1 TINDAKAN UGD

no NAMA TINDAKAN NILAI TOTAL 30% 1

1 Pemeriksaan Dokter Umum UGD 50,000 15,000 35,000
2 Pemeriksaan UGD Dokter Spesialis 70,000 14,000
3 JPM 50,000
4 JPRS IDM/UGD 25,000
PEMBAGIAN JASA TARIF
TINDAKAN 20% 0
1 Amputasi Jari Kaki / Tangan ( Dr. Spes )* 150,000 30,000 60,000
2 Amputasi Jari Kaki / Tangan ( Dr. Umum )* 100,000 20,000 40,000
3 Bilas Lambung dr. Spesialis* 150,000 30,000 60,000
4 Bilas Lambung dr. Umum* 100,000 20,000 40,000
5 Blass Fungtie Dr.Spesialis* 90,000 18,000 36,000
6 Blass Fungtie Dr.Umum* 60,000 12,000 24,000
7 Ekstirpasi Dr. Spesialis* 150,000 30,000 60,000
8 Ekstirpasi Dr. Umum* 100,000 20,000 40,000
9 Ekstraksi Corpus Alieneum Dr. Spesialis* 75,000 15,000 30,000
10 Ekstraksi Corpus Alieneum Dr. Umum* 50,000 10,000 20,000
11 Fungsi Pleura* 100,000 20,000 40,000
12 Ganti Verban* 20,000 4,000 8,000
13 GDS* 30,000 6,000 12,000
14 Incisi Abses Sederhana Dr Umum* 100,000 20,000 40,000
15 Incisi Abses Sederhana Dr. Spesialis* 150,000 30,000 60,000
16 Jahit Luka ke 1 - 5 Dr. Spesialis* 75,000 15,000 30,000
17 Jahit Luka ke 1 - 5 Dr. Umum* 50,000 10,000 20,000
18 Jahit Luka ke 11 - 15 Dr. Spesialis* 150,000 30,000 60,000
19 Jahit Luka ke 11 - 15 Dr. Umum* 100,000 20,000 40,000
20 Jahit Luka ke 16 - 20 Dr. Spesialis* 225,000 45,000 90,000
21 Jahit Luka ke 16 - 20 Dr. Umum* 150,000 30,000 60,000
22 Jahit Luka ke 6 - 10 Dr. Spesialis* 112,500 22,500 45,000
23 Jahit Luka ke 6 - 10 Dr. Umum* 75,000 15,000 30,000
24 Jahitan lebih dari 20 Dr. Spesialis* 300,000 60,000 120,000
25 Jahitan lebih dari 20 Dr. Umum* 200,000 40,000 80,000
26 Lavemen* 100,000 20,000 40,000
27 Manual Placenta* 100,000 20,000 40,000
28 Mengganti Kantong Colostomi dr. spesialis* 150,000 30,000 60,000
29 Mengganti Kantong Colostomi dr. Umum* 100,000 20,000 40,000
30 Nebulizer Sewa Alat 20,000 4,000 8,000
31 Necrotomy Luka bakar Dr. Spesialis* 75,000 15,000 30,000
32 Necrotomy Luka bakar Dr. Umum* 50,000 10,000 20,000
33 Observasi < 3 jam ( Biasa )* 20,000 4,000 8,000
34 Observasi < 3 jam ( Ketat )* 40,000 8,000 16,000
35 Observasi > 3 jam ( Biasa )* 60,000 12,000 24,000
36 Observasi > 3 jam ( Ketat )* 80,000 16,000 32,000
37 OP Nebulizer 10,000 2,000 4,000
 38 Penanggung Jawab Partus / Normal / Dr. Spec 195,000 39,000 78,000
39 Penanggung Jawab Resusitasi Partus / Normal / D 105,000 21,000 42,000
40 Perlengkapan Kamar Jenazah (ISO) 200,000 40,000 80,000
41 Peti Jenazah (ISO) 1,750,000 350,000 700,000
42 Plastik Jenazah (ISO) 260,000 52,000 104,000
43 Pungsi Pleura dr. Umum* 100,000 20,000 40,000
44 Pungsi Pluera dr. Spesialis* 150,000 30,000 60,000
45 Reposisi Sendi Rahang dr. Spesialis* 225,000 45,000 90,000
46 Reposisi Sendi Rahang dr. Umum* 150,000 30,000 60,000
47 Resusitasi Dr. Umum* 100,000 20,000 40,000
48 Resusitasi Partus/Vakum Dr. Spesialis* 227,500 45,500 91,000
49 Sewa Alat Partus/Vakum 100,000 20,000 40,000
50 Sewa Alat Suction 30,000 6,000 12,000
51 Sewa Ambulan Jenazah (ISO)* 500,000 100,000 200,000
52 Sewa Kendaraan (Cov) 100,000 20,000 40,000
53 Sirkumsisi / Dorsumsisi Dr. Spesialis* 450,000 90,000 180,000
54 Sirkumsisi / Dorsumsisi Dr. Umum* 300,000 60,000 120,000
55 Spoling cateter ( pada pasien post op prostatecto 50,000 10,000 20,000
56 Spooling BPH/Colostomy* 100,000 20,000 40,000
57 Suction Dr. Spesialis* 75,000 15,000 30,000
58 Suction dr. Umum* 50,000 10,000 20,000
59 Tnd Asisten partus oleh ( Bidan)* 100,000 20,000 40,000
60 Tnd Asisten pemasangan Gips* 20,000 4,000 8,000
61 Tnd Asisten pemasangan Traksi* 20,000 4,000 8,000
62 Tnd Asisten WSD* 20,000 4,000 8,000
63 Tnd Cateter Dr. Umum* 50,000 10,000 20,000
64 Tnd Cateter Dr.Spesialis* 75,000 15,000 30,000
65 Tnd Gips Dr. Spesialis* 75,000 15,000 30,000
66 Tnd Gips Dr. Umum* 50,000 10,000 20,000
67 Tnd Hecting Laserasi Vagina dr. spesialis* 75,000 15,000 30,000
68 Tnd Hecting Laserasi Vagina dr. Umum* 50,000 10,000 20,000
69 Tnd NGT dr. Spesialis* 75,000 15,000 30,000
70 Tnd NGT dr. Umum* 50,000 10,000 20,000
71 Tnd Partus / Normal / Bidan* 300,000 60,000 120,000
72 Tnd Resusitasi Perawat Terlatih SC/VE/Forceps/S 50,000 10,000 20,000
73 Tnd Spalk dr. Spesialis* 22,500 4,500 9,000
74 Tnd Spalk dr. Umum* 15,000 3,000 6,000
75 Tnd Tampon Drain dr. spesialis* 75,000 15,000 30,000
76 Tnd Tampon drain dr. Umum* 50,000 10,000 20,000
77 Vena Seksi Dr. Umum* 200,000 40,000 80,000
78 Vena Seksi Dr.Spesialis* 300,000 60,000 120,000

id NAMA TINDAKAN VIP I

DR RS DR
1 BK Embriotomi [ Dr ] 1,800,000 450,000 1,320,000
 3 BK Embriotomi_A [ Dr ] 720,000 180,000 528,000
5 BK Embriotomi_AA [ Pr ] 216,000 54,000 158,400
7 BK Embriotomi_AO 240,000 60,000 176,000
2,976,000 744,000 2,182,400
TOTAL TARIF 3,720,000 2,728,000

1 BU Varikorel ( Dr ) 1,800,000 1,320,000

2 BU Tumor Rahang ( Dr ) 1,800,000 1,320,000
3 BU Tumor Pembuluh darah_ ( Dr ) 1,800,000 1,320,000
4 BU Tumor Mediastinum ( Dr ) 1,800,000 1,320,000
5 BU Tumor Jinak Payudara ( Dr ) 1,800,000 1,320,000
6 BU
BU Tumor
Tumor Jinak
Jinak Parotes ( Dr non
leher/muka ) komplikasi 1,800,000 1,320,000
7 ( Dr ) 1,800,000 1,320,000
8 BU Tumor Jinak Kulit ( Dr ) 1,800,000 1,320,000
9 BU Tumor Intra Abdominal ( Dr ) 1,800,000 1,320,000
10 BU Tumor ganas ( Dr ) 1,800,000 1,320,000
11 BU Trans Uretrae Reseksi ( TUR) ( Dr ) 1,800,000 1,320,000
12 BU Tiroid ( Dr ) 1,800,000 1,320,000
13 BU Tindakan Operasi sedang dg penyulit ( Dr ) 1,800,000 1,320,000
14 BU Strikurra Uretha ( Dr ) 1,800,000 1,320,000
15 BU Saluran kemih ( Dr ) 1,800,000 1,320,000
16 BU Pendarahan torak ( Dr ) 1,800,000 1,320,000
17 BU Orchitis ( Dr ) 1,800,000 1,320,000
18 BU Operasi sedang dg penyulit ( Dr ) 1,800,000 1,320,000
19 BU Megakolon ( Dr ) 1,800,000 1,320,000
20 BU Mamae ( Dr ) 1,800,000 1,320,000
21 BU Kriptorkismus ( Dr ) 1,800,000 1,320,000
22 BU Kelainan Bawaan ( Dr ) 1,800,000 1,320,000
23 BU Invaginasi ( Dr ) 1,800,000 1,320,000
24 BU Infiltrat ( Dr ) 1,800,000 1,320,000
25 BU Ileus Obstruktif ( Dr ) 1,800,000 1,320,000
26 BU Hipospadia ( Dr ) 1,800,000 1,320,000
27 BU Hidrokel ( Dr ) 1,800,000 1,320,000
28 BU Hernia Inkarserata ( Dr ) 1,800,000 1,320,000
29 BU Hernia ( Dr ) 1,800,000 1,320,000
30 BU Haemoroid ( Dr ) 1,800,000 1,320,000
31 BU Gynecomastia ( Dr ) 1,800,000 1,320,000
32 BU Fistula Ani ( Dr ) 1,800,000 1,320,000
33 BU Eksplorasi conpus alineum dg penyulit ( Dr ) 1,800,000 1,320,000
34 BU Colostomi ( Dr ) 1,800,000 1,320,000
35 BU Bibir Sumbing ( Dr ) 1,800,000 1,320,000
36 BU Batu Uretra ( Dr ) 1,800,000 1,320,000
37 BU Batu Buli-buli ( Dr ) 1,800,000 1,320,000
38 BU Atresia usus ( Dr ) 1,800,000 1,320,000
39 BU Atresia Ani. ( Dr ) 1,800,000 1,320,000
 40 BU Appendistis ( Dr ) 1,800,000 1,320,000
41 BU Appendiksitis Perpopasi ( Dr ) 1,800,000 1,320,000
42 BU Abdomen ( Dr ) 1,800,000 1,320,000
43 BT Tysoidectomy ( Dr ) 1,800,000 1,320,000
44 BT Tumor Telinga ( Dr ) 1,800,000 1,320,000
45 BT Tumor maxilla ( Dr ) 1,800,000 1,320,000
46 BT Tumor hidung ( Dr ) 1,800,000 1,320,000
47 BT Tonsilectomy besar ( Dr ) 1,800,000 1,320,000
48 BT Timpanoplastik ( Dr ) 1,800,000 1,320,000
49 BT Septum Reseksi ( Dr ) 1,800,000 1,320,000
50 BT Septoplasty ( Dr ) 1,800,000 1,320,000
51 BT Renoplastik ( Dr ) 1,800,000 1,320,000
52 BT Paratyroidectomy ( Dr ) 1,800,000 1,320,000
53 BT Paratidektomi ( Dr ) 1,800,000 1,320,000
54 BT Palatoplastik ( Dr ) 1,800,000 1,320,000
55 BT Operus caedueeluc ( Dr ) 1,800,000 1,320,000
56 BT Miringoplastik ( Dr ) 1,800,000 1,320,000
57 BT Mastoidektomi ( Dr ) 1,800,000 1,320,000
58 BT
BO Decompresi
Revinal knailbucallis
& kwiring( Dr( )posisi di dalam ) 1,800,000 1,320,000
59 ( Dr ) 1,800,000 1,320,000
60 BO Removal plate-screw ( Dr ) 1,800,000 1,320,000
61 BO Guttering pd kasus Osteomyelitis ( Dr ) 1,800,000 1,320,000
62 BO Debridement pd kasus Ostemyelitis ( Dr ) 1,800,000 1,320,000
63 BO Debridement luka terbuka ( Dr ) 1,800,000 1,320,000
74 BK Tumor Vagina ( Dr ) 1,800,000 1,320,000
75 BK Tumor ganas ovarium ( Dr ) 1,800,000 1,320,000
76 BK Tuba Ovarium Abses ( Dr ) 1,800,000 1,320,000
77 BK Tuba Ovarial ( Dr ) 1,800,000 1,320,000
78 BK Sectio tanpa penyulit ( Dr. ) 1,800,000 1,320,000
79 BK Sectio Cesaria ( Dr. ) 1,800,000 1,320,000
80 BK Salpingofortektomi_ ( Dr ) 1,800,000 1,320,000
81 BK Reparasi fistel/tuba ( Dr ) 1,800,000 1,320,000
82 BK Repair Perinium ( Dr ) 1,800,000 1,320,000
83 BK Laparatomi Explorasi ( Dr ) 1,800,000 1,320,000
84 BK Laparatomi ( Dr ) 1,800,000 1,320,000
85 BK Kiste Ovarium_ ( Dr ) 1,800,000 1,320,000
86 BK Kehamilan ektopik ( Dr ) 1,800,000 1,320,000
29 BK K E T ( Dr ) 1,800,000 1,320,000

70,000 20% 14,000

80% 56,000
id NAMA TINDAKAN VIP I
DR RS DR
1 BK Sterilisasi ( Dr ) 1,120,000 280,000 770,000
3 BK Sterilisasi _A ( Dr ) 448,000 112,000 308,000
 5 BK Sterilisasi _AA ( Pr ) 134,400 33,600 92,400
7 BK Sterilisasi _AO 128,000 32,000 88,000
1,830,400 457,600 1,258,400
TOTAL TARIF 2,288,000 1,573,000

1 BK Induksi head ( Dr ) 1,120,000 770,000

2 BK Laparoskopi ( Dr ) 1,120,000 770,000
3 BO Aff hecting ( Bius ) ( Dr ) 1,120,000 770,000
4 BU
BU Ateroma ( Drpost
Buka Jahitan ) operatif anak/dws ( Bius) 1,120,000 770,000
5 ( Dr ) 1,120,000 770,000
6 BU Dislokasi Sederhana ( Dr ) 1,120,000 770,000
7 BU Ganglion_( Dr ) 1,120,000 770,000
8 BU Incisi/Exisi ( Dr ) 1,120,000 770,000
9 BU Incisi_ ( Dr ) 1,120,000 770,000
10 BU Lypoma_ ( Dr ) 1,120,000 770,000
11 BU Sirkumsisi (Lokal) ( Dr ) 1,120,000 770,000
12 BU Tumor jinak ( Dr ) 1,120,000 770,000
13 BU WSD ( DR ) 1,120,000 770,000

200,000 20% 40,000

80% 160,000
id NAMA TINDAKAN VIP I
DR RS DR
1 BU UR REPAIR BULI BULI ( DR ) 2,400,000 600,000 1,800,000
3 BU UR REPAIR BULI BULI_A ( DR ) 960,000 240,000 720,000
5 BU UR REPAIR BULI BULI_AA ( PR ) 288,000 72,000 216,000
7 BU UR REPAIR BULI BULI_AO 320,000 80,000 240,000
3,968,000 992,000 2,976,000
TOTAL TARIF 4,960,000 3,720,000

1 BK Histerektomi pervagina ( Dr ) 2,400,000 1,800,000

2 BK Histerektomi total / supra vaginal ( Dr ) 2,400,000 1,800,000
3 BK Kiste Ovarium dg perlengketan ( Dr ) 2,400,000 1,800,000
4 BK Miomauteri ( Dr ) 2,400,000 1,800,000
5 BK Sectio dg penyulit ( Dr. ) 2,400,000 1,800,000
8 BO Amputasi ( Dr ) 2,400,000 1,800,000
9 BO Disartikulasi ( Dr ) 2,400,000 1,800,000
10 BO Eksisi tumor pd compartemen yg luas ( Dr ) 2,400,000 1,800,000
11 BO Faciotomy ( Dr ) 2,400,000 1,800,000
12 BO
BO Hip
OREFarthoplasty ( Dr ) External Fixation )
( Open Reduction 2,400,000 1,800,000
13 (BO
DrORIF
) ( Open Reduction Internal Fixation ) ( Dr 2,400,000 1,800,000
14 )BO Rekonstruksi mal union # & non union # 2,400,000 1,800,000
15 ( Dr ) 2,400,000 1,800,000
16 BO Repair neruus, arteri & Vein ( Dr ) 2,400,000 1,800,000
17 BO Repair tendon flexor & extensor ( Dr ) 2,400,000 1,800,000
 BO Reposisi tertutup pd kasus dislokasi sendi
18 ( Dr ) 2,400,000 1,800,000
19 BO
BO STSG
Tendon& Flap ( Dr )
lengethening, bone lengethening --> 2,400,000 1,800,000
20 CTEV ( Dr ) 2,400,000 1,800,000
21 BT Angiofibroma ( Dr ) 2,400,000 1,800,000
22 BT Fronto Etmoedektomi ekstranasal ( Dr ) 2,400,000 1,800,000
23 BT Pympanoplasty ( Dr ) 2,400,000 1,800,000
24 BT Rekonstruksi hidung ( Dr ) 2,400,000 1,800,000
25 BT Rhinoplasty augmentum ( Dr ) 2,400,000 1,800,000
26 BU Anterior Infusion ( Dr ) 2,400,000 1,800,000
27 BU Batu Ginjal ( Dr ) 2,400,000 1,800,000
28 BU Batu Ureter ( Dr ) 2,400,000 1,800,000
29 BU BPH dg penyulit ( Dr ) 2,400,000 1,800,000
30 BU Illeus ( Dr ) 2,400,000 1,800,000
31 BU Multiple Fractur dg Kompilasi ( Dr ) 2,400,000 1,800,000
32 BU Operasi besar dg penyulit ( Dr ) 2,400,000 1,800,000
33 BU Operasi vaskuler ( Dr ) 2,400,000 1,800,000
34 BU Peritonitis ( Dr ) 2,400,000 1,800,000
35 BU Perporasi gaster ( Dr ) 2,400,000 1,800,000
36 BU Polvulus ( Dr ) 2,400,000 1,800,000
37 BU Radical Mastectomi ( Dr ) 2,400,000 1,800,000
38 BU Radical neck disection ( Dr ) 2,400,000 1,800,000
39 BU Radical neprectomi ( Dr ) 2,400,000 1,800,000
40 BU Radikal Mastektomi dg penyulit ( Dr ) 2,400,000 1,800,000
41 BU Regional perfusion ( Dr ) 2,400,000 1,800,000
42 BU Reseksi Usus ( Dr ) 2,400,000 1,800,000
43 BU Sediosis Carrection ( Dr ) 2,400,000 1,800,000
44 BU Struma ( Dr ) 2,400,000 1,800,000
45 BU Total Cytestomi ( Dr ) 2,400,000 1,800,000
46 BU Total HTP ( Dr ) 2,400,000 1,800,000
47 BU Trauma Abdomen ( Dr ) 2,400,000 1,800,000
48 BU Tumor Abdomen ( Dr ) 2,400,000 1,800,000
49 BU UR BATU URETER ( DR ) 2,400,000 1,800,000
50 BU UR BPH ( DR ) 2,400,000 1,800,000
51 BU UR CALCULUS IN URETTRA ( DR ) 2,400,000 1,800,000
52 BU UR DISTENT INSITU ( DR ) 2,400,000 1,800,000
53 BU UR EVAKUSI ( DR ) 2,400,000 1,800,000
54 BU UR STRUKTUR URETTRA ( DR ) 2,400,000 1,800,000
55 BU UR VESICOLTHIASIS ( DR ) 2,400,000 1,800,000

110,000 20% 22,000

80% 88,000
id NAMA TINDAKAN VIP I
DR RS DR
2565 BK AF IUD dg Perlengketan ( Dr ) 1,560,000 390,000 1,040,000
2566 BK AF IUD dg Perlengketan_A ( Dr ) 624,000 156,000 416,000
2567 BK AF IUD dg Perlengketan_AA ( Pr ) 187,200 46,800 124,800
2568 BK AF IUD dg Perlengketan_AO 192,000 48,000 128,000
2,563,200 640,800 1,708,800
TOTAL 3,204,000 2,136,000

1 BK Bartolini ( Dr ) 1,560,000 1,040,000

1 BK Ca Cervic ( Dr ) 1,560,000 1,040,000
1 BK Ca Vagina ( Dr ) 1,560,000 1,040,000
1 BK Ca Vulva (Dr) 1,560,000 1,040,000
1 BK Eksterpasi Condiloma ( Dr ) 1,560,000 1,040,000
1 BK Explorasi Vagina ( Dr ) 1,560,000 1,040,000
1 BK Inparperata ( Dr ) 1,560,000 1,040,000
1 BK Insisi Bartolini ( Dr ) 1,560,000 1,040,000
1 BK Kolpodeksis [ Dr ] 1,560,000 1,040,000
1 BK Kuretase hisap ( Dr ) 1,560,000 1,040,000
1 BK Kuretase Post Partum ( Dr ) 1,560,000 1,040,000
1 BK Kuretase tajam ( Dr ) 1,560,000 1,040,000
1 BK Laparatomi Mini ( Dr ) 1,560,000 1,040,000
1 BK Laparatomi Percobaan_ ( Dr ) 1,560,000 1,040,000
1 BK Laserasi Vagina ( Dr ) 1,560,000 1,040,000
1 BK Laserasi Vorsio ( Dr ) 1,560,000 1,040,000
1 BK Marsualisasi ( Dr ) 1,560,000 1,040,000
1 BK Medoskopi diagnostik laparatomi _ ( Dr ) 1,560,000 1,040,000
1 BK Myomectomi_ ( Dr ) 1,560,000 1,040,000
1 BK Tumor jinak ovarium ( Dr ) 1,560,000 1,040,000
1 BK Vacum Extraksi Dalam Narkose ( Dr ) 1,560,000 1,040,000
2 BO Biopsi Tumor ( Dr ) 1,560,000 1,040,000
2 BO Pemasangan skin traksi ( Dr ) 1,560,000 1,040,000
2 BO Pemasangan traksi dg skele traksi ( Dr ) 1,560,000 1,040,000
2 BO Removal K - Wire pada posisi luar ( Dr ) 1,560,000 1,040,000
2 BO Removal Kista Ganglion ( Dr ) 1,560,000 1,040,000
2 BO Removal Tumor Jaringan Lunak ( Dr ) 1,560,000 1,040,000
4 BT A W O [ Dr ] 1,560,000 1,040,000
4 BT Antrostomi sinus maxilaris ( Dr ) 1,560,000 1,040,000
4 BT Bronkoskopi ( Dr ) 1,560,000 1,040,000
4 BT Ekstirpasi polip ( Dr ) 1,560,000 1,040,000
4 BT Ethmoidecstomi inrtanasal ( Dr ) 1,560,000 1,040,000
4 BT Laryngoskopi ( Dr ) 1,560,000 1,040,000
4 BT Oesophagoskopi ( Dr ) 1,560,000 1,040,000
4 BT Tonsilecktomi ( Dr ) 1,560,000 1,040,000
4 BT Tracheostomy ( Dr ) 1,560,000 1,040,000
2 BU Amputasi jari ( Narkose Umum ) ( Dr ) 1,560,000 1,040,000
2 BU Biopsi dgn Narkose Umum ( Dr ) 1,560,000 1,040,000
2 BU Corpus Alinum ( Narkose Umum ) ( Dr ) 1,560,000 1,040,000
2 BU Debridemen ( Narkose Umum ) ( Dr ) 1,560,000 1,040,000
 2 BU Dislokasi Bahu ( Dr ) 1,560,000 1,040,000
2 BU
BU Dislokasi
Dislokasi Panggul ( Dr )tangan interpalangs
Pergelangan 1,560,000 1,040,000
2 ( Dr ) 1,560,000 1,040,000
2 BU Dislokasi Rahang ( Dr ) 1,560,000 1,040,000
2 BU Dislokasi Sendi ( Dr ) 1,560,000 1,040,000
2 BU Dislokasi Sikut ( Dr ) 1,560,000 1,040,000
2 BU Dislokasi Tumit ( Dr ) 1,560,000 1,040,000
2 BU Ekplorsi ( Narkose Umum ) ( Dr ) 1,560,000 1,040,000
2 BU Eksterpasi ( Narkose Umum ) ( Dr ) 1,560,000 1,040,000
2 BU Explorasi ( Dr ) 1,560,000 1,040,000
2 BU Exsisi ( Narkose Umum ) ( Dr ) 1,560,000 1,040,000
2 BU F A M ( Dr ) 1,560,000 1,040,000
2 BU Ganglion ( Narkose Umum ) ( Dr ) 1,560,000 1,040,000
2 BU Penyakit pembuluh darah periper ( Dr ) 1,560,000 1,040,000
2 BU Sirkumsisi ( Narkose umum ) ( Dr ) 1,560,000 1,040,000
2 BU Sympisis ( Dr ) 1,560,000 1,040,000

1 BG Sewa K. Bedah Op Sedang 300,000 300,000

2 BG Sewa Alat Operasi 300,000 300,000
3 BG Sewa K. Bedah Op Besar 400,000 400,000
4 BO Sewa Alat Operasi 300,000 300,000
5 BO Sewa Alat Orthopedi 300,000 300,000
6 BO Sewa K. Bedah Op Besar 1,000,000 800,000
7 BO Sewa K. Bedah Op Kecil 700,000 550,000
8 BO Sewa K. Bedah Op Khusus 1,000,000 800,000
9 BO Sewa K. Bedah Op Sedang 800,000 600,000
10 BS Sewa Alat Operasi 300,000 300,000
11 BS Sewa K. Bedah Op Besar 1,000,000 800,000
12 BS Sewa K. Bedah Op Kecil 700,000 600,000
13 BS Sewa K. Bedah Op Khusus 1,000,000 800,000
14 BS Sewa K. Bedah Op Sedang 800,000 600,000
15 BK Sewa K. Bedah Op Besar 1,000,000 800,000
16 BU Sewa K. Bedah Op Besar 1,000,000 800,000
17 BU UR SEWA ALAT UROLOGI ( DR ) 1,500,000 1,500,000
18 BG Sewa K. Bedah Op Kecil 250,000 250,000
19 BK Sewa K. Bedah Op Kecil 700,000 550,000
20 BU Sewa K. Bedah Op Kecil 700,000 550,000
21 BG Sewa K. Bedah Op Khusus 400,000 400,000
22 BK Sewa K. Bedah Op Khusus 1,000,000 800,000
23 BU Sewa K. Bedah Op Khusus 1,000,000 800,000
 0 1

14,000 56,000

0
60,000
40,000
60,000
40,000
36,000
24,000
60,000
40,000
30,000
20,000
40,000
8,000
12,000
40,000
60,000
30,000
20,000
60,000
40,000
90,000
60,000
45,000
30,000
120,000
80,000
40,000
40,000
60,000
40,000
8,000
30,000
20,000
8,000
16,000
24,000
32,000
4,000
 78,000
42,000
80,000
700,000
104,000
40,000
60,000
90,000
60,000
40,000
91,000
40,000
12,000
200,000
40,000
180,000
120,000
20,000
40,000
30,000
20,000
40,000
8,000
8,000
8,000
20,000
30,000
30,000
20,000
30,000
20,000
30,000
20,000
120,000
20,000
9,000
6,000 20% 80%
30,000 44,000 176,000 220,000
20,000
80,000
120,000

I II III idkel idunit JENIS OP

RS DR RS DR RS BMHP
330,000 1,080,000 270,000 900,000 225,000 10 8 Besar
132,000 432,000 108,000 360,000 90,000 11 8 Besar
39,600 129,600 32,400 108,000 27,000 11 8 Besar
44,000 144,000 36,000 120,000 30,000 19 8 Besar
545,600 1,785,600 446,400 1,488,000 372,000
2,232,000 1,860,000

1,080,000 900,000 10 8 Besar

1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
 1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar
1,080,000 900,000 10 8 Besar

I II III idkel idunit JENIS OP

RS DR RS DR RS BMHP
192,500 630,000 157,500 490,000 122,500 10 8 Kecil
77,000 252,000 63,000 196,000 49,000 11 8 Kecil
 23,100 75,600 18,900 58,800 14,700 11 8 Kecil
22,000 72,000 18,000 56,000 14000 19 8 Kecil
314,600 1,029,600 257,400 800,800 200,200
1,287,000 1,001,000

630,000 490,000 10 8 Kecil

630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil
630,000 490,000 10 8 Kecil

1,500,000

I II III idkel idunit JENIS OP

RS DR RS DR RS BMHP
450,000 1,440,000 360,000 1,200,000 300,000 10 8 kusus
180,000 576,000 144,000 480,000 120,000 11 8 kusus
54,000 172,800 43,200 144,000 36,000 11 8 kusus
60,000 192,000 48,000 160,000 40,000 19 8 kusus
744,000 2,380,800 595,200 1,984,000 496,000
2,976,000 2,480,000

1,440,000 1,200,000 10 8 Khusus

1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
 1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 KHUSUS
1,440,000 1,200,000 10 8 Khusus
1,440,000 1,200,000 10 8 Khusus

II III idkel idunitJENIS OP

RS DR RS DR RS BMHP
260,000 844,800 211,200 714,800 178,700 10 8 Sedang
104,000 337,920 84,480 285,920 71,480 11 8 Sedang
 31,200 101,376 25,344 85,776 21,444 11 8 Sedang
32,000 104,000 26,000 88,000 22000 19 8 Sedang
427,200 1,388,096 347,024 1,174,496 293,624
1,735,120 1,468,120

844,800 714,800 10 8 Sedang

844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
 844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang
844,800 714,800 10 8 Sedang

300,000 300,000 2 8 Sedang

300,000 300,000 2 8 Besar
400,000 400,000 2 8 Besar
300,000 300,000 2 8 Besar
300,000 300,000 2 8 Besar
700,000 600,000 2 8 Besar
400,000 300,000 2 8 Besar
700,000 600,000 2 8 Besar
450,000 350,000 2 8 Besar
300,000 300,000 2 8 Besar
700,000 600,000 2 8 Besar
450,000 350,000 2 8 Besar
700,000 600,000 2 8 Besar
450,000 350,000 2 8 Besar
700,000 600,000 2 8 Besar
700,000 600,000 2 8 Besar
1,500,000 1,500,000 10 8 Besar
250,000 250,000 2 8 Kecil
400,000 300,000 2 8 Kecil
400,000 300,000 2 8 Kecil
400,000 400,000 2 8
700,000 600,000 2 8 Khusus
700,000 600,000 2 8 Khusus
7. Jasa Tindakan Operasi :
a. Jasa Tindakan Operator :

Jasa Operasi Jasa Operasi

24
KELOMPOK 1 KELOMPOK 2
VIP Rp. 780,000 Rp. 1,350,000
I. Rp. 520,000 Rp. 900,000
II. Rp. 460,000 Rp. 800,000
III. Rp. 380,000 Rp. 650,000

b. Jasa Anestesi Oleh Dokter Ahli : ( 40 % X Jasa Operator )

Jasa Operasi Jasa Operasi

Kelas
KELOMPOK 1 KELOMPOK 2
VIP Rp. 312,000 Rp. 540,000
I. Rp. 208,000 Rp. 360,000
II. Rp. 184,000 Rp. 320,000
III. Rp. 152,000 Rp. 260,000

c. Jasa Asisten Anestesi : ( 30 % X Jasa Dokter Anestesi )

Jasa Operasi Jasa Operasi

Kelas
KELOMPOK 1 KELOMPOK 2
VIP Rp. 93,600 Rp. 162,000
I. Rp. 62,400 Rp. 108,000
II. Rp. 55,200 Rp. 96,000
III. Rp. 45,600 Rp. 78,000

d. Jasa Asisten Operator Kamar Bedah :

Jasa Operasi Jasa Operasi

Kelas
KELOMPOK 1 KELOMPOK 2
VIP Rp. 85,800 Rp. 148,500
I. Rp. 57,200 Rp. 99,000
II. Rp. 50,600 Rp. 88,000
III. Rp. 41,800 Rp. 71,500

57,200 20% 11,440.00

80% 45,760.00
BPJS OPERASI KECIL
NAMA TINDAKA VIP I
DR RS DR RS
DOKTER 624,000 156,000 416,000 104,000
ANESTESI 249,600 62,400 166,400 41,600
PER-ANESTSI 74,880 18,720 49,920 12,480
ASISTEN OFF 68,640 17,160 45,760 11,440
1,017,120 254,280 678,080 169,520
TOTAL TARIF 1,271,400 847,600

BPJS OPERASI SEDANG

NAMA TINDAKA VIP I
DR RS DR RS
DOKTER 1,080,000 270,000 720,000 180,000
ANESTESI 432,000 108,000 288,000 72,000
PER-ANESTSI 129,600 32,400 86,400 21,600
ASISTEN OFF 118,800 29,700 79,200 19,800
1,760,400 440,100 1,173,600 293,400
TOTAL TARIF 2,200,500 1,467,000

BPJS OPERASI BESAR

NAMA TINDAKA VIP I
DR RS DR RS
DOKTER 1,440,000 360,000 960,000 240,000
ANESTESI 576,000 144,000 384,000 96,000
PER-ANESTSI 172,800 43,200 115,200 28,800
ASISTEN OFF 158,400 39,600 105,600 26,400
2,347,200 586,800 1,564,800 391,200
TOTAL TARIF 2,934,000 1,956,000

BPJS OPERASI KUSUS

NAMA TINDAKA VIP I
DR RS DR RS
DOKTER 1,800,000 450,000 1,200,000 300,000
ANESTESI 720,000 180,000 480,000 120,000
PER-ANESTSI 216,000 54,000 144,000 36,000
ASISTEN OFF 198,000 49,500 132,000 33,000
2,934,000 733,500 1,956,000 489,000
TOTAL TARIF 3,667,500 2,445,000
 Jasa Operasi Jasa Operasi 20%
KELOMPOK 3 KELOMPOK 4 80%
Rp. 1,800,000 Rp. 2,250,000 20 1,800,000 2,250,000
Rp. 1,200,000 Rp. 1,500,000
Rp. 1,050,000 Rp. 1,350,000
Rp. 900,000 Rp. 1,200,000

asa Operator )

Jasa Operasi Jasa Operasi 20%

KELOMPOK 3 KELOMPOK 4 80%
Rp. 720,000 Rp. 900,000
Rp. 480,000 Rp. 600,000
Rp. 420,000 Rp. 540,000
Rp. 360,000 Rp. 480,000

Jasa Operasi Jasa Operasi 20%

KELOMPOK 3 KELOMPOK 4 80%
Rp. 216,000 Rp. 270,000
Rp. 144,000 Rp. 180,000
Rp. 126,000 Rp. 162,000
Rp. 108,000 Rp. 144,000

Jasa Operasi Jasa Operasi 20%

KELOMPOK 3 KELOMPOK 4 80% kecil sedang besar
Rp. 198,000 Rp. 247,500 Rp. 1,271,400 Rp. 2,200,500 Rp. 2,934,000
Rp. 132,000 Rp. 165,000 Rp. 847,600 Rp. 1,467,000 Rp. 1,956,000
Rp. 115,500 Rp. 148,500 Rp. 749,800 Rp. 1,304,000 Rp. 1,711,500
Rp. 99,000 Rp. 132,000 Rp. 619,400 Rp. 1,059,500 Rp. 1,467,000

II III JENIS OP
DR RS DR RS BMHP
368,000 92,000 304,000 76,000 Kecil
147,200 36,800 121,600 30,400 Kecil
 44,160 11,040 36,480 9,120 Kecil
40,480 10,120 33,440 8360 Kecil
599,840 149,960 495,520 123,880
84 619,400

II III JENIS OP
DR RS DR RS BMHP
640,000 160,000 520,000 130,000 SEDANG
256,000 64,000 208,000 52,000 SEDANG
76,800 19,200 62,400 15,600 SEDANG
70,400 17,600 57,200 14,300 SEDANG
1,043,200 260,800 847,600 211,900
1,304,000 1,059,500

II III JENIS OP
DR RS DR RS BMHP
840,000 210,000 720,000 180,000 BESAR
336,000 84,000 288,000 72,000 BESAR
100,800 25,200 86,400 21,600 BESAR
92,400 23,100 79,200 19,800.00 BESAR
1,369,200 342,300 1,173,600 293,400
1,711,500 1,467,000

II III JENIS OP
DR RS DR RS BMHP
1,080,000 270,000 960,000 240,000 KHUSUS
432,000 108,000 384,000 96,000 KHUSUS
129,600 32,400 115,200 28,800 KHUSUS
118,800 29,700 105,600 26,400 KHUSUS
1,760,400 440,100 1,564,800 391,200
2,200,500 1,956,000
 khusus
Rp. 3,667,500
Rp. 2,445,000
Rp. 2,200,500
Rp. 1,956,000
DOKTER OPERATOR
Jasa Operasi Jasa Operasi Jasa Operasi Jasa Operasi
Kelas
KECIL SEDANG BESAR KHUSUS
VIP 1610000 2242500 2587500 3450000
I. 1106875 1495000 1897500 2587500
II. 905625 1214400 1552500 2070000
III. 704375 1027525 1293750 1725000

DOKTER ANESTESI
Jasa Operasi Jasa Operasi Jasa Operasi Jasa Operasi
Kelas
KECIL SEDANG BESAR KHUSUS
VIP 644000 897000 1035000 1380000
I. 442750 598000 759000 1035000
II. 362250 485760 621000 828000
III. 281750 411010 517500 690000

PERAWAT ANESTESI
Jasa Operasi Jasa Operasi Jasa Operasi Jasa Operasi
Kelas
KECIL SEDANG BESAR KHUSUS
VIP 193200 269100 310500 414000
I. 132825 179400 227700 310500
II. 108675 145728 186300 248400
III. 84525 123303 155250 207000

ASISTEN OPERASI
Jasa Operasi Jasa Operasi Jasa Operasi Jasa Operasi
Kelas
KECIL SEDANG BESAR KHUSUS
VIP 184000 276000 345000 460000
I. 126500 184000 253000 345000
II. 103500 149500 207000 276000
III. 80500 126500 172500 230000

BPJS OPERASI KECIL

NAMA TIN VIP I II
DR RS DR RS DR
DOKTER 1288000 322000 885500 221375 724500
ANESTESI
PER- 515200 128800 354200 88550 289800
ANESTSI
ASISTEN 154560 38640 106260 26565 86940
OFF 147200 36800 101200 25300 82800
TOTAL 2104960 526240 1447160 361790 1184040
TARIF 2631200 1808950 1480050

BPJS OPERASI SEDANG

NAMA TIN VIP I II
 DR RS DR RS DR
DOKTER 1794000 448500 1196000 299000 971520
ANESTESI
PER- 717600 179400 478400 119600 388608
ANESTSI
ASISTEN 215280 53820 143520 35880 116582.4
OFF 220800 55200 147200 36800 119600
TOTAL 2947680 736920 1965120 491280 1596310.4
TARIF 3684600 2456400 1995388

BPJS OPERASI BESAR

NAMA TIN VIP I II
DR RS DR RS DR
DOKTER 2070000 517500 1518000 379500 1242000
ANESTESI
PER- 828000 207000 607200 151800 496800
ANESTSI
ASISTEN 248400 62100 182160 45540 149040
OFF 276000 69000 202400 50600 165600
TOTAL 3422400 855600 2509760 627440 2053440
TARIF 4278000 3137200 2566800

BPJS OPERASI KUSUS

NAMA TIN VIP I II
DR RS DR RS DR
DOKTER 2760000 690000 2070000 517500 1656000
ANESTESI
PER- 1104000 276000 828000 207000 662400
ANESTSI
ASISTEN 331200 82800 248400 62100 198720
OFF 368000 92000 276000 69000 220800
TOTAL 4563200 1140800 3422400 855600 2737920
TARIF 5704000 4278000 3422400
 KECIL SEDANG BESAR KHUSUS
VIP 2631200 3684600 4278000 5704000
1 1808950 2456400 3137200 4278000
2 1480050 1995388 2566800 3422400
3 1151150 1688338 2139000 2852000

III JENIS OP RS
RS DR RS BMHP 20%
181125 563500 140875 Kecil 704,375 DR 140,875
72450 225400 56350 Kecil 281,750 DRA 56,350
21735 67620 16905 Kecil 84,525 PRA 16,905
20700 64400 16100 Kecil 80,500 PR 16,100
296010 920920 230230 1,151,150 230,230
1151150

III JENIS OP RS
 RS DR RS BMHP 20%
242880 822020 205505 SEDANG 1,027,525 DR 205,505
97152 328808 82202 SEDANG 411,010 DRA 82,202
29145.6 98642.4 24660.6 SEDANG 123,303 PRA 24,661
29900 101200 25300 SEDANG 126,500 PR 25,300
399077.6 1350670.4 337667.6 1,688,338
1688338

III JENIS OP RS
RS DR RS BMHP 20%
310500 1035000 258750 BESAR 1,293,750 DR 258,750
124200 414000 103500 BESAR 517,500 DRA 103,500
37260 124200 31050 BESAR 155,250 PRA 31,050
41400 138000 34500 BESAR 172,500 PR 34,500
513360 1711200 427800 2,139,000
2139000

III JENIS OP RS
RS DR RS BMHP 20%
414000 1380000 345000 KHUSUS 11,500 DR 2,300
165600 552000 138000 KHUSUS 690,000 DRA 138,000
49680 165600 41400 KHUSUS 207,000 PRA 41,400
55200 184000 46000 KHUSUS 230,000 PR 46,000
684480 2281600 570400 1,138,500
2852000
DR
80%
563,500.00
225,400.00
67,620.00
64,400.00

DR
 80%
822,020.00
328,808.00
98,642.40
101,200.00

DR
80%
1,035,000.00
414,000.00
124,200.00
138,000.00

DR
80%
9,200.00
552,000.00
165,600.00
184,000.00
 BS EDH
(Epidural
BS EDH
BEDAH SYARAF
BS EDH
Haemorh
(Epidural
(Epidural
1085 BS
age) (Dr)
EDH
Haemorh ### ### ### ### 10 8 Khusus
Haemorh
(Epidural
2888 BS
age) (RS)
EDH
age)_A ### 750,000 750,000 750,000 10 8 Khusus
Haemorh
(Epidural
BS
1086 BS
(Dr)EDH
age)_A ### ### ### ### 11 8 Khusus
Haemorh
Fraktur
(Epidural
BS
1087 (RS)
age)_AA
Depresed 500,000 375,000 375,000 375,000 11 8 Khusus
Haemorh
Fraktur
BS EDH
2903 (Tanpa
(Pr)
age)_AA
Depresed 600,000 450,000 450,000 450,000 11 8 Khusus
(Epidural
Fraktur
Pendarah
1088 BS
(RS)
(Tanpa
BS
Haemorh
Depresed 150,000 112,500 112,500 112,500 11 8 Khusus
an
Fraktur
Pendarah
2901 Fraktur
age)_AO
(Tanpa
BS
Intracrani
Depresed 600,000 450,000 450,000 450,000 19 8 Khusus
an
Depresed
Pendarah
4833 Fraktur
al) (Dr)
(Tanpa
Intracrani
(Tanpa ### ### ### ### 10 8 Khusus
an
Depresed
Pendarah
BS
4834 Pendarah
al) (RS)
Intracrani
(Tanpa ### 750,000 750,000 750,000 10 8 Khusus
an
Fraktur
an
4835 Pendarah
al)_A (Dr)
Intracrani
Depresed ### ### ### ### 11 8 Khusus
Intracrani
an
1083 (Tanpa
al)_A
al)_AA (RS) 500,000 375,000 375,000 375,000 11 8 Khusus
Intracrani
Pendarah
2886 (Pr)
al)_AA 600,000 450,000 450,000 450,000 11 8 Khusus
an
1084 (RS)
Intracrani 150,000 112,500 112,500 112,500 11 8 Khusus
2887 al)_AO
BS HNP 600,000 450,000 450,000 450,000 19 8 Khusus
4864 (Dr)
BS HNP ### ### ### ### 10 8 Khusus
4865 (RS)
BS HNP_A ### ### ### ### 10 8 Khusus
4866 (BSDrHNP_A
) ### ### ### ### 11 8 Khusus
BS
4867 (HNP_AA
RS ) 625,000 500,000 500,000 500,000 11 8 Khusus
BS
4868 BS
(Pr)ICH
HNP_AA 750,000 600,000 600,000 600,000 11 8 Khusus
(Intracran
4869 BS
(RS)ICH 187,500 150,000 150,000 150,000 11 8 Khusus
BS
ial ICH
4870 (Intracran
HNP_AO
(Intracran
Haemorh
BS 600,000 450,000 450,000 450,000 19 8 Khusus
ial ICH
4836 ial
age) (Dr)
(Intracran
Haemorh
BS ICH ### ### ### ### 10 8 Khusus
Haemorh
ial
4837 (Intracran
age)
age)_A
BS (RS)
ICH ### ### ### ### 10 8 Khusus
Haemorh
ial
BS
4838 (Intracran
(Dr)
age)_A ### ### ### ### 11 8 Khusus
Haemorh
Meningoc
4839 ial
BS
(RS)
BS ICH
age)_AA
ele/Meni 625,000 500,000 500,000 500,000 11 8 Khusus
Haemorh
Meningoc
(Intracran
BS
4840 ngoencep
(Pr)
age)_AA
ele/Meni 750,000 600,000 600,000 600,000 11 8 Khusus
ial
Meningoc
halocele
4841 BS
(RS)
ngoencep
Haemorh
ele/Meni 187,500 150,000 150,000 150,000 11 8 Khusus
Regio
Meningoc
4842 halocele
age)_AO
ngoencep
Kepala
ele/Meni 600,000 450,000 450,000 450,000 19 8 Khusus
Regio
4843 halocele
(Dr)
ngoencep
Kepala ### ### ### ### 10 8 Khusus
Regio
4844 halocele
(RS)
Kepala_A ### ### ### ### 10 8 Khusus
Regio
4845 (Dr)
Kepala_A ### ### ### ### 11 8 Khusus
4846 (RS) 625,000 500,000 500,000 500,000 11 8 Khusus
 BS
ele/Meni
Meningoc
BS
ngoencep
ele/Meni
Meningoc
halocele
ngoencep
ele/Meni
Regio
halocele
ngoencep
Kepala_A
Regio
4847 halocele
A
BS (Pr)
Kepala_A 750,000 600,000 600,000 600,000 11 8 Khusus
Regio
Meningoc
4848 BS
A (RS)
Kepala_A
BS 187,500 150,000 150,000 150,000 11 8 Khusus
ele/Meni
4849 Meningoc
O
Meningoc
ngomyelo
BS 600,000 450,000 450,000 450,000 19 8 Khusus
ele/Meni
4850 ele/Meni
cele (Dr)
Meningoc
ngomyelo
BS ### ### ### ### 10 8 Khusus
ngomyelo
ele/Meni
4851 Meningoc
cele
cele_A
BS (RS) ### 750,000 750,000 750,000 10 8 Khusus
ngomyelo
ele/Meni
4852 Meningoc
(Dr)
cele_A ### ### ### ### 11 8 Khusus
ngomyelo
4853 ele/Meni
(RS)
BS
cele_AA 500,000 375,000 375,000 375,000 11 8 Khusus
ngomyelo
4854 Meningoc
(Pr)
cele_AA 600,000 450,000 450,000 450,000 11 8 Khusus
ele/Meni
4855 BS
(RS) SDH
ngomyelo 150,000 112,500 112,500 112,500 11 8 Khusus
(Subdural
4856 BS
BS SDH
cele_AO
SDH
Haemorh 600,000 450,000 450,000 450,000 19 8 Khusus
(Subdural
(Subdural
1089 BS
age) (Dr)
SDH
Haemorh ### ### ### ### 10 8 Khusus
Haemorh
(Subdural
2902 BS
age) (RS)
SDH
age)_A ### ### ### ### 10 8 Khusus
Haemorh
(Subdural
1090 BS
(Dr) SDH
age)_A ### ### ### ### 11 8 Khusus
Haemorh
(Subdural
4798 (RS)
age)_AA 625,000 500,000 500,000 500,000 11 8 Khusus
Haemorh
4802 BS
(Pr) SDH
age)_AA 750,000 600,000 600,000 600,000 11 8 Khusus
(Subdural
4796 (RS)
Haemorh 187,500 150,000 150,000 150,000 11 8 Khusus
4800 age)_AO
BS 600,000 450,000 450,000 450,000 19 8 Khusus
BS VPVP
4857 Shunt
Shunt (Dr) ### ### ### ### 10 8 Khusus
BS VP
4858 (RS)
Shunt_A ### 750,000 750,000 750,000 10 8 Khusus
BS VP
4859 (Dr)
Shunt_A ### ### ### ### 11 8 Khusus
BS VP
4860 (RS)
Shunt_AA 500,000 375,000 375,000 375,000 11 8 Khusus
BS VP
4861 Shunt_AA
(Pr) 600,000 450,000 450,000 450,000 11 8 Khusus
4862 (RS)
BS 150,000 112,500 112,500 112,500 11 8 Khusus
BMVP
4863 Shunt_AO
Bleparopl 600,000 450,000 450,000 450,000 19 8 Khusus
BM
290 BM
asty ( Dr )
Bleparopl ### ### 844,800 714,800 10 8 Sedang
Bleparopl
BM
2895 asty
asty _A( RS ) 390,000 260,000 211,200 178,700 10 8 Sedang
Bleparopl
291 BM
(asty
Dr )_A 624,000 416,000 337,920 285,920 11 8 Sedang
Bleparopl
2896 BM(asty_AA
RS ) 156,000 104,000 84,480 71,480 11 8 Sedang
Bleparopl(
292 Pr )
asty_AA ( 187,200 124,800 101,376 85,776 11 8 Sedang
BM
2897 Bleparopl
RS ) 52,000 38,000 32,000 28,000 11 8 Sedang
BM
780 aty_AO
Congenita 240,000 160,000 130,000 110,000 19 8 Sedang
BM
1222 lCongenita
(Dr) ### ### 844,800 714,800 10 8 Sedang
4876 l (RS) 390,000 260,000 211,200 178,700 10 8 Sedang
 BM
Congenita
BM
999 l_A
Congenita (Dr) 624,000 416,000 337,920 285,920 11 8 Sedang
BM
4878 l_A
Congenita (RS) 156,000 104,000 84,480 71,480 11 8 Sedang
BM
1974 l_AA
Congenita (Pr) 78,000 57,000 48,000 42,000 11 8 Sedang
BM
4877 l_AA
Congenita (RS) 52,000 38,000 32,000 28,000 11 8 Sedang
BM
1975 l_AO
Eksentera 240,000 160,000 130,000 110,000 19 8 Sedang
BM
287 si
Eksentera ( Dr ) ### ### 844,800 714,800 10 8 Sedang
BM
2982 BM
si
Eksentera ( RS ) 390,000 260,000 211,200 178,700 10 8 Sedang
Eksentera
BM
288 si
si _A
_A ( Dr ) 624,000 416,000 337,920 285,920 11 8 Sedang
Eksentera
BM
2983 (BM
si RS
_AA ) ( Pr 156,000 104,000 84,480 71,480 11 8 Sedang
Eksentera
289 Eksterpasi
)BM
si _AA 187,200 124,800 101,376 85,776 11 8 Sedang
BM
2984 korpus
(BM RS )
Eksterpasi
Eksentera 46,800 31,200 25,344 21,444 11 8 Sedang
alienum
korpus
788 Eksterpasi
si_AO
kornea
BM 240,000 160,000 130,000 110,000 19 8 Sedang
alienum
317 korpus
(BM Dr )
Eksterpasi
kornea ### ### 844,800 714,800 10 8 Sedang
alienum
korpus
3031 Eksterpasi
(BM
kornea RS ) _A 390,000 260,000 211,200 178,700 10 8 Sedang
alienum
318 korpus
(BM Dr ) _A
Eksterpasi
kornea 624,000 416,000 337,920 285,920 11 8 Sedang
alienum
korpus
3032 Eksterpasi
(kornea_A
RS ) 156,000 104,000 84,480 71,480 11 8 Sedang
alienum
korpus
319 A ( Pr )
kornea_A 187,200 124,800 101,376 85,776 11 8 Sedang
alienum
BM
3033 A ( RS )
kornea_A 46,800 31,200 25,344 21,444 11 8 Sedang
Eksterpasi
1062 BM O
perengiu 240,000 160,000 130,000 110,000 19 8 Sedang
Eksterpasi
272 BM m ( Dr )
perengiu ### ### 844,800 714,800 10 8 Sedang
Eksterpasi
BM
3047 BM m ( RS )
perengiu 390,000 260,000 211,200 178,700 10 8 Sedang
Eksterpasi
Eksterpasi
273 BM m_A ( Dr )
perengiu 624,000 416,000 337,920 285,920 11 8 Sedang
perengiu
3050 Eksterpasi
m_A
m_AA ( RS
( Pr) 156,000 104,000 84,480 71,480 11 8 Sedang
perengiu
BM
274 BM )m_AA 187,200 124,800 101,376 85,776 11 8 Sedang
Eksterpasi
3051 Ekstraksi
(BM
BM RS )
perengiu 46,800 31,200 25,344 21,444 11 8 Sedang
tumor
Ekstraksi dg
792 Ekstraksim_AO
rekonstru
BM 240,000 160,000 130,000 110,000 19 8 Sedang
tumor dg
278 tumor ksi ( Drdg
Ekstraksi
rekonstru
BM ) ### ### 844,800 714,800 10 8 Sedang
rekonstru
tumor dg
3058 Ekstraksiksi
ksi_A
BM ( RS ) 390,000 260,000 211,200 178,700 10 8 Sedang
rekonstru
tumor
279 Ekstraksi Dr ) dg
(ksi_A 624,000 416,000 337,920 285,920 11 8 Sedang
rekonstru
3059 tumor ( RS ) dg
BM
ksi_AA 156,000 104,000 84,480 71,480 11 8 Sedang
rekonstru
280 Ekstraksi (ksi_AA
Pr ) 187,200 124,800 101,376 85,776 11 8 Sedang
tumor dg
3060 (rekonstru RS ) 46,800 31,200 25,344 21,444 11 8 Sedang
795 ksi_AO 240,000 160,000 130,000 110,000 19 8 Sedang
 BM
Enukleasi
BM
281 (Enukleasi
Dr ) ### ### 844,800 714,800 10 8 Sedang
BM
3067 (Enukleasi
RS ) 390,000 260,000 211,200 178,700 10 8 Sedang
BM
282 _A
Enukleasi ( Dr ) 624,000 416,000 337,920 285,920 11 8 Sedang
BM
3068 _A
Enukleasi ( RS ) 156,000 104,000 84,480 71,480 11 8 Sedang
BM
283 _AA
Enukleasi ( Pr ) 187,200 124,800 101,376 85,776 11 8 Sedang
BM
3069 _AA
Enukleasi ( RS ) 46,800 31,200 25,344 21,444 11 8 Sedang
BM
796 _AO
Eviscerasi 240,000 160,000 130,000 110,000 19 8 Sedang
BM
284 (Eviscerasi
Dr ) ### ### 844,800 714,800 10 8 Sedang
BM
3073 (Eviscerasi
RS ) 390,000 260,000 211,200 178,700 10 8 Sedang
BM
285 _A
Eviscerasi ( Dr ) 624,000 416,000 337,920 285,920 11 8 Sedang
BM
3075 _A
Eviscerasi ( RS ) 156,000 104,000 84,480 71,480 11 8 Sedang
BM
286 _AA
Eviscerasi ( Pr ) 187,200 124,800 101,376 85,776 11 8 Sedang
BM
BM Jahit
3076 _AA
Eviscerasi ( RS ) 46,800 31,200 25,344 21,444 11 8 Sedang
palbea
BM Jahitdg
798 BM
_AO
rekonstru Jahit 240,000 160,000 130,000 110,000 19 8 Sedang
palbea dg
275 palbea
ksi
BM
rekonstru Dr dg
(Jahit ) ### ### 844,800 714,800 10 8 Sedang
rekonstru
palbea dg
3284 BM
ksi
ksi (_ARS( )Dr
Jahit 390,000 260,000 211,200 178,700 10 8 Sedang
rekonstru
palbea
BM dg
276 BM
)ksi _A Jahit
( RS 624,000 416,000 337,920 285,920 11 8 Sedang
rekonstru
Penanggu
palbea dg
3285 BM)ng
ksi _AA
Jawab 156,000 104,000 84,480 71,480 11 8 Sedang
rekonstru
Penanggu
BM Jahit
277 Dr.(ng
ksi PrJawab
)
_AA 187,200 124,800 101,376 85,776 11 8 Sedang
palbea
Penanggu
Anestesi
BM dg
3286 Dr. (ng RSJawab
rekonstru) 46,800 31,200 25,344 21,444 11 8 Sedang
Operasi
Penanggu
Anestesi
1309 BM ksi
Dr.
Besar
ng _AO
Jawab _A ( 240,000 160,000 130,000 110,000 19 8 Sedang
Operasi
Penanggu
Anestesi
BM
12331 Dr. Dr
Besar
ng )
Jawab _A ( 216,000 158,400 129,600 108,000 11 8 Sedang
Operasi
Penanggu
12351 Anestesi
BM
RS
Dr.
Kecil
ng )
Jawab_A 54,000 39,600 32,400 27,000 11 8 Sedang
Operasi
Penanggu
Anestesi
12321 BM (ng
Dr.Dr
Kecil )
Jawab_A 134,400 92,400 75,600 58,800 11 8 Sedang
Operasi
Penanggu
12341 Anestesi
(ngRS
Dr.
Khusus )
Jawab 33,600 23,100 18,900 14,700 11 8 Sedang
Operasi
12336 Anestesi
_A ( Dr )
Dr.
Khusus 288,000 216,000 172,800 144,000 11 8 Sedang
Operasi
12356 Anestesi
_A ( RS )
Sedang 72,000 54,000 43,200 36,000 11 8 Sedang
Operasi
BM
12326 _A ( Dr )
Sedang 187,200 124,800 101,376 85,776 11 8 Sedang
Trabecule
BM
12346 BM _A
ctomy( RS ) 46,800 31,200 25,344 21,444 11 8 Sedang
Reposisi
Reposisi
64 strabismu
( Dr ) ### ### ### 900,000 10 8 Besar
retina dg
65 spunctie ( Dr ) ### ### ### 900,000 10 8 Besar
BM
66 (Parasente
Dr ) ### ### ### 900,000 10 8 Besar
67 sa ( Dr ) ### ### ### 900,000 10 8 Besar
 BM Jahit
kornea
BM
68 Extraksi
(BMDr Jahit
) ### ### ### 900,000 10 8 Besar
BM
katarak
69 Extraksi
iris ( Dr )
Iridektom ### ### ### 900,000 10 8 Besar
intra
70 katarak
ykapsular
( Dr ) ( ### ### ### 900,000 10 8 Besar
extra
71 BMDr )
kapsular ### ### ### 900,000 10 8 Besar
Ekstraksi (
72 Dr )
katarak ### ### ### 900,000 10 8 Besar
73 ( Dr ) ### ### ### 900,000 10 8 Besar
BMHP OPERASI SESAR 1 QTY HARGA TOTAL BACK
1 TOPI OPERASI Satuan :BH Qty:3 Hrg.: 550 Jumlah:1,650 3 550 1,650
2 KASA KECIL Satuan :LEMBAR Qty:40 Hrg.: 1,800 Jumlah:72,000 40 1,800 72,000
3 KASA BESAR Satuan :LEMBAR Qty:1 Hrg.: 27,000 Jumlah:27,000 1 27,000 27,000
4 CAUTER PEN Satuan :PCS Qty:1 Hrg.: 7,200 Jumlah:7,200 1 7,200 7,200
5 YANKUR SUCTION Satuan :BH Qty:2 Hrg.: 2,700 Jumlah:5,400 2 2,700 5,400
6 BAJU/GOWN DISPOSIBLE* Satuan :PCS Qty:1 Hrg.: 20,000 Jumlah:20,000 1 20,000 20,000
7 MASKER DIS Satuan :BH Qty:5 Hrg.: 450 Jumlah:2,250 5 450 2,250
8 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 550 Jumlah:3,300 6 550 3,300
9 OXIGEN BESAR 1 Satuan :LITER Qty:200 Hrg.: 20 Jumlah:4,000 200 20 4,000
10 ALKOHOL LITER Satuan :ML Qty:150 Hrg.: 100 Jumlah:15,000 150 100 15,000
11 FIXOMUL BESAR Satuan :CM Qty:20 Hrg.: 450 Jumlah:9,000 20 450 9,000
12 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:2 Hrg.: 3,750 Jumlah:7,500 2 3,750 7,500
13 STARDIN GALON Satuan :ML Qty:75 Hrg.: 250 Jumlah:18,750 75 250 18,750
14 HANSAPLAS Satuan :BH Qty:1 Hrg.: 700 Jumlah:700 1 700 700
15 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
194,700

BMHP OPERASI SESAR 2 QTY HARGA TOTAL

1 TOPI OPERASI Satuan :BH Qty:3 Hrg.: 550 Jumlah:1,650 3 550 1,650
2 KASA KECIL Satuan :LEMBAR Qty:40 Hrg.: 1,800 Jumlah:72,000 40 1,800 72,000
3 KASA BESAR Satuan :LEMBAR Qty:1 Hrg.: 27,000 Jumlah:27,000 1 27,000 27,000
4 CAUTER PEN Satuan :PCS Qty:1 Hrg.: 7,200 Jumlah:7,200 1 7,200 7,200
5 YANKUR SUCTION Satuan :BH Qty:2 Hrg.: 2,700 Jumlah:5,400 2 2,700 5,400
6 BAJU/GOWN DISPOSIBLE* Satuan :PCS Qty:2 Hrg.: 20,000 Jumlah:40,000 2 20,000 40,000
7 MASKER DIS Satuan :BH Qty:4 Hrg.: 450 Jumlah:1,800 4 450 1,800
8 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 550 Jumlah:3,300 6 550 3,300
9 OXIGEN BESAR 1 Satuan :LITER Qty:200 Hrg.: 20 Jumlah:4,000 200 20 4,000
10 ALKOHOL LITER Satuan :ML Qty:150 Hrg.: 100 Jumlah:15,000 150 100 15,000
11 FIXOMUL BESAR Satuan :CM Qty:25 Hrg.: 450 Jumlah:11,250 25 450 11,250
12 STARDIN GALON Satuan :ML Qty:75 Hrg.: 250 Jumlah:18,750 75 250 18,750
13 HANSAPLAS Satuan :BH Qty:1 Hrg.: 700 Jumlah:700 1 700 700
14 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
209,000
BMHP OPERASI DEBRIDEMEN BACK
NAMA TINDAKAN QTY HARGA TOTAL
1 TOPI OPERASI Satuan :BH Qty:3 Hrg.: 550 Jumlah:1,650 3 550 1,650
2 L M A NO. 4 Satuan :PCS Qty:1 Hrg.: 36,000 Jumlah:36,000 1 36,000 36,000
3 KASA KECIL Satuan :LEMBAR Qty:20 Hrg.: 1,800 Jumlah:36,000 20 1,800 36,000
4 NOTRIXUM INJ AMP* Satuan :VIA Qty:2 Hrg.: 27,000 Jumlah:54,000 2 27,000 54,000
5 MASKER DIS Satuan :BH Qty:4 Hrg.: 450 Jumlah:1,800 4 450 1,800
6 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 550 Jumlah:3,300 6 550 3,300
7 OXIGEN BESAR 1 Satuan :LITER Qty:200 Hrg.: 20 Jumlah:4,000 200 20 4,000
8 ALKOHOL LITER Satuan :ML Qty:100 Hrg.: 100 Jumlah:10,000 100 100 10,000
9 FIXOMUL BESAR Satuan :CM Qty:20 Hrg.: 450 Jumlah:9,000 20 450 9,000
10 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:2 Hrg.: 3,750 Jumlah:7,500 2 3750 7,500
11 STARDIN GALON Satuan :ML Qty:75 Hrg.: 250 Jumlah:18,750 75 250 18,750
12 NOREVEL 250 Satuan :ML Qty:10 Hrg.: 16,200 Jumlah:162,000 10 16200 162,000
344,000

BMHP OPERASI EKSISI/INCISI BACK

NAMA TINDAKAN QTY HARGA TOTAL
1 TOPI OPERASI Satuan :BH Qty:3 Hrg.: 550 Jumlah:1,650 3 550 1,650
2 PLESTER 3 X 5 Satuan :CM Qty:25 Hrg.: 200 Jumlah:5,000 25 200 5,000
3 HARUM PLATE NON KABEL Satuan :PCS Qty:1 Hrg.: 6,000 Jumlah:6,000 1 6000 6,000
4 KASA KECIL Satuan :LEMBAR Qty:30 Hrg.: 1,800 Jumlah:54,000 30 1800 54,000
5 KASA BESAR Satuan :LEMBAR Qty:1 Hrg.: 27,000 Jumlah:27,000 1 27000 27,000
6 CAUTER PEN Satuan :PCS Qty:1 Hrg.: 7,200 Jumlah:7,200 1 7200 7,200
7 YANKUR SUCTION Satuan :BH Qty:2 Hrg.: 2,700 Jumlah:5,400 2 2700 5,400
8 MASKER DIS Satuan :BH Qty:4 Hrg.: 450 Jumlah:1,800 4 450 1,800
9 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 1,250 Jumlah:7,500 6 1250 7,500
10 OXIGEN BESAR 1 Satuan :LITER Qty:200 Hrg.: 20 Jumlah:4,000 200 20 4,000
11 ALKOHOL LITER Satuan :ML Qty:175 Hrg.: 100 Jumlah:17,500 175 100 17,500
12 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:3 Hrg.: 3,750 Jumlah:11,250 3 3750 11,250
13 STARDIN GALON Satuan :ML Qty:75 Hrg.: 250 Jumlah:18,750 75 250 18,750
14 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
168,000
BMHP OPERASI EKSISI (NARKOSE UMUM) BACK
NAMA TINDAKAN QTY HARGA TOTAL
1 NUPOVEL INJ AMP* Satuan :AMP Qty:10 Hrg.: 7,150 Jumlah:71,500 10 7,150 71,500
2 OXIGEN BESAR 1 Satuan :LITER Qty:300 Hrg.: 20 Jumlah:6,000 300 20 6,000
3 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
78,450

BMHP OPERASI KURETASE BACK

NAMA TINDAKAN QTY HARGA TOTAL
1 TOPI OPERASI Satuan :BH Qty:2 Hrg.: 550 Jumlah:1,100 2 550 1,100
2 KASA KECIL Satuan :LEMBAR Qty:5 Hrg.: 1,800 Jumlah:9,000 5 1,800 9,000
3 YANKUR SUCTION Satuan :BH Qty:2 Hrg.: 2,700 Jumlah:5,400 2 2,700 5,400
4 MASKER DIS Satuan :BH Qty:2 Hrg.: 450 Jumlah:900 2 450 900
5 SARUNG TANGAN ON STERIL Satuan :BH Qty:2 Hrg.: 1,250 Jumlah:2,500 2 1,250 2,500
6 ALKOHOL LITER Satuan :ML Qty:50 Hrg.: 100 Jumlah:5,000 50 100 5,000
7 STARDIN GALON Satuan :ML Qty:50 Hrg.: 250 Jumlah:12,500 50 250 12,500
8 HANSAPLAS Satuan :BH Qty:1 Hrg.: 600 Jumlah:600 1 600 600
37,000
BMHP OPERASI ortopedi (REPOSISI FRAKTUR DISLOKASI SENDI) BACK
NAMA TINDAKAN QTY HARGA TOTAL
1 TOPI OPERASI Satuan :BH Qty:4 Hrg.: 550 Jumlah:2,200 4 550 2,200
2 KASA KECIL Satuan :LEMBAR Qty:30 Hrg.: 1,800 Jumlah:54,000 30 1,800 54,000
3 CAUTER PEN Satuan :PCS Qty:1 Hrg.: 7,200 Jumlah:7,200 1 7,200 7,200
4 YANKUR SUCTION Satuan :BH Qty:1 Hrg.: 2,700 Jumlah:2,700 1 2,700 2,700
5 MASKER DIS Satuan :BH Qty:4 Hrg.: 450 Jumlah:1,800 4 450 1,800
6 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 550 Jumlah:3,300 6 550 3,300
7 OXIGEN BESAR 1 Satuan :LITER Qty:300 Hrg.: 20 Jumlah:6,000 300 20 6,000
8 ALKOHOL LITER Satuan :ML Qty:100 Hrg.: 100 Jumlah:10,000 100 100 10,000
9 FIXOMUL BESAR Satuan :CM Qty:30 Hrg.: 450 Jumlah:13,500 30 450 13,500
10 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:3 Hrg.: 3,750 Jumlah:11,250 3 3,750 11,250
11 STARDIN GALON Satuan :ML Qty:100 Hrg.: 250 Jumlah:25,000 100 250 25,000
12 PROANES INJ Satuan :AMP Qty:15 Hrg.: 5,100 Jumlah:76,500 15 5,100 76,500
13 NOREVEL 250 Satuan :ML Qty:10 Hrg.: 16,200 Jumlah:162,000 10 16,200 162,000
14 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
376,400

BMHP OPERASI ortopedi DEBRIDEMEN LUKA TERBUKA BACK

NAMA TINDAKAN QTY HARGA TOTAL
1 NUPOVEL INJ AMP* Satuan :AMP Qty:10 Hrg.: 7,150 Jumlah:71,500 10 7,150 71,500
2 SEVOFLURANE Satuan :ML Qty:20 Hrg.: 9,400 Jumlah:188,000 20 9,400 188,000
3 OXIGEN BESAR 1 Satuan :LITER Qty:300 Hrg.: 20 Jumlah:6,000 300 20 6,000
4 ATRACURIUM 2,5 ML INJ Satuan :ML Qty:1 Hrg.: 10,800 Jumlah:10,800 1 10,800 10,800
1 TOPI OPERASI Satuan :BH Qty:4 Hrg.: 550 Jumlah:2,200 4 550 2,200
2 KASA KECIL Satuan :LEMBAR Qty:20 Hrg.: 1,800 Jumlah:36,000 20 1,800 36,000
3 YANKUR SUCTION Satuan :BH Qty:1 Hrg.: 2,700 Jumlah:2,700 1 2,700 2,700
4 MASKER DIS Satuan :BH Qty:4 Hrg.: 450 Jumlah:1,800 4 450 1,800
5 SARUNG TANGAN ON STERIL Satuan :BH Qty:4 Hrg.: 1,250 Jumlah:5,000 4 1,250 5,000
6 OXIGEN BESAR 1 Satuan :LITER Qty:300 Hrg.: 20 Jumlah:6,000 300 20 6,000
7 ALKOHOL LITER Satuan :ML Qty:50 Hrg.: 100 Jumlah:5,000 50 100 5,000
8 FIXOMUL BESAR Satuan :CM Qty:30 Hrg.: 450 Jumlah:13,500 30 450 13,500
9 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:3 Hrg.: 3,750 Jumlah:11,250 3 3,750 11,250
10 STARDIN GALON Satuan :ML Qty:50 Hrg.: 250 Jumlah:12,500 50 250 12,500
11 HANSAPLAS Satuan :BH Qty:2 Hrg.: 600 Jumlah:1,200 2 600 1,200
12 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
374,400

BMHP OPERASI ortopedi ORIF BACK

NAMA TINDAKAN QTY HARGA TOTAL
1 TOPI OPERASI Satuan :BH Qty:3 Hrg.: 550 Jumlah:1,650 3 550 1,650
2 L M A NO. 3 Satuan :BH Qty:1 Hrg.: 36,000 Jumlah:36,000 1 36,000 36,000
3 KASA KECIL Satuan :LEMBAR Qty:40 Hrg.: 1,800 Jumlah:72,000 40 1,800 72,000
4 CAUTER PEN Satuan :PCS Qty:1 Hrg.: 7,200 Jumlah:7,200 1 7,200 7,200
5 YANKUR SUCTION Satuan :BH Qty:2 Hrg.: 2,700 Jumlah:5,400 2 2,700 5,400
6 BAJU/GOWN DISPOSIBLE* Satuan :PCS Qty:1 Hrg.: 20,000 Jumlah:20,000 1 20,000 20,000
7 MASKER DIS Satuan :BH Qty:5 Hrg.: 450 Jumlah:2,250 5 450 2,250
8 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 1,250 Jumlah:7,500 6 1,250 7,500
9 NUPOVEL INJ AMP* Satuan :AMP Qty:5 Hrg.: 7,150 Jumlah:35,750 5 7,150 35,750
10 OXIGEN BESAR 1 Satuan :LITER Qty:200 Hrg.: 20 Jumlah:4,000 200 20 4,000
11 ALKOHOL LITER Satuan :ML Qty:150 Hrg.: 100 Jumlah:15,000 150 100 15,000
12 FIXOMUL BESAR Satuan :CM Qty:20 Hrg.: 450 Jumlah:9,000 20 450 9,000
13 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:2 Hrg.: 3,750 Jumlah:7,500 2 3,750 7,500
14 STARDIN GALON Satuan :ML Qty:75 Hrg.: 250 Jumlah:18,750 75 250 18,750
15 ATRACURIUM 2,5 ML INJ Satuan :ML Qty:1 Hrg.: 10,800 Jumlah:10,800 1 10,800 10,800
252,800
BMHP OPERASI FISTULEKTOMI BACK
NAMA TINDAKAN QTY HARGA TOTAL
1 NUPOVEL INJ AMP* Satuan :AMP Qty:10 Hrg.: 7,150 Jumlah:71,500 10 7,150 71,500
2 SEVOFLURANE Satuan :ML Qty:25 Hrg.: 9,400 Jumlah:235,000 25 9,400 235,000
3 OXIGEN BESAR 1 Satuan :LITER Qty:300 Hrg.: 20 Jumlah:6,000 300 20 6,000
4 L M A NO. 2 Satuan :PCS Qty:1 Hrg.: 36,000 Jumlah:36,000 1 36,000 36,000
5 ATRACURIUM 2,5 ML INJ Satuan :ML Qty:2 Hrg.: 10,800 Jumlah:21,600 2 10,800 21,600
1 TOPI OPERASI Satuan :BH Qty:4 Hrg.: 550 Jumlah:2,200 4 550 2,200
2 KASA KECIL Satuan :LEMBAR Qty:20 Hrg.: 1,800 Jumlah:36,000 20 20 400
3 CAUTER PEN Satuan :PCS Qty:1 Hrg.: 7,200 Jumlah:7,200 1 7,200 7,200
4 MASKER DIS Satuan :BH Qty:4 Hrg.: 450 Jumlah:1,800 4 450 1,800
5 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 1,250 Jumlah:7,500 6 1,250 7,500
6 ALKOHOL LITER Satuan :ML Qty:100 Hrg.: 100 Jumlah:10,000 100 100 10,000
7 FIXOMUL BESAR Satuan :CM Qty:30 Hrg.: 450 Jumlah:13,500 30 450 13,500
8 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:2 Hrg.: 3,750 Jumlah:7,500 2 3,750 7,500
9 STARDIN GALON Satuan :ML Qty:100 Hrg.: 250 Jumlah:25,000 100 250 25,000
10 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
446,150
BMHP OPERASI TONSILECTOMI BACK
NAMA TINDAKAN QTY HARGA TOTAL
1 TOPI OPERASI Satuan :BH Qty:4 Hrg.: 550 Jumlah:2,200 4 550 2,200
2 CAUTER BIPOLAR Satuan :BH Qty:1 Hrg.: 450,000 Jumlah:450,000 1 450,000 450,000
3 KASA KECIL Satuan :LEMBAR Qty:10 Hrg.: 1,800 Jumlah:18,000 10 1,800 18,000
4 MASKER DIS Satuan :BH Qty:4 Hrg.: 450 Jumlah:1,800 4 450 1,800
5 SARUNG TANGAN ON STERIL Satuan :BH Qty:6 Hrg.: 1,250 Jumlah:7,500 6 1,250 7,500
6 NUPOVEL INJ AMP* Satuan :AMP Qty:10 Hrg.: 7,150 Jumlah:71,500 10 7,150 71,500
7 SEVOFLURANE Satuan :ML Qty:25 Hrg.: 9,400 Jumlah:235,000 25 9,400 235,000
8 OXIGEN BESAR 1 Satuan :LITER Qty:300 Hrg.: 20 Jumlah:6,000 300 20 6,000
9 POT URINE UK 50 Satuan :BTL Qty:1 Hrg.: 1,500 Jumlah:1,500 1 1,500 1,500
10 ALKOHOL LITER Satuan :ML Qty:50 Hrg.: 100 Jumlah:5,000 50 100 5,000
11 FORMALIN BUFFER 10 % Satuan :LITER Qty:30 Hrg.: 250 Jumlah:7,500 30 250 7,500
12 SCOTH DISPOSIBLE/APRON Satuan :PCS Qty:1 Hrg.: 3,750 Jumlah:3,750 1 3,750 3,750
13 STARDIN GALON Satuan :ML Qty:50 Hrg.: 250 Jumlah:12,500 50 250 12,500
14 KASA DAFFER BALL (S) Satuan :pcs Qty:5 Hrg.: 3,000 Jumlah:15,000 5 3,000 15,000
15 ATRACURIUM 2,5 ML INJ Satuan :ML Qty:2 Hrg.: 10,800 Jumlah:21,600 2 10,800 21,600
16 TRANSOFIX* Satuan :BH Qty:1 Hrg.: 950 Jumlah:950 1 950 950
859,800