DokumenPeraturan Bupati (Perbup)Berlaku

Peraturan Bupati (Perbup) Kabupaten Mamuju Tengah Nomor 20 Tahun 2025

Nomor: 20
Tahun: 2025
Ditetapkan: 6 Oktober 2025
Status: Berlaku
Pasal terindeks: 4

Lembaga terkait

Ringkasan

Dalam Peraturan Bupati ini diatur tentang Perubahan Tarif Retribusi Jasa Umum Atas Pelayanan Kesehatan dengan menetapkan batasan istilah yang digunakan dalam pengaturannya. Besaran tarif Retribusi Jasa Umum atas Pelayanan Kesehatan sebagaimana diatur dalam Lampiran yang merupakan bagian tidak terpisahkan dari Peraturan Bupati ini.

Isi peraturan

Menetapkan

menetapkan Peraturan Bupati tentang Perubahan Tarif Retribusi Jasa Umum atas Pelayanan Kesehatan. Mengingat : 1. Pasal 18 ayat (6) Undang-Undang Dasar Negara Republik Indonesia Tahun 1945;

2.Undang-Undang Nomor 4 Tahun 2013 tentang Pembentukan Kabupaten Mamuju Tengah (Lembaran Negara Republik Indonesia Tahun 2013 Nomor 19, Tambahan Lembaran Negara Republik Indonesia Nomor 5397);
3.Undang-Undang Nomor 23 Tahun 2014 tentang Pemerintahan Daerah (Lembaran Negara Republik Indonesia Tahun 2014 Nomor 244, Tambahan Lembaran Negara Republik Indonesia Nomor 5587) sebagaimana telah diubah beberapa kali, terakhir dengan Undang– Undang Nomor 6 Tahun 2023 tentang Penetapan Peraturan Pemerintah Pengganti Undang-Undang Nomor 2 Tahun 2022 tentang Cipta Kerja menjadi Undang-undang (Lembaran Negara Republik Indonesia Tahun 2023 Nomor 41, Tambahan Lembaran Negara Republik Indonesia Nomor 6856);
4.Peraturan Daerah Kabupaten Mamuju Tengah Nomor 1 Tahun 2024 tentang Pajak Daerah dan Retribusi Daerah (Lembaran Daerah Kabupaten Mamuju Tengah Tahun 2024 Nomor 1, Tambahan Lembaran Daerah Kabupaten Mamuju Tengah Nomor 6). MEMUTUSKAN: Menetapkan : PERATURAN BUPATI TENTANG PERUBAHAN TARIF RETRIBUSI JASA UMUM ATAS PELAYANAN KESEHATAN. SALINAN

Pasal 1

1.Pemerintah Daerah adalah Pemerintah Kabupaten Mamuju Tengah.
2.Bupati adalah Bupati Mamuju Tengah.
3.Retribusi Daerah yang selanjutnya disebut Retribusi adalah pungutan daerah sebagai pembayaran atas jasa atau pemberian izin tertentu yang khusus disediakan dan/atau diberikan oleh Pemerintah Daerah untuk kepentingan orang pribadi atau badan.
4.Jasa Umum adalah jasa yang disediakan atau diberikan oleh Pemerintah Daerah untuk tujuan kepentingan dan kemanfaatan umum serta dapat dinikmati oleh orang pribadi atau badan.
5.Pelayanan Kesehatan adalah segala kegiatan pelayanan kesehatan yang diberikan kepada seseorang dalam rangka observasi, diagnosis, pengobatan atau pelayanan kesehatan lainnya

Pasal 2

Besaran tarif Retribusi Jasa Umum atas Pelayanan Kesehatan sebagaimana diatur dalam Lampiran yang merupakan bagian tidak terpisahkan dari Peraturan Bupati ini.

Pasal 3

Peraturan Bupati ini mulai berlaku pada tanggal diundangkan. Agar setiap orang mengetahuinya, memerintahkan pengundangan Peraturan Bupati ini dengan penempatannya dalam Berita Daerah Kabupaten Mamuju Tengah. Ditetapkan di Tobadak pada tanggal 6 Oktober 2025 BUPATI MAMUJU TENGAH, ttd ARSAL ARAS Diundangkan di Tobadak pada tanggal 6 Oktober 2025 SEKRETARIS DAERAH KABUPATEN MAMUJU TENGAH, ttd LITHA FEBRIANI BERITA DAERAH KABUPATEN MAMUJU TENGAH TAHUN 2025 NOMOR 20 Salinan sesuai dengan aslinya KEPALA BAGIAN HUKUM, LUKMAN,S.Sos NIP.19690604 200112 1 007 LAMPIRAN PERATURAN BUPATI MAMUJU TENGAH NOMOR 20 TAHUN 2025 TENTANG PERUBAHAN TARIF RETRIBUSI JASA UMUM ATAS PELAYANAN KESEHATAN. RUMAH SAKIT UMUM DAERAH No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total I. Pelayanan Medis A. Tarif Pelayanan Rawat Jalan 1 Pemeriksaan dr.Umum/drg.Umum Perpemeriksaan 20,000 40,000 60,000 2 Pemeriksaan dr.Spesialis/drg.Spesialis Perpemeriksaan 60,000 90,000 150,000 3 Konsul Antar Spesialis Perkonsultasi 40,000 90,000 130,000 B. Tarif Pelayanan Rawat Darurat 4 Pemeriksaan dr.Umum/drg.Umum (Cito) Perpemeriksaan 20,000 60,000 80,000 5 Pemeriksaan dr. Spesialis/drg.Spesialis (Cito) Perpemeriksaan 60,000 120,000 180,000 6 Konsul Antar Spesialis (Cito) Perkonsultasi 40,000 120,000 160,000 C. Tarif Pelayanan Rawat Inap No Jenis Pelayanan Jasa Sarana Jasa Pelayanan Total No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 1 Visite dr.Umum/drg.Umum Perhari 20,000 50,000 70,000 2 Visite dr.Spesialis/drg.Spesialis Perhari 60,000 120,000 180,000 3 Tele Visite dr.Spesialis/drg.Spesialis Perhari 20,000 60,000 80,000 4 Akomodasi Kelas VIP Perhari 377,500 22,500 400,000 5 Akomodasi Kelas I Perhari 288,000 12,000 300,000 6 Akomodasi Kelas II Perhari 189,500 10,500 200,000 7 Akomodasi Kelas III Perhari 141,000 9,000 150,000 8 Akomodasi Perawatan ICU Perhari 488,000 12,000 500,000 9 Akomodasi Perawatan Isolasi Perhari 289,500 10,500 300,000 D. Tarif Tindakan Medik Rawat Jalan, Rawat Inap, IGD, dan ICU 1 Aff Drain Pertindakan 28,000 22,000 50,000 2 Aff Elektroda Pertindakan 8,400 6,600 15,000 3 Aff GIPS Pertindakan 44,240 34,760 79,000 4 Aff Gudel Pertindakan 8,400 6,600 15,000 5 aff hecting Pertindakan 28,000 22,000 50,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Aff Infus Pertindakan 14,000 11,000 25,000 7 Aff infus pump Pertindakan 11,200 8,800 20,000 8 Aff Kateter Pertindakan 19,600 15,400 35,000 9 Aff Monitor Pertindakan 19,600 15,400 35,000 10 Aff NGT Pertindakan 19,152 15,048 34,200 11 Aff O2 Pertindakan 19,600 15,400 35,000 12 Aff OGT Pertindakan 19,152 15,048 34,200 13 Aff Spalak Pertindakan 11,088 8,712 19,800 14 Aff Syringe pump Pertindakan 11,200 8,800 20,000 15 Aff Tampon Pertindakan 22,400 17,600 40,000 16 Aff transfusi darah Pertindakan 8,400 6,600 15,000 17 Aff try Way Pertindakan 8,400 6,600 15,000 18 Ambulasi Pertindakan 22,400 17,600 40,000 19 Amniotomi Pertindakan 14,000 11,000 25,000 20 Angkat jahit WSD Pertindakan 140,000 110,000 250,000 21 Aspirasi Jarum Halus Pertindakan 112,000 88,000 200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 22 Balance Cairan Pertindakan 19,600 15,400 35,000 23 Biopsi Pertindakan 138,320 108,680 247,000 24 Biospi Pleura Pertindakan 439,775 345,538 785,313 25 Biopsi Tumor Paru/ Transthoracic needle aspiration (TTNA) Pertindakan 613,200 481,800 1,095,000 26 Biopsi Core (Guide) Tuntunan USG Pertindakan 1,356,405 1,065,747 2,422,152 27 Bebat tekan Pertindakan 25,200 19,800 45,000 28 Blader Training Pertindakan 39,200 30,800 70,000 29 Bronchoskopi/Bronchoskopi Pertindakan 504,000 396,000 900,000 30 Dilatasi Serviks Pertindakan 42,000 33,000 75,000 31 Edukasi pasien dan keluarga Pertindakan 33,600 26,400 60,000 32 Eksplorasi Benda Asing Pertindakan 80,000 63,000 143,000 33 Ekstraksi Kuku Pertindakan 140,000 110,000 250,000 34 Ekstubasi Pertindakan 44,800 35,200 80,000 35 Fetal Doppler Pertindakan 14,000 11,000 25,000 36 Ganti balutan Pertindakan 16,800 13,200 30,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 37 Ganti Cairan Pertindakan 14,000 11,000 25,000 38 Ganti popok/ pembalut Pertindakan 19,600 15,400 35,000 39 Ganti Verban (Berat) Pertindakan 224,000 176,000 400,000 40 Ganti Verban (Ringan) Pertindakan 75,600 59,400 135,000 41 Ganti Verban (Sedang) Pertindakan 84,000 66,000 150,000 42 Hecting luka besar Pertindakan 224,000 176,000 400,000 43 Hecting luka kecil Pertindakan 56,000 44,000 100,000 44 Hecting luka sedang Pertindakan 112,000 88,000 200,000 45 Hukna/ klisma Pertindakan 50,400 39,600 90,000 46 Induksi Persalinan Pertindakan 89,600 70,400 160,000 47 Injeksi Pertindakan 11,200 8,800 20,000 48 Injeksi Intra Muscular Pertindakan 11,200 8,800 20,000 49 Injeksi intra vena Pertindakan 11,200 8,800 20,000 50 injeksi intramuscular Pertindakan 11,200 8,800 20,000 51 Injeksi Intravena Pertindakan 11,200 8,800 20,000 52 injeksi kontrasepsi hormonal Pertindakan 19,600 15,400 35,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 53 Injeksi Skleroterapi Pertindakan 64,400 50,600 115,000 54 Injeksi sub Cutan Pertindakan 11,200 8,800 20,000 55 Insisi Abces (Berat) Pertindakan 56,000 44,000 100,000 56 Insisi Abces (ringan) Pertindakan 26,320 20,680 47,000 57 Insisi Abces (Sedang) Pertindakan 30,800 24,200 55,000 58 Intubasi Pertindakan 88,000 112,000 200,000 59 Irigasi Cairan Acites Pertindakan 112,000 88,000 200,000 60 Irigasi Cairan pleura Pertindakan 98,000 77,000 175,000 61 irigasi mata Pertindakan 16,800 13,200 30,000 62 Jahit Perineum Tk. 1 dan 2 Pertindakan 56,000 44,000 100,000 63 Jahit Perineum Tk. 3 dan 4 Pertindakan 168,000 132,000 300,000 64 klisma/hukna Pertindakan 50,400 39,600 90,000 65 Kompres (Pegaturan Suhu Tubuh) Pertindakan 14,000 11,000 25,000 66 kompres luka Pertindakan 14,000 11,000 25,000 67 kumbah lambung Pertindakan 49,280 38,720 88,000 68 Leopold Pertindakan 11,200 8,800 20,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 69 lepas iud Pertindakan 84,000 66,000 150,000 70 lepas kontrasepsi implan Pertindakan 75,600 59,400 135,000 71 lepas pesarium Pertindakan 23,520 18,480 42,000 72 Manual Placenta Pertindakan 296,800 233,200 530,000 73 Melahirkan Plasenta Normal Pertindakan 154,000 121,000 275,000 74 Memandikan Bayi Pertindakan 33,600 26,400 60,000 75 Memandikan Pasien Pertindakan 33,600 26,400 60,000 76 Membantu pemenuhan eliminasi Pertindakan 19,600 15,400 35,000 77 Mobilisasi Pertindakan 15,680 12,320 28,000 78 Nebulizer Anak Pertindakan 53,200 41,800 95,000 79 Nebulizer Bayi Pertindakan 53,200 41,800 95,000 80 Nebulizer Dewasa Pertindakan 53,200 41,800 95,000 81 Neck colar Pertindakan 44,800 35,200 80,000 82 Needle krikotiroidotomi Pertindakan 50,400 39,600 90,000 83 Needle Thoracosintesis Pertindakan 50,400 39,600 90,000 84 NGT decompresi Pertindakan 61,600 48,400 110,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 85 NGT Dekompresi Pertindakan 61,600 48,400 110,000 86 Observasi harian Pertindakan 19,600 15,400 35,000 87 observasi Perdarahan Berat Pertindakan 30,800 24,200 55,000 88 Observasi Perdarahan Ringan Pertindakan 19,600 15,400 35,000 89 Observasi Perdarahan Sedang Pertindakan 25,200 19,800 45,000 90 Observasi Persalinan Pertindakan 98,000 77,000 175,000 91 Observasi UGD Pertindakan 19,600 15,400 35,000 92 Oral higiene Pertindakan 19,600 15,400 35,000 93 Pasang Balutan Pertindakan 16,800 13,200 30,000 94 Pasang CPAP Pertindakan 406,000 319,000 725,000 95 Pasang Elektroda Pertindakan 14,000 11,000 25,000 96 Pasang Gudel Pertindakan 32,200 25,300 57,500 97 Pasang Infus Anak Pertindakan 50,400 39,600 90,000 98 pasang infus bayi Pertindakan 50,400 39,600 90,000 99 Pasang infus dengan penyulit Pertindakan 56,000 44,000 100,000 100 Pasang Infus Dewasa Pertindakan 39,200 30,800 70,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 101 Pasang Infuse Pump Pertindakan 44,800 35,200 80,000 102 Pasang Kateter Pertindakan 64,400 50,600 115,000 103 Pasang Kateter Anak Pertindakan 78,400 61,600 140,000 104 Pasang Monitor Pertindakan 56,000 44,000 100,000 105 Pasang O2 Pertindakan 19,600 15,400 35,000 106 Pasang O2 NRM Pertindakan 44,240 34,760 79,000 107 Pasang O2 sungkup Pertindakan 28,000 22,000 50,000 108 Pemakaian O2 Perliter Pertindakan 200 - 200 109 pasang pesarium Pertindakan 56,000 44,000 100,000 110 Pasang restrain Pertindakan 39,200 30,800 70,000 111 Pasang Spalak Pertindakan 44,800 35,200 80,000 112 Pasang Syringe pump Pertindakan 33,600 26,400 60,000 113 Pasang Tampon Pertindakan 33,600 26,400 60,000 114 Pasang Try Way Pertindakan 11,200 8,800 20,000 115 Pasang ventilator Pertindakan 56,000 44,000 100,000 116 Pasang WSD Pertindakan 128,800 101,200 230,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 117 pemakaian pulse oxymetri Pertindakan 5,600 4,400 10,000 118 Pemasangan DC shock Pertindakan 35,280 27,720 63,000 119 Pemasangan Defibrilator Pertindakan 35,280 27,720 63,000 120 pemasangan elastis perban Pertindakan 44,800 35,200 80,000 121 Pemasangan infus Pertindakan 37,800 29,700 67,500 122 pemasangan iud Pertindakan 92,400 72,600 165,000 123 Pemasangan Neck colar Pertindakan 25,200 19,800 45,000 124 pemasangan NGT/OGT Pertindakan 48,720 38,280 87,000 125 pemasanggan implan Pertindakan 86,800 68,200 155,000 126 Pemberian makan sonde Pertindakan 5,600 4,400 10,000 127 Pemberian obat suppositoria rectal Pertindakan 22,400 17,600 40,000 128 Pemberian obat suppositoria vaginal Pertindakan 20,160 15,840 36,000 129 Pemberian Obat Topikal Pertindakan 20,160 15,840 36,000 130 Pemberian Obat/Nutrisi Lewat NGT Pertindakan 22,400 17,600 40,000 131 pembuatan SKBS dan SKBN Pertindakan 36,400 28,600 65,000 132 pembuatan Surat keterangan sakit Pertindakan 36,400 28,600 65,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 133 pemeriksaan Buta warna/ishihara chart Pertindakan 4,480 3,520 8,000 134 Pemeriksaan CTG Pertindakan 112,000 88,000 200,000 135 Pemeriksaan DJJ Abnormal Pertindakan 22,400 17,600 40,000 136 Pemeriksaan EKG Pertindakan 44,800 35,200 80,000 137 Pemeriksaan EKG Anak Pertindakan 56,000 44,000 100,000 138 pemeriksaan rumple leed test Pertindakan 36,400 28,600 65,000 139 Pemeriksaan TTV/Fisik Perhari Pertindakan 28,000 22,000 50,000 140 Pemeriksaan TTV/Fisik Anak Perhari Pertindakan 28,000 22,000 50,000 141 Pemeriksaan TTV/Fisik Perjam Pertindakan 7,000 5,500 12,500 142 pemeriksaan visus / snellen chart Pertindakan 14,000 11,000 25,000 143 Penanganan Perdarahan Post Partum Pertindakan 104,160 81,840 186,000 144 Pengambilan Spesimen Urine (melalui kateter) Pertindakan 11,200 8,800 20,000 145 Pengukuran antropometri Pertindakan 28,000 22,000 50,000 146 Pengukuran saturasi oksigen Pertindakan 5,600 4,400 10,000 147 Perawat Luka bakar (11-20%) Pertindakan 106,400 83,600 190,000 148 Perawat Luka bakar (21-30%) Pertindakan 128,800 101,200 230,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 149 Perawat Luka bakar (5-10%) Pertindakan 81,200 63,800 145,000 150 Perawatan infan warmer Pertindakan 56,000 44,000 100,000 151 Perawatan Infus Pertindakan 28,000 22,000 50,000 152 Perawatan luka Kecil Pertindakan 22,400 17,600 40,000 153 Perawatan luka decubitus berat Pertindakan 168,000 132,000 300,000 154 Perawatan luka decubitus ringan Pertindakan 42,000 33,000 75,000 155 Perawatan luka decubitus sedang Pertindakan 84,000 66,000 150,000 156 perawatan luka diabetik infeksi Pertindakan 84,000 66,000 150,000 157 perawatan luka diabetik non infeksi Pertindakan 42,000 33,000 75,000 158 Perawatan Luka Gangreng Pertindakan 224,000 176,000 400,000 159 Perawatan Luka Kotor Pertindakan 193,200 151,800 345,000 160 Perawatan Luka Perineum Pertindakan 42,000 33,000 75,000 161 Perawatan Luka Sedang Pertindakan 44,800 35,200 80,000 162 Perawatan Luka Tanpa Jahitan Pertindakan 22,400 17,600 40,000 163 Perawatan Payudara Pertindakan 28,000 22,000 50,000 164 Perawatan tali pusat Pertindakan 11,200 8,800 20,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 165 Persalinan Patologis Pertindakan 490,000 385,000 875,000 166 Persiapan Operasi Pertindakan 28,000 22,000 50,000 167 personal Hygine Pertindakan 33,600 26,400 60,000 168 phototerapi Pertindakan 112,000 88,000 200,000 169 PIGTAIL/ PIGTAIL ASITES Pertindakan 422,549 332,002 754,551 170 pleurodesis Pertindakan 448,000 352,000 800,000 171 Pleurodesis Bleomycin Pertindakan 1,988,078 1,562,061 3,550,139 172 Pleurodesis Doksisiklin Pertindakan 528,778 415,469 944,247 173 Pleurodesis Sitostatika Pertindakan 603,599 474,256 1,077,855 174 Potong tali pusat Pertindakan 33,600 26,400 60,000 175 Punksi Acites Pertindakan 112,000 88,000 200,000 176 Punksi Pleura Pertindakan 80,080 62,920 143,000 177 Punksi Pleura Cito Pertindakan 80,080 125,840 205,920 178 rawat tali pusat Pertindakan 26,320 20,680 47,000 179 Rectal Toucher Pertindakan 12,000 22,200 34,200 180 Resusitasi BBL dengan penyulit (SC,Sungsang) Pertindakan 60,000 90,000 150,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 181 Resusitasi Jantung Paru Pertindakan Pertindakan 40,000 60,000 100,000 182 Resusitasi Kardiopulmoner (RJP) Pertindakan Pertindakan 40,000 60,000 100,000 183 resusitasi sederhana (VTP) Pertindakan Pertindakan 40,000 60,000 100,000 184 Rumple leede test Pertindakan 56,000 44,000 100,000 185 Sirkumsisi Pertindakan 476,000 374,000 850,000 186 Skin Test Pertindakan 20,160 15,840 36,000 187 Skrining PJB Pertindakan 15,680 12,320 28,000 188 Skrining Hipotiroid Kongenital Pertindakan 28,000 22,000 50,000 189 spirometri Pertindakan 30,000 45,000 75,000 190 spuling kateter Pertindakan 16,800 13,200 30,000 191 Suction Pertindakan 28,000 22,000 50,000 192 Suction Bayi Pertindakan 28,000 22,000 50,000 193 Suction Bayi Pertindakan 44,800 35,200 80,000 194 Tampon telinga Pertindakan 44,800 35,200 80,000 195 Tatalaksana gizi pasien neonatus Pertindakan 39,760 31,240 71,000 196 tes tuberkulin Pertindakan 25,760 20,240 46,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 197 Transfusi Darah Pertindakan 252,000 198,000 450,000 198 usg diagnostik kehamilan Pertindakan 75,000 75,000 150,000 199 usg ginekologi Pertindakan 64,500 85,500 150,000 200 usg thorax Pertindakan 84,000 66,000 150,000 201 Vagina Toilet Pertindakan 28,000 22,000 50,000 202 Vagina Toucher Pertindakan 28,000 22,000 50,000 203 Vaksinasi Pertindakan 30,800 24,200 55,000 204 Vulva Hygiene Pertindakan 28,000 22,000 50,000 205 Otoskopi telinga Pertindakan 166,320 130,680 297,000 206 Endoskopi telinga Pertindakan 84,000 66,000 150,000 207 Toilet telinga Pertindakan 56,000 44,000 100,000 208 Spooling telinga Pertindakan 35,280 27,720 63,000 209 Parasintesis Pertindakan 56,000 44,000 100,000 210 Tampon burowi Pertindakan 6,272 4,928 11,200 211 Tampon antibiotik Pertindakan 112,000 88,000 200,000 212 Rawat luka post operasi Pertindakan 56,000 44,000 100,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 213 Faringoskopi Pertindakan 112,000 88,000 200,000 214 tampon hidung Pertindakan 61,880 48,620 110,500 215 Toilet hidung Pertindakan 56,000 44,000 100,000 216 Kaustik faring Pertindakan 86,800 68,200 155,000 217 Endoskopi hidung Pertindakan 140,000 110,000 250,000 218 Endoskopi laring Pertindakan 180,320 141,680 322,000 219 Rawat luka operasi hidung Pertindakan 56,000 44,000 100,000 220 Injeksi intra Pleura Pertindakan 99,120 77,880 177,000 221 Injeksi IM/Subcutan/Intracutan Pertindakan 25,200 19,880 45,000 222 Pemasangan buli-buli hangat & dingin Pertindakan 18,480 14,520 33,000 223 Spooling cairan Pertindakan 19,600 15,400 35,000 224 Colostomy care Pertindakan 52,080 40,920 93,000 225 irigasi suprapubrik Pertindakan 144,900 113,850 258,750 226 test garpu tala Pertindakan 20,160 15,840 36,000 227 MMPI Pertindakan 100,000 450,000 550,000 228 Transcranial Magnetic Stimulation (TMS) Pertindakan 1,120,000 880,000 2,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 229 HDRS/HARS Mini Metal Pertindakan 17,920 14,080 32,000 230 warteg HTP Rorschach Pertindakan 17,920 14,080 32,000 231 Raven Test / IQ Test Pertindakan 18,480 14,520 33,000 232 Perawatan Kolostomi Pertindakan 54,000 39,000 93,000 233 Perawatan Inkubator Pertindakan 42,000 30,000 72,000 234 Aspirasi Suprapubik Pertindakan 18,000 15,000 33,000 235 Pemeriksan dalam dengan Inspekulo Pertindakan 147,000 115,000 262,000 E. Tindakan Pelayanan Gigi dan Mulut 1 Pengunaan anastesi Pertindakan 61,600 48,400 110,000 2 Pencabutan gigi (Gigi Susu-CE) Pertindakan 67,200 52,800 120,000 3 Pencabutan gigi (Gigi Susu-Infiltrasi) Pertindakan 44,240 34,760 79,000 4 Pencabutan permanen Pertindakan 72,800 57,200 130,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 5 Pencabutan permanen dengan Penyulit Pertindakan 92,400 72,600 165,000 6 Pembersihan karang gigi Manual Pertindakan 72,800 57,200 130,000 7 Penambalan GI/komposit Pertindakan 89,600 70,400 160,000 8 Penambalan Sementara Pertindakan 112,000 88,000 200,000 9 Aplikasi Eugenol Pertindakan 61,600 48,400 110,000 10 Trepanasi Abses Pertindakan 64,400 50,600 115,000 11 ulkus Decubitus Pertindakan 72,800 57,200 130,000 12 Escavasi kavitasi Pertindakan 70,000 55,000 125,000 13 Scalling ultrasonic 1/4 regio (ringan) Pertindakan 61,600 48,400 110,000 14 Scalling ultrasonic 1/2 regio (sedang) Pertindakan 70,000 55,000 125,000 15 Scalling ultrasonic full (berat) Pertindakan 81,200 63,800 145,000 16 Tambalan compossite / ligt curing Pertindakan 168,000 132,000 300,000 17 Orturasi PSA posterior Pertindakan 168,000 132,000 300,000 18 Orturasi PSA Anterior Pertindakan 145,600 114,400 260,000 19 Open cavity Pertindakan 61,600 48,400 110,000 20 Tambalan kecil Pertindakan 112,000 88,000 200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 21 Tambalan besar Pertindakan 168,000 132,000 300,000 22 polishing Pertindakan 56,000 44,000 100,000 23 open orifice Pertindakan 47,600 37,400 85,000 24 eksterpasi pulpa Pertindakan 72,800 57,200 130,000 25 built up wall Pertindakan 218,400 171,600 390,000 5 preparasi saluran akar Pertindakan 64,400 50,600 115,000 27 sterilisasi saluran akar Pertindakan 72,800 57,200 130,000 28 obturasi saluran akar Pertindakan 44,240 34,760 79,000 29 Anastesi infiltrasi Pertindakan 64,400 50,600 115,000 30 Anastesi blok mandibula Pertindakan 64,400 50,600 115,000 31 Anastesi citoject Pertindakan 64,400 50,600 115,000 32 luksasi/ekstraksi sederhana Pertindakan 64,400 50,600 115,000 33 luksasi/ekstraksi kompleks (separasi bur) Pertindakan 112,000 88,000 200,000 34 irigasi povidon,tampon Pertindakan 61,600 48,400 110,000 35 hecting (perhecting) Pertindakan 72,800 57,200 130,000 38 Alveolectomi Pertindakan 92,400 72,600 165,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 42 aff hecting Pertindakan 56,000 44,000 100,000 43 pulpa cupping Pertindakan 112,000 88,000 200,000 45 Ondontectomy Pertindakan 112,000 88,000 200,000 46 Ondontectomy dengan lokal anastesi Pertindakan 123,200 96,800 220,000 47 Fixed Apliance Standard Metal (1 Rahang-Oklusi Normal) Pertindakan 2,240,000 1,760,000 4,000,000 48 Fixed Apliance Standard Metal (2 Rahang) Pertindakan 2,800,000 2,200,000 5,000,000 49 Composite Brace (2 Rahang) Pertindakan 3,920,000 3,080,000 7,000,000 50 Fixed Appliance Self Ligate (2 Rahang) Pertindakan 4,480,000 3,520,000 8,000,000 51 Cetak Model Studi Gigi untuk Orto per rahang Pertindakan 112,000 88,000 200,000 52 Analisis Kebutuhan Ortodontik Pertindakan 56,000 44,000 100,000 53 Kontrol Orto Cekat Pertindakan 56,000 44,000 100,000 54 Fixed Apliance Standart Metal sedang (2 Rahang) Pertindakan 3,640,000 2,860,000 6,500,000 55 Composite Brace (2 Rahang) Pertindakan 4,480,000 3,520,000 8,000,000 56 Fixed Appliance Self Ligate Sedang (2 Rahang) Pertindakan 5,040,000 3,960,000 9,000,000 57 Fixed Apliance Standart Metal Besar (2 rahang) Pertindakan 3,920,000 3,080,000 7,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 58 Composite Brace (2 rahang) Pertindakan 5,040,000 3,960,000 9,000,000 59 Fixed Appliance Self Ligate Besar (2 Rahang) Pertindakan 5,600,000 4,400,000 10,000,000 60 Ganti Kawat Niti/SS (1 rahang) Pertindakan 56,000 44,000 100,000 61 Ganti Kawat Niti/SS (2 rahang) Pertindakan 105,280 82,720 188,000 F. Tarif Pelayanan Rehabilitas Medik

1.Fleksibilitas di lingkup gerak Pertindakan 8.000 19.800 27.800
2.Fungsi eksekusi gerak Pertindakan 8.000 19.800 27.800
3.Fungsi kardiorespirasi Pertindakan 8.000 19.800 27.800
4.Lokomotor Pertindakan 8.000 19.800 27.800
5.IntegralSensori Motor Pertindakan 8.000 19.800 27.800
6.Kebugaran Pertindakan 8.000 19.800 27.800
7.Kelemahan Otot Pertindakan 8.000 19.800 27.800 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total
8.Kesemibangan statik dan dinamik Pertindakan 8.000 19.800 27.800
9.Motorik halus Pertindakan 8.000 19.800 27.800
10.Pola Jalan Pertindakan 8.000 19.800 27.800
11.Fungsi postur Control Pertindakan 8.000 19.800 27.800 12 Sensibilitas Pertindakan 8.000 19.800 27.800
13.Fungsi Muskulo Skeletol Pertindakan 8.000 19.800 27.800
14.Fungsi Neuromuskular Pertindakan 8.000 19.800 27.800
15.Pediatrik Pertindakan 8.000 19.800 27.800
16.Geriatri Pertindakan 8.000 19.800 27.800
17.Fisiotherapi Integumen Pertindakan 8.000 19.800 27.800
18.Kesehatan Wanita Pertindakan 8.000 19.800 27.800 20 MWD Pertindakan 12.000 22.200 34.200 21 Infrared Pertindakan 12.000 22.200 34.200 22 Massage/Vibra Pertindakan 12.000 22.200 34.200 23 Chest Fisio Pertindakan 16.000 24.600 40.600 24 Manual Therapy Pertindakan 16.000 24.600 40.600 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 25 Exercise Therapy Pertindakan 16.000 24.600 40.600 26 17 / Tens / Paradik Pertindakan 16.000 24.600 40.600 27 Traksi 2/c Pertindakan 16.000 24.600 40.600 28 Crio set therapy Pertindakan 16.000 24.600 40.600 29 Vacum unit therapy Pertindakan 16.000 24.600 40.600 30 Parafin Bath Pertindakan 16.000 24.600 40.600 31 Magnetik Therapy Pertindakan 16.000 24.600 40.600 32 Ultra Sound Pertindakan 16.000 24.600 40.600 33 Stimulasi sensori/Tumbang Pertindakan 16.000 24.600 40.600 34 Cold Therapy Pertindakan 16.000 24.600 40.600 35 Sport Medicine Pertindakan 16.000 24.600 40.600 G. Tarif Tindakan Pertolongan Persalinan 1 Persalinan Normal Pertindakan 280,000 420,000 700,000 2 Persalinan Patologis Spesialis Pertindakan 340,000 510,000 850,000 3 Tindakan Kuret Sisa Placenta/Abortus Pertindakan 300,000 450,000 750,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 4 Tindakan Kuret Molahidatidosa (Umur Kehamilan Kurang dari < 3 Bulan) Pertindakan 340,000 510,000 850,000 5 Jahitan Portio Pertindakan 60,000 90,000 150,000 6 Jahitan Perineum I & II Pertindakan 80,000 120,000 200,000 7 Jahitan Perineum IV & V Pertindakan 120,000 180,000 300,000 8 Manual Plasenta Pertindakan 200,000 300,000 500,000 9 Rest Plasenta Pertindakan 40,000 75,000 115,000 10 Observasi Persalinan Pertindakan 70,000 105,000 175,000 11 Observasi/Persiapan Operasi Pertindakan 20,000 30,000 50,000 12 Tampon Vagina Pertindakan 10,000 15,000 25,000 13 Kuldosintesis Pertindakan 30,000 45,000 75,000 14 Dilatasi Serviks Pertindakan 30,000 45,000 75,000 15 Amniotomi Pertindakan 6,000 9,000 15,000 16 Perawatan Lukan Perineum Pertindakan 6,000 9,050 15,050 17 Pasang Laminarian Stiff Pertindakan 24,000 36,000 60,000 18 Klisma Pertindakan 20,000 30,000 50,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 19 Indiksi Persalinan Pertindakan 60,000 90,000 150,000 20 Melahirkan Plasenta Normal Pertindakan 140,000 210,000 350,000 21 Vagina Toilet Pertindakan 12,000 22,200 34,200 22 Kompresi Bimanual Eksternal Pertindakan 200,000 300,000 500,000 23 Induksi Persalianan Surgical Pertindakan 400,000 600,000 1,000,000 24 Rawat Dehisensi Luka Operasi Pertindakan 40,000 60,000 100,000 25 Ganti Verban Luka Operasi Pertindakan 30,000 45,000 75,000 26 Pemasangan dan Pencabutan IUD Pertindakan 60,000 90,000 150,000 27 Pemasangan dan Pencabutan Implant Pertindakan 60,000 90,000 150,000 28 Perawatan Febris/Sepsis Pueperalis Pertindakan 60,000 90,000 150,000 29 Abses Mammae Pertindakan 60,000 90,000 150,000 30 Hematon Pada Luka Obstetri Pertindakan 80,000 120,000 200,000 31 Dehisensi Luka Perenium Pertindakan 80,000 120,000 200,000 32 Mastitis Pasca Persalinan Pertindakan 60,000 90,000 150,000 33 Konseling Kontrasepsi Pertindakan 20,000 30,000 50,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total No Jenis Pelayanan Jasa Sarana Jasa Pelayanan Total II. TARIF PELAYANAN PENUNJANG DIAGNOSTIK A. Pelayanan Laboratorium HEMATOLOGI - - - 1 Pemeriksaan darah rutin 3 diff Pertindakan 172,000 43,000 215,000 2 Pemeriksaan darah rutin 5 diff Pertindakan 189,200 47,300 236,500 3 Golongan darah Pertindakan 30,100 12,900 43,000 4 CT Pertindakan 35,000 15,000 50,000 5 BT Pertindakan 28,000 12,000 40,000 6 PT Pertindakan 136,500 58,500 195,000 7 APTT Pertindakan 196,000 84,000 280,000 8 LED Pertindakan 105,000 45,000 150,000 9 Diff count Pertindakan 45,500 19,500 65,000 10 Sifilis (VDRL) Pertindakan 59,500 25,500 85,000 Kimia Klinik No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 1 Albumin Pertindakan 17,500 7,500 25,000 2 Pemeriksaan Gula darah Pertindakan 24,500 10,500 35,000 3 Pemeriksaan asam urat Pertindakan 17,500 7,500 25,000 4 Pemeriksaan kolesterol Pertindakan 28,000 12,000 40,000 5 Pemeriksaan SGOT Pertindakan 21,000 9,000 30,000 6 Pemeriksaan SGPT Pertindakan 21,000 9,000 30,000 7 Pemeriksaan Creatinin Pertindakan 17,500 7,500 25,000 8 Ureum Pertindakan 21,000 9,000 30,000 9 Bilirubin Total Pertindakan 17,500 7,500 25,000 10 Bilirubin Direk Pertindakan 17,500 7,500 25,000 11 HDL Pertindakan 49,000 21,000 70,000 12 LDL Pertindakan 119,000 51,000 170,000 13 Trigliserida Pertindakan 28,000 12,000 40,000 14 Kalium Pertindakan 129,500 55,500 185,000 15 Natrium Pertindakan 105,000 45,000 150,000 16 Clorida Pertindakan 105,000 45,000 150,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 17 Protein Total Pertindakan 17,500 7,500 25,000 URINALISA - - - 27 Urine rutin Pertindakan 31,500 13,500 45,000 28 Urine Esbach Pertindakan 14,000 6,000 20,000 29 Sedimen Urine Pertindakan 31,500 13,500 45,000 30 Narkoba 3 Parameter Pertindakan 87,500 37,500 125,000 31 Narkoba 6 Parameter Pertindakan 126,000 54,000 180,000 32 Narkoba Alkohol Pertindakan 70,000 30,000 100,000 SEROLOGI/IMMUNOLOGI - - - 30 Widal Pertindakan 77,000 33,000 110,000 31 HIV Pertindakan 119,000 51,000 170,000 32 HBsAg Pertindakan 70,000 30,000 100,000 33 HCV Pertindakan 105,000 45,000 150,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total PARASITOLOGI - - - 34 Malaria Pertindakan 45,500 19,500 65,000 35 Sampling Pertindakan 7,000 3,000 10,000 36 CK MB Pertindakan 56,000 24,000 80,000 37 NT ProBNP Pertindakan 38,500 16,500 55,000 38 FT4 Pertindakan 147,000 63,000 210,000 39 TSHS Pertindakan 115,500 49,500 165,000 40 CEA Pertindakan 133,000 57,000 190,000 41 CA. 15.3 Pertindakan 224,000 96,000 320,000 42 BHCG Pertindakan 157,500 67,500 225,000 43 CA 125 Pertindakan 164,500 70,500 235,000 44 FT3 Pertindakan 126,000 54,000 180,000 45 ANA Pertindakan 161,000 69,000 230,000 46 RF Pertindakan 203,000 87,000 290,000 47 FERITIN Pertindakan 185,500 79,500 265,000 48 LED Pertindakan 42,000 18,000 60,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 49 HbA1c Pertindakan 91,000 39,000 130,000 50 ASO Pertindakan 38,500 16,500 55,000 51 RF Pertindakan 38,500 16,500 55,000 52 CRP Pertindakan 31,500 13,500 45,000 53 HS-CRP Pertindakan 38,500 16,500 55,000 54 MICROALBUMIN Pertindakan 59,500 25,500 85,000 55 Analisa darah Tepi (ADT) Pertindakan 68,600 29,400 98,000 56 Phelebotomy Pertindakan 10,000 15,000 25,000 57 Phelebotomy Terapi Pertindakan 75,600 113,400 189,000 58 Na, K, Cl (elektrolit) Pertindakan 120,000 180,000 300,000 59 Analisa Gas Darah Pertindakan 100,000 75,000 175,000 FESES 60 Feses Rutin Pertindakan 42,000 28,000 70,000 MIKROBIOLOGI 60 Kultur BTA Pertindakan 159,600 125,400 285,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 61 Mikroskopik Gram Pertindakan 104,720 82,280 187,000 62 Pemeriksaan Dahak (BTA) Pertindakan 151,200 118,800 270,000 63 Mikroskopik KOH/LPCB (jamur) Pertindakan 112,000 88,000 200,000 PEMERIKSAAN LAINNYA 64 Analisa Sperma Pertindakan 112,000 88,000 200,000 65 Analisa Cairan otak Pertindakan 140,000 110,000 250,000 66 Analisa Cairan pleura Pertindakan 112,000 88,000 200,000 67 Analisa Cairan Ascites Pertindakan 140,000 110,000 250,000 68 Analisa Cairan sendi Pertindakan 112,000 88,000 200,000 69 IT Ratio Pertindakan 35,000 65,000 100,000 No Jenis Pelayanan Jasa Sarana Jasa Pelayanan Total B. Pemeriksaan Penunjang Radiografi X RAY GENERAL KONVENSIONAL 1 Cranium AP/LAT Pertindakan 192,500 82,500 275,000 2 Basis Cranii/ Sheedel Basis Pertindakan 192,500 82,500 275,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 3 Waters/ SPN Pertindakan 192,500 82,500 275,000 4 Mastoid Pertindakan 192,500 82,500 275,000 5 Mandibula Pertindakan 192,500 82,500 275,000 6 Orbita Pertindakan 192,500 82,500 275,000 7 Os Nasal Pertindakan 140,000 60,000 200,000 8 Thorax AP/AP/Lat Pertindakan 140,000 60,000 200,000 9 BOF/BNO Pertindakan 192,500 82,500 275,000 10 Abdomen 1/2 duduk LLD Pertindakan 269,500 115,500 385,000 11 Pelvis/ Panggul Pertindakan 140,000 60,000 200,000 12 Cervical/ Leher AP/Lat/ Obl Pertindakan 269,500 115,500 385,000 13 Shoulder/ Bahu Pertindakan 192,500 82,500 275,000 14 Clavicula Pertindakan 192,500 82,500 275,000 15 Scupula Pertindakan 192,500 82,500 275,000 16 Manus AP/Lat/Oblique Pertindakan 192,500 82,500 275,000 17 Wrist/perg.tangan AP/Lat Pertindakan 192,500 82,500 275,000 18 Antebrachi AP/Lat Pertindakan 192,500 82,500 275,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 19 Cubiti AP/Lat Pertindakan 192,500 82,500 275,000 20 Humerus AP/Lat Pertindakan 192,500 82,500 275,000 21 Pedis AP/Oblique Pertindakan 192,500 82,500 275,000 22 Ankle AP/Lat Pertindakan 192,500 82,500 275,000 23 Cruris AP/Lat Pertindakan 192,500 82,500 275,000 24 Genu AP/Lat Pertindakan 192,500 82,500 275,000 25 Femur AP/Lat Pertindakan 192,500 82,500 275,000 26 Thoracal AP/Lat Pertindakan 269,500 115,500 385,000 27 Lumbal AP/Lat Pertindakan 269,500 115,500 385,000 28 Thoraco- Lumbal AP/Lat Pertindakan 269,500 115,500 385,000 29 Sacrum AP/Lat Pertindakan 269,500 115,500 385,000 30 Lumbo- Sacral AP/Lat Pertindakan 269,500 115,500 385,000 31 Coxygeus AP/Lat Pertindakan 269,500 115,500 385,000 32 Dental X- Ray Pertindakan 280,000 120,000 400,000 33 Abdomen 3 posis Pertindakan 350,000 150,000 500,000 34 Top lordotic Pertindakan 189,000 81,000 270,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total X RAY KONVENSIONAL DENGAN KONTRAS - - - 35 Intra Vena Pielografi Pertindakan 490,000 210,000 700,000 36 Oesophagus Pertindakan 490,000 210,000 700,000 37 Cystografi Pertindakan 490,000 210,000 700,000 38 Uretrocystografi Pertindakan 490,000 210,000 700,000 39 Caudografi Pertindakan 490,000 210,000 700,000 40 HSG Pertindakan 490,000 210,000 700,000 41 MD Foto Pertindakan 490,000 210,000 700,000 42 Colon in loop Pertindakan 490,000 210,000 700,000 USG - - - 43 USG Standar Pertindakan 199,500 85,500 285,000 44 USG Dopler Pertindakan 199,500 85,500 285,000 45 USG Transvaginal Pertindakan 199,500 85,500 285,000 46 USG 4 Dimensi Pertindakan 199,500 85,500 285,000 47 USG Thorax marker Pertindakan 199,500 85,500 285,000 48 USG Mammae Pertindakan 199,500 85,500 285,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 49 Usg Upper abdomen Pertindakan 140,000 60,000 200,000 50 USG Lower Abdomen Pertindakan 199,500 85,500 285,000 51 USG thyroid Pertindakan 227,500 97,500 325,000 52 Usg Scrotum Pertindakan 227,500 97,500 325,000 53 Usg Tissue Pertindakan 227,500 97,500 325,000 54 Usg Cranial Pertindakan 227,500 97,500 325,000 CT SCAN NON KONTRAS - - - 55 CT Scan Kepala Pertindakan 1,920,000 480,000 2,400,000 56 CT Scan Spn Coronial/Axial Pertindakan 1,920,000 480,000 2,400,000 57 CT Scan Ekstremitas Pertindakan 1,920,000 480,000 2,400,000 58 CT Scan Patella Pertindakan 1,920,000 480,000 2,400,000 59 CT Scan Thorax Pertindakan 1,920,000 480,000 2,400,000 60 CT Scan Abdomen Pertindakan 1,920,000 480,000 2,400,000 61 CT Scan While Abdomen Pertindakan 1,920,000 480,000 2,400,000 62 CT Scan Cervicalis Pertindakan 1,920,000 480,000 2,400,000 63 CT Scan Thoracalis/lumbal/sacral Pertindakan 1,920,000 480,000 2,400,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 64 CT Scan Nasopharinx/larinx Pertindakan 1,920,000 480,000 2,400,000 65 CT Scan Orbita Pertindakan 1,280,000 320,000 1,600,000 Mamography - - - 66 Mamography Pertindakan 560,000 240,000 800,000 Panoramic 67 Panoramic dental Pertindakan 50,400 39,600 90,000 C. Pemeriksaan Diagnostik Elektromedis Diagnostik Sederhana 1 Fotal Dopler Pertindakan 4,000 6,000 10,000 2 CTQ Pertindakan 4,800 7,200 12,000 3 Tonometri Pertindakan 2,800 4.200 7,000 4 Funducopi Pertindakan 2,800 4.200 7,000 5 Visus (Koreksi) Pertindakan 2,600 3,900 6,500 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Buta Warna Pertindakan 3,000 4,500 7,500 Diagnostik Sedang 1 EEG Pertindakan 15,000 25,000 40,000 2 Slip Lamp Pertindakan 5,000 7,500 12,500 3 Audiometri Pertindakan 24,000 36,000 60,000 4 Endoscopi Pertindakan 24,000 36,000 60,000 5 USG Mata Pertindakan 12,000 18,000 30,000 Diagnostik Canggih 1 Monitor ICU Pertindakan 40,000 60,000 100,000 2 Ventilator Pertindakan 40,000 60,000 100,000 3 CPAP Pertindakan 40,000 60,000 100,000 D. Pelayanan Farmasi No Jenis Pelayanan Nilai 1 Faktor Pelayanan 30% x Harga Dasar Farmasi (Sudah Termasuk PPN) 2 Emblage No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total - Puyer ∑ Tiap Bungkus Puyer x Rp 300 - Resep Obat Jadi ∑ Resep x Rp 1.500 - Kapsul ∑ Tiap Bungkus Kapsul x Rp 300 - Racikan Salep/ Cream ∑ Tiap Racikan x Rp 5.000 E. Pelayanan Medico Legal No Jenis Pelayanan Jasa Sarana Jasa Pelayanan Total 1 Visum – pemeriksaan jenazah bagian luar saja Perpemeriksaan 50,000 50,000 100,000 2 Visum – pemeriksaan jenazah bagian luar saja – pada hari libur Perpemeriksaan 50,000 100,000 150,000 3 Visum – otopsi Perpemeriksaan 100,000 150,000 250,000 4 Visum – otopsi – hari libur Perpemeriksaan 100,000 200,000 300,000 5 Visum di luar RS – TKP Perpemeriksaan 160,000 200,000 360,000 6 Visum di luar RS – TKP dg penggalian Perpemeriksaan 160,000 250,000 410,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 7 Visum Et Repartum Perpemeriksaan 50,000 50,000 100,000 8 Mengeluarkan bayi dari jenazah ibu Pertindakan 50,000 50,000 100,000 F. Pelayanan Perawatan Jenazah 1 Penyimpanan Jenazah perhari 10,000 5.000 15,000 2 Pendinginan di kulkas/ hari 30,000 20,000 50,000 3 Pengawetan Jenazah 250,000 100,000 350,000 4 Pembedahan Jenazah 300,000 300,000 600,000 5 Pemusalaran Jenazah 150,000 150,000 300,000 G. Pelayanan Ambulance 1 Ambulan paramedik (Abodemen) Abodemen Awal 48,750 26,250 75,000 2 Ambulan Medik umum (Abodemen) Abodemen Awal 48,750 26,250 75,000 3 Ambulan Medik Spesialis (Abodemen) Abodemen Awal 48,750 26,250 75,000 4 Ambulance Jenazah (Abodemen) Abodemen Awal 48,750 26,250 75,000 5 Ambulan paramedik (Per-Km) Per-Km 4,480 3,520 8,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Ambulan Medik umum (Per-Km) Per-Km 5,600 4,400 10,000 7 Ambulan Medik Spesialis (Per-Km) Per-Km 6,720 5,280 12,000 8 Ambulance Jenazah (Per-Km) Per-Km 5,600 4,400 10,000 9 Ambulance Antar / Jemput Pasien (Per-Km) Per-Km 5,600 4,400 10,000 Komponen biaya pelayanan kendaraan ambulance meliput :
1.Jasa Sarana 50%
2.Jasa Pelayanan 50% dengan rincian pembagian sebagai berikut:

a.Direktur : 4%
b.Driver Ambulance : 21% (djadikan 100%, dan dibagi 98% untuk driver ambulance dan 2% untuk penanggung jawab ambulance)
c.Perawat : 17%
d.Unit Penjaminan Pasien : 4%
e.Rekam Medik : 2%
f.Kasir : 2% No Jenis Pelayanan Jasa Sarana Jasa Pelayanan Total H. Pelayanan Transfusi Darah 1 Pemeriksaan Golongan Darah Pertindakan 36,790 28,763 65,553 2 Pemeriksaan HB Pertindakan 36,790 28,763 65,553 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 3 Aftaf/ Penyadapan darah Pertindakan 69,460 54,305 123,766 4 Uji Saring IMLTD Pertindakan 19,373 15,146 34,520 5 Uji Silang Serasi/ Crossmatching Pertindakan 111,673 87,308 198,982 6 Pengolahan/Pemisahan Darah Pertindakan 913 714 1,626 III. Non Layanan Medis A. Pelayanan Surat Keterangan Kesehatan No Jenis Pelayanan Jasa Sarana Jasa Pelayanan Total 1 Pengujian Kesehatan (SKBS) Perpemeriksaan 28,000 22,000 50,000 2 Surat Kesehatan Kematian Perpemeriksaan 8,000 12,000 20,000 3 Surat Keterangan Kelahiran Perpemeriksaan 4,000 6,000 10,000 4 Surat Keterangan Lainnya Perpemeriksaan 4,000 6,000 10,000 5 Surat Keterangan Bebas Narkoba Perpemeriksaan 31,000 24,000 55,000 6 Surat Keterangan Berbadan Sehat dengan Pemeriksaan Lengkap Darah Rutin dan Thorax Perpemeriksaan 135,000 105,000 240,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total B. Praktek Klinik Praktek Klinik per orang/hari 1 DIII Perhari 4,000 6,000 10,000 2 DIV Perhari 4,000 11,000 15,000 3 Profesi Perhari 11,000 9,000 20,000 4 S I Keperawatan Perhari 4,000 11,000 15,000 5 S I Kesehatan Masyarakat Perhari 4,000 11,000 15,000 6 S I Kedokteran Perhari 4,000 11,000 15,000 7 S1 kebidanan Perhari 4,000 11,000 15,000 C. Penelitian Penelitian per Orang per Paket 1 DIII Perpenelitian 15,000 60,000 75,000 2 DIV Perpenelitian 30,000 120,000 150,000 3 S1 Keperawatan Perpenelitian 30,000 120,000 150,000 4 S1 Bidang Kesehatan Perpenelitian 30,000 120,000 150,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 5 S1 di luar Bidang Kesehatan Perpenelitian 25,000 100,000 125,000 6 S1 Kedokteran Perpenelitian 45,000 155,000 200,000 7 S2 Bidang Kesehatan Perpenelitian 75,000 225,000 300,000 8 S2 di luar Bidang Kesehatan Perpenelitian 65,000 200,000 265,000 9 Profesi Perpenelitian 75,000 225,000 300,000 10 Kaji banding luar/dalam Bidang Kesehatan Perorang 75,000 225,000 300,000 D. Pemakaian Oksigen Tariff pemakaian O2 tabung Rp. 200,- per liter untuk semua ruang perawatan Tarif layanan Isi Ulang Oksigen O2 (PAD lainnya RSUD)
1. 1.Tabung Besar 215,000
2. 2.Tabung Sedang 135,000
3. 3.Tabung Kecil 95,000 IV. Tarif Pelayanan Operasi Tindakan Operatif No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total A. Bedah Digestif Kecil 1 Ekstraksi Benda Asing di Saluran Cerna Bagian Atas/Bawah Pertindakan 1,575,280 1,237,720 2,813,000 2 Hemostasis Saluran Cerna Bagian Atas/Bawah Pertindakan 1,575,280 1,237,720 2,813,000 3 Operasi Hernia tanpa Komplikasi Pertindakan 1,575,280 1,237,720 2,813,000 4 Pemasangan Flocare Pertindakan 1,575,280 1,237,720 2,813,000 5 Polipektomi Saluran Cerna Bagian Atas/Bawah Pertindakan 1,575,280 1,237,720 2,813,000 6 Savariy Bougie Pertindakan 1,575,280 1,237,720 2,813,000 7 Skleroterapi Varises Esofagus Pertindakan 1,575,280 1,237,720 2,813,000 Sedang - - 1 Apendektomi Akut Pertindakan 2,520,000 1,980,000 4,500,000 2 Fistulektomi/Fistula Ani Pertindakan 2,888,480 2,269,520 5,158,000 3 Hemoroidektomi Pertindakan 2,454,480 1,928,520 4,383,000 4 Herniatomi Pertindakan 2,425,360 1,905,640 4,331,000 5 Hernioraphi Pertindakan 2,425,360 1,905,640 4,331,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Kolostomi Pertindakan 2,525,040 1,983,960 4,509,000 Besar - - 1 Apendektomi Perforata Pertindakan 3,829,280 3,008,720 6,838,000 2 Eksplorasi Kolekdokus Pertindakan 4,460,400 3,504,600 7,965,000 3 Hernia Incarcerata Pertindakan 3,884,160 3,051,840 6,936,000 4 Kolesistektomi Pertindakan 3,857,280 3,030,720 6,888,000 5 Laparatomi Eksplorasi Pertindakan 3,663,520 2,878,480 6,542,000 6 Laparatomi Vries Coupe (VC) Pertindakan 3,836,000 3,014,000 6,850,000 7 Reseksi Anastomosis Pertindakan 4,306,960 3,384,040 7,691,000 8 Transeksi Esofagus Pertindakan 3,747,520 2,944,480 6,692,000 Khusus - - 1 Apendektomi Laparaskopi Pertindakan 8,512,000 6,688,000 15,200,000 2 Gastrectomi (Bilroth 1 dan 2) Pertindakan 8,512,000 6,688,000 15,200,000 3 Herniatomi Bilateral Pertindakan 8,512,000 6,688,000 15,200,000 4 Koledoko Jejunostomi Pertindakan 8,512,000 6,688,000 15,200,000 5 Laparaskopik Kolesistektomi Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Mega Kolon Hierchprung Pertindakan 8,512,000 6,688,000 15,200,000 7 Miles Operation Pertindakan 8,512,000 6,688,000 15,200,000 8 Pankreaktektomi Pertindakan 8,512,000 6,688,000 15,200,000 9 Reseksi Esofagus dan Interposisi Kolon Pertindakan 8,512,000 6,688,000 15,200,000 10 Reseksi Hepar Pertindakan 8,512,000 6,688,000 15,200,000 11 Spleenektomi Pertindakan 8,512,000 6,688,000 15,200,000 B. Bedah Anak Kecil 1 Biopsi Eksisi Kelenjar Getah Bening Dengan Anastesi Umum Pertindakan 1,149,120 902,880 2,052,000 2 Biopsi Insisi Tumor dengan Anastesi Umum Pertindakan 1,149,120 902,880 2,052,000 3 Biopsi Rectum Full Thicknesis Pertindakan 1,149,120 902,880 2,052,000 4 Circumsisi Bayi dan anak dengan Anastesi Umum Pertindakan 1,149,120 902,880 2,052,000 5 Eksisi Granuloma/Granuloma Hibilical/Hemanioma Kecil Pertindakan 1,149,120 902,880 2,052,000 6 Eksisi Hemangioma Kecil Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 7 Eksterpasi Limpoma, Ganglion Kista Epidermoid, Neurolibroma Sactase Pertindakan 1,149,120 902,880 2,052,000 8 Ekstrackel Benda Asing dengan Anastesi Umum Pertindakan 1,149,120 902,880 2,052,000 9 Insisi/drainase Abses dengan Anastesi Umum Pertindakan 1,149,120 902,880 2,052,000 10 Polipectomi Rectum Pertindakan 1,149,120 902,880 2,052,000 11 Release Tongue Tie Pertindakan 1,575,280 1,237,720 2,813,000 12 Sirkumsisi pada Phymosis dengan Narkose Pertindakan 1,575,280 1,237,720 2,813,000 Sedang 1 Herniotomi Unilateral Pertindakan 3,558,240 2,795,760 6,354,000 2 Appendectomy Simple Pertindakan 2,240,000 1,760,000 4,000,000 3 Eksisi Baker Cyst Pertindakan 3,002,720 2,359,280 5,362,000 4 Eksisi Gynecomastia Pertindakan 2,996,560 2,354,440 5,351,000 5 Eksisi Hemangmioma Sedang Pertindakan 2,240,000 1,760,000 4,000,000 6 Eksisi Hygroma/Lymhagioma Simple Pertindakan 2,240,000 1,760,000 4,000,000 7 Eksisi Kista Brachialis Pertindakan 2,240,000 1,760,000 4,000,000 8 Eksisi Kista Duktus Triglosus Pertindakan 3,459,680 2,718,320 6,178,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 9 Eksisi Neurofibroma Multiple Pertindakan 2,956,240 2,322,760 5,279,000 10 Eksisi/Limfangioma Simple Pertindakan 2,815,680 2,212,320 5,028,000 11 Fistulectomy Perianal Pertindakan 2,600,080 2,042,920 4,643,000 12 Gastroduodenoskopi Pertindakan 2,996,560 2,354,440 5,351,000 13 Insisi Tongue Tie Pertindakan 2,996,560 2,354,440 5,351,000 14 Kolonoskopi Pertindakan 3,274,880 2,573,120 5,848,000 15 Kolostomi/Ikostomi/Kemonostomi Anak Pertindakan 2,949,520 2,317,480 5,267,000 16 Ligasi Tinggi Hidrokel pada Anak Pertindakan 2,643,200 2,076,800 4,720,000 17 Orchidectomy pada Anak Pertindakan 2,629,200 2,065,800 4,695,000 18 Orchidectomy/Orchidopexy Unilateral Pertindakan 3,001,600 2,358,400 5,360,000 19 Polypectomy Rectum Pertindakan 2,240,000 1,760,000 4,000,000 20 Potong Stump Pertindakan 2,738,400 2,151,600 4,890,000 21 Potong Stump (Rectum) Pertindakan 2,240,000 1,760,000 4,000,000 22 Prosedur Thiersch (Prolaps Anus) Pertindakan 2,240,000 1,760,000 4,000,000 23 Release Synechia Vulva Pertindakan 2,994,320 2,352,680 5,347,000 24 Repair Defek Hernia Umbilikalis Pertindakan 3,002,720 2,359,280 5,362,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 25 Repair VP Shunt Pertindakan 3,022,320 2,374,680 5,397,000 26 Septectomy (Potong Septum) Pertindakan 3,216,080 2,526,920 5,743,000 27 Sphincterotomy/Lynn Procedure Pertindakan 3,002,720 2,359,280 5,362,000 Besar 1 Anoplasty/Limited Posterior Sagittal Anorectoplasty (PSARP)/Repair Anoplasty Pertindakan 3,745,280 2,942,720 6,688,000 2 Biopsi/Proof Laparatomy Pertindakan 3,836,000 3,014,000 6,850,000 3 Detorsi Testis dan Orchidopexy Pertindakan 3,702,720 2,909,280 6,612,000 4 Eksisi Hemangioma Besar/Multiple Pertindakan 3,698,240 2,905,760 6,604,000 5 Eksisi Hemangioma Besar Skingraft (Split-Thickness Skin Graft (STSG)/ Full-Thickness Skin Grafts (FTSG)) Pertindakan 3,698,240 2,905,760 6,604,000 6 Eksisi Higroma pada Anak Pertindakan 3,702,720 2,909,280 6,612,000 7 Eksisi Kista Bronchia Pertindakan 3,702,720 2,909,280 6,612,000 8 Eksisi Kista Urachus Pertindakan 3,702,720 2,909,280 6,612,000 9 Gastroduodenoskopi Pertindakan 3,836,000 3,014,000 6,850,000 10 Gastronomi pada Neonatus Pertindakan 3,925,600 3,084,400 7,010,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 11 Herniotomi Bilateral Pertindakan 3,702,720 2,909,280 6,612,000 12 Herniotomi Hernia Inkarserata/Strangulate Pertindakan 3,925,600 3,084,400 7,010,000 13 Higroma Colli/Limfangioma Besar Pertindakan 3,702,720 2,909,280 6,612,000 14 Khordektomi Pertindakan 3,739,120 2,937,880 6,677,000 15 Khordektomi pada Hyspopadia Pertindakan 3,836,000 3,014,000 6,850,000 16 Kolostomi Neonatus/Ikostomi/Jejunostomi Pertindakan 3,657,920 2,874,080 6,532,000 17 Koreksi Atresia Ani Pertindakan 3,696,000 2,904,000 6,600,000 18 Laparatomi dan Apendoktomi Apendix Perforasi Pertindakan 5,216,400 4,098,600 9,315,000 19 Laparatomi dan Milking/Reseksi pada Invaginasi Pertindakan 5,216,400 4,098,600 9,315,000 20 Laparatomy pada Perforasi Usus pada Anak Pertindakan 3,836,000 3,014,000 6,850,000 21 Laparatomy pada Trauma Abdomen Pertindakan 3,836,000 3,014,000 6,850,000 22 Operasi Hernia dengan Komplikasi Pertindakan 3,857,840 3,031,160 6,889,000 23 Operasi Hernia tanpa Komplikasi Pertindakan 3,799,040 2,984,960 6,784,000 24 Operasi Hydrokel Pertindakan 3,747,520 2,944,480 6,692,000 25 Operasi Hypospadia/Kordektomi Pertindakan 4,252,080 3,340,920 7,593,000 26 Prosedur Tiersch (Prolapsus Recti) Pertindakan 3,702,720 2,909,280 6,612,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 27 Repair Fistula Recto Vaginal Pertindakan 3,702,720 2,909,280 6,612,000 28 Skrotoplasti Pertindakan 3,702,720 2,909,280 6,612,000 29 Splenectomy pada Trauma Pertindakan 3,721,200 2,923,800 6,645,000 Khusus 1 Abdominoperinal Pull-Through (Malfromasi) Pertindakan 8,512,000 6,688,000 15,200,000 2 Abdominoperinal Pull-Through/Swenson Pertindakan 8,512,000 6,688,000 15,200,000 3 Astresia Esofagus Pertindakan 8,512,000 6,688,000 15,200,000 C Bedah Kebidanan dan Kandungan Kecil 1 Cone Biopsi/Konisasi/ Large Loop Excision of the Transformation Zone (LLETZ) Pertindakan 1,575,280 1,237,720 2,813,000 2 Drainase Pus pada Tuboovarial Abses dengan Punksi Doglasi Pertindakan 1,575,280 1,237,720 2,813,000 3 Eksterpasi Kista Bartholin/Miom Geburt Pertindakan 1,575,280 1,237,720 2,813,000 4 Histerectomi Trans Vaginal/trans abdominal et SOB Pertindakan 1,575,280 1,237,720 2,813,000 5 Kuretase/Dilatasi Kuretasi dengan Narkose Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Laparascopy Operatif -Histereroskopi/Laparatomy Percobaan Pertindakan 1,575,280 1,237,720 2,813,000 7 Marsupialisasi Abses Bartholin Pertindakan 1,575,280 1,237,720 2,813,000 8 Repair Perinium Grade III -IV Pasca Persalinan Pertindakan 1,575,280 1,237,720 2,813,000 9 Tindakan Manual Plasenta Pertindakan 1,575,280 1,237,720 2,813,000 10 Tuba Plasty Pertindakan 1,575,280 1,237,720 2,813,000 11 Vasektomi Pertindakan 1,575,280 1,237,720 2,813,000 Sedang Pertindakan - - 1 Eksisi/Konisasi Pertindakan 3,741,920 2,940,080 6,682,000 2 Kuretase dengan Perdarahan Uterus Disfungsional (PUD)/Polip Pertindakan 2,900,800 2,279,200 5,180,000 3 Laparatomy Percobaan Pertindakan 3,435,600 2,699,400 6,135,000 4 Sirklase Pertindakan 3,225,600 2,534,400 5,760,000 5 Tubektomi Pertindakan 3,220,000 2,530,000 5,750,000 Berat Pertindakan - - 1 Adesolisis Pertindakan 3,752,000 2,948,000 6,700,000 2 Ekstipasi Adenomiosis Pertindakan 3,752,000 2,948,000 6,700,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 3 Exflorasi Vagina Pertindakan 3,752,000 2,948,000 6,700,000 4 Hystrectomy Partial Pertindakan 4,011,840 3,152,160 7,164,000 5 Hystrectomy Total Pertindakan 3,836,560 3,014,440 6,851,000 6 Kalporeksis Pertindakan 3,752,000 2,948,000 6,700,000 7 Kehamilan Ektopik Terganggu (KET) Pertindakan 3,811,360 2,994,640 6,806,000 8 Kistektomi Pertindakan 4,215,680 3,312,320 7,528,000 9 Laparatomi FC Pertindakan 3,949,120 3,102,880 7,052,000 10 Myomectomy Pertindakan 3,752,000 2,948,000 6,700,000 11 Operasi Manchester Fortegil Pertindakan 3,752,000 2,948,000 6,700,000 12 Operasi Perineum Pertindakan 3,752,000 2,948,000 6,700,000 13 Operasi Tumor Jinak Ovarium Pertindakan 3,752,000 2,948,000 6,700,000 14 Repair Fistel Pertindakan 3,752,000 2,948,000 6,700,000 15 Reseksi Adenomiosis Pertindakan 4,280,640 3,363,360 7,644,000 16 Salpingo Ophorectomy Bilateral Pertindakan 3,752,000 2,948,000 6,700,000 17 Salpingo Ovarectomy Pertindakan 3,752,000 2,948,000 6,700,000 18 Seksio Sesaria Pertindakan 3,752,000 2,948,000 6,700,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total Khusus Pertindakan - - 1 Adenolisis Pertindakan 8,848,000 6,952,000 15,800,000 2 Debulking Pertindakan 8,848,000 6,952,000 15,800,000 3 Histerectomy Radikal Pertindakan 8,848,000 6,952,000 15,800,000 4 Hysterectomy Supravaginal Pertindakan 8,848,000 6,952,000 15,800,000 5 Laparascopy Operatif Pertindakan 8,848,000 6,952,000 15,800,000 6 Operasi Tumor Ganas Ovarium Pertindakan 8,848,000 6,952,000 15,800,000 7 Rekonstruksi Urogenitalia Pertindakan 8,848,000 6,952,000 15,800,000 8 Repair Fistel Pertindakan 8,848,000 6,952,000 15,800,000 9 SC dengan B Lynch/SC dengan HT Subtotal/SC dengan Ligasi Arteri Uterine/SC dengan SO (Torsi Kista) Pertindakan 8,848,000 6,952,000 15,800,000 10 Surgical Staging Pertindakan 8,848,000 6,952,000 15,800,000 11 Vulvektomi Pertindakan 8,848,000 6,952,000 15,800,000 D Bedah Mata Kecil No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 1 Eksisi Tumor Adneksa Kecil Pertindakan 1,575,280 1,237,720 2,813,000 2 Foto Koagulasi Laser Pertindakan 1,575,280 1,237,720 2,813,000 3 Gonioplasty Pertindakan 1,575,280 1,237,720 2,813,000 4 Goniotomi Pertindakan 1,575,280 1,237,720 2,813,000 5 Laser Iridotomi Perifer Pertindakan 1,575,280 1,237,720 2,813,000 6 Pterigium dan CLG Pertindakan 1,575,280 1,237,720 2,813,000 7 Repair Ruptur Palpebra Simpel Pertindakan 1,575,280 1,237,720 2,813,000 8 Reposisi Dislokasi Lensa Intraokular (IOL) Pertindakan 1,575,280 1,237,720 2,813,000 9 Reposisi Iris Pertindakan 1,575,280 1,237,720 2,813,000 10 Retcam dan Narkose Pertindakan 1,575,280 1,237,720 2,813,000 11 Yag Laser Pertindakan 1,575,280 1,237,720 2,813,000 Sedang 1 Foto Koagulasi (Acc) Pertindakan 2,105,600 1,654,400 3,760,000 2 Biopsi Tumor Orbita Pertindakan 2,279,200 1,790,800 4,070,000 3 Eksisi Tumor Adneksa Sedang Pertindakan 2,279,200 1,790,800 4,070,000 4 Koreksi Symblepharon Pertindakan 2,279,200 1,790,800 4,070,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 5 Pthisis Bulbi (Graft Mukosa Bibir) Pertindakan 2,279,200 1,790,800 4,070,000 6 Repair Ruptur Palpebra Transkanal Pertindakan 2,279,200 1,790,800 4,070,000 7 Tindakan Congenital Fornix Plastik Pertindakan 2,279,200 1,790,800 4,070,000 8 Tindakan Cyclodia Terni Pertindakan 2,279,200 1,790,800 4,070,000 9 Trabekulektomi Pertindakan 2,279,200 1,790,800 4,070,000 Besar 1 Ekstraksi katarak ekstrakapsular/intrakapsular ICCE/ECCE (Tidak Termasuk IOL) (Acc) Pertindakan 3,696,000 2,904,000 6,600,000 2 Anterio/Posterior Sklerotomi Pertindakan 3,696,000 2,904,000 6,600,000 3 Argon Laser/Kenon Pertindakan 3,822,000 3,003,000 6,825,000 4 Congenital Formix Plastik/Rekst Soket Berat Pertindakan 3,696,000 2,904,000 6,600,000 5 Cyclodia Termi Pertindakan 3,696,000 2,904,000 6,600,000 6 Cyclodialysa Pertindakan 3,696,000 2,904,000 6,600,000 7 Ekstraksi Linear Pertindakan 3,696,000 2,904,000 6,600,000 8 Goniotomi/ Goniotomi dan Anastesi Pertindakan 3,696,000 2,904,000 6,600,000 9 Kapsulektomi Posterior Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 10 Keratoplastie Lamelar Pertindakan 3,696,000 2,904,000 6,600,000 11 Koreksi Ektropion/Entropion/ Koreksi Ektropion/Entropion (Anak-anak) Pertindakan 3,696,000 2,904,000 6,600,000 12 Orbiotomi Anterior Pertindakan 3,696,000 2,904,000 6,600,000 13 Parasentesa Pertindakan 3,696,000 2,904,000 6,600,000 14 Rekanalisasi Ruptura/Transkanal Pertindakan 3,696,000 2,904,000 6,600,000 15 Repair Ruptur Korneosklera Pertindakan 3,696,000 2,904,000 6,600,000 16 Ruptur Palpebra Moderate Pertindakan 3,696,000 2,904,000 6,600,000 17 Sceral Buckling Pertindakan 3,696,000 2,904,000 6,600,000 18 Strabismus Pertindakan 3,696,000 2,904,000 6,600,000 19 Symblepharon Pertindakan 3,696,000 2,904,000 6,600,000 20 Symblepharon dan Anastesi Pertindakan 3,696,000 2,904,000 6,600,000 21 Trakbekulektomi Pertindakan 3,696,000 2,904,000 6,600,000 22 Tridenelisis Pertindakan 3,696,000 2,904,000 6,600,000 23 Tumor Ganas/Adnesa Luas Rekontruksi Pertindakan 3,696,000 2,904,000 6,600,000 Khusus No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 1 Ablatio Retina Pertindakan 11,478,880 9,019,120 20,498,000 2 Dacryo Cysto Rhinostomy Pertindakan 8,512,000 6,688,000 15,200,000 3 DCR dan Silikon Tube Pertindakan 8,512,000 6,688,000 15,200,000 4 Dekompresi Orbita Pertindakan 8,512,000 6,688,000 15,200,000 5 Eksenterasi Pertindakan 8,512,000 6,688,000 15,200,000 6 Ekstirpasi Tumor Ganas Adnesa dan Rekonstruksi Pertindakan 8,512,000 6,688,000 15,200,000 7 Enukleas dan DFG/ Eviserasi danDFG Pertindakan 8,512,000 6,688,000 15,200,000 8 Fraktur Tripodo/Multiple Pertindakan 8,512,000 6,688,000 15,200,000 9 Keratoplasti Pertindakan 8,512,000 6,688,000 15,200,000 10 Koreksi Simblefaron Berat Pertindakan 8,512,000 6,688,000 15,200,000 11 Operasi Fraktur Tripod/Multiple Pertindakan 9,135,280 7,177,720 16,313,000 12 Orbitotomi Lateral Pertindakan 8,512,000 6,688,000 15,200,000 13 Phacoemulsifikasi Pertindakan 8,512,000 6,688,000 15,200,000 14 Ptosis Pertindakan 8,512,000 6,688,000 15,200,000 15 Ptosis dan Anastesi Pertindakan 8,512,000 6,688,000 15,200,000 16 Rekonstruksi Orbita Kongenital Pertindakan 9,135,280 7,177,720 16,313,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 17 Rekontruksi Kelopak Berat/Orbita Congenital/ Saket Berat Pertindakan 8,512,000 6,688,000 15,200,000 18 Scheral Buckel dan Cyro dan C3F8 Pertindakan 8,512,000 6,688,000 15,200,000 19 Strabismus 3-4 Otot Pertindakan 8,512,000 6,688,000 15,200,000 20 Syndroma Blefarophimosis Pertindakan 8,512,000 6,688,000 15,200,000 21 Trabekulektomi/Trabekulektomi dan ECCE- Phacoemulsifikasi Pertindakan 8,512,000 6,688,000 15,200,000 22 Triple Prosedur Keratoplasti dengan Glaukoma Pertindakan 8,512,000 6,688,000 15,200,000 23 Vitrektomi Pertindakan 12,181,680 9,571,320 21,753,000 24 Vitrektomi dan Endo Laser dan SB dan Silikon Oil/Gas Pertindakan 11,970,000 9,405,000 21,375,000 F Onkology Kecil 1 Biopsi Eksisional dalam Narkose/Incisional dalam Narkose Pertindakan 1,575,280 1,237,720 2,813,000 2 Eksisi FAM <5 cm Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 3 Ekstirpasi Kista Ateroma/Lipoma/Ganglion >2 cm Pertindakan 1,575,280 1,237,720 2,813,000 4 Ekstirpasi Tumor Jinak Kulit 0<3 cm (Lipoma Atheroma) Pertindakan 1,575,280 1,237,720 2,813,000 5 Pengangkatan Fibro Adenoma Mamae Pertindakan 1,575,280 1,237,720 2,813,000 6 Reshaping untuk Torus/Tumor Tulang Pertindakan 1,575,280 1,237,720 2,813,000 Sedang 1 Biopsi dalam Narkose Umum Pertindakan 2,162,720 1,699,280 3,862,000 2 Drainage Kista Pankreas Pertindakan 2,279,200 1,790,800 4,070,000 3 Eksisi Multiple Fibro Adenoma Mamae (FAM) Pertindakan 2,279,200 1,790,800 4,070,000 4 Fibro Adenoma Mamae Pertindakan 2,215,920 1,741,080 3,957,000 5 Pemasangan Traksi Servikal Pertindakan 2,279,200 1,790,800 4,070,000 6 Salphingo Oophorektomy Unilateral Pertindakan 2,279,200 1,790,800 4,070,000 7 Segmentektomi Pertindakan 2,279,200 1,790,800 4,070,000 Besar No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 1 Breast Conserving Surgery Pertindakan 3,696,000 2,904,000 6,600,000 2 Eksisi Higroma/ Kista Branchiogenik/ Kista Tiroglosus/ Luas local/ Mammae Aberran Pertindakan 3,696,000 2,904,000 6,600,000 3 Eksisi Pertindakan 3,696,000 2,904,000 6,600,000 4 Enucleatie Kista D 42 Pertindakan 3,696,000 2,904,000 6,600,000 5 Hemiglosektomi/Eksisi Tumor Lidah Pertindakan 3,696,000 2,904,000 6,600,000 6 Hemimandibulektomi Pertindakan 3,696,000 2,904,000 6,600,000 7 Isthmolobektomi Pertindakan 3,696,000 2,904,000 6,600,000 8 Isthobektomi Pertindakan 3,696,000 2,904,000 6,600,000 9 Lobektomi Tiroid Pertindakan 3,696,000 2,904,000 6,600,000 10 Mandibulektomi Marginalis Pertindakan 3,696,000 2,904,000 6,600,000 11 Masilektomi Partialis, Simple, Sub kutaneus Pertindakan 3,696,000 2,904,000 6,600,000 12 Near Total Tiroidektomi Pertindakan 3,696,000 2,904,000 6,600,000 13 Ophorektomi Bilateral Pertindakan 3,696,000 2,904,000 6,600,000 14 Parotidektomi Pertindakan 3,696,000 2,904,000 6,600,000 15 Pembedahan Kompartemental Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 16 Potong Flap Pertindakan 3,696,000 2,904,000 6,600,000 17 Rekonstruksi Sedang (STSG FTSG Flap Lokal) Pertindakan 3,696,000 2,904,000 6,600,000 18 Salphingo Oophorektomy Bilateral Pertindakan 3,696,000 2,904,000 6,600,000 19 Segmentektomi Pertindakan 3,696,000 2,904,000 6,600,000 20 Tirodektomi Pertindakan 3,696,000 2,904,000 6,600,000 21 Tracheostomi Pertindakan 3,696,000 2,904,000 6,600,000 Khusus 1 Deseksi Kelenjar Inguinal Pertindakan 8,512,000 6,688,000 15,200,000 2 Debulking Pertindakan 8,512,000 6,688,000 15,200,000 3 Diseksi Leher Radikal Modifikasi/Fungsional Pertindakan 8,512,000 6,688,000 15,200,000 4 Eksisi Kelenjar Liur Submandibula Pertindakan 8,512,000 6,688,000 15,200,000 5 Eksisi Luas Radikal dan Rekontruksi Pertindakan 8,512,000 6,688,000 15,200,000 6 Glosektomi Totalis Pertindakan 8,512,000 6,688,000 15,200,000 7 Hemiglosektomi dan Radical Neck Dissection (RND) Pertindakan 8,512,000 6,688,000 15,200,000 8 Hemipelvektomi Pertindakan 8,512,000 6,688,000 15,200,000 9 Maksilektomi Totalis Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 10 Mandibulektomi Partialis dengan Rekontruksi Pertindakan 8,512,000 6,688,000 15,200,000 11 Mandibulektomi Totalis Pertindakan 8,512,000 6,688,000 15,200,000 12 Mastektomi Radikal/simpleks Pertindakan 8,512,000 6,688,000 15,200,000 13 Operasi Commando Pertindakan 8,512,000 6,688,000 15,200,000 14 Parotidektomi Radikal dan Mandibulektomi Pertindakan 8,512,000 6,688,000 15,200,000 15 Pembedahan Forequater Pertindakan 8,512,000 6,688,000 15,200,000 16 Rekonstruksi Mayor Pertindakan 8,512,000 6,688,000 15,200,000 G Bedah Orthopedi Kecil 1 Amputasi dan Rakonstruksi Jari Polydactil/Amputasi Jari Extra Digit (Single) Pertindakan 1,575,280 1,237,720 2,813,000 2 Skin Graft Orthopedi Pertindakan 1,575,280 1,237,720 2,813,000 3 Angkat K-Wire dengan Hecting Pertindakan 1,575,280 1,237,720 2,813,000 4 Arthoplasty Sendi (Jari) Various Lesions Pertindakan 1,575,280 1,237,720 2,813,000 5 Arthrodesis Sendi Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Biopsy Nerve Various Lesions Pertindakan 1,575,280 1,237,720 2,813,000 7 Bony Bridengane Release pada Kasus Tarsal Coalition Pertindakan 1,575,280 1,237,720 2,813,000 8 Capsulectomy/Capsulotomy Sendi (Jari) Contracture Pertindakan 1,575,280 1,237,720 2,813,000 9 Closed Reduction dan Pemasangan Gips Fraktur Femur pada Anak Pertindakan 1,575,280 1,237,720 2,813,000 10 Curretage dan Bonegraft Tumor Jinak Tulang Pertindakan 1,575,280 1,237,720 2,813,000 11 Debridement dan Soft Tissue Release pada Infeksi Sendi Pertindakan 1,575,280 1,237,720 2,813,000 12 Debridement Fraktur Terbuka/Jari/ Nekrotik Tissue/Necrotomy dan Saucerization pada Chronic Osteomyelits Pertindakan 1,575,280 1,237,720 2,813,000 13 Debridement Pertindakan 1,575,280 1,237,720 2,813,000 14 Debulking Jari (Macrodactyly) Pertindakan 1,575,280 1,237,720 2,813,000 15 Defect Grafting (Single) Tendon-Plexor (Ektremitas Atas) Pertindakan 1,575,280 1,237,720 2,813,000 16 Dekompresi (Unilateral/Bilateral) Ekstremitas Atas Pertindakan 1,575,280 1,237,720 2,813,000 17 Drainage Jari Superficial/Deep Infection-Drainage Jaringan Lunak (Parmar Space) Abscess/ Drainage Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total Tendon Sheath (Ekstremitas Atas) Tenosynovitis (Single/Multiple) 18 Transposisi Nerve Ulnar Entrapment Pertindakan 1,575,280 1,237,720 2,813,000 19 Terminalisation Jari Trauma Pertindakan 1,575,280 1,237,720 2,813,000 20 Eksisi/Diseksi Of Neurovasculer Bundle (Jari Tumor) Pertindakan 1,575,280 1,237,720 2,813,000 21 Eksisi Bony Fragment Elbow (Medical Epicondyle) Fracture Pertindakan 1,575,280 1,237,720 2,813,000 22 Eksisi JarJaringan Lunak Tumor/Wart/Com/Naevus Pertindakan 1,575,280 1,237,720 2,813,000 23 Eksisi Tendon Sheath (Extremitas Atas) & Jaringan Subkutis Ganglion/Villo Nodular Synovitis Pertindakan 1,575,280 1,237,720 2,813,000 24 Fiksasi Cannuated Screw pada SCFE Pertindakan 1,575,280 1,237,720 2,813,000 25 Fiksasi Externa Sederhana/ Fiksasi Interna Sederhana Pertindakan 1,575,280 1,237,720 2,813,000 26 Synovectomy Arthroscopy Pertindakan 1,575,280 1,237,720 2,813,000 27 Fraktur Tulang Panjang-MIPO/ Open Reduction and Internal Fixation (ORIF) dan Implat Removal (Long Bone) Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 28 Free Full Thickness Graft Kulit dan Jaringan Subkultis Defect (Single Digit) Pertindakan 1,575,280 1,237,720 2,813,000 29 Graft Nerve Defect/Peripheral/Tendon-Flexor (Ekstremitas Atas) Injury Pertindakan 1,575,280 1,237,720 2,813,000 30 Koreksi Curly Toe/ Koreksi Overriding Toe Polidactily/ Koreksi Syndactyly Pertindakan 1,575,280 1,237,720 2,813,000 31 Tenolysis (Multiple) Tendon-Flexor (Ekstremitas Atas) Pertindakan 1,575,280 1,237,720 2,813,000 32 Tenotomy Tendon (Ekstremitas Atas) Contracture Pertindakan 1,575,280 1,237,720 2,813,000 33 Lengthening Open Achilles Tendon Pertindakan 1,575,280 1,237,720 2,813,000 34 Limb Ablation: Above/Below Knee Amputation Soft Tissue Tumor/Sacroma/Bone Tumor Pertindakan 1,575,280 1,237,720 2,813,000 35 Local Flap Kulit dan Jaringan Subkutis Defect (Multiple Digits) Pertindakan 1,575,280 1,237,720 2,813,000 36 Necrotomy Pertindakan 1,575,280 1,237,720 2,813,000 37 Open Biopsy Bone Tumor Pertindakan 1,575,280 1,237,720 2,813,000 38 Open Knee Debridement Pertindakan 1,575,280 1,237,720 2,813,000 39 Operasi Flap (Defect (Deep) Staged Distant Flap (Division) (Kulit dan Jaringan Subkus) Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 40 ORIF Closed Fraktur Shaft Femur/ Radius/ Ulna/ Humerus/ Tibia/ Open Fraktur Shaft Femur/Radius/Ulna/Humerus (Grade 1&2) Pertindakan 1,575,280 1,237,720 2,813,000 41 Open reduction internal fixation /ORIF Pertindakan 1,575,280 1,237,720 2,813,000 42 Pengangkatan Ganglion Poplitea dengan Narkose Pertindakan 1,575,280 1,237,720 2,813,000 43 Release (Bilateral with Endoneurolysis) Nerve (Ekstremitas Atas) Pertindakan 1,575,280 1,237,720 2,813,000 44 Release (Unilateral) Nerve (Ekstremitas Atas) Guyon's Tunnel Syndrome Pertindakan 1,575,280 1,237,720 2,813,000 45 Release JarDeformity Instrinsic Muscle/Kompartemen Otot/Soft tissue/Tendon Sheath (ekstremitas atas) Pertindakan 1,575,280 1,237,720 2,813,000 46 Relokasi Jari Deformity Instrinsic Muscle Extensor Pertindakan 1,575,280 1,237,720 2,813,000 47 Removasi Sendi (Ekstemitas Atas) Rush Rods/Wires/Screw Pertindakan 1,575,280 1,237,720 2,813,000 48 Repair Suture Nerve Various Lesions Pertindakan 1,575,280 1,237,720 2,813,000 49 Reposisi Joint Dislocation Pertindakan 1,575,280 1,237,720 2,813,000 50 Reposisi Tertutup dan Gips pada Fraktur Anak Kecuali Fraktur Femur Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 51 Reposisi Tertutup Arthrogram dan Hemispica pada Developmental Dysplasia of the Hip (DDH) Pertindakan 1,575,280 1,237,720 2,813,000 52 Skin Graft Orthopedi Pertindakan 1,575,280 1,237,720 2,813,000 53 Synovectomy Arthroscopy Pertindakan 1,575,280 1,237,720 2,813,000 54 Tenolysis (Multiple) Temdon-Flexor (Ekstremitas Atas) Pertindakan 1,575,280 1,237,720 2,813,000 55 Tenotomy Tendon (Ekstremitas Atas) Contracture Pertindakan 1,575,280 1,237,720 2,813,000 56 Terminalisation Jari Trauma Pertindakan 1,575,280 1,237,720 2,813,000 57 Transposisi Nerve Ulnar Entrapment Pertindakan 1,575,280 1,237,720 2,813,000 Sedang Pertindakan - - 1 Amputasi Jari Pertindakan 2,646,560 2,079,440 4,726,000 2 Amputasi Transmedular Pertindakan 2,240,000 1,760,000 4,000,000 3 Angkat Pen/Screw Pertindakan 2,559,200 2,010,800 4,570,000 4 Atrhrotomy/Synovectomy Pertindakan 2,523,360 1,982,640 4,506,000 5 Biopsi dalam Narkose Pertindakan 2,621,920 2,060,080 4,682,000 6 Biopsi Saraf Kutaneus/Otot Pertindakan 2,525,040 1,983,960 4,509,000 7 Biopsy Vetebra (1 Level) Pertindakan 2,240,000 1,760,000 4,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 8 Blok Saraf Tepi Pertindakan 2,366,560 1,859,440 4,226,000 9 Closed Fraktur Intercondylar Femur/ Closed Fraktur Proksimal Tibia Involve Intraatikular/ Closed Fraktur Supracondylar Femur Pertindakan 2,240,000 1,760,000 4,000,000 10 Closed Reduksi dengan Anastesi umum Pertindakan 2,240,000 1,760,000 4,000,000 11 Dibredement Fraktur Terbuka Pertindakan 2,656,640 2,087,360 4,744,000 12 Discograph (1 level/multilevel) Pertindakan 2,240,000 1,760,000 4,000,000 13 Double Oesteotomy Pelvis Posterior pada Extrophy Bladder Pertindakan 2,240,000 1,760,000 4,000,000 14 Facet Block (1 Level/Multilevel) Pertindakan 2,240,000 1,760,000 4,000,000 15 Fiksasi External Sederhana Pertindakan 2,613,520 2,053,480 4,667,000 16 Fiksasi Internal Sederhana Pertindakan 2,937,200 2,307,800 5,245,000 17 Fiksasi Internal yang Kompleks Pertindakan 3,362,800 2,642,200 6,005,000 18 Foraminal Block (1 Level/Multilevel) Pertindakan 2,240,000 1,760,000 4,000,000 19 Fracture Acetabulum & Pelvic -ORIF Acetabulum & Pelvic Pertindakan 2,240,000 1,760,000 4,000,000 20 Fracture Acetabulum 1 Collum - ORIF (TR 14) Pertindakan 2,240,000 1,760,000 4,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 21 Fracture Artikuler -> MIPO/ORIF Acetabulum & Pelvic Pertindakan 2,240,000 1,760,000 4,000,000 22 Fracture Neck Humerus pada Orang Tua (>60)/ Fracture Subtrochanter Femur pada Orang Tua (>60) Pertindakan 2,240,000 1,760,000 4,000,000 23 Ganglion Poplitea Pertindakan 2,553,600 2,006,400 4,560,000 24 Hemiarthroplasty: Metastatic Bone Disease Pertindakan 2,240,000 1,760,000 4,000,000 25 Hemiarthroplasty Bahu/Hemiarthroplasty Fraktur Collum Femur pada Orang Tua (>60) Pertindakan 2,240,000 1,760,000 4,000,000 26 Skingrafting yang Tidak Luas Pertindakan 2,240,000 1,760,000 4,000,000 27 Intrasdiscal Electrohermic Therapy (IDET) Multilevel Pertindakan 2,240,000 1,760,000 4,000,000 28 Koreksi Disartikulasi Pertindakan 2,611,280 2,051,720 4,663,000 29 Koreksi Jari/Ring Construction (Single/Multiple)/Deformitas Pertindakan 2,240,000 1,760,000 4,000,000 30 Liberation Joint Stiffness Pertindakan 2,240,000 1,760,000 4,000,000 31 Limb Salvage Surgery Pertindakan 2,240,000 1,760,000 4,000,000 32 Multiple Fracture Tulang Panjang-MIPO/ORIF dan Removal Implant > 1 Pertindakan 2,240,000 1,760,000 4,000,000 33 Open Biopsy: Soft Tissue Pertindakan 2,240,000 1,760,000 4,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 34 Open Reduction Dislokasi Panggul dengan Acetabuplasty dan Femoral Osteomy Pertindakan 2,240,000 1,760,000 4,000,000 35 Operasi Rekonstruksi Ibu Jari pada Kaki Hallux Valgus Pertindakan 2,240,000 1,760,000 4,000,000 36 Oppnens Plasty Thumb Paralysis Pertindakan 2,240,000 1,760,000 4,000,000 37 ORIF: MBD Pertindakan 2,419,200 1,900,800 4,320,000 38 ORIF Fracture Pelvic Simple/ ORIF Shaft Tibia/Femur/ Radius/ Ulna/Humerus Grade 3 Pertindakan 2,240,000 1,760,000 4,000,000 39 Osteomyelitis Pertindakan 2,240,000 1,760,000 4,000,000 40 Osteotomy Jari Deformities Pertindakan 2,240,000 1,760,000 4,000,000 41 Palster Application Of Extremity and Spine Pertindakan 2,240,000 1,760,000 4,000,000 42 Potong Flap Pertindakan 3,008,880 2,364,120 5,373,000 43 Reconstruction Anterior Cruciate Ligament (Anterior/Posterior/ Lateral/Media) Pertindakan 2,240,000 1,760,000 4,000,000 44 Recurrent Shoulder Disclocation Repair TUBS and AMBRI Pertindakan 2,240,000 1,760,000 4,000,000 45 Reduksi Terbuka dan Fiksasi Interna Jari Carpus Fracture/Disclocation Pertindakan 2,240,000 1,760,000 4,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 46 Regional Flap Pertindakan 2,994,880 2,353,120 5,348,000 47 Rekonstruksi Instability Joint Infection Pertindakan 2,240,000 1,760,000 4,000,000 48 Rekonstruksi Jari Defect/Contracture (Single/Multiple) Pertindakan 2,240,000 1,760,000 4,000,000 49 Rekonstruksi Kelainan Jari/Ekstremitas Pertindakan 2,745,120 2,156,880 4,902,000 50 Rekonstruksi Limb Leg Inequality-Bone Lengthening Transport Pertindakan 2,240,000 1,760,000 4,000,000 51 Rekonstruksi Neglected Case-Bone Pertindakan 2,240,000 1,760,000 4,000,000 52 Rekonstruksi Pulley Tendon (Ekstremitas Atas) Bowstringing/Entrapment Pertindakan 2,240,000 1,760,000 4,000,000 53 Rekontruksi Kontraktur Pertindakan 3,969,280 3,118,720 7,088,000 54 Release Carpal Tunnel Syndrom Unilateral Pertindakan 2,845,360 2,235,640 5,081,000 55 Removal of implants (Plate Nail Screw) Pertindakan 2,240,000 1,760,000 4,000,000 56 Repair Muscle/Tendon Pertindakan 5,642,560 4,433,440 10,076,000 57 Repair Nerve-Digital Injury (Microsurgical) Pertindakan 2,240,000 1,760,000 4,000,000 58 Repair Tendon Jari Pertindakan 3,470,320 2,726,680 6,197,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 59 Repair Tendon-Extensor (Extremitas Atas)/Nail Bed/Nerve Digital Pertindakan 2,240,000 1,760,000 4,000,000 60 Reposisi Fixatic (Compucate) Pertindakan 2,751,840 2,162,160 4,914,000 61 Reposisi Fraktur/Dislokasi dalam Nerkose Pertindakan 3,734,640 2,934,360 6,669,000 62 Reposisi Terbuka & Fiksasi Interna Fraktur Tulang Panjang pada Anak/ Reposisi Terbuka & Fiksasi Interna pada kasus fraktur Salter Harris III-IV Pertindakan 2,240,000 1,760,000 4,000,000 63 Reposisi Terbuka dan Fiksasi Interna Kasus Fraktur Intra Artikular pada Anak Pertindakan 2,240,000 1,760,000 4,000,000 64 Reshaping untuk Torus/Tumor Tulang Pertindakan 2,523,360 1,982,640 4,506,000 65 Revisi Jari/Digit Stump Oestotomy Pertindakan 2,240,000 1,760,000 4,000,000 66 Revisi Total Knee/Shoulder Replacement Pertindakan 2,240,000 1,760,000 4,000,000 67 Sequesterektomy dengan Narkose Pertindakan 2,737,280 2,150,720 4,888,000 68 Skingrafting yang Tidak Luas Pertindakan 3,341,520 2,625,480 5,967,000 69 Tendor Transfer Ekstremitas Bawah pada Kasus Neuromuskular Anak Pertindakan 2,240,000 1,760,000 4,000,000 70 Total Joiny Arthroplasty/Total Knee/Shoulder Replacement Pertindakan 2,240,000 1,760,000 4,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 71 Transfer Jari Deformity Instrinsic Muscle Pertindakan 2,240,000 1,760,000 4,000,000 Besar Pertindakan - - 1 Acetabuloplasty (Salter Innominate Pemberton Dega) pada Kasus Panggul Pertindakan 3,696,000 2,904,000 6,600,000 2 Alat Transverse Fusion Pertindakan 3,696,000 2,904,000 6,600,000 3 Amputasi Jari (Multiple) Pertindakan 3,696,000 2,904,000 6,600,000 4 Amputasi Transmedular Pertindakan 3,696,000 2,904,000 6,600,000 5 Anterior Cervcal Corpectomy and Fusion (ACCF)/ Anterior Cervcal Discetomy and Fusion (ACDF) Pertindakan 3,696,000 2,904,000 6,600,000 6 Total Disc Replacement (Multilevel) Pertindakan 3,696,000 2,904,000 6,600,000 7 Arthrodesis Sendi (Panggul, Wrist Ankle Triple Arthrodesis) Pertindakan 3,696,000 2,904,000 6,600,000 8 Synovectomy Pertindakan 3,696,000 2,904,000 6,600,000 9 Arthrosplasty/Arthroscopy Therapeutik Pertindakan 3,696,000 2,904,000 6,600,000 10 Bony Reconnstruction pada Ekstremitas atas Anak (Misalnya Malunion Fraktur Supracondylar Lateral Condyle) Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 11 Bony Reconnstruction pada Ekstremitas Bawah Anak (Misalnya CTEV Blount Disease Kelainan Kongenital Malunion Fraktur) Pertindakan 3,696,000 2,904,000 6,600,000 12 Debridement And Anterior Fusion In TB Spine Pertindakan 3,696,000 2,904,000 6,600,000 13 Debridement Major Desloughing Pertindakan 3,696,000 2,904,000 6,600,000 14 Double Oesteotomy Pelvis Anterior pada Bladder Ekstrophy Pertindakan 3,696,000 2,904,000 6,600,000 15 Koreksi CTEV/Congenital Talipes Equinovarus Pertindakan 3,696,000 2,904,000 6,600,000 16 Koreksi Tortikolis Pertindakan 3,696,000 2,904,000 6,600,000 17 Laminectomy (1 level) pada Simple Spine Stenosis Pertindakan 3,696,000 2,904,000 6,600,000 18 Limb Lengthening atau Operasi Rekonstruksi pada Anak yang Menggunakan Alat Khusus Pertindakan 3,696,000 2,904,000 6,600,000 19 s. Micro Endoscopic Disectomy Pertindakan 3,696,000 2,904,000 6,600,000 20 Microscopic Disectomy Pertindakan 3,696,000 2,904,000 6,600,000 21 Open Disectomy/Open Disectomy Multilevel Pertindakan 3,696,000 2,904,000 6,600,000 22 Open Reduction dan Stabilisation of Spinal Fracture/Open Reduction Dislokasi Panggul Tanpa Acetabuloplasty Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 23 Open Reduksi Fraktur/Diskolasi Pertindakan 3,696,000 2,904,000 6,600,000 24 Pembedahan Kompartemental Pertindakan 3,696,000 2,904,000 6,600,000 25 Posterior Cervical Fusion Pertindakan 3,696,000 2,904,000 6,600,000 26 Posterior Lumbar Interbody Fusion (FLIF) dan Posterior Stabilisation Pertindakan 3,696,000 2,904,000 6,600,000 27 Posterolateral Fusion Pertindakan 3,696,000 2,904,000 6,600,000 28 Rekonstruksi Defek/Kelainan Tubuh Kompleks/Rekonstruksi Kontraktur Kompleks Pertindakan 3,696,000 2,904,000 6,600,000 29 Release Carpal Tunnel Syndrom Bilateral Pertindakan 3,696,000 2,904,000 6,600,000 30 Replantasi Pertindakan 3,696,000 2,904,000 6,600,000 31 Skingrafting yang Luas Pertindakan 3,696,000 2,904,000 6,600,000 32 Synovectomy Pertindakan 3,696,000 2,904,000 6,600,000 33 Total Disc Replacement (Multilevel) Pertindakan 3,696,000 2,904,000 6,600,000 Khusus 1 Amputasi Forequater/ Amputasi Hind Quarter Pertindakan 8,512,000 6,688,000 15,200,000 2 Debulking Pertindakan 8,512,000 6,688,000 15,200,000 3 Dekompresi Syaraf Tepi Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 4 Diseksi Kelenjar Getah Bening (KGB) Pelvis Pertindakan 8,512,000 6,688,000 15,200,000 5 Eksisi Luas Radikal dan Rekonstruksi Pertindakan 8,512,000 6,688,000 15,200,000 6 Free Flap Surgery Pertindakan 8,512,000 6,688,000 15,200,000 7 Ganti Sendi (Total Knee, HIP, Elbow) Pertindakan 8,512,000 6,688,000 15,200,000 8 Grafting Pada Arterial Insufisiensi Pertindakan 8,512,000 6,688,000 15,200,000 9 Hemipelvictomi Pertindakan 8,512,000 6,688,000 15,200,000 10 Koreksi Fraktur Impresif Pertindakan 8,512,000 6,688,000 15,200,000 11 Koreksi Spondilitis/ Koreksi Scoliosis Pertindakan 8,512,000 6,688,000 15,200,000 12 Laminektomi Sederhana / Laminektomi Kompleks Pertindakan 8,512,000 6,688,000 15,200,000 13 Microsurgery Pertindakan 8,512,000 6,688,000 15,200,000 14 Myocutaneus Flap/Pectoral Mayor Pertindakan 8,512,000 6,688,000 15,200,000 15 Neurektomi/Neurolise Pertindakan 8,512,000 6,688,000 15,200,000 16 Operasi Fraktur Kompleks (fraktur Acetabulum, Tulang Belakang, Fraktur Pelvis) Pertindakan 8,512,000 6,688,000 15,200,000 17 Operasi Fraktur Tripodo/Multiple Fracture Pertindakan 8,512,000 6,688,000 15,200,000 18 Operasi Fusi Korpus Vertebra Approach Anterior/Posterior Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 19 s. Operasi Konvensional plexus Brakhialias/Lumbalis/Sacralis/Cranialis/Spinalis perifer Pertindakan 8,512,000 6,688,000 15,200,000 20 Operasi Pemasangan Traksi Cervical Pertindakan 8,512,000 6,688,000 15,200,000 21 Operasi Shunting Femoralis/ Poplitea/Tibialis Pertindakan 8,512,000 6,688,000 15,200,000 22 Operasi Tumor Spinal Daerah Cervikal/Torakolumbal Pertindakan 8,512,000 6,688,000 15,200,000 23 Pembedahan Forequarter Pertindakan 8,512,000 6,688,000 15,200,000 24 Rekonstruksi Meningokel Spina Bifida Pertindakan 8,512,000 6,688,000 15,200,000 25 Replantasi Pertindakan 8,512,000 6,688,000 15,200,000 26 Surgical Staging Pertindakan 8,512,000 6,688,000 15,200,000 H Bedah Plastik Kecil 1 Angkat Arch Bar Pertindakan 1,575,280 1,237,720 2,813,000 2 Eksisi Fibroma/ Eksisi Giant Nevus (Tanpa Skin Graft)/ Eksisi Tragus Acsesories/ Eksisi Xantelasma/Eksisi Fistel Preauricular Pertindakan 1,575,280 1,237,720 2,813,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 3 Rekonstruksi Kelainan Jari (Polidaktil Simple) Pertindakan 1,575,280 1,237,720 2,813,000 4 Repair Fistel Urethra Pascauretroplasti Pertindakan 1,575,280 1,237,720 2,813,000 5 Repair Muscle/Tendon Pertindakan 1,575,280 1,237,720 2,813,000 6 Reposisi Fraktur Sederhana Os Nassal Pertindakan 1,575,280 1,237,720 2,813,000 7 Terapi Sklerosing Pertindakan 1,575,280 1,237,720 2,813,000 8 Trauma Jaringan Lunak Wajah Sederhana Pertindakan 1,575,280 1,237,720 2,813,000 Sedang 1 Debridement Dengan Skingarfting Kecil Pertindakan 2,240,000 1,760,000 4,000,000 2 Ekstirpasi Tumor Jinak Lain > 5 Cm Pertindakan 2,240,000 1,760,000 4,000,000 3 Fraktur Sederhana Os Nassal dan Lokal Pertindakan 2,801,120 2,200,880 5,002,000 4 Fraktur Sederhana Os Nassal dan Narkose Umum Pertindakan 2,801,120 2,200,880 5,002,000 5 Kelainan Jari/Ektremitas Sederhana Pertindakan 2,936,080 2,306,920 5,243,000 6 Labioplasti Unilateral Pertindakan 2,829,120 2,222,880 5,052,000 7 Rekons Defek/Kelainan Tubuh Yang Simple Pertindakan 2,240,000 1,760,000 4,000,000 8 Release Kontraktur Pertindakan 2,240,000 1,760,000 4,000,000 9 Repair Fistel Urethra Pascauretroplasti Pertindakan 3,096,240 2,432,760 5,529,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 10 Repair Luka Robek Sederhana Pada Wajah Pertindakan 3,096,240 2,432,760 5,529,000 11 Reposisi dislokasi Temporo mandibula (TMJ) Pertindakan 2,240,000 1,760,000 4,000,000 12 Terapi Sklerosing Pertindakan 3,096,240 2,432,760 5,529,000 Besar 1 Amputasi Jari (Multiple) Pertindakan 3,696,000 2,904,000 6,600,000 2 Debridement Pertindakan 3,696,000 2,904,000 6,600,000 3 Debridement Dengan Skin Grafting Luas/ Dengan Flap Pertindakan 3,696,000 2,904,000 6,600,000 4 Debridement Pada Luka Bakar >40% Pertindakan 3,696,000 2,904,000 6,600,000 5 Eksisi/Reduksi Neurofibroma Kompleks/Eksisi Heangiona Luas Pertindakan 3,696,000 2,904,000 6,600,000 6 Eksisi Chordae Hyspospadia Pertindakan 3,696,000 2,904,000 6,600,000 7 Eksisi Giant Nevus dan Skin Graft Pertindakan 3,696,000 2,904,000 6,600,000 8 Eksisi Limfedema dan Skin Graft (Charles Prosedur) Pertindakan 3,696,000 2,904,000 6,600,000 9 Fore Head Flap Pertindakan 3,696,000 2,904,000 6,600,000 10 Fraktur Maksila/Zygoma Pertindakan 4,623,360 3,632,640 8,256,000 11 Fraktur Rahang Sederhana Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 12 Kontraktur dan STSG Pertindakan 3,916,640 3,077,360 6,994,000 13 Koreksi dan Rekonstruksi Ptosis Pertindakan 3,696,000 2,904,000 6,600,000 14 Labiopalatoplasti Bilateral Pertindakan 4,392,640 3,451,360 7,844,000 15 Labioplasti Bilateral Pertindakan 3,801,840 2,987,160 6,789,000 16 Latisimus Dorsi Flap Pertindakan 3,696,000 2,904,000 6,600,000 17 Operasi Mikrotia Pertindakan 4,370,240 3,433,760 7,804,000 18 Palatoplasti Pertindakan 3,950,240 3,103,760 7,054,000 19 Pharingoplasty Pertindakan 3,696,000 2,904,000 6,600,000 20 Rekonnstruksi Koreksi Camplodactyl/Clinidactyl Pertindakan 3,696,000 2,904,000 6,600,000 21 Rekonnstruksi Koreksi Makrodactyl Pertindakan 3,696,000 2,904,000 6,600,000 22 Rekonstruksi Avulsi Kulit Pertindakan 3,696,000 2,904,000 6,600,000 23 Rekonstruksi Club Hand Pertindakan 3,696,000 2,904,000 6,600,000 24 Rekonstruksi Craniosinostosis Pertindakan 3,696,000 2,904,000 6,600,000 25 Rekonstruksi Defek/Kelainan Tubuh Yang Kompleks Pertindakan 3,696,000 2,904,000 6,600,000 26 Rekonstruksi Defek Dengan Flap Lokal/Rekonstruksi Defek Dengan Flap Jauh Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 27 Rekonstruksi Degloving Injury Pertindakan 3,696,000 2,904,000 6,600,000 28 Rekonstruksi Duktus Lacrimalis/Stenosis Sederhana Pertindakan 3,696,000 2,904,000 6,600,000 29 Rekonstruksi Gigantomastia Pertindakan 3,696,000 2,904,000 6,600,000 30 Rekonstruksi Kelainan Craniofacial Congenila Pertindakan 3,696,000 2,904,000 6,600,000 31 Rekonstruksi Kelainan Mata/Kontraktur Palpebra Pertindakan 3,696,000 2,904,000 6,600,000 32 Rekonstruksi Kontraktur Difus Pertindakan 3,696,000 2,904,000 6,600,000 33 Rekonstruksi Mammae dengan Miocutaneus Pertindakan 3,696,000 2,904,000 6,600,000 34 Rekonstruksi Meningo Encephalocele Anterior (MEA) Pertindakan 3,696,000 2,904,000 6,600,000 35 Rekonstruksi Repair Tendon Complikata Pertindakan 3,696,000 2,904,000 6,600,000 36 Rekonstruksi Ring Avulsion Pertindakan 3,696,000 2,904,000 6,600,000 37 Rekonstruksi Ulkus Decubitus Dengan Flap Pertindakan 3,696,000 2,904,000 6,600,000 38 Rekonstruksi Vagina Pertindakan 3,696,000 2,904,000 6,600,000 39 Release Kontraktur dan Flap/ Release Kontraktur Kompleks dan STSG Pertindakan 3,696,000 2,904,000 6,600,000 40 Release Syndacil kompleks Pertindakan 3,696,000 2,904,000 6,600,000 41 Repair Luka Pada Wajah Kompleks Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 42 Repair Luka Pada Wajah Melibatkan Saraf Ducyus Lakrimal/Kelenjar Liur Pertindakan 3,696,000 2,904,000 6,600,000 43 Repair Tendon Jari Pertindakan 4,732,560 3,718,440 8,451,000 44 Reposisi & Fiksasi Fraktur Tunggal Tulang Wajah/ Reposisi Fraktur Mandibula Multiple Multiple/Kompleks/ Reposisi Fraktur Mandibula Sederhana Pertindakan 3,696,000 2,904,000 6,600,000 45 Salvaging Operasi Mikro Pertindakan 22,398,320 17,598,680 39,997,000 46 Skingrafting yang Luas Pertindakan 4,473,280 3,514,720 7,988,000 47 Skingrafting yang Tidak Luas Pertindakan 3,791,200 2,978,800 6,770,000 48 Tram Flap Pertindakan 3,696,000 2,904,000 6,600,000 49 Trauma Kompleks Jaringan Lunak Wajah Pertindakan 3,696,000 2,904,000 6,600,000 50 Uretroplasti Pertindakan 4,615,520 3,626,480 8,242,000 Khusus 1 Alveolar Bone Graft Pertindakan 8,512,000 6,688,000 15,200,000 2 Cross Leg flap Pertindakan 8,512,000 6,688,000 15,200,000 3 Fraktur Muka Multiple (Tanpa Miniplate Screw) Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 4 Free Flap Surgery Pertindakan 20,520,640 16,123,360 36,644,000 5 Fronto-Orbital Advancement pada Craniosynostosis Pertindakan 20,520,640 16,123,360 36,644,000 6 Labioplasty Bilateral Pertindakan 8,512,000 6,688,000 15,200,000 7 Le-ford Advancement Surgery Pertindakan 8,512,000 6,688,000 15,200,000 8 Mandibulektomi Pertindakan 8,568,000 6,732,000 15,300,000 9 Orthognatic Surgery Pertindakan 8,512,000 6,688,000 15,200,000 10 Rekonstruksi Telinga Pertindakan 8,512,000 6,688,000 15,200,000 11 Replantasi Pertindakan 20,492,640 16,101,360 36,594,000 12 Reposisi/Fiksasi FMaksila dan Mandibula/FNaso Orbita Edmoe (NOE)/FNorbita Pertindakan 8,512,000 6,688,000 15,200,000 I Bedah THT Kecil 1 tes BERA Pertindakan 461.440 362.560 824.000 2 Test OAE Pertindakan 152.880 120.120 273.000 3 Ekstraksi benda asing hidung Pertindakan 179.200 140.800 320.000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 4 ekstraksi benda asing telinga Pertindakan 179.200 140.800 320.000 5 Ekstraksi serumen Pertindakan 126.000 99.000 225.000 6 Biopsi tumor Pertindakan 163.520 128.480 292.000 7 Fiber optik laringoskopi Pertindakan 140.000 110.000 250.000 8 Esofagoskopi Transnasal Pertindakan 140.000 110.000 250.000 9 fistulektomi Pertindakan 1.518.160 1.192.840 2.711.000 10 ekstirpasi tumor Pertindakan 168.000 132.000 3.125.000 11 Belloque Tampon dalam Narkose Pertindakan 1,750,000 1,375,000 3,125,000 12 Biopsi Telinga Pertindakan 1,750,000 1,375,000 3,125,000 13 Biopsi Tumor Hidung, Lidah,Nasofaring THT Pertindakan 1,680,000 1,320,000 3,000,000 14 Extirpasi Polip Pertindakan 1,680,000 1,320,000 3,000,000 15 Insisional Biopsi Kelenjar Leher Pertindakan 1,680,000 1,320,000 3,000,000 16 Irigasi Sinus/Dawo Pertindakan 1,680,000 1,320,000 3,000,000 17 Lobulaplasti (1 Telinga/2 Telinga) Pertindakan 1,680,000 1,320,000 3,000,000 18 Pemasangan Grommet dengan Narkose (di luar Alkes Gromet) Pertindakan 1,680,000 1,320,000 3,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 19 Pemasangan Pilar Implant/Somnoplasty Pertindakan 1,680,000 1,320,000 3,000,000 20 Revisi Parut THT Pertindakan 1,680,000 1,320,000 3,000,000 12 Sinuskopi/Sinuskopi dengan Tindakan Pertindakan 1,680,000 1,320,000 3,000,000 22 Somnoplasty Pertindakan 1,680,000 1,320,000 3,000,000 23 Turbinoplasty Pertindakan 1,680,000 1,320,000 3,000,000 Sedang Pertindakan - - 1 Pemasangan Pipa Shepard Pertindakan 2,450,000 1,925,000 4,375,000 2 Pemasangan T Tube Pertindakan 2,450,000 1,925,000 4,375,000 3 Pembukaan lubang hidung THT Pertindakan 2,450,000 1,925,000 4,375,000 4 Regional Flap Pertindakan 2,450,000 1,925,000 4,375,000 5 Septum Reseksi Pertindakan 2,450,000 1,925,000 4,375,000 6 Skingrafting Tidak Luas THT Pertindakan 2,450,000 1,925,000 4,375,000 7 Tonsilektomi Pertindakan 3,079,440 2,419,560 5,499,000 8 Tonsilo Adenoidectomi Pertindakan 2,450,000 1,925,000 4,375,000 9 Tracheostomi Pertindakan 2,450,000 1,925,000 4,375,000 10 Trakestomi dengan Penyulit Pertindakan 2,450,000 1,925,000 4,375,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 11 Turbinektomi Pertindakan 2,723,840 2,140,160 4,864,000 Besar 1 Angiofibroma Nasofaring Pertindakan 3,640,000 2,860,000 6,500,000 2 Bronschoscopy Pertindakan 3,696,000 2,904,000 6,600,000 3 Bedah Sinus Endoskopi Fungsional (BSEF)/ Functional Endoscopic Sinus Surgery (FESS) 1: Mini Pertindakan 3,696,000 2,904,000 6,600,000 4 BSEF/FESS 2: Mini dan Maksila/etmoid Pertindakan 3,696,000 2,904,000 6,600,000 5 Dekompresia Fasialis Pertindakan 3,696,000 2,904,000 6,600,000 6 Eksplorasi Abses Multiple THT Pertindakan 3,696,000 2,904,000 6,600,000 7 Eksplorasi Kista Branchial, Kista Ductus Tiroglosus, Kista Tiroid Pertindakan 3,696,000 2,904,000 6,600,000 8 Trancheostomi Pertindakan 3,696,000 2,904,000 6,600,000 9 Wide Eksisi Tumor Tonsil Orofaring Pertindakan 3,696,000 2,904,000 6,600,000 10 Ekstirpasi Preaurikuler Fistel , Tumor Jinak Kel Liur THT Pertindakan 3,696,000 2,904,000 6,600,000 11 Tonsilo Edenoidectomi Pertindakan 3,696,000 2,904,000 6,600,000 12 Esophagoscopy Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 13 Ethmoidektomi (Intranasal) Pertindakan 3,696,000 2,904,000 6,600,000 14 Fare Head Flap Pertindakan 3,696,000 2,904,000 6,600,000 15 Faringotomi Pertindakan 3,696,000 2,904,000 6,600,000 16 Forehead Flap THT Pertindakan 3,696,000 2,904,000 6,600,000 17 Hemiglosektomi THT Pertindakan 3,696,000 2,904,000 6,600,000 18 Konkoplasti Pertindakan 3,696,000 2,904,000 6,600,000 19 Labiopalatoplasti Bilateral Pertindakan 3,696,000 2,904,000 6,600,000 20 Laringo Fisur/Eksplorasi Laring Pertindakan 3,696,000 2,904,000 6,600,000 21 Ligasi Karotis Eksterna Pertindakan 3,696,000 2,904,000 6,600,000 22 Maksilektomi Partialis Pertindakan 3,696,000 2,904,000 6,600,000 23 Mandibulektomi Parsial THT Pertindakan 3,696,000 2,904,000 6,600,000 24 Mastoidektomi Radikal/Sederhana Pertindakan 3,696,000 2,904,000 6,600,000 25 Miringoplasti Pertindakan 3,696,000 2,904,000 6,600,000 26 Neuroktomi Saraf Vidian Pertindakan 3,696,000 2,904,000 6,600,000 27 Otoplasty THT Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 28 Panendoscopi (Eksplorasi NF Laringoscopi Esofagoscopi Bronkoscopi dengan Biopsi Pertindakan 3,696,000 2,904,000 6,600,000 29 Parotidektomi Pertindakan 3,696,000 2,904,000 6,600,000 30 Pemasangan Pipa Shepard Pertindakan 3,696,000 2,904,000 6,600,000 31 Pemasangan T Tube Pertindakan 3,696,000 2,904,000 6,600,000 32 Pharyngeal Flap Pertindakan 3,696,000 2,904,000 6,600,000 33 Pronto Etmoidektomi (Ekstranasal) Pertindakan 3,696,000 2,904,000 6,600,000 34 Regional Flap Tidak Luas THT, Flap luas THT Pertindakan 3,696,000 2,904,000 6,600,000 35 Rekonstruksi Fraktur Rahang THT Pertindakan 3,696,000 2,904,000 6,600,000 36 Rekonstruksi Kontraktur Kompleks Pertindakan 3,696,000 2,904,000 6,600,000 37 Faktor Reumatoid (RF) Dasar Lidah THT Pertindakan 3,696,000 2,904,000 6,600,000 38 Rinoplasty THT Pertindakan 3,696,000 2,904,000 6,600,000 39 Rinotomi Lateralis Pertindakan 3,696,000 2,904,000 6,600,000 40 Septoplasti Pertindakan 3,696,000 2,904,000 6,600,000 41 Septum Reseksi Pertindakan 3,696,000 2,904,000 6,600,000 42 Tindakan Pharyngeal Flap Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 43 Tiroidektomi THT Pertindakan 3,696,000 2,904,000 6,600,000 44 Tonsilo Edenoidectomi Pertindakan 3,696,000 2,904,000 6,600,000 45 Trancheostomi Pertindakan 3,696,000 2,904,000 6,600,000 46 Wide Eksisi Tumor Tonsil Orofaring Pertindakan 3,696,000 2,904,000 6,600,000 11 Functional endoscopic sinus surgery Pertindakan 3,696,000 2,904,000 6,600,000 12 tonsilektomi Pertindakan 3,079,440 2,419,560 5,499,000 Khusus 1 Bedah Sinus Endoskopik Fungsional BSEF/FESS 3: Mini dan Frontal/Sfenoid Pertindakan 8,512,000 6,688,000 15,200,000 2 BSEF/FESS 4: Mini dan Maksila/Etmoid dan Frontal/Sfenoid Pertindakan 8,512,000 6,688,000 15,200,000 3 BSEF/FESS Lanjut: Ekstirpasi Tumor Penutupan defek intracranial Pertindakan 8,512,000 6,688,000 15,200,000 4 Eksisi Angiofibroma Nasofaring Pertindakan 8,512,000 6,688,000 15,200,000 5 Fungsional Endoscopy Sinus Surgery (FESS) Pertindakan 8,512,000 6,688,000 15,200,000 6 Glosektomi Total Pertindakan 8,512,000 6,688,000 15,200,000 7 Kanaloplasti/Penggangkatan Massa Tulang Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 8 Laringektomi Pertindakan 8,512,000 6,688,000 15,200,000 9 Maksilektomi Totalis Pertindakan 8,512,000 6,688,000 15,200,000 10 Mastoidektomi Radikal Pertindakan 8,512,000 6,688,000 15,200,000 11 Mastoidektomi Radikal dengan Penyulit Pertindakan 8,512,000 6,688,000 15,200,000 12 Myocutaneus Flap/Pectoral Mayor Pertindakan 8,512,000 6,688,000 15,200,000 13 Radikal Neck Desection Pertindakan 8,512,000 6,688,000 15,200,000 14 Rekonstruksi Fraktur muka dengan Plate Screw THT/ Rekonstruksi Hidung dengan Defek THT Pertindakan 8,512,000 6,688,000 15,200,000 15 Rekonstruksi Mandibula THT/ Rekonstruksi Telinga (Tahap 1/Tahap 2) Pertindakan 8,512,000 6,688,000 15,200,000 16 Rinoplasty dengan Augmentasi Tulang Rawan THT Pertindakan 8,512,000 6,688,000 15,200,000 17 Rinotomi Lateralis Pertindakan 8,512,000 6,688,000 15,200,000 18 Septorinoplasty THT Pertindakan 8,512,000 6,688,000 15,200,000 19 Stapedektomi Pertindakan 8,512,000 6,688,000 15,200,000 20 Temporal Bone Resection Pertindakan 8,512,000 6,688,000 15,200,000 21 Timpano Plastik Pertindakan 8,512,000 6,688,000 15,200,000 22 Tindakan Dekompresi Fasialis Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 23 PTA Pertindakan 8,960,000 7,040,000 16,000,000 J Bedah Urologi Kecil 1 Cabut DJ Stent Pertindakan 1,575,280 1,237,720 2,813,000 2 Meatoplasti Pertindakan 1,575,280 1,237,720 2,813,000 3 Operasi Hydrokel Pertindakan 1,575,280 1,237,720 2,813,000 4 Vasektomi dengan Narkose Pertindakan 1,625,680 1,277,320 2,903,000 Sedang Pertindakan - - 1 Biopsi Ginjal Perkutan Pertindakan 2,436,000 1,914,000 4,350,000 2 Biopsi Prostat Pertindakan 2,321,760 1,824,240 4,146,000 3 Biopsi Testis Pertindakan 2,430,400 1,909,600 4,340,000 4 Hidrokel per scrotal Pertindakan 2,436,000 1,914,000 4,350,000 5 Meatotomi Pertindakan 2,321,760 1,824,240 4,146,000 6 Operasi Priapismus (Prosedur Winter) Pertindakan 2,436,000 1,914,000 4,350,000 7 Orchidektomi/Orchidektomi Subkapsuler Pertindakan 2,436,000 1,914,000 4,350,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 8 Pasang Kateter Tenckhoff untuk Continuous Ambulatory Peritoneal Dialysis (CAPD) Pertindakan 2,436,000 1,914,000 4,350,000 9 Sirkumsisi dengan Phymosis Pertindakan 2,436,000 1,914,000 4,350,000 10 Sistokopi, Sistoskopi Osmotic demyelination syndrome (ODS) Pertindakan 2,436,000 1,914,000 4,350,000 11 Sistostomi Perkutan, Sitostomi Terbuka Pertindakan 2,436,000 1,914,000 4,350,000 12 Spermatokelektomi Pertindakan 2,436,000 1,914,000 4,350,000 13 Urettroskopi/Uretrosistoskopi Pertindakan 2,436,000 1,914,000 4,350,000 14 Varikokelektomi (Palomo) Pertindakan 2,436,000 1,914,000 4,350,000 15 Vesicolithomi/Sectio Alta Pertindakan 2,436,000 1,914,000 4,350,000 Besar 1 Anastomosis End to End Ureter Pertindakan 3,696,000 2,904,000 6,600,000 2 Biopsi Ginjal Terbuka Pertindakan 3,696,000 2,904,000 6,600,000 3 Deroofing/Unroofing Kista Pertindakan 3,696,000 2,904,000 6,600,000 4 Divertikulektomi Pertindakan 4,869,760 3,826,240 8,696,000 5 Divertikulum Uretra Pertindakan 3,696,000 2,904,000 6,600,000 6 Drainage Periureter Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 7 Eksisi Chodee, Webbed Penis Pertindakan 3,696,000 2,904,000 6,600,000 8 Ekstraksi Batu Pertindakan 3,696,000 2,904,000 6,600,000 9 Enukleasi Kista Ginjal Pertindakan 4,914,560 3,861,440 8,776,000 10 Evakuasi Bekuan Darah (Clot) Pertindakan 3,696,000 2,904,000 6,600,000 11 Fistula Eterovesika Pertindakan 4,914,000 3,861,000 8,775,000 12 Fistulektomi/Repair Fistel Uretra Pertindakan 3,696,000 2,904,000 6,600,000 13 Hidrokel per Inguinal/Ligasi Tinggi Pertindakan 3,696,000 2,904,000 6,600,000 14 Insersi DJ Stent Pertindakan 3,696,000 2,904,000 6,600,000 15 Internal Urethrotomi Pertindakan 4,104,240 3,224,760 7,329,000 16 Johanson, Johanson I Pertindakan 3,696,000 2,904,000 6,600,000 17 Koreksi Priapismus Pertindakan 3,696,000 2,904,000 6,600,000 18 Laparatomi Eksplorasi Pertindakan 3,696,000 2,904,000 6,600,000 19 Litrotipasi/Litotripsi Pertindakan 3,969,280 3,118,720 7,088,000 20 MMK/Sling Uretra Pertindakan 3,696,000 2,904,000 6,600,000 21 Nefropeksi/Renopeksi Pertindakan 3,696,000 2,904,000 6,600,000 22 Nefropexie Pertindakan 4,422,880 3,475,120 7,898,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 23 Nefrostomi Pertindakan 4,422,880 3,475,120 7,898,000 24 Nefrostomi Terbuka/Permanen Pertindakan 3,696,000 2,904,000 6,600,000 25 Open Renal Biopsi Pertindakan 3,696,000 2,904,000 6,600,000 26 Operasi Peyronie Pertindakan 4,422,880 3,475,120 7,898,000 27 Operasi Repair Bull Trauma Pertindakan 3,696,000 2,904,000 6,600,000 28 Orchidektomi Ligasi Tinggi Pertindakan 3,905,440 3,068,560 6,974,000 29 Orchidektomi Subkapsuler Pertindakan 3,640,000 2,860,000 6,500,000 30 Orchidopexi Pertindakan 3,995,600 3,139,400 7,135,000 31 Orkhidektomi Extended Pertindakan 3,696,000 2,904,000 6,600,000 32 Penektomi Pertindakan 3,825,920 3,006,080 6,832,000 33 Penektomi Parsial Pertindakan 3,696,000 2,904,000 6,600,000 34 Pielolitotomi Pertindakan 3,696,000 2,904,000 6,600,000 35 Prostatektomi Retropubik Pertindakan 4,388,160 3,447,840 7,836,000 36 Prostatektomi Terbuka, Prostatektomi Terbuka dan Sectio Alta Pertindakan 3,696,000 2,904,000 6,600,000 37 Psoas Histch/Boari Flap Pertindakan 4,583,040 3,600,960 8,184,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 38 Pyelolithototomi Pertindakan 4,300,240 3,378,760 7,679,000 39 Pyeloplasty Pertindakan 4,418,960 3,472,040 7,891,000 40 Rekontruksi Blassemeck/Bladder Neck Pertindakan 4,422,880 3,475,120 7,898,000 41 Rekontruksi Vesika Pertindakan 4,422,880 3,475,120 7,898,000 42 Repair Fistel Vesikokutan Pertindakan 3,696,000 2,904,000 6,600,000 43 Reparasi Fistula Vesiko Vaginal Pertindakan 4,595,360 3,610,640 8,206,000 44 Reseksi Partial Vesika Pertindakan 4,582,480 3,600,520 8,183,000 45 Reseksi Reduksi Pertindakan 5,064,640 3,979,360 9,044,000 46 Sistoplasti Reduksi Pertindakan 5,090,960 4,000,040 9,091,000 47 Skrotoplasti Pertindakan 3,696,000 2,904,000 6,600,000 48 Spermatocele Pertindakan 3,696,000 2,904,000 6,600,000 49 Torsio Testis Pertindakan 3,696,000 2,904,000 6,600,000 50 TVP/TMP Pertindakan 3,696,000 2,904,000 6,600,000 51 Uretero Sigmoidostomi Pertindakan 4,980,640 3,913,360 8,894,000 52 Uretero Ureterostomi Pertindakan 5,015,920 3,941,080 8,957,000 53 Ureterocutanneostomi Pertindakan 5,015,360 3,940,640 8,956,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 54 Ureterolithotomi Pertindakan 5,061,840 3,977,160 9,039,000 55 Ureterolithotomi proksimal Pertindakan 3,696,000 2,904,000 6,600,000 56 Ureterolysis Pertindakan 3,696,000 2,904,000 6,600,000 57 Ureterostomi Pertindakan 3,696,000 2,904,000 6,600,000 58 Urethrektomi Pertindakan 4,842,320 3,804,680 8,647,000 59 Vasografi Pertindakan 3,696,000 2,904,000 6,600,000 60 Vericocele/Palomo Pertindakan 3,696,000 2,904,000 6,600,000 61 Vesicolithotomi (Sectio Alta) Pertindakan 3,696,000 2,904,000 6,600,000 Khusus 1 Adrenalektomi Abdominotorakal Pertindakan 8,512,000 6,688,000 15,200,000 2 Bladder Neck Incision Pertindakan 8,512,000 6,688,000 15,200,000 3 Diseksi KGB Pelvis Pertindakan 8,512,000 6,688,000 15,200,000 4 Divertikulektomi Vesika Pertindakan 8,512,000 6,688,000 15,200,000 5 Epidimovasostomi/Epididimovasostomi Pertindakan 8,512,000 6,688,000 15,200,000 6 Explorasi Testis Mikro Surgery Pertindakan 8,512,000 6,688,000 15,200,000 7 Extended Pyelolithektomi (Gilverne) Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 8 Horsesche Kidney Koreksi Pertindakan 8,512,000 6,688,000 15,200,000 9 Ileal Condoit (Bricker)/Operasi Pertindakan 8,512,000 6,688,000 15,200,000 10 Limfadenektomi Ileoinguinal, Limfadenektomi Retroperitoneal Pertindakan 8,512,000 6,688,000 15,200,000 11 Longitudinal Nefrolithotomi (Kadet) Pertindakan 8,512,000 6,688,000 15,200,000 12 Mikrosurgen Ligasi Vena Spermatika Pertindakan 8,512,000 6,688,000 15,200,000 13 Nefrektomi Partikal/partial Pertindakan 8,512,000 6,688,000 15,200,000 14 Nefro Ureterektomi Pertindakan 8,512,000 6,688,000 15,200,000 15 Nefrostomi Percutan Pertindakan 8,512,000 6,688,000 15,200,000 16 Percutaneous Nephrolithostripst (PNCL) Pertindakan 8,512,000 6,688,000 15,200,000 17 Radikal Cystektomi Pertindakan 8,512,000 6,688,000 15,200,000 18 Radikal Nefroktomi Pertindakan 8,512,000 6,688,000 15,200,000 19 Radikal Prostatektomi Pertindakan 8,512,000 6,688,000 15,200,000 20 Rekontruksi Renovaskuler Pertindakan 8,512,000 6,688,000 15,200,000 21 Repair Vesico Vagina Fistel Complex Pertindakan 8,512,000 6,688,000 15,200,000 22 Retroperitoneal Lymph Node Dissection (RPLND) Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 23 Trans Uretra (TUR) Prostat Pertindakan 8,512,000 6,688,000 15,200,000 24 TUR Tumor Buli - Buli Pertindakan 8,512,000 6,688,000 15,200,000 25 Uretetoneo Cystosthomi Pertindakan 8,512,000 6,688,000 15,200,000 26 Uretroplasty Pertindakan 8,512,000 6,688,000 15,200,000 27 Ureteroscopy/Ureterorenoscopy (URS) Pertindakan 8,512,000 6,688,000 15,200,000 K Bedah Vaskuler Kecil 1 Debridement Ulang Vaskuler/Debridement dengan Amputasi Mayor Pertindakan 1,750,000 1,375,000 3,125,000 2 Ekstirpasi Fibroma Pertindakan 1,750,000 1,375,000 3,125,000 3 Fasciotomi Pertindakan 1,750,000 1,375,000 3,125,000 4 Flebektomi Pertindakan 1,750,000 1,375,000 3,125,000 5 Reapir Komplikasi AV Shunt Pertindakan 1,750,000 1,375,000 3,125,000 6 Rekonstruksi Vaskuler Sederhana Pertindakan 1,750,000 1,375,000 3,125,000 7 Trombektomi/Lysis dengan Catheter For Vein Pertindakan 1,750,000 1,375,000 3,125,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total Sedang 1 Eksplorasi Abses Multiple Pertindakan 2,450,000 1,925,000 4,375,000 Besar 1 Operasi Tumor Pembuluh Darah Pertindakan 3,696,000 2,904,000 6,600,000 2 Skin Laser Treatment Pertindakan 3,696,000 2,904,000 6,600,000 3 Splenektomi Pertindakan 3,696,000 2,904,000 6,600,000 Khusus 1 Aneurisma Aorta Pertindakan 8,512,000 6,688,000 15,200,000 2 Arteri Carotis, Arteri Renalis Stenosis Pertindakan 8,512,000 6,688,000 15,200,000 3 Cimino Pertindakan 8,512,000 6,688,000 15,200,000 4 Graf Vena Membuat A Vistula Pertindakan 8,512,000 6,688,000 15,200,000 5 Grafting Pada Arterial Insufisiensi Pertindakan 8,512,000 6,688,000 15,200,000 6 Operasi Vaskuler Teknik Operasi Khusus Pertindakan 8,512,000 6,688,000 15,200,000 7 Pasang Akses Port Celsite Pertindakan 8,512,000 6,688,000 15,200,000 8 Penyakit Pembuluh Darah Perifer Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 9 Shunting Femoralis, Shunting Poplitea/Tibialis, Shunting Splenorea Pertindakan 8,512,000 6,688,000 15,200,000 10 Simpatektomi Pertindakan 8,512,000 6,688,000 15,200,000 11 Solonektomi Pertindakan 8,512,000 6,688,000 15,200,000 12 Tumor Pembuluh Darah Pertindakan 8,512,000 6,688,000 15,200,000 L Bedah Paru/Thorax Sedang 1 Rewiring Sternum Pertindakan 2,450,000 1,925,000 4,375,000 2 Tracheostomi Pertindakan 2,450,000 1,925,000 4,375,000 Khusus 1 Air Plumbage Pertindakan 14,421,120 11,330,880 25,752,000 2 Dikortikasi Pertindakan 14,421,120 11,330,880 25,752,000 3 Lobektomi Pertindakan 14,421,120 11,330,880 25,752,000 4 Muscle Plombage Pertindakan 14,421,120 11,330,880 25,752,000 5 Omentumpexi Pertindakan 14,421,120 11,330,880 25,752,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 6 Pnemonektomi Pertindakan 14,421,120 11,330,880 25,752,000 7 Reseksi Trachea Pertindakan 14,421,120 11,330,880 25,752,000 8 Segmentektomi Pertindakan 14,421,120 11,330,880 25,752,000 9 Slevece Lobektomi Pertindakan 14,421,120 11,330,880 25,752,000 10 Torakoplasty Pertindakan 14,421,120 11,330,880 25,752,000 11 Trakeoplasi Pertindakan 14,421,120 11,330,880 25,752,000 M Bedah Saraf 1 Biopsi Saraf Kutaneus/Otot Pertindakan 8,512,000 6,688,000 15,200,000 2 Blok Saraf Tepi Pertindakan 8,512,000 6,688,000 15,200,000 3 Complicated Functional Neuro Pertindakan 8,512,000 6,688,000 15,200,000 4 Stereotaxy Sederhana Pertindakan 8,512,000 6,688,000 15,200,000 5 Percuteneus Kordotomi Pertindakan 8,512,000 6,688,000 15,200,000 6 Paraverteb/Visceral Blok Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 7 Dekompresi Syaraf Tepi Pertindakan 8,512,000 6,688,000 15,200,000 8 Ekstipasi Tumor Scalp/Cranium Pertindakan 8,512,000 6,688,000 15,200,000 9 Fusi Korpus Vertebra Approach Anterior / Vertebra Approach Posterior Pertindakan 8,512,000 6,688,000 15,200,000 10 Koreksi Impresif Fraktur Sederhana Pertindakan 8,512,000 6,688,000 15,200,000 11 Kranioplasti/Koreksi Fraktur Pertindakan 8,512,000 6,688,000 15,200,000 12 Kraniotomi/Trepanasi Konvensional Pertindakan 8,512,000 6,688,000 15,200,000 13 Kraniotomi dan Bedah Mikro / Kraniotomi dan Endoskopi Pertindakan 8,512,000 6,688,000 15,200,000 14 Laminektomi Pertindakan 8,512,000 6,688,000 15,200,000 15 Neuroktomi/Neurolise Pertindakan 8,512,000 6,688,000 15,200,000 16 Neuroplasti/Anastomosis/Eksplorasi Pertindakan 8,512,000 6,688,000 15,200,000 17 Plexus Brakhialis/Lumbalis Sacralis Pertindakan 8,512,000 6,688,000 15,200,000 18 Cranialis/Spinalis Perifer Pertindakan 8,512,000 6,688,000 15,200,000 19 Pemasangan Fiksasi Interna Pertindakan 8,512,000 6,688,000 15,200,000 20 Pemasangan Pintasan VA/VP Shunt Pertindakan 8,512,000 6,688,000 15,200,000 21 Pemasangan Traksi Cervical/Pemasangan Halovest Pertindakan 8,512,000 6,688,000 15,200,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 22 Punksi Cairan Otak Pertindakan 8,512,000 6,688,000 15,200,000 23 Rekonstruksi Meningokel Kranial : Pertindakan 8,512,000 6,688,000 15,200,000 24 Kranial (Anterior/Posterior) Pertindakan 8,512,000 6,688,000 15,200,000 25 Spinal Bifida Pertindakan 8,512,000 6,688,000 15,200,000 26 Simple Functional N Surgery Pertindakan 8,512,000 6,688,000 15,200,000 27 Percutaneus Rhizotomy/ Percutaneous Retrogasserian Glycerol Rhizotomy (PRGR) Pertindakan 8,512,000 6,688,000 15,200,000 28 Percutaneus Facet Denevation Pertindakan 8,512,000 6,688,000 15,200,000 29 Tumor Spinal Daerah Cervikal, Kraniospinal , Torakolumbal Pertindakan 8,512,000 6,688,000 15,200,000 30 Ventrikulostomi/VE Drainage Pertindakan 8,512,000 6,688,000 15,200,000 N Bedah Gigi dan Mulut Kecil 1 Alveolectomi Pertindakan 1,750,000 1,375,000 3,125,000 2 Apek Reseksi (Gigi) Pertindakan 1,750,000 1,375,000 3,125,000 3 Enucleatie Kista Pertindakan 1,750,000 1,375,000 3,125,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 4 Excohliasi Pertindakan 1,750,000 1,375,000 3,125,000 5 Extirpasi Tumor Pertindakan 1,750,000 1,375,000 3,125,000 6 Fistulectomy Pertindakan 1,750,000 1,375,000 3,125,000 7 Frenectomy, Gingivectomy, Operculectomy Pertindakan 1,750,000 1,375,000 3,125,000 8 Insisi Mucocele Pertindakan 1,750,000 1,375,000 3,125,000 9 Marsupialisasi Ranula Pertindakan 1,750,000 1,375,000 3,125,000 10 Odentectomy >2 Elemen dengan Narkose Pertindakan 1,750,000 1,375,000 3,125,000 11 Pencabutan Gigi dan dengan Komplikasi Pertindakan 1,750,000 1,375,000 3,125,000 12 Penutupan Oroantral Fistula Pertindakan 1,750,000 1,375,000 3,125,000 13 Sequesterctomy dengan Narkose Pertindakan 1,750,000 1,375,000 3,125,000 Sedang 1 Extirpatie Plunging Ranula Pertindakan 2,450,000 1,925,000 4,375,000 2 Reposisi Fixatie/Compucate Pertindakan 2,450,000 1,925,000 4,375,000 3 Tindakan Block Resectie Pertindakan 2,450,000 1,925,000 4,375,000 Besar 1 Arthroplasty Pertindakan 3,696,000 2,904,000 6,600,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 2 Condylotomy Mandibula Pertindakan 3,696,000 2,904,000 6,600,000 3 Reposisi Fraktur Rahang Simple Pertindakan 3,696,000 2,904,000 6,600,000 4 Resectie Rahang Pertindakan 3,696,000 2,904,000 6,600,000 O Bedah Jantung Khusus 1 Absent Pulmonary Valve Syndrome Repair/dengan atau tanpa MOF/CABG High Risk/Operasi Mitral Valve Repair (MVR)/Atrial Valve Repair (AVR)/Aortic Repair dan PS Pertindakan 41,440,000 32,560,000 74,000,000 2 Adult Complex Repair/Operation/ Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) Repair dan MOF/Off Pump/Aneurysmectomy/ Arterial Switch Operation/AVR-MVR dan MOF/CABG dan MVR/CABG dan AVR/Congenital Heart Complex Repair/Damuskez/Noorwood Operation/Senning Operation/TVR/AV Replacement dan MV Repair dan TV Repair/Repair L' etage Ventrikuler Pertindakan 50,400,000 39,600,000 90,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 3 ALPACA Repair/AP Window dan MOF/AVSD Repair/BCPS On Off Pump dan MOF/Coarctasio Aorta dan MOF Pertindakan 34,440,000 27,060,000 61,500,000 4 AP Window/ASD Primum/Extirpasi Tumor Tanpa Komplikasi/Repair Partial Anomalous Pulmonary Venous Drainage (PAPVD) Pertindakan 29,400,000 23,100,000 52,500,000 5 ASD Closure dan PFO Creation dan TV Pertindakan 29,120,000 22,880,000 52,000,000 6 Repair (TAP DE VEGA) Pertindakan - - 7 ASD dan MOF/CABG/Total Koreksi dan AV Repair/PV Repair/Total Koreksi TOF dan PDA Ligasi/Ligasi Ventricle Duct Pertindakan 33,600,000 26,400,000 60,000,000 8 ASD dan Reseksi Infudibular Pertindakan 31,360,000 24,640,000 56,000,000 9 Aortic Valve Replacement (AVR) Pertindakan 45,360,000 35,640,000 81,000,000 10 Bidirectional Cavopulmonary Shunt (BCPS) dan Ligasi BT Shunt Pertindakan 26,880,000 21,120,000 48,000,000 11 BCPS dan PA Banding Pertindakan 22,120,000 17,380,000 39,500,000 12 BCPS dan PDA Ligasi Pertindakan 27,048,000 21,252,000 48,300,000 13 BCPS Bilateral dan Mitral Cleft Repair Pertindakan 27,160,000 21,340,000 48,500,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 14 BCPS On Pump atau Off Pump/Repair Fistula Coroner/Repair Vascular Ring Pertindakan 26,600,000 20,900,000 47,500,000 15 Bentall/Ross Procedure/Eksisi Sub Aortic Stenosis dan VSD Closure dan PDA Ligasi dan Epicardial PPM/Truncus Arterious Repair/Rastelli With Contegra/Operasi Jantung Terbuka dengan Dua Katup dan Pacu Jantung Temporer Pertindakan 55,440,000 43,560,000 99,000,000 16 Brock dan BT Shunt/ASD Closure dan PDA Ligasi Pertindakan 28,000,000 22,000,000 50,000,000 17 Brock/BT Shunt/Coarctasio Aorta/PA Banding/Sling/Unifokalisasi Pertindakan 20,720,000 16,280,000 37,000,000 18 BT Shunt dan Ligasi MAPCA Pertindakan 25,088,000 19,712,000 44,800,000 19 CABG dan Double Valve Replacement (DVR) Pertindakan 56,000,000 44,000,000 100,000,000 20 CABG Lima dan Repair Aneurysme Artery Coroner Pertindakan 45,920,000 36,080,000 82,000,000 21 CABG Lima dan TV Repair/TAP DE VEGA dan TPM dan PPM/Endovasculer Stent Aorta Pertindakan 72,800,000 57,200,000 130,000,000 22 Chest Re Open Rekonstruksi Pertindakan 10,080,000 7,920,000 18,000,000 23 Coartasio Aorta Repair dan PDA Ligasi dan PA Banding Pertindakan 21,896,000 17,204,000 39,100,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 24 Debridement/Embolisasi Sederhana/Operasi Jantung Tertutup/Percutan Transluminal Angioplasty (PTA)/Trans Arteri Infusion (TAI) Pertindakan 8,960,000 7,040,000 16,000,000 25 Ebstein (TV) Anomali Repair/TAPVD Pertindakan 36,960,000 29,040,000 66,000,000 26 Embolektomi (Through Toracotomi)/Pleurodesis/Redo Operation For Stop Bleeding/Thoracotomi Pertindakan 9,240,000 7,260,000 16,500,000 27 Epicardial Permanent Pace Maker (Microny)/PDA = MOF/Pengangkatan Embolusi (Device Embolusi) dengan Pertindakan 23,240,000 18,260,000 41,500,000 28 CPB)/PS Repair Pertindakan - - 29 aIntra Aortic Baloon Pump (IABP) Pertindakan 13,104,000 10,296,000 23,400,000 30 Operasi Jantung Terbuka dengan Pacu Jantung Temporer Pertindakan 46,449,200 36,495,800 82,945,000 31 Operasi Jantung Terbuka dengan Pacu Jantung Temporer/Penutupan PDA tanpa Pembedahan dengan Menggunakan Device ADO/Plug Ocluder/PDA dan PA Banding/Corangiography dan IABP (Intra Aortic Ballon Pump) Pertindakan 17,920,000 14,080,000 32,000,000 32 Operasi Jantung Terbuka dengan Satu Pertindakan 40,320,000 31,680,000 72,000,000 33 Katup dan Pacu Jantung Temporer/TOF dan MOF Pertindakan - - 34 Operasi Jantung Terbuka Dua Katup Pertindakan 100,800,000 79,200,000 180,000,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 35 Operasi Jantung Terbuka Satu Katup Pertindakan 77,336,000 60,764,000 138,100,000 36 Operasi Jantung Terbuka Standar/ASD Pertindakan 49,249,200 38,695,800 87,945,000 37 Operasi Jantung Terbuka Standar/VSD/ASD Closure dan Reseksi Infudibulum dan Transanular Patch/Repair Left Ventricle Out Flow Track dan VSD Closure Pertindakan 29,960,000 23,540,000 53,500,000 38 Operasi Jantung Tertutup/PDA Pertindakan 32,118,800 25,236,200 57,355,000 39 PDA Ligasi Pertindakan 10,640,000 8,360,000 19,000,000 40 Penutupan ASD tanpa Pembedahan dengan Menggunakan Device (ASO)/Penutupan PFO tanpa Pembedahan dengan Device (PFO Ocluder)/PTA Carotis dengan Stent Pertindakan 25,760,000 20,240,000 46,000,000 41 PS 1 ½ Ventrikular Repair/RVOT Repair/AVR dan VSD Closure dan ASD Closure Pertindakan 31,920,000 25,080,000 57,000,000 42 Pulmonal Valve Replacement Pertindakan 38,640,000 30,360,000 69,000,000 43 Redo BT Shunt/Redo PS Repair/VSD dan PS Repair Pertindakan 33,880,000 26,620,000 60,500,000 44 Tindakan CABG Pertindakan 56,924,000 44,726,000 101,650,000 45 Tindakan MVR/AVR Pertindakan 78,540,000 61,710,000 140,250,000 No Jenis Pelayanan Satuan Jasa Sarana Jasa Pelayanan Total 46 TOF Low Risk/ASD Closure dan MV Repair/Cleft Repair/VSD dan PDA Division dan Coarctasio Repair/VSD Closure dan AV Repair/MV Repair Pertindakan 30,800,000 24,200,000 55,000,000 47 VSD Closure dan Reroute PAPVD dan TV Repair Pertindakan 35,840,000 28,160,000 64,000,000 48 VSD dan MOF (<10 Hari Perawatan) Pertindakan 35,560,000 27,940,000 63,500,000 BUPATI MAMUJU TENGAH, ttd ARSAL ARAS Salinan sesuai dengan aslinya KEPALA BAGIAN HUKUM, LUKMAN,S.Sos NIP.19690604 200112 1 007

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