CP Mata Revisi 2023

Perhitungan Tarif Paket Rawat Inap
Diagnosa : ABORTUS INKOMPLIT

Koding / INCbgs : prosedur dilatasi kuret, intrauterin & serviks ( W-1-11-I )
Kelas Perawatan : III
Lama Perawatan : 2 hari
URAIAN JUMLAH HARGA Total

POLIKLINIK
Pemeriksaan Dokter Spesialis 1 52,500 52,500
Jasa Paramedis 1 7,500 7,500
Bia.ADM 1 5,000 5,000
Sewa ruangan 1 60,000 60,000
USG 1 55,000 55,000
RANAP
Perawatan ranap 2 225,000 450,000
Jasa Paramedis ranap 2 15,000 30,000
Visite dr spesialis kebidanan & kandungan 2 60,000 120,000
Visite dr Anesthesi 1 60,000 60,000
Visite Awal Medis (Dokter Jaga Ruangan) 1 10,000 10,000
Biaya pasang infus 1 30,000 30,000
Biaya fiksasi infus 1 30,000 30,000
Biaya Injeksi 1 18,000 18,000
Oksigen 3/lt 1 27,000 27,000
WT 1 100,000 100,000
Biaya Adm 1 50,000 50,000
KAMAR OPERASI
Operator operasi besar 1
Anesthesi operasi besar 1 -
Penata anesthesi operasi besar 1 -
Jasa paramedis operasi besar 1 -
Kamar operasi besar 1 -
Paket spinal dan bahan operasi besar 1 -
WT 1 50,000 50,000
Oksigen 1 9,000 9,000
LABORATORIUM
darah rutin 1 84,000 84,000
OBAT-OBATAN
cairan RL 2 9,514 19,028
Biosanbe 1x1 tab 3 1,596 4,788
Cotrimoxazole 2x1 tab 10 364 3,640
Paracetamol 3x1 10 231 2,310
infus set makro 1 10,074 10,074
Abocath 20 1 10,538 10,538
total 1,277,766
tarif BPJS 2,436,700
selisih 1,158,934
Kelas Perawatan : II
URAIAN JUMLAH HARGA TOTAL

POLIKLINIK
Bia.ADM 1 5,000 5,000
Sewa ruangan 1 60,000 60,000
USG 1 55,000 55,000
RANAP
Visite dr Anesthesi 1 65,000 65,000
Oksigen 3/lt 1 27,000 27,000
WT 1 100,000 100,000
Biaya Adm 1 50,000 50,000
KAMAR OPERASI
Operator operasi besar 1 -
WT 1 50,000 50,000
Oksigen 1 9,000 9,000
LABORATORIUM
darah rutin 1 84,000 84,000
OBAT-OBATAN -
cairan RL 2 9,514 19,028
Abocath 20 1 10,538 10,538
total 1,548,766
selisih 1,290,034
Kelas Perawatan : I

POLIKLINIK
Bia.ADM 1 5,000 5,000
Sewa ruangan 1 2,500 2,500
USG 1 55,000 55,000
RANAP
Jasa medis dr Anesthesi 1 70,000 70,000
Oksigen 3/lt 1 27,000 27,000
WT 1 100,000 100,000
Biaya Adm 1 50,000 50,000
KAMAR OPERASI
Operator operasi besar 1 -
WT 1 50,000 50,000
Oksigen 1 9,000 9,000
LABORATORIUM
darah rutin 1 84,000 84,000
OBAT-OBATAN
cairan RL 2 9,514 19,028
Abocath 20 1 10,538 10,538
total 1,742,378
selisih 1,498,422
biaya (diluar jasa medis
no diagnosis kode ina tarif ina jasa medis) (tarif lama)
1 partus normal
kelas III o-6-13-i 2,233,500 #REF! 350,000
kelas II o-6-13-i
kelas I o-6-13-i
typhoid
jumlah kasus 1 tahun 1,000
total jasa medis dibyrkan 200,000,000
rt-rt js medis perkasus 200,000
% js medis trf baru % catatan
16 tdk termasuk dr anak

Perhitungan Tarif Rawat Jalan
Diagnosa : Katarak
Koding / INCbgs : Operasi Katarak ( H-2-36-0)
Kelas Perawatan : I,II,III
Lama Perawatan : Rawat Jalan

POLIKLINIK
Pemeriksaan Dokter Spesialis 1 Rp 40,000 Rp 40,000
Jasa Paramedis 1 Rp 5,000 Rp 5,000
Biaya Adm 1 Rp 7,500 Rp 7,500
Otoref 1 Rp 50,000 Rp 50,000
Visus 1 Rp 25,000 Rp 25,000
Funduscopy 1 Rp 20,000 Rp 20,000
Tonometri 1 Rp 20,000 Rp 20,000
Ganti Verban 1 Rp 25,000 Rp 25,000
Rp 192,500
LABORATORIUM
BSS 1 Rp 24,000 Rp 24,000
CTBT 1 Rp 20,000 Rp 20,000
HIV 1 Rp 76,000 Rp 76,000
vacut /spuit 1 Rp 6,500 Rp 6,500
126,500
OBAT-OBATAN
Glaucon (oral) 1 Rp 4,956 Rp 5,656
Methil Prednisolon 8MG Tab 20 Rp 301 Rp 6,720
Iremax (oral) 10 Rp 1,076 Rp 10,760
Cendo Mydriatil 1% (Cendo/Salep) 1 Rp 49,888 Rp 49,888
Tobroson MD (Cendo/salep) 5 Rp 7,565 Rp 37,825
Cendo LFX MD (Cendo/Salep) 5 Rp 17,999 Rp 89,995
Cendo P-Pred MD (Cendo/Salep) 5 Rp 9,978 Rp 49,890
Eye Fresh Plus MD (Cendo/Salep) 5 Rp 1,586 Rp 7,930
Lidocain 2% INJ( Injeksi) 1 Rp 1,586 Rp 1,586
Sagestam 40 MG/ML INJ (Injeksi) 1 Rp 13,369 Rp 13,369
Methyl Prednisolon 8MG TAb (Oral) 20 Rp 301 Rp 6,020
Levofloxacin Tab (Oral) 10 Rp 1,058 Rp 10,580
Iremax Tablet (oral) 10 Rp 1,076 Rp 10,760
xiety tablet (oral) 5 Rp 5,869 Rp 29,345
Star Blue-Trypan Blue (oral) 1 Rp 75,114 Rp 75,114
Glaucon (oral) 1 Rp 4,956 Rp 4,956
Transfusit Set Gea ( Alkes) 1 Rp 8,025 Rp 8,025
Spuit 1CC Onemed (Alkes) 2 Rp 908 Rp 908
Spuit 10CC Nipro (Alkes) 1 Rp 1,821 Rp 1,821
HandScond Steril MPM 0.8 (Alkes) 1 Rp 7,531 Rp 7,531
RL Satoria INF 1 Rp 8,943 Rp 8,943
437,622
ALKES OKA
Lensa IOL PMMA 1 Rp 178,328 Rp 178,328
Viscot / HPMC 1 Rp 138,728 Rp 138,728
Trifam Blue 0.25 Rp 100,000 Rp 25,000
Carbacol 0.25 Rp 100,000 Rp 25,000
Benang 1 Rp 280,969 Rp 280,969
Cauter Bovie 0.1 Rp 400,000 Rp 40,000
Slit Knife 2.75 % 0.16 Rp 300,000 Rp 48,000
Cresyen Knife 0.16 Rp 300,000 Rp 48,000
Stab Knife 0.16 Rp 300,000 Rp 48,000
Doop Mata 1 Rp 12,222 Rp 12,222
BHP 1 Rp 50,000 Rp 50,000
Oksigen 1 Rp 18,000 Rp 18,000
912,247
KAMAR OPERASI
Operator 1 - -
Jasa Paramedis 1 Rp 200,000 200,000
Sewa Kamar 1 Rp 700,000 700,000
Paket Lensa 1 - -
Obat-obatan 1 - -
Rp 900,000
TOTAL : 2,568,869
TARIF BPJS : 3,738,100
SELISIH : 1,169,231
15% 560,715
17.50% 654,168
20% 747,620
BHP kamar operasi

Topi 4 3,200
Masker 4 2,000
Kassa 5 lembar 2,500
KApas 10 gulung 2,500
Hypapik 3 lmbr 1,500
Handrub 5,000
Teralin cair 5,000
Handscoon biasa 1 pasang 2,000
Hand wash 3,000
Microzid 5,000
31,700 50,000
GV poli mata
Pre op
Pantocain 4,000
Midriazil 20,000
Post op -
Kassa 2 lbr 1,000 -
Cairan Rl 10 cc 500
Hypapix 2 lbr 1,000
26,500 25,000
Diagnosa : Pteregium
Koding / INCbgs : Pteregium ( H-1-20-I )
Lama Perawatan : 2 Hari

POLIKLINIK
Pemeriksaan Dokter Spesialis 1 Rp 40,000 Rp 40,000
Bia.ADM 1 Rp 7,500 Rp 7,500
Slit Lamp 1 Rp 30,000 Rp 30,000
RANAP
Perawatan ranap 2 Rp 225,000 Rp 450,000
Jasa medis dr spesialis mata 2 Rp 60,000 Rp -
Jasa Paramedis ranap 2 Rp 45,000 Rp 90,000
Biaya Adm 1 Rp 50,000 Rp 50,000
GV 1 Rp 25,000 Rp 25,000
LABORATORIUM
BSS 1 Rp 24,000 Rp 24,000
CTBT 1 Rp 20,000 Rp 20,000
HIV 1 Rp 76,000 Rp 76,000
vacut /spuit 1 Rp 6,500 Rp 6,500
OBAT-OBATAN
Cendo Xytrol 1 Rp 43,783 Rp 43,783
Cendo Tobroson MD (Cendo/Salep) 5 Rp 7,245 Rp 36,225
pehacain inj 1 Rp 4,241 Rp 4,241
spui 1 cc 2 Rp 1,290 Rp 2,580
nylon 10 1 Rp 280,969 Rp 280,969
underpad 0.5 Rp 16,004 Rp 8,002
cresyen 0.1 Rp 300,000 Rp 30,000
gentamicin 1 Rp 3,900 Rp 3,900
transofik 1 Rp 6,000 Rp 6,000
rl sanbe 1 Rp 10,000 Rp 10,000
Handscoon 7,5 2 Rp 12,000 Rp 24,000
spui 10 cc 2 Rp 1,938 Rp 3,876
KAMAR OPERASI
Operator 1 - -
Kamar Operasi 1 Rp 700,000 Rp 700,000
Oksigen 1 Rp 27,000 Rp 27,000

Wount Toilet 1 Rp 50,000 Rp 50,000
Obat bius dan BHP 1 Rp 228,537 Rp 228,537
TOTAL : 2,504,813
SELISIH : 2,204,787
15% 706,440
17.50% 824,180
20% 941,920
URAIAN JUMLAH HARGA

POLIKLINIK
Pemeriksaan Dokter Spesialis 1 Rp 40,000
Jasa Paramedis 1 Rp 5,000
Bia.ADM 1 Rp 7,500
Slit Lamp 1 Rp 30,000
RANAP
Perawatan ranap 2 Rp 350,000
Jasa medis dr spesialis mata 2 Rp 65,000
Jasa Paramedis ranap 2 Rp 45,000
Biaya Adm 1 Rp 50,000
GV 1 Rp 45,000
LABORATORIUM
BSS 1 Rp 24,000
CTBT 1 Rp 20,000
HIV 1 Rp 76,000
vacut /spuit 1 Rp 6,500
OBAT-OBATAN
Cendo Xytrol 1 Rp 43,783
Cendo Tobroson MD (Cendo/Salep) 5 Rp 7,245
Levofloxacin Tab (Oral) 10 Rp 1,138
Iremax Tablet (oral) 10 Rp 1,032
pehacain inj 1 Rp 4,241
spui 1 cc 2 Rp 1,290
nylon 10 1 Rp 280,969
underpad 0.5 Rp 16,004
cresyen 0.1 Rp 300,000
gentamicin 1 Rp 3,900
transofik 1 Rp 6,000
rl sanbe 1 Rp 10,000
Handscoon 7,5 2 Rp 12,000
spui 10 cc 2 Rp 1,938
KAMAR OPERASI
Operator 1 -
Kamar Operasi 1 Rp 700,000
Oksigen 1 Rp 27,000
Wount Toilet 1 Rp 50,000
Obat bius dan BHP 1 Rp 228,537
TOTAL :
TARIF BPJS :
SELISIH :
15%
17.50%
20%
Kelas Perawatan : I
TOTAL URAIAN JUMLAH

POLIKLINIK
Rp 40,000 Pemeriksaan Dokter Spesialis 1
Rp 5,000 Jasa Paramedis 1
Rp 7,500 Bia.ADM 1
Rp 30,000 Slit Lamp 1
RANAP
Rp 700,000 Perawatan ranap 2
Rp - Jasa medis dr spesialis mata 2
Rp 90,000 Jasa Paramedis ranap 2
Rp 50,000 Biaya Adm 1
Rp 45,000 GV 1
LABORATORIUM
Rp 24,000 BSS 1
Rp 20,000 CTBT 1
Rp 76,000 HIV 1
Rp 6,500 vacut /spuit 1
OBAT-OBATAN
Rp 43,783 Cendo Xytrol 1
Rp 36,225 Cendo Tobroson MD (Cendo/Salep) 5
Rp 11,380 Levofloxacin Tab (Oral) 10
Rp 10,320 Iremax Tablet (oral) 10
Rp 4,241 pehacain inj 1
Rp 2,580 spui 1 cc 2
Rp 280,969 nylon 10 1
Rp 8,002 underpad 0.5
Rp 30,000 cresyen 0.1
Rp 3,900 gentamicin 1
Rp 6,000 transofik 1
Rp 10,000 rl sanbe 1
Rp 24,000 Handscoon 7,5 2
Rp 3,876 spui 10 cc 2
KAMAR OPERASI
- Operator 1
Rp 200,000 Jasa Paramedis 1
Rp 700,000 Kamar Operasi 1
Rp 27,000 Oksigen 1
Rp 50,000 Wount Toilet 1
Rp 228,537 Obat bius dan BHP 1
2,774,813
5,486,600
2,711,787
822,990
960,155
1,097,320
Perhitungan Tarif Paket Rawat Jalan
Diagnosa :
regium ( H-1-20-I ) Koding / INCbgs :
Kelas Perawatan :
Lama Perawatan :
HARGA TOTAL URAIAN

POLIKLINIK
Rp 40,000 Rp 40,000 Pemeriksaan Dokter Spesialis
Rp 5,000 Rp 5,000 Jasa Paramedis
Rp 7,500 Rp 7,500 Bia.ADM
Rp 30,000 Rp 30,000 KAMAR OPRASI
Operator
Rp 450,000 Rp 900,000 Jasa Paramedis
Rp 65,000 Rp 130,000 Sewa ruangan
Rp 45,000 Rp 90,000 OBAT-OBATAN
Rp 50,000 Rp 50,000 Levofloxacin Tab (Oral)
Rp 45,000 Rp 45,000 Asam Mefenamat
Chloramphenicol 1 %
Rp 24,000 Rp 24,000 Lidocain 2% INJ( Injeksi)
Rp 20,000 Rp 20,000 Handscoon
Rp 76,000 Rp 76,000 Spuit 1 Cc
Rp 6,500 Rp 6,500 Spuit 10 Cc
Mess No. 11
Rp 43,783 Rp 43,783
Rp 7,245 Rp 36,225
Rp 1,138 Rp 11,380
Rp 1,032 Rp 10,320
Rp 4,241 Rp 4,241
Rp 1,290 Rp 2,580
Rp 280,969 Rp 280,969
Rp 16,004 Rp 8,002
Rp 300,000 Rp 30,000
Rp 3,900 Rp 3,900
Rp 6,000 Rp 6,000
Rp 10,000 Rp 10,000
Rp 12,000 Rp 24,000
Rp 1,938 Rp 3,876
- -
Rp 200,000 Rp 200,000
Rp 700,000 Rp 700,000
Rp 18,000 Rp 18,000
Rp 50,000 Rp 50,000
Rp 228,537 Rp 228,537
TOTAL : 3,095,813
SELISIH : 3,167,887
15% 939,555
17.50% 1,096,148
20% 1,252,740
Chalazion
Hordeolum ( H-2-23-0 )
I,II,III
Rawat Jalan
JUMLAH HARGA TOTAL
1 Rp 40,000 Rp 40,000
1 Rp 5,000 Rp 5,000
1 Rp 7,500 Rp 7,500
1 Rp 150,000 Rp -
1 Rp 50,000 Rp 50,000
1 Rp 200,000 Rp 200,000
6 Rp 1,015 Rp 5,656
6 Rp 3,200 Rp 19,200
1 Rp 11,500 Rp 11,500
1 Rp 2,042 Rp 2,042
1 Rp 9,590 Rp 9,590
1 Rp 1,192 Rp 1,192
1 Rp 1,834 Rp 1,834
1 Rp 4,313 Rp 4,313
TOTAL : 357,827
TARIF BPJS : 676,500
SELISIH : 318,673
15% 101,475
17.50% 118,388
20% 135,300
Diagnosa : TONSILITIS
Koding / INCbgs : U-I-15-1

POLIKLINIK
Pemeriksaan Dokter Spesialis Rp 52,500 Rp 52,500
Jasa medis dr mata 1 Rp 40,000
Bia.ADM 1 Rp 7,500
RANAP
Jasa Medis dr anestesi 1 Rp 65,000 Rp 65,000
Jasa Medis dr PDL/Anak 1 Rp 65,000 Rp 65,000
Jasa Medis dr ruangan 1 Rp 10,000 Rp 10,000
Jasa Paramedis Ranap 2 Rp 45,000 Rp 90,000

Biaya Adm 1 Rp 100,000 Rp 100,000
Biaya Fiksasi infus dan WT 1 Rp 75,000 Rp 75,000
JASA SARANA
Sewa ruangan rawat inap 2 Rp 350,000 Rp 700,000
Biaya Pasang infus 1 Rp 30,000 Rp 30,000
Biaya Injeksi 2 Rp 18,000 Rp 36,000
Biaya skintest 1 Rp 2,500 Rp 2,500
JASA MEDIS(VISITE & TINDAKAN)

KAMAR OPERASI
Operator
Anaesthesi
Penata
Jasa Paramedis
sewa OK
Oksigen
WT
Obat bius dan BHP
LABORATORIUM
BSS 1 Rp 24,000 Rp 24,000
CT BT 1 Rp 20,000 Rp 20,000
HIV 1 Rp 76,000 Rp 76,000
SPUIT /VACUM 1 Rp 6,500 Rp 6,500
RADIOLOGI
Thorax foto 1 Rp 75,000 Rp 75,000
EKG 1 Rp 35,000 Rp 35,000
OBAT-OBATAN
spui 1 cc 2 Rp 1,290 Rp 2,580
nylon 10 1 Rp 280,969 Rp 280,969
underpad 0.5 Rp 16,004 Rp 8,002
cresyen 0.1 Rp 300,000 Rp 30,000
rl sanbe 1 Rp 10,000 Rp 10,000
Handscoon 7,5 2 Rp 12,000 Rp 24,000
spui 10 cc 2 Rp 1,938 Rp 3,876
TOTAL 1,885,276
TARIF BPJS 4,709,600
SELISIH 2,824,324
15% 706,440
17.50% 824,180
20% 941,920
tranfusi set 1 8,538 8,538

cairan RL 4 9,514 38,056
urine bag 1 7,458 7,458
balon cateter 16 1 13,609 13,609
aquadest 2 3,694 7,388
Metronidazole 3x1 tab 15 458 6,870
Clindamycin 300mg 3x1 tab 15 1,450 21,750
Etorixocid 2 x 120mg 4 4,680 18,720
Paracetamol / Asam mefenamat 3x1 10 403 4,030
Kantong darah 1
total 13,911,415
selisih (7,075,215)

POLIKLINIK
Bia.ADM 1 Rp 7,500
RANAP

Biaya Adm 1 Rp 100,000 Rp 100,000
JASA SARANA

KAMAR OPERASI
Operator
Anaesthesi
Penata
Jasa Paramedis
sewa OK
Oksigen
WT
Obat bius dan BHP
LABORATORIUM
BSS 1 Rp 24,000 Rp 24,000
CT BT 1 Rp 20,000 Rp 20,000
HIV 1 Rp 76,000 Rp 76,000
RADIOLOGI
EKG 1 Rp 35,000 Rp 35,000
OBAT-OBATAN
spui 1 cc 2 Rp 1,290 Rp 2,580
nylon 10 1 Rp 280,969 Rp 280,969
underpad 0.5 Rp 16,004 Rp 8,002
cresyen 0.1 Rp 300,000 Rp 30,000
rl sanbe 1 Rp 10,000 Rp 10,000
Handscoon 7,5 2 Rp 12,000 Rp 24,000
spui 10 cc 2 Rp 1,938 Rp 3,876
TOTAL 1,885,276
SELISIH 3,601,324
15% 822,990
17.50% 960,155
20% 1,097,320
Kelas Perawatan : I

POLIKLINIK
Bia.ADM 1 Rp 7,500
RANAP

Biaya Adm 1 Rp 100,000 Rp 100,000
JASA SARANA

KAMAR OPERASI
Operator
Anaesthesi
Penata
Jasa Paramedis
sewa OK
Oksigen
WT
Obat bius dan BHP
LABORATORIUM
BSS 1 Rp 24,000 Rp 24,000
CT BT 1 Rp 20,000 Rp 20,000
HIV 1 Rp 76,000 Rp 76,000
RADIOLOGI
EKG 1 Rp 35,000 Rp 35,000
OBAT-OBATAN
spui 1 cc 2 Rp 1,290 Rp 2,580
nylon 10 1 Rp 280,969 Rp 280,969
underpad 0.5 Rp 16,004 Rp 8,002
cresyen 0.1 Rp 300,000 Rp 30,000
rl sanbe 1 Rp 10,000 Rp 10,000
Handscoon 7,5 2 Rp 12,000 Rp 24,000
spui 10 cc 2 Rp 1,938 Rp 3,876
TOTAL 1,885,276
SELISIH 4,378,424
15% 939,555
17.50% 1,096,148
20% 1,252,740
Kelas Perawatan : VIP

POLIKLINIK
Bia.ADM 1 Rp 7,500
RANAP

Biaya Adm 1 Rp 100,000 Rp 100,000
JASA SARANA

KAMAR OPERASI
Operator
Anaesthesi
Penata
Jasa Paramedis
sewa OK
Oksigen
WT
Obat bius dan BHP
LABORATORIUM
BSS 1 Rp 24,000 Rp 24,000
CT BT 1 Rp 20,000 Rp 20,000
HIV 1 Rp 76,000 Rp 76,000
RADIOLOGI
EKG 1 Rp 35,000 Rp 35,000
OBAT-OBATAN
spui 1 cc 2 Rp 1,290 Rp 2,580
nylon 10 1 Rp 280,969 Rp 280,969
underpad 0.5 Rp 16,004 Rp 8,002
cresyen 0.1 Rp 300,000 Rp 30,000
rl sanbe 1 Rp 10,000 Rp 10,000
Handscoon 7,5 2 Rp 12,000 Rp 24,000
spui 10 cc 2 Rp 1,938 Rp 3,876
TOTAL : 1,885,276
SELISIH : 4,378,424
15% 939,555
17.50% 1,096,148
20% 1,252,740

CP Mata Revisi 2023

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Perhitungan Tarif Paket Rawat Inap

Diagnosa : ABORTUS INKOMPLIT

URAIAN JUMLAH HARGA Total

URAIAN JUMLAH HARGA TOTAL

URAIAN JUMLAH HARGA TOTAL

16 tdk termasuk dr anak

URAIAN JUMLAH HARGA TOTAL

BHP kamar operasi

URAIAN JUMLAH HARGA TOTAL

Oksigen 1 Rp 27,000 Rp 27,000

URAIAN JUMLAH HARGA

TOTAL URAIAN JUMLAH

HARGA TOTAL URAIAN

JUMLAH HARGA TOTAL

URAIAN JUMLAH HARGA TOTAL

Jasa Paramedis Ranap 2 Rp 45,000 Rp 90,000

JASA MEDIS(VISITE & TINDAKAN)

tranfusi set 1 8,538 8,538

URAIAN JUMLAH HARGA TOTAL

Jasa Paramedis Ranap 2 Rp 45,000 Rp 90,000

JASA MEDIS(VISITE & TINDAKAN)

URAIAN JUMLAH HARGA TOTAL

Jasa Paramedis Ranap 2 Rp 45,000 Rp 90,000

JASA MEDIS(VISITE & TINDAKAN)

URAIAN JUMLAH HARGA TOTAL

Jasa Paramedis Ranap 2 Rp 45,000 Rp 90,000

JASA MEDIS(VISITE & TINDAKAN)

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