RAJAL

RS WINDU HUSADA
Jalan Mambal Ubud, Mekar Bhuwana, Abiansemal, Badung, Bali

(0361) 898 2 888 / 081-999-774-696
E-mail : winduhusada@gmail.com
DATA TINDAKAN/PERAWATAN/TAGIHAN
Kode NAMA PERAWATAN/TINDAKAN/TAGIHAN KATEGORI J.S. R.S. BHP/Paket JASA MEDIS JASA MEDIS KSO MENEJEME TOTAL BIAYATOTAL BIAYA PR TTL BIAYA DR
KITAS.RJRS Administrasi Rawat Jalan Pasien IGD Jasa Pelayanan Rp 2,750.00 19,500 0 2,750 0 0 22,250 25,000 25,000
WH001
KITAS.RJRS Administrasi Rawat Jalan Poli / Rujukan Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 15,000
WH002 Penunjang
KITAS.RJRS Administrasi Rawat Inap Jasa Pelayanan Rp 16,500.00 44,000 0 49,500 0 0 60,500 110,000 110,000
WH003
KITAS.RJRS Administrasi Pengisian Medical Report Tindakan Rp 0.00 5,500 16,500 5,500 0 0 22,000 11,000 27,500
WH004 (Asuransi Reimbuserment)
KITAS.RJRS Adminstrasi Asuransi Jasa Pelayanan Rp 0.00 0 55,000 0 0 0 55,000 0 55,000
WH005
KITAS.RJRS Konsultasi Dokter Umum IGD Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH006
KITAS.RJRS USG 2D Tindakan Rp 0.00 0 0 0 0 0 0 0 180,000
WH009
KITAS.RJRS Jasa Medis Dokter Umum On Call 1 Konsultasi Rp 0.00 0 165,000 55,000 0 0 165,000 55,000 220,000
WH010
WH011
WH012
KITAS.RJRS Jasa Periksa Bidan VK Tindakan Rp 0.00 0 0 44,000 0 0 0 44,000 44,000
WH013
KITAS.RJRS Jasa Perawat/Bidan On Call/Home Care 1 Jasa Pelayanan Rp 0.00 0 0 110,000 0 0 0 110,000 110,000
WH014
WH015
WH016
KITAS.RJRS Jasa Tindakan Injeksi Formalin On Call 1 Tindakan Rp 0.00 0 0 0 0 0 0 0 3,000,000
WH017
KITAS.RJRS Jasa Tindakan Injeksi Formalin On Call 2 Tindakan Rp 0.00 0 0 0 0 0 0 0 3,400,000
WH018
KITAS.RJRS Aff Drain Tindakan Rp 132,000.00 97,900 22,000 11,000 0 0 251,900 240,900 262,900
WH019
KITAS.RJRS Aff Hecting Tindakan Rp 127,600.00 57,200 0 15,400 0 0 184,800 200,200 200,200
WH020
KITAS.RJRS Aff Infus/Katheter/NGT Tindakan Rp 6,600.00 46,200 0 15,400 0 0 52,800 68,200 68,200
WH021
KITAS.RJRS Aff Tampon Hidung/Telinga/Vagina Tindakan Rp 127,600.00 44,000 0 15,400 0 0 171,600 187,000 187,000
WH022
KITAS.RJRS Diet Via Sonde Jasa Pelayanan Rp 6,600.00 11,000 0 15,400 0 0 17,600 33,000 33,000
WH023
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KITAS.RJRS DJJ Jasa Pelayanan Rp 11,000.00 11,660 0 11,000 0 0 22,660 33,660 33,660
WH024
KITAS.RJRS EKG 3 chanel Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 150,000
WH025
KITAS.RJRS EKG 12 chanel Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 250,000
WH026
KITAS.RJRS Eksplorasi Luka (Ictum/Snake Bite) Jasa Pelayanan Rp 132,000.00 74,800 22,000 11,000 0 0 228,800 217,800 239,800
WH027
KITAS.RJRS Ekstirpasi Kecil Jasa Pelayanan Rp 143,000.00 220,000 220,000 88,000 0 0 583,000 451,000 671,000
WH028
KITAS.RJRS Ekstirpasi Sedang Jasa Pelayanan Rp 143,000.00 242,000 275,000 143,000 0 0 660,000 528,000 803,000
WH029
KITAS.RJRS Ekstirpasi Besar Jasa Pelayanan Rp 143,000.00 275,000 330,000 198,000 0 0 748,000 616,000 946,000
WH030
KITAS.RJRS Ekstraksi Corpus Alienum Tindakan Rp 132,000.00 50,600 55,000 22,000 0 0 237,600 204,600 259,600
WH031
KITAS.RJRS Ekstraksi Kuku Tindakan Rp 132,000.00 82,500 55,000 22,000 0 0 269,500 236,500 291,500
WH032
KITAS.RJRS Explorasi Post SC Tindakan Rp 11,000.00 156,200 0 33,000 0 0 167,200 200,200 200,200
WH033
KITAS.RJRS Tindakan Fisioterapi Infra Red Tindakan Rp 0.00 17,600 0 26,400 0 0 17,600 44,000 44,000
WH034
KITAS.RJRS Tindakan Fisioterapi SWD Tindakan Rp 0.00 0 0 0 0 0 0 0 100,000
WH035
KITAS.RJRS Tindakan Fisioterapi Traksi Tindakan Rp 0.00 0 0 0 0 0 0 0 200,000
WH036
KITAS.RJRS Tindakan Fisioterapi Ultra Sound Tindakan Rp 0.00 17,600 0 26,400 0 0 17,600 44,000 44,000
WH037
KITAS.RJRS Tindakan Fisioterapi TENS Tindakan Rp 0.00 17,600 0 26,400 0 0 17,600 44,000 44,000
WH038
KITAS.RJRS Tindakan Fisioterapi Exercise/Latihan Tindakan Rp 0.00 17,600 0 26,400 0 0 17,600 44,000 44,000
WH039
KITAS.RJRS Tindakan Fisioterapi Massage Tindakan Rp 0.00 17,600 0 26,400 0 0 17,600 44,000 44,000
WH040
KITAS.RJRS Tindakan Fisioterapi Breathing Exercise Tindakan Rp 0.00 17,600 0 26,400 0 0 17,600 44,000 44,000
WH041
KITAS.RJRS Fixasi Costae Tindakan Rp 6,600.00 79,200 22,000 26,400 0 0 107,800 112,200 134,200
WH042
KITAS.RJRS Fototerapi 8 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 200,000
WH043
KITAS.RJRS Fototerapi 12 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 300,000
WH044
KITAS.RJRS Fototerapi 24 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 5,000,000
WH045
KITAS.RJRS Imunisasi Dasar Tindakan Rp 0.00 27,500 55,000 27,500 0 0 82,500 55,000 110,000
WH046
KITAS.RJRS Injeksi Delladryl/Xyllo della Tindakan Rp 0.00 11,000 0 11,000 0 0 11,000 22,000 22,000
WH047
KITAS.RJRS Injeksi IM/IV/IC/SC Tindakan Rp 0.00 0 0 0 0 0 0 0 66,000
WH048
KITAS. Insisi Abses Tindakan Rp 143,000.00 133,100 66,000 22,000 0 0 342,100 298,100 364,100
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RJRSWH04
KITAS.RJRS Intubasi/Pasang ETT Tindakan Rp 231,000.00 110,000 220,000 55,000 0 0 561,000 396,000 616,000
WH050
KITAS.RJRS Irigasi / Spoeling mata/Telinga Tindakan Rp 22,000.00 48,400 22,000 11,000 0 0 92,400 81,400 103,400
WH051
KITAS.RJRS Kumbah Lambung Tindakan Rp 22,000.00 53,900 35,200 22,000 0 0 111,100 97,900 133,100
WH052
KITAS.RJRS Lavement Tindakan Rp 33,000.00 89,100 0 44,000 0 0 122,100 166,100 166,100
WH053
KITAS.RJRS Rawat Luka Bakar 1 (<5%) Perawatan Rp 143,000.00 114,400 0 22,000 0 0 257,400 279,400 279,400
WH054
KITAS.RJRS Rawat Luka Bakar 2 (5 - 15%) Perawatan Rp 143,000.00 183,700 44,000 44,000 0 0 370,700 370,700 414,700
WH055
KITAS.RJRS Rawat Luka Bakar 3 (15 - 20%) Perawatan Rp 154,000.00 220,000 132,000 55,000 0 0 506,000 429,000 561,000
WH056
KITAS.RJRS Rawat Luka Bakar Luas > 20% Perawatan Rp 165,000.00 264,000 220,000 66,000 0 0 649,000 495,000 715,000
WH057
KITAS.RJRS Rawat Luka Lecet 1 (<5%) Perawatan Rp 132,000.00 52,800 0 11,000 0 0 184,800 195,800 195,800
WH058
KITAS.RJRS Rawat Luka Lecet 2 (5 - 10%) Perawatan Rp 143,000.00 143,000 22,000 22,000 0 0 308,000 308,000 330,000
WH059
KITAS.RJRS Rawat Luka Lecet 3 ( > 10%) Perawatan Rp 143,000.00 183,700 55,000 33,000 0 0 381,700 359,700 414,700
WH060
KITAS.RJRS Hecting 1 (HT<5) Tindakan Rp 176,000.00 91,300 22,000 22,000 0 0 289,300 289,300 311,300
WH061
KITAS.RJRS Hecting 2 (HT 5-10) Tindakan Rp 187,000.00 214,500 44,000 22,000 0 0 445,500 423,500 467,500
WH062
KITAS.RJRS Hecting 3 (HT > 10) Tindakan Rp 198,000.00 306,900 66,000 33,000 0 0 570,900 537,900 603,900
WH063
KITAS.RJRS Nebulizer Tindakan Rp 52,140.00 12,100 0 33,000 0 0 64,240 97,240 97,240
WH064
KITAS.RJRS NST Tindakan Rp 66,000.00 57,200 0 55,000 0 0 123,200 178,200 178,200
WH065
KITAS.RJRS Observasi IGD per jam Tindakan Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
WH066
KITAS.RJRS Observasi VK < 12 Jam Tindakan Rp 44,000.00 209,000 110,000 60,500 0 0 363,000 313,500 423,500
WH067
KITAS.RJRS Observasi VK > 12 Jam -< 24 Jam Tindakan Rp 110,000.00 616,000 220,000 99,000 0 0 946,000 825,000 1,045,000
WH068
KITAS.RJRS Pasang Guedel Tindakan Rp 6,600.00 11,000 11,000 4,400 0 0 28,600 22,000 33,000
WH069
KITAS.RJRS Pasang Infus Akses V. Umbilical Tindakan Rp 22,000.00 111,980 55,000 33,000 0 0 188,980 166,980 221,980
WH070
KITAS.RJRS Pasang Infus Anak/Bayi Tindakan Rp 11,000.00 84,480 33,000 22,000 0 0 128,480 117,480 150,480
WH071
KITAS.RJRS Pasang Infus Dewasa Tindakan Rp 11,000.00 51,700 22,000 11,000 0 0 84,700 73,700 95,700
WH072
KITAS.RJRS Pasang Katheter Tindakan Rp 16,500.00 56,100 44,000 27,500 0 0 116,600 100,100 144,100
WH073
KITAS.RJRS Pasang NGT Tindakan Rp 11,000.00 49,500 27,500 16,500 0 0 88,000 77,000 104,500
WH074
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KITAS.RJRS Pasang Ring Pesarium Tindakan Rp 0.00 66,000 0 165,000 0 0 66,000 231,000 231,000
WH075
KITAS.RJRS Pasang Ransel Verban Tindakan Rp 11,000.00 11,000 44,000 22,000 0 0 66,000 44,000 88,000
WH076
KITAS.RJRS Pasang spalk kecil 1 bilah Tindakan Rp 4,400.00 75,900 11,000 6,600 0 0 91,300 86,900 97,900
WH077
KITAS.RJRS Pasang spalk panjang 2 bilah Tindakan Rp 6,600.00 252,780 22,000 15,400 0 0 281,380 274,780 296,780
WH078
KITAS.RJRS Pasang spalk sedang 2 bilah Tindakan Rp 6,600.00 141,460 15,400 11,000 0 0 163,460 159,060 174,460
WH079
KITAS.RJRS Pasang Tampon Hidung Anterior / Telinga Tindakan Rp 11,000.00 55,000 33,000 11,000 0 0 99,000 77,000 110,000
WH080
KITAS.RJRS Pasang Tampon Hidung Posterior Tindakan Rp 15,400.00 84,700 66,000 28,600 0 0 166,100 128,700 194,700
WH081
KITAS.RJRS Pasang Tampon Vagina Tindakan Rp 11,000.00 80,300 27,500 13,500 0 0 118,800 104,800 132,300
WH082
KITAS.RJRS Pemakaian Collar Brace (incl. sewa Collar Tindakan Rp 6,600.00 330,000 15,400 11,000 0 0 352,000 347,600 363,000
WH083 Brace)
KITAS.RJRS Pemakaian Collar Brace Tindakan Rp 6,600.00 11,000 15,400 11,000 0 0 33,000 28,600 44,000
WH084
KITAS.RJRS Pemakaian O2 Kanul per 1 jam Tindakan Rp 0.00 17,380 0 0 0 0 17,380 17,380 17,380
WH085
KITAS.RJRS Pemakaian O2 Face Masker per 1 jam Tindakan Rp 0.00 34,760 0 0 0 0 34,760 34,760 34,760
WH086
KITAS.RJRS Pemakaian O2 Head Box per 1 jam Tindakan Rp 0.00 52,140 0 0 0 0 52,140 52,140 52,140
WH087
KITAS.RJRS Perawatan Infus Tindakan Rp 0.00 51,700 0 11,000 0 0 51,700 62,700 62,700
WH088
KITAS.RJRS Rawat luka ringan Tindakan Rp 0.00 0 0 0 0 0 0 0 120,000
WH089
KITAS.RJRS Rawat luka sedang Tindakan Rp 0.00 0 0 0 0 0 0 0 160,000
WH090
KITAS.RJRS Rawat luka berat Tindakan Rp 0.00 0 0 0 0 0 0 0 200,000
WH091
KITAS.RJRS Rawat Luka Diabetic 1 / Post Op. Sedang Tindakan Rp 132,000.00 135,300 27,500 16,500 0 0 294,800 283,800 311,300
WH092
KITAS.RJRS Rawat Luka Diabetic 2 / Post Op. Besar Tindakan Rp 137,500.00 139,700 38,500 22,000 0 0 315,700 299,200 337,700
WH093
KITAS.RJRS Rawat Luka Diabetic 3 / Post Op. Extra Tindakan Rp 143,000.00 269,500 66,000 44,000 0 0 478,500 456,500 522,500
WH094
KITAS.RJRS Rectal Toucher/Colok Dubur Tindakan Rp 4,400.00 41,800 22,000 6,600 0 0 68,200 52,800 74,800
WH095
KITAS.RJRS Rectal/ Per Vaginam Supp Tindakan Rp 4,400.00 14,300 0 6,600 0 0 18,700 25,300 25,300
WH096
KITAS.RJRS Resusitasi Dasar Tindakan Rp 11,000.00 89,100 22,000 11,000 0 0 122,100 111,100 133,100
WH097
KITAS.RJRS Resusitasi Lanjutan Tindakan Rp 55,000.00 89,100 165,000 110,000 0 0 309,100 254,100 419,100
WH098
KITAS.RJRS Resusitasi Bayi Tindakan Rp 0.00 0 0 0 0 0 0 0 240,000
WH099
KITAS. Rumple Leed Tindakan Rp 4,400.00 0 0 6,600 0 0 4,400 11,000 11,000
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RJRSWH10
KITAS.RJRS Sceren Tindakan Rp 6,600.00 52,800 0 15,400 0 0 59,400 74,800 74,800
WH101
KITAS.RJRS Skin Test Tindakan Rp 4,400.00 5,500 6,600 5,500 0 0 16,500 15,400 22,000
WH102
KITAS.RJRS Surface Cooling Tindakan Rp 4,400.00 11,000 0 15,400 0 0 15,400 30,800 30,800
WH103
KITAS.RJRS Test Lakmus Tindakan Rp 0.00 11,000 0 11,000 0 0 11,000 22,000 22,000
WH104
KITAS.RJRS Tindakan Suction Tindakan Rp 15,400.00 13,200 15,400 11,000 0 0 44,000 39,600 55,000
WH105
KITAS.RJRS Tranfusi Tindakan Rp 22,000.00 11,000 0 22,000 0 0 33,000 55,000 55,000
WH106
KITAS.RJRS Visum Et Repertum Tindakan Rp 16,500.00 11,000 66,000 16,500 0 0 93,500 44,000 110,000
WH107
KITAS.RJRS VT (Bidan) Tindakan Rp 4,400.00 49,940 0 28,600 0 0 54,340 82,940 82,940
WH108
KITAS.RJRS Pasang Infus anak/bayi Sulit (on call) Tindakan Rp 11,000.00 84,480 220,000 22,000 0 0 315,480 117,480 337,480
WH109
KITAS.RJRS Pemerksaan dan Konsultasi VCT Tindakan Rp 11,000.00 11,000 220,000 33,000 0 0 242,000 55,000 275,000
WH110
KITAS.RJRS Monitor per 1 jam Tindakan Rp 55,000.00 0 0 0 0 0 55,000 55,000 55,000
WH111
KITAS.RJRS Pemakaian Continus Suction Pump(WSD) Tindakan Rp 352,000.00 0 0 0 0 0 352,000 352,000 352,000
WH112
KITAS.RJRS Flowcart - Rp 15,400.00 0 0 0 0 0 15,400 15,400 15,400
WH113
KITAS.RJRS Pemakaian O2 NIP perjam (ICU) Tindakan Rp 0.00 253,000 0 0 0 0 253,000 253,000 253,000
WH114
KITAS.RJRS Pemakaian C-PAP Tindakan Rp 0.00 0 0 0 0 0 0 0 500,000
WH115
KITAS.RJRS Ekstubasi (aff intubasi) Tindakan Rp 0.00 46,200 66,000 0 0 0 112,200 46,200 112,200
WH116
KITAS.RJRS Tindakan Oral Hygine Tindakan Rp 89,100.00 0 0 22,000 0 0 89,100 111,100 111,100
WH117
KITAS.RJRS Tindakan Injeksi Formalin Tindakan Rp 0.00 0 0 0 0 0 0 0 2,800,000
WH118
KITAS.RJRS Tindakan Injeksi Intraartikulars (umum) Tindakan Rp 184,250.00 97,064 275,000 0 0 0 556,314 281,314 556,314
WH119
KITAS.RJRS Tarif Tambahan Injeksi Formalin Tindakan Rp 220,000.00 292,600 330,000 0 0 0 842,600 512,600 842,600
WH120
KITAS.RJRS Pasang Infus Radiologi Tindakan Rp 11,000.00 51,700 126,500 63,800 0 0 189,200 126,500 253,000
WH121
KITAS.RJRS Tarif Kerohanian Tindakan Rp 44,000.00 0 440,000 0 0 0 484,000 44,000 484,000
WH122
KITAS.RJRS Syring Pump per 1 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 50,000
WH123
KITAS.RJRS Konsultasi dokter umum IGD dr. Bagus Gde Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH124 Ariesta Darmahendra
KITAS.RJRS Konsultasi dokter umum IGD dr. I Kadek Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH125 Oka Widiana
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KITAS.RJRS Konsultasi dokter umum IGD dr. Kadek Mia Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH126 Risdayanthi
KITAS.RJRS Konsultasi dokter umum IGD dr. Ni Nym Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH127 Putri Widyastiti
KITAS.RJRS Konsultasi dokter umum IGD dr. Ida Ayu Cili Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH128 Swesis
KITAS.RJRS Konsultasi dokter umum IGD dr. I Gusti Ayu Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH129 Ria Mardewi
KITAS.RJRS Konsultasi dokter umum IGD dr. Pande Konsultasi Rp 44,000.00 0 44,000 22,000 0 0 88,000 66,000 110,000
WH130 Nyoman Tri Mas Saptini
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH131 Ngurah Darmaja, Sp.OG
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Wayan Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH132 Sudania Anggra, Sp.OG
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH133 Shely Prihastuti Rudy, Sp.PD
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. Wy Giri Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH134 Putra Semaradana, M.Biomed, Sp.PD
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH135 Ketut Oka Nurjaya, Sp.A
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH136 Nyoman Putra Arcana, Sp.A
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH137 Oka Novi Purnawan, Sp.A
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH138 Gede Fajar Maha Yasa, Sp.B
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH139 Adipta Adiputra, Sp.B
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. Pande Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH140 Made Krisna Ekassiana, Sp.B
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Dewa Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH141 Made Sudiatmika, Sp.THT
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH142 Adhy Putra Widyartha, Sp.THT-KL
WH143 Sudiasa, Sp.THT
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Gde Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH144 Agus Shuarsedana Putra, Sp.An
WH145 Agung Wirahadi Sanjaya, Sp.OT
KITAS.RJRS Konsultasi dokter spesialis (poli) dr.Farida Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH146 Noor, Sp.S
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH147 Wayan Nurlina Ekasari, M.Biomed, Sp.S
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH148 Nyoman Gede Sudana, M.Sc., Sp.PK (K)
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. A A Istri Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH149 Murwita Prasanti Agung, Sp.JP
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH150 Widastuti Dharmapala, Sp. Rad
KITAS. Konsultasi dokter spesialis (poli) dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
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RJRSWH15 Komang Gede Dwi Maya Rustadi, Sp.KFR
WH152 Nyoman Sura Oka, Sp.Kj
WH153 Putu Adityo Ananta Ardika, Sp.M
KITAS.RJRS Konsultasi dokter spesialis (poli) dr. Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH154 Sasmika Suwandi, Sp.P
KITAS.RJRS Konsultasi dokter spesialis (poli) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH155 Komang Triana AK.
KITAS.RJRS Konsultasi dokter spesialis (poli) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 240,000
WH156 Tjokorda Istri Pramiari S
KITAS.RJRS Konsultasi dokter spesialis by phone dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 150,000
WH157 Gusti Ngurah Darmaja, Sp.OG
WH158 Wayan Sudania Anggra, Sp.OG
KITAS.RJRS Konsultasi dokter spesialis by phone dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 150,000
WH159 Putu Shely Prihastuti Rudy, Sp.PD
WH160 Wayan Giri Putra S , M.Biomed, Sp.PD
WH163 Gede Oka Novi Purnawan, Sp.A
WH164 Putu Gede Fajar Maha Yasa, Sp.B
WH165 Made Adipta Adiputra, Sp.B
WH166 Pande Made Krisna Ekassiana, Sp.B
WH167 Dewa Made Sudiatmika, Sp.THT
WH168 Made Adhy Putra Widyartha, Sp.THT-KL
WH169 Putu Sudiasa, Sp.THT
WH170 Gde Agus Shuarsedana Putra, Sp.An
WH171 Putu Agung Wirahadi Sanjaya, Sp.OT
KITAS.RJRS Konsultasi dokter spesialis by phone Konsultasi Rp 0.00 0 0 0 0 0 0 0 150,000
WH172 dr.Farida Noor, Sp.S
KITAS.RJRS Konsultasi dokter spesialis by phone dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 150,000
WH173 Wy Nurlina Ekasari, M.Biomed, Sp.S
KITAS.RJRS Konsultasi dokter spesialis by phone dr. A A Konsultasi Rp 0.00 0 0 0 0 0 0 0 150,000
WH175 Istri Murwita Prasanti Agung, Sp.JP
WH177 Komang Gede Dwi Maya Rustadi, Sp.KFR
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WH178 Pande Nyoman Sura Oka, Sp.Kj
WH179 Pande Putu Adityo Ananta Ardika, Sp.M
WH180 Gede Sasmika S, Sp.P
KITAS.RJRS Konsultasi dokter spesialis by phone drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 150,000
KITAS.RJRS Konsultasi dokter spesialis by phone drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 150,000
KITAS.SPR Aff Cateter (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 90,255
SWH001
KITAS.SPR Aff Drain/WSD (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 435,930
SWH002
KITAS.SPR Aff NGT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 96,525
SWH003
KITAS.SPR Biopsi Lokal (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 682,252
SWH004
KITAS.SPR First Konsul (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 206,250
SWH005
KITAS.SPR Jasa Medis On Call Dokter Spesialis 1 Tindakan Rp 0.00 0 0 0 0 0 0 0 453,750
SWH006
SWH007
SWH008
KITAS.SPR Jasa Medis Poliklinik Spesialis I (Bpjs) Tindakan Rp 0.00 0 0 0 0 0 0 0 82,500
SWH009
KITAS.SPR Jasa Medis Poliklinik Spesialis II (Ikatan Tindakan Rp 0.00 0 0 0 0 0 0 0 99,000
SWH010 Kerja Sama Tertentu)
KITAS.SPR Jasa Medis Poliklinik Spesialis III (Ikatan Tindakan Rp 0.00 0 0 0 0 0 0 0 123,750
SWH011 kerja sama tertentu)
KITAS.SPR Jasa Medis Poliklinik Spesialis IV (umum) Tindakan Rp 0.00 0 0 0 0 0 0 0 165,000
SWH012
KITAS.SPR Jasa Pasang Infus (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 244,860
SWH013
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 247,500
SWH014
KITAS.SPR Konsul di atas Meja Operasi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 825,000
SWH015
KITAS.SPR Konsul Via Telepon (RJ) (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 66,000
SWH016
KITAS.SPR Lumbal Punksi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 862,950
SWH017
KITAS.SPR Pasang ETT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 504,735
SWH018
KITAS.SPR Pasang Kateter/NGT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 222,915
SWH019
KITAS.SPR Pasang WSD (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 812,625
SWH020
KITAS. Punksi Ascites (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 704,550
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SPRSWH02
KITAS.SPR Rawat Luka Post Op. Obgyn/Bedah Sedang Tindakan Rp 0.00 0 0 0 0 0 0 0 34,650
SWH022 RJ (Sp)
KITAS.SPR Rawat Luka Post Op. Obgyn/Bedah Berat Tindakan Rp 0.00 0 0 0 0 0 0 0 67,650
SWH023 RJ (Sp)
KITAS.SPR Rawat Luka Post Op. Obgyn/Bedah Extra Tindakan Rp 0.00 0 0 0 0 0 0 0 104,775
SWH024 Berat RJ (Sp)
KITAS.SPR Tindik Telinga (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 330,000
SWH025
KITAS.SPR Tuberculin Test (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 379,500
SWH026
KITAS.SPR Vena Section (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 653,730
SWH027
KITAS.SPR Vena Umbilical (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 265,485
SWH028
KITAS.SPR Pasang Ventilator (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 227,370
SWH029
KITAS.SPR Tes Provokasi Obat RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 750,750
SWH030
KITAS.SPR Tes Rapid Desensitisasi Obat RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 750,750
SWH031
KITAS.SPR Ekstubasi (AF Intubasi) (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 100,650
SWH032
KITAS.SPR Echocardiografi (Umum) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,125,000
SWH033
KITAS.SPR Psikometri Test Tindakan Rp 0.00 0 0 0 0 0 0 0 165,000
SWH034
KITAS.SPR MMPI Tindakan Rp 0.00 0 0 0 0 0 0 0 330,000
SWH035
KITAS.SPR BHP Pemeriksaan Mata Rutin (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 4,950
SWH054
KITAS.SPR Ekstirpasi Pterigium (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,386,000
SWH055
KITAS.SPR Ekstraksi Corpus Alienum Mata dg alat Tindakan Rp 0.00 0 0 0 0 0 0 0 536,250
SWH056 khusus (Sp)
KITAS.SPR Ekstraksi Corpus Alienum Mata dg cotton Tindakan Rp 0.00 0 0 0 0 0 0 0 198,000
SWH057 bud (Sp)
KITAS.SPR Insisi & Kuretase Hordeolum (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 750,750
SWH058
KITAS.SPR Irigasi Ductus Nasolakrimalis (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 321,750
SWH059
KITAS.SPR Lithiasis Tindakan Rp 0.00 0 0 0 0 0 0 0 643,500
SWH060
KITAS.SPR Probbing Tindakan Rp 0.00 0 0 0 0 0 0 0 429,000
SWH061
KITAS.SPR Ruptur Konjungtiva Tindakan Rp 0.00 0 0 0 0 0 0 0 734,250
SWH062
KITAS.SPR Ruptur Palpebra Tindakan Rp 0.00 0 0 0 0 0 0 0 643,500
SWH063
KITAS.SPR Refraksi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 75,000
SWH064
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KITAS.SPR Aff Tampon Hidung / Telinga (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 87,450
SWH065
KITAS.SPR Ext. Corpus Alienum THT/Serumen/Krusta Tindakan Rp 0.00 0 0 0 0 0 0 0 128,700
SWH066 Hidung (Sp)
KITAS.SPR Irigasi Sinus Satu Sisi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 976,800
SWH067
KITAS.SPR Irigasi Sinus Dua Sisi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,465,200
SWH068
KITAS.SPR Parasintesa/Pungsi Aspirasi Othematom Tindakan Rp 0.00 0 0 0 0 0 0 0 288,750
SWH069
KITAS.SPR Pasang Tampon Hidung Anterior / Telinga Tindakan Rp 0.00 0 0 0 0 0 0 0 177,375
SWH070 (Sp)
KITAS.SPR Pasang Tampon Hidung Posterior (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 426,525
SWH071
KITAS.SPR Reposisi Hidung (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 775,500
SWH072
KITAS.SPR Spooling Telinga (Sp) 1 telinga Tindakan Rp 0.00 0 0 0 0 0 0 0 126,555
SWH073
KITAS.SPR Biopsi THT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 976,800
SWH074
KITAS.SPR Aff Tampon Hidung / Telinga RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 367,950
SWH075
KITAS.SPR Aff Implant / Susuk KB (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 429,825
SWH076
KITAS.SPR Aff Tampon Vagina (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 87,450
SWH077
KITAS.SPR Ekstraksi IUD Biasa (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 219,450
SWH079
KITAS.SPR Ekstraksi IUD Missing Tail (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 310,200
SWH080
KITAS.SPR Explorasi Post Abortus (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 564,300
SWH081
KITAS.SPR Explorasi Post Partum (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 564,300
SWH082
KITAS.SPR Pap Smear (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 300,000
SWH083
KITAS.SPR Pasang / Insersi IUD (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 310,200
SWH084
KITAS.SPR Pasang Tampon Vagina (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 150,975
SWH085
KITAS.SPR Pasang Ring Pesarium (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 321,750
SWH086
KITAS.SPR USG Intra Vaginal (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 247,500
SWH087
KITAS.SPR USG Obgyn dengan Print pada ANC (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 135,000
SWH088
KITAS.SPR USG Obgyn tanpa Print pada ANC (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 112,500
SWH089
KITAS.SPR USG Obgyn dengan Print RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 141,900
SWH090
KITAS. USG Obgyn tanpa Print RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 125,400
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SPRSWH09
KITAS.SPR Vaginal Swab (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 59,400
SWH092
KITAS.SPR Vaginal Toucher/VT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 134,805
SWH093
KITAS.SPR Pasang Tampon Sayeba Kondom (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,036,200
SWH094
KITAS.SPR Biopsi FNAB (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 761,475
SWH095
KITAS.SPR Buka gips short arm/leg (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 152,625
SWH096
KITAS.SPR Buka gips long arm/leg (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 288,750
SWH097
KITAS.SPR Circumsisi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 860,475
SWH098
KITAS.SPR Debridement + Hecting (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 614,790
SWH099
KITAS.SPR Dilatasi phimosis (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 280,665
SWH100
KITAS.SPR Eksisi/ekstirpasi kecil (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 709,500
SWH101
KITAS.SPR Eksisi/ekstirpasi sedang (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 816,750
SWH102
KITAS.SPR Eksisi/ekstirpasi besar (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 932,250
SWH103
KITAS.SPR Incisi Abses (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 371,415
SWH104
KITAS.SPR Pasang gips tanpa reposisi short arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 561,000
SWH105 (Sp)
KITAS.SPR Pasang gips tanpa reposisi long arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 742,500
SWH106
KITAS.SPR Pasang gips dengan reposisi short arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 924,000
SWH107 (Sp)
KITAS.SPR Pasang gips dengan reposisi long arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 1,105,500
SWH108 (Sp)
KITAS.SPR Pasang Ransel Verban (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 306,900
SWH109
KITAS.SPR Pasang Skin Traksi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 379,500
SWH110
KITAS.SPR Pungsi Sendi/Sinopial (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 502,920
SWH111
KITAS.SPR Rawat Luka Kecil RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 200,145
SWH112
KITAS.SPR Rawat Luka Sedang RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 292,875
SWH113
KITAS.SPR Rawat Luka Besar RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 442,200
SWH114
KITAS.SPR Rawat Luka Ekstra Besar RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 623,700
SWH115
KITAS.SPR Rawat Luka Post Op. Ortho Sedang (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 210,045
SWH116
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KITAS.SPR Rawat Luka Post Op. Ortho Berat (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 286,275
SWH117
KITAS.SPR Rawat Luka Post Op. Ortho Exstra Berat Tindakan Rp 0.00 0 0 0 0 0 0 0 528,495
SWH118 (Sp)
KITAS.SPR Reposisi & Pasang Ransel Verban (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 651,750
SWH119
KITAS.SPR Kemoterapi Grade I (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,155,000
SWH120
KITAS.SPR Kemoterapi Grade II (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 701,250
SWH121
KITAS.SPR Luka Bakar (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 693,000
SWH122
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH123 Gusti Ngurah Darmaja, Sp.OG
SWH124 Wayan Sudania Anggra, Sp.OG
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH125 Shely Prihastuti Rudy, Sp.PD
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH126 Wayan Giri Putra S, M.Biomed, Sp.PD
KITAS.SPR Konsul Antar Dokter Spesialis (Sp)dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH127 Ketut Oka Nurjaya, Sp.A
KITAS.SPR Konsul Antar Dokter Spesialis (Sp)dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH128 Nyoman Putra Arcana, Sp.A
SWH129 Gede Oka Novi Purnawan, Sp.A
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. I Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH130 Gede Fajar Maha Yasa, Sp.B
SWH131 Made Adipta Adiputra, Sp.B
SWH132 Pande Made Krisna Ekassiana, Sp.B
SWH133 Dewa Made Sudiatmika, Sp.THT
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH134 Adhy Putra Widyartha, Sp.THT-KL
SWH135 Sudiasa, Sp.THT
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. I Gde Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH136 Agus Shuarsedana Putra, Sp.An
SWH137 Agung Wirahadi Sanjaya, Sp.OT
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr.Farida Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH138 Noor, Sp.S
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH139 Wayan Nurlina Ekasari, M.Biomed, Sp.S
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. I Nym Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH140 Gede Sudana, M.Sc., Sp.PK (K)
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. A A Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH141 Istri Murwita Prasanti Agung, Sp.JP
KITAS. Konsul Antar Dokter Spesialis (Sp) dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
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SPRSWH14 Widastuti Dharmapala, Sp. Rad
SWH143 Komang Gede Dwi Maya Rustadi, Sp.KFR
SWH144 Pande Nyoman Sura Oka, Sp.Kj
SWH145 Pande Putu Adityo Ananta Ardika, Sp.M
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) dr. Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH146 Sasmika Suwandi, Sp.P
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH147 Komang Triana AK.
KITAS.SPR Konsul Antar Dokter Spesialis (Sp) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 247,500
SWH148 Tjokorda Istri Pramiari S
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH149 Ngurah Darmaja, Sp.OG
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH150 Wayan Sudania Anggra, Sp.OG
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH151 Shely Prihastuti Rudy, Sp.PD
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. Wayan Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH152 Giri Putra S, M.Biomed, Sp.PD
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH154 Nyoman Putra Arcana, Sp.A
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH155 Oka Novi Purnawan, Sp.A
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH157 Adipta Adiputra, Sp.B
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. Pande Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH158 Made Krisna Ekassiana, Sp.B
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Dewa Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH159 Made Sudiatmika, Sp.THT
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH160 Adhy Putra Widyartha, Sp.THT-KL
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. I Gde Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH162 Agus Shuarsedana Putra, Sp.An
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr.Farida Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH164 Noor, Sp.S
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH165 Wayan Nurlina Ekasari, M.Biomed, Sp.S
SWH166 Nyoman Gede Sudana, M.Sc., Sp.PK (K)
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. A A Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH167 Istri Murwita Prasanti Agung, Sp.JP
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KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH168 Widastuti Dharmapala, Sp. Rad
SWH169 Komang Gede Dwi Maya Rustadi, Sp.KFR
SWH170 Nyoman Sura Oka, Sp.Kj
SWH171 Putu Adityo Ananta Ardika, Sp.M
KITAS.SPR Konsul di atas Meja Operasi (Sp) dr. Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
KITAS.SPR Konsul di atas Meja Operasi (Sp) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH173 Komang Triana AK.
KITAS.SPR Konsul di atas Meja Operasi (Sp) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 825,000
SWH174 Tjokorda Istri Pramiari S
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH175 Ngurah Darmaja, Sp.OG
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Wayan Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH176 Sudania Anggra, Sp.OG
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Putu Shely Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH177 Prihastuti Rudy, Sp.PD
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Wayan Giri Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH178 Putra Semaradana, M.Biomed, Sp.PD
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Nyoman Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH180 Putra Arcana, Sp.A
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Gede Oka Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH181 Novi Purnawan, Sp.A
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH183 Adipta Adiputra, Sp.B
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Pande Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH184 Made Krisna Ekassiana, Sp.B
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Dewa Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH185 Made Sudiatmika, Sp.THT
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Made Adhy Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH186 Putra Widyartha, Sp.THT-KL
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Gde Agus Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH188 Shuarsedana P, Sp.An
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr.Farida Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH190 Noor, Sp.S
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Ni Wayan Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH191 Nurlina Ekasari, M.Biomed, Sp.S
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Nyoman Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH192 Gede Sudana, M.Sc., Sp.PK (K)
KITAS. Konsul Via Telepon (RJ) (Sp) dr. A A Istri Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
10/16/22, 9:16 AM Page 14 of 43

SPRSWH19 Murwita Prasanti Agung, Sp.JP
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Widastuti Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH194 Dharmapala, Sp. Rad
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. I Komang Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH195 Gede Dwi Maya Rustadi, Sp.KFR
SWH196 Nyoman Sura Oka, Sp.Kj
SWH197 Putu Adityo Ananta Ardika, Sp.M
KITAS.SPR Konsul Via Telepon (RJ) (Sp) dr. Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
KITAS.SPR Konsul Via Telepon (RJ) (Sp) drg. Komang Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH199 Triana AK.
KITAS.SPR Konsul Via Telepon (RJ) (Sp) drg. Tjokorda Konsultasi Rp 0.00 0 0 0 0 0 0 0 66,000
SWH200 Istri Pramiari S
PSPR.RJRS Administrasi Rawat Jalan Pasien IGD Jasa Pelayanan Rp 2,750.00 19,500 0 2,750 0 0 22,250 25,000 25,000
WH001
PSPR.RJRS Administrasi Rawat Jalan Poli / Rujukan Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 15,000
WH002 Penunjang
PSPR.RJRS Administrasi Rawat Inap Jasa Pelayanan Rp 16,500.00 44,000 0 49,500 0 0 60,500 110,000 110,000
WH003
PSPR.RJRS Administrasi Pengisian Medical Report Tindakan Rp 0.00 5,500 16,500 5,500 0 0 22,000 11,000 27,500
WH004 (Asuransi Reimbuserment)
PSPR.RJRS Adminstrasi Asuransi Jasa Pelayanan Rp 0.00 0 55,000 0 0 0 55,000 0 55,000
WH005
PSPR.RJRS Konsultasi Dokter Umum IGD Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH006
PSPR.RJRS USG 2D Tindakan Rp 0.00 0 0 0 0 0 0 0 270,000
WH009
PSPR.RJRS Jasa Medis Dokter Umum On Call 1 Konsultasi Rp 0.00 0 247,500 82,500 0 0 247,500 82,500 330,000
WH010
WH011
WH012
PSPR.RJRS Jasa Periksa Bidan VK Tindakan Rp 0.00 0 0 66,000 0 0 0 66,000 66,000
WH013
PSPR.RJRS Jasa Perawat/Bidan On Call/Home Care 1 Jasa Pelayanan Rp 0.00 0 0 165,000 0 0 0 165,000 165,000
WH014
PSPR.RJRS Jasa Perawat/Bidan On Call/Home Care 2 Jasa Pelayanan Rp 0.00 0 0 247,500 0 0 0 0 247,500
WH015
PSPR.RJRS Jasa Perawat/Bidan On Call/Home Care 3 Jasa Pelayanan Rp 0.00 0 0 330,000 0 0 0 330,000 330,000
WH016
PSPR.RJRS Jasa Tindakan Injeksi Formalin On Call 1 Tindakan Rp 0.00 0 0 0 0 0 0 0 4,500,000
WH017
PSPR.RJRS Jasa Tindakan Injeksi Formalin On Call 2 Tindakan Rp 0.00 0 0 0 0 0 0 0 5,100,000
WH018
PSPR.RJRS Aff Drain Tindakan Rp 198,000.00 146,850 33,000 16,500 0 0 377,850 361,350 394,350
WH019
PSPR.RJRS Aff Hecting Tindakan Rp 191,400.00 85,800 0 23,100 0 0 277,200 300,300 300,300
WH020
10/16/22, 9:16 AM Page 15 of 43

PSPR.RJRS Aff Infus/Katheter/NGT Tindakan Rp 9,900.00 69,300 0 23,100 0 0 79,200 102,300 102,300
WH021
PSPR.RJRS Aff Tampon Hidung/Telinga/Vagina Tindakan Rp 191,400.00 66,000 0 23,100 0 0 257,400 280,500 280,500
WH022
PSPR.RJRS Diet Via Sonde Jasa Pelayanan Rp 9,900.00 16,500 0 23,100 0 0 26,400 49,500 49,500
WH023
PSPR.RJRS DJJ Jasa Pelayanan Rp 16,500.00 17,490 0 16,500 0 0 33,990 50,490 50,490
WH024
PSPR.RJRS EKG 3 chanel Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 225,000
WH025
PSPR.RJRS EKG 12 chanel Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 375,000
WH026
PSPR.RJRS Eksplorasi Luka (Ictum/Snake Bite) Jasa Pelayanan Rp 198,000.00 112,200 33,000 16,500 0 0 343,200 326,700 359,700
WH027
PSPR.RJRS Ekstirpasi Kecil Jasa Pelayanan Rp 214,500.00 330,000 330,000 132,000 0 0 874,500 676,500 1,006,500
WH028
PSPR.RJRS Ekstirpasi Sedang Jasa Pelayanan Rp 214,500.00 363,000 412,500 214,500 0 0 990,000 792,000 1,204,500
WH029
PSPR.RJRS Ekstirpasi Besar Jasa Pelayanan Rp 214,500.00 412,500 495,000 297,000 0 0 1,122,000 924,000 1,419,000
WH030
PSPR.RJRS Ekstraksi Corpus Alienum Tindakan Rp 198,000.00 75,900 82,500 33,000 0 0 356,400 306,900 389,400
WH031
PSPR.RJRS Ekstraksi Kuku Tindakan Rp 198,000.00 123,750 82,500 33,000 0 0 404,250 354,750 437,250
WH032
PSPR.RJRS Explorasi Post SC Tindakan Rp 16,500.00 234,300 0 49,500 0 0 250,800 300,300 300,300
WH033
PSPR.RJRS Tindakan Fisioterapi Infra Red Tindakan Rp 0.00 26,400 0 39,600 0 0 26,400 66,000 66,000
WH034
PSPR.RJRS Tindakan Fisioterapi SWD Tindakan Rp 0.00 0 0 0 0 0 0 0 150,000
WH035
PSPR.RJRS Tindakan Fisioterapi Traksi Tindakan Rp 0.00 0 0 0 0 0 0 0 300,000
WH036
PSPR.RJRS Tindakan Fisioterapi Ultra Sound Tindakan Rp 0.00 26,400 0 39,600 0 0 26,400 66,000 66,000
WH037
PSPR.RJRS Tindakan Fisioterapi TENS Tindakan Rp 0.00 26,400 0 39,600 0 0 26,400 66,000 66,000
WH038
PSPR.RJRS Tindakan Fisioterapi Exercise/Latihan Tindakan Rp 0.00 26,400 0 39,600 0 0 26,400 66,000 66,000
WH039
PSPR.RJRS Tindakan Fisioterapi Massage Tindakan Rp 0.00 26,400 0 39,600 0 0 26,400 66,000 66,000
WH040
PSPR.RJRS Tindakan Fisioterapi Breathing Exercise Tindakan Rp 0.00 26,400 0 39,600 0 0 26,400 66,000 66,000
WH041
PSPR.RJRS Fixasi Costae Tindakan Rp 9,900.00 118,800 33,000 39,600 0 0 161,700 168,300 201,300
WH042
PSPR.RJRS Fototerapi 8 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 300,000
WH043
WH044
WH045
PSPR. Imunisasi Dasar Tindakan Rp 0.00 41,250 82,500 41,250 0 0 123,750 82,500 165,000
10/16/22, 9:16 AM Page 16 of 43

RJRSWH04
PSPR.RJRS Injeksi Delladryl/Xyllo della Tindakan Rp 0.00 16,500 0 16,500 0 0 16,500 33,000 33,000
WH047
PSPR.RJRS Injeksi IM/IV/IC/SC Tindakan Rp 0.00 0 0 0 0 0 0 0 99,000
WH048
PSPR.RJRS Insisi Abses Tindakan Rp 214,500.00 199,650 99,000 33,000 0 0 513,150 447,150 546,150
WH049
PSPR.RJRS Intubasi/Pasang ETT Tindakan Rp 346,500.00 165,000 330,000 82,500 0 0 841,500 594,000 924,000
WH050
PSPR.RJRS Irigasi / Spoeling mata/Telinga Tindakan Rp 33,000.00 72,600 33,000 16,500 0 0 138,600 122,100 155,100
WH051
PSPR.RJRS Kumbah Lambung Tindakan Rp 33,000.00 80,850 52,800 33,000 0 0 166,650 146,850 199,650
WH052
PSPR.RJRS Lavement Tindakan Rp 49,500.00 133,650 0 66,000 0 0 183,150 249,150 249,150
WH053
PSPR.RJRS Rawat Luka Bakar 1 (<5%) Perawatan Rp 214,500.00 171,600 0 33,000 0 0 386,100 419,100 419,100
WH054
PSPR.RJRS Rawat Luka Bakar 2 (5 - 15%) Perawatan Rp 214,500.00 275,550 66,000 66,000 0 0 556,050 556,050 622,050
WH055
PSPR.RJRS Rawat Luka Bakar 3 (15 - 20%) Perawatan Rp 231,000.00 330,000 198,000 82,500 0 0 759,000 643,500 841,500
WH056
PSPR.RJRS Rawat Luka Bakar Luas > 20% Perawatan Rp 247,500.00 396,000 330,000 99,000 0 0 973,500 742,500 1,072,500
WH057
PSPR.RJRS Rawat Luka Lecet 1 (<5%) Perawatan Rp 198,000.00 79,200 0 16,500 0 0 277,200 293,700 293,700
WH058
PSPR.RJRS Rawat Luka Lecet 2 (5 - 10%) Perawatan Rp 214,500.00 214,500 33,000 33,000 0 0 462,000 462,000 495,000
WH059
PSPR.RJRS Rawat Luka Lecet 3 ( > 10%) Perawatan Rp 214,500.00 275,550 82,500 49,500 0 0 572,550 539,550 622,050
WH060
PSPR.RJRS Hecting 1 (HT<5) Tindakan Rp 264,000.00 136,950 33,000 33,000 0 0 433,950 433,950 466,950
WH061
PSPR.RJRS Hecting 2 (HT 5-10) Tindakan Rp 280,500.00 321,750 66,000 33,000 0 0 668,250 635,250 701,250
WH062
PSPR.RJRS Hecting 3 (HT > 10) Tindakan Rp 297,000.00 460,350 99,000 49,500 0 0 856,350 806,850 905,850
WH063
PSPR.RJRS Nebulizer Tindakan Rp 78,210.00 18,150 0 49,500 0 0 96,360 145,860 145,860
WH064
PSPR.RJRS NST Tindakan Rp 99,000.00 85,800 0 82,500 0 0 184,800 267,300 267,300
WH065
PSPR.RJRS Observasi IGD per jam Tindakan Rp 33,000.00 0 33,000 16,500 0 0 66,000 49,500 82,500
WH066
PSPR.RJRS Observasi VK < 12 Jam Tindakan Rp 66,000.00 313,500 165,000 90,750 0 0 544,500 470,250 635,250
WH067
PSPR.RJRS Observasi VK > 12 Jam -< 24 Jam Tindakan Rp 165,000.00 924,000 330,000 148,500 0 0 1,419,000 1,237,500 1,567,500
WH068
PSPR.RJRS Pasang Guedel Tindakan Rp 9,900.00 16,500 16,500 6,600 0 0 42,900 33,000 49,500
WH069
PSPR.RJRS Pasang Infus Akses V. Umbilical Tindakan Rp 33,000.00 167,970 82,500 49,500 0 0 283,470 250,470 332,970
WH070
PSPR.RJRS Pasang Infus Anak/Bayi Tindakan Rp 16,500.00 126,720 49,500 33,000 0 0 192,720 176,220 225,720
WH071
10/16/22, 9:16 AM Page 17 of 43

PSPR.RJRS Pasang Infus Dewasa Tindakan Rp 16,500.00 77,550 33,000 16,500 0 0 127,050 110,550 143,550
WH073
PSPR.RJRS Pasang NGT Tindakan Rp 16,500.00 74,250 41,250 24,750 0 0 132,000 115,500 156,750
WH074
PSPR.RJRS Pasang Ring Pesarium Tindakan Rp 0.00 99,000 0 247,500 0 0 99,000 346,500 346,500
WH075
PSPR.RJRS Pasang Ransel Verban Tindakan Rp 16,500.00 16,500 66,000 33,000 0 0 99,000 66,000 132,000
WH076
PSPR.RJRS Pasang spalk kecil 1 bilah Tindakan Rp 6,600.00 113,850 16,500 9,900 0 0 136,950 130,350 146,850
WH077
PSPR.RJRS Pasang spalk panjang 2 bilah Tindakan Rp 9,900.00 379,170 33,000 23,100 0 0 422,070 412,170 445,170
WH078
PSPR.RJRS Pasang spalk sedang 2 bilah Tindakan Rp 9,900.00 212,190 23,100 16,500 0 0 245,190 238,590 261,690
WH079
PSPR.RJRS Pasang Tampon Hidung Anterior / Telinga Tindakan Rp 16,500.00 82,500 49,500 16,500 0 0 148,500 115,500 165,000
WH080
PSPR.RJRS Pasang Tampon Hidung Posterior Tindakan Rp 23,100.00 127,050 99,000 42,900 0 0 249,150 193,050 292,050
WH081
PSPR.RJRS Pasang Tampon Vagina Tindakan Rp 16,500.00 120,450 41,250 24,750 0 0 178,200 161,700 202,950
WH082
PSPR.RJRS Pemakaian Collar Brace (incl. sewa Collar Tindakan Rp 9,900.00 495,000 23,100 16,500 0 0 528,000 521,400 544,500
WH083 Brace)
PSPR.RJRS Pemakaian Collar Brace (incl. sewa Collar Tindakan Rp 9,900.00 16,500 23,100 16,500 0 0 49,500 42,900 66,000
WH084 Brace)
PSPR.RJRS Pemakaian O2 Kanul per 1 jam Tindakan Rp 0.00 26,070 0 0 0 0 26,070 26,070 26,070
WH085
PSPR.RJRS Pemakaian O2 Face Masker per 1 jam Tindakan Rp 0.00 52,140 0 0 0 0 52,140 52,140 52,140
WH086
PSPR.RJRS Pemakaian O2 Head Box per 1 jam Tindakan Rp 0.00 78,210 0 0 0 0 52,140 52,140 52,140
WH087
PSPR.RJRS Perawatan Infus Tindakan Rp 0.00 77,550 0 16,500 0 0 77,550 94,050 94,050
WH088
PSPR.RJRS Rawat luka ringan Tindakan Rp 0.00 0 0 0 0 0 0 0 180,000
WH089
PSPR.RJRS Rawat luka sedang Tindakan Rp 0.00 0 0 0 0 0 0 0 240,000
WH090
PSPR.RJRS Rawat luka berat Tindakan Rp 0.00 0 0 0 0 0 0 0 300,000
WH091
PSPR.RJRS Rawat Luka Diabetic 1 / Post Op. Sedang Tindakan Rp 198,000.00 202,950 41,250 24,750 0 0 442,200 425,700 466,950
WH092
PSPR.RJRS Rawat Luka Diabetic 2 / Post Op. Besar Tindakan Rp 206,250.00 209,550 57,750 33,000 0 0 473,550 448,800 506,550
WH093
PSPR.RJRS Rawat Luka Diabetic 3 / Post Op. Extra Tindakan Rp 214,500.00 404,250 99,000 66,000 0 0 717,750 684,750 783,750
WH094
PSPR.RJRS Rectal Toucher/Colok Dubur Tindakan Rp 6,600.00 62,700 33,000 9,900 0 0 102,300 79,200 112,200
WH095
PSPR.RJRS Rectal/ Per Vaginam Supp Tindakan Rp 6,600.00 21,450 0 9,900 0 0 28,050 37,950 37,950
WH096
PSPR.RJRS Resusitasi Dasar Tindakan Rp 16,500.00 133,650 33,000 16,500 0 0 183,150 166,650 199,650
WH097
PSPR. Resusitasi Lanjutan Tindakan Rp 82,500.00 133,650 247,500 165,000 0 0 463,650 381,150 628,650
10/16/22, 9:16 AM Page 18 of 43

RJRSWH09
PSPR.RJRS Resusitasi Bayi Tindakan Rp 0.00 0 0 0 0 0 0 0 360,000
WH099
PSPR.RJRS Rumple Leed Tindakan Rp 6,600.00 0 0 9,900 0 0 6,600 16,500 16,500
WH100
PSPR.RJRS Sceren Tindakan Rp 9,900.00 79,200 0 23,100 0 0 89,100 112,200 112,200
WH101
PSPR.RJRS Skin Test Tindakan Rp 6,600.00 8,250 9,900 8,250 0 0 24,750 23,100 33,000
WH102
PSPR.RJRS Surface Cooling Tindakan Rp 6,600.00 16,500 0 23,100 0 0 23,100 46,200 46,200
WH103
PSPR.RJRS Test Lakmus Tindakan Rp 0.00 16,500 0 16,500 0 0 16,500 33,000 33,000
WH104
PSPR.RJRS Tindakan Suction Tindakan Rp 23,100.00 19,800 23,100 16,500 0 0 66,000 59,400 82,500
WH105
PSPR.RJRS Tranfusi Tindakan Rp 33,000.00 16,500 0 33,000 0 0 49,500 82,500 82,500
WH106
PSPR.RJRS Visum Et Repertum Tindakan Rp 24,750.00 16,500 99,000 24,750 0 0 140,250 66,000 165,000
WH107
PSPR.RJRS VT (Bidan) Tindakan Rp 6,600.00 74,910 0 42,900 0 0 81,510 124,410 124,410
WH108
PSPR.RJRS Pasang Infus anak/bayi Sulit (on call) Tindakan Rp 16,500.00 126,720 330,000 33,000 0 0 473,220 176,220 506,220
WH109
PSPR.RJRS Pemerksaan dan Konsultasi VCT Tindakan Rp 16,500.00 16,500 330,000 49,500 0 0 363,000 82,500 412,500
WH110
PSPR.RJRS Monitor per 1 jam Tindakan Rp 82,500.00 0 0 0 0 0 82,500 82,500 82,500
WH111
PSPR.RJRS Pemakaian Continus Suction Pump(WSD) Tindakan Rp 528,000.00 0 0 0 0 0 528,000 528,000 528,000
WH112
PSPR.RJRS Flowcart - Rp 23,100.00 0 0 0 0 0 23,100 23,100 23,100
WH113
PSPR.RJRS Pemakaian O2 NIP perjam (ICU) Tindakan Rp 0.00 379,500 0 0 0 0 379,500 379,500 379,500
WH114
PSPR.RJRS Pemakaian C-PAP Tindakan Rp 0.00 0 0 0 0 0 0 0 750,000
WH115
PSPR.RJRS Ekstubasi (aff intubasi) Tindakan Rp 0.00 69,300 99,000 0 0 0 168,300 69,300 168,300
WH116
PSPR.RJRS Tindakan Oral Hygine Tindakan Rp 133,650.00 0 0 33,000 0 0 133,650 166,650 166,650
WH117
PSPR.RJRS Tindakan Injeksi Formalin Tindakan Rp 0.00 0 0 0 0 0 0 0 4,200,000
WH118
PSPR.RJRS Tindakan Injeksi Intraartikulars (umum) Tindakan Rp 276,375.00 145,596 412,500 0 0 0 834,471 421,971 834,471
WH119
PSPR.RJRS Tarif Tambahan Injeksi Formalin Tindakan Rp 330,000.00 438,900 495,000 0 0 0 1,263,900 768,900 1,263,900
WH120
PSPR.RJRS Pasang Infus Radiologi Tindakan Rp 16,500.00 77,550 189,750 95,700 0 0 283,800 189,750 379,500
WH121
PSPR.RJRS Tarif Kerohanian Tindakan Rp 66,000.00 0 660,000 0 0 0 726,000 66,000 726,000
WH122
PSPR.RJRS Syring Pump per 1 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 75,000
WH123
10/16/22, 9:16 AM Page 19 of 43

PSPR.RJRS Konsultasi dokter umum IGD dr. Bagus Gde Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH124 Ariesta Darmahendra
PSPR.RJRS Konsultasi dokter umum IGD dr. I Kadek Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH125 Oka Widiana
PSPR.RJRS Konsultasi dokter umum IGD dr. Kadek Mia Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH126 Risdayanthi
PSPR.RJRS Konsultasi dokter umum IGD dr. Ni Nyoman Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH127 Putri Widyastiti
PSPR.RJRS Konsultasi dokter umum IGD dr. Ida Ayu Cili Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH128 Swesis
PSPR.RJRS Konsultasi dokter umum IGD dr. I Gusti Ayu Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH129 Ria Mardewi
PSPR.RJRS Konsultasi dokter umum IGD dr. Pande Konsultasi Rp 66,000.00 0 66,000 33,000 0 0 132,000 99,000 165,000
WH130 Nyoman Tri Mas Saptini
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Wayan Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. W Giri Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. Pande Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Dewa Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. I Gde Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr.Farida Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
WH146 Noor, Sp.S
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR. Konsultasi dokter spesialis (poli) dr. A A Istri Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
10/16/22, 9:16 AM Page 20 of 43

RJRSWH14 Murwita Prasanti Agung, Sp.JP
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) dr. Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis (poli) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 360,000
PSPR.RJRS Konsultasi dokter spesialis by phone dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 200,000
WH157 Gusti Ngurah Darmaja, Sp.OG
PSPR.RJRS Konsultasi dokter spesialis by phone dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 200,000
WH159 Putu Shely Prihastuti Rudy, Sp.PD
WH160 Wayan Giri Putra S, M.Biomed, Sp.PD
WH161 Gusti Ketut Oka Nurjaya, Sp.A
WH164 Putu Gede Fajar Maha Yasa, Sp.B
WH168 Made Adhy Putra Widyartha, Sp.THT-KL
WH169 Putu Sudiasa, Sp.THT
WH170 Gde Agus Shuarsedana Putra, Sp.An
WH171 Putu Agung Wirahadi Sanjaya, Sp.OT
PSPR.RJRS Konsultasi dokter spesialis by phone Konsultasi Rp 0.00 0 0 0 0 0 0 0 200,000
WH172 dr.Farida Noor, Sp.S
PSPR.RJRS Konsultasi dokter spesialis by phone dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 200,000
WH173 W Nurlina Ekasari, M.Biomed, Sp.S
10/16/22, 9:16 AM Page 21 of 43

PSPR.RJRS Konsultasi dokter spesialis by phone dr. A A Konsultasi Rp 0.00 0 0 0 0 0 0 0 200,000
WH180 Gede Sasmika Suwandi, Sp.P
PSPR.RJRS Konsultasi dokter spesialis by phone drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 200,000
PSPR.RJRS Konsultasi dokter spesialis by phone drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 200,000
PSPR.SPRS Aff Cateter (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 120,340
WH001
PSPR.SPRS Aff Drain/WSD (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 581,240
WH002
PSPR.SPRS Aff NGT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 128,700
WH003
PSPR.SPRS Biopsi Lokal (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 909,669
WH004
PSPR.SPRS First Konsul (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 275,000
WH005
PSPR.SPRS Jasa Medis On Call Dokter Spesialis 1 Tindakan Rp 0.00 0 0 0 0 0 0 0 605,000
WH006
WH007
WH008
PSPR.SPRS Jasa Medis Poliklinik Spesialis I (Bpjs) Tindakan Rp 0.00 0 0 0 0 0 0 0 110,000
WH009
PSPR.SPRS Jasa Medis Poliklinik Spesialis II (Ikatan Tindakan Rp 0.00 0 0 0 0 0 0 0 132,000
WH010 Kerja Sama Tertentu)
PSPR.SPRS Jasa Medis Poliklinik Spesialis III (Ikatan Tindakan Rp 0.00 0 0 0 0 0 0 0 165,000
WH011 kerja sama tertentu)
PSPR.SPRS Jasa Medis Poliklinik Spesialis IV (umum) Tindakan Rp 0.00 0 0 0 0 0 0 0 220,000
WH012
PSPR.SPRS Jasa Pasang Infus (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 326,480
WH013
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 330,000
WH014
PSPR.SPRS Konsul di atas Meja Operasi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,100,000
WH015
PSPR.SPRS Konsul Via Telepon (RJ) (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 88,000
WH016
PSPR.SPRS Lumbal Punksi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,150,600
WH017
PSPR. Pasang ETT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 672,980
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SPRSWH01
PSPR.SPRS Pasang Kateter/NGT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 297,220
WH019
PSPR.SPRS Pasang WSD (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,083,500
WH020
PSPR.SPRS Punksi Ascites (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 939,400
WH021
PSPR.SPRS Rawat Luka Post Op. Obgyn/Bedah Sedang Tindakan Rp 0.00 0 0 0 0 0 0 0 46,200
WH022 RJ (Sp)
PSPR.SPRS Rawat Luka Post Op. Obgyn/Bedah Berat Tindakan Rp 0.00 0 0 0 0 0 0 0 90,200
WH023 RJ (Sp)
PSPR.SPRS Rawat Luka Post Op. Obgyn/Bedah Extra Tindakan Rp 0.00 0 0 0 0 0 0 0 139,700
WH024 Berat RJ (Sp)
PSPR.SPRS Tindik Telinga (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 440,000
WH025
PSPR.SPRS Tuberculin Test (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 506,000
WH026
PSPR.SPRS Vena Section (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 871,640
WH027
PSPR.SPRS Vena Umbilical (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 353,980
WH028
PSPR.SPRS Pasang Ventilator (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 303,160
WH029
PSPR.SPRS Tes Provokasi Obat RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,001,000
WH030
PSPR.SPRS Tes Rapid Desensitisasi Obat RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,001,000
WH031
PSPR.SPRS Ekstubasi (AF Intubasi) (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 134,200
WH032
PSPR.SPRS Echocardiografi (Umum) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,500,000
WH033
PSPR.SPRS Psikometri Test Tindakan Rp 0.00 0 0 0 0 0 0 0 220,000
WH034
PSPR.SPRS MMPI Tindakan Rp 0.00 0 0 0 0 0 0 0 440,000
WH035
PSPR.SPRS Ekstirpasi Pterigium (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,848,000
WH054
PSPR.SPRS BHP Pemeriksaan Mata Rutin (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 6,600
WH055
PSPR.SPRS Ekstraksi Corpus Alienum Mata dg alat Tindakan Rp 0.00 0 0 0 0 0 0 0 715,000
WH056 khusus (Sp)
PSPR.SPRS Ekstraksi Corpus Alienum Mata dg cotton Tindakan Rp 0.00 0 0 0 0 0 0 0 264,000
WH057 bud (Sp)
PSPR.SPRS Insisi & Kuretase Hordeolum (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,001,000
WH058
PSPR.SPRS Irigasi Ductus Nasolakrimalis (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 429,000
WH059
PSPR.SPRS Lithiasis Tindakan Rp 0.00 0 0 0 0 0 0 0 858,000
WH060
PSPR.SPRS Ruptur Konjungtiva Tindakan Rp 0.00 0 0 0 0 0 0 0 979,000
WH061
10/16/22, 9:16 AM Page 23 of 43

PSPR.SPRS Probbing Tindakan Rp 0.00 0 0 0 0 0 0 0 572,000
WH062
PSPR.SPRS Ruptur Palpebra Tindakan Rp 0.00 0 0 0 0 0 0 0 858,000
WH063
PSPR.SPRS Refraksi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 100,000
WH064
PSPR.SPRS Aff Tampon Hidung / Telinga (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 116,600
WH065
PSPR.SPRS Ext. Corpus Alienum THT/Serumen/Krusta Tindakan Rp 0.00 0 0 0 0 0 0 0 171,600
WH066 Hidung (Sp)
PSPR.SPRS Irigasi Sinus Satu Sisi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,302,400
WH067
PSPR.SPRS Irigasi Sinus Dua Sisi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,953,600
WH068
PSPR.SPRS Parasintesa/Pungsi Aspirasi Othematom Tindakan Rp 0.00 0 0 0 0 0 0 0 385,000
WH069
PSPR.SPRS Pasang Tampon Hidung Anterior / Telinga Tindakan Rp 0.00 0 0 0 0 0 0 0 236,500
WH070 (Sp)
PSPR.SPRS Pasang Tampon Hidung Posterior (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 568,700
WH071
PSPR.SPRS Reposisi Hidung (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,034,000
WH072
PSPR.SPRS Spooling Telinga (Sp) 1 telinga Tindakan Rp 0.00 0 0 0 0 0 0 0 168,740
WH073
PSPR.SPRS Biopsi THT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,302,400
WH074
PSPR.SPRS Aff Tampon Hidung / Telinga RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 490,600
WH075
PSPR.SPRS Aff Implant / Susuk KB (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 573,100
WH076
PSPR.SPRS Aff Tampon Vagina (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 116,600
WH077
PSPR.SPRS Ekstraksi Fragmen IUD (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 474,100
WH078
PSPR.SPRS Ekstraksi IUD Biasa (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 292,600
WH079
PSPR.SPRS Ekstraksi IUD Missing Tail (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 413,600
WH080
PSPR.SPRS Explorasi Post Abortus (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 752,400
WH081
PSPR.SPRS Explorasi Post Partum (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 752,400
WH082
PSPR.SPRS Pap Smear (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 400,000
WH083
PSPR.SPRS Pasang / Insersi IUD (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 413,600
WH084
PSPR.SPRS Pasang Tampon Vagina (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 201,300
WH085
PSPR.SPRS Pasang Ring Pesarium (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 429,000
WH086
PSPR. USG Intra Vaginal (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 330,000
10/16/22, 9:16 AM Page 24 of 43

SPRSWH08
PSPR.SPRS USG Obgyn dengan Print pada ANC (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 180,000
WH088
PSPR.SPRS USG Obgyn tanpa Print pada ANC (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 150,000
WH089
PSPR.SPRS USG Obgyn dengan Print RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 189,200
WH090
PSPR.SPRS USG Obgyn tanpa Print RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 167,200
WH091
PSPR.SPRS Vaginal Swab (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 79,200
WH092
PSPR.SPRS Vaginal Toucher/VT (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 179,740
WH093
PSPR.SPRS Pasang Tampon Sayeba Kondom (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,381,600
WH094
PSPR.SPRS Biopsi FNAB (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,015,300
WH095
PSPR.SPRS Buka gips short arm/leg (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 203,500
WH096
PSPR.SPRS Buka gips long arm/leg (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 385,000
WH097
PSPR.SPRS Circumsisi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,147,300
WH098
PSPR.SPRS Debridement + Hecting (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 819,720
WH099
PSPR.SPRS Dilatasi phimosis (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 374,220
WH100
PSPR.SPRS Eksisi/ekstirpasi kecil (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 946,000
WH101
PSPR.SPRS Eksisi/ekstirpasi sedang (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,089,000
WH102
PSPR.SPRS Eksisi/ekstirpasi besar (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,243,000
WH103
PSPR.SPRS Incisi Abses (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 495,220
WH104
PSPR.SPRS Pasang gips tanpa reposisi short arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 748,000
WH105 (Sp)
PSPR.SPRS Pasang gips tanpa reposisi long arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 990,000
WH106
PSPR.SPRS Pasang gips dengan reposisi short arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 1,232,000
WH107 (Sp)
PSPR.SPRS Pasang gips dengan reposisi long arm/leg Tindakan Rp 0.00 0 0 0 0 0 0 0 1,474,000
WH108 (Sp)
PSPR.SPRS Pasang Ransel Verban (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 409,200
WH109
PSPR.SPRS Pasang Skin Traksi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 506,000
WH110
PSPR.SPRS Pungsi Sendi/Sinopial (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 670,560
WH111
PSPR.SPRS Rawat Luka Kecil RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 266,860
WH112
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PSPR.SPRS Rawat Luka Sedang RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 390,500
WH113
PSPR.SPRS Rawat Luka Besar RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 589,600
WH114
PSPR.SPRS Rawat Luka Ekstra Besar RI (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 831,600
WH115
PSPR.SPRS Rawat Luka Post Op. Ortho Sedang (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 280,060
WH116
PSPR.SPRS Rawat Luka Post Op. Ortho Berat (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 381,700
WH117
PSPR.SPRS Rawat Luka Post Op. Ortho Exstra Berat Tindakan Rp 0.00 0 0 0 0 0 0 0 704,660
WH118 (Sp)
PSPR.SPRS Reposisi & Pasang Ransel Verban (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 869,000
WH119
PSPR.SPRS Kemoterapi Grade I (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 1,540,000
WH120
PSPR.SPRS Kemoterapi Grade II (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 935,000
WH121
PSPR.SPRS Luka Bakar (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 924,000
WH122
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. I G N Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
WH201 Darmaja, Sp.OG
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. I Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. Putu Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. W Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
WH204 Giri Putra Semaradana, M.Biomed, Sp.PD
WH205 Gusti Ketut Oka Nurjaya, Sp.A
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. I Putu Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. Made Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. I Gde Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR. Konsul Antar Dokter Spesialis (Sp) dr.Farida Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
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SPRSWH21 Noor, Sp.S
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. Ni Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. A A Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) dr. Gede Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) drg. Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul Antar Dokter Spesialis (Sp) drg. Konsultasi Rp 0.00 0 330,000 0 0 0 330,000 0 330,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Gusti Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. Putu Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. W Giri Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Gusti Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Gede Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Putu Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Made Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. Pande Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Dewa Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. Made Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. I Gde Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
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PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr.Farida Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
WH242 Noor, Sp.S
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. Ni Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. A A Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) dr. Gede Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) drg. Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul di atas Meja Operasi (Sp) drg. Konsultasi Rp 0.00 0 1,100,000 0 0 0 1,100,000 0 1,100,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Gusti Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Wayan Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Putu Shely Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH255 Prihastuti Rudy, Sp.PD
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. W Giri Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Gusti Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Nyoman Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH258 Putra Arcana, Sp.A
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Gede Oka Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH259 Novi Purnawan, Sp.A
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Putu Gede Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH260 Fajar Maha Yasa, Sp.B
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Made Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Pande Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Dewa Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Made Adhy Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH264 Putra Widyartha, Sp.THT-KL
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Putu Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Gde Agus Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH266 Shuarsedana Putra, Sp.An
PSPR. Konsul Via Telepon (RJ) (Sp)dr. Putu Agung Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
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SPRSWH26 Wirahadi Sanjaya, Sp.OT
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr.Farida Noor, Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH268 Sp.S
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Ni Wayan Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH269 Nurlina Ekasari, M.Biomed, Sp.S
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Nyoman Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH270 Gede Sudana, M.Sc., Sp.PK (K)
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. A A Istri Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH271 Murwita Prasanti Agung, Sp.JP
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Widastuti Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH272 Dharmapala, Sp. Rad
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. I Komang Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH273 Gede Dwi Maya Rustadi, Sp.KFR
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Pande Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Pande Putu Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH275 Adityo Ananta Ardika, Sp.M
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)dr. Gede Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)drg. Komang Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH277 Triana AK.
PSPR.SPRS Konsul Via Telepon (RJ) (Sp)drg. Tjokorda Konsultasi Rp 0.00 0 88,000 0 0 0 88,000 0 88,000
WH278 Istri Pramiari S
RJRSWH.S Aff Cateter (Sp) Tindakan Rp 5,500.00 18,370 33,000 3,300 0 0 56,870 27,170 60,170
PE001
RJRSWH.S Aff Drain/WSD (Sp) Tindakan Rp 7,700.00 40,920 220,000 22,000 0 0 268,620 70,620 290,620
PE002
RJRSWH.S Aff NGT (Sp) Tindakan Rp 5,500.00 22,550 33,000 3,300 0 0 61,050 31,350 64,350
PE003
RJRSWH.S Biopsi Lokal (Sp) Tindakan Rp 11,000.00 20,335 385,000 38,500 0 0 416,335 69,835 454,835
PE004
RJRSWH.S First Konsul (Sp) Tindakan Rp 0.00 0 137,500 0 0 0 137,500 0 137,500
PE005
RJRSWH.S Jasa Medis On Call Dokter Spesialis 1 Tindakan Rp 0.00 0 275,000 27,500 0 0 275,000 27,500 302,500
PE006
PE007
PE008
RJRSWH.S Jasa Medis Poliklinik Spesialis I (Bpjs) Tindakan Rp 11,000.00 0 44,000 0 0 0 55,000 11,000 55,000
PE009
RJRSWH.S Jasa Medis Poliklinik Spesialis II (Ikatan Tindakan Rp 13,200.00 0 52,800 0 0 0 66,000 13,200 66,000
PE010 Kerja Sama Tertentu)
RJRSWH.S Jasa Medis Poliklinik Spesialis III (Ikatan Tindakan Rp 16,500.00 0 66,000 0 0 0 82,500 16,500 82,500
PE011 kerja sama tertentu)
RJRSWH.S Jasa Medis Poliklinik Spesialis IV (umum) Tindakan Rp 22,000.00 0 88,000 0 0 0 110,000 22,000 110,000
PE012
RJRSWH.S Jasa Pasang Infus (Sp) Tindakan Rp 5,500.00 36,740 110,000 11,000 0 0 152,240 53,240 163,240
PE013
RJRSWH.S Lumbal Punksi (Sp) Tindakan Rp 11,000.00 80,300 440,000 44,000 0 0 531,300 135,300 575,300
PE017
10/16/22, 9:16 AM Page 29 of 43

RJRSWH.S Pasang ETT (Sp) Tindakan Rp 11,000.00 22,990 275,000 27,500 0 0 308,990 61,490 336,490
PE018
RJRSWH.S Pasang Kateter/NGT (Sp) Tindakan Rp 5,500.00 22,110 110,000 11,000 0 0 137,610 38,610 148,610
PE019
RJRSWH.S Pasang WSD (Sp) Tindakan Rp 7,700.00 50,050 440,000 44,000 0 0 497,750 101,750 541,750
PE020
RJRSWH.S Punksi Ascites (Sp) Tindakan Rp 16,500.00 29,700 385,000 38,500 0 0 431,200 84,700 469,700
PE021
RJRSWH.S Rawat Luka Post Op. Obgyn/Bedah Sedang Tindakan Rp 5,500.00 17,600 0 0 0 0 23,100 23,100 23,100
PE022 RJ (Sp)
RJRSWH.S Rawat Luka Post Op. Obgyn/Bedah Berat Tindakan Rp 6,600.00 38,500 0 0 0 0 45,100 45,100 45,100
PE023 RJ (Sp)
RJRSWH.S Rawat Luka Post Op. Obgyn/Bedah Extra Tindakan Rp 7,700.00 62,150 0 0 0 0 69,850 69,850 69,850
PE024 Berat RJ (Sp)
RJRSWH.S Tindik Telinga (Sp) Tindakan Rp 44,000.00 55,000 110,000 11,000 0 0 209,000 110,000 220,000
PE025
RJRSWH.S Tuberculin Test (Sp) Tindakan Rp 5,500.00 5,500 220,000 22,000 0 0 231,000 33,000 253,000
PE026
RJRSWH.S Vena Section (Sp) Tindakan Rp 16,500.00 56,320 330,000 33,000 0 0 402,820 105,820 435,820
PE027
RJRSWH.S Vena Umbilical (Sp) Tindakan Rp 11,000.00 44,990 110,000 11,000 0 0 165,990 66,990 176,990
PE028
RJRSWH.S Pasang Ventilator (Sp) Tindakan Rp 11,000.00 19,580 110,000 11,000 0 0 140,580 41,580 151,580
PE029
RJRSWH.S Tes Provokasi Obat RI (Sp) Tindakan Rp 11,000.00 5,500 440,000 44,000 0 0 456,500 60,500 500,500
PE030
RJRSWH.S Tes Rapid Desensitisasi Obat RI (Sp) Tindakan Rp 11,000.00 5,500 440,000 44,000 0 0 456,500 60,500 500,500
PE031
RJRSWH.S Ekstubasi (AF Intubasi) (Sp) Tindakan Rp 11,000.00 23,100 33,000 0 0 0 67,100 34,100 67,100
PE032
RJRSWH.S Echocardiografi Tindakan Rp 0.00 0 0 0 0 0 0 0 750,000
PE033
RJRSWH.S Psikometri Test Tindakan Rp 55,000.00 0 55,000 0 0 0 110,000 55,000 110,000
PE034
RJRSWH.S MMPI Tindakan Rp 55,000.00 0 165,000 0 0 0 220,000 55,000 220,000
PE035
RJRSWH.S BHP Pemeriksaan Mata Rutin (Sp) Tindakan Rp 0.00 3,300 0 0 0 0 3,300 3,300 3,300
PE054
RJRSWH.S Ekstirpasi Pterigium (Sp) Tindakan Rp 16,500.00 60,500 770,000 77,000 0 0 847,000 154,000 924,000
PE055
RJRSWH.S Ekstraksi Corpus Alienum Mata dg alat Tindakan Rp 11,000.00 44,000 275,000 27,500 0 0 330,000 82,500 357,500
PE056 khusus (Sp)
RJRSWH.S Ekstraksi Corpus Alienum Mata dg cotton Tindakan Rp 5,500.00 5,500 110,000 11,000 0 0 121,000 22,000 132,000
PE057 bud (Sp)
RJRSWH.S Insisi & Kuretase Hordeolum (Sp) Tindakan Rp 22,000.00 55,000 385,000 38,500 0 0 462,000 115,500 500,500
PE058
RJRSWH.S Irigasi Ductus Nasolakrimalis (Sp) Tindakan Rp 7,700.00 25,300 165,000 16,500 0 0 198,000 49,500 214,500
PE059
RJRSWH.S Lithiasis Tindakan Rp 16,500.00 49,500 330,000 33,000 0 0 396,000 99,000 429,000
PE060
RJRSWH. Probbing Tindakan Rp 11,000.00 33,000 220,000 22,000 0 0 264,000 66,000 286,000
10/16/22, 9:16 AM Page 30 of 43

SPE061
RJRSWH.S Ruptur Konjungtiva Tindakan Rp 16,500.00 49,500 385,000 38,500 0 0 451,000 104,500 489,500
PE062
RJRSWH.S Ruptur Palpebra Tindakan Rp 16,500.00 49,500 330,000 33,000 0 0 396,000 99,000 429,000
PE063
RJRSWH.S Refraksi (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 50,000
PE064
RJRSWH.S Aff Tampon Hidung / Telinga (Sp) Tindakan Rp 5,500.00 16,500 33,000 3,300 0 0 55,000 25,300 58,300
PE065
RJRSWH.S Ext. Corpus Alienum THT/Serumen/Krusta Tindakan Rp 7,700.00 17,600 55,000 5,500 0 0 80,300 30,800 85,800
PE066 Hidung (Sp)
RJRSWH.S Irigasi Sinus Satu Sisi (Sp) Tindakan Rp 16,500.00 29,700 550,000 55,000 0 0 596,200 101,200 651,200
PE067
RJRSWH.S Irigasi Sinus Dua Sisi (Sp) Tindakan Rp 25,300.00 44,000 825,000 82,500 0 0 894,300 151,800 976,800
PE068
RJRSWH.S Parasintesa/Pungsi Aspirasi Othematom Tindakan Rp 5,500.00 5,500 165,000 16,500 0 0 176,000 27,500 192,500
PE069
RJRSWH.S Pasang Tampon Hidung Anterior / Telinga Tindakan Rp 11,000.00 16,500 82,500 8,250 0 0 110,000 35,750 118,250
PE070 (Sp)
RJRSWH.S Pasang Tampon Hidung Posterior (Sp) Tindakan Rp 16,500.00 25,850 220,000 22,000 0 0 262,350 64,350 284,350
PE071
RJRSWH.S Reposisi Hidung (Sp) Tindakan Rp 11,000.00 22,000 440,000 44,000 0 0 473,000 77,000 517,000
PE072
RJRSWH.S Spooling Telinga (Sp) 1 telinga Tindakan Rp 6,600.00 17,270 55,000 5,500 0 0 78,870 29,370 84,370
PE073
RJRSWH.S Biopsi THT (Sp) Tindakan Rp 16,500.00 29,700 550,000 55,000 0 0 596,200 101,200 651,200
PE074
RJRSWH.S Aff Tampon Hidung / Telinga RI (Sp) Tindakan Rp 0.00 22,000 220,000 3,300 0 0 242,000 25,300 245,300
PE075
RJRSWH.S Aff Implant / Susuk KB (Sp) Tindakan Rp 11,000.00 33,550 220,000 22,000 0 0 264,550 66,550 286,550
PE076
RJRSWH.S Aff Tampon Vagina (Sp) Tindakan Rp 5,500.00 16,500 33,000 3,300 0 0 55,000 25,300 58,300
PE077
RJRSWH.S Ekstraksi Fragmen IUD (Sp) Tindakan Rp 7,700.00 17,600 192,500 19,250 0 0 217,800 44,550 237,050
PE078
RJRSWH.S Ekstraksi IUD Biasa (Sp) Tindakan Rp 7,700.00 17,600 110,000 11,000 0 0 135,300 36,300 146,300
PE079
RJRSWH.S Ekstraksi IUD Missing Tail (Sp) Tindakan Rp 7,700.00 17,600 165,000 16,500 0 0 190,300 41,800 206,800
PE080
RJRSWH.S Explorasi Post Abortus (Sp) Tindakan Rp 16,500.00 57,200 275,000 27,500 0 0 348,700 101,200 376,200
PE081
RJRSWH.S Explorasi Post Partum (Sp) Tindakan Rp 16,500.00 57,200 275,000 27,500 0 0 348,700 101,200 376,200
PE082
RJRSWH.S Pap Smear (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 200,000
PE083
RJRSWH.S Pasang / Insersi IUD (Sp) Tindakan Rp 11,000.00 14,300 165,000 16,500 0 0 190,300 41,800 206,800
PE084
RJRSWH.S Pasang Tampon Vagina (Sp) Tindakan Rp 5,500.00 34,650 55,000 5,500 0 0 95,150 45,650 100,650
PE085
RJRSWH.S Pasang Ring Pesarium (Sp) Tindakan Rp 11,000.00 22,000 165,000 16,500 0 0 198,000 49,500 214,500
PE086
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RJRSWH.S USG Obgyn tanpa Print RI (Sp) Tindakan Rp 5,500.00 16,500 66,000 6,600 0 0 88,000 28,600 94,600
PE087
RJRSWH.S USG Obgyn tanpa Print RI (Sp) Tindakan Rp 5,500.00 5,500 66,000 6,600 0 0 77,000 17,600 83,600
PE088
RJRSWH.S USG Intra Vaginal (Sp) Tindakan Rp 16,500.00 16,500 110,000 22,000 0 0 143,000 55,000 165,000
PE089
RJRSWH.S USG Obgyn dengan Print pada ANC (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 90,000
PE090
RJRSWH.S USG Obgyn tanpa Print pada ANC (Sp) Tindakan Rp 0.00 0 0 0 0 0 0 0 75,000
PE091
RJRSWH.S Vaginal Swab (Sp) Tindakan Rp 4,400.00 11,000 22,000 2,200 0 0 37,400 17,600 39,600
PE092
RJRSWH.S Vaginal Toucher/VT (Sp) Tindakan Rp 4,400.00 24,970 55,000 5,500 0 0 84,370 34,870 89,870
PE093
RJRSWH.S Pasang Tampon Sayeba Kondom (Sp) Tindakan Rp 37,400.00 48,400 550,000 55,000 0 0 635,800 140,800 690,800
PE094
RJRSWH.S Luka Bakar (Sp) Tindakan Rp 0.00 132,000 330,000 0 0 0 462,000 132,000 462,000
PE095
RJRSWH.S Biopsi FNAB (Sp) Tindakan Rp 5,500.00 18,150 440,000 44,000 0 0 463,650 67,650 507,650
PE096
RJRSWH.S Buka gips short arm/leg (Sp) Tindakan Rp 5,500.00 5,500 82,500 8,250 0 0 93,500 19,250 101,750
PE097
RJRSWH.S Buka gips long arm/leg (Sp) Tindakan Rp 5,500.00 5,500 165,000 16,500 0 0 176,000 27,500 192,500
PE098
RJRSWH.S Circumsisi (Sp) Tindakan Rp 27,500.00 62,150 440,000 44,000 0 0 529,650 133,650 573,650
PE099
RJRSWH.S Debridement + Hecting (Sp) Tindakan Rp 16,500.00 90,860 275,000 27,500 0 0 382,360 134,860 409,860
PE100
RJRSWH.S Dilatasi phimosis (Sp) Tindakan Rp 11,000.00 55,110 110,000 11,000 0 0 176,110 77,110 187,110
PE101
RJRSWH.S Eksisi/ekstirpasi kecil (Sp) Tindakan Rp 11,000.00 99,000 330,000 33,000 0 0 440,000 143,000 473,000
PE102
RJRSWH.S Eksisi/ekstirpasi sedang (Sp) Tindakan Rp 11,000.00 110,000 385,000 38,500 0 0 506,000 159,500 544,500
PE103
RJRSWH.S Eksisi/ekstirpasi besar (Sp) Tindakan Rp 11,000.00 126,500 440,000 44,000 0 0 577,500 181,500 621,500
PE104
RJRSWH.S Incisi Abses (Sp) Tindakan Rp 11,000.00 55,110 165,000 16,500 0 0 231,110 82,610 247,610
PE105
RJRSWH.S Pasang gips tanpa reposisi short arm/leg Tindakan Rp 5,500.00 5,500 330,000 33,000 0 0 341,000 44,000 374,000
PE106 (Sp)
RJRSWH.S Pasang gips tanpa reposisi long arm/leg Tindakan Rp 5,500.00 5,500 440,000 44,000 0 0 451,000 55,000 495,000
PE107
RJRSWH.S Pasang gips dengan reposisi short arm/leg Tindakan Rp 5,500.00 5,500 550,000 55,000 0 0 561,000 66,000 616,000
PE108 (Sp)
RJRSWH.S Pasang gips dengan reposisi long arm/leg Tindakan Rp 5,500.00 5,500 660,000 66,000 0 0 671,000 77,000 737,000
PE109 (Sp)
RJRSWH.S Pasang Ransel Verban (Sp) Tindakan Rp 5,500.00 5,500 176,000 17,600 0 0 187,000 28,600 204,600
PE110
RJRSWH.S Pasang Skin Traksi (Sp) Tindakan Rp 5,500.00 5,500 220,000 22,000 0 0 231,000 33,000 253,000
PE111
RJRSWH. Pungsi Sendi/Sinopial (Sp) Tindakan Rp 7,700.00 25,080 275,000 27,500 0 0 307,780 60,280 335,280
10/16/22, 9:16 AM Page 32 of 43

SPE112
RJRSWH.S Rawat Luka Kecil RI (Sp) Tindakan Rp 11,000.00 61,930 55,000 5,500 0 0 127,930 78,430 133,430
PE113
RJRSWH.S Rawat Luka Sedang RI (Sp) Tindakan Rp 11,000.00 63,250 110,000 11,000 0 0 184,250 85,250 195,250
PE114
RJRSWH.S Rawat Luka Besar RI (Sp) Tindakan Rp 11,000.00 102,300 165,000 16,500 0 0 278,300 129,800 294,800
PE115
RJRSWH.S Rawat Luka Ekstra Besar RI (Sp) Tindakan Rp 11,000.00 102,300 275,000 27,500 0 0 388,300 140,800 415,800
PE116
RJRSWH.S Rawat Luka Post Op. Ortho Sedang (Sp) Tindakan Rp 5,500.00 61,930 66,000 6,600 0 0 133,430 74,030 140,030
PE117
RJRSWH.S Rawat Luka Post Op. Ortho Berat (Sp) Tindakan Rp 6,600.00 63,250 110,000 11,000 0 0 179,850 80,850 190,850
PE118
RJRSWH.S Rawat Luka Post Op. Ortho Exstra Berat Tindakan Rp 7,700.00 126,830 198,000 19,800 0 0 332,530 154,330 352,330
PE119 (Sp)
RJRSWH.S Reposisi & Pasang Ransel Verban (Sp) Tindakan Rp 5,500.00 5,500 385,000 38,500 0 0 396,000 49,500 434,500
PE120
RJRSWH.S Kemoterapi Grade I (Sp) Tindakan Rp 19,250.00 145,750 550,000 55,000 0 0 715,000 220,000 770,000
PE121
RJRSWH.S Kemoterapi Grade II (Sp) Tindakan Rp 19,250.00 145,750 275,000 27,500 0 0 440,000 192,500 467,500
PE122
RJRSWH05 Administrasi Rawat Jalan Pasien IGD Jasa Pelayanan Rp 2,750.00 19,500 0 2,750 0 0 22,250 25,000 25,000
002
RJRSWH05 Administrasi Rawat Jalan Poli / rujukan Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 15,000
003 penunjang
RJRSWH05 Administrasi Rawat Inap Jasa Pelayanan Rp 16,500.00 44,000 0 49,500 0 0 60,500 110,000 110,000
004
RJRSWH05 Administrasi Pengisian Medical Report Tindakan Rp 0.00 5,500 16,500 5,500 0 0 22,000 11,000 27,500
005 (Asuransi Reimbuserment)
RJRSWH05 Adminstrasi Asuransi Jasa Pelayanan Rp 0.00 0 55,000 0 0 0 55,000 0 55,000
006
RJRSWH05 USG 2D Tindakan Rp 0.00 0 0 0 0 0 0 0 90,000
010
RJRSWH05 Jasa Medis Dokter Umum On Call 1 Konsultasi Rp 0.00 0 82,500 27,500 0 0 82,500 27,500 110,000
011
012
013
RJRSWH05 Jasa Periksa Bidan VK Tindakan Rp 0.00 0 0 22,000 0 0 0 22,000 22,000
014
RJRSWH05 Jasa Perawat/Bidan On Call/Home Care 1 Jasa Pelayanan Rp 0.00 0 0 55,000 0 0 0 55,000 55,000
015
016
017
RJRSWH05 Pasang Infus radiologi Radiologi Rp 5,500.00 25,850 63,250 31,900 0 0 94,600 63,250 126,500
022
RJRSWH05 Tarif Tambahan Injeksi Formalin Tindakan Rp 0.00 0 0 0 0 0 0 0 421,300
023
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RJRSWH05 Injeksi Intraartikulars Tindakan Rp 0.00 0 0 0 0 0 0 0 278,157
024
025
RJRSWH05 Jasa Tindakan Injeksi Formalin On Call 1 Tindakan Rp 0.00 0 0 0 0 0 0 0 1,500,000
026
RJRSWH05 Jasa Tindakan Injeksi Formalin On Call 2 Tindakan Rp 0.00 0 0 0 0 0 0 0 1,700,000
027
RJRSWH05 Aff Drain Tindakan Rp 66,000.00 48,950 11,000 5,500 0 0 125,950 120,450 131,450
028
RJRSWH05 Aff Hecting Tindakan Rp 63,800.00 28,600 0 7,700 0 0 92,400 100,100 100,100
029
RJRSWH05 Aff Infus/Katheter/NGT Tindakan Rp 3,300.00 23,100 0 7,700 0 0 26,400 34,100 34,100
030
RJRSWH05 Aff Tampon Hidung/Telinga/Vagina Tindakan Rp 63,800.00 22,000 0 7,700 0 0 85,800 93,500 93,500
031
RJRSWH05 Diet Via Sonde Jasa Pelayanan Rp 3,300.00 5,500 0 7,700 0 0 8,800 16,500 16,500
032
RJRSWH05 DJJ Jasa Pelayanan Rp 5,500.00 5,830 0 5,500 0 0 11,330 16,830 16,830
033
RJRSWH05 EKG 3 chanel Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 75,000
034
RJRSWH05 EKG 12 chanel Jasa Pelayanan Rp 0.00 0 0 0 0 0 0 0 125,000
035
RJRSWH05 Eksplorasi Luka (Ictum/Snake Bite) Jasa Pelayanan Rp 66,000.00 37,400 11,000 5,500 0 0 114,400 108,900 119,900
036
RJRSWH05 Ekstirpasi Kecil Jasa Pelayanan Rp 71,500.00 110,000 110,000 44,000 0 0 291,500 225,500 335,500
037
RJRSWH05 Ekstirpasi Sedang Jasa Pelayanan Rp 71,500.00 121,000 137,500 71,500 0 0 330,000 264,000 401,500
038
RJRSWH05 Ekstirpasi Besar Jasa Pelayanan Rp 71,500.00 137,500 165,000 99,000 0 0 374,000 308,000 473,000
039
RJRSWH05 Ekstraksi Corpus Alienum Tindakan Rp 66,000.00 25,300 27,500 11,000 0 0 118,800 102,300 129,800
040
RJRSWH05 Ekstraksi Kuku Tindakan Rp 66,000.00 41,250 27,500 11,000 0 0 134,750 118,250 145,750
041
RJRSWH05 Explorasi Post SC Tindakan Rp 5,500.00 78,100 0 16,500 0 0 83,600 100,100 100,100
042
RJRSWH05 Tindakan Fisioterapi Infra Red Tindakan Rp 0.00 8,800 0 13,200 0 0 8,800 22,000 22,000
043
RJRSWH05 Tindakan Fisioterapi SWD Tindakan Rp 0.00 0 0 0 0 0 0 0 50,000
044
RJRSWH05 Tindakan Fisioterapi Traksi Tindakan Rp 0.00 0 0 0 0 0 0 0 100,000
045
RJRSWH05 Tindakan Fisioterapi Ultra Sound Tindakan Rp 0.00 8,800 0 13,200 0 0 8,800 22,000 22,000
046
RJRSWH05 Tindakan Fisioterapi TENS Tindakan Rp 0.00 8,800 0 13,200 0 0 8,800 22,000 22,000
047
RJRSWH05 Tindakan Fisioterapi Exercise/Latihan Tindakan Rp 0.00 8,800 0 13,200 0 0 8,800 22,000 22,000
048
RJRSWH05 Tindakan Fisioterapi Massage Tindakan Rp 0.00 8,800 0 13,200 0 0 8,800 22,000 22,000
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49
RJRSWH05 Tindakan Fisioterapi Breathing Exercise Tindakan Rp 0.00 8,800 0 13,200 0 0 8,800 22,000 22,000
050
RJRSWH05 Fixasi Costae Tindakan Rp 3,300.00 39,600 11,000 13,200 0 0 53,900 56,100 67,100
051
RJRSWH05 Fototerapi 8 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 100,000
052
053
054
RJRSWH05 Imunisasi Dasar Tindakan Rp 0.00 13,750 27,500 13,750 0 0 41,250 27,500 55,000
055
RJRSWH05 Injeksi Delladryl/Xyllo della Tindakan Rp 0.00 5,500 0 5,500 0 0 5,500 11,000 11,000
056
RJRSWH05 Injeksi IM/IV/IC/SC Tindakan Rp 0.00 0 0 0 0 0 0 0 33,000
057
RJRSWH05 Insisi Abses Tindakan Rp 71,500.00 66,550 33,000 11,000 0 0 171,050 149,050 182,050
058
RJRSWH05 Intubasi/Pasang ETT Tindakan Rp 115,500.00 55,000 110,000 27,500 0 0 280,500 198,000 308,000
059
RJRSWH05 Tindakan Injeksi Formalin Tindakan Rp 0.00 0 0 0 0 0 0 0 1,400,000
060
RJRSWH05 Tindakan Oral Hygine Tindakan Rp 44,550.00 0 0 11,000 0 0 44,550 55,550 55,550
061
RJRSWH05 Irigasi / Spoeling mata/Telinga Tindakan Rp 11,000.00 24,200 11,000 5,500 0 0 46,200 40,700 51,700
062
RJRSWH05 Ekstubasi (aff intubasi) Tindakan Rp 0.00 23,100 33,000 0 0 0 56,100 23,100 56,100
063
RJRSWH05 Pemakaian C-PAP Tindakan Rp 0.00 0 0 0 0 0 0 0 250,000
064
RJRSWH05 Pemakaian O2 NIP perjam (ICU) Tindakan Rp 0.00 126,500 0 0 0 0 126,500 126,500 126,500
065
RJRSWH05 Kumbah Lambung Tindakan Rp 11,000.00 26,950 17,600 11,000 0 0 55,550 48,950 66,550
066
RJRSWH05 Flowcart - Rp 7,700.00 0 0 0 0 0 7,700 7,700 7,700
067
RJRSWH05 Lavement Tindakan Rp 16,500.00 44,550 0 22,000 0 0 61,050 83,050 83,050
068
RJRSWH05 Rawat Luka Bakar 1 (<5%) Perawatan Rp 71,500.00 57,200 0 11,000 0 0 128,700 139,700 139,700
069
RJRSWH05 Pemakaian Continus Suction Pump(WSD) Tindakan Rp 176,000.00 0 0 0 0 0 176,000 176,000 176,000
070
RJRSWH05 Rawat Luka Bakar 2 (5 - 15%) Perawatan Rp 71,500.00 91,850 22,000 22,000 0 0 185,350 185,350 207,350
071
RJRSWH05 Monitor per 1 jam Jasa Pelayanan Rp 27,500.00 0 0 0 0 0 27,500 27,500 27,500
072
RJRSWH05 Rawat Luka Bakar 3 (15 - 20%) Perawatan Rp 77,000.00 110,000 66,000 27,500 0 0 253,000 214,500 280,500
073
RJRSWH05 Pemeriksaan dan Konsultasi VCT Konsultasi Rp 5,500.00 5,500 110,000 16,500 0 0 121,000 27,500 137,500
074
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RJRSWH05 Rawat Luka Bakar Luas > 20% Perawatan Rp 82,500.00 132,000 110,000 33,000 0 0 324,500 247,500 357,500
075
RJRSWH05 Rawat Luka Lecet 1 (<5%) Perawatan Rp 66,000.00 26,400 0 5,500 0 0 92,400 97,900 97,900
076
RJRSWH05 Pasang Infus anak/bayi Sulit (on call) Tindakan Rp 5,500.00 42,240 110,000 11,000 0 0 157,740 58,740 168,740
077
RJRSWH05 Rawat Luka Lecet 2 (5 - 10%) Perawatan Rp 71,500.00 71,500 11,000 11,000 0 0 154,000 154,000 165,000
078
RJRSWH05 VT (Bidan) Tindakan Rp 2,200.00 24,970 0 14,300 0 0 27,170 41,470 41,470
079
RJRSWH05 Rawat Luka Lecet 3 ( > 10%) Perawatan Rp 71,500.00 91,850 27,500 16,500 0 0 190,850 179,850 207,350
080
RJRSWH05 Visum Et Repertum Jasa Pelayanan Rp 8,250.00 5,500 33,000 8,250 0 0 46,750 22,000 55,000
081
RJRSWH05 Hecting 1 (HT<5) Tindakan Rp 88,000.00 45,650 11,000 11,000 0 0 144,650 144,650 155,650
082
RJRSWH05 Tranfusi Tindakan Rp 11,000.00 5,500 0 11,000 0 0 16,500 27,500 27,500
083
RJRSWH05 Hecting 2 (HT 5-10) Tindakan Rp 93,500.00 107,250 22,000 11,000 0 0 222,750 211,750 233,750
084
RJRSWH05 Tindakan Suction Tindakan Rp 7,700.00 6,600 7,700 5,500 0 0 22,000 19,800 27,500
085
RJRSWH05 Hecting 3 (HT > 10) Tindakan Rp 99,000.00 153,450 33,000 16,500 0 0 285,450 268,950 301,950
086
RJRSWH05 Test Lakmus Tindakan Rp 0.00 5,500 0 5,500 0 0 5,500 11,000 11,000
087
RJRSWH05 Nebulizer Tindakan Rp 26,070.00 6,050 0 16,500 0 0 32,120 48,620 48,620
088
RJRSWH05 Surface Cooling Tindakan Rp 2,200.00 5,500 0 7,700 0 0 7,700 15,400 15,400
089
RJRSWH05 NST Tindakan Rp 33,000.00 28,600 0 27,500 0 0 61,600 89,100 89,100
090
RJRSWH05 Skin Test Tindakan Rp 2,200.00 2,750 3,300 2,750 0 0 8,250 7,700 11,000
091
RJRSWH05 Observasi IGD per jam Tindakan Rp 11,000.00 0 11,000 5,500 0 0 22,000 16,500 27,500
092
RJRSWH05 Sceren Tindakan Rp 3,300.00 26,400 0 7,700 0 0 29,700 37,400 37,400
093
RJRSWH05 Observasi VK < 12 Jam Tindakan Rp 22,000.00 104,500 55,000 30,250 0 0 181,500 156,750 211,750
094
RJRSWH05 Rumple Leed Tindakan Rp 2,200.00 0 0 3,300 0 0 2,200 5,500 5,500
095
RJRSWH05 Observasi VK > 12 Jam -< 24 Jam Tindakan Rp 55,000.00 308,000 110,000 49,500 0 0 473,000 412,500 522,500
096
RJRSWH05 Resusitasi Bayi Tindakan Rp 0.00 0 0 0 0 0 0 0 120,000
097
RJRSWH05 Pasang Guedel Tindakan Rp 3,300.00 5,500 5,500 2,200 0 0 14,300 11,000 16,500
098
RJRSWH05 Resusitasi Lanjutan Tindakan Rp 27,500.00 44,550 82,500 55,000 0 0 154,550 127,050 209,550
099
RJRSWH05 Pasang Infus Akses V. Umbilical Tindakan Rp 11,000.00 55,990 27,500 16,500 0 0 94,490 83,490 110,990
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00
RJRSWH05 Resusitasi Dasar Tindakan Rp 5,500.00 44,550 11,000 5,500 0 0 61,050 55,550 66,550
101
RJRSWH50 Pasang Infus Anak/Bayi Tindakan Rp 5,500.00 42,240 16,500 11,000 0 0 64,240 58,740 75,240
102
RJRSWH50 Rectal/ Per Vaginam Supp Tindakan Rp 2,200.00 7,150 0 3,300 0 0 9,350 12,650 12,650
103
RJRSWH50 Pasang Infus Dewasa Tindakan Rp 5,500.00 25,850 11,000 5,500 0 0 42,350 36,850 47,850
104
RJRSWH50 Rectal Toucher/Colok Dubur Tindakan Rp 2,200.00 20,900 11,000 3,300 0 0 34,100 26,400 37,400
105
RJRSWH50 Pasang Katheter Tindakan Rp 8,250.00 28,050 22,000 13,750 0 0 58,300 50,050 72,050
106
RJRSWH50 Rawat Luka Diabetic 3 / Post Op. Extra Tindakan Rp 71,500.00 134,750 33,000 22,000 0 0 239,250 228,250 261,250
107
RJRSWH50 Pasang NGT Tindakan Rp 5,500.00 24,750 13,750 8,250 0 0 44,000 38,500 52,250
108
RJRSWH50 Rawat Luka Diabetic 2 / Post Op. Besar Tindakan Rp 68,750.00 69,850 19,250 11,000 0 0 157,850 149,600 168,850
109
RJRSWH50 Pasang Ring Pesarium Tindakan Rp 0.00 33,000 0 82,500 0 0 33,000 115,500 115,500
110
RJRSWH50 Rawat Luka Diabetic 1 / Post Op. Sedang Tindakan Rp 66,000.00 67,650 13,750 8,250 0 0 147,400 141,900 155,650
111
RJRSWH50 Pasang Ransel Verban Tindakan Rp 5,500.00 5,500 22,000 11,000 0 0 33,000 22,000 44,000
112
RJRSWH50 Rawat luka berat Tindakan Rp 0.00 0 0 0 0 0 0 0 100,000
113
RJRSWH50 Pasang spalk kecil 1 bilah Tindakan Rp 2,200.00 37,950 5,500 3,300 0 0 45,650 43,450 48,950
114
RJRSWH50 Rawat luka sedang Tindakan Rp 0.00 0 0 0 0 0 0 0 80,000
115
RJRSWH50 Pasang spalk panjang 2 bilah Tindakan Rp 3,300.00 126,390 11,000 7,700 0 0 140,690 137,390 148,390
116
RJRSWH50 Rawat luka ringan Tindakan Rp 0.00 0 0 0 0 0 0 0 60,000
117
RJRSWH50 Pasang spalk sedang 2 bilah Tindakan Rp 3,300.00 70,730 7,700 5,500 0 0 81,730 79,530 87,230
118
RJRSWH50 Perawatan Infus Tindakan Rp 0.00 25,850 0 5,500 0 0 25,850 31,350 31,350
119
RJRSWH50 Pasang Tampon Hidung Anterior / Telinga Tindakan Rp 5,500.00 27,500 16,500 5,500 0 0 49,500 38,500 55,000
120
RJRSWH50 Pemakaian O2 Head Box per 1 jam Tindakan Rp 0.00 26,070 0 0 0 0 26,070 26,070 26,070
121
RJRSWH50 Pasang Tampon Hidung Posterior Tindakan Rp 7,700.00 42,350 33,000 14,300 0 0 83,050 64,350 97,350
122
RJRSWH50 Pemakaian O2 Face Masker per 1 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 17,380
123
RJRSWH50 Pasang Tampon Vagina Tindakan Rp 5,500.00 40,150 13,750 8,250 0 0 59,400 53,900 67,650
124
RJRSWH50 Pemakaian O2 Kanul per 1 jam Tindakan Rp 0.00 8,690 0 0 0 0 8,690 8,690 8,690
125
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RJRSWH50 Pemakaian Collar Brace Tindakan Rp 3,300.00 5,500 7,700 5,500 0 0 16,500 14,300 22,000
126
RJRSWH50 Pemakaian Collar Brace (incl. sewa Collar Tindakan Rp 3,300.00 165,000 7,700 5,500 0 0 176,000 173,800 181,500
127 Brace)
RJRSWH50 PASIEN MCU TREADMIL Tindakan Rp 0.00 0 0 0 0 0 0 0 550,000
17
RJRSWH50 PASIEN UMUM TREADMIL Tindakan Rp 0.00 0 0 0 0 0 0 0 650,000
174
RJRSWH50 Syring Pump per 1 jam Tindakan Rp 0.00 0 0 0 0 0 0 0 25,000
175
RJRSWH50 Pemerksaan dan Konsultasi VCT Tindakan Rp 5,500.00 5,500 110,000 16,500 0 0 121,000 27,500 137,500
176
RJRSWH50 Tindakan Injeksi Intraartikulars (umum) Tindakan Rp 92,125.00 48,532 137,500 0 0 0 278,157 140,657 278,157
177
RJRSWH50 Tarif Kerohanian Tindakan Rp 22,000.00 0 220,000 0 0 0 242,000 22,000 242,000
178
RJRSWH50 Konsultasi dokter umum IGD dr. Bagus Gde Konsultasi Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
179 Ariesta Darmahendra
RJRSWH50 Konsultasi dokter umum IGD dr. I Kadek Konsultasi Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
180 Oka Widiana
RJRSWH50 Konsultasi dokter umum IGD dr. Kadek Mia Konsultasi Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
181 Risdayanthi
RJRSWH50 Konsultasi dokter umum IGD dr. Ni Nyoman Konsultasi Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
182 Putri Widyastiti
RJRSWH50 Konsultasi dokter umum IGD dr. Ida Ayu Cili Konsultasi Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
183 Swesis
RJRSWH50 Konsultasi dokter umum IGD dr. I Gusti Ayu Konsultasi Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
184 Ria Mardewi
RJRSWH50 Konsultasi dokter umum IGD dr. Pande Konsultasi Rp 22,000.00 0 22,000 11,000 0 0 44,000 33,000 55,000
185 Nyoman Tri Mas Saptini
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
186 Ngurah Darmaja, Sp.OG
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Wayan Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
187 Sudania Anggra, Sp.OG
RJRSWH50 Konsultasi dokter spesialis (poli) dr. Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
188 Shely Prihastuti Rudy, Sp.PD
RJRSWH50 Konsultasi dokter spesialis (poli) dr. W Giri Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
189 Putra Semaradana, M.Biomed, Sp.PD
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Gusti Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
190 Ketut Oka Nurjaya, Sp.A
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
191 Nyoman Putra Arcana, Sp.A
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
192 Oka Novi Purnawan, Sp.A
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Putu Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
193 Gede Fajar Maha Yasa, Sp.B
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
194 Adipta Adiputra, Sp.B
RJRSWH50 Konsultasi dokter spesialis (poli) dr. Pande Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
195 Made Krisna Ekassiana, Sp.B
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Dewa Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
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96 Made Sudiatmika, Sp.THT
RJRSWH50 Konsultasi dokter spesialis (poli) dr. Made Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
197 Adhy Putra Widyartha, Sp.THT-KL
198 Sudiasa, Sp.THT
RJRSWH50 Konsultasi dokter spesialis (poli) dr. I Gde Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
199 Agus Shuarsedana Putra, Sp.An
200 Agung Wirahadi Sanjaya, Sp.OT
RJRSWH50 Konsultasi dokter spesialis (poli) dr.Farida Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
201 Noor, Sp.S
RJRSWH50 Konsultasi dokter spesialis (poli) dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
202 Wayan Nurlina Ekasari, M.Biomed, Sp.S
203 Nyoman Gede Sudana, M.Sc., Sp.PK (K)
RJRSWH50 Konsultasi dokter spesialis (poli) dr. A A Istri Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
204 Murwita Prasanti Agung, Sp.JP
RJRSWH50 Konsultasi dokter spesialis (poli) dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
205 Widastuti Dharmapala, Sp. Rad
206 Komang Gede Dwi Maya Rustadi, Sp.KFR
207 Nyoman Sura Oka, Sp.Kj
208 Putu Adityo Ananta Ardika, Sp.M
RJRSWH50 Konsultasi dokter spesialis (poli) dr. Gede Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
209 Sasmika Suwandi, Sp.P
RJRSWH50 Konsultasi dokter spesialis (poli) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
210 Komang Triana AK.
RJRSWH50 Konsultasi dokter spesialis (poli) drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 120,000
211 Tjokorda Istri Pramiari S
RJRSWH50 Konsultasi dokter spesialis by phone dr. I Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
212 Gusti Ngurah Darmaja, Sp.OG
213 Wayan Sudania Anggra, Sp.OG
RJRSWH50 Konsultasi dokter spesialis by phone dr. Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
214 Putu Shely Prihastuti Rudy, Sp.PD
RJRSWH50 Konsultasi dokter spesialis by phone dr. W Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
215 Giri Putra S, M.Biomed, Sp.PD
216 Gusti Ketut Oka Nurjaya, Sp.A
218 Gede Oka Novi Purnawan, Sp.A
219 Putu Gede Fajar Maha Yasa, Sp.B
220 Made Adipta Adiputra, Sp.B
221 Pande Made Krisna Ekassiana, Sp.B
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222 Dewa Made Sudiatmika, Sp.THT
223 Made Adhy Putra Widyartha, Sp.THT-KL
224 Putu Sudiasa, Sp.THT
225 Gde Agus Shuarsedana Putra, Sp.An
226 Putu Agung Wirahadi Sanjaya, Sp.OT
RJRSWH50 Konsultasi dokter spesialis by phone Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
227 dr.Farida Noor, Sp.S
RJRSWH50 Konsultasi dokter spesialis by phone dr. Ni Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
228 W Nurlina Ekasari, M.Biomed, Sp.S
RJRSWH50 Konsultasi dokter spesialis by phone dr. A A Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
230 Istri Murwita Prasanti Agung, Sp.JP
233 Pande Nyoman Sura Oka, Sp.Kj
234 Pande Putu Adityo Ananta Ardika, Sp.M
235 Gede Sasmika Suwandi, Sp.P
RJRSWH50 Konsultasi dokter spesialis by phone drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
RJRSWH50 Konsultasi dokter spesialis by phone drg. Konsultasi Rp 0.00 0 0 0 0 0 0 0 100,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. I Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
245 Gusti Ngurah Darmaja, Sp.OG
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. Putu Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. W Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp)dr. I Gusti Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp)dr. I Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
251 Gede Oka Novi Purnawan, Sp.A
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. I Putu Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
253 Made Adipta Adiputra, Sp.B
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
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255 Dewa Made Sudiatmika, Sp.THT
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. Made Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
257 Sudiasa, Sp.THT
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. I Gde Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr.Farida Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
260 Noor, Sp.S
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. Ni Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. A A Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
266 Pande Nyoman Sura Oka, Sp.Kj
267 Pande Putu Adityo Ananta Ardika, Sp.M
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) dr. Gede Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) drg. Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul Antar Dokter Spesialis (Sp) drg. Konsultasi Rp 0.00 0 165,000 0 0 0 165,000 0 165,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Gusti Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. Putu Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. Wayan Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Gusti Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Gede Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
277 Oka Novi Purnawan, Sp.A
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Putu Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Made Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
10/16/22, 9:16 AM Page 41 of 43

RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. Pande Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Dewa Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. Made Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
283 Sudiasa, Sp.THT
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. I Gde Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr.Farida Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
286 Noor, Sp.S
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. Ni Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. A A Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) dr. Gede Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) drg. Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul di atas Meja Operasi (Sp) drg. Konsultasi Rp 0.00 0 550,000 0 0 0 550,000 0 550,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Gusti Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Wayan Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
298 Sudania Anggra, Sp.OG
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Putu Shely Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
299 Prihastuti Rudy, Sp.PD
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Wayan Giri Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
300 Putra S, M.Biomed, Sp.PD
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Gusti Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Nyoman Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
302 Putra Arcana, Sp.A
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Gede Oka Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
303 Novi Purnawan, Sp.A
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Putu Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Made Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
10/16/22, 9:16 AM Page 42 of 43

RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Pande Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Dewa Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Made Adhy Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
308 Putra Widyartha, Sp.THT-KL
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Putu Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
309 Sudiasa, Sp.THT
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Gde Agus Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
310 Shuarsedana Putra, Sp.An
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Putu Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr.Farida Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
312 Noor, Sp.S
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Ni Wayan Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
313 Nurlina Ekasari, M.Biomed, Sp.S
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Nyoman Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
314 Gede Sudana, M.Sc., Sp.PK (K)
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. A A Istri Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
315 Murwita Prasanti Agung, Sp.JP
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Widastuti Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
316 Dharmapala, Sp. Rad
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. I Komang Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
317 Gede Dwi Maya Rustadi, Sp.KFR
RJRSWH50 Konsul Via Telepon (RJ) (Sp) dr. Gede Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
RJRSWH50 Konsul Via Telepon (RJ) (Sp) drg. Komang Konsultasi Rp 0.00 0 44,000 0 0 0 44,000 0 44,000
321 Triana AK.
RJRSWH50 Konsul Via Telepon (RJ) (Sp) drg. Tjokorda Konsultasi Rp 0.00 0 0 0 0 0 0 0 44,000
322 Istri Pramiari S
10/16/22, 9:16 AM Page 43 of 43

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