Lampiran 1

LAMPIRAN I
PERATURAN GUBERNUR NUSA TENGGARA BARAT

NOMOR 31 TAHUN 2018
TENTANG TARIF PELAYANAN KESEHATAN PADA RUMAH SAKIT H.L. MANAMBAI ABDUL KADIR PROVINSI
NUSA TENGGARA BARAT
TARIF LAYANAN PELAYANAN KESEHATAN BLUD RSMA
Jasa
NO URAIAN Jasa Sarana TARIF KET
Pelayanan
(1) (2) (3) (4) (5) (6)
I. PENDAFTARAN, PEMERIKSAAN, TINDAKAN DAN AKOMODASI
A PENDAFTARAN
1 Administrasi sistem informasi 1,000 9,000 10,000
2 Berkas RM Rawat Jalan / Kartu Pasien 2,000 10,000 12,000
3 Berkas RM Rawat Inap 2,000 15,000 17,000
B PEMERIKSAAN POLIKLINIK
1 Pemeriksaan poliklinik oleh dokter umum 15,000 5,000 20,000
2 Pemeriksaan poliklinik oleh dokter spesialis 25,000 10,000 35,000
C AKOMODASI
Biaya Kamar
1 VVIP 55,000 375,000 430,000
2 VIP A 42,500 232,500 275,000
3 VIP B 42,500 207,500 250,000
3 Kelas I 35,000 145,000 180,000
4 Kelas II 28,000 72,000 100,000
5 Kelas III 12,000 43,000 55,000
6 ICU/NICU 42,500 200,000 242,500
7 Ruang Isolasi 30,000 120,000 150,000
D VISITE DOKTER SPESIALIS

1 VVIP 60,000 10,000 70,000
2 VIP 50,000 8,000 58,000
3 Kelas I, Kelas II, Kelas III 40,000 10,000 50,000
E VISITE DOKTER UMUM

1 VVIP 35,000 10,000 45,000
2 VIP 30,000 8,000 38,000
3 Kelas I, Kelas II, Kelas III 20,000 5,000 25,000
Page 1 of 53
Jasa
Pelayanan
F POLI EKSEKUTIF/KHUSUS
1 - Servis Layanan 12,500 7,500 20,000
2 - Pemeriksaan dan Konsultasi dokter 35,000 12,500 47,500
3 - Konsultasi antar SMF 22,500 12,500 35,000
G GENERAL CHECK UP
Untuk tarif layanan pemeriksaan General check up disesuaikan dengan permintaan klien/ pihak yang
mengajukan permintaan Medical Check up dan diperhitungkan tarif layanan berdasarkan jenis, ketegori
dan tindakan layanan yang dipilih ;
H SURAT KETERANGAN DOKTER

1 Surat Keterangan sehat 10,000 15,000 25,000
2 Surat Keterangan untuk asuransi umum 10,000 15,000 25,000
3 Surat Keterangan Formalin dengan Masa Pengawetan/Liter 10,000 15,000 25,000
4 Visum Et Refertum 10,000 15,000 25,000
II. PELAYANAN RAWAT JALAN
1 POLI KLINIK TUMBUH KEMBANG
A IMUNISASI DIWAJIBKAN (PPI)

1 BCG 5,000 11,500 16,500
2 DPT - Hb 5,000 11,500 16,500
3 Hepatitis B 5,000 11,500 16,500 Semua item Imunisasi ,
tidak termasuk biaya
4 Polio 5,000 11,500 16,500 Vaksin
5 TT 5,000 11,500 16,500
6 Campak 5,000 11,500 16,500
7 Pengukuran Vital Sign 2,000 1,000 3,000
B PSIKOLOGI TEST
1 - Tes Perkembangan Anak (DDST) pasien baru 20,000 15,000 35,000
2 - Tes Perkembangan Anak (DDST) pasien lama 15,000 15,000 30,000
C SCREENING
1 - Tes Lambat Belajar 10,000 13,000 23,000
2 - Tes Hiperaktif & Gangguan Konsentrasi 10,000 13,000 23,000
3 - Tes Autisme 15,000 13,000 28,000
D TES INTELEGENSI (IQ)

1 - Tes Intelegensia Anak 15,000 20,000 35,000
2 - Tes Intelegensia Remaja 20,000 20,000 40,000
E TES KEPRIBADIAN
1 - Tes Kepribadian Anak 20,000 20,000 40,000
2 - Tes Kepribadian Remaja 25,000 20,000 45,000
F TES MINAT BAKAT

- Tes Minat Bakat Dewasa / Anak 25,000 20,000 45,000
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Jasa
Pelayanan
G KONSELING PSIKOLOGI (ANAK, REMAJA & DEWASA) 20,000 25,000 45,000
H TERAPI WICARA 20,000 25,000 45,000
I TERAPI EDUKASI 20,000 25,000 45,000
J TERAPI OKUPASI 20,000 25,000 45,000
2. POLIKLINIK PENYAKIT ANAK

1 BMP(lumbal punksi) 35,000 49,000 84,000 Tidak termasuk spuit
2 Therapi Inhalasi tanpa obat / Nebulizer 14,000 10,000 24,000
3 ECG 25,000 35,000 60,000
4 RRO 10,000 14,000 24,000
5 Pemeriksaan pasien autisme 15,000 13,000 28,000
6 Pemeriksaan Vital Sign 2,000 1,000 3,000
3. POLIKLINIK BEDAH UMUM

1 Rawat Luka
a. Kecil (< 5 cm) 7,000 11,000 18,000
b. Sedang (5-10 cm) 10,000 15,000 25,000
c. Besar (10-20 cm) 17,500 40,000 57,500
d. Khusus (> 20 cm) 35,000 45,000 80,000
2 Jahit luka / Repair Jahitan

- Kecil (< 5 Jahitan) 25,000 35,000 60,000
- Sedang (5 s/d 10 Jahitan) 35,000 45,000 80,000
- Besar (10 -20 Jahitan) 40,000 55,000 95,000
- Khusus (>20 Jahitan) 50,000 70,000 120,000
3 Angkat Jahitan
- Kecil (< 5Jahitan) 8,000 12,000 20,000
- Sedang (5s/d 10 Jahitan) 10,000 15,000 25,000
- Besar (10 - 20 Jahitan) 20,000 25,000 45,000
- Khusus >20 25,000 35,000 60,000
- Pemasangan Volley Cateter 10,000 25,000 35,000
- GFF NGT / Cateter Urin 30,000 30,000 60,000
Debbridement dan Neorotomy
- Rawat Luka Kecil 10,000 15,000 25,000
- Rawat Luka Sedang 24,000 26,000 50,000
Rawat Luka Besar 60,000 40,000 100,000
4 Rectal Toucher 10,000 17,000 27,000
5 Anoskopi 12,000 20,000 32,000
6 Coller And Cup 10,000 17,000 27,000
7 Angkat Wire 12,000 20,000 32,000
8 Nail Ekstrasi 17,000 13,000 30,000
9 Rozer Plasty 65,000 100,000 165,000
10 Incisi Abses 50,000 47,500 97,500
11 Eksisi 40,000 60,000 100,000
12 Ekstirpasi 50,000 70,000 120,000
13 Circumsisi 250,000 150,000 400,000
14 Biopsi 70,000 105,000 175,000
15 Tindik 5,000 5,000 10,000
16 Lobulo Plasty 70,000 115,000 185,000
17 Exploarasi Corpus alienum 50,000 70,000 120,000
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Jasa
Pelayanan
18 Aspirasi 10,000 15,000 25,000

19 Bouginasi 10,000 15,000 25,000
20 Spooling dawer cateter 10,000 14,000 24,000
21 Debridment Luka 35,000 55,000 90,000
Tidak biaya termasuk
22 Injeksi Keloid / Kenacord / (IC) 5,000 15,000 20,000 Obat
23 Necrotomy 50,000 70,000 120,000

24 Amputasi 1 Jari 50,000 70,000 120,000
4. POLIKLINIK ORTHOPEDI
1 Rawat Luka
a. Kecil (< 5 cm) 7,000 11,000 18,000
b. Sedang (5-10 cm) 10,000 15,000 25,000
c. Besar (10-20 cm) 17,500 40,000 57,500
d. Khusus (> 20 cm) 35,000 45,000 80,000
- Kecil (< 5 Jahitan) 25,000 35,000 60,000
- Besar (10 - 20 jahitan) 40,000 55,000 95,000
- Khusus (>20 Jahitan) 50,000 70,000 120,000
3 Angkat Jahitan
- Kecil (< 5 Jahitan) 8,000 12,000 20,000
- Besar (10 - 20 Jahitan) 20,000 25,000 45,000
- Khusus > 20 25,000 35,000 60,000
4 Gips Kecil Anak * 25,000 15,000 40,000
5 Gips Kecil Dewasa* 30,000 42,000 72,000
6 Gips Sedang Anak* 35,000 52,000 87,000 Tidak termasuk biaya
7 Gips Sedang Dewasa* 42,000 83,000 125,000 Gipsona
8 Gips Besar Anak* 56,000 83,000 139,000

9 Gips Besar Dewasa* 70,000 104,000 174,000
10 Buka Gips 20,000 28,000 48,000
11 Ransel verband Anak 50,000 69,000 119,000
12 Ransel verband Dewasa 70,000 104,000 174,000
13 Injeksi Arthtritis / articuler* 33,000 15,000 48,000 Obat
14 Body cast* 140,000 207,000 347,000
15 Hemi Spica* 140,000 207,000 347,000
16 Necrotomy Ex Op 14,000 21,000 35,000
5. POLIKLINIK UROLOGI
1 Pasang Fowley Cateter* 10,000 25,000 35,000
2 Pasang Cateter Logam* 20,000 28,000 48,000
3 Tindakan Blast Punctie 60,000 50,000 110,000
4 Tindakan Blast Pistel / Cytostom 50,000 70,000 120,000
5 Ekstraksi batu uretra dengn GA di OK 1,150,000 1,725,000 2,875,000
6 Ekstraksi batu uretra anterior 50,000 70,000 120,000
7 Rawat Luka -
a. Kecil (< 5 cm) 7,000 11,000 18,000
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Jasa
Pelayanan
b. Sedang (5-10 cm) 10,000 15,000 25,000

c. Besar (10-20 cm) 17,500 40,000 57,500
d. Khusus (> 20 cm) 35,000 45,000 80,000
8 Incisi Abses 50,000 47,500 97,500
9 Sitostomi 210,000 315,000 525,000
10 Buginasi / Dilatasi Uretra 50,000 70,000 120,000
6. POLIKLINIK GIGI DAN MULUT

A TINDAKAN PENCABUTAN GIGI
1 Pencabutan Gigi Susu
- Chlor Etyl 15,500 48,000 63,500
- Injeksi 25,000 64,000 89,000
2 Pencabutan Gigi Susu Perforasi Akar 20,000 73,000 93,000
3 Pencabutan Gigi Mesiodens 48,000 98,000 146,000
4 Pencabutan Gigi Eksosterm 3 48,000 98,000 146,000
5 Pencabutan Gigi Permanen Dengan Akar Tunggal 46,000 98,000 144,000
6 Pencabutan Gigi Permanen Dengan Akar Ganda 52,000 105,000 157,000
7 Pencabutan Gigi Dengan Komplikasi 55,000 120,000 175,000
8 Pencabutan Sisa Akar Yang Tertinggal 46,000 98,000 144,000
B TINDAKAN PENAMBALAN GIGI

1 Perawatan Pulpa 30,000 98,000 128,000
2 Perawatan Pulpektomy
a. Saluran Akar tunggal 25,000 75,000 100,000
b. Saluran akar ganda 35,000 110,000 145,000
c. One Visit Saluran Akar Tunggal 30,000 87,000 117,000
d. One Visit Saluran akar ganda 41,000 127,000 168,000
3 Pengisian Saluran Akar Tunggal 41,000 127,000 168,000
4 Pengisian Saluran Akar Ganda 46,000 150,000 196,000
5 Tambalan Sinar
a. Kecil 35,000 110,000 145,000
b. Sedang 40,000 120,000 160,000
c. Besar 50,000 133,000 183,000
d. Venneer direct / Besar Sekali 52,000 230,000 282,000
6 Penambalan Amalgam 52,000 92,000 144,000
7 Perawatan saluran akar Endo Intrakanal
a. Saluran akar tunggal 25,000 75,000 100,000
b. Saluran akar ganda 35,000 110,000 145,000
c. One Visit Saluran Akar Tunggal 30,000 87,000 117,000
d. One Visit Saluran akar ganda 50,000 127,000 177,000
8 Penambalan Glass Lonomer
a. Kecil 35,000 98,000 133,000
b. Sedang 41,000 110,000 151,000
c. Besar 50,000 121,000 171,000
9 Penambalan Eugenol, ChKM, depupil
a. Devitalisasi, sterilisasi SA, Pulp Capping 25,000 75,000 100,000
b. Open Bur / Eksterpatie dgn lokal anaestesi 20,000 25,000 45,000
10 Penambalan Eugenol Cavit 25,000 75,000 100,000
11 Pin Screw + Sementasi 87,000 202,000 289,000
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Jasa
Pelayanan
C TINDAKAN PENGOBATAN / PERAWATAN JARINGAN PENYANGGA GIGI

1 Pembersihan karang gigi per regio 25,000 95,000 120,000
2 Perawatan Pocet Periodental 35,000 111,000 146,000
3 Gingivektomy per regio 50,000 98,000 148,000
4 Eksterpasi Mucocele / epulis 50,000 98,000 148,000
D PEMBUATAN PROTESA / GIGI PALSU

1 Gigi Tiruan per rahang
a. Satu gigi pertama 230,000 437,000 667,000
b. Dua gigi 290,000 518,000 808,000
c. Tiga gigi 345,000 633,000 978,000
d. Empat gigi 403,000 690,000 1,093,000
e. Lima gigi 460,000 805,000 1,265,000
biaya adalah paket dari
f. Full per rahang 575,000 1,150,000 1,725,000 pengukuran,
2 Reparasi Plat Patah pemasangan,dan kontrol
a. Reparasi plat patah full 58,000 184,000 242,000
b. Reparasi plat patah parsial 50,000 156,000 206,000
3 Reparasi Penambahan gigi per Rahang
a. Satu gigi pertama 104,000 299,000 403,000
b. Penambahan gigi berikutna 144,000 386,000 530,000
4 Rebasing / relining per rahang 70,000 230,000 300,000
5 Orthodontic
a. Alat orthodontic 104,000 334,000 438,000
b. Aktivasi ortho lepasan 25,000 52,000 77,000 paket dari cetak sampai
pemasangan
c. Reparasi clamer (kawatortho) / rahang 35,000 87,000 122,000
6 Orthodontic cekat RA / RB 290,000 1,208,000 1,498,000
7 Perawatan / kontrol Orthodentic ceat RA / RB 30,000 75,000 105,000
E TINDAKAN BEDAH MULUT

1 Odontectomy 100,000 190,000 290,000
2 Operculectom 58,000 138,000 196,000

3 Inter dental wiring / rahang 81,000 207,000 288,000
4 Inter maxilla wiring / rahang 64,000 150,000 214,000
5 Replantasi gigi 64,000 150,000 214,000
6 Alveolectomy / debridement per regio 64,000 150,000 214,000
7 Enukleasi kista (lokal anestesi) 50,000 115,000 165,000
8 Incisi / Eksisi abses 50,000 47,500 97,500
9 Pemeriksaan komplikasi post op / kontrol 18,000 46,000 64,000
10 Pemeriksaan dan perbaikan posisi IDW / IMW 23,000 46,000 69,000

11 Pembukaan IDW / Rahang 23,000 46,000 69,000
12 Pembukaan IMW 23,000 46,000 69,000
13 Dry Socket / curetage per gigi 29,000 75,000 104,000
14 Extirpasi mucocelle / epulis 41,000 92,000 133,000
15 Aff heacting epulis / mucocelle 12,000 23,000 35,000
16 Grinding 12,000 23,000 35,000
F PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dengan LOGAM

1 Jembatan Adoro porcelain fusi metal 288,000 748,000 1,036,000
paket dari pencetakan,
2 Inlay porcelain fusi metal 173,000 518,000 691,000 pemasangan,dan kontrol
3 Uplay porcelain fusi metal 173,000 518,000 691,000
G PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY tanpa LOGAM

1 Jembatan/bridge full porcelain 368,000 1,300,000 1,668,000
2 Inlay / Uplay full porcelain 322,000 920,000 1,242,000
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Jasa
Pelayanan
7. POLIKLINIK PENYAKIT KULIT DAN KELAMIN

1 Elektro fulgurasi / Elektro Couter :
a. Seboroik Keratosis :
- Kecil 26,000 38,000 64,000
- Sedang 38,000 57,000 95,000
- Besar 60,000 90,000 150,000
b. Skin Tag ;
- Kecil 25,000 38,000 63,000
- Sedang 26,000 66,000 92,000
- Besar 69,000 104,000 173,000
c. Kondyloma Akuminata :
- Kecil 44,000 66,000 110,000
- Sedang 69,000 104,000 173,000
- Besar 115,000 173,000 288,000
2 Ekstraksi Komedo 21,000 32,000 53,000
3 Enukleasi 19,000 28,000 47,000
4 Solarium / Photo Therapi 8,000 12,000 20,000
5 Excisi Wajah 95,000 142,000 237,000
6 Excisi Non wajah 58,000 87,000 145,000
7 Test Tempel / Patch Test Standard 81,000 121,000 202,000
8 Test Tempel Standard Kosmetik 81,000 121,000 202,000
9 Dermabrasi / Microdemabrasi 72,000 107,000 179,000
10 Rekonstruki Kulit 115,000 10,000 125,000
11 Heating Aff 15,000 10,000 25,000
12 Incisi Abses 50,000 47,500 97,500
13 Swab : Vagina, Cervix, Fornik 11,000 16,000 27,000
14 Swab : Uretra 11,000 16,000 27,000
15 Swab discar lesi 11,000 16,000 27,000
16 Kerokan Kulit, Kuku, Rmbut 9,000 13,000 22,000
17 Kultur 20,000 30,000 50,000
18 Ganti Verband 10,000 14,000 24,000
19 Revisi Parut 41,000 61,000 102,000
20 Injeksi Kenacort 21,000 32,000 53,000
21 Punch Biopsi 63,000 94,000 157,000
22 Insisonal biopsi 63,000 94,000 157,000
23 Ekstirpasi 46,000 70,000 116,000
24 Kuretase Kulit 19,000 28,000 47,000
25 Radioton 44,000 66,000 110,000
26 Trichlor Acetic Acid 17,000 25,000 42,000
27 Chemical Peeling :
- GA Peeling 81,000 121,000 202,000
- Proopeel 161,000 242,000 403,000
- PHA 49,000 73,000 122,000
28 Facial Regula 44,000 656,000 700,000
29 Test Allergi Tusuk
- Tusuk 41,000 61,000 102,000
- Tempel 58,000 87,000 145,000
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Jasa
Pelayanan
8. POLIKLINIK PENYAKIT PARU

1 Terapi Inhalasi tanpa obat / Nebulizer 12,000 18,000 30,000
2 Punctie Pleura 173,000 230,000 403,000
tidak termasuk
3 Spirometri komputer 37,000 56,000 93,000 selang,needle,botol,
BMHP
4 Portable Spirometri 30,000 45,000 75,000
9. POLIKLINIK PENYAKIT DALAM

1 Punctie asctes 115,000 173,000 288,000
2 Aspirasi jarum halus 23,000 35,000 58,000 tidak termasuk
selang,needle,botol,
3 BMP 41,000 61,000 102,000 BMHP
4 ECG 25,000 35,000 60,000
10. POLIKLINIK PENYAKIT JANTUNG

1 Defribilasi 143,000 214,000 357,000
2 ECG 25,000 35,000 60,000
3 Echocardiografi Dopler collor (Transtorakal) 160,000 200,000 360,000
4 Punksi pericard 184,000 276,000 460,000
5 Resusitasi jantung dengan DC Shock 80,000 119,000 199,000
6 Telemetri 36,000 54,000 90,000
7 Treadmill 92,000 138,000 230,000
8 Fowley Catheter 19,000 28,000 47,000
9 NGT / kali 30,000 30,000 60,000
10 Pacemaker temporer 300,000 700,000 1,000,000
11 Pemasangan SB Tube 49,000 73,000 122,000
12 Pemasangan Cardiac Monitor 12,000 18,000 30,000
tidak termasuk
13 Pemasangan CVP 805,000 575,000 1,380,000 selang,needle,botol,
BMHP
14 Pemasangan Cardiac monitor / hari 21,000 32,000 53,000
15 Dopler Vascular Pembuluh Darah 220,000 252,000 472,000
16 Transesofageal Echocardiografi 300,000 400,000 700,000
17 Pemasangan Holter 1 x 24 Jam 200,000 150,000 350,000
18 Pemasangan Holter 2 x 24 Jam 320,000 180,000 500,000
11. POLIKLINIK SYARAF/NEUROLOGI

1 Injeksi Intramuskuler 3,000 4,000 7,000
2 Injeksi Intraartikuler 33,000 49,000 82,000
3 Assessment Neurobehaviour fit n proper test 345,000 518,000 863,000
4 Assessment Neurobehaviour 150,000 225,000 375,000
5 Pemeriksaan EEG 81,000 121,000 202,000
6 Baca EEG 35,000 52,000 87,000
7 Assessment Nyeri 7,000 11,000 18,000
8 Pemeriksaan EMNG 115,000 173,000 288,000
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Jasa
Pelayanan
12. POLIKLINIK MATA

1 Pterigium (Bale Sclera) 300,000 400,000 700,000
2 S B L ( Bleparoplasty ) 184,000 276,000 460,000

3 Campimetri / perimetri 1 mata dengan Humpray 138,000 207,000 345,000
5 U S G Mata 100,000 150,000 250,000
6 Keratometri 28,000 42,000 70,000
7 Pemeriksaan fundus (indirec) 28,000 42,000 70,000
8 Tonometri Aplansi(schiutz) 28,000 42,000 70,000
9 Water Drinking 7,000 11,000 18,000
10 Retinoskopi 28,000 42,000 70,000
11 Gonioskopi 28,000 42,000 70,000
12 Synophtophor 58,000 87,000 145,000
13 Sondage 23,000 35,000 58,000
14 Anel test 23,000 35,000 58,000

15 Angkat jahitan di palpebra dan konjungtiva 42,000 63,000 105,000
16 Angkat jahitan di kornea 79,000 118,000 197,000
17 Amotio corpus Alienum 42,000 63,000 105,000
18 Irigasi 12,000 18,000 30,000
19 Refraktometer 28,000 42,000 70,000

20 Ekstirpasi kista konjungtiva 184,000 276,000 460,000
21 Ekstarpasi nevus / granulotoma 115,000 173,000 288,000
22 Epilasi 19,000 28,000 47,000
23 Excochleasi / Amotio Lithiasis 60,000 90,000 150,000
24 Ekstirpasi tumor / kista di palpebra 184,000 276,000 460,000
25 Biopsi dai palpebra 184,000 276,000 460,000
26 Refraksi 30,000 30,000 60,000
27 Biopsi di Konjungtiva 300,000 160,000 460,000
28 Jahitan di Palpebra 400,000 600,000 1,000,000
29 Reposisi iris 1,500,000 1,500,000 3,000,000
30 Paracentesis 300,000 400,000 700,000
31 Transplantasi Memberan Amnion 2,000,000 1,000,000 3,000,000

32 Biopsi di konjungtiva 184,000 276,000 460,000
33 Tarsoraphy / Jahitan di palpebra 184,000 276,000 460,000
34 Paracentesis 184,000 276,000 460,000
35 Iridektomi Perifer 230,000 345,000 575,000
36 Transplantasi membran amnion 184,000 276,000 460,000
37 Excochleasi / Amotio Lithiasis 115,000 173,000 288,000
38 Pemeriksaan Refraksi 23,000 35,000 58,000
39 Pemeriksaan Slit Biomikroskop 28,000 42,000 70,000
40 Tonometri SCHIOTZ 28,000 42,000 70,000
41 Test Ishihara 12,000 18,000 30,000
13. POLIKLINIK KEBIDANAN DAN PENYAKIT KANDUNGAN ( OBSGYN )
1 Biopsi Pervaginam 65,000 97,000 162,000

2 Pap Smear 30,000 50,000 80,000
3 Vaginal Swab 10,000 14,000 24,000
4 Kolposkopi 46,000 70,000 116,000
5 Kauter Elektrik 19,000 28,000 47,000
6 Pasang IUD 35,000 52,000 87,000
7 Angkat IUD tanpa penyulit 35,000 52,000 87,000
8 Angkat IUD dengan penyulit 58,000 52,000 110,000
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Jasa
Pelayanan
9 Pasang Implant 35,000 52,000 87,000

10 Angkat implant tanpa penyulit 35,000 52,000 87,000
11 Angkat Implant dengan penyulit 58,000 52,000 110,000
12 Diathermi ( satu seri = 6 kali kunjungan ) 35,000 52,000 87,000
13 Ganti verband / Buka jahitan / Rawat Luka 25,000 30,000 55,000
14 Pasang / Ganti tampon 10,000 14,000 24,000
15 Kauter Albotyl 9,000 15,000 24,000
16 USG
- Tanpa Print Out 50,000 30,000 80,000
- Dengan Print Out 80,000 70,000 150,000
17 Pasang Pessarium 23,000 50,000 73,000
18 Buka pessarium 23,000 35,000 58,000
19 CTG 50,000 30,000 80,000
20 Suntikan KB 14,000 21,000 35,000
21 Pemeriksaan Gnekologi 15,000 10,000 25,000
22 Pemeriksaan Obstetri 15,000 10,000 25,000
23 Tindakan pasang kateter 12,000 20,000 32,000
24 Tindakan pasang infus Dewasa 9,000 6,000 15,000
25 USG Transvaginal tanpa print out
- Tanpa print out 35,000 75,000 110,000
- Dengan print out 52,000 87,000 139,000
26 Konseling KB 7,000 11,000 18,000
27 MOW / MOP / Mini Laparotomy 249,000 373,000 622,000
28 Pelayanan ANC 15,000 10,000 25,000
29 IUD/Implant 250,000 150,000 400,000
14. POLIKLINIK PENYAKIT THT

1 Biopsi 70,000 105,000 175,000
2 Spoelling 36,000 53,000 89,000
3 Corpal Alienum telinga 36,000 53,000 89,000
4 Corpal Alienum tenggorokan 36,000 53,000 89,000
5 Corpal Alienum hidung 36,000 53,000 89,000
6 Caustik 10,000 20,000 30,000
7 Extirpasi granuloma 64,000 95,000 159,000
8 Swab Nasal 12,000 20,000 32,000
9 Test Allergi 41,000 61,000 102,000
10 Ganti verband 26,000 39,000 65,000
11 Evakuasi Cerumen Ringan 30,000 45,000 75,000
12 Swab Nasopharing Endoscopy 13,000 19,000 32,000
13 Audiometri murni 46,000 69,000 115,000
14 Audiometri tutur 35,000 52,000 87,000
15 Schimer test 41,000 61,000 102,000
16 Incisi Abses 50,000 47,500 97,500
17 Myringobridge 35,000 52,000 87,000
18 Buka pessarium 35,000 52,000 87,000
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15. REHABILITASI MEDIK

1 Micro Wave Diathermy 12,000 30,000 42,000
2 Electrical Stimulation 10,000 23,000 33,000
3 Ultrasound Diathermy 10,000 23,000 33,000
4 Traksi 12,000 29,000 41,000
5 InfraPhil 2 Lamp 7,000 10,000 17,000
6 Infra Phil 3 Lamp 9,000 21,000 30,000
7 Fibrator / Massage 7,000 18,000 25,000
8 Senam hamil 23,000 12,000 35,000
9 Senam Nifas 23,000 12,000 35,000
10 Postural drainage 10,000 14,000 24,000
11 Bladder Training 23,000 13,000 36,000
12 Fisioterapi Stroke 23,000 18,000 41,000
13 Fisioterapi Anak 41,000 18,000 59,000
14 Fisioterapi Dada/ Breathing Exc 23,000 12,000 35,000
15 Back Exercise 23,000 12,000 35,000
16 Latihan Sepeda Statis 7,000 18,000 25,000
17 Latihan Paralel Bars 7,000 18,000 25,000
18 Continous Pasive Movement 18,000 10,000 28,000
19 Latihan Gerak Sendi / Penguatan Otot 18,000 7,000 25,000
20 Pemasangan Spalk 23,000 20,000 43,000
21 Short Wave Diathermy 12,000 29,000 41,000
22 Parafin Bath 10,000 25,000 35,000
23 Nebulizer 12,000 18,000 30,000
24 Active Movement Exercise 18,000 10,000 28,000
16. POLIKLINIK BEDAH SYARAF

1 Rawat Luka
a. Kecil (< 5 cm) 7,000 11,000 18,000
b. Sedang (5-10 cm) 10,000 15,000 25,000
c. Besar (10-20 cm) 17,500 40,000 57,500
d. Khusus (> 20 cm) 35,000 45,000 80,000
2 Angkat Jahitan
- Kecil (< 5 Jahitan) 8,000 12,000 20,000
- Sedang (5-10 Jahitan) 10,000 15,000 25,000
- Besar (10-20Jahitan) 20,000 25,000 45,000
- Khusus > 20 Jahitan 25,000 35,000 60,000
3 Pungsi CSF Cranial 138,000 207,000 345,000
4 Pungsi Lumbal 58,000 87,000 145,000
5 Injeksi Spinal 138,000 207,000 345,000
6 Injeksi obat ( IV ) / Injeksi 3,000 4,000 7,000
7 Pasang Elastic Band 23,000 35,000 58,000
Page 11 of 53
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17. POLIKLINIK JIWA / PSIKIATRI

A PEMERIKAAN PSIKOMETRI
1 HHouse man tree test 7,000 11,000 18,000
2 Warteg test 7,000 11,000 18,000
3 HDRS 10,000 14,000 24,000
4 HARS 10,000 14,000 24,000
5 BDI 10,000 14,000 24,000
6 MMSE 10,000 14,000 24,000
7 MMPI 138,000 207,000 345,000
8 PANS score 10,000 14,000 24,000
9 GDS 10,000 14,000 24,000
B PSIKOTERAPI
1 Psikoterapi suportif 23,000 35,000 58,000
2 Cognitif Behaviour therapy 92,000 138,000 230,000
3 Hipnotherapi 230,000 345,000 575,000
III. PELAYANAN TINDAKAN MEDIK OPERATIF DAN TERAPI TERENCANA

A OPERASI BEDAH DIGESTIF
1 Anastomosis of small intestine to rectal stump (pancolestomy) 2,783,000 4,200,000 6,983,000
2 Laparoscopyt terapi 2,429,000 3,700,000 6,129,000

3 LAR and to end anastomose 2,656,500 4,000,000 6,656,500
LAR dengan colostomy (anterior resection of rectum with

4 2,657,000 4,000,000 6,657,000
synchronous colostomy)
5 Pungsi Pleura/Abdomen 2,500,000 1,555,000 4,055,000

6 Miles prosedur 3,036,000 4,555,000 7,591,000
7 Pancreatectomy roux n y 2,834,000 4,255,000 7,089,000
8 Ruptur gaster gastrojejunustomy + jejunustomy feeding 2,429,000 3,650,000 6,079,000
9 Soave 2,657,000 3,985,000 6,642,000

10 Achlasia Aesophagus 3,036,000 4,555,000 7,591,000
11 Hordiulum (Mata) 2,500,000 1,555,000 4,055,000
12 Arthroscopy diagnostic 2,277,000 3,416,000 5,693,000
13 Arthroscopy debridement 2,277,000 3,416,000 5,693,000
14 Bristow Procedure 2,277,000 3,416,000 5,693,000
15 Choledochojejunustomy roux n y 2,277,000 3,416,000 5,693,000
16 Cysto jejunostomy roux n y pada kista empedu 2,277,000 3,416,000 5,693,000
17 Cysto jejunostomy roux n y pada kista pankreas 2,277,000 3,416,000 5,693,000
18 Discectomy 2,277,000 3,416,000 5,693,000

19 Open and other left hemicolectomy 2,277,000 3,416,000 5,693,000
20 Open and other resection colon transfersum 2,277,000 3,416,000 5,693,000
21 Open and other sigmoidectomy 2,277,000 3,416,000 5,693,000
22 Open Drainage abses hepar 2,277,000 3,416,000 5,693,000
23 Other and unspecified partial excision of large intestine 2,277,000 3,416,000 5,693,000
24 Repair recto vaginal fistula 2,277,000 3,416,000 5,693,000

25 Ruptur gaster jahit primer omental patch 2,277,000 3,416,000 5,693,000
26 Laparoscopy 2,429,000 3,416,000 5,845,000
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27 Anastomosis other small-to-large intestinal 1,771,000 3,416,000 5,187,000

28 Anastomosis Smal-to-small intestinal 1,771,000 3,416,000 5,187,000
29 Appendiktomi and drainage appendikceal abses 1,771,000 3,416,000 5,187,000
30 Cholesistectomy 1,771,000 3,416,000 5,187,000

31 Debulking 1,771,000 3,416,000 5,187,000
32 Eviscerasi dengan GA 1,771,000 3,416,000 5,187,000
33 Exteriorization of small intestine 1,771,000 3,416,000 5,187,000
34 Hernia fomaralis bilateral dengan atau tanpa graft 1,771,000 3,416,000 5,187,000
35 Herniotomi hernioraphi anostomosis 1,771,000 3,416,000 5,187,000
HIL bilateral (other and open bilateral repair of direct inguinal

36 1,771,000 3,416,000 5,187,000
hernia) dengan atau tanpa graft
HIM bilateral (other and open bilateral repair of indirect inguinal

37 1,771,000 3,416,000 5,187,000
hernia) dengan atau tanpa graft
38 Laparoscopic appendectomy 1,771,000 3,416,000 5,187,000

39 Laparotomy eksplorasi dengan stoma 1,771,000 3,416,000 5,187,000
Other and open bilateral repair of inguinal hernia, one direct and
40 1,771,000 3,416,000 5,187,000
one indirect
41 Repair Sub total perianal rupture 1,771,000 3,416,000 5,187,000
42 Repair total perianal rupture 1,771,000 3,416,000 5,187,000
43 Suture of laceration of duodenum 1,771,000 3,416,000 5,187,000
44 Suture of laceration of small intestine 1,771,000 3,416,000 5,187,000
45 Appendiktomi pada apendicities akut/kronis 1,771,000 2,126,000 3,897,000
Hernia femoralis unilateral dg atau tanpa graft (unilateral repair

46 1,771,000 2,657,000 4,428,000
of femoral hernia with graft or prosthesis)
47 Herniotomi hernioraphi selain HIM atau HIL dngan graft 1,771,000 2,657,000 4,428,000
48 Herniotomi pada anak 1,771,000 2,657,000 4,428,000
Hernitomy hernioraphi HIL unilateral dg atau tanpa graft (other

49 1,771,000 2,657,000 4,428,000
and open repair of direct inguinal hernia with graft or prosthesis)
Hernitomy hernioraphi HIM unilateral dg atau tanpa graft (other

50 and open repair of indirect inguinal hernia with graft or 1,771,000 2,657,000 4,428,000
prosthesis)
51 Hidrocele komunikan 1,771,000 2,657,000 4,428,000
52 Hidrocele punikuli 1,771,000 2,657,000 4,428,000
Hidrocele testis (hidrocele/excision af hydrocele of tunica
53 1,771,000 2,657,000 4,428,000
vaginalis)
54 Laparascopic diagnostic 1,771,000 2,657,000 4,428,000
Penutupan stoma pada colostomy (closure of stoma of large
55 1,771,000 2,657,000 4,428,000
intestine)
Penutupan stoma pada ileustomy (closure of stoma of small
56 1,771,000 2,657,000 4,428,000
intestine)
57 Funikokelektomy 1,771,000 2,657,000 4,428,000
58 Hydrokelektomy per inguinal 1,771,000 2,657,000 4,428,000
59 Hydrokelektomy per scrotal 1,771,000 2,657,000 4,428,000
60 Anoplasty pada setriktural anus 1,164,000 1,746,000 2,910,000
61 Closed Drainage abses hepar dengan GA 1,164,000 1,746,000 2,910,000
62 Colostomi 1,164,000 1,746,000 2,910,000
63 Excision of varicocele and hydrocele of spermatic cord 1,164,000 1,746,000 2,910,000
64 Exici polip recti dengan GA 1,164,000 1,746,000 2,910,000
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65 Exteriorication of large intestine 1,164,000 1,746,000 2,910,000

66 Gastrostomy 1,164,000 1,746,000 2,910,000
67 Haemorroidectomi/procedur on hemorrhoids) 1,164,000 1,746,000 2,910,000
68 Perianal Fistulectomy 1,164,000 1,746,000 2,910,000
69 Preauricula Fistulectomy 1,164,000 1,746,000 2,910,000
70 Prolaps recti (repair) 1,164,000 1,746,000 2,910,000
71 Release constriction band 1,164,000 1,746,000 2,910,000
72 Repair anus 1,164,000 1,746,000 2,910,000
73 Repair old perineal ruphture 1,164,000 1,746,000 2,910,000
74 Repair uracus 1,164,000 1,746,000 2,910,000
75 Stepler haemorroidectomi 1,164,000 1,746,000 2,910,000
76 Reseksi urachus 1,164,000 1,746,000 2,910,000
77 Closed Drainage abses hepar dengan LA 911,000 1,367,000 2,278,000
78 Colonoscopi disertai extirpasi tumor 911,000 1,367,000 2,278,000
79 Exici polip recti dengan LA 911,000 1,367,000 2,278,000
80 Fistulectomy 911,000 1,367,000 2,278,000
81 Perianal fistulotomi 911,000 1,367,000 2,278,000
82 Colonoscopi 658,000 987,000 1,645,000
83 Lavage 658,000 987,000 1,645,000
84 Potong stoma pada soave 658,000 987,000 1,645,000
85 Gastroscopi 355,000 532,000 887,000
86 Gastroscopi disertai biopsi 355,000 532,000 887,000
87 Gastroscopi disertai ligasi varises esofagus (LVE) 355,000 532,000 887,000
88 Gastroscopi disertai sclero terapi endoskopi (STE) 355,000 532,000 887,000
89 Insisi absces perineum 253,000 380,000 633,000
90 Insisi ansces scrotum 253,000 380,000 633,000
91 Anuscopy biopsi dengan LA (Local anaesthesia) 152,000 300,000 452,000
92 Open biopsy of breast dengan LA 152,000 250,000 402,000
93 Bipolar resectoscopy 2,277,000 3,416,000 5,693,000
94 Ekstraksi ductus choledocy 1,771,000 2,657,000 4,428,000
95 Ekstraksi batu ductus choledocus 2,277,000 3,416,000 5,693,000
96 Histeroscopy diagnostic 1,164,000 1,746,000 2,910,000
97 Histeroscopy operative 2,277,000 3,416,000 5,693,000
98 Laparotomy + release adhesi 2,277,000 3,416,000 5,693,000
99 Re-open Laparotomy 1,771,000 2,657,000 4,428,000
100 Transanal Endorected pull through 3,036,000 4,554,000 7,590,000
101 Transanal swense eike 3,036,000 4,554,000 7,590,000
B OPERASI BEDAH ANAK

1 Anaplasty PSA (postero sagital anoplasty) 2,783,000 4,175,000 6,958,000
2 Ilizarov 2,783,000 4,175,000 6,958,000
3 Invaginasi 2,277,000 3,416,000 5,693,000
4 Eksisi ductus thyroglosus 1,771,000 2,657,000 4,428,000
5 Illeustomi pada anak 1,771,000 2,657,000 4,428,000
6 Laparatomi pada anak 1,771,000 2,657,000 4,428,000
7 Orchidectomy bilateral 1,771,000 2,657,000 4,428,000
8 Hirschprung's/colostomy pada hirsprung's 1,164,000 1,746,000 2,910,000
9 Anoplasty atresia ani letak rendah (cutback incision) 658,000 1,000,000 1,658,000
10 Anoplastyh + uretheroplasty 2,783,000 4,175,000 6,958,000
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11 Postero sagictal anorected pull through 3,036,000 4,555,000 7,591,000
C OPERASI BEDAH ORTHOPEDI

1 Koreksi Scoliosis 2,783,000 4,175,000 6,958,000
2 Total elbow arthtoplasty 2,783,000 4,175,000 6,958,000
3 Total Hip arthtoplasty 2,783,000 4,175,000 6,958,000
4 Total knee arthtoplasty 2,783,000 4,175,000 6,958,000
5 Total shoulder arthtoplasty 2,783,000 4,175,000 6,958,000
6 Debridement TB tulang belakang 2,277,000 3,416,000 5,693,000
7 Hemiarthroplasty (AMP, bipolar) complicated 2,277,000 3,416,000 5,693,000
8 Internal fiksasi fraktur acetabulum complicated 2,277,000 3,416,000 5,693,000
9 Internal fiksasi fraktur collumn femur complicated 2,277,000 3,416,000 5,693,000
10 Internal fiksasi fraktur collumn femur dengan DHS complicated 2,277,000 3,416,000 5,693,000
11 Internal fiksasi fraktur collumn femur dengan ABP complicated 2,277,000 3,416,000 5,693,000
12 Internal fiksasi fraktur pelvis complicated 2,277,000 3,416,000 5,693,000

13 Internal fiksasi fraktur scapula complicated 2,277,000 3,416,000 5,693,000
14 Osteotomi korektif(HTO, freanch, dll) 2,277,000 3,416,000 5,693,000
15 Other reconstructive procedure of the shoulder 2,277,000 3,416,000 5,693,000
16 Rekonstruksi ACL/PCL 2,277,000 3,416,000 5,693,000
17 Koreksi horshoe kidney (ishmectomy) 2,277,000 3,416,000 5,693,000
18 Bone graft iliac/fibular/autograft lainnya 1,771,000 2,657,000 4,428,000
19 Disartikulasi Hip 1,771,000 2,657,000 4,428,000
20 Disartikulasi shoulder 1,771,000 2,657,000 4,428,000
21 Elevation of skull fracture fragments 1,771,000 2,657,000 4,428,000
22 Eviscerasi dengan GA 1,771,000 2,657,000 4,428,000
23 Hemiarthroplasty (AMP, bipolar) 1,771,000 2,657,000 4,428,000
24 Internal fiksasi fraktur acetabulum 1,771,000 2,657,000 4,428,000
25 Internal fiksasi fraktur collumn femur 1,771,000 2,657,000 4,428,000
26 Internal fiksasi fraktur femur dengan ABP 1,771,000 2,657,000 4,428,000
27 Internal fiksasi fraktur femur dengan K wire complicated 1,771,000 2,657,000 4,428,000
28 Internal fiksasi fraktur femur dengan plate & screw complicated 1,771,000 2,657,000 4,428,000
29 Internal fiksasi fraktur femur dengan DHS 1,771,000 2,657,000 4,428,000

30 Internal fiksasi fraktur humerus complicated 1,771,000 2,657,000 4,428,000
31 Iinternal fiksasi fraktur pelvis 1,771,000 2,657,000 4,428,000
32 Iinternal fiksasi fraktur radius complicated 1,771,000 2,657,000 4,428,000
33 Iinternal fiksasi fraktur scapula 1,771,000 2,657,000 4,428,000
Iinternal fiksasi fraktur symphisis pubis/symphisiolisis
34 1,771,000 2,657,000 4,428,000
complicated
35 Internal fiksasi fraktur tibia complicated 1,771,000 2,657,000 4,428,000
36 Open reduction dislocation 1,771,000 2,657,000 4,428,000
37 Operasi avulsi PCL/ACL 1,771,000 2,657,000 4,428,000
38 Patellar stabilization 1,771,000 2,657,000 4,428,000
39 Pengambilan implant tulang belakang 1,771,000 2,657,000 4,428,000
40 Phacoemulsifikasi 1,771,000 2,657,000 4,428,000
41 Rekonstruksi bunion 1,771,000 2,657,000 4,428,000
42 Arthroscopy other procedures 1,417,000 2,126,000 3,543,000
43 Internal fiksasi fraktur carpalia 1,417,000 2,126,000 3,543,000
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44 Internal fiksasi fraktur clavikula complicated 1,417,000 2,126,000 3,543,000

45 Internal fiksasi fraktur femur dengan K wire 1,417,000 2,126,000 3,543,000
46 Internal fiksasi fraktur femur dengan nail 1,417,000 2,126,000 3,543,000
47 Internal fiksasi fraktur femur dengan plate & screw 1,417,000 2,126,000 3,543,000
48 Internal fiksasi fraktur fibula complicated 1,417,000 2,126,000 3,543,000
49 Internal fiksasi fraktur radius 1,417,000 2,126,000 3,543,000
50 Internal fiksasi fraktur radius ulna 1,417,000 2,126,000 3,543,000
51 Internal fiksasi fraktur tibia fibula 1,417,000 2,126,000 3,543,000
52 Internal fiksasi fraktur ulna complicated 1,417,000 2,126,000 3,543,000
53 Arhtrodesis Pantalar 1,164,000 1,746,000 2,910,000
54 Arhtrodesis shoulder 1,164,000 1,746,000 2,910,000
55 Arhtrodesis subtalar 1,164,000 1,746,000 2,910,000
56 Arhtrodesis elbow 1,164,000 1,746,000 2,910,000
57 Arhtrodesis genu 1,164,000 1,746,000 2,910,000
58 Arhtrodesis hip 1,164,000 1,746,000 2,910,000
59 Arhtrodesis talocrural 1,164,000 1,746,000 2,910,000
60 Arhtrodesis triple 1,164,000 1,746,000 2,910,000
61 Arhtrodesis wrist 1,164,000 1,746,000 2,910,000
62 Bone graft allograft/xenograft/hydroxyapatite 1,164,000 1,746,000 2,910,000
63 Debridement osteomyelitis 1,164,000 1,746,000 2,910,000
64 Eksternal fiksasi pelvis 1,164,000 1,746,000 2,910,000
65 Eksternal fiksasi wrist 1,164,000 1,746,000 2,910,000
66 Ekstirpasi tumor + rekonstruksi (diluar orthopedi) 1,164,000 1,746,000 2,910,000
67 Excisi bone tumor 1,164,000 1,746,000 2,910,000
68 Fraktur costae dg internal fiksasi (pasang shapp plate) singgle 1,164,000 1,746,000 2,910,000
69 Free skin graft not otherwise specified 1,164,000 1,746,000 2,910,000

70 Internal fiksasi fraktur clavikula 1,164,000 1,746,000 2,910,000
71 Internal fiksasi fraktur fibula 1,164,000 1,746,000 2,910,000
72 Internal fiksasi fraktur humerus 1,164,000 1,746,000 2,910,000
73 Internal fiksasi fraktur patella complicated 1,164,000 1,746,000 2,910,000
74 Internal fiksasi fraktur tibia 1,164,000 1,746,000 2,910,000
75 Internal fiksasi fraktur tibia plateau complicated 1,164,000 1,746,000 2,910,000
76 Internal fiksasi fraktur ulna 1,164,000 1,746,000 2,910,000
77 Osteotomy sederhana 1,164,000 1,746,000 2,910,000
78 Pengambilan implant ABP 1,164,000 1,746,000 2,910,000
79 Pengambilan implant DHS 1,164,000 1,746,000 2,910,000
Pengambilan nail/plate termasuk implant symphisis pubis
80 1,164,000 1,746,000 2,910,000
complicated
81 Amputasi below knee 911,000 1,367,000 2,278,000
82 Amputasi above elbow 911,000 1,367,000 2,278,000
83 Amputasi chopart 911,000 1,367,000 2,278,000
84 Amputasi Lisfranc 911,000 1,367,000 2,278,000
85 Amputasi syme 911,000 1,367,000 2,278,000
86 Amputasi ankle 911,000 1,367,000 2,278,000
87 Arthrodesis phalang manus 911,000 1,367,000 2,278,000
88 Arthrodesis phalang metacarpal 911,000 1,367,000 2,278,000
89 Arthrodesis phalang metatarsal 911,000 1,367,000 2,278,000
90 Arthrodesis phalang pedis 911,000 1,367,000 2,278,000
91 Debridement open fracture 911,000 1,367,000 2,278,000
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92 Disartikulasi ankle 911,000 1,367,000 2,278,000

93 Disartikulasi elbow 911,000 1,367,000 2,278,000
94 Disartikulasi knee 911,000 1,367,000 2,278,000
95 Disartikulasi wrist 911,000 1,367,000 2,278,000
96 Disisi Aspirasi katarak dengan LA 911,000 1,367,000 2,278,000
97 Eksternal fiksasi tulang panjang 911,000 1,367,000 2,278,000
98 Internal fiksasi fraktur metacarpal complicated 911,000 1,367,000 2,278,000
99 Internal fiksasi fraktur olecranon 911,000 1,367,000 2,278,000
100 Internal fiksasi fraktur patella 911,000 1,367,000 2,278,000
101 Internal fiksasi fraktur phalang complicated 911,000 1,367,000 2,278,000
102 Internal fiksasi manus multiple 911,000 1,367,000 2,278,000
103 Osteoclasis 911,000 1,367,000 2,278,000
104 Pengambilan nail/plate termasuk implant symphisis pubis 911,000 1,367,000 2,278,000
105 Adductor tenotomy off the hip 658,000 987,000 1,645,000

106 Amputasi metacarpal 658,000 987,000 1,645,000
107 Amputasi phalang manus dengan GA (General Anaesthesia) 658,000 987,000 1,645,000
108 Amputasi phalang pedis dengan GA (General Anaesthesia) 658,000 987,000 1,645,000
109 Closed tenotomy achiles (achilotenotomy) 658,000 987,000 1,645,000

110 Excision of the bone 658,000 987,000 1,645,000
111 Internal fiksasi fraktur metacarpal 658,000 987,000 1,645,000
112 Internal fiksasi faktur phalang 658,000 987,000 1,645,000
113 Internal fiksasi fraktur tibia plateau 658,000 987,000 1,645,000
114 Pasang skeletal traksi dg GA 658,000 987,000 1,645,000
115 Pengambilan intramedulary nail (femur, tibia) 658,000 987,000 1,645,000
116 Pengambilan K Wire dengan GA 658,000 987,000 1,645,000
117 Release de Quervain tenosynovitis GA 658,000 987,000 1,645,000
118 Amputasi phalang manus dengan LA (local Anaesthesia) 355,000 532,000 887,000
119 Amputasi phalang pedis dengan LA (local anaesthesia) 355,000 532,000 887,000
120 Anuscopy biopsi dengan GA (general anaesthesia) 355,000 532,000 887,000
121 Ateroma ekstirpasi dengan LA 355,000 532,000 887,000
122 Biopsy of skin and subcutaneous tissue dengan LA 355,000 532,000 887,000
123 Bone marrow analisa (BMA) 355,000 532,000 887,000
124 Closed reduction fractur nasal 355,000 532,000 887,000
125 Pelepasan eksternal fiksasi dengan GA (General Anaesthesia) 355,000 532,000 887,000
126 Sondage canaliculi lacrimalis 355,000 532,000 887,000

127 Release CTS dg LA 355,000 532,000 887,000
128 Reposisi fraktur/dislokasi dg GA 355,000 532,000 887,000
Reposisi tertutup fraktur dan imobilisasi plaster cast dengan GA
129 355,000 532,000 887,000
(general anaesthesia)
130 Pelepasan eksternal fiksasi dengan LA (local anaesthesia) 253,000 380,000 633,000
131 Release de Quervain tenosynovitis 253,000 380,000 633,000
132 Suture of laceration of lip dengan LA (local anaesthesia) 253,000 380,000 633,000
Suture of laceration of other part of mount dengan LA (local

133 253,000 380,000 633,000
anaesthesia)
134 Suture of laceration of palate dengan LA (local anaesthesia) 253,000 380,000 633,000
135 Triger finger 253,000 380,000 633,000
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136 In growing nail (ekstraksi kuku) dg LA 152,000 228,000 380,000

137 Antrostomi dengan CWL 1,771,000 2,657,000 4,428,000
138 Arthroscopy rekonstruksi 3,036,000 4,554,000 7,590,000
139 Stabilisasi posterior 2,783,000 4,175,000 6,958,000
140 Ekstirpasi tumor + rekonstruksi (orthopedi) 2,277,000 3,416,000 5,693,000
D OPERASI BEDAH ONKOLOGI - - -

1 Neck dissection radical bilateral 2,429,000 3,644,000 6,073,000
2 Deseksi kelenjar inguinal 2,277,000 3,416,000 5,693,000
3 Mestectomy subcutaneous unilateral 2,277,000 3,416,000 5,693,000
4 Mastectomy extended simple unilateral 2,277,000 3,416,000 5,693,000
5 Mastectomy simple unilateral 2,277,000 3,416,000 5,693,000
6 Mastectomy sub total 2,277,000 3,416,000 5,693,000
7 Mastectomy Unilateral 2,277,000 3,416,000 5,693,000
8 MRM (modified radical mastectomy) 2,277,000 3,416,000 5,693,000
9 Neck dissection radical unilateral 2,277,000 3,416,000 5,693,000
10 Parotidectomy total 2,277,000 3,416,000 5,693,000
11 Pedicle flaps (advanced) 2,277,000 3,416,000 5,693,000
12 Reseksi hemi mandibula (hemimandibulektomi) 2,277,000 3,416,000 5,693,000
13 Thyroidectomy total 2,277,000 3,416,000 5,693,000
14 Deseksi kelenjar leher 1,771,000 2,657,000 4,428,000
15 Glossectomy parrtial 1,771,000 2,657,000 4,428,000
16 Parotidectomy superfisial 1,771,000 2,657,000 4,428,000
17 Reseksi mandibula bilateral 1,771,000 2,657,000 4,428,000
18 Soft tissue tumor (kompartment reseksi) 1,771,000 2,657,000 4,428,000
19 Sub total unilateral isthmo lobectomy 1,771,000 2,657,000 4,428,000
20 Thyroidectomy subtotal 1,771,000 2,657,000 4,428,000
21 Enukleasi dg GA 1,771,000 2,657,000 4,428,000
Basalioma (excision or destruction of lesion or tissue of skin and
22 1,417,000 2,126,000 3,543,000
subcutaneous tissue) dengan graft
23 Eksisi fibro sarcomamae mama 1,417,000 2,126,000 3,543,000
24 Eksisi ginecomasti/subcutoneus mastectomy 1,417,000 2,126,000 3,543,000
25 Eksisi kelenjar liur 1,417,000 2,126,000 3,543,000
26 Eksisi limfangioma luas 1,417,000 2,126,000 3,543,000
27 Eksisi tumor kelenjar leher 1,417,000 2,126,000 3,543,000
28 Excision or destruction of lesion or tissue of tongue 1,417,000 2,126,000 3,543,000
29 Kista radicular (eksisi) 1,417,000 2,126,000 3,543,000
30 Soft tissue tumor (muscle reseksi) 1,417,000 2,126,000 3,543,000
31 Tumor palatum (eksisi) 1,417,000 2,126,000 3,543,000
Basalioma (excision or destruction of lesion or tissue of skin and
32 1,164,000 1,746,000 2,910,000
subcutaneous tissue) tanpa graft
33 Eksisi kelenjar inguinal 1,164,000 1,746,000 2,910,000
34 Eksisi limfangioma 1,164,000 1,746,000 2,910,000
35 Eksisi mamae aberan 1,164,000 1,746,000 2,910,000
Epidermoid carsinoma (excision or destruction of lesion or skin
36 1,164,000 1,746,000 2,910,000
and subcutaneous tissue) dengan graft
37 Liposarcoma (eksisi) 1,164,000 1,746,000 2,910,000
38 Soft tissue tumor (eksisi) 1,164,000 1,746,000 2,910,000
39 Trabekulektomi 1,164,000 1,746,000 2,910,000
40 Eksisi fibroma 1,164,000 1,746,000 2,910,000
Page 18 of 53
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41 Eksisi fibro adenoma (fam) dengan GA 911,000 1,367,000 2,278,000

42 Eksisi tumor adneksa sedang 911,000 1,367,000 2,278,000
43 Eksisi tumor kel. Submandibula 911,000 1,367,000 2,278,000
44 Eksisi tumor multiple 911,000 1,367,000 2,278,000
Epidermoid carsinoma (excision or destruction of lesion or skin
45 911,000 1,367,000 2,278,000
and subcutaneous tissue) tanpa graft
46 Eviscerasi 911,000 1,367,000 2,278,000
47 Excision of lesion of breast dengan GA 911,000 1,367,000 2,278,000
48 Ganglion Carpi/tarsa 911,000 1,367,000 2,278,000
49 Lipoma nochae (ekstirpasi) 911,000 1,367,000 2,278,000
50 Ateroma ekstirpasi dengan GA 355,000 550,000 905,000
51 Biopsy of skin and subcutaneous tissue dengan GA 355,000 550,000 905,000
52 Chemical peeling 658,000 1,000,000 1,658,000
53 Eksisi fibro adenoma (fam) dengan LA 658,000 1,000,000 1,658,000
54 Eksisi tumor adneksa kecil 658,000 1,000,000 1,658,000
55 Eksisi tumor dengan GA 658,000 1,000,000 1,658,000
56 Ekstirpasi korpal dengan penyulit (LA) 658,000 1,000,000 1,658,000
57 Excision of lesion of breast dengan LA 658,000 1,000,000 1,658,000
58 Lipoma (ekstirpasi) dengan GA 658,000 1,000,000 1,658,000
59 Neurofibroma (eksisi) dengan GA 658,000 1,000,000 1,658,000
60 Open biopsy of breast dengan GA 658,000 1,000,000 1,658,000
61 Tofus (eksisi) dengan GA 658,000 1,000,000 1,658,000
62 Ateroma ekstirpasi dengan LA 658,000 1,000,000 1,658,000
63 Biopsy of skin and subcutaneous tissue dengan LA 658,000 1,000,000 1,658,000
64 Eksisi tumor dengan LA 355,000 550,000 905,000
65 Tofus (eksisi) dengan LA 355,000 550,000 905,000
66 Extirpasi geborn myoma 253,000 400,000 653,000
67 Lipoma (ekstirpasi) dengan LA 253,000 400,000 653,000
68 Extirpasi tumor jinak kulit dan bawah kulit 152,000 250,000 402,000
69 Neurofibroma (eksisi) dengan LA 152,000 250,000 402,000
70 Excisi non wajah 152,000 250,000 402,000
E OPERASI BEDAH SYARAF

1 Replantansi/revaskularisasi 2,783,000 4,500,000 7,283,000
2 ###Trepanasi 2,783,000 4,500,000 7,283,000
3 Laminectomy 2,277,000 3,500,000 5,777,000
4 Laminoplasty 2,277,000 3,500,000 5,777,000
5 Open reduction cervical 2,277,000 3,500,000 5,777,000
6 Spinal fusion (PLIF/ALIF) 2,277,000 3,500,000 5,777,000
7 Stabilisasi posterior 2,277,000 3,500,000 5,777,000
8 Other craniectomy 2,277,000 3,500,000 5,777,000
9 Other craniotomy 1,771,000 3,500,000 5,271,000
10 Evakuasi bekuan darah (clot) 1,417,000 2,500,000 3,917,000
11 Parasentesa 839,000 1,500,000 2,339,000
12 Injeksi tulang belakang dengan C Arm 152,000 300,000 452,000
F OPERASI BEDAH UROLOGI

1 ###Nefrolithotomy bivalve 2,277,000 3,500,000 5,777,000
2 Open prostatectomy 2,277,000 3,500,000 5,777,000
Page 19 of 53
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3 Uretero litotomi batu ureter pasang stent 2,277,000 3,500,000 5,777,000

4 Bladder neck rekonstruksi 2,277,000 3,500,000 5,777,000
5 Boary flap 2,277,000 3,500,000 5,777,000
6 PNL/PCNL 2,277,000 3,500,000 5,777,000
7 Reimplantasi ureter bilateral 2,277,000 3,500,000 5,777,000
8 Repair fistel enterovesica 2,277,000 3,500,000 5,777,000
9 Repair vesicorectal 2,277,000 3,500,000 5,777,000
10 Repair vesicovagina 2,277,000 3,500,000 5,777,000
11 TUR buli 2,277,000 3,500,000 5,777,000
12 TURP/BNI 2,277,000 3,500,000 5,777,000
13 URS 2,277,000 3,500,000 5,777,000
14 Pielolithotomy 1,771,000 3,000,000 4,771,000
15 Repair urethra 1,771,000 3,000,000 4,771,000
Uretero litotomi batu ureter 1/3 distal tanpa neo implantasi
16 1,771,000 3,000,000 4,771,000
ureter
17 Uretroplasty pada hypospadias 1,771,000 3,000,000 4,771,000
18 Vaginal histerectomy 1,771,000 3,000,000 4,771,000
19 Anastomose ureter end to end 1,771,000 3,000,000 4,771,000
20 Anastomose urethra end to end 1,771,000 3,000,000 4,771,000
21 Divertikulektomy buli 1,771,000 3,000,000 4,771,000
22 Extended pielolithotomy 1,771,000 3,000,000 4,771,000
23 Internal urethrotomy (sache) 1,771,000 3,000,000 4,771,000
24 Johanson II 1,771,000 3,000,000 4,771,000
25 Lithotripsi 1,771,000 3,000,000 4,771,000
26 Nefroureterectomy 1,771,000 3,000,000 4,771,000
27 Nefropeksi 1,771,000 3,000,000 4,771,000
28 Pieloplasty 1,771,000 3,000,000 4,771,000
29 Radikal nefrectomy 1,771,000 3,000,000 4,771,000
30 Radikal orchidektomy 1,771,000 3,000,000 4,771,000
31 Railroading ruptur urethra 1,771,000 3,000,000 4,771,000
32 Repair fistel vesikokutan 1,771,000 3,000,000 4,771,000
33 Repair trauma buli 1,771,000 3,000,000 4,771,000
34 Sistectomy parsial 1,771,000 3,000,000 4,771,000
35 Ureterocutaneostomy 1,771,000 3,000,000 4,771,000
36 Uretero litotomi distal 1,771,000 3,000,000 4,771,000
37 Enukleasi dg GA 1,771,000 3,000,000 4,771,000
38 Nephrotomy and nephrostomy 1,417,000 2,500,000 3,917,000
39 Orchidectomi + orchidopexy contra lateral 1,417,000 2,500,000 3,917,000
40 Orchidectomi pada undescensus testis unilateral 1,417,000 2,500,000 3,917,000
41 Partial nefrektomi 1,417,000 2,500,000 3,917,000
42 Repair AC joint sclera dengan GA 1,417,000 2,500,000 3,917,000
43 Unilateral orchidectomy 1,417,000 2,500,000 3,917,000
44 Insisi posterior urethral valve 1,417,000 2,500,000 3,917,000
45 Johanson I 1,417,000 2,500,000 3,917,000
46 Koreksi priapismus alghorab 1,417,000 2,500,000 3,917,000
47 Open nefrostomy 1,417,000 2,500,000 3,917,000
48 Orchidopeksi (torsio testis) 1,417,000 2,500,000 3,917,000
49 Orchidopeksi (undescencus testis) 1,417,000 2,500,000 3,917,000
50 Palomo 1,417,000 2,500,000 3,917,000
Page 20 of 53
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Pelayanan
51 PER (primary endoscopy realignment) 1,417,000 2,500,000 3,917,000

52 Uretero litotomi proksimal 1,417,000 2,500,000 3,917,000
53 Batu buli-buli (sectio alta) 1,164,000 2,000,000 3,164,000
54 Percutaneous nephrostomy without fragmentation 1,164,000 2,000,000 3,164,000
55 Release constriction band 1,164,000 2,000,000 3,164,000
56 Repair of testis 1,164,000 2,000,000 3,164,000
57 Cordektomi 1,164,000 2,000,000 3,164,000
58 Drainase periureter 1,164,000 2,000,000 3,164,000
59 Eksis web penis 1,164,000 2,000,000 3,164,000
60 Epispadia 1,164,000 2,000,000 3,164,000
61 Nefrostomi percutan 1,164,000 2,000,000 3,164,000
62 Parsial penektomi 1,164,000 2,000,000 3,164,000
63 Rekonstruksi penis 1,164,000 2,000,000 3,164,000
64 RPG (retrograde pielografi) 1,164,000 2,000,000 3,164,000
65 Subcapsuler orchidectomi 1,164,000 2,000,000 3,164,000
66 Tailoring ureter 1,164,000 2,000,000 3,164,000
67 Total penektomi 1,164,000 2,000,000 3,164,000
68 Vasoepididimostomy 1,164,000 2,000,000 3,164,000
69 Vesikolithotomy 1,164,000 2,000,000 3,164,000
70 Open cistostomi dg GA 911,000 1,500,000 2,411,000
71 Other repair of urinary bladder 911,000 1,500,000 2,411,000
72 Sialo lithiasis (ekstraksi batu dan marsupiasisasi) 911,000 1,500,000 2,411,000
Urethro litotomi batu uretra anterior dengan atau tanpa
73 911,000 1,500,000 2,411,000
meatothomy (dengan GA)
74 Cistectomy ginjal 911,000 1,500,000 2,411,000
75 Divertikulektomy urethra 911,000 1,500,000 2,411,000
76 Insersi DJ Stent 911,000 1,500,000 2,411,000
77 Insersi selang tenckhof CAPD 911,000 1,500,000 2,411,000
78 pungsi dan sklesrosing kista ginjal 911,000 1,500,000 2,411,000
79 Repair fistel urethra 911,000 1,500,000 2,411,000
80 Skrotoplasty 911,000 1,500,000 2,411,000
81 Urethrolithotomy (GA) 911,000 1,500,000 2,411,000
82 Percutaneous cystostomy (closed cystotomy) 658,000 1,000,000 1,658,000
83 Spermatocele 658,000 1,000,000 1,658,000
Urethro litotomi batu uretra anterior dengan atau tanpa
84 658,000 1,000,000 1,658,000
meatothomy (dengan LA)
85 Vitrektomi 658,000 1,000,000 1,658,000
86 Spermatokelectomy 658,000 1,000,000 1,658,000
87 Dilantasi uretra/bouginasi caterisasi 355,000 600,000 955,000
88 Vasectomi LA 355,000 600,000 955,000
89 Biopsi testis 152,000 300,000 452,000
90 Circumsisi dengan LA (local anaesthesia) 152,000 300,000 452,000
91 Biopsi penis 152,000 300,000 452,000
92 Cabut DJ stent 355,000 600,000 955,000
93 Circumsisi dengan GA (general anaesthesia) 355,000 600,000 955,000
94 Meatotomy 355,000 600,000 955,000
95 Operasi priapismus winter's procedure 355,000 600,000 955,000
96 Panendoscopy 355,000 600,000 955,000
97 Sitoscopy 355,000 600,000 955,000
98 Vasectomy (narkose) 355,000 600,000 955,000
Page 21 of 53
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Pelayanan
99 Casting 253,000 500,000 753,000

100 Transurethral prostatectomy 2,277,000 3,500,000 5,777,000
101 Uretero litotomi batu ureter 1/3 distal + neo implantasi ureter 2,277,000 3,500,000 5,777,000
102 Nefrolithotomy 1,771,000 3,000,000 4,771,000
G OPERASI BEDAH THORAX KARDIO VASKULER( BTKV )

1 Sternotomy pada tumor mediastinum 3,036,000 4,554,000 7,590,000
2 Thorakotomy lobectomy tumor paru 3,036,000 4,554,000 7,590,000
3 Thorakotomy pada PDA (patent ductus ateriosus persistent) 3,036,000 4,554,000 7,590,000
4 Thoraktomy pada tamponade jantung 3,036,000 4,554,000 7,590,000
5 Internal fiksasi (pasang shapp plate) fraktur costae multiple 2,277,000 3,416,000 5,693,000
6 Repair vascular dg graft 2,277,000 3,416,000 5,693,000

7 Tendon transfer 2,277,000 3,416,000 5,693,000
8 Thorakotomy pada emphiema 2,277,000 3,416,000 5,693,000
9 Thorakotomy pada hematothotax 2,277,000 3,416,000 5,693,000
10 Thorakotomy pada hematothotax dg lobectomy paru 2,277,000 3,416,000 5,693,000
11 Thoraktomy pada tumor pleura 2,277,000 3,416,000 5,693,000

12 Anastomose vascular end to end 1,771,000 3,000,000 4,771,000
13 Fraktur costae dg internal fiksasi (pasang shapp plate) multiple 1,771,000 3,000,000 4,771,000
14 Repair vascular 1,771,000 3,000,000 4,771,000

15 Vasografi 1,417,000 2,500,000 3,917,000
16 Eksisi hemangioma 1,164,000 2,000,000 3,164,000
17 Skin graft flap sederhana 1,164,000 2,000,000 3,164,000
18 A-V Shunt (cimino) 911,000 1,500,000 2,411,000
19 Debridement excisional of wound 911,000 1,500,000 2,411,000
20 Debridement incisi & drainage septic arthritis 911,000 1,500,000 2,411,000
21 Nevus pigmentosus (eksisi) dengan GA 658,000 1,000,000 1,658,000
22 Incisi abces dengan GA (general anaesthesia) 355,000 600,000 955,000
23 Pasang WSD 550,000 150,000 700,000
24 Electro encephalography (EEG) 152,000 300,000 452,000
25 Incisi abces dengan LA (Local anaesthesia) 152,000 300,000 452,000
26 Pasang central venous presure (CVP/CVC) 600,000 100,000 700,000 tidak termasuk
selang,needle,botol,
27 Double lumen 1,417,000 2,500,000 3,917,000 BMHP
H OPERASI BEDAH PLASTIK

1 Fraktur maxilla lefolt III (internal fiksasi) 1,771,000 3,000,000 4,771,000
2 Neo Implantasi boary flap 2,277,000 4,000,000 6,277,000
3 Labio genatopalatoschisis 1,771,000 3,000,000 4,771,000
4 Other operations on mouth and face 1,771,000 3,000,000 4,771,000
5 Other reconstruction of the toe 1,771,000 3,000,000 4,771,000
6 Rekonstruksi kelopak mata berat 1,771,000 3,000,000 4,771,000
7 Rekonstruksi sindaktili 1,771,000 3,000,000 4,771,000
8 Rekonstruksi digiti 1,771,000 3,000,000 4,771,000
9 Release kontraktur luas 1,771,000 3,000,000 4,771,000
10 Fraktur hemimaksila (internal fiksasi) 1,417,000 2,500,000 3,917,000
11 Fraktur mandibula simple (internal fiksasi) 1,417,000 2,500,000 3,917,000
Page 22 of 53
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12 Fraktur maxila lefolt I (internal fiksasi) 1,417,000 2,500,000 3,917,000

13 Other tendon lengthening 1,417,000 2,500,000 3,917,000
14 Palatoplasty 1,417,000 2,500,000 3,917,000
15 Partial Nefrektomi 1,417,000 2,500,000 3,917,000
16 Pedicle flaps sederhana 1,417,000 2,500,000 3,917,000
17 Reduksi macrodactili 1,417,000 2,500,000 3,917,000
18 Release chordae(release of chordae) 1,417,000 2,500,000 3,917,000
19 Repair ruptur palpebra transkanal dengan GA 1,417,000 2,500,000 3,917,000
20 Repair ruptur moderate 1,417,000 2,500,000 3,917,000
21 Tendon transfer for stabilization of patella 1,417,000 2,500,000 3,917,000
22 FTSG (full-thickness skin graft to other sites) 1,164,000 2,000,000 3,164,000
23 Labioplasti/repair of cleft lip 1,164,000 2,000,000 3,164,000
24 Rekonstruksi palpebra 1,164,000 2,000,000 3,164,000
25 Relese kontraktur sederhana 1,164,000 2,000,000 3,164,000
26 Skin graft (STSG) 1,164,000 2,000,000 3,164,000
27 STSG (skinn graf : free skin graft) 1,164,000 2,000,000 3,164,000
28 Debridement infection or burn 910,800 1,500,000 2,410,800
29 Fasciotomy 911,000 1,500,000 2,411,000
30 Fraktur alfeolaris (pasang archbar) 911,000 1,500,000 2,411,000
31 Couterisasi clavus/veruca dengan GA 658,000 1,000,000 1,658,000
32 Eksisi keloid dengan GA (general anaesthesia) 658,000 1,000,000 1,658,000
33 Fiksasi arch bar dengan GA 658,000 1,000,000 1,658,000
34 Finger tip injury (repair v-y flap) dg GA 658,000 1,000,000 1,658,000
35 In growing nail (ekstraksi kuku) dg GA 658,000 1,000,000 1,658,000
36 Re hechting dengan GA 658,000 1,000,000 1,658,000
37 Re hechting dengan GA pada burst abdomen 658,000 1,000,000 1,658,000
38 Rekonstruksi polidaktili 658,000 1,000,000 1,658,000
39 Couterisasi clavus/veruca dengan LA 355,000 700,000 1,055,000
40 Jahit luka diwajah dengan GA (general anasthesia) 355,000 700,000 1,055,000
41 Lobuloplasty bilateral 355,000 700,000 1,055,000
42 Lobuloplasty unilateral 355,000 700,000 1,055,000
43 Parasentesa BMD 355,000 700,000 1,055,000
Suture of laceration of other part of mounth dengan GA (general
44 355,000 700,000 1,055,000
anaesthesia)
45 Explorasi corpus alienum simple dengan LA 253,000 500,000 753,000
46 Jahit luka diwajah dengan LA (local anasthesia) 253,000 500,000 753,000
47 Eksisi keloid dengan LA (local anaesthesia) 152,000 300,000 452,000
48 Incisi pada hidung 152,000 300,000 452,000
49 Injeksi sub konjungtiva 152,000 300,000 452,000
50 Jahit palpebra kecil 152,000 300,000 452,000
51 Nevus pigmentosus (eksisi) dengan LA 152,000 300,000 452,000
52 Re hechting dengan LA 152,000 300,000 452,000
53 Excisi wajah 152,000 300,000 452,000
54 Glossectomy total (complet) 152,000 300,000 452,000
I OPERASI BEDAH TRAUMA

1 Internal bleeding ruptur ginjal/hepar/lien/sebab lain 2,277,000 3,500,000 5,777,000
2 Amputasi forequarter 1,771,000 3,000,000 4,771,000
3 Amputasi hindquarter 1,771,000 3,000,000 4,771,000
4 Fraktur mandibula complicated (internal fiksasi) 1,771,000 3,000,000 4,771,000
Page 23 of 53
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5 Fraktur mandibula simple (internal fiksasi + pasang arch bar) 1,771,000 3,000,000 4,771,000
6 Fraktur maxilla lefolt II (internal fiksasi) 1,771,000 2,657,000 4,428,000

7 Repair old perineal ruphture 1,164,000 2,000,000 3,164,000
8 Repair tendon achiles complicated 1,164,000 2,000,000 3,164,000
9 Ekstirpasi korpal dengan penyulit (GA) 911,000 1,367,000 2,278,000
10 Repair tendon achiles 911,000 1,367,000 2,278,000
11 Repair tendon ekstersor pedis 911,000 1,367,000 2,278,000
12 Repair tendon fleksor pedis 911,000 1,367,000 2,278,000
13 Repair tendon patella 911,000 1,367,000 2,278,000
14 Tendon achiles lengthening 911,000 1,367,000 2,278,000
15 Repair tendon fleksor/ekstensor pedis 658,000 987,000 1,645,000
16 Repair tendon fleksor/ekstensor manus (1 tendon) 658,000 987,000 1,645,000
17 Tracheostomi permanent 658,000 987,000 1,645,000
18 Transfusi tukar 658,000 987,000 1,645,000
19 Explorasi corpus alienum dengan penyulit 355,000 550,000 905,000
20 Finger tip injury (repair v-y flap) dengan LA 355,000 550,000 905,000
21 Tracheostomi temporer 355,000 550,000 905,000
22 Repair tendon sederhana (1 tendon) 253,000 550,000 803,000
23 Extraksi corpus alienum sederhana (bedah) 152,000 550,000 702,000
J OPERASI OBSTETRI DAN GINEKOLOGI(OBSGIN)

1 Supra vaginal histeroctomy/total abdominal histerectomy 2,277,000 3,416,000 5,693,000
2 Cystektomi/ovarektomi bilateral 1,771,000 2,657,000 4,428,000

3 Miomektomi 1,771,000 2,657,000 4,428,000
4 Repeated sectio caesaria 1,771,000 2,657,000 4,428,000
5 Salphingo oophorectomy bilateral 1,771,000 2,657,000 4,428,000
6 Salphingo oophorectomy unilateral 1,771,000 2,657,000 4,428,000
7 Sectio caesaria 2,070,000 2,875,000 4,945,000
8 Sectio caesaria + cystektomy/ovarektomy bilateral 2,300,000 3,416,000 5,716,000
9 Sectio caesaria + cystektomy/ovarektomy unilateral 2,300,000 3,416,000 5,716,000
10 Sectio caesaria + miomektomy 2,300,000 3,416,000 5,716,000
11 Sectio caesaria + salphingo oophorectomy bilateral 2,300,000 3,416,000 5,716,000
12 Sectio caesaria + salphingo oophorectomy unilateral 2,300,000 3,416,000 5,716,000

13 Sectio caesaria + tubektomy pomeroy 2,300,000 3,416,000 5,716,000
14 Sectio caesaria gemelly 2,185,000 3,105,000 5,290,000
15 Vaginal histerectomy 1,771,000 2,657,000 4,428,000
16 Vaginal reconstruction 1,771,000 2,657,000 4,428,000
17 Cystektomi/ovarektomi unilateral 1,164,000 1,746,000 2,910,000
18 Vaginoplasty 1,164,000 1,746,000 2,910,000
19 Curettage abortus incipien (inkomplit) 658,000 1,100,000 1,758,000
20 Curettage HPP (late HPP) 658,000 1,100,000 1,758,000
21 Curettage meno (metorrhagia) 658,000 1,100,000 1,758,000
22 Curettage missed abortion (death conceptus, blighted ovum) 658,000 1,100,000 1,758,000
23 Curettage molla hydatidosa 658,000 1,100,000 1,758,000

24 Incisi hymen imperforate 658,000 1,100,000 1,758,000
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25 Kista dermoid eksisi dengan GA 658,000 1,100,000 1,758,000

26 Repair perineum/vagina (perineoraphy) 658,000 1,100,000 1,758,000
27 Repair vagina/cerviks/portio 658,000 1,100,000 1,758,000
28 Seconderi repair ephisiotomi 658,000 1,100,000 1,758,000
29 Tubektomy laparoscopy 658,000 1,100,000 1,758,000
30 Tubektomy laparoscopy 658,000 1,100,000 1,758,000
31 Tubektomy minilaparotomy 658,000 1,100,000 1,758,000
32 Eksterpasi cysta bartolin 355,000 550,000 905,000
33 Kista dermoid eksisi dengan LA 355,000 550,000 905,000
34 Extirpasi tumor jinak vagina 253,000 380,000 633,000
35 Dermaroller platellet rich plasma (PRP) 253,000 380,000 633,000
36 Insisi absces bartholini + marsupialisasi 253,000 380,000 633,000
37 Reposisi inversio uteri 253,000 380,000 633,000
38 Extirpasi polip cervik 152,000 300,000 452,000
39 Extraksi corpus alienum vagina 152,000 250,000 402,000
40 Salphingo/Oophorectomy 1,417,000 2,126,000 3,543,000
41 Total abdominal hysterektomy + bisalphingoo oophorectomy 2,277,000 3,416,000 5,693,000
K OPERASI MATA
1 Disisi aspirasi katarak dengan GA 1,417,000 2,126,000 3,543,000
2 Repair ruptur cornea sclera dengan GA 1,417,000 2,126,000 3,543,000
3 Ekstraksi katarak pasang IOL 1,417,000 2,126,000 3,543,000
4 Koreksi entropion 1,540,000 2,310,000 3,850,000
5 Koreksi extropion 1,164,000 1,746,000 2,910,000
6 Koreksi simblepharon 1,164,000 1,746,000 2,910,000
7 Repari ruptur cornea sclera 1,164,000 1,746,000 2,910,000
8 Saucerization 1,164,000 1,746,000 2,910,000
9 Sequestrectomy 1,164,000 1,746,000 2,910,000
10 Jahit lid mirgin 911,000 1,467,000 2,378,000
11 Kanalisasi lakrimal 911,000 1,467,000 2,378,000
12 Repair laserasi konjungtiva 911,000 1,467,000 2,378,000
13 Repair laserasi kornea 911,000 1,467,000 2,378,000
14 Repair laserasi sclera 911,000 1,467,000 2,378,000
15 Repair ruptur palpebra simple 911,000 1,467,000 2,378,000
16 Repair ruptur palpebra transkanal 911,000 1,467,000 2,378,000
17 Aspirasi katarak sekunder 658,000 987,000 1,645,000
18 Extirpasi pterygium 658,000 987,000 1,645,000
19 Flap konjungtiva 658,000 987,000 1,645,000
20 Hymenorapi 658,000 987,000 1,645,000
21 Repair ruptur cornea 658,000 987,000 1,645,000
22 Repair ruptur konjungtiva 658,000 987,000 1,645,000
23 Eksisi calazion 355,000 532,000 887,000
24 Eksisi hordiolum 355,000 532,000 887,000
25 Ekstirpasi granuloma 355,000 532,000 887,000
26 Ekstraksi lithiasis 355,000 532,000 887,000
27 Insisi cornea 355,000 532,000 887,000
28 Irigasi trauma kimia perdrip 355,000 532,000 887,000
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29 Sondage canaliculi lacrimalis 355,000 532,000 887,000

30 Skarping cornea 253,000 380,000 633,000
31 Ekstrasi corpus alienum cornea 152,000 228,000 380,000
L OPERASI TELINGA HIDUNG TENGGOROKAN (THT)

1 Tonsilektomi 911,000 1,367,000 2,278,000
2 Exstraksi polip nasi 658,000 987,000 1,645,000
3 Irigasi sinus 152,000 228,000 380,000
4 Anastesi 115,000 300,000 415,000
5 Adenotonsilectomy 2,277,000 3,416,000 5,693,000
6 Ethmoidektomy 1,417,000 2,126,000 3,543,000
7 Faringectomy 1,771,000 2,657,000 4,428,000
IV. PELAYANAN TINDAKAN MEDIK OPERATIF TIDAK TERENCANA/ EMERGENCY/ CYTO
* tarif dikalikan 25% dari tindakan medik operatif pada tarif

pada masing masing item (JP + JS)
V. PELAYANAN TINDAKAN MEDIK NON OPERATIF

1 Peritonial Dialisis 226,000 338,000 564,000
2 Injeksi LP Intratekal 58,000 90,000 148,000
3 Injeksi LP Epidural 58,000 90,000 148,000
4 Injeksi Impletol 3,000 5,000 8,000
5 Etanol Terapi Tumor Hati 115,000 173,000 288,000
6 Pasang Sonde 3,000 4,000 7,000
7 Pasang Skin Traction 28,000 42,000 70,000
8 Skleroterapi 299,000 449,000 748,000
9 Injeksi Intranodul 14,000 30,000 44,000
10 Esofagogastroduodenoskopi 138,000 207,000 345,000
11 Esofagogastroduodenoskopi dengan biopsi 207,000 311,000 518,000
12 Kolonoskopi 230,000 345,000 575,000
13 Kolonoskopi dengan biopsi 322,000 483,000 805,000
14 Ligasi Varises 368,000 552,000 920,000
15 Polipektomi 414,000 621,000 1,035,000
16 Dilatasi Esofagus 368,000 552,000 920,000
17 Clip 414,000 621,000 1,035,000
18 Regulasi Hemostatis 368,000 552,000 920,000
19 Bronkoskopi dengan biopsi 184,000 276,000 460,000
20 Bronkoskopi dengan brushing 230,000 345,000 575,000
21 Bronkoskopi dengan washing 230,000 345,000 575,000
22 BAL 230,000 345,000 575,000
23 Bronkoskopi pengambilan benda asing 368,000 552,000 920,000
24 Aspirasi mucous 368,000 552,000 920,000
25 Pungsi Lever 230,000 345,000 575,000
26 Tindakan pemberian Sitostatika / Kemoterapi 92,000 138,000 230,000
27 Pemasangan Water Seal Drainage / WSD 550,000 150,000 700,000
VI. PELAYANAN KEGAWAT DARURATAN / INSTALASI GAWAT DARURAT (IGD)
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A RUANG RAWAT DARURAT

1 Ruang Observasi Reguler/P3
- Akomodasi / Jam 2,500 2,500
- Visite Dokter Umum 18,000 6,000 24,000
- Visite Dokter / Konsul Spesialis On Site 23,000 6,000 29,000
- Jasa Keperawatan 25,000 25,000
2 Ruang High Care/P2
- Akomodasi / Jam - 3,000 3,000
- Visite dokter umum 23,000 6,000 29,000
- Visite dokter / konsul spesialis on site 46,000 6,000 52,000
- Jasa Keperawatan 35,000 35,000
3 Ruang observasi intensive/P1
- Akomodasi / Jam - 4,500 4,500
- Visite dokter umum 46,000 20,000 66,000
- Visite dokter / konsul spesialis on site 92,000 25,000 117,000
- Jasa Keperawatan 45,000
B TINDAKAN UMUM
1 Injeksi im (intra muskular) per kali 2,500 7,500 10,000
2 Injeksi iv (intra vena) per kali 2,500 7,500 10,000
tidak termasuk spuit
3 Injeksi ic (intra cutan)per kali 2,500 7,500 10,000
4 Injeksi sc (sub cutan)per kali 2,500 7,500 10,000
5 Pasang infus dewasa 9,000 6,000 15,000
tidak termasuk iv cateter
6 Pasang infus anak / bayi 12,000 8,000 20,000 dan infuset
7 Ambil sampel darah vena 3,000 4,000 7,000
Tidak Termasuk Biaya
8 Ambil sampel darah arteri 15,000 5,000 20,000 Spuid
9 Pasang NGT dewasa 30,000 30,000 60,000
10 ###Pasang NGT anak / bayi 30,000 30,000 60,000
11 Pasang folley cateter 10,000 25,000 35,000
12 ECG 25,000 35,000 60,000
13 Pemeriksaan glukotest 10,000 15,000 25,000
14 suppositoria 5,000 5,000 10,000
15 Pemasangan Kondom Cateter 15,000 5,000 20,000
16 Ambil Sample Urine 1,000 2,000 3,000
17 Aff Infus/NGT/Urine/Catether 2,000 2,000 4,000
18 Persiapan Pre Operasi 6,000 9,000 15,000
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C TINDAKAN KHUSUS EMERGENCY

1 Pasang mayo / oropharengeal tube* 7,500 7,500 15,000
2 Suction aktif / slem suction* 5,000 10,000 15,000 tidak termasuk selang
tidak termasuk tube,

3 Pasang ETT + RSI 710,000 150,000 860,000 oksigen
4 Pasang ETT tanpa RSI 360,000 100,000 460,000
5 Needle cricothyroidectomy 115,000 115,000 230,000 tidak termasuk needle
6 Pasang neck collar 5,000 15,000 20,000 tidak termasuk collar
tidak termasuk
7 Punctie pleural 173,000 230,000 403,000 selang,needle,botol,
BMHP
tidak termasuk
8 Punctie ascites 115,000 173,000 288,000 selang,needle,botol,
BMHP
9 Punctie blast 92,000 138,000 230,000 tidak termasuk needle
tidak sudah termasuk

10 Cytostomi 173,000 173,000 346,000 alat dan BMHP
tidak sudah termasuk

11 Pemasangan cateter vena central(CVC) 600,000 100,000 700,000 cateter vena central,
oksigen
12 Pemasangan cateter intra osseus /umbilical,vena dalam 92,000 138,000 230,000
sudah termasuk iv
13 Pemasangan vena sectie 144,000 144,000 288,000 cateter, infus set
14 Needle chest 35,000 52,000 87,000 tidak tmsk needle

tidak termasuk
15 Cricothroidectomy 805,000 575,000 1,380,000 tube,oksigen
16 Pemasangan monitor vital sign/jam 21,000 14,000 35,000
17 sewa monitor vital sign/ jam 3,000 7,000 10,000
18 Pemasangan syringe pump 7,000 11,000 18,000
19 Sewa syringe pump 1,500 2,000 3,500
20 Pemasangan infussion pump 7,000 11,000 18,000
21 Sewa infussion pump 1,500 2,000 3,500
sudah termasuk
22 Therapi inhalasi tanpa obat / Nebulizer per kali 10,000 14,000 24,000 oksigen,tidak termasuk
masker
23 Pemasangan ventilator 92,000 138,000 230,000
24 Sewa Ventilator 2,000 10,000 12,000
25 Pemasangan infus warmer 5,000 7,000 12,000
26 Pemasangan infant warmer 5,000 10,000 15,000
27 Resusitasi Jantung Paru 115,000 - 115,000
28 defribrilator / DC shock 92,000 138,000 230,000
29 Manual ventilasi / jam 5,000 7,000 12,000
30 kardioversi 100,000 75,000 175,000
31 Slim Suction/kali 7,500 7,500 15,000
32 RJP tanpa defibilator 50,000 70,000 120,000
33 RJP dengan Defibilator 100,000 130,000 230,000
34 Pasang SPO2 10,000 13,000 23,000
35 Pemasangan Oksigen 3,000 - 3,000
36 Penggunaan Oksigen per liter/menit - 200 200
37 Nebulizer perkali dengan obat 12,000 18,000 30,000
38 pemasangan Monitor Vital sign perjam 21,000 14,000 35,000
39 sewa monitor vital sign/ jam 3,000 7,000 10,000
40 Ekstraksi Corpus Alienum
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- Ringan 15,000 20,000 35,000

- Sedang 30,000 30,000 60,000
- Berat 40,000 50,000 90,000
41 Irigasi Lambung 100,000 75,000 175,000
42 USG Dopler Colour (3D/ 4D) 150,000 300,000 450,000
43 Usg Emergency 130,000 160,000 290,000
44 Pemasangan Pacemaker Temporer 300,000 700,000 1,000,000
45 sewa alat monitor / jam 3,000 7,000 10,000
46 Rawat Luka
a. Kecil (< 5 cm) 7,000 11,000 18,000
b. Sedang (5-10 cm) 10,000 15,000 25,000
c. Besar (10-20 cm) 17,500 40,000 57,500
d. Khusus (> 20 cm) 35,000 45,000 80,000
47 Rawat luka bakar < 10 % 12,000 25,000 37,000
48 Rawat luka bakar 10 - 50 % 23,000 50,000 73,000
49 Rawat luka bakar > 50 % 46,000 80,000 126,000
50 Debridemant dan necrotomy
- Luka kecil 12,000 25,000 37,000
- Luka sedang 19,000 35,000 54,000
- Luka Luas 28,000 50,000 78,000
51 Amputasi sendi kecil 92,000 300,000 392,000
52 Cross incisi 19,000 250,000 269,000
53 Nail Ekstrasi 17,000 13,000 30,000
54 Gips 58,000 300,000 358,000 tidak termasuk gips
tidak termasuk ransel

55 Ransel verband 23,000 35,000 58,000 verband
56 Imobilisasi Fraktur dengan spalk

kecil 10,000 35,000 45,000
sedang 15,000 45,000 60,000 sudah termasuk spalk
besar 20,000 55,000 75,000

57 Immobilisasi fraktur dengan back slab 28,000 42,000 70,000 tidak termasuk gips
58 imobilisasi fraktur dengan verban

kecil 7,500 17,500 25,000
sedang 10,000 20,000 30,000
besar 15,000 40,000 55,000

- Kecil (< 5 Jahitan) 25,000 35,000 60,000

- Besar (10 - 20 jahitan) 40,000 55,000 95,000
- Khusus (>20 Jahitan) 50,000 70,000 120,000
60 Incisi abses 50,000 47,500 97,500
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61 Ekstraksi korpus alienum THT/mata/kulit 14,000 21,000 35,000

- Ringan 14,000 21,000 35,000
- Sedang 23,000 35,000 58,000
- Berat 35,000 52,000 87,000
62 Ekstraksi batu urethra antherior 35,000 52,000 87,000
63 Tindakan lavement/spoeling 14,000 21,000 35,000
64 Tindakan reposisi:
- kecil 23,000 35,000 58,000
- sedang 23,000 35,000 58,000
- besar 23,000 35,000 58,000
65 Pemasangan tampon* 10,000 14,000 24,000
66 Pelepasan tampon 5,000 7,000 12,000
67 Angkat Jahitan
- Kecil (< 5 Jahitan) 8,000 12,000 20,000
- Besar (10 - 20 Jahitan) 20,000 25,000 45,000
- khusus 25,000 35,000 60,000
68 Aff infus / NGT / Cateter Urine 2,000 2,000 4,000
69 Pemasangan WSD 550,000 150,000 700,000
70 pemasangan Transfusi darah per kali 15,000 5,000 20,000
71 Jahit luka di wajah dengan LA (Kosmetik) 350,000 225,000 575,000 Tidak termasuk BMHP
72 jahit telinga 70,000 50,000 120,000 Tidak termasuk BMHP
C PELAYANAN KANDUNGAN dan KEBIDANAN

1 USG Obgyn tanpa Print 50,000 30,000 80,000
2 USG Obgyn dengan Print 50,000 50,000 100,000
3 Pemeriksaan Ginekologi 15,000 10,000 25,000
4 pemeriksaan Obstetri 15,000 10,000 25,000
5 persalinan Normal 600,000 150,000 750,000
E PELAYANAN PREHOSPITAL DAN RUJUKAN

1 Sewa ambulance BLS ( Team ) penyeberangan
- Antar / jemput dalam kota 80,000 120,000 200,000 prwt+sopir
- Luar kota / kilometer 2,000 3,000 5,000 Tarif PP, Sopir
2 Sewa ambulance ALS ( Team ) penyeberangan
- Antar / jemput dalam kota / 100,000 150,000 250,000 prwt+sopir
- Luar kota / kilometer 2,000 3,500 5,500 sopir
3 Dokter umum / 24 jam 1,150,000 - 1,150,000 Sesuai indikasi medis
4 Dokter spesialis / 24 jam 2,875,000 - 2,875,000 Sesuai indikasi medis

5 Perawat / 24 jam 400,000 - 400,000
6 Sopir 300,000 - 300,000
VII. PELAYANAN RAWAT INAP DAN KEPERAWATAN

A PELAYANAN TINDAKAN KEPERAWATAN
1 Minimal Care per hari 20,000 20,000
2 Moderate Care per hari 25,000 25,000
3 High Care per hari 30,000 30,000
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4 Intensif Care per hari 50,000 50,000
B PELAYANAN TINDAKAN RAWAT INAP

1 Pemeriksaan oleh dokter jaga 7,500 12,500 20,000
2 Pemeriksaan pasien rawat inap gawat oleh dokter jaga 15,000 10,000 25,000
3 Pasang infus dewasa 9,000 6,000 15,000
4 Pasang infus anak / bayi 12,000 8,000 20,000
5 Rawat Lokasi infus per hari / Shift 2,000 5,000 7,000
6 Rawat Luka
a. Kecil (< 5 cm) 7,000 11,000 18,000
b. Sedang (5-10 cm) 10,000 15,000 25,000
c. Besar (10-20 cm) 17,500 40,000 57,500
d. Khusus (> 20 cm) 30,000 50,000 80,000
7 Rawat luka bakar < 10 % 12,000 25,000 37,000

8 Rawat luka bakar 10 - 50 % 23,000 50,000 73,000
9 Rawat luka bakar > 50 % 46,000 80,000 126,000
10 infus tali pusat 69,000 104,000 173,000
11 Necrotomy jaring ( kecil ) 10,000 15,000 25,000
12 Angkat Jahitan
- Kecil (< 5 Jahitan) 8,000 12,000 20,000
- Besar (10 - 20 Jahitan) 20,000 25,000 45,000
- khusus > 20 25,000 35,000 60,000
13 Pasang tampon 10,000 14,000 24,000
14 Aff Tampon 8,000 4,000 12,000
15 Memandikan bayi/kali 12,000 18,000 30,000
16 Memandikan Pasien/kali 12,000 18,000 30,000 sesuai indikasi
17 Keramas pasien/kali 10,000 10,000 20,000 sesuai indikasi
18 Injeksi im (intra muskular) per kali 2,500 7,500 10,000

19 Injeksi iv (intra vena) per kali 2,500 7,500 10,000
20 Injeksi ic (intra cutan)per kali 2,500 7,500 10,000
21 Injeksi sc (sub cutan)per kali 2,500 7,500 10,000
22 Skin Test 3,000 4,000 7,000
23 Memberi Obat melalui Gastrotomy 3,000 4,000 7,000
24 Memberi Obat Supositoria 4,000 6,000 10,000
25 Penanganan Pre Operasi 10,000 1,000 11,000
26 Pasang Fowley Cateter* 10,000 25,000 35,000
27 Pasang Kondom Cateter* 15,000 5,000 20,000
28 Pasang Bidai* 5,000 7,000 12,000
29 Pasang Neck Collar * 5,000 15,000 20,000
30 Penanganan Keracunan 23,000 18,000 41,000
31 Perawatan Payudara 5,000 7,000 12,000
32 Perawatan WSD 12,000 18,000 30,000
33 Perawatan Kolostomy / Iliestomy 5,000 7,000 12,000
34 Resusitasi Jantung Paru 58,000 58,000 116,000
35 Pasang NGT Dewasa / Anak 30,000 30,000 60,000
tidak termasuk tube
36 Pasang ETT 805,000 575,000 1,380,000
oksigen
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37 Pasang Mayo / Oroparingeal 7,500 7,500 15,000

38 Aff infus 2,000 2,000 4,000
39 Aff NGT 2,000 2,000 4,000
40 Aff Cateter Urine 2,000 2,000 4,000
41 Perawatan Tracheostomy 5,000 7,000 12,000
42 Irigasi Mata 12,500 12,500 25,000
43 ECG 25,000 35,000 60,000
44 Ambil sampel darah vena 3,000 4,000 7,000
45 ambil sampel darah arteri 5,000 15,000 20,000
46 SAMPEL URINE 1,000 2,000 3,000
47 Irigasi Lambung 100,000 75,000 175,000
48 Irigasi Telinga 30,000 30,000 60,000
49 Pemasangan WSD ? Sama seperti poli dan IGD 550,000 150,000 700,000
50 RJP dengan Defib 100,000 130,000 230,000
51 Penggunaan Oksigen ( O2)
- Pemakaian O2 1 Ltr/Mnt 130 130
- pemasangan O2 per kali tanpa ventilator 3,000 3,000
52 Suctioning* 5,000 7,000 12,000
53 Therapi Inhalasi tanpa obat / Nebuizer per kali 10,000 14,000 24,000
54 irigasi BPH/hari 23,000 12,000 35,000
55 Spoeling BPH/kali 5,000 7,000 12,000
56 Klisma / Huknah 5,000 7,000 12,000
57 Postural Drainase 10,000 14,000 24,000
58 Rawat lokasi iv /kali 2,000 3,000 5,000
59 Pemasangan Sonde 7,500 7,500 15,000
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VIII. PELAYANAN KEBIDANAN

A PERSALINAN PERVAGINAM
1 Partus Spontan 600,000 150,000 750,000
2 Partus Vacum Ekstraksi 1,000,000 300,000 1,300,000
3 Kelainan Letak ( Sungsang/ lintang / Oblique) 1,000,000 300,000 1,300,000
4 Persalian Gemeli 1,000,000 300,000 1,300,000
B PENYULIT PENYERTA -
1 Embriotomi 2,000,000 1,500,000 3,500,000
2 Laparotomi 3,800,000 2,000,000 5,800,000
3 Versi Ekstraksi 400,000 100,000 500,000
4 Induksi ( Drip Oksitoksin/Ripening Misoprostol) 400,000 100,000 500,000
5 Manual Plasenta 400,000 100,000 500,000
6 Rehidrasi 75,000 15,000 90,000
7 HPP 250,000 100,000 350,000
8 Perineorhaphy ( Drajad 3 dan 4 ) 200,000 250,000 450,000
9 Atonia Uteri ( KBI / KBE ) 200000 150,000 350,000
10 Insersi IUD 100,000 25,000 125,000
C ABORTUS -
1 Spontan 400,000 200,000 600,000
2 Induksi 600,000 200,000 800,000
3 Curettage 1,050,000 150,000 1,200,000
D NEONATAL CARE -
1 Pemasangan Infant Warmer 5,000 10,000 15,000
2 Resusitasi Bayi baru Lahir ( VTP / Komprensi Dada) 90,000 60,000 150,000
3 Suctioning 10,000 15,000 25,000
4 Perawatan Tali pusat 5,000 5,000 10,000
5 Pasang Infus Bayi / Mikro 12,000 8,000 20,000
6 Pemasangan SPO2 10,000 13,000 23,000
E TINDAKAN -
1 VT 10,000 5,000 15,000
2 DJJ 5,000 5,000 10,000
3 USG Tanpa Print 50,000 30,000 80,000
4 USG Dengan Print 50,000 50,000 100,000
5 CTG 50,000 30,000 80,000
6 Injeksi ( IM/IV/IC/SC ) 2,500 7,500 10,000
7 Pasang Infus Makro 9,000 6,000 15,000
8 Pasang Folley Cateter 10,000 25,000 35,000
9 Pasang Tampon 10,000 14,000 24,000
10 Pasang NGT 30,000 30,000 60,000
11 Pasang O2 dengan / tanpa Ventilator 8,000 15,000 23,000
12 Ambil Sampel Darah 1,000 2,000 3,000
13 Ambil Sample Urine 1,000 2,000 3,000
14 Ambil Sample Sputum 1,000 2,000 3,000
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15 Pemakainan O2/ liter/ jam 110 110

16 AFF Cateter 2,000 2,000 4,000
17 Aff Infus 2,000 2,000 4,000
18 Aff Tampon 2,000 2,000 4,000
19 Aff NGT 2,000 2,000 4,000
20 Aff O2 2,000 2,000 4,000
21 Persiapan Operasi 10,000 1,000 11,000
22 Perawatan Jenazah BBL 150,000 50,000 200,000
F TINDAKAN NIFAS -
1 Skin Test 3,000 4,000 7,000
2 pemeriksaan ginekologi 15,000 10,000 25,000
3 memandikan bayi 15,000 15,000 30,000
4 Perawatan Tali Pusat 5,000 5,000 10,000
5 Massage Bayi 15,000 10,000 25,000
6 Perawatan Payudara 5,000 7,000 12,000
7 rawat lokasi iv / kali 2,000 3,000 5,000
IX. PELAYANAN ICU/NICU

1 Tarif visite dokter / Intensiv / Konsultasi antar SMF 90,000 90,000
2 Visite Dokter Umum/Kali 40,000 40,000
3 Jasa Keperawatan ICU / hari 60,000 - 60,000
TINDAKAN
1 Pemasangan monitor vital sign 21,000 14,000 35,000
2 Sewa alat dan monitoring per jam 3,000 7,000 10,000
3 Bedside monitor / hari 40,000 7,000 47,000
4 Pasang Syring pump/kali 7,000 11,000 18,000
5 Sewa syring pump/jam 1,500 2,000 3,500
6 Pasang infusion pump/ kali 8,000 12,000 20,000
7 Sewa Infusion pump / jam 1,500 2,000 3,500
8 pasang Ventilator / kali 92,000 138,000 230,000
9 setting Ventilator / kali 115,000 23,000 138,000
10 Observasi Ventilator / hari 100,000 50,000 150,000
11 Sewa Ventilator / jam 2,000 10,000 12,000
12 Pasang Feeding pump / kali 7,000 11,000 18,000
13 Sewa alat Feeding pump / jam 3,000 8,000 11,000
14 Nebulizer dengan obat / kali 12,000 18,000 30,000
15 Nebulizer tanpa obat / kali 14,000 10,000 24,000
16 Pemasangan collarneck / kali 5,000 15,000 20,000
17 Pemasangan LMA / kali 100,000 100,000 200,000
18 Pasang Mayo/ PA per kali 7,500 7,500 15,000
19 Pemasangan warm air set / kali 5,000 7,000 12,000
20 sewa Warm air set / jam 2,000 3,000 5,000
21 pemasangan blanket roll / kali 8,000 10,000 18,000
22 sewa blanket roll / jam 2,000 3,000 5,000
23 pemasangan bed decubal / kali 5,000 7,000 12,000
24 pasang infusion warmer / kali 5,000 7,000 12,000
Page 34 of 53
Jasa
Pelayanan
25 sewa alat decubal / jam 2,000 4,000 6,000

26 Pasang O2 tanpa Ventilator / kali 8,000 15,000 23,000
27 pasang O2 dengan Ventilator / kali 18,000 12,000 30,000
28 Sewa O2 /liter / jam 110 110
29 pasang SPO2 10,000 13,000 23,000
30 Pasang NGT / kali 30,000 30,000 60,000
31 AFF NGT / Kali 2,000 2,000 4,000
32 Irigasi lambung / kali 100,000 75,000 175,000
33 Irigasi mata / kali 12,500 12,500 25,000
34 Pasang ETT + RSI / Kali 710,000 150,000 860,000
35 Pasang ETT Tanpa RSI / Kali 360,000 100,000 460,000
36 Perawatan ETT / kali 5,000 7,000 12,000
37 Ekstubasi 60,000 45,000 105,000
38 tindakan anastesi GA/RA per kali 422,000 500,000 922,000
39 Pasang Kondom Cateter / kali 15,000 5,000 20,000
40 AFF kondom Cateter 2,000 2,000 4,000
41 Pasang Cateter / kali 20,000 15,000 35,000
42 AFF cateter / kali 2,000 2,000 4,000
43 Irigasi BPH / kali 23,000 12,000 35,000
44 Spooling dawer cateter / kali 10,000 14,000 24,000
45 blast Punction / kali 60,000 50,000 110,000
46 Acites puntion / kali 115,000 173,000 288,000
47 Transfusi / kali 15,000 30,000 45,000
48 Injeksi IC / kali 2,500 7,500 10,000
49 Injeksi SC / kali 2,500 7,500 10,000
50 Injeksi IM / kali 2,500 7,500 10,000
51 Injeksi IV / kali 2,500 7,500 10,000
52 Skintest / kali 3,000 4,000 7,000
53 pemberian obat Supositoria / kali 4,000 6,000 10,000
54 Pemberian obat oral / kali 5,000 5,000
55 memberikan obat via sonde / kali 5,000 5,000
56 Huknah / kali 5,000 7,000 12,000
57 GLUkOTEST 10,000 15,000 25,000
58 Pemberian TROMBOLITIK / kali 200,000 50,000 250,000
59 Pasang Infus Dewasa / kali 9,000 6,000 15,000
60 Pasang Infus Anak / Kali 12,000 8,000 20,000
61 AFF Infus 2,000 2,000 4,000
62 Rawat lokasi IV / kali 2,000 3,000 5,000
63 ECG 25,000 35,000 60,000
64 Pemasangan alat pacemaker temporer 300,000 700,000 1,000,000
65 USG Biasa dengan print out / kali 80,000 70,000 150,000
66 USG Biasa tanpa print out / kali 50,000 30,000 80,000
67 USG Emergency / kali 130,000 160,000 290,000
68 Suction / kali 10,000 5,000 15,000
69 Bronchial washing dengan alat / kali 111,000 200,000 311,000
70 Fisioterapi dada / kali 23,000 12,000 35,000
71 Postural drainase / kali 10,000 14,000 24,000
72 Pemasangan WSD / kali 550,000 150,000 700,000
Page 35 of 53
Jasa
Pelayanan
73 Perawatan WSD / kali 12,000 18,000 30,000

74 Needle thoracostomi / kali 42,000 63,000 105,000
75 PLEURAL punction / kali 173,000 230,000 403,000
76 AFF Tampon 8,000 4,000 12,000
77 Pemasangan tampon / kali 10,000 14,000 24,000
78 Personal Hygien ( memandikan ) / kali 12,000 18,000 30,000
79 Oral hygiene / kali 15,000 10,000 25,000
80 Perianal Hygiene / kali 15,000 10,000 25,000
81 Vulava Hygien / kali 15,000 10,000 25,000
82 Keramas Pasien / kali 10,000 10,000 20,000
83 Perawatan Payudara / kali 5,000 7,000 12,000
84 Manual Ventilation / bagging/kali 5,000 7,000 12,000
85 RJP tanpa Defib. / siklus 50,000 70,000 120,000
86 RJP Dengan Defib. / kali 100,000 130,000 230,000
87 Kardioversi / kali 75,000 100,000 175,000
88 Perawatan Jenazah tak beresiko / kali 200,000 75,000 275,000
89 Perawatan Jenazah beresiko / kali 225,000 75,000 300,000
90 Pengambilan sampel vena / kali 3,000 4,000 7,000
91 Pengambian Sampel Arteri / kali 10,000 10,000 20,000
92 pengambilan Sampel urine / kali 1,000 2,000 3,000
93 ambil Spesimen Lab. Sputum / kali 3,000 15,000 18,000
94 Pengembilan Sampel kultur / kali 20,000 30,000 50,000
95 Insisi Abses 20,000 77,500 97,500
96 Pasang cateter CVC / kali 600,000 100,000 700,000
97 AFF CVC 20,000 15,000 35,000
98 Pasang Cateter Vena provunda 23,000 35,000 58,000
99 Pasang cateter arteri / arteri line / kali 230,000 230,000 460,000
100 AFF arteri line / kali 20,000 15,000 35,000
101 Pasang Cateter HD / kali 115,000 115,000 230,000
102 Pasang kateter ntraoseus / intra umbilical / kali 92,000 138,000 230,000
103 Vena Sectie / kali 144,000 144,000 288,000
104 Balance Cairan per kali 10,000 10,000 20,000
105 TRAKEOSTOMI, cricothiroitdectomi/kali 900,000 350,000 1,250,000
106 Perawatan trakeostomi/kali 5,000 7,000 12,000
107 cictotomy/kali 173,000 170,000 343,000
108 Penanganan keracunan /kali 23,000 18,000 41,000
109 Penanganan Pre-operasi/kali 6,000 9,000 15,000
110 Jahit luka kecil (< 5 jahitan) 25,000 35,000 60,000
111 Jahit luka sedang (5-10 Jahitan) 35,000 45,000 80,000
112 Jahit luka besar (>10 jahitan) 40,000 55,000 95,000
113 Rawat luka kecil (< 5cm) 7,000 11,000 18,000
114 Rawat luka sedang (5-10cm) 10,000 15,000 25,000
115 Rawat luka besar (10-20cm) 17,500 40,000 57,500
116 Rawat luka khusus (> 20cm) 35,000 45,000 80,000
Page 36 of 53
Jasa
Pelayanan
117 Rawat luka ganggren/bakar <10% 12,000 25,000 37,000

118 Rawat luka bakar/ganggren 10-50% 23,000 50,000 73,000
119 Rawat luka ganggren/bakar 50% 46,000 80,000 126,000
120 debribment dan nekrotomi kecil 12,000 25,000 37,000
121 debridment dan nekrotomi sedang 19,000 35,000 54,000
122 debridment dan nekrotomi luas 28,000 50,000 78,000
123 Amputasi sendi kecil 192,000 200,000 392,000
124 Nail ekstraksi 17,000 13,000 30,000
125 Cross insisi/kali 19,000 250,000 269,000
126 Pemasangan spalk/kali -
a. Kecil 15,000 30,000 45,000
b. Sedang 20,000 40,000 60,000
c. Besar 30,000 45,000 75,000
127 Pemasangan gips/kali 70,000 104,000 174,000 Obat
128 Pemasangan kateter epidural/kali 138,000 207,000 345,000

Tidak termasuk obat
129 Drainase cairan pleura/kali 120,000 30,000 150,000 dan BMHP
Tidak termasuk obat
130 Drainase cairan abdomen / kali 120,000 30,000 150,000 dan BMHP
131 pengangkatan corpusalieneum

- Ringan 15,000 20,000 35,000
- sedang 25,000 35,000 60,000
- Berat 35,000 55,000 90,000
X. PELAYANAN NICU
1 Pemasangan Respirator / hari 10,000 20,000 30,000
2 Sewa alat dan monitoring per jam 3,000 7,000 10,000

3 Pemasangan monitor vital sign 21,000 14,000 35,000
4 Pemasangan syringe pump: 7,000 11,000 18,000
5 Sewa Syringe Pump 1,500 2,000 3,500
6 Pemasangan infussion pump: 8,000 12,000 20,000
7 Sewa infussion pump 1,500 2,000 3,500
8 Pemasangan Feeding Pump: 7,000 11,000 18,000
9 Sewa Feeding pump 3,000 8,000 11,000
10 Pemasangan Radiant / Infant Warmer : 5,000 10,000 15,000
tidak termasuk iv
11 Vena seksi 144,000 180,000 324,000
cateter,infus set
12 Foto Theraphy / hari 19,000 30,000 49,000
13 Resusitasi bayi bermasalah / RKP 46,000 69,000 115,000
14 Portable pulse oximeter 14,000 21,000 35,000
15 Resusitasi bayi normal 46,000 69,000 115,000
16 Intubasi 87,000 58,000 145,000
17 Suction pump 5,000 30,000 35,000
18 Pasang NGT 30,000 30,000 60,000
19 Aff NGT 2,000 2,000 4,000
Page 37 of 53
Jasa
Pelayanan
tidak termasuk tube

20 Pasang ET 575,000 400,000 975,000
oksigen
21 Pasang Cateter 20,000 15,000 35,000
22 Aff Cateter 2,000 2,000 4,000
23 Lumbal Punctie 58,000 100,000 158,000
24 pemasangan transfusi / kali 15,000 5,000 20,000
25 Massage bayi 15,000 10,000 25,000
26 Pasang ventilator / NCPAP 92,000 138,000 230,000
27 Observasi Ventilator / NCPAP / hari 100,000 50,000 150,000
28 Perawatan luka 7,000 11,000 18,000
29 Tindakan metode kangguru 12,000 18,000 30,000
30 Perawatan tali pusat 5,000 5,000 10,000
31 Transfusi Tukar 322,000 500,000 822,000
32 Pemberian Surfactan 322,000 550,000 872,000
33 Pemasangan WSD pada Neonatus 550,000 150,000 700,000
34 Pemasangan cateter umbilical 58,000 100,000 158,000
35 Sensor saturasi oksigen (BHP ) 23,000 35,000 58,000
36 Rawat luka bakar < 10 % 12,000 25,000 37,000
37 Rawat luka bakar 10 - 50 % 23,000 50,000 73,000
38 Rawat luka bakar > 50 % 46,000 80,000 126,000
39 Pemasangan cateter Arteri ( artery line ) 115,000 150,000 265,000
40 Bronchial Washing dengan alat 111,000 200,000 311,000
41 Therapi Inhalasi tanpa obat / Nebuizer per shift 12,000 25,000 37,000
42 Debridement dan necrotomy 12,000 30,000 42,000
43 Pemasangan infus bayi per kali 12,000 8,000 20,000
44 Injeksi im per kali 2,500 7,500 10,000
45 Injeksi iv per kali 2,500 7,500 10,000
46 Injeksi ic per kali 2,500 7,500 10,000
47 Injeksi sc per kali 2,500 7,500 10,000
48 Memberi obat Supositoria 4,000 6,000 10,000
49 Penanganan Pre Operasi 6,000 9,000 15,000
50 Mengambil sample darah vena 3,000 4,000 7,000
51 Melakukan klisma / huknah rendah / Drumbuisa (Nacl Hangat) 5,000 20,000 25,000
52 Pemasangan dan penggunaan Oksigen ( O2 )

a. Penggunaan Tiap 1 liter / menit / jam 130 130
b. pemasangan O2 per kali tanpa ventilator 3,000 3,000
c. pemasangan O2 per kali dengan ventilator 3,000 5,000 8,000
XI. PELAYANAN HEMODIALISIS

A PELAYANAN HEMODIALISIS TERENCANA
1 Penggantian transver set ( CAPD ) 33,000 49,000 82,000
2 Pelayanan HD tanpa Reuse 437,000 656,000 1,093,000

3 Pelayanan HD dengan Reuse 345,000 518,000 863,000
4 Pelayanan HD tanpa Reuse di bawa pasien sendiri 184,000 276,000 460,000
5 Pelayanan HD dengan Reuse di bawa pasien sendiri 138,000 207,000 345,000
Page 38 of 53
Jasa
Pelayanan
B PELAYANAN HEMODIALISIS CITO

1 Penggantian Transfusi set 41,000 61,000 102,000
2 Pelayanan HD tanpa Reuse 547,000 820,000 1,367,000
3 Pelayanan HD dengan Reuse 432,000 647,000 1,079,000
4 Pelayanan HD tanpa Reuse di bawa pasien sendiri 230,000 345,000 575,000
5 Pelayanan HD dengan Reuse di bawa pasien sendiri 173,000 259,000 432,000
XII. PELAYANAN PENUNJANG MEDIK

A APELAYANAN TINDAKAN MEDIK DIAGNOSTIK ELEKTROMEDIK DAN NON ELEKTROMEDIK
1 WSD Kontinu 575,000 575,000 1,150,000
2 Laringoscopi 56,000 83,000 139,000
tidak termasuk
3 Punctie Pluera / Lung Punctie 173,000 230,000 403,000 selang,needle, botol,
BMHP
4 AJH ( Paru ) 46,000 69,000 115,000

5 Portable spirometri 30,000 45,000 75,000
6 Pungsi Acites 115,000 173,000 288,000
7 Pungsi Pericard 184,000 276,000 460,000
8 Treadmile 92,000 138,000 230,000
9 Holter Monitoring 92,000 138,000 230,000
10 Ochocardiografi Dopler Color 189,000 283,000 472,000
11 ECG Simple 25,000 35,000 60,000
12 Biopsi Hati 184,000 400,000 584,000
13 Pungsi abses hati 35,000 100,000 135,000
14 Gastroscopy 171,000 256,000 427,000
15 Colonoscopy 171,000 256,000 427,000
16 Pungsi abses hati 58,000 87,000 145,000
17 BMP ( Basic Metabolic Panel ) 58,000 87,000 145,000
18 BMP dengan General Anesthesi 115,000 173,000 288,000
19 Biopsi Ginjal 184,000 276,000 460,000
20 Supra Public Punctie 35,000 52,000 87,000
21 Suntikan / Injeksi Intra Arikuler 33,000 49,000 82,000
22 Lumbal Pungsi 58,000 87,000 145,000
23 Ganglion Pungsi 23,000 35,000 58,000
24 Biopsi Transtorakal 58,000 87,000 145,000
25 Dopler Kamar Operasi 10,000 14,000 24,000
26 FFA / Fluorescin Fundus Angio 60,000 90,000 150,000
27 Toracoskopi 115,000 173,000 288,000
28 Kolposkopi 23,000 35,000 58,000
29 Test Perspirasi 12,000 17,000 29,000
30 Biopsi THT 52,000 78,000 130,000
31 AJH THT 23,000 35,000 58,000
32 Pemeriksaan EEG 81,000 121,000 202,000
33 Baca EEG 35,000 - 35,000
34 Pemeriksaan ENMG 115,000 173,000 288,000
35 CTG 50,000 30,000 80,000
36 Audiometri murni 46,000 69,000 115,000
37 Audiometri tutur 35,000 52,000 87,000
Page 39 of 53
Jasa
Pelayanan
38 Test Vestibuler 12,000 18,000 30,000

39 Foto Fundus Mata 23,000 35,000 58,000
40 Funduscopy Indirect 28,000 42,000 70,000
41 Sinopthor 12,000 18,000 30,000
42 Test Provokasi 23,000 35,000 58,000
43 Skin Test Allergi Elektro 46,000 69,000 115,000
44 Desensitisasi ( Paket ) 42,000 63,000 105,000
45 Nasolaringokopi 28,000 42,000 70,000
46 Swab Nasofaring 13,000 19,000 32,000
49 Keratometri 28,000 42,000 70,000
50 Anal Test 23,000 35,000 58,000
51 Gonioskopi 28,000 42,000 70,000
52 Retinoskopi 28,000 42,000 70,000
53 Biopsi Adneksa Mata 12,000 18,000 30,000
54 USG Mata 58,000 87,000 145,000
55 Tonometri Aplanasi 28,000 42,000 70,000
56 Water Drinking 7,000 11,000 18,000
B. RADIOLOGI ( Untuk Tarip Penunjang Radio Diagnostik, Tidak Termasuk Bahan Kontras )
KECIL (Tidak Menggunakan Kontras)
1 Kepala AP / Lat 46,000 115,000 161,000
2 Kepala 3 Posisi 69,000 161,000 230,000
3 SPN ( Sinus Para Nasal ) 70,000 50,000 120,000
4 Nasal 70,000 50,000 120,000
5 Cervical AP / Lat ( 2 Film ) 46,000 115,000 161,000
6 Cervical AP / Lat / Obl ( 4 Film ) 92,000 230,000 322,000
7 Thoracal / AP / Lat ( 2 Film ) 46,000 115,000 161,000
8 Thoracal / AP / Lat Obl ( 4 Film ) 92,000 230,000 322,000
9 Thoraco Lumbal AP / Lat 46,000 115,000 161,000
10 Thoraco Lumbal AP / Lat / Obl 69,000 173,000 242,000
11 Lumbal AP / Lat ( 2 Film ) 46,000 115,000 161,000
12 Lumbal AP / Lat / Obl ( 4 Film ) 92,000 230,000 322,000
13 Lumbosakral AP / Lat 46,000 115,000 161,000
14 Pelvis ( 1 Film ) 30,000 50,000 80,000
15 Femur AP / Lat Genu AP / Lat 46,000 100,000 146,000
16 Genu AP / Lat 46,000 100,000 146,000
17 Cruris AP / Lat 46,000 100,000 146,000
18 Pedis AP / Lat 46,000 100,000 146,000
19 Ankle Joint AP / Lat 46,000 100,000 146,000
20 Manus AP / Lat 46,000 100,000 146,000
21 Wrist Joint AP / Lat 46,000 100,000 146,000
22 Antebrachi AP / Lat 46,000 100,000 146,000
23 Elbow Joint AP / Lat 46,000 100,000 146,000
24 Humerus AP / Lat 46,000 100,000 146,000
25 Shoulder AP / Lat 46,000 100,000 146,000
26 Clavicula 30,000 50,000 80,000
Page 40 of 53
Jasa
Pelayanan
27 Thorax PA Dewasa 30,000 50,000 80,000

28 Thorax Lat Dewasa 30,000 50,000 80,000
29 Thorax AP / Lat Dewasa 30,000 50,000 80,000
30 Thorax AP Anak 30,000 50,000 80,000
31 Thorax AP / Lat Anak 30,000 50,000 80,000
32 Abdomen / BNO Dewasa 30,000 50,000 80,000
33 Abdomen / BNO Anaka 30,000 50,000 80,000
34 Abdomen 3 Posisi Dewasa 69,000 173,000 242,000
35 Abdomen 3 Posisi Anak 69,000 173,000 242,000
36 Panoramic gigi 30,000 60,000 90,000
SEDANG (Menggunakan Kontras)

1 Mammografi 111,000 250,000 361,000
2 Pelvis dengan sonde 56,000 92,000 148,000
3 Pelvimeteri 111,000 184,000 295,000
4 Uretrografi 275,000 250,000 525,000
5 Cystografi 275,000 250,000 525,000
6 Uretro Cystografi 221,000 450,000 671,000
7 H S G dengan kontras 221,000 450,000 671,000
8 RPG / APG 276,000 460,000 736,000
9 OMD dengan kontras 221,000 368,000 589,000
10 Oesofagografi 166,000 276,000 442,000
11 Colon In Loop Dewasa 276,000 500,000 776,000
12 Colon In Loop Anak 276,000 500,000 776,000
13 Fluoroscopy 111,000 250,000 361,000
14 Intra Vena Pyelography ( IVP ) 5 Film 276,000 460,000 736,000
15 Intra Vena Pyelography ( IVP ) 6-7 Film 387,000 644,000 1,031,000
CANGGIH
1 Myelografi Lumbal 230,000 345,000 575,000
2 Myelografi Thoracal / Cervical 230,000 345,000 575,000
3 Arthrografi 230,000 345,000 575,000
4 Phlebografi extr superior 184,000 276,000 460,000
5 Phlebografi extr inf 161,000 241,500 402,500
6 CT Scan kepala non kontras 276,000 414,000 690,000
7 CT Scan Kepala kontras 414,000 650,000 1,064,000
8 a. Whole Body CT Scan non kontras 506,000 759,000 1,265,000
9 b. Whole Body CT scan dengan kontras 920,000 1,380,000 2,300,000
10 CT Scan thorax nn kontras 300,000 505,000 805,000
11 CT scan thorax kontras 400,000 1,100,000 1,500,000
12 CT scan abdomen atas / bawah non kontras 322,000 1,000,000 1,322,000
13 CT scan abdomen atas / bawah dengan kontras 552,000 1,000,000 1,552,000
14 CT scan ekstrimitas non kontras 276,000 800,000 1,076,000
15 CT scan ekstrimitas kontras 414,000 800,000 1,214,000
16 C- Arm 184,000 500,000 684,000
17 USG Abdomen atas 138,000 300,000 438,000
18 USG Abdomen bawah 138,000 300,000 438,000
19 USG Abdomen atas bawah 104,000 400,000 504,000
Page 41 of 53
Jasa
Pelayanan
20 USG Ginjal 104,000 300,000 404,000

21 USG Testis 92,000 200,000 292,000
22 USG Payudara 92,000 200,000 292,000
23 USG Musculoskeletal 92,000 200,000 292,000
24 USG Neonatus 92,000 200,000 292,000
25 USG Thorax 104,000 200,000 304,000
26 USG Dopler Color 184,000 276,000 460,000
C PELAYANAN PEMERIKSAAN LABORATORIUM / PATOLOGI KLINIK

I HAEMATOLOGY
1 Darah rutin ( HMK ) :
5 Dift 18,000 35,000 53,000
3 Dift 14,000 27,000 41,000
2 Reticolusit 6,000 11,000 17,000
3 Angka Eosinofil 6,000 11,000 17,000
4 Limfosit Plasma Biru 6,000 11,000 17,000
5 Malaria Mikroskopis 5,000 10,000 15,000
6 Malaria Stik 10,000 22,000 32,000
7 Filaria 6,000 11,000 17,000
8 Golongan Darah + Rhesus 5,000 10,000 15,000
9 Coomb's Test 12,000 23,000 35,000
10 Morfologi Darah Tepi 23,000 46,000 69,000
11 B M P ( Pemeriksaan ) 69,000 104,000 173,000
12 Aspirasi BMP 92,000 207,000 299,000
13 Ratio IM / IT 6,000 11,000 17,000
14 Hemosidirin 7,000 14,000 21,000
15 LE Cell 11,000 19,000 30,000
16 OFT 10,000 18,000 28,000
17 Alkali Denaturasi / HBF 9,000 15,000 24,000
18 HbA2 23,000 46,000 69,000
19 Angka Eritrosit 6,000 11,000 17,000
20 Angka Leukosit 6,000 11,000 17,000
21 Angka Trombosit 6,000 11,000 17,000
22 Differential count 6,000 11,000 17,000
23 LED 4,000 7,000 11,000
24 Retraksi Bekuan 5,000 7,000 12,000
25 Serum Iron ( SI ) 29,000 58,000 87,000
26 Total Iron Binding Capacity ( TIBC ) 29,000 58,000 87,000
27 INR 13,000 32,000 45,000
28 OFT ( Screaning ) 9,000 15,000 24,000
29 OFT ( Semi Kuantitatif ) 15,000 26,000 41,000
30 HbF 21,000 37,000 58,000
Page 42 of 53
Jasa
Pelayanan
Faal Hemostasis
1 Masa Jendal ( CT ) 4,000 9,000 13,000
2 Masa Pendarahan ( BT ) 3,000 5,000 8,000
3 PPT 40,000 65,000 105,000
4 APTT 70,000 130,000 200,000
5 APTT Substitusi 41,000 75,000 116,000
6 Fibrinogen 35,000 63,000 98,000
7 Fibrinogen Degradition Product ( FDP ) / D Dimer 58,000 115,000 173,000
Pewarnaan Sitokimia
1 PAS 10,000 18,000 28,000
2 SBB 10,000 18,000 28,000
3 Peroksidase ( MPO ) 10,000 18,000 28,000
4 NSE 10,000 18,000 28,000
5 Pearl 10,000 18,000 28,000
II KIMIA KLINIK
Faal Ginjal
1 Ureum 5,000 18,000 23,000
2 Kreatinin 5,000 18,000 23,000
3 Uric Acid 12,000 20,000 32,000
4 Urea Clearance 12,000 20,000 32,000
Faal Hati
1 Bilirubin Direk 6,000 23,000 29,000
2 Bilirubin Total 6,000 23,000 29,000
3 Bilirubin Indirect 6,000 23,000 29,000
4 Bilirubin ( Urine ) 5,000 3,000 8,000
5 Total Protein 6,000 17,000 23,000
6 Albumin 6,000 17,000 23,000
7 Globulin 6,000 17,000 23,000
8 SGOT 6,000 23,000 29,000
9 SGPT 6,000 23,000 29,000
10 GGT 6,000 17,000 23,000
11 Alakali Fosfatase 7,000 17,000 24,000
Diabetes
1 Gula Darah Puasa 9,000 16,000 25,000
2 Gula darah puasa 2 jam 9,000 16,000 25,000
3 Gula darah sewaktu 9,000 16,000 25,000
4 HbA1C ( AIC ) 46,000 92,000 138,000
5 Glukosa Stick 9,000 18,000 27,000
Lemak
1 Cholesterol Total 6,000 17,000 23,000
2 Cholesterol HDL 15,000 29,000 44,000
3 Cholesterol LDL 18,000 41,000 59,000
Page 43 of 53
Jasa
Pelayanan
4 Trigilserida 7,000 25,000 32,000

5 HDL Direct 18,000 39,000 57,000
6 LDL Direct 23,000 41,000 64,000
ELEKTROLIT 58,000 98,000 156,000
1 Elektrolit Na + 18,000 35,000 53,000
2 Elektrolit K+ 18,000 35,000 53,000
3 Elektrolit Cl- 18,000 35,000 53,000
Lain - lain
1 CKMB 52,000 98,000 150,000
2 LDH 23,000 46,000 69,000
3 Analisa Gas Darah dan Elektrolit 81,000 207,000 288,000
4 CK ( Creatine Kinase ) 52,000 98,000 150,000
5 Protein Elektroforesis 46,000 98,000 144,000
6 Mikro Albumin 46,000 81,000 127,000
III IMUNOLOGI
1 TORCH 144,000 288,000 432,000
2 Torch IgM Rapid 144,000 288,000 432,000
3 Toxoplasma IgG IgM 35,000 81,000 116,000
4 Toxoplasma IgG 35,000 81,000 116,000
5 Rubela Ig.M 69,000 162,000 231,000
6 Rubella Ig.G 29,000 87,000 116,000
7 CMV Ig.M 69,000 138,000 207,000
8 CMV Ig.G 41,000 87,000 128,000
IV HEPATITIS
1 HBsAg (ELFA ) 29,000 58,000 87,000
2 HBsAg Rapid 11,000 22,000 33,000
3 HBsAg ( Elisa ) 19,000 38,000 57,000
4 Anti HIV ( Elva ) 51,000 102,000 153,000
5 Anti HIV ( Elisa ) 23,000 44,000 67,000
6 Anti HIV ( Rapid ) 23,000 46,000 69,000
7 Ferritin 46,000 115,000 161,000
9 Anti HBs Elisa 46,000 75,000 121,000
10 Anti HBs Rapid 12,000 29,000 41,000
Anti HBS ( ELVA ) 45,000 109,000 154,000
11 Anti HCV Elisa 52,000 133,000 185,000
12 Anti HCV Rapid 18,000 41,000 59,000
Anti HCV ( ELVA ) 70,000 150,000 220,000
HBE/ Anti HBE 50,000 150,000 200,000
V INFEKSI LAIN
1 TPHA 6,000 12,000 18,000
2 VDRL 5,000 9,000 14,000
3 DHF IgG IgM 46,000 115,000 161,000
4 Anti TB Rapid 18,000 41,000 59,000
Page 44 of 53
Jasa
Pelayanan
5 IgM Anti Leptospira 12,000 29,000 41,000

6 IgG Anti Leptospira 15,000 29,000 44,000
7 ICT Malaria 9,000 18,000 27,000
8 Widal 5,000 18,000 23,000
9 HIV Elisa 41,000 92,000 133,000
10 HIV Rapid 18,000 46,000 64,000
ß HCG ( ELVA ) 120,000 230,000 350,000
11 NSI 69,000 161,000 230,000
VI PETANDA TUMOR
1 AFP 41,000 92,000 133,000
2 CEA 46,000 133,000 179,000
3 PSA 46,000 127,000 173,000
4 CA 15.3 92,000 230,000 322,000
5 CA 125 69,000 161,000 230,000
6 CA 19.9 104,000 242,000 346,000
VII FUNGSI THYROID

1 Total Ig.E 58,000 115,000 173,000
2 T3 Total 35,000 81,000 116,000
3 FSH 58,000 115,000 173,000
4 T4 Total 35,000 81,000 116,000
5 Free T4 41,000 87,000 128,000
Free T4 (ELVA) 94,000 139,000 233,000
6 TSH 35,000 81,000 116,000
TSH ( ELVA ) 64,000 110,000 174,000
7 Free T3 52,000 115,000 167,000
VIII LAIN-LAIN
1 RA / RF 23,000 46,000 69,000
2 ASTO 18,000 41,000 59,000
3 CRP 23,000 58,000 81,000
4 HBsAg ( Elisa ) 23,000 52,000 75,000
5 HBsAg Rapid 6,000 15,000 21,000
6 Tubex TF 12,000 35,000 47,000
7 HIV Elisa 46,000 92,000 138,000
8 HIV Rapid 23,000 46,000 69,000
9 Progesteron 52,000 161,000 213,000
10 Testosteron 46,000 150,000 196,000
11 Anti HP 18,000 47,000 65,000
12 Anti HP IgG
a. Troponin I 58,000 185,000 243,000
b. Mantoux Test 35,000 81,000 116,000
Page 45 of 53
Jasa
Pelayanan
IX MIKROBIOLOGI KULTUR URINE

A KULTUR URINE
1 Kultur + sensi ( Manual ) 65,000 97,000 162,000
2 Kultur + sensi ( Bactec ) 92,000 173,000 265,000
B KULTUR FAECES
C KULTUR DARAH
1 Kultur Anaerob ( Manual ) 74,000 110,400 184,400
2 Kultur Anaerob ( Alat) 92,000 190,000 282,000
D SPUTUM
E USAPAN TENGGOROK
F USAPAN LUKA
G CAIRAN CEREBROSPINAL
H CAIRAN PLEURA
I CAIRAN PERITONIUM
J CAIRAN PERICARDIUM
Page 46 of 53
Jasa
Pelayanan
K CAIRAN DRAIN
L CAIRAN ASCITES
M BIAKAN GALL
N BIAKAN AN AEROB
X MIKROSKOPIK
1 Sperma Direct 3,000 4,000 7,000
2 Cat Gram 5,000 10,000 15,000
3 BTA Sputum 6,000 9,000 15,000
4 Jamur / Spora 6,000 9,000 15,000
5 Trichomonas 7,000 11,000 18,000
6 Leptospira 7,000 11,000 18,000
a. Secret 6,000 9,000 15,000
b. BTA Lepral 19,000 28,000 47,000
7 Cat Giemsa 3,000 8,000 11,000
XI PEMERIKSAAN LAINNYA
URINALISIS
1 Urine Rutin 6,000 15,000 21,000
2 Urin Protein 3,000 5,000 8,000
3 Urin Bilirubin 3,000 5,000 8,000
4 Urine Reduksi 3,000 5,000 8,000
5 Urin Urobilin 3,000 5,000 8,000
6 Analisa Sperma 18,000 32,000 50,000
7 Urine keton 3,000 5,000 8,000
8 Sedimen 3,000 5,000 8,000
9 Urine Bence Jones 3,000 5,000 8,000
10 Uji kehamilan/PP test 6,000 17,000 23,000
11 Uji kehamilan ( titrasi ) 15,000 23,000 38,000
XII ANALISIS FAECES

1 Faeces Rutin 6,000 12,000 18,000
2 Faeces Amoeba 7,000 10,000 17,000
3 Faeces Consentrasi 7,000 10,000 17,000
4 Faeces Benzidin 7,000 10,000 17,000
5 Faeces Stercobilin 7,000 10,000 17,000
Page 47 of 53
Jasa
Pelayanan
XIII NARKOBA
1 Urine Narkoba Amfetamin 13,000 27,000 40,000
2 Urine Narkoba THC 13,000 27,000 40,000
3 Urine Narkoba Morfine 13,000 27,000 40,000
4 Urine Narkoba Benzodiazefin 13,000 27,000 40,000
5 Urine Narkoba Meth Amphetamine 13,000 27,000 40,000
XIV ANALISA CAIRAN TUBUH LAIN

1 Angka cell LCS 9,000 13,000 22,000
2 Diff Cell LCS 7,000 10,000 17,000
3 Pandy 5,000 7,000 12,000
4 Rivalta Test 5,000 7,000 12,000
5 Glukosa 7,000 10,000 17,000
6 Protein 7,000 10,000 17,000
7 Patologi Anatomi / Histopatologi Besar 182,000 343,000 525,000
8 Patologi Anatomi/Histopatologi sedang 106,000 269,000 375,000
9 Patologi Anatomi / Histopatologi kecil 81,000 228,000 309,000
10 Sitologi 86,000 128,000 214,000
XV PATOLOGI ANATOMI
A Pemeriksaan Histopatologi
1 Sedang
Pemeriksaan PA kecil (1-4 blok) 212,500 318,500 531,000
Biopsi endoscopy 1-2 blok 231,000 346,500 577,500
Bone marrow aspirasi atau biopsi 404,000 606,000 1,010,000
Bone marrow aspirasi dan biopsi 404,000 606,000 1,010,000
Kulit (1-4 blok) 350,000 525,000 875,000
2 Canggih
Biopsi endoscopy 3 blok 404,000 606,000 1,010,000
Pemeriksaan PA sedang (5-8 blok) 572,500 858,500 1,431,000
Ca. Cervic stadium IB keatas 577,500 866,000 1,443,500
Pemeriksaan PA besar (>8 blok) 717,000 1,075,500 1,792,500
Ca. Cervic stadium IA, insitu 751,000 1,072,500 1,823,500
B Pemeriksaan Sitologi
Konsultasi dokter (tidak jadi FNAB) 15,000 - 15,000
Pap smear - kiriman slide 147,000 220,500 367,500
Pap smear - diambil di Lab PA 200,000 300,000 500,000
Urine, sputum dan sitologi eksfoliatif lainnya (bronkoskopi,
141,000 211,500 352,500
broncial washing
FNAB - kiriman slide 115,000 172,500 287,500
Cell Block 216,000 324,000 540,000
FNAB - diambil do Lab PA & di ruangan (superfisial) 230,000 345,000 575,000
Urine dan sputum seri 3 kali 224,000 336,000 560,000
FNAB - FNAB Deep (diluar Lab PA, Tuntunan USG / CT-
600,000 900,000 1,500,000
Scan)
Page 48 of 53
Jasa
Pelayanan
C Frozen Zection
Frozen Zection (FZ) pemeriksaan 1-2 blok 385,000 577,500 962,500
Frozen Zection (FZ) pemeriksaan >2 blok 462,000 639,000 1,101,000
Frozen Zection (FZ) dari Rumah Sakit Swasta pemeriksaan 1-2
1,425,000 2,137,500 3,562,500
blok
Frozen Zection (FZ) dari Rumah Sakit Swasta pemeriksaan >2
2,310,000 3,465,000 5,775,000
blok
D Histokimia
1 Kecil
- 1 jenis pemeriksaan 65,000 97,500 162,500
2 Sedang
Bone marrow aspirasi dan biopsi 180,000 162,000 342,000
E imunohistokimia
imunohistokimia 1 jenis pemeriksaan 200,000 300,000 500,000
imunohistokimia 2 jenis pemeriksaan 400,000 600,000 1,000,000
imunohistokimia 3 jenis pemeriksaan 450,000 675,000 1,125,000
imunohistokimia lebih dari 3 jenis pemeriksaan 1,000,000 1,500,000 2,500,000
F Otopsi
Otopsi bahan kecil (1 organ) 650,000 975,000 1,625,000
Otopsi bahan sedang (2-3 organ) 1,400,000 2,100,000 3,500,000
Otopsi bahan besar (>3 organ) 2,100,000 3,150,000 5,250,000
II Tarif Prosesing tanpa pembacaan oleh spesialis patologi anatomi
A Histopatologi
Pemeriksaan PA kecil (1-4 blok) 145,000 217,500 362,500
Pemeriksaan Pa sedang (5-8 blok) 230,000 345,000 575,000
Pemeriksaan PA besar (>8 blok) 350,000 525,000 875,000
Ca. Cervic stadium IB keatas 300,000 450,000 750,000
Ca. Cervic stadium IA, insitu 350,000 525,000 875,000
kulit 145,000 217,500 362,500
Biopsi endoscopy 1-2 blok 145,000 217,500 362,500
Biopsi endoscopi 3 blok 170,000 255,000 425,000
B Sitologi
Pap smear kiriman - 1 slide 40,000 60,000 100,000
Pap smear kiriman - 2 slide 50,000 75,000 125,000
Urine,sputum dan sitologi eksfoliatif lain 60,000 90,000 150,000
Bronkoskopi, bronchial washing 60,000 90,000 150,000
FNAB kiriman slide 40,000 60,000 100,000
Page 49 of 53
Jasa
Pelayanan
C Histokimia
1 jenis pemeriksaan 40,000 60,000 100,000
D Imunohistokimia
imunohistokimia lebih dari 3 jenis pemeriksaan 250,000 800,000 1,050,000
III Pemeriksaan yang disetarakan dengan PA kecil

a Sitologi tanpa histokimia (FNA tanpa tuntunan USG/CT-Scan)
110,000 165,000 275,000
b Papsmear / Vaginal Smear 110,000 165,000 275,000
c Semua sitologi lain dengan pengecatan giemsa / papacicoulaon /
Diff Quick 110,000 165,000 275,000
d Sitologi scrapping 110,000 165,000 275,000
IV Pemeriksaan yang di setarakan dengan PA sedang 222,000 333,000 555,000

a FNA dengan tuntunan USG 222,000 333,000 555,000
b Sitologi Sputum dengan pengecatan Ziehl-nielsen(Histokimia)
222,000 333,000 555,000
V Pemeriksaan yangn disetarakan dengan PA besar

a FNA tumor paru dengan tuntunan CT-Scan 240,000 360,000 600,000
b FNA tumor jaringan lunak dan tulang dengan tuntunan CT-Scan
240,000 360,000 600,000
PELAYANAN FARMASI
A BIAYA FARMASI
Untuk tarif layanan pelayanan kesehatan tidak termasuk
I
obat-obatan
II BIAYA OBAT NON RACIKAN
Harga obat= (HNA+PPN)+25% keuntungan
III BIAYA OBAT RACIKAN

Harga obat racikan salep/krim/sirup = (HNA+PPN)+25%
keuntungan+ 5.000 /pot/botol
Pelayanan obat pulveres/racikan kapsul=(HNA+PPN)+25%
+1.000/kapsul/bungkus
IV EMBALASE 1500/R
V Tuslah
- Obat Racikan 5000/R
- Obat jadi 500/R
Catatan
Penggunaan bahan pakai habis di perhitungkan berdasaekan jumlaj bahan pakai habis yang dipakai termasuk spuit, maag selang, infus
set, dll sesuai daftar bahan alat pakai habis kesehatan terlampi dalam lampiran IV
E. PELAYANAN BANK DARAH
Page 50 of 53
Jasa
Pelayanan
1 Crossmacth ( metode gel ) 12,000 78,000 90,000

2 Golongan darah 5,000 10,000 15,000
3 Phlebotomy 25,000 150,000 175,000
F. PELAYANAN PEMULASARAN JENASAH / FORENSIK DAN MOBIL JENAZAH

1 Pemeriksaan Jenasah 12,000 18,000 30,000
2 Konservasi / Pengawetan 350,000 275,000 625,000
3 Rekonstruksi Jenasah 92,000 138,000 230,000
4 Penitipan Jenasah tanpa pendingin / hari 15,000 100,000 115,000
5 Penitipan Jenasah dengan pendingin / hari 20,000 200,000 220,000
6 Perawatan Jenasah
a. Tanpa resiko 25,000 40,000 65,000
b. Dengan resiko 50,000 70,000 120,000
7 Visum Et Repertum
- Luar 40,000 55,000 95,000
- Dalam / Otopsi 470,000 680,000 1,150,000
8 Biaya mobil jenazah
a. Dalam kota 80,000 120,000 200,000
tidak termasuk
b. Luar kota/km 2,000 3,000 5,000
penyeberangan
G. PELAYANAN STERILISASI DAN LOUNDRY

1 Gaas Kecil 250 250 500
2 Gaas Besar 250 500 750
3 Buiq Gaas (bungkus) 2,000 8,000 10,000
4 Gaas waten tanpa kapas 1,000 1,000 2,000
5 Gaas waten dengan kapas 1,000 1,000 2,000
6 Gaas mata 1,000 1,000 2,000
7 Tampon Vagina 500 2,000 2,500
8 Papan Spalk ukuran 100 cm 5,000 25,000 30,000
9 Papan Spalk ukuran 50 cm 3,000 15,000 18,000
10 Ransel Verband 10,000 37,000 47,000
11 Deppers HD dan Tonsil 20,000 50,000 70,000
12 Tampon Gigi 23,000 35,000 58,000
13 Donat 2,000 13,000 15,000
14 Tampon tanpa Boorzalft (bungkus) 1,000 3,000 4,000
15 Tampon dengan Boorzalft (bungkus) 2,000 5,000 7,000
16 Lidi Kapas (bungkus) 12,000 18,000 30,000
17 Kapas Savlon (bungkus) 5,000 15,000 20,000
18 Kapas Alkohol (Bungkus) 5,000 10,000 15,000
19 Kapas potong segi empat 5,000 20,000 25,000
20 Benang tali pusat 5,000 20,000 25,000
21 Sterilisasi Handscun 2,000 5,000 7,000
22 Sterilisasi Instrumen dari unit RS 1,000 5,000 6,000
23 Sterilisasi Instrumen dari luar RS / Kilo 5,000 10,000 15,000
24 Loundry / kg 1,000 3,000 4,000
H. PELAYANAN GIZI
1 Konsultasi Gizi
Page 51 of 53
Jasa
Pelayanan
a. VVIP 20,000 10,000 30,000

b. VIP 15,000 8,000 23,000
c. Kelas I, Kelas II, Kelas III, ICU 10,000 7,000 17,000
d. PICU/ NICU 10,000 7,000 17,000 Jika ada diit
I. PELAYANAN PENUNJANG MEDIK LAINNYA
Per kali operasional/

1 Incinerator 20,000 287,000 307,000
150 Kg
Penambahan biaya per kg setelah berat 150 Kg per satuan kg

2 1,000 3,000 4,000 per kilogram
sampai dengan berat maksimal 200 kg
GUBERNUR NUSA TENGGARA BARAT,
ttd.
H. M. ZAINUL MAJDI
Page 52 of 53
LAMPIRAN II
PERATURAN GUBERNUR NUSA TENGGARA BARAT
NOMOR TAHUN 2018
TENTANG TARIF PELAYANAN KESEHATAN PADA RUMAH SAKIT H.L. MANAMBAI ABDUL
KADIR PROVINSI NUSA TENGGARA BARAT
TARIF LAYANAN NON PELAYANAN KESEHATAN
I. PENDIDIKAN DAN PELATIHAN
JASA JASA
NO URAIAN PELAYANAN SARANA TARIF (Rp) KETERANGAN
(Rp) (Rp)
(1) (2) (3) (4) (5) (6)
1 Praktek Klinik dokter muda 35,000 55,000 90,000 orang/minggu
2 Praktek Klinik keperawatan 25,000 45,000 70,000 orang/minggu
3 Praktek Klinik kebidanan 25,000 45,000 70,000 orang/minggu
4 Seminar 150,000 50,000 200,000 kali/pembimbing/Org
5 Narasumber 250,000 250,000 kali/Pertemuan
II. PENELITIAN
JASA JASA
(Rp) (Rp)
(1) (2) (3) (4) (5) (6)
Penerbitan Izin Penelitian/Pengambilan

1 30,000 50,000 80,000 orang/judul
data Mahasiswa DIII/D IV
Penerbitan Izin Penelitian/Pengambilan

2 50,000 100,000 150,000 orang/judul
data Mahasiswa S1
3 Penggunaan berkas untuk penelitian 4,000 6,000 10,000 per berkas
III. KANTIN
JASA JASA
(Rp) (Rp)
(1) (2) (3) (4) (5) (6)
1 sewa kantin 10,000 50,000 60,000 per meter persegi/ bulan
IV. SEWA RUANG/AULA dan PERLENGKAPAN
JASA JASA
(Rp) (Rp)
(1) (2) (3) (4) (5) (6)
1 sewa ruang/aula 15,000 250,000 265,000 per hari
2 Sewa alat/ peralatan presentasi 10,000 20,000 Audio Video
GUBERNUR NUSA TENGGARA BARAT,
ttd.
H. M. ZAINUL MAJDI
Page 53 of 53

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LAMPIRAN I

PERATURAN GUBERNUR NUSA TENGGARA BARAT

TARIF LAYANAN PELAYANAN KESEHATAN BLUD RSMA

(1) (2) (3) (4) (5) (6)

I. PENDAFTARAN, PEMERIKSAAN, TINDAKAN DAN AKOMODASI

D VISITE DOKTER SPESIALIS

E VISITE DOKTER UMUM

H SURAT KETERANGAN DOKTER

4 Visum Et Refertum 10,000 15,000 25,000

II. PELAYANAN RAWAT JALAN

1 POLI KLINIK TUMBUH KEMBANG

A IMUNISASI DIWAJIBKAN (PPI)

D TES INTELEGENSI (IQ)

F TES MINAT BAKAT

G KONSELING PSIKOLOGI (ANAK, REMAJA & DEWASA) 20,000 25,000 45,000

H TERAPI WICARA 20,000 25,000 45,000

I TERAPI EDUKASI 20,000 25,000 45,000

J TERAPI OKUPASI 20,000 25,000 45,000

2. POLIKLINIK PENYAKIT ANAK

3. POLIKLINIK BEDAH UMUM

2 Jahit luka / Repair Jahitan

18 Aspirasi 10,000 15,000 25,000

23 Necrotomy 50,000 70,000 120,000

8 Gips Besar Anak* 56,000 83,000 139,000

b. Sedang (5-10 cm) 10,000 15,000 25,000

6. POLIKLINIK GIGI DAN MULUT

B TINDAKAN PENAMBALAN GIGI

C TINDAKAN PENGOBATAN / PERAWATAN JARINGAN PENYANGGA GIGI

D PEMBUATAN PROTESA / GIGI PALSU

E TINDAKAN BEDAH MULUT

2 Operculectom 58,000 138,000 196,000

8 Incisi / Eksisi abses 50,000 47,500 97,500

9 Pemeriksaan komplikasi post op / kontrol 18,000 46,000 64,000

10 Pemeriksaan dan perbaikan posisi IDW / IMW 23,000 46,000 69,000

F PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dengan LOGAM

G PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY tanpa LOGAM

7. POLIKLINIK PENYAKIT KULIT DAN KELAMIN

8. POLIKLINIK PENYAKIT PARU

9. POLIKLINIK PENYAKIT DALAM

10. POLIKLINIK PENYAKIT JANTUNG

16 Transesofageal Echocardiografi 300,000 400,000 700,000

17 Pemasangan Holter 1 x 24 Jam 200,000 150,000 350,000

18 Pemasangan Holter 2 x 24 Jam 320,000 180,000 500,000

19 Pemeriksaan Vital Sign 2,000 1,000 3,000

11. POLIKLINIK SYARAF/NEUROLOGI

12. POLIKLINIK MATA

2 S B L ( Bleparoplasty ) 184,000 276,000 460,000

6 Keratometri 28,000 42,000 70,000

7 Pemeriksaan fundus (indirec) 28,000 42,000 70,000

8 Tonometri Aplansi(schiutz) 28,000 42,000 70,000

9 Water Drinking 7,000 11,000 18,000

10 Retinoskopi 28,000 42,000 70,000

11 Gonioskopi 28,000 42,000 70,000

12 Synophtophor 58,000 87,000 145,000

13 Sondage 23,000 35,000 58,000

14 Anel test 23,000 35,000 58,000

18 Irigasi 12,000 18,000 30,000

19 Refraktometer 28,000 42,000 70,000

26 Refraksi 30,000 30,000 60,000

27 Biopsi di Konjungtiva 300,000 160,000 460,000

28 Jahitan di Palpebra 400,000 600,000 1,000,000

29 Reposisi iris 1,500,000 1,500,000 3,000,000

30 Paracentesis 300,000 400,000 700,000