RATUMBUYSANG
USULAN TARIF RETRIBUSI
Jasa
Tarif (Rp) Jasa Sarana Jumlah
Pelayanan
I RAWAT JALAN
1 Rawat Jalan Reguler
a Dokter Umum/Gigi 70,000 42,000 28,000 70,000
b Psikiater 100,000 60,000 40,000 100,000
c Dokter Spesialis Lainnya 100,000 60,000 40,000 100,000
d Psikiater Konsultan/Sub Spesialis 120,000 72,000 48,000 120,000
e Dokter Sub Spesialis Lainnya 120,000 72,000 48,000 120,000
f Psikolog Klinis 50,000 30,000 20,000 50,000
g Perawat Jiwa 40,000 24,000 16,000 40,000
h Gizi/Dieticen 40,000 24,000 16,000 40,000
i Pekerja Sosial 20,000 12,000 8,000 20,000
2 Rawat Jalan Eksekutif
a Dokter Umum/Gigi 70,000 42,000 28,000 70,000
b Psikiater 120,000 72,000 48,000 120,000
c Dokter Spesialis Lainnya 120,000 72,000 48,000 120,000
d Psikiater Konsultan/Sub Spesialis 150,000 90,000 60,000 150,000
e Dokter Sub Spesialis Lainnya 150,000 90,000 60,000 150,000
f Psikolog Klinis 70,000 42,000 28,000 70,000
g Perawat Jiwa 50,000 30,000 20,000 50,000
h Gizi/Dieticen 50,000 30,000 20,000 50,000
i Pekerja Sosial 25,000 15,000 10,000 25,000
3 Telemedicine
a Pendaftaran 150,000 90,000 60,000 150,000
b Administrasi Rekam Medis 35,000 21,000 14,000 35,000
c Psikiater 150,000 90,000 60,000 150,000
d Dokter Spesialis Lainnya 150,000 90,000 60,000 150,000
e Psikiater Konsultan/Sub Spesialis 200,000 120,000 80,000 200,000
f Dokter Sub Spesialis Lainnya 200,000 120,000 80,000 200,000
g Biaya Pengiriman Obat - - - -
1) dalam kota 50,000 30,000 20,000 50,000
2) luar kota radius 60 km 100,000 60,000 40,000 100,000
3) diatas 60 km 150,000 90,000 60,000 150,000
4 Pelayanan Kesehatan Gigi
a Pemeriksaan dengan resep 30,000 18,000 12,000 30,000
b Pemeriksaan tanpa resep 30,000 18,000 12,000 30,000
c Pemeriksaan kontrol 36,000 21,600 14,400 36,000
d Cabut gigi decidu (anak) satu elemen 60,000 36,000 24,000 60,000
Cabut gigi luksasi derajat 2 dan 3 satu
e 90,000 54,000 36,000 90,000
elemen
Rawat syaraf gigi (endodontik) sekali
f 90,000 54,000 36,000 90,000
kunjungan
g Rawat gigi sensitif 36,000 21,600 14,400 36,000
h Cabut gigi tetap satu elemen 90,000 54,000 36,000 90,000
i Cabut gigi dengan komplikasi 180,000 108,000 72,000 180,000
j Cabut gigi permanen tanpa penyulit 72,000 43,200 28,800 72,000
Tambal gigi satu elemen dengan komposit
k 300,000 180,000 120,000 300,000
resin
l Tambal gigi satu elemen dengan GIC 180,000 108,000 72,000 180,000
m Tambal dengan silikat 120,000 72,000 48,000 120,000
Pembersihan karang gigi rahang
n 150,000 90,000 60,000 150,000
atas/bawah
o Insisi abses 60,000 36,000 24,000 60,000
5 Surat Keterangan Medis 30,000 18,000 12,000 30,000
a Legalisir 10,000 6,000 4,000 10,000
II RAWAT INAP
1 Rawat Inap VIP
a Akomodasi/hari 750,000 450,000 300,000 750,000
b Visite - - - -
1) dokter sub spesialis 175,000 105,000 70,000 175,000
2) dokter spesialis 150,000 90,000 60,000 150,000
3) dokter umum 70,000 42,000 28,000 70,000
4) dieticen 50,000 30,000 20,000 50,000
5) apoteker 50,000 30,000 20,000 50,000
c Asuhan Keperawatan 50,000 30,000 20,000 50,000
2 Rawat Inap Kelas I dan Ruang Psychiatric ICU/PICU
a Akomodasi 300,000 180,000 120,000 300,000
b Visite - - - -
1) dokter sub spesialis 140,000 84,000 56,000 140,000
2) dokter spesialis 100,000 60,000 40,000 100,000
3) dokter umum 70,000 42,000 28,000 70,000
4) dieticen 45,000 27,000 18,000 45,000
5) apoteker 27,000 16,200 10,800 27,000
c Asuhan Keperawatan 45,000 27,000 18,000 45,000
3 Rawat Inap Kelas II
a Akomodasi 200,000 120,000 80,000 200,000
b Visite - - - -
1) dokter sub spesialis 90,000 54,000 36,000 90,000
2) dokter spesialis 70,000 42,000 28,000 70,000
3) dokter umum 40,000 24,000 16,000 40,000
4) dieticen 30,000 18,000 12,000 30,000
5) apoteker 30,000 18,000 12,000 30,000
c Asuhan Keperawatan 30,000 18,000 12,000 30,000
4 Rawat Inap Kelas III
a Akomodasi 150,000 90,000 60,000 150,000
b Visite - - - -
1) dokter sub spesialis 50,000 30,000 20,000 50,000
2) dokter spesialis 40,000 24,000 16,000 40,000
3) dokter umum 18,000 10,800 7,200 18,000
4) dieticen 20,000 12,000 8,000 20,000
5) apoteker 20,000 12,000 8,000 20,000
c Asuhan Keperawatan 20,000 12,000 8,000 20,000
III LAYANAN PSIKIATRI KHUSUS / SUB SPESIALIS
1 Psikiatri Anak dan Remaja
a Asesmen/Psikometri/Diagnostik Anak
13) Psikoterapi Supportif Pada Orang Tua 35,000 21,000 14,000 35,000
Harga racikan
1) Kapsul +
Rp.500/kapsul
+ Rp. 10.000 - - -
Harga racikan
2) Pulvis - - -
+ Rp. 10.000,-
Per resep +
b Non Racikan - - -
Rp. 500,-
VIII ASUHAN KEPERAWATAN JIWA
1 Rawat Jalan (per kunjungan) 10,000 6,000 4,000 10,000
2 IGD (per paket) 50,000 30,000 20,000 50,000
3 Rawat Inap (per paket) 100,000 60,000 40,000 100,000
4 Pengambilan Specimen (per kegiatan) 25,000 15,000 10,000 25,000
5 Konsultasi Keperawatan (per kegiatan) 50,000 30,000 20,000 50,000
IX TINDAKAN
1 Suppositoria 33,000 19,800 13,200 33,000
2 Suntikan IM/IV 33,000 19,800 13,200 33,000
3 Pasang/Aff Infus/Venpion 55,000 33,000 22,000 55,000
4 Transfusi Darah 27,500 16,500 11,000 27,500
5 Pasang/Aff Kateter 55,000 33,000 22,000 55,000
6 Pasang/Aff NGT 110,000 66,000 44,000 110,000
7 Pemakaian Oksigen (per liter per menit) 200 120 80 200
8 Elektro Cardio Gram (EKG) Manual 137,500 82,500 55,000 137,500
9 Elektro Cardio Gram (EKG) Monitor 165,000 99,000 66,000 165,000
10 Nebulizer 110,000 66,000 44,000 110,000
11 Resusitasi Jantung Pulmuner 165,000 99,000 66,000 165,000
12 Actifity Daily Living (ADL) 33,000 19,800 13,200 33,000
13 Therapie Aktifitas Kelompok (TAK) 55,000 33,000 22,000 55,000
14 Rawat Luka - - - -
- Ringan 55,000 33,000 22,000 55,000
- Sedang 82,500 49,500 33,000 82,500
- Berat 110,000 66,000 44,000 110,000
15 Cabut Benang 22,000 13,200 8,800 22,000
16 Suction 27,500 16,500 11,000 27,500
17 DC Shock 110,000 66,000 44,000 110,000
18 Hecting 1 sampai 5 55,000 33,000 22,000 55,000
19 Hecting >5 (per jahitan) 11,000 6,600 4,400 11,000
20 Psikoterapi per sesi per jam 165,000 99,000 66,000 165,000
21 Relaksasi Hipnoterapi 165,000 99,000 66,000 165,000
22 Lumbal Punksi 220,000 132,000 88,000 220,000
23 Punksi cairan pleura/sendi/asites 220,000 132,000 88,000 220,000
24 Fiksasi 55,000 33,000 22,000 55,000
25 Observasi tanda vital 55,000 33,000 22,000 55,000
26 Bilas lambung 55,000 33,000 22,000 55,000
27 Cross Insisi 55,000 33,000 22,000 55,000
X PENUNJANG DIAGNOSTIK
1 Pemeriksaan Laboratorium
a Pemeriksaan Haematologi
1) Haematologi rutin
100,000 60,000 40,000 100,000
2) Gambaran Darah Tepi (Blood Smear)
115,000 69,000 46,000 115,000
3) LED/BBS
20,000 12,000 8,000 20,000
4) Malaria (DDR)
30,000 18,000 12,000 30,000
5) Tes golongan darah
30,000 18,000 12,000 30,000
6) CT/BT
20,000 12,000 8,000 20,000
b Imuno-Serologi
1) HbsAg 100,000 60,000 40,000 100,000
2) Test Kehamilan (HCG) 40,000 24,000 16,000 40,000
3) Widal 80,000 48,000 32,000 80,000
4) HIV 150,000 90,000 60,000 150,000
5) Dengue IgG 200,000 120,000 80,000 200,000
6) Dengue IgM 200,000 120,000 80,000 200,000
7) NS1 150,000 90,000 60,000 150,000
8) VDRL 90,000 54,000 36,000 90,000
c Pemeriksaan Kimia Klinis
1) Gula darah puasa (GDP) 35,000 21,000 14,000 35,000
2) Gula darah 2 JPP (2 jam PP) 35,000 21,000 14,000 35,000
3) Gula darah sewaktu (GDS) 35,000 21,000 14,000 35,000
4) HbAlc 280,000 168,000 112,000 280,000
5) Kolesterol Total 40,000 24,000 16,000 40,000
6) Trigliserida 50,000 30,000 20,000 50,000
7) HDL 50,000 30,000 20,000 50,000
8) LDL 70,000 42,000 28,000 70,000
9) SGOT 45,000 27,000 18,000 45,000
10) SGPT 45,000 27,000 18,000 45,000
11) GGT 60,000 36,000 24,000 60,000
12) Billirubin Total 45,000 27,000 18,000 45,000
13) Billirubin Direk 45,000 27,000 18,000 45,000
14) Billirubin Indirek 45,000 27,000 18,000 45,000
15) Albumin 45,000 27,000 18,000 45,000
16) Total Protein 45,000 27,000 18,000 45,000
17) Ureum 40,000 24,000 16,000 40,000
18) Alkalin Phospatase (AP) 50,000 30,000 20,000 50,000
19) Creatinin 40,000 24,000 16,000 40,000
20) Uric Acid 55,000 33,000 22,000 55,000
21) HB 25,000 15,000 10,000 25,000
22) HbSAg 65,000 39,000 26,000 65,000
23) CK 130,000 78,000 52,000 130,000
24) CK-MB 130,000 78,000 52,000 130,000
25) Elektrolit Na, K, Cl 200,000 120,000 80,000 200,000
d Pemeriksaan Urine
1) Rutin/Sedimen 35,000 21,000 14,000 35,000
2) Test Kehamilan (HCG) 40,000 24,000 16,000 40,000
e Pemeriksaan Faeces
1) Cacing 30,000 18,000 12,000 30,000
f Urinalis
1) Urin Rutin 40,000 24,000 16,000 40,000
2) Sedimen Urin (Mikroscopic) 35,000 21,000 14,000 35,000
3) Narkoba 6 Parameter 250,000 150,000 100,000 250,000
g Pemeriksaan Kulit
1) Elektrokauter Ringan 350,000 210,000 140,000 350,000
2) Elektrokauter Sedang 550,000 330,000 220,000 550,000
3) Elektrokauter Berat 750,000 450,000 300,000 750,000
4) Biopsi Punch 500,000 300,000 200,000 500,000
5) TCA Kosmetik Ringan 100,000 60,000 40,000 100,000
6) TCA Kosmetik Sedang 200,000 120,000 80,000 200,000
7) TCA Kosmetik Berat 300,000 180,000 120,000 300,000
8) IMS Ringan 150,000 90,000 60,000 150,000
9) IMS Sedang 250,000 150,000 100,000 250,000
10) IMS Berat 500,000 300,000 200,000 500,000
11) Podofilin Ringan 150,000 90,000 60,000 150,000
12) Podofilin Sedang 250,000 150,000 100,000 250,000
13) Podofilin Berat 500,000 300,000 200,000 500,000
h Bakteriologi
1) BTA 40,000 24,000 16,000 40,000
2) Gram 35,000 21,000 14,000 35,000
XI RADIO DIAGNOSTIK
A Pemeriksaan Radiodiagnostik Computer Radiografy (CR)
1 Sederhana
a. Gigi Intra Oral (HAP) 75,000 45,000 30,000 75,000
b. Ekstremitas Atas
1) Manus 100,000 60,000 40,000 100,000
2) Pergelangan 100,000 60,000 40,000 100,000
3) Sendi siku 100,000 60,000 40,000 100,000
4) Humerus 100,000 60,000 40,000 100,000
5) Antebrachi 100,000 60,000 40,000 100,000
6) Scapula 100,000 60,000 40,000 100,000
7) Bahu 100,000 60,000 40,000 100,000
8) Clavicula 100,000 60,000 40,000 100,000
9) Digiti 100,000 60,000 40,000 100,000
c. Ekstremitas Bawah
1) Femur 105,000 63,000 42,000 105,000
2) Cruris 105,000 63,000 42,000 105,000
3) Genu/pattela 105,000 63,000 42,000 105,000
4) Ankle joint 105,000 63,000 42,000 105,000
5) Pedis 105,000 63,000 42,000 105,000
d. Toraks 100,000 60,000 40,000 100,000
e. Abdomen/BNO Polos
1) Abdomen Supine 105,000 63,000 42,000 105,000
2) Abdomen Tega 105,000 63,000 42,000 105,000
3) Abdomen 3 (tiga) posisi 315,000 189,000 126,000 315,000
Sedang
a. Kepala 150,000 90,000 60,000 150,000
b. Ekstremitas Bawah 125,000 75,000 50,000 125,000
1) Sendi panggul (coxae)
c. Pelvis/panggul 125,000 75,000 50,000 125,000
d. Columna vertebrata/tulang belakang 160,000 96,000 64,000 160,000
Besar
a. Pemeriksaan dengan kontras 400,000 240,000 160,000 400,000
B. Pemeriksaan Radiodiagnostik
1 CT Scan Kepala (Alat Canggih)
a Dengan kontras 1,500,000 900,000 600,000 1,500,000
b Tanpa Kontras 1,000,000 600,000 400,000 1,000,000
XII REHABILITASI MEDIK
1 Infra Red 130,000 78,000 52,000 130,000
2 Trancutaneus Electric Nerve Stimulation 130,000 78,000 52,000 130,000
3 Laser 130,000 78,000 52,000 130,000
4 Ultra Sound Diatemi 130,000 78,000 52,000 130,000
5 Cervical Traction 130,000 78,000 52,000 130,000
6 Sepeda Statik 130,000 78,000 52,000 130,000
7 Massage 130,000 78,000 52,000 130,000
8 Chest Therapy 100,000 60,000 40,000 100,000
9 Exercise Therapy 130,000 78,000 52,000 130,000
10 Terapi Okupasi 100,000 60,000 40,000 100,000
11 Terapi Wicara 100,000 60,000 40,000 100,000
XIII PEMERIKSAAN ALAT-ALAT CANGGIH
1 USG Biasa 150,000 90,000 60,000 150,000
2 USG 4 Dimensi 200,000 120,000 80,000 200,000
3 ECT 280,000 168,000 112,000 280,000
4 EEG 200,000 120,000 80,000 200,000
5 ECG 50,000 30,000 20,000 50,000
6 Stress Analyzer 120,000 72,000 48,000 120,000
XIV KOMKORDIK
1 Biaya Praktek Klinik (orang/hari) - - - -
a DIII / SMK 75,000 45,000 30,000 75,000
b S1 / S2 Non Kedokteran 125,000 75,000 50,000 125,000
Kepaniteraan Klinik Psikiatri (untuk
c 125,000 75,000 50,000 125,000
mahasiswa kedokteran umum)
d PPDS 1 atau PPDS 2 (orang/bulan) 500,000 300,000 200,000 500,000
2 Biaya Pembekalan Awal Praktek (orang/hari) - - - -
a DIII 50,000 30,000 20,000 50,000
b S1 100,000 60,000 40,000 100,000
Biaya
c S2Pengambilan Data Untuk Penelitian 100,000 60,000 40,000 100,000
3 (KTI, Skripsi, Tesis, dll) DIII/S1 100,000 60,000 40,000 100,000
4 Biaya Penelitian - - - -
a Karya Tulis Ilmiah DIII 250,000 150,000 100,000 250,000
b Skripsi S1 300,000 180,000 120,000 300,000
c Tesis S2 500,000 300,000 200,000 500,000
d Penelitian Perorangan 300,000 180,000 120,000 300,000
XV PELAYANAN PERAWATAN JENAZAH
1 Pelayanan Jenazah Biasa 95,000 57,000 38,000 95,000
2 Pelayanan Jenazah Dengan Resiko 220,000 132,000 88,000 220,000
3 Konservasi Jenazah Untuk 3 Hari 1,250,000 750,000 500,000 1,250,000
4 Konservasi Jenazah Lebih 3 Hari 1,500,000 900,000 600,000 1,500,000
5 Pengiriman Jenazah 1,250,000 750,000 500,000 1,250,000
6 Penyimpanan Jenazah Per Hari 100,000 60,000 40,000 100,000
7 Pemulangan Jenazah - - - -
a Sampai 20 km 400,000 240,000 160,000 400,000
b Sampai 60 km 700,000 420,000 280,000 700,000
c S.D > 100 km 850,000 510,000 340,000 850,000
8 Paket Pemakaman Jenazah 6,000,000 3,600,000 2,400,000 6,000,000
Untuk konservasi jenazah biaya diatas adalah biaya perawatan tidak termasuk bahan yang diperlukan
(cairan formalin, dll)
5. Jasa sarana dan jasa pelayanan merupakan Pendapatan Asli Daerah (PAD) yang harus disetor seluruhnya ke Kas Daerah.
6. Jasa pelayanan akan diperhitungkan langsung kepada pemberi pelayanan yang ditetapkan dengan Keputusan Direktur.
DIREKTUR,