Lampiran

LAMPIRAN PERATURAN GUBERNUR NUSA TENGGARA BARAT
NOMOR......................TAHUN 2015
TANGGAL..............DESEMBER 2015
TARIF PELAYANAN KESEHATAN INSTALASI RAWAT JALAN
RSUD PROVINSI NUSA TENGGARA BARAT
JASA JUMLAH TARIF

NO JENIS PELAYANAN JASA SARANA PELAYANAN
1 2 3 4 5
1 INSTALASI RAWAT JALAN REGULER

A. Biaya Poliklinik
1. Registrasi / pendaftaran / karcis 9,000 - 9,000
2. Administrasi Sistem Informasi 600 - 600
3. Berkas RM Rawat Jalan / Kartu Pasien 8,400 - 8,400
B. Biaya Pemeriksaan
1. Dokter Spesialis / Dokter Gigi Spesialis - 25,000 25,000
2. Konsultasi antar SMF - 25,000 25,000
3. Konsultasi Gizi - - 18,000
4. Konsultasi / Konseling HIV / AIDS - - 18,000
2 INSTALASI RAWAT JALAN EKSEKUTIF

A. Biaya Poliklinik
2. Konsultasi antar SMF - 100,000 100,000
3. Konsultasi Gizi - 30,000 30,000
4. Konsultasi / Konseling HIV / AIDS - 30,000 30,000
3 INSTALASI RAWAT JALAN (POLI KHUSUS)

A. Biaya Poliklinik
Keterangan :
a. Biaya karcis berlaku untuk 1 (satu) kali kunjungan, tanpa obat
b. Apabila ada pemeriksaan penunjangdiagnostik, tindakan medik, radiotherapi dan rehabilitasi medik, dibayar
sesuai dengan tarif RSUD Provinsi NTB
c. Konsultasi harus berdasarkan rujukan intern dari bagian / SMF yang memerlukan hal tersebut ke bagian / SMF lain
dan gizi, untuk keperluan tindak lanjut observasi diagnosa, pengobatan dan pelayanan kesehatan lainnya, tanpa
tinggal di ruangan rawat inap, dan pasien membayar hanya biaya konsultasi tersebut.
d. Kartu identitas pasien (Embosar) hanya dibayar 1 (satu) kali, apabila kartu identitas hilang harus membayar lagi
sesuai tarif yang berlaku.
TARIF PELAYANAN DI INSTALASI GAWAT DARURAT
TARIF
No. JENIS PELAYANAN JASA JASA JUMLAH
SARANA PELAYANAN TARIF
1 2 3 4 5
A. REGISTRASI
1 registrasi berkas RM IGD 18,000 - 18,000
2 registrasi berkas RM MRS 12,000 - 12,000
B. PEMERIKSAAN DOKTER
1 Periksa Dokter IGD - 25,000 25,000
2 Periksa / Konsultasi Dokter Spesialis On site - 50,000 50,000
3 Periksa / Konsultasi Dokter Spesialis On site (di luar jam kerja) - 62,500 62,500
C. LAYANAN UMUM IGD

1 Layanan Prioritas 3 ( green area) 60,000 40,000 100,000
2 Layanan Prioritas 2 ( yellow area) 120,000 80,000 200,000
3 Layanan Prioritas 1 ( Red zone ) 180,000 120,000 300,000
D. TINDAKAN KHUSUS KEGAWATDARURATAN

1 Pemasangan ET (Endotracheal Tube) 125,000 75,000 200,000
2 needle cricothyroidotomy 125,000 75,000 200,000
3 pungsi pleural 125,000 75,000 200,000
4 pungsi ascites 125,000 75,000 200,000
5 blast pungsi 125,000 75,000 200,000
6 pemasangan CVC 375,000 225,000 600,000
7 pemasangan cateter intra osseus 218,750 131,250 350,000
8 vena sectie 108,000 72,000 180,000
9 needle cest decompressi 93,750 56,250 150,000
10 pemasangan WSD 240,000 360,000 600,000
12 amputasi sendi kecil 93,750 56,250 150,000
13 Cross Incisi 50,000 30,000 80,000
14 ekstraksi kuku ( roser plasty ) 93,750 56,250 150,000
17 Jahit Luka
a. kecil ( < 5 cm ) 18,750 11,250 30,000
b. sedang ( 5 - 10 cm ) 43,750 26,250 70,000
c. besar ( 10 - 20 cm ) 62,500 37,500 100,000
d. khusus ( > 20 cm, melebihi lapisan kulit) 93,750 56,250 150,000
18 incisi abses
a. kecil ( < 5 cm ) 18,750 11,250 30,000
b. sedang ( 5 - 10 cm ) 53,125 31,875 85,000
c. besar ( 10 - 20 cm ) 75,000 45,000 120,000
19 ekstraksi korpus alienum
a. Ringan 12,500 7,500 20,000
b. sedang 31,250 18,750 50,000
c. berat / dalam 62,500 37,500 100,000
20 ekstraksi batu uretra anterior 75,000 45,000 120,000
21 lavement 31,250 18,750 50,000
22 Reposisi
a. mandibula 31,250 18,750 50,000
b. dislokasi sendi2 kecil extremitas 31,250 18,750 50,000
c. dislokasi sendi2 besar extremitas 62,500 37,500 100,000
24 Resusitasi 75,000 45,000 120,000
25 Cardiac Shock / Cardioversi 125,000 75,000 200,000
TARIF
E. PEMAKAIAN ALAT BANTU

26 Pemakaian O2 per liter/menit per jam 2,400 - 2,400
27 Pemakaian Ventilator Transport per jam 3,125 1,875 5,000
28 Pemakaian Infus Pump 2,160 1,440 3,600
29 Pemakaian Syring Pump per jam 2,160 1,440 3,600
30 Pemakaian Nebulizer 20,400 10,800 31,200
31 Pemakaian Vital sign Monitor per jam 2,160 1,440 3,600
32 Automatic cardiac kompression
F. TINDAKAN PENUNJANG DIAGNOSTIK

1 Pemeriksaan EKG 39,000 21,000 60,000
2 Rapid glukotest 15,600 8,400 24,000
G. AKOMODASI RUANG OBSERVASI (tidak lebih dari 2 x 24 jam)

1 Akomodasi Intermediate Care (per hari) 120,000 - 120,000
3 Akomodasi High Care (per hari) 240,000 - 240,000
4 Akomodasi Intensive Care (per hari) 240,000 - 240,000
5 Visite dokter /konsul spesialis on site - 50,000 50,000
H. PELAYANAN PREHOSPITAL DAN RUJUKAN

1 perawat (per jam) - 50,000 50,000
2 dokter umum (per jam) - 66,000 66,000
3 dokter spesialis (per jam) - 100,000 100,000
Keterangan :
1. Layanan Prioritas 3 (P3 / Green Area) adalah layanan kesehatan yang diberikan kepada pasien yang tidak gawat dan tidak
darurat, meliputi : pemeriksaan Dokter, konsultasi Dokter, tindakan keperawatan / tindakan medik dasar (pasang O2, injeksi,
rawat luka ringan sampai sedang) serta Observasi
2. Layanan Prioritas 2 (P2 / Yellow Area) adalah layanan kesehatan yang diberikan kepada pasien yang gawat dan tidak darurat,
meliputi : pemeriksaan Dokter, konsultasi Dokter, tindakan keperawatan / tindakan medik dasar (pasang O2, pasang infus, pasang
NGT, pasang cateter urine, injeksi) serta Observasi (Primary dan Secondary service)
3. Layanan Prioritas 1 (P1 / Red Area) adalah layanan kesehatan yang diberikan kepada pasien yang gawat darurat dan ada
ancaman live saving, meliputi : pemeriksaan Dokter, konsultasi Dokter, tindakan keperawatan / tindakan medik dasar (pasang O2,
pasang infus, pasang NGT pasang cateter urine, injeksi, RJP manual) serta Observasi (Primary dan Secondary service)
4. Tindakan medik / tindakan keperawatan lainnya di rawat inap yang dilakukan di IGD dikenakan tarif 100% dari tindakan
medik/tindakan keperawatan di Rawat Inap
TARIF PELAYANAN AKOMODASI, VISITE , KONSUL DAN TINDAKAN KEPERAWATAN RAWAT INAP
KELAS III KELAS II KELAS I

No. JENIS PELAYANAN JASA JASA JUMLAH JASA JASA JUMLAH JASA JASA JUMLAH
SARANA PELAYANAN TARIF SARANA PELAYANAN TARIF SARANA PELAYANAN TARIF
1 2 3 4 5 6 7 8 9 10 11
I TINDAKAN MEDIK RAWAT INAP
1 Pemeriksaan awal pasien oleh dokter jaga 3,600 14,400 18,000 3,600 14,400 18,000 3,600 14,400 18,000
2 Pemeriksaan pasien rawat inap gawat oleh dokter jaga 3,600 14,400 18,000 3,600 14,400 18,000 3,600 14,400 18,000
3 pasang infus dewasa 7,800 4,200 12,000 7,800 4,200 12,000 7,800 4,200 12,000
4 pasang infus anak/bayi 12,000 6,000 18,000 12,000 6,000 18,000 12,000 6,000 18,000
5 Rawat Luka
a. Kecil (< 5 cm) 9,600 5,400 15,000 9,600 5,400 15,000 9,600 5,400 15,000
b. Sedang (5 - 10 cm) 12,000 6,000 18,000 12,000 6,000 18,000 12,000 6,000 18,000
c. Besar (10 - 20 cm) 14,400 6,600 21,000 14,400 6,600 21,000 14,400 6,600 21,000
d. Khusus (> 20 cm) 19,200 10,800 30,000 19,200 10,800 30,000 19,200 10,800 30,000
6 Rawat Luka Bakar < 10 % 19,200 10,800 30,000 19,200 10,800 30,000 19,200 10,800 30,000
7 Rawat Luka Bakar 10 -50 % 39,000 21,000 60,000 39,000 21,000 60,000 39,000 21,000 60,000
8 Rawat Luka Bakar > 50 60,000 30,000 90,000 60,000 30,000 90,000 60,000 30,000 90,000
9 Rawat Luka Khusus (Ganggren, dll) 78,000 42,000 120,000 78,000 42,000 120,000 78,000 42,000 120,000
10 Necrotomy jaringan (kecil) 15,600 8,400 24,000 15,600 8,400 24,000 15,600 8,400 24,000
11 Angkat Jahitan
a. Kecil ( < 5 Jahitan) 14,400 6,600 21,000 14,400 6,600 21,000 14,400 6,600 21,000
b. Sedang ( 5 - 10 Jahitan) 15,000 9,000 24,000 15,000 9,000 24,000 15,000 9,000 24,000
c. Besar (10 - 20Jahitan) 19,200 10,800 30,000 19,200 10,800 30,000 19,200 10,800 30,000
d. Khusus (> 20 jahitan) 22,800 13,200 36,000 22,800 13,200 36,000 22,800 13,200 36,000
12 Pasang Tampon 12,000 6,000 18,000 12,000 6,000 18,000 12,000 6,000 18,000
13 Aff Tampon 6,000 3,000 9,000 6,000 3,000 9,000 6,000 3,000 9,000
14 aff CVP 11,430 7,640 19,070 11,430 7,640 19,070 11,430 7,640 19,070
15 aff drain 5,860 3,920 9,780 5,860 3,920 9,780 5,860 3,920 9,780
16 aff kateter 2,423 1,600 4,023 2,423 1,600 4,023 2,423 1,600 4,023
17 Ambil sample sputum 750 520 1,270 750 520 1,270 750 520 1,270
18 Biopsi hepar 144,000 216,000 360,000 144,000 216,000 360,000 144,000 216,000 360,000
19 Biopsi Kulit 26,050 17,360 43,410 26,050 17,360 43,410 26,050 17,360 43,410
20 BMP 124,302 82,880 207,182 124,302 82,880 207,182 124,302 82,880 207,182
21 Bronchoscopi 1,376,425 2,064,600 3,441,025 1,376,425 2,064,600 3,441,025 1,376,425 2,064,600 3,441,025
22 Ganti vakum drain 2,620 1,760 4,380 2,620 1,760 4,380 2,620 1,760 4,380
23 Gaster Colling 13,865 9,240 23,105 13,865 9,240 23,105 13,865 9,240 23,105
24 Lepas WSD 18,075 12,040 30,115 18,075 12,040 30,115 18,075 12,040 30,115
25 Memandikan bayi 3,795 2,520 6,315 3,795 2,520 6,315 3,795 2,520 6,315
1 2 3 4 5 6 7 8 9 10 11
26 Memberikan obat oral via NGT 1,958 1,320 3,278 1,958 1,320 3,278 1,958 1,320 3,278
27 Memberikan susu via NGT 1,958 1,320 3,278 1,958 1,320 3,278 1,958 1,320 3,278
28 Injeksi im per shift 3,600 2,400 6,000 3,600 2,400 6,000 3,600 2,400 6,000
29 Injeksi iv per shift 3,600 2,400 6,000 3,600 2,400 6,000 3,600 2,400 6,000
30 Injeksi ic per shift 3,600 2,400 6,000 3,600 2,400 6,000 3,600 2,400 6,000
31 Injeksi sc per shift 3,600 2,400 6,000 3,600 2,400 6,000 3,600 2,400 6,000
32 Skin Test 3,600 2,400 6,000 3,600 2,400 6,000 3,600 2,400 6,000
33 Memberi Obat Melalui Gastrotomy 12,000 6,000 18,000 12,000 6,000 18,000 12,000 6,000 18,000
34 Memberi Obat Supositoria 3,600 2,400 6,000 3,600 2,400 6,000 3,600 2,400 6,000
35 Penanganan Pre Operasi 4,800 7,200 12,000 4,800 7,200 12,000 4,800 7,200 12,000
36 Pasang Fowley Cateter* 19,800 10,200 30,000 19,800 10,200 30,000 19,800 10,200 30,000
37 Pasang Kondom Cateter* 9,600 8,400 18,000 9,600 8,400 18,000 9,600 8,400 18,000
38 Pasang Back Slap 4,800 7,200 12,000 4,800 7,200 12,000 4,800 7,200 12,000
39 Pasang Bidai* 4,800 7,200 12,000 4,800 7,200 12,000 4,800 7,200 12,000
40 Pasang Neck Collar* 4,800 7,200 12,000 4,800 7,200 12,000 4,800 7,200 12,000
41 Pasang WSD/reposisi WSD 181,527 272,280 453,807 181,527 272,280 453,807 181,527 272,280 453,807
42 Pemeriksaan inspekulo 9,445 6,280 15,725 9,445 6,280 15,725 9,445 6,280 15,725
43 Penis Hygiene 3,140 2,080 5,220 3,140 2,080 5,220 3,140 2,080 5,220
44 Plebotomi 38,843 25,880 64,723 38,843 25,880 64,723 38,843 25,880 64,723
45 Pungsi Genu 19,313 12,880 32,193 19,313 12,880 32,193 19,313 12,880 32,193
46 Pungsi hepar 144,000 216,000 360,000 144,000 216,000 360,000 144,000 216,000 360,000
47 Pungsi Pleura 144,000 216,000 360,000 144,000 216,000 360,000 144,000 216,000 360,000
48 Rawat kateter 5,265 3,520 8,785 5,265 3,520 8,785 5,265 3,520 8,785
49 Rawat mata 11,210 7,480 18,690 11,210 7,480 18,690 11,210 7,480 18,690
50 Rawat NGT 3,667 2,440 6,107 3,667 2,440 6,107 3,667 2,440 6,107
51 Rawat WSD 10,516 7,000 17,516 10,516 7,000 17,516 10,516 7,000 17,516
52 Penanganan Keracunan 12,000 18,000 30,000 12,000 18,000 30,000 12,000 18,000 30,000
53 Perawatan Payudara 9,000 9,000 18,000 9,000 9,000 18,000 9,000 9,000 18,000
54 Perawatan Kolostomy/Iliestomy 19,200 10,800 30,000 19,200 10,800 30,000 19,200 10,800 30,000
55 Resusitasi Jantung Paru 54,000 30,000 84,000 54,000 30,000 84,000 54,000 30,000 84,000
56 Pasang NGT Dewasa / Anak 15,600 8,400 24,000 15,600 8,400 24,000 15,600 8,400 24,000
57 Pasang ET 96,000 54,000 150,000 96,000 54,000 150,000 96,000 54,000 150,000
58 Pasang Mayo/Oroparingeal 3,600 2,400 6,000 3,600 2,400 6,000 3,600 2,400 6,000
59 Aff infus,/NGT/cateter urine 1,200 1,800 3,000 1,200 1,800 3,000 1,200 1,800 3,000
60 Perawatan Tracheostomy 7,800 4,200 12,000 7,800 4,200 12,000 7,800 4,200 12,000
61 Irigasi Mata 19,800 10,200 30,000 19,800 10,200 30,000 19,800 10,200 30,000
62 EKG 39,000 21,000 60,000 39,000 21,000 60,000 39,000 21,000 60,000
63 Ambil sampel darah vena 1,800 1,200 3,000 1,800 1,200 3,000 1,800 1,200 3,000
64 Penggunaan Oksigen (O2)
1 2 3 4 5 6 7 8 9 10 11
a. tiap 1 liter/menit/jam 2,400 - 2,400 2,400 - 2,400 2,400 - 2,400
b. Pemakaian dan pemasangan O2 per kali tanpa ventilator 19,200 4,800 24,000 19,200 4,800 24,000 19,200 4,800 24,000
c.Pemakaian dan pemasangan O2 per kali dg ventilator 24,000 6,000 30,000 24,000 6,000 30,000 24,000 6,000 30,000
65 Suctioning* 7,800 4,200 12,000 7,800 4,200 12,000 7,800 4,200 12,000
66 Therapi Inhalasi tanpa obat / Nebulizer per shift 20,400 10,800 31,200 20,400 10,800 31,200 20,400 10,800 31,200
67 Irigasi Post BPH (Spoling) 7,800 4,200 12,000 7,800 4,200 12,000 7,800 4,200 12,000
Postural Drainase 15,600 8,400 24,000 15,600 8,400 24,000 15,600 8,400 24,000
II LAIN-LAIN
a. Penggantian paket formula Anak KRP 48,000 6,000 54,000 48,000 6,000 54,000 48,000 6,000 54,000
b. Pembuatan surat keterangan kelahiran 13,200 4,800 18,000 13,200 4,800 18,000 13,200 4,800 18,000
c. Pembuatan surat keterangan jasa raharja 36,000 24,000 60,000 36,000 24,000 60,000 36,000 24,000 60,000
d. Pembuatan surat keterangan Asuransi 36,000 24,000 60,000 36,000 24,000 60,000 36,000 24,000 60,000
e. penggantian air panas rawat inap/termos (1500cc) 2,400 1,200 3,600 2,400 1,200 3,600 2,400 1,200 3,600

No. JENIS PELAYANAN JASA JASA JASA JASA
JASA JUMLAH JASA JUMLAH
SARAN PELAYA JUMLAH PELAYA PELAYANA
NAN SARANA NAN TARIF SARANA N TARIF
A TARIF
1 2 3 4 5 6 7 8 9 10 11
A ADMINISTRASI
1. Berkas RM MRS 12,000 - 12,000 12,000 - 12,000 12,000 - 12,000
2. Tambahan Berkas RM Rawat Inap /Minggu 10,000 10,000 10,000 10,000 10,000 10,000
B AKOMODASI
1. Ruang Rawat Inap 50,000 - 50,000 75,000 - 75,000 100,000 - 100,000
2. Ruang Rawat Inap Bayi 40,000 - 40,000 50,000 - 50,000
3. Ruang Rawat Inap Isolasi Flu Burung - - 150,000 - 150,000
4. Ruang Rawat Inap HCU 200,000 - 200,000 250,000 - 250,000
C VISITE DAN KONSUL DOKTER

1. Dokter Spesialis - 20,000 20,000 - 40,000 40,000 - 60,000 60,000
2. Dokter Umum - 15,000 15,000 - 20,000 20,000 - 25,000 25,000
3. Cito Visite Dokter Spesialis On Side - 40,000 40,000 - 80,000 80,000 - 100,000 100,000
4. Cito Visite Dokter Umum On Side - 20,000 20,000 - 40,000 40,000 - 50,000 50,000
D Konsul / Konseling HIV - AIDS

1. Dokter - 12,500 12,500 - 25,000 25,000 - 40,000 40,000
2. Paramedis - 7,500 7,500 - 15,000 15,000 - 20,000 20,000
E Visite / Konsul Pasien Flu Burung

1. Dokter - - - - - - - 100,000 100,000
2. Paramedis - - - - - - - 50,000 50,000
F Konsul Gizi - 10,000 10,000 - 15,000 15,000 - 20,000 20,000
G TINDAKAN KEPERAWATAN
1. Minimal Care per hari 3,600 13,000 16,600 3,600 13,000 16,600 3,600 15,000 18,600
2. Moderate Care per hari 4,800 16,000 20,800 4,800 16,000 20,800 4,800 17,500 22,300
3. High Care per hari 6,000 24,000 30,000 6,000 24,000 30,000 6,000 25,000 31,000
Keterangan :
1. Layanan Minimal Care adalah layanan yang diberikan kepada pasien rawat inap seperti monitor dan mengukur TTV; monitor, mengganti dan mengatur tetesan infus;
mengantar dan mobilisasi pasien ke tempat diagnostik; memberikan KIE (komunikasi, informasi dan edukasi) kepada pasien dan keluarga.
2. Layanan Moderate/ Partial Care adalah layanan yang diberikan kepada pasien rawat inap seperti membantu menaikkan dan menurunkan pasien dari tempat tidur;
membantu ambulasi dan berjalan; membantu makan/menyuapi pasien; membantu oral hygine; membantu berpakaian/berdandan; membantu BAB/BAK di tempat
tidur/kamar mandi; monitor dan mengukur TTV; monitor, mengganti dan mengatur tetesan infus; mengganti botol drainase; melakukan KIE kepada pasien dan keluarga.
3. Layanan Total/High Care adalah layanan yang diberikan kepada pasien rawat inap yang meliputi layanan minimal care, moderate/partial care serta memandikan pasien;
melatih gerakan pasif (ROM = Range Of Motion); memberikan nutrisi lewat NGT; melatih bladder training; mengukur dan mengawasi GCS pasien; memasang canul/masker
O2; mengatur pemberian O2; mengganti botol WSD; melakukan irigasi kandung kemih; memasang fiksasi dan pengawasan; pengawasan imobilisasi pasca operasi tulang
belakang.
J
A
S
VIPAC VIP A, B SUPER VIP
No. JENIS PELAYANAN JASA JASA JUMLAH JASA JASA JUMLAH
S
SARANA PELAYANAN TARIF SARANA PELAYANAN TARIF
A
1 2 ###R 6 7 8 9 10 11
A
A ADMINISTRASI N
A
1. Berkas RM MRS ### 25,000 - 25,000 35,000 - 35,000
B AKOMODASI
1. Ruang Rawat Inap ### 400,000 - 400,000 750,000 - 750,000
2. Ruang Rawat Inap Bayi ### 200,000 - 200,000 300,000 - 300,000

1. Dokter Spesialis ### - 125,000 125,000 - 150,000 150,000
2. Dokter Umum ### - 35,000 35,000 - 50,000 50,000
D Konsul / Konseling HIV - AIDS

1. Dokter ### - 50,000 50,000 - 100,000 100,000
2. Paramedis ### - 30,000 30,000 - 50,000 50,000
E Konsul Gizi ### - 50,000 50,000 - 100,000 100,000
F TINDAKAN KEPERAWATAN
1. Minimal Care per hari ### 3,600 21,400 25,000 3,600 26,400 30,000
2. Moderate Care per hari ### 4,800 30,200 35,000 4,800 35,200 40,000
3. High Care per hari ### 6,000 44,000 50,000 6,000 54,000 60,000
G TINDAKAN MEDIK
Pemeriksaan awal pasien oleh dokter jaga ### 3,600 25,200 28,800 3,600 28,800 32,400
Pemeriksaan pasien rawat inap gawat oleh dokter jaga### 3,600 25,200 28,800 3,600 28,800 32,400
pasang infus dewasa ### 7,800 7,350 15,150 7,800 8,400 16,200
pasang infus anak/bayi ### 12,000 10,500 22,500 12,000 12,000 24,000
Rawat Lokasi Infus per hari ### 900 1,575 2,475 900 1,800 2,700
Rawat Luka
a. Kecil (< 5 cm) ### 9,600 9,450 19,050 9,600 10,800 20,400
b. Sedang (5 - 10 cm) ### 12,000 10,500 22,500 12,000 12,000 24,000
c. Besar (10 - 20 cm) ### 14,400 11,550 25,950 14,400 13,200 27,600
J
A
S
S
A
1 2 ###
R 6 7 8 9 10 11
d. Khusus (> 20 cm) ### A 19,200 18,900 38,100 19,200 21,600 40,800
Rawat Luka Bakar < 10 % ### N 19,200 18,900 38,100 19,200 21,600 40,800
A
Rawat Luka Bakar 10 -50 % ### 39,000 36,750 75,750 39,000 42,000 81,000
Rawat Luka Bakar > 50 ### 60,000 52,500 112,500 60,000 60,000 120,000
Rawat Luka Khusus (Ganggren, dll) ### 78,000 73,500 151,500 78,000 84,000 162,000
Necrotomy jaringan (kecil) ### 15,600 14,700 30,300 15,600 16,800 32,400
Angkat Jahitan
a. Kecil ( < 5 Jahitan) ### 14,400 11,550 25,950 14,400 13,200 27,600
b. Sedang ( 5 - 10 Jahitan) ### 15,000 15,750 30,750 15,000 18,000 33,000
c. Besar (10 - 20Jahitan) ### 19,200 18,900 38,100 19,200 21,600 40,800
d. Khusus (> 20 jahitan) ### 22,800 23,100 45,900 22,800 26,400 49,200
Pasang Tampon ### 12,000 10,500 22,500 12,000 12,000 24,000
Aff Tampon ### 6,000 5,250 11,250 6,000 6,000 12,000
aff CVP ### 11,430 13,370 24,800 11,430 15,280 26,710
aff drain ### 5,860 5,860 5,860 5,860
aff kateter ### 2,423 2,800 5,223 2,423 3,200 5,623
Ambil sample sputum ### 750 910 1,660 750 1,040 1,790
Biopsi hepar ### 144,000 378,000 522,000 144,000 432,000 576,000
Biopsi Kulit ### 26,050 30,380 56,430 26,050 34,720 60,770
BMP ### 124,302 145,040 269,342 124,302 165,760 290,062
Bronchoscopi ### 1,376,425 3,613,050 4,989,475 1,376,425 4,129,200 5,505,625
Ganti vakum drain ### 2,620 3,080 5,700 2,620 3,520 6,140
Gaster Colling ### 13,865 16,170 30,035 13,865 18,480 32,345
Lepas WSD ### 18,075 21,070 39,145 18,075 24,080 42,155
Memandikan bayi ### 3,795 4,410 8,205 3,795 5,040 8,835
Memberikan obat oral via NGT ### 1,958 2,310 4,268 1,958 2,640 4,598
Memberikan susu via NGT ### 1,958 2,310 4,268 1,958 2,640 4,598
Injeksi im per shift ### 3,600 4,200 7,800 3,600 4,800 8,400
Injeksi iv per shift ### 3,600 4,200 7,800 3,600 4,800 8,400
Injeksi ic per shift ### 3,600 4,200 7,800 3,600 4,800 8,400
Injeksi sc per shift ### 3,600 4,200 7,800 3,600 4,800 8,400
Skin Test ### 3,600 4,200 7,800 3,600 4,800 8,400
Memberi Obat Melalui Gastrotomy ### 12,000 10,500 22,500 12,000 12,000 24,000
Memberi Obat Supositoria ### 3,600 4,200 7,800 3,600 4,800 8,400
Penanganan Pre Operasi ### 4,800 12,600 17,400 4,800 14,400 19,200
J
A
S
S
A
1 2 ###
R 6 7 8 9 10 11
Pasang Fowley Cateter* ### A 19,800 17,850 37,650 19,800 20,400 40,200
Pasang Kondom Cateter* ### N 9,600 14,700 24,300 9,600 16,800 26,400
A
Pasang Bidai* ### 4,800 12,600 17,400 4,800 14,400 19,200
Pasang Back Slap ### 4,800 7,200 12,000 4,800 7,200 12,000
Pasang Neck Collar* ### 4,800 12,600 17,400 4,800 14,400 19,200
Pasang WSD/reposisi WSD ### 181,527 476,490 658,017 181,527 544,560 726,087
Pemeriksaan inspekulo ### 9,445 10,990 20,435 9,445 12,560 22,005
Penis Hygiene ### 3,140 3,640 6,780 3,140 4,160 7,300
Plebotomi ### 38,843 45,290 84,133 38,843 51,760 90,603
Pungsi Genu ### 19,313 22,540 41,853 19,313 25,760 45,073
Pungsi hepar ### 144,000 378,000 522,000 144,000 432,000 576,000
Pungsi Pleura ### 144,000 378,000 522,000 144,000 432,000 576,000
Rawat kateter ### 5,265 6,160 11,425 5,265 7,040 12,305
Rawat mata ### 11,210 13,090 24,300 11,210 14,960 26,170
Rawat NGT ### 3,667 4,270 7,937 3,667 4,880 8,547
Rawat WSD ### 10,516 12,250 22,766 10,516 14,000 24,516
Penanganan Keracunan ### 12,000 31,500 43,500 12,000 36,000 48,000
Perawatan Payudara ### 9,000 15,750 24,750 9,000 18,000 27,000
Perawatan Kolostomy/Iliestomy ### 19,200 18,900 38,100 19,200 21,600 40,800
Resusitasi Jantung Paru ### 54,000 52,500 106,500 54,000 60,000 114,000
Pasang NGT Dewasa / Anak ### 15,600 14,700 30,300 15,600 16,800 32,400
Pasang ET ### 96,000 94,500 190,500 96,000 108,000 204,000
Pasang Mayo/Oroparingeal ### 3,600 4,200 7,800 3,600 4,800 8,400
Aff infus,/NGT/cateter urine ### 1,200 3,150 4,350 1,200 3,600 4,800
Perawatan Tracheostomy ### 7,800 7,350 15,150 7,800 8,400 16,200
Irigasi Mata ### 19,800 17,850 37,650 19,800 20,400 40,200
EKG ### 39,000 36,750 75,750 39,000 42,000 81,000
Ambil sampel darah vena ### 1,800 2,100 3,900 1,800 2,400 4,200
Penggunaan Oksigen (O2)
a. tiap 1 liter/menit/jam ### 2,400 - 2,400 2,400 - 2,400
b. Pemakaian dan pemasangan O2 per kali tanpa ventilator ### 19,200 8,400 27,600 19,200 9,600 28,800
c.Pemakaian dan pemasangan O2 per kali dg ventilator ### 24,000 10,500 34,500 24,000 12,000 36,000
Suctioning* ### 7,800 7,350 15,150 7,800 8,400 16,200
Therapi Inhalasi tanpa obat / Nebulizer per shift ### 20,400 18,900 39,300 20,400 21,600 42,000
Irigasi Post BPH (Spoling) ### 7,800 7,350 15,150 7,800 8,400 16,200
J
A
S
S
A
1 2 ###
R 6 7 8 9 10 11
Postural Drainase ### A 15,600 14,700 30,300 15,600 16,800 32,400
N
A
LAIN-LAIN
a. Penggantian paket formula Anak KRP ### 48,000 10,500 58,500 48,000 12,000 60,000
b. Pembuatan surat keterangan kelahiran ### 13,200 8,400 21,600 13,200 9,600 22,800
c. Pembuatan surat keterangan jasa raharja ### 36,000 42,000 78,000 36,000 48,000 84,000
d. Pembuatan surat keterangan Asuransi ### 36,000 42,000 78,000 36,000 48,000 84,000
e. penggantian air panas rawat inap/termos (1500cc) ### 2,400 2,100 4,500 2,400 2,400 4,800
TARIF PELAYANAN AKOMODASI, VISITE , KONSUL DAN TINDAKAN MEDIK ICU - ICCU - PICU
ICU, ICCU, PICU

No. JENIS PELAYANAN JASA JASA JUMLAH TARIF
SARANA PELAYANAN
1 2 3 4 5
A ADMINISTRASI
1. Berkas RM MRS 12,000 - 12,000
B AKOMODASI
1. Ruang Rawat Inap 250,000 - 250,000

1. Dokter Spesialis - 100,000 100,000
2. Dokter Umum - 50,000 50,000
3. Visite Konsultasi On Side - 100,000 100,000
4.Konsultasi via telpon (di luar jam kerja) - 30,000 30,000
D TINDAKAN KEPERAWATAN
1. Total Care Intensif per hari 12,000 48,000 60,000
E TINDAKAN MEDIK
1. Monitoring memakai Bedside Monitor / per hari 28,800 19,200 48,000
2. Pemasangan Arteri Line - 150,000 150,000
3. Pemasangan CVC ( 1 kali ) 360,000 240,000 600,000
4. Setting awal ventilator / per hari - 300,000 300,000
5. Intubasi Tracheal ( 1 kali ) 141,000 94,000 235,000
6. Extubasi ( 1 kali ) - 150,000 150,000
7. Suction / Bronchial Washing ( per hari ) - 150,000 150,000
8. Nebulizer ( per kali ) - 150,000 150,000
9. Pemakaian Syringe Pump ( per hari) 29,400 19,600 49,000
10. Pemakaian Infusion Pump (per hari) 32,400 21,600 54,000
11. Pemakaian Ventilator ( per hari) 60,000 40,000 100,000
12. Pemakaian RJP / DC Shock ( 1 kali) 420,000 280,000 700,000
13. Resusitasi (1 kali) - 150,000 150,000
14. Therapy Trombolitik 300,000 1,000,000 1,300,000
15. Pemakaian EKG (1 kali) 36,000 24,000 60,000
16. Pembacaan Hasil EKG - 30,000 30,000
17. Pemakaian Blanket Roll (per kali) - 150,000 150,000
18. Vena sectie ( 1 kali) - 150,000 150,000
19. Tracheostomy - 150,000 150,000
20. Pemakaian Temporary Pace Maker ( per hari) 4,890,000 3,260,000 8,150,000
21. Kardioversi Elektrik 270,000 180,000 450,000
22. Kardioversi Farmakologi 270,000 180,000 450,000
23. Perikardiosintesis 510,000 340,000 850,000
24. Treadmill 240,000 160,000 400,000
25. Monitor ventilator (per hari) 50,000 50,000 100,000
26. Aff CVC 10,000 30,000 40,000
27. Perawatan ETT ( Perkali) 10,000 20,000 30,000
28. Persiapan Pre OP (Perkali) 10,000 30,000 40,000
29. Spoeling Kateter ( per kali) 10,000 15,000 25,000
30. Blanket Warmer 30,000 20,000 50,000
31. Injeksi serial (5x per hari) 10,000 20,000 30,000
32. Pasang Mayo 3,600 2,400 6,000
33. Pasang NGT 15,600 8,400 24,000
34. Aff NGT 1,200 1,800 3,000
ICU, ICCU, PICU
SARANA PELAYANAN
1 2 3 4 5
35. Pasang ET 96,000 54,000 150,000
36. Needlle thorakostomi 66,000 42,000 108,000
37. Pasang Cateter 19,800 10,200 30,000
38. Aff cateter 1,200 1,800 3,000
39. Rawat Luka Bakar < 10 % 19,200 10,800 30,000
40. Rawat Luka Bakar 10 -50 % 39,000 21,000 60,000
41. Rawat Luka Bakar > 50 60,000 30,000 90,000
42. Rawat Luka Dekubitus
a. Kecil (< 5 cm) 14,400 9,600 24,000
b. Sedang (5 - 10 cm) 18,000 12,000 30,000
c. Besar (10 - 20 cm) 21,600 14,400 36,000
d. Khusus (> 20 cm) 25,200 16,800 42,000
44. Pasang Kondom Cateter 9,600 8,400 18,000
45. Pasang infus dewasa 7,800 4,200 12,000
46. Pasang infus anak 12,000 6,000 18,000
47. Pemasangan kateter vena profunda 36,000 24,000 60,000
48. Pemasangan kateter HD 108,000 72,000 180,000
49. Cricothyroidotomy / Tracheostomy 186,000 102,000 288,000
50. Pleural Punction 13,200 48,000 61,200
51. Therapi Inhalasi tanpa obat / Nebulizer per shift 20,400 10,800 31,200
52. Debridemant dan necrotomy -
- Luka kecil 19,200 10,800 30,000
- Luka sedang 39,000 21,000 60,000
- Luka luas 78,000 42,000 120,000
53. Pemasangan kateter epidural 144,000 216,000 360,000
54. Fisioterapi Dada 15,600 8,400 24,000
55. Tindakan Anesthesi (GA atau RA) di ICU 108,000 72,000 180,000
56. Resusitasi Kardiopulmonal (dg DC Shock ) 120,000 60,000 180,000
57. Pemasangan WSD 240,000 360,000 600,000
58. Asites Puction 90,000 60,000 150,000
59. Penggunaan Oksigen (O2)
a. tiap 1 liter/menit/jam 2,400 2,400
b. Pemakaian dan pemasangan O2 per kali tanpa ventilator 19,200 4,800 24,000
c.Pemakaian dan pemasangan O2 per kali dg ventilator 24,000 6,000 30,000
F LAIN-LAIN
a. Penggantian paket formula Anak KRP 48,000 6,000 54,000
b. Pembuatan surat keterangan kelahiran 13,200 4,800 18,000
c. Pembuatan surat keterangan jasa raharja 36,000 24,000 60,000
d. Pembuatan surat keterangan Asuransi 36,000 24,000 60,000
Keterangan :
1. Tindakan medik / tindakan keperawatan lainnya di rawat inap yang dilakukan di ICU dikenakan tarif 150% dari tindakan
medik/tindakan keperawatan di Rawat Inap
TARIF PELAYANAN AKOMODASI, VISITE , KONSUL DAN TINDAKAN MEDIK NICU
NICU
1 2 3 4 5
A ADMINISTRASI
1. Berkas RM MRS 12,000 - 12,000
B AKOMODASI
1. NICU / Intensive Bayi Baru Lahir 240,000 - 240,000

1. Visite Intensive - 80,000 80,000
2. Visite Konsultasi On Side - 80,000 80,000
3. Visite Intensive (di luar jam kerja) - 60,000 60,000
D TINDAKAN KEPERAWATAN
1. Total Care Intensif per hari 12,000 48,000 60,000
E TINDAKAN MEDIK
1. Monitoring memakai Bedside Monitor / per hari 28,800 19,200 48,000
2. Pemasangan Arteri Line 36,000 24,000 60,000
3. Observasi ventilator / NCPAP ( per hari) 120,000 60,000 180,000
4. Intubasi Tracheal ( 1 kali ) 96,000 54,000 150,000
5.Extubasi Tracheal ( 1 kali ) 96,000 54,000 150,000
7. Bronchial Washing ( per hari ) 186,000 102,000 288,000
8. Nebulizer ( per kali ) 20,400 10,800 31,200
9. Pemakaian Syringe Pump ( per hari) 50,000 - 50,000
10. Pemakaian Infusion Pump (per hari) 50,000 - 50,000
11. Pemakaian Ventilator / NCPAP ( per hari) 198,000 102,000 300,000
12. Pemakaian Radiant / Infant Warmer (per hari) 50,000 - 50,000
13. Resusitasi (1 kali) 72,000 48,000 120,000
14. Foto therapy (per hari) 36,000 12,000 48,000
15. Pemakaian Portable Pulse Oximeter (1 kali) 24,000 12,000 36,000
16. Lumbal Punctie (per kali) 90,000 60,000 150,000
17. Vena sectie ( 1 kali) 58,800 31,200 90,000
18. Tranfusi Tukar 546,000 294,000 840,000
19. Pemakaian WSD ( per hari) 186,000 102,000 288,000
20. Pemasangan Cateter Umbilical 90,000 60,000 150,000
21.Pemasangan Sensor Saturasi Oksigen 60,000 - 60,000
22.Pasang Respirator / hari 15,600 8,400 24,000
- Sewa alat dan monitoring per jam 2,400 1,200 3,600
23. Pemasangan monitor vital sign 18,000 6,000 24,000
- Sewa alat dan monitoring per jam 1,200 600 1,800
24. Pemasangan Feeding Pump 12,000 6,000 18,000
- Sewa alat dan monitoring per jam 720 480 1,200
25. Vena seksi 58,800 31,200 90,000
26. Intubasi 96,000 54,000 150,000
27. Suction Pump* 7,800 4,200 12,000
28. Pasang NGT 15,600 8,400 24,000
29. Aff NGT 1,200 1,800 3,000
NICU
1 2 3 4 5
30. Pasang ET 96,000 54,000 150,000
31. Pasang Cateter 19,800 10,200 30,000
32. Aff cateter 1,200 1,800 3,000
33. Tindakan Tranfusi* 11,700 6,300 18,000
34. Massage bayi 19,800 10,200 30,000
35. Pasang Ventilator/NCPAP 198,000 102,000 300,000
36. Observasi Ventilator/NCPAP/hari 120,000 60,000 180,000
37. Perawatan Luka 12,000 6,000 18,000
38. Tindakan Metode Kanguru 12,000 18,000 30,000
39. Perawatan Tali Pusat 12,000 6,000 18,000
40. Pemberian surfactan 546,000 294,000 840,000
41. Rawat Luka Bakar < 10 % 19,200 10,800 30,000
42. Rawat Luka Bakar 10 -50 % 39,000 21,000 60,000
43. Rawat Luka Bakar > 50 60,000 30,000 90,000
44. Pemasangan Kateter arteri (artery line) 36,000 24,000 60,000
45. Therapi Inhalasi tanpa obat / Nebulizer per shift 20,400 10,800 31,200
46. Debridement/Necrotomi 19,200 10,800 30,000
47. Fisioterapi 15,600 8,400 24,000
48. Pemasangan Infus Bayi per shift 12,000 6,000 18,000
49. Injeksi im per shift 3,600 2,400 6,000
50. Injeksi iv per shift 3,600 2,400 6,000
51. Injeksi ic per shift 3,600 2,400 6,000
52. Injeksi sc per shift 3,600 2,400 6,000
53. Memberi obat Supositoria 3,600 2,400 6,000
54. Penanganan Pre Operasi 4,800 7,200 12,000
55. Melakukan Sampling Spesimen Lab 3,600 2,400 6,000
56. Melakukan Klisma/huknah rendah /Drumbuisa (Nacl Hangat) 7,800 4,200 12,000
57. Penggunaan Oksigen (O2) -
a. tiap 1 liter/menit/jam 2,400 - 2,400
b. Pemakaian dan pemasangan O2 per kali tanpa ventilator 19,200 4,800 24,000
c.Pemakaian dan pemasangan O2 per kali dg ventilator 24,000 6,000 30,000
F LAIN-LAIN -
a. Penggantian paket formula Anak KRP 48,000 6,000 54,000
b. Pembuatan surat keterangan kelahiran 13,200 4,800 18,000
c. Pembuatan surat keterangan jasa raharja 36,000 24,000 60,000
d. Pembuatan surat keterangan Asuransi 36,000 24,000 60,000
Keterangan :
1. Tindakan medik / tindakan keperawatan lainnya di rawat inap yang dilakukan di NICU dikenakan tarif 150%
dari tindakan medik/tindakan keperawatan di Rawat Inap
TARIF PELAYANAN PEMERIKSAAN LABORATORIUM PATOLOGI KLINIK
KELAS, IRD, POLIKLINIK VIP A,B, SUPER VIP
No. JENIS PELAYANAN JASA JUMLAH TARIF JASA JASA JUMLAH TARIF
JASA SARANA PELAYANAN PELAYANAN
SARANA
1 2 3 4 5 6 7 8
HEMATOLOGI
1 Darah Rutin (HMK)
5 dift 55,000 18,000 73,000 55,000 28,950 83,950
3 dift 31,500 13,500 45,000 31,500 20,250 51,750
2 Reticolusit 9,000 6,000 15,000 9,000 8,250 17,250
3 Angka Eosinofil 10,500 3,000 13,500 10,500 5,025 15,525
4 Limfosit Plasma Biru 10,500 3,000 13,500 10,500 5,025 15,525
5 Malaria Mikroskopis 10,500 3,000 13,500 10,500 5,025 15,525
6 Malaria Stix 20,000 6,000 26,000 20,000 9,900 29,900
7 Filaria 10,500 3,000 13,500 10,500 5,025 15,525
8 Golongan Darah + Rhesus 9,000 6,000 15,000 9,000 8,250 17,250
9 Coomb's Test 56,000 24,000 80,000 56,000 36,000 92,000
10 Morfologi Darah Tepi 40,000 40,000 80,000 40,000 52,000 92,000
11 B M P (Pemeriksaan) 100,000 100,000 200,000 100,000 130,000 230,000
12 Aspirasi BMP 160,000 240,000 400,000 160,000 300,000 460,000
13 Ratio IM / IT 9,000 6,000 15,000 9,000 8,250 17,250
14 Hemosidirin 15,500 6,500 22,000 15,500 9,800 25,300
15 LE Cell 24,000 6,000 30,000 24,000 10,500 34,500
16 O F T 20,000 8,000 28,000 20,000 12,200 32,200
17 Alkali Denaturasi / HBF 15,000 9,000 24,000 15,000 12,600 27,600
18 HbA2 60,000 15,000 75,000 60,000 26,250 86,250
19 Angka Eritrosit 9,000 6,000 15,000 9,000 8,250 17,250
20 Angka Leukosit 9,000 6,000 15,000 9,000 8,250 17,250
21 Angka Trombosit 9,000 6,000 15,000 9,000 8,250 17,250
22 Differential count 9,000 6,000 15,000 9,000 8,250 17,250
23 LED 8,000 3,000 11,000 8,000 4,650 12,650
24 Retraksi Bekuan 9,000 3,000 12,000 9,000 4,800 13,800
25 Serum Iron (SI) 70,000 20,000 90,000 70,000 33,500 103,500
26 Total Iron Binding Capacity (TIBC) 70,000 20,000 90,000 70,000 33,500 103,500
27 INR 85,000 30,000 115,000 85,000 47,250 132,250
28 OFT (Screaning) 12,000 12,000 24,000 12,000 15,600 27,600
29 OFT (Semi Kuantitatif) 25,000 20,000 45,000 25,000 26,750 51,750
SARANA
1 2 3 4 5 6 7 8
30 HbF 40,000 20,000 60,000 40,000 29,000 69,000
FAAL HEMOSTASIS
31 Masa Jendal (CT) 8,500 3,500 12,000 8,500 5,300 13,800
32 Masa Pendarahan (BT) 5,000 3,000 8,000 5,000 4,200 9,200
33 PPT 45,000 15,000 60,000 45,000 24,000 69,000
34 APTT 45,000 15,000 60,000 45,000 24,000 69,000
35 APTT Substitusi 90,000 20,000 110,000 90,000 36,500 126,500
36 Fibrinogen 80,000 20,000 100,000 80,000 35,000 115,000
37 Fibrinogen Degradition Product (FDP)/D Dimer 150,000 20,000 170,000 150,000 45,500 195,500
38 Dimer (Elfa) 330,000 50,000 380,000 330,000 107,000 437,000
PEWARNAAN SITOKIMIA
39 PAS 22,000 5,000 27,000 22,000 9,050 31,050
40 SBB 22,000 5,000 27,000 22,000 9,050 31,050
41 Peroksidase (MPO) 22,000 5,000 27,000 22,000 9,050 31,050
42 NSE 22,000 5,000 27,000 22,000 9,050 31,050
43 Pearl 22,000 5,000 27,000 22,000 9,050 31,050
KIMIA KLINIK
FAAL GINJAL
44 Ureum 14,000 4,000 18,000 14,000 6,700 20,700
45 Kreatinin 12,000 4,000 16,000 12,000 6,400 18,400
46 Uric Acid 16,000 4,000 20,000 16,000 7,000 23,000
47 Urea clearance 30,000 5,000 35,000 30,000 10,250 40,250
FAAL HATI
48 Bilirubin Direk 14,000 6,000 20,000 14,000 9,000 23,000
49 Bilirubin Total 14,000 6,000 20,000 14,000 9,000 23,000
50 Billirubin Indirect 14,000 6,000 20,000 14,000 9,000 23,000
51 Bilirubin(urine) 14,000 6,000 20,000 14,000 9,000 23,000
52 Total Protein 14,000 4,000 18,000 14,000 6,700 20,700
53 Albumin 12,000 3,000 15,000 12,000 5,250 17,250
54 Globulin 15,000 10,000 25,000 15,000 13,750 28,750
55 SGOT 17,000 6,000 23,000 17,000 9,450 26,450
56 SGPT 17,000 6,000 23,000 17,000 9,450 26,450
57 GGT 28,000 6,000 34,000 28,000 11,100 39,100
58 Alakali Fosfatase 14,000 6,000 20,000 14,000 9,000 23,000
SARANA
1 2 3 4 5 6 7 8
DIABETES
59 Gula darah puasa 13,000 4,000 17,000 13,000 6,550 19,550
60 Gula darah puasa 2 jam 13,000 4,000 17,000 13,000 6,550 19,550
61 Gula darah sewaktu 13,000 4,000 17,000 13,000 6,550 19,550
62 HbA1C (A1C) 130,000 20,000 150,000 130,000 42,500 172,500
LEMAK
63 Cholesterol Total 16,000 4,000 20,000 16,000 7,000 23,000
64 Cholesterol HDL 16,000 4,000 20,000 16,000 7,000 23,000
65 Cholesterol LDL 13,000 4,000 17,000 13,000 6,550 19,550
66 Trigilserida 18,000 5,000 23,000 18,000 8,450 26,450
67 HDL Direct 43,000 7,000 50,000 43,000 14,500 57,500
68 LDL Direct 38,000 7,000 45,000 38,000 13,750 51,750
ELEKTROLIT
69 Elektrolit Na+ 50,000 5,000 55,000 50,000 13,250 63,250
70 Elektrolit K+ 50,000 5,000 55,000 50,000 13,250 63,250
71 Elektrolit Cl- 50,000 5,000 55,000 50,000 13,250 63,250
LAIN-LAIN
72 CKMB 80,000 20,000 100,000 80,000 35,000 115,000
73 Analisa Gas Darah dan Elektrolit 180,000 30,000 210,000 180,000 61,500 241,500
74 CK (Creatine Kinase) 36,000 7,000 43,000 36,000 13,450 49,450
75 Protein Elektroforesis 125,000 25,000 150,000 125,000 47,500 172,500
76 Mikro Albumin 108,000 12,000 120,000 108,000 30,000 138,000
IMUNOSEROLOGI
TORCH
77 Toxoplasma IgG IgM 110,000 20,000 130,000 110,000 39,500 149,500
78 Toxoplasma IgG 110,000 20,000 130,000 110,000 39,500 149,500
79 Rubella Ig.M 230,000 20,000 250,000 230,000 57,500 287,500
80 Rubella Ig.G 110,000 20,000 130,000 110,000 39,500 149,500
81 CMV Ig.M 200,000 20,000 220,000 200,000 53,000 253,000
82 CMV Ig.G 110,000 20,000 130,000 110,000 39,500 149,500
83 CMV lg. G andity 75,000 25,000 100,000 75,000 40,000 115,000
84 Toxo lg. G andity 195,000 25,000 220,000 195,000 58,000 253,000
HEPATITIS
SARANA
1 2 3 4 5 6 7 8
85 HBsAg (ELFA) 75,000 15,000 90,000 75,000 28,500 103,500
86 HbsAg Rapid 16,000 4,000 20,000 16,000 7,000 23,000
87 HbsAg (Elisa) 30,000 15,000 45,000 30,000 21,750 51,750
88 Anti HIV (Elva) 135,000 15,000 150,000 135,000 37,500 172,500
89 Anti HIV (Elisa) 35,000 15,000 50,000 35,000 22,500 57,500
90 Anti HIV (Rapid) 65,000 10,000 75,000 65,000 21,250 86,250
91 Ferritin 140,000 40,000 180,000 140,000 67,000 207,000
92 Anti HBs 110,000 15,000 125,000 110,000 33,750 143,750
93 Anti HBs Rapid 30,000 10,000 40,000 30,000 16,000 46,000
94 Anti HCV 170,000 30,000 200,000 170,000 60,000 230,000
95 Anti HCV Rapid 30,000 10,000 40,000 30,000 16,000 46,000
96 Tubex TF 230,000 70,000 300,000 230,000 115,000 345,000
97 lg E 110,000 40,000 150,000 110,000 62,500 172,500
98 HAV 285,000 55,000 340,000 285,000 106,000 391,000
99 Hbe Ag 239,000 56,000 295,000 239,000 100,250 339,250
100 Anti Hbc 245,000 55,000 300,000 245,000 100,000 345,000
101 Rapid TB 50,000 30,000 80,000 50,000 42,000 92,000
102 Salmonela lg 120,000 30,000 150,000 120,000 52,500 172,500
INFEKSI LAIN
103 TPHA 13,500 4,000 17,500 13,500 6,625 20,125
104 VDRL 10,000 3,000 13,000 10,000 4,950 14,950
105 DHF IgG IgM 160,000 20,000 180,000 160,000 47,000 207,000
106 Anti TB 45,000 15,000 60,000 45,000 24,000 69,000
107 IgM Anti Leptospira 30,000 10,000 40,000 30,000 16,000 46,000
108 IgG Anti Leptospira 33,000 12,000 45,000 33,000 18,750 51,750
109 ICT Malaria 21,000 4,000 25,000 21,000 7,750 28,750
110 Widal 30,000 10,000 40,000 30,000 16,000 46,000
111 HIV Elisa 130,000 20,000 150,000 130,000 42,500 172,500
112 HIV Rapid 60,000 15,000 75,000 60,000 26,250 86,250
113 NSI 210,000 20,000 230,000 210,000 54,500 264,500
CARDIAC MARKER
114 Troponin I 275,000 50,000 325,000 275,000 98,750 373,750
115 Myoglobin 195,000 30,000 225,000 195,000 63,750 258,750
116 CKMB 200,000 30,000 230,000 200,000 64,500 264,500
SARANA
1 2 3 4 5 6 7 8
117 NT Pro BNP 395,000 30,000 425,000 395,000 93,750 488,750
118 Digoxin 270,000 30,000 300,000 270,000 75,000 345,000
PETANDA TUMOR
119 AFP 130,000 20,000 150,000 130,000 42,500 172,500
120 CEA 185,000 25,000 210,000 185,000 56,500 241,500
121 PSA 150,000 25,000 175,000 150,000 51,250 201,250
122 CA 15.3 275,000 25,000 300,000 275,000 70,000 345,000
123 CA 125 125,000 25,000 150,000 125,000 47,500 172,500
124 CA 19.9 285,000 25,000 310,000 285,000 71,500 356,500
IMUNOLOGI
125 Total Ig.E 130,000 20,000 150,000 130,000 42,500 172,500
126 T3 Total 70,000 15,000 85,000 70,000 27,750 97,750
127 FSH 150,000 20,000 170,000 150,000 45,500 195,500
128 T4 Total 70,000 20,000 90,000 70,000 33,500 103,500
129 Free T4 130,000 20,000 150,000 130,000 42,500 172,500
130 TSH 100,000 20,000 120,000 100,000 38,000 138,000
131 Free T3 140,000 20,000 160,000 140,000 44,000 184,000
LAIN-LAIN
132 RA/RF 32,500 7,500 40,000 32,500 13,500 46,000
133 ASTO 25,000 10,000 35,000 25,000 15,250 40,250
134 CRP 27,500 7,500 35,000 27,500 12,750 40,250
135 HBSAg (Elisa) 60,000 5,000 65,000 60,000 14,750 74,750
136 HBSAg Rapid 16,000 4,000 20,000 16,000 7,000 23,000
137 HIV Rapid 55,000 10,000 65,000 55,000 19,750 74,750
138 Progesteron 200,000 20,000 220,000 200,000 53,000 253,000
139 Testosteron 310,000 50,000 360,000 310,000 104,000 414,000
140 Anti HP 55,000 20,000 75,000 55,000 31,250 86,250
a. Mantoux Test 100,000 25,000 125,000 100,000 43,750 143,750
MIKROBIOLOGI
KULTUR
Urine
141 Kultur + sensi (Manual) 120,000 50,000 170,000 120,000 75,500 195,500
142 Kultur + sensi (Bactec) 300,000 50,000 350,000 300,000 102,500 402,500
Faeces
SARANA
1 2 3 4 5 6 7 8
Darah
Pus
Sputum
Usapan Tenggorok
Usapan Luka
Cairan Cerebrospinal
Cairan Pleura
Cairan Peritonium
Cairan Pericardium
Cairan Drain
Ascites
SARANA
1 2 3 4 5 6 7 8
Biakan Gall
Biakan An aerob
MIKROSKOPIK
171 Cat Gram 11,000 6,000 17,000 11,000 8,550 19,550
172 BTA Sputum 10,000 6,000 16,000 10,000 8,400 18,400
173 Jamur/Spora 9,000 6,000 15,000 9,000 8,250 17,250
174 Trichomonas 11,000 6,000 17,000 11,000 8,550 19,550
175 Leptospira 11,000 6,000 17,000 11,000 8,550 19,550
176 a. Secret 9,000 6,000 15,000 9,000 8,250 17,250
b. BTA lepral 25,000 15,000 40,000 25,000 21,000 46,000
177 Gene Expert (subsidi) 45,000 80,000 125,000 45,000 98,750 143,750
178 Gene Expert (Non subsidi) 170,000 80,000 250,000 170,000 117,500 287,500
179 CD 4 (fax count) Subsidi 70,000 60,000 130,000 70,000 79,500 149,500
180 CD 4 (Non Subsidi) 270,000 60,000 330,000 270,000 109,500 379,500
URINALISIS
181 Urine Rutin 16,000 4,000 20,000 16,000 7,000 23,000
182 Urin Protein 7,000 3,000 10,000 7,000 4,500 11,500
183 Urin Bilirubin 7,000 3,000 10,000 7,000 4,500 11,500
184 Urin Urobilin 7,000 3,000 10,000 7,000 4,500 11,500
185 Analisa Sperma 35,000 40,000 75,000 35,000 51,250 86,250
186 Urin Keton 7,000 3,000 10,000 7,000 4,500 11,500
187 Sedimen 7,000 3,000 10,000 7,000 4,500 11,500
188 Urin Esbach 7,000 3,000 10,000 7,000 4,500 11,500
189 Urin Bence Jones 7,000 3,000 10,000 7,000 4,500 11,500
190 Uji Kehamilan 15,000 5,000 20,000 15,000 8,000 23,000
191 Uji Kehamilan (titrasi) 30,000 10,000 40,000 30,000 16,000 46,000
ANALISIS FAECES
192 Faeces Rutin 12,000 5,000 17,000 12,000 7,550 19,550
193 Faeces Amoeba 12,000 5,000 17,000 12,000 7,550 19,550
SARANA
1 2 3 4 5 6 7 8
194 Faeces Consentrasi 12,000 5,000 17,000 12,000 7,550 19,550
195 Faeces Benzidin 12,000 5,000 17,000 12,000 7,550 19,550
196 Faeces Stercobilin 12,000 5,000 17,000 12,000 7,550 19,550
NARKOBA
197 Urine Narkoba Amfetamin 30,000 10,000 40,000 30,000 16,000 46,000
198 Urine Narkoba THC 30,000 10,000 40,000 30,000 16,000 46,000
199 Urine Narkoba Morfine 30,000 10,000 40,000 30,000 16,000 46,000
200 Urine Narkoba Benzodiazefin 30,000 10,000 40,000 30,000 16,000 46,000
201 Urine Narkoba Meth Amphetamin 30,000 10,000 40,000 30,000 16,000 46,000
ANALISA CAIRAN TUBUH LAIN
202 Angka Cell LCS 10,000 10,000 20,000 10,000 13,000 23,000
203 Diff Cell LCS 10,000 5,000 15,000 10,000 7,250 17,250
204 None 9,000 3,000 12,000 9,000 4,800 13,800
205 Pandy 9,000 3,000 12,000 9,000 4,800 13,800
206 Rivalta Test 9,000 3,000 12,000 9,000 4,800 13,800
207 Glukosa 12,000 5,000 17,000 12,000 7,550 19,550
208 Protein 12,000 5,000 17,000 12,000 7,550 19,550
PATOLOGI ANATOMI
209 Patologi Anatomi / Histopatologi Besar 288,000 192,000 480,000 288,000 264,000 552,000
210 Patologi Anatomi / Histopatologi 266,400 177,600 444,000 266,400 244,200 510,600
211 Patologi Anatomi / Histopatologi 237,600 158,400 396,000 237,600 217,800 455,400
212 Sitologi 133,200 88,800 222,000 133,200 122,100 255,300
Lain - lain
213 Phlebotomi (Vena) 1,500 1,500 3,000 1,500 1,950 3,450
214 Phlebotomi (Arteri) 2,000 3,000 5,000 2,000 3,750 5,750
215 Packing Dan Kirim Spesimen Ke luar Kota 115,000 35,000 150,000 115,000 57,500 172,500
216 Contsol S 175,000 25,000 200,000 175,000 55,000 230,000
217 VWF 125,000 25,000 150,000 125,000 47,500 172,500
218 Beta 2 Mikroglobin 270,000 30,000 300,000 270,000 75,000 345,000
Keterangan :
1. Pemeriksaan / tindakan yang dilakukan kepada pasien Rawat Inap dibayar oleh pasien sesuai tarif kelas perawatannya.
TARIF PELAYANAN PEMERIKSAAN RADIOLOGI

No. JENIS PELAYANAN JASA JUMLAH TARIF JASA JUMLAH TARIF
JASA SARANA PELAYANAN
1 2 3 4 5 6 7 8
A KECIL / TANPA KONTRAS

1 Kepala AP / Lat 115,200 28,800 144,000 115,200 36,000 151,200
2 Kepala 3 Posisi 172,800 43,200 216,000 172,800 54,000 226,800
3 SPN (Sinus Para Nasal) 67,200 16,800 84,000 67,200 21,000 88,200
4 Nasal 67,200 16,800 84,000 67,200 21,000 88,200
5 Cervical AP / Lat (2 FILM) 115,200 28,800 144,000 115,200 36,000 151,200
6 Cervical AP / Lat / Obl.(4 FILM) 206,400 81,600 288,000 206,400 102,000 308,400
7 Thoracal / AP / Lat (2 FILM) 153,600 38,400 192,000 153,600 48,000 201,600
8 Thoracal / AP / Lat / Obl.(4 FILM) 230,400 57,600 288,000 230,400 72,000 302,400
9 Thoraco Lumbal AP / Lat 153,600 38,400 192,000 153,600 48,000 201,600
10 Thoraco Lumbal AP / Lat / Obl 230,400 57,600 288,000 230,400 72,000 302,400
11 Lumbal AP / Lat (2 FILM) 153,600 38,400 192,000 153,600 48,000 201,600
12 Lumbal AP / Lat / Obl (4 FILM) 230,400 57,600 288,000 230,400 72,000 302,400
13 Lumbosakral AP / Lat 153,600 38,400 192,000 153,600 48,000 201,600
14 Pelvis (1 FILM) 76,800 19,200 96,000 76,800 24,000 100,800
15 Femur AP / Lat 153,600 38,400 192,000 153,600 48,000 201,600
16 Genu AP / Lat 115,200 28,800 144,000 115,200 36,000 151,200
17 Cruris AP / Lat 153,600 38,400 192,000 153,600 48,000 201,600
18 Pedis AP / Lat 115,200 28,800 144,000 115,200 36,000 151,200
19 Ankle Joint AP / Lat 115,200 28,800 144,000 115,200 36,000 151,200
20 Manus AP/Lat 115,200 28,800 144,000 115,200 36,000 151,200
21 Wrist joint AP/lat 115,200 28,800 144,000 115,200 36,000 151,200
22 Antebrachii AP/Lat 134,400 33,600 168,000 134,400 42,000 176,400
23 Elbow Joint AP/Lat 115,200 28,800 144,000 115,200 36,000 151,200
24 Humerus AP/Lat 134,400 33,600 168,000 134,400 42,000 176,400
25 Shoulder AP /Lat 115,200 28,800 144,000 115,200 36,000 151,200
26 Clavicula 67,200 16,800 84,000 67,200 21,000 88,200
27 Thorax PA Dewasa 67,200 16,800 84,000 67,200 21,000 88,200
28 Thorax Lat. Dewasa 67,200 16,800 84,000 67,200 21,000 88,200
29 Thorax AP / Lat Dewasa 134,400 33,600 168,000 134,400 42,000 176,400
1 2 3 4 5 6 7 8
30 Thorax AP Anak 57,600 14,400 72,000 57,600 18,000 75,600
31 Thorax AP / Lat Anak 115,200 28,800 144,000 115,200 36,000 151,200
32 Abdomen / BNO Dewasa 76,800 19,200 96,000 76,800 24,000 100,800
33 Abdomen / BNO Anak 57,600 14,400 72,000 57,600 18,000 75,600
34 Abdomen 3 Posisi Dewasa 230,400 57,600 288,000 230,400 72,000 302,400
35 Abdomen 3 Posisi Anak 172,800 43,200 216,000 172,800 54,000 226,800
36 Dental Regio 48,000 12,000 60,000 48,000 15,000 63,000
37 Panoramic gigi 67,200 16,800 84,000 67,200 21,000 88,200
B SEDANG / DENGAN KONTRAS
1 Mammografi 230,400 57,600 288,000 230,400 72,000 302,400
2 Pelvis dengan Sonde 168,000 72,000 240,000 168,000 90,000 258,000
3 Pelvimeteri 180,000 60,000 240,000 180,000 75,000 255,000
4 Uretrografi 282,000 78,000 360,000 282,000 97,500 379,500
5 Cystografi 282,000 78,000 360,000 282,000 97,500 379,500
6 Uretro Cystografi 336,000 144,000 480,000 336,000 180,000 516,000
7 H S G dengan kontras 360,000 90,000 450,000 360,000 112,500 472,500
8 RPG/APG 273,000 147,000 420,000 273,000 183,750 456,750
9 OMD dengan kontras 480,000 120,000 600,000 480,000 150,000 630,000
10 Oesofagografi 240,000 60,000 300,000 240,000 75,000 315,000
11 Colon In Loop Dewasa 480,000 120,000 600,000 480,000 150,000 630,000
12 Colon In Loop Anak 336,000 84,000 420,000 336,000 105,000 441,000
13 Fluoroscopy 156,000 84,000 240,000 156,000 105,000 261,000
14 Intra Vena Pyelography (IVP) 5 film 384,000 96,000 480,000 384,000 120,000 504,000
15 Intra Vena Pyelography (IVP) 6- 7 film 432,000 108,000 540,000 432,000 135,000 567,000
C CANGGIH
1 Myelografi Lumbal 360,000 240,000 600,000 360,000 300,000 660,000
2 Myelografi Thoracal / Cervical 360,000 240,000 600,000 360,000 300,000 660,000
3 Arthrografi 360,000 240,000 600,000 360,000 300,000 660,000
4 Phlebografi extr superior 288,000 192,000 480,000 288,000 240,000 528,000
5 Phlebografi extr inf 252,000 168,000 420,000 252,000 210,000 462,000
6 CT scan kepala non kontras 432,000 288,000 720,000 432,000 360,000 792,000
7 CT Scan Kepala kontras 648,000 432,000 1,080,000 648,000 540,000 1,188,000
8 a. Whole Body CT scan non kontras 792,000 528,000 1,320,000 792,000 660,000 1,452,000
b. Whole Body CT scan dengan kontras 1,440,000 960,000 2,400,000 1,440,000 1,200,000 2,640,000
1 2 3 4 5 6 7 8
9 CT scan thorax non kontras 432,000 288,000 720,000 432,000 360,000 792,000
10 CT scan thorax kontras 648,000 432,000 1,080,000 648,000 540,000 1,188,000
11 CT scan abdomen Atas /Bawah non kontras 504,000 336,000 840,000 504,000 420,000 924,000
12 CT Scan abdomen Atas /Bawah dengan kontras 864,000 576,000 1,440,000 864,000 720,000 1,584,000
13 CT scan ekstrimitas non kontras 432,000 288,000 720,000 432,000 360,000 792,000
14 CT scan ekstrimitas kontras 648,000 432,000 1,080,000 648,000 540,000 1,188,000
15 C-Arm 288,000 192,000 480,000 288,000 240,000 528,000
16 USG Abdomen Atas 162,000 108,000 270,000 162,000 135,000 297,000
17 USG Abdomen Bawah 162,000 108,000 270,000 162,000 135,000 297,000
18 USG Abdomen Atas Bawah 216,000 144,000 360,000 216,000 180,000 396,000
19 USG Ginjal 162,000 108,000 270,000 162,000 135,000 297,000
20 USG Testis 144,000 96,000 240,000 144,000 120,000 264,000
21 USG Payudara 144,000 96,000 240,000 144,000 120,000 264,000
22 USG Musculoskeletal 144,000 96,000 240,000 144,000 120,000 264,000
23 USG Neonatus 144,000 96,000 240,000 144,000 120,000 264,000
24 USG Thorax 162,000 108,000 270,000 162,000 135,000 297,000
25 USG Obsgin 162,000 108,000 270,000 162,000 135,000 297,000
26 USG Dopler Color 288,000 192,000 480,000 288,000 240,000 528,000
TARIF PELAYANAN BANK DARAH
KELAS, POLIKLINIK, IGD ICU/ICCU/PICU/NICU VIP A,B, SUPER VIP

No. JENIS PELAYANAN JASA JASA JASA JUMLAH JASA JASA JUMLAH
PELAYANAN
JUMLAH TARIF JASA SARANA PELAYANAN
SARANA TARIF SARANA PELAYANAN TARIF
1 2 3 4 5 6 7 8 9 10 11
1 Biaya Pengelolaan Darah 395,000 75,000 470,000 395,000 80,000 470,000 395,000 100,000 470,000
2 Crossmacth (metode gel) 140,000 20,000 160,000 140,000 30,000 160,000 140,000 50,000 160,000
3 Golongan Darah 39,000 5,000 44,000 39,000 7,500 44,000 39,000 10,000 44,000
4 Phlebotomy 110,000 50,000 160,000 110,000 60,000 160,000 110,000 75,000 160,000
TARIF PELAYANAN TINDAKAN HAEMODIALISA
TARIF
SARANA PELAYANAN
1 2 3 4 5
I PAKET PERAWATAN TINDAKAN CAPD
1 Penggantian Transver set (capd) 54,000 46,800 100,800
2 Pelayanan HD tanpa Reuse 960,000 408,000 1,368,000
3 Pelayanan HD dengan Reuse 840,000 240,000 1,080,000
4 Pelayanan HD tanpa re-use dibawa pasien sendiri 300,000 276,000 576,000
5 Pelayanan HD dengan re-use dibawa pasien sendiri 300,000 132,000 432,000
TARIF CITO PELAYANAN TINDAKAN HAEMODIALISA
JASA JASA
NO KETERANGAN TARIF
SARANA PELAYANAN
I PAKET PERAWATAN TINDAKAN CAPD
1 Penggantian Transfusi set 81,000 53,700 134,700
2 Pelayanan HD tanpa Reuse 1,440,000 513,000 1,953,000
3 Pelayanan HD dengan Reuse 1,260,000 327,000 1,587,000
4 Pelayanan HD tanpa re-use dibawa pasien sendiri 450,000 315,000 765,000
5 Pelayanan HD dengan re-use dibawa pasien sendiri 450,000 165,000 615,000
Keterangan :
1. Tarif di atas sudah termasuk bahan habis pakai sesuai standar RSUD Provinsi NTB, kecuali alat kesehatan.
TARIF PELAYANAN TINDAKAN REHAB MEDIK
KELAS, POLIKLINIK, IGD VIP A,B, SUPER VIP
1 2 3 4 5 3 4 5
1 Assesmen Komprehensif KFR / pemeriksaan dokter 7,500 30,000 37,500 11,250 45,000 56,250
2 Bladder training/training kateter berkala 19,500 10,500 30,000 29,250 15,750 45,000
3 Cold pack 9,750 5,250 15,000 14,625 7,875 22,500
4 Diatermi MWD 26,000 14,000 40,000 39,000 21,000 60,000
5 Diatermi SWD 26,000 14,000 40,000 39,000 21,000 60,000
6 Diatermi USD 26,000 14,000 40,000 39,000 21,000 60,000
7 Drainase postural 25,025 13,475 38,500 37,538 20,213 57,750
8 Electrical Stimulation/ IF therapy /TENS 26,000 14,000 40,000 39,000 21,000 60,000
9 Fibrator 13,000 7,000 20,000 19,500 10,500 30,000
10 infraphill 13,000 7,000 20,000 19,500 10,500 30,000
11 Infra red 6 lampu 25,025 13,475 38,500 37,538 20,213 57,750
12 Laser 26,000 14,000 40,000 39,000 21,000 60,000
13 Latihan pernafasan/ fisioterapi dada 15,600 8,400 24,000 23,400 12,600 36,000
14 Latihan ROM, peregangan, inhibisi aktif 16,250 8,750 25,000 24,375 13,125 37,500
15 Latihan pelvic floor 16,250 8,750 25,000 24,375 13,125 37,500
16 Latihan dengan alat Wall climbing / shoulder wheel/ pulley/QB 16,250 8,750 25,000 24,375 13,125 37,500
17 Latihan dgn mesin Continous Passive Movement 26,000 14,000 40,000 39,000 21,000 60,000
18 Latihan dgn tilthing table 26,000 14,000 40,000 39,000 21,000 60,000
19 Latihan penguatan otot 16,250 8,750 25,000 24,375 13,125 37,500
20 Latihan mobilisasi/ambulasi/gait training 32,500 17,500 50,000 48,750 26,250 75,000
21 latihan dgn treadmill 13,000 7,000 20,000 19,500 10,500 30,000
22 latihan dgn sepeda statik 13,000 7,000 20,000 19,500 10,500 30,000
23 Latihan vertigo 19,500 10,500 30,000 29,250 15,750 45,000
24 Latihan koordinasi & keterampilan motorik (PNF/NDT/dll)/FT ANAK/STROKE 39,000 21,000 60,000 58,500 31,500 90,000
25 Masase 25,025 13,475 38,500 37,538 20,213 57,750
26 Massase bayi 25,025 13,475 38,500 37,538 20,213 57,750
27 MLDV 65,000 35,000 100,000 97,500 52,500 150,000
28 OT :terapi persepsi,kognisi, psikomotor 39,000 21,000 60,000 58,500 31,500 90,000
1 2 3 4 5 3 4 5
29 OT: latihan sensori motorik 39,000 21,000 60,000 58,500 31,500 90,000
30 OT : hand therapy 39,000 21,000 60,000 58,500 31,500 90,000
31 OT: terapi snoezellen 39,000 21,000 60,000 58,500 31,500 90,000
32 OT: terapi integrasi sensoris 39,000 21,000 60,000 58,500 31,500 90,000
33 OT sederhana ( ADL/produktivitas/leisure/PBM/relaksasi) 16,250 8,750 25,000 24,375 13,125 37,500
34 Parafin bath 19,500 10,500 30,000 29,250 15,750 45,000
35 Senam hamil/nifas 16,250 8,750 25,000 24,375 13,125 37,500
36 spray & stretch 65,000 35,000 100,000 97,500 52,500 150,000
37 Terapi inhalasi / Nebulizer (tanpa obat) 20,800 11,200 32,000 31,200 16,800 48,000
38 Terapi latihan lain (skoliosis, osteoporosis,koreksi postur) 39,000 21,000 60,000 58,500 31,500 90,000
39 Terapi manipulasi (spinal, sendi perifer) 48,750 26,250 75,000 73,125 39,375 112,500
40 Terapi Wicara (TW): latihan artikulasi/fonasi/kelancaran bicara 19,500 10,500 30,000 29,250 15,750 45,000
41 TW : TW dewasa 39,000 21,000 60,000 58,500 31,500 90,000
42 TW : latihan menelan 39,000 21,000 60,000 58,500 31,500 90,000
43 TW : TW anak 39,000 21,000 60,000 58,500 31,500 90,000
44 tapping/ strapping (belum trmasuk BHP) 22,750 12,250 35,000 34,125 18,375 52,500
45 Traksi (mekanik/manual) 26,000 14,000 40,000 39,000 21,000 60,000
46 akupunktur 30,000 70,000 100,000 30,000 70,000 150,000
47 akupunktur + moksa 40,000 80,000 120,000 40,000 80,000 180,000
48 akupunktur + stimulasi listrik 50,000 70,000 120,000 50,000 70,000 180,000
49 akupunktur + TDP 50,000 70,000 120,000 50,000 70,000 180,000
TARIF PELAYANAN TINDAKAN MEDIK OPERATIF INSTALASI BEDAH SENTRAL
1 2 3 4 5 6 7 8
A OPERASI KECIL 1,000,000 1,500,000 2,500,000 1,200,000 1,875,000 3,075,000

B OPERASI SEDANG 1,200,000 2,000,000 3,200,000 1,440,000 2,500,000 3,940,000
C OPERASI BESAR 1,700,000 2,500,000 4,200,000 2,040,000 3,125,000 5,165,000
D OPERASI KHUSUS 2,000,000 4,000,000 6,000,000 2,400,000 5,000,000 7,400,000
E OPERASI CANGGIH
1 Histrecktomy Radikal 2,300,000 4,700,000 7,000,000 2,760,000 5,875,000 8,635,000
2 Radikal Cystektomi 2,300,000 4,700,000 7,000,000 2,760,000 5,875,000 8,635,000
3 Repair Vesico Vagina Fistel Complex 2,300,000 4,700,000 7,000,000 2,760,000 5,875,000 8,635,000
4 Replantasi 2,300,000 4,700,000 7,000,000 2,760,000 5,875,000 8,635,000
5 Koreksi Fraktur Impresif 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
6 Nefrektomi Radikal 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
7 Nefro Ureterektomi 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
8 Operasi Aneurisme Aorta 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
9 Operasi Arteri Carotis 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
10 Operasi Arteri Renalis Stenosis 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
11 Operasi Fraktur Compleks (A.T.P) 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
12 Operasi Fraktur Muka Multipe 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
13 Operasi Fraktur Tripido / Multipe 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
14 Operasi Pada Atresia Esopagus 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
15 Radikal Prostatektomi 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
16 Reseksi Esofagus + Interposisi Kolon 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
17 Reseksi Hepar 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
18 Spelenektomi 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
19 Stapedektomi 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
20 Temporal Bone Resection 2,500,000 5,000,000 7,500,000 3,000,000 6,250,000 9,250,000
21 Discectomy 2,257,500 5,267,500 7,525,000 2,709,000 6,584,375 9,293,375
1 2 3 4 5 6 7 8
22 Koreksi Scoliosis 2,600,000 5,400,000 8,000,000 3,120,000 6,750,000 9,870,000
23 Koreksi Spondilitis 2,600,000 5,400,000 8,000,000 3,120,000 6,750,000 9,870,000
24 Operasi Pemasangan Fiksasi Interna 2,600,000 5,400,000 8,000,000 3,120,000 6,750,000 9,870,000
25 Evacuation EDH Inpratentorial 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
26 Evacuation SDH 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
27 Evacuation ICH Supratentorial 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
28 Boorhole 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
29 Drainage Subdural Hygroma 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
30 Drainage Subdural Empyema 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
31 Open Evacuation Of Abscess 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
32 Excision meningioma convexitas 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
33 Excision Tumor Spine Extra Dural 2,580,000 6,020,000 8,600,000 3,096,000 7,525,000 10,621,000
34 Craniotomy 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
35 Evacuation ICH Infratentorial 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
36 Ventriculostomy EVD 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
37 Ventriculostomy ICP 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
38 Cranioplasty Autografi 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
39 Excision meningioma Parasagital 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
40 Excision meningioma Falx 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
41 Excision meningioma sphenoid 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
42 Excision Glioma /Astrocytoma 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
43 Pedicle Screw 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
44 Excision Tumor Spine 3,225,000 7,525,000 10,750,000 3,870,000 9,406,250 13,276,250
45 Cranioplasty Acrylic 4,031,250 9,406,250 13,437,500 4,837,500 11,757,813 16,595,313
46 Excision Tumor sella 4,031,250 9,406,250 13,437,500 4,837,500 11,757,813 16,595,313
47 Excision Craniopharyngioma 4,031,250 9,406,250 13,437,500 4,837,500 11,757,813 16,595,313
48 Excision Tumor Cerebellum 4,031,250 9,406,250 13,437,500 4,837,500 11,757,813 16,595,313
49 HemyLaminectomy 4,031,250 9,406,250 13,437,500 4,837,500 11,757,813 16,595,313
50 Excision Tumor spine 4,031,250 9,406,250 13,437,500 4,837,500 11,757,813 16,595,313
51 Subocipital decompretion 4,031,250 9,406,250 13,437,500 4,837,500 11,757,813 16,595,313
52 Elevation Depresed Fracture 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
53 Decompressive Craniectomy 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
1 2 3 4 5 6 7 8
54 Ventriculoperitonial shunting 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
55 Excision CPA Tumor 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
56 Laminectomy 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
57 PLIF 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
58 Interlaminar Wiring 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
59 SRSSI 4,837,500 11,287,500 16,125,000 5,805,000 14,109,375 19,914,375
60 Excision Of Encephalocele 5,643,600 13,168,400 18,812,000 6,772,320 16,460,500 23,232,820
61 SLTH 5,643,600 13,168,400 18,812,000 6,772,320 16,460,500 23,232,820
62 Excision Myelocele 6,450,000 15,050,000 21,500,000 7,740,000 18,812,500 26,552,500
63 Anterior Cervical Discectomy 6,450,000 15,050,000 21,500,000 7,740,000 18,812,500 26,552,500
64 Cervical Laminoplasty 6,450,000 15,050,000 21,500,000 7,740,000 18,812,500 26,552,500
TARIF PELAYANAN TINDAKAN MEDIK OPERATIF (CITO) INSTALASI BEDAH SENTRAL
JASA JASA
NO KETERANGAN
PELAYANAN
TARIF
SARANA
A OPERASI KECIL 1,250,000 1,875,000 3,125,000
B OPERASI SEDANG 1,500,000 2,500,000 4,000,000
C OPERASI BESAR 2,125,000 3,125,000 5,250,000
D OPERASI KHUSUS 2,500,000 5,000,000 7,500,000
E OPERASI CANGGIH
1 Histrecktomy Radikal 4,050,000 4,700,000 8,750,000
2 Radikal Cystektomi 4,050,000 4,700,000 8,750,000
3 Repair Vesico Vagina Fistel Complex 4,050,000 4,700,000 8,750,000
4 Replantasi 4,050,000 4,700,000 8,750,000
5 Koreksi Fraktur Impresif 4,375,000 5,000,000 9,375,000
6 Nefrektomi Radikal 4,375,000 5,000,000 9,375,000
7 Nefro Ureterektomi 4,375,000 5,000,000 9,375,000
8 Operasi Aneurisme Aorta 4,375,000 5,000,000 9,375,000
9 Operasi Arteri Carotis 4,375,000 5,000,000 9,375,000
10 Operasi Arteri Renalis Stenosis 4,375,000 5,000,000 9,375,000
11 Operasi Fraktur Compleks (A.T.P) 4,375,000 5,000,000 9,375,000
12 Operasi Fraktur Muka Multipe 4,375,000 5,000,000 9,375,000
13 Operasi Fraktur Tripido / Multipe 4,375,000 5,000,000 9,375,000
14 Operasi Pada Atresia Esopagus 4,375,000 5,000,000 9,375,000
15 Radikal Prostatektomi 4,375,000 5,000,000 9,375,000
16 Reseksi Esofagus + Interposisi Kolon 4,375,000 5,000,000 9,375,000
17 Reseksi Hepar 4,375,000 5,000,000 9,375,000
18 Spelenektomi 4,375,000 5,000,000 9,375,000
19 Stapedektomi 4,375,000 5,000,000 9,375,000
20 Temporal Bone Resection 4,375,000 5,000,000 9,375,000
21 Discectomy 2,821,875 6,584,375 9,406,250
22 Koreksi Scoliosis 3,250,000 6,750,000 10,000,000
23 Koreksi Spondilitis 3,250,000 6,750,000 10,000,000
24 Operasi Pemasangan Fiksasi Interna 3,250,000 6,750,000 10,000,000
25 Evacuation EDH Inpratentorial 3,225,000 7,525,000 10,750,000
26 Evacuation SDH 3,225,000 7,525,000 10,750,000
27 Evacuation ICH Supratentorial 3,225,000 7,525,000 10,750,000
28 Boorhole 3,225,000 7,525,000 10,750,000
29 Drainage Subdural Hygroma 3,225,000 7,525,000 10,750,000
30 Drainage Subdural Empyema 3,225,000 7,525,000 10,750,000
31 Open Evacuation Of Abscess 3,225,000 7,525,000 10,750,000
32 Excision meningioma convexitas 3,225,000 7,525,000 10,750,000
33 Excision Tumor Spine Extra Dural 3,225,000 7,525,000 10,750,000
34 Craniotomy 4,031,250 9,406,250 13,437,500
35 Evacuation ICH Infratentorial 4,031,250 9,406,250 13,437,500
36 Ventriculostomy EVD 4,031,250 9,406,250 13,437,500
37 Ventriculostomy ICP 4,031,250 9,406,250 13,437,500
38 Cranioplasty Autografi 4,031,250 9,406,250 13,437,500
39 Excision meningioma Parasagital 4,031,250 9,406,250 13,437,500
40 Excision meningioma Falx 4,031,250 9,406,250 13,437,500
41 Excision meningioma sphenoid 4,031,250 9,406,250 13,437,500
42 Excision Glioma /Astrocytoma 4,031,250 9,406,250 13,437,500
43 Pedicle Screw 4,031,250 9,406,250 13,437,500
44 Excision Tumor Spine 4,031,250 9,406,250 13,437,500
45 Cranioplasty Acrylic 5,039,063 11,757,813 16,796,875
46 Excision Tumor sella 5,039,063 11,757,813 16,796,875
47 Excision Craniopharyngioma 5,039,063 11,757,813 16,796,875
JASA JASA
NO KETERANGAN
PELAYANAN
TARIF
SARANA
48 Excision Tumor Cerebellum 5,039,063 11,757,813 16,796,875
49 HemyLaminectomy 5,039,063 11,757,813 16,796,875
50 Excision Tumor spine 5,039,063 11,757,813 16,796,875
51 Subocipital decompretion 5,039,063 11,757,813 16,796,875
52 Elevation Depresed Fracture 6,046,875 14,109,375 20,156,250
53 Decompressive Craniectomy 6,046,875 14,109,375 20,156,250
54 Ventriculoperitonial shunting 6,046,875 14,109,375 20,156,250
55 Excision CPA Tumor 6,046,875 14,109,375 20,156,250
56 Laminectomy 6,046,875 14,109,375 20,156,250
57 PLIF 6,046,875 14,109,375 20,156,250
58 Interlaminar Wiring 6,046,875 14,109,375 20,156,250
59 SRSSI 6,046,875 14,109,375 20,156,250
60 Excision Of Encephalocele 7,054,500 16,460,500 23,515,000
61 SLTH 7,054,500 16,460,500 23,515,000
62 Excision Myelocele 8,062,500 18,812,500 26,875,000
63 Anterior Cervical Discectomy 8,062,500 18,812,500 26,875,000
64 Cervical Laminoplasty 8,062,500 18,812,500 26,875,000
TARIF PELAYANAN TINDAKAN MEDIK OPERATIF INSTALASI BEDAH SENTRAL
1 2 3 4 5 6 7 8
BEDAH PLASTIK
A TINDAKAN SEDANG
1 Kiste, ulcus, scar (<3 lesi) - Diameter < 10 mm 1,562,400 669,600 2,232,000 1,562,400 837,000 2,399,400
2 Kiste, ulcus, scar (<3 lesi) - Diameter > 10 mm 1,562,400 669,600 2,232,000 1,562,400 837,000 2,399,400
3 Nevus Pigmentosum Eksisi Primer 1,562,400 669,600 2,232,000 1,562,400 837,000 2,399,400
4 Kiste, ulcus, scar (<3 lesi) - Diameter > 20 mm 1,562,400 669,600 2,232,000 1,562,400 837,000 2,399,400
5 Kiste, ulcus, scar (4-10 lesi ) 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
6 Trakheostomi 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
7 Escharotomi/Fasciotomi 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
8 Release, Z Plasti 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
9 Mandibula Simple 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
10 Nasal 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
11 Processus Alveolaris 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
12 Ligasi Injeksi 1,821,750 780,750 2,602,500 1,821,750 975,938 2,797,688
B TINDAKAN BESAR
1 Mandibula Segmental 3,138,800 1,345,200 4,484,000 3,138,800 1,681,500 4,820,300
2 Debridement Sederhana 3,138,800 1,345,200 4,484,000 3,138,800 1,681,500 4,820,300
3 Palatoplasti 3,138,800 1,345,200 4,484,000 3,138,800 1,681,500 4,820,300
4 Amputasi 4,026,820 1,725,780 5,752,600 4,026,820 2,157,225 6,184,045
5 Debridement Luas 4,026,820 1,725,780 5,752,600 4,026,820 2,157,225 6,184,045
6 Labioplasti Unilateral 4,026,820 1,725,780 5,752,600 4,026,820 2,157,225 6,184,045
7 Labioplasti Bilateral 4,026,820 1,725,780 5,752,600 4,026,820 2,157,225 6,184,045
8 Eksisi Tangantial (ET) 4,026,820 1,725,780 5,752,600 4,026,820 2,157,225 6,184,045
9 Release & STSG 4,026,820 1,725,780 5,752,600 4,026,820 2,157,225 6,184,045
C TINDAKAN KHUSUS
10 Revisi Labioplasti 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
1 2 3 4 5 6 7 8
11 Labiorhinoplasti 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
12 Tutup Fistel Palatoplasti 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
13 Repalatoplasti 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
14 Nasofrontal 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
15 Eksisi & Rekonstruksi 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
16 Sndactili & Grafting 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
17 Faringoplasti 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
18 Bone Grafting 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
19 Le Fort I 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
20 TM Joint 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
21 Maksila 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
22 Fraktur Lama 3,624,250 1,553,250 5,177,500 3,624,250 1,941,563 5,565,813
23 Polidaktili 4,481,400 1,920,600 6,402,000 4,481,400 2,400,750 6,882,150
24 Tendon Transfer 4,481,400 1,920,600 6,402,000 4,481,400 2,400,750 6,882,150
25 Reliase & FTSG 4,481,400 1,920,600 6,402,000 4,481,400 2,400,750 6,882,150
26 Reliase & Flap Lokal 4,481,400 1,920,600 6,402,000 4,481,400 2,400,750 6,882,150
27 Angulus / Ramus 4,481,400 1,920,600 6,402,000 4,481,400 2,400,750 6,882,150
28 Nevus + Flap / Graf 4,481,400 1,920,600 6,402,000 4,481,400 2,400,750 6,882,150
29 ET + Skin Graft 25% Luas Luka Bakar 4,481,400 1,920,600 6,402,000 4,481,400 2,400,750 6,882,150
30 Zygoma 7,392,280 3,168,120 10,560,400 7,392,280 3,960,150 11,352,430
31 Release & Flap Jauh 7,392,280 3,168,120 10,560,400 7,392,280 3,960,150 11,352,430
32 Loposuction 7,392,280 3,168,120 10,560,400 7,392,280 3,960,150 11,352,430
33 Le Fort 7,392,280 3,168,120 10,560,400 7,392,280 3,960,150 11,352,430
34 Replantasi, Rekonstruksi 7,392,280 3,168,120 10,560,400 7,392,280 3,960,150 11,352,430
35 Tumor Perlu Rekonstruksi 7,392,280 3,168,120 10,560,400 7,392,280 3,960,150 11,352,430
36 Tumor Tulang Wajah 7,392,280 3,168,120 10,560,400 7,392,280 3,960,150 11,352,430
37 Mamma Augmentasi/Reduksi 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
38 Abdominoliopectomi 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
39 Facelift 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
40 Congenital Anomali 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
41 Release & Free Flap Bedah Mikro 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
42 Estetetik Cranio Facial 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
43 Nerve Graft 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
44 Tendon Graft 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
1 2 3 4 5 6 7 8
45 Transplantasi Autologus 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
46 Brachial Plexus Mikrosurgery 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
47 Transplantasi Heterolugus 10,115,280 4,335,120 14,450,400 10,115,280 5,418,900 15,534,180
TARIF PELAYANAN TINDAKAN MEDIK OPERATIF (CITO) BEDAH PLASTIK
TARIF
1 2 3 4 5
BEDAH PLASTIK
A TINDAKAN SEDANG
1 Kiste, ulcus, scar (<3 lesi) - Diameter < 10 mm 1,953,000 837,000 2,790,000
2 Kiste, ulcus, scar (<3 lesi) - Diameter > 10 mm 1,953,000 837,000 2,790,000
3 Nevus Pigmentosum Eksisi Primer 1,953,000 837,000 2,790,000
4 Kiste, ulcus, scar (<3 lesi) - Diameter > 20 mm 1,953,000 837,000 2,790,000
5 Kiste, ulcus, scar (4-10 lesi ) 2,277,188 975,938 3,253,125
6 Trakheostomi 2,277,188 975,938 3,253,125
7 Escharotomi/Fasciotomi 2,277,188 975,938 3,253,125
8 Release, Z Plasti 2,277,188 975,938 3,253,125
9 Mandibula Simple 2,277,188 975,938 3,253,125
10 Nasal 2,277,188 975,938 3,253,125
11 Processus Alveolaris 2,277,188 975,938 3,253,125
12 Ligasi Injeksi 2,277,188 975,938 3,253,125
B TINDAKAN BESAR
1 Mandibula Segmental 3,923,500 1,681,500 5,605,000
2 Debridement Sederhana 3,923,500 1,681,500 5,605,000
3 Palatoplasti 3,923,500 1,681,500 5,605,000
4 Amputasi 5,033,525 2,157,225 7,190,750
5 Debridement Luas 5,033,525 2,157,225 7,190,750
6 Labioplasti Unilateral 5,033,525 2,157,225 7,190,750
7 Labioplasti Bilateral 5,033,525 2,157,225 7,190,750
8 Eksisi Tangantial (ET) 5,033,525 2,157,225 7,190,750
9 Release & STSG 5,033,525 2,157,225 7,190,750
C TINDAKAN KHUSUS
10 Revisi Labioplasti 4,530,313 1,941,563 6,471,875
11 Labiorhinoplasti 4,530,313 1,941,563 6,471,875
12 Tutup Fistel Palatoplasti 4,530,313 1,941,563 6,471,875
13 Repalatoplasti 4,530,313 1,941,563 6,471,875
14 Nasofrontal 4,530,313 1,941,563 6,471,875
15 Eksisi & Rekonstruksi 4,530,313 1,941,563 6,471,875
16 Sndactili & Grafting 4,530,313 1,941,563 6,471,875
17 Faringoplasti 4,530,313 1,941,563 6,471,875
18 Bone Grafting 4,530,313 1,941,563 6,471,875
19 Le Fort I 4,530,313 1,941,563 6,471,875
20 TM Joint 4,530,313 1,941,563 6,471,875
21 Maksila 4,530,313 1,941,563 6,471,875
22 Fraktur Lama 4,530,313 1,941,563 6,471,875
23 Polidaktili 5,601,750 2,400,750 8,002,500
24 Tendon Transfer 5,601,750 2,400,750 8,002,500
25 Reliase & FTSG 5,601,750 2,400,750 8,002,500
26 Reliase & Flap Lokal 5,601,750 2,400,750 8,002,500
27 Angulus / Ramus 5,601,750 2,400,750 8,002,500
28 Nevus + Flap / Graf 5,601,750 2,400,750 8,002,500
29 ET + Skin Graft 25% Luas Luka Bakar 5,601,750 2,400,750 8,002,500
30 Zygoma 9,240,350 3,960,150 13,200,500
TARIF
1 2 3 4 5
31 Release & Flap Jauh 9,240,350 3,960,150 13,200,500
32 Loposuction 9,240,350 3,960,150 13,200,500
33 Le Fort 9,240,350 3,960,150 13,200,500
34 Replantasi, Rekonstruksi 9,240,350 3,960,150 13,200,500
35 Tumor Perlu Rekonstruksi 9,240,350 3,960,150 13,200,500
36 Tumor Tulang Wajah 9,240,350 3,960,150 13,200,500
37 Mamma Augmentasi/Reduksi 12,644,100 5,418,900 18,063,000
38 Abdominoliopectomi 12,644,100 5,418,900 18,063,000
39 Facelift 12,644,100 5,418,900 18,063,000
40 Congenital Anomali 12,644,100 5,418,900 18,063,000
41 Release & Free Flap Bedah Mikro 12,644,100 5,418,900 18,063,000
42 Estetetik Cranio Facial 12,644,100 5,418,900 18,063,000
43 Nerve Graft 12,644,100 5,418,900 18,063,000
44 Tendon Graft 12,644,100 5,418,900 18,063,000
45 Transplantasi Autologus 12,644,100 5,418,900 18,063,000
46 Brachial Plexus Mikrosurgery 12,644,100 5,418,900 18,063,000
47 Transplantasi Heterolugus 12,644,100 5,418,900 18,063,000
TARIF PELAYANAN STERILISASI (CSSD) DAN LOUNDRY
TARIF
1 2 3 4 5
1 Benang Tali pusat 132 18 150

2 Buiq Gaas 15,720 480 16,200
3 Deppers HD dan Tonsil 804 96 900
4 Donat 960 120 1,080
5 Gaas Besar 2,940 180 3,120
6 Gaas mata 900 60 960
7 Gaas Kecil 852 108 960
8 Gaas waten dengan kapas 1,236 84 1,320
9 Gaas waten tanpa kapas 1,140 60 1,200
10 Kapas Alkohol 180 60 240
11 Kapas Potong segi empat 444 36 480
12 Kapas Savlon 240 60 300
13 Lidi kapas 264 36 300
14 Papan Spalk ukuran 100 cm 11,400 600 12,000
15 Papan Spalk ukuran 50 cm 5,760 240 6,000
16 Ransel Verband 58,020 780 58,800
17 Tampon dengan Boorzalft 4,620 180 4,800
18 Tampon gigi 516 84 600
19 Tampon Tanpa Boorzalft 4,440 120 4,560
20 Tampon vagina 2,640 120 2,760
21 Verband Gulung 3,500
22 Sterilisasi Handscun 420 180 600
23 Sterilisasi Instrumen dari Unit RS 1,560 240 1,800
24 Sterilisasi Instrumen dari luar RS/Kilo 12,000 6,000 18,000
25 Loundry bahan Infeksius Noda Berat 9,000 3,000 12,000
26 Loundry bahan Infeksius Noda Ringan 7,000 2,000 9,000
27 Loundry bahan Non Infeksius 4,000 1,000 5,000
28 Loundry/kg 6,000 2,400 8,400
TARIF PELAYANAN INSTALASI KEDOKTERAN FORENSIK DAN PERAWATAN JENAZAH
TARIF
NO JENIS PELAYANAN JASA JASA JUMLAH TARIF
SARANA PELAYANAN
1 2 3 4 5
1 Pemeriksaan Jenazah 325,000 175,000 500,000
2 Koservasi / Pengawetan Jenazah
a. Dengan Formalin 975,000 525,000 1,500,000
b. DS Long 812,500 437,500 1,250,000
c. DS Beauty 975,000 525,000 1,500,000
3 Koservasi / Pengawetan Jenazah WNA
a. Dengan Formalin 1,950,000 1,050,000 3,000,000
b. DS Long 1,625,000 875,000 2,500,000
c. DS Beauty 1,950,000 1,050,000 3,000,000
4 Rekonstruksi Jenazah
a. Luka Ringan 162,500 87,500 250,000
b. Luka Berat 812,500 437,500 1,250,000
5 Penitipan Jenazah RS 162,500 87,500 250,000
6 Penitipan Jenazah Luar RS 227,500 122,500 350,000
7 Perawatan Jenazah
a. Tanpa Resiko (Non Infeksius) 130,000 70,000 200,000
b. Dengan Resiko (Infeksius) 487,500 262,500 750,000
8 Surat Keterangan
a. Kematian 32,500 17,500 50,000
b. Bebas Penyakit Menular 32,500 17,500 50,000
9 Visum Et Repertum Kasus Hidup 162,500 87,500 250,000
10 Otopsi di RSUD Prov. NTB 2,275,000 1,225,000 3,500,000
11 Otopsi di Luar RSUD Prov. NTB 3,250,000 1,750,000 5,000,000
12 Otopsi Gali Kubur / Exumatio 5,200,000 2,800,000 8,000,000
13 Pelayanan Rumah Duka 650,000 350,000 1,000,000
TARIF PELAYANAN PEMERIKSAAN MEDICAL CHECK UP POLIKLINIK KHUSUS
TARIF
SARANA PELAYANAN
1 2 3 4 5
1 PAKET A
1. Pendaftaran 18,000 - 18,000
2. Pemeriksaan Fisik - 25,000 25,000
3. Pemeriksaan MATA - 25,000 25,000
JUMLAH 18,000 50,000 68,000
2 PAKET B
1. Pendaftaran 18,000 - 18,000
4. Pemeriksaan KULIT dan KELAMIN - 25,000 25,000
JUMLAH 18,000 75,000 93,000
3 PAKET C
1. Pendaftaran 18,000 - 18,000
4. Pemeriksaan KULIT dan KELAMIN - 25,000 25,000
5. Pemeriksaan BEDAH - 25,000 25,000
JUMLAH 18,000 100,000 118,000
4 PAKET D
1. Pendaftaran 18,000 - 18,000
4. Pemeriksaan THT - 25,000 25,000
JUMLAH 18,000 75,000 93,000
5 PAKET E
1. Pendaftaran 18,000 - 18,000
5. Pemeriksaan GIGI - 25,000 25,000
6. Pemeriksaan EKG 36,000 24,000 60,000
7. Pembacaan EKG - 30,000 30,000
8. Rontgen Thorax 67,200 16,800 84,000
9. Laboratorium
a. Darah Rutin (5 dift) 55,000 18,000 73,000
b. Urine Rutin 16,000 4,000 20,000
JUMLAH 192,200 192,800 385,000
6 PAKET F (PELAYARAN)
1. Pendaftaran 18,000 - 18,000
TARIF
SARANA PELAYANAN
1 2 3 4 5
6. Pemeriksaan JANTUNG - 25,000 25,000
7. Pemeriksaan EKG 36,000 24,000 60,000
8. Pembacaan EKG - 30,000 30,000
9. Audiometri Murni 127,075 68,425 195,500
10. Psikotest 113,750 61,250 175,000
11. Rontgen Thorax 67,200 16,800 84,000
12. Laboratorium
b. Urine Rutin 16,000 4,000 20,000
c. Ureum 14,000 4,000 18,000
d. Creatinin 12,000 4,000 16,000
e. Asam Urat 16,000 4,000 20,000
f. SGOT 17,000 6,000 23,000
g. SGPT 17,000 6,000 23,000
h. Gula Darah Puasa 13,000 4,000 17,000
i. Gula Darah 2 jam PP 13,000 4,000 17,000
j. Cholesterol Total 16,000 4,000 20,000
k. Trigliserida 18,000 5,000 23,000
l. Golongan Darah 9,000 6,000 15,000
m. HBsAg 16,000 4,000 20,000
n. VDRL 10,000 3,000 13,000
13. Sertifikat Pelayaran 70,000 - 70,000
JUMLAH 674,025 401,475 1,075,500
7 PAKET F
1. Pendaftaran 18,000 - 18,000
6. Pemeriksaan SYARAF - 25,000 25,000
7. Pemeriksaan JANTUNG - 25,000 25,000
6. Pemeriksaan EKG 36,000 24,000 60,000
7. Pembacaan EKG - 30,000 30,000
10. Rontgen Thorax 67,200 16,800 84,000
9. Laboratorium
b. Urine Rutin 16,000 4,000 20,000
c. Ureum 14,000 4,000 18,000
d. Creatinin 12,000 4,000 16,000
e. Asam Urat 16,000 4,000 20,000
f. Bilirubin Total 14,000 6,000 20,000
g. SGOT 17,000 6,000 23,000
h. SGPT 17,000 6,000 23,000
i. Total Protein 14,000 4,000 18,000
j. Albumin 12,000 3,000 15,000
k. Alkali Fosfatase 14,000 6,000 20,000
TARIF
SARANA PELAYANAN
1 2 3 4 5
l. Gula Darah Puasa 13,000 4,000 17,000
m. Gula Darah 2 jam PP 13,000 4,000 17,000
n. Cholesterol Total 16,000 4,000 20,000
o. Cholesterol HDL 16,000 4,000 20,000
p. Cholesterol LDL 13,000 4,000 17,000
q. Trigliserida 18,000 5,000 23,000
r. HBsAg 16,000 4,000 20,000
JUMLAH 427,200 314,800 742,000
TARIF PELAYANAN TINDAKAN POLI GIGI DAN MULUT
TARIF
1 2 3 4 5
A. SPESIFIKASI TINDAKAN PENCABUTAN GIGI

1 Pencabutan gigi susu 18,000 12,000 30,000
2 Pencabutan gigi susu perforasi akar 18,000 12,000 30,000
3 Pencabutan gigi mesiodens 44,640 29,760 74,400
4 Pencabutan gigi eksosterm 3 44,640 29,760 74,400
5 Pencabutan gigi permanen dg akar tunggal 44,640 29,760 74,400
6 Pencabutan gigi permanen dg akar ganda 67,800 45,200 113,000
7 Pencabutan gigi dengan komplikasi 112,080 74,720 186,800
8 Pencabutan sisa akar yang tertinggal 112,080 74,720 186,800
B. SPESIFIKASI TINDAKAN PENAMBALAN GIGI

1 Perawatan Pulpa
a. Open bur / exterpasi dengan lokal anastesi 40,560 27,040 67,600
b. Penambalan enguenol, CHKM, depupil 31,440 20,960 52,400
2 Perawatan Pulpektomy
a. Saluran akar tunggal 54,000 36,000 90,000
b. Saluran akar ganda 62,880 41,920 104,800
c. One Visit Saluran Akar tunggal 121,200 80,800 202,000
d.One Visit saluran akar ganda 139,920 93,280 233,200
3 Pengisian Saluran Akar Tunggal 44,640 29,760 74,400
4 Pengisian Saluran Akar Ganda 54,000 36,000 90,000
5 Tambalan sinar
a. Kecil 54,000 36,000 90,000
b. Sedang 62,880 41,920 104,800
c. Besar 81,120 54,080 135,200
d. Venneer direct/ Besar Sekali 90,000 60,000 150,000
8 Penambalan Glass Ionomer
a. Kecil 36,000 24,000 60,000
b. Sedang 44,640 29,760 74,400
c. Besar 54,000 36,000 90,000
9 Pin Screw + Sementasi 89,640 59,760 149,400
C. SPESIFIKASI TINDAKAN PENGOBATAN/ PERAWATAN JARINGAN

PENYANGGA GIGI
1 Pembersihan karang gigi per regio 27,360 18,240 45,600

2 Perawatan Pocet Periodental 31,440 20,960 52,400
D. SPESIFIKASI PEMBUATAN PROTESA /GIGI PALSU

1 Gigi Tiruan per rahang
a. satu gigi pertama 225,600 150,400 376,000
b. dua gigi 261,600 174,400 436,000
c. tiga gigi 295,200 196,800 492,000
d. empat gigi 331,200 220,800 552,000
e. lima gigi 367,200 244,800 612,000
f. full per rahang 496,800 331,200 828,000
2 Reparasi Plat Patah
a. Reparasi Plat Patah Full 157,200 104,800 262,000
b. Reparasi Plat Patah Parsial 134,400 89,600 224,000
TARIF
1 2 3 4 5
3 Reparasi Penambahan gigi per Rahang
a. satu gigi pertama 90,000 60,000 150,000
b. penambahan gigi berikutnya 44,640 29,760 74,400
4 Rebasing / relining per rahang 202,800 135,200 338,000
5 Orthodontic
a. alat orthodontic 448,800 299,200 748,000
b. aktivasi gigi lepasan 26,880 17,920 44,800
c. reparasi clamer (kawat ortho)/rahang 18,000 12,000 30,000
6 Orthodontic cekat RA/RB 2,700,000 1,800,000 4,500,000
7 Perawatan /kontrol Orthodentic cekat RA/RB 54,000 36,000 90,000
E. SPESIFIKASI TINDAKAN BEDAH MULUT

1 Odontectomy 270,240 180,160 450,400
2 Operculectomy 134,880 89,920 224,800
3 Inter dental wiring/rahang 225,600 150,400 376,000
4 Inter maxilla wiring/rahang 44,640 29,760 74,400
5 Replantasi gigi 315,360 210,240 525,600
6 Alveolectomy/debridement per regio 202,800 135,200 338,000
7 Enukleasi kista (lokal anestesi) 360,000 240,000 600,000
8 Incisi / Eksisi abses 89,400 59,600 149,000
9 Pemeriksaan komplikasi post op/kontrol 26,880 17,920 44,800
10 Pemeriksaan & perbaikan posisi IDW/IMW 44,640 29,760 74,400
11 Pembukaan IDW /rahang 90,000 60,000 150,000
12 Pembukaan IMW 44,640 29,760 74,400
13 Gingivektomy per regio 90,000 60,000 150,000
14 Dry Socket / curetage per gigi 67,440 44,960 112,400
15 Extirpasi mucocelle/epulis 180,000 120,000 300,000
16 aff heacting epulis/mucocelle 26,880 17,920 44,800
F. SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dg

LOGAM
1 Jembatan adoro per unit 340,800 227,200 568,000

2 in lay per unit 180,000 120,000 300,000
3 up lay per unit 225,600 150,400 376,000
G SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY &

UPLAY tanpa LOGAM
1 Jembatan adoro per unit 340,800 227,200 568,000
2 in lay /up lay per unit 180,000 120,000 300,000
H SPESIFIKASI PEMBUATAN JAKET CROWN DENGAN AKRILIK
1. Crown dan Jembatan per unit 184,800 123,200 308,000
Keterangan :
1. Tariftersebut di atas termasuk bahan dan alat kesehatan standar yang ditetapkan RSUD Provinsi NTB.
TARIF PELAYANAN TINDAKAN POLI PENYAKIT THT
TARIF
1 2 3 4 5
1 Audiometri Nada Mumi / Garputala 127,075 68,425 195,500

2 Audiometri tutur 58,500 31,500 90,000
3 Biopsi 162,500 87,500 250,000
4 Caustik / Kauterisasi 127,075 68,425 195,500
5 Corpal Alienum hidung 59,670 32,130 91,800
6 Corpal Alienum telinga 59,670 32,130 91,800
7 Corpal Alienum tenggorokan 71,500 38,500 110,000
8 Ear Toilet 16,250 8,750 25,000
9 Eksisi Massa Hidung / Abses Septum Lokal anastesi 339,820 182,980 522,800
10 Evakuasi Cerumen Ringan 50,700 27,300 78,000
11 Extirpasi granuloma 227,500 122,500 350,000
12 Ganti Kanul trachea 339,820 182,980 522,800
13 Ganti verband 43,680 23,520 67,200
14 Incisi Abses / Drainase 227,500 122,500 350,000
15 Irigasi Sinus Maksila, Lokal Anastesi 339,820 182,980 522,800
16 Kultur discart cavum timpani 128,700 69,300 198,000
17 Kuret / Cauter Granulasi telinga / Faring Lokal Anastesi 130,650 70,350 201,000
18 Krikotiroiddektomi Emergency 1,101,360 593,040 1,694,400
19 Laringoscopy Indireck 127,075 68,425 195,500
20 Laringo Nasopharing Endoscopy 243,750 131,250 375,000
21 Manuver Vertigo Verifer 65,000 35,000 100,000
22 Mastoiditis, Massa / Fistel Mastoid 243,750 131,250 375,000
23 Myringobridge/myringotomi 128,700 69,300 198,000
24 Oto Acustic Emission (OAE) 127,075 68,425 195,500
25 Pasang Gips Hidung / Telinga 97,500 52,500 150,000
26 Buka Gips 26,000 14,000 40,000
27 Rawat Luka
a. Kecil (< 5 cm) 8,125 4,375 12,500
b. Sedang (5-10 cm) 9,750 5,250 15,000
c. Besar (10 - 20 cm) 11,375 6,125 17,500
d. Khusus (>20 cm) 16,250 8,750 25,000
28 Jahit Luka / Repair Jahitan
a. Kecil (< 5 jahitan) 32,500 17,500 50,000
b. Sedang (5 sd 10 jahitan) 45,500 24,500 70,000
c. Besar (10 - 20 jahitan) 52,000 28,000 80,000
d. Khusus (>20 jahitan) 65,000 35,000 100,000
29 Angkat Jahitan
a. Kecil (< 5 jahitan) 11,375 6,125 17,500
b. Sedang (5 sd 10 jahitan) 13,000 7,000 20,000
c. Besar (10 - 20 jahitan) 16,250 8,750 25,000
d. Khusus (>20 jahitan) 19,500 10,500 30,000
30 Reduksi Tertutup os Nasal, Lokal Anastesi 494,455 266,245 760,700
31 Rekonstruksi lobulus telinga dng lokal anastesi 130,650 70,350 201,000
32 Repair Palatum Lokal Anastesi 239,850 129,150 369,000
33 Rinoskopi Posterior (odenoid) 127,075 68,425 195,500
TARIF
1 2 3 4 5
34 Schimer test 68,640 36,960 105,600
35 Spoelling 58,500 31,500 90,000
36 Swab Nasal 19,500 10,500 30,000
37 Swab Nasofaring 21,450 11,550 33,000
38 Swab Telinga 19,500 10,500 30,000
39 Tampon Hidung anterior, pasang/lepas 58,110 31,290 89,400
40 Tampon Hidung Pasterior / Bellog pasang/lepas 102,180 55,020 157,200
41 Test Allergi 68,640 36,960 105,600
42 Tes Alergi Ingestan 211,250 113,750 325,000
43 Tes Alergi Inhalan 127,075 68,425 195,500
44 Tes Fungsi Tuba Eustacius 127,075 68,425 195,500
45 Tes Keseimbangan 52,000 28,000 80,000
46 Tes Mucosa Clereance 58,110 31,290 89,400
47 Tes Penghidu 117,585 63,315 180,900
48 Tes Perasa / Pengecap 117,585 63,315 180,900
49 Tes Vertigo Periver 127,075 68,425 195,500
50 Trakeotomi Emergency / Perawatan 926,640 498,960 1,425,600
51 Tympanometri 127,075 68,425 195,500
TARIF PELAYANAN TINDAKAN POLI PENYAKIT KULIT & KELAMIN
TARIF
1 2 3 4 5
1 Chemical Peeling :
- GA peeling 182,000 98,000 280,000
- Proopeel 364,000 196,000 560,000
- PHA 109,200 58,800 168,000
2 Dermabrasi /microdemabrasi 161,200 86,800 248,000
3 Ekstirpasi 104,000 56,000 160,000
4 Ekstraksi Komedo 46,800 25,200 72,000
5 Elektro Fulgurasi /Elektro Couter :
a. Seboroik Keratosis :
- kecil 57,200 30,800 88,000
- sedang 98,800 53,200 152,000
- besar 156,000 84,000 240,000
b. Skin tag
- kecil 57,200 30,800 88,000
- sedang 98,800 53,200 152,000
- besar 156,000 84,000 240,000
c. Kondyloma Akuminata
- kecil 98,800 53,200 152,000
- sedang 156,000 84,000 240,000
- besar 260,000 140,000 400,000
6 Enukleasi 41,600 22,400 64,000
7 Excisi Non Wajah 213,200 114,800 328,000
8 Excisi Wajah 130,000 70,000 200,000
9 Facial Regula 98,800 53,200 152,000
10 Ganti Verband 20,800 11,200 32,000
11 Heating Aff 18,720 10,080 28,800
12 Incisi Abses 88,400 47,600 136,000
13 Injeksi Kenacort 46,800 25,200 72,000
14 Insisonal biopsi 140,400 75,600 216,000
15 Kerokan Kulit, Kuku, Rambut 19,240 10,360 29,600
16 Kultur 44,200 23,800 68,000
17 Kuretase Kulit 41,600 22,400 64,000
18 Punch Biopsi 140,400 75,600 216,000
19 Radioton 98,800 53,200 152,000
20 Rekonstruksi Kulit 260,000 140,000 400,000
21 Revisi Parut 91,000 49,000 140,000
22 Solarium / Photo Therapi 16,640 8,960 25,600
23 Swab : Uretra 22,880 12,320 35,200
24 Swab : Vagina, Cervix, Fornik 22,880 12,320 35,200
TARIF
1 2 3 4 5
25 Swab discar lesi 22,880 12,320 35,200
26 Test Alergi Tusuk
- Tusuk 91,520 49,280 140,800
- Tempel 130,000 70,000 200,000
27 Test Tempel /Patch Test Standard 182,000 98,000 280,000
28 Test Tempel Standard Kosmetik 182,000 98,000 280,000
29 Trichlor Acetic Acid 36,400 19,600 56,000
TARIF PELAYANAN TINDAKAN POLI PENYAKIT PARU
TARIF
No. JENIS PELAYANAN JASA JASA
JUMLAH TARIF
SARANA PELAYANAN
1 2 3 4 5
1 AJH (Paru) 78,000 42,000 120,000

2 Portable Spirometri 50,700 27,300 78,000
4 Punctie pleura 234,000 126,000 360,000
5 Spirometri komputer 62,400 33,600 96,000
6 Therapi Inhalasi tanpa obat / Nebulizer 20,280 10,920 31,200
7 Trans Toracal Biopsi 97,500 52,500 150,000
8 USG Paru 117,000 63,000 180,000
9 WSD Kontinu / Mini WSD 187,200 100,800 288,000
TARIF PELAYANAN TINDAKAN POLI PENYAKIT DALAM
TARIF
1 2 3 4 5
1 Punctie ascites 97,500 52,500 150,000

2 Aspirasi jarum halus 39,000 21,000 60,000
3 BMP (Basic Metabolic Panel) 97,500 52,500 150,000
4 BMP dengan General Anesthesi 195,000 105,000 300,000
5 EKG 39,000 21,000 60,000
6 Supra Pubic Puncture (SPP) 58,500 31,500 90,000
7 Injeksi Intra artikuler 54,600 29,400 84,000
8 Biopsi Hati 312,000 168,000 480,000
9 Biopsi Ginjal 312,000 168,000 480,000
10 Punctie Pericard / Pleura 312,000 168,000 480,000
11 Aspirasi Abses Hati 97,500 52,500 150,000
12 USG Liver 117,000 63,000 180,000
13 Kemoterapi 130,000 70,000 200,000
14 Gastroscopy 288,600 155,400 444,000
15 Colonoscopy 288,600 155,400 444,000
TARIF PELAYANAN TINDAKAN POLI PENYAKIT SYARAF
TARIF
1 2 3 4 5
1 Assesment Nyeri 11,700 6,300 18,000

2 Assessment Neurobehaviour 253,500 136,500 390,000
3 Assessment Neurobehaviour fit n proper test 585,000 315,000 900,000
4 EEG 136,500 73,500 210,000
5 EKG 39,000 21,000 60,000
6 ENMG 195,000 105,000 300,000
7 Injeksi Intra artikuler 54,600 29,400 84,000
8 Lumbar Fungsi 97,500 52,500 150,000
9 Pembacaan EEG 6,000 84,000 90,000
TARIF PELAYANAN TINDAKAN POLI PENYAKIT JANTUNG
TARIF
1 2 3 4 5
1 Defibrilasi 325,000 175,000 500,000

2 Echocardiografi Dopler Collor 357,500 192,500 550,000
3 EKG 39,000 21,000 60,000
4 FNAB 53,040 28,560 81,600
5 Holter 260,000 140,000 400,000
6 IABP 3,250,000 1,750,000 5,000,000
7 Kardioversi Elektrik 292,500 157,500 450,000
8 Kardioversi farmakologik 292,500 157,500 450,000
9 Trombolitik 400,000 600,000 1,000,000
10 Pacemaker temporer 5,297,500 2,852,500 8,150,000
11 PCI Komplek 5,850,000 3,150,000 9,000,000
12 PCI simple 3,900,000 2,100,000 6,000,000
13 Pemasangan Cardiac Monitor 19,890 10,710 30,600
14 Pemasangan CVP 650,000 350,000 1,000,000
15 Pembacaan EKG 13,000 7,000 20,000
16 Punksi Pericard 312,000 168,000 480,000
17 Regulasi Krisis Hipertensi,aritmia maligna, digitalisasi 292,500 157,500 450,000
18 Reposisi TPM/CVP 292,500 157,500 450,000
19 RJP 227,500 122,500 350,000
20 RJP dgn DC Shock 650,000 350,000 1,000,000
21 Treadmill 260,000 140,000 400,000
TARIF PELAYANAN TINDAKAN POLI PENYAKIT MATA
TARIF
1 2 3 4 5
1 Amotio Corpus Alienum 70,200 37,800 108,000

2 Anal tes 39,000 21,000 60,000
3 Angkat jahitan dikornea 132,600 71,400 204,000
4 Angkat jahitan dipalpebra dan konjunctifa 70,200 37,800 108,000
Biopsi di Konjungtiva 312,000 168,000 480,000
Biopsi di palpebra 312,000 168,000 480,000
5 Campimetri Goldman 81,250 43,750 125,000
6 Campimetri/ perimetri 1 mata dengan Humpray 234,000 126,000 360,000
Campimetri/ perimetri 2 mata dengan Humpray 390,000 210,000 600,000
7 Ekstarpasi nevus / granuloma 195,000 105,000 300,000
8 Ekstirpasi kista konjungtiva 312,000 168,000 480,000
9 Ektirpasi tumor / kista di palpebra 312,000 168,000 480,000
Epilasi 31,200 16,800 48,000
10 Excochleasi / Amotio Lithiasis 101,400 54,600 156,000
11 Excochleasi / Amotio Lithiasis 195,000 105,000 300,000
12 Foto Fundus (Mata) 81,250 43,750 125,000
13 Gonioskopi 46,800 25,200 72,000
14 Iridektomi Perifer 390,000 210,000 600,000
15 Irigasi 19,500 10,500 30,000
16 Keratometri 46,800 25,200 72,000
17 NCT (Non Contac Tonometri) 39,000 21,000 60,000
18 Paracentesis 312,000 168,000 480,000
19 Pemeriksaan Fundus (indirec) 46,800 25,200 72,000
20 Pemeriksaan Refraksi 39,000 21,000 60,000
21 Pemeriksaan Slit Biomikroskop 46,800 25,200 72,000
22 PRP Laser / Laser PC 650,000 350,000 1,000,000
23 Pterigium 312,000 168,000 480,000
24 Refraktometer 46,800 25,200 72,000
25 Reposisi iris 312,000 168,000 480,000
26 Retinoskopi 46,800 25,200 72,000
27 S B L ( Bleparoplasty ) 312,000 168,000 480,000
28 Sondage 39,000 21,000 60,000
29 Synophtophor 97,500 52,500 150,000
30 Tarsoraphy/jahitan di palpebra 312,000 168,000 480,000
31 Test Ishihara 19,500 10,500 30,000
32 Tonometri Aplansi 46,800 25,200 72,000
33 Tonometri SCHIOTZ 39,000 21,000 60,000
34 Transplantasi membran amnion 312,000 168,000 480,000
35 U S G mata 97,500 52,500 150,000
36 Water Drinking 11,700 6,300 18,000
TARIF PELAYANAN TINDAKAN POLI PENYAKIT BEDAH
TARIF
1 2 3 4 5
1 Amputasi Jari 78,000 42,000 120,000

2 Angkat wire 19,500 10,500 30,000
3 Anoskopi 19,500 10,500 30,000
4 Aspirasi 15,600 8,400 24,000
5 Biopsi Besar 162,500 87,500 250,000
6 Biopsi Kecil 48,750 26,250 75,000
7 Biopsi sedang 97,500 52,500 150,000
8 Bouginasi 15,600 8,400 24,000
9 Circumsisi Anak 117,000 63,000 180,000
10 Circumsisi Dewasa 162,500 87,500 250,000
11 Coller And Cup 15,600 8,400 24,000
12 Curetage 117,000 63,000 180,000
13 Debridment Luka 58,500 31,500 90,000
14 Eksisi 66,300 35,700 102,000
15 Ekstirpasi 78,000 42,000 120,000
16 Ekstraksi Batu uretra anterior 78,000 42,000 120,000
17 Exploarasi Corpus alienum 78,000 42,000 120,000
18 Incisi Abses 66,300 35,700 102,000
19 Injeksi Keloid/Kenacord/(IC) 7,800 4,200 12,000
20 Lobulo Plasty 117,000 63,000 180,000
21 Nail Ekstrasi 65,000 35,000 100,000
22 Necrotomy 78,000 42,000 120,000
23 Rawat Luka
a. Kecil (< 5 cm) 9,750 5,250 15,000
b. Sedang (5 - 10 cm) 11,700 6,300 18,000
c. Besar (10 - 20 cm) 13,650 7,350 21,000
d. Khusus (> 20 cm) 48,750 26,250 75,000
24 Jahit Luka / Repair Jahitan
- Kecil ( < 5 jahitan ) 39,000 21,000 60,000
- Sedang ( 5 s/d 10 jahitan ) 54,600 29,400 84,000
- Besar ( 10 - 20 jahitan ) 62,400 33,600 96,000
- Khusus (>20 jahitan) 78,000 42,000 120,000
25 Angkat Jahitan
a. Kecil ( < 5 Jahitan) 13,650 7,350 21,000
b. Sedang ( 5 - 10 Jahitan) 15,600 8,400 24,000
c. Besar (10 - 20Jahitan) 19,500 10,500 30,000
d. Khusus (> 20 jahitan) 23,400 12,600 36,000
26 Rectal Toucher 26,000 14,000 40,000
27 Rozer Plasty 109,200 58,800 168,000
28 Spooling dawer cateter 15,600 8,400 24,000
29 Spoor dawer cateter 78,000 42,000 120,000
30 Tindik 15,600 8,400 24,000
31 Vasektomi 195,000 105,000 300,000
TARIF PELAYANAN TINDAKAN POLI ORTHOPEDI
TARIF
1 2 3 4 5
1 Rawat Luka
a. Kecil (< 5 cm) 9,750 5,250 15,000
b. Sedang (5 - 10 cm) 11,700 6,300 18,000
c. Besar (10 - 20 cm) 13,650 7,350 21,000
d. Khusus (> 20 cm) 48,750 26,250 75,000
2 JahitLuka / Repair Jahitan
- Kecil ( < 5 jahitan ) 39,000 21,000 60,000
- Sedang ( 5 s/d 10 jahitan ) 54,600 29,400 84,000
- Besar ( 10 - 20 jahitan ) 62,400 33,600 96,000
- Khusus (>20 jahitan) 78,000 42,000 120,000
3 Angkat Jahitan
a. Kecil ( < 5 Jahitan) 13,650 7,350 21,000
b. Sedang ( 5 - 10 Jahitan) 15,600 8,400 24,000
c. Besar (10 - 20Jahitan) 19,500 10,500 30,000
d. Khusus (> 20 jahitan) 23,400 12,600 36,000
4 Gips Kecil Anak* 39,000 21,000 60,000
5 Gips Kecil Dewasa* 46,800 25,200 72,000
6 Gips Sedang Anak* 58,500 31,500 90,000
7 Gips Sedang Dewasa* 70,200 37,800 108,000
8 Gips Besar Anak* 93,600 50,400 144,000
9 Gips Besar Dewasa* 117,000 63,000 180,000
10 Buka gips 31,200 16,800 48,000
11 Ransel verband Anak 78,000 42,000 120,000
12 Ransel verband Dewasa 117,000 63,000 180,000
13 Injeksi Arthtritis/articuler* 54,600 29,400 84,000
14 Body cast* 234,000 126,000 360,000
15 Hemi Spica* 234,000 126,000 360,000
16 Necrotomy Ex Op 23,400 12,600 36,000
TARIF PELAYANAN TINDAKAN POLI UROLOGI
TARIF
1 2 3 4 5
1 Ekstraksi batu uretra anterior / Buginasi 195,000 105,000 300,000

2 Ekstraksi batu uretra dengan Anestesi Umum di OK 1,950,000 1,050,000 3,000,000
3 Incisi Abses 66,300 35,700 102,000
4 Injeksi Keloid/Kenacord/(IC) 7,800 4,200 12,000
5 Pasang Fowley Cateter* 19,500 10,500 30,000
6 Pasang kateter Logam* 31,200 16,800 48,000
7 Rawat Luka
a. Kecil (< 5 cm) 9,750 5,250 15,000
b. Sedang (5 - 10 cm) 11,700 6,300 18,000
c. Besar (10 - 20 cm) 13,650 7,350 21,000
d. Khusus (> 20 cm) 48,750 26,250 75,000
8 SWL pada OE 650,000 350,000 1,000,000
9 Tindakan Blast Pistel/Cytostomy 487,500 262,500 750,000
10 Tindakan Blast Punctie 195,000 105,000 300,000
TARIF PELAYANAN TINDAKAN POLI PENYAKIT ANAK
TARIF
1 2 3 4 5
1 BMP 67,600 36,400 104,000

2 EKG 39,000 21,000 60,000
3 Pemeriksaan pasien autisme 35,100 18,900 54,000
4 Pemasangan O2 /jam 19,500 10,500 30,000
5 RRO 27,300 14,700 42,000
6 Therapi Inhalasi tanpa obat / Nebulizer 20,280 10,920 31,200
7 Tindik 15,600 8,400 24,000
8 USG 94,380 50,820 145,200
TARIF PELAYANAN TINDAKAN POLI TUMBUH KEMBANG
TARIF
1 2 3 4 5
1 IMUNISASI DIWAJIBKAN (PPI)

a. BCG 15,600 8,400 24,000
b. DPT – Hb 15,600 8,400 24,000
c. Hepatitis B 15,600 8,400 24,000
d. Polio 15,600 8,400 24,000
e. TT 15,600 8,400 24,000
f. Campak 15,600 8,400 24,000
2 IMUNISASI DIANJURKAN (Non PPI)
a. Infantrik (DTAP) 312,000 168,000 480,000
b. Infantrik – HiB 429,000 231,000 660,000
c. Hepatitis B 156,000 84,000 240,000
d. HiB 273,000 147,000 420,000
e. IPD 780,000 420,000 1,200,000
f. Hepatitis A 390,000 210,000 600,000
g. Valirix (cacar air) 390,000 210,000 600,000
h. Typim (Typoid) 195,000 105,000 300,000
i. MMR 195,000 105,000 300,000
3 Psikologi Test
- Tes Perkembangan Anak (DDST) pasien baru 32,500 17,500 50,000
- Tes Perkembangan Anak (DDST) pasien lama 22,750 12,250 35,000
4 Screening
- Tes Lambat Belajar 16,250 8,750 25,000
-Tes Hiperaktif & Gangguan Konsentrasi 16,250 8,750 25,000
-Tes Autisme 22,750 12,250 35,000
5 Tes Intelegensi (IQ)
- Tes Intelegensia Anak 48,750 26,250 75,000
- Tes Intelegensia Remaja 65,000 35,000 100,000
6 Tes Kepribadian
- Tes Kepribadian Anak 48,750 26,250 75,000
- Tes Kepribadian Remaja 65,000 35,000 100,000
7 Tes Minat Bakat
- Tes minat -bakat Dewasa/anak 81,250 43,750 125,000
8 Psiko Tes 113,750 61,250 175,000
9 Konseling Psikologi (anak, remaja & dewasa) 65,000 35,000 100,000
10 Terapi Wicara 39,000 21,000 60,000
11 Terapi Edukasi 39,000 21,000 60,000
12 Terapi Okupasi 39,000 21,000 60,000
13 Fisioterapi Anak 39,000 21,000 60,000
TARIF PELAYANAN TINDAKAN POLI KEBIDANAN & KANDUNGAN
TARIF
JUMLAH TARIF
SARANA PELAYANAN
1 2 3 4 5
1 Angkat Implant 58,500 31,500 90,000

2 Angkat IUD 58,500 31,500 90,000
3 Biopsi Perpaginam 109,200 58,800 168,000
4 Buka Pessarium 39,000 21,000 60,000
5 CTG 62,400 33,600 96,000
6 Diathermi ( satu seri = 6 kali kunjungan ) 58,500 31,500 90,000
7 Ganti Verban / Buka Jahitan 13,650 7,350 21,000
8 Kauter Albotyl 13,650 7,350 21,000
9 Kauter Elektrik 31,200 16,800 48,000
10 KIE (Komunikasi Informasi Edukasi) 32,500 17,500 50,000
11 Kolposkopi 487,500 262,500 750,000
12 Konseling KB 11,700 6,300 18,000
13 Krayo Terapi 455,000 245,000 700,000
14 MOW / MOP / Mini Laparotomy 421,200 226,800 648,000
15 Pap Smear 31,200 16,800 48,000
16 Pasang Implant 58,500 31,500 90,000
17 Pasang IUD / AKDR 58,500 31,500 90,000
18 Pasang pessarium 39,000 21,000 60,000
19 Pasang/Ganti Tampon 13,650 7,350 21,000
20 Pemeriksaan Gynekologi 11,700 6,300 18,000
21 Pemeriksaan IVA 16,250 8,750 25,000
22 Suntikan KB 23,400 12,600 36,000
23 Tindakan pasang Infus 7,800 4,200 12,000
24 Tindakan pasang kateter 19,500 10,500 30,000
25 USG
- Tampa Print Out 50,700 27,300 78,000
- Dengan Print Out 78,000 42,000 120,000
26 USG Trans Vaginal
- Tampa Print Out 58,500 31,500 90,000
- Dengan Print Out 97,500 52,500 150,000
27 Vaginal Swab 17,160 9,240 26,400
TARIF PELAYANAN TINDAKAN MEDIK PERSALINAN
TARIF
1 2 3 4 5
1 Amniotomi 32,500 17,500 50,000

2 CTG 62,400 33,600 96,000
3 Eksplorasi Digital 65,000 35,000 100,000
4 Ekterpasi kuret pada polip serviks 975,000 525,000 1,500,000
5 Insersi Misoprosol Pervaginam/1 kali insersi 19,500 10,500 30,000
6 KB Suntik 23,400 12,600 36,000
7 KBI (kompresi Bimanual Internal) 812,500 437,500 1,250,000
8 KIE (Komunikasi Informasi Edukasi) 32,500 17,500 50,000
9 Kuretase dengan narcosa 1,625,000 875,000 2,500,000
10 Kuretase tanpa narcosa 812,500 437,500 1,250,000
11 Menjahit robekan portio 97,500 52,500 150,000
12 Pemasangan AKDR 58,500 31,500 90,000
13 Pemberian Mgso4 (per 1 X pemberian) 65,000 35,000 100,000
14 Pemberian Zalf mata 22,750 12,250 35,000
15 Persalinan dengan eklamsi 1,300,000 700,000 2,000,000
16 Persalinan dengan kondiplikasi korporil 455,000 245,000 700,000
17 Persalinan dengan PEB Impending Eklamsi 1,072,500 577,500 1,650,000
18 Persalinan Letsu Manual Aid 812,500 437,500 1,250,000
19 Persalinan spontan dengan bayi gemelli 1,625,000 875,000 2,500,000
20 Persalinan Sungsang (Bracht) Ringan 650,000 350,000 1,000,000
21 Persalinan Normal 432,000 288,000 720,000
22 Persalinan dengan penyulit ringan:
a. Oxytosin Drip 720,000 480,000 1,200,000
b. Misoprostal 720,000 480,000 1,200,000
c. Rehidrasi (Pasang Infus) 720,000 480,000 1,200,000
d. Pwerineorafi 720,000 480,000 1,200,000
23 Persalinan dengan penyulit sedang
a. Ekstraksi Vakum 900,000 600,000 1,500,000
b. HPP 900,000 600,000 1,500,000
c. KDI 900,000 600,000 1,500,000
d. Manual Placenta 1,080,000 720,000 1,800,000
e. Manual AID 1,080,000 720,000 1,800,000
f. Versi Ekstraksi 900,000 600,000 1,500,000
24 Persalinan dengan penyulit besar
a. Embriotomi 1,440,000 2,400,000 3,840,000
b. SC 1,440,000 2,400,000 3,840,000
c. Laparotomi 1,440,000 2,400,000 3,840,000
25 Resusitasi intra uterin 812,500 437,500 1,250,000
26 Suction Curetage tanpa narcosa 1,300,000 700,000 2,000,000
27 Tindakan Gagal Vakum 650,000 350,000 1,000,000
28 Tindakan inspekulo 32,500 17,500 50,000
29 Tindakan Oksitisin Drip (per Botol) 65,000 35,000 100,000
TARIF
1 2 3 4 5
30 Tindakan Oksitisin Drip pada kasus HPP 65,000 35,000 100,000
31 Tindakan SC dng impending eklamsi 9,750,000 5,250,000 15,000,000
32 USG kandungan dengan Print Out 78,000 42,000 120,000
33 USG Trans Vaginal dengan Print Out 97,500 52,500 150,000
34 VT (vagina toucher) untuk 1 X VT 13,000 7,000 20,000
TARIF PELAYANAN PENDIDIKAN, PELATIHAN & PENELITIAN
TARIF TARIF
PELAYANAN
JUMLAH TARIF
SARANA
1 2 3 4 5 ###
I PENDIDIKAN PROFESI
1 Biaya Masuk Praktek Klinik Dokter Muda 180,000 120,000 300,000
###
2 Praktek Klinik Dokter Muda 450,000 300,000 750,000
###
3 Praktek Klinik Dokter Gigi 60,000 40,000 100,000
###
4 Biaya Masuk Praktek Klinik D III, D IV, S I 300,000 200,000 500,000
###
5 Praktek D_III / D_IV (Per orang / HARI ) 7,800 5,200 13,000
###
6 Praktek S_1 (Per orang / HARI ) 9,000 6,000 15,000
###
7 Praktek Profesi Ners (Per orang / HARI ) 10,200 6,800 17,000
###
II UJIAN PRAKTEK
1 Uji Pre Praktek Klinik / Pembekalan (pre test) 75,000 50,000 125,000
###
2 Ujian Klinik Mahasiswa FK (Post Test) 108,000 72,000 180,000
###
3 Ujian Klinik Mahasiswa Keperawatan (Post Test) 60,000 40,000 100,000
###
4 Ujian Klinik Mahasiswa Kebidanan (Post Test) 60,000 40,000 100,000
###
Ujian Klinik Mahasiswa Kefarmasian (Post Test) 60,000 40,000 100,000
###
III KEGIATAN UMUM
1 Praktek Mahasiswa S_1 Teknik (Per orang /HARI ) 6,000 4,000 10,000
###
2 Praktek Mahasiswa S_1 Sains (Per orang / HARI ) 6,000 4,000 10,000
###
3 Praktek Siswa SMK (Per orang /HARI ) 3,600 2,400 6,000
###
4 Praktek Siswa SMU (Per orang /HARI ) 3,600 2,400 6,000
###
5 Kunjungan Lapangan (per orang / hari ) 50,000 25,000 75,000
###
6 Job Training 150,000 100,000 250,000
###
p
7 Study Banding (per orang / hari) 100,000 80,000 200,000
###
e
8 Orientasi / Magang (per orang / hari) 12,000 8,000 20,000
### r
IV PENELITIAN
1 Penerbitan Ethical Clearence Mahasiswa DIII s.d S1. 40,000 60,000 100,000
###
2 Penerbitan Ethical Clearence Mahasiswa S2 s.d S3. 100,000 150,000 250,000
###
3 Penerbitan Ethical Clearence Peneliti Bukan Mahasiswa 100,000 300,000 400,000
###
4 Penerbitan Ijin Penelitian / Pengambilan Data Mahasiswa DIII/S1 60,000 40,000 100,000
###
5 Penerbitan Ijin Penelitian / Pengambilan Data Mahasiswa S2/S3 120,000 80,000 200,000
###
6 Penerbitan Ijin Penelitian / Pengambilan Data Oleh Bukan Mahasiswa 120,000 80,000 200,000
###
7 Pemakaian Ruangan Laboratorium Mikrobiologi Mahasiswa DIII/S1 90,000 60,000 150,000
###
8 Pemakaian Ruangan Laboratorium Mikrobiologi Mahasiswa S2/S3 150,000 100,000 250,000
###
9 Pemakaian Ruangan Laboratorium Mikrobiologi Oleh Bukan Mahasiswa 150,000 100,000 250,000
###
10 Pemakaian Ruangan Laboratorium Imuno Serologi Mahasiswa DIII/S1 90,000 60,000 150,000
###
11 Pemakaian Ruangan Laboratorium Imuno Serologi Mahasiswa S2/S3 150,000 100,000 250,000
###
12 Pemakaian Ruangan Laboratorium Imuno Serologi Oleh Bukan Mahasiswa 150,000 100,000 250,000
###
13 Pemakaian Ruangan Laboratorium Biologi Molekuler Mahasiswa DIII/S1 120,000 80,000 200,000
###
14 Pemakaian Ruangan Laboratorium Biologi Molekuler Mahasiswa S2/S3 180,000 120,000 300,000
###
15 Pemakaian Ruangan Laboratorium Biologi Molekuler Oleh Bukan Mahasiswa 180,000 120,000 300,000
###
16 Pemakaian Ruang Pertemuan Biomedik 120,000 80,000 200,000
###
17 Pemeriksaan Spesimen Penelitian PCR TB 210,000 140,000 350,000
###
18 Pemeriksaan Spesimen Penelitian PCR HBV DNA 210,000 140,000 350,000
###
19 Pemeriksaan Spesimen Penelitian PCR HCV RNA 270,000 180,000 450,000
###
20 Pemeriksaan Spesimen Penelitian PCR HEV RNA 270,000 180,000 450,000
###
21 Pemeriksaan Spesimen Penelitian PCR HPV 16-18 210,000 140,000 350,000
###
22 Pemeriksaan Spesimen Penelitian PCR H. Pylori 210,000 140,000 350,000
###
23 Pemeriksaan Spesimen Penelitian PCR S. Typhi 210,000 140,000 350,000
###
24 Pemeriksaan Spesimen Penelitian PCR Bakteri Jenis Lain 210,000 140,000 350,000
###
25 Pemeriksaan Spesimen Penelitian SPS PAGE 180,000 120,000 300,000
###
26 Pemeriksaan Spesimen Penelitian Western Blotting 210,000 140,000 350,000
###
27 Pemeriksaan Spesimen Penelitian ELISA 18,000 12,000 30,000
###
28 Pemeriksaan Spesimen Penelitian HPLC 60,000 40,000 100,000
###
29 Pemeriksaan Spesimen Penelitian Ekstraksi Senyawa 90,000 60,000 150,000
###
30 Pemeriksaan Spesimen Penelitian Identifikasi Bakteri 42,000 28,000 70,000
###
31 Pemeriksaan Spesimen Penelitian Tes Sensitivitas 24,000 16,000 40,000
###
32 Pemeriksaan Spesimen Penelitian Uji Senyawa Bioaktif 60,000 40,000 100,000
###
TARIF TARIF
PELAYANAN
JUMLAH TARIF
SARANA
1 2 3 4 5 ###
33 Pemeriksaan Spesimen Penelitian Angka Lempeng total 24,000 16,000 40,000
###
34 Pemeriksaan Spesimen Penelitian MPN Coliform 18,000 12,000 30,000
###
35 Penyimpanan Isolat Bakteri 30,000 20,000 50,000
###
36 Pemeliharaan Isolat Bakteri 48,000 32,000 80,000
###
37 Pemakaian Alat BSC2 50,000 - 50,000
###
38 Pemakaian Alat Autoclav 50,000 - 50,000
###
39 Pemakaian Alat Thermocycler 100,000 - 100,000
###
40 Pemakaian Alat Centrifuse 50,000 - 50,000
###
41 Pemakaian Alat Inkubator CO2 25,000 - 25,000
###
42 Pemakaian Alat Freezer/Kulkas di Ruang Lab Instalasi Litbangkes 300,000 - 300,000
###
43 Pemakaian Inkubator Aerob 10,000 - 10,000
###
44 Pemakaian Shaker 30,000 - 30,000
###
45 Pemakaian ruang Binatang Percobaan 150,000 - 150,000
###
46 Penelusuran Artikel Penelitian 12,000 8,000 20,000
###
47 Penyimpanan Data hasil Penelitian 60,000 40,000 100,000
###
48 Dokumentasi Pemeriksaan 15,000 10,000 25,000
###
49 Akses Hasil Penelitian 60,000 40,000 100,000
###
TARIF PELAYANAN AMBULANCE TRANSPORT INSTALASI GAWAT DARURAT
AMBULANCE TRANSPORT AMBULANCE BLS AMBULANCE ALS
1 2
I Kota Mataram 79,200 64,800 144,000 79,200 139,800 219,000 79,200 238,800 318,000
II LOMBOK BARAT
A. KECAMATAN BATULAYAR
1 Desa Batulayar 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
2 Senteluk 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
3 Senggigi 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
4 Kerandangan 120,000 84,000 204,000 120,000 159,000 279,000 120,000 258,000 378,000
B KECAMATAN GUNUNGSARI
1 Desa Kekait 98,400 87,600 186,000 98,400 162,600 261,000 98,400 261,600 360,000
2 Desa Mambalan 98,400 87,600 186,000 98,400 162,600 261,000 98,400 261,600 360,000
3 Desa Persiapan Gelangsar 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
4 Desa Dopang 98,400 87,600 186,000 98,400 162,600 261,000 98,400 261,600 360,000
5 Desa Persiapan Ranjok 98,400 87,600 186,000 98,400 162,600 261,000 98,400 261,600 360,000
6 Desa Guntur Macan 98,400 87,600 186,000 98,400 162,600 261,000 98,400 261,600 360,000
7 Desa Penimbung 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
8 Desa Mekar Sari 121,800 96,600 218,400 121,800 171,600 293,400 121,800 270,600 392,400
Dusun Erat Mate 121,800 96,600 218,400 121,800 171,600 293,400 121,800 270,600 392,400
Dusun Ranjok Timur 121,800 96,600 218,400 121,800 171,600 293,400 121,800 270,600 392,400
C KECAMATAN LINGSAR
1 Desa Karang Bayan 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
2 Desa Batu Mekar 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
3 Desa Batu Kumbung 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
D KECAMATAN NARMADA
1 2
1 Desa Narmada 84,000 96,000 180,000 84,000 171,000 255,000 84,000 270,000 354,000
2 Desa Keru 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
3 Desa Sedau 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
4 Desa Suranadi 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
5 Desa Lembah Sempage 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
6 Desa Sesaot 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
E KECAMATAN KEDIRI
1 Desa Kediri 96,000 84,000 180,000 96,000 159,000 255,000 96,000 258,000 354,000
2 Desa Montong Are 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
3 Desa Ombe 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
4 Desa Banyumulek 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
5 Desa Jagaraga Indah 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
F KECAMATAN KURIPAN
1 Desa Kuripan 120,000 120,000 240,000 120,000 195,000 315,000 120,000 294,000 414,000
2 Desa Kuripan Selatan 144,000 126,000 270,000 144,000 201,000 345,000 144,000 300,000 444,000
3 Desa Kuripan Utara 120,000 108,000 228,000 120,000 183,000 303,000 120,000 282,000 402,000
4 Desa Jagaraga 114,000 96,000 210,000 114,000 171,000 285,000 114,000 270,000 384,000
G KECAMATAN LABUAPI
1 Desa Bagik Polak 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
2 Desa Telaga Waru 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
3 Desa Bajur 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
4 Desa Terong Tawah 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
5 Desa Perampuan 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
6 Desa Bengkel 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
7 Desa Karang Sembung 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
8 Desa Kuranji 98,400 84,000 182,400 98,400 159,000 257,400 98,400 258,000 356,400
H KECAMATAN GERUNG
1 Desa Gerung 120,000 108,000 228,000 120,000 183,000 303,000 120,000 282,000 402,000
2 Desa Persiapan Tembesi 132,000 120,000 252,000 132,000 195,000 327,000 132,000 294,000 426,000
1 2
3 Desa Banyu Urip 160,800 139,200 300,000 160,800 214,200 375,000 160,800 313,200 474,000
4 Desa Kebon Ayu 129,600 110,400 240,000 129,600 185,400 315,000 129,600 284,400 414,000
5 Desa Tempos 129,600 110,400 240,000 129,600 185,400 315,000 129,600 284,400 414,000
I KECAMATAN LEMBAR
1 Desa Lembar 150,000 120,000 270,000 150,000 195,000 345,000 150,000 294,000 444,000
2 Desa Jembatan Kembar 129,600 110,400 240,000 129,600 185,400 315,000 129,600 284,400 414,000
Dusun Gumesa 152,400 123,600 276,000 152,400 198,600 351,000 152,400 297,600 450,000
3 Desa Mareje 174,000 126,000 300,000 174,000 201,000 375,000 174,000 300,000 474,000
4 Desa Jelateng 153,000 123,000 276,000 153,000 198,000 351,000 153,000 297,000 450,000
5 Desa Labuan Treng 153,000 123,000 276,000 153,000 198,000 351,000 153,000 297,000 450,000
J KECAMATAN SEKOTONG TENGAH

1 Desa Sekotong Tengah 223,200 166,800 390,000 223,200 266,800 490,000 223,200 348,800 572,000
2 Desa Persiapan Cendi Manik 240,000 162,000 402,000 240,000 262,000 502,000 240,000 394,000 634,000
3 Desa Buwun Mas 264,000 174,000 438,000 264,000 299,000 563,000 264,000 464,000 728,000
Dusun Pengantap / Sepi 330,000 270,000 600,000 330,000 420,000 750,000 330,000 618,000 948,000
4 Desa Sekotong Barat 270,000 210,000 480,000 270,000 335,000 605,000 270,000 500,000 770,000
5 Desa Kedaro 285,600 194,400 480,000 285,600 344,400 630,000 285,600 542,400 828,000
Dusun Mendawe Selatan 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
Dusun Majapahit 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
Dusun Pelangan 312,000 348,000 660,000 312,000 498,000 810,000 312,000 696,000 1,008,000
Dusun Tibu Samut 306,000 204,000 510,000 306,000 379,000 685,000 306,000 610,000 916,000
Dusun Tirta Sari 306,000 204,000 510,000 306,000 379,000 685,000 306,000 610,000 916,000
6 Desa Betu Putih 336,000 204,000 540,000 336,000 379,000 715,000 336,000 610,000 946,000
Dusun Labuan Poh 360,000 180,000 540,000 360,000 355,000 715,000 360,000 586,000 946,000
Dusun Bangko-Bangko, Blongas 396,000 264,000 660,000 396,000 464,000 860,000 396,000 728,000 1,124,000
Dusun Brambang 394,800 265,200 660,000 394,800 265,200 660,000 394,800 265,200 660,000
III KABUPATEN LOMBOK UTARA

A KECAMATAN BAYAN - - - - 150,000 150,000 - 348,000 348,000
1 Desa Mumpung Sari 276,000 204,000 480,000 276,000 329,000 605,000 276,000 494,000 770,000
1 2
Dusun Mundar 300,000 198,000 498,000 300,000 348,000 648,000 300,000 546,000 846,000
Dusun Beloncong 300,000 198,000 498,000 300,000 348,000 648,000 300,000 546,000 846,000
2 Desa Akar-Akar 282,000 198,000 480,000 282,000 323,000 605,000 282,000 488,000 770,000
Dusun Batu Jingkiran 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
Dusun Pawang Timpas 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
3 Desa Sukadana 300,000 240,000 540,000 300,000 390,000 690,000 300,000 588,000 888,000
Dusun Beban Kuta 330,000 228,000 558,000 330,000 403,000 733,000 330,000 634,000 964,000
Dusun Batu Rakit, Sembagiek 330,000 228,000 558,000 330,000 403,000 733,000 330,000 634,000 964,000
4 Desa Anyar 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
Dusun Telaga Banyak 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
Dusun Dasan Gerisak 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
5 Desa Karang Bajo 330,000 228,000 558,000 330,000 403,000 733,000 330,000 634,000 964,000
Dusun Plang Bupati 330,000 228,000 558,000 330,000 403,000 733,000 330,000 634,000 964,000
Dusn Dasan Baru 330,000 228,000 558,000 330,000 403,000 733,000 330,000 634,000 964,000
6 Desa Senaru 342,000 258,000 600,000 342,000 433,000 775,000 342,000 664,000 1,006,000
Dusun Lendang Cempaka 342,000 258,000 600,000 342,000 433,000 775,000 342,000 664,000 1,006,000
Dusun Pawang Karya 390,000 270,000 660,000 390,000 445,000 835,000 390,000 676,000 1,066,000
7 Desa Bayan 330,000 270,000 600,000 330,000 445,000 775,000 330,000 676,000 1,006,000
Dusun Dasan Tutul 360,000 276,000 636,000 360,000 451,000 811,000 360,000 682,000 1,042,000
Dusun Nangka Repek 360,000 276,000 636,000 360,000 451,000 811,000 360,000 682,000 1,042,000
8 Desa Loloan 360,000 240,000 600,000 360,000 415,000 775,000 360,000 646,000 1,006,000
Dusun Korean 360,000 276,000 636,000 360,000 451,000 811,000 360,000 682,000 1,042,000
Dusun Tanjung Biru 360,000 270,000 630,000 360,000 445,000 805,000 360,000 676,000 1,036,000
9 Desa Sambik Elen 360,000 240,000 600,000 360,000 415,000 775,000 360,000 646,000 1,006,000
Dusun Batu Santek Atas 360,000 270,000 630,000 360,000 445,000 805,000 360,000 676,000 1,036,000
Dusun Santek Bawah 360,000 270,000 630,000 360,000 445,000 805,000 360,000 676,000 1,036,000
B KECAMATAN KAYANGAN
1 Desa Kayangan 270,000 210,000 480,000 270,000 335,000 605,000 270,000 500,000 770,000
Dusun Perbakong 282,000 198,000 480,000 282,000 348,000 630,000 282,000 546,000 828,000
Dusun Sejongga 282,000 198,000 480,000 282,000 323,000 605,000 282,000 488,000 770,000
2 Desa Selengan 270,000 210,000 480,000 270,000 335,000 605,000 270,000 500,000 770,000
Dusun Sangia 282,000 198,000 480,000 282,000 348,000 630,000 282,000 546,000 828,000
1 2
Dusun Sambik Jengker Barat 270,000 210,000 480,000 270,000 335,000 605,000 270,000 500,000 770,000
3 Desa Salut 306,000 204,000 510,000 306,000 354,000 660,000 306,000 552,000 858,000
Dusun Salut Kendal 324,000 216,000 540,000 324,000 366,000 690,000 324,000 564,000 888,000
Dusun Sambik Rindang 324,000 216,000 540,000 324,000 391,000 715,000 324,000 622,000 946,000
4 Desa Gumantar 324,000 216,000 540,000 324,000 391,000 715,000 324,000 622,000 946,000
Dusun 342,000 258,000 600,000 342,000 433,000 775,000 342,000 664,000 1,006,000
Dusun 342,000 258,000 600,000 342,000 433,000 775,000 342,000 664,000 1,006,000
5 Desa Dangiang 282,000 198,000 480,000 282,000 348,000 630,000 282,000 546,000 828,000
Dusun Banten Dawai 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
Dusun Kebun Kunyit 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
6 Desa Sesait 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
Dusun Pansor Daye 324,000 216,000 540,000 324,000 391,000 715,000 324,000 622,000 946,000
Dusun Teluk Ware 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
7 Desa Pendua 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
Dusun Lekok Bantan 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
Dusun Pendua Lauk 312,000 228,000 540,000 312,000 403,000 715,000 312,000 634,000 946,000
8 Desa Santong 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
Dusun Gubuk Baru 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
Dusun Sempako 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
C KECAMATAN GANGGA
1 Desa Gondang 240,000 162,000 402,000 240,000 262,000 502,000 240,000 394,000 634,000
Dusun Jeliti 264,000 156,000 420,000 264,000 256,000 520,000 264,000 388,000 652,000
Dusun Gondang Timur 264,000 156,000 420,000 264,000 281,000 545,000 264,000 446,000 710,000
2 Desa Bentek 264,000 156,000 420,000 264,000 281,000 545,000 264,000 446,000 710,000
Dusun Batu Ringgit 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
Dusun Selelos 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
3 Desa Genggelang 264,000 156,000 420,000 264,000 281,000 545,000 264,000 446,000 710,000
Dusun Mongal 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
Dusun Paok Rempek 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
4 Desa Rempek 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
Dusun Kuripan 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
Dusun Lempojang 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
1 2
5 Desa Sambik Bangkol 276,000 204,000 480,000 276,000 329,000 605,000 276,000 494,000 770,000
Dusun Senjajap 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
Dusun Ropang Sumbangun 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
D KECAMATAN TANJUNG
1 Desa Tanjung 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
Dusun Lading-Lading 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
Dusun Kandang Kaok 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
2 Desa Sokong 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
Dusun Batu Tumping 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Pengembuk 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
3 Desa Jenggik / Jenggala 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
Dusun Dasan Tengak 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Kopu 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
4 Desa Tegal Maja 210,000 180,000 390,000 210,000 280,000 490,000 210,000 412,000 622,000
Dusun Leong Barat 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Leong Timur 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
5 Desa Sigar Penjalin 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Marpayung 234,000 174,000 408,000 234,000 299,000 533,000 234,000 464,000 698,000
Dusun Rangset Barat 234,000 174,000 408,000 234,000 299,000 533,000 234,000 464,000 698,000
6 Desa Medana 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
Dusun Kopang 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
Dusun Gool 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
7 Desa Teniga 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Batu Lilir 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Honggong 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
E KECAMATAN PEMENANG
1 Desa Pemenang Timur 156,000 144,000 300,000 156,000 219,000 375,000 156,000 318,000 474,000
Dusun Poloh Tanjung 180,000 132,000 312,000 180,000 207,000 387,000 180,000 306,000 486,000
Dusun Trengan 168,000 144,000 312,000 168,000 219,000 387,000 168,000 318,000 486,000
2 Desa Pemenang Barat 168,000 144,000 312,000 168,000 219,000 387,000 168,000 318,000 486,000
Dusun Bentek 180,000 144,000 324,000 180,000 244,000 424,000 180,000 376,000 556,000
1 2
Dusun Teluk Kobal 180,000 144,000 324,000 180,000 244,000 424,000 180,000 376,000 556,000
3 Desa Malaka 150,000 150,000 300,000 150,000 225,000 375,000 150,000 324,000 474,000
Dusun Kelui 168,000 144,000 312,000 168,000 219,000 387,000 168,000 318,000 486,000
Dusun Lendang Luar 168,000 144,000 312,000 168,000 219,000 387,000 168,000 318,000 486,000
IV. KABUPATEN LOMBOK TENGAH

A. KECAMATAN PRAYA
1 Kelurahan Prapen 162,000 138,000 300,000 162,000 213,000 375,000 162,000 312,000 474,000
2 Kelurahan Gerunung 162,000 138,000 300,000 162,000 213,000 375,000 162,000 312,000 474,000
3 Desa Bunut Baok 162,000 138,000 300,000 162,000 213,000 375,000 162,000 312,000 474,000
4 Desa Pengeot 162,000 138,000 300,000 162,000 213,000 375,000 162,000 312,000 474,000
5 Desa Jago 162,000 138,000 300,000 162,000 213,000 375,000 162,000 312,000 474,000
B KECAMATAN PRINGGARATA
1 Desa Pringgarata 162,000 138,000 300,000 162,000 213,000 375,000 162,000 312,000 474,000
Dusun Beber Timur 174,000 162,000 336,000 174,000 262,000 436,000 174,000 394,000 568,000
Dusun Arjangka 174,000 162,000 336,000 174,000 262,000 436,000 174,000 394,000 568,000
2 Desa Pemepek 150,000 120,000 270,000 150,000 195,000 345,000 150,000 294,000 444,000
Dusun Repuk Pidendang 174,000 162,000 336,000 174,000 237,000 411,000 174,000 336,000 510,000
Dusun Cerorong Utara 150,000 162,000 312,000 150,000 237,000 387,000 150,000 336,000 486,000
3 Desa Sepakek 150,000 162,000 312,000 150,000 237,000 387,000 150,000 336,000 486,000
Dusun Jurang Sate 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
Dusun Pidendang 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
4 Desa Murbaye 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
Dusun Karang Genteng 174,000 162,000 336,000 174,000 262,000 436,000 174,000 394,000 568,000
5 Desa Sintung 150,000 162,000 312,000 150,000 237,000 387,000 150,000 336,000 486,000
6 Desa Bagu 144,000 132,000 276,000 144,000 207,000 351,000 144,000 306,000 450,000
7 Desa Bilebante 144,000 132,000 276,000 144,000 207,000 351,000 144,000 306,000 450,000
Dusun Kumbung 144,000 132,000 276,000 144,000 207,000 351,000 144,000 306,000 450,000
C KECAMATAN BATUKLIANG
1 Desa Mantang 144,000 132,000 276,000 144,000 207,000 351,000 144,000 306,000 450,000
2 Desa Barabali 144,000 132,000 276,000 144,000 207,000 351,000 144,000 306,000 450,000
1 2
3 Desa Aik Darek 144,000 132,000 276,000 144,000 207,000 351,000 144,000 306,000 450,000
4 Desa Selebung 151,200 160,800 312,000 151,200 235,800 387,000 151,200 334,800 486,000
Dusun Dasan Lekong 168,000 156,000 324,000 168,000 231,000 399,000 168,000 330,000 498,000
Dusun Tanak Embeng Daye 168,000 156,000 324,000 168,000 231,000 399,000 168,000 330,000 498,000
5 Desa Tampak Siring 168,000 156,000 324,000 168,000 231,000 399,000 168,000 330,000 498,000
6 Desa Presak 168,000 156,000 324,000 168,000 231,000 399,000 168,000 330,000 498,000
7 Desa Bujak 150,000 162,000 312,000 150,000 237,000 387,000 150,000 336,000 486,000
8 Desa Beber 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
9 Desa Pagutan 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
D KECAMATAN KOPANG
1 Desa Kopang Rembiga 198,000 162,000 360,000 198,000 262,000 460,000 198,000 394,000 592,000
2 Desa Dasan Baru 198,000 162,000 360,000 198,000 262,000 460,000 198,000 394,000 592,000
3 Desa Muncan 198,000 162,000 360,000 198,000 262,000 460,000 198,000 394,000 592,000
4 Desa Darmaji 198,000 162,000 360,000 198,000 262,000 460,000 198,000 394,000 592,000
Dusun Presak 210,000 180,000 390,000 210,000 280,000 490,000 210,000 412,000 622,000
Dusun Boyot 210,000 180,000 390,000 210,000 280,000 490,000 210,000 412,000 622,000
5 Desa Monggas 210,000 180,000 390,000 210,000 280,000 490,000 210,000 412,000 622,000
6 Desa Montong Gamang 198,000 162,000 360,000 198,000 262,000 460,000 198,000 394,000 592,000
Dusun Dasan Tinggi 198,000 162,000 360,000 198,000 262,000 460,000 198,000 394,000 592,000
7 Desa Bebuak 222,000 138,000 360,000 222,000 238,000 460,000 222,000 370,000 592,000
8 Desa Lendang Ade 222,000 138,000 360,000 222,000 238,000 460,000 222,000 370,000 592,000
9 Desa Geseng 222,000 138,000 360,000 222,000 238,000 460,000 222,000 370,000 592,000
E KECAMATAN JANAPRIA
1 Desa Janapria 216,000 174,000 390,000 216,000 274,000 490,000 216,000 406,000 622,000
Dusun Suge Nunang 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Liwung 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
2 Desa Bakan 192,000 168,000 360,000 192,000 243,000 435,000 192,000 342,000 534,000
Dusun Suge 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
Dusun Tanak Kaken 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
3 Desa Karembong 204,000 156,000 360,000 204,000 231,000 435,000 204,000 330,000 534,000
4 Desa Saba 222,000 168,000 390,000 222,000 268,000 490,000 222,000 400,000 622,000
1 2
5 Desa Lekor 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
Dusun Pepaok Timur 264,000 126,000 390,000 264,000 251,000 515,000 264,000 416,000 680,000
Dusun Pepaok Barat 264,000 126,000 390,000 264,000 251,000 515,000 264,000 416,000 680,000
6 Desa Loang Maka 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
7 Desa Selebung 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
Dusun Lengara 252,000 138,000 390,000 252,000 263,000 515,000 252,000 428,000 680,000
Dusun Pucung 252,000 138,000 390,000 252,000 263,000 515,000 252,000 428,000 680,000
8 Desa Durian 252,000 138,000 390,000 252,000 238,000 490,000 252,000 370,000 622,000
9 Desa Pendem 222,000 138,000 360,000 222,000 238,000 460,000 222,000 370,000 592,000
10 Desa Lanko 198,000 162,000 360,000 198,000 262,000 460,000 198,000 394,000 592,000
F KECAMATAN PRAYA TIMUR

1 Desa Mujur 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
2 Desa Sukaraja 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
3 Desa Marong 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
4 Desa Kidang 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Peras 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Batu Bokah 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
5 Desa Bilelando 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Kelongkong 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
6 Desa Semoyang 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
7 Desa Ganti 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
8 Desa Beleka 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Embung Waru 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Pendagi 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
9 Desa Landah 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
10 Desa Sengkerang 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
G KECAMATAN PRAYA TENGAH

1 Desa Batu Nyale 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Riris 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Tongkok 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
2 Desa Jurang Jaler 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
1 2
3 Desa Pengandang 198,000 192,000 390,000 198,000 292,000 490,000 198,000 424,000 622,000
4 Desa Sasaki 180,000 156,000 336,000 180,000 231,000 411,000 180,000 330,000 510,000
5 Desa Jontlak 180,000 156,000 336,000 180,000 231,000 411,000 180,000 330,000 510,000
6 Desa Gerantung 180,000 156,000 336,000 180,000 231,000 411,000 180,000 330,000 510,000
7 Desa Lajut 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Perendek 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Selebung 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
8 Desa Pejanggik 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
9 Desa Kelebuh 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Lendang Re 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
Dusun Lelong 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
10 Desa Beraing 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Jorong 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
Dusun Batu Tepong 240,000 150,000 390,000 240,000 250,000 490,000 240,000 382,000 622,000
H KECAMATAN PUJUT
1 Desa Sengkol 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
2 Desa Tanak Awu 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
3 Desa Ketara 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
4 Desa Kawo 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
Dusun Sarang Angin 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
5 Desa Segala Anyar 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
6 Desa Rembitan 252,000 138,000 390,000 252,000 263,000 515,000 252,000 428,000 680,000
Dusun Seleman 276,000 168,000 444,000 276,000 293,000 569,000 276,000 458,000 734,000
7 Desa Sukadana 252,000 168,000 420,000 252,000 293,000 545,000 252,000 458,000 710,000
Dusun Kener 276,000 168,000 444,000 276,000 293,000 569,000 276,000 458,000 734,000
Dusun Brami 276,000 168,000 444,000 276,000 293,000 569,000 276,000 458,000 734,000
8 Desa Pengengat 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
Dusun Pak-Pak 282,000 162,000 444,000 282,000 287,000 569,000 282,000 452,000 734,000
9 Desa Pengembur 264,000 156,000 420,000 264,000 281,000 545,000 264,000 446,000 710,000
Dusun Tamping 276,000 168,000 444,000 276,000 293,000 569,000 276,000 458,000 734,000
10 Desa Truwai 270,000 174,000 444,000 270,000 299,000 569,000 270,000 464,000 734,000
Dusun Pasung 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
1 2
Torung Arung 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
11 Desa Gapura 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Pejeruk 276,000 168,000 444,000 276,000 293,000 569,000 276,000 458,000 734,000
12 Desa Kuta 276,000 168,000 444,000 276,000 293,000 569,000 276,000 458,000 734,000
Dusun Molang 294,000 186,000 480,000 294,000 311,000 605,000 294,000 476,000 770,000
Dusun Rangkap 294,000 186,000 480,000 294,000 311,000 605,000 294,000 476,000 770,000
13 Desa Prabu 294,000 186,000 480,000 294,000 336,000 630,000 294,000 534,000 828,000
Dusun Bengawan 294,000 186,000 480,000 294,000 336,000 630,000 294,000 534,000 828,000
Dusun Temek 294,000 186,000 480,000 294,000 336,000 630,000 294,000 534,000 828,000
14 Desa Tumpak 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
Dusun Arguling 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
Dusun Jelateng 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
15 Desa Mertak 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
Dusun Awang 336,000 144,000 480,000 336,000 319,000 655,000 336,000 550,000 886,000
Dusun Takar-Akar 336,000 144,000 480,000 336,000 319,000 655,000 336,000 550,000 886,000
I KECAMATAN PRAYA BARAT

1 Desa Penujak 192,000 132,000 324,000 192,000 207,000 399,000 192,000 306,000 498,000
2 Desa Batujai 192,000 132,000 324,000 192,000 207,000 399,000 192,000 306,000 498,000
3 Desa Stanggur 216,000 144,000 360,000 216,000 219,000 435,000 216,000 318,000 534,000
4 Desa Bonder 240,000 180,000 420,000 240,000 280,000 520,000 240,000 412,000 652,000
5 Desa Mangkung 240,000 180,000 420,000 240,000 280,000 520,000 240,000 412,000 652,000
Dusun Keling 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
Dusun Patre 228,000 162,000 390,000 228,000 262,000 490,000 228,000 394,000 622,000
6 Desa Kateng 240,000 180,000 420,000 240,000 280,000 520,000 240,000 412,000 652,000
Dusun Tatal 264,000 156,000 420,000 264,000 281,000 545,000 264,000 446,000 710,000
Dusun Sadang Daye 240,000 180,000 420,000 240,000 305,000 545,000 240,000 470,000 710,000
7 Desa Banyu Urip 240,000 180,000 420,000 240,000 280,000 520,000 240,000 412,000 652,000
Dusun Lendang Lantang 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
Dusun Prapah 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
8 Desa Selong Belanak 264,000 156,000 420,000 264,000 281,000 545,000 264,000 446,000 710,000
Dusun Serangan 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
Dusun Kapal 276,000 168,000 444,000 276,000 293,000 569,000 276,000 458,000 734,000
1 2
9 Desa Mekar Sari 264,000 180,000 444,000 264,000 305,000 569,000 264,000 470,000 734,000
Dusun Tampah 282,000 162,000 444,000 282,000 287,000 569,000 282,000 452,000 734,000
Dusun Lancing 282,000 162,000 444,000 282,000 287,000 569,000 282,000 452,000 734,000
-
J KECAMATAN PRAYA BARAT DAYA -
1 Desa Darek 174,000 162,000 336,000 174,000 262,000 436,000 174,000 394,000 568,000
2 Desa Rangagata 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
Dusun Kumbak 210,000 150,000 360,000 210,000 225,000 435,000 210,000 324,000 534,000
Dusun Brobot 168,000 192,000 360,000 168,000 267,000 435,000 168,000 366,000 534,000
3 Desa Pandan Indah 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
4 Desa Ungga 162,000 150,000 312,000 162,000 225,000 387,000 162,000 324,000 486,000
5 Desa Pelambek 240,000 150,000 390,000 240,000 225,000 465,000 240,000 324,000 564,000
6 Desa Batu Jangkih 240,000 150,000 390,000 240,000 275,000 515,000 240,000 440,000 680,000
7 Desa Kabul 252,000 138,000 390,000 252,000 263,000 515,000 252,000 428,000 680,000
8 Desa Montong Sapah 324,000 216,000 540,000 324,000 341,000 665,000 324,000 506,000 830,000
9 Montong Ajan 324,000 216,000 540,000 324,000 341,000 665,000 324,000 506,000 830,000
10 Desa Serage 270,000 150,000 420,000 270,000 225,000 495,000 270,000 324,000 594,000
-
K KECAMATAN JONGGAT -
1 Desa Ubung 138,000 72,000 210,000 138,000 147,000 285,000 138,000 246,000 384,000
Dusun Bagek Nunggal 144,000 66,000 210,000 144,000 141,000 285,000 144,000 240,000 384,000
2 Desa Jelantik 144,000 66,000 210,000 144,000 141,000 285,000 144,000 240,000 384,000
3 Desa Nyerot 144,000 66,000 210,000 144,000 141,000 285,000 144,000 240,000 384,000
4 Desa Puyung 150,000 90,000 240,000 150,000 165,000 315,000 150,000 264,000 414,000
5 Desa Sukarara 150,000 90,000 240,000 150,000 165,000 315,000 150,000 264,000 414,000
6 Desa Bare Julat 150,000 90,000 240,000 150,000 165,000 315,000 150,000 264,000 414,000
7 Desa Bunkate 150,000 90,000 240,000 150,000 165,000 315,000 150,000 264,000 414,000
8 Desa Batu Putih 150,000 90,000 240,000 150,000 165,000 315,000 150,000 264,000 414,000
9 Desa Labulia 150,000 90,000 240,000 150,000 165,000 315,000 150,000 264,000 414,000
-
V KABUPATEN LOMBOK TIMUR -
A. KECAMATAN SELONG -
Kelurahan Kelayu Selatan 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
1 2
-
B KECAMATAN SUKAMULIA -
Desa Sukamulia 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
-
C KECAMATAN LABUHAN HAJI -
1 Desa Kertasari 300,000 240,000 540,000 300,000 365,000 665,000 300,000 530,000 830,000
2 Desa Penede 300,000 240,000 540,000 300,000 365,000 665,000 300,000 530,000 830,000
3 Desa Ijo Balit 306,000 234,000 540,000 306,000 384,000 690,000 306,000 582,000 888,000
4 Desa Tirtanadi 306,000 234,000 540,000 306,000 384,000 690,000 306,000 582,000 888,000
Dusun Dasan Treng 306,000 234,000 540,000 306,000 384,000 690,000 306,000 582,000 888,000
5 Desa Korleko 318,000 222,000 540,000 318,000 372,000 690,000 318,000 570,000 888,000
-
D KECAMATAN SUWELA -
1 Desa Suwela 282,000 228,000 510,000 282,000 353,000 635,000 282,000 518,000 800,000
2 Desa Suntalango 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
3 Desa Ketangga 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
4 Desa Selaparang 300,000 210,000 510,000 300,000 360,000 660,000 300,000 558,000 858,000
5 Desa Sapit 318,000 222,000 540,000 318,000 372,000 690,000 318,000 570,000 888,000
6 Desa Prigi 336,600 203,400 540,000 336,600 353,400 690,000 336,600 551,400 888,000
Dusun Jeringo 354,000 186,000 540,000 354,000 361,000 715,000 354,000 592,000 946,000
Dusun Limbungan 354,000 186,000 540,000 354,000 361,000 715,000 354,000 592,000 946,000
-
E KECAMATAN SAMBELIA -
1 Desa Sambelia 420,000 300,000 720,000 420,000 500,000 920,000 420,000 764,000 1,184,000
2 Desa Saku Pandan 420,000 300,000 720,000 420,000 500,000 920,000 420,000 764,000 1,184,000
3 Desa Sugian 420,000 300,000 720,000 420,000 500,000 920,000 420,000 764,000 1,184,000
4 Desa Belanting 480,000 300,000 780,000 480,000 500,000 980,000 480,000 764,000 1,244,000
Dusun Pedamekan 480,000 300,000 780,000 480,000 525,000 1,005,000 480,000 822,000 1,302,000
Dusun Lepik Loang 480,000 300,000 780,000 480,000 525,000 1,005,000 480,000 822,000 1,302,000
5 Desa Obel-Obel 480,000 300,000 780,000 480,000 525,000 1,005,000 480,000 822,000 1,302,000
Dusun Beburung 480,000 300,000 780,000 480,000 525,000 1,005,000 480,000 822,000 1,302,000
Dusun 480,000 300,000 780,000 480,000 525,000 1,005,000 480,000 822,000 1,302,000
-
1 2
F KECAMATAN KERUAK -
1 Desa Selebung Ketangga 300,000 180,000 480,000 300,000 280,000 580,000 300,000 412,000 712,000
2 Desa Ketapang Raya 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
3 Desa Pijot 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
4 Desa Tanjung Luar 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
5 Desa Batu Putik 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
6 Desa Spied 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
-
G KECAMATAN JEROWARU -
1 Desa Jerowaru 270,000 150,000 420,000 270,000 250,000 520,000 270,000 382,000 652,000
2 Desa Batu Nampar 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
Dusun Batu Nampar 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
Dusun Pene 330,000 210,000 540,000 330,000 360,000 690,000 330,000 558,000 888,000
3 Desa Sekaroh 300,000 240,000 540,000 300,000 390,000 690,000 300,000 588,000 888,000
Dusun Ujung Ketangga 312,000 228,000 540,000 312,000 378,000 690,000 312,000 576,000 888,000
Dusun Sunut 372,000 228,000 600,000 372,000 403,000 775,000 372,000 634,000 1,006,000
4 Desa Sukaraja 240,000 120,000 360,000 240,000 220,000 460,000 240,000 352,000 592,000
5 Desa Pemokong 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Serong 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
Dusun Tabuan 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
-
H KECAMATAN MASBAGIK -
1 Desa Masbagik 234,000 186,000 420,000 234,000 286,000 520,000 234,000 418,000 652,000
2 Desa Lendang Nangka 264,000 156,000 420,000 264,000 256,000 520,000 264,000 388,000 652,000
3 Desa Danger 276,000 174,000 450,000 276,000 274,000 550,000 276,000 406,000 682,000
-
I KECAMATAN TERARA -
1 Desa Terara 210,000 150,000 360,000 210,000 250,000 460,000 210,000 382,000 592,000
2 Desa Sukada 210,000 150,000 360,000 210,000 250,000 460,000 210,000 382,000 592,000
3 Desa Rarang 210,000 150,000 360,000 210,000 250,000 460,000 210,000 382,000 592,000
-
J KECAMATAN SURALAGA -
Desa Suralaga 300,000 240,000 540,000 300,000 390,000 690,000 300,000 588,000 888,000
1 2
-
K KECAMATAN RARANG -
Desa Rarang 204,000 156,000 360,000 204,000 256,000 460,000 204,000 388,000 592,000
-
L KECAMATAN AIKMEL -
Desa Aikmel 300,000 240,000 540,000 300,000 390,000 690,000 300,000 588,000 888,000
-
M KECAMATAN WANASABA -
1 Desa Wanasaba 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
2 Desa Sakra 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
3 Desa Gelem 282,000 174,000 456,000 282,000 299,000 581,000 282,000 464,000 746,000
-
N KECAMATAN PRINGGASELA -
1 Desa Pringgasela 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
2 Desa Jurid 270,000 150,000 420,000 270,000 250,000 520,000 270,000 382,000 652,000
3 Desa Timbanuh 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
-
O KECAMATAN PRINGGABAYA -
1 Desa Poh Gading 300,000 180,000 480,000 300,000 305,000 605,000 300,000 470,000 770,000
2 Desa Pringgabaya 300,000 240,000 540,000 300,000 365,000 665,000 300,000 530,000 830,000
3 Kayangan / Labuhan Lombok 360,000 240,000 600,000 360,000 390,000 750,000 360,000 588,000 948,000
4 300,000 240,000 540,000 300,000 240,000 540,000 300,000 240,000 540,000
-
P KECAMATAN SAKRA -
1 Desa Rensing 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
2 Desa Embung Tiang 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
3 Desa Pengkelak Emas 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
4 Desa Rumbuk 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
5 Desa Kabar 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
6 Desa Songak 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
7 Desa Dasan Baru 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
Q KECAMATAN SAKRA TIMUR

1 2
1 Desa Lepak 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
2 Desa Montong Tangi 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
3 Desa Grunung 300,000 150,000 450,000 300,000 275,000 575,000 300,000 440,000 740,000
4 Desa Menceh 300,000 150,000 450,000 300,000 275,000 575,000 300,000 440,000 740,000
5 Desa Surabaya 300,000 180,000 480,000 300,000 330,000 630,000 300,000 528,000 828,000
6 Desa Gelanggang 300,000 150,000 450,000 300,000 275,000 575,000 300,000 440,000 740,000
R KECAMATAN SIKUR
1 Desa Sikur 222,000 138,000 360,000 222,000 238,000 460,000 222,000 370,000 592,000
2 Desa Kota Raja 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
Dusun Dasan Lauq 276,000 144,000 420,000 276,000 269,000 545,000 276,000 434,000 710,000
3 Desa Tete Batu 270,000 150,000 420,000 270,000 275,000 545,000 270,000 440,000 710,000
S KECAMATAN SEMBALUN
Desa Sembalun 540,000 360,000 900,000 540,000 610,000 1,150,000 540,000 940,000 1,480,000
PULAU SUMBAWA (Biaya Penyebrangan PP. Rp. 874.000,-)

I KABUPATEN SUMBAWA BARAT
1 Kecamatan Poto Tano 1,800,000 480,000 2,280,000 1,800,000 830,000 2,630,000 1,800,000 1,292,000 3,092,000
2 Kecamatan Jereweh 1,890,000 750,000 2,640,000 1,890,000 1,150,000 3,040,000 1,890,000 1,678,000 3,568,000
3 Kecamatan Sekongkang 2,064,000 816,000 2,880,000 2,064,000 1,216,000 3,280,000 2,064,000 1,744,000 3,808,000
4 Kecamatan Taliwang 1,860,000 660,000 2,520,000 1,860,000 1,010,000 2,870,000 1,860,000 1,472,000 3,332,000
II KABUPATEN SUMBAWA
1 Kecamatan Sumbawa Besar 2,064,000 816,000 2,880,000 2,064,000 1,266,000 3,330,000 2,064,000 1,860,000 3,924,000
2 Kecamatan Alas 1,860,000 660,000 2,520,000 1,860,000 1,010,000 2,870,000 1,860,000 1,472,000 3,332,000
3 Kecamatan Empang 2,404,800 895,200 3,300,000 2,404,800 1,495,200 3,900,000 2,404,800 2,287,200 4,692,000
4 Kecamatan Labuhan Jambu 2,451,600 908,400 3,360,000 2,451,600 1,508,400 3,960,000 2,451,600 2,300,400 4,752,000
5 Kecamatan Lape 2,139,600 740,400 2,880,000 2,139,600 1,190,400 3,330,000 2,139,600 1,784,400 3,924,000
6 Kecamatan Lendang Guar 2,202,000 678,000 2,880,000 2,202,000 1,178,000 3,380,000 2,202,000 1,838,000 4,040,000
7 Kecamatan Lopok 2,170,800 600,000 2,770,800 2,170,800 1,100,000 3,270,800 2,170,800 1,760,000 3,930,800
1 2
8 Kecamatan Lantung 2,358,000 762,000 3,120,000 2,358,000 1,362,000 3,720,000 2,358,000 2,154,000 4,512,000
9 Kecamatan Lunyuk 2,358,000 762,000 3,120,000 2,358,000 1,362,000 3,720,000 2,358,000 2,154,000 4,512,000
10 Kecamatan Moyo Hilir 2,202,000 678,000 2,880,000 2,202,000 1,178,000 3,380,000 2,202,000 1,838,000 4,040,000
11 Kecamatan Moyo Hulu 2,202,000 678,000 2,880,000 2,202,000 1,178,000 3,380,000 2,202,000 1,838,000 4,040,000
12 Kecamatan Plampang 2,280,000 720,000 3,000,000 2,280,000 1,270,000 3,550,000 2,280,000 1,996,000 4,276,000
III KABUPATEN DOMPU

1 Kecamatan Calabai 3,254,400 1,305,600 4,560,000 3,254,400 2,255,600 5,510,000 3,254,400 3,509,600 6,764,000
2 Kecamatan Dompu 2,848,800 991,200 3,840,000 2,848,800 1,741,200 4,590,000 2,848,800 2,731,200 5,580,000
3 Kecamatan Hu'u 2,989,200 1,030,800 4,020,000 2,989,200 1,830,800 4,820,000 2,989,200 2,886,800 5,876,000
4 Kecamatan Kempo 2,942,400 957,600 3,900,000 2,942,400 1,757,600 4,700,000 2,942,400 2,813,600 5,756,000
5 Kecamatan Kilo 2,973,600 986,400 3,960,000 2,973,600 1,786,400 4,760,000 2,973,600 2,842,400 5,816,000
6 Kecamatan Nangadoro 3,036,000 984,000 4,020,000 3,036,000 1,834,000 4,870,000 3,036,000 2,956,000 5,992,000
7 Kecamatan Pekat 3,098,400 1,041,600 4,140,000 3,098,400 1,891,600 4,990,000 3,098,400 3,013,600 6,112,000
8 Kecamatan Rasabou Hu'u 2,942,400 1,017,600 3,960,000 2,942,400 1,817,600 4,760,000 2,942,400 2,873,600 5,816,000
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IV KABUPATEN BIMA / KOTA -
1 Kota Bima 3,036,000 984,000 4,020,000 3,036,000 1,834,000 4,870,000 3,036,000 2,956,000 5,992,000
2 Kecamatan Donggo 3,254,400 1,305,600 4,560,000 3,254,400 2,255,600 5,510,000 3,254,400 3,509,600 6,764,000
3 Kecamatan Hidirasa 3,348,000 1,212,000 4,560,000 3,348,000 2,212,000 5,560,000 3,348,000 3,532,000 6,880,000
4 Kecamatan Karumbu 3,254,400 1,305,600 4,560,000 3,254,400 2,155,600 5,410,000 3,254,400 3,277,600 6,532,000
5 Kecamatan Lambu 3,379,200 1,300,800 4,680,000 3,379,200 2,300,800 5,680,000 3,379,200 3,620,800 7,000,000
6 Kecamatan Monta 3,114,000 1,086,000 4,200,000 3,114,000 1,986,000 5,100,000 3,114,000 3,174,000 6,288,000
7 Kecamatan Parado 3,238,800 1,321,200 4,560,000 3,238,800 2,271,200 5,510,000 3,238,800 3,525,200 6,764,000
8 Kecamatan Sanggar 3,129,600 1,310,400 4,440,000 3,129,600 2,210,400 5,340,000 3,129,600 3,398,400 6,528,000
9 Kecamatan Sape 3,176,400 1,263,600 4,440,000 3,176,400 2,163,600 5,340,000 3,176,400 3,351,600 6,528,000
10 Kecamatan Sila 2,942,400 1,257,600 4,200,000 2,942,400 2,057,600 5,000,000 2,942,400 3,113,600 6,056,000
11 Kecamatan Sumi Sape 3,254,400 1,305,600 4,560,000 3,254,400 2,255,600 5,510,000 3,254,400 3,509,600 6,764,000
12 Kecamatan Tente (Woha) 3,051,600 1,028,400 4,080,000 3,051,600 1,828,400 4,880,000 3,051,600 2,884,400 5,936,000
13 Kecamatan Wawo 3,114,000 1,086,000 4,200,000 3,114,000 1,986,000 5,100,000 3,114,000 3,174,000 6,288,000
14 Kecamatan Wane 3,254,400 1,305,600 4,560,000 3,254,400 2,255,600 5,510,000 3,254,400 3,509,600 6,764,000
15 Kecamatan Wera Barat 3,129,600 1,310,400 4,440,000 3,129,600 2,210,400 5,340,000 3,129,600 3,398,400 6,528,000
16 Kecamatan Wera Timur (Tawali) 3,254,400 1,305,600 4,560,000 3,254,400 2,255,600 5,510,000 3,254,400 3,509,600 6,764,000
1 2
PROVINSI BALI
1 Denpasar 2,900,000 1,000,000 3,900,000 2,900,000 1,700,000 4,600,000 2,900,000 2,624,000 5,524,000
Keterangan
1. Pelayanan Ambulance Transport adalah Layanan pengantaran / Penjemputan pasien tanpa didampingi perawat / dokter
2. Pelayanan Ambulance BLS adalah Layanan pengantaran / Penjemputan pasien didampingi perawat
3. Pelayanan Ambulance ALS adalah Layanan pengantaran / Penjemputan pasien didampingi perawat dan dokter
GUBERNUR NUSA TENGGARA BARAT
H. M. ZAINUL MAJDI

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LAMPIRAN PERATURAN GUBERNUR NUSA TENGGARA BARAT

JASA JUMLAH TARIF

1 INSTALASI RAWAT JALAN REGULER

2 INSTALASI RAWAT JALAN EKSEKUTIF

3 INSTALASI RAWAT JALAN (POLI KHUSUS)

C. LAYANAN UMUM IGD

D. TINDAKAN KHUSUS KEGAWATDARURATAN

E. PEMAKAIAN ALAT BANTU

F. TINDAKAN PENUNJANG DIAGNOSTIK

G. AKOMODASI RUANG OBSERVASI (tidak lebih dari 2 x 24 jam)

H. PELAYANAN PREHOSPITAL DAN RUJUKAN

KELAS III KELAS II KELAS I

I TINDAKAN MEDIK RAWAT INAP

KELAS III KELAS II KELAS I

C VISITE DAN KONSUL DOKTER

D Konsul / Konseling HIV - AIDS

E Visite / Konsul Pasien Flu Burung

F Konsul Gizi - 10,000 10,000 - 15,000 15,000 - 20,000 20,000

C VISITE DAN KONSUL DOKTER

D Konsul / Konseling HIV - AIDS

E Konsul Gizi ### - 50,000 50,000 - 100,000 100,000

ICU, ICCU, PICU

C VISITE DAN KONSUL DOKTER

C VISITE DAN KONSUL DOKTER

KELAS, IRD, POLIKLINIK VIP A,B, SUPER VIP

A KECIL / TANPA KONTRAS

RSUD PROVINSI NUSA TENGGARA BARAT

KELAS, POLIKLINIK, IGD ICU/ICCU/PICU/NICU VIP A,B, SUPER VIP

TARIF CITO PELAYANAN TINDAKAN HAEMODIALISA

A OPERASI KECIL 1,000,000 1,500,000 2,500,000 1,200,000 1,875,000 3,075,000

1 Benang Tali pusat 132 18 150

A. SPESIFIKASI TINDAKAN PENCABUTAN GIGI

B. SPESIFIKASI TINDAKAN PENAMBALAN GIGI

C. SPESIFIKASI TINDAKAN PENGOBATAN/ PERAWATAN JARINGAN

1 Pembersihan karang gigi per regio 27,360 18,240 45,600

D. SPESIFIKASI PEMBUATAN PROTESA /GIGI PALSU

E. SPESIFIKASI TINDAKAN BEDAH MULUT

F. SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY & UPLAY dg

1 Jembatan adoro per unit 340,800 227,200 568,000

G SPESIFIKASI PEMBUATAN JEMBATAN ADORO, INLAY &

H SPESIFIKASI PEMBUATAN JAKET CROWN DENGAN AKRILIK

1. Crown dan Jembatan per unit 184,800 123,200 308,000

1 Audiometri Nada Mumi / Garputala 127,075 68,425 195,500

1 AJH (Paru) 78,000 42,000 120,000

1 Punctie ascites 97,500 52,500 150,000

1 Assesment Nyeri 11,700 6,300 18,000

1 Defibrilasi 325,000 175,000 500,000

1 Amotio Corpus Alienum 70,200 37,800 108,000

1 Amputasi Jari 78,000 42,000 120,000

1 Ekstraksi batu uretra anterior / Buginasi 195,000 105,000 300,000

1 BMP 67,600 36,400 104,000

1 IMUNISASI DIWAJIBKAN (PPI)

1 Angkat Implant 58,500 31,500 90,000

1 Amniotomi 32,500 17,500 50,000

AMBULANCE TRANSPORT AMBULANCE BLS AMBULANCE ALS

J KECAMATAN SEKOTONG TENGAH

III KABUPATEN LOMBOK UTARA

IV. KABUPATEN LOMBOK TENGAH

F KECAMATAN PRAYA TIMUR

G KECAMATAN PRAYA TENGAH

I KECAMATAN PRAYA BARAT

Q KECAMATAN SAKRA TIMUR

PULAU SUMBAWA (Biaya Penyebrangan PP. Rp. 874.000,-)

III KABUPATEN DOMPU