Perda No. 1 Tahun 2016 (Lampiran II)

LAMPIRAN II
PERATURAN DAERAH PROVINSI

NOMOR 1 TAHUN 2016
TENTANG
RETRIBUSI PELAYANAN KESEHA
STRUKTUR DAN BESARAN TARIF RUMAH SAKIT UMUM DAERAH MALINGPING
A. TARIF PEMERIKSAAN DOKTER, TINDAKAN MEDIS DAN TINDAKAN KEPERAWATAN
RAWAT INAP
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE IGD/VK ICU/HCU
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Jasa Jasa Jasa Jasa Jasa Jasa Jasa Jasa Jasa Jasa Jasa
Total Total Jasa Sarana Total Total Jasa Sarana Total Total
layanan Sarana layanan Sarana layanan layanan Sarana layanan layanan Sarana layanan
Akomodasi Rawat Inap
33,000 42,000 75,000 52,800 67,200 120,000 66,000 84,000 150,000 110,000 140,000 250,000 176,000 224,000 400,000 110,000
PEMERIKSAAN DAN KONSULTASI

Jasa Jasa Jasa Jasa
Total Total
1 layanan Sarana layanan Sarana
Pemeriksaan / Konsultasi
1.1 / Visite Dokter Spesialis
19,800 25,200 45,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800
1.2
/ Visite Dokter Spesialis
110,000
Diluar Hari/Jam Kerja 22,000 28,000 50,000 28,600 36,400 65,000 15,400 19,600 35,000 17,600 22,400 40,000 24,200 30,800 55,000 35,200 44,800 80,000 48,400 61,600 26,400 33,600 60,000 26,400
1.3
Dokter Umum
8,800 11,200 20,000 11,000 14,000 25,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800
1.4
Dokter Umum diluar
Hari/Jam Kerja 11,000 14,000 25,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 8,800
1.5 Pemeriksaan / Konsultasi
Dokter Gigi 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 8,400 15,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800
1.6 Dokter Gigi diluar
Hari/Jam Kerja 11,000 14,000 25,000 19,800 25,200 45,000 8,800 11,200 20,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000
1.7
Konsultasi Dokter
Spesialis Via Telepon 15,400 19,600 35,000 - - 8,800 11,200 20,000 11,000 14,000 25,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400
1.8
Konsultasi Pasien Pulang - - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 11,000
1.9 Pemeriksaan / Konsultasi

Bidan / Perawat 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
1.10
Konsultasi Gizi 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
- - - - - - - - - - - - - - - - -
TINDAKAN MEDIS - -
2 - - - - - - - - - - - - - - -
2.1
BAGIAN OBSTETRI
GINEKOLOGI - - - - - - - - - - - - - - - - -
2.2 Biopsi / Pengambilan
Jaringan 22,000 28,000 50,000 26,400 33,600 60,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000
2.3
100,000 66,000 84,000 150,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 57,200 72,800 130,000 35,200 44,800 80,000 35,200
USG 2D ( + hasil foto ) 44,000 56,000
2.4
USG 3D ( + hasil foto ) 132,000 168,000 300,000 165,000 210,000 375,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 132,000
2.5
USG 4D ( + hasil foto ) 132,000 168,000 300,000 165,000 210,000 375,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 132,000
2.6
Visum Kebidanan 44,000 56,000 100,000 66,000 84,000 150,000 26,400 33,600 60,000 26,400 33,600 60,000 30,800 39,200 70,000 66,000 84,000 150,000 88,000 112,000 200,000 44,000 56,000 100,000 -
108
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
2.7
Manual Plasenta - - - - 88,000 112,000 200,000 96,800 123,200 220,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 88,000 112,000 200,000 88,000
2.8
Hidrotubasi 132,000 168,000 300,000 143,000 182,000 325,000 88,000 112,000 200,000 96,800 123,200 220,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 88,000 112,000 200,000 88,000
2.9
Kardiotokografi 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 11,000
2.10
Curatese di VK - - - - - - - - - - - - - - 264,000 336,000 600,000 -
2.11 Persalinan Normal Oleh
Dokter - - - - - - - - - - - - - - 352,000 448,000 800,000 -
2.12 Persalinan Dengan
1,200,000
Penyulit Oleh Dokter - - - - - - - - - - - - - - 528,000 672,000 -
2.13 angkat iud 100,000 52,800 67,200 120,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000 -
44,000 56,000
2.14
75,000
biopsi 33,000 42,000 75,000 44,000 56,000 100,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 33,000 42,000 22,000
2.15
30,000
bladder training 13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 26,400 33,600 60,000 35,200 44,800 80,000 13,200 16,800 -
2.16
100,000
buka implant 44,000 56,000 100,000 52,800 67,200 120,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 -
2.17
cukur 2,200 2,800 5,000 3,080 3,920 7,000 2,200 2,800 5,000 2,200 2,800 5,000 2,200 2,800 5,000 4,400 5,600 10,000 6,600 8,400 15,000 2,200 2,800 5,000 6,600
2.18
dilatasi serviks 8,800 11,200 20,000 13,200 16,800 30,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 33,000 42,000 75,000 8,800 11,200 20,000 33,000
2.19
douglas punksi 22,000 28,000 50,000 33,000 42,000 75,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 22,000
2.20
genek (periksa dalam) 6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 7,040 8,960 16,000 11,000 14,000 25,000 15,400 19,600 35,000 17,600 22,400 40,000 6,600 8,400 15,000 8,800
2.21
incisi himen impervorata 22,000 28,000 50,000 26,400 33,600 60,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 22,000 28,000 50,000 22,000
2.22
- - 220,000 280,000 500,000 330,000 420,000 750,000 440,000 560,000 1,000,000 660,000 840,000 1,500,000 880,000 1,120,000 2,000,000 - - -
inseminasi - -
2.23
jahit parinum 1-5 6,600 8,400 15,000 11,000 14,000 25,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 6,600 8,400 15,000 22,000
2.24
jahit parinum 6-10 8,800 11,200 20,000 15,400 19,600 35,000 11,000 14,000 25,000 8,800 11,200 20,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 8,800 11,200 20,000 26,400
2.25
jahit parinum 11-15 13,200 16,800 30,000 19,800 25,200 45,000 15,400 19,600 35,000 13,200 16,800 30,000 19,800 25,200 45,000 24,200 30,800 55,000 30,800 39,200 70,000 13,200 16,800 30,000 30,800
2.26
jahit parinum 15-20 17,600 22,400 40,000 24,200 30,800 55,000 19,800 25,200 45,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 17,600 22,400 40,000 35,200
2.27 jahit perineum > 20 per
jahitan + 2.000 22,880 29,120 52,000 29,480 37,520 67,000 25,080 31,920 57,000 22,880 29,120 52,000 29,480 37,520 67,000 33,880 43,120 77,000 40,480 51,520 92,000 22,880 29,120 52,000 40,480
2.28
konsultasi laktasi 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
2.29
lepas drainage 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 4,400 5,600 10,000 13,200
2.30
observasi 1-6 jam - - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 8,800 11,200 20,000 11,000
2.31
observasi 6-12 jam - - - - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400
2.32
observasi 12-24 jam - - - - 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800
2.33
pap smear 22,000 28,000 50,000 33,000 42,000 75,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 22,000 28,000 50,000 -
2.34 pasang balon cateter
untuk dilatasi serviks 8,800 11,200 20,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 8,800 11,200 20,000 13,200
2.35
pasang folley cateter 6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 6,600 8,400 15,000 11,000
2.36
pasang implant 8,800 11,200 20,000 17,600 22,400 40,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 8,800 11,200 20,000 13,200
2.37
pasang iud 26,400 33,600 60,000 33,000 42,000 75,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 26,400 33,600 60,000 26,400
2.38
pasang laminaria 15,400 19,600 35,000 19,800 25,200 45,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 22,000 28,000 50,000 33,000 42,000 75,000 15,400 19,600 35,000 26,400
2.39
pasang pessarium 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 28,600 36,400 65,000 30,800
2.40
pasang tampon 15,400 19,600 35,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 22,000
109
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
2.41
pasang tampon > 6 jam - - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 22,000
2.42
pemeriksaan dengan ctg - - - - 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 44,000 56,000 100,000 -
2.43
pencabutan implant 26,400 33,600 60,000 33,000 42,000 75,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 26,400 33,600 60,000 -
2.44 perawatan luka
episiotomi 13,200 16,800 30,000 22,000 28,000 50,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 -
2.45
perawatan payudara 6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 -
2.46
punksi amniotomi - - - - 6,600 8,400 15,000 11,000 14,000 25,000 15,400 19,600 35,000 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 -
2.47
- - 44,000 56,000 100,000 77,000 98,000 175,000 132,000 168,000 300,000 198,000 252,000 450,000 264,000 336,000 600,000 198,000 252,000 450,000 -
tindakan hidrotubasi - -
2.48
tindakan doppler - - - - 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 17,600 22,400 40,000 6,600 8,400 15,000 -
2.49
tindik bayi 4,400 5,600 10,000 8,800 11,200 20,000 3,520 4,480 8,000 4,400 5,600 10,000 6,600 8,400 15,000 11,000 14,000 25,000 17,600 22,400 40,000 6,600 8,400 15,000 -
2.50
tutul abothyl 4,400 5,600 10,000 6,600 8,400 15,000 2,200 2,800 5,000 3,520 4,480 8,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 2,200 2,800 5,000 -
2.51
90,000 44,000 56,000 100,000 22,000 28,000 50,000 44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 132,000 168,000 300,000 39,600 50,400 90,000 39,600
usg dengan klise 39,600 50,400
2.52
usg tanpa klise 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000
2.53
usg trans vaginal - - - - 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 26,400 33,600 60,000 26,400
2.54
versi luar - - - - - - - - - - - - - - 44,000 56,000 100,000 -
2.55
visum kebidanan - - - - - - - - - - - - - - 39,600 50,400 90,000 -
2.56
vulva higiene - - - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 6,600
Persalinan Normal - - - - - - - - - - - - - - - - -
2.57
- - 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 440,000 560,000 1,000,000 528,000 672,000 1,200,000 308,000 392,000 700,000 308,000
dokter spesialis - -
2.58
- - 220,000 280,000 500,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 264,000 336,000 600,000 -
dokter umum - -
2.59
- - 176,000 224,000 400,000 220,000 280,000 500,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 220,000 280,000 500,000 -
bidan - -
Persalinan Patologis - - - - - - - - - - - - - - - - -
4.1
352,000 448,000 800,000 396,000 504,000 900,000 440,000 560,000 1,000,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 396,000 504,000 900,000 352,000
dokter spesialis - - - -
4.2
264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 440,000 560,000 1,000,000 308,000 392,000 700,000 -
dokter umum - - - -
4.3
220,000 280,000 500,000 264,000 336,000 600,000 3,080,000 3,920,000 7,000,000 352,000 448,000 800,000 396,000 504,000 900,000 264,000 336,000 600,000 -
bidan - - - -
3 BAGIAN ANAK - - - - - - - - - - - - - - - - -
3.1
Resusitasi Bayi / Anak - - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 13,200 16,800 30,000 -
3.2
Resusitasi Bayi Baru Lahir - - - - 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 17,600 22,400 40,000 -
3.3
Infus Intra Osteous - - - - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 -
4 BAGIAN BEDAH - - - - - - - - - - - - - - - - - - - - - - - -
Perawatan luka dengan
hecting - - - - - - - - - - - - - - - - - - - - -
4.1
1-5 jahitan - - - - - - - - - - - - - - - - - - - - - 13 000 17,000 30,000
4.2
6-10 jahitan - - - - - - - - - - - - - - - - - - - - - 20,000 25,000 45,000
4.3
11-15 jahitan - - - - - - - - - - - - - - - - - - - - - 23,000 32,000 55,000
4.4
16-20 jahitan - - - - - - - - - - - - - - - - - - - - - 27,000 38,000 65,000
4.5 1500/ 2000/jah 3500/jah
lebih dari 20
jahitan - - - - - - - - - - - - - - - - - - - - - jahitan itan itan
4.6
28,600 36,400
Insisi kecil 65,000 33,000 42,000 75,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 28,600 36,400 65,000 -
110
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
4.7
33,000 42,000
Insisi sedang 75,000 37,400 47,600 85,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 33,000 42,000 75,000 -
4.8
44,000 56,000 100,000 55,000 70,000 125,000 100,000
Insisi besar 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 44,000 56,000 - - -
4.9 Pemasangan kateter
- -
anestesi - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 - - -
4.10 Baougenasi punksi
- - 100,000 150,000 88,000 112,000 200,000
kandung kemih - - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 66,000 84,000 - - -
4.11
110,000 140,000 250,000 132,000 168,000 300,000 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 99,000 126,000 225,000 132,000 168,000 300,000 - - -
Sirkumsisi
4.12
55,000 70,000 125,000 75,600 135,000
Ektirpasi kecil 59,400 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 33,000 42,000 75,000 -
4.13
66,000 84,000 150,000 89,600 160,000 100,000
Ekstirpasi sedang 70,400 35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 - - -
4.14
74,800 95,200 170,000 100,800 180,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 - -
Ekstirpasi besar 79,200 44,000 56,000 -
4.15
264,000 336,000 600,000 286,000 364,000 650,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 - - -
Eksisi Fibroma
4.16 Pengangkatan aterom /
264,000 336,000 600,000 286,000 364,000 650,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 - - -
lipoma / ganglion
4.17
- - 880,000 1,120,000 2,000,000 1,100,000 1,400,000 2,500,000 1,320,000 1,680,000 3,000,000 1,540,000 1,960,000 3,500,000 1,760,000 2,240,000 4,000,000 - - -
Open prostat - -
4.18 Reposisi,traksi,dislokasi
66,000 84,000 150,000 175,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 72,600 92,400 165,000 - - -
dengan spalk (anak) 77,000 98,000
4.19
Reposisi,traksi,dislokasi 77,000 98,000 175,000 112,000 200,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 72,600 92,400 165,000 77,000 98,000 175,000 - - -
dengan spalk (dewasa) 88,000
4.20 Perawatan luka gigitan
48,400 61,600 110,000 120,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 30,800 39,200 70,000 -
serangga 52,800 67,200
4.21 Perawatan luka gigitan
binatang ( ular , 66,000 84,000 150,000 160,000 33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 44,000 56,000 100,000 48,400 61,600 110,000 44,000 56,000 100,000 -
monyet,dll) 70,400 89,600
4.22
11,000 14,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 7,040 8,960 16,000 7,920 10,080 18,000 7,040 8,960 16,000 -
Angkat jahitan < 5 25,000 13,200 16,800 30,000
4.23 Angkat jahitan > 5 2000/ 2000/ 2000/ 2000/ 2000/ 2000/ 2000/
2000/ jahitan -
jahitan jahitan jahitan jahitan jahitan jahitan jahitan
4.24 Pemasangan Collar neck
66,000 84,000 150,000 175,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 30,800 39,200 70,000 -
(termasuk alat) 77,000 98,000
4.25
300,000 154,000 196,000 350,000 - - - - - - - - - - 132,000 168,000 300,000 -
Amputasi Jari 132,000 168,000
4.26
Dilatasi Pimosis 22,000 28,000 50,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 -
4.27
DC Shock - - - - 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000
4.28
Eksisi Clavus 35,200 44,800 80,000 44,000 56,000 100,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 35,200 44,800 80,000 -
4.29 Eksisi Condiloma
Acuminata 44,000 56,000 100,000 52,800 67,200 120,000 33,000 42,000 75,000 35,200 44,800 80,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 33,000 42,000 75,000 33,000
4.30 Eksisi Granuloma
Piogenicum 44,000 56,000 100,000 52,800 67,200 120,000 33,000 42,000 75,000 35,200 44,800 80,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 33,000 42,000 75,000 33,000
4.31
Eksisi Keloid Kecil > 5 cm 35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 30,800 39,200 70,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 35,200 44,800 80,000 -
4.32
Eksisi Keloid Besar < 5 cm 66,000 84,000 150,000 88,000 112,000 200,000 44,000 56,000 100,000 44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 110,000 140,000 250,000 44,000 56,000 100,000 -
4.33
Eksisi Syiringoma 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 35,200 44,800 80,000 37,400 47,600 85,000 30,800 39,200 70,000 44,000
4.34
Eksisi Veruca Vulgaris 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 35,200 44,800 80,000 37,400 47,600 85,000 30,800 39,200 70,000 44,000
4.35
Eksplorasi Luka 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 24,200 30,800 55,000 11,000 14,000 25,000 11,000
4.36
Ekstraksi Batu Urethra 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000
4.37
Ekstraksi Corpus Alineum 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000
4.38
Ekstraksi Kuku 26,400 33,600 60,000 35,200 44,800 80,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 -
4.39
170,000 120,000 125,000
Ekstrakpasi Kista Aterum 66,000 84,000 150,000 74,800 95,200 52,800 67,200 55,000 70,000 66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 -
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4.40
170,000 120,000 125,000
Ekstrakpasi Lipoma 66,000 84,000 150,000 74,800 95,200 52,800 67,200 55,000 70,000 66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 -
4.41
170,000 120,000 125,000
Ekstrakpasi Ganglion 66,000 84,000 150,000 74,800 95,200 52,800 67,200 55,000 70,000 66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 -
4.42
250,000 132,000 168,000 300,000 88,000 112,000 200,000 101,200 128,800 230,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 110,000
Ekstrakpasi Fibroma 110,000 140,000
4.43 Injeksi Varises (tidak 280,000 132,000 168,000 300,000 110,000 140,000 250,000 118,800 151,200 270,000 123,200 156,800 280,000 132,000 168,000 300,000 154,000 196,000 350,000 123,200 156,800 280,000 -
termasuk obat) 123,200 156,800
4.44 Injeksi Hemoroid (tidak 280,000 132,000 168,000 300,000 110,000 140,000 250,000 118,800 151,200 270,000 123,200 156,800 280,000 132,000 168,000 300,000 154,000 196,000 350,000 123,200 156,800 280,000 -
termasuk obat) 123,200 156,800
4.45
Pasang Guedel 13,200 16,800 30,000 17,600 22,400 40,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200
4.46
300,000 154,000 196,000 350,000 110,000 140,000 250,000 121,000 154,000 275,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 132,000 168,000 300,000 132,000
Pasang WSD 132,000 168,000
4.47 Pasang Drain
Handscoen/kasa 4,400 5,600 10,000 6,600 8,400 15,000 3,520 4,480 8,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400
4.48
250,000 132,000 168,000 300,000 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 132,000
Sirkumsisi 110,000 140,000
4.49
150,000 160,000 100,000 120,000
Blast Punksi 66,000 84,000 70,400 89,600 44,000 56,000 52,800 67,200 66,000 84,000 150,000 74,800 95,200 170,000 88,000 112,000 200,000 66,000 84,000 150,000 66,000
4.50 Visum et repertum (korban
hidup) 22,000 28,000 50,000 - - 17,600 22,400 40,000 22,000 28,000 50,000 22,000 28,000 50,000 30,800 39,200 70,000 35,200 44,800 80,000 22,000 28,000 50,000 22,000
4.51 Visum Mayat (Periksa
Luar) - - - - - - - - - - - - - - 66,000 84,000 150,000 -
- - - - - - - - - - - - - - - - -
5 BAGIAN THT - - - - - - - - - - - - - - - - -
Tindakan Sederhana - - - - - - - - - - - - - - - - -
5.1
Tes Penala 6,600 8,400 15,000 8,800 11,200 20,000 6,600 8,400 15,000 6,600 8,400 15,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 -
5.2
Ekstraksi Serumen
Profunda / Toilet 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 15,400 19,600 35,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 15,400 19,600 35,000 -
Tindakan Sedang - - - - - - - - - - - - - - - - -
5.3
Angkat Jaringan Granulasi 100,000 120,000
di Telinga 44,000 56,000 52,800 67,200 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 - - -
5.4 Insisi Pseudokista dg
Pemasangan Verban Tekan 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
5.5
Irigasi Telinga / Hidung 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
5.6
Kaustik Hidung 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
5.7
Kaustik Tenggorok 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
5.8 Punksi Pseudokista Daun
Telinga 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 - - -
Tindakan Khusus - - - - - - - - - - - - - - - - -
5.9 Angkat/Pasang Tampon
Hidung 6,600 8,400 15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
5.10
Audiogram 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 39,600 50,400 90,000 - - -
5.11
Biopsi Cavum Nasi 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - -
5.12
Biopsi Nasofaring 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - -
5.13
Biopsi Orofaring 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - -
5.14 Ekstraksi Post Aurikular
Kista 33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 -
5.15 Ekstraksi Pre Aurikular
Kista 33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 -
5.16
Ekstraksi Benda Asing 33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 -
5.17
Gips Telinga 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
5.18
Insisi Abses Mastoid 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
5.19
Insisi Abses Peritonsil 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
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5.20 Insisi Abses Sub 100,000

Mandibula 57,200 72,800 130,000 66,000 84,000 150,000 39,600 50,400 90,000 44,000 56,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 - - -
5.21
Insisi Septum Nasi 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
5.22
150,000
Irigasi Sinus Maksila 55,000 70,000 125,000 66,000 84,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 - - -
5.23
Parasintese
Perawatan
22,000 28,000 50,000 26,400 33,600 60,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - -
5.24 Epistaksis/Tampon Bagian
Depan 17,600 22,400 40,000 22,000 28,000 50,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - -
5.25
Rhinoscope Posterior 11,000 14,000 25,000 15,400 19,600 35,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 12,320 15,680 28,000 15,400 19,600 35,000 - - -
5.26
Suction Telinga (OMP) 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,920 10,080 18,000 11,000 14,000 25,000 - - -
5.27 Tampon Hidung Bagian
Belakang (Belloque 100,000
Tampon) 39,600 50,400 90,000 44,000 56,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 44,000 56,000 100,000 - - -
5.28
Up Hecting 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,920 10,080 18,000 11,000 14,000 25,000 6,600 8,400 15,000 -
- - - - - - - - - - - - - - - - -
6 BAGIAN MATA - - - - - - - - - - - - - - - - -
Tindakan Sederhana - - - - - - - - - - - - - - - - -
6.1
Atropinisasi 4,400 5,600 10,000 6,600 8,400 15,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 -
6.2
Epilasi 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 - - -
6.3 Irigasi Auqades Pada
Konjungtiva 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 -
6.4 Irigasi Auqades Pada
Trauma Kimia 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 -
6.5
100,000
Keratometri 39,600 50,400 90,000 44,000 56,000 35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 48,400 61,600 110,000 55,000 70,000 125,000 - - -
6.6
Koreksi Refraksi 8,800 11,200 20,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 - - -
6.7 Pemeriksaan Pantocain,
Antibiotik, Verband 6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 11,000 14,000 25,000 -
6.8
Pemeriksaan Tonometri 6,600 8,400 15,000 11,000 14,000 25,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 - - -
6.9 Penetesan Mediatrika
Efrisell 4,400 5,600 10,000 6,600 8,400 15,000 3,520 4,480 8,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 -
6.10
Slit Lamp 11,000 14,000 25,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 - - -
- - - - - - - - - - - - - - - - -
Tindakan Sedang - - - - - - - - - - - - - - - - -
6.11
anal test 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
6.12 Ekstirpasi Corpus 100,000 100,000
Aleneum Ekstra Okuler 39,600 50,400 90,000 44,000 56,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 55,000 70,000 125,000 66,000 84,000 150,000 - - -
6.13
Fluerosin Test 15,400 19,600 35,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
6.14 Pemeriksaan Fundus Kopi
Indireksi
Pengangkatan Jahitan di
19,800 25,200 45,000 26,400 33,600 60,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
6.15 Konjungtiva, Kornea dan
Sklera 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - -
6.16
Refraktometri 22,000 28,000 50,000 26,400 33,600 60,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 28,600 36,400 65,000 44,000 56,000 100,000 - - -
6.17
Strikretinoskopi 19,800 25,200 45,000 26,400 33,600 60,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 - - -
6.18
Suntikan Sub Konjungtiva 17,600 22,400 40,000 22,000 28,000 50,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 - - -
- - - - - - - - - - - - - - - - -
Tindakan Sedang dengan

Lokal Anestesi - - - - - - - - - - - - - - - - -
6.19
100,000
Ekstirpasi Gram/Kornea 39,600 50,400 90,000 44,000 56,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 - - -
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6.20 Ekstirpasi Granulasi Tanpa 100,000 120,000

Jahit 44,000 56,000 52,800 67,200 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - -
6.21
100,000 120,000
Ekstirpasi Litiasis 44,000 56,000 52,800 67,200 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - -
6.22
125,000 150,000
Ekstirpasi Ptegrium 55,000 70,000 66,000 84,000 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 46,200 58,800 105,000 48,400 61,600 110,000 - - -
6.23 Ekstirpasi Veruca Nevus 90,000 110,000
Palpebra 39,600 50,400 48,400 61,600 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 46,200 58,800 105,000 48,400 61,600 110,000 - - -
6.24
150,000 175,000
Insisi Abses 66,000 84,000 77,000 98,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000 -
6.25
75,000 100,000
Insisi Hordeolum 33,000 42,000 44,000 56,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 35,200 44,800 80,000 -
6.26 Insisi Khalazion dengan 85,000 110,000
Kuretase 37,400 47,600 48,400 61,600 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
6.27
75,000 100,000
Jahitan Kurang dari 2 cm 33,000 42,000 44,000 56,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 35,200 44,800 80,000 - - -
6.28
75,000 100,000
Biometri 33,000 42,000 44,000 56,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 35,200 44,800 80,000 - - -
6.29
100,000 125,000
#REF! USG A Scan ( Organ Mata ) 44,000 56,000 55,000 70,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 44,000 56,000 100,000 - - -
- - - - - - - - - - - - - - - - -
BAGIAN BEDAH
7 MULUT - - - - - - - - - - - - - - - - -
7.1
55,000 70,000 125,000 66,000 84,000 150,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 - - -
Pencabutan Gigi dengan Flap
7.2 Insisi Abses ( Bedah Mulut
55,000 70,000 125,000 66,000 84,000 150,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 - - -
)
7.3 Insisi Biopsi Intra Oral
88,000 112,000 200,000 101,200 128,800 230,000 57,200 72,800 130,000 66,000 84,000 150,000 74,800 95,200 170,000 83,600 106,400 190,000 99,000 126,000 225,000 - - -
dengan Bius Lokal
7.4
81,400 103,600 185,000 88,000 112,000 200,000 66,000 84,000 150,000 70,400 89,600 160,000 74,800 95,200 170,000 79,200 100,800 180,000 83,600 106,400 190,000 - - -
Insisi Plegmon
Eksisi Tumor Jinak /
7.5 Ekstripsi Epulis ? Ekstra
88,000 112,000 200,000 110,000 140,000 250,000 66,000 84,000 150,000 68,200 86,800 155,000 70,400 89,600 160,000 72,600 92,400 165,000 79,200 100,800 180,000 - - -
Oral
7.6
176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -
Alveolectomi / Regio
7.7
176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -
Operculectomi
7.8
176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -
Gingivectomi
7.9
264,000 336,000 600,000 308,000 392,000 700,000 198,000 252,000 450,000 242,000 308,000 550,000 286,000 364,000 650,000 330,000 420,000 750,000 396,000 504,000 900,000 - - -
OD M3 IMP KLI
7.10
352,000 448,000 800,000 396,000 504,000 900,000 330,000 420,000 750,000 374,000 476,000 850,000 440,000 560,000 1,000,000 484,000 616,000 1,100,000 528,000 672,000 1,200,000 - - -
OD M3 IMP KLI II
7.11 Enukleasi Kista Kecil /
176,000 224,000 400,000 198,000 252,000 450,000 88,000 112,000 200,000 110,000 140,000 250,000 154,000 196,000 350,000 176,000 224,000 400,000 330,000 420,000 750,000 - - -
Sedang / besar
7.12
220,000 280,000 500,000 264,000 336,000 600,000 202,400 257,600 460,000 220,000 280,000 500,000 242,000 308,000 550,000 264,000 336,000 600,000 330,000 420,000 750,000 - - -
Apex Reseksi
7.13
110,000 140,000 250,000 154,000 196,000 350,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 220,000 280,000 500,000 - - -
Windowing
7.14 Debridement Ringan /
88,000 112,000 200,000 110,000 140,000 250,000 66,000 84,000 150,000 77,000 98,000 175,000 83,600 106,400 190,000 92,400 117,600 210,000 110,000 140,000 250,000 - - -
Sedang
7.15
253,000 322,000 575,000 264,000 336,000 600,000 176,000 224,000 400,000 264,000 336,000 600,000 352,000 448,000 800,000 528,000 672,000 1,200,000 616,000 784,000 1,400,000 - - -
Debridement Berat
7.16 Reposisi Dislokasi Tmj
330,000 420,000 750,000 352,000 448,000 800,000 198,000 252,000 450,000 242,000 308,000 550,000 286,000 364,000 650,000 330,000 420,000 750,000 440,000 560,000 1,000,000 - - -
Secara Manual
7.17 Reposisi Fiksasi dengan
374,000 476,000 850,000 396,000 504,000 900,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 484,000 616,000 1,100,000 - - -
Arch Bar ( 1 Rahang )
7.18 Reposisi Fiksasi dengan
374,000 476,000 850,000 396,000 504,000 900,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 484,000 616,000 1,100,000 - - -
Arch Bar ( RA / RB )
7.19 Buka Jahitan / Angkat
55,000 70,000 125,000 66,000 84,000 150,000 44,000 56,000 100,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 70,400 89,600 160,000 - - -
Jahitan ( Bedah Mulut )
7.20 Implant Dental Titanium 1 2,640,000 3,360,000 6,000,000 3,080,000 3,920,000 7,000,000 1,980,000 2,520,000 4,500,000 2,640,000 3,360,000 6,000,000 3,080,000 3,920,000 7,000,000 3,520,000 4,480,000 8,000,000 3,960,000 5,040,000 9,000,000 - - -
#REF! Unit
- - - - - - - - - - - - - - - - -
BAGIAN GIGI DAN - - - - - - - - - - - - - - - - -

8 MULUT
114
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Penambahan - - - - - - - - - - - - - - - - -
8.1
Fuji 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
8.2
Sinar 55,000 70,000 125,000 66,000 84,000 150,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 77,000 98,000 175,000 88,000 112,000 200,000 - - -
8.3
Scalling 77,000 98,000 175,000 88,000 112,000 200,000 44,000 56,000 100,000 52,800 67,200 120,000 61,600 78,400 140,000 110,000 140,000 250,000 154,000 196,000 350,000 - - -
- - - - - - - - - - - - - - - - -
Pengobatan - - - - - - - - - - - - - - - - -
8.4
Pengisian Saluran Akar 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
8.5
Tambal Sementara 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
- - - - - - - - - - - - - - - - -
Pencabutan - - - - - - - - - - - - - - - - -
8.6
22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
Curretage Per Regio
8.7
26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
Gigi Tetap
8.8 Gigi Tetap dengan Jahitan
44,000 56,000 100,000 48,400 61,600 110,000 33,000 42,000 75,000 39,600 50,400 90,000 48,400 61,600 110,000 57,200 72,800 130,000 66,000 84,000 150,000 - - -
/ Komplikasi
8.9
22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
Gigi Susu dengan Suntik
8.10
19,800 25,200 45,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 17,600 22,400 40,000 -
Gigi Susu tanpa Suntik
8.11
26,400 33,600
Insisi abses/intr oral 60000 33,000 42,000 75000 22,000 28,000 50000 24,200 30,800 55000 26,400 33,600 60000 28,600 36,400 65000 33,000 42,000 75,000 - - -
- -
Orthodonty - - - - - - - - - - - - - - -
8.12 Ortho lepas kasus berat
198,000 252,000 450000 220,000 280,000 500000 110,000 140,000 250000 132,000 168,000 300000 154,000 196,000 350000 176,000 224,000 400000 220,000 280,000 500,000 - - -
perahang
8.13
22,000 28,000 50000 26,400 33,600 60000 - - - - - - - - - - - - -
Control Orto Lepas
Prothesa - - - - - - - - - - - - - - - - -
8.14
110,000 140,000 250,000 132,000 168,000 300,000 77,000 98,000 175,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 220,000 280,000 500,000 - - -
Plat + 1 Elemen
8.15 Penambalan PerElemen
26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 - - -
Gigi
8.16
660,000 840,000 1,500,000 770,000 980,000 1,750,000 440,000 560,000 1,000,000 484,000 616,000 1,100,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 660,000 840,000 1,500,000 - - -
Full Denture
8.17
110,000 140,000 250,000 132,000 168,000 300,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 275,000 350,000 625,000 385,000 490,000 875,000 - - -
Rebasing ( Per rahang )
8.18
88,000 112,000 200,000 110,000 140,000 250,000 88,000 112,000 200,000 105,600 134,400 240,000 123,200 156,800 280,000 220,000 280,000 500,000 308,000 392,000 700,000 - - -
Reparasi
- - - - - - - - - - - - - - - - -
Fix Protesa
8.19
154,000 196,000 350,000 176,000 224,000 400,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 220,000 280,000 500,000 - - -
Jaket crown Acrilic
8.20 Jaket crown Acrilic
176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 264,000 336,000 600,000 - - -
Backing Metal
8.21
264,000 336,000 600,000 308,000 392,000 700,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 242,000 308,000 550,000 264,000 336,000 600,000 - - -
Jaket Crown Porselen
- - - - - - - - - - - - - - - - -
Fixed Ortodonty
8.22
770,000 980,000
Perahang 1,750,000 836,000 1,064,000 1,900,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 616,000 784,000 1,400,000 660,000 840,000 1,500,000 704,000 896,000 1,600,000 - - -
8.23
1,100,000 1,400,000
Rahang atas + bawah 2,500,000 1,144,000 1,456,000 2,600,000 1,012,000 1,288,000 2,300,000 1,056,000 1,344,000 2,400,000 1,100,000 1,400,000 2,500,000 1,144,000 1,456,000 2,600,000 1,188,000 1,512,000 2,700,000 - - -
9 BAGIAN PSIKIATRI - - - - - - - - - - - - - - - - -
9.1
Psikoterapi > 30 menit 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - -
9.2
Psikoterapi < 30 menit 19,800 25,200 45,000 26,400 33,600 60,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - -
9.3
Psikometri Sedang 39,600 50,400 90,000 44,000 56,000 100,000 33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 46,200 58,800 105,000 52,800 67,200 120,000 - - -
9.4
Psikometri Komplek 88,000 112,000 200,000 110,000 140,000 250,000 70,400 89,600 160,000 74,800 95,200 170,000 79,200 100,800 180,000 83,600 106,400 190,000 88,000 112,000 200,000 - - -
115
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
BAGIAN PENYAKIT - - - - - - - - - - - - - - - - -
10 DALAM DAN PARU
10.1
22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 22,000 28,000 50,000 -
Angkat Jahitan Post WSD
10.2
Biopsi Kelanjer Leher / - - 66,000 84,000 150,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - 39,600
Biopsi Jarum Halus KGB
10.3 Biopsi Pleura /
Transthoracal Needle - - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 - - 110,000
Biopsi (Blind)
10.4
- - - - 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 33,000 42,000 75,000 -
Lepas Selang WSD
10.5 Punksi Pleura
154,000 196,000 350,000 176,000 224,000 400,000 70,400 89,600 160,000 77,000 98,000 175,000 83,600 106,400 190,000 92,400 117,600 210,000 110,000 140,000 250,000 - - 83,600
(Thoracocentesis)
10.6 Punksi Percobaan ("Proef
17,600 22,400 40,000 26,400 33,600 60,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 30,800 39,200 70,000 - - 19,800
Punctie")
10.7
- - - - 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 - - 88,000
Pleurodesis
10.8
- - - - 44,000 56,000 100,000 52,800 67,200 120,000 61,600 78,400 140,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000
Pasang Continous Suction
10.9
- - - - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 - - 44,000
Pasang Drain Suction
10.10
- - - - 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000
Reposisi Selang WSD
10.11
66,000 84,000 150,000 70,400 89,600 160,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - 39,600
Spirometri
10.12
- - - - 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 - - 154,000
Thoracostomi (WSD)
10.13
- - - - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 - - 44,000
Endotracheal Tube (ETT)
10.14 Punksi Ascites (Diluar
- - - - 44,000 56,000 100,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000
Bahan Dan Alat)
10.15 Punksi Sendi (Diluar
- - - - 44,000 56,000 100,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000
Bahan Dan Alat)
10.16
- - - - - - - - - - - - - - 66,000 84,000 150,000 -
Needle Decompresi
10.17
- - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 88,000 112,000 200,000 88,000
Vena Sectie
10.18
33,000 42,000 75,000 39,600 50,400 90,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 26,400
Peak Flow Rate
10.19
35,200 44,800 80,000 39,600 50,400 90,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 39,600 50,400 90,000 37,400 47,600 85,000 37,400
Infus Intra Osteous
10.20 Pemasangan Kateter
- - - - 6,600 8,400 15,000 7,920 10,080 18,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 11,000 14,000 25,000 11,000
Double Lumen
10.21
- - - - - - - - - - - - - - - - 55,000
Pemasangan Ventilator
10.22
- - - - - - - - - - - - - - - - 44,000
Perawatan Ventilator/Hari
10.23 Pemasangan CVP /
- - - - - - - - - - - - - - - - 308,000
Perawatan
10.24 Pemasangan Monitor ECG
- - - - - - - - - - - - - - - 22,000
/ Hari
11 HEMODIALISA - - - - - - - - - - - - - - - - -
11.1
HEMODIALISA 330,000 420,000 750,000 - - 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000
- - - - - - - - - - - - - - - - -
12 BAGIAN ORTHOPEDI
12.1
22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 30,800
Angkat Wire
12.2 Angkat Wire Dengan
44,000 56,000 100,000 48,400 61,600 110,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 66,000 84,000 150,000 - - -
Jahitan
12.3
44,000 56,000 100,000 48,400 61,600 110,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 66,000 84,000 150,000 - - 44,000
Aspirasi Kista
12.4
22,000 28,000 50,000 33,000 42,000 75,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - 35,200
BMD
12.5
55,000 70,000
Ganglion 125,000 57,200 72,800 130,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 52,800 67,200 120,000 52,800
116
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
12.6
Injeksi Trigger Finger 1 Jari 44,000 56,000
(Diluar Bahan Dan Alat) 100,000 48,400 61,600 110,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - 44,000
12.7
Injeksi Trigger Finger 2 Jari 55,000 70,000 125,000 57,200 72,800 130,000 48,400 61,600 110,000 55,000 70,000 125,000 61,600 78,400 140,000 70,400 89,600 160,000 77,000 98,000 175,000 - - -
(Diluar Bahan Dan Alat)
12.8 Injeksi Trigger Thumb 1
Jari (Diluar Bahan Dan 39,600 50,400 90,000 44,000 56,000 100,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
Alat)
12.9 Injeksi Trigger Thumb 2
Jari (Diluar Bahan Dan 77,000 98,000 175,000 81,400 103,600 185,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 70,400 89,600 160,000 - - -
Alat)
12.10 Injeksi Intra Artikuler 1
Knee (Diluar Bahan dan 55,000 70,000 125,000 59,400 75,600 135,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - -
Alat)
12.11 Injeksi Intra Artikuler 2
Knee (Diluar Bahan dan 99,000 126,000 225,000 110,000 140,000 250,000 88,000 112,000 200,000 96,800 123,200 220,000 105,600 134,400 240,000 114,400 145,600 260,000 123,200 156,800 280,000 - - -
Alat)
12.12
Injeksi Dequarvain (Diluar 44,000 56,000 100,000 48,400 61,600 110,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - -
Bahan Dan Alat)
12.13 Injeksi Carpal Tunnel
Syndrome (Diluar Bahan 55,000 70,000 125,000 59,400 75,600 135,000 41,800 53,200 95,000 46,200 58,800 105,000 50,600 64,400 115,000 55,000 70,000 125,000 66,000 84,000 150,000 - - -
Dan Alat)
12.14
Injeksi Keloid (Diluar 39,600 50,400 90,000 4,400 5,600 10,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - -
Bahan Dan Alat)
12.15
55,000 70,000 125,000 59,400 75,600 135,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 - - -
Punksi / Aspirasi 2 Lutut
12.16
99,000 126,000 225,000 110,000 140,000 250,000 79,200 100,800 180,000 83,600 106,400 190,000 88,000 112,000 200,000 92,400 117,600 210,000 96,800 123,200 220,000 - - -
Punksi / Aspirasi 1 Lutut
12.17
33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 - - -
Punksi Abses
12.18
154,000 196,000 350,000 176,000 224,000 400,000 92,400 117,600 210,000 96,800 123,200 220,000 101,200 128,800 230,000 105,600 134,400 240,000 110,000 140,000 250,000 - - -
Pasang Skin Traksi
12.19
35,200 44,800 80,000 39,600 50,400 90,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
Pasang Ransel Verband
- - - - - - - - - - - - - - - - -
13 BAGIAN SYARAF - - - - - - - - - - - - - - - - -
13.1
- - - - 39,600 50,400 90,000 52,800 67,200 120,000 66,000 84,000 150,000 79,200 100,800 180,000 88,000 112,000 200,000 - - 66,000
Lumbal Punksi
13.2 Punksi Sum-Sum Tulang
- - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 - - 132,000
(BMP)
13.3 Skrining Fungsi Luhur
88,000 112,000 200,000 110,000 140,000 250,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 70,400 89,600 160,000 - - 66,000
(Untuk Pasien Umum)
13.4 Skrining Amnestia
66,000 84,000 150,000 70,400 89,600 160,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - 48,400
Traumatic Brain Injury
13.5
66,000 84,000 150,000 77,000 98,000 175,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 74,800 95,200 170,000 - - 63,800
EEG
13.6
66,000 84,000 150,000 77,000 98,000 175,000 57,200 72,800 130,000 63,800 81,200 145,000 70,400 89,600 160,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000
Carotid Doppler
13.7
66,000 84,000 150,000 77,000 98,000 175,000 57,200 72,800 130,000 63,800 81,200 145,000 70,400 89,600 160,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000
Vascular Doppler
BAGIAN KULIT DAN - - - - - - - - - - - - - - - - -

14 KELAMIN
14.1
33,000 42,000 75,000 44,000 56,000 100,000 - - - - - - - - - - - - -
Aspirasi Kista
14.2
132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - - - -
Biopsi / Eksisi Wajah
14.3
110,000 140,000 250,000 132,000 168,000 300,000 - - - - - - - - - - - - -
Biopsi / Eksisi Non Wajah
14.4
66,000 84,000 150,000 88,000 112,000 200,000 - - - - - - - - - - - - -
Chlorethyl Spray
14.5
110,000 140,000 250,000 132,000 168,000 300,000 - - - - - - - - - - - - -
Dermabrasi
14.6
22,000 28,000 50,000 26,400 33,600 60,000 - - - - - - - - - - - - -
Elektro Desikasi Keratosis
117
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
14.7
Elektro Desikasi Melasma 110,000 140,000 250,000 154,000 196,000 350,000 - - - - - - - - - - - - -
Fleseboroik & Keratosis
14.8
Elektrokauterisasi Verucca 154,000 196,000 350,000 176,000 224,000 400,000 - - - - - - - - - - - - -
Vulgaris, Veruca Plana
14.9 Ekstirpasi Clavus, Nevus
132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - - - -
Pada Wajah
14.10
Elektrokauterisasi 125,400 159,600 285,000 154,000 196,000 350,000 - - - - - - - - - - - - -

Syiringoma Trichocolium
14.11
Ekstirpasi Fibroma Molle, 176,000 224,000 400,000 198,000 252,000 450,000 - - - - - - - - - - - - -
Granuloma Pyogenikum
14.12
44,000 56,000 100,000 52,800 67,200 120,000 - - - - - - - - - - - - -
Enukleasi Komedo
14.13 Ekstirpasi Total Tumor
66,000 84,000 150,000 77,000 98,000 175,000 - - - - - - - - - - - - -
Jinak Non Muka
14.14
116,600 148,400 265,000 132,000 168,000 300,000 - - - - - - - - - - - - -
Elektrokauter Wajah
14.15
88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -
Elektrokauter Non Wajah
14.16
33,000 42,000 75,000 44,000 56,000 100,000 - - - - - - - - - - - - -
Facial Care / Skin Care
14.17
66,000 84,000 150,000 77,000 98,000 175,000 - - - - - - - - - - - - -
Insisi Abses Banal
14.18 Injeksi Varices (Diluar
24,200 30,800 55,000 28,600 36,400 65,000 - - - - - - - - - - - - -
Bahan Dan Obat)
14.19
77,000 98,000 175,000 79,200 100,800 180,000 - - - - - - - - - - - - -
Injeksi Kenacort
14.20
8,800 11,200 20,000 13,200 16,800 30,000 - - - - - - - - - - - - -
Perawatan Luka
14.21
88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -
Prick Test
14.22
88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -
Patch Test
14.23
44,000 56,000 100,000 55,000 70,000 125,000 - - - - - - - - - - - - -
Peeling Oleh Dokter
14.24
22,000 28,000 50,000 26,400 33,600 60,000 - - - - - - - - - - - - -
Peeling Oleh Perawat
14.25
44,000 56,000 100,000 55,000 70,000 125,000 - - - - - - - - - - - - -
Test Penisilin Dan Procain
- - - - - - - - - - - - - - - - -
15 TINDAKAN KEPERAWATAN - - - - - - - - - - - - - - - - -
15.1
- - - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 17,600 22,400 40,000 13,200
Bilas Lambung
15.2
- -
Blue Light Per Hari - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 13,200 16,800 30,000 13,200
15.3 Buka Drain Handscoen /
4,400 5,600
Kassa 10,000 8,800 11,200 20,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
15.4
11,000 14,000
Buka Drain Tube / Suction 25,000 15,400 19,600 35,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 9,680 12,320 22,000 9,680
15.5
39,600 50,400 100,000
Buka Gips (Long) 90,000 44,000 56,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 -
15.6
35,200 44,800 85,000
Buka Gips (Short) 80,000 37,400 47,600 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 39,600 50,400 90,000 28,600 36,400 65,000 -
15.7
66,000 84,000 150,000 160,000
Buka Gips Berat 70,400 89,600 33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 46,200 58,800 105,000 55,000 70,000 125,000 44,000 56,000 100,000 -
15.8
55,000 70,000 125,000 140,000
Buka Gips Ringan 61,600 78,400 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 39,600 50,400 90,000 -
15.9
- -
Buka Infus - - 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400
15.10
48,400 61,600 110,000 120,000
Buka Jendela Gips 52,800 67,200 35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 39,600 50,400 90,000 -
15.11
6,600 8,400
Buka Kateter 15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800
15.12
- -
Buka NGT - - 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 7,480 9,520 17,000 8,800 11,200 20,000 6,600 8,400 15,000 6,600
118
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
15.13
6,600 8,400
Buka Spalk 15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800
15.14
- -
Buka WSD - - 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 30,800
15.15
22,000 28,000
EKG 50,000 26,400 33,600 60,000 11,000 14,000 25,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800
15.16 Ganti Balutan + Perawatan
22,000 28,000
Luka / Hari 50,000 26,400 33,600 60,000 11,000 14,000 25,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800
15.17
13,200 16,800
Ganti Verban 30,000 17,600 22,400 40,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200
15.18
- -
Gliserin Spuit - - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800
15.19 Imunisasi BCG (Diluar
8,800 11,200
Obat) 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.20 Imunisasi Campak (Diluar
8,800 11,200
Obat) 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.21 Imunisasi DPT (Diluar
8,800 11,200
Obat) 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.22 Imunisasi Hepatitis B
8,800 11,200
(Diluar Obat) 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.23 Imunisasi Polio (Diluar
8,800 11,200
Obat) 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.24 Kateterisasi vena
- -
Umbilikalis - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 - - 13,200
15.25
- -
Klisma / Lavamen - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000
15.26 Mantoux Test (Dengan
33,000 42,000
Obat) 75,000 37,400 47,600 85,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 35,200
15.27
22,000 28,000
Nebulizer/Hari 50,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 11,000 14,000 25,000 11,000
15.28
33,000 42,000
Necrotomi 75,000 35,200 44,800 80,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 -
15.29 Observasi Khusus Pada
- -
Pasien Post Op. BPH - - 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 -
15.30
- -
Pasang Cerobong Angin - - 4,400 5,600 10,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 13,200
15.31 Pasang Gips (Long)
44,000 56,000
termasuk dan bahan 100,000 48,400 61,600 110,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 44,000 56,000 100,000 33,000 42,000 75,000 28,600
15.32
35,200 44,800
Pasang Gips (Short) 80,000 39,600 50,400 90,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 22,000 28,000 50,000 19,800
15.33
- -
Pasang Infus Anak - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 8,800
15.34
- -
Pasang Infus Bayi - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000
15.35
- -
Pasang Infus Dewasa - - 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
15.36
- -
Pasang Kateter Folley - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 11,880 15,120 27,000 13,200 16,800 30,000 11,000 14,000 25,000 8,800
15.37
- -
Pasang Kateter Kondom - - 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 8,800 11,200 20,000 6,600
15.38
- -
Pasang NGT - - 6,600 8,400 15,000 8,800 11,200 20,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 8,800 11,200 20,000 8,800
15.39
- -
Pasang NGT Pessarium - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000
15.40
22,000 28,000
Pasang Spalk 50,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200
15.41
6,600 8,400
Pasang Tampon Luka 15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000
15.42
8,800 11,200
Pasang Tampon Vagina 20,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200
15.43 Pemberian Obat
1,320 1,680
IM,SC/Kali 3,000 1,760 2,240 4,000 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 4,400
15.44 Pemberian Obat Melalui
- -
NGT. OGT/Kali - - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800
15.45
- -
Pemberian Supositori/Kali - - 2,200 2,800 5,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 4,400
15.46 Pemeriksaan Kehamilan
6,600 8,400
Dengan Doppler 15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 6,600 8,400 15,000 6,600
119
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
15.47
- -
Pengambilan Darah Arteri - - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200
15.48 Pengambilan Darah Vena (
- -
Vac + EDTA ) - - 4,400 5,600 10,000 6,600 8,400 15,000 7,480 9,520 17,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
- -
SST ) - - 6,600 8,400 15,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 9,680 12,320 22,000 9,680
- -
SST + EDTA ) - - 6,600 8,400 15,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200
15.51 Perawatan Fraktur
33,000 42,000
Terbuka 75,000 37,400 47,600 85,000 19,800 25,200 45,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 26,400 33,600 60,000 22,000
15.52
- -
Perawatan Jenazah - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000
15.53 Perawatan Luka Bakar
- -
Besar ( > 50% ) - - 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 28,600 36,400 65,000 28,600
- -
Kecil (< 30% ) - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 17,600 22,400 40,000 17,600
- -
Sedang ( 30 - 50 % ) - - 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000
15.56 Perawatan Luka
6,600 8,400
Episiotomi 15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000
15.57 Perawatan Luka Operasi
- -
Besar / Hari - - 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000
- -
Kecil / Hari - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000
- -
Sedang / Hari - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 15,400
15.60 Perawatan Payudara
6,600 8,400
Bermasalah 15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000
15.61
- -
Perawatan Tali Pusat - - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800
15.62 Perawatan Normal Oeh
8,800 11,200
Bidan 20,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 -
15.63
- - 120,000 96,800 123,200 220,000 135,520 172,480 308,000
Repair Perineum - - 38,720 49,280 88,000 46,200 58,800 105,000 52,800 67,200 - - 96,800
15.64
- -
Spooling Infus/hari - - 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,480 9,520 17,000 4,400 5,600 10,000 4,400
15.65
- -
Spooling Kateter/hari - - 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,480 9,520 17,000 4,400 5,600 10,000 4,400
15.66
- -
Suctioning/hari - - 6,600 8,400 15,000 7,920 10,080 18,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 9,680 12,320 22,000 9,680
15.67
- -
Suntik Insulin/Kali - - 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 4,400 5,600 10,000 4,400
15.68
8,800 11,200
Tes Buta Warna 20,000 13,200 16,800 30,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 7,480 9,520 17,000 8,800 11,200 20,000 5,280 6,720 12,000 -
15.69
- -
Ganti Veerboden/sprei - - 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 - - 3,080
15.70
- -
Mobilisasi Pasien - - 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 - - 3,080
16 Pelayanan fisioterapi -
- - - - - - - - - -
-
Tindakan dengan elektropterapi - - - - - - - - - -
16.1
8,800 11,200
microwave diathermi 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.2
8,800 11,200
ultra sound 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.3
8,800 11,200
elecktrikal stimulasi 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.4
8,800 11,200
traksi cervikal/lumbal 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.5
8,800 11,200
ultraviolet lamp 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.6
8,800 11,200
infra lamp 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.7
8,800 11,200
whirl pool 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.8
8,800 11,200
hot pack 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
120
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
16.9
15,400 19,600
nebuliser 35,000 17,600 22,400 40,000 8,800 11,200 20,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000
16.10
8,800 11,200
parafin bath 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
Tindakan sederhana - -
- - - - - - - - - - - -
16.11
8,800 11,200
terapi manipulasi 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.12
8,800 11,200
massage 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.13
8,800 11,200
latihan anggota gerak 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.14
8,800 11,200
latihan pernafasan 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.15
8,800 11,200
latihan pola hidup sehari-hari 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.16
8,800 11,200
latihann kekuatan otot 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.17
8,800 11,200
senam asam 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.18
8,800 11,200
senam stroke 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.19
8,800 11,200
senam hamil 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
16.20
8,800 11,200
senam nifas 20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
17 Pelayanan tindakan bedah
- - - - - - - - - -
Operasi elektif - - - - - - - - - -
17.1
operasi kecil 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 121,000 154,000 275,000 132,000 168,000 300,000
17.2
operasi kecil dengan narkose 352,000 448,000 800,000 462,000 588,000 1,050,000 792,000 1,008,000 1,800,000 968,000 1,232,000 2,200,000 1,188,000 1,512,000 2,700,000
17.3
operasi sedang 704,000 896,000 1,600,000 792,000 1,008,000 1,800,000 1,364,000 1,736,000 3,100,000 1,628,000 2,072,000 3,700,000 2,068,000 2,632,000 4,700,000
17.4
operasi besar 1,540,000 1,960,000 3,500,000 1,980,000 2,520,000 4,500,000 2,112,000 2,688,000 4,800,000 3,080,000 3,920,000 7,000,000 3,520,000 4,480,000 8,000,000
17.5
operasi besar khusus 1,980,000 2,520,000 4,500,000 2,420,000 3,080,000 5,500,000 2,552,000 3,248,000 5,800,000 2,948,000 3,752,000 6,700,000 3,828,000 4,872,000 8,700,000
Operasi Cito
- - - - - - - - - -
17.6
operasi kecil 132,000 168,000 300,000 143,000 182,000 325,000 154,000 196,000 350,000 165,000 210,000 375,000 176,000 224,000 400,000
17.7
operasi kecil dengan narkose 440,000 560,000 1,000,000 550,000 700,000 1,250,000 198,000 252,000 450,000 1,056,000 1,344,000 2,400,000 1,276,000 1,624,000 2,900,000
17.8
operasi sedang 924,000 1,176,000 2,100,000 1,012,000 1,288,000 2,300,000 1,584,000 2,016,000 3,600,000 1,848,000 2,352,000 4,200,000 2,288,000 2,912,000 5,200,000
17.9
operasi besar 1,760,000 2,240,000 4,000,000 2,200,000 2,800,000 5,000,000 2,332,000 2,968,000 5,300,000 3,300,000 4,200,000 7,500,000 3,740,000 4,760,000 8,500,000
17.10
operasi besar khusus 2,200,000 2,800,000 5,000,000 2,640,000 3,360,000 6,000,000 2,772,000 3,528,000 6,300,000 3,168,000 4,032,000 7,200,000 4,048,000 5,152,000 9,200,000
18 BAGIAN JANTUNG - - - - - - - - - - - - - - - - -
18.1
EKG 22,000 28,000 50,000 26,400 33,600 60,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 33,000 42,000 75,000 44,000 56,000 100,000 19,800 25,200 45,000 19,800
18.2
Echokardiografi 35000 40000 75000 40000 45000 85000 26400 33,600 60000 33000 42,000 75000 35,200 44800 80000 39600 50400 90000 44000 56,000 100,000 39600
121
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
122
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
123
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
124
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
125
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
126
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
127
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
128
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
129
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
130
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
131
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
132
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
133
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
134
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
135
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
136
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
137
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
138
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
139
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
140
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
141
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
142
RAWAT INAP
III II I VIP VVIP
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
143
PERATURAN DAERAH PROVINSI BANTEN
RETRIBUSI PELAYANAN KESEHATAN
F RUMAH SAKIT UMUM DAERAH MALINGPING
ICU/HCU PERINATOLOGI
28 28 30 31 32
Jasa Jasa Jasa

Total Total
Sarana layanan Sarana
140,000 250,000 110,000 140,000 250,000
- -
- -
25,200 45,000 19,800 25,200 45,000
33,600 60,000 26,400 33,600 60,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
14,000 25,000 11,000 14,000 25,000
19,600 35,000 15,400 19,600 35,000
14,000 25,000 6,600 8,400 15,000
8,400 15,000 6,600 8,400 15,000
8,400 15,000 6,600 8,400 15,000
- - -
- - -
- - -
28,000 50,000 22,000 28,000 50,000

44,800 80,000 35,200 44,800 80,000
168,000 300,000 132,000 168,000 300,000
168,000 300,000 132,000 168,000 300,000
- - -
144
28 28 30 31 32
112,000 200,000 88,000 112,000 200,000
112,000 200,000 88,000 112,000 200,000
14,000 25,000 11,000 14,000 25,000
- - -
- - -
- - -
- - -
28,000 50,000 - -
- - -
- - -
8,400 15,000 - -
42,000 75,000 - -
28,000 50,000 - -
11,200 20,000 - -
28,000 50,000 - -
-
- -
28,000 50,000 - -
33,600 60,000 - -
39,200 70,000 - -
44,800 80,000 - -
51,520 92,000 - -
8,400 15,000 6,600 8,400 15,000
16,800 30,000 13,200 16,800 30,000
14,000 25,000 11,000 14,000 25,000
19,600 35,000 15,400 19,600 35,000
25,200 45,000 19,800 25,200 45,000
- - -
16,800 30,000 - -
14,000 25,000 - -
16,800 30,000 - -
33,600 60,000 - -
33,600 60,000 - -
39,200 70,000 - -
28,000 50,000 - -
145
28 28 30 31 32
28,000 50,000 - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- 6,600 8,400 15,000
- - -
50,400 90,000 - -
28,000 50,000 - -
33,600 60,000 - -
- - -
- - -
8,400 15,000 - -
- - -
392,000 700,000 - -
- - -
- - -
- - -
448,000 800,000 - -
- - -
- - -
- - -
- 13,200 16,800 30,000
- 17,600 22,400 40,000
- 11,000 14,000 25,000
- - -
- - -
146
28 28 30 31 32
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
28,000 50,000 22,000 28,000 50,000
- - -
42,000 75,000 33,000 42,000 75,000
42,000 75,000 33,000 42,000 75,000
- - -
- - -
56,000 100,000 44,000 56,000 100,000
56,000 100,000 44,000 56,000 100,000
14,000 25,000 11,000 14,000 25,000
28,000 50,000 22,000 28,000 50,000
28,000 50,000 22,000 28,000 50,000
- - -
- - -
147
28 28 30 31 32
- - -
- - -
140,000 250,000 110,000 140,000 250,000
- - -
- - -
16,800 30,000 13,200 16,800 30,000

168,000 300,000 132,000 168,000 300,000
5,600 10,000 4,400 5,600 10,000

168,000 300,000 132,000 168,000 300,000
84,000 150,000 66,000 84,000 150,000
28,000 50,000 22,000 28,000 50,000
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
8,400 15,000 - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
148
28 28 30 31 32
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
149
28 28 30 31 32
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
150
28 28 30 31 32
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
151
28 28 30 31 32
- - -
- - -
50,400 90,000 - -
140,000 250,000 - -
- - -
106,400 190,000 - -
25,200 45,000 - -
112,000 200,000 - -
98,000 175,000 - -
56,000 100,000 - -
70,000 125,000 - -
50,400 90,000 - -
196,000 350,000 - -
56,000 100,000 - -
70,000 125,000 - -
70,000 125,000 - -
- - -
112,000 200,000 - -
33,600 60,000 - -
47,600 85,000 - -
14,000 25,000 - -
70,000 125,000 55,000 70,000 125,000
56,000 100,000 44,000 56,000 100,000
392,000 700,000 308,000 392,000 700,000
28,000 50,000 22,000 28,000 50,000
- - -
420,000 750,000 330,000 420,000 750,000
- - -
39,200 70,000 - -
- - -
56,000 100,000 - -
44,800 80,000 - -
67,200 120,000 - -
152
28 28 30 31 32
56,000 100,000 - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
84,000 150,000 66,000 84,000 150,000
168,000 300,000 132,000 168,000 300,000
84,000 150,000 66,000 84,000 150,000
61,600 110,000 48,400 61,600 110,000
81,200 145,000 63,800 81,200 145,000
98,000 175,000 77,000 98,000 175,000
98,000 175,000 77,000 98,000 175,000
- - -
- - -
- - -
- - -
- - -
- - -
- - -
153
28 28 30 31 32
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
16,800 30,000 - -
16,800 30,000 13,200 16,800 30,000
8,400 15,000 6,600 8,400 15,000
12,320 22,000 9,680 12,320 22,000
- - -
- - -
- - -
- - -
5,600 10,000 4,400 5,600 10,000
- - -
11,200 20,000 8,800 11,200 20,000
8,400 15,000 6,600 8,400 15,000
154
28 28 30 31 32
11,200 20,000 8,800 11,200 20,000
39,200 70,000 30,800 39,200 70,000
25,200 45,000 19,800 25,200 45,000
25,200 45,000 19,800 25,200 45,000
16,800 30,000 13,200 16,800 30,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
16,800 30,000 22,000 28,000 50,000
14,000 25,000 - -
44,800 80,000 35,200 44,800 80,000
14,000 25,000 11,000 14,000 25,000
- - -
- - -
16,800 30,000 - -
36,400 65,000 - -
25,200 45,000 - -
11,200 20,000 8,800 11,200 20,000
14,000 25,000 11,000 14,000 25,000
8,400 15,000 6,600 8,400 15,000
11,200 20,000 8,800 11,200 20,000
8,400 15,000 6,600 8,400 15,000
11,200 20,000 8,800 11,200 20,000
14,000 25,000 11,000 14,000 25,000
16,800 30,000 13,200 16,800 30,000
14,000 25,000 8,800 11,200 20,000
16,800 30,000 - -
5,600 10,000 4,400 5,600 10,000
11,200 20,000 8,800 11,200 20,000
5,600 10,000 4,400 5,600 10,000
8,400 15,000 - -
155
28 28 30 31 32
16,800 30,000 22,000 28,000 50,000
8,400 15,000 6,600 8,400 15,000
12,320 22,000 9,680 12,320 22,000
16,800 30,000 13,200 16,800 30,000
28,000 50,000 - -
14,000 25,000 11,000 14,000 25,000
36,400 65,000 - -
22,400 40,000 - -
28,000 50,000 - -
14,000 25,000 - -
28,000 50,000 - -
14,000 25,000 - -
19,600 35,000 - -
14,000 25,000 - -
11,200 20,000 - -
- 8,800 11,200 20,000
123,200 220,000 - -
5,600 10,000 4,400 5,600 10,000
5,600 10,000 4,400 5,600 10,000
12,320 22,000 9,680 12,320 22,000
5,600 10,000 - -
- - -
3,920 7,000 3,080 3,920 7,000
3,920 7,000 3,080 3,920 7,000
156
28 28 30 31 32
- - -
25,200 45,000 19,800 25,200 45,000
50400 90000
157
28 28 30 31 32
158
28 28 30 31 32
159
28 28 30 31 32
160
28 28 30 31 32
161
28 28 30 31 32
162
28 28 30 31 32
163
28 28 30 31 32
164
28 28 30 31 32
165
28 28 30 31 32
166
28 28 30 31 32
167
28 28 30 31 32
168
28 28 30 31 32
169
28 28 30 31 32
170
28 28 30 31 32
171
28 28 30 31 32
172
28 28 30 31 32
173
28 28 30 31 32
174
28 28 30 31 32
175
28 28 30 31 32
176
28 28 30 31 32
177
28 28 30 31 32
178
28 28 30 31 32
179

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Perda No. 1 Tahun 2016 (Lampiran II)

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LAMPIRAN II

PERATURAN DAERAH PROVINSI

STRUKTUR DAN BESARAN TARIF RUMAH SAKIT UMUM DAERAH MALINGPING

A. TARIF PEMERIKSAAN DOKTER, TINDAKAN MEDIS DAN TINDAKAN KEPERAWATAN

PEMERIKSAAN DAN KONSULTASI

1.9 Pemeriksaan / Konsultasi

5.20 Insisi Abses Sub 100,000

Tindakan Sedang dengan

6.20 Ekstirpasi Granulasi Tanpa 100,000 120,000

BAGIAN GIGI DAN - - - - - - - - - - - - - - - - -

BAGIAN KULIT DAN - - - - - - - - - - - - - - - - -

Elektrokauterisasi 125,400 159,600 285,000 154,000 196,000 350,000 - - - - - - - - - - - - -

RETRIBUSI PELAYANAN KESEHATAN

F RUMAH SAKIT UMUM DAERAH MALINGPING

Jasa Jasa Jasa

140,000 250,000 110,000 140,000 250,000

25,200 45,000 19,800 25,200 45,000

33,600 60,000 26,400 33,600 60,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

14,000 25,000 11,000 14,000 25,000

19,600 35,000 15,400 19,600 35,000

14,000 25,000 6,600 8,400 15,000

8,400 15,000 6,600 8,400 15,000

8,400 15,000 6,600 8,400 15,000

28,000 50,000 22,000 28,000 50,000

168,000 300,000 132,000 168,000 300,000

168,000 300,000 132,000 168,000 300,000

112,000 200,000 88,000 112,000 200,000

112,000 200,000 88,000 112,000 200,000

14,000 25,000 11,000 14,000 25,000

8,400 15,000 6,600 8,400 15,000

16,800 30,000 13,200 16,800 30,000

14,000 25,000 11,000 14,000 25,000

19,600 35,000 15,400 19,600 35,000

25,200 45,000 19,800 25,200 45,000

- 6,600 8,400 15,000

- 13,200 16,800 30,000

- 17,600 22,400 40,000

- 11,000 14,000 25,000

28,000 50,000 22,000 28,000 50,000

42,000 75,000 33,000 42,000 75,000

42,000 75,000 33,000 42,000 75,000

56,000 100,000 44,000 56,000 100,000

56,000 100,000 44,000 56,000 100,000

14,000 25,000 11,000 14,000 25,000

28,000 50,000 22,000 28,000 50,000

28,000 50,000 22,000 28,000 50,000

16,800 30,000 13,200 16,800 30,000

5,600 10,000 4,400 5,600 10,000

84,000 150,000 66,000 84,000 150,000

28,000 50,000 22,000 28,000 50,000

70,000 125,000 55,000 70,000 125,000

56,000 100,000 44,000 56,000 100,000

392,000 700,000 308,000 392,000 700,000

28,000 50,000 22,000 28,000 50,000

420,000 750,000 330,000 420,000 750,000

84,000 150,000 66,000 84,000 150,000

168,000 300,000 132,000 168,000 300,000

84,000 150,000 66,000 84,000 150,000

61,600 110,000 48,400 61,600 110,000

81,200 145,000 63,800 81,200 145,000

98,000 175,000 77,000 98,000 175,000