Tarif Terbaru Rsu Bunga Bangsa 2021 - Asuransi

I.
TARIF RAWAT JALAN / POLIKLINIK DAN RAWAT INAP
1. REGISTRASI ( Pendaftaran Pasien)

DAFTAR TARIF LAYANAN
JENIS KODE
RAWAT JALAN TARIF
LAYANAN
REG0001 Administrasi Rumah Sakit 27,500

REG0002 Administrasi UGD
10 % dari total unit UGD
REG0003 Asuhan Keperawatan 29,700
REG0004 Jasa Sarana Prasarana 27,500
REG0005 Tuslag dan Embalage Poliklinik 11,000
REG0006 Tuslag dan Embalage UGD 22,000
RAWAT INAP/ IN PATIENT
Administrasi Rawat Inap
5 % dari Total Tagihan
2.JASA DOKTER
JENIS KODE Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
LAYANAN JASA DOKTER / DOCTOR'S FEE fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS dan
LAYANAN RAWAT JALAN RS dan BHP KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B RS dan BHP VIP A fee Medis (70%)
(70%) (70%) HCU (70%) ISOLASI (70%) (70%) BHP (30%)
(30%) (30%) (30%) (30%) (30%)
DOK00001 Jasa Dokter Poliklinik Spesialis (Rawat Jalan) 93,500 28,050 65,450 93,500 28,050 65,450 102,850 30,855 71,995 112,200 33,660 78,540 130,900 39,270 91,630 149,600 44,880 104,720
DOK00002 Jasa Dokter Umum ( UGD ) / GP at Emergency 18,150 42,350 60,500 18,150 42,350 66,550 46,585 72,600 21,780 50,820 84,700 25,410 59,290
60,500 19,965
Unit 96,800 29,040 67,760
DOK00003 21,450 50,050 71,500 21,450 50,050 78,650 55,055 85,800 25,740 60,060 100,100 30,030 70,070
Jasa Dokter Spesialis Yang Dikonsulkan dari UGD 71,500 23,595
114,400 34,320 80,080
DOK00004 Konsultasi Gizi Dokter 55,000 16,500 38,500 55,000 16,500 38,500 60,500 18,150 42,350 66,000 19,800 46,200 77,000 23,100 53,900 88,000 26,400 61,600
DOK00005 Jasa Visit Dokter Spesialis / Room Visit Specialist 24,750 57,750 82,500 24,750 57,750 90,750 63,525 99,000 29,700 69,300 115,500 34,650 80,850
82,500 27,225
132,000 39,600 92,400
DOK00006 Jasa Dokter MCU 49,500 14,850 34,650 49,500 14,850 34,650 54,450 16,335 38,115 59,400 17,820 41,580 69,300 20,790 48,510 79,200 23,760 55,440
DOK00007 Jasa Visit Dokter Rawat Bersama Spesialis 82,500 24,750 57,750 82,500 24,750 57,750 90,750 27,225 63,525 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
DOK00008 Jasa Visit Dokter Konsul Spesialis 82,500 24,750 57,750 82,500 24,750 57,750 90,750 27,225 63,525 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
DOK00009 Jasa Visit Dokter Spesialis Pengganti 82,500 24,750 57,750 82,500 24,750 57,750 90,750 27,225 63,525 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
DOK00010 Jasa Dokter Umum (Poli) 60,500 18,150 42,350 60,500 18,150 42,350 66,550 19,965 46,585 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
DOK00011 Jasa Dokter Gigi ( Umum) 77,000 23,100 53,900 77,000 23,100 53,900 84,700 25,410 59,290 92,400 27,720 64,680 107,800 32,340 75,460 123,200 36,960 86,240
DOK00012 Jasa Konsultasi Dokter Rawat Inap On Line ( Via 9,900 23,100 33,000 9,900 23,100 36,300 25,410 39,600 11,880 27,720 46,200 13,860 32,340
Telepon ) 33,000 10,890
52,800 15,840 36,960
DOK00013 Jasa Visit Dokter Bangsal ( Dokter Umum) 60,500 18,150 42,350 60,500 18,150 42,350 66,550 19,965 46,585 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
DOK00014 Jasa Konsultasi Tumbuh Kembang Anak 195,800 58,740 137,060 195,800 58,740 137,060 215,380 64,614 150,766 234,960 70,488 164,472 274,120 82,236 191,884 313,280 93,984 219,296
DOK00015 Jasa Dokter Poliklinik Spesialis dr. Enny 115,500 34,650 80,850 115,500 34,650 80,850 127,050 38,115 88,935 138,600 41,580 97,020 161,700 48,510 113,190 184,800 55,440 129,360
DOK00016 Jasa Dokter Psikolog Tumbuh Kembang Anak 156,200 46,860 109,340 156,200 46,860 109,340 171,820 51,546 120,274 187,440 56,232 131,208 218,680 65,604 153,076 249,920 74,976 174,944
DOK00017 Jasa Ahli Gizi Tumbuh Kembang Anak 44,000 13,200 30,800 44,000 13,200 30,800 48,400 14,520 33,880 52,800 15,840 36,960 61,600 18,480 43,120 70,400 21,120 49,280
DOK00018 Jasa Konsultasi Dokter Radiologi 93,500 28,050 65,450 93,500 28,050 65,450 102,850 30,855 71,995 112,200 33,660 78,540 130,900 39,270 91,630 149,600 44,880 104,720
DOK00019 Jasa Asisten Operator Radiografer 82,500 82,500 - - -
3.POLI ANAK SPESIALIS

JENIS KODE LAYANAN POLIKLINIK ANAK / PEDIATRIC KELAS II / KELAS I / Jasa
Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana
LAYANAN CLINIC fee Medis fee Medis fee Medis fee Medis Sarana RS fee Medis Jasa Sarana RS dan
RAWAT JALAN RS dan BHP KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B VIP A fee Medis (70%)
(30%)
(70%)
(30%)
(70%) HCU (30%)
(70%) ISOLASI (30%)
(70%) dan BHP (70%) BHP (30%)
(30%)
MED00001 Pemeriksaan Autisme (Rawat Jalan) 48,400 14,520 33,880 48,400 14,520 33,880 53,240 15,972 37,268 58,080 17,424 40,656 67,760 20,328 47,432 77,440 23,232 54,208
MED00002 B M P (Rawat Jalan) 95,095 28,529 66,567 95,095 28,529 66,567 104,605 31,381 73,223 114,114 34,234 79,880 133,133 39,940 93,193 152,152 45,646 106,506
MED00003 RRO (Rawat Jalan) 37,895 11,369 26,527 37,895 11,369 26,527 41,685 12,505 29,179 45,474 13,642 31,832 53,053 15,916 37,137 60,632 18,190 42,442
MED00004 Dilatasi Fimosis (Rawat Jalan) 66,495 19,949 46,547 66,495 19,949 46,547 73,145 21,943 51,201 79,794 23,938 55,856 93,093 27,928 65,165 106,392 31,918 74,474
MED00005 Pengambilan Cairan Lambung (Rawat Jalan) 85,800 25,740 60,060 85,800 25,740 60,060 94,380 28,314 66,066 102,960 30,888 72,072 120,120 36,036 84,084 137,280 41,184 96,096
MED00006 Injeksi Vaksin (Tindakan Dokter) (Rawat Jalan) 38,500 11,550 26,950 38,500 11,550 26,950 42,350 12,705 29,645 46,200 13,860 32,340 53,900 16,170 37,730 61,600 18,480 43,120
MED00007 Injeksi IM (Rawat Jalan) 27,500 8,250 19,250 27,500 8,250 19,250 30,250 9,075 21,175 33,000 9,900 23,100 38,500 11,550 26,950 44,000 13,200 30,800
MED00008 Injeksi IV (Rawat Jalan) 27,500 8,250 19,250 27,500 8,250 19,250 30,250 9,075 21,175 33,000 9,900 23,100 38,500 11,550 26,950 44,000 13,200 30,800
MED00009 Pengambilan Darah Vena (Rawat Jalan) 44,000 13,200 30,800 44,000 13,200 30,800 48,400 14,520 33,880 52,800 15,840 36,960 61,600 18,480 43,120 70,400 21,120 49,280
MED00010 Aff Infus (Rawat Jalan) 27,500 8,250 19,250 27,500 8,250 19,250 30,250 9,075 21,175 33,000 9,900 23,100 38,500 11,550 26,950 44,000 13,200 30,800
MED00011 FOTOTERAPI BAYI / HARI 412,500 123,750 288,750 412,500 123,750 288,750 453,750 136,125 317,625 495,000 148,500 346,500 577,500 173,250 404,250 660,000 198,000 462,000
4.POLI BEDAH SPESIALIS
JENIS KODE LAYANAN POLIKLINIK BEDAH / SURGICAL KELAS II / KELAS I / Jasa fee Medis
Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana
LAYANAN CLINIC fee Medis fee Medis fee Medis fee Medis Sarana RS (70%) Jasa Sarana RS dan
RAWAT JALAN RS dan BHP
(70%)
KELAS III RS dan BHP
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%) VIP B VIP A BHP (30%)
fee Medis (70%)
(30%) (30%) HCU (30%) ISOLASI (30%) dan BHP
(30%)
MED00011 WT - Combutio,< 10% ( Bedah ) (Rawat Jalan) 238,810 71,643 167,167 238,810 71,643 167,167 262,691 78,807 183,884 286,572 85,972 200,600 334,334 100,300 234,034 382,096 114,629 267,467
MED00012 Angkat IDW ( Bedah ) (Rawat Jalan) 46,200 13,860 32,340 46,200 13,860 32,340 50,820 15,246 35,574 55,440 16,632 38,808 64,680 19,404 45,276 73,920 22,176 51,744
MED00013 Angkat Jahitan > 10 Jahitan ( Bedah ) (Rawat 36,300 84,700 121,000 36,300 84,700 133,100 93,170 145,200 43,560 101,640 169,400 50,820 118,580
121,000 39,930
Jalan) 193,600 58,080 135,520
MED00014 Angkat Jahitan 1 - 5 Jahitan ( Bedah ) (Rawat 10,560 24,640 35,200 10,560 24,640 38,720 27,104 42,240 12,672 29,568 49,280 14,784 34,496
35,200 11,616
Jalan) 56,320 16,896 39,424
Jasa
JENIS KODE LAYANAN POLIKLINIK BEDAH / Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana fee Medis
LAYANAN SURGICAL CLINIC fee Medis fee Medis fee Medis fee Medis Sarana RS Jasa Sarana RS dan
RAWAT JALAN RS dan BHP KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B (70%) VIP A fee Medis (70%)
(30%)
(70%)
(30%)
(70%) HCU (30%)
(70%) ISOLASI (30%)
(70%) dan BHP BHP (30%)
(30%) 153,296 45,989 107,307
MED00015 Angkat Wire ( Bedah ) (Rawat Jalan) 95,810 28,743 67,067 95,810 28,743 67,067 105,391 31,617 73,774 114,972 34,492 80,480 134,134 40,240 93,894
MED00016 Eksplorasi Besar ( Bedah ) (Rawat Jalan) 347,600 104,280 243,320 347,600 104,280 243,320 382,360 114,708 267,652 417,120 125,136 291,984 486,640 145,992 340,648 556,160 166,848 389,312
MED00017 Eksisi / BE Tumor Jinak < 2 cm ( Bedah ) (Rawat 51,150 119,350 170,500 51,150 119,350 187,550 131,285 204,600 61,380 143,220 238,700 71,610 167,090
170,500 56,265 272,800 81,840 190,960
Jalan)
MED00018 Drainage Abses ( Bedah ) (Rawat Jalan) 114,400 34,320 80,080 114,400 34,320 80,080 125,840 37,752 88,088 137,280 41,184 96,096 160,160 48,048 112,112 183,040 54,912 128,128
MED00019 Coller & Cup ( Bedah ) (Rawat Jalan) 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00020 Biopsi ( Bedah ) (Rawat Jalan) 112,200 33,660 78,540 112,200 33,660 78,540 123,420 37,026 86,394 134,640 40,392 94,248 157,080 47,124 109,956 179,520 53,856 125,664
MED00021 Anuskopi ( Bedah ) (Rawat Jalan) 170,500 51,150 119,350 170,500 51,150 119,350 187,550 56,265 131,285 204,600 61,380 143,220 238,700 71,610 167,090 272,800 81,840 190,960
MED00022 Pasang Foley Catheter ( Bedah ) (Rawat Jalan) 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00023 WT - Combutio < 30% ( Bedah ) (Rawat Jalan) 167,310 50,193 117,117 167,310 50,193 117,117 184,041 55,212 128,829 200,772 60,232 140,540 234,234 70,270 163,964 267,696 80,309 187,387
MED00024 Nagel Ekstrasi ( Bedah ) (Rawat Jalan) 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00025 Jahit Luka Tambahan Per Jahitan ( Bedah ) 2,640 6,160 8,800 2,640 6,160 9,680 6,776 10,560 3,168 7,392 12,320 3,696 8,624
8,800 2,904
(Rawat Jalan) 14,080 4,224 9,856
MED00026 Jahit Luka Sampai Dengan 3 Jahitan ( Bedah ) 25,410 59,290 84,700 25,410 59,290 93,170 65,219 101,640 30,492 71,148 118,580 35,574 83,006
84,700 27,951
(Rawat Jalan) 135,520 40,656 94,864
MED00027 Insisi ( Bedah ) (Rawat Jalan) 95,810 28,743 67,067 95,810 28,743 67,067 105,391 31,617 73,774 114,972 34,492 80,480 134,134 40,240 93,894 153,296 45,989 107,307
MED00028 Eksterpasi Kecil ( Bedah ) (Rawat Jalan) 398,200 119,460 278,740 398,200 119,460 278,740 438,020 131,406 306,614 477,840 143,352 334,488 557,480 167,244 390,236 637,120 191,136 445,984
MED00029 Eksterpasi Besar ( Bedah ) (Rawat Jalan) 679,800 203,940 475,860 679,800 203,940 475,860 747,780 224,334 523,446 815,760 244,728 571,032 951,720 285,516 666,204 1,087,680 326,304 761,376
MED00030 Eksplorasi Kecil ( Bedah ) (Rawat Jalan) 170,500 51,150 119,350 170,500 51,150 119,350 187,550 56,265 131,285 204,600 61,380 143,220 238,700 71,610 167,090 272,800 81,840 190,960
MED00031 Roster Plasty ( Bedah ) (Rawat Jalan) 143,715 43,115 100,601 143,715 43,115 100,601 158,087 47,426 110,661 172,458 51,737 120,721 201,201 60,360 140,841 229,944 68,983 160,961
MED00032 Reposisi ( Bedah ) (Rawat Jalan) 190,905 57,272 133,634 190,905 57,272 133,634 209,996 62,999 146,997 229,086 68,726 160,360 267,267 80,180 187,087 305,448 91,634 213,814
MED00033 Pasang Splint Sedang ( Bedah ) (Rawat Jalan) 128,700 38,610 90,090 128,700 38,610 90,090 141,570 42,471 99,099 154,440 46,332 108,108 180,180 54,054 126,126 205,920 61,776 144,144
MED00034 Pasang Splint Khusus ( Bedah ) (Rawat Jalan) 525,525 157,658 367,868 525,525 157,658 367,868 578,078 173,423 404,654 630,630 189,189 441,441 735,735 220,721 515,015 840,840 252,252 588,588
MED00035 Pasang Splint Besar ( Bedah ) (Rawat Jalan) 262,405 78,722 183,684 262,405 78,722 183,684 288,646 86,594 202,052 314,886 94,466 220,420 367,367 110,210 257,157 419,848 125,954 293,894
MED00036 Pasang Spalk Sedang ( Bedah ) (Rawat Jalan) 152,900 45,870 107,030 152,900 45,870 107,030 168,190 50,457 117,733 183,480 55,044 128,436 214,060 64,218 149,842 244,640 73,392 171,248
MED00037 Pasang Spalk Khusus ( Bedah ) (Rawat Jalan) 525,525 157,658 367,868 525,525 157,658 367,868 578,078 173,423 404,654 630,630 189,189 441,441 735,735 220,721 515,015 840,840 252,252 588,588
MED00038 Pasang Spalk Besar ( Bedah ) (Rawat Jalan) 312,400 93,720 218,680 312,400 93,720 218,680 343,640 103,092 240,548 374,880 112,464 262,416 437,360 131,208 306,152 499,840 149,952 349,888
MED00039 Pasang Metal Catheter ( Bedah ) (Rawat Jalan) 71,500 21,450 50,050 71,500 21,450 50,050 78,650 23,595 55,055 85,800 25,740 60,060 100,100 30,030 70,070 114,400 34,320 80,080
MED00040 Pasang Gips ( Belum Termasuk Bahan ) Sedang 38,610 90,090 128,700 38,610 90,090 141,570 99,099 154,440 46,332 108,108 180,180 54,054 126,126
128,700 42,471
( Bedah ) (Rawat Jalan) 205,920 61,776 144,144
MED00041 Pasang Gips ( Belum Termasuk Bahan ) Khusus ( 154,869 361,361 516,230 154,869 361,361 567,853 397,497 619,476 185,843 433,633 722,722 216,817 505,905
516,230 170,356
Bedah ) (Rawat Jalan) 825,968 247,790 578,178
MED00042 Pasang Gips ( Belum Termasuk Bahan ) Besar 78,936 184,184 263,120 78,936 184,184 289,432 202,602 315,744 94,723 221,021 368,368 110,510 257,858
263,120 86,830
MED00043 Angkat Jahitan 5 - 10 Jahitan ( Bedah ) (Rawat 12,540 29,260 41,800 12,540 29,260 45,980 32,186 50,160 15,048 35,112 58,520 17,556 40,964
41,800 13,794
Jalan) 66,880 20,064 46,816
MED00044 Buka Gips (Bedah) (Rawat Jalan) 103,400 31,020 72,380 103,400 31,020 72,380 113,740 34,122 79,618 124,080 37,224 86,856 144,760 43,428 101,332 165,440 49,632 115,808
MED00045 Eksisi Ganglion (Bedah) (Rawat Jalan) 199,100 59,730 139,370 199,100 59,730 139,370 219,010 65,703 153,307 238,920 71,676 167,244 278,740 83,622 195,118 318,560 95,568 222,992
MED00046 Ganti Balutan Kecil (Bedah) (Rawat Jalan) 42,185 12,656 29,530 42,185 12,656 29,530 46,404 13,921 32,482 50,622 15,187 35,435 59,059 17,718 41,341 67,496 20,249 47,247
MED00047 Katerisasi (Bedah) (Rawat Jalan) 46,200 13,860 32,340 46,200 13,860 32,340 50,820 15,246 35,574 55,440 16,632 38,808 64,680 19,404 45,276 73,920 22,176 51,744
MED00048 Rectal Taucher (Rawat Jalan) 118,800 35,640 83,160 118,800 35,640 83,160 130,680 39,204 91,476 142,560 42,768 99,792 166,320 49,896 116,424 190,080 57,024 133,056
MED00049 Ganti Balutan Sedang (Bedah) (Rawat Jalan) 73,700 22,110 51,590 73,700 22,110 51,590 81,070 24,321 56,749 88,440 26,532 61,908 103,180 30,954 72,226 117,920 35,376 82,544
MED00050 Ganti Balutan Besar (Bedah) (Rawat Jalan) 117,700 35,310 82,390 117,700 35,310 82,390 129,470 38,841 90,629 141,240 42,372 98,868 164,780 49,434 115,346 188,320 56,496 131,824
MED00051 Eksisi tumor (Rawat Jalan) 1,025,200 307,560 717,640 1,025,200 307,560 717,640 1,127,720 338,316 789,404 1,230,240 369,072 861,168 1,435,280 430,584 1,004,696 1,640,320 492,096 1,148,224
MED00052 Release Tongue tie (Rawat Jalan) 220,000 66,000 154,000 220,000 66,000 154,000 242,000 72,600 169,400 264,000 79,200 184,800 308,000 92,400 215,600 352,000 105,600 246,400
MED00053 Rectoscopy (Rawat Jalan) 364,100 109,230 254,870 364,100 109,230 254,870 400,510 120,153 280,357 436,920 131,076 305,844 509,740 152,922 356,818 582,560 174,768 407,792
MED00054 Jahit Stapler (Rawat Jalan) 11,000 3,300 7,700 11,000 3,300 7,700 12,100 3,630 8,470 13,200 3,960 9,240 15,400 4,620 10,780 17,600 5,280 12,320
MED00055 Evakuasi feces (Rawat Jalan) 330,000 99,000 231,000 330,000 99,000 231,000 363,000 108,900 254,100 396,000 118,800 277,200 462,000 138,600 323,400 528,000 158,400 369,600
MED00056 Tindik (Rawat Jalan) 199,100 59,730 139,370 199,100 59,730 139,370 219,010 65,703 153,307 238,920 71,676 167,244 278,740 83,622 195,118 318,560 95,568 222,992
MED00057 Lepas Tampon (Rawat Jalan) 37,400 11,220 26,180 37,400 11,220 26,180 41,140 12,342 28,798 44,880 13,464 31,416 52,360 15,708 36,652 59,840 17,952 41,888
MED00058 Dressing VAC Besar (Rawat Jalan) 487,300 146,190 341,110 487,300 146,190 341,110 536,030 160,809 375,221 584,760 175,428 409,332 682,220 204,666 477,554 779,680 233,904 545,776
MED00059 Dressing VAC Sedang (Rawat Jalan) 203,500 61,050 142,450 203,500 61,050 142,450 223,850 67,155 156,695 244,200 73,260 170,940 284,900 85,470 199,430 325,600 97,680 227,920
MED00060 WSD (Rawat Jalan) 856,900 257,070 599,830 856,900 257,070 599,830 942,590 282,777 659,813 1,028,280 308,484 719,796 1,199,660 359,898 839,762 1,371,040 411,312 959,728
MED00061 Paket Khitan 1,375,000 412,500 962,500 1,375,000 412,500 962,500 1,512,500 453,750 1,058,750 1,650,000 495,000 1,155,000 1,925,000 577,500 1,347,500 2,200,000 660,000 1,540,000
5.POLI KEBIDANAN SPESIALIS
LAYANAN POLIKLINIK DAFTAR TARIF LAYANAN
JENIS KODE KEBIDANAN & PENYAKIT KANDUNGAN / Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
LAYANAN fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS dan
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A BHP (30%)
fee Medis (70%)
(30%) (30%) HCU (30%) ISOLASI (30%) (30%)
OBSTETRY AND GYNECOLOGY CLINIC
MED00062 Angkat IUD ( Obgyn ) (Rawat Jalan) 178,200 53,460 124,740 178,200 53,460 124,740 196,020 58,806 137,214 213,840 64,152 149,688 249,480 74,844 174,636 285,120 85,536 199,584
MED00063 Angkat jahitan >10 jahitan (Rawat Jalan) 51,590 15,477 36,113 51,590 15,477 36,113 56,749 17,025 39,724 61,908 18,572 43,336 72,226 21,668 50,558 82,544 24,763 57,781
MED00064 Biopsi ( Obgyn ) (Rawat Jalan) 100,870 30,261 70,609 100,870 30,261 70,609 110,957 33,287 77,670 121,044 36,313 84,731 141,218 42,365 98,853 161,392 48,418 112,974
MED00065 Kolposkopi (Obgyn) (Rawat Jalan) 381,150 114,345 266,805 381,150 114,345 266,805 419,265 125,780 293,486 457,380 137,214 320,166 533,610 160,083 373,527 609,840 182,952 426,888
MED00066 KB Suntik ( Obgyn ) (Rawat Jalan) 30,800 9,240 21,560 30,800 9,240 21,560 33,880 10,164 23,716 36,960 11,088 25,872 43,120 12,936 30,184 49,280 14,784 34,496
MED00067 Kauter Elektrik ( Obgyn ) (Rawat Jalan) 71,500 21,450 50,050 71,500 21,450 50,050 78,650 23,595 55,055 85,800 25,740 60,060 100,100 30,030 70,070 114,400 34,320 80,080
MED00068 Kauter Albotyl ( Obgyn ) (Rawat Jalan) 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00069 SIS ( Obgyn ) (Rawat Jalan) 385,000 115,500 269,500 385,000 115,500 269,500 423,500 127,050 296,450 462,000 138,600 323,400 539,000 161,700 377,300 616,000 184,800 431,200
MED00070 Ganti Verband ( Obgyn ) (Rawat Jalan) 42,900 12,870 30,030 42,900 12,870 30,030 47,190 14,157 33,033 51,480 15,444 36,036 60,060 18,018 42,042 68,640 20,592 48,048
MED00071 Ganti Tampon ( Osbgyn ) (Rawat Jalan) 56,980 17,094 39,886 56,980 17,094 39,886 62,678 18,803 43,875 68,376 20,513 47,863 79,772 23,932 55,840 91,168 27,350 63,818
MED00072 Diathermi ( Osbgyn ) (Rawat Jalan) 158,015 47,405 110,611 158,015 47,405 110,611 173,817 52,145 121,672 189,618 56,885 132,733 221,221 66,366 154,855 252,824 75,847 176,977
MED00073 Cabut Implant ( Osbgyn ) (Rawat Jalan) 169,400 50,820 118,580 169,400 50,820 118,580 186,340 55,902 130,438 203,280 60,984 142,296 237,160 71,148 166,012 271,040 81,312 189,728
MED00074 Vaginal Swab ( Osbgyn ) (Rawat Jalan) 43,890 13,167 30,723 43,890 13,167 30,723 48,279 14,484 33,795 52,668 15,800 36,868 61,446 18,434 43,012 70,224 21,067 49,157
MED00075 Pasang IUD ( Osbgyn ) (Rawat Jalan) 185,900 55,770 130,130 185,900 55,770 130,130 204,490 61,347 143,143 223,080 66,924 156,156 260,260 78,078 182,182 297,440 89,232 208,208
MED00076 Pasang Implant ( Osbgyn ) (Rawat Jalan) 169,400 50,820 118,580 169,400 50,820 118,580 186,340 55,902 130,438 203,280 60,984 142,296 237,160 71,148 166,012 271,040 81,312 189,728
KEBIDANAN & PENYAKIT KANDUNGAN / KELAS II / KELAS I /
Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana
JENIS KODE fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS dan
LAYANAN
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A BHP (30%)
fee Medis (70%)
OBSTETRY AND GYNECOLOGY CLINIC (30%) (30%) HCU (30%) ISOLASI (30%) (30%)
MED00077 Pap Smear ( Osbgyn ) (Rawat Jalan) 82,500 24,750 57,750 82,500 24,750 57,750 99,000 29,700 69,300 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
MED00078 Angkat Jahitan < 5 Jahitan ( Osbgyn ) (Rawat 9,240 21,560 30,800 9,240 21,560 36,960 25,872 36,960 11,088 25,872 43,120 12,936 30,184
30,800 11,088 49,280 14,784 34,496
Jalan)
MED00079 Angkat Jahitan 5 - 10 Jahitan ( Osbgyn ) (Rawat 12,243 28,567 40,810 12,243 28,567 48,972 34,280 48,972 14,692 34,280 57,134 17,140 39,994
40,810 14,692
Jalan) 65,296 19,589 45,707
MED00080 Injeksi ( Osbgyn ) (Rawat Jalan) 42,900 12,870 30,030 42,900 12,870 30,030 51,480 15,444 36,036 51,480 15,444 36,036 60,060 18,018 42,042 68,640 20,592 48,048
MED00081 Pemeriksaan Ginekologi (dengan kamera) (Rawat 22,737 53,053 75,790 22,737 53,053 90,948 63,664 90,948 27,284 63,664 106,106 31,832 74,274
75,790 27,284 121,264 36,379 84,885
Jalan)
MED00082 IVA TEST (Rawat Jalan) 60,500 18,150 42,350 60,500 18,150 42,350 72,600 21,780 50,820 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
MED00083 Pasang Pesarium 66,550 19,965 46,585 66,550 19,965 46,585 79,860 23,958 55,902 79,860 23,958 55,902 93,170 27,951 65,219 106,480 31,944 74,536
- - -
6.POLI PENYAKIT DALAM SPESIALIS
JENIS DAFTAR TARIF LAYANAN
KODE LAYANAN POLIKLINIK PENYAKIT DALAM / Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
INTERNIST CLINIC fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS dan
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A BHP (30%)
fee Medis (70%)
LAYANAN (30%) (30%) HCU (30%) ISOLASI (30%) (30%)
BBM00100 Aspirasi Jarum Halus (Rawat Jalan) 266,200 79,860 186,340 266,200 79,860 186,340 292,820 87,846 204,974 319,440 95,832 223,608 372,680 111,804 260,876 425,920 127,776 298,144
BBM00101 BMP (Rawat Jalan) 238,095 71,429 166,667 238,095 71,429 166,667 261,905 78,571 183,333 285,714 85,714 200,000 333,333 100,000 233,333 380,952 114,286 266,666
BBM00102 Inhalasi Therapy (Rawat Jalan) 57,200 17,160 40,040 57,200 17,160 40,040 62,920 18,876 44,044 68,640 20,592 48,048 80,080 24,024 56,056 91,520 27,456 64,064
BBM00103 WSD Mini (Rawat Jalan) 95,810 28,743 67,067 95,810 28,743 67,067 105,391 31,617 73,774 114,972 34,492 80,480 134,134 40,240 93,894 153,296 45,989 107,307
BBM00104 WSD Continue (Rawat Jalan) 119,405 35,822 83,584 119,405 35,822 83,584 131,346 39,404 91,942 143,286 42,986 100,300 167,167 50,150 117,017 191,048 57,314 133,734
BBM00105 Spirometri (Rawat Jalan) 125,840 37,752 88,088 125,840 37,752 88,088 138,424 41,527 96,897 151,008 45,302 105,706 176,176 52,853 123,323 201,344 60,403 140,941
BBM00106 Punctie Pleura (Rawat Jalan) 224,510 67,353 157,157 224,510 67,353 157,157 246,961 74,088 172,873 269,412 80,824 188,588 314,314 94,294 220,020 359,216 107,765 251,451
BBM00107 Punctie Ascites (Rawat Jalan) 176,605 52,982 123,624 176,605 52,982 123,624 194,266 58,280 135,986 211,926 63,578 148,348 247,247 74,174 173,073 282,568 84,770 197,798
BBM00108 Injeksi Intra artikuler ( per sendi ) (Rawat Jalan) 286,715 86,015 200,701 286,715 86,015 200,701 315,387 94,616 220,771 344,058 103,217 240,841 401,401 120,420 280,981 458,744 137,623 321,121
BBM00109 INJEKSI AMTOCORT (Rawat Jalan) 38,500 11,550 26,950 38,500 11,550 26,950 42,350 12,705 29,645 46,200 13,860 32,340 53,900 16,170 37,730 61,600 18,480 43,120
7.TARIF KONSULTASI GIZI

KODE LAYANAN TARIF GIZI / NUTRITION RATE Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS dan
RAWAT JALAN
RS dan BHP
fee Medis KELAS III
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis VIP A BHP (30%)
fee Medis (70%)
LAYANAN HCU ISOLASI
BBM00110 KONSULTASI GIZI 55,000 55,000 55,000 55,000 55,000 55,000
8.TARIF GIGI UMUM
KODE LAYANAN TARIF GIGI UMUM Jasa Sarana Jasa Sarana KELAS II / KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS dan
RAWAT JALAN
RS dan BHP
fee Medis KELAS III
RS dan BHP
fee Medis Jasa Sarana RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis (50%)
LAYANAN HCU ISOLASI
GUMH2001 Konsultasi (Medikasi) 60,500 42,350 18,150 60,500 42,350 18,150 66,550 33,275 33,275 72,600 36,300 36,300 84,700 42,350 42,350 96,800 48,400 48,400
Tumpatan SIK - -
GUMH2002 Kecil 114,400 57,200 57,200 114,400 57,200 57,200 125,840 62,920 62,920 137,280 68,640 68,640 160,160 80,080 80,080 183,040 91,520 91,520
GUMH2003 Sedang 157,300 78,650 78,650 157,300 78,650 78,650 173,030 86,515 86,515 188,760 94,380 94,380 220,220 110,110 110,110 251,680 125,840 125,840
GUMH2004 Besar 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
Tumpatan LC - -
GUMH2005 Kecil 157,300 78,650 78,650 157,300 78,650 78,650 173,030 86,515 86,515 188,760 94,380 94,380 220,220 110,110 110,110 251,680 125,840 125,840
GUMH2006 Sedang 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
GUMH2007 Besar 314,600 157,300 157,300 314,600 157,300 157,300 346,060 173,030 173,030 377,520 188,760 188,760 440,440 220,220 220,220 503,360 251,680 251,680
GUMH2008 Tumpatan Sementara 85,800 42,900 42,900 85,800 42,900 42,900 94,380 47,190 47,190 102,960 51,480 51,480 120,120 60,060 60,060 137,280 68,640 68,640
Ektraksi Gigi Permanen - -
GUMH2009 Ringan 171,600 85,800 85,800 171,600 85,800 85,800 188,760 94,380 94,380 205,920 102,960 102,960 240,240 120,120 120,120 274,560 137,280 137,280
GUMH2010 Sedang 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
GUMH2011 Berat 314,600 157,300 157,300 314,600 157,300 157,300 346,060 173,030 173,030 377,520 188,760 188,760 440,440 220,220 220,220 503,360 251,680 251,680
GUMH2012 Ekstraksi Gigi Desidui 85,800 42,900 42,900 85,800 42,900 42,900 94,380 47,190 47,190 102,960 51,480 51,480 120,120 60,060 60,060 137,280 68,640 68,640
Skalling Rahang Atas Bawah - -
GUMH2013 Ringan 157,300 78,650 78,650 157,300 78,650 78,650 173,030 86,515 86,515 188,760 94,380 94,380 220,220 110,110 110,110 251,680 125,840 125,840
GUMH2014 Sedang 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
GUMH2015 Berat 314,600 157,300 157,300 314,600 157,300 157,300 346,060 173,030 173,030 377,520 188,760 188,760 440,440 220,220 220,220 503,360 251,680 251,680
KONSERVASI GIGI ( TAMBAL ) - -
Penambalan bahan SIK ( glass ionomer ) - -
GIGI0001 Kecil 165,000 82,500 82,500 165,000 82,500 82,500 181,500 90,750 90,750 198,000 99,000 99,000 231,000 115,500 115,500 264,000 132,000 132,000
GIGI0002 Sedang 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
GIGI0003 Besar 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
Penambalan Komposit resin bahan standar - - - - - - - - - - - -
GIGI0004 Kecil 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
GIGI0005 Sedang 275,000 137,500 137,500 275,000 137,500 137,500 302,500 151,250 151,250 330,000 165,000 165,000 385,000 192,500 192,500 440,000 220,000 220,000
GIGI0006 Besar 275,000 137,500 137,500 275,000 137,500 137,500 302,500 151,250 151,250 330,000 165,000 165,000 385,000 192,500 192,500 440,000 220,000 220,000
Penambalan Komposit resin bahan kualitas utama - - - - - - - - - - - -
GIGI0007 Kecil 275,000 137,500 137,500 275,000 137,500 137,500 302,500 151,250 151,250 330,000 165,000 165,000 385,000 192,500 192,500 440,000 220,000 220,000
GIGI0008 Sedang 330,000 165,000 165,000 330,000 165,000 165,000 363,000 181,500 181,500 396,000 198,000 198,000 462,000 231,000 231,000 528,000 264,000 264,000
GIGI0009 Besar 385,000 192,500 192,500 385,000 192,500 192,500 423,500 211,750 211,750 462,000 231,000 231,000 539,000 269,500 269,500 616,000 308,000 308,000
Penambalan Estetika ( Sandwich System ) - - - - - - - - - - - -
GIGI0010 Kecil 330,000 165,000 165,000 330,000 165,000 165,000 363,000 181,500 181,500 396,000 198,000 198,000 462,000 231,000 231,000 528,000 264,000 264,000
GIGI0011 Sedang 385,000 192,500 192,500 385,000 192,500 192,500 423,500 211,750 211,750 462,000 231,000 231,000 539,000 269,500 269,500 616,000 308,000 308,000
KODE LAYANAN TARIF GIGI UMUM Jasa Sarana Jasa Sarana KELAS II / KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS dan
RAWAT JALAN
RS dan BHP
fee Medis KELAS III
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis (50%)
LAYANAN HCU ISOLASI
GIGI0012 Besar 440,000 220,000 220,000 440,000 220,000 220,000 484,000 242,000 242,000 528,000 264,000 264,000 616,000 308,000 308,000 704,000 352,000 352,000
GIGI0013 Devitalisasi ( mematikan pulpa gigi ) 165,000 82,500 82,500 165,000 82,500 82,500 181,500 90,750 90,750 198,000 99,000 99,000 231,000 115,500 115,500 264,000 132,000 132,000
Jacket Crown - - - - - - - - - - - -
GIGI0014 Akrilik / per gigi 825,000 412,500 412,500 825,000 412,500 412,500 907,500 453,750 453,750 990,000 495,000 495,000 1,155,000 577,500 577,500 1,320,000 660,000 660,000
GIGI0015 Porselain Fused to Metal / pergigi 1,650,000 825,000 825,000 1,650,000 825,000 825,000 1,815,000 907,500 907,500 1,980,000 990,000 990,000 2,310,000 1,155,000 1,155,000 2,640,000 1,320,000 1,320,000
GIGI0016 All porselain / per gigi 3,300,000 1,650,000 1,650,000 3,300,000 1,650,000 1,650,000 3,630,000 1,815,000 1,815,000 3,960,000 1,980,000 1,980,000 4,620,000 2,310,000 2,310,000 5,280,000 2,640,000 2,640,000
GIGI0017 Bleaching ( Pemutihan gigi ) 2,200,000 1,100,000 1,100,000 2,200,000 1,100,000 1,100,000 2,420,000 1,210,000 1,210,000 2,640,000 1,320,000 1,320,000 3,080,000 1,540,000 1,540,000 3,520,000 1,760,000 1,760,000
GIGI0018 Sementasi onlay/inlay/jembatan yang lepas 110,000 55,000 55,000 1,100,000 550,000 550,000 1,210,000 605,000 605,000 1,320,000 660,000 660,000 1,540,000 770,000 770,000 1,760,000 880,000 880,000
HARGA KAWAT / BEHEL GIGI - - - - - - - - - - - -
GIGI0019 Pasang Kawat / Behel Gigi 4,400,000 2,200,000 2,200,000 4,400,000 2,200,000 2,200,000 4,840,000 2,420,000 2,420,000 5,280,000 2,640,000 2,640,000 6,160,000 3,080,000 3,080,000 7,040,000 3,520,000 3,520,000
GIGI0020 Pemasangan Bracket I ( satu ) rahang saja 2,750,000 1,375,000 1,375,000 2,750,000 1,375,000 1,375,000 3,025,000 1,512,500 1,512,500 3,300,000 1,650,000 1,650,000 3,850,000 1,925,000 1,925,000 4,400,000 2,200,000 2,200,000
GIGI0021 Pasien lanjutan dokter gigi lain 1,650,000 825,000 825,000 1,650,000 825,000 825,000 1,815,000 907,500 907,500 1,980,000 990,000 990,000 2,310,000 1,155,000 1,155,000 2,640,000 1,320,000 1,320,000
GIGI0022 Kontrol Rutin Pasien 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
GIGI0023 Hilang bracket 55,000 27,500 27,500 55,000 27,500 27,500 60,500 30,250 30,250 66,000 33,000 33,000 77,000 38,500 38,500 88,000 44,000 44,000
GIGI0024 Ganti Kawat 55,000 27,500 27,500 55,000 27,500 27,500 60,500 30,250 30,250 66,000 33,000 33,000 77,000 38,500 38,500 88,000 44,000 44,000
GIGI0025 Retainer lepasan 2 ( dua ) rahang 1,100,000 550,000 550,000 1,100,000 550,000 550,000 1,210,000 605,000 605,000 1,320,000 660,000 660,000 1,540,000 770,000 770,000 1,760,000 880,000 880,000
GIGI0026 Scalling rutin pasien ortho / kawat gigi 110,000 55,000 55,000 110,000 55,000 55,000 121,000 60,500 60,500 132,000 66,000 66,000 154,000 77,000 77,000 176,000 88,000 88,000
Pembuatan Gigi Palsu - - -
GTS ( Gigi Tiruan Sebagian ) - - -
Bahan akrilik + gigi standar - - -
GIGI0027 Plat / per rahang 385,000 192,500 192,500 385,000 192,500 192,500 423,500 211,750 211,750 462,000 231,000 231,000 539,000 269,500 269,500 616,000 308,000 308,000
GIGI0028 Gigi Selanjutnya / per gigi 110,000 55,000 55,000 110,000 55,000 55,000 121,000 60,500 60,500 132,000 66,000 66,000 154,000 77,000 77,000 176,000 88,000 88,000
Bahan akrilik + gigi ortholux - - - - - - - - - - - -
GTS ( Gigi Tiruan Sebagian ) bahan Valplast - - -
- - - - - - - - -
Bahan Valplast + gigi ortholux - - - - - - - - - - - -
GIGI0031 Plat / per rahang 1,100,000 550,000 550,000 1,100,000 550,000 550,000 1,210,000 605,000 605,000 1,320,000 660,000 660,000 1,540,000 770,000 770,000 1,760,000 880,000 880,000
GTS ( Gigi Tiruan Sebagian ) Frame Logam - - - - - - - - - - - -
Frame Logam + Gigi Ortholux - - - - - - - - - - - -
GIGI0033 Plat / per rahang 1,375,000 687,500 687,500 1,375,000 687,500 687,500 1,512,500 756,250 756,250 1,650,000 825,000 825,000 1,925,000 962,500 962,500 2,200,000 1,100,000 1,100,000
GIGI0035 4,400,000 2,200,000 2,200,000
GTL (Gigi Tiruan Lengkap ) Akrilik per rahang 2,750,000 1,375,000 1,375,000 2,750,000 1,375,000 1,375,000 3,025,000 1,512,500 1,512,500 3,300,000 1,650,000 1,650,000 3,850,000 1,925,000 1,925,000
GTL ( Gigi Tiruan Lengkap ) Kerangka Logam
GIGI0036 6,160,000 3,080,000 3,080,000
per rahang 3,850,000 1,925,000 1,925,000 3,850,000 1,925,000 1,925,000 4,235,000 2,117,500 2,117,500 4,620,000 2,310,000 2,310,000 5,390,000 2,695,000 2,695,000
GIGI0037 GTL ( Gigi Tiruan Lengkap ) Valplast per rahang 5,280,000 2,640,000 2,640,000
3,300,000 1,650,000 1,650,000 3,300,000 1,650,000 1,650,000 3,630,000 1,815,000 1,815,000 3,960,000 1,980,000 1,980,000 4,620,000 2,310,000 2,310,000
GTC ( Gigi Tiruan Cekat ) Bahan Akrilik ( Sudah
GIGI0038 1,320,000 660,000 660,000
termasuk sementasi ) / per gigi 825,000 412,500 412,500 825,000 412,500 412,500 907,500 453,750 453,750 990,000 495,000 495,000 1,155,000 577,500 577,500
GTC ( Gigi Tiruan Cekat ) Bahan Porselain
GIGI0039 2,640,000 1,320,000 1,320,000
( Sudah termasuk sementasi ) / per gigi 1,650,000 825,000 825,000 1,650,000 825,000 825,000 1,815,000 907,500 907,500 1,980,000 990,000 990,000 2,310,000 1,155,000 1,155,000
GIGI0040 Reparasi GTS / GTL per rahang 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
Tambahan Cabut Gigi - - - - - - - - - - - -
GIGI0041 Cabut gigi dengan penyulit 330,000 165,000 165,000 330,000 165,000 165,000 363,000 181,500 181,500 396,000 198,000 198,000 462,000 231,000 231,000 528,000 264,000 264,000
Odontectomi - - - - - - - - - - - -
GIGI0042 Ringan 715,000 429,000 286,000 715,000 429,000 286,000 786,500 471,900 314,600 858,000 514,800 343,200 1,001,000 600,600 400,400 1,144,000 572,000 572,000
GIGI0043 Sedang 1,100,000 660,000 440,000 1,100,000 660,000 440,000 1,210,000 726,000 484,000 1,320,000 792,000 528,000 1,540,000 924,000 616,000 1,760,000 880,000 880,000
GIGI0044 Berat 2,200,000 1,320,000 880,000 2,200,000 1,320,000 880,000 2,420,000 1,452,000 968,000 2,640,000 1,584,000 1,056,000 3,080,000 1,848,000 1,232,000 3,520,000 1,760,000 1,760,000
9.TARIF LAKTASI
KODE LAYANAN TARIF LAKTASI Jasa Sarana KELAS III Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS dan
RAWAT JALAN
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis VIP A BHP
fee Medis
LAYANAN HCU ISOLASI
LBBM2001 Perkedatangan -Jasa Edukasi 77,000 77,000 84,700 92,400 107,800 123,200 36,960 86,240
LBBM2002 Paket Edukasi Laktasi ( 5x kedatangan ) 385,000 385,000 385,000 385,000 385,000 616,000 184,800 431,200
10. TARIF FISIOTERAPI

KODE LAYANAN TARIF FISIOTERAPI KELAS III KELAS II / KELAS I /
Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana RS dan
RAWAT JALAN
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis VIP A BHP
fee Medis
LAYANAN HCU ISOLASI
FBBM2001 Jasa Fisioterapi 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2002 Jasa Creambath 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2003 Jasa Pijat 88,000 88,000 96,800 105,600 123,200 140,800 42,240 98,560
FBBM2004 Jasa Oral Terapi 11,000 11,000 12,100 13,200 15,400 17,600 5,280 12,320
FBBM2005 Jasa Pijat Oksitosin / Bayi 44,000 44,000 48,400 52,800 61,600 70,400 21,120 49,280
FBBM2006 Jasa Pijat Anak Batuk pilek dg penyinaran 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2007 Jasa Pijat Bayi usia 12 bl keatas 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2008 Senam Hamil 55000 55,000 60,500 66,000 77,000 88,000 26,400 61,600
II. TARIF PENUNJANG MEDIK
1.TARIF LABORATORIUM
KODE LAYANAN LABORATORIUM / LABORATORY Jasa Sarana Fee Medis Jasa Sarana Fee Medis KELAS II / Jasa Sarana Fee Medis KELAS I / Jasa Sarana Fee Medis Jasa Sarana Fee Medis Jasa Sarana RS dan
RAWAT JALAN
RS dan BHP 2,5%
KELAS III
RS dan BHP 2,5% RS dan BHP 2,5% RS dan BHP 2,5%
VIP B
RS dan BHP 2,5% VIP A BHP
Fee Medis 2,5%
LAYANAN HCU ISOLASI
LAB100001 Analisa Ascities (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100002 Analisa Batu Ginjal (Rawat Jalan) 504,000 504,000 554,400 604,800 655,200 705,600
LAB100003 Analisa Cairan Lambung (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100004 Analisa Cairaln LCS (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100005 Analisa Cairan Lengkap (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100006 Analisa Cairan Pleura (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
RAWAT JALAN
RS dan BHP 2,5%
KELAS III
VIP B
Fee Medis 2,5%
LAYANAN HCU ISOLASI
LAB100007 Analisa Cairan Sendi (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100008 Ferritin (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100009 Saturasi Transferin (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100010 Serum Iron (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
LAB100011 TIBC (Rawat Jalan) 315,000 315,000 346,500 378,000 409,500 441,000
LAB100012 Transferin (Rawat Jalan) 1,500,000 1,500,000 1,650,000 1,800,000 1,950,000 2,100,000
LAB100013 UIBC (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
LAB100014 Vitamin B 12 (Rawat Jalan) 3,500,000 3,500,000 3,850,000 4,200,000 4,550,000 4,900,000
LAB100015 HbA1C (Rawat Jalan) 342,000 342,000 376,200 410,400 444,600 478,800
LAB100016 Insulin (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100017 Insulin 2 JPP (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100018 Insulin Puasa (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100019 Mikroalbumin Kuantitatif (Rawat Jalan) 360,000 360,000 396,000 432,000 468,000 504,000
LAB100020 Calcitonon (Rawat Jalan) 4,400,000 4,400,000 4,840,000 5,280,000 5,720,000 6,160,000
LAB100021 Calcium (Rawat Jalan) 220,000 220,000 242,000 264,000 286,000 308,000
LAB100022 Calcium (Urine) (Rawat Jalan) 220,000 220,000 242,000 264,000 286,000 308,000
LAB100023 Chlorida (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100024 Kalium (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100025 Magnesium (Rawat Jalan) 230,000 230,000 253,000 276,000 299,000 322,000
LAB100026 Natruim (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100027 Phospor Anorganik (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100028 Alkali Fosfatase (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100029 Cholinesterase (Rawat Jalan) 300,000 300,000 330,000 360,000 390,000 420,000
LAB100030 GAMMA GT (Rawat Jalan) 220,000 220,000 242,000 264,000 286,000 308,000
LAB100031 Cystatin C (Rawat Jalan) 1,400,000 1,400,000 1,540,000 1,680,000 1,820,000 1,960,000
LAB100032 eGFR (Rawat Jalan) 180,000 180,000 198,000 216,000 234,000 252,000
LAB100033 Albumin (Rawat Jalan) 180,000 180,000 198,000 216,000 234,000 252,000
LAB100034 Globulin (Rawat Jalan) 285,000 285,000 313,500 342,000 370,500 399,000
LAB100035 Protein Lengkap (Rawat Jalan) 288,000 288,000 316,800 345,600 374,400 403,200
LAB100036 Protein Pleura (Rawat Jalan) 160,000 160,000 176,000 192,000 208,000 224,000
LAB100037 Acid Phospatase (Rawat Jalan) 1,600,000 1,600,000 1,760,000 1,920,000 2,080,000 2,240,000
LAB100038 Protein Total (Rawat Jalan) 180,000 180,000 198,000 216,000 234,000 252,000
LAB100039 D-Dimer Kuantitatif (Rawat Jalan) 1,040,000 1,040,000 1,144,000 1,248,000 1,352,000 1,456,000
LAB100040 Fibrinogen (Rawat Jalan) 360,000 360,000 396,000 432,000 468,000 504,000
LAB100041 INR (Rawat Jalan) 320,000 320,000 352,000 384,000 416,000 448,000
LAB100042 Tes Agregasi Trombosit (Rawat Jalan) 800,000 800,000 880,000 960,000 1,040,000 1,120,000
LAB100043 Waktu Protrombin (Rawat Jalan) 320,000 320,000 352,000 384,000 416,000 448,000
LAB100044 CK-MB (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100045 CK-Total/CPK (Rawat Jalan) 285,000 285,000 313,500 342,000 370,500 399,000
LAB100046 Homosisein (Rawat Jalan) 2,500,000 2,500,000 2,750,000 3,000,000 3,250,000 3,500,000
LAB100047 LDH (Rawat Jalan) 230,000 230,000 253,000 276,000 299,000 322,000
LAB100048 Troponin I (Rawat Jalan) 960,000 960,000 1,056,000 1,152,000 1,248,000 1,344,000
LAB100049 Troponin T (Rawat Jalan) 540,000 540,000 594,000 648,000 702,000 756,000
LAB100050 CD 8 (Rawat Jalan) 1,000,000 1,000,000 1,100,000 1,200,000 1,300,000 1,400,000
LAB100051 CD 4 (Rawat Jalan) 970,000 970,000 1,067,000 1,164,000 1,261,000 1,358,000
LAB100052 EOSINOFIL (Rawat Jalan) 80,000 80,000 88,000 96,000 104,000 112,000
LAB100053 EOSINOFIL Absolut (Rawat Jalan) 210,000 210,000 231,000 252,000 273,000 294,000
LAB100054 Gambaran Darah Tepi (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100055 HB Elektroforesa (Rawat Jalan) 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
LAB100056 LE-Sel (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100057 Le Test (Rawat Jalan) 600,000 600,000 660,000 720,000 780,000 840,000
LAB100058 Malaria (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100059 Malaria ICT (Rawat Jalan) 500,000 500,000 550,000 600,000 650,000 700,000
LAB100060 Retikulosit (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100061 Anti Mullerian Hormon (AMH) (Rawat Jalan) 1,600,000 1,600,000 1,760,000 1,920,000 2,080,000 2,240,000
LAB100062 BETA HCG SERUM (Rawat Jalan) 640,000 640,000 704,000 768,000 832,000 896,000
LAB100063 Estradiol (Rawat Jalan) 640,000 640,000 704,000 768,000 832,000 896,000
LAB100064 FSH (Rawat Jalan) 560,000 560,000 616,000 672,000 728,000 784,000
LAB100065 Progesteron (Rawat Jalan) 810,000 810,000 891,000 972,000 1,053,000 1,134,000
LAB100066 Prolaktin (Rawat Jalan) 560,000 560,000 616,000 672,000 728,000 784,000
LAB100067 Testosteron Total (Rawat Jalan) 810,000 810,000 891,000 972,000 1,053,000 1,134,000
LAB100068 Anti Leptospira (Rawat Jalan) 1,425,000 1,425,000 1,567,500 1,710,000 1,852,500 1,995,000
LAB100069 Helicobacter Phylori igG (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100070 Helicobacter Phylori igM (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100071 IgG - IgM Anti Virus Dengue (Rawat Jalan) 540,000 540,000 594,000 648,000 702,000 756,000
LAB100072 IgG Anti Chlamydia (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100073 IgM Anti Chlamydia (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100074 IgM Leptospira (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100075 NS1 (Rawat Jalan) 520,000 520,000 572,000 624,000 676,000 728,000
LAB100076 NSE (Rawat Jalan) 2,400,000 2,400,000 2,640,000 2,880,000 3,120,000 3,360,000
RAWAT JALAN
RS dan BHP 2,5%
KELAS III
VIP B
Fee Medis 2,5%
LAYANAN HCU ISOLASI
LAB100077 Salmonela Typhi IGG (Rawat Jalan) 1,400,000 1,400,000 1,540,000 1,680,000 1,820,000 1,960,000
LAB100078 Salmonela Typhi IGM (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100079 Seramoeba (Rawat Jalan) 700,000 700,000 770,000 840,000 910,000 980,000
LAB100080 TPHA (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
RAWAT JALAN
RS dan BHP 2,5%
KELAS III
VIP B
Fee Medis 2,5%
LAYANAN HCU ISOLASI
LAB100081 Kultur Bactec (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100082 Kultur BTA (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100083 Kultur For Salmonelia Shigela (Rawat Jalan) 665,000 665,000 731,500 798,000 864,500 931,000
LAB100084 Kultur for Vibrio Cholera (Rawat Jalan) 960,000 960,000 1,056,000 1,152,000 1,248,000 1,344,000
LAB100085 Kultur Gaal (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100086 Kultur Jamur/Candida (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100087 Kultur Jaringan (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100088 Kultur MGIT (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100089 Kultur Sen. Kerokan Kulit (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100090 Kultur Sen. Pleura (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100091 Kultur Sen. Cairan Sendi (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100092 Kultur Sen. Mata Kanan (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100093 Kultur Sen. Mata Kiri (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100094 Kultur Sen. Test Darah (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100095 Kultur Sen. Test Faeces (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100096 Kultur Sen. Test Pus (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100097 Kultur Sen. Test Sekret (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100098 Kultur Sen. Test Sputum (Rawat Jalan) 1,141,000 1,141,000 1,255,100 1,369,200 1,483,300 1,597,400
LAB100099 Kultur Sen. Test TBC (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100100 Kultur Sen. Test Urine + Hit (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100101 Kultur Sen. Test Cairan Acites (Rawat Jalan) 1,425,000 1,425,000 1,567,500 1,710,000 1,852,500 1,995,000
LAB100102 Kultur Sen. Test Cairan LCS (Rawat Jalan) 1,425,000 1,425,000 1,567,500 1,710,000 1,852,500 1,995,000
LAB100103 Kultur Vitex (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100104 Magnesium ( LCS ) (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100105 Pengecatan Gram (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100106 Lippo Protein (a) (Rawat Jalan) 1,700,000 1,700,000 1,870,000 2,040,000 2,210,000 2,380,000
LAB100107 Phospho Lipid (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100108 Sall Dense LDL (Rawat Jalan) 450,000 450,000 495,000 540,000 585,000 630,000
LAB100109 VLDL (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100110 BTA Cairan Pleura (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100111 KOH (Rawat Jalan) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100112 Rectal Swab (Culture) (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100113 Rectal Swab (Mikroskopis) (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100114 Sekret Endocervix (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100115 Sekret Hidung (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100116 Sekret Lidah (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100117 Sekret Mata Kanan (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100118 Sekret Mata Kiri (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100119 Sekret PUS (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100120 Sekret Serviks (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100121 Sekret Telinga (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100122 Sekret Tenggorok (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100123 Sekret Uretra (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100124 Sputum BTA (Ziehl-Neelsen) (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100125 Sputum BTA +Gram I (Rawat Jalan) 260,000 260,000 286,000 312,000 338,000 364,000
LAB100126 Sputum BTA +Gram II (Rawat Jalan) 340,000 340,000 374,000 408,000 442,000 476,000
LAB100127 Sputum BTA +Gram III (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100128 Sputum BTA 2 Kali (Rawat Jalan) 260,000 260,000 286,000 312,000 338,000 364,000
LAB100130 Sputum Gram (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100131 ALPHA AMYLASE (Rawat Jalan) 320,000 320,000 352,000 384,000 416,000 448,000
LAB100132 Lipase (Rawat Jalan) 280,000 280,000 308,000 336,000 364,000 392,000
LAB100133 BCR ABL Kualitatif (Rawat Jalan) 6,175,000 6,175,000 6,792,500 7,410,000 8,027,500 8,645,000
LAB100134 PCR MH (Morbus Hansen) (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100135 PCR TB (EFUSI PLEURA) (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100136 PCR TB (Darah) (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100137 PCR TB (Tulang) (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100138 PCR TB Ascites (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100139 PCR TB LCS (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100140 PCR HSV 1 (Rawat Jalan) 2,090,000 2,090,000 2,299,000 2,508,000 2,717,000 2,926,000
LAB100141 FT3 (Rawat Jalan) 560,000 560,000 616,000 672,000 728,000 784,000
LAB100143 Parathyroid (Rawat Jalan) 2,200,000 2,200,000 2,420,000 2,640,000 2,860,000 3,080,000
LAB100144 T3 (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100145 T3 (ELFA) (Rawat Jalan) 450,000 450,000 495,000 540,000 585,000 630,000
LAB100146 T4 (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100148 Thyroglobulin (Rawat Jalan) 2,200,000 2,200,000 2,420,000 2,640,000 2,860,000 3,080,000
LAB100149 TSH Resptor Antibodi (Rawat Jalan) 1,800,000 1,800,000 1,980,000 2,160,000 2,340,000 2,520,000
LAB100150 TSH-s (Rawat Jalan) 450,000 450,000 495,000 540,000 585,000 630,000
LAB100151 Anti HAV Total (Rawat Jalan) 810,000 810,000 891,000 972,000 1,053,000 1,134,000
LAB100152 Anti HBc Total (Rawat Jalan) 665,000 665,000 731,500 798,000 864,500 931,000
LAB100153 Anti Hbe (Rawat Jalan) 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
LAB100154 Anti HBs (Rawat Jalan) 380,000 380,000 418,000 456,000 494,000 532,000
RAWAT JALAN
RS dan BHP 2,5%
KELAS III
VIP B
RS dan BHP 2,5%
VIP A BHP
Fee Medis 2,5%
LAYANAN HCU ISOLASI
LAB100155 Anti HCV (Rawat Jalan) 665,000 665,000 731,500 798,000 864,500 931,000
LAB100156 HBeAg (Rawat Jalan) 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
LAB100157 HBsAg Kuantitatif (Rawat Jalan) 720,000 720,000 792,000 864,000 936,000 1,008,000
LAB100158 HBsAg Ultra Sensitif (Rawat Jalan) 351,500 351,500 386,650 421,800 456,950 492,100
LAB100159 IgM Anti HAV (Rawat Jalan) 720,000 720,000 792,000 864,000 936,000 1,008,000
LAB100160 IgM HBC (Rawat Jalan) 855,000 855,000 940,500 1,026,000 1,111,500 1,197,000
LAB100161 IgM Anti HCV (Rawat Jalan) 3,200,000 3,200,000 3,520,000 3,840,000 4,160,000 4,480,000
LAB100162 AMA (Anti Microsomal Antibody)-THYROID (Rawat
2,375,000 2,375,000 2,612,500 2,850,000 3,087,500 3,325,000
Jalan)
LAB100163 ANA (Rawat Jalan) 850,000 850,000 935,000 1,020,000 1,105,000 1,190,000
LAB100164 ANA IF (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100165 ANCA (Rawat Jalan) 1,400,000 1,400,000 1,540,000 1,680,000 1,820,000 1,960,000
LAB100166 ASTO Kualitatif (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100167 ASTO Kuantitatif (Rawat Jalan) 300,000 300,000 330,000 360,000 390,000 420,000
LAB100168 C3-Komplemen (Rawat Jalan) 960,000 960,000 1,056,000 1,152,000 1,248,000 1,344,000
LAB100170 CRP Kualitatif (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100171 CRP Kuantitatif (Rawat Jalan) 405,000 405,000 445,500 486,000 526,500 567,000
LAB100172 HS CRP (Rawat Jalan) 440,000 440,000 484,000 528,000 572,000 616,000
LAB100173 IgG ACA (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100174 IgM (Rawat Jalan) 1,700,000 1,700,000 1,870,000 2,040,000 2,210,000 2,380,000
LAB100175 IgM ACA (Rawat Jalan) 1,200,000 1,200,000 1,320,000 1,440,000 1,560,000 1,680,000
LAB100176 RF Kualitatif (Rawat Jalan) 234,000 234,000 257,400 280,800 304,200 327,600
LAB100177 RF Kuantitatif (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
LAB100178 IgE (Rawat Jalan) 600,000 600,000 660,000 720,000 780,000 840,000
LAB100179 IgE Atopy 54 Alergen (Rawat Jalan) 3,300,000 3,300,000 3,630,000 3,960,000 4,290,000 4,620,000
LAB100180 Aviditas IgG CMV (Rawat Jalan) 1,040,000 1,040,000 1,144,000 1,248,000 1,352,000 1,456,000
LAB100181 Aviditas IgG CMV (Tanpa IgC CMV) (Rawat Jalan)
840,000 840,000 924,000 1,008,000 1,092,000 1,176,000
LAB100182 Aviditas IgG Toxoplasma (Rawat Jalan) 1,000,000 1,000,000 1,100,000 1,200,000 1,300,000 1,400,000
LAB100183 Aviditas IgG Toxoplasma (Tanpa IgC Toxo) (Rawat
800,000 800,000 880,000 960,000 1,040,000 1,120,000
Jalan)
LAB100184 IgG Anti CMV (Rawat Jalan) 540,000 540,000 594,000 648,000 702,000 756,000
LAB100185 IgG Anti HSV 1 (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100186 IgG Anti HSV 1 (ECLIA) (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100187 IgG Anti HSV II (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100188 IgG Anti HSV II (ECLIA) (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100189 IgG Anti Rubella (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100190 IgG Anti Toxoplasma (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100191 igM Anti CMV 600,000 600,000 660,000 720,000 780,000 840,000
LAB100192 igM Anti HSV I 712,500 712,500 783,750 855,000 926,250 997,500
LAB100193 igM Anti HSV II 712,500 712,500 783,750 855,000 926,250 997,500
LAB100194 igM Anti Rubella 800,000 800,000 880,000 960,000 1,040,000 1,120,000
LAB100195 igM Anti Toxoplasma 570,000 570,000 627,000 684,000 741,000 798,000
LAB100196 Alfa Feto Protein (Rawat Jalan) 665,000 665,000 731,500 798,000 864,500 931,000
LAB100197 Ca 12-5 (Rawat Jalan) 990,000 990,000 1,089,000 1,188,000 1,287,000 1,386,000
LAB100199 Ca 19-9 (Rawat Jalan) 1,045,000 1,045,000 1,149,500 1,254,000 1,358,500 1,463,000
LAB100200 CA 72-4 (Rawat Jalan) 3,200,000 3,200,000 3,520,000 3,840,000 4,160,000 4,480,000
LAB100201 CEA (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100202 Free PSA (Rawat Jalan) 1,120,000 1,120,000 1,232,000 1,344,000 1,456,000 1,568,000
LAB100203 PSA Total (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100204 Albumin (Cairan Ascites) (Rawat Jalan) 160,000 160,000 176,000 192,000 208,000 224,000
LAB100205 Chlorida (Urine) (Rawat Jalan) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100206 Esbach (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100207 Kalium (Urine) (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100208 Magnesium (Urine) 230,000 230,000 253,000 276,000 299,000 322,000
LAB100209 Natruium (Urine) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100210 Phosphat Anorganik (Urine) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100211 Protein Bence Jones 200,000 200,000 220,000 240,000 260,000 280,000
LAB100212 Sedimen Prepp Go 200,000 200,000 220,000 240,000 260,000 280,000
LAB100213 Ureum (Sewaktu ) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100214 Ureum (Urine) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100215 Ureum Clearance 250,000 250,000 275,000 300,000 325,000 350,000
LAB100216 Cortisol 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100217 Cyfra 21.1 2,200,000 2,200,000 2,420,000 2,640,000 2,860,000 3,080,000
LAB100218 Protein Ascities 160,000 160,000 176,000 192,000 208,000 224,000
LAB100219 pb Darah 460,000 460,000 506,000 552,000 598,000 644,000
LAB100220 Vit. D25 OH 820,000 820,000 902,000 984,000 1,066,000 1,148,000
LAB100221 IgG B2GP1 2,100,000 2,100,000 2,310,000 2,520,000 2,730,000 2,940,000
LAB100222 igM B2GP1 2,100,000 2,100,000 2,310,000 2,520,000 2,730,000 2,940,000
LAB100223 Pemeriksaan Jaringan PA Kecil 390,000 390,000 429,000 468,000 507,000 546,000
LAB100224 Pemeriksaan Jaringan PA Sedang 500,000 500,000 550,000 600,000 650,000 700,000
LAB100225 Pemeriksaan Jaringan PA Besar 700,000 700,000 770,000 840,000 910,000 980,000
LAYANAN LABORATORIUM / LABORATORY

KODE Jasa Sarana Fee Medis Jasa Sarana Fee Medis KELAS II / Jasa Sarana Fee Medis KELAS I / Jasa Sarana Fee Medis Jasa Sarana Fee Medis Jasa Sarana RS dan
RAWAT JALAN
RS dan BHP 2,5%
KELAS III
VIP B
Fee Medis 2,5%
LAYANAN HCU ISOLASI

Pemeriksaan Jaringan Histerectomy, Mastectomy,
LAB100226
Colonoscopy, Laparotomy
700,000 700,000 770,000 840,000 910,000
980,000
LAB100227 Pemeriksaan Radikalitas 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
LAB100228 Pemeriksaan Sitologi Ginekologi ( Papsmear ) 200,000 200,000 220,000 240,000 260,000 280,000
Pemeriksaan Sitologi Non Ginekologi ( Pleura,
LAB100229
Acities, dll )
390,000 390,000 429,000 468,000 507,000 546,000
LAB100230 Pemeriksaan Per ITEM ER, PR 700,000 700,000 770,000 840,000 910,000 980,000
LAB100231 Pemeriksaan HER2, Ki67 per item 800,000 800,000 880,000 960,000 1,040,000 1,120,000
Peminjaman Blok Parafin ( Uang Jaminan Rp.
LAB100232
200.000 kembali saat blok dikembalikan )
460,000 460,000 506,000 552,000 598,000 644,000
LAB200233 Golongan Darah (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200234 Hematologi Rutin (Rawat Jalan) 70,000 70,000 77,000 84,000 91,000 98,000
LAB200235 Bilirubin Total (Rawat Jalan) 110,000 110,000 121,000 132,000 143,000 154,000
LAB200236 Glukosa Darah (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200237 Urine Rutin (Rawat Jalan) 31,000 31,000 34,100 37,200 40,300 43,400
LAB200238 Tes Kehamilan/Cassette (Rawat Jalan) 45,000 45,000 49,500 54,000 58,500 63,000
LAB200239 Faeces (Rawat Jalan) 47,500 47,500 52,250 57,000 61,750 66,500
LAB200240 HBS-AG (Rapid) (Rawat Jalan) 62,500 62,500 68,750 75,000 81,250 87,500
LAB200241 Anti HIV (Rapid) (Rawat Jalan) 82,000 82,000 90,200 98,400 106,600 114,800
LAB200242 Asam Urat (Urine) (Rawat Jalan) 60,500 60,500 66,550 72,600 78,650 84,700
LAB200243 Cholesterol (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200244 SGOT (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200245 SGPT (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200246 Ureum (Rawat Jalan) 55,000 55,000 60,500 66,000 71,500 77,000
LAB200247 Creatinin (Rawat Jalan) 55,000 55,000 60,500 66,000 71,500 77,000
LAB200248 LDL (Rawat Jalan) 71,500 71,500 78,650 85,800 92,950 100,100
LAB200249 HDL (Rawat Jalan) 71,500 71,500 78,650 85,800 92,950 100,100
LAB200250 Sekret Vagina (Rawat Jalan) 71,500 71,500 78,650 85,800 92,950 100,100
LAB200251 TSH Neonatus (Rawat Jalan) 125,000 125,000 137,500 150,000 162,500 175,000
LAB200252 Golongan Darah Rhesus (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200253 Gula Darah Sewaktu (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200254 Anto Body Covid (Rawat Jalan) 100,000 100,000 110,000 120,000 130,000 140,000
LAB200255 Hematologi Darah Lengkap (Rawat Jalan) 85,000 85,000 93,500 102,000 110,500 119,000
LAB200256 Bilirubin Direk (Rawat Jalan) 143,000 143,000 157,300 171,600 185,900 200,200
LAB200257 Urin Lengkap (Rawat Jalan) 70,000 70,000 77,000 84,000 91,000 98,000
LAB200258 Trigliserida (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200259 Uric Acid (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200260 Gula Darah Puasa (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200261 Gula Darah 2 Jam PP (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200262 PTT (Rawat Jalan) 170,000 170,000 187,000 204,000 221,000 238,000
LAB200263 APTT 135,000 135,000 148,500 162,000 175,500 189,000
LAB200264 HCG Rapid (Rawat Jalan) 22,000 22,000 24,200 26,400 28,600 30,800
LAB200265 CT 40,000 40,000 44,000 48,000 52,000 56,000
LAB200266 BT 40,000 40,000 44,000 48,000 52,000 56,000
LAB200267 Analisa Sperma 250,000 250,000 275,000 300,000 325,000 350,000
LAB200268 Sars Void- Antigen 170,000 170,000 187,000 204,000 221,000 238,000
LAB200269 VDRL / Syphilis Rapid (Rawat Jalan) 108,000 108,000 118,800 129,600 140,400 151,200
LAB200270 Widal (Rawat Jalan) 135,000 135,000 148,500 162,000 175,500 189,000
LAB200271 Urine Tengah 70,000 70,000 77,000 84,000 91,000 98,000
LAB200272 LH 455000 455,000 500,500 546,000 591,500 637,000
2. TARIF RADIOLOGI
KODE LAYANAN RADIOLOGI Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
Fee Medis 20 Fee Medis 20 Fee Medis 20 Fee Medis 20 Fee Medis 20 Jasa Sarana RS dan
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
%
VIP A BHP 80%
Fee Medis 20 %
LAYANAN 80% 80% HCU 80% ISOLASI 80% 80%
S02630 - ABDOMEN IUD C-R ( RAWAT JALAN ) 240,570
BBMRT001 192,456 48,114 240,570 192,456 48,114 264,627 211,702 52,925 288,684 230,947 57,737 336,798 269,438 67,360 384,912 307,930 76,982
BBMRT002 S02631 - ABDOMEN POLOS ( 1 POSISI ) C-R ) 218,790 175,032 43,758 218,790 175,032 43,758 240,669 192,535 48,134 262,548 210,038 52,510 306,306 245,045 61,261 350,064 280,051 70,013
S02632 - ABDOMEN POLOS 2 POSISI C-R
261,360 418,176 334,541 83,635
BBMRT003 ( RAWAJALAN) 209,088 52,272 261,360 209,088 52,272 287,496 229,997 57,499 313,632 250,906 62,726 365,904 292,723 73,181
S02633 - Abdomen Polos 3 Posisi C-R ( RAWAT
335,610 536,976 429,581 107,395
BBMRT004 JALAN ) 268,488 67,122 335,610 268,488 67,122 369,171 295,337 73,834 402,732 322,186 80,546 469,854 375,883 93,971
BBMRT005 S02634 - ADENOID C-R ( RAWAT JALAN ) 244,530 195,624 48,906 244,530 195,624 48,906 268,983 215,186 53,797 293,436 234,749 58,687 342,342 273,874 68,468 391,248 312,998 78,250
S02635 - ANKLE JOINT SINISTRA C - R
203,940 326,304 261,043 65,261
BBMRT006 ( RAWAT JALAN ) 163,152 40,788 203,940 163,152 40,788 224,334 179,467 44,867 244,728 195,782 48,946 285,516 228,413 57,103
S02636 - ANKLE JOINT DEXTRA C - R ( RAWAT
203,940 326,304 261,043 65,261
BBMRT007 JALAN ) 163,152 40,788 203,940 163,152 40,788 224,334 179,467 44,867 244,728 195,782 48,946 285,516 228,413 57,103
S02637 - ANKLE JOINT DEXTRA SINISTRA C - R
293,040 468,864 375,091 93,773
S05736 - ANKLE MORTISE VIEW ( RAWAT
257,400 411,840 329,472 82,368
BBMRT009 JALA) 205,920 51,480 257,400 205,920 51,480 283,140 226,512 56,628 308,880 247,104 61,776 360,360 288,288 72,072
S02638 - ANTEBRACHI DEXTRA C - R ( RAWAT
BBMRT010 207,900 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212 332,640 266,112 66,528
JALAN )- ANTEBRACHI DEXTRA SINISTRA C- R
S02639
BBMRT011 348,480 278,784 69,696 348,480 278,784 69,696 383,328 306,662 76,666 418,176 334,541 83,635 487,872 390,298 97,574 557,568 446,054 111,514
(RAWAT JALAN )
S02640 - ANTEBRACHI SINISTRA C - R (RAWAT
207,900
BBMRT012 JALAN ) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212 332,640 266,112 66,528
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
% VIP A BHP 80%
Fee Medis 20 %
S02641 - APENDICOGRAFI C-R( Kontras )
547,470 875,952 700,762 175,190
BBMRT013 (RAWAT JALAN) 437,976 109,494 547,470 437,976 109,494 602,217 481,774 120,443 656,964 525,571 131,393 766,458 613,166 153,292
S02642 - APG DEXTRA C-R( Kontras ) (RAWAT
742,500 1,188,000 950,400 237,600
BBMRT014 JALAN ) 594,000 148,500 742,500 594,000 148,500 816,750 653,400 163,350 891,000 712,800 178,200 1,039,500 831,600 207,900
S02643 - APG DEXTRA SINSITRA C-R (Kontras )
930,600 1,488,960 1,191,168 297,792
BBMRT015 (RAWAT JALAN) 744,480 186,120 930,600 744,480 186,120 1,023,660 818,928 204,732 1,116,720 893,376 223,344 1,302,840 1,042,272 260,568
S02644 - APG SINSITRA C-R ( Kontras ) (RAWAT
742,500 1,188,000 950,400 237,600
BBMRT016 JALAN) 594,000 148,500 742,500 594,000 148,500 816,750 653,400 163,350 891,000 712,800 178,200 1,039,500 831,600 207,900
S02645 - ARTERIOGRAFI FEMORALIS
2,407,680 3,852,288 3,081,830 770,458
BBMRT017 UNILATERAL C-R( Kontras ) (Rawat Jalan ) 1,926,144 481,536 2,407,680 1,926,144 481,536 2,648,448 2,118,758 529,690 2,889,216 2,311,373 577,843 3,370,752 2,696,602 674,150
S05216 - ASISTEN SEDASI PROSEDUR (RAWAT
108,900 174,240 139,392 34,848
BBMRT018 JALAN) 87,120 21,780 108,900 87,120 21,780 119,790 95,832 23,958 130,680 104,544 26,136 152,460 121,968 30,492
S05216 - ASISTEN SEDASI PROSEDUR - RS
103,950 166,320 133,056 33,264
S02646 - Aspirasi Jarum Halus (AJH) - Radiologi
425,700 681,120 544,896 136,224
BBMRT021 S00242 - AUDIOMETRI - RS (RAWAT JALAN) 138,600 110,880 27,720 138,600 110,880 27,720 152,460 121,968 30,492 166,320 133,056 33,264 194,040 155,232 38,808 221,760 177,408 44,352
BBMRT022 S02647 - Babygram C-R (RAWAT JALAN) 216,810 173,448 43,362 216,810 173,448 43,362 238,491 190,793 47,698 260,172 208,138 52,034 303,534 242,827 60,707 346,896 277,517 69,379
S02648 - BASIS CRANIUM C-R (RAWAT JALAN) 247,500 396,000 316,800 79,200
BBMRT023 198,000 49,500 247,500 198,000 49,500 272,250 217,800 54,450 297,000 237,600 59,400 346,500 277,200 69,300
S00244 - Biopsi / Aspirasi kelenjar - RS (RAWAT
357,390 571,824 457,459 114,365
BBMRT024 JALAN) 285,912 71,478 357,390 285,912 71,478 393,129 314,503 78,626 428,868 343,094 85,774 500,346 400,277 100,069
S03767 - Biopsi / Aspirasi Jarum Halus ( FNAB ) -
326,700 522,720 418,176 104,544
BBMRT025 RS (RAWAT JALAN) 261,360 65,340 326,700 261,360 65,340 359,370 287,496 71,874 392,040 313,632 78,408 457,380 365,904 91,476
S02650 - BNO - IVP C-R (Kontras ) (RAWAT
1,336,500 2,138,400 1,710,720 427,680
BBMRT026 JALAN) 1,069,200 267,300 1,336,500 1,069,200 267,300 1,470,150 1,176,120 294,030 1,603,800 1,283,040 320,760 1,871,100 1,496,880 374,220
S02651 - BNO DEWASA C-R (RAWAT JALAN) 216,810 346,896 277,517 69,379
BBMRT027 173,448 43,362 216,810 173,448 43,362 238,491 190,793 47,698 260,172 208,138 52,034 303,534 242,827 60,707
S02652 - BONE SURVEY + C-R (RAWAT JALAN) 1,055,340 1,688,544 1,350,835 337,709
BBMRT028 844,272 211,068 1,055,340 844,272 211,068 1,160,874 928,699 232,175 1,266,408 1,013,126 253,282 1,477,476 1,181,981 295,495
S02669 - CEPHALOMETRY C-R (RAWAT JALAN) 236,610 378,576 302,861 75,715

BBMRT029 189,288 47,322 236,610 189,288 47,322 260,271 208,217 52,054 283,932 227,146 56,786 331,254 265,003 66,251
S02670 - Cervical AP / Lat C1 Khusus C-R
287,100 459,360 367,488 91,872
S02671 - Cervical AP/ Lat C-R (RAWAT JALAN) 228,690 365,904 292,723 73,181
BBMRT031 182,952 45,738 228,690 182,952 45,738 251,559 201,247 50,312 274,428 219,542 54,886 320,166 256,133 64,033
S02672 - CERVICOTHORACAL AP / LAT C-R
242,550 388,080 310,464 77,616
S02673 - CLAVICULA DEXTRA (RAWAT JALAN) 193,050

BBMRT033 154,440 38,610 193,050 154,440 38,610 212,355 169,884 42,471 231,660 185,328 46,332 270,270 216,216 54,054 308,880 247,104 61,776
S02674 - CLAVICULA DEXTRA SINISTRA
235,620 376,992 301,594 75,398
S02675 - CLAVICULA SINISTRA (RAWAT JALAN) 193,050 308,880 247,104 61,776

BBMRT035 154,440 38,610 193,050 154,440 38,610 212,355 169,884 42,471 231,660 185,328 46,332 270,270 216,216 54,054
S02676 - COCCYGIS AP / LAT C-R (RAWAT
269,280 430,848 344,678 86,170
BBMRT036 JALAN) 215,424 53,856 269,280 215,424 53,856 296,208 236,966 59,242 323,136 258,509 64,627 376,992 301,594 75,398
S02677 - COLLUM FEMUR AP / AXIAL C-R
225,720 361,152 288,922 72,230
S02678 - COLLUM FEMUR AP C-R (RAWAT
193,050 308,880 247,104 61,776
BBMRT038 JALAN) 154,440 38,610 193,050 154,440 38,610 212,355 169,884 42,471 231,660 185,328 46,332 270,270 216,216 54,054
S02679 - COLON - INLOOP C-R ( Kontras )
994,950 1,591,920 1,273,536 318,384
211,860 338,976 271,181 67,795

BBMRT040 S02680 - COR ANALYSA C-R (RAWAT JALAN) 169,488 42,372 211,860 169,488 42,372 233,046 186,437 46,609 254,232 203,386 50,846 296,604 237,283 59,321
S02681 - CRANIAL AP / LAT. TOMNE`S C-R
305,910 489,456 391,565 97,891
S02682 - CRANIUM AP / LAT C-R (RAWAT
289,080 462,528 370,022 92,506
BBMRT042 JALAN) 231,264 57,816 289,080 231,264 57,816 317,988 254,390 63,598 346,896 277,517 69,379 404,712 323,770 80,942
S02683 - CRURIS SINISTRA C - R (RAWAT
221,760 354,816 283,853 70,963
BBMRT043 JALAN) 177,408 44,352 221,760 177,408 44,352 243,936 195,149 48,787 266,112 212,890 53,222 310,464 248,371 62,093
S02684 - CRURIS DEXTRA C - R (RAWAT
221,760 354,816 283,853 70,963
BBMRT044 JALAN) 177,408 44,352 221,760 177,408 44,352 243,936 195,149 48,787 266,112 212,890 53,222 310,464 248,371 62,093
S02693 - FISTULUGRAFI C-R ( Kontras ) (RAWAT
848,430 1,357,488 1,085,990 271,498
BBMRT045 JALAN) 678,744 169,686 848,430 678,744 169,686 933,273 746,618 186,655 1,018,116 814,493 203,623 1,187,802 950,242 237,560
S02694 - FOLLOW THROUGH C-R ( kontras )
894,960 1,431,936 1,145,549 286,387
BBMRT046 (RAWAT JALAN) 715,968 178,992 894,960 715,968 178,992 984,456 787,565 196,891 1,073,952 859,162 214,790 1,252,944 1,002,355 250,589
BBMRT047 S02695 - Genu Dextra (RAWAT JALAN) 245,520 196,416 49,104 245,520 196,416 49,104 270,072 216,058 54,014 294,624 235,699 58,925 343,728 274,982 68,746 392,832 314,266 78,566
400,950 641,520 513,216 128,304
BBMRT048 S02696 - Genu dextra sinistra (RAWAT JALAN) 320,760 80,190 400,950 320,760 80,190 441,045 352,836 88,209 481,140 384,912 96,228 561,330 449,064 112,266
BBMRT049 S02697 - GENU SINISTRA (RAWAT JALAN) 245,520 196,416 49,104 245,520 196,416 49,104 270,072 216,058 54,014 294,624 235,699 58,925 343,728 274,982 68,746 392,832 314,266 78,566
235,620 376,992 301,594 75,398
BBMRT050 S02698 - HIP JOINT DEXTRA (RAWAT JALAN) 188,496 47,124 235,620 188,496 47,124 259,182 207,346 51,836 282,744 226,195 56,549 329,868 263,894 65,974
235,620 376,992 301,594 75,398

BBMRT051 S02699 - HIP JOINT SINISTRA (RAWAT JALAN) 188,496 47,124 235,620 188,496 47,124 259,182 207,346 51,836 282,744 226,195 56,549 329,868 263,894 65,974
207,900 332,640 266,112 66,528

BBMRT052 S02701 - HUMERUS DEXTRA (RAWAT JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212
S02702 - HUMERUS DEXTRA SINISTRA
341,550 546,480 437,184 109,296
206,910 331,056 264,845 66,211

BBMRT054 S02703 - HUMERUS SINISTRA (RAWAT JALAN) 165,528 41,382 206,910 165,528 41,382 227,601 182,081 45,520 248,292 198,634 49,658 289,674 231,739 57,935
BBMRT055 S00243 -- Jasa
S00253 Jasa Bera -(RAWAT JALAN)
Echocardiography -(RAWAT 193,050 154,440 38,610 193,050 154,440 38,610 212,355 169,884 42,471 231,660 185,328 46,332 270,270 216,216 54,054 308,880 247,104 61,776
BBMRT056 JALAN) 174,240 139,392 34,848 174,240 139,392 34,848 191,664 153,331 38,333 209,088 167,270 41,818 243,936 195,149 48,787 278,784 223,027 55,757
S02704 - K. CERVICOTHORACAL AP / LAT / OBL 331,650

BBMRT057 C-R (RAWAT JALAN) 265,320 66,330 331,650 265,320 66,330 364,815 291,852 72,963 397,980 318,384 79,596 464,310 371,448 92,862 530,640 424,512 106,128
LAYANAN
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
% VIP A BHP 80%
Fee Medis 20 %
80% 80% HCU 80% ISOLASI 80% 80%
S02705 - KEPALA AP / LAT C - R (RAWAT
247,500 396,000 316,800 79,200
BBMRT058 JALAN) 198,000 49,500 247,500 198,000 49,500 272,250 217,800 54,450 297,000 237,600 59,400 346,500 277,200 69,300
S02706 - KEPALA AP / LAT,TOWNE`S C - R
264,330 422,928 338,342 84,586
S02707 - MAAG DUODENUM FOTO C-R ( kontras
920,700 1,473,120 1,178,496 294,624
BBMRT060 ) (RAWAT JALAN) 736,560 184,140 920,700 736,560 184,140 1,012,770 810,216 202,554 1,104,840 883,872 220,968 1,288,980 1,031,184 257,796
BBMRT061 S04720 - MAMOGRAPHY(RAWAT JALAN) 79,200 63,360 15,840 79,200 63,360 15,840 87,120 69,696 17,424 95,040 76,032 19,008 110,880 88,704 22,176 126,720 101,376 25,344
BBMRT062 S04720 - MAMOGRAPHY (RAWAT JALAN) 490,050 392,040 98,010 490,050 392,040 98,010 539,055 431,244 107,811 588,060 470,448 117,612 686,070 548,856 137,214 784,080 627,264 156,816
BBMRT063 S02708 - MANDIBULA C-R (RAWAT JALAN) 326,700 261,360 65,340 326,700 261,360 65,340 359,370 287,496 71,874 392,040 313,632 78,408 457,380 365,904 91,476 522,720 418,176 104,544
207,900 332,640 266,112 66,528
BBMRT064 S02709 - MANUS DEXTRA C- R (RAWAT JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212
S02710 - MANUS DEXTRA SINISTRA C- R
281,160 449,856 359,885 89,971
S02711 - MANUS SINISTRA C- R (RAWAT
207,900 332,640 266,112 66,528
BBMRT066 JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212
BBMRT067 S02712 - MASTOID C-R (RAWAT JALAN) 326,700 261,360 65,340 326,700 261,360 65,340 359,370 287,496 71,874 392,040 313,632 78,408 457,380 365,904 91,476 522,720 418,176 104,544
BBMRT068 S02713 - MAXILLA C-R (RAWAT JALAN) 236,610 189,288 47,322 236,610 189,288 47,322 260,271 208,217 52,054 283,932 227,146 56,786 331,254 265,003 66,251 378,576 302,861 75,715
BBMRT069 S02080 - MRA (RAWAT JALAN) 2,379,960 1,903,968 475,992 2,379,960 1,903,968 475,992 2,617,956 2,094,365 523,591 2,855,952 2,284,762 571,190 3,331,944 2,665,555 666,389 3,807,936 3,046,349 761,587
BBMRT070 S05793 - MRCP KONTRAS(RAWAT JALAN) 1,980,000 1,584,000 396,000 1,980,000 1,584,000 396,000 2,178,000 1,742,400 435,600 2,376,000 1,900,800 475,200 2,772,000 2,217,600 554,400 3,168,000 2,534,400 633,600
1,534,500 2,455,200 1,964,160 491,040
BBMRT071 S05796 - MRCP NON KONTRAS(RAWAT JALAN) 1,227,600 306,900 1,534,500 1,227,600 306,900 1,687,950 1,350,360 337,590 1,841,400 1,473,120 368,280 2,148,300 1,718,640 429,660
S02714 - Myelography Cervical C-R (RAWAT
980,100 1,568,160 1,254,528 313,632
BBMRT072 JALAN) 784,080 196,020 980,100 784,080 196,020 1,078,110 862,488 215,622 1,176,120 940,896 235,224 1,372,140 1,097,712 274,428
S02715 - MYELOGRAPHY LUMBAL C-R ( Kontras
1,087,020 1,739,232 1,391,386 347,846
BBMRT073 ) (RAWAT JALAN) 869,616 217,404 1,087,020 869,616 217,404 1,195,722 956,578 239,144 1,304,424 1,043,539 260,885 1,521,828 1,217,462 304,366
S02716 - MYELOGRAPHY THORACAL C-R
1,129,590 1,807,344 1,445,875 361,469
BBMRT074 ( kontras ) (RAWAT JALAN) 903,672 225,918 1,129,590 903,672 225,918 1,242,549 994,039 248,510 1,355,508 1,084,406 271,102 1,581,426 1,265,141 316,285
S02717 - OESOPHAGUS C-R ( Kontras ) (RAWAT
610,830 977,328 781,862 195,466
BBMRT075 JALAN) 488,664 122,166 610,830 488,664 122,166 671,913 537,530 134,383 732,996 586,397 146,599 855,162 684,130 171,032
S02718 - OMD FOTO C-R ( Kontras ) (RAWAT
851,400 1,362,240 1,089,792 272,448
BBMRT076 JALAN) 681,120 170,280 851,400 681,120 170,280 936,540 749,232 187,308 1,021,680 817,344 204,336 1,191,960 953,568 238,392
BBMRT077 S02719 - ORBIT C-R (RAWAT JALAN) 224,730 179,784 44,946 224,730 179,784 44,946 247,203 197,762 49,441 269,676 215,741 53,935 314,622 251,698 62,924 359,568 287,654 71,914
BBMRT078 S02720 - OS. NASAL C-R (RAWAT JALAN) 216,810 173,448 43,362 216,810 173,448 43,362 238,491 190,793 47,698 260,172 208,138 52,034 303,534 242,827 60,707 346,896 277,517 69,379
207,900
BBMRT079 S02721 - Panoramic Dental C-R (RAWAT JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212 332,640 266,112 66,528
S02722 - PASANG MARKER VERTEBRAE C-R
224,730 359,568 287,654 71,914
212,850 340,560 272,448 68,112

BBMRT081 S02725 - PEDIS SINISTRA C - R (RAWAT JALAN) 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598
212,850 340,560 272,448 68,112

BBMRT082 S02726 - PEDIS DEXTRA C - R (RAWAT JALAN) 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598
S02727 - PEDIS DEXTRA SINISTRA C - R
298,980 478,368 382,694 95,674
S02730 - PHLEBOGRAFI C-R (kontras ) (RAWAT
1,312,740 2,100,384 1,680,307 420,077
BBMRT084 JALAN) 1,050,192 262,548 1,312,740 1,050,192 262,548 1,444,014 1,155,211 288,803 1,575,288 1,260,230 315,058 1,837,836 1,470,269 367,567
2,603,700 4,165,920 3,332,736 833,184

BBMRT085 S00273 - Polipektomi SCBA - RS (RAWAT JALAN) 2,082,960 520,740 2,603,700 2,082,960 520,740 2,864,070 2,291,256 572,814 3,124,440 2,499,552 624,888 3,645,180 2,916,144 729,036
4,056,030 6,489,648 5,191,718 1,297,930

BBMRT086 S00274 - Polipektomi SCBB - RS (RAWAT JALAN) 3,244,824 811,206 4,056,030 3,244,824 811,206 4,461,633 3,569,306 892,327 4,867,236 3,893,789 973,447 5,678,442 4,542,754 1,135,688
BBMRT087 S03859 - Punksi Pleura - RS (RAWAT JALAN) 352,440 281,952 70,488 352,440 281,952 70,488 387,684 310,147 77,537 422,928 338,342 84,586 493,416 394,733 98,683 563,904 451,123 112,781
BBMRT088 S02731 - RO Gigi 11 (RAWAT JALAN) 164,340 131,472 32,868 164,340 131,472 32,868 180,774 144,619 36,155 197,208 157,766 39,442 230,076 184,061 46,015 262,944 210,355 52,589
164,340
BBMRT114 S02757 - RO Gigi 43 (RAWAT JALAN) 131,472 32,868 164,340 131,472 32,868 180,774 144,619 36,155 197,208 157,766 39,442 230,076 184,061 46,015 262,944 210,355 52,589
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
% VIP A BHP 80%
Fee Medis 20 %
BBMRT120 S02763 - Ro Gigi Anak 51 (RAWAT JALAN) 164,340 131,472 32,868 164,340 131,472 32,868 180,774 144,619 36,155 197,208 157,766 39,442 230,076 184,061 46,015 262,944 210,355 52,589
S02784 - RPG DEXTRA C- R ( Kontras ) (RAWAT
BBMRT140 JALAN) 712,800 570,240 142,560 712,800 570,240 142,560 784,080 627,264 156,816 855,360 684,288 171,072 997,920 798,336 199,584 1,140,480 912,384 228,096
S02785 - RPG DEXTRA SINISTRA C- R
BBMRT141 ( kontras ) (RAWAT JALAN) 930,600 744,480 186,120 930,600 744,480 186,120 1,023,660 818,928 204,732 1,116,720 893,376 223,344 1,302,840 1,042,272 260,568 1,488,960 1,191,168 297,792
S02786 - RPG SINISTRA C - R ( kontras )
BBMRT142 (RAWAT JALAN) 717,750 574,200 143,550 717,750 574,200 143,550 789,525 631,620 157,905 861,300 689,040 172,260 1,004,850 803,880 200,970 1,148,400 918,720 229,680
S02787 - SACRUM AP / LAT C-R (RAWAT
BBMRT143 JALAN) 249,480 199,584 49,896 249,480 199,584 49,896 274,428 219,542 54,886 299,376 239,501 59,875 349,272 279,418 69,854 399,168 319,334 79,834
S02788 - SCAPULA DEXTRA C- R (RAWAT
BBMRT144 JALAN) 221,760 177,408 44,352 221,760 177,408 44,352 243,936 195,149 48,787 266,112 212,890 53,222 310,464 248,371 62,093 354,816 283,853 70,963
S02789 - SCAPULA SINISTRA C- R (RAWAT
BBMRT145 JALAN) 221,760 177,408 44,352 221,760 177,408 44,352 243,936 195,149 48,787 266,112 212,890 53,222 310,464 248,371 62,093 354,816 283,853 70,963
S05737 - SCOLIOSOSIS PROGRAM AP/L
BBMRT146 BENDING KA/KI(RAWAT JALAN) 475,200 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056 760,320 608,256 152,064
BBMRT147 S05215 - SEDASI PROSEDUR(RAWAT JALAN) 509,850 407,880 101,970 509,850 407,880 101,970 560,835 448,668 112,167 611,820 489,456 122,364 713,790 571,032 142,758 815,760 652,608 163,152
S05215 - SEDASI PROSEDUR - RS(RAWAT
BBMRT148 JALAN) 56,430 45,144 11,286 56,430 45,144 11,286 62,073 49,658 12,415 67,716 54,173 13,543 79,002 63,202 15,800 90,288 72,230 18,058
S02790 - SELEKTIF ANGIOGRAFI C-R(RAWAT
BBMRT149 JALAN) 5,474,700 4,379,760 1,094,940 5,474,700 4,379,760 1,094,940 6,022,170 4,817,736 1,204,434 6,569,640 5,255,712 1,313,928 7,664,580 6,131,664 1,532,916 8,759,520 7,007,616 1,751,904
BBMRT150 S02791 - SELLA TURCICA C-R (RAWAT JALAN) 187,110 149,688 37,422 187,110 149,688 37,422 205,821 164,657 41,164 224,532 179,626 44,906 261,954 209,563 52,391 299,376 239,501 59,875
S02792 - SHOULDER DEXTRA C - R (RAWAT
BBMRT151 JALAN) 212,850 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598 340,560 272,448 68,112
S02793 - SHOULDER JOINT DEXTRA (RAWAT
BBMRT152 JALAN) 212,850 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598 340,560 272,448 68,112
S02794 - SHOULDER JOINT DEXTRA SINISTRA
BBMRT153 (RAWAT JALAN) 357,390 285,912 71,478 357,390 285,912 71,478 393,129 314,503 78,626 428,868 343,094 85,774 500,346 400,277 100,069 571,824 457,459 114,365
S02795 - SHOULDER JOINT SINISTRA (RAWAT
BBMRT154 JALAN) 212,850 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598 340,560 272,448 68,112
S02796 - SHOULDER SINISTRA C- R (RAWAT
BBMRT155 JALAN) 212,850 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598 340,560 272,448 68,112
BBMRT156 S00279 - Sikatan Bronchus - RS(RAWAT JALAN) 171,270 137,016 34,254 171,270 137,016 34,254 188,397 150,718 37,679 205,524 164,419 41,105 239,778 191,822 47,956 274,032 219,226 54,806
BBMRT157 S02723 - SKILINE DEXTRA (RAWAT JALAN) 203,940 163,152 40,788 203,940 163,152 40,788 224,334 179,467 44,867 244,728 195,782 48,946 285,516 228,413 57,103 326,304 261,043 65,261
BBMRT158 S02724 - SKILINE SINISTRA (RAWAT JALAN) 203,940 163,152 40,788 203,940 163,152 40,788 224,334 179,467 44,867 244,728 195,782 48,946 285,516 228,413 57,103 326,304 261,043 65,261
BBMRT159 S00280 - Skreloterapy - RS(RAWAT JALAN) 2,603,700 2,082,960 520,740 2,603,700 2,082,960 520,740 2,864,070 2,291,256 572,814 3,124,440 2,499,552 624,888 3,645,180 2,916,144 729,036 4,165,920 3,332,736 833,184
S00281 - Spike dan Seizure Analysis - RS(RAWAT
BBMRT160 JALAN) 171,270 137,016 34,254 171,270 137,016 34,254 188,397 150,718 37,679 205,524 164,419 41,105 239,778 191,822 47,956 274,032 219,226 54,806
BBMRT161 S00282 - Spirometry - RS(RAWAT JALAN) 134,640 107,712 26,928 134,640 107,712 26,928 148,104 118,483 29,621 161,568 129,254 32,314 188,496 150,797 37,699 215,424 172,339 43,085
BBMRT162 S02798 - SPN (RAWAT JALAN) 271,260 217,008 54,252 271,260 217,008 54,252 298,386 238,709 59,677 325,512 260,410 65,102 379,764 303,811 75,953 434,016 347,213 86,803
BBMRT163 S02799 - T.M.J (RAWAT JALAN) 316,800 253,440 63,360 316,800 253,440 63,360 348,480 278,784 69,696 380,160 304,128 76,032 443,520 354,816 88,704 506,880 405,504 101,376
BBMRT164 S02800 - TAMBAHAN FILM C-R(RAWAT JALAN) 101,970 81,576 20,394 101,970 81,576 20,394 112,167 89,734 22,433 122,364 97,891 24,473 142,758 114,206 28,552 163,152 130,522 32,630
BBMRT165 S00283 - TBB - RS(RAWAT JALAN) 601,920 481,536 120,384 601,920 481,536 120,384 662,112 529,690 132,422 722,304 577,843 144,461 842,688 674,150 168,538 963,072 770,458 192,614
S02801 - THORACOLUMBAL AP / LAT / OBL C-R
S02802 - THORACOLUMBAL AP / LAT C-R
BBMRT167 (RAWAT
S02803 - JALAN)
THORAX PA / LAT DEXTRA C-R 269,280 215,424 53,856 269,280 215,424 53,856 296,208 236,966 59,242 323,136 258,509 64,627 376,992 301,594 75,398 430,848 344,678 86,170
BBMRT168 (RAWAT- JALAN)
S02804 THORAX PA / LAT SINISTRA C-R 253,440 202,752 50,688 253,440 202,752 50,688 278,784 223,027 55,757 304,128 243,302 60,826 354,816 283,853 70,963 405,504 324,403 81,101
BBMRT170 S02805 - THORAX PA C-R (RAWAT JALAN) 229,680 183,744 45,936 229,680 183,744 45,936 252,648 202,118 50,530 275,616 220,493 55,123 321,552 257,242 64,310 367,488 293,990 73,498
LAYANAN
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
% VIP A BHP 80%
Fee Medis 20 %
80% 80% HCU 80% ISOLASI 80% 80%
BBMRT172 S05738 - THORAX RLD(RAWAT JALAN) 257,400 205,920 51,480 257,400 205,920 51,480 283,140 226,512 56,628 308,880 247,104 61,776 360,360 288,288 72,072 257,398 205,919 51,480
196,020 196,018 156,815 39,204
BBMRT173 S02807 - TOP LORDOTIC C-R (RAWAT JALAN) 156,816 39,204 196,020 156,816 39,204 215,622 172,498 43,124 235,224 188,179 47,045 274,428 219,542 54,886
S02808 - Translete Hasil Radiologi (RAWAT
301,950 301,948 241,559 60,390
BBMRT174 JALAN) 241,560 60,390 301,950 241,560 60,390 332,145 265,716 66,429 362,340 289,872 72,468 422,730 338,184 84,546
BBMRT175 S00284 - TREADMILL - RS(RAWAT JALAN) 375,210 300,168 75,042 375,210 300,168 75,042 412,731 330,185 82,546 450,252 360,202 90,050 525,294 420,235 105,059 375,208 300,167 75,042
1,374,120 1,374,118 1,099,295 274,824
BBMRT176 S00241 - TTB Guiding CT Scan (RAWAT JALAN) 1,099,296 274,824 1,374,120 1,099,296 274,824 1,511,532 1,209,226 302,306 1,648,944 1,319,155 329,789 1,923,768 1,539,014 384,754
S02813 - VERT. CERVICAL AP / LAT C-R
211,860 211,858 169,487 42,372
S02814 - VERT. CERVICAL AP / LAT/ OBL C-R
374,220 374,218 299,375 74,844
S02815 - VERT. LUMBAL AP / LAT / OBL C-R
475,200 475,198 380,159 95,040
S02816 - Vert. Lumbal AP / Lat C-R (RAWAT
273,240 273,238 218,591 54,648
BBMRT180 JALAN) 218,592 54,648 273,240 218,592 54,648 300,564 240,451 60,113 327,888 262,310 65,578 382,536 306,029 76,507
S02817 - VERT. LUMBALSACRAL AP / LAT / OBL
475,200 475,198 380,159 95,040
BBMRT181 C-R (RAWAT JALAN) 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056
S02818 - Vert. LumbalSacral AP / Lat C-R
258,390 258,388 206,711 51,678
S02819 - VERT. THORACAL AP / LAT / OBL C-R
475,200 475,198 380,159 95,040
S02820 - VERT. THORACAL AP / LAT C-R
269,280 269,278 215,423 53,856
S02809 - URETHROCYSTOGRAFI C-R
746,064 746,062 596,850 149,212
BBMRT185 (KONTRAS ) (RAWAT JALAN) 596,851 149,213 746,064 596,851 149,213 820,670 656,536 164,134 895,277 716,221 179,055 1,044,490 835,592 208,898
S02810 - URETHROGRAFI C-R (KONTRAS )
659,340 659,338 527,471 131,868
BBMRT187 S00285 - UROFLOMETRI - RS(RAWAT JALAN) 120,780 96,624 24,156 120,780 96,624 24,156 132,858 106,286 26,572 144,936 115,949 28,987 169,092 135,274 33,818 120,778 96,623 24,156
BBMRT188 S02821 - WATER`S C-R (RAWAT JALAN) 189,090 151,272 37,818 189,090 151,272 37,818 207,999 166,399 41,600 226,908 181,526 45,382 264,726 211,781 52,945 189,088 151,271 37,818
475,200 475,198 380,159 95,040
BBMRT189 S05739 - WHOLE SPINE X-RAY(RAWAT JALAN) 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056
S02822 - WRIST JOINT DEXTRA C- R (RAWAT
225,720 225,718 180,575 45,144
BBMRT190 JALAN) 180,576 45,144 225,720 180,576 45,144 248,292 198,634 49,658 270,864 216,691 54,173 316,008 252,806 63,202
S02823 - WRIST JOINT DEXTRA SINITRA
264,330 264,328 211,463 52,866
S02824 - WRIST JOINT SINISTRA C- R (RAWAT
225,720 225,718 180,575 45,144
BBMRT192 JALAN) 180,576 45,144 225,720 180,576 45,144 248,292 198,634 49,658 270,864 216,691 54,173 316,008 252,806 63,202
BBMRT193 S00302 - WSD - RS(RAWAT JALAN) 330,660 264,528 66,132 330,660 264,528 66,132 363,726 290,981 72,745 396,792 317,434 79,358 462,924 370,339 92,585 330,658 264,527 66,132
463,320 421,198 336,959 84,240
BBMUSG001 USG Abd. Bawah / Pelvis/ Obs-Gin DOPPLER 370,656 92,664 421,200 336,960 84,240 463,320 370,656 92,664 505,440 404,352 84,240 589,680 471,744 117,936
BBMUSG002 USG Abdomen Atas DENGAN FOTO 334,620 267,696 66,924 334,620 267,696 66,924 368,082 294,466 73,616 401,544 321,235 80,309 468,468 374,774 93,694 334,618 267,695 66,924
BBMUSG003 USG Abdomen Atas DOPPLER 463,320 370,656 92,664 463,320 370,656 92,664 509,652 407,722 101,930 555,984 444,787 111,197 648,648 518,918 129,730 463,318 370,655 92,664
USG EKSTREMITAS ATAS SISTEM ARTERI 1
692,010 692,008 553,607 138,402
BBMUSG004 SISI DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
USG EKSTREMITAS ATAS SISTEM VENA 1 SISI
692,010 692,008 553,607 138,402
BBMUSG005 DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
BBMUSG006 USG KEPALA DOPPLER 558,360 446,688 111,672 558,360 446,688 111,672 614,196 491,357 122,839 670,032 536,026 134,006 781,704 625,363 156,341 558,358 446,687 111,672
BBMUSG007 USG Leher DENGAN FOTO 249,480 199,584 49,896 249,480 199,584 49,896 274,428 219,542 54,886 299,376 239,501 59,875 349,272 279,418 69,854 249,478 199,583 49,896
BBMUSG008 USG MUSKULAR DOPPLER - RS 398,970 319,176 79,794 398,970 319,176 79,794 438,867 351,094 87,773 478,764 383,011 95,753 558,558 446,846 111,712 398,968 319,175 79,794
285,120 285,118 228,095 57,024
BBMUSG009 USG Organ Superfisial / Lainnya DENGAN FOTO 228,096 57,024 285,120 228,096 57,024 313,632 250,906 62,726 342,144 273,715 68,429 399,168 319,334 79,834
BBMUSG010 USG PROSTAT DOPPLER 474,210 379,368 94,842 474,210 379,368 94,842 521,631 417,305 104,326 569,052 455,242 113,810 663,894 531,115 132,779 474,208 379,367 94,842
BBMUSG011 USG Sist. Karotis dan Vert. 2 Sisi DOPPLER 1,210,770 968,616 242,154 1,210,770 968,616 242,154 1,331,847 1,065,478 266,369 1,452,924 1,162,339 290,585 1,695,078 1,356,062 339,016 1,210,768 968,615 242,154
BBMUSG012 USG SISTEM KAROTIS 1 SISI DOPPLER 692,010 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763 692,008 553,607 138,402
S00314 - USG Sistem Vertebralis 1 Sisi DOPPLER
1,210,770 1,210,768 968,615 242,154
BBMUSG013 968,616 242,154 1,210,770 968,616 242,154 1,331,847 1,065,478 266,369 1,452,924 1,162,339 290,585 1,695,078 1,356,062 339,016
S00287 - USG TRANSRECTAL ( DGN PRINT ) -
362,340 362,338 289,871 72,468
BBMUSG014 RS 289,872 72,468 362,340 289,872 72,468 398,574 318,859 79,715 434,808 347,846 86,962 507,276 405,821 101,455
S00315 - USG TUNGKAI SISTEM ARTERI 1 SISI
692,010 692,008 553,607 138,402
BBMUSG015 DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
S00316 - USG TUNGKAI SISTEM VENA 1 SISI
692,010 692,008 553,607 138,402
BBMUSG016 DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
S00317 - USG Abdomen Bawah / Pelvis DENGAN
334,620 334,618 267,695 66,924
BBMUSG017 FOTO 267,696 66,924 334,620 267,696 66,924 368,082 294,466 73,616 401,544 321,235 80,309 468,468 374,774 93,694
S00318 - USG Abdomen Lengkap DENGAN
550,000 549,998 439,999 110,000
BBMUSG018 FOTO 440,000 110,000 550,000 440,000 110,000 605,000 484,000 121,000 660,000 528,000 132,000 770,000 616,000 154,000
BBMUSG019 S00319 - USG Abdomen Lengkap DOPPLER 971,190 776,952 194,238 971,190 776,952 194,238 1,068,309 854,647 213,662 1,165,428 932,342 233,086 1,359,666 1,087,733 271,933 971,188 776,951 194,238
BBMUSG020 S00290 - USG DOPPLER VASKULER - RS 370,260 296,208 74,052 370,260 296,208 74,052 407,286 325,829 81,457 444,312 355,450 88,862 518,364 414,691 103,673 370,258 296,207 74,052
BBMUSG021 S00295 - USG INTERVENSI ABDOMEN - RS 915,750 732,600 183,150 915,750 732,600 183,150 1,007,325 805,860 201,465 1,098,900 879,120 219,780 1,282,050 1,025,640 256,410 915,748 732,599 183,150
S00296 - USG INTERVENSI NON - ABDOMEN -
822,690 822,688 658,151 164,538
BBMUSG022 RS 658,152 164,538 822,690 658,152 164,538 904,959 723,967 180,992 987,228 789,782 197,446 1,151,766 921,413 230,353
BBMUSG023 S00320 - USG Kepala DENGAN FOTO 249,480 199,584 49,896 249,480 199,584 49,896 274,428 219,542 54,886 299,376 239,501 59,875 349,272 279,418 69,854 249,478 199,583 49,896
BBMUSG024 S00321 - USG MAMMAE DOPPLER 434,610 347,688 86,922 434,610 347,688 86,922 478,071 382,457 95,614 521,532 417,226 104,306 608,454 486,763 121,691 434,608 347,687 86,922
BBMUSG025 S00322 - USG MOSKULOSKELETAL Fascia Plantari 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG026 S00323 - USG MOSKULOSKELETAL Otot - Otot / Fasc 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG027 S00324 - USG MOSKULOSKELETAL Otot - Otot / Fas 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG028 S00325 - USG MOSKULOSKELETAL Sendi Lutut 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG029 S00326 - USG MOSKULOSKELETAL Sendi Tumit 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
808,830
BBMUSG030 S00327 - USG MOSKULOSKELETAL Tendon Achille 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
LAYANAN
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
% VIP A BHP 80%
Fee Medis 20 %
80% 80% HCU 80% ISOLASI 80% 80%
BBMUSG031 S00328 - USG MOSKULOSKELETAL Bahu 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 1,294,128 1,035,302 258,826
BBMUSG032 S00329 - USG Paru - Paru DENGAN FOTO 336,600 269,280 67,320 336,600 269,280 67,320 370,260 296,208 74,052 403,920 323,136 80,784 471,240 376,992 94,248 538,560 430,848 107,712
BBMUSG033 S00330 - USG Payudara / Thyroid DENGAN FOTO 491,040 392,832 98,208 491,040 392,832 98,208 540,144 432,115 108,029 589,248 471,398 117,850 687,456 549,965 137,491 785,664 628,531 157,133
BBMUSG034 S02811 - USG Payudara dengan Foto C-R 588,060 470,448 117,612 588,060 470,448 117,612 646,866 517,493 129,373 705,672 564,538 141,134 823,284 658,627 164,657 940,896 752,717 188,179
BBMUSG035 S00331 - USG TESTIS DOPPLER 420,750 336,600 84,150 420,750 336,600 84,150 462,825 370,260 92,565 504,900 403,920 100,980 589,050 471,240 117,810 673,200 538,560 134,640
BBMUSG036 S04696 - USG THORAX 316,800 253,440 63,360 316,800 253,440 63,360 348,480 278,784 69,696 380,160 304,128 76,032 443,520 354,816 88,704 506,880 405,504 101,376
BBMUSG037 S02812 - USG Thyroid dengan Foto C-R 588,060 470,448 117,612 588,060 470,448 117,612 646,866 517,493 129,373 705,672 564,538 141,134 823,284 658,627 164,657 940,896 752,717 188,179
BBMUSG038 S00332 - USG Tiroid / Carotis / Leher DOPPLER 460,350 368,280 92,070 460,350 368,280 92,070 506,385 405,108 101,277 552,420 441,936 110,484 644,490 515,592 128,898 736,560 589,248 147,312
BBMUSG039 S02700 - HSG C-R ( kontras ) 960,300 768,240 192,060 960,300 768,240 192,060 1,056,330 845,064 211,266 1,152,360 921,888 230,472 1,344,420 1,075,536 268,884 1,536,480 1,229,184 307,296
S02701 - USG Mammae / Mammografi ( Rawat 325,000 455,000
357,500
BBMUSG040 Jalan ) 286,000 71,500 260,000 65,000 357,500 286,000 71,500 390,000 312,000 78,000 364,000 91,000 520,000 416,000 104,000
BBMUSG041 SO2702 - USG Testis Bilaterl 421,300 337,040 84,260 383,000 306,400 76,600 421,300 337,040 84,260 459,600 367,680 91,920 536,200 428,960 107,240 612,800 490,240 122,560
3.TARIF DIAGNOSTIK ELEKTROMEDIK

KODE LAYANAN DIAGNOSTIK ELEKTROMEDIK Jasa Sarana KELAS III Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS dan
(30%)
RS dan BHP
(30%)
RS dan BHP
(30%)
RS dan BHP
(30%)
VIP B RS dan BHP
(30%)
VIP A BHP (70%)
fee Medis (30%)
BBMH0116 GYN (Rawat Jalan) 44,000 30,800 12,000 44,000 30,800 13,200 48,400 33,880 14,520 52,800 36,960 15,840 57,200 40,040 17,160 70,400 49,280 21,120
BBMH0119 NST (Rawat Jalan) 110,000 88,000 12,000 110,000 88,000 12,000 121,000 84,700 36,300 132,000 92,400 39,600 143,000 100,100 42,900 176,000 123,200 52,800
BBMH0121 Periksa Dalam (Rawat Jalan) 44,000 35,000 15,000 44,000 30,800 13,200 48,400 33,880 14,520 52,800 36,960 15,840 57,200 40,040 17,160 70,400 49,280 21,120
BBMH0123 GV (Rawat Jalan) 42,900 30,030 12,870 42,900 30,030 12,870 47,190 33,033 14,157 51,480 36,036 15,444 55,770 39,039 16,731 68,640 48,048 20,592
BBMH0124 Doppler (Rawat Jalan) 27,500 19,250 8,250 27,500 19,250 8,250 30,250 21,175 9,075 33,000 23,100 9,900 35,750 25,025 10,725 44,000 30,800 13,200
BBM00125 EKG (Rawat Jalan) 77,000 53,900 23,100 77,000 53,900 23,100 84,700 59,290 25,410 83,200 58,240 24,960 100,100 70,070 30,030 123,200 86,240 36,960
BBM00128 Polipektomi SCBB (Rawat Jalan) 3,605,360 2,523,752 1,081,608 3,605,360 2,523,752 1,081,608 3,965,896 2,776,127 1,189,769 3,933,600 2,753,520 1,180,080 4,686,968 3,280,878 1,406,090 5,768,576 4,038,003 1,730,573
BBM00129 Biopsi Bronchus (Rawat Jalan) 182,160 127,512 54,648 182,160 127,512 54,648 200,376 140,263 60,113 199,200 139,440 59,760 236,808 165,766 71,042 291,456 204,019 87,437
BBM00131 Sikatan Bronchus (Rawat Jalan) 152,240 106,568 45,672 152,240 106,568 45,672 167,464 117,225 50,239 165,600 115,920 49,680 197,912 138,538 59,374 243,584 170,509 73,075
BBM00132 ERCP + Spingteromi / Ekstr. Batu (Rawat Jalan)
7,663,920 5,364,744 2,299,176 7,663,920 5,364,744 2,299,176 8,430,312 5,901,218 2,529,094 8,360,800 5,852,560 2,508,240 9,963,096 6,974,167 2,988,929 12,262,272 8,583,590 3,678,682
BBM00133 ERCP + Pasang NBD / Stent (Rawat Jalan) 7,573,280 5,301,296 2,271,984 7,573,280 5,301,296 2,271,984 8,330,608 5,831,426 2,499,182 8,262,400 5,783,680 2,478,720 9,845,264 6,891,685 2,953,579 12,117,248 8,482,074 3,635,174
BBM00134 ERCP (Rawat Jalan) 4,695,680 3,286,976 1,408,704 4,695,680 3,286,976 1,408,704 5,165,248 3,615,674 1,549,574 5,122,400 3,585,680 1,536,720 6,104,384 4,273,069 1,831,315 7,513,088 5,259,162 2,253,926
BBM00137 Skreloterapy (Rawat Jalan) 2,250,600 1,841,000 205,000 2,250,600 1,575,420 675,180 2,475,660 1,732,962 742,698 2,805,600 1,963,920 841,680 2,925,780 2,048,046 877,734 3,600,960 2,520,672 1,080,288
BBM00138 USG Muskular DOPPLER (Rawat Jalan) 394,240 275,968 118,272 394,240 275,968 118,272 433,664 303,565 130,099 430,400 301,280 129,120 512,512 358,758 153,754 630,784 441,549 189,235
BBM00139 AUDIOMETRI (Rawat Jalan) 137,280 96,096 41,184 137,280 96,096 41,184 151,008 105,706 45,302 149,600 104,720 44,880 178,464 124,925 53,539 219,648 153,754 65,894
BBM00140 Spirometry (Rawat Jalan) 154,880 108,416 46,464 154,880 108,416 46,464 170,368 119,258 51,110 168,800 118,160 50,640 201,344 140,941 60,403 247,808 173,466 74,342
BBM00141 Evoked Respon : VEP (Rawat Jalan) 569,360 398,552 170,808 569,360 398,552 170,808 626,296 438,407 187,889 620,800 434,560 186,240 740,168 518,118 222,050 910,976 637,683 273,293
BBM00142 Evoked Respon : BAEP (Rawat Jalan) 569,360 398,552 170,808 569,360 398,552 170,808 626,296 438,407 187,889 620,800 434,560 186,240 740,168 518,118 222,050 910,976 637,683 273,293
BBM00143 EMG : KHS (Rawat Jalan) 476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
BBM00144 EMG : Spasmophilia (Rawat Jalan) 476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
BBM00145 Regional Block (Rawat Jalan) 332,640 232,848 99,792 332,640 232,848 99,792 365,904 256,133 109,771 362,400 253,680 108,720 432,432 302,702 129,730 532,224 372,557 159,667
BBM00146 Spike & Seizure Analysis (Rawat Jalan) 152,240 106,568 45,672 152,240 106,568 45,672 167,464 117,225 50,239 165,600 115,920 49,680 197,912 138,538 59,374 243,584 170,509 73,075
BBM00147 Bera (Rawat Jalan) 520,960 364,672 156,288 520,960 364,672 156,288 573,056 401,139 171,917 568,000 397,600 170,400 677,248 474,074 203,174 833,536 583,475 250,061
BBM00148 EEG + Brain Mapping (Rawat Jalan) 520,960 364,672 156,288 520,960 364,672 156,288 573,056 401,139 171,917 568,000 397,600 170,400 677,248 474,074 203,174 833,536 583,475 250,061
BBM00149 EEG (Rawat Jalan) 201,520 141,064 60,456 201,520 141,064 60,456 221,672 155,170 66,502 219,200 153,440 65,760 261,976 183,383 78,593 322,432 225,702 96,730
BBM00150 Biopsi / Aspirasi Jarum Halus ( FNAB ) (Rawat
264,000 184,800 79,200 264,000 184,800 79,200 290,400 203,280 87,120 288,000 201,600 86,400 343,200 240,240 102,960 422,400 295,680 126,720
Jalan)
BBM00151 Biopsi / Aspirasi kelenjar (Rawat Jalan) 317,680 222,376 95,304 317,680 222,376 95,304 349,448 244,614 104,834 346,400 242,480 103,920 412,984 289,089 123,895 508,288 355,802 152,486
BBM00152 Biopsi Pleura (Rawat Jalan) 520,960 364,672 156,288 520,960 364,672 156,288 573,056 401,139 171,917 568,000 397,600 170,400 677,248 474,074 203,174 833,536 583,475 250,061
BBM00153 Punksi Pleura (Rawat Jalan) 316,800 221,760 95,040 316,800 221,760 95,040 348,480 243,936 104,544 345,600 241,920 103,680 411,840 288,288 123,552 506,880 354,816 152,064
BBM00154 TBB (Rawat Jalan) 535,040 374,528 160,512 535,040 374,528 160,512 588,544 411,981 176,563 584,000 408,800 175,200 695,552 486,886 208,666 856,064 599,245 256,819
BBM00155 WSD (Rawat Jalan) 978,560 684,992 293,568 978,560 684,992 293,568 1,076,416 753,491 322,925 1,067,200 747,040 320,160 1,272,128 890,490 381,638 1,565,696 1,095,987 469,709
BBM00156 Bronkografi (Rawat Jalan) 351,120 245,784 105,336 351,120 245,784 105,336 386,232 270,362 115,870 383,200 268,240 114,960 456,456 319,519 136,937 561,792 393,254 168,538
BBM00157 Broncoscopy ( dengan Anastesi ) (Rawat Jalan) 2,790,480 1,953,336 837,144 2,790,480 1,953,336 837,144 3,069,528 2,148,670 920,858 3,044,000 2,130,800 913,200 3,627,624 2,539,337 1,088,287 4,464,768 3,125,338 1,339,430
BBM00158 Broncoscopy ( Tanpa Anastesi ) (Rawat Jalan) 2,347,840 1,643,488 704,352 2,347,840 1,643,488 704,352 2,582,624 1,807,837 774,787 2,561,600 1,793,120 768,480 3,052,192 2,136,534 915,658 3,756,544 2,629,581 1,126,963
BBM00159 UROFLOMETRI (Rawat Jalan) 139,920 97,944 41,976 139,920 97,944 41,976 153,912 107,738 46,174 152,800 106,960 45,840 181,896 127,327 54,569 223,872 156,710 67,162
BBM00160 MAMMOGRAPHY (Rawat Jalan) 238,480 166,936 71,544 238,480 166,936 71,544 262,328 183,630 78,698 260,000 182,000 78,000 310,024 217,017 93,007 381,568 267,098 114,470
BBM00161 USG INTERVENSI Non - Abdomen (Rawat Jalan)
812,240 568,568 243,672 812,240 568,568 243,672 893,464 625,425 268,039 886,400 620,480 265,920 1,055,912 739,138 316,774 1,299,584 909,709 389,875
BBM00162 USG INTERVENSI Abdomen (Rawat Jalan) 904,640 633,248 271,392 904,640 633,248 271,392 995,104 696,573 298,531 986,400 690,480 295,920 1,176,032 823,222 352,810 1,447,424 1,013,197 434,227
BBM00163 USG Transrectal ( Dgn print ) (Rawat Jalan) 358,160 250,712 107,448 358,160 250,712 107,448 393,976 275,783 118,193 391,200 273,840 117,360 465,608 325,926 139,682 573,056 401,139 171,917
BBM00165 Polipektomi SCBA (Rawat Jalan) 3,605,360 2,523,752 1,081,608 3,605,360 2,523,752 1,081,608 3,965,896 2,776,127 1,189,769 2,805,600 1,963,920 841,680 4,686,968 3,280,878 1,406,090 5,768,576 4,038,003 1,730,573
BBM00168 TREADMILL (Rawat Jalan) 432,960 303,072 129,888 432,960 303,072 129,888 476,256 333,379 142,877 472,000 330,400 141,600 562,848 393,994 168,854 692,736 484,915 207,821
BBM00169 USG Kepala bayi (Rawat Jalan) 391,600 274,120 117,480 391,600 274,120 117,480 430,760 301,532 129,228 427,200 299,040 128,160 509,080 356,356 152,724 626,560 438,592 187,968
BBM00170 Peak Flow (Rawat Jalan) 48,400 33,880 14,520 48,400 33,880 14,520 53,240 37,268 15,972 53,000 37,100 15,900 62,920 44,044 18,876 77,440 54,208 23,232
BBM00172 USG Doppler Vaskuler (Rawat Jalan) 365,200 255,640 109,560 365,200 255,640 109,560 401,720 281,204 120,516 399,200 279,440 119,760 474,760 332,332 142,428 584,320 409,024 175,296
BBM00173 Echocardiography Anak ( Cito ) (Rawat Jalan) 726,000 508,200 217,800 726,000 508,200 217,800 798,600 559,020 239,580 792,000 554,400 237,600 943,800 660,660 283,140 1,161,600 813,120 348,480
BBM00174 EMG/ENMG : KHS (Rawat Jalan) 476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
BBM00175 EMG/ENMG : KHS Extermitas Bawah (Rawat
476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
Jalan)
BBM00176 EMG/ENMG : KHS Extermitas Atas (Rawat Jalan)
476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014
763,136 534,195 228,941
BBM00177 USG 4 Dimensi Ginekologi (Rawat Jalan) 495,000 315,000 135,000 495,000 346,500 148,500 544,500 381,150 163,350 594,000 415,800 178,200 643,500 450,450 193,050 792,000 554,400 237,600
BBM00178 USG Obstetri - Ginekologi Dengan Print (Rawat
132,000 96,000 24,000 132,000 105,600 26,400 145,200 101,640 43,560 158,400 110,880 47,520 171,600 120,120 51,480 211,200 147,840 63,360
Jalan)
BBM00179 USG Obstetri - Ginekologi Tanpa Print (Rawat
77,000 56,000 14,000 77,000 61,600 15,400 84,700 59,290 25,410 92,400 64,680 27,720 100,100 70,070 30,030 123,200 86,240 36,960
Jalan)
BBM00180 USG Ginekologi Transvaginal Dengan Print (Rawat
193,600 154,000 22,000 193,600 154,000 22,000 212,960 149,072 63,888 232,320 162,624 69,696 251,680 176,176 75,504 309,760 216,832 92,928
Jalan)
BBM00181 USG Ginekologi Transvaginal Tanpa Print(Rawat
77,000 56,000 14,000 77,000 56,000 14,000 84,700 59,290 25,410 92,400 64,680 27,720 100,100 70,070 30,030
Jalan) 123,200 86,240 36,960
III. TARIF TINDAKAN
1.TARIF TINDAKAN DOKTER

KODE TINDAKAN DOKTER Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A BHP (30%)
fee Medis (70%)
BBM00182 Punksi Lumbal (Rawat Jalan) 143,715 39,195 91,455 130,650 39,195 91,455 143,715 43,115 100,601 156,780 47,034 109,746 182,910 54,873 128,037 209,040 62,712 146,328
BBM00183 Punksi Pleura (Rawat Jalan)-Dr 266,200 65,000 177,000 204,100 61,230 142,870 224,510 67,353 157,157 244,920 73,476 171,444 285,740 85,722 200,018 326,560 97,968 228,592
BBM00184 Punksi BMP (Rawat Jalan) 238,810 65,130 151,970 217,100 65,130 151,970 238,810 71,643 167,167 260,520 78,156 182,364 303,940 91,182 212,758 347,360 104,208 243,152
BBM00185 Punksi Abdomen (Rawat Jalan) 312,400 77,000 207,000 284,000 77,000 207,000 312,400 93,720 218,680 340,800 102,240 238,560 397,600 119,280 278,320 454,400 136,320 318,080
BBM00186 Vena Sectie (Rawat Jalan) 282,700 69,000 188,000 257,000 69,000 188,000 282,700 84,810 197,890 308,400 92,520 215,880 359,800 107,940 251,860 411,200 123,360 287,840
BBM00187 Pemasangan CVP (Rawat Jalan) 839,300 206,000 557,000 763,000 206,000 557,000 839,300 251,790 587,510 915,600 274,680 640,920 1,068,200 320,460 747,740 1,220,800 366,240 854,560
BBM00188 Pemasangan Catheter Umbilikal (Rawat Jalan) 190,905 52,065 121,485 173,550 52,065 121,485 190,905 57,272 133,634 208,260 62,478 145,782 242,970 72,891 170,079 277,680 83,304 194,376
BBM00190 Punksi Pericard (Rawat Jalan) 363,000 89,000 241,000 330,000 89,000 241,000 363,000 108,900 254,100 396,000 118,800 277,200 462,000 138,600 323,400 528,000 158,400 369,600
BBM00191 Punksi Ascites (Rawat Jalan) 209,000 51,000 139,000 190,000 51,000 139,000 209,000 62,700 146,300 228,000 68,400 159,600 266,000 79,800 186,200 304,000 91,200 212,800
BBM00192 Punksi Kista Hati (Rawat Jalan) 162,305 44,265 103,285 147,550 44,265 103,285 162,305 48,692 113,614 177,060 53,118 123,942 206,570 61,971 144,599 236,080 70,824 165,256
BBM00193 A. J. H. (Rawat Jalan) 162,305 44,265 103,285 147,550 44,265 103,285 162,305 48,692 113,614 177,060 53,118 123,942 206,570 61,971 144,599 236,080 70,824 165,256
BBM00194 Ethanol Therapy (Rawat Jalan) 214,500 58,500 136,500 195,000 58,500 136,500 214,500 64,350 150,150 234,000 70,200 163,800 273,000 81,900 191,100 312,000 93,600 218,400
BBM00195 Lepas Tampon (Rawat Jalan) 37,400 9,000 25,000 34,000 9,000 25,000 37,400 11,220 26,180 40,800 12,240 28,560 47,600 14,280 33,320 54,400 16,320 38,080
BBM00197 Canul Trachea Aff (Rawat Jalan) 143,715 39,195 91,455 130,650 39,195 91,455 143,715 43,115 100,601 156,780 47,034 109,746 182,910 54,873 128,037 209,040 62,712 146,328
BBM00198 Pasang HD Catheter (Rawat Jalan) 1,625,195 443,235 1,034,215 1,477,450 443,235 1,034,215 1,625,195 487,559 1,137,637 1,772,940 531,882 1,241,058 2,068,430 620,529 1,447,901 2,363,920 709,176 1,654,744
BBM00199 Aff Catheter Epidural (Rawat Jalan) 410,300 101,000 272,000 373,000 101,000 272,000 410,300 123,090 287,210 447,600 134,280 313,320 522,200 156,660 365,540 596,800 179,040 417,760
BBM00200 Aff HD Catheter (Rawat Jalan) 677,600 185,000 431,000 616,000 185,000 431,000 677,600 203,280 474,320 739,200 221,760 517,440 862,400 258,720 603,680 985,600 295,680 689,920
BBM00206 Eksisi Clavus (Rawat Jalan) 495,000 148,500 346,500 450,000 135,000 315,000 495,000 148,500 346,500 540,000 162,000 378,000 630,000 189,000 441,000 720,000 216,000 504,000
BBM00207 Eksisi / eksterpasi Aterom (Rawat Jalan) 735,900 201,000 468,000 669,000 201,000 468,000 735,900 220,770 515,130 802,800 240,840 561,960 936,600 280,980 655,620 1,070,400 321,120 749,280
BBM00211 Plebotomy (Dokter) (Rawat Jalan) 141,570 38,610 90,090 128,700 38,610 90,090 141,570 42,471 99,099 154,440 46,332 108,108 180,180 54,054 126,126 205,920 61,776 144,144
BBM00212 Aspirasi Jarum Halus (Dokter) (Rawat Jalan) 143,000 39,000 91,000 130,000 39,000 91,000 143,000 42,900 100,100 156,000 46,800 109,200 182,000 54,600 127,400 208,000 62,400 145,600
BBM00213 Eksisi Mococel (Rawat Jalan) 495,000 148,500 346,500 450,000 135,000 315,000 495,000 148,500 346,500 540,000 162,000 378,000 630,000 189,000 441,000 720,000 216,000 504,000
BBM00214 Reduksi Terteutup ( Anestesi Lokal ) (Rawat Jalan)
92,400 23,000 61,000 84,000 23,000 61,000 92,400 27,720 64,680 100,800 30,240 70,560 117,600 35,280 82,320 134,400 40,320 94,080
BBM00214 Insersi / pasang IUD Mirena (Rawat Jalan) 388,300 106,000 247,000 388,300 106,000 247,000 427,130 128,139 298,991 465,960 139,788 326,172 543,620 163,086 380,534 621,280 186,384 434,896
BBM00215 Aff Inter Maxillary Wiring (Rawat Jalan) 361,900 97,000 232,000 329,000 97,000 232,000 361,900 108,570 253,330 394,800 118,440 276,360 460,600 138,180 322,420 526,400 157,920 368,480
BBM00219 Pemeriksaan Ginekologi ( Obsgyn ) (Rawat Jalan)
44,000 12,000 30,800 40,000 12,000 28,000 44,000 13,200 30,800 48,000 14,400 33,600 56,000 16,800 39,200 64,000 19,200 44,800
BBM00220 Injeksi Epidural (Rawat Jalan) 860,145 258,044 602,102 781,950 234,585 547,365 860,145 258,044 602,102 938,340 281,502 656,838 1,094,730 328,419 766,311 1,251,120 375,336 875,784
BBM00221 Aspirasi Haemarothrosis (Rawat Jalan) 298,870 89,661 209,209 271,700 81,510 190,190 298,870 89,661 209,209 326,040 97,812 228,228 380,380 114,114 266,266 434,720 130,416 304,304
BBM00222 Skin Traksi (Rawat Jalan) 200,200 49,000 133,000 182,000 49,000 133,000 200,200 60,060 140,140 218,400 65,520 152,880 254,800 76,440 178,360 291,200 87,360 203,840
BBM00223 Skeletal Traksi (Rawat Jalan) 562,705 168,812 393,894 511,550 153,465 358,085 562,705 168,812 393,894 613,860 184,158 429,702 716,170 214,851 501,319 818,480 245,544 572,936
BBM00224 Debridement (Ortopedic) (Rawat Jalan) 337,480 101,244 236,236 306,800 92,040 214,760 337,480 101,244 236,236 368,160 110,448 257,712 429,520 128,856 300,664 490,880 147,264 343,616
BBM00225 Backslab (Rawat Jalan) 267,300 66,000 177,000 243,000 66,000 177,000 267,300 80,190 187,110 291,600 87,480 204,120 340,200 102,060 238,140 388,800 116,640 272,160
BBM00226 Pemasangan Gips Kecil (Rawat Jalan) 225,225 67,568 157,658 204,750 61,425 143,325 225,225 67,568 157,658 245,700 73,710 171,990 286,650 85,995 200,655 327,600 98,280 229,320
BBM00227 Pemasangan Gips Sedang (Rawat Jalan) 337,480 101,244 236,236 306,800 92,040 214,760 337,480 101,244 236,236 368,160 110,448 257,712 429,520 128,856 300,664 490,880 147,264 343,616
BBM00228 Pemasangan Gips Besar (Rawat Jalan) 449,735 134,921 314,815 408,850 122,655 286,195 449,735 134,921 314,815 490,620 147,186 343,434 572,390 171,717 400,673 654,160 196,248 457,912
BBM00229 Close Reduction + Gips (Rawat Jalan) 666,600 163,000 443,000 606,000 163,000 443,000 666,600 199,980 466,620 727,200 218,160 509,040 848,400 254,520 593,880 969,600 290,880 678,720
BBM00230 Aff Pinning (Rawat Jalan) 666,600 164,000 442,000 606,000 164,000 442,000 666,600 199,980 466,620 727,200 218,160 509,040 848,400 254,520 593,880 969,600 290,880 678,720
BBM00231 Lepas gips (Rawat Jalan) 112,970 33,891 79,079 102,700 30,810 71,890 112,970 33,891 79,079 123,240 36,972 86,268 143,780 43,134 100,646 164,320 49,296 115,024
BBM00232 Aff Lea (Rawat Jalan) 382,525 114,758 267,768 347,750 104,325 243,425 382,525 114,758 267,768 417,300 125,190 292,110 486,850 146,055 340,795 556,400 166,920 389,480
BBM00233 Pasang Laminaria (Rawat Jalan) 170,500 42,000 113,000 155,000 42,000 113,000 170,500 51,150 119,350 186,000 55,800 130,200 217,000 65,100 151,900 248,000 74,400 173,600
BBM00234 Aff Drain (dokter) (Rawat Jalan) 77,000 19,000 51,000 70,000 19,000 51,000 77,000 23,100 53,900 84,000 25,200 58,800 98,000 29,400 68,600 112,000 33,600 78,400
BBM00235 Debridement Kecil - Dokter Umum (Rawat Jalan)
47,905 14,372 33,534 43,550 13,065 30,485 47,905 14,372 33,534 52,260 15,678 36,582 60,970 18,291 42,679 69,680 20,904 48,776
BBM00236 Debridement Sedang - Dokter Umum (Rawat
95,810 28,743 67,067 87,100 26,130 60,970 95,810 28,743 67,067 104,520 31,356 73,164 121,940 36,582 85,358
Jalan) 139,360 41,808 97,552
BBM00237 Debridement Besar - Dokter Umum (Rawat Jalan)
143,715 43,115 100,601 130,650 39,195 91,455 143,715 43,115 100,601 156,780 47,034 109,746 182,910 54,873 128,037 209,040 62,712 146,328
BBM00238 Debridement Kecil - Dokter Spesialis (Rawat Jalan) 95,810 28,743 67,067 87,100 26,130 60,970 95,810 28,743 67,067 104,520 31,356 73,164 121,940 36,582 85,358
139,360 41,808 97,552
BBM00239 Debridement Sedang - Dokter Spesialis (Rawat
190,905 57,272 133,634 173,550 52,065 121,485 190,905 57,272 133,634 208,260 62,478 145,782 242,970 72,891 170,079 277,680 83,304 194,376
Jalan)
BBM00240 Debridement Besar - Dokter Spesialis (Rawat
286,715 86,015 200,701 260,650 78,195 182,455 286,715 86,015 200,701 312,780 93,834 218,946 364,910 109,473 255,437
Jalan) 417,040 125,112 291,928
BBM00241 Tutul Pedofilin (Rawat Jalan) 82,500 24,750 57,750 75,000 22,500 52,500 82,500 24,750 57,750 90,000 27,000 63,000 105,000 31,500 73,500 120,000 36,000 84,000
BBM00242 Businasi (Rawat Jalan) 71,500 21,450 50,050 65,000 19,500 45,500 71,500 21,450 50,050 78,000 23,400 54,600 91,000 27,300 63,700 104,000 31,200 72,800
BBM00243 Spooeling / Kateter (Rawat Jalan) 69,300 19,000 44,000 63,000 19,000 44,000 69,300 20,790 48,510 75,600 22,680 52,920 88,200 26,460 61,740 100,800 30,240 70,560
BBM00244 Pasang Tampon Hidung (Rawat Jalan) 165,000 49,500 115,500 150,000 45,000 105,000 165,000 49,500 115,500 180,000 54,000 126,000 210,000 63,000 147,000 240,000 72,000 168,000
BBM00245 Kauterisasi Faring/Kaustik Faring (Rawat Jalan) 71,500 21,450 50,050 65,000 19,500 45,500 71,500 21,450 50,050 78,000 23,400 54,600 91,000 27,300 63,700 104,000 31,200 72,800
BBM00246 Angkat Tampon Hidung (Rawat Jalan) 84,700 23,000 54,000 77,000 23,000 54,000 84,700 25,410 59,290 92,400 27,720 64,680 107,800 32,340 75,460 123,200 36,960 86,240
BBM00247 Pasang Gips Pada CTEV (Rawat Jalan) 382,525 114,758 267,768 347,750 104,325 243,425 382,525 114,758 267,768 417,300 125,190 292,110 486,850 146,055 340,795 556,400 166,920 389,480
BBM00248 Ekstirpasi Lipoma (Rawat Jalan) 735,900 201,000 468,000 669,000 201,000 468,000 735,900 220,770 515,130 802,800 240,840 561,960 936,600 280,980 655,620 1,070,400 321,120 749,280
BBM00249 Necrotomie (Rawat Jalan) 95,810 28,743 67,067 87,100 26,130 60,970 95,810 28,743 67,067 104,520 31,356 73,164 121,940 36,582 85,358 139,360 41,808 97,552
BBM00250 Sklerotheraphy Hemoroid (STH) (Rawat Jalan) 865,150 259,545 605,605 786,500 235,950 550,550 865,150 259,545 605,605 943,800 283,140 660,660 1,101,100 330,330 770,770 1,258,400 377,520 880,880
BBM00253 Ganti Balutan(Rawat Jalan) 50,600 13,000 33,000 46,000 13,000 33,000 50,600 15,180 35,420 55,200 16,560 38,640 64,400 19,320 45,080 73,600 22,080 51,520
BBM00256 Pemasangan Kateter Vena Dalam (Dewasa) 519,090 155,727 363,363 471,900 141,570 330,330 519,090 155,727 363,363 566,280 169,884 396,396 660,660 198,198 462,462 755,040 226,512 528,528
BBM00257 (Rawat Jalan)Kateter Vena Dalam (Anak) (Rawat
Pemasangan
Jalan) 649,220 194,766 454,454 590,200 177,060 413,140 649,220 194,766 454,454 708,240 212,472 495,768 826,280 247,884 578,396
944,320 283,296 661,024
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A BHP (30%)
fee Medis (70%)
BBM00258 Pemasangan CVC/CVP (Dewasa) (Rawat Jalan) 839,300 206,000 557,000 763,000 206,000 557,000 839,300 251,790 587,510 915,600 274,680 640,920 1,068,200 320,460 747,740 1,220,800 366,240 854,560
BBM00259 Pemasangan CVC/CVP (Anak) (Rawat Jalan) 951,665 285,500 666,166 865,150 259,545 605,605 951,665 285,500 666,166 1,038,180 311,454 726,726 1,211,210 363,363 847,847 1,384,240 415,272 968,968
BBM00260 Aff Cateter Vena Presure (CVC/CVP) (Rawat
512,600 126,000 340,000 466,000 126,000 340,000 512,600 153,780 358,820 559,200 167,760 391,440 652,400 195,720 456,680 745,600 223,680 521,920
Jalan)
BBM00261 Sleep Analisis (Rawat Jalan) 1,714,570 514,371 1,200,199 1,558,700 467,610 1,091,090 1,714,570 514,371 1,200,199 1,870,440 561,132 1,309,308 2,182,180 654,654 1,527,526 2,493,920 748,176 1,745,744
BBM00264 Inseminasi (Dokter) (Rawat Jalan) 3,025,000 850,000 1,900,000 2,750,000 825,000 1,925,000 3,025,000 907,500 2,117,500 3,300,000 990,000 2,310,000 3,850,000 1,155,000 2,695,000 4,400,000 1,320,000 3,080,000
BBM00265 Kemoterapi Anak (Rawat Jalan) 250,965 75,290 175,676 228,150 68,445 159,705 250,965 75,290 175,676 273,780 82,134 191,646 319,410 95,823 223,587 365,040 109,512 255,528
BBM00266 Kemoterapi Umum (Dewasa) (Rawat Jalan) 303,160 90,948 212,212 275,600 82,680 192,920 303,160 90,948 212,212 330,720 99,216 231,504 385,840 115,752 270,088 440,960 132,288 308,672
BBM00267 Pemasangan IV Line (Vena Dalam) (Rawat Jalan)
130,130 39,039 91,091 118,300 35,490 82,810 130,130 39,039 91,091 141,960 42,588 99,372 165,620 49,686 115,934 189,280 56,784 132,496
BBM00268 Pasang Cateter Umbilica (Rawat Jalan) 130,130 39,039 91,091 118,300 35,490 82,810 130,130 39,039 91,091 141,960 42,588 99,372 165,620 49,686 115,934 189,280 56,784 132,496
BBM00269 Biopsi / Aspirasi Jarum Halus ( FNAB ) (Rawat
266,200 65,000 177,000 242,000 65,000 177,000 266,200 79,860 186,340 290,400 87,120 203,280 338,800 101,640 237,160 387,200 116,160 271,040
Jalan)
BBM00270 IVA TEST (Rawat Jalan) 60,500 18,150 42,350 102,050 30,615 71,435 112,255 33,677 78,579 122,460 36,738 85,722 142,870 42,861 100,009 163,280 48,984 114,296
BBM00271 TUTUL TCA (Rawat Jalan) 56,485 16,946 39,540 51,350 15,405 35,945 56,485 16,946 39,540 61,620 18,486 43,134 71,890 21,567 50,323 82,160 24,648 57,512
BBM00272 Buddy Tapping (Rawat Jalan) 240,240 72,072 168,168 218,400 65,520 152,880 240,240 72,072 168,168 262,080 78,624 183,456 305,760 91,728 214,032 349,440 104,832 244,608
BBM00273 Pemasangan Endo Trachel Tube / Intubasi
131,560 39,468 92,092 119,600 35,880 83,720 131,560 39,468 92,092 143,520 43,056 100,464 167,440 50,232 117,208 191,360 57,408 133,952
(Rawat Jalan)
BBM00274 Pasang Tampon (Rawat Jalan) 149,600 41,000 95,000 136,000 41,000 95,000 149,600 44,880 104,720 163,200 48,960 114,240 190,400 57,120 133,280 217,600 65,280 152,320
BBM00275 Anastesi CT - SCAN ( Anak ) (Rawat Jalan) 157,300 47,190 110,110 143,000 42,900 100,100 157,300 47,190 110,110 171,600 51,480 120,120 200,200 60,060 140,140 228,800 68,640 160,160
BBM00276 Pasang Gripper (Rawat Jalan) 377,520 113,256 264,264 343,200 102,960 240,240 377,520 113,256 264,264 411,840 123,552 288,288 480,480 144,144 336,336 549,120 164,736 384,384
BBM00277 Aff / Lepas Gripper (Rawat Jalan) 223,300 61,000 142,000 203,000 61,000 142,000 223,300 66,990 156,310 243,600 73,080 170,520 284,200 85,260 198,940 324,800 97,440 227,360
BBM00278 Biopsi TTB Guiding CT SCan (Rawat Jalan) 196,625 58,988 137,638 178,750 53,625 125,125 196,625 58,988 137,638 214,500 64,350 150,150 250,250 75,075 175,175 286,000 85,800 200,200
BBM00279 Wide Eksisi / Wide Eksterpasi (Lokal Anastesi)
564,850 169,455 395,395 513,500 154,050 359,450 564,850 169,455 395,395 616,200 184,860 431,340 718,900 215,670 503,230
(Rawat Jalan) 821,600 246,480 575,120
BBM00280 Assesment Memory (Rawat Jalan) 449,735 134,921 314,815 408,850 122,655 286,195 449,735 134,921 314,815 490,620 147,186 343,434 572,390 171,717 400,673 654,160 196,248 457,912
BBM00281 Lepas Tampon Hidung dan Debridement Pasca
629,200 188,760 440,440 572,000 171,600 400,400 629,200 188,760 440,440 686,400 205,920 480,480 800,800 240,240 560,560 915,200 274,560 640,640
Operasi (Rawat Jalan)
BBM00284 Hecting Aff Sedang Poli Umum ( Benang 6 -10 )
44,000 13,200 30,800 40,000 12,000 28,000 44,000 13,200 30,800 48,000 14,400 33,600 56,000 16,800 39,200 64,000 19,200 44,800
(Rawat Jalan)
BBM00285 Hecting Aff Berat Poli Umum ( Benang > 10 )
66,000 19,800 46,200 60,000 18,000 42,000 66,000 19,800 46,200 72,000 21,600 50,400 84,000 25,200 58,800 96,000 28,800 67,200
(Rawat Jalan)
BBM00286 Rawat Luka Ringan ( Dokter Poli Umum ) (Rawat
33,000 9,900 23,100 30,000 9,000 21,000 33,000 9,900 23,100 36,000 10,800 25,200 42,000 12,600 29,400 48,000 14,400 33,600
Jalan)
BBM00287 Rawat Luka Sedang ( Dokter Poli Umum ) (Rawat
49,500 14,850 34,650 45,000 13,500 31,500 49,500 14,850 34,650 54,000 16,200 37,800 63,000 18,900 44,100 72,000 21,600 50,400
Jalan)
BBM00288 Rawat Luka Berat ( Dokter Poli Umum ) (Rawat
64,900 19,470 45,430 59,000 17,700 41,300 64,900 19,470 45,430 70,800 21,240 49,560 82,600 24,780 57,820 94,400 28,320 66,080
Jalan)
BBM00289 Intubasi - Dokter Umum (Rawat Jalan) 130,130 39,039 91,091 118,300 35,490 82,810 130,130 39,039 91,091 141,960 42,588 99,372 165,620 49,686 115,934 189,280 56,784 132,496
BBM00290 Injeksi Tendon (Rawat Jalan) 117,975 35,393 82,583 107,250 32,175 75,075 117,975 35,393 82,583 128,700 38,610 90,090 150,150 45,045 105,105 171,600 51,480 120,120
BBM00291 Incisi Bulla di Membran Tymfani (Rawat Jalan) 74,360 22,308 52,052 67,600 20,280 47,320 74,360 22,308 52,052 81,120 24,336 56,784 94,640 28,392 66,248 108,160 32,448 75,712
BBM00292 Perawatan Stoma/ Colostomi (Rawat Jalan) 77,000 21,000 49,000 70,000 21,000 49,000 77,000 23,100 53,900 84,000 25,200 58,800 98,000 29,400 68,600 112,000 33,600 78,400
BBM00293 Injeksi Kenacort A Intra Lesi (Rawat Jalan) 77,000 20,000 50,000 70,000 20,000 50,000 77,000 23,100 53,900 84,000 25,200 58,800 98,000 29,400 68,600 112,000 33,600 78,400
BBM00296 Hematologi ( ORTHOPEDI ) (Rawat Jalan) 103,400 25,000 69,000 94,000 25,000 69,000 103,400 31,020 72,380 112,800 33,840 78,960 131,600 39,480 92,120 150,400 45,120 105,280
BBM00297 Cystostomy ( Tanpa Kateter ) (Urologi) (Rawat
396,000 97,000 263,000 360,000 97,000 263,000 396,000 118,800 277,200 432,000 129,600 302,400 504,000 151,200 352,800 576,000 172,800 403,200
Jalan)
BBM00298 D.C Shock (Rawat Jalan) 268,400 73,000 171,000 244,000 73,000 171,000 268,400 80,520 187,880 292,800 87,840 204,960 341,600 102,480 239,120 390,400 117,120 273,280
BBM00299 Angkat Drain (Rawat Jalan) 33,000 9,000 21,000 30,000 9,000 21,000 33,000 9,900 23,100 36,000 10,800 25,200 42,000 12,600 29,400 48,000 14,400 33,600
BBM00300 AFF Katater ( UROLOGI ) (Rawat Jalan) 40,700 10,000 27,000 37,000 10,000 27,000 40,700 12,210 28,490 44,400 13,320 31,080 51,800 15,540 36,260 59,200 17,760 41,440
BBM00301 Sirkumsisi (Rawat Jalan) 1,430,000 300,000 1,000,000 1,300,000 300,000 1,000,000 1,430,000 429,000 1,001,000 1,560,000 468,000 1,092,000 1,820,000 546,000 1,274,000 2,080,000 624,000 1,456,000
BBM00302 Swab Hidung (Rawat Jalan) 84,700 23,000 54,000 77,000 23,000 54,000 84,700 25,410 59,290 92,400 27,720 64,680 107,800 32,340 75,460 123,200 36,960 86,240
BBM00303 Tindakan PILA (Rawat Jalan) 1,378,300 378,000 875,000 1,253,000 378,000 875,000 1,378,300 413,490 964,810 1,503,600 451,080 1,052,520 1,754,200 526,260 1,227,940 2,004,800 601,440 1,403,360
BBM00304 Intubasi ETT (Rawat Jalan) 155,100 42,000 99,000 141,000 42,000 99,000 155,100 46,530 108,570 169,200 50,760 118,440 197,400 59,220 138,180 225,600 67,680 157,920
BBM00305 Terminasi Kehamilan 825,000 247,500 577,500 750,000 225,000 525,000 825,000 247,500 577,500 900,000 270,000 630,000 1,050,000 315,000 735,000 1,200,000 360,000 840,000
BBM00306 Vagina Touch -Dokter Spesialis (Rawat Jalan) 57,200 17,160 40,040 57,200 17,160 40,040 62,920 18,876 44,044 68,640 20,592 48,048 80,080 24,024 56,056 91,520 27,456 64,064
2.TARIF TINDAKAN UGD

KODE LAYANAN TINDAKAN UGD Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS dan fee Medis Dokter
(10%)
(10%)
RS dan BHP
(10%)
RS dan BHP
(10%)
VIP B RS dan BHP
Dokter (10%)
VIP A BHP (90%)+ BHP (10%)
LAYANAN (90%) (90%) HCU (90%) ISOLASI (90%) (90%)+ BHP
BBM00292 Pengambilan Corpus Alienum ( Emergency ) 102,366 11,374 94,000 84,600 9,400 103,400 10,340 112,800 101,520 11,280 131,600 118,440 13,160
113,740 93,060 150,400 135,360 15,040
(Rawat Jalan) UGD
BBM00293 Tindakan Defibrilator / DC Shock > 5 kali 490,050 54,450 450,000 405,000 45,000 495,000 49,500 540,000 486,000 54,000 630,000 567,000 63,000
544,500 445,500 720,000 648,000 72,000
( Emergency )(Rawat Jalan) UGD
BBM00294 E K G ( Emergency )(Rawat Jalan) UGD 102,850 92,565 10,285 85,000 76,500 8,500 93,500 84,150 9,350 102,000 91,800 10,200 119,000 107,100 11,900 136,000 122,400 13,600
BBM00295 Tindakan Defibrilator / DC Shock < 5 kali 345,213 38,357 317,000 285,300 31,700 348,700 34,870 380,400 342,360 38,040 443,800 399,420 44,380
383,570 313,830 507,200 456,480 50,720
BBM00296 Tindik Telinga ( Emergency )(Rawat Jalan) UGD 48,763 43,887 4,876 40,300 36,270 4,030 44,330 39,897 4,433 48,360 43,524 4,836 56,420 50,778 5,642 64,480 58,032 6,448
BBM00297 Suction ( Emergency )(Rawat Jalan) UGD 36,966 33,269 3,697 30,550 27,495 3,055 33,605 30,245 3,361 36,660 32,994 3,666 42,770 38,493 4,277 48,880 43,992 4,888
BBM00298 Aff TT ( Emergency )(Rawat Jalan) UGD 220,220 198,198 22,022 182,000 163,800 18,200 200,200 180,180 20,020 218,400 196,560 21,840 254,800 229,320 25,480 291,200 262,080 29,120
BBM00299 Resusitasi Kardio Pulmoner ( Emergency )(Rawat 193,479 174,131 19,348 159,900 143,910 15,990 175,890 158,301 17,589 191,880 172,692 19,188 223,860 201,474 22,386 255,840 230,256 25,584
BBM00300 Jalan) UGD( Emergency )(Rawat Jalan) UGD
Lavement 40,347 4,483 37,050 33,345 3,705 40,755 4,076 44,460 40,014 4,446 51,870 46,683 5,187
44,831 36,680
59,280 53,352 5,928
(10%)
(10%)
RS dan BHP
(10%)
RS dan BHP
(10%)
VIP B RS dan BHP
Dokter (10%) VIP A BHP (90%)+ BHP (10%)
BBM00303 Ganti Balutan UGD 42,185 37,967 4,219 38,350 34,515 3,835 42,185 37,967 4,219 46,020 41,418 4,602 53,690 48,321 5,369 61,360 55,224 6,136
BBM00304 Vena Seksi ( Emergency )(Rawat Jalan) UGD 129,415 116,474 12,942 117,650 105,885 11,765 129,415 116,474 12,942 141,180 127,062 14,118 164,710 148,239 16,471 188,240 169,416 18,824
BBM00305 Ekstraksi Kuku UGD ( Emergency )(Rawat Jalan) 74,646 8,294 75,400 67,860 7,540 82,940 8,294 90,480 81,432 9,048 105,560 95,004 10,556
82,940 74,646 120,640 108,576 12,064
UGD
BBM00306 Circumsisi UGD ( Emergency )(Rawat Jalan) UGD 361,647 40,183 365,300 328,770 36,530 401,830 40,183 438,360 394,524 43,836 511,420 460,278 51,142
401,830 361,647 584,480 526,032 58,448
BBM00307 Spalk uk. 20 cm ( Emergency )(Rawat Jalan) UGD 14,801 1,645 14,950 13,455 1,495 16,445 1,645 17,940 16,146 1,794 20,930 18,837 2,093
16,445 14,801 23,920 21,528 2,392
BBM00308 Spalk uk. 30 cm ( Emergency ) (Rawat Jalan) UGD 18,018 2,002 18,200 16,380 1,820 20,020 2,002 21,840 19,656 2,184 25,480 22,932 2,548
20,020 18,018 29,120 26,208 2,912
23,595 21,236 34,320 30,888 3,432
26,455 23,810 38,480 34,632 3,848
BBM00311 Spalk uk. 100 cm ( Emergency ) (Rawat Jalan) 27,671 3,075 27,950 25,155 2,795 30,745 3,075 33,540 30,186 3,354 39,130 35,217 3,913
30,745 27,671 44,720 40,248 4,472
UGD
BBM00312 Jasa Tindakan Pasang Spalk UGD (Rawat Jalan) 23,810 2,646 24,050 21,645 2,405 26,455 2,646 28,860 25,974 2,886 33,670 30,303 3,367
26,455 23,810 38,480 34,632 3,848
BBM00313 Jasa Tindakan Pasang Gyps Sederhana UGD 189,189 21,021 191,100 171,990 19,110 210,210 21,021 229,320 206,388 22,932 267,540 240,786 26,754
210,210 189,189 305,760 275,184 30,576
(Rawat Jalan)
BBM00314 Incisi Absces Kecil UGD (Rawat Jalan) 38,610 34,749 3,861 35,100 31,590 3,510 38,610 34,749 3,861 42,120 37,908 4,212 49,140 44,226 4,914 56,160 50,544 5,616
BBM00315 Incisi Absces Besar UGD (Rawat Jalan) 67,210 60,489 6,721 61,100 54,990 6,110 67,210 60,489 6,721 73,320 65,988 7,332 85,540 76,986 8,554 97,760 87,984 9,776
BBM00317 Angkat Jahitan Lebih dari 10 Jahitan UGD (Rawat 56,430 6,270 57,000 51,300 5,700 62,700 6,270 68,400 61,560 6,840 79,800 71,820 7,980
62,700 56,430 91,200 82,080 9,120
Jalan)
BBM00318 Angkat Jahitan 6 s/d 10 Jahitan UGD (Rawat 43,560 4,840 44,000 39,600 4,400 48,400 4,840 52,800 47,520 5,280 61,600 55,440 6,160
48,400 43,560 70,400 63,360 7,040
Jalan)
BBM00319 Angkat Jahitan s/d 5 Jahitan UGD (Rawat Jalan) 33,000 29,700 3,300 30,000 27,000 3,000 33,000 29,700 3,300 36,000 32,400 3,600 42,000 37,800 4,200 48,000 43,200 4,800
BBM00320 Hecting Tambahan ( per jahitan ) UGD (Rawat 8,366 930 8,450 7,605 845 9,295 930 10,140 9,126 1,014 11,830 10,647 1,183
9,295 8,366 13,520 12,168 1,352
Jalan)
BBM00321 Hechting s/d 3 Jahitan UGD (Rawat Jalan) 71,500 64,350 7,150 65,000 58,500 6,500 71,500 64,350 7,150 78,000 70,200 7,800 91,000 81,900 9,100 104,000 93,600 10,400
BBM00322 Pasang Infus dengan Venaseksi UGD (Rawat 250,965 27,885 253,500 228,150 25,350 278,850 27,885 304,200 273,780 30,420 354,900 319,410 35,490
278,850 250,965
Jalan) 405,600 365,040 40,560
BBM00323 Amputasi Jari UGD (Rawat Jalan) 76,505 68,855 7,651 69,550 62,595 6,955 76,505 68,855 7,651 83,460 75,114 8,346 97,370 87,633 9,737 111,280 100,152 11,128
BBM00324 Tindakan Klisma / Glycerin Spuit UGD (Rawat 50,837 5,649 51,350 46,215 5,135 56,485 5,649 61,620 55,458 6,162 71,890 64,701 7,189
56,485 50,837 82,160 73,944 8,216
Jalan)
BBM00325 Pemasangan NGT + Bilas Lambung UGD (Rawat 173,250 19,250 175,000 157,500 17,500 192,500 19,250 210,000 189,000 21,000 245,000 220,500 24,500
192,500 173,250 280,000 252,000 28,000
Jalan)
BBM00326 Pemasangan NGT UGD (Rawat Jalan) 62,205 55,985 6,221 56,550 50,895 5,655 62,205 55,985 6,221 67,860 61,074 6,786 79,170 71,253 7,917 90,480 81,432 9,048
BBM00327 Resusitasi Jantung Paru UGD (Rawat Jalan) 95,810 86,229 9,581 87,100 78,390 8,710 95,810 86,229 9,581 104,520 94,068 10,452 121,940 109,746 12,194 139,360 125,424 13,936
BBM00328 Delatasi Preputium UGD (Rawat Jalan) 33,605 30,245 3,361 30,550 27,495 3,055 33,605 30,245 3,361 36,660 32,994 3,666 42,770 38,493 4,277 48,880 43,992 4,888
BBM00329 Pemasangan Endo Trachel Tube / Intubasi ( di luar 129,344 14,372 130,650 117,585 13,065 143,715 14,372 156,780 141,102 15,678 182,910 164,619 18,291
143,715 129,344 209,040 188,136 20,904
alat ) (Rawat Jalan)
BBM00330 Pemasangan Kateter Urine UGD (Rawat Jalan) 44,330 39,897 4,433 40,300 36,270 4,030 44,330 39,897 4,433 48,360 43,524 4,836 56,420 50,778 5,642 64,480 58,032 6,448
BBM00331 Punksi Supra Pubik UGD (Rawat Jalan) 82,940 74,646 8,294 75,400 67,860 7,540 82,940 74,646 8,294 90,480 81,432 9,048 105,560 95,004 10,556 120,640 108,576 12,064
BBM00332 Pasang Infus UGD (Rawat Jalan) 28,600 25,740 2,860 26,000 23,400 2,600 28,600 25,740 2,860 31,200 28,080 3,120 36,400 32,760 3,640 41,600 37,440 4,160
BBM00333 Roserplasty UGD (Rawat Jalan) 113,685 102,317 11,369 103,350 93,015 10,335 113,685 102,317 11,369 124,020 111,618 12,402 144,690 130,221 14,469 165,360 148,824 16,536
BBM00334 Inhalasi UGD (Rawat Jalan) 67,210 60,489 6,721 61,100 54,990 6,110 67,210 60,489 6,721 73,320 65,988 7,332 85,540 76,986 8,554 97,760 87,984 9,776
BBM00336 Eksplorasi Luka Sederhana UGD (Rawat Jalan) 52,910 47,619 5,291 48,100 43,290 4,810 52,910 47,619 5,291 57,720 51,948 5,772 67,340 60,606 6,734 76,960 69,264 7,696
BBM00337 Nebulizer ( Emergency ) (Rawat Jalan) 56,485 50,837 5,649 51,350 46,215 5,135 56,485 50,837 5,649 61,620 55,458 6,162 71,890 64,701 7,189 82,160 73,944 8,216
BBM00338 Bilas lambung UGD (Rawat Jalan) 129,415 116,474 12,942 117,650 105,885 11,765 129,415 116,474 12,942 141,180 127,062 14,118 164,710 148,239 16,471 188,240 169,416 18,824
BBM00340 Sewa Ruang Tindakan UGD (Rawat Jalan) 331,045 297,941 33,105 300,950 270,855 30,095 331,045 297,941 33,105 361,140 325,026 36,114 421,330 379,197 42,133 481,520 433,368 48,152
BBM00341 Psg. Neck Kollar UGD (Rawat Jalan) 22,880 20,592 2,288 20,800 18,720 2,080 22,880 20,592 2,288 24,960 22,464 2,496 29,120 26,208 2,912 33,280 29,952 3,328
BBM00342 Aff Catheter UGD (Rawat Jalan) 33,000 29,700 3,300 30,000 27,000 3,000 33,000 29,700 3,300 36,000 32,400 3,600 42,000 37,800 4,200 48,000 43,200 4,800
BBM00343 Aff Drain UGD (Rawat Jalan) 48,400 43,560 4,840 44,000 39,600 4,400 48,400 43,560 4,840 52,800 47,520 5,280 61,600 55,440 6,160 70,400 63,360 7,040
BBM00344 Irigasi Mata UGD (Rawat Jalan) 22,880 20,592 2,288 20,800 18,720 2,080 22,880 20,592 2,288 24,960 22,464 2,496 29,120 26,208 2,912 33,280 29,952 3,328
BBM00345 Psg. OGT UGD (Rawat Jalan) 81,510 73,359 8,151 74,100 66,690 7,410 81,510 73,359 8,151 88,920 80,028 8,892 103,740 93,366 10,374 118,560 106,704 11,856
BBM00347 Injeksi IM UGD (Rawat Jalan) 23,100 20,790 2,310 21,000 18,900 2,100 23,100 20,790 2,310 25,200 22,680 2,520 29,400 26,460 2,940 33,600 30,240 3,360
BBM00348 Injeksi IV UGD (Rawat Jalan) 23,100 20,790 2,310 21,000 18,900 2,100 23,100 20,790 2,310 25,200 22,680 2,520 29,400 26,460 2,940 33,600 30,240 3,360
BBM00349 Injeksi IC/ SC UGD (Rawat Jalan) 23,100 20,790 2,310 21,000 18,900 2,100 23,100 20,790 2,310 25,200 22,680 2,520 29,400 26,460 2,940 33,600 30,240 3,360
Observasi Pasien UGD 2 - 4 jam (Rawat Jalan) 67,100 60,390 6,710 - - -
BBM00352 Observasi Pasien UGD 4 - 6 jam (Rawat Jalan) 108,900 98,010 10,890 99,000 89,100 9,900 108,900 98,010 10,890 118,800 106,920 11,880 138,600 124,740 13,860 158,400 142,560 15,840
BBM00353 Observasi Pasien UGD 6 - 8 jam (Rawat Jalan) 121,000 108,900 12,100 110,000 99,000 11,000 121,000 108,900 12,100 132,000 118,800 13,200 154,000 138,600 15,400 176,000 158,400 17,600
BBM00354 HECTING AFF RINGAN UGD ( BENANG 1- 5) 29,700 3,300 30,000 27,000 3,000 33,000 3,300 36,000 32,400 3,600 42,000 37,800 4,200
33,000 29,700 48,000 43,200 4,800
(Rawat Jalan)
BBM00355 (Rawat Jalan)HECTING AFF SEDANG UGD 54,450 6,050 55,000 49,500 5,500 60,500 6,050 66,000 59,400 6,600 77,000 69,300 7,700
60,500 54,450 88,000 79,200 8,800
( BENANG 6- 10)
BBM00356 HECTING AFF BERAT UGD ( BENANG >10) 87,120 9,680 88,000 79,200 8,800 96,800 9,680 105,600 95,040 10,560 123,200 110,880 12,320
96,800 87,120 140,800 126,720 14,080
(Rawat Jalan)
BBM00357 RAWAT LUKA RINGAN ( DOKTER UGD) (Rawat 39,600 4,400 40,000 36,000 4,000 44,000 4,400 48,000 43,200 4,800 56,000 50,400 5,600
44,000 39,600 64,000 57,600 6,400
Jalan)
BBM00358 RAWAT LUKA SEDANG ( DOKTER UGD) (Rawat 66,000 59,400 6,600 60,000 54,000 6,000 66,000 59,400 6,600 72,000 64,800 7,200 84,000 75,600 8,400 96,000 86,400 9,600
BBM00359 Jalan)
RAWAT LUKA BERAT ( DOKTER UGD) (Rawat 88,000 79,200 8,800 80,000 72,000 8,000 88,000 79,200 8,800 96,000 86,400 9,600 112,000 100,800 11,200 128,000 115,200 12,800
BBM00360 Jalan)
Suppositoria (Rawat Jalan) 20,790 2,310 21,000 18,900 2,100 23,100 2,310 25,200 22,680 2,520 29,400 26,460 2,940
23,100 20,790 33,600 30,240 3,360
(10%)
(10%)
RS dan BHP
(10%)
RS dan BHP
(10%)
VIP B RS dan BHP
Dokter (10%)
VIP A BHP (90%)+ BHP (10%)
BBM0361 Injeksi Vitamin C ( Paket ) 96,800 87,120 9,680 96,800 87,120 9,680 154,880 139,392 15,488
BBM00362 Injeksi Vitamin C ( Premium ) 144,100 129,690 14,410 144,100 129,690 14,410 230,560 207,504 23,056
BBM00363 Swab Antigen ( Paket ) 187,000 135,000 35,000 187,000 135,000 35,000 299,200 269,280 29,920
BBM00364 Swab Antigen ( Paket Mahasiswa ) 108,900 93,900 15,000 108,900 93,900 15,000 174,240 156,816 17,424
BBM00365 Pemeriksaan Fisik Dokter Umum 44,000 32,000 12,000 44,000 32,000 12,000 70,400 63,360 7,040
BBM00366 Vagina Touch(DOKTER UGD) 44,000 32,000 12,000 44,000 32,000 12,000 70,400 63,360 7,040
3.TARIF ASUHAN KEPERAWATAN

KODE LAYANAN ASUHAN KEPERAWATAN KELAS II / KELAS I /
RAWAT JALAN KELAS III VIP B VIP A
LAYANAN HCU ISOLASI
BBM00361 Intubasi / ETT (Rawat Jalan) ASKEP 130,130 118,300 130,130 141,960 165,620 189,280
BBM00362 Resusitasi Jantung Paru (Rawat Jalan) ASKEP 122,265 111,150 122,265 133,380 155,610 177,840
BBM00363 D.C. Shock (Rawat Jalan) ASKEP 226,655 206,050 226,655 247,260 288,470 329,680
BBM00364 Pasang NGT / Flow Care (Rawat Jalan) ASKEP 72,215 65,650 72,215 78,780 91,910 105,040
BBM00365 Pasang Kateter Urine (Rawat Jalan) ASKEP 71,500 65,000 71,500 78,000 91,000 104,000
BBM00366 Ganti Balutan Kecil (Rawat Jalan) ASKEP 38,610 35,100 38,610 42,120 49,140 56,160
BBM00367 Ganti Balutan Sedang (Rawat Jalan) ASKEP 67,210 61,100 67,210 73,320 85,540 97,760
BBM00368 Ganti Balutan Besar (Rawat Jalan) ASKEP 107,250 97,500 107,250 117,000 136,500 156,000
BBM00369 Necrotomie (Rawat Jalan) ASKEP 44,330 40,300 44,330 48,360 56,420 64,480
BBM00370 Angkat Jahitan 1 - 5 Jahitan (Rawat Jalan) ASKEP
53,625 48,750 53,625 58,500 68,250
78,000
BBM00371 Angkat Jahitan 6 - 10 Jahitan (Rawat Jalan)ASKEP
72,930 66,300 72,930 79,560 92,820 106,080
BBM00372 Angkat Jahitan > 10 Jahitan (Rawat Jalan) ASKEP
101,530 92,300 101,530 110,760 129,220
147,680
BBM00373 Perawatan Stoma / Colostomi (Rawat Jalan)
56,485 51,350 56,485 61,620 71,890 82,160
ASKEP
BBM00374 Pasang Infus (Rawat Jalan) ASKEP 42,185 38,350 42,185 46,020 53,690 61,360
BBM00375 Merawat Luka Gangren Kecil (Rawat Jalan)
27,885 25,350 27,885 30,420 35,490 40,560
ASKEP
BBM00376 Merawat Luka Gangren Besar (Rawat Jalan)
47,905 43,550 47,905 52,260 60,970 69,680
ASKEP
BBM00377 Merawat Luka Gangren Sedang (Rawat Jalan)
36,465 33,150 36,465 39,780 46,410 53,040
ASKEP
BBM00378 Inhalsi Therapy (Rawat Jalan) ASKEP 67,210 61,100 67,210 73,320 85,540 97,760
BBM00379 Blue Light (Rawat Jalan) ASKEP 44,330 40,300 44,330 48,360 56,420 64,480
BBM00381 Skin Test (Rawat Jalan) ASKEP 36,465 33,150 36,465 39,780 46,410 53,040
BBM00382 Klisma / Glycerin Spuit (Rawat Jalan) ASKEP 56,485 51,350 56,485 61,620 71,890 82,160
BBM00383 Spoeling Mahokar (Rawat Jalan) ASKEP 33,605 30,550 33,605 36,660 42,770 48,880
BBM00384 Angkat Drain (Rawat Jalan) ASPER 27,885 25,350 27,885 30,420 35,490 40,560
BBM00385 Perawatan Tracheostomi (Rawat Jalan) ASPER 27,885 25,350 27,885 30,420 35,490 40,560
BBM00390 Nebulizer Dgn Obat (Rawat Jalan) ASKEP 56,485 51,350 56,485 61,620 71,890 82,160
BBM00392 Pasang OGT (Rawat Jalan) ASKEP 73,645 66,950 73,645 80,340 93,730 107,120
BBM00394 Ekstra Bed (Rawat Jalan) ASKEP 62,920 57,200 62,920 68,640 80,080 91,520
BBM00395 Nebulizer Tanpa Obat (Rawat Jalan) ASKEP 39,325 35,750 39,325 42,900 50,050 57,200
BBM00396 Aff Katheter (Rawat Jalan) ASKEP 19,305 17,550 19,305 21,060 24,570 28,080
BBM00397 Aff Drain (Rawat Jalan) ASKEP 27,885 25,350 27,885 30,420 35,490 40,560
BBM00398 Alat Cukur (Rawat Jalan) ASKEP 20,020 18,200 20,020 21,840 25,480 29,120
BBM00400 Lavement (Rawat Jalan) ASKEP 44,330 40,300 44,330 48,360 56,420 64,480
BBM00403 Debridement ( WT ) Berat (Rawat Jalan) ASKEP 86,900 79,000 86,900 94,800 110,600 126,400
BBM00404 Sewa Alat Animax / Jam (Rawat Jalan) ASKEP 12,870 11,700 12,870 14,040 16,380 18,720
BBM00405 Perawatan Luka / Medikasi - Kecil (Rawat Jalan)
27,885 25,350 27,885 30,420 35,490 40,560
ASKEP
BBM00406 Perawatan Luka / Medikasi - Sedang (Rawat
40,755 37,050 40,755 44,460 51,870 59,280
Jalan) ASKEP
BBM00407 Perawatan Luka / Medikasi - Besar (Rawat Jalan)
86,900 79,000 86,900 94,800 110,600 126,400
ASKEP
BBM00408 Injeksi Formalin (Rawat Jalan) ASKEP 492,800 448,000 492,800 537,600 627,200 716,800
BBM00409 Endoscopy Asuhan Keperawatan (Rawat Jalan)
133,100 121,000 133,100 145,200 169,400 193,600
ASKEP
BBM00410 Debridement Kecil - Perawat (Rawat Jalan) ASKEP
33,000 30,000 33,000 36,000 42,000 48,000
BBM00411 Debridement Sedang - Perawat (Rawat Jalan)
67,100 61,000 67,100 73,200 85,400 97,600
ASKEP
BBM00412 Debridement Besar - Perawat (Rawat Jalan)
100,100 91,000 100,100 109,200 127,400 145,600
ASKEP
BBM00413 Paket Persalinan ( oleh Bidan) (Rawat
1,925,000 1,750,000 1,925,000 2,100,000 2,450,000 2,800,000
Jalan)ASKEP
BBM00414 Tindik Bayi (Rawat Jalan) ASKEP 44,330 40,300 44,330 48,360 56,420 64,480
BBM00415 Injeksi IM (Rawat Jalan) ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00416 Injeksi IV (Rawat Jalan) ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00426 Aff Infus (Rawat Jalan) ASKEP 24,200 22,000 24,200 26,400 30,800 35,200
BBM00430 Injeksi Kenacort A Intra Lesi Sedang (Rawat Jalan)
154,000 140,000 154,000 168,000 196,000
ASKEP 224,000
LAYANAN HCU ISOLASI
BBM00431 Tampon (Rawat Jalan) ASKEP 36,300 33,000 36,300 39,600 46,200 52,800
BBM00432 Kultur (Rawat Jalan) ASKEP 53,900 49,000 53,900 58,800 68,600 78,400
BBM00433 Ganti verband (Kulit) (Rawat Jalan) ASKEP 29,700 27,000 29,700 32,400 37,800 43,200
BBM00434 Injeksi kenacort (Rawat Jalan) ASKEP 33,000 30,000 33,000 36,000 42,000 48,000
BBM00435 Normal Dressing ( Orthopedi ) (Rawat Jalan)
58,300 53,000 58,300 63,600 74,200 84,800
ASKEP
BBM00436 Eksplorasi Kecil ( Orthopedi ) (Rawat Jalan)
221,100 201,000 221,100 241,200 281,400 321,600
ASKEP
BBM00437 Moderat Care (Rawat Jalan) ASKEP 46,200 42,000 46,200 50,400 58,800 67,200
BBM00438 Intermediate Care (Rawat Jalan)ASKEP 59,400 54,000 59,400 64,800 75,600 86,400
BBM00439 Maksimal Care (Rawat Jalan) ASKEP 93,500 85,000 93,500 102,000 119,000 136,000
BBM00440 Intensive Care (Rawat Jalan) ASKEP 133,100 121,000 133,100 145,200 169,400 193,600
BBM00441 Pemasangan Catheter Umbilikal (Rawat Jalan)
293,700 267,000 293,700 320,400 373,800
ASKEP 427,200
BBM00442 Inhalasi Therapy (Rawat Jalan) ASKEP 88,000 80,000 88,000 96,000 112,000 128,000
BBM00444 Lepas Tampon (Rawat Jalan) ASKEP 48,400 44,000 48,400 52,800 61,600 70,400
BBM00445 Aff Catheter Epidural (Rawat Jalan) ASKEP 532,400 484,000 532,400 580,800 677,600 774,400
BBM00446 Aff HD Catheter (Rawat Jalan)ASKEP 882,200 802,000 882,200 962,400 1,122,800 1,283,200
BBM00450 Aspirasi Jarum Halus (Rawat Jalan) ASKEP 143,000 130,000 143,000 156,000 182,000 208,000
BBM00451 Insersi / pasang IUD Mirena Asper (Rawat Jalan)
154,000 140,000 154,000 168,000 196,000 224,000
ASKEP
BBM00452 Pemasangan Gips Kecil (Rawat Jalan)ASKEP 346,500 315,000 346,500 378,000 441,000 504,000
BBM00453 Pemasangan Gips Sedang (Rawat Jalan) ASKEP
519,200 472,000 519,200 566,400 660,800 755,200
BBM00454 Pemasangan Gips Besar (Rawat Jalan) ASKEP 691,900 629,000 691,900 754,800 880,600 1,006,400
BBM00455 Aff Pinning (Rawat Jalan) ASKEP 865,700 787,000 865,700 944,400 1,101,800 1,259,200
BBM00456 Aff Lea (Rawat Jalan) ASPER 588,500 535,000 588,500 642,000 749,000 856,000
BBM00458 Spooeling / Kateter (Rawat Jalan) ASKEP 95,700 87,000 95,700 104,400 121,800 139,200
BBM00459 Pasang Tampon Hidung (Rawat Jalan) ASKEP 213,400 194,000 213,400 232,800 271,600 310,400
BBM00460 Pemasangan Kateter Vena Dalam (Dewasa)
798,600 726,000 798,600 871,200 1,016,400 1,161,600
(Rawat Jalan) ASKEP
BBM00461 Pemasangan Kateter Vena Dalam (Anak) (Rawat
998,800 908,000 998,800 1,089,600 1,271,200 1,452,800
Jalan) ASKEP
BBM00462 Aff Cateter Vena Presure (CVC/CVP) (Rawat
665,500 605,000 665,500 726,000 847,000 968,000
Jalan) ASKEP
BBM00463 Pengambilan Corpus Alienum (Rawat Jalan)
103,400 94,000 103,400 112,800 131,600 150,400
ASKEP
BBM00464 Tindakan Defibrilator / DC Shock > 5 kali (Rawat
509,300 463,000 509,300 555,600 648,200 740,800
Jalan) ASKEP
BBM00465 Tindakan Defibrilator / DC Shock < 5 kali (Rawat
348,700 317,000 348,700 380,400 443,800 507,200
Jalan) ASKEP
BBM00466 Suction (Rawat Jalan) ASKEP 51,700 47,000 51,700 56,400 65,800 75,200
BBM00467 Aff TT (Rawat Jalan) ASKEP 308,000 280,000 308,000 336,000 392,000 448,000
BBM00468 Resusitasi Kardio Pulmoner (Rawat Jalan) ASKEP
270,600 246,000 270,600 295,200 344,400 393,600
BBM00470 Spalk uk. 20 cm (Rawat Jalan) ASKEP 25,300 23,000 25,300 27,600 32,200 36,800
BBM00472 Jasa Tindakan Pasang Spalk (Rawat Jalan)
36,300 33,000 36,300 39,600 46,200 52,800
ASKEP
BBM00473 Jasa Tindakan Pasang Gyps Sederhana (Rawat
323,400 294,000 323,400 352,800 411,600 470,400
Jalan) ASKEP
BBM00474 Incisi Absces Kecil (Rawat Jalan) ASKEP 59,400 54,000 59,400 64,800 75,600 86,400
BBM00475 Incisi Absces Besar (Rawat Jalan) ASKEP 103,400 94,000 103,400 112,800 131,600 150,400
BBM00477 Hecting Tambahan ( per jahitan ) (Rawat
14,300 13,000 14,300 15,600 18,200 20,800
Jalan)ASKEP
BBM00478 Hechting s/d 3 Jahitan (Rawat Jalan) ASKEP 110,000 100,000 110,000 120,000 140,000 160,000
BBM00479 Pasang Infus dengan Venaseksi (Rawat Jalan)
429,000 390,000 429,000 468,000 546,000 624,000
ASKEP
BBM00480 Tindakan Klisma / Glycerin Spuit (Rawat Jalan)
86,900 79,000 86,900 94,800 110,600 126,400
ASKEP
BBM00481 Pemasangan NGT + Bilas Lambung (Rawat
235,400 214,000 235,400 256,800 299,600 342,400
Jalan) ASKEP
BBM00482 Pemasangan NGT (Rawat Jalan) ASKEP 95,700 87,000 95,700 104,400 121,800 139,200
BBM00483 Delatasi Preputium (Rawat Jalan) ASKEP 51,700 47,000 51,700 56,400 65,800 75,200
BBM00484 Pemasangan Endo Trachel Tube / Intubasi ( di luar
222,200 202,000 222,200 242,400 282,800 323,200
alat ) (Rawat Jalan) ASKEP
BBM00485 Punksi Supra Pubik (Rawat Jalan) ASKEP 127,600 116,000 127,600 139,200 162,400 185,600
BBM00486 Bilas lambung (Rawat Jalan) ASKEP 198,000 180,000 198,000 216,000 252,000 288,000
BBM00487 Psg. Neck Kollar (Rawat Jalan)ASKEP 35,200 32,000 35,200 38,400 44,800 51,200
BBM00488 Irigasi Mata (Rawat Jalan)ASKEP 35,200 32,000 35,200 38,400 44,800 51,200
BBM00489 Injeksi Epidural oleh Perawat (Rawat Jalan)
67,100 61,000 67,100 73,200 85,400 97,600
ASKEP
BBM00490 Pengambilan Darah Perifer (Rawat Jalan) ASKEP
23,100 21,000 23,100 25,200 29,400 33,600
BBM00491 Pengambilan Darah Vena (Rawat Jalan) ASKEP
23,100 21,000 23,100 25,200 29,400 33,600
BBM00492 Injeksi IC/SC (Rawat Jalan)ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00493 Funduscopi (Rawat Jalan) ASKEP 64,900 59,000 64,900 70,800 82,600 94,400
BBM00494 Ganti Condom Catheter (Rawat Jalan) ASKEP 39,600 36,000 39,600 43,200 50,400 57,600
BBM00497 Moderat Care (Kelas 3) (Rawat Jalan) ASKEP 42,900 39,000 42,900 46,800 54,600 62,400
BBM00498 Minimal Care (Rawat Jalan) ASKEP 18,700 17,000 18,700 20,400 23,800 27,200
BBM00499 Minimal Care (UGD) (Rawat Jalan) ASKEP 24,200 22,000 24,200 26,400 30,800 35,200
LAYANAN HCU ISOLASI
BBM00500 Moderat Care (UGD) (Rawat Jalan) ASKEP 42,900 39,000 42,900 46,800 54,600 62,400
BBM00503 Intermediat Care (Kelas 3) (Rawat Jalan) ASKEP
55,000 50,000 55,000 60,000 70,000 80,000
BBM00506 Maksimal Care (Kelas 3) (Rawat Jalan) ASKEP 84,700 77,000 84,700 92,400 107,800 123,200
BBM00509 Intensive Care (Kelas 3) (Rawat Jalan) ASKEP 121,000 110,000 121,000 132,000 154,000 176,000
BBM00517 Moderat Care (HD) (Rawat Jalan)ASKEP 42,900 39,000 42,900 46,800 54,600 62,400
BBM00518 Maksimal Care (HD) (Rawat Jalan) ASKEP 93,500 85,000 93,500 102,000 119,000 136,000
BBM00519 Moderat Care (Minor-Kamar Operasi) (Rawat
42,900 39,000 42,900 46,800 54,600 62,400
Jalan) ASKEP
BBM00520 Moderat Care (Medium-Kamar Operasi) (Rawat
51,700 47,000 51,700 56,400 65,800 75,200
Jalan) ASKEP
BBM00521 Maksimal Care (Mayor-Kamar Operasi) (Rawat
84,700 77,000 84,700 92,400 107,800 123,200
Jalan) ASKEP
BBM00522 Maksimal Care (Khusus-Kamar Operasi) (Rawat
102,300 93,000 102,300 111,600 130,200 148,800
Jalan)ASKEP
BBM00523 Maksimal Care (Canggih-Kamar Operasi) (Rawat
112,200 102,000 112,200 122,400 142,800
Jalan)ASKEP 163,200
BBM00524 Pemberian Sonde (Rawat Jalan)ASKEP 13,200 12,000 13,200 14,400 16,800 19,200
BBM00525 Suction (pengambilan lendir) (Rawat Jalan)
19,800 18,000 19,800 21,600 25,200 28,800
ASKEP
BBM00526 Dressing Infus (Rawat Jalan) ASKEP 19,800 18,000 19,800 21,600 25,200 28,800
BBM00527 One Touch (Rawat Jalan) ASKEP 31,900 29,000 31,900 34,800 40,600 46,400
BBM00528 Mouthcare (Rawat Jalan) ASKEP 19,800 18,000 19,800 21,600 25,200 28,800
BBM00529 Kemoterapi Anak (Rawat Jalan) ASKEP 386,100 351,000 386,100 421,200 491,400 561,600
BBM00530 Kemoterapi Umum ( Dewasa) (Rawat Jalan)
466,400 424,000 466,400 508,800 593,600 678,400
ASKEP
BBM00532 Pemasangan IV Line (Vena Dalam) (Rawat Jalan)
133,100 121,000 133,100 145,200 169,400 193,600
ASKEP
BBM00533 Jasa Resusitasi Bayi Baru Lahir SC Perina ASKEP
157,300 143,000 157,300 171,600 200,200 228,800
BBM00534 Jasa Resusitasi Bayi Baru Lahir Normal Perina
119,900 109,000 119,900 130,800 152,600 174,400
(Rawat Jalan) ASKEP
BBM00535 Mantoux Test ( PPD Test ) Dewasa (Rawat Jalan)
236,500 215,000 236,500 258,000 301,000 344,000
ASKEP
BBM00536 Mantoux Test ( PPD Test ) Anak - Primer (Rawat
236,500 215,000 236,500 258,000 301,000 344,000
Jalan)ASKEP
BBM00537 Mantoux Test ( PPD Test ) Anak - Intermediate
236,500 215,000 236,500 258,000 301,000 344,000
(Rawat Jalan) ASKEP
BBM00538 Mantoux Test ( PPD Test ) Anak - Sekunder
236,500 215,000 236,500 258,000 301,000 344,000
(Rawat Jalan) ASKEP
BBM00542 Spalk 5 - 20 cm (Rawat Jalan) ASKEP 31,900 29,000 31,900 34,800 40,600 46,400
BBM00543 Spalk 20 - 40 cm (Rawat Jalan)ASKEP 53,900 49,000 53,900 58,800 68,600 78,400
BBM00544 Spalk > 40 cm (Rawat Jalan) ASKEP 93,500 85,000 93,500 102,000 119,000 136,000
BBM00545 Evakuasi Serumen Telinga - (Rawat Jalan) ASKEP
49,500 45,000 49,500 54,000 63,000 72,000
BBM00546 Cukur Kepala - (Rawat Jalan)ASKEP 110,000 100,000 110,000 120,000 140,000 160,000
BBM00547 Suppositoria (Rawat Jalan) ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00548 Vagina Touch (Rawat Jalan)ASKEP 44,000 44,000 48,400 52,800 61,600 70,400
BBM00549 Pemasangan Infus Pump - (Rawat Jalan) ASKEP
38,500 38,500 42,350 46,200 53,900 61,600
BBM00550 Pemasangan Oksigen- (Rawat Jalan) ASKEP 27,500 27,500 30,250 33,000 38,500 44,000
BBM00551 Pemasangan Syringe Pump - (Rawat Jalan)
26,950 26,950 29,645 32,340 37,730 43,120
ASKEP
BBM00552 TINDAKAN NST -(Rawat Jalan) ASKEP 96,800 96,800 106,480 116,160 135,520 154,880
BBM00553 Breast Care -(Rawat Jalan) ASKEP 41,470 41,470 45,617 49,764 58,058 66,352
BBM00554 Periksa Dalam -(Rawat Jalan) ASKEP 44,000 44,000 48,400 52,800 61,600 70,400
IV.KAMAR PERAWATAN / ROOM CHARGE
KODE DAFTAR TARIF LAYANAN KAMAR

TARIF
LAYANAN PERAWATAN
R.001 VIP A 750,000
R..002 VIP B 500,000
R..003 Kelas I 350,000
R.004 Kelas II 250,000
R.005 Kelas III 125,000
R.006 Pediatric 250,000
R..007 HCU 350,000
R.008 VK 500,000
R.009 Bayi sehat 200,000
R.010 OK 715,000
V. KAMAR BERSALIN

KODE LAYANAN KAMAR BERSALIN Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana
fee Medis fee Medis fee Medis fee Medis fee Medis
KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B RS dan BHP VIP A RS dan BHP
LAYANAN (70%) HCU (70%) ISOLASI (70%) (70%) (70%)
(30%) (30%) (30%) (30%) (30%)
VK001 Sewa Kamar Bersalin 550,000 605,000 660,000 770,000 880,000
OK001 Sewa Kamar Operasi 786,500 865,150 943,800 1,101,100 1,258,400
VK002 Jasa DOKTER ANAK ( OBGYN ) 165,000 49,500 115,500 181,500 54,450 127,050 198,000 59,400 138,600 231,000 69,300 161,700 264,000 79,200 184,800
165,000
VK003 Jasa Resusitasi Bayi Baru Lahir SC (Dokter Anak ) 181,500 198,000 231,000 264,000
Jasa Resusitasi Bayi Baru Lahir Normal ( Dokter
220,000
VK004 Anak ) 242,000 264,000 308,000 352,000
Jasa Pengawasan Dokter Pada Persalinan Bidan
220,000
VK005 Normal 242,000 264,000 308,000 352,000
110,000
VK006 Jasa Resusitasi Dokter Anak jika persalinan Bidan 121,000 132,000 154,000 176,000
VK007 OBSERVASI VK < 6 JAM 88,000 26,400 61,600 96,800 29,040 105,600 31,680 73,920 123,200 36,960 86,240 140,800 42,240 98,560
VK008 OBSERVASI VK > 6JAM 121,000 36,300 84,700 133,100 39,930 93,170 145,200 43,560 101,640 169,400 50,820 118,580 193,600 58,080 135,520
VK009 INFANT WARMER 29,700 8,910 20,790 32,670 9,801 22,869 35,640 10,692 24,948 41,580 12,474 29,106 47,520 14,256 33,264
OK002 KAMAR OBSERVASI RAWAT INAP 60,500 18,150 42,350 66,550 19,965 46,585 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
VK010 Persalinan Epidural 3,577,650 3,935,415 4,293,180 5,008,710 5,724,240
VK011 PAKET KURETASE - Kelas III - VK 2,970,000
VK012 PAKET KURETASE - Kelas II - VK 3,696,000
VK013 PAKET KURETASE - Kelas I - VK 4,466,000
VK014 PAKET KURETASE - Kelas VIP B - VK 5,170,000
VK015 PAKET KURETASE - Kelas VIP A- VK 6,006,000
OK003 PAKET KURETASE - Kelas III - OK 4,235,000
OK004 PAKET KURETASE - Kelas II - OK 5,280,000
OK005 PAKET KURETASE - Kelas I - OK 6,380,000
OK006 PAKET KURETASE - Kelas VIP B - OK 7,480,000
OK007 PAKET KURETASE - Kelas VIP A- OK 8,580,000
VK016 PAKET PERSALINAN NORMAL KELAS III 5,175,000
VK017 PAKET PERSALINAN NORMAL KELAS II 5,750,000
PAKET PERSALINAN NORMAL KELAS I
VK023 (DENGAN PENYULIT) 7,590,000
PAKET PERSALINAN NORMAL KELAS VIP B
PAKET PERSALINAN NORMAL KELAS VIP A
OK008 PAKET PERSALINAN SC KELAS III 8,250,000
OK009 PAKET PERSALINAN SC KELAS II 9,075,000
PAKET PERSALINAN SC KELAS I (DENGAN
OK015 PENYULIT) 13,310,000
PAKET PERSALINAN SC KELAS VIP B
OK016 (DENGAN PENYULIT) 18,150,000
PAKET PERSALINAN SC KELAS VIP A
OK017 (DENGAN PENYULIT) 20,570,000
OK018 PAKET PERSALINAN RE SC KELAS III 9,350,000
OK019 PAKET PERSALINAN RE SC KELAS II 10,285,000
OK020 PAKET PERSALINAN RE SC KELAS I 13,200,000
OK021 PAKET PERSALINAN RE SC KELAS VIP B 17,600,000
OK022 PAKET PERSALINAN RE SC KELAS VIP A 19,800,000
PAKET PERSALINAN GEMELI / Bayi Kembar
9,350,000
OK023 Kelas III
OK024 Kelas II 10,285,000
OK025 Kelas I 13,200,000
OK026 Kelas VIP B 17,600,000
OK027 Kelas VIP A 19,800,000
VK026 PAKET PERSALINAN - BIDAN 3,850,000 4,658,500 5,082,000 5,929,000 6,776,000
OK028 Paket Verikokel 10,450,000 12,100,000 13,750,000 15,400,000 16,720,000
Tindakan Dengan Penyulit Dikenakan Kenaikan Tarif 50% dari Tarif Normal
BEDAH UMUM
KODE LAYANAN
KELAS III DR ( 70% ) RS 30 % KELAS II DR ( 70% ) RS 30 % KELAS I DR ( 70% ) RS 30 % KELAS VIP B DR ( 70% ) RS 30 % KELAS VIP A DR ( 70% ) RS 30 %
LAYANAN
MEDIUM
KOBU0001 Dokter operator 1,430,000 1,100,000 330,000 2,005,575 1,542,750 462,825 2,674,100 2,057,000 617,100 3,646,500 2,805,000 841,500 4,132,700 3,179,000 953,700
KOBU0002 Dokter Anestesi 715,000 550,000 165,000 802,230 617,100 185,130 1,069,640 822,800 246,840 1,458,600 1,122,000 336,600 1,653,080 1,271,600 381,480
KOBU0003 Asisten Operator jika SpOG 520,000 400,000 120,000 520,000 400,000 120,000 650,000 500,000 150,000 780,000 600,000 180,000 780,000 600,000 180,000
KOBU0004 Penata Anestesi 260,000 200,000 60,000 260,000 200,000 60,000 260,000 200,000 60,000 260,000 200,000 60,000 260,000 200,000 60,000
KOBU0006 Kamar Operasi 1,022,450 786,500 235,950 1,022,450 786,500 235,950 1,022,450 786,500 235,950 1,022,450 786,500 235,950 1,022,450 786,500 235,950
KOBU0007 Sewa Alat 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000
TOTAL 4,662,450 3,586,500 1,075,950 5,325,255 4,096,350 1,228,905 6,391,190 4,916,300 1,474,890 7,882,550 6,063,500 1,819,050 8,563,230 6,587,100 1,976,130
MAYOR
KOBU0013 Dokter operator 1,859,000 1,430,000 429,000 2,272,985 1,748,450 524,535 2,917,200 2,244,000 673,200 3,889,600 2,992,000 897,600 4,533,815 3,487,550 1,046,265
KOBU0019 Sewa Alat 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000
TOTAL 5,120,050 3,938,500 1,181,550 5,699,629 4,384,330 1,315,299 6,731,530 5,178,100 1,553,430 8,222,890 6,325,300 1,897,590 9,124,791 7,019,070 2,105,721
KODE LAYANAN
LAYANAN
KHUSUS
KOBU0025 Dokter operator 4,004,000 3,080,000 924,000 4,404,400 3,388,000 1,016,400 4,804,800 3,696,000 1,108,800 5,605,600 4,312,000 1,293,600 6,406,400 4,928,000 1,478,400
KOBU0026 Dokter Anestesi 1,601,600 1,232,000 369,600 1,761,760 1,355,200 406,560 1,921,920 1,478,400 443,520 2,242,240 1,724,800 517,440 2,562,560 1,971,200 591,360
KOBU0031 Sewa Alat 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000
TOTAL 8,123,050 6,248,500 1,874,550 8,683,610 6,679,700 2,003,910 9,374,170 7,210,900 2,163,270 10,625,290 8,173,300 2,451,990 11,746,410 9,035,700 2,710,710
BEDAH KEBIDANAN

KODE LAYANAN
LAYANAN
PAKET SC
SCBBM001 Jasa Operator 1,430,000 1,100,000 330,000 2,005,575 1,542,750 462,825 2,674,100 2,057,000 617,100 3,646,500 2,805,000 841,500 4,132,700 3,179,000 953,700
SCBBM002 Jasa Anestesi 715,000 550,000 165,000 802,230 617,100 185,130 1,069,640 822,800 246,840 1,458,600 1,122,000 336,600 1,653,080 1,271,600 381,480
SCBBM003 Jasa Asisten Dokter SpOG 572,000 440,000 132,000 520,000 400,000 120,000 650,000 500,000 150,000 780,000 600,000 180,000 780,000 600,000 180,000
SCBBM004 Jasa Dokter Anak 286,000 220,000 66,000 314,600 242,000 72,600 343,200 264,000 79,200 371,800 286,000 85,800 364,000 280,000 84,000
SCBBM005 Perawat Eksternal 260,000 200,000 60,000 260,000 200,000 60,000 260,000 200,000 60,000 260,000 200,000 60,000 260,000 200,000 60,000
SCBBM006 Sewa OK 1,001,000 770,000 231,000 1,001,000 770,000 231,000 1,001,000 770,000 231,000 1,001,000 770,000 231,000 1,001,000 770,000 231,000
SCBBM007 Sewa Alat 700,000 538,462 161,538 700,000 538,462 161,538 700,000 538,462 161,538 700,000 538,462 161,538 700,000 538,462 161,538
TOTAL 4,964,000 3,818,462 1,145,538 5,603,405 4,310,312 1,293,093 6,697,940 5,152,262 1,545,678 8,217,900 6,321,462 1,896,438 8,890,780 6,839,062 2,051,718
PAKET RE SC
SCBBM008 Jasa Operator 1,859,000 1,430,000 429,000 2,272,985 1,748,450 524,535 2,917,200 2,244,000 673,200 3,889,600 2,992,000 897,600 4,533,815 3,487,550 1,046,265
SCBBM013 Sewa OK 1,101,100 847,000 254,100 1,101,100 847,000 254,100 1,101,100 847,000 254,100 1,101,100 847,000 254,100 1,101,100 847,000 254,100
SCBBM014 Sewa Alat 1,078,000 829,231 248,769 1,078,000 829,231 248,769 1,078,000 829,231 248,769 1,078,000 829,231 248,769 1,078,000 829,231 248,769
TOTAL 5,933,500 4,564,231 1,369,269 6,550,259 5,038,661 1,511,598 7,619,340 5,861,031 1,758,309 9,185,060 7,065,431 2,119,629 10,161,321 7,816,401 2,344,920
Catatan : Untuk tindakan dengan penyulit dan cito berlaku kenaikan tarif 30 % dari tarif normal.
VII. TARIF HIGH CARE UNIT (HCU)
1.TARIF TINDAKAN UNIT HCU

JENIS Jasa Sarana
fee Medis
KODE LAYANAN HIGH CARE UNIT TARIF RS dan BHP
Dokter (60%)
LAYANAN (40%)+ BHP
BBM00813 Pasang Catheter Vena Central ( CVC ) 255,200 382,800

638,000
Rawat Jalan HCU
BBM00814 Pasang Arteri Line Rawat Jalan HCU 266,200 106,480 159,720
BBM00815 Pasang Catheter Vena Central Tehnik 255,200 382,800
638,000
Seldinger Rawat Jalan HCU
BBM00816 Resusitasi Cardio Pulmoner Rawat Jalan 93,720 140,580
234,300
HCU
BBM00817 Venaseksi Rawat Jalan HCU 366,300 146,520 219,780
BBM00818 Intubasi Rawat Jalan HCU 176,000 70,400 105,600
BBM00819 Lumbal Punctie Rawat Jalan HCU 220,000 88,000 132,000
BBM00820 Pasang Drain Thorax Rawat Jalan HCU 532,400 212,960 319,440
BBM00821 Punctie Thorax / Abdomen / Pleura Rawat 137,720 206,580
344,300
Jalan HCU
BBM00822 Pasang I.V. Line selain di lengan dan di 63,800 95,700
159,500
kaki Rawat Jalan HCU
BBM00823 Trakeostomi Rawat Jalan HCU 798,600 319,440 479,160
BBM00824 Set Ventilator Rawat Jalan HCU 292,600 117,040 175,560
BBM00825 Ekstubasi pada Prolonged Intubation 42,680 64,020
106,700
Rawat Jalan HCU
BBM00826 Pasang Swan - Ganz Catheter Rawat 255,640 383,460
639,100
Jalan HCU
BBM00827 Analgesia Epidural Rawat Jalan HCU 266,200 106,480 159,720
BBM00828 Ganti Kanul Trakeostomi Rawat Jalan 74,360 111,540
185,900
HCU
2.TARIF PEMAKAIAN OKSIGEN

JENIS TARIF LAYANAN
KODE LAYANAN OKSIGEN / OXYGEN KELAS II / KELAS I /
KELAS III VIP B VIP A
LAYANAN HCU ISOLASI
BBM00843 Oksigen 1 Lt / Menit 3,300 3,960 4,620 5,280 5,940
BBM00853 Oksigen Paket / Jam di OK 128,700 129,000 141,000 152,000 231,660
BBM00854 Nitrogen Paket / Jam di OK 128,700 129,000 141,000 152,000 231,660
BBM00855 Oksigen ( Sewa tabung kecil ) / Hari 39,600 40,000 44,000 47,000 71,280
BBM00856 Oksigen ( Sewa tabung besar ) / Hari 80,300 80,000 87,000 94,000 144,540
BBM00857 Oksigen ( Biaya isi tabung kecil ) 46,200 47,000 51,000 55,000 83,160
BBM00858 Oksigen ( Biaya isi tabung besar ) 93,500 93,000 102,000 110,000 168,300
BBM00859 Oksigen ( Jaminan tabung kecil ) 1,464,100 1,464,000 1,597,000 1,730,000 2,635,380
BBM00860 Oksigen ( Jaminan tabung besar ) 2,928,200 2,928,000 3,194,000 3,461,000 5,270,760
BBM00861 Oksigen Ventilator 3 Lt / Menit (30%) 7,700 7,000 8,000 9,000 13,860
BBM00862 Oksigen Ventilator 3,5 Lt / Menit (35%) 8,800 9,000 9,000 10,000 15,840
VIII.TARIF PEMAKAIAN ALAT EMERGENCY
JENIS TARIF LAYANAN
KODE LAYANAN PEMAKAIAN ALAT EMERGENCY KELAS II / KELAS I /
LAYANAN HCU ISOLASI
BBM00868 Ventilator ( UGD ) 177,100 177,000 193,000 230,230 256,795
BBM00869 Ventilator ( Emergency ) perhari 188,100 244,530 272,745
BBM00870 Monitor EKG / Bed Side Monitor ( UGD ) 44,000 48,000 157,300 175,450
121,000
( perhari )
BBM00871 Observasi di UGD < 2 Jam ( UGD ) 89,100 89,000 97,000 115,830 129,195
BBM00872 Observasi di UGD > 2 jam < 4 jam (UGD ) 106,700 106,000 116,000 138,710 154,715
BBM00873 Nebulizer ( UGD ) 61,600 62,000 68,000 80,080 89,320
BBM00874 Nebulizer ( Emergency ) 74,800 97,240 108,460
BBM00875 Doppler (UGD) 38,500 22,000 24,000 50,050 55,825
BBM00876 EKG ( Emergency ) 71,500 92,950 103,675
BBM00877 Monitor Tensi ( UGD ) 35,200 35,000 39,000 45,760 51,040
BBM00878 One Touch ( UGD ) 35,200 35,000 39,000 45,760 51,040
BBM00879 Pesawat WSD ( UGD ) 67,100 67,000 73,000 87,230 97,295
BBM00880 Oksimetri ( UGD ) 13,200 13,000 15,000 17,160 19,140
BBM00881 Inkubator Lebih dari 6 Jam s/d 1 Hari 128,700 141,570 154,440 167,310 186,615
BBM00882 Inkubator Kurang dari 6 Jam 80,300 88,330 96,360 104,390 116,435
BBM00883 Kasur Decubitus 31,900 35,090 38,280 41,470 46,255
BBM00884 Infusion Pump 422,400 464,640 506,880 549,120 612,480
BBM00885 Syringe Pump 422,400 464,640 506,880 549,120 612,480
BBM00886 Monitor EKG / Bed Side Monitor 121,000 133,100 145,200 157,300 175,450
BBM00887 CTG 93,500 102,850 112,200 121,550 135,575
BBM00888 Breast Pump Elektrik 31,900 35,090 38,280 41,470 46,255
BBM00889 C-ARM 266,200 292,820 319,440 346,060 385,990
BBM00890 SEWA ALAT OK 965,800 1,062,380 1,158,960 1,255,540 1,400,410
BBM00891 Kursi Roda ( Sewa ) 110,000 121,000 132,000 143,000 159,500
BBM00892 Kursi Roda ( Jaminan Sewa ) 2,928,200 3,221,020 3,513,840 3,806,660 4,245,890
BBM00893 Animec 16,500 18,150 19,800 21,450 23,925
BBM00894 Oksimetri 12,100 13,310 14,520 15,730 17,545
BBM00895 Sewa Alat Holter -
BBM00896 KACAMATA FOTOTERAPI 64,350 70,785 77,220 83,655 93,308
BBM00897 NST Continue / Jam 32,267 35,493 38,720 41,947 46,787
IX.TARIF AMBULANCE

KODE LAYANAN AMBULANCE RAWAT JALAN/ KELAS KELAS II KELAS I
III
VIP B VIP A
LAYANAN HCU ISOLASI
BBM00001 AMBULANCE - PAKET ON CALL HOTEL 600,000 600,000 600,000 600,000 600,000
BBM00002 AMBULANCE - PAKET ON CALL RUMAH 300,000 300,000 300,000 300,000 300,000
BBM00003 Ambulance Antar Atau Jemput Pasien Luar Kota 15,000 15,000 15,000 15,000
15,000
( 200,000 )+ Per Km
BBM00004 Ambulance Antar Pasien Dalam Kota ( 5 Km
- - - - -
Pertama )
BBM00005 Ambulance Antar Pasien Dalam Kota ( > 5 Km
70,000 70,000 70,000 70,000 70,000
Pertama )
BBM00006 Ambulance Antar Atau Jemput Pasien Dalam Kota
25,000 25,000 25,000 25,000 25,000
( 70,000 )+ Per Km
X.TARIF MEDICAL CHECK UP

KODE
MEDICAL CHECK UP RAWAT JALAN
LAYANAN
MCU001 PAKET BASIC 620,000
MCU002 PAKET SILVER 1,500,000
MCU003 PAKET GOLD 4,650,000
MCU004 PAKET PLATINUM 5,270,000
MCU005 PAKET PRE MARITAL TORCH 1,975,000
2.TARIF LAUNDRY

KODE LAYANAN LAUNDRY & PRESSING SERVICE RAWAT JALAN/KELAS KELAS II KELAS I /
III
VIP B VIP A
LAYANAN HCU ISOLASI
BBM00894 SHIRT / KEMEJA 16,500 18,150 19,800 25,410 26,400
BBM00895 T-SHIRT / KAOS OBLONG 12,100 13,310 14,520 18,634 19,360
BBM00896 NECTIE / DASI 5,500 6,050 6,600 8,470 8,800
BBM00897 UNDERSHIRT / KAOS DALAM 7,700 8,470 9,240 11,858 12,320
BBM00898 UNDERWEAR / CELANA DALAM 7,700 8,470 9,240 11,858 12,320
BBM00899 TRAUSER / CELANA PANJANG 17,600 19,360 21,120 27,104 28,160
BBM00900 POLO SHIRT / KAOS BERKERAH 13,200 14,520 15,840 20,328 21,120
BBM00901 SARONG / SARUNG 12,100 13,310 14,520 18,634 19,360
BBM00902 VEST / ROMPI 12,100 13,310 14,520 18,634 19,360
BBM00903 SOCK / KAOS KAKI 4,400 4,840 5,280 6,776 7,040
BBM00904 SHORT / CELANA PENDEK 12,100 13,310 14,520 18,634 19,360
BBM00905 BLOUSE / BLUES 17,600 19,360 21,120 27,104 28,160
BBM00906 SKRIT / ROK BAWAH 12,100 13,310 14,520 18,634 19,360
BBM00907 LONG SKRIT / ROK BAWAH PANJANG 17,600 19,360 21,120 27,104 28,160
BBM00908 SLACK / CELANA PANJANG 17,600 19,360 21,120 27,104 28,160
BBM00909 BRASSIERES / BH 4,400 4,840 5,280 6,776 7,040
BBM00910 PANTIES / CELANA DALAM 4,400 4,840 5,280 6,776 7,040
BBM00911 NIGHT GOWN / BAJU TIDUR 17,600 19,360 21,120 27,104 28,160
BBM00912 MUKENA 17,600 19,360 21,120 27,104 28,160
BBM00913 HANDKERCHIEF 4,400 4,840 5,280 6,776 7,040
3.TARIF AMINITIES
KODE AMUNITIES RAWAT JALAN/KELAS KELAS II KELAS I /
III
VIP B VIP A
LAYANAN HCU ISOLASI
BBM00914 Kendil 8,800 9,680 10,560 12,320 14,080
BBM00915 Paket Plastik Kamar Bersalin 11,000 12,100 13,200 15,400 17,600
BBM00916 Paket Plastik Kamar Operasi 11,000 12,100 13,200 15,400 17,600
BBM00917 Paket Bayi 77,000 84,700 92,400 107,800 123,200
BBM00918 Paket Mandi Ibu 33,000 30,000 30,000 60,000 60,000
I. TARIF RAWAT JALAN / POLIKLINIK DAN RAWAT INAP
1. REGISTRASI ( Pendaftaran Pasien)

JENIS KODE
RAWAT JALAN TARIF
LAYANAN
REG0001 Administrasi Rumah Sakit 27,500

REG0002 Administrasi UGD
10 % dari total unit UGD
REG0003 Asuhan Keperawatan 29,700
REG0004 Jasa Sarana Prasarana 27,500
REG0005 Tuslag dan Embalage Poliklinik 11,000
REG0006 Tuslag dan Embalage UGD 22,000
RAWAT INAP/ IN PATIENT
Administrasi Rawat Inap
5 % dari Total Tagihan
2.JASA DOKTER
JENIS
LAYANAN JASA DOKTER / Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana
KODE RAWAT fee Medis fee Medis KELAS II / fee Medis KELAS I / fee Medis fee Medis fee Medis
DOCTOR'S FEE RS dan BHP KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B RS dan BHP VIP A RS & BHP
LAYANAN JALAN (70%) (70%) HCU (70%) ISOLASI (70%) (70%) (70%)
(30%) (30%) (30%) (30%) (30%) (30%)
DOK00001 Jasa Dokter Poliklinik Spesialis (Rawat 28,050 65,450 93,500 28,050 65,450 102,850 71,995 112,200 33,660 78,540 130,900 39,270 91,630
93,500 30,855 149,600 44,880 104,720
Jalan)
DOK00002 Jasa Dokter Umum ( UGD ) / GP at 18,150 42,350 60,500 18,150 42,350 66,550 46,585 72,600 21,780 50,820 84,700 25,410 59,290
60,500 19,965
Emergency Unit 96,800 29,040 67,760
DOK00003 Jasa Dokter Spesialis Yang Dikonsulkan dari 21,450 50,050 71,500 21,450 50,050 78,650 55,055 85,800 25,740 60,060 100,100 30,030 70,070
71,500 23,595
UGD 114,400 34,320 80,080
DOK00004 Konsultasi Gizi Dokter 55,000 16,500 38,500 55,000 16,500 38,500 60,500 18,150 42,350 66,000 19,800 46,200 77,000 23,100 53,900 88,000 26,400 61,600
DOK00005 Jasa Visit Dokter Spesialis / Room Visit 24,750 57,750 82,500 24,750 57,750 90,750 63,525 99,000 29,700 69,300 115,500 34,650 80,850
Specialist 82,500 27,225
132,000 39,600 92,400
DOK00006 Jasa Dokter MCU 49,500 14,850 34,650 49,500 14,850 34,650 54,450 16,335 38,115 59,400 17,820 41,580 69,300 20,790 48,510 79,200 23,760 55,440
DOK00007 Jasa Visit Dokter Rawat Bersama Spesialis 82,500 24,750 57,750 82,500 24,750 57,750 90,750 27,225 63,525 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
DOK00008 Jasa Visit Dokter Konsul Spesialis 82,500 24,750 57,750 82,500 24,750 57,750 90,750 27,225 63,525 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
DOK00009 Jasa Visit Dokter Spesialis Pengganti 82,500 24,750 57,750 82,500 24,750 57,750 90,750 27,225 63,525 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
DOK00010 Jasa Dokter Umum (Poli) 60,500 18,150 42,350 60,500 18,150 42,350 66,550 19,965 46,585 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
DOK00011 Jasa Dokter Gigi ( Umum) 77,000 23,100 53,900 77,000 23,100 53,900 84,700 25,410 59,290 92,400 27,720 64,680 107,800 32,340 75,460 123,200 36,960 86,240
DOK00012 Jasa Konsultasi Dokter Rawat Inap On Line ( 9,900 23,100 33,000 9,900 23,100 36,300 25,410 39,600 11,880 27,720 46,200 13,860 32,340
Via Telepon ) 33,000 10,890
52,800 15,840 36,960
DOK00013 Jasa Visit Dokter Bangsal ( Dokter Umum) 60,500 18,150 42,350 60,500 18,150 42,350 66,550 19,965 46,585 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
DOK00014 Jasa Konsultasi Tumbuh Kembang Anak 195,800 58,740 137,060 195,800 58,740 137,060 215,380 64,614 150,766 234,960 70,488 164,472 274,120 82,236 191,884 313,280 93,984 219,296
DOK00015 Jasa Dokter Poliklinik Spesialis dr. Enny 115,500 34,650 80,850 115,500 34,650 80,850 127,050 38,115 88,935 138,600 41,580 97,020 161,700 48,510 113,190 184,800 55,440 129,360
DOK00016 Jasa Dokter Psikolog Tumbuh Kembang 156,200 46,860 109,340 156,200 46,860 109,340 171,820 51,546 120,274 187,440 56,232 131,208 218,680 65,604 153,076 249,920 74,976 174,944
DOK00017 Anak
Jasa Ahli Gizi Tumbuh Kembang Anak 44,000 13,200 30,800 44,000 13,200 30,800 48,400 14,520 33,880 52,800 15,840 36,960 61,600 18,480 43,120 70,400 21,120 49,280
DOK00018 Jasa Konsultasi Dokter Radiologi 93,500 28,050 65,450 93,500 28,050 65,450 102,850 30,855 71,995 112,200 33,660 78,540 130,900 39,270 91,630 149,600 44,880 104,720
DOK00019 Jasa Asisten Operator Radiografer 82,500 82,500 - - -
3.POLI ANAK SPESIALIS

JENIS
LAYANAN POLIKLINIK ANAK / Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana
KODE RAWAT fee Medis fee Medis KELAS II / fee Medis KELAS I / fee Medis fee Medis fee Medis
PEDIATRIC CLINIC RS dan BHP KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B RS dan BHP VIP A RS & BHP
LAYANAN JALAN (70%) (70%) HCU (70%) ISOLASI (70%) (70%) (70%)
(30%) (30%) (30%) (30%) (30%) (30%)
MED00001 Pemeriksaan Autisme (Rawat Jalan) 48,400 14,520 33,880 48,400 14,520 33,880 53,240 15,972 37,268 58,080 17,424 40,656 67,760 20,328 47,432 77,440 23,232 54,208
MED00002 B M P (Rawat Jalan) 95,095 28,529 66,567 95,095 28,529 66,567 104,605 31,381 73,223 114,114 34,234 79,880 133,133 39,940 93,193 152,152 45,646 106,506
MED00003 RRO (Rawat Jalan) 37,895 11,369 26,527 37,895 11,369 26,527 41,685 12,505 29,179 45,474 13,642 31,832 53,053 15,916 37,137 60,632 18,190 42,442
MED00004 Dilatasi Fimosis (Rawat Jalan) 66,495 19,949 46,547 66,495 19,949 46,547 73,145 21,943 51,201 79,794 23,938 55,856 93,093 27,928 65,165 106,392 31,918 74,474
MED00005 Pengambilan Cairan Lambung (Rawat Jalan) 85,800 25,740 60,060 85,800 25,740 60,060 94,380 28,314 66,066 102,960 30,888 72,072 120,120 36,036 84,084 137,280 41,184 96,096
MED00006 Injeksi Vaksin (Tindakan Dokter) (Rawat 38,500 11,550 26,950 38,500 11,550 26,950 42,350 12,705 29,645 46,200 13,860 32,340 53,900 16,170 37,730 61,600 18,480 43,120
MED00007 Jalan)
Injeksi IM (Rawat Jalan) 27,500 8,250 19,250 27,500 8,250 19,250 30,250 9,075 21,175 33,000 9,900 23,100 38,500 11,550 26,950 44,000 13,200 30,800
MED00008 Injeksi IV (Rawat Jalan) 27,500 8,250 19,250 27,500 8,250 19,250 30,250 9,075 21,175 33,000 9,900 23,100 38,500 11,550 26,950 44,000 13,200 30,800
MED00009 Pengambilan Darah Vena (Rawat Jalan) 44,000 13,200 30,800 44,000 13,200 30,800 48,400 14,520 33,880 52,800 15,840 36,960 61,600 18,480 43,120 70,400 21,120 49,280
MED00010 Aff Infus (Rawat Jalan) 27,500 8,250 19,250 27,500 8,250 19,250 30,250 9,075 21,175 33,000 9,900 23,100 38,500 11,550 26,950 44,000 13,200 30,800
MED00011 FOTOTERAPI BAYI / HARI 412,500 123,750 288,750 412,500 123,750 288,750 453,750 136,125 317,625 495,000 148,500 346,500 577,500 173,250 404,250 660,000 198,000 462,000
4.POLI BEDAH SPESIALIS
JENIS KODE LAYANAN POLIKLINIK BEDAH / Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana
LAYANAN SURGICAL CLINIC RAWAT fee Medis fee Medis KELAS II / fee Medis KELAS I / fee Medis fee Medis fee Medis
RS dan BHP KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B RS dan BHP VIP A RS & BHP
JALAN (70%) (70%) HCU (70%) ISOLASI (70%) (70%) (70%)
(30%) (30%) (30%) (30%) (30%) (30%)
MED00011 WT - Combutio,< 10% ( Bedah ) (Rawat 71,643 167,167 238,810 71,643 167,167 262,691 183,884 286,572 85,972 200,600 334,334 100,300 234,034
238,810 78,807 382,096 114,629 267,467
Jalan)
MED00012 Angkat IDW ( Bedah ) (Rawat Jalan) 46,200 13,860 32,340 46,200 13,860 32,340 50,820 15,246 35,574 55,440 16,632 38,808 64,680 19,404 45,276 73,920 22,176 51,744
MED00013 Angkat Jahitan > 10 Jahitan ( Bedah ) 36,300 84,700 121,000 36,300 84,700 133,100 93,170 145,200 43,560 101,640 169,400 50,820 118,580
121,000 39,930
(Rawat Jalan) 193,600 58,080 135,520
MED00014 Angkat Jahitan 1 - 5 Jahitan ( Bedah ) 10,560 24,640 35,200 10,560 24,640 38,720 27,104 42,240 12,672 29,568 49,280 14,784 34,496
35,200 11,616
(Rawat Jalan) 56,320 16,896 39,424
MED00016 Eksplorasi Besar ( Bedah ) (Rawat Jalan) 347,600 104,280 243,320 347,600 104,280 243,320 382,360 114,708 267,652 417,120 125,136 291,984 486,640 145,992 340,648 556,160 166,848 389,312
MED00017 Eksisi / BE Tumor Jinak < 2 cm ( Bedah ) 51,150 119,350 170,500 51,150 119,350 187,550 131,285 204,600 61,380 143,220 238,700 71,610 167,090
170,500 56,265 272,800 81,840 190,960
(Rawat Jalan)
MED00018 Drainage Abses ( Bedah ) (Rawat Jalan) 114,400 34,320 80,080 114,400 34,320 80,080 125,840 37,752 88,088 137,280 41,184 96,096 160,160 48,048 112,112 183,040 54,912 128,128
MED00019 Coller & Cup ( Bedah ) (Rawat Jalan) 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00020 Biopsi ( Bedah ) (Rawat Jalan) 112,200 33,660 78,540 112,200 33,660 78,540 123,420 37,026 86,394 134,640 40,392 94,248 157,080 47,124 109,956 179,520 53,856 125,664
MED00021 Anuskopi ( Bedah ) (Rawat Jalan) 170,500 51,150 119,350 170,500 51,150 119,350 187,550 56,265 131,285 204,600 61,380 143,220 238,700 71,610 167,090 272,800 81,840 190,960
MED00022 Pasang Foley Catheter ( Bedah ) (Rawat 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00023 Jalan)
WT - Combutio < 30% ( Bedah ) (Rawat 167,310 50,193 117,117 167,310 50,193 117,117 184,041 55,212 128,829 200,772 60,232 140,540 234,234 70,270 163,964 267,696 80,309 187,387
MED00024 Jalan)
Nagel Ekstrasi ( Bedah ) (Rawat Jalan) 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00025 Jahit Luka Tambahan Per Jahitan ( Bedah ) 2,640 6,160 8,800 2,640 6,160 9,680 6,776 10,560 3,168 7,392 12,320 3,696 8,624
8,800 2,904
(Rawat Jalan) 14,080 4,224 9,856
MED00026 Jahit Luka Sampai Dengan 3 Jahitan 25,410 59,290 84,700 25,410 59,290 93,170 65,219 101,640 30,492 71,148 118,580 35,574 83,006
84,700 27,951
MED00027 Insisi ( Bedah ) (Rawat Jalan) 95,810 28,743 67,067 95,810 28,743 67,067 105,391 31,617 73,774 114,972 34,492 80,480 134,134 40,240 93,894 153,296 45,989 107,307
MED00028 Eksterpasi Kecil ( Bedah ) (Rawat Jalan) 398,200 119,460 278,740 398,200 119,460 278,740 438,020 131,406 306,614 477,840 143,352 334,488 557,480 167,244 390,236 637,120 191,136 445,984
MED00029 Eksterpasi Besar ( Bedah ) (Rawat Jalan) 679,800 203,940 475,860 679,800 203,940 475,860 747,780 224,334 523,446 815,760 244,728 571,032 951,720 285,516 666,204 1,087,680 326,304 761,376
MED00030 Eksplorasi Kecil ( Bedah ) (Rawat Jalan) 170,500 51,150 119,350 170,500 51,150 119,350 187,550 56,265 131,285 204,600 61,380 143,220 238,700 71,610 167,090 272,800 81,840 190,960
MED00031 Roster Plasty ( Bedah ) (Rawat Jalan) 143,715 43,115 100,601 143,715 43,115 100,601 158,087 47,426 110,661 172,458 51,737 120,721 201,201 60,360 140,841 229,944 68,983 160,961
MED00032 Reposisi ( Bedah ) (Rawat Jalan) 190,905 57,272 133,634 190,905 57,272 133,634 209,996 62,999 146,997 229,086 68,726 160,360 267,267 80,180 187,087 305,448 91,634 213,814
MED00033 Pasang Splint Sedang ( Bedah ) (Rawat 128,700 38,610 90,090 128,700 38,610 90,090 141,570 42,471 99,099 154,440 46,332 108,108 180,180 54,054 126,126 205,920 61,776 144,144
MED00034 Jalan)
Pasang Splint Khusus ( Bedah ) (Rawat 525,525 157,658 367,868 525,525 157,658 367,868 578,078 173,423 404,654 630,630 189,189 441,441 735,735 220,721 515,015 840,840 252,252 588,588
MED00035 Jalan)
Pasang Splint Besar ( Bedah ) (Rawat Jalan) 262,405 78,722 183,684 262,405 78,722 183,684 288,646 86,594 202,052 314,886 94,466 220,420 367,367 110,210 257,157 419,848 125,954 293,894
MED00036 Pasang Spalk Sedang ( Bedah ) (Rawat 152,900 45,870 107,030 152,900 45,870 107,030 168,190 50,457 117,733 183,480 55,044 128,436 214,060 64,218 149,842 244,640 73,392 171,248
MED00037 Jalan)
Pasang Spalk Khusus ( Bedah ) (Rawat 525,525 157,658 367,868 525,525 157,658 367,868 578,078 173,423 404,654 630,630 189,189 441,441 735,735 220,721 515,015 840,840 252,252 588,588
MED00038 Jalan)
Pasang Spalk Besar ( Bedah ) (Rawat Jalan) 312,400 93,720 218,680 312,400 93,720 218,680 343,640 103,092 240,548 374,880 112,464 262,416 437,360 131,208 306,152 499,840 149,952 349,888
MED00039 Pasang Metal Catheter ( Bedah ) (Rawat 71,500 21,450 50,050 71,500 21,450 50,050 78,650 23,595 55,055 85,800 25,740 60,060 100,100 30,030 70,070 114,400 34,320 80,080
MED00040 Jalan) 38,610 90,090 128,700 38,610 90,090 141,570 99,099 154,440 46,332 108,108 180,180 54,054 126,126
Pasang Gips ( Belum Termasuk Bahan )
128,700 42,471
Sedang ( Bedah ) (Rawat Jalan) 205,920 61,776 144,144
MED00041 Pasang Gips ( Belum Termasuk Bahan ) 154,869 361,361 516,230 154,869 361,361 567,853 397,497 619,476 185,843 433,633 722,722 216,817 505,905
516,230 170,356
Khusus ( Bedah ) (Rawat Jalan) 825,968 247,790 578,178
MED00042 Pasang Gips ( Belum Termasuk Bahan ) 78,936 184,184 263,120 78,936 184,184 289,432 202,602 315,744 94,723 221,021 368,368 110,510 257,858
263,120 86,830
Besar ( Bedah ) (Rawat Jalan) 420,992 126,298 294,694
MED00043 Angkat Jahitan 5 - 10 Jahitan ( Bedah ) 12,540 29,260 41,800 12,540 29,260 45,980 32,186 50,160 15,048 35,112 58,520 17,556 40,964
41,800 13,794
(Rawat Jalan) 66,880 20,064 46,816
MED00044 Buka Gips (Bedah) (Rawat Jalan) 103,400 31,020 72,380 103,400 31,020 72,380 113,740 34,122 79,618 124,080 37,224 86,856 144,760 43,428 101,332 165,440 49,632 115,808
MED00045 Eksisi Ganglion (Bedah) (Rawat Jalan) 199,100 59,730 139,370 199,100 59,730 139,370 219,010 65,703 153,307 238,920 71,676 167,244 278,740 83,622 195,118 318,560 95,568 222,992
MED00046 Ganti Balutan Kecil (Bedah) (Rawat Jalan) 42,185 12,656 29,530 42,185 12,656 29,530 46,404 13,921 32,482 50,622 15,187 35,435 59,059 17,718 41,341 67,496 20,249 47,247
MED00047 Katerisasi (Bedah) (Rawat Jalan) 46,200 13,860 32,340 46,200 13,860 32,340 50,820 15,246 35,574 55,440 16,632 38,808 64,680 19,404 45,276 73,920 22,176 51,744
MED00048 Rectal Taucher (Rawat Jalan) 118,800 35,640 83,160 118,800 35,640 83,160 130,680 39,204 91,476 142,560 42,768 99,792 166,320 49,896 116,424 190,080 57,024 133,056
MED00049 Ganti Balutan Sedang (Bedah) (Rawat 73,700 22,110 51,590 73,700 22,110 51,590 81,070 24,321 56,749 88,440 26,532 61,908 103,180 30,954 72,226 117,920 35,376 82,544
MED00050 Jalan)
Ganti Balutan Besar (Bedah) (Rawat Jalan) 117,700 35,310 82,390 117,700 35,310 82,390 129,470 38,841 90,629 141,240 42,372 98,868 164,780 49,434 115,346 188,320 56,496 131,824
MED00051 Eksisi tumor (Rawat Jalan) 1,025,200 307,560 717,640 1,025,200 307,560 717,640 1,127,720 338,316 789,404 1,230,240 369,072 861,168 1,435,280 430,584 1,004,696 1,640,320 492,096 1,148,224
MED00052 Release Tongue tie (Rawat Jalan) 220,000 66,000 154,000 220,000 66,000 154,000 242,000 72,600 169,400 264,000 79,200 184,800 308,000 92,400 215,600 352,000 105,600 246,400
MED00053 Rectoscopy (Rawat Jalan) 364,100 109,230 254,870 364,100 109,230 254,870 400,510 120,153 280,357 436,920 131,076 305,844 509,740 152,922 356,818 582,560 174,768 407,792
MED00054 Jahit Stapler (Rawat Jalan) 11,000 3,300 7,700 11,000 3,300 7,700 12,100 3,630 8,470 13,200 3,960 9,240 15,400 4,620 10,780 17,600 5,280 12,320
MED00055 Evakuasi feces (Rawat Jalan) 330,000 99,000 231,000 330,000 99,000 231,000 363,000 108,900 254,100 396,000 118,800 277,200 462,000 138,600 323,400 528,000 158,400 369,600
MED00056 Tindik (Rawat Jalan) 199,100 59,730 139,370 199,100 59,730 139,370 219,010 65,703 153,307 238,920 71,676 167,244 278,740 83,622 195,118 318,560 95,568 222,992
MED00057 Lepas Tampon (Rawat Jalan) 37,400 11,220 26,180 37,400 11,220 26,180 41,140 12,342 28,798 44,880 13,464 31,416 52,360 15,708 36,652 59,840 17,952 41,888
MED00058 Dressing VAC Besar (Rawat Jalan) 487,300 146,190 341,110 487,300 146,190 341,110 536,030 160,809 375,221 584,760 175,428 409,332 682,220 204,666 477,554 779,680 233,904 545,776
MED00059 Dressing VAC Sedang (Rawat Jalan) 203,500 61,050 142,450 203,500 61,050 142,450 223,850 67,155 156,695 244,200 73,260 170,940 284,900 85,470 199,430 325,600 97,680 227,920
MED00060 WSD (Rawat Jalan) 856,900 257,070 599,830 856,900 257,070 599,830 942,590 282,777 659,813 1,028,280 308,484 719,796 1,199,660 359,898 839,762 1,371,040 411,312 959,728
MED00061 Paket Khitan 1,375,000 412,500 962,500 1,375,000 412,500 962,500 1,512,500 453,750 1,058,750 1,650,000 495,000 1,155,000 1,925,000 577,500 1,347,500 2,200,000 660,000 1,540,000
5.POLI KEBIDANAN SPESIALIS
LAYANAN POLIKLINIK DAFTAR TARIF LAYANAN
JENIS KODE KEBIDANAN & PENYAKIT KANDUNGAN / Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
LAYANAN fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS fee Medis
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A dan BHP (30%) (70%)
(30%) (30%) HCU (30%) ISOLASI (30%) (30%)
OBSTETRY AND GYNECOLOGY CLINIC
MED00062 Angkat IUD ( Obgyn ) (Rawat Jalan) 178,200 53,460 124,740 178,200 53,460 124,740 196,020 58,806 137,214 213,840 64,152 149,688 249,480 74,844 174,636 285,120 85,536 199,584
MED00063 Angkat jahitan >10 jahitan (Rawat Jalan) 51,590 15,477 36,113 51,590 15,477 36,113 56,749 17,025 39,724 61,908 18,572 43,336 72,226 21,668 50,558 82,544 24,763 57,781
MED00064 Biopsi ( Obgyn ) (Rawat Jalan) 100,870 30,261 70,609 100,870 30,261 70,609 110,957 33,287 77,670 121,044 36,313 84,731 141,218 42,365 98,853 161,392 48,418 112,974
MED00065 Kolposkopi (Obgyn) (Rawat Jalan) 381,150 114,345 266,805 381,150 114,345 266,805 419,265 125,780 293,486 457,380 137,214 320,166 533,610 160,083 373,527 609,840 182,952 426,888
MED00066 KB Suntik ( Obgyn ) (Rawat Jalan) 30,800 9,240 21,560 30,800 9,240 21,560 33,880 10,164 23,716 36,960 11,088 25,872 43,120 12,936 30,184 49,280 14,784 34,496
MED00067 Kauter Elektrik ( Obgyn ) (Rawat Jalan) 71,500 21,450 50,050 71,500 21,450 50,050 78,650 23,595 55,055 85,800 25,740 60,060 100,100 30,030 70,070 114,400 34,320 80,080
MED00068 Kauter Albotyl ( Obgyn ) (Rawat Jalan) 47,905 14,372 33,534 47,905 14,372 33,534 52,696 15,809 36,887 57,486 17,246 40,240 67,067 20,120 46,947 76,648 22,994 53,654
MED00069 SIS ( Obgyn ) (Rawat Jalan) 385,000 115,500 269,500 385,000 115,500 269,500 423,500 127,050 296,450 462,000 138,600 323,400 539,000 161,700 377,300 616,000 184,800 431,200
MED00070 Ganti Verband ( Obgyn ) (Rawat Jalan) 42,900 12,870 30,030 42,900 12,870 30,030 47,190 14,157 33,033 51,480 15,444 36,036 60,060 18,018 42,042 68,640 20,592 48,048
MED00071 Ganti Tampon ( Osbgyn ) (Rawat Jalan) 56,980 17,094 39,886 56,980 17,094 39,886 62,678 18,803 43,875 68,376 20,513 47,863 79,772 23,932 55,840 91,168 27,350 63,818
MED00072 Diathermi ( Osbgyn ) (Rawat Jalan) 158,015 47,405 110,611 158,015 47,405 110,611 173,817 52,145 121,672 189,618 56,885 132,733 221,221 66,366 154,855 252,824 75,847 176,977
MED00073 Cabut Implant ( Osbgyn ) (Rawat Jalan) 169,400 50,820 118,580 169,400 50,820 118,580 186,340 55,902 130,438 203,280 60,984 142,296 237,160 71,148 166,012 271,040 81,312 189,728
MED00074 Vaginal Swab ( Osbgyn ) (Rawat Jalan) 43,890 13,167 30,723 43,890 13,167 30,723 48,279 14,484 33,795 52,668 15,800 36,868 61,446 18,434 43,012 70,224 21,067 49,157
MED00075 Pasang IUD ( Osbgyn ) (Rawat Jalan) 185,900 55,770 130,130 185,900 55,770 130,130 204,490 61,347 143,143 223,080 66,924 156,156 260,260 78,078 182,182 297,440 89,232 208,208
MED00076 Pasang Implant ( Osbgyn ) (Rawat Jalan) 169,400 50,820 118,580 169,400 50,820 118,580 186,340 55,902 130,438 203,280 60,984 142,296 237,160 71,148 166,012 271,040 81,312 189,728
KEBIDANAN & PENYAKIT KANDUNGAN / KELAS II / KELAS I /
Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana
JENIS KODE fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS fee Medis
LAYANAN
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A dan BHP (30%) (70%)
OBSTETRY AND GYNECOLOGY CLINIC (30%) (30%) HCU (30%) ISOLASI (30%) (30%)
MED00077 Pap Smear ( Osbgyn ) (Rawat Jalan) 82,500 24,750 57,750 82,500 24,750 57,750 99,000 29,700 69,300 99,000 29,700 69,300 115,500 34,650 80,850 132,000 39,600 92,400
MED00078 Angkat Jahitan < 5 Jahitan ( Osbgyn ) 9,240 21,560 30,800 9,240 21,560 36,960 25,872 36,960 11,088 25,872 43,120 12,936 30,184
30,800 11,088 49,280 14,784 34,496
(Rawat Jalan)
MED00079 Angkat Jahitan 5 - 10 Jahitan ( Osbgyn ) 12,243 28,567 40,810 12,243 28,567 48,972 34,280 48,972 14,692 34,280 57,134 17,140 39,994
40,810 14,692
(Rawat Jalan) 65,296 19,589 45,707
MED00080 Injeksi ( Osbgyn ) (Rawat Jalan) 42,900 12,870 30,030 42,900 12,870 30,030 51,480 15,444 36,036 51,480 15,444 36,036 60,060 18,018 42,042 68,640 20,592 48,048
MED00081 Pemeriksaan Ginekologi (dengan kamera) 22,737 53,053 75,790 22,737 53,053 90,948 63,664 90,948 27,284 63,664 106,106 31,832 74,274
75,790 27,284 121,264 36,379 84,885
(Rawat Jalan)
MED00082 IVA TEST (Rawat Jalan) 60,500 18,150 42,350 60,500 18,150 42,350 72,600 21,780 50,820 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
MED00083 Pasang Pesarium 66,550 19,965 46,585 66,550 19,965 46,585 79,860 23,958 55,902 79,860 23,958 55,902 93,170 27,951 65,219 106,480 31,944 74,536
- - -
6.POLI PENYAKIT DALAM SPESIALIS
KODE LAYANAN POLIKLINIK PENYAKIT Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
DALAM / INTERNIST CLINIC fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS fee Medis
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A dan BHP (30%) (70%)
BBM00100 Aspirasi Jarum Halus (Rawat Jalan) 266,200 79,860 186,340 266,200 79,860 186,340 292,820 87,846 204,974 319,440 95,832 223,608 372,680 111,804 260,876 425,920 127,776 298,144
BBM00101 BMP (Rawat Jalan) 238,095 71,429 166,667 238,095 71,429 166,667 261,905 78,571 183,333 285,714 85,714 200,000 333,333 100,000 233,333 380,952 114,286 266,666
BBM00102 Inhalasi Therapy (Rawat Jalan) 57,200 17,160 40,040 57,200 17,160 40,040 62,920 18,876 44,044 68,640 20,592 48,048 80,080 24,024 56,056 91,520 27,456 64,064
BBM00103 WSD Mini (Rawat Jalan) 95,810 28,743 67,067 95,810 28,743 67,067 105,391 31,617 73,774 114,972 34,492 80,480 134,134 40,240 93,894 153,296 45,989 107,307
BBM00104 WSD Continue (Rawat Jalan) 119,405 35,822 83,584 119,405 35,822 83,584 131,346 39,404 91,942 143,286 42,986 100,300 167,167 50,150 117,017 191,048 57,314 133,734
BBM00105 Spirometri (Rawat Jalan) 125,840 37,752 88,088 125,840 37,752 88,088 138,424 41,527 96,897 151,008 45,302 105,706 176,176 52,853 123,323 201,344 60,403 140,941
BBM00106 Punctie Pleura (Rawat Jalan) 224,510 67,353 157,157 224,510 67,353 157,157 246,961 74,088 172,873 269,412 80,824 188,588 314,314 94,294 220,020 359,216 107,765 251,451
BBM00107 Punctie Ascites (Rawat Jalan) 176,605 52,982 123,624 176,605 52,982 123,624 194,266 58,280 135,986 211,926 63,578 148,348 247,247 74,174 173,073 282,568 84,770 197,798
BBM00108 Injeksi Intra artikuler ( per sendi ) (Rawat 86,015 200,701 86,015 200,701 220,771 103,217 240,841 120,420 280,981
286,715 94,616 458,744 137,623 321,121
Jalan) 286,715 315,387 344,058 401,401
BBM00109 INJEKSI AMTOCORT (Rawat Jalan) 38,500 11,550 26,950 38,500 11,550 26,950 42,350 12,705 29,645 46,200 13,860 32,340 53,900 16,170 37,730 61,600 18,480 43,120
7.TARIF KONSULTASI GIZI

KODE LAYANAN TARIF GIZI / NUTRITION RATE Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS fee Medis
RAWAT JALAN
RS dan BHP
fee Medis KELAS III
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis VIP A dan BHP (30%) (70%)
LAYANAN HCU ISOLASI
BBM00110 KONSULTASI GIZI 55,000 55,000 55,000 55,000 55,000 55,000
8.TARIF GIGI UMUM
KODE LAYANAN TARIF GIGI UMUM Jasa Sarana Jasa Sarana KELAS II / KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS fee Medis
RAWAT JALAN
RS dan BHP
fee Medis KELAS III
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
LAYANAN HCU ISOLASI
GUMH2001 Konsultasi (Medikasi) 60,500 42,350 18,150 60,500 42,350 18,150 66,550 33,275 33,275 72,600 36,300 36,300 84,700 42,350 42,350 96,800 48,400 48,400
Tumpatan SIK - -
GUMH2002 Kecil 114,400 57,200 57,200 114,400 57,200 57,200 125,840 62,920 62,920 137,280 68,640 68,640 160,160 80,080 80,080 183,040 91,520 91,520
GUMH2003 Sedang 157,300 78,650 78,650 157,300 78,650 78,650 173,030 86,515 86,515 188,760 94,380 94,380 220,220 110,110 110,110 251,680 125,840 125,840
GUMH2004 Besar 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
Tumpatan LC - -
GUMH2005 Kecil 157,300 78,650 78,650 157,300 78,650 78,650 173,030 86,515 86,515 188,760 94,380 94,380 220,220 110,110 110,110 251,680 125,840 125,840
GUMH2006 Sedang 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
GUMH2007 Besar 314,600 157,300 157,300 314,600 157,300 157,300 346,060 173,030 173,030 377,520 188,760 188,760 440,440 220,220 220,220 503,360 251,680 251,680
GUMH2008 Tumpatan Sementara 85,800 42,900 42,900 85,800 42,900 42,900 94,380 47,190 47,190 102,960 51,480 51,480 120,120 60,060 60,060 137,280 68,640 68,640
Ektraksi Gigi Permanen - -
GUMH2009 Ringan 171,600 85,800 85,800 171,600 85,800 85,800 188,760 94,380 94,380 205,920 102,960 102,960 240,240 120,120 120,120 274,560 137,280 137,280
GUMH2010 Sedang 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
GUMH2011 Berat 314,600 157,300 157,300 314,600 157,300 157,300 346,060 173,030 173,030 377,520 188,760 188,760 440,440 220,220 220,220 503,360 251,680 251,680
GUMH2012 Ekstraksi Gigi Desidui 85,800 42,900 42,900 85,800 42,900 42,900 94,380 47,190 47,190 102,960 51,480 51,480 120,120 60,060 60,060 137,280 68,640 68,640
Skalling Rahang Atas Bawah - -
GUMH2013 Ringan 157,300 78,650 78,650 157,300 78,650 78,650 173,030 86,515 86,515 188,760 94,380 94,380 220,220 110,110 110,110 251,680 125,840 125,840
GUMH2014 Sedang 228,800 114,400 114,400 228,800 114,400 114,400 251,680 125,840 125,840 274,560 137,280 137,280 320,320 160,160 160,160 366,080 183,040 183,040
GUMH2015 Berat 314,600 157,300 157,300 314,600 157,300 157,300 346,060 173,030 173,030 377,520 188,760 188,760 440,440 220,220 220,220 503,360 251,680 251,680
KONSERVASI GIGI ( TAMBAL ) - -
Penambalan bahan SIK ( glass ionomer ) - -
GIGI0001 Kecil 165,000 82,500 82,500 165,000 82,500 82,500 181,500 90,750 90,750 198,000 99,000 99,000 231,000 115,500 115,500 264,000 132,000 132,000
GIGI0002 Sedang 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
GIGI0003 Besar 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
Penambalan Komposit resin bahan standar - - - - - - - - - - - -
GIGI0004 Kecil 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
GIGI0005 Sedang 275,000 137,500 137,500 275,000 137,500 137,500 302,500 151,250 151,250 330,000 165,000 165,000 385,000 192,500 192,500 440,000 220,000 220,000
GIGI0006 Besar 275,000 137,500 137,500 275,000 137,500 137,500 302,500 151,250 151,250 330,000 165,000 165,000 385,000 192,500 192,500 440,000 220,000 220,000
Penambalan Komposit resin bahan kualitas utama - - - - - - - - - - - -
GIGI0007 Kecil 275,000 137,500 137,500 275,000 137,500 137,500 302,500 151,250 151,250 330,000 165,000 165,000 385,000 192,500 192,500 440,000 220,000 220,000
GIGI0008 Sedang 330,000 165,000 165,000 330,000 165,000 165,000 363,000 181,500 181,500 396,000 198,000 198,000 462,000 231,000 231,000 528,000 264,000 264,000
GIGI0009 Besar 385,000 192,500 192,500 385,000 192,500 192,500 423,500 211,750 211,750 462,000 231,000 231,000 539,000 269,500 269,500 616,000 308,000 308,000
Penambalan Estetika ( Sandwich System ) - - - - - - - - - - - -
GIGI0010 Kecil 330,000 165,000 165,000 330,000 165,000 165,000 363,000 181,500 181,500 396,000 198,000 198,000 462,000 231,000 231,000 528,000 264,000 264,000
GIGI0011 Sedang 385,000 192,500 192,500 385,000 192,500 192,500 423,500 211,750 211,750 462,000 231,000 231,000 539,000 269,500 269,500 616,000 308,000 308,000
KODE LAYANAN TARIF GIGI UMUM Jasa Sarana Jasa Sarana KELAS II / KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS fee Medis
RAWAT JALAN
RS dan BHP
fee Medis KELAS III
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
LAYANAN HCU ISOLASI
GIGI0012 Besar 440,000 220,000 220,000 440,000 220,000 220,000 484,000 242,000 242,000 528,000 264,000 264,000 616,000 308,000 308,000 704,000 352,000 352,000
GIGI0013 Devitalisasi ( mematikan pulpa gigi ) 165,000 82,500 82,500 165,000 82,500 82,500 181,500 90,750 90,750 198,000 99,000 99,000 231,000 115,500 115,500 264,000 132,000 132,000
Jacket Crown - - - - - - - - - - - -
GIGI0014 Akrilik / per gigi 825,000 412,500 412,500 825,000 412,500 412,500 907,500 453,750 453,750 990,000 495,000 495,000 1,155,000 577,500 577,500 1,320,000 660,000 660,000
GIGI0015 Porselain Fused to Metal / pergigi 1,650,000 825,000 825,000 1,650,000 825,000 825,000 1,815,000 907,500 907,500 1,980,000 990,000 990,000 2,310,000 1,155,000 1,155,000 2,640,000 1,320,000 1,320,000
GIGI0016 All porselain / per gigi 3,300,000 1,650,000 1,650,000 3,300,000 1,650,000 1,650,000 3,630,000 1,815,000 1,815,000 3,960,000 1,980,000 1,980,000 4,620,000 2,310,000 2,310,000 5,280,000 2,640,000 2,640,000
GIGI0017 Bleaching ( Pemutihan gigi ) 2,200,000 1,100,000 1,100,000 2,200,000 1,100,000 1,100,000 2,420,000 1,210,000 1,210,000 2,640,000 1,320,000 1,320,000 3,080,000 1,540,000 1,540,000 3,520,000 1,760,000 1,760,000
GIGI0018 1,760,000 880,000 880,000
Sementasi onlay/inlay/jembatan yang lepas 110,000 55,000 55,000 1,100,000 550,000 550,000 1,210,000 605,000 605,000 1,320,000 660,000 660,000 1,540,000 770,000 770,000
HARGA KAWAT / BEHEL GIGI - - - - - - - - - - - -
GIGI0019 Pasang Kawat / Behel Gigi 4,400,000 2,200,000 2,200,000 4,400,000 2,200,000 2,200,000 4,840,000 2,420,000 2,420,000 5,280,000 2,640,000 2,640,000 6,160,000 3,080,000 3,080,000 7,040,000 3,520,000 3,520,000
GIGI0020 Pemasangan Bracket I ( satu ) rahang saja 2,750,000 1,375,000 1,375,000 2,750,000 1,375,000 1,375,000 3,025,000 1,512,500 1,512,500 3,300,000 1,650,000 1,650,000 3,850,000 1,925,000 1,925,000 4,400,000 2,200,000 2,200,000
GIGI0021 Pasien lanjutan dokter gigi lain 1,650,000 825,000 825,000 1,650,000 825,000 825,000 1,815,000 907,500 907,500 1,980,000 990,000 990,000 2,310,000 1,155,000 1,155,000 2,640,000 1,320,000 1,320,000
GIGI0022 Kontrol Rutin Pasien 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
GIGI0023 Hilang bracket 55,000 27,500 27,500 55,000 27,500 27,500 60,500 30,250 30,250 66,000 33,000 33,000 77,000 38,500 38,500 88,000 44,000 44,000
GIGI0024 Ganti Kawat 55,000 27,500 27,500 55,000 27,500 27,500 60,500 30,250 30,250 66,000 33,000 33,000 77,000 38,500 38,500 88,000 44,000 44,000
GIGI0025 Retainer lepasan 2 ( dua ) rahang 1,100,000 550,000 550,000 1,100,000 550,000 550,000 1,210,000 605,000 605,000 1,320,000 660,000 660,000 1,540,000 770,000 770,000 1,760,000 880,000 880,000
GIGI0026 Scalling rutin pasien ortho / kawat gigi 110,000 55,000 55,000 110,000 55,000 55,000 121,000 60,500 60,500 132,000 66,000 66,000 154,000 77,000 77,000 176,000 88,000 88,000
Pembuatan Gigi Palsu - - -
GTS ( Gigi Tiruan Sebagian ) - - -
Bahan akrilik + gigi standar - - -
Bahan akrilik + gigi ortholux - - - - - - - - - - - -
GTS ( Gigi Tiruan Sebagian ) bahan
Valplast - - - - - - - - - - - -
Bahan Valplast + gigi ortholux - - - - - - - - - - - -
GIGI0031 Plat / per rahang 1,100,000 550,000 550,000 1,100,000 550,000 550,000 1,210,000 605,000 605,000 1,320,000 660,000 660,000 1,540,000 770,000 770,000 1,760,000 880,000 880,000
GTS ( Gigi Tiruan Sebagian ) Frame Logam - - - - - - - - - - - -
Frame Logam + Gigi Ortholux - - - - - - - - - - - -
GIGI0033 Plat / per rahang 1,375,000 687,500 687,500 1,375,000 687,500 687,500 1,512,500 756,250 756,250 1,650,000 825,000 825,000 1,925,000 962,500 962,500 2,200,000 1,100,000 1,100,000
GTL (Gigi Tiruan Lengkap ) Akrilik per
GIGI0035 4,400,000 2,200,000 2,200,000
rahang 2,750,000 1,375,000 1,375,000 2,750,000 1,375,000 1,375,000 3,025,000 1,512,500 1,512,500 3,300,000 1,650,000 1,650,000 3,850,000 1,925,000 1,925,000
GTL ( Gigi Tiruan Lengkap ) Kerangka
GIGI0036 6,160,000 3,080,000 3,080,000
Logam per rahang 3,850,000 1,925,000 1,925,000 3,850,000 1,925,000 1,925,000 4,235,000 2,117,500 2,117,500 4,620,000 2,310,000 2,310,000 5,390,000 2,695,000 2,695,000
GTL ( Gigi Tiruan Lengkap ) Valplast per
GIGI0037 5,280,000 2,640,000 2,640,000
rahang 3,300,000 1,650,000 1,650,000 3,300,000 1,650,000 1,650,000 3,630,000 1,815,000 1,815,000 3,960,000 1,980,000 1,980,000 4,620,000 2,310,000 2,310,000
GIGI0038 GTC ( Gigi Tiruan Cekat ) Bahan Akrilik

( Sudah termasuk sementasi ) / per gigi 825,000 412,500 412,500 825,000 412,500 412,500 907,500 453,750 453,750 990,000 495,000 495,000 1,155,000 577,500 577,500 1,320,000 660,000 660,000
GTC ( Gigi Tiruan Cekat ) Bahan
GIGI0039 Porselain ( Sudah termasuk sementasi ) /
per gigi 1,650,000 825,000 825,000 1,650,000 825,000 825,000 1,815,000 907,500 907,500 1,980,000 990,000 990,000 2,310,000 1,155,000 1,155,000 2,640,000 1,320,000 1,320,000
GIGI0040 Reparasi GTS / GTL per rahang 220,000 110,000 110,000 220,000 110,000 110,000 242,000 121,000 121,000 264,000 132,000 132,000 308,000 154,000 154,000 352,000 176,000 176,000
Tambahan Cabut Gigi - - - - - - - - - - - -
GIGI0041 Cabut gigi dengan penyulit 330,000 165,000 165,000 330,000 165,000 165,000 363,000 181,500 181,500 396,000 198,000 198,000 462,000 231,000 231,000 528,000 264,000 264,000
Odontectomi - - - - - - - - - - - -
GIGI0042 Ringan 715,000 429,000 286,000 715,000 429,000 286,000 786,500 471,900 314,600 858,000 514,800 343,200 1,001,000 600,600 400,400 1,144,000 572,000 572,000
GIGI0043 Sedang 1,100,000 660,000 440,000 1,100,000 660,000 440,000 1,210,000 726,000 484,000 1,320,000 792,000 528,000 1,540,000 924,000 616,000 1,760,000 880,000 880,000
GIGI0044 Berat 2,200,000 1,320,000 880,000 2,200,000 1,320,000 880,000 2,420,000 1,452,000 968,000 2,640,000 1,584,000 1,056,000 3,080,000 1,848,000 1,232,000 3,520,000 1,760,000 1,760,000
9.TARIF LAKTASI
KODE LAYANAN TARIF LAKTASI Jasa Sarana KELAS III Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS
RAWAT JALAN
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis VIP A dan BHP
fee Medis
LAYANAN HCU ISOLASI
LBBM2001 Perkedatangan -Jasa Edukasi 77,000 77,000 84,700 92,400 107,800 123,200 36,960 86,240
LBBM2002 Paket Edukasi Laktasi ( 5x kedatangan ) 385,000 385,000 385,000 385,000 385,000 616,000 184,800 431,200
10. TARIF FISIOTERAPI

KODE LAYANAN TARIF FISIOTERAPI KELAS III KELAS II / KELAS I /
Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana Jasa Sarana RS
RAWAT JALAN
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis
RS dan BHP
fee Medis VIP B
RS dan BHP
fee Medis VIP A dan BHP
fee Medis
LAYANAN HCU ISOLASI
FBBM2001 Jasa Fisioterapi 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2002 Jasa Creambath 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2003 Jasa Pijat 88,000 88,000 96,800 105,600 123,200 140,800 42,240 98,560
FBBM2004 Jasa Oral Terapi 11,000 11,000 12,100 13,200 15,400 17,600 5,280 12,320
FBBM2005 Jasa Pijat Oksitosin / Bayi 44,000 44,000 48,400 52,800 61,600 70,400 21,120 49,280
FBBM2006 Jasa Pijat Anak Batuk pilek dg penyinaran 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2007 Jasa Pijat Bayi usia 12 bl keatas 66,000 66,000 72,600 79,200 92,400 105,600 31,680 73,920
FBBM2008 Senam Hamil 55,000 55,000 60,500 66,000 77,000 88,000 26,400 61,600
II. TARIF PENUNJANG MEDIK
1.TARIF LABORATORIUM
LAYANAN LABORATORIUM /
KODE Jasa Sarana Fee Medis Jasa Sarana Fee Medis KELAS II / Jasa Sarana Fee Medis KELAS I / Jasa Sarana Fee Medis Jasa Sarana Fee Medis Jasa Sarana RS Fee Medis
LABORATORY RAWAT JALAN KELAS III VIP B VIP A
LAYANAN RS dan BHP 2,5% RS dan BHP 2,5% HCU RS dan BHP 2,5% ISOLASI RS dan BHP 2,5% RS dan BHP 2,5% dan BHP 2,5%
LAB100001 Analisa Ascities (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100002 Analisa Batu Ginjal (Rawat Jalan) 504,000 504,000 554,400 604,800 655,200 705,600
LAB100003 Analisa Cairan Lambung (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100004 Analisa Cairaln LCS (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100005 Analisa Cairan Lengkap (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100006 Analisa Cairan Pleura (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100007 Analisa Cairan Sendi (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100008 Ferritin (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100009 Saturasi Transferin (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100010 Serum Iron (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
LAB100011 TIBC (Rawat Jalan) 315,000 315,000 346,500 378,000 409,500 441,000
LAB100012 Transferin (Rawat Jalan) 1,500,000 1,500,000 1,650,000 1,800,000 1,950,000 2,100,000
LAB100013 UIBC (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
LAB100014 Vitamin B 12 (Rawat Jalan) 3,500,000 3,500,000 3,850,000 4,200,000 4,550,000 4,900,000
LAB100015 HbA1C (Rawat Jalan) 342,000 342,000 376,200 410,400 444,600 478,800
LAB100016 Insulin (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100017 Insulin 2 JPP (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100018 Insulin Puasa (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100019 Mikroalbumin Kuantitatif (Rawat Jalan) 360,000 360,000 396,000 432,000 468,000 504,000
LAB100020 Calcitonon (Rawat Jalan) 4,400,000 4,400,000 4,840,000 5,280,000 5,720,000 6,160,000
LAB100021 Calcium (Rawat Jalan) 220,000 220,000 242,000 264,000 286,000 308,000
LAB100022 Calcium (Urine) (Rawat Jalan) 220,000 220,000 242,000 264,000 286,000 308,000
LAB100023 Chlorida (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100024 Kalium (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100025 Magnesium (Rawat Jalan) 230,000 230,000 253,000 276,000 299,000 322,000
LAB100026 Natruim (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100027 Phospor Anorganik (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100028 Alkali Fosfatase (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100029 Cholinesterase (Rawat Jalan) 300,000 300,000 330,000 360,000 390,000 420,000
LAB100030 GAMMA GT (Rawat Jalan) 220,000 220,000 242,000 264,000 286,000 308,000
LAB100031 Cystatin C (Rawat Jalan) 1,400,000 1,400,000 1,540,000 1,680,000 1,820,000 1,960,000
LAB100032 eGFR (Rawat Jalan) 180,000 180,000 198,000 216,000 234,000 252,000
LAB100033 Albumin (Rawat Jalan) 180,000 180,000 198,000 216,000 234,000 252,000
LAB100034 Globulin (Rawat Jalan) 285,000 285,000 313,500 342,000 370,500 399,000
LAB100035 Protein Lengkap (Rawat Jalan) 288,000 288,000 316,800 345,600 374,400 403,200
LAB100036 Protein Pleura (Rawat Jalan) 160,000 160,000 176,000 192,000 208,000 224,000
LAB100037 Acid Phospatase (Rawat Jalan) 1,600,000 1,600,000 1,760,000 1,920,000 2,080,000 2,240,000
LAB100038 Protein Total (Rawat Jalan) 180,000 180,000 198,000 216,000 234,000 252,000
LAB100039 D-Dimer Kuantitatif (Rawat Jalan) 1,040,000 1,040,000 1,144,000 1,248,000 1,352,000 1,456,000
LAB100040 Fibrinogen (Rawat Jalan) 360,000 360,000 396,000 432,000 468,000 504,000
LAB100041 INR (Rawat Jalan) 320,000 320,000 352,000 384,000 416,000 448,000
LAB100042 Tes Agregasi Trombosit (Rawat Jalan) 800,000 800,000 880,000 960,000 1,040,000 1,120,000
LAB100043 Waktu Protrombin (Rawat Jalan) 320,000 320,000 352,000 384,000 416,000 448,000
LAB100044 CK-MB (Rawat Jalan) 480,000 480,000 528,000 576,000 624,000 672,000
LAB100045 CK-Total/CPK (Rawat Jalan) 285,000 285,000 313,500 342,000 370,500 399,000
LAB100046 Homosisein (Rawat Jalan) 2,500,000 2,500,000 2,750,000 3,000,000 3,250,000 3,500,000
LAB100047 LDH (Rawat Jalan) 230,000 230,000 253,000 276,000 299,000 322,000
LAB100048 Troponin I (Rawat Jalan) 960,000 960,000 1,056,000 1,152,000 1,248,000 1,344,000
LAB100049 Troponin T (Rawat Jalan) 540,000 540,000 594,000 648,000 702,000 756,000
LAB100050 CD 8 (Rawat Jalan) 1,000,000 1,000,000 1,100,000 1,200,000 1,300,000 1,400,000
LAB100051 CD 4 (Rawat Jalan) 970,000 970,000 1,067,000 1,164,000 1,261,000 1,358,000
LAB100052 EOSINOFIL (Rawat Jalan) 80,000 80,000 88,000 96,000 104,000 112,000
LAB100053 EOSINOFIL Absolut (Rawat Jalan) 210,000 210,000 231,000 252,000 273,000 294,000
LAB100054 Gambaran Darah Tepi (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100055 HB Elektroforesa (Rawat Jalan) 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
LAB100056 LE-Sel (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100057 Le Test (Rawat Jalan) 600,000 600,000 660,000 720,000 780,000 840,000
LAB100058 Malaria (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100059 Malaria ICT (Rawat Jalan) 500,000 500,000 550,000 600,000 650,000 700,000
LAB100060 Retikulosit (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100061 Anti Mullerian Hormon (AMH) (Rawat Jalan)
1,600,000 1,600,000 1,760,000 1,920,000 2,080,000 2,240,000
LAB100062 BETA HCG SERUM (Rawat Jalan) 640,000 640,000 704,000 768,000 832,000 896,000
LAB100063 Estradiol (Rawat Jalan) 640,000 640,000 704,000 768,000 832,000 896,000
LAB100064 FSH (Rawat Jalan) 560,000 560,000 616,000 672,000 728,000 784,000
LAB100065 Progesteron (Rawat Jalan) 810,000 810,000 891,000 972,000 1,053,000 1,134,000
LAB100066 Prolaktin (Rawat Jalan) 560,000 560,000 616,000 672,000 728,000 784,000
LAB100067 Testosteron Total (Rawat Jalan) 810,000 810,000 891,000 972,000 1,053,000 1,134,000
LAB100068 Anti Leptospira (Rawat Jalan) 1,425,000 1,425,000 1,567,500 1,710,000 1,852,500 1,995,000
LAB100069 Helicobacter Phylori igG (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100070 Helicobacter Phylori igM (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100071 IgG - IgM Anti Virus Dengue (Rawat Jalan) 540,000 540,000 594,000 648,000 702,000 756,000
LAB100072 IgG Anti Chlamydia (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100073 IgM Anti Chlamydia (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100074 IgM Leptospira (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100075 NS1 (Rawat Jalan) 520,000 520,000 572,000 624,000 676,000 728,000
LAB100076 NSE (Rawat Jalan) 2,400,000 2,400,000 2,640,000 2,880,000 3,120,000 3,360,000
LAB100077 Salmonela Typhi IGG (Rawat Jalan) 1,400,000 1,400,000 1,540,000 1,680,000 1,820,000 1,960,000
LAB100078 Salmonela Typhi IGM (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100079 Seramoeba (Rawat Jalan) 700,000 700,000 770,000 840,000 910,000 980,000
LAB100080 TPHA (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
LAB100081 Kultur Bactec (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100082 Kultur BTA (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100083 Kultur For Salmonelia Shigela (Rawat Jalan)
665,000 665,000 731,500 798,000 864,500 931,000
LAB100084 Kultur for Vibrio Cholera (Rawat Jalan) 960,000 960,000 1,056,000 1,152,000 1,248,000 1,344,000
LAB100085 Kultur Gaal (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100086 Kultur Jamur/Candida (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100087 Kultur Jaringan (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100088 Kultur MGIT (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100089 Kultur Sen. Kerokan Kulit (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100090 Kultur Sen. Pleura (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100091 Kultur Sen. Cairan Sendi (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100092 Kultur Sen. Mata Kanan (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100093 Kultur Sen. Mata Kiri (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100094 Kultur Sen. Test Darah (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100095 Kultur Sen. Test Faeces (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100096 Kultur Sen. Test Pus (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100097 Kultur Sen. Test Sekret (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100098 Kultur Sen. Test Sputum (Rawat Jalan) 1,141,000 1,141,000 1,255,100 1,369,200 1,483,300 1,597,400
LAB100099 Kultur Sen. Test TBC (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100100 Kultur Sen. Test Urine + Hit (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100101 Kultur Sen. Test Cairan Acites (Rawat Jalan)
1,425,000 1,425,000 1,567,500 1,710,000 1,852,500 1,995,000
LAB100102 Kultur Sen. Test Cairan LCS (Rawat Jalan)
1,425,000 1,425,000 1,567,500 1,710,000 1,852,500 1,995,000
LAB100103 Kultur Vitex (Rawat Jalan) 1,235,000 1,235,000 1,358,500 1,482,000 1,605,500 1,729,000
LAB100104 Magnesium ( LCS ) (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100105 Pengecatan Gram (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100106 Lippo Protein (a) (Rawat Jalan) 1,700,000 1,700,000 1,870,000 2,040,000 2,210,000 2,380,000
LAB100107 Phospho Lipid (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100108 Sall Dense LDL (Rawat Jalan) 450,000 450,000 495,000 540,000 585,000 630,000
LAB100109 VLDL (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100110 BTA Cairan Pleura (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100111 KOH (Rawat Jalan) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100112 Rectal Swab (Culture) (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100113 Rectal Swab (Mikroskopis) (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100114 Sekret Endocervix (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100115 Sekret Hidung (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100116 Sekret Lidah (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100117 Sekret Mata Kanan (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100118 Sekret Mata Kiri (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100119 Sekret PUS (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100120 Sekret Serviks (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100121 Sekret Telinga (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100122 Sekret Tenggorok (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100123 Sekret Uretra (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100124 Sputum BTA (Ziehl-Neelsen) (Rawat Jalan)
200,000 200,000 220,000 240,000 260,000 280,000
LAB100125 Sputum BTA +Gram I (Rawat Jalan) 260,000 260,000 286,000 312,000 338,000 364,000
LAB100126 Sputum BTA +Gram II (Rawat Jalan) 340,000 340,000 374,000 408,000 442,000 476,000
LAB100127 Sputum BTA +Gram III (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100130 Sputum Gram (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100131 ALPHA AMYLASE (Rawat Jalan) 320,000 320,000 352,000 384,000 416,000 448,000
LAB100132 Lipase (Rawat Jalan) 280,000 280,000 308,000 336,000 364,000 392,000
LAB100133 BCR ABL Kualitatif (Rawat Jalan) 6,175,000 6,175,000 6,792,500 7,410,000 8,027,500 8,645,000
LAB100134 PCR MH (Morbus Hansen) (Rawat Jalan) 1,330,000 1,330,000 1,463,000 1,596,000 1,729,000 1,862,000
LAB100135 PCR TB (EFUSI PLEURA) (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100136 PCR TB (Darah) (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100137 PCR TB (Tulang) (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100138 PCR TB Ascites (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100139 PCR TB LCS (Rawat Jalan) 2,280,000 2,280,000 2,508,000 2,736,000 2,964,000 3,192,000
LAB100140 PCR HSV 1 (Rawat Jalan) 2,090,000 2,090,000 2,299,000 2,508,000 2,717,000 2,926,000
LAB100143 Parathyroid (Rawat Jalan) 2,200,000 2,200,000 2,420,000 2,640,000 2,860,000 3,080,000
LAB100144 T3 (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100146 T4 (Rawat Jalan) 400,000 400,000 440,000 480,000 520,000 560,000
LAB100148 Thyroglobulin (Rawat Jalan) 2,200,000 2,200,000 2,420,000 2,640,000 2,860,000 3,080,000
LAB100149 TSH Resptor Antibodi (Rawat Jalan) 1,800,000 1,800,000 1,980,000 2,160,000 2,340,000 2,520,000
LAB100150 TSH-s (Rawat Jalan) 450,000 450,000 495,000 540,000 585,000 630,000
LAB100151 Anti HAV Total (Rawat Jalan) 810,000 810,000 891,000 972,000 1,053,000 1,134,000
LAB100152 Anti HBc Total (Rawat Jalan) 665,000 665,000 731,500 798,000 864,500 931,000
LAB100153 Anti Hbe (Rawat Jalan) 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
LAB100154 Anti HBs (Rawat Jalan) 380,000 380,000 418,000 456,000 494,000 532,000
LAB100155 Anti HCV (Rawat Jalan) 665,000 665,000 731,500 798,000 864,500 931,000
LAB100156 HBeAg (Rawat Jalan) 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
LAB100157 HBsAg Kuantitatif (Rawat Jalan) 720,000 720,000 792,000 864,000 936,000 1,008,000
LAB100158 HBsAg Ultra Sensitif (Rawat Jalan) 351,500 351,500 386,650 421,800 456,950 492,100
LAB100159 IgM Anti HAV (Rawat Jalan) 720,000 720,000 792,000 864,000 936,000 1,008,000
LAB100160 IgM HBC (Rawat Jalan) 855,000 855,000 940,500 1,026,000 1,111,500 1,197,000
LAB100161 IgM Anti HCV (Rawat Jalan) 3,200,000 3,200,000 3,520,000 3,840,000 4,160,000 4,480,000
LAB100162 AMA (Anti Microsomal Antibody)-THYROID
2,375,000 2,375,000 2,612,500 2,850,000 3,087,500 3,325,000
(Rawat Jalan)
LAB100163 ANA (Rawat Jalan) 850,000 850,000 935,000 1,020,000 1,105,000 1,190,000
LAB100164 ANA IF (Rawat Jalan) 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100165 ANCA (Rawat Jalan) 1,400,000 1,400,000 1,540,000 1,680,000 1,820,000 1,960,000
LAB100166 ASTO Kualitatif (Rawat Jalan) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100167 ASTO Kuantitatif (Rawat Jalan) 300,000 300,000 330,000 360,000 390,000 420,000
LAB100170 CRP Kualitatif (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100171 CRP Kuantitatif (Rawat Jalan) 405,000 405,000 445,500 486,000 526,500 567,000
LAB100172 HS CRP (Rawat Jalan) 440,000 440,000 484,000 528,000 572,000 616,000
LAB100173 IgG ACA (Rawat Jalan) 1,140,000 1,140,000 1,254,000 1,368,000 1,482,000 1,596,000
LAB100174 IgM (Rawat Jalan) 1,700,000 1,700,000 1,870,000 2,040,000 2,210,000 2,380,000
LAB100175 IgM ACA (Rawat Jalan) 1,200,000 1,200,000 1,320,000 1,440,000 1,560,000 1,680,000
LAB100176 RF Kualitatif (Rawat Jalan) 234,000 234,000 257,400 280,800 304,200 327,600
LAB100177 RF Kuantitatif (Rawat Jalan) 270,000 270,000 297,000 324,000 351,000 378,000
LAB100178 IgE (Rawat Jalan) 600,000 600,000 660,000 720,000 780,000 840,000
LAB100179 IgE Atopy 54 Alergen (Rawat Jalan) 3,300,000 3,300,000 3,630,000 3,960,000 4,290,000 4,620,000
LAB100180 Aviditas IgG CMV (Rawat Jalan) 1,040,000 1,040,000 1,144,000 1,248,000 1,352,000 1,456,000
LAB100181 Aviditas IgG CMV (Tanpa IgC CMV) (Rawat
840,000 840,000 924,000 1,008,000 1,092,000 1,176,000
Jalan)
LAB100182 Aviditas IgG Toxoplasma (Rawat Jalan) 1,000,000 1,000,000 1,100,000 1,200,000 1,300,000 1,400,000
LAB100183 Aviditas IgG Toxoplasma (Tanpa IgC Toxo)
800,000 800,000 880,000 960,000 1,040,000 1,120,000
(Rawat Jalan)
LAB100184 IgG Anti CMV (Rawat Jalan) 540,000 540,000 594,000 648,000 702,000 756,000
LAB100185 IgG Anti HSV 1 (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100186 IgG Anti HSV 1 (ECLIA) (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100187 IgG Anti HSV II (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100188 IgG Anti HSV II (ECLIA) (Rawat Jalan) 675,000 675,000 742,500 810,000 877,500 945,000
LAB100189 IgG Anti Rubella (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100190 IgG Anti Toxoplasma (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100191 igM Anti CMV 600,000 600,000 660,000 720,000 780,000 840,000
LAB100192 igM Anti HSV I 712,500 712,500 783,750 855,000 926,250 997,500
LAB100193 igM Anti HSV II 712,500 712,500 783,750 855,000 926,250 997,500
LAB100194 igM Anti Rubella 800,000 800,000 880,000 960,000 1,040,000 1,120,000
LAB100195 igM Anti Toxoplasma 570,000 570,000 627,000 684,000 741,000 798,000
LAB100196 Alfa Feto Protein (Rawat Jalan) 665,000 665,000 731,500 798,000 864,500 931,000
LAB100199 Ca 19-9 (Rawat Jalan) 1,045,000 1,045,000 1,149,500 1,254,000 1,358,500 1,463,000
LAB100200 CA 72-4 (Rawat Jalan) 3,200,000 3,200,000 3,520,000 3,840,000 4,160,000 4,480,000
LAB100201 CEA (Rawat Jalan) 570,000 570,000 627,000 684,000 741,000 798,000
LAB100202 Free PSA (Rawat Jalan) 1,120,000 1,120,000 1,232,000 1,344,000 1,456,000 1,568,000
LAB100203 PSA Total (Rawat Jalan) 630,000 630,000 693,000 756,000 819,000 882,000
LAB100204 Albumin (Cairan Ascites) (Rawat Jalan) 160,000 160,000 176,000 192,000 208,000 224,000
LAB100205 Chlorida (Urine) (Rawat Jalan) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100206 Esbach (Rawat Jalan) 190,000 190,000 209,000 228,000 247,000 266,000
LAB100207 Kalium (Urine) (Rawat Jalan) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100208 Magnesium (Urine) 230,000 230,000 253,000 276,000 299,000 322,000
LAB100209 Natruium (Urine) 240,000 240,000 264,000 288,000 312,000 336,000
LAB100210 Phosphat Anorganik (Urine) 200,000 200,000 220,000 240,000 260,000 280,000
LAB100211 Protein Bence Jones 200,000 200,000 220,000 240,000 260,000 280,000
LAB100212 Sedimen Prepp Go 200,000 200,000 220,000 240,000 260,000 280,000
LAB100213 Ureum (Sewaktu ) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100214 Ureum (Urine) 120,000 120,000 132,000 144,000 156,000 168,000
LAB100215 Ureum Clearance 250,000 250,000 275,000 300,000 325,000 350,000
LAB100216 Cortisol 3,000,000 3,000,000 3,300,000 3,600,000 3,900,000 4,200,000
LAB100217 Cyfra 21.1 2,200,000 2,200,000 2,420,000 2,640,000 2,860,000 3,080,000
LAB100218 Protein Ascities 160,000 160,000 176,000 192,000 208,000 224,000
LAB100219 pb Darah 460,000 460,000 506,000 552,000 598,000 644,000
LAB100220 Vit. D25 OH 820,000 820,000 902,000 984,000 1,066,000 1,148,000
LAB100221 IgG B2GP1 2,100,000 2,100,000 2,310,000 2,520,000 2,730,000 2,940,000
LAB100222 igM B2GP1 2,100,000 2,100,000 2,310,000 2,520,000 2,730,000 2,940,000
LAB100223 Pemeriksaan Jaringan PA Kecil 390,000 390,000 429,000 468,000 507,000 546,000
LAB100224 Pemeriksaan Jaringan PA Sedang 500,000 500,000 550,000 600,000 650,000 700,000
LAB100225 Pemeriksaan Jaringan PA Besar 700,000 700,000 770,000 840,000 910,000 980,000
KODE LABORATORY Jasa Sarana Fee Medis Jasa Sarana Fee Medis KELAS II / Jasa Sarana Fee Medis KELAS I / Jasa Sarana Fee Medis Jasa Sarana Fee Medis Jasa Sarana RS Fee Medis
RAWAT JALAN
RS dan BHP 2,5%
KELAS III
VIP B
RS dan BHP 2,5% VIP A dan BHP 2,5%
LAYANAN HCU ISOLASI
Pemeriksaan Jaringan Histerectomy,
LAB100226
Mastectomy, Colonoscopy, Laparotomy
700,000 700,000 770,000 840,000 910,000
980,000
LAB100227 Pemeriksaan Radikalitas 900,000 900,000 990,000 1,080,000 1,170,000 1,260,000
Pemeriksaan Sitologi Ginekologi ( Papsmear
LAB100228
)
200,000 200,000 220,000 240,000 260,000 280,000
Pemeriksaan Sitologi Non Ginekologi
LAB100229
( Pleura, Acities, dll )
390,000 390,000 429,000 468,000 507,000 546,000
LAB100230 Pemeriksaan Per ITEM ER, PR 700,000 700,000 770,000 840,000 910,000 980,000
LAB100231 Pemeriksaan HER2, Ki67 per item 800,000 800,000 880,000 960,000 1,040,000 1,120,000
Peminjaman Blok Parafin ( Uang Jaminan
LAB100232 Rp. 200.000 kembali saat blok 460,000 460,000 506,000 552,000 598,000 644,000
dikembalikan )
LAB200233 Golongan Darah (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200234 Hematologi Rutin (Rawat Jalan) 70,000 70,000 77,000 84,000 91,000 98,000
LAB200235 Bilirubin Total (Rawat Jalan) 110,000 110,000 121,000 132,000 143,000 154,000
LAB200236 Glukosa Darah (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200237 Urine Rutin (Rawat Jalan) 31,000 31,000 34,100 37,200 40,300 43,400
LAB200238 Tes Kehamilan/Cassette (Rawat Jalan) 45,000 45,000 49,500 54,000 58,500 63,000
LAB200239 Faeces (Rawat Jalan) 47,500 47,500 52,250 57,000 61,750 66,500
LAB200240 HBS-AG (Rapid) (Rawat Jalan) 62,500 62,500 68,750 75,000 81,250 87,500
LAB200241 Anti HIV (Rapid) (Rawat Jalan) 82,000 82,000 90,200 98,400 106,600 114,800
LAB200242 Asam Urat (Urine) (Rawat Jalan) 60,500 60,500 66,550 72,600 78,650 84,700
LAB200243 Cholesterol (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200244 SGOT (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200245 SGPT (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200246 Ureum (Rawat Jalan) 55,000 55,000 60,500 66,000 71,500 77,000
LAB200247 Creatinin (Rawat Jalan) 55,000 55,000 60,500 66,000 71,500 77,000
LAB200248 LDL (Rawat Jalan) 71,500 71,500 78,650 85,800 92,950 100,100
LAB200249 HDL (Rawat Jalan) 71,500 71,500 78,650 85,800 92,950 100,100
LAB200250 Sekret Vagina (Rawat Jalan) 71,500 71,500 78,650 85,800 92,950 100,100
LAB200251 TSH Neonatus (Rawat Jalan) 125,000 125,000 137,500 150,000 162,500 175,000
LAB200252 Golongan Darah Rhesus (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200253 Gula Darah Sewaktu (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200254 Anto Body Covid (Rawat Jalan) 100,000 100,000 110,000 120,000 130,000 140,000
LAB200255 Hematologi Darah Lengkap (Rawat Jalan) 85,000 85,000 93,500 102,000 110,500 119,000
LAB200256 Bilirubin Direk (Rawat Jalan) 143,000 143,000 157,300 171,600 185,900 200,200
LAB200257 Urin Lengkap (Rawat Jalan) 70,000 70,000 77,000 84,000 91,000 98,000
LAB200258 Trigliserida (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200259 Uric Acid (Rawat Jalan) 40,000 40,000 44,000 48,000 52,000 56,000
LAB200260 Gula Darah Puasa (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200261 Gula Darah 2 Jam PP (Rawat Jalan) 35,000 35,000 38,500 42,000 45,500 49,000
LAB200262 PTT (Rawat Jalan) 170,000 170,000 187,000 204,000 221,000 238,000
LAB200263 APTT 135,000 135,000 148,500 162,000 175,500 189,000
LAB200264 HCG Rapid (Rawat Jalan) 22,000 22,000 24,200 26,400 28,600 30,800
LAB200265 CT 40,000 40,000 44,000 48,000 52,000 56,000
LAB200266 BT 40,000 40,000 44,000 48,000 52,000 56,000
LAB200267 Analisa Sperma 250,000 250,000 275,000 300,000 325,000 350,000
LAB200268 Sars Void- Antigen 170,000 170,000 187,000 204,000 221,000 238,000
LAB200269 VDRL / Syphilis Rapid (Rawat Jalan) 108,000 108,000 118,800 129,600 140,400 151,200
LAB200270 Widal (Rawat Jalan) 135,000 135,000 148,500 162,000 175,500 189,000
LAB200271 Urine Tengah 70,000 70,000 77,000 84,000 91,000 98,000
LAB200272 LH 455,000 455,000 500,500 546,000 591,500 637,000
2. TARIF RADIOLOGI
Fee Medis 20 Fee Medis 20 Fee Medis 20 Fee Medis 20 Fee Medis 20 Jasa Sarana RS Fee Medis 20
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
%
VIP A dan BHP 80% %
S02630 - ABDOMEN IUD C-R ( RAWAT
240,570
BBMRT001 JALAN ) 192,456 48,114 240,570 192,456 48,114 264,627 211,702 52,925 288,684 230,947 57,737 336,798 269,438 67,360 384,912 307,930 76,982
S02631 - ABDOMEN POLOS ( 1 POSISI )
218,790 350,064 280,051 70,013
BBMRT002 C-R ) 175,032 43,758 218,790 175,032 43,758 240,669 192,535 48,134 262,548 210,038 52,510 306,306 245,045 61,261
S02632 - ABDOMEN POLOS 2 POSISI C-R
261,360 418,176 334,541 83,635
BBMRT003 ( RAWAJALAN) 209,088 52,272 261,360 209,088 52,272 287,496 229,997 57,499 313,632 250,906 62,726 365,904 292,723 73,181
S02633 - Abdomen Polos 3 Posisi C-R
335,610 536,976 429,581 107,395
S02634 - ADENOID C-R ( RAWAT JALAN ) 244,530 391,248 312,998 78,250

BBMRT005 195,624 48,906 244,530 195,624 48,906 268,983 215,186 53,797 293,436 234,749 58,687 342,342 273,874 68,468
S02635 - ANKLE JOINT SINISTRA C - R
203,940 326,304 261,043 65,261
S02636 - ANKLE JOINT DEXTRA C - R
203,940 326,304 261,043 65,261
S02637 - ANKLE JOINT DEXTRA
293,040 468,864 375,091 93,773
BBMRT008 SINISTRA C - R ( RAWAT JALAN ) 234,432 58,608 293,040 234,432 58,608 322,344 257,875 64,469 351,648 281,318 70,330 410,256 328,205 82,051
S05736 - ANKLE MORTISE VIEW ( RAWAT
257,400 411,840 329,472 82,368
BBMRT009 JALA) 205,920 51,480 257,400 205,920 51,480 283,140 226,512 56,628 308,880 247,104 61,776 360,360 288,288 72,072
S02638 - ANTEBRACHI DEXTRA C - R
BBMRT010 207,900 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212 332,640 266,112 66,528
( RAWAT- ANTEBRACHI
S02639 JALAN ) DEXTRA
BBMRT011 348,480 278,784 69,696 348,480 278,784 69,696 383,328 306,662 76,666 418,176 334,541 83,635 487,872 390,298 97,574 557,568 446,054 111,514
SINISTRA C- R (RAWAT JALAN )
S02640 - ANTEBRACHI SINISTRA C - R
207,900
BBMRT012 (RAWAT JALAN ) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212 332,640 266,112 66,528
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
% VIP A dan BHP 80% %
S02641 - APENDICOGRAFI C-R( Kontras )
547,470
BBMRT013 (RAWAT JALAN) 437,976 109,494 547,470 437,976 109,494 602,217 481,774 120,443 656,964 525,571 131,393 766,458 613,166 153,292 875,952 700,762 175,190
S02642 - APG DEXTRA C-R( Kontras )
742,500 1,188,000 950,400 237,600
BBMRT014 (RAWAT JALAN ) 594,000 148,500 742,500 594,000 148,500 816,750 653,400 163,350 891,000 712,800 178,200 1,039,500 831,600 207,900
S02643 - APG DEXTRA SINSITRA C-R
930,600 1,488,960 1,191,168 297,792
BBMRT015 (Kontras ) (RAWAT JALAN) 744,480 186,120 930,600 744,480 186,120 1,023,660 818,928 204,732 1,116,720 893,376 223,344 1,302,840 1,042,272 260,568
S02644 - APG SINSITRA C-R ( Kontras )
742,500 1,188,000 950,400 237,600
BBMRT016 (RAWAT JALAN) 594,000 148,500 742,500 594,000 148,500 816,750 653,400 163,350 891,000 712,800 178,200 1,039,500 831,600 207,900
S02645 - ARTERIOGRAFI FEMORALIS

2,407,680
UNILATERAL C-R( Kontras ) (Rawat Jalan )
BBMRT017 1,926,144 481,536 2,407,680 1,926,144 481,536 2,648,448 2,118,758 529,690 2,889,216 2,311,373 577,843 3,370,752 2,696,602 674,150 3,852,288 3,081,830 770,458
S05216 - ASISTEN SEDASI PROSEDUR
108,900 174,240 139,392 34,848
S05216 - ASISTEN SEDASI PROSEDUR -
103,950 166,320 133,056 33,264
BBMRT019 RS (RAWAT JALAN) 83,160 20,790 103,950 83,160 20,790 114,345 91,476 22,869 124,740 99,792 24,948 145,530 116,424 29,106
S02646 - Aspirasi Jarum Halus (AJH) -
425,700 681,120 544,896 136,224
BBMRT020 Radiologi (RAWAT JALAN) 340,560 85,140 425,700 340,560 85,140 468,270 374,616 93,654 510,840 408,672 102,168 595,980 476,784 119,196
S00242 - AUDIOMETRI - RS (RAWAT
138,600 221,760 177,408 44,352
BBMRT021 JALAN) 110,880 27,720 138,600 110,880 27,720 152,460 121,968 30,492 166,320 133,056 33,264 194,040 155,232 38,808
S02647 - Babygram C-R (RAWAT JALAN) 216,810 346,896 277,517 69,379

BBMRT022 173,448 43,362 216,810 173,448 43,362 238,491 190,793 47,698 260,172 208,138 52,034 303,534 242,827 60,707
S02648 - BASIS CRANIUM C-R (RAWAT
247,500 396,000 316,800 79,200
BBMRT023 JALAN) 198,000 49,500 247,500 198,000 49,500 272,250 217,800 54,450 297,000 237,600 59,400 346,500 277,200 69,300
S00244 - Biopsi / Aspirasi kelenjar - RS
357,390 571,824 457,459 114,365
S03767 - Biopsi / Aspirasi Jarum Halus
326,700
BBMRT025 ( FNAB ) - RS (RAWAT JALAN) 261,360 65,340 326,700 261,360 65,340 359,370 287,496 71,874 392,040 313,632 78,408 457,380 365,904 91,476 522,720 418,176 104,544
S02650 - BNO - IVP C-R (Kontras ) (RAWAT
1,336,500 2,138,400 1,710,720 427,680
BBMRT026 JALAN) 1,069,200 267,300 1,336,500 1,069,200 267,300 1,470,150 1,176,120 294,030 1,603,800 1,283,040 320,760 1,871,100 1,496,880 374,220
S02651 - BNO DEWASA C-R (RAWAT
216,810
BBMRT027 JALAN) 173,448 43,362 216,810 173,448 43,362 238,491 190,793 47,698 260,172 208,138 52,034 303,534 242,827 60,707 346,896 277,517 69,379
S02652 - BONE SURVEY + C-R (RAWAT
1,055,340 1,688,544 1,350,835 337,709
BBMRT028 JALAN) 844,272 211,068 1,055,340 844,272 211,068 1,160,874 928,699 232,175 1,266,408 1,013,126 253,282 1,477,476 1,181,981 295,495
S02669 - CEPHALOMETRY C-R (RAWAT
236,610
BBMRT029 JALAN) 189,288 47,322 236,610 189,288 47,322 260,271 208,217 52,054 283,932 227,146 56,786 331,254 265,003 66,251 378,576 302,861 75,715
S02670 - Cervical AP / Lat C1 Khusus C-R
287,100 459,360 367,488 91,872
S02671 - Cervical AP/ Lat C-R (RAWAT
228,690 365,904 292,723 73,181
BBMRT031 JALAN) 182,952 45,738 228,690 182,952 45,738 251,559 201,247 50,312 274,428 219,542 54,886 320,166 256,133 64,033
S02672 - CERVICOTHORACAL AP / LAT C-
242,550 388,080 310,464 77,616
BBMRT032 R (RAWAT JALAN) 194,040 48,510 242,550 194,040 48,510 266,805 213,444 53,361 291,060 232,848 58,212 339,570 271,656 67,914
S02673 - CLAVICULA DEXTRA (RAWAT
193,050 308,880 247,104 61,776
BBMRT033 JALAN) 154,440 38,610 193,050 154,440 38,610 212,355 169,884 42,471 231,660 185,328 46,332 270,270 216,216 54,054
S02674 - CLAVICULA DEXTRA SINISTRA
235,620 376,992 301,594 75,398
S02675 - CLAVICULA SINISTRA (RAWAT
193,050 308,880 247,104 61,776
BBMRT035 JALAN) 154,440 38,610 193,050 154,440 38,610 212,355 169,884 42,471 231,660 185,328 46,332 270,270 216,216 54,054
S02676 - COCCYGIS AP / LAT C-R
269,280 430,848 344,678 86,170
S02677 - COLLUM FEMUR AP / AXIAL C-R
225,720 361,152 288,922 72,230
S02678 - COLLUM FEMUR AP C-R
193,050 308,880 247,104 61,776
S02679 - COLON - INLOOP C-R ( Kontras )
994,950 1,591,920 1,273,536 318,384
S02680 - COR ANALYSA C-R (RAWAT
211,860 338,976 271,181 67,795
BBMRT040 JALAN) 169,488 42,372 211,860 169,488 42,372 233,046 186,437 46,609 254,232 203,386 50,846 296,604 237,283 59,321
S02681 - CRANIAL AP / LAT. TOMNE`S C-
305,910 489,456 391,565 97,891
S02682 - CRANIUM AP / LAT C-R (RAWAT
289,080 462,528 370,022 92,506
BBMRT042 JALAN) 231,264 57,816 289,080 231,264 57,816 317,988 254,390 63,598 346,896 277,517 69,379 404,712 323,770 80,942
S02683 - CRURIS SINISTRA C - R (RAWAT
221,760 354,816 283,853 70,963
BBMRT043 JALAN) 177,408 44,352 221,760 177,408 44,352 243,936 195,149 48,787 266,112 212,890 53,222 310,464 248,371 62,093
S02684 - CRURIS DEXTRA C - R (RAWAT
221,760 354,816 283,853 70,963
BBMRT044 JALAN) 177,408 44,352 221,760 177,408 44,352 243,936 195,149 48,787 266,112 212,890 53,222 310,464 248,371 62,093
S02693 - FISTULUGRAFI C-R ( Kontras )
848,430 1,357,488 1,085,990 271,498
BBMRT045 (RAWAT JALAN) 678,744 169,686 848,430 678,744 169,686 933,273 746,618 186,655 1,018,116 814,493 203,623 1,187,802 950,242 237,560
S02694 - FOLLOW THROUGH C-R
894,960 1,431,936 1,145,549 286,387
BBMRT046 ( kontras ) (RAWAT JALAN) 715,968 178,992 894,960 715,968 178,992 984,456 787,565 196,891 1,073,952 859,162 214,790 1,252,944 1,002,355 250,589
BBMRT047 S02695 - Genu Dextra (RAWAT JALAN) 245,520 196,416 49,104 245,520 196,416 49,104 270,072 216,058 54,014 294,624 235,699 58,925 343,728 274,982 68,746 392,832 314,266 78,566
S02696 - Genu dextra sinistra (RAWAT
400,950 641,520 513,216 128,304
BBMRT048 JALAN) 320,760 80,190 400,950 320,760 80,190 441,045 352,836 88,209 481,140 384,912 96,228 561,330 449,064 112,266
245,520 392,832 314,266 78,566

BBMRT049 S02697 - GENU SINISTRA (RAWAT JALAN) 196,416 49,104 245,520 196,416 49,104 270,072 216,058 54,014 294,624 235,699 58,925 343,728 274,982 68,746
S02698 - HIP JOINT DEXTRA (RAWAT
235,620 376,992 301,594 75,398
BBMRT050 JALAN) 188,496 47,124 235,620 188,496 47,124 259,182 207,346 51,836 282,744 226,195 56,549 329,868 263,894 65,974
S02699 - HIP JOINT SINISTRA (RAWAT
235,620 376,992 301,594 75,398
BBMRT051 JALAN) 188,496 47,124 235,620 188,496 47,124 259,182 207,346 51,836 282,744 226,195 56,549 329,868 263,894 65,974
S02701 - HUMERUS DEXTRA (RAWAT
207,900 332,640 266,112 66,528
BBMRT052 JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212
S02702 - HUMERUS DEXTRA SINISTRA
341,550 546,480 437,184 109,296
S02703 - HUMERUS SINISTRA (RAWAT
206,910 331,056 264,845 66,211
BBMRT054 JALAN) 165,528 41,382 206,910 165,528 41,382 227,601 182,081 45,520 248,292 198,634 49,658 289,674 231,739 57,935
BBMRT055 S00243 -- Jasa
S00253 Jasa Bera -(RAWAT JALAN)
Echocardiography -(RAWAT 193,050 154,440 38,610 193,050 154,440 38,610 212,355 169,884 42,471 231,660 185,328 46,332 270,270 216,216 54,054 308,880 247,104 61,776
BBMRT056 JALAN) 174,240 139,392 34,848 174,240 139,392 34,848 191,664 153,331 38,333 209,088 167,270 41,818 243,936 195,149 48,787 278,784 223,027 55,757
S02704 - K. CERVICOTHORACAL AP / LAT 331,650

BBMRT057 / OBL C-R (RAWAT JALAN) 265,320 66,330 331,650 265,320 66,330 364,815 291,852 72,963 397,980 318,384 79,596 464,310 371,448 92,862 530,640 424,512 106,128
LAYANAN
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
80% 80% HCU 80% ISOLASI 80% 80%
S02705 - KEPALA AP / LAT C - R (RAWAT
247,500 396,000 316,800 79,200
BBMRT058 JALAN) 198,000 49,500 247,500 198,000 49,500 272,250 217,800 54,450 297,000 237,600 59,400 346,500 277,200 69,300
S02706 - KEPALA AP / LAT,TOWNE`S C -
264,330 422,928 338,342 84,586
S02707 - MAAG DUODENUM FOTO C-R
920,700 1,473,120 1,178,496 294,624
BBMRT060 ( kontras ) (RAWAT JALAN) 736,560 184,140 920,700 736,560 184,140 1,012,770 810,216 202,554 1,104,840 883,872 220,968 1,288,980 1,031,184 257,796
79,200 126,720 101,376 25,344

BBMRT061 S04720 - MAMOGRAPHY(RAWAT JALAN) 63,360 15,840 79,200 63,360 15,840 87,120 69,696 17,424 95,040 76,032 19,008 110,880 88,704 22,176
490,050 784,080 627,264 156,816

BBMRT062 S04720 - MAMOGRAPHY (RAWAT JALAN) 392,040 98,010 490,050 392,040 98,010 539,055 431,244 107,811 588,060 470,448 117,612 686,070 548,856 137,214
S02708 - MANDIBULA C-R (RAWAT
326,700 522,720 418,176 104,544
BBMRT063 JALAN) 261,360 65,340 326,700 261,360 65,340 359,370 287,496 71,874 392,040 313,632 78,408 457,380 365,904 91,476
S02709 - MANUS DEXTRA C- R (RAWAT
207,900 332,640 266,112 66,528
BBMRT064 JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212
S02710 - MANUS DEXTRA SINISTRA C- R
281,160 449,856 359,885 89,971
S02711 - MANUS SINISTRA C- R (RAWAT
207,900 332,640 266,112 66,528
BBMRT066 JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212
326,700 522,720 418,176 104,544

BBMRT067 S02712 - MASTOID C-R (RAWAT JALAN) 261,360 65,340 326,700 261,360 65,340 359,370 287,496 71,874 392,040 313,632 78,408 457,380 365,904 91,476
236,610 378,576 302,861 75,715

BBMRT068 S02713 - MAXILLA C-R (RAWAT JALAN) 189,288 47,322 236,610 189,288 47,322 260,271 208,217 52,054 283,932 227,146 56,786 331,254 265,003 66,251
BBMRT069 S02080 - MRA (RAWAT JALAN) 2,379,960 1,903,968 475,992 2,379,960 1,903,968 475,992 2,617,956 2,094,365 523,591 2,855,952 2,284,762 571,190 3,331,944 2,665,555 666,389 3,807,936 3,046,349 761,587
S05793 - MRCP KONTRAS(RAWAT
1,980,000 3,168,000 2,534,400 633,600
BBMRT070 JALAN) 1,584,000 396,000 1,980,000 1,584,000 396,000 2,178,000 1,742,400 435,600 2,376,000 1,900,800 475,200 2,772,000 2,217,600 554,400
S05796 - MRCP NON KONTRAS(RAWAT
1,534,500 2,455,200 1,964,160 491,040
BBMRT071 JALAN) 1,227,600 306,900 1,534,500 1,227,600 306,900 1,687,950 1,350,360 337,590 1,841,400 1,473,120 368,280 2,148,300 1,718,640 429,660
S02714 - Myelography Cervical C-R
980,100 1,568,160 1,254,528 313,632
S02715 - MYELOGRAPHY LUMBAL C-R
1,087,020 1,739,232 1,391,386 347,846
BBMRT073 ( Kontras ) (RAWAT JALAN) 869,616 217,404 1,087,020 869,616 217,404 1,195,722 956,578 239,144 1,304,424 1,043,539 260,885 1,521,828 1,217,462 304,366
S02716 - MYELOGRAPHY THORACAL C-R
1,129,590 1,807,344 1,445,875 361,469
BBMRT074 ( kontras ) (RAWAT JALAN) 903,672 225,918 1,129,590 903,672 225,918 1,242,549 994,039 248,510 1,355,508 1,084,406 271,102 1,581,426 1,265,141 316,285
S02717 - OESOPHAGUS C-R ( Kontras )
610,830 977,328 781,862 195,466
S02718 - OMD FOTO C-R ( Kontras )
851,400 1,362,240 1,089,792 272,448
BBMRT076 (RAWAT JALAN) 681,120 170,280 851,400 681,120 170,280 936,540 749,232 187,308 1,021,680 817,344 204,336 1,191,960 953,568 238,392
BBMRT077 S02719 - ORBIT C-R (RAWAT JALAN) 224,730 179,784 44,946 224,730 179,784 44,946 247,203 197,762 49,441 269,676 215,741 53,935 314,622 251,698 62,924 359,568 287,654 71,914
216,810 346,896 277,517 69,379
BBMRT078 S02720 - OS. NASAL C-R (RAWAT JALAN) 173,448 43,362 216,810 173,448 43,362 238,491 190,793 47,698 260,172 208,138 52,034 303,534 242,827 60,707
S02721 - Panoramic Dental C-R (RAWAT
207,900 332,640 266,112 66,528
BBMRT079 JALAN) 166,320 41,580 207,900 166,320 41,580 228,690 182,952 45,738 249,480 199,584 49,896 291,060 232,848 58,212
S02722 - PASANG MARKER VERTEBRAE
224,730 359,568 287,654 71,914
S02725 - PEDIS SINISTRA C - R (RAWAT
212,850
BBMRT081 JALAN) 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598 340,560 272,448 68,112
S02726 - PEDIS DEXTRA C - R (RAWAT
212,850 340,560 272,448 68,112
BBMRT082 JALAN) 170,280 42,570 212,850 170,280 42,570 234,135 187,308 46,827 255,420 204,336 51,084 297,990 238,392 59,598
S02727 - PEDIS DEXTRA SINISTRA C - R
298,980 478,368 382,694 95,674
S02730 - PHLEBOGRAFI C-R (kontras )
1,312,740 2,100,384 1,680,307 420,077
BBMRT084 (RAWAT JALAN) 1,050,192 262,548 1,312,740 1,050,192 262,548 1,444,014 1,155,211 288,803 1,575,288 1,260,230 315,058 1,837,836 1,470,269 367,567
S00273 - Polipektomi SCBA - RS (RAWAT
2,603,700 4,165,920 3,332,736 833,184
BBMRT085 JALAN) 2,082,960 520,740 2,603,700 2,082,960 520,740 2,864,070 2,291,256 572,814 3,124,440 2,499,552 624,888 3,645,180 2,916,144 729,036
S00274 - Polipektomi SCBB - RS (RAWAT
4,056,030 6,489,648 5,191,718 1,297,930
BBMRT086 JALAN) 3,244,824 811,206 4,056,030 3,244,824 811,206 4,461,633 3,569,306 892,327 4,867,236 3,893,789 973,447 5,678,442 4,542,754 1,135,688
S03859 - Punksi Pleura - RS (RAWAT
352,440 563,904 451,123 112,781
BBMRT087 JALAN) 281,952 70,488 352,440 281,952 70,488 387,684 310,147 77,537 422,928 338,342 84,586 493,416 394,733 98,683
164,340
BBMRT114 S02757 - RO Gigi 43 (RAWAT JALAN) 131,472 32,868 164,340 131,472 32,868 180,774 144,619 36,155 197,208 157,766 39,442 230,076 184,061 46,015 262,944 210,355 52,589
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
S02784 - RPG DEXTRA C- R ( Kontras )
BBMRT140 (RAWAT JALAN) 712,800 570,240 142,560 712,800 570,240 142,560 784,080 627,264 156,816 855,360 684,288 171,072 997,920 798,336 199,584 1,140,480 912,384 228,096
S02785 - RPG DEXTRA SINISTRA C- R
BBMRT141 ( kontras ) (RAWAT JALAN) 930,600 744,480 186,120 930,600 744,480 186,120 1,023,660 818,928 204,732 1,116,720 893,376 223,344 1,302,840 1,042,272 260,568 1,488,960 1,191,168 297,792
S02786 - RPG SINISTRA C - R ( kontras )
BBMRT142 (RAWAT JALAN) 717,750 574,200 143,550 717,750 574,200 143,550 789,525 631,620 157,905 861,300 689,040 172,260 1,004,850 803,880 200,970 1,148,400 918,720 229,680
S02787 - SACRUM AP / LAT C-R (RAWAT
BBMRT143 JALAN) 249,480 199,584 49,896 249,480 199,584 49,896 274,428 219,542 54,886 299,376 239,501 59,875 349,272 279,418 69,854 399,168 319,334 79,834
S02788 - SCAPULA DEXTRA C- R (RAWAT
BBMRT144 JALAN) 221,760 177,408 44,352 221,760 177,408 44,352 243,936 195,149 48,787 266,112 212,890 53,222 310,464 248,371 62,093 354,816 283,853 70,963
S02789 - SCAPULA SINISTRA C- R
S05737 - SCOLIOSOSIS PROGRAM AP/L
BBMRT146 BENDING KA/KI(RAWAT JALAN) 475,200 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056 760,320 608,256 152,064
S05215 - SEDASI PROSEDUR(RAWAT
BBMRT147 JALAN) 509,850 407,880 101,970 509,850 407,880 101,970 560,835 448,668 112,167 611,820 489,456 122,364 713,790 571,032 142,758 815,760 652,608 163,152
S05215 - SEDASI PROSEDUR -
BBMRT148 RS(RAWAT JALAN) 56,430 45,144 11,286 56,430 45,144 11,286 62,073 49,658 12,415 67,716 54,173 13,543 79,002 63,202 15,800 90,288 72,230 18,058
S02790 - SELEKTIF ANGIOGRAFI C-
BBMRT149 R(RAWAT JALAN) 5,474,700 4,379,760 1,094,940 5,474,700 4,379,760 1,094,940 6,022,170 4,817,736 1,204,434 6,569,640 5,255,712 1,313,928 7,664,580 6,131,664 1,532,916 8,759,520 7,007,616 1,751,904
S02791 - SELLA TURCICA C-R (RAWAT
BBMRT150 JALAN) 187,110 149,688 37,422 187,110 149,688 37,422 205,821 164,657 41,164 224,532 179,626 44,906 261,954 209,563 52,391 299,376 239,501 59,875
S02792 - SHOULDER DEXTRA C - R
S02793 - SHOULDER JOINT DEXTRA
S02794 - SHOULDER JOINT DEXTRA
BBMRT153 SINISTRA (RAWAT JALAN) 357,390 285,912 71,478 357,390 285,912 71,478 393,129 314,503 78,626 428,868 343,094 85,774 500,346 400,277 100,069 571,824 457,459 114,365
S02795 - SHOULDER JOINT SINISTRA
S02796 - SHOULDER SINISTRA C- R
S00279 - Sikatan Bronchus - RS(RAWAT
BBMRT156 JALAN) 171,270 137,016 34,254 171,270 137,016 34,254 188,397 150,718 37,679 205,524 164,419 41,105 239,778 191,822 47,956 274,032 219,226 54,806
S02723 - SKILINE DEXTRA (RAWAT
BBMRT157 JALAN) 203,940 163,152 40,788 203,940 163,152 40,788 224,334 179,467 44,867 244,728 195,782 48,946 285,516 228,413 57,103 326,304 261,043 65,261
S02724 - SKILINE SINISTRA (RAWAT
BBMRT158 JALAN) 203,940 163,152 40,788 203,940 163,152 40,788 224,334 179,467 44,867 244,728 195,782 48,946 285,516 228,413 57,103 326,304 261,043 65,261
BBMRT159 S00280 - Skreloterapy - RS(RAWAT JALAN) 2,603,700 2,082,960 520,740 2,603,700 2,082,960 520,740 2,864,070 2,291,256 572,814 3,124,440 2,499,552 624,888 3,645,180 2,916,144 729,036 4,165,920 3,332,736 833,184
S00281 - Spike dan Seizure Analysis -
BBMRT160 RS(RAWAT JALAN) 171,270 137,016 34,254 171,270 137,016 34,254 188,397 150,718 37,679 205,524 164,419 41,105 239,778 191,822 47,956 274,032 219,226 54,806
BBMRT161 S00282 - Spirometry - RS(RAWAT JALAN) 134,640 107,712 26,928 134,640 107,712 26,928 148,104 118,483 29,621 161,568 129,254 32,314 188,496 150,797 37,699 215,424 172,339 43,085
BBMRT162 S02798 - SPN (RAWAT JALAN) 271,260 217,008 54,252 271,260 217,008 54,252 298,386 238,709 59,677 325,512 260,410 65,102 379,764 303,811 75,953 434,016 347,213 86,803
BBMRT163 S02799 - T.M.J (RAWAT JALAN) 316,800 253,440 63,360 316,800 253,440 63,360 348,480 278,784 69,696 380,160 304,128 76,032 443,520 354,816 88,704 506,880 405,504 101,376
S02800 - TAMBAHAN FILM C-R(RAWAT
BBMRT164 JALAN) 101,970 81,576 20,394 101,970 81,576 20,394 112,167 89,734 22,433 122,364 97,891 24,473 142,758 114,206 28,552 163,152 130,522 32,630
BBMRT165 S00283 - TBB - RS(RAWAT JALAN) 601,920 481,536 120,384 601,920 481,536 120,384 662,112 529,690 132,422 722,304 577,843 144,461 842,688 674,150 168,538 963,072 770,458 192,614
S02801 - THORACOLUMBAL AP / LAT /
BBMRT166 OBL C-R (RAWAT JALAN) 490,050 392,040 98,010 490,050 392,040 98,010 539,055 431,244 107,811 588,060 470,448 117,612 686,070 548,856 137,214 784,080 627,264 156,816
S02802 - THORACOLUMBAL AP / LAT C-R
BBMRT167 (RAWAT
S02803 - JALAN)
THORAX PA / LAT DEXTRA C-R 269,280 215,424 53,856 269,280 215,424 53,856 296,208 236,966 59,242 323,136 258,509 64,627 376,992 301,594 75,398 430,848 344,678 86,170
BBMRT168 (RAWAT- JALAN)
S02804 THORAX PA / LAT SINISTRA C-R 253,440 202,752 50,688 253,440 202,752 50,688 278,784 223,027 55,757 304,128 243,302 60,826 354,816 283,853 70,963 405,504 324,403 81,101
S02805 - THORAX PA C-R (RAWAT
BBMRT170 JALAN) 229,680 183,744 45,936 229,680 183,744 45,936 252,648 202,118 50,530 275,616 220,493 55,123 321,552 257,242 64,310 367,488 293,990 73,498
LAYANAN
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
80% 80% HCU 80% ISOLASI 80% 80%
BBMRT172 S05738 - THORAX RLD(RAWAT JALAN) 257,400 205,920 51,480 257,400 205,920 51,480 283,140 226,512 56,628 308,880 247,104 61,776 360,360 288,288 72,072 257,398 205,919 51,480
S02807 - TOP LORDOTIC C-R (RAWAT
196,020 196,018 156,815 39,204
BBMRT173 JALAN) 156,816 39,204 196,020 156,816 39,204 215,622 172,498 43,124 235,224 188,179 47,045 274,428 219,542 54,886
S02808 - Translete Hasil Radiologi (RAWAT
301,950 301,948 241,559 60,390
BBMRT174 JALAN) 241,560 60,390 301,950 241,560 60,390 332,145 265,716 66,429 362,340 289,872 72,468 422,730 338,184 84,546
375,210
BBMRT175 S00284 - TREADMILL - RS(RAWAT JALAN) 300,168 75,042 375,210 300,168 75,042 412,731 330,185 82,546 450,252 360,202 90,050 525,294 420,235 105,059 375,208 300,167 75,042
S00241 - TTB Guiding CT Scan (RAWAT
1,374,120 1,374,118 1,099,295 274,824
BBMRT176 JALAN) 1,099,296 274,824 1,374,120 1,099,296 274,824 1,511,532 1,209,226 302,306 1,648,944 1,319,155 329,789 1,923,768 1,539,014 384,754
S02813 - VERT. CERVICAL AP / LAT C-R
211,860
BBMRT177 (RAWAT JALAN) 169,488 42,372 211,860 169,488 42,372 233,046 186,437 46,609 254,232 203,386 50,846 296,604 237,283 59,321 211,858 169,487 42,372
S02814 - VERT. CERVICAL AP / LAT/ OBL
374,220 374,218 299,375 74,844
S02815 - VERT. LUMBAL AP / LAT / OBL
475,200
BBMRT179 C-R (RAWAT JALAN) 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056 475,198 380,159 95,040
S02816 - Vert. Lumbal AP / Lat C-R
273,240 273,238 218,591 54,648
S02817 - VERT. LUMBALSACRAL AP / LAT
475,200 475,198 380,159 95,040
BBMRT181 / OBL C-R (RAWAT JALAN) 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056
S02818 - Vert. LumbalSacral AP / Lat C-R
258,390 258,388 206,711 51,678
S02819 - VERT. THORACAL AP / LAT /
475,200 475,198 380,159 95,040
BBMRT183 OBL C-R (RAWAT JALAN) 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056
S02820 - VERT. THORACAL AP / LAT C-R
269,280 269,278 215,423 53,856
S02809 - URETHROCYSTOGRAFI C-R
746,064 746,062 596,850 149,212
BBMRT185 (KONTRAS ) (RAWAT JALAN) 596,851 149,213 746,064 596,851 149,213 820,670 656,536 164,134 895,277 716,221 179,055 1,044,490 835,592 208,898
S02810 - URETHROGRAFI C-R (KONTRAS
659,340 659,338 527,471 131,868
BBMRT186 ) (RAWAT JALAN) 527,472 131,868 659,340 527,472 131,868 725,274 580,219 145,055 791,208 632,966 158,242 923,076 738,461 184,615
S00285 - UROFLOMETRI - RS(RAWAT
120,780 120,778 96,623 24,156
BBMRT187 JALAN) 96,624 24,156 120,780 96,624 24,156 132,858 106,286 26,572 144,936 115,949 28,987 169,092 135,274 33,818
189,090 189,088 151,271 37,818

BBMRT188 S02821 - WATER`S C-R (RAWAT JALAN) 151,272 37,818 189,090 151,272 37,818 207,999 166,399 41,600 226,908 181,526 45,382 264,726 211,781 52,945
S05739 - WHOLE SPINE X-RAY(RAWAT
475,200 475,198 380,159 95,040
BBMRT189 JALAN) 380,160 95,040 475,200 380,160 95,040 522,720 418,176 104,544 570,240 456,192 114,048 665,280 532,224 133,056
S02822 - WRIST JOINT DEXTRA C- R
225,720 225,718 180,575 45,144
S02823 - WRIST JOINT DEXTRA SINITRA
264,330 264,328 211,463 52,866
S02824 - WRIST JOINT SINISTRA C- R
225,720 225,718 180,575 45,144
BBMRT193 S00302 - WSD - RS(RAWAT JALAN) 330,660 264,528 66,132 330,660 264,528 66,132 363,726 290,981 72,745 396,792 317,434 79,358 462,924 370,339 92,585 330,658 264,527 66,132
USG Abd. Bawah / Pelvis/ Obs-Gin
463,320 421,198 336,959 84,240
BBMUSG001 DOPPLER 370,656 92,664 421,200 336,960 84,240 463,320 370,656 92,664 505,440 404,352 84,240 589,680 471,744 117,936
BBMUSG002 USG Abdomen Atas DENGAN FOTO 334,620 267,696 66,924 334,620 267,696 66,924 368,082 294,466 73,616 401,544 321,235 80,309 468,468 374,774 93,694 334,618 267,695 66,924
BBMUSG003 USG Abdomen Atas DOPPLER 463,320 370,656 92,664 463,320 370,656 92,664 509,652 407,722 101,930 555,984 444,787 111,197 648,648 518,918 129,730 463,318 370,655 92,664
USG EKSTREMITAS ATAS SISTEM
692,010 692,008 553,607 138,402
BBMUSG004 ARTERI 1 SISI DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
USG EKSTREMITAS ATAS SISTEM VENA
692,010 692,008 553,607 138,402
BBMUSG005 1 SISI DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
BBMUSG006 USG KEPALA DOPPLER 558,360 446,688 111,672 558,360 446,688 111,672 614,196 491,357 122,839 670,032 536,026 134,006 781,704 625,363 156,341 558,358 446,687 111,672
BBMUSG007 USG Leher DENGAN FOTO 249,480 199,584 49,896 249,480 199,584 49,896 274,428 219,542 54,886 299,376 239,501 59,875 349,272 279,418 69,854 249,478 199,583 49,896
BBMUSG008 USG MUSKULAR DOPPLER - RS 398,970 319,176 79,794 398,970 319,176 79,794 438,867 351,094 87,773 478,764 383,011 95,753 558,558 446,846 111,712 398,968 319,175 79,794
USG Organ Superfisial / Lainnya DENGAN
285,120 285,118 228,095 57,024
BBMUSG009 FOTO 228,096 57,024 285,120 228,096 57,024 313,632 250,906 62,726 342,144 273,715 68,429 399,168 319,334 79,834
BBMUSG010 USG PROSTAT DOPPLER 474,210 379,368 94,842 474,210 379,368 94,842 521,631 417,305 104,326 569,052 455,242 113,810 663,894 531,115 132,779 474,208 379,367 94,842
BBMUSG011 USG Sist. Karotis dan Vert. 2 Sisi DOPPLER 1,210,770 968,616 242,154 1,210,770 968,616 242,154 1,331,847 1,065,478 266,369 1,452,924 1,162,339 290,585 1,695,078 1,356,062 339,016 1,210,768 968,615 242,154
BBMUSG012 USG SISTEM KAROTIS 1 SISI DOPPLER 692,010 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763 692,008 553,607 138,402
S00314 - USG Sistem Vertebralis 1 Sisi
1,210,770 1,210,768 968,615 242,154
BBMUSG013 DOPPLER 968,616 242,154 1,210,770 968,616 242,154 1,331,847 1,065,478 266,369 1,452,924 1,162,339 290,585 1,695,078 1,356,062 339,016
S00287 - USG TRANSRECTAL ( DGN
362,340 362,338 289,871 72,468
BBMUSG014 PRINT ) - RS 289,872 72,468 362,340 289,872 72,468 398,574 318,859 79,715 434,808 347,846 86,962 507,276 405,821 101,455
S00315 - USG TUNGKAI SISTEM ARTERI
692,010 692,008 553,607 138,402
BBMUSG015 1 SISI DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
S00316 - USG TUNGKAI SISTEM VENA 1
692,010 692,008 553,607 138,402
BBMUSG016 SISI DOPPLER 553,608 138,402 692,010 553,608 138,402 761,211 608,969 152,242 830,412 664,330 166,082 968,814 775,051 193,763
S00317 - USG Abdomen Bawah / Pelvis
334,620 334,618 267,695 66,924
BBMUSG017 DENGAN FOTO 267,696 66,924 334,620 267,696 66,924 368,082 294,466 73,616 401,544 321,235 80,309 468,468 374,774 93,694
S00318 - USG Abdomen Lengkap DENGAN
550,000 549,998 439,999 110,000
BBMUSG018 FOTO 440,000 110,000 550,000 440,000 110,000 605,000 484,000 121,000 660,000 528,000 132,000 770,000 616,000 154,000
S00319 - USG Abdomen Lengkap
971,190 971,188 776,951 194,238
BBMUSG019 DOPPLER 776,952 194,238 971,190 776,952 194,238 1,068,309 854,647 213,662 1,165,428 932,342 233,086 1,359,666 1,087,733 271,933
370,260 370,258 296,207 74,052

BBMUSG020 S00290 - USG DOPPLER VASKULER - RS 296,208 74,052 370,260 296,208 74,052 407,286 325,829 81,457 444,312 355,450 88,862 518,364 414,691 103,673
S00295 - USG INTERVENSI ABDOMEN -
915,750 915,748 732,599 183,150
BBMUSG021 RS 732,600 183,150 915,750 732,600 183,150 1,007,325 805,860 201,465 1,098,900 879,120 219,780 1,282,050 1,025,640 256,410
S00296 - USG INTERVENSI NON -
822,690 822,688 658,151 164,538
BBMUSG022 ABDOMEN - RS 658,152 164,538 822,690 658,152 164,538 904,959 723,967 180,992 987,228 789,782 197,446 1,151,766 921,413 230,353
BBMUSG023 S00320 - USG Kepala DENGAN FOTO 249,480 199,584 49,896 249,480 199,584 49,896 274,428 219,542 54,886 299,376 239,501 59,875 349,272 279,418 69,854 249,478 199,583 49,896
BBMUSG024 S00321 - USG MAMMAE DOPPLER 434,610 347,688 86,922 434,610 347,688 86,922 478,071 382,457 95,614 521,532 417,226 104,306 608,454 486,763 121,691 434,608 347,687 86,922
BBMUSG025 S00322 - USG MOSKULOSKELETAL Fascia Pla 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG026 S00323 - USG MOSKULOSKELETAL Otot - Otot 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG027 S00324 - USG MOSKULOSKELETAL Otot - Otot 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG028 S00325 - USG MOSKULOSKELETAL Sendi Lut 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
BBMUSG029 S00326 - USG MOSKULOSKELETAL Sendi Tum 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
808,830
BBMUSG030 S00327 - USG MOSKULOSKELETAL Tendon Ac 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 808,828 647,063 161,766
LAYANAN
%
%
RS dan BHP
%
RS dan BHP
%
VIP B RS dan BHP
80% 80% HCU 80% ISOLASI 80% 80%
BBMUSG031 S00328 - USG MOSKULOSKELETAL Bahu 808,830 647,064 161,766 808,830 647,064 161,766 889,713 711,770 177,943 970,596 776,477 194,119 1,132,362 905,890 226,472 1,294,128 1,035,302 258,826
BBMUSG032 S00329 - USG Paru - Paru DENGAN FOTO 336,600 269,280 67,320 336,600 269,280 67,320 370,260 296,208 74,052 403,920 323,136 80,784 471,240 376,992 94,248 538,560 430,848 107,712
BBMUSG033 S00330 - USG Payudara / Thyroid DENGAN 491,040 392,832 98,208 491,040 392,832 98,208 540,144 432,115 108,029 589,248 471,398 117,850 687,456 549,965 137,491 785,664 628,531 157,133
BBMUSG034 S02811 - USG Payudara dengan Foto C-R 588,060 470,448 117,612 588,060 470,448 117,612 646,866 517,493 129,373 705,672 564,538 141,134 823,284 658,627 164,657 940,896 752,717 188,179
BBMUSG035 S00331 - USG TESTIS DOPPLER 420,750 336,600 84,150 420,750 336,600 84,150 462,825 370,260 92,565 504,900 403,920 100,980 589,050 471,240 117,810 673,200 538,560 134,640
BBMUSG036 S04696 - USG THORAX 316,800 253,440 63,360 316,800 253,440 63,360 348,480 278,784 69,696 380,160 304,128 76,032 443,520 354,816 88,704 506,880 405,504 101,376
BBMUSG037 S02812 - USG Thyroid dengan Foto C-R 588,060 470,448 117,612 588,060 470,448 117,612 646,866 517,493 129,373 705,672 564,538 141,134 823,284 658,627 164,657 940,896 752,717 188,179
BBMUSG038 S00332 - USG Tiroid / Carotis / Leher DOPPL 460,350 368,280 92,070 460,350 368,280 92,070 506,385 405,108 101,277 552,420 441,936 110,484 644,490 515,592 128,898 736,560 589,248 147,312
BBMUSG039 S02700 - HSG C-R ( kontras ) 960,300 768,240 192,060 960,300 768,240 192,060 1,056,330 845,064 211,266 1,152,360 921,888 230,472 1,344,420 1,075,536 268,884 1,536,480 1,229,184 307,296
S02701 - USG Mammae / Mammografi 325,000 455,000
357,500
BBMUSG040 ( Rawat Jalan ) 286,000 71,500 260,000 65,000 357,500 286,000 71,500 390,000 312,000 78,000 364,000 91,000 520,000 416,000 104,000
BBMUSG041 SO2702 - USG Testis Bilaterl 421,300 337,040 84,260 383,000 306,400 76,600 421,300 337,040 84,260 459,600 367,680 91,920 536,200 428,960 107,240 612,800 490,240 122,560
3.TARIF DIAGNOSTIK ELEKTROMEDIK

KODE LAYANAN DIAGNOSTIK ELEKTROMEDIK Jasa Sarana KELAS III Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana
fee Medis fee Medis fee Medis fee Medis fee Medis Jasa Sarana RS fee Medis
(30%)
RS dan BHP
(30%)
RS dan BHP
(30%)
RS dan BHP
(30%)
VIP B RS dan BHP
(30%)
VIP A dan BHP (70%) (30%)
BBMH0116 GYN (Rawat Jalan) 44,000 30,800 12,000 44,000 30,800 13,200 48,400 33,880 14,520 52,800 36,960 15,840 57,200 40,040 17,160 70,400 49,280 21,120
BBMH0119 NST (Rawat Jalan) 110,000 88,000 12,000 110,000 88,000 12,000 121,000 84,700 36,300 132,000 92,400 39,600 143,000 100,100 42,900 176,000 123,200 52,800
BBMH0121 Periksa Dalam (Rawat Jalan) 44,000 35,000 15,000 44,000 30,800 13,200 48,400 33,880 14,520 52,800 36,960 15,840 57,200 40,040 17,160 70,400 49,280 21,120
BBMH0123 GV (Rawat Jalan) 42,900 30,030 12,870 42,900 30,030 12,870 47,190 33,033 14,157 51,480 36,036 15,444 55,770 39,039 16,731 68,640 48,048 20,592
BBMH0124 Doppler (Rawat Jalan) 27,500 19,250 8,250 27,500 19,250 8,250 30,250 21,175 9,075 33,000 23,100 9,900 35,750 25,025 10,725 44,000 30,800 13,200
BBM00125 EKG (Rawat Jalan) 77,000 53,900 23,100 77,000 53,900 23,100 84,700 59,290 25,410 83,200 58,240 24,960 100,100 70,070 30,030 123,200 86,240 36,960
BBM00128 Polipektomi SCBB (Rawat Jalan) 3,605,360 2,523,752 1,081,608 3,605,360 2,523,752 1,081,608 3,965,896 2,776,127 1,189,769 3,933,600 2,753,520 1,180,080 4,686,968 3,280,878 1,406,090 5,768,576 4,038,003 1,730,573
BBM00129 Biopsi Bronchus (Rawat Jalan) 182,160 127,512 54,648 182,160 127,512 54,648 200,376 140,263 60,113 199,200 139,440 59,760 236,808 165,766 71,042 291,456 204,019 87,437
BBM00131 Sikatan Bronchus (Rawat Jalan) 152,240 106,568 45,672 152,240 106,568 45,672 167,464 117,225 50,239 165,600 115,920 49,680 197,912 138,538 59,374 243,584 170,509 73,075
BBM00132 ERCP + Spingteromi / Ekstr. Batu (Rawat
7,663,920 5,364,744 2,299,176 7,663,920 5,364,744 2,299,176 8,430,312 5,901,218 2,529,094 8,360,800 5,852,560 2,508,240 9,963,096 6,974,167 2,988,929 12,262,272 8,583,590 3,678,682
Jalan)
BBM00133 ERCP + Pasang NBD / Stent (Rawat Jalan)
7,573,280 5,301,296 2,271,984 7,573,280 5,301,296 2,271,984 8,330,608 5,831,426 2,499,182 8,262,400 5,783,680 2,478,720 9,845,264 6,891,685 2,953,579 12,117,248 8,482,074 3,635,174
BBM00134 ERCP (Rawat Jalan) 4,695,680 3,286,976 1,408,704 4,695,680 3,286,976 1,408,704 5,165,248 3,615,674 1,549,574 5,122,400 3,585,680 1,536,720 6,104,384 4,273,069 1,831,315 7,513,088 5,259,162 2,253,926
BBM00137 Skreloterapy (Rawat Jalan) 2,250,600 1,841,000 205,000 2,250,600 1,575,420 675,180 2,475,660 1,732,962 742,698 2,805,600 1,963,920 841,680 2,925,780 2,048,046 877,734 3,600,960 2,520,672 1,080,288
BBM00138 USG Muskular DOPPLER (Rawat Jalan) 394,240 275,968 118,272 394,240 275,968 118,272 433,664 303,565 130,099 430,400 301,280 129,120 512,512 358,758 153,754 630,784 441,549 189,235
BBM00139 AUDIOMETRI (Rawat Jalan) 137,280 96,096 41,184 137,280 96,096 41,184 151,008 105,706 45,302 149,600 104,720 44,880 178,464 124,925 53,539 219,648 153,754 65,894
BBM00140 Spirometry (Rawat Jalan) 154,880 108,416 46,464 154,880 108,416 46,464 170,368 119,258 51,110 168,800 118,160 50,640 201,344 140,941 60,403 247,808 173,466 74,342
BBM00141 Evoked Respon : VEP (Rawat Jalan) 569,360 398,552 170,808 569,360 398,552 170,808 626,296 438,407 187,889 620,800 434,560 186,240 740,168 518,118 222,050 910,976 637,683 273,293
BBM00142 Evoked Respon : BAEP (Rawat Jalan) 569,360 398,552 170,808 569,360 398,552 170,808 626,296 438,407 187,889 620,800 434,560 186,240 740,168 518,118 222,050 910,976 637,683 273,293
BBM00143 EMG : KHS (Rawat Jalan) 476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
BBM00144 EMG : Spasmophilia (Rawat Jalan) 476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
BBM00145 Regional Block (Rawat Jalan) 332,640 232,848 99,792 332,640 232,848 99,792 365,904 256,133 109,771 362,400 253,680 108,720 432,432 302,702 129,730 532,224 372,557 159,667
BBM00146 Spike & Seizure Analysis (Rawat Jalan) 152,240 106,568 45,672 152,240 106,568 45,672 167,464 117,225 50,239 165,600 115,920 49,680 197,912 138,538 59,374 243,584 170,509 73,075
BBM00147 Bera (Rawat Jalan) 520,960 364,672 156,288 520,960 364,672 156,288 573,056 401,139 171,917 568,000 397,600 170,400 677,248 474,074 203,174 833,536 583,475 250,061
BBM00148 EEG + Brain Mapping (Rawat Jalan) 520,960 364,672 156,288 520,960 364,672 156,288 573,056 401,139 171,917 568,000 397,600 170,400 677,248 474,074 203,174 833,536 583,475 250,061
BBM00149 EEG (Rawat Jalan) 201,520 141,064 60,456 201,520 141,064 60,456 221,672 155,170 66,502 219,200 153,440 65,760 261,976 183,383 78,593 322,432 225,702 96,730
BBM00150 Biopsi / Aspirasi Jarum Halus ( FNAB )
264,000 184,800 79,200 264,000 184,800 79,200 290,400 203,280 87,120 288,000 201,600 86,400 343,200 240,240 102,960
(Rawat Jalan) 422,400 295,680 126,720
BBM00151 Biopsi / Aspirasi kelenjar (Rawat Jalan) 317,680 222,376 95,304 317,680 222,376 95,304 349,448 244,614 104,834 346,400 242,480 103,920 412,984 289,089 123,895 508,288 355,802 152,486
BBM00152 Biopsi Pleura (Rawat Jalan) 520,960 364,672 156,288 520,960 364,672 156,288 573,056 401,139 171,917 568,000 397,600 170,400 677,248 474,074 203,174 833,536 583,475 250,061
BBM00153 Punksi Pleura (Rawat Jalan) 316,800 221,760 95,040 316,800 221,760 95,040 348,480 243,936 104,544 345,600 241,920 103,680 411,840 288,288 123,552 506,880 354,816 152,064
BBM00154 TBB (Rawat Jalan) 535,040 374,528 160,512 535,040 374,528 160,512 588,544 411,981 176,563 584,000 408,800 175,200 695,552 486,886 208,666 856,064 599,245 256,819
BBM00155 WSD (Rawat Jalan) 978,560 684,992 293,568 978,560 684,992 293,568 1,076,416 753,491 322,925 1,067,200 747,040 320,160 1,272,128 890,490 381,638 1,565,696 1,095,987 469,709
BBM00156 Bronkografi (Rawat Jalan) 351,120 245,784 105,336 351,120 245,784 105,336 386,232 270,362 115,870 383,200 268,240 114,960 456,456 319,519 136,937 561,792 393,254 168,538
BBM00157 Broncoscopy ( dengan Anastesi ) (Rawat
2,790,480 1,953,336 837,144 2,790,480 1,953,336 837,144 3,069,528 2,148,670 920,858 3,044,000 2,130,800 913,200 3,627,624 2,539,337 1,088,287 4,464,768 3,125,338 1,339,430
Jalan)
BBM00158 Broncoscopy ( Tanpa Anastesi ) (Rawat
2,347,840 1,643,488 704,352 2,347,840 1,643,488 704,352 2,582,624 1,807,837 774,787 2,561,600 1,793,120 768,480 3,052,192 2,136,534 915,658
Jalan) 3,756,544 2,629,581 1,126,963
BBM00159 UROFLOMETRI (Rawat Jalan) 139,920 97,944 41,976 139,920 97,944 41,976 153,912 107,738 46,174 152,800 106,960 45,840 181,896 127,327 54,569 223,872 156,710 67,162
BBM00160 MAMMOGRAPHY (Rawat Jalan) 238,480 166,936 71,544 238,480 166,936 71,544 262,328 183,630 78,698 260,000 182,000 78,000 310,024 217,017 93,007 381,568 267,098 114,470
BBM00161 USG INTERVENSI Non - Abdomen (Rawat
812,240 568,568 243,672 812,240 568,568 243,672 893,464 625,425 268,039 886,400 620,480 265,920 1,055,912 739,138 316,774 1,299,584 909,709 389,875
Jalan)
BBM00162 USG INTERVENSI Abdomen (Rawat Jalan)
904,640 633,248 271,392 904,640 633,248 271,392 995,104 696,573 298,531 986,400 690,480 295,920 1,176,032 823,222 352,810 1,447,424 1,013,197 434,227
BBM00163 USG Transrectal ( Dgn print ) (Rawat Jalan)
358,160 250,712 107,448 358,160 250,712 107,448 393,976 275,783 118,193 391,200 273,840 117,360 465,608 325,926 139,682 573,056 401,139 171,917
BBM00165 Polipektomi SCBA (Rawat Jalan) 3,605,360 2,523,752 1,081,608 3,605,360 2,523,752 1,081,608 3,965,896 2,776,127 1,189,769 2,805,600 1,963,920 841,680 4,686,968 3,280,878 1,406,090 5,768,576 4,038,003 1,730,573
BBM00168 TREADMILL (Rawat Jalan) 432,960 303,072 129,888 432,960 303,072 129,888 476,256 333,379 142,877 472,000 330,400 141,600 562,848 393,994 168,854 692,736 484,915 207,821
BBM00169 USG Kepala bayi (Rawat Jalan) 391,600 274,120 117,480 391,600 274,120 117,480 430,760 301,532 129,228 427,200 299,040 128,160 509,080 356,356 152,724 626,560 438,592 187,968
BBM00170 Peak Flow (Rawat Jalan) 48,400 33,880 14,520 48,400 33,880 14,520 53,240 37,268 15,972 53,000 37,100 15,900 62,920 44,044 18,876 77,440 54,208 23,232
BBM00172 USG Doppler Vaskuler (Rawat Jalan) 365,200 255,640 109,560 365,200 255,640 109,560 401,720 281,204 120,516 399,200 279,440 119,760 474,760 332,332 142,428 584,320 409,024 175,296
BBM00173 Echocardiography Anak ( Cito ) (Rawat 726,000 508,200 217,800 726,000 508,200 217,800 798,600 559,020 239,580 792,000 554,400 237,600 943,800 660,660 283,140 1,161,600 813,120 348,480
BBM00174 Jalan)
EMG/ENMG : KHS (Rawat Jalan) 476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
BBM00175 EMG/ENMG : KHS Extermitas Bawah
476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
(Rawat Jalan)
BBM00176 EMG/ENMG : KHS Extermitas Atas (Rawat
476,960 333,872 143,088 476,960 333,872 143,088 524,656 367,259 157,397 520,000 364,000 156,000 620,048 434,034 186,014 763,136 534,195 228,941
Jalan)
BBM00177 USG 4 Dimensi Ginekologi (Rawat Jalan) 495,000 315,000 135,000 495,000 346,500 148,500 544,500 381,150 163,350 594,000 415,800 178,200 643,500 450,450 193,050 792,000 554,400 237,600
BBM00178 USG Obstetri - Ginekologi Dengan Print
132,000 96,000 24,000 132,000 105,600 26,400 145,200 101,640 43,560 158,400 110,880 47,520 171,600 120,120 51,480 211,200 147,840 63,360
(Rawat Jalan)
BBM00179 USG Obstetri - Ginekologi Tanpa Print
77,000 56,000 14,000 77,000 61,600 15,400 84,700 59,290 25,410 92,400 64,680 27,720 100,100 70,070 30,030
(Rawat Jalan) 123,200 86,240 36,960
BBM00180 USG Ginekologi Transvaginal Dengan Print
193,600 154,000 22,000 193,600 154,000 22,000 212,960 149,072 63,888 232,320 162,624 69,696 251,680 176,176 75,504 309,760 216,832 92,928
(Rawat Jalan)
BBM00181 USG Ginekologi Transvaginal Tanpa
77,000 56,000 14,000 77,000 56,000 14,000 84,700 59,290 25,410 92,400 64,680 27,720 100,100 70,070 30,030
Print(Rawat Jalan) 123,200 86,240 36,960
III. TARIF TINDAKAN
1.TARIF TINDAKAN DOKTER

(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A dan BHP (30%) (70%)
BBM00182 Punksi Lumbal (Rawat Jalan) 143,715 39,195 91,455 130,650 39,195 91,455 143,715 43,115 100,601 156,780 47,034 109,746 182,910 54,873 128,037 209,040 62,712 146,328
BBM00183 Punksi Pleura (Rawat Jalan)-Dr 266,200 65,000 177,000 204,100 61,230 142,870 224,510 67,353 157,157 244,920 73,476 171,444 285,740 85,722 200,018 326,560 97,968 228,592
BBM00184 Punksi BMP (Rawat Jalan) 238,810 65,130 151,970 217,100 65,130 151,970 238,810 71,643 167,167 260,520 78,156 182,364 303,940 91,182 212,758 347,360 104,208 243,152
BBM00185 Punksi Abdomen (Rawat Jalan) 312,400 77,000 207,000 284,000 77,000 207,000 312,400 93,720 218,680 340,800 102,240 238,560 397,600 119,280 278,320 454,400 136,320 318,080
BBM00186 Vena Sectie (Rawat Jalan) 282,700 69,000 188,000 257,000 69,000 188,000 282,700 84,810 197,890 308,400 92,520 215,880 359,800 107,940 251,860 411,200 123,360 287,840
BBM00187 Pemasangan CVP (Rawat Jalan) 839,300 206,000 557,000 763,000 206,000 557,000 839,300 251,790 587,510 915,600 274,680 640,920 1,068,200 320,460 747,740 1,220,800 366,240 854,560
BBM00188 Pemasangan Catheter Umbilikal (Rawat
190,905 52,065 121,485 173,550 52,065 121,485 190,905 57,272 133,634 208,260 62,478 145,782 242,970 72,891 170,079 277,680 83,304 194,376
Jalan)
BBM00190 Punksi Pericard (Rawat Jalan) 363,000 89,000 241,000 330,000 89,000 241,000 363,000 108,900 254,100 396,000 118,800 277,200 462,000 138,600 323,400 528,000 158,400 369,600
BBM00191 Punksi Ascites (Rawat Jalan) 209,000 51,000 139,000 190,000 51,000 139,000 209,000 62,700 146,300 228,000 68,400 159,600 266,000 79,800 186,200 304,000 91,200 212,800
BBM00192 Punksi Kista Hati (Rawat Jalan) 162,305 44,265 103,285 147,550 44,265 103,285 162,305 48,692 113,614 177,060 53,118 123,942 206,570 61,971 144,599 236,080 70,824 165,256
BBM00193 A. J. H. (Rawat Jalan) 162,305 44,265 103,285 147,550 44,265 103,285 162,305 48,692 113,614 177,060 53,118 123,942 206,570 61,971 144,599 236,080 70,824 165,256
BBM00194 Ethanol Therapy (Rawat Jalan) 214,500 58,500 136,500 195,000 58,500 136,500 214,500 64,350 150,150 234,000 70,200 163,800 273,000 81,900 191,100 312,000 93,600 218,400
BBM00195 Lepas Tampon (Rawat Jalan) 37,400 9,000 25,000 34,000 9,000 25,000 37,400 11,220 26,180 40,800 12,240 28,560 47,600 14,280 33,320 54,400 16,320 38,080
BBM00197 Canul Trachea Aff (Rawat Jalan) 143,715 39,195 91,455 130,650 39,195 91,455 143,715 43,115 100,601 156,780 47,034 109,746 182,910 54,873 128,037 209,040 62,712 146,328
BBM00198 Pasang HD Catheter (Rawat Jalan) 1,625,195 443,235 1,034,215 1,477,450 443,235 1,034,215 1,625,195 487,559 1,137,637 1,772,940 531,882 1,241,058 2,068,430 620,529 1,447,901 2,363,920 709,176 1,654,744
BBM00199 Aff Catheter Epidural (Rawat Jalan) 410,300 101,000 272,000 373,000 101,000 272,000 410,300 123,090 287,210 447,600 134,280 313,320 522,200 156,660 365,540 596,800 179,040 417,760
BBM00200 Aff HD Catheter (Rawat Jalan) 677,600 185,000 431,000 616,000 185,000 431,000 677,600 203,280 474,320 739,200 221,760 517,440 862,400 258,720 603,680 985,600 295,680 689,920
BBM00206 Eksisi Clavus (Rawat Jalan) 495,000 148,500 346,500 450,000 135,000 315,000 495,000 148,500 346,500 540,000 162,000 378,000 630,000 189,000 441,000 720,000 216,000 504,000
BBM00207 Eksisi / eksterpasi Aterom (Rawat Jalan) 735,900 201,000 468,000 669,000 201,000 468,000 735,900 220,770 515,130 802,800 240,840 561,960 936,600 280,980 655,620 1,070,400 321,120 749,280
BBM00211 Plebotomy (Dokter) (Rawat Jalan) 141,570 38,610 90,090 128,700 38,610 90,090 141,570 42,471 99,099 154,440 46,332 108,108 180,180 54,054 126,126 205,920 61,776 144,144
BBM00212 Aspirasi Jarum Halus (Dokter) (Rawat Jalan)
143,000 39,000 91,000 130,000 39,000 91,000 143,000 42,900 100,100 156,000 46,800 109,200 182,000 54,600 127,400 208,000 62,400 145,600
BBM00213 Eksisi Mococel (Rawat Jalan) 495,000 148,500 346,500 450,000 135,000 315,000 495,000 148,500 346,500 540,000 162,000 378,000 630,000 189,000 441,000 720,000 216,000 504,000
BBM00214 Reduksi Terteutup ( Anestesi Lokal ) (Rawat
92,400 23,000 61,000 84,000 23,000 61,000 92,400 27,720 64,680 100,800 30,240 70,560 117,600 35,280 82,320 134,400 40,320 94,080
Jalan)
BBM00214 Insersi / pasang IUD Mirena (Rawat Jalan) 388,300 106,000 247,000 388,300 106,000 247,000 427,130 128,139 298,991 465,960 139,788 326,172 543,620 163,086 380,534 621,280 186,384 434,896
BBM00215 Aff Inter Maxillary Wiring (Rawat Jalan) 361,900 97,000 232,000 329,000 97,000 232,000 361,900 108,570 253,330 394,800 118,440 276,360 460,600 138,180 322,420 526,400 157,920 368,480
BBM00219 Pemeriksaan Ginekologi ( Obsgyn ) (Rawat
44,000 12,000 30,800 40,000 12,000 28,000 44,000 13,200 30,800 48,000 14,400 33,600 56,000 16,800 39,200 64,000 19,200 44,800
Jalan)
BBM00220 Injeksi Epidural (Rawat Jalan) 860,145 258,044 602,102 781,950 234,585 547,365 860,145 258,044 602,102 938,340 281,502 656,838 1,094,730 328,419 766,311 1,251,120 375,336 875,784
BBM00221 Aspirasi Haemarothrosis (Rawat Jalan) 298,870 89,661 209,209 271,700 81,510 190,190 298,870 89,661 209,209 326,040 97,812 228,228 380,380 114,114 266,266 434,720 130,416 304,304
BBM00222 Skin Traksi (Rawat Jalan) 200,200 49,000 133,000 182,000 49,000 133,000 200,200 60,060 140,140 218,400 65,520 152,880 254,800 76,440 178,360 291,200 87,360 203,840
BBM00223 Skeletal Traksi (Rawat Jalan) 562,705 168,812 393,894 511,550 153,465 358,085 562,705 168,812 393,894 613,860 184,158 429,702 716,170 214,851 501,319 818,480 245,544 572,936
BBM00224 Debridement (Ortopedic) (Rawat Jalan) 337,480 101,244 236,236 306,800 92,040 214,760 337,480 101,244 236,236 368,160 110,448 257,712 429,520 128,856 300,664 490,880 147,264 343,616
BBM00225 Backslab (Rawat Jalan) 267,300 66,000 177,000 243,000 66,000 177,000 267,300 80,190 187,110 291,600 87,480 204,120 340,200 102,060 238,140 388,800 116,640 272,160
BBM00226 Pemasangan Gips Kecil (Rawat Jalan) 225,225 67,568 157,658 204,750 61,425 143,325 225,225 67,568 157,658 245,700 73,710 171,990 286,650 85,995 200,655 327,600 98,280 229,320
BBM00227 Pemasangan Gips Sedang (Rawat Jalan) 337,480 101,244 236,236 306,800 92,040 214,760 337,480 101,244 236,236 368,160 110,448 257,712 429,520 128,856 300,664 490,880 147,264 343,616
BBM00228 Pemasangan Gips Besar (Rawat Jalan) 449,735 134,921 314,815 408,850 122,655 286,195 449,735 134,921 314,815 490,620 147,186 343,434 572,390 171,717 400,673 654,160 196,248 457,912
BBM00229 Close Reduction + Gips (Rawat Jalan) 666,600 163,000 443,000 606,000 163,000 443,000 666,600 199,980 466,620 727,200 218,160 509,040 848,400 254,520 593,880 969,600 290,880 678,720
BBM00230 Aff Pinning (Rawat Jalan) 666,600 164,000 442,000 606,000 164,000 442,000 666,600 199,980 466,620 727,200 218,160 509,040 848,400 254,520 593,880 969,600 290,880 678,720
BBM00231 Lepas gips (Rawat Jalan) 112,970 33,891 79,079 102,700 30,810 71,890 112,970 33,891 79,079 123,240 36,972 86,268 143,780 43,134 100,646 164,320 49,296 115,024
BBM00232 Aff Lea (Rawat Jalan) 382,525 114,758 267,768 347,750 104,325 243,425 382,525 114,758 267,768 417,300 125,190 292,110 486,850 146,055 340,795 556,400 166,920 389,480
BBM00233 Pasang Laminaria (Rawat Jalan) 170,500 42,000 113,000 155,000 42,000 113,000 170,500 51,150 119,350 186,000 55,800 130,200 217,000 65,100 151,900 248,000 74,400 173,600
BBM00234 Aff Drain (dokter) (Rawat Jalan) 77,000 19,000 51,000 70,000 19,000 51,000 77,000 23,100 53,900 84,000 25,200 58,800 98,000 29,400 68,600 112,000 33,600 78,400
BBM00235 Debridement Kecil - Dokter Umum (Rawat
47,905 14,372 33,534 43,550 13,065 30,485 47,905 14,372 33,534 52,260 15,678 36,582 60,970 18,291 42,679 69,680 20,904 48,776
Jalan)
BBM00236 Debridement Sedang - Dokter Umum (Rawat
95,810 28,743 67,067 87,100 26,130 60,970 95,810 28,743 67,067 104,520 31,356 73,164 121,940 36,582 85,358 139,360 41,808 97,552
Jalan)
BBM00237 Debridement Besar - Dokter Umum (Rawat
143,715 43,115 100,601 130,650 39,195 91,455 143,715 43,115 100,601 156,780 47,034 109,746 182,910 54,873 128,037 209,040 62,712 146,328
Jalan)
BBM00238 Debridement Kecil - Dokter Spesialis (Rawat
95,810 28,743 67,067 87,100 26,130 60,970 95,810 28,743 67,067 104,520 31,356 73,164 121,940 36,582 85,358 139,360 41,808 97,552
Jalan)
BBM00239 Debridement Sedang - Dokter Spesialis
190,905 57,272 133,634 173,550 52,065 121,485 190,905 57,272 133,634 208,260 62,478 145,782 242,970 72,891 170,079 277,680 83,304 194,376
(Rawat Jalan)
BBM00240 Debridement Besar - Dokter Spesialis
286,715 86,015 200,701 260,650 78,195 182,455 286,715 86,015 200,701 312,780 93,834 218,946 364,910 109,473 255,437 417,040 125,112 291,928
(Rawat Jalan)
BBM00241 Tutul Pedofilin (Rawat Jalan) 82,500 24,750 57,750 75,000 22,500 52,500 82,500 24,750 57,750 90,000 27,000 63,000 105,000 31,500 73,500 120,000 36,000 84,000
BBM00242 Businasi (Rawat Jalan) 71,500 21,450 50,050 65,000 19,500 45,500 71,500 21,450 50,050 78,000 23,400 54,600 91,000 27,300 63,700 104,000 31,200 72,800
BBM00243 Spooeling / Kateter (Rawat Jalan) 69,300 19,000 44,000 63,000 19,000 44,000 69,300 20,790 48,510 75,600 22,680 52,920 88,200 26,460 61,740 100,800 30,240 70,560
BBM00244 Pasang Tampon Hidung (Rawat Jalan) 165,000 49,500 115,500 150,000 45,000 105,000 165,000 49,500 115,500 180,000 54,000 126,000 210,000 63,000 147,000 240,000 72,000 168,000
BBM00245 Kauterisasi Faring/Kaustik Faring (Rawat
71,500 21,450 50,050 65,000 19,500 45,500 71,500 21,450 50,050 78,000 23,400 54,600 91,000 27,300 63,700 104,000 31,200 72,800
Jalan)
BBM00246 Angkat Tampon Hidung (Rawat Jalan) 84,700 23,000 54,000 77,000 23,000 54,000 84,700 25,410 59,290 92,400 27,720 64,680 107,800 32,340 75,460 123,200 36,960 86,240
BBM00247 Pasang Gips Pada CTEV (Rawat Jalan) 382,525 114,758 267,768 347,750 104,325 243,425 382,525 114,758 267,768 417,300 125,190 292,110 486,850 146,055 340,795 556,400 166,920 389,480
BBM00248 Ekstirpasi Lipoma (Rawat Jalan) 735,900 201,000 468,000 669,000 201,000 468,000 735,900 220,770 515,130 802,800 240,840 561,960 936,600 280,980 655,620 1,070,400 321,120 749,280
BBM00249 Necrotomie (Rawat Jalan) 95,810 28,743 67,067 87,100 26,130 60,970 95,810 28,743 67,067 104,520 31,356 73,164 121,940 36,582 85,358 139,360 41,808 97,552
BBM00250 Sklerotheraphy Hemoroid (STH) (Rawat
865,150 259,545 605,605 786,500 235,950 550,550 865,150 259,545 605,605 943,800 283,140 660,660 1,101,100 330,330 770,770 1,258,400 377,520 880,880
Jalan)
BBM00253 Ganti Balutan(Rawat Jalan) 50,600 13,000 33,000 46,000 13,000 33,000 50,600 15,180 35,420 55,200 16,560 38,640 64,400 19,320 45,080 73,600 22,080 51,520
BBM00256 Pemasangan Kateter Vena Dalam (Dewasa) 519,090 155,727 363,363 471,900 141,570 330,330 519,090 155,727 363,363 566,280 169,884 396,396 660,660 198,198 462,462 755,040 226,512 528,528
BBM00257 (Rawat Jalan)Kateter Vena Dalam (Anak)
Pemasangan
(Rawat Jalan) 649,220 194,766 454,454 590,200 177,060 413,140 649,220 194,766 454,454 708,240 212,472 495,768 826,280 247,884 578,396
944,320 283,296 661,024
(70%)
(70%)
RS dan BHP
(70%)
RS dan BHP
(70%)
VIP B RS dan BHP
(70%) VIP A dan BHP (30%) (70%)
BBM00258 Pemasangan CVC/CVP (Dewasa) (Rawat
839,300 206,000 557,000 763,000 206,000 557,000 839,300 251,790 587,510 915,600 274,680 640,920 1,068,200 320,460 747,740 1,220,800 366,240 854,560
Jalan)
BBM00259 Pemasangan CVC/CVP (Anak) (Rawat
951,665 285,500 666,166 865,150 259,545 605,605 951,665 285,500 666,166 1,038,180 311,454 726,726 1,211,210 363,363 847,847 1,384,240 415,272 968,968
Jalan)
BBM00260 Aff Cateter Vena Presure (CVC/CVP)
512,600 126,000 340,000 466,000 126,000 340,000 512,600 153,780 358,820 559,200 167,760 391,440 652,400 195,720 456,680 745,600 223,680 521,920
(Rawat Jalan)
BBM00261 Sleep Analisis (Rawat Jalan) 1,714,570 514,371 1,200,199 1,558,700 467,610 1,091,090 1,714,570 514,371 1,200,199 1,870,440 561,132 1,309,308 2,182,180 654,654 1,527,526 2,493,920 748,176 1,745,744
BBM00264 Inseminasi (Dokter) (Rawat Jalan) 3,025,000 850,000 1,900,000 2,750,000 825,000 1,925,000 3,025,000 907,500 2,117,500 3,300,000 990,000 2,310,000 3,850,000 1,155,000 2,695,000 4,400,000 1,320,000 3,080,000
BBM00265 Kemoterapi Anak (Rawat Jalan) 250,965 75,290 175,676 228,150 68,445 159,705 250,965 75,290 175,676 273,780 82,134 191,646 319,410 95,823 223,587 365,040 109,512 255,528
BBM00266 Kemoterapi Umum (Dewasa) (Rawat Jalan)
303,160 90,948 212,212 275,600 82,680 192,920 303,160 90,948 212,212 330,720 99,216 231,504 385,840 115,752 270,088 440,960 132,288 308,672
BBM00267 Pemasangan IV Line (Vena Dalam) (Rawat
130,130 39,039 91,091 118,300 35,490 82,810 130,130 39,039 91,091 141,960 42,588 99,372 165,620 49,686 115,934 189,280 56,784 132,496
Jalan)
BBM00268 Pasang Cateter Umbilica (Rawat Jalan) 130,130 39,039 91,091 118,300 35,490 82,810 130,130 39,039 91,091 141,960 42,588 99,372 165,620 49,686 115,934 189,280 56,784 132,496
BBM00269 Biopsi / Aspirasi Jarum Halus ( FNAB )
266,200 65,000 177,000 242,000 65,000 177,000 266,200 79,860 186,340 290,400 87,120 203,280 338,800 101,640 237,160 387,200 116,160 271,040
(Rawat Jalan)
BBM00270 IVA TEST (Rawat Jalan) 60,500 18,150 42,350 102,050 30,615 71,435 112,255 33,677 78,579 122,460 36,738 85,722 142,870 42,861 100,009 163,280 48,984 114,296
BBM00271 TUTUL TCA (Rawat Jalan) 56,485 16,946 39,540 51,350 15,405 35,945 56,485 16,946 39,540 61,620 18,486 43,134 71,890 21,567 50,323 82,160 24,648 57,512
BBM00272 Buddy Tapping (Rawat Jalan) 240,240 72,072 168,168 218,400 65,520 152,880 240,240 72,072 168,168 262,080 78,624 183,456 305,760 91,728 214,032 349,440 104,832 244,608
131,560 39,468 92,092 119,600 35,880 83,720 131,560 39,468 92,092 143,520 43,056 100,464 167,440 50,232 117,208 191,360 57,408 133,952
(Rawat Jalan)
BBM00274 Pasang Tampon (Rawat Jalan) 149,600 41,000 95,000 136,000 41,000 95,000 149,600 44,880 104,720 163,200 48,960 114,240 190,400 57,120 133,280 217,600 65,280 152,320
BBM00275 Anastesi CT - SCAN ( Anak ) (Rawat Jalan)
157,300 47,190 110,110 143,000 42,900 100,100 157,300 47,190 110,110 171,600 51,480 120,120 200,200 60,060 140,140
228,800 68,640 160,160
BBM00276 Pasang Gripper (Rawat Jalan) 377,520 113,256 264,264 343,200 102,960 240,240 377,520 113,256 264,264 411,840 123,552 288,288 480,480 144,144 336,336 549,120 164,736 384,384
BBM00277 Aff / Lepas Gripper (Rawat Jalan) 223,300 61,000 142,000 203,000 61,000 142,000 223,300 66,990 156,310 243,600 73,080 170,520 284,200 85,260 198,940 324,800 97,440 227,360
BBM00278 Biopsi TTB Guiding CT SCan (Rawat Jalan)
196,625 58,988 137,638 178,750 53,625 125,125 196,625 58,988 137,638 214,500 64,350 150,150 250,250 75,075 175,175 286,000 85,800 200,200
BBM00279 Wide Eksisi / Wide Eksterpasi (Lokal
564,850 169,455 395,395 513,500 154,050 359,450 564,850 169,455 395,395 616,200 184,860 431,340 718,900 215,670 503,230 821,600 246,480 575,120
Anastesi) (Rawat Jalan)
BBM00280 Assesment Memory (Rawat Jalan) 449,735 134,921 314,815 408,850 122,655 286,195 449,735 134,921 314,815 490,620 147,186 343,434 572,390 171,717 400,673 654,160 196,248 457,912
BBM00281 Lepas Tampon Hidung dan Debridement
629,200 188,760 440,440 572,000 171,600 400,400 629,200 188,760 440,440 686,400 205,920 480,480 800,800 240,240 560,560 915,200 274,560 640,640
Pasca Operasi (Rawat Jalan)
BBM00284 Hecting Aff Sedang Poli Umum ( Benang 6
44,000 13,200 30,800 40,000 12,000 28,000 44,000 13,200 30,800 48,000 14,400 33,600 56,000 16,800 39,200
-10 ) (Rawat Jalan) 64,000 19,200 44,800
BBM00285 Hecting Aff Berat Poli Umum ( Benang >
66,000 19,800 46,200 60,000 18,000 42,000 66,000 19,800 46,200 72,000 21,600 50,400 84,000 25,200 58,800 96,000 28,800 67,200
10 ) (Rawat Jalan)
BBM00286 Rawat Luka Ringan ( Dokter Poli Umum )
33,000 9,900 23,100 30,000 9,000 21,000 33,000 9,900 23,100 36,000 10,800 25,200 42,000 12,600 29,400
(Rawat Jalan) 48,000 14,400 33,600
BBM00287 Rawat Luka Sedang ( Dokter Poli Umum )
49,500 14,850 34,650 45,000 13,500 31,500 49,500 14,850 34,650 54,000 16,200 37,800 63,000 18,900 44,100 72,000 21,600 50,400
(Rawat Jalan)
BBM00288 Rawat Luka Berat ( Dokter Poli Umum )
64,900 19,470 45,430 59,000 17,700 41,300 64,900 19,470 45,430 70,800 21,240 49,560 82,600 24,780 57,820 94,400 28,320 66,080
(Rawat Jalan)
BBM00289 Intubasi - Dokter Umum (Rawat Jalan) 130,130 39,039 91,091 118,300 35,490 82,810 130,130 39,039 91,091 141,960 42,588 99,372 165,620 49,686 115,934 189,280 56,784 132,496
BBM00290 Injeksi Tendon (Rawat Jalan) 117,975 35,393 82,583 107,250 32,175 75,075 117,975 35,393 82,583 128,700 38,610 90,090 150,150 45,045 105,105 171,600 51,480 120,120
BBM00291 Incisi Bulla di Membran Tymfani (Rawat
74,360 22,308 52,052 67,600 20,280 47,320 74,360 22,308 52,052 81,120 24,336 56,784 94,640 28,392 66,248 108,160 32,448 75,712
Jalan)
BBM00292 Perawatan Stoma/ Colostomi (Rawat Jalan)
77,000 21,000 49,000 70,000 21,000 49,000 77,000 23,100 53,900 84,000 25,200 58,800 98,000 29,400 68,600 112,000 33,600 78,400
BBM00293 Injeksi Kenacort A Intra Lesi (Rawat Jalan)
77,000 20,000 50,000 70,000 20,000 50,000 77,000 23,100 53,900 84,000 25,200 58,800 98,000 29,400 68,600 112,000 33,600 78,400
BBM00296 Hematologi ( ORTHOPEDI ) (Rawat Jalan) 103,400 25,000 69,000 94,000 25,000 69,000 103,400 31,020 72,380 112,800 33,840 78,960 131,600 39,480 92,120 150,400 45,120 105,280
BBM00297 Cystostomy ( Tanpa Kateter ) (Urologi)
396,000 97,000 263,000 360,000 97,000 263,000 396,000 118,800 277,200 432,000 129,600 302,400 504,000 151,200 352,800 576,000 172,800 403,200
(Rawat Jalan)
BBM00298 D.C Shock (Rawat Jalan) 268,400 73,000 171,000 244,000 73,000 171,000 268,400 80,520 187,880 292,800 87,840 204,960 341,600 102,480 239,120 390,400 117,120 273,280
BBM00299 Angkat Drain (Rawat Jalan) 33,000 9,000 21,000 30,000 9,000 21,000 33,000 9,900 23,100 36,000 10,800 25,200 42,000 12,600 29,400 48,000 14,400 33,600
BBM00300 AFF Katater ( UROLOGI ) (Rawat Jalan) 40,700 10,000 27,000 37,000 10,000 27,000 40,700 12,210 28,490 44,400 13,320 31,080 51,800 15,540 36,260 59,200 17,760 41,440
BBM00301 Sirkumsisi (Rawat Jalan) 1,430,000 300,000 1,000,000 1,300,000 300,000 1,000,000 1,430,000 429,000 1,001,000 1,560,000 468,000 1,092,000 1,820,000 546,000 1,274,000 2,080,000 624,000 1,456,000
BBM00302 Swab Hidung (Rawat Jalan) 84,700 23,000 54,000 77,000 23,000 54,000 84,700 25,410 59,290 92,400 27,720 64,680 107,800 32,340 75,460 123,200 36,960 86,240
BBM00303 Tindakan PILA (Rawat Jalan) 1,378,300 378,000 875,000 1,253,000 378,000 875,000 1,378,300 413,490 964,810 1,503,600 451,080 1,052,520 1,754,200 526,260 1,227,940 2,004,800 601,440 1,403,360
BBM00304 Intubasi ETT (Rawat Jalan) 155,100 42,000 99,000 141,000 42,000 99,000 155,100 46,530 108,570 169,200 50,760 118,440 197,400 59,220 138,180 225,600 67,680 157,920
BBM00305 Terminasi Kehamilan 825,000 247,500 577,500 750,000 225,000 525,000 825,000 247,500 577,500 900,000 270,000 630,000 1,050,000 315,000 735,000 1,200,000 360,000 840,000
BBM00306 Vagina Touch -Dokter Spesialis (Rawat 57,200 17,160 40,040 57,200 17,160 40,040 62,920 18,876 44,044 68,640 20,592 48,048 80,080 24,024 56,056 91,520 27,456 64,064
Jalan)
2.TARIF TINDAKAN UGD

KODE LAYANAN TINDAKAN UGD Jasa Sarana Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana RS
fee Medis fee Medis fee Medis fee Medis fee Medis fee Medis
(10%)
(10%)
RS dan BHP
(10%)
RS dan BHP
(10%)
VIP B RS dan BHP
Dokter (10%) VIP A dan BHP (90%)
Dokter (10%)
LAYANAN (90%) (90%) HCU (90%) ISOLASI (90%) (90%)+ BHP + BHP
BBM00292 Pengambilan Corpus Alienum ( Emergency ) 102,366 11,374 94,000 84,600 9,400 103,400 10,340 112,800 101,520 11,280 131,600 118,440 13,160
113,740 93,060 150,400 135,360 15,040
(Rawat Jalan) UGD
BBM00293 Tindakan Defibrilator / DC Shock > 5 kali 490,050 54,450 450,000 405,000 45,000 495,000 49,500 540,000 486,000 54,000 630,000 567,000 63,000
544,500 445,500 720,000 648,000 72,000
BBM00294 E K G ( Emergency )(Rawat Jalan) UGD 102,850 92,565 10,285 85,000 76,500 8,500 93,500 84,150 9,350 102,000 91,800 10,200 119,000 107,100 11,900 136,000 122,400 13,600
BBM00295 Tindakan Defibrilator / DC Shock < 5 kali 345,213 38,357 317,000 285,300 31,700 348,700 34,870 380,400 342,360 38,040 443,800 399,420 44,380
383,570 313,830 507,200 456,480 50,720
BBM00296 Tindik Telinga ( Emergency )(Rawat Jalan) 43,887 4,876 40,300 36,270 4,030 44,330 4,433 48,360 43,524 4,836 56,420 50,778 5,642
48,763 39,897
UGD 64,480 58,032 6,448
BBM00297 Suction ( Emergency )(Rawat Jalan) UGD 36,966 33,269 3,697 30,550 27,495 3,055 33,605 30,245 3,361 36,660 32,994 3,666 42,770 38,493 4,277 48,880 43,992 4,888
BBM00298 Aff TT ( Emergency )(Rawat Jalan) UGD 220,220 198,198 22,022 182,000 163,800 18,200 200,200 180,180 20,020 218,400 196,560 21,840 254,800 229,320 25,480 291,200 262,080 29,120
BBM00299 Resusitasi Kardio Pulmoner ( Emergency ) 193,479 174,131 19,348 159,900 143,910 15,990 175,890 158,301 17,589 191,880 172,692 19,188 223,860 201,474 22,386 255,840 230,256 25,584
BBM00300 (Rawat Jalan)
Lavement UGD
( Emergency )(Rawat Jalan) UGD 40,347 4,483 37,050 33,345 3,705 40,755 4,076 44,460 40,014 4,446 51,870 46,683 5,187
44,831 36,680
59,280 53,352 5,928
(10%)
(10%)
RS dan BHP
(10%)
RS dan BHP
(10%)
VIP B RS dan BHP
Dokter (10%)
LAYANAN (90%) (90%) HCU (90%) ISOLASI (90%) (90%)+ BHP + BHP
BBM00303 Ganti Balutan UGD 42,185 37,967 4,219 38,350 34,515 3,835 42,185 37,967 4,219 46,020 41,418 4,602 53,690 48,321 5,369 61,360 55,224 6,136
BBM00304 Vena Seksi ( Emergency )(Rawat Jalan) 116,474 12,942 117,650 105,885 11,765 129,415 12,942 141,180 127,062 14,118 164,710 148,239 16,471
129,415 116,474 188,240 169,416 18,824
UGD
BBM00305 Ekstraksi Kuku UGD ( Emergency )(Rawat 74,646 8,294 75,400 67,860 7,540 82,940 8,294 90,480 81,432 9,048 105,560 95,004 10,556
82,940 74,646 120,640 108,576 12,064
Jalan) UGD
BBM00306 Circumsisi UGD ( Emergency )(Rawat Jalan) 361,647 40,183 365,300 328,770 36,530 401,830 40,183 438,360 394,524 43,836 511,420 460,278 51,142
401,830 361,647 584,480 526,032 58,448
UGD
BBM00307 Spalk uk. 20 cm ( Emergency )(Rawat Jalan) 14,801 1,645 14,950 13,455 1,495 16,445 1,645 17,940 16,146 1,794 20,930 18,837 2,093
16,445 14,801 23,920 21,528 2,392
UGD
BBM00308 Spalk uk. 30 cm ( Emergency ) (Rawat 18,018 2,002 18,200 16,380 1,820 20,020 2,002 21,840 19,656 2,184 25,480 22,932 2,548
20,020 18,018 29,120 26,208 2,912
Jalan) UGD
23,595 21,236 34,320 30,888 3,432
Jalan) UGD
26,455 23,810 38,480 34,632 3,848
Jalan) UGD
30,745 27,671 44,720 40,248 4,472
Jalan) UGD
BBM00312 Jasa Tindakan Pasang Spalk UGD (Rawat 23,810 2,646 24,050 21,645 2,405 26,455 2,646 28,860 25,974 2,886 33,670 30,303 3,367
26,455 23,810 38,480 34,632 3,848
Jalan)
BBM00313 Jasa Tindakan Pasang Gyps Sederhana 189,189 21,021 191,100 171,990 19,110 210,210 21,021 229,320 206,388 22,932 267,540 240,786 26,754
210,210 189,189 305,760 275,184 30,576
UGD (Rawat Jalan)
BBM00314 Incisi Absces Kecil UGD (Rawat Jalan) 38,610 34,749 3,861 35,100 31,590 3,510 38,610 34,749 3,861 42,120 37,908 4,212 49,140 44,226 4,914 56,160 50,544 5,616
BBM00315 Incisi Absces Besar UGD (Rawat Jalan) 67,210 60,489 6,721 61,100 54,990 6,110 67,210 60,489 6,721 73,320 65,988 7,332 85,540 76,986 8,554 97,760 87,984 9,776
BBM00317 Angkat Jahitan Lebih dari 10 Jahitan UGD 56,430 6,270 57,000 51,300 5,700 62,700 6,270 68,400 61,560 6,840 79,800 71,820 7,980
62,700 56,430 91,200 82,080 9,120
(Rawat Jalan)
BBM00318 Angkat Jahitan 6 s/d 10 Jahitan UGD (Rawat 43,560 4,840 44,000 39,600 4,400 48,400 4,840 52,800 47,520 5,280 61,600 55,440 6,160
48,400 43,560 70,400 63,360 7,040
Jalan)
BBM00319 Angkat Jahitan s/d 5 Jahitan UGD (Rawat 29,700 3,300 30,000 27,000 3,000 33,000 3,300 36,000 32,400 3,600 42,000 37,800 4,200
33,000 29,700 48,000 43,200 4,800
Jalan)
BBM00320 Hecting Tambahan ( per jahitan ) UGD 8,366 930 8,450 7,605 845 9,295 930 10,140 9,126 1,014 11,830 10,647 1,183
9,295 8,366 13,520 12,168 1,352
(Rawat Jalan)
BBM00321 Hechting s/d 3 Jahitan UGD (Rawat Jalan) 71,500 64,350 7,150 65,000 58,500 6,500 71,500 64,350 7,150 78,000 70,200 7,800 91,000 81,900 9,100 104,000 93,600 10,400
BBM00322 Pasang Infus dengan Venaseksi UGD 250,965 27,885 253,500 228,150 25,350 278,850 27,885 304,200 273,780 30,420 354,900 319,410 35,490
278,850 250,965 405,600 365,040 40,560
(Rawat Jalan)
BBM00323 Amputasi Jari UGD (Rawat Jalan) 76,505 68,855 7,651 69,550 62,595 6,955 76,505 68,855 7,651 83,460 75,114 8,346 97,370 87,633 9,737 111,280 100,152 11,128
BBM00324 Tindakan Klisma / Glycerin Spuit UGD 50,837 5,649 51,350 46,215 5,135 56,485 5,649 61,620 55,458 6,162 71,890 64,701 7,189
56,485 50,837 82,160 73,944 8,216
(Rawat Jalan)
BBM00325 Pemasangan NGT + Bilas Lambung UGD 173,250 19,250 175,000 157,500 17,500 192,500 19,250 210,000 189,000 21,000 245,000 220,500 24,500
192,500 173,250 280,000 252,000 28,000
(Rawat Jalan)
BBM00326 Pemasangan NGT UGD (Rawat Jalan) 62,205 55,985 6,221 56,550 50,895 5,655 62,205 55,985 6,221 67,860 61,074 6,786 79,170 71,253 7,917 90,480 81,432 9,048
BBM00327 Resusitasi Jantung Paru UGD (Rawat Jalan) 86,229 9,581 87,100 78,390 8,710 95,810 9,581 104,520 94,068 10,452 121,940 109,746 12,194
95,810 86,229 139,360 125,424 13,936
BBM00328 Delatasi Preputium UGD (Rawat Jalan) 33,605 30,245 3,361 30,550 27,495 3,055 33,605 30,245 3,361 36,660 32,994 3,666 42,770 38,493 4,277 48,880 43,992 4,888
BBM00329 Pemasangan Endo Trachel Tube / Intubasi 129,344 14,372 130,650 117,585 13,065 143,715 14,372 156,780 141,102 15,678 182,910 164,619 18,291
143,715 129,344 209,040 188,136 20,904
( di luar alat ) (Rawat Jalan)
BBM00330 Pemasangan Kateter Urine UGD (Rawat 39,897 4,433 40,300 36,270 4,030 44,330 4,433 48,360 43,524 4,836 56,420 50,778 5,642
44,330 39,897
Jalan) 64,480 58,032 6,448
BBM00331 Punksi Supra Pubik UGD (Rawat Jalan) 82,940 74,646 8,294 75,400 67,860 7,540 82,940 74,646 8,294 90,480 81,432 9,048 105,560 95,004 10,556 120,640 108,576 12,064
BBM00332 Pasang Infus UGD (Rawat Jalan) 28,600 25,740 2,860 26,000 23,400 2,600 28,600 25,740 2,860 31,200 28,080 3,120 36,400 32,760 3,640 41,600 37,440 4,160
BBM00333 Roserplasty UGD (Rawat Jalan) 113,685 102,317 11,369 103,350 93,015 10,335 113,685 102,317 11,369 124,020 111,618 12,402 144,690 130,221 14,469 165,360 148,824 16,536
BBM00334 Inhalasi UGD (Rawat Jalan) 67,210 60,489 6,721 61,100 54,990 6,110 67,210 60,489 6,721 73,320 65,988 7,332 85,540 76,986 8,554 97,760 87,984 9,776
BBM00336 Eksplorasi Luka Sederhana UGD (Rawat 47,619 5,291 48,100 43,290 4,810 52,910 5,291 57,720 51,948 5,772 67,340 60,606 6,734
52,910 47,619 76,960 69,264 7,696
Jalan)
BBM00337 Nebulizer ( Emergency ) (Rawat Jalan) 56,485 50,837 5,649 51,350 46,215 5,135 56,485 50,837 5,649 61,620 55,458 6,162 71,890 64,701 7,189 82,160 73,944 8,216
BBM00340 Sewa Ruang Tindakan UGD (Rawat Jalan) 331,045 297,941 33,105 300,950 270,855 30,095 331,045 297,941 33,105 361,140 325,026 36,114 421,330 379,197 42,133 481,520 433,368 48,152
BBM00341 Psg. Neck Kollar UGD (Rawat Jalan) 22,880 20,592 2,288 20,800 18,720 2,080 22,880 20,592 2,288 24,960 22,464 2,496 29,120 26,208 2,912 33,280 29,952 3,328
BBM00342 Aff Catheter UGD (Rawat Jalan) 33,000 29,700 3,300 30,000 27,000 3,000 33,000 29,700 3,300 36,000 32,400 3,600 42,000 37,800 4,200 48,000 43,200 4,800
BBM00343 Aff Drain UGD (Rawat Jalan) 48,400 43,560 4,840 44,000 39,600 4,400 48,400 43,560 4,840 52,800 47,520 5,280 61,600 55,440 6,160 70,400 63,360 7,040
BBM00344 Irigasi Mata UGD (Rawat Jalan) 22,880 20,592 2,288 20,800 18,720 2,080 22,880 20,592 2,288 24,960 22,464 2,496 29,120 26,208 2,912 33,280 29,952 3,328
BBM00345 Psg. OGT UGD (Rawat Jalan) 81,510 73,359 8,151 74,100 66,690 7,410 81,510 73,359 8,151 88,920 80,028 8,892 103,740 93,366 10,374 118,560 106,704 11,856
BBM00347 Injeksi IM UGD (Rawat Jalan) 23,100 20,790 2,310 21,000 18,900 2,100 23,100 20,790 2,310 25,200 22,680 2,520 29,400 26,460 2,940 33,600 30,240 3,360
BBM00348 Injeksi IV UGD (Rawat Jalan) 23,100 20,790 2,310 21,000 18,900 2,100 23,100 20,790 2,310 25,200 22,680 2,520 29,400 26,460 2,940 33,600 30,240 3,360
BBM00349 Injeksi IC/ SC UGD (Rawat Jalan) 23,100 20,790 2,310 21,000 18,900 2,100 23,100 20,790 2,310 25,200 22,680 2,520 29,400 26,460 2,940 33,600 30,240 3,360
Observasi Pasien UGD 2 - 4 jam (Rawat 60,390 6,710
67,100 - - -
Jalan)
BBM00352 Observasi Pasien UGD 4 - 6 jam (Rawat 98,010 10,890 99,000 89,100 9,900 108,900 10,890 118,800 106,920 11,880 138,600 124,740 13,860
108,900 98,010 158,400 142,560 15,840
Jalan)
BBM00353 Observasi Pasien UGD 6 - 8 jam (Rawat 108,900 12,100 110,000 99,000 11,000 121,000 12,100 132,000 118,800 13,200 154,000 138,600 15,400
121,000 108,900 176,000 158,400 17,600
Jalan)
BBM00354 HECTING AFF RINGAN UGD ( BENANG 1- 29,700 3,300 30,000 27,000 3,000 33,000 3,300 36,000 32,400 3,600 42,000 37,800 4,200
33,000 29,700 48,000 43,200 4,800
5) (Rawat Jalan)
BBM00355 (Rawat Jalan)HECTING AFF SEDANG 54,450 6,050 55,000 49,500 5,500 60,500 6,050 66,000 59,400 6,600 77,000 69,300 7,700
60,500 54,450 88,000 79,200 8,800
UGD ( BENANG 6- 10)
BBM00356 HECTING AFF BERAT UGD ( BENANG 87,120 9,680 88,000 79,200 8,800 96,800 9,680 105,600 95,040 10,560 123,200 110,880 12,320
96,800 87,120 140,800 126,720 14,080
>10) (Rawat Jalan)
BBM00357 RAWAT LUKA RINGAN ( DOKTER UGD) 39,600 4,400 40,000 36,000 4,000 44,000 4,400 48,000 43,200 4,800 56,000 50,400 5,600
44,000 39,600 64,000 57,600 6,400
(Rawat Jalan)
BBM00358 RAWAT LUKA SEDANG ( DOKTER UGD) 66,000 59,400 6,600 60,000 54,000 6,000 66,000 59,400 6,600 72,000 64,800 7,200 84,000 75,600 8,400 96,000 86,400 9,600
BBM00359 (Rawat Jalan)
RAWAT LUKA BERAT ( DOKTER UGD) 88,000 79,200 8,800 80,000 72,000 8,000 88,000 79,200 8,800 96,000 86,400 9,600 112,000 100,800 11,200 128,000 115,200 12,800
BBM00360 (Rawat Jalan)(Rawat Jalan)
Suppositoria 20,790 2,310 21,000 18,900 2,100 23,100 2,310 25,200 22,680 2,520 29,400 26,460 2,940
23,100 20,790 33,600 30,240 3,360
LAYANAN
(10%)
(10%)
RS dan BHP
(10%)
RS dan BHP
(10%)
VIP B RS dan BHP
Dokter (10%)
(90%) (90%) HCU (90%) ISOLASI (90%) (90%)+ BHP + BHP
BBM0361 Injeksi Vitamin C ( Paket ) 96,800 87,120 9,680 96,800 87,120 9,680 154,880 139,392 15,488
BBM00362 Injeksi Vitamin C ( Premium ) 144,100 129,690 14,410 144,100 129,690 14,410 230,560 207,504 23,056
BBM00363 Swab Antigen ( Paket ) 187,000 135,000 35,000 187,000 135,000 35,000 299,200 269,280 29,920
BBM00364 Swab Antigen ( Paket Mahasiswa ) 108,900 93,900 15,000 108,900 93,900 15,000 174,240 156,816 17,424
BBM00365 Pemeriksaan Fisik Dokter Umum 44,000 32,000 12,000 44,000 32,000 12,000 70,400 63,360 7,040
BBM00366 Vagina Touch(DOKTER UGD) 44,000 32,000 12,000 44,000 32,000 12,000 70,400 63,360 7,040
3.TARIF ASUHAN KEPERAWATAN
LAYANAN HCU ISOLASI
BBM00361 Intubasi / ETT (Rawat Jalan) ASKEP 130,130 118,300 130,130 141,960 165,620 189,280
BBM00362 Resusitasi Jantung Paru (Rawat Jalan)
122,265 111,150 122,265 133,380 155,610 177,840
ASKEP
BBM00363 D.C. Shock (Rawat Jalan) ASKEP 226,655 206,050 226,655 247,260 288,470 329,680
BBM00364 Pasang NGT / Flow Care (Rawat Jalan)
72,215 65,650 72,215 78,780 91,910 105,040
ASKEP
BBM00365 Pasang Kateter Urine (Rawat Jalan) ASKEP
71,500 65,000 71,500 78,000 91,000 104,000
BBM00366 Ganti Balutan Kecil (Rawat Jalan) ASKEP 38,610 35,100 38,610 42,120 49,140 56,160
BBM00367 Ganti Balutan Sedang (Rawat Jalan) ASKEP
67,210 61,100 67,210 73,320 85,540 97,760
BBM00368 Ganti Balutan Besar (Rawat Jalan) ASKEP
107,250 97,500 107,250 117,000 136,500 156,000
BBM00369 Necrotomie (Rawat Jalan) ASKEP 44,330 40,300 44,330 48,360 56,420 64,480
BBM00370 Angkat Jahitan 1 - 5 Jahitan (Rawat Jalan)
53,625 48,750 53,625 58,500 68,250 78,000
ASKEP
BBM00371 Angkat Jahitan 6 - 10 Jahitan (Rawat
72,930 66,300 72,930 79,560 92,820 106,080
Jalan)ASKEP
BBM00372 Angkat Jahitan > 10 Jahitan (Rawat Jalan)
101,530 92,300 101,530 110,760 129,220 147,680
ASKEP
BBM00373 Perawatan Stoma / Colostomi (Rawat Jalan)
56,485 51,350 56,485 61,620 71,890 82,160
ASKEP
BBM00374 Pasang Infus (Rawat Jalan) ASKEP 42,185 38,350 42,185 46,020 53,690 61,360
BBM00375 Merawat Luka Gangren Kecil (Rawat Jalan)
27,885 25,350 27,885 30,420 35,490
ASKEP 40,560
BBM00376 Merawat Luka Gangren Besar (Rawat Jalan)
47,905 43,550 47,905 52,260 60,970 69,680
ASKEP
BBM00377 Merawat Luka Gangren Sedang (Rawat
36,465 33,150 36,465 39,780 46,410 53,040
Jalan) ASKEP
BBM00378 Inhalsi Therapy (Rawat Jalan) ASKEP 67,210 61,100 67,210 73,320 85,540 97,760
BBM00379 Blue Light (Rawat Jalan) ASKEP 44,330 40,300 44,330 48,360 56,420 64,480
BBM00381 Skin Test (Rawat Jalan) ASKEP 36,465 33,150 36,465 39,780 46,410 53,040
BBM00382 Klisma / Glycerin Spuit (Rawat Jalan)
56,485 51,350 56,485 61,620 71,890 82,160
ASKEP
BBM00383 Spoeling Mahokar (Rawat Jalan) ASKEP 33,605 30,550 33,605 36,660 42,770 48,880
BBM00384 Angkat Drain (Rawat Jalan) ASPER 27,885 25,350 27,885 30,420 35,490 40,560
BBM00385 Perawatan Tracheostomi (Rawat Jalan)
27,885 25,350 27,885 30,420 35,490 40,560
ASPER
BBM00390 Nebulizer Dgn Obat (Rawat Jalan) ASKEP 56,485 51,350 56,485 61,620 71,890 82,160
BBM00394 Ekstra Bed (Rawat Jalan) ASKEP 62,920 57,200 62,920 68,640 80,080 91,520
BBM00395 Nebulizer Tanpa Obat (Rawat Jalan) ASKEP
39,325 35,750 39,325 42,900 50,050 57,200
BBM00396 Aff Katheter (Rawat Jalan) ASKEP 19,305 17,550 19,305 21,060 24,570 28,080
BBM00397 Aff Drain (Rawat Jalan) ASKEP 27,885 25,350 27,885 30,420 35,490 40,560
BBM00398 Alat Cukur (Rawat Jalan) ASKEP 20,020 18,200 20,020 21,840 25,480 29,120
BBM00403 Debridement ( WT ) Berat (Rawat Jalan)
86,900 79,000 86,900 94,800 110,600 126,400
ASKEP
BBM00404 Sewa Alat Animax / Jam (Rawat Jalan)
12,870 11,700 12,870 14,040 16,380 18,720
ASKEP
BBM00405 Perawatan Luka / Medikasi - Kecil (Rawat
27,885 25,350 27,885 30,420 35,490 40,560
Jalan) ASKEP
BBM00406 Perawatan Luka / Medikasi - Sedang (Rawat
40,755 37,050 40,755 44,460 51,870 59,280
Jalan) ASKEP
BBM00407 Perawatan Luka / Medikasi - Besar (Rawat
86,900 79,000 86,900 94,800 110,600 126,400
Jalan) ASKEP
BBM00408 Injeksi Formalin (Rawat Jalan) ASKEP 492,800 448,000 492,800 537,600 627,200 716,800
BBM00409 Endoscopy Asuhan Keperawatan (Rawat
133,100 121,000 133,100 145,200 169,400 193,600
Jalan) ASKEP
BBM00410 Debridement Kecil - Perawat (Rawat Jalan)
33,000 30,000 33,000 36,000 42,000 48,000
ASKEP
BBM00411 Debridement Sedang - Perawat (Rawat
67,100 61,000 67,100 73,200 85,400
Jalan) ASKEP 97,600
BBM00412 Debridement Besar - Perawat (Rawat Jalan)
100,100 91,000 100,100 109,200 127,400 145,600
ASKEP
BBM00413 Paket Persalinan ( oleh Bidan) (Rawat
1,925,000 1,750,000 1,925,000 2,100,000 2,450,000
Jalan)ASKEP 2,800,000
BBM00414 Tindik Bayi (Rawat Jalan) ASKEP 44,330 40,300 44,330 48,360 56,420 64,480
BBM00415 Injeksi IM (Rawat Jalan) ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00416 Injeksi IV (Rawat Jalan) ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00426 Aff Infus (Rawat Jalan) ASKEP 24,200 22,000 24,200 26,400 30,800 35,200
BBM00430 Injeksi Kenacort A Intra Lesi Sedang (Rawat
154,000 140,000 154,000 168,000 196,000
Jalan) ASKEP 224,000
LAYANAN HCU ISOLASI
BBM00431 Tampon (Rawat Jalan) ASKEP 36,300 33,000 36,300 39,600 46,200 52,800
BBM00432 Kultur (Rawat Jalan) ASKEP 53,900 49,000 53,900 58,800 68,600 78,400
BBM00433 Ganti verband (Kulit) (Rawat Jalan) ASKEP
29,700 27,000 29,700 32,400 37,800 43,200
BBM00434 Injeksi kenacort (Rawat Jalan) ASKEP 33,000 30,000 33,000 36,000 42,000 48,000
BBM00435 Normal Dressing ( Orthopedi ) (Rawat Jalan)
58,300 53,000 58,300 63,600 74,200 84,800
ASKEP
BBM00436 Eksplorasi Kecil ( Orthopedi ) (Rawat Jalan)
221,100 201,000 221,100 241,200 281,400 321,600
ASKEP
BBM00437 Moderat Care (Rawat Jalan) ASKEP 46,200 42,000 46,200 50,400 58,800 67,200
BBM00438 Intermediate Care (Rawat Jalan)ASKEP 59,400 54,000 59,400 64,800 75,600 86,400
BBM00439 Maksimal Care (Rawat Jalan) ASKEP 93,500 85,000 93,500 102,000 119,000 136,000
BBM00440 Intensive Care (Rawat Jalan) ASKEP 133,100 121,000 133,100 145,200 169,400 193,600
BBM00441 Pemasangan Catheter Umbilikal (Rawat
293,700 267,000 293,700 320,400 373,800 427,200
Jalan) ASKEP
BBM00442 Inhalasi Therapy (Rawat Jalan) ASKEP 88,000 80,000 88,000 96,000 112,000 128,000
BBM00444 Lepas Tampon (Rawat Jalan) ASKEP 48,400 44,000 48,400 52,800 61,600 70,400
BBM00445 Aff Catheter Epidural (Rawat Jalan) ASKEP
532,400 484,000 532,400 580,800 677,600 774,400
BBM00446 Aff HD Catheter (Rawat Jalan)ASKEP 882,200 802,000 882,200 962,400 1,122,800 1,283,200
BBM00450 Aspirasi Jarum Halus (Rawat Jalan) ASKEP
143,000 130,000 143,000 156,000 182,000 208,000
BBM00451 Insersi / pasang IUD Mirena Asper (Rawat
154,000 140,000 154,000 168,000 196,000 224,000
Jalan) ASKEP
BBM00452 Pemasangan Gips Kecil (Rawat
346,500 315,000 346,500 378,000 441,000 504,000
Jalan)ASKEP
BBM00453 Pemasangan Gips Sedang (Rawat Jalan)
519,200 472,000 519,200 566,400 660,800 755,200
ASKEP
BBM00454 Pemasangan Gips Besar (Rawat Jalan)
691,900 629,000 691,900 754,800 880,600 1,006,400
ASKEP
BBM00455 Aff Pinning (Rawat Jalan) ASKEP 865,700 787,000 865,700 944,400 1,101,800 1,259,200
BBM00456 Aff Lea (Rawat Jalan) ASPER 588,500 535,000 588,500 642,000 749,000 856,000
BBM00458 Spooeling / Kateter (Rawat Jalan) ASKEP 95,700 87,000 95,700 104,400 121,800 139,200
BBM00459 Pasang Tampon Hidung (Rawat Jalan)
213,400 194,000 213,400 232,800 271,600 310,400
ASKEP
BBM00460 Pemasangan Kateter Vena Dalam (Dewasa)
798,600 726,000 798,600 871,200 1,016,400 1,161,600
(Rawat Jalan) ASKEP
BBM00461 Pemasangan Kateter Vena Dalam (Anak)
998,800 908,000 998,800 1,089,600 1,271,200 1,452,800
(Rawat Jalan) ASKEP
BBM00462 Aff Cateter Vena Presure (CVC/CVP)
665,500 605,000 665,500 726,000 847,000 968,000
(Rawat Jalan) ASKEP
BBM00463 Pengambilan Corpus Alienum (Rawat Jalan)
103,400 94,000 103,400 112,800 131,600 150,400
ASKEP
BBM00464 Tindakan Defibrilator / DC Shock > 5 kali
509,300 463,000 509,300 555,600 648,200 740,800
(Rawat Jalan) ASKEP
BBM00465 Tindakan Defibrilator / DC Shock < 5 kali
348,700 317,000 348,700 380,400 443,800 507,200
(Rawat Jalan) ASKEP
BBM00466 Suction (Rawat Jalan) ASKEP 51,700 47,000 51,700 56,400 65,800 75,200
BBM00467 Aff TT (Rawat Jalan) ASKEP 308,000 280,000 308,000 336,000 392,000 448,000
BBM00468 Resusitasi Kardio Pulmoner (Rawat Jalan)
270,600 246,000 270,600 295,200 344,400 393,600
ASKEP
BBM00472 Jasa Tindakan Pasang Spalk (Rawat Jalan)
36,300 33,000 36,300 39,600 46,200 52,800
ASKEP
BBM00473 Jasa Tindakan Pasang Gyps Sederhana
323,400 294,000 323,400 352,800 411,600 470,400
(Rawat Jalan) ASKEP
BBM00474 Incisi Absces Kecil (Rawat Jalan) ASKEP 59,400 54,000 59,400 64,800 75,600 86,400
BBM00475 Incisi Absces Besar (Rawat Jalan) ASKEP
103,400 94,000 103,400 112,800 131,600 150,400
BBM00477 Hecting Tambahan ( per jahitan ) (Rawat
14,300 13,000 14,300 15,600 18,200 20,800
Jalan)ASKEP
BBM00478 Hechting s/d 3 Jahitan (Rawat Jalan)
110,000 100,000 110,000 120,000 140,000 160,000
ASKEP
BBM00479 Pasang Infus dengan Venaseksi (Rawat
429,000 390,000 429,000 468,000 546,000 624,000
Jalan) ASKEP
BBM00480 Tindakan Klisma / Glycerin Spuit (Rawat
86,900 79,000 86,900 94,800 110,600 126,400
Jalan) ASKEP
BBM00481 Pemasangan NGT + Bilas Lambung
235,400 214,000 235,400 256,800 299,600 342,400
(Rawat Jalan) ASKEP
BBM00482 Pemasangan NGT (Rawat Jalan) ASKEP 95,700 87,000 95,700 104,400 121,800 139,200
BBM00483 Delatasi Preputium (Rawat Jalan) ASKEP
51,700 47,000 51,700 56,400 65,800
75,200
222,200 202,000 222,200 242,400 282,800 323,200
( di luar alat ) (Rawat Jalan) ASKEP
BBM00485 Punksi Supra Pubik (Rawat Jalan) ASKEP
127,600 116,000 127,600 139,200 162,400
185,600
BBM00486 Bilas lambung (Rawat Jalan) ASKEP 198,000 180,000 198,000 216,000 252,000 288,000
BBM00487 Psg. Neck Kollar (Rawat Jalan)ASKEP 35,200 32,000 35,200 38,400 44,800 51,200
BBM00488 Irigasi Mata (Rawat Jalan)ASKEP 35,200 32,000 35,200 38,400 44,800 51,200
BBM00489 Injeksi Epidural oleh Perawat (Rawat Jalan)
67,100 61,000 67,100 73,200 85,400 97,600
ASKEP
BBM00490 Pengambilan Darah Perifer (Rawat Jalan)
23,100 21,000 23,100 25,200 29,400 33,600
ASKEP
BBM00491 Pengambilan Darah Vena (Rawat Jalan)
23,100 21,000 23,100 25,200 29,400 33,600
ASKEP
BBM00492 Injeksi IC/SC (Rawat Jalan)ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00493 Funduscopi (Rawat Jalan) ASKEP 64,900 59,000 64,900 70,800 82,600 94,400
BBM00494 Ganti Condom Catheter (Rawat Jalan)
39,600 36,000 39,600 43,200 50,400 57,600
ASKEP
BBM00497 Moderat Care (Kelas 3) (Rawat Jalan)
42,900 39,000 42,900 46,800 54,600 62,400
ASKEP
BBM00498 Minimal Care (Rawat Jalan) ASKEP 18,700 17,000 18,700 20,400 23,800 27,200
BBM00499 Minimal Care (UGD) (Rawat Jalan) ASKEP
24,200 22,000 24,200 26,400 30,800
35,200
LAYANAN HCU ISOLASI
BBM00500 Moderat Care (UGD) (Rawat Jalan) ASKEP
42,900 39,000 42,900 46,800 54,600 62,400
BBM00503 Intermediat Care (Kelas 3) (Rawat Jalan)
55,000 50,000 55,000 60,000 70,000 80,000
ASKEP
BBM00506 Maksimal Care (Kelas 3) (Rawat Jalan)
84,700 77,000 84,700 92,400 107,800 123,200
ASKEP
BBM00509 Intensive Care (Kelas 3) (Rawat Jalan)
121,000 110,000 121,000 132,000 154,000 176,000
ASKEP
BBM00517 Moderat Care (HD) (Rawat Jalan)ASKEP 42,900 39,000 42,900 46,800 54,600 62,400
BBM00518 Maksimal Care (HD) (Rawat Jalan) ASKEP
93,500 85,000 93,500 102,000 119,000 136,000
BBM00519 Moderat Care (Minor-Kamar Operasi)
42,900 39,000 42,900 46,800 54,600 62,400
(Rawat Jalan) ASKEP
BBM00520 Moderat Care (Medium-Kamar Operasi)
51,700 47,000 51,700 56,400 65,800 75,200
(Rawat Jalan) ASKEP
BBM00521 Maksimal Care (Mayor-Kamar Operasi)
84,700 77,000 84,700 92,400 107,800 123,200
(Rawat Jalan) ASKEP
BBM00522 Maksimal Care (Khusus-Kamar Operasi)
102,300 93,000 102,300 111,600 130,200 148,800
(Rawat Jalan)ASKEP
BBM00523 Maksimal Care (Canggih-Kamar Operasi)
112,200 102,000 112,200 122,400 142,800 163,200
(Rawat Jalan)ASKEP
BBM00524 Pemberian Sonde (Rawat Jalan)ASKEP 13,200 12,000 13,200 14,400 16,800 19,200
BBM00525 Suction (pengambilan lendir) (Rawat Jalan)
19,800 18,000 19,800 21,600 25,200 28,800
ASKEP
BBM00526 Dressing Infus (Rawat Jalan) ASKEP 19,800 18,000 19,800 21,600 25,200 28,800
BBM00527 One Touch (Rawat Jalan) ASKEP 31,900 29,000 31,900 34,800 40,600 46,400
BBM00528 Mouthcare (Rawat Jalan) ASKEP 19,800 18,000 19,800 21,600 25,200 28,800
BBM00529 Kemoterapi Anak (Rawat Jalan) ASKEP 386,100 351,000 386,100 421,200 491,400 561,600
BBM00530 Kemoterapi Umum ( Dewasa) (Rawat Jalan)
466,400 424,000 466,400 508,800 593,600 678,400
ASKEP
BBM00532 Pemasangan IV Line (Vena Dalam) (Rawat
133,100 121,000 133,100 145,200 169,400 193,600
Jalan) ASKEP
BBM00533 Jasa Resusitasi Bayi Baru Lahir SC Perina
157,300 143,000 157,300 171,600 200,200 228,800
ASKEP
BBM00534 Jasa Resusitasi Bayi Baru Lahir Normal
119,900 109,000 119,900 130,800 152,600 174,400
Perina (Rawat Jalan) ASKEP
BBM00535 Mantoux Test ( PPD Test ) Dewasa (Rawat
236,500 215,000 236,500 258,000 301,000 344,000
Jalan) ASKEP
BBM00536 Mantoux Test ( PPD Test ) Anak - Primer
236,500 215,000 236,500 258,000 301,000 344,000
(Rawat Jalan)ASKEP
BBM00537 Mantoux Test ( PPD Test ) Anak -
236,500 215,000 236,500 258,000 301,000 344,000
Intermediate (Rawat Jalan) ASKEP
BBM00538 Mantoux Test ( PPD Test ) Anak - Sekunder
236,500 215,000 236,500 258,000 301,000 344,000
(Rawat Jalan) ASKEP
BBM00542 Spalk 5 - 20 cm (Rawat Jalan) ASKEP 31,900 29,000 31,900 34,800 40,600 46,400
BBM00543 Spalk 20 - 40 cm (Rawat Jalan)ASKEP 53,900 49,000 53,900 58,800 68,600 78,400
BBM00544 Spalk > 40 cm (Rawat Jalan) ASKEP 93,500 85,000 93,500 102,000 119,000 136,000
BBM00545 Evakuasi Serumen Telinga - (Rawat Jalan)
49,500 45,000 49,500 54,000 63,000 72,000
ASKEP
BBM00546 Cukur Kepala - (Rawat Jalan)ASKEP 110,000 100,000 110,000 120,000 140,000 160,000
BBM00547 Suppositoria (Rawat Jalan) ASKEP 23,100 21,000 23,100 25,200 29,400 33,600
BBM00548 Vagina Touch (Rawat Jalan)ASKEP 44,000 44,000 48,400 52,800 61,600 70,400
BBM00549 Pemasangan Infus Pump - (Rawat Jalan)
38,500 38,500 42,350 46,200 53,900 61,600
ASKEP
BBM00550 Pemasangan Oksigen- (Rawat Jalan)
27,500 27,500 30,250 33,000 38,500 44,000
ASKEP
BBM00551 Pemasangan Syringe Pump - (Rawat Jalan)
26,950 26,950 29,645 32,340 37,730 43,120
ASKEP
BBM00552 TINDAKAN NST -(Rawat Jalan) ASKEP 96,800 96,800 106,480 116,160 135,520 154,880
BBM00553 Breast Care -(Rawat Jalan) ASKEP 41,470 41,470 45,617 49,764 58,058 66,352
BBM00554 Periksa Dalam -(Rawat Jalan) ASKEP 44,000 44,000 48,400 52,800 61,600 70,400
IV.KAMAR PERAWATAN / ROOM CHARGE
KODE DAFTAR TARIF LAYANAN KAMAR

TARIF
LAYANAN PERAWATAN
R.001 VIP A 750,000
R..002 VIP B 500,000
R..003 Kelas I 350,000
R.004 Kelas II 250,000
R.005 Kelas III 125,000
R.006 Pediatric 250,000
R..007 HCU 350,000
R.008 VK 500,000
R.009 Bayi sehat 200,000
R.010 OK 715,000
V. KAMAR BERSALIN

KODE LAYANAN KAMAR BERSALIN Jasa Sarana KELAS II / Jasa Sarana KELAS I / Jasa Sarana Jasa Sarana Jasa Sarana
fee Medis fee Medis fee Medis fee Medis fee Medis
KELAS III RS dan BHP RS dan BHP RS dan BHP VIP B RS dan BHP VIP A RS dan BHP
LAYANAN (70%) HCU (70%) ISOLASI (70%) (70%) (70%)
(30%) (30%) (30%) (30%) (30%)
VK001 Sewa Kamar Bersalin 550,000 605,000 660,000 770,000 880,000
OK001 Sewa Kamar Operasi 786,500 865,150 943,800 1,101,100 1,258,400
VK002 Jasa DOKTER ANAK ( OBGYN ) 165,000 49,500 115,500 181,500 54,450 127,050 198,000 59,400 138,600 231,000 69,300 161,700 264,000 79,200 184,800
Jasa Resusitasi Bayi Baru Lahir SC (Dokter
165,000
VK003 Anak ) 181,500 198,000 231,000 264,000
Jasa Resusitasi Bayi Baru Lahir Normal
220,000
VK004 ( Dokter Anak ) 242,000 264,000 308,000 352,000
Jasa Pengawasan Dokter Pada Persalinan
220,000
VK005 Bidan Normal 242,000 264,000 308,000 352,000
Jasa Resusitasi Dokter Anak jika persalinan
110,000
VK006 Bidan 121,000 132,000 154,000 176,000
VK007 OBSERVASI VK < 6 JAM 88,000 26,400 61,600 96,800 29,040 105,600 31,680 73,920 123,200 36,960 86,240 140,800 42,240 98,560
VK008 OBSERVASI VK > 6JAM 121,000 36,300 84,700 133,100 39,930 93,170 145,200 43,560 101,640 169,400 50,820 118,580 193,600 58,080 135,520
VK009 INFANT WARMER 29,700 8,910 20,790 32,670 9,801 22,869 35,640 10,692 24,948 41,580 12,474 29,106 47,520 14,256 33,264
OK002 KAMAR OBSERVASI RAWAT INAP 60,500 18,150 42,350 66,550 19,965 46,585 72,600 21,780 50,820 84,700 25,410 59,290 96,800 29,040 67,760
VK010 Persalinan Epidural 3,577,650 3,935,415 4,293,180 5,008,710 5,724,240
VK011 PAKET KURETASE - Kelas III - VK 2,970,000
VK012 PAKET KURETASE - Kelas II - VK 3,696,000
VK013 PAKET KURETASE - Kelas I - VK 4,466,000
VK014 PAKET KURETASE - Kelas VIP B - VK 5,170,000
VK015 PAKET KURETASE - Kelas VIP A- VK 6,006,000
OK003 PAKET KURETASE - Kelas III - OK 4,235,000
OK004 PAKET KURETASE - Kelas II - OK 5,280,000
OK005 PAKET KURETASE - Kelas I - OK 6,380,000
OK006 PAKET KURETASE - Kelas VIP B - OK 7,480,000
OK007 PAKET KURETASE - Kelas VIP A- OK 8,580,000
5,175,000
VK016 PAKET PERSALINAN NORMAL KELAS III
VK017 PAKET PERSALINAN NORMAL KELAS II 5,750,000
PAKET PERSALINAN NORMAL KELAS I
PAKET PERSALINAN NORMAL KELAS
VK024 VIP B (DENGAN PENYULIT) 8,855,000
PAKET PERSALINAN NORMAL KELAS
VK025 VIP A (DENGAN PENYULIT) 10,752,500
OK008 PAKET PERSALINAN SC KELAS III 8,250,000
OK009 PAKET PERSALINAN SC KELAS II 9,000,000
OK015 PAKET PERSALINAN SC KELAS I 12,705,000
OK016 PAKET PERSALINAN SC KELAS VIP B 17,325,000
OK017 PAKET PERSALINAN SC KELAS VIP A 19,635,000
OK018 PAKET PERSALINAN RE SC KELAS III 9,350,000
OK019 PAKET PERSALINAN RE SC KELAS II 10,285,000
OK020 PAKET PERSALINAN RE SC KELAS I 13,200,000
OK021 PAKET PERSALINAN RE SC KELAS VIP B 17,600,000
OK022 PAKET PERSALINAN RE SC KELAS VIP A 19,800,000

PAKET PERSALINAN GEMELI / Bayi
9,350,000
OK023 Kembar Kelas III
OK024 Kembar Kelas II 10,285,000
OK025 Kembar Kelas I 13,200,000
OK026 Kembar Kelas VIP B 17,600,000
OK027 Kembar Kelas VIP A 19,800,000
VK026 PAKET PERSALINAN - BIDAN 3,850,000 4,658,500 5,082,000 5,929,000 6,776,000
OK028 Paket Verikokel 10,450,000 12,100,000 13,750,000 15,400,000 16,720,000
Tindakan Dengan Penyulit Dikenakan Kenaikan Tarif 50% dari Tarif Normal
BEDAH UMUM
KODE LAYANAN
LAYANAN
MEDIUM
KOBU0001 Dokter operator 1,430,000 1,100,000 330,000 2,005,575 1,542,750 462,825 2,674,100 2,057,000 617,100 3,646,500 2,805,000 841,500 4,132,700 3,179,000 953,700
KOBU0007 Sewa Alat 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000
TOTAL 4,662,450 3,586,500 1,075,950 5,325,255 4,096,350 1,228,905 6,391,190 4,916,300 1,474,890 7,882,550 6,063,500 1,819,050 8,563,230 6,587,100 1,976,130
MAYOR
KOBU0013 Dokter operator 1,859,000 1,430,000 429,000 2,272,985 1,748,450 524,535 2,917,200 2,244,000 673,200 3,889,600 2,992,000 897,600 4,533,815 3,487,550 1,046,265
KOBU0019 Sewa Alat 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000
TOTAL 5,120,050 3,938,500 1,181,550 5,699,629 4,384,330 1,315,299 6,731,530 5,178,100 1,553,430 8,222,890 6,325,300 1,897,590 9,124,791 7,019,070 2,105,721
KODE LAYANAN
LAYANAN
KHUSUS
KOBU0025 Dokter operator 4,004,000 3,080,000 924,000 4,404,400 3,388,000 1,016,400 4,804,800 3,696,000 1,108,800 5,605,600 4,312,000 1,293,600 6,406,400 4,928,000 1,478,400
KOBU0026 Dokter Anestesi 1,601,600 1,232,000 369,600 1,761,760 1,355,200 406,560 1,921,920 1,478,400 443,520 2,242,240 1,724,800 517,440 2,562,560 1,971,200 591,360
KOBU0031 Sewa Alat 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000 715,000 550,000 165,000
TOTAL 8,123,050 6,248,500 1,874,550 8,683,610 6,679,700 2,003,910 9,374,170 7,210,900 2,163,270 10,625,290 8,173,300 2,451,990 11,746,410 9,035,700 2,710,710
BEDAH KEBIDANAN

KODE LAYANAN
LAYANAN
PAKET SC
SCBBM001 Jasa Operator 1,430,000 1,100,000 330,000 2,005,575 1,542,750 462,825 2,674,100 2,057,000 617,100 3,646,500 2,805,000 841,500 4,132,700 3,179,000 953,700
SCBBM006 Sewa OK 1,001,000 770,000 231,000 1,001,000 770,000 231,000 1,001,000 770,000 231,000 1,001,000 770,000 231,000 1,001,000 770,000 231,000
SCBBM007 Sewa Alat 700,000 538,462 161,538 700,000 538,462 161,538 700,000 538,462 161,538 700,000 538,462 161,538 700,000 538,462 161,538
TOTAL 4,964,000 3,818,462 1,145,538 5,603,405 4,310,312 1,293,093 6,697,940 5,152,262 1,545,678 8,217,900 6,321,462 1,896,438 8,890,780 6,839,062 2,051,718
PAKET RE SC
SCBBM008 Jasa Operator 1,859,000 1,430,000 429,000 2,272,985 1,748,450 524,535 2,917,200 2,244,000 673,200 3,889,600 2,992,000 897,600 4,533,815 3,487,550 1,046,265
SCBBM013 Sewa OK 1,101,100 847,000 254,100 1,101,100 847,000 254,100 1,101,100 847,000 254,100 1,101,100 847,000 254,100 1,101,100 847,000 254,100
SCBBM014 Sewa Alat 1,078,000 829,231 248,769 1,078,000 829,231 248,769 1,078,000 829,231 248,769 1,078,000 829,231 248,769 1,078,000 829,231 248,769
TOTAL 5,933,500 4,564,231 1,369,269 6,550,259 5,038,661 1,511,598 7,619,340 5,861,031 1,758,309 9,185,060 7,065,431 2,119,629 10,161,321 7,816,401 2,344,920
Catatan : Untuk tindakan dengan penyulit dan cito berlaku kenaikan tarif 30 % dari tarif normal.
VII. TARIF HIGH CARE UNIT (HCU)
1.TARIF TINDAKAN UNIT HCU

JENIS Jasa Sarana
fee Medis
KODE LAYANAN HIGH CARE UNIT TARIF RS dan BHP
Dokter (60%)
LAYANAN (40%)+ BHP
BBM00813 Pasang Catheter Vena Central ( CVC 255,200 382,800

638,000
) Rawat Jalan HCU
BBM00814 Pasang Arteri Line Rawat Jalan HCU 106,480 159,720
266,200
BBM00815 Pasang Catheter Vena Central 255,200 382,800
Tehnik Seldinger Rawat Jalan HCU 638,000
BBM00816 Resusitasi Cardio Pulmoner Rawat 93,720 140,580

234,300
Jalan HCU
BBM00817 Venaseksi Rawat Jalan HCU 366,300 146,520 219,780
BBM00818 Intubasi Rawat Jalan HCU 176,000 70,400 105,600
BBM00819 Lumbal Punctie Rawat Jalan HCU 220,000 88,000 132,000
BBM00820 Pasang Drain Thorax Rawat Jalan 212,960 319,440
532,400
HCU
BBM00821 Punctie Thorax / Abdomen / Pleura 137,720 206,580
344,300
Rawat Jalan HCU
BBM00822 Pasang I.V. Line selain di lengan dan 63,800 95,700
159,500
di kaki Rawat Jalan HCU
BBM00823 Trakeostomi Rawat Jalan HCU 798,600 319,440 479,160
BBM00824 Set Ventilator Rawat Jalan HCU 292,600 117,040 175,560
BBM00825 Ekstubasi pada Prolonged Intubation 42,680 64,020
106,700
Rawat Jalan HCU
BBM00826 Pasang Swan - Ganz Catheter Rawat 255,640 383,460
639,100
Jalan HCU
BBM00827 Analgesia Epidural Rawat Jalan HCU 106,480 159,720
266,200
BBM00828 Ganti Kanul Trakeostomi Rawat 74,360 111,540
185,900
Jalan HCU
2.TARIF PEMAKAIAN OKSIGEN

JENIS TARIF LAYANAN
KODE LAYANAN OKSIGEN / OXYGEN KELAS II / KELAS I /
LAYANAN HCU ISOLASI
BBM00853 Oksigen Paket / Jam di OK 128,700 129,000 141,000 152,000 231,660
BBM00854 Nitrogen Paket / Jam di OK 128,700 129,000 141,000 152,000 231,660
BBM00855 Oksigen ( Sewa tabung kecil ) / Hari 39,600 40,000 44,000 47,000 71,280
BBM00856 Oksigen ( Sewa tabung besar ) / Hari 80,300 80,000 87,000 94,000 144,540
BBM00857 Oksigen ( Biaya isi tabung kecil ) 46,200 47,000 51,000 55,000 83,160
BBM00858 Oksigen ( Biaya isi tabung besar ) 93,500 93,000 102,000 110,000 168,300
BBM00859 Oksigen ( Jaminan tabung kecil ) 1,464,100 1,464,000 1,597,000 1,730,000 2,635,380
BBM00860 Oksigen ( Jaminan tabung besar ) 2,928,200 2,928,000 3,194,000 3,461,000 5,270,760
VIII.TARIF PEMAKAIAN ALAT EMERGENCY
JENIS TARIF LAYANAN
KODE LAYANAN PEMAKAIAN ALAT KELAS II / KELAS I /
EMERGENCY KELAS III VIP B VIP A
LAYANAN HCU ISOLASI
BBM00868 Ventilator ( UGD ) 177,100 177,000 193,000 230,230 256,795
BBM00869 Ventilator ( Emergency ) perhari 188,100 244,530 272,745
BBM00870 Monitor EKG / Bed Side Monitor ( UGD ) 44,000 48,000 157,300 175,450
121,000
( perhari )
BBM00871 Observasi di UGD < 2 Jam ( UGD ) 89,100 89,000 97,000 115,830 129,195
BBM00872 Observasi di UGD > 2 jam < 4 jam (UGD ) 106,000 116,000 138,710 154,715
106,700
BBM00873 Nebulizer ( UGD ) 61,600 62,000 68,000 80,080 89,320

BBM00874 Nebulizer ( Emergency ) 74,800 97,240 108,460
BBM00875 Doppler (UGD) 38,500 22,000 24,000 50,050 55,825
BBM00876 EKG ( Emergency ) 71,500 92,950 103,675
BBM00877 Monitor Tensi ( UGD ) 35,200 35,000 39,000 45,760 51,040
BBM00878 One Touch ( UGD ) 35,200 35,000 39,000 45,760 51,040
BBM00879 Pesawat WSD ( UGD ) 67,100 67,000 73,000 87,230 97,295
BBM00880 Oksimetri ( UGD ) 13,200 13,000 15,000 17,160 19,140
BBM00881 Inkubator Lebih dari 6 Jam s/d 1 Hari 128,700 141,570 154,440 167,310 186,615
BBM00882 Inkubator Kurang dari 6 Jam 80,300 88,330 96,360 104,390 116,435
BBM00883 Kasur Decubitus 31,900 35,090 38,280 41,470 46,255
BBM00884 Infusion Pump 422,400 464,640 506,880 549,120 612,480
BBM00885 Syringe Pump 422,400 464,640 506,880 549,120 612,480
BBM00886 Monitor EKG / Bed Side Monitor 121,000 133,100 145,200 157,300 175,450
BBM00887 CTG 93,500 102,850 112,200 121,550 135,575
BBM00888 Breast Pump Elektrik 31,900 35,090 38,280 41,470 46,255
BBM00889 C-ARM 266,200 292,820 319,440 346,060 385,990
BBM00890 SEWA ALAT OK 965,800 1,062,380 1,158,960 1,255,540 1,400,410
BBM00891 Kursi Roda ( Sewa ) 110,000 121,000 132,000 143,000 159,500
BBM00892 Kursi Roda ( Jaminan Sewa ) 2,928,200 3,221,020 3,513,840 3,806,660 4,245,890
BBM00893 Animec 16,500 18,150 19,800 21,450 23,925
BBM00894 Oksimetri 12,100 13,310 14,520 15,730 17,545
BBM00895 Sewa Alat Holter -
BBM00896 KACAMATA FOTOTERAPI 64,350 70,785 77,220 83,655 93,308
BBM00897 NST Continue / Jam 32,267 35,493 38,720 41,947 46,787
IX.TARIF AMBULANCE

KODE LAYANAN AMBULANCE RAWAT JALAN/ KELAS II KELAS I
KELAS III
VIP B VIP A
LAYANAN HCU ISOLASI
BBM00001 AMBULANCE - PAKET ON CALL HOTEL 600,000 600,000 600,000 600,000 600,000
BBM00002 AMBULANCE - PAKET ON CALL RUMAH 300,000 300,000 300,000 300,000
300,000
BBM00003 Ambulance Antar Atau Jemput Pasien Luar 15,000 15,000 15,000 15,000
15,000
Kota ( 200,000 )+ Per Km
BBM00004 Ambulance Antar Pasien Dalam Kota ( 5 Km
- - - - -
Pertama )
BBM00005 Ambulance Antar Pasien Dalam Kota ( > 5
70,000 70,000 70,000 70,000 70,000
Km Pertama )
BBM00006 Ambulance Antar Atau Jemput Pasien
25,000 25,000 25,000 25,000 25,000
Dalam Kota ( 70,000 )+ Per Km
X.TARIF MEDICAL CHECK UP

KODE
MEDICAL CHECK UP RAWAT JALAN
LAYANAN
MCU001 PAKET BASIC 620,000
MCU002 PAKET SILVER 1,500,000
MCU003 PAKET GOLD 4,650,000
MCU004 PAKET PLATINUM 5,270,000
MCU005 PAKET PRE MARITAL TORCH 1,975,000
2.TARIF LAUNDRY

KODE LAYANAN LAUNDRY & PRESSING SERVICE RAWAT KELAS II KELAS I /
JALAN/KELAS VIP B VIP A
LAYANAN III HCU ISOLASI
BBM00894 SHIRT / KEMEJA 16,500 18,150 19,800 25,410 26,400
BBM00895 T-SHIRT / KAOS OBLONG 12,100 13,310 14,520 18,634 19,360
BBM00896 NECTIE / DASI 5,500 6,050 6,600 8,470 8,800
BBM00897 UNDERSHIRT / KAOS DALAM 7,700 8,470 9,240 11,858 12,320
BBM00898 UNDERWEAR / CELANA DALAM 7,700 8,470 9,240 11,858 12,320
BBM00899 TRAUSER / CELANA PANJANG 17,600 19,360 21,120 27,104 28,160
BBM00900 POLO SHIRT / KAOS BERKERAH 13,200 14,520 15,840 20,328 21,120
BBM00901 SARONG / SARUNG 12,100 13,310 14,520 18,634 19,360
BBM00902 VEST / ROMPI 12,100 13,310 14,520 18,634 19,360
BBM00903 SOCK / KAOS KAKI 4,400 4,840 5,280 6,776 7,040
BBM00904 SHORT / CELANA PENDEK 12,100 13,310 14,520 18,634 19,360
BBM00905 BLOUSE / BLUES 17,600 19,360 21,120 27,104 28,160
BBM00906 SKRIT / ROK BAWAH 12,100 13,310 14,520 18,634 19,360
BBM00907 LONG SKRIT / ROK BAWAH PANJANG 17,600 19,360 21,120 27,104 28,160
BBM00908 SLACK / CELANA PANJANG 17,600 19,360 21,120 27,104 28,160
BBM00909 BRASSIERES / BH 4,400 4,840 5,280 6,776 7,040
BBM00910 PANTIES / CELANA DALAM 4,400 4,840 5,280 6,776 7,040
BBM00911 NIGHT GOWN / BAJU TIDUR 17,600 19,360 21,120 27,104 28,160
BBM00912 MUKENA 17,600 19,360 21,120 27,104 28,160
BBM00913 HANDKERCHIEF 4,400 4,840 5,280 6,776 7,040
3.TARIF AMINITIES
KODE AMUNITIES RAWAT KELAS II KELAS I /
JALAN/KELAS VIP B VIP A
LAYANAN III HCU ISOLASI
BBM00914 Kendil 8,800 9,680 10,560 12,320 14,080
BBM00915 Paket Plastik Kamar Bersalin 11,000 12,100 13,200 15,400 17,600
BBM00916 Paket Plastik Kamar Operasi 11,000 12,100 13,200 15,400 17,600
BBM00917 Paket Bayi 77,000 84,700 92,400 107,800 123,200
BBM00918 Paket Mandi Ibu 33,000 30,000 30,000 60,000 60,000
TARIF ASURANSI SILOAM
Normal
BASIC 6,000,000
STANDAR 7,000,000
DELUXE 8,000,000
VIP 9,000,000
Casesar
STANDAR 14,000,000
DELUXE 16,000,000
VIP 18,000,000
Biaya Paket :
Administrasi
Biaya Kamar Rawat Inap ( 3 Hari 2 Malam )
Biaya Kamar Bersalin
Biaya Kamar Operasi
PAKET LAB IBU
Visit Dokter Spesialis Kandungan
Visit Dokter Spesialis Anak
Pemeriksaan Screening Pendengaran Anak
SC DAN PARTUS
KELAS III KELAS II KELAS I VIP B VIP A

400,000 400,000 400,000 400,000 400,000
375,000 750,000 1,050,000 1,500,000 2,250,000
500,000 500,000 500,000 500,000 500,000
715,000 715,000 715,000 715,000 715,000
774,500 851,950 929,400 1,006,850 1,084,300
150,000 165,000 180,000 210,000 240,000
150,000 165,000 180,000 210,000 240,000
3,064,500 3,546,950 3,954,400 4,541,850 5,429,300

TARIF VISIT DOKTER SPESIALIS
KELAS III KELAS II KELAS I KELAS VIP B KELAS VIP A
75,000 82,500 90,000 105,000 120,000
PAKET LAB
KELAS III KELAS II KELAS I KELAS VIP B KELAS VIP A
774,500 851,950 929,400 1,006,850 1,084,300
KONTAINER HIJAU
HARGA HARGA DASAR
NO NAMA ITEM QTY KELAS III KELAS II KELAS I KELAS VIP B KELAS VIP A
DASAR X QTY
1 Apron 5 1,920 Rp 9,600 Rp 12,480 Rp 17,472 Rp 18,720 Rp 19,968 Rp 21,216

2 Asifit / ASI M 12 1,500 Rp 18,000 Rp 23,400 Rp 32,760 Rp 35,100 Rp 37,440 Rp 39,780
3 Betadine 5 9,000 Rp 45,000 Rp 58,500 Rp 81,900 Rp 87,750 Rp 93,600 Rp 99,450
4 Biosyn 1 154,000 Rp 154,000 Rp 200,200 Rp 280,280 Rp 300,300 Rp 320,320 Rp 340,340
5 Bisturi 2 3,000 Rp 6,000 Rp 7,800 Rp 10,920 Rp 11,700 Rp 12,480 Rp 13,260
6 Cefazol 4 30,000 Rp 120,000 Rp 156,000 Rp 218,400 Rp 234,000 Rp 249,600 Rp 265,200
7 Cendo Genta (farmasi) 1 50,016 Rp 50,016 Rp 65,021 Rp 91,029 Rp 97,531 Rp 104,033 Rp 110,535
8 Catheter 1 18,467 Rp 18,467 Rp 24,007 Rp 33,610 Rp 36,011 Rp 38,411 Rp 40,812
9 Cromic gut 1 83,600 Rp 83,600 Rp 108,680 Rp 152,152 Rp 163,020 Rp 173,888 Rp 184,756
10 D5% 2 7,630 Rp 15,260 Rp 19,838 Rp 27,773 Rp 29,757 Rp 31,741 Rp 33,725
11 daryatule 1 34,100 Rp 34,100 Rp 44,330 Rp 62,062 Rp 66,495 Rp 70,928 Rp 75,361
12 Dexamethason 3 3,000 Rp 9,000 Rp 11,700 Rp 16,380 Rp 17,550 Rp 18,720 Rp 19,890
13 Face Shield 2 6,000 Rp 12,000 Rp 15,600 Rp 21,840 Rp 23,400 Rp 24,960 Rp 26,520
14 Fetik / Pronalget supo 6 19,500 Rp 117,000 Rp 152,100 Rp 212,940 Rp 228,150 Rp 243,360 Rp 258,570
15 Handscoon Non Steril 12 4,000 Rp 48,000 Rp 62,400 Rp 87,360 Rp 93,600 Rp 99,840 Rp 106,080
16 Handscoon STERIL 8 19,200 Rp 153,600 Rp 199,680 Rp 279,552 Rp 299,520 Rp 319,488 Rp 339,456
17 Hypafix 2 5,000 Rp 10,000 Rp 13,000 Rp 18,200 Rp 19,500 Rp 20,800 Rp 22,100
18 INFUS SET 1 15,068 Rp 15,068 Rp 19,588 Rp 27,424 Rp 29,383 Rp 31,341 Rp 33,300
19 Kalmoxillin / amoxillin 12 4,200 Rp 50,400 Rp 65,520 Rp 91,728 Rp 98,280 Rp 104,832 Rp 111,384
20 Kalnex 2 16,500 Rp 33,000 Rp 42,900 Rp 60,060 Rp 64,350 Rp 68,640 Rp 72,930
21 Kassa 20 1,900 Rp 38,000 Rp 49,400 Rp 69,160 Rp 74,100 Rp 79,040 Rp 83,980
22 Ketorolac 1 16,667 Rp 16,667 Rp 21,667 Rp 30,333 Rp 32,500 Rp 34,667 Rp 36,833
23 Lactamam 12 3,500 Rp 42,000 Rp 54,600 Rp 76,440 Rp 81,900 Rp 87,360 Rp 92,820
24 Lidokain 3 2,000 Rp 6,000 Rp 7,800 Rp 10,920 Rp 11,700 Rp 12,480 Rp 13,260
25 Masker 4 600 Rp 2,400 Rp 3,120 Rp 4,368 Rp 4,680 Rp 4,992 Rp 5,304
26 MISOTAB / NOPROSTOL 3 6,800 Rp 20,400 Rp 26,520 Rp 37,128 Rp 39,780 Rp 42,432 Rp 45,084
27 NACL 2 6,272 Rp 12,544 Rp 16,307 Rp 22,830 Rp 24,461 Rp 26,092 Rp 27,722
28 Nasal Canul 1 6,272 Rp 6,272 Rp 8,154 Rp 11,415 Rp 12,230 Rp 13,046 Rp 13,861
29 NEO K INJEKSI 1 17,050 Rp 17,050 Rp 22,165 Rp 31,031 Rp 33,248 Rp 35,464 Rp 37,681
30 Ondansentron 1 10,000 Rp 10,000 Rp 13,000 Rp 18,200 Rp 19,500 Rp 20,800 Rp 22,100
31 Opsite 1 41,800 Rp 41,800 Rp 54,340 Rp 76,076 Rp 81,510 Rp 86,944 Rp 92,378
32 Oxyla 2 25,300 Rp 50,600 Rp 65,780 Rp 92,092 Rp 98,670 Rp 105,248 Rp 111,826
33 Pampers 1 7,000 Rp 7,000 Rp 9,100 Rp 12,740 Rp 13,650 Rp 14,560 Rp 15,470
34 Pembalut (pack) 1 6,500 Rp 6,500 Rp 8,450 Rp 11,830 Rp 12,675 Rp 13,520 Rp 14,365
35 Pentanyl 1 64,372 Rp 64,372 Rp 83,684 Rp 117,157 Rp 125,525 Rp 133,894 Rp 142,262
36 Polysorb 4 143,000 Rp 572,000 Rp 743,600 Rp 1,041,040 Rp 1,115,400 Rp 1,189,760 Rp 1,264,120
37 Regivell 1 77,000 Rp 77,000 Rp 100,100 Rp 140,140 Rp 150,150 Rp 160,160 Rp 170,170
38 RL 5 7,630 Rp 38,150 Rp 49,595 Rp 69,433 Rp 74,393 Rp 79,352 Rp 84,312
39 Sanmol 12 600 Rp 7,200 Rp 9,360 Rp 13,104 Rp 14,040 Rp 14,976 Rp 15,912
40 Sarung tangan panjang GLOVE 1 39,000 Rp 39,000 Rp 50,700 Rp 70,980 Rp 76,050 Rp 81,120 Rp 86,190
41 Spinochan 1 37,081 Rp 37,081 Rp 48,205 Rp 67,487 Rp 72,308 Rp 77,128 Rp 81,949
42 Spuit 1 cc 3 1,000 Rp 3,000 Rp 3,900 Rp 5,460 Rp 5,850 Rp 6,240 Rp 6,630
46 Stagen 1 25,000 Rp 25,000 Rp 32,500 Rp 45,500 Rp 48,750 Rp 52,000 Rp 55,250
47 Suction biru 1 6,232 Rp 6,232 Rp 8,102 Rp 11,342 Rp 12,152 Rp 12,963 Rp 13,773
49 Topi operasi 4 1,100 4,400 Rp 5,720 Rp 8,008 Rp 8,580 Rp 9,152 Rp 9,724
50 Transofix 1 8,900 8,900 Rp 11,570 Rp 16,198 Rp 17,355 Rp 18,512 Rp 19,669
51 umbilical Clamb 1 3,000 3,000 Rp 3,900 Rp 5,460 Rp 5,850 Rp 6,240 Rp 6,630
52 Underpad Besar 5 3,500 17,500 Rp 22,750 Rp 31,850 Rp 34,125 Rp 36,400 Rp 38,675
53 Urine bag 1 4,950 4,950 Rp 6,435 Rp 9,009 Rp 9,653 Rp 10,296 Rp 10,940
54 Vaksin hepatitis B (fermasi) 1 75,000 75,000 Rp 97,500 Rp 136,500 Rp 146,250 Rp 156,000 Rp 165,750
55 WFI 4 5,000 20,000 Rp 26,000 Rp 36,400 Rp 39,000 Rp 41,600 Rp 44,200
56 Plain 0 1 80,000 80,000 Rp 104,000 Rp 145,600 Rp 156,000 Rp 166,400 Rp 176,800
TOTAL 1,228,627 2,403,629 3,124,717 4,374,604 4,687,076 4,999,548 5,312,019

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I.

TARIF RAWAT JALAN / POLIKLINIK DAN RAWAT INAP

1. REGISTRASI ( Pendaftaran Pasien)

REG0001 Administrasi Rumah Sakit 27,500

3.POLI ANAK SPESIALIS

DAFTAR TARIF LAYANAN

7.TARIF KONSULTASI GIZI

10. TARIF FISIOTERAPI

LAYANAN LABORATORIUM / LABORATORY

LAYANAN HCU ISOLASI

S02669 - CEPHALOMETRY C-R (RAWAT JALAN) 236,610 378,576 302,861 75,715

S02673 - CLAVICULA DEXTRA (RAWAT JALAN) 193,050

S02675 - CLAVICULA SINISTRA (RAWAT JALAN) 193,050 308,880 247,104 61,776

211,860 338,976 271,181 67,795

235,620 376,992 301,594 75,398

207,900 332,640 266,112 66,528

206,910 331,056 264,845 66,211

S02704 - K. CERVICOTHORACAL AP / LAT / OBL 331,650

212,850 340,560 272,448 68,112

212,850 340,560 272,448 68,112

2,603,700 4,165,920 3,332,736 833,184

4,056,030 6,489,648 5,191,718 1,297,930

3.TARIF DIAGNOSTIK ELEKTROMEDIK

1.TARIF TINDAKAN DOKTER

2.TARIF TINDAKAN UGD

3.TARIF ASUHAN KEPERAWATAN

IV.KAMAR PERAWATAN / ROOM CHARGE

KODE DAFTAR TARIF LAYANAN KAMAR

JENIS DAFTAR TARIF LAYANAN

JENIS DAFTAR TARIF LAYANAN

VII. TARIF HIGH CARE UNIT (HCU)

1.TARIF TINDAKAN UNIT HCU

BBM00813 Pasang Catheter Vena Central ( CVC ) 255,200 382,800

2.TARIF PEMAKAIAN OKSIGEN

DAFTAR TARIF LAYANAN

X.TARIF MEDICAL CHECK UP

JENIS DAFTAR TARIF LAYANAN

1. REGISTRASI ( Pendaftaran Pasien)

REG0001 Administrasi Rumah Sakit 27,500

3.POLI ANAK SPESIALIS

DAFTAR TARIF LAYANAN

7.TARIF KONSULTASI GIZI

GIGI0038 GTC ( Gigi Tiruan Cekat ) Bahan Akrilik

10. TARIF FISIOTERAPI

S02634 - ADENOID C-R ( RAWAT JALAN ) 244,530 391,248 312,998 78,250

S02645 - ARTERIOGRAFI FEMORALIS

S02647 - Babygram C-R (RAWAT JALAN) 216,810 346,896 277,517 69,379

245,520 392,832 314,266 78,566

S02704 - K. CERVICOTHORACAL AP / LAT 331,650

79,200 126,720 101,376 25,344

490,050 784,080 627,264 156,816

326,700 522,720 418,176 104,544

236,610 378,576 302,861 75,715

189,090 189,088 151,271 37,818

370,260 370,258 296,207 74,052

3.TARIF DIAGNOSTIK ELEKTROMEDIK

1.TARIF TINDAKAN DOKTER

2.TARIF TINDAKAN UGD

KODE DAFTAR TARIF LAYANAN KAMAR

JENIS DAFTAR TARIF LAYANAN

OK021 PAKET PERSALINAN RE SC KELAS VIP B 17,600,000

OK022 PAKET PERSALINAN RE SC KELAS VIP A 19,800,000

JENIS DAFTAR TARIF LAYANAN