DokumenPeraturan Gubernur (Pergub)Berlaku

Peraturan Gubernur (Pergub) Provinsi Maluku Nomor 37 Tahun 2024

Nomor: 37
Tahun: 2024
Ditetapkan: 15 November 2024
Status: Berlaku
Pasal terindeks: 7

Lembaga terkait

Pemerintah Provinsi Maluku

aturan_pelaksanaan

Ringkasan

Peraturan Gubernur ini mengatur mengenai pedoman dalam pemungutan atas Penetapan Tarif Retribusi.

Isi peraturan

Menetapkan

menetapkan Peraturan Gubernur tentang Penetapan Tarif Retribusi Daerah, 1.

2.Undang-Undang Nomor 23 Tahun 2014 tentang Pasal 18 ayat (6) Undang-Undang Dasar Negara Republik Indonesia Tahun 1945, Pemerintahan Daerah (Lembaran Negara Republik Indonesia Tahun 2014 Nomor 244, Tambahan Lembaran Negara Republik Indonesia Nomor 5587), sebagaimana telah diubah beberapa kali terakhir dengan UndangUndang Nomor 6 Tahun 2023 tentang Penetapan Peraturan Pemerintah Pengganti Undang-Undang Nomor 2 Tahun 2022 tentang Cipta Kerja Menjadi UndangUndang (Lembaran Negara Republik Indonesia Tahun 2023 Nomor 41, Tambahan Lembaran Negara Republik Indonesia Nomor 6856),
3.Undang-Undang Nomor 1 Tahun 2022 tentang Hubungan Keuangan Antara Pemerintah Pusat dan Pemerintah Daerah (Lembaran Negara Republik Indonesia Tahun 2022 Nomor 4, Tambahan Lembaran Negara Republik Indonesia Nomor 6757),
4.Undang-Undang Nomor 13 Tahun 2023 tentang Provinsi Maluku (Lembaran Negara Tahun 2023 Nomor 60, Tambahan Lembaran Negara Republik Indonesia Nomor 6869):
5.Peraturan Pemerintah Nomor 35 Tahun 2023 Tentang Ketentuan Umum Pajak Daerah dan Retribusi Daerah (Lembaran Negera Republik Indonesia Tahun 2023 Nomor 85, Tambahan Lembaran Negara Republik Indonesia Nomor 6881):
6.Peraturan Daerah Provinsi Maluku Nomor 6 Tahun 2016 tentang Pembentukan dan Susunan Perangkat Daerah Provinsi Maluku (Lembaran Daerah Provinsi Maluku Tahun 2016 Nomor 6, Tambahan Lembaran Daerah Provinsi Maluku Nomor 66) sebagaimana telah diubah dengan Peraturan Daerah Nomor 4 Tahun 2020 tentang Perubahan atas Peraturan Daerah Provinsi Maluku Nomor &6 Tahun 2016 tentang Pembentukan san Susunan Perangkat Daerah Provinsi Maluku (Lembaran Bea Nomor 4, Tambahan Lembaran Daerah Nomor
7.Peraturan Daerah Provinsi Maluku Nomor 2 Tahun 2024 tentang Pajak Daerah dan Retribusi Daerah (Tambahan Lembaran Daerah Provinsi Maluku 2024 Nomor 2, Tambahan Lembaran Daerah Provinsi Maluku Nomor 136):
8.Peraturan Daerah Provinsi Maluku Nomor 3 Tahun 2024 tentang Pengelolaan Keuangan Daerah (Tambahan Lembaran Daerah Provinsi Maluku 2024 Nomor 3, Tambahan Lembaran Daerah Provinsi Maluku Nomor 137), Daerah MEMUTUSKAN: Menetapkan : PERATURAN GUBERNUR TENTANG PENETAPAN TARIF RETRIBUSI DAERAH.

Pasal 1

Dalam Peraturan Gubernur ini yang dimaksud dengan:

1.Daerah adalah Provinsi Maluku.
2.Pemerintah Daerah adalah Gubernur sebagai unsur penyelenggara Pemerintahan Daerah yang memimpin pelaksanaan urusan pemerintahan yang menjadi kewenangan daerah otonom.
3.Gubernur adalah Gubernur Maluku.
4.Retribusi Daerah yang selanjutnya disebut Retribusi adalah pungutan Daerah sebagai pembayaran atas jasa atau pemberian izin tertentu yang khusus disediakan atau diberikan oleh Pemerintah Daerah untuk kepentingan orang pribadi atau badan.
5.Subjek Retribusi adalah Orang Pribadi atau Badan yang menggunakan/menikmati pelayanan barang, jasa, dan/atau perizinan.

BAB II

MAKSUD DAN TUJUAN

Pasal 2

Pembentukan Peraturan Gubernur ini dimaksudkan sebagai pedoman dalam pemungutan atas Penetapan Tarif Retribusi.

Pasal 3

Pembentukan Peraturan Gubernur ini bertujuan untuk meningkatkan pendapatan asli Daerah guna membiayai penyelenggaraan pemerintahan Daerah, tugas pemerintahan, pembangunan dan pelayanan kepada Masyarakat.

BAB III

PENETAPAN TARIF RETRIBUSI

Pasal 4

(1)Perubahan Tarif Retribusi Daerah dilakukan pada jenis Retribusi yang meliputi: pelayanan Kesehatan di Balai Paru: pelayanan Kesehatan di Balai Laboratorium Kesehatan: pelayanan Kesehatan di Rumah Sakit Umum Daerah Dr. Haulussy, pelayanan Pemanfaatan Aset Daerah pada Balai Pelatihan Kesehatan: dan
1. e.penyediaan tempat kegiatan usaha berupa pasar grosir, pertokoan dan tempat kegiatan usaha lainnya.
(2)Ketentuan mengenai Stuktur dan besaran perubahan Tarif Retribusi Daerah sebagaimana dimaksud pada ayat (1) tercantum dalam Lampiran yang merupakan bagian tidak terpisahkan dari Peraturan Gubernur ini. app

Pasal 5

Perubahan Tarif Retribusi sebagaimana dimaksud dalam Pasal 4 dilakukan dengan memperhatikan indeks harga dan perkembangan perekonomian serta kemampuan Masyarakat.

Pasal 6

Peraturan Gubernur ini mulai berlaku pada tanggal diundangkan. Agar setiap orang mengetahuinya, memerintahkan pengundangan Peraturan Gubernur ini dengan penempatannya dalam Berita Daerah Provinsi Maluku. Ditetapkan di Ambon pada no, al November 2024 Pj tu NAN MALUKU, At IE ta Diundangkan di Ambon pada tanggal 5 November 2024 Pih. SEKRETARIS DAERAH PROVINSI MALUKU, BTAH Pp 4 SABIR « 0 ? t RITA DA TS 0 VINSI MALUKU TAHUN 2024 NOMOR 360. LAMPIRAN PERATURAN GUBERNUR MALUKU NOMOR 37 TAHUN 2024 TENTANG PENETAPAN TARIF RETRIBUSI DAERAH STRUKTUR DAN BESARNYA TARIF RETRIBUSI PELAYANAN KESEHATAN BALAI KESEHATAN PARU MASYARAKAT PROVINSI MALUKU

1.POLKLINK TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU NO POLIKLINIK JASA TARIF JASA UNIT COST PELAYANAN RETRIBUSI UNIT COST PELAYANAN JASA MEDIS TARIF BARU 1 Umum Rp 24,000 Rp 16,000 Rp 40,000 Rp 24,000 Rp 6,400 Rp 9,600 Rp 40,000 2 Spesialis Rp 36,000 Rp 24,000 Rp 60,000 Rp 36,000 Rp 9,600 Rp 14,400 Rp 60,000 3 400,000Pungsi Pleura Rp 240,000 Rp 160,000 Rp 400,000 Rp 240,000 Rp 64,000 Rp 96,000 Rp 4 Uji APE Rp 75,000 Rp 50,000 Rp 125,000 Rp 75,000 Rp 20,000 Rp 30,000 Rp 125,000 5 Biopsi Pleura Rp 240,000 Rp 160,000 Rp 400,000 Rp 240,000 64,000 Rp 96,000 Rp 400,000 Biopsi Jarum Halus/ 6 Rp 360,000 Rp 240,000 Rp 600,000 Rp 360,000 Rp 96,000 Rp 144,000 Rp 600,000 FNAB TTNA (Transthoracic 7 Rp 450,000 Rp.300,000 Rp 750,000 Rp 450,000 Rp. 120,000 Rp 180,000 Rp 750,000 Needle Aspiration) 8 Pemasangan Infus Rp 30,000 Rp 20,000 50,000 Rp 30,000 Rp 8,000 Rp 12,000 Rp 50,000 Pemberian Oksigen/Jam Rp. 9 21,000 Rp 14,000 Rp 35,000 Rp 21,000 Rp 5,600 Rp 8,400 Rp 35,000 10 Rp Pemasangan Kateter Rp 42,000 Rp 28,000 Rp 70,000 Rp 42,000 11,200 Rp 16,800 Rp 70,000 INGT 11 Gizi Rp 6,000 Rp 4,000 Rp 10,000 Rp 6,000 Rp 2,400 Rp 1,600 Rp 10,000 12 Berhenti Merokok Rp 10,000 Rp 25,000 Rp 15,000 Rp 6,000 Rp 4,000 Rp 25,000Rp 15,000 13 Fisioterapi Rp 60,000 Rp 40,000 Rp 100,000 Rp 60,000 Rp 24,000 Rp 16,000 Rp 100,000 Treadmil dengan 14 200,000 500,000 300,000 Rp 80,000 Rp 120,000 500,000Cardio Pulmonary Rp 300,000 Rp Rp Rp Rp Test 15 Uji Jalan 6 Menit Rp 75,000 Rp 50,000 Rp 125,000 Rp 75,000 Rp 20,000 Rp 30,000 Rp 125,000 16 4,000 Rp 10,000 Rp 6,000 Rp 4,000 Rp Rp 10,000Injeksi Rp 6,000 Rp 17 Spirometri Rp 150,000 Rp 100,000 Rp 250,000 Rp 150,000 Rp. 60,000 Rp 40,000 Rp 250,000 18 Mantoux Test Rp 120,000 Rp 80,000 Rp 200,000 Rp 120,000 Rp 48,000 Rp 32,000 Rp 200,000
2.LABORATORIUM UNIT COST UNIT COSTNO LABORATORIUM JASA TARIF JASA PELAYANAN RETRIBUSI PELAYANAN JASA MEDIK TARIF BARU 1 Rp Paket Dara Rutin Hb, Leko, Eri,LED) 30,000 Rp. 20,000 Rp. 50,000 Rp. 84,000 /Rp. 33,600jRp. 22,400 Rp. 140,000 Urine Rutin (BJ, PH, Bil) 3 IPaket Darah Lengkap Rp. 42,000 28,000 Rp. 70,000 4 Paket Urin Lengkap Rp. 36,000 Rp. 2a,000 rp. c0oooo rp. 3e,oo0o rp. 14,400 Rp, 9,600 rp. 60,000 5 (Hbaic Rp. 90000 Rp, 60000 Rp, 150,000 IRp. 78o00 Rp, 3i,200 Rp. 20,800 Rp. 130,000 6 Sputum BTA Rp. 24000 Rp. 16,000 Rp. 40,000 Rp. 24000 Rp. 9,600 Rp. 6,400/Rp. 40,000 7 IKultur BTA a (kultur BTA Rp. 180000 Rp. 120000IRp. soo,ooolRp. 180,000lRp. 48,000IRp. 72,000lRp. 300,000

b.(Resistensi OAT Rp. 180,000 Rp. 120,0001Rp. 300,0001Rp. 180,0001Rp. 48,0001Rp. 72,000/Rp. 300,000
c.IMedia Padat (Li) Rp. 180,000 Rp. 120,0001Rp. 300,0001Rp. iso,00olRp. 48,000lRp. 72,0001Rp. 300,000 d. Ubi Kepekaan Metode Rp. 180000 Rp. 180,000 Rp. 3e60,oo0olRp. 180,000 Rp. 4s,ooo rp. 72.000 Rp. 300,000 e IMediaCair (MGIT) Rp. 240,000 Rp. 160,000 rp. 400,000 Rp. 240,000 rp. 64,000 Rp. 9e,ooo Rp. 400,000 Kepekaan Metode ph, 180,000 Rp. 120,000 Rp. 300,000olrp. 180,000 Rp. 4s,000 Rp. 72,000 Rp. 300,000 Trem Rp. 270000 Rp. 180000 Rp. 450000 Rp. 270000 Rp. 108.000 Rp. 72,000 Rp. 450,000 8 Kimia Darah a (Glukosa Darah &ooo Rp, 4000 Rp. 25.000 b HDL c LDL d (Cholesterol Total Rp. 18000 Rp. 12000 Rp. 30,000 Rp. 15,000 IRp. 6,000 Rp. 4000 Rp. 25,000 e SGOT 6,000 Rp. 4,000 Rp. 25,000 1 SGPT Rp. 18,000 Rp. 12000 Rp, 30,000 Rp. 15000 Rp, 6,000 Rp. 4000 Rp. 25,000 Gamma GT Rp. 21000 Rp. 14000 Rp, 35000/Rp. 18,000 Rp. 7,200 Rp. 4,800 Rp. 30,000 h (Creatinin Rp. 18000 Rp. 12,000 Rp. 30,0001Rp. 15,000 Rp. 6,000 Rp. 4000 Rp. 25,000 1 TUreum Rp. 18000 Rp. 12,000 Rp. 30,0001Rp. 15,000 Rp. 6000 Rp. 4,000 Rp. 25,000 Asam Urat 6,000 Rp. 4,000 Rp. 25,000 k Jrigliserida Rp. 1 JBilirubin Total Rp. 18,000 Rp. 12,000 Rp. 30,0001Rp. 15,000 Rp, 6000 Rp. 4000 Rp, 25,000 Warna, Prot Kejernihan, Glu, Uro Rp. 30,000 Rp. 20,000 Rp. S0,000/Rp. 30,000 Rp. 12,000 Rp. 8,000 Rp. 50,000 2 Uji
f.MGIT Ro. 18.000 Rp. 12.000 Rp. 30,000 Rp. 15,000 R R 18.000 R 12.000 R 30.000 R 15.000 R 6.000 R 4.000 R 25.000 R 18.000 R 12.000 R 30.000 R 15,000 R 6.000 R 4.000 R 25.000 Ro. 18.000 Rp. 12.000 Rp. 30,000 Rp. 15.000 R Ro. 18.000 Rp. 12,000 Rp. 30,000| Rp. 15,000 R 21.000! Rp. 14,000 Rp. 35,000| Rp. 18,000 Rp. 7,200 Rp. 4,800 Rp. 30.000 m Bilirubin Direk Rp 18.000 Rp 12,000 Rp 30,000 Rp 15,000 Rp 6,000 Rp 4,000 Rp 25,000 n Bilirubin Indirek Rp 18,000 Rp 12,000 Rp 30,000 Rp 15,000 Rp 6,000 Rp 4,000 Rp 25,000 Albumin Rp 18,000 Rp 12,000 Rp 30,000 Rp 15,000 Rp 6,000 Rp 4,000 Rp 25,000 9 Pemeriksaan Widal Rp 27,000 Rp 18,000 Rp 45,000 Rp 21,000 Rp 8,400 Rp 5,600 Rp. 35,000 Pemeriksaan Darah 10 Rp 27,000 Rp 18,000 Rp 45,000 Rp 12,000 Rp 4,800 Rp 3,200 Rp 20,000Malaria 11 Pemeriksaan Golongan Darah. Rp. 18,000 Rp 12,000 Rp 30,000 Rp 12,000 Rp 4,800 Rp 3,200 Rp 20,000 Tes Kehamilan12 Rp 21,000 Rp 14,000 Rp 35,000 Rp 21,000 Rp 8,400 Rp 5,600 Rp 35,000 13 HIV « Sifilis (Rapid) Rp 60,000 40,000Rp Rp 100,000 Rp 42,000 Rp 16,800 Rp 11,200 Rp 70,000 14 HBS Ag (Rapid) Rp 36,000 Rp 24,000 Rp 60,000 Rp 36,000 Rp 14,400 Rp 9,600 Rp 60,000
1. 3.RONTGEN NO RONTGEN UNIT COST JASA TARIF JASA PELAYANAN RETRIBUSI UNIT COST PELAYANAN JASA MEDIK TARIF BARU 1 Thorax Rp. 120,000 Rp 80,000 Rp. 200,000 Rp. 120,000 Rp 48,000 Rp 32,000 Rp 200,000 2 Extremitas Atas Rp. 135,000 R 90,000) Rp. 225,000 Rp 105,000) Rp 42,000 Rp 28,000 Rp 175,000 3 Extremitas Bawah Rp. 135,000 Rp 90,000 Rp. 225,000 Rp 105,000 Rp 42,000 Rp 28,000 Rp 175,000 4 Vertebra Rp. 135,000 Rp 90,000 Rp. 225,000| Rp 105,000 Rp 42,000 Rp 28,000 Rp 175,000 5s Abdomen Rp. 135,000 Rp 90,000 Rp. 225,000 Rp 6 Cranium 105,000 Rp 42,000 Rp 28,000 Rp 175,000 Rp. 135,000 Rp 90,000 Rp. 225,000 Rp 105,000) Rp 42,000 Rp 28,000 Rp 175,000
2. 4.ELEKTROMEDIK NO ELEKTROMEDIK UNIT COST JASA TARIF UNIT COST JASA JASA MEDIK TARIF BARU PELAYANAN RETRIBUSI PELAYANAN 1 EKG Rp. 75,000 Rp. 50,000 Rp. 125,000 Rp. 45,000 Rp. 18,000 Rp. 12,000 Rp. 75,000 2 CO Smokker Rp. 72,000 Rp. 48.000 Rp. 120,000 Rp. 72,000 Rp. 28,800 Rp. 19,200 Rp. 120,000 3 |Nebulizer Rp. 30,000 Rp. 20,000 Rp. 50,000) Rp. 30,000) Rp. 12,000 Rp. 8,000 Rp. 50,000
3. 5.USG NO RONTGEN UNIT COST JASA TARIF UNIT COST JASA JASA MEDIK TARIF BARU PELAYANAN RETRIBUSI PELAYANAN 1 Abdomen Rp 137,500 Rp 112,000 Rp 249,500 Rp 120,000 Rp 32,000 Rp 48,000 Rp 200,000 2 Parotis Rp. 90,000 Rp 60,000 Rp 150,000 Rp 78,000 Rp 20,800 Rp 31,200 Rp 130,000 3 Payudara Rp 90,000 Rp 60,000 Rp 150,000 Rp 78,000 Rp 20,800 Rp 31,200 Rp 130,000 4 Testis Rp 90,000 Rp 60,000 Rp 150,000 Rp 78,000 Rp 20,800 Rp 31,200 Rp 130,000 5 Tyroid Rp 180,000 Rp 120,000) Rp 300,000 Rp 150,000 Rp 40,000 Rp 60,000 Rp 250,000 6 Abdomen Atas # Bawah Rp 270,000 Rp. 180,000 Rp. 450,000 Rp. 180,000 Rp. 48,000 Rp. 72,000 Rp. 300,000 7 Thoraax Rp. 180,000 Rp. 120,000 Rp. 300,000) Rp. 150,000 Rp. 40,000| Rp. 60,000| Rp. 250,000 Keterangan Warna: Ll Jenis pemeriksaan yang lama Daftar harga retribusi baru STRUKTUR DAN BESARNYA TARIF RETRIBUSI PELAYANAN KESEHATAN BALAI LABORATORIUM KESEHATAN DAN KALIBRASI ALAT KESEHATAN PROVINSI MALUKU
4. 1.HEMATOLOGI NO JENIS LAYANAN TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU UNIT COST JASA LAYANAN TARIF UNIT COST JASA AYANAN TARIF BARU PEMERIKSAAN RUTIN Hitung Jumlah
a.Limfosit Plasma Biru Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 b Lekosit, Mikroskopis Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000
c.Eritrosit, Mikroskopis Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 d Trombosit Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 4,800 16,000 . Eosinofil Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 3,600 Rp 12,000 £ Retikolosif Rp 2 Hematokrit 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 3 Leukosit Hitung Jenis Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 4 Cloysis Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 5 Cryofobrinogen/ Cyoglobilin Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 6 Masa Pembekuan Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 7 Percobaan Pembendungan Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 3,600 8 Masa Pendarahan Rp Rp 12,000 Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 9 Retraksi Bekuan Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 10 Laju Endap Darah (LED) Rp 18,200 Rp 7,800 Rp 26,000 Rp 18,200 7,800 Rp 26,000 11 Hemopglobin eritrosit Rata-rata/ HER Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 12 Konsentrasi Hb Eritrosit rata-rata/ KHER Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 13 Volume Eritrosit rata-rata (VER), Perhitungan Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 14 Konsentrasi Hemoglobin Eritrosit Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 15 Euglobulin ( SIA ) Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 16 Gologan Darah : A, B, O dan Rhesus Rp 14,000 Rp 6,000 Rp 20,000 Rp 14,000 Rp 6,000 Rp 20,000 17 100,100 42,900 143,000Darah Rutin Lengkap Rp Rp Rp Rp 100,100 Rp 42,900 Rp 143,000 18 Hemaglobin Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 19 Eritrosit Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 20 Leukosit Rp 11,200 Rp 4,800 16,000Rp Rp 11,200 Rp 4,800 Rp 16,000 21 Nilai MC Rp 32,900 Rp 14,100 Rp 47,000 Rp 32,900 Rp 14,100 Rp 47,000 R n PEMERIKSAAN SPESIALIS 1 Ketahanan Osmotik Rp 11,200 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 2 Ham Test Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 R 4,800 Rp 16,000 3 Sugar water Test Rp 11,200 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 4 Masa Trombin Rp 11,900 5,100 Rp 17,000 Rp 11,900 Rp 5,100 Rp 17,000 5 Protrombin plasma 11,900 5,100 Rp 17,000 Rp 11,900 Rp 5,100 Rp 17,000 6 Hitung Jumlah 7 Tromboplastin, Masa Partial Rp 11,200 4,800 Rp 16,000 R 11,200 Rp 4,800 16,000 Euglobin Clotlysis (Coagulometer) Rp 9,800 4,200 Rp 14,000 Rp 9,800 Rp 4,200 14,000 9 Besi Pewernaan Rp 9,800 Rp 4,200 Rp 14,000 Rp 9,800 Rp 4,200 Rp 14,000 10 Besi Pewernaan Rp 18,200 7,800 Rp 26,000 Rp 18,200 Rp 7,800 Rp 26,000 11 Trombin Penetapan waktu seri Rp 36,400 15,600 Rp 52,000 Rp 36,400 Rp 15,600 Rp 52,000 12 Trombosit Agregasi Rp 23,100 Rp 9,900 Rp 33,000 Rp 23,100 Rp 9,900 33,000 13 Fibrinogen Rp 23,100 9,900 Rp 33,000 Rp 23,100 Rp 9,900 Rp 33,000 14 Fibrinogen Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 PEMERIKSAAN SUB SPESIALIS 1 Morfology Sel/ Apusan Darah Tepi (ADT) Rp 12,600 Rp 5,400 Rp 18,000 Rp 70,000 Rp 30,000 Rp 100,000 50,000Neutropil Alkaline phosphatase 35,000 Rp 15,000 Rp Rp 35,000 Rp 15,000 Rp 50,000 Nitroblue tetrazoleum pewarnaan 35,000 Rp 15,000 50,000 Rp 35,000 Rp 15,000 Rp 50,000 Perodic Acid Schiff/ PAS, Pewarnaan 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 5 Poroksidae, Pewernaan 35,000 15,000 50,000 35,000 15,000Rp Rp Rp Rp Rp 50,000 Sudan Block B, Pewernaan Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 7 Hemoglobin (Elektroforesis) Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 R
1. 2.KIMIA KLINIK TARIF PERDA NOMOR 02 TAHUN 2024 NO JENIS LAYANAN PERUBAHAN TARIF RETRIBUSI BARU UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN TARIF BARU 1 PEMERIKSAAN URIN LENGKAP 1 10,000Fisik : Volume, Bau, warna, kekeruhan Rp 7,000 Rp 3,000 Rp Rp 7,000 Rp 3,000 10,000 2 PH Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 3,000 Rp 10,000 3 Darah Samar Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 4 Keton Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 10,000Rp 5 Albumin Urin (Reaksi) Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 6 Bilirubin Urin (Reaksi) Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 3,000 R 10,000 7 Globulin Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 3,000 Rp 10,000 8 Methemoglobin Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 10,000 9 |Protein Bence Jones (reaksi) 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 10 Protein Kwalitatif/ semi kuantitatif 7,000 3,000 7,000 3,000 Rp 10,000 11 Rp Rp Rp 10,000 Rp Rp Pemekatan percobaan (reaksi) Rp 7,000 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 12 Pengencaran Percobaan 7,000 Rp 3,000 Rp 10,000 7,000 Rp 3,000 Rp 10,000 13 Glukosa, Urin (reaksi) Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 14 Nirrit Rp 7,000 Rp 3,000 Rp 10,000 R 7,000 Rp 3,000 Rp 10,000 15 Analisa batu Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 16 Analisa Tinja : Sel darah, Lemak Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 17 Oval fat bodies 7,000 3,000 7,000 10,000 18 Rp Rp Rp 10,000 Rp Rp 3,000 Rp Sedimen Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 19 Urobilin 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 20 Urobilinogen 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 21 7,000Protein penetapan kuantitaif Rp Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 22 Indikan Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 23 Carik Celup Urin 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 n PEMERIKSAAN SPESIALIS 1 Thymol Turbidy test (MT) Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 FUNGSI HATI 1 SGOT Rp 14,000 6,000 Rp 20,000 Rp 14,000 6,000 20,000 2 SGPT 14,000 Rp Rp Rp 6,000 Rp 20,000 Rp 14,000 Rp 6,000 Rp 20,000 3 Bilirubin Total Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 4 Bilirubin Direct Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 16,000 5 Alkali Fostatase 14,000 R 14,000Rp 6,000 Rp 20,000 Rp Rp 6,000 20,000 6 Protein Total Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 7 Albumin Rp 13,300 Rp 5,700 Rp 19,000 Rp 13,300 Rp 5,700 Rp 19,000 Globulin Rp 11,200 4,800 16,000 11,200 v PROFIL LIPID Rp Rp Rp 4,800 Rp 16,000 1 Kolcsterol Total Rp 13,300 Rp 5,700 Rp 19,000 Rp 13,300 Rp 5,700 Rp 19,000 2 HDL Kolesterol Rp 16,100 Rp 6,900 Rp 23,000 16,100 3 LDL Kolesterol Rp Rp 6,900 Rp 23,000 Rp 13,300 Rp 5,700 Rp 19,000 Rp 13,300 Rp 5,700 Rp 19,000 4 Trigliserida Rp 16,100 Rp 6,900 Rp 23,000 Rp 16,100 Rp 6,900 Rp 23,000 VI FUNGSI GINJAL 1 Ureum 5,700Rp 13,300 Rp 19,000 Rp 13,300 Rp 5,700 19,000 2 Creatirun Rp 11,200 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 3 Asam Urat Rp 13,300 Rp 5,700 Rp 19,000 Rp 13,300 Rp 5,700 Rp 19,000 R VII FUNGSI METABOLISME DAN KARBOHIDRAT I Glukosa Darah Puasa Rp 13,300 Rp 5,700 Rp 19,000 Rp 13,300 Rp 5,700 Rp 19,000 2 Glukosa Darah 2 PP Rp 13,300 Rp 5,700 Rp 19,000 Rp 13,300 Rp 5,700 Rp 19,000 3 HBAIC Rp 136,500 Rp 58,500 Rp 195,000 Rp 105,000 Rp 45,000 Rp 150,000 4 Elektrolite Rp 182,000 Rp 78,000 Rp 260,000 Rp 140,000 Rp 60,000 Rp 200,000
2. 3.MIKROBIOLOGI NO TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU JENIS LAYANAN UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN TARIF BARU KATEGORI MIKROSKOPIK A Parasit /"Jamur/kapang BAKTERI 1 Corynebakterium Dipteriac 14,000 Rp 6,000 Rp 20,000 Rp 14,000 Rp 6,000 Rp 20,000 2 Mvcobakterium Leprae Rp 14,000 Rp 6,000 Rp 20,000 Rp 14,000 Rp 6,000 Rp 20,000 3 Mvcobakterium Tubercolosis Rp 14,000 Rp 6,000 Rp 20,000 Rp 14,000 Rp 6,000 Rp 20,000 4 Bacillus arithraxis 14,000 Rp 6,000 Rp 20,000 Rp 14,000 6,000 20,000 5 Neisseria Gonorhea Rp 14,000 Rp 6,000 Rp 20,000 Rp 14,000 6,000 Rp 20,000 6 Treponema pallidum Rp 14,000 Rp 6,000 Rp 20,000 Rp 14,000 6,000 Rp 20,000 PEMERIKSAAN SPESIALIS BIAKAN A Parasit/Jamur/kapang Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 1 Larva A Duodenale /N.Americanus Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 2 Plasmodium spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 10,500 35,000Rp Rp 3 Schistosoma spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 4 Trichomonas spp Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 5 Jamur Sistemik Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 6 Candida spp Rp 35,000 Rp 15,000 R 50,000 Rp 35,000 Rp 15,000 Rp 50,000 7 Jamur Subentnin Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 Jamur Superficial Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 9 Scl Ragi/Ycast Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 BAKTERI 1 Sterptococcus spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 2 Stapycoccus spp Rp 24,500 Rp 10,500 Rp 35,000 24,500Rp Rp 10,500 Rp 35,000 3 Angka Kuman Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 4 Trichomonas spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 5 Acinotebacter spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 6 Aeromonas spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 7 |Bacteroides Fragilis Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 8 |Basillus spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 9 |Bordetlla spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 10 |Borrelia spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 11 |Banhamella spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 j Rp 35,000 12 Brucella spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 13 jCitrobacter spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 14 |Edwarsiella spp Rp 24,500 Rp 10500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 15 |Liseria spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 16 Seratia spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 17 Ervsipelothrixru Sioppathalae Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 18 Enterobacter spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 19 Enterecoccus Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 20 |E.Colli Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 21 Fransiella Novicade Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 22 |Fusobaxterium necrophorus Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 23 |Haemophilus spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 24 |Helicobacterpylori Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 25 |Klebsiella spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 26 |Mvcobacterium spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 27 Yersinia spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 28 Salmonella spp Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 29 Ishigela spp Rp 24,500 Rp 10,500 j Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 30 Vibrio NAG Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 31 Vibrio Parahaemolyticus Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 32 |Neiseria Gonorhea Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 j Rp 50,000 35 |Nocardia sp Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 36 Campvlobacter jejuni Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 37 IClostridium sp Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 38 Corynebacterium sp Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 39 |Legionella sp Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 40 Leptospira sp 35,000 15,000 50,000 Rp 35,000 Rp 15,000 Rp 50,000 41 |Pseudomonas sp Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp S0,000 33 Neiseria Meningitidis Rp 35,000 Rp 15,000 Rp 50,000 Rp 35.000 Rp 15,000 Rp 50,000 34 Vibrio Colera R 35,000 R 15,000 R 50,000 R 35,000 R 15,000 R 50,000 R R R 42 Pseudomonas sp Rp 35,000 15,000 43 Rp 50,000 Rp 35,000 15,000 Rp 50,000 Providentia sp Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 44 Uji Kepekaan dilusi Rp 126,000 Rp 54,000 Rp 180,000 Rp 126,000 Rp 54,000 Rp 180,000 PEMERIKSAAN SUB SPESIALIS Penetapan Sub Type Rp 56,000 24,000 Rp 80,000 Rp 56,000 24,000 Rp 80,000 2 Hewan Percobaan Rp 56,000 Rp 24,000 Rp 80,000 Rp 56,000 Rp 24,000 Rp 80,000 3 Biakan Jaringn Virus Polio Rp 595,000 Rp 255,000 Rp 850,000 Rp 595,000 Rp 255,000 Rp 850,000 4 Uji Kepekaan Dilusi 24,000Rp 56,000 Rp Rp 80,000 Rp 56,000 24,000 Rp 80,000 Ss Biakan Jaringan Chlarnyda sp Rp 595,000 Rp 255,000 Rp 850,000 Rp 595,000 255,000 Rp 850,000 6 Biakan Jaringan Mycoplasma sp Rp 595,000 Rp 255,000 Rp 850,000 Rp 595,000 Rp 255,000 Rp 850,000 MIKROSKOPIK 1 Bakteri 18,200 7,800 Rp 26,000 Rp 18,200 7,800 26,000 2 Jamur 18,200 Rp 7,800 Rp 26,000 Rp 18,200 7,800 26,000 3 Plasmodium/DDR 18,200 Rp 7,800 Rp 26,000 Rp 18,200 7,800 26,000Rp 4 Pengecatan Gram R 18,200 Rp 7,800 Rp 26,000 Rp 18,200 7,800 Rp 26,000 5 BTA Rp 18,200 Rp 7,800 Rp 26,000 Rp 18,200 7,800 Rp 26,000 6 Feces Lengkap Rp 45,500 Rp 19 500 Rp 65,000 Rp 45,500 Rp 19,500 65,000 7 Mikrofilaria 7,80018,200 Rp 26,000 Rp 18,200 7,800 Rp 26,000 IV BIAKAN/KULTUR Bakteri 45,500 Rp 19 500 65,000 Rp 45,500 R 19,500 65,000 2 Jamur Rp 45,500 Rp 19,500 65,000Rp Rp 45,500 Rp 19,500 Rp 65,000 3 Sensitivitas Antibiotika Rp 168,700 Rp 72,300 Rp 241,000 Rp 129,500 Rp 55,500 Rp 185,000 4 Uji Kepekaan Defusi (Kultur) Rp 168,700 Rp 72,300 Rp 241,000 Rp 129,500 Rp 55,500 Rp 185,000 v BAKTERIOLOGI AIR 1 Coliform Rp 20,300 Rp 8,700 29,000 Rp 20,300 8,700 Rp 29,000 2 Counja Rp 45,500 Rp 19,500 Rp 65,000 Rp 45,500 Rp 19,500 Rp 65,000 VI BAKTERIOLOGI UDARA 1 Bakteri Udara Rp 163,800 Rp 70,200 Rp 234,000 Rp 163,800 Rp 70,200 Rp 234,000
3. 4.IMUNOLOGI TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU JENIS LAYANAN UNIT COST JASA AYANAN TARIF .UNIT COST JASA LAYANAN TARIF BARU PEMERIKSAAN RUTIN Rheumotoloid Factor Rp 56,000 j Rp 24000 Rp 80,000 Rp 56,000 Rp 24,000 Rp 80,000 Anti Simtorysin (ASTO) Rp . 56,000 j Rp 24,000 Rp 80,000 Rp 56,000 Rp 24,000 Rp 80,0 PEMERIKSAAN SPESIALIS 25 Anti HAV (Anti Hepatitis A Virus Rp 49,000 Rp 21,000 Rp 70,000 Rp 49,000 Rp 21,000 Rp 70,000 26 Anti Rp 38,500 Rp 16,500 Rp 55,000 Rp 38,500 Rp 16,500 Rp 55,000 28 (Hepatitis B Mikro Elisa Rp 49,000 Rp 21,000 Rp 70,000 j Rp 49,000 Rp 21,000 Rp 70,000 II PEMERIKSAAN SUB SPESIALIS 1 (HIV RIA (Human Imun Virus Radio Imuno Assay) 210000 Rp 90000 Rp 300,000 Rp210,0001 Rp 90,000 Rp 300,000 IV HEPATITIS 1 HbsAg (Rapid) Rp 29,400 Rp 12,600 Rp 42,000 Rp 29,400 Rp 12,600 Rp 42,000 2 |HbsAg (ELFA) Rp 119,000 Rp 51,000 Rp 170,000 Rp 119,000 Rp 51,000 Rp 170,000 6 Anti HCV Rp 84,000 Rp 36,000 Rp 120,000 Rp 84,000 Rp 36,000 Rp 120,000 7 Anti HBE/ Anti HBS Rp 60,200 Rp 25,800 Rp 86,000 Rp 60,200 Rp 25,800 Rp 86,000 8 Anti HAV Rp 63,700 Rp 27,300 Rp 91,000 Rp 63,700 Rp 27,300 Rp 91,000 V PENYAKIT MENULAR SEKSUAL 1 RPR Rp 65,800 Rp 28,200 Rp 94,000 Rp 65,800 Rp 28,200 Rp 94,000 2 TPHA Rp 20,300 Rp 8,700 Rp 29,000 Rp 20,300 Rp 8,700 Rp 29,000 VII PERTANDA TUMOR X TEST ALERGI 1 IgE Imunuglobulin E) Rp 145,600 Rp 62,400 Rp 208,000 Rp145,600 Rp 62,400 Rp 208,000 XI INFEKSI LAINNYA TOXIOLOGY (SPECIMEN MANUSIA) NO JENIS LAYANAN TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU UNIT COST JASA LAYANAN TARIF UNIT COST JASA AYANAN TARIF BARU I PEMERIKSAAN RUTIN 1 Narkotika (Gas Chromatografy) R 42,000 18,000 60,000 Rp 42,000 18,000 Rp 60,000 2 Arsen/ AS (Gas Choromatografy) Rp 49,000 Rp 21,000 Rp 70,000 Rp 49,000 Rp 21,000 Rp 70,000 3 Cadmium/ Cd (Spektrofotometri Serapan Atom Rp 49,000 Rp 21,000 70,000 Rp 49,000 Rp 21,000 Rp 70,000 4 Crom/ Cr (Spektrofotometri Serapan Atom Rp 49,000 Rp 21,000 70,000 Rp 49,000 Rp 21,000 Rp 70,000 Raksa/ Hg (Spektrofotometri Serapan Atom 49,000 Rp 21,000 Rp 70,000 Rp 49,000 Rp 21,000 Rp 70,000 6 Seng/ Zn (Spektrofotometri Serapan Atom Rp 49,000 Rp 21,000 Rp 70,000 Rp 49,000 Rp 21,000 Rp 70,000 7 Tembaga/ Cu (Spektrofotometri Serapan Atom 49,000 Rp 21,000 70,000 Rp 49,000 Rp 21,000 Rp 70,000 Timah/ Sn (Spektrofotometri Serapan Atom R 49,000 Rp 21,000 Rp 70,000 Rp 49,000 Rp 21,000 Rp 70,000 9 Timbal/ Pb (Spektrofotornetri Serapan Atom R 49,000 Rp 21,000 Rp 70,000 Rp 49,000 Rp 21,000 Rp 70,000 10 |Pestisida (KC) 49,000 21,000 21,000 70,000Rp Rp 70,000 Rp 49,000 KIMIA LINGKUNGAN (AIR, UDARA, PADATAN, MINUM DAN BAHANNYA TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU NO JENIS LAYANAN UNIT COST JASA LAYANAN TARIF UNIT COST ASA LAYANAN TARIF BARU I PEMERIKSAAN RUTIN 1 Bau Rp 1,400 Rp 600 Rp 2,000 Rp 1,400 Rp 600 Rp 2,000 2 Rasa 6001,400 Rp Rp 2,000 Rp 1,400 600 Rp 2,000 3 Suhu Rp 1,400 Rp 600 Rp 2,000 Rp 1,400 Rp 600 Rp 2,000 4 Warna 2,100 R 900 Rp 3,000 Rp 2,100 900 Rp 3,000 5 2,100 900 R 900Daya Hantar Listrik Rp 3,000 Rp 2,100 Rp Rp 3,000 6 Kecerahan/ Kejernihan Rp 1,400 600 2,000 Rp 1,400 Rp 600 Rp 2,000 7 Lapisan Minyak Rp 1,750 Rp 750 2,500 Rp 1,750 Rp 750 Rp 2,500 Derajat Kcasaman/ Rp 2,100 Rp 900 Rp 3,000 Rp 2,100 900 Rp 3,000 9 Kebasahan Rp 1,750 Rp 750 Rp 2,500 Rp 1,750 Rp 750 Rp 2,500 10 Cior Bebas (C 12) Rp 1,400 Rp 600 Rp 2,000 Rp 1,400 600 Rp 2,000 11 Zat Terendap Rp 2,100 Rp 900 Rp 3,000 Rp 2,100 Rp 900 3,000 900 Rp 12 Benda Terapung Rp 2,100 Rp Rp 3,000 Rp 2100 Rp 900 Rp 3,000 13 Kekeruhan Rp 2,800 Rp 1,200 Rp 4,000 Rp 2,800 Rp 1,200 Rp 4,000 14 Timbal/ Pb (Reaksi) Rp 2,800 Rp 1,200 Rp 4,000 Rp 2,800 1,200 Rp 4,000 16 Oksigen Terlarut Rp 2,800 Rp 1,200 Rp 4,000 Rp 2,800 1,200 Rp 4,000 25 Zat Organik (KMNO4) Rp 2,800 Rp 1,200 Rp 4,000 Rp 2,800 Rp 1,200 4,000 6. 26 Salinitas Rp 4,200 Rp 1,800 Rp 6,000 Rp 4,200 Rp 1800 Rp 6,000 27 Sisa Klor Rp 4,200 Rp 1800 Rp 6,000 Rp 4,200 Rp 1800 Rp 6,000 28 Kesadahan Cac03 Rp 4,200 Rp 1800 Rp 6,000 Rp 4,200 Rp 1800 Rp 6,000 29 |Kalium Klorat Rp 4,200 Rp 1800 Rp 6,000 Rp 4,200 Rp 1,800 Rp 6,000 30 Zat yang Teroksidasi dengan KMNO4 Rp 4,200 Rp 180 Rp 6,000 Rp 4,200 Rp 1800 Rp 6,000 11 PEMERIKSAAN SPESIALIS 5 Kebisingan Rp 5,600 Rp 2,400 Rp 8,000 Rp 5,600 Rp 2,400 Rp 8,000 6 Amoniak Bebas (CH3-N) Rp 2,450 Rp 1,050 Rp 3,500 Rp 2,450 Rp 1,050 Rp 3,500 7 Karbon Dioksid (C02) Rp 4,900 Rp 2,100 Rp 7,000 Rp 4,900 Rp 2,100 Rp 7,000 10 Sulfat Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 11 Fluoride Rp 7,000 Rp 3,000 Rp 10,000 Rp 7.000 Rp 3,000 Rp 10,000 12 Asam Formiat Rp 3,500 Rp 1500 Rp 5,000 Rp 3,500 Rp 1,500 Rp 5,000 13 AsamSalisilat Rp 15,400 Rp 6,600 Rp 22,000 Rp 15,400 Rp 6,600 Rp 22,000 14 Selenium (Se) Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 15 IFosfat (FO4) Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 16 Nitrit (NO2-N Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 21 Zat Pengawet, Natrium Nitrat Rp 6,300 Rp 2700 Rp 2,000 Rp 6,300 Rp 2700 Rp 9,000 22 Residual Sodium Carbonar Rp 5,600 Rp 2400 Rp 8,000 Rp 5,600 Rp 2,400 Rp 8,000 23 Sodium Absorbtion Ratio/ SAR Rp 5,600 Rp 2,400 Rp 8,000 Rp 5,600 Rp 2,400 Rp 8,000 24 Lopam Rp 15,400 Rp 6,600 Rp 22,000 Rp 15,400 Rp 6,600 Rp 22,000 25 ILogam Berat Rp 15,400 Rp 6,600 Rp 22,000 Rp 15,400 Rp 6,600 Rp 22,000 26 KOBALT (Co), Spektrofotometri Rp 7,700 Rp 3,300 Rp 11,000 Rp 7,700 Rp 3,300 Rp 11,000 27 Alumunium (Al) Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 1 Padatan Zat teruspensi 2,100 R 900 R 3,000 R 2,100 R 900 3,000 2 Zat Padat Terlarut 2,100 R 900 R 3,000 R 2,100 R 900 3,000 3 C02A esif R 2,100 R 900 R 3,000 R 2,100 R 900 R 3,000 4 Debu Udara R 15,400 R 6,600 R 22,000 R 15,400 R 6,600 R 22,000 8 Oksi en terabso si R 4,900 R 2,100 R 7,000 R 4,900 R 2,100 R 7,000 9 Oksidan 03 Ozon R 2,450 R 1,050 R 3,500 R 2,450 R 1,050 R 3,500 17 Zat Pengawet, Natrium Nitrit Na-N2) R 7,000 R 3,000 Rp 10,000 /R 7000 R 3,000 Rp 10,000 18 IKarbon Monoksida (CO), (Spektrofotometri) Rp 7,000 Rp 3,000 Rp 10,00 Rp 7,0/Rp 3,000 / Rp 10,000 19 Kebutuhan Kimiawi akan Oksigen/ COD Rp 6,300 Rp 2700 Rp 9,0 Rp 2,700 Rp 9,000 20 INitrat (N02-N) R 6,300 R 2,700 Rp 9,000 Rp 6,300 R 2700 Rp 9,000 28 IBarium (Ba) Rp 7,700 /R 3,300 Rp 11,000 Rp 7,700 R 3,300 Rp 11,000 29 INatrium (Bal Rp 7,700 3,300 Rp 11,000 Rp 7,700 R 3,300 Rp 11,000 30 ISeng (Zn) Rp 8,400 /R 3,600 Rp 12,000| Rp 8,400 R 3,600 Rp 12,000 31 Boron 5,600 Rp 2,400 Rp 8,000Rp 5,600 2,400 Rp 8,000 Rp 32 Hidrokarbon (HC) Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 33 Arsen/ As Rp 2,100 Rp 900 Rp 3,000 Rp 2,100 900 Rp 3,000 34 Besi/ Fe Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 35 Cadmium (Cd) Rp 14,000 Rp 6,000 Rp 20,000 Rp 14,000 6,000 Rp 20,000 36 Timbal/ Pb (udara) Rp 22,400 Rp 9,600 Rp 32,000 Rp 22,400 Rp 9,600 Rp 32,000 Kebutihan Biologi Oksigen 5 Hari pada 20"C 37 Rp 18,200 Rp 7,800 Rp 26,000 Rp 18,200 Rp 7,800 Rp 26,000sebagai 02/ BOD 38 Sulfida dalam air R 7,700 Rp 3,300 Rp 11,000 Rp 7,700 Rp 3,300 Rp 11,000 39 Minyak dan Lemak Rp 10,500 4,500 Rp 15,000 Rp 10,500 Rp 4,500 Rp 15,000 40 Minyak nabati Rp 9,100 Rp 3,900 Rp 13,000 Rp 9,100 3,900 Rp 13,000 41 Fenol Rp 10,500 Rp 4,500 Rp 15,000 Rp 10,500 Rp 4,500 Rp 15,000 42 Detergen/Uji biru metilen R 14,000 Rp 6,000 Rp 20,000 Rp 14,000 Rp 6,000 Rp 20,000 43 Obat Narkotika/ Narkoba Rp 87,500 Rp 37,500 Rp 125,000 Rp 108,500 Rp 46,500 Rp 155,000
4. 7.DAFTAR PEMERIKSAAN KUALITAS UDARA TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARUNO JENIS LAYANAN TARIFUNIT COST JASA AYANAN UNIT COST J ASA LAYANAN TARIF BARU 1 FISIKA 1 Suhu Udara Rp 10,500 Rp 4,500 Rp 15,000 Rp 10,500 4.500 15,000 2 Kelembaban udara 4,500 15,000 10,500 R 10,500 Rp Rp Rp 4,500 Rp 15,000 3 Kecepatan Angin Rp 10,500 Rp 4,500 Rp 15,000 Rp 10,500 4,500 Rp 15,000 4 Kebisingan Rp 10,500 Rp 4,500 Rp 15,000 Rp 10,500 4,500 Rp 15,000 n UDARA AMBIEN 1 Nitrit (N02) 10,500 R 4,500 Rp 15,000 Rp 10,500 4,500 Rp 15,000 2 Sulfur (S02) Rp 25,900 Rp 11,100 Rp 37,000 Rp 25,900 11,100 Rp 37,000 3 Rp 25,900 Rp 11,100 Rp 37,000 Rp 25,900 Rp 11,100 Rp 37,000 Ozon (03) 4 Timbal (Pb) Rp 25,900 Rp 11,100 Rp 37,000 Rp 25,900 R 11,100 Rp 37,000 5 C02 (Carbondioxida) Rp 31,500 Rp 13,500 Rp 45,000 Rp 31,500 Rp 13,500 Rp 45,000 6 TSP (Partikcl Dcbu) Rp 25,900 Rp 11,100 Rp 37,000 Rp 25,900 Rp 11,100 Rp 37,000 7 NH3 (Amoniaj Rp 31,500 Rp 13,500 Rp 45,000 31,500 13,500 Rp 45,000 8 CO (Carbon Monoxida) Rp 31,500 Rp 13,500 Rp 45,000 Rp 31,500 Rp 13,500 Rp 45,000 9 Timbal (Pb) Rp 42,000 Rp 18,000 Rp 60,000 Rp 42,000 Rp 18,000 Rp 60,000
5. 8.TARIF USG NO JENIS LAYANAN TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN T.ARIF RETRIBUSI BARU UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN TARIF BARU 1 Abdomen atas Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 Rp 46,800 Rp 156,000 2 Abdomen bawah Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 Rp 46,800 Rp 156,000 3 Parotis Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 46,800 Rp 156,000 4 Payudara Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 46,800 Rp 156,000 5 Testis 46,800Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 Rp Rp 156,000 6 Tyroid Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 46,800 Rp 156,000 7 Abdomen alat bawah Rp 109,200 Rp 46,800 156,000 Rp 109,200 Rp 46,800 Rp 156,000 Abdomen alat atas t Appendix Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 46,800 Rp 156,000
6. 9.TARIF RONTGEN TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU NO JENIS LAYANAN UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN) TARIF BARU 1 Abdomen atas Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 Rp 46,800 Rp 156,000 2 Ekstremitas Atas Rp 42,000 Rp 18,000 Rp 60,000 Rp 42,000 Rp 18,000 Rp 60,000 3 Ekstremitas Bawah Rp 42,000 Rp 18,000 60,000 42,000Rp 18,000 Rp 60,000 4 Vertebra Rp 42,000 Rp 18,000 Rp 60,000 Rp 42,000 Rp 18,000 Rp 60,000 Abdomen Rp 42,000 Rp 18,000 Rp 60,000 Rp 42,000 18,000 Rp 60,000 6 Cranium Rp 42,000 Rp 18,000 Rp 60,000 Rp 42,000 Rp 18,000 60,000Rp 10 ELEKTROMEDIK TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU NO JENIS LAYANAN UNIT COST j JASA LAYANAN TARIF UNIT COST (JASA LAYANAN TARIF BARU 1 EKG Rp 109,200 Rp 46,800 Rp 156,000 Rp 109,200 Rp 46,800 Rp 156,000 2 Spirometri Rp 66,500 Rp 28,500 Rp 95,000 Rp 66,500 Rp 28,500 Rp 95,000 3 Co Smoker Rp 35,000 Rp 15,000 50,000Rp Rp 35,000 Rp 15,000 Rp 50,000 4 7 Rp 35,000 Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 11 PENGGOLONGAN LIMBAH NO JENIS LAYANAN TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN) TARIF BARU 1 Rp 14,000 Rp 6,000 Rp 20,000 Rp 14000 RpLimbah Medis « 1 Kg 6,000 Rp 20,000 2 Limbah Medis Per Kg Rp 21,000 Rp 9000 Rp 30,000 Rp 21,000 Rp 9,000 Rp 30,000 12 TARIF ANALISA MAKANAN NO JENIS LAYANAN TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN TARIF BARU 1 Salmonella Rp 22750 Rp 9750 Rp 32,500 Rp 22,750 Rp 9,750 Rp 32,500 2 IE.coli Rp 38,500 Rp 16,500 Rp 55,000 Rp 38,500 Rp 16,500 Rp 55,000 3 Coliform Rp 22,750 Rp 9,750 Rp 32,500 Rp 22,750 Rp 9750) Rp 32,500 13 TARIF PELAYANAN MEDIKO LEGAL TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU NO JENIS LAYANAN UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN) TARIF BARU 1 Surat Keterangan Berbadan Sehat Rp 24,500 Rp 10,500 Rp 35,000 Rp 24,500 Rp 10,500 Rp 35,000 2 35,000Pemeriksaan Fisik (MCU) Rp Rp 15,000 Rp 50,000 Rp 35,000 Rp 15,000 Rp 50,000 3 Konsultasi Dokter Rp 7,000 Rp 3,000 Rp 10,000 Rp 7,000 Rp 3,000 Rp 10,000 4 Pelayanan Cito Rp Rp Rp 2596 " 1596 " Pelayanan Rumah Rp Rp Rp " Untuk pengambilan sampel pasien di lapangan (mobilisasi ) maka retribusi yang dikenakan tarif tambahan 15 Yo dari masing masing pemeriksaan dan untuk Pelayanan Cito. tarif tambahan 25 Yo dari masing masing pemeriksaan . 14 TARIF KIMIA KESEHATAN LINGKUNGAN NO JENIS LAYANAN TARIF PERDA NOMOR 02 TAHUN 2024 PERUBAHAN TARIF RETRIBUSI BARU UNIT COST JASA LAYANAN TARIF UNIT COST JASA LAYANAN) TARIF BARU I PARAMETER AIR MINUM A FISIKA 1 Bau Rp 2,100 Rp 900 Rp 3,000 Rp 2,100 Rp 900 Rp 3,000 2 Jumlah Zat Padat (TDS) Rp 2,800 Rp 1,200 Rp 4,000 Rp 2,800 Rp 1,200 Rp 4,000 3 6,000 4,200 1,800Kekeruhan Rp 4,200 Rp 1,800 Rp Rp Rp Rp 6,000 4 Rasa Rp 2,100 Rp 900 Rp 3,000 Rp 2,100 Rp 900 Rp 3,000 s Suhu Rp 2,100 Rp 900 Rp 3,000 Rp 2,100 Rp 900 Rp 3,000 6 Warna 2,800 Rp 1,200 Rp 4,000 Rp 2,800 Rp 1,200 Rp 4,000Rp B KIMIA 1 Arsen Rp 2,800 Rp 1,200 Rp 4,000 Rp 2,800 Rp 1,200 Rp 4,000 2 Flourida Rp 9,100 Rp 3,900 Rp 13,000 Rp 9,100 Rp 3,900 Rp 13,000 3 Kadmium Rp 4,200 Rp 1,800 Rp 6,000 Rp 4,200 Rp 1,800 Rp 6,000 4 Nitrit Rp 9,100 Rp 3,900 Rp 13,000 Rp 9,100 Rp 3,900 Rp 13,000 5 Nitrat Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 6 Siarida Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 7 Selerium R 9,100 Rp 3,900 Rp 13,000 Rp 9,100 Rp 3,900 Rp 13,000 8 Aluminium Rp 9,100 Rp 3,900 Rp 13,000 Rp 9,100 Rp 3,900 Rp 13,000 9 iBesi Rp 11,200 Rp 4800 Rp 16,000 Rp 11,200 Rp 4,800 Rp 16,000 10 |(Khlorida Rp 4,200 Rp 1,800 Rp 6,000 Rp 4,200 Rp 1800 Rp 6,000 11 |Mangan Rp 9,100 Rp 3,900 Rp 13,000 Rp 9,100 Rp 3,900 Rp 13,000 12 PH Rp 2,800 Rp 1200 Rp 4,000 Rp 2,800 Rp 1,200 Rp 4,000 17 Zat Organik Rp 5,600 Rp 2,400 Rp 8,000 Rp 5,600 Rp 2400 Rp 8,000 C MIKROBIOLOGI 1 JE.Coli Rp 45,500 Rp 19,500 Rp 65,000 Rp 45,500 Rp 19,500 Rp 65,000 2 Total Koliform Rp 20,300 Rp 8700 Rp 29,000 Rp 20,300 Rp 8,700 Rp 29,000 11 (PARAMETER LAIN 3 (COD Rp 8,400 Rp 3,600 Rp 12,000 Rp 8,400 Rp 3,600 Rp 12,000 4 BOD Rp 23,800 Rp 10,200 Rp 34,000 Rp 23,800 Rp 10,200 Rp 34,000 5 DO Rp 4,200 Rp 1,800 Rp 6,000 Rp 4,200 Rp 1800 Rp 6,000 6 Minyak dan Lemak Rp 14,000 Rp 6,000 Rp 20,000 Rp 14,000 Rp 6,000 Rp 20,000 7 |Salinitas Rp 5,600 Rp 2400Rp 8,000Rp 5,600 Rp 2400 Rp 8,000 8 IM Bas (Detergen) Rp 18,200 Rp 7800 Rp 26,000 Rp 18,200 Rp 7,800 Rp 26,000 9 Clor Bebas Rp 18,200 Rp 7,800 Rp 26,000 Rp 18,200 Rp 7,800 Rp 26,000 12 |(Padatan Tersuspensi (TSS) Rp 2,800 Rp 1,200 Rp 4,000 Rp 2,800 Rp 1,200 Rp 4,000 A TOXIOLOGI OBAT 1 Bau Rp 2,100 Rp 900 Rp 3,000/Rp 2,100 Rp 900 Rp 3,000 2 Jumlah Zat Padat (TDS) Rp 2,800 Rp 1200 Rp 4,000 Rp 2,800 Rp 1200 Rp 4,000 B (KEMAMPUAN PEMERIKSAAN 1 Arsen Rp 2,800 Rp 1200 Rp 4,000 Rp 2,800 Rp 1,200 Rp 4,000 2 Flourida Rp 9,100 Rp 3,900 Rp 13,000|/ Rp 9,100 Rp 3900 Rp 13,000 13 Seng Rp 11,200 Rp 4,800 Rp 16,000 Rp 11,200 4,800 Rp 16,000 14 Sulfat Rp 9,100 Rp 3,900 Rp 13,000 9,100 R 3,900 Rp 13,000 15 Tembaga Rp 4,200 Rp 1800 Rp 6,000 Rp 4,200 R 1800 R 6,000 16 jAmonia Rp 3,500 Rp 500 Rp 5,000 Rp 3,500 R 1,500 5,000 1 NAPZA (Gas Chromato R 455,000 R 195,000 R 650,000 350,000 R 150,000 500,000 2 Pestisida KC R 273,000 R 117,000 R 390,000 R 273,000 R 117,000 R 390,000 10 IPhospat Rp 9100 R 3,900 Rp 13,000 Rp 9,100 R 3,900 Rp 13,000 11 Sulfida Rp 10,500 R 4,500 Rp 15,000 Rp 10,500 R 4,500 15,000 3 Kadmium 4,200 R' 1800 Rp 6,000 Rp 4200 R 1,800 Rp 6,000 4 Nitrit R 9,100 R 3,900 R 13,000 R 9,100 R 3,900 R 13,000 STRUKTUR DAN BESARNYA TARIF RETRIBUSI PELAYANAN KESEHATAN RUMAH SAKIT DAERAH Dr. HAULUSSY 1 PELAYANAN KESEHATAN DI RSUD dr. M. Haulussy 1.7 Rincian Objek Retribusi Pelayanan Kesehatan RAWAT INAP Jasa UC Jasa Sarana Jasa Tarif Jasa Sarana Pelayanan Tarif Baru No Jenis Pemeriksaan Pelayanan Baru (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) 1 Kelas III 75,000 50,000 125,000 120,000 80,000 200,000 2 Kelas II 150,000 100,000 250,000 150,000 100,000 250,000 3 Kelas I 210,000 350,000140,000 210,000 140,000 350,000 4 Kelas Utama /VIP 300,000 200,000 500,000 300,000 200,000 500,000 Kelas Utama Khusus /Ruang Intensif 5 360,000 240,000 600,000324,000 700,000 300,000 1,000,000 1.8 Rincian Objek Retribusi Pelayanan Kesehatan Pemeriksaan Dokter / Visite Jasa No Jenis Pemeriksaan Uc Jasa Sarana, Pelayanan Tarif Jasa Tarif (Rp) (Rp) (Rp) Layanan (Rp) 1 kelas III 15,000 15,000 50,000 50,000 2 Kelas II 30,000 30,000 70,000 70,000 3 Kelas I 45,000 45,000 100,000 100,000 4 Semi Intensif 45,000 45,000 Intensif 60,000 60,000 6 Kelas Utama / VIP 100,000 100,000 150,000 150,000 Kelas Utama Khusus / Ruang 7 125,000 125,000 Intensif 175,000 175,000 Jasa layanan dokter diluar jam kerja/libur/citor dikenakan 2 kali jasa layanan pada jam kerja dan terdapat penambahan tarif. Ket 1.1 Rincian Objek Retribusi Pelayanan Kesehatan pada IGD Jasa Jasa SarSarana Jasa No Jenis Pemeriksaan Uc Jasa Sarana Tarif UC Baru anan Baru Pelay Tarif Baru (Rp) (Rp) Pelayanan (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 Rawat Observasi IGD » 6 Jam 135,000 150,000 100,000 250,000 45,000 45,000 60,000 150,000 2 32,400 100,000 100,000Konsul dr Spesialis jam kerja 36,000 24,000 60,000 3 Konsul dr Spesialis diluar jam kerja 40,500 45,000 30,000 75,000 150,000 150,000 4 94,500 105,000 70,000 175,000 95,000 85,000 70,000 250,000Pemeriksaan / Kunjungan 5 Resusitasi Bayi 189,000 210,000 140,000 350,000 200,000 90,000 60,000 350,000 6 Buka Gips 94,500 105,000 70,000 175,000 94,500 105,000 70,000 269,500 7 Kumbah Lambung 135,000 150,000 100,000 250,000 135,000 150,000 100,000 385,000 8 Reposisi Mandibula 67,500 75,000 50,000 125,000 67,500 80,000 120,000 267,500 9 Blast punctie / Cystostomy 94,500 105,000 70,000 175,000 95,000 50,000 75,000 220,000 10 Extraksi Cincin 81,000 90,000 60,000 150,000 81,000 60,000 90,000 231,000 11 162,000 180,000 120,000 300,000 50,000 120,000 180,000 350,000Extirpasi Kuku 12 Explorasi Inka kecil (cross huka 162,000 180,000 120,000 300,000 100,000 120,000 implant paku) 180,000 400,000 13 Explorasi luka sedang» 3 Cm ( Peluru 459,000 510,000 340,000 850,000 300,000 510,000 340,000 1,150,000 Senapan Angin ) Extirpasi Lipoma (« 5 cm) : Incisi 14 Abses 405,000 450,000 300,000 750,000 405,000 300,000 450,000 1,155,000 15 Hecting luka simpel/superfisial (1-5 189,000 210,000 140,000 350,000 189,000 60,000 90,000 339,000 jahitan) Hecting luka simpel/superfisial (»5 16 270,000 300,000 200,000 500,000 270,000 100,000 150,000 520,000 jahitan) 17 Hecting luka multiple/kosmetik/otot 360,000 240,000 600,000 (1-5 jahitan) 324,000 324,000 100,000 150,000 574,000 18 Hecting luka multiple /kosmetik/otot 405,000 450,000 750,000 405,000 140,000 210,000 755,000 (P5 jahitan) 300,000 19 Hecting luka repair tendon 405,000 450,000 300,000 750,000 405,000 280,000 420,000 1,105,000 20 Hecting Perineum Grade I 189,000 210,000 140,000 350,000 189,000 154,000 231,000 574,000 21 Hecting Perineum Grade II 297,000 330,000 220,000 550,000 297,000 220,000 330,000 847,000 22 (Hecting Perineum Grade II 405,000 450,000 3o0,000l 750,000 405,000 280,000 420,000 1,105,000 27 |Manual Placenta (Tanpa Narcose 405,000 450,000 300,000 750,000 400,000 300,000 200,000 900,000 28 (Pasang Spalk 81,000 90,000 60,000 150,000 80,000 175,000 150,000 405,000 29 Partus Normal (Ridan) 810,000 900,000 c0o0,000 1,500,000 250,000 500,000 900,000 1,650,000 30 Vakum Extraksi 405,000 450,000 300,000 750,000 300,000 1,350,000 850,000 2,500,000 31 (Pasang Bolus 27,000 30,000 20,000 50,000 25,000 30,000 20,000 75,000 32 Pemasangan Infus /Transfusi 27,000 30,000 20,000 50,000 60,000 15,000 25,000 100,000 33 (Pemasangan Kateter / NGT 40,500 45,000 30,000 75,000 20,000 12,000 48,000 80,000 34 Endotracheal Tube (ETT) 70,200 78,000 52,000 130,000 50,000 30,000 70,000 150,000 35 (Perawatan Luka Bakar «109 189,000 210,000 140,000 350,000 40,000 90,000 60,000 190,000 36 |Perawatan Luka Bakar 10-309c 270,000 300,000 200,000 500,000 80,000 120,000 80,000 280,000 37 Perawatan Imka Bakar »30x 351,000 390,000 260,000 650,000 80,000 170,000 110,000 360,000 38 Pelebaran Phimosis 70,200 78,000 52,000 130,000 70,000 78,000 52,000 200,000 39 (Perawatan Tali Pusat 21,600 24,000 16,000 40,000 10,000 24,000 16,000 50,000 40 (Perawatan WSD 43,200 48,000 32,000 80,000 150,000 80,000 70,000 300,000 41 (Perawatan Infus 27,000 30,000 20,000 50,000 5,000 5,000 10,000 20,000 42 |Punksi Pleura 216,000 240,000 160,000 400,000 216,000 240000 160,000 616,000 43 |Punksi Lumbal 216,000 240000 160,000 400,000 216,000 240,000 160,000 616,000 44 (Punksi Ascites 148,500 165,000 110000 275,000 148,500 165,000 110,000 423,500 45 |Reposisi Fraktur Tertutup 148,500 165,000 110,000 275,000 130,000 160,000 110,000 400,000 50 (Spalk untuk infus Anak/Bayi 13,500 15,000 10,000 25,000 10,000 15,000 10,000 35,000 51 (Sirkumsisi 432,000 480,000 320,000 800,000 432,000 480,000 320,000 1,232,000 52 |Spooling Blast 67,500 75,000 50,000 125,000 95,000 50,000 75,000 220,000 23 |Hecting Perimeum Grade IV 594,000 660,000 440,000 1,100,000 594,000 484,000 726,000 1,804,000 24 rigasi Telinga: Mata 94,500 105,000 70,000 25,000 70,000 80,000 175,000175,000 25 Men jahitan (Up Hecting) 94,500 105,000 70,000 10,000 52,500 22,500 85,000175,000 26 67,500 75,000 50.000 125.000 50,000 50,000 75,000 175,000 Mengangkat Corpus alienum (Benda 46 RJP 81,000 90,000 60,000 150,000 80,000 50,000 70,000 200,000 47 Tampon Epistaksis Anterior 54,000 60,000 40,000 100,000 20,000 30,000 50,000 100,000 48 Tam E staksis Posterior 189,000 210,000 140,000 350,000 50,000 160,000 140,000 350,000 49 Tracheos 810,000 900,000 600,000 1,500,000 400,000 500,000 600,000 1,500,000 53 Suction Dewasa per hari 27,000 30,000 20,000 50,000 48,000 12,000 20,000 80,000 54 Vagina Toucher / Periksa dalam 35,100 39,000 26,000 65,000 15,000 25,000 35,000 75,000 55 Vena Sectie 135,000 300,000 400,000 1,000,000150,000 100,000 250,000 300,000 56 Wound Tollet 54,000 60,000 40,000 100,000 60,000 60,000 40,000 160,000 57 24,300 27,000 18,000 45,000 10,000 10,000 20,000Penggunaan Liter / Jam 58 Denyut jantung Bayi 18,900 21,000 14,000 35,000 15,000 21,000 14,000 50,000 59 Perawatan Luka 24,300 27,000 18,000 45,000 25,000 18,000 27,000 70,000 Ket: Untuk pemeriksaan pasien warga Negara Asing Tarif dinaikan 30006 dari tarif yang ada/ yang berlaku. Terdapat penambahan dan pengurangan pada tarif sesuai objek pada retribusi IGD. Semua tindakan helmum termasuk BMHP (Bahan Medis Habis Pakai). 1.2 Rincian Objek Retribusi Pelayanan Kesehatan pada ICU Jasa Jasa Jasa Sarana No Jenis Pemeriksaan Uc Ss a Pelayanan Tarif UC Baru Baru Pelayanan Tarif Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 RJP 81,000 90,000 60,000 150,000 80,000 50,000 70,000 200,000 2 Bedside monitor 26,000 45,000 30,000 75,000 20,000 50,000 30,000 100,000 3 Infus pump 70,000 60,000 40,000 100,000 39,000 78,000 13,000 130,000 4 78,000 78,000 52,000 130,000 39,000 78,000 13,000 130,000 Syringr pump Ventlator 775,000 780,000 520,000 1,300,000 910,000 260,000 130,000 1,300,000 6 EKG 20,000 21,000 14,000 35,000 78,000 40,000 12,000 130,000 6,000GDS 35,000 24,000 16,000 40,000 24,000 10,000 40,000 Pemasangan NGT 30,000 45,000 30,000 75,000 20,000 12,000 48,000 80,000 9 50,000 25,000 15,000 60,000 100,000 Pasang Infus 20,000 30,000 20,000 10 50,000 45,000 30,000 75,000 20,000 12,000 48,000 80,000 Pasang catheter 420,000 200,000 100,000 500,000 800,00011 Pemasangan CVP peripher 300,000 252,000 168,000 12 Pemasangan CVP Central 300,000 252,000 168,000 420,000 200,000 100,000 500,000 800,000 52,000 130,000 50,000 30,000 70,000 150,00013 Endotracheal Tube (ETT) 127,000 78,000 14 390,000 390,000 260,000 650,000 390,000 350,000 260,000 1,000,000 Pemasangan WSD Baruru 7 15 Tracheostomy 850,000 900,000 600,000 1,500,000 400,000 500,000 600,000 1,500,000 16 DC shock 150,000 153,000 102,000 255,000 150,000 150,000 100,000 400,000 17 Vena scctie 450,000 150,000 100,000 250,000 300,0 300,000 400,000 1,000,000 18 150,000 100,000 385,Bilas lambung 50,000 150,000 100,000 250,000 135,000 19 Suction Dewasa per hari 77,000 30,000 20,000 50,000 48,000 12,000 20,000 80,0 20 Tranfusi darah 36,000 60,000 40,000 100,0 60,000 15,000 25,000 100,000 21 off drain 5,000 5,000 10,00019,000 18,000 12,000 30,000 20,000 22 off hecting 15,000 15,000 10,000 25,0 5,000 5,000 10,000 20,000 23 Debridement lokal 58,000 60,000 40,000 100,000 40,000 20,0 30,000 90,000 24 30,000 75,000 50,000 125,000 95,000 50,000 75,000 220,0Spoeling blast 25 Spoeling catheter 20,000 30,000 20,000 50,000 20,000 30,000 20,000 70,0 26 Punktie pleura 59,000 240,000 160,000 400,000 60,0 150,000 200,000 410,000 27 13,000 24,000 16,000 40,000 10,000 24,000 16,000 50,000Perawatan tali pusat 28 Tampon epistaksis 13,000 45,000 30,000 75,000 20,000 30,000 50,000 100,000 29 Perawatan luka bakar « 1096 41,000 90,000 60,000 150,0 40,000 90,000 60,000 190,000 30 60,000 120,000 80,000 200,0 80,000 120,000 80,000 280,000perawatan luka bakar 10-30 31 Perawatan luka hakar »30x9 82,000 165,000 110,000 275,000 80,000 170,000 110,000 360,0 32 Nebulizer ( per kati ) 28,000 33,000 22,000 55,000 28,000 30,0 22,000 80,000 33 Perawatan decubitus 59,000 60,000 40,000 100,000 50,000 60,0 40,000 150,000 34 Pemasangan artery line 65,000 150,000 100,000 250,0 50,000 100,000 150,000 300,000 35 Oral hygienes 8,100 9,000 6,000 15,000 10,000 9,000 6,000 25,000 36 8,100 9,000 6,000 15,000 8,100 9,000 6,000 15,000Vulva / penis hygienes 37 Pengambilan darah vena 8,100 9,000 6,000 15,000 10,000 9,000 6,000 25,0 38 pengambilan dara arteri 24,300 27,000 18,000 45,000 25,000 27,000 18,000 70,0 39 ANALISA GAS DARAH 171,000 190,000 000 75,0 45,000 180,000 300,00060,000 220, Terdapt penambahan dan pengurangan pada tarif sesuai objek pada jenis retribusi ICUKet 1.3 Rincian Objek Retribusi Pelayanan Kesehatan pada Laboratorium Klinik 1.3.1 HEMATOLOGI Jasa Jasa Jasa Sarana No Jenis Pemeriksaan Baru uc Jasa Sarana Tarif UC Baru Pelayanan Tarif Baru (Rp) (Rp) Pelayanan (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 Darah Lengkap (SYSMEX)) 50,130 55,700 22,300 78,000 66,000 24,200 19,800 110,0 2 LED Automatic 15,750 85,045,900 51,000 34,000 85,000 50,000 19,250 3 Golongan darah (ABO # Rhesus) 16,200 18,000 12,000 30,0 21,000 7,700 6,300 35,000 4 Malaria/filaria 16,200 18,000 12,000 30,000 60,000 22,000 18,000 100,000 5 APUSAN DARAH TEPI 10,000 90,000 250,00045,000 50,0 150,000 200,000 150,000 EVALUASI SUMSUM TULANG 6 45,000 50,000 350,0 400,000 45,000 100,000 300,000 445,000 (TINDAKAN DAN ANALISIS) 7 IT RATIO 9,000 10,000 20,000 30,000 45,000 16,500 13,500 75,000 TERAPI FLEBOTOMI 27,000 30,000 150,000 180,000 120,0 40,000 40,000 200,000 9 LED (Manual) 9,180 10,200 6,800 17,000 10,000 10,000 7,000 27,000 10 Retikulosit 18,900 21,000 14,000 35,000 19,000 21,000 15,000 55,000 11 Hitung cosinofil 27,000 30,00o 20,000 50,000 27,000 30,000 20,000 77,000 Gambaran Darah Tepi 1 ADT 64,800 72,0 48,000 120,000 150,000 10,000 90,000 250,000 2 SST 81,000 90,000 60,000 150,000 80,000 90,000 60,000 230,000 3 IT Ratio 16,200 18,000 12,000 30,000 45,000 16,500 13,500 75,000 4 Sel LE 32,400 36,000 24,000 60,000 32,000 36,000 24,000 92,000 Coombs Test 54,000 60,000 40,000 100,000 54,000 60,000 40,000 154,000 6 Resist, Osmotik 27,000 30,000 20,000 50,000 27,000 30,000 20,000 77,000 Ket Terdapat penambahan tarif pada objek retribusi. 1.3.2 Ket: 1.3.3 URINALISIS Jasa Jasa Sarana Jasa UC Jasa Sarana Tarif UC Baru Pelayanan No Jenis Pemeriksaan Pelayanan Baru ru(Rp)(Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 Urin lengkap (Rutin t Sedimen) 60,000 63,000 14,850 12,150 90,000 40,000 20,000 Tarif Baru Baru ru HEMOSTASIS Terdapat penambahan tarif pada objek retribusi. Terdapat penambahan tarif pada objek retribusi. Jasa Jasa Sarana Jasa UC Jasa Sarana Tarif UC Pelayanan Tarif Baru No Jenis Pemeriksaan Pelayanan Baru Baru (Rp)(Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 Masa Perdarahan 6,300 7,000 3,000 10,000 15,000 5,500 4,500 25,000 2 Masa Pembekuan 8,100 9,000 3,000 12,000 15,000 5,500 4,500 25,000 3 Digoxin 116,100 129,000 86,000 215,000 116,000 129,000 86,000 331,000 4 116,100 129,000 86,000 215,000 116,000 129,000 86,000 331,000 Digotoxin s PT 54,000 60,000 40,000 100,000 220,000 72,000 58,000 350,000 6 APTT 54,000 60,000 40,0001 100,000 330,000 77,000 63,000 470,000 7 THOROMBIN TIME 54,0 60,000 40,000| 100,000 200,000 72,000 58,000 330,000 FIBRINOGEN 54,000 60,000 40,000 100,000 220,000 72,000 58,000 350,000 Ket: 1.3.4 TINJA (Rp) 1 Lengkap (Rutin t pH # Reduksi) 22,000 28,000 50,000 30,000 11,000 9,000 50,000 Ket: Terdapat penambahan tarif pada objek retribusi. Jasa Jasa Sarana Jasa UC Jasa Sarana Tarif UC Baru No Jenis Pemeriksaan Rp (Rp) Pelayanan Pelayanan Tarif Baru (Rp) Rp Rp Rp) Baru (Rp) Baruru 1.3.5 KIMIA DARAH FUNGSI HATI Jasa Jasa Sarana Jasa No Uc Jasa Sarana Tarif UC Baru Pelayanan Tarif Baru Jenis Pemeriksaan (Rp) Pelayanan Baru Baru (Rp)(Rp) (Rp) (Rp) (Rp) (Rp) Rp) 1 SGOT 21,600 24,000 16,000 40,000 42,000 9,900 8,100 60,000 2 SGPT 21,600 40,000 42,000 9,900 8,100 60,00024,000 16,000 3 Bilirubin total 21,600 24,000 16,000 40,000 56,000 13,200 10,800 80,000 4 Bilirubin direk 21,600 24,000 16,000 40,000 56,000 13,200 10,800 80,000 s Bilirubin indirek 21,600 24,000 16,000 40,000 56,000 13,200 10,800 80,000 6 ALP 27,000 30,000 20,000 50,000 27,000 30,000 20,000 77,000 7 Protein total 18,900 21,000 14,000 35,000 22,200 8,140 6,660 37,000 Albumin 18,900 21,000 14,000 35,000 24,000 8,800 7,200 40,000 9 Globulin 18,900 21,000 14,000 35,000 24,000 8,800 7,200 40,000 10 CHE 54,000 60,000 40,000 100,000 50,000 40,000 20,000 110,000 Ket: Terdapat penambahan tarif pada objek retribusi. 1.3.6 FUNGSI GINJAL Jasa UC Jasa Sarana Jasa Tarif UC Baru Jasa Sarana Tarif Baru No Jenis Pemeriksaan Pelayanan Baru Pelayanan (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 16,000 40,000 20,000 24,000 16,000 60,000Ureum 21,600 24,000 2 Kreatinin 21,600 24,000 16,000 40,000 20,000 24,000 16,000 60,000 3 Asam urat 24,300 27,000 18,000 45,000 25,000 27,000 18,000 70,000 4 Urea Urine 27,000 30,000 20,000 50,000 27,000 30,000 20,000 77,000 Kretinin Urine 27,000 30,000 20,000 50,000 27,000 30,000 20,000 77,000 6 30,000Creatinin Clearance 40,500 45,000 30,000 75,000 40,000 45,000 115,000 7 Asam Urat Urin 40,500 45,000 30,000 75,000 40,000 45,000 30,000 115,000 20,000 50,000 27,000 30,000 20,000 77,000Albumin Urine 27,000 30,000 9 Electrolit 108,000 120,000 80,000 200,000 250,000 55,000 45,000 350,000 10 135,000 150,000 100,000 250,000 75,000 45,000 180,000 300,000AGD (Analisa Gas Darah) ru Ket: Terdapat penambahan tarif pada objek retribusi. -- Jasa Jasa Sarana Tarif B No Jenis Pemeriksaan UC Jasa Sarana Tarif UC Baru Baru Pelayanan (Rp) (Rp) Baru Pelayanan (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 14,000 53,000Kolesterol total 18,900 21,000 14,000 35,000 18,000 21,000 2 Ingliserida 21,600 24,000 16,000 40,000 20,000 24,000 16,000 60,000 3 Kolesterol HDL 37,000 42,000 28,000 107,00037,800 42,000 28,000 70,000 4 Kolesterol LDL 35,100 39,000 26,000 65,000 35,000 39,000 26,000 100,000 1.3.7 Jasa ru Ket Terdapat penambahan tarif pada objek retribusi. 13.8 GLUKOSA Jasa Jasa Jasa Sarana No Jenis Pemeriksaan Uc Jasa Sarana Pelayanan Pelayanan Tarif UC Baru Tarif Baru (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 Glukosa darah ( rapid ) 13,500 15,000 10.0 25,000 12,000 4,400 3,600 20,000 2 Glukosa darah 2 Jam PP 13,500 15,000 10,000 25,000 24,000 8,800 7,200 40,000 3 Glukosa Puasa 13,500 15,000 10,000 25,000 24,000 8,800 7,200 40,000 4 16,200 18,000 12,000 30,000 20,000 18,000 12,000 50,000Glukosa Cito/Strip TTGO (5x GDS) 32,400 36,000 24,000 60,000 120,000 50,000 30,000 200,000 6 49,500 40,500HBAIc 108,000 120,000 80,000 200,000 210,000 300,000 ru Ket: Terdapat penambahan tarif pada objek retribusi. 1.3.9 JANTUNG Jasa UC Jasa Sarana Jasa Tarif UC Baru Jasa Sarana Pelayanan Tarif Baru No Jenis Pemeriksaan Pelayanan Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) 1 CK 67,500 75,000 50,000 125,000 67,500 75,000 50,000 192,500 2 CKMB 135,000 150,000j 100,000 250,000 135,000 150,000 100,000 385,000 3 TROPT 108,000 120,000 80,000 200,000 108,000 120,000 80,000 308,0 4 TROPI 5 LDH 135,000 150,000 100,0ooo 250,000 135,000 150,000 100,000 385,000 54,000 60,000 100,000 54,000 60,000 40,000 154,00040,000 Tiroid 8 Gamma GT 77,400 86,000 35,000 121,000 77,400 86,000 35,000 198,400 9 Na, darba C1 (elektrolit darah Analisa gas 171000 190,000 60,000 250,000 75,000 45,000 180,000 300,000 1 FT3 135,000 150,000 135,000 2 FT4 100,000 250,000 150,000 100,000 385,000 121,500 135,000 90,000 225,000 121,500 135,000 90,000 346,500 3 T3 121,500 135,000 90,000 225,000 121,500 135,000 90,000 346,500 5 4 TSHS 108,000 120,000 80,000 200,000 108,000 120,000 8B0,000 308,000 T4 81,000 90,000 60,000 150,000 81,000 90,000 60,000 231,000 135,000 150,000 100,000 250,000 135,000 150,000 100,000 Thyroyglobulin 7 385,000 6 HbAlc 148,500 165,000 35,000 200,000 148,500 165,000 35,000 348,500 Ket: Terdapat penambahan tarif pada objek retribusi. 13.10 IMUNOSEROLOGI Jasa Uc Jasa Sarana Jasa Tarif Jasa No Jenis Pemeriksaan Pelayanan UCBaru Baru Pelayanan Tarif Baru (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 HBsAg rapid 32,400 36,000 24,000 60,000 70,000 16,500 13,500 100,000 2 Anti HBs 32,400 36,000 24,000 60,000 32,400 36,000 24,000 92,400 3 Anti HCV rapid 54,000 60,000 40,000 100,000 150,000 22,000 18,000 190,000 4 Widal 35,100 39,000 26,000 65,000 56,000 13,200 10,800 80,000 5 VDRL 69,300 77,000 31,000 50,000 69,300 77,000 31,000 177,300 6 37,800 42,000 28,000 70,000Anti HIV (rapid) 200,000 27,500 22,500 250,000 7 CD4 108,000 120,000 80,000 200,000 108,000 120,000 80,000 308,000 Genexpert 108,000 120,000 80,000 200,000 108,000 120,000 80,000 308,000 9 Dengue IgA 94,500 105,000 70,000 175,000 112,000 26,400 21,600 160,000 10 Igm salmonella 124,200 138,000 92,000 230,000 124,200 138,000 92,000 354,200 11 NS1 124,200 138,000 92,000 230,000 140,000 33,000 27,000 200,0 12 ASTO 37,800 42,000 28,000 70,000 37,800 42,000 28,000 107,800 13 Igm TB 81,000 90,000 60,000 150,000 81,000 90,000 60,000 231,000 14 RF ( Rheumatoid Factor) 40,500 45,000 30,000 75,000 40,500 45,000 30,000 115,500 15 H Pylari 81,000 90,000 60,000 150,000 81,000 90,000 60,000 231,000 16 CRP 27,000 30,000 20,000 50,000 200,000 44,000 36,000 280,000 17 hs CRP 81,000 90,000 60,000 150,000 81,000 90,000 60,000 231,000 18 TPHA 23,400 26,000 29,000 55,000 23,400 26,000 29,000 78,400 19 DENGUE IgM IgG 108,000 120,000 30,000 150,000 140,000 33,000 27,000 200,000 20 DENGUE NS1 108,000 120,000 30,000 150,000 108,000 120,000 30,000 258,000 21 108,000 24,750 20,250 150,000ANTI MALARIA (RAPID) 120,000 30,000 150,000 105,000 22 ANTI LEPTOSPIRA 108,000 120,000 30,000 150,000 108,000 120,000 30,000 258,000 Ket: Terdapat penamhahan tarif pada objek retribusi. 13.11 IMUNOLOGI OTOMATIK Jasa Jasa Jasa Sran No Jenis Pemeriksaan UC Jasa Sarana Tarif UC Baru Baru Pelayanan Tarif Baru (Rp) (Rp) Pelayanan (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 TSH3 121,500 135,000 54,000 189,000 121,500 135,000 54,000 310,500 2 FT4 117,000 130,000 52,000 182,000 117,000 130,000 52,000 299,000 3 CEA 148,500 165,000 66,000 231,000 148,500 165,000 66,000 379,500 4 FERRITTIN 90,000 100,000 40,000 140,000 90,000 100,000 40,000 230,000 5 TROPONIN I 198,000 220,000 88,000 308,000 198,000 220,000 88,000 506,000 rg PT PP(Pnanda Tumor) 1 CEA 94,500 105,000 70,000 175,000 94,500 105,000 70,000 269,500 2 CA 125 67,500 75,000 50,000 125,000 67,500 75,000 50,000 192,500 3 CA 153 67,500 75,000 50,000 125,000 67,500 75,000 50,000 192,500 4 CA 19.9 67,500 75,000 50,000 125,000 67,500 75,000 50,000 192,500 HE4 121,500 135,000 90,000 225,000 121,500 135,000 90,000 346,500 6 HEA 4 4 CA 125 (ROMA) 540,000 600,000 400,000 1,000,000 540,000 600,000 400,000 1,540,000 7 AFP 100,000 250,000 135,000 150,000 100,000135,000 150,000 385,000 Ket: Terdapat penambahan tarif pada objek retribusi. -» 1 - Jasa Jasa Jasa Sarana aru an Tarif Baru No Jenis Pemeriksaan Uc Jasa Sarana Tarif UCB Baru Pelayan (Rp) (Rp) Pelayanan (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 12,000Pewarnaan Gram 16,200 18,000 12,000 30,000 16,200 18,000 46,200 2 Pewarnaan BTA 1x 16,200 18,000 12,000 30,000 16,200 18,000 12,000 46,200 3 Jamur KOH 32,400 36,000 24,000 92,40032,400 36,000 24,000 60,000 4 N.Go 32,400 36,000 24,000 60,000 32,400 36,000 24,000 92,400 s 32,400 24,000 60,000 32,400 36,000 24,000 92,400Trikhomonas Vagina 36,000 6 Mikrofilaria 32,400 36,000 24,000 60,000 32,400 36,000 24,000 92,400 7 Kultur BTA 108,000 120,000 80,000 200,000 108,000 120,000 80,000 308,000 Kultur lain 108,000 120,000 80,000 200,000 108,000 120,000 80,000 308,000 9 Kulsen 108,000 120,000 80,000 200,000 108,000 120,000 80,000 308,000 10 80,000 308,000Kul Otomatik 108,000 120,000 80,000 200,000 108,000 120,000 MIKROBIOLOGI1. Sn Ket: Terdapat penambahan tarif pada objek retribusi. MIKROBIOLOGI MIKROSKOPIK1.3.13 Jasa Jasa Sarana Jasa UC Jasa Sarana Tarif UC Baru Pelay Tarif Baru No Jenis Pemeriksaan Pelayanan Baru Baru (Rp)(Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 JAMUR/SPORA 15,750 17,500 12,500 30,000 15,750 17,500 12,500 45,750 2 SEKRET VAGINA 17,500 30,000 15,750 17,500 12,500 45,75015,750 12,500 ru Ket: Terdapat penambahan tarif pada objek retribusi. Jasa Jasa Tarif UC Baru Jasa Sarana Tarif Baru No Jenis Pemeriksaan Baru UC Jasa Sarana Pelayanan Pelayanan (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) (Rp) NARKOBA Ket: Terdapat penambahan tarif pada objek retribusi. 1.3.15 HISTOPATOLOGI Jasa Biopsi Khusus (Hati Esofagus, Gaster Colon Gunjal) 1 Biopsi 1-2 Jaringan 156,000 240,000 160,000 400,000 156,000 240,000 160,000 556,000 2 Biopsi 3-4 Jaringan 234,000 360,000 240,000 600,000 234,000 360,000 240,000 834,000 Ket: Terdapat penambahan tarif pada objek retribusi. 13.16 SITOPATOLOGI 1 Slide Pap's Smear 100,000 70,000 105,000 175,000 100,000 70,000 105,000 275,000 3 FNAB Superfisial 195,000 200,000 300,000 500,000 195,000 200,000 300,000 695,000 4 Deep (Guidance) 292,500 300,000 450,000 750,000 292,500 300,000 450,000 1,042,500 Ket Terdapat penamhahan tarif pada objek retribusi. 1.3.17 KULTUR Jasa 1 KULTUR DARAH 1 BOTOL 402,039 446,710 162,440 609,150 402,039 446,710 162,440 1,011,189 Jasa Jasa Sarana No BaruJenis Pemeriksaan uc Jasa Sarana (Rp) Rp) (Rp) Pelayanan Tarif UCBaru Pelayanan Tarif Baru Rp (Rp) (Rp) Bau (Rp) R 156,000 240,000 160,000 400,000 50,000 360,000 240,000 650,000 Jaringan Kecil1 234,000 360,000 240,000 600,000 50,000 510,000 340,000 900,000 Jaringan Sedan2 312,000 480,000 320,000 800,000 50,000 660,000 440,000 1,150,000Jaringan Besar3 312,000 480,000 320,000 800,000 312,000 480,000 Biopsi lebih dari 4 Jaringan 320,000 1,112,0003 351,000 540,000 360,000 900,000 351,000 540,000 360,000 1,251,000 VC/ Frosen Section4 Jasa Jasa Sarana Jasa No Jenis Pemeriksaan uc Tarif UC Baru Baru Jasa Sarana Pelayanan Pelayanan Tarif Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) 200,000 107,200 160,800 268,000 200,000 107,200 160,800 468,000 Sitologi cairan efusi, ascites,sputum,urin 2 Uc Jasa Sarana Tarif UC Baru Jasa Jasa Sarana Jenis Pemeriksaan (Rp) (Rp) Pelayanan (Rp) Rp) (Rp) Baru Pelayanan Tarif Baru (Rp) (Rp)BaruruNo R 2 KULTUR FESES 323,855 359,839 130,850 490,689 323,855 359,839 130,850 814,544 3 KULTUR PUS 323,631 359,590 130,760 490,350 323,631 359,590 130,760 813,981 4 KULTUR URINE 369,052 410,058 149,112 559,170 369,052 410,058 149,112 928,222 5 KULTUR SWAB DLL 323,631 359,590 130,760 490,350 323,631 359,590 130,760 813,981 6 Analisis Batu 70,200 78,000 52,000 130,000 70,200 78,000 52,000 200,200 7 Flebotomi Ter 202,500 225,000 150,000 375,000 232,599 225,000 150,000 577,500 8 Fe Serum 40,500 45,000 30,000 75,000 40,500 45,000 30,000 115,500 9 T1Bc 54,000 60,000 40,000 100,000 54,000 60,000 40,000 154,000 10 'IFerritin 81,000 90,000 60,000 150,000 81,000 90,000 60,000 231,000 11 |D-Dymer 94,500 105,000 70,000 175,000 94,500 105,000 70,000 269,500 12 |Mygoglobin 97,200 108,000 72,000 180,000 97,200 108,000 72,000 277,200 13 AFP 94,500 105,000 70,000 175,000 94,500 105,000 70,000 269,500 14 ICA72.4 129,600 144,000 96,000 240,000 129,600 144,000 96,000 369,600 15 ICvfrab21.1 148,500 165,000 110,000 275,000 148,500 165,000 110,000 423,500 16 Nse 124,200 138,000 92,000 230,000 124,200 138,000 92,000 354,200 17 |Folate 102,600 114,000 76,000 190,000 102,600 114,000 76,000 292,600 18 Vit B12 10,260 11,400 7,600 19,000 10,260 11,400 7,600 29,260 19 SIBC 56,700 63,000 42,000 105,000 56,700 63,000 42,000 161,700 20 HbF 56,700 63,000 42,000 105,000 56,700 63,000 42,000 161,700 21 Tranferin 78,300 87,000 58,000 145,000 78,300 87,000 58,000 223,300 22 Antibodi Sperma 81,000 90,000 60,000 150,000 81,000 90,000 60,000 231,000 23 Fruktone Sperma 35,100 39,000 26,000 65,000 35,100 39,000 26,000 100,100 24 Trombost Owen 86,400 96,000 64,000 160,000 86,400 96,000 64,000 246,400 25 Agregasi Trombosit 121,500 135,000 90,000 225,000 121,500 135,000 90,000 346,500 26 |Rumple Leede 16,200 18,000 12,000 30,000 16,200 18,000 12,000 46,200 27 Amyiase 59,400 66,000 44,000 110,000 59,400 66,000 44,000 169,400 28 |Lipase 59,400 66,000 44,000 110,000 59,400 66,000 44,000 169,400 29 |Laktase 102,600 114,000 76,000 190,000 102,600 114,000 76,000 292,600 30 Anti Toxo IgM 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 31 Anti Toxo IgG 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 32 Anti Rubella IgM 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 3 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100Anti Rubella IgG 34 Anti CMV IgM 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 35 Anti CMV 1gG 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 36 Anti HSV1 IgM 89,100 99,000 66,000 165,0 89,100 99,000 66,000 254,100 37 Anti HSVI 1gG 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 38 Anti HSV2 IgM 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 39 Anti HSV2 1gG 89,100 99,000 66,000 165,000 89,100 99,000 66,000 254,100 Ket: Terdapat penambahan tarif pada objek retribusi. 14 Rincian Objek Retribusi Pelayanan Kesehatan papada ICCU Jasa UC Jasa Sarana UC Baru Jasa Tarif Jasa Sarana Pelayanan Tarif Baru Jenis Pemeriksaan Pelayanan Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) 1 RJP 81,000 90,000 60,000 150,000 80,000 50,000 70,000 200,000 2 Bedside monitor 26,000 45,000 30,000 75,000 20,000 50,000 30,000 100,000 3 Infus pump 70,000 60,000 40,000 100,000 39,000 78,000 13,000 130,000 4 Syringr pump 78,000 78,000 52,000 130,000 39,000 78,000 13,000 130,000 Ventilator 775,000 780,000 520,000 1,300,000 910,000 260,000 130,000 1,300,000 6 Pemasangan EKG 20,000 21,000 14,000 35,000 78,000 40,000 12,000 130,000 7 GDS 35,000 24,000 16,000 40,000 24,000 10,000 6,000 40,000 8 Pemasangan NGT 30,000 45,000 30,000 75,000 20,000 12,000 48,000 80,000 9 Pasang Infus 20,000 30,000 20,000 50,000 25,000 15,000 60,000 100,000 10 50,000 45,000 30,0 75,000 20,000Pasang catheter 12,000 48,000 80,000 11 Pemasangan CVP peripher 300,000 252,000 168,000 420,000 200,000 100,000 500,000 800,000 12 Pemasangan CVP Central 300,000 252,000 168,000 420,000 200,000 100,000 13 500,000 800,000 Endotracheal Tube (ETT) 127,000 78,000 52,000 130,000 50,000 30,000 70,000 150,000 14 Pemasangan WSD 390,000 390,000 260,000 650,000 390,000 350,000 260,000 15 1,000,000 Tracheostomy 850,000 900,000 600,000 1,500,000 400,000 500,000 600,000 1,500,000 16 DC shock 150,000 153,000 102,000 255,000 150,000 150,000 100,000 17 Vena sectie 400,000 450,000 150,000 100,000 250,000 300,000 300,000 400,000 1,000,000 18 Bilas lamhun 50,000 150,000 100,000 250,000 135,000 150,000 100,000 385,000 No 19 Suction Dewasa per hari 77,000 30,000 20,000 50,000 48,000 12,000 20,000 80,0 20 Tranfusi darah 36,000 60,000 40,000 100,000 60,000 15,000 25,000 100,000 21 off drain 19,000 18,000 12,0 30,000 5,000 5,000 10,000 20,000 22 off hecting 15,000 15,000 10,000 25,000j 5,000 5,000 10,000 20,000 23 Debridement lokal 58,000 60,000 40,000 100,000 40,000 20,000 30,000 90,0 24 30,000 50,000 75,000 220,000Spoeling blast 75,000 50,000 125,000 95,000 25 Spoeling catheter 20,000 30,000 20,000 50,000 20,000 30,000 20,000 70,000 26 Punktie pleura 59,000 240,000 160,000 400,0 60,000 150,000 200,000 410,000 27 Perawatan talipusat 13,000 24,000 16,000 40,000 10,000 24,000 16,000 50,000 28 Tampon epistaksis 13,000 45,000 30,000 75,0 20,000 30,000 50,000 100,000 29 Perawatan luka bakar « 10Y6 41,000 90,000 60,000 150,000 40,000 90,000 60,000 190,000 30 perawatan luka bakar 10-3056 60,000 120,000 80,000 200,000 80,000 120,000 80,000 280,0 31 Perawatan luka bakar »3046 82,000 165,000 110,000 275,000 80,000 170,000 110,000 360,0 32 Nebulizer ( per kali ) 28,000 33,0 22,000 55,000 28,000 30,000 22,000 80,000 3 Perawatan decubitus 59,000 60,000 40,000 100,000 50,000 60,000 40,000 150,000 34 Pemasangan artery line 65,000 150,000 100,000 250,000 50,000 100,000 150,000 300,0 35 4,957 9,000 6,000 15,000 10,000 9,000 6,000 25,0oral hygienes 36 Vulva / penis hygienes 4,957 9,000 6,000 15,000 8,100 9,000 6,000 23,100 37 9,033 9,000 6,000 15,000 10,000 9,000 6,000 25,000Pengambilan darah vena 38 pengambilan dara arteri 17,735 27,000 18,000 45,000 25,000 27,000 18,000 70,000 39 ANALISA GAS DARAH 171,000 190,000 60,000 250,000 75,000 45,000 180,000 300,0 40 171,000 190,000 60,000 25,000,000 171,000 190,000Pemasangan IABP 60,000 421,000 Ket: Terdapat penambahan dan pengurangan pada tarif sesuai objek pada retribusi ICCU. 1.5 Rincian Objek Retribusi Pelayanan Kesehatan pada RADIOLOGI Jasa Jasa Sarana Jasa Uc Jasa Sarana Tarif UC Baru Pelayanan Tarif Baru No Jenis Pemeriksaan (Rp) (Rp) Pelayanan (Rp) (Rp) Baru Baru (Rp) (Rp) (Rp) (Rp) 1 Foto thorax AP 94,500 105,000 70,000 175,000 113,750 24,500 36,750 175,000 2 162,000 180,000 120,000 300,000 195,000 42,000 63,000 300,000Foto thorax AP/ Lat 3 Foto Abdomen polos 94,500 105,0 70,000 175,000 113,750 24,500 36,750 175,000 4 Foto Abdomen 2 Posisi 243,000 270,000 180,000 450,000 195,000 42,000 63,000 300,000 5 Foto Cranium 94,500 105,000 70,000 175,000 195,000) 42,000 63,000 300,000 6 Sinus Paranasal : 3 Foto 162,000 180,000 120,000 300,000 195,000 42,000 63,000 300,000 7 Mastoid : 2 Foto 94,500 105,000 70,000 175,000 325,000 70,000 105,000 500,000 8 Cervical 94,500 105,000 70,000 175,000 195,000 42,000 63,000 300,000 9 Pelvis 94,500 105,000 70,000 175,000 113,750 24,500 36,750 175,000 10 Extrimitas atas 94,500 105,000 70,000 175,000 113,750 24,500 36,750 175,000 11 Extrimitas bawah 108,000 120,000 80,000 200,000 113,750 24,500 36,750 175,000 12 Mandihulla 94,500 105,000 70,000 175,000 195,000 42,000 63,000 300,000 13 USG 162,000 180,000 120,000 300,000 422,500 91,000 136,500 650,000 14 BNO IVP 810,000 900,000 600,000 1,500,000 1,501,500 323,400 485,100 2,310,000 15 Appendicogram 513,000 570,000 380,000 950,000 950,950 204,820 307,230 1,463,000 16 LS 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 17 Foto clavicula 67,500 75,000 50,000 125,000 195,000 42,000 63,000 300,000 18 Foto scapula 67,500 75,000 50,000 125,000 195,000 42,000 63,000 300,000 19 Humerus 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 20 Elbow Joint 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 21 Manus AP/ Lat 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 22 Wrist Joint 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 23 Femur AP/ Lat 162,000 180,000 120,000 300,000 195,000 42,000 63,000 300,000 24 Cruris Ap/ Lat 162,000 180,000 120,000 300,000 195,000 42,000 63,000 300,000 25 Genue Ap/ Lat 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 26 Pedis AP/ Lat 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 27 Ankle Joint AP/Lat 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 28 Kepala 94,500 105,000 70,000 175,000 195,000 42,000 63,000 300,000 29 Antebrachi 94,500 105,000 70,000 175,000 113,750 24,500 36,750 175,000 30 Patela 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 31 Lumbal 94,500 105,000 70,000j 175,000 113,750 24,500 36,750 175,000 32 Caltancus 94,500 105,000 70,000 175,000 175,175 37,730 56,595 269,500 33 Orbita 94,500 105,000 70,000 175,000 113,750 24,500 36,750 175,000 34 C Arm Ortopedi 405,000 450,000 300,000 750,000 975,000 210,000 315,000 1,500,000 35 Foto Panoramic 162,000 180,000 120,000 200,000 195,000 42,000 63,000 300,000 Ket: Terdapat penambahan tarif pada objek retribusi. 1.6 Rincian Objek Retribusi Pelayanan Kesehatan pada KAMAR OPERASI 2 Operasi Sedan 3,800,000 2,103,000 1,402,000 3,505,000 2,100,000 525,000 875,000 3,500,000 3 Operasi Besar 5,700,000 5,520,000 3,680,000 9,200,000 5,700,000 1,425,000 2,375,000 9,500,000 4 Operasi Khusus 6,800,000 13,200,000 8,800,000 22,000,000 13,500,000 3,375,000 5,625,000 22,500,000 1.9 Rincian Objek Retribusi Pela:yanan Kesehatan TINDAKAN UMUM RAWAT INAP Jasa Jasa Sarana Jasa (Rp) (Rp) Pelayanan No Jenis Pemeriksaan Uc Jasa Sarana Tarif UCBaru Pelayanan Tarif Baru (Rp) (Rp) Baru Rp) Baruru (Rp) Rp) 1 1,100,000 621,000 660,000 165,000 275,000 1,100,000 Kecil 414,000 1,035,000 Jasa Uc Jasa Sarana Jasa Tarif UC Baru Jasa Sarana No Pelayanan Tarif Baru sJenia Pemeriksaan Pelayanan Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) 1 Kumhah Lambung 157,261 150,000 100,000 250,000 135,000 150,000 100,000 385,000 2 Blast punctie / Cystostomy 117,946 105,000 70,000 175,000 95,000 50,000 75,000 220,000 3 Irigasi Telinga: Mata 117,946 105,000 70,000 175,000 25,000 70,000 80,000 175,0 Mengangkat jahitan (Up Hectin 117,946 105,000 70,000 175,000 10,000 52,500 22,500 85,000 Mengangkat Corpus alisnum (Benda3 asing) 78,631 75,000 50,000 125,000 50,000 50,000 175,000 6 Pasang Bolus 39,315 30,000 20,000 50,000 25,000 30,000 20,000 75,000 7 Pemasangan Infus / Transfusi 39,315 30,000 20,000 50,000 60,000 15,000 25,000 100,000 Pemasangan Kateter / NGT 39,315 45,000 30,0 75,000 20,000 12,000 48,000 80,000 9 Perawatan Tali Pusat 78,631 24,000 16,000 40,000 10,000 24,000 16,000 50,000 10 Perawatan WSD 78,631 48,000 32,000 80,000 150,000 80,000 70,000 300,000 11 Perawatan Infus 39,315 30,000 20,000 50,000 5,000 5,000 10,000 20,000 12 Punksi Pleura 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,0 13 Punksi Lumbal 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,000 4 75,000 14 Punksi Ascites 157,261 165,000 110,000 275,000 148,500 165,000 110,000 423,500 15 RJP 235,892 210,000 140,000 350,000 80,000 50,000) 70,000 200,000 16 35,000Spalk untuk infus Anak/Bayi 15,726 15,000 10,000 25,000 10,000 15,000 10,000 17 Spooling Blast 78,631 75,000 50,000 125,000 95,000 50,000 75,000 220,000 18 Suction Dewasa per hari 39,315 30,000 20,000 50,000 48,000 12,000 20,000 80,000 19 Vena Sectie 235,892 150,000 100,000 250,000 300,000 300,000 400,000 1,000,000 20 Wound Toilet 62,905 60,000j 40,000 100,000 60,000 60,000 40,000 160,000 21 Bedside monitor 26,000 45,000 30,000 75,000 20,000 50,000 30,000 100,000 22 Infus pump 70,000 60,000 40,000 100,000 39,000 78,000 13,000 130,0 23 78,000 78,000 52,000 130,000 39,000 78,000 13,000 130,000Syringr pump 24 Pemasangan EKG 20,000 21,000 14,000 35,000 78,000 40,000 12,000 130,000 25 GDS 35,393 24,000 16,000 40,000 24,000 10,000 6,000 40,000 26 Pemasangan NGT 30,000 45,000 30,000 75,000 23,95 12,000 48,000 80,000 Ket: Terdapat pendobolan nama pada objek retribusi nomor 9 dan 10. 1.10 Rincian Objek Retribusi Pelayanan Kesehatan pada RUANGAN BEDAH Jasa Jasa Sarana Jasa No Jenis Pemeriksaan Baru Uc Jasa Sarana Tarif UC Baru Pelayanan Tarif Baru (Rp) (Rp) Pelayanan (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 Buka Gips 117,946 105,000 70,000 175,000 94,500 105,000 70,000 269,500 2 157,261 150,000 100,000 250,000 135,000 150,000 100,000 385,000Kumbah Lambung 3 Reposisi Mandibula 78,631 75,000 50,000 125,000 67,500 80,000 120,000 267,500 4 Blast punctie / Cystostomy 117,946 105,000 70,000 175,000 95,000 50,000 75,000 220,000 Extraksi Cincin 117,946 90,000 60,000 150,000 81,000 60,000 90,000 231,000 6 Extirpasi Kuku 235,892 180,000 120,000 300,000 50,000 120,000 180,000 350,000 Explorasi hika kecil(cross, buka 7 235,892 180,000 120,000 300,000 100,000 120,000 180,000 400,000 implant, paku) Explorasi luka sedang» 3 Cm (Peluru 707,676 660,000 440,000 1,100,000 300,000 340,000 510,000 1,150,000 Senapan Angin ) Extirpasi Lipoma (« 5 cm): Incisi 471,784 450,000 300,000 750,000 405,000 300,000 Abses 450,000 1,155,0009 10 Ainan luka simpel/superfisial (1-5 235,892 210,000 140,000 350,000 189,000 60,000 90,000 339,000 11 Kg luka simpel/superfisial (»5 353,838 300,000 200,000 500,000 270,000 100,000 150,000 520,000 12 353,838 360,000 240,000 600,000 324,000 100,000 150,000 574,000 13 Hecting luka mulEpIe/kosmetik/ 471784 450,000 300,000 750,000 405,000 140,000 210,000 755,000 14 Hecting luka repair tendon 471,784 450,000 300,000 750,000 405,000 280000 420,000 1,105,000 17 haiBi Corpus alienum (Benda 78,631 75,000 50,000 125,000 50,000 50,000 75,000 175,000 18 Pasang Spalk 78,631 90,000 60,000 150,000 80,000 175,000 150,000 405,000 19 Pasang Bolus 39,315 30,000 20,000 50,000 25,000 30,000 20,000 75,000 20 Pemasangan Infus / Transfusi 39,315 30,000 20,000 50,000 60,000 15,000 25,000 100,000 ahitan Hecting luka multiple/kosmetik/ otot (1-5 jahitan otot (25 ishitan 15 Irigasi Telinga, Mata 117,946 105,000 70,000 175,000 25,000 70,000 80,000 175,000 16 Mengangkat jahitan (Up Hecting 117,946 105,000 70,000 175,000 10,000 52,500 22,500 85,000 asn 21 Pemasangan Kateter / NGT 39,315 45,000 30,000 75,000 20,000 12,000 48,000 80,000 22 Endotracheal Tube (ETT) 78,631 78,000 52,000 130,000 50,000 30,000 70,000 150,000 23 Perawatan Luka Bakar « 1096 78,631 90,000 60,000 150,000 40,000 90,000 60,000 190,000 24 Perawatan Luka Bakar 10-3096 117,946 120,000 80,000 120,000 80,000 280,00080,000 200,000 25 Perawatan Luka »30x 157,261 165,000 110,000 275,000 80,000 170,000 110,000 360,000 26 Pelebaran Phimosis 78,631 78,000 52,000 130,000 70,000 78,000 52,000 200,000 27 Perawatan WSD 78,631 48,000 32,000 80,000 150,000 80,000 70,000 300,000 28 Perawatan Infus 39,315 30,000 20,000 50,000 5,000 5,000 10,000 20,000 29 Punksi Pleura 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,000 31 Punksi Ascites 157,261 165,000 148,500 423,500 30 Punksi Lumbal 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,000 110,000 275,000 165,000 110,000 32 Reposisi Mandibula 78,631 90,000 60,000 67,500 80,000 267,500150,000 120,000 33 Fraktur Tertutu 157,261 165,000 130,000 160,000 400,000110,000 275,000 110,000 34 RJP 235,892 350,000210,000 140,000 80,000 50,000 70,000 200,000 36 Tracheostom 235,892 1,500,000 35 Tam Epistaksis 39,315 45,000 30,000 75,000 20,000 30,000 50,000 100,000 900,000 600,000 1,500,000 400,000 500,000 600,000 37 Sirkumsisi 471,784 480,000 1,232,000 480,000 320,000 800,000 432,000 320,000 38 Spooling Blast 78,631 75,000 50,000 125,000 95,000 50,000 75,000 220,000 39 80,000Suction Dewasa per hari 39,315 30,000 20,000 50,000 48,000 12,000 20,000 40 Vena Sectie 235,892 150,000 100,000 250,000 300,000 300,000 400,000 1,000,000 41 Wound Toilet 40,000 160,00062,905 60,000 40,000 100,000 60,000 60,000 1.11 Rincian Objek Retribusi Pelayanan Kesehatan papada RUANG PERAWATAN ANAK Jasa UC Jasa Sarana Pelayanan Jasa asa Saran Tarif UC Baru Ji a Tarif Baru No Jenis Pemeriksaan Pelayanan Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) 1 157,261 150,000 100,000 250,000 135,000 150,000 100,000 385,000Kumbah Lambung 2 Blast punctie / Cystostomy 117,946 105,000 70,000 175,000 95,000 50,000 75,000 220,000 3 Irigasi Telinga: Mata 117,946 105,000 70,000 175,000 25,000 70,000 80,000 175,000 4 Mengangkat jahitan (Up Hecting) 117,946 105,000 70,000 175,0 10,000 52,500 22,500 85,000 Mengangkat Corpus alienum (Benda asing) 5 78,631 75,000 50,000 125,000 50,000 50,000 75,000 175,0 6 50,000Pasang Bolus 39,315 30,000 20,000 25,000 30,000 20,000 75,000 7 Pemasangan Infus / Transfusi 39,315 30,000 20,000 50,000 60,000 15,000 25,000 100,000 39,315 45,000 30,000 75,000 20,000 12,000 48,000 80,000 Pemasangan Kateter / NGT 9 Perawatan Tali Pusat 78,631 24,000 16,000 40,000 10,000 24,000 16,000 50,000 10 Perawatan WSD 78,631 48,000 32,000 80,000 150,000 80,000 70,000 300,000 11 Perawatan Infus 39,315 30,000 20,000 50,000 5,000 5,000 10,000 20,000 12 Punksi Pleura 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,000 13 Punksi Lumbal 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,000 14 Punksi Ascites 157,261 165,000 110,000 275,000 148,500 165,000 110,000 423,500 15 RJP 81,000 90,000 60,000 150,000 80,000 50,000 70,000 200,000 16 Spalk untuk infus Anak /Bayi 15,726 15,000 10,000 25,000 10,000 15,000 10,000 35,000 17 Spooling Blast 78,631 75,000 50,000 125,000 95,000 50,000 75,000 220,000 18 Suction Bayi per hari 39,315 30,000 20,000 50,000 30,000 20,000 50,000 100,000 19 Vena Sectie 235,892 150,000 100,000 250,000 300,000 300,000 400,000 1,000,000 20 Wound Toilet 62,905 60,000 40,000 100,000 60,000 60,000 40,000 160,000 21 Bedside monitor 26,000 45,000 30,000 75,000 20,000 50,000 30,000 100,000 Sn 1.12 Terdapat pendobolan nama pada objek retribusi nomor 9 dan 10. 22 Infus pump 70,000 60,000 40,000 100,000 39,000 78,000 13,000 130,000 23 Syringr pump 78,000 78,000 52,000 130,000 39,000 78,000 13,000 130,000 24 Ventilator 775,000 780,000 520,000 1,300,000 910,000 260,000 130,000 1,300,000 25 Pemasangan EKG 130,00020,000 21,000 14,000 35,000 78,000 40,000 12,000 26 GDS 35,000 24,000 16,000 40,000 24,000 10,000 6,000 40,000 27 30,000 45,000 30,000 75,000 20,000 12,000 48,000 80,000Pemasangan NGT 28 NJEKSI (Intra Vena 88,955 15,000 10,000 25,000 10,000 10,000 30,000 50,000 Ket: Rincian Objek Retribusi Pelayanan Kesehatan TINDAKAN OBGYN Jasa Jasa Sarana Jasa uc Jasa Sarana Tarif UC Baru Pelayanan Tarif Baru No Jenis Pemeriksaan (Rp) (Rp) Pelayanan Baru Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 Partus Normal ( Primi ) oleh bidan 945,000 1,050,000 700,000 1,750,000 250,000 500,000 900,000 1,650,000 2 Partus Normal ( Multi ) oleh bidan 810,000 900,000 600,000 1,500,000 250,000 400,000 850,000 1,500,000 3 Asisten Bayi 40,500 45,000 30,000 75,000 20,000 25,000 55,000 100,000 4 Perawatan Tali Pusat 21,600 24,000 16,000 40,000 10,000 24,000 16,000 50,000 s RJP 124,200 138,000 92,000 230,000 80,000 50,000 70,000 200,000 6 Hecting Perineum Gr III 248,400 276,000 184,000 460,000 405,000 280,000 420,000 1,105,000 7 Manual Placenta Tanpa Narcose 124,200 138,000 92,000 230,000 400,000 300,000 200,000 900,000 Ganti Verband 62,100 69,000 46,000 115,000 60,000 30,000 40,000 130,000 9 Vaccum Extraksi 135,000 150,000 100,000 250,000 300,000 1,350,000 850,000 2,500,000 10 Pasang Infus 62,100 69,000 46,000 115,000 25,000 15,000 60,000 100,000 11 40,500 45,000 30,000 75,000 20,000 12,000 48,000Pasang katether 80,000 12 Transfusi darah 54,000 60,000 40,000 100,000 60,000 15,000 25,000 100,000 Partus normal oleh dokter dengan 13 1,080,000 1,200,000 800,000 2,000,000 250,000 800,000 1,200,000 2,250,000 yulit 14 Rawat Luka 40,500 45,000 30,000 75,000 40,000 48,000 32,000 120,000 15 13,500 15,000 10,000 25,000 10,000 10,000 30,000Suntik (Intra Vena 50,000 16 Cukur Pubis 13,500 15,000 10,000 25,000 10,000 10,000 10,000 30,000 17 CTG 40,500 45,000 30,000 75,000 40,000 25,000 20,000 85,000 18 Perawatan Payudara 13,500 15,000 10,000 25,000 5,000 10,000 15,000 30,000 19 Perawatan Luka Perineum 24,3001| 27,000 18,000 45,000 30,000 18,000 12,000 60,000 1.13 Rincian Objek Retribusi Pelayanan Kesehatan PERINATOLOGI Jasa UC Jasa Sarana Jasa Tarif UC Baru Jasa Sarana Tarif BaruNo Jenis Pemeriksaan Pelayanan Baru Pelayanan (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) 1 Foto terapi 266,212 210,000 140,000 350,000 170,000 100,000 180,000 450,000 2 Perawatan tali pusat 66,553 24,000 16,000 40,000 10,000 24,000 16,0 50,000 3 Infus umbilical 532,425 276,000 184,000 460,000 100,000 130,000 320,000 550,000 4 Kumbah Lambung 157,261 150,000 100,000 250,000 135,000 150,000 100,000 385,000 Blast punctie / Cystostomy 117,946 105,000 70,000 175,000 95,000 50,000 75,000 220,000 6 Irigasi Telinga. Mata 117,946 105,000 70,000 175,000 25,000 70,000 80,000 175,000 7 Mengangkat jahitan (Up Hecting) 117,946 105,000 70,000 175,000 10,000 52,500 22,500 85,000 Mengangkat Corpus alienum 78,631 75,000 50,000 125,000 50,000 50,000 75,000 175,000(Benda asing) 9 Pasang Bolus 39,315 30,000 20,000 50,000 25,000 30,000 20,000 75,000 10 39,315Pemasangan Infus / Transfusi 30,000 20,000 50,000 60,000 15,000 25,000 100,000 11 Pemasangan Kateter / NGT 39,315 45,000 30,000 75,000 20,000 12,000 48,000 80,000 12 Perawatan Tali Pusat 78,631 24,000 16,000 40,000 10,000 24,000 16,000 50,000 13 Perawatan WSD 78,631 48,000 32,000 80,000 150,000 80,000 300,000 14 Perawatan Infus 39,315 30,000 20,000 50,000 5,000 5,000 10,000 15 Punksi Plcura 40,000 20,000 235,892 240,000 160,000 216,000 240,000 160,000 616,000 16 Punksi Lumbal 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,000 17 Punkai Ascites 157,261 165,000 110,000 275,000 148,500 165,000 110,000 423,500 18 RJP 235,892 210,000 140,000 350,000 80,000 50,000 70,000 200,000 19 15,726Spalk untuk infus Anak /Bayi 15,000 10,000 25,000 10,000 15,000 10,000 35,000 20 Spooling Blast 78,631 75,000 50,000 125,000 95,000 50,000 75,000 220,000 21 Suction Bayiper 39,315 30,000 20,000 50,000 22 30,000 20,000 50,000 100,000 Vena Sectie 235,892 150,000 100,000 250,000 300,000 300,000 400,000 1,000,0 23 Wound Toilet 62,905 60,000 40,000 100,000 60,000| 60,000 40,000 160,000 70,000 24 Bedside manitor 26,000 45,000 30,0 75,000 20,000 50,000 30,000 100,000 25 Infus pump 70,000 60,000 40,000 100,000 39,000 78,000 13,000 130,000 26 78,000 78,000 52,000 130,000 39,000 78,000 13,0 130,000 27 Ventilatnr 130,0 1,300,000775,000 780,000 520,000 1,300,000 910,000 260,000 28 20,000 21,000 14,000 35,000 78,000 40,000 12,0 130,000 29 Gps 24,0 10,000 6,000 40,00035,000 24,000 16,000 40,000 30 Pemasangan NGT 30,000 45,000 30,000 75,000 20,000 12,000 48,0 80,000 Ket Terdapat pendobolan nama pada objek retribusi namar 12 dan 13. 1.14 Rincian Objek Retribusi Pelayanan Kesehatan NEONATOLOGI Jasa Jana Sarana Jasa Uc Jasa Sarana Tarif UC Pelayanan Tarif Baru No Jenis Pemeriksaan Pelayanan Baru Rp (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 Injekai (Intra Vena 4,914 15,000 10,000 25,000 10,000 10,000 30,000 50,000 » OGT 32,000 80,000 30,000 30,000 40,0 100,00039,556 48,000 3 Incubator 54,000 60,000 40,000 100,000 30,000 30, 000 40,0 100,000 4 93,000 62,000 155,000 80,000 50,0 70,000 200,000Reguiritasi (RJP) 5 CPAP 279,000 186,000 465,000 179,0 100,000 186,000 465,000 6 Foto Terapi 210,000 140,000 350,000 170,000 100,0 180,000 450,000 7 250,000j 135,000 150,000 100,000 385,000157,261 150,000 100,000 Blast puncrie / Cystostomy 117,946 105,000 70,000 175,000 95,000 50,000 75,000 220,0 9 117,946 105,000 70,000 175,000 25,000 70,000 80,000 175,000 Irigasi Telinga: Mata 10 Mengangkat jahitan (Up Hectingj 117,946 105,000 70,000 175,000 10,000 52,50 22,500 85,000 Mengangkat Corpus aliemum 11 78,631 75,000 50,000 1 25.000 so,oo0 50,000 75,000 175,0 12 39,315 30,000 20,000 50,000 30,000 20,0 Pasang Bolus 25.000 7s,o00 13 Pemasangan Infus Transfusi 39,315 30,000 20,000 50,0 60,000 15,000 25,000 1 00,000 30,000 75,000 20,000 12,0 48,000 80,000 14 Pemasangan Kateter / NGT 39,315 45,000 15 Perawatan Tali Pusat 78,631 24,000 16,000 40,060 10,000 24,0 16,000 50,000 78,631 48,000 32,000 80,000 150,000 80,0 70,000 300,000 16 Perawatan WSD 17 Perawatan Infus 39,315 30,000 20,000 50,0 5,000 5,000 10,000 20,000 Baru Rp ru 18 Punksi Pleura 235,892 240,000 160,000 400,000 216,000 240,000 160,000 616,000 160,000 616,00019 Punksi Lumbal 235,892 240,000 160,000 400,000 216,000 240,000 20 Punksi Ascites 157,261 165,000 110,000 275,000 148,500 165,000 110,000 423,500 21 10,000 35,000 Spalk untuk infus Anak/Bayi 15,726 15,000 10,000 25,000 10,000 15,000 22 Spooling Blast 78,631 75,000 50,000 125,000 95,000 50,000 75,000 220,000 23 30,000 20,000 50,000 100,000Suction Bayi per hari 39,315 30,000 20,000 50,000 24 Vena Sectie 235,892 150,000 100,000 250,000 300,000 300,000 400,000 1,000,000 25 Wound Toilet 62,905 60,000 40,000 100,000 60,000 60,000 40,000 160,000 26 Bedside monitor 26,000 45,000 30,000 75,000 20,000 50,000 30,000 100,000 27 Infus pump 70,000 60,000 40,000 100,000 39,000 78,000 13,000 130,000 130,00028 Syringr pump 78,000 78,000 52,000 130,000 39,000 78,000 13,000 29 Ventilator 775,000 780,000 520,000 1,300,000 910,000 260,000 130,000 1,300,000 30 40,000 12,000 130,000 Pemasangan EKG 20,000 21,000 14,000 35,000 78,000 31 GDS 35,000 24,000 16,000 40,000 24,000 10,000 6,000 40,000 75,000 20,000 12,000 48,000 80,00032 Pemasangan NGT 30,000 45,000 30,000 Ket: Terdapat pendobolan nama pada objek retribusi nomor 8, 17 ddan 18. 1.15 Rincian Objek Retribusi Pelayanan Kesehatan pada KLINIK PARU-PARU 1 SPIROMETRI 135,000 150,000 100,000 250,000 74,000 100,000 116,000 290,000 2 NEBULAIZER ( per kali) 29,700 33,000 22,000 55,000 28,000 30,000 22,000 80,000 3 PUNKSI (Pleura) 467,100 519,000 346,000 865,000 150,000 200,000 250,000 600,000 4 RAWAT LUKA 43,200 48,000 32,000 80,000 40,000 48,000 32,000 120,000 5 SATURASI OKSIGEN (dengan1 alat) 115,000 360,000 475,000 180,000 180,000 115,000 475,000 6 INJEKSI (IM/Subcutan/ Intracutan) 115,000 360,000 475,000 20,000 20,000 40,000 80,000 7 BIOPSI PARU 115,000 360,000 475,000 300,000 326,000 940,000 1,566,000 8 FOB 425,000 1,200,000 1,625,000 200,000 225,000 1,200,000 1,625,000 (Rp) (Rp) (Rp) (Rp) Baru (Rp) No Jenis Pemeriksaan Uc Jasa Sarana Jasa Pelayanan Tarif UCBaru Jasa Sarana Jasa Baru Pelayanan Tarif Baru (Rp) (Rp) R 9 FNAB 115,000 170,000 285,000 200,000 160,000 240,000 600,000 10 FAAL PARU 53,000 140,000 193,000 50,000 20,000 140,000 210,000 11 Pemasangan WSD 115,000 245,000 360,000 390,000 350,000 260,000 1,000,000 12 PUNKSI PERCOBAAN DEWASA 53,000 250,000 303,000 100,000 121,000 180,000 401,000 13 TES PROVOKASI BRONCHIAL 115,000 245,000 360,000 200,000 274,000 316,000 790,000 14 SKIN TES 24,000 50,000 74,000 35,000 14,000 21,000 70,000 15 ANGKAT DRAIN 24,000 100,000 124,000 5,000 5,000 10,000 20,000 16 BILASAN BRONKUS (#Bronkoskopi) 115,000 311,000 426,000 500,000 500,000 1,500,000 2,500,000 17 TRANSBROCHIAL BIOPSI 115,000 345,000 460,000 200,000 300,000 350,000 850,000 19 PLEURODESIS 53,000 275,000 328,000) 200,000 213,000 620,000 1,033,000 PLEURA) 21 PEAK FLOW METER 24,000 75,000 99,000 24,000 59,000 39,000 122,000 22 POLYSOMNOGRAFI 115,000 750,000 865,000 130,000 800,000 620,000 1,550,000 23 PIGITAIL CARTER 115,000 1,500,000 1,615,000 400,000 480,000 1,320,000 2,200,000 24 REPOSISI THORAX KATETER 115,000 300,000 415,000 100,000 150,000 200,000 450,000 Ket: Objek dan tarif yang berwarna biru, tidak memiliki tarif sebelumnya. 1.16 Rincian Objek Retribusi Pelayanan Kesehatan pada KLINIK JANTUNG Rp 1 Tredmil 270,000 300,000 200,000 500,000 300,000 40,000 160,000 500,000 18 115,000 365,000 480,000 500,000 SIKATAN BRONKHUS 500.000 1.500.000 2.500.000 #tBronkoskoni 20 THORACOCINTESIS (PUNKSI 350,000 465,000 240,000 160,000 616,000216,0001 15,000 PASANG Uc Jasa Sarana Jasa Tarif Jenis Pemeriksaan (Rp) (Rp) Pelayanan UC Baru Jasa Sarana Jasa (Rp) (Rp) (Rp) Baru Pelayanan Tarif Baru (Rp) Baru (Rp) No 40,500 45,000 30,000 75,000 78,000 40,000 12,000 130,000EKG2 270,000 300,000 200,000 500,000 360,000 68,000 272,000 700,000 3 Echocardio 1.17 Rincian Objek Retribusi Pelayanan Kesehatan pada KLINIK OBGYN 1.18 Jasa UC Jasa Sarana Jasa Jasa Sarana Tarif UC Baru Pelayanan Tarif B No Jenis Pemeriksaan Pelayanan Baru Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 KUNJUNGAN 42,120 46,800 31,200 78,000 42,000 46,800 31,200 120,000 u Rincian Objek Retribusi Pelayanan Kesehatan papada KLINIK PENYAKIT DALAM Jasa Jasa Sarana Jasa Uc Jasa Sarana Tarif UC Baru Pelayanan Tarif Baru No Jenis Pemeriksaan Pelayanan (Rp) (Rp) Baru Baru (Rp)(Rp) (Rp) (Rp) (Rp) (Rp) 1 KUNJUNGAN 42,120 46,800 31,200 78,000 42,000 46,800 31,200 120,000 1.19 Rincian Objek Retribusi Pelayanan Kesehatan ANAK Jasa Jasa MEN 1 KUNJUNGAN 42,120 46,800 31,200| 78,000 42,000 46,800 31,200 120,000 1.20 Rincian Objek Retribusi Pelayanan Kesehatan pada KLINIK ANAK Jasa 1 KUNJUNGAN 46,800 31,200 78,000 42,000 46,800 31,200 120,000 IMUNISASI 1 HBO 44,100,000 21,000 14,000 35,000 45,000 14,000 21,000 80,000 2 BCG 44,100,000 21,000 14,000 35,000 45,000 14,000 21,000 80,000 3 PENTABIO (DPT, HB, HIB) 44,100,000 21,000 14,000 35,000 45,000 14,000 21,000 80,000 4 CAMPAK 44,100,000 21,000 14,000 35,000 45,000 14,000 21,000 80,000 Sarana No Jenis Pemeriksaan Uc Pelayanan Tarif UC Baru Jasa Jasa Sarana Baru Pelayanan Tarif Baru (Rp) (Rp) Rp) (Rp) Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) (Rp) Baru (Rp) Jenis Pemeriksan UC Jasa Sarana Pelayanan Tarif UCBaru Jasa Sarana Pelayanan Tarif Baru Jasa Baruru NoN (Rp) (Rp) R E POLIO 14,400,000 1 2,000 8,000 23,399 45,000 8,000 12,000 65,000 1.21 Rincian Objek Retribusi Pelayanan Kesehatan papada KLINIK ANAK Ket: Tidak merubah objek, tetapi menambahkan unit cost pada tarif yang baru. Ket: Semua unit cost lama dirubah menjadi yang baru. Jasa Jasa Jasa Sarana Tarif Baru No Jenis Pemeriksaan UC Jasa Sarana Pelayanan ru Tarif UC Baru Baru Pelayanan (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 Pemeriksaan visus 5,000 5,000 20,0006,000 6,000 4,000 10,000 10,000 2 45,000 45,000 30,000 75,000 82,500 15,000 52.50 150,000 3 Refraksi Slit lamp 45,000 45,000 30,000 75,000 30,000 26,250 18,750 75,000 4 Tonometer 30,000 30,000 20,000 50,000 20,000 17,50 12,500 50,000 6,250Test buta warna 15,000 15,000 10,000 25.000) 10,000 8,750 25,000 6 10,000 5,000 10,000 25,000 Epilasi bulu mata 9,000 9,000 6,000 15,000 7 Irigasi mata 9,000 9,000 6,000 15,000 25,000 70,000 80,000 175,0 Funduskopi 45,000 45,000 30,000 75,000 50,000 10,000 40,000 Baru s 100,000 1.2 Rincian Objek Retribusi Pelayanan Kesehatan pada FISIOTERAPI No Jenis Pemeriksaan Uc Jasa Sarana Jasa (Rp) (Rp) (Rp) (Rp) Baru (Rp) Pelayanan Tarif UCBaru Jasa Sarana Tarif Baru (Rp) (Rp) 80,000Infra red 37,800 42,000 28,000 70,000 8,000 24,000 48,0001 2 Latihan Gerak / Fisik 62,100 69,000 46,000 115,000 48,000 42,000 30,000 120,000 3 Stimulasi (TENS) 40,500 45,000 30,000 75,000 8,000 24,000 48,000 80,000 4 MWD 135,000 50,000 100,000 250,000 100,000 87,500 62,500 250,000 5 US (Ultrasound) 40,500 45,000 30,000 75,000 8,000 24,000 48,000 80,000 1 6 Prafin 100,000 250,000 100,000 87,500 62,500 250,000135,000 150,000 42,000Plestery 37,800 28,0001 70,000) 38,000| 42,000) 30,000 110,0007 EMG (Elektromiografi) 1 ANGGOTA GERAK ATAS 303,750 337,500 337,500 675,000 405,000 33,750 236,250 675,000 2 ANGGOTA GERAK BAWAH 303,750 337,500 337,500 675,000 405,000 33,750 236,250 675,000 ANGGOTA GERAK ATAS DAN 3 506,250 562,500 562,500 1,125,000 660,000 5S,0 385,000 1,100,000 BAWAH 4 NERVUS KRANIALIS 675,000303,750 337,500 337,500 675,000 405,000 33,750 236,250 5 PERIKSAAN KHUSUS TERTENTU 303,750 337,500 337,500 675,000 405,000 33,750 236,250 675,000 6 Statis Bike 31,500 35,000 35,000 70,000 30,000 35,000 35,000 100,000 Ket: Terdapat pendobolan pengetikan pada Pelayanan Kesehatan Klinik Mata. Seharusnya Fisioterapi. 1.23 Rincian Objek Retribusi Pelayanan Kesehatan papada KLINIK OBGIN 1.24 Rincian Objek Retribusi Pelayanan Kesehatan GIZI Jasa UC Jasa Sarana dana Tarif UC Baru Jasa Sarana Tarif Baru No Jenis Pemeriksaan Pelayanan Baru Pelayanan (Rp) (Rp) (Rp) (Rp) Baru (Rp) (Rp) (Rp) (Rp) 1 Pasang" IUD 256,369 310,206 206,804 517,000 250,000 310,000 200,000 760,000 2 Lepas1 IUD 128,184 155,103 103,402 250,000 127,000 155,000 103,000 385,000 3 384,553 465,309 310,206 775,000 385,000 465,000 310,000 1,160,000Papsmear 4 Biopsi 256,369 310,206 206,804 517,000 250,000 310,000 200,000 760,000 5 Rawat Luka 128,184 155,103 103,402 250,000 127,000 155,000 103,000 385,000 6 USG 128,184 155,103 103,402 250,000 127,000 155,000 103,000 385,000 7 Cryo 256,369 310,206 206,804 500,000 250,000 310,000 200,000 760,000 Suntik KB 128,184 155,103 103,402 160,000 10,000 24,000 36,000 70,000 Jasa UC Jasa Sarana Jasa Tarif Uc Baru Jasa Sarana Pelayanan Tarif Baru No Jenis Pemeriksaan Pelayanan Baru Baru(Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 1 Porsi Makan VIP 81,354 78,000 52,000 130,000 150,000 150,000 55,000 355,000 2 Porsi Makan Kls 1 73,957 72,000 48,000 120,000 100,000 125,000 50,000 275,000 ru 3 Porsi Makan KLs 2 45,772 45,000 30,000 75,000 75,000 100,000 30,000 205,000 150,0004 Porsi Makan KLs 3 38,040 36,600 24,400 61,000 50,000 75,000 25,000 Ket: Selain penambahan unit cost, ada penamhahan tarif yang lain (berdasarkan usulan dari Instalasi Gizi). 1.25 Rincian Objek Retribusi Pelayanan Kesehatan pada KLINIK THT Jasa 0Rp) 1 Audiometri 135,000 150,000 100,000 250,000 100,000 75,000 75,000 250,000 6 TYMPANOMETRI 31,500 35,000 40,000 75,000 10,000 30,000 35,000 75,000 7 OTO ACUSTIK EMISSION 31,500 35,000 40,000 75,000 10,000 30,000 35,000 75,000 8 BERA 135,000 150,000 200,000 350,000 140,000 105,000 105,000 350,000 9 Reposisi (THT) 135,000 150,000 200,000 150,000 60,000 45,000 45,000 150,000 10 EKSTRAKSI KORPUS ALINEUNM 126,000 140,000 210,000 350,000 100,000 75,000 75,000 250,000 11 PARASENTESE 126,000 140,000 210,000 350,000 140,000 105,000 105,000 350,000 14 CAUTEA (Caustik) 72,000 80,000 120,000 200,000 80,000 60,000 60,000 200,000 15 INSISI ABSES 72,000 80,000 120,000 200,000 80,000 60,000 60,000 200,000 Ket: Terdapat penambahan dan pengurangan tarif pada unit cost. 126 Rincian Objek Retribusi Pelayanan Kesehatan pada KLINIK KULIT KELAMIN Jasa 1 Pemeriksaan KDH 40,500 45,000 30,000 75,000 40,000 45,000 30,000 115,000 Baru (Rp) No Pelayanan Baru Uc Jasa Sarana Jasa Tarif UC Baru Jasa Sran Pelayanan Tarif Baru (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) 2 189,000 210,000 140,000 350,000 190,000 210,000 140,000 540,000 3 189,000 210,000 140,000 350,000 150,000 310,000 200,000 660,000 Aspirasi Abse Bio 4 54,000 40,000 100,000 54,000 60,000 40,000 154,000 Spuling Telin 60,000 5 Ekstraksi Serumen 54,000 60,000 40,000 100,000 54,000 60,000 40,000 154,000 12 126,000 140,000 210,000 350,000 140,000 105,000 105,000 350,000TAMPON AMENALIM d 13 TAMPON BOR SLAF 126,000 140,000 210,000 350,000 140,000 105,000 105,000 350,000 Jenis Pemerikraan Uc Jasa Sarana Jasa Rp) (Rp) Pelayanan Tarif UCBaru Tara Pelayanan Tarif Baru (Rp) Rp) (Rp) (Rp) (Rp)Baruru Baruru No 2 (Pewarnaan Gram 54,000 60,000 40,000 100,000 54,000 48,000 33,000 135,000 3 Pemeriksaan Reits Serum 81,000 90,000 60,000 150,000 80,000 90,000 60,000 230,000 10 JElektrokauterisasi 72,000 80,000 120,000 200,000 75,000 75,000 100,000 250,000 11 |Lesi Kulit Ringan 54,000 60,000 90,000 150,000 54,000 60,000 90,000 204,000 12 Papiloma Kulit 72,000 80,000 120,000 200,000 72,000 80,000 120,000 272,000 Ker Terdapat penamhehan dan pengurangan tarif pada unit cost. 127 Rincian Objek Retribusi Pelayanan Kesehatan TINDAKAN NEUROLOGI 127.1 Pemeriksaan EMG (Rp) 1 ANGOTA GERAK ATAS 405,000 450,000 225,000) 675,000 405,000 33,750 236,250 675,000 2 ANGGOTA GERAK BAWAH 405,000 450,000 225,000 675,000 405,000 33,750 236,250 675,000 4 81,000 90,000 60,000 150,000 30,000 18,000 12,000 60,000 Pemeriksaan Lampu Wood 5 81,000 90,000 60,000 150,000 40,000 50,000 60,000 150,000 Swab V 6 Test Asam Asetat 36,000 40,000 60,000 100,000 36,000 20,000 12,000 68,000 7 35,000 285,000Perawatan Luka Pada Kulit 36,000 40,000 60,000 100,000 100,000 150,000 Rin 54,000 60,000 90,000 150,000 50,000 400,000 Perawatan Luka Pada Kulit Sed 140,000 210,000 72,000 80,000 120,000 200,000 70,000 180,000 270,000 520,000 Perawatan Luka Pada Kulit Berat9 54,000 60,000 90,000 150,000 54,000 60,000 90,000 204,000 13 Kondiloma Akuminant 14 cO2Laner 252,000 280,000 420,000 700,000 100,000 450,000 300,000 850,000 216,000 240,000 360,000 816,000 15 Kulit 240,000 360,000 600,000 216,000 ah 108,000 120,000 408,000ah 180,000 300 000 108,000 1 20,000 1 80,000 16 Lesi Tertentu di Uc Jasa Jenis Pemeriksaan Pelayanan Tarf UC Baru Jasa Sarana Jasa Tarif BaruPelayanan Rp Rp Bau (Rp) Jas Rp(Rp) Rp)Rp 55,000 385,000 1,100,00060.000 ANGGOTA GERAK ATAS DAN BAWAH 675,000 750,000 375,0 1,125, 4 NERVS KRANIALIS 405 450,000 225,000 675,000 405,000 33,750 236,250 675,000 225,000 675,0005 PERIKSAAN KHUSUS TERTENTU 405,000| 450,000 675,000| 405,000| 33,750) 236,250 127.2 Pemeriksaan TCD 1 PEMERIKSAAN TCD 315,000 350,000 400,000 750,000 450,000) 37,500 262,500 750,000 127.3 Pemeriksaan EEG 1 PEMERIKSAAN EEG 292,500 325,000 350,000 675,000 435,000 130,500 159,500 725,000 127.4 SUNTIKAN Jasa 1 TRIGER POINT 54,000 60,000 140,000 200,000 75,000 25,000 150,000 250,000 2 DRY NEEDLING 81,000 90,000 210,000 300,000 90,000 30,000 180,000 300,000 3 INTRA LESI 81,000 90,000 210,000 300,000 90,000 30,000 180,000 300,000 4 INTRA ARTIKULAR 81,000 90,000 210,000 300,000 90,000 30,000 180,000 300,000 Ket: Terdapat penambahan dan pengurangan tarif pada unit cost. 1.28 Rincian Objek Retribusi Pelayanan Kesehatan CT SCAN 1 Kepala Tanpa Kontras 155,000 400,000 222,000 815,750 980,000 210,000 210,000 1,400,000 2 Kepala Kecelakaan Lalulintas 235,000 400,000 254,000 947,750 980,000 210,000 210,000 1,400,000 3 Kepala dengan Kontras 1,107,500 400,000 603,000 2,387,375 1,400,000 300,000 300,000 2,000,000 4 Orbita tanpa kontras 235,000 400,000 254,000 947,750 980,000 315,000 315,000 1,610,000 No Jenis Pemeriksaan UC Jasa Sarana Jasa Tarif UC Baru Jasa Jasa Pelayanan Tarif Baru (Rp) (Rp) (Rp) Pelayanan Rp) (Rp Baru (Rp) ru (Rp) () R No Jenis Pemeriksaan UC TarifJasa Sarana Jasa Pelayanan UC Baru Jasa Sarana Jasa Pelayanan Tarif Baru (Rp) (Rp) (Rp (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) (Rp) Rp) (Rp) No Jenis Pemeriksaan Uc Jasa Sarana Jasa Pelayanan Tarf UCBaru Jasa Sarana Pelayanan Tarif Baru Baruru Baruru No Jenis Pemeriksaan uc Jasa Sarana Jasa (Rp) (Rp) Rp) Rp Pelayanan Tarif UCBaru Jasa Sarana asa Pelayanan Tarif Baru Rp) (Rp Baru (Rp) Orbita dengan Kontras 1,267,500 400,000 667,000 2,651,375 1,470,000 315,000 315,000 2,100,000 6 400,000 254,000 889,000Sinus tanpa Kontras 235,000 400,000 254,000 947,750 235,000 7 Sinus dengan Kontras 1,427,500 400,000 731,000 2,915,375 1,427,500 400,000 731,000 2,558,500 235,000 400,000 254,000 947,750 235,000 400,000 254,000 889,000Mastoid tanpa Kontras 9 Mastoid dengan Kontras 1,427,500 400,000 731,000 2,915,375 1,427,500 400,000 731,000 2,558,500 10 Leher tanpa Kontras 235,000 400,000 254,000 947,750 1,050,000 225,000 225,000 1,500,000 11 Leher dengan Kontras 1,427,500 400,000 731,000 2,915,375 1,400,000 300,000 300,000 2,000,000 12 Thorax tanpa Kontras 185,000 400,000 234,000 865,250 185,000 400,000 234,000 819,000 13 Thorax dengan Kontras 1,802,500 400,000 881,000 3,534,125 1,802,500 400,000 881,000 3,083,500 14 Abdomen tanpa Kontras 315,000 400,000 286,000 1,079,750 1,400,000 300,000 300,000 2,000,000 15 Abdomen dengan Kontras 2,230,000 400,000 1,052,000 4,239,500 2,450,000 525,000 525,000 3,500,000 16 Extremitas tanpa Kontras 235,000 400,000 254,000 947,750 1,050,000 225,000 225,000 1,500,000 17 400,000 731,000 2,915,375 300,000 300,000 2,000,000Extremitas dengan Kontras 1,427,500 1,400,000 18 Whole Body tanpa Kontras 2,926,000 400,000 1,330,400 4,217,500 2,926,000 400,000 1,330,400 4,656,400 19 3,352,500 400,000 1,501,000 6,091,625 3,352,500 400,000 1,501,000 5,253,500Whole Body dengan Kontras 20 Permintaan Tambah Hasil Film 90,000 50,000 36,000 198,500 150,000 50,000 50,000 250,0002 Ket Terdapt penambahan dan pengurangan tarif pada Unit cost. TARIF RETRIBUSI PELAYANAN PEMANFAATAN ASET DAERAH BALAI PELATIHAN KESEHATAN PROVINSI MALUKU TARIF NO FASILITAS LAMA BARU 1 SEWA KELAS A. KESEHATAN 500.000/HARI 300.000/HARI B. UMUM 500.000/HARI 350.000/HARI 2 SEWA ASRAMA A. KESEHATAN 200.000/ORG/HARI 50.000/ORG/HARI B. UMUM 150.000/ORG/HARI 75.000/ORG/HARI 3 SEWA KAMAR VIP A. KESEHATAN 450.000/ORG/HARI 125.000/ORG/HARI B. UMUM 250.000/ORG/ HARI 150.000/ORG/HARI 4 SEWA AUDIOTRIUM AC A. KESEHATAN 500.000/HARI 350.000/HARI B. UMUM 750.000/HARI 500.000/HARI 5 SEWA RUANG MAKAN A. KESEHATAN 500.000/HARI 350.000/HARI B. UMUM 750.000/HARI 500.000/HARI 6 SEWA INFOKUS A. KESEHATAN 300.000/KEGIATAN 150.000/KEGIATAN B. UMUM 350.000/KEGIATAN 200.000/ KEGIATAN 7 SEWA LAPTOP A. KESEHATAN 250.000/KEGIATAN 150.000/KEGIATAN B. UMUM 300.000/KEGIATAN 200.000/KEGIATAN 8 SEWA WIRELES A. KESEHATAN 250.000/KEGIATAN 150.000/KEGIATAN B. UMUM 300.000/KEGIATAN 250.000/ KEGIATAN 9 SEWA WHITEBOARD A. KESEHATAN 150.000/ KEGIATAN 125.000/KEGIATAN B. UMUM 150.000/KEGIATAN 150.000/ KEGIATAN 10 SEWA SOUND SYSTEM A. KESEHATAN 400.000/KEGIATAN 200.000/ KEGIATAN B. UMUM 500.000/KEGIATAN 300.000/ KEGIATAN TARIF RETRIBUSI PENYEDIAAN TEMPAT KEGIATAN USAHA BERUPA PASAR GROSIR, PERTOKOAN DAN TEMPAT KEGIATAN USAHA LAINNYA LAMA BARU NO OBJEK RETRIBUSI TARIF RETRUBUSI SATUAN TARIF RETRUBUSI SATUAN Sewa Los Lantai I Pasar 1 Mardika (1 m) RP 23.333,00 /hari RP 13.333,00 /hari Sewa Los Lantai II 2 Pasar Mardika (1 m) RP 23.333,00 /hari RP 13.333,00 /hari Sewa Los Lantai 3 3 Pasar Mardika (2 m) RP 40.000,00 /hari 26.667,00 /hari Sewa Kios Lantai II 4 Pujasera Pelataran RP 66.667,00 /hari RP 50.000,00 /hari Pasar Mardika (10) Sewa Kios Lantai III 5 Pasar Mardika (4,80 m) RP 50.000,00 /hari RP 33.333,00 /hari Sewa Kios Lantai IV 6 RPPasar Mardika (4,80 m) 50.000,00 /hari RP 33.333,00 /hari Sewa Kios Lantai IV 7 Pasar Mardika (7,20 m) RP 56.667,00 /hari RP 55.000,00 /hari Sewa Kios Lantai IV 8 Pasar Mardika (8,64 m) RP 66.667,00 /hari RP 65.000,00 /hari Sewa Kios Lantai IV 9g Pujasera Pelataran RP 200.000,00 /hari RP 100.000,00 /hari Pasar Mardika (24 m Sewa Kios Lantai IV 10 Pedagang Elektronik RP 33.333,00 /hari RP 20.000,00 /hari Pasar Mardika (3,24 m RP aa KR.Pa UR MALUKU men vs At

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