,575,000
87 Operasi Besar I - Debridement kompleks 6,552,000 5,023,000 11,575,000
88 Operasi Besar I - Eksisi Baker cyst 6,552,000 5,023,000 11,575,000
89 Operasi Besar I - Eksisi Hemangioma > 3 cm 6,552,000 5,023,000 11,575,000
90 Operasi Besar I - Eksisi higroma colli/limfangioma simple 6,552,000 5,023,000 11,575,000
91 Operasi Besar I - Eksisi kelenjar getah bening/Limfadenektomi 6,552,000 5,023,000 11,575,000
92 Operasi Besar I - Eksisi kelenjar liur submandibula 6,552,000 5,023,000 11,575,000
93 Operasi Besar I - Eksisi kista branchial 6,552,000 5,023,000 11,575,000
94 Operasi Besar I - Eksisi kista branchiogeniki 6,552,000 5,023,000 11,575,000
95 Operasi Besar I - Eksisi kista duktus tiroglosus 6,552,000 5,023,000 11,575,000
Operasi Besar I - Eksisi Ligasi & rekonstruksi malformasi vaskuler
96 6,552,000 5,023,000 11,575,000
sederhana (tanpa graft)
97 Operasi Besar I - Eksisi Ligasi pseudoaneurisma sederhana 6,552,000 5,023,000 11,575,000
98 Operasi Besar I - Eksisi Limfangioma 6,552,000 5,023,000 11,575,000
99 Operasi Besar I - Eksisi limfedema 6,552,000 5,023,000 11,575,000
100 Operasi Besar I - Eksisi mamma aberant > 3cm 6,552,000 5,023,000 11,575,000
101 Operasi Besar I - Eksisi Papiloma 6,552,000 5,023,000 11,575,000
102 Operasi Besar I - Eksisi Tumor Jinak Sinonasal 6,552,000 5,023,000 11,575,000
103 Operasi Besar I - Eksisi Tumor Scalp 6,552,000 5,023,000 11,575,000
JASA
PELAYANAN
104 Operasi Besar I - Eksplorasi vaskuler intraabdomen tanpa rekonstruksi 6,552,000 5,023,000 11,575,000
105 Operasi Besar I - Eksplorasi vaskuler leher tanpa rekonstruksi 6,552,000 5,023,000 11,575,000
Operasi Besar I - Ekstirpasi Tumor Jinak Kulit > 3 cm (
106 6,552,000 5,023,000 11,575,000
lipoma,atheroma dll)
107 Operasi Besar I - Ekstremitas Angiografi sederhana (+ Radiografer) 6,552,000 5,023,000 11,575,000
108 Operasi Besar I - Evakuasi feses 6,552,000 5,023,000 11,575,000
109 Operasi Besar I - Fistulektomi Kompleks 6,552,000 5,023,000 11,575,000
110 Operasi Besar I - Flap kulit sederhana 6,552,000 5,023,000 11,575,000
111 Operasi Besar I - Flap kulit sederhana 1 (advancement) 6,552,000 5,023,000 11,575,000
112 Operasi Besar I - Gastroduodenoskopi 6,552,000 5,023,000 11,575,000
113 Operasi Besar I - Gastrostomi anak 6,552,000 5,023,000 11,575,000
114 Operasi Besar I - Hernioplasti dengan mesh 6,552,000 5,023,000 11,575,000
115 Operasi Besar I - Herniotomi 6,552,000 5,023,000 11,575,000
116 Operasi Besar I - Herniotomi Umbilikalis 6,552,000 5,023,000 11,575,000
117 Operasi Besar I - Kelainan umbilikus 6,552,000 5,023,000 11,575,000
118 Operasi Besar I - Kolangiografi intra operasi kasai prosedur 6,552,000 5,023,000 11,575,000
119 Operasi Besar I - Kolonoskopi 6,552,000 5,023,000 11,575,000
120 Operasi Besar I - Kolostomi anak 6,552,000 5,023,000 11,575,000
121 Operasi Besar I - Kolotomi 6,552,000 5,023,000 11,575,000
122 Operasi Besar I - Labioplasty bilateral 6,552,000 5,023,000 11,575,000
123 Operasi Besar I - Ligasi tinggi 6,552,000 5,023,000 11,575,000
124 Operasi Besar I - Lobektomi sub totalis (tiroid) 6,552,000 5,023,000 11,575,000
125 Operasi Besar I - Mandibula sederhana 6,552,000 5,023,000 11,575,000
126 Operasi Besar I - Open Cystostomy 6,552,000 5,023,000 11,575,000
127 Operasi Besar I - Orchidektomi 6,552,000 5,023,000 11,575,000
128 Operasi Besar I - Pasang drain 6,552,000 5,023,000 11,575,000
Operasi Besar I - Pasang implantable akses porrt (celsite) (+
129 6,552,000 5,023,000 11,575,000
Radiografer)
130 Operasi Besar I - Polipektomi 6,552,000 5,023,000 11,575,000
131 Operasi Besar I - Potong stump 6,552,000 5,023,000 11,575,000
132 Operasi Besar I - Prosedur Tiersch pada prolap rekti 6,552,000 5,023,000 11,575,000
133 Operasi Besar I - Rehecting 6,552,000 5,023,000 11,575,000
134 Operasi Besar I - Rekonstruksi FTSG 6,552,000 5,023,000 11,575,000
Operasi Besar I - Rekonstruksi komplikasi pseudoaneurisma repair
135 6,552,000 5,023,000 11,575,000
primer
136 Operasi Besar I - Rekonstruksi STSG 6,552,000 5,023,000 11,575,000
137 Operasi Besar I - Repair defek hernia umbilikalis 6,552,000 5,023,000 11,575,000
138 Operasi Besar I - Repair stoma 6,552,000 5,023,000 11,575,000
139 Operasi Besar I - Salpingo Ooophorektomi bilateral 6,552,000 5,023,000 11,575,000
140 Operasi Besar I - Segmentektomi 6,552,000 5,023,000 11,575,000
141 Operasi Besar I - Septectomi (potong septum) 6,552,000 5,023,000 11,575,000
142 Operasi Besar I - Sphincterotomy 6,552,000 5,023,000 11,575,000
143 Operasi Besar I - Stripping varises 1 tungkai dengan flebektomi 6,552,000 5,023,000 11,575,000
Operasi Besar I - Stripping varises 1 tungkai kompleks
144 6,552,000 5,023,000 11,575,000
(flebektomi/debridement ulkus vena)
145 Operasi Besar I - Stripping Varises 2 tungkai sederhana 6,552,000 5,023,000 11,575,000
146 Operasi Besar I - Tracheostomi cito 6,552,000 5,023,000 11,575,000
147 Operasi Besar I - Trombektomi 6,552,000 5,023,000 11,575,000
Operasi Besar I - Trombektomi 1 ekstremitas (+ Angiografi, +
148 6,552,000 5,023,000 11,575,000
Radiografer)
149 Operasi Besar I - Trombektomi dengan / tanpa debridement 6,552,000 5,023,000 11,575,000
150 Operasi Besar I - Tutup fistel palatum 6,552,000 5,023,000 11,575,000
151 Operasi Besar II - Amputasi Mayor kaki diabetik atau kasus vaskular 7,838,000 6,009,000 13,847,000
152 Operasi Besar II - AVM Angio Selektif (+ Radiografer) 7,838,000 6,009,000 13,847,000
Operasi Besar II - Eksisi ligasi dan rekonstruksi malformasi vaskuler
153 7,838,000 6,009,000 13,847,000
sederhana
154 Operasi Besar II - Eksisi Ligasi pseudoaneurisma kompleks 7,838,000 6,009,000 13,847,000
155 Operasi Besar II - Eksplorasi dan ligasi tinggi vena ovarica pada PCS 7,838,000 6,009,000 13,847,000
156 Operasi Besar II - Eksteriosasi 7,838,000 6,009,000 13,847,000
157 Operasi Besar II - Ekstremitas Angiografi selektif (+ Radiografer) 7,838,000 6,009,000 13,847,000
158 Operasi Besar II - Endovenous Laser Treatment (EVLT) 1 ekstremitas 7,838,000 6,009,000 13,847,000
159 Operasi Besar II - Evakuasi hematoma 7,838,000 6,009,000 13,847,000
Operasi Besar II - Flap kulit sederhana 2 (pedicled skin flap, keystone
160 7,838,000 6,009,000 13,847,000
flap)
161 Operasi Besar II - Hernia Bilateral 7,838,000 6,009,000 13,847,000
JASA
PELAYANAN
162 Operasi Besar II - Hernia Residif 7,838,000 6,009,000 13,847,000
163 Operasi Besar II - Isthmolobektomi 7,838,000 6,009,000 13,847,000
164 Operasi Besar II - Karotis Angiografi (+ Radiografer) 7,838,000 6,009,000 13,847,000
165 Operasi Besar II - Kolesistektomi terbuka 7,838,000 6,009,000 13,847,000
166 Operasi Besar II - Laparoskopi biopsi 7,838,000 6,009,000 13,847,000
167 Operasi Besar II - Laparoskopik Diagnostik/Biopsi 7,838,000 6,009,000 13,847,000
168 Operasi Besar II - Laparotomi Biopsi Diagnostik 7,838,000 6,009,000 13,847,000
169 Operasi Besar II - Laparotomi Reseksi Anastomosis Biasa 7,838,000 6,009,000 13,847,000
170 Operasi Besar II - Limfadenektomi Multiple 7,838,000 6,009,000 13,847,000
171 Operasi Besar II - Mastektomi simpleks 7,838,000 6,009,000 13,847,000
172 Operasi Besar II - Mastektomi subkutaneus 7,838,000 6,009,000 13,847,000
173 Operasi Besar II - Parotidektomi superfisialis 7,838,000 6,009,000 13,847,000
Operasi Besar II - PPH Haemoroidektomi/Haemoroidektomi dengan
174 7,838,000 6,009,000 13,847,000
stapler (II)
Operasi Besar II - Rekonstruksi komplikasi pseudoaneurisma dengan
175 7,838,000 6,009,000 13,847,000
graft
176 Operasi Besar II - Repair Hernia Insisional 7,838,000 6,009,000 13,847,000
177 Operasi Besar II - Sclerotherapi USG guided 7,838,000 6,009,000 13,847,000
Operasi Besar II - Stripping varises 1 tungkai, debridement ligasi vena
178 7,838,000 6,009,000 13,847,000
perforantes/penyulit
Operasi Besar II - Trombektomi 1 ekstremitas dengan debridement dan
179 7,838,000 6,009,000 13,847,000
fasciotomi (+ angiografi, + radiografer)
Operasi Besar II - Trombektomi 2 ekstremitas (+ Angiografi, +
180 7,838,000 6,009,000 13,847,000
Radiografer)
181 Operasi Besar II - Tutup santuli 7,838,000 6,009,000 13,847,000
182 Operasi Besar II - Tutup stoma 7,838,000 6,009,000 13,847,000
183 Operasi Besar II - Viseral Angiografi (+ Radiografer) 7,838,000 6,009,000 13,847,000
184 Operasi Besar III - Anoplasty 10,246,000 7,856,000 18,102,000
185 Operasi Besar III - Biopsi perlaparatomi 10,246,000 7,856,000 18,102,000
186 Operasi Besar III - Bishoop koop procedure 10,246,000 7,856,000 18,102,000
187 Operasi Besar III - Chordektomi 10,246,000 7,856,000 18,102,000
188 Operasi Besar III - Debulking 10,246,000 7,856,000 18,102,000
189 Operasi Besar III - Detorsi testis + orchidopexy 10,246,000 7,856,000 18,102,000
190 Operasi Besar III - Eksisi hemangioma besar/multiple 10,246,000 7,856,000 18,102,000
191 Operasi Besar III - Eksisi hemangioma dengan skin graft STSG/FTSG 10,246,000 7,856,000 18,102,000
192 Operasi Besar III - Eksisi kista urachus 10,246,000 7,856,000 18,102,000
193 Operasi Besar III - Eksisi, Jahit primer 10,246,000 7,856,000 18,102,000
194 Operasi Besar III - Eksisi, rekonstruksi 10,246,000 7,856,000 18,102,000
195 Operasi Besar III - Eksisi, skin graft 10,246,000 7,856,000 18,102,000
196 Operasi Besar III - Fistulektomi 10,246,000 7,856,000 18,102,000
197 Operasi Besar III - Gastrostomi neonatus 10,246,000 7,856,000 18,102,000
198 Operasi Besar III - Hemikolektomi kanan, kiri, reseksi transversum 10,246,000 7,856,000 18,102,000
199 Operasi Besar III - Herniotomi bilateral 10,246,000 7,856,000 18,102,000
200 Operasi Besar III - Herniotomi pada hernia strangulata 10,246,000 7,856,000 18,102,000
201 Operasi Besar III - Higroma colli/limfangioma besar 10,246,000 7,856,000 18,102,000
202 Operasi Besar III - Kolostomi neonatus 10,246,000 7,856,000 18,102,000
203 Operasi Besar III - Laparatomi + Appendektomi pada APP perforasi 10,246,000 7,856,000 18,102,000
204 Operasi Besar III - Laparatomi + Milking / reseksi pada invaginasi 10,246,000 7,856,000 18,102,000
205 Operasi Besar III - Laparatomi + reseksi usus halus/kolon 10,246,000 7,856,000 18,102,000
206 Operasi Besar III - Laparatomi adhesiolisis 10,246,000 7,856,000 18,102,000
207 Operasi Besar III - Laparatomi pada perforsi usus 10,246,000 7,856,000 18,102,000
208 Operasi Besar III - Laparatomi pada trauma abdomen 10,246,000 7,856,000 18,102,000
209 Operasi Besar III - Lumbal simpatektomi unilateral 10,246,000 7,856,000 18,102,000
210 Operasi Besar III - Mikulitz procedure 10,246,000 7,856,000 18,102,000
211 Operasi Besar III - Minimal/Limited PSARP 10,246,000 7,856,000 18,102,000
212 Operasi Besar III - Rekonstruksi tumor simple 10,246,000 7,856,000 18,102,000
213 Operasi Besar III - RELEASE KONTRAKTUR Dengan skin graft 10,246,000 7,856,000 18,102,000
214 Operasi Besar III - Repair defek dinding abdomen 10,246,000 7,856,000 18,102,000
215 Operasi Besar III - Repair fistel rectovaginal 10,246,000 7,856,000 18,102,000
216 Operasi Besar III - Reseksi Sigmoid 10,246,000 7,856,000 18,102,000
217 Operasi Besar III - Sectio alta 10,246,000 7,856,000 18,102,000
218 Operasi Besar III - Splenectomi pada trauma 10,246,000 7,856,000 18,102,000
219 Operasi Besar III - Splenektomi 10,246,000 7,856,000 18,102,000
Operasi Besar III - Splenektomi ec hipertensi portal/kelainan
220 10,246,000 7,856,000 18,102,000
hematologi lain
221 Operasi Besar III - Tutup Kolostomi Laparotomi 10,246,000 7,856,000 18,102,000
222 Operasi Besar III - Wide eksisi 10,246,000 7,856,000 18,102,000
JASA
PELAYANAN
223 Operasi Khusus I - A-V Shunt dengan graft vena/sintetis 12,334,000 9,456,000 21,790,000
224 Operasi Khusus I - AVM Angiografi + embolisasi (+ Radiografer) 12,334,000 9,456,000 21,790,000
225 Operasi Khusus I - Biopsi hepar 12,334,000 9,456,000 21,790,000
226 Operasi Khusus I - Breast Conserving Treatment 12,334,000 9,456,000 21,790,000
227 Operasi Khusus I - CAPD Perlaparoskopik 12,334,000 9,456,000 21,790,000
228 Operasi Khusus I - Coiling/Embolisasi PCS (+Radiografer) 12,334,000 9,456,000 21,790,000
229 Operasi Khusus I - Debridement angkat graft intraabdomen 12,334,000 9,456,000 21,790,000
230 Operasi Khusus I - Debulking tumor 12,334,000 9,456,000 21,790,000
231 Operasi Khusus I - Diseksi kelenjar inguinal 12,334,000 9,456,000 21,790,000
232 Operasi Khusus I - Diseksi leher posteralateral ( 1 sisi ) 12,334,000 9,456,000 21,790,000
233 Operasi Khusus I - Diseksi leher radikal klasik ( 1 sisi ) 12,334,000 9,456,000 21,790,000
234 Operasi Khusus I - Diseksi leher radikal modifikasi/fungsional 12,334,000 9,456,000 21,790,000
235 Operasi Khusus I - Diseksi leher supra omohyoid ( 1 sisi ) 12,334,000 9,456,000 21,790,000
236 Operasi Khusus I - Diseksi leher upper neck ( 1 sisi ) 12,334,000 9,456,000 21,790,000
237 Operasi Khusus I - Duodenoduodenostomi/duodenojejunostomi 12,334,000 9,456,000 21,790,000
238 Operasi Khusus I - Eksisi dan rekonstruksi limfedema 12,334,000 9,456,000 21,790,000
239 Operasi Khusus I - Eksisi hygroma colli/axilla pada neonatus 12,334,000 9,456,000 21,790,000
240 Operasi Khusus I - Eksisi luas 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Eksisi Luas dan Rekonstruksi Malformasi vaskular
241 12,334,000 9,456,000 21,790,000
Kompleks (tanpa graft)
242 Operasi Khusus I - Eksisi neurofibroma simpel 12,334,000 9,456,000 21,790,000
243 Operasi Khusus I - Eksisi teratoma ovarium 12,334,000 9,456,000 21,790,000
244 Operasi Khusus I - Eksisi, flap 12,334,000 9,456,000 21,790,000
245 Operasi Khusus I - Eksisi, rekonstruksi dengan skin graft 12,334,000 9,456,000 21,790,000
246 Operasi Khusus I - Eksplorasi buli 12,334,000 9,456,000 21,790,000
247 Operasi Khusus I - Eksplorasi CBD - Pasang T-Tube 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Ekstremitas Angiografi dengan balon (1 balon) (+
248 12,334,000 9,456,000 21,790,000
Radiografer)
Operasi Khusus I - Ekstremitas Angiografi dengan balon + stent (1
249 12,334,000 9,456,000 21,790,000
balon, 1 stent) + Radiografer
250 Operasi Khusus I - Esofagomyotomi (Operasi Heller) 12,334,000 9,456,000 21,790,000
251 Operasi Khusus I - Esofagostomi + gastrostomi (atreswia esofagus) 12,334,000 9,456,000 21,790,000
252 Operasi Khusus I - EVLT dengan multiple flebektomi 1 ekstremitas 12,334,000 9,456,000 21,790,000
253 Operasi Khusus I - Fistilektomi 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Flap kompleks 1 (lebih dari 1 flap, keystone flap 2
254 12,334,000 9,456,000 21,790,000
sisi)
255 Operasi Khusus I - Flap Kulit Komplek 12,334,000 9,456,000 21,790,000
256 Operasi Khusus I - Fundoplikasi gaster 12,334,000 9,456,000 21,790,000
257 Operasi Khusus I - Gastropexy 12,334,000 9,456,000 21,790,000
258 Operasi Khusus I - Hemiglosektomi 12,334,000 9,456,000 21,790,000
259 Operasi Khusus I - Hemimandibulektomi 12,334,000 9,456,000 21,790,000
260 Operasi Khusus I - Implantasi vena cava filter (+ Radiografer) 12,334,000 9,456,000 21,790,000
261 Operasi Khusus I - Kontraktur jari - jari 12,334,000 9,456,000 21,790,000
262 Operasi Khusus I - Laparatomi ekplorasi 12,334,000 9,456,000 21,790,000
263 Operasi Khusus I - Laparatomi pada peritonitis neonatus 12,334,000 9,456,000 21,790,000
264 Operasi Khusus I - Laparoskopik Appendektomi 12,334,000 9,456,000 21,790,000
265 Operasi Khusus I - Laparoskopik Kolesistektomi 12,334,000 9,456,000 21,790,000
266 Operasi Khusus I - Laparotomi Tumor Intra Abdomen 12,334,000 9,456,000 21,790,000
267 Operasi Khusus I - Laparotomi Tumor Retroperitoneal 12,334,000 9,456,000 21,790,000
268 Operasi Khusus I - Lumbal simpatektomi bilateral 12,334,000 9,456,000 21,790,000
269 Operasi Khusus I - Maksilektomi partialis 12,334,000 9,456,000 21,790,000
270 Operasi Khusus I - Mandibula kompleks 12,334,000 9,456,000 21,790,000
271 Operasi Khusus I - Mandibulektomi marginalis 12,334,000 9,456,000 21,790,000
272 Operasi Khusus I - Mandibulektomi partialis 12,334,000 9,456,000 21,790,000
273 Operasi Khusus I - Mastektomi radikal klasik 12,334,000 9,456,000 21,790,000
274 Operasi Khusus I - Mastektomi radikal modifikasi 12,334,000 9,456,000 21,790,000
275 Operasi Khusus I - MEA sederhana (cula) 12,334,000 9,456,000 21,790,000
276 Operasi Khusus I - Near total tiroidektomi 12,334,000 9,456,000 21,790,000
277 Operasi Khusus I - Nefrektomi parsial 12,334,000 9,456,000 21,790,000
278 Operasi Khusus I - Oovorektomi 12,334,000 9,456,000 21,790,000
279 Operasi Khusus I - Orchidopexy 12,334,000 9,456,000 21,790,000
280 Operasi Khusus I - Palatoplasty 12,334,000 9,456,000 21,790,000
281 Operasi Khusus I - Paratiroidektomi Partial 12,334,000 9,456,000 21,790,000
282 Operasi Khusus I - Parotidektomi totalis 12,334,000 9,456,000 21,790,000
283 Operasi Khusus I - Pasang akses vena 12,334,000 9,456,000 21,790,000
284 Operasi Khusus I - Pasang longline 12,334,000 9,456,000 21,790,000
285 Operasi Khusus I - Pembedahan kompartemental 12,334,000 9,456,000 21,790,000
JASA
PELAYANAN
286 Operasi Khusus I - Pyeloplasty 12,334,000 9,456,000 21,790,000
287 Operasi Khusus I - Pyloromyotomi (Operasi Fredet Ramstedt) 12,334,000 9,456,000 21,790,000
288 Operasi Khusus I - Redo release chordae 12,334,000 9,456,000 21,790,000
289 Operasi Khusus I - Reimplantasi ureter 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Rekonstruksi Aneurisma Arteri Iliaka per
290 12,334,000 9,456,000 21,790,000
laparotomi
291 Operasi Khusus I - Rekonstruksi dengan LD flap 12,334,000 9,456,000 21,790,000
292 Operasi Khusus I - Rekonstruksi Flaps 12,334,000 9,456,000 21,790,000
293 Operasi Khusus I - Rekonstruksi limfedema 12,334,000 9,456,000 21,790,000
294 Operasi Khusus I - Rekonstruksi Plate & Screw 12,334,000 9,456,000 21,790,000
295 Operasi Khusus I - Rekonstruksi sindaktili 12,334,000 9,456,000 21,790,000
296 Operasi Khusus I - Release chordae 12,334,000 9,456,000 21,790,000
297 Operasi Khusus I - Release chorde dan tunneling 12,334,000 9,456,000 21,790,000
298 Operasi Khusus I - RELEASE KONTRAKTUR Kompleks 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Repair defek dinding perut
299 12,334,000 9,456,000 21,790,000
(omphalocele/gastroschizis)
300 Operasi Khusus I - Repair gastrostomi 12,334,000 9,456,000 21,790,000
301 Operasi Khusus I - Repair perineum 12,334,000 9,456,000 21,790,000
302 Operasi Khusus I - Repair tendon 12,334,000 9,456,000 21,790,000
303 Operasi Khusus I - Reseksi anastomosis pada atresia usus, duplikasi 12,334,000 9,456,000 21,790,000
304 Operasi Khusus I - Reseksi gaster 12,334,000 9,456,000 21,790,000
305 Operasi Khusus I - Salvingoovarektomi 12,334,000 9,456,000 21,790,000
306 Operasi Khusus I - Santuli prosedur 12,334,000 9,456,000 21,790,000
307 Operasi Khusus I - Scrotoplasty+chordectomy 12,334,000 9,456,000 21,790,000
308 Operasi Khusus I - Splenektomi ec Hipertensi portal/lain 12,334,000 9,456,000 21,790,000
309 Operasi Khusus I - Splenektomi pada thalasemia, hipersplenisme 12,334,000 9,456,000 21,790,000
310 Operasi Khusus I - Split thickness skin graft luas (>10x20 cm) 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Stripping 2 tungkai, debridement, dan ligasi vena
311 12,334,000 9,456,000 21,790,000
perforantes
Operasi Khusus I - Stripping varises 2 tungkai dengan multiple
312 12,334,000 9,456,000 21,790,000
flebektomi
Operasi Khusus I - Stripping Varises 2 tungkai kompleks
313 12,334,000 9,456,000 21,790,000
(flebektomi/debridement ulkus vena)
314 Operasi Khusus I - Tiroidektomi subtotalis 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Total tiroidektomi + Berrypicking
315 12,334,000 9,456,000 21,790,000
(limfadenektomi)
Operasi Khusus I - Trombektomi 1 ekstremitas dengan angiojet (+
316 12,334,000 9,456,000 21,790,000
Angiografi, + Radiografer)
317 Operasi Khusus I - Unroofing kista higroma 12,334,000 9,456,000 21,790,000
Operasi Khusus I - Viseral Angiografi dengan balon (1 balon) (+
318 12,334,000 9,456,000 21,790,000
Radiografer)
Operasi Khusus I - Viseral Angiografi dengan balon + stent (1 balon, 1
319 12,334,000 9,456,000 21,790,000
stent) + Radiografer
320 Operasi Khusus II - Anastomosis usus dengan stapler 14,267,000 10,938,000 25,205,000
321 Operasi Khusus II - Bedah Laparaskopi anak 14,267,000 10,938,000 25,205,000
322 Operasi Khusus II - Cystojejenostomi 14,267,000 10,938,000 25,205,000
323 Operasi Khusus II - Eksisi luas malformasi vaskuler 14,267,000 10,938,000 25,205,000
324 Operasi Khusus II - Eksisi Neuroblastoma 14,267,000 10,938,000 25,205,000
325 Operasi Khusus II - Eksisi neurofibroma kompleks 14,267,000 10,938,000 25,205,000
326 Operasi Khusus II - Eksisi teratoma retroperitoneal 14,267,000 10,938,000 25,205,000
327 Operasi Khusus II - Eksisi teratoma sacrococcygeal 14,267,000 10,938,000 25,205,000
328 Operasi Khusus II - Eksisi tumor angiomatosis 14,267,000 10,938,000 25,205,000
329 Operasi Khusus II - Eksplorasi AVM 14,267,000 10,938,000 25,205,000
330 Operasi Khusus II - Eksplorasi CBD + bypass Biliodigestif 14,267,000 10,938,000 25,205,000
331 Operasi Khusus II - Eksplorasi dan rekonstruksi Aorta kasus trauma 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Eksplorasi dan rekonstruksi Aorta kasus trauma
332 14,267,000 10,938,000 25,205,000
dengan graft sintesis
Operasi Khusus II - Eksplorasi dan rekonstruksi vena cava dengan
333 14,267,000 10,938,000 25,205,000
autograft
Operasi Khusus II - Eksplorasi dan rekonstruksi vena cava dengan
334 14,267,000 10,938,000 25,205,000
graft sintesis
Operasi Khusus II - Eksplorasi dan rekonstruksi vena iliaka dengan
335 14,267,000 10,938,000 25,205,000
autograft
Operasi Khusus II - Eksplorasi dan rekonstruksi vena iliaka dengan
336 14,267,000 10,938,000 25,205,000
graft sintesis
337 Operasi Khusus II - Endoskopi tiroidektomi bilateral 14,267,000 10,938,000 25,205,000
338 Operasi Khusus II - Endoskopi tiroidektomi unilateral 14,267,000 10,938,000 25,205,000
339 Operasi Khusus II - Esofagostomi 14,267,000 10,938,000 25,205,000
JASA
PELAYANAN
340 Operasi Khusus II - Faringoplasty 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Flap kompleks 2 (myocutan flap, keystone flap di
341 14,267,000 10,938,000 25,205,000
atas 2 sisi)
Operasi Khusus II - Genitoplasty (Clitoroplasty, vaginoplasty,
342 14,267,000 10,938,000 25,205,000
phalioplasty)
343 Operasi Khusus II - Glosektomi totalis 14,267,000 10,938,000 25,205,000
344 Operasi Khusus II - Hemipelvektomi 14,267,000 10,938,000 25,205,000
345 Operasi Khusus II - Herniotomy + laparotomy + reseksi + anastomosis 14,267,000 10,938,000 25,205,000
346 Operasi Khusus II - Jahit hepar & hemositasis 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Karotis Angiografi dengan balon (1 balon) (+
347 14,267,000 10,938,000 25,205,000
Radiografer)
Operasi Khusus II - Karotis Angiografi dengan balon+stent (1 balon, 1
348 14,267,000 10,938,000 25,205,000
stent) (+Radiografer)
Operasi Khusus II - Karotis Endarterektomi (CEA, BEA) (+
349 14,267,000 10,938,000 25,205,000
Radiografer)
Operasi Khusus II - Karotis Endarterektomi (CEA, BEA) dengan graft
350 14,267,000 10,938,000 25,205,000
(+ Radiografer)
351 Operasi Khusus II - Konversi EVAR -> Open 14,267,000 10,938,000 25,205,000
352 Operasi Khusus II - Laparoskopi eksplorasi 14,267,000 10,938,000 25,205,000
353 Operasi Khusus II - Ligasi tinggi perlaparoskopi 14,267,000 10,938,000 25,205,000
354 Operasi Khusus II - Maksilektomi totalis 14,267,000 10,938,000 25,205,000
355 Operasi Khusus II - Miles/APR terbuka 14,267,000 10,938,000 25,205,000
356 Operasi Khusus II - Nefroureterectomy tumor wilms 14,267,000 10,938,000 25,205,000
357 Operasi Khusus II - Operasi Commando 14,267,000 10,938,000 25,205,000
358 Operasi Khusus II - Orbita 14,267,000 10,938,000 25,205,000
359 Operasi Khusus II - Parotidektomi radikal 14,267,000 10,938,000 25,205,000
360 Operasi Khusus II - Partial laringektomi 14,267,000 10,938,000 25,205,000
361 Operasi Khusus II - Pembedahan Forequater 14,267,000 10,938,000 25,205,000
362 Operasi Khusus II - Plikasi diafragma 14,267,000 10,938,000 25,205,000
363 Operasi Khusus II - Postero Sagital Anorectoplaty / PSARP 14,267,000 10,938,000 25,205,000
364 Operasi Khusus II - Reduksi Payudara 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Rekonstruksi Aneurisma Aorta Abdominalis dan
365 14,267,000 10,938,000 25,205,000
Arteri Iliaka per Laparotomi
Operasi Khusus II - Rekonstruksi Aneurisma Aorta Abdominalis per
366 14,267,000 10,938,000 25,205,000
laparotomi
Operasi Khusus II - Rekonstruksi Aortoiliak/bifemoral pada kasus
367 14,267,000 10,938,000 25,205,000
Leriche's syndrom
368 Operasi Khusus II - Rekonstruksi dengan silicon 14,267,000 10,938,000 25,205,000
369 Operasi Khusus II - Rekonstruksi dengan TRAM falp 14,267,000 10,938,000 25,205,000
370 Operasi Khusus II - Rekonstruksi Karotid body tumor 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Rekonstruksi kompleks arteri ekstremitas pada
371 14,267,000 10,938,000 25,205,000
CLI dengan graft
Operasi Khusus II - Rekonstruksi komplikasi A-V shunt
372 14,267,000 10,938,000 25,205,000
(pseudoaneurisma) A-V shunt dengan graft vena / sintetis
Operasi Khusus II - Rekonstruksi komplikasi pasca trauma (A-V
373 14,267,000 10,938,000 25,205,000
fistula/pseudoaneurisma)
374 Operasi Khusus II - Rekonstruksi plate and screw + bone graft 14,267,000 10,938,000 25,205,000
375 Operasi Khusus II - Rekonstruksi polidaktili 14,267,000 10,938,000 25,205,000
376 Operasi Khusus II - Rekonstruksi telinga tahap II 14,267,000 10,938,000 25,205,000
377 Operasi Khusus II - Rekonstruksi tumor dengan flap 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Rekonstruksi Vaskular arteri inomiata atau
378 14,267,000 10,938,000 25,205,000
subklavia dengan graft sintesis
379 Operasi Khusus II - Rekonstruksi vaskuler aneurisma perifer 14,267,000 10,938,000 25,205,000
380 Operasi Khusus II - Release Thoracic Outlet Syndrome 14,267,000 10,938,000 25,205,000
381 Operasi Khusus II - Repair buli 14,267,000 10,938,000 25,205,000
382 Operasi Khusus II - Repair fistula urethrokutan 14,267,000 10,938,000 25,205,000
383 Operasi Khusus II - Repair omfalokel 14,267,000 10,938,000 25,205,000
384 Operasi Khusus II - Repair PSARP 14,267,000 10,938,000 25,205,000
385 Operasi Khusus II - Repair Urethroplasty 14,267,000 10,938,000 25,205,000
386 Operasi Khusus II - Repair vagina 14,267,000 10,938,000 25,205,000
387 Operasi Khusus II - Repair vesica 14,267,000 10,938,000 25,205,000
388 Operasi Khusus II - Reseksi Anterior Terbuka 14,267,000 10,938,000 25,205,000
389 Operasi Khusus II - Reseksi Gaster Parsial 14,267,000 10,938,000 25,205,000
390 Operasi Khusus II - Reseksi+anastomosis esofagus 14,267,000 10,938,000 25,205,000
391 Operasi Khusus II - Rhinoplasty 14,267,000 10,938,000 25,205,000
392 Operasi Khusus II - Simpatektomi laparoskopi 14,267,000 10,938,000 25,205,000
393 Operasi Khusus II - Simpatektomi torakoskopi 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Splenektomi dan Ligasi vv coronaria serta
394 14,267,000 10,938,000 25,205,000
Splenorenal Shunt
JASA
PELAYANAN
Operasi Khusus II - Splenektomi, Ligasi vv coronaria serta Splenorenal
395 14,267,000 10,938,000 25,205,000
shunt pada hipertensi porta
396 Operasi Khusus II - Splenorenal Shunt warren pada hipertensi portal 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Splenorenal Shunt warren pada hipertensi portal
397 14,267,000 10,938,000 25,205,000
dengan graft sinstesis
398 Operasi Khusus II - Subcondylus 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Tindakan embolisasi+angiografi (endoleak)
399 14,267,000 10,938,000 25,205,000
(+Radiografer)
400 Operasi Khusus II - TIPS Endovaskular (+ Radiografer) 14,267,000 10,938,000 25,205,000
401 Operasi Khusus II - Total laringektomi 14,267,000 10,938,000 25,205,000
402 Operasi Khusus II - Total mandibulektomi 14,267,000 10,938,000 25,205,000
403 Operasi Khusus II - Transposisi penis 14,267,000 10,938,000 25,205,000
Operasi Khusus II - Trombektomi 2 ekstremitas dengan angiojet (+
404 14,267,000 10,938,000 25,205,000
Radiografer, + Angiografi)
405 Operasi Khusus II - Urethroplasty 14,267,000 10,938,000 25,205,000
406 Operasi Khusus II - ZMC 14,267,000 10,938,000 25,205,000
Operasi Khusus III - Abdominoperineal pull through (malformasi
407 19,067,000 14,619,000 33,686,000
anorectal)
Operasi Khusus III - Abdominorectal pull through (Swenson
408 19,067,000 14,619,000 33,686,000
Procedure)
409 Operasi Khusus III - Alveolar bone graft 19,067,000 14,619,000 33,686,000
410 Operasi Khusus III - Cervicotomy + Debridement 19,067,000 14,619,000 33,686,000
411 Operasi Khusus III - Cervicotomy + Repair Esofagus 19,067,000 14,619,000 33,686,000
412 Operasi Khusus III - Cervicotomy + Repair Trakea 19,067,000 14,619,000 33,686,000
413 Operasi Khusus III - Cervicotomy + Sternotomi + Debridement 19,067,000 14,619,000 33,686,000
414 Operasi Khusus III - Choledochojejunostomy roux en y 19,067,000 14,619,000 33,686,000
415 Operasi Khusus III - Cystojejunostomi anastomosis roux en y 19,067,000 14,619,000 33,686,000
416 Operasi Khusus III - Duhamel-Adang procedure 19,067,000 14,619,000 33,686,000
417 Operasi Khusus III - Duhamel-Martin procedure 19,067,000 14,619,000 33,686,000
418 Operasi Khusus III - Eksenterasi Pelvis 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Eksisi & rekonstruksi vaskuler pada malformasi
419 19,067,000 14,619,000 33,686,000
vaskuler
420 Operasi Khusus III - Eksisi kista saluran empedu 19,067,000 14,619,000 33,686,000
421 Operasi Khusus III - Eksisi, rekonstruksi dengan flap/implant 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Eksplorasi & rekonstruksi vaskuler pada trauma
422 19,067,000 14,619,000 33,686,000
vaskuler akut
423 Operasi Khusus III - Endorectal pull through (Soave-bolley procedure) 19,067,000 14,619,000 33,686,000
424 Operasi Khusus III - Esophagus replacement procedure 19,067,000 14,619,000 33,686,000
425 Operasi Khusus III - EVAR Abdomen+iliaka single (+ Radiografer) 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Evar Aorta abdominalis sederhana (+
426 19,067,000 14,619,000 33,686,000
Radiografer)
427 Operasi Khusus III - EVAR iliaka bilateral (+ Radiografer) 19,067,000 14,619,000 33,686,000
428 Operasi Khusus III - EVAR Iliaka Single (+ Radiografer) 19,067,000 14,619,000 33,686,000
429 Operasi Khusus III - EVAR kompleks (+ Radiografer) 19,067,000 14,619,000 33,686,000
430 Operasi Khusus III - Free flap 19,067,000 14,619,000 33,686,000
431 Operasi Khusus III - Fronto orbita advancement 19,067,000 14,619,000 33,686,000
432 Operasi Khusus III - Hartman procedure 19,067,000 14,619,000 33,686,000
433 Operasi Khusus III - Karotis Endarterektomi 19,067,000 14,619,000 33,686,000
434 Operasi Khusus III - Kasai prosedur 19,067,000 14,619,000 33,686,000
435 Operasi Khusus III - Ladd's procedure 19,067,000 14,619,000 33,686,000
436 Operasi Khusus III - Laparoskopi herniotomi 19,067,000 14,619,000 33,686,000
437 Operasi Khusus III - Laparoskopik Anterior Reseksi 19,067,000 14,619,000 33,686,000
438 Operasi Khusus III - Laparoskopik Gastrektomi 19,067,000 14,619,000 33,686,000
439 Operasi Khusus III - Laparoskopik Kolektomi 19,067,000 14,619,000 33,686,000
440 Operasi Khusus III - Laparoskopik Miles/ LAR 19,067,000 14,619,000 33,686,000
441 Operasi Khusus III - Laparoskopik Reseksi Hati 19,067,000 14,619,000 33,686,000
442 Operasi Khusus III - LAR Terbuka 19,067,000 14,619,000 33,686,000
443 Operasi Khusus III - MEA kompleks (kraniotomi) 19,067,000 14,619,000 33,686,000
444 Operasi Khusus III - Mediastinoskopi + Biopsi 19,067,000 14,619,000 33,686,000
445 Operasi Khusus III - Orthognatic surgery 19,067,000 14,619,000 33,686,000
446 Operasi Khusus III - Osteotomi + repair buli 19,067,000 14,619,000 33,686,000
447 Operasi Khusus III - Panfacial fracture 19,067,000 14,619,000 33,686,000
448 Operasi Khusus III - Pemisahan kembar siam 19,067,000 14,619,000 33,686,000
449 Operasi Khusus III - Penutupan defek hernia diafragmatika 19,067,000 14,619,000 33,686,000
450 Operasi Khusus III - Portoenterostomi (Operasi Kassai) 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Posterosagital
451 19,067,000 14,619,000 33,686,000
anorectovaginourethroplasty/PSARVUP
JASA
PELAYANAN
452 Operasi Khusus III - PSARP + laparotomy 19,067,000 14,619,000 33,686,000
453 Operasi Khusus III - Redo thoracotomy 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Rekonstruksi kerusakan katup vena dalam
454 19,067,000 14,619,000 33,686,000
tungkai pada DVT kronik/CVI
455 Operasi Khusus III - Rekonstruksi kloaka 19,067,000 14,619,000 33,686,000
456 Operasi Khusus III - Rekonstruksi telinga tahap I 19,067,000 14,619,000 33,686,000
457 Operasi Khusus III - Rekonstruksi tumor dengan kraniotomi 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Rekonstruksi vaskuler arteri tungkai / lengan pada
458 19,067,000 14,619,000 33,686,000
Chronic Limb Ischemic
Operasi Khusus III - Rekonstruksi vaskuler pada AAA + Arteri
459 tungkai Spleno renal shunt pada hipertensi portal Rekonstruksi vena- 19,067,000 14,619,000 33,686,000
vena abdomen pelvis
Operasi Khusus III - Rekonstruksi vaskuler pada AAA/arteri illiaka
460 19,067,000 14,619,000 33,686,000
per laparatomi
461 Operasi Khusus III - Release chordae + urethroplasty 19,067,000 14,619,000 33,686,000
462 Operasi Khusus III - RELEASE KONTRAKTUR Dengan free lap 19,067,000 14,619,000 33,686,000
463 Operasi Khusus III - Repair bifid scrotum 19,067,000 14,619,000 33,686,000
464 Operasi Khusus III - Repair bladder extrophy 19,067,000 14,619,000 33,686,000
465 Operasi Khusus III - Repair cloacal extrophy 19,067,000 14,619,000 33,686,000
466 Operasi Khusus III - repair ekstrofi 19,067,000 14,619,000 33,686,000
467 Operasi Khusus III - Repair esofagostomi 19,067,000 14,619,000 33,686,000
468 Operasi Khusus III - Repair fistel 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Repair Pectus Excavatum (Sternal
469 19,067,000 14,619,000 33,686,000
Turnover/Ravitch Procedure)
470 Operasi Khusus III - Replantasi 19,067,000 14,619,000 33,686,000
471 Operasi Khusus III - Reseksi Esofagus & Rekonstruksi 19,067,000 14,619,000 33,686,000
472 Operasi Khusus III - Reseksi hepar (tumor, trauma) 19,067,000 14,619,000 33,686,000
473 Operasi Khusus III - Reseksi Hepar Parsial/Segmental/Lobus terbuka 19,067,000 14,619,000 33,686,000
474 Operasi Khusus III - Retrorectal pull through (duhamel procedure) 19,067,000 14,619,000 33,686,000
475 Operasi Khusus III - Sternotomi + Biopsi 19,067,000 14,619,000 33,686,000
476 Operasi Khusus III - Sternotomi + Debridement 19,067,000 14,619,000 33,686,000
477 Operasi Khusus III - Sternotomi + Eksisi Tumor Mediastinum 19,067,000 14,619,000 33,686,000
478 Operasi Khusus III - Sternotomi + Perikardiektomi 19,067,000 14,619,000 33,686,000
479 Operasi Khusus III - Sternotomi + Rekonstruksi Dinding Dada 19,067,000 14,619,000 33,686,000
480 Operasi Khusus III - Sternotomi + Repair jantung 19,067,000 14,619,000 33,686,000
481 Operasi Khusus III - Sternotomi+Timektomi 19,067,000 14,619,000 33,686,000
482 Operasi Khusus III - Sub Xyphoid Pericardial Window 19,067,000 14,619,000 33,686,000
483 Operasi Khusus III - TEVAR (+Radiografer) 19,067,000 14,619,000 33,686,000
484 Operasi Khusus III - TEVAR Kompleks (+ Radiografer) 19,067,000 14,619,000 33,686,000
485 Operasi Khusus III - Thoracotomi + anastomosis esofagus 19,067,000 14,619,000 33,686,000
486 Operasi Khusus III - Thoracotomy + Gastrostomi 19,067,000 14,619,000 33,686,000
487 Operasi Khusus III - Torakoplasti 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Torakotomi /Mediastinostomi + Biopsi
488 19,067,000 14,619,000 33,686,000
Chamberlains
489 Operasi Khusus III - Torakotomi + Air Plombage 19,067,000 14,619,000 33,686,000
490 Operasi Khusus III - Torakotomi + Anastomosis Esofagus 19,067,000 14,619,000 33,686,000
491 Operasi Khusus III - Torakotomi + Bullaectomy 19,067,000 14,619,000 33,686,000
492 Operasi Khusus III - Torakotomi + Debridement 19,067,000 14,619,000 33,686,000
Operasi Khusus III - Torakotomi + Debridement + Drainase Abses
493 19,067,000 14,619,000 33,686,000
Hepar
494 Operasi Khusus III - Torakotomi + Dekortikasi 19,067,000 14,619,000 33,686,000
495 Operasi Khusus III - Torakotomi + Ekstraksi Benda Asing 19,067,000 14,619,000 33,686,000
496 Operasi Khusus III - Torakotomi + Eloeser Window 19,067,000 14,619,000 33,686,000
497 Operasi Khusus III - Torakotomi + Esofagektomi 19,067,000 14,619,000 33,686,000
498 Operasi Khusus III - Torakotomi + Fiksasi Iga 19,067,000 14,619,000 33,686,000
499 Operasi Khusus III - Torakotomi + Hemostasis 19,067,000 14,619,000 33,686,000
500 Operasi Khusus III - Torakotomi + Lobektomi 19,067,000 14,619,000 33,686,000
501 Operasi Khusus III - Torakotomi + Muscle Plumbage 19,067,000 14,619,000 33,686,000
502 Operasi Khusus III - Torakotomi + Pericardial Window 19,067,000 14,619,000 33,686,000
503 Operasi Khusus III - Torakotomi + Pleurectomy 19,067,000 14,619,000 33,686,000
504 Operasi Khusus III - Torakotomi + Pneumektomi 19,067,000 14,619,000 33,686,000
505 Operasi Khusus III - Torakotomi + Rekonstruksi Dinding Dada 19,067,000 14,619,000 33,686,000
506 Operasi Khusus III - Torakotomi + Repair Bronchus 19,067,000 14,619,000 33,686,000
507 Operasi Khusus III - Torakotomi + Repair Diafragma 19,067,000 14,619,000 33,686,000
508 Operasi Khusus III - Torakotomi + Repair Duktus Torasikus 19,067,000 14,619,000 33,686,000
509 Operasi Khusus III - Torakotomi + Repair Fistula Bronchopleura 19,067,000 14,619,000 33,686,000
510 Operasi Khusus III - Torakotomi + Repair paru 19,067,000 14,619,000 33,686,000
511 Operasi Khusus III - Torakotomi + Repair Trakea 19,067,000 14,619,000 33,686,000
JASA
PELAYANAN
512 Operasi Khusus III - Torakotomi + Simpatektomi Torakal 19,067,000 14,619,000 33,686,000
513 Operasi Khusus III - Torakotomi+ Eksisi Tumor Mediastinum 19,067,000 14,619,000 33,686,000
514 Operasi Khusus III - Total Gastrektomi dan Rekonstruksi/Deseksi D2 19,067,000 14,619,000 33,686,000
515 Operasi Khusus III - Transanal mucosektomy 19,067,000 14,619,000 33,686,000
516 Operasi Khusus III - Transanal pull through 19,067,000 14,619,000 33,686,000
517 Operasi Khusus III - Transplantasi hepar/hati 19,067,000 14,619,000 33,686,000
518 Operasi Khusus III - Transposisi kolon 19,067,000 14,619,000 33,686,000
519 Operasi Khusus III - Whipple's Procedure (P3D) 19,067,000 14,619,000 33,686,000
Operasi Khusus Alat - Minimally Invasive Repair of Pectus
520 20,975,000 16,085,000 37,060,000
Excavatum (Nuss Procedure)
521 Operasi Khusus Alat - Sternotomi + Bypass Graft Vena 20,975,000 16,085,000 37,060,000
Operasi Khusus Alat - Torakotomi + Repair Hernia Diafragma dengan
522 20,975,000 16,085,000 37,060,000
Mesh Graft
523 Operasi Khusus Alat - VATS + Bullaectomi 20,975,000 16,085,000 37,060,000
524 Operasi Khusus Alat - VATS + Dekortikasi 20,975,000 16,085,000 37,060,000
525 Operasi Khusus Alat - VATS + Eksisi Baji Paru 20,975,000 16,085,000 37,060,000
526 Operasi Khusus Alat - VATS + Ekstraksi Benda Asing 20,975,000 16,085,000 37,060,000
527 Operasi Khusus Alat - VATS + Lobektomi 20,975,000 16,085,000 37,060,000
Operasi Khusus Alat - VATS + Lung Volume Reduction Surgery
528 20,975,000 16,085,000 37,060,000
(LVRS)
529 Operasi Khusus Alat - VATS + Pleurodesis 20,975,000 16,085,000 37,060,000
530 Operasi Khusus Alat - VATS + Repair Ductus Thoracicus 20,975,000 16,085,000 37,060,000
531 Operasi Khusus Alat - VATS + Thymectomy 20,975,000 16,085,000 37,060,000
Operasi Khusus Alat - VATS + Uni / Bilateral Thoracic
532 20,975,000 16,085,000 37,060,000
Sympathetocctomy (Bilateral ETS)
8. CLEFT DAN CRANIOFACIAL CENTER
1 Abdominolipectomy 8,952,000 6,863,000 15,815,000
2 ALT Free Flap 16,852,000 12,920,000 29,772,000
3 Amputasi + STSG 16,070,000 12,321,000 28,391,000
4 Angkat jaitan besar/Dresing/Jait Luka 8,933,000 6,848,000 15,781,000
5 Angkat jaitan kecil/Dresing/Jait Luka 3,308,000 2,537,000 5,845,000
6 Angkat jaitan sedang/Dresing/Jait Luka 4,623,000 3,544,000 8,167,000
7 augmentasi mamae 8,991,000 6,893,000 15,884,000
8 BLEPHARO PLASTY Bawah 8,991,000 6,893,000 15,884,000
9 Debridement + STSG 19,443,000 14,906,000 34,349,000
10 Face lift Mini 8,991,000 6,893,000 15,884,000
11 Free Fibular Flap /FFF(microsurgery) 49,424,000 37,891,000 87,315,000
12 Ganti balutan ( dlm narkose ) 18,997,000 14,565,000 33,562,000
13 Hipospadi Tahap II ( Uretroplasty ) 8,015,000 6,144,000 14,159,000
14 Injeksi sklerosing 7,048,000 5,404,000 12,452,000
15 Labio Plasty 8,573,000 6,572,000 15,145,000
16 Ld free flap 16,852,000 12,920,000 29,772,000
17 Liposuction 10,064,000 7,717,000 17,781,000
18 Microtia Tahap II 16,068,000 12,319,000 28,387,000
19 Necklift 8,991,000 6,893,000 15,884,000
20 ORIF fraktur parasimpisis Mandibula 7,048,000 5,404,000 12,452,000
21 ORIF Pan Facial fractur 16,426,000 12,594,000 29,020,000
22 Palato Plasty 9,541,000 7,315,000 16,856,000
23 Pasang tissue ekspander 18,799,000 14,413,000 33,212,000
24 Potong flap (lokal) 18,993,000 14,561,000 33,554,000
25 Radial for arm free flap 16,852,000 12,920,000 29,772,000
26 Rekonstruksi hidung dgn Facial Cleft (bius) 12,273,000 9,409,000 21,682,000
27 Rekonstruksi Rima Orbitha 15,205,000 11,658,000 26,863,000
28 Rekonstruksi Sindaktili , 1,455,000 1,116,000 2,571,000
29 Rekonstruksi telinga ( microtia ) Tahap I 19,023,000 14,584,000 33,607,000
30 Release Kontraktur 20,234,000 15,512,000 35,746,000
31 Rhino Plasty 10,559,000 8,096,000 18,655,000
32 Rhino Plasty ( Lokal ) 7,108,000 5,450,000 12,558,000
33 sirkumsisi bius umum 2,579,000 1,978,000 4,557,000
34 STSG 7,827,000 6,001,000 13,828,000
35 total face lift 8,991,000 6,893,000 15,884,000
36 Total liposuction 8,991,000 6,893,000 15,884,000
37 Tutup Defek 7,827,000 6,001,000 13,828,000
9. UNIT LUKA BAKAR
1 EXCISIONAL DEBRIDEMENT + STSG + Aputasi 5,457,000 4,184,000 9,641,000
Excisional Debridement / Nekrotomi/ Eskarektomi (kategori tindakan
2 5,438,000 4,170,000 9,608,000
disamakan)
3 Excisional Debridement dan STSG 5,434,000 4,166,000 9,600,000
4 Fasiotomi 3,822,000 2,930,000 6,752,000
JASA
PELAYANAN
5 Non Excisional Debridement 3,827,000 2,935,000 6,762,000
10. ORTHOPEDI
Above elbow / below elbow amputation for Bone / Soft tissue tumor of
1 12,194,000 9,350,000 21,544,000
upper extremity
Above elbow / below elbow amputation for Infection/ Necrotic/ Non
2 12,190,000 9,346,000 21,536,000
vital/ Injury of upper extremity
Above knee / Below knee amputation for Bone / Soft tissue tumor of
3 12,164,000 9,325,000 21,489,000
lower extremity
Above knee / Below knee amputation for Infection/ Necrotic/ Non
4 12,190,000 9,346,000 21,536,000
vital/ Injury of lower extremity
Above knee / Below knee amputation for Infection/ Necrotic/ Non
5 12,189,000 9,345,000 21,534,000
vital/ Injury of upper extremity
Amputation / disarticulation for Finger injury / trauma/ Non vital tissue
6 7,710,000 5,911,000 13,621,000
(Single)
Amputation / disarticulation for Toe injury / trauma/ Non vital tissue
7 6,410,000 4,914,000 11,324,000
(Single)
Amputation / disarticulation of finger (single) for Bone / soft tissue
8 8,672,000 6,648,000 15,320,000
tumor of hand
Amputation / disarticulation of toe (Single) for Bone / Soft tissue
9 7,534,000 5,776,000 13,310,000
tumor (toe)
10 Amputation for Polydactily 8,686,000 6,660,000 15,346,000
11 Amputation with soft tissue reconstruction for Polydactily 13,424,000 10,291,000 23,715,000
12 Anterior discectomy / release for Scoliosis 14,526,000 11,137,000 25,663,000
13 Aplication of skeletal traction for Fracture of femur / pelvis 5,086,000 3,900,000 8,986,000
Application of axial traction or external fixation device for Simple
14 7,908,000 6,063,000 13,971,000
vertebral fracture / dislocation / deformity
15 Application of external fixation for Pelvic fracture 11,345,000 8,697,000 20,042,000
16 Arhtroscopic debridement & loose bodies removal for Joint arthritis 11,469,000 8,793,000 20,262,000
17 Arhtroscopic diagnostic / biopsy for Joint Arthritis / Capsulitis 9,192,000 7,047,000 16,239,000
18 Arthoscopic bankart repair for Reccurent shoulder dislocation 16,742,000 12,835,000 29,577,000
19 Arthrodhesis for Large joint destruction / infection /injury/deformity 14,047,000 10,770,000 24,817,000
Arthrodhesis for Small joint arthritis/ destruction / infection
20 11,639,000 8,923,000 20,562,000
/injury/deformity
21 Arthroscopic ligament reconstruction for Patellar ligament injury 16,742,000 12,835,000 29,577,000
22 Arthroscopic meniscus repair for Knee meniscus injury 16,742,000 12,835,000 29,577,000
23 Arthroscopic Menisectomy for Knee meniscus injury 13,961,000 10,703,000 24,664,000
24 Arthroscopic plica release for Knee plica syndrome 13,961,000 10,703,000 24,664,000
25 Arthroscopic reconstruction for Knee ligament injury 16,742,000 12,835,000 29,577,000
26 Arthroscopic release / reconstruction for Joint impingement 15,834,000 12,139,000 27,973,000
27 Arthroscopic release for Peripheral nerve entrapment 11,555,000 8,860,000 20,415,000
28 Arthroscopic repair for Rotator cuff injury 16,742,000 12,835,000 29,577,000
29 Body cast for Simple vertebral fracture / dislocation / deformity 8,051,000 6,172,000 14,223,000
30 Bone lengthening for Limb length inequality 16,676,000 12,785,000 29,461,000
31 Bone procedure for Cerebral palsy 16,676,000 12,785,000 29,461,000
32 Bone procedure for Finger and Hand deformity 16,464,000 12,622,000 29,086,000
33 Bone procedure for Foot / Ankle Deformity 16,229,000 12,442,000 28,671,000
34 Bone procedure for Hand & forearm deformity 16,464,000 12,622,000 29,086,000
35 Bone procedure for Sprain / dislocation of ligaments and tendons 16,385,000 12,561,000 28,946,000
36 Bone Procedure for Stiffness / spastic / contracture joint 16,678,000 12,787,000 29,465,000
Bone Procedure for Stiffness / spastic / contracture joint of hand &
37 16,464,000 12,622,000 29,086,000
forearm
38 Bone reconstruction for Neglected Case 16,678,000 12,787,000 29,465,000
Bone reconstruction with stem cell therapy for Non union / bone defect
39 16,678,000 12,787,000 29,465,000
/ Pseudoarthrosis
40 Bone spacer application for Bone defect 9,355,000 7,173,000 16,528,000
41 Botox injection for Cerebral palsy 5,758,000 4,415,000 10,173,000
42 Bristow / letarjet procedure for Reccurent shoulder dislocation 16,646,000 12,763,000 29,409,000
Cancellous / Non Vascularized Bone graft for Bone Defect <2cm /
43 8,217,000 6,300,000 14,517,000
Non union
Cancellous / Non Vascularized Bone graft for Bone Defect > 2cm /
44 9,493,000 7,278,000 16,771,000
Non union
45 Cancellous Bone graft for Bone Defect < 2cm / Non union 8,217,000 6,300,000 14,517,000
46 Closed reduction & Casting for Closed fracture (All) 8,407,000 6,446,000 14,853,000
47 Closed reduction & fixation for Acquired Joint dislocation (Acute) 6,921,000 5,306,000 12,227,000
Closed reduction & simple wire pinning for Closed fracture of
48 11,192,000 8,581,000 19,773,000
periarticular
49 Closed reduction, arthrogram & Hemispica for DDH 10,869,000 8,333,000 19,202,000
JASA
PELAYANAN
50 Closed reduction, Casting for Salter Harris Fracture 8,353,000 6,404,000 14,757,000
51 Closed reduction, percutaneous fixation for SCFE 11,564,000 8,865,000 20,429,000
52 Complicated Total Joint Arthroplasty for Hip fracture / arthritis 16,804,000 12,883,000 29,687,000
53 Complicated Total Joint Arthroplasty for Knee arthritis 16,913,000 12,966,000 29,879,000
54 Correction with bone procedure for CTEV 16,676,000 12,785,000 29,461,000
55 Corrective osteotomy & fixation for Bone deformity 16,678,000 12,787,000 29,465,000
56 Curretage and bone graft for Large sized benign bone tumor (>10cm) 14,138,000 10,839,000 24,977,000
Curretage and bone graft for Small / medium sized benign bone tumor
57 11,768,000 9,023,000 20,791,000
(<10cm)
Debridement & application of external fixation for Open fracture GA
58 9,842,000 7,546,000 17,388,000
III of long bone (Single)
Debridement & application of Joint spanning external fixation for
59 12,119,000 9,292,000 21,411,000
Open fracture of periarticular / intra articular
Debridement & external splinting for Open fracture GA I-II of long
60 8,415,000 6,452,000 14,867,000
bone (Single)
Debridement & ORIF for Open Fracture GA I-II of shaft long bone
61 11,770,000 9,024,000 20,794,000
(Single)
Debridement & Primary Suture for Open wound (<10cm without skin
62 5,455,000 4,183,000 9,638,000
loss)
Debridement & Primary Suture for Open wound (>10cm without skin
63 6,002,000 4,602,000 10,604,000
loss)
64 Debridement and decompression for Specific / pyogenic spondylitis 16,594,000 12,722,000 29,316,000
65 Debridement for Necrotic tissue (Multiple) 6,002,000 4,602,000 10,604,000
66 Debridement for Necrotic tissue (Single) 5,455,000 4,183,000 9,638,000
67 Debridement for Open fracture GA I-II 6,572,000 5,038,000 11,610,000
Debridement only, anterior / posterior for Specific / pyogenic
68 11,830,000 9,070,000 20,900,000
spondylitis
69 Debridement or abcess drainage for Finger infection 6,594,000 5,055,000 11,649,000
Debridement, saucerization & sequestrectomy for Chronic
70 9,211,000 7,062,000 16,273,000
osteomyelitis
71 Debulking for Macrodactily 15,926,000 12,211,000 28,137,000
Decompression only (laminectomy or laminotomy) (Single) for
72 14,318,000 10,978,000 25,296,000
Compression of spinal cord or nerve root
73 Deformity correction (multiple) for Spinal deformity 16,904,000 12,961,000 29,865,000
74 Discography (Multiple) for Chronic back pain / leg pain 7,730,000 5,927,000 13,657,000
75 Discography (Single) for Chronic back pain / leg pain 6,321,000 4,846,000 11,167,000
76 Distant Flap for Soft tissue defect 18,354,000 14,071,000 32,425,000
Double pelvic osteotomy and internal or external fixation for
77 16,676,000 12,785,000 29,461,000
Symphysiolysis
78 Epidural Block for Chronic back pain / leg pain 6,727,000 5,158,000 11,885,000
79 Epidurolysis for Chronic back pain / leg pain 6,321,000 4,846,000 11,167,000
80 Excision (Multiple) for Malignancy 16,904,000 12,961,000 29,865,000
81 Excision (Single) for Malignancy 14,316,000 10,976,000 25,292,000
Excision / Resection for Bone / Soft tissue tumor in difficult site
82 18,114,000 13,887,000 32,001,000
(Scapula, pelvic, spine, deep muscles, or complex neurovascular area)
83 Excision for Ganglion / Wart/ Nevus/ Clavus 7,090,000 5,436,000 12,526,000
84 Exploration & extraction (open) for Corpus Alieum (Single) 7,710,000 5,911,000 13,621,000
85 Facet block (Multiple) for Chronic back pain / leg pain 8,350,000 6,402,000 14,752,000
86 Facet block (Single) for Chronic back pain / leg pain 6,321,000 4,846,000 11,167,000
87 Femoral osteotomy and fixation for LCPD 14,400,000 11,040,000 25,440,000
88 forequarter amputation for Bone / Soft tissue tumor of upper extremity 13,628,000 10,449,000 24,077,000
Forequarter amputation for Infection/Necrotic/Non vital/Injury of
89 17,645,000 13,527,000 31,172,000
upper extremity
Forminal / Nerve Root Block (Multiple) for Chronic back pain / leg
90 7,730,000 5,927,000 13,657,000
pain
91 Forminal / Nerve Root Block (Single) for Chronic back pain / leg pain 6,321,000 4,846,000 11,167,000
92 FTSG for Skin defect 11,214,000 8,597,000 19,811,000
Hemiarthroplasty for Bone / Soft tissue tumor with pathological
93 14,534,000 11,142,000 25,676,000
fracture
94 Hemiarthroplasty for Hip fracture / arthritis 10,896,000 8,354,000 19,250,000
95 Hemipelvectomy for Bone / Soft tissue tumor of lower extremity 19,188,000 14,711,000 33,899,000
Hemipelvectomy for Infection/Necrotic/Non vital/Injury of lower
96 17,647,000 13,530,000 31,177,000
extremity
97 Hip disarticulation for Bone / Soft tissue tumor of lower extremity 12,645,000 9,695,000 22,340,000
JASA
PELAYANAN
Hip disarticulation for Infection/Necrotic/Non vital/Injury of lower
98 14,713,000 11,280,000 25,993,000
extremity
99 IDET (multiple) for Discogenic pain / intervertebral disc herniaton 10,007,000 7,673,000 17,680,000
100 IDET (single) for Discogenic pain / intervertebral disc herniaton 8,078,000 6,194,000 14,272,000
101 Implant removal for Fused vertebra 8,919,000 6,838,000 15,757,000
102 Interbody fusion for Spinal Instability 17,015,000 13,044,000 30,059,000
103 Intralessional stem cell injection for Spinal cord injury 7,730,000 5,927,000 13,657,000
104 Kyphoplasty / vertebroplasty for Compression / burst fracture 11,145,000 8,545,000 19,690,000
105 laminoplasty for Cervical myelopathy 16,885,000 12,946,000 29,831,000
106 Liberation for Joint Stiffness 11,578,000 8,877,000 20,455,000
107 Limb salvage surgery: (stage 2) for Bone / Soft tissue tumor 18,115,000 13,889,000 32,004,000
108 Limb salvage surgery: Extracorporeal irradiation (stage 1) 18,898,000 14,489,000 33,387,000
Limb salvage surgery: Extracorporeal irradiation (stage 2) for Bone /
109 18,115,000 13,889,000 32,004,000
Soft tissue tumor
Limb salvage surgery: reconstruction with arthrodhesis for
110 18,482,000 14,169,000 32,651,000
Periarticular Bone / Soft tissue tumor
111 Limb salvage surgery: reconstruction with endoprosthesis 18,945,000 14,525,000 33,470,000
Limb salvage surgery: reconstruction with non vascularized bone / soft
112 17,155,000 13,153,000 30,308,000
tissue graft for Bone / Soft tissue tumor
Limb salvage surgery: reconstruction with non vascularized bone graft
113 19,431,000 14,897,000 34,328,000
for Bone / Soft tissue tumor
Limb salvage surgery: reconstruction with vascularized bone / soft
114 22,058,000 16,911,000 38,969,000
tissue graft for Bone / Soft tissue tumor
115 Limb salvage surgery: stage 1 for Bone / Soft tissue tumor 19,431,000 14,897,000 34,328,000
Marginal Excision for Large sized benign soft tissue tumor (diameter
116 11,214,000 8,597,000 19,811,000
>10cm)
Marginal Excision for Medium sized benign soft tissue tumor
117 8,672,000 6,648,000 15,320,000
(diameter 5-10cm)
Marginal Excsion for Small sized benign soft tissue tumor (diameter
118 7,281,000 5,582,000 12,863,000
<5cm)
119 Medial branch block (Multiple) for Chronic back pain / leg pain 7,730,000 5,927,000 13,657,000
120 Medial branch block (Single) for Chronic back pain / leg pain 6,321,000 4,846,000 11,167,000
121 Microscopic discectomy (single) for Intervertebral disc herniation 14,036,000 10,762,000 24,798,000
Minimal invasive osteosynthesis with image guided for Closed shaft/
122 14,078,000 10,794,000 24,872,000
intra articular/ peri articular fracture
123 Mobilization under GA for Joint stiffness 5,214,000 3,997,000 9,211,000
124 Nerve procedure for Brachial plexus injury 17,386,000 13,330,000 30,716,000
125 Neurolysis only for Brachial plexus injury 13,939,000 10,687,000 24,626,000
Open / closed reduction with internal fixation for Other pathological
126 14,402,000 11,041,000 25,443,000
fracture (except malignancy
127 Open / mini open reconstruction for Rotator cuff injury 16,646,000 12,763,000 29,409,000
128 Open achilles tendon lengthening (single) for CTEV 11,119,000 8,525,000 19,644,000
129 Open arthrotomy & debridement for Joint infection (acute) 8,415,000 6,452,000 14,867,000
Open arthrotomy, debridement & joint release for Joint infection
130 9,264,000 7,102,000 16,366,000
(chronic)
131 Open biopsy / Core biopsy for Bone / soft tissue tumor 7,607,000 5,833,000 13,440,000
132 Open biopsy for Infection / inflamation (except spine and malignancy) 6,025,000 4,620,000 10,645,000
133 Open Biopsy for Infection / malignancy 8,415,000 6,452,000 14,867,000
134 Open discectomy (Multiple) for Intervertebral disc herniation 14,318,000 10,978,000 25,296,000
135 Open discectomy (single) for Intervertebral disc herniation 11,830,000 9,070,000 20,900,000
136 Open ligament reconstruction for MCL / LCL injury 11,544,000 8,850,000 20,394,000
Open reduction & ligament reconstruction for Neglected joint
137 16,679,000 12,787,000 29,466,000
dislocation
138 Open reduction and fixation for Neglected joint dislocation 14,047,000 10,770,000 24,817,000
139 Open reduction and internal fixation for SCFE 14,400,000 11,040,000 25,440,000
140 Open Reduction and soft tissue procedure for DDH 16,212,000 12,429,000 28,641,000
141 Open reduction for Vertebral fracture / dislocation 14,316,000 10,976,000 25,292,000
142 Open reduction with soft tissue and bone procedure for DDH 17,493,000 13,411,000 30,904,000
143 Opponens plasty for Thumb Paralysis 13,809,000 10,587,000 24,396,000
144 ORIF & Bone graft for Non union / bone defect / Pseudoarthrosis 16,678,000 12,787,000 29,465,000
145 ORIF (Single) for Bone / Soft tissue tumor with pathological fracture 15,839,000 12,143,000 27,982,000
ORIF / Minimal invasive osteosyntesis with image guided for Complex
146 17,240,000 13,218,000 30,458,000
fracture of irregular bone (scapula/pelvis/ sacrum/acetabulum)
ORIF / Minimal invasive osteosyntesis with image guided for Simple
147 13,441,000 10,305,000 23,746,000
fracture of irregular bone (scapula/pelvis/ sacrum/acetabulum)
148 ORIF for Closed intra articular fracture 14,402,000 11,041,000 25,443,000
149 ORIF for Complex small bone fracture or dislocation of foot 13,467,000 10,325,000 23,792,000
JASA
PELAYANAN
150 ORIF for Complex small bone fracture or dislocation of Hand 13,895,000 10,652,000 24,547,000
151 ORIF for Salter Harris fracture 11,769,000 9,023,000 20,792,000
152 ORIF/MIPO for Closed shaft fracture of long bone 11,770,000 9,024,000 20,794,000
153 Osteotomy & Gradual correction for Bone deformity 16,678,000 12,787,000 29,465,000
Pain intervention - image guided radiofrequency (multiple) for Chronic
154 6,742,000 5,169,000 11,911,000
pain (except spine)
Pain intervention - image guided radiofrequency (single) for Chronic
155 5,608,000 4,300,000 9,908,000
pain (except spine)
Pain intervention - image guided selective nerve block (multiple) for
156 6,732,000 5,161,000 11,893,000
Chronic pain (except spine)
Pain intervention - image guided selective nerve block (single) for
157 5,594,000 4,290,000 9,884,000
Chronic pain (except spine)
158 Patellectomy for Articular bone /soft tissue tumor 14,306,000 10,969,000 25,275,000
159 Percutaneous achilles tenotomy (single) for CTEV 8,333,000 6,388,000 14,721,000
Percutaneous endoscopic discectomy (single) Intervertebral disc
160 14,500,000 11,117,000 25,617,000
herniation
161 Percutaneous endoscopic spinal decompression for Spinal stenosis 17,256,000 13,230,000 30,486,000
Percutanous decompression and steroid injection for Benign bone
162 8,956,000 6,867,000 15,823,000
tumor
163 Posterolateral fusion for Spinal Instability 14,316,000 10,976,000 25,292,000
164 Posteromedial soft tisue release (single) for CTEV 13,396,000 10,271,000 23,667,000
165 Primary repair for Arterial injury 13,980,000 10,718,000 24,698,000
Primary repair for Large tendon rupture (quadriceps/ patellar/ achilles
166 11,578,000 8,877,000 20,455,000
tendon)
167 Primary repair for Nail bed laceration (Multiple) 7,090,000 5,436,000 12,526,000
168 Primary repair for Nail bed laceration (Single) 6,594,000 5,055,000 11,649,000
169 Primary repair for Nerve injury 13,980,000 10,718,000 24,698,000
170 Primary stump closure for Traumatic amputation of finger and hand 8,848,000 6,784,000 15,632,000
Primary stump closure for Traumatic amputation of upper or lower
171 8,686,000 6,660,000 15,346,000
extremities
172 Primary Total Joint Arthroplasty for Hip fracture / arthritis 13,917,000 10,670,000 24,587,000
173 Primary Total Joint Arthroplasty for Knee arthritis 14,034,000 10,759,000 24,793,000
174 Prosthetic removal and bone spacer for Infected arthroplasty 16,311,000 12,505,000 28,816,000
175 Radical Excision for Malignant Soft tissue Tumor 19,120,000 14,659,000 33,779,000
176 Ray Amputation for Bone / soft tissue tumor of hand / foot 11,214,000 8,597,000 19,811,000
177 Ray amputation for Finger injury / trauma/ Non vital tissue (Single) 11,147,000 8,546,000 19,693,000
178 reconstruction for Bone / Soft tissue tumor 19,431,000 14,897,000 34,328,000
179 Reconstruction for Tenosynovitis / tendon entrapment 13,424,000 10,291,000 23,715,000
180 Reconstruction procedure for Halux Valgus 16,385,000 12,561,000 28,946,000
Reconstruction procedure for Large tendon rupture (quadriceps/
181 13,775,000 10,562,000 24,337,000
patellar, achilles tendon)
Reconstruction procedure for Large tendon rupture / Avulsion
182 13,741,000 10,535,000 24,276,000
(quadriceps/ patellar, achilles tendon)
183 Regional flap for Soft tissue defect 13,809,000 10,587,000 24,396,000
184 Release for Compartment Syndrome 9,059,000 6,945,000 16,004,000
185 Release for Congenital Tenosynovitis / tendon entrapment (single) 10,963,000 8,405,000 19,368,000
186 Release for Peripheral nerve entrapment 11,125,000 8,530,000 19,655,000
187 Release for Ring Constriction 11,147,000 8,546,000 19,693,000
188 Release for Syndactily (complex) 13,809,000 10,587,000 24,396,000
189 Release for Syndactily (Simple) 11,147,000 8,546,000 19,693,000
190 Release for Tenosynovitis / tendon entrapment (single) 8,848,000 6,784,000 15,632,000
191 Remove Implant for Union fracture (Single) 7,596,000 5,824,000 13,420,000
192 Repair for Tendon injury (≤8) 11,398,000 8,739,000 20,137,000
193 Repair for Tendon injury (≥8) 16,830,000 12,903,000 29,733,000
194 Repair for Tendon injury (Single) 8,932,000 6,848,000 15,780,000
195 Repair microsurgery for nerve injury 17,149,000 13,148,000 30,297,000
196 Repair with graft for Arterial injury 16,618,000 12,741,000 29,359,000
197 Repair with graft for Nerve injury 16,618,000 12,741,000 29,359,000
198 Repair with graft for Tendon injury / entrapment 13,809,000 10,587,000 24,396,000
Replantation for Ring avulsion or traumatic amputaton of finger and
199 17,626,000 13,514,000 31,140,000
hand (single)
200 Revision of Total Joint Arthroplasty for hip fracture / arthritis 16,804,000 12,883,000 29,687,000
201 Revision of Total Joint Arthroplasty for Knee arthritis 16,913,000 12,966,000 29,879,000
202 Scoliosis correction for Scoliosis 20,286,000 15,553,000 35,839,000
203 Selective rhizotomy for Cerebral Palsy 14,318,000 10,978,000 25,296,000
JASA
PELAYANAN
204 Shoulder disarticulation for Bone / Soft tissue tumor upper extremity 14,952,000 11,463,000 26,415,000
Shoulder disarticulation for Infection/Necrotic/Non vital/Injury of
205 14,743,000 11,303,000 26,046,000
upper extremity
206 Shoulder hemiarthroplasty for Shoulder injury / arthritis 14,034,000 10,759,000 24,793,000
207 Soft tissue procedure (Multiple) for Cerebral palsy 14,216,000 10,900,000 25,116,000
208 Soft tissue procedure (Single) for Cerebral palsy 11,314,000 8,674,000 19,988,000
209 Soft tissue procedure for Brachial plexus injury 18,354,000 14,071,000 32,425,000
210 Soft tissue procedure for Finger & hand deformity 13,640,000 10,458,000 24,098,000
211 Soft tissue procedure for Foot / Ankle Deformity 11,413,000 8,750,000 20,163,000
212 Soft tissue procedure for Hand & forearm deformity 11,363,000 8,712,000 20,075,000
213 Soft tissue procedure for Sprain / dislocation of ligaments and tendons 13,855,000 10,623,000 24,478,000
Soft tissue release / reconstruction (single joint) for Stiffness / spastic /
214 13,855,000 10,623,000 24,478,000
contracture joint
Soft tissue release for Stiffness / spastic / joint contracture of hand &
215 13,640,000 10,458,000 24,098,000
forearm
216 Spinal osteotomy (multiple) for Spinal deformity 16,904,000 12,961,000 29,865,000
217 Spinal osteotomy (single) for Spinal deformity 14,316,000 10,976,000 25,292,000
218 Spinal stabilization, anterior or posterior for Spinal Instability 17,015,000 13,044,000 30,059,000
219 STSG for Skin defect 8,848,000 6,784,000 15,632,000
Stump closure with local flap for Traumatic amputation of upper or
220 11,214,000 8,597,000 19,811,000
lower extremities
221 Synovectomy for Articular bone /soft tissue tumor 11,214,000 8,597,000 19,811,000
222 Tendon Transfer for Drop Foot 11,498,000 8,816,000 20,314,000
223 Tendon transfer for Drop hand 13,809,000 10,587,000 24,396,000
224 Tendon Transfer for stiffness/spastic/contracure joint 13,775,000 10,562,000 24,337,000
225 Tenolysis for Tendon adhesion/ entrapment (single) 11,147,000 8,546,000 19,693,000
226 Tenotomy for Tendinitis / tendon contracture 8,848,000 6,784,000 15,632,000
Terminalization for Ring avulsion or traumatic amputaton of finger
227 11,444,000 8,775,000 20,219,000
and hand
228 Total disc replacement (multiple) for Intervertebral disc herniation 17,237,000 13,216,000 30,453,000
229 Total disc replacement (single) for Intervertebral disc herniation 14,534,000 11,144,000 25,678,000
Total Joint Replacement for Bone / Soft tissue tumor with pathological
230 18,231,000 13,977,000 32,208,000
fracture
231 Total Shoulder Arthoplasty for Shoulder injury / arthritis 16,795,000 12,877,000 29,672,000
232 Transpedicular biopsy (Multiple) for Infection / malignancy 8,783,000 6,733,000 15,516,000
233 Transpedicular biopsy (single) for Infection / malignancy 7,469,000 5,726,000 13,195,000
234 Transposition for Peripheral nerve entrapment 13,809,000 10,587,000 24,396,000
Tubular Micro endoscopic discectomy (single) Intervertebral disc
235 14,450,000 11,078,000 25,528,000
herniation
236 Vascularized bone graft for Bone defect 18,812,000 14,423,000 33,235,000
237 Wide Excision for Bone / Soft tissue tumor 15,616,000 11,973,000 27,589,000
11. INSTALASI PELAYANAN JANTUNG TERPADU
1 TPM KELAS 2 17,684,000 12,905,000 30,589,000
2 TPM KELAS 1 18,239,000 12,905,000 31,144,000
3 TPM KELAS VIP 19,535,000 12,905,000 32,440,000
4 CORANGIOGRAFI KELAS 2 13,793,000 12,905,000 26,698,000
5 CORANGIOGRAFI KELAS 1 14,348,000 12,905,000 27,253,000
6 CORANGIOGRAFI KELAS VIP 15,644,000 12,905,000 28,549,000
CORANGIOGRAFI+KATETERISASI DENGAN ANESTESI
7 16,614,000 20,172,000 36,786,000
KELAS 2
8 17,169,000 20,172,000 37,341,000
KELAS 1
9 18,465,000 20,172,000 38,637,000
KELAS VIP
10 CORANGIOGRAFI+TPM KELAS 2 22,120,000 16,812,000 38,932,000
11 CORANGIOGRAFI+TPM KELAS 2 22,675,000 16,812,000 39,487,000
12 CORANGIOGRAFI+TPM KELAS VIP 23,971,000 16,812,000 40,783,000
13 PTCA 1STENT DES KELAS 2 58,151,000 18,640,000 76,791,000
15 PTCA 1STENT DES KELAS VIP 60,002,000 18,640,000 78,642,000
JASA
PELAYANAN
25 EVAR CUT DOWN/DENGAN PEMBEDAHAN KELAS 2 193,658,000 48,640,000 242,298,000
26 EVAR CUT DOWN/DENGAN PEMBEDAHAN KELAS 1 194,213,000 48,640,000 242,853,000
27 EVAR CUT DOWN/DENGAN PEMBEDAHAN KELAS VIP 195,509,000 48,640,000 244,149,000
EVAR DENGAN PROGLIDE (TANPA PEMBEDAHAN) -
28 290,885,000 33,640,000 324,525,000
KOMPLEKS KELAS 2
29 291,440,000 33,640,000 325,080,000
KOMPLEKS KELAS 1
30 292,736,000 33,640,000 326,376,000
KOMPLEKS KELAS VIP
31 PPM DOUBLE CHAMBER + HIS BUNDLE KELAS 2 86,505,000 34,390,000 120,895,000
32 PPM DOUBLE CHAMBER + HIS BUNDLE KELAS 1 87,060,000 34,390,000 121,450,000
33 PPM DOUBLE CHAMBER + HIS BUNDLE KELAS VIP 88,356,000 34,390,000 122,746,000
34 PPM DOUBLE CHAMBER KELAS 2 63,955,000 27,190,000 91,145,000
35 PPM DOUBLE CHAMBER KELAS 1 64,510,000 27,190,000 91,700,000
36 PPM DOUBLE CHAMBER KELAS VIP 65,806,000 27,190,000 92,996,000
37 PPM SINGLE CHAMBER KELAS 2 47,467,000 27,190,000 74,657,000
38 PPM SINGLE CHAMBER KELAS 1 48,022,000 27,190,000 75,212,000
39 PPM SINGLE CHAMBER KELAS VIP 49,318,000 27,190,000 76,508,000
40 PDA LIGASI KELAS 2 37,692,000 57,860,000 95,552,000
41 PDA LIGASI KELAS 1 38,617,000 57,860,000 96,477,000
42 PDA LIGASI KELAS VIP 40,777,000 57,860,000 98,637,000
43 PA BANDING /UNIFOKALISASI KELAS 2 55,811,000 59,010,000 114,821,000
44 PA BANDING /UNIFOKALISASI KELAS 1 56,736,000 59,010,000 115,746,000
45 PA BANDING /UNIFOKALISASI KELAS VIP 58,896,000 59,010,000 117,906,000
46 VSD CLOSURE KELAS 2 85,916,000 64,760,000 150,676,000
47 VSD CLOSURE KELAS 1 89,616,000 64,760,000 154,376,000
48 VSD CLOSURE KELAS VIP 98,256,000 64,760,000 163,016,000
49 CABG KELAS 2 97,006,000 73,385,000 170,391,000
50 CABG KELAS 1 98,116,000 73,385,000 171,501,000
51 CABG KELAS VIP 100,708,000 73,385,000 174,093,000
SINGLE VALVE REPAIR (MITRAL /AORTIC / TRICUSPID
52 103,012,000 78,991,000 182,003,000
VALVE REPAIR ) + LAA PLICATION KELAS 2
53 104,122,000 78,991,000 183,113,000
VALVE REPAIR ) + LAA PLICATION KELAS 1
54 106,714,000 78,991,000 185,705,000
VALVE REPAIR ) + LAA PLICATION KELAS VIP
SINGLE VALVE REPLACEMENT ( MITRAL / AORTIC /
55 TRICUSPID VALVE REPLACEMENT )+ LAA PLICATION 126,669,000 71,947,000 198,616,000
KELAS 2
KELAS 1
KELAS VIP
58 DOUBLE VALVE REPLACE-REPAIR KELAS 2 152,782,000 100,122,000 252,904,000
59 DOUBLE VALVE REPLACE-REPAIR KELAS 1 153,892,000 100,122,000 254,014,000
60 DOUBLE VALVE REPLACE-REPAIR KELAS VIP 156,484,000 100,122,000 256,606,000
61 CABG + AORTIC-MITRAL VALVE REPAIR-REPLACE KELAS 2 155,267,000 100,122,000 255,389,000
62 CABG + AORTIC-MITRAL VALVE REPAIR-REPLACE KELAS 1 156,377,000 100,122,000 256,499,000

CABG + AORTIC-MITRAL VALVE REPAIR-REPLACE KELAS
63 158,969,000 100,122,000 259,091,000
VIP
EPICARDIAL MICRONI PACE MAKER SINGLE CHAMBER
64 73,896,000 59,010,000 132,906,000
KELAS 2
65 75,746,000 59,010,000 134,756,000
KELAS 1
66 80,066,000 59,010,000 139,076,000
KELAS VIP
EPICARDIAL MICRONI PACE MAKER DOUBLE CHAMBER
67 89,283,000 59,010,000 148,293,000
KELAS 2
68 91,133,000 59,010,000 150,143,000
KELAS 1
69 95,453,000 59,010,000 154,463,000
KELAS VIP
70 ASD CLOSURE KELAS 2 82,692,000 76,260,000 158,952,000
71 ASD CLOSURE KELAS 1 86,392,000 76,260,000 162,652,000
JASA
PELAYANAN
72 ASD CLOSURE KELAS VIP 95,032,000 76,260,000 171,292,000
73 BT SHUNT KELAS 2 62,275,000 73,385,000 135,660,000
74 BT SHUNT KELAS 1 63,200,000 73,385,000 136,585,000
75 BT SHUNT KELAS VIP 65,360,000 73,385,000 138,745,000
76 TOTAL KOREKSI KELAS 2 108,993,000 73,385,000 182,378,000
77 TOTAL KOREKSI KELAS 1 112,693,000 73,385,000 186,078,000
78 TOTAL KOREKSI KELAS VIP 121,333,000 73,385,000 194,718,000
79 BCPS KELAS 2 89,798,000 73,385,000 163,183,000
80 BCPS KELAS 1 93,498,000 73,385,000 166,883,000
81 BCPS KELAS VIP 102,138,000 73,385,000 175,523,000
82 PAPVD KELAS 2 92,797,000 73,385,000 166,182,000
83 PAPVD KELAS 1 96,497,000 73,385,000 169,882,000
84 PAPVD KELAS VIP 105,137,000 73,385,000 178,522,000
85 RASTELLI WITH CONDUIT KELAS 2 185,442,000 106,160,000 291,602,000
86 RASTELLI WITH CONDUIT KELAS 1 189,142,000 106,160,000 295,302,000
87 RASTELLI WITH CONDUIT KELAS VIP 197,782,000 106,160,000 303,942,000
88 CAVSD KELAS 2 85,088,000 87,760,000 172,848,000
89 CAVSD KELAS 1 88,788,000 87,760,000 176,548,000
90 CAVSD KELAS VIP 97,428,000 87,760,000 185,188,000
BENTALL OPERATION PROCEDURE ( IMPLANT CORONER +
91 182,529,000 98,009,000 280,538,000
KATUB) / ANEURYSMECTOMY KELAS 2
92 183,454,000 98,009,000 281,463,000
KATUB) / ANEURYSMECTOMY KELAS 1
93 185,614,000 98,009,000 283,623,000
KATUB) / ANEURYSMECTOMY KELAS VIP
94 DEBRIDEMENT KELAS 2 28,826,000 20,641,000 49,467,000
95 DEBRIDEMENT KELAS 1 29,751,000 20,641,000 50,392,000
96 DEBRIDEMENT KELAS VIP 31,911,000 20,641,000 52,552,000
97 ARTERIAL SWITCH KELAS 2 131,307,000 110,185,000 241,492,000
98 ARTERIAL SWITCH KELAS 1 135,007,000 110,185,000 245,192,000
99 ARTERIAL SWITCH KELAS VIP 143,647,000 110,185,000 253,832,000
100 TAPVD KELAS 2 99,817,000 81,147,000 180,964,000
101 TAPVD KELAS 1 103,517,000 81,147,000 184,664,000
102 TAPVD KELAS VIP 112,157,000 81,147,000 193,304,000
103 FONTAN KELAS 2 116,134,000 107,597,000 223,731,000
104 FONTAN KELAS 1 119,834,000 107,597,000 227,431,000
105 FONTAN KELAS VIP 128,474,000 107,597,000 236,071,000
REPAIR INTERUPTED AORTIC ARCH / REPAIR CO-ARCH
106 111,381,000 94,660,000 206,041,000
KELAS 2
107 115,081,000 94,660,000 209,741,000
KELAS 1
108 123,721,000 94,660,000 218,381,000
KELAS VIP
109 CABG + DOUBLE VALVE REPAIR-REPLACE KELAS 2 174,190,000 107,597,000 281,787,000
110 CABG + DOUBLE VALVE REPAIR-REPLACE KELAS 1 177,890,000 107,597,000 285,487,000
111 CABG + DOUBLE VALVE REPAIR-REPLACE KELAS VIP 186,530,000 107,597,000 294,127,000
112 KAWASHIMA KELAS 2 84,420,000 79,135,000 163,555,000
113 KAWASHIMA KELAS 1 88,120,000 79,135,000 167,255,000
114 KAWASHIMA KELAS VIP 96,760,000 79,135,000 175,895,000
115 CABG + BENTAL KELAS 2 215,845,000 113,347,000 329,192,000
116 CABG + BENTAL KELAS 1 219,545,000 113,347,000 332,892,000
117 CABG + BENTAL KELAS VIP 228,185,000 113,347,000 341,532,000
118 CABG OFF PUMP KELAS 2 143,356,000 91,210,000 234,566,000
119 CABG OFF PUMP KELAS 1 144,466,000 91,210,000 235,676,000
120 CABG OFF PUMP KELAS VIP 147,058,000 91,210,000 238,268,000
ELEKTROFISIOLOGY STUDY + RADIOFREQUENCY ABLASI
121 145,777,000 34,390,000 180,167,000
EP 3D AF + TEE (NON IRRIGATION) KELAS 2
122 146,332,000 34,390,000 180,722,000
EP 3D AF + TEE (NON IRRIGATION) KELAS 1
123 147,628,000 34,390,000 182,018,000
EP 3D AF + TEE (NON IRRIGATION) KELAS VIP
124 122,345,000 28,990,000 151,335,000
EP 3D NON AF + TEE (NON IRRIGATION) KELAS 2
125 122,900,000 28,990,000 151,890,000
EP 3D NON AF + TEE (NON IRRIGATION) KELAS 1
126 124,196,000 28,990,000 153,186,000
EP 3D NON AF + TEE (NON IRRIGATION) KELAS VIP
127 85,538,000 28,990,000 114,528,000
(KONVENSIONAL NON IRRIGATION) KELAS 2
JASA
PELAYANAN
128 86,093,000 28,990,000 115,083,000
(KONVENSIONAL NON IRRIGATION) KELAS 1
129 87,389,000 28,990,000 116,379,000
(KONVENSIONAL NON IRRIGATION) KELAS VIP
130 ELEKTROFISIOLOGY STUDY KELAS 2 81,884,000 16,755,000 98,639,000
131 ELEKTROFISIOLOGY STUDY KELAS 1 82,439,000 16,755,000 99,194,000
132 ELEKTROFISIOLOGY STUDY KELAS VIP 83,735,000 16,755,000 100,490,000
133 KATETERISASI ANAK + ANESTESI KELAS 2 17,040,000 14,246,000 31,286,000
134 KATETERISASI ANAK + ANESTESI KELAS 1 17,595,000 14,246,000 31,841,000
135 KATETERISASI ANAK + ANESTESI KELAS VIP 18,891,000 14,246,000 33,137,000
136 TEE + ANESTESI KELAS 2 9,804,000 7,246,000 17,050,000
137 TEE + ANESTESI KELAS 1 10,359,000 7,246,000 17,605,000
138 TEE + ANESTESI KELAS VIP 11,655,000 7,246,000 18,901,000
139 KATETERISASI ANAK + TEE KELAS 2 17,354,000 15,646,000 33,000,000
140 KATETERISASI ANAK + TEE KELAS 1 17,909,000 15,646,000 33,555,000
141 KATETERISASI ANAK + TEE KELAS VIP 19,205,000 15,646,000 34,851,000
142 PUNKSI EFUSI PERICARD/EFUSI PLEURA KELAS 2 12,940,000 6,446,000 19,386,000
143 PUNKSI EFUSI PERICARD/EFUSI PLEURA KELAS 1 13,495,000 6,446,000 19,941,000
144 PUNKSI EFUSI PERICARD/EFUSI PLEURA KELAS VIP 14,791,000 6,446,000 21,237,000
145 BAS KELAS 2 52,184,000 27,181,000 79,365,000
146 BAS KELAS 1 52,739,000 27,181,000 79,920,000
147 BAS KELAS VIP 54,035,000 27,181,000 81,216,000
148 HPVG KELAS 2 14,230,000 11,655,000 25,885,000
149 HPVG KELAS 1 14,415,000 11,655,000 26,070,000
150 HPVG KELAS VIP 14,847,000 11,655,000 26,502,000
151 TRANSJUGULAR LIVER BIOPSI KELAS 2 32,280,000 13,530,000 45,810,000
152 TRANSJUGULAR LIVER BIOPSI KELAS 1 32,465,000 13,530,000 45,995,000
153 TRANSJUGULAR LIVER BIOPSI KELAS VIP 32,897,000 13,530,000 46,427,000
PELAYANAN PENUNJANG MEDIS
1. PATOLOGI KLINIK
JASA
PELAYANAN
KIMIA KLINIK
1 ALBUMIN (ALB) 47.000 7.000 54.000
2 AMILASE DARAH 146.000 17.000 163.000
3 AMILASE URIN 146.000 17.000 163.000
4 AMMONIAK 257.000 40.000 297.000
5 AMPHETAMIN (SABU-SABU) 69.000 12.000 81.000
6 ANALISA GAS DARAH 189.000 29.000 218.000
7 ASAM URAT DARAH 44.000 7.000 51.000
8 ASAM URAT URIN 44.000 7.000 51.000
9 BENZODIAZEPIN 69.000 12.000 81.000
10 BERSIHAN KREATININ 63.000 17.000 80.000
11 BETA HIDROKSI BUTIRAT 47.000 9.000 56.000
12 BILIRUBIN TOTAL + DIREK+INDIREK 71.000 13.000 84.000
13 C0CAIN 69.000 12.000 81.000
14 CALSIUM DARAH 47.000 9.000 56.000
15 CALSIUM ION 165.000 36.000 201.000
16 CALSIUM URIN 47.000 9.000 56.000
17 CHOLESTEROL HDL 65.000 10.000 75.000
18 CHOLESTEROL LDL 87.000 11.000 98.000
19 CHOLESTEROL TOTAL 48.000 10.000 58.000
20 CK 105.000 18.000 123.000
21 CKMB 119.000 21.000 140.000
22 ELEKTROFORESIS PROTEIN 165.000 37.000 202.000
23 ELEKTROLIT DARAH (Na, K, Cl) 122.000 17.000 139.000
24 ELEKTROLIT URIN (Na, K, Cl) 122.000 17.000 139.000
25 FE(SI) + TIBC + UIBC 165.000 75.000 240.000
26 FOLAT 548.000 42.000 590.000
27 FOSFAT INORGANIK DARAH 56.000 10.000 66.000
28 FOSFAT INORGANIK URIN 56.000 10.000 66.000
29 FOSFATASE ALKALI 50.000 12.000 62.000
30 FOSFATASE ASAM 345.000 29.000 374.000
31 GAMMA GT 56.000 10.000 66.000
32 GLIKO HB (HBA1C) 165.000 22.000 187.000
33 GLUKOSA 2 JAM PP 36.000 5.000 41.000
34 GLUKOSA PUASA 36.000 5.000 41.000
35 GLUKOSA RAPID (POCT) 36.000 5.000 41.000
36 GLUKOSA SEWAKTU 36.000 5.000 41.000
37 GLUKOSA URIN 36.000 5.000 41.000
38 GTT (3X : PUASA, 1 JAM, 2 JAM) 78.000 14.000 92.000
39 Hs TROPONIN I 381.000 72.000 453.000
40 KOLINESTERASE 60.000 13.000 73.000
41 KREATININ DARAH 42.000 5.000 47.000
42 KREATININ URIN 42.000 5.000 47.000
43 KURVA HARIAN (3X) 78.000 14.000 92.000
44 LACTAT 69.000 12.000 81.000
45 LDH 86.000 15.000 101.000
46 LIPASE DARAH 131.000 23.000 154.000
47 LIPASE URIN 131.000 23.000 154.000
48 MAGNESIUM 57.000 10.000 67.000
49 MARIJUANA (GANJA) 69.000 12.000 81.000
50 METAMPHETAMIN (ECTASY) 69.000 12.000 81.000
51 MIKROALBUMINURIA 114.000 13.000 127.000
52 MORPHINE (HEROIN, PUTAW,OPIAT) 69.000 12.000 81.000
JASA
PELAYANAN
53 NITROGEN URIN 47.000 9.000 56.000
54 NT- PROBNP 390.000 92.000 482.000
55 OSMOLARITAS PLASMA 53.000 17.000 70.000
56 OSMOLARITAS URIN 53.000 17.000 70.000
57 PROTEIN KWANTITATIF URIN 47.000 9.000 56.000
58 PROTEIN TOTAL 41.000 9.000 50.000
59 SGOT (AST) 45.000 5.000 50.000
60 SGPT (ALT) 45.000 5.000 50.000
61 TRIGLISERIDA 48.000 10.000 58.000
62 TROPONIN T 301.000 72.000 373.000
63 TSH NEONATUS 56.000 22.000 78.000
64 UREA CLEARANCE 83.000 14.000 97.000
65 UREUM DARAH 51.000 7.000 58.000
66 UREUM URIN 51.000 7.000 58.000
IMUNOLOGI
1 25-OH VITAMIN D TOTAL 315.000 64.000 379.000
2 AFP 164.000 34.000 198.000
3 ANA 443.000 57.000 500.000
4 ANTI DENGUE IGG + IGM 210.000 37.000 247.000
5 ANTI DS-DNA 266.000 72.000 338.000
6 ANTI HAV IGM 261.000 30.000 291.000
7 ANTI HBC IGM 261.000 30.000 291.000
8 ANTI HBC TOTAL 156.000 18.000 174.000
9 ANTI HBE 309.000 53.000 362.000
10 ANTI HBs 105.000 17.000 122.000
11 ANTI HCV Ig M 711.000 49.000 760.000
12 ANTI HCV TOTAL 197.000 43.000 240.000
13 ANTI HELICOBACTER PYLORI IGG 161.000 27.000 188.000
14 ANTI HELICOBACTER PYLORI IGM 123.000 12.000 135.000
15 ANTI HIV KONFIRMASI (WB) 849.000 148.000 997.000
16 ANTI HIV PENYARING 270.000 58.000 328.000
17 ANTI MULLERIAN HORMON 470.000 50.000 520.000
18 ANTI -TB IG M 290.000 21.000 311.000
19 ANTI -TB TOTAL 107.000 20.000 127.000
20 ASTO KUANTIATIF 107.000 18.000 125.000
21 BETA 2 GLIKOPROTEIN IGG 270.000 36.000 306.000
22 BETA 2 GLIKOPROTEIN IGM 270.000 36.000 306.000
23 BETA HCG (KUANTITATIF) 290.000 21.000 311.000
24 C3 218.000 34.000 252.000
25 C4 218.000 34.000 252.000
26 CA 125 296.000 51.000 347.000
27 CA 15-3 365.000 63.000 428.000
28 CA 19-9 299.000 49.000 348.000
29 CD 14 290.000 92.000 382.000
30 CD 19 290.000 92.000 382.000
31 CD 20 180.000 18.000 198.000
32 CD 3 + CD 4 + (T HELPER LYMPHOCYTE) 338.000 99.000 437.000
33 CD 4 180.000 14.000 194.000
34 CD 56 290.000 92.000 382.000
35 CEA 191.000 49.000 240.000
36 CHLAMYDIA TR IgG 342.000 90.000 432.000
37 CHLAMYDIA TR IgM 342.000 90.000 432.000
38 CRP (KUANTITATIF) 117.000 18.000 135.000
39 CRP HS 285.000 53.000 338.000
40 ESTRADIOL 258.000 20.000 278.000
41 FERRITIN 147.000 26.000 173.000
42 FREE PSA 461.000 67.000 528.000
43 FREE T3 140.000 25.000 165.000
44 FREE T4 140.000 25.000 165.000
JASA
PELAYANAN
45 FREE TESTOTERON 222.000 15.000 237.000
46 FSH 219.000 38.000 257.000
47 FTI (FREE TYHROXINE INDEX ) 297.000 64.000 361.000
48 H1N1 (RAPID SWAB) 396.000 42.000 438.000
49 HBeAg 345.000 23.000 368.000
50 HBsAg 98.000 15.000 113.000
51 HBV DNA 1.800.000 200.000 2.000.000
52 HCV RNA 2.500.000 250.000 2.750.000
53 HUMAN IL-6 410.000 101.000 511.000
54 ICT TB 113.000 14.000 127.000
55 IGA. 213.000 65.000 278.000
56 IGE 221.000 29.000 250.000
57 IGG 221.000 29.000 250.000
58 IGG ANTI CARDIOLIPIN 214.000 36.000 250.000
59 IGG ANTI CMV 162.000 30.000 192.000
60 IGG ANTI HSV 1 159.000 66.000 225.000
61 IGG ANTI HSV II 159.000 66.000 225.000
62 IGG ANTI RUBELLA 150.000 21.000 171.000
63 IGG ANTI TOXOPLASMA 177.000 34.000 211.000
64 IGM ANTI CARDIOLIPIN 237.000 38.000 275.000
65 IGM ANTI CMV 165.000 36.000 201.000
66 IGM ANTI HSV I 159.000 66.000 225.000
67 IGM ANTI HSV II 159.000 66.000 225.000
68 IGM ANTI RUBELLA 185.000 26.000 211.000
69 IGM ANTI TOXOPLASMA 191.000 34.000 225.000
70 IGM. 219.000 66.000 285.000
71 IMUNOFIKSASI 531.000 110.000 641.000
72 IMUNOFIKSASI LIGHT CHAIN 531.000 110.000 641.000
73 INHIBIN B ELISA 509.000 73.000 582.000
74 INSULIN 116.000 26.000 142.000
75 INTERFERRON GAMMA RELEASING ASSAY(IGRA) 1.043.000 64.000 1.107.000
76 LEUKIMIA PHENOTYPING 903.000 97.000 1.000.000
77 LH 227.000 40.000 267.000
78 LYMPHOCYTE CD 45 290.000 92.000 382.000
79 LYMPHOSIT SUBSET 449.000 34.000 483.000
80 MYCOPLASMA IgG 342.000 90.000 432.000
81 MYCOPLASMA IgM 342.000 90.000 432.000
82 NS-1 ANTIGEN 330.000 81.000 411.000
83 PAKET CD 34 (TOTAL CD 34 + VIABILITY CD 34 705.000 172.000 877.000
84 PAKET CD 4 + CD 8 338.000 58.000 396.000
85 PAKET STEM CELL (CD33, CD 34, DAN CD 133) 845.000 249.000 1.094.000
86 PCR HIV (VIRAL LOOD) 900.000 133.000 1.033.000
87 PCR HIV (VIRAL LOOD) DISCOUNT 50% 326.000 55.000 381.000
88 PCR TB 433.000 67.000 500.000
89 PRESEPSIN 758.000 58.000 816.000
90 PROCALCITONIN 497.000 65.000 562.000
91 PROGESTERON 258.000 14.000 272.000
92 PROLAKTIN 227.000 40.000 267.000
93 PSA TOTAL 228.000 40.000 268.000
94 RF. 113.000 10.000 123.000
95 SALMONELLA IG M 165.000 35.000 200.000
96 SHBG 162.000 30.000 192.000
97 SIKLOSPORIN 1.500.000 127.000 1.627.000
98 T3 126.000 34.000 160.000
99 T3 UPTAKE 171.000 30.000 201.000
100 T4 126.000 34.000 160.000
101 TACROLIMUS 975.000 127.000 1.102.000
102 TES KEHAMILAN 50.000 5.000 55.000
103 TPHA 86.000 26.000 112.000
JASA
PELAYANAN
104 TSH 126.000 34.000 160.000
105 TYROGLOBULIN 479.000 35.000 514.000
106 UREA BREATH TEST / UBT 1.418.000 64.000 1.482.000
107 VDRL 47.000 13.000 60.000
108 WIDAL 74.000 15.000 89.000
BAKTERIOLOGI
1 BIAKAN +RES SS DARAH 264.000 35.000 299.000
2 BIAKAN +RES SS SPUTUM 264.000 35.000 299.000
3 BIAKAN +RES SS TINJA 450.000 50.000 500.000
4 BIAKAN +RES SS URIN 450.000 50.000 500.000
5 BIAKAN AEROB LAIN-LAIN 300.000 50.000 350.000
6 BIAKAN AEROB PUS 300.000 50.000 350.000
7 BIAKAN AEROB SPUTUM 300.000 50.000 350.000
8 BIAKAN AEROB URINE 300.000 50.000 350.000
9 BIAKAN ANAEROB LAIN-LAIN 525.000 75.000 600.000
10 BIAKAN ANAEROB PUS 525.000 75.000 600.000
11 BIAKAN ANAEROB SWAB 474.000 28.000 502.000
12 BIAKAN ANAEROB URINE 474.000 28.000 502.000
13 BIAKAN BTA LAIN LAIN 675.000 75.000 750.000
14 BIAKAN BTA SPUTUM 675.000 75.000 750.000
15 BIAKAN BTA TINJA 675.000 75.000 750.000
16 BIAKAN BTA URINE 675.000 75.000 750.000
17 BIAKAN DARAH SITO (VITEK) 495.000 29.000 524.000
18 BIAKAN SS+RES SWAB 270.000 36.000 306.000
19 BIAKAN THAYER MARTHIN 143.000 56.000 199.000
20 BIAKAN+RES AEROB LKP DARAH 550.000 50.000 600.000
21 BIAKAN+RES AEROB LKP LAIN LAIN 550.000 50.000 600.000
22 BIAKAN+RES AEROB LKP PUS 550.000 50.000 600.000
23 BIAKAN+RES AEROB LKP SWAB 550.000 50.000 600.000
24 BIAKAN+RES AEROB LKP TINJA 550.000 50.000 600.000
25 BIAKAN+RES AEROB LKP URIN 550.000 50.000 600.000
26 BIAKAN+RES AEROB SPUTUM 550.000 50.000 600.000
27 BIAKAN+RES AEROB TINJA 284.000 36.000 320.000
28 BIAKAN+RES ANAEROB STD DARAH 572.000 78.000 650.000
29 BIAKAN+RES ANAEROB STD LAIN-LAIN 572.000 78.000 650.000
30 BIAKAN+RES ANAEROB STD PUS 572.000 78.000 650.000
31 BIAKAN+RES ANAEROB STD SPUTUM 545.000 78.000 623.000
32 BIAKAN+RES ANAEROB STD SWAB 545.000 78.000 623.000
33 BIAKAN+RES ANAEROB STD URINE 545.000 78.000 623.000
34 MIC MEROPENEM 165.000 38.000 203.000
35 PEWARNAAN JAMUR 35.000 41.000 76.000
36 PULASAN GRAM LAIN-LAIN 47.000 5.000 52.000
37 PULASAN GRAM PUS 47.000 5.000 52.000
38 PULASAN GRAM SPUTUM 47.000 5.000 52.000
39 PULASAN GRAM SWAB 47.000 5.000 52.000
40 PULASAN TAHAN ASAM DARAH 47.000 5.000 52.000
41 PULASAN TAHAN ASAM LAIN-LAIN 47.000 5.000 52.000
42 PULASAN TAHAN ASAM PUS 47.000 5.000 52.000
43 PULASAN TAHAN ASAM SPUTUM 47.000 5.000 52.000
44 PULASAN TAHAN ASAM SWAB 47.000 5.000 52.000
45 PULASAN TAHAN ASAM TINJA 47.000 5.000 52.000
46 PULASAN TAHAN ASAM URINE 47.000 5.000 52.000
47 TB ANTIGEN 204.000 111.000 315.000
HEMATOLOGI
1 AGREGAGSI TROMBOSIT (ADP) 161.000 41.000 202.000
2 AGREGASI TROMBOSIT (RISTOCETIN) 249.000 41.000 290.000
3 ANALISA CAIRAN ASITES 249.000 41.000 290.000
4 ANALISA CAIRAN DIALISIS EMPEDU 249.000 41.000 290.000
5 ANALISA CAIRAN DIALISIS PERICARD 249.000 41.000 290.000
JASA
PELAYANAN
6 ANALISA CAIRAN DIALISIS PERITO 249.000 41.000 290.000
7 ANALISA CAIRAN OTAK 249.000 41.000 290.000
8 ANALISA CAIRAN PLEURA 249.000 41.000 290.000
9 ANALISA CAIRAN SENDI 249.000 41.000 290.000
10 ANALISA CAIRAN TUBUH LAINNYA 249.000 41.000 290.000
11 ANALISA FESES KHUSUS 135.000 184.000 319.000
12 ANALISA HB 270.000 58.000 328.000
13 APT TEST 53.000 14.000 67.000
14 APTT 75.000 25.000 100.000
15 ASSAY FAKTOR IX 435.000 69.000 504.000
16 ASSAY FAKTOR VIII 435.000 69.000 504.000
17 AT-III 368.000 74.000 442.000
18 CLOSTRIDIUM DEFFICILE 234.000 40.000 274.000
19 DARAH SAMAR AB MONOKLONAL 63.000 12.000 75.000
20 D-DIMER 206.000 27.000 233.000
21 ECLT (EUGLOBULIN CLOT LYSIS TIME) 143.000 27.000 170.000
22 ESBACH 45.000 7.000 52.000
23 FAKTOR VON WILLEBRAND 338.000 99.000 437.000
24 FIBRINOGEN 78.000 14.000 92.000
25 FILARIA 42.000 7.000 49.000
26 FREE LIGHT CHAIN KAPPA 452.000 63.000 515.000
27 FREE LIGHT CHAIN LAMDA 452.000 63.000 515.000
28 G6PD 158.000 51.000 209.000
29 GAMBARAN SUMSUM TULANG/BMP BAGIAN ANAK 135.000 111.000 246.000
30 GOLONGAN DARAH 42.000 12.000 54.000
31 HEMATOLOGI LENGKAP TANPA LED 72.000 14.000 86.000
32 HEMATOLOGI LENGKAP TANPA LED + I/T RATIO 72.000 75.000 147.000
33 HEMATOLOGI RUTIN 63.000 12.000 75.000
34 HEMOGLOBIN URIN 60.000 6.000 66.000
35 HEMOSIDERIN 59.000 14.000 73.000
36 INHIBITOR F VIII 450.000 98.000 548.000
37 JUMLAH EOSINOFIL 63.000 12.000 75.000
38 LAJU ENDAP DARAH 35.000 7.000 42.000
39 LE REAKSI 47.000 7.000 54.000
40 LUPUS ANTIKOAGULAN 465.000 41.000 506.000
41 MALARIA (ICT+Sediaan) PAKET 125.000 26.000 151.000
42 MASA PEMBEKUAN LEE&WHITE 33.000 9.000 42.000
43 MASA PENDARAHAN IVY 36.000 20.000 56.000
44 MIOGLOBIN URIN 38.000 7.000 45.000
45 MIX APTT 150.000 25.000 175.000
46 OBERMEYER / INDIKAN URIN 36.000 13.000 49.000
47 OVAL FAT BODIES 53.000 10.000 63.000
PAKET HEMATOLOGI ONKOLOGI (HEMA LENGKAP TANPA
48 98.000 36.000 134.000
LED + RET-HE + RETICULOSIT + IPF)
PAKET HEMATOLOGI ONKOLOGI + GAMBARAN DARAH
49 158.000 135.000 293.000
TEPI
PAKET HEMATOLOGI ONKOLOGI + GAMBARAN SUMSUM
50 135.000 110.000 245.000
TULANG
51 PENYARING F XIII 323.000 26.000 349.000
52 PERCOBAAN PEMBENDUNGAN 35.000 12.000 47.000
53 PROTEIN BENCE JONES (TSA 12%) 47.000 11.000 58.000
54 PROTEIN C 675.000 75.000 750.000
55 PROTEIN S 675.000 75.000 750.000
56 PT + INR 60.000 12.000 72.000
57 PT. 60.000 12.000 72.000
58 RESISTENSI OSMOTIK 57.000 12.000 69.000
59 RETIKULOSIT 72.000 13.000 85.000
60 SEKRET HIDUNG 44.000 5.000 49.000
61 SEL LE 60.000 12.000 72.000
JASA
PELAYANAN
62 SUGAR WATER TEST + HAM TES 222.000 52.000 274.000
63 TES FUNGSI TROMBOSIT ASPIRIN 996.000 106.000 1.102.000
64 TES FUNGSI TROMBOSIT P2Y12 996.000 106.000 1.102.000
65 THROMBOTES 179.000 13.000 192.000
66 TINJA 54.000 10.000 64.000
67 TSH NEONATUS KEMENKES 59.000 6.000 65.000
68 TT (MASA TROMBIN ) 81.000 14.000 95.000
69 TT SERIAL 249.000 18.000 267.000
70 TZANCK CELL 109.000 5.000 114.000
71 URIN LENGKAP 47.000 9.000 56.000
72 VISKOSITAS PLASMA DAN DARAH (PAKET) 140.000 25.000 165.000
2. PATOLOGI ANATOMI
No NAMA KEGIATAN JASA SARANA JASA PELAYANAN TARIF

1 Pemeriksaan EBER-ISH 1,753,000 1,382,000 3,135,000
2 Pemeriksaan HER2-CISH 1,823,000 1,413,000 3,236,000
3 Pemeriksaan Histokimia Non-Perak 197,000 160,000 357,000
4 Pemeriksaan Histokimia Perak 230,000 173,000 403,000
5 Pemeriksaan Histopatologi Biopsi Esofagus/Gaster/Colon/Kulit 1,009,000 805,000 1,814,000
6 Pemeriksaan Histopatologi Biopsi Khusus Ginjal 1,685,000 1,305,000 2,990,000
7 Pemeriksaan Histopatologi Biopsi khusus hati/sumsum tulang 1,273,000 978,000 2,251,000
8 Pemeriksaan Histopatologi Jaringan Besar 2,171,000 1,438,000 3,609,000
9 Pemeriksaan Histopatologi Jaringan Kecil 663,000 460,000 1,123,000
10 Pemeriksaan Histopatologi Jaringan Khusus 3,888,000 1,438,000 5,326,000
11 Pemeriksaan Histopatologi Jaringan Sedang 1,431,000 863,000 2,294,000
12 Pemeriksaan Imunofluoresensi (IF) 1,128,000 805,000 1,933,000
Pemeriksaan Imunohistokimia Paket IHK diagnostik (Limfoma, kasus
2,356,000 1,438,000 3,794,000
13 sulit, GIST)
Pemeriksaan Imunohistokimia Paket prognostik payudara (ER, PR,
1,117,000 859,000 1,976,000
14 HER2, Topo & Ki67) / PDL-1
15 Pemeriksaan Imunohistokimia Per Antibody 795,000 575,000 1,370,000
16 Pemeriksaan Konsul Blok/Slide 341,000 369,000 710,000
17 Pemeriksaan Sitologi Aspirasi dengan ROSE 1,286,000 920,000 2,206,000
18 Pemeriksaan Sitologi aspirasi jarum halus 879,000 575,000 1,454,000
19 Pemeriksaan Sitologi Aspirasi kiriman/Sikatan 845,000 688,000 1,533,000
20 Pemeriksaan Sitologi Bilasan/Cairan Tubuh 503,000 288,000 791,000
21 Pemeriksaan Sitologi Papsmear Konvensional 148,000 115,000 263,000
22 Pemeriksaan Sitologi Papsmear LBC (Liquid Base Cytology) 330,000 288,000 618,000
23 Pemeriksaan Sitologi Sputum 320,000 230,000 550,000
24 Tindakan potong beku batas sayatan 1,463,000 1,134,000 2,597,000
25 Tindakan potong beku diagnostik 447,000 390,000 837,000
26 Tindakan potong beku Mohs Surgery 1,988,000 1,438,000 3,426,000
3. LABORATORIUM GIGI
JASA
PELAYANAN
1 Crown Komposit / ceramage 242.000 185.000 427.000
2 elemen gigi akrilik 29.000 23.000 52.000
3 Elemen Gigi ortholux 60.000 46.000 106.000
4 Gigi Tiruan Lengkap Lepasan 803.000 615.000 1.418.000
5 Gigi Tiruan Lengkap Lepasan RA / RB 560.000 413.000 973.000
6 Lingual arch 189.000 145.000 334.000
7 NAM plate 150.000 107.000 257.000
8 Nance appliance 155.000 113.000 268.000
9 Onlay Komposit / ceramage 242.000 185.000 427.000
10 Palatal arch 158.000 122.000 280.000
11 plat akrilik bilateral 237.000 161.000 398.000
12 Plat Akrilik saddle 133.000 92.000 225.000
13 Plat flexy bilateral 298.000 209.000 507.000
14 Plat flexy sadle 222.000 170.000 392.000
15 Plat Obturator hollow 193.000 144.000 337.000
16 Plat Obturator sementara 153.000 113.000 266.000
17 provisoris 96.000 74.000 170.000
18 Relining / rebassing full 134.000 97.000 231.000
19 Reparasi Patah 132.000 95.000 227.000
20 Reparasi Tambah Gigi 132.000 94.000 226.000
21 Retainer 186.000 112.000 298.000
22 scp akrilik per rahang 139.000 98.000 237.000
23 scp stent per rahang 78.000 60.000 138.000
24 Solder 1 point 81.000 62.000 143.000
25 splint akrilik / bruxism splint 149.000 114.000 263.000
26 study model 76.000 59.000 135.000
27 Surgical wafer 218.000 158.000 376.000
28 Vacuum Splint / night guard 199.000 104.000 303.000
29 Veneer Komposit / ceramage 242.000 185.000 427.000
4. RADIOLOGI DAN KEDOKTERAN NUKLIR
JASA
PELAYANAN
1. RADIOLOGI
1 Permintaan 3D 84,000 19,000 103,000
2 Permintaan 3D + Volumetri 168,000 37,000 205,000
3 Permintaan burning ulang CD/DVD (per lembar) 42,000 10,000 52,000
4 Permintaan dengan Bone Window (per lembar) 50,000 12,000 62,000
5 Permintaan print ulang film (per lembar film) 42,000 10,000 52,000
1.1 RADIO DIAGNOSTIK TANPA KONTRAS
1 Abdomen 2 posisi 288,000 83,000 371,000
2 Abdomen 3 posisi 328,000 97,000 425,000
3 Abdomen Polos (BNO) 224,000 65,000 289,000
4 Ankle 200,000 58,000 258,000
5 Ankle AP/Lat/Mortis 200,000 58,000 258,000
6 Ankle AP/Lat/Mortis Bilateral 380,000 115,000 495,000
7 Ankle Bilateral 380,000 115,000 495,000
8 Antebrachii 200,000 58,000 258,000
9 Antebrachii Bilateral 380,000 115,000 495,000
10 Bahu (Shoulder) 200,000 58,000 258,000
11 Bahu (Shoulder) Bilateral 380,000 115,000 495,000
12 Bone Mineral Density (3sites) 322,000 518,000 840,000
13 Cervical 2 posisi 320,000 92,000 412,000
14 Cervical 4 posisi 640,000 184,000 824,000
15 Clavicula 200,000 58,000 258,000
16 Clavicula Bilateral 380,000 115,000 495,000
17 Comberg 380,000 115,000 495,000
18 Cruris 272,000 79,000 351,000
19 Cruris Bilateral 544,000 157,000 701,000
20 Cubiti 200,000 58,000 258,000
21 Cubiti Bilateral 380,000 115,000 495,000
22 DXA Total Body Composition 322,000 518,000 840,000
23 Femur 246,000 76,000 322,000
24 Femur Bilateral 607,000 152,000 759,000
25 Genu AP & Lat 248,000 72,000 320,000
26 Genu AP & Lat Bilateral 479,000 143,000 622,000
27 Genu AP/Lat, SkyLine & ViewTunnel 380,000 104,000 484,000
28 Genu AP/Lat, SkyLine & ViewTunnel Bilateral 663,000 207,000 870,000
29 Humerus 200,000 58,000 258,000
30 Humerus Bilateral 380,000 115,000 495,000
31 Leher 296,000 76,000 372,000
32 Lumbal Dinamik 560,000 161,000 721,000
33 Manus 200,000 58,000 258,000
34 Manus Bilateral 380,000 115,000 495,000
35 Mastoid 280,000 81,000 361,000
36 Orbita 296,000 86,000 382,000
37 Os Nasal 296,000 76,000 372,000
38 Pedis 200,000 58,000 258,000
39 Pedis Bilateral 380,000 115,000 495,000
40 Pelvis 224,000 65,000 289,000
41 Perg. Tgn / Wrist Joint 228,000 66,000 294,000
42 Rahang 296,000 86,000 382,000
43 Rheese 280,000 81,000 361,000
44 Sakrum 2 posisi 320,000 92,000 412,000
45 Scapula 192,000 56,000 248,000
46 Scapula Bilateral 384,000 111,000 495,000
47 Schedel AP & Lat 280,000 81,000 361,000
48 Scoliosis Program 640,000 184,000 824,000
49 Shoulder Impingment Series 330,000 98,000 428,000
50 Shoulder Impingment Series Bilateral 593,000 196,000 789,000
51 Shoulder Instability Series 330,000 98,000 428,000
52 Shoulder Instability Series Bilateral 692,000 196,000 888,000
53 Sinus Paranasal 280,000 81,000 361,000
54 Stenvers 280,000 81,000 361,000
55 TMJ 296,000 86,000 382,000
56 Thorax 168,000 49,000 217,000
57 Thorax AP & Lateral 254,000 60,000 314,000
JASA
PELAYANAN
58 Thorax AP & Top 254,000 60,000 314,000
59 Top Foto 168,000 49,000 217,000
60 Vert. Lumbal 2 posisi 370,000 92,000 462,000
61 Vert. Lumbal 4 pos 512,000 148,000 660,000
62 Vert. Thoracal 2 posisi 320,000 92,000 412,000
1.2 RADIO DIAGNOSTIK DENGAN KONTRAS
1 APG 1,073,000 311,000 1,384,000
2 Artrografi 1,200,000 345,000 1,545,000
3 BNO - IVP 923,000 276,000 1,199,000
4 Bone Age 202,000 58,000 260,000
5 Bone Survey 983,000 253,000 1,236,000
6 C-Arm 750,000 184,000 934,000
7 C-Arm Dengan Kontras 800,000 230,000 1,030,000
8 Cholangiografi T. Tube 923,000 276,000 1,199,000
9 Colon in loop 923,000 276,000 1,199,000
10 Cystogram 760,000 219,000 979,000
11 Dacriosistografi 800,000 230,000 1,030,000
12 Ductulografi 1,200,000 345,000 1,545,000
13 E R C P + Tindakan 1,398,000 414,000 1,812,000
14 E R C P Diagnostik 1,040,000 299,000 1,339,000
15 Fistulografi 760,000 219,000 979,000
16 Follow Through 833,000 242,000 1,075,000
17 HSG 720,000 207,000 927,000
18 Lopografi 833,000 242,000 1,075,000
19 Mammografi 560,000 161,000 721,000
20 Myelografi Cervical 1,200,000 345,000 1,545,000
21 Myelografi Lumbal 1,200,000 345,000 1,545,000
22 Myelografi Thoracal 1,200,000 345,000 1,545,000
23 OMD 760,000 219,000 979,000
24 Phlebografi 1,600,000 460,000 2,060,000
25 Phlebografi Bilateral 1,952,000 644,000 2,596,000
26 RPG 1,073,000 311,000 1,384,000
27 Radiografi Pada Ruang Operasi 640,000 184,000 824,000
28 Radiografi Pada Ruang Operasi + KM 800,000 230,000 1,030,000
29 Sialografi 1,200,000 345,000 1,545,000
30 Spot Fluoroscopic 520,000 150,000 670,000
31 Urethrocystogram 760,000 219,000 979,000
32 USG Abdomen Atas 736,000 132,000 868,000
33 USG Abdomen Bawah 697,000 75,000 772,000
34 USG Abdomen Lengkap 1,433,000 203,000 1,636,000
35 USG Ankle 820,000 229,000 1,049,000
36 USG Ankle Bilateral 1,323,000 459,000 1,782,000
37 USG Bahu 520,000 132,000 652,000
38 USG Bahu Bilateral 994,000 263,000 1,257,000
39 USG Bayi 1,337,000 193,000 1,530,000
40 USG Doppler Vaskular Abdomen 778,000 156,000 934,000
41 USG Doppler Vaskular Carotis 752,000 193,000 945,000
42 USG Doppler Vaskular Extremitas Arteri 928,000 267,000 1,195,000
43 USG Doppler Vaskular Extremitas Arteri Bilateral 1,615,000 534,000 2,149,000
44 USG Doppler Vaskular Extremitas Vena 668,000 193,000 861,000
45 USG Doppler Vaskular Extremitas Vena Bilateral 1,273,000 385,000 1,658,000
46 USG Doppler Vaskular testis 935,000 229,000 1,164,000
47 USG Elbow 603,000 174,000 777,000
48 USG Elbow Bilateral 922,000 348,000 1,270,000
49 USG Genu 584,000 168,000 752,000
50 USG Genu Bilateral 1,035,000 337,000 1,372,000
51 USG Guide / Operasi 817,000 118,000 935,000
52 USG Leher Lengkap 519,000 150,000 669,000
53 USG Mammae 568,000 75,000 643,000
54 USG Muskulosckletal/Superfisial 520,000 75,000 595,000
55 USG Sendi Kecil 698,000 156,000 854,000
56 USG Testis 568,000 75,000 643,000
57 USG Thorax 606,000 132,000 738,000
58 USG Thyroid 523,000 75,000 598,000
59 USG Traktus Urinarius 390,000 75,000 465,000
60 USG Transrectal (Prostat) 568,000 75,000 643,000
61 USG Wrist 758,000 229,000 987,000
62 USG Wrist Bilateral 1,283,000 459,000 1,742,000
1.3 CT SCAN NON KONTRAS
1 Abdomen Atas-Non Kontras 2,572,000 564,000 3,136,000
JASA
PELAYANAN
2 Angkle & Pedis-Non Kontras 2,381,000 523,000 2,904,000
3 Antebrachi-Non Kontras 2,381,000 523,000 2,904,000
4 Bahu-Non Kontras 2,381,000 523,000 2,904,000
5 Cruris-Non Kontras 2,381,000 523,000 2,904,000
6 CT Biopsy + Jarum-Non Kontras 3,044,000 667,000 3,711,000
7 CT Urografi-Non Kontras 3,609,000 791,000 4,400,000
8 Cubity / Elbow-Non Kontras 2,381,000 523,000 2,904,000
9 Femur-Non Kontras 2,381,000 523,000 2,904,000
10 Genue-Non Kontras 2,381,000 523,000 2,904,000
11 Humerus-Non Kontras 2,381,000 523,000 2,904,000
12 Mastoid High Resolution-Non Kontras 1,294,000 283,000 1,577,000
13 Nasofaring / Orofaring / Laring / Leher-Non Kontras 1,294,000 283,000 1,577,000
14 Otak-Non Kontras 1,270,000 279,000 1,549,000
15 Pelvis (Abdomen Bawah)-Non Kontras 2,678,000 587,000 3,265,000
16 Sinus / Orbita / Wajah-Non Kontras 1,462,000 320,000 1,782,000
17 Thorax-Non Kontras 2,572,000 564,000 3,136,000
18 Vertebra Cervical-Non Kontras 2,394,000 525,000 2,919,000
19 Vertebra Cerviothoracal-Non Kontras 2,394,000 525,000 2,919,000
20 Vertebra Lumbal-Non Kontras 2,394,000 525,000 2,919,000
21 Vertebra Lumbosacral-Non Kontras 2,394,000 525,000 2,919,000
22 Vertebra Thoracal-Non Kontras 2,394,000 525,000 2,919,000
23 Vertebra Thoracolumbal-Non Kontras 2,394,000 525,000 2,919,000
24 Virtual Bronchoscopy / Thorax-Non Kontras 2,572,000 564,000 3,136,000
25 Virtual Colonoscopy-Non Kontras 3,609,000 791,000 4,400,000
26 Whole Abdomen (Abd. Atas & Bawah)-Non Kontras 3,609,000 791,000 4,400,000
27 Wrist / Tangan-Non Kontras 2,381,000 523,000 2,904,000
1.4 CT SCAN KONTRAS
1 Abdomen Atas 3,524,000 772,000 4,296,000
2 Abdomen Atas dengan Multifase / Volumetri 4,297,000 941,000 5,238,000
3 Angkle & Pedis 3,259,000 715,000 3,974,000
4 Antebrachi 3,259,000 715,000 3,974,000
5 Aorta Abdominalis 5,821,000 1,276,000 7,097,000
6 Aorta Thoraxalis 5,821,000 1,276,000 7,097,000
7 Aortha Thoraxalis & Abdominalis 10,802,000 2,367,000 13,169,000
8 Bahu 3,259,000 715,000 3,974,000
9 Cardiac Scan 4,541,000 995,000 5,536,000
10 Cardiac Scoring 2,297,000 503,000 2,800,000
11 Cruris 3,259,000 715,000 3,974,000
12 CT Angio Carotis 3,281,000 719,000 4,000,000
13 CT Angio Cerebral 3,281,000 719,000 4,000,000
14 CT Angio Cerebral & Carotis 5,722,000 1,254,000 6,976,000
15 Ct Angio Ekstremitas Atas 4,922,000 1,078,000 6,000,000
16 CT Angio Ekstremitas Bawah 6,668,000 1,461,000 8,129,000
17 CT Urografi 4,922,000 1,078,000 6,000,000
18 Cubity / Elbow 3,259,000 715,000 3,974,000
19 Femur 3,259,000 715,000 3,974,000
20 Genue 3,259,000 715,000 3,974,000
21 Humerus 3,259,000 715,000 3,974,000
22 Mastoid High Resolution 2,223,000 487,000 2,710,000
23 Nasofaring / Orofaring / Laring / Leher 2,223,000 487,000 2,710,000
24 Otak 2,011,000 441,000 2,452,000
25 Pelvis (Abdomen Bawah) 3,630,000 795,000 4,425,000
26 Perfusi Kepala 4,244,000 930,000 5,174,000
27 Sinus / Orbita / Wajah 2,369,000 519,000 2,888,000
28 Thorakoabdominal 5,821,000 1,276,000 7,097,000
29 Thorax 3,524,000 772,000 4,296,000
30 Vertebra Cervical 3,259,000 715,000 3,974,000
31 Vertebra Cerviothoracal 3,259,000 715,000 3,974,000
32 Vertebra Lumbal 3,259,000 715,000 3,974,000
33 Vertebra Lumbosacral 3,259,000 715,000 3,974,000
34 Vertebra Thoracal 3,259,000 715,000 3,974,000
35 Vertebra Thoracolumbal 3,259,000 715,000 3,974,000
36 Whole Abdomen (Abd. Atas & Bawah) 4,562,000 1,000,000 5,562,000
37 Wrist / Tangan 3,259,000 715,000 3,974,000
1.5 KEDOKTERAN NUKLIR
1 Bone Scan 1,591,000 575,000 2,166,000
2 Bone Scan Pasca Terapi Sm-153 EDTMP 466,000 358,000 824,000
3 Brain Scan 3,425,000 1,265,000 4,690,000
4 Dacrioskintigrafi 414,000 317,000 731,000
5 GI Bleeding Scan/LPI 5,564,000 546,000 6,110,000
JASA
PELAYANAN
6 Limfoskintigrafi 1,600,000 690,000 2,290,000
7 Liver/spleen Scan 1,004,000 771,000 1,775,000
8 Lung Perfusion Scan 1,269,000 575,000 1,844,000
9 Lung Ventilation Scan 2,522,000 863,000 3,385,000
10 Meckel Scan 917,000 690,000 1,607,000
11 MIBG Scan 5,927,000 4,544,000 10,471,000
12 Na-131 dosis 100 m Ci 12,575,000 2,300,000 14,875,000
13 Na-131 dosis 150 m Ci 18,578,000 2,300,000 20,878,000
14 Na-131 dosis 200 m Ci 20,718,000 2,300,000 23,018,000
15 Parathyroid Scan MIBI 2,548,000 575,000 3,123,000
16 Parotis Scan 530,000 406,000 936,000
17 Pemeriksaan Gastric Emptying Test (GET) 1,288,000 988,000 2,276,000
18 Renogram/GFR 720,000 489,000 1,209,000
19 Salivary Scan 482,000 345,000 827,000
20 Sentinel Node intraoperatif 1,600,000 1,150,000 2,750,000
21 Sidik DMSA 938,000 518,000 1,456,000
22 Sidik Hepatobilier / HIDA 1,243,000 748,000 1,991,000
23 Sidik Perfusi Miokard farmakological stress-rest test 3,431,000 1,380,000 4,811,000
24 Sidik Perfusi Miokard saat rest 3,303,000 1,035,000 4,338,000
25 Sidik Perfusi Miokard stress-rest test 3,303,000 1,380,000 4,683,000
26 Sistenogram 1,504,000 575,000 2,079,000
27 Skintimamografi 2,548,000 690,000 3,238,000
28 Therapy I-131 10mCi 1,690,000 863,000 2,553,000
29 Therapy I-131 15 mCi 2,479,000 1,901,000 4,380,000
30 Therapy I-131 30 mCi 4,828,000 863,000 5,691,000
31 Therapy I-131 5 mCi 907,000 696,000 1,603,000
32 Therapy Sm-153 EDTMP 50mCi 4,386,000 3,363,000 7,749,000
33 Therapy Sm-153 EDTMP 75mCi 5,459,000 4,185,000 9,644,000
34 Thyroid Scan 498,000 382,000 880,000
35 Whole Body MIBI 2,548,000 575,000 3,123,000
36 Whole Body Scan I-131 663,000 508,000 1,171,000
37 Whole Body Scan Pasca Terapi I-131 461,000 353,000 814,000
1.6 MRI NON KONTRAS
1 MRA Aorta Abdominalis 1,984,000 502,000 2,486,000
2 MRA Aorta Abdominalis (Cabang) 1,984,000 502,000 2,486,000
3 MRA Aorta Thoracalis 1,984,000 502,000 2,486,000
4 MRA Brain 1,885,000 477,000 2,362,000
5 MRA Carotis 1,885,000 477,000 2,362,000
6 MRA Extremitas ( Bawah) 1,984,000 502,000 2,486,000
7 MRA Pelvis 1,984,000 502,000 2,486,000
8 MRA Pulmonal Artery 1,984,000 502,000 2,486,000
9 MRA Upper Extremitas ( Atas) 1,984,000 502,000 2,486,000
10 MRA Whole Aorta 2,977,000 751,000 3,728,000
11 MRI Abdomen Atas 1,984,000 502,000 2,486,000
12 MRI Abdomen Atas + MRCP 1,984,000 502,000 2,486,000
13 MRI Abdomen Atas 3 Face 2,431,000 615,000 3,046,000
14 MRI Abdomen Atas Dynamic 3Fase 2,509,000 634,000 3,143,000
15 MRI Abdomen Bawah/Pelvis 1,786,000 451,000 2,237,000
16 MRI Brain 1,786,000 451,000 2,237,000
17 MRI Brain + DWI 1,984,000 502,000 2,486,000
18 MRI Brain + MRA 1,786,000 451,000 2,237,000
19 MRI Brain + MRA + Venografi 1,984,000 502,000 2,486,000
20 MRI Brain + MRS 2,084,000 526,000 2,610,000
21 MRI Brain + PWI* 2,381,000 602,000 2,983,000
22 MRI Brain 3DASL+SWAN 2,312,000 585,000 2,897,000
23 MRI Brain/Epilepsi 2,312,000 585,000 2,897,000
24 MRI Cardiac 5,141,000 1,299,000 6,440,000
25 MRI Cartigram 1,816,000 459,000 2,275,000
26 MRI Cartigram + Genu 2,263,000 572,000 2,835,000
27 MRI Cervical 1,786,000 451,000 2,237,000
28 MRI Cervico Thoracal 1,786,000 451,000 2,237,000
29 MRI CISS/Cochlea 2,460,000 621,000 3,081,000
30 MRI Cochlea+DTI 3,132,000 792,000 3,924,000
31 MRI DTI 2,312,000 585,000 2,897,000
32 MRI Endometrosis 2,312,000 585,000 2,897,000
33 MRI Extremitas Atas 1,984,000 502,000 2,486,000
34 MRI Extremitas Bawah 1,984,000 502,000 2,486,000
35 MRI FUNCTIONAL Brain 3,554,000 897,000 4,451,000
36 MRI Hipofisis Dynamic 2,308,000 584,000 2,892,000
37 MRI Laring 1,885,000 477,000 2,362,000
JASA
PELAYANAN
38 MRI Leher/Neck Soft Tissue 1,885,000 477,000 2,362,000
39 MRI Leher/Tractography 2,411,000 609,000 3,020,000
40 MRI Lumbosacral 1,984,000 502,000 2,486,000
41 MRI Mammae/MRS 2,084,000 526,000 2,610,000
42 MRI Mastoid 1,885,000 477,000 2,362,000
43 MRI MRCP 2,084,000 526,000 2,610,000
44 MRI MRCP Dynamic 2,624,000 663,000 3,287,000
45 MRI Nasofaring 1,885,000 477,000 2,362,000
46 MRI Orbita 1,786,000 451,000 2,237,000
47 MRI Orofaring 1,885,000 477,000 2,362,000
48 MRI Prostat 1,984,000 502,000 2,486,000
49 MRI Prostat Dynamic 2,509,000 634,000 3,143,000
50 MRI Prostat Spectroscopy + 25% 1,984,000 502,000 2,486,000
51 MRI Sinus Pranasal 1,885,000 477,000 2,362,000
52 MRI Tempora Mandibula Joint 1,885,000 477,000 2,362,000
53 MRI Thalasemia Hepar+Jantung 1,885,000 477,000 2,362,000
54 MRI Thalasemia Jantung/Hepar 1,885,000 477,000 2,362,000
55 MRI Thoracal 1,984,000 502,000 2,486,000
56 MRI Thorako Lumbal 2,381,000 602,000 2,983,000
57 MRI Thoraks 1,984,000 502,000 2,486,000
58 MRI Whole Abdomen 2,877,000 727,000 3,604,000
59 MRI Whole Abdomen Dynamic 3,419,000 864,000 4,283,000
60 MRI Whole Spine 3,274,000 827,000 4,101,000
1.7 MRI KONTRAS
1 MRA Aorta Abdominalis 3,112,000 786,000 3,898,000
2 MRA Aorta Abdominalis (Cabang) 3,112,000 786,000 3,898,000
3 MRA Aorta Thoracalis 3,112,000 786,000 3,898,000
4 MRA Brain 3,004,000 758,000 3,762,000
5 MRA Carotis 3,004,000 758,000 3,762,000
6 MRA Extremitas ( Bawah) 3,112,000 786,000 3,898,000
7 MRA Pelvis 3,112,000 786,000 3,898,000
8 MRA Pulmonal Artery 3,112,000 786,000 3,898,000
9 MRA Upper Extremitas ( Atas) 3,112,000 786,000 3,898,000
10 MRA Whole Aorta 4,257,000 1,076,000 5,333,000
11 MRI Abdomen Atas 2,609,000 659,000 3,268,000
12 MRI Abdomen Atas + MRCP 2,609,000 659,000 3,268,000
13 MRI Abdomen Atas 3 Face 3,022,000 763,000 3,785,000
14 MRI Abdomen Atas Dynamic 3Fase 3,358,000 848,000 4,206,000
15 MRI Abdomen Atas+PRIMOVIS 6,052,000 1,529,000 7,581,000
16 MRI Abdomen Bawah/Pelvis 2,381,000 602,000 2,983,000
17 MRI Abdomen Bawah+PRIMOVIS 5,818,000 1,469,000 7,287,000
18 MRI Brain 2,381,000 602,000 2,983,000
19 MRI Brain + DWI 2,616,000 661,000 3,277,000
20 MRI Brain + MRA 2,886,000 730,000 3,616,000
21 MRI Brain + MRA + Venografi 3,112,000 786,000 3,898,000
22 MRI Brain + MRS 2,724,000 688,000 3,412,000
23 MRI Brain + PWI* 3,563,000 900,000 4,463,000
24 MRI Brain 3DASL+SWAN 2,869,000 725,000 3,594,000
25 MRI Brain/Epilepsi 2,869,000 725,000 3,594,000
26 MRI Cardiac 5,502,000 1,390,000 6,892,000
27 MRI Cartigram 2,459,000 621,000 3,080,000
28 MRI Cartigram + Genu 2,992,000 756,000 3,748,000
29 MRI Cervical 2,381,000 602,000 2,983,000
30 MRI Cervico Thoracal 2,381,000 602,000 2,983,000
31 MRI CISS/Cochlea 3,033,000 766,000 3,799,000
32 MRI Cochlea+DTI 3,839,000 970,000 4,809,000
33 MRI DTI 2,869,000 725,000 3,594,000
34 MRI Endometrosis 2,869,000 725,000 3,594,000
35 MRI Extremitas Atas 2,609,000 659,000 3,268,000
36 MRI Extremitas Bawah 2,609,000 659,000 3,268,000
37 MRI Hipofisis Dynamic 3,136,000 792,000 3,928,000
38 MRI Laring 2,499,000 631,000 3,130,000
39 MRI Leher/Neck Soft Tissue 2,499,000 631,000 3,130,000
40 MRI Leher/Tractography 2,979,000 753,000 3,732,000
41 MRI Lumbosacral 2,609,000 659,000 3,268,000
42 MRI Mammae/MRS 2,724,000 688,000 3,412,000
43 MRI Mastoid 2,499,000 631,000 3,130,000
44 MRI MRCP 2,724,000 688,000 3,412,000
45 MRI MRCP Dynamic 3,484,000 880,000 4,364,000
46 MRI Nasofaring 2,499,000 631,000 3,130,000
JASA
PELAYANAN
47 MRI Orbita 2,381,000 602,000 2,983,000
48 MRI Orofaring 2,499,000 631,000 3,130,000
49 MRI Prostat 2,609,000 659,000 3,268,000
50 MRI Prostat Dynamic 3,087,000 780,000 3,867,000
51 MRI Prostat Spectroscopy + 25% 2,818,000 711,000 3,529,000
52 MRI Sinus Pranasal 2,499,000 631,000 3,130,000
53 MRI Tempora Mandibula Joint 2,499,000 631,000 3,130,000
54 MRI Thoracal 2,609,000 659,000 3,268,000
55 MRI Thorako Lumbal 3,066,000 774,000 3,840,000
56 MRI Thoraks 2,609,000 659,000 3,268,000
57 MRI Whole Abdomen 3,635,000 918,000 4,553,000
58 MRI Whole Abdomen Dynamic 4,359,000 1,101,000 5,460,000
59 MRI Whole Abdomen+PRIMOVIS 7,081,000 1,788,000 8,869,000
60 MRI Whole Spine 4,092,000 1,033,000 5,125,000
2. RADIOLOGI GIGI
2.1 RADIOLOGI GIGI
1 Chepalo 90,000 69,000 159,000
2 Dental X-ray 46,000 36,000 82,000
3 Panoramic 90,000 69,000 159,000
2.2 RADIOLOGI GIGI (PKG ADITYAWARMAN)
1 Chepalo 90,000 69,000 159,000
2 Dental X-ray 46,000 36,000 82,000
3 Panoramic 90,000 69,000 159,000
3. RADIOLOGI ANAK
1 Abdomen 1 posisi 195,000 85,000 280,000
2 Abdomen 2 Posisi 259,000 174,000 433,000
3 Abdomen 3 Posisi 322,000 217,000 539,000
4 Ankle 2 posisi bilateral 239,000 160,000 399,000
5 Ankle 2 posisi Kanan ATAU kiri 182,000 123,000 305,000
8 Antebrachii 2 posisi bilateral 243,000 164,000 407,000
9 AntebrachiI 2 posisi Kanan ATAU kiri 172,000 116,000 288,000
10 Apendicogram 889,000 596,000 1,485,000
11 APG 727,000 488,000 1,215,000
12 Baby Gram 211,000 92,000 303,000
13 BNO IVP 793,000 532,000 1,325,000
14 Bone Age 182,000 79,000 261,000
15 Bone Survey 829,000 556,000 1,385,000
16 Clavicula (kanan DAN kiri) 158,000 106,000 264,000
17 Colon in loop 986,000 662,000 1,648,000
18 Cruris 2 posisi bilateral 346,000 232,000 578,000
19 Cruris 2 posisi Kanan ATAU kiri 211,000 143,000 354,000
20 Cubiti 2 posisi bilateral 239,000 160,000 399,000
21 Cubiti 2 posisi Kanan ATAU kiri 183,000 124,000 307,000
22 Esofagogram 632,000 424,000 1,056,000
23 Facial bones caldwell /towne dan lateral sinar horisontal 222,000 150,000 372,000
24 Femur 2 posisi bilateral 346,000 232,000 578,000
25 Femur 2 posisi Kanan ATAU kiri 211,000 143,000 354,000
26 Fistulografi 847,000 569,000 1,416,000
27 Follow Trough 958,000 643,000 1,601,000
28 Genitografi 829,000 556,000 1,385,000
29 Genu 2 posisi bilateral 287,000 193,000 480,000
30 Genu 2 posisi Kanan ATAU kiri 198,000 133,000 331,000
33 Humerus 2 posisi bilateral 198,000 133,000 331,000
34 Humerus 2 posisi Kanan ATAU kiri 175,000 118,000 293,000
35 Kepala 2 posisi 211,000 143,000 354,000
36 Kontras enema 871,000 584,000 1,455,000
37 Kontras meal / upper GI series 871,000 584,000 1,455,000
38 Leher Soft Tissue 2 posisi 215,000 145,000 360,000
39 Lopografi 858,000 576,000 1,434,000
40 Mandibula 199,000 134,000 333,000
41 Manus 2 posisi bilateral 215,000 145,000 360,000
42 Mastoid 221,000 149,000 370,000
43 MCU (Micturating Cysto Urethrography) 805,000 540,000 1,345,000
44 Nasal 253,000 110,000 363,000
45 Orbita 253,000 110,000 363,000
46 Pedis 2 posisi bilateral 255,000 171,000 426,000
JASA
PELAYANAN
47 Pedis 2 posisi Kanan ATAU kiri 158,000 106,000 264,000
48 Pelvis 1 posisi 198,000 86,000 284,000
49 Pelvis 2 posisi 219,000 147,000 366,000
50 Pelvis 3 posisi 255,000 171,000 426,000
51 Pemeriksaan POUCH 697,000 468,000 1,165,000
52 Pergelangan tangan / Wrist Joint (2 posisi) bilateral 239,000 160,000 399,000
53 Pergelangan tangan / Wrist Joint (2 posisi) kanan ATAU kiri 182,000 123,000 305,000
54 RPG 727,000 488,000 1,215,000
55 Sacrum 2 posisi 239,000 160,000 399,000
56 Scanogram 450,000 303,000 753,000
57 Scapula 2 posisi bilateral 231,000 156,000 387,000
58 Scapula 2 posisi kanan ATAU kiri 158,000 106,000 264,000
59 Scoliosis Program 472,000 317,000 789,000
60 Shoulder 2 posisi bilateral 229,000 154,000 383,000
61 Shoulder 2 posisi Kanan ATAU kiri 157,000 106,000 263,000
63 Shoulder 3 posisi kanan ATAU kiri 188,000 126,000 314,000
64 Sinus Paranasal (waters dan lateral) 198,000 133,000 331,000
65 Spot Flouroscopic 450,000 302,000 752,000
66 Thoraco Abdominal 1 posisi 322,000 139,000 461,000
68 Thorax 1 posisi 172,000 75,000 247,000
69 Thorax 2 posisi 243,000 164,000 407,000
70 TMJ 221,000 149,000 370,000
71 Urethrocystogram 698,000 469,000 1,167,000
72 USG Abdomen atas 526,000 353,000 879,000
73 USG Abdomen atas dan Doppler 1,004,000 673,000 1,677,000
74 USG abdomen bawah / ginjal dan doppler 1,005,000 674,000 1,679,000
75 USG abdomen bawah / Ginjal dan saluran kemih 516,000 346,000 862,000
76 USG Abdomen lengkap 930,000 624,000 1,554,000
77 USG abdomen lengkap dan doppler 1,750,000 1,173,000 2,923,000
78 USG colli/leher 446,000 299,000 745,000
79 USG diafragma 306,000 206,000 512,000
80 USG doppler vaskuler abdomen atas 536,000 359,000 895,000
81 USG Doppler vaskuler abdomen bawah / ginjal 526,000 353,000 879,000
82 USG doppler vaskuler abdomen lengkap 1,004,000 673,000 1,677,000
83 USG Doppler vaskuler Carotis 516,000 346,000 862,000
84 USG doppler vaskuler ekstremitas atas kanan ATAU kiri 520,000 349,000 869,000
85 USG doppler vaskuler ekstremitas atas kanan dan kiri 1,004,000 673,000 1,677,000
86 USG doppler vaskuler ekstremitas bawah kanan ATAU kiri 520,000 349,000 869,000
87 USG doppler vaskuler ekstremitas bawah kanan dan kiri 1,004,000 673,000 1,677,000
88 USG doppler vaskuler kepala 526,000 353,000 879,000
89 USG doppler vaskuler superfisial 520,000 349,000 869,000
90 USG Guidance biopsi atau pengeluaran cairan 301,000 203,000 504,000
91 USG Hepatobilier 2 fase 961,000 645,000 1,606,000
92 USG hip 516,000 346,000 862,000
93 USG Kepala 446,000 299,000 745,000
94 USG Kepala dan Doppler 927,000 622,000 1,549,000
95 USG Mamae/ payudara 446,000 299,000 745,000
96 USG muskuloskeletal bilateral 1,219,000 818,000 2,037,000
97 USG muskuloskeletal ipsi lateral 656,000 440,000 1,096,000
98 USG Pelvis wanita - genitalia interna 516,000 346,000 862,000
99 USG spinal / vertebra 446,000 299,000 745,000
100 USG superfisial 446,000 299,000 745,000
101 USG superfisial dan doppler 930,000 624,000 1,554,000
102 USG Testis 446,000 299,000 745,000
103 USG Tiroid 446,000 299,000 745,000
104 USG toraks / paru 446,000 299,000 745,000
105 Vertebra Cervical 2 posisi 239,000 160,000 399,000
106 Vertebra Lumbal 2 posisi 277,000 186,000 463,000
107 Vertebra Lumbalsacral 2 posisi 307,000 206,000 513,000
108 Vertebra Thoracal 2 posisi 270,000 182,000 452,000
109 Vertebra Thoracal Lumbal 2 posisi 322,000 217,000 539,000
5. ORTHOTICS DAN PROSTHETICS
JASA
PELAYANAN
UNILATERAL
1 AFO - Ground Reaction (GRAFO)_A_Unilateral 1.218.000 122.000 1.340.000
2 AFO - Ground Reaction (GRAFO)_B_Unilateral 963.000 97.000 1.060.000
3 AFO - Ground Reaction (GRAFO)_C_Unilateral 768.000 77.000 845.000
4 AFO - Ground Reaction (GRAFO)_D_Unilateral 582.000 58.000 640.000
5 AFO - Ground Reaction (GRAFO)_E_Unilateral 445.000 45.000 490.000
AFO CONVENTIONAL/ Short Leg Brace (Belum Termasuk
6 1.473.000 147.000 1.620.000
Sepatu)_A_Unilateral
7 1.322.000 133.000 1.455.000
Sepatu)_B_Unilateral
8 1.177.000 118.000 1.295.000
Sepatu)_C_Unilateral
9 1.032.000 103.000 1.135.000
Sepatu)_D_Unilateral
10 882.000 88.000 970.000
Sepatu)_E_Unilateral
11 AFO Flexible - Posterior Leaf Spring_A_Unilateral 1.218.000 122.000 1.340.000
12 AFO Flexible - Posterior Leaf Spring_B_Unilateral 1.000.000 100.000 1.100.000
13 AFO Flexible - Posterior Leaf Spring_C_Unilateral 809.000 81.000 890.000
14 AFO Flexible - Posterior Leaf Spring_D_Unilateral 568.000 57.000 625.000
15 AFO Flexible - Posterior Leaf Spring_E_Unilateral 427.000 43.000 470.000
16 AFO Flexible - Swedish_A_Unilateral 1.218.000 122.000 1.340.000
17 AFO Flexible - Swedish_B_Unilateral 1.000.000 100.000 1.100.000
18 AFO Flexible - Swedish_C_Unilateral 809.000 81.000 890.000
19 AFO Flexible - Swedish_D_Unilateral 568.000 57.000 625.000
20 AFO Flexible - Swedish_E_Unilateral 427.000 43.000 470.000
21 AFO Jointed (lokal)_A_Unilateral 1.254.000 126.000 1.380.000
22 AFO Jointed (lokal)_B_Unilateral 1.113.000 112.000 1.225.000
23 AFO Jointed (lokal)_C_Unilateral 586.000 59.000 645.000
24 AFO Jointed (lokal)_D_Unilateral 718.000 72.000 790.000
25 AFO Jointed (lokal)_E_Unilateral 500.000 50.000 550.000
26 AFO Nancy Hilton - Tone Reduction Orthosis_A_Unilateral 1.218.000 122.000 1.340.000
27 AFO Nancy Hilton - Tone Reduction Orthosis_B_Unilateral 1.000.000 100.000 1.100.000
28 AFO Nancy Hilton - Tone Reduction Orthosis_C_Unilateral 809.000 81.000 890.000
29 AFO Nancy Hilton - Tone Reduction Orthosis_D_Unilateral 568.000 57.000 625.000
30 AFO Nancy Hilton - Tone Reduction Orthosis_E_Unilateral 427.000 43.000 470.000
31 AFO Patellar Tendon Bearing (Full Plastic)_A_Unilateral 1.218.000 122.000 1.340.000
32 AFO Patellar Tendon Bearing (Full Plastic)_B_Unilateral 1.595.000 160.000 1.755.000
33 AFO Patellar Tendon Bearing (Full Plastic)_C_Unilateral 1.086.000 109.000 1.195.000
34 AFO Patellar Tendon Bearing (Full Plastic)_D_Unilateral 932.000 93.000 1.025.000
35 AFO Patellar Tendon Bearing (Full Plastic)_E_Unilateral 618.000 62.000 680.000
36 AFO RIGID UNILATERAL_A 1.218.000 122.000 1.340.000
37 AFO RIGID UNILATERAL_B 1.000.000 100.000 1.100.000
38 AFO RIGID UNILATERAL_C 809.000 81.000 890.000
39 AFO RIGID UNILATERAL_D 568.000 57.000 625.000
40 AFO RIGID UNILATERAL_E 427.000 43.000 470.000
41 AFO Supra Malleolar Orthosis (SMO)_A_Unilateral 650.000 65.000 715.000
42 AFO Supra Malleolar Orthosis (SMO)_B_Unilateral 577.000 58.000 635.000
43 AFO Supra Malleolar Orthosis (SMO)_C_Unilateral 473.000 47.000 520.000
44 AFO Supra Malleolar Orthosis (SMO)_D_Unilateral 413.000 42.000 455.000
45 AFO Supra Malleolar Orthosis (SMO)_E_Unilateral 345.000 35.000 380.000
46 CTO 2 POST_A_Unilateral 1.718.000 172.000 1.890.000
JASA
PELAYANAN
47 CTO 2 POST_B_Unilateral 1.550.000 155.000 1.705.000
48 CTO 4 POST_A_Unilateral 1.868.000 187.000 2.055.000
49 CTO 4 POST_B_Unilateral 1.700.000 170.000 1.870.000
50 DIABETIC SHOE_A_Unilateral 1.504.000 151.000 1.655.000
51 DIABETIC SHOE_B_Unilateral 1.327.000 133.000 1.460.000
52 DYNAMIC HAND SPLINT_BESAR_Unilateral 836.000 84.000 920.000
53 DYNAMIC HAND SPLINT_KECIL_Unilateral 636.000 64.000 700.000
54 ELBOW ORTHOSIS JOINTED_BESAR_Unilateral 1.254.000 126.000 1.380.000
55 ELBOW ORTHOSIS JOINTED_KECIL_Unilateral 791.000 79.000 870.000
56 FINGER SPLINT (all size)_Unilateral 123.000 12.000 135.000
57 Hand Splint; based MCP Orthosis (Besar)_Unilateral 727.000 73.000 800.000
58 Hand Splint; based MCP Orthosis (Kecil)_Unilateral 522.000 53.000 575.000
59 Hand Splint; C Bar (Functional Splint) (Besar)_Unilateral 727.000 73.000 800.000
60 Hand Splint; C Bar (Functional Splint) (Kecil)_Unilateral 522.000 53.000 575.000
Hand Splint; Circumferential Static Forearm Base Orthosis
61 727.000 73.000 800.000
(Besar)_Unilateral
62 522.000 53.000 575.000
(Kecil)_Unilateral
63 Hand Splint; Cock Up Splint (Besar)_Unilateral 727.000 73.000 800.000
64 Hand Splint; Cock Up Splint (Kecil)_Unilateral 522.000 53.000 575.000
65 Hand Splint; Dorsal Static FBOs (Besar)_Unilateral 727.000 73.000 800.000
66 Hand Splint; Dorsal Static FBOs (Kecil)_Unilateral 522.000 53.000 575.000
Hand Splint; Radial Static Forearm Base Orthosis
67 727.000 73.000 800.000
(Besar)_Unilateral
68 522.000 53.000 575.000
(Kecil)_Unilateral
69 Hand Splint; Resting Splint (Besar)_Unilateral 727.000 73.000 800.000
70 Hand Splint; Resting Splint (Kecil)_Unilateral 522.000 53.000 575.000
71 Hand Splint; Static Thumb Orthosis (Besar)_Unilateral 727.000 73.000 800.000
72 Hand Splint; Static Thumb Orthosis (Kecil)_Unilateral 522.000 53.000 575.000
73 Hand Splint; Ulnar hand based orthosis (Besar)_Unilateral 727.000 73.000 800.000
74 Hand Splint; Ulnar hand based orthosis (Kecil)_Unilateral 522.000 53.000 575.000
75 Heel Cushion (Heel area)_Unilateral 64.000 6.000 70.000
76 Heel Flare (Heel area)_Unilateral 64.000 6.000 70.000
77 Heel Lift (Heel area)_Unilateral 64.000 6.000 70.000
78 Heel Wedge (Heel area)_Unilateral 64.000 6.000 70.000
79 HELMET ORTHOSIS (all size)_Unilateral 786.000 79.000 865.000
80 HIP ABDUCTION BRACE_A_Unilateral 2.118.000 212.000 2.330.000
81 HIP ABDUCTION BRACE_B_Unilateral 1.677.000 168.000 1.845.000
82 HIP ABDUCTION BRACE_C_Unilateral 1.354.000 136.000 1.490.000
83 HKAFO Conventional (tidak termasuk sepatu)_A_Unilateral 2.968.000 297.000 3.265.000
84 HKAFO Conventional (tidak termasuk sepatu)_B_Unilateral 2.650.000 265.000 2.915.000
85 HKAFO Conventional (tidak termasuk sepatu)_C_Unilateral 2.600.000 260.000 2.860.000
86 HKAFO Conventional (tidak termasuk sepatu)_D_Unilateral 2.532.000 253.000 2.785.000
87 HKAFO Conventional (tidak termasuk sepatu)_E_Unilateral 2.123.000 212.000 2.335.000
88 HKAFO Moulded (Plastic)_A_Unilateral 4.077.000 408.000 4.485.000
89 HKAFO Moulded (Plastic)_B_Unilateral 5.109.000 511.000 5.620.000
90 HKAFO Moulded (Plastic)_C_Unilateral 4.695.000 470.000 5.165.000
91 HKAFO Moulded (Plastic)_D_Unilateral 4.895.000 490.000 5.385.000
92 HKAFO Moulded (Plastic)_E_Unilateral 3.650.000 365.000 4.015.000
93 Insole Heel Cushion (Full length)_A_Unilateral 591.000 59.000 650.000
94 Insole Heel Cushion (Full length)_B_Unilateral 518.000 52.000 570.000
95 Insole Heel Cushion (Full length)_C_Unilateral 427.000 43.000 470.000
96 Insole Heel Cushion (Full length)_D_Unilateral 391.000 39.000 430.000
97 Insole Heel Cushion (Full length)_E_Unilateral 350.000 35.000 385.000
98 INSOLE HEEL RELIEVE (Full length)_A_Unilateral 591.000 59.000 650.000
99 INSOLE HEEL RELIEVE (Full length)_B_Unilateral 518.000 52.000 570.000
JASA
PELAYANAN
100 INSOLE HEEL RELIEVE (Full length)_C_Unilateral 427.000 43.000 470.000
101 INSOLE HEEL RELIEVE (Full length)_D_Unilateral 391.000 39.000 430.000
102 INSOLE HEEL RELIEVE (Full length)_E_Unilateral 350.000 35.000 385.000
103 INSOLE MEDIAL ARCH SUPPORT (Full length)_A_Unilateral 591.000 59.000 650.000
104 INSOLE MEDIAL ARCH SUPPORT (Full length)_B_Unilateral 518.000 52.000 570.000
105 INSOLE MEDIAL ARCH SUPPORT (Full length)_C_Unilateral 427.000 43.000 470.000
106 INSOLE MEDIAL ARCH SUPPORT (Full length)_D_Unilateral 391.000 39.000 430.000
107 INSOLE MEDIAL ARCH SUPPORT (Full length)_E_Unilateral 350.000 35.000 385.000
108 INSOLE METATARSAL PAD (Full length)_A_Unilateral 591.000 59.000 650.000
109 INSOLE METATARSAL PAD (Full length)_B_Unilateral 518.000 52.000 570.000
110 INSOLE METATARSAL PAD (Full length)_C_Unilateral 427.000 43.000 470.000
111 INSOLE METATARSAL PAD (Full length)_D_Unilateral 391.000 39.000 430.000
112 INSOLE METATARSAL PAD (Full length)_E_Unilateral 350.000 35.000 385.000
KAFO CONVENTIONAL/ (Belum Termasuk
113 2.918.000 292.000 3.210.000
Sepatu)_A_Unilateral
114 2.518.000 252.000 2.770.000
Sepatu)_B_Unilateral
115 2.123.000 212.000 2.335.000
Sepatu)_C_Unilateral
116 1.722.000 173.000 1.895.000
Sepatu)_D_Unilateral
117 1.459.000 146.000 1.605.000
Sepatu)_E_Unilateral
118 KAFO Full Plastic (Splint) ; Rigid knee joint_A_Unilateral 2.045.000 205.000 2.250.000
119 KAFO Full Plastic (Splint) ; Rigid knee joint_B_Unilateral 1.841.000 184.000 2.025.000
120 KAFO Full Plastic (Splint) ; Rigid knee joint_C_Unilateral 1.400.000 140.000 1.540.000
121 KAFO Full Plastic (Splint) ; Rigid knee joint_D_Unilateral 1.164.000 116.000 1.280.000
122 KAFO Full Plastic (Splint) ; Rigid knee joint_E_Unilateral 764.000 76.000 840.000
KAFO Moulded Double Bar ; Single axis - Ankle
123 2.900.000 290.000 3.190.000
Joint_A_Unilateral
124 2.591.000 259.000 2.850.000
Joint_B_Unilateral
125 2.300.000 230.000 2.530.000
Joint_C_Unilateral
126 2.009.000 201.000 2.210.000
Joint_D_Unilateral
127 1.882.000 188.000 2.070.000
Joint_E_Unilateral
128 3.486.000 349.000 3.835.000
Rigid_A_Unilateral
129 3.281.000 329.000 3.610.000
Rigid_B_Unilateral
130 2.845.000 285.000 3.130.000
Rigid_C_Unilateral
131 2.004.000 201.000 2.205.000
Rigid_D_Unilateral
132 1.291.000 129.000 1.420.000
Rigid_E_Unilateral
KAFO Moulded Single Bar ; Single axis - Ankle
133 2.900.000 290.000 3.190.000
Joint_A_Unilateral
134 2.591.000 259.000 2.850.000
Joint_B_Unilateral
135 2.300.000 230.000 2.530.000
Joint_C_Unilateral
136 2.009.000 201.000 2.210.000
Joint_D_Unilateral
JASA
PELAYANAN
137 1.882.000 188.000 2.070.000
Joint_E_Unilateral
138 3.486.000 349.000 3.835.000
Rigid_A_Unilateral
139 3.281.000 329.000 3.610.000
Rigid_B_Unilateral
140 2.845.000 285.000 3.130.000
Rigid_C_Unilateral
141 2.004.000 201.000 2.205.000
Rigid_D_Unilateral
142 1.173.000 117.000 1.290.000
Rigid_E_Unilateral
143 KO Moulded Adjustable Knee Joint_A_Unilateral 1.600.000 160.000 1.760.000
144 KO Moulded Adjustable Knee Joint_B_Unilateral 1.445.000 145.000 1.590.000
145 KO Moulded Adjustable Knee Joint_C_Unilateral 1.304.000 131.000 1.435.000
146 KO Moulded Free Knee Joint_A_Unilateral 1.377.000 138.000 1.515.000
147 KO Moulded Free Knee Joint_B_Unilateral 1.295.000 130.000 1.425.000
148 KO Moulded Free Knee Joint_C_Unilateral 1.232.000 123.000 1.355.000
149 Lateral/ Medial heel Wedge (Full length)_Unilateral 64.000 6.000 70.000
150 Lateral/Medial Flare (Full length)_Unilateral 64.000 6.000 70.000
151 LSO CHAIRBACK (all size)_Unilateral 845.000 85.000 930.000
152 LSO KNIGHT (all size)_Unilateral 845.000 85.000 930.000
153 Metatarsal Bar (Full length)_Unilateral 64.000 6.000 70.000
154 MILWAUKEE_A_Unilateral 4.609.000 461.000 5.070.000
155 MILWAUKEE_B_Unilateral 3.845.000 385.000 4.230.000
156 MILWAUKEE_C_Unilateral 3.882.000 388.000 4.270.000
157 MILWAUKEE_D_Unilateral 3.250.000 325.000 3.575.000
158 MILWAUKEE_E_Unilateral 1.577.000 158.000 1.735.000
159 MINERVA_A_Unilateral 2.013.000 202.000 2.215.000
160 MINERVA_B_Unilateral 1.700.000 170.000 1.870.000
161 Outsole LLD_Unilateral 64.000 6.000 70.000
162 PAVLIK HARNES_Unilateral 318.000 32.000 350.000
PROSTESIS ANKLE
163 4.027.000 403.000 4.430.000
DISARTICULATION/SYME_A_Unilateral
PROSTESIS ANKLE
164 2.645.000 265.000 2.910.000
DISARTICULATION/SYME_B_Unilateral
PROSTESIS ELBOW DISARTICULATION
165 10.164.000 1.016.000 11.180.000
(COSMESIS)_A_Unilateral
166 8.563.000 857.000 9.420.000
(COSMESIS)_B_Unilateral
PROSTESIS KNEE DISARTICULATION EXOSKELETAL ;
167 10.145.000 1.015.000 11.160.000
SACH FOOT_A_Unilateral
168 7.441.000 744.000 8.185.000
SACH FOOT_B_Unilateral
169 PROSTESIS PARTIAL FOOT_A_Unilateral 1.359.000 136.000 1.495.000
170 PROSTESIS PARTIAL FOOT_B_Unilateral 1.113.000 112.000 1.225.000
171 PROSTESIS PARTIAL HAND (COSMESIS)_A_Unilateral 8.709.000 871.000 9.580.000
172 PROSTESIS PARTIAL HAND (COSMESIS)_B_Unilateral 7.123.000 712.000 7.835.000
173 PROSTESIS TRANS RADIAL (COSMESIS)_A_Unilateral 8.709.000 871.000 9.580.000
174 PROSTESIS TRANS RADIAL (COSMESIS)_B_Unilateral 7.123.000 712.000 7.835.000
PROSTESIS TRANSFEMORAL ENDOSKELETAL; SACH
175 21.241.000 2.124.000 23.365.000
FOOT_A_Unilateral
176 17.391.000 1.739.000 19.130.000
FOOT_B_Unilateral
177 PROSTESIS TRANSHUMERAL_A_Unilateral 24.341.000 2.434.000 26.775.000
178 PROSTESIS TRANSHUMERAL_B_Unilateral 23.032.000 2.303.000 25.335.000
JASA
PELAYANAN
PROSTESIS TRANSTIBIAL ENDOSKELETAL; SACH
179 12.154.000 1.216.000 13.370.000
FOOT_A_Unilateral
180 10.059.000 1.006.000 11.065.000
FOOT_B_Unilateral
PROSTESIS TRANSTIBIAL EXOSKELETAL; SACH
181 4.423.000 442.000 4.865.000
FOOT_Unilateral
PROSTESIS WRIST DISARTICULATION
182 8.709.000 871.000 9.580.000
(COSMESIS)_A_Unilateral
183 7.123.000 712.000 7.835.000
(COSMESIS)_B_Unilateral
184 REPARASI PAKET A_Unilateral 100.000 10.000 110.000
185 REPARASI PAKET B_Unilateral 127.000 13.000 140.000
186 REPARASI PAKET C_Unilateral 223.000 22.000 245.000
187 REPARASI PAKET D_Unilateral 345.000 35.000 380.000
188 REPARASI PAKET E_Unilateral 532.000 53.000 585.000
189 REPARASI PAKET F_Unilateral 745.000 75.000 820.000
190 REPARASI PAKET G_Unilateral 1.332.000 133.000 1.465.000
191 Rocker Bottom (Full length)_Unilateral 64.000 6.000 70.000
192 SCOLIOSIS / UNDERARM BRACE_A_Unilateral 4.086.000 409.000 4.495.000
193 SCOLIOSIS / UNDERARM BRACE_B_Unilateral 3.718.000 372.000 4.090.000
194 SCOLIOSIS / UNDERARM BRACE_C_Unilateral 2.941.000 294.000 3.235.000
195 SCOLIOSIS / UNDERARM BRACE_D_Unilateral 2.309.000 231.000 2.540.000
196 SCOLIOSIS / UNDERARM BRACE_E_Unilateral 1.245.000 125.000 1.370.000
197 TLSO BODY JACKET_A_Unilateral 4.677.000 468.000 5.145.000
198 TLSO BODY JACKET_B_Unilateral 4.000.000 400.000 4.400.000
199 TLSO BODY JACKET_C_Unilateral 3.318.000 332.000 3.650.000
200 TLSO BODY JACKET_D_Unilateral 2.641.000 264.000 2.905.000
201 TLSO BODY JACKET_E _Unilateral 1.964.000 196.000 2.160.000
202 TLSO COWHORN (all size)_Unilateral 791.000 79.000 870.000
203 TLSO JEWETT (all size)_Unilateral 791.000 79.000 870.000
204 TLSO_KNIGHT TYLOR (all size)_Unilateral 850.000 85.000 935.000
205 UCBL_A_Unilateral 677.000 68.000 745.000
206 UCBL_B_Unilateral 595.000 60.000 655.000
207 UCBL_C_Unilateral 523.000 52.000 575.000
208 UCBL_D_Unilateral 450.000 45.000 495.000
209 UCBL_E_Unilateral 354.000 36.000 390.000
210 Ulnar Static Forearm Base Orthosis (Besar)_Unilateral 727.000 73.000 800.000
211 Ulnar Static Forearm Base Orthosis (Kecil)_Unilateral 522.000 53.000 575.000
BILATERAL
1 AFO - Ground Reaction (GRAFO)_A_Bilateral 2.432.000 243.000 2.675.000
2 AFO - Ground Reaction (GRAFO)_B_Bilateral 1.927.000 193.000 2.120.000
3 AFO - Ground Reaction (GRAFO)_C_Bilateral 1.536.000 154.000 1.690.000
4 AFO - Ground Reaction (GRAFO)_D_Bilateral 1.159.000 116.000 1.275.000
5 AFO - Ground Reaction (GRAFO)_E_Bilateral 891.000 89.000 980.000
6 2.941.000 294.000 3.235.000
Sepatu)_A_Bilateral
7 2.645.000 265.000 2.910.000
Sepatu)_B_Bilateral
8 2.350.000 235.000 2.585.000
Sepatu)_C_Bilateral
9 2.059.000 206.000 2.265.000
Sepatu)_D_Bilateral
10 1.764.000 176.000 1.940.000
Sepatu)_E_Bilateral
11 AFO Flexible - Posterior Leaf Spring_A_Bilateral 2.427.000 243.000 2.670.000
12 AFO Flexible - Posterior Leaf Spring_B_Bilateral 2.000.000 200.000 2.200.000
13 AFO Flexible - Posterior Leaf Spring_C_Bilateral 1.614.000 161.000 1.775.000
JASA
PELAYANAN
14 AFO Flexible - Posterior Leaf Spring_D_Bilateral 1.136.000 114.000 1.250.000
15 AFO Flexible - Posterior Leaf Spring_E_Bilateral 854.000 86.000 940.000
16 AFO Flexible - Swedish_A_Bilateral 2.427.000 243.000 2.670.000
17 AFO Flexible - Swedish_B_Bilateral 2.000.000 200.000 2.200.000
18 AFO Flexible - Swedish_C_Bilateral 1.614.000 161.000 1.775.000
19 AFO Flexible - Swedish_D_Bilateral 1.136.000 114.000 1.250.000
20 AFO Flexible - Swedish_E_Bilateral 854.000 86.000 940.000
21 AFO Jointed (lokal)_A_Bilateral 2.504.000 251.000 2.755.000
22 AFO Jointed (lokal)_B_Bilateral 2.222.000 223.000 2.445.000
23 AFO Jointed (lokal)_C_Bilateral 1.168.000 117.000 1.285.000
24 AFO Jointed (lokal)_D_Bilateral 1.436.000 144.000 1.580.000
25 AFO Jointed (lokal)_E_Bilateral 1.000.000 100.000 1.100.000
26 AFO Nancy Hilton - Tone Reduction Orthosis_A_Bilateral 2.427.000 243.000 2.670.000
27 AFO Nancy Hilton - Tone Reduction Orthosis_B_Bilateral 2.000.000 200.000 2.200.000
28 AFO Nancy Hilton - Tone Reduction Orthosis_C_Bilateral 1.614.000 161.000 1.775.000
29 AFO Nancy Hilton - Tone Reduction Orthosis_D_Bilateral 1.136.000 114.000 1.250.000
30 AFO Nancy Hilton - Tone Reduction Orthosis_E_Bilateral 854.000 86.000 940.000
31 AFO Patellar Tendon Bearing (Full Plastic)_A_Bilateral 2.432.000 243.000 2.675.000
32 AFO Patellar Tendon Bearing (Full Plastic)_B_Bilateral 3.191.000 319.000 3.510.000
33 AFO Patellar Tendon Bearing (Full Plastic)_C_Bilateral 2.172.000 218.000 2.390.000
34 AFO Patellar Tendon Bearing (Full Plastic)_D_Bilateral 1.859.000 186.000 2.045.000
35 AFO Patellar Tendon Bearing (Full Plastic)_E_Bilateral 1.236.000 124.000 1.360.000
36 AFO RIGID BILATERAL_A 2.427.000 243.000 2.670.000
37 AFO RIGID BILATERAL_B 2.000.000 200.000 2.200.000
38 AFO RIGID BILATERAL_C 1.614.000 161.000 1.775.000
39 AFO RIGID BILATERAL_D 1.136.000 114.000 1.250.000
40 AFO RIGID BILATERAL_E 854.000 86.000 940.000
41 AFO Supra Malleolar Orthosis (SMO)_A_Bilateral 1.300.000 130.000 1.430.000
42 AFO Supra Malleolar Orthosis (SMO)_B_Bilateral 1.150.000 115.000 1.265.000
43 AFO Supra Malleolar Orthosis (SMO)_C_Bilateral 941.000 94.000 1.035.000
44 AFO Supra Malleolar Orthosis (SMO)_D_Bilateral 827.000 83.000 910.000
45 AFO Supra Malleolar Orthosis (SMO)_E_Bilateral 691.000 69.000 760.000
46 DYNAMIC HAND SPLINT_BESAR_Bilateral 1.668.000 167.000 1.835.000
47 DYNAMIC HAND SPLINT_KECIL_Bilateral 1.268.000 127.000 1.395.000
48 ELBOW ORTHOSIS JOINTED_BESAR_Bilateral 2.504.000 251.000 2.755.000
49 ELBOW ORTHOSIS JOINTED_KECIL_Bilateral 1.577.000 158.000 1.735.000
50 FINGER SPLINT (all size)_Bilateral 241.000 24.000 265.000
51 Hand Splint; based MCP Orthosis (Besar)_Bilateral 1.445.000 145.000 1.590.000
52 Hand Splint; based MCP Orthosis (Kecil)_Bilateral 1.045.000 105.000 1.150.000
53 Hand Splint; C Bar (Functional Splint) (Besar)_Bilateral 1.445.000 145.000 1.590.000
54 Hand Splint; C Bar (Functional Splint) (Kecil)_Bilateral 1.045.000 105.000 1.150.000
55 1.445.000 145.000 1.590.000
(Besar)_Bilateral
56 1.045.000 105.000 1.150.000
(Kecil)_Bilateral
57 Hand Splint; Cock Up Splint (Besar)_Bilateral 1.445.000 145.000 1.590.000
58 Hand Splint; Cock Up Splint (Kecil)_Bilateral 1.045.000 105.000 1.150.000
59 Hand Splint; Dorsal Static FBOs (Besar)_Bilateral 1.445.000 145.000 1.590.000
60 Hand Splint; Dorsal Static FBOs (Kecil)_Bilateral 1.045.000 105.000 1.150.000
61 1.445.000 145.000 1.590.000
(Besar)_Bilateral
62 1.045.000 105.000 1.150.000
(Kecil)_Bilateral
63 Hand Splint; Resting Splint (Besar)_Bilateral 1.445.000 145.000 1.590.000
64 Hand Splint; Resting Splint (Kecil)_Bilateral 1.045.000 105.000 1.150.000
65 Hand Splint; Static Thumb Orthosis (Besar)_Bilateral 1.445.000 145.000 1.590.000
66 Hand Splint; Static Thumb Orthosis (Kecil)_Bilateral 1.045.000 105.000 1.150.000
JASA
PELAYANAN
67 Hand Splint; Ulnar hand based orthosis (Besar)_Bilateral 1.445.000 145.000 1.590.000
68 Hand Splint; Ulnar hand based orthosis (Kecil)_Bilateral 1.045.000 105.000 1.150.000
69 Heel Cushion (Heel area)_Bilateral 123.000 12.000 135.000
70 Heel Flare (Heel area)_Bilateral 123.000 12.000 135.000
71 Heel Lift (Heel area)_Bilateral 123.000 12.000 135.000
72 Heel Wedge (Heel area)_Bilateral 123.000 12.000 135.000
73 HKAFO Conventional (tidak termasuk sepatu)_A_Bilateral 5.936.000 594.000 6.530.000
74 HKAFO Conventional (tidak termasuk sepatu)_B_Bilateral 5.300.000 530.000 5.830.000
75 HKAFO Conventional (tidak termasuk sepatu)_C_Bilateral 5.195.000 520.000 5.715.000
76 HKAFO Conventional (tidak termasuk sepatu)_D_Bilateral 5.059.000 506.000 5.565.000
77 HKAFO Conventional (tidak termasuk sepatu)_E_Bilateral 4.241.000 424.000 4.665.000
78 HKAFO Moulded (Plastic)_A_Bilateral 8.154.000 816.000 8.970.000
79 HKAFO Moulded (Plastic)_B_Bilateral 10.213.000 1.022.000 11.235.000
80 HKAFO Moulded (Plastic)_C_Bilateral 9.386.000 939.000 10.325.000
81 HKAFO Moulded (Plastic)_D_Bilateral 9.791.000 979.000 10.770.000
82 HKAFO Moulded (Plastic)_E_Bilateral 7.300.000 730.000 8.030.000
83 5.832.000 583.000 6.415.000
Sepatu)_A_Bilateral
84 5.036.000 504.000 5.540.000
Sepatu)_B_Bilateral
85 4.241.000 424.000 4.665.000
Sepatu)_C_Bilateral
86 3.445.000 345.000 3.790.000
Sepatu)_D_Bilateral
87 2.913.000 292.000 3.205.000
Sepatu)_E_Bilateral
88 KAFO Full Plastic (Splint) ; Rigid knee joint_A_Bilateral 4.081.000 409.000 4.490.000
89 KAFO Full Plastic (Splint) ; Rigid knee joint_B_Bilateral 3.682.000 368.000 4.050.000
90 KAFO Full Plastic (Splint) ; Rigid knee joint_C_Bilateral 2.800.000 280.000 3.080.000
91 KAFO Full Plastic (Splint) ; Rigid knee joint_D_Bilateral 2.323.000 232.000 2.555.000
92 KAFO Full Plastic (Splint) ; Rigid knee joint_E_Bilateral 1.523.000 152.000 1.675.000
93 5.800.000 580.000 6.380.000
Joint_A_Bilateral
94 5.177.000 518.000 5.695.000
Joint_B_Bilateral
95 4.595.000 460.000 5.055.000
Joint_C_Bilateral
96 4.013.000 402.000 4.415.000
Joint_D_Bilateral
97 3.759.000 376.000 4.135.000
Joint_E_Bilateral
98 6.968.000 697.000 7.665.000
Rigid_A_Bilateral
99 6.563.000 657.000 7.220.000
Rigid_B_Bilateral
100 5.686.000 569.000 6.255.000
Rigid_C_Bilateral
101 4.009.000 401.000 4.410.000
Rigid_D_Bilateral
102 2.582.000 258.000 2.840.000
Rigid_E_Bilateral
103 5.800.000 580.000 6.380.000
Joint_A_Bilateral
104 5.177.000 518.000 5.695.000
Joint_B_Bilateral
105 4.595.000 460.000 5.055.000
Joint_C_Bilateral
JASA
PELAYANAN
106 4.013.000 402.000 4.415.000
Joint_D_Bilateral
107 3.759.000 376.000 4.135.000
Joint_E_Bilateral
108 6.968.000 697.000 7.665.000
Rigid_A_Bilateral
109 6.563.000 657.000 7.220.000
Rigid_B_Bilateral
110 5.686.000 569.000 6.255.000
Rigid_C_Bilateral
111 4.009.000 401.000 4.410.000
Rigid_D_Bilateral
112 2.341.000 234.000 2.575.000
Rigid_E_Bilateral
113 KO Moulded Adjustable Knee Joint_A_Bilateral 3.195.000 320.000 3.515.000
114 KO Moulded Adjustable Knee Joint_B_Bilateral 2.886.000 289.000 3.175.000
115 KO Moulded Adjustable Knee Joint_C_Bilateral 2.609.000 261.000 2.870.000
116 KO Moulded Free Knee Joint_A_Bilateral 2.750.000 275.000 3.025.000
117 KO Moulded Free Knee Joint_B_Bilateral 2.591.000 259.000 2.850.000
118 KO Moulded Free Knee Joint_C_Bilateral 2.459.000 246.000 2.705.000
119 Lateral/ Medial heel Wedge (Full length)_Bilateral 123.000 12.000 135.000
120 Lateral/Medial Flare (Full length)_Bilateral 123.000 12.000 135.000
121 Metatarsal Bar (Full length)_Bilateral 123.000 12.000 135.000
122 Outsole LLD_Bilateral 123.000 12.000 135.000
123 PROSTESIS ANKLE DISARTICULATION/SYME_A_Bilateral 8.050.000 805.000 8.855.000
124 PROSTESIS ANKLE DISARTICULATION/SYME_B_Bilateral 5.291.000 529.000 5.820.000
125 20.323.000 2.032.000 22.355.000
(COSMESIS)_A_Bilateral
126 17.127.000 1.713.000 18.840.000
(COSMESIS)_B_Bilateral
127 20.291.000 2.029.000 22.320.000
SACH FOOT_A_Bilateral
128 14.877.000 1.488.000 16.365.000
SACH FOOT_B_Bilateral
129 PROSTESIS PARTIAL FOOT_A_Bilateral 2.718.000 272.000 2.990.000
130 PROSTESIS PARTIAL FOOT_B_Bilateral 2.227.000 223.000 2.450.000
131 PROSTESIS PARTIAL HAND (COSMESIS)_A_Bilateral 17.418.000 1.742.000 19.160.000
132 PROSTESIS PARTIAL HAND (COSMESIS)_B_Bilateral 14.241.000 1.424.000 15.665.000
133 PROSTESIS TRANS RADIAL (COSMESIS)_A_Bilateral 17.418.000 1.742.000 19.160.000
134 PROSTESIS TRANS RADIAL (COSMESIS)_B_Bilateral 14.241.000 1.424.000 15.665.000
135 42.477.000 4.248.000 46.725.000
FOOT_A_Bilateral
136 34.777.000 3.478.000 38.255.000
FOOT_B_Bilateral
137 PROSTESIS TRANSHUMERAL_A_Bilateral 48.677.000 4.868.000 53.545.000
138 PROSTESIS TRANSHUMERAL_B_Bilateral 46.059.000 4.606.000 50.665.000
139 24.304.000 2.431.000 26.735.000
FOOT_A_Bilateral
140 20.113.000 2.012.000 22.125.000
FOOT_B_Bilateral
PROSTESIS TRANSTIBIAL EXOSKELETAL; SACH
141 8.841.000 884.000 9.725.000
FOOT_Bilateral
142 17.418.000 1.742.000 19.160.000
(COSMESIS)_A_Bilateral
143 14.241.000 1.424.000 15.665.000
(COSMESIS)_B_Bilateral
144 Rocker Bottom (Full length)_Bilateral 123.000 12.000 135.000
JASA
PELAYANAN
145 UCBL_A_Bilateral 1.354.000 136.000 1.490.000
146 UCBL_B_Bilateral 1.191.000 119.000 1.310.000
147 UCBL_C_Bilateral 1.041.000 104.000 1.145.000
148 UCBL_D_Bilateral 895.000 90.000 985.000
149 UCBL_E_Bilateral 709.000 71.000 780.000
150 Ulnar Static Forearm Base Orthosis (Besar)_Bilateral 1.445.000 145.000 1.590.000
151 Ulnar Static Forearm Base Orthosis (Kecil)_Bilateral 1.045.000 105.000 1.150.000
6. FORENSIK DAN PEMULASARAN JENAZAH
JASA
PELAYANAN
1 Administrasi + Surat Keterangan Kematian 25.000 20.000 45.000
2 Alkali dilusi CO 107.000 82.000 189.000
3 Asuransi Korban hidup 99.000 76.000 175.000
4 Asuransi Korban mati (jasa Raharja/Astek) 129.000 99.000 228.000
5 Asuransi Korban mati (Nasional) 144.000 110.000 254.000
6 Gali kubur Dalam kota 2.707.000 2.076.000 4.783.000
7 Gali kubur Luar kota 4.207.000 3.226.000 7.433.000
8 Legalisir Surat Keterangan Kematian 19.000 15.000 34.000
9 Microdiffusi Conway/Alkohol 198.000 152.000 350.000
10 Pemeriksaan Bercak Darah 261.000 200.000 461.000
11 Pemeriksaan Bercak Mani/Swab Vagina 261.000 200.000 461.000
12 Pemeriksaan Diatome 238.000 183.000 421.000
13 Pemeriksaan Forensik Klinik 209.000 160.000 369.000
14 Pemeriksaan Kerangka 1.969.000 1.510.000 3.479.000
15 Pengawetan Jenazah 689.000 529.000 1.218.000
16 Pengawetan Jenazah Asing 1.139.000 874.000 2.013.000
17 Pengawetan Jenazah Pasca Autopsi 2.080.000 1.595.000 3.675.000
18 Penggunaan Kamar Pendingin/hari 167.000 128.000 295.000
19 Penggunaan Ruang Upacara/hari 427.000 328.000 755.000
20 Perawatan Jenazah Anak <12 tahun 344.000 265.000 609.000
21 Perawatan Jenazah HIV dan Penyakit Khusus 599.000 459.000 1.058.000
22 Perawatan Jenazah Muslim Dewasa 418.000 321.000 739.000
23 Perawatan Jenazah Non Muslim 228.000 175.000 403.000
24 Periksa Dalam Asing 2.890.000 2.216.000 5.106.000
25 Periksa Dalam Forensik 1.385.000 1.063.000 2.448.000
26 Periksa Luar 582.000 446.000 1.028.000
27 Periksa Luar Asing 1.482.000 1.136.000 2.618.000
28 Rekonstruksi Berat 349.000 268.000 617.000
29 Rekonstruksi Ringan 205.000 158.000 363.000
30 Rekonstruksi Sedang 272.000 208.000 480.000
31 Toksikologi Kualitatif NAPZA 197.000 152.000 349.000
32 Toksikologi Kuantitatif Napza 53.000 40.000 93.000
7. UNIT TRANSFUSI DARAH
JASA
PELAYANAN
1 Biaya Pemeriksaan Uji Saring NAT 300,000 - 300,000
2 Crossmatch/Immediate spin 112,000 11,000 123,000
3 Golongan darah ( Pasien & Donor ) 125,000 13,000 138,000
4 Pemeriksaan Coombs Test* 900,000 - 900,000
5 Pemeriksaan Identifikasi Antibodi Trombosit* 550,000 - 550,000
6 Pemeriksaan Incompatible* 900,000 - 900,000
7 Pemeriksaan Skrining Antibodi Trombosit* 450,000 - 450,000
8 Skrining antibodi (PRC) 151,000 15,000 166,000
DARAH NAT*
1 Biaya Penambahan filter leukosit untuk PRC biasa (Leukodepleted) 350,000 - 350,000
2 Buffycoat Concentrate 630,000 - 630,000
3 Cryoprecipitate (AHF) 630,000 - 630,000
4 PCLR (Leukoreduksi) 730,000 - 730,000
5 Plasma Cair (Liquid Plasma) 630,000 - 630,000
6 Plasma Segar Beku (FFP) 630,000 - 630,000
7 PRC Biasa 630,000 - 630,000
8 PRC Leukodepleted (Filter) 955,000 - 955,000
9 TC Biasa 630,000 - 630,000
10 Washed Erythrocyte (WE) 780,000 - 780,000
11 WB Biasa 630,000 - 630,000
12 WB Segar 630,000 - 630,000
13 Trombopheresis 4,300,000 - 4,300,000
14 TC Pool 4,015,000 - 4,015,000
DARAH NON NAT*
1 Buffycoat Concentrate 385,000 - 385,000
2 Cryoprecipitate (AHF) 385,000 - 385,000
3 PCLR (Leukoreduksi) 480,000 - 480,000
4 Plasma Cair (Liquid Plasma) 385,000 - 385,000
5 Plasma Segar Beku (FFP) 385,000 - 385,000
6 PRC Biasa 385,000 - 385,000
7 PRC Leukodepleted (Filter) 680,000 - 680,000
8 TC Biasa 385,000 - 385,000
9 Washed Erythrocyte (WE) 385,000 - 385,000
10 WB Biasa 385,000 - 385,000
11 WB Segar 385,000 - 385,000
*Tarif bisa berubah sewaktu-waktu karena mengikuti tarif dari PMI

8. OBAT
JASA
PELAYANAN
1 Lipid 10 ml 60.000 6.000 66.000
2 Lipid 25ml 68.000 7.000 75.000
3 Lipid 50ml 86.000 9.000 95.000
4 PG 1 plus Lipid (Awal) 100ml 81.000 9.000 90.000
5 PG 1 plus Lipid (Awal) 50ml 65.000 7.000 72.000
6 PG 1 tanpa Lipid (Awal) 100ml 77.000 8.000 85.000
7 PG 1 tanpa Lipid (Awal) 50 ml 63.000 7.000 70.000
8 PG 2 plus Lipid (Lanjutan) 100ml 93.000 10.000 103.000
9 PG 2 plus Lipid (Lanjutan) 50ml 71.000 8.000 79.000
10 PG 2 tanpa Lipid (Lanjutan) 100ml 85.000 9.000 94.000
11 PG 2 tanpa Lipid (Lanjutan) 50ml 67.000 7.000 74.000
9. PELAYANAN COVID19
JASA
NO NAMA KEGIATAN JASA SARANA TARIF
PELAYANAN
REGULER
1 Rapid Antibodi Sars Cov-2 135,000 15,000 150,000
2 Rapid Antigen Sars Cov-2 245,000 15,000 260,000
3 Paket Pemeriksaan PCR Covid19* 805,000 95,000 900,000
KENCANA
1 Rapid Antibodi Sars Cov-2 135,000 15,000 150,000
2 SARS CoV-2 Real Time PCR 705,000 60,000 765,000
3 Tindakan Pengambilan Swab 100,000 35,000 135,000
4 Paket Essential 1 2,527,000 1,410,000 3,937,000
5 Paket Essential 2 4,287,000 1,550,000 5,837,000
6 Telekonsultasi A 100,000 350,000 450,000
10. LAYANAN AMBULANS
JASA
No ZONA JASA SARANA TARIF
PELAYANAN
IGD
Dengan Emergency Medical Officer
I Dalam kota < 10 Km 400.000 300.000 700.000
II Dalam kota 10 ≤ s.d. < 20 Km 600.000 500.000 1.100.000
III Dalam Kota 20 ≤ s.d. 30 Km 700.000 600.000 1.300.000
IV Banten
1 Kabupaten tangerang 950.000 1.000.000 1.950.000
2 kabupaten serang 2.000.000 1.200.000 3.200.000
3 kabupaten Lebak 2.500.000 1.400.000 3.900.000
4 kabupaten Pandeglang 2.800.000 2.200.000 5.000.000
5 Kota Cilegon dan pelabuhan Merak 2.200.000 1.300.000 3.500.000
6 Kota Serang 2.000.000 1.040.000 3.040.000
V Jawa Barat
1 Kabupaten Bekasi 850.000 600.000 1.450.000
2 Kabupaten Bogor 1.200.000 1.000.000 2.200.000
3 Kota bogor 900.000 1.000.000 1.900.000
4 Kabupaten Karawang 2.000.000 1.000.000 3.000.000
5 Kabupaten Purwakarta 2.100.000 1.000.000 3.100.000
6 Kabupaten Sukabumi 3.400.000 1.700.000 5.100.000
7 Kabupaten Cianjur 3.450.000 2.000.000 5.450.000
8 Kabupaten Subang 3.400.000 1.250.000 4.650.000
9 Kabupaten Bandung Barat 3.400.000 1.300.000 4.700.000
10 Kabupaten Bandung 3.800.000 1.700.000 5.500.000
11 Kabupaten Sumedang 4.000.000 2.000.000 6.000.000
12 Kabupaten Majalengka 4.200.000 1.800.000 6.000.000
13 Kabupaten Indramayu 4.200.000 2.200.000 6.400.000
14 Kabupaten Cirebon 4.500.000 2.050.000 6.550.000
15 Kabupaten Tasikmalaya 5.000.000 3.000.000 8.000.000
16 Kabupaten Kuningan 5.500.000 2.500.000 8.000.000
17 Kabupaten garut 6.000.000 2.150.000 8.150.000
18 Kabupaten Ciamis 6.300.000 2.600.000 8.900.000
19 Kota Bandung 3.500.000 1.500.000 5.000.000
20 Kota Sukabumi 3.000.000 1.100.000 4.100.000
21 Kota Tasikmalaya 4.500.000 2.500.000 7.000.000
22 Kota Banjar 5.750.000 2.900.000 8.650.000
23 Kota Cirebon 4.100.000 2.100.000 6.200.000
24 Kota Cimahi 2.500.000 1.400.000 3.900.000
Tanpa Emergency Medical Officer
I Dalam kota < 10 Km 400.000 - 400.000
II Dalam kota 10 ≤ s.d. < 20 Km 600.000 - 600.000
III Dalam Kota 20 ≤ s.d. 30 Km 700.000 - 700.000
IV Banten
1 Kabupaten tangerang 950.000 - 950.000
2 kabupaten serang 2.000.000 - 2.000.000
3 kabupaten Lebak 2.500.000 - 2.500.000
4 kabupaten Pandeglang 2.800.000 - 2.800.000
5 Kota Cilegon dan pelabuhan Merak 2.200.000 - 2.200.000
6 Kota Serang 2.000.000 - 2.000.000
V Jawa Barat
10. LAYANAN AMBULANS
JASA
No ZONA JASA SARANA TARIF
PELAYANAN
1 Kabupaten Bekasi 850,000 - 850,000
2 Kabupaten Bogor 1,200,000 - 1,200,000
3 Kota Bogor 900,000 - 900,000
4 Kabupaten Karawang 2,000,000 - 2,000,000
5 Kabupaten Purwakarta 2,100,000 - 2,100,000
6 Kabupaten Sukabumi 3,400,000 - 3,400,000
7 Kabupaten Cianjur 3,450,000 - 3,450,000
8 Kabupaten Subang 3,400,000 - 3,400,000
9 Kabupaten Bandung Barat 3,400,000 - 3,400,000
10 Kabupaten Bandung 3,800,000 - 3,800,000
11 Kabupaten Sumedang 4,000,000 - 4,000,000
12 Kabupaten Majalengka 4,200,000 - 4,200,000
13 Kabupaten Indramayu 4,200,000 - 4,200,000
14 Kabupaten Cirebon 4,500,000 - 4,500,000
15 Kabupaten Tasikmalaya 5,000,000 - 5,000,000
16 Kabupaten Kuningan 5,500,000 - 5,500,000
17 Kabupaten garut 6,000,000 - 6,000,000
18 Kabupaten Ciamis 6,300,000 - 6,300,000
19 Kota Bandung 3,500,000 - 3,500,000
20 Kota Sukabumi 3,000,000 - 3,000,000
21 Kota Tasikmalaya 4,500,000 - 4,500,000
22 Kota Banjar 5,750,000 - 5,750,000
23 Kota Cirebon 4,100,000 - 4,100,000
24 Kota Cimahi 2,500,000 - 2,500,000
UPT KIARA
1 PER 6 JAM 5,000,000 2,500,000 7,500,000
2 Tambahan per jam 850,000 400,000 1,250,000
RSCM KENCANA
1 Area Jakarta 1,875,000 1,500,000 3,375,000
2 Area Bodetabek 2,350,000 2,250,000 4,600,000
DIREKTUR UTAMA,
Ttd.
LIES DINA LIASTUTI

Lampiran II Peraturan Direktur Utama
Nomor : HK.01.07/4.2/8320/2020
INSTALASI PELAYANAN TERPADU ONKOLOGI RADIASI
JASA
PELAYANAN
1. KONSULTASI
1 Konsultasi awal / CITO / Second Opinion 129,000 350,000 479,000
2 Follow up selama radiasi/kemoterapi 104,000 150,000 254,000
2. NON OPERATIF
1 Pengukuran paparan Radiasi 186,000 399,000 585,000
Planning Radiasi 3D
1 Treatmen Planning System 2 D 2,821,000 788,000 3,609,000
2 Treatmen Planning System 3 D 3,800,000 867,000 4,667,000
3 Treatmen Planning System Kompleks (IMRT) 6,080,000 1,773,000 7,853,000
4 Treatmen Planning System Stereotactic 6,077,000 3,269,000 9,346,000
5 Treatmen Planning System Brachyterapi 2 D 2,273,000 2,363,000 4,636,000
6 Treatmen Planning System Brachyterapi 3 D 4,269,000 4,057,000 8,326,000
Tindakan radiasi eksterna
1 Paket Radiasi Eksterna Konvensional Ringan 17,433,000 4,862,000 22,295,000
2 Paket Radiasi Eksterna Konvensional Sedang 24,820,000 7,701,000 32,521,000
3 Paket Radiasi Eksterna Konvensional Berat (Tindakan Khusus) 28,897,000 9,027,000 37,924,000
4 Paket Radiasi Eksterna Konformal 3D Ringan 24,820,000 9,432,000 34,252,000
5 Paket Radiasi Eksterna Konformal 3D Sedang 28,512,000 9,432,000 37,944,000
6 Paket Radiasi Eksterna Konformal 3D Berat 36,714,000 11,154,000 47,868,000
7 Paket Radiasi Eksterna IMRT Ringan 36,714,000 11,154,000 47,868,000
8 Paket Radiasi Eksterna IMRT Sedang 50,616,000 18,400,000 69,016,000
9 Paket Radiasi Eksterna IMRT Berat (+IGRT) 58,811,000 21,597,000 80,408,000
10 Stereotactic Radiotherapy Ringan 36,356,000 11,704,000 48,060,000
11 Stereotactic Radiosurgery 44,764,000 12,707,000 57,471,000
12 Stereotactic Radiotherapy Berat (termasuk SBRT) 50,706,000 16,208,000 66,914,000
Tindakan brakiterapi
1 Brakhiterapi intrakaviter Ringan 23,231,000 5,484,000 28,715,000
2 Brakhiterapi intrakaviter sedang 25,554,000 5,785,000 31,339,000
3 Brakhiterapi intrakaviter Berat 27,878,000 6,455,000 34,333,000
4 Brakhiterapi interstisial ringan 27,878,000 6,455,000 34,333,000
5 Brakhiterapi interstisial sedang 27,878,000 11,414,000 39,292,000
6 Brakhiterapi Interstisial berat 33,453,000 11,514,000 44,967,000
7 Brakhiterapi interstisial khusus 36,241,000 11,346,000 47,587,000
Tindakan CT Simulator
1 CT Simulator 2,193,000 323,000 2,516,000
2 Simulator 1,658,000 374,000 2,032,000
3 Stereotactic Surgery 19,340,000 6,615,000 25,955,000
4 Tindakan CITO 13,439,000 3,938,000 17,377,000
5 Rawat Luka 150,000 105,000 255,000
6 Targeted Therapy 150,000 126,000 276,000
7 One Day Care 558,000 242,000 800,000
8 Sewa C-Arm 1,500,000 50,000 1,550,000
POLIKLINIK MADYA
JASA
PELAYANAN
1. KONSULTASI
2 Konsultasi dan Pemeriksaan 104,000 150,000 254,000
3 Konsultasi dan Pemeriksaan MCU Perusahaan 50,000 90,000 140,000
2. NON OPERATIF
1 Abortus Spontan 311,000 240,000 551,000
2 Amnioinfusion, Pungsi 498,000 384,000 882,000
3 Amnioreduksi, Aspirasi 557,000 427,000 984,000
4 Analisa Sperma 480,000 369,000 849,000
5 Aspirasi Vakum Manual 261,000 201,000 462,000
6 Buka pasang susuk 237,000 163,000 400,000
7 Businasi Penyakit Kebidanan 333,000 72,000 405,000
8 CTG 102,000 28,000 130,000
9 CVS 478,000 366,000 844,000
10 EKG 80,000 61,000 141,000
11 Ekstirpasi Polip 230,000 177,000 407,000
13 Hacting 838,000 221,000 1,059,000
14 Hidrotubasi 311,000 238,000 549,000
15 Hifosi 1,893,000 1,452,000 3,345,000
16 Inspekulo VT 66,000 53,000 119,000
17 Irigasi Vagina 164,000 127,000 291,000
18 IVA 124,000 95,000 219,000
19 Kolposkopi 642,000 494,000 1,136,000
21 Kolposkopi Cryotherapy 302,000 231,000 533,000
22 Kolposkopi LLETZ 364,000 279,000 643,000
23 Kordosintesis 498,000 384,000 882,000
24 Lepas pasang IUD 220,000 169,000 389,000
25 Lepas Pesarium 88,000 68,000 156,000
26 Manual Plasenta 828,000 635,000 1,463,000
27 Marsupialisasi Penyakit Kebidanan 3,974,000 3,048,000 7,022,000
28 Mikrokuret 129,000 48,000 177,000
29 NST/ CTG 74,000 44,000 118,000
30 Paket Evakuasi Hematom 3,302,000 2,531,000 5,833,000
32 Papsmear Thinprep 144,000 111,000 255,000
33 Partus Forsep 1,706,000 1,308,000 3,014,000
34 Partus Normal 1,245,000 955,000 2,200,000
35 Partus Vakum 1,704,000 1,308,000 3,012,000
36 Pasang kateter 162,000 56,000 218,000
37 Pasang O2 118,000 56,000 174,000
38 Pasang pesarium 671,000 72,000 743,000
39 Pasang susuk 183,000 117,000 300,000
40 Pasang/angkat susuk 158,000 48,000 206,000
41 Pasang/Lepas Mold Vagina 81,000 63,000 144,000
42 Pemasangan Laminaria 675,000 518,000 1,193,000
43 Pemberian terapi oral / Injeksi 45,000 35,000 80,000
44 Pemeriksaan Dalam 122,000 94,000 216,000
45 Pungsi Asites 287,000 56,000 343,000
46 Sistoskopi 834,000 641,000 1,475,000
47 Sistoskopi + Biopsi 904,000 693,000 1,597,000
48 Tes Busa 248,000 192,000 440,000
49 Test Metilium Blue 222,000 72,000 294,000
50 USG Abdomen + CTG/Transvaginal 216,000 166,000 382,000
51 USG GINEKOLOGI 281,000 183,000 464,000
JASA
PELAYANAN
52 USG Onkologi 417,000 321,000 738,000
53 USG Uroginekologi Patologis 345,000 265,000 610,000
54 USG Uroginekologi Skrining/ Sederhana 194,000 150,000 344,000
2.2 BEDAH SYARAF
7 Overhecting 558,000 134,000 692,000
8 PUNGSI SUB GALEAL 225,000 102,000 327,000
9 PUNGSI VENTRIKEL 282,000 218,000 500,000
2.3 UROLOGI
1 Biofeedback 1,174,000 690,000 1,864,000
2 BIOPSI PROSTAT 1,722,000 552,000 2,274,000
3 Businasi 503,000 157,000 660,000
4 CIC 1,302,000 414,000 1,716,000
5 ESWL 3,492,000 2,678,000 6,170,000
6 ESWL ULANG 2,988,000 2,291,000 5,279,000
7 Ganti verban Kecil 106,000 35,000 141,000
8 Instilasi obat 298,000 230,000 528,000
9 MASSAGE PROSTAT 95,000 74,000 169,000
10 METHYLENE BLUE TEST 238,000 183,000 421,000
11 Pasang kateter dengan mandrain 400,000 186,000 586,000
12 SISTOGRAFI 1,338,000 760,000 2,098,000
13 Sistouretrografi Bipolar 1,338,000 898,000 2,236,000
14 URODINAMIK 7,133,000 2,070,000 9,203,000
15 UROFLOWMETRI 101,000 78,000 179,000
16 USG PROSTAT/USG GINJAL 101,000 78,000 179,000
17 USG TESTIS 112,000 86,000 198,000
2.4 NEUROLOGI
1 Blink Refleks 422,000 323,000 745,000
2 Brainstem Auditory Evoked Potential 377,000 289,000 666,000
3 Carotid Duplex 252,000 194,000 446,000
4 Cognitive Event Related Potential (P300) 346,000 266,000 612,000
5 doppler perifer 252,000 194,000 446,000
6 EEG Challenge Diazepam 1,126,000 863,000 1,989,000
8 EEG Premedikasi 936,000 718,000 1,654,000
9 EEG rutin 800,000 280,000 1,080,000
10 EMG dengan jarum 522,000 401,000 923,000
11 EMG tanpa jarum 262,000 201,000 463,000
12 Fisioterapi 152,000 117,000 269,000
13 Hemodilusi isotonik 386,000 296,000 682,000
14 Injeksi ekstraartikular <2 cc 176,000 136,000 312,000
15 Injeksi ekstraartikular <2 cc dengan guided USG 270,000 208,000 478,000
16 Injeksi ekstraartikular >2 cc 221,000 170,000 391,000
17 Injeksi ekstraartikular >2 cc guided USG 317,000 244,000 561,000
18 Injeksi Epidural USG Guided 1,018,000 782,000 1,800,000
19 Injeksi Facet Joint USG Guided 999,000 766,000 1,765,000
20 Injeksi intra muskular <2 cc 174,000 135,000 309,000
21 Injeksi Intraartikular <2 cc 176,000 136,000 312,000
22 Injeksi Intraartikular <2 cc dengan guided USG 270,000 208,000 478,000
23 Injeksi Intraartikular >2 cc 221,000 170,000 391,000
24 Injeksi Intraartikular >2 cc dengan guided USG 317,000 244,000 561,000
25 Injeksi intramuskular <2 cc dengan guided USG 270,000 208,000 478,000
26 Injeksi intramuskular >2 cc 221,000 170,000 391,000
27 Injeksi intramuskular >2 cc guided USG 317,000 244,000 561,000
28 Injeksi Intratekal USG Guided 1,032,000 792,000 1,824,000
29 Injeksi Neuromuskular guided USG 387,000 297,000 684,000
30 Injeksi Perineural 304,000 233,000 537,000
31 Injeksi Peripheral selective nerve block USG Guided 994,000 763,000 1,757,000
JASA
PELAYANAN
32 Injeksi Piriformis USG Guided 984,000 756,000 1,740,000
33 Injeksi Sacroiliac USG Guided 987,000 757,000 1,744,000
34 Injeksi Trigger Point 272,000 210,000 482,000
35 Injeksi Trigger Point USG Guided 260,000 200,000 460,000
37 IOM HNP Servikal 6,542,000 5,015,000 11,557,000
39 IOM Skoliosis 9,394,000 7,203,000 16,597,000
43 IVM 248,000 192,000 440,000
44 Kecepatan Hantar Saraf 292,000 224,000 516,000
45 Kecepatan Hantar Saraf dan F-wave/H-Refleks 352,000 271,000 623,000
46 Lumbal Pungsi Guided 826,000 634,000 1,460,000
47 Lumbal Pungsi non guided 824,000 633,000 1,457,000
48 monitoring trombolisis intravena 3,012,000 2,311,000 5,323,000
49 NOT 206,000 158,000 364,000
50 Okupasi Terapi 150,000 117,000 267,000
51 Pain intervensi injeksi dengan radiofrekuensi guided C-ARM 2,434,000 1,867,000 4,301,000
52 Pain intervensi injeksi guided C-ARM 2,434,000 1,867,000 4,301,000
53 Pemeriksaan NO 213,000 164,000 377,000
54 PSG 24 jam 4,019,000 1,604,000 5,623,000
55 PSG 8 jam 1,500,000 800,000 2,300,000
56 Repetitive Nerve Stimulation 364,000 279,000 643,000
57 skrining karotis 148,000 114,000 262,000
58 skrining TCD 142,000 81,000 223,000
59 Somatosensory Evoked Potential 377,000 289,000 666,000
60 Spasmofili 293,000 225,000 518,000
61 Speech Terapi 204,000 138,000 342,000
62 Sympathetic Skin Response 406,000 313,000 719,000
63 Tapping and straping 389,000 138,000 527,000
64 TCD Buble Contrast 369,000 284,000 653,000
65 terapi fungsi luhur 206,000 158,000 364,000
66 TMS 252,000 194,000 446,000
67 Trans Cranial Doppler 252,000 194,000 446,000
69 Visual Evoked Potential 377,000 289,000 666,000
2.5 PSIKIATRI
1 Cognitive-Behavioral Therapy 96,000 75,000 171,000
2 Hipnoterapi 52,000 40,000 92,000
3 Intervensi Keluarga 279,000 214,000 493,000
Layanan untuk memberikan kesaksian sebagai konsultan ahli psikiatri
4 137,000 3,540,000 3,677,000
forensik (common case)
5 137,000 14,160,000 14,297,000
forensik (Kasus berat dengan penyulit)
6 137,000 7,080,000 7,217,000
forensik (Kasus berat)
7 Manajemen gaduh gelisah 198,000 153,000 351,000
8 Manajemen risiko bunuh diri 198,000 153,000 351,000
9 Melakukan Tindakan ECT 239,000 184,000 423,000
10 Melakukan tindakan pengambilan darah intra vena 22,000 18,000 40,000
11 Melakukan tindakan Terapi Aktivitas Kelompok (TAK) 215,000 166,000 381,000
12 Motivational enhancement therapy 93,000 73,000 166,000
13 Motivational Interviewing 96,000 75,000 171,000
16 Pemeriksaan cognistat 576,000 442,000 1,018,000
17 Pemeriksaan psikiatrik pada orangtua 50,000 38,000 88,000
18 Pemeriksaan Psikologi pada kasus psikiatri forensik 348,000 269,000 617,000
20 Pengkajian fungsi kognitif (penapisan demensia) 58,000 45,000 103,000
21 Penjemputan pasien 358,000 275,000 633,000
JASA
PELAYANAN
22 Problem Solving Therapy (Individual) 96,000 75,000 171,000
23 Problem Solving Therapy (Kelompok) 154,000 118,000 272,000
24 Program Keterampilan Hidup Harian (Individual) 416,000 320,000 736,000
25 Program Keterampilan Hidup Harian (Kelompok) 562,000 432,000 994,000
26 Program Pemanfaatan Waktu Luang & Rekreasi (Kelompok) 429,000 330,000 759,000
28 Psikiatri Forensik 2 206,000 850,000 1,056,000
31 Psikoterapi I (Suportif dan Edukasi) 52,000 40,000 92,000
32 Psikoterapi II (dengan konseling keluarga) 96,000 75,000 171,000
34 Psikoterapi suportif pada anak 48,000 38,000 86,000
35 Psikoterapi suportif pada orangtua 24,000 20,000 44,000
36 Remediasi Kognitif berbasis Games 161,000 123,000 284,000
37 Skrining kognitif berbasis kertas 71,000 56,000 127,000
38 Skrining Narkoba 96,000 75,000 171,000
39 Social Skills Training (Individual) 282,000 218,000 500,000
40 Social Skills Training (Kelompok) 429,000 330,000 759,000
41 Terapi bermain pada anak (playtherapy) 72,000 56,000 128,000
42 Terapi Kejang Listrik (ECT) = tindakan: "Melakukan Tindakan ECT" 316,000 242,000 558,000
43 Terapi Kelompok 107,000 82,000 189,000
44 Terapi substitusi 48,000 38,000 86,000
45 Tes inteligensi (IQ) 170,000 131,000 301,000
46 Tes IQ 218,000 168,000 386,000
47 Tes Minat Bakat Anak dan Remaja 260,000 201,000 461,000
48 Tes minat bakat Dewasa (tes IQ, minat & MMPI) 236,000 182,000 418,000
49 Tes MMPI, print grafik MMPI dan pembuatan hasil 102,000 79,000 181,000
50 Tes Neurocognitive (NCT) 76,000 57,000 133,000
51 Uji Kompetensi 1 (rekrutmen/ laik kerja) 384,000 295,000 679,000
52 Uji Kompetensi 2 (laik studi) 378,000 291,000 669,000
2.6 REHABILITASI MEDIK
4 Dry Needling (5 titik) 201,000 156,000 357,000
5 340,000 261,000 601,000
Evaluasi kapasitas fungsional return to activities--> Manajemen
6 635,000 488,000 1,123,000
rehabilitasi interdisiplin
Evaluasi kapasitas fungsional return to work --> Manajemen
7 635,000 488,000 1,123,000
rehabilitasi interdisiplin ?
8 Evaluasi kemampuan intelektual (Tes IQ) 395,000 304,000 699,000
11 Layanan psikologis lainnya 395,000 304,000 699,000
12 Low level laser therapy 201,000 156,000 357,000
15 154,000 118,000 272,000
Rehabilitasi psikososial, lingkungan, rumah, dan hambatan kerja;
17 168,000 129,000 297,000
20 Tatalaksana dengan Virtual Reality 620,000 476,000 1,096,000
21 Tatalaksana dengan Work simulator 615,000 472,000 1,087,000
24 146,000 113,000 259,000
menelan
JASA
PELAYANAN
26 183,000 140,000 323,000
30 Terapi inhalasi 100,000 78,000 178,000
31 Terapi injeksi Botulinum Toksin A dengan panduan USG 242,000 185,000 427,000
Terapi injeksi steroid dengan panduan USG Muskuloskeletal (pada
32 242,000 185,000 427,000
bursa, ligamen, tendon)
33 242,000 185,000 427,000
34 242,000 185,000 427,000
35 329,000 253,000 582,000
36 242,000 185,000 427,000
Muskuloskeletal (pada tendon tangan)
37 150,000 115,000 265,000
Jalan)
40 Terapi latihan dengan robotic system 1,017,000 780,000 1,797,000
42 162,000 125,000 287,000
osteoporosis, koreksi postur
44 96,000 75,000 171,000
Dasar Panggul)
45 143,000 111,000 254,000
55 Terapi Modalitas : TENS, ES, PTNS, NMES, Tapping Straping 201,000 155,000 356,000
57 Terapi Modalitas Dingin (Ice Massage/ Vapocoolant spray) 112,000 86,000 198,000
60 Terapi musik 146,000 113,000 259,000
61 Terapi perilaku 146,000 113,000 259,000
62 Terapi rekreasi 111,000 86,000 197,000
63 160,000 123,000 283,000
66 Uji Fungsi Persepsi, Uji Fungsi Kognisi 154,000 118,000 272,000
Uji Kemampuan Fungsional (Menelan, Sensori integrasi, Sensori
taktil dan proprioseptif, Komunikasi, Motorik halus anak, Fungsi
67 194,000 149,000 343,000
tangan, Kardiorespirasi, Spirometri, AKS, Vokasional, Uji Fungsi
Berkemih)
68 158,000 122,000 280,000
JASA
PELAYANAN
2.7 GIGI DAN MULUT
1 Ablatio 515,000 396,000 911,000
2 AKTIVATOR 702,000 539,000 1,241,000
9 ANALISA 167,000 129,000 296,000
10 Apeksreseksi 458,000 291,000 749,000
13 Bongkar Prothesa/ Unit 657,000 504,000 1,161,000
15 Buka Jahitan 124,000 90,000 214,000
16 Cetak Alginate 141,000 109,000 250,000
20 CHIN CUP 225,000 173,000 398,000
21 Composite Besar 384,000 295,000 679,000
22 Composite Kecil 280,000 214,000 494,000
23 CRIMPABLE HOOK 183,000 138,000 321,000
25 Dental Implant 6,222,000 4,772,000 10,994,000
26 Eksisi Mucocele 602,000 461,000 1,063,000
29 Enukleasi Kista 694,000 532,000 1,226,000
31 FACEMASK 2,982,000 760,000 3,742,000
32 Feeding plate 539,000 413,000 952,000
34 FIXED RETAINER RA / RB SAJA 1,385,000 1,064,000 2,449,000
35 Flexi Denture * 826,000 634,000 1,460,000
36 FOTO SLIDE 98,000 75,000 173,000
39 GIC besar 195,000 150,000 345,000
40 GIC kecil 124,000 95,000 219,000
42 GTS Frame 669,000 514,000 1,183,000
43 HEAD GEAR 1,990,000 966,000 2,956,000
44 Home Bleaching * 891,000 683,000 1,574,000
45 In Office Bleaching * 1,348,000 1,034,000 2,382,000
46 Incisi Abses 602,000 461,000 1,063,000
47 Incisi Biopsi 602,000 461,000 1,063,000
48 Incisi/cauterisasi 602,000 461,000 1,063,000
50 InLay / OnLay * 1,149,000 882,000 2,031,000
51 KARET INTRA ORAL 81,000 28,000 109,000
52 Kontrol 262,000 90,000 352,000
53 Kuret per Gigi 400,000 194,000 594,000
54 Labial Veneer Direct 599,000 460,000 1,059,000
55 Labial Veneer In Direct * 1,506,000 1,157,000 2,663,000
56 Mahkota All Porcelain* 1,184,000 909,000 2,093,000
57 Mahkota Metal* 683,000 525,000 1,208,000
60 Mocking * 226,000 175,000 401,000
62 NEKROPSI 468,000 331,000 799,000
JASA
PELAYANAN
63 Obturator * 686,000 527,000 1,213,000
66 Occlusal Splint 495,000 380,000 875,000
67 OD M3 IMP Kls I 1,112,000 854,000 1,966,000
68 OD M3 IMP Kls II 1,233,000 946,000 2,179,000
69 OD M3 IMP Kls III 1,664,000 1,276,000 2,940,000
71 Operkulektomi 868,000 479,000 1,347,000
74 PAPER SURGERY 262,000 203,000 465,000
77 Penambahan Wing 447,000 343,000 790,000
80 Pencabutan Gigi 320,000 246,000 566,000
86 Pin Casting* 418,000 321,000 739,000
90 Plat Prothesa* 498,000 384,000 882,000
91 PLAT REMOVABLE AKTIF RINGAN RA / RB SAJA 1,091,000 838,000 1,929,000
92 PLAT REMOVABLE AKTIF SEDANG RA / RB SAJA 1,157,000 888,000 2,045,000
94 POSTERIOR BITE RISER PLAT 567,000 435,000 1,002,000
95 PREMEDIKASI 178,000 109,000 287,000
96 PSA 1 Saluran Akar 170,000 131,000 301,000
97 PSA 2 Saluran Akar 232,000 177,000 409,000
98 PSA 3 Saluran Akar 287,000 221,000 508,000
99 PSA One Visit 1 SA 728,000 559,000 1,287,000
100 PSA One Visit 2 SA 886,000 680,000 1,566,000
102 Pulp capping 218,000 168,000 386,000
103 QUAD HELIX 1,005,000 771,000 1,776,000
104 RAPID PALATAL EXPANSION 1,180,000 904,000 2,084,000
107 REMOVABLE RETAINER RA / RB SAJA 600,000 461,000 1,061,000
109 Rep. Fix dgn Arcbar ( RA & RB ) 1,184,000 909,000 2,093,000
113 Reposisi Disi TMJ 1,019,000 782,000 1,801,000
120 Sementasi Ulang 299,000 230,000 529,000
121 SEPARASI 194,000 111,000 305,000
122 SIALOMETRI 75,000 53,000 128,000
123 Single Denture 849,000 653,000 1,502,000
JASA
PELAYANAN
128 TEMPORARY ANCHORAGE DEVICE 1,192,000 914,000 2,106,000
130 TRANS PALATAL ARCH 1,154,000 828,000 1,982,000
2.8 MATA
Corneal topography pemeriksaan permukaan kornea karena mesin
2 38,000 30,000 68,000
rusak maka dipakai mesin occulizer
4 Demodex 53,000 42,000 95,000
6 Dermolipoma 569,000 437,000 1,006,000
7 Eksisi Nevus (setara dengan eksisi granuloma) 142,000 110,000 252,000
8 Ekstirpasi papiloma / kista 150,000 115,000 265,000
11 ERG dan VEP Multifokal 330,000 208,000 538,000
14 HESS Screen 83,000 42,000 125,000
15 Hordeolum ( Insici ) 155,000 120,000 275,000
16 Humprey 96,000 42,000 138,000
18 IOL Master 102,000 80,000 182,000
19 Jahit Palpebra Ringan 537,000 138,000 675,000
20 Keratometri 50,000 39,000 89,000
21 Laser Perifer Iridektomi (LPI) 246,000 191,000 437,000
22 Laser Photocoagulation (Argon Laser) 86,000 67,000 153,000
23 Low Vision 268,000 125,000 393,000
24 Nekrotomi 119,000 92,000 211,000
25 Non Con Robo 45,000 21,000 66,000
26 OCT Scan / Visante 84,000 42,000 126,000
27 Octopus 176,000 42,000 218,000
Pemeriksaan Calon PPDS (BCVA, Humprey, Segmen Anterior,
29 192,000 149,000 341,000
Segmen Posterior, Stereoscopis)
30 Pemeriksaan ERG 204,000 125,000 329,000
31 Pemeriksaan FFA 197,000 70,000 267,000
32 Pemeriksaan Foto Fundus Foto Fundus NON Midriatikum 51,000 39,000 90,000
33 Pemeriksaan Kampimetri ( Kampimetri Goldmann ) 119,000 62,000 181,000
34 Pemeriksaan Non Contact 28,000 8,000 36,000
35 Pemeriksaan VEP 208,000 125,000 333,000
38 RETINOMETRI 59,000 42,000 101,000
39 Screening ROP 173,000 98,000 271,000
41 Streak Retinoscopy 64,000 48,000 112,000
42 Suntik Botox 2,392,000 690,000 3,082,000
43 Tes Schimer (BUT) 34,000 8,000 42,000
44 Toppolyzer 83,000 65,000 148,000
45 UBM (pemeriksaan bilik mata depan ) 159,000 122,000 281,000
46 USG mata 66,000 53,000 119,000
47 Xantelasma ( tindakan ambil lemak di bawah kulit ) 728,000 559,000 1,287,000
48 Yag Laser 218,000 168,000 386,000
2.9 TELINGA, HIDUNG DAN TENGGOROKAN
1 ABR Bone Kom 266,000 205,000 471,000
2 ABR Click 267,000 205,000 472,000
3 ABR dengan Sedasi 670,000 515,000 1,185,000
4 ABR Skrining 192,000 149,000 341,000
5 Ambil Bahan Kultur 113,000 87,000 200,000
JASA
PELAYANAN
6 Ambil Sedian Spes Kultur 113,000 87,000 200,000
7 Analisis Suara 196,000 151,000 347,000
8 Angkat Tampon Hidung Anterior 472,000 109,000 581,000
9 Angkat Tampon Hidung Posterior 472,000 94,000 566,000
10 ASSR 510,000 393,000 903,000
11 Audiometri tes gliserol 384,000 218,000 602,000
12 Audometri Nada Murni 93,000 73,000 166,000
13 Audometri Tutur 149,000 115,000 264,000
14 Benda asing Dengan Penyulit 297,000 228,000 525,000
15 BERA 170,000 130,000 300,000
17 Biopsi Lidah Palatum 268,000 206,000 474,000
18 Biopsi Nasofaring Rigid 1,000,000 346,000 1,346,000
19 Biopsi Sinus Maksila 640,000 346,000 986,000
20 Biopsi tumor hipofaring LF 418,000 321,000 739,000
21 Biopsi Tumor Kavumnasi 869,000 188,000 1,057,000
22 Biopsi tumor oral cavity LF 345,000 266,000 611,000
23 BOA/VRA 192,000 149,000 341,000
24 Dekanulasi 364,000 279,000 643,000
25 Dokumentasi & Tata Laksana 110,000 85,000 195,000
26 DPOAE 11 Frekuensi Komp Double 226,000 175,000 401,000
27 DPOAE Diagnostic Kom 216,000 166,000 382,000
28 DPOAE Skrining Kom 148,000 114,000 262,000
29 Ear Toilet 128,000 100,000 228,000
30 Ekstirpasi Tumor Jinak 588,000 452,000 1,040,000
31 Ekstraksi Benda Asing Daerah Hidung 90,000 50,000 140,000
32 Ekstraksi Benda asing Dengan RFL 680,000 322,000 1,002,000
33 Ekstrasi jaringan Granulasi 144,000 111,000 255,000
34 Ekstrasi kolesteatom Eksterna 342,000 263,000 605,000
35 EKSTRASI SERUMEN DI NO 161,000 123,000 284,000
36 ENG Komp 273,000 210,000 483,000
37 Fasialis N VII 126,000 98,000 224,000
38 FEES 492,000 379,000 871,000
39 FEES dengan Rehab Medik 725,000 556,000 1,281,000
40 Fleksibel esophagoscopy 680,000 346,000 1,026,000
41 Free Field Test 196,000 151,000 347,000
42 Ganti Cuci Kanul 250,000 193,000 443,000
43 Ganti Provok 1,047,000 804,000 1,851,000
44 Ganti Verban besar 296,000 227,000 523,000
45 Inj Kenacort 262,000 201,000 463,000
47 Irigasi Sinus 144,000 50,000 194,000
48 Kauterisasi Hidung 482,000 265,000 747,000
50 Nasalance 567,000 346,000 913,000
51 Nasoendoskopi 490,000 142,000 632,000
52 Nasoendoskopi dengan Fiber 609,000 208,000 817,000
53 Nasoendoskopi Polpektomi 516,000 265,000 781,000
54 Nasoendoskopi Rigid 873,000 138,000 1,011,000
55 Nasofaringoskopi BSO 890,000 138,000 1,028,000
56 Nasolaringoskopi 243,000 186,000 429,000
57 OAE dengan Sedasi 506,000 389,000 895,000
59 P 300 262,000 203,000 465,000
60 Parasintesis 252,000 194,000 446,000
61 Pasang grommet 442,000 341,000 783,000
62 Pasang NGT 248,000 191,000 439,000
63 Pasang NGT dengan Guiding 692,000 81,000 773,000
64 Pasang Tampon 495,000 76,000 571,000
65 Pasang Tampon Hidung Anterior 908,000 58,000 966,000
66 Pasang Tampon Hidung Posterior 498,000 72,000 570,000
67 Patch Paper Therapi 462,000 356,000 818,000
JASA
PELAYANAN
69 PEAK NASAL INSPIRATORY FLOWMETRI ( PNIF) 158,000 122,000 280,000
70 Penatalaksanaan Epistaksis 891,000 265,000 1,156,000
71 Pengangkatan Jaringan (Debridement) 389,000 299,000 688,000
72 Posturografi NO 538,000 291,000 829,000
73 Pseudokista 609,000 468,000 1,077,000
74 Reposisi Hidung 908,000 690,000 1,598,000
75 Revisi jaringan Parut 514,000 394,000 908,000
76 Rinomanometri 1,331,000 690,000 2,021,000
77 Serumen dengan penyulit 402,000 310,000 712,000
78 Sinuskopi Diagnostik 677,000 142,000 819,000
79 Sleep Nasoendoskopi 717,000 404,000 1,121,000
80 Speech Assesment 156,000 121,000 277,000
81 Telelaringoskopi Fleksibel 214,000 165,000 379,000
82 Telelaringoskopi Rigid 142,000 110,000 252,000
83 Terapi Bicara 159,000 122,000 281,000
84 TERAPI REHABILITASI VESTIBULER(VRT) 249,000 192,000 441,000
85 Terapi reposisi otolit 148,000 114,000 262,000
86 TES ELEKTROFISIOLOGI N. FASIALIS 258,000 198,000 456,000
87 TES KESEIMBANGAN DENGAN VIDEOOCULOGRAFI 358,000 275,000 633,000
88 Tes Keseimbangan dg Frenzel 160,000 123,000 283,000
90 TES MOTORIK N. FASIALIS 158,000 121,000 279,000
91 TES OAE (OTO ACOUSTIK EMISSION) 164,000 127,000 291,000
92 TES PSIKOAKUSTIK TINITUS 280,000 214,000 494,000
93 Tes Psikolog 161,000 125,000 286,000
94 TES SAL (sensorineural acquity level) 233,000 180,000 413,000
95 TES TOPOGRAFI N. FASIALIS 208,000 159,000 367,000
96 TES VISUAL DINAMIC ACQUTY (VDA) 371,000 286,000 657,000
97 Test Alergi Quick Test 414,000 318,000 732,000
98 Test Alergi Skin Prick Test 404,000 276,000 680,000
99 Test Alergi Stellerpoint 432,000 332,000 764,000
100 Test Sisi Decay 141,000 109,000 250,000
101 Test Sniffin 506,000 389,000 895,000
102 Timpanometri 93,000 73,000 166,000
103 Timpanometri High Frequensi 158,000 121,000 279,000
104 Tone burst Kom 267,000 205,000 472,000
105 Transnasal Esoohagoskopi 1,325,000 346,000 1,671,000
106 Vibrasi 107,000 82,000 189,000
107 Wound Toilet THT 186,000 142,000 328,000
2.10 BEDAH
4 Aspirasi Kista 278,000 213,000 491,000
5 Biopsi Eksisi < 3 cm 808,000 620,000 1,428,000
6 Biopsi Eksisi > 3 cm 938,000 720,000 1,658,000
7 Biopsi Insisi 689,000 529,000 1,218,000
12 Ekstirpasi Tumor Jinak 588,000 452,000 1,040,000
17 Inj Kenacort 262,000 201,000 463,000
18 Insisi Abses 502,000 386,000 888,000
19 Jahit < 10 simpul 610,000 469,000 1,079,000
20 Jahit > 10 simpul 825,000 633,000 1,458,000
21 Pasang Folley Catheter 148,000 111,000 259,000
22 Pasang kateter 162,000 56,000 218,000
JASA
PELAYANAN
24 Perawatan Luka Bakar dengan sedasi 3,362,000 2,577,000 5,939,000
25 Perawatan Luka bakar di wajah 156,000 121,000 277,000
26 Perawatan Luka Bakar tanpa sedasi dengan atau tanpa STSG 669,000 514,000 1,183,000
30 Rozer plasty 689,000 529,000 1,218,000
31 Thakheostomy 795,000 611,000 1,406,000
32 WSD 677,000 520,000 1,197,000
2.11 AKUPUNTUR
1 Akuapunktur 62,000 47,000 109,000
2 Akupunktur Cupping 52,000 40,000 92,000
3 Akupunktur Daerah Mata 64,000 50,000 114,000
4 Akupunktur Kecantikan 82,000 63,000 145,000
5 Akupunktur Kepala 78,000 60,000 138,000
6 Akupunktur Laser Multilead 75,000 59,000 134,000
7 Akupunktur Laser Portable 72,000 56,000 128,000
8 Akupunktur Obesitas 86,000 66,000 152,000
9 Akupunktur Tanam Benang 147,000 70,000 217,000
10 Akupunktur Telinga 64,000 50,000 114,000
13 Pencabutan jarum 15,000 3,000 18,000
14 Sonopunktur 71,000 55,000 126,000
2.12 KULIT DAN KELAMIN
2 Anoskopi 260,000 138,000 398,000
3 Aspirasi Abses 165,000 128,000 293,000
4 Bedah listrik Berat 882,000 677,000 1,559,000
5 Bedah listrik Ringan 489,000 377,000 866,000
6 Bedah listrik Sedang 753,000 578,000 1,331,000
7 Bedah Mohs 1 layer (Ringan) 2,268,000 1,739,000 4,007,000
8 Bedah Mohs 2-3 layer (sedang) 4,050,000 3,106,000 7,156,000
9 Bedah Mohs 4-5 layer (erat) 6,392,000 4,140,000 10,532,000
10 Bedah Skapel Berat 2,169,000 1,664,000 3,833,000
11 Bedah skapel Ringan 1,457,000 1,117,000 2,574,000
12 Bedah Skapel Sedang 1,787,000 1,371,000 3,158,000
13 Biopsi Besar 1,977,000 1,516,000 3,493,000
14 Biopsi Kuku I 1,733,000 1,329,000 3,062,000
15 Biopsi Kuku II 2,150,000 1,648,000 3,798,000
16 Biopsi Ringan 1,509,000 1,158,000 2,667,000
17 Biopsi Sedang 1,694,000 1,300,000 2,994,000
18 BTA MH 83,000 65,000 148,000
19 Dermoskopi 101,000 78,000 179,000
23 ENUKLEASI > 5 lesi 250,000 193,000 443,000
24 ENUKLEASI 1 - 5 lesi 165,000 128,000 293,000
25 Fat Transfer 1,326,000 512,000 1,838,000
26 Fenolisasi 90,000 70,000 160,000
27 Flap/Graft 2,714,000 1,332,000 4,046,000
29 Gram ganda 101,000 70,000 171,000
30 Gram tunggal 76,000 55,000 131,000
31 High Resolution Anoskopi 416,000 320,000 736,000
32 Injeksi BotoX I 2,326,000 512,000 2,838,000
33 Injeksi Botox II 4,454,000 690,000 5,144,000
34 Injeksi Filler I 3,420,000 766,000 4,186,000
35 Injeksi Filler II 6,642,000 1,202,000 7,844,000
37 Kil I 101,000 78,000 179,000
38 Kil II 141,000 109,000 250,000
JASA
PELAYANAN
39 Kil III 167,000 129,000 296,000
40 Kil Kuku I ≤ 3 kuku 291,000 223,000 514,000
41 Kil Kuku II › 3 kuku 314,000 241,000 555,000
42 KOH + WL 72,000 32,000 104,000
43 KOH Ganda 76,000 47,000 123,000
44 KOH Tunggal 56,000 32,000 88,000
45 Kredo 108,000 83,000 191,000
46 Laser CO2 Berat 993,000 763,000 1,756,000
47 Laser CO2 Ringan 591,000 453,000 1,044,000
48 Laser CO2 Sedang 826,000 634,000 1,460,000
49 Laser Diode 113,000 39,000 152,000
50 Laser NdYag A 399,000 307,000 706,000
51 Laser NdYag B 513,000 394,000 907,000
52 Laser NdYag C 618,000 474,000 1,092,000
53 Mikro Dermabrasi 450,000 346,000 796,000
54 Miniliposuction (per area) 1,190,000 913,000 2,103,000
55 Nitrogen cair berat 683,000 525,000 1,208,000
56 Nitrogen cair ringan 251,000 193,000 444,000
57 Nitrogen cair sedang 467,000 359,000 826,000
58 Paket Uji Urtikaria 1,572,000 552,000 2,124,000
61 Pengambilan Specimen Gram Wanita I tanpa Spekulum 104,000 80,000 184,000
62 Pengambilan Specimen Gram Wanita II dengan Spekulum 120,000 93,000 213,000
63 Pengambulan Specimen Gram Pria 83,000 65,000 148,000
64 Perawatan Ulkus > 5 lesi 228,000 176,000 404,000
65 Perawatan Ulkus 1-5 lesi 158,000 122,000 280,000
66 Pewarnaan Gram Pria 48,000 38,000 86,000
67 Pewarnaan Gram Wanita I tanpa Spekulum 63,000 48,000 111,000
68 Pewarnaan Gram wanita II dengan Spekulum 72,000 56,000 128,000
69 Ph Vagina 68,000 53,000 121,000
70 Podopilin > 5 lesi 166,000 128,000 294,000
71 Podopilin 1-5 lesi 118,000 90,000 208,000
72 PRF ( Platelet Rich Fibrim) 198,000 153,000 351,000
73 PRP (automated) 1,155,000 690,000 1,845,000
74 PRP (Manual) 658,000 504,000 1,162,000
75 Punch Grafting I < 5 lesi 1,752,000 1,344,000 3,096,000
76 Punch Grafting II > 5 lesi 1,916,000 1,469,000 3,385,000
77 Sedimen Urine 63,000 42,000 105,000
78 Subsicion Berat 431,000 331,000 762,000
81 TCA 6-10 lesi 162,000 125,000 287,000
82 TCA 90% > 10 lesi 214,000 165,000 379,000
83 TCA 90% 1-5 lesi 116,000 89,000 205,000
84 TCA 90%> 10 cm (Giant) 196,000 151,000 347,000
85 Tes Amin 69,000 54,000 123,000
86 Tes Asam Asetat 82,000 65,000 147,000
87 Tutul KOH 60,000 47,000 107,000
88 Uji Patergi 328,000 252,000 580,000
89 Uji Penisilin I 482,000 369,000 851,000
90 uji penisilin Ulang 386,000 296,000 682,000
91 Uji Provokasi Obat (per kedatangan) 788,000 138,000 926,000
92 Uji Serum Autolog 362,000 278,000 640,000
93 Uji Tempel Obat 521,000 401,000 922,000
94 Uji Tempel Standar 732,000 484,000 1,216,000
95 Uji Tusuk Obat 398,000 306,000 704,000
96 Uji Tusuk Standar 1,385,000 414,000 1,799,000
97 UV Localized I (1-2 lesi) 83,000 37,000 120,000
98 UV Localized II (= 3 lesi) 101,000 31,000 132,000
99 UV Localized III 152,000 78,000 230,000
100 UV Whole Body 95,000 32,000 127,000
2.13 PENYAKIT DALAM
JASA
PELAYANAN
1 ABPM (Ambulatory Blood Pressure Machine) 540,000 414,000 954,000
5 Artificial Ascites 564,000 434,000 998,000
6 Aspirasi + Injeksi Ethanol Tiroid dengan Panduan USG 866,000 665,000 1,531,000
7 Aspirasi abses hati 2,039,000 1,564,000 3,603,000
8 Aspirasi Kista hati 2,087,000 1,601,000 3,688,000
9 Aspirasi Kista Tiroid 335,000 258,000 593,000
10 Aspirasi Kista Tiroid dengan Panduan USG 509,000 391,000 900,000
11 ASPIRASI LIMPA 2,142,000 1,643,000 3,785,000
12 Aspirasi Nodul (Tumor) 2,432,000 1,866,000 4,298,000
13 ASPIRASI PANKREAS 2,352,000 1,805,000 4,157,000
15 BAJAH Kista Tiroid 371,000 286,000 657,000
16 BAJAH Kista Tiroid dengan Panduan USG 570,000 439,000 1,009,000
18 BAJAH Nodul Tiroid dengan Panduan USG 492,000 379,000 871,000
21 Band Ligation / Ligasi VE 2,105,000 884,000 2,989,000
22 BIA 782,000 599,000 1,381,000
23 Biopsi Core (Guide) Tuntunan USG 3,191,000 2,448,000 5,639,000
24 BIOPSI GASTER 10,012,000 2,511,000 12,523,000
25 Biopsi Ginjal 1,101,000 845,000 1,946,000
26 Biopsi hati membuta 1,863,000 1,428,000 3,291,000
27 Biopsi KGB 1,290,000 991,000 2,281,000
28 Biopsi pleura 591,000 453,000 1,044,000
29 BMP + Biopsi SUMSUM TULANG 1,394,000 1,069,000 2,463,000
30 BMP SUMSUM TULANG 939,000 720,000 1,659,000
33 Bronkoskopi + BAL 1,442,000 1,106,000 2,548,000
46 CABUT PTBD/PIGTAIL/ PIGTAIL ASITES 688,000 528,000 1,216,000
47 Core Biopsi Tiroid 1,073,000 823,000 1,896,000
48 CRYOTHERAPY 9,518,000 7,297,000 16,815,000
50 CVC 2,134,000 1,638,000 3,772,000
51 Drainage Abses dengan Pigtail (Cathether) 12,677,000 9,720,000 22,397,000
52 Drainage Asites dengan Pigtail (Cathether) 9,518,000 7,298,000 16,816,000
54 EBUS Diagnostik 2,667,000 2,045,000 4,712,000
56 EBUS Linier + TBNA 15,947,000 12,226,000 28,173,000
JASA
PELAYANAN
66 13,940,000 10,688,000 24,628,000
Bawah
Endoscopt Rectrograde Cholangio Pancreatography (ERCP)
71 3,945,000 3,026,000 6,971,000
diagnostik
72 Endosonografi Diagnostik 25,540,000 5,291,000 30,831,000
73 Endosonografi Terapeutik 25,904,000 5,361,000 31,265,000
80 Esofagogastroduodenoskopi 1,179,000 904,000 2,083,000
81 Fibrinolitik Intrapleura 542,000 416,000 958,000
83 Fibroscan 1,156,000 887,000 2,043,000
84 Flicker Test 118,000 90,000 208,000
85 Flushing cellsite 280,000 208,000 488,000
86 FNAB 256,000 197,000 453,000
88 Foto Retina 135,000 104,000 239,000
89 FRAILTY 132,000 70,000 202,000
90 Gastroscopy / Esofagogastroduodenoscopy EGD 1,742,000 914,000 2,656,000
91 HD CITO 1,918,000 1,472,000 3,390,000
92 HD sled 1,989,000 1,526,000 3,515,000
93 Hemodialisis 1,073,000 276,000 1,349,000
95 Hemostasis SCBA 2,674,000 2,050,000 4,724,000
96 Hemostasis SCBB 3,224,000 2,473,000 5,697,000
97 IMOBILISASI 105,000 70,000 175,000
98 Induksi Sputum 263,000 203,000 466,000
101 Infus obat (drip) 420,000 208,000 628,000
102 Inhalasi 84,000 66,000 150,000
103 Injeksi etanol (PEIT) 2,000,000 870,000 2,870,000
104 Injeksi Histoacryl 8,418,000 4,193,000 12,611,000
105 Injeksi intraartikular sendi besar 298,000 183,000 481,000
106 Injeksi intraartikular sendi kecil 293,000 159,000 452,000
107 Injeksi Obat anti hemofilia 156,000 121,000 277,000
108 Injeksi Obat kemo dan Th/Hormonal 302,000 232,000 534,000
109 Injeksi Obat Khusus GCSF 156,000 121,000 277,000
112 Injeksi PegIFN 46,000 35,000 81,000
113 Injeksi periartikuler 293,000 183,000 476,000
114 INNANISI 140,000 70,000 210,000
115 INSTABILITAS 122,000 70,000 192,000
116 Intratekal 917,000 703,000 1,620,000
117 Intubasi 1,148,000 881,000 2,029,000
118 Kemoterapi 762,000 584,000 1,346,000
119 Kemoterapi drip 2 Hari RINAP 617,000 474,000 1,091,000
122 Kemoterapi IM bolus 108,000 83,000 191,000
JASA
PELAYANAN
123 Kemoterapi IV drip < 3 jam (Hidrasi 1 jam) 1/ 2 regimen 917,000 690,000 1,607,000
124 Kemoterapi IV drip > 3 jam (Hidrasi 1 jam) 3 regimen 900,000 690,000 1,590,000
125 Kolangioskopi 7,404,000 5,251,000 12,655,000
127 Leukoferesis Dewasa Tanpa Kit 1,659,000 1,036,000 2,695,000
129 Manometri 2,489,000 1,292,000 3,781,000
130 Mantuox Tes 126,000 98,000 224,000
131 Pasang Infus 159,000 122,000 281,000
132 Patch Test Obat* 160,000 123,000 283,000
137 Pemasangan NJT 6,508,000 3,126,000 9,634,000
142 Pemeiksaan Sitogenetika 1,505,000 552,000 2,057,000
143 Pemeriksaan Kaki (Deteksi Dini) 118,000 90,000 208,000
144 Pemeriksaan Otonom (HRV) 154,000 120,000 274,000
145 Pencabutan kateter Lumen ganda semi permanen 444,000 342,000 786,000
Perawatan CAPD (transfer set)* tanpa bmhp --> Penggantian transfer
149 147,000 113,000 260,000
set CAPD
150 Perawatan Cateter CAPD --> perawatan exit site capd 148,000 114,000 262,000
151 Perawatan Kaki Non Ulkus 189,000 146,000 335,000
152 Perawatan Luka Berat 390,000 301,000 691,000
153 Perawatan Luka Sedang 306,000 236,000 542,000
154 peritoneoscopy 1,562,000 1,197,000 2,759,000
155 Peritoneoscopy + biopsi 1,560,000 1,197,000 2,757,000
157 PICC 4,101,000 3,145,000 7,246,000
158 PICC (Pripheralty inserted central catheher) 10,629,000 449,000 11,078,000
159 plasmaferesis Dewasa Tanpa Kit 1,973,000 1,036,000 3,009,000
161 Pleurodesis Doksisiklin 545,000 418,000 963,000
166 Provokasi histamin 480,000 369,000 849,000
167 Provokasi Vaksin 336,000 259,000 595,000
168 PSIKOTERAPI PSIKOSOMATIK 149,000 115,000 264,000
169 PTBD (Percutaneous trans hepatic billiary drainage) 13,613,000 5,269,000 18,882,000
170 PTGBD (Percutaneous Transhepatic Gallbladder Drainage) 60" 8,117,000 5,269,000 13,386,000
171 Pungsi asites membuta 638,000 489,000 1,127,000
172 Pungsi asites tuntunan usg (guided) 1,299,000 522,000 1,821,000
173 Pungsi Pleura / Torakosintesis 572,000 440,000 1,012,000
174 Pungsi sendi besar 300,000 191,000 491,000
175 Pungsi sendi kecil 297,000 191,000 488,000
176 Radio Frequency Ablation (RFA) Tiroid 10,858,000 4,140,000 14,998,000
177 REKTOSIGMOIDOSKOPI 1,101,000 845,000 1,946,000
178 REPAIR PTBD 725,000 556,000 1,281,000
179 RFA (Radio Frequency Abblation) 14,092,000 4,343,000 18,435,000
180 Savari bougie 2,138,000 1,185,000 3,323,000
181 Skin Prick Test 285,000 208,000 493,000
182 Skleroterapi VE 1,917,000 1,470,000 3,387,000
184 Spirometri 179,000 137,000 316,000
JASA
PELAYANAN
186 STE Hemoroid 486,000 374,000 860,000
187 STE Histoakril 1,786,000 1,370,000 3,156,000
188 Stroop Test 107,000 83,000 190,000
190 Terapi infus non kemoterapi 258,000 198,000 456,000
191 Terapi Oksigen 64,000 48,000 112,000
192 Tes Mantoux 248,000 98,000 346,000
193 Tes obat oral 306,000 236,000 542,000
194 Tes obat suntik 588,000 452,000 1,040,000
197 Transfusi darah dgn filter 657,000 208,000 865,000
198 Transfusi darah tanpa filter 339,000 208,000 547,000
199 Tromboferesis Dewasa tanpa kit 1,659,000 1,036,000 2,695,000
200 TTB 1,319,000 1,012,000 2,331,000
202 TTNA 582,000 446,000 1,028,000
203 USG Abdomen 279,000 214,000 493,000
204 USG Dopller 334,000 258,000 592,000
205 USG Guide Injeksi dan Pungsi 676,000 248,000 924,000
206 USG Kontras 3,996,000 870,000 4,866,000
207 USG Muskuloskeletal 292,000 183,000 475,000
208 USG Thorax/Colli 179,000 137,000 316,000
209 Vaksinasi 70,000 55,000 125,000
2.14 ORTHOPEDI
3 Aspirasi Kista 278,000 213,000 491,000
4 Aspirasi Sendi 201,000 156,000 357,000
5 Biopsi Eksisi < 3 cm 808,000 620,000 1,428,000
6 Biopsi Eksisi > 3 cm 938,000 720,000 1,658,000
7 Biopsi Insisi 689,000 529,000 1,218,000
8 Bone Marrow Aspiration 2,082,000 630,000 2,712,000
9 Buka body jacket 270,000 208,000 478,000
10 Buka gips atas lutut 255,000 196,000 451,000
11 Buka Gips atas siku 255,000 196,000 451,000
12 Buka Gips bawah lutut 214,000 165,000 379,000
13 Buka Gips bawah siku 214,000 165,000 379,000
14 Buka hip spica 270,000 208,000 478,000
15 Cabut K-wire / pin dengan anestesi lokal 634,000 487,000 1,121,000
20 Ekstraksi corpus alienum 634,000 487,000 1,121,000
22 infus bisphosphonate 2,054,000 398,000 2,452,000
23 Injeksi Intraarticular 396,000 304,000 700,000
24 412,000 316,000 728,000
compression)
25 Insisi Abses 502,000 386,000 888,000
26 Jahit < 10 simpul 610,000 469,000 1,079,000
27 Jahit > 10 simpul 825,000 633,000 1,458,000
28 Pemasangan body jacket 592,000 454,000 1,046,000
29 Pemasangan Gips atas lutut tanpa reposisi 470,000 361,000 831,000
30 Pemasangan Gips atas siku tanpa reposisi 376,000 289,000 665,000
31 Pemasangan Gips bawah lutut tanpa reposisi 365,000 280,000 645,000
32 Pemasangan Gips bawah siku tanpa reposisi 491,000 378,000 869,000
33 Pemasangan hip spica 1,401,000 503,000 1,904,000
34 Pemasangan Slab 390,000 301,000 691,000
JASA
PELAYANAN
35 pemasangan total contact cast 466,000 358,000 824,000
39 Reposisi dan pemasangan gips atas lutut dengan lokal anestesi 731,000 562,000 1,293,000
40 Reposisi dan pemasangan gips atas siku dengan lokal anestesi 687,000 527,000 1,214,000
41 Reposisi dan pemasangan gips bawah lutut dengan lokal anestesi 623,000 479,000 1,102,000
42 Reposisi dan Pemasangan Gips bawah siku dengan lokal anestesi 578,000 444,000 1,022,000
43 Rozer plasty 689,000 529,000 1,218,000
44 Serial plaster / ponseti (<3bln) (Single) 333,000 256,000 589,000
45 Serial plaster / ponseti (>4th / relaps) (Single) 632,000 486,000 1,118,000
46 Serial plaster / ponseti (1th - 4th) (Single) 490,000 377,000 867,000
47 Serial plaster / ponseti (3bln - 1th) (Single) 419,000 322,000 741,000
48 Skin Traction 284,000 219,000 503,000
49 Strapping 404,000 310,000 714,000
2.15 KARDIOLOGI
1 Doppler Vaskular 407,000 313,000 720,000
2 Doppler Vaskular 2 tungkai/carotis 759,000 582,000 1,341,000
3 Echocardiography 524,000 403,000 927,000
4 Holter Monitoring 24 jam 994,000 762,000 1,756,000
5 Holter Monitoring 48 jam 1,894,000 1,453,000 3,347,000
6 klinik gagal jantung 186,000 142,000 328,000
7 Programming PPM 138,000 108,000 246,000
8 Rehabilitasi Medik Fase II / Club Senam jantung 158,000 121,000 279,000
9 Stress Echo Debutamin 807,000 619,000 1,426,000
10 Trans Esofageale Echo (TEE) 497,000 382,000 879,000
11 Treadmill Test 268,000 205,000 473,000
2.16 GIZI KLINIK
1 Food Recall 24 H notes 56,000 44,000 100,000
2 Interpretasi bioelectric impedance 44,000 34,000 78,000
3 Interpretasi bioelectric impedance pada pasien bedridden 368,000 283,000 651,000
4 Kalorimetri indirek 334,000 256,000 590,000
5 Pengukuran knee height 52,000 40,000 92,000
6 Pengukuran lingkar pinggang/panggul 20,000 15,000 35,000
7 Pengukuran MUAC (Mid Upper Arm Circumference) 20,000 15,000 35,000
8 Status hidrasi (Urine Specific Gravity) 20,000 17,000 37,000
2.17 KEDOKTERAN OKUPASI
1 Desain atau Proposal Program 240,000 660,000 900,000
2 Interpretasi ILO Radiograph 51,000 99,000 150,000
3 Laporan Analisa Data Okupasi Berbasis Statistik per Outcome 800,000 2,200,000 3,000,000
4 Paket Kelaikan Kerja 310,000 590,000 900,000
5 Paket Penilaian Risiko Kesehatan dan Keselamatan Kerja (per hari kerja) 440,000 1,760,000 2,200,000
6 Paket Penyakit Akibat Kerja Kategori Berat 794,000 2,060,000 2,854,000
7 Paket Penyakit Akibat Kerja Kategori Ringan 310,000 590,000 900,000
8 Paket Program Kembali Kerja Kategori Berat 942,000 2,320,000 3,262,000
9 Paket Program Kembali Kerja Kategori Ringan 562,000 1,000,000 1,562,000
10 Pembuatan Desain Tempat Kerja (per meter persegi) 280,000 460,000 740,000
11 Pembuatan Rekomendasi dan Pelaporan Program 250,000 550,000 800,000
12 Pemeriksaan dan Interpretasi HRV 61,000 89,000 150,000
13 Pemeriksaan Kekuatan Menggenggam Kuantitatif 55,000 35,000 90,000
14 Pemeriksaan Keseimbangan dan Koordinasi Kerja 55,000 35,000 90,000
15 Pemeriksaan Narkoba 125,000 125,000 250,000
16 Pemeriksaan Neuromuskuloskeletal Kerja 55,000 35,000 90,000
17 Pemeriksaan Occupational Force Capasity Evaluation 168,000 276,000 444,000
18 Pemeriksaan OCRA 84,000 66,000 150,000
19 Pemeriksaan Steroskopik Kerja 84,000 66,000 150,000
20 Pengembangan Program Kebugaran Pekerja (Per Pekerja) 530,000 2,970,000 3,500,000
21 Perhitungan Kecacatan Kerja 162,000 418,000 580,000
22 Presentasi Kesehatan 400,000 1,100,000 1,500,000
23 Rekomendasi Pembuatan Desain Tempat Kerja 260,000 440,000 700,000
24 Surat Keterangan Sehat 104,000 150,000 254,000
25 Survey ke tempat kerja 380,000 1,320,000 1,700,000
JASA
PELAYANAN
26 Swab RT PCR 1,434,000 370,000 1,804,000
Tatalaksana Industrial Disaster dalam Menangani Kasus Intervensi
27 840,000 1,380,000 2,220,000
dan Risiko Tinggi (Medical Emergency Respond Plan)
28 Tindakan Pemberian Vaksinasi pada Pekerja 84,000 66,000 150,000
29 Pemeriksaan Lingkungan ISBG/WBGT: per titik
30 Pemeriksaan Lingungan dengan Sound Level Meter: per titik
31 Pemeriksaan Lingkungan untuk Getaran: per titik
mengacu ke data UI
Pemeriksan Lingkungan untuk Pencahayaan Menggunakan Luxmeter:
32
per titik
33 Data Entry & Proses perCell
3. PENUNJANG PELAYANAN MEDIS
3.1 PATOLOGI KLINIK
1 Rapid Antibody SARS COV-2 135,000 15,000 150,000
3.2 RADIOLOGI INTERVENSI
1 DSA (DIGITAL SUBTRACTING ANGIOGRAM) DIAGNOSTIK 1 21,870,000 7,500,000 29,370,000
3 TACETTACI HEPATOMA 1 40,740,000 11,250,000 51,990,000
6 EMBOLI5ASI PRE-OPERATIF 1 35,340,000 7,500,000 42,840,000
8 CCF WITH COIL 1 87,625,000 18,750,000 106,375,000
9 CCF WITH COIL 2 132,430,000 22,500,000 154,930,000
10 CCF WITH BALOON 1 63,705,000 15,000,000 78,705,000
11 CCF WITH BALOON 2 96,960,000 18,750,000 115,710,000
12 EMBOLISASI PENDAFLAHAN WITH COIL 1 49,560,000 11,250,000 60,810,000
14 EMBOLISASI AVM PCRIFER 1 60,550,000 11,250,000 71,800,000
16 EMBOLISASI AVM BRAIN 1 101,045,000 15,000,000 116,045,000
18 SKLIROTERAPI 1 22,930,000 7,500,000 30,430,000
19 SKLIROTERAPI 2 26,985,000 9,000,000 35,985,000
20 PTA (PERCUTANEUS TRANSLUMINAL ANGIOPLASTY) 1 34,030,000 11,250,000 45,280,000
3.3 RADIOLOGI GIGI
1 Chepalo 108,000 83,000 191,000
2 Dental X-ray 56,000 43,000 99,000
3 Panoramic 108,000 83,000 191,000
KIRANA CITRA
JASA
PELAYANAN
1. KONSULTASI
2. NON OPERATIF
1 Analyzer 180,000 70,000 250,000
3 Angkat jahitan blefarorafi + Paha(PO) 300,000 200,000 500,000
4 Angkat jahitan kornea (PO) 300,000 200,000 500,000
5 Angkat Jahitan Kornea 300,000 150,000 450,000
6 Angkat Jahitan Palpebra 200,000 100,000 300,000
7 Bandage Lens 180,000 65,000 245,000
10 Demodex 200,000 67,000 267,000
12 Dermolipoma 1,000,000 784,000 1,784,000
13 Eksisi/insisi Tumor Konjungtiva 1,200,000 1,050,000 2,250,000
14 Eksisi/insisi Tumor Palpebra 1,200,000 945,000 2,145,000
17 ERG dan VEP Full Field 700,000 300,000 1,000,000
18 ERG dan VEP Multifokal 900,000 560,000 1,460,000
19 FFA 1,060,000 650,000 1,710,000
21 Ganti Balutan daerah mata 150,000 78,000 228,000
22 HESS Screen 170,000 67,000 237,000
23 Humprey 180,000 100,000 280,000
24 Indocyanine Green Angiography (ICG) 1,860,000 70,000 1,930,000
25 Indocyanine Green Angiography (ICG) + FFA 1,915,000 690,000 2,605,000
26 Injeksi Intrakameral / COA / Bubble 1,500,000 756,000 2,256,000
27 Injeksi Intrastromal Kornea 1,500,000 756,000 2,256,000
28 Injeksi Intravitreal 1,500,000 756,000 2,256,000
29 Injeksi Subkonjungtiva/ Subkutis 1,500,000 635,000 2,135,000
30 Injeksi Subtenon/ Sclera 1,500,000 735,000 2,235,000
32 IOL Master 300,000 168,000 468,000
33 Jahit Palpebra Ringan 1,100,000 1,097,000 2,197,000
34 Keratometri 120,000 67,000 187,000
35 Laser Perifer Iridektomi (LPI) 800,000 672,000 1,472,000
36 Laser Photocoagulation (Argon Laser) 1,500,000 1,120,000 2,620,000
37 Low Vision 600,000 224,000 824,000
38 Membranektomi konjungtivitis (PO) 400,000 300,000 700,000
39 Nd Yag Laser 1,000,000 560,000 1,560,000
40 Nekrotomi 220,000 145,000 365,000
41 Non Con Robo 90,000 67,000 157,000
42 OCT Scan / Visante 300,000 168,000 468,000
43 Octopus 200,000 100,000 300,000
45 Pemeriksaan ERG Full field 400,000 224,000 624,000
46 Pemeriksaan ERG Multifokal 500,000 300,000 800,000
47 Pemeriksaan Foto Fundus Midriatikum 200,000 70,000 270,000
48 Pemeriksaan VEP Full field 400,000 224,000 624,000
49 Pemeriksaan VEP Multifokal 500,000 300,000 800,000
52 RETINOMETRI 120,000 67,000 187,000
53 Screening ROP/Retcam 350,000 280,000 630,000
55 Spooling / Irigasi bola mata 120,000 80,000 200,000
56 Suntik Botox 5,350,000 784,000 6,134,000
JASA
PELAYANAN
57 Tes Schimer (BUT) 70,000 33,000 103,000
58 Tonometri tonopen 180,000 70,000 250,000
59 Toppolyzer 180,000 70,000 250,000
60 UBM (pemeriksaan bilik mata depan ) 1,000,000 224,000 1,224,000
61 USG mata 350,000 280,000 630,000
3. OPERATIF
1 Ahmed Implant LOKAL 16,150,000 3,990,000 20,140,000
2 Ahmed Implant NARKOSE 17,000,000 4,777,000 21,777,000
3 ALR+Spliting Tarsus LOKAL 3,650,000 2,415,000 6,065,000
4 ALR+Spliting Tarsus NARKOSE 4,500,000 2,730,000 7,230,000
5 Amnion Membrane Transplant LOKAL 5,650,000 2,835,000 8,485,000
6 Amnion Membrane Transplant NARKOSE 6,500,000 3,412,000 9,912,000
7 Angkat Jahitan LOKAL 1,650,000 1,155,000 2,805,000
8 Angkat Jahitan NARKOSE 2,500,000 1,365,000 3,865,000
9 Aspirasi Hipopion + Injeksi Intracameral (Tanpa Obat) LOKAL 5,150,000 2,835,000 7,985,000
10 Aspirasi Hipopion + Injeksi Intracameral (Tanpa Obat) NARKOSE 6,000,000 3,412,000 9,412,000
11 Aspirasi Sisa Korteks LOKAL 4,650,000 1,260,000 5,910,000
12 Aspirasi Sisa Korteks NARKOSE 5,500,000 1,365,000 6,865,000
13 Beevelt Implant LOKAL 13,400,000 3,990,000 17,390,000
14 Beevelt Implant NARKOSE 14,250,000 4,777,000 19,027,000
15 Biopsi insisi kelopak LOKAL 4,150,000 2,572,000 6,722,000
16 Biopsi insisi kelopak NARKOSE 5,000,000 3,071,000 8,071,000
17 Biopsi insisi konjungtiva LOKAL 4,350,000 2,572,000 6,922,000
18 Biopsi insisi konjungtiva NARKOSE 5,200,000 3,071,000 8,271,000
19 Biopsi insisi orbita LOKAL 5,650,000 4,410,000 10,060,000
20 Biopsi insisi orbita NARKOSE 6,500,000 5,460,000 11,960,000
21 Blefaroplasti LOKAL 6,650,000 3,465,000 10,115,000
22 Blefaroplasti NARKOSE 7,500,000 4,095,000 11,595,000
23 Cyclocrio/Tcp LOKAL 6,350,000 1,575,000 7,925,000
24 Cyclocrio/Tcp NARKOSE 7,200,000 1,774,000 8,974,000
25 Eksenterasi 10,000,000 7,507,000 17,507,000
26 Eksenterasi kompleks 11,000,000 8,872,000 19,872,000
Eksisi/ Ekstirpasi luas tumor kelopak kecil (<5 mm) dan rekonstruksi
27 7,500,000 6,825,000 14,325,000
kelopak sederhana
Eksisi/ Ekstirpasi tumor kelopak besar (>5 mm) dan rekonstruksi
28 8,700,000 7,507,000 16,207,000
kelopak kompleks
29 Eksisi/ Ekstirpasi tumor kelopak besar (>5 mm) LOKAL 6,150,000 3,885,000 10,035,000
30 Eksisi/ Ekstirpasi tumor kelopak besar (>5 mm) NARKOSE 7,000,000 4,777,000 11,777,000
31 Eksisi/ Ekstirpasi tumor kelopak kecil (<5 mm) LOKAL 5,150,000 3,360,000 8,510,000
32 Eksisi/ Ekstirpasi tumor kelopak kecil (<5 mm) NARKOSE 6,000,000 4,095,000 10,095,000
33 7,850,000 4,515,000 12,365,000
LOKAL
34 8,700,000 5,460,000 14,160,000
NARKOSE
35 6,650,000 2,572,000 9,222,000
LOKAL
36 7,500,000 3,071,000 10,571,000
NARKOSE
37 Ekstraksi katarak+IOL+PPC+Vitrektomi anterior 13,000,000 6,142,000 19,142,000
38 Ekstraksi katarak+IOL+PPC+Vitrektomi anterior pars plana 13,500,000 6,415,000 19,915,000
39 Ekstraksi katarak+PPC+Vitrektomi anterior 10,500,000 6,142,000 16,642,000
40 Enukleasi DFG + Retcam 8,750,000 8,100,000 16,850,000
41 Enukleasi (PO) 6,000,000 5,460,000 11,460,000
42 ENUKLEASI WITH ball ORBITAL IMPLANT 6,500,000 5,460,000 11,960,000
43 ENUKLEASI WITH ORBITAL IMPLANT 7,000,000 5,460,000 12,460,000
44 Enukleasi/ Eviserasi 6,000,000 5,460,000 11,460,000
45 Enukleasi/ Eviserasi with DFG 7,000,000 6,825,000 13,825,000
46 ERG Full field Surgery 1,800,000 683,000 2,483,000
47 ERG Multifokal Surgery 2,000,000 819,000 2,819,000
48 Evakuasi Silicon Oil + Endolaser LOKAL 17,150,000 2,940,000 20,090,000
49 Evakuasi Silicon Oil + Endolaser NARKOSE 18,000,000 3,412,000 21,412,000
50 Examination under anesthesia 4,000,000 2,047,000 6,047,000
51 EXTERNAL DCR+SIL TUBE LOKAL 9,150,000 5,775,000 14,925,000
52 EXTERNAL DCR+SIL TUBE NARKOSE 10,000,000 6,825,000 16,825,000
53 Fasalata Graft LOKAL 5,150,000 2,415,000 7,565,000
JASA
PELAYANAN
54 Fasalata Graft NARKOSE 6,000,000 2,730,000 8,730,000
55 Flap Konjungtiva LOKAL 5,650,000 2,835,000 8,485,000
56 Flap Konjungtiva NARKOSE 6,500,000 3,412,000 9,912,000
57 Gas-Fluid Exchange (GFX)/ Drainage subretinal Fluid LOKAL 6,250,000 420,000 6,670,000
58 Gas-Fluid Exchange (GFX)/ Drainage subretinal Fluid NARKOSE 7,100,000 735,000 7,835,000
59 Glueing LOKAL 4,450,000 2,835,000 7,285,000
60 Glueing NARKOSE 5,300,000 3,412,000 8,712,000
61 GRAFT SKLERA lokal 5,895,000 3,045,000 8,940,000
62 GRAFT SKLERA narkose 7,140,000 3,685,000 10,825,000
63 ICCE / ECCE / SICS / SCLERAL FIKSASI LOKAL 7,650,000 2,310,000 9,960,000
64 ICCE / ECCE / SICS / SCLERAL FIKSASI NARKOSE 8,500,000 2,730,000 11,230,000
65 ICCE/ECCE/SICS/SEKUNDER IMPLANT LOKAL 7,450,000 2,310,000 9,760,000
66 ICCE/ECCE/SICS/SEKUNDER IMPLANT NARKOSE 8,300,000 2,730,000 11,030,000
67 Injeksi Intrakameral / COA / Bubble LOKAL 2,150,000 1,155,000 3,305,000
68 Injeksi Intrakameral / COA / Bubble NARKOSE 3,000,000 1,365,000 4,365,000
69 Injeksi Intrastromal Kornea LOKAL 2,150,000 1,155,000 3,305,000
70 Injeksi Intrastromal Kornea NARKOSE 3,000,000 1,365,000 4,365,000
71 Injeksi Intravitreal LOKAL 2,150,000 1,155,000 3,305,000
72 Injeksi Intravitreal NARKOSE 3,000,000 1,365,000 4,365,000
73 Injeksi Subkonjungtiva/ Subkutis LOKAL 2,150,000 1,155,000 3,305,000
74 Injeksi Subkonjungtiva/ Subkutis NARKOSE 3,000,000 1,333,000 4,333,000
75 Injeksi Subtenon/ Sclera LOKAL 2,150,000 1,155,000 3,305,000
76 Injeksi Subtenon/ Sclera NARKOSE 3,000,000 1,365,000 4,365,000
77 INSISI HORDEOLUM / KALAZION 5,000,000 1,365,000 6,365,000
78 Iridektomi LOKAL 5,650,000 1,785,000 7,435,000
79 Iridektomi NARKOSE 6,500,000 2,047,000 8,547,000
80 Kantopeksi LOKAL 3,350,000 2,940,000 6,290,000
81 Kantopeksi NARKOSE 4,200,000 3,412,000 7,612,000
82 Kapsulotomi posterior sekunder + vitrektomi anterior + sinekiolisis 10,500,000 4,777,000 15,277,000
83 KELOPAK BERAT LOKAL 13,150,000 7,035,000 20,185,000
84 KELOPAK BERAT NARKOSE 14,000,000 8,190,000 22,190,000
85 KELOPAK RINGAN LOKAL 6,150,000 3,570,000 9,720,000
86 KELOPAK RINGAN NARKOSE 7,000,000 4,095,000 11,095,000
87 KELOPAK SEDANG I LOKAL 6,650,000 4,095,000 10,745,000
88 KELOPAK SEDANG I NARKOSE 7,500,000 4,777,000 12,277,000
89 KELOPAK SEDANG II LOKAL 7,150,000 5,775,000 12,925,000
90 KELOPAK SEDANG II NARKOSE 8,000,000 6,825,000 14,825,000
91 Keratoplasty (Tanpa donor) LOKAL 23,150,000 4,725,000 27,875,000
92 Keratoplasty (Tanpa donor) NARKOSE 24,000,000 5,460,000 29,460,000
93 kornea tattoo LOKAL 4,450,000 2,835,000 7,285,000
94 kornea tattoo NARKOSE 5,300,000 3,412,000 8,712,000
95 Lateral Tarsal Strip LOKAL 5,150,000 2,415,000 7,565,000
96 Lateral Tarsal Strip NARKOSE 6,000,000 2,730,000 8,730,000
97 Levator reseksi LOKAL 5,150,000 2,415,000 7,565,000
98 Levator reseksi NARKOSE 6,000,000 2,990,000 8,990,000
99 limbal stem cell graft LOKAL 7,000,000 5,250,000 12,250,000
100 limbal stem cell graft NARKOSE 7,850,000 6,142,000 13,992,000
101 Lip Mucosa Graft LOKAL 4,150,000 3,465,000 7,615,000
102 Lip Mucosa Graft NARKOSE 5,000,000 4,095,000 9,095,000
103 LRI ( Limbal relaxing Incision ) LOKAL 5,750,000 1,785,000 7,535,000
104 LRI ( Limbal relaxing Incision ) NARKOSE 6,600,000 2,047,000 8,647,000
105 Medial wall and orbital floor fracture/naso orbital fracture 10,500,000 8,190,000 18,690,000
106 Micropulse LOKAL 13,400,000 1,680,000 15,080,000
107 Micropulse NARKOSE 14,050,000 2,047,000 16,097,000
108 Mild Soket reconstruction 7,000,000 5,460,000 12,460,000
109 Moderate soket rekonstruktion 10,000,000 6,142,000 16,142,000
110 Naso orbital fracture with complete rhinoplasty 12,000,000 8,190,000 20,190,000
111 Naso orbital fracture with DCR 14,000,000 8,190,000 22,190,000
112 Naso orbital fracture with Partial rhinoplasty 11,000,000 8,190,000 19,190,000
113 Nekrotomi Surgery LOKAL 4,450,000 3,360,000 7,810,000
114 Nekrotomi Surgery NARKOSE 5,300,000 4,095,000 9,395,000
115 orbital floor fracture 10,000,000 6,825,000 16,825,000
116 Orbitotomi anterior dan eksisi tumor kompleks 10,000,000 8,190,000 18,190,000
JASA
PELAYANAN
117 Orbitotomi anterior dan ekstirpasi tumor 9,500,000 6,825,000 16,325,000
118 Orbitotomi lateral dan eksisi tumor 11,000,000 9,555,000 20,555,000
119 Orbitotomi lateral dan eksisi tumor kompleks 12,000,000 10,920,000 22,920,000
120 periosteal graft LOKAL 7,650,000 4,200,000 11,850,000
121 periosteal graft NARKOSE 8,500,000 4,777,000 13,277,000
122 Phaco LOKAL 13,150,000 3,045,000 16,195,000
123 Phaco NARKOSE 14,000,000 3,549,000 17,549,000
124 Phaco Regular LOKAL 10,150,000 3,040,000 13,190,000
125 Phaco Reguler NARKOSE 11,000,000 3,540,000 14,540,000
126 Pneumatic Retinopexy LOKAL 5,500,000 2,285,000 7,785,000
127 Pneumatic Retinopexy NARKOSE 6,500,000 2,645,000 9,145,000
128 Probing with/ without Infracturing Concha LOKAL 3,150,000 1,785,000 4,935,000
129 Probing with/ without Infracturing Concha NARKOSE 4,000,000 1,995,000 5,995,000
130 Probing with/ without Infracturing Concha with Endoscopy LOKAL 4,150,000 1,785,000 5,935,000
Probing with/ without Infracturing Concha with Endoscopy
131 5,000,000 1,995,000 6,995,000
NARKOSE
132 Pterigium Plasty LOKAL 4,450,000 2,205,000 6,655,000
133 Pterigium Plasty NARKOSE 5,300,000 2,593,000 7,893,000
134 Punctum Atresia LOKAL 2,150,000 1,155,000 3,305,000
135 Punctum Atresia NARKOSE 3,000,000 1,365,000 4,365,000
136 Reconstruction post tumor berat 10,000,000 8,190,000 18,190,000
137 Reconstruction post tumor sedang 6,000,000 5,460,000 11,460,000
138 Repair Cyclodialysis LOKAL 7,150,000 3,045,000 10,195,000
139 Repair Cyclodialysis NARKOSE 8,000,000 3,549,000 11,549,000
140 Repair Kornea LOKAL 6,650,000 2,835,000 9,485,000
141 Repair Kornea NARKOSE 7,500,000 3,412,000 10,912,000
142 Repair Sklera LOKAL 6,900,000 3,045,000 9,945,000
143 Repair Sklera NARKOSE 7,750,000 3,685,000 11,435,000
144 Repair Tube LOKAL 4,650,000 2,205,000 6,855,000
145 Repair Tube NARKOSE 5,500,000 2,593,000 8,093,000
146 Reposisi LOKAL 3,650,000 1,155,000 4,805,000
147 Reposisi NARKOSE 4,500,000 1,365,000 5,865,000
148 RETCAM ODS 2,700,000 2,730,000 5,430,000
149 RetCam ODS + Cryotherapy OD/OS 5,100,000 2,730,000 7,830,000
150 RetCam ODS + Cryotherapy ODS 6,000,000 4,095,000 10,095,000
151 RetCam ODS + Injeksi Avastine ODS 5,700,000 4,095,000 9,795,000
152 RetCam ODS+ Injeksi Avastine OD/OS 4,800,000 3,412,000 8,212,000
153 RetCam ODS+ Injeksi carboplatin OD/OS 5,000,000 3,412,000 8,412,000
154 RetCam ODS+ Injeksi carboplatin ODS 5,700,000 4,095,000 9,795,000
155 RetCam ODS+LIO OD/OS 4,300,000 3,412,000 7,712,000
156 RetCam ODS+LIO ODS 5,500,000 4,777,000 10,277,000
157 RetCam+LIO+Cryotherapy 5,600,000 4,095,000 9,695,000
158 Revisi Iridektomi / Bleb LOKAL 4,650,000 2,205,000 6,855,000
159 Revisi Iridektomi / Bleb NARKOSE 5,500,000 2,593,000 8,093,000
160 Revormasi Coa LOKAL 4,650,000 1,155,000 5,805,000
161 Revormasi Coa NARKOSE 5,500,000 1,365,000 6,865,000
162 Schlera Buckle LOKAL 8,850,000 2,940,000 11,790,000
163 Schlera Buckle NARKOSE 9,700,000 3,412,000 13,112,000
164 scleral patch LOKAL 7,000,000 4,200,000 11,200,000
165 scleral patch NARKOSE 7,850,000 4,777,000 12,627,000
166 scrapping kornea / keratektomi superfisial LOKAL 4,450,000 2,835,000 7,285,000
167 scrapping kornea / keratektomi superfisial NARKOSE 5,300,000 3,412,000 8,712,000
168 Sekunder Implant Dengan penyulit + Vitrektomi Anterior 12,000,000 5,460,000 17,460,000
169 Semi Eksentrasi /Eksenterasi + RetCam 7,150,000 8,190,000 15,340,000
170 Severe soket rekonstruktion 10,000,000 9,555,000 19,555,000
171 Sklerotomi posterior LOKAL 5,650,000 1,785,000 7,435,000
172 Sklerotomi posterior NARKOSE 6,500,000 2,047,000 8,547,000
173 Strabismus 1 NARKOSE 6,700,000 3,412,000 10,112,000
174 Strabismus 1LOKAL 5,850,000 2,835,000 8,685,000
175 Strabismus 2 LOKAL 6,850,000 3,360,000 10,210,000
179 Tambah Jahitan LOKAL 1,950,000 1,155,000 3,105,000
180 Tambah Jahitan NARKOSE 2,800,000 1,365,000 4,165,000
JASA
PELAYANAN
181 Tarsorapi Beban Emas (Goldweight) LOKAL 4,150,000 2,415,000 6,565,000
182 Tarsorapi Beban Emas (Goldweight) NARKOSE 5,000,000 2,730,000 7,730,000
183 Trabekulo-Trabekulektomi + MMU LOKAL 7,150,000 3,045,000 10,195,000
184 Trabekulo-Trabekulektomi + MMU NARKOSE 8,000,000 3,549,000 11,549,000
185 Tripod fraktur 15,200,000 9,555,000 24,755,000
186 VEP Full field Surgery 1,800,000 683,000 2,483,000
187 VEP Multifokal Surgery 2,000,000 819,000 2,819,000
188 Virna Implant LOKAL 8,850,000 3,990,000 12,840,000
189 Virna Implant NARKOSE 9,700,000 4,777,000 14,477,000
190 Vitrektomi Anterior LOKAL 4,550,000 1,995,000 6,545,000
191 Vitrektomi Anterior NARKOSE 5,400,000 2,320,000 7,720,000
192 Vitrektomi Complex Exclusive LOKAL 28,000,000 6,600,000 34,600,000
193 Vitrektomi Complex Exclusive NARKOSE 28,500,000 8,100,000 36,600,000
194 Vitrektomi Complex LOKAL 21,400,000 6,600,000 28,000,000
195 Vitrektomi Complex NARKOSE 21,900,000 8,100,000 30,000,000
196 Vitrektomi simple Exclusive LOKAL 21,800,000 5,800,000 27,600,000
197 Vitrektomi simple Exclusive NARKOSE 22,500,000 7,100,000 29,600,000
198 Vitrektomi simple LOKAL 15,200,000 5,800,000 21,000,000
199 Vitrektomi simple NARKOSE 15,900,000 7,100,000 23,000,000
200 Vitreus /Aqueous Tap LOKAL 5,750,000 2,835,000 8,585,000
201 Vitreus /Aqueous Tap NARKOSE 6,600,000 3,412,000 10,012,000
POLIKLINIK TUMBUH KEMBANG ANAK
JASA
PELAYANAN
1. KONSULTASI
1 Konsultasi A 129.000 350.000 479.000
2 Konsultasi B 129.000 500.000 629.000
2. NON OPERATIF
2.1 PEDIATRI SOSIAL
1 Terapi motivational counseling remaja 191.000 173.000 364.000
2 Terapi perilaku korban kekerasan anak 191.000 173.000 364.000
3 Tindakan imunisasi biasa 176.000 87.000 263.000
4 258.000 173.000 431.000
hemofilia, dll)
5 Uji psikososial remaja HEEADSSS 236.000 202.000 438.000
6 Uji depresi anak CDI 191.000 144.000 335.000
7 Uji gangguan perilaku autisme MCHATR/F 191.000 144.000 335.000
8 Uji gangguan perilaku hiperaktivitas Conners ASQ 191.000 144.000 335.000
9 Uji gangguan psikososial SDQ 191.000 144.000 335.000
10 Uji Kemampuan Bahasa Capute Scale 303.000 288.000 591.000
11 Uji kualitas hidup PedsQL 191.000 144.000 335.000
12 Uji Perkembangan Denver 281.000 230.000 511.000
13 Uji perkembangan khusus BSID III 587.000 575.000 1.162.000
2.2 KARDIOLOGI
1 Ekokardiogragi 470.000 690.000 1.160.000
2 Elektrokardiografi 192.000 115.000 307.000
3 Suntik BPG 255.000 115.000 370.000
1 Desensitasi obat level I (durasi 12 jam) 617.000 575.000 1.192.000
2 Desensitasi obat level II (durasi 24 jam) 870.000 805.000 1.675.000
3 Patch Test Obat* 200.000 155.000 355.000
4 Provokasi histamin 600.000 463.000 1.063.000
5 Provokasi Vaksin 420.000 325.000 745.000
6 Skin Prick Test 540.000 345.000 885.000
7 Tes Mantoux 309.000 240.000 549.000
8 Tes obat oral 383.000 296.000 679.000
9 Tes obat suntik 735.000 567.000 1.302.000
10 Uji provokasi makanan/ obat level I (DURASI 4 JAM) 389.000 460.000 849.000
11 Uji provokasi makanan/ obat level II (durasi 6 jam) 547.000 575.000 1.122.000
12 Vaksinasi 87.000 68.000 155.000
2.5 NEUROLOGI
1 Blink reflex 574.000 245.000 819.000
2 Brainstem evoked auditory potential (BERA) 863.000 245.000 1.108.000
3 EEG bedside 1.303.000 403.000 1.706.000
4 EEG digital rutin 1.303.000 245.000 1.548.000
5 EEG LONG TERM MONITORING 3.471.000 575.000 4.046.000
6 EMG Jarum 557.000 294.000 851.000
7 EMG KHS 246.000 190.000 436.000
8 EMG SPASMOFILI 292.000 245.000 537.000
9 H. Reflex 204.000 121.000 325.000
10 Lumbal pungsi 803.000 460.000 1.263.000
11 Otoacoustic emission (OAE) 321.000 121.000 442.000
12 RNS 343.000 245.000 588.000
13 Single-fiber EMG 518.000 245.000 763.000
14 SSEP 1.058.000 245.000 1.303.000
2.6 NEFROLOGI
1 biopsi ginjal 2.327.000 1.829.000 4.156.000
2 biopsi ginjal tanpa needle 1.797.000 1.829.000 3.626.000
JASA
PELAYANAN
3 Bladder washout 404.000 242.000 646.000
4 CIC (Continuous Intermittent Catheterization) 314.000 207.000 521.000
5 Cook/Surmisil acute peritoneal dilysis cath removal 854.000 276.000 1.130.000
10 Exit site checking 255.000 138.000 393.000
11 ganti tranfer set 809.000 449.000 1.258.000
12 ganti tranfer set tanpa alat 534.000 449.000 983.000
13 hemodialisa 1.163.000 656.000 1.819.000
14 Injeksi eriropoietin 1.055.000 483.000 1.538.000
15 Injeksi eriropoietin tanpa obat 480.000 483.000 963.000
16 Injeksi pre transplantasi 431.000 104.000 535.000
17 Injeksi pre transplantasi tanpa obat 180.000 104.000 284.000
18 Intradialytic parenteral nutrition 515.000 242.000 757.000
19 Intradialytic parenteral nutrition tanpa obat 306.000 242.000 548.000
20 Pemasangan Cook peritoneal dialisis 7.257.000 1.967.000 9.224.000
21 Pemasangan Cook peritoneal dialisis tanpa alat 2.556.000 1.967.000 4.523.000
22 Pemasangan surmisil silicone peritoneal dialisis akut 7.257.000 1.967.000 9.224.000
23 Pemasangan surmisil silicone peritoneal dialisis akut tanpa alat 2.556.000 1.967.000 4.523.000
24 pemasangan temporer hemodialysis catheter 3.189.000 1.518.000 4.707.000
25 pemasangan temporer hemodialysis catheter tanpa alat 1.407.000 1.518.000 2.925.000
26 perawatan CAPD baru 855.000 587.000 1.442.000
27 perawatan CAPD baru tanpa obat 642.000 587.000 1.229.000
28 perawatan CAPD kronik 1.529.000 690.000 2.219.000
29 perawatan CAPD kronik tanpa obat 834.000 690.000 1.524.000
30 peritoneal dialisis akut harian 594.000 276.000 870.000
31 peritoneal dialisis akut harian tanpa obat 362.000 276.000 638.000
32 peritoneal dialisis kronik harian 440.000 173.000 613.000
33 peritoneal dialisis kronik harian tanpa obat 239.000 173.000 412.000
34 Peritoneal permeability check 611.000 311.000 922.000
35 Peritoneal permeability check tanpa obat 376.000 311.000 687.000
36 PET Kt/V 615.000 483.000 1.098.000
37 PET Kt/V tanpa obat 558.000 483.000 1.041.000
38 plasmaferesis 17.556.000 7.970.000 25.526.000
39 Plasmaferesis tanpa alat, tanpa prismasol 6.486.000 7.970.000 14.456.000
40 reposisi cdl 600.000 449.000 1.049.000
41 reposisi kateter peritoneal dialisis akut cook/surmisil 1.695.000 794.000 2.489.000
42 reposisi kateter peritoneal dialisis akut cook/surmisil tanpa obat 1.427.000 794.000 2.221.000
43 Sedasi Sedang Anak 766.000 483.000 1.249.000
44 Sedasi Sedang Anak tanpa obat 520.000 483.000 1.003.000
45 SLED 2.486.000 897.000 3.383.000
46 terapi besi intravena 537.000 311.000 848.000
47 terapi besi intravena tanpa obat 362.000 311.000 673.000
48 terapi obat khusus cyclophosphamide intravena 675.000 345.000 1.020.000
49 terapi obat khusus cyclophosphamide intravena tanpa obat 485.000 345.000 830.000
50 terapi obat khusus IV Ig immunoglobulin intravena 719.000 449.000 1.168.000
51 terapi obat khusus IV Ig immunoglobulin intravena tanpa obat 548.000 449.000 997.000
52 terapi obat khusus metilprednisolon pulse harian 551.000 345.000 896.000
53 terapi obat khusus metilprednisolon pulse harian tanpa obat 438.000 345.000 783.000
54 thrombolytics for dialysis catheter fibrin occlusion dengan heparin 813.000 759.000 1.572.000
55 thrombolytics for hemodialys catheter fibrin occlusion 1.242.000 759.000 2.001.000
56 thrombolytics for hemodialys catheter fibrin occlusion tanpa obat 749.000 759.000 1.508.000
57 thrombolytics for peritoneal dialysis catheter fibrin occlusion 999.000 276.000 1.275.000
58 476.000 276.000 752.000
obat
2.7 NUTRISI DAN METABOLIK
1 Asuhan nutrisi enteral dasar 189.000 115.000 304.000
JASA
PELAYANAN
2 Asuhan nutrisi enteral khusus 471.000 115.000 586.000
3 Asuhan nutrisi parenteral 2.045.000 230.000 2.275.000
4 Terapi sulih enzim 989.000 863.000 1.852.000
2.8 ENDOKTRINOLOGI
1 Desmopresin (DDAVP) test 573.000 230.000 803.000
2 Program inisiasi terapi insulin pada pasien baru DM Tipe-1 671.000 690.000 1.361.000
3 Protokol pemberian asam zoledronat pada Osteogenesis Imperfecta 603.000 345.000 948.000
4 Psikoterapi / psikoedukasi pada DM 287.000 230.000 517.000
5 Tindakan injeksi GnRH analog / Leuprorelin acetate (Tapros®) 1.047.000 173.000 1.220.000
6 Tindakan injeksi testosteron ester (Sustanon®) 288.000 173.000 461.000
7 Tindakan uji stimulasi GH 852.000 863.000 1.715.000
8 Tindakan uji stimulasi HCG 459.000 173.000 632.000
9 Uji haus (water deprivation test) - 15 jam 2.369.000 518.000 2.887.000
11 Uji stimulasi hormon pertumbuhan (clonidine test) 813.000 633.000 1.446.000
2.9 RESPIROLOGI
1 Argon Plasma Coagulation-anak 11.435.000 8.792.000 20.227.000
2 Bronkoskopi 1.814.000 1.380.000 3.194.000
3 Bronkoskopi dan biopsi 13.097.000 1.380.000 14.477.000
4 Bronkoskopi dan brush 3.005.000 1.380.000 4.385.000
5 Bronkoskopi dan transbronchial nodul aspiration 4.328.000 1.380.000 5.708.000
6 Cryotherapy-anak 5.469.000 5.814.000 11.283.000
7 Ekstraksi benda asing-anak 19.985.000 15.410.000 35.395.000
8 Induksi sputum-anak 270.000 115.000 385.000
9 Pemasangan mini-WSD certofix 1.598.000 863.000 2.461.000
10 Poligrafi 855.000 920.000 1.775.000
11 Polisomnografi 1.250.000 920.000 2.170.000
12 Pungsi cairan pleura 711.000 575.000 1.286.000
13 Rinofaringolaringoskopi 726.000 575.000 1.301.000
14 Uji fungsi paru / spirometri anak 969.000 173.000 1.142.000
15 Uji fungsi paru pre- dan post- bronkodilator anak 1.011.000 288.000 1.299.000
16 Uji keringat atau sweat test 2.745.000 288.000 3.033.000
2.10 HEMATOLOGI
1 Bone marrow puncture anak **** 1.116.000 863.000 1.979.000
2 201.000 115.000 316.000
obat ***
3 Injeksi Obat Khusus GCSF ** 194.000 115.000 309.000
4 Kemoterapi drip 24 jam (durasi 24 jam) dan hidrasi 24 jam * 1.633.000 230.000 1.863.000
5 Kemoterapi Intratekal **** 710.000 575.000 1.285.000
6 Kemoterapi IV bolus * 233.000 144.000 377.000
7 Kemoterapi IV drip 12 jam (durasi 12 jam) dan hidrasi 6 jam * 681.000 202.000 883.000
8 Kemoterapi IV drip 4 jam (durasi 4 jam) * 338.000 173.000 511.000
9 Kemoterapi SC Leunase * 194.000 115.000 309.000
10 Leukoferesis anak (durasi 6 jam) 1.866.000 2.013.000 3.879.000
11 497.000 173.000 670.000
12 Plasmaferesis anak (durasi 6 jam) 1.866.000 2.013.000 3.879.000
13 Sedasi sedang anak (untuk kemoterapi IT dan BMP) **** 576.000 477.000 1.053.000
14 561.000 115.000 676.000
3. RADIOLOGI
1 Abdomen 1 posisi 245.000 97.000 342.000
2 Abdomen 2 Posisi 354.000 200.000 554.000
3 Abdomen 3 Posisi 542.000 371.000 913.000
4 Ankle 2 posisi bilateral 377.000 275.000 652.000
5 Ankle 2 posisi Kanan ATAU kiri 242.000 141.000 383.000
6 Ankle 3 posisi bilateral 459.000 314.000 773.000
7 Ankle 3 posisi Kanan ATAU kiri 278.000 190.000 468.000
8 Antebrachii 2 posisi bilateral 432.000 280.000 712.000
JASA
PELAYANAN
9 AntebrachiI 2 posisi Kanan ATAU kiri 264.000 133.000 397.000
10 Apendicogram 889.000 686.000 1.575.000
11 APG 727.000 561.000 1.288.000
12 Baby Gram 245.000 105.000 350.000
13 BNO IVP 793.000 612.000 1.405.000
14 Bone Age 224.000 90.000 314.000
15 Bone Survey 1.308.000 954.000 2.262.000
16 Clavicula (kanan DAN kiri) 242.000 122.000 364.000
17 Colon in loop 986.000 761.000 1.747.000
18 Cruris 2 posisi bilateral 432.000 398.000 830.000
19 Cruris 2 posisi Kanan ATAU kiri 264.000 164.000 428.000
20 Cubiti 2 posisi bilateral 377.000 275.000 652.000
21 Cubiti 2 posisi Kanan ATAU kiri 309.000 142.000 451.000
22 Esofagogram 632.000 488.000 1.120.000
23 Facial bones caldwell /towne dan lateral sinar horisontal 282.000 172.000 454.000
24 Femur 2 posisi bilateral 432.000 398.000 830.000
25 Femur 2 posisi Kanan ATAU kiri 264.000 164.000 428.000
26 Fistulografi 847.000 654.000 1.501.000
27 Follow Trough 958.000 739.000 1.697.000
28 Genitografi 829.000 640.000 1.469.000
29 Genu 2 posisi bilateral 377.000 330.000 707.000
30 Genu 2 posisi Kanan ATAU kiri 242.000 153.000 395.000
31 Genu 3 posisi bilateral 459.000 468.000 927.000
32 Genu 3 posisi Kanan ATAU kiri 321.000 271.000 592.000
33 Humerus 2 posisi bilateral 344.000 228.000 572.000
34 Humerus 2 posisi Kanan ATAU kiri 282.000 135.000 417.000
35 Kepala 2 posisi 264.000 164.000 428.000
36 Kontras enema 871.000 672.000 1.543.000
37 Kontras meal / upper GI series 871.000 672.000 1.543.000
38 Leher Soft Tissue 2 posisi 309.000 166.000 475.000
39 Lopografi 858.000 662.000 1.520.000
40 Mandibula 377.000 229.000 606.000
41 Manus 2 posisi bilateral 377.000 248.000 625.000
42 Mastoid 242.000 172.000 414.000
43 MCU (Micturating Cysto Urethrography) 805.000 620.000 1.425.000
44 Nasal 253.000 126.000 379.000
45 Orbita 253.000 126.000 379.000
46 Pedis 2 posisi bilateral 377.000 294.000 671.000
47 Pedis 2 posisi Kanan ATAU kiri 242.000 122.000 364.000
48 Pelvis 1 posisi 224.000 98.000 322.000
49 Pelvis 2 posisi 264.000 169.000 433.000
50 Pelvis 3 posisi 360.000 294.000 654.000
51 Pemeriksaan POUCH 697.000 538.000 1.235.000
52 Pergelangan tangan / Wrist Joint (2 posisi) bilateral 377.000 275.000 652.000
53 Pergelangan tangan / Wrist Joint (2 posisi) kanan ATAU kiri 242.000 141.000 383.000
54 RPG 727.000 561.000 1.288.000
55 Sacrum 2 posisi 309.000 184.000 493.000
56 Scanogram 450.000 518.000 968.000
57 Scapula 2 posisi bilateral 360.000 266.000 626.000
58 Scapula 2 posisi kanan ATAU kiri 242.000 122.000 364.000
59 Scoliosis Program 870.000 543.000 1.413.000
60 Shoulder 2 posisi bilateral 278.000 264.000 542.000
61 Shoulder 2 posisi Kanan ATAU kiri 228.000 122.000 350.000
62 Shoulder 3 posisi bilateral 432.000 353.000 785.000
63 Shoulder 3 posisi kanan ATAU kiri 321.000 217.000 538.000
64 Sinus Paranasal (waters dan lateral) 242.000 153.000 395.000
65 Spot Flouroscopic 450.000 348.000 798.000
66 Thoraco Abdominal 1 posisi 410.000 160.000 570.000
67 Thoraco Abdominal 2 posisi 354.000 212.000 566.000
JASA
PELAYANAN
68 Thorax 1 posisi 245.000 86.000 331.000
69 Thorax 2 posisi 354.000 188.000 542.000
70 TMJ 242.000 172.000 414.000
71 Urethrocystogram 698.000 539.000 1.237.000
72 USG Abdomen atas 536.000 413.000 949.000
73 USG Abdomen atas dan Doppler 1.026.000 792.000 1.818.000
74 USG abdomen bawah / ginjal dan doppler 1.027.000 792.000 1.819.000
75 USG abdomen bawah / Ginjal dan saluran kemih 526.000 406.000 932.000
76 USG Abdomen lengkap 950.000 732.000 1.682.000
77 USG abdomen lengkap dan doppler 1.790.000 1.380.000 3.170.000
78 USG colli/leher 454.000 351.000 805.000
79 USG diafragma 311.000 241.000 552.000
80 USG doppler vaskuler abdomen atas 546.000 421.000 967.000
81 USG Doppler vaskuler abdomen bawah / ginjal 536.000 413.000 949.000
82 USG doppler vaskuler abdomen lengkap 1.026.000 792.000 1.818.000
83 USG Doppler vaskuler Carotis 526.000 406.000 932.000
84 USG doppler vaskuler ekstremitas atas kanan ATAU kiri 530.000 409.000 939.000
85 USG doppler vaskuler ekstremitas atas kanan dan kiri 1.026.000 792.000 1.818.000
86 USG doppler vaskuler ekstremitas bawah kanan ATAU kiri 530.000 409.000 939.000
87 USG doppler vaskuler ekstremitas bawah kanan dan kiri 1.026.000 792.000 1.818.000
88 USG doppler vaskuler kepala 536.000 413.000 949.000
89 USG doppler vaskuler superfisial 530.000 409.000 939.000
90 USG Guidance biopsi atau pengeluaran cairan 306.000 236.000 542.000
91 USG Hepatobilier 2 fase 986.000 761.000 1.747.000
92 USG hip 526.000 406.000 932.000
93 USG Kepala 454.000 351.000 805.000
94 USG Kepala dan Doppler 947.000 730.000 1.677.000
95 USG Mamae/ payudara 454.000 351.000 805.000
96 USG muskuloskeletal bilateral 1.246.000 961.000 2.207.000
97 USG muskuloskeletal ipsi lateral 669.000 516.000 1.185.000
98 USG Pelvis wanita - genitalia interna 526.000 406.000 932.000
99 USG spinal / vertebra 454.000 351.000 805.000
100 USG superfisial 454.000 351.000 805.000
101 USG superfisial dan doppler 950.000 733.000 1.683.000
102 USG Testis 454.000 351.000 805.000
103 USG Tiroid 455.000 351.000 806.000
104 USG toraks / paru 454.000 351.000 805.000
105 Vertebra Cervical 2 posisi 309.000 184.000 493.000
106 Vertebra Lumbal 2 posisi 277.000 214.000 491.000
107 Vertebra Lumbalsacral 2 posisi 307.000 237.000 544.000
108 Vertebra Thoracal 2 posisi 282.000 209.000 491.000
109 Vertebra Thoracal Lumbal 2 posisi 354.000 249.000 603.000
KINTANI HERITAGE
JASA
PELAYANAN
1. KONSULTASI
1 Konsultasi Dokter 104.000 150.000 254.000
2. NON OPERATIF
1 Analisa Sperma 540.000 415.000 955.000
2 Buka pasang susuk 266.000 183.000 449.000
3 Ekstirpasi Polip 258.000 199.000 457.000
4 Hidrotubasi 350.000 267.000 617.000
5 Hifosi 2.129.000 1.633.000 3.762.000
6 Histereskopi Office 1.400.000 1.074.000 2.474.000
7 Irigasi Vagina 184.000 142.000 326.000
8 IVA 140.000 108.000 248.000
9 Kolposkopi 723.000 555.000 1.278.000
10 Kolposkopi Cryotherapy 339.000 260.000 599.000
11 Kolposkopi LLETZ 410.000 314.000 724.000
12 Lepas pasang IUD 248.000 190.000 438.000
13 Pasang susuk 206.000 132.000 338.000
14 Pemeriksaan Dalam 137.000 106.000 243.000
15 Perineumetri (Perkali datang) 135.000 82.000 217.000
16 Sistoskopi+ Biopsi 963.000 739.000 1.702.000
17 USG GINEKOLOGI 316.000 206.000 522.000
18 USG Onkologi 469.000 362.000 831.000
19 USG Uroginekologi Patologis 388.000 298.000 686.000
3. OPERATIF
1 Histereskopi diagnostik 1.411.000 1.083.000 2.494.000
2 Histereskopi operatif 2.831.000 2.172.000 5.003.000
3 Histeroskopi Biopsi Uterus 2.050.000 829.000 2.879.000
4 IBS Shaver 1.649.000 1.264.000 2.913.000
5 Insisi/Eksisi 2.880.000 1.803.000 4.683.000
6 Laparascopi Ouklusi Tuba Anestesi Lokal ( LOTAL ) 2.146.000 1.377.000 3.523.000
7 LAPARASKOPI 3.898.000 1.781.000 5.679.000
8 Mini Laparatomi 2.885.000 1.803.000 4.688.000
PATOLOGI KLINIK NON REGULER
JASA
PELAYANAN
KIMIA KLINIK
1 ALBUMIN (ALB) 67.000 14.000 81.000
2 AMILASE DARAH 204.000 36.000 240.000
3 AMILASE URIN 204.000 36.000 240.000
4 AMMONIAK 360.000 83.000 443.000
5 AMPHETAMIN (SABU-SABU) 97.000 25.000 122.000
6 ANALISA GAS DARAH 265.000 63.000 328.000
7 ASAM URAT DARAH 60.000 14.000 74.000
8 ASAM URAT URIN 60.000 14.000 74.000
9 BENZODIAZEPIN 97.000 25.000 122.000
10 BERSIHAN KREATININ 89.000 36.000 125.000
11 BETA HIDROKSI BUTIRAT 67.000 17.000 84.000
12 BILIRUBIN TOTAL + DIREK+INDIREK 99.000 28.000 127.000
13 C0CAIN 97.000 25.000 122.000
14 CALSIUM DARAH 65.000 17.000 82.000
15 CALSIUM ION 231.000 76.000 307.000
16 CALSIUM URIN 65.000 17.000 82.000
17 CHOLESTEROL HDL 91.000 19.000 110.000
18 CHOLESTEROL LDL 122.000 22.000 144.000
19 CHOLESTEROL TOTAL 68.000 19.000 87.000
20 CK 147.000 38.000 185.000
21 CKMB 166.000 43.000 209.000
22 ELEKTROFORESIS PROTEIN 231.000 79.000 310.000
23 ELEKTROLIT DARAH (Na, K, Cl) 171.000 36.000 207.000
24 ELEKTROLIT URIN (Na, K, Cl) 171.000 36.000 207.000
25 FE(SI) + TIBC + UIBC 231.000 158.000 389.000
26 FOLAT 767.000 89.000 856.000
27 FOSFAT INORGANIK DARAH 78.000 19.000 97.000
28 FOSFAT INORGANIK URIN 78.000 19.000 97.000
29 FOSFATASE ALKALI 69.000 25.000 94.000
30 FOSFATASE ASAM 483.000 63.000 546.000
31 GAMMA GT 78.000 19.000 97.000
32 GLIKO HB (HBA1C) 231.000 45.000 276.000
33 GLUKOSA 2 JAM PP 52.000 12.000 64.000
34 GLUKOSA PUASA 52.000 12.000 64.000
35 GLUKOSA RAPID (POCT) 52.000 12.000 64.000
36 GLUKOSA SEWAKTU 52.000 12.000 64.000
37 GLUKOSA URIN 52.000 12.000 64.000
38 GTT (3X : PUASA, 1 JAM, 2 JAM) 110.000 30.000 140.000
39 Hs TROPONIN I 534.000 150.000 684.000
40 KOLINESTERASE 84.000 28.000 112.000
41 KREATININ DARAH 60.000 12.000 72.000
42 KREATININ URIN 60.000 12.000 72.000
43 KURVA HARIAN (3X) 110.000 30.000 140.000
44 LACTAT 97.000 25.000 122.000
45 LDH 120.000 33.000 153.000
46 LIPASE DARAH 183.000 49.000 232.000
47 LIPASE URIN 183.000 49.000 232.000
48 MAGNESIUM 79.000 19.000 98.000
49 MARIJUANA (GANJA) 97.000 25.000 122.000
50 METAMPHETAMIN (ECTASY) 97.000 25.000 122.000
51 MIKROALBUMINURIA 160.000 28.000 188.000
52 MORPHINE (HEROIN, PUTAW,OPIAT) 97.000 25.000 122.000
JASA
PELAYANAN
53 NITROGEN URIN 65.000 17.000 82.000
54 NT- PROBNP 546.000 194.000 740.000
55 OSMOLARITAS PLASMA 74.000 36.000 110.000
56 OSMOLARITAS URIN 74.000 36.000 110.000
57 PROTEIN KWANTITATIF URIN 65.000 17.000 82.000
58 PROTEIN TOTAL 58.000 17.000 75.000
59 SGOT (AST) 63.000 12.000 75.000
60 SGPT (ALT) 63.000 12.000 75.000
61 TRIGLISERIDA 68.000 19.000 87.000
62 TROPONIN T 362.000 120.000 482.000
63 TSH NEONATUS 78.000 45.000 123.000
64 UREA CLEARANCE 116.000 30.000 146.000
65 UREUM DARAH 72.000 14.000 86.000
66 UREUM URIN 72.000 14.000 86.000
IMUNOLOGI
1 25-OH VITAMIN D TOTAL 441.000 134.000 575.000
2 AFP 229.000 69.000 298.000
3 ANA 620.000 113.000 733.000
4 ANTI DENGUE IGG + IGM 294.000 79.000 373.000
5 ANTI DS-DNA 372.000 150.000 522.000
6 ANTI HAV IGM 366.000 65.000 431.000
7 ANTI HBC IGM 366.000 65.000 431.000
8 ANTI HBC TOTAL 219.000 38.000 257.000
9 ANTI HBE 433.000 112.000 545.000
10 ANTI HBs 147.000 36.000 183.000
11 ANTI HCV Ig M 996.000 103.000 1.099.000
12 ANTI HCV TOTAL 276.000 91.000 367.000
13 ANTI HELICOBACTER PYLORI IGG 225.000 57.000 282.000
14 ANTI HELICOBACTER PYLORI IGM 173.000 25.000 198.000
15 ANTI HIV KONFIRMASI (WB) 1.189.000 309.000 1.498.000
16 ANTI HIV PENYARING 378.000 121.000 499.000
17 ANTI MULLERIAN HORMON 658.000 105.000 763.000
18 ANTI -TB IG M 406.000 43.000 449.000
19 ANTI -TB TOTAL 150.000 41.000 191.000
20 ASTO KUANTIATIF 150.000 38.000 188.000
21 BETA 2 GLIKOPROTEIN IGG 378.000 76.000 454.000
22 BETA 2 GLIKOPROTEIN IGM 378.000 76.000 454.000
23 BETA HCG (KUANTITATIF) 406.000 43.000 449.000
24 C3 305.000 69.000 374.000
25 C4 305.000 69.000 374.000
26 CA 125 414.000 107.000 521.000
27 CA 15-3 511.000 132.000 643.000
28 CA 19-9 418.000 103.000 521.000
29 CD 14 406.000 196.000 602.000
30 CD 19 406.000 196.000 602.000
31 CD 20 252.000 36.000 288.000
32 CD 3 + CD 4 + (T HELPER LYMPHOCYTE) 473.000 209.000 682.000
33 CD 4 252.000 30.000 282.000
34 CD 56 406.000 196.000 602.000
35 CEA 267.000 103.000 370.000
36 CHLAMYDIA TR IgG 479.000 189.000 668.000
37 CHLAMYDIA TR IgM 479.000 189.000 668.000
38 CRP (KUANTITATIF) 164.000 38.000 202.000
39 CRP HS 399.000 112.000 511.000
40 ESTRADIOL 362.000 41.000 403.000
41 FERRITIN 206.000 54.000 260.000
42 FREE PSA 645.000 142.000 787.000
43 FREE T3 196.000 52.000 248.000
44 FREE T4 196.000 52.000 248.000
JASA
PELAYANAN
45 FREE TESTOTERON 311.000 33.000 344.000
46 FSH 307.000 81.000 388.000
47 FTI (FREE TYHROXINE INDEX ) 416.000 134.000 550.000
48 H1N1 (RAPID SWAB) 555.000 89.000 644.000
49 HBeAg 483.000 49.000 532.000
50 HBsAg 137.000 33.000 170.000
51 HBV DNA 1.890.000 300.000 2.190.000
52 HCV RNA 2.625.000 378.000 3.003.000
53 HUMAN IL-6 574.000 211.000 785.000
54 ICT TB 158.000 30.000 188.000
55 IGA. 299.000 136.000 435.000
56 IGE 223.000 63.000 286.000
57 IGG 223.000 61.000 284.000
58 IGG ANTI CARDIOLIPIN 227.000 76.000 303.000
59 IGG ANTI CMV 227.000 65.000 292.000
60 IGG ANTI HSV 1 223.000 138.000 361.000
61 IGG ANTI HSV II 223.000 138.000 361.000
62 IGG ANTI RUBELLA 210.000 43.000 253.000
63 IGG ANTI TOXOPLASMA 213.000 69.000 282.000
64 IGM ANTI CARDIOLIPIN 307.000 81.000 388.000
65 IGM ANTI CMV 231.000 76.000 307.000
66 IGM ANTI HSV I 223.000 138.000 361.000
67 IGM ANTI HSV II 223.000 138.000 361.000
68 IGM ANTI RUBELLA 259.000 54.000 313.000
69 IGM ANTI TOXOPLASMA 213.000 69.000 282.000
70 IGM. 307.000 138.000 445.000
71 IMUNOFIKSASI 744.000 229.000 973.000
72 IMUNOFIKSASI LIGHT CHAIN 744.000 220.000 964.000
73 INHIBIN B ELISA 712.000 152.000 864.000
74 INSULIN 162.000 54.000 216.000
75 INTERFERRON GAMMA RELEASING ASSAY(IGRA) 1.147.000 128.000 1.275.000
76 LEUKIMIA PHENOTYPING 1.264.000 203.000 1.467.000
77 LH 318.000 83.000 401.000
78 LYMPHOCYTE CD 45 406.000 196.000 602.000
79 LYMPHOSIT SUBSET 628.000 69.000 697.000
80 MYCOPLASMA IgG 479.000 189.000 668.000
81 MYCOPLASMA IgM 479.000 189.000 668.000
82 NS-1 ANTIGEN 462.000 170.000 632.000
83 PAKET CD 34 (TOTAL CD 34 + VIABILITY CD 34 987.000 359.000 1.346.000
84 PAKET CD 4 + CD 8 473.000 121.000 594.000
85 PAKET STEM CELL (CD33, CD 34, DAN CD 133) 1.183.000 521.000 1.704.000
86 PCR HIV (VIRAL LOOD) 1.260.000 279.000 1.539.000
87 PCR HIV (VIRAL LOOD) DISCOUNT 50% 456.000 114.000 570.000
88 PCR TB 606.000 142.000 748.000
89 PRESEPSIN 910.000 116.000 1.026.000
90 PROCALCITONIN 696.000 136.000 832.000
91 PROGESTERON 362.000 30.000 392.000
92 PROLAKTIN 318.000 83.000 401.000
93 PSA TOTAL 320.000 83.000 403.000
94 RF. 158.000 20.000 178.000
95 SALMONELLA IG M 231.000 73.000 304.000
96 SHBG 227.000 65.000 292.000
97 SIKLOSPORIN 1.650.000 254.000 1.904.000
98 T3 177.000 69.000 246.000
99 T3 UPTAKE 240.000 65.000 305.000
100 T4 177.000 69.000 246.000
101 TACROLIMUS 1.073.000 254.000 1.327.000
102 TES KEHAMILAN 69.000 12.000 81.000
103 TPHA 120.000 54.000 174.000
JASA
PELAYANAN
104 TSH 177.000 69.000 246.000
105 TYROGLOBULIN 670.000 73.000 743.000
106 UREA BREATH TEST / UBT 1.560.000 128.000 1.688.000
107 VDRL 67.000 28.000 95.000
108 WIDAL 103.000 33.000 136.000
BAKTERIOLOGI
1 BIAKAN +RES SS DARAH 370.000 73.000 443.000
2 BIAKAN +RES SS SPUTUM 370.000 73.000 443.000
3 BIAKAN +RES SS TINJA 540.000 100.000 640.000
4 BIAKAN +RES SS URIN 540.000 100.000 640.000
5 BIAKAN AEROB LAIN-LAIN 360.000 100.000 460.000
6 BIAKAN AEROB PUS 360.000 100.000 460.000
7 BIAKAN AEROB SPUTUM 360.000 100.000 460.000
8 BIAKAN AEROB URINE 360.000 100.000 460.000
9 BIAKAN ANAEROB LAIN-LAIN 630.000 150.000 780.000
10 BIAKAN ANAEROB PUS 630.000 150.000 780.000
11 BIAKAN ANAEROB SWAB 664.000 59.000 723.000
12 BIAKAN ANAEROB URINE 664.000 59.000 723.000
13 BIAKAN BTA LAIN LAIN 750.000 130.000 880.000
14 BIAKAN BTA SPUTUM 750.000 130.000 880.000
15 BIAKAN BTA TINJA 750.000 130.000 880.000
16 BIAKAN BTA URINE 750.000 130.000 880.000
17 BIAKAN DARAH SITO (VITEK) 693.000 61.000 754.000
18 BIAKAN SS+RES SWAB 378.000 76.000 454.000
19 BIAKAN THAYER MARTHIN 200.000 117.000 317.000
20 BIAKAN+RES AEROB LKP DARAH 650.000 100.000 750.000
21 BIAKAN+RES AEROB LKP LAIN LAIN 650.000 100.000 750.000
22 BIAKAN+RES AEROB LKP PUS 650.000 100.000 750.000
23 BIAKAN+RES AEROB LKP SWAB 650.000 100.000 750.000
24 BIAKAN+RES AEROB LKP TINJA 650.000 100.000 750.000
25 BIAKAN+RES AEROB LKP URIN 650.000 100.000 750.000
26 BIAKAN+RES AEROB SPUTUM 650.000 100.000 750.000
27 BIAKAN+RES AEROB TINJA 397.000 76.000 473.000
28 BIAKAN+RES ANAEROB STD DARAH 630.000 163.000 793.000
29 BIAKAN+RES ANAEROB STD LAIN-LAIN 630.000 163.000 793.000
30 BIAKAN+RES ANAEROB STD PUS 630.000 163.000 793.000
31 BIAKAN+RES ANAEROB STD SPUTUM 763.000 163.000 926.000
32 BIAKAN+RES ANAEROB STD SWAB 763.000 163.000 926.000
33 BIAKAN+RES ANAEROB STD URINE 763.000 163.000 926.000
34 MIC MEROPENEM 231.000 81.000 312.000
35 PEWARNAAN JAMUR 50.000 86.000 136.000
36 PULASAN GRAM LAIN-LAIN 66.000 12.000 78.000
37 PULASAN GRAM PUS 66.000 12.000 78.000
38 PULASAN GRAM SPUTUM 66.000 12.000 78.000
39 PULASAN GRAM SWAB 66.000 12.000 78.000
40 PULASAN TAHAN ASAM DARAH 66.000 12.000 78.000
41 PULASAN TAHAN ASAM LAIN-LAIN 66.000 12.000 78.000
42 PULASAN TAHAN ASAM PUS 66.000 12.000 78.000
43 PULASAN TAHAN ASAM SPUTUM 66.000 12.000 78.000
44 PULASAN TAHAN ASAM SWAB 66.000 12.000 78.000
45 PULASAN TAHAN ASAM TINJA 66.000 12.000 78.000
46 PULASAN TAHAN ASAM URINE 66.000 12.000 78.000
47 TB ANTIGEN 286.000 232.000 518.000
HEMATOLOGI
1 AGREGAGSI TROMBOSIT (ADP) 225.000 86.000 311.000
2 AGREGASI TROMBOSIT (RISTOCETIN) 349.000 86.000 435.000
3 ANALISA CAIRAN ASITES 349.000 86.000 435.000
4 ANALISA CAIRAN DIALISIS EMPEDU 349.000 86.000 435.000
5 ANALISA CAIRAN DIALISIS PERICARD 349.000 86.000 435.000
JASA
PELAYANAN
6 ANALISA CAIRAN DIALISIS PERITO 349.000 86.000 435.000
7 ANALISA CAIRAN OTAK 349.000 86.000 435.000
8 ANALISA CAIRAN PLEURA 349.000 86.000 435.000
9 ANALISA CAIRAN SENDI 349.000 86.000 435.000
10 ANALISA CAIRAN TUBUH LAINNYA 349.000 86.000 435.000
11 ANALISA FESES KHUSUS 189.000 387.000 576.000
12 ANALISA HB 378.000 121.000 499.000
13 APT TEST 74.000 30.000 104.000
14 APTT 105.000 52.000 157.000
15 ASSAY FAKTOR IX 609.000 145.000 754.000
16 ASSAY FAKTOR VIII 609.000 145.000 754.000
17 AT-III 515.000 156.000 671.000
18 CLOSTRIDIUM DEFFICILE 328.000 83.000 411.000
19 DARAH SAMAR AB MONOKLONAL 89.000 25.000 114.000
20 D-DIMER 288.000 57.000 345.000
21 ECLT (EUGLOBULIN CLOT LYSIS TIME) 200.000 57.000 257.000
22 ESBACH 65.000 14.000 79.000
23 FAKTOR VON WILLEBRAND 473.000 209.000 682.000
24 FIBRINOGEN 110.000 30.000 140.000
25 FILARIA 59.000 14.000 73.000
26 FREE LIGHT CHAIN KAPPA 633.000 126.000 759.000
27 FREE LIGHT CHAIN LAMDA 633.000 126.000 759.000
28 G6PD 221.000 107.000 328.000
29 GAMBARAN SUMSUM TULANG/BMP BAGIAN ANAK 189.000 233.000 422.000
30 GOLONGAN DARAH 59.000 25.000 84.000
31 HEMATOLOGI LENGKAP TANPA LED 101.000 30.000 131.000
32 HEMATOLOGI LENGKAP TANPA LED + I/T RATIO 101.000 150.000 251.000
33 HEMATOLOGI RUTIN 89.000 25.000 114.000
34 HEMOGLOBIN URIN 84.000 13.000 97.000
35 HEMOSIDERIN 82.000 30.000 112.000
36 INHIBITOR F VIII 630.000 206.000 836.000
37 JUMLAH EOSINOFIL 89.000 25.000 114.000
38 LAJU ENDAP DARAH 49.000 14.000 63.000
39 LE REAKSI 66.000 14.000 80.000
40 LUPUS ANTIKOAGULAN 651.000 86.000 737.000
41 MALARIA (ICT+Sediaan) PAKET 175.000 54.000 229.000
42 MASA PEMBEKUAN LEE&WHITE 47.000 17.000 64.000
43 MASA PENDARAHAN IVY 51.000 41.000 92.000
44 MIOGLOBIN URIN 52.000 14.000 66.000
45 MIX APTT 210.000 50.000 260.000
46 OBERMEYER / INDIKAN URIN 51.000 28.000 79.000
47 OVAL FAT BODIES 74.000 19.000 93.000
PAKET HEMATOLOGI ONKOLOGI (HEMA LENGKAP TANPA
48 137.000 72.000 209.000
LED + RET-HE + RETICULOSIT + IPF)
PAKET HEMATOLOGI ONKOLOGI + GAMBARAN DARAH
49 221.000 270.000 491.000
TEPI
50 PAKET HEMATOLOGI ONKOLOGI + GAMBARAN SUMSUM TULANG 189.000 220.000 409.000
51 PENYARING F XIII 452.000 54.000 506.000
52 PERCOBAAN PEMBENDUNGAN 50.000 25.000 75.000
53 PROTEIN BENCE JONES (TSA 12%) 67.000 22.000 89.000
54 PROTEIN C 810.000 150.000 960.000
55 PROTEIN S 810.000 150.000 960.000
56 PT + INR 84.000 25.000 109.000
57 PT. 84.000 25.000 109.000
58 RESISTENSI OSMOTIK 80.000 25.000 105.000
59 RETIKULOSIT 101.000 28.000 129.000
60 SEKRET HIDUNG 61.000 12.000 73.000
61 SEL LE 84.000 25.000 109.000
62 SUGAR WATER TEST + HAM TES 311.000 110.000 421.000
JASA
PELAYANAN
63 TES FUNGSI TROMBOSIT ASPIRIN 1.395.000 225.000 1.620.000
64 TES FUNGSI TROMBOSIT P2Y12 1.395.000 225.000 1.620.000
65 THROMBOTES 250.000 28.000 278.000
66 TINJA 77.000 19.000 96.000
67 TSH NEONATUS KEMENKES 59.000 6.000 65.000
68 TT (MASA TROMBIN ) 114.000 30.000 144.000
69 TT SERIAL 349.000 38.000 387.000
70 TZANCK CELL 153.000 10.000 163.000
71 URIN LENGKAP 65.000 17.000 82.000
72 VISKOSITAS PLASMA DAN DARAH (PAKET) 196.000 52.000 248.000
PATOLOGI ANATOMI NON REGULER
No NAMA KEGIATAN JASA SARANA JASA PELAYANAN TARIF

1 Pemeriksaan Biopsi Prostat Robotic 2,050,000 1,800,000 3,850,000
2 Pemeriksaan EBER-ISH 2,455,000 1,935,000 4,390,000
3 Pemeriksaan HER2-CISH 2,553,000 1,979,000 4,532,000
4 Pemeriksaan Histokimia Non-Perak 276,000 225,000 501,000
5 Pemeriksaan Histokimia Perak 322,000 243,000 565,000
6 Pemeriksaan Histopatologi Biopsi Esofagus/Gaster/Colon/Kulit 1,413,000 1,127,000 2,540,000
7 Pemeriksaan Histopatologi Biopsi Khusus Ginjal 2,359,000 1,827,000 4,186,000
8 Pemeriksaan Histopatologi Biopsi khusus hati/sumsum tulang 1,783,000 1,370,000 3,153,000
9 Pemeriksaan Histopatologi Jaringan Besar 3,040,000 2,014,000 5,054,000
10 Pemeriksaan Histopatologi Jaringan Kecil 929,000 644,000 1,573,000
11 Pemeriksaan Histopatologi Jaringan Khusus 5,444,000 2,014,000 7,458,000
12 Pemeriksaan Histopatologi Jaringan Sedang 2,004,000 1,209,000 3,213,000
13 Pemeriksaan Imunofluoresensi (IF) 1,580,000 1,127,000 2,707,000
Pemeriksaan Imunohistokimia Paket IHK diagnostik (Limfoma, kasus
14 3,299,000 2,014,000 5,313,000
sulit, GIST)
Pemeriksaan Imunohistokimia Paket prognostik payudara (ER, PR,
15 1,564,000 1,203,000 2,767,000
HER2, Topo & Ki67) / PDL-1
16 Pemeriksaan Imunohistokimia Per Antibody 1,113,000 805,000 1,918,000
17 Pemeriksaan Konsul Blok/Slide 478,000 518,000 996,000
18 Pemeriksaan Sitologi Aspirasi dengan ROSE 1,800,000 1,288,000 3,088,000
19 Pemeriksaan Sitologi aspirasi jarum halus 1,231,000 805,000 2,036,000
20 Pemeriksaan Sitologi Aspirasi kiriman/Sikatan 1,183,000 964,000 2,147,000
21 Pemeriksaan Sitologi Bilasan/Cairan Tubuh 704,000 404,000 1,108,000
22 Pemeriksaan Sitologi Papsmear Konvensional 208,000 161,000 369,000
23 Pemeriksaan Sitologi Papsmear LBC (Liquid Base Cytology) 462,000 404,000 866,000
24 Pemeriksaan Sitologi Sputum 448,000 322,000 770,000
25 Tindakan potong beku batas sayatan 2,049,000 1,589,000 3,638,000
26 Tindakan potong beku diagnostik 626,000 547,000 1,173,000
27 Tindakan potong beku Mohs Surgery 2,784,000 2,014,000 4,798,000
PKG MADYA ADITYAWARMAN
JASA
PELAYANAN
1. KONSULTASI
1 Konsultasi Dokter 104.000 150.000 254.000
2. NON OPERATIF
1 Ablatio 515.000 396.000 911.000
2 AKTIVATOR 702.000 539.000 1.241.000
3 ALAT CEKAT CERAMIC RA/ RB SAJA 6.063.000 4.648.000 10.711.000
4 ALAT CEKAT CERAMIK RA & RB 11.000.000 8.435.000 19.435.000
5 Alat Cekat Metal RA dan RB 5.931.000 4.547.000 10.478.000
6 Alat Cekat Metal RA dan RB komplek 6.549.000 5.022.000 11.571.000
7 Alat Cekat Metal RA/ RB saja 3.173.000 2.361.000 5.534.000
8 Alveolektomi Per Regio 576.000 318.000 894.000
9 ANALISA 167.000 129.000 296.000
10 Apeksreseksi 458.000 291.000 749.000
11 Band Gigi Fraktur 238.000 183.000 421.000
12 Bongkar Crown/pin per Unit 489.000 376.000 865.000
13 Bongkar Prothesa/ Unit 657.000 504.000 1.161.000
14 Buka Fiksasi /Archbar 262.000 201.000 463.000
15 Buka Jahitan 124.000 90.000 214.000
16 Cetak Alginate 141.000 109.000 250.000
17 Cetak Double Impression 224.000 172.000 396.000
18 CETAK ORTHO + MODEL KERJA 141.000 109.000 250.000
19 CETAK ORTHO DOUBLE IMPRESSION+ MODEL KERJA 348.000 138.000 486.000
20 CHIN CUP 225.000 173.000 398.000
21 Composite Besar 384.000 295.000 679.000
22 Composite Kecil 280.000 214.000 494.000
23 CRIMPABLE HOOK 183.000 138.000 321.000
24 Debonding pergigi 329.000 182.000 511.000
25 Dental Implant 6.222.000 4.772.000 10.994.000
26 Eksisi Mucocele 602.000 461.000 1.063.000
27 Eksisi Tumor Jinak 951.000 729.000 1.680.000
28 ELIMINASI TRAUMA LOKAL (TINDAKAN BARU) 450.000 322.000 772.000
29 Enukleasi Kista 694.000 532.000 1.226.000
30 FACEBOW TRANSFER 484.000 371.000 855.000
31 FACEMASK 2.982.000 760.000 3.742.000
32 Feeding plate 539.000 413.000 952.000
33 FIXED RETAINER RA & RB 2.146.000 1.646.000 3.792.000
34 FIXED RETAINER RA / RB SAJA 1.385.000 1.064.000 2.449.000
35 Flexi Denture * 826.000 634.000 1.460.000
36 FOTO SLIDE 98.000 75.000 173.000
37 Full Denture (RA dan RB) 1.974.000 1.515.000 3.489.000
38 GANTI BAND/bracket BARU 201.000 111.000 312.000
39 GIC besar 195.000 150.000 345.000
40 GIC kecil 124.000 95.000 219.000
41 Gingivextomy/ Frenectomy 520.000 399.000 919.000
42 GTS Frame 669.000 514.000 1.183.000
43 HEAD GEAR 1.990.000 966.000 2.956.000
44 Home Bleaching * 891.000 683.000 1.574.000
45 In Office Bleaching * 1.348.000 1.034.000 2.382.000
46 Incisi Abses 602.000 461.000 1.063.000
47 Incisi Biopsi 602.000 461.000 1.063.000
JASA
PELAYANAN
48 Incisi/cauterisasi 602.000 461.000 1.063.000
49 Inj Scleret Agent 309.000 238.000 547.000
50 InLay / OnLay * 1.149.000 882.000 2.031.000
51 KARET INTRA ORAL 81.000 28.000 109.000
52 Kontrol 262.000 90.000 352.000
53 Kuret per Gigi 400.000 194.000 594.000
54 Labial Veneer Direct 599.000 460.000 1.059.000
55 Labial Veneer In Direct * 1.506.000 1.157.000 2.663.000
56 Mahkota All Porcelain* 1.184.000 909.000 2.093.000
57 Mahkota Metal* 683.000 525.000 1.208.000
58 Mahkota Sementara Direct 335.000 258.000 593.000
59 Mahkota Sementara In Direct * 398.000 306.000 704.000
60 Mocking * 226.000 175.000 401.000
61 NASO ALVEOLAR MOLDING 1.296.000 994.000 2.290.000
62 NEKROPSI (TINDAKAN BARU) 468.000 331.000 799.000
63 Obturator * 686.000 527.000 1.213.000
64 OCCLUSAL ADJUSTMENT 224.000 128.000 352.000
65 Occlusal adjustment / coronoplasty 224.000 128.000 352.000
66 Occlusal Splint 495.000 380.000 875.000
67 OD M3 IMP Kls I 1.112.000 854.000 1.966.000
68 OD M3 IMP Kls II 1.233.000 946.000 2.179.000
69 OD M3 IMP Kls III 1.664.000 1.276.000 2.940.000
70 Open flap debridement perregio 544.000 417.000 961.000
71 Operkulektomi 868.000 479.000 1.347.000
72 Oral Profilaksis/DHE 257.000 198.000 455.000
73 Ortho Removable RA + RB * 920.000 707.000 1.627.000
74 PAPER SURGERY 262.000 203.000 465.000
75 PASANG BRACKET/ BAND LEPAS 114.000 89.000 203.000
76 Penambahan Elemen * 198.000 152.000 350.000
77 Penambahan Wing 447.000 343.000 790.000
78 Pencabutan dgn komplikasi 510.000 393.000 903.000
79 Pencabutan dgn suntik 320.000 246.000 566.000
80 Pencabutan Gigi 320.000 246.000 566.000
81 Pencabutan Gigi dengan komplikasi 510.000 393.000 903.000
82 Pencabutan tanpa suntik 197.000 151.000 348.000
83 Pengisian 1 Saluran Akar 189.000 146.000 335.000
84 Pengisian 2 Saluran Akar 254.000 196.000 450.000
85 Pengisian 3 Saluran Akar/Lebih 314.000 241.000 555.000
86 Pin Casting* 418.000 321.000 739.000
87 Pin Ready Made Fiber 848.000 652.000 1.500.000
88 Pin Ready Made Metal 810.000 622.000 1.432.000
89 Pit and Fissure Sealent 183.000 141.000 324.000
90 Plat Prothesa* 498.000 384.000 882.000
91 PLAT REMOVABLE AKTIF RINGAN RA / RB SAJA 1.091.000 838.000 1.929.000
92 PLAT REMOVABLE AKTIF SEDANG RA / RB SAJA 1.157.000 888.000 2.045.000
93 POSTERIOR BITE RISER DG TAMBALAN 112.000 86.000 198.000
94 POSTERIOR BITE RISER PLAT 567.000 435.000 1.002.000
95 PREMEDIKASI 178.000 109.000 287.000
96 PSA 1 Saluran Akar 170.000 131.000 301.000
97 PSA 2 Saluran Akar 232.000 177.000 409.000
98 PSA 3 Saluran Akar 287.000 221.000 508.000
99 PSA One Visit 1 SA 728.000 559.000 1.287.000
100 PSA One Visit 2 SA 886.000 680.000 1.566.000
101 PSA One Visit 3 atau lebih SA 1.202.000 921.000 2.123.000
102 Pulp capping 218.000 168.000 386.000
103 QUAD HELIX 1.005.000 771.000 1.776.000
JASA
PELAYANAN
104 RAPID PALATAL EXPANSION 1.180.000 904.000 2.084.000
105 Reline/Rebase : Soft Liner 498.000 384.000 882.000
106 REMOVABLE RETAINER RA & RB 920.000 707.000 1.627.000
107 REMOVABLE RETAINER RA / RB SAJA 600.000 461.000 1.061.000
108 Rep. Fix dgn Arcbar ( 1 rahang ) 890.000 682.000 1.572.000
109 Rep. Fix dgn Arcbar ( RA & RB ) 1.184.000 909.000 2.093.000
110 Reparasi Kompleks 389.000 299.000 688.000
111 Reparasi Ringan : Reparasi Kawat 346.000 266.000 612.000
112 Reparasi Ringan : Reparasi Patah 346.000 266.000 612.000
113 Reposisi Disi TMJ 1.019.000 782.000 1.801.000
114 RMGIC/MRGIC besar 292.000 224.000 516.000
115 RMGIC/MRGIC kecil 203.000 157.000 360.000
116 Scalling 1 kuadran 207.000 159.000 366.000
120 Sementasi Ulang 299.000 230.000 529.000
121 SEPARASI 194.000 111.000 305.000
122 SIALOMETRI (TINDAKAN BARU) 75.000 53.000 128.000
123 Single Denture 849.000 653.000 1.502.000
124 Space Maintainer Removable 1 Gigi 299.000 230.000 529.000
125 Splinting Per Gigi 520.000 221.000 741.000
126 SURGICAL WAFER SPLINT (1 splint) 1.223.000 938.000 2.161.000
127 Tambalan Sementara 144.000 111.000 255.000
128 TEMPORARY ANCHORAGE DEVICE 1.192.000 914.000 2.106.000
129 TOPICAL FLOUR APPLICATION RA / RB 219.000 168.000 387.000
130 TRANS PALATAL ARCH 1.154.000 828.000 1.982.000
131 Windowing Exposure 854.000 655.000 1.509.000
3. RADIOLOGI
1 Chepalo 108.000 83.000 191.000
2 Dental X-ray 56.000 43.000 99.000
3 Panoramic 108.000 83.000 191.000
RSCM KENCANA
JASA
NO NAMA TINDAKAN JASA SARANA TARIF
PELAYANAN
1. KONSULTASI DAN VISITE
1 Adminitrasi Cluster 100,000 - 100,000
2 Konseling khusus 171,000 175,000 346,000
3 Konsultasi A 129,000 350,000 479,000
4 Konsultasi B 129,000 500,000 629,000
5 Visite - 575,000 575,000
2. AKOMODASI
1 Pelayanan rawat inap - ruang isolasi (1 bed) 2,000,000 - 2,000,000
2 Perawatan Bayi 250,000 - 250,000
3 President Suite K1A 7,500,000 - 7,500,000
4 President Suite K1B 7,500,000 - 7,500,000
5 Ruang Perawatan ICU 3,600,000 - 3,600,000
6 SUITE ROOM 5,500,000 - 5,500,000
7 VIP A 2,250,000 - 2,250,000
8 VIP B 1,500,000 - 1,500,000
9 VVIP A 3,250,000 - 3,250,000
10 VVIP B 2,000,000 - 2,000,000
1 Angkat drain 66,000 7,000 73,000
2 Bilas lambung dengan NGT 102,000 11,000 113,000
3 code blue 114,000 12,000 126,000
4 Cukur gundul 38,000 4,000 42,000
5 EKG record 31,000 4,000 35,000
6 Ganti Balutan Besar 527,000 147,000 674,000
7 Ganti Balutan Besar Sulit 901,000 367,000 1,268,000
8 Ganti Balutan Kecil 514,000 49,000 563,000
9 Ganti Balutan Sedang 514,000 98,000 612,000
10 Melakukan Penis / vulva Hygine 64,000 7,000 71,000
11 Melakukan perawatan WSD 181,000 19,000 200,000
12 Melepas kateter 118,000 12,000 130,000
13 Memandikan pasien di tempat tidur 137,000 14,000 151,000
14 Memasang NGT 101,000 11,000 112,000
15 Memberi obat melalui inhalasi 180,000 18,000 198,000
16 Memberi terapi inj IM 43,000 5,000 48,000
17 Memberi terapi inj IV 80,000 8,000 88,000
18 Memberi tranfusi 211,000 22,000 233,000
19 Neurorestorasi 320,000 32,000 352,000
20 Pemasangan infus 130,000 13,000 143,000
21 Pemasangan kateter 200,000 20,000 220,000
22 Pemasangan Syringe Pump 66,000 7,000 73,000
23 Pemberian kemoterapi 196,000 20,000 216,000
24 Pemberian terapi inj sub cutan 43,000 5,000 48,000
25 Perawatan colostomi 523,000 53,000 576,000
26 Perawatan fistel peri anal 104,000 11,000 115,000
27 Perawatan illiustomi 692,000 70,000 762,000
28 Perawatan Kateter 196,000 20,000 216,000
29 Perawatan luka besar 278,000 28,000 306,000
30 Perawatan luka kecil 172,000 18,000 190,000
31 Perawatan luka sedang 216,000 22,000 238,000
32 Perawatan nefrostomi 151,000 16,000 167,000
33 Perawatan sistostomi 137,000 14,000 151,000
34 Perawatan urostomi 518,000 52,000 570,000
35 Spulling Kateter 250,000 25,000 275,000
36 Tindakan Vena sektie 77,000 8,000 85,000
4. TINDAKAN RUANG INTENSIVE
1 Cabut CVC/Double lumen HD 179,000 387,000 566,000
2 Pungsi Arteri/Vena (Oleh Dokter) 187,000 387,000 574,000
3 Pasang Infus IV Line Bayi/Anak-anak (Oleh dokter) 227,000 575,000 802,000
4 RJP dan Kardioversi 675,000 460,000 1,135,000
5 EKG 12 lead 232,000 58,000 290,000
6 CRRT 10,300,000 3,220,000 13,520,000
7 Intubasi ETT 651,000 575,000 1,226,000
8 Extubasi ETT 651,000 387,000 1,038,000
9 Extubasi ETT Sulit 851,000 460,000 1,311,000
JASA
PELAYANAN
10 Pasang Central Vena Catheter (CVC) 905,000 3,450,000 4,355,000
11 Pasang Double Lumen HD 905,000 3,450,000 4,355,000
12 Pasang Arteri Line 905,000 1,771,000 2,676,000
13 PICC 905,000 3,450,000 4,355,000
14 PICO/EV1000/ICON/MOSTCARE 9,615,000 1,771,000 11,386,000
15 SwanGanz 905,000 3,450,000 4,355,000
16 Videolaringoskop/CMAC/Instrumentasi sulit airway lainnya 187,000 460,000 647,000
17 TEE intraoperatif/BIS/NIRS 651,000 863,000 1,514,000
18 Intrahospital transport (diluar layanan OK, HCU, dan ICU) 179,000 1,150,000 1,329,000
19 interhospital transport / jam 179,000 1,150,000 1,329,000
20 Pasang folley catheter 187,000 129,000 316,000
21 Trakeostomi (PDT) 905,000 2,875,000 3,780,000
22 mini WSD 187,000 575,000 762,000
23 Blok epidural kontinyu 956,000 575,000 1,531,000
24 Blok spinal kontinyu 319,000 575,000 894,000
25 Blok saraf perifer kontinyu 419,000 575,000 994,000
26 Visite APS/hari - 575,000 575,000
27 Trigger Point Injection VIP 226,000 690,000 916,000
Steroid injection torakolumbal, radiofrekuensi neuraksial, blok
28 simpatis kraniofasial torakolumbal, dan chemical neurolytic VIP 1,469,000 5,750,000 7,219,000
(SEDANG)
Steroid injection torakolumbal, radiofrekuensi neuraksial, blok
29 simpatis kraniofasial torakolumbal, dan chemical neurolytic VIP 1,469,000 6,900,000 8,369,000
(BESAR)
30 Injeksi Sacroiliac Umum/ VIP 822,000 8,050,000 8,872,000
31 Pasang NGT oleh dokter 265,000 483,000 748,000
32 Seting Ventilator - 450,000 450,000
33 CT Scan dengan anestesi 965,000 540,000 1,505,000
34 Bronkoskopi anestesi 1,442,000 570,000 2,012,000
35 Minimal Invasive Hemodynamic Monitoring/ hari 447,000 570,000 1,017,000
36 USG Vascular akses/POCUS/NERVE BLOCK 736,000 495,000 1,231,000
37 Sedasi Anestesi resiko tinggi (Luar OK) 965,000 540,000 1,505,000
38 Sewa Ventilator 1,080,000 582,000 1,662,000
39 Pemasangan Epidural Catheter Continue 1,080,000 4,140,000 5,220,000
40 Pemasangan Intrathecal Catheter Continue 1,080,000 4,140,000 5,220,000
41 Pemasangan Kateter Blok Saraf Perifer 1,080,000 4,140,000 5,220,000
42 Patient Controlled Analgesia System 1,080,000 4,140,000 5,220,000
43 Intrathecal Labor Analgesia 1,080,000 4,140,000 5,220,000
44 Epidural Labor Analgesia 1,080,000 4,140,000 5,220,000
45 Systemic Analgesia 1,080,000 4,140,000 5,220,000
46 Triger Point Miofasial 288,000 1,104,000 1,392,000
47 Transcutaneus Elektric Nerve Stimulation 288,000 1,104,000 1,392,000
48 Accupunture Analgesia (Electro Accupunture Analgesia) 288,000 1,104,000 1,392,000
Injeksi Saraf Perifer (N. Occipital, Suprascapular, Lateral Femoral
49 288,000 1,104,000 1,392,000
Cutaneus, Dll) Single Shot tanpa Catheter Continue
50 Triger Point Miofasial Guiding USG 432,000 1,656,000 2,088,000
51 Transcutaneus Elektric Nerve Stimulation Guiding USG 432,000 1,656,000 2,088,000
52 Accupunture Analgesia (Electro Accupunture Analgesia) Guiding USG 432,000 1,656,000 2,088,000
53 432,000 1,656,000 2,088,000
Cutaneus, Dll) Single Shot tanpa Catheter Continue Guiding USG
Injeksi Intraartikuler Genu dan Sendi Glenohumeral tanpa penuntun
54 1,080,000 4,140,000 5,220,000
USG
55 Injeksi Intraartikuler Genu dan Sendi Glenohumeral Guided USG 1,440,000 4,140,000 5,580,000
56 Cutaneus, Dll) Single Shot dengan Catheter Continue tanpa penuntun 1,080,000 4,140,000 5,220,000
USG
57 1,440,000 4,140,000 5,580,000
Cutaneus, Dll) Single Shot dengan Catheter Continue Guided USG
PATIENT CONTROLLED ANALGESIA SYSTEM TANPA
58 1,080,000 4,140,000 5,220,000
PENUNTUN USG
59 PATIENT CONTROLLED ANALGESIA SYSTEM Guided USG 1,440,000 4,140,000 5,580,000
Injeksi Epidural Intralaminer dan Caudal Tanpa C-Arm Fluoroskopi
60 1,080,000 4,140,000 5,220,000
tanpa penuntun USG
Injeksi Epidural Intralaminer dan Caudal Tanpa C-Arm Fluoroskopi
61 1,440,000 4,140,000 5,580,000
Guided USG
62 Neurolisis (Kimiawi) Saraf Perifer (Fenol, Alkohol) 1,440,000 5,520,000 6,960,000
Injeksi Epidural Intralaminer, Transforaminal dan Caudal dengan
63 1,440,000 5,520,000 6,960,000
penuntun USG dan/atau C-Arm Fluoroskopi
JASA
PELAYANAN
Injeksi Sendi Facet Lumbal dan Thoracic dengan Penuntun USG
64 1,440,000 5,520,000 6,960,000
dan/atau C-Arm Fluoroskopi
Blok Saraf Medial Branch Lumbal dan Thoracic untuk Sendi Facet
65 1,440,000 5,520,000 6,960,000
dengan Penuntun USG dan/atau C-Arm Fluoroskopi
Injeksi Sacro-Iliaca dengan Penuntun USG dan /atau C-Arm
66 1,440,000 5,520,000 6,960,000
Fluoroskopi
INJEKSI SARAF GANGLION : GANGLION STELLATE, IMPAR
67 1,440,000 5,520,000 6,960,000
DENGAN PENUNTUN USG DAN/ATAU C-ARM FLUOROSKOPI
BLOK SARAF PARAVERTEBRAL DAN INJEKSI RADIKS
68 1,440,000 5,520,000 6,960,000
SARAF (NERVE ROOT INJECTION)
INJEKSI SENDI FACET CERVICAL DENGAN PENUNTUN USG
69 2,160,000 8,280,000 10,440,000
DAN/ATAU C-ARM FLUOROSKOPI
BLOK SARAF MEDIAL BRANCH CERVICAL UNTUK SENDI
70 FACET DENGAN PENUNTUN USG DAN/ATAU C-ARM 2,160,000 8,280,000 10,440,000
FLUOROSKOPI
INJEKSI GANGLION SIMPATIK LUMBAL DAN THORACIC
71 2,160,000 8,280,000 10,440,000
DENGAN PENUNTUN USG DAN/ATAU C-ARM FLUOROSKOPI
BLOK DORSAL ROOT GANGLION (DRG) LUMBAL,
72 THORACIC DAN CERVICAL DENGAN PENUNTUN C-ARM 2,160,000 8,280,000 10,440,000
DAN FLUOROSKOPI
BLOK SARAF N. SPLANCNIC DAN PLEXUS COELIAC
73 DENGAN PENUNTUN USG DAN/ ATAU C-ARM 3,600,000 13,800,000 17,400,000
FLUOROSKOPI
BLOK SARAF TRIGEMINAL DENGAN PENUNTUN C-ARM
74 3,600,000 13,800,000 17,400,000
FLUOROSKOPI
75 SPINAL CORD STIMULATION (SCS) 7,200,000 27,600,000 34,800,000
76 INTRA DISCAL ELECTROTHERMAL THERAPY 7,200,000 27,600,000 34,800,000
77 EPIDUROSKOPI 7,200,000 27,600,000 34,800,000
78 VERTEBROPLASTY 7,200,000 27,600,000 34,800,000
BLOK SARAF/GANGLION Guided PENUNTUN USG DAN/ATAU
79 900,000 3,450,000 4,350,000
C-ARM FLUOROSKOPI RADIOFREKUENSI (RF)
5. NON OPERATIF
5.1 DENTISTRY
1 Alveolektomi Per Regio 747,000 886,000 1,633,000
2 Apeksreseksi 599,000 948,000 1,547,000
3 Buka Fiksasi /Archbar 299,000 823,000 1,122,000
4 Buka Jahitan (kasus Bedah Mulut) 135,000 409,000 544,000
5 Debridement 458,000 938,000 1,396,000
6 Eksisi Tumor Jinak 1,131,000 1,380,000 2,511,000
7 Enukleasi Kista 841,000 2,392,000 3,233,000
8 Incisi Abses 709,000 649,000 1,358,000
9 Incisi Biopsi 709,000 943,000 1,652,000
11 OD M3 IMP Kls I 1,170,000 3,579,000 4,749,000
12 OD M3 IMP Kls II 1,174,000 4,186,000 5,360,000
13 OD M3 IMP Kls III 1,597,000 4,600,000 6,197,000
14 Operkulektomi (Kasus Bedah Mulut) 1,139,000 1,438,000 2,577,000
15 Pencabutan Gigi 374,000 518,000 892,000
16 Pencabutan Gigi dengan komplikasi 605,000 897,000 1,502,000
17 Rep. Fix dgn Arcbar ( RA & RB ) 1,417,000 2,967,000 4,384,000
18 Rep. Fix dgn Arcbar ( 1 rahang ) 1,068,000 1,610,000 2,678,000
19 Reposisi Disi TMJ 1,181,000 920,000 2,101,000
20 Windowing EXP 1,022,000 1,380,000 2,402,000
21 Dental Implant 1,018,000 13,800,000 14,818,000
24 Apeksreseksi 599,000 718,000 1,317,000
26 Cetak Alginate 164,000 161,000 325,000
28 Composite Besar 454,000 518,000 972,000
29 Composite Kecil 329,000 400,000 729,000
30 GIC besar 231,000 403,000 634,000
31 GIC kecil 146,000 235,000 381,000
32 Home Bleaching * 630,000 1,035,000 1,665,000
33 In Office Bleaching * 927,000 2,760,000 3,687,000
34 InLay / OnLay * 916,000 1,449,000 2,365,000
JASA
PELAYANAN
35 Labial Veneer Direct 704,000 690,000 1,394,000
36 Labial Veneer In Direct * 982,000 3,312,000 4,294,000
37 Mahkota All Poecelain* 909,000 4,048,000 4,957,000
38 Mahkota Metal Porcelain* 571,000 2,875,000 3,446,000
41 Pengisian 1 SA 225,000 345,000 570,000
42 Pengisian 2 SA 304,000 373,000 677,000
43 Pengisian 3 atau lebih SA 377,000 400,000 777,000
44 Fiber post 398,000 805,000 1,203,000
46 Premedikasi 110,000 173,000 283,000
47 PSA 1 SA 207,000 331,000 538,000
48 PSA 2 SA 280,000 412,000 692,000
49 PSA 3 SA 347,000 428,000 775,000
50 PSA One Visit 1 SA 857,000 1,339,000 2,196,000
51 PSA One Visit 2 SA 1,048,000 1,608,000 2,656,000
52 PSA One Visit 3 atau lebih SA 1,416,000 1,684,000 3,100,000
53 Pulp Capping 256,000 258,000 514,000
54 Mocking * 268,000 345,000 613,000
55 Topical Fluor Application (kasus konservasi gigi) RA / RB 259,000 248,000 507,000
56 Tambal Sementara 169,000 242,000 411,000
57 Aktivator 2,358,000 2,268,000 4,626,000
58 Analisa 207,000 245,000 452,000
59 Chin Cup 251,000 1,352,000 1,603,000
60 Debonding / Slicing (kasus ortho) 262,000 196,000 458,000
61 Facemask 3,737,000 1,150,000 4,887,000
62 Facebow Transfer 566,000 294,000 860,000
63 Fixed Retainer RA & RB 2,460,000 2,751,000 5,211,000
64 Fixed Retainer RA / RB saja 1,543,000 1,603,000 3,146,000
65 Foto Slide 110,000 127,000 237,000
66 Ganti Band baru 249,000 138,000 387,000
67 Ganti Bracket baru 243,000 138,000 381,000
68 Ganti Kawat baru 213,000 117,000 330,000
69 Head Gear 2,496,000 1,166,000 3,662,000
70 Karet Intra Oral 104,000 230,000 334,000
71 Kontrol Alat Cekat 153,000 288,000 441,000
72 Kontrol Alat Lepasan 152,000 288,000 440,000
73 Kontrol Alat Retainer 154,000 288,000 442,000
74 Kontrol NAM 205,000 288,000 493,000
75 Naso Alveolar Molding 1,605,000 1,780,000 3,385,000
76 Paper Surgery 315,000 196,000 511,000
77 Pasang Band Lepas 105,000 83,000 188,000
78 Pasang Bracket Lepas 136,000 104,000 240,000
79 Plat Removable Aktif Ringan RA / RB saja 1,186,000 1,799,000 2,985,000
80 Plat Removable Aktif Sedang RA / RB saja 1,265,000 1,799,000 3,064,000
81 Posterior Bite Riser Plat 658,000 840,000 1,498,000
82 Posterior Bite Riser Dengan Tambalan 132,000 238,000 370,000
83 Quad Helix 1,171,000 1,111,000 2,282,000
84 Rapid Palatal Expansion 1,371,000 1,587,000 2,958,000
85 Removable Retainer RA & RB 1,025,000 1,419,000 2,444,000
86 Removable Retainer RA/RB saja 704,000 978,000 1,682,000
87 Separasi 244,000 113,000 357,000
88 SurgicalL Wafer Splint (1 splint) 1,447,000 2,116,000 3,563,000
89 Temporary Anchorage Device 1,061,000 1,518,000 2,579,000
90 Trans Palatal Arch 1,452,000 1,093,000 2,545,000
91 Feeding plate 627,000 1,104,000 1,731,000
94 Space Maintainer Removable 1 Gigi 350,000 1,104,000 1,454,000
95 PSA Gigi Sulung Anterior (1 Saluran Akar) 311,000 345,000 656,000
96 PSA Gigi Sulung Posterior ( 2 atau 3 Saluran Akar) 424,000 359,000 783,000
97 Pengisian PSA Gigi Sulung Anterior (1 Saluran Akar) 303,000 304,000 607,000
98 Pengisian PSA Gigi Sulung Posterior ( 2 atau 3 Saluran Akar) 420,000 331,000 751,000
100 Eksisi Mucocele 709,000 690,000 1,399,000
101 GIC besar 231,000 235,000 466,000
102 Incisi/cauterisasi 709,000 304,000 1,013,000
103 Inlay/Onlay * Pedo 916,000 1,449,000 2,365,000
104 Kontrol Alat Lepasan 152,000 173,000 325,000
JASA
PELAYANAN
105 Ortho Removable RA + RB * pedo 1,025,000 1,884,000 2,909,000
107 Plat Removable Aktif Sedang RA/ RB Saja 1,186,000 1,799,000 2,985,000
108 Pit & Fissure sealant 216,000 230,000 446,000
109 Premedikasi 110,000 173,000 283,000
110 Skeling 4 Kuadran 551,000 380,000 931,000
111 Skeling 3 Kuadran 448,000 322,000 770,000
112 Skeling 2 Kuadran 344,000 265,000 609,000
113 Skeling 1 Kuadran 240,000 236,000 476,000
114 Occlusal adjustment 270,000 370,000 640,000
115 Buka Jahitan (Kasus Perio) 135,000 179,000 314,000
116 Topical Fluor application (kasus perio) RA / RB 259,000 155,000 414,000
117 Kontrol (Kasus Perio) 241,000 230,000 471,000
119 Kuret per Gigi 475,000 386,000 861,000
120 Splinting Per Gigi 614,000 863,000 1,477,000
121 Gingivextomy/ Frenectomy 572,000 897,000 1,469,000
122 Open flap debridement perregio 624,000 1,076,000 1,700,000
123 Alveolektomi Per Regio 747,000 1,150,000 1,897,000
124 Operkulektomi 1,052,000 897,000 1,949,000
125 Ablatio 597,000 1,014,000 1,611,000
126 Kasus Penyakit Mulut 232,000 187,000 419,000
127 Kontrol Penyakit Mulut 191,000 230,000 421,000
128 Kasus Penyakit Infeksi 221,000 190,000 411,000
129 Sialometri 93,000 43,000 136,000
130 Nekropsi 584,000 275,000 859,000
131 Eliminasi Trauma Lokal 562,000 268,000 830,000
132 Bongkar Crown/ per Unit 576,000 497,000 1,073,000
133 Bongkar Pin / Unit 576,000 497,000 1,073,000
134 Bongkar Prothesa/ Unit 766,000 938,000 1,704,000
135 Seal Protect 40,000 150,000 190,000
136 Cetak Alginate 164,000 161,000 325,000
138 Flexi Denture Unilateral * 795,000 1,587,000 2,382,000
139 Flexi Denture Bilateral * 795,000 1,840,000 2,635,000
140 Full Denture per rahang* 2,298,000 5,405,000 7,703,000
141 GTS Frame per rahang * 777,000 1,780,000 2,557,000
142 Inlay/Onlay * 916,000 1,449,000 2,365,000
143 Kontrol Prothesa 393,000 239,000 632,000
144 Mahkota all Porcelain* 909,000 4,048,000 4,957,000
145 Mahkota Metal Porcelain * 571,000 2,875,000 3,446,000
147 Obturator * 585,000 897,000 1,482,000
148 Occlusal Splint 579,000 690,000 1,269,000
150 Penambahan Wing 518,000 478,000 996,000
151 Pin Casting * 357,000 649,000 1,006,000
153 Plat Prothesa* 514,000 1,288,000 1,802,000
154 Reline/Rebase : Soft Liner 578,000 507,000 1,085,000
158 Sementasi Ulang 353,000 462,000 815,000
159 Single Denture* 989,000 5,750,000 6,739,000
160 Alat Cekat Metal RA dan RB (MBT)* 2,500,000 12,075,000 14,575,000
161 Alat Cekat Metal RA dan RB (Damon)* 2,500,000 12,075,000 14,575,000
162 Alat Cekat Metal RA/RB* 2,500,000 12,075,000 14,575,000
163 Alat Cekat Metal RA dan RB (MBT) Komplek* 2,500,000 12,075,000 14,575,000
164 Alat Cekat Metal RA dan RB (Damon) Komplek* 2,500,000 12,075,000 14,575,000
165 Alat Cekat Ceramic RA dan RB (MBT)* 2,500,000 12,075,000 14,575,000
166 Alat Cekat Ceramic RA dan RB (Damon)* 2,500,000 12,075,000 14,575,000
167 Alat Cekat Ceramic RA dan RB (MBT) Komplek* 2,500,000 12,075,000 14,575,000
168 Alat Cekat Ceramic RA dan RB (Damon) Komplek* 2,500,000 12,075,000 14,575,000
169 Invisalign* 2,500,000 12,075,000 14,575,000
Laboratorium - - -
1 Lab Mahkota Metal Porcelain 125,000 575,000 700,000
2 Lab Chepalo 125,000 196,000 321,000
3 Lab elemen gigi akrilik 60,000 41,000 101,000
4 Lab Elemen Gigi ortholux 130,000 90,000 220,000
JASA
PELAYANAN
5 Lab Gigi Tiruan Lengkap Lepasan 1,320,000 911,000 2,231,000
6 Lab Gigi Tiruan Lengkap Lepasan RA / RB 660,000 455,000 1,115,000
7 Lab plat akrilik bilateral 150,000 104,000 254,000
8 Lab Plat Akrilik saddle 100,000 69,000 169,000
9 Lab Plat flexy bilateral 460,000 317,000 777,000
10 Lab Plat flexy sadle 430,000 297,000 727,000
11 Lab Plat Obturator hollow 240,000 166,000 406,000
12 Lab Plat Obturator sementara 200,000 138,000 338,000
13 Lab provisoris 100,000 69,000 169,000
14 Lab Relining / rebassing full 150,000 104,000 254,000
15 Lab Reparasi Patah 150,000 104,000 254,000
16 Lab Reparasi Tambah Gigi 150,000 104,000 254,000
17 Lab scp akrilik per rahang 120,000 83,000 203,000
18 Lab scp stent per rahang 80,000 55,000 135,000
19 Lab splint akrilik / bruxism splint 190,000 131,000 321,000
20 Lab Vacuum Splint / night guard 180,000 124,000 304,000
21 Lab Onlay Komposit / ceramage 320,000 184,000 504,000
22 Lab Crown Komposit / ceramage 480,000 276,000 756,000
23 Lab Veneer Komposit / ceramage 400,000 230,000 630,000
24 Lab Lingual arch 350,000 242,000 592,000
25 Lab Nance appliance 350,000 242,000 592,000
26 Lab Palatal arch 350,000 242,000 592,000
27 Lab Quad helix 450,000 311,000 761,000
28 Lab Retainer 250,000 173,000 423,000
29 Lab Solder 1 point 90,000 62,000 152,000
30 Lab study model 150,000 104,000 254,000
31 Lab Surgical wafer 300,000 207,000 507,000
32 Lab Feeding Plate 160,000 110,000 270,000
33 Lab NAM plate 200,000 138,000 338,000
5.2 WELLNESS
1 Laserpunktur (Laser Pen) 36,000 460,000 496,000
2 Laserpunktur (Laser Needle Multilead) 70,000 610,000 680,000
3 Sonopunktur 76,000 115,000 191,000
4 Farmakopunktur 91,000 288,000 379,000
5 Elektro Akupunktur 91,000 288,000 379,000
6 Manual Akupunktur 76,000 173,000 249,000
7 Thread Embedded Akupunktur (TEA) 600,000 575,000 1,175,000
8 Thread Embedded Akupunktur (TEA) Estetik 1,200,000 1,725,000 2,925,000
9 Press Needle Punktur 36,000 115,000 151,000
10 AkuPressure Estetik 70,000 115,000 185,000
5.3 TERATAI
2 Bronkoskopi + BAL 3,544,000 2,731,000 6,275,000
16 CRYOTHERAPY 12,870,000 9,916,000 22,786,000
28 EBUS Diagnostik 4,958,000 3,820,000 8,778,000
JASA
PELAYANAN
30 EBUS Linier + TBNA 20,295,000 15,637,000 35,932,000
31 USG Thorax/Colli 220,000 169,000 389,000
39 Pungsi Pleura / Torakosintesis 674,000 519,000 1,193,000
40 TTNA 685,000 528,000 1,213,000
41 TTB 1,537,000 1,184,000 2,721,000
43 Fibrinolitik Intrapleura 639,000 492,000 1,131,000
47 Pleurodesis Doksisiklin 643,000 495,000 1,138,000
49 Biopsi pleura 695,000 536,000 1,231,000
51 Spirometri 209,000 161,000 370,000
53 Terapi Oksigen 79,000 61,000 140,000
54 Inhalasi/Induksi Sputum 310,000 239,000 549,000
55 CVC 2,478,000 1,909,000 4,387,000
56 PICC 4,749,000 3,659,000 8,408,000
57 Intubasi 1,324,000 1,019,000 2,343,000
58 Biopsi KGB 1,504,000 1,159,000 2,663,000
60 FNAB 606,000 1,495,000 2,101,000
61 Infus obat (drip) 153,000 147,000 300,000
62 Injeksi Obat 52,000 49,000 101,000
63 Patch Test 1,019,000 173,000 1,192,000
64 Skin Prick Test 1,448,000 587,000 2,035,000
65 Tapping/ Plebotomi (terapeutik dan diagnostik) 2,305,000 98,000 2,403,000
66 Transfusi darah 2 Jam 1,020,000 196,000 1,216,000
67 Transfusi darah 2-4 Jam 1,448,000 293,000 1,741,000
68 BMP + Biopsi SUMSUM TULANG 2,000,000 2,300,000 4,300,000
69 Infus obat (drip) 500,000 288,000 788,000
70 Injeksi Obat 100,000 173,000 273,000
71 Kemoterapi < 6 Jam 2,250,000 1,150,000 3,400,000
72 Kemoterapi > 6 Jam 2,500,000 1,725,000 4,225,000
73 Kemoterapi < 2 Jam 1,000,000 863,000 1,863,000
75 Tes Mantoux 350,000 115,000 465,000
76 Transfusi darah < 6 Jam 750,000 575,000 1,325,000
77 Transfusi darah > 6 Jam 1,000,000 575,000 1,575,000
5.4 ENT
1 Analisis Suara 297,000 293,000 590,000
2 Angkat Tampon Hidung 297,000 345,000 642,000
3 ASSR 464,000 391,000 855,000
4 ASSR dengan Sedasi 972,000 2,070,000 3,042,000
5 Audiometri Nada Murni 297,000 147,000 444,000
6 Audiometri Tutur 297,000 345,000 642,000
7 Bera Click 409,000 293,000 702,000
8 Bera Skrining 378,000 196,000 574,000
9 Bera Tonebrust 409,000 345,000 754,000
10 Bera Click dengan anestesi 709,000 2,070,000 2,779,000
11 Bera + ASSR 709,000 575,000 1,284,000
12 Biopsi Telinga 434,000 293,000 727,000
13 Biopsi Tumor - Nasofaring 606,000 489,000 1,095,000
14 Biopsi Tumor - Oro / Hipofaring 546,000 391,000 937,000
15 Biopsi Tumor - Rongga Hidung 546,000 293,000 839,000
16 CRT (Canalith Retraining Therapy) 297,000 415,000 712,000
17 Dekanulasi 428,000 575,000 1,003,000
18 Ekstraksi Cerumen - Mudah 192,000 173,000 365,000
19 Ekstraksi Cerumen - Sulit 297,000 345,000 642,000
20 Ekstraksi Polip 419,000 1,150,000 1,569,000
21 Ekstrasi Benda Asing Hidung 297,000 345,000 642,000
JASA
PELAYANAN
22 Ekstrasi Benda Asing Telinga - Mudah 297,000 196,000 493,000
23 Ekstrasi Benda Asing Telinga - Sulit 378,000 345,000 723,000
24 Ekstrasi Benda Asing Tenggorok - Mudah 297,000 196,000 493,000
25 Ekstrasi Benda Asing Tenggorok - Sulit 343,000 345,000 688,000
26 ENG 606,000 575,000 1,181,000
27 FEES 493,000 1,093,000 1,586,000
28 Fleksibel RFL 439,000 403,000 842,000
29 Ganti Canul Tracheostomi 378,000 489,000 867,000
30 Insisi / Aspirasi Abses Peritonsil (Anestesi lokal) 133,000 575,000 708,000
31 Insisi / Aspirasi Abses Telinga (termasuk Odhematom / Pseudokista) 133,000 345,000 478,000
32 Insisi Abses/Hematoma Septum 791,000 575,000 1,366,000
34 Kaustik Hidung 660,000 230,000 890,000
35 Kaustik Faring 313,000 230,000 543,000
36 Kauter Konka* 660,000 978,000 1,638,000
38 Miringotomy 297,000 345,000 642,000
39 Nasoendoskopi Rigid 350,000 173,000 523,000
40 Otoakustik Emission 419,000 345,000 764,000
41 Otoakustik Emission (anestesi) 409,000 1,840,000 2,249,000
43 Parasintesis 487,000 345,000 832,000
44 Pasang grommet 447,000 575,000 1,022,000
45 Pasang grommet 2 Telinga 485,000 825,000 1,310,000
46 Pasang NGT 200,000 345,000 545,000
47 Pasang NGT dengan Guiding Endoscopy (ENT) 546,000 575,000 1,121,000
48 Pasang Tampon Hidung 1 sisi 297,000 288,000 585,000
49 Pasang Tampon Hidung 2 sisi 297,000 460,000 757,000
50 Pasang Tampon Telinga 192,000 173,000 365,000
52 Pemeriksaan Keseimbangan Dengan (Frenzel Videoscope) 409,000 425,000 834,000
53 Pemeriksaan N.Fasialis 297,000 345,000 642,000
54 Posturografi 297,000 575,000 872,000
55 Smell test 297,000 460,000 757,000
56 Stroboskopi 589,000 920,000 1,509,000
57 Terapi Bicara 259,000 230,000 489,000
59 Tes Shelong 297,000 196,000 493,000
60 Test Alergi Skin Prick Test 644,000 587,000 1,231,000
61 Test Psikoakustik Tinitus 297,000 575,000 872,000
62 Trakeostomi (ICU) 1,319,000 4,106,000 5,425,000
63 Tympanometri 419,000 147,000 566,000
5.5 IVF
1 Assisted Hatching 2,500,000 575,000 3,075,000
2 FET (Transfer embrio dari proses simpan beku) 12,000,000 4,025,000 16,025,000
3 FET (Transfer embrio dari proses simpan beku) dengan anestesi 12,000,000 4,945,000 16,945,000
4 Inseminasi Conventional 1,716,000 784,000 2,500,000
5 Inseminasi ICSI 5,000,000 1,265,000 6,265,000
6 IVF ICSI MESA-TESE 6,000,000 1,725,000 7,725,000
7 IVM 34,612,000 8,476,000 43,088,000
8 Kultur Embrio 1,500,000 345,000 1,845,000
9 OPU 13,000,000 7,130,000 20,130,000
10 Simpan Beku Embrio 3,000,000 575,000 3,575,000
11 Simpan Beku Oosit 3,000,000 575,000 3,575,000
12 Simpan Beku Sperma 1,500,000 575,000 2,075,000
13 Sperm Thawing 2,039,000 598,000 2,637,000
14 Transfer Embrio 5,500,000 3,393,000 8,893,000
15 Sperm Washing 1,100,000 1,042,000 2,142,000
16 Sperm Analisa 326,000 230,000 556,000
17 Persentage X/Y 520,000 432,000 952,000
18 HALLO TEST 835,000 432,000 1,267,000
19 Inseminasi/IUI 1,300,000 1,725,000 3,025,000
20 USG 2D 150,000 144,000 294,000
21 USG hamil 150,000 238,000 388,000
22 Eksplorasi testis 670,000 330,000 1,000,000
23 Simpan beku embrio/oosit 500,000 - 500,000
24 Simpan beku sperma 250,000 - 250,000
25 Simpan beku embrio/oosit/sperma infeksius 1,000,000 - 1,000,000
26 OPU 13,000,000 7,130,000 20,130,000
JASA
PELAYANAN
27 Paket OPU 19,500,000 8,700,000 28,200,000
28 Paket ET 8,000,000 3,968,000 11,968,000
29 Paket Inseminasi 2,400,000 2,767,000 5,167,000
5.6 REPRODUCTIVE
1 Aspirasi kista dengan anestesi 4,305,000 3,011,000 7,316,000
2 Aspirasi kista tanpa anestesi 3,308,000 1,564,000 4,872,000
3 Biopsi endometrium 245,000 863,000 1,108,000
4 Businasi dengan anestesi 245,000 1,208,000 1,453,000
5 Ekstirpasi Polip/Miom Geburt Kecil 152,000 345,000 497,000
6 HALLO TEST 935,000 374,000 1,309,000
7 Hidrotubasi 305,000 863,000 1,168,000
8 Hidrotubasi dengan anestesi 1,136,000 1,208,000 2,344,000
9 Histeroskopi Office Diagnostik 567,000 1,438,000 2,005,000
10 Histeroskopi Office Terapeutik 565,000 1,725,000 2,290,000
11 Histeroskopi Office Terapeutik dengan anestesi 565,000 2,415,000 2,980,000
12 Inseminasi/IUI 2,413,000 2,652,000 5,065,000
13 Irigasi Vagina / Vulva Hygiene 218,000 288,000 506,000
14 Mikrokuret 245,000 863,000 1,108,000
16 Papsmear LBC HPV DNA 101,000 288,000 389,000
17 Pasang/Lepas IUD 323,000 575,000 898,000
18 Pasang/Lepas IUD dengan anestesi 1,158,000 805,000 1,963,000
19 suntik 108,000 29,000 137,000
20 USG Ginekologi 200,000 288,000 488,000
21 USG SIS 488,000 547,000 1,035,000
22 Angkat/pasang Tampon 85,000 288,000 373,000
23 Kauterisasi Kondiloma + TCA 500,000 345,000 845,000
24 Paket Konsultasi ANC + USG Rutin 230,000 460,000 690,000
5.7 WHC
1 Biopsi 127,000 288,000 415,000
2 Businasi 236,000 288,000 524,000
3 Cryotherapy 271,000 345,000 616,000
4 Kolposkopi 277,000 288,000 565,000
6 Kolposkopi dan LLETZ 277,000 575,000 852,000
7 Lepas/pasang Pesarium 104,000 288,000 392,000
8 NST/ CTG 152,000 117,000 269,000
9 Pasang/lepas kateter 155,000 288,000 443,000
10 Pungsi Asites 460,000 863,000 1,323,000
11 Test Metilen Blue 370,000 345,000 715,000
12 USG 3D / 4D 250,000 288,000 538,000
13 USG Fetomternal/Gine Onko/Gine Uro/Gine Endokrin 250,000 575,000 825,000
5.8 DIGESTIVE
1 Anuskopi + ligasi 1,819,000 4,959,000 6,778,000
2 Aspirasi abses hepat guided USG 2,340,000 3,832,000 6,172,000
3 Aspirasi hepatoma guided USG 2,194,000 2,480,000 4,674,000
4 Aspirasi kista hati guided USG 2,340,000 3,832,000 6,172,000
5 Aspirasi limpa guided USG 2,292,000 3,381,000 5,673,000
6 Aspirasi pankreas guided USG 2,292,000 3,381,000 5,673,000
7 Businasi Hurtz (Achalasia) + anestesia 332,000 3,156,000 3,488,000
8 Dilatasi Esofagus 1,897,000 18,032,000 19,929,000
9 Ekstraksi benda asing SCBA 4,225,000 15,553,000 19,778,000
10 Ekstraksi benda asing SCBB 4,875,000 15,553,000 20,428,000
12 ERCP (terapetik) 15,969,000 32,458,000 48,427,000
13 ERCP + Ekstraksi batu 2,652,000 25,245,000 27,897,000
15 ERCP + Stent Metal 1,950,000 18,483,000 20,433,000
16 ERCP + Stent Plastik 1,430,000 13,750,000 15,180,000
17 Esofagogastroduodenoskopi 611,000 5,861,000 6,472,000
18 Fibro Scan 195,000 2,029,000 2,224,000
19 Fungsi Asites 1,495,000 2,029,000 3,524,000
20 Gastroscopy 3,242,000 6,086,000 9,328,000
21 Gastroscopy + hemostasis 2,914,000 27,725,000 30,639,000
22 Hemostasis SCBB 5,148,000 18,032,000 23,180,000
23 Injeksi etanol 2,438,000 4,734,000 7,172,000
24 Injeksi Histoacril 4,225,000 15,553,000 19,778,000
25 Kolonoskopi 3,679,000 10,369,000 14,048,000
26 Kolonoskopi + Polipectomy 1,897,000 18,032,000 19,929,000
27 Ligasi hemoroid 1,690,000 3,832,000 5,522,000
JASA
PELAYANAN
28 Ligasi Varices Esofagus 3,679,000 10,369,000 14,048,000
29 Manometri 527,000 5,185,000 5,712,000
30 NGT Guided Endoscopy 3,493,000 8,566,000 12,059,000
31 NJT Guided Endoscopy 7790000 4,388,000 17,131,000 21,519,000
32 PEG 2,438,000 23,217,000 25,655,000
33 PEG + Asistensi 5,038,000 23,217,000 28,255,000
34 Pemasangan Flocare 3,283,000 6,537,000 9,820,000
35 Pemasangan PigTail 2,243,000 2,931,000 5,174,000
36 Pemasangan stent esofagus 1,528,000 14,651,000 16,179,000
37 Polipectomy SCBA 4,498,000 18,032,000 22,530,000
38 Polipectomy SCBB 5,148,000 18,032,000 23,180,000
39 PTBD 2,633,000 6,537,000 9,170,000
40 Rektoscopi + ligasi 1,690,000 3,832,000 5,522,000
41 Rektoscopi/Rigit+Biopsi 1,235,000 2,029,000 3,264,000
42 Rektosigmoidoskopi 488,000 3,558,000 4,046,000
43 Rektosigmoidoskopi + Anestesi 488,000 4,734,000 5,222,000
44 RFA 3,803,000 17,582,000 21,385,000
45 STE Varises 3,679,000 10,369,000 14,048,000
46 Transnasal EGD 3,242,000 6,086,000 9,328,000
47 USG 459,000 677,000 1,136,000
48 USG biopsi 2,243,000 2,931,000 5,174,000
49 USG Blind Biopsi 2,292,000 3,381,000 5,673,000
50 USG Doppler 468,000 902,000 1,370,000
51 USG jarum halus 2,292,000 3,381,000 5,673,000
52 Bilas lambung (Spooling NGT) oleh dokter 265,000 677,000 942,000
53 Klisma oleh dokter 168,000 677,000 845,000
54 Pasang NGT oleh dokter 265,000 677,000 942,000
55 Pasang Infus oleh dokter 281,000 677,000 958,000
56 Pasang Infus 228,000 23,000 251,000
57 Bilas lambung (Spooling NGT) 195,000 20,000 215,000
58 Klisma 98,000 10,000 108,000
59 Pasang NGT 195,000 20,000 215,000
60 Pemasangan kateter urine 195,000 20,000 215,000
61 Suction 195,000 20,000 215,000
62 Per Oral Endoscopy Myotomy (POEM) 17,064,000 28,980,000 46,044,000
63 Endoscopy Submucosal Disection (ESD) SCBA 8,040,000 24,150,000 32,190,000
64 Endoscopy Submucosal Disection (ESD) SCBB 8,280,000 27,370,000 35,650,000
65 pH Metri 527,000 5,185,000 5,712,000
66 Spy Glass (Belum termasuk sewa alat) 15,969,000 32,458,000 48,427,000
5.9 DIABETIC
1 Aspirasi + Injeksi Ethanol Tiroid dengan Panduan USG 693,000 5,750,000 6,443,000
2 Aspirasi Kista Tiroid 218,000 805,000 1,023,000
3 Aspirasi Kista Tiroid dengan Panduan USG 459,000 4,600,000 5,059,000
4 BAJAH Kista Tiroid 212,000 805,000 1,017,000
5 BAJAH Kista Tiroid dengan Panduan USG 455,000 4,600,000 5,055,000
7 BAJAH Nodul Tiroid dengan Panduan USG 433,000 4,600,000 5,033,000
8 Deteksi dini Kaki Diabetes 131,000 230,000 361,000
10 Injeksi intraartikular sendi besar 197,000 1,150,000 1,347,000
11 Injeksi intraartikular sendi kecil 189,000 863,000 1,052,000
12 Injeksi periartikuler 191,000 863,000 1,054,000
13 Perawatan Kaki 1-2 penebalan kuku dan kalus 192,000 288,000 480,000
14 Perawatan Kaki 3-5 penebalan kuku dan kalus 254,000 345,000 599,000
15 Perawatan Kaki 6 atau lebih penebalan kuku dan kalus 299,000 460,000 759,000
16 Pungsi sendi besar 198,000 1,150,000 1,348,000
17 Pungsi sendi kecil 194,000 863,000 1,057,000
18 Rawat luka terbuka besar (>11cm) 353,000 575,000 928,000
19 Rawat luka terbuka kecil (< 5cm) 219,000 288,000 507,000
20 Rawat luka terbuka sedang (6cm - 10cm) 288,000 460,000 748,000
21 Suntik IV/IM/SC 59,000 49,000 108,000
22 USG Guide Injeksi dan Pungsi 736,000 2,300,000 3,036,000
23 USG Muskuloskeletal 444,000 1,150,000 1,594,000
24 USG Tiroid dengan print 237,000 345,000 582,000
25 USG Tiroid tanpa print 234,000 345,000 579,000
5.10 URONEPHRO
1 Aff kateter 139,000 173,000 312,000
2 Aff Kateter Per Flouroskopi 1,200,000 719,000 1,919,000
3 Biopsi Ginjal 2,263,000 2,300,000 4,563,000
4 BUSINASI 670,000 345,000 1,015,000
JASA
PELAYANAN
5 CIC 400,000 345,000 745,000
6 Dokter DPJP Transplantasi Ginjal 300,000 1,955,000 2,255,000
7 Elektrocauter Berat 1,045,000 391,000 1,436,000
8 Elektrocauter Sedang 549,000 265,000 814,000
9 ESWL 1,864,000 12,650,000 14,514,000
10 ESWL ULANG 1,864,000 10,120,000 11,984,000
11 ESWT disfungsi ereksi awal (4 sesi) 4,340,000 6,900,000 11,240,000
12 ESWT disfungsi ereksi lanjutan (2 sesi lanjutan) 2,170,000 3,450,000 5,620,000
13 ESWT peyronie disease (3 sesi) 3,255,000 5,175,000 8,430,000
14 ESWT prostatitis/CPPS awal (4 sesi) 4,340,000 6,900,000 11,240,000
15 ESWT prostatitis/CPPS lanjutan (per sesi) 1,085,000 1,725,000 2,810,000
16 Ganti Balutan 528,000 115,000 643,000
17 Ganti kateter 300,000 345,000 645,000
18 HD CITO 3,782,000 1,150,000 4,932,000
19 HD SLED (> 6 Jam) 3,782,000 1,150,000 4,932,000
20 Hemodialisis 1,905,000 575,000 2,480,000
21 Infus Zometa/Bonefos 150,000 173,000 323,000
22 Injeksi Hormonal Therapy (Zoladex/Tapros) 150,000 173,000 323,000
23 Injeksi Intrakavernosa Penis 150,000 345,000 495,000
24 Instilasi Obat Cystitat 460,000 345,000 805,000
25 Introduction phase 400,000 575,000 975,000
26 Keperawatan HD Transplantasi Ginjal 1,025,000 - 1,025,000
27 Keperawatan Transplantasi Ginjal 1,000,000 - 1,000,000
28 Maintenance phase (4 sesi) 1,600,000 1,610,000 3,210,000
29 MASSAGE PROSTAT 94,000 144,000 238,000
30 METHYLENE BLUE TEST 901,000 345,000 1,246,000
31 Pasang Kateter dengan Mandrain 516,000 288,000 804,000
32 Pasang Urine Kateter 387,000 173,000 560,000
33 Pelvic Floor Exercise 400,000 575,000 975,000
34 Pelvic Floor Relaxation 400,000 575,000 975,000
37 Podophilin 226,000 147,000 373,000
38 PTNS (per sesi) 400,000 403,000 803,000
39 Rigiscan 3,000,000 1,725,000 4,725,000
40 Sistografi 1,200,000 719,000 1,919,000
41 Sistoskopi fleksibel (lokal) 1,500,000 2,300,000 3,800,000
42 Sistostomi perkutan (lokal) 400,000 575,000 975,000
43 Skrining APD 50,000,000 - 50,000,000
44 Tim Transplantasi Ginjal 8,100,000 52,785,000 60,885,000
45 Uretrografi 1,200,000 719,000 1,919,000
46 Uretrosistografi bipolar 1,200,000 863,000 2,063,000
47 URODINAMIK 6,000,000 1,898,000 7,898,000
48 Urodinamik + Urethral Pressure Profile 3,763,000 2,300,000 6,063,000
49 UROFLOWMETRI 139,000 144,000 283,000
50 Uroflowmetri dengan EMG 279,000 202,000 481,000
51 Urostym 400,000 575,000 975,000
52 USG Doppler 506,000 489,000 995,000
53 USG GINJAL 280,000 288,000 568,000
54 USG PROSTAT 280,000 288,000 568,000
55 USG TESTIS 305,000 288,000 593,000
56 VCUG 1,200,000 1,725,000 2,925,000
57 Videourodinamik (OK) 11,178,000 4,600,000 15,778,000
5.11 PSIKIATRI
1 Forensik I 222,000 516,000 738,000
2 Forensik II 396,000 966,000 1,362,000
3 Forensik III 568,000 1,932,000 2,500,000
4 Forensik IV 600,000 2,576,000 3,176,000
5 Hipnoterapi 72,000 263,000 335,000
6 Konseling Keluarga 80,000 253,000 333,000
7 KONSULTASI ONE STOP ASSESSMENT 203,000 343,000 546,000
8 Konsultasi Psikiatri Anak 45,000 35,000 80,000
9 KONSULTASI PSIKOLOG 123,000 148,000 271,000
10 Konsultasi Psikolog 47,000 67,000 114,000
11 Konsultasi Ruangan 45,000 67,000 112,000
12 125,000 3,594,000 3,719,000
forensik (common case)
13 125,000 14,375,000 14,500,000
forensik (Kasus berat dengan penyulit)
JASA
PELAYANAN
14 125,000 7,188,000 7,313,000
forensik (Kasus berat)
15 MMPI 196,000 235,000 431,000
16 Motivational Enhancement Therapy 200,000 345,000 545,000
17 NCT 232,000 426,000 658,000
18 Paket CBT 160,000 391,000 551,000
19 Paket Eksternal kelas manajemen stress (Maks 20 orang) 2,001,000 9,545,000 11,546,000
20 Paket Internal kelas manajemen stress (Maks 20 orang) 5,045,000 8,625,000 13,670,000
21 Paket Terapi I Okupasi Terapi/Terapi Wicara/Sensori Integrasi 60,000 391,000 451,000
22 Paket Terapi II Okupasi Terapi/Terapi Wicara/Sensori Integrasi 460,000 391,000 851,000
24 Play Therapy 108,000 34,000 142,000
25 Psikoterapi I 45,000 35,000 80,000
26 Psikoterapi II 47,000 67,000 114,000
28 Psikoterapi Suportif 90,000 242,000 332,000
29 Remediasi Kognitif 206,000 166,000 372,000
30 Remediasi kognitif Berbasis Games 5x Kunjungan 665,000 575,000 1,240,000
31 Remediasi Kognitif Berbasis Games 8x kunjungan 1,064,000 460,000 1,524,000
32 Saksi Ahli 125,000 2,875,000 3,000,000
33 Skrining Kognitif berbasis Kertas 62,000 181,000 243,000
34 Terapi Kelompok 132,000 194,000 326,000
35 Terapi Keluarga 140,000 587,000 727,000
36 TERAPI KELUARGA A 123,000 148,000 271,000
37 TERAPI KELUARGA B 130,000 196,000 326,000
38 TERAPI KELUARGA C 138,000 245,000 383,000
39 Terapi Kognitif Prilaku Anak 40,000 34,000 74,000
40 Terapi Marital 94,000 467,000 561,000
41 Terapi Modifikasi Prilaku 40,000 34,000 74,000
42 TERAPI PERILAKU A 123,000 148,000 271,000
43 TERAPI PERILAKU B 130,000 196,000 326,000
44 TERAPI PERILAKU C 138,000 245,000 383,000
45 Terapi Prilaku 47,000 34,000 81,000
46 TERAPI REMEDIAL OLEH ORTHOPEDAGOG 690,000 587,000 1,277,000
TES PSIKOMETRI:PSIKOTEST (IQ) MMPI, NCT, MINAT DAN
47 218,000 245,000 463,000
BAKAT
48 Uji Psikometri/Tes IQ 92,000 84,000 176,000
5.12 BREAST
1 Angkat drain 67,000 78,000 145,000
2 Angkat Jahitan 85,000 173,000 258,000
3 Biopsi/ Eksisi Lokal 304,000 2,645,000 2,949,000
4 Core Biopsi 394,000 1,955,000 2,349,000
5 Core Biopsi (Guide) Tuntunan USG 348,000 2,737,000 3,085,000
6 Ekstirpasi 151,000 1,955,000 2,106,000
7 Evakuasi Hematom 305,000 - 305,000
8 Flushing cellsite 133,000 - 133,000
9 FNAB 225,000 1,495,000 1,720,000
10 FNAB + USG Guide 242,000 1,495,000 1,737,000
11 Ganti Verban Berat 161,000 575,000 736,000
12 Ganti Verban Ringan 64,000 115,000 179,000
14 Inj Kenacort 76,000 - 76,000
15 Injeksi Obat kemo/ Hormonal 109,000 - 109,000
18 Pasang NGT 116,000 352,000 468,000
19 Rawat luka 87,000 147,000 234,000
20 Skin Test Alergi Obat 140,000 587,000 727,000
5.13 ESTETIK
1 Angkat Jahitan berat 341,000 863,000 1,204,000
2 Angkat Jahitan Ringan 126,000 173,000 299,000
3 Anoskopi 574,000 805,000 1,379,000
4 aspirasi abses bartholin 495,000 345,000 840,000
5 Augmentasi 3,825,000 20,082,000 23,907,000
6 Augmentasi dengan implan dagu 2,550,000 13,388,000 15,938,000
7 Augmentasi hidung + tlg rwn 3,740,000 19,635,000 23,375,000
8 Augmentasi hidung sederhana 2,295,000 12,049,000 14,344,000
9 Augmentasi rhino implan + graft tulang rawan telinga 3,570,000 18,743,000 22,313,000
10 Auriculoplasty non mikrotia 3,570,000 18,743,000 22,313,000
11 Bedah beku Berat 1,120,000 690,000 1,810,000
JASA
PELAYANAN
12 Bedah beku Ringan 460,000 230,000 690,000
13 Bedah beku Sedang 790,000 460,000 1,250,000
14 bedah Mohs 1 stage 5,000,000 5,750,000 10,750,000
15 bedah Mohs 2 stage 10,000,000 8,625,000 18,625,000
16 bedah Mohs 3 stage 15,000,000 11,500,000 26,500,000
17 Blepharoplasty Atas 2,550,000 13,388,000 15,938,000
18 Blepharoplasty atas + brow lift 3,315,000 17,404,000 20,719,000
19 Blepharoplasty atas dan bawah 4,590,000 24,098,000 28,688,000
20 Blepharoplasty bawah 3,060,000 16,065,000 19,125,000
21 Botox Injeksi Per area, kiri & kanan 255,000 1,339,000 1,594,000
22 Brow lift 3,060,000 16,065,000 19,125,000
23 Brow Lift (reduksi kulit atas alis) 1,530,000 8,033,000 9,563,000
24 Brow Lift Open 3,060,000 16,065,000 19,125,000
25 CO2 Lesi dengan Luas < 1/4 wajah 1,019,000 460,000 1,479,000
26 CO2 Lesi dengan Luas 1/2 wajah s.d seluruh wajah 2,568,000 1,495,000 4,063,000
27 CO2 Lesi dengan Luas 1/4 wajah s.d 1/2 wajah 2,117,000 518,000 2,635,000
28 CO2 Lesi Terhitung 699,000 403,000 1,102,000
29 Debridement 4,080,000 21,420,000 25,500,000
30 debridement & kompres berat 660,000 460,000 1,120,000
31 debridement & kompres ringan 330,000 230,000 560,000
32 debridement & kompres sedang 495,000 345,000 840,000
33 Dermoskopi 413,000 288,000 701,000
34 DIODE A (5 - 15) 200,000 115,000 315,000
35 DIODE B (15 - 30') 250,000 173,000 423,000
36 DIODE C (>30') 300,000 288,000 588,000
37 Eksisi - Berat 1,800,000 3,450,000 5,250,000
38 Eksisi - Ringan 1,100,000 1,150,000 2,250,000
39 Eksisi - Sedang 1,500,000 2,300,000 3,800,000
40 Eksisi Fibroma Ganglion 2,380,000 12,495,000 14,875,000
41 Eksisi lokal 850,000 4,463,000 5,313,000
42 Eksisi nevus kompleks* 1,700,000 8,925,000 10,625,000
43 Eksisi nevus sederhana 1,020,000 5,355,000 6,375,000
44 Eksisi tumor sederhana (lipoma, fibroma, kista atheroma, dll) 2,550,000 13,388,000 15,938,000
45 Ekstraksi Corpus Alineum 1,020,000 5,355,000 6,375,000
49 Elektrokauter - Berat 793,000 1,380,000 2,173,000
50 Elektrokauter - Ringan 450,000 288,000 738,000
51 Elektrokauter - Sedang 649,000 690,000 1,339,000
52 Entropion/ectropion/ptosis lebih dar isatu Operasi Sedang II lokal 4,080,000 21,420,000 25,500,000
53 Entropion/ectropion/ptosis satu sisi Operasi Sedang Lokal 2,550,000 13,388,000 15,938,000
54 enukleasi moluskum >5 lesi 413,000 288,000 701,000
55 enukleasi moluskum 1-5 lesi 248,000 173,000 421,000
56 epidermal thinning 200,000 230,000 430,000
57 Epikantoplasti 2,040,000 10,710,000 12,750,000
58 Evakuasi silikonoma bibir atas 1,530,000 8,033,000 9,563,000
59 Evakuasi silikonoma bibir atas bawah 2,550,000 13,388,000 15,938,000
60 Evakuasi silikonoma bibir bawah 1,530,000 8,033,000 9,563,000
61 Evakuasi silikonoma dagu 2,040,000 10,710,000 12,750,000
62 Evakuasi silikonoma dengan implan dagu 3,060,000 16,065,000 19,125,000
63 Evakuasi Silikonoma Hidung (tanpa implan atau graft) 2,040,000 10,710,000 12,750,000
64 Evakuasi Silikonoma Hidung dengan implan 2,550,000 13,388,000 15,938,000
65 Fototerapi localized 1 125,000 87,000 212,000
68 Fototerapi localized whole body 248,000 173,000 421,000
69 Ganti Verban Berat 442,000 345,000 787,000
70 Ganti Verban Ringan 141,000 173,000 314,000
72 Genioplasty - Augmentasi 3,060,000 16,065,000 19,125,000
73 High Resolution Anoskopi 1,035,000 3,542,000 4,577,000
74 Hump Nose dengan osteotomi 5,100,000 26,775,000 31,875,000
75 Hump Nose tanpa osteotomi 2,550,000 13,388,000 15,938,000
76 Hymenoplasty 2,550,000 13,388,000 15,938,000
77 Incisi drainage abses multiple/kompleks Sedang 1 1,870,000 9,818,000 11,688,000
78 injeksi agen biologik* 250,000 288,000 538,000
79 Injeksi BotoX I* 2,100,000 2,300,000 4,400,000
80 Injeksi Botox II* 2,500,000 3,450,000 5,950,000
81 Injeksi Filler 1,020,000 5,355,000 6,375,000
JASA
PELAYANAN
82 Injeksi Filler I* 2,100,000 4,025,000 6,125,000
83 Injeksi Filler II* 2,500,000 5,175,000 7,675,000
84 Injeksi Kortikosteroid Intralesi Berat* 300,000 230,000 530,000
85 Injeksi Kortikosteroid Intralesi Ringan* 200,000 115,000 315,000
86 Injeksi Kortikosteroid Intralesi Sedang* 250,000 173,000 423,000
88 Insisi & drainase abses 340,000 1,785,000 2,125,000
89 insisi abses 400,000 460,000 860,000
90 insisi abses bartholin 660,000 460,000 1,120,000
91 Insisi Furunkel / Abses 200,000 1,050,000 1,250,000
92 Jahitan > 10 (jahit kulit primer wajah oleh bedah plastik) 1,870,000 9,818,000 11,688,000
Jahitan Kulit dan Jahitan < 10 (jahit kulit primer wajah oleh bedah
93 935,000 4,909,000 5,844,000
plastik)
94 Kontraktur jari-jari Operasi Khusus I 1,530,000 8,033,000 9,563,000
95 Kontraktur linier dan difus dengan Z-plasty dan skin graft 1,734,000 9,104,000 10,838,000
97 Kontraktur linier jari tangan dengan multipel Z-Plasty > 1 Jari 850,000 4,463,000 5,313,000
98 Kontraktur linier jari tangan dengan multipel Z-plasty 1 jari 1,020,000 5,355,000 6,375,000
100 Lase V-Beam - Jumlah pulsa = 10 1,342,000 460,000 1,802,000
101 Lase V-Beam - Jumlah pulsa 11-30 2,080,000 633,000 2,713,000
102 Lase V-Beam - Jumlah pulsa 31-60 3,262,000 863,000 4,125,000
103 Lase V-Beam 1 wajah - Jumlah pulsa 250-400 6,500,000 3,220,000 9,720,000
104 Lase V-Beam 1 wajah - Jumlah pulsa 250-400 -JR 9,340,000 3,680,000 13,020,000
105 Lesung pipi 1,700,000 8,925,000 10,625,000
106 Lipofilling Bibir 2,040,000 10,710,000 12,750,000
107 Lipofilling Blepharo atas 2,040,000 10,710,000 12,750,000
108 Lipofilling Blepharo bawah 2,040,000 10,710,000 12,750,000
109 Lipofilling Wajah 2,550,000 13,388,000 15,938,000
110 Liposuction 2,040,000 10,710,000 12,750,000
111 Liposuction 2,040,000 11,730,000 13,770,000
112 Liposuction - Perut 2,720,000 14,280,000 17,000,000
113 Liposuction - Paha luar/dlm 3,400,000 17,850,000 21,250,000
114 Liposuction - Punggung/ats bokong 1,360,000 7,140,000 8,500,000
115 Liposuction + Fat transfer 2,729,000 15,690,000 18,419,000
116 Liposuction Betis/angkle 3,400,000 17,850,000 21,250,000
118 Liposuction Fat Transfer 2,729,000 14,326,000 17,055,000
119 Liposuction Leher 2,550,000 13,388,000 15,938,000
120 Liposuction Paha 2,550,000 13,388,000 15,938,000
121 Liposuction Paha Bilateral 4,208,000 22,090,000 26,298,000
122 Liposuction Punggung/area (atas/bawah) 1,020,000 5,355,000 6,375,000
123 Liposuction-Wajah 2,550,000 13,388,000 15,938,000
124 Lobuloplasty 1,530,000 8,033,000 9,563,000
125 Lower Blefaro 3,060,000 16,065,000 19,125,000
126 Medial Epichantoplasty (buka sudut mata)* 1,700,000 8,925,000 10,625,000
127 Membentuk bibir atas 1,530,000 8,033,000 9,563,000
128 Membentuk bibir atas bawah 2,550,000 13,388,000 15,938,000
129 Membentuk bibir bawah 1,530,000 8,033,000 9,563,000
130 Mengecilkan areola mammae 1,530,000 8,033,000 9,563,000
131 Mini face lift 2,550,000 13,388,000 15,938,000
132 NdYag Lesi dengan luas < 1/4 wajah 1,658,000 748,000 2,406,000
133 NdYag Lesi dengan luas 1/2 wajah s.d. seluruh wajah 3,314,000 1,265,000 4,579,000
134 NdYag Lesi dengan luas 1/4 wajah s.d. 1/2 wajah 2,125,000 978,000 3,103,000
135 Neck lift 3,060,000 16,065,000 19,125,000
136 Open Rhinoplasty/augmentasi + Revisi Ala Nasi 3,570,000 18,743,000 22,313,000
139 pemeriksaan asam asetat 165,000 115,000 280,000
140 pengambilan spesimen laki-laki 165,000 115,000 280,000
141 pengambilan spesimen perempuan dengan spekulum 413,000 288,000 701,000
142 pengambilan spesimen perempuan tanpa spekulum 248,000 173,000 421,000
143 Podopilin > 5 lesi 202,000 230,000 432,000
144 Podopilin 1-5 lesi 161,000 147,000 308,000
145 PRP 1,000,000 1,150,000 2,150,000
146 Ptosis Correction dua sisi 4,080,000 21,420,000 25,500,000
147 Ptosis Correction satu sisi 2,550,000 13,388,000 15,938,000
148 Reduksi hiperplasia labia minora 2,040,000 10,710,000 12,750,000
149 Reduksi makroklitoris 2,550,000 13,388,000 15,938,000
150 Rejuvanation 3,382,000 1,783,000 5,165,000
JASA
PELAYANAN
151 Rekonstruksi dengan STSG Sederhana (<5x5cm) 1,530,000 8,033,000 9,563,000
152 Rekonstruksi Glans Penis 3,417,000 17,940,000 21,357,000
153 Rekontruksi dengan Flap Kulit Sederhana 3,825,000 20,082,000 23,907,000
155 Repair tendon 5,100,000 26,775,000 31,875,000
156 Revisi ala nasi 1,275,000 6,694,000 7,969,000
157 Revisi Scar 2,720,000 14,280,000 17,000,000
158 Rhinoplasty Operasi Khusus II 3,570,000 18,743,000 22,313,000
159 Septoplasty Operasi Sedang II 3,570,000 18,743,000 22,313,000
160 Septoplasty/humpnose/open 4,080,000 21,420,000 25,500,000
161 Septorhinoplasty Operasi besar II 3,570,000 18,743,000 22,313,000
162 Sirkumsisi 2,040,000 10,710,000 12,750,000
163 Subsicion Berat 250,000 460,000 710,000
166 tato removal Berat 3,314,000 1,265,000 4,579,000
167 tato removal Ringan 2,125,000 978,000 3,103,000
168 Tip rhinoplasty 2,550,000 13,388,000 15,938,000
169 Tip Rhinoplasty (tanpa graft dan tanpa implan) 2,550,000 13,388,000 15,938,000
170 Tip Rhinoplasty dan Septoplasty dengan anestesi 3,825,000 20,082,000 23,907,000
171 Trichloro acetat >5 lesi 330,000 230,000 560,000
172 Trichloro acetat 1-5 lesi 211,000 147,000 358,000
173 Uji Patergi 300,000 460,000 760,000
174 Uji penisilin 1 726,000 580,000 1,306,000
175 uji penisilin ulangan 550,000 506,000 1,056,000
176 Uji Provokasi Obat 726,000 506,000 1,232,000
177 uji serum autolog 1,000,000 608,000 1,608,000
178 uji serum autolog & uji tusuk standar 1,452,000 1,012,000 2,464,000
179 Uji tempel Obat >5 obat 1,000,000 1,012,000 2,012,000
180 Uji tempel Obat 1-5 obat 726,000 506,000 1,232,000
181 Uji tusuk Obat >5 obat 1,300,000 1,012,000 2,312,000
182 Uji tusuk Obat 1-5 obat 1,100,000 690,000 1,790,000
183 Uji tusuk standar 1,100,000 690,000 1,790,000
184 Vaginoplasty (aging) 4,590,000 24,098,000 28,688,000
185 whiff test / Test Amin 50,000 115,000 165,000
5.14 SPINE DAN BONE JOINT
1 Angkat Jahitan besar (>15jahitan) 652,000 1,150,000 1,802,000
2 Angkat Jahitan kecil (1-7jahitan) 516,000 288,000 804,000
3 Angkat Jahitan sedang (8-15jahitan) 516,000 575,000 1,091,000
4 Aspirasi Kista 405,000 805,000 1,210,000
5 Aspirasi Sendi 405,000 1,150,000 1,555,000
6 Biopsi Eksisi < 3 cm 1,227,000 1,725,000 2,952,000
7 Biopsi Eksisi > 3 cm 1,329,000 2,300,000 3,629,000
8 Biopsi Insisi 1,180,000 2,300,000 3,480,000
9 Bone marrow aspiration 1,500,000 5,750,000 7,250,000
10 Buka body jacket 131,000 2,300,000 2,431,000
11 Buka gips atas lutut 131,000 1,150,000 1,281,000
12 Buka Gips atas siku 131,000 1,150,000 1,281,000
13 Buka Gips bawah lutut 131,000 1,150,000 1,281,000
14 Buka Gips bawah siku 131,000 1,150,000 1,281,000
15 Buka hip spica 131,000 2,300,000 2,431,000
16 Cabut K-wire / pin dengan anestesi lokal 1,180,000 1,725,000 2,905,000
17 Core Biopsi (CT guided) 2,932,000 2,300,000 5,232,000
18 Debridement luka besar (>11cm) 1,066,000 1,725,000 2,791,000
19 Debridement luka kecil (<5cm) 824,000 575,000 1,399,000
20 Debridement luka sedang (6cm - 10cm) 824,000 1,150,000 1,974,000
21 Ekstraksi corpus alienum 1,180,000 1,725,000 2,905,000
22 Ganti Balutan Besar Sulit 300,000 1,150,000 1,450,000
23 Gips Total Contact Cast 600,000 2,300,000 2,900,000
24 Implantasi sel punca pada intrakompartemen 900,000 3,450,000 4,350,000
25 Implantasi sel punca pada kelainan tendon 900,000 3,450,000 4,350,000
26 Implantasi sel punca secara intra tekal pada kasus neurologi 1,500,000 5,750,000 7,250,000
27 Infus intravena sel punca 1,200,000 4,600,000 5,800,000
28 Injeksi Intraarticular 731,000 863,000 1,594,000
29 Injeksi intraartikular sel punca 450,000 1,725,000 2,175,000
30 731,000 863,000 1,594,000
compression)
31 Injeksi intralesional sel punca 450,000 1,725,000 2,175,000
32 Injeksi intramuskuler sel punca 450,000 1,725,000 2,175,000
33 Insisi Abses Kulit 1,156,000 863,000 2,019,000
JASA
PELAYANAN
34 Jahit < 10 simpul 1,102,000 1,150,000 2,252,000
35 Jahit > 10 simpul 1,746,000 1,150,000 2,896,000
36 Pemasangan Bandage 300,000 403,000 703,000
37 Pemasangan body jacket 780,000 2,300,000 3,080,000
38 Pemasangan Gips atas lutut tanpa reposisi 777,000 2,300,000 3,077,000
39 Pemasangan Gips atas siku tanpa reposisi 590,000 2,300,000 2,890,000
40 Pemasangan Gips bawah lutut tanpa reposisi 574,000 2,300,000 2,874,000
41 Pemasangan Gips bawah siku tanpa reposisi 384,000 2,300,000 2,684,000
42 Pemasangan hip spica 3,401,000 2,300,000 5,701,000
43 Pemasangan Slab 849,000 863,000 1,712,000
44 pemasangan total contact cast 757,000 1,150,000 1,907,000
45 Ponseti A 540,000 2,070,000 2,610,000
46 Ponseti B 900,000 3,450,000 4,350,000
47 Rawat luka terbuka besar (>11cm) 1,047,000 575,000 1,622,000
48 Rawat luka terbuka kecil (< 5cm) 813,000 403,000 1,216,000
49 Rawat luka terbuka sedang (6cm - 10cm) 813,000 460,000 1,273,000
50 Release trigger finger percutaneous 450,000 1,725,000 2,175,000
51 Reposisi dan pemasangan gips atas lutut dengan lokal anestesi 1,112,000 2,300,000 3,412,000
52 Reposisi dan pemasangan gips atas siku dengan lokal anestesi 926,000 2,300,000 3,226,000
53 Reposisi dan pemasangan gips bawah lutut dengan lokal anestesi 910,000 2,300,000 3,210,000
54 Reposisi dan Pemasangan Gips bawah siku dengan lokal anestesi 720,000 2,300,000 3,020,000
55 Rozer plasty 1,180,000 1,150,000 2,330,000
56 Skin Traction 433,000 1,150,000 1,583,000
57 Strapping 538,000 863,000 1,401,000
5.15 NEUROSCIENCE
1 Administrasi + Surat Keterangan Kematian 25,000 20,000 45,000
2 AFHECHTING / ANGKAT JAHITAN 143,000 733,000 876,000
3 Asuransi Korban hidup 99,000 76,000 175,000
4 Asuransi Korban mati 144,000 110,000 254,000
5 Blink Refleks 574,000 748,000 1,322,000
6 Brainstem Auditory Evoked Potential 862,000 863,000 1,725,000
7 Carotid Duplex 422,000 978,000 1,400,000
8 Cognitive Event Related Potential (P300) 862,000 863,000 1,725,000
9 Diagnostik TMS 319,000 748,000 1,067,000
10 EEG Challenge Diazepam 1,681,000 1,150,000 2,831,000
12 EEG Premedikasi 1,433,000 863,000 2,296,000
13 EEG rutin 1,302,000 460,000 1,762,000
14 EEG Sleep Depriviation 1,430,000 863,000 2,293,000
15 EMG dengan jarum 548,000 748,000 1,296,000
16 EMG tanpa jarum 319,000 748,000 1,067,000
17 fungsi luhur rutin 257,000 1,150,000 1,407,000
18 Implantasi sel punca intratekal 1,543,000 5,750,000 7,293,000
19 Implantasi sel punca tulang belakang dengan C-Arm 4,000,000 16,963,000 20,963,000
20 Index Vascular Migrain (IVM) 346,000 690,000 1,036,000
21 Infus intravena sel punca 239,000 4,600,000 4,839,000
22 Injeksi Intraartikular 165,000 575,000 740,000
23 Injeksi Intraartikular dengan guided USG 375,000 920,000 1,295,000
24 Injeksi Intraartikular Khusus 165,000 920,000 1,085,000
25 Injeksi intraartikular sel punca 239,000 1,725,000 1,964,000
26 Injeksi intralesional sel punca 239,000 1,725,000 1,964,000
27 Injeksi intramuskular 165,000 575,000 740,000
28 Injeksi intramuskular 165,000 920,000 1,085,000
29 Injeksi intramuskular guided USG 375,000 920,000 1,295,000
30 Injeksi spine guided USG 750,000 2,875,000 3,625,000
31 Injeksi spine guided USG Khusus 750,000 3,450,000 4,200,000
33 IOM HNP Servikal 5,408,000 8,349,000 13,757,000
35 IOM Skoliosis 6,995,000 12,524,000 19,519,000
39 Kecepatan Hantar Saraf 321,000 690,000 1,011,000
40 Kecepatan Hantar Saraf dan F-wave/H-Refleks 321,000 863,000 1,184,000
41 Kemoterapi Intratekal* 1,543,000 5,988,000 7,531,000
42 Legalisir Surat Keterangan Kematian 19,000 15,000 34,000
43 Lumbal Pungsi Guided 750,000 3,450,000 4,200,000
44 Lumbal Pungsi non guided 206,000 2,300,000 2,506,000
45 Medikolegal 75,000 489,000 564,000
JASA
PELAYANAN
46 Pasang Chateter 219,000 196,000 415,000
47 Pasang NGT 244,000 196,000 440,000
48 Pelayanan Etikomedikolegal Forensik-Advokasi Transplantasi Organ 568,000 1,560,000 2,128,000
49 Pelayanan Gamma Knife 125,017,000 12,000,000 137,017,000
50 Poli Somno Grafi (PSG) 3,471,000 2,300,000 5,771,000
51 Repetitive Nerve Stimulation 342,000 748,000 1,090,000
52 rTMS Single Treatment 525,000 978,000 1,503,000
53 rTMS Treatment Pakcage 5,250,000 9,775,000 15,025,000
54 Somatosensory Evoked Potential 1,057,000 863,000 1,920,000
55 Spasmofili 291,000 748,000 1,039,000
56 Sympathetic Skin Response 640,000 748,000 1,388,000
57 TCD Buble Contrast 298,000 978,000 1,276,000
58 Terapi injeksi Botulinum Toksin 239,000 1,150,000 1,389,000
59 Trans Cranial Doppler 422,000 978,000 1,400,000
61 USG Guided Pain Management - Ekstrimitas 1,543,000 1,150,000 2,693,000
62 Visual Evoked Potential 862,000 863,000 1,725,000
5.16 CARDIOVASCULAR
1 Angkat jahitan 107,000 733,000 840,000
2 Dopler Extremitas Bawah 1 Tungkai 727,000 2,070,000 2,797,000
3 Dopler Extremitas Bawah 2 Tungkai 727,000 4,025,000 4,752,000
4 Dopler Extremitas Vaskuler 1 Tangan 727,000 863,000 1,590,000
5 Dopler Extremitas Vaskuler 2 Tangan 727,000 1,725,000 2,452,000
6 Doppler Vaskular carotis 588,000 1,725,000 2,313,000
7 Echocardiography 546,000 932,000 1,478,000
8 Echocardiography (Pendampingan tindakan) 546,000 1,256,000 1,802,000
9 Echocardiography bubble test 337,000 1,438,000 1,775,000
10 EKG 108,000 58,000 166,000
11 Foam Skleroterapi 1 tungkai non USG guided 192,000 611,000 803,000
12 Perawatan Luka besar 419,000 805,000 1,224,000
13 Perawatan Luka besar sulit 542,000 1,725,000 2,267,000
14 Perawatan Luka kecil 173,000 288,000 461,000
15 Perawatan Luka sedang 295,000 575,000 870,000
16 Skin Laser 244,000 1,222,000 1,466,000
17 Skleroterapi 1 tungkai Multiple 337,000 575,000 912,000
18 Skleroterapi dua tungkai 337,000 5,242,000 5,579,000
19 Skleroterapi satu tungkai 192,000 4,032,000 4,224,000
20 Stress Echo Debutamin 466,000 2,599,000 3,065,000
21 Trans Esofageale Echo (TEE) 727,000 3,105,000 3,832,000
22 Trans Esofageale Echo (TEE) dengan anestesi 965,000 5,859,000 6,824,000
23 Treadmill Test 368,000 920,000 1,288,000
24 USG pre operasi untuk vein mapping 243,000 1,410,000 1,653,000
5.17 REHABILITASI MEDIK
4 Chest Terapi 135,000 115,000 250,000
5 Dry Needling @ 5 Titik 128,000 173,000 301,000
6 429,000 230,000 659,000
7 Evaluasi kapasitas fungsional return to activities 246,000 863,000 1,109,000
8 Evaluasi kapasitas fungsional return to work 246,000 863,000 1,109,000
9 Evaluasi Kemampuan Intelektual (Test IQ) 434,000 252,000 686,000
12 Layanan Psikologis Lainnya 434,000 252,000 686,000
13 Low Level Laser Therapy 122,000 137,000 259,000
16 96,000 173,000 269,000
Rehab psikososial, lingkungan, rumah, dan hambatan kerja;
18 121,000 107,000 228,000
21 Tatalaksana dengan Virtual Reality 169,000 863,000 1,032,000
22 Tatalaksana dengan Work simulator 534,000 575,000 1,109,000
JASA
PELAYANAN
25 71,000 173,000 244,000
menelan
27 135,000 151,000 286,000
31 Terapi inhalasi 86,000 86,000 172,000
32 Terapi Injeksi Botulinum Toksin A @ 5 titik 128,000 219,000 347,000
33 Terapi Injeksi Botulinum Toksin A dengan Panduan USG @ 5 titik 128,000 219,000 347,000
34 128,000 219,000 347,000
35 128,000 219,000 347,000
36 128,000 219,000 347,000
Terapi injeksi substansi terapeutik dengan panduan USG
37 128,000 219,000 347,000
Muskuloskeletal (tendon)
38 185,000 173,000 358,000
Jalan)
41 Terapi latihan dengan robotic system 623,000 1,150,000 1,773,000
43 132,000 173,000 305,000
osteoporosis, koreksi postur, robotik, virtual reality
45 84,000 86,000 170,000
Dasar Panggul)
46 73,000 173,000 246,000
56 Terapi Modalitas : PTNS, NMES 125,000 173,000 298,000
57 Terapi Modalitas : Tapping Straping 125,000 137,000 262,000
58 Terapi Modalitas : TENS, ES 75,000 87,000 162,000
62 Terapi Modalitas: Dingin (Ice Massage/ Vapocoolant spray) 75,000 87,000 162,000
63 Terapi musik 87,000 173,000 260,000
64 Terapi perilaku 101,000 173,000 274,000
65 Terapi rekreasi 120,000 86,000 206,000
66 101,000 173,000 274,000
69 Uji Fungsi Persepsi dan Kognisi 90,000 173,000 263,000
dan proprioseptif, Komunikasi, Motorik halus anak, Fungsi Koordinasi
70 184,000 173,000 357,000
dan Deksteritas Manual, Kardiorespirasi, Spirometri, AKS,
Vokasional, Uji Fungsi Berkemih)
JASA
PELAYANAN
71 96,000 173,000 269,000
72 USG muskuloskeletal 329,000 230,000 559,000
5.18 MATA
1 Ahmed Implant (Lokal) 10,910,000 5,175,000 16,085,000
2 Ahmed Implant (Umum) 14,530,000 7,245,000 21,775,000
3 ALR+Spliting Tarsus (Lokal) 8,100,000 7,648,000 15,748,000
4 ALR+Spliting Tarsus (Umum) 7,100,000 5,463,000 12,563,000
6 Angkat Jahitan (Lokal) 990,000 835,000 1,825,000
7 Angkat Jahitan (Umum) 3,800,000 1,638,000 5,438,000
8 Angkat Jahitan kornea 300,000 230,000 530,000
9 Angkat Jahitan Palpebra / DFG 200,000 230,000 430,000
10 Autoref 15,000 12,000 27,000
11 Baevelt implant (Lokal) 8,430,000 5,175,000 13,605,000
12 Baevelt implant (Umum) 12,050,000 7,245,000 19,295,000
13 Biopsi insisi kelopak (Lokal) 6,300,000 5,796,000 12,096,000
14 Biopsi insisi kelopak (Umum) 5,300,000 4,140,000 9,440,000
15 Biopsi insisi konjungtiva (Lokal) 9,300,000 5,796,000 15,096,000
16 Biopsi insisi konjungtiva (Umum) 8,300,000 4,140,000 12,440,000
17 Biopsi insisi orbita (Lokal) 6,000,000 7,648,000 13,648,000
18 Biopsi insisi orbita (Umum) 5,000,000 5,463,000 10,463,000
19 Blefaroplasti (Lokal) 11,400,000 10,063,000 21,463,000
20 Blefaroplasti (Umum) 10,400,000 7,188,000 17,588,000
23 Demodex 200,000 86,000 286,000
25 Dermolipoma 1,000,000 1,150,000 2,150,000
26 Eksenterasi (Umum) 14,400,000 18,515,000 32,915,000
27 Eksenterasi kompleks (Lokal) 18,000,000 21,494,000 39,494,000
28 Eksisi Granuloma 1,520,000 805,000 2,325,000
29 Eksisi tumor kelopak besar (>5 mm) (Lokal) 6,000,000 8,855,000 14,855,000
30 Eksisi tumor kelopak besar (>5 mm) (Umum) 5,000,000 6,325,000 11,325,000
31 Eksisi tumor kelopak kecil (<5 mm) (Lokal) 5,400,000 5,796,000 11,196,000
32 Eksisi tumor kelopak kecil (<5 mm) (Umum) 4,400,000 4,140,000 8,540,000
33 Eksisi tumor konjungtiva besar (keterlibatan >1 clock hour) (Lokal) 7,200,000 7,648,000 14,848,000
34 Eksisi tumor konjungtiva besar (keterlibatan >1 clock hour) (Umum) 6,200,000 5,463,000 11,663,000
35 Eksisi tumor konjungtiva kecil (keterlibatan <1 clock hour) (Lokal) 4,800,000 4,830,000 9,630,000
36 Eksisi tumor konjungtiva kecil (keterlibatan <1 clock hour) (Umum) 3,800,000 3,450,000 7,250,000
38 Enucleation (Umum) 10,440,000 7,648,000 18,088,000
39 Enucleation with dermofat graft (Lokal) 11,700,000 12,075,000 23,775,000
40 Enucleation with orbital implant (Umum) 11,100,000 10,063,000 21,163,000
41 Enukleasi dan eksisi tumor (Lokal) 14,700,000 20,125,000 34,825,000
43 ERG 300,000 288,000 588,000
44 Evisceration (Lokal) 10,440,000 6,440,000 16,880,000
45 Evisceration with dermofat graft (Umum) 11,700,000 11,270,000 22,970,000
46 External DCR + silicon tube (Lokal) 7,580,000 9,488,000 17,068,000
47 External DCR + silicon tube (Umum) 8,580,000 13,283,000 21,863,000
49 Foto Fundus 140,000 69,000 209,000
50 Ganti Balutan(Verband) / Fitting Protesa 150,000 115,000 265,000
51 HESS Screen 170,000 115,000 285,000
52 Hordeolum ( Insici )/Kalazion OK 3,800,000 4,025,000 7,825,000
53 Humprey 180,000 173,000 353,000
54 Humprey 180,000 173,000 353,000
55 ICG Fundus /FFA optos (umum dan perusahaan) 2,350,000 633,000 2,983,000
56 ICG Fundus /FFA optos (umum dan perusahaan) 2,350,000 633,000 2,983,000
57 Injeksi Intrastromal (ok) 521,000 690,000 1,211,000
58 Injeksi Intrastromal (POLI) 521,000 690,000 1,211,000
59 Injeksi intravitreal ( Cymeven ) (Lokal) 2,486,000 1,438,000 3,924,000
60 Injeksi intravitreal ( Cymeven ) (Umum) 6,105,000 2,013,000 8,118,000
61 Injeksi intravitreal ( Fungizone ) (Lokal) 1,833,000 1,438,000 3,271,000
62 Injeksi intravitreal ( Fungizone ) (Umum) 5,452,000 2,013,000 7,465,000
63 Injeksi intravitreal ( Lucentis ) (Lokal) 10,320,000 1,438,000 11,758,000
64 Injeksi intravitreal ( Lucentis ) (Umum) 10,320,000 2,013,000 12,333,000
65 Injeksi intravitreal ( Vancep + Ceftazidime ) (Lokal) 1,595,000 1,438,000 3,033,000
JASA
PELAYANAN
66 Injeksi intravitreal ( Vancep + Ceftazidime ) (Umum) 5,216,000 2,013,000 7,229,000
67 Injeksi intravitreal (ok) 470,000 690,000 1,160,000
68 Injeksi intravitreal (POLI) 472,000 690,000 1,162,000
69 Injeksi intravitreal/Subkonjungtiva ( Avastine ) (Lokal) 1,336,000 1,438,000 2,774,000
70 Injeksi intravitreal/Subkonjungtiva ( Avastine ) (Umum) 3,749,000 2,013,000 5,762,000
71 Injeksi intravitreal/Subtenon ( Triamcinolone ) (Lokal) 1,426,000 1,438,000 2,864,000
72 Injeksi intravitreal/Subtenon ( Triamcinolone ) (Umum) 5,045,000 2,013,000 7,058,000
73 Insisi abses 400,000 805,000 1,205,000
74 IOL Master - (700) 300,000 173,000 473,000
75 Iridektomi operatif (Lokal) 4,158,000 2,300,000 6,458,000
76 Iridektomi operatif (Umum) 7,779,000 3,220,000 10,999,000
77 Jahit Palpebra Ringan 1,100,000 1,150,000 2,250,000
78 Kantopeksi (Lokal) 11,400,000 10,063,000 21,463,000
79 Kantopeksi (Umum) 10,400,000 7,188,000 17,588,000
80 Keratoplasty (Umum) 17,064,000 10,465,000 27,529,000
81 Lacrimal probing with/without infracturing concha (Lokal) 3,080,000 3,450,000 6,530,000
82 Lacrimal probing with/without infracturing concha (Umum) 4,080,000 4,830,000 8,910,000
Lacrimal probing with/without infracturing concha with endoscope
83 4,640,000 4,888,000 9,528,000
(Lokal)
Lacrimal probing with/without infracturing concha with endoscope
84 5,640,000 6,843,000 12,483,000
(Umum)
85 Laser Perifer Iridektomi (LPI) - Glaukoma 800,000 863,000 1,663,000
86 Lateral tarsal strip (Lokal) 8,100,000 7,648,000 15,748,000
87 Lateral tarsal strip (Umum) 7,100,000 5,463,000 12,563,000
88 Levator reseksi (Lokal) 8,100,000 7,648,000 15,748,000
89 Levator reseksi (Umum) 7,100,000 5,463,000 12,563,000
90 Limbal stem cell graft/Conjunctivolimbal allograft (Lokal) 11,100,000 12,880,000 23,980,000
91 Lip mucosal graft (Lokal) 10,800,000 8,050,000 18,850,000
92 Low Vision 600,000 230,000 830,000
93 Medial wall and orbital floor fracture/naso orbital fracture (Umum) 15,900,000 20,125,000 36,025,000
94 Mild Soket reconstruction (Lokal) 10,800,000 10,063,000 20,863,000
95 Moderate soket rekonstruktion (Umum) 12,600,000 15,698,000 28,298,000
96 Naso orbital fracture with complete rhinoplasty (Lokal) 17,100,000 21,494,000 38,594,000
97 Naso orbital fracture with DCR (Umum) 17,100,000 21,494,000 38,594,000
98 Naso orbital fracture with Partial rhinoplasty (Lokal) 16,200,000 20,125,000 36,325,000
99 Nekrotomi 220,000 288,000 508,000
100 OCT Scan / Visante 300,000 173,000 473,000
101 Octopus 200,000 173,000 373,000
102 Operasi Kelopak Berat (Lokal) 14,420,000 12,363,000 26,783,000
103 Operasi Kelopak Berat (Umum) 15,420,000 17,308,000 32,728,000
104 Operasi Kelopak Ringan (Lokal) 7,820,000 3,163,000 10,983,000
105 Operasi Kelopak Ringan (Umum) 8,820,000 4,428,000 13,248,000
106 Operasi Kelopak Sedang 1 (Lokal) 8,960,000 5,175,000 14,135,000
107 Operasi Kelopak Sedang 1 (Umum) 9,960,000 7,245,000 17,205,000
108 Operasi Kelopak Sedang 2 (Lokal) 11,360,000 8,625,000 19,985,000
109 Operasi Kelopak Sedang 2 (Umum) 12,360,000 12,075,000 24,435,000
110 orbital floor fracture (Umum) 14,100,000 17,710,000 31,810,000
111 Orbitotomi anterior dan eksisi tumor kompleks (Umum) 12,300,000 15,295,000 27,595,000
112 Orbitotomi anterior dan ekstirpasi tumor (Lokal) 11,100,000 12,478,000 23,578,000
113 Orbitotomi lateral dan eksisi tumor (Lokal) 14,100,000 18,515,000 32,615,000
114 Orbitotomi lateral dan eksisi tumor kompleks (Umum) 18,000,000 21,494,000 39,494,000
115 Parasentesa 250,000 345,000 595,000
Pemeriksaan Calon PPDS (BCVA, Humprey, Segmen Anterior,
116 173,000 - 173,000
Segmen Posterior, Stereoscopis)
117 Pemeriksaan ERG dan VEP 800,000 575,000 1,375,000
118 Pemeriksaan Foto Fundus non midriatikum 140,000 69,000 209,000
119 Pengukuran tekanan intra okular 15,000 12,000 27,000
122 Periosteal atau Fascialata Graft (Lokal) 11,100,000 8,453,000 19,553,000
123 Periosteal atau Fascialata Graft (Umum) 10,100,000 6,038,000 16,138,000
124 Photokoagulasi Laser (Argon Laser) -Retina 1,500,000 1,438,000 2,938,000
125 Pterigium plasti / tato kornea (Lokal) 3,168,000 2,338,000 5,506,000
126 Pterigium plasti / tato kornea (Umum) 6,789,000 3,274,000 10,063,000
127 Punctum atresia (Lokal) 2,600,000 3,163,000 5,763,000
128 Punctum atresia (Umum) 3,600,000 4,428,000 8,028,000
129 Reconstruction post tumor berat (Umum) 11,400,000 10,465,000 21,865,000
130 Reconstruction post tumor sedang (Lokal) 10,500,000 7,648,000 18,148,000
131 Reformasi COA ( operasi dari luar ) (Lokal) 2,970,000 2,875,000 5,845,000
JASA
PELAYANAN
132 Reformasi COA ( operasi dari luar ) (Umum) 6,591,000 4,025,000 10,616,000
133 Refraksi 15,000 12,000 27,000
134 Repair kornea ( Emergency) (Lokal) 7,949,000 5,175,000 13,124,000
135 Repair kornea ( Emergency) (Umum) 9,257,000 7,245,000 16,502,000
136 Repair sklera ( Emergency ) (Lokal) 8,410,000 5,750,000 14,160,000
137 Repair sklera ( Emergency ) (Umum) 9,965,000 8,050,000 18,015,000
138 Reposisi IOL (luar RSCM) (Lokal) 3,370,000 3,738,000 7,108,000
139 Reposisi IOL (luar RSCM) (Umum) 6,591,000 5,233,000 11,824,000
140 Reposisi Iris (luar RSCM) (Lokal) 3,687,000 3,163,000 6,850,000
141 Reposisi Iris (luar RSCM) (Umum) 6,591,000 4,428,000 11,019,000
142 Retinometri 120,000 115,000 235,000
143 Revisi Bleb / Trabekulektomi (Lokal) 2,970,000 2,013,000 4,983,000
144 Revisi Bleb / Trabekulektomi (Umum) 6,591,000 2,818,000 9,409,000
145 Screening ROP 350,000 403,000 753,000
146 Severe soket rekonstruktion (Lokal) 16,200,000 20,125,000 36,325,000
147 skin graft /Periosteal graft (Lokal) 10,800,000 8,453,000 19,253,000
148 skin graft /Periosteal graft (Umum) 9,800,000 6,038,000 15,838,000
150 Specullar Microscope (Non Con Robo) 90,000 115,000 205,000
151 Strabismus otot 1 (Lokal) 4,356,000 4,025,000 8,381,000
152 Strabismus otot 1 (Umum) 7,977,000 5,635,000 13,612,000
159 Suntik Botox 2,979,000 1,150,000 4,129,000
160 Tambah Jahitan (Lokal) 2,970,000 835,000 3,805,000
161 Tambah Jahitan (Umum) 4,000,000 1,638,000 5,638,000
162 Tarsorafi Beban Emas (Lokal) 8,100,000 7,648,000 15,748,000
163 Tarsorafi Beban Emas (Umum) 7,100,000 5,463,000 12,563,000
164 Tes Schimer (BUT) 70,000 86,000 156,000
165 Toppolyzer 180,000 115,000 295,000
166 Trabeculectomy + MMC/injeksi 5FU (Lokal) 5,742,000 4,025,000 9,767,000
167 Trabeculectomy + MMC/injeksi 5FU (Umum) 9,363,000 5,635,000 14,998,000
168 Tripod fraktur (Umum) 17,100,000 21,494,000 38,594,000
169 UBM (minimal 4 org perhari) 1,000,000 288,000 1,288,000
170 USG 350,000 288,000 638,000
171 VEP 300,000 288,000 588,000
172 Vitreus Tap (Lokal) 4,258,000 1,898,000 6,156,000
173 Vitreus Tap (Umum) 7,877,000 2,657,000 10,534,000
174 Yag Laser - KBR/ Glaukoma 1,000,000 863,000 1,863,000
5.19 PEDIATRIK
2 Arteri line 410,000 1,898,000 2,308,000
3 Asuhan nutrisi enteral dasar 132,000 115,000 247,000
4 Asuhan nutrisi enteral khusus 320,000 115,000 435,000
5 Asuhan nutrisi parenteral 1,468,000 230,000 1,698,000
6 Bilas Lambung 57,000 87,000 144,000
7 biopsi ginjal 1,467,000 1,829,000 3,296,000
8 biopsi ginjal tanpa needle 878,000 1,829,000 2,707,000
9 Bladder washout 287,000 242,000 529,000
10 Blanket Roll 61,000 403,000 464,000
11 Blink reflex 574,000 245,000 819,000
12 Bone marrow puncture anak **** 556,000 1,725,000 2,281,000
13 Brainstem evoked auditory potential (BERA) 863,000 245,000 1,108,000
14 Bronchoscopy 3,610,000 2,415,000 6,025,000
15 Bronkoskopi 926,000 1,380,000 2,306,000
16 Bronkoskopi dan biopsi 8,843,000 1,380,000 10,223,000
17 Bronkoskopi dan brush 2,115,000 1,380,000 3,495,000
18 Bronkoskopi dan transbronchial nodul aspiration 2,988,000 1,380,000 4,368,000
19 Cerebral monitoring 385,000 403,000 788,000
20 CIC (Continuous Intermittent Catheterization) 217,000 207,000 424,000
21 Cook/Surmisil acute peritoneal dilysis cath removal 642,000 276,000 918,000
22 Cryotherapy 1,969,000 5,814,000 7,783,000
23 CVP Akses Vaskuler 862,000 1,898,000 2,760,000
24 CVP dengan USG 1,000,000 2,300,000 3,300,000
25 CVP Monitoring 997,000 1,150,000 2,147,000
26 CVP removal 250,000 633,000 883,000
JASA
PELAYANAN
27 CVVH/CVVHD/CVVHDF 24,201,000 8,039,000 32,240,000
28 CVVH/CVVHD/CVVHDF harian tanpa Prismasol 7,403,000 3,899,000 11,302,000
29 Defibrilator 290,000 460,000 750,000
30 Desensitasi obat level I (durasi 12 jam) 617,000 575,000 1,192,000
31 Desensitasi obat level II (durasi 24 jam) 870,000 805,000 1,675,000
32 Desmopresin (DDAVP) test 573,000 230,000 803,000
33 Echocardiographi 541,000 863,000 1,404,000
34 EEG bedside 1,303,000 403,000 1,706,000
35 EEG digital rutin 1,303,000 245,000 1,548,000
36 EEG LONG TERM MONITORING 3,471,000 575,000 4,046,000
37 EEG Sleep deprivation 1,430,000 245,000 1,675,000
38 EKG 55,000 173,000 228,000
39 Ekokardiogragi 192,000 690,000 882,000
40 Ekstraksi benda asing 9,264,000 15,410,000 24,674,000
41 Ekstubasi 250,000 575,000 825,000
42 Elektrokardiografi 52,000 115,000 167,000
43 EMG Jarum 549,000 294,000 843,000
44 EMG SPASMOFILI 292,000 245,000 537,000
45 Exit site checking 145,000 138,000 283,000
46 Ganti Balutan 117,000 288,000 405,000
47 ganti tranfer set 474,000 449,000 923,000
48 ganti tranfer set tanpa alat 171,000 449,000 620,000
49 H. Reflex 84,000 121,000 205,000
50 HFO setting awal 1,000,000 1,150,000 2,150,000
51 HFO setting harian 1,000,000 685,000 1,685,000
Home care khusus/panjang > 2 jam ( maksimal 2 orang). transport
52 100,000 1,150,000 1,250,000
ditanggung pasien dan tidak termasuk alat medis yang dibutuhkan
Home care untuk tindakan sederhana < 2 jam (maksimal 2 orang).
53 transport ditanggung pasien dan tidak termasuk alat medis yang 100,000 575,000 675,000
dibutuhkan
54 ICU 1,760,000 805,000 2,565,000
55 Induksi sputum 153,000 115,000 268,000
56 Infus Perifer 284,000 87,000 371,000
57 Inhalasi 76,000 58,000 134,000
58 Injeksi eriropoietin 687,000 483,000 1,170,000
59 Injeksi eriropoietin 687,000 183,000 870,000
62 66,000 115,000 181,000
obat ***
63 66,000 288,000 354,000
obat ***
66 Intradialytic parenteral nutrition 300,000 242,000 542,000
67 Intradialytic parenteral nutrition tanpa obat 87,000 242,000 329,000
68 intraosseus 1,520,000 1,150,000 2,670,000
69 Intubasi Endotra Sulit 285,000 1,725,000 2,010,000
70 Intubasi Endotracheal 285,000 1,438,000 1,723,000
71 Kateter Urine 176,000 87,000 263,000
72 Kecepatan hantar saraf 322,000 245,000 567,000
73 Kemoterapi drip 24 jam (durasi 24 jam) dan hidrasi 24 jam * 1,633,000 230,000 1,863,000
74 Kemoterapi Intratekal **** 354,000 575,000 929,000
75 Kemoterapi Intratekal **** 354,000 1,725,000 2,079,000
78 Kemoterapi IV drip 12 jam (durasi 12 jam) dan hidrasi 6 jam * 681,000 202,000 883,000
79 Kemoterapi IV drip 4 jam (durasi 4 jam) * 338,000 173,000 511,000
82 Konseling Genetik dan Penyakit Metabolik 289,000 575,000 864,000
83 Konseling khusus 48,000 202,000 250,000
84 Konsul Antimicrobial stewardship program di PICU / NICU 145,000 87,000 232,000
Konsul Antimicrobial stewardship program di Rawat Inap Anak
85 145,000 87,000 232,000
Gedung A
Konsultasi dan Konseling Komperehensif Disorder of Sex
86 102,000 202,000 304,000
Development (DSD)
87 Konsultasi dan Konseling Komperehensif DM 103,000 173,000 276,000
88 Konsultasi dan Konseling Komperehensif DM (Inisial) 126,000 230,000 356,000
JASA
PELAYANAN
89 Konsultasi dan Konseling Lanjutan DM Tipe 1 92,000 115,000 207,000
90 Konsultasi dan Konseling Lanjutan DM Tipe 2 92,000 115,000 207,000
91 Konsultasi dan Konseling Lanjutan DM Tipe lain 92,000 115,000 207,000
92 Konsultasi dan Konseling Nutrisi pada DM 85,000 87,000 172,000
93 Konsultasi dan Konseling Psikososial pada DM 89,000 173,000 262,000
94 Konsultasi nutrisi 146,000 115,000 261,000
95 Konsultasi Umum 51,000 87,000 138,000
96 Laktat 50,000 29,000 79,000
97 Leukoferesis anak (durasi <6 jam) 1,449,000 5,750,000 7,199,000
98 Leukoferesis anak (durasi 6 jam) 1,449,000 2,013,000 3,462,000
99 Light Terapi 336,000 144,000 480,000
100 Lumbal pungsi 425,000 460,000 885,000
101 Mengembil Pemeriksaan (non darah) 86,000 58,000 144,000
102 Monitoring Cardiac Output 131,000 115,000 246,000
103 Monitoring End tidal CO2 206,000 87,000 293,000
104 Monitoring Hemodinamik 422,000 863,000 1,285,000
105 Non-invasive respiratory support 150,000 1,898,000 2,048,000
106 Otoacoustic emission (OAE) 165,000 121,000 286,000
107 Pasang NGT 104,000 115,000 219,000
108 Pemantauan hemodinamik non-invasif 152,000 288,000 440,000
109 Pemasangan Cook peritoneal dialisis 5,091,000 1,967,000 7,058,000
110 Pemasangan Cook peritoneal dialisis tanpa alat 1,384,000 1,967,000 3,351,000
111 Pemasangan mini-WSD 1,155,000 1,380,000 2,535,000
112 Pemasangan mini-WSD certofix 1,098,000 863,000 1,961,000
113 Pemasangan surmisil silicone peritoneal dialisis akut 5,091,000 1,967,000 7,058,000
114 Pemasangan surmisil silicone peritoneal dialisis akut tanpa alat 1,388,000 1,967,000 3,355,000
115 pemasangan temporer hemodialysis catheter 2,201,000 1,518,000 3,719,000
116 pemasangan temporer hemodialysis catheter tanpa alat 317,000 1,518,000 1,835,000
117 Pemberian minum per sonde 64,000 46,000 110,000
118 Pemberian Obat IV/IM 36,000 58,000 94,000
119 Pengambilan Darah Arteri 86,000 58,000 144,000
120 perawatan CAPD baru 500,000 587,000 1,087,000
121 perawatan CAPD baru tanpa obat 265,000 587,000 852,000
122 perawatan CAPD kronik tanpa obat 576,000 690,000 1,266,000
123 370,000 173,000 543,000
124 370,000 288,000 658,000
125 Perawatan Kolostomi 95,000 87,000 182,000
126 peritoneal dialisis akut harian 536,000 276,000 812,000
127 peritoneal dialisis akut harian tanpa obat 301,000 276,000 577,000
128 peritoneal dialisis kronik harian 319,000 173,000 492,000
129 peritoneal dialisis kronik harian tanpa obat 141,000 173,000 314,000
130 Peritoneal permeability check 611,000 311,000 922,000
131 Peritoneal permeability check tanpa obat 376,000 311,000 687,000
132 PET Kt/V 294,000 483,000 777,000
133 PET Kt/V tanpa obat 230,000 483,000 713,000
134 plasmaferesis (Non PICU) 12,906,000 7,970,000 20,876,000
135 Plasmaferesis (PICU) 13,836,000 11,270,000 25,106,000
136 Plasmaferesis anak (durasi <6 jam) 1,449,000 5,750,000 7,199,000
137 Plasmaferesis anak (durasi 6 jam) 1,449,000 2,013,000 3,462,000
138 Plasmaferesis tanpa alat, tanpa prismasol 1,479,000 7,970,000 9,449,000
139 Poligrafi 375,000 920,000 1,295,000
140 Polisomnografi 813,000 920,000 1,733,000
141 Program inisiasi terapi insulin pada pasien baru DM Tipe-1 418,000 690,000 1,108,000
142 Protokol pemberian asam zoledronat pada Osteogenesis Imperfecta 409,000 345,000 754,000
143 Psikoterapi / psikoedukasi pada DM 191,000 230,000 421,000
144 Pungsi Acites 450,000 575,000 1,025,000
145 Pungsi cairan pleura 281,000 575,000 856,000
146 Pungsi cairan pleura 520,000 644,000 1,164,000
147 Pungsi Darah Vena 76,000 58,000 134,000
148 Pungsi Lumbal (IAN.Ligor CRB SPI) 210,000 805,000 1,015,000
149 R. Isolasi 1,760,000 805,000 2,565,000
150 R. Rawat Bayi Post Operasi 1,760,000 805,000 2,565,000
151 reposisi cdl 349,000 449,000 798,000
152 reposisi kateter peritoneal dialisis akut cook/surmisil 1,384,000 794,000 2,178,000
153 reposisi kateter peritoneal dialisis akut cook/surmisil tanpa obat 1,149,000 794,000 1,943,000
154 Resusitasi Jantung Paru 375,000 518,000 893,000
155 Rinofaringolaringoskopi 508,000 575,000 1,083,000
JASA
PELAYANAN
156 RNS 343,000 245,000 588,000
157 Sedasi Anak 828,000 690,000 1,518,000
158 Sedasi Sedang Anak 766,000 483,000 1,249,000
159 Sedasi sedang anak (untuk kemoterapi IT dan BMP) **** 292,000 477,000 769,000
160 Sedasi sedang anak (untuk kemoterapi IT dan BMP) **** 292,000 805,000 1,097,000
161 Sedasi Sedang Anak tanpa obat 520,000 483,000 1,003,000
162 Single-fiber EMG 335,000 245,000 580,000
163 Skin prick test 540,000 345,000 885,000
164 SLED 748,000 897,000 1,645,000
165 SSEP 1,058,000 245,000 1,303,000
166 Suction 94,000 29,000 123,000
167 Suntik BPG 81,000 115,000 196,000
168 Terapi motivational counseling remaja 72,000 173,000 245,000
169 terapi besi intravena 392,000 311,000 703,000
172 terapi obat khusus dan kemoterapi 239,000 449,000 688,000
173 Terapi Oksigen 181,000 58,000 239,000
174 Terapi perilaku korban kekerasan anak 72,000 173,000 245,000
175 Terapi sulih enzim 852,000 863,000 1,715,000
176 thrombolytics for dialysis catheter fibrin occlusion dengan heparin 576,000 759,000 1,335,000
177 thrombolytics for hemodialys catheter fibrin occlusion 700,000 759,000 1,459,000
178 thrombolytics for hemodialys catheter fibrin occlusion tanpa obat 330,000 759,000 1,089,000
179 thrombolytics for peritoneal dialysis catheter fibrin occlusion 646,000 276,000 922,000
180 448,000 276,000 724,000
obat
181 211,000 173,000 384,000
hemofilia, dll)
182 Tindakan injeksi GnRH analog / Leuprorelin acetate (Tapros®) 627,000 173,000 800,000
183 Tindakan injeksi testosteron ester (Sustanon®) 99,000 173,000 272,000
184 Tindakan uji stimulasi GH 674,000 863,000 1,537,000
185 Tindakan uji stimulasi HCG 459,000 173,000 632,000
186 Transcutaneaus CO2 91,000 87,000 178,000
187 Transfusi Darah 185,000 202,000 387,000
188 Transfusi Darah (tindakan dan BMHP, tidak termasuk labu darah) 185,000 277,000 462,000
189 561,000 115,000 676,000
190 561,000 288,000 849,000
191 Uji psikososial remaja HEEADSSS 113,000 202,000 315,000
192 Uji depresi anak CDI 78,000 144,000 222,000
193 Uji fungsi paru / spirometri anak 624,000 173,000 797,000
194 Uji fungsi paru pre- dan post- bronkodilator anak 691,000 288,000 979,000
195 Uji gangguan perilaku autisme MCHATR/F 91,000 144,000 235,000
196 Uji gangguan perilaku hiperaktivitas Conners ASQ 73,000 144,000 217,000
197 Uji gangguan psikososial SDQ 75,000 144,000 219,000
198 Uji haus (water deprivation test) - 15 jam 2,369,000 518,000 2,887,000
199 Uji haus (water deprivation test) - 8 jam 1,402,000 345,000 1,747,000
200 Uji Kemampuan Bahasa Capute Scale 126,000 288,000 414,000
201 Uji keringat atau sweat test 1,802,000 288,000 2,090,000
204 Uji perkembangan khusus BSID III 587,000 575,000 1,162,000
205 Uji provokasi makanan/ obat level I (DURASI 4 JAM) 377,000 460,000 837,000
206 Uji provokasi makanan/ obat level II (durasi 6 jam) 547,000 575,000 1,122,000
207 Uji stimulasi hormon pertumbuhan (clonidine test) 748,000 633,000 1,381,000
208 Vena Seksi 341,000 1,898,000 2,239,000
209 Ventilator setting awal 800,000 1,035,000 1,835,000
210 Ventilator setting harian 800,000 604,000 1,404,000
211 Abdomen 1 posisi 195,000 97,000 292,000
212 Abdomen 2 Posisi 259,000 200,000 459,000
213 Abdomen 3 Posisi 322,000 371,000 693,000
214 Ankle 1 posisi (AP ATAU lateral ATAU mortise) Kanan ATAU kiri 158,000 - 158,000
215 Ankle 1 posisi (AP ATAU lateral ATAU mortise) Kanan DAN kiri 198,000 - 198,000
JASA
PELAYANAN
220 AntebrachIi 1 posisi (AP ATAU lateral) Kanan ATAU kiri 172,000 - 172,000
221 AntebrachIi 1 posisi (AP ATAU lateral) kanan DAN kiri 211,000 - 211,000
222 AntebrachiI 2 posisi Kanan ATAU kiri 172,000 133,000 305,000
223 Antebrachii 2 posisi bilateral 243,000 280,000 523,000
224 Apendicogram 889,000 686,000 1,575,000
225 APG 727,000 561,000 1,288,000
226 Baby Gram 211,000 105,000 316,000
227 BNO IVP 793,000 612,000 1,405,000
228 Bone Age 182,000 90,000 272,000
229 Bone Survey 829,000 954,000 1,783,000
230 Clavicula (kanan DAN kiri) 158,000 122,000 280,000
231 Colon in loop 986,000 761,000 1,747,000
232 Cruris 1 posisi (AP ATAU lateral ATAU oblig) Kanan ATAU kiri 172,000 - 172,000
233 Cruris 1 posisi (AP ATAU lateral ATAU oblig) Kanan DAN kiri 211,000 - 211,000
234 Cruris 2 posisi Kanan ATAU kiri 211,000 164,000 375,000
235 Cruris 2 posisi bilateral 346,000 398,000 744,000
Cruris 4 posisi (AP - lateral DAN oblig kanan - oblig kiri) Kanan
236 346,000 - 346,000
ATAU kiri
Cruris 4 posisi (AP - lateral DAN oblig kanan - oblig kiri) Kanan
237 497,000 - 497,000
DAN kiri
238 Cubiti 1 posisi (AP atau lateral ) kanan DAN kiri 198,000 - 198,000
239 Cubiti 1 posisi (AP atau lateral) Kanan ATAU kiri 158,000 - 158,000
240 Cubiti 2 posisi Kanan ATAU kiri 183,000 142,000 325,000
241 Cubiti 2 posisi bilateral 239,000 275,000 514,000
242 Esofagogram 632,000 488,000 1,120,000
243 Facial bones caldwell /towne dan lateral sinar horisontal 222,000 172,000 394,000
244 Femur 1 posisi (AP ATAU lateral ) Kanan ATAU kiri 172,000 - 172,000
245 Femur 1 posisi (AP ATAU lateral ) Kanan DAN kiri 211,000 - 211,000
246 Femur 2 posisi Kanan ATAU kiri 211,000 164,000 375,000
247 Femur 2 posisi bilateral 346,000 398,000 744,000
Femur 4 posisi (AP - lateral DAN oblig kanan - oblig kiri) Kanan
248 346,000 - 346,000
ATAU kiri
Femur 4 posisi (AP - lateral DAN oblig kanan - oblig kiri) Kanan
249 497,000 - 497,000
DAN kiri
250 Fistulografi 847,000 654,000 1,501,000
251 Follow Trough 958,000 739,000 1,697,000
252 Genitografi 829,000 640,000 1,469,000
253 Genu 1 posisi (AP ATAU lateral ATAU sky line ) Kanan DAN kiri 198,000 - 198,000
254 Genu 1 posisi (AP ATAU lateral ATAU sky line) Kanan ATAU kiri 158,000 - 158,000
259 Humerus 1 posisi (AP ATAU lateral ) Kanan ATAU kiri 158,000 - 158,000
260 Humerus 1 posisi (AP atau lateral ) Kanan DAN kiri 222,000 - 222,000
261 Humerus 2 posisi Kanan ATAU kiri 175,000 135,000 310,000
262 Humerus 2 posisi bilateral 198,000 228,000 426,000
263 Kepala 1 posisi (AP ATAU Lateral ) 211,000 - 211,000
264 Kepala 2 posisi 211,000 164,000 375,000
265 Kontras enema 871,000 672,000 1,543,000
266 Kontras meal / upper GI series 871,000 672,000 1,543,000
267 Leher Soft Tissue 1 posisi (AP ATAU lateral) 198,000 - 198,000
268 Leher Soft Tissue 2 posisi 215,000 166,000 381,000
269 Lopografi 858,000 662,000 1,520,000
270 Mandibula 199,000 229,000 428,000
271 Manus 1 posisi ( AP atau oblig) Kanan ATAU kiri 158,000 - 158,000
272 Manus 1 posisi ( AP atau oblig) Kanan DAN kiri 239,000 - 239,000
273 Manus 2 posisi bilateral 215,000 248,000 463,000
274 Manus 2 posisi Kanan ATAU kiri 150,000 117,000 267,000
275 Mastoid 221,000 172,000 393,000
276 Mastoid (kanan ATAU kiri) 237,000 - 237,000
277 MCU (Micturating Cysto Urethrography) 805,000 620,000 1,425,000
278 Nasal 253,000 126,000 379,000
279 Orbita 253,000 126,000 379,000
280 Orbita AP dan Foramen optikum kanan ATAU kiri 319,000 - 319,000
281 Orbita AP dan Foramen optikum kanan DAN kiri 359,000 - 359,000
282 Pedis 1 posisi (AP ATAU Lateral ATAU oblig ) Kanan ATAU kiri 158,000 - 158,000
JASA
PELAYANAN
283 Pedis 1 posisi (AP ATAU Lateral ATAU oblig ) Kanan DAN kiri 198,000 - 198,000
284 Pedis 2 posisi Kanan ATAU kiri 158,000 122,000 280,000
285 Pedis 2 posisi bilateral 255,000 294,000 549,000
286 Pedis 3 posisi (AP - Lateral DAN oblig ) Kanan ATAU kiri 291,000 - 291,000
287 Pedis 3 posisi (AP - Lateral DAN oblig ) Kanan DAN kiri 400,000 - 400,000
288 Pelvis 1 posisi 198,000 98,000 296,000
289 Pelvis 2 posisi 219,000 169,000 388,000
290 Pelvis 3 posisi 255,000 294,000 549,000
291 Pemeriksaan POUCH 697,000 538,000 1,235,000
292 Pergelangan tangan / Wrist Joint (1 posisi) kanan ATAU kiri 158,000 - 158,000
293 Pergelangan tangan / Wrist Joint (1 posisi) kanan DAN kiri 198,000 - 198,000
294 Pergelangan tangan / Wrist Joint (2 posisi) bilateral 239,000 275,000 514,000
295 Pergelangan tangan / Wrist Joint (2 posisi) kanan ATAU kiri 182,000 141,000 323,000
296 RPG 727,000 561,000 1,288,000
297 Sacrum 1 posisi (AP ATAU lateral) 158,000 - 158,000
298 Sacrum 2 posisi 239,000 184,000 423,000
299 Scanogram 450,000 518,000 968,000
300 Scapula 1 posisi kanan ATAU kiri 182,000 - 182,000
301 Scapula 1 posisi (AP/lat =y view) kanan DAN kiri 277,000 - 277,000
302 Scapula 2 posisi bilateral 231,000 266,000 497,000
303 Scapula 2 posisi kanan ATAU kiri 158,000 122,000 280,000
304 Scoliosis Program 472,000 543,000 1,015,000
305 Shoulder 1 posisi Kanan ATAU kiri 182,000 - 182,000
306 Shoulder 1 posisi Kanan DAN kiri 173,000 - 173,000
308 Shoulder 2 posisi Kanan ATAU kiri 157,000 122,000 279,000
310 Shoulder 3 posisi kanan ATAU kiri 188,000 217,000 405,000
311 Sinus Paranasal (waters dan lateral) 198,000 153,000 351,000
312 Spot Flouroscopic 450,000 348,000 798,000
315 Thorax 2 posisi 243,000 188,000 431,000
316 Thorax 1 posisi 172,000 86,000 258,000
317 TMJ 221,000 172,000 393,000
318 TMJ kanan ATAU kiri 336,000 - 336,000
319 Urethrocystogram 698,000 539,000 1,237,000
320 USG doppler vaskuler superfisial 530,000 409,000 939,000
321 USG doppler vaskuler abdomen lengkap 1,026,000 792,000 1,818,000
322 USG abdomen bawah / ginjal dan doppler 1,027,000 792,000 1,819,000
323 USG abdomen bawah / Ginjal dan saluran kemih 526,000 406,000 932,000
324 USG abdomen lengkap dan doppler 1,790,000 1,380,000 3,170,000
325 USG Kepala dan Doppler 947,000 730,000 1,677,000
326 USG superfisial dan doppler 950,000 733,000 1,683,000
327 USG Abdomen atas 536,000 413,000 949,000
328 USG Abdomen atas dan Doppler 1,026,000 792,000 1,818,000
329 USG Abdomen lengkap 950,000 732,000 1,682,000
330 USG colli/leher 454,000 351,000 805,000
331 USG diafragma 311,000 241,000 552,000
332 USG Doppler vaskuler Carotis 526,000 406,000 932,000
333 USG doppler vaskuler ekstremitas atas kanan ATAU kiri 530,000 409,000 939,000
334 USG doppler vaskuler ekstremitas atas kanan dan kiri 1,026,000 792,000 1,818,000
335 USG doppler vaskuler abdomen atas 546,000 421,000 967,000
336 USG Doppler vaskuler abdomen bawah / ginjal 536,000 413,000 949,000
337 USG doppler vaskuler ekstremitas bawah kanan ATAU kiri 530,000 409,000 939,000
338 USG doppler vaskuler ekstremitas bawah kanan dan kiri 1,026,000 792,000 1,818,000
339 USG doppler vaskuler kepala 536,000 413,000 949,000
340 USG Guidance biopsi atau pengeluaran cairan 306,000 236,000 542,000
341 USG Hepatobilier 2 fase 986,000 761,000 1,747,000
342 USG hip 526,000 406,000 932,000
343 USG Kepala 454,000 351,000 805,000
344 USG Mamae/ payudara 454,000 351,000 805,000
345 USG muskuloskeletal bilateral 1,246,000 961,000 2,207,000
346 USG muskuloskeletal ipsi lateral 669,000 516,000 1,185,000
347 USG Pelvis wanita - genitalia interna 526,000 406,000 932,000
348 USG spinal / vertebra 454,000 351,000 805,000
349 USG superfisial 454,000 351,000 805,000
350 USG Testis 454,000 351,000 805,000
351 USG Tiroid 455,000 351,000 806,000
352 USG toraks / paru 454,000 351,000 805,000
JASA
PELAYANAN
353 Vertebra Cervical 2 posisi 239,000 184,000 423,000
354 Vertebra Lumbal 2 posisi 277,000 214,000 491,000
355 Vertebra Lumbal Dinamik 229,000 - 229,000
356 Vertebra Lumbalsacral 2 posisi 307,000 237,000 544,000
357 Vertebra Lumbalsacral Ap ATAU lateral 211,000 - 211,000
358 Vertebra Thoracal 2 posisi 270,000 209,000 479,000
359 Vertebra Thoracal AP 172,000 - 172,000
360 Vertebra Thoracal Lumbal 2 posisi 322,000 249,000 571,000
5.20 GIZI KLINIK
1 Interpretasi Bioelectric Impedance (BIA) /Tanita 26,000 207,000 233,000
2 Interpretasi Bioelectric Impedance (BIA) Bedridden/Seca 26,000 230,000 256,000
3 Pemeriksaan kalorimetri indirek 26,000 230,000 256,000
4 Pengukuran knee-hight 26,000 58,000 84,000
5 Pengukuran lingkar lengan atas 26,000 58,000 84,000
6 Tindakan Analisa Asupan 24,000 58,000 82,000
8 USG massa otot 26,000 230,000 256,000
5.21 KEDOKTERAN OKUPASI
1 Konsultasi dan Pemeriksaan Paket Surat Keterangan Sehat Pekerja 114,000 350,000 464,000
2 Konsultasi dan Pemeriksaan MCU Perusahaan 114,000 350,000 464,000
3 Pemeriksaan Neuromuskuloskeletal Kerja 66,000 42,000 108,000
4 Pemeriksaan Keseimbangan dan Koordinasi Kerja 66,000 42,000 108,000
5 Pemeriksaan OCRA 66,000 42,000 108,000
6 Pemeriksaan Kekuatan Menggenggam Kuantitatif 66,000 42,000 108,000
7 Pemeriksaan Steroskopik Kerja 66,000 42,000 108,000
8 Pemeriksaan Occupational Force Capasity Evaluation 202,000 332,000 534,000
9 Pemeriksaan dan Interpretasi HRV 66,000 83,000 149,000
10 Perhitungan Kecacatan Kerja 404,000 663,000 1,067,000
11 Paket Kelaikan Kerja 656,000 1,077,000 1,733,000
12 Paket Penegakan Diagnosis PAK 656,000 1,077,000 1,733,000
13 Paket Program Kembali Kerja 2,615,000 4,514,000 7,129,000
14 Kunjungan ke Perusahaan 1,260,000 2,070,000 3,330,000
Tatalaksana Industrial Disaster dalam Menangani Kasus Intervensi dan
15 1,008,000 1,656,000 2,664,000
Risiko Tinggi (Medical Emergency Respond Plan)
16 Presentasi Kesehatan 1,008,000 1,656,000 2,664,000
17 Pembuatan Rekomendasi dan Pelaporan Program 580,000 953,000 1,533,000
18 Pembuatan Desain Tempat Kerja (per meter persegi) 336,000 552,000 888,000
19 Rekomendasi Pembuatan Desain Tempat Kerja 580,000 953,000 1,533,000
Paket Penilaian Risiko Kesehatan dan Keselamatan Kerja (per hari
20 1,260,000 2,070,000 3,330,000
kerja)
21 Desain atau Proposal Program 656,000 1,077,000 1,733,000
22 Tindakan Pemberian Vaksinasi pada Pekerja 65,000 70,000 135,000
23 Pengembangan Program Kebugaran Pekerja (Per Pekerja) 3,683,000 6,376,000 10,059,000
24 Interpretasi ILO Radiograph 20,000 83,000 103,000
25 Pemeriksaan Lingkungan ISBG/WBGT: per titik
26 Pemeriksaan Lingungan dengan Sound Level Meter: per titik
27 Pemeriksaan Lingkungan untuk Getaran: per titik
mengacu ke data UI
Pemeriksan Lingkungan untuk Pencahayaan Menggunakan Luxmeter:
28
per titik
29 Data Entry & Proses perCell
30 Laporan Analisa Data Okupasi Berbasis Statistik per Outcome - - -
6. OPERATIF
6.1 BEDAH ANAK
1 Abdominoperineal pull through (malformasi anorectal) 15,872,000 29,247,000 45,119,000
2 Abdominorectal pull through (Swenson Procedure) 15,872,000 46,796,000 62,668,000
3 Biopsi perlaparatomi 15,456,000 26,882,000 42,338,000
4 Biopsi rektum "Full thickness" 8,000,000 11,769,000 19,769,000
5 Biopsi/Eksisi KGB, Lipoma. Ateroma, ganglion 8,000,000 11,769,000 19,769,000
6 Chordektomi 6,331,000 21,189,000 27,520,000
7 Cystojejunostomi 15,872,000 24,375,000 40,247,000
8 Detorsi testis + orcidopexy 12,000,000 23,839,000 35,839,000
9 Duodenoduodenostomi/ duodenojejunostomi 11,762,000 32,903,000 44,665,000
10 Eksisi baker cyst 5,000,000 8,211,000 13,211,000
11 Eksisi granuloma umbilikal 8,000,000 11,769,000 19,769,000
12 Eksisi hemangioma besar/multiple 12,000,000 21,189,000 33,189,000
13 Eksisi hemangioma dengan skin graft STSG/FTSG 12,000,000 21,189,000 33,189,000
14 Eksisi hemangioma kecil 7,000,000 10,600,000 17,600,000
15 Eksisi higroma coli/ limfangioma simple 12,000,000 21,190,000 33,190,000
JASA
PELAYANAN
16 Eksisi Kista Brachial 12,000,000 21,190,000 33,190,000
17 Eksisi kista duktus tiroglosus 9,000,000 16,484,000 25,484,000
18 Eksisi kista saluran empedu 15,872,000 46,796,000 62,668,000
19 Eksisi kista urachus 12,000,000 21,189,000 33,189,000
20 Eksisi Neuroblastoma 17,914,000 36,657,000 54,571,000
21 Eksisi teratoma ovarium 13,000,000 23,839,000 36,839,000
22 Eksisi teratoma retroperitoneal 13,500,000 24,375,000 37,875,000
23 Eksisi teratoma sacrococcygeal 13,500,000 24,375,000 37,875,000
24 Eksisi tumor sacrocogeal 17,914,000 32,903,000 50,817,000
25 Ekstirpasi Kista Preaurikuler 16,546,000 9,422,000 25,968,000
26 Endorectal pull through (Soave-bolley procedure) 17,914,000 46,796,000 64,710,000
27 Esofagomyotomi (Operasi Heller) 14,500,000 23,839,000 38,339,000
28 Esofagostomi + gastrostomi (atresia esofagus) 17,914,000 36,657,000 54,571,000
29 Esophagus replacement procedure 17,914,000 46,872,000 64,786,000
30 Fundoplikasi gaster 14,500,000 23,839,000 38,339,000
31 Gastroduodenoskopi 8,000,000 8,241,000 16,241,000
32 Gastrostomi anak 11,000,000 16,484,000 27,484,000
33 Gastrostomi neonatus 13,500,000 23,839,000 37,339,000
34 Genitoplasty (Clitoroplasty, vaginoplasty, phalioplasty) 17,914,000 32,903,000 50,817,000
35 Herniotomi 11,000,000 16,484,000 27,484,000
36 Herniotomi bilateral 12,000,000 21,189,000 33,189,000
37 Herniotomi pada hernia strangulata 12,000,000 21,189,000 33,189,000
38 Herniotomy + laparatomy + reseksi + anastomosis 15,000,000 29,247,000 44,247,000
39 Higroma coli/limfangioma besar 13,500,000 23,839,000 37,339,000
40 Insisi drainase/debridement abses 8,000,000 11,769,000 19,769,000
41 Insisi tongue tie Grade I - II 2,250,000 1,858,000 4,108,000
42 Insisi tongue tie Grade III - IV 8,000,000 11,769,000 19,769,000
43 Kolonoskopi 8,000,000 8,241,000 16,241,000
44 Kolostomi anak 11,000,000 16,484,000 27,484,000
45 Kolostomi Neonatus+Anestesi 14,504,000 23,839,000 38,343,000
46 Ladd's Procedure 17,914,000 36,657,000 54,571,000
47 Laparatomi + Appendektomi pada APP perforasi 12,000,000 21,189,000 33,189,000
48 Laparatomi + Milking/reseksi pada invaginasi 13,500,000 23,839,000 37,339,000
49 Laparatomi + reseksi usus halus/kolon 18,588,000 32,903,000 51,491,000
50 Laparatomi pada perforasi usus 13,500,000 23,839,000 37,339,000
51 Laparatomi pada peritonitis neonatus 15,456,000 26,970,000 42,426,000
52 Laparatomi pada trauma abdomen 13,500,000 23,839,000 37,339,000
53 Ligasi tinggi 11,000,000 16,484,000 27,484,000
54 Minimal/ limited PSARP 15,000,000 29,247,000 44,247,000
55 Nefrektomi 17,914,000 31,639,000 49,553,000
56 Nefrektomi parsial 17,914,000 23,839,000 41,753,000
57 Nefrouretektomi tumor wilms 17,914,000 36,657,000 54,571,000
58 Nefrouretektomi tumor wilms dengan penyulit 17,914,000 46,872,000 64,786,000
59 Orchidektomi 11,000,000 16,484,000 27,484,000
60 Penutupan defek hernia diafragmatika bukan pada neonatus 15,872,000 29,247,000 45,119,000
61 Penutupan defek hernia diafragmatika neonatus 10,440,000 29,247,000 39,687,000
62 Penutupan defek hernia diafragmatika neonatus dengan penyulit 10,440,000 36,657,000 47,097,000
63 Plikasi diafragma 8,000,000 24,375,000 32,375,000
64 Polipektomi rektum 8,000,000 11,769,000 19,769,000
65 Portoenterostomi (Operasi Kassai) 17,914,000 50,430,000 68,344,000
66 Postero Sagital Anorectoplasty/ PSARP 18,588,000 36,657,000 55,245,000
67 Posterosagital anorectovaginourethroplasty/ PSARVUP 17,914,000 50,435,000 68,349,000
68 Potong stump & Potong septum 14,478,000 21,188,000 35,666,000
69 Prosedur Tiersch pada prolap rekti 11,000,000 16,484,000 27,484,000
70 PSARP + laparotomy 17,914,000 46,796,000 64,710,000
71 Pyeloplasty 11,500,000 21,189,000 32,689,000
72 Pyloromyotomi (Operasi Fredet Ramstedt) 14,500,000 23,839,000 38,339,000
73 Reimplantasi ureter 17,914,000 26,967,000 44,881,000
74 Rekontruksi Penis 11,762,000 11,769,000 23,531,000
75 Rekontruksi Penis Lokal 1,468,000 8,106,000 9,574,000
76 Release sinekhia vagina 2,508,000 1,725,000 4,233,000
77 Release sinekhia vagina Cluster 300,000 1,093,000 1,393,000
78 Release sinekhia vulva 7,000,000 10,600,000 17,600,000
79 Repair bladder extrophy 17,914,000 50,435,000 68,349,000
80 Repair cloacal extrophy 17,914,000 50,435,000 68,349,000
81 Repair defek dinding perut (omphalocele/ gastroschizis) 17,914,000 23,839,000 41,753,000
82 Repair defek hernia umbilikalis 11,000,000 16,484,000 27,484,000
83 Repair fistel rectovaginal 12,000,000 23,839,000 35,839,000
84 Repair Uretroplasty 6,896,000 7,439,000 14,335,000
85 Reseksi + anastomosis esofagus 14,000,000 24,375,000 38,375,000
JASA
PELAYANAN
86 Reseksi anastomosis pada atresia usus, duplikasi 17,914,000 32,903,000 50,817,000
87 Reseksi gaster 15,456,000 26,970,000 42,426,000
88 Reseksi hepar (tumor, trauma) 17,914,000 36,657,000 54,571,000
89 Reseksi hepar (tumor, trauma) dengan penyulit 12,482,000 50,430,000 62,912,000
90 Retrorectal pull through (duhamel procedure) 17,914,000 46,796,000 64,710,000
91 Scrotoplasty + Chordectomy 11,500,000 21,189,000 32,689,000
92 Sirkumsisi bayi Lokal 3,468,000 7,205,000 10,673,000
93 Sirkumsisi Lokal 3,468,000 5,688,000 9,156,000
94 Sirkumsisi+Anestesi 6,935,000 10,600,000 17,535,000
95 Sphincterotomy 11,000,000 16,484,000 27,484,000
96 Splenectomi pada trauma 15,456,000 26,967,000 42,423,000
97 Splenektomi pada thalasemia, hipersplenisme 12,000,000 21,189,000 33,189,000
98 Thoracotomi + anastomosis esofagus 17,914,000 50,430,000 68,344,000
99 Transanal mucosektomy 17,914,000 46,796,000 64,710,000
100 Uretroplasty 13,791,000 22,312,000 36,103,000
6.2 BREAST
1 BCT 9,651,000 18,819,000 28,470,000
2 BCT Dengan Penyulit 12,064,000 23,524,000 35,588,000
3 Biopsi cubit ( oral kanker lokal ) 6,935,000 3,163,000 10,098,000
4 Biopsi cubit ( oral kanker lokal ) Dengan Penyulit 8,668,000 3,953,000 12,621,000
5 Biopsi Insisi 6,935,000 3,163,000 10,098,000
6 Biopsi Insisi Dengan Penyulit 8,668,000 3,953,000 12,621,000
7 Biopsi Sentinel 6,935,000 11,066,000 18,001,000
8 Biopsi Sentinel Dengan Penyulit 8,668,000 13,832,000 22,500,000
9 Breast augmentation -JR 11,598,000 17,107,000 28,705,000
10 Breast augmentation -JR Dengan Penyulit 14,498,000 21,383,000 35,881,000
11 Breast augmentation -SR 11,598,000 21,132,000 32,730,000
12 Breast augmentation -SR Dengan Penyulit 14,498,000 26,414,000 40,912,000
13 Breast lift (Mc Kissock/Vertical) -JR 13,544,000 18,819,000 32,363,000
14 Breast lift (Mc Kissock/Vertical) -JR Dengan Penyulit 16,930,000 23,524,000 40,454,000
15 Breast lift (Mc Kissock/Vertical) -SR 11,598,000 23,949,000 35,547,000
16 Breast lift (Mc Kissock/Vertical) -SR Dengan Penyulit 14,498,000 29,936,000 44,434,000
17 Breast lift and augmentation -JR 9,651,000 18,819,000 28,470,000
18 Breast lift and augmentation -JR Dengan Penyulit 12,064,000 23,524,000 35,588,000
19 Breast lift and augmentation -SR 9,651,000 23,949,000 33,600,000
20 Breast lift and augmentation -SR Dengan Penyulit 12,064,000 29,936,000 42,000,000
21 Breast lift periaareolar -JR 13,544,000 17,107,000 30,651,000
22 Breast lift periaareolar -JR Dengan Penyulit 16,930,000 21,383,000 38,313,000
23 Breast lift periaareolar -SR 11,598,000 21,132,000 32,730,000
24 Breast lift periaareolar -SR Dengan Penyulit 14,498,000 26,414,000 40,912,000
25 Breast reconstruction dengan latissimus dorsi dan implant -JR 9,651,000 31,597,000 41,248,000
Breast reconstruction dengan latissimus dorsi dan implant -JR Dengan
26 12,064,000 39,495,000 51,559,000
Penyulit
27 Breast reconstruction dengan latissimus dorsi dan implant -SR 9,651,000 33,609,000 43,260,000
Breast reconstruction dengan latissimus dorsi dan implant -SR Dengan
28 12,064,000 42,011,000 54,075,000
Penyulit
29 Breast reconstruction dengan latissimus dorsi -JR 9,651,000 17,107,000 26,758,000
30 Breast reconstruction dengan latissimus dorsi -JR Dengan Penyulit 12,064,000 21,383,000 33,447,000
31 Breast reconstruction dengan latissimus dorsi -SR 16,464,000 21,132,000 37,596,000
32 Breast reconstruction dengan latissimus dorsi -SR Dengan Penyulit 20,580,000 26,414,000 46,994,000
33 Breast recontruction dengan tissue expander -JR 13,544,000 29,584,000 43,128,000
34 Breast recontruction dengan tissue expander -JR Dengan Penyulit 16,930,000 36,977,000 53,907,000
35 Breast recontruction dengan tissue expander -SR 11,598,000 33,609,000 45,207,000
36 Breast recontruction dengan tissue expander -SR Dengan Penyulit 14,497,000 42,011,000 56,508,000
37 Breast recontruction dengan TRAM -JR 9,651,000 31,597,000 41,248,000
38 Breast recontruction dengan TRAM -JR Dengan Penyulit 12,064,000 39,495,000 51,559,000
39 Breast recontruction dengan TRAM -SR 16,464,000 33,609,000 50,073,000
40 Breast recontruction dengan TRAM -SR Dengan Penyulit 20,580,000 42,011,000 62,591,000
41 Breast recontruction exchange dengan implant -JR 9,651,000 29,584,000 39,235,000
42 Breast recontruction exchange dengan implant -JR Dengan Penyulit 12,064,000 36,977,000 49,041,000
43 Breast recontruction exchange dengan implant -SR 9,651,000 33,609,000 43,260,000
44 Breast recontruction exchange dengan implant -SR Dengan Penyulit 12,064,000 42,011,000 54,075,000
45 Breast reduction -JR 13,544,000 27,572,000 41,116,000
46 Breast reduction -JR Dengan Penyulit 16,930,000 34,464,000 51,394,000
47 Breast reduction -SR 9,651,000 33,609,000 43,260,000
48 Breast reduction -SR Dengan Penyulit 12,064,000 42,011,000 54,075,000
JASA
PELAYANAN
COMMANDO Surgery (Reseksi Mandibula + Diseksi Leher Radikal)
49 19,949,000 50,590,000 70,539,000
+ Wide exison
COMMANDO Surgery (Reseksi Mandibula + Diseksi Leher Radikal)
50 24,936,000 63,236,000 88,172,000
+ Wide exison Dengan Penyulit
51 Comprehensive neck dissection unilateral 14,517,000 25,450,000 39,967,000
52 Comprehensive neck dissection unilateral Dengan Penyulit 18,146,000 31,811,000 49,957,000
53 Core Biopsi 6,935,000 3,422,000 10,357,000
54 Core Biopsi Dengan Penyulit 8,668,000 4,276,000 12,944,000
55 Core Biopsi dengan asisten 6,935,000 3,422,000 10,357,000
56 Core Biopsi dengan asisten Dengan Penyulit 8,668,000 4,276,000 12,944,000
57 Debridement 9,651,000 20,528,000 30,179,000
58 Debridement Dengan Penyulit 12,064,000 25,659,000 37,723,000
59 Debulking 17,437,000 27,708,000 45,145,000
60 Debulking Dengan Penyulit 21,796,000 34,634,000 56,430,000
61 Diseksi Inguinal Profunda 14,517,000 38,173,000 52,690,000
62 Diseksi Inguinal Profunda Dengan Penyulit 18,146,000 47,715,000 65,861,000
63 Diseksi KGB Inguinal superficial 14,517,000 25,450,000 39,967,000
64 Diseksi KGB Inguinal superficial Dengan Penyulit 18,146,000 31,811,000 49,957,000
65 Diseksi Modifikasi Radikal Neck Sinistra 14,517,000 25,450,000 39,967,000
66 Diseksi Modifikasi Radikal Neck Unilateral 14,517,000 25,450,000 39,967,000
67 Diseksi Modifikasi Radikal Neck Unilateral Dengan Penyulit 18,146,000 31,811,000 49,957,000
68 EKSISI ADENO LIMPOMA BILATERAL 13,544,000 23,949,000 37,493,000
69 EKSISI ADENO LIMPOMA BILATERAL Dengan Penyulit 16,930,000 29,936,000 46,866,000
70 Eksisi FAM / Jaringan lunak ( ≥ 3 FAM) 9,651,000 22,130,000 31,781,000
71 Eksisi FAM / Jaringan lunak ( ≥ 3 FAM) Dengan Penyulit 12,064,000 27,661,000 39,725,000
72 Eksisi FAM / Jaringan lunak ( 2 FAM) 9,651,000 16,598,000 26,249,000
73 Eksisi FAM / Jaringan lunak ( 2 FAM) Dengan Penyulit 12,064,000 20,747,000 32,811,000
74 Eksisi FAM (1 FAM) 9,651,000 11,976,000 21,627,000
75 Eksisi FAM (1 FAM) Dengan Penyulit 12,064,000 14,969,000 27,033,000
77 Eksisi Fibroma Ganglion Dengan Penyulit 12,064,000 14,969,000 27,033,000
78 Eksisi Jaringan Lunak ≤ 3 cm 6,935,000 11,066,000 18,001,000
79 Eksisi Jaringan Lunak ≤ 3 cm Dengan Penyulit 8,668,000 13,832,000 22,500,000
80 Eksisi kelenjar liur sub mandibula 9,651,000 10,236,000 19,887,000
81 Eksisi kelenjar liur sub mandibula Dengan Penyulit 12,064,000 12,793,000 24,857,000
82 Eksisi KGB 9,651,000 11,066,000 20,717,000
83 Eksisi KGB Dengan Penyulit 12,064,000 13,832,000 25,896,000
84 Eksisi Kista Tyroglosus 9,651,000 25,450,000 35,101,000
85 Eksisi Kista Tyroglosus Dengan Penyulit 12,064,000 31,811,000 43,875,000
86 Eksisi kulit brachiogenik 9,651,000 25,449,000 35,100,000
87 Eksisi kulit brachiogenik Dengan Penyulit 12,064,000 31,811,000 43,875,000
88 Eksisi lokal 6,935,000 4,629,000 11,564,000
89 Eksisi lokal ≤ 3 cm 6,935,000 3,163,000 10,098,000
90 Eksisi Luas 13,544,000 21,132,000 34,676,000
91 Eksisi Luas Dengan Penyulit 16,930,000 26,414,000 43,344,000
92 Eksisi mammae abberans 9,651,000 19,119,000 28,770,000
93 Eksisi mammae abberans Dengan Penyulit 12,064,000 23,897,000 35,961,000
94 Eksisi tumor jinak kulit ≤ 3 cm 6,935,000 10,236,000 17,171,000
95 Eksisi tumor jinak kulit ≤ 3 cm Dengan Penyulit 8,668,000 12,793,000 21,461,000
96 Ekstirpasi 6,935,000 3,422,000 10,357,000
97 Endoskopi Tiroidektomi Totalis 17,437,000 50,590,000 68,027,000
98 Endoskopi Tiroidektomi Totalis Dengan Penyulit 21,796,000 63,236,000 85,032,000
99 Endoskopi Tiroidektomi Unilateral 17,437,000 31,049,000 48,486,000
100 Endoskopi Tiroidektomi Unilateral Dengan Penyulit 21,796,000 38,810,000 60,606,000
101 Flap kulit sederhana 9,651,000 12,116,000 21,767,000
102 Flap kulit sederhana Dengan Penyulit 12,064,000 15,144,000 27,208,000
103 Flap Perforator 9,651,000 18,679,000 28,330,000
104 Flap Perforator 12,064,000 23,348,000 35,412,000
105 Forequarter 19,949,000 50,590,000 70,539,000
106 Forequarter Dengan Penyulit 24,936,000 63,236,000 88,172,000
107 Glosektomi Total 13,544,000 38,173,000 51,717,000
108 Glosektomi Total Dengan Penyulit 16,930,000 47,715,000 64,645,000
109 Hemiglisektomi 13,544,000 27,543,000 41,087,000
110 Hemiglisektomi Dengan Penyulit 16,930,000 34,427,000 51,357,000
111 Insisi + Drainase Abses 9,651,000 11,066,000 20,717,000
112 Insisi + Drainase Abses Dengan Penyulit 12,064,000 13,832,000 25,896,000
113 Ismolubektomi Tiroid 13,544,000 18,179,000 31,723,000
114 Ismolubektomi Tiroid 13,544,000 20,930,000 34,474,000
115 Ismolubektomi Tiroid Dengan Penyulit 16,930,000 26,162,000 43,092,000
116 Lobektomi Tiroid 13,544,000 25,450,000 38,994,000
JASA
PELAYANAN
117 Lobektomi Tiroid 13,544,000 19,320,000 32,864,000
118 Lobektomi Tiroid Dengan Penyulit 16,930,000 24,150,000 41,080,000
119 Maksilektomi Parsial 19,949,000 25,450,000 45,399,000
120 Maksilektomi Parsial Dengan Penyulit 24,936,000 31,811,000 56,747,000
121 Maksilektomi Total 19,949,000 38,173,000 58,122,000
122 Maksilektomi Total Dengan Penyulit 24,936,000 47,715,000 72,651,000
123 Mastektomi Radikal / Modifikasi 19,949,000 27,543,000 47,492,000
124 Mastektomi Radikal / Modifikasi Dengan Penyulit 24,936,000 34,427,000 59,363,000
125 Mastektomi simpel 13,544,000 19,673,000 33,217,000
126 Mastektomi simpel Dengan Penyulit 16,930,000 24,590,000 41,520,000
127 Mastektomi subkutan 13,544,000 19,673,000 33,217,000
128 Mastektomi subkutan Dengan Penyulit 16,930,000 24,590,000 41,520,000
129 Near Total Tiroidektomi 17,437,000 27,708,000 45,145,000
130 Near Total Tiroidektomi 17,437,000 25,450,000 42,887,000
131 Near Total Tiroidektomi Dengan Penyulit 21,796,000 31,811,000 53,607,000
132 Paratiroidektomi 17,437,000 27,708,000 45,145,000
133 PAROTIDEKTOMI 14,517,000 29,987,000 44,504,000
134 Parotidektomi Superfisial 17,437,000 25,450,000 42,887,000
135 Parotidektomi Superfisial Dengan Penyulit 21,796,000 31,811,000 53,607,000
136 Parotidektomi Total 17,437,000 29,987,000 47,424,000
137 Parotidektomi Total Dengan Penyulit 21,796,000 37,483,000 59,279,000
138 Pembedahan kompartemen 19,949,000 25,449,000 45,398,000
139 Pembedahan kompartemen Dengan Penyulit 24,936,000 31,811,000 56,747,000
140 Rekonstruksi plate screw 13,544,000 25,449,000 38,993,000
141 Rekonstruksi plate screw Dengan Penyulit 16,930,000 31,811,000 48,741,000
142 Reseksi Mandibula 13,544,000 25,450,000 38,994,000
143 Reseksi Mandibula Dengan Penyulit 16,930,000 31,811,000 48,741,000
144 Salphingo Ooverektomi bilateral 9,651,000 25,449,000 35,100,000
145 Salphingo Ooverektomi bilateral Dengan Penyulit 12,064,000 31,811,000 43,875,000
146 Selective neck dissection unilateral 14,517,000 25,450,000 39,967,000
147 Selective neck dissection unilateral Dengan Penyulit 18,146,000 31,811,000 49,957,000
148 Tiroidektomi Total 17,437,000 25,450,000 42,887,000
149 Tiroidektomi Total Dengan Penyulit 21,796,000 31,811,000 53,607,000
150 Total Mandibulektomi 19,949,000 38,173,000 58,122,000
151 Total Mandibulektomi Dengan Penyulit 24,936,000 47,715,000 72,651,000
152 Tracheostomi 6,935,000 10,236,000 17,171,000
153 Tracheostomi Dengan Penyulit 8,668,000 12,793,000 21,461,000
6.3 CARDIOVASCULAR
1 AF Ablasi dengan 3D Mapping System dan anestesi 128,926,000 47,438,000 176,364,000
2 Amputasi mayor kaki diabetik atau kasus vaskuler Besar 2 9,315,000 22,540,000 31,855,000
3 Angiografi dan Coiling/embolisasi PCS Khusus 1 dengan anestesi 14,746,000 32,200,000 46,946,000
4 Angiografi dan Coiling/embolisasi PCS Khusus 1 tanpa anestesi 12,583,000 23,000,000 35,583,000
Angiografi dan embolisasi endoleak kompleks Khusus 2 dengan
5 14,746,000 56,925,000 71,671,000
anestesi
6 Angiografi dan embolisasi endoleak kompleks Khusus 2 tanpa anestesi 12,583,000 43,125,000 55,708,000
Angiografi dan embolisasi endoleak sederhana Khusus 1 dengan
7 14,746,000 37,950,000 52,696,000
anestesi
8 Angiografi dan embolisasi endoleak sederhana Khusus 1 tanpa anestesi 12,583,000 28,750,000 41,333,000
Angiografi dan embolisasi organ (ginjal, limpa, dll) Khusus 1 dengan
9 14,746,000 32,200,000 46,946,000
anestesi
Angiografi dan embolisasi organ (ginjal, limpa, dll) Khusus 1 tanpa
10 12,583,000 23,000,000 35,583,000
anestesi
11 Angiografi dan embolisasi perdarahan Khusus 1 dengan anestesi 14,746,000 32,200,000 46,946,000
12 Angiografi dan embolisasi perdarahan Khusus 1 tanpa anestesi 12,583,000 23,000,000 35,583,000
Angiografi, angioplasty dan Catheter directed thrombolysis 1
13 9,315,000 37,950,000 47,265,000
ekstremitas Khusus 1 dengan anestesi
Angiografi, angioplasty dan Catheter directed thrombolysis 1
14 7,152,000 28,750,000 35,902,000
ekstremitas Khusus 1 tanpa anestesi
Angiografi, Trombektomi angiojet dengan atau tanpa angioplasty 1
15 17,867,000 56,925,000 74,792,000
16 14,746,000 43,125,000 57,871,000
ekstremitas Khusus 2 tanpa anestesi
17 17,867,000 75,900,000 93,767,000
Angiografi, Trombektomi dengan atau tanpa angioplasty 1 ekstremitas
18 14,746,000 37,950,000 52,696,000
Khusus 1 dengan anestesi
JASA
PELAYANAN
19 12,583,000 28,750,000 41,333,000
Khusus 1 tanpa anestesi
20 17,867,000 75,900,000 93,767,000
21 14,746,000 57,500,000 72,246,000
22 Arteriografi/Venografi 16,113,000 10,350,000 26,463,000
23 Arteriografi/Venografi dengan anestesi 16,113,000 17,078,000 33,191,000
24 Arteriografi/Venografi dengan asistensi 16,113,000 12,938,000 29,051,000
25 Arteriografi/Venografi Kompleks 17,918,000 11,500,000 29,418,000
26 Arteriografi/Venografi Kompleks dengan anestesi 17,918,000 18,975,000 36,893,000
27 Arteriografi/Venografi Kompleks dengan asistensi 17,918,000 14,375,000 32,293,000
28 ASD Closure 97,605,000 115,728,000 213,333,000
29 AV Shunt Cubiti Besar 2 dengan anestesi 7,152,000 22,540,000 29,692,000
30 AV Shunt Cubiti Besar 2 tanpa anestesi 5,000,000 16,100,000 21,100,000
31 AV Shunt dengan graft vena/sintesis Khusus 1 dengan anestesi 9,315,000 32,200,000 41,515,000
32 AV Shunt Radial (Brescia Cimino) Besar 1 dengan anestesi 7,152,000 16,905,000 24,057,000
33 AV Shunt Radial (Brescia Cimino) Besar 1 tanpa anestesi 5,000,000 12,075,000 17,075,000
34 AVM angiografi + embolisasi kompleks Khusus 2 dengan anestesi 17,867,000 56,925,000 74,792,000
35 AVM angiografi + embolisasi kompleks Khusus 2 tanpa anestesi 14,746,000 43,125,000 57,871,000
36 AVM Angiografi + Embolisasi sederhana Khusus 1 dengan anestesi 14,746,000 37,950,000 52,696,000
37 AVM Angiografi + Embolisasi sederhana Khusus 1 tanpa anestesi 12,583,000 28,750,000 41,333,000
38 AVM Angiografi selektif Besar 2 dengan anestesi 12,583,000 26,565,000 39,148,000
39 AVM Angiografi selektif Besar 2 tanpa anestesi 9,315,000 20,125,000 29,440,000
40 BAS 32,982,000 19,320,000 52,302,000
41 BCPS OFF 59,967,000 115,728,000 175,695,000
42 BCPS ON 71,390,000 115,728,000 187,118,000
43 BENTALL 177,885,000 115,728,000 293,613,000
44 Biopsi Lokal 12,123,000 18,926,000 31,049,000
45 Bronchoscopy 12,123,000 18,926,000 31,049,000
46 BRONCOGRAM 18,665,000 11,270,000 29,935,000
47 BT SHUNT 60,545,000 115,728,000 176,273,000
48 CABG High Risk 97,151,000 115,728,000 212,879,000
49 CABG Low Risk 84,474,000 115,728,000 200,202,000
50 CABG MOF-IABP-SG-CRRT 204,489,000 115,728,000 320,217,000
51 CABG-SINGLE VALVE REPAIR 99,746,000 115,728,000 215,474,000
52 Cabut CDL semi permanen tanpa anestesi 3,500,000 4,600,000 8,100,000
53 Cabut Chemoport/Cellsite Sedang 1 dengan anestesi 5,000,000 10,465,000 15,465,000
54 Cabut Chemoport/Cellsite Sedang 1 tanpa anestesi 3,500,000 7,475,000 10,975,000
55 Cardiac Resinkronisasi Terapi (CRT) 176,807,000 37,950,000 214,757,000
56 Cardiac Resinkronisasi Terapi Defibliator (CRTD) 362,409,000 47,438,000 409,847,000
57 CAVSD-AVSD 81,005,000 115,728,000 196,733,000
58 Cervicotomy + Debridement 35,046,000 76,087,000 111,133,000
59 Cervicotomy + Repair Esofagus 35,046,000 76,087,000 111,133,000
60 Cervicotomy + Repair Trakea 35,046,000 76,087,000 111,133,000
61 Cervicotomy + Sternotomi + Debridement 35,046,000 76,087,000 111,133,000
62 COARCTASIO AORTA REPAIR 112,684,000 115,728,000 228,412,000
63 COR Angiografi 17,084,000 10,350,000 27,434,000
64 COR Angiografi + Arteriografi 20,374,000 10,350,000 30,724,000
65 COR Angiografi + Arteriografi dengan Anestesi 20,374,000 17,078,000 37,452,000
66 COR Angiografi + Arteriografi dengan Asistensi 20,374,000 12,938,000 33,312,000
67 COR Angiografi dengan Anestesi 17,084,000 17,078,000 34,162,000
68 COR Angiografi dengan Asistensi 17,084,000 12,938,000 30,022,000
69 CORANGIOGRAFI + IABP 42,408,000 11,500,000 53,908,000
70 CORANGIOGRAFI + IABP dengan anestesi 42,408,000 18,975,000 61,383,000
71 CORANGIOGRAFI + IABP dengan asistensi 42,408,000 14,375,000 56,783,000
72 CORANGIOGRAFI + PENYADAPAN (KATETERISASI) 23,390,000 11,500,000 34,890,000
CORANGIOGRAFI + PENYADAPAN (KATETERISASI) dengan
73 23,390,000 18,975,000 42,365,000
anestesi
CORANGIOGRAFI + PENYADAPAN (KATETERISASI) dengan
74 23,390,000 14,375,000 37,765,000
asistensi
75 CORANGIOGRAFI + TPM 26,315,000 11,500,000 37,815,000
76 CORANGIOGRAFI + TPM dengan anestesi 26,315,000 18,975,000 45,290,000
77 CORANGIOGRAFI + TPM dengan asistensi 26,315,000 14,375,000 40,690,000
78 DEBRIDEMENT 26,855,000 115,728,000 142,583,000
79 Debridement dan eksplorasi angkat graft ekstremitas Besar 2 9,315,000 22,540,000 31,855,000
80 Debridement dan eksplorasi angkat graft intraabdomen Khusus 1 12,583,000 37,950,000 50,533,000
JASA
PELAYANAN
81 Debridement dan evakuasi hematom Sedang 2 7,152,000 12,880,000 20,032,000
Debridement dan tutup defek dengan STSG kaki diabetik/CVI
82 9,315,000 22,540,000 31,855,000
kompleks Besar 2
83 Debridement dan tutup defek kaki diabetik/CVI sederhana Besar 1 9,315,000 16,905,000 26,220,000
84 Debridement dengan ultrasound Besar 2 14,746,000 22,540,000 37,286,000
85 Debridement kompleks dengan amputasi minor kaki diabetik Besar 2 9,315,000 22,540,000 31,855,000
86 Debridement kompleks gangren diabetik Besar 2 9,315,000 22,540,000 31,855,000
87 Debridement sederhana dengan amputasi minor kaki diabetik Besar 1 9,315,000 16,905,000 26,220,000
88 Debridement Sederhana Gangren Diabetik Sedang 2 7,152,000 12,880,000 20,032,000
89 Double Valve REPAIR 135,200,000 115,728,000 250,928,000
90 Double Valve REPLACE 154,908,000 115,728,000 270,636,000
Eksisi dan rekonstruksi pseudoaneurisma kompleks Khusus 1 dengan
91 14,746,000 37,950,000 52,696,000
anestesi
Eksisi dan rekonstruksi pseudoaneurisma kompleks Khusus 1 tanpa
92 12,583,000 28,750,000 41,333,000
anestesi
Eksisi dan rekonstruksi pseudoaneurisma sederhana Besar 2 dengan
93 12,583,000 22,540,000 35,123,000
anestesi
Eksisi dan rekonstruksi pseudoaneurisma sederhana Besar 2 tanpa
94 9,315,000 16,100,000 25,415,000
anestesi
95 Eksisi ligasi dan rekonstruksi malformasi vaskuler sederhana Besar 2 12,583,000 22,540,000 35,123,000
96 Eksisi ligasi pseudoaneurisma kompleks Besar 2 12,583,000 22,540,000 35,123,000
97 Eksisi ligasi pseudoaneurisma sederhana Besar 1 7,152,000 16,905,000 24,057,000
98 Eksisi limfedema kompleks Khusus 1 14,746,000 37,950,000 52,696,000
99 Eksisi limfedema sederhana Besar 2 12,583,000 22,540,000 35,123,000
Eksisi Luas & Rekonstruksi Malformasi Vaskuler kompleks (tanpa
100 12,583,000 37,950,000 50,533,000
graft) Khusus 1
Eksplorasi dan ligasi tinggi vena ovarica pada Pelvic Congestive
101 12,583,000 37,950,000 50,533,000
Disease Khusus 1
102 Eksplorasi dan rekonstruksi aorta kasus trauma Khusus 3 17,867,000 75,900,000 93,767,000
103 Eksplorasi dan rekonstruksi vaskular extremitas Besar 2 9,315,000 22,540,000 31,855,000
104 Eksplorasi dan rekonstruksi vaskular intraabdomen Khusus 1 12,583,000 37,950,000 50,533,000
105 Eksplorasi dan rekonstruksi vena cava dengan graft Khusus 2 12,583,000 56,925,000 69,508,000
106 Eksplorasi dan rekonstruksi vena iliaka dengan graft Khusus 2 12,583,000 56,925,000 69,508,000
107 Eksplorasi vaskuler ekstremitas tanpa rekonstruksi Besar 1 9,315,000 16,905,000 26,220,000
108 Eksplorasi vaskuler intraabdomen tanpa rekonstruksi Besar 2 9,315,000 16,905,000 26,220,000
109 Eksplorasi vaskuler leher tanpa rekonstruksi Besar 1 9,315,000 16,905,000 26,220,000
110 Ekstemitas Angiografi Besar 2 dengan anestesi 12,583,000 22,540,000 35,123,000
111 Ekstemitas Angiografi Besar 2 tanpa anestesi 9,315,000 16,100,000 25,415,000
Ekstremitas Angiografi dan angioplasty kompleks Khusus 2 dengan
112 14,746,000 56,925,000 71,671,000
anestesi
Ekstremitas Angiografi dan angioplasty kompleks Khusus 2 tanpa
113 12,583,000 56,925,000 69,508,000
anestesi
Ekstremitas Angiografi dan angioplasty sederhana (balloon, stent)
114 14,746,000 37,950,000 52,696,000
Ekstremitas Angiografi dan angioplasty sederhana (balloon, stent)
115 12,583,000 28,750,000 41,333,000
116 Electro Phisiologi Study (EPS) 80,788,000 11,500,000 92,288,000
117 Electro Phisiologi Study (EPS) dan Ablasi Konvensional 80,788,000 11,500,000 92,288,000
Electro Phisiologi Study (EPS) dan Ablasi SVT Kompleks dengan 3D
118 20,374,000 17,079,000 37,453,000
Mapping System
119 Electro Phisiologi Study (EPS) dengan asistensi 80,788,000 14,375,000 95,163,000
120 Electro Phisiologi Study (EPS) dengana anestesi 80,788,000 18,975,000 99,763,000
Endovenous Laser Treatment (EVLT) 1 ekstremitas Besar 2 dengan
121 14,746,000 22,540,000 37,286,000
anestesi
Endovenous Laser Treatment (EVLT) 1 ekstremitas Besar 2 tanpa
122 12,583,000 22,540,000 35,123,000
anestesi
123 EVAR aortoiliac/aorta/iliac kompleks Khusus 3 dengan anestesi 17,867,000 75,900,000 93,767,000
124 EVAR aortoiliac/aorta/iliac sederhana Khusus 2 dengan anestesi 17,867,000 56,925,000 74,792,000
125 EVAR dengan Cut Down 255,158,000 56,925,000 312,083,000
126 EVAR dengan Proglide Closure Device 294,758,000 56,925,000 351,683,000
127 EVLT dengan multiple flebektomi 1 ekstremitas Khusus 1 14,746,000 37,950,000 52,696,000
128 Explorasi dan rekonstruksi vaskular leher Besar 2 9,315,000 22,540,000 31,855,000
129 Fasciotomi dekompresi Sedang 1 7,152,000 10,465,000 17,617,000
130 Flebektomi 1 tungkai kompleks Sedang 2 dengan anestesi 7,152,000 12,880,000 20,032,000
131 Flebektomi 1 tungkai sederhana Sedang 1 dengan anestesi 7,152,000 10,465,000 17,617,000
132 Flebektomi 1 tungkai sederhana Sedang 1 tanpa anestesi 7,152,000 7,475,000 14,627,000
JASA
PELAYANAN
133 Flebektomi 2 tungkai Sedang 2 dengan anestesi 9,315,000 15,180,000 24,495,000
134 Foam skleroterapi, USG guided 1 tungkai Kecil 1 dengan anestesi 5,000,000 6,440,000 11,440,000
135 Foam skleroterapi, USG guided 2 tungkai Sedang 1 dengan anestesi 5,000,000 10,465,000 15,465,000
136 FONTAN 85,956,000 115,728,000 201,684,000
137 Implantasi chemoport atau cellsite Besar 1 dengan anestesi 9,315,000 16,905,000 26,220,000
138 Implantasi chemoport atau cellsite Besar 1 tanpa anestesi 7,152,000 12,075,000 19,227,000
Insersi CDL semipermanen/tunnelling untuk hemodialisa Sedang 2
140 7,152,000 12,880,000 20,032,000
dengan anestesi
Insersi CDL semipermanen/tunnelling untuk hemodialisa Sedang 2
141 5,000,000 9,200,000 14,200,000
tanpa anestesi
142 Insersi CDL temporer atau CVC Kecil tanpa anestesi 3,500,000 4,600,000 8,100,000
143 Insersi chest tube + WSD 6,405,000 18,926,000 25,331,000
144 Insersi Heimlich Valve 12,123,000 18,926,000 31,049,000
145 Insersi Indweling Pleural Catheter (IPC) 13,866,000 18,926,000 32,792,000
Insersi PICC untuk akses parenteral USG guieded atau Open tanpa
146 5,000,000 7,475,000 12,475,000
anestesi
147 Insert Baloon Pump 42,408,000 17,078,000 59,486,000
Joint operasi/pendampingan Operasi khusus divisi lain tanpa
148 7,152,000 12,075,000 19,227,000
rekonstruksi vaskuler Besar 1
149 Karotis Endarterektomi (CEA, EEA) Khusus 2 dengan anestesi 9,315,000 56,925,000 66,240,000
150 Karotis Endarterektomi (CEA, EEA) Khusus 2 tanpa anestesi 7,152,000 43,125,000 50,277,000
151 Karotis/Visceral Angiografi dan angioplasti Khusus 2 dengan anestesi 14,746,000 56,925,000 71,671,000
152 Karotis/Visceral Angiografi dan angioplasti Khusus 2 tanpan anestesi 12,583,000 43,125,000 55,708,000
153 Karotis/Viseral Angiografi Besar 2 dengan anestesi 12,583,000 22,540,000 35,123,000
154 Karotis/Viseral Angiografi Besar 2 tanpa anestesi 9,315,000 16,100,000 25,415,000
155 KATETERISASI ANAK + ANESTESI 22,424,000 14,490,000 36,914,000
156 KATETERISASI ANAK + TEE 25,772,000 16,100,000 41,872,000
157 KAWASHIMA 66,987,000 115,728,000 182,715,000
Konsultasi cito intra operasi dari divisi/ bagian lain tanpa tindakan
158 - - -
(50% dari Operator/DPJP)
159 Konversi EVAR -> open Khusus 3 dengan anestesi 17,867,000 75,900,000 93,767,000
160 LAA Occluder 176,807,000 75,900,000 252,707,000
161 Ligasi AV shunt Sedang 1 dengan anestesi 5,000,000 10,465,000 15,465,000
162 Ligasi AV shunt Sedang 1 tanpa anestesi 5,000,000 7,475,000 12,475,000
163 Ligasi cabang draining vein AV shunt Sedang 1 tanpa anestesi 5,000,000 7,475,000 12,475,000
164 Lumbal simpatektomi bilateral Khusus 1 dengan anestesi 14,746,000 37,950,000 52,696,000
165 Lumbal simpatektomi unilateral Besar 2 dengan anestesi 14,746,000 26,565,000 41,311,000
166 Mediastinoskopi + Biopsi 35,046,000 76,087,000 111,133,000
167 Mediastinostomi 12,123,000 18,926,000 31,049,000
168 Minimally Invasive Repair of Pectus Excavatum (Nuss Procedure) 38,612,000 89,021,000 127,633,000
169 Mitral Clip 600,000,000 94,875,000 694,875,000
170 MV-AV REPAIR 101,158,000 115,728,000 216,886,000
171 MV-AV REPLACE 131,348,000 115,728,000 247,076,000
172 PA BANDING 52,287,000 115,728,000 168,015,000
173 PAPVD REPAIR 64,856,000 115,728,000 180,584,000
174 PDA LIGASI 35,427,000 89,021,000 124,448,000
175 PDA Stenting 65,226,000 27,370,000 92,596,000
176 PEMASANGAN COIL JANTUNG 28,976,000 19,320,000 48,296,000
Pendampingan pada operasi khusus dari divisi/bagian lain tanpa
177 - - -
tindakan (50% dari Operator/DPJP)
178 Percutaneus Coronary Intervensi (PCI) Balon/PCI 1 Stent 65,226,000 11,500,000 76,726,000
Percutaneus Coronary Intervensi (PCI) Balon/PCI 1 Stent dengan
179 65,226,000 18,975,000 84,201,000
anestesi
Percutaneus Coronary Intervensi (PCI) Balon/PCI 1 Stent dengan
180 65,226,000 14,375,000 79,601,000
asistensi
181 Percutaneus Coronary Intervensi (PCI) PCI 2 Stent 103,394,000 17,250,000 120,644,000
182 Percutaneus Coronary Intervensi (PCI) PCI 2 Stent dengan anestesi 103,394,000 28,463,000 131,857,000
183 Percutaneus Coronary Intervensi (PCI) PCI 2 Stent dengan asistensi 103,394,000 21,563,000 124,957,000
184 Percutaneus Coronary Intervensi (PCI) PCI 3 Stent 136,724,000 23,000,000 159,724,000
185 Percutaneus Coronary Intervensi (PCI) PCI 3 Stent dengan anestesi 136,724,000 37,950,000 174,674,000
186 Percutaneus Coronary Intervensi (PCI) PCI 3 Stent dengan asistensi 136,724,000 28,750,000 165,474,000
JASA
PELAYANAN
187 Percutaneus Coronary Intervensi (PCI) PCI Kompleks 173,255,000 28,750,000 202,005,000
188 Percutaneus Coronary Intervensi (PCI) PCI Kompleks dengan anestesi 173,255,000 47,438,000 220,693,000
189 Percutaneus Coronary Intervensi (PCI) PCI Kompleks dengan asistensi 173,255,000 35,938,000 209,193,000
Percutaneus Coronary Intervensi (PCI) PCI Kompleks dengan
190 225,306,000 56,925,000 282,231,000
Rotablator dengan anestesi*
191 225,306,000 43,125,000 268,431,000
Rotablator dengan asistensi*
192 225,306,000 34,500,000 259,806,000
Rotablator*
193 Percutaneus Coronary Intervensi (PCI) PCI Primary 95,669,000 17,250,000 112,919,000
194 Percutaneus Coronary Intervensi (PCI) PCI Primary dengan anestesi 95,669,000 28,463,000 124,132,000
195 Percutaneus Coronary Intervensi (PCI) PCI Primary dengan asistensi 95,669,000 21,563,000 117,232,000
196 Percutaneus Transluminal Angioplasty (PTA) 1 Stent 65,226,000 11,500,000 76,726,000
197 Percutaneus Transluminal Angioplasty (PTA) 1 Stent dengan anestesi 65,226,000 18,975,000 84,201,000
198 Percutaneus Transluminal Angioplasty (PTA) 1 Stent dengan asistensi 65,226,000 14,375,000 79,601,000
205 Percutaneus Transluminal Angioplasty (PTA) Kompleks 173,255,000 28,750,000 202,005,000
Percutaneus Transluminal Angioplasty (PTA) Kompleks dengan
206 173,255,000 47,438,000 220,693,000
anestesi
Percutaneus Transluminal Angioplasty (PTA) Kompleks dengan
207 173,255,000 35,938,000 209,193,000
asistensi
208 Percutaneus Transluminal Mitral Comissurotomi (PTMC) 76,883,000 23,000,000 99,883,000
Percutaneus Transluminal Mitral Comissurotomi (PTMC) dengan
209 76,883,000 37,950,000 114,833,000
anestesi
Percutaneus Transluminal Mitral Comissurotomi (PTMC) dengan
210 76,883,000 28,750,000 105,633,000
asistensi
211 Permanen Pace Maker (PPM) 82,142,000 28,463,000 110,605,000
212 Pleurodesis 35,086,000 18,926,000 54,012,000
213 Pleurofibrosis 35,086,000 18,926,000 54,012,000
214 PPM SINGLE CHAMBER/ PTCA-2VESSEL 53,033,000 24,150,000 77,183,000
215 PS RESEKSI-REPAIR 79,635,000 115,728,000 195,363,000
216 PTBV AORTA 43,571,000 24,150,000 67,721,000
217 PTBV Pulmoner 43,571,000 24,150,000 67,721,000
218 PUNKSI EFUSI PERIKARD/EFUSI PLEURA 14,979,000 8,050,000 23,029,000
219 PVC atau VT Ablation dengan 3D Mapping System 128,926,000 35,938,000 164,864,000
220 RASTELLI 170,176,000 115,728,000 285,904,000
221 Redebridement Sedang 1 dengan anestesi 7,152,000 10,465,000 17,617,000
Rekonstruksi Aneurisma Aortailiak/Aorta/Iliaka kompleks per
222 14,746,000 75,900,000 90,646,000
laparotomi Khusus 3
Rekonstruksi Aneurisma Aortailiak/Aorta/Iliaka sederhana per
223 14,746,000 56,925,000 71,671,000
laparotomi Khusus 2
Rekonstruksi Aortoiliak/bifemoral pada kasus Leriche's syndrom
224 14,746,000 56,925,000 71,671,000
Khusus 2
225 Rekonstruksi Karotid body tumor Khusus 2 14,746,000 56,925,000 71,671,000
226 Rekonstruksi kerusakan katup vena dalam tungkai Khusus 2 14,746,000 56,925,000 71,671,000
Rekonstruksi kompleks arteri ekstremitas pada CLI dengan graft
227 14,746,000 56,925,000 71,671,000
Khusus 2
Rekonstruksi vaskuler arteri inominata atau subklavia dengan graft
228 14,746,000 56,925,000 71,671,000
sintetis Khusus 2
229 Rekonstruksi vena pada kasus-kasus DVT kronik Khusus 2 14,746,000 56,925,000 71,671,000
230 Release Thoracic Outlet Syndrome Khusus 2 14,746,000 56,925,000 71,671,000
231 Repair Pectus Excavatum (Sternal Turnover/Ravitch Procedure) 35,046,000 76,087,000 111,133,000
232 REPOSISI TPM 10,144,000 2,875,000 13,019,000
233 RFA PTBV 65,226,000 27,370,000 92,596,000
234 Second look laparotomi pasca Op I tanpa rekonstruksi Besar 1 9,315,000 16,905,000 26,220,000
JASA
PELAYANAN
235 Simpatektomi laparoskopi Khusus 2 14,746,000 56,925,000 71,671,000
236 Simpatektomi torakoskopi Khusus 2 14,746,000 56,925,000 71,671,000
237 Skin laser varises 1 tungkai Kecil tanpa anestesi 7,152,000 4,600,000 11,752,000
238 Skin laser varises 2 tungkai Sedang 1 tanpa anestesi 7,152,000 7,475,000 14,627,000
239 Splenektomi dan ligasi vv coronaria serta splenorenal shunt Khusus 2 14,746,000 56,925,000 71,671,000
240 Splenektomi ec Hipertensi portal/lain Khusus 1 12,583,000 37,950,000 50,533,000
241 Stent CoA 65,226,000 27,370,000 92,596,000
242 Sternotomi + Biopsi 35,046,000 76,087,000 111,133,000
243 Sternotomi + Bypass Graft Vena 35,046,000 89,021,000 124,067,000
244 Sternotomi + Debridement 35,046,000 76,087,000 111,133,000
245 Sternotomi + Eksisi Tumor Mediastinum 35,046,000 76,087,000 111,133,000
246 Sternotomi + Perikardiektomi 35,046,000 76,087,000 111,133,000
247 Sternotomi + Rekonstruksi Dinding Dada 35,046,000 76,087,000 111,133,000
248 Sternotomi + Repair jantung 35,046,000 76,087,000 111,133,000
249 Sternotomi + Timektomi 35,046,000 76,087,000 111,133,000
Stripping Varises 1 tungkai kompleks (flekbektomi/debridement ulkus
250 9,315,000 22,540,000 31,855,000
vena/ligasi vena perforantes) Besar 2
251 Stripping Varises 1 tungkai sederhana Besar 1 7,152,000 16,905,000 24,057,000
252 Stripping Varises 2 tungkai kompleks Khusus 1 14,746,000 37,950,000 52,696,000
253 Stripping Varises 2 tungkai sederhana Besar 2 12,583,000 22,540,000 35,123,000
254 Sub Xyphoid Pericardial Window 35,046,000 76,087,000 111,133,000
255 TAPVD 96,254,000 115,728,000 211,982,000
256 TEE + ANESTESI 9,981,000 3,220,000 13,201,000
257 Temporary Pace Maker (TPM) 25,427,000 10,350,000 35,777,000
258 Terapi Ablasi 128,926,000 28,750,000 157,676,000
259 Terapi Ablasi dengan anestesi 128,926,000 47,438,000 176,364,000
260 Terapi Ablasi dengan asistensi 128,926,000 35,938,000 164,864,000
261 TEVAR dengan Cut Down 231,962,000 47,438,000 279,400,000
262 TEVAR dengan Proglide Closure Device 267,962,000 47,438,000 315,400,000
263 TEVAR kompleks khusus 3 dengan anestesi 17,867,000 75,900,000 93,767,000
264 TEVAR sederhana khusus 2 dengan anestesi 17,867,000 56,925,000 74,792,000
265 TIPS endovaskuler Khusus 2 dengan anestesi 14,746,000 56,925,000 71,671,000
266 TOF 101,829,000 115,728,000 217,557,000
267 TOF HR 182,007,000 115,728,000 297,735,000
268 Torakoplasti 35,046,000 76,087,000 111,133,000
269 Torakotomi /Mediastinostomi + Biopsi Chamberlains 35,046,000 76,087,000 111,133,000
270 Torakotomi + Air Plombage 35,046,000 76,087,000 111,133,000
271 Torakotomi + Anastomosis Esofagus 35,046,000 76,087,000 111,133,000
272 Torakotomi + Bullaectomy 35,046,000 76,087,000 111,133,000
273 Torakotomi + Debridement 35,046,000 76,087,000 111,133,000
274 Torakotomi + Debridement + Drainase Abses Hepar 35,046,000 76,087,000 111,133,000
275 Torakotomi + Dekortikasi 35,046,000 76,087,000 111,133,000
276 Torakotomi + Ekstraksi Benda Asing 35,046,000 76,087,000 111,133,000
277 Torakotomi + Eloeser Window 35,046,000 76,087,000 111,133,000
278 Torakotomi + Esofagektomi 35,046,000 76,087,000 111,133,000
279 Torakotomi + Fiksasi Iga 35,046,000 76,087,000 111,133,000
280 Torakotomi + Hemostasis 35,046,000 76,087,000 111,133,000
281 Torakotomi + Lobektomi 35,046,000 76,087,000 111,133,000
282 Torakotomi + Muscle Plombage 35,046,000 76,087,000 111,133,000
283 Torakotomi + Pericardial Window 35,046,000 76,087,000 111,133,000
284 Torakotomi + Pleurectomy 35,046,000 76,087,000 111,133,000
285 Torakotomi + Pneumonektomi 35,046,000 76,087,000 111,133,000
286 Torakotomi + Rekonstruksi Dinding Dada 35,046,000 76,087,000 111,133,000
287 Torakotomi + Repair Bronchus 35,046,000 76,087,000 111,133,000
288 Torakotomi + Repair Diafragma 35,046,000 76,087,000 111,133,000
289 Torakotomi + Repair Duktus Torasikus 35,046,000 76,087,000 111,133,000
290 Torakotomi + Repair Fistula Bronchopleura 35,046,000 76,087,000 111,133,000
291 Torakotomi + Repair Hernia Diafragma dengan Mesh Graft 35,046,000 89,021,000 124,067,000
292 Torakotomi + Repair paru 35,046,000 76,087,000 111,133,000
293 Torakotomi + Repair Trakea 35,046,000 76,087,000 111,133,000
294 Torakotomi + Simpatektomi Torakal 35,046,000 76,087,000 111,133,000
295 Torakotomi+ Eksisi Tumor Mediastinum 35,046,000 76,087,000 111,133,000
296 TPM 25,427,000 14,490,000 39,917,000
297 Trakheostomi 6,405,000 18,926,000 25,331,000
298 Transcatheter Aortic Valve Inplantion (TAVI) 600,000,000 94,875,000 694,875,000
299 TRANSKATETER CLOSURE OF ASD 83,554,000 24,150,000 107,704,000
300 TRANSKATETER CLOSURE OF PDA /PLUG OCCLUDER 58,442,000 24,150,000 82,592,000
301 TRANSKATETER CLOSURE VSD / PFO OCLUDER 94,035,000 27,370,000 121,405,000
302 Trombektomi 1 ekstremitas Besar 2 dengan anestesi 9,315,000 22,540,000 31,855,000
JASA
PELAYANAN
303 Trombektomi 1 ekstremitas Besar 2 tanpa anestesi 7,152,000 16,100,000 23,252,000
304 Trombektomi 2 ekstremitas Khusus 1 dengan anestesi 12,583,000 37,950,000 50,533,000
305 Trombektomi 2 ekstremitas Khusus 1 tanpa anestesi 9,315,000 28,750,000 38,065,000
Trombektomi dengan debridement dan atau fasciotomi 1 ekstremitas
306 14,746,000 37,950,000 52,696,000
307 VATS + Bullaectomi 38,612,000 89,021,000 127,633,000
308 VATS + Dekortikasi 38,612,000 89,021,000 127,633,000
309 VATS + Eksisi Baji Paru 38,612,000 89,021,000 127,633,000
310 VATS + Ekstraksi Benda Asing 38,612,000 89,021,000 127,633,000
311 VATS + Lobektomi 38,612,000 89,021,000 127,633,000
312 VATS + Lung Volume Reduction Surgery (LVRS) 38,612,000 89,021,000 127,633,000
313 VATS + Pleurodesis 38,612,000 89,021,000 127,633,000
314 VATS + Repair Ductus Thoracicus 38,612,000 89,021,000 127,633,000
315 VATS + Thymectomy 38,612,000 89,021,000 127,633,000
316 VATS + Uni / Bilateral Thoracic Sympathetocctomy (Bilateral ETS) 38,612,000 89,021,000 127,633,000
317 Vena seksi Sedang 1 tanpa anestesi 5,000,000 7,475,000 12,475,000
318 Venografi dan Implantasi vena cava filter Khusus 1 dengan anestesi 12,583,000 37,950,000 50,533,000
319 Venografi dan Implantasi vena cava filter Khusus 1 tanpa anestesi 9,315,000 28,750,000 38,065,000
320 VSD 88,532,000 115,728,000 204,260,000
321 VSD PS RESEKSI 98,052,000 115,728,000 213,780,000
322 VSD-ASD CLOSURE 97,605,000 115,728,000 213,333,000
6.4 DENTISTRY
6.4.1 DENTISTRY ANAK
1 Paket Operasi Ringan (1-5 tindakan) 10,747,000 14,490,000 25,237,000
- Penambalan - - -
- Perawatan Saluran Akar Anterior - - -
- Perawatan Saluran Akar Posterior - - -
- Pencabutan - - -
- Pit Fissure Sealant - - -
2 Paket Operasi Sedang (6-10 tindakan) 13,837,000 19,320,000 33,157,000
- Penambalan - - -
- Pencabutan - - -
3 Paket Operasi Berat ( > 10 tindakan 15,817,000 25,760,000 41,577,000
- Penambalan - - -
- Pencabutan - - -
6.4.2 DENTISTRY DEWASA
1 Paket Operasi Ringan Dengan Lokal Anestesi : 15,394,000 12,880,000 28,274,000
- Extirpaste Mucocele - - -
- Extirpaste Fibroma - - -
- Extirpaste Papiloma - - -
- Extirpaste Epulis - - -
- Exisi/ Incisi Biopsi - - -
- Apex Resectie - - -
- Windowing Exposure - - -
- Frenektomy - - -
- Multiple Extraksi - - -
- Odontektomy 1 Gigi - - -
- Bongkar Crown atau Protesa per Gigi Tiruan + Cetak - - -
- Obturator - - -
2 Paket Operasi Sedang Dengan Narkose : 23,918,000 17,175,000 41,093,000
- Marsupialisasi dengan Ranula - - -
- Debridement - - -
- Alveolectomy > 1 Quadrant - - -
- Penutupan Oroantral Fistula - - -
- Gingivectomy s/d 1 Rahang - - -
- Windowing Exposure - - -
- Frenektomy - - -
- Incisi Abses Submandibula - - -
- Odontectomy 1-2 Elemen - - -
- Reposisi Fixatie (ORIF Simple Fracture) - - -
- Squestrectomy - - -
- Excochliasi - - -
JASA
PELAYANAN
- Enucleatie Kista - - -
- Multiple Extraksi - - -
- Labioplasty Unilateral - - -
3 Paket Operasi Berat dengan penyulit Dengan Narkose : 34,967,000 25,760,000 60,727,000
- Extirpasi Tumor - - -
- Block Resectie - - -
- Extirpasi Plunging Ranula - - -
- Eksisi Tumor Tulang - - -
- Radical Curetase - - -
- Rekonstruksi Lidah - - -
- Palatoplasty - - -
- Labioplasty Bilateral - - -
- Reposisi Fixatie (Complex Fracture) - - -
- Arthroplasty - - -
- Odontectomy 3-4 Element - - -
- Resectie Rahang - - -
- Reposisi Fract Rahang dengan Plate (ORIF) - - -
- Orthognatie Surgery - - -
6.5 DIGESTIVE
1 Anterior perianal resection (APR)/Milles 20,144,000 46,207,000 66,351,000
2 Anterior perianal resection (APR)/Milles + Asistensi 20,144,000 54,459,000 74,603,000
3 Anterior resection (AR) 20,144,000 46,207,000 66,351,000
4 Anterior resection (AR) + Asistensi 20,144,000 54,459,000 74,603,000
5 Apendektomi perforasi (laparotomi/non laparotomi)/Lap. APP 20,144,000 19,803,000 39,947,000
Apendektomi perforasi (laparotomi/non laparotomi)/Lap. APP +
6 20,144,000 23,340,000 43,484,000
Asistensi
7 Apendisitis akut /elektif 20,144,000 13,202,000 33,346,000
8 Apendisitis akut /elektif + Asistensi 8,994,000 15,560,000 24,554,000
9 Batu Empedu : Bilio-digestif /Double bypass 8,994,000 31,717,000 40,711,000
10 Batu Empedu : Bilio-digestif /Double bypass + Asistensi 8,994,000 37,381,000 46,375,000
11 Batu Empedu : Eksplorasi CBD (non laparoskopik) 14,116,000 31,717,000 45,833,000
12 Batu Empedu : Eksplorasi CBD (non laparoskopik) + Asistensi 14,116,000 37,381,000 51,497,000
13 CAPD 16,615,000 26,404,000 43,019,000
14 CAPD + Asistensi 16,615,000 31,119,000 47,734,000
15 Distal Pankreatektomi 20,144,000 39,606,000 59,750,000
16 Distal Pankreatektomi + Asistensi 20,144,000 46,679,000 66,823,000
17 Fissura ani 14,546,000 13,202,000 27,748,000
18 Fissura ani + Asistensi 14,546,000 15,560,000 30,106,000
19 Hemoroidectomy (PPH/Non PPH) 8,994,000 15,939,000 24,933,000
20 Hemoroidectomy (PPH/Non PPH) + Asistensi 8,994,000 18,786,000 27,780,000
21 Hepatiko jejunostomi 20,144,000 39,606,000 59,750,000
22 Hepatiko jejunostomi + Asistensi 20,144,000 46,679,000 66,823,000
23 Hernia (Lateralis, Mediana, Femoralis) sederhana + Asistensi 11,710,000 15,560,000 27,270,000
24 Hernia (Lateralis, Mediana, Femoralis) sederhana + Asistensi 11,710,000 15,560,000 27,270,000
25 Hernia residif/bilateral/permagna 21,311,000 19,803,000 41,114,000
26 Hernia residif/bilateral/permagna + Asistensi 21,311,000 23,340,000 44,651,000
27 Hernia umbilikalis besar/insisional 14,426,000 19,803,000 34,229,000
28 Hernia umbilikalis besar/insisional + Asistensi 14,426,000 23,340,000 37,766,000
29 Kelainan esofagus 1/3 Proksimal & 1/3 Tengah Striktur 14,426,000 52,808,000 67,234,000
30 Kelainan esofagus 1/3 Proksimal & 1/3 Tengah Striktur + Asistensi 14,426,000 62,238,000 76,664,000
31 Kelainan esofagus 1/3 Proksimal & 1/3 Tengah Tumor 14,426,000 52,808,000 67,234,000
32 Kelainan esofagus 1/3 Proksimal & 1/3 Tengah Tumor + Asistensi 14,426,000 62,238,000 76,664,000
33 Kelainan-kelainan Hernia umbilikalis sederhana 11,710,000 16,583,000 28,293,000
34 Kelainan-kelainan Hernia umbilikalis sederhana + Asistensi 11,710,000 19,545,000 31,255,000
Kelainan-kelainan umbilikalis Ductus urachus/ductus
35 11,710,000 19,545,000 31,255,000
omphalomesenterikus + Asistensi
36 Kelainan-kelainan umbilikalis Sinus umbilikalis + Asistensi 11,710,000 15,560,000 27,270,000
37 Kolesistektomi Laparoskopik 21,311,000 33,005,000 54,316,000
38 Kolesistektomi Laparoskopik + Asistensi 21,311,000 38,899,000 60,210,000
39 Kolesistektomi Terbuka 14,116,000 26,404,000 40,520,000
40 Kolesistektomi Terbuka + Asistensi 14,116,000 31,119,000 45,235,000
41 Lap. App 11,335,000 19,803,000 31,138,000
42 Lap. App + Asistensi 11,335,000 23,340,000 34,675,000
43 Laparoskopik Adhesiolisis 24,216,000 18,483,000 42,699,000
44 Laparoskopik Adhesiolisis +Asistensi 24,216,000 21,784,000 46,000,000
45 Laparoskopik Eksplorasi CBD 18,595,000 59,409,000 78,004,000
46 Laparoskopik Eksplorasi CBD + Asistensi 24,216,000 70,018,000 94,234,000
47 Laparoskopik Perforasi gaster 24,216,000 39,606,000 63,822,000
JASA
PELAYANAN
48 Laparoskopik Perforasi gaster + Asistensi 24,216,000 46,679,000 70,895,000
49 Laparoskopik AR/LAR/APR 24,216,000 81,627,000 105,843,000
50 Laparoskopik CAPD 18,595,000 26,404,000 44,999,000
51 Laparoskopik CAPD + Asistensi 18,595,000 31,119,000 49,714,000
52 Laparoskopik Reseksi kolon 24,216,000 59,409,000 83,625,000
53 Laparoskopik Reseksi kolon + Asistensi 24,216,000 70,018,000 94,234,000
54 Laparoskopik Trauma / biopsi 21,311,000 33,005,000 54,316,000
55 Laparoskopik Trauma / biopsi + Asistensi 21,311,000 38,899,000 60,210,000
Laparotomi :Kelainan usus (Invaginasi, Trombosis, Tumor usus halus,
56 14,116,000 33,005,000 47,121,000
dsb) Dengan pembuatan stoma
Laparotomi :Kelainan usus(Invaginasi,Trombosis,Tumor usus halus,
57 14,116,000 38,899,000 53,015,000
dsb) Dengan pembuatan stoma +Ass
58 Laparotomi :Perforasi usus 14,116,000 26,404,000 40,520,000
59 Laparotomi :Perforasi usus 25,348,000 26,404,000 51,752,000
60 Laparotomi :Perforasi usus + Asistensi 14,116,000 31,119,000 45,235,000
61 Laparotomi :Trauma abdomen sederhana 14,116,000 26,404,000 40,520,000
62 Laparotomi :Trauma abdomen sederhana + Asistensi 14,116,000 31,119,000 45,235,000
63 Laparotomi adhesiolisis 14,426,000 46,207,000 60,633,000
64 Laparotomi adhesiolisis + Asistensi 14,426,000 54,459,000 68,885,000
65 Laparotomi kelainan esofagus distal Achalasia 21,311,000 33,005,000 54,316,000
66 Laparotomi kelainan esofagus distal Achalasia + Asistensi 21,311,000 38,899,000 60,210,000
67 Laparotomi kelainan esofagus distal Tumor 14,050,000 39,606,000 53,656,000
68 Laparotomi kelainan esofagus distal Tumor + Asistensi 14,050,000 46,679,000 60,729,000
69 Laparotomi kelainan esofagus distal Striktur 21,311,000 33,005,000 54,316,000
70 Laparotomi kelainan esofagus distal Striktur + Asistensi 21,311,000 38,899,000 60,210,000
71 Laparotomi tumor intra abdomen 14,050,000 39,606,000 53,656,000
72 Laparotomi tumor intra abdomen + Asistensi 14,050,000 46,679,000 60,729,000
73 LAR & Ileostomi 20,144,000 59,409,000 79,553,000
74 LAR & Ileostomi + Asistensi 20,144,000 70,018,000 90,162,000
75 Partial gastrektomi dengan anastomosis (Biltroth I/II) 21,311,000 33,005,000 54,316,000
76 Partial gastrektomi dengan anastomosis (Biltroth I/II) + Asistensi 21,311,000 38,899,000 60,210,000
77 PEG 8,994,000 16,583,000 25,577,000
78 PEG + Asistensi 8,994,000 19,545,000 28,539,000
79 Pembuatan stoma (Jejunostomi, gastrostomi, Iliostomi, kolostomi) 14,546,000 13,202,000 27,748,000
Pembuatan stoma (Jejunostomi, gastrostomi, Iliostomi, kolostomi) +
80 14,546,000 15,560,000 30,106,000
Asistensi
81 Perianal abses 14,546,000 13,202,000 27,748,000
82 Perianal abses + Asistensi 14,546,000 15,560,000 30,106,000
83 Perianal fistel kompleks/residif 11,710,000 19,803,000 31,513,000
84 Perianal fistel kompleks/residif + Asistensi 11,710,000 23,340,000 35,050,000
85 Perianal fistel sederhana 11,710,000 13,202,000 24,912,000
86 Perianal fistel sederhana + Asistensi 11,710,000 15,560,000 27,270,000
87 Pneumatic bouginasi dilatation + anestesi 14,546,000 15,560,000 30,106,000
88 Relaparotomi 14,050,000 39,606,000 53,656,000
89 Relaparotomi + Asistensi 14,050,000 46,679,000 60,729,000
90 Reseksi hepar kompleks/ 1 lobus 20,144,000 39,606,000 59,750,000
91 Reseksi hepar kompleks/ 1 lobus + Asistensi 20,144,000 46,679,000 66,823,000
92 Reseksi hepar sederhana 20,144,000 33,005,000 53,149,000
93 Reseksi hepar sederhana + Asistensi 20,144,000 38,899,000 59,043,000
94 savary bouginasi + anestesi 14,546,000 14,611,000 29,157,000
95 Splenektomi I 16,615,000 26,404,000 43,019,000
96 Splenektomi I + Asistensi 16,615,000 31,119,000 47,734,000
97 Splenektomi II 21,311,000 33,005,000 54,316,000
98 Splenektomi II + Asistensi 21,311,000 38,899,000 60,210,000
99 Trauma hepar 20,144,000 39,606,000 59,750,000
100 Trauma hepar + Asistensi 20,144,000 46,679,000 66,823,000
101 Tumor kolon Hemikolektomi kanan/kiri 14,050,000 39,606,000 53,656,000
102 Tumor kolon Hemikolektomi kanan/kiri + Asistensi 14,050,000 46,679,000 60,729,000
103 Tumor kolon Reseksi kolon transversum 14,050,000 39,606,000 53,656,000
104 Tumor kolon Reseksi kolon transversum + Asistensi 14,050,000 46,679,000 60,729,000
105 Tumor kolon Reseksi sigmoid 14,050,000 39,606,000 53,656,000
106 Tumor kolon Reseksi sigmoid + Asistensi 14,050,000 46,679,000 60,729,000
107 Tumor lambung : Total gastrektomi 22,632,000 39,606,000 62,238,000
108 Tumor lambung : Total gastrektomi + Asistensi 22,632,000 46,679,000 69,311,000
109 Ulkus gaster /duodenum 14,116,000 33,005,000 47,121,000
110 Ulkus gaster /duodenum + Asistensi 14,116,000 38,899,000 53,015,000
111 Whipple / Pankreatiko duodenektomi 20,144,000 59,409,000 79,553,000
112 Whipple / Pankreatiko duodenektomi + Asistensi 20,144,000 70,018,000 90,162,000
6.6 ENT
JASA
PELAYANAN
1 Aff T-Tube 7,123,000 5,474,000 12,597,000
2 Bronkoskopi Diagnostik 8,382,000 8,050,000 16,432,000
3 Center of Snoring & OSA -Reduksi Konka 10,500,000 8,050,000 18,550,000
4 Center of Snoring & OSA -Septoplasty '' 9,000,000 12,830,000 21,830,000
5 Center of Snoring & OSA -Sleep Endoscopy 4,700,000 4,830,000 9,530,000
6 Center of Snoring & OSA -Tonsilektomi + Adenoidektomi (TA) 6,999,000 10,063,000 17,062,000
7 Center of Snoring & OSA -Turbinoplasty 10,500,000 10,264,000 20,764,000
8 Diseksi Leher 17,437,000 23,482,000 40,919,000
9 Ear Center -Cochlear Implant 17,437,000 19,320,000 36,757,000
10 Ear Center -Cochlear Implant 2 telinga 19,537,000 28,980,000 48,517,000
11 Ear Center -Dekompresi N Facialis 17,437,000 27,370,000 44,807,000
12 Ear Center -Gromet Insection 2 Telinga* 7,123,000 5,440,000 12,563,000
13 Ear Center -Gromet Insection* 7,123,000 3,220,000 10,343,000
14 Ear Center -Kanalomeatoplasty 14,721,000 24,150,000 38,871,000
15 Ear Center -Meatoplasty 10,000,000 6,440,000 16,440,000
16 Ear Center -Radical Mastoidektomi 14,721,000 20,930,000 35,651,000
17 Ear Center -Simple Mastoidectomi 14,721,000 11,270,000 25,991,000
18 Ear Center -Stapedectomy 14,721,000 27,370,000 42,091,000
19 Ear Center -Tympanoplasty Type 1/Miringoplasty 17,437,000 12,075,000 29,512,000
20 Ear Center -Tympanoplasty type 2 17,437,000 24,150,000 41,587,000
21 Ear Center-Temporal Bone Resection 17,437,000 40,323,000 57,760,000
22 MAKSILEKTOMI MEDIAL 17,437,000 19,320,000 36,757,000
23 Mapping 378,000 805,000 1,183,000
Operasi THT lain-lain -Eksplorasi abses Leher Dalam (sub
24 7,123,000 16,100,000 23,223,000
Mandibula/Retrofaring)
Operasi THT lain-lain -Eksplorasi Abses Leher Dalam Multiple/
25 7,123,000 24,150,000 31,273,000
Parafaring
26 Operasi THT lain-lain -Ekstirpasi Papiloma Laryng I 7,123,000 12,880,000 20,003,000
27 Operasi THT lain-lain -Ekstirpasi Papiloma Laryng II 9,839,000 20,125,000 29,964,000
28 Operasi THT lain-lain -FESS 1 : Mini 16,602,000 8,050,000 24,652,000
29 Operasi THT lain-lain -FESS 2 : Maxilla + Etmoid 16,602,000 16,100,000 32,702,000
30 Operasi THT lain-lain -FESS 3 : Frontal + Sfenoid 16,602,000 24,150,000 40,752,000
31 Operasi THT lain-lain -FESS 4 : Complate 19,318,000 32,200,000 51,518,000
32 Operasi THT lain-lain -Laringofisure 7,123,000 18,975,000 26,098,000
33 Operasi THT lain-lain -Laryngectomy 14,721,000 51,233,000 65,954,000
34 Operasi THT lain-lain -Laryngectomy + RND ( 2 Operator) 14,721,000 56,925,000 71,646,000
35 Operasi THT lain-lain -Pemasangan T-Tube' 7,123,000 28,463,000 35,586,000
36 Operasi THT lain-lain -Tracheostomi 8,989,000 12,580,000 21,569,000
37 Paket OSA 1 UPPP + Turbinoplasty 19,318,000 33,810,000 53,128,000
38 Paket OSA 2 UPPP + Turbinoplasty + Septoplasty 19,318,000 43,470,000 62,788,000
39 Parotidektomi 17,437,000 28,615,000 46,052,000
40 Posterior Nasal Neorektomi 19,318,000 19,320,000 38,638,000
41 Repair Stoma 8,989,000 12,880,000 21,869,000
42 Voice Clinic/Phonosurgery -Botox Injection 7,123,000 10,063,000 17,186,000
43 Voice Clinic/Phonosurgery -Hemikordectomy + Arytenoidektomy 14,721,000 19,320,000 34,041,000
44 Voice Clinic/Phonosurgery -Larygoscopy (Diagnostic) 7,123,000 6,440,000 13,563,000
45 Voice Clinic/Phonosurgery -Larygoscopy Biopsi 7,123,000 8,050,000 15,173,000
Voice Clinic/Phonosurgery -Larygoscopy Ekstirpasi (Nodul,
46 7,123,000 12,880,000 20,003,000
Kista,Granuloma)
Voice Clinic/Phonosurgery -Midealisasi / Thynoplasty (Gonotex,
47 7,123,000 19,320,000 26,443,000
Colagen, Adipose)
48 Voice Clinic/Phonosurgery -Supraglotoplasty 7,123,000 19,320,000 26,443,000
6.7 ESTETIK
1 2 Jaws 27,200,000 78,880,000 106,080,000
2 Abbe flap 8,925,000 25,883,000 34,808,000
3 Abdomen/kuadran (atas/bawah/pinggang kiri/pinggang kanan)* 1,913,000 5,547,000 7,460,000
4 Abdomino lipectomi mini 10,200,000 29,580,000 39,780,000
5 Abdominoplasty 20,400,000 59,160,000 79,560,000
6 Alveolar Bone Graft Operasi Khusus III 10,200,000 29,580,000 39,780,000
7 Amputasi Kaki 9,981,000 7,494,000 17,475,000
8 Amputasi Tangan 8,538,000 9,966,000 18,504,000
9 Augmentasi 9,563,000 27,732,000 37,295,000
10 Augmentasi dengan Diced Cartilage 9,563,000 27,732,000 37,295,000
11 Augmentasi dengan implan dagu 6,375,000 18,488,000 24,863,000
12 Augmentasi hidung + tlg rwn 9,350,000 27,115,000 36,465,000
13 Augmentasi hidung sederhana 5,738,000 16,639,000 22,377,000
14 Augmentasi rhino dengan implan Dengan Anestesi 6,375,000 18,488,000 24,863,000
15 Augmentasi rhino dengan tulang rawan iga* 9,563,000 27,732,000 37,295,000
16 Augmentasi rhino implan + graft tulang rawan telinga 8,925,000 25,883,000 34,808,000
JASA
PELAYANAN
17 Auriculoplasty non mikrotia 8,925,000 25,883,000 34,808,000
18 Bawah (BSSO) 17,000,000 49,300,000 66,300,000
19 Blepharoplasty Atas 6,375,000 18,488,000 24,863,000
20 Blepharoplasty atas + brow lift 8,288,000 24,034,000 32,322,000
21 Blepharoplasty atas dan bawah 11,475,000 33,278,000 44,753,000
22 Blepharoplasty bawah 7,650,000 22,185,000 29,835,000
23 Bone Contouring Angulus 12,750,000 36,975,000 49,725,000
24 Bone Contouring Zygoma 15,300,000 44,370,000 59,670,000
25 Bone Contouring Zygoma + angulus 22,950,000 66,555,000 89,505,000
26 Botox Injeksi Per area, kiri & kanan 638,000 1,849,000 2,487,000
27 Breast augmentation 12,750,000 36,975,000 49,725,000
28 Breast augmentation -JR 8,500,000 24,650,000 33,150,000
29 Breast Explantation 3,825,000 11,093,000 14,918,000
30 Breast lift 14,450,000 41,905,000 56,355,000
31 Breast lift & augmentation 20,400,000 59,160,000 79,560,000
32 Breast lift (Mc Kissock/Vertical) -JR 11,688,000 33,894,000 45,582,000
33 Breast lift (Mc Kissock/Vertical) -SR 14,875,000 43,138,000 58,013,000
34 Breast lift and augmentation -JR 12,750,000 36,975,000 49,725,000
35 Breast lift periaareolar 8,500,000 24,650,000 33,150,000
36 Breast lift periaareolar -SR 10,625,000 30,813,000 41,438,000
37 Breast lift/reduction+augmentasi 15,300,000 44,370,000 59,670,000
38 Breast reconstruction dengan latissimus dorsi dan implant -JR 14,875,000 43,138,000 58,013,000
39 Breast reconstruction dengan latissimus dorsi dan implant -SR 17,000,000 49,300,000 66,300,000
40 Breast reconstruction dengan latissimus dorsi -JR 8,500,000 24,650,000 33,150,000
41 Breast reconstruction dengan latissimus dorsi -SR 10,625,000 30,813,000 41,438,000
42 Breast recontruction exchange dengan implant -JR 8,500,000 24,650,000 33,150,000
43 Breast recontruction exchange dengan implant -SR 10,625,000 30,813,000 41,438,000
44 Breast recontructiondengan tissue expander -JR 10,625,000 30,813,000 41,438,000
45 Breast recontructiondengan tissue expander -SR 12,750,000 36,975,000 49,725,000
46 Breast recontructiondengan TRAM -JR 15,300,000 44,370,000 59,670,000
47 Breast recontructiondengan TRAM -SR 17,850,000 51,765,000 69,615,000
48 Breast reduction 17,000,000 49,300,000 66,300,000
49 Breast reduction -JR 12,750,000 36,975,000 49,725,000
50 Brow lift 7,650,000 22,185,000 29,835,000
51 Brow Lift (reduksi kulit atas alis) 3,825,000 11,093,000 14,918,000
52 Brow Lift Endoskopi 9,563,000 27,732,000 37,295,000
53 Brow Lift Open 7,650,000 22,185,000 29,835,000
54 Clift Lip Rhinoplasty 8,925,000 25,883,000 34,808,000
55 DCR OperasiBesar I 2,975,000 8,628,000 11,603,000
56 Debridement 10,200,000 29,580,000 39,780,000
57 Debridement dengan anestesi 3,825,000 11,093,000 14,918,000
58 Debridement Luka bakar Operasi Besar I 7,485,000 6,694,000 14,179,000
59 Distraction Ostogenesi Palatal 8,500,000 24,650,000 33,150,000
60 Distraction Ostogenesi Posterior cranial vault 13,600,000 39,440,000 53,040,000
61 Distraction Ostogenesis Mandibula 13,600,000 39,440,000 53,040,000
62 Distraction Ostogenesis Sagital sutures 13,600,000 39,440,000 53,040,000
63 Eksisi + liposuction 7,650,000 22,185,000 29,835,000
65 Eksisi HEMANGIOMA, flap OperasiKhusus I 9,563,000 27,732,000 37,295,000
66 Eksisi lokal 2,125,000 6,163,000 8,288,000
67 Eksisi Luas 8,224,000 23,849,000 32,073,000
68 Eksisi mammae abberans 4,250,000 12,325,000 16,575,000
69 Eksisi neurofibroma kompleks Operasi Khusus II 10,063,000 29,182,000 39,245,000
70 Eksisi neurofibroma simpel Operasi Khusus I 9,563,000 27,732,000 37,295,000
71 Eksisi nevus kompleks* 4,250,000 12,325,000 16,575,000
72 Eksisi nevus sederhana 2,550,000 7,395,000 9,945,000
Eksisi tumor kompleks (neurofibroma, malformasi, vaskular, dll)
73 9,563,000 27,732,000 37,295,000
dengan anestesi
Eksisi tumor sederhana (lipoma, fibroma, kista atheroma, dll) dengan
74 6,375,000 18,488,000 24,863,000
anestesi
Eksisi tumor sederhana (lipoma, fibroma, kista atheroma, dll) dengan
75 6,375,000 18,488,000 24,863,000
anestesi
76 Eksisi, Flap Operasi Khusus I 9,563,000 27,732,000 37,295,000
77 Eksisi, jahit primer Operasi Besar I 4,675,000 13,558,000 18,233,000
78 Eksisi, rekonstruksi Operasi Besar III 9,563,000 27,732,000 37,295,000
79 Eksisi, skin graft Operasi Besar II 6,375,000 18,488,000 24,863,000
80 Ekstraksi Corpus Alineum 2,550,000 7,395,000 9,945,000
81 Entropion/ectropion/ptosis lebih dar isatu Operasi Sedang II lokal 10,200,000 29,580,000 39,780,000
82 Entropion/ectropion/ptosis satu sisi Operasi Sedang Lokal 6,375,000 18,488,000 24,863,000
83 Epikantoplasti 5,100,000 14,790,000 19,890,000
JASA
PELAYANAN
84 Evakuasi silikonoma bibir atas bawah 6,375,000 18,488,000 24,863,000
85 Evakuasi silikonoma dagu 5,100,000 14,790,000 19,890,000
86 Evakuasi silikonoma dengan implan dagu 7,650,000 22,185,000 29,835,000
87 Evakuasi silikonoma gluteal dengan anestesi 7,650,000 22,185,000 29,835,000
88 Evakuasi silikonoma gluteal dengan anestesi 7,650,000 22,185,000 29,835,000
89 Evakuasi Silikonoma Hidung (tanpa implan atau graft) 5,100,000 14,790,000 19,890,000
90 Evakuasi Silikonoma Hidung dengan implan 6,375,000 18,488,000 24,863,000
91 Face lift - 1/3 Atas 6,800,000 19,720,000 26,520,000
92 Face lift - 2/3 Atas 9,350,000 27,115,000 36,465,000
93 Face lift - Total 15,300,000 44,370,000 59,670,000
94 Face lift - Total Face & Neck Lift dengan anastesi 20,400,000 59,160,000 79,560,000
95 Face lift - Total Neck Lift 10,200,000 29,580,000 39,780,000
Facial bone reconstruction (mandibula, maxilla, dll di luar biaya free
96 17,000,000 49,300,000 66,300,000
flap)
97 Facial cleft kompleks 12,750,000 36,975,000 49,725,000
98 Faringoplasty Operasi Khusus II 10,200,000 29,580,000 39,780,000
99 Fasciotomi dekompresi Sedang 1 4,675,000 13,558,000 18,233,000
100 Flap Kompleks 1 (lebih dari 1 flap) Operasi Khusus I 12,750,000 36,975,000 49,725,000
101 Flap Kompleks 2 (myocutan Flap) Operasi Khusus II 13,250,000 38,425,000 51,675,000
102 Flap Kulit Sederhana 1 (advancement) Operasi Besar I 6,375,000 18,488,000 24,863,000
103 Flap Kulit Sederhana 2 (oedicled skin flap) Operasi Besar II 9,563,000 27,732,000 37,295,000
104 Forehead lift 6,800,000 19,720,000 26,520,000
105 Forehead lift 6,800,000 19,720,000 26,520,000
106 Free flap 34,000,000 98,600,000 132,600,000
107 Free flap 34,000,000 98,600,000 132,600,000
108 Frontoorbita advancement OperasiKhusus III 17,000,000 49,300,000 66,300,000
109 Genioplasty - Augmentasi 7,650,000 22,185,000 29,835,000
110 Genioplasty - Sliding genioplasty 15,300,000 44,370,000 59,670,000
111 Gluteal Augmentasi dengan anestesi 10,200,000 29,580,000 39,780,000
112 Gluteoplasty 5,100,000 14,790,000 19,890,000
113 Hump Nose dengan osteotomi 12,750,000 36,975,000 49,725,000
114 Hump Nose tanpa osteotomi 6,375,000 18,488,000 24,863,000
115 Hymenoplasty 6,375,000 18,488,000 24,863,000
117 Injeksi Filler 2,550,000 7,395,000 9,945,000
118 Injeksi scleroting agent malformasi vaskular 4,250,000 12,325,000 16,575,000
119 Insisi & drainase abses 850,000 2,465,000 3,315,000
120 Insisi Furunkel / Abses 500,000 1,450,000 1,950,000
121 Jahit Primer Operasi Besar I 4,675,000 13,558,000 18,233,000
122 Jahitan > 10 (jahit kulit primer wajah oleh bedah plastik) 4,675,000 13,558,000 18,233,000
Jahitan Kulit dan Jahitan < 10 (jahit kulit primer wajah oleh bedah
123 2,338,000 6,779,000 9,117,000
plastik)
124 Kongenital Facial cleft sederhana dengan anestesi 6,375,000 18,488,000 24,863,000
125 Kontraktur difus ditutup dengan skin graft dengan anestesi 4,463,000 12,942,000 17,405,000
126 Kontraktur difus leher dengan flap (bukan bedah mikro) 6,375,000 18,488,000 24,863,000
127 Kontraktur difus leher dengan Skin Graft 7,438,000 21,569,000 29,007,000
128 Kontraktur difus pada wajah dengan flap (bukan bedah mikro) 5,950,000 17,255,000 23,205,000
129 Kontraktur difus pada wajah dengan flap (bukan bedah mikro) 5,950,000 17,255,000 23,205,000
130 Kontraktur difus pada wajah dengan skin graft 4,250,000 12,325,000 16,575,000
131 Kontraktur difus pada wajah dengan skin graft 4,250,000 12,325,000 16,575,000
132 Kontraktur difus sendi besar dengan flap (bukan bedah mikro) 6,800,000 19,720,000 26,520,000
133 Kontraktur difus sendi besar dengan skin graft dengan anestesi 4,463,000 12,942,000 17,405,000
134 Kontraktur jari-jari Operasi Khusus I 3,825,000 11,093,000 14,918,000
137 Kontraktur linier jari tangan dengan multipel Z-Plasty > 1 Jari 2,125,000 6,163,000 8,288,000
140 Kontraktur linier leher dengan multipel Z-plasty 5,100,000 14,790,000 19,890,000
141 Kontraktur linier leher dengan multipel Z-plasty 5,100,000 14,790,000 19,890,000
142 Kontraktur linier pada wajah dengan multipel Z-plasty 2,550,000 7,395,000 9,945,000
143 Kontraktur linier pada wajah dengan multipel Z-plasty 2,550,000 7,395,000 9,945,000
144 Kontraktur linier sendi besar dengan multipel Z-plasty 5,100,000 14,790,000 19,890,000
145 Kontraktur linier sendi besar dengan multipel Z-plasty 5,100,000 14,790,000 19,890,000
146 Labioplasty bilateral + primary rhinoplasty 7,650,000 22,185,000 29,835,000
147 Labioplasty bilateral dengan anestesi 6,375,000 18,488,000 24,863,000
148 Labioplasty unilateral + primary rhinoplasty 6,375,000 18,488,000 24,863,000
149 Labioplasty Unilateral dengan anestesi 5,100,000 14,790,000 19,890,000
150 Le Fort 1 13,600,000 39,440,000 53,040,000
151 Le Fort 1 osteotomy 17,000,000 49,300,000 66,300,000
JASA
PELAYANAN
152 Le Fort 2 17,000,000 49,300,000 66,300,000
153 Le Fort 3 20,400,000 59,160,000 79,560,000
154 Lesung pipi 4,250,000 12,325,000 16,575,000
155 Lipofilling Bibir 5,100,000 14,790,000 19,890,000
156 Lipofilling Blepharo atas 5,100,000 14,790,000 19,890,000
157 Lipofilling Blepharo bawah 5,100,000 14,790,000 19,890,000
158 Lipofilling Wajah 6,375,000 18,488,000 24,863,000
159 Liposuction 5,100,000 14,790,000 19,890,000
160 Liposuction - Perut 6,800,000 19,720,000 26,520,000
161 Liposuction - Paha luar/dlm 8,500,000 24,650,000 33,150,000
162 Liposuction - Punggung/ats bokong 3,400,000 9,860,000 13,260,000
165 Liposuction Fat Transfer 6,822,000 19,782,000 26,604,000
166 Liposuction Leher 6,375,000 18,488,000 24,863,000
167 Liposuction Paha 6,375,000 18,488,000 24,863,000
168 Liposuction Paha Bilateral 10,519,000 30,505,000 41,024,000
169 Liposuction Punggung/area (atas/bawah) 2,550,000 7,395,000 9,945,000
170 Liposuction-Wajah 6,375,000 18,488,000 24,863,000
171 Lobuloplasty 3,825,000 11,093,000 14,918,000
172 Lower Blefaro 7,650,000 22,185,000 29,835,000
173 Mandibula kompleks (Rekonstruksi Mandibula) Operasi Khusus I 17,000,000 49,300,000 66,300,000
174 Mandibula kompleks (Reseksi Mandibula) Operasi Khusus I 17,000,000 49,300,000 66,300,000
175 Mandibula Sederhana Operasi Besar I 10,200,000 29,580,000 39,780,000
176 MEA Kompleks (kraniotomi) Operasi Khusus III 17,000,000 49,300,000 66,300,000
177 MEA Sederhana (cula) Operasi Khusus I 17,000,000 49,300,000 66,300,000
178 Medial Epichantoplasty (buka sudut mata)* 4,250,000 12,325,000 16,575,000
179 Membentuk bibir atas 3,825,000 11,093,000 14,918,000
180 Membentuk bibir atas bawah 6,375,000 18,488,000 24,863,000
181 Membentuk bibir bawah 3,825,000 11,093,000 14,918,000
182 Mengecilkan areola mammae 3,825,000 11,093,000 14,918,000
183 Midface advancement 17,000,000 49,300,000 66,300,000
184 Mini Abdominoplasty 12,750,000 36,975,000 49,725,000
185 Mini face lift 6,375,000 18,488,000 24,863,000
186 Neck lift 7,650,000 22,185,000 29,835,000
187 Non exsisional debridement 1,594,000 4,622,000 6,216,000
188 Open Rhinoplasty/augmentasi + Revisi Ala Nasi 8,925,000 25,883,000 34,808,000
189 Orbita kompleks Operasi Khusus II 12,750,000 36,975,000 49,725,000
190 Orbita sederhana Operasi Sedang II 10,200,000 29,580,000 39,780,000
191 ORIF Fraktur mandibula kompleks 17,000,000 49,300,000 66,300,000
192 ORIF Fraktur mandibula sederhana 10,200,000 29,580,000 39,780,000
193 ORIF Fraktur nasal (closed reduction) 6,800,000 19,720,000 26,520,000
194 ORIF Fraktur NOE 12,750,000 36,975,000 49,725,000
195 ORIF Fraktur orbita kompleks 12,750,000 36,975,000 49,725,000
196 ORIF Fraktur orbita sederhana 10,200,000 29,580,000 39,780,000
197 ORIF Fraktur Panfacial Fraktur dengan anestesi 22,313,000 64,707,000 87,020,000
198 ORIF Fraktur ZMC kompleks 18,700,000 54,230,000 72,930,000
199 ORIF Fraktur ZMC sederhana 12,750,000 36,975,000 49,725,000
200 Orthognatic surgery 25,500,000 73,950,000 99,450,000
201 otoplasty rekonstruksi Operasi Sedang II 8,925,000 25,883,000 34,808,000
202 Palatoplasty dengan anestesi 8,925,000 25,883,000 34,808,000
203 Potong Flap Abbe dengan Anastesi 3,188,000 9,244,000 12,432,000
204 Ptosis Correction dua sisi 10,200,000 29,580,000 39,780,000
205 Ptosis Correction satu sisi 6,375,000 18,488,000 24,863,000
206 Redebridement Sedang 1 4,675,000 13,558,000 18,233,000
207 Reduksi hiperplasia labia minora 5,100,000 14,790,000 19,890,000
208 Reduksi makroklitoris 6,375,000 18,488,000 24,863,000
209 Rekonstruksi craniosynostosis 17,000,000 49,300,000 66,300,000
210 Rekonstruksi dengan flap kulit kompleks 12,750,000 36,975,000 49,725,000
211 Rekonstruksi dengan flap kulit kompleks 12,750,000 36,975,000 49,725,000
212 Rekonstruksi dengan STSG Kompleks (>5x5 cm) 12,750,000 36,975,000 49,725,000
213 Rekonstruksi dengan STSG Kompleks (>5x5 cm) 12,750,000 36,975,000 49,725,000
216 Rekonstruksi Glans Penis 8,543,000 24,774,000 33,317,000
217 Rekonstruksi hidung dengan iga Operasi Khusus I 9,350,000 27,115,000 36,465,000
218 Rekonstruksi hypospadia 1 tahap 18,700,000 54,230,000 72,930,000
219 Rekonstruksi hypospadia 1 tahap 18,700,000 54,230,000 72,930,000
220 Rekonstruksi limfadema 12,750,000 36,975,000 49,725,000
221 Rekonstruksi limfedema Operasi khusus I 12,750,000 36,975,000 49,725,000
JASA
PELAYANAN
222 Rekonstruksi limfedema Operasi khusus I 9,563,000 27,732,000 37,295,000
223 Rekonstruksi makrodactili 12,750,000 36,975,000 49,725,000
224 Rekonstruksi makrodactili 12,750,000 36,975,000 49,725,000
225 Rekonstruksi MEA 17,000,000 49,300,000 66,300,000
226 Rekonstruksi mikrotia dengan anestesi 18,700,000 54,230,000 72,930,000
227 Rekonstruksi mikrotia dengan anestesi 18,700,000 54,230,000 72,930,000
228 Rekonstruksi polidactili_Hand 4,250,000 12,325,000 16,575,000
229 Rekonstruksi polidaktilli Operasi Sedang II 2,125,000 6,163,000 8,288,000
230 Rekonstruksi polidaktilli Operasi Sedang II 4,250,000 12,325,000 16,575,000
231 Rekonstruksi sindaktili Operasi Khusus I 3,825,000 11,093,000 14,918,000
232 Rekonstruksi sindaktili Operasi Khusus I 6,375,000 18,488,000 24,863,000
233 Rekonstruksi syndactili_Hand 6,375,000 18,488,000 24,863,000
234 Rekonstruksi telinga tahap I Operasi Khusus III 18,700,000 54,230,000 72,930,000
235 Rekonstruksi telinga tahap I Operasi Khusus III' 18,700,000 54,230,000 72,930,000
236 Rekonstruksi telinga tahap II Operasi Khusus II 18,700,000 54,230,000 72,930,000
237 Rekonstruksi TMJ bilateral 25,500,000 73,950,000 99,450,000
238 Rekonstruksi TMJ bilateral 25,500,000 73,950,000 99,450,000
239 Rekonstruksi TMJ 1 sisi 17,000,000 49,300,000 66,300,000
240 Rekonstruksi tumor dengan flap Operasi Khusus II 13,250,000 38,425,000 51,675,000
241 rekonstruksi tumor simple OperasiBesar III 6,375,000 18,488,000 24,863,000
244 Rekontruksi Penis 4,819,000 13,974,000 18,793,000
245 Release chordae & tunneling 15,300,000 44,370,000 59,670,000
246 Release kontraktur 12,750,000 36,975,000 49,725,000
247 RELEASE KONTRAKTUR Dengan free lap Operasi khusus III 34,000,000 98,600,000 132,600,000
248 RELEASE KONTRAKTUR Dengan skin graft Operasi Besar III 4,335,000 12,572,000 16,907,000
249 RELEASE KONTRAKTUR Kompleks Operasi Khusus I 6,375,000 18,488,000 24,863,000
250 Repair Fistel Operasi Khusus I 8,500,000 24,650,000 33,150,000
251 Repair fistel urethrokutan 8,500,000 24,650,000 33,150,000
252 Repair tendon 12,750,000 36,975,000 49,725,000
253 Repair Uretroplasty 7,608,000 22,063,000 29,671,000
254 Replantasi 1 jari 25,500,000 73,950,000 99,450,000
255 Replantasi tangan 34,000,000 98,600,000 132,600,000
256 retrected nipple 3,825,000 11,093,000 14,918,000
257 Revisi ala nasi 3,188,000 9,244,000 12,432,000
258 Revisi fistel palatoplasty 8,925,000 25,883,000 34,808,000
259 Revisi fistel palatoplasty 8,925,000 25,883,000 34,808,000
260 Revisi Scar 6,800,000 19,720,000 26,520,000
261 Revisi scar bilateral cleft 6,375,000 18,488,000 24,863,000
262 Revisi scar unilateral cleft 5,100,000 14,790,000 19,890,000
263 Rhinoplasty cleft nose 8,925,000 25,883,000 34,808,000
264 Rhinoplasty Operasi Khusus II 8,925,000 25,883,000 34,808,000
265 Septoplasty Operasi Sedang II 8,925,000 25,883,000 34,808,000
266 Septoplasty/humpnose/open 10,200,000 29,580,000 39,780,000
267 Septorhinoplasty Operasi besar II 8,925,000 25,883,000 34,808,000
268 Sirkumsisi 5,100,000 14,790,000 19,890,000
269 Sliding genioplasty 10,200,000 29,580,000 39,780,000
Split thickness skin graft luas (>10X21 cm) Operasi Khusus I dengan
270 7,650,000 22,185,000 29,835,000
anestesi
271 Split thickness skin graft sederhana (10X20 cm) Operasi Sedang II 3,825,000 11,093,000 14,918,000
272 STSG dan Debdridement Luka Bakar 8,885,000 9,344,000 18,229,000
273 Subcondylus Operasi Khusus II 17,000,000 49,300,000 66,300,000
274 Suntik scleroting agent Operasi Sedang II 4,250,000 12,325,000 16,575,000
275 Tip rhinoplasty 6,375,000 18,488,000 24,863,000
276 Tip Rhinoplasty (tanpa graft dan tanpa implan) 6,375,000 18,488,000 24,863,000
277 Tip Rhinoplasty dan Septoplasty dengan anestesi 9,563,000 27,732,000 37,295,000
278 Total abdominolipectomi 10,200,000 29,580,000 39,780,000
279 Total Abdominoplasty 15,300,000 44,370,000 59,670,000
280 Total Facelift dengan Anestesi 11,475,000 33,278,000 44,753,000
281 Tutup Fistula 7,650,000 22,185,000 29,835,000
282 Umbilicoplasty 3,825,000 11,093,000 14,918,000
283 Upper and Lower 11,475,000 33,278,000 44,753,000
284 Urethroplasty 12,750,000 36,975,000 49,725,000
285 Urethroplasty Operasi Khusus I 12,750,000 36,975,000 49,725,000
286 Vaginoplasty (aging) 11,475,000 33,278,000 44,753,000
287 VPI Surgery 10,200,000 29,580,000 39,780,000
288 Wasmund (maxillary set back) 11,475,000 33,278,000 44,753,000
289 Wvakuasi silikonoma bibir atas 3,825,000 11,093,000 14,918,000
JASA
PELAYANAN
290 Wvakuasi silikonoma bibir bawah 3,825,000 11,093,000 14,918,000
291 ZMC Operasi Khusus II 12,750,000 36,975,000 49,725,000
292 ZMC operasi khusus II + assist 12,750,000 36,975,000 49,725,000
6.8 NEUROSCIENCE
1 Arterial occlusion - sacrifice 21,000,000 33,207,000 54,207,000
2 Ballon test occlusion 19,000,000 23,719,000 42,719,000
3 Carotid Endarterectomy (CEA) 33,251,000 56,925,000 90,176,000
4 Carotid/Vertebral Arteri Stenting 23,000,000 28,750,000 51,750,000
5 Carotid/Vertebral Arteri Stenting dengan Anestesi 23,000,000 37,950,000 60,950,000
6 CCF kompleks - ballooning/coil 21,000,000 33,207,000 54,207,000
7 CCF simpel - ballooning 21,000,000 28,463,000 49,463,000
8 Coiling Aneurisma (stent-assisted atau balloon-asisted) 27,000,000 47,438,000 74,438,000
9 Coiling Aneurisma kompleks (>5 coil) 25,000,000 37,950,000 62,950,000
10 Coiling Aneurisma simpel (3-5 coil) 23,000,000 33,207,000 56,207,000
11 Complicated Functional Neuro -Op. stereotaxy komplex 18,986,000 66,413,000 85,399,000
12 Complicated Functional Neuro -Op. stereotaxy sederhana 18,986,000 56,925,000 75,911,000
13 Complicated Functional Neuro -P Paraverteb/visceral block 25,372,000 38,709,000 64,081,000
14 Complicated Functional Neuro -Percutaneus Kordotomi 25,372,000 48,387,000 73,759,000
15 Dekompresi saraf tepi/CTS 11,884,000 30,360,000 42,244,000
16 17,000,000 10,782,000 27,782,000
Craniocervical
17 18,000,000 14,232,000 32,232,000
18 19,000,000 14,375,000 33,375,000
Craniocervical
19 20,000,000 18,975,000 38,975,000
20 DSA ( DIGITAL SUBTRACTING ANGIOGRAM ) Superselektif 19,000,000 14,375,000 33,375,000
21 DSA ( DIGITAL SUBTRACTING ANGIOGRAM )-Spinal 19,000,000 14,375,000 33,375,000
DSA ( DIGITAL SUBTRACTING ANGIOGRAM )-Spinal dengan
22 20,000,000 18,975,000 38,975,000
Anestesi
23 Ekstirpasi tumor scalp/kranium/saraf tepi 13,554,000 17,078,000 30,632,000
24 Embolisasi brain AVM kompleks kombinasi transarterial-transvena 27,000,000 47,438,000 74,438,000
25 Embolisasi brain AVM kompleks transarterial 25,000,000 37,950,000 62,950,000
26 Embolisasi brain AVM simpel 21,000,000 28,463,000 49,463,000
27 Embolisasi Cerebral-Glue 21,000,000 28,463,000 49,463,000
28 Embolisasi perioperatif 21,000,000 28,463,000 49,463,000
29 Embolisasi spinal AVM/AVF 25,000,000 37,950,000 62,950,000
30 Epidural steroid injection cervical 4,000,000 21,563,000 25,563,000
31 Epidural steroid injection lumbal 4,000,000 14,375,000 18,375,000
32 Flow Diverter Stent 29,000,000 56,925,000 85,925,000
33 Intrakranial angioplasti 25,000,000 37,950,000 62,950,000
34 Kraniektomi dekompresi 16,270,000 45,540,000 61,810,000
35 Kranioplasti/koreksi impresi fraktur kompleks I 21,702,000 41,745,000 63,447,000
36 Kranioplasti/koreksi impresi fraktur kompleks II 33,251,000 47,438,000 80,689,000
37 Kraniotomi / trepanasi dekompresi evakuasi hematoma 16,270,000 49,335,000 65,605,000
38 Kraniotomi / trepanasi evakuasi hematoma 16,270,000 45,540,000 61,810,000
39 Kraniotomi bedah mikro clipping aneurisma 33,251,000 85,388,000 118,639,000
40 Kraniotomi bedah mikro evakuasi hematoma ICH letak dalam 25,372,000 49,335,000 74,707,000
41 Kraniotomi bedah mikro evakuasi hematoma ICH lobaris 25,372,000 45,540,000 70,912,000
42 kraniotomi bedah mikro kompleks I 25,372,000 70,208,000 95,580,000
43 kraniotomi bedah mikro kompleks II 33,251,000 85,388,000 118,639,000
44 kraniotomi bedah mikro kompleks III 38,251,000 94,875,000 133,126,000
45 Kraniotomi bedah mikro reseksi AVM kompleks I 33,251,000 85,388,000 118,639,000
46 Kraniotomi bedah mikro reseksi AVM kompleks II 38,251,000 94,875,000 133,126,000
47 Kraniotomi debridement 16,270,000 45,540,000 61,810,000
48 Kraniotomi high flow bypass 33,251,000 85,388,000 118,639,000
49 Kraniotomi low flow bypass 33,251,000 70,208,000 103,459,000
50 Kraniotomi removal abses 16,270,000 45,540,000 61,810,000
51 Kraniotomi removal tumor metastasis 25,372,000 66,413,000 91,785,000
52 Kraniotomi removal tumor mikro basis kranii kompleks I 25,372,000 70,208,000 95,580,000
53 Kraniotomi removal tumor mikro basis kranii kompleks II 33,251,000 85,388,000 118,639,000
54 Kraniotomi removal tumor mikro basis kranii kompleks III 38,251,000 94,875,000 133,126,000
55 Kraniotomi removal tumor mikro ekstraaksial superficial 25,372,000 66,413,000 91,785,000
56 Kraniotomi removal tumor mikro intraaksial dalam 25,372,000 70,208,000 95,580,000
57 Kraniotomi removal tumor mikro intraaksial superficial 25,372,000 66,413,000 91,785,000
58 Kraniotomi reseksi cavernoma kompleks I 25,372,000 70,208,000 95,580,000
59 Kraniotomi reseksi cavernoma kompleks II 33,251,000 85,388,000 118,639,000
JASA
PELAYANAN
60 Kraniotomi/trepanasi konvensional kompleks I 16,270,000 45,540,000 61,810,000
61 Kraniotomi/trepanasi konvensional kompleks II 21,702,000 56,925,000 78,627,000
62 Ligasi carotis 11,884,000 34,155,000 46,039,000
63 Neuroplasty/Anastomosis/explorasi -Bedah konvensional 11,884,000 30,360,000 42,244,000
Neuroplasty/Anastomosis/explorasi -Bedah Mikro N.Cranialis/Spinalis
64 21,702,000 56,925,000 78,627,000
perifer
Neuroplasty/Anastomosis/explorasi -Bedah Mikro Plexus
65 21,702,000 68,310,000 90,012,000
brakialis/LbSacralis
66 Operas tulang punggung stabilisasi kraniospinal 25,372,000 66,413,000 91,785,000
67 Operasi epilepsi kompleks 1 25,372,000 66,413,000 91,785,000
68 Operasi epilepsi kompleks 2 33,251,000 70,208,000 103,459,000
69 Operasi microvascular decompression hemifascial spasm 25,372,000 66,413,000 91,785,000
70 Operasi microvascular decompression trigeminal neuralgia 25,372,000 66,413,000 91,785,000
Operasi removal tumor endonasal approach microscopic/endoscopic
71 25,372,000 66,413,000 91,785,000
kompleks I
Operasi removal tumor endonasal approach microscopic/endoscopic
72 33,251,000 75,900,000 109,151,000
kompleks II
73 Operasi revisi VPshunt/VA shunt 16,734,000 49,335,000 66,069,000
74 Operasi scoliosis 25,372,000 62,618,000 87,990,000
75 Operasi Stereotaktik biopsi 11,884,000 48,387,000 60,271,000
76 Operasi tulang pungguna laminektomi cervical 25,372,000 56,925,000 82,297,000
77 Operasi tulang punggung debridement 25,372,000 45,540,000 70,912,000
78 Operasi tulang punggung endoskopik HNP Kompleks 1 25,372,000 51,233,000 76,605,000
79 Operasi tulang punggung endoskopik HNP Kompleks 2 25,372,000 56,925,000 82,297,000
80 Operasi tulang punggung laminektomi kraniospinal 25,372,000 68,310,000 93,682,000
81 Operasi tulang punggung laminektomi lumbal 25,372,000 45,540,000 70,912,000
82 Operasi tulang punggung laminektomi thorakal 25,372,000 56,925,000 82,297,000
83 Operasi tulang punggung micorsurgery diksektomi > 3 level 27,000,000 68,310,000 95,310,000
84 Operasi tulang punggung microsrugery removal tumor ekstra dura 27,000,000 56,925,000 83,925,000
Operasi tulang punggung microsrugery removal tumor
85 30,000,000 62,618,000 92,618,000
intraduraekstramedula
86 Operasi tulang punggung microsrugery removal tumor intramedula 30,000,000 68,310,000 98,310,000
87 Operasi tulang punggung microsurgery + instrumentasi cervical 25,372,000 62,618,000 87,990,000
88 Operasi tulang punggung microsurgery + instrumentasi kraniospinal 25,372,000 72,105,000 97,477,000
89 Operasi tulang punggung microsurgery + instrumentasi lumbal 25,372,000 51,233,000 76,605,000
90 Operasi tulang punggung microsurgery + instrumentasi Thorakal 25,372,000 62,618,000 87,990,000
91 Operasi tulang punggung microsurgery diksektomi 2 level 27,000,000 62,618,000 89,618,000
92 Operasi tulang punggung microsurgery diskektomi 1 level 27,000,000 56,925,000 83,925,000
Operasi tulang punggung microsurgery fusi vertebra cervical anterior
93 25,372,000 74,003,000 99,375,000
approach >3 level
94 25,372,000 62,618,000 87,990,000
approach 1 level
95 25,372,000 68,310,000 93,682,000
approach 2 level
96 Operasi tulang punggung stabilisasi cervical 25,372,000 56,925,000 82,297,000
97 Operasi tulang punggung stabilisasi lumbal 25,372,000 47,438,000 72,810,000
98 Operasi tulang punggung stabilisasi thorakal 25,372,000 56,925,000 82,297,000
99 Operasi Ventrikulostomi/EVD 11,884,000 15,295,000 27,179,000
100 Operasi VPshunt/VA shunt kompleks 1 16,734,000 45,540,000 62,274,000
101 Operasi VPshunt/VA shunt kompleks 2 16,734,000 49,335,000 66,069,000
102 Pemasangan ICP monitor 11,884,000 15,295,000 27,179,000
103 Pemasangan traksi servikal/Halovest 11,884,000 14,517,000 26,401,000
104 Pungsi Cairan oak 4,000,000 2,933,000 6,933,000
105 Rekonstruksi kraniosinostosis 15,046,000 49,335,000 64,381,000
106 Rekonstruksi meningocele anterior 21,702,000 45,540,000 67,242,000
107 Rekonstruksi meningocele superior/posterior 21,702,000 45,540,000 67,242,000
108 Rekonstruksi spina bifida 15,046,000 45,540,000 60,586,000
Simple Functional Nsurgery -Perc. Facet Denervation dengan
109 7,000,000 29,032,000 36,032,000
pembiusan
Simple Functional Nsurgery -Percutaneus Rhzotomy/PRGR dengan
110 7,000,000 35,104,000 42,104,000
pembiusan
Simple Functional Nsurgery -Percutaneus Rhzotomy/PRGR tanpa
111 6,000,000 26,594,000 32,594,000
pembiusan
112 Simple Functional surgery -Perc. Facet Denervation tanpa pembiusan 6,000,000 21,994,000 27,994,000
113 Stenting Intrakranial-Sirkulasi anterior 27,000,000 47,438,000 74,438,000
114 Stenting Intrakranial-Sirkulasi posterior 27,000,000 47,438,000 74,438,000
JASA
PELAYANAN
115 Transarterial intracranial therapy 21,000,000 22,569,000 43,569,000
116 Trombektomi Stroke 23,000,000 37,950,000 60,950,000
117 Trombolisis Intraarteri 19,000,000 14,375,000 33,375,000
118 Wada test 19,000,000 18,975,000 37,975,000
6.9 REPRODUCTIVE DAN WHC
1 Abdomino SakroKolpopeksi 17,995,000 28,463,000 46,458,000
2 Abses Vulva 9,114,000 8,211,000 17,325,000
3 ASPIRASI KISTA vagina 11,163,000 2,190,000 13,353,000
4 Conservative Surgical Staging 17,995,000 14,517,000 32,512,000
5 D/C KURETASE 6,942,000 4,830,000 11,772,000
6 D/C KURETASE + Asistensi 6,942,000 5,549,000 12,491,000
7 EKSISI SEPTUM VAGINA 10,151,000 14,232,000 24,383,000
8 EKSTIRPASI MIOM GEBURT / EKSTIRPASI POLIP SERVIX 11,163,000 3,220,000 14,383,000
9 HDLO 17,032,000 18,975,000 36,007,000
10 HDLO DENGAN PENYULIT 19,683,000 23,719,000 43,402,000
11 HEMATOM VULVA DAN VAGINA 9,114,000 8,050,000 17,164,000
12 HISTEREKTOMI 17,995,000 18,975,000 36,970,000
13 HISTEREKTOMI DENGAN PENYULIT 17,995,000 25,617,000 43,612,000
14 Histerektomi Radikal 17,995,000 37,950,000 55,945,000
15 Histereskopi PENGANGKATAN IUD 10,624,000 8,050,000 18,674,000
16 HISTEROSCOPY OPERATIVE 10,624,000 14,232,000 24,856,000
17 HT SOB+Adesiolisis 17,995,000 28,463,000 46,458,000
18 Insisi Abses Bartolin 9,114,000 7,245,000 16,359,000
19 INSISI ADHESIA LABIA 10,151,000 9,488,000 19,639,000
20 INSISI HIMEN IMPERFORATA 10,151,000 9,488,000 19,639,000
21 Kauterisasi Kondiloma 9,114,000 7,245,000 16,359,000
22 Kistektomi 10,151,000 18,975,000 29,126,000
23 KONISASI 10,151,000 8,050,000 18,201,000
24 LAPARATOMI EKSPLORASI DENGAN PENYULIT 15,279,000 23,719,000 38,998,000
25 Laparatomi Eksplorasi standar 10,151,000 18,975,000 29,126,000
26 Laparoskopi KET 15,000,000 23,100,000 38,100,000
27 Laparoskopik Sakrokolpopeksi 17,995,000 28,463,000 46,458,000
28 Laparotomi KET 10,151,000 18,975,000 29,126,000
29 Laparotomi MIOMEKTOMI 10,151,000 18,975,000 29,126,000
30 LAPAROTOMI SURGICAL STAGING 17,995,000 37,950,000 55,945,000
31 Marsupialisasi Kista Bartolin 10,151,000 9,488,000 19,639,000
32 MIOMEKTOMI DENGAN PENYULIT 12,867,000 23,345,000 36,212,000
33 Neo Vagina 13,899,000 28,463,000 42,362,000
34 Partus dengan Penyulit 9,759,000 9,321,000 19,080,000
35 Partus Normal + Insersi IUD 7,047,000 7,694,000 14,741,000
36 Partus Normal tanpa penyulit 7,047,000 7,021,000 14,068,000
37 Partus per Vaginal dengan Ruptur Grade III/IV 7,500,000 9,994,000 17,494,000
38 Pemasangan Cell Site 7,047,000 12,317,000 19,364,000
39 Radical Trachelektomi 13,899,000 28,463,000 42,362,000
40 Radikal Vulvektomi 13,899,000 28,463,000 42,362,000
41 Rekonstruksi Tuba 13,879,000 25,617,000 39,496,000
42 Rekonstruksi Vagina 17,995,000 28,463,000 46,458,000
43 Relaparatomi 17,995,000 28,463,000 46,458,000
44 REPAIR RUPTUR PARINEUM TOTAL LAMA 12,867,000 28,463,000 41,330,000
45 REPAIR VESIKA URINARIA / REPAIR FISTULA 13,879,000 28,463,000 42,342,000
46 RESEKSI ADENOMIOSIS 11,163,000 23,719,000 34,882,000
47 RESEKSI ADENOMIOSIS dengan penyulit 12,867,000 28,463,000 41,330,000
48 Sakrospinosus Histeropeksi 13,899,000 28,463,000 42,362,000
49 Sectio Caesaria 7,047,000 20,344,000 27,391,000
50 Sectio Caesaria + Histerektomi 12,500,000 29,831,000 42,331,000
51 Sectio Caesaria + Insersi IUD 7,500,000 20,344,000 27,844,000
52 Sectio Caesaria + Kompresi B-Lynch 8,000,000 25,088,000 33,088,000
53 Sectio Caesaria + Tubektomi 7,500,000 20,344,000 27,844,000
54 Sectio Caesaria Bayi Kembar 8,000,000 26,456,000 34,456,000
55 SECTIO CAESARIA DENGAN PENYULIT 9,114,000 25,122,000 34,236,000
56 Sirklase 9,114,000 9,488,000 18,602,000
57 Sterilisasi 9,105,000 9,488,000 18,593,000
58 STRELISASI / TUBEKTOMI PER LAPAROSKOPI 13,899,000 14,232,000 28,131,000
59 TVHKPRKA 13,899,000 28,463,000 42,362,000
60 TVHKPRKA + Sakrospinosus Fiksasi 13,899,000 37,950,000 51,849,000
61 TVHKPRKA + TVT 13,899,000 37,950,000 51,849,000
62 TVT (TENSIONFREE VAGINAL TAPE) 10,151,000 24,150,000 34,301,000
63 Vaginoplasti 13,899,000 28,463,000 42,362,000
6.10 SPINE DAN BONE JOINT
1 above elbow amputation 13,607,000 37,950,000 51,557,000
JASA
PELAYANAN
2 above elbow amputation Dengan Penyulit 13,607,000 49,335,000 62,942,000
3 Above knee amputation 13,607,000 37,950,000 51,557,000
4 Above knee amputation Dengan Penyulit 13,607,000 49,335,000 62,942,000
5 Achilles tendon lengthening dewasa 13,607,000 39,374,000 52,981,000
6 Achilles tendon lengthening dewasa Dengan Penyulit 13,607,000 51,185,000 64,792,000
7 Adhesiolisis tendon 13,544,000 25,760,000 39,304,000
8 Adhesiolisis tendon Dengan Penyulit 13,544,000 33,488,000 47,032,000
9 Amputasi ekstra digiti 9,651,000 19,481,000 29,132,000
10 Amputasi ekstra digiti Dengan Penyulit 9,651,000 25,326,000 34,977,000
11 Amputasi Forequarter 19,697,000 42,694,000 62,391,000
12 Amputasi Forequarter Dengan Penyulit 19,697,000 55,502,000 75,199,000
13 Amputasi Ray 15,582,000 23,345,000 38,927,000
14 Amputasi Ray 8,000,000 18,515,000 26,515,000
15 Amputasi Ray Dengan Penyulit 8,000,000 24,070,000 32,070,000
16 Amputasi Toe 6,000,000 11,270,000 17,270,000
17 Amputasi Toe Dengan Penyulit 6,000,000 14,651,000 20,651,000
18 Amputasi Toe multipel 9,651,000 24,955,000 34,606,000
19 Amputasi Toe multipel Dengan Penyulit 9,651,000 32,442,000 42,093,000
20 Ankle Arthroscopy diagnostic, debridement 13,607,000 39,374,000 52,981,000
21 Ankle Arthroscopy diagnostic, debridement Dengan Penyulit 13,607,000 51,185,000 64,792,000
22 Ankle Arthroscopy rekonstruksi ligamen 19,510,000 51,233,000 70,743,000
23 Ankle Arthroscopy rekonstruksi ligamen Dengan Penyulit 19,510,000 66,603,000 86,113,000
24 Ankle Arthroscopy rekonstruksi ligamen multipel 19,510,000 51,233,000 70,743,000
25 Ankle Arthroscopy rekonstruksi ligamen multipel Dengan Penyulit 19,510,000 66,603,000 86,113,000
26 Anterior Disectomy for Corection of Scoliosis 16,513,000 42,665,000 59,178,000
27 Anterior Disectomy for Corection of Scoliosis Dengan Penyulit 16,513,000 55,465,000 71,978,000
28 Arthrodesis jari, tangan, wrist 13,544,000 29,785,000 43,329,000
29 Arthrodesis jari, tangan, wrist Dengan Penyulit 13,544,000 38,721,000 52,265,000
30 Arthrodesis jari, tangan, wrist multipel 13,544,000 51,233,000 64,777,000
31 Arthrodesis jari, tangan, wrist multipel Dengan Penyulit 13,544,000 66,603,000 80,147,000
32 Arthrodesis regio tangan, wrist / kaki, ankle 13,544,000 29,785,000 43,329,000
33 Arthrodesis regio tangan, wrist / kaki, ankle Dengan Penyulit 13,544,000 38,721,000 52,265,000
34 Arthrodesis regio tangan, wrist / kaki, ankle multipel 13,544,000 51,233,000 64,777,000
35 Arthrodesis regio tangan, wrist / kaki, ankle multipel Dengan Penyulit 13,544,000 66,603,000 80,147,000
36 Arthrodesis sendi 15,582,000 39,374,000 54,956,000
37 Arthrodesis sendi Dengan Penyulit 15,582,000 51,185,000 66,767,000
38 Arthroplasty sendi regio tangan, wrist 14,530,000 42,694,000 57,224,000
39 Arthroplasty sendi regio tangan, wrist / kaki, ankle 14,530,000 42,694,000 57,224,000
40 Arthroplasty sendi regio tangan, wrist / kaki, ankle Dengan Penyulit 14,530,000 55,502,000 70,032,000
41 Arthroplasty sendi regio tangan, wrist Dengan Penyulit 14,530,000 55,502,000 70,032,000
42 Below elbow amputation 13,607,000 37,950,000 51,557,000
43 Below elbow amputation Dengan Penyulit 13,607,000 49,335,000 62,942,000
44 Below knee amputation 13,607,000 37,950,000 51,557,000
45 Below knee amputation Dengan Penyulit 13,607,000 49,335,000 62,942,000
46 Biopsi terbuka tulang, soft tissue 8,000,000 17,710,000 25,710,000
47 Biopsi terbuka tulang, soft tissue Dengan Penyulit 8,000,000 23,023,000 31,023,000
48 Biopsi Vertebrae 9,651,000 18,515,000 28,166,000
49 Biopsi Vertebrae Dengan Penyulit 9,651,000 24,070,000 33,721,000
50 Bone Marrow aspiration 9,651,000 12,075,000 21,726,000
51 Bone Marrow aspiration Dengan Penyulit 9,651,000 15,698,000 25,349,000
52 Bony bridge release tarsal coalition 9,651,000 24,955,000 34,606,000
53 Bony bridge release tarsal coalition Dengan Penyulit 9,651,000 32,442,000 42,093,000
54 Bony Procedure pada CTEV 15,582,000 51,233,000 66,815,000
55 Bony Procedure pada CTEV Dengan Penyulit 15,582,000 66,603,000 82,185,000
Bony procedure pada Kelainan Cerebral Plasy, Arthogryposis, Spina
56 13,607,000 39,374,000 52,981,000
Bifida
Bony procedure pada Kelainan Cerebral Plasy, Arthogryposis, Spina
57 13,607,000 51,185,000 64,792,000
Bifida Dengan Penyulit
58 Cervical Laminoplasty (open door, etc) 16,513,000 53,130,000 69,643,000
59 Cervical Laminoplasty (open door, etc) Dengan Penyulit 16,513,000 69,069,000 85,582,000
60 CMC 1 arthroscopy 19,510,000 51,233,000 70,743,000
61 CMC 1 arthroscopy Dengan Penyulit 19,510,000 66,603,000 86,113,000
62 Core biopsy 9,651,000 24,955,000 34,606,000
63 Core biopsy CT Scan guided 16,507,000 27,531,000 44,038,000
64 Core biopsy CT Scan guided Dengan Penyulit 16,507,000 35,791,000 52,298,000
65 Core biopsy Dengan Penyulit 9,651,000 32,442,000 42,093,000
66 Core Decompression dan injeksi Steroid 12,418,000 28,175,000 40,593,000
JASA
PELAYANAN
67 Core Decompression dan injeksi Steroid Dengan Penyulit 12,418,000 36,628,000 49,046,000
68 Corrective osteotomy surgery neglected fracture tangan, wrist 13,544,000 47,438,000 60,982,000
Corrective osteotomy surgery neglected fracture tangan, wrist Dengan
69 13,544,000 61,669,000 75,213,000
Penyulit
70 Corrective osteotomy surgery, ORIF 13,544,000 47,438,000 60,982,000
71 Corrective osteotomy surgery, ORIF Dengan Penyulit 13,544,000 61,669,000 75,213,000
72 Curretage + bone cement 15,582,000 24,150,000 39,732,000
73 Curretage + bone cement Dengan Penyulit 15,582,000 31,395,000 46,977,000
74 Curretage + bone cement+ ORIF 15,582,000 56,925,000 72,507,000
75 Curretage + bone cement+ ORIF Dengan Penyulit 15,582,000 74,003,000 89,585,000
76 Curretage dan bone graft 13,607,000 20,930,000 34,537,000
77 Curretage dan bone graft Dengan Penyulit 13,607,000 27,209,000 40,816,000
78 Debridement 9,651,000 14,088,000 23,739,000
79 Debridement and Anterior, posterior Fusion in TB Spine 16,513,000 53,130,000 69,643,000
Debridement and Anterior, posterior Fusion in TB Spine Dengan
80 16,513,000 69,069,000 85,582,000
Penyulit
81 Debridement dan Soft Tissue Release pada Infeksi Sendi 13,607,000 39,374,000 52,981,000
Debridement dan Soft Tissue Release pada Infeksi Sendi Dengan
82 13,607,000 51,185,000 64,792,000
Penyulit
83 Debridement Dengan Penyulit 9,651,000 18,314,000 27,965,000
84 Debridement fraktur terbuka anak 9,651,000 18,515,000 28,166,000
85 Debridement fraktur terbuka anak Dengan Penyulit 9,651,000 24,070,000 33,721,000
86 Debridement jari, tangan kompleks 13,544,000 28,175,000 41,719,000
87 Debridement jari, tangan kompleks Dengan Penyulit 13,544,000 36,628,000 50,172,000
88 Debridement jari, tangan simpel 9,651,000 19,481,000 29,132,000
89 Debridement jari, tangan simpel Dengan Penyulit 9,651,000 25,326,000 34,977,000
90 Debridement, nekrotomy dan saucerization Chronic Osteomyelits 13,607,000 39,374,000 52,981,000
Debridement, nekrotomy dan saucerization Chronic Osteomyelits
91 13,607,000 51,185,000 64,792,000
Dengan Penyulit
Decompression and stabilization for degenerative spine (PLIF/TLIF,
92 19,697,000 53,130,000 72,827,000
Posterior / Anterior Stabilization)
93 19,697,000 74,003,000 93,700,000
Posterior / Anterior Stabilization) dengan implantasi sel punca
94 Posterior / Anterior Stabilization) dengan implantasi sel punca Dengan 19,697,000 96,204,000 115,901,000
Penyulit
95 19,697,000 69,069,000 88,766,000
Posterior / Anterior Stabilization) Dengan Penyulit
96 Decompression Laminotomy for HNP, Tumor and Spinal Stenosis 16,513,000 37,950,000 54,463,000
Decompression Laminotomy for HNP, Tumor and Spinal Stenosis
97 16,513,000 49,335,000 65,848,000
Dengan Penyulit
98 Discograph 9,651,000 16,905,000 26,556,000
99 Discograph Dengan Penyulit 9,651,000 21,977,000 31,628,000
100 Discograph multilevel 9,651,000 23,345,000 32,996,000
101 Discograph multilevel Dengan Penyulit 9,651,000 30,349,000 40,000,000
102 Drainage infeksi tangan, tenosynovitis 9,651,000 25,760,000 35,411,000
103 Drainage infeksi tangan, tenosynovitis Dengan Penyulit 9,651,000 33,488,000 43,139,000
104 Eksisi marginal margin tumor jaringan lunak besar 14,537,000 17,710,000 32,247,000
105 Eksisi marginal margin tumor jaringan lunak besar Dengan Penyulit 14,537,000 23,023,000 37,560,000
106 Eksisi marginal margin tumor jaringan lunak ukuran kecil 6,000,000 11,270,000 17,270,000
Eksisi marginal margin tumor jaringan lunak ukuran kecil Dengan
107 6,000,000 14,651,000 20,651,000
Penyulit
Eksisi Tendon Sheath, Jaringan Subkutis, ganglion, bursitis , tumor
108 15,582,000 20,930,000 36,512,000
soft tissue lain kompleks
109 15,582,000 27,209,000 42,791,000
soft tissue lain kompleks Dengan Penyulit
110 8,000,000 16,100,000 24,100,000
soft tissue lain simpel
111 8,000,000 20,930,000 28,930,000
soft tissue lain simpel Dengan Penyulit
112 Eksplorasi, evakuasi corpus alienum 13,607,000 16,905,000 30,512,000
113 Eksplorasi, evakuasi corpus alienum Dengan Penyulit 13,607,000 21,977,000 35,584,000
114 Elbow arthroscopy diagnostic, debridement 19,510,000 38,813,000 58,323,000
115 Elbow arthroscopy diagnostic, debridement Dengan Penyulit 19,510,000 50,457,000 69,967,000
116 Elbow arthroscopy rekonstruksi ligamen 19,510,000 38,813,000 58,323,000
117 Elbow arthroscopy rekonstruksi ligamen Dengan Penyulit 19,510,000 50,457,000 69,967,000
118 Elbow disarticulation 15,582,000 37,950,000 53,532,000
JASA
PELAYANAN
119 Elbow disarticulation Dengan Penyulit 15,582,000 49,335,000 64,917,000
120 Elbow reconstruction revision procedure 19,510,000 49,594,000 69,104,000
121 Elbow reconstruction revision procedure Dengan Penyulit 19,510,000 64,472,000 83,982,000
122 Enblock resection dan shoulder hemiarthroplasty 19,510,000 66,413,000 85,923,000
123 Enblock resection dan shoulder hemiarthroplasty Dengan Penyulit 19,510,000 86,337,000 105,847,000
124 Enblock resection distal radius, ulna 16,513,000 28,175,000 44,688,000
125 Enblock resection distal radius, ulna Dengan Penyulit 16,513,000 36,628,000 53,141,000
126 Enblock resection NFVG 16,513,000 66,413,000 82,926,000
127 Enblock resection NFVG Dengan Penyulit 16,513,000 86,337,000 102,850,000
128 Enblock resection Proximal tibia 13,607,000 37,950,000 51,557,000
129 Enblock resection Proximal tibia Dengan Penyulit 13,607,000 49,335,000 62,942,000
130 Epidural, sacroilliac Block 9,651,000 16,905,000 26,556,000
131 Epidural, sacroilliac Block Dengan Penyulit 9,651,000 21,977,000 31,628,000
132 Extended Curretage dan bone graft 15,582,000 24,150,000 39,732,000
133 Extended Curretage dan bone graft Dengan Penyulit 15,582,000 31,395,000 46,977,000
134 Facet Block 9,651,000 16,905,000 26,556,000
135 Facet Block Dengan Penyulit 9,651,000 21,977,000 31,628,000
136 Facet Block multilevel 9,651,000 23,345,000 32,996,000
137 Facet Block multilevel Dengan Penyulit 9,651,000 30,349,000 40,000,000
138 Fasciocutaneus Flap 19,510,000 16,100,000 35,610,000
139 Fasciocutaneus Flap Dengan Penyulit 19,510,000 20,930,000 40,440,000
140 Fasciotomy 8,000,000 14,088,000 22,088,000
141 Fasciotomy Dengan Penyulit 8,000,000 18,314,000 26,314,000
142 Fiksasi Cannulated Screw pada SCFE 13,607,000 39,374,000 52,981,000
143 Fiksasi Cannulated Screw pada SCFE Dengan Penyulit 13,607,000 51,185,000 64,792,000
144 Fiksasi internal dan bone cement MBD Long bone 15,582,000 37,950,000 53,532,000
145 Fiksasi internal dan bone cement MBD Long bone Dengan Penyulit 15,582,000 49,335,000 64,917,000
146 Flap latissimus dorsi 13,607,000 37,950,000 51,557,000
147 Flap latissimus dorsi Dengan Penyulit 13,607,000 49,335,000 62,942,000
148 Flap medial gastrocnemius 13,607,000 24,150,000 37,757,000
149 Flap medial gastrocnemius Dengan Penyulit 13,607,000 31,395,000 45,002,000
150 Flap sural 13,607,000 24,150,000 37,757,000
151 Flap sural Dengan Penyulit 13,607,000 31,395,000 45,002,000
152 Foraminal Block 9,651,000 16,905,000 26,556,000
153 Foraminal Block Dengan Penyulit 9,651,000 21,977,000 31,628,000
154 Foraminal Block multilevel 9,651,000 23,345,000 32,996,000
155 Foraminal Block multilevel Dengan Penyulit 9,651,000 30,349,000 40,000,000
156 Free Functional Muscular Transfer (FFMT) (microsurgery) 19,697,000 80,644,000 100,341,000
157 Free Functional Muscular Transfer (FFMT) (microsurgery) 19,697,000 97,175,000 116,872,000
Free Functional Muscular Transfer (FFMT) (microsurgery) Dengan
158 19,697,000 104,837,000 124,534,000
Penyulit
Free Functional Muscular Transfer (FFMT) (microsurgery) Dengan
159 19,697,000 126,328,000 146,025,000
Penyulit
160 Hemiarthroplasty Hip 13,607,000 34,914,000 48,521,000
161 Hemiarthroplasty hip 19,697,000 47,438,000 67,135,000
162 Hemiarthroplasty Hip Dengan Penyulit 13,607,000 45,389,000 58,996,000
163 Hemiarthroplasty hip Dengan Penyulit 19,697,000 61,669,000 81,366,000
164 Hemiarthroplasty Shoulder 13,607,000 34,914,000 48,521,000
165 Hemiarthroplasty Shoulder Dengan Penyulit 13,607,000 45,389,000 58,996,000
166 Hemipelvectomy 19,697,000 47,438,000 67,135,000
167 Hemipelvectomy Dengan Penyulit 19,697,000 61,669,000 81,366,000
168 Hip Arthroplasty dengan implantasi sel punca 15,582,000 61,669,000 77,251,000
169 Hip Arthroplasty dengan implantasi sel punca Dengan Penyulit 15,582,000 80,170,000 95,752,000
170 Hip Arthroscopy diagnostic, debridement 19,697,000 24,955,000 44,652,000
171 Hip Arthroscopy diagnostic, debridement Dengan Penyulit 19,697,000 32,442,000 52,139,000
172 Hip Arthroscopy repair ligament 19,697,000 51,233,000 70,930,000
173 Hip Arthroscopy repair ligament Dengan Penyulit 19,697,000 66,603,000 86,300,000
174 Hip disarticulation 15,582,000 27,370,000 42,952,000
175 Hip Disarticulation 16,513,000 37,950,000 54,463,000
176 Hip Disarticulation Dengan Penyulit 16,513,000 49,335,000 65,848,000
177 Hip disarticulation Dengan Penyulit 15,582,000 35,581,000 51,163,000
178 IDET 1 Level 13,544,000 28,980,000 42,524,000
179 IDET 1 Level Dengan Penyulit 13,544,000 37,674,000 51,218,000
180 Implant removal spine 13,544,000 24,955,000 38,499,000
181 Implant removal spine Dengan Penyulit 13,544,000 32,442,000 45,986,000
182 Implant removal tulang panjang 9,651,000 24,955,000 34,606,000
183 Implant removal tulang panjang Dengan Penyulit 9,651,000 32,442,000 42,093,000
184 Implant removal tulang panjang multipel 15,582,000 51,233,000 66,815,000
JASA
PELAYANAN
185 Implant removal tulang panjang multipel Dengan Penyulit 15,582,000 66,603,000 82,185,000
186 Implantasi sel punca pada Avascular Nekrosis pada Hip 9,651,000 20,125,000 29,776,000
Implantasi sel punca pada Avascular Nekrosis pada Hip Dengan
187 9,651,000 26,163,000 35,814,000
Penyulit
188 Implantasi sel punca pada Brachial Plexus Injury 9,651,000 20,125,000 29,776,000
189 Implantasi sel punca pada Brachial Plexus Injury Dengan Penyulit 9,651,000 26,163,000 35,814,000
190 Implantasi sel punca pada defek tulang/non union fraktur 9,651,000 18,515,000 28,166,000
Implantasi sel punca pada defek tulang/non union fraktur Dengan
191 9,651,000 24,070,000 33,721,000
Penyulit
192 Implantasi sel punca pada kasus tulang belakang (C-arms guide) 9,651,000 28,497,000 38,148,000
Implantasi sel punca pada kasus tulang belakang (C-arms guide)
193 9,651,000 37,047,000 46,698,000
Dengan Penyulit
194 Injeksi botox neuromuscular disease 8,000,000 18,515,000 26,515,000
195 Injeksi botox neuromuscular disease Dengan Penyulit 8,000,000 24,070,000 32,070,000
196 Interpositional arthroplasty 15,582,000 51,233,000 66,815,000
197 Interpositional arthroplasty Dengan Penyulit 15,582,000 66,603,000 82,185,000
198 Knee Arthroscopy diagnostic, debridement 13,607,000 24,955,000 38,562,000
199 Knee Arthroscopy diagnostic, debridement Dengan Penyulit 13,607,000 32,442,000 46,049,000
200 Knee Arthroscopy menisectomy, synovectomy 15,875,000 39,374,000 55,249,000
201 Knee Arthroscopy menisectomy, synovectomy Dengan Penyulit 15,875,000 51,185,000 67,060,000
202 Knee Arthroscopy microfracture, Autogenus Condrocythe Implantation 19,510,000 51,233,000 70,743,000
Knee Arthroscopy microfracture, Autogenus Condrocythe Implantation
203 19,510,000 66,603,000 86,113,000
Dengan Penyulit
204 Knee Arthroscopy rekonstruksi ACL, PCL 19,510,000 51,233,000 70,743,000
205 Knee Arthroscopy rekonstruksi ACL, PCL Dengan Penyulit 19,510,000 66,603,000 86,113,000
206 Knee Arthroscopy rekonstruksi ligamen multipel 19,510,000 80,644,000 100,154,000
207 Knee Arthroscopy rekonstruksi ligamen multipel Dengan Penyulit 19,510,000 104,837,000 124,347,000
208 Knee Arthroscopy rekonstruksi MCL, LCL 19,510,000 51,233,000 70,743,000
209 Knee Arthroscopy rekonstruksi MCL, LCL Dengan Penyulit 19,510,000 66,603,000 86,113,000
210 Knee Arthroscopy repair meniscus 15,875,000 51,233,000 67,108,000
211 Knee Arthroscopy repair meniscus Dengan Penyulit 15,875,000 66,603,000 82,478,000
212 Knee disarticulation 15,582,000 36,053,000 51,635,000
213 Knee disarticulation Dengan Penyulit 15,582,000 46,869,000 62,451,000
214 Knee ligamant reconstruction revision procedure 19,510,000 49,594,000 69,104,000
215 Knee ligamant reconstruction revision procedure Dengan Penyulit 19,510,000 64,472,000 83,982,000
216 Koreksi Hallux valgus bony procedure 13,607,000 51,233,000 64,840,000
217 Koreksi Hallux valgus bony procedure Dengan Penyulit 13,607,000 66,603,000 80,210,000
218 Koreksi Hallux valgus soft tissue procedure 13,607,000 39,374,000 52,981,000
219 Koreksi Hallux valgus soft tissue procedure Dengan Penyulit 13,607,000 51,185,000 64,792,000
220 Kyphoplasty / vertebroplasty 13,544,000 32,200,000 45,744,000
221 Kyphoplasty / vertebroplasty Dengan Penyulit 13,544,000 41,860,000 55,404,000
222 Lepas K Wire anestesia lokal 15,582,000 12,880,000 28,462,000
223 Lepas K Wire anestesia lokal Dengan Penyulit 15,582,000 16,744,000 32,326,000
224 Lepas K Wire, screw, miniplate dengan anestesi lokal 8,000,000 16,100,000 24,100,000
225 Lepas K Wire, screw, miniplate dengan anestesi lokal Dengan Penyulit 8,000,000 20,930,000 28,930,000
226 Lepas K Wire, screw, miniplate dengan anestesi regional, umum 9,651,000 19,481,000 29,132,000
Lepas K Wire, screw, miniplate dengan anestesi regional, umum
227 9,651,000 25,326,000 34,977,000
Dengan Penyulit
228 Lepas K Wire, screw, miniplate multipel dengan anestesi lokal 8,000,000 19,481,000 27,481,000
Lepas K Wire, screw, miniplate multipel dengan anestesi lokal Dengan
229 8,000,000 25,326,000 33,326,000
Penyulit
230 Lepas K Wire, screw, miniplate multipel dengan regional, umum 13,544,000 23,345,000 36,889,000
Lepas K Wire, screw, miniplate multipel dengan regional, umum
231 13,544,000 30,349,000 43,893,000
Dengan Penyulit
Limb lengthening atau operasi rekonstruksi pada anak yang
232 19,510,000 65,464,000 84,974,000
menggunakan alat khusus
Limb lengthening atau operasi rekonstruksi pada anak yang
233 19,510,000 85,103,000 104,613,000
menggunakan alat khusus Dengan Penyulit
Limb lengthening atau operasi rekonstruksi yang menggunakan alat
234 19,697,000 65,464,000 85,161,000
khusus
Limb lengthening atau operasi rekonstruksi yang menggunakan alat
235 19,697,000 85,103,000 104,800,000
khusus Dengan Penyulit
236 Limb salvage surgery - Arthrodesis 15,582,000 66,413,000 81,995,000
237 Limb salvage surgery - Arthrodesis Dengan Penyulit 15,582,000 86,337,000 101,919,000
238 Limb salvage surgery ( enblock resection ) 16,513,000 47,438,000 63,951,000
239 Limb salvage surgery ( enblock resection ) Dengan Penyulit 16,513,000 61,669,000 78,182,000
JASA
PELAYANAN
240 Limb salvage surgery ( NFVFG/ Megaprosthesis ) 16,513,000 66,413,000 82,926,000
241 Limb salvage surgery ( NFVFG/ Megaprosthesis ) Dengan Penyulit 16,513,000 86,337,000 102,850,000
242 Limb salvage surgery ECI tahap I 14,537,000 42,694,000 57,231,000
243 Limb salvage surgery ECI tahap I Dengan Penyulit 14,537,000 55,502,000 70,039,000
244 Limb salvage surgery ECI tahap II 14,537,000 28,175,000 42,712,000
245 Limb salvage surgery ECI tahap II Dengan Penyulit 14,537,000 36,628,000 51,165,000
246 Limb salvage surgery with Megaprosthesis 19,510,000 66,413,000 85,923,000
247 Limb salvage surgery with Megaprosthesis Dengan Penyulit 19,510,000 86,337,000 105,847,000
Manipulation & Reduction of Simple Fracture and Dislocation with
248 9,651,000 24,955,000 34,606,000
General Anaesthesia
Manipulation & Reduction of Simple Fracture and Dislocation with
249 9,651,000 32,442,000 42,093,000
General Anaesthesia Dengan Penyulit
250 Modified - Rotational plasty 16,513,000 66,413,000 82,926,000
251 Modified - Rotational plasty Dengan Penyulit 16,513,000 86,337,000 102,850,000
Multiple procedure pada Kelainan Cerebral Palsy, Arthrogryposis,
252 19,510,000 65,464,000 84,974,000
Spina Bifida
Multiple procedure pada Kelainan Cerebral Palsy, Arthrogryposis,
253 19,510,000 85,103,000 104,613,000
Spina Bifida Dengan Penyulit
254 Multiple procedures on bone and soft tissue A 16,513,000 55,200,000 71,713,000
255 Multiple procedures on bone and soft tissue A Dengan Penyulit 16,513,000 71,760,000 88,273,000
256 Multiple procedures on bone and soft tissue B 19,510,000 75,624,000 95,134,000
257 Multiple procedures on bone and soft tissue B Dengan Penyulit 19,510,000 98,312,000 117,822,000
258 Multiple procedures on bone and soft tissue C 19,697,000 95,220,000 114,917,000
259 Multiple procedures on bone and soft tissue C Dengan Penyulit 19,697,000 123,786,000 143,483,000
260 Multiple release syndactyly 15,582,000 51,233,000 66,815,000
261 Multiple release syndactyly Dengan Penyulit 15,582,000 66,603,000 82,185,000
262 Nekrotomi 8,000,000 12,075,000 20,075,000
263 Nekrotomi Dengan Penyulit 8,000,000 15,698,000 23,698,000
264 Nekrotomi pada anak 9,651,000 18,515,000 28,166,000
265 Nekrotomi pada anak Dengan Penyulit 9,651,000 24,070,000 33,721,000
266 Nerve transfer BPI kompleks 15,866,000 65,464,000 81,330,000
267 Nerve transfer BPI kompleks dengan implantasi sel punca 15,866,000 80,644,000 96,510,000
Nerve transfer BPI kompleks dengan implantasi sel punca Dengan
268 15,866,000 104,837,000 120,703,000
Penyulit
269 Nerve transfer BPI kompleks Dengan Penyulit 15,866,000 85,103,000 100,969,000
270 Nerve transfer BPI simpel 15,582,000 43,643,000 59,225,000
271 Nerve transfer BPI simpel dengan implantasi sel punca 15,582,000 64,515,000 80,097,000
Nerve transfer BPI simpel dengan implantasi sel punca Dengan
272 15,582,000 83,870,000 99,452,000
Penyulit
273 Nerve transfer BPI simpel Dengan Penyulit 15,582,000 56,736,000 72,318,000
274 Neurolisis 14,530,000 39,848,000 54,378,000
275 Neurolisis Dengan Penyulit 14,530,000 51,802,000 66,332,000
276 Open achilles tendon lengthening (ATL) anak 9,651,000 24,955,000 34,606,000
277 Open achilles tendon lengthening (ATL) anak Dengan Penyulit 9,651,000 32,442,000 42,093,000
278 Open Bankart repair 15,875,000 51,233,000 67,108,000
279 Open Bankart repair Dengan Penyulit 15,875,000 66,603,000 82,478,000
280 Open biopsy tumor di spine/pelvis 13,544,000 24,150,000 37,694,000
281 Open biopsy tumor di spine/pelvis Dengan Penyulit 13,544,000 31,395,000 44,939,000
282 Open Disectomy 1 Level 13,544,000 29,785,000 43,329,000
283 Open Disectomy 1 Level Dengan Penyulit 13,544,000 38,721,000 52,265,000
284 Open MPFL reconstruction 15,875,000 51,233,000 67,108,000
285 Open MPFL reconstruction Dengan Penyulit 15,875,000 66,603,000 82,478,000
286 Open Reduction and stabilization of Spinal Fracture 16,513,000 50,284,000 66,797,000
Open Reduction and stabilization of Spinal Fracture dengan implantasi
287 16,513,000 71,157,000 87,670,000
sel punca
Open Reduction and stabilization of Spinal Fracture dengan implantasi
288 16,513,000 92,503,000 109,016,000
sel punca Dengan Penyulit
289 Open Reduction and stabilization of Spinal Fracture Dengan Penyulit 16,513,000 65,369,000 81,882,000
290 Open rotator cuff repair 15,875,000 51,233,000 67,108,000
291 Open rotator cuff repair Dengan Penyulit 15,875,000 66,603,000 82,478,000
292 Opponensplasty 15,582,000 42,694,000 58,276,000
293 Opponensplasty Dengan Penyulit 15,582,000 55,502,000 71,084,000
294 Osteotomi korektif Blount's disease, pseudoarthrosis 16,513,000 51,233,000 67,746,000
295 Osteotomi korektif Blount's disease, pseudoarthrosis Dengan Penyulit 16,513,000 66,603,000 83,116,000
296 Pelvic Resection II 19,510,000 66,413,000 85,923,000
297 Pelvic Resection II Dengan Penyulit 19,510,000 86,337,000 105,847,000
298 Pelvic Resection I 19,510,000 56,925,000 76,435,000
JASA
PELAYANAN
299 Pelvic Resection I Dengan Penyulit 19,510,000 74,003,000 93,513,000
300 Pelvic Resection III 19,510,000 66,413,000 85,923,000
301 Pelvic Resection III Dengan Penyulit 19,510,000 86,337,000 105,847,000
302 Percutaneous achilles tendon lengthening (ATL) 9,651,000 34,914,000 44,565,000
303 Percutaneous achilles tendon lengthening (ATL) Dengan Penyulit 9,651,000 45,389,000 55,040,000
304 Percutaneous pinning fraktur acetabulum 15,582,000 39,279,000 54,861,000
305 Percutaneous pinning fraktur acetabulum Dengan Penyulit 15,582,000 51,062,000 66,644,000
306 Percutaneous, Open release trigger finger 6,000,000 16,905,000 22,905,000
307 Percutaneous, Open release trigger finger Dengan Penyulit 6,000,000 21,977,000 27,977,000
308 Percutaneous, Open release trigger finger multipel 9,651,000 20,125,000 29,776,000
309 Percutaneous, Open release trigger finger multipel Dengan Penyulit 9,651,000 26,163,000 35,814,000
310 Plaster Aplication of Spine (body jacket, minerva) 9,651,000 18,515,000 28,166,000
311 Plaster Aplication of Spine (body jacket, minerva) Dengan Penyulit 9,651,000 24,070,000 33,721,000
312 Posterolateral Fusion / Alar Transverse Fusion 13,544,000 20,930,000 34,474,000
313 Posterolateral Fusion / Alar Transverse Fusion Dengan Penyulit 13,544,000 27,209,000 40,753,000
314 Prosedur Bonegraft 8,000,000 18,515,000 26,515,000
315 Prosedur Bonegraft Dengan Penyulit 8,000,000 24,070,000 32,070,000
316 Prosedur Bristow 15,875,000 39,374,000 55,249,000
317 Prosedur Bristow Dengan Penyulit 15,875,000 51,185,000 67,060,000
318 Prosedur release soft tissue kontraktur sendi elbow, knee 19,510,000 39,374,000 58,884,000
Prosedur release soft tissue kontraktur sendi elbow, knee Dengan
319 19,510,000 51,185,000 70,695,000
Penyulit
320 Prosedur Saha 15,866,000 43,643,000 59,509,000
321 Prosedur Saha Dengan Penyulit 15,866,000 56,736,000 72,602,000
322 Prosedur Steindler 15,866,000 43,643,000 59,509,000
323 Prosedur Steindler Dengan Penyulit 15,866,000 56,736,000 72,602,000
324 Proximal femur resection dan Megaprosthesis 19,510,000 66,413,000 85,923,000
325 Proximal femur resection dan Megaprosthesis Dengan Penyulit 19,510,000 86,337,000 105,847,000
326 Proximal row carpectomy 13,544,000 27,370,000 40,914,000
327 Proximal row carpectomy Dengan Penyulit 13,544,000 35,581,000 49,125,000
328 Radial head arthroplasty 14,530,000 42,694,000 57,224,000
329 Radial head arthroplasty Dengan Penyulit 14,530,000 55,502,000 70,032,000
330 Radical excision soft tissue sarcoma 16,513,000 42,694,000 59,207,000
331 Radical excision soft tissue sarcoma Dengan Penyulit 16,513,000 55,502,000 72,015,000
332 Recurrent Shoulder Dislocation Repair TUBS and AMBRI 15,875,000 39,374,000 55,249,000
Recurrent Shoulder Dislocation Repair TUBS and AMBRI Dengan
333 15,875,000 51,185,000 67,060,000
Penyulit
334 Rekonstruksi bifid thumb 15,866,000 38,899,000 54,765,000
335 Rekonstruksi bifid thumb Dengan Penyulit 15,866,000 50,569,000 66,435,000
336 Rekonstruksi DRUJ 16,513,000 37,950,000 54,463,000
337 Rekonstruksi DRUJ Dengan Penyulit 16,513,000 49,335,000 65,848,000
338 Rekonstruksi fraktur, dislokasi neglected ekstremitas atas pada anak 15,875,000 51,233,000 67,108,000
Rekonstruksi fraktur, dislokasi neglected ekstremitas atas pada anak
339 15,875,000 66,603,000 82,478,000
Dengan Penyulit
340 Rekonstruksi fraktur, dislokasi neglected ekstremitas bawah pada anak 15,875,000 51,233,000 67,108,000
Rekonstruksi fraktur, dislokasi neglected ekstremitas bawah pada anak
341 15,875,000 66,603,000 82,478,000
Dengan Penyulit
342 Rekonstruksi fraktur, dislokasi neglected jari, carpus, tangan, wrist 16,513,000 51,992,000 68,505,000
Rekonstruksi fraktur, dislokasi neglected jari, carpus, tangan, wrist
343 16,513,000 67,589,000 84,102,000
Dengan Penyulit
344 19,697,000 85,388,000 105,085,000
dengan vasculrized graft (microsurgery)
345 19,697,000 111,004,000 130,701,000
dengan vasculrized graft (microsurgery) Dengan Penyulit
Rekonstruksi fraktur, dislokasi neglected regio tangan, wrist / kaki,
346 16,513,000 51,992,000 68,505,000
ankle
347 16,513,000 67,589,000 84,102,000
ankle Dengan Penyulit
348 19,697,000 85,388,000 105,085,000
ankle dengan vasculrized graft (microsurgery)
349 19,697,000 111,004,000 130,701,000
ankle dengan vasculrized graft (microsurgery) Dengan Penyulit
Rekonstruksi fraktur, dislokasi neglected, malunion, nonunion
350 19,697,000 51,233,000 70,930,000
ekstremitas atas (bone, ligament)
JASA
PELAYANAN
351 19,697,000 72,105,000 91,802,000
ekstremitas atas (bone, ligament) dengan implantasi sel punca
352 ekstremitas atas (bone, ligament) dengan implantasi sel punca Dengan 19,697,000 93,737,000 113,434,000
Penyulit
353 19,697,000 66,603,000 86,300,000
ekstremitas atas (bone, ligament) Dengan Penyulit
354 19,697,000 61,669,000 81,366,000
ekstremitas bawah (bone, ligament)
355 19,697,000 80,644,000 100,341,000
ekstremitas bawah (bone, ligament) dengan implantasi sel punca
356 ekstremitas bawah (bone, ligament) dengan implantasi sel punca 19,697,000 104,837,000 124,534,000
Dengan Penyulit
357 19,697,000 80,170,000 99,867,000
ekstremitas bawah (bone, ligament) Dengan Penyulit
358 Rekonstruksi MPFL arthroscopy assisted 19,510,000 51,233,000 70,743,000
359 Rekonstruksi MPFL arthroscopy assisted Dengan Penyulit 19,510,000 66,603,000 86,113,000
360 Rekonstruksi neglected ruptur tendon fleksor stage 1 using spacer 9,651,000 20,930,000 30,581,000
Rekonstruksi neglected ruptur tendon fleksor stage 1 using spacer
361 9,651,000 27,209,000 36,860,000
Dengan Penyulit
362 Rekonstruksi neglected ruptur tendon fleksor stage 2 tendon graft 9,651,000 28,175,000 37,826,000
Rekonstruksi neglected ruptur tendon fleksor stage 2 tendon graft
363 9,651,000 36,628,000 46,279,000
Dengan Penyulit
Rekonstruksi pada kontraktur, deformitas jari kompleks (bouttonniere,
364 13,544,000 29,785,000 43,329,000
swan neck)
Rekonstruksi pada kontraktur, deformitas jari kompleks (bouttonniere,
365 13,544,000 38,721,000 52,265,000
swan neck) Dengan Penyulit
Rekonstruksi pada kontraktur, deformitas jari simpel (z-plasty, skin
366 13,544,000 29,785,000 43,329,000
graft, soft tissue release, dan lainnya)
Rekonstruksi pada kontraktur, deformitas jari simpel (z-plasty, skin
367 13,544,000 38,721,000 52,265,000
graft, soft tissue release, dan lainnya) Dengan Penyulit
368 Rekonstruksi panggul ekstrofi buli 16,513,000 51,233,000 67,746,000
369 Rekonstruksi panggul ekstrofi buli Dengan Penyulit 16,513,000 66,603,000 83,116,000
370 Rekonstruksi pulley 13,544,000 29,785,000 43,329,000
371 Rekonstruksi pulley Dengan Penyulit 13,544,000 38,721,000 52,265,000
Release CTS, Guyon tunnel, cubital tunnel, kompresi nerve lainnya
372 11,000,000 32,200,000 43,200,000
dengan neurolisis
Release CTS, Guyon tunnel, cubital tunnel, kompresi nerve lainnya
373 11,000,000 41,860,000 52,860,000
dengan neurolisis Dengan Penyulit
Release de quervain, CTS, Guyon tunnel, cubital tunnel dan kompresi
374 7,000,000 16,905,000 23,905,000
nerve lainnya
375 9,651,000 28,175,000 37,826,000
nerve lainnya bilateral
376 9,651,000 36,628,000 46,279,000
nerve lainnya bilateral Dengan Penyulit
377 7,000,000 21,977,000 28,977,000
nerve lainnya Dengan Penyulit
Release recurrent CTS, Guyon tunnel, cubital tunnel, kompresi nerve
378 13,544,000 37,030,000 50,574,000
lainnya
Release recurrent CTS, Guyon tunnel, cubital tunnel, kompresi nerve
379 13,544,000 48,139,000 61,683,000
lainnya Dengan Penyulit
380 Release Ring constriction 13,544,000 25,760,000 39,304,000
381 Release Ring constriction Dengan Penyulit 13,544,000 33,488,000 47,032,000
382 Release syndactyly 15,866,000 26,565,000 42,431,000
383 Release syndactyly Dengan Penyulit 15,866,000 34,535,000 50,401,000
384 Release tennis elbow 15,582,000 21,735,000 37,317,000
385 Release tennis elbow Dengan Penyulit 15,582,000 28,256,000 43,838,000
386 Release torticollis 13,607,000 39,374,000 52,981,000
387 Release torticollis Dengan Penyulit 13,607,000 51,185,000 64,792,000
388 Repair nail bed, skin laceration 8,000,000 23,345,000 31,345,000
389 Repair nail bed, skin laceration Dengan Penyulit 8,000,000 30,349,000 38,349,000
390 Repair nail bed, skin laceration multipel 8,000,000 26,565,000 34,565,000
391 Repair nail bed, skin laceration multipel Dengan Penyulit 8,000,000 34,535,000 42,535,000
392 Repair nerve, arteri simpel 15,582,000 29,785,000 45,367,000
393 Repair nerve, arteri simpel Dengan Penyulit 15,582,000 38,721,000 54,303,000
Repair nerve, vascular kompleks (nerve, vascular graft, multiple
394 15,582,000 61,669,000 77,251,000
injury)
Repair nerve, vascular kompleks (nerve, vascular graft, multiple
395 15,582,000 80,170,000 95,752,000
injury) Dengan Penyulit
JASA
PELAYANAN
396 Repair stump jari, regio tangan dengan flap kompleks 15,582,000 32,200,000 47,782,000
397 Repair stump jari, regio tangan dengan flap kompleks Dengan Penyulit 15,582,000 41,860,000 57,442,000
398 Repair stump jari, regio tangan dengan skin graft, flap simpel 13,544,000 24,150,000 37,694,000
Repair stump jari, regio tangan dengan skin graft, flap simpel Dengan
399 13,544,000 31,395,000 44,939,000
Penyulit
400 Repair stump primer amputasi jari, regio tangan 8,000,000 16,100,000 24,100,000
401 Repair stump primer amputasi jari, regio tangan Dengan Penyulit 8,000,000 20,930,000 28,930,000
402 Repair tendon fleksor, ekstensor kompleks (multipel, tendon graft) 15,582,000 32,200,000 47,782,000
Repair tendon fleksor, ekstensor kompleks (multipel, tendon graft)
403 15,582,000 41,860,000 57,442,000
Dengan Penyulit
404 Repair tendon fleksor, ekstensor simpel 9,651,000 20,930,000 30,581,000
405 Repair tendon fleksor, ekstensor simpel Dengan Penyulit 9,651,000 27,209,000 36,860,000
406 Replantasi ekstremitas (dengan atau tanpa microsurgery) 19,697,000 80,644,000 100,341,000
407 Replantasi ekstremitas (dengan atau tanpa microsurgery) 19,697,000 97,175,000 116,872,000
Replantasi ekstremitas (dengan atau tanpa microsurgery) Dengan
408 19,697,000 104,837,000 124,534,000
Penyulit
Replantasi ekstremitas (dengan atau tanpa microsurgery) Dengan
409 19,697,000 126,328,000 146,025,000
Penyulit
410 Reposisi dan fiksasi fraktur jari, carpus, tangan multipel 16,513,000 65,464,000 81,977,000
Reposisi dan fiksasi fraktur jari, carpus, tangan multipel Dengan
411 16,513,000 85,103,000 101,616,000
Penyulit
412 Reposisi dan fiksasi fraktur multipel 19,510,000 50,284,000 69,794,000
413 Reposisi dan fiksasi fraktur multipel Dengan Penyulit 19,510,000 65,369,000 84,879,000
414 Reposisi dan fiksasi fraktur multiple anak 19,510,000 65,464,000 84,974,000
415 Reposisi dan fiksasi fraktur multiple anak Dengan Penyulit 19,510,000 85,103,000 104,613,000
416 Reposisi dan fiksasi fraktur pelvis, sacrum 19,510,000 65,464,000 84,974,000
417 Reposisi dan fiksasi fraktur pelvis, sacrum Dengan Penyulit 19,510,000 85,103,000 104,613,000
418 Reposisi dan fiksasi fraktur regio tangan, wrist / kaki, ankle multipel 16,513,000 65,464,000 81,977,000
Reposisi dan fiksasi fraktur regio tangan, wrist / kaki, ankle multipel
419 16,513,000 85,103,000 101,616,000
Dengan Penyulit
420 Reposisi dan fiksasi interna fraktur salter harris 13,607,000 39,374,000 52,981,000
421 Reposisi dan fiksasi interna fraktur salter harris Dengan Penyulit 13,607,000 51,185,000 64,792,000
422 Reposisi dan pemasangan gips fraktur salter harris 9,651,000 24,955,000 34,606,000
423 Reposisi dan pemasangan gips fraktur salter harris Dengan Penyulit 9,651,000 32,442,000 42,093,000
424 Reposisi terbuka dan fiksasi eksternal fraktur anak 13,607,000 39,374,000 52,981,000
425 Reposisi terbuka dan fiksasi eksternal fraktur anak Dengan Penyulit 13,607,000 51,185,000 64,792,000
Reposisi terbuka dan fiksasi eksternal fraktur pelvis (C-clamp, anterior
426 19,510,000 23,345,000 42,855,000
frame)
Reposisi terbuka dan fiksasi eksternal fraktur pelvis (C-clamp, anterior
427 19,510,000 30,349,000 49,859,000
frame) Dengan Penyulit
Reposisi terbuka dan fiksasi eksternal fraktur tulang panjang (eksternal
428 15,582,000 20,930,000 36,512,000
fiksasi, skeletal traction)
Reposisi terbuka dan fiksasi eksternal fraktur tulang panjang (eksternal
429 15,582,000 27,209,000 42,791,000
fiksasi, skeletal traction) Dengan Penyulit
430 Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular anak 13,607,000 39,374,000 52,981,000
Reposisi terbuka dan fiksasi interna kasus fraktur intra artikular anak
431 13,607,000 51,185,000 64,792,000
Dengan Penyulit
Reposisi terbuka dan fiksasi internal fraktur regio tangan, wrist / kaki,
432 16,513,000 32,200,000 48,713,000
ankle
Reposisi terbuka dan fiksasi internal fraktur regio tangan, wrist / kaki,
433 16,513,000 41,860,000 58,373,000
ankle Dengan Penyulit
434 Reposisi terbuka dan fiksasi internal fraktur acetabulum 19,510,000 43,643,000 63,153,000
Reposisi terbuka dan fiksasi internal fraktur acetabulum Dengan
435 19,510,000 56,736,000 76,246,000
Penyulit
Reposisi terbuka dan fiksasi internal fraktur jari, carpus, tangan dan
436 16,513,000 32,200,000 48,713,000
wrist (distal radius, ulna)
Reposisi terbuka dan fiksasi internal fraktur jari, carpus, tangan dan
437 16,513,000 41,860,000 58,373,000
wrist (distal radius, ulna) Dengan Penyulit
438 Reposisi terbuka dan fiksasi internal fraktur tulang panjang (ORIF) 13,607,000 24,955,000 38,562,000
Reposisi terbuka dan fiksasi internal fraktur tulang panjang (ORIF)
439 13,607,000 32,442,000 46,049,000
Dengan Penyulit
440 Reposisi terbuka dan fiksasi internal fraktur tulang panjang anak 13,607,000 39,374,000 52,981,000
JASA
PELAYANAN
Reposisi terbuka dan fiksasi internal fraktur tulang panjang anak
441 13,607,000 51,185,000 64,792,000
Dengan Penyulit
Reposisi terbuka dan fiksasi internal fraktur tulang panjang minimal
442 15,582,000 28,497,000 44,079,000
invasive (IM Nail, MIPO, DHS, percutaneous pinning)
Reposisi terbuka dan fiksasi internal fraktur tulang panjang minimal
443 invasive (IM Nail, MIPO, DHS, percutaneous pinning) Dengan 15,582,000 37,047,000 52,629,000
Penyulit
444 Reposisi terbuka dan fiksasi internal kasus fraktur intra artikular 15,582,000 27,370,000 42,952,000
Reposisi terbuka dan fiksasi internal kasus fraktur intra artikular
445 15,582,000 35,581,000 51,163,000
Dengan Penyulit
446 Reposisi terbuka dengan acetabuloplasty dislokasi panggul, DDH 16,513,000 51,233,000 67,746,000
Reposisi terbuka dengan acetabuloplasty dislokasi panggul, DDH
447 16,513,000 66,603,000 83,116,000
Dengan Penyulit
Reposisi terbuka dengan acetabuloplasty dan VDRO dislokasi
448 19,510,000 65,464,000 84,974,000
panggul, DDH
Reposisi terbuka dengan acetabuloplasty dan VDRO dislokasi
449 19,510,000 85,103,000 104,613,000
panggul, DDH Dengan Penyulit
450 Reposisi terbuka tanpa acetabuloplasty dislokasi panggul, DDH 13,607,000 39,374,000 52,981,000
Reposisi terbuka tanpa acetabuloplasty dislokasi panggul, DDH
451 13,607,000 51,185,000 64,792,000
Dengan Penyulit
Reposisi tertutup dan fiksasi percutaneous fraktur regio tangan, wrist /
452 13,544,000 28,175,000 41,719,000
kaki, ankle
Reposisi tertutup dan fiksasi percutaneous fraktur regio tangan, wrist /
453 13,544,000 36,628,000 50,172,000
kaki, ankle Dengan Penyulit
454 Reposisi tertutup dan pemasangan gips fraktur anak 9,651,000 24,955,000 34,606,000
455 Reposisi tertutup dan pemasangan gips fraktur anak Dengan Penyulit 9,651,000 32,442,000 42,093,000
456 Reposisi tertutup dan pemasangan hemispica fraktur femur anak 9,651,000 24,955,000 34,606,000
Reposisi tertutup dan pemasangan hemispica fraktur femur anak
457 9,651,000 32,442,000 42,093,000
Dengan Penyulit
458 Reposisi tertutup dan pemasangan splint, gips pada fraktur, dislokasi 8,000,000 16,905,000 24,905,000
Reposisi tertutup dan pemasangan splint, gips pada fraktur, dislokasi
459 8,000,000 21,977,000 29,977,000
Dengan Penyulit
Reposisi tertutup dan percutaneous pinning fraktur jari, carpus, tangan
460 13,544,000 28,175,000 41,719,000
dan wris(distal radius, ulna)t
Reposisi tertutup dan percutaneous pinning fraktur jari, carpus, tangan
461 13,544,000 36,628,000 50,172,000
dan wris(distal radius, ulna)t Dengan Penyulit
Reposisi tertutup dan percutaneous pinning pada fraktur seputar sendi
462 13,607,000 39,374,000 52,981,000
siku pada anak
Reposisi tertutup dan percutaneous pinning pada fraktur seputar sendi
463 13,607,000 51,185,000 64,792,000
siku pada anak Dengan Penyulit
Reposisi tertutup dan splint fraktur jari, carpus, tangan dan wrist
464 9,651,000 17,710,000 27,361,000
(distal radius, ulna)
Reposisi tertutup dan splint fraktur jari, carpus, tangan dan wrist
465 9,651,000 23,023,000 32,674,000
(distal radius, ulna) Dengan Penyulit
466 Reposisi tertutup dan splint fraktur regio tangan, wrist / kaki, ankle 9,651,000 17,710,000 27,361,000
Reposisi tertutup dan splint fraktur regio tangan, wrist / kaki, ankle
467 9,651,000 23,023,000 32,674,000
Dengan Penyulit
Reposisis Tertutup, Arthogram dan Hemispica dislokasi panggul,
468 12,418,000 24,955,000 37,373,000
DDH
Reposisis Tertutup, Arthogram dan Hemispica dislokasi panggul,
469 12,418,000 32,442,000 44,860,000
DDH Dengan Penyulit
470 Sacrectomy 19,510,000 66,413,000 85,923,000
471 Sacrectomy Dengan Penyulit 19,510,000 86,337,000 105,847,000
472 Shoulder Arthroscopy diagnostic, debridement 13,607,000 24,955,000 38,562,000
473 Shoulder Arthroscopy diagnostic, debridement Dengan Penyulit 13,607,000 32,442,000 46,049,000
474 Shoulder Arthroscopy rotator cuff repair 15,875,000 65,464,000 81,339,000
475 Shoulder Arthroscopy rotator cuff repair Dengan Penyulit 15,875,000 85,103,000 100,978,000
476 Shoulder disarticulation 15,582,000 37,950,000 53,532,000
477 Shoulder Disarticulation 16,513,000 37,950,000 54,463,000
478 Shoulder Disarticulation Dengan Penyulit 16,513,000 49,335,000 65,848,000
479 Shoulder disarticulation Dengan Penyulit 15,582,000 49,335,000 64,917,000
480 Shoulder reconstruction revision procedure 19,510,000 49,594,000 69,104,000
481 Shoulder reconstruction revision procedure 19,510,000 49,594,000 69,104,000
482 Shoulder reconstruction revision procedure Dengan Penyulit 19,510,000 64,472,000 83,982,000
483 Shoulder reconstruction revision procedure Dengan Penyulit 19,510,000 64,472,000 83,982,000
484 Soft tissue debulking macrodactily 15,866,000 27,370,000 43,236,000
JASA
PELAYANAN
Soft tissue debulking macrodactily dengan diseksi neurovaskular
485 15,582,000 42,694,000 58,276,000
(microsurgery)
Soft tissue debulking macrodactily dengan diseksi neurovaskular
486 15,582,000 55,502,000 71,084,000
(microsurgery) Dengan Penyulit
487 Soft tissue debulking macrodactily Dengan Penyulit 15,866,000 35,581,000 51,447,000
488 Soft tissue defect closure dengan flap island, distant flap 15,582,000 46,489,000 62,071,000
Soft tissue defect closure dengan flap island, distant flap Dengan
489 15,582,000 60,436,000 76,018,000
Penyulit
490 Soft tissue defect closure dengan flap perforator, propeller 15,582,000 55,028,000 70,610,000
Soft tissue defect closure dengan flap perforator, propeller Dengan
491 15,582,000 71,536,000 87,118,000
Penyulit
492 Soft tissue defect closure dengan free flap (microsurgery) 19,697,000 80,644,000 100,341,000
Soft tissue defect closure dengan free flap (microsurgery) Dengan
493 19,697,000 104,837,000 124,534,000
Penyulit
494 Soft tissue defect closure dengan STSG, FTSG, flap simpel 15,582,000 29,785,000 45,367,000
Soft tissue defect closure dengan STSG, FTSG, flap simpel Dengan
495 15,582,000 38,721,000 54,303,000
Penyulit
496 Soft tissue defect closure flap harvesting 9,651,000 26,565,000 36,216,000
497 Soft tissue defect closure flap harvesting Dengan Penyulit 9,651,000 34,535,000 44,186,000
498 Soft Tissue Procedure CTEV 13,544,000 51,233,000 64,777,000
499 Soft Tissue Procedure CTEV Dengan Penyulit 13,544,000 66,603,000 80,147,000
Soft Tissue Release dan Enhancement pada Kasus Fraktur Habitual
500 13,607,000 39,374,000 52,981,000
Dislokasi Lutut pada Anak
Soft Tissue Release dan Enhancement pada Kasus Fraktur Habitual
501 13,607,000 51,185,000 64,792,000
Dislokasi Lutut pada Anak Dengan Penyulit
Soft Tisue Release pada Kelainan Cerebral Palsy, Arthrogryposis,
502 13,607,000 39,374,000 52,981,000
Spina Bifida
Soft Tisue Release pada Kelainan Cerebral Palsy, Arthrogryposis,
503 13,607,000 51,185,000 64,792,000
Spina Bifida Dengan Penyulit
504 Spinal endoscopy (PELD, PLDD, etc) 15,582,000 50,284,000 65,866,000
505 Spinal endoscopy (PELD, PLDD, etc) Dengan Penyulit 15,582,000 65,369,000 80,951,000
506 Spinal endoscopy (PELD, PLDD, etc) multilevel 15,582,000 65,464,000 81,046,000
507 Spinal endoscopy (PELD, PLDD, etc) multilevel Dengan Penyulit 15,582,000 85,103,000 100,685,000
508 Spinal Osteotomy 19,697,000 53,130,000 72,827,000
509 Spinal Osteotomy Dengan Penyulit 19,697,000 69,069,000 88,766,000
510 Spinal traction (Halo, gardner well tong) 15,582,000 23,345,000 38,927,000
511 Spinal traction (Halo, gardner well tong) Dengan Penyulit 15,582,000 30,349,000 45,931,000
512 STSG 13,544,000 37,950,000 51,494,000
513 STSG Dengan Penyulit 13,544,000 49,335,000 62,879,000
514 Synovectomy knee joint/elbow 15,582,000 27,370,000 42,952,000
515 Synovectomy knee joint/elbow Dengan Penyulit 15,582,000 35,581,000 51,163,000
516 Synovectomy regio poplitea 15,582,000 21,735,000 37,317,000
517 Synovectomy regio poplitea Dengan Penyulit 15,582,000 28,256,000 43,838,000
518 Tendon transfer ekstremitas bawah 13,607,000 39,374,000 52,981,000
519 Tendon transfer ekstremitas bawah Dengan Penyulit 13,607,000 51,185,000 64,792,000
520 Tendon transfer ekstremitas bawah neuromuscular disease 13,607,000 39,374,000 52,981,000
Tendon transfer ekstremitas bawah neuromuscular disease Dengan
521 13,607,000 51,185,000 64,792,000
Penyulit
522 Tendon transfer regio tangan 15,582,000 30,590,000 46,172,000
523 Tendon transfer regio tangan Dengan Penyulit 15,582,000 39,767,000 55,349,000
524 Total Ankle Arthroplasty primer 19,697,000 39,374,000 59,071,000
525 Total Ankle Arthroplasty primer Dengan Penyulit 19,697,000 51,185,000 70,882,000
526 Total Ankle Arthroplasty revisi 19,697,000 65,464,000 85,161,000
527 Total Ankle Arthroplasty revisi Dengan Penyulit 19,697,000 85,103,000 104,800,000
528 Total Contact Cast 8,000,000 15,054,000 23,054,000
529 Total Contact Cast Dengan Penyulit 8,000,000 19,570,000 27,570,000
530 Total Disc Replacement 19,697,000 50,284,000 69,981,000
531 Total Disc Replacement Dengan Penyulit 19,697,000 65,369,000 85,066,000
532 Total Disc Replacement multilevel 19,697,000 65,464,000 85,161,000
533 Total Disc Replacement multilevel Dengan Penyulit 19,697,000 85,103,000 104,800,000
534 Total Elbow Arthroplasty primer 13,607,000 39,374,000 52,981,000
535 Total Elbow Arthroplasty primer Dengan Penyulit 13,607,000 51,185,000 64,792,000
536 Total Elbow Arthroplasty revisi 19,697,000 65,464,000 85,161,000
537 Total Elbow Arthroplasty revisi Dengan Penyulit 19,697,000 85,103,000 104,800,000
538 Total femur resection dan Megaprosthesis 19,510,000 80,644,000 100,154,000
539 Total femur resection dan Megaprosthesis Dengan Penyulit 19,510,000 104,837,000 124,347,000
540 Total Hip Arthroplasty primer 15,582,000 39,374,000 54,956,000
541 Total Hip Arthroplasty primer Dengan Penyulit 15,582,000 51,185,000 66,767,000
542 Total Hip Arthroplasty revisi 19,697,000 65,464,000 85,161,000
543 Total Hip Arthroplasty revisi Dengan Penyulit 19,697,000 85,103,000 104,800,000
JASA
PELAYANAN
544 Total Knee Arthroplasty primer 15,875,000 39,374,000 55,249,000
545 Total Knee Arthroplasty primer Dengan Penyulit 15,875,000 51,185,000 67,060,000
546 Total Knee Arthroplasty revisi 19,697,000 65,464,000 85,161,000
547 Total Knee Arthroplasty revisi Dengan Penyulit 19,697,000 85,103,000 104,800,000
548 Total Shoulder Arthroplasty primer 13,607,000 39,374,000 52,981,000
549 Total Shoulder Arthroplasty primer Dengan Penyulit 13,607,000 51,185,000 64,792,000
550 Total Shoulder Arthroplasty revisi 19,697,000 65,464,000 85,161,000
551 Total Shoulder Arthroplasty revisi Dengan Penyulit 19,697,000 85,103,000 104,800,000
552 Total Wrist Arthroplasty primer 13,607,000 39,374,000 52,981,000
553 Total Wrist Arthroplasty primer Dengan Penyulit 13,607,000 51,185,000 64,792,000
554 Total Wrist Arthroplasty revisi 19,697,000 65,464,000 85,161,000
555 Total Wrist Arthroplasty revisi Dengan Penyulit 19,697,000 85,103,000 104,800,000
556 Transposisi nervus ulnaris 15,582,000 38,899,000 54,481,000
557 Transposisi nervus ulnaris Dengan Penyulit 15,582,000 50,569,000 66,151,000
558 Wide excision soft tissue sarcoma ekstremitas atas 16,513,000 37,950,000 54,463,000
559 Wide excision soft tissue sarcoma ekstremitas atas Dengan Penyulit 16,513,000 49,335,000 65,848,000
560 Wide excision soft tissue tumor ekstremitas bawah 15,582,000 37,950,000 53,532,000
561 Wide excision soft tissue tumor ekstremitas bawah Dengan Penyulit 15,582,000 49,335,000 64,917,000
562 Wide excision soft tissue tumor regio poplitea 15,582,000 37,950,000 53,532,000
563 Wide excision soft tissue tumor regio poplitea Dengan Penyulit 15,582,000 49,335,000 64,917,000
564 Wide excision/radical excision soft tissue tumor ekstremitas atas 15,582,000 27,370,000 42,952,000
Wide excision/radical excision soft tissue tumor ekstremitas atas
565 15,582,000 35,581,000 51,163,000
Dengan Penyulit
566 Wrist arthroscopy diagnostic, debridement 19,510,000 51,233,000 70,743,000
567 Wrist arthroscopy diagnostic, debridement Dengan Penyulit 19,510,000 66,603,000 86,113,000
568 Wrist arthroscopy rekonstruksi ligamen, TFCC 19,510,000 51,233,000 70,743,000
569 Wrist arthroscopy rekonstruksi ligamen, TFCC Dengan Penyulit 19,510,000 66,603,000 86,113,000
570 Wrist nerve denervation carpal instability 13,544,000 27,370,000 40,914,000
571 Wrist nerve denervation carpal instability Dengan Penyulit 13,544,000 35,581,000 49,125,000
572 Wrist reconstruction revision procedure 19,510,000 49,594,000 69,104,000
573 Wrist reconstruction revision procedure Dengan Penyulit 19,510,000 64,472,000 83,982,000
6.11 URONEPHRO
1 BIOPSI PROSTAT ROBOTIK 3,202,000 6,440,000 9,642,000
2 Debridement 6,399,000 4,255,000 10,654,000
3 Debridement dengan Anestesi 6,399,000 5,735,000 12,134,000
4 Khusus III - Laparoskopi Parsial Nefrektomi 35,443,000 66,413,000 101,856,000
5 Operasi Besar II Debridement Gangren Fournier Bilateral + Anes 16,507,000 28,336,000 44,843,000
6 Operasi Besar Bucal Mucosa Graft 16,507,000 27,280,000 43,787,000
7 Operasi Besar Eksisi condiloma sederhana 10,631,000 17,050,000 27,681,000
8 Operasi Besar Evakuasi Hematom 10,631,000 17,050,000 27,681,000
9 Operasi Besar Full Thickness Skin Graft 10,631,000 17,050,000 27,681,000
10 Operasi Besar Glanduloplasty 10,631,000 17,050,000 27,681,000
11 Operasi Besar Tutup Defek Primer 10,631,000 17,050,000 27,681,000
12 OPERASI BESAR -EKSISI PUNIKOKEL 16,507,000 17,710,000 34,217,000
13 OPERASI BESAR -HIDROKEL 16,507,000 17,710,000 34,217,000
14 OPERASI BESAR I -BIOPSI GINJAL TERBUKA + ANES 16,507,000 17,710,000 34,217,000
OPERASI BESAR I -BIOPSI GINJAL TERBUKA + ANES
15 16,507,000 28,336,000 44,843,000
BILATERAL
16 OPERASI BESAR I -EKSISI DIVERTIKEL URETRA + ANES 16,507,000 17,710,000 34,217,000
17 OPERASI BESAR I -EKSISI WEBBED PENIS + ANES 11,075,000 17,710,000 28,785,000
18 OPERASI BESAR I -ORKHIDEKTOMI LIGASI TINGGI + ANES 16,507,000 17,710,000 34,217,000
19 OPERASI BESAR I -ORKHIDEKTOMI LIGASI TINGGI + ANES 16,507,000 17,710,000 34,217,000

OPERASI BESAR I -ORKHIDEKTOMI LIGASI TINGGI + ANES
20 16,507,000 28,336,000 44,843,000
BILATERAL
OPERASI BESAR I -REKONSTRUKSI TRANSPOSISI
21 16,507,000 17,710,000 34,217,000
PENOSKROTAL + ANES
22 OPERASI BESAR I -REPAIR VISTEL VESIKOKUTAN + ANES 16,507,000 17,710,000 34,217,000
23 OPERASI BESAR I -TORSIO TESTIS + ANES 16,507,000 17,710,000 34,217,000
24 OPERASI BESAR I -TORSIO TESTIS + ANES BILATERAL 16,507,000 28,336,000 44,843,000
OPERASI BESAR I -UNROOFING/DEROOFING KISTA GINJAL
25 16,507,000 17,710,000 34,217,000
+ ANES
OPERASI BESAR I -UNROOFING/DEROOFING KISTA GINJAL
26 16,507,000 28,336,000 44,843,000
+ ANES BILATERAL
27 OPERASI BESAR I -URETEROLISIS + ANES BILATERAL 16,507,000 28,336,000 44,843,000
JASA
PELAYANAN
28 OPERASI BESAR I -URETEROLITOTOMI + ANES 16,507,000 17,710,000 34,217,000
29 OPERASI BESAR I -URETEROLITOTOMI + ANES BILATERAL 16,507,000 28,336,000 44,843,000
30 OPERASI BESAR I -URETEROLYSIS + ANES 16,507,000 17,710,000 34,217,000
OPERASI BESAR II -DEBRIDEMENT GANGREN FOURNIER +
31 16,507,000 17,710,000 34,217,000
ANES
32 OPERASI BESAR II -HIDROKEL LIGASI TINGGI + ANES 16,507,000 17,710,000 34,217,000
OPERASI BESAR II -HIDROKEL LIGASI TINGGI + ANES
33 16,507,000 28,336,000 44,843,000
BILATERAL
34 OPERASI BESAR II -INSERS DJ STENT + ANES 10,631,000 17,710,000 28,341,000
35 OPERASI BESAR II -INSERS DJ STENT + ANES BILATERAL 16,507,000 28,336,000 44,843,000
36 OPERASI BESAR II -LAPAROTOMI EKSPLORASI + ANES 16,507,000 17,710,000 34,217,000
37 OPERASI BESAR II -NEFROPEKSI + ANES 16,507,000 17,710,000 34,217,000
38 OPERASI BESAR II -NEFROPEKSI + ANES BILATERAL 16,507,000 28,336,000 44,843,000
OPERASI BESAR II -NEFROSTOMI TERBUKA/PERMANEN +
39 16,507,000 17,710,000 34,217,000
ANES
OPERASI BESAR II -NEFROSTOMI TERBUKA/PERMANEN +
40 16,507,000 28,336,000 44,843,000
ANES BILATERAL
41 OPERASI BESAR II -PENEKTOMI + ANES 16,507,000 17,710,000 34,217,000
42 OPERASI BESAR II -PIELOLITOTOMI + ANES 16,507,000 17,710,000 34,217,000
43 OPERASI BESAR II -PIELOLITOTOMI + ANES BILATERAL 16,507,000 28,336,000 44,843,000
44 OPERASI BESAR II -PROSTATEKTOMI TERBUKA + ANES 16,507,000 17,710,000 34,217,000
45 OPERASI BESAR II -REPAIR FISTEL URETROKUTAN + ANES 16,507,000 17,710,000 34,217,000
46 OPERASI BESAR II -REPAIR TRAUMA BULI-BULI + ANES 16,507,000 17,710,000 34,217,000
OPERASI BESAR II -REPAIR TRAUMA BULI-BULI + ANES +
47 16,507,000 17,710,000 34,217,000
Asisten
48 OPERASI BESAR II -REPAIR TRAUMA URETRA + ANES 16,507,000 17,710,000 34,217,000
49 OPERASI BESAR II -RESEKSI ANASTOMOSIS URETER + ANES 16,507,000 17,710,000 34,217,000
OPERASI BESAR II -RESEKSI DAN ANASTOMOSIS URETER +
50 16,507,000 28,336,000 44,843,000
ANES BILATERAL
OPERASI BESAR II -SISTOSKOPI DAN EVAKUASI BEKUAN
51 10,631,000 17,710,000 28,341,000
DARAH (CLOT) + ANES
52 OPERASI BESAR II-PUBEKTOMI INFERIOR 16,507,000 17,710,000 34,217,000
53 OPERASI BESAR -OPEN RENAL BIOPSI 19,646,000 17,710,000 37,356,000
54 OPERASI BESAR -ORCHIDEKTOMI 16,931,000 17,710,000 34,641,000
55 OPERASI BESAR -PYELOLITOTOMI 16,507,000 17,710,000 34,217,000
56 OPERASI BESAR -SECTIO ALTA 19,646,000 17,710,000 37,356,000
57 OPERASI BESAR -SECTIO ALTA + Asistensi 16,931,000 17,710,000 34,641,000
58 OPERASI BESAR -SPERMATOKEL 16,507,000 17,710,000 34,217,000
59 OPERASI BESAR -URETEROSTOMI 19,646,000 17,710,000 37,356,000
60 OPERASI KECIL AFF DJ STENT 6,399,000 4,477,000 10,876,000
61 OPERASI KECIL -APG 5,399,000 4,477,000 9,876,000
62 OPERASI KECIL -APG (PUNKSI PERKUTAN) + ANES 6,399,000 5,957,000 12,356,000
63 OPERASI KECIL CABUT DJ STENT (AFF DJ STENT) 6,399,000 7,164,000 13,563,000
OPERASI KECIL -CABUT DJ STENT (AFF DJ STENT)
64 6,399,000 9,532,000 15,931,000
BILATERAL
65 OPERASI KECIL -DILATASI/KALIBRASI URETRA + ANES 10,631,000 5,957,000 16,588,000
66 OPERASI KECIL -DORSUMSISI 6,399,000 4,477,000 10,876,000
67 OPERASI KECIL DORSUMSISI + ANES 6,935,000 5,957,000 12,892,000
68 OPERASI KECIL -HECTING + ANES 6,935,000 5,957,000 12,892,000
69 OPERASI KECIL -INSISI DRAINAGE ABSES 6,399,000 4,477,000 10,876,000
70 OPERASI KECIL -INSISI/DRAINAGE ABSES + ANES 6,935,000 5,957,000 12,892,000
71 OPERASI KECIL -MEATOPLASTY 6,399,000 4,477,000 10,876,000
72 OPERASI KECIL MEATOPLASTY + ANES 6,399,000 5,957,000 12,356,000
73 OPERASI KECIL -MEATOTOMI 6,399,000 4,477,000 10,876,000
74 OPERASI KECIL MEATOTOMI + ANES 6,399,000 5,957,000 12,356,000
75 OPERASI KECIL -SEKUNDER HECTING 6,399,000 4,477,000 10,876,000
76 OPERASI KECIL -SIRKUMSISI 6,399,000 4,477,000 10,876,000
77 OPERASI KECIL SIRKUMSISI + ANES 6,935,000 5,957,000 12,892,000
78 OPERASI KECIL SIRKUMSISI + ANES + Asist 6,399,000 5,957,000 12,356,000
79 OPERASI KECIL -VASEKTOMI 6,399,000 4,477,000 10,876,000
80 OPERASI KECIL VASEKTOMI + ANES 6,399,000 5,957,000 12,356,000
81 OPERASI KECIL -VCUG 1,200,000 4,255,000 5,455,000
82 OPERASI KECIL -VCUG + ANES 2,200,000 5,957,000 8,157,000
83 OPERASI KHUSUS I - LAPAROSKOPI INSERSI TENCKHOFF 13,351,000 19,320,000 32,671,000
84 OPERASI KHUSUS I (NARKOSE) -BNI 13,351,000 19,320,000 32,671,000
85 OPERASI KHUSUS I (NARKOSE) -INSISI URETROKEL 13,351,000 19,320,000 32,671,000
JASA
PELAYANAN
86 OPERASI KHUSUS I (NARKOSE) -INTERNA UREHTHROTOMI 13,351,000 19,320,000 32,671,000
87 OPERASI KHUSUS I (NARKOSE) -OTIS 13,347,000 19,320,000 32,667,000
88 OPERASI KHUSUS I (NARKOSE) -PESA TESE 13,791,000 19,320,000 33,111,000
89 OPERASI KHUSUS I (NARKOSE) -PESA TESE-ASISTEN 13,791,000 19,320,000 33,111,000
OPERASI KHUSUS I (NARKOSE) -PROSTATEKTOMI
90 19,646,000 17,710,000 37,356,000
RETROPUBIK
91 OPERASI KHUSUS I (NARKOSE) -TUR BULI 13,351,000 19,320,000 32,671,000
92 OPERASI KHUSUS I (NARKOSE) -UREHTHROTOMI 13,351,000 19,320,000 32,671,000
93 OPERASI KHUSUS I (NARKOSE) -VULGURASI URETHRA 13,351,000 19,320,000 32,671,000
94 OPERASI KHUSUS I -BLADDER NECK INSISI + ANES 13,351,000 19,320,000 32,671,000
95 OPERASI KHUSUS I -DIVERTIKULEKTOMI BULI-BULI + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -EKSISI CHORDEE/CHORDEKTOMY +
96 13,351,000 19,320,000 32,671,000
ANES
97 OPERASI KHUSUS I -EXTENDED PYELOLITHOTOMI + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -FULGURASI/ABIASI/KATUP URETRA
98 13,351,000 19,320,000 32,671,000
POSTERIOR PER ENDOSKOPI + ANES
99 OPERASI KHUSUS I -GANTI NEFROSTOMI 12,351,000 13,800,000 26,151,000
100 OPERASI KHUSUS I -GANTI NEFROSTOMI + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -GANTI NEFROSTOMI + ANES
101 13,351,000 30,912,000 44,263,000
BILATERAL
102 OPERASI KHUSUS I -GANTI NEFROSTOMI BILATERAL 13,351,000 30,912,000 44,263,000
103 OPERASI KHUSUS I -KOREKSI PRIAPISMUS + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -LAPAROSKOPI
104 13,351,000 19,320,000 32,671,000
DEROOFING/UNROOFING KISTA GINJAL + ANES
OPERASI KHUSUS I -LAPAROSKOPI
105 13,351,000 30,912,000 44,263,000
DEROOFING/UNROOFING KISTA GINJAL + ANES BILATERAL
106 OPERASI KHUSUS I -LAPAROSKOPI DIAGNOSTIK + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -LAPAROSKOPI EKSISI REMNANT
107 13,351,000 19,320,000 32,671,000
DUKTUS MULLERI + ANES
108 OPERASI KHUSUS I -LAPAROSKOPI ORCHIDOPEKSI + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -LAPAROSKOPI ORCHIDOPEKSI + ANES
109 13,351,000 30,912,000 44,263,000
BILATERAL
110 OPERASI KHUSUS I -LITHOTRIPSI BATU BULI-BULI + ANES 13,351,000 19,320,000 32,671,000
111 OPERASI KHUSUS I -NEFROSTOMI PERKUTAN 12,351,000 13,800,000 26,151,000
112 OPERASI KHUSUS I -NEFROSTOMI PERKUTAN + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -NEFROSTOMI PERKUTAN + ANES
113 13,351,000 30,912,000 44,263,000
BILATERAL
114 OPERASI KHUSUS I -NEFROSTOMI PERKUTAN BILATERAL 12,351,000 22,080,000 34,431,000
115 OPERASI KHUSUS I -ORCHIDOPEKSI UDT + ANES 13,791,000 27,370,000 41,161,000
116 OPERASI KHUSUS I -ORCHIDOPEKSI UDT + ANES + Asist 13,791,000 16,696,000 30,487,000
OPERASI KHUSUS I -ORCHIDOPEKSI UDT + ANES
117 13,791,000 30,053,000 43,844,000
BILATERAL
118 OPERASI KHUSUS I -PENEKTOMI TOTAL + ANES 13,791,000 19,320,000 33,111,000
119 OPERASI KHUSUS I -PIELOKALIKOTOMI + ANES BILATERAL 13,351,000 30,912,000 44,263,000
120 OPERASI KHUSUS I -PIELOKALIKOTOMI +ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -PRIMARY ENDOSCOPIC REALIGNMENT
121 13,351,000 19,320,000 32,671,000
URETHRA PASCATRAUMA + ANES
122 OPERASI KHUSUS I -PUNKSI KISTA GINJAL 12,351,000 13,800,000 26,151,000
123 OPERASI KHUSUS I -PUNKSI KISTA GINJAL + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -PUNKSI KISTA GINJAL + ANES
124 13,351,000 30,912,000 44,263,000
BILATERAL
125 OPERASI KHUSUS I -PUNKSI KISTA GINJAL BILATERAL 13,351,000 30,912,000 44,263,000
126 OPERASI KHUSUS I -REPAIR FRAKTUR PENIS + ANES 13,351,000 19,320,000 32,671,000
127 OPERASI KHUSUS I -RESEKSI URACHUS + ANES 13,351,000 19,320,000 32,671,000
128 OPERASI KHUSUS I -SISTEKTOMI PARSIAL + ANES 13,351,000 19,320,000 32,671,000
129 OPERASI KHUSUS I -SISTOKEL + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -TRANSURETEROURETEROSTOMI +
130 13,351,000 19,320,000 32,671,000
ANES
131 OPERASI KHUSUS I -TRAUMA GINJAL + ANES 13,351,000 19,320,000 32,671,000
132 OPERASI KHUSUS I -TRAUMA GINJAL + ANES BILATERAL 13,351,000 30,912,000 44,263,000
133 OPERASI KHUSUS I -TUR PROSTAT + ANES 13,351,000 19,320,000 32,671,000
JASA
PELAYANAN
134 OPERASI KHUSUS I -TUR PROSTAT + ANES (Asisten) 13,351,000 19,320,000 32,671,000
135 OPERASI KHUSUS I -TUR TUMOR BULI-BULI + ANES 13,351,000 19,320,000 32,671,000
136 OPERASI KHUSUS I -URETEROKUTANEOSTOMI + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -URETEROKUTANEOSTOMI + ANES
137 13,351,000 30,912,000 44,263,000
BILATERAL
138 OPERASI KHUSUS I -URETEROLITHOTOMY DISTAL + ANES 13,351,000 19,320,000 32,671,000
OPERASI KHUSUS I -URETEROLITHOTOMY DISTAL + ANES
139 13,351,000 30,912,000 44,263,000
BILATERAL
140 OPERASI KHUSUS I -URETHROSKOPI SACHSE + ANES 13,347,000 19,320,000 32,667,000
OPERASI KHUSUS I -URS LITHOTRIPSY BATU URETER +
141 13,351,000 19,320,000 32,671,000
ANES
OPERASI KHUSUS I -URS LITHOTRIPSY BATU URETER +
142 13,351,000 30,912,000 44,263,000
ANES BILATERAL
143 OPERASI KHUSUS II - BOARI FLAP + ANES BILATERAL 13,791,000 51,612,000 65,403,000
144 Operasi Khusus II HEMINEFREKTOMI 19,646,000 31,000,000 50,646,000
145 OPERASI KHUSUS II - LAPAROSKOPI NEFREKTOMI 19,646,000 48,387,000 68,033,000
146 OPERASI KHUSUS II - NEFREKTOMI 19,646,000 32,258,000 51,904,000
147 Operasi Khusus II OPERASI MITROFANOFF 19,646,000 31,000,000 50,646,000
148 OPERASI KHUSUS II - URETROTOMI 13,791,000 32,258,000 46,049,000
149 OPERASI KHUSUS II (NARKOSE) -EKSISI CORDHEAE 13,791,000 32,258,000 46,049,000
150 OPERASI KHUSUS II (NARKOSE) -EPIDIDIMOVASOSTOMI 13,791,000 32,258,000 46,049,000
OPERASI KHUSUS II (NARKOSE) -LONGITUDINAL
151 13,791,000 32,258,000 46,049,000
NEFROLITHOTOMI
OPERASI KHUSUS II (NARKOSE) -REKONSTRUKSI
152 13,791,000 32,258,000 46,049,000
BLASSEMECK
OPERASI KHUSUS II (NARKOSE) -REPAIR FISTULA VESICA
153 13,791,000 32,258,000 46,049,000
VAGINAL
154 OPERASI KHUSUS II (NARKOSE) -RESEKSI PARTIAL VESICA 13,791,000 32,258,000 46,049,000
OPERASI KHUSUS II (NARKOSE) -SISTOPLASTI
155 13,791,000 32,258,000 46,049,000
SIGMOIDOSTOMI
156 OPERASI KHUSUS II (NARKOSE) -URETERO URETROSTOMI 13,791,000 32,258,000 46,049,000
157 Operasi Khusus II Aff Penile Prosthesis 19,646,000 31,000,000 50,646,000
OPERASI KHUSUS II -BLADDER NECK REKONSTRUKSI +
158 13,791,000 32,258,000 46,049,000
ANES
159 OPERASI KHUSUS II -BOARI FLAP + ANES 13,791,000 32,258,000 46,049,000
160 Operasi Khusus II Clitoroplasty 19,646,000 31,000,000 50,646,000
161 Operasi Khusus II CYTOREDUCTIVE NEFREKTOMI 19,646,000 31,000,000 50,646,000
OPERASI KHUSUS II -DISEKSI KELENJAR GETAH BENING
162 13,791,000 32,258,000 46,049,000
INGUINAL + ANES
163 Operasi Khusus II Eksisi condiloma komplek 13,351,000 18,600,000 31,951,000
164 OPERASI KHUSUS II -EKSISI PARAFINOMA PENIS + ANES 13,791,000 32,258,000 46,049,000
165 OPERASI KHUSUS II -EKSISI PARAFINOMA PENIS + ANES 13,791,000 32,258,000 46,049,000
Operasi Khusus II EKSPLORASI TESTIS (MICROSURGERY &
166 19,646,000 31,000,000 50,646,000
BILATERAL)
OPERASI KHUSUS II -EKSPLORASI TESTIS (MICROSURGERY)
167 13,791,000 32,258,000 46,049,000
+ ANES
OPERASI KHUSUS II -EKSPLORASI TESTIS (MICROSURGERY)
168 13,791,000 51,612,000 65,403,000
+ ANES BILATERAL
169 Operasi Khusus II Endopyelolitotomi interna (unilateral) 13,351,000 18,600,000 31,951,000
170 Operasi Khusus II Fascial Sling 19,646,000 31,000,000 50,646,000
171 OPERASI KHUSUS II -ILEAL CONDUIT (BRICKER) + ANES 13,791,000 32,258,000 46,049,000
172 Operasi Khusus II Injeksi Botox Intravesika 13,351,000 18,600,000 31,951,000
173 Operasi Khusus II Injeksi Debulking Agent 13,351,000 18,600,000 31,951,000
174 OPERASI KHUSUS II -KOREKSI PROLAPS + ANES 13,791,000 32,258,000 46,049,000
OPERASI KHUSUS II -KOREKSI STRESS INCONTINENCE +
175 13,791,000 32,258,000 46,049,000
ANES
176 OPERASI KHUSUS II -LAPAROSKOPI PYELOPLASTY + ANES 19,646,000 48,387,000 68,033,000
OPERASI KHUSUS II -LAPAROSKOPI PYELOPLASTY + ANES
177 19,646,000 77,418,000 97,064,000
BILATERAL
OPERASI KHUSUS II -LAPAROSKOPI REIMPLANTASI
178 19,646,000 48,387,000 68,033,000
URETER (URETERONEOSISTOMI) + ANES
OPERASI KHUSUS II -LAPAROSKOPIREIMPLANTASI URETER
179 19,646,000 77,418,000 97,064,000
(URETERONEOSISTOMI) + ANES BILATERAL
OPERASI KHUSUS II -LIGASI VENA SPERMATIKA INTERNA
180 19,646,000 32,258,000 51,904,000
(MICROSURGERY) + ANES
JASA
PELAYANAN
OPERASI KHUSUS II -LIGASI VENA SPERMATIKA INTERNA
181 19,646,000 51,612,000 71,258,000
(MICROSURGERY) + ANES BILATERAL
182 Operasi Khusus II Lithotripsi batu buli (Non-Laser) 13,351,000 18,600,000 31,951,000
183 Operasi Khusus II Lithotripsi batu buli dengan laser 19,646,000 31,000,000 50,646,000
184 Operasi Khusus II Lue Procedure 19,646,000 31,000,000 50,646,000
185 Operasi Khusus II MINI-PCNL 19,646,000 31,000,000 50,646,000
186 Operasi Khusus II Nesbitt Procedure 19,646,000 31,000,000 50,646,000
187 Operasi Khusus II OPERASI MONTI 19,646,000 31,000,000 50,646,000
188 OPERASI KHUSUS II -PCNL BATU GINJAL + ANES 19,646,000 32,258,000 51,904,000
OPERASI KHUSUS II -PCNL BATU GINJAL + ANES
189 19,646,000 51,612,000 71,258,000
BILATERAL
190 Operasi Khusus II PCNL DENGAN LASER 19,646,000 31,000,000 50,646,000
191 Operasi Khusus II Percutaneouscopy Vesikolithotripsi 13,351,000 18,600,000 31,951,000
192 Operasi Khusus II Perineostomi 13,351,000 18,600,000 31,951,000
193 OPERASI KHUSUS II -PSOAS HITCH + ANES 19,646,000 32,258,000 51,904,000
194 OPERASI KHUSUS II -PSOAS HITCH + ANES BILATERAL 19,646,000 51,612,000 71,258,000
195 OPERASI KHUSUS II -PYELOPLASTY + ANES 19,646,000 32,258,000 51,904,000
196 OPERASI KHUSUS II -PYLOPLASTY + ANES BILATERAL 19,646,000 51,612,000 71,258,000
197 Operasi Khusus II RADIKAL PROSTATEKTOMI 19,646,000 31,000,000 50,646,000
OPERASI KHUSUS II -REIMPLANTASI URETER
198 19,646,000 32,258,000 51,904,000
(URETERONEOSISTOMI) + ANES
OPERASI KHUSUS II -REIMPLANTASI URETER
199 19,646,000 51,612,000 71,258,000
(URETERONEOSISTOMI) + ANES BILATERAL
200 Operasi Khusus II Rekonstruksi Buried penis 13,351,000 18,600,000 31,951,000
OPERASI KHUSUS II -REKONSTRUKSI EKSTROFI BULI-BULI
201 19,646,000 32,258,000 51,904,000
+ ANES
OPERASI KHUSUS II -REKONSTRUKSI EKSTROFI BULI-BULI
202 19,646,000 32,258,000 51,904,000
+ ANES
203 OPERASI KHUSUS II -REKONSTRUKSI EPISPADIA + ANES 19,646,000 32,258,000 51,904,000
OPERASI KHUSUS II -REKONSTRUKSI HORSE-SHOE KIDNEY
204 19,646,000 32,258,000 51,904,000
+ ANES
OPERASI KHUSUS II -REKONSTRUKSI PEYRONIE DISEASE
205 19,646,000 32,258,000 51,904,000
(EKSISI PLAQUE) + ANES
206 Operasi Khusus II REKONSTRUKSI RENOVASKULAR 19,646,000 31,000,000 50,646,000
207 Operasi Khusus II Rekonstruksi Sinus Urogenital 19,646,000 31,000,000 50,646,000
OPERASI KHUSUS II -REPAIR FISTEL ENTEROVESIKA +
208 19,646,000 32,258,000 51,904,000
ANES
OPERASI KHUSUS II -REPAIR FISTEL ENTEROVESIKA +
209 19,646,000 32,258,000 51,904,000
ANES
Operasi Khusus II REPAIR FISTEL
210 19,646,000 31,000,000 50,646,000
VESICOVAGINAL/VESICOUTERINA KOMPLEKS
OPERASI KHUSUS II -REPAIR FISTEL VESIKOREKTAL +
211 19,646,000 32,258,000 51,904,000
ANES
OPERASI KHUSUS II -REPAIR FISTEL VESIKOVAGINA +
212 19,646,000 32,258,000 51,904,000
ANES
OPERASI KHUSUS II -REPAIR FISTEL VESIKOVAGINA +
213 19,646,000 32,258,000 51,904,000
ANES
OPERASI KHUSUS II -RESEKSI ANASTOMOSIS STRIKTUR
214 19,646,000 32,258,000 51,904,000
URETRA + ANES
215 Operasi Khusus II Reseksi Anastomosis Urethra Kompleks 19,646,000 31,000,000 50,646,000
OPERASI KHUSUS II -RETROPERITONEAL LYMPH NODE
216 19,646,000 32,258,000 51,904,000
DISSECTION (RPLND) + ANES
217 Operasi Khusus II RIRS 19,646,000 31,000,000 50,646,000
218 Operasi Khusus II Rotational Flap 19,646,000 31,000,000 50,646,000
219 Operasi Khusus II SACROCOLPOPEXY 19,646,000 31,000,000 50,646,000
220 Operasi Khusus II Skrotoplasty 13,351,000 18,600,000 31,951,000
221 OPERASI KHUSUS II -TAILORING URETER + ANES 19,646,000 32,258,000 51,904,000
222 Operasi Khusus II TOT/TVT 13,351,000 18,600,000 31,951,000
223 Operasi Khusus II Trauma Ginjal (McAninch) 19,646,000 31,000,000 50,646,000
224 Operasi Khusus II TURED 13,351,000 18,600,000 31,951,000
225 OPERASI KHUSUS II TURP/B LASER 19,646,000 27,370,000 47,016,000
226 OPERASI KHUSUS II -URETROPLASTY HYPOSPADIA + ANES 13,791,000 32,258,000 46,049,000
227 OPERASI KHUSUS II -URETROPLASTY HYPOSPADIA + ANES 13,791,000 32,258,000 46,049,000

OPERASI KHUSUS II -URETROPLASTY STRIKTUR URETRA +
228 13,791,000 32,258,000 46,049,000
ANES
229 Operasi Khusus II URS dengan laser (unilateral) 19,646,000 31,000,000 50,646,000
230 Operasi Khusus II Vaginoplasty 19,646,000 31,000,000 50,646,000
231 OPERASI KHUSUS II -WIDE EKSISI TUMOR + ANES 19,646,000 32,258,000 51,904,000
JASA
PELAYANAN
232 OPERASI KHUSUS III - ECIRS 19,646,000 48,387,000 68,033,000
233 OPERASI KHUSUS III -ADRENALEKTOMI + ANES 19,646,000 37,950,000 57,596,000
234 OPERASI KHUSUS III -ADRENALEKTOMI + ANES BILATERAL 19,646,000 60,720,000 80,366,000
235 OPERASI KHUSUS III -AUGMENTASI BULI-BULI + ANES 19,646,000 62,618,000 82,264,000
Operasi Khusus III Donor Transplant dengan operasi terbuka (Khusus
236 19,646,000 89,250,000 108,896,000
III+khusus II)
OPERASI KHUSUS III -IMPLANT ARTIFISIAL SPHINCTER +
237 19,646,000 62,618,000 82,264,000
ANES
OPERASI KHUSUS III -LAPARASKOPI NEFREKTOMI
238 19,646,000 66,413,000 86,059,000
RADIKAL
OPERASI KHUSUS III -LAPARASKOPI NEFROURETEREKTOMI
239 19,646,000 66,413,000 86,059,000
+ ANES
OPERASI KHUSUS III -LAPAROSKOPI ADRENALEKTOMI +
240 35,443,000 66,413,000 101,856,000
ANES
OPERASI KHUSUS III -LAPAROSKOPI ADRENALEKTOMI +
241 35,443,000 106,260,000 141,703,000
ANES BILATERAL
OPERASI KHUSUS III -LAPAROSKOPI DISEKSI KELENJAR
242 35,443,000 66,413,000 101,856,000
GETAH BENING PELVIS + ANES
OPERASI KHUSUS III -LAPAROSKOPI PROSTATEKTOMI
243 35,443,000 94,875,000 130,318,000
RADIKAL + ANES
OPERASI KHUSUS III -LAPAROSKOPI SISTEKTOMI RADIKAL
244 35,443,000 94,875,000 130,318,000
+ ANES
OPERASI KHUSUS III -NEFEREKTOMI RADIKAL + ANES
245 19,646,000 60,720,000 80,366,000
BILATERAL
246 OPERASI KHUSUS III -NEFREKTOMI PARSIAL + ANES 19,646,000 37,950,000 57,596,000
OPERASI KHUSUS III -NEFREKTOMI PARSIAL + ANES
247 19,646,000 60,720,000 80,366,000
BILATERAL
248 OPERASI KHUSUS III -NEFREKTOMI RADIKAL + ANES 19,646,000 37,950,000 57,596,000
249 OPERASI KHUSUS III -NEFRO URETERKTOMI 19,646,000 37,950,000 57,596,000
250 OPERASI KHUSUS III -NEFROURETEREKTOMI + ANES 19,646,000 37,950,000 57,596,000
251 OPERASI KHUSUS III -NEFROURETEREKTOMI + ANES 19,646,000 37,950,000 57,596,000
OPERASI KHUSUS III -NEFROURETEREKTOMI + ANES
252 19,646,000 60,720,000 80,366,000
BILATERAL
253 OPERASI KHUSUS III -NEOBLADDER + ANES 19,646,000 62,618,000 82,264,000
254 OPERASI KHUSUS III -PROSTHESIS PENIS + ANES (Diluar Alat) 19,646,000 62,618,000 82,264,000
255 OPERASI KHUSUS III -RADIKAL CYSTEKTOMI 19,646,000 37,950,000 57,596,000
OPERASI KHUSUS III -REKONSTRUKSI RENOVASKULAR +
256 19,646,000 37,950,000 57,596,000
ANES
OPERASI KHUSUS III -REKONSTRUKSI RENOVASKULAR +
257 19,646,000 60,720,000 80,366,000
ANES BILATERAL
258 OPERASI KHUSUS III -SISTEKTOMI RADIKAL + ANES 19,646,000 37,950,000 57,596,000
OPERASI KHUSUS III -VASOEPIDIDIMOSTOMY
259 19,646,000 37,950,000 57,596,000
(MICROSURGERY) + ANES
OPERASI KHUSUS III -VASOEPIDIDIMOSTOMY
260 19,646,000 60,720,000 80,366,000
(MICROSURGERY) + ANES BILATERAL
OPERASI KHUSUS III -VASOVASOSTOMY (MICROSURGERY)
261 19,646,000 37,950,000 57,596,000
+ ANES
OPERASI KHUSUS III -VASOVASOSTOMY (MICROSURGERY)
262 19,646,000 60,720,000 80,366,000
+ ANES BILATERAL
263 OPERASI KHUSUS III -VASOVASOSTOMY + ANES 19,646,000 37,950,000 57,596,000
264 Operasi Sedang Sistoskopi Biopsi Tepi Fistel 10,631,000 10,850,000 21,481,000
OPERASI SEDANG (NARKOSE) PEMASANGAN URETER
265 10,631,000 11,270,000 21,901,000
KATETER
266 OPERASI SEDANG (NARKOSE) SISTOSKOPI VCUG 10,631,000 11,270,000 21,901,000
267 OPERASI SEDANG (NORKOSE) GANTI DJ STENT 10,631,000 11,270,000 21,901,000
268 OPERASI SEDANG (NORKOSE) PASANG DJ STENT 10,631,000 11,270,000 21,901,000
269 Operasi Sedang Aff JJ Stent Lokal (Unilateral) 10,631,000 10,850,000 21,481,000
270 Operasi Sedang Aff kateter tenckhoff CAPD 10,631,000 10,850,000 21,481,000
271 Operasi Sedang Biopsi Penis Lokal 10,631,000 10,850,000 21,481,000
272 Operasi Sedang Biopsi Prostat (TransPerineal & Open) 10,631,000 10,850,000 21,481,000
273 Operasi Sedang Biopsi Prostat (TransRectal Lokal) 10,631,000 10,850,000 21,481,000
274 Operasi Sedang Debridement Luas 10,631,000 10,850,000 21,481,000
275 Operasi Sedang Drainase Urinoma 10,631,000 10,850,000 21,481,000
276 Operasi Sedang Eksisi Karunkula 10,631,000 10,850,000 21,481,000
277 Operasi Sedang Eksisi polip uretra dengan Laser 10,631,000 10,850,000 21,481,000
278 OPERASI SEDANG I -BIOPSI MUKOSA BULI-BULI + ANES 10,631,000 11,270,000 21,901,000
279 OPERASI SEDANG I -BIOPSI PENIS + ANES 6,935,000 11,270,000 18,205,000
280 OPERASI SEDANG I -BIOPSI PROSTAT + ANES 10,631,000 11,270,000 21,901,000
JASA
PELAYANAN
281 OPERASI SEDANG I -BIOPSI TESTIS/GONAD + ANES 10,631,000 11,270,000 21,901,000
OPERASI SEDANG I -BIOPSI TESTIS/GONAD + ANES
282 10,631,000 18,032,000 28,663,000
BILATERAL
283 OPERASI SEDANG I -HIDROKELEKTOMI + ANES 10,631,000 11,270,000 21,901,000
284 OPERASI SEDANG I -HIDROKELEKTOMI + ANES BILATERAL 10,631,000 18,032,000 28,663,000
OPERASI SEDANG I -ORKHIDEKTOMI/ORKHIDEKTOMI
285 10,631,000 11,270,000 21,901,000
SUBKAPSULAR
286 10,631,000 11,270,000 21,901,000
SUBKAPSULAR + ANES
287 10,631,000 18,032,000 28,663,000
SUBKAPSULAR BILATERAL
288 OPERASI SEDANG I -SISTOSKOPI 9,631,000 8,050,000 17,681,000
289 OPERASI SEDANG I -SISTOSKOPI + ANES 10,631,000 11,270,000 21,901,000
290 OPERASI SEDANG I -SISTOSTOMI PERKUTAN 9,631,000 8,050,000 17,681,000
291 OPERASI SEDANG I -SISTOSTOMI PERKUTAN + ANES 10,631,000 11,270,000 21,901,000
292 OPERASI SEDANG I -SISTOSTOMI TERBUKA 9,631,000 8,050,000 17,681,000
293 OPERASI SEDANG I -SISTOSTOMI TERBUKA + ANES 10,631,000 11,270,000 21,901,000
294 OPERASI SEDANG I -SPERMATOKELEKTOMI + ANES 10,631,000 11,270,000 21,901,000
OPERASI SEDANG I -SPERMATOKELEKTOMI + ANES
295 10,631,000 18,032,000 28,663,000
BILATERAL
296 OPERASI SEDANG I -URETROSISTOSKOPI + ANES 10,631,000 11,270,000 21,901,000
297 OPERASI SEDANG I -URETROSKOPI + ANES 10,631,000 11,270,000 21,901,000
298 OPERASI SEDANG I -VASOGRAFI + ANES 10,631,000 11,270,000 21,901,000
299 OPERASI SEDANG I -VASOGRAFI + ANES BILATERAL 10,631,000 18,032,000 28,663,000
300 OPERASI SEDANG II -BIOPSI GINJAL PERKUTAN + ANES 10,631,000 11,270,000 21,901,000
OPERASI SEDANG II -BIOPSI GINJAL PERKUTAN + ANES
301 10,631,000 18,032,000 28,663,000
BILATERAL
302 OPERASI SEDANG II -DRAINAGE PERIURETER + ANES 10,631,000 11,270,000 21,901,000
303 OPERASI SEDANG II -DRAINAGE PERIURETER + ANES 10,631,000 11,270,000 21,901,000
OPERASI SEDANG II -DRAINASE ABSES
304 10,631,000 11,270,000 21,901,000
PERINEFRIK/PARANEFRIK + ANES
OPERASI SEDANG II -DRAINASE ABSES
305 10,631,000 18,032,000 28,663,000
PERINEFRIK/PARANEFRIK + ANES BILATERAL
OPERASI SEDANG II -PASANG KATETER TENCHOFF UNTUK
306 10,631,000 11,270,000 21,901,000
CAPD + ANES
OPERASI SEDANG II -PROSEDUR WINTER (PRIAPISMUS) +
307 10,631,000 11,270,000 21,901,000
ANES
308 OPERASI SEDANG II -RPG + ANES 10,631,000 11,270,000 21,901,000
309 OPERASI SEDANG II -RPG + ANES BILATERAL 10,631,000 18,032,000 28,663,000
OPERASI SEDANG II -VESIKOLITOTOMI (SECTIO ALTA) +
310 10,631,000 11,270,000 21,901,000
ANES
311 OPERASI SEDANG -PASANG DJ STENT 10,631,000 11,270,000 21,901,000
312 OPERASI SEDANG -PASANG DJ STENT 10,631,000 11,270,000 21,901,000
313 OPERASI SEDANG -PEMASANGAN URETER KATETER 10,631,000 11,270,000 21,901,000
314 Operasi Sedang Revisi Nefrostomi (Unilateral) lokal anatesi 10,631,000 10,850,000 21,481,000
315 Operasi Sedang Varikokelektomi (Palomo &Unilateral) 10,631,000 10,850,000 21,481,000
316 RIRS/Flexible URS - Khusus II 19,646,000 27,370,000 47,016,000
TRANSPLANTASI GINJAL-DONOR TRANSPLAN-
317 46,306,000 121,137,000 167,443,000
LAPAROSKOPI
TRANSPLANTASI GINJAL-DONOR TRANSPLAN-
318 46,306,000 144,137,000 190,443,000
LAPAROSKOPI MIKRO
319 TRANSPLANTASI GINJAL-RESIPIEN TRANSPLAN ASISTENSI 31,636,000 121,137,000 152,773,000
320 TRANSPLANTASI GINJAL-RESIPIEN TRANSPLAN-MIKRO 46,306,000 144,137,000 190,443,000
VIDEOURODINAMIK (PEMASANGAN KATETER DALAM
321 11,178,000 6,200,000 17,378,000
NARKOSE)
7. PELAYANAN PENUNJANG MEDIS
7.1 LAB PTH
1 DPL 105,000 58,000 163,000
2 PT/INR 316,000 59,000 375,000
3 APTT 215,000 69,000 284,000
4 FIBRINOGEN 234,000 46,000 280,000
5 D - Dimer 557,000 161,000 718,000
6 LA 977,000 242,000 1,219,000
7 AT III 3 (Anti Thrombin) 539,000 244,000 783,000
8 PROTEIN C 920,000 197,000 1,117,000
9 PROTEIN S 2,110,000 193,000 2,303,000
10 FAKTOR VIII 393,000 138,000 531,000
11 FAKTOR IX 472,000 138,000 610,000
JASA
PELAYANAN
12 FAKTOR Xa ( Axa ) 317,000 362,000 679,000
13 MIX Aptt 222,000 112,000 334,000
14 ACA IgG & IgM 990,000 196,000 1,186,000
15 B2GP I IgG & IgM 1,064,000 196,000 1,260,000
16 DS DNA 827,000 200,000 1,027,000
17 FVW 614,000 417,000 1,031,000
18 Aggregasi trombosit 202,000 161,000 363,000
7.2 RADIOLOGI
1 Copy CD USG 96,000 - 96,000
2 Copy CD CR 96,000 - 96,000
3 Copy CD DDR 127,000 - 127,000
4 Copy CD Mammografi 177,000 - 177,000
5 Copy Kertas USG 67,000 - 67,000
6 Copy Film Ukuran 8 x 10 inc 124,000 - 124,000
9 tambahan tarif copy film MRI per lembar 150,000 - 150,000
10 Pendampingan Anestesi - 1,000,000 1,000,000
7.2.1 RADIOLOGI KONVENSIONAL TANPA KONTRAS
7.2.1.1 Toraks
1 Toraks 1 proyeksi (PA / AP / Lateral / Top Lordotik) 121,000 202,000 323,000
2 Toraks 2 proyeksi 171,000 274,000 445,000
3 Costae 121,000 202,000 323,000
4 Sternum 121,000 202,000 323,000
7.2.1.2 Abdomen
1 Abdomen Polos (BNO) 121,000 202,000 323,000
2 Abdomen 2 posisi 171,000 455,000 626,000
3 Abdomen 3 posisi 357,000 541,000 898,000
7.2.1.3 Kepala-Leher
1 Cephalometri 177,000 196,000 373,000
2 Panoramik 177,000 202,000 379,000
3 Schedel AP - Lateral 171,000 274,000 445,000
4 Sinus paranasal 348,000 331,000 679,000
5 Sinus Adenoid 341,000 389,000 730,000
6 Mastoid 171,000 331,000 502,000
7 Sendi Temporo Mandibula 348,000 403,000 751,000
8 Orbita 121,000 453,000 574,000
9 Mandibula 171,000 452,000 623,000
10 Os Nasal 171,000 453,000 624,000
11 Jaringan lunak leher AP dan Lateral 178,000 331,000 509,000
12 Stenvers 121,000 476,000 597,000
13 Rheese 121,000 405,000 526,000
14 Comberg 121,000 610,000 731,000
15 Basis kranii 171,000 274,000 445,000
16 Vertebra C1-C2 171,000 274,000 445,000
17 CBCT 341,000 1,150,000 1,491,000
7.2.1.4 Muskuloskeletal
1 Vertebra Servikal 2 proyeksi (AP - Lateral) 121,000 403,000 524,000
2 Vertebra Servikal 4 proyeksi (AP - Lateral - Oblik kanan - Oblik kiri) 259,000 604,000 863,000
3 Vertebra Torakal 2 proyeksi (AP dan Lateral) 121,000 419,000 540,000
4 Vertebra Torakal 4 proyeksi (Ap - Lateral - Oblik kanan - Oblik kiri) 259,000 628,000 887,000
5 Vertebra Lumbosakral 2 proyeksi (AP dan Lateral) 273,000 419,000 692,000
6 Vertebra Lumbal 4 proyeksi (AP - Lateral - Oblik kanan - Oblik kiri) 440,000 628,000 1,068,000
7 Vertebra Lumbal 6 proyeksi 440,000 805,000 1,245,000
8 Vertebra Lumbal Dinamik 440,000 805,000 1,245,000
9 Sakrum 2 proyeksi 121,000 419,000 540,000
10 Vertebra Lengkap (servikal s/d sakrum) 357,000 920,000 1,277,000
11 Program Skoliosis 357,000 1,150,000 1,507,000
12 Manus 2 proyeksi (AP - Oblik) 121,000 207,000 328,000
13 Manus Bilateral 2 proyeksi (AP - Oblik) 171,000 414,000 585,000
14 Manus 3 proyeksi (AP - Oblik - Lateral) 141,000 311,000 452,000
15 Manus Bilateral 3 proyeksi (AP - Oblik - Lateral) 191,000 621,000 812,000
16 Pergelangan Tangan 2 proyeksi 121,000 207,000 328,000
17 Pergelangan Tangan Bilateral 2 proyeksi 171,000 414,000 585,000
19 Pergelangan Tangan Bilateral 3 proyeksi 191,000 621,000 812,000
JASA
PELAYANAN
21 Pergelangan Tangan Bilateral 4 proyeksi 211,000 828,000 1,039,000
22 Antebrachii 2 proyeksi (AP - Lateral) 121,000 207,000 328,000
23 Antebrachii Bilateral 2 proyeksi (AP - Lateral) 171,000 414,000 585,000
24 Antebrachii 3 proyeksi (AP - Lateral - Oblik) 141,000 311,000 452,000
25 Antebrachii Bilateral 3 proyeksi (AP - Lateral - Oblik) 191,000 621,000 812,000
26 Kubiti 2 proyeksi 121,000 253,000 374,000
27 Kubiti Bilateral 2 proyeksi 171,000 506,000 677,000
28 Kubiti 3 proyeksi 141,000 311,000 452,000
29 Kubiti Bilateral 3 proyeksi 191,000 621,000 812,000
30 Kubiti 4 proyeksi 161,000 414,000 575,000
31 Kubiti Bilateral 4 proyeksi 211,000 828,000 1,039,000
32 Humerus 2 proyeksi (AP - Lateral) 121,000 207,000 328,000
33 Humerus Bilateral 2 proyeksi (AP - Lateral) 171,000 414,000 585,000
34 Humerus 3 proyeksi (AP - Lateral - Oblik) 141,000 311,000 452,000
35 Humerus Bilateral 3 proyeksi (AP - Lateral - Oblik) 191,000 621,000 812,000
36 Humerus 4 proyeksi 161,000 414,000 575,000
37 Humerus Bilateral 4 proyeksi 211,000 828,000 1,039,000
38 Sendi Bahu 2 proyeksi 121,000 230,000 351,000
39 Sendi Bahu Bilateral 2 proyeksi 171,000 460,000 631,000
45 Sendi Bahu Bilateral 6 proyeksi 251,000 805,000 1,056,000
47 Sendi Bahu Biateral 8 proyeksi 291,000 920,000 1,211,000
48 Sendi Bahu - Impingment Series 440,000 518,000 958,000
49 Sendi Bahu Bilateral - Impingment Series 600,000 1,035,000 1,635,000
50 Sendi Bahu - Instability Series 350,000 518,000 868,000
51 Sendi Bahu Bilateral - Instability Series 500,000 1,035,000 1,535,000
52 Klavikula 2 proyeksi 121,000 207,000 328,000
53 Klavikula Bilateral 2 proyeksi 171,000 414,000 585,000
54 Skapula 121,000 230,000 351,000
55 Skapula Bilateral 171,000 460,000 631,000
56 Pedis 2 proyeksi (AP - Oblik) 121,000 207,000 328,000
57 Pedis Bilateral 2 proyeksi (AP - Oblik) 171,000 414,000 585,000
58 Pedis 3 proyeksi (AP - Oblik - Lateral) 141,000 311,000 452,000
59 Pedis Bilateral 3 proyeksi (AP - Oblik - Lateral) 191,000 621,000 812,000
60 Pergelangan Kaki 2 proyeksi 121,000 207,000 328,000
61 Pergelangan Kaki Bilateral 2 proyeksi 171,000 414,000 585,000
62 Pergelangan Kaki 3 proyeksi 141,000 311,000 452,000
63 Pergelangan Kaki Bilateral 3 proyeksi 191,000 621,000 812,000
64 Kalkaneus 2 proyeksi 121,000 207,000 328,000
65 Kalkaneus Bilateral 2 proyeksi 171,000 414,000 585,000
66 Kruris 2 proyeksi (AP - Lateral) 121,000 368,000 489,000
67 Kruris Bilateral 2 proyeksi (AP - Lateral) 171,000 736,000 907,000
68 Kruris 3 proyeksi (AP - Lateral - Oblik) 141,000 426,000 567,000
69 Kruris Bilateral 3 proyeksi (AP - Lateral - Oblik) 191,000 851,000 1,042,000
70 Sendi Genu 2 proyeksi 121,000 230,000 351,000
71 Sendi Genu Bilateral 2 proyeksi 171,000 460,000 631,000
76 Genu proyeksi Skyline 121,000 202,000 323,000
77 Genu Bilateral proyeksi Skyline 171,000 304,000 475,000
78 Genu Tunnel View 121,000 202,000 323,000
79 Genu Bilateral Tunnel View 171,000 304,000 475,000
80 Genu Merchant View 121,000 201,000 322,000
81 Genu Bilateral Merchant View 171,000 304,000 475,000
82 Femur 2 proyeksi (AP - Lateral) 121,000 368,000 489,000
83 Femur Bilateral 2 proyeksi (AP - Lateral) 171,000 736,000 907,000
84 Femur 3 proyeksi (AP - Lateral - Oblik) 141,000 426,000 567,000
85 Femur Bilateral 3 proyeksi (AP - Lateral - Oblik) 191,000 851,000 1,042,000
86 Femur 4 proyeksi 161,000 483,000 644,000
87 Femur Bilateral 4 proyeksi 211,000 966,000 1,177,000
88 Pelvis AP 121,000 504,000 625,000
89 Pelvis Inlet 121,000 504,000 625,000
90 Pelvis Outlet 121,000 504,000 625,000
JASA
PELAYANAN
91 Pelvis AP, Inlet, dan Outlet 161,000 619,000 780,000
92 Pelvis Sendi Sakroiliaka 266,000 575,000 841,000
93 Pelvis Obturator view 121,000 575,000 696,000
94 Pelvis Alar view 121,000 575,000 696,000
95 Pelvis Obturator view dan Alar view 141,000 633,000 774,000
96 Sendi Panggul 1 proyeksi 121,000 230,000 351,000
100 Sendi Panggul Bilateral 1 proyeksi 171,000 460,000 631,000
103 Sendi Panggul Bilateral 4 proyeksi 251,000 805,000 1,056,000
104 Ekstremitas Bawah Lengkap (Long Leg) 357,000 863,000 1,220,000
105 Survei Skeletal (Bone Survey) 357,000 1,035,000 1,392,000
106 Bone Mineral Density (3sites) 322,000 518,000 840,000
107 DXA Total Body Composition 322,000 518,000 840,000
7.2.1.5 Pediatrik
1 Bone Age 121,000 460,000 581,000
7.2.1.6 Payudara
1 Mammografi 133,000 518,000 651,000
2 Mammografi Guided Localization 150,000 575,000 725,000
7.2.1.7 Lainnya
1 C-Arm 171,000 662,000 833,000
2 Radiografi Intra-operatif 171,000 2,591,000 2,762,000
3 Fluoroscopy Guided Sclerotheraphy 3,000,000 3,700,000 6,700,000
4 Fluoroscopy Guided Tuba Recanalization 17,760,000 5,200,000 22,960,000
5 Fluoroscopy Guided Abscess/Fluid Drainage 3,000,000 3,200,000 6,200,000
6 Fluoroscopy Guided Biopsy 3,000,000 3,200,000 6,200,000
7.2.2 RADIOLOGI KONVENSIONAL DENGAN
FLUOROSKOPI/KONTRAS
7.2.2.1 Traktus Genitourinarius
1 Urografi Intravena 1,300,000 842,000 2,142,000
2 Pielografi Antegard 1,300,000 1,431,000 2,731,000
3 Pielografi Retrogard 1,300,000 1,431,000 2,731,000
4 Sistografi 1,200,000 1,193,000 2,393,000
5 Urethrosistografi Bipolar 1,200,000 1,736,000 2,936,000
6 Urethrografi 1,200,000 1,195,000 2,395,000
7 Mictionaring Urography 1,200,000 1,480,000 2,680,000
8 Histerosalfingografi 1,200,000 1,478,000 2,678,000
9 Fistulografi 1,200,000 1,193,000 2,393,000
10 Genitografi 1,200,000 1,271,000 2,471,000
7.2.2.2 Traktus Gastrointestinal
1 Apendikofragi 1,090,000 818,000 1,908,000
2 Sialografi 1,647,000 1,727,000 3,374,000
3 Esofagografi 1,202,000 1,116,000 2,318,000
4 OMD 1,424,000 1,727,000 3,151,000
5 Follow Through 1,090,000 1,727,000 2,817,000
6 Cholangiografi T. Tube 1,090,000 1,842,000 2,932,000
7 ERCP Diagnostik 1,424,000 1,978,000 3,402,000
8 ERCP + Terapi 1,647,000 1,978,000 3,625,000
9 Colon in loop 1,424,000 1,842,000 3,266,000
10 Lopografi 1,424,000 1,225,000 2,649,000
7.2.2.3 Kepala-Leher
1 Dakriosistografi 1,647,000 1,380,000 3,027,000
1 Spot Fluoroscopi 1,090,000 1,070,000 2,160,000
2 Artrografi 1,200,000 1,742,000 2,942,000
7.2.2.5 Payudara
1 Duktulografi 1,200,000 1,193,000 2,393,000
7.2.2.6 Vaskular & Medula Spinalis
1 Phlebografi superfisial (1 ekstremitas) 2,760,000 1,323,000 4,083,000
2 Phlebografi superfisial (2 ekstremitas) 4,500,000 2,500,000 7,000,000
3 Mielografi Servikal 2,760,000 1,315,000 4,075,000
4 Mielografi Torakal 2,760,000 1,306,000 4,066,000
5 Mielografi Lumbal 2,760,000 1,306,000 4,066,000
7.2.2.7 Lainnya
1 C-Arm dengan Kontras 1,229,000 865,000 2,094,000
2 Radiografi kontras intra-operatif 1,229,000 894,000 2,123,000
7.2.3 ULTRASONOGRAFI
JASA
PELAYANAN
7.2.3.1 Pediatrik
1 USG Abdomen Bayi 178,000 683,000 861,000
2 USG Doppler Abdomen Bayi 178,000 1,155,000 1,333,000
3 USG Abdomen Bayi + Elastografi 272,000 1,260,000 1,532,000
4 USG Abdomen Bayi + Doppler + Elastografi 272,000 1,680,000 1,952,000
5 USG Kepala Bayi 173,000 627,000 800,000
6 USG Vertebra Neonatus 178,000 945,000 1,123,000
7 USG Sendi Panggul Bayi (1 sisi) 178,000 735,000 913,000
7.2.3.2 Kepala - Leher
1 USG Tiroid 178,000 642,000 820,000
2 USG Parotis 178,000 589,000 767,000
3 USG Leher Lengkap 178,000 735,000 913,000
4 USG Doppler Vaskular Karotis 309,000 1,391,000 1,700,000
5 USG Leher + Elastografi 272,000 1,070,000 1,342,000
7.2.3.3 Payudara
1 USG Payudara 165,000 735,000 900,000
2 USG Payudara + Elastografi 255,000 945,000 1,200,000
3 ABUS 115,000 735,000 850,000
4 USG Guided Payudara 178,000 667,000 845,000
5 USG Guided Localization Payudara 165,000 788,000 953,000
7.2.3.4 Abdomen-Pelvis
1 USG Abdomen Lengkap 193,000 726,000 919,000
2 USG Abdomen Atas 193,000 565,000 758,000
3 USG Abdomen Bawah 193,000 565,000 758,000
4 USG Traktus Urinarius 193,000 565,000 758,000
5 USG Testis 193,000 785,000 978,000
6 USG Doppler Vaskular Testis 316,000 1,150,000 1,466,000
7 USG Transrektal 272,000 569,000 841,000
8 USG Doppler Hepar 317,000 1,150,000 1,467,000
9 USG Doppler Ginjal 317,000 1,150,000 1,467,000
10 USG Doppler Aorta 317,000 1,150,000 1,467,000
11 USG Abdomen + Elastografi 272,000 1,035,000 1,307,000
1 USG Digiti 178,000 575,000 753,000
2 USG Manus 178,000 863,000 1,041,000
3 USG Pergelangan Tangan 178,000 891,000 1,069,000
4 USG Kubiti 178,000 920,000 1,098,000
5 USG Bahu 193,000 863,000 1,056,000
6 USG Plantar Pedis 178,000 633,000 811,000
7 USG Tendon Achilles 178,000 633,000 811,000
8 USG Pergelangan Kaki 178,000 891,000 1,069,000
9 USG Pedis 178,000 863,000 1,041,000
10 USG Genu 178,000 863,000 1,041,000
11 USG Elastografi Muskuloskeletal 272,000 920,000 1,192,000
7.2.3.6 Toraks
1 USG Toraks 193,000 572,000 765,000
7.2.3.7 Doppler Vaskular
1 USG Doppler Vaskular Extremitas Arteri 317,000 1,495,000 1,812,000
2 USG Doppler Vaskular Extremitas Arteri Bilateral 317,000 2,990,000 3,307,000
3 USG Doppler Vaskular Extremitas Vena 317,000 920,000 1,237,000
4 USG Doppler Vaskular Extremitas Vena Bilateral 317,000 1,840,000 2,157,000
5 USG Doppler Akses Dialisis 132,000 2,715,000 2,847,000
6 USG Doppler Jaringan Lunak / Superfisial 266,000 1,035,000 1,301,000
7.2.3.8 Jaringan Lunak/Superfisial
1 USG Intra-operasi 438,000 2,096,000 2,534,000
2 USG Guiding 178,000 667,000 845,000
3 USG Guided + Needle Aspiration Biopsy 438,000 2,585,000 3,023,000
4 USG Guided + Core Biopsy 1,138,000 3,085,000 4,223,000
5 USG Guided + Sclerotheraphy 3,000,000 4,200,000 7,200,000
6 USG Jaringan lunak/ Superfisial 178,000 667,000 845,000
7 USG Elastografi Jaringan Lunak / Superfisial 272,000 805,000 1,077,000
8 USG Jaras Saraf Perifer 272,000 1,150,000 1,422,000
7.2.4 MRI NON KONTRAS
7.2.4.1 NEURORADIOLOGI - KEPALA LEHER
1 MRI Otak 2,283,000 1,017,000 3,300,000
2 MRI Otak + MRA 2,988,000 1,312,000 4,300,000
3 MRI Otak + MRA + MRV 3,266,000 1,434,000 4,700,000
4 MRI Otak + MRS 2,988,000 1,312,000 4,300,000
5 MRI Otak + Perfusi 2,988,000 1,312,000 4,300,000
6 MRI Otak - Epilepsi 2,988,000 1,312,000 4,300,000
JASA
PELAYANAN
7 MRI Nervus Kranial 2,988,000 1,312,000 4,300,000
8 MRI Koklea + DTI 3,596,000 1,604,000 5,200,000
9 MRI Otak + DTI 3,596,000 1,604,000 5,200,000
10 MRI Orbita 2,436,000 1,064,000 3,500,000
11 MRI Sinus Pranasal 2,436,000 1,064,000 3,500,000
12 MRI Mastoid 3,166,000 1,334,000 4,500,000
13 MRI Tempora Mandibula 3,604,000 1,596,000 5,200,000
14 MRI Leher (Faring-Laring) 3,093,000 1,407,000 4,500,000
15 MRI Otak Fungsional 3,596,000 1,604,000 5,200,000
7.2.4.2 MUSKULOSKELETAL
1 MRI Leher Pleksus Brakialis 2,919,000 1,281,000 4,200,000
2 MRI Vetebra Servikal 2,224,000 976,000 3,200,000
3 MRI Vertebra Servikal + Torakal 3,613,000 1,587,000 5,200,000
4 MRI Vertebra Torakal 2,224,000 976,000 3,200,000
5 MRI Vertebra Torakal + Lumbal 3,613,000 1,587,000 5,200,000
6 MRI Vertebra Lumbal 2,224,000 976,000 3,200,000
7 MRI Tulang Pelvis 2,919,000 1,281,000 4,200,000
8 MRI Sendi Sakroiliaka 2,919,000 1,281,000 4,200,000
9 MRI Sendi Panggul (hip) - 1 sendi 2,224,000 976,000 3,200,000
10 MRI Sendi Panggul bilateral (hip bilateral) 4,308,000 1,892,000 6,200,000
11 MRI Vertebra Lengkap (wholespine) 4,308,000 1,892,000 6,200,000
12 MRI Klavikula 2,224,000 976,000 3,200,000
13 MRI Bahu 2,224,000 976,000 3,200,000
14 MRI Humerus 2,224,000 976,000 3,200,000
15 MRI Sendi Kubiti 2,224,000 976,000 3,200,000
16 MRI Antebrachii 2,224,000 976,000 3,200,000
17 MRI Pergelangan Tangan 2,919,000 1,281,000 4,200,000
18 MRI Manus 2,919,000 1,281,000 4,200,000
19 MRI Phalang Manus 2,919,000 1,281,000 4,200,000
20 MRI Femur 2,224,000 976,000 3,200,000
21 MRI Genu 2,224,000 976,000 3,200,000
22 MRI Kruris 2,224,000 976,000 3,200,000
23 MRI Pergelangan Kaki 2,919,000 1,281,000 4,200,000
24 MRI Pedis 2,919,000 1,281,000 4,200,000
25 MRI Phalang Pedis 2,919,000 1,281,000 4,200,000
26 MRI Cartigram + genu 3,596,000 1,604,000 5,200,000
7.2.4.3 TORAKS - KARDIOVASKULAR
1 MRI Toraks 2,919,000 1,281,000 4,200,000
2 MRI Kardiak 8,686,000 3,814,000 12,500,000
7.2.4.4 PAYUDARA
1 MRI Payudara 2,224,000 976,000 3,200,000
7.2.4.5 ABDOMEN
1 MRI Abdomen Atas 2,919,000 1,281,000 4,200,000
2 MRI Abdomen Atas + MRCP 3,197,000 1,403,000 4,600,000
3 MRI Abdomen Bawah 2,363,000 1,037,000 3,400,000
4 MRI Prostat 2,224,000 976,000 3,200,000
5 MRI Abdomen Lengkap (Abdomen Atas + Pelvis) 4,517,000 1,983,000 6,500,000
6 MRI Urografi 3,613,000 1,587,000 5,200,000
7 MRI Fistula perianal 2,293,000 1,007,000 3,300,000
7.2.4.6 PEDIATRIK
1 MRI Fetus 2,919,000 1,281,000 4,200,000
7.2.4.7 THALASEMIA
1 MRI Thalasemia Jantung/Hepar 2,919,000 1,281,000 4,200,000
2 MRI Thalasemia Hepar+Jantung+Pankreas 4,517,000 1,983,000 6,500,000
3 MRI Thalasemia Hipofisis 2,224,000 976,000 3,200,000
7.2.4.8 ANGIOGRAFI
1 MRA Otak 2,919,000 1,281,000 4,200,000
2 MRA Karotis 2,919,000 1,281,000 4,200,000
3 MRA Aorta Torakalis 3,613,000 1,587,000 5,200,000
4 MRA Aorta Abdominalis 3,613,000 1,587,000 5,200,000
5 MRA Pelvis 2,919,000 1,281,000 4,200,000
6 MRA Extremitas Atas 3,173,000 1,393,000 4,566,000
7 MRA Ekstremitas Bawah 3,946,000 1,732,000 5,678,000
8 MRA Aorta Lengkap (Arkus Aorta s/d Bifurkasio) 6,949,000 3,051,000 10,000,000
7.2.5 MRI KONTRAS
7.2.5.1 NEURORADIOLOGI - KEPALA LEHER
1 MRI Otak 2,919,000 1,281,000 4,200,000
2 MRI Otak + MRA 3,822,000 1,678,000 5,500,000
3 MRI Otak + MRA + MRV 4,169,000 1,831,000 6,000,000
4 MRI Otak + MRS 3,822,000 1,678,000 5,500,000
JASA
PELAYANAN
5 MRI Otak + Perfusi 3,822,000 1,678,000 5,500,000
6 MRI Hipofisis Kontras Dinamik 4,144,000 1,356,000 5,500,000
7 MRI Otak - Epilepsi 4,144,000 1,356,000 5,500,000
8 MRI Nervus Kranial 4,144,000 1,356,000 5,500,000
9 MRI Koklea + DTI 4,685,000 2,075,000 6,760,000
10 MRI Otak + DTI 4,685,000 2,075,000 6,760,000
11 MRI Orbita 3,112,000 1,388,000 4,500,000
12 MRI Sinus Pranasal 3,112,000 1,388,000 4,500,000
13 MRI Mastoid 2,715,000 1,785,000 4,500,000
14 MRI Tempora Mandibula 4,698,000 2,062,000 6,760,000
15 MRI Leher (Faring-Laring) 4,065,000 1,785,000 5,850,000
16 MRI Otak Fungsional 4,685,000 2,075,000 6,760,000
7.2.5.2 MUSKULOSKELETAL
1 MRI Leher Pleksus Brakialis 3,794,000 1,666,000 5,460,000
2 MRI Vetebra Servikal 2,891,000 1,269,000 4,160,000
3 MRI Vertebra Servikal + Torakal 4,698,000 2,062,000 6,760,000
4 MRI Vertebra Torakal 2,891,000 1,269,000 4,160,000
5 MRI Vertebra Torakal + Lumbal 4,698,000 2,062,000 6,760,000
6 MRI Vertebra Lumbal 2,891,000 1,269,000 4,160,000
7 MRI Tulang Pelvis 3,794,000 1,666,000 5,460,000
8 MRI Sendi Sakroiliaka 3,794,000 1,666,000 5,460,000
9 MRI Sendi Panggul (hip) - 1 sendi 2,891,000 1,269,000 4,160,000
10 MRI Sendi Panggul bilateral (hip bilateral) 5,601,000 2,459,000 8,060,000
11 MRI Vertebra Lengkap (wholespine) 5,601,000 2,459,000 8,060,000
12 MRI Klavikula 2,891,000 1,269,000 4,160,000
13 MRI Bahu 2,891,000 1,269,000 4,160,000
14 MRI Humerus 2,891,000 1,269,000 4,160,000
15 MRI Sendi Kubiti 2,891,000 1,269,000 4,160,000
16 MRI Antebrachii 2,891,000 1,269,000 4,160,000
17 MRI Pergelangan Tangan 3,794,000 1,666,000 5,460,000
18 MRI Manus 3,794,000 1,666,000 5,460,000
19 MRI Phalang Manus 3,794,000 1,666,000 5,460,000
20 MRI Femur 2,891,000 1,269,000 4,160,000
21 MRI Genu 2,891,000 1,269,000 4,160,000
22 MRI Kruris 2,891,000 1,269,000 4,160,000
23 MRI Pergelangan Kaki 3,794,000 1,666,000 5,460,000
24 MRI Pedis 3,794,000 1,666,000 5,460,000
25 MRI Phalang Pedis 3,794,000 1,666,000 5,460,000
26 MRI Cartigram + genu 4,685,000 2,075,000 6,760,000
7.2.5.3 TORAKS - KARDIOVASKULAR
1 MRI Toraks 3,794,000 1,666,000 5,460,000
2 MRI Kardiak 10,424,000 4,576,000 15,000,000
7.2.5.4 PAYUDARA
1 MRI Payudara 2,891,000 1,269,000 4,160,000
7.2.5.5 ABDOMEN
1 MRI Abdomen Atas 3,794,000 1,666,000 5,460,000
2 MRI Abdomen Atas + MRCP 4,155,000 1,825,000 5,980,000
3 MRI Abdomen Atas Kontras Dinamik 3 fase 4,864,000 2,136,000 7,000,000
4 MRI Abdomen Atas Kontras Dinamik 3 fase + MRCP 5,142,000 2,258,000 7,400,000
5 MRI Abdomen Bawah 3,072,000 1,348,000 4,420,000
6 MRI Prostat 2,891,000 1,269,000 4,160,000
7 MRI Abdomen Lengkap (Abdomen Atas + Pelvis) 5,872,000 2,578,000 8,450,000
8 MRI Urografi 4,698,000 2,062,000 6,760,000
9 MRI Abdomen Lengkap Kontras Dinamik 4,864,000 2,136,000 7,000,000
MRI Abdomen Atas Kontras Hepatobiliaris (belum termasuk media
10 4,864,000 2,136,000 7,000,000
kontras)
MRI Whole Abdomen Kontras Hepatobiliaris (belum termasuk media
11 5,872,000 2,578,000 8,450,000
kontras)
12 MRI Fistula perianal 2,981,000 1,309,000 4,290,000
7.2.5.6 ANGIOGRAFI
1 MRA Otak 3,809,000 1,651,000 5,460,000
2 MRA Karotis 3,809,000 1,651,000 5,460,000
3 MRA Aorta Torakalis 4,800,000 1,904,000 6,704,000
4 MRA Aorta Abdominalis 4,800,000 1,904,000 6,704,000
5 MRA Pelvis 4,800,000 1,904,000 6,704,000
6 MRA Extremitas Atas 3,809,000 2,128,000 5,937,000
7 MRA Ekstremitas Bawah 5,149,000 2,232,000 7,381,000
8 MRA Aorta Lengkap (Arkus Aorta s/d Bifurkasio) 9,069,000 3,931,000 13,000,000
7.2.6 RADIOLOGI INTERVENSI
JASA
PELAYANAN
8 CCF WITH COIL 1 89,500,000 25,000,000 114,500,000
9 CCF WITH COIL 2 134,680,000 30,000,000 164,680,000
10 CCF WITH BALOON 1 65,205,000 20,000,000 85,205,000
11 CCF WITH BALOON 2 98,835,000 25,000,000 123,835,000
18 SKLIROTERAPI 1 23,680,000 10,000,000 33,680,000
19 SKLIROTERAPI 2 27,885,000 12,000,000 39,885,000
7.3 HOMECARE
1 Homecare area jakarta 1 shift area Botabek 248,000 753,000 1,001,000
2 Homecare area jakarta 1 shift area Jakarta 220,000 580,000 800,000
3 Homecare area jakarta 2 shift area Botabek 248,000 1,403,000 1,651,000
4 Homecare area jakarta 2 shift area Jakarta 220,000 1,080,000 1,300,000
5 Homecare area jakarta 3 shift area Botabek 248,000 2,153,000 2,401,000
6 Homecare area jakarta 3 shift area Jakarta 220,000 1,680,000 1,900,000
7 Visite dokter home care 50,000 650,000 700,000
8 Visite perawat/terapis/analis area Botabek 25,000 525,000 550,000
9 Visite perawat/terapis/analis area jakarta 25,000 420,000 445,000
8. PAKET TINDAKAN DAN MCU
1 Tindakan PCR 175,000 575,000 750,000
2 Tindakan PCR < 30 Orang 285,000 315,000 600,000
3 Tindakan PCR > 30 Orang 235,000 315,000 550,000
4 Tindakan PCR > 100 Orang 185,000 315,000 500,000
5 Sirkumsisi Cluster 3,409,000 6,091,000 9,500,000
6 Sirkumsisi OK 8,312,000 5,957,000 14,269,000
7 Gastroscopy (ODC) 6,067,000 7,213,000 13,280,000
8 Colonoscopy (ODC) 6,651,000 11,496,000 18,147,000
9 Gastroscopy & Colonoscopy (ODC) 7,419,000 17,582,000 25,001,000
10 Paket Perioperatif - Paket A 589,000 752,000 1,341,000
11 Paket Perioperatif - Paket B (Endoskopi & Bayi Tabung) 1,843,000 1,553,000 3,396,000
12 Paket Perioperatif - Paket C (OK) 2,809,000 2,711,000 5,520,000
13 Paket Perioperatif - Paket D (Transplantasi) 5,054,000 3,484,000 8,538,000
14 DPT 257,000 437,000 694,000
15 BCG 460,000 437,000 897,000
16 DT 242,000 437,000 679,000
17 DTPa 460,000 437,000 897,000
18 Campak 340,000 437,000 777,000
19 Hepatitis B 293,000 437,000 730,000
20 Influenza 433,000 437,000 870,000
21 Meningitis 334,000 437,000 771,000
22 MR 341,000 437,000 778,000
23 MMR 519,000 437,000 956,000
24 PCV 964,000 437,000 1,401,000
25 Polio Oral 254,000 437,000 691,000
26 Polio Injeksi 338,000 437,000 775,000
27 TT 271,000 437,000 708,000
28 Hepatitis A & B 568,000 437,000 1,005,000
29 Demam Tifoid 441,000 437,000 878,000
30 Rotavirus 523,000 437,000 960,000
31 Cervix (Kanker Leher Rahim) 1,105,000 437,000 1,542,000
32 Meningitis 334,000 437,000 771,000
VAKSIN COMBO KENCANA 1
33 939,000 437,000 1,376,000
Hexaxim (DTPa-hepB-IPV-Hib)
34 1,739,000 437,000 2,176,000
(Hexaxim - PCV)
35 2,098,000 437,000 2,535,000
(Hexaxim - PCV - Rotavirus)
JASA
PELAYANAN
36 2,368,000 437,000 2,805,000
(Hexaxim - PCV - Rotavirus-Influenza)
37 Paket MCU SKS-Jasmani 830,000 916,000 1,746,000
38 Paket MCU SKS-Zat Adiktif 392,000 639,000 1,031,000
39 Paket MCU SKS-Rohani (SKKJ) 197,000 735,000 932,000
40 Paket MCU Simply 633,000 478,000 1,111,000
41 Paket MCU Bronze 2,108,000 2,408,000 4,516,000
42 Paket MCU Silver 2,053,000 3,421,000 5,474,000
43 MCU GOLD (PRIA) 4,322,000 4,133,000 8,455,000
44 MCU GOLD (WANITA) 4,906,000 5,152,000 10,058,000
45 MCU PLATINUM (PRIA) 6,695,000 7,071,000 13,766,000
46 MCU PLATINUM (WANITA) 7,440,000 8,181,000 15,621,000
47 Paket Partus Normal 16,141,000 10,002,000 26,143,000
48 Paket Sectio Cesaria Tanpa Penyulit 20,499,000 24,666,000 45,165,000
49 Paket Brain Check Up 4,831,000 4,779,000 9,610,000
50 Paket Resiko Stroke 4,955,000 4,292,000 9,247,000
51 Paket Layak Kerja 3,385,000 2,951,000 6,336,000
52 Paket Diagnostik Nyeri Kepala/Migrain 3,772,000 3,469,000 7,241,000
53 Paket Gastroscopy (ODC) 6,087,000 7,213,000 13,300,000
54 Paket Colonoscopy (ODC) 6,651,000 11,496,000 18,147,000
55 Paket Gastroscopy & Colonoscopy (ODC) 7,419,000 17,582,000 25,001,000
KENCANA EXECUTIVE 24 JAM
JASA JASA
NO NAMA TINDAKAN TARIF
SARANA PELAYANAN
1. KONSULTASI
1 Adminitrasi Executive 24 Jam 372.000 - 372.000
2 Konseling khusus 231.000 237.000 468.000
3 Konsultasi A 175.000 473.000 648.000
4 Konsultasi B 175.000 675.000 850.000
1 Angkat drain 90.000 10.000 100.000
2 Bilas lambung dengan NGT 138.000 15.000 153.000
3 code blue 154.000 17.000 171.000
4 Cukur gundul 52.000 6.000 58.000
5 EKG record 42.000 6.000 48.000
6 Ganti Balutan Besar 712.000 199.000 911.000
7 Ganti Balutan Besar Sulit 1.217.000 496.000 1.713.000
8 Ganti Balutan Kecil 694.000 67.000 761.000
9 Ganti Balutan Sedang 694.000 133.000 827.000
10 Melakukan Penis / vulva Hygine 87.000 10.000 97.000
11 Melakukan perawatan WSD 245.000 26.000 271.000
12 Melepas kateter 160.000 17.000 177.000
13 Memandikan pasien di tempat tidur 185.000 19.000 204.000
14 Memasang NGT 137.000 15.000 152.000
15 Memberi obat melalui inhalasi 243.000 25.000 268.000
16 Memberi terapi inj IM 59.000 7.000 66.000
17 Memberi terapi inj IV 108.000 11.000 119.000
18 Memberi tranfusi 285.000 30.000 315.000
19 Neurorestorasi 432.000 44.000 476.000
20 Pemasangan infus 176.000 18.000 194.000
21 Pemasangan kateter 270.000 27.000 297.000
22 Pemasangan Syringe Pump 90.000 10.000 100.000
23 Pemberian kemoterapi 265.000 27.000 292.000
24 Pemberian terapi inj sub cutan 59.000 7.000 66.000
25 Perawatan colostomi 707.000 72.000 779.000
26 Perawatan fistel peri anal 141.000 15.000 156.000
27 Perawatan illiustomi 935.000 95.000 1.030.000
28 Perawatan Kateter 265.000 27.000 292.000
29 Perawatan luka besar 376.000 38.000 414.000
30 Perawatan luka kecil 233.000 25.000 258.000
31 Perawatan luka sedang 292.000 30.000 322.000
32 Perawatan nefrostomi 204.000 22.000 226.000
33 Perawatan sistostomi 185.000 19.000 204.000
34 Perawatan urostomi 700.000 71.000 771.000
35 Spulling Kateter 338.000 34.000 372.000
36 Tindakan Vena sektie 104.000 11.000 115.000
3. NON OPERATIF
3.1 DENTISTRY
1 Ablatio 806.000 1.369.000 2.175.000
2 Aktivator 3.184.000 3.062.000 6.246.000
3 Alat Cekat Ceramic RA dan RB (Damon) Komplek* 3.375.000 16.302.000 19.677.000
4 Alat Cekat Ceramic RA dan RB (Damon)* 3.375.000 16.302.000 19.677.000
5 Alat Cekat Ceramic RA dan RB (MBT) Komplek* 3.375.000 16.302.000 19.677.000
6 Alat Cekat Ceramic RA dan RB (MBT)* 3.375.000 16.302.000 19.677.000
JASA JASA
SARANA PELAYANAN
7 Alat Cekat Metal RA dan RB (Damon) Komplek* 3.375.000 16.302.000 19.677.000
8 Alat Cekat Metal RA dan RB (Damon)* 3.375.000 16.302.000 19.677.000
9 Alat Cekat Metal RA dan RB (MBT) Komplek* 3.375.000 16.302.000 19.677.000
10 Alat Cekat Metal RA dan RB (MBT)* 3.375.000 16.302.000 19.677.000
11 Alat Cekat Metal RA/RB* 3.375.000 16.302.000 19.677.000
12 Alveolektomi Per Regio 1.009.000 1.197.000 2.206.000
13 Alveolektomi Per Regio 1.009.000 1.553.000 2.562.000
14 Analisa 280.000 331.000 611.000
15 Apeksreseksi 809.000 1.280.000 2.089.000
16 Apeksreseksi 809.000 970.000 1.779.000
17 Band Gigi Fraktur 380.000 373.000 753.000
18 Bongkar Crown/ per Unit 778.000 671.000 1.449.000
19 Bongkar Pin / Unit 778.000 671.000 1.449.000
20 Bongkar Prothesa/ Unit 1.035.000 1.267.000 2.302.000
21 Buka Fiksasi /Archbar 404.000 1.112.000 1.516.000
22 Buka Jahitan (kasus Bedah Mulut) 183.000 553.000 736.000
23 Buka Jahitan (Kasus Perio) 183.000 242.000 425.000
24 Cetak Alginate 222.000 218.000 440.000
25 Cetak Alginate 222.000 218.000 440.000
28 Chin Cup 339.000 1.826.000 2.165.000
29 Composite Besar 613.000 700.000 1.313.000
30 Composite Kecil 445.000 540.000 985.000
31 Debonding / Slicing (kasus ortho) 354.000 265.000 619.000
32 Debridement 619.000 1.267.000 1.886.000
33 Dental Implant 1.375.000 18.630.000 20.005.000
34 Eksisi Mucocele 958.000 932.000 1.890.000
35 Eksisi Tumor Jinak 1.527.000 1.863.000 3.390.000
36 Eliminasi Trauma Lokal 759.000 362.000 1.121.000
37 Enukleasi Kista 1.136.000 3.230.000 4.366.000
38 Facebow Transfer 765.000 397.000 1.162.000
39 Facemask 5.045.000 1.553.000 6.598.000
40 Feeding plate 847.000 1.491.000 2.338.000
41 Fiber post 538.000 1.087.000 1.625.000
42 Fixed Retainer RA & RB 3.321.000 3.714.000 7.035.000
43 Fixed Retainer RA / RB saja 2.084.000 2.165.000 4.249.000
44 Flexi Denture Bilateral * 1.074.000 2.484.000 3.558.000
45 Flexi Denture Unilateral * 1.074.000 2.143.000 3.217.000
46 Foto Slide 149.000 172.000 321.000
47 Full Denture per rahang* 3.103.000 7.297.000 10.400.000
48 Ganti Band baru 337.000 187.000 524.000
49 Ganti Bracket baru 329.000 187.000 516.000
50 Ganti Kawat baru 288.000 158.000 446.000
51 GIC besar 312.000 545.000 857.000
52 GIC besar 312.000 318.000 630.000
53 GIC kecil 198.000 318.000 516.000
54 Gingivextomy/ Frenectomy 773.000 1.211.000 1.984.000
55 GTS Frame per rahang * 1.049.000 2.403.000 3.452.000
56 Head Gear 3.370.000 1.575.000 4.945.000
57 Home Bleaching * 851.000 1.398.000 2.249.000
58 In Office Bleaching * 1.252.000 3.726.000 4.978.000
59 Incisi Abses 958.000 877.000 1.835.000
60 Incisi Biopsi 958.000 1.274.000 2.232.000
61 Incisi/cauterisasi 958.000 411.000 1.369.000
JASA JASA
SARANA PELAYANAN
62 Inj Scleret Agent 489.000 559.000 1.048.000
63 InLay / OnLay * 1.237.000 1.957.000 3.194.000
64 Inlay/Onlay * 1.237.000 1.957.000 3.194.000
65 Inlay/Onlay * Pedo 1.237.000 1.957.000 3.194.000
66 Invisalign* 3.375.000 16.302.000 19.677.000
67 Karet Intra Oral 141.000 311.000 452.000
68 Kasus Penyakit Infeksi 299.000 257.000 556.000
69 Kasus Penyakit Mulut 314.000 253.000 567.000
70 Kontrol (Kasus Perio) 326.000 311.000 637.000
71 Kontrol Alat Cekat 207.000 389.000 596.000
72 Kontrol Alat Lepasan 206.000 389.000 595.000
73 Kontrol Alat Lepasan 206.000 234.000 440.000
74 Kontrol Alat Retainer 208.000 389.000 597.000
75 Kontrol NAM 277.000 389.000 666.000
76 Kontrol Penyakit Mulut 258.000 311.000 569.000
77 Kontrol Prothesa 531.000 323.000 854.000
78 Kuret per Gigi 642.000 522.000 1.164.000
79 Labial Veneer Direct 951.000 932.000 1.883.000
80 Labial Veneer In Direct * 1.326.000 4.472.000 5.798.000
81 Mahkota All Poecelain* 1.228.000 5.465.000 6.693.000
82 Mahkota all Porcelain* 1.228.000 5.465.000 6.693.000
83 Mahkota Metal Porcelain * 771.000 3.882.000 4.653.000
84 Mahkota Metal Porcelain* 771.000 3.882.000 4.653.000
85 Mahkota Sementara Direct 538.000 389.000 927.000
86 Mahkota Sementara In Direct * 492.000 620.000 1.112.000
87 Mahkota Sementara In Direct * 492.000 620.000 1.112.000
88 Mocking * 362.000 466.000 828.000
89 Naso Alveolar Molding 2.167.000 2.403.000 4.570.000
90 Nekropsi 789.000 372.000 1.161.000
91 Obturator * 790.000 1.211.000 2.001.000
92 Occlusal adjustment 365.000 500.000 865.000
93 Occlusal adjustment / coronoplasty 365.000 516.000 881.000
94 Occlusal Splint 782.000 932.000 1.714.000
95 OD M3 IMP Kls I 1.580.000 4.832.000 6.412.000
96 OD M3 IMP Kls II 1.585.000 5.652.000 7.237.000
97 OD M3 IMP Kls III 2.156.000 6.210.000 8.366.000
98 Open flap debridement perregio 843.000 1.453.000 2.296.000
99 Operkulektomi 1.421.000 1.211.000 2.632.000
100 Operkulektomi (Kasus Bedah Mulut) 1.538.000 1.942.000 3.480.000
101 Oral Profilaksis/DHE 412.000 373.000 785.000
102 Ortho Removable RA + RB * pedo 1.384.000 2.544.000 3.928.000
103 Paper Surgery 426.000 265.000 691.000
104 Pasang Band Lepas 142.000 113.000 255.000
105 Pasang Bracket Lepas 184.000 141.000 325.000
106 Penambahan Elemen * 441.000 411.000 852.000
107 Penambahan Wing 700.000 646.000 1.346.000
108 Pencabutan dgn suntik 505.000 389.000 894.000
109 Pencabutan Gigi 505.000 700.000 1.205.000
110 Pencabutan Gigi dengan komplikasi 817.000 1.211.000 2.028.000
111 Pencabutan tanpa suntik 306.000 304.000 610.000
112 Pengisian 1 SA 304.000 466.000 770.000
113 Pengisian 2 SA 411.000 504.000 915.000
114 Pengisian 3 atau lebih SA 509.000 540.000 1.049.000
115 Pengisian PSA Gigi Sulung Anterior (1 Saluran Akar) 410.000 411.000 821.000
116 Pengisian PSA Gigi Sulung Posterior ( 2 atau 3 Saluran Akar) 567.000 447.000 1.014.000
JASA JASA
SARANA PELAYANAN
117 Pin Casting * 482.000 877.000 1.359.000
118 Pin Ready Made Metal 1.271.000 1.087.000 2.358.000
119 Pit & Fissure sealant 292.000 311.000 603.000
120 Pit and Fissure Sealent 292.000 311.000 603.000
121 Plat Prothesa* 694.000 1.739.000 2.433.000
122 Plat Removable Aktif Sedang RA/ RB Saja 1.602.000 2.429.000 4.031.000
123 Plat Removable Aktif Ringan RA / RB saja 1.602.000 2.429.000 4.031.000
124 Plat Removable Aktif Sedang RA / RB saja 1.708.000 2.429.000 4.137.000
125 Posterior Bite Riser Dengan Tambalan 179.000 322.000 501.000
126 Posterior Bite Riser Plat 889.000 1.134.000 2.023.000
127 Premedikasi 149.000 234.000 383.000
128 Premedikasi 149.000 234.000 383.000
129 PSA 1 SA 280.000 447.000 727.000
130 PSA 2 SA 378.000 557.000 935.000
131 PSA 3 SA 469.000 578.000 1.047.000
132 PSA Gigi Sulung Anterior (1 Saluran Akar) 420.000 466.000 886.000
133 PSA Gigi Sulung Posterior ( 2 atau 3 Saluran Akar) 573.000 485.000 1.058.000
134 PSA One Visit 1 SA 1.157.000 1.808.000 2.965.000
135 PSA One Visit 2 SA 1.415.000 2.171.000 3.586.000
136 PSA One Visit 3 atau lebih SA 1.912.000 2.274.000 4.186.000
137 Pulp Capping 346.000 349.000 695.000
138 Quad Helix 1.581.000 1.500.000 3.081.000
139 Rapid Palatal Expansion 1.851.000 2.143.000 3.994.000
140 Reline/Rebase : Soft Liner 781.000 685.000 1.466.000
141 Removable Retainer RA & RB 1.384.000 1.916.000 3.300.000
142 Removable Retainer RA/RB saja 951.000 1.321.000 2.272.000
143 Rep. Fix dgn Arcbar ( 1 rahang ) 1.442.000 2.174.000 3.616.000
144 Rep. Fix dgn Arcbar ( RA & RB ) 1.913.000 4.006.000 5.919.000
145 Reparasi Kompleks 612.000 648.000 1.260.000
146 Reparasi Ringan : Reparasi Kawat 543.000 685.000 1.228.000
147 Reparasi Ringan : Reparasi Patah 543.000 707.000 1.250.000
148 Reposisi Disi TMJ 1.595.000 1.242.000 2.837.000
149 RMGIC/MRGIC besar 465.000 545.000 1.010.000
150 RMGIC/MRGIC besar 465.000 318.000 783.000
151 RMGIC/MRGIC kecil 324.000 318.000 642.000
152 Seal Protect 81.000 203.000 284.000
153 Sementasi Ulang 477.000 624.000 1.101.000
154 Separasi 330.000 153.000 483.000
155 Sialometri 126.000 59.000 185.000
156 Single Denture* 1.336.000 7.763.000 9.099.000
157 Skeling 1 Kuadran 324.000 319.000 643.000
158 Skeling 2 Kuadran 465.000 358.000 823.000
159 Skeling 3 Kuadran 605.000 435.000 1.040.000
160 Skeling 4 Kuadran 744.000 513.000 1.257.000
161 Space Maintainer Removable 1 Gigi 473.000 1.491.000 1.964.000
162 Splinting Per Gigi 829.000 1.166.000 1.995.000
163 Surgical Wafer Splint (1 splint) 1.954.000 2.857.000 4.811.000
164 Tambal Sementara 229.000 327.000 556.000
165 Temporary Anchorage Device 1.433.000 2.050.000 3.483.000
166 Topical Fluor Application (kasus konservasi gigi) RA / RB 350.000 335.000 685.000
167 Topical Fluor application (kasus perio) RA / RB 350.000 210.000 560.000
168 Trans Palatal Arch 1.961.000 1.476.000 3.437.000
169 Windowing EXP 1.380.000 1.863.000 3.243.000
3.2 WELLNESS
1 AkuPressure Estetik 95.000 156.000 251.000
JASA JASA
SARANA PELAYANAN
2 Asesmen dengan Cardiopulmonary exercise testing 534.000 777.000 1.311.000
3 Asesmen dengan Motion and gait analyzer 437.000 1.166.000 1.603.000
4 Asesmen fungsi seksual 322.000 311.000 633.000
5 Chest Terapi 183.000 156.000 339.000
6 Dry Needling @ 5 Titik 173.000 234.000 407.000
7 Elektro Akupunktur 123.000 389.000 512.000
8 580.000 311.000 891.000
9 Evaluasi kapasitas fungsional return to activities 333.000 1.166.000 1.499.000
10 Evaluasi kapasitas fungsional return to work 333.000 1.166.000 1.499.000
11 Evaluasi Kemampuan Intelektual (Test IQ) 586.000 341.000 927.000
12 Evaluasi USG neuromuskuloskeletal 337.000 311.000 648.000
13 Farmakopunktur 123.000 389.000 512.000
14 Functional check up 113.000 311.000 424.000
15 Laserpunktur (Laser Needle Multilead) 95.000 824.000 919.000
16 Laserpunktur (Laser Pen) 49.000 621.000 670.000
17 Layanan Psikologis Lainnya 586.000 341.000 927.000
18 Low Level Laser Therapy 165.000 185.000 350.000
19 Manual Akupunktur 103.000 234.000 337.000
20 Pemeriksaan Kedokteran Fisik dan Rehabilitasi Komprehensif 161.000 260.000 421.000
21 Pengukuran, Fitting, Revisi Orthosis dan Sepatu 130.000 234.000 364.000
22 130.000 234.000 364.000
23 Peresepan dan Check Out Prosthesis 130.000 234.000 364.000
24 Press Needle Punktur 49.000 156.000 205.000
Rehab psikososial, lingkungan, rumah, dan hambatan kerja;
25 164.000 145.000 309.000
26 Rehabilitasi vokasional dan okupasi 122.000 234.000 356.000
27 Sonopunktur 103.000 156.000 259.000
28 Tatalaksana dengan Human Body Equilibrium 501.000 777.000 1.278.000
29 Tatalaksana dengan Virtual Reality 229.000 1.166.000 1.395.000
30 Tatalaksana dengan Work simulator 721.000 777.000 1.498.000
31 Tatalaksana gangguan berbahasa 180.000 234.000 414.000
32 Tatalaksana gangguan berbahasa tidak spesifik : disleksia, dispraksia 180.000 234.000 414.000
33 96.000 234.000 330.000
menelan
34 Tatalaksana gangguan proses bicara pada kelainan kraniofasial 91.000 234.000 325.000
35 183.000 204.000 387.000
36 Terapi edukasi & Home Program 102.000 187.000 289.000
37 Terapi Extracorporeal Shock Wave 198.000 311.000 509.000
38 Terapi imobilisasi sendi dengan casting dan splinting 133.000 234.000 367.000
39 Terapi inhalasi 117.000 117.000 234.000
40 Terapi Injeksi Botulinum Toksin A @ 5 titik 173.000 296.000 469.000
41 Terapi Injeksi Botulinum Toksin A dengan Panduan USG @ 5 titik 173.000 296.000 469.000
42 173.000 296.000 469.000
43 173.000 296.000 469.000
44 173.000 296.000 469.000
Terapi injeksi substansi terapeutik dengan panduan USG
45 173.000 296.000 469.000
Muskuloskeletal (tendon)
46 250.000 234.000 484.000
Jalan)
JASA JASA
SARANA PELAYANAN
47 Terapi latihan bicara esofageal 91.000 234.000 325.000
48 Terapi latihan dengan Neuromuscular Activation System 418.000 311.000 729.000
49 Terapi latihan dengan robotic system 842.000 1.553.000 2.395.000
50 Terapi Latihan Kebugaran Kardiorespirasi 292.000 172.000 464.000
51 179.000 234.000 413.000
osteoporosis, koreksi postur, robotik, virtual reality
52 Terapi Latihan Lingkup Gerak Sendi Ekstremitas 72.000 117.000 189.000
53 114.000 117.000 231.000
Dasar Panggul)
54 99.000 234.000 333.000
55 Terapi Latihan Lingkup Gerak Sendi Tulang Belakang 117.000 117.000 234.000
56 Terapi Latihan menggunakan ortosis, prostesis, dan alat bantu jalan 110.000 117.000 227.000
57 Terapi Latihan Penguatan Otot 187.000 117.000 304.000
58 Terapi Latihan Peregangan 154.000 117.000 271.000
59 spirometry, inspiratory muscle training, positive expiratory pressure, 165.000 210.000 375.000
60 Terapi Manipulasi Sendi Ekstremitas 188.000 234.000 422.000
61 Terapi Manipulasi Sendi Kraniofasial dan Lainnya 188.000 234.000 422.000
62 Terapi Manipulasi Sendi Vertebra 127.000 234.000 361.000
63 Terapi Manual Limfatik, Fascia, dan Otot 162.000 272.000 434.000
64 Terapi Modalitas : PTNS, NMES 169.000 234.000 403.000
65 Terapi Modalitas : Tapping Straping 169.000 185.000 354.000
66 Terapi Modalitas : TENS, ES 169.000 118.000 287.000
67 Terapi Modalitas Diatermi: US, MWD, SWD 157.000 118.000 275.000
68 Terapi Modalitas Panas Superfisial: Parafin Bath, IRR 140.000 102.000 242.000
69 Terapi Modalitas Traksi 150.000 156.000 306.000
70 Terapi Modalitas: Dingin (Ice Massage/ Vapocoolant spray) 238.000 118.000 356.000
71 Terapi musik 118.000 234.000 352.000
72 Terapi perilaku 137.000 234.000 371.000
73 Terapi rekreasi 162.000 117.000 279.000
74 137.000 234.000 371.000
75 Thread Embedded Akupunktur (TEA) 810.000 777.000 1.587.000
76 Thread Embedded Akupunktur (TEA) Estetik 1.620.000 2.329.000 3.949.000
77 Uji Fungsi Defekasi 117.000 117.000 234.000
78 Uji Fungsi Kekuatan Otot menggunakan alat 203.000 234.000 437.000
79 Uji Fungsi Persepsi dan Kognisi 122.000 234.000 356.000
dan proprioseptif, Komunikasi, Motorik halus anak, Fungsi Koordinasi
80 249.000 234.000 483.000
dan Deksteritas Manual, Kardiorespirasi, Spirometri, AKS,
Vokasional, Uji Fungsi Berkemih)
81 130.000 234.000 364.000
82 USG muskuloskeletal 445.000 311.000 756.000
3.3 TERATAI
1 Aff or Repair pleural drain 677.000 522.000 1.199.000
2 Argon Plasma Coagulation 14.463.000 11.143.000 25.606.000
3 Argon Plasma Coagulation dengan sedasi 16.657.000 12.834.000 29.491.000
4 Aspirasi pneumotoraks / Lung 748.000 577.000 1.325.000
5 Balon dilatasi saluran nafas 26.331.000 20.288.000 46.619.000
6 Balon dilatasi saluran nafas dengan sedasi 28.491.000 21.953.000 50.444.000
JASA JASA
SARANA PELAYANAN
7 Biopsi KGB 2.031.000 1.565.000 3.596.000
8 Biopsi pleura 939.000 724.000 1.663.000
9 BMP + Biopsi SUMSUM TULANG 108.000 1.849.000 1.957.000
10 BMP SUMSUM TULANG 549.000 924.000 1.473.000
11 BRONKOKOPI + TBLB guided EBUS Radial 23.230.000 17.899.000 41.129.000
12 BRONKOKOPI + TBLB guided EBUS Radial dengan sedasi 25.424.000 19.589.000 45.013.000
13 Bronkoskopi + BAL 4.785.000 3.687.000 8.472.000
14 Bronkoskopi + BAL dengan sedasi 6.945.000 5.351.000 12.296.000
15 Bronkoskopi + Brushing 6.629.000 5.108.000 11.737.000
16 Bronkoskopi + Brushing + Biopsi 9.229.000 7.111.000 16.340.000
17 Bronkoskopi + Brushing + Biopsi dengan sedasi 11.423.000 8.801.000 20.224.000
18 Bronkoskopi + Brushing dengan sedasi 8.823.000 6.798.000 15.621.000
19 Bronkoskopi + TBLB Blind 9.229.000 7.111.000 16.340.000
20 Bronkoskopi + TBLB Blind dengan sedasi 11.423.000 8.801.000 20.224.000
21 Bronkoskopi + TBLB guided Fluroskopi 9.455.000 7.284.000 16.739.000
22 Bronkoskopi + TBLB guided Fluroskopi dengan sedasi 11.648.000 8.975.000 20.623.000
23 Bronkoskopi+ TBNA Konvensional 13.762.000 10.603.000 24.365.000
24 Bronkoskopi+ TBNA Konvensional dengan sedasi 15.956.000 12.294.000 28.250.000
25 CRYOTHERAPY 17.375.000 13.387.000 30.762.000
26 CRYOTHERAPY dengan sedasi 19.569.000 15.077.000 34.646.000
27 CVC 3.346.000 2.578.000 5.924.000
28 EBUS Diagnostik 6.694.000 5.157.000 11.851.000
29 EBUS Diagnostik dengan sedasi 8.888.000 6.848.000 15.736.000
30 EBUS Linier + TBNA 27.399.000 21.110.000 48.509.000
31 EBUS Linier + TBNA dengan sedasi 29.592.000 22.801.000 52.393.000
32 Ekstraksi Benda Asing 21.981.000 16.936.000 38.917.000
33 Ekstraksi Benda Asing dengan sedasi 24.175.000 18.628.000 42.803.000
34 Fibrinolitik Intrapleura 863.000 665.000 1.528.000
35 Fibrinolitik Lanjutan 558.000 430.000 988.000
36 FNAB 819.000 2.019.000 2.838.000
37 FNAB /Aspirasi jarum halus KGB 554.000 427.000 981.000
38 Indwelling Pleural Catheter 17.637.000 13.590.000 31.227.000
39 Indwelling Pleural Catheter dengan sedasi 19.831.000 15.280.000 35.111.000
40 Infus obat (drip) 207.000 199.000 406.000
41 Inhalasi/Induksi Sputum 419.000 323.000 742.000
42 Injeksi Obat 2.305.000 67.000 2.372.000
43 Intubasi 1.788.000 1.377.000 3.165.000
44 Kemoterapi A 1.413.000 396.000 1.809.000
45 Kemoterapi B 329.000 661.000 990.000
46 Kemoterapi C 83.000 924.000 1.007.000
47 Mantuox Tes 200.000 154.000 354.000
48 Patch Test 1.376.000 234.000 1.610.000
49 Pemasangan stent metal saluran napas 35.165.000 27.095.000 62.260.000
50 Pemasangan stent metal saluran napas dengan sedasi 37.325.000 28.760.000 66.085.000
51 Pemasangan stent silikon saluran napas 48.699.000 37.524.000 86.223.000
52 Pemasangan stent silikon saluran napas dengan sedasi 50.928.000 39.241.000 90.169.000
53 Pemeriksaan PCR Corona Virus 851.000 770.000 1.621.000
54 PICC 6.412.000 4.940.000 11.352.000
55 Pleurodesis Bleomycin 736.000 567.000 1.303.000
56 Pleurodesis Doksisiklin 869.000 669.000 1.538.000
57 Pleurodesis Talc 736.000 567.000 1.303.000
58 Pungsi Pleura / Torakosintesis 910.000 701.000 1.611.000
59 Skin Prick Test 1.955.000 793.000 2.748.000
60 Small Pleural Catheter 2.796.000 2.155.000 4.951.000
61 Spirometri 283.000 218.000 501.000
JASA JASA
SARANA PELAYANAN
62 Spirometri 2.534.000 185.000 2.719.000
63 Spirometri dengan bronkodilator 291.000 225.000 516.000
64 Tapping/ Plebotomi (terapeutik dan diagnostik) 3.112.000 133.000 3.245.000
65 Terapi Oksigen 107.000 83.000 190.000
66 Tes Mantoux 1.957.000 156.000 2.113.000
67 TORAKOSKOPI MEDIS 12.663.000 9.757.000 22.420.000
68 TORAKOSKOPI MEDIS dengan sedasi 14.857.000 11.447.000 26.304.000
69 Transfusi darah 2 Jam 3.586.000 265.000 3.851.000
70 Transfusi darah 2-4 Jam 3.586.000 396.000 3.982.000
71 Transfusi darah 4-6 Jam 3.586.000 661.000 4.247.000
72 Transfusi darah 6-8 Jam 327.000 924.000 1.251.000
73 Transfusi darah tanpa filter 387.000 265.000 652.000
74 TTB 2.075.000 1.599.000 3.674.000
75 TTB guided CT Scan 3.496.000 2.692.000 6.188.000
76 TTNA 925.000 713.000 1.638.000
77 USG Thorax/Colli 297.000 229.000 526.000
78 WSD Chest Tube Konvensional 4.198.000 3.234.000 7.432.000
79 WSD Chest Tube Seldinger 8.003.000 6.166.000 14.169.000
3.4 ENT
1 ABR Click 674.000 396.000 1.070.000
2 ABR dengan Sedasi BARU 1.234.000 265.000 1.499.000
3 ABR Skrining 572.000 265.000 837.000
4 Aff T-Tube 1.781.000 3.960.000 5.741.000
5 Analisis Suara 401.000 396.000 797.000
6 Angkat Tampon 470.000 466.000 936.000
7 Angkat Tampon Hidung 401.000 466.000 867.000
8 ASSR 627.000 528.000 1.155.000
9 ASSR dengan Sedasi BARU 908.000 528.000 1.436.000
10 Audiometri Nada Murni 566.000 199.000 765.000
11 Audiometri Tutur 401.000 466.000 867.000
12 Benda asing Dengan Penyulit 459.000 466.000 925.000
13 Bera Click 553.000 396.000 949.000
14 Bera Skrining 511.000 265.000 776.000
15 Bera Skrining (anestesi) 511.000 466.000 977.000
16 Bera Tonebrust 553.000 466.000 1.019.000
17 Biopsi hipofaring Onko 453.000 528.000 981.000
18 Biopsi Nasofaring Onko 1.801.000 661.000 2.462.000
19 Biopsi Telinga 1.126.000 396.000 1.522.000
20 Biopsi Tumor - Nasofaring 819.000 661.000 1.480.000
21 Biopsi Tumor - Oro / Hipofaring 738.000 528.000 1.266.000
22 Biopsi Tumor - Rongga Hidung 738.000 396.000 1.134.000
23 Biopsi Tumor - Telinga 738.000 396.000 1.134.000
24 Bronkoskopi Diagnostik 1.673.000 4.223.000 5.896.000
25 CRT (Canalith Retraining Therapy) 401.000 777.000 1.178.000
26 Dekanulasi 578.000 777.000 1.355.000
27 Ear Toilet 462.000 466.000 928.000
28 Ekstraksi Benda Asing 569.000 466.000 1.035.000
29 Ekstraksi Benda Asing Hidung 1.421.000 466.000 1.887.000
30 Ekstraksi Cerumen - Mudah 260.000 234.000 494.000
31 Ekstraksi Cerumen - Sulit 401.000 466.000 867.000
32 Ekstraksi Polip 566.000 777.000 1.343.000
33 Ekstraksi Serumen Mudah/ Sulit 1.056.000 466.000 1.522.000
34 Ekstrasi Benda Asing Hidung - Mudah 401.000 265.000 666.000
35 Ekstrasi Benda Asing Telinga - Mudah 401.000 265.000 666.000
36 Ekstrasi Benda Asing Telinga - Sulit 511.000 466.000 977.000
JASA JASA
SARANA PELAYANAN
37 Ekstrasi Benda Asing Tenggorok - Mudah 401.000 265.000 666.000
38 Ekstrasi Benda Asing Tenggorok - Sulit 464.000 466.000 930.000
39 ENG 819.000 777.000 1.596.000
40 ENG Komp 420.000 777.000 1.197.000
41 FEES 666.000 1.476.000 2.142.000
42 Fleksibel RFL 1.673.000 545.000 2.218.000
43 Ganti Canul Tracheostomi 511.000 661.000 1.172.000
44 Ganti Kanul 626.000 661.000 1.287.000
45 Insisi / Aspirasi Abses Peritonsil (Anestesi lokal) 180.000 777.000 957.000
46 Insisi / Aspirasi Abses Telinga (termasuk Odhematom / Pseudokista) 180.000 466.000 646.000
47 Insisi Abses 835.000 777.000 1.612.000
48 Insisi Abses Peritonsil 632.000 777.000 1.409.000
49 Insisi Abses/Hematoma Septum 1.068.000 777.000 1.845.000
50 Irigasi Liang Telinga 623.000 466.000 1.089.000
51 Irigasi Telinga 401.000 466.000 867.000
52 Kaustik Hidung 891.000 311.000 1.202.000
53 Kaustik Faring 423.000 311.000 734.000
54 Kauter Konka 1.423.000 1.321.000 2.744.000
55 Mapping 511.000 466.000 977.000
56 Mapping implant koklea 262.000 466.000 728.000
57 Miringotomy 401.000 466.000 867.000
58 Nasal Toilet 725.000 234.000 959.000
59 Nasoendoskopi Rigid 878.000 234.000 1.112.000
60 Otoakustik Emission 566.000 265.000 831.000
61 Otoakustik Emission (anestesi) 553.000 4.658.000 5.211.000
62 Otomikroskopi Diagnostik 534.000 466.000 1.000.000
63 Parasintesis 658.000 466.000 1.124.000
64 Pasang grommet 604.000 777.000 1.381.000
65 Pasang NGT dengan Guiding 1.842.000 777.000 2.619.000
66 Pasang NGT dengan Guiding Endoscopy (ENT) 738.000 777.000 1.515.000
67 Pasang Tampon 883.000 389.000 1.272.000
68 Pasang Tampon Hidung 401.000 389.000 790.000
69 Pasang Tampon Telinga 260.000 234.000 494.000
70 Patch Test Diagnostik 616.000 466.000 1.082.000
71 Pemeriksaan Keseimbangan Dengan (Frenzel Videoscope) 553.000 777.000 1.330.000
72 Pemeriksaan N.Fasialis 401.000 466.000 867.000
73 Polipektomi 1.141.000 777.000 1.918.000
74 Posturografi 401.000 777.000 1.178.000
75 Posturografi NO 928.000 777.000 1.705.000
76 Pseudokista 659.000 466.000 1.125.000
77 Skin Prick Tes 553.000 793.000 1.346.000
78 Smell test 401.000 621.000 1.022.000
79 Stroboskopi 796.000 2.329.000 3.125.000
80 Terapi Bicara 350.000 311.000 661.000
81 Tes Keseimbangan dg Frenzel 254.000 777.000 1.031.000
82 Tes keseimbangan sederhana 464.000 777.000 1.241.000
83 Tes Shelong 401.000 265.000 666.000
84 Test Alergi Skin Prick Test 870.000 793.000 1.663.000
85 Test Psikoakustik Tinitus 401.000 777.000 1.178.000
86 Test Sniffin 1.105.000 1.242.000 2.347.000
87 Timpanometri 153.000 199.000 352.000
88 Tone burst Kom 674.000 466.000 1.140.000
89 Trakeostomi 1.781.000 3.960.000 5.741.000
90 Tympanometri 566.000 199.000 765.000
3.5 REPRODUCTIVE
JASA JASA
SARANA PELAYANAN
1 Aspirasi kista dengan anestesi 5.812.000 2.904.000 8.716.000
2 Aspirasi kista tanpa anestesi 4.466.000 2.112.000 6.578.000
3 Biopsi endometrium 331.000 350.000 681.000
4 Businasi 323.000 466.000 789.000
6 HALLO TEST 1.938.000 505.000 2.443.000
7 Hidrotubasi 412.000 951.000 1.363.000
8 Hidrotubasi dengan anestesi 1.534.000 1.234.000 2.768.000
9 Histeroskopi Office Diagnostik 766.000 1.452.000 2.218.000
10 Histeroskopi Office Terapeutik 763.000 3.035.000 3.798.000
11 Histeroskopi Terapeutik 833.000 5.159.000 5.992.000
12 Inseminasi/IUI 5.958.000 2.250.000 8.208.000
13 Irigasi Vagina / Vulva Hygiene 295.000 79.000 374.000
14 Mikrokuret 312.000 350.000 662.000
15 Papsmear Konvesional 140.000 234.000 374.000
16 Papsmear LBC HPV DNA 137.000 234.000 371.000
17 Pasang/Lepas IUD 437.000 234.000 671.000
18 Pasang/Lepas IUD dengan anestesi 1.564.000 653.000 2.217.000
19 Sperma Analisa 1.770.000 303.000 2.073.000
20 suntik 146.000 40.000 186.000
21 USG 2D dengan print 569.000 156.000 725.000
22 USG 2D tanpa print 562.000 156.000 718.000
23 USG hamil 569.000 156.000 725.000
24 USG SIS 659.000 739.000 1.398.000
25 Washing sperma 6.032.000 1.253.000 7.285.000
3.6 WHC
1 Angkat Tampon 115.000 265.000 380.000
2 Biopsi 172.000 199.000 371.000
3 Businasi 319.000 466.000 785.000
4 Cryotherapy 366.000 311.000 677.000
6 Hidrotubasi 516.000 1.584.000 2.100.000
7 Irigasi Vagina / Vulva Hygiene 253.000 79.000 332.000
8 Kolposkopi 374.000 466.000 840.000
9 Kolposkopi & Biopsi 366.000 621.000 987.000
10 Kolposkopi dan LLETZ 374.000 661.000 1.035.000
11 Lepas IUD 208.000 234.000 442.000
12 Lepas Pesarium 141.000 265.000 406.000
13 Mikrokuret 275.000 311.000 586.000
14 NST/ CTG 206.000 158.000 364.000
15 Papsmear Thinprep 145.000 234.000 379.000
16 Pasang IUD 237.000 234.000 471.000
17 Pasang pesarium 192.000 265.000 457.000
18 Pasang Tampon 175.000 265.000 440.000
19 Pasang/lepas kateter 210.000 466.000 676.000
20 Pungsi Asites 621.000 1.957.000 2.578.000
21 Test Metilium Blue 500.000 466.000 966.000
22 USG 2D, USG Abdominal 422.000 528.000 950.000
23 USG 3D / 4D 582.000 621.000 1.203.000
3.7 DIGESTIVE
1 Anuskopi + ligasi 2.456.000 6.695.000 9.151.000
2 Anuskopi + ligasi 1.010.000 1.522.000 2.532.000
3 Aspirasi abses hepat guided USG 3.159.000 5.174.000 8.333.000
4 Aspirasi hepatoma guided USG 2.962.000 3.348.000 6.310.000
5 Aspirasi kista hati guided USG 3.159.000 5.174.000 8.333.000
JASA JASA
SARANA PELAYANAN
6 Aspirasi limpa guided USG 3.095.000 4.565.000 7.660.000
7 Aspirasi pankreas guided USG 3.095.000 4.565.000 7.660.000
8 Bilas lambung (Spooling NGT) 264.000 27.000 291.000
9 Bilas lambung (Spooling NGT) oleh dokter 358.000 914.000 1.272.000
10 Businasi Hurtz (Achalasia) + anestesia 449.000 4.261.000 4.710.000
11 Dilatasi Esofagus 2.561.000 24.344.000 26.905.000
12 Ekstraksi benda asing 5.704.000 20.997.000 26.701.000
13 Ekstraksi benda asing SCBB 6.582.000 20.997.000 27.579.000
14 Endoscopic Ultrasound Terapeutik 4.616.000 43.819.000 48.435.000
15 Endoscopy Submucosal Disection (ESD) SCBA 10.854.000 32.603.000 43.457.000
16 Endoscopy Submucosal Disection (ESD) SCBB 11.178.000 36.950.000 48.128.000
17 ERCP (terapetik) 21.559.000 43.819.000 65.378.000
18 ERCP + Ekstraksi batu 3.581.000 34.081.000 37.662.000
19 ERCP + Spingterotomi 2.304.000 21.910.000 24.214.000
20 ERCP + Stent Metal 2.633.000 24.953.000 27.586.000
21 ERCP + Stent Plastik 1.931.000 18.563.000 20.494.000
22 Esofagogastroduodenoskopi 825.000 7.913.000 8.738.000
23 Fibro Scan 264.000 2.740.000 3.004.000
24 Fungsi Asites 2.019.000 2.740.000 4.759.000
25 Gastroscopy 4.377.000 8.217.000 12.594.000
26 Gastroscopy + hemostasis 3.934.000 37.429.000 41.363.000
27 Hemostasis SCBB 6.950.000 24.344.000 31.294.000
28 Injeksi etanol 3.292.000 6.391.000 9.683.000
29 Injeksi Histoacril 5.704.000 20.997.000 26.701.000
30 Klisma 133.000 14.000 147.000
31 Klisma oleh dokter 227.000 914.000 1.141.000
32 Kolonoskopi 4.967.000 13.999.000 18.966.000
33 Kolonoskopi + Polipectomy 2.561.000 24.344.000 26.905.000
34 Ligasi hemoroid 2.282.000 5.174.000 7.456.000
35 Ligasi Varices Esofagus 4.967.000 13.999.000 18.966.000
36 Manometri 712.000 7.000.000 7.712.000
37 NGT Guided Endoscopy 4.716.000 11.565.000 16.281.000
38 NJT Guided Endoscopy 7790000 5.924.000 23.127.000 29.051.000
39 Pasang Infus 308.000 32.000 340.000
40 Pasang Infus oleh dokter 380.000 914.000 1.294.000
41 Pasang NGT 264.000 27.000 291.000
42 Pasang NGT oleh dokter 358.000 914.000 1.272.000
43 PEG 3.292.000 31.343.000 34.635.000
44 PEG + Asistensi 6.802.000 31.343.000 38.145.000
45 Pemasangan Flocare 4.433.000 8.825.000 13.258.000
46 Pemasangan kateter urine 264.000 27.000 291.000
47 Pemasangan PigTail 3.029.000 3.957.000 6.986.000
48 Pemasangan stent esofagus 2.063.000 19.779.000 21.842.000
49 Per Oral Endoscopy Myotomy (POEM) 23.037.000 39.123.000 62.160.000
50 pH Metri 712.000 7.000.000 7.712.000
51 Polipectomy SCBA 6.073.000 24.344.000 30.417.000
52 Polipectomy SCBB 6.950.000 24.344.000 31.294.000
53 PTBD 3.555.000 8.825.000 12.380.000
54 Rektoscopi / Rigit + Biopsi + Anestesi 351.000 3.348.000 3.699.000
55 Rektoscopi + ligasi 2.282.000 5.174.000 7.456.000
56 Rektoscopi/Rigit+Biopsi 1.668.000 2.740.000 4.408.000
57 Rektosigmoidoskopi 659.000 6.391.000 7.050.000
58 Rektosigmoidoskopi + Anestesi 659.000 6.391.000 7.050.000
59 RFA 5.135.000 23.736.000 28.871.000
60 Spy Glass (Belum termasuk sewa alat) 21.559.000 43.819.000 65.378.000
JASA JASA
SARANA PELAYANAN
61 STE Varises 4.967.000 13.999.000 18.966.000
62 Suction 264.000 27.000 291.000
63 Transnasal EGD 4.377.000 8.217.000 12.594.000
64 USG 620.000 914.000 1.534.000
65 USG biopsi 3.029.000 3.957.000 6.986.000
66 USG Blind Biopsi 3.095.000 4.565.000 7.660.000
67 USG Doppler 632.000 1.218.000 1.850.000
68 USG jarum halus 3.095.000 4.565.000 7.660.000
3.8 DIABETIC
1 Aspirasi + Injeksi Ethanol Tiroid dengan Panduan USG 936.000 7.763.000 8.699.000
2 Aspirasi Kista Tiroid 295.000 1.087.000 1.382.000
3 Aspirasi Kista Tiroid dengan Panduan USG 620.000 6.210.000 6.830.000
4 BAJAH Kista Tiroid 287.000 1.087.000 1.374.000
5 BAJAH Kista Tiroid dengan Panduan USG 615.000 6.210.000 6.825.000
6 BAJAH Nodul Tiroid 262.000 1.087.000 1.349.000
7 BAJAH Nodul Tiroid dengan Panduan USG 585.000 6.210.000 6.795.000
8 Deteksi dini Kaki Diabetes 177.000 311.000 488.000
9 Edukasi Diabetes 189.000 311.000 500.000
10 Injeksi intraartikular sendi besar 266.000 1.553.000 1.819.000
11 Injeksi intraartikular sendi kecil 256.000 1.166.000 1.422.000
12 Injeksi periartikuler 258.000 1.166.000 1.424.000
13 Perawatan Kaki 1-2 penebalan kuku dan kalus 260.000 389.000 649.000
14 Perawatan Kaki 3-5 penebalan kuku dan kalus 343.000 466.000 809.000
15 Perawatan Kaki 6 atau lebih penebalan kuku dan kalus 404.000 621.000 1.025.000
16 Pungsi sendi besar 268.000 1.553.000 1.821.000
17 Pungsi sendi kecil 262.000 1.166.000 1.428.000
18 Rawat luka terbuka besar (>11cm) 477.000 777.000 1.254.000
19 Rawat luka terbuka kecil (< 5cm) 296.000 389.000 685.000
20 Rawat luka terbuka sedang (6cm - 10cm) 389.000 621.000 1.010.000
21 Suntik IV/IM/SC 80.000 67.000 147.000
22 USG Guide Injeksi dan Pungsi 994.000 3.105.000 4.099.000
23 USG Muskuloskeletal 600.000 1.553.000 2.153.000
24 USG Tiroid dengan print 320.000 466.000 786.000
25 USG Tiroid tanpa print 316.000 466.000 782.000
3.9 URONEFRO
1 Biopsi Ginjal 3.056.000 3.105.000 6.161.000
2 BUSINASI 905.000 466.000 1.371.000
3 CIC 540.000 466.000 1.006.000
4 Elektrocauter Berat 1.411.000 528.000 1.939.000
5 Elektrocauter Sedang 742.000 358.000 1.100.000
6 ESWL 2.517.000 17.078.000 19.595.000
7 ESWL ULANG 2.517.000 13.662.000 16.179.000
8 Ganti Balutan 713.000 156.000 869.000
9 HD CITO 5.106.000 1.553.000 6.659.000
10 HD SLED (> 6 Jam) 5.106.000 1.553.000 6.659.000
11 Hemodialisis 2.572.000 777.000 3.349.000
12 Instilasi Obat Cystitat 621.000 466.000 1.087.000
13 MASSAGE PROSTAT 127.000 195.000 322.000
14 METHYLENE BLUE TEST 1.217.000 466.000 1.683.000
15 Pasang Urine Kateter 523.000 234.000 757.000
16 Pemasangan CDL Semi Permanen 8.199.000 5.550.000 13.749.000
17 Pemasangan CDL Temporary 8.202.000 4.271.000 12.473.000
18 Podophilin 306.000 199.000 505.000
19 URODINAMIK 8.100.000 2.563.000 10.663.000
20 UROFLOWMETRI 188.000 195.000 383.000
JASA JASA
SARANA PELAYANAN
21 Urostym 2.684.000 777.000 3.461.000
22 USG GINJAL 378.000 389.000 767.000
23 USG PROSTAT 378.000 389.000 767.000
24 USG TESTIS 412.000 389.000 801.000
25 Videourodinamik (OK) 15.091.000 6.210.000 21.301.000
3.10 PSIKIATRI
1 Paket CBT 216.000 528.000 744.000
2 Hipnoterapi 98.000 354.000 452.000
3 Motivational Enhancement Therapy 270.000 466.000 736.000
4 NCT 314.000 495.000 809.000
5 Forensik I 300.000 820.000 1.120.000
6 Forensik II 535.000 1.326.000 1.861.000
7 Forensik III 767.000 2.379.000 3.146.000
8 Psikoterapi Suportif 122.000 327.000 449.000
9 Psikoterapi Psikodinamik 176.000 576.000 752.000
10 Terapi Kelompok 179.000 261.000 440.000
11 Terapi keluarga 189.000 793.000 982.000
12 Terapi marital 127.000 631.000 758.000
13 MMPI 265.000 318.000 583.000
14 Remediasi Kognitif 279.000 225.000 504.000
3.11 BREAST
1 Angkat drain 91.000 106.000 197.000
2 Angkat Jahitan 115.000 234.000 349.000
3 Biopsi/ Eksisi Lokal 411.000 3.571.000 3.982.000
4 Core Biopsi 532.000 2.640.000 3.172.000
5 Core Biopsi (Guide) Tuntunan USG 470.000 3.695.000 4.165.000
6 Ekstirpasi 204.000 2.640.000 2.844.000
7 Evakuasi Hematom 412.000 42.000 454.000
8 Flushing cellsite 180.000 19.000 199.000
9 FNAB 304.000 2.019.000 2.323.000
10 FNAB + USG Guide 327.000 2.019.000 2.346.000
11 Ganti Verban Berat 218.000 777.000 995.000
12 Ganti Verban Ringan 87.000 156.000 243.000
13 Ganti Verban Sedang 171.000 466.000 637.000
14 Inj Kenacort 103.000 11.000 114.000
15 Injeksi Obat kemo/ Hormonal 148.000 15.000 163.000
16 Injeksi Obat subkutan 91.000 133.000 224.000
17 Injeksi Obat Zoladex 71.000 133.000 204.000
18 Pasang NGT 157.000 476.000 633.000
19 Rawat luka 118.000 199.000 317.000
20 Skin Test Alergi Obat 189.000 793.000 982.000
3.12 ESTETIK
1 Angkat Jahitan erat 308.000 990.000 1.298.000
2 Angkat Jahitan Ringan 140.000 199.000 339.000
3 Anoskopi 634.000 1.087.000 1.721.000
4 CO2 Lesi dengan Luas < 1/4 wajah (JR) 1.244.000 615.000 1.859.000
5 CO2 Lesi dengan Luas < 1/4 wajah (SR) 1.244.000 736.000 1.980.000
6 CO2 Lesi dengan Luas 1/2 wajah s.d seluruh wajah (JR) 3.204.000 1.325.000 4.529.000
7 CO2 Lesi dengan Luas 1/2 wajah s.d seluruh wajah (SR) 3.204.000 1.976.000 5.180.000
8 CO2 Lesi dengan Luas 1/4 wajah s.d 1/2 wajah (JR) 2.696.000 993.000 3.689.000
9 CO2 Lesi dengan Luas 1/4 wajah s.d 1/2 wajah (SR) 2.696.000 1.187.000 3.883.000
10 CO2 Lesi Terhitung (JR) 775.000 473.000 1.248.000
11 CO2 Lesi Terhitung (SR) 832.000 563.000 1.395.000
12 DIODE A (5 - 15) 563.000 100.000 663.000
13 DIODE B (15 - 30') 563.000 133.000 696.000
JASA JASA
SARANA PELAYANAN
14 DIODE C (>30') 715.000 173.000 888.000
15 Eksisi - Berat (SR) 2.696.000 1.321.000 4.017.000
16 Eksisi - Ringan (SR) 2.696.000 528.000 3.224.000
17 Eksisi - Sedang (SR) 2.696.000 924.000 3.620.000
18 Ekstraksi komedo - Berat 532.000 80.000 612.000
19 Ekstraksi komedo - Ringan 462.000 60.000 522.000
20 Ekstraksi komedo - Sedang 532.000 72.000 604.000
21 Ekstrasi Komedo Berat 557.000 80.000 637.000
22 Ekstrasi Komedo Ringan 280.000 60.000 340.000
23 Ekstrasi Komedo Sedang 392.000 72.000 464.000
24 Elektrokauter - Berat 788.000 528.000 1.316.000
25 Elektrokauter - Ringan 715.000 199.000 914.000
26 Elektrokauter - Sedang 775.000 358.000 1.133.000
27 Ganti Verban Berat 536.000 199.000 735.000
28 Ganti Verban Ringan 160.000 67.000 227.000
29 Ganti Verban Sedang 353.000 133.000 486.000
30 High Resolution Anoskopi 774.000 4.782.000 5.556.000
31 Injeksi Aetoksi Scerol 563.000 1.849.000 2.412.000
32 Injeksi BotoX I 7.443.000 1.321.000 8.764.000
33 Injeksi Botox II 14.494.000 1.321.000 15.815.000
34 Injeksi Filler I 11.134.000 5.279.000 16.413.000
35 Injeksi Filler II 21.893.000 5.279.000 27.172.000
36 Injeksi Penisilin 277.000 265.000 542.000
37 Kil I 119.000 1.553.000 1.672.000
38 Kil II 165.000 1.553.000 1.718.000
39 Kil III 231.000 1.553.000 1.784.000
40 Kil Kuku I ≤ 3 kuku 345.000 1.553.000 1.898.000
41 Kil Kuku II › 3 kuku 420.000 1.553.000 1.973.000
42 Kortikosteroid Intralesi (Kenacort 10 mg/cc) ( >1-2 cc) tanpa kenacort 486.000 158.000 644.000
43 Kortikosteroid Intralesi (Kenacort 10 mg/cc) (< 0,5 cc) tanpa kenacort 486.000 80.000 566.000
44 Kortikosteroid Intralesi (Kenacort 10 mg/cc) (0,5-1 cc) tanpa kenacort 486.000 121.000 607.000
45 Kortikosteroid Intralesi (Kenacort 40 mg/cc) (< 0,5 cc) tanpa kenacort 486.000 121.000 607.000
Kortikosteroid Intralesi (Kenacort 40 mg/cc) B (0,5-1 cc) tanpa
46 486.000 158.000 644.000
kenacort
Kortikosteroid Intralesi (Kenacort 40 mg/cc) C (>1-2 cc) tanpa
47 553.000 231.000 784.000
kenacort
48 Lase V-Beam - Jumlah pulsa = 10 -SR 1.731.000 443.000 2.174.000
49 Lase V-Beam - Jumlah pulsa 11-30 -SR 2.696.000 469.000 3.165.000
50 Lase V-Beam - Jumlah pulsa 31-60 -SR 4.252.000 640.000 4.892.000
51 Lase V-Beam 1 wajah - Jumlah pulsa 250-400 -JR 11.961.000 3.828.000 15.789.000
52 Lase V-Beam 1 wajah - Jumlah pulsa 250-400 -SR 11.961.000 4.488.000 16.449.000
53 Laser CO2 Berat 1.031.000 1.976.000 3.007.000
54 Laser CO2 Ringan 468.000 736.000 1.204.000
55 Laser CO2 Sedang 701.000 1.187.000 1.888.000
56 Laser Diode 237.000 173.000 410.000
57 Laser NdYag A 736.000 806.000 1.542.000
58 Laser NdYag B 1.055.000 1.201.000 2.256.000
59 Laser NdYag C 1.306.000 1.625.000 2.931.000
60 NdYag Lesi dengan luas < 1/4 wajah (JR) 2.106.000 628.000 2.734.000
61 NdYag Lesi dengan luas < 1/4 wajah (SR) 2.106.000 806.000 2.912.000
62 NdYag Lesi dengan luas 1/2 wajah s.d. seluruh wajah (JR) 4.252.000 1.394.000 5.646.000
63 NdYag Lesi dengan luas 1/2 wajah s.d. seluruh wajah (SR) 4.252.000 1.625.000 5.877.000
64 NdYag Lesi dengan luas 1/4 wajah s.d. 1/2 wajah 2.106.000 1.078.000 3.184.000
65 NdYag Lesi dengan luas 1/4 wajah s.d. 1/2 wajah (JR) 2.696.000 1.002.000 3.698.000
66 NdYag Lesi dengan luas 1/4 wajah s.d. 1/2 wajah (SR) 2.696.000 1.201.000 3.897.000
JASA JASA
SARANA PELAYANAN
67 Peeling 775.000 265.000 1.040.000
68 Peeling Wajah & Leher AHA - TCA 499.000 265.000 764.000
69 Peeling Wajah AHA-TCA 400.000 265.000 665.000
70 Podopilin > 5 lesi 233.000 199.000 432.000
71 Podopilin 1-5 lesi 191.000 133.000 324.000
72 Rejuvanation (JR) 4.252.000 1.321.000 5.573.000
73 Rejuvanation (SR) 4.252.000 1.782.000 6.034.000
74 Subscicion - Berat 788.000 859.000 1.647.000
75 Subscicion - Ringan 715.000 331.000 1.046.000
76 Subscicion - Sedang 715.000 555.000 1.270.000
77 Subsicion Berat 871.000 859.000 1.730.000
78 Subsicion Ringan 1-2 lesi 621.000 331.000 952.000
79 Subsicion Sedang 877.000 555.000 1.432.000
80 Uji Provokasi Obat 1.437.000 156.000 1.593.000
3.13 BONE JOINT
1 Angkat Jahitan besar (>15jahitan) 881.000 1.553.000 2.434.000
2 Angkat Jahitan kecil (1-7jahitan) 697.000 389.000 1.086.000
3 Angkat Jahitan sedang (8-15jahitan) 697.000 777.000 1.474.000
4 Aspirasi Kista 547.000 1.087.000 1.634.000
5 Aspirasi Sendi 547.000 1.553.000 2.100.000
6 Biopsi Eksisi < 3 cm 1.657.000 2.329.000 3.986.000
7 Biopsi Eksisi > 3 cm 1.795.000 3.105.000 4.900.000
8 Biopsi Insisi 1.593.000 3.105.000 4.698.000
9 Bone Marrow Aspiration 6.900.000 3.105.000 10.005.000
10 Buka body jacket 177.000 3.105.000 3.282.000
11 Buka gips atas lutut 177.000 1.553.000 1.730.000
12 Buka Gips atas siku 177.000 1.553.000 1.730.000
13 Buka Gips bawah lutut 177.000 1.553.000 1.730.000
14 Buka Gips bawah siku 177.000 1.553.000 1.730.000
15 Buka hip spica 177.000 3.105.000 3.282.000
16 Cabut K-wire / pin dengan anestesi lokal 1.593.000 2.329.000 3.922.000
17 Core Biopsi (CT guided) 3.959.000 3.105.000 7.064.000
18 Debridement luka besar (>11cm) 1.440.000 2.329.000 3.769.000
19 Debridement luka kecil (<5cm) 1.113.000 777.000 1.890.000
20 Debridement luka sedang (6cm - 10cm) 1.113.000 1.553.000 2.666.000
21 Ekstraksi corpus alienum 1.593.000 2.329.000 3.922.000
22 Ganti Balutan Besar ( > 11cm ) 875.000 777.000 1.652.000
23 Ganti Balutan Kecil (< 5cm) 696.000 545.000 1.241.000
24 Ganti Balutan Sedang ( 6cm - 10cm ) 696.000 621.000 1.317.000
25 Injeksi Intraarticular 987.000 1.166.000 2.153.000
26 987.000 1.166.000 2.153.000
compression)
27 Insisi Abses Kulit 1.561.000 1.166.000 2.727.000
28 Jahit < 10 simpul 1.488.000 1.553.000 3.041.000
29 Jahit > 10 simpul 2.358.000 1.553.000 3.911.000
30 Pemasangan body jacket 1.053.000 3.105.000 4.158.000
31 Pemasangan Gips atas lutut tanpa reposisi 1.049.000 3.105.000 4.154.000
32 Pemasangan Gips atas siku tanpa reposisi 797.000 3.105.000 3.902.000
33 Pemasangan Gips bawah lutut tanpa reposisi 775.000 3.105.000 3.880.000
34 Pemasangan Gips bawah siku tanpa reposisi 519.000 3.105.000 3.624.000
35 Pemasangan hip spica 4.592.000 3.105.000 7.697.000
36 Pemasangan Slab 1.147.000 1.166.000 2.313.000
37 pemasangan total contact cast 1.022.000 1.553.000 2.575.000
38 Rawat luka terbuka besar (>11cm) 1.414.000 777.000 2.191.000
39 Rawat luka terbuka kecil (< 5cm) 1.098.000 545.000 1.643.000
JASA JASA
SARANA PELAYANAN
40 Rawat luka terbuka sedang (6cm - 10cm) 1.098.000 621.000 1.719.000
41 Reposisi dan pemasangan gips atas lutut dengan lokal anestesi 1.502.000 3.105.000 4.607.000
42 Reposisi dan pemasangan gips atas siku dengan lokal anestesi 1.251.000 3.105.000 4.356.000
43 Reposisi dan pemasangan gips bawah lutut dengan lokal anestesi 1.229.000 3.105.000 4.334.000
44 Reposisi dan Pemasangan Gips bawah siku dengan lokal anestesi 972.000 3.105.000 4.077.000
45 Rozer plasty 1.593.000 1.553.000 3.146.000
46 Serial plaster / ponseti (<3bln) (Single) 330.000 1.553.000 1.883.000
47 Serial plaster / ponseti (>4th / relaps) (Single) 974.000 2.329.000 3.303.000
48 Serial plaster / ponseti (1th - 4th) (Single) 515.000 2.329.000 2.844.000
49 Serial plaster / ponseti (3bln - 1th) (Single) 424.000 1.553.000 1.977.000
50 Skin Traction 585.000 1.553.000 2.138.000
51 Strapping 727.000 1.166.000 1.893.000
3.14 NEUROSCIENCE
1 AFHECHTING / ANGKAT JAHITAN 194.000 990.000 1.184.000
2 AFHECHTING / ANGKAT JAHITAN 194.000 990.000 1.184.000
3 Blink Refleks 775.000 1.010.000 1.785.000
4 Brainstem Auditory Evoked Potential 1.164.000 1.166.000 2.330.000
5 Carotid Duplex 570.000 1.166.000 1.736.000
6 Cognitive Event Related Potential (P300) 1.164.000 1.166.000 2.330.000
7 EEG Challenge Diazepam 2.270.000 1.553.000 3.823.000
8 EEG Long Term Monitoring 4.686.000 1.242.000 5.928.000
9 EEG Premedikasi 1.935.000 777.000 2.712.000
10 EEG rutin 1.758.000 621.000 2.379.000
11 EEG Sleep Depriviation 1.931.000 621.000 2.552.000
12 EMG dengan jarum 740.000 1.010.000 1.750.000
13 EMG tanpa jarum 431.000 1.010.000 1.441.000
14 fungsi luhur rutin 347.000 1.242.000 1.589.000
15 Injeksi ekstraartikular <2 cc 223.000 777.000 1.000.000
16 Injeksi ekstraartikular <2 cc dengan guided USG 323.000 932.000 1.255.000
17 Injeksi ekstraartikular >2 cc 223.000 777.000 1.000.000
18 Injeksi ekstraartikular >2 cc guided USG 323.000 932.000 1.255.000
19 Injeksi intra muskular <2 cc 223.000 621.000 844.000
20 Injeksi Intraartikular <2 cc 223.000 777.000 1.000.000
21 Injeksi Intraartikular <2 cc dengan guided USG 323.000 932.000 1.255.000
22 Injeksi Intraartikular >2 cc 223.000 777.000 1.000.000
23 Injeksi Intraartikular >2 cc dengan guided USG 323.000 932.000 1.255.000
24 Injeksi intramuskular <2 cc dengan guided USG 323.000 932.000 1.255.000
25 Injeksi intramuskular >2 cc 223.000 777.000 1.000.000
26 Injeksi intramuskular >2 cc guided USG 323.000 932.000 1.255.000
27 IOM HNP Lumbal Sakral 7.288.000 15.781.000 23.069.000
28 IOM HNP Servikal 7.301.000 15.781.000 23.082.000
29 IOM Pleksus Brachialis/N. Fasialis 8.682.000 15.781.000 24.463.000
30 IOM Skoliosis 9.444.000 23.670.000 33.114.000
31 IOM Tumor Fosa anterior kortikal mapping 34.246.000 23.670.000 57.916.000
32 IOM Tumor Fosa Posterior 13.823.000 29.981.000 43.804.000
33 IOM Tumor Medula Spinalis 25.333.000 29.981.000 55.314.000
34 Kecepatan Hantar Saraf 434.000 1.010.000 1.444.000
35 Kecepatan Hantar Saraf dan F-wave/H-Refleks 434.000 1.010.000 1.444.000
36 Lumbal Pungsi Guided 2.084.000 6.467.000 8.551.000
37 Lumbal Pungsi non guided 279.000 2.609.000 2.888.000
38 monitoring Trombolisis intravena 1.265.000 11.046.000 12.311.000
39 Pasang Chateter 296.000 265.000 561.000
40 Pasang NGT 330.000 265.000 595.000
41 Repetitive Nerve Stimulation 462.000 1.010.000 1.472.000
42 skrining TCD 468.000 932.000 1.400.000
JASA JASA
SARANA PELAYANAN
43 Somatosensory Evoked Potential 1.427.000 1.166.000 2.593.000
44 Spasmofili 393.000 1.010.000 1.403.000
45 Sympathetic Skin Response 864.000 1.010.000 1.874.000
46 TCD Buble Contrast 403.000 1.321.000 1.724.000
47 Trans Cranial Doppler 3.573.000 1.166.000 4.739.000
48 Trombolisis Intravena 18.830.000 11.046.000 29.876.000
49 Visual Evoked Potential 1.164.000 1.166.000 2.330.000
3.15 CARDIO
1 Angkat jahitan 145.000 990.000 1.135.000
2 Dopler Vaskuler 1 TK 982.000 1.166.000 2.148.000
3 Dopler Vaskuler 2 TK 982.000 2.329.000 3.311.000
4 Doppler Vaskular carotis 794.000 1.553.000 2.347.000
5 Echocardiography 738.000 932.000 1.670.000
6 Echocardiography bubble test 455.000 932.000 1.387.000
7 EKG 146.000 79.000 225.000
8 Foam Skleroterapi 1 tungkai non USG guided 260.000 825.000 1.085.000
9 Perawatan Luka besar 566.000 777.000 1.343.000
10 Perawatan Luka besar sulit 732.000 1.087.000 1.819.000
11 Perawatan Luka kecil 234.000 199.000 433.000
12 Perawatan Luka sedang 399.000 621.000 1.020.000
13 Skin Laser 330.000 1.650.000 1.980.000
14 Skleroterapi 1 tungkai Multiple 455.000 777.000 1.232.000
15 Skleroterapi dua tungkai 455.000 7.077.000 7.532.000
16 Skleroterapi satu tungkai 260.000 5.444.000 5.704.000
17 Stress Echo Debutamin 630.000 2.329.000 2.959.000
18 Trans Esofageale Echo (TEE) 982.000 3.105.000 4.087.000
19 Trans Esofageale Echo (TEE) dengan anestesi 1.303.000 4.347.000 5.650.000
20 Treadmill Test 497.000 777.000 1.274.000
21 USG pre operasi untuk vein mapping 329.000 1.456.000 1.785.000
3.16 MATA
1 Anel Lakrimalis / Anel Test 162.000 156.000 318.000
2 Angkat Jahitan kornea 405.000 311.000 716.000
3 Angkat Jahitan Palpebra / DFG 270.000 311.000 581.000
4 Corneal topography 243.000 110.000 353.000
5 DBR/Biometri/Synoptophore 203.000 234.000 437.000
6 Demodex 270.000 117.000 387.000
7 Dermabrasi / Ekstraksi corpus alenium 419.000 389.000 808.000
8 Dermolipoma 1.350.000 1.553.000 2.903.000
9 Eksisi Granuloma 2.052.000 1.087.000 3.139.000
10 Ekstraksi Lithiasis 405.000 545.000 950.000
11 Epilasi bulu mata 140.000 156.000 296.000
12 ERG 405.000 389.000 794.000
13 Fitting Lensa Kontak RGP 270.000 234.000 504.000
14 Foto Fundus 189.000 94.000 283.000
15 Ganti Balutan(Verband) / Fitting Protesa 203.000 156.000 359.000
16 HESS Screen 230.000 156.000 386.000
17 Hordeolum ( Insici ) 540.000 1.087.000 1.627.000
18 Humprey 243.000 234.000 477.000
19 Humprey 243.000 234.000 477.000
20 ICG Fundus /FFA optos (umum dan perusahaan) 3.173.000 855.000 4.028.000
21 ICG Fundus /FFA optos (umum dan perusahaan) 3.173.000 855.000 4.028.000
22 Injeksi Intrastromal (ok) 704.000 932.000 1.636.000
23 Injeksi Intrastromal (POLI) 704.000 932.000 1.636.000
24 Injeksi intravitreal (ok) 635.000 932.000 1.567.000
25 Injeksi intravitreal (POLI) 638.000 932.000 1.570.000
JASA JASA
SARANA PELAYANAN
26 Insisi abses 540.000 1.087.000 1.627.000
27 IOL Master - (700) 405.000 234.000 639.000
28 Jahit Palpebra Ringan 1.485.000 1.553.000 3.038.000
29 Laser Perifer Iridektomi (LPI) - Glaukoma 1.080.000 1.166.000 2.246.000
30 Low Vision 810.000 311.000 1.121.000
31 Nekrotomi 297.000 389.000 686.000
32 OCT Scan / Visante 405.000 234.000 639.000
33 Octopus 270.000 234.000 504.000
34 Parasentesa 338.000 466.000 804.000
35 Pemeriksaan ERG dan VEP 1.080.000 777.000 1.857.000
36 Pemeriksaan Foto Fundus non midriatikum 189.000 94.000 283.000
37 Pentacam/ Oculyzer 243.000 156.000 399.000
38 Pentacam/ Oculyzer 243.000 156.000 399.000
39 Photokoagulasi Laser (Argon Laser) -Retina 2.025.000 1.942.000 3.967.000
40 Retinometri 162.000 156.000 318.000
41 Screening ROP 473.000 545.000 1.018.000
42 Slitlamp Examination 48.000 54.000 102.000
43 Specullar Microscope (Non Con Robo) 122.000 156.000 278.000
44 Streak Retinoscopy 216.000 234.000 450.000
45 Streak Retinoscopy 216.000 234.000 450.000
46 Suntik Botox 4.022.000 1.553.000 5.575.000
47 Tes Schimer (BUT) 95.000 117.000 212.000
48 Toppolyzer 243.000 156.000 399.000
49 UBM (minimal 4 org perhari) 1.350.000 389.000 1.739.000
50 USG 473.000 389.000 862.000
51 VEP 405.000 389.000 794.000
52 Yag Laser - KBR/ Glaukoma 1.350.000 1.166.000 2.516.000
3.17 PEDIATRIK
1 Argon Plasma Coagulation 15.438.000 11.870.000 27.308.000
2 Arteri line 3.932.000 2.563.000 6.495.000
3 Asuhan nutrisi enteral dasar 256.000 156.000 412.000
4 Asuhan nutrisi enteral khusus 636.000 156.000 792.000
5 Asuhan nutrisi parenteral 2.761.000 311.000 3.072.000
6 Bilas Lambung 77.000 118.000 195.000
7 biopsi ginjal 3.142.000 2.470.000 5.612.000
8 biopsi ginjal tanpa needle 2.426.000 2.470.000 4.896.000
9 Bladder washout 546.000 327.000 873.000
10 Blanket Roll 83.000 545.000 628.000
11 Blink reflex 775.000 331.000 1.106.000
12 Bone marrow puncture anak **** 1.507.000 1.166.000 2.673.000
13 Brainstem evoked auditory potential (BERA) 1.166.000 331.000 1.497.000
14 Bronchoscopy 4.874.000 3.261.000 8.135.000
15 Bronkoskopi 2.449.000 1.863.000 4.312.000
16 Bronkoskopi dan biopsi 17.681.000 1.863.000 19.544.000
17 Bronkoskopi dan brush 4.057.000 1.863.000 5.920.000
18 Bronkoskopi dan transbronchial nodul aspiration 5.843.000 1.863.000 7.706.000
19 Cerebral Monitoring 2.012.000 545.000 2.557.000
20 CIC (Continuous Intermittent Catheterization) 424.000 280.000 704.000
21 Cook/Surmisil acute peritoneal dilysis cath removal 1.153.000 373.000 1.526.000
22 Cryotherapy 7.384.000 7.849.000 15.233.000
23 CVP Akses Vaskuler 2.613.000 2.563.000 5.176.000
24 CVP dengan USG 2.641.000 3.105.000 5.746.000
25 CVP Monitoring 1.346.000 1.553.000 2.899.000
26 CVP removal 883.000 855.000 1.738.000
JASA JASA
SARANA PELAYANAN
31 Desensitasi obat level I (durasi 12 jam) 833.000 777.000 1.610.000
32 Desensitasi obat level II (durasi 24 jam) 1.175.000 1.087.000 2.262.000
33 Desmopresin (DDAVP) test 774.000 311.000 1.085.000
34 Echocardiographi 731.000 1.166.000 1.897.000
35 EEG bedside 1.760.000 545.000 2.305.000
36 EEG digital rutin 1.760.000 331.000 2.091.000
37 EEG LONG TERM MONITORING 4.686.000 777.000 5.463.000
38 EEG Sleep deprivation 1.931.000 331.000 2.262.000
39 EKG 75.000 234.000 309.000
40 Ekokardiogragi 635.000 932.000 1.567.000
41 Ekstraksi benda asing 26.980.000 20.804.000 47.784.000
42 Ekstubasi 338.000 777.000 1.115.000
45 EMG Jarum 752.000 397.000 1.149.000
46 EMG SPASMOFILI 395.000 331.000 726.000
47 Exit site checking 345.000 187.000 532.000
48 Ganti Balutan 158.000 389.000 547.000
49 ganti tranfer set 1.093.000 607.000 1.700.000
50 ganti tranfer set tanpa alat 721.000 607.000 1.328.000
51 H. Reflex 276.000 164.000 440.000
52 hemodialisa 1.571.000 886.000 2.457.000
53 HFO setting awal 1.350.000 1.553.000 2.903.000
54 HFO setting harian 1.350.000 925.000 2.275.000
55 Induksi sputum 365.000 156.000 521.000
56 Infus Perifer 384.000 118.000 502.000
57 Inhalasi 103.000 79.000 182.000
58 Injeksi eriropoietin 1.425.000 653.000 2.078.000
59 Injeksi eriropoietin tanpa obat 648.000 653.000 1.301.000
60 272.000 156.000 428.000
obat ***
61 Injeksi Obat Khusus GCSF ** 262.000 156.000 418.000
62 Injeksi pre transplantasi 582.000 141.000 723.000
63 Injeksi pre transplantasi tanpa obat 243.000 141.000 384.000
64 Intradialytic parenteral nutrition 696.000 327.000 1.023.000
65 Intradialytic parenteral nutrition tanpa obat 414.000 327.000 741.000
66 Intubasi Endotra Sulit 385.000 2.329.000 2.714.000
67 Intubasi Endotracheal 385.000 1.942.000 2.327.000
68 Kateter Urine 238.000 118.000 356.000
69 Kecepatan hantar saraf 435.000 331.000 766.000
70 Kemoterapi drip 24 jam (durasi 24 jam) dan hidrasi 24 jam * 2.205.000 311.000 2.516.000
71 Kemoterapi Intratekal **** 959.000 777.000 1.736.000
72 Kemoterapi IV bolus * 315.000 195.000 510.000
73 Kemoterapi IV drip 12 jam (durasi 12 jam) dan hidrasi 6 jam * 920.000 273.000 1.193.000
74 Kemoterapi IV drip 4 jam (durasi 4 jam) * 457.000 234.000 691.000
75 Kemoterapi SC Leunase * 262.000 156.000 418.000
76 Laktat 68.000 40.000 108.000
77 Leukoferesis anak (durasi 6 jam) 2.520.000 2.718.000 5.238.000
78 Light Terapi 454.000 195.000 649.000
79 Lumbal pungsi 1.085.000 621.000 1.706.000
80 Mengembil Pemeriksaan (non darah) 117.000 79.000 196.000
81 Monitoring Cardiac Output 177.000 156.000 333.000
JASA JASA
SARANA PELAYANAN
82 Monitoring End tidal CO2 279.000 118.000 397.000
83 Monitoring Hemodinamik 754.000 1.166.000 1.920.000
84 Otoacoustic emission (OAE) 434.000 164.000 598.000
85 Paket Dukungan Nutrisi Enteral 341.000 156.000 497.000
86 Paket Dukungan Nutrisi Parenteral 616.000 156.000 772.000
87 Pasang NGT 141.000 156.000 297.000
88 Pemantauan hemodinamik non-invasif 206.000 389.000 595.000
89 Pemasangan Akses Intraoseus 2.981.000 1.553.000 4.534.000
90 Pemasangan Cook peritoneal dialisis 9.797.000 2.656.000 12.453.000
91 Pemasangan Cook peritoneal dialisis tanpa alat 3.451.000 2.656.000 6.107.000
92 Pemasangan Defibrilator pada Anak 1.036.000 621.000 1.657.000
93 Pemasangan mini-WSD certofix 2.158.000 1.166.000 3.324.000
94 Pemasangan Non-invasive respiratory support 10.067.000 2.563.000 12.630.000
95 Pemasangan surmisil silicone peritoneal dialisis akut 9.797.000 2.656.000 12.453.000
96 Pemasangan surmisil silicone peritoneal dialisis akut tanpa alat 3.451.000 2.656.000 6.107.000
97 pemasangan temporer hemodialysis catheter 4.306.000 2.050.000 6.356.000
98 pemasangan temporer hemodialysis catheter tanpa alat 1.900.000 2.050.000 3.950.000
99 Pemberian minum per sonde 87.000 63.000 150.000
100 Pemberian Obat IV/IM 49.000 79.000 128.000
101 Pengambilan Darah Arteri 117.000 79.000 196.000
102 perawatan CAPD baru 1.155.000 793.000 1.948.000
103 perawatan CAPD baru tanpa obat 867.000 793.000 1.660.000
104 perawatan CAPD kronik 2.065.000 932.000 2.997.000
105 perawatan CAPD kronik tanpa obat 1.126.000 932.000 2.058.000
106 671.000 234.000 905.000
107 Perawatan Kolostomi 129.000 118.000 247.000
108 peritoneal dialisis akut harian 802.000 373.000 1.175.000
109 peritoneal dialisis akut harian tanpa obat 489.000 373.000 862.000
110 peritoneal dialisis kronik harian 594.000 234.000 828.000
111 peritoneal dialisis kronik harian tanpa obat 323.000 234.000 557.000
112 Peritoneal permeability check 825.000 420.000 1.245.000
113 Peritoneal permeability check tanpa obat 508.000 420.000 928.000
114 PET Kt/V 831.000 653.000 1.484.000
115 PET Kt/V tanpa obat 754.000 653.000 1.407.000
116 plasmaferesis 23.701.000 10.760.000 34.461.000
117 Plasmaferesis anak (durasi 6 jam) 2.520.000 2.718.000 5.238.000
118 Plasmaferesis tanpa alat, tanpa prismasol 8.757.000 10.760.000 19.517.000
119 Poligrafi 1.155.000 1.242.000 2.397.000
120 Polisomnografi 1.688.000 1.242.000 2.930.000
121 Program inisiasi terapi insulin pada pasien baru DM Tipe-1 906.000 932.000 1.838.000
122 Protokol pemberian asam zoledronat pada Osteogenesis Imperfecta 815.000 466.000 1.281.000
123 Psikoterapi / psikoedukasi pada DM 388.000 311.000 699.000
124 Pungsi Acites 608.000 777.000 1.385.000
125 Pungsi cairan pleura 960.000 777.000 1.737.000
126 Pungsi Darah Vena 103.000 79.000 182.000
127 Pungsi Lumbal (IAN.Ligor CRB SPI) 284.000 1.087.000 1.371.000
128 reposisi cdl 810.000 607.000 1.417.000
129 reposisi kateter peritoneal dialisis akut cook/surmisil 2.289.000 1.072.000 3.361.000
130 reposisi kateter peritoneal dialisis akut cook/surmisil tanpa obat 1.927.000 1.072.000 2.999.000
131 Resusitasi Jantung Paru 507.000 700.000 1.207.000
132 Rinofaringolaringoskopi 981.000 777.000 1.758.000
133 RNS 464.000 331.000 795.000
134 Sedasi Anak 1.118.000 932.000 2.050.000
135 Sedasi Sedang Anak 1.035.000 653.000 1.688.000
JASA JASA
SARANA PELAYANAN
136 Sedasi sedang anak (untuk kemoterapi IT dan BMP) **** 778.000 644.000 1.422.000
137 Sedasi Sedang Anak tanpa obat 702.000 653.000 1.355.000
138 Single-fiber EMG 700.000 331.000 1.031.000
139 Skin prick test 1.214.000 466.000 1.680.000
140 Skin Prick Test 729.000 466.000 1.195.000
141 SLED 3.357.000 1.211.000 4.568.000
142 SSEP 1.429.000 331.000 1.760.000
143 Suction 127.000 40.000 167.000
144 Suntik BPG 345.000 156.000 501.000
145 Terapi motivational counseling remaja 258.000 234.000 492.000
146 terapi besi intravena 725.000 420.000 1.145.000
147 terapi besi intravena tanpa obat 489.000 420.000 909.000
148 terapi obat khusus cyclophosphamide intravena 912.000 466.000 1.378.000
149 terapi obat khusus cyclophosphamide intravena tanpa obat 655.000 466.000 1.121.000
150 terapi obat khusus IV Ig immunoglobulin intravena 971.000 607.000 1.578.000
151 terapi obat khusus IV Ig immunoglobulin intravena tanpa obat 740.000 607.000 1.347.000
152 terapi obat khusus metilprednisolon pulse harian 744.000 466.000 1.210.000
153 terapi obat khusus metilprednisolon pulse harian tanpa obat 592.000 466.000 1.058.000
154 Terapi Oksigen 245.000 79.000 324.000
155 Terapi perilaku korban kekerasan anak 258.000 234.000 492.000
156 Terapi sulih enzim 1.336.000 1.166.000 2.502.000
157 thrombolytics for dialysis catheter fibrin occlusion dengan heparin 1.098.000 1.025.000 2.123.000
158 thrombolytics for hemodialys catheter fibrin occlusion 1.677.000 1.025.000 2.702.000
159 thrombolytics for hemodialys catheter fibrin occlusion tanpa obat 1.012.000 1.025.000 2.037.000
160 thrombolytics for peritoneal dialysis catheter fibrin occlusion 1.349.000 373.000 1.722.000
161 643.000 373.000 1.016.000
obat
162 Tindakan imunisasi biasa 238.000 118.000 356.000
163 349.000 234.000 583.000
hemofilia, dll)
164 Tindakan injeksi GnRH analog / Leuprorelin acetate (Tapros®) 1.414.000 234.000 1.648.000
165 Tindakan injeksi testosteron ester (Sustanon®) 389.000 234.000 623.000
166 Tindakan uji stimulasi GH 1.151.000 1.166.000 2.317.000
167 Tindakan uji stimulasi HCG 620.000 234.000 854.000
168 Transcutaneaus CO2 123.000 118.000 241.000
169 Transfusi Darah 250.000 273.000 523.000
170 758.000 156.000 914.000
171 Uji psikososial remaja HEEADSSS 319.000 273.000 592.000
172 Uji depresi anak CDI 258.000 195.000 453.000
173 Uji fungsi paru / spirometri anak 843.000 234.000 1.077.000
174 Uji fungsi paru / spirometri anak 1.309.000 234.000 1.543.000
175 Uji fungsi paru pre- dan post- bronkodilator anak 1.365.000 389.000 1.754.000
176 Uji gangguan perilaku autisme MCHATR/F 258.000 195.000 453.000
177 Uji gangguan perilaku hiperaktivitas Conners ASQ 258.000 195.000 453.000
178 Uji gangguan psikososial SDQ 258.000 195.000 453.000
181 Uji Kemampuan Bahasa Capute Scale 410.000 389.000 799.000
182 Uji keringat atau sweat test 3.706.000 389.000 4.095.000
183 Uji kualitas hidup PedsQL 258.000 195.000 453.000
184 Uji Perkembangan Denver 380.000 311.000 691.000
185 Uji perkembangan khusus BSID III 793.000 777.000 1.570.000
186 Uji provokasi makanan/ obat level I (DURASI 4 JAM) 526.000 621.000 1.147.000
187 Uji provokasi makanan/ obat level II (durasi 6 jam) 739.000 777.000 1.516.000
KENCANA EXECUTIVE 24 JAM
JASA JASA
SARANA PELAYANAN
1. KONSULTASI
185 Uji perkembangan khusus BSID III 793,000 777,000 1,570,000
186 Uji provokasi makanan/ obat level I (DURASI 4 JAM) 526,000 621,000 1,147,000
187 Uji provokasi makanan/ obat level II (durasi 6 jam) 739,000 777,000 1,516,000
188 Uji stimulasi hormon pertumbuhan (clonidine test) 1,098,000 855,000 1,953,000
189 Vena Seksi 461,000 2,563,000 3,024,000
190 Ventilator setting awal 1,080,000 1,398,000 2,478,000
191 Ventilator setting harian 4,001,000 816,000 4,817,000
3.18 GIZI KLINIK
1 Interpretasi Bioelectric Impedance (BIA) /Tanita 36,000 280,000 316,000
2 Interpretasi Bioelectric Impedance (BIA) Bedridden/Seca 36,000 311,000 347,000
3 Pemeriksaan kalorimetri indirek 36,000 311,000 347,000
4 Pengukuran knee-hight 36,000 79,000 115,000
5 Pengukuran lingkar lengan atas 36,000 79,000 115,000
6 Tindakan Analisa Asupan 33,000 79,000 112,000
8 USG massa otot 36,000 311,000 347,000
DIREKTUR UTAMA,
Ttd.
LIES DINA LIASTUTI

Lampiran III Peraturan Direktur Utama
Nomor : HK.01.07/3.3/8320/2020
Ketentuan kebijakan Tarif Pelayanan di RSUP Nasional Dr. Cipto Mangunkusumo terdiri dari :
1. Pola Tarif Rumah Sakit ditetapkan berdasarkan komponen biaya satuan pembiayaan (unit cost);
2. Komponen biaya satuan pembiayaan (unit cost) dihitung dengan mempertimbangkan kontinuitas
dan pengembangan layanan, daya beli masyarakat, asas keadilan dan kepatutan, dan kompetisi
yang sehat;
3. Biaya satuan pembiayaan (unit cost) merupakan hasil perhitungan total biaya (total cost) masing-
masing kegiatan yang dikeluarkan Rumah Sakit;
4. Kegiatan pelayanan yang dikenakan Tarif Rumah Sakit dikelompokkan berdasarkan jenis
pelayanan pada masing-masing tempat pelayanan yang terdiri atas Pelayanan Medis dan Pelayanan
Penunjang Medis;
5. Tempat pelayanan terdiri atas pelayanan pada rawat jalan, rawat inap, dan rawat darurat;
6. Tempat pelayanan pada rawat jalan meliputi poliklinik, kamar operasi, rawat rehabilitasi, dan
kamar tindakan lainnya;
7. Tempat pelayanan pada rawat inap meliputi ruang perawatan, kamar operasi, kamar bersalin, rawat
intensif, dan rawat rehabilitasi;
8. Tempat pelayanan pada rawat darurat merupakan instalasi gawat darurat;
9. Jenis Pelayanan Medis meliputi pemeriksaan dan Pelayanan Konsultasi, visite dan Pelayanan
Konsultasi, tindakan operatif, tindakan non operatif, persalinan;
10. Pelayanan Penunjang Medis merupakan pelayanan untuk menunjang Pelayanan Medis meliputi
pelayanan laboratorium, pelayanan radiodiagnostik, pelayanan diagnostik elektromedis, pelayanan
diagnostik khusus, pelayanan Rehabilitasi Medis, pelayanan darah, pelayanan farmasi, pelayanan
gizi, pemulasaraan jenazah, dan Pelayanan Penunjang Medis lainnya;
11. Tarif Rumah Sakit untuk kegiatan pelayanan diperhitungkan berdasarkan komponen jasa sarana
dan jasa pelayanan yang diperlukan pada rawat jalan, rawat inap, dan rawat darurat;
12. Komponen jasa sarana merupakan imbalan yang diterima oleh Rumah Sakit atas pemakaian
akomodasi, bahan non medis, obat-obatan, bahan/alat kesehatan habis pakai yang digunakan
langsung dalam rangka Pelayanan Medis dan Pelayanan Penunjang Medis;
13. Komponen jasa pelayanan merupakan imbalan yang diterima oleh pemberi pelayanan atas jasa
yang diberikan kepada pasien dalam rangka Pelayanan Medis, Pelayanan Penunjang Medis
dan/atau pelayanan lainnya;
14. Jasa pelayanan terdiri atas jasa tenaga kesehatan dan jasa tenaga lainnya;
15. Perhitungan tarif rawat jalan dibedakan berdasarkan pelayanan Rawat Jalan Reguler dan Rawat
Jalan Non Reguler dengan ketentuan :
a. Pelayanan Rawat Jalan Reguler ditetapkan sesuai dengan titik impas (break even point);
b. Pelayanan Rawat Jalan Non Reguler ditetapkan lebih besar dari Pelayanan Rawat Jalan Reguler
dengan besaran yang ditetapkan berdasarkan asas kepatutan;
16. Perhitungan tarif rawat inap dibedakan berdasarkan kelas perawatan dengan ketentuan sebagai
berikut:
a. Kelas III (tiga) ditetapkan lebih kecil dari kelas II (dua);
b. Kelas II (dua) ditetapkan sesuai titik impas (break even point); dan
c. Kelas selain huruf a dan huruf b, ditetapkan lebih besar dari kelas II (dua) dengan besaran yang
ditetapkan berdasarkan asas kepatutan.
17. Dalam hal terjadi 2 (dua) atau lebih tindakan medis operatif dalam waktu yang bersamaan terhadap
pasien yang sama dengan dokter spesialis yang berbeda maka tarifnya dikenakan sesuai tarif yang
berlaku;
18. Dalam hal terjadi 2 (dua) atau lebih tindakan medis operatif dalam waktu yang bersamaan terhadap
pasien yang sama dengan dokter spesialis yang sama maka jasa tindakan pertama dihitung 100%
(seratus persen), jasa tindakan kedua dihitung 60% (enam puluh persen) dari jasa tindakan pertama,
jasa tindakan ketiga dihitung 30% (tiga puluh persen) dari jasa tindakan kedua, dan jasa tindakan
keempat dihitung 15% (lima belas persen) dari jasa tindakan ketiga;
19. Perhitungan tarif rawat darurat ditetapkan lebih besar dari titik impas (break even point) dengan
besaran yang ditetapkan berdasarkan asas kepatutan;
20. Pemberian diskon terhadap tarif pelayanan dilakukan berdasarkan kebijakan pimpinan rumah sakit;
dan
21. Dalam hal tidak terdapat pelayanan atau dikarenakan ada kerusakan alat medik atau alasan lain
sehingga harus dilakukan rujukan parsial kepada pasien, maka tanda bukti pembayaran atas
pelayanan diluar RSUP Nasional Dr. Cipto Mangunkusumo harus disertakan pada saat penerbitan
tagihan RSUP Nasional Dr. Cipto Mangunkusumo.
DIREKTUR UTAMA,
.
. Ttd.
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KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

DIREKTORAT JENDERAL PELAYANAN KESEHATAN

PERATURAN DIREKTUR UTAMA RSUP NASIONAL Dr. CIPTO MANGUNKUSUMO

DENGAN RAHMAT TUHAN YANG MAHA ESA

Menimbang : a. bahwa berdasarkan Peraturan Pemerintah Republik

“ Menolong, memberikan yang terbaik”

4. Peraturan Pemerintah Republik Indonesia Nomor 23 Tahun

Memperhatikan : Rapat Pimpinan RSUP Nasional Dr. Cipto Mangunkusumo.

Menetapkan : PERATURAN DIREKTUR UTAMA RSUP NASIONAL

Memberlakukan Tarif Pelayanan RSUP Nasional Dr. Cipto Mangunkusumo

Pemberlakuan Tarif Pelayanan sebagaimana dimaksud dalam Pasal 1 adalah acuan

Ketentuan kebijakan sebagaimana dimaksud pada Pasal 1 tercantum dalam

Direktorat Keuangan bertanggungjawab terhadap sosialisasi dan pelaksanaan

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1. KONSULTASI DAN VISITE

2. INSTALASI GAWAT DARURAT

5. TINDAKAN RUANG INTENSIVE

62 CABG + AORTIC-MITRAL VALVE REPAIR-REPLACE KELAS 1 156,377,000 100,122,000 256,499,000

No NAMA KEGIATAN JASA SARANA JASA PELAYANAN TARIF

4. RADIOLOGI DAN KEDOKTERAN NUKLIR

5. ORTHOTICS DAN PROSTHETICS

6. FORENSIK DAN PEMULASARAN JENAZAH

7. UNIT TRANSFUSI DARAH

*Tarif bisa berubah sewaktu-waktu karena mengikuti tarif dari PMI

10. LAYANAN AMBULANS

10. LAYANAN AMBULANS

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INSTALASI PELAYANAN TERPADU ONKOLOGI RADIASI

No NAMA KEGIATAN JASA SARANA JASA PELAYANAN TARIF

19 OPERASI BESAR I -ORKHIDEKTOMI LIGASI TINGGI + ANES 16,507,000 17,710,000 34,217,000

227 OPERASI KHUSUS II -URETROPLASTY HYPOSPADIA + ANES 13,791,000 32,258,000 46,049,000

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