LAMPIRAN PERATURAN BUPATI SAMOSIR

NOMOR : 2018
TANGGAL : 2018
TENTANG : PERUBAHAN ATAS LAMPIRAN PERATURAN
BUPATI SAMOSIR NOMOR 18 TAHUN 2017
TENTANG PERUBAHAN ATAS LAMPIRAN
PERATURAN BUPATI SAMOSIR NOMOR 11
TAHUN 2015 TENTANG PERUBAHAN TARIF
RETRIBUSI PELAYANAN KESEHATAN PADA
RUMAH SAKIT UMUM DAERAH Dr.
HADRIANUS SINAGA PANGURURAN
KABUPATEN SAMOSIR

STRUKTUR DAN BESARNYA TARIF PELAYANAN KESEHATAN PADA RUMAH SAKIT UMUM DAERAH
Dr. HADRIANUS SINAGA PANGURURAN

A. PELAYANAN RAWAT JALAN

JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Dokter Umum/ Dokter gigi/ Psikolog 6,250 6,250 12,500 25,000
2 Dokter Spesialis 7,000 7,000 21,000 35,000

B. PELAYANAN RAWAT INAP

1. SUPERVIP, VIP DAN KELAS

JASA RUMAH SAKIT

NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Super Vip
- Dokter Umum / dokter gigi 128,125 128,125 256,250 512,500
- Spesialis 143,750 143,750 287,500 575,000
2 VIP
- Dokter Umum / dokter gigi 63,125 63,125 126,250 252,500
- Spesialis 71,875 71,875 143,750 287,500
3 Kelas I
- Dokter Umum / dokter gigi 51,250 51,250 102,500 205,000
- Spesialis 56,250 56,250 112,500 225,000
4 Kelas II
- Dokter Umum / dokter gigi 37,813 37,813 75,625 151,250
- Spesialis 41,563 41,563 83,125 166,250
5 Kelas III
- Dokter Umum / dokter gigi 26,875 26,875 53,750 107,500
- Spesialis 31,250 31,250 62,500 125,000
6 Ruang perawatan Bayi Baru Lahir (Neonatal)
- Dokter Umum 5,938 5,938 11,875 23,750
- Spesialis 16,313 16,313 32,625 65,250
7 Perinatologi usia anak diatas 28 hari
- Dokter Umum 31,250 31,250 62,500 125,000
- Spesialis 36,563 36,563 73,125 146,250
Inkubator
- Dokter Umum 49,063 49,063 98,125 196,250
- Spesialis 57,813 57,813 115,625 231,250

2. RECOVERY ROOM (Ruang Pemulihan Pasca Operasi)

JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Recovery room
- Dokter Umum / dokter gigi - 50,000 50,000 100,000
- Spesialis - 50,000 62,500 125,000
3. KONSULTASI MEDIS

NO JENIS PELAYANAN Dokter Spesialis Antar Spesialis

1 KONSULTASI di ruang perawatan 65,000 65,000

2 KONSULTASI DI ICU 110,000 110,000
3 KONSULTASI IGD 70,000 70,000

C. PELAYANAN IGD ( INSTALASI GAWAT DARURAT )

JASA RUMAH SAKIT
NO TINDAKAN PELAYANAN JASA JASA JUMLAH
BHP SARANA PELAYANAN
1 2 3 4 5 6
1 Heacting
a. Luka Jahitan 1-3 15,625 15,625 31,250 62,500
b. Pertambahan setiap 2,500 - 2,500 5,000
jahitan luka > 3 jahitan
c. Buka heacting/heacting
Buka heacting 5,000 5,000 10,000 20,000
d. Pembersihan luka/non Heacting
- Kecil 10,000 10,000 20,000 40,000
- Sedang 13,750 13,750 27,500 55,000
- Besar 17,500 17,500 35,000 70,000
2 Kumbah lambung 39,063 39,063 78,125 156,250
3 Cooling Spoling 32,813 32,813 65,625 131,250
4 Tindakan emergency
a. Syok ( R.J.P ) 26,563 26,563 53,125 106,250
b. Luka Bakar Ringan 17,188 17,188 34,375 68,750
c. Luka Bakar Sedang 26,563 26,563 53,125 106,250
d. Luka Bakar Berat 39,063 39,063 78,125 156,250
5 Pelayanan Umum 5,938 5,938 11,875 23,750
6 Extirpasi benda asing :
a. Kecil
- Cerumen poof ( 1 telinga ) 17,188 17,188 34,375 68,750
- Padi, kapas, jagung
b. Sedang
- Kacang, manik-manik, mainan 50,000 50,000 100,000 200,000
- Ekstraksi kuku, Clavus
c. Besar
- Mimis ( peluru senapan angin)
23,438 23,438 46,875 93,750
- Extirpasi kutis, clavus
- Insisi abses
7 Observasi di IGD
a. 0 s/d 4 jam 12,500 12,500 25,000 50,000
b. 4 jam s/d 8 jam 20,313 20,313 40,625 81,250
c. > 8 jam (One Day Care) 21,875 21,875 43,750 87,500
8 Pemasangan NGT 32,813 32,813 65,625 131,250
9 Pemasangan Spalk
a. 1 s/d 2 extremitas 21,875 21,875 43,750 87,500
b. diatas 2 extremitas 31,250 31,250 62,500 125,000
10 Nebulaizer / kali 12,500 12,500 25,000 50,000
11 Sirkumsisi 90,000 90,000 270,000 450,000
12 Amputasi Jari Ekstremitas -
b. I ruas 33,750 33,750 67,500 135,000
c. Amputasi pertambahan tiap ruas jari - - 75,000 75,000
13 Pasang Collar neck 17,500 17,500 35,000 70,000
14 Extirpasi benda asing di mata/spooling 50,000 50,000 100,000 200,000
15 Operasi tumor/Limpoma diameter < 2 cm 25,000 25,000 150,000 200,000
16 Punksi Blast 75,000 75,000 150,000 300,000
17 Perawatan Luka dengan Jahitan :
1 s/d 5 cm 15,000 10,000 25,000 50,000
6 s/d 10 cm 21,000 14,000 35,000 70,000
> 10 cm 30,000 20,000 50,000 100,000
18 Reposisi Dislokasi 44,000 44,000 132,000 220,000

D. PELAYANAN PONEK
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 Persalinan Normal 140,625 140,625 281,250 562,500
2 Persalinan Giemelli/ Kembar dst 171,875 171,875 343,750 687,500
3 Persalinan dengan tindakan Vakum 171,875 171,875 343,750 687,500
4 Persalinan Letak Bokong( Abnormal) 171,875 171,875 343,750 687,500
5 Curetase 125,000 125,000 250,000 500,000
6 Manual Plasenta 109,375 109,375 218,750 437,500
Hecting Porsio/refair laresari servik 250,000 250,000 600,000 1,100,000
Curetage encloserviks 100,000 100,000 200,000 400,000
Inspekulo 15,000 15,000 30,000 60,000
7 Embriotomi 193,750 193,750 387,500 775,000
E. PELAYANAN ICU (INTENSIVE CARE UNIT)
JASA RUMAH SAKIT
NO BHP JASA JASA JUMLAH
JENIS PELAYANAN SARANA PELAYANAN
1 Perawatan Khusus di ICU
Dokter Spesialis 0 178,125 178,125 356,250
Dokter Umum/Dokter jaga ICU 0 146,875 146,875 293,750

2 Tindakan Pelayanan
Kanulasi Vena Perifer/Infus 15,625 - 15,625 31,250
Kanulasi Vena Sentral (CVC) Dewasa 93,750 93,750 187,500 375,000
Kanulasi Vena Sentral (CVC) Anak 93,750 93,750 187,500 375,000
WSD (Water Sealed Drainage) 187,500 187,500 375,000 750,000
Vena Sectie 37,500 37,500 75,000 150,000
DC Shock 34,375 34,375 68,750 137,500
Tracheostomy 140,625 140,625 281,250 562,500
Intubasi Trakhea 62,500 62,500 125,000 250,000
Ekstubasi Trakhea 31,250 31,250 62,500 125,000
RJP 46,875 46,875 93,750 187,500
Setting Ventilator 40,625 40,625 81,250 162,500
Suction/Washing/Hari 10,938 10,938 21,875 43,750
Nebulizer/kali 12,500 12,500 25,000 50,000
Insersi NGT 25,000 25,000 50,000 100,000
Maag-cooling/ Cooling Spoeling 31,250 31,250 62,500 125,000
Pasang Catheter Urine 25,000 25,000 50,000 100,000
Lepas Catheter Urine 6,250 6,250 12,500 25,000
Klisma 14,063 14,063 28,125 56,250
EKG 20,313 20,313 40,625 81,250
Ventilator (Jasa sarana/hari) 84,375 84,375 168,750 337,500
Siringe Pump ( Jasa sarana/hari 20,313 20,313 40,625 81,250
Infusion Pump ( Jasa sarana/hari) 20,313 20,313 40,625 81,250
Bed Decubitus - 50,000 - 50,000
Warm mattres/Hari - 50,000 - 50,000
Oksigen/Liter (sistem central) 28 29 56 113
Oksigen/Liter 28 29 56 113

F. TINDAKAN OPERATIF BEDAH

NO JENIS PELAYANAN BHP JASA RUMAH SAKIT JUMLAH
JASA JASA
SARANA PELAYANAN
1 Operasi Kecil 390,625 390,625 781,250 1,562,500
2 Operasi Sedang 578,125 578,125 1,156,250 2,312,500
3 Operasi Besar 812,500 812,500 1,625,000 3,250,000
4 Operasi Khusus/ Estetika 1,000,000 1,000,000 2,000,000 4,000,000

Ketentuan :
Kelompok Penyakit berdasarkan kategori :
1. Operasi Kecil yang dikerjakan dikamar operasi :
No Nama Penyakit
1 Tumor Jinak ( Ateroma, Limpoma dan lain-lain)
2 Reposisi fraktur tertutup / dislokasi sederhana
3 Debridemen
4 Sunat
5 Blast fungsi
6 Biopsi Surgical pada organ dalam di poliklinik
7 Meatositotomy
8 Vasectomy
9 Basinasi (pada awal stenasis)
10 Pemasangan gips tanpa traksi
11 Bibir sumbing di poliklinik
12 Sambung Scuden di poliklinik
2. Operasi Sedang
No Nama Penyakit
1 Hernia, Hidrokel,Varikokel
2 Apendiksitis, infiltrat
3 Batu buli-buli
4 Peyakit Pembuluh Drah Perifer
5 Bibir sumbing biasa/Duplek besar
6 Kelainan tangan bawaan
7 Luka bakar diatas 10% tanpa komplikasi
8 Diskolasi sendi bahu,siku,pergelangan tangan,
interphalans, Panggul tumit sendisis,rahang
9 Kateterisasi Uretra
10 Pasang gips dengan anastesi umum atau traksi
11 Biopsi dengan anastesi
12 Sistotomi urine
13 Sonde Heacting
14 Reposisi extremitas tertutup atau pemasangan gips
15 Herniothrapi
16 Haemorroid
17 Vesicolithiasis
18 Fibroadenoma mamae
19 Thorax Drainage
20 Exploras Corpus
21 Amputasi jari kaki dan jari tangan
22 Debridemen fraktur terbuka pemasangan gips
23 Cabut Implan S

3. Operasi Besar
No Nama Penyakit
1 Kelainan bawaan di tulang muka,
jaringan lunak muka neurofibroma
2 Kriptorkismus, Mekakolon, Hypospadi CTEV
dan kelainan orthopedi lain
3 Pembuluh darah intra abdominal,
retroperitoneum, mediastinum
4 Semua jenis tumor ganas
5 Semua jenis trauma yang tidak termasuk
dalam kelompok tindakan sedang
6 Prostatectomy
7 Operasi plastik
8 Siplemastectomy
9 Sub total lebectomy
10 Sub total thyroindectomy
11 Colostomy
12 Amputasi extremitas
13 Debridement
14 Bibir sumbing mengenai platum/rongga hidung
15 Platum plastik
16 Tumor thyroid, mamae,rahang paru-paru,pembuluh darah,
Intra abdominal,retroperitonial,mediastinum.
17 Tumor sedang yang memakai Narkose
18 Pendarahan thorax ,abdomen,saluran kemih,jaringan muka,
rongga mulut,kerusakan pembuluh darah
19 Atresia usus
20 Obstruksi saluran pernafasan
21 Trans uretra reseksi
22 Fixatia external
23 Lixatie External
24 Reposisi terbuka di lokasi sendi
25 Sambung tendon
26 Lielolitomy
27 Neprollitotomy
28 Ureter Cateter
29 Peritonitis Diffuse (karena maag perporasi Thypoid)
30 Apendixitis perporasi dll
31 Reposisi fraktur terbuka dengan internal pixatie
32 Koreksi mal union ostheomyelitis
33 Total Crystectomy urine
34 Thelecytectomy
35 Cipino Broscia Fictule
 G. TINDAKAN OPERATIF OBSTETRI dan GINEKOLOGI
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 Operasi kecil 390,625 390,625 781,250 1,562,500
2 Operasi sedang 578,125 578,125 1,156,250 2,312,500
3 Operasi Besar 812,500 812,500 1,625,000 3,250,000
4 Operasi Khusus/ Estetika 1,000,000 1,000,000 2,000,000 4,000,000

Ketentuan :
Kelompok penyakit berdasarkan kategori :
1. Operasi Kecil :
No Nama Penyakit
1 Kista Bartolini
2 Exterpasi polip
3 Tubectomi
4 Ekstirpasi mioma geburt
5 Insisi Himen Inferporat
6 Pamorif/Kr.C/Tubectomi
7 Inseminasi
8 Tumor jinak ( Marsupialisasi mengangkat tumor kecil
9 Biopsi Endometrium
10 Exterpasi Condilomata
11 Conterisasi Erois Persionis
12 Pertubasi/Hidrotubasi
13 Biopsi tumor genitalia eksterna
14 Exterpasi septum vagina
15 Penjahitan luka diatas 10 jahitan

2. Operasi Sedang
No Nama Penyakit
1 Kolporapi
2 Minilaparatomi (kontap)
3 Laparatomi KET (Kehamilan Ektolik Terganggu)
4 Manual Plasenta
5 Konisasi Servik
6 Curetage isap (Vakum)
7 Curetage
8 Sterilisasi post partus
9 Sterilisasi culdus copy
10 Sterilisasi laparoscopy
11 Laparascopy diagnostic
12 Calporeksi
13 Partus Normal
14 Vakum/Extraksi/Forcef
15 Embriotomi
16 Tumor Jinak ovarium
17 Miomectomy
19 Laparatomy kehamilan ektopik terganggu/KET
20 Salpingoperektomy/Histerektomy
18 Operasi Shrodkar
19 Utilisasi arteria hipogastrica

3. Operasi Besar
No Nama Penyakit
1 Kista Ovarium
2 Sectio Caesaria
3 Rapair Ruptur Perineum Grade III, IV
4 Miomektomi
5 Histerektomy
6 Tumor ganas ovarium
7 Reporasi Fistel
8 Reporasi Tuba/Rekalisasi
9 Operasi Porro
10 Histerorapia Anterior/Posterior
11 Operasi reposisi infersion uteria
12 Operasi Plastik vaginam
13 Vulvectomy
4. Operasi Khusus
NO NAMA PENYAKIT
1 Histerektomi abdominal atau vaginal
2 Laparatomi keganasan Ginekologi
3 Vaginoplasti
4 Reparasi vistel dan Tuba
5 Radical mastectomy
6 Radical neck Disectomy regional perfusion
7 Hiphorostesis
8 Scoliosis Corection
9 Anterior fusion vertebra
10 Hip Frakture
11 Bedah paru reseksi
12 Multiple Frakture
13 Operasi vasculer
14 Trans section aesofagus
15 Resecti Hepar rectum
16 Comminutive frakture
17 Shunting
18 Knee Protesis
19 Pelvix frakture
20 Internal Pixatie tulang belakang
21 Operasi sendi besar ( Coxae Knee)
22 Megacolon
23 Laparatomy resectio usus

H. PELAYANAN DI POLIKLINIK SPESIALIS

1. POLI BEDAH
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Sederhana / Ganti Verban 14,063 14,063 28,125 56,250
2 Pemasangan Bidai 20,313 20,313 40,625 81,250
3 Pemasangan Gyps 21,875 21,875 43,750 87,500
4 Pemasangan Neck Kollar 9,375 9,375 18,750 37,500
5 Pemasangan Ransel verban 10,000 10,000 30,000 50,000
6 Pemasangan ETT Intubasi 16,250 16,250 32,500 65,000
7 Pemberian Nebulizer 12,500 12,500 25,000 50,000
8 Debridement Kecil 9,375 9,375 18,750 37,500
9 Debridement Sedang 14,063 14,063 28,125 56,250
10 Primer Heacting 10,938 10,938 21,875 43,750
11 Cross Insisi 15,625 15,625 31,250 62,500
12 Blass Puncti 15,625 15,625 31,250 62,500
13 Reposisi Sendi 17,188 17,188 34,375 68,750
14 Bedah minor khusus (yang tidak dikerjakan
46,875 46,875 93,750 187,500
dalam kamar operasi seperti sirkumsisi
Heacting :
a. Luka Jahitan 1-3 15,625 15,625 31,250 62,500
b. Pertambahan setiap
1,250 1,250 2,500 5,000
jahitan luka > 3 jahitan
15 c. Buka heacting/heacting 5000 5000 10000 20,000
d. Pembersihan luka/non Heacting
- Kecil 10,000 10,000 20,000 40,000
- Sedang 13,750 27,500 55,000
- Besar 17,500 17,500 35,000 70,000

2. POLI KEBIDANAN
JASA RUMAH SAKIT
NO TINDAKAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 NORPLAN 42,188 42,188 84,375 168,750
2 AKDR/IUD 29,688 29,688 59,375 118,750
3 Depo/Injeksi 5,625 5,625 11,250 22,500
4 Pasang Ring 28,125 28,125 56,250 112,500
5 Pemeriksaan Selaput Dara 17,188 17,188 34,375 68,750
6 Papsmear 14,063 14,063 28,125 56,250
7 Biopsi Endometrium 21,875 21,875 43,750 87,500
3. POLI ANAK
JASA RUMAH SAKIT
NO TINDAKAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Mantoux Test 60,000 60,000 30,000 150000
2 Inhalasi 10,938 10,938 21,875 43,750
3 Imunisasi 3,750 3,750 7,500 15,000
4 Rectal Tube 6,250 6,250 12,500 25,000

4. POLI THT-KL
JASA RUMAH SAKIT
NO TINDAKAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
TINDAKAN MEDIK NON OPERATIF
1 Mikroskopi telinga luar 31,250 31,250 62,500 125,000
2 Mikroskopi telinga tengah 31,250 31,250 62,500 125,000
3 Endoskopi telinga 31,250 31,250 62,500 125,000
4 Pasang tampon anterior hidung 31,250 31,250 62,500 125,000
5 Pasang tampon posterior hidung 31,250 31,250 62,500 225,000
6 Kaustik hidung epistaksis 15,625 15,625 62,500 125,000
7 Tes fungsi penghidu 12,500 12,500 50,000 100,000
8 Nasoendescopi 15,625 15,625 62,500 125,000
9 Nasofaringoskopi rigid 18,750 18,750 75,000 150,000
10 Kaustik faring 18,750 18,750 75,000 150,000
11 Telelaringoskopi rigid 18,750 18,750 75,000 150,000
12 Penutupan stoma trakeostomi 65,625 65,625 262,500 525,000
13 Skin prick test 46,875 46,875 187,500 375,000
14 Tes fungsi N. VII 18,750 18,750 75,000 150,000
15 Canalith repositional therapy (CRT) 34,375 34,375 137,500 275,000
16 Tes penala/ garpu tala 9,375 9,375 37,500 75,000
17 Tes berbisik 6,250 6,250 25,000 50,000
18 Tes vestibular klinis/tes kalori 9,375 9,375 37,500 75,000
19 Tes dix halpike dengan frenzel 12,500 12,500 50,000 100,000
20 Pasang ngt dengan endoskopi 21,875 21,875 87,500 175,000
21 Pasang tampon telinga 12,500 12,500 50,000 100,000
22 Ekstraksi / irigasi serumen 21,875 21,875 87,500 175,000
23 Irigasi hidung 18,750 18,750 75,000 150,000
24 Cuci kanul trakeostomi pada mucous plug 12,500 12,500 50,000 100,000
25 Cuci luka (operasi hidung / telinga) 12,500 12,500 50,000 100,000
26 Ganti verban / drain 12,500 12,500 50,000 100,000
27 Ganti tampon hidung 6,250 6,250 25,000 50,000
28 Angkat tampon hidung anterior 9,375 9,375 37,500 75,000
29 Angkat tampon hidung posterior 21,875 21,875 87,500 175,000
30 Angkat kanul trakeostomi 15,625 15,625 62,500 125,000
31 Angkat jahitan operasi 9,375 9,375 37,500 75,000
32 Ekstraksi benda asing mulut 16,000 16,000 48,000 80,000
33 Ekstraksi benda asing telinga 20,000 20,000 60,000 100,000
34 Ekstraksi benda asing hidung 22,000 22,000 66,000 110,000
35 Ekstraksi benda asing tonsil-faring 24,000 24,000 72,000 120,000
36 Ekstraksi benda asing faring dengan endoskopi 28,000 28,000 84,000 140,000
37 Insisi pseudokista / hematoma aurikula 21,875 21,875 87,500 175,000
38 Insisi pseudokista / hematoma aurikula dengan pasang gips 34,375 34,375 137,500 275,000
39 Biopsi telinga luar 28,125 28,125 112,500 225,000
40 Insisi abses preaurikular 12,500 12,500 50,000 100,000
41 Ekstraksi granulasi telinga 21,875 21,875 87,500 175,000
42 Ekstraksi kolesteatoma eksterna 34,375 34,375 137,500 275,000
43 Jahit luka telinga luar 21,875 21,875 87,500 175,000
44 Miringoplasti lemak / patch miringoplasty 28,125 28,125 112,500 225,000
45 Pemasangan pipa ventilasi (grommet) 28,125 28,125 112,500 225,000
46 Miringotomi / aspirasi telinga tengah 21,875 21,875 87,500 175,000
47 Pelepasan pipa ventilasi (grommet) 18,750 18,750 75,000 150,000
48 Insisi abses retroaurikular 28,125 28,125 112,500 225,000
49 Biopsi telinga tengah & dalam 46,875 46,875 187,500 375,000
50 Injeksi intra timpani 21,875 21,875 87,500 175,000
51 Insisi hidung, insisi septum hidung 28,125 28,125 112,500 225,000
52 Biopsi hidung 28,125 28,125 112,500 225,000
53 Ekstraksi massa / polip intranasal 34,375 34,375 137,500 275,000
54 Eksisi lesi hidung lainnya (sinekia, pelebaran ostium) 34,375 34,375 137,500 275,000
55 Reduksi tertutup fraktur os nasal 65,625 65,625 262,500 525,000
56 Jahit luka hidung 21,875 21,875 87,500 175,000
57 Antrostomi 65,625 65,625 262,500 525,000
58 Biopsi sinus 46,875 46,875 187,500 375,000
59 Biopsi lidah 28,125 28,125 112,500 225,000
60 Insisi abses wajah, submandibula, angina ludovici 78,125 78,125 312,500 625,000
61 Biopsi oral cavity 28,125 28,125 112,500 225,000
62 Revisi sinekia hidung 40,625 40,625 162,500 325,000
63 Jahit laserasi bibir 21,875 21,875 87,500 175,000
64 Jahit laserasi mulut 21,875 21,875 87,500 175,000
65 Hecting laserasi palatum 40,625 40,625 162,500 325,000
66 Insisi uvula 28,125 28,125 112,500 225,000
67 Eksisi uvula 28,125 28,125 112,500 225,000
68 Insisi abses peritonsil 78,125 78,125 312,500 625,000
69 Biopsi tonsil & adenoid 46,875 46,875 187,500 375,000
70 Biopsi faring (nasofaring / orofaring / hipofaring) 53,125 53,125 212,500 425,000
71 Krikotirotomi 78,125 78,125 312,500 625,000
72 Biopsi laring per endoskopik 56,250 56,250 225,000 450,000
73 Biopsi kelenjar limfe 28,125 28,125 112,500 225,000
74 Ganti kanul trakeostomi 43,750 43,750 175,000 350,000
 TINDAKAN DIAGNOSTIK ELEKTROMEDIK
75 Audiometri nada murni 21,875 21,875 87,500 175,000
76 Timpanometri 21,875 21,875 87,500 175,000
77 Refleks stapedius ipsilateral/ 15,625 15,625 62,500 125,000
78 Kontralateral 18,750 18,750 75,000 150,000
79 Eustachian tube function test 18,750 18,750 75,000 150,000
80 Audiometri tutur (speech audiometri) 21,875 21,875 87,500 175,000
81 Audiometri tutur dalam bising 21,875 21,875 87,500 175,000
82 Oto-acoustic emission (oae) 21,875 21,875 87,500 175,000
83 Behavioral observation audiometry (boa) 21,875 21,875 87,500 175,000
TINDAKAN BEDAH THT-KL
TELINGA
84 Insisi drenase liang telinga 84,375 84,375 337,500 675,000
85 Insisi pseudokista/hematoma aurikula 84,375 84,375 337,500 675,000
86 Biopsi liang telinga 56,250 56,250 225,000 450,000
87 Eksisi fistel/abses preaurikular 312,500 312,500 1,250,000 2,500,000
88 Eksisi lesi liang telinga 187,500 187,500 750,000 1,500,000
89 Eksisi luas liang telinga 250,000 250,000 1,000,000 2,000,000
90 Hecting laserasi telinga luar 93,750 93,750 375,000 750,000
91 Kanaloplasti/Meatoplasty 375,000 375,000 1,500,000 3,000,000
92 Miringoplasti 575,000 575,000 2,300,000 4,600,000
93 Obliterasi mastoid/penutupan fistel mastoid 375,000 375,000 1,500,000 3,000,000
94 Pemasangan grommet 300,000 300,000 1,200,000 2,400,000
95 Miringotomi 125,000 125,000 500,000 1,000,000
96 Pelepasan grommet 125,000 125,000 500,000 1,000,000
97 Insisi drenase abses retroaurikular/ mastoid 93,750 93,750 375,000 750,000
98 Atikotomi 250,000 250,000 1,000,000 2,000,000
99 Biopsi telinga tengah dan dalam 106,250 106,250 425,000 850,000
100 Mastoidektomi sederhana 412,500 412,500 1,650,000 3,300,000
101 Mastoidektomi radikal 512,500 512,500 2,050,000 4,100,000
102 Atticoantrostomi/Mastoidektomi modifikasi 625,000 625,000 2,500,000 5,000,000
103 Eksisi lesi telinga tengah 250,000 250,000 1,000,000 2,000,000
104 Injeksi telinga dalam 125,000 125,000 500,000 1,000,000
105 Labirinectomy 250,000 250,000 1,000,000 2,000,000
106 Operasi tuba eustachius 250,000 250,000 1,000,000 2,000,000
107 Mastoidektomi revisi 625,000 625,000 2,500,000 5,000,000
108 Ekstraksi benda asing telinga 84,375 84,375 337,500 675,000

HIDUNG
109 Kontrol epistaksis dengan tampon anterior 37,500 37,500 150,000 300,000
110 Kontrol epistaksis dengan tampon posterior dan anterior 56,250 56,250 225,000 450,000
111 Kontrol epistaksis dengan kauterisasi dan tampon 56,250 56,250 225,000 450,000
112 Insisi abses hidung/ septum 84,375 84,375 337,500 675,000
113 Biopsi hidung 56,250 56,250 225,000 450,000
114 Eksisi lesi hidung 187,500 187,500 750,000 1,500,000
115 Polipektomi nasal 22,500 22,500 90,000 180,000
116 Reduksi konka dengan kauter/ RDF 187,500 187,500 750,000 1,500,000
117 Konkoplasti 225,000 225,000 900,000 1,800,000
118 Reduksi fraktur nasal tertutup 225,000 225,000 900,000 1,800,000
119 Hecting laserasi hidung 93,750 93,750 375,000 750,000
120 Penutupan fistel hidung 84,375 84,375 337,500 675,000
121 Revisi sinekia hidung 187,500 187,500 750,000 1,500,000
122 Irigasi sinus 62,500 62,500 250,000 500,000
123 Irigasi sinus dari ostium alamiah 84,375 84,375 337,500 675,000
124 Biopsi sinonasal dengan endoskopi 93,750 93,750 375,000 750,000
125 Biopsi sinonasal terbuka 56,250 56,250 225,000 450,000
126 FESS mini 300,000 300,000 1,200,000 2,400,000
127 FESS mini + (maksila/ etmoid) 475,000 475,000 1,900,000 3,800,000
128 FESS mini + (ssfenoid/ frontal) 525,000 525,000 2,100,000 4,200,000
129 Caldwell Luc 250,000 250,000 1,000,000 2,000,000
130 Septoplasti 312,500 312,500 1,250,000 2,500,000
131 Penutupan fistel sinus 187,500 187,500 750,000 1,500,000
FARING
132 Insisi drenase abses wajah/ submandibula/ angina ludovici 93,750 93,750 375,000 750,000
133 Insisi palatum 62,500 62,500 250,000 500,000
134 Biopsi palatum durum 65,625 65,625 262,500 525,000
135 Biopsi uvula/ palatum mole 65,625 65,625 262,500 525,000
136 Eksisi lesi palatum durum 84,375 84,375 337,500 675,000
137 Eksisi luas lesi palatum durum 93,750 93,750 375,000 750,000
138 Hecting laserasi palatum 62,500 62,500 250,000 500,000
139 Insisi uvula 62,500 62,500 250,000 500,000
140 Eksisi uvula 62,500 62,500 250,000 500,000
141 Insisi drenase abses 93,750 93,750 375,000 750,000
142 Biopsi tonsil dan adenoid 84,375 84,375 337,500 675,000
143 Tonsilektomi 225,000 225,000 900,000 1,800,000
144 Eksisi tonsil lingual 250,000 250,000 1,000,000 2,000,000
145 Adenoidektomi 187,500 187,500 750,000 1,500,000
146 Kontrol perdarahan pasca tonsilektomi dan adenoidektomi 125,000 125,000 500,000 1,000,000
147 Ekstraksi benda asing tonsil/adenoid dengan insisi 96,875 96,875 387,500 775,000
148 Eksisi lesi di tonsil dan adenoid 96,875 96,875 387,500 775,000
149 Biopsi nasofaring/orofaring/hipofaring 78,125 78,125 312,500 625,000
150 Ekstraksi benda asing faring 100,000 100,000 400,000 800,000

LARING-TRAKEA-ESOFAGUS-HEAD NECK
151 Rhinotomi lateral 312,500 312,500 1,250,000 2,500,000
152 Maksilektomi medial 375,000 375,000 1,500,000 3,000,000
153 Trakeostomi temporer 175,000 175,000 700,000 1,400,000
154 Trakeostomi dengan penyulit 350,000 350,000 1,400,000 2,800,000
155 Trakeostomi permanen 250,000 250,000 1,000,000 2,000,000
156 Ekstraksi benda asing esofagus 262,500 262,500 1,050,000 2,100,000
157 Ekstraksi benda asing laring 250,000 250,000 1,000,000 2,000,000
158 Ekstraksi benda asing trakea 312,500 312,500 1,250,000 2,500,000
159 Ekstraksi benda asing bronkus 375,000 375,000 1,500,000 3,000,000

BIBIR MULUT
160 Biopsi sinonasal app gingivobuccal 62,500 62,500 250,000 500,000
161 Biopsi lidah 56,250 56,250 225,000 450,000
162 Hecting laserasi lidah 62,500 62,500 250,000 500,000
163 Frenektomi lingual 93,750 93,750 375,000 750,000
164 Insisi drenase kelenjar liur 93,750 93,750 375,000 750,000
165 Biopsi kelenjar liur 56,250 56,250 225,000 450,000
166 Biopsi bibir 56,250 56,250 225,000 450,000
167 Biopsi mulut/ basis lidah 56,250 56,250 225,000 450,000

168 Biopsi eksisi rongga mulut 56,250 56,250 225,000 450,000

169 Frenektomi labial 93,750 93,750 375,000 750,000
170 Hecting laserasi bibir 62,500 62,500 250,000 500,000
171 Hecting laserasi mulut 62,500 62,500 250,000 500,000
172 Ekstraksi benda asing mulut 62,500 62,500 250,000 500,000
PLASTIK REKONSTRUKSI
173 Rekonstruksi daun telinga putus 500,000 500,000 2,000,000 4,000,000
174 Reseksi hidung 500,000 500,000 2,000,000 4,000,000
175 Submukosa reseksi septum (SMR) 250,000 250,000 1,000,000 2,000,000
176 Reduksi fraktur nasal terbuka 250,000 250,000 1,000,000 2,000,000
177 Repair perforasi septum hidung 125,000 125,000 500,000 1,000,000
178 Palatoplasty 300,000 300,000 1,200,000 2,400,000
179 Uvuloplasty 300,000 300,000 1,200,000 2,400,000

5. POLI MATA
JASA RUMAH SAKIT
NO TINDAKAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Refraksi 7,813 7,813 15,625 31,250
2 Glukoma 10,938 10,938 21,875 43,750
3 Katarak 10,938 10,938 21,875 43,750
4 Pterigium 21,875 21,875 43,750 87,500
5 Pinguikulitis 7,813 7,813 15,625 31,250
6 Dibetik retinopati 7,813 7,813 15,625 31,250
7 Dibetik hipertensi 7,813 7,813 15,625 31,250
8 Ablasio retina 10,938 10,938 21,875 43,750
9 Kekeruhan vitrius 7,813 7,813 15,625 31,250
10 Corpus alineum 18,750 18,750 37,500 75,000
11 Entropion 18,750 18,750 37,500 75,000
12 Ektropion 18,750 18,750 37,500 75,000
13 Trichiasis 7,813 7,813 15,625 31,250
14 Papil edema 7,813 7,813 15,625 31,250
15 Papilitis 7,813 7,813 15,625 31,250
16 Neuritis retrobulair 14,063 14,063 28,125 56,250
17 Diplopia 7,813 7,813 15,625 31,250
18 Tumor palpebra 26,563 26,563 53,125 106,250
19 Tumor konjetifa 26,563 26,563 53,125 106,250
20 Conyunctivitis 7,813 7,813 15,625 31,250
21 Blefaritis 7,813 7,813 15,625 31,250
22 Episkheritis 7,813 7,813 15,625 31,250
23 Skeritis 7,813 7,813 15,625 31,250
24 Hordiolum 23,438 23,438 46,875 93,750
25 Kalazion 23,438 23,438 46,875 93,750
26 Keratitis 7,813 7,813 15,625 31,250
27 Dakriosistitis 7,813 7,813 15,625 31,250
28 Ulcus Kornea 18,750 18,750 37,500 75,000
29 Erosi kornea 18,750 18,750 37,500 75,000
30 Laserasi kornea 18,750 18,750 37,500 75,000
31 Trauma kimia 18,750 18,750 37,500 75,000
32 Dakriostenonis 7,813 7,813 15,625 31,250
33 Xantelasma 7,813 7,813 15,625 31,250
34 Fraktur orbita 18,750 18,750 37,500 75,000
35 Herpes zoster 7,813 7,813 15,625 31,250
36 Selulitis orbital 7,813 7,813 15,625 31,250
37 Selulitis preseptal 7,813 7,813 15,625 31,250
38 Visus 14,063 14,063 28,125 56,250
39 Koreksi 7,813 7,813 15,625 31,250
40 Tonometri 15,625 15,625 31,250 62,500
41 Funduscopy 7,813 7,813 15,625 31,250
42 Slit lamp examination 7,813 7,813 15,625 31,250
43 Exterpatie corpus 17,188 17,188 34,375 68,750
44 Test buta warna 7,813 7,813 15,625 31,250
45 Kerator meter 7,813 7,813 15,625 31,250
46 Streak retmos kope 7,813 7,813 15,625 31,250
47 Biometri 7,813 7,813 15,625 31,250
48 Laser yag,ag laser 17,188 17,188 34,375 68,750
49 Goldumen 7,813 7,813 15,625 31,250
50 Nel test 7,813 7,813 15,625 31,250
6. POLI KULIT DAN KELAMIN
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Ganti Verban 14,063 14,063 28,125 56,250
2 Curretage 14,063 14,063 28,125 56,250
3 Biopsi 31,250 31,250 62,500 125,000
4 Cauter 31,250 31,250 62,500 125,000
5 Incici 20,313 20,313 40,625 81,250
6 Excici 20,313 20,313 40,625 81,250
7 Cryo surgey 20,313 20,313 40,625 81,250
8 Laser 125,000 125,000 250,000 500,000
9 Aff hecting 6,250 6,250 12,500 25,000
10 Larva migra 7,813 7,813 15,625 31,250

7. POLI PARU
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Pemeriksaan Spirometri / faal paru 15,625 15,625 31,250 62,500
2 Nebulizer 9,375 9,375 18,750 37,500
3 WSD 640,625 640,625 1,281,250 2,562,500
4 Punksi Cairan Pleura 81,250 81,250 16,250 325000
5 Biopsi Asp Jarum hp (dengan tindakan) 70,000 70,000 210,000 350,000
6 Biopsi Asp Jarum hp (tanpa tindakan) 60,000 60,000 180,000 300,000
7 Bronchoscopy 250,000 250,000 700,000 1,200,000
8 test Bronchodilator 40,000 40,000 120,000 200,000
9 Pleuroscopy 150,000 150,000 350,000 650,000
10 Pleurodesis 125,000 125,000 250,000 500000
11 TTNA 250,000 250,000 500,000 1000000
12 Spirometri 25,000 25,000 50,000 100000
13 Biopsi Pleura 175,000 175,000 350,000 700000
14 Aff WSD 50,000 50,000 100,000 200000
15 Mantoux Test 60,000 60,000 30,000 150000
16 Punksi Pleura Diagnostik 50,000 50,000 150,000 250000
17 Punksi Pleura Terapeutik 50,000 50,000 200,000 300000
18 Aspirasi pneumo Thoraks 120,000 120,000 360,000 600000

8. POLI JIWA
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Psikometri
2 Standar Progresive Matries - 12,500 12,500 25,000
3 House tree person - 12,500 12,500 25,000
4 Draw A Man Test - 12,500 12,500 25,000
5 Test Baum - 12,500 12,500 25,000
6 Edward Personel Preference Sched - 15,625 15,625 31,250
7 Theamatic Aperception Test - 15,625 15,625 31,250
8 MMPI 25,000 25,000 50,000 100,000
9 Wechler Adult Intelegence Scate - 15,625 15,625 31,250
10 Wechler Intelegence Scate for Children - 15,625 15,625 31,250
11 Pemeriksaan kesehatan jiwa/narkotik
12 Sederhana :
a. Anak Sekolah - 9,375 9,375 18,750
b. Pegawai Negeri - 12,500 12,500 25,000
13 Sedang :
a. Calon Legislatif - 21,875 21,875 43,750
b. Untuk Keperluan cerai - 21,875 21,875 43,750
c. Untuk keperluan warisan - 21,875 21,875 43,750
14 Poli Psikiatri 6000 6500 37500 50000
15 Day Care 6000 6500 37500 50000
16 Poli PKO / IPWL 6000 6500 37500 50000
17 UGD Psikiatri 6000 6500 37500 50000
18 Terapi keluarga 25000 25000 50000 100000
19 Terapi Kelompok 15000 15000 30000 60000
20 Terapi Individu 6000 6500 37500 50000
21 Pemeriksaan psikologi
a) Tes Kecerdasan 11500 11500 52000 75000
b) Tes Kematangan Anak 11500 11500 52000 75000
c) Tes Konsentrasi 7500 7500 35000 50000
d) Tes Kesiapan masuk TK / SD 15000 15000 70000 100000
 e) Evaluasi Kepribadian bermasalah 16500 16500 87000 125000
f) Tes Minat dan Bakat 16500 16500 87000 125000
g) Penjurusan Studi) 16500 16500 87000 125000
h) MMPI Anak Anak dan Remaja 30000 30000 140000 200000
22 Pedagogik
a) Terapi Perilaku 6000 6000 28000 40000
b) Remedial Teaching 6000 6000 28000 40000
c) Paket Terapi 5 kali / minggu 30000 30000 140000 200000
d). Terapi Wicara 11500 11500 53000 76000
e) Quadricep table 4000 4000 12000 20000
f) Konsultasi Dokter Rehap 6000 6500 37500 50000
g) IR + TENS 14000 14000 42000 70000
h) SWD + Traction 18000 18000 54000 90000
i) IF + Traction 15000 15000 45000 75000
j) IR + Exercise Therapy 15000 15000 65000 95000
k) SWD + Quadricep table 14000 14000 42000 70000
l) SWD + US 17000 17000 51000 85000
23 Pemeriksaan psikologi
a) Test Kecerdasan 7500 7500 35000 50000
b) Test seleksi rehab 11500 11500 52000 75000
c) Test Minat dan Bakat 11500 11500 52000 75000
d) Evaluasi kepribadian 11500 11500 52000 75000
e) Konseling/ therapy psikolog (1x) 7500 7500 35000 50000
f) Brain Mapping 30000 30000 140000 200000
g) MMPI 19000 19000 87000 125000
24 Pelayanan Rehabilitasi
a) ADL 2000 2000 1000 14000
b) Terapy Okupasi 3000 3000 14000 20000
c) Bimbingan psikomotorik kasar 1500 1500 7000 10000
d) Bimbingan psiko motorik halus 3000 3000 14000 20000
e) Bimbingan rekreasi / Musik 3000 3000 14000 20000
25 Pelayanan Penunjang Medik, Psikoteat, MMPI
26 Pelayanan Sosio Medik
a) Anamnesa 6000 6000 28000 40000
b) Mediasi 15000 15000 70000 100000
c) Bimbingan sosial individu 5500 5500 24000 35000
d) Diskusi kelompok 4000 4000 17000 25000
e) Simulasi 7500 7500 35000 50000
f) Kerohanian 4000 4000 17000 25000
g) Sosio drama 5500 5500 24000 35000
h) Konsultasi sosiomedik khusus 7500 7500 35000 50000
i) Terapy psiko sosial 15000 15000 70000 100000
27 Konsultasi Khusus
a) Konsultasi dokter sub spesialis 9000 9000 52000 70000
b) Konsultasi Spesialis 6500 6500 37000 50000
c) Konsultasi Dokter Umum 4000 4000 22000 30000

9. POLI SARAF
JASA RUMAH SAKIT JUMLAH
NO JENIS PELAYANAN BHP JASA JASA
SARANA PELAYANAN
1 2 3 4 5 6
1 EEG 46,875 46,875 93,750 187,500
2 EMG 46,875 46,875 93,750 187,500
3 Lumbal Fungsi 175,000 175,000 350,000 700,000
4 Ocupation therapy 25,000 25,000 50,000 100,000
5 Stroke Infra Merah 25,000 25,000 50,000 100,000
6 Speech Therapy 25,000 25,000 50,000 100,000

10 POLI JANTUNG & RAWAT INAP

JASA RUMAH SAKIT
NO TINDAKAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Pemberian Trombolitik, Sindrom Koroner Akut 350,000 350,000 700,000 1,400,000
2 Electro Cardio Graphy/EKG 37,500 37,500 75,000 150,000
3 Treadmil TEST 250,000 250,000 500,000 1,000,000
4 Echocardiografi 250,000 250,000 500,000 1,000,000
5 Holter EKG 250,000 250,000 500,000 1,000,000
6 Dobutamin Stress Echo 250,000 250,000 500,000 1,000,000
7 Pemeriksaan Tekanan Ankle-Brachid Index (ABI) 200,000 200,000 400,000 800,000
8 Pemeriksaan 6 Minute Walk Test 300,000 300,000 600,000 1,200,000
9 Emergency Echo Cardiography (ICU, IGD, durante Operasi) 400,000 400,000 800,000 1,600,000
10 Kardiovesi/DC Shock/RJP 250,000 250,000 500,000 1,000,000
I. PELAYANAN GIGI DAN MULUT
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 TUMPATAN
a. Sementara 9,375 9,375 18,750 37,500
b. 1.
Permanen
Silicate
15,625 15,625 31,250 62,500
2. Sinar Laser
- Kls I 18,750 18,750 37,500 75,000
- Kls III,IV 25,000 25,000 50,000 100,000
3. GIC Kls I.V 12,500 12,500 25,000 50,000
4. GIC Kls II 14,063 14,063 28,125 56,250
II SCALING
a. Score I 15,625 15,625 31,250 62,500
b. Score II 23,438 23,438 46,875 93,750
c. Score III 29,688 29,688 59,375 118,750
d. Score III + Sub Gingiva 39,063 39,063 78,125 156,250
III EXO/ ELEMEN
a. Decidui
1. Chlor aethyl 8,438 8,438 16,875 33,750
2. Infiltrasi 10,938 10,938 21,875 43,750
3. Ulcus 14,063 14,063 28,125 56,250
b. Permanen
1. Radix 9,375 9,375 18,750 37,500
2. Normal 10,938 10,938 21,875 43,750
 3. Polyp. Granulom 12,500 12,500 25,000 50,000
4. Ancylose 15,625 15,625 31,250 62,500
IV OPERASI TUMOR
a. < 1 cm 39,063 39,063 78,125 156,250
b. 1-2 cm 67,188 67,188 134,375 268,750
c. > 2 cm 104,688 104,688 209,375 418,750
V LAIN-LAIN
a. Socket Gusi 9,375 9,375 18,750 37,500
b. Pulpotomy 9,375 9,375 18,750 37,500
c. P.S.A 12,500 12,500 25,000 50,000
d. Hecting I 6,250 6,250 12,500 25,000
e. Incisiabcess / cm 18,750 18,750 37,500 75,000
f. Luxasi TMG 18,750 18,750 37,500 75,000
VI OPERASI DILUAR KAMAR BEDAH
a. 1. Impacted I 57,813 57,813 115,625 231,250
2. Abnormal 78,125 78,125 156,250 312,500
3. Embeded 132,813 132,813 265,625 531,250
4. Alveolectomy 57,813 57,813 115,625 231,250
5. Exostosis 57,813 57,813 115,625 231,250
6. Mucocele 57,813 57,813 115,625 231,250
7. Overculectomy 57,813 57,813 115,625 231,250
8. Frenectomy 57,813 57,813 115,625 231,250
9. Gingivectomy 57,813 57,813 115,625 231,250
b. 1. Odontotectomy lebih dua elemen 70,313 70,313 140,625 281,250
2. Enucleatie cysta 70,313 70,313 140,625 281,250
3. Block resectie 70,313 70,313 140,625 281,250
4. Fracture rahang simple 70,313 70,313 140,625 281,250
5. Reposisi/ rahang simple 70,313 70,313 140,625 281,250
6. Extirpatie tumor 70,313 70,313 140,625 281,250
VII RONTGEN FOTO
a. Phanoramex 20,313 20,313 40,625 81,250
b. Intra oral ( Dental x-ray ) 12,500 12,500 25,000 50,000

J. PELAYANAN REHABILITASI MEDIK

JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Ultrasound 7,813 7,813 15,625 31,250
2 Infra Merah 6,250 6,250 12,500 25,000
3 Interferential frensi 9,375 9,375 18,750 37,500
4 Diatermi 10,938 10,938 21,875 43,750
5 Exercise therapy 6,250 6,250 12,500 25,000
6 Message 7,813 7,813 15,625 31,250
7 Chest Therapy 7,813 7,813 15,625 31,250
8 Treadmill 6,250 6,250 12,500 25,000
9 Hot Pack 6,250 6,250 12,500 25,000
10 Cool Pack 6,250 6,250 12,500 25,000
11 Vibrator 6,250 6,250 12,500 25,000
12 Parafin bath 6,250 6,250 12,500 25,000
13 Pararel Bar 6,250 6,250 12,500 25,000
14 Latihan Fisik ringan 5,000 5,000 30,000 40,000
15 Latihan Fisik sedang 6,000 6,000 37,000 50,000
16 Latihan Fisik berat 7,500 7,500 45,000 60,000
17 Infra Red Diathermy 7,000 7,000 21,000 35,000
18 Short Wave Diathermy 10,000 10,000 30,000 50,000
19 Micro Wave Diathermy 10,000 10,000 30,000 50,000
20 Electrical Stimulation 7,000 7,000 21,000 35,000
21 Ultrasound Nebulizer 12,500 12,500 25,000 50,000
22 Traksi Lumbal 8,000 8,000 24,000 40,000
23 Latihan Pernapasan 3,500 3,500 18,000 25,000
24 IF / TENS 7,000 7,000 21,000 35,000
25 Ultrasound Diathermy 7,000 7,000 21,000 35,000
26 Parafin bath 7,000 7,000 21,000 35,000
27 Ocupational therapy 6,000 6,000 37,000 50,000
28 Speech Therapy 6,000 6,000 37,000 50,000
29 Latihan pada gangguan proses fungsi Laringectomi 11,500 11,500 67,000 90,000
Latihan pada gangguan proses bicara pada kelainan
67,000
30 Krantotatial 11,500 11,500 90,000
31 Taping 5,000 5,000 30,000 40,000
32 Strapping 5,000 5,000 30,000 40,000
33 Dry Needling Therapy sedang 16,000 16,000 48,000 80,000
34 Dry Needling Therapy berat 30,000 30,000 90,000 150,000
35 Injeksi Intra Articular 16,500 16,500 54,000 90,000
36 Laser 36,000 36,000 108,000 180,000
37 Paradic 6,000 6,000 18,000 30,000
38 Tiiting Table 6,000 6,000 18,000 30,000
39 Vacum 6,000 6,000 18,000 30,000
40 Neodinator / Galvanic 6,000 6,000 18,000 30,000
41 Ultraviolet 6,000 6,000 18,000 30,000
42 Postural Drainage 17,000 17,000 51,000 85,000
43 Manual Limpatic Drainage 18,000 18,000 54,000 90,000
44 Hydrotherapy 12,000 12,000 36,000 60,000
45 Therapy dingin ( Cool Therapy ) 6,000 6,000 18,000 30,000
46 Injeksi Peri Artikuler 26,000 26,000 78,000 130,000
47 Drug Needle 6,000 6,000 18,000 30,000
48 NTPS 9,000 9,000 27,000 45,000
49 Profile Biofisik 35,000 35,000 105,000 175,000
K. PELAYANAN PENUNJANG DIAGNOSTIK MEDIK
1. INSTALASI RADIOLOGI
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Ro Thorax (PA/AP) 25,000 25,000 50,000 100,000
2 Ro Thorax LaTERAL 25,000 25,000 50,000 100,000
3 Ro Thorax Top Lordotic 25,000 25,000 50,000 100,000
4 Ro. Schedell 37,500 37,500 75,000 150,000
5 Ro. Nasal 37,500 37,500 75,000 150,000
6 Ro.Sinus Paranasalis (SPN) 37,500 37,500 75,000 150,000
7 Ro. Mastoid Air Cells 37,500 37,500 75,000 150,000
8 Ro. Temporal Mandibular Joint (TNJ) 37,500 37,500 75,000 150,000
9 Ro. Mandibula 37,500 37,500 75,000 150,000
10 Ro. Maxilla 37,500 37,500 75,000 150,000
11 Ro. Cervical 37,500 37,500 75,000 150,000
12 Ro. Cervico Thoracall Joint 37,500 37,500 75,000 150,000
13 Ro. Shoulder Joint 21,250 21,250 42,500 85,000
14 Ro. Scapula 37,500 37,500 75,000 150,000
15 Ro. Clavicula 21,250 21,250 42,500 85,000
16 Ro. Brachium / Humerus 25,000 25,000 50,000 100,000
17 Ro. Anthebrachii 30,000 30,000 60,000 120,000
18 Ro. Wrist Joint 25,000 25,000 50,000 100,000
19 Ro. Manus 25,000 25,000 50,000 100,000
20 Ro. Elbow Joint 25,000 25,000 50,000 100,000
21 Ro. Pedis 25,000 25,000 50,000 100,000
22 Ro. Ankle Joint 25,000 25,000 50,000 100,000
23 Ro. Cruris (Tibia +Fibula) 30,000 30,000 60,000 120,000
24 Ro. Knee Joint (Genu) 25,000 25,000 50,000 100,000
25 Ro. Femur 45,000 45,000 90,000 180,000
26 Ro. Pelvic AP 25,000 25,000 50,000 100,000
27 Ro. Pelvic Oplique 25,000 25,000 50,000 100,000
28 Ro. Abdomen Polos AP 22,500 22,500 45,000 90,000
29 Ro. Abdomen 3 Posisi 67,500 67,500 135,000 270,000
30 Ro. BNO AP 22,500 22,500 45,000 90,000
31 Ro. BNO IVP 187,500 187,500 375,000 750,000
32 Ro. Appendixogram 125,000 125,000 250,000 500,000
33 Ro. Maag Duodenal Foto (MDF) 125,000 125,000 250,000 500,000
34 Ro. Colon Inloop 150,000 150,000 300,000 600,000
35 Ro. Oesophagoegraphy 125,000 125,000 250,000 500,000
36 Ro. Vistulography 150,000 150,000 300,000 600,000
37 Ro. Vertebrae Thoracal 45,000 45,000 90,000 180,000
38 Ro. Vertebrae Lumbalis 45,000 45,000 90,000 180,000
39 Ro. Lumbosacral 45,000 45,000 90,000 180,000
40 Ro. Coxaegeus 45,000 45,000 90,000 180,000
41 Ro. Gigi (Panoramic) 22,500 22,500 45,000 90,000
42 CT-Scan kepala 200,000 200,000 400,000 800,000
43 CT-Scan kepala kontras 375,000 375,000 750,000 1,500,000
44 CT-Scan Thorax 225,000 225,000 450,000 900,000
45 CT-Scan Thorax kontras 425,000 425,000 850,000 1,700,000
46 CT-Scan Abdomen 225,000 225,000 450,000 900,000
47 CT-Scan Abdomen kontras 425,000 425,000 850,000 1,700,000
48 CT-Scan sinus paranasalis 200,000 200,000 400,000 800,000
49 CT-Scan Sinus paranasalis kontras 375,000 375,000 750,000 1,500,000
50 CT-Scan mastoid 200,000 200,000 400,000 800,000
51 CT-Scan mastoid kontras 375,000 375,000 750,000 1,500,000
52 CT-Scan extremitas atas 212,500 212,500 425,000 850,000
53 CT-Scan Extremitas atas kontras 375,000 375,000 750,000 1,500,000
54 CT-Scan Extremitas bawah 212,500 212,500 425,000 850,000
55 CT-Scan Extremitas bawah kontras 375,000 375,000 750,000 1,500,000
56 CT-Scan Leher Nasofaring 200,000 200,000 400,000 800,000
57 CT-Scan Leher Nasofaring kontras 375,000 375,000 750,000 1,500,000
58 CT-Scan Vertebrae 212,500 212,500 425,000 850,000
59 CT-Scan Vertebrae kontras 425,000 425,000 850,000 1,700,000
60 CT-Scan Pelvic 212,500 212,500 425,000 850,000
61 CT-Scan Pelvic Kontras 375,000 375,000 750,000 1,500,000
62 CT-Scan 425,000 425,000 850,000 1,700,000
2. INSTALASI LABORATORIUM
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
I DARAH RUTIN/HEMATOLOGI
1. Haemoglobin 3,300 3,300 6,600 13,200
2. Leukosit 3,300 3,300 6,600 13,200
3. Eritrosit 3,300 3,300 6,600 13,200
4. Trombosit 3,300 3,300 6,600 13,200
5. LED/BBS 3,300 3,300 6,600 13,200
6. Diffel 3,300 3,300 6,600 13,200
7. Haemotokrit 3,300 3,300 6,600 13,200
8. Morfologi Darah Tepi 25,000 25,000 50,000 100,000
II FAECES RUTIN 4,200 4,200 8,400 16,800
III URINE RUTIN 4,500 4,500 9,000 18,000
IV GOLONGAN DARAH 3,600 3,600 7,200 14,400
V TEST KOAGULASI
1. Waktu Pendarahan 9,300 9,300 18,600 37,200
2. Waktu Pembekuan 9,300 9,300 18,600 37,200
VI FAAL HATI :
1. G.O.T 10,200 10,200 20,400 40,800
2. G.P.T 10,200 10,200 20,400 40,800
3. G.G.T 10,200 10,200 20,400 40,800
4. LDH 10,200 10,200 20,400 40,800
5. Bilirubin Total 10,200 10,200 20,400 40,800
6. Bilirubin Direk 10,200 10,200 20,400 40,800
7. Protein Total 8,700 8,700 17,400 34,800
8. Alkali Pospatase 8,700 8,700 17,400 34,800
VII TEST GULA DARAH
1. Glucosa Puasa 6,900 6,900 13,800 27,600
2. Glucosa 2 jam PP 6,900 6,900 13,800 27,600
3. Glucosa sewaktu 6,900 6,900 13,800 27,600
VIII LEMAK
1. Cholesterol total 9,300 9,300 18,600 37,200
2. Cholesterol LDL 15,300 15,300 30,600 61,200
3. Cholesterol HDL 15,300 15,300 30,600 61,200
4. Trigliserida 12,300 12,300 24,600 49,200
IX JANTUNG
1. CK 19,500 19,500 39,000 78,000
2. CK - MB 16,500 16,500 33,000 66,000
3. LDH 16,500 16,500 33,000 66,000
X GINJAL
1. Ureum 8,400 8,400 16,800 33,600
2. Kreatinin 8,400 8,400 16,800 33,600
3. Asam Urat 8,400 8,400 16,800 33,600
4. Urea Clearance 10,500 10,500 21,000 42,000
5. Kreatinin Clearance 10,500 10,500 21,000 42,000
6. Mikroalbumin Urine 10,500 10,500 21,000 42,000
XI ELEKTROLIT
1. Kalium 10,800 10,800 21,600 43,200
2. Natrium 10,800 10,800 21,600 43,200
 3. Chlorida 35,400
17,700 17,700 70,800
4. Calcium 17,700 17,700 35,400 70,800
5. Magnesium 17,700 17,700 35,400 70,800
XII AGDA ( Analisa Gas Darah ) 25,800 25,800 51,600 103,200
XIII PROFIL PANKREAS
1. Lipase 24,900 24,900 49,800 99,600
2. Amilase 24,900 24,900 49,800 99,600
XIV IMMUNO SEROLOGI SEROMARKER
1. Hbs. Ag 18,900 18,900 37,800 75,600
2. Anti Hbs 18,900 18,900 37,800 75,600
3. Anti Hbc 48,900 48,900 97,800 195,600
4. Anti Hbc-IGM 62,400 62,400 124,800 249,600
5. HbeAg 38,400 38,400 76,800 153,600
6. Anti HAV 43,500 43,500 87,000 174,000
7. Anti HCV 39,900 39,900 79,800 159,600
8. Widal 10,800 10,800 21,600 43,200
9. Malaria ( Mikroskopik ) 5,700 5,700 11,400 22,800
10. Anti HIV ( ICT ) 29,400 29,400 58,800 117,600
11. Anti Hbe 39,300 39,300 78,600 157,200
12. Tubex TF 67,500 67,500 135,000 270,000
13. IgG Anti Dengue 35,000 35,000 70,000 140,000
14.IgM Anti Dengue 35,000 35,000 70,000 140,000
XIII CSP
1. Albumin 9,600 9,600 19,200 38,400
2. Nonne-Pandy 9,900 9,900 19,800 39,600
XIV NARKOBA
1. Methamphetamine 21,900 21,900 43,800 87,600
2. T.H.C 21,900 21,900 43,800 87,600
3. Morphin 21,900 21,900 43,800 87,600
4. Kokain 21,900 21,900 43,800 87,600
LAIN-LAIN
1. Analisa Sperma 11,400 11,400 22,800 45,600
2. Test Kehamilan 8,400 8,400 16,800 33,600
3. KOH 10% 7,200 7,200 14,400 28,800
4. ASTO 13,500 13,500 27,000 54,000
5. IRON 13,500 13,500 27,000 54,000
6. Reumatoid Factor (RF) 19,500 19,500 39,000 78,000
7. CRF 12,000 12,000 24,000 48,000
8. HFV 25,500 25,500 51,000 102,000
9. CA 125 61,500 61,500 123,000 246,000
10. CEA 28,500 28,500 57,000 114,000
11. T3 T4 27,000 27,000 54,000 108,000
12. TSH 28,500 28,500 57,000 114,000
13. Feritin 34,500 34,500 69,000 138,000
14. TIBC 12,000 12,000 24,000 48,000
15. PT 13,500 13,500 27,000 54,000
16. APTT 18,000 18,000 36,000 72,000
17. TT 18,000 18,000 36,000 72,000
18. Analisa Cairan Pleura 13,500 13,500 27,000 54,000
19. Analisa Cairan Asites 13,500 13,500 27,000 54,000
20. Reticulosid 6,900 6,900 13,800 27,600

L. ASUHAN KEPERAWATAN
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Pasang kateter/tindakan 21,875 21,875 43,750 87,500
2 Lepas kateter/aff kateter 6,250 6,250 12,500 25,000
3 Infus/tindakan 6,250 6,250 12,500 25,000
4 Sonde/tindakan 4,375 4,375 8,750 17,500
5 Injeksi/tindakan 1,875 1,875 3,750 7,500
6 Klisma/tindakan 6,250 6,250 12,500 25,000
7 Voorbreading/tindakan 3,750 3,750 7,500 15,000
8 Cooling Spooling/tindakan 28,125 28,125 56,250 112,500
9 Vulva Hygiene/tindakan 3,750 3,750 7,500 15,000
10 Debridemen luka :
a. Luka Kecil/hari 7,813 7,813 15,625 31,250
b. Luka sedang/hari 10,938 10,938 21,875 43,750
c. Luka besar/hari 14,063 14,063 28,125 56,250
11 Breastcare 1,875 1,875 3,750 7,500
12 Memandikan bayi 2,188 2,188 4,375 8,750
13 Pijat bayi 2,188 2,188 4,375 8,750
14 Senam nifas 2,188 2,188 4,375 8,750
15 Kateter umbilikal 18,750 18,750 37,500 75,000
16 Pasang tampon 3,750 3,750 7,500 15,000
17 Aff Tampon 1,875 1,875 3,750 7,500
18 Personal Hygiene/tindakan 12,500 12,500 25,000
19 Pasang NGT/aff NGT 6,000 6,500 12,500 25,000
20 Pasang Lamianaria 120,000 30,000 50,000 200,000
21 Manajemen Kala III 25,000 25,000 50,000 100,000
22 Buka/Aff Implan 25,000 25,000 50,000 100,000
23 Buka/Aff IUD 25,000 25,000 50,000 100,000
24 Oral Hygiene/tindakan 3,750 3,750 7,500 15,000

M. TINDAKAN PEMERIKSAAN DENGAN ALAT KHUSUS (ELEKTRO MEDIK CANGGIH KHUSUS)

JASA RUMAH SAKIT
NO TINDAKAN PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 ENDOSCOPY
a. esofagogastro duodenoscopi 176,000 352,000 352,000 880,000
b. kolonoscopi 200,000 400,000 400,000 1,000,000
c. Ligasi/skero terapi varices esophagus 220,000 440,000 440,000 1,100,000
d. Laparoscopy 220,000 440,000 440,000 1,100,001
2 EKG 12,500 12,500 25,000 50,000
3 CTG 12,500 12,500 25,000 50,000
4 USG
a. USG Ginekologi Trans Abdominal 35,000 35,000 70,000 140,000
b. USG Doppler Sederhana 31,250 31,250 62,500 125,000
c. USG Superjilial 82,500 82,500 165,000 330,000
d. USG Abdomen Lengkap 35,000 35,000 70,000 140,000
e. USG Vaskuler 45,000 45,000 90,000 180,000
f. USG Abdomen Upper 31,250 31,250 62,500 125,000
g. USG Abdomen Lower 31,250 31,250 62,500 125,000
h. USG Thyroid 50,000 50,000 100,000 200,000
i. USG Scrotum 50,000 50,000 100,000 200,000
j. USG Trans Vaginal 25,000 25,000 50,000 100,000
k. USG Mammae / Payudara 50,000 50,000 100,000 200,000
l. USG Bayi + Doppler 50,000 50,000 100,000 200,000
m. USG Super Fisial / Leher 37,500 37,500 75,000 150,000
n. USG Doppler Vascular 50,000 50,000 100,000 200,000
o. USG bayi 50,000 50,000 100,000 200,000
p. USG Doppler 50,000 50,000 100,000 200,000
q. USG Leher/Supervisial 35,000 35,000 70,000 140,000
r. Guiding USG 35,000 35,000 70,000 140,000
5 Elektro Enchephalografi (EEG) 28,125 28,125 56,250 112,500
6 Light Therapi 15,625 15,625 31,250 62,500
7 Radian Warmer 10,938 10,938 21,875 43,750
8 Bronchoscopy 140,625 140,625 281,250 562,500
9 Bed Side Monitor 14,063 14,063 28,125 56,250
10 Tindakan Resusitasi (Ambu,Nebulizer,ETT) 31,250 31,250 62,500 125,000
11 Hemodialisa 203,125 203,125 406,250 812,500
12 Infus Pump/Hari 20,313 20,313 40,625 81,250
13 Syringe Pump/Hari 20,313 20,313 40,625 81,250
14 Pemakaian CVAP 50,000 50,000 150,000 250,000
15 Suction/Hari 10,938 10,938 21,875 43,750
N. PELAYANAN INSTALASI TRANSFUSI DARAH
JASA RUMAH SAKIT
NO URAIAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 4 5 6

1 Penyediaan Darah 101,563 101,563 203,125 406,250

2 Kantong Darah Regensia Double 47,500 47,500 95,000 190,000
 3 Kantong Darah Regensia Single 43,750 43,750 87,500 175,000
4 Plebotomi 50,000 50,000 100,000 200,000

O.PEMAKAIAN OKSIGEN
JASA RUMAH SAKIT
NO URAIAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 4 5 4 7
1 Oksigen (O2) / liter ( sistem central) 100 13 - 113
2 Oksigen (O2) / liter 100 13 - 113

P. PELAYANAN INSTALASI KAMAR JENAZAH

JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 RAWAT INAP JENAZAH
a. Ruang Biasa / hr 12,500 12,500 25,000 50,000
b. Ruang Pendingin / hr 39,063 39,063 78,125 156,250
2 PEMERIKSAAN JENAZAH
a. Periksa Luar 20,313 20,313 40,625 81,250
b. Periksa Dalam / Otopsi 171,875 171,875 343,750 687,500
3 PERBAIKAN JENAZAH
a. Hecting 1 s/d 10 12,500 12,500 25,000 50,000
b. Hecting 11 s/d 20 15,625 15,625 31,250 62,500
c. Hecting ≥ 21 18,750 18,750 37,500 75,000
4 PEMBERSIHAN JENAZAH 46,875 46,875 93,750 187,500
5 PENGAWETAN JENAZAH
a. Untuk 1 ( satu ) hari 53,125 53,125 106,250 212,500
b. Untuk 2 ( dua ) hari 84,375 84,375 168,750 337,500
c. Untuk 3 ( tiga ) hari 115,625 115,625 231,250 462,500
d. Untuk > 3 ( tiga ) hari
( Maksimal 7 hari) 146,875 146,875 293,750 587,500
6 PERAWATAN JENAZAH ( MEMANDIKAN JENAZAH)
a. Kondisi Segar 46,875 46,875 93,750 187,500
b. Kondisi busuk 93,750 93,750 187,500 375,000
7 SALON JENAZAH 156,250 156,250 312,500 625,000
( Rias Jenazah )

Q. PELAYANAN LAINNYA
1. KONSULTASI PSIKOLOGI
JASA RUMAH SAKIT
NO TINDAKAN PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Konsultasi Psikologi 7,813 7,813 15,625 31,250
2 Test Psikologik Baterai lengkap 10,938 10,938 21,875 43,750
3 Test Emosional 7,813 7,813 15,625 31,250
4 Test Bakat 7,813 7,813 15,625 31,250
5 Test Kepribadian 7,813 7,813 15,625 31,250

2 KONSULTASI GIZI
JASA RUMAH SAKIT
NO JENIS PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Gizi/piring - 7,500 7,500 15,000
3 MOBIL AMBULANCE
JASA RUMAH SAKIT
NO TEMPAT TUJUAN BBM JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Dalam Daerah
(tidak termasuk biaya penyeberangan)
a. Dalam Kota (Kec. Pangururan) 31,250 31,250 62,500 125,000
 b. Luar Kota Kecamatan Pangururan 78,125 78,125 156,250 312,500
2Luar Daerah
(tidak termasuk biaya penyeberangan)
Pangururan-Medan
- Siang 406,250 406,250 812,500 1,625,000
- Malam 421,875 421,875 843,750 1,687,500
Pangururan-Siantar
- Siang 203,125 203,125 406,250 812,500
- Malam 218,750 218,750 437,500 875,000
Pangururan-Kabanjahe
- Siang 265,625 265,625 531,250 1,062,500
- Malam 281,250 281,250 562,500 1,125,000
Pangururan-Sidikalang
- Siang 218,750 218,750 437,500 875,000
- Malam 234,375 234,375 468,750 937,500
Pangururan-Tarutung
- Siang 250,000 250,000 500,000 1,000,000
- Malam 265,625 265,625 531,250 1,062,500
Pangururan-Balige
- Siang 250,000 250,000 500,000 1,000,000
- Malam 265,625 265,625 531,250 1,062,500
NB :Biaya ferry ditanggung oleh keluarga pasien.

4. MOBIL JENAZAH (tidak termasuk biaya penyeberangan)

JASA RUMAH SAKIT
NO JARAK TEMPUH BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 0 s/d 10 Km 31,250 31,250 62,500 125,000
2 11 s/d 20 Km 46,875 46,875 93,750 187,500
3 ≥ 21 Km (Biaya tambahan per Km) 1,563 1,563 3,125 6,250

5. ADMINISTRASI KESEHATAN
JASA RUMAH SAKIT
NO JENIS TINDAKAN/ADMINISTRASI BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Surat Keterangan Dokter 6,250 6,250 12,500
2 Surat Keterangan Visum Et Refertum : 18,750 18,750 37,500
3 Surat Keterangan ASURANSI Kesehatan/Jiwa
- Pasien Hidup 9,375 9,375 18,750
- Pasien Meninggal 9,375 9,375 18,750

6. TARIF CUCI LAKEN PASIEN

JASA RUMAH SAKIT
NO TINDAKAN PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Biaya cuci pakaian pasien/potong 1,000 2,000 3,000 6,000

R. PARKIR KENDARAAN BERMOTOR

JASA RUMAH SAKIT
NO JENIS TINDAKAN/ADMINISTRASI BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 3 4 5 6
1 Parkir Sepeda Motor/Becak 500 500 1,000
2 Parkir Kenderaan bermotor roda empat 1,000 1,000 2,000

S TINDAKAN KHUSUS DI LUAR KAMAR OPERASI

JASA RUMAH SAKIT
NO TINDAKAN PELAYANAN BHP JASA JASA JUMLAH
SARANA PELAYANAN
1 2 4 5 6 7
1 Pungsi lumbal 50,000 - 50,000 100,000
2 Infus Intraoseus Umbilikal 37,500 - 37,500 75,000
3 Pungsi Liver 60,000 - 60,000 120,000
4 Pungsi Asites 62,500 - 62,500 125,000
5 Hemodialisa 1,210,000

T. PELAYANAN DIKLAT
JASA RUMAH SAKIT
JASA
NO JENIS PELAYANAN BHP JASA PELAYANAN JUMLAH
SARANA ADMINISTRAS
I
 1 Magang (Institusi Swasta)
Setingkat SLTA (per minggu per orang) - 10,000 40,000 50,000
Setingkat D-III (per minggu per orang) - 12,500 62,500 75,000
Setingkat S-I (per minggu per orang) - 25,000 225,000 250,000

2 Magang (Institusi Negeri)

Setingkat SLTA (per minggu per orang) - 5,000 20,000 25,000
Setingkat D-III (per minggu per orang) - 7,500 37,500 45,000
Setingkat S-I (per minggu per orang) - 10,000 90,000 100,000

3 Penelitian
Setingkat D-III (per minggu per orang) - 10,000 40,000 50,000
Setingkat S-I (per minggu per orang) - 25,000 75,000 100,000

4 Pengambilan Data - 10,000 15,000 25,000

5 Studi Banding (per orang) - 50,000 150,000 200,000

Catatan : Jasa pelayanan administrasi adalah jasa tim pengelola kegiatan yang dihunjuk Direktur belum termasuk jasa :
Pembimbing teknis, Tutor, Narasumber, instruktur jika diperlukan oleh institusi pengguna dan biaya fotocopi
 Jasa Sarana +BHP
Jasa pelayan Jasa Sarana
17,000 21,250 10,625 5,313
22000 27,500 13,750 6,875
- - -
- - -

- - -
JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
- - -
410000 512,500 256,250 128,125
460000 575,000 287,500 143,750
0 - - -
202000 252,500 126,250 63,125
230000 287,500 143,750 71,875
0 - - -
164000 205,000 102,500 51,250
180000 225,000 112,500 56,250
0 - - -
121000 151,250 75,625 37,813
133000 166,250 83,125 41,563
0 - - -
86000 107,500 53,750 26,875
100000 125,000 62,500 31,250
0 - - -
19000 23,750 11,875 5,938
65250 81,563 40,781 20,391
0 - - -
100000 125,000 62,500 31,250
117000 146,250 73,125 36,563
0 - - -
157000 196,250 98,125 49,063
185000 231,250 115,625 57,813
0 - - -

- - -
- - -
- - -
- - -
- - -
80000 100,000 50,000 25,000
100000 125,000 62,500 31,250
- - -
 - - -
75000 93,750 46,875 23,438

135000 168,750 84,375 42,188

70000 87,500 43,750 21,875

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
- - -
50000 62,500 31,250 15,625
4000 5,000 2,500 1,250
- - -
- - -
16000 20,000 10,000 5,000
0 - - -
32000 40,000 20,000 10,000
44000 55,000 27,500 13,750
56000 70,000 35,000 17,500
125000 156,250 78,125 39,063
105000 131,250 65,625 32,813
0 - - -
85000 106,250 53,125 26,563
55000 68,750 34,375 17,188
85000 106,250 53,125 26,563
125000 156,250 78,125 39,063
19000 23,750 11,875 5,938
0 - - -
55000 68,750 34,375 17,188
- - -
- - -
65000 81,250 40,625 20,313
- - -
- - -
75000 93,750 46,875 23,438
- - -
- - -
- - -
- - -
40000 50,000 25,000 12,500
65000 81,250 40,625 20,313
70000 87,500 43,750 21,875
105000 131,250 65,625 32,813
0 - - -
70000 87,500 43,750 21,875
100000 125,000 62,500 31,250
35000 43,750 21,875 10,938
150000 187,500 93,750 46,875
0 - - -
155000 193,750 96,875 48,438
67,500 125000 156,250 78,125 39,063
37,500 70000 87,500 43,750 21,875
35,000 200000 250,000 125,000 62,500
100,000 200000 250,000 125,000 62,500
100,000 300000 375,000 187,500 93,750
150,000 - - -

JUM #VALUE! #VALUE! #VALUE!

- - -
- - -
450000 562,500 281,250 140,625
550000 687,500 343,750 171,875
550000 687,500 343,750 171,875
550000 687,500 343,750 171,875
400000 500,000 250,000 125,000
350000 437,500 218,750 109,375
620000 775,000 387,500 193,750

- - -
 - - -
- - -
- - -
- - -
285000 356,250 178,125 89,063
235000 293,750 146,875 73,438
- - -
- - -
25000 31,250 15,625 7,813
300000 375,000 187,500 93,750
300000 375,000 187,500 93,750
600000 750,000 375,000 187,500
120000 150,000 75,000 37,500
110000 137,500 68,750 34,375
450000 562,500 281,250 140,625
200000 250,000 125,000 62,500
100000 125,000 62,500 31,250
150000 187,500 93,750 46,875
130000 162,500 81,250 40,625
35000 43,750 21,875 10,938
35000 43,750 21,875 10,938
80000 100,000 50,000 25,000
100000 125,000 62,500 31,250
80000 100,000 50,000 25,000
20000 25,000 12,500 6,250
45000 56,250 28,125 14,063
65000 81,250 40,625 20,313
270000 337,500 168,750 84,375
65000 81,250 40,625 20,313
65000 81,250 40,625 20,313
40000 50,000 25,000 12,500
40000 50,000 25,000 12,500
90 113 56 28
56.25 90 113 56 28
- - -
- - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
1250000 1,562,500 781,250 390,625
1850000 2,312,500 1,156,250 578,125
2600000 3,250,000 1,625,000 812,500
3200000 4,000,000 2,000,000 1,000,000
- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

- - -
- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
1250000 1,562,500 781,250 390,625
1850000 2,312,500 1,156,250 578,125
2600000 3,250,000 1,625,000 812,500
3200000 4,000,000 2,000,000 1,000,000
- - -

- - -
- - -
- - -
- - -
- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
 - - -
- - -

- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -

- - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
45000 56,250 28,125 14,063
65000 81,250 40,625 20,313
70000 87,500 43,750 21,875
30000 37,500 18,750 9,375
32000 40,000 20,000 10,000
52000 65,000 32,500 16,250
25000 31,250 15,625 7,813
30000 37,500 18,750 9,375
45000 56,250 28,125 14,063
35000 43,750 21,875 10,938
50000 62,500 31,250 15,625
50000 62,500 31,250 15,625
55000 68,750 34,375 17,188
150000 187,500 93,750 46,875
- - -
- - -
50000 62,500 31,250 15,625
4000 5,000 2,500 1,250
- - -
16000 20,000 10,000 5,000
- - -
32000 40,000 20,000 10,000
44000 55,000 27,500 13,750
56000 70,000 35,000 17,500
- - -
- - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
135000 168,750 84,375 42,188
95000 118,750 59,375 29,688
18000 22,500 11,250 5,625
90000 112,500 56,250 28,125
55000 68,750 34,375 17,188
45000 56,250 28,125 14,063
70000 87,500 43,750 21,875
- - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
105000 131,250 65,625 32,813
35000 43,750 21,875 10,938
12000 15,000 7,500 3,750
20000 25,000 12,500 6,250
- - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
175000 218,750 109,375 54,688

15,625
15,625
62,500
93,750
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
25000 31,250 15,625 7,813
35000 43,750 21,875 10,938
35000 43,750 21,875 10,938
70000 87,500 43,750 21,875
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
35000 43,750 21,875 10,938
25000 31,250 15,625 7,813
60000 75,000 37,500 18,750
60000 75,000 37,500 18,750
60000 75,000 37,500 18,750
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
45000 56,250 28,125 14,063
25000 31,250 15,625 7,813
85000 106,250 53,125 26,563
85000 106,250 53,125 26,563
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
75000 93,750 46,875 23,438
75000 93,750 46,875 23,438
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
60000 75,000 37,500 18,750
60000 75,000 37,500 18,750
- - -
60000 75,000 37,500 18,750
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
60000 75,000 37,500 18,750
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
45000 56,250 28,125 14,063
25000 31,250 15,625 7,813
50000 62,500 31,250 15,625
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
55000 68,750 34,375 17,188
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
55000 68,750 34,375 17,188
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
- - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -

- - -
45000 56,250 28,125 14,063
45000 56,250 28,125 14,063
100000 125,000 62,500 31,250
100000 125,000 62,500 31,250
65000 81,250 40,625 20,313
65000 81,250 40,625 20,313
65000 81,250 40,625 20,313
400000 500,000 250,000 125,000
20000 25,000 12,500 6,250
25000 31,250 15,625 7,813
- - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
50000 62,500 31,250 15,625

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -

6 8 4 2
- - -
20000 25,000 12,500 6,250
20000 25,000 12,500 6,250
20000 25,000 12,500 6,250
20000 25,000 12,500 6,250
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
100000 125,000 62,500 31,250
0 - - -
0 - - -
15000 18,750 9,375 4,688
20000 25,000 12,500 6,250
0 - - -
35000 43,750 21,875 10,938

35000 43,750 21,875 10,938

35000 43,750 21,875 10,938
- - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
150000 187,500 93,750 46,875
150000 187,500 93,750 46,875
700000 875,000 437,500 218,750
100000 125,000 62,500 31,250
100000 125,000 62,500 31,250
 100000 125,000 62,500 31,250
- - -
- - -
JUMLAH #VALUE! #VALUE! #VALUE!

JUMLAH #VALUE! #VALUE! #VALUE!

- - -

35000 43,750 21,875 10,938

45000 56,250 28,125 14,063
- - -
30000 37,500 18,750 9,375
35000 43,750 21,875 10,938
40000 50,000 25,000 12,500
50000 62,500 31,250 15,625
- - -
125000 156,250 78,125 39,063
215000 268,750 134,375 67,188
335000 418,750 209,375 104,688
- - -
30000 37,500 18,750 9,375
30000 37,500 18,750 9,375
40000 50,000 25,000 12,500
20000 25,000 12,500 6,250
60000 75,000 37,500 18,750
60000 75,000 37,500 18,750
- - -
185000 231,250 115,625 57,813
250000 312,500 156,250 78,125
425000 531,250 265,625 132,813
185000 231,250 115,625 57,813
185000 231,250 115,625 57,813
185000 231,250 115,625 57,813
185000 231,250 115,625 57,813
185000 231,250 115,625 57,813
 185000 231,250 115,625 57,813
225000 281,250 140,625 70,313
225000 281,250 140,625 70,313
225000 281,250 140,625 70,313
225000 281,250 140,625 70,313
225000 281,250 140,625 70,313
225000 281,250 140,625 70,313
- - -
65000 81,250 40,625 20,313
40000 50,000 25,000 12,500
- - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
25000 31,250 15,625 7,813
20000 25,000 12,500 6,250
30000 37,500 18,750 9,375
35000 43,750 21,875 10,938
20000 25,000 12,500 6,250
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
20000 25,000 12,500 6,250
- - -
20000 25,000 12,500 6,250
20000 25,000 12,500 6,250
20000 25,000 12,500 6,250
20000 25,000 12,500 6,250
- - -
 - - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
60000 75,000 37,500 18,750
 JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
- - -
11000 13,750 6,875 3,438
6,600 11000 13,750 6,875 3,438
6,600 11000 13,750 6,875 3,438
6,600 11000 13,750 6,875 3,438
6,600 11000 13,750 6,875 3,438
6,600 11000 13,750 6,875 3,438
6,600 11000 13,750 6,875 3,438
6,600
50,000 14000 17,500 8,750 4,375
8,400 15000 18,750 9,375 4,688
9,000 12000 15,000 7,500 3,750
7,200 0 - - -
- 31000 38,750 19,375 9,688
18,600 31000 38,750 19,375 9,688
18,600 0 - - -
- 34000 42,500 21,250 10,625
20,400 34000 42,500 21,250 10,625
20,400 34000 42,500 21,250 10,625
20,400 34000 42,500 21,250 10,625
20,400 34000 42,500 21,250 10,625
20,400 34000 42,500 21,250 10,625
20,400 29000 36,250 18,125 9,063
17,400 29000 36,250 18,125 9,063
17,400 0 - - -
- 23000 28,750 14,375 7,188
13,800 23000 28,750 14,375 7,188
13,800 23000 28,750 14,375 7,188
13,800 0 - - -
- 31000 38,750 19,375 9,688
18,600 51000 63,750 31,875 15,938
30,600 51000 63,750 31,875 15,938
30,600 41000 51,250 25,625 12,813
24,600 0 - - -
- 65000 81,250 40,625 20,313
39,000 55000 68,750 34,375 17,188
33,000 55000 68,750 34,375 17,188
33,000 0 - - -
- 28000 35,000 17,500 8,750
16,800 28000 35,000 17,500 8,750
16,800 28000 35,000 17,500 8,750
16,800 35000 43,750 21,875 10,938
21,000 35000 43,750 21,875 10,938
21,000 35000 43,750 21,875 10,938
21,000 0 - - -
 - 36000 45,000 22,500 11,250
21,600 36000 45,000 22,500 11,250
21,600 59000 73,750 36,875 18,438
35,400 59000 73,750 36,875 18,438
35,400 59000 73,750 36,875 18,438
35,400 86000 107,500 53,750 26,875
51,600 0 - - -
- 83000 103,750 51,875 25,938
49,800 83000 103,750 51,875 25,938
49,800 0 - - -
- 63000 78,750 39,375 19,688
37,800 63000 78,750 39,375 19,688
37,800 163000 203,750 101,875 50,938
97,800 208000 260,000 130,000 65,000
124,800 128000 160,000 80,000 40,000
76,800 145000 181,250 90,625 45,313
87,000 133000 166,250 83,125 41,563
79,800 36000 45,000 22,500 11,250
21,600 19000 23,750 11,875 5,938
11,400 98000 122,500 61,250 30,625
58,800 131000 163,750 81,875 40,938
78,600
135,000
70,000
70,000 0 - - -
- 32000 40,000 20,000 10,000
19,200 33000 41,250 20,625 10,313
19,800 0 - - -
- 73000 91,250 45,625 22,813
43,800 73000 91,250 45,625 22,813
43,800 73000 91,250 45,625 22,813
43,800 73000 91,250 45,625 22,813
43,800 0 - - -
- 38000 47,500 23,750 11,875
22,800 28000 35,000 17,500 8,750
16,800 24000 30,000 15,000 7,500
14,400 45000 56,250 28,125 14,063
27,000 45000 56,250 28,125 14,063
27,000 65000 81,250 40,625 20,313
39,000 40000 50,000 25,000 12,500
24,000 85000 106,250 53,125 26,563
51,000 205000 256,250 128,125 64,063
123,000 95000 118,750 59,375 29,688
57,000 90000 112,500 56,250 28,125
54,000 95000 118,750 59,375 29,688
57,000 115000 143,750 71,875 35,938
69,000 40000 50,000 25,000 12,500
24,000 45000 56,250 28,125 14,063
27,000 60000 75,000 37,500 18,750
36,000 60000 75,000 37,500 18,750
36,000 45000 56,250 28,125 14,063
27,000 45000 56,250 28,125 14,063
27,000 23000 28,750 14,375 7,188
13,800 - - -
 - - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
43,750 70000 87,500 43,750 21,875
12,500 20000 25,000 12,500 6,250
12,500 17000 21,250 10,625 5,313
8,750 14000 17,500 8,750 4,375
3,750 6000 7,500 3,750 1,875
12,500 12000 15,000 7,500 3,750
7,500 12000 15,000 7,500 3,750
56,250 90000 112,500 56,250 28,125
12,500 25500 31,875 15,938 7,969
- 0 - - -
15,625 25000 31,250 15,625 7,813
21,875 35000 43,750 21,875 10,938
28,125 45000 56,250 28,125 14,063
3,750 6000 7,500 3,750 1,875
4,375 7000 8,750 4,375 2,188
4,375 7000 8,750 4,375 2,188
4,375 7000 8,750 4,375 2,188
37,500 60000 75,000 37,500 18,750
7,500 12000 15,000 7,500 3,750
12,500 19000 23,750 11,875 5,938
7,500
7,500 12000 15,000 7,500 3,750
7,500 12000 15,000 7,500 3,750

3,750 - - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
450000 562,500 281,250 140,625
490000 612,500 306,250 153,125
40000 50,000 25,000 12,500
40000 50,000 25,000 12,500
0 - - -
50000 62,500 31,250 15,625
330000 412,500 206,250 103,125
- - -
140000 175,000 87,500 43,750
140000 175,000 87,500 43,750

140000 175,000 87,500 43,750

65000 81,250 40,625 20,313
50000 62,500 31,250 15,625
35000 43,750 21,875 10,938
450000 562,500 281,250 140,625
45000 56,250 28,125 14,063
100000 125,000 62,500 31,250
650000 812,500 406,250 203,125
65000 81,250 40,625 20,313
65000 81,250 40,625 20,313
35000 43,750 21,875 10,938

- - -
#VALUE! JUMLAH #VALUE! #VALUE! #VALUE!
- - - -
- - - -
- - - -
203,125 325000 406,250 203,125 101,563
95,000 190000 237,500 118,750 59,375
87,500 175000 218,750 109,375 54,688
100,000 175000 218,750 109,375 54,688
43750 - - -

#VALUE! JUMLAH #VALUE! #VALUE! #VALUE!

- - - -
- - - -
4 7 9 4 2
56 90 113 56 28
56 90 113 56 28
- - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2

- - -
40000 50,000 25,000 12,500
125000 156,250 78,125 39,063
- - -
65000 81,250 40,625 20,313
550000 687,500 343,750 171,875
0 - - -
40000 50,000 25,000 12,500
50000 62,500 31,250 15,625
60000 75,000 37,500 18,750
150000 187,500 93,750 46,875
0 - - -
170000 212,500 106,250 53,125
270000 337,500 168,750 84,375
370000 462,500 231,250 115,625
0 - - -
470000 587,500 293,750 146,875
0 - - -
150000 187,500 93,750 46,875
300000 375,000 187,500 93,750

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
25000 31,250 15,625 7,813
35000 43,750 21,875 10,938
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
25000 31,250 15,625 7,813
- - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2

15000 18,750 9,375 4,688

- - -
 JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
6 8 4 2
- - -
100000 125,000 62,500 31,250

250000 312,500 156,250 78,125

- - -
- - -

1300000 1,625,000 812,500 406,250

1350000 1,687,500 843,750 421,875
- - -
650000 812,500 406,250 203,125
700000 875,000 437,500 218,750
- - -
850000 1,062,500 531,250 265,625
900000 1,125,000 562,500 281,250
- - -
700000 875,000 437,500 218,750
750000 937,500 468,750 234,375
- - -
800000 1,000,000 500,000 250,000
850000 1,062,500 531,250 265,625
- - -
800000 1,000,000 500,000 250,000
850000 1,062,500 531,250 265,625
- - -
- - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
100000 125,000 62,500 31,250
150000 187,500 93,750 46,875
5000 6,250 3,125 1,563
- - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
6,250 10000 12,500 6,250 3,125
18,750 30000 37,500 18,750 9,375
- 0 - - -
9,375 15000 18,750 9,375 4,688
9,375 15000 18,750 9,375 4,688
#REF! - - -

JUMLAH #VALUE! #VALUE! #VALUE!

- - -
- - -
6 8 4 2
6000 7,500 3,750 1,875
- - -

#VALUE! JUMLAH #VALUE! #VALUE! #VALUE!

- - - -
- - - -
3 6 8 4 2
500 1000 1,250 625 313
1,000 2000 2,500 1,250 625
#REF! - - -
JUMLAH #VALUE! #VALUE! #VALUE!
- - -
- - -
7 9 4 2
100000 125,000 62,500 31,250
75000 93,750 46,875 23,438
120000 150,000 75,000 37,500
125000 156,250 78,125 39,063
800000 1,000,000 500,000 250,000
- - -

- - -

- - -
- - -
- - -
 IV GOLONGAN DARAH 3,600 3,600 7,200 14,400
V TEST KOAGULASI
1. Waktu Pendarahan 9,300 9,300 18,600 37,200
2. Waktu Pembekuan 9,300 9,300 18,600 37,200
VI FAAL HATI :
1. G.O.T 10,200 10,200 20,400 40,800
2. G.P.T 10,200 10,200 20,400 40,800
3. G.G.T 10,200 10,200 20,400 40,800
4. LDH 10,200 10,200 20,400 40,800
5. Bilirubin Total 10,200 10,200 20,400 40,800
6. Bilirubin Direk 10,200 10,200 20,400 40,800
7. Protein Total 8,700 8,700 17,400 34,800
8. Alkali Pospatase 8,700 8,700 17,400 34,800
VII TEST GULA DARAH
1. Glucosa Puasa 6,900 6,900 13,800 27,600
2. Glucosa 2 jam PP 6,900 6,900 13,800 27,600
3. Glucosa sewaktu 6,900 6,900 13,800 27,600
4.HBA1C 145,000 32,500 32,500 210,000
VIII LEMAK
1. Cholesterol total 9,300 9,300 18,600 37,200
2. Cholesterol LDL 15,300 15,300 30,600 61,200
3. Cholesterol HDL 15,300 15,300 30,600 61,200
4. Trigliserida 12,300 12,300 24,600 49,200
IX JANTUNG
1. CK 19,500 19,500 39,000 78,000
2. CK - MB 16,500 16,500 33,000 66,000
3. LDH 16,500 16,500 33,000 66,000
X GINJAL
1. Ureum 8,400 8,400 16,800 33,600
2. Kreatinin 8,400 8,400 16,800 33,600
3. Asam Urat 8,400 8,400 16,800 33,600
4. Urea Clearance 10,500 10,500 21,000 42,000
5. Kreatinin Clearance 10,500 10,500 21,000 42,000
6. Mikroalbumin Urine 10,500 10,500 21,000 42,000
XI ELEKTROLIT
ELEKTROLIT 124,000 40,000 46,000 210,000
XII AGDA ( Analisa Gas Darah )
AGDA ( Analisa Gas Darah ) 252,000 62,000 66,000 380,000
XIII PROFIL PANKREAS
1. Lipase 24,900 24,900 49,800 99,600
2. Amilase 24,900 24,900 49,800 99,600
XIV IMMUNO SEROLOGI SEROMARKER
1. Hbs. Ag 18,900 18,900 37,800 75,600
2. Anti Hbs 18,900 18,900 37,800 75,600
3. Anti Hbc 48,900 48,900 97,800 195,600
4. Anti Hbc-IGM 62,400 62,400 124,800 249,600
5. HbeAg 38,400 38,400 76,800 153,600
6. Anti HAV 43,500 43,500 87,000 174,000
7. Anti HCV 39,900 39,900 79,800 159,600
8. Widal 10,800 10,800 21,600 43,200
9. Malaria ( Mikroskopik ) 5,700 5,700 11,400 22,800
10. Anti HIV ( ICT ) 29,400 29,400 58,800 117,600
11. Anti Hbe 39,300 39,300 78,600 157,200
12. Tubex TF 67,500 67,500 135,000 270,000
13. Tubex Salmonella 155,000 62,000 63,000 280,000
14. IgG Anti Dengue 35,000 35,000 70,000 140,000
15.IgM Anti Dengue 35,000 35,000 70,000 140,000
16. IgG Anti Sars COV - 2 80,000 20,000 50,000 150,000
17.IgM Anti Sars COV - 2 80,000 20,000 50,000 150,000
XIII CSP
1. Albumin 9,600 9,600 19,200 38,400
2. Nonne-Pandy 9,900 9,900 19,800 39,600
XIV NARKOBA
1. Methamphetamine 21,900 21,900 43,800 87,600
2. T.H.C 21,900 21,900 43,800 87,600
3. Morphin 21,900 21,900 43,800 87,600
4. Kokain 21,900 21,900 43,800 87,600
LAIN-LAIN
1. Analisa Sperma 11,400 11,400 22,800 45,600