A. TARIF PEMERIKSAAN DOKTER, TINDAKAN MEDIS DAN TINDAKAN KEPERAWATAN
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Jasa
layanan
Jasa
Sarana Total
Jasa
layanan
Jasa
Sarana Total
Jasa
layanan Jasa Sarana Total
Jasa
layanan
Jasa
Sarana Total
Jasa
layanan Jasa Sarana Total
Jasa
layanan
Jasa
Sarana Total
Jasa
layanan
Akomodasi Rawat Inap33,000 42,000 75,000 52,800 67,200 120,000 66,000 84,000 150,000 110,000 140,000 250,000 176,000 224,000 400,000 110,000
1
Jasa
layanan
Jasa
Sarana Total
Jasa
layanan
Jasa
Sarana Total
1.1
19,800 25,200 45,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800
1.2
22,000 28,000 50,000 28,600 36,400 65,000 15,400 19,600 35,000 17,600 22,400 40,000 24,200 30,800 55,000 35,200 44,800 80,000 48,400 61,600
110,000
26,400 33,600 60,000 26,400
1.3
8,800 11,200 20,000 11,000 14,000 25,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800
1.4
11,000 14,000 25,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 8,800
1.5 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 8,400 15,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800
1.6
11,000 14,000 25,000 19,800 25,200 45,000 8,800 11,200 20,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 1.7
15,400 19,600 35,000 - - 8,800 11,200 20,000 11,000 14,000 25,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400
1.8
- - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 11,000
1.9
6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
1.10
6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
- - - - - - - - - - - - - - - - -
2TINDAKAN MEDIS - - - - - - - - - - - - - - - - -
2.1
- - - - - - - - - - - - - - - - - 2.2
22,000 28,000 50,000 26,400 33,600 60,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000 2.3
USG 2D ( + hasil foto ) 44,000 56,000 100,000 66,000 84,000 150,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 57,200 72,800 130,000 35,200 44,800 80,000 35,200
2.4
USG 3D ( + hasil foto ) 132,000 168,000 300,000 165,000 210,000 375,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 132,000 2.5
USG 4D ( + hasil foto ) 132,000 168,000 300,000 165,000 210,000 375,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 132,000 2.6
Visum Kebidanan 44,000 56,000 100,000 66,000 84,000 150,000 26,400 33,600 60,000 26,400 33,600 60,000 30,800 39,200 70,000 66,000 84,000 150,000 88,000 112,000 200,000 44,000 56,000 100,000 -
I
RAWAT INAP
IGD/VK
VIP VVIP
BAGIAN OBSTETRI
GINEKOLOGI
Konsultasi Pasien Pulang
Pemeriksaan / Konsultasi
Bidan / Perawat
Konsultasi Gizi
2
NO JENIS TINDAKAN
Pemeriksaan / Konsultasi
/ Visite Dokter Spesialis
Diluar Hari/Jam Kerja
Pemeriksaan / Konsultasi
/ Visite Dokter Spesialis
Pemeriksaan / Konsultasi
Dokter Umum diluar
Hari/Jam Kerja
RAWAT JALAN RAWAT JALAN EXECUTIVE
III
STRUKTUR DAN BESARAN TARIF RUMAH SAKIT UMUM DAERAH MALINGPING
II
ICU/HCU
Pemeriksaan / Konsultasi
Dokter Gigi
Pemeriksaan / Konsultasi
Dokter Gigi diluar
Hari/Jam Kerja
Konsultasi Dokter
Spesialis Via Telepon
PEMERIKSAAN DAN KONSULTASI
Pemeriksaan / Konsultasi
Dokter Umum
Biopsi / Pengambilan
Jaringan
LAMPIRAN IIPERATURAN DAERAH PROVINSI BANTENNOMOR 1 TAHUN 2016 TENTANG RETRIBUSI PELAYANAN KESEHATAN
108
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
2.7
Manual Plasenta - - - - 88,000 112,000 200,000 96,800 123,200 220,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 88,000 112,000 200,000 88,000 2.8
Hidrotubasi 132,000 168,000 300,000 143,000 182,000 325,000 88,000 112,000 200,000 96,800 123,200 220,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 88,000 112,000 200,000 88,000 2.9
Kardiotokografi 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 11,000 2.10
Curatese di VK - - - - - - - - - - - - - - 264,000 336,000 600,000 - 2.11
- - - - - - - - - - - - - - 352,000 448,000 800,000 - 2.12
- - - - - - - - - - - - - - 528,000 672,000 1,200,000
-
2.13 44,000 56,000
100,000 52,800 67,200 120,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000 -
2.14
33,000 42,000 75,000 44,000 56,000 100,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 33,000 42,000 75,000
22,000 2.15
13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 26,400 33,600 60,000 35,200 44,800 80,000 13,200 16,800 30,000
- 2.16
44,000 56,000 100,000 52,800 67,200 120,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000
- 2.17
2,200 2,800 5,000 3,080 3,920 7,000 2,200 2,800 5,000 2,200 2,800 5,000 2,200 2,800 5,000 4,400 5,600 10,000 6,600 8,400 15,000 2,200 2,800 5,000 6,600 2.18
8,800 11,200 20,000 13,200 16,800 30,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 33,000 42,000 75,000 8,800 11,200 20,000 33,000 2.19
22,000 28,000 50,000 33,000 42,000 75,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 22,000 2.20
6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 7,040 8,960 16,000 11,000 14,000 25,000 15,400 19,600 35,000 17,600 22,400 40,000 6,600 8,400 15,000 8,800 2.21
22,000 28,000 50,000 26,400 33,600 60,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 22,000 28,000 50,000 22,000 2.22
inseminasi - - - - 220,000 280,000 500,000 330,000 420,000 750,000 440,000 560,000 1,000,000 660,000 840,000 1,500,000 880,000 1,120,000 2,000,000 - - -
2.23
jahit parinum 1-5 6,600 8,400 15,000 11,000 14,000 25,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 6,600 8,400 15,000 22,000 2.24
jahit parinum 6-10 8,800 11,200 20,000 15,400 19,600 35,000 11,000 14,000 25,000 8,800 11,200 20,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 8,800 11,200 20,000 26,400 2.25
jahit parinum 11-15 13,200 16,800 30,000 19,800 25,200 45,000 15,400 19,600 35,000 13,200 16,800 30,000 19,800 25,200 45,000 24,200 30,800 55,000 30,800 39,200 70,000 13,200 16,800 30,000 30,800 2.26
jahit parinum 15-20 17,600 22,400 40,000 24,200 30,800 55,000 19,800 25,200 45,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 17,600 22,400 40,000 35,200 2.27
22,880 29,120 52,000 29,480 37,520 67,000 25,080 31,920 57,000 22,880 29,120 52,000 29,480 37,520 67,000 33,880 43,120 77,000 40,480 51,520 92,000 22,880 29,120 52,000 40,480 2.28
konsultasi laktasi 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 2.29
4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 4,400 5,600 10,000 13,200 2.30
- - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 8,800 11,200 20,000 11,000 2.31
- - - - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 2.32
- - - - 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 2.33
22,000 28,000 50,000 33,000 42,000 75,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 22,000 28,000 50,000 - 2.34
8,800 11,200 20,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 8,800 11,200 20,000 13,200 2.35
6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 6,600 8,400 15,000 11,000 2.36
8,800 11,200 20,000 17,600 22,400 40,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 8,800 11,200 20,000 13,200 2.37
26,400 33,600 60,000 33,000 42,000 75,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 26,400 33,600 60,000 26,400 2.38
15,400 19,600 35,000 19,800 25,200 45,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 22,000 28,000 50,000 33,000 42,000 75,000 15,400 19,600 35,000 26,400 2.39
22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 28,600 36,400 65,000 30,800 2.40
15,400 19,600 35,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 22,000
observasi 1-6 jam
Persalinan Dengan
Penyulit Oleh Dokter
jahit perineum > 20 per
jahitan + 2.000
pasang implant
pasang iud
pasang laminaria
observasi 6-12 jam
observasi 12-24 jam
pap smear
pasang pessarium
pasang tampon
pasang folley cateter
cukur
dilatasi serviks
douglas punksi
genek (periksa dalam)
Persalinan Normal Oleh
Dokter
lepas drainage
buka implant
angkat iud
biopsi
bladder training
incisi himen impervorata
pasang balon cateter
untuk dilatasi serviks
109
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
2.41
- - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 22,000 2.42
- - - - 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 44,000 56,000 100,000 - 2.43
26,400 33,600 60,000 33,000 42,000 75,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 26,400 33,600 60,000 - 2.44
13,200 16,800 30,000 22,000 28,000 50,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 - 2.45
6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 - 2.46
- - - - 6,600 8,400 15,000 11,000 14,000 25,000 15,400 19,600 35,000 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 - 2.47
- - - - 44,000 56,000 100,000 77,000 98,000 175,000 132,000 168,000 300,000 198,000 252,000 450,000 264,000 336,000 600,000 198,000 252,000 450,000 -
2.48
- - - - 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 17,600 22,400 40,000 6,600 8,400 15,000 - 2.49
4,400 5,600 10,000 8,800 11,200 20,000 3,520 4,480 8,000 4,400 5,600 10,000 6,600 8,400 15,000 11,000 14,000 25,000 17,600 22,400 40,000 6,600 8,400 15,000 - 2.50
4,400 5,600 10,000 6,600 8,400 15,000 2,200 2,800 5,000 3,520 4,480 8,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 2,200 2,800 5,000 - 2.51
39,600 50,400 90,000 44,000 56,000 100,000 22,000 28,000 50,000 44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 132,000 168,000 300,000 39,600 50,400 90,000 39,600
2.52
22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000 2.53
- - - - 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 26,400 33,600 60,000 26,400 2.54
- - - - - - - - - - - - - - 44,000 56,000 100,000 - 2.55
- - - - - - - - - - - - - - 39,600 50,400 90,000 - 2.56
- - - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 6,600
Persalinan Normal - - - - - - - - - - - - - - - - - 2.57
- - - - 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 440,000 560,000 1,000,000 528,000 672,000 1,200,000 308,000 392,000 700,000 308,000
2.58
- - - - 220,000 280,000 500,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 264,000 336,000 600,000 -
2.59
- - - - 176,000 224,000 400,000 220,000 280,000 500,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 220,000 280,000 500,000 -
Persalinan Patologis - - - - - - - - - - - - - - - - - 4.1
- - - - 352,000 448,000 800,000 396,000 504,000 900,000 440,000 560,000 1,000,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 396,000 504,000 900,000 352,000
4.2
- - - - 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 440,000 560,000 1,000,000 308,000 392,000 700,000 -
4.3
- - - - 220,000 280,000 500,000 264,000 336,000 600,000 3,080,000 3,920,000 7,000,000 352,000 448,000 800,000 396,000 504,000 900,000 264,000 336,000 600,000 -
3 BAGIAN ANAK - - - - - - - - - - - - - - - - - 3.1
Resusitasi Bayi / Anak - - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 13,200 16,800 30,000 - 3.2
- - - - 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 17,600 22,400 40,000 - 3.3
Infus Intra Osteous - - - - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 -
4 BAGIAN BEDAH - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - 4.1
1-5 jahitan - - - - - - - - - - - - - - - - - - - - - 13 000 17,000 30,000 4.2
6-10 jahitan - - - - - - - - - - - - - - - - - - - - - 20,000 25,000 45,000 4.3
11-15 jahitan - - - - - - - - - - - - - - - - - - - - - 23,000 32,000 55,000 4.4
16-20 jahitan - - - - - - - - - - - - - - - - - - - - - 27,000 38,000 65,000 4.5
- - - - - - - - - - - - - - - - - - - - -
1500/
jahitan
2000/jah
itan
3500/jah
itan 4.6
Insisi kecil 28,600 36,400
65,000 33,000 42,000 75,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 28,600 36,400 65,000 -
visum kebidanan
Perawatan luka dengan
hecting
lebih dari 20
jahitan
tindik bayi
tutul abothyl
usg dengan klise
usg tanpa klise
pemeriksaan dengan ctg
pencabutan implant
usg trans vaginal
versi luar
perawatan luka
episiotomi
perawatan payudara
punksi amniotomi
tindakan doppler
tindakan hidrotubasi
vulva higiene
dokter spesialis
dokter umum
bidan
dokter spesialis
dokter umum
bidan
pasang tampon > 6 jam
Resusitasi Bayi Baru Lahir
110
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
4.7
Insisi sedang 33,000 42,000
75,000 37,400 47,600 85,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 33,000 42,000 75,000 - 4.8
Insisi besar 44,000 56,000 100,000 55,000 70,000 125,000
24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 44,000 56,000 100,000
- - - 4.9
- - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 - - -
4.10 - -
- - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000
66,000 84,000 150,000 88,000 112,000 200,000
- - - 4.11
Sirkumsisi 110,000 140,000 250,000 132,000 168,000 300,000 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 99,000 126,000 225,000 132,000 168,000 300,000 - - -
4.12
Ektirpasi kecil 55,000 70,000 125,000
59,400 75,600 135,000
30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 33,000 42,000 75,000 - 4.13
Ekstirpasi sedang 66,000 84,000 150,000
70,400 89,600 160,000
35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000
- - - 4.14
Ekstirpasi besar 74,800 95,200 170,000
79,200 100,800 180,000
44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 - -
- 4.15
Eksisi Fibroma 264,000 336,000 600,000 286,000 364,000 650,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 - - -
4.16 264,000 336,000 600,000 286,000 364,000 650,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 - - -
4.17
Open prostat - -
- - 880,000 1,120,000 2,000,000 1,100,000 1,400,000 2,500,000 1,320,000 1,680,000 3,000,000 1,540,000 1,960,000 3,500,000 1,760,000 2,240,000 4,000,000 - - -
4.18 66,000 84,000 150,000
77,000 98,000 175,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 72,600 92,400 165,000 - - -
4.19
77,000 98,000 175,000 88,000
112,000 200,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 72,600 92,400 165,000 77,000 98,000 175,000 - - -
4.20 48,400 61,600 110,000
52,800 67,200 120,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 30,800 39,200 70,000 -
4.21
66,000 84,000 150,000 70,400 89,600
160,000 33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 44,000 56,000 100,000 48,400 61,600 110,000 44,000 56,000 100,000 -
4.22
Angkat jahitan < 5 11,000 14,000
25,000 13,200 16,800 30,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 7,040 8,960 16,000 7,920 10,080 18,000 7,040 8,960 16,000 -
4.23 2000/
jahitan
2000/
jahitan 2000/
jahitan
2000/
jahitan
2000/
jahitan
2000/
jahitan 2000/ jahitan
2000/
jahitan -
4.24 66,000 84,000 150,000
77,000 98,000 175,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 30,800 39,200 70,000 -
4.25
Amputasi Jari 132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - 132,000 168,000 300,000 -
4.26
Dilatasi Pimosis 22,000 28,000 50,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 - 4.27
DC Shock - - - - 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 4.28
Eksisi Clavus 35,200 44,800 80,000 44,000 56,000 100,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 35,200 44,800 80,000 - 4.29
44,000 56,000 100,000 52,800 67,200 120,000 33,000 42,000 75,000 35,200 44,800 80,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 33,000 42,000 75,000 33,000 4.30
44,000 56,000 100,000 52,800 67,200 120,000 33,000 42,000 75,000 35,200 44,800 80,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 33,000 42,000 75,000 33,000 4.31
35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 30,800 39,200 70,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 35,200 44,800 80,000 - 4.32
66,000 84,000 150,000 88,000 112,000 200,000 44,000 56,000 100,000 44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 110,000 140,000 250,000 44,000 56,000 100,000 - 4.33
Eksisi Syiringoma 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 35,200 44,800 80,000 37,400 47,600 85,000 30,800 39,200 70,000 44,000 4.34
Eksisi Veruca Vulgaris 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 35,200 44,800 80,000 37,400 47,600 85,000 30,800 39,200 70,000 44,000 4.35
Eksplorasi Luka 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 24,200 30,800 55,000 11,000 14,000 25,000 11,000 4.36
Ekstraksi Batu Urethra 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000 4.37
22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000 4.38
Ekstraksi Kuku 26,400 33,600 60,000 35,200 44,800 80,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 - 4.39
66,000 84,000 150,000 74,800 95,200 170,000
52,800 67,200 120,000
55,000 70,000 125,000
66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 -
Perawatan luka gigitan
binatang ( ular ,
monyet,dll)
Pemasangan Collar neck
(termasuk alat)
Angkat jahitan > 5
Baougenasi punksi
kandung kemih
Pengangkatan aterom /
lipoma / ganglion
Reposisi,traksi,dislokasi
dengan spalk (anak)
Reposisi,traksi,dislokasi
dengan spalk (dewasa)
Perawatan luka gigitan
serangga
Eksisi Keloid Kecil > 5 cm
Eksisi Keloid Besar < 5 cm
Ekstraksi Corpus Alineum
Ekstrakpasi Kista Aterum
Eksisi Condiloma
Acuminata
Eksisi Granuloma
Piogenicum
Pemasangan kateter
anestesi
111
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
4.40
Ekstrakpasi Lipoma 66,000 84,000 150,000 74,800 95,200 170,000
52,800 67,200 120,000
55,000 70,000 125,000
66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 - 4.41
Ekstrakpasi Ganglion 66,000 84,000 150,000 74,800 95,200 170,000
52,800 67,200 120,000
55,000 70,000 125,000
66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 - 4.42
Ekstrakpasi Fibroma 110,000 140,000 250,000 132,000 168,000 300,000 88,000 112,000 200,000 101,200 128,800 230,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 110,000
4.43
123,200 156,800 280,000 132,000 168,000 300,000 110,000 140,000 250,000 118,800 151,200 270,000 123,200 156,800 280,000 132,000 168,000 300,000 154,000 196,000 350,000 123,200 156,800 280,000 -
4.44
123,200 156,800 280,000 132,000 168,000 300,000 110,000 140,000 250,000 118,800 151,200 270,000 123,200 156,800 280,000 132,000 168,000 300,000 154,000 196,000 350,000 123,200 156,800 280,000 -
4.45
Pasang Guedel 13,200 16,800 30,000 17,600 22,400 40,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200 4.46
Pasang WSD 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 121,000 154,000 275,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 132,000 168,000 300,000 132,000
4.47
4,400 5,600 10,000 6,600 8,400 15,000 3,520 4,480 8,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 4.48
Sirkumsisi 110,000 140,000 250,000 132,000 168,000 300,000 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 132,000
4.49
Blast Punksi 66,000 84,000 150,000
70,400 89,600 160,000
44,000 56,000 100,000
52,800 67,200 120,000
66,000 84,000 150,000 74,800 95,200 170,000 88,000 112,000 200,000 66,000 84,000 150,000 66,000 4.50
22,000 28,000 50,000 - - 17,600 22,400 40,000 22,000 28,000 50,000 22,000 28,000 50,000 30,800 39,200 70,000 35,200 44,800 80,000 22,000 28,000 50,000 22,000 4.51
- - - - - - - - - - - - - - 66,000 84,000 150,000 -
- - - - - - - - - - - - - - - - -
5 BAGIAN THT - - - - - - - - - - - - - - - - -
Tindakan Sederhana - - - - - - - - - - - - - - - - - 5.1
Tes Penala 6,600 8,400 15,000 8,800 11,200 20,000 6,600 8,400 15,000 6,600 8,400 15,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 - 5.2
15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 15,400 19,600 35,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 15,400 19,600 35,000 -
Tindakan Sedang - - - - - - - - - - - - - - - - - 5.3
44,000 56,000 100,000
52,800 67,200 120,000
22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 - - - 5.4
22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.5
Irigasi Telinga / Hidung 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.6
Kaustik Hidung 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.7
Kaustik Tenggorok 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.8
17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 - - -
Tindakan Khusus - - - - - - - - - - - - - - - - - 5.9
6,600 8,400 15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 5.10
Audiogram 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 39,600 50,400 90,000 - - - 5.11
Biopsi Cavum Nasi 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - - 5.12
Biopsi Nasofaring 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - - 5.13
Biopsi Orofaring 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - - 5.14
33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 - 5.15
33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 - 5.16
Ekstraksi Benda Asing 33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 - 5.17
Gips Telinga 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - - 5.18
Insisi Abses Mastoid 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - - 5.19
Insisi Abses Peritonsil 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
Angkat Jaringan Granulasi
di Telinga
Angkat/Pasang Tampon
Hidung
Pasang Drain
Handscoen/kasa
Ekstraksi Serumen
Profunda / Toilet
Visum Mayat (Periksa
Luar)
Insisi Pseudokista dg
Pemasangan Verban Tekan
Punksi Pseudokista Daun
Telinga
Injeksi Varises (tidak
termasuk obat)
Visum et repertum (korban
hidup)
Injeksi Hemoroid (tidak
termasuk obat)
Ekstraksi Post Aurikular
Kista
Ekstraksi Pre Aurikular
Kista
112
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
5.20
57,200 72,800 130,000 66,000 84,000 150,000 39,600 50,400 90,000 44,000 56,000 100,000
48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 - - - 5.21
Insisi Septum Nasi 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.22
Irigasi Sinus Maksila 55,000 70,000 125,000 66,000 84,000 150,000
39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 - - - 5.23
Parasintese 22,000 28,000 50,000 26,400 33,600 60,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - - 5.24
17,600 22,400 40,000 22,000 28,000 50,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - - 5.25
Rhinoscope Posterior 11,000 14,000 25,000 15,400 19,600 35,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 12,320 15,680 28,000 15,400 19,600 35,000 - - - 5.26
Suction Telinga (OMP) 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,920 10,080 18,000 11,000 14,000 25,000 - - - 5.27
39,600 50,400 90,000 44,000 56,000 100,000
30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 44,000 56,000 100,000 - - - 5.28
Up Hecting 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,920 10,080 18,000 11,000 14,000 25,000 6,600 8,400 15,000 -
- - - - - - - - - - - - - - - - -
6 BAGIAN MATA - - - - - - - - - - - - - - - - -
Tindakan Sederhana - - - - - - - - - - - - - - - - - 6.1
Atropinisasi 4,400 5,600 10,000 6,600 8,400 15,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 - 6.2
Epilasi 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 - - - 6.3
22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 - 6.4
22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 - 6.5
Keratometri 39,600 50,400 90,000 44,000 56,000 100,000
35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 48,400 61,600 110,000 55,000 70,000 125,000 - - - 6.6
Koreksi Refraksi 8,800 11,200 20,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 - - - 6.7
6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 11,000 14,000 25,000 - 6.8
6,600 8,400 15,000 11,000 14,000 25,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 - - - 6.9
4,400 5,600 10,000 6,600 8,400 15,000 3,520 4,480 8,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 - 6.10
Slit Lamp 11,000 14,000 25,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 - - -
- - - - - - - - - - - - - - - - -
Tindakan Sedang - - - - - - - - - - - - - - - - - 6.11
22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.12
39,600 50,400 90,000 44,000 56,000 100,000
35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000
55,000 70,000 125,000 66,000 84,000 150,000 - - - 6.13
15,400 19,600 35,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.14
19,800 25,200 45,000 26,400 33,600 60,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.15
22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.16
Refraktometri 22,000 28,000 50,000 26,400 33,600 60,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 28,600 36,400 65,000 44,000 56,000 100,000 - - - 6.17
Strikretinoskopi 19,800 25,200 45,000 26,400 33,600 60,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 - - - 6.18
17,600 22,400 40,000 22,000 28,000 50,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 - - -
- - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - 6.19
Ekstirpasi Gram/Kornea 39,600 50,400 90,000 44,000 56,000 100,000
22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 - - -
Pemeriksaan Pantocain,
Antibiotik, Verband
Pemeriksaan Tonometri
Pemeriksaan Fundus Kopi
Indireksi
Perawatan
Epistaksis/Tampon Bagian
Depan
Tampon Hidung Bagian
Belakang (Belloque
Tampon)
Irigasi Auqades Pada
Konjungtiva
anal test
Penetesan Mediatrika
Efrisell
Ekstirpasi Corpus
Aleneum Ekstra Okuler
Fluerosin Test
Irigasi Auqades Pada
Trauma Kimia
Suntikan Sub Konjungtiva
Tindakan Sedang dengan
Lokal Anestesi
Pengangkatan Jahitan di
Konjungtiva, Kornea dan
Sklera
Insisi Abses Sub
Mandibula
113
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
6.20
44,000 56,000 100,000
52,800 67,200 120,000
30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - - 6.21
Ekstirpasi Litiasis 44,000 56,000 100,000
52,800 67,200 120,000
30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - - 6.22
Ekstirpasi Ptegrium 55,000 70,000 125,000
66,000 84,000 150,000
39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 46,200 58,800 105,000 48,400 61,600 110,000 - - - 6.23
39,600 50,400 90,000
48,400 61,600 110,000
39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 46,200 58,800 105,000 48,400 61,600 110,000 - - - 6.24
Insisi Abses 66,000 84,000 150,000
77,000 98,000 175,000
39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000 - 6.25
Insisi Hordeolum 33,000 42,000 75,000
44,000 56,000 100,000
22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 35,200 44,800 80,000 - 6.26
37,400 47,600 85,000
48,400 61,600 110,000
22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 - - - 6.27
Jahitan Kurang dari 2 cm 33,000 42,000 75,000
44,000 56,000 100,000
22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 35,200 44,800 80,000 - - - 6.28
Biometri 33,000 42,000 75,000
44,000 56,000 100,000
22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 35,200 44,800 80,000 - - -
#REF!
6.29
USG A Scan ( Organ Mata ) 44,000 56,000 100,000
55,000 70,000 125,000
30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 44,000 56,000 100,000 - - -
- - - - - - - - - - - - - - - - -
7 - - - - - - - - - - - - - - - - - 7.1
Pencabutan Gigi dengan Flap 55,000 70,000 125,000 66,000 84,000 150,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 - - -
7.2 55,000 70,000 125,000 66,000 84,000 150,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 - - -
7.3 88,000 112,000 200,000 101,200 128,800 230,000 57,200 72,800 130,000 66,000 84,000 150,000 74,800 95,200 170,000 83,600 106,400 190,000 99,000 126,000 225,000 - - -
7.4
Insisi Plegmon 81,400 103,600 185,000 88,000 112,000 200,000 66,000 84,000 150,000 70,400 89,600 160,000 74,800 95,200 170,000 79,200 100,800 180,000 83,600 106,400 190,000 - - -
7.5 88,000 112,000 200,000 110,000 140,000 250,000 66,000 84,000 150,000 68,200 86,800 155,000 70,400 89,600 160,000 72,600 92,400 165,000 79,200 100,800 180,000 - - -
7.6
Alveolectomi / Regio 176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -
7.7
Operculectomi 176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -
7.8
Gingivectomi 176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -
7.9
OD M3 IMP KLI 264,000 336,000 600,000 308,000 392,000 700,000 198,000 252,000 450,000 242,000 308,000 550,000 286,000 364,000 650,000 330,000 420,000 750,000 396,000 504,000 900,000 - - -
7.10
OD M3 IMP KLI II 352,000 448,000 800,000 396,000 504,000 900,000 330,000 420,000 750,000 374,000 476,000 850,000 440,000 560,000 1,000,000 484,000 616,000 1,100,000 528,000 672,000 1,200,000 - - -
7.11 176,000 224,000 400,000 198,000 252,000 450,000 88,000 112,000 200,000 110,000 140,000 250,000 154,000 196,000 350,000 176,000 224,000 400,000 330,000 420,000 750,000 - - -
7.12
Apex Reseksi 220,000 280,000 500,000 264,000 336,000 600,000 202,400 257,600 460,000 220,000 280,000 500,000 242,000 308,000 550,000 264,000 336,000 600,000 330,000 420,000 750,000 - - -
7.13
Windowing 110,000 140,000 250,000 154,000 196,000 350,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 220,000 280,000 500,000 - - -
7.14 88,000 112,000 200,000 110,000 140,000 250,000 66,000 84,000 150,000 77,000 98,000 175,000 83,600 106,400 190,000 92,400 117,600 210,000 110,000 140,000 250,000 - - -
7.15
Debridement Berat 253,000 322,000 575,000 264,000 336,000 600,000 176,000 224,000 400,000 264,000 336,000 600,000 352,000 448,000 800,000 528,000 672,000 1,200,000 616,000 784,000 1,400,000 - - -
7.16 330,000 420,000 750,000 352,000 448,000 800,000 198,000 252,000 450,000 242,000 308,000 550,000 286,000 364,000 650,000 330,000 420,000 750,000 440,000 560,000 1,000,000 - - -
7.17 374,000 476,000 850,000 396,000 504,000 900,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 484,000 616,000 1,100,000 - - -
7.18 374,000 476,000 850,000 396,000 504,000 900,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 484,000 616,000 1,100,000 - - -
7.19 55,000 70,000 125,000 66,000 84,000 150,000 44,000 56,000 100,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 70,400 89,600 160,000 - - -
#REF!
7.20 2,640,000 3,360,000 6,000,000 3,080,000 3,920,000 7,000,000 1,980,000 2,520,000 4,500,000 2,640,000 3,360,000 6,000,000 3,080,000 3,920,000 7,000,000 3,520,000 4,480,000 8,000,000 3,960,000 5,040,000 9,000,000 - - -
- - - - - - - - - - - - - - - - -
8 - - - - - - - - - - - - - - - - -
Ekstirpasi Granulasi Tanpa
Jahit
Buka Jahitan / Angkat
Jahitan ( Bedah Mulut )
BAGIAN GIGI DAN
MULUT
Implant Dental Titanium 1
Unit
Insisi Abses ( Bedah Mulut
)
Ekstirpasi Veruca Nevus
Palpebra
Insisi Khalazion dengan
Kuretase
Insisi Biopsi Intra Oral
dengan Bius Lokal
Eksisi Tumor Jinak /
Ekstripsi Epulis ? Ekstra
Oral
Reposisi Dislokasi Tmj
Secara Manual
Reposisi Fiksasi dengan
Arch Bar ( 1 Rahang )
Reposisi Fiksasi dengan
Arch Bar ( RA / RB )
Debridement Ringan /
Sedang
Enukleasi Kista Kecil /
Sedang / besar
BAGIAN BEDAH
MULUT
114
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
Penambahan - - - - - - - - - - - - - - - - -
8.1Fuji 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
8.2Sinar 55,000 70,000 125,000 66,000 84,000 150,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 77,000 98,000 175,000 88,000 112,000 200,000 - - -
8.3Scalling 77,000 98,000 175,000 88,000 112,000 200,000 44,000 56,000 100,000 52,800 67,200 120,000 61,600 78,400 140,000 110,000 140,000 250,000 154,000 196,000 350,000 - - -
- - - - - - - - - - - - - - - - -
Pengobatan - - - - - - - - - - - - - - - - -
8.4Pengisian Saluran Akar 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
8.5Tambal Sementara 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
- - - - - - - - - - - - - - - - -
Pencabutan - - - - - - - - - - - - - - - - -
8.6
Curretage Per Regio 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
8.7
Gigi Tetap 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
8.8 44,000 56,000 100,000 48,400 61,600 110,000 33,000 42,000 75,000 39,600 50,400 90,000 48,400 61,600 110,000 57,200 72,800 130,000 66,000 84,000 150,000 - - -
8.9
Gigi Susu dengan Suntik 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -
8.10
Gigi Susu tanpa Suntik 19,800 25,200 45,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 17,600 22,400 40,000 -
8.11
Insisi abses/intr oral 26,400 33,600
60000 33,000 42,000 75000 22,000 28,000 50000 24,200 30,800 55000 26,400 33,600 60000 28,600 36,400 65000 33,000 42,000 75,000 - - -
Orthodonty - -
- - - - - - - - - - - - - - - 8.12
198,000 252,000 450000 220,000 280,000 500000 110,000 140,000 250000 132,000 168,000 300000 154,000 196,000 350000 176,000 224,000 400000 220,000 280,000 500,000 - - -
8.13
Control Orto Lepas 22,000 28,000 50000 26,400 33,600 60000 - - - - - - - - - - - - -
Prothesa - - - - - - - - - - - - - - - - -
8.14
Plat + 1 Elemen 110,000 140,000 250,000 132,000 168,000 300,000 77,000 98,000 175,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 220,000 280,000 500,000 - - -
8.15 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 - - -
8.16
Full Denture 660,000 840,000 1,500,000 770,000 980,000 1,750,000 440,000 560,000 1,000,000 484,000 616,000 1,100,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 660,000 840,000 1,500,000 - - -
8.17
Rebasing ( Per rahang ) 110,000 140,000 250,000 132,000 168,000 300,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 275,000 350,000 625,000 385,000 490,000 875,000 - - -
8.18
Reparasi 88,000 112,000 200,000 110,000 140,000 250,000 88,000 112,000 200,000 105,600 134,400 240,000 123,200 156,800 280,000 220,000 280,000 500,000 308,000 392,000 700,000 - - -
Fix Protesa - - - - - - - - - - - - - - - - -
8.19
Jaket crown Acrilic 154,000 196,000 350,000 176,000 224,000 400,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 220,000 280,000 500,000 - - -
8.20 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 264,000 336,000 600,000 - - -
8.21
Jaket Crown Porselen 264,000 336,000 600,000 308,000 392,000 700,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 242,000 308,000 550,000 264,000 336,000 600,000 - - -
Fixed Ortodonty - - - - - - - - - - - - - - - - -
8.22
Perahang 770,000 980,000
1,750,000 836,000 1,064,000 1,900,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 616,000 784,000 1,400,000 660,000 840,000 1,500,000 704,000 896,000 1,600,000 - - -
8.23
Rahang atas + bawah 1,100,000 1,400,000
2,500,000 1,144,000 1,456,000 2,600,000 1,012,000 1,288,000 2,300,000 1,056,000 1,344,000 2,400,000 1,100,000 1,400,000 2,500,000 1,144,000 1,456,000 2,600,000 1,188,000 1,512,000 2,700,000 - - -
9 BAGIAN PSIKIATRI - - - - - - - - - - - - - - - - -
9.1Psikoterapi > 30 menit 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - -
9.2Psikoterapi < 30 menit 19,800 25,200 45,000 26,400 33,600 60,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - -
9.3Psikometri Sedang 39,600 50,400 90,000 44,000 56,000 100,000 33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 46,200 58,800 105,000 52,800 67,200 120,000 - - -
9.4Psikometri Komplek 88,000 112,000 200,000 110,000 140,000 250,000 70,400 89,600 160,000 74,800 95,200 170,000 79,200 100,800 180,000 83,600 106,400 190,000 88,000 112,000 200,000 - - -
Jaket crown Acrilic
Backing Metal
Ortho lepas kasus berat
perahang
Penambalan PerElemen
Gigi
Gigi Tetap dengan Jahitan
/ Komplikasi
115
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
10
- - - - - - - - - - - - - - - - -
10.1 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 22,000 28,000 50,000 -
10.2
- - 66,000 84,000 150,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - 39,600
10.3
- - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 - - 110,000
10.4
Lepas Selang WSD - - - - 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 33,000 42,000 75,000 -
10.5 154,000 196,000 350,000 176,000 224,000 400,000 70,400 89,600 160,000 77,000 98,000 175,000 83,600 106,400 190,000 92,400 117,600 210,000 110,000 140,000 250,000 - - 83,600
10.6 17,600 22,400 40,000 26,400 33,600 60,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 30,800 39,200 70,000 - - 19,800
10.7
Pleurodesis - - - - 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 - - 88,000
10.8
Pasang Continous Suction - - - - 44,000 56,000 100,000 52,800 67,200 120,000 61,600 78,400 140,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000
10.9
Pasang Drain Suction - - - - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 - - 44,000
10.10
Reposisi Selang WSD - - - - 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000
10.11
Spirometri 66,000 84,000 150,000 70,400 89,600 160,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - 39,600
10.12
Thoracostomi (WSD) - - - - 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 - - 154,000
10.13
Endotracheal Tube (ETT) - - - - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 - - 44,000
10.14 - - - - 44,000 56,000 100,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000
10.15 - - - - 44,000 56,000 100,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000
10.16
Needle Decompresi - - - - - - - - - - - - - - 66,000 84,000 150,000 -
10.17
Vena Sectie - - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 88,000 112,000 200,000 88,000
10.18
Peak Flow Rate 33,000 42,000 75,000 39,600 50,400 90,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 26,400
10.19
Infus Intra Osteous 35,200 44,800 80,000 39,600 50,400 90,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 39,600 50,400 90,000 37,400 47,600 85,000 37,400
10.20 - - - - 6,600 8,400 15,000 7,920 10,080 18,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 11,000 14,000 25,000 11,000
10.21
Pemasangan Ventilator - - - - - - - - - - - - - - - - 55,000
10.22 - - - - - - - - - - - - - - - - 44,000
10.23 - - - - - - - - - - - - - - - - 308,000
10.24 - - - - - - - - - - - - - - - 22,000
11 HEMODIALISA - - - - - - - - - - - - - - - - -
11.1HEMODIALISA 330,000 420,000 750,000 - - 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000
12
- - - - - - - - - - - - - - - - -
12.1
Angkat Wire 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 30,800
12.2 44,000 56,000 100,000 48,400 61,600 110,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 66,000 84,000 150,000 - - -
12.3
Aspirasi Kista 44,000 56,000 100,000 48,400 61,600 110,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 66,000 84,000 150,000 - - 44,000
12.4
BMD 22,000 28,000 50,000 33,000 42,000 75,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - 35,200
12.5
Ganglion 55,000 70,000
125,000 57,200 72,800 130,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 52,800 67,200 120,000 52,800
Pemasangan CVP /
Perawatan
Pemasangan Monitor ECG
/ Hari
Biopsi Pleura /
Transthoracal Needle
Biopsi (Blind)
Punksi Pleura
(Thoracocentesis)
Punksi Percobaan ("Proef
Punctie")
Punksi Ascites (Diluar
Bahan Dan Alat)
Punksi Sendi (Diluar
Bahan Dan Alat)
Angkat Wire Dengan
Jahitan
Pemasangan Kateter
Double Lumen
BAGIAN PENYAKIT
DALAM DAN PARU
Biopsi Kelanjer Leher /
Biopsi Jarum Halus KGB
Angkat Jahitan Post WSD
Perawatan Ventilator/Hari
BAGIAN ORTHOPEDI
116
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
12.6
44,000 56,000 100,000 48,400 61,600 110,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - 44,000
12.7
55,000 70,000 125,000 57,200 72,800 130,000 48,400 61,600 110,000 55,000 70,000 125,000 61,600 78,400 140,000 70,400 89,600 160,000 77,000 98,000 175,000 - - -
12.8
39,600 50,400 90,000 44,000 56,000 100,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
12.9
77,000 98,000 175,000 81,400 103,600 185,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 70,400 89,600 160,000 - - -
12.10
55,000 70,000 125,000 59,400 75,600 135,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - -
12.11
99,000 126,000 225,000 110,000 140,000 250,000 88,000 112,000 200,000 96,800 123,200 220,000 105,600 134,400 240,000 114,400 145,600 260,000 123,200 156,800 280,000 - - -
12.12
44,000 56,000 100,000 48,400 61,600 110,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - -
12.13
55,000 70,000 125,000 59,400 75,600 135,000 41,800 53,200 95,000 46,200 58,800 105,000 50,600 64,400 115,000 55,000 70,000 125,000 66,000 84,000 150,000 - - -
12.14
39,600 50,400 90,000 4,400 5,600 10,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - -
12.15 55,000 70,000 125,000 59,400 75,600 135,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 - - -
12.16 99,000 126,000 225,000 110,000 140,000 250,000 79,200 100,800 180,000 83,600 106,400 190,000 88,000 112,000 200,000 92,400 117,600 210,000 96,800 123,200 220,000 - - -
12.17
Punksi Abses 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 - - -
12.18
Pasang Skin Traksi 154,000 196,000 350,000 176,000 224,000 400,000 92,400 117,600 210,000 96,800 123,200 220,000 101,200 128,800 230,000 105,600 134,400 240,000 110,000 140,000 250,000 - - -
12.19
Pasang Ransel Verband 35,200 44,800 80,000 39,600 50,400 90,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -
- - - - - - - - - - - - - - - - -
13 BAGIAN SYARAF - - - - - - - - - - - - - - - - -
13.1
Lumbal Punksi - - - - 39,600 50,400 90,000 52,800 67,200 120,000 66,000 84,000 150,000 79,200 100,800 180,000 88,000 112,000 200,000 - - 66,000
13.2 - - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 - - 132,000
13.3 88,000 112,000 200,000 110,000 140,000 250,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 70,400 89,600 160,000 - - 66,000
13.4 66,000 84,000 150,000 70,400 89,600 160,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - 48,400
13.5
EEG 66,000 84,000 150,000 77,000 98,000 175,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 74,800 95,200 170,000 - - 63,800
13.6
Carotid Doppler 66,000 84,000 150,000 77,000 98,000 175,000 57,200 72,800 130,000 63,800 81,200 145,000 70,400 89,600 160,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000
13.7
Vascular Doppler 66,000 84,000 150,000 77,000 98,000 175,000 57,200 72,800 130,000 63,800 81,200 145,000 70,400 89,600 160,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000
14 - - - - - - - - - - - - - - - - -
14.1
Aspirasi Kista 33,000 42,000 75,000 44,000 56,000 100,000 - - - - - - - - - - - - -
14.2
Biopsi / Eksisi Wajah 132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - - - -
14.3 110,000 140,000 250,000 132,000 168,000 300,000 - - - - - - - - - - - - -
14.4
Chlorethyl Spray 66,000 84,000 150,000 88,000 112,000 200,000 - - - - - - - - - - - - -
14.5
Dermabrasi 110,000 140,000 250,000 132,000 168,000 300,000 - - - - - - - - - - - - -
14.6 22,000 28,000 50,000 26,400 33,600 60,000 - - - - - - - - - - - - -
Skrining Amnestia
Traumatic Brain Injury
Elektro Desikasi Keratosis
Injeksi Dequarvain (Diluar
Bahan Dan Alat)
Injeksi Carpal Tunnel
Syndrome (Diluar Bahan
Dan Alat)
Injeksi Keloid (Diluar
Bahan Dan Alat)
Punksi Sum-Sum Tulang
(BMP)
Skrining Fungsi Luhur
(Untuk Pasien Umum)
Injeksi Trigger Finger 2 Jari
(Diluar Bahan Dan Alat)
Injeksi Trigger Thumb 1
Jari (Diluar Bahan Dan
Alat)
Injeksi Trigger Thumb 2
Jari (Diluar Bahan Dan
Alat)
Injeksi Intra Artikuler 1
Knee (Diluar Bahan dan
Alat)
Injeksi Intra Artikuler 2
Knee (Diluar Bahan dan
Alat)
Injeksi Trigger Finger 1 Jari
(Diluar Bahan Dan Alat)
BAGIAN KULIT DAN
KELAMIN
Punksi / Aspirasi 1 Lutut
Biopsi / Eksisi Non Wajah
Punksi / Aspirasi 2 Lutut
117
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
14.7
110,000 140,000 250,000 154,000 196,000 350,000 - - - - - - - - - - - - -
14.8
154,000 196,000 350,000 176,000 224,000 400,000 - - - - - - - - - - - - -
14.9 132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - - - -
14.10
125,400 159,600 285,000 154,000 196,000 350,000 - - - - - - - - - - - - -
14.11
176,000 224,000 400,000 198,000 252,000 450,000 - - - - - - - - - - - - -
14.12
Enukleasi Komedo 44,000 56,000 100,000 52,800 67,200 120,000 - - - - - - - - - - - - -
14.13 66,000 84,000 150,000 77,000 98,000 175,000 - - - - - - - - - - - - -
14.14
Elektrokauter Wajah 116,600 148,400 265,000 132,000 168,000 300,000 - - - - - - - - - - - - -
14.15 88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -
14.16
Facial Care / Skin Care 33,000 42,000 75,000 44,000 56,000 100,000 - - - - - - - - - - - - -
14.17
Insisi Abses Banal 66,000 84,000 150,000 77,000 98,000 175,000 - - - - - - - - - - - - -
14.18 24,200 30,800 55,000 28,600 36,400 65,000 - - - - - - - - - - - - -
14.19
Injeksi Kenacort 77,000 98,000 175,000 79,200 100,800 180,000 - - - - - - - - - - - - -
14.20
Perawatan Luka 8,800 11,200 20,000 13,200 16,800 30,000 - - - - - - - - - - - - -
14.21
Prick Test 88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -
14.22
Patch Test 88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -
14.23
Peeling Oleh Dokter 44,000 56,000 100,000 55,000 70,000 125,000 - - - - - - - - - - - - -
14.24
Peeling Oleh Perawat 22,000 28,000 50,000 26,400 33,600 60,000 - - - - - - - - - - - - -
14.25 44,000 56,000 100,000 55,000 70,000 125,000 - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - -
15 TINDAKAN KEPERAWATAN - - - - - - - - - - - - - - - - -
15.1
Bilas Lambung - - - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 17,600 22,400 40,000 13,200
15.2
Blue Light Per Hari - -
- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 13,200 16,800 30,000 13,200 15.3
4,400 5,600 10,000 8,800 11,200 20,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
15.4 11,000 14,000
25,000 15,400 19,600 35,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 9,680 12,320 22,000 9,680 15.5
Buka Gips (Long) 39,600 50,400
90,000 44,000 56,000 100,000
22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 - 15.6
Buka Gips (Short) 35,200 44,800
80,000 37,400 47,600 85,000
19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 39,600 50,400 90,000 28,600 36,400 65,000 - 15.7
Buka Gips Berat 66,000 84,000 150,000
70,400 89,600 160,000
33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 46,200 58,800 105,000 55,000 70,000 125,000 44,000 56,000 100,000 - 15.8
Buka Gips Ringan 55,000 70,000 125,000
61,600 78,400 140,000
26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 39,600 50,400 90,000 - 15.9
Buka Infus - -
- - 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 15.10
Buka Jendela Gips 48,400 61,600 110,000
52,800 67,200 120,000
35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 39,600 50,400 90,000 - 15.11
Buka Kateter 6,600 8,400
15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.12
Buka NGT - -
- - 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 7,480 9,520 17,000 8,800 11,200 20,000 6,600 8,400 15,000 6,600
Elektro Desikasi Melasma
Fleseboroik & Keratosis
Elektrokauterisasi Verucca
Vulgaris, Veruca Plana
Ekstirpasi Clavus, Nevus
Pada Wajah
Elektrokauterisasi
Syiringoma Trichocolium
Elektrokauter Non Wajah
Test Penisilin Dan Procain
Ekstirpasi Fibroma Molle,
Granuloma Pyogenikum
Ekstirpasi Total Tumor
Jinak Non Muka
Injeksi Varices (Diluar
Bahan Dan Obat)
Buka Drain Handscoen /
Kassa
Buka Drain Tube / Suction
118
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
15.13
Buka Spalk 6,600 8,400
15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.14
Buka WSD - -
- - 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 30,800 15.15
EKG 22,000 28,000
50,000 26,400 33,600 60,000 11,000 14,000 25,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800 15.16
22,000 28,000 50,000 26,400 33,600 60,000 11,000 14,000 25,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800
15.17
Ganti Verban 13,200 16,800
30,000 17,600 22,400 40,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200 15.18
Gliserin Spuit - -
- - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.19
8,800 11,200 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.20 8,800 11,200
20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800 15.21
8,800 11,200 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.22 8,800 11,200
20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800 15.23
8,800 11,200 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800
15.24 - -
- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 - - 13,200 15.25
Klisma / Lavamen - -
- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000 15.26
33,000 42,000 75,000 37,400 47,600 85,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 35,200
15.27
Nebulizer/Hari 22,000 28,000
50,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 11,000 14,000 25,000 11,000 15.28
Necrotomi 33,000 42,000
75,000 35,200 44,800 80,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 - 15.29
- - - - 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 -
15.30
Pasang Cerobong Angin - -
- - 4,400 5,600 10,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 13,200 15.31
44,000 56,000 100,000 48,400 61,600 110,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 44,000 56,000 100,000 33,000 42,000 75,000 28,600
15.32
Pasang Gips (Short) 35,200 44,800
80,000 39,600 50,400 90,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 22,000 28,000 50,000 19,800 15.33
Pasang Infus Anak - -
- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 8,800 15.34
Pasang Infus Bayi - -
- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 15.35
Pasang Infus Dewasa - -
- - 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 15.36
Pasang Kateter Folley - -
- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 11,880 15,120 27,000 13,200 16,800 30,000 11,000 14,000 25,000 8,800 15.37
Pasang Kateter Kondom - -
- - 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 8,800 11,200 20,000 6,600 15.38
Pasang NGT - -
- - 6,600 8,400 15,000 8,800 11,200 20,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 8,800 11,200 20,000 8,800 15.39
Pasang NGT Pessarium - -
- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 15.40
Pasang Spalk 22,000 28,000
50,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200 15.41
Pasang Tampon Luka 6,600 8,400
15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000 15.42
Pasang Tampon Vagina 8,800 11,200
20,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200 15.43
1,320 1,680 3,000 1,760 2,240 4,000 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 4,400
15.44 - -
- - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.45
- - - - 2,200 2,800 5,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 4,400
15.46 6,600 8,400
15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 6,600 8,400 15,000 6,600
Pasang Gips (Long)
termasuk dan bahan
Pemberian Obat Melalui
NGT. OGT/Kali
Pemeriksaan Kehamilan
Dengan Doppler
Imunisasi Campak (Diluar
Obat)
Imunisasi Hepatitis B
(Diluar Obat)
Kateterisasi vena
Umbilikalis
Mantoux Test (Dengan
Obat)
Observasi Khusus Pada
Pasien Post Op. BPH
Imunisasi Polio (Diluar
Obat)
Ganti Balutan + Perawatan
Luka / Hari
Pemberian Obat
IM,SC/Kali
Imunisasi BCG (Diluar
Obat)
Imunisasi DPT (Diluar
Obat)
Pemberian Supositori/Kali
119
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
15.47 - -
- - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200 15.48
- - - - 4,400 5,600 10,000 6,600 8,400 15,000 7,480 9,520 17,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600
15.49 - -
- - 6,600 8,400 15,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 9,680 12,320 22,000 9,680 15.50
- - - - 6,600 8,400 15,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200
15.51 33,000 42,000
75,000 37,400 47,600 85,000 19,800 25,200 45,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 26,400 33,600 60,000 22,000 15.52
Perawatan Jenazah - -
- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000 15.53
- - - - 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 28,600 36,400 65,000 28,600
15.54 - -
- - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 17,600 22,400 40,000 17,600 15.55
- - - - 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000
15.56 6,600 8,400
15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000 15.57
- - - - 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000
15.58 - -
- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 15.59
- - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 15,400
15.60 6,600 8,400
15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000 15.61
Perawatan Tali Pusat - -
- - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.62
8,800 11,200 20,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 -
15.63
Repair Perineum - -
- - 38,720 49,280 88,000 46,200 58,800 105,000 52,800 67,200 120,000 96,800 123,200 220,000 135,520 172,480 308,000
- - 96,800 15.64
Spooling Infus/hari - -
- - 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,480 9,520 17,000 4,400 5,600 10,000 4,400 15.65
Spooling Kateter/hari - -
- - 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,480 9,520 17,000 4,400 5,600 10,000 4,400 15.66
Suctioning/hari - -
- - 6,600 8,400 15,000 7,920 10,080 18,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 9,680 12,320 22,000 9,680 15.67
Suntik Insulin/Kali - -
- - 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 4,400 5,600 10,000 4,400 15.68
Tes Buta Warna 8,800 11,200
20,000 13,200 16,800 30,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 7,480 9,520 17,000 8,800 11,200 20,000 5,280 6,720 12,000 - 15.69
Ganti Veerboden/sprei - -
- - 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 - - 3,080 15.70
Mobilisasi Pasien - -
- - 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 - - 3,080
16 - - - - - - - - - - -
Tindakan dengan elektropterapi -
- - - - - - - - - - 16.1
microwave diathermi 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.2
ultra sound 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.3
elecktrikal stimulasi 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.4
traksi cervikal/lumbal 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.5
ultraviolet lamp 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.6
infra lamp 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.7
whirl pool 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.8
hot pack 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
Pelayanan fisioterapi
Perawatan Luka Operasi
Besar / Hari
Perawatan Luka Operasi
Kecil / Hari
Perawatan Luka Operasi
Sedang / Hari
Perawatan Payudara
Bermasalah
Perawatan Normal Oeh
Bidan
Pengambilan Darah Vena (
SST )
Pengambilan Darah Vena (
SST + EDTA )
Perawatan Luka Bakar
Besar ( > 50% )
Perawatan Luka Bakar
Kecil (< 30% )
Perawatan Luka Bakar
Sedang ( 30 - 50 % )
Pengambilan Darah Vena (
Vac + EDTA )
Pengambilan Darah Arteri
Perawatan Luka
Episiotomi
Perawatan Fraktur
Terbuka
120
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
16.9
nebuliser 15,400 19,600
35,000 17,600 22,400 40,000 8,800 11,200 20,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 16.10
parafin bath 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
- - - - - - - - - - - - - -
16.11
terapi manipulasi 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.12
massage 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.13
latihan anggota gerak 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.14
latihan pernafasan 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.15
latihan pola hidup sehari-hari 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.16
latihann kekuatan otot 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.17
senam asam 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.18
senam stroke 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.19
senam hamil 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.20
senam nifas 8,800 11,200
20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000
17 Pelayanan tindakan bedah- - - - - - - - - -
- - - - - - - - - -
17.1operasi kecil 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 121,000 154,000 275,000 132,000 168,000 300,000
17.2operasi kecil dengan narkose 352,000 448,000 800,000 462,000 588,000 1,050,000 792,000 1,008,000 1,800,000 968,000 1,232,000 2,200,000 1,188,000 1,512,000 2,700,000
17.3operasi sedang 704,000 896,000 1,600,000 792,000 1,008,000 1,800,000 1,364,000 1,736,000 3,100,000 1,628,000 2,072,000 3,700,000 2,068,000 2,632,000 4,700,000
17.4operasi besar 1,540,000 1,960,000 3,500,000 1,980,000 2,520,000 4,500,000 2,112,000 2,688,000 4,800,000 3,080,000 3,920,000 7,000,000 3,520,000 4,480,000 8,000,000
17.5operasi besar khusus 1,980,000 2,520,000 4,500,000 2,420,000 3,080,000 5,500,000 2,552,000 3,248,000 5,800,000 2,948,000 3,752,000 6,700,000 3,828,000 4,872,000 8,700,000
- - - - - - - - - - 17.6
operasi kecil 132,000 168,000 300,000 143,000 182,000 325,000 154,000 196,000 350,000 165,000 210,000 375,000 176,000 224,000 400,000 17.7
operasi kecil dengan narkose 440,000 560,000 1,000,000 550,000 700,000 1,250,000 198,000 252,000 450,000 1,056,000 1,344,000 2,400,000 1,276,000 1,624,000 2,900,000 17.8
operasi sedang 924,000 1,176,000 2,100,000 1,012,000 1,288,000 2,300,000 1,584,000 2,016,000 3,600,000 1,848,000 2,352,000 4,200,000 2,288,000 2,912,000 5,200,000 17.9
operasi besar 1,760,000 2,240,000 4,000,000 2,200,000 2,800,000 5,000,000 2,332,000 2,968,000 5,300,000 3,300,000 4,200,000 7,500,000 3,740,000 4,760,000 8,500,000
17.10
operasi besar khusus 2,200,000 2,800,000 5,000,000 2,640,000 3,360,000 6,000,000 2,772,000 3,528,000 6,300,000 3,168,000 4,032,000 7,200,000 4,048,000 5,152,000 9,200,000
18 BAGIAN JANTUNG - - - - - - - - - - - - - - - - -
18.1EKG 22,000 28,000 50,000 26,400 33,600 60,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 33,000 42,000 75,000 44,000 56,000 100,000 19,800 25,200 45,000 19,800
18.2Echokardiografi 35000 40000 75000 40000 45000 85000 26400 33,600 60000 33000 42,000 75000 35,200 44800 80000 39600 50400 90000 44000 56,000 100,000 39600
Tindakan sederhana
Operasi Cito
Operasi elektif
121
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
122
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
123
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
124
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
125
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
126
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
127
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
128
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
129
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
130
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
131
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
132
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
133
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
134
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
135
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
136
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
137
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
138
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
139
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
140
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
141
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
142
1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
I
RAWAT INAP
IGD/VK
VIP VVIP
2
NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE
III II
ICU/HCU
143
28 28 30 31 32
Jasa
Sarana Total
Jasa
layanan
Jasa
Sarana Total
140,000 250,000 110,000 140,000 250,000
- -
- -
25,200 45,000 19,800 25,200 45,000
33,600 60,000 26,400 33,600 60,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
14,000 25,000 11,000 14,000 25,000
19,600 35,000 15,400 19,600 35,000
14,000 25,000 6,600 8,400 15,000
8,400 15,000 6,600 8,400 15,000
8,400 15,000 6,600 8,400 15,000
- - -
- - -
- - -
28,000 50,000 22,000 28,000 50,000
44,800 80,000 35,200 44,800 80,000
168,000 300,000 132,000 168,000 300,000
168,000 300,000 132,000 168,000 300,000
- - -
PERINATOLOGI
STRUKTUR DAN BESARAN TARIF RUMAH SAKIT UMUM DAERAH MALINGPING
ICU/HCU
PERATURAN DAERAH PROVINSI BANTEN
RETRIBUSI PELAYANAN KESEHATAN
144
28 28 30 31 32
PERINATOLOGIICU/HCU
112,000 200,000 88,000 112,000 200,000
112,000 200,000 88,000 112,000 200,000
14,000 25,000 11,000 14,000 25,000
- - -
- - -
- - -
- - -
28,000 50,000 - -
- - -
- - -
8,400 15,000 - -
42,000 75,000 - -
28,000 50,000 - -
11,200 20,000 - -
28,000 50,000 - -
- - -
28,000 50,000 - -
33,600 60,000 - -
39,200 70,000 - -
44,800 80,000 - -
51,520 92,000 - -
8,400 15,000 6,600 8,400 15,000
16,800 30,000 13,200 16,800 30,000
14,000 25,000 11,000 14,000 25,000
19,600 35,000 15,400 19,600 35,000
25,200 45,000 19,800 25,200 45,000
- - -
16,800 30,000 - -
14,000 25,000 - -
16,800 30,000 - -
33,600 60,000 - -
33,600 60,000 - -
39,200 70,000 - -
28,000 50,000 - -
145
28 28 30 31 32
PERINATOLOGIICU/HCU
28,000 50,000 - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- 6,600 8,400 15,000
- - -
50,400 90,000 - -
28,000 50,000 - -
33,600 60,000 - -
- - -
- - -
8,400 15,000 - -
- - -
392,000 700,000 - -
- - -
- - -
- - -
448,000 800,000 - -
- - -
- - -
- - -
- 13,200 16,800 30,000
- 17,600 22,400 40,000
- 11,000 14,000 25,000
- - -
- - -
146
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
28,000 50,000 22,000 28,000 50,000
- - -
42,000 75,000 33,000 42,000 75,000
42,000 75,000 33,000 42,000 75,000
- - -
- - -
56,000 100,000 44,000 56,000 100,000
56,000 100,000 44,000 56,000 100,000
14,000 25,000 11,000 14,000 25,000
28,000 50,000 22,000 28,000 50,000
28,000 50,000 22,000 28,000 50,000
- - -
- - -
147
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
- - -
140,000 250,000 110,000 140,000 250,000
- - -
- - -
16,800 30,000 13,200 16,800 30,000
168,000 300,000 132,000 168,000 300,000
5,600 10,000 4,400 5,600 10,000
168,000 300,000 132,000 168,000 300,000
84,000 150,000 66,000 84,000 150,000
28,000 50,000 22,000 28,000 50,000
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
8,400 15,000 - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
148
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
149
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
150
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
151
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
- - -
50,400 90,000 - -
140,000 250,000 - -
- - -
106,400 190,000 - -
25,200 45,000 - -
112,000 200,000 - -
98,000 175,000 - -
56,000 100,000 - -
70,000 125,000 - -
50,400 90,000 - -
196,000 350,000 - -
56,000 100,000 - -
70,000 125,000 - -
70,000 125,000 - -
- - -
112,000 200,000 - -
33,600 60,000 - -
47,600 85,000 - -
14,000 25,000 - -
70,000 125,000 55,000 70,000 125,000
56,000 100,000 44,000 56,000 100,000
392,000 700,000 308,000 392,000 700,000
28,000 50,000 22,000 28,000 50,000
- - -
420,000 750,000 330,000 420,000 750,000
- - -
39,200 70,000 - -
- - -
56,000 100,000 - -
44,800 80,000 - -
67,200 120,000 - -
152
28 28 30 31 32
PERINATOLOGIICU/HCU
56,000 100,000 - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
84,000 150,000 66,000 84,000 150,000
168,000 300,000 132,000 168,000 300,000
84,000 150,000 66,000 84,000 150,000
61,600 110,000 48,400 61,600 110,000
81,200 145,000 63,800 81,200 145,000
98,000 175,000 77,000 98,000 175,000
98,000 175,000 77,000 98,000 175,000
- - -
- - -
- - -
- - -
- - -
- - -
- - -
153
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
16,800 30,000 - -
16,800 30,000 13,200 16,800 30,000
8,400 15,000 6,600 8,400 15,000
12,320 22,000 9,680 12,320 22,000
- - -
- - -
- - -
- - -
5,600 10,000 4,400 5,600 10,000
- - -
11,200 20,000 8,800 11,200 20,000
8,400 15,000 6,600 8,400 15,000
154
28 28 30 31 32
PERINATOLOGIICU/HCU
11,200 20,000 8,800 11,200 20,000
39,200 70,000 30,800 39,200 70,000
25,200 45,000 19,800 25,200 45,000
25,200 45,000 19,800 25,200 45,000
16,800 30,000 13,200 16,800 30,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
11,200 20,000 8,800 11,200 20,000
16,800 30,000 22,000 28,000 50,000
14,000 25,000 - -
44,800 80,000 35,200 44,800 80,000
14,000 25,000 11,000 14,000 25,000
- - -
- - -
16,800 30,000 - -
36,400 65,000 - -
25,200 45,000 - -
11,200 20,000 8,800 11,200 20,000
14,000 25,000 11,000 14,000 25,000
8,400 15,000 6,600 8,400 15,000
11,200 20,000 8,800 11,200 20,000
8,400 15,000 6,600 8,400 15,000
11,200 20,000 8,800 11,200 20,000
14,000 25,000 11,000 14,000 25,000
16,800 30,000 13,200 16,800 30,000
14,000 25,000 8,800 11,200 20,000
16,800 30,000 - -
5,600 10,000 4,400 5,600 10,000
11,200 20,000 8,800 11,200 20,000
5,600 10,000 4,400 5,600 10,000
8,400 15,000 - -
155
28 28 30 31 32
PERINATOLOGIICU/HCU
16,800 30,000 22,000 28,000 50,000
8,400 15,000 6,600 8,400 15,000
12,320 22,000 9,680 12,320 22,000
16,800 30,000 13,200 16,800 30,000
28,000 50,000 - -
14,000 25,000 11,000 14,000 25,000
36,400 65,000 - -
22,400 40,000 - -
28,000 50,000 - -
14,000 25,000 - -
28,000 50,000 - -
14,000 25,000 - -
19,600 35,000 - -
14,000 25,000 - -
11,200 20,000 - -
- 8,800 11,200 20,000
123,200 220,000 - -
5,600 10,000 4,400 5,600 10,000
5,600 10,000 4,400 5,600 10,000
12,320 22,000 9,680 12,320 22,000
5,600 10,000 - -
- - -
3,920 7,000 3,080 3,920 7,000
3,920 7,000 3,080 3,920 7,000
156
28 28 30 31 32
PERINATOLOGIICU/HCU
- - -
25,200 45,000 19,800 25,200 45,000
50400 90000
157
28 28 30 31 32
PERINATOLOGIICU/HCU
158
28 28 30 31 32
PERINATOLOGIICU/HCU
159
28 28 30 31 32
PERINATOLOGIICU/HCU
160
28 28 30 31 32
PERINATOLOGIICU/HCU
161
28 28 30 31 32
PERINATOLOGIICU/HCU
162
28 28 30 31 32
PERINATOLOGIICU/HCU
163
28 28 30 31 32
PERINATOLOGIICU/HCU
164
28 28 30 31 32
PERINATOLOGIICU/HCU
165
28 28 30 31 32
PERINATOLOGIICU/HCU
166
28 28 30 31 32
PERINATOLOGIICU/HCU
167
28 28 30 31 32
PERINATOLOGIICU/HCU
168
28 28 30 31 32
PERINATOLOGIICU/HCU
169
28 28 30 31 32
PERINATOLOGIICU/HCU
170
28 28 30 31 32
PERINATOLOGIICU/HCU
171
28 28 30 31 32
PERINATOLOGIICU/HCU
172
28 28 30 31 32
PERINATOLOGIICU/HCU
173
28 28 30 31 32
PERINATOLOGIICU/HCU
174
28 28 30 31 32
PERINATOLOGIICU/HCU
175
28 28 30 31 32
PERINATOLOGIICU/HCU
176
28 28 30 31 32
PERINATOLOGIICU/HCU
177
28 28 30 31 32
PERINATOLOGIICU/HCU
178
28 28 30 31 32
PERINATOLOGIICU/HCU
179