DokumenPeraturan Gubernur (Pergub)Berlaku

Peraturan Gubernur (PERGUB) Provinsi Sulawesi Barat Nomor 31 Tahun 2022

Nomor: 31
Tahun: 2022
Ditetapkan: 13 September 2022
Status: Berlaku
Pasal terindeks: 5

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Ringkasan

Pergub ini mengatur Perubahan Atas Peraturan Gunernur Sulawesi Barat Nomor 4 Tahun 2021 tentang Tarif Layanan Badan Layanan Umum Daerah Rumah Sakit Umum Daerah. Pasal yang diubah adalah Pasal 3 tentang Kegiatan layanan, Pasal 15 tentang pembebasan tarif, dan Pasal 19 tentang Pendapatan dari biaya pelayanan kesehatan pada BLUD RSUD.

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b.bahwa beberapa ketentuan dalan Peraturan Gubernur Sulawesi Barat Nomor 4 Tahun 2021 tentang Tarif Layanan Badan Layanan Umum Daerah Rumah Sakit Umum Daerah, tidak sesuai lagi dengan kondisi saat ini, sehingga perlu dilakukan perubahan;
c.bahwa berdasarkan pertimbangan sebagaimana dimaksud dalam huruf a dan huruf b, perlu

Menetapkan

menetapkan Peraturan Gubernur tentang Perubahan Atas Peraturan Gunernur Sulawesi Barat Nomor 4 Tahun 2021 tentang Tarif Layanan Badan Layanan Umum Daerah Rumah Sakit Umum Daerah; Mengingat : 1. Pasal 18 ayat (6) Undang-Undang Dasar Negara Republik Indonesia Tahun 1945;

2.Undang-Undang Nomor 26 Tahun 2004 tentang Pembentukan Provinsi Sulawesi Barat (Lembaran Negara Republik Indonesia Tahun 2004 Nomor 105, Tambahan Lembaran Negara Republik Indonesia Nomor 4422);
3.Undang-Undang Nomor 36 Tahun 2009 tentang Kesehatan (Lembaran Negara Republik Indonesia Tahun 2009 Nomor 144, Tambahan Lembaran Negara Republik Indonesia Nomor 5063) sebagaimana telah beberapa kali diubah, terakhir dengan Undang-Undang Nomor 11 Tahun 2020 tentang Cipta Kerja (Lembaran Negara Republik Indonesia Tahun 2020 Nomor 245, Tambahan Lembaran Negara Republik Indonesia Nomor 6573);
4.Undang-Undang … SALINAN
4.Undang-Undang Nomor 44 Tahun 2009 tentang Rumah Sakit (Lembaran Negara Republik Indonesia Tahun 2009 Nomor 153, Tambahan Lembaran Negara Republik Indonesia Nomor 5072) sebagaimana telah diubah dengan Undang-Undang Nomor 11 Tahun 2020 tentang Cipta Kerja (Lembaran Negara Republik Indonesia Tahun 2020 Nomor 245, Tambahan Lembaran Negara Republik Indonesia Nomor 6573);
5.Undang-Undang Nomor 23 Tahun 2014 tentang Pemerintahan Daerah (Lembaran Negara Republik Indonesia Tahun 2014 Nomor 244, Tambahan Lembaran Negara Republik Indonesia Nomor 5587) sebagaimana telah beberapa kali diubah, terakhir dengan 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);
6.Peraturan Pemerintah Nomor 23 Tahun 2005 tentang Pengelolaan Keuangan Badan Layanan Umum (Lembaran Negara Republik Indonesia Tahun 2005 Nomor 48, Tambahan Lembaran Negara Republik Indonesia Nomor 4502) sebagaimana telah diubah dengan Peraturan Pemerintah Nomor 74 Tahun 2012 tentang Perubahan Atas Peraturan Pemerintah Nomor 23 Tahun 2005 tentang Pengelolaan Keuangan Badan Layanan Umum (Lembaran Negara Republik Indonesia Tahun 2012 Nomor 171, Tambahan Lembaran Negara Republik Indonesia Nomor 5340);
7.Peraturan Presiden Nomor 82 Tahun 2018 tentang Jaminan Kesehatan (Lembaran Negara Republik Indonesia Tahun 2018 Nomor 165) sebagaimana telah beberapa kali diubah, terakhir dengan Peraturan Presiden Nomor 64 Tahun 2020 tentang Perubahan Kedua Atas Peraturan Presiden Nomor 82 Tahun 2018 tentang Jaminan Kesehatan (Lembaran Negara Republik Indonesia Tahun 2020 Nomor 130);
8.Peraturan Menteri Dalam Negeri Nomor 80 Tahun 2015 tentang Pembentukan Produk Hukum Daerah (Berita Negara Republik Indonesia Tahun 2015 Nomor 2036) sebagaimana telah diubah dengan Peraturan Menteri Dalam Negeri Nomor 120 Tahun 2018 tentang Perubahan Atas Peraturan Menteri Dalam Negeri Nomor 80 Tahun 2015 tentang Pembentukan Produk Hukum Daerah (Berita Negara Republik Indonesia Tahun 2018 Nomor 157);
9.Peraturan Menteri Dalam Negeri Nomor 79 Tahun 2018 tentang Badan Layanan Umum Daerah (Berita Negara Republik Indonesia Tahun 2018 Nomor 1213);
10.Peraturan Gubernur Sulawesi Barat Nomor 4 Tahun 2021 tentang Tarif Layanan Badan Layanan Umum Daerah Rumah Sakit Umum Daerah (Berita Daerah Provinsi Sulawesi Barat Tahun 2021 Nomor 4); MEMUTUSKAN … MEMUTUSKAN: Menetapkan : PERATURAN GUBERNUR TENTANG PERUBAHAN ATAS PERATURAN GUNERNUR SULAWESI BARAT NOMOR 4 TAHUN 2021 TENTANG TARIF LAYANAN BADAN LAYANAN UMUM DAERAH RUMAH SAKIT UMUM DAERAH. Pasal I Beberapa Ketentuan dalam Peraturan Gubernur Sulawesi Barat Nomor 4 Tahun 2021 tentang Tarif Layanan Badan Layanan Umum Daerah Rumah Sakit Umum Daerah (Berita Daerah Provinsi Sulawesi Barat Tahun 2021 Nomor 4), diubah sebagai berikut :
1.Ketentuan Pasal 3 diubah, sehingga Pasal 3 berbunyi sebagai berikut :

Pasal 3

(1)Kegiatan layanan BLUD RSUD yang dikenakan tarif adalah kegiatan pelayanan medis dan pelayanan penunjang.
(2)Tarif layanan sebagaimana dimaksud pada ayat (1) merupakan imbalan atas barang dan/atau jasa yang diberikan oleh BLUD RSUD yang bertujuan untuk menutup seluruh atau sebagian dari biaya per unit layanan.
(3)BLUD RSUD mengenakan tarif layanan sebagai imbalan atas penyediaan layanan barang/jasa kepada masyarakat dan seluruh penerimaan merupakan pendapatan BLUD RSUD yang berasal dari jasa layanan.
(4)Tarif untuk golongan masyarakat yang pembayarannya dijamin oleh pihak penjamin, ditetapkan berdasarkan prinsip kesetaraan dan saling menguntungkan dengan suatu ikatan perjanjian kerja sama secara tertulis.
(5)Tarif sebagaimana dimaksud pada ayat (1) ditetapkan berdasarkan asas keadilan dengan tetap mempertimbangkan masyarakat berpenghasilan rendah.
(6)Terhadap Lembaga/Instansi/Perangkat Daerah/Organisasi yang telah melakukan kerjasama dengan Direktur RSUD, pemberlakuan tarif dilaksanakan sesuai dengan kesepakatan yang tercamtum dalam dokumen kerja sama.
(7)Ketentuan mengenai Kerja Sama sebagaimana dimaksud pada ayat (4), ayat (5) dan ayat (6) dilaksanakan sesuai dengan ketentuan peraturan perundang-undangan.

2.Ketentuan Pasal 15 ayat (2) ditambahkan huruf baru yaitu huruf c dan ditambahkan satu ayat baru yaitu ayat (4), sehingga Pasal 15 berbunyi sebagai berikut :

Pasal 15

(1)Direktur dapat membebaskan sebagian atau seluruh tarif pelayanan untuk pasien berstatus miskin atau tidak mampu membayar dan kondisi tertentu dengan mempertimbangkan kemampuan keuangan RSUD.
(2)Miskin atau tidak mampu membayar sebagaimana dimaksud pada ayat (1) terdiri dari:
1. a.pasien yang tidak memiliki kartu jaminan kesehatan;
2. b.pasien tidak mampu yang dibuktikan dengan surat keterangan tidak mampu dari Pemerintah Desa/Lurah di tempat domisili; dan
3. c.pasien …
4. c.pasien kasus pidana yang tidak mampu dan tidak ditanggung Jaminan Kesehatan, yang dibuktikan dengan surat keterangan dari pihak kepolisian atau pihak penegak hukum yang lain.
(3)Kondisi tertentu sebagaimana dimaksud pada ayat (1) terdiri dari:
1. a.pelayanan dalam keadaan darurat dan bencana yang meliputi banjir, gempa bumi, kebakaran, investigasi, tersambar petir dan gunung meletus;
2. b.kejadian yang diakibatkan kerusuhan dan/atau huru-hara yang mengakibatkan sarana, prasarana dan peralatan kesehatan menjadi rusak; dan
3. c.kejadian yang diakibatkan kesalahan alat/standar prosedur operasional/human error yang menimbulkan korban yang berupa genset meledak, boiler meledak, Central Sterile Supply Department (CSSD) meledak, gas sentral bocor, serta lift pasien rusak.
(4)Dalam hal kemampuan keuangan BLUD RSUD tidak lagi mencukupi terhadap kondisi tertentu sebagaimana dimaksud pada ayat (3), pembebanan tarif terhadap layanan dapat dibebankan pada APBD melalui Belanja Tidak Terduga sesuai dengan ketentuan peraturan perundang- undangan.

3.Ketentuan Pasal 19 ayat (3) dan ayat (4) dihapus dan ditambahkan satu ayat baru yaitu ayat (6), sehingga Pasal 19 berbunyi sebagai berikut :

Pasal 19

(1)Pendapatan dari biaya pelayanan kesehatan pada BLUD RSUD dikelola sesuai dengan ketentuan peraturan perundang-undangan.
(2)Pendapatan sebagaimana dimaksud pada ayat (1) digunakan untuk mengganti biaya pelayanan kesehatan yang meliputi jasa sarana RSUD dan jasa pelayanan.
(3)Dihapus.
(4)Dihapus.
(5)Pendapatan dan pengeluaran BLUD RSUD dituangkan dalam RBA selanjutnya disampaikan ke PPKD/TAPD untuk disampaikan sebagai bagian yang tidak terpisahkan dari Rancangan Peraturan Daerah tentang APBD.
(6)Persentase penggunaan jasa sarana RSUD dan jasa pelayanan sebagaimana dimaksud pada ayat (2) tercantum dalam lampiran yang merupakan bagian tidak terpisahkan dari Peraturan Gubernur ini.

4.Ketentuan Lampiran I. PELAYAN MEDIS : 1. Rawat Jalan : A. Poliklinik Umum, Poliklinik KIA /KB, UGD dan Gigi, B. Poliklinik Spesialis/Sub Spesialis, C. Poliklinik Konsulen, D. Tindakan Dasar Keperawatan dan E. Poli Klinik, 6. Poli THT, 7. Poli Bedah, 8. Poli Anak, 10. Kandungan (OBGYN), 11. Poli Gigi dan Mulut : Tindakan Pemeriksaan Khusus, 16. Poli Jiwa, 18. Poli Penyakit Mulut,
19.Poli Orthopedi, 2O. Psikologi, 22. Telemedicine Hospital Based. 2. Tarif Layanan Rawat Inap : C. Visite Dokter Spesialis, D. Tindakan Umum Rawat Inap, E. Rawat Inap Khusus : 1. Perawatan Dasar Intensif, 2. Perawatan NICU,
3.Perawatan PICU, 4. Tindakan Intensif Perawatan ICU, 5. Perawatan ICVCU, F. Gawat Darurat, G. Persalinan, II. PELAYANAN NON MEDIS : C. Pelayanan Ambulance, III. PELAYANAN PENUNJANG MEDIS : A. Tarif Layanan Laboratorium, Radiologi, Fisioterapi : 1. Laboratorium, IV. PENUNJANG NON MEDIS : 1. Rekam Medik, 2. Unit Gas Medik, 3. Tarif Laundry diubah, sehingga Lampiran berbunyi sebagaimana tercantum dalam Lampiran Peraturan Gubernur ini. Pasal II … Ditetapkan di Mamuju pada tanggal 13 September 2022 Pj. GUBERNUR SULAWESI BARAT, ttd AKMAL MALIK Pasal II Peraturan Gubernur ini mulai berlaku pada tanggal diundangkan. Agar setiap orang mengetahuinya, memerintahkan pengundangan Peraturan Gubernur ini dengan penempatannya dalam Berita Daerah Provinsi Sulawesi Barat. BERITA DAERAH PROVINSI SULAWESI BARAT TAHUN 2022 NOMOR 31 Diundangkan di Mamuju pada tanggal 13 September 2022 SEKRETARIS DAERAH PROVINSI SULAWESI BARAT, ttd MUHAMMAD IDRIS Salinan Sesuai Dengan Aslinya KEPALA BIRO HUKUM, ttd Dr. SUYUTI MARZUKI, SPi, MT, M.Sc Pangkat : Pembina Tk.I/IV.b NIP. : 19690820 199903 1 005 : : : : 1 Konsultasi + Pemeriksaan Fisik Rp 27,500 27,500Rp 55,000Rp 1 Rp 32,500 32,500Rp 65,000Rp 1 Konsultasi + Pemeriksaan Fisik Rp 37,500 37,500Rp 75,000Rp 1 32,500Rp 32,500Rp 65,000Rp 2 40,000Rp 40,000Rp 80,000Rp 3 12,500Rp 12,500Rp 25,000Rp 4 60,000Rp 60,000Rp 120,000Rp 5 83,000Rp 83,000Rp 166,000Rp 6 12,500Rp 12,500Rp 25,000Rp 7 25,000Rp 25,000Rp 50,000Rp 8 50,000Rp 50,000Rp 100,000Rp 9 50,000Rp 50,000Rp 100,000Rp 10 75,000Rp 75,000Rp 150,000Rp 11 12,500Rp 12,500Rp 25,000Rp 12 15,000Rp 15,000Rp 30,000Rp 13 30,000Rp 30,000Rp 60,000Rp E. POLI KLINIK 1 250,000Rp 250,000Rp 500,000Rp 2 200,000Rp 200,000Rp 400,000Rp 3 300,000Rp 300,000Rp 600,000Rp 4 200,000Rp 200,000Rp 400,000Rp 1 25,000Rp 25,000Rp 50,000Rp 2 125,000Rp 125,000Rp 250,000Rp 1 25,000Rp 25,000Rp 50,000Rp 1 25,000Rp 25,000Rp 50,000Rp 2 10,000Rp 10,000Rp 20,000Rp 1 50,000Rp 50,000Rp 100,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 27,500Rp 27,500Rp 55,000Rp 4 40,000Rp 40,000Rp 80,000Rp 5 75,000Rp 75,000Rp 150,000Rp TES VESTIBULER PEMERIKSAAN FUNDOSCOPY TES MMSE/MOCA INA PERAWATAN LUKA (BERAT) AFF KATETER GANTI VERBAN KECIL TREADMILL Rectal Touch Aspirasi dan Injeksi intra artikular RECTAL TOUCH KONSELING RECTAL TOUCH AFF HECTING ≥ 5 POLI/POLIKLINIK/INSTALASI Pemeriksaan ECHO USG Vaskuler TEE LAMPIRAN JENIS PEMERIKSAAN JENIS PEMERIKSAAN NOMOR TANGGAL TENTANG PERATURAN GUBERNUR SULAWESI BARAT 31 TAHUN 2022 13 SEPTEMBER 2022 PERUBAHAN ATAS PERATURAN GUNERNUR SULAWESI BARAT NOMOR 4 TAHUN 2021 TENTANG TARIF LAYANAN BADAN LAYANAN UMUM DAERAH RUMAH SAKIT UMUM DAERAH JUMLAH I. PELAYAN MEDIS
1.RAWAT JALAN A. POLIKLINIK UMUM, POLIKLINIK KIA /KB, UGD DAN GIGI NO JASA SARANA JASA PELAYANAN
5.SYARAF (NEUROLOGI)
1.JANTUNG (CARDIO)
2.INTERNA
3.INTERNA (GERIATRI) Pemeriksaan Fisik JENIS PEMERIKSAAN Konsultasi + Pemeriksaan Fisik Pemeriksaan ECG JASA PELAYANAN B. POLIKLINIK SPESIALIS/ SUB SPESIALIS NO JASA SARANA JASA PELAYANAN JASA PELAYANAN C. POLIKLINIK KONSULEN NO JASA SARANA NO NO
4.INTERNA (HIV) JUMLAH JUMLAH JUMLAH PEMERIKSAAN DENGAN TINDAKAN PEMERIKSAAN NEUROLOGI DASAR TES PESPIRASI JASA SARANA JASA PELAYANAN JUMLAH D. TINDAKAN DASAR KEPERAWATAN JASA SARANA GANTI VERBAN BESAR PASANG KATETER NEBULIZER INJEKSI AFF HECTING ˂ 5 PERAWATAN LUKA (RINGAN) PERAWATAN LUKA (SEDANG) JENIS PEMERIKSAAN 6 35,000Rp 35,000Rp 70,000Rp 7 40,000Rp 40,000Rp 80,000Rp 8 100,000Rp 100,000Rp 200,000Rp 9 100,000Rp 100,000Rp 200,000Rp 10 17,000Rp 17,000Rp 34,000Rp 100,000Rp 100,000Rp 200,000Rp 125,000Rp 125,000Rp 250,000Rp 150,000Rp 150,000Rp 300,000Rp 11 50,000Rp 50,000Rp 100,000Rp 12 50,000Rp 50,000Rp 100,000Rp 13 25,000Rp 25,000Rp 50,000Rp 14 275,000Rp 275,000Rp 550,000Rp 15 275,000Rp 275,000Rp 550,000Rp 16 275,000Rp 275,000Rp 550,000Rp 17 150,000Rp 150,000Rp 300,000Rp 1 25,000Rp 25,000Rp 50,000Rp 2 30,000Rp 30,000Rp 60,000Rp 3 30,000Rp 30,000Rp 60,000Rp 4 30,000Rp 30,000Rp 60,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 42,500Rp 42,500Rp 85,000Rp 7 75,000Rp 75,000Rp 150,000Rp 8 75,000Rp 75,000Rp 150,000Rp 9 65,500Rp 65,500Rp 131,000Rp 10 125,000Rp 125,000Rp 250,000Rp 11 36,500Rp 36,500Rp 73,000Rp 12 100,000Rp 100,000Rp 200,000Rp 13 75,000Rp 75,000Rp 150,000Rp 14 25,000Rp 25,000Rp 50,000Rp 15 30,000Rp 30,000Rp 60,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 50,000Rp 50,000Rp 100,000Rp 18 117,000Rp 117,000Rp 234,000Rp 19 153,500Rp 153,500Rp 307,000Rp 20 155,000Rp 155,000Rp 310,000Rp 21 103,500Rp 103,500Rp 207,000Rp 22 135,500Rp 135,500Rp 271,000Rp 23 25,000Rp 25,000Rp 50,000Rp 24 37,500Rp 37,500Rp 75,000Rp 25 50,000Rp 50,000Rp 100,000Rp 26 100,000Rp 100,000Rp 200,000Rp 27 50,000Rp 50,000Rp 100,000Rp 28 100,000Rp 100,000Rp 200,000Rp 29 75,000Rp 75,000Rp 150,000Rp 30 100,000Rp 100,000Rp 200,000Rp 31 37,500Rp 37,500Rp 75,000Rp 32 75,000Rp 75,000Rp 150,000Rp 33 50,000Rp 50,000Rp 100,000Rp 34 75,000Rp 75,000Rp 150,000Rp 35 150,000Rp 150,000Rp 300,000Rp 36 50,000Rp 50,000Rp 100,000Rp 37 60,000Rp 60,000Rp 120,000Rp TES GARPUTALA ENDOSCOPY DIAGNOSTIK HIDUNG/TELINGA EXTRAKSI CORUMEN OBTURANS EXTRAKSI CORUMEN OBTURANS DENGAN PENYULIT OTORED/OAE EXTRAKSI CORPUS ALIENUM TENGGOROKAN TANPA PENYULIT EXTRAKSI CORPUS ALIENUM TENGGOROKAN DENGAN PENYULIT TAMPON BOORZALF HIDUNG TAMPON BELLOQUE HIDUNG FARINGOSKOPI THT LARINGOSKOPI INDIRECT KAUSTIK THT EXTRAKSI RINOLITH TERAPI REPOSISI OTOLIT PEMERIKSAAN MEDIK ELECTRO ENCEPHALOGRAPH EEG ELECTRO MYO GRAPH TRANS CRANIAL DOPPLER INJEKSI INTRAARTICULAR * BESAR PEMERIKSAAN NEUROLOGI TAMBAHAN TES DEMENSIA KONSUL NEUROLOGI PEMERIKSAAN PENUNJANG LUMBAL FUNGSI PEMERIKSAAN PKL INJEKSI LOKAL * RINGAN * SEDANG TES HALPIKE PEMERIKSAAN FUNDOSCOPY
6.POLI THT EXTRAKSI CORPUS ALIENUM MAE (TANPA PENYULIT) EXTRAKSI CORPUS ALIENUM MAE (KOMPLIKASI) EXTIRPASI GRANULASI MAE GANTI VERBAN POST OPERASI THT INSISI ABSES TELINGA/KISTA TOILET TELINGA + CRUUM NESI TOILET TELINGA + ZALF IRIGASI TELINGA TAMPON BUROWI TELINGA PARASINTESIS IRIGASI SINUS MAXILARIS EXTRAKSI CORPUS ALIENUM HIDUNG INSISI ABSES SEPTUM POLIPEKTOMI SIMPLEX REPOSISI HIDUNG INJEKSI PERIKONDRITIS (TELINGA) TES AUDOUMETRI TES VESTIBULER TOILET HIDUNG TAMPON HIDUNG SEMENTARA INSISI ABSES TENGGOROKAN ASPIRASI ABSES TENGGOROKAN PERAWATAN STOMA TRAKEA 38 75,000Rp 75,000Rp 150,000Rp 39 100,000Rp 100,000Rp 200,000Rp 40 50,000Rp 50,000Rp 100,000Rp 41 41,000Rp 41,000Rp 82,000Rp 42 100,000Rp 100,000Rp 200,000Rp 43 100,000Rp 100,000Rp 75,000Rp 1 137,500Rp 137,500Rp 275,000Rp 2 175,000Rp 175,000Rp 350,000Rp 3 100,000Rp 100,000Rp 200,000Rp 4 25,000Rp 25,000Rp 50,000Rp 5 500,000Rp 500,000Rp 1,000,000Rp 6 25,000Rp 25,000Rp Rp 50,000 7 37,500Rp 37,500Rp Rp 75,000 8 50,000Rp 50,000Rp Rp 100,000 9 277,500Rp 277,500Rp Rp 555,000 10 50,000Rp 50,000Rp Rp 100,000 11 75,000Rp 75,000Rp Rp 150,000 12 1,600,000Rp 1,600,000Rp Rp 3,200,000 13 1,600,000Rp 1,600,000Rp Rp 3,200,000 14 25,000Rp 25,000Rp Rp 50,000 15 50,000Rp 50,000Rp Rp 100,000 16 125,000Rp 125,000Rp Rp 250,000 17 100,000Rp 100,000Rp Rp 200,000 18 25,000Rp 25,000Rp Rp 50,000 1 162,500Rp 162,500Rp 325,000Rp 2 150,000Rp 150,000Rp 300,000Rp 3 25,000Rp 25,000Rp 50,000Rp 4 32,500Rp 32,500Rp 65,000Rp 5 30,000Rp 30,000Rp 600,000Rp 6 40,000Rp 40,000Rp 80,000Rp 7 100,000Rp 100,000Rp 200,000Rp 8 100,000Rp 100,000Rp 200,000Rp 9 50,000Rp 50,000Rp 100,000Rp 10 30,000Rp 30,000Rp 60,000Rp 11 20,000Rp 20,000Rp 40,000Rp 12 50,000Rp 50,000Rp 100,000Rp 13 40,000Rp 40,000Rp 80,000Rp 14 50,000Rp 50,000Rp 100,000Rp 15 100,000Rp 100,000Rp 200,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 100,000Rp 100,000Rp 200,000Rp 18 100,000Rp 100,000Rp 200,000Rp 19 20,000Rp 20,000Rp 40,000Rp 20 75,000Rp 75,000Rp 150,000Rp 21 40,000Rp 40,000Rp 80,000Rp 22 32,500Rp 32,500Rp 65,000Rp 23 50,000Rp 50,000Rp 100,000Rp 24 100,000Rp 100,000Rp 200,000Rp NEBULIZER SPIROMETRI INJEKSI IV/IM/SC/IC EKG FRENTOMY IMUNISASI KONSULTASI TUMBUH KEMBANG ANAK KONSULTASI KETERLAMBATAN PERKEMBANGAN SENSORI MOTORIK DAN BAHASA PADA ANAK MENGUKUR TEKANAN DARAH PEMASANGAN OGT/NGT AFF OGT/NGT TEST MANTOUX/TUBERKULIN TEST PERAWATAN LUKA PERAWATAN TALI PUSAT PENGUKURAN ANTROPOMETRI PENILAIAN/INTERPRETASI ANTROPOMETRI PELAYANAN GIZI PEMERIKSAAN FISIK ANAK DAN NEONATUS PEMERIKSAAN NEOROLOGI ANAK Pasang Elastis Verban TUBERKULIN TEST SPIROMETRI RAWAT TALI PUSAT INJEKSI VIT.K EXTIRPASI BIOPSI CROS INSISI RECTAL TOUCHEA ASPIRASI DAN INJEKSI INTRA ARTIKULAR PUNKSI CAIRAN HECTING BERAT DEBRIDEMEN INJEKSI KORTIKOSTEROID R INJEKSI KORTIKOSTEROID S ASPIRASI BIOPSI RECTAL TOUCHEA SIRKUMSISI HECTING RINGAN HECTING SEDANG SPOLING TELINGA LARINGOSKOPI PLEKSIBEL TES KESEIMBANGAN SEDERHANA INSISI ABSES KECIL INSISI ABSES BESAR PENATALAKSANAAN EPISTAKSIS TES TYMPANOMETRI ANGKAT TAMPON ANTERIOR EKSTRAKSI KUKU
8.POLI ANAK
7.POLI BEDAH 25 100,000Rp 100,000Rp 200,000Rp 26 100,000Rp 100,000Rp 200,000Rp 27 50,000Rp 50,000Rp 100,000Rp 28 30,000Rp 30,000Rp 60,000Rp 29 30,000Rp 30,000Rp 60,000Rp 1 10,000Rp 10,000Rp 20,000Rp 2 25,000Rp 25,000Rp 50,000Rp 3 40,000Rp 40,000Rp 80,000Rp 4 22,500Rp 22,500Rp 45,000Rp 1 75,000Rp 75,000Rp 150,000Rp 2 125,000Rp 125,000Rp 250,000Rp 3 100,000Rp 100,000Rp 200,000Rp 4 125,000Rp 125,000Rp 250,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 25,000Rp 25,000Rp 50,000Rp 7 50,000Rp 50,000Rp 100,000Rp 8 32,500Rp 32,500Rp 65,000Rp 9 100,000Rp 100,000Rp 200,000Rp 10 50,000Rp 50,000Rp 100,000Rp 11 50,000Rp 50,000Rp 100,000Rp 12 75,000Rp 75,000Rp 150,000Rp 13 50,000Rp 50,000Rp 100,000Rp 14 30,000Rp 30,000Rp 60,000Rp 15 75,000Rp 75,000Rp 150,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 175,000Rp 175,000Rp 350,000Rp 18 32,500Rp 32,500Rp 65,000Rp 19 100,000Rp 100,000Rp Rp 200,000 20 125,000Rp 125,000Rp Rp 250,000 21 150,000Rp 150,000Rp Rp 300,000 22 200,000Rp 200,000Rp 400,000Rp 23 24 90,000Rp 110,000Rp Rp 200,000 25 90,000Rp 110,000Rp Rp 200,000 26 180,000Rp 220,000Rp Rp 400,000 27 90,000Rp 110,000Rp 200,000Rp 28 135,000Rp 165,000Rp 300,000Rp 29 58,500Rp 71,500Rp Rp 130,000 11 1 60,000Rp 60,000Rp 120,000Rp 2 35,000Rp 35,000Rp 70,000Rp 3 47,500Rp 47,500Rp 95,000Rp 4 37,500Rp 37,500Rp 75,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 50,000Rp 50,000Rp 100,000Rp 7 25,000Rp 25,000Rp 50,000Rp 8 25,000Rp 25,000Rp 50,000Rp 9 35,000Rp 35,000Rp 70,000Rp 10 75,000Rp 75,000Rp 150,000Rp 11 25,000Rp 25,000Rp 50,000Rp 12 25,000Rp 25,000Rp 50,000RpORAL DIAGNOSES SOLUX BUKA JAHITAN KONTROL ORTHODONTIC REMOVABLE DENTAL RONTGEN FOTO NON RUJUKAN CURRETAGE POCKET/GIGI PENCABUTAN GIGI ANAK (BIASA) PENCABUTAN GIGI ANAK/GIGI -CITOJECT PENAMBALAN GIGI SEMENTARA REPARASI SALURAN GIGI/GIGI ESTIRPASI GANTI OBAT Cuci vagina Kreyterapi Doopler POLI GIGI DAN MULUT PENCABUTAN GIGI DEWASA TINDAKAN PEMERIKSAAN KHUSUS Cabut IUD dengan penyulit KB Penyulit Pasang IUD tanpa penyulit Buka IUD tanpa penyulit Buka implant dengan penyulit USG 4 DIMENSI KONSUL + PEMERIKSAAN FISIK pasangg implan tanpa penyulit Cabut implan tanpa penyulit Pasang implan dengan penyulit USG OBSTETRI/GINEKOLOGI INSPEKULO KONTROL HECTING/AFF HECTING PUNKSI USG TRANSVAGINAL TOILET VAGINA VAGINA TOUCHEA/RECTAL TOUCHER PASANG/BUKA PASSARIUM RECTAL TOUCHEA AMNIOSCOPY PASANG IMPLAN BUKA IMPLANT IUD DENGAN PENYULITAN/PERLENGKETAN PAPSMEAR/IVA TEST TAMPON VAGINA IMUNISASI PADA IBU HAMIL PEMERIKSAAN IBU HAMIL TINDIK TELINGA INJEKSI KB BIOPSI
10.KANDUNGAN (OBGYN) KONSELING MENYUSUI PIJAT BAYI TINDIK ANGKAT JAHIT GANTI BALUT
9.POLI KIA 1 75,000Rp 75,000Rp 150,000Rp 2 75,000Rp 75,000Rp 150,000Rp 3 125,000Rp 125,000Rp 250,000Rp 4 75,000Rp 75,000Rp 150,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 100,000Rp 100,000Rp 200,000Rp 7 125,000Rp 125,000Rp 250,000Rp 8 75,000Rp 75,000Rp 150,000Rp 9 62,500Rp 62,500Rp 125,000Rp 10 32,500Rp 32,500Rp 65,000Rp 11 175,000Rp 175,000Rp 350,000Rp 12 125,000Rp 125,000Rp 250,000Rp 13 125,000Rp 125,000Rp 250,000Rp 14 175,000Rp 175,000Rp 350,000Rp 15 100,000Rp 100,000Rp 200,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 100,000Rp 100,000Rp 200,000Rp 18 125,000Rp 125,000Rp 250,000Rp 1 100,000Rp 100,000Rp 200,000Rp 2 100,000Rp 100,000Rp 200,000Rp 3 100,000Rp 100,000Rp 200,000Rp 4 100,000Rp 100,000Rp 200,000Rp 5 400,000Rp 400,000Rp 800,000Rp 6 250,000Rp 250,000Rp 500,000Rp 7 1,000,000Rp 1,000,000Rp 2,000,000Rp 8 500,000Rp 500,000Rp 1,000,000Rp 9 150,000Rp 150,000Rp 300,000Rp 10 750,000Rp 750,000Rp 1,500,000Rp 11 500,000Rp 500,000Rp 1,000,000Rp 12 175,000Rp 175,000Rp 350,000Rp 13 175,000Rp 175,000Rp 350,000Rp 14 375,000Rp 375,000Rp 750,000Rp 15 175,000Rp 175,000Rp 350,000Rp 16 250,000Rp 250,000Rp 500,000Rp 17 150,000Rp 150,000Rp 300,000Rp 18 50,000Rp 50,000Rp 100,000Rp 19 50,000Rp 50,000Rp 100,000Rp 20 50,000Rp 50,000Rp 100,000Rp 21 100,000Rp 100,000Rp 200,000Rp 22 100,000Rp 100,000Rp 200,000Rp 23 175,000Rp 175,000Rp 350,000Rp 24 225,000Rp 225,000Rp 450,000Rp 25 250,000Rp 250,000Rp 500,000Rp 26 425,000Rp 425,000Rp 850,000Rp 27 800,000Rp 800,000Rp 1,600,000Rp 28 2,500,000Rp 2,500,000Rp 5,000,000Rp 29 2,500,000Rp 2,500,000Rp 5,000,000Rp 30 300,000Rp 300,000Rp Rp 600,000 31 150,000Rp 150,000Rp Rp 300,000 FULL DENTURE RA DAN RB PROTESA FLEXI DENTURE FULL PROTESA FLEXI PARSIAL Gigitiruan penuh RA dan RB akrilik Gigitiruan penuh RA akrilik PERAWATAN MUMIFIKASI PROTESA AKRILIK 1 SAMPAI 3 GIGI PROTESA AKRILIK 4 SAMPAI 6 GIGI PROTESA AKRILIK 7 SAMPAI 8 GIGI FULL PERRAHANG RESTORASI POST ENDODONTIK DEVITALISASI SALURAN AKAR PERAWATAN PULP CAPPING APLIKASI EUGONAL RETREATMENT/UP CUTTA PERCHA - FRENECTOMY - GINGIVECTOMY/GIGI - SPLIN OKLUSAL - SQUESTERECTOMY/REGIO - OBTURATOR - JACKET CROWN/GIGI PORCELAIN - PLAT STEEL DENTURE - PEMASANGAN PIN SCREW/GIGI - PIN CROWN/BAHAN PORCELAIN KHUSUS - ORTHODONTIC REMOVEABLE/RAHANG - ENUKLEASI MUCOCELE - FRACTURE RAHANG SEDERHANA - ODONTECTOMY-ED - APEKS RESEKSI - JACKET CROWN/GIGI ACRYLIC REPARASI PROTHESA OPERCULECTOMY REPOSISI DISLOKASI TMJ OBTURASI/PENGISIAN SALURAN AKAR/GIGI - ENUKLEASI KISTA TINDAKAN PEMERIKSAAN KHUSUS ONTROL ORTHODONTIC CEKAT/KUNJUNGAN (GANTI KARET) ALVEOLECTOMY/ROGIO PREPARASI SALURAN AKAR TAMBALAN COMPOSITE-SINAR/GIGI REBASING/RELINING PROTHESA PEMBERSIHAN KARANG GIGI/RAHANG SEDERHANA PEMBERSIHAN KARANG GIGI/RAHANG KOMPLEKS TAMBALAN PERMANEN AMALGAM TANPA KOMPLIKASI TAMBALAN GLASS LOMONER KONTROL ORTHODONTIC CEKAT/KUNJUNGAN (GANTI WIRE) PENCABUTAN GIGI DEWASA CITOJECT PEMASANGAN JACKET LEPAS/TEMPORARY CROWN PENCABUTAN GIGI KOMPLIKASI INCISI ABSES, BIOPSI TINDAKAN PEMERIKSAAN SEDANG : 32 150,000Rp 150,000Rp Rp 300,000 33 50,000Rp 50,000Rp Rp 100,000 34 100,000Rp 100,000Rp Rp 200,000 35 125,000Rp 125,000Rp Rp 250,000 36 85,000Rp 85,000Rp Rp 170,000 37 310,000Rp 310,000Rp Rp 620,000 1 30,000Rp 30,000Rp 60,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 50,000Rp 50,000Rp 100,000Rp 1 50,000Rp 50,000Rp 100,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 50,000Rp 50,000Rp 100,000Rp 5 50,000Rp 50,000Rp 100,000Rp 6 300,000Rp 300,000Rp 600,000Rp 1 150,000Rp 150,000Rp 300,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 150,000Rp 150,000Rp 300,000Rp 5 125,000Rp 125,000Rp 250,000Rp 6 250,000Rp 250,000Rp 500,000Rp 7 400,000Rp 400,000Rp 800,000Rp 8 125,000Rp 125,000Rp 250,000Rp 9 250,000Rp 250,000Rp 500,000Rp 10 400,000Rp 400,000Rp 800,000Rp 11 125,000Rp 125,000Rp 250,000Rp 12 250,000Rp 250,000Rp 500,000Rp 13 400,000Rp 400,000Rp 800,000Rp 14 150,000Rp 150,000Rp 300,000Rp 15 200,000Rp 200,000Rp 400,000Rp 16 300,000Rp 300,000Rp 600,000Rp 17 400,000Rp 400,000Rp 800,000Rp 18 250,000Rp 250,000Rp 500,000Rp 19 175,000Rp 175,000Rp 350,000Rp 20 600,000Rp 600,000Rp 1,200,000Rp 21 350,000Rp 350,000Rp 700,000Rp 22 450,000Rp 450,000Rp 900,000Rp 23 600,000Rp 600,000Rp 1,200,000Rp 24 200,000Rp 200,000Rp 400,000Rp 25 400,000Rp 400,000Rp 800,000Rp EKSISI NEVUS ( ˃ 2 CM s/d ˂ 5 CM) EKSISI NEVUS ( ˃ 5 CM) ELEKTROCAUTER CONDILOMA 1 - 5 (KECIL) ELEKTROCAUTER CONDILOMA 5 - 10 EKSISI/EKSTIRPASI SEDANG ( ˃ 2 CM s/d ˂ 5 CM) EKSISI/EKSTIRPASI KECIL ( 7,5 CM) - MARSUPIALISASI - EKSTRAKSI KUKU (BESAR) EKSISI XANTELASMA - EKSTRAKSI MILIA ˃ 20 - INSISI ABSES EKSISI/EKSTIRPASI KECIL (˂ 2 CM) - ELEKTROCAUTER 6-10 - ELEKTROCAUTER > 10 - ENUKLEASI MOLUSKUM KECIL 1-10 - ENUKLEASI MOLUSKUM BESAR 10-20 - ENUKLEASI MOLUSCUM BESAR > 20 EKSISI NEVUS (˂ 2 CM) - INJEKSI KORTIKOSTEROID (TRIAMCINOLON) ˃ 5 cm (BESAR) - ELEKTROCAUTER (KECIL) 1-5 Membuat ulang gigitiruan per rahang KONSULTASI - INSPECULO (SPECULUM) - TES SENSIBILITAS MORBUS HANSEN - PEMERIKSAAN KOH - EKSTRAKSI MILIA 1-10 - EKSTRAKSI MILIA 10 - 20 TINDAKAN PEMERIKSAAN SEDERHANA :
12.POLI KULIT DAN KELAMIN PEMERIKSAAN PENUNJANG Gigitiruan penuh RB akrilik Gigitiruan akrilik1-3 gigi 4-6 gigi akrilik 7-8 gigi akrilik Reparasi gigitiruan TINDAKAN MEDIS BEDAH KULIT - PEMERIKSAAN GRAM, TRICHOMONAS - PEMERIKSAAN WHIFF TES - PEMERIKSAAN SARCOPTES PEMERIKSAAN LAMPU WOOD PEMERIKSAAN SEROLOGI ANTI PGL-1 - PUNCH BIOPSI - INJEKSI KORTIKOSTEROID (TRIAMCINOLON) ˂ 2 cm (KECIL) - INJEKSI KORTIKOSTEROID (TRIAMCINOLON) 2 cm - ˂ 5 cm (SEDANG) 26 600,000Rp 600,000Rp 1,200,000Rp 27 200,000Rp 200,000Rp 400,000Rp 28 350,000Rp 350,000Rp 700,000Rp 29 450,000Rp 450,000Rp 900,000Rp 30 650,000Rp 650,000Rp 1,300,000Rp 31 300,000Rp 300,000Rp 600,000Rp 1 75,000Rp 75,000Rp 150,000Rp 2 125,000Rp 125,000Rp 250,000Rp 3 150,000Rp 150,000Rp 300,000Rp 4 125,000Rp 125,000Rp 250,000Rp 5 200,000Rp 200,000Rp 400,000Rp 6 175,000Rp 175,000Rp 350,000Rp 7 500,000Rp 500,000Rp 1,000,000Rp 8 750,000Rp 750,000Rp 1,500,000Rp 9 650,000Rp 650,000Rp 1,300,000Rp 10 1,250,000Rp 1,250,000Rp 2,500,000Rp 11 500,000Rp 500,000Rp 1,000,000Rp 12 1,000,000Rp 1,000,000Rp 2,000,000Rp 13 1,250,000Rp 1,250,000Rp 2,500,000Rp 14 1,500,000Rp 1,500,000Rp 3,000,000Rp 15 750,000Rp 750,000Rp 1,500,000Rp 16 1,000,000Rp 1,000,000Rp 2,000,000Rp 17 1,250,000Rp 1,250,000Rp 2,500,000Rp 1 400,000Rp 400,000Rp 800,000Rp 2 500,000Rp 500,000Rp 1,000,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 200,000Rp 200,000Rp 400,000Rp 5 50,000Rp 50,000Rp 100,000Rp 6 125,000Rp 125,000Rp 250,000Rp 7 300,000Rp 300,000Rp 600,000Rp 1 55,000Rp 55,000Rp 110,000Rp 2 75,000Rp 75,000Rp 150,000Rp 3 135,000Rp 135,000Rp 270,000Rp 4 800,000Rp 800,000Rp 1,600,000Rp 5 525,000Rp 525,000Rp 1,050,000Rp 6 400,000Rp 400,000Rp 800,000Rp 7 550,000Rp 550,000Rp 1,100,000Rp 8 525,000Rp 525,000Rp 1,050,000Rp 9 800,000Rp 800,000Rp 1,600,000Rp 10 175,000Rp 175,000Rp 350,000Rp 11 1,250,000Rp 1,250,000Rp 2,500,000Rp PLEURODESIS PADA PNEUMOTORAKS PASANG CHEST TUBE/WSB AFF CHEST TUBE/WSD BRONCOSHCOPY + BIOPSI +WASHING + BROSHING TERAPI CREEPING ERUPTION/SEMPROT CHLOR ETHYL FOTOTHERAPY - VITILIGO RINGAN ˂ 5 LESI - VITILIGO RINGAN ≥ 5 - 10 LESI - VITILIGO BERAT/LUAS ≥ 10 LESI LASER NOYAG UNTUK LESI ˂ 5 cm LASER NOYAG UNTUK LESI ≥ 5 cm LASER NOYAG UNTUK LESI FULL FACE SKIN PRICK TEST SKIN PATCH TEST TES ALERGI LASER CO2 BERAT LASER PROYELLOW UNTUK LESI ˂ 5 cm LASER PROYELLOW UNTUK LESI ˃ 5 cm s/d 10 cm LASER PROYELLOW UNTUK LESI ˃10 cm LASER PROYELLOW UNTUK LESI FULL FACE MIKRODERMABRASI INJEKSI WHITENING STANDAR DERMAROLIER STANDAR DERMAROLIER PREMIUM LASER CO2 RINGAN TCA KARDIOVASKULER RISK TINGGI FACIAL CHEMICAL PEELING AHA LOKAL CHEMICAL PEELING AHA IMPORT CHEMICAL PEELING TEA ELEKTROCAUTER CONDILOMA ≥10 BEDAH LISTRIK KERATOSIS SEBOROIK 1 - 5 BEDAH LISTRIK KERATOSIS SEBOROIK 5 - 10 BEDAH LISTRIK KERATOSIS SEBOROIK 10 s/d 20 BEDAH LISTRIK KERATOSIS SEBOROIK ˃ 20
13.POLI PARU PEMERIKSAAN DENGAN TINDAKAN TINDAKAN KOSMETIK MEDIK NEBULIZER/TERAPI INHALASI FUNGSI PLEURA/PROEF PANKSI/TRIAL EVALUATION SPIROMETRI BRONCOSHCOPY/FOB THORA COSINTESIS / EVALUATION C PLEURA IRIGASI PLEURA / SPOOLING PLEURODESIS 12 1,500,000Rp 1,500,000Rp 3,000,000Rp 13 325,000Rp 325,000Rp 650,000Rp 14 105,000Rp 105,000Rp 210,000Rp 15 300,000Rp 300,000Rp 600,000Rp 16 600,000Rp 600,000Rp 1,200,000Rp 17 250,000Rp 250,000Rp 500,000Rp 18 12,500Rp 12,500Rp 25,000Rp 19 12,500Rp 12,500Rp 25,000Rp 1 34,000Rp 34,000Rp 68,000Rp 2 25,000Rp 25,000Rp 50,000Rp 3 25,000Rp 25,000Rp 50,000Rp 4 25,000Rp 25,000Rp 50,000Rp 5 25,000Rp 25,000Rp 50,000Rp 6 100,000Rp 100,000Rp 200,000Rp 7 42,500Rp 42,500Rp 85,000Rp 8 25,000Rp 25,000Rp 50,000Rp 9 25,000Rp 25,000Rp 50,000Rp 10 35,000Rp 35,000Rp 70,000Rp 11 25,000Rp 25,000Rp 50,000Rp 12 25,000Rp 25,000Rp 50,000Rp 13 25,000Rp 25,000Rp 50,000Rp 14 25,000Rp 25,000Rp 50,000Rp 15 37,500Rp 37,500Rp 75,000Rp 16 25,000Rp 25,000Rp 50,000Rp 17 75,000Rp 75,000Rp 150,000Rp 18 50,000Rp 50,000Rp 100,000Rp 19 600,000Rp 600,000Rp 1,200,000Rp 20 Rp 25,000 Rp 25,000 Rp 50,000 21 Rp 131,250 Rp 131,250 Rp 262,500 22 Rp 12,500 Rp 12,500 Rp 25,000 23 42,500Rp 42,500Rp 85,000Rp 24 90,000Rp 90,000Rp 180,000Rp 25 42,500Rp 42,500Rp 85,000Rp 26 3,250,000Rp 3,250,000Rp 6,500,000Rp 27 1,050,000Rp 1,050,000Rp 2,100,000Rp 28 100,000Rp 100,000Rp 200,000Rp 29 1,250,000Rp 1,250,000Rp 2,500,000Rp 1 12,500Rp 12,500Rp 25,000Rp 2 20,000Rp 20,000Rp 40,000Rp 3 10,000Rp 10,000Rp 20,000Rp 4 25,000Rp 25,000Rp 50,000Rp 1 75,000Rp 75,000Rp 150,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 32,500Rp 32,500Rp 65,000Rp 4 42,500Rp 42,500Rp 85,000Rp Wawancara Awal dan Pemeriksaan Psikiatri Psikoterapi Suportif Psikoedukasi Individu Psikoedukasi Keluarga - EKSISI PTERYGIUM + GRAFT KONJUTIVA PENGUKURAN ANTROPOMETRI - PERHITUNGAN KEBUTUHAN KALORI - PENETAPAN STATUS GIZI - PENYULUHAN GIZI
15.POLI GIZI
16.POLI JIWA - USG MATA - KERATOMETRI - PHACO EMULSIFIKASI - YAG LASER / LASER IRIDOKTOMI - GONIOSKOPY - OPERASI PTEREYGIUM - PEMERIKSAAN BUTA WARNA - INSISI HORDEUUWM/KALAZION - AFF HECTING/HECTING - BIOMETRI - CHECK UP MATA - SLIT LAMP + FOTO - GUNTING BULU MATA / CILIA - KOREKSI KACA MATA - TES ANNCL - MASSAGE MATA - INJEKSI SUBKONJUNGTIVA - REKFRAKSIMETER - TESFLOURESENDS/TESCIDEL - VISUS/REGFRAKSI GANTI PERBAN - FUNDOSCOFIE - EXTERPASI CORPUS ALIENUM - SPULLING BOLA MATA - EPILASI BULU MATA INJEKSI SKIN TEST SLIT LAMP TONOMETRI SHIOTS TONOMETRI APPLARASI GOLDMAN POSTURAL DRAINAGE UJI JALAN 6 MENIT FNAB (FINE NEEDLE ASPIRASI BIOPSI) TTNA (TRANS TORACAL NEEDLE ASPIRASI) USG THORAKS BRONCOSHCOPY + EKSTRAKSI BENDA ASING
14.POLI MATA PEMERIKSAAN DENGAN TINDAKAN 5 50,000Rp 50,000Rp 100,000Rp 6 50,000Rp 50,000Rp 100,000Rp 7 75,000Rp 75,000Rp 150,000Rp 8 42,500Rp 42,500Rp 85,000Rp 9 50,000Rp 50,000Rp 100,000Rp 10 62,500Rp 62,500Rp 125,000Rp 13 125,000Rp 125,000Rp 250,000Rp 14 125,000Rp 125,000Rp 250,000Rp 15 50,000Rp 50,000Rp 100,000Rp 16 50,000Rp 50,000Rp 100,000Rp 17 50,000Rp 50,000Rp 100,000Rp 18 125,000Rp 125,000Rp 250,000Rp 19 42,500Rp 42,500Rp 85,000Rp 20 42,500Rp 42,500Rp 85,000Rp 21 50,000Rp 50,000Rp 100,000Rp 22 42,500Rp 42,500Rp 85,000Rp 1 48,500Rp 48,500Rp 97,000Rp 2 102,500Rp 102,500Rp 205,000Rp 4 32,500Rp 32,500Rp 65,000Rp 5 277,500Rp 277,500Rp 555,000Rp 6 277,500Rp 277,500Rp 555,000Rp 7 277,500Rp 277,500Rp 555,000Rp 8 750,000Rp 750,000Rp 1,500,000Rp 9 750,000Rp 750,000Rp 1,500,000Rp 10 750,000Rp 750,000Rp 1,500,000Rp 11 750,000Rp 750,000Rp 1,500,000Rp 12 750,000Rp 750,000Rp 1,500,000Rp 13 750,000Rp 750,000Rp 1,500,000Rp 14 750,000Rp 750,000Rp 1,500,000Rp 15 750,000Rp 750,000Rp 1,500,000Rp 16 750,000Rp 750,000Rp 1,500,000Rp 17 750,000Rp 750,000Rp 1,500,000Rp 18 750,000Rp 750,000Rp 1,500,000Rp 19 750,000Rp 750,000Rp 1,500,000Rp 20 750,000Rp 750,000Rp 1,500,000Rp 21 1,600,000Rp 1,600,000Rp 3,200,000Rp 22 1,600,000Rp 1,600,000Rp 3,200,000Rp 23 1,600,000Rp 1,600,000Rp 3,200,000Rp 24 1,600,000Rp 1,600,000Rp 3,200,000Rp 25 1,600,000Rp 1,600,000Rp 3,200,000Rp 26 1,600,000Rp 1,600,000Rp 3,200,000Rp 27 1,600,000Rp 1,600,000Rp 3,200,000Rp 28 1,600,000Rp 1,600,000Rp 3,200,000Rp 29 1,600,000Rp 1,600,000Rp 3,200,000Rp 30 1,600,000Rp 1,600,000Rp 3,200,000Rp 31 1,600,000Rp 1,600,000Rp 3,200,000Rp 32 1,600,000Rp 1,600,000Rp 3,200,000Rp 33 1,600,000Rp 1,600,000Rp 3,200,000Rp 34 1,600,000Rp 1,600,000Rp 3,200,000Rp 35 1,600,000Rp 1,600,000Rp 3,200,000Rp 36 1,600,000Rp 1,600,000Rp 3,200,000Rp Excisi Hiperplasia denture Gingivektomi/Gingivoplasty Peregio Aspirasi Biopsi Extirpasi Biopsi Enukleasi Frenektomy per Rahang Exposure mahkota gigi terpendam pergig Alveolektomi perkuadran Vestibuloplasty per rahang Excisi torus peregio Sinus Lifting Penutupan fistula oroantral (Buccal/palatal flap) Sequesterectomy perkuadran Odontectomy kelas 2 pergigi Odontectomy kelas 3 pergigi Wiring per rahang Nekrotomi perkuadran Reposisi dislokasi mandibula Repair wound Gingiva Pengambilan fragmen gigi dalam sinus Penutupan fistula ekstraoral Ridge Augmentasi perkuadran Apex reseksi/apikoektomy pergigi Excisi Biopsi Insisi Biopsi Ekstraksi per gigi Ekstraksi gigi /fragmen fraktur gigi dengan flap per gigi Insisi/Eksisi Abses Odontektomy kelas I pergigi Opperkulektomy peregio Ganti verban kecil Bedah Mulut Ganti verban besar Bedah Mulut Aff Hacting Gigi Bedah Mulut Debridemen Bedah Mulut Kuretase Hipnoterapi Terapi Relaksasi Fiksasi Mekanik Fiksasi Kimiawi (injeksi/neuroleptisasi cepat) Pemeriksaan Tingkat Kecemasan/Depresi/Mania
17.POLI BEDAH MULUT MMPI Dewasa MMPI Anak & Remaja Krisis Intervensi (30 menit) Konseling Adiksi Terapi Pernikahan (Marital Therapy) Terapi Perilaku Terapi Kognitif Perilaku (CBT) Terapi Keluarga ≤ 60 menit Terapi Keluarga > 60 menit Play Therapy Terapi Kognitif 37 1,600,000Rp 1,600,000Rp 3,200,000Rp 38 1,600,000Rp 1,600,000Rp 3,200,000Rp 39 1,600,000Rp 1,600,000Rp 3,200,000Rp 40 1,600,000Rp 1,600,000Rp 3,200,000Rp 41 1,600,000Rp 1,600,000Rp 3,200,000Rp 42 1,600,000Rp 1,600,000Rp 3,200,000Rp 43 1,600,000Rp 1,600,000Rp 3,200,000Rp 44 1,600,000Rp 1,600,000Rp 3,200,000Rp 45 1,600,000Rp 1,600,000Rp 3,200,000Rp 46 1,600,000Rp 1,600,000Rp 3,200,000Rp 1 50,000Rp 50,000Rp 100,000Rp 2 37,500Rp 37,500Rp 75,000Rp 3 42,500Rp 42,500Rp 85,000Rp 4 60,000Rp 60,000Rp 120,000Rp 5 60,000Rp 60,000Rp 120,000Rp 6 50,000Rp 50,000Rp 100,000Rp 7 60,000Rp 60,000Rp 120,000Rp 8 50,000Rp 50,000Rp 100,000Rp 9 42,500Rp 42,500Rp 85,000Rp 10 65,000Rp 65,000Rp 130,000Rp JASA SARANA JASA PELAYANAN 1 390,000Rp 390,000Rp 780,000Rp 2 70,000Rp 70,000Rp 140,000Rp 3 82,500Rp 82,500Rp 165,000Rp 4 51,500Rp 51,500Rp 103,000Rp 5 85,000Rp 85,000Rp 170,000Rp A Tindakan Medik Spesialistik 1 450,000Rp 450,000Rp 900,000Rp 2 337,500Rp 337,500Rp 675,000Rp 3 187,500Rp 187,500Rp 375,000Rp 4 487,500Rp 487,500Rp 975,000Rp 5 247,500Rp 247,500Rp 495,000Rp 6 120,000Rp 120,000Rp 240,000Rp 7 150,000Rp 150,000Rp 300,000Rp 8 93,750Rp 93,750Rp 187,500Rp 9 157,500Rp 157,500Rp 315,000Rp 10 92,500Rp 92,500Rp 185,000Rp 11 78,750Rp 78,750Rp 157,500Rp 12 51,250Rp 51,250Rp 102,500Rp 13 202,500Rp 202,500Rp 405,000Rp 14 75,000Rp 75,000Rp 150,000Rp 15 225,000Rp 225,000Rp 450,000Rp B. 112,500Rp 112,500Rp 225,000Rp 17 600,000Rp 600,000Rp 1,200,000Rp Reposisi fraktur tertutup Pasang Skin Traksi Buka Skeletal Traksi Injeksi Hyaluronat Remove Gips Besar & Sedang Remove Gips Kecil Insisi Abses pd ekstremitas Evakuasi hematom sublingual Ekstirpasi kuku / roserplasty Pemasangan Gips Khusus (body jacket, hip spica) Pemasangan Gips Splint (slab) Remove wire Buka wire (dengan anastesi) Buka wire (tanpa anastesi) Pearawatan Luka Infeksi Subspesialistik Orthopedi Pemasangan Gips Besar (Body Spice, Long leg cast) Pemasangan Gips Sedang (Short leg cast, Long arm cast, short arm cast)) Pemasangan Gips Kecil (Back slab, hand) JENIS PELAYANAN Pemasangan Gips Aff Gips Aff K'wire Aspirasi perwatan jamur,virus,bakteri perawatan lesi keratosis,non keratosis perawan kelainan kelenjar liur perawan bekala biopsi jarum halus (FNAB) Oral Healt Care Pemeriksaan sitologi pemeriksaan hapudsan microba perawatan keradangan/mukositis Perawatan Lesi Ulserasi/laserasi Penjahitan perkuadran Replantasi gigi asli per gigi Repair wound kulit peregio Repair wound lidah Repair wound mukosa,otot peregio Marsupialisasi perkuadran Eksisi/ekstirpasi Sialolitiasis/Ranula Fraktur Edentulous/per rahang Fraktur dentoalveolar per rahang Splinting pekuadran TARIF JUMLAHNO
19.POLI ORTHOPEDI
18.POLI PENYAKIT MULUT 18 135,000Rp 135,000Rp 270,000Rp 19 53,000Rp 53,000Rp 106,000Rp 20 62,500Rp 62,500Rp 125,000Rp 21 90,000Rp 90,000Rp 180,000Rp 22 25,000Rp 25,000Rp 50,000Rp 23 35,000Rp 35,000Rp 70,000Rp 24 50,000Rp 50,000Rp 100,000Rp 25 25,000Rp 25,000Rp 50,000Rp 26 25,000Rp 25,000Rp 50,000Rp JASA SARANA JASA PELAYANAN 1. 82,500Rp 82,500Rp 165,000Rp 82,500Rp 82,500Rp 165,000Rp 40,000Rp 40,000Rp 80,000Rp 36,000Rp 36,000Rp 72,000Rp 2 112,500Rp 112,500Rp 225,000Rp 92,500Rp 92,500Rp 185,000Rp 75,000Rp 75,000Rp 150,000Rp 67,500Rp 67,500Rp 135,000Rp 3 152,500Rp 152,500Rp 305,000Rp 152,500Rp 152,500Rp 305,000Rp 100,000Rp 100,000Rp 200,000Rp 90,000Rp 90,000Rp 180,000Rp 5 75,000Rp 75,000Rp 150,000Rp 60,000Rp 60,000Rp 120,000Rp 50,000Rp 50,000Rp 100,000Rp 45,000Rp 45,000Rp 90,000Rp 6 110,000Rp 110,000Rp 220,000Rp 90,000Rp 90,000Rp 180,000Rp 75,000Rp 75,000Rp 150,000Rp 67,500Rp 67,500Rp 135,000Rp 7 150,000Rp 150,000Rp 300,000Rp 120,000Rp 120,000Rp 240,000Rp 100,000Rp 100,000Rp 200,000Rp 90,000Rp 90,000Rp 180,000Rp 9 38,500Rp 38,500Rp 77,000Rp 33,000Rp 33,000Rp 66,000Rp 27,500Rp 27,500Rp 55,000Rp 24,500Rp 24,500Rp 49,500Rp 10 76,500Rp 76,500Rp 153,000Rp 60,000Rp 60,000Rp 120,000Rp Vip Kelas 1 Vip Kelas 1 Kelas 2 Kelas 3 Psikotes Sederhana Vip Kelas 1 Kelas 2 Kelas 3 Psikologi Dasar Vip Kelas 1 Kelas 2 Kelas 3 Terapi Anak Besar Vip Kelas 1 Kelas 2 Kelas 3 Terapi Anak Sedang Vip Kelas 1 Kelas 2 Kelas 3 Terapi Anak Kecil Vip Kelas 1 Kelas 2 Kelas 3 Psikoterapi Kompleks VIP Kelas 1 kelas 2 Kelas 3 Psikoterapi Sedang Ganti Verban Berat Pasang Elastis Verban Aff Drain JENIS PELAYANAN Psikoterapi Dasar Rawat Luka Infeksi Kecil Rawat Luka Infeksi Sedang Rawat Luka Infeksi Berat Ganti Verban Ringan Ganti Verban Sedang Aspirasi hematom 2O. PSIKOLOGI NO TARIF JUMLAH 50,000Rp 50,000Rp 100,000Rp 45,000Rp 45,000Rp 90,000Rp 11 231,000Rp 231,000Rp 462,000Rp 231,000Rp 231,000Rp 462,000Rp 137,500Rp 137,500Rp 275,000Rp 123,500Rp 123,500Rp 247,500Rp 12 309,500Rp 309,500Rp 619,000Rp 240,000Rp 240,000Rp 480,000Rp 200,000Rp 200,000Rp 400,000Rp 180,000Rp 180,000Rp 360,000Rp 14 56,250Rp 56,250Rp 112,500Rp 45,000Rp 45,000Rp 90,000Rp 37,500Rp 37,500Rp 75,000Rp 33,750Rp 33,750Rp 67,500Rp 15 101,250Rp 101,250Rp 81,250Rp 81,250Rp 162,500Rp 67,500Rp 67,500Rp 135,000Rp 78,750Rp 78,750Rp 157,500Rp 16 131,250Rp 131,250Rp 262,500Rp 105,000Rp 105,000Rp 210,000Rp 87,500Rp 87,500Rp 175,000Rp 62,500Rp 62,500Rp 125,500Rp 18 76,500Rp 76,500Rp 153,000Rp 76,500Rp 76,500Rp 153,000Rp 37,500Rp 37,500Rp 75,000Rp 33,500Rp 33,500Rp 67,500Rp 19 101,250Rp 101,250Rp 202,500Rp 85,000Rp 85,000Rp 170,000Rp 67,500Rp 67,500Rp 135,000Rp 62,500Rp 62,500Rp 125,500Rp 20 131,000Rp 131,000Rp 262,500Rp 130,000Rp 130,000Rp 260,000Rp 87,500Rp 87,500Rp 175,000Rp 78,500Rp 78,500Rp 157,500Rp 1 150,000Rp 150,000Rp 300,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 100,000Rp 100,000Rp 200,000Rp 5 125,000Rp 125,000Rp 250,000Rp 6 150,000Rp 150,000Rp 300,000Rp 7 150,000Rp 150,000Rp 300,000Rp 8 150,000Rp 150,000Rp 300,000Rp 9 375,000Rp 375,000Rp 750,000Rp Inj. Profasi Instilasi kandung kemih / sistostatika Pasang kateter dengan mandrain Ganti Catheter Ganti Cytostomy Inj LHRH agonist Inj. Kenacort (peyronie) Inj. Papaverin / Impotence test Vip Kelas 1 Kelas 2 Kelas 3 CIC (Clien Intermitten Self Cateterisasi) Vip Kelas 1 Kelas 2 Kelas 3 Konseling Kompleks Vip Kelas 1 Kelas 2 Kelas 3 Konseling Sedang Vip Kelas 1 Kelas 2 Kelas 3 Konseling Dasar Vip Kelas 1 Kelas 2 Kelas 3 Psikoedukasi Kompleks Vip Kelas 1 Kelas 2 Kelas 3 Psikoedukasi Sedang Vip Kelas 1 Kelas 2 Kelas 3 Psikoedukasi Dasar Vip Kelas 1 Kelas 2 Kelas 3 Psikotes Kompleks Kelas 2 Kelas 3 Psikotes Sedang
21.POLI UROLOGI 10 50,000Rp 50,000Rp 100,000Rp 11 40,000Rp 40,000Rp 80,000Rp 12 75,000Rp 75,000Rp 150,000Rp 13 100,000Rp 100,000Rp 200,000Rp 14 100,000Rp 100,000Rp 200,000Rp 15 250,000Rp 250,000Rp 500,000Rp 16 750,000Rp 750,000Rp 1,500,000Rp 17 1,000,000Rp 1,000,000Rp 2,000,000Rp 18 150,000Rp 150,000Rp 300,000Rp 19 150,000Rp 150,000Rp 300,000Rp 20 62,500Rp 62,500Rp 125,000Rp 21 75,000Rp 75,000Rp 150,000Rp 22 150,000Rp 150,000Rp 300,000Rp 23 150,000Rp 150,000Rp 300,000Rp JASA PELAYANAN JASA SARANA TARIF VENDOR TARIF TOTAL KETERANGAN 24 125,000Rp 125,000Rp 250,000Rp 500,000Rp Pihak ke Tiga 25 1,250,000Rp 1,250,000Rp 2,500,000Rp 5,000,000Rp Pihak ke Tiga JASA LAYANAN JASA SARANA 1 Rp - Rp 10,000 5,000Rp 15,000 2 Rp 15,000 Rp 12,500 5,000Rp 32500 3 Rp 20,000 Rp 12,500 5,000Rp 37500 Telekonsultasi Klinis TELE EKG* TELE USG* Konsultasi poliklinik infertilitas pria Tindakan UGD dan perawatan khusus TINDAKAN Uroflowmetri PVR ESWL Urodinamik Uroflowmetri PVR USG Urologi Businasi/ dilatasi uretra poli Konsultasi poliklinik umum Pemasangan DK (Dower kateter) Rawat Luka Spoeling Kandung Kemih TRUS TRUS + Biopsi Pelepasan Cystostomy Pelepasan DK (Lepas Dower Kateter) JUMLAH PKRTL TARIF 22.TELEMEDICINE HOSPITAL BASED NO FKTP JENIS PELAYANAN A KONSUL ANTAR BAGIAN 1 DOKTER SPESIALIS KE DOKTER SPESIALIS Rp 25,000 Rp 22,500 50,000Rp 2 DOKTER SPESIALIS KE DOKTER SUB SPESIALIS Rp 37,500 Rp 33,750 75,000Rp B RUANG RAWAT INAP 1 KAMAR SUPER VIP Rp 600,000 Rp 600,000 1,200,000Rp 2 KAMAR VVIP Rp 500,000 Rp 500,000 1,000,000Rp 3 KAMAR VIP Rp 350,000 Rp 350,000 700,000Rp 4 KAMAR KELAS I Rp 250,000 Rp 250,000 500,000Rp 5 KAMAR KELAS II Rp 100,000 Rp 100,000 200,000Rp 6 KAMAR KELAS III Rp 50,000 Rp 50,000 100,000Rp 7 KAMAR INTERNSIF (HCU/ICU/PICU/NICU/ICVCU) PERHARI Rp 250,000 Rp 250,000 500,000Rp 8 ISOLASI KELAS I Rp 250,000 Rp 250,000 500,000Rp 9 ISOLASI KELAS II Rp 100,000 Rp 100,000 200,000Rp 10 ISOLASI KELAS III Rp 50,000 Rp 50,000 100,000Rp 11 KAMAR VIP PICU Rp 300,000 Rp 300,000 600,000Rp 12 KAMAR VIP ICU Rp 300,000 Rp 300,000 600,000Rp 13 RUANG KHUSUS INFEKSI TB MDR Rp 250,000 Rp 250,000 500,000Rp 14 INTERMEDIATE (RPK) Rp 250,000 Rp 250,000 500,000Rp C VISITE DOKTER SPESIALIS 1 Visite Dokter Umum Kelas 3 Rp 15,000 Rp 15,000 30,000Rp Kelas 2 Rp 20,000 Rp 20,000 40,000Rp Kelas 1 Rp 25,000 Rp 25,000 50,000Rp VIP Rp 30,000 Rp 30,000 60,000Rp VVIP Rp 35,000 Rp 35,000 70,000Rp 2 Visite dr.Spesialis Kelas 3 Rp 20,000 Rp 20,000 40,000Rp Kelas 2 Rp 25,000 Rp 25,000 50,000Rp Kelas 1 Rp 30,000 Rp 30,000 60,000Rp VIP Rp 50,000 Rp 50,000 100,000Rp VVIP Rp 55,000 Rp 55,000 110,000Rp PEMERIKSAAN DASAR
2.TARIF LAYANAN RAWAT INAP NO JENIS PELAYANAN TARIF JUMLAHJASA SARANA JASA PELAYANAN D. NO TINDAKAN UMUM RAWAT INAP JASA SARANA JASA PELAYANAN JUMLAH 1 AFF DRAIN Rp 22,500 Rp 22,500 45,000Rp 2 AFF HECTING PERJAHITAN Rp 2,500 Rp 2,500 5,000Rp 3 AFF INFUS Rp 5,000 Rp 5,000 10,000Rp 4 AFF KATETER Rp 10,000 Rp 10,000 20,000Rp TINDAKAN UMUM RAWAT INAP 5 AFF MONITOR Rp 5,000 Rp 5,000 10,000Rp 6 AFF O2 Rp 5,000 Rp 5,000 10,000Rp 7 AFF OGT/NGT Rp 17,500 Rp 17,500 35,000Rp 8 AMBULANSI/TRANSPORTER PASIEN Rp 10,000 Rp 10,000 20,000Rp 9 BLENDER TRAINING Rp 15,000 Rp 15,000 30,000Rp 10 CTG (KARDIOTOKOGRAFI) Rp 100,000 Rp 100,000 200,000Rp 11 DAPTON Rp 25,000 Rp 25,000 50,000Rp 12 DISCHANGE PLANNING Rp 20,000 Rp 20,000 40,000Rp 13 EDUKASI PASIEN Rp 20,000 Rp 20,000 40,000Rp 14 HUKNA RENDAH Rp 25,000 Rp 25,000 50,000Rp 15 HUKNA TINGGI Rp 25,000 Rp 25,000 50,000Rp 16 KATERERISASI PADA RETENSIO URINE Rp 17,500 Rp 17,500 35,000Rp 17 KONSUL DOKTER SPESIALIS Rp 10,000 Rp 10,000 20,000Rp 18 KONSUL DOKTER SPESIALIS DILUAR JAM KERJA (VISITE) Rp 37,500 Rp 37,500 75,000Rp 19 KUMBAH LAMBUNG Rp 45,000 Rp 45,000 90,000Rp 20 MENCUCI RAMBUT Rp 10,000 Rp 10,000 20,000Rp 21 MENERIMA PASIEN BARU ANAK/DEWASA Rp 25,000 Rp 25,000 50,000Rp 22 MENGGANTI CAIRAN INFUS Rp 5,000 Rp 5,000 10,000Rp 23 MERAPIKAN JENAZAH Rp 12,500 Rp 12,500 25,000Rp 24 MOBILISASI Rp 10,000 Rp 10,000 20,000Rp 25 NEBULASI Rp 15,000 Rp 15,000 30,000Rp 26 NEKROTOMI Rp 25,000 Rp 25,000 50,000Rp 27 OBSERVASI PASIEN > 8 JAM Rp 50,000 Rp 50,000 100,000Rp 28 OBSERVASI TANDA-TANDA VITAL PERHARI Rp 25,000 Rp 25,000 50,000Rp 29 ORAL HYGENE Rp 10,000 Rp 10,000 20,000Rp 30 PEMASANGAN INFUS DENGAN PENYULIT DEWASA Rp 30,000 Rp 30,000 60,000Rp 31 PEMASANGAN BED SIDE MONITOR Rp 75,000 Rp 75,000 150,000Rp 32 PEMASANGAN EKG Rp 75,000 Rp 75,000 150,000Rp 33 PEMASANGAN INFUS DENGAN PENYULIT ANAK Rp 40,000 Rp 40,000 80,000Rp 34 PEMASANGAN INFUS DENGAN PENYULIT BAYI Rp 40,000 Rp 40,000 80,000Rp 35 PEMASANGAN INFUS PUMP Rp 30,000 Rp 30,000 60,000Rp 36 PEMASANGAN INFUS TANPA PENYULIT ANAK Rp 30,000 Rp 30,000 60,000Rp 37 PEMASANGAN INFUS TANPA PENYULIT BAYI Rp 30,000 Rp 30,000 60,000Rp 38 PEMASANGAN KATETER DENGAN PENYULIT Rp 30,000 Rp 30,000 60,000Rp 39 PEMASANGAN KATETER TANPA PENYULIT DEWASA Rp 25,000 Rp 25,000 50,000Rp 40 PEMASANGAN MONITOR Rp 10,000 Rp 10,000 20,000Rp 41 PEMASANGAN NGT/OGT Rp 35,000 Rp 35,000 70,000Rp 42 PEMASANGAN SYRINGE PUMP Rp 30,000 Rp 30,000 60,000Rp 43 PEMASANGAN TRANSFUSI DARAH Rp 20,000 Rp 20,000 40,000Rp 44 PEMBERIAN NUTRISI MELALUI NGT/OGT Rp 15,000 Rp 15,000 30,000Rp 45 PEMBERIAN OBAT INJEKSI EMERGENCY Rp 25,000 Rp 25,000 50,000Rp 46 PEMBERIAN OBAT INJEKSI IM Rp 17,500 Rp 17,500 35,000Rp 47 PEMBERIAN OBAT INJEKSI IV Rp 20,000 Rp 20,000 40,000Rp 48 PEMBERIAN OBAT INJEKSI SUBCUTAN (INSULIN) Rp 30,000 Rp 30,000 60,000Rp 49 PEMBERIAN OBAT KULIT (TROPIKAL) PER HARI Rp 20,000 Rp 20,000 40,000Rp 50 PEMBERIAN OBAT MELALUI RECTAL/VAGINA Rp 22,500 Rp 22,500 45,000Rp 51 PEMBERIAN OBAT ORAL PERHARI Rp 15,000 Rp 15,000 30,000Rp 52 PEMBERIAN OBAT TETES MATA PERHARI Rp 7,500 Rp 7,500 15,000Rp 53 PEMBERIAN OKSIGEN DENGAN NASAL CANULA Rp 15,000 Rp 15,000 30,000Rp 54 PEMBERIAN OKSIGEN DENGAN NRM Rp 25,000 Rp 25,000 50,000Rp 55 PEMBERIAN OKSIGEN DENGAN SIMPLE MASK Rp 17,500 Rp 17,500 35,000Rp 56 PEMBERIAN SALEP MATA PADA BAYI Rp 15,000 Rp 15,000 30,000Rp 57 PEMERIKSAAN FISIK ANAK Rp 25,000 Rp 25,000 50,000Rp 58 PEMERIKSAAN FISIK BAYI Rp 25,000 Rp 25,000 50,000Rp 59 PEMERIKSAAN FISIK DEWASA Rp 22,500 Rp 22,500 45,000Rp 60 PENAGANAN PASIEN KEJANG Rp 25,000 Rp 25,000 50,000Rp 61 PENANGANAN PASIEN PERDARAHAN Rp 37,500 Rp 37,500 75,000Rp 62 PENGKAJIAN KEPERAWATAN LANJUTAN Rp 20,000 Rp 20,000 40,000Rp 63 PENIMBANGAN BERAT BADAN ANAK/ DEWASA Rp 7,500 Rp 7,500 15,000Rp 64 PENIMBANGAN BERAT BADAN BAYI Rp 10,000 Rp 10,000 20,000Rp 65 PERAWATAN BAYI LETAK BOKONG Rp 155,000 Rp 155,000 310,000Rp 66 PERAWATAN BAYI PARTUS FISIOLOGIS Rp 80,000 Rp 80,000 160,000Rp 67 PERAWATAN COLOCTOMI Rp 37,500 Rp 37,500 75,000Rp 68 PERAWATAN LUKA BAKAR 30 % - 60% Rp 75,000 Rp 75,000 150,000Rp 69 PERAWATAN LUKA BAKAR > 60% Rp 100,000 Rp 100,000 200,000Rp 70 PERAWATAN LUKA BAKAR ≤ 30 % Rp 37,500 Rp 37,500 75,000Rp 71 PERAWATAN LUKA PERINEUM Rp 20,000 Rp 20,000 40,000Rp 72 PERAWATAN TALI PUSAT Rp 10,000 Rp 10,000 20,000Rp 73 PERAWATAN WSD Rp 15,000 Rp 15,000 30,000Rp 74 PERSONAL HYGIENE PARSIAL CARE PERHARI Rp 12,500 Rp 12,500 25,000Rp 75 PERSONAL HYGIENE PASIEN BAYI Rp 17,500 Rp 17,500 35,000Rp 76 PERSONAL HYGIENE PASIEN TOTAL CARE Rp 25,000 Rp 25,000 50,000Rp 77 PUNKSI CAIRAN ASITES Rp 100,000 Rp 100,000 200,000Rp 78 PUNKSI CAIRAN PLEURA Rp 400,000 Rp 400,000 800,000Rp 79 PUNKSI CAIRAN SENDI Rp 100,000 Rp 100,000 200,000Rp 80 RAWAT LUKA BERAT Rp 25,000 Rp 25,000 50,000Rp 81 RAWAT LUKA DIABETIK INFEKSI Rp 75,000 Rp 75,000 150,000Rp 82 RAWAT LUKA DIABETIK NON INFEKSI Rp 37,500 Rp 37,500 75,000Rp 83 RAWAT LUKA GANGRENG BERAT Rp 25,000 Rp 25,000 50,000Rp 84 RAWAT LUKA GANGRENG KECIL Rp 10,000 Rp 10,000 20,000Rp 85 RAWAT LUKA GANGRENG SEDANG Rp 17,500 Rp 17,500 35,000Rp 86 RAWAT LUKA RINGAN Rp 10,000 Rp 10,000 20,000Rp 87 RAWAT LUKA SEDANG Rp 17,500 Rp 17,500 35,000Rp 88 RESUSITASI JANTUNG PARU (RJP) Rp 50,000 Rp 50,000 100,000Rp 89 SKIN TEST Rp 15,000 Rp 15,000 30,000Rp 90 SKL Rp 5,000 Rp 5,000 10,000Rp 91 SPOLING KATETER Rp 15,000 Rp 15,000 30,000Rp 92 SUCTION Rp 30,000 Rp 30,000 60,000Rp 93 TERIMA BAYI BARU LAHIR OLEH BIDAN Rp 50,000 Rp 50,000 100,000Rp 94 TRANSFUSI DARAH Rp 12,500 Rp 12,500 25,000Rp 95 USG ABDOMINAL Rp 50,000 Rp 50,000 100,000Rp 96 USG TRANSUGINAL Rp 65,000 Rp 65,000 130,000Rp 97 VENTILASI Rp 100,000 Rp 100,000 200,000Rp 98 VULVA HIEGINE Rp 15,000 Rp 15,000 30,000Rp 99 MENGGANTI TABUNG OKSIGEN Rp 12,500 Rp 12,500 25,000Rp 100 MENGGANTI OBAT VIA SYRING PUMP Rp 20,000 Rp 20,000 40,000Rp 101 PERAWATAN INFUS Rp 15,000 Rp 15,000 30,000Rp 102 PERAWATAN CATETER Rp 25,000 Rp 25,000 50,000Rp 103 PERAWATAN NGT/OGT Rp 25,000 Rp 25,000 50,000Rp 104 PERBAIKAN POSISI INFUS MACET Rp 15,000 Rp 15,000 30,000Rp 105 PELAYANAN DASAR (PENEGAKAN DIAGNOSA KEPERAWATAN KEPADA PASIEN BARU) Rp 25,000 Rp 25,000 50,000Rp 106 Observasi pasien > 8 jam Rp 100,000 Rp 100,000 200,000Rp 107 Terima Bayi Baru Lahir oleh bidan Rp 50,000 Rp 50,000 100,000Rp 108 Pemasangan O2 NRM Rp 25,000 Rp 25,000 50,000Rp 109 Penaganan pasien kejang Rp 25,000 Rp 25,000 50,000Rp 110 Penagan pasien perdarahan Rp 37,500 Rp 37,500 75,000Rp 1. 1 AFF 02 Rp 10,000 Rp 10,000 20,000Rp 2 AFF DRAIN Rp 22,500 Rp 22,500 45,000Rp 3 AFF GUEDEL Rp 25,000 Rp 25,000 50,000Rp 4 AFF INFUS Rp 12,500 Rp 12,500 25,000Rp 5 AFF KATETER Rp 15,000 Rp 15,000 30,000Rp 6 AFF NGT Rp 12,500 Rp 12,500 25,000Rp 7 AFF OGT Rp 7,500 Rp 7,500 15,000Rp 8 AMBULASI PASIEN Rp 10,000 Rp 10,000 20,000Rp 9 BALANCE CAIRAN PERHARI Rp 25,000 Rp 25,000 50,000Rp 10 EDUKASI PASIEN Rp 10,000 Rp 10,000 20,000Rp 11 GANTI OBAT VIA SYRING PUMP Rp 12,500 Rp 12,500 25,000Rp E. RAWAT INAP KHUSUS PERAWATAN DASAR INTENSIF 12 INFUS PUMP PERHARI Rp 37,500 Rp 37,500 75,000Rp 13 KOMPRES BIASA Rp 12,500 Rp 12,500 25,000Rp 14 KOMPRES LUKA Rp 13,000 Rp 13,000 26,000Rp 15 KONSUL DOKTER SPESIALIS Rp 10,000 Rp 10,000 20,000Rp 16 KONSUL DOKTER SPESIALIS DILUAR JAM KERJA (VISITE) Rp 35,000 Rp 35,000 70,000Rp 17 MENGGANTI CAIRAN INFUS Rp 5,000 Rp 5,000 10,000Rp 18 MENGGANTI OBAT VIA SYRING PUMP Rp 15,000 Rp 15,000 30,000Rp 19 MENGGANTI TABUNG OKSIGEN Rp 12,500 Rp 12,500 25,000Rp 20 MERAPIKAN JENAZAH Rp 12,500 Rp 12,500 25,000Rp 21 MONITOR PERHARI Rp 25,000 Rp 25,000 50,000Rp 22 NEBULIZER Rp 35,000 Rp 35,000 70,000Rp 23 NUTRISI PARENTRAL PERHARI Rp 20,000 Rp 20,000 40,000Rp 24 OBSERVASI KETAT (TTV) Rp 50,000 Rp 50,000 100,000Rp 25 OBSERVASI TANDA-TANDA VITAL PERJAM Rp 15,000 Rp 15,000 30,000Rp 26 ORAL HIEGIENE DENGAN PENYULIT Rp 50,000 Rp 50,000 100,000Rp 27 ORAL HIEGIENE TANPA PENYULIT Rp 25,000 Rp 25,000 50,000Rp 28 PELAYANAN DASAR (PENEGAKAN DIAGNOSA KEPERAWATAN KEPADA PASIEN BARU) Rp 7,500 Rp 7,500 15,000Rp 29 PEMAKAIAN MATRAS DECUBITUS PERHARI Rp 35,000 Rp 35,000 70,000Rp 30 PEMAKAIAN NEBULIZER PERKALI Rp 25,000 Rp 25,000 50,000Rp 31 PEMAKAIAN PULSE OXYMETRI PERHARI Rp 20,000 Rp 20,000 40,000Rp 32 PEMASANGAN BED SIDE MONITOR Rp 75,000 Rp 75,000 150,000Rp 33 PEMASANGAN EKG Rp 75,000 Rp 75,000 150,000Rp 34 PEMASANGAN GUEDEL/MOUTHGATE Rp 42,500 Rp 42,500 85,000Rp 35 PEMASANGAN INFUS DENGAN PENYULIT Rp 40,000 Rp 40,000 80,000Rp 36 PEMASANGAN INFUS TANPA PENYULIT Rp 52,500 Rp 52,500 50,000Rp 37 PEMASANGAN KATETER DENGAN PENYULIT Rp 30,000 Rp 30,000 60,000Rp 38 PEMASANGAN KATETER TANPA PENYULIT Rp 25,000 Rp 25,000 50,000Rp 39 PEMASANGAN OGT Rp 20,000 Rp 20,000 40,000Rp 40 PEMASANGAN OKSIGEN Rp 10,000 Rp 10,000 20,000Rp 41 PEMBERIAN INJEKSI (IM) Rp 20,000 Rp 20,000 40,000Rp 42 PEMBERIAN INJEKSI (IV) Rp 20,000 Rp 20,000 40,000Rp 43 PEMBERIAN MAKAN /OBAT VIA NGT (SONDE) PERKALI Rp 12,500 Rp 12,500 25,000Rp 44 PEMBERIAN OBAT INJEKSI EMERGENCY Rp 25,000 Rp 25,000 50,000Rp 45 PEMBERIAN OBAT INSULIN/SC Rp 12,500 Rp 12,500 60,000Rp 46 PEMBERIAN OBAT MELALUI RECTAL/VAGINA Rp 22,500 Rp 22,500 45,000Rp 47 PEMBERIAN OBAT ORAL PERHARI Rp 15,000 Rp 15,000 30,000Rp 48 PEMBERIAN OKSIGEN DENGAN NASAL CANULA Rp 15,000 Rp 15,000 30,000Rp 49 PEMBERIAN OKSIGEN DENGAN SIMPLE MASK Rp 17,500 Rp 17,500 35,000Rp 50 PEMBERIAN OKSIGEN REBREATHING Rp 25,000 Rp 25,000 50,000Rp 51 PEMBERIAN SALEP MATA Rp 16,950 Rp 16,950 33,900Rp 52 PEMERIKSAAN FISIK ANAK Rp 25,000 Rp 25,000 50,000Rp 53 PEMERIKSAAN FISIK DEWASA Rp 22,500 Rp 22,500 45,000Rp 54 PENGGUNAAN INFANT WARMER PERHARI Rp 125,000 Rp 125,000 250,000Rp 55 PENGURUSAN MAYAT Rp 50,000 Rp 50,000 100,000Rp 56 PERAWATAN CATETER Rp 15,000 Rp 15,000 30,000Rp 57 PERAWATAN INFUS Rp 25,000 Rp 25,000 50,000Rp 58 PERAWATAN LUKA DEKUBITUS Rp 37,500 Rp 37,500 75,000Rp 59 PERAWATAN NGT/OGT Rp 25,000 Rp 25,000 50,000Rp 60 PERBAIKAN POSISI INFUS MACET Rp 5,000 Rp 5,000 10,000Rp 61 PERSONAL HIEGENE TOTAL CARE PERHARI Rp 25,000 Rp 25,000 50,000Rp 62 PERSONAL HYGIENE PARSIAL CARE PERHARI Rp 12,500 Rp 12,500 25,000Rp 63 RESUSITASI CAIRAN Rp 25,000 Rp 25,000 50,000Rp 64 SKIN TEST BAYI/ANAK Rp 20,000 Rp 20,000 50,000Rp 65 SKIN TEST DEWASA Rp 25,000 Rp 25,000 50,000Rp 66 SPOLING KATETER Rp 15,000 Rp 15,000 30,000Rp 67 SUCTION/MENGHISAP LENDIR Rp 30,000 Rp 30,000 60,000Rp 68 SYRINGE PUMP PERHARI Rp 37,500 Rp 37,500 75,000Rp 69 TERPAKAI OKSIGEN (JAM) Rp 7,500 Rp 7,500 15,000Rp 70 TERPAKAI PKSIGEN JAM BERIKUTNYA / JAM Rp 3,750 Rp 3,750 7,500Rp 71 TINDAKAN INVASIF Rp - Rp -

a.PASANG INFUS Rp 25,000 Rp 25,000 50,000Rp
b.PASANG CHATETER URINE Rp 25,000 Rp 25,000 50,000Rp
c.TRANSFUSI DARAH Rp 25,000 Rp 25,000 50,000Rp
d.PEMASANGAN NGT Rp 37,500 Rp 37,500 75,000Rp e.PASANG SYRINGE PUMP Rp 75,000 Rp 75,000 150,000Rp f.PASANG INFUS PUMP Rp 75,000 Rp 75,000 150,000Rp 72 VULVA HIEGENE Rp 10,000 Rp 10,000 20,000Rp 2. 1 IMUNISASI Rp 10,000 Rp 10,000 20,000Rp 2 MEMANDIKAN BAYI/HARI Rp 5,000 Rp 5,000 10,000Rp 3 PEMAKAIAN CPAP/HARI Rp 150,000 Rp 150,000 300,000Rp 5 PEMAKAIAN INKUBATOR PERHARI Rp 60,000 Rp 60,000 120,000Rp 6 PEMBERIAN MAKAN VIA CUP FEEDING Rp 12,500 Rp 12,500 25,000Rp 7 PENANGANAN PASIEN KEJANG Rp 25,000 Rp 25,000 100,000Rp 8 PENGUKURAN ANTROPOMETRI Rp 10,000 Rp 10,000 20,000Rp PERAWATAN NICU 9 PERAWATAN COLOCTOMI Rp 37,500 Rp 37,500 75,000Rp 10 PERAWATAN METODE KANGURU PERHARI Rp 5,000 Rp 5,000 10,000Rp 11 PERAWATAN TALI PUSAT Rp 12,250 Rp 12,250 24,500Rp 12 PERAWATAN WSD Rp 15,000 Rp 15,000 30,000Rp 13 PHOTOTERAPI ≤ 48 JAM Rp 50,000 Rp 50,000 100,000Rp 14 PHOTOTERAPI ≥ 48 JAM. DOUBLE FOTOTHERAPI Rp 75,000 Rp 75,000 150,000Rp 15 RESUSUTASI SEDERHANA (VTP) Rp 75,000 Rp 75,000 150,000Rp 16 TERIMA DAN RESUSITASI BBL DENGAN PENYULIT (SC,SUNSANG, ASFIKSIA) Rp 175,000 Rp 175,000 350,000Rp 17 PASANG INFUS TANPA PENYULIT 25,000Rp 25,000Rp 50,000Rp 18 PASANG INFUS DENGAN PENYULIT 30,000Rp 30,000Rp 60,000Rp 19 PASANG KATETER TANPA PENYULIT 25,000Rp 25,000Rp 50,000Rp 20 PASANG KATETER DENGAN PENYULIT 30,000Rp 30,000Rp 60,000Rp 21 Pengukuran antropometri 30,000Rp 30,000Rp 600,000Rp 22 penilaian/interpretasi antropometri 40,000Rp 40,000Rp 80,000Rp 23 pelayanan gizi 100,000Rp 100,000Rp 200,000Rp 24 pemeriksaan fisik anak dan neonatus 100,000Rp 100,000Rp 200,000Rp 25 pemeriksaan neorologi anak 50,000Rp 50,000Rp 100,000Rp 26 pemasangan ogt/ngt 30,000Rp 30,000Rp 60,000Rp 27 Aff ogt/ngt 20,000Rp 20,000Rp 40,000Rp 28 test mantoux/tuberkulin test 50,000Rp 50,000Rp 100,000Rp 29 perawatan luka 40,000Rp 40,000Rp 80,000Rp 30 perawatan tali pusat 50,000Rp 50,000Rp 100,000Rp 31 imunisasi 100,000Rp 100,000Rp 200,000Rp 32 konsultasi tumbuh kembang anak 100,000Rp 100,000Rp 200,000Rp 33 konsultasi keterlambatan perkembangan 100,000Rp 100,000Rp 200,000Rp 34 mengukur tekanan darah 20,000Rp 20,000Rp 40,000Rp 35 nebulizer 75,000Rp 75,000Rp 150,000Rp 36 spirometri 40,000Rp 40,000Rp 80,000Rp 37 injeksi iv/im/sc/ic 32,500Rp 32,500Rp 65,000Rp 38 ekg 50,000Rp 50,000Rp 100,000Rp 39 frentomy 100,000Rp 100,000Rp 200,000Rp 40 konseling menyusui 100,000Rp 100,000Rp 200,000Rp 41 Pasang umbilical kateter 125,000Rp 125,000Rp 250,000Rp 42 Ventilator 450,000Rp 450,000Rp 900,000Rp 43 Intubasi ETT 175,000Rp 175,000Rp 350,000Rp 44 Extubasi ETT 75,000Rp 75,000Rp 150,000Rp 45 Pemasangan CPAP Mesin 150,000Rp 150,000Rp 300,000Rp 46 Pemasangan Infus Penyulit 75,000Rp 75,000Rp 150,000Rp 47 Pemasangan CPAP Manual 75,000Rp 75,000Rp 150,000Rp 48 Penyulit AFF Umbical Cateter 75,000Rp 75,000Rp 150,000Rp 49 Terima SC 150,000Rp 150,000Rp 300,000Rp
1. 3.PERAWATAN PICU JASA SARANA JASA PELAYANAN JUMLAH 1 BAGGIN FACEWASH Rp 75,000 Rp 75,000 150,000Rp 2 PENANGANAN BAYI KEJANG Rp 50,000 Rp 50,000 100,000Rp 3 PEMERIKSAAN FISIK BAYI 30,000Rp 30,000Rp 60,000Rp 4 PEMERIKSAAN FISIK ANAK 25,000Rp 25,000Rp 50,000Rp 5 PEMERIKSAAN FISIK DEWASA 25,000Rp 25,000Rp 50,000Rp 6 PENIMBANGAN BERAT BADAN BAYI 22,500Rp 22,500Rp 45,000Rp 7 PENIMBANGAN BERAT BADAN BAYI/DEWASA 10,000Rp 10,000Rp 20,000Rp 8 PEMERIKSAAN OKSIGEN DENGAN SIMPLE 7,500Rp 7,500Rp 15,000Rp 9 PEMERIKSAAN OKSIGEN DENGAN NASAL CANULA 17,500Rp 17,500Rp 35,000Rp 10 Pasang Infus Anak 30,000Rp 30,000Rp 60,000Rp 11 Pasang infus dengan penyulit 40,000Rp 40,000Rp 80,000Rp 12 Pasang kateter tanpa penyulit 25,000Rp 25,000Rp 50,000Rp 13 Pasang kateter dengan penyulit 30,000Rp 30,000Rp 60,000Rp 14 Bladder training 10,000Rp 10,000Rp 20,000Rp 15 Aff kateter 10,000Rp 10,000Rp 20,000Rp 16 Aff infus 5,000Rp 5,000Rp 10,000Rp 17 Hukna 25,000Rp 25,000Rp 50,000Rp 18 Pemasangan EKG 75,000Rp 75,000Rp 150,000Rp 19 Pemasangan bed side monitor 75,000Rp 75,000Rp 150,000Rp 20 Pemberian injeksi SC perkali 12,500Rp 12,500Rp 25,000Rp 21 Pemberian Injeksi IV perkali 20,000Rp 20,000Rp 40,000Rp 22 Pemberian Injeksi IM perkali 17,500Rp 17,500Rp 35,000Rp 23 Pemberian obat oral perhari 15,000Rp 15,000Rp 30,000Rp 24 Pemberian obat melalui rektal 22,500Rp 22,500Rp 45,000Rp 25 Pemberian obat salep kulit perhari 10,000Rp 10,000Rp 20,000Rp 26 Pemberian obat injeksi emergency 25,000Rp 25,000Rp 50,000Rp 27 Observasi tanda-tanda vital perhari 25,000Rp 25,000Rp 50,000Rp 28 mobilisasi 10,000Rp 10,000Rp 20,000Rp 29 Perawatan luka - luka ringan 15,000Rp 15,000Rp 30,000Rp - luka sedang 25,000Rp 25,000Rp 50,000Rp - luka berat 35,000Rp 35,000Rp 70,000Rp 30 Ambulansi 7,500Rp 7,500Rp 15,000Rp 31 Pemasangan NGT 37,500Rp 37,500Rp 75,000Rp 32 Aff NGT / OGT 17,500Rp 17,500Rp 35,000Rp 33 Pemasangan Infus Pump 37,500Rp 37,500Rp 75,000Rp 34 Pemasangan Syringe pump per hari 37,500Rp 37,500Rp 75,000Rp 35 Pemeriksaan Fisik Bayi 25,000Rp 25,000Rp 50,000Rp 36 Pemeriksaan Fisik Anak 25,000Rp 25,000Rp 50,000Rp 37 Penimbangan berat badan bayi 10,000Rp 10,000Rp 20,000Rp 38 Penimbangan berat badan anak 7,500Rp 7,500Rp 15,000Rp 39 Pemberian oksigen dengan simple mask 17,500Rp 17,500Rp 35,000Rp 40 Pemberian oksigen dengan nasal canula 15,000Rp 15,000Rp 30,000Rp 41 Pemberian oksigen dengan rebreatyhing 25,000Rp 25,000Rp 50,000Rp 42 Personal hygiene parsial care perhari 12,500Rp 12,500Rp 25,000Rp 43 Personal hygiene total care perhari 25,000Rp 25,000Rp 50,000Rp 44 Pemberian obat oral 7,500Rp 7,500Rp 15,000Rp 45 Nebulasi perhari 35,000Rp 35,000Rp 70,000Rp 46 suction 30,000Rp 30,000Rp 60,000Rp 47 transfusi darah 37,500Rp 37,500Rp 75,000Rp 48 Ganti cairan 2,500Rp 2,500Rp 5,000Rp 49 Perawatan luka dekubitus 37,500Rp 37,500Rp 75,000Rp 50 Pemberian nutrisi via NGT/OGT 15,000Rp 15,000Rp 30,000Rp 51 Resusitasi Jantung Paru (RJP) 75,000Rp 75,000Rp 150,000Rp 52 Ventilator 900,000Rp 900,000Rp 1,800,000Rp 53 Memandikan Pasien Bayi 17,500Rp 17,500Rp 35,000Rp 54 Memandikan Pasien Anak 20,000Rp 20,000Rp 40,000Rp 55 Konsul dokter spesialis 25,000Rp 25,000Rp 50,000Rp 56 Visite dokter spesialis 30,000Rp 30,000Rp 60,000Rp 57 Konsul dokter spesialis diluar jam kerja 35,000Rp 35,000Rp 70,000Rp 58 Kompres luka 13,000Rp 13,000Rp 26,000Rp 59 Kompres biasa 12,500Rp 12,500Rp 25,000Rp 60 Pemakaian CPAP perhari 150,000Rp 150,000Rp 300,000Rp 61 Pemakaian inkubator perhari 60,000Rp 60,000Rp 120,000Rp 62 Pemakaian pulse oxymetri perhari 20,000Rp 20,000Rp 40,000Rp 63 Pasang ETT 75,000Rp 75,000Rp 150,000Rp 64 Pemberian obat oral 10,000Rp 10,000Rp 20,000Rp 65 Intubasi 125,000Rp 125,000Rp 250,000Rp 66 Ekstubasi 75,000Rp 75,000Rp 150,000Rp 67 Observasi TTV perjam 15,000Rp 15,000Rp 30,000Rp 68 Paket Adrenalin 50,000Rp 50,000Rp 100,000Rp 69 Paket SA 50,000Rp 50,000Rp 100,000Rp 70 Merapikan jenazah 12,500Rp 12,500Rp 25,000Rp
2. 4.TINDAKAN INTENSIF PERAWATAN ICU JASA SARANA JASA PELAYANAN JUMLAH 1 PERAWATAN LUKA Rp - Rp - * LUKA RINGAN Rp 15,000 Rp 15,000 30,000Rp * LUKA SEDANG Rp 25,000 Rp 25,000 50,000Rp * LUKA BERAT Rp 35,000 Rp 35,000 70,000Rp 2 VENTILATOR Rp 900,000 Rp 900,000 1,800,000Rp 3 INTUBASI Rp 125,000 Rp 125,000 250,000Rp 4 EKSTUBASI Rp 75,000 Rp 75,000 150,000Rp 5 EPIDURAL ANALGETIK PERHARI Rp 150,000 Rp 150,000 300,000Rp 6 PEMASANGAN TEKANAN VENA SENTRAL (CVP) MONOLUMEN Rp 750,000 Rp 750,000 1,500,000Rp 7 RESUSITASI JANTUNG PARU (RJP) Rp 75,000 Rp 75,000 150,000Rp 8 ELECTRO CARDIOGRAPH (ECG) Rp 37,500 Rp 37,500 75,000Rp 9 RESUSITASI DC SHOCK Rp 100,000 Rp 100,000 200,000Rp 10 PASANG TAMPON Rp 15,000 Rp 15,000 30,000Rp 11 PEMASANGAN TEKANAN VENA SENTRAL (CVP) Rp 750,000 Rp 750,000 1,500,000Rp 12 RESUSITASI JANTUNG PARU OTAK (RJPO) Rp 80,000 Rp 80,000 160,000Rp 13 BAGGING FACEWASH Rp 75,000 Rp 75,000 150,000Rp 14 PAKET SA Rp 50,000 Rp 50,000 100,000Rp 15 PAKET ADRENALIN Rp 50,000 Rp 50,000 100,000Rp 16 PAKET PENANGANAN EPITAKSIS Rp 25,000 Rp 25,000 50,000Rp 17 AFF CVP Rp 75,000 Rp 75,000 150,000Rp 18 AFF EPIDURAL Rp 35,000 Rp 35,000 70,000Rp 19 PASANG TRAKSI BHP Rp 30,000 Rp 30,000 60,000Rp 20 DOUBLE LUMEN CVP HD Rp 1,000,000 Rp 1,000,000 2,000,000Rp 21 AFF CVP Rp 75,000 Rp 75,000 150,000Rp 22 AFF TRAKSI BPH Rp 30,000 Rp 30,000 60,000Rp 23 KLISMA Rp 30,000 Rp 30,000 60,000Rp 24 BLAIDER TARINING PERHARI Rp 10,000 Rp 10,000 20,000Rp 25 MOBILISASI PASIEN Rp 5,000 Rp 5,000 10,000Rp 26 MOUTH GATE Rp 50,000 Rp 50,000 100,000Rp 27 TRILUMEN CAP Rp 1,250,000 Rp 1,250,000 2,500,000Rp 28 MAAG COLING Rp 35,000 Rp 35,000 70,000Rp 29 DOUBLE LUMEN CVP HD Rp 1,000,000 Rp 1,000,000 2,000,000Rp 30 DOUBLE LUMEN CVP HD Rp 1,000,000 Rp 1,000,000 2,000,000Rp 31 ABDOMNAL TRUST Rp 35,000 Rp 35,000 70,000Rp 32 TINDAKAN PEMBEBASAN JALAN NAFAS Rp 35,000 Rp 35,000 70,000Rp 33 PASANG ETT Rp 75,000 Rp 75,000 150,000Rp 34 TAMPON TELINGA Rp 17,500 Rp 17,500 35,000Rp 35 TAMPON HIDUNG Rp 17,500 Rp 17,500 35,000Rp 36 TAMPON GIGI/MULUT Rp 25,000 Rp 25,000 50,000Rp 37 SPOOLING MATA Rp 42,500 Rp 42,500 85,000Rp 38 SPOOLING TELINGA Rp 20,000 Rp 20,000 40,000Rp 39 EKSPLORASI BENDA ASING TELINGA Rp 25,000 Rp 25,000 50,000Rp 40 EKSPLORASI BENDA ASING HIDUNG Rp 25,000 Rp 25,000 50,000Rp 41 EKSPLORASI BENDA ASING KULIT/AHA Rp 40,000 Rp 40,000 80,000Rp 42 IRIGASI TELINGA Rp 35,000 Rp 35,000 70,000Rp 43 BIOPSI Rp 75,000 Rp 75,000 150,000Rp 44 PASANG BULI-BULI PANAS/DINGIN Rp 7,500 Rp 7,500 15,000Rp 45 SPIROMETRI Rp 135,000 Rp 135,000 270,000Rp 46 PEMERIKSAAN TANPA TINDAKAN
a.Dokter Umum/Dokter Gigi Rp 20,000 Rp 20,000 40,000Rp
b.Dokter Spesialis Rp 25,000 Rp 25,000 50,000Rp
c.Dokter Sub Spesialis Rp 35,000 Rp 35,000 70,000Rp 47 - Observasi
a.Dokter Umum/Dokter Gigi Rp 20,000 Rp 20,000 40,000Rp
b.Dokter Spesialis Rp 25,000 Rp 25,000 50,000Rp
c.Dokter Sub Spesialis Rp 35,000 Rp 35,000 70,000Rp 1 Perawatan kamar ICVCU/Hari Rp 300,000 Rp 300,000 600,000Rp 2 Konsul dokter spesialis diluar jam kerja (visite) Rp 35,000 Rp 35,000 70,000Rp
1. 5.PERAWATAN ICVCU 3 Pemberian obat injeksi perhari Rp 20,000 Rp 20,000 40,000Rp 4 Pasang infus Rp 25,000 Rp 25,000 50,000Rp 5 Pasang chateter urine Rp 25,000 Rp 25,000 50,000Rp 6 Transfusi darah Rp 25,000 Rp 25,000 50,000Rp 7 Pemasangan NGT Rp 37,500 Rp 37,500 75,000Rp 8 Observasi tanda- tanda vital/jam Rp 15,000 Rp 15,000 30,000Rp 9 Resusitasi jantung paru (RJP) Rp 75,000 Rp 75,000 150,000Rp 10 Electrocardiography (ECG) Rp 37,500 Rp 37,500 75,000Rp 11 Nebulizer Rp 35,000 Rp 35,000 70,000Rp 12 Suction / Penghisapan lendir Rp 35,000 Rp 35,000 70,000Rp 13 Syringe pump / hari Rp 37,500 Rp 37,500 75,000Rp 14 infus pimp / Hari Rp 37,500 Rp 37,500 Rp 75,000 15 Resusitasi DC Shock Rp 100,000 Rp 100,000 Rp 200,000 16 Perbaikan posisi infus macet Rp 5,000 Rp 5,000 Rp 10,000 17 Balance cairan / Hari Rp 15,000 Rp 15,000 Rp 30,000 18 Resusitasi Jantung Paru otak (RJPO) Rp 80,000 Rp 80,000 Rp 160,000 19 Bagging Facemask Rp 75,000 Rp 75,000 Rp 150,000 20 Resusitasi cairan Rp 10,000 Rp 10,000 Rp 20,000 21 Observasi ketat (TTV) Rp 50,000 Rp 50,000 Rp 100,000 22 Paket SA Rp 50,000 Rp 50,000 Rp 100,000 23 Paket Adrenalin Rp 50,000 Rp 50,000 Rp 100,000 24 Paket penanganan epistaksis Rp 25,000 Rp 25,000 Rp 50,000 25 Pelayanan dasar (penegakan diagnosa keperawatan) Rp 10,000 Rp 10,000 Rp 20,000 26 Monitor/hari Rp 25,000 Rp 25,000 Rp 50,000 27 Klisma Rp 30,000 Rp 30,000 Rp 60,000 28 Mobilisasi pasien Rp 5,000 Rp 5,000 Rp 10,000 29 pemberian makan/obat melalui NGT per kali pemberian Rp 15,000 Rp 15,000 Rp 30,000 30 ganti obat via syringe pump Rp 12,500 Rp 12,500 Rp 25,000 31 Pemasangan Guedel Rp 25,000 Rp 25,000 Rp 50,000 32 Maag cooling Rp 35,000 Rp 35,000 Rp 70,000 33 Terpakai oksigen/ jam Rp 7,500 Rp 7,500 Rp 15,000 34 oksigen jam berikutnya/ jam Rp 3,750 Rp 3,750 Rp 7,500 35 pasang syringe pump Rp 75,000 Rp 75,000 Rp 150,000 36 pasang infus pump Rp 75,000 Rp 75,000 Rp 150,000 37 pasang transfusi Rp 37,500 Rp 37,500 Rp 75,000 38 kompres Rp 7,500 Rp 7,500 Rp 15,000 39 pemasangan pulse oxymetri/hari Rp 40,000 Rp 40,000 Rp 80,000 40 aff infus Rp 7,500 Rp 7,500 Rp 15,000 41 nutrisi parenteral/ hari Rp 20,000 Rp 20,000 Rp 40,000 42 Penyuluhan kesehatan/edukasi Rp 10,000 Rp 10,000 Rp 20,000 43 Perawatan jenazah Rp 25,000 Rp 25,000 Rp 50,000 44 pemberian obat melalui rectal Rp 30,000 Rp 30,000 Rp 60,000 45 pemberian bat-obatan injeksi emergency Rp 30,000 Rp 30,000 Rp 60,000 46 pemeriksaan fisik Rp 25,000 Rp 25,000 Rp 50,000 47 pemasangan terapi oksigen nasal kanul/mask Rp 20,000 Rp 20,000 Rp 40,000 48 Personal Hygiene Rp 30,000 Rp 30,000 Rp 60,000 49 Ganti Cairan Rp 2,500 Rp 2,500 5,000Rp 50 Pemberian Obat oral Rp 7,500 Rp 7,500 15,000Rp 51 pungksi cairan pleura Rp 400,000 Rp 400,000 800,000Rp 52 oral hygiene Rp 10,000 Rp 10,000 20,000Rp 53 Pemasangan bedside monitor Rp 75,000 Rp 75,000 150,000Rp 54 skin test Rp 20,000 Rp 20,000 Rp 40,000 55 pemeriksaan tanpa tindakan dokter spesialis Rp 25,000 Rp 25,000 Rp 50,000 56 observasi dokter spesialis Rp 25,000 Rp 25,000 Rp 50,000 57 MENGGANTI TABUNG OKSIGEN 12,500Rp 12,500Rp 25,000Rp 58 MENGGANTI OBAT VIA SYRING PUMP 20,000Rp 20,000Rp 40,000Rp 59 PERAWATAN INFUS 15,000Rp 15,000Rp 30,000Rp 60 PERAWATAN CATETER 25,000Rp 25,000Rp 50,000Rp 61 PERAWATAN NGT/OGT 25,000Rp 25,000Rp 50,000Rp 62 PERBAIKAN POSISI INFUS MACET 15,000Rp 15,000Rp 30,000Rp 63 PELAYANAN DASAR (PENEGAKAN DIAGNOSA KEPERAWATAN KEPADA PASIEN BARU) 25,000Rp 25,000Rp 50,000Rp 64 Observasi pasien > 8 jam 100,000Rp 100,000Rp 200,000Rp 65 Terima Bayi Baru Lahir oleh bidan 50,000Rp 50,000Rp 100,000Rp 66 Pemasangan O2 NRM 25,000Rp 25,000Rp 50,000Rp 67 Penaganan pasien kejang 25,000Rp 25,000Rp 50,000Rp 68 Penagan pasien perdarahan 37,500Rp 37,500Rp 75,000Rp 69 PENGKAJIAN KEPERAWATAN LANJUTAN 20,000Rp 20,000Rp 40,000Rp 70 PEMASANGAN INFUS DENGAN PENYULIT BAYI 40,000Rp 40,000Rp 80,000Rp 71 PEMASANGAN INFUS TANPA PENYULIT ANAK 30,000Rp 30,000Rp 60,000Rp 72 PEMASANGAN INFUS TANPA PENYULIT BAYI 30,000Rp 30,000Rp 60,000Rp 73 DISCHANGE PLANNING 20,000Rp 20,000Rp 40,000Rp 74 EDUKASI PASIEN 20,000Rp 20,000Rp 40,000Rp 75 KONSUL DOKTER SPESIALIS DILUAR JAM KERJA (VISITE) 37,500Rp 37,500Rp 75,000Rp 76 MENERIMA PASIEN BARU ANAK/DEWASA 25,000Rp 25,000Rp 50,000Rp 77 AFF MONITOR 5,000Rp 5,000Rp 10,000Rp 78 SKIN TEST DEWASA 25,000Rp 25,000Rp 50,000Rp 79 MENGGGANTI TABUNG OKSIGEN 12,500Rp 12,500Rp 25,000Rp NO JENIS PELAYANAN JASA SARANA JASA PELAYANAN JUMLAH 1 PEMASANGAN INFUS BIASA Rp 52,500 Rp 52,500 105,000Rp 2 PEMASANGAN INFUS DEWASA DENGAN PENYULIT Rp 40,000 Rp 40,000 Rp 80,000 3 INTURBASI Rp 125,000 Rp 125,000 250,000Rp D. GAWAT DARURAT 4 PEMERIKSAAN TTV Rp 15,000 Rp 15,000 30,000Rp 5 PEMASANGAN INFUS ANAK/BAYI TANPA PENYULIT Rp 30,000 Rp 30,000 60,000Rp 5 PEMASANGAN INFUS ANAK/BAYI DENGAN PENYULIT Rp 30,000 Rp 30,000 60,000Rp 6 PEMASANGAN INFUS DEWASA TANPA PENYULIT Rp 30,000 Rp 30,000 60,000Rp 7 AFF INFUS Rp 12,500 Rp 12,500 25,000Rp 8 PEMASANGAN KATETER Rp 67,500 Rp 67,500 135,000Rp 9 AFF KATETER Rp 15,000 Rp 15,000 30,000Rp 10 EKG Rp 30,000 Rp 30,000 60,000Rp 11 RAWAT LUKA RINGAN Rp 12,500 Rp 12,500 25,000Rp 12 RAWAT LUKA SEDANG Rp 17,500 Rp 17,500 35,000Rp 13 RAWAT LUKA BERAT Rp 25,000 Rp 25,000 50,000Rp 14 RAWAT LUKA BERAT + PENYULIT Rp 37,500 Rp 37,500 75,000Rp 15 HECTING (1-5 JAHITAN) Rp 25,000 Rp 25,000 50,000Rp 16 HECTING (6-10 JAHITAN) Rp 37,500 Rp 37,500 75,000Rp 17 HECTING (11-20 JAHITAN) Rp 50,000 Rp 50,000 100,000Rp 18 HECTING (> 20 JAHITAN) Rp 75,000 Rp 75,000 150,000Rp 19 PENANGANAN PASIEN PERDARAHAN Rp 37,500 Rp 37,500 75,000Rp 20 PENANGANAN PASIEN LUKA BAKAR RINGAN Rp 25,000 Rp 25,000 50,000Rp 21 PENANGANAN PASIEN LUKA BAKAR SEDANG Rp 37,500 Rp 37,500 75,000Rp 22 PENANGANAN PASIEN LUKA BAKAR BERAT Rp 100,000 Rp 100,000 200,000Rp 23 CROSS INSISI Rp 25,000 Rp 25,000 50,000Rp 24 EKSTRAKSI KUKU Rp 20,000 Rp 20,000 40,000Rp 25 NEBULIZER Rp 61,000 Rp 61,000 122,000Rp 26 RJP Rp 50,000 Rp 50,000 100,000Rp 27 SUCTION Rp 50,000 Rp 50,000 100,000Rp 28 INJEKSI Rp 50,000 Rp 50,000 100,000Rp 29 INJEKSI IV Rp 10,000 Rp 10,000 20,000Rp 30 INJEKSI IM Rp 20,000 Rp 20,000 40,000Rp 31 INJEKSI TT Rp 20,000 Rp 20,000 40,000Rp 32 PEMASANGAN O2 NASAL Rp 7,500 Rp 7,500 15,000Rp 33 PEMASANGAN O2 SIMPLE MASK Rp 10,000 Rp 10,000 20,000Rp 34 PEMASANGAN O2 REBREATHING Rp 25,000 Rp 25,000 50,000Rp 35 PEMASANGAN NGT Rp 37,500 Rp 37,500 75,000Rp 36 AFF NGT Rp 12,500 Rp 12,500 25,000Rp 37 AFF O2 Rp 10,000 Rp 10,000 20,000Rp 38 PEMBERIAN OBAT SUPPOSITORIA Rp 5,000 Rp 5,000 10,000Rp 39 PENGURUSAN MAYAT Rp 50,000 Rp 50,000 100,000Rp 40 MOBILISASI PASIEN KE RUANGAN LAIN Rp 12,500 Rp 12,500 25,000Rp 41 PENANGANAN PASIEN KEJANG Rp 25,000 Rp 25,000 50,000Rp 42 EKSTRAKSI KORPUS ALENIUM Rp 37,500 Rp 37,500 75,000Rp 43 PEMASANAGAN GUDEL/OPT Rp 37,500 Rp 37,500 75,000Rp 44 KUMBAH LAMBUNG Rp 50,000 Rp 50,000 100,000Rp 45 PEMASANGAN NECK COLLER Rp 25,000 Rp 25,000 50,000Rp 46 RESUSITASI CAIRAN Rp 25,000 Rp 25,000 50,000Rp 47 PEMASANGAN SPALAK BIASA Rp 5,000 Rp 5,000 10,000Rp 48 PEMASANGAN SPALAK PENYULIT Rp 15,000 Rp 15,000 30,000Rp 49 PASANG ELASTIS VERBAN Rp 15,000 Rp 15,000 30,000Rp 50 IRIGASI MATA Rp 25,000 Rp 25,000 50,000Rp 51 VISUM ET REPERTUM (HIDUP) Rp 50,000 Rp 50,000 100,000Rp 52 VISUM ET REPERTUM (MATI) Rp 75,000 Rp 75,000 150,000Rp 53 OBSERVASI 6-8 JAM Rp 12,500 Rp 12,500 25,000Rp 54 OBSERVASI > 8 JAM Rp 60,000 Rp 60,000 120,000Rp 55 PENANGANAN PASIEN PERCOBAAN BUNUH DIRI Rp 50,000 Rp 50,000 100,000Rp 56 KLISMA Rp 25,000 Rp 25,000 50,000Rp 57 TIMBANG BERAT BADAN Rp 10,000 Rp 10,000 20,000Rp 58 PASANG MONITOR Rp 50,000 Rp 50,000 100,000Rp 59 PEMASANGAN DC SHOCK Rp 75,000 Rp 75,000 150,000Rp 60 GANTI CAIRAN Rp 5,000 Rp 5,000 10,000Rp 61 SKIN TEST Rp 20,000 Rp 20,000 40,000Rp 62 INSISI ABSES Rp 40,000 Rp 40,000 80,000Rp 63 SIKUM SISI Rp 10,000 Rp 10,000 20,000Rp 64 AFF HECTING Rp 12,500 Rp 12,500 25,000Rp 65 GANTI PERBAN RINGAN Rp 32,500 Rp 32,500 65,000Rp 66 GANTI PERBAN SEDANG Rp 45,000 Rp 45,000 90,000Rp 67 GANTI PERBAN BERAT Rp 55,000 Rp 55,000 110,000Rp 68 PEMBERIAN OBAT ORAL Rp 7,500 Rp 7,500 15,000Rp 69 PEMBERIAN OBAT SALEP Rp 15,000 Rp 15,000 30,000Rp 70 ABDOMNAL TRUST Rp 35,000 Rp 35,000 70,000Rp 71 TINDAKAN PEMBEBASAN JALAN NAFAS Rp 35,000 Rp 35,000 70,000Rp 72 TERPAKAI OKSIGEN (JAM) Rp 7,500 Rp 7,500 15,000Rp 73 JAM BERIKUTNYA / JAM Rp 3,750 Rp 3,750 7,500Rp 74 PASANG SYRINGE PUMP Rp 75,000 Rp 75,000 150,000Rp 75 PASANG INFUS PUMP Rp 75,000 Rp 75,000 150,000Rp 76 PASANG TRANSFUSI Rp 37,500 Rp 37,500 75,000Rp 77 PASANG ETT Rp 75,000 Rp 75,000 150,000Rp 78 TAMPON TELINGA Rp 17,500 Rp 17,500 35,000Rp 79 TAMPON HIDUNG Rp 17,500 Rp 17,500 35,000Rp 80 TAMPON GIGI/MULUT Rp 25,000 Rp 25,000 50,000Rp 81 SPOOLING MATA Rp 42,500 Rp 42,500 85,000Rp 82 SPOOLING TELINGA Rp 20,000 Rp 20,000 40,000Rp 83 EKSPLORASI BENDA ASING TELINGA Rp 25,000 Rp 25,000 50,000Rp 84 EKSPLORASI BENDA ASING HIDUNG Rp 25,000 Rp 25,000 50,000Rp 85 EKSPLORASI BENDA ASING KULIT/AHA Rp 40,000 Rp 40,000 80,000Rp 86 IRIGASI TELINGA Rp 35,000 Rp 35,000 70,000Rp 87 BIOPSI Rp 75,000 Rp 75,000 150,000Rp 88 KOMPRES Rp 7,500 Rp 7,500 15,000Rp 89 PASANG BULI-BULI PANAS/DINGIN Rp 7,500 Rp 7,500 15,000Rp 90 MOBILISASI Rp 10,000 Rp 10,000 20,000Rp 91 SPIROMETRI Rp 135,000 Rp 135,000 270,000Rp 92 PEMERIKSAAN TANPA TINDAKAN
a.Dokter Umum/Dokter Gigi Rp 20,000 Rp 20,000 40,000Rp
b.Dokter Spesialis Rp 25,000 Rp 25,000 50,000Rp
c.Dokter Sub Spesialis Rp 35,000 Rp 35,000 70,000Rp - Observasi
a.Dokter Umum/Dokter Gigi Rp 20,000 Rp 20,000 40,000Rp
b.Dokter Spesialis Rp 25,000 Rp 25,000 50,000Rp
c.Dokter Sub Spesialis Rp 35,000 Rp 35,000 70,000Rp 58 PEMASANGAN NGT Rp 37,500 Rp 37,500 75,000Rp 59 PEMASANGAN O2 NASAL Rp 7,500 Rp 7,500 15,000Rp 60 PEMASANGAN O2 REBREATHING Rp 25,000 Rp 25,000 50,000Rp 61 PEMASANGAN O2 SIMPLE MASK Rp 10,000 Rp 10,000 20,000Rp 62 PEMASANGAN SPALAK BIASA Rp 5,000 Rp 5,000 10,000Rp 63 PEMASANGAN SPALAK PENYULIT Rp 15,000 Rp 15,000 30,000Rp 64 Pemberian makanan lewat donde/NGT Rp 10,000 Rp 10,000 20,000Rp 65 PEMBERIAN OBAT EMERGENCY Rp 25,000 Rp 25,000 50,000Rp 66 PEMBERIAN OBAT ORAL Rp 7,500 Rp 7,500 15,000Rp 67 PEMBERIAN OBAT SALEP Rp 15,000 Rp 15,000 30,000Rp 68 PEMBERIAN OBAT SUPPOSITORIA Rp 5,000 Rp 5,000 10,000Rp 69 PEMERIKSAAN FISIK Rp 15,000 Rp 15,000 30,000Rp 70 PEMERIKSAAN TTV Rp 15,000 Rp 15,000 30,000Rp 71 PENANGANAN PASIEN KEJANG Rp 25,000 Rp 25,000 50,000Rp 72 PENANGANAN PASIEN LUKA BAKAR BERAT Rp 100,000 Rp 100,000 200,000Rp 73 PENANGANAN PASIEN LUKA BAKAR RINGAN Rp 25,000 Rp 25,000 50,000Rp 74 PENANGANAN PASIEN LUKA BAKAR SEDANG Rp 37,500 Rp 37,500 75,000Rp 75 PENANGANAN PASIEN PERCOBAAN BUNUH DIRI Rp 50,000 Rp 50,000 100,000Rp 76 PENANGANAN PASIEN PERDARAHAN Rp 37,500 Rp 37,500 75,000Rp 77 PENGURUSAN MAYAT Rp 50,000 Rp 50,000 100,000Rp 78 OBSERVASI DI IGD Rp 50,000 Rp 50,000 100,000Rp 79 OBSERVASI PASIEN ISOLASI DI UGD Rp 60,000 Rp 60,000 120,000Rp 80 RAWAT LUKA BERAT Rp 25,000 Rp 25,000 50,000Rp 81 RAWAT LUKA BERAT + PENYULIT Rp 37,500 Rp 37,500 75,000Rp 82 RAWAT LUKA RINGAN Rp 12,500 Rp 12,500 25,000Rp 83 RAWAT LUKA SEDANG Rp 17,500 Rp 17,500 35,000Rp 84 RESUSITASI CAIRAN Rp 25,000 Rp 25,000 50,000Rp 85 RJP Rp 50,000 Rp 50,000 100,000Rp 86 SIKUM SISI Rp 10,000 Rp 10,000 20,000Rp 87 SKIN TEST Rp 20,000 Rp 20,000 40,000Rp 88 SPIROMETRI Rp 135,000 Rp 135,000 270,000Rp 89 SPOOLING KATETER Rp 15,000 Rp 15,000 30,000Rp 90 SPOOLING MATA Rp 42,500 Rp 42,500 85,000Rp 91 SPOOLING TELINGA Rp 20,000 Rp 20,000 40,000Rp 93 SUCTION Rp 50,000 Rp 50,000 100,000Rp 94 TAMPON GIGI/MULUT Rp 25,000 Rp 25,000 50,000Rp 95 TAMPON HIDUNG Rp 17,500 Rp 17,500 35,000Rp 96 TAMPON TELINGA Rp 17,500 Rp 17,500 35,000Rp 97 TERPAKAI OKSIGEN (JAM) Rp 7,500 Rp 7,500 15,000Rp 98 TIMBANG BERAT BADAN Rp 10,000 Rp 10,000 20,000Rp 99 TINDAKAN PEMBEBASAN JALAN NAFAS Rp 35,000 Rp 35,000 70,000Rp 100 TRIASE Rp 10,000 Rp 10,000 20,000Rp 101 VISUM ET REPERTUM (HIDUP) Rp 50,000 Rp 50,000 100,000Rp 102 VISUM ET REPERTUM (MATI) Rp 75,000 Rp 75,000 150,000Rp 103 PEMERIKSAAN TANPA TINDAKAN
a.Dokter Umum/Dokter Gigi Rp 20,000 Rp 20,000 40,000Rp
b.Dokter Spesialis Rp 25,000 Rp 25,000 50,000Rp
c.Dokter Sub Spesialis Rp 35,000 Rp 35,000 70,000Rp - Observasi Rp - Rp -
a.Dokter Umum/Dokter Gigi Rp 20,000 Rp 20,000 40,000Rp
b.Dokter Spesialis Rp 25,000 Rp 25,000 50,000Rp
c.Dokter Sub Spesialis Rp 35,000 Rp 35,000 70,000Rp 104 Konsultasi dr Spesialis Rp 25,000 Rp 25,000 50,000Rp 105 Konsultasi dr Sub Spesialis Rp 35,000 Rp 35,000 70,000Rp 106 Perawatan di IGD Rp 50,000 Rp 50,000 100,000Rp 107 Perawatan di Isolasi IGD Rp 60,000 Rp 60,000 120,000Rp 108 Bladder training Rp 10,000 Rp 10,000 20,000Rp 109 Spolling Kateter Rp 15,000 Rp 15,000 30,000Rp JASA SARANA JASA PELAYANAN 1 PERSALINAN NORMAL OLEH DOKTER Rp 425,000 Rp 425,000 850,000Rp 2 PERSALINAN NORMAL OLEH BIDAN Rp 375,000 Rp 375,000 750,000Rp 3 PERSALINAN PATOLOGIS Rp 570,000 Rp 570,000 1,140,000Rp 4 PARTUS GAMELLI FISIOLOGI Rp 500,000 Rp 500,000 1,000,000Rp 5 INDUKSI PERSALINAN Rp 175,000 Rp 175,000 350,000Rp 6 VAKUM EKSTRAKSI Rp 525,000 Rp 525,000 1,050,000Rp 7 EKSTRAKSI FORCEPS Rp 525,000 Rp 525,000 1,050,000Rp 8 KOMPRESI BIMANUAL INTERNA Rp 525,000 Rp 525,000 1,050,000Rp 9 KOMPRESI BIMANUAL EKSTERNA Rp 525,000 Rp 525,000 1,050,000Rp E. PERSALINAN KAMAR BERSALIN/PONEK NO JENIS PELAYANAN JUMLAH TARIF 10 KURET ABORTUS TANPA ANASTESI Rp 375,000 Rp 375,000 750,000Rp 11 KURET DIAGNOSTIK TANPA ANASTESI Rp 375,000 Rp 375,000 750,000Rp 12 KURET ABORTUS DENGAN ANASTESI Rp 375,000 Rp 375,000 750,000Rp 13 KURET MOLAHIDATIDOSA TANPA ANASTESI < 12 MINGGU Rp 375,000 Rp 375,000 750,000Rp 14 KURET MOLAHIDATIDOSA TANPA ANASTESI > 12 MINGGU Rp 425,000 Rp 425,000 850,000Rp 15 KURET PERCOBAAN Rp 88,000 Rp 88,000 176,000Rp 16 JAHITAN PORSIO Rp 250,000 Rp 250,000 500,000Rp 17 JAHITAN PERINEUM TK 1 DAN II Rp 75,000 Rp 75,000 150,000Rp 18 JAHITAN PERINEUM TK III DAN IV Rp 100,000 Rp 100,000 200,000Rp 19 MANUAL PLASENTA Rp 250,000 Rp 250,000 500,000Rp 20 OBSERVASI/PERSIAPAN OPERASI Rp 35,000 Rp 35,000 70,000Rp 21 TAMPON VAGINA Rp 15,000 Rp 15,000 30,000Rp 22 DILATASI SERVIKS Rp 50,000 Rp 50,000 100,000Rp 23 AMNIOTOMI Rp 20,000 Rp 20,000 40,000Rp 24 PERAWATAN LUKA PERINEUM Rp 20,000 Rp 20,000 40,000Rp 25 PASANG LAMINARIA Rp 87,500 Rp 87,500 175,000Rp 26 KULDOSENTESIS Rp 37,500 Rp 37,500 75,000Rp 27 EPISIOTOMI Rp 50,000 Rp 50,000 100,000Rp 28 VAGINAL TOUCHER Rp 25,000 Rp 25,000 50,000Rp 29 INSPEKULO Rp 97,500 Rp 97,500 195,000Rp 30 DAPTON Rp 25,000 Rp 25,000 50,000Rp 31 CTG (KARDIOTOGRAFI) Rp 100,000 Rp 100,000 200,000Rp 32 RESUSITASI BAYI BARU LAHIR NORMAL Rp 150,000 Rp 150,000 300,000Rp 33 PERAWATAN TALI PUSAT Rp 10,000 Rp 10,000 20,000Rp 34 PERAWATAN BAYI LETAK BOKONG Rp 155,000 Rp 155,000 310,000Rp 35 PERAWATAN BAYI LETAK KEPALA (NORMAL) Rp 78,000 Rp 78,000 156,000Rp 36 TERIMA BAYI DOKTER SPESIALIS Rp 150,000 Rp 150,000 300,000Rp 37 RECTAL TOUCHER Rp 21,500 Rp 21,500 43,000Rp 38 USG ABDOMINAL Rp 50,000 Rp 50,000 100,000Rp 39 USG TRANSVAGINAL Rp 65,000 Rp 65,000 130,000Rp 40 DOPLER Rp 65,000 Rp 65,000 130,000Rp 41 BUSINASI Rp 182,750 Rp 182,750 365,500Rp 42 Observasi pasien > 8 jam Rp 100,000 Rp 100,000 200,000Rp 43 Observasi pasien 6 - 8 jam Rp 12,500 Rp 12,500 25,000Rp 43 Terima Bayi Baru Lahir oleh bidan Rp 50,000 Rp 50,000 100,000Rp 44 Penaganan pasien kejang Rp 25,000 Rp 25,000 50,000Rp 45 Penagan pasien perdarahan Rp 37,500 Rp 37,500 75,000Rp PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL I. ADRENAL 1 Adrenalektomi (abdominotorakal) 19,140,625 6,380,208 25,520,833 22,011,719 7,337,240 29,348,958 23,925,781 7,975,260 31,901,042 28,710,938 9,570,313 38,281,250 2 Laparoskopi adrenalektomi 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 3 Adrenalektomi 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 II. GINJAL 1 Biopsi ginjal terbuka 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 2 Deroofing/unroofing kista 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 3 Deroofing kista ginjal per laparoskopi 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 4 Extended pyelolithotomy 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 5 Anatropic nephrolithotomy (bivalve) 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 6 Ganti nefrostomi 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 7 Koreksi horseshoe kidney 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 8 Nefrektomi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 9 Nefrektomi per laparoskopi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 10 Nefrektomi radikal 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 11 Nefrektomi parsial 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 12 Nefropeksi/ renopeksi 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 13 Nefrostomi perkutan/ temporer 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 14 Nefrostomi terbuka/ permanen 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 15 Nefroureterektomi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 16 PCNL/ PNL 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 17 Pielolitotomi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 18 Pielokalikolitotomi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 19 Pieloplasti 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 20 Pieloplasti per laparoskopi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 21 Rekonstruksi renovaskuler 15,234,375 5,078,125 20,312,500 17,519,531 5,839,844 23,359,375 19,042,969 6,347,656 25,390,625 22,851,563 7,617,188 30,468,750 22 Nefrektomi donor transplant 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 23 Transplantasi resipien 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 24 Operasi trauma ginjal repair vaskular 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 25 Operasi trauma ginjal repair parenkim (renoraphy) 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 26 Operasi trauma ginjal nefrektomi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 27 Biopsi ginjal perkutan 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 28 Laparoskopi Nefrektomi 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 29 Nefroureterektomi per laparoskopik 11,718,750 3,906,250 15,625,000 13,476,563 4,492,188 17,968,750 14,648,438 4,882,813 19,531,250 17,578,125 5,859,375 23,437,500 30 Nefrektomi donor transplant per laparoskopi 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 III. URETER - - - - - - - - 1 Anastomosis end to end ureter 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 2 Cabut DJ stent 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 3 Drainase periureter 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 4 Ekstraksi batu 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 5 Insersi DJ stent 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 6 Reimplantasi ureter unilateral/ ureteroneosistostomi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 7 Reimplantasi ureter bilateral 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 8 RPG, URS diagnostik 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 9 Tailoring ureter 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 10 Transuretero-ureterostomi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 11 Ureterolithotomi proksimal 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 12 Ureterolithotomi distal 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 13 Ureterolisis 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 14 Ureterostomi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 15 Ureterouretostomi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 16 URS/ lithotripsi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 17 Ureterolitotomi proksimal per laparoskopik 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 F. TINDAKAN MEDIS DAN TERAPI OPERATIF DAN NON OPERAWTIF NO NAMA TINDAKAN KELAS III KELAS II VIPKELAS I IV. BULI-BULI - - - - - - - - 1 Augmentasi buli 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 2 Bladder neck rekonstruksi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 3 Divertikulektomi buli 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 4 Divertikulektomi buli per laparoskopi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 5 Ekstrofi buli rekonstruksi 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 6 Evakuasi bekuan darah (clot) 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 7 Litholapaksi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 8 Lithotripsi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 9 Neobladder 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 10 Psoas Hitch/ Boari flap 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 11 Repair fistel enterovesika 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 12 Repair fistel vesikokutan 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 13 Repair fistel vesikorektal 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 14 Repair fistel vesikovagina 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 15 Repair fistel vesikovagina kompleks 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 16 Sectio alta/ vesikolithotomi 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 17 Sistoskopi ODS 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 18 Sistoskopi 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 19 Sistostomi perkutan 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 20 Sistostomi terbuka 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 21 Sistektomi total/ radikal 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 22 Sistektomi parsial/ sistoplasti reduksi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 23 Sistektomi per laparoskopi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 24 TUR tumor buli 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 25 Operasi repair buli trauma 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 V. DIVERSI URIN/CONDUIT - - - - - - - - 1 Ileal conduit (Bricker) 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 2 Ureterosigmoidostomi (Coffey) 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 3 Ureterokutaneostomi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 4 Neobladder 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 VI. URETRA - - - - - - - - 1 Businasi/ dilatasi uretra dengan pembiusan 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 2 Divertikulum uretra 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 3 Epispadia 13,281,250 4,427,083 17,708,333 15,273,438 5,091,146 20,364,583 16,601,563 5,533,854 22,135,417 19,921,875 6,640,625 26,562,500 4 Fistulektomi/ repair fistel uretra 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 5 Uretroplasti hipospadia 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 6 Hipospadia subkoronal 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 7 Insisi posterior urethral valve 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 8 Uretrotomi interna (Sachse) 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 9 Johanson I 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 10 Johanson II 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 11 Kalibrasi uretra 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 12 Meatotomi 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 13 Meatoplasti 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 14 Pasang kateter 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 15 Pasang kateter dengan mandrain 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 16 Railroading ruptur uretra 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 17 PER (primary endoscopic realignment ) 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 18 Reseksi-anastomosis uretra 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 19 Uretroskopi/ uretrosistoskopi 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 20 Uretroplasti bukal graf 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 21 Uretrotomi eksterna 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 VII. PROSTAT - - - - - - - - 1 Biopsi prostat 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 2 Masase prostat 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 3 Prostatektomi terbuka 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 4 Prostatektomi retropubik 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 5 Prostatektomi radikal 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 6 TUR Prostat/ TUIP/ BNI 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 7 TVP/TMP 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 8 Laparoskopik Radikal Prostatektomi 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 9 Transurethral clearence of bladder removal foreign body 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 VIII. GENITALIA & INGUINAL - - - - - - - - 1 Biopsi penis 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 2 Biopsi testis 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 3 Diseksi kelenjar getah bening inguinal 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 4 Sirkumsisi, Dorsumsisi 2,148,438 716,146 2,864,583 2,470,703 823,568 3,294,271 2,685,547 895,182 3,580,729 3,222,656 1,074,219 4,296,875 5 Eksisi chordae/ chordektomi 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 6 Eksisi plaque (Peyronie disease ) 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 7 Eksplorasi testis (microsurgery ) 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 8 Eksisi fibroma/ rekonstruksi penis 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 9 Funikokelektomi 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 10 Hidrokel per skrotal 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 11 Hidrokel per inguinal/ ligasi tinggi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 12 Insisi abses perineum 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 13 Insisi abses skrotum 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 14 Operasi priapismus (prosedur Winter) 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 15 Koreksi priapismus 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 16 Ligasi v. Spermatika interna (microsurgery ) 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 17 Limfadenektomi ilioinguinal 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 18 Orkhidektomi 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 19 Orkhidektomi extended 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 20 Orkhidektomi ligasi tinggi 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 21 Orkhidektomi subkapsuler 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 22 Orkhidopeksi (torsio testis) 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 23 Orkhidopeksi (UDT) 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 24 Orkhidopeksi per laparoskopi 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 25 Penektomi parsial 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 26 Penektomi total/ amputasi penis 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 27 Reparasi penis 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 28 Skrotoplasti 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 29 Spermatokelektomi 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 30 Varikokelektomi (Palomo) 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 31 Vasektomi (anestesi lokal) 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 32 Vasektomi (narkose) 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 33 Vasoepididimostomi 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 34 Vasovasostomi 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 35 Vasografi 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 36 Eksisi webbed penis 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 37 Buried penis 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 IX. LAIN-LAIN - - - - - - - - 1 Diseksi kelenjar getah bening pelvis 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 2 Biopsi uretra endoscopy 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 3 Cabut kateter Tenckhoff untuk CAPD 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 4 Cystoscopy + biopsy 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 5 Diseksi kelenjar getah bening pelvis per laparoskopi 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 6 Drainage abses renal 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 7 Endoscopy/Panendoscopy 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 8 ESWL 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 9 Excisi Carancula 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 10 Holmium YaG laser 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 11 Injection or infusion of cancer chemotherapeutic substance 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 12 Kauterisasi 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 13 Laparotomi eksplorasi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 14 Limfadenektomi retroperitoneal/ RPLND 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 15 MMK/sling uretra 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 16 Operasi sistokel 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 17 Operasi urakhus/reseksi urakhus 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 18 Pasang kateter Tenckhoff untuk CAPD 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 19 Punksi dan sklerosing kista ginjal 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 20 Retrograde Pyelogram (RPG) 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 21 TindakanPESA/MESApembedahan) testis untuk pengambilan spermatozoa ( TESA/TESE/PESA/MESA ) 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 22 Biopsi scrotum 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 23 Debridement skrotum + penis 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 24 Excisi Papiloma 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 25 Exterpasi 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 26 Ganti nephrostomy/ PNS/ Ureterocutan D 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 27 Ganti nephrostomy/ PNS/ Ureterocutan S 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 28 Incicional Biopsi 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 29 Release torsio 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 30 Sekunder Hecting 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 X. JASA KONSULTASI & VISITE - - - - - - - - 1 Visite ruang rawat inap - - - - - - - - PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL 1 Aff Arch Barr 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 2 Aff Arch Barr dan suspensi maksila 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 3 Amputasi Above Knee 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 4 Amputasi Below Knee 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 5 Amputasi Jari (Phalangs - Traumatik) 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 6 Amputation of digiti single ** 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 7 Anal fistulectomy 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 8 Anal fistulotomy 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 9 Aneurisma A. Brachialis (diluar graft) 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 10 Aneurisma A. Femoralis (diluar graft) 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 11 Appendicostomy 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 12 Arterial pungsi, kanulasi, sectie 3,320,313 1,106,771 4,427,083 3,818,359 1,272,786 5,091,146 4,150,391 1,383,464 5,533,854 4,980,469 1,660,156 6,640,625 13 Arteriovenous shunt (AV Shunt) brakiosefalika 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 14 Arteriovenous shunt (AV Shunt) radiosefalika 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 15 AV – Shunt (Lokal Anestesi) 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 16 Axillary dissection 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 17 Babcock 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 18 Batu Saluran Kemih * 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 19 Bilateral excision of ectopic breast tissue (mamma aberans) 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 20 Bilateral inguinal hernia repair with graft or prosthesis, not otherwise specified 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 21 Bilateral multipel excision of lesion of breast with narcose 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 22 Bilateral Ovariectomy 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 23 Bilateral radical mastectomy 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 24 Bilateral repair of direct inguinal hernia 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 25 Bilateral repair of direct inguinal hernia with graft or prosthetis 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 26 Bilateral repair of femoral hernia with/without graft of prosthesis 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 27 Bilateral repair of indirect inguinal hernia 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 28 Bilateral repair of indirect inguinal hernia with graft or prosthesis 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 29 Bilateral repair of inguinal hernia, not otherwise specified 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 30 Bilateral repair of inguinal hernia, one direct and one indirect 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 31 Bilateral repair of inguinal hernia, one direct and one indirect, with graft or prosthesis 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 32 Bilateral simple mastectomy 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS BEDAH UMUM RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 33 Biopsi pembuluh darah (perifer) * 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 34 Biopsi Perikardium * 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 35 Biopsi terbuka bronkhus * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 36 Biopsi terbuka diafragma * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 37 Biopsi terbuka mediastinum * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 38 Biopsi terbuka paru * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 39 Biopsi terbuka pleura * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 40 Biopsi terbuka pleura dengan VATS * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 41 Biopsi terbuka tumor dinding thoraks * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 42 Biopsy insisional dengan anastesi lokal 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 43 Biopsy of anus 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 44 Biopsy of perianal tissue 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 45 Caecostomy 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 46 Cholecystectomy 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 47 Choledochoplasty 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 48 Clipping Costae (diluar plate) 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 49 Closed reduction of temporomandibular dislocation 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 50 Closure of anal fistula 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 51 Closure of appendiceal fistula 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 52 Closure of cholecystostomy 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 53 Closure of fistula of large intestine 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 54 Closure of fistula of small intestine, except duodenum 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 55 Closure of intestinal stoma 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 56 Closure of leceration of liver 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 57 Colostomy, not otherwise specified 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 58 Combustio (Luka Bakar) * 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 59 Common duct exploration for removal of calculus 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 60 Compartement excision 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 61 complete glossectomy 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 62 Complete thyroidectomy 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 63 Control of hemorrhage of anus 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 64 Debridement mediastinum (Sternotomi) * 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 65 Debridement-nekrotomi luka gangren 3,320,313 1,106,771 4,427,083 3,818,359 1,272,786 5,091,146 4,150,391 1,383,464 5,533,854 4,980,469 1,660,156 6,640,625 66 Deseksi submandibula 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 67 Disartikulasi sendi ekstremitas 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 68 Diseksi leher radikal / radikal neck dissection * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 69 Dislokasi bahu * 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 70 Drainage of appediceal abscess 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 71 Drainage of pancreatic cyst by catheter 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 72 Eksisi Biopsi Tumor pembuluh darah 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 73 Eksisi gld submandibula 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 74 Eksisi higroma leher * 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 75 Eksisi kista tiroglosus 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 76 Eksisi luas tumor ganas bibir dengan rekonstruksi flap lokal 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 77 Eksisi luas tumor ganas dengan rekonstruksi flap jauh 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 78 Eksisi luas tumor ganas kulit tanpa rekonstruksi 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 79 Eksisi luas tumor ganas rongga mulut dengan rekonstruksi flap lokal 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 80 Eksisi pada bronkhus 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 81 Eksisi parsial+marsupialisasi Ranula 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 82 Eksisi Pseudoaneurisma 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 83 Eksisi Tumor Dinding dada * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 84 Eksisi tumor ganas kulit dengan flap local atau graft kulit 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 85 Eksisi tumor jinak dengan anastesi lokal 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 86 Eksisi Tumor Pembuluh Darah Perifer ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 87 Eksisi tumor pembuluh darah perifer (hemangioma) ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 88 Ekskokleasi epulis 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 89 Ekskokleasi kista folikuler 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 90 Ekskokleasi kista radikuler 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 91 Eksplorasi vaskular (Trauma/ Non Trauma) 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 92 Ekstirpasi / eksisi tumor jinak jaringan lunak ukuran <2cm ** 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 93 Ekstirpasi kista dermoid * 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 94 Ekstraksi Corpus Alienum di Regio Toraks * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 95 Ekstraksi Corpus Alienum di Regio Toraks dengan VATS * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 96 Embolektomi (diluar alat) 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 97 Embolektomi/trombektomi aorta 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 98 Embolektomi/trombektomi pembuluh darah arteri ekstremitas bawah * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 99 Embolektomi/trombektomi pembuluh darah arteri abdominal * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 100 Embolektomi/trombektomi pembuluh darah ekstremitas atas (diluar alat) * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 101 Embolektomi/trombektomi pembuluh darah ekstremitas bawah (diluar alat) * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 102 Embolektomi/trombektomi pembuluh darah regio servikal (karotis,jugular) (diluar alat) * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 103 Endoscopic polypectomy of rectum 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 104 Endoscopic thyroidectomy 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 105 Evakuasi Hematom (pasca pungsi) 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 106 Evakuasi hematom di ekstremitas (pasca pungsi HD/traumatik) 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 107 Excision of ectopic breast tissue 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 108 Excision of hemorrhoids 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 109 excision of lesion of breast with narcose 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 110 Excision of other bile duct 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 111 Excision of perianal skin tags 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 112 Excision of thyroglossal duct or trac 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 113 Exploration of common duct 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 114 Exploratory laparotomy 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 115 Exteriorization of large intestine 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 116 Exteriorization of small intestine 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 117 Fasciotomy * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 118 Fiksasi interna fraktur maksilofasial 1-2 tempat patahan * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 119 Fiksasi interna fraktur nasal 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 120 Fiksasi interna Fraktur Panfacial 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 121 Fiksasi Sternum (Wire, Plate) (diluar wire/plate) * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 122 Fraktur Antebrachi 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 123 Fraktur Colles & Pergelangan tangan lainnya 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 124 Fraktur Cruris 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 125 Fraktur Femur * 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 126 Fraktur Humerus * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 127 Fraktur klavikula 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 128 Fraktur Olekranon 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 129 Fraktur Patela 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 130 Fraktur Suprakondiler Humerus 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 131 Free skin graft 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 132 Full-thickness skin graft to hand 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 133 Full-thickness skin graft to other sites * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 134 Gastrostomi * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 135 Groin dissection 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 136 Hemiglosektomi 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 137 Hidrokel Testis/Funikuli ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 138 Hipertropi Prostat Beningna (BPH) * 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 139 Ileostomy, not otherwise specified * 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 140 Incision of perianal abscess 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 141 Incisional hernia repair 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 142 Incisional hernia repair with prosthesis 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 143 insertion of synthetic implant in facial bone 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 144 Insisi abses dengan anastesi lokal 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 145 Insisi flegmon dasar mulut 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 146 Internal drainage of pancreatic cyst 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 147 Internal Fiksasi fraktur condylus mandibula 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 148 Internal fiksasi fraktur maksilofasial 5 tempat patahan/ lebih 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 149 Internal Fiksasi fraktur Mandibula segmental 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 150 Intra-abdominal manipulation of intestine, not otherwise specified 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 151 Intra-abdominal manipulation of large intestine 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 152 Intra-abdominal manipulation of small intestine 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 153 Labioshisis * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 154 Laparoscopic appendectomy 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 155 Laparoscopic appendectomy (elective) 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 156 Laparoscopic cholecystectomy 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 157 Laparoscopic incidental appendectomy 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 158 Laparoscopic lysis of peritoneal adhesions 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 159 Laparoscopy 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 160 Large-to-large intestinal anastomosis 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 161 Laringectomi * 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 162 Laringectomi dengan diseksi leher * 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 163 Left hemicolectomy 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 164 Left lateral anal sphincterotomy 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 165 Ligasi vaskular ekstremitas 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 166 Ligation of hemorrhoids 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 167 Lobektomi parsial (reseksi paru segmental) * 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 168 Local excision of lesion of breast 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 169 Local excision of rectal lesion or tissue 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 170 Maksilektomi total + Rekonstruksi * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 171 Mediastinostomy 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 172 Modifikasi RND / functional neck dissection 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 173 Multipel excision of lesion of breast with narcose 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 174 Muscle flap graft to breast 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 175 Muscle flap graft to breast (TRAM flap/LD flap) 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 176 Mutilasi digiti ekstremitas (Multiple) 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 177 Open biopsi of breast 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 178 Open biopsy of gallbladder or bile ducts 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 179 Open biopsy of liver 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 180 Open biopsy of pancreas 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 181 Open biopsy of rectum 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 182 open biopsy of salivary gland or duct 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 183 open reduction of alveolar fracture * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 184 open reduction of malar and zygomatic fracture 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 185 Open reduction of mandibular fractur 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 186 open reduction of maxillary fracture 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 187 Operasi Commando 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 188 Osteotomi eksisi tulang maksilofasial 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 189 Other appendectomy (elective) * 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 190 Other bilateral femoral herniorraphy 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 191 Other destruction of lesion of liver 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 192 Other diagnostic procedures of abdominal region 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 193 Other excision of perianal tissue 3,320,313 1,106,771 4,427,083 3,818,359 1,272,786 5,091,146 4,150,391 1,383,464 5,533,854 4,980,469 1,660,156 6,640,625 194 Other hernia repair 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 195 Other incidental appendectomy * 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 196 Other incision of anus 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 197 Other incision of skin and subcutaneous tissue 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 198 Other laparotomy 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 199 Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 200 Other lysis of peritoneal adhesions 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 201 Other operations on anus 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 202 Other operations on intestines 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 203 Other operations on pancreas 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 204 Other operations on the breast/ Reconstruction of the breast 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 205 Other operations on trachea 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 206 Other pancreatotomy 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 207 Other partial excision of large intestine 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 208 Other partial thyroidectomy 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 209 Other procedures on hemorrhoids 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 210 Other reconstruction of other facial bone 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 211 Other reconstruction of mandible 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 212 Other repair and plastic operation of tongue 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 213 Other repair of abdominal wall 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 214 Other repair of anal sphincter 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 215 Other repair of intestine 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 216 Other repair of mesentery 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 217 Other skin graft to hand 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 218 Other skin graft to other sites 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 219 Other small-to-large intestinal anastomosis 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 220 Other suture of abdominal wall 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 221 Other umbilical herniorraphy* 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 222 Other unilateral femoral herniorraphy 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 223 Palatoshisis ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 224 Parathyroidectomy subtotal 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 225 Parathyroidectomy total 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 226 Parotidektomi superfisial * 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 227 Parotidektomi total 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 228 Partial Gastrectomy 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 229 partial glossectomy 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 230 Partial hepatectomy 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 231 partial mandibulectomy hemimandibulectomy 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 232 Partial splenectomy 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 233 Pasang Double Lumen Hemodialysis (HD) (diluar alat) 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 234 Pasang Implantable Central Venous Access (diluar alat:port-a-cath®,celsite®) * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 235 Pasang Thoraks Drain/ WSD (diluar alat) * 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 236 Pedicle or flaps graft, not otherwise specified 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 237 Pelepasan plat & skrup maksilofasial 3 tempat atau lebih 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 238 Pelepasan plat & skrup tulang maksilofasial 1-2 tempat 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 239 Pemasangan Central Venous Catheter (CVC) (diluar alat) 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 240 Pemasangan interdental wiring / arch bar 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 241 Pemasangan Peritoneal Dialysis (PD) Catheter (diluar alat) 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 242 Pembedahan teleangiectasis 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 243 Pembuatan Thoracic window 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 244 Pericardiocentesis * 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 245 Perikardiektomi * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 246 Perikardiotomi/ Pericardial window * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 247 Permanent colostomy 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 248 Permanent ileostomy 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 249 Pionephrosis 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 250 Pleural window (Eloeser Flap) * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 251 Pleurektomi * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 252 Pleurodesis (pleurosklerosis) * 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 253 Plikasi Bulae / Bleb Emfisematous 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 254 Plikasi diafragma * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 255 Pneumonectomy * 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 256 Prosedur Sistrunk kista duktus tiroglosus 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 257 Pulmonary decortication * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 258 Pungsi hematom/ seroma 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 259 Radical excision of skin lesion 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 260 Reclosure of postoperative disruption of abdominal wall 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 261 Redo Torakotomi * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 262 Reduction of anal prolapse 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 263 Rekonstruksi arteri ekstremitas dengan Bypass Graft synthetic (diluar protesa) 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 264 Rekonstruksi fraktur blow-out 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 265 Rekonstruksi menggunakan flap bebas 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 266 Rekonstruksi sternum & dinding dada 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 267 Rekonstruksi vaskular ekstremitas inferior (Arteri femoralis & poplitea) (diluar graft) 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 268 Rekonstruksi vaskular ekstremitas superior (Arteri brakialis,radialis & ulnaris) (diluar graft) 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 269 Release Kontraktur mandibula 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 270 Release tong tie * 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 271 Release tortikolis 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 272 Removal of foreign body from retro-peritoneal cavity 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 273 Removal of foreign body from peritoneal cavity 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 274 Reopening of recent laparotomy site 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 275 Repair aneurisma Aorta Abdominalis (diluar protesa) * 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 276 Repair Ar.Poplitea & Femoralis (diluar graft) 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 277 Repair Laserasi Diafragma * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 278 Repair of diaphragmatic hernia, abdominal approach 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 279 Repair of direct inguinal hernia 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 280 Repair of direct inguinal hernia with graft or prosthesis 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 281 Repair of gastroschisis 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 282 Repair of indirect inguinal hernia 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 283 Repair of indirect inguinal hernia with graft or prosthesis 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 284 Repair of laceration of gallbladder 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 285 Repair of other bile ducts 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 286 Repair of other hernia of anterior abdominal wall 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 287 Repair of other hernia of anterior abdominal wall with prosthesis 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 288 Repair of umbilical hernia with prosthesis * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 289 Repair pembuluh darah regio servikal (karotis,jugular) * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 290 Reposisi Dislokasi sendi rahang dengan Pembiusan ( TMJ ) * 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 291 Reposisi Dislokasi TMJ tanpa pembiusan 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 292 Reposisi tertutup Fraktur Condilus Mandibula 3,320,313 1,106,771 4,427,083 3,818,359 1,272,786 5,091,146 4,150,391 1,383,464 5,533,854 4,980,469 1,660,156 6,640,625 293 Reposisi tertutup fraktur nasal 3,320,313 1,106,771 4,427,083 3,818,359 1,272,786 5,091,146 4,150,391 1,383,464 5,533,854 4,980,469 1,660,156 6,640,625 294 Resection of transverse colon 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 295 Reseksi maksila infrastuktural 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 296 Reseksi maksila suprastuktural 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 297 Reseksi mandibula dengan rekonstruksi graft tulang / K-wire ** 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 298 Reseksi mandibula tanpa rekonstruksi 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 299 Revisi Arteriovenous shunt * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 300 Revisi Thoraks drain/ Water Sealed Drainage (WSD) (diluar alat) 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 301 Revision of anastomosis of large intestine 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 302 Revision of anastomosis of small intestine 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 303 Revision of stoma of large intestine 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 304 Revision of stoma of small intestine 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 305 Revision of tracheostomy 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 306 Right hemicolectomy 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 307 Rupture Buli-buli * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 308 Rupture tendon Achiles 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 309 Scleroterapi dan / atau ligasi hemangioma 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 310 Sigmoidectomy 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 311 Simple suture of common bile duct 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 312 Sirkumsisi *** 2,148,438 716,146 2,864,583 2,470,703 823,568 3,294,271 2,685,547 895,182 3,580,729 3,222,656 1,074,219 4,296,875 313 Skleroterapi vena (Varises, Hemangioma) * 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 314 Small-to-small intestinal anastomosis 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 315 Split-thickness graft to breast 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 316 Stripping varises ekstremitas inferior 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 317 Subtotal mastectomy 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 318 Suture of laceration of anus 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 319 Suture of laceration of large intestine 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 320 Suture of laceration of small intestine, except duodenum 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 321 Suture of peritoneum 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 322 Temporary colostomy 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 323 Temporary ileostomy * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 324 Thoracal Symphatectomy dengan Video Assissted Thoracoscopic Surgery (VATS) 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 325 Thoracocentesis * 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 326 Thymectomy dengan VATS 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 327 Tiroidektomi subtotal/ total nodul tiroid ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 328 Tiroidektomi total dengan Berry Picking 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 329 Tiroidektomi total dengan diseksi leher fungsional 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 330 Torakotomi/ Sternotomi Eksplorasi * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 331 Torsio testis ** 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 332 Total Gastrectomy 11,718,750 3,906,250 15,625,000 13,476,563 4,492,188 17,968,750 14,648,438 4,882,813 19,531,250 17,578,125 5,859,375 23,437,500 333 Total splenectomy * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 334 Trakeostomi dengan penyulit tumor pada akses trakea *** 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 335 Trakeostomi temporary ** 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 336 Tumor Jinak Kulit&Tumor Non Neoplastik Kulit * 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 337 Unilateral excision of ectopic breast tissue (mamma aberans) 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 338 Unilateral radical mastectomy 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 339 Unilateral repair of femoral/inguinal hernia with/without graft or prosthesis 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 340 Unilateral simple mastectomy 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 341 Unilateral thyroid lobectomy 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 342 Vascular shunting (Splenorenal shunt, De palma shunt) 11,718,750 3,906,250 15,625,000 13,476,563 4,492,188 17,968,750 14,648,438 4,882,813 19,531,250 17,578,125 5,859,375 23,437,500 343 Vena punctie, kanulasi, sectie * 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 344 Whipple Procedure 11,718,750 3,906,250 15,625,000 13,476,563 4,492,188 17,968,750 14,648,438 4,882,813 19,531,250 17,578,125 5,859,375 23,437,500 345 Wide excision of Soft tissue tumor 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL 1 Pasang IUD 146,484 48,828 195,313 168,457 56,152 224,609 183,105 61,035 244,141 219,727 73,242 292,969 2 Ektraksi IUD 146,484 48,828 195,313 168,457 56,152 224,609 183,105 61,035 244,141 219,727 73,242 292,969 3 Pasang Implant 146,484 48,828 195,313 168,457 56,152 224,609 183,105 61,035 244,141 219,727 73,242 292,969 4 Aff Implan 195,313 65,104 260,417 224,609 74,870 299,479 244,141 81,380 325,521 292,969 97,656 390,625 5 Kolposkopi 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 6 Kardiotokografi 292,969 97,656 390,625 336,914 112,305 449,219 366,211 122,070 488,281 439,453 146,484 585,938 7 Papsmear 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 8 IVA #VALUE! #VALUE! Gratis #VALUE! #VALUE! Gratis #VALUE! #VALUE! Gratis #VALUE! #VALUE! Gratis 9 Biopsi 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 10 Hidrotubasi 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 11 Inseminasi 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 12 Swim up sperma + inseminasi 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 13 Histeroskopi Office 976,563 325,521 1,302,083 1,123,047 374,349 1,497,396 1,220,703 406,901 1,627,604 1,464,844 488,281 1,953,125 14 Kriosurgery 439,453 146,484 585,938 505,371 168,457 673,828 549,316 183,105 732,422 659,180 219,727 878,906 15 Irigasi/vaginal toilet 292,969 97,656 390,625 336,914 112,305 449,219 366,211 122,070 488,281 439,453 146,484 585,938 16 Mikrokuret 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 17 Punksi cavum Douglas 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 18 Pasang + laminaria 292,969 97,656 390,625 336,914 112,305 449,219 366,211 122,070 488,281 439,453 146,484 585,938 19 Debridement Luka Operasi 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 20 Podofilin 146,484 48,828 195,313 168,457 56,152 224,609 183,105 61,035 244,141 219,727 73,242 292,969 21 Pasang pesarium 292,969 97,656 390,625 336,914 112,305 449,219 366,211 122,070 488,281 439,453 146,484 585,938 22 Swab vagina 146,484 48,828 195,313 168,457 56,152 224,609 183,105 61,035 244,141 219,727 73,242 292,969 23 Ektripasi polip 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 24 Pasang/angkat tampon 146,484 48,828 195,313 168,457 56,152 224,609 183,105 61,035 244,141 219,727 73,242 292,969 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS OBGYN RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 25 Suntik KB/Obat/vaksin 58,594 19,531 78,125 67,383 22,461 89,844 73,242 24,414 97,656 87,891 29,297 117,188 26 - Dasar 390,625 130,208 520,833 449,219 149,740 598,958 488,281 162,760 651,042 585,938 195,313 781,250 27 - Lanjut (Konsultasi tingkat IV oleh expert) 732,422 244,141 976,563 842,285 280,762 1,123,047 915,527 305,176 1,220,703 1,098,633 366,211 1,464,844 28 - Khusus (Intervensi) 1,513,672 504,557 2,018,229 1,740,723 580,241 2,320,964 1,892,090 630,697 2,522,786 2,270,508 756,836 3,027,344 29 Induksi / akselerasi persalinan 292,969 97,656 390,625 336,914 112,305 449,219 366,211 122,070 488,281 439,453 146,484 585,938 30 Partus pervaginam tanpa penyulit 1,660,156 553,385 2,213,542 1,909,180 636,393 2,545,573 2,075,195 691,732 2,766,927 2,490,234 830,078 3,320,313 31 Partus pervaginam dengan penyulit (EV-EF dll) 2,441,406 813,802 3,255,208 2,807,617 935,872 3,743,490 3,051,758 1,017,253 4,069,010 3,662,109 1,220,703 4,882,813 32 Manual plasenta post partum 292,969 97,656 390,625 336,914 112,305 449,219 366,211 122,070 488,281 439,453 146,484 585,938 33 Manual plasenta rujukan 683,594 227,865 911,458 786,133 262,044 1,048,177 854,492 284,831 1,139,323 1,025,391 341,797 1,367,188 34 Jahitan ruptur perineum grade 3 - 4 post partum, robekan serviks 976,563 325,521 1,302,083 1,123,047 374,349 1,497,396 1,220,703 406,901 1,627,604 1,464,844 488,281 1,953,125 35 Persalinan dengan embryotomi 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 36 Kuretase pascapersalinan 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 37 Kuretase abortus 1,660,156 553,385 2,213,542 1,909,180 636,393 2,545,573 2,075,195 691,732 2,766,927 2,490,234 830,078 3,320,313 38 Sectio caesaria tanpa penyulit 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 39 Section dengan penyulit (perlekatan berat, histerorafi). 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 40 Section caesaria + histerektomi obstetri 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 41 Operasi obstetri Khusus (plasenta akreta) 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 Kecil - - - - - - - - 42 Sistoskopi LEETZ 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 43 Kista Bartholin/kista Gartner 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 44 Konisasi 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 45 Ekstraksi IUD dengan anestesi 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 46 Polip serviks 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 47 Kauterisasi kondiloma akuminata 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 48 Penjahitan laserasi ringan 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 49 Drainase abses 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 50 Shirodkar 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 51 Kolpotomi pada abses cavum Douglas 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 Sedang - - - - - - - - 52 Ekstirpasi 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 53 Mioma geburt 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 54 Robekan serviks/forniks 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 55 Hematoma / ruptur 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 56 Histerorafi 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 Besar - - - - - - - - 57 Kolporafi anterior 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 58 Kolporafi posterior 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 Khusus - - - - - - - - 59 Repair fistula 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 60 Vaginoplasti 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 61 Rekonstruksi vagina 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 62 Histerektomi pervaginam + kolpoperineoplasti 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 63 Purandare 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 64 Penyulit + 50% 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 TINDAKAN GINEKOLOGI - - - - - - - - Kecil - - - - - - - - 65 Tubektomi 1,757,813 585,938 2,343,750 2,021,484 673,828 2,695,313 2,197,266 732,422 2,929,688 2,636,719 878,906 3,515,625 66 Kemoterapi 683,594 227,865 911,458 786,133 262,044 1,048,177 854,492 284,831 1,139,323 1,025,391 341,797 1,367,188 Sedang - - - - - - - - 67 Kehamilan ektopik 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 68 Miomektomi 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 69 Kistektomi 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 70 Salpingo-ooforektomi 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 71 Pemasangan Implan Tableport 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 72 Laparotomi Diagnostik 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 73 Ligasi Arteri Hipogastrica / Uterina 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 74 Ekstirpasi Giant Condiloma 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 75 Penyulit + 50% 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 Besar - - - - - - - - 76 Histerektomi 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 77 Miomektomi 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 78 Reseksi adenomiosis 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 79 Infeksi panggul/PUS dengan perlekatan. 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 80 Adhesiolisis perlekatan berat pelvik. 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 81 Repair tuba (tubaplasti) 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 82 Transposisi Ovarium 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 83 Penyulit + 50 % 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 Khusus - - - - - - - - 84 Histerektomi radikal 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 85 Staging Laparatomi 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 86 Trachelectomy Radical Servix 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 87 Eksenterasi (Anterior Posterior) 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 88 Vulvektomi radikal 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 89 Debulking Kanker Ovarium Lanjut 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 90 Ultra Radikal Histerektomi 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 91 Operasi Frozen Pelvic 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 92 Relaparatomi High-risk complication 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 93 Penyulit + 50% 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 LAPAR OSKOP I/ - - - - - - - - Kecil - - - - - - - - 94 Tubektomi 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 95 Second Look 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 96 Histeroskopi diagnostik 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 97 Laparoskopi diagnostik 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 Sedang - - - - - - - - 98 Kistektomi 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 99 Ooforektomi/salpingektomi 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 100 Salpingoooforektomi 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 101 Eksplorasi – ektraksi IUD translokasi. 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 102 Adhesiolisis Perlekatan Ringan 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 103 Penyulit + 50% 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 104 Transposisi Ovarium 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 105 Ovareksi 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 Besar - - - - - - - - 106 Histerektomi 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 107 Miomektomi 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 108 Adhesiolisis Perlekatan berat 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 109 Reseksi endometriosis 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 110 Reseksi adenomiosis 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 111 Histeroskopi operatif 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 112 Rekanalisasi tuba 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 113 Laparaskopi histerektomi radikal 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 114 Laparaskopi Histerektomi / Kistektomi / Adesiolisis Berat 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 115 Penyulit + 50% 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 Khusus - - - - - - - - 116 Onkologi 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 117 Penyulit + 50 % 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL OTOLOGI - - - - - - - - 1 Ekstraksi Benda Asing Telinga 4,174,805 1,391,602 5,566,406 4,801,025 1,600,342 6,401,367 5,218,506 1,739,502 6,958,008 6,262,207 2,087,402 8,349,609 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS THT RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 2 Hecting Laserasi Telinga Luar 4,394,531 1,464,844 5,859,375 5,053,711 1,684,570 6,738,281 5,493,164 1,831,055 7,324,219 6,591,797 2,197,266 8,789,063 3 Biopsi Liang Telinga 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 4 Eksisi Fistel / Abses Preauricular 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 5 Insisi dan Drainage Abses Preaurikular 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 6 Insisi Drainase Abses Retroaurikular / Mastoid 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 7 Insisi Drainase Liang Telinga 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 8 Eksisi Lesi Liang Telinga 6,152,344 2,050,781 8,203,125 7,075,195 2,358,398 9,433,594 7,690,430 2,563,477 10,253,906 9,228,516 3,076,172 12,304,688 9 Insisi dan Kompresi Pseudokista / Hematoma Aurikula 6,152,344 2,050,781 8,203,125 7,075,195 2,358,398 9,433,594 7,690,430 2,563,477 10,253,906 9,228,516 3,076,172 12,304,688 10 Kuretase Jaringan Granulasi CAE 6,152,344 2,050,781 8,203,125 7,075,195 2,358,398 9,433,594 7,690,430 2,563,477 10,253,906 9,228,516 3,076,172 12,304,688 11 Pelepasan Grommet 7,470,703 2,490,234 9,960,938 8,591,309 2,863,770 11,455,078 9,338,379 3,112,793 12,451,172 11,206,055 3,735,352 14,941,406 12 Miringotomi 7,910,156 2,636,719 10,546,875 9,096,680 3,032,227 12,128,906 9,887,695 3,295,898 13,183,594 11,865,234 3,955,078 15,820,313 13 Pemasangan Grommet 7,910,156 2,636,719 10,546,875 9,096,680 3,032,227 12,128,906 9,887,695 3,295,898 13,183,594 11,865,234 3,955,078 15,820,313 14 Injeksi Telinga Dalam 8,349,609 2,783,203 11,132,813 9,602,051 3,200,684 12,802,734 10,437,012 3,479,004 13,916,016 12,524,414 4,174,805 16,699,219 15 Mastoidektomi Sederhana 9,667,969 3,222,656 12,890,625 11,118,164 3,706,055 14,824,219 12,084,961 4,028,320 16,113,281 14,501,953 4,833,984 19,335,938 16 Biopsi Telinga Tengah dan Dalam 9,887,695 3,295,898 13,183,594 11,370,850 3,790,283 15,161,133 12,359,619 4,119,873 16,479,492 14,831,543 4,943,848 19,775,391 17 Eksisi Neoplasma Telinga 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 18 Timpanoplasti Tipe 1 / Miringoplasti 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 19 Kanaloplasti / Meatoplasti 11,425,781 3,808,594 15,234,375 13,139,648 4,379,883 17,519,531 14,282,227 4,760,742 19,042,969 17,138,672 5,712,891 22,851,563 20 Mastoidektomi Radikal 14,062,500 4,687,500 18,750,000 16,171,875 5,390,625 21,562,500 17,578,125 5,859,375 23,437,500 21,093,750 7,031,250 28,125,000 21 Timpanoplasti Tipe II, III, IV, V 14,062,500 4,687,500 18,750,000 16,171,875 5,390,625 21,562,500 17,578,125 5,859,375 23,437,500 21,093,750 7,031,250 28,125,000 RHINOLOGI - - - - - - - - 1 Pengangkatan Tampon Hidung 3,955,078 1,318,359 5,273,438 4,548,340 1,516,113 6,064,453 4,943,848 1,647,949 6,591,797 5,932,617 1,977,539 7,910,156 2 Ekstraksi Benda Asing Hidung 3,955,078 1,318,359 5,273,438 4,548,340 1,516,113 6,064,453 4,943,848 1,647,949 6,591,797 5,932,617 1,977,539 7,910,156 3 Penggantian Tampon Hidung 4,394,531 1,464,844 5,859,375 5,053,711 1,684,570 6,738,281 5,493,164 1,831,055 7,324,219 6,591,797 2,197,266 8,789,063 4 Insisi Abses Hidung / Septum 4,614,258 1,538,086 6,152,344 5,306,396 1,768,799 7,075,195 5,767,822 1,922,607 7,690,430 6,921,387 2,307,129 9,228,516 5 Kontrol Epistaksis dengan Tampon Anterior 4,614,258 1,538,086 6,152,344 5,306,396 1,768,799 7,075,195 5,767,822 1,922,607 7,690,430 6,921,387 2,307,129 9,228,516 6 Kontrol Epistaksis dengan Tampon Posterior 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 7 Kontrol Epistaksis dengan Kauterisasi dan Tampon 5,712,891 1,904,297 7,617,188 6,569,824 2,189,941 8,759,766 7,141,113 2,380,371 9,521,484 8,569,336 2,856,445 11,425,781 8 Biopsi Lesi Jinak Sinonasal dengan Endoskop 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 9 Irigasi Sinus dari Ostium Alamiah 5,932,617 1,977,539 7,910,156 6,822,510 2,274,170 9,096,680 7,415,771 2,471,924 9,887,695 8,898,926 2,966,309 11,865,234 10 Irigasi Sinus 6,152,344 2,050,781 8,203,125 7,075,195 2,358,398 9,433,594 7,690,430 2,563,477 10,253,906 9,228,516 3,076,172 12,304,688 11 Caldwell Luc 6,591,797 2,197,266 8,789,063 7,580,566 2,526,855 10,107,422 8,239,746 2,746,582 10,986,328 9,887,695 3,295,898 13,183,594 12 Konkotomi 7,690,430 2,563,477 10,253,906 8,843,994 2,947,998 11,791,992 9,613,037 3,204,346 12,817,383 11,535,645 3,845,215 15,380,859 13 Polipektomi Nasal 7,690,430 2,563,477 10,253,906 8,843,994 2,947,998 11,791,992 9,613,037 3,204,346 12,817,383 11,535,645 3,845,215 15,380,859 14 Reduksi Konka dengan Kauter / RD 7,690,430 2,563,477 10,253,906 8,843,994 2,947,998 11,791,992 9,613,037 3,204,346 12,817,383 11,535,645 3,845,215 15,380,859 15 Revisi Sinekia Hidung 8,349,609 2,783,203 11,132,813 9,602,051 3,200,684 12,802,734 10,437,012 3,479,004 13,916,016 12,524,414 4,174,805 16,699,219 16 Reduksi Fraktur Nasal Tertutup 8,349,609 2,783,203 11,132,813 9,602,051 3,200,684 12,802,734 10,437,012 3,479,004 13,916,016 12,524,414 4,174,805 16,699,219 17 Antrotomi Intranasal (FESS) 10,327,148 3,442,383 13,769,531 11,876,221 3,958,740 15,834,961 12,908,936 4,302,979 17,211,914 15,490,723 5,163,574 20,654,297 18 Penutupan Fistel Sinus 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 19 Ethmoidektomi (FESS) 12,744,141 4,248,047 16,992,188 14,655,762 4,885,254 19,541,016 15,930,176 5,310,059 21,240,234 19,116,211 6,372,070 25,488,281 20 Sfenoidektomi (FESS) 14,062,500 4,687,500 18,750,000 16,171,875 5,390,625 21,562,500 17,578,125 5,859,375 23,437,500 21,093,750 7,031,250 28,125,000 21 Sinusektomi Sinus Frontal (FESS) 14,062,500 4,687,500 18,750,000 16,171,875 5,390,625 21,562,500 17,578,125 5,859,375 23,437,500 21,093,750 7,031,250 28,125,000 22 Septoplasti Dengan Endoskopi 14,062,500 4,687,500 18,750,000 16,171,875 5,390,625 21,562,500 17,578,125 5,859,375 23,437,500 21,093,750 7,031,250 28,125,000 LARING-FARING - - - - - - - - - - - - 1 Penggantian Nasogastric Tube (NGT) 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 2 Pembersihan Kanul Trakeostomi 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 3 Pengangkatan Kanul Trakeostomi 3,735,352 1,245,117 4,980,469 4,295,654 1,431,885 5,727,539 4,669,189 1,556,396 6,225,586 5,603,027 1,867,676 7,470,703 4 Penggantian Kanul Trakeostomi 4,174,805 1,391,602 5,566,406 4,801,025 1,600,342 6,401,367 5,218,506 1,739,502 6,958,008 6,262,207 2,087,402 8,349,609 5 Ekstraksi Benda Asing Faring 4,614,258 1,538,086 6,152,344 5,306,396 1,768,799 7,075,195 5,767,822 1,922,607 7,690,430 6,921,387 2,307,129 9,228,516 6 Ekstraksi Benda Asing Mulut 4,614,258 1,538,086 6,152,344 5,306,396 1,768,799 7,075,195 5,767,822 1,922,607 7,690,430 6,921,387 2,307,129 9,228,516 7 Ekstraksi Benda Asing Tonsil / Adenoid dengan Insisi 6,152,344 2,050,781 8,203,125 7,075,195 2,358,398 9,433,594 7,690,430 2,563,477 10,253,906 9,228,516 3,076,172 12,304,688 8 Hecting Laserasi Faring 4,174,805 1,391,602 5,566,406 4,801,025 1,600,342 6,401,367 5,218,506 1,739,502 6,958,008 6,262,207 2,087,402 8,349,609 9 Hecting Laserasi Lidah 4,174,805 1,391,602 5,566,406 4,801,025 1,600,342 6,401,367 5,218,506 1,739,502 6,958,008 6,262,207 2,087,402 8,349,609 10 Hecting Laserasi Palatum 4,174,805 1,391,602 5,566,406 4,801,025 1,600,342 6,401,367 5,218,506 1,739,502 6,958,008 6,262,207 2,087,402 8,349,609 11 Tonsilektomi 7,910,156 2,636,719 10,546,875 9,096,680 3,032,227 12,128,906 9,887,695 3,295,898 13,183,594 11,865,234 3,955,078 15,820,313 12 Adenoidektomi 7,470,703 2,490,234 9,960,938 8,591,309 2,863,770 11,455,078 9,338,379 3,112,793 12,451,172 11,206,055 3,735,352 14,941,406 13 Tonsilektomi dengan Adenoidektomi 8,349,609 2,783,203 11,132,813 9,602,051 3,200,684 12,802,734 10,437,012 3,479,004 13,916,016 12,524,414 4,174,805 16,699,219 14 Kontrol Perdarahan Pasca Tonsilektomi & Adenoidektomi 7,470,703 2,490,234 9,960,938 8,591,309 2,863,770 11,455,078 9,338,379 3,112,793 12,451,172 11,206,055 3,735,352 14,941,406 15 Laringoskopi Direct 7,470,703 2,490,234 9,960,938 8,591,309 2,863,770 11,455,078 9,338,379 3,112,793 12,451,172 11,206,055 3,735,352 14,941,406 16 Sleep Endoscopy 7,470,703 2,490,234 9,960,938 8,591,309 2,863,770 11,455,078 9,338,379 3,112,793 12,451,172 11,206,055 3,735,352 14,941,406 17 Trakeostomi 8,129,883 2,709,961 10,839,844 9,349,365 3,116,455 12,465,820 10,162,354 3,387,451 13,549,805 12,194,824 4,064,941 16,259,766 18 Insisi Drainase Abses Wajah / Submandibula / Angina Ludovici 9,448,242 3,149,414 12,597,656 10,865,479 3,621,826 14,487,305 11,810,303 3,936,768 15,747,070 14,172,363 4,724,121 18,896,484 19 Insisi Drainase Abses Tonsil/Peritonsil/Parafaring/Retrofaring 9,887,695 3,295,898 13,183,594 11,370,850 3,790,283 15,161,133 12,359,619 4,119,873 16,479,492 14,831,543 4,943,848 19,775,391 20 Ekstraksi Benda Asing Laring 9,448,242 3,149,414 12,597,656 10,865,479 3,621,826 14,487,305 11,810,303 3,936,768 15,747,070 14,172,363 4,724,121 18,896,484 BRONKOESOFAGOLOGI - - - - - - - - 1 Esofageal Manometri 6,152,344 2,050,781 8,203,125 7,075,195 2,358,398 9,433,594 7,690,430 2,563,477 10,253,906 9,228,516 3,076,172 12,304,688 2 Trakeoskopi melalui Stoma Trakea 7,470,703 2,490,234 9,960,938 8,591,309 2,863,770 11,455,078 9,338,379 3,112,793 12,451,172 11,206,055 3,735,352 14,941,406 3 Esofagoskopi 9,228,516 3,076,172 12,304,688 10,612,793 3,537,598 14,150,391 11,535,645 3,845,215 15,380,859 13,842,773 4,614,258 18,457,031 4 Ekstraksi Benda Asing Esofagus 9,887,695 3,295,898 13,183,594 11,370,850 3,790,283 15,161,133 12,359,619 4,119,873 16,479,492 14,831,543 4,943,848 19,775,391 5 Bronkoskopi 13,842,773 4,614,258 18,457,031 15,919,189 5,306,396 21,225,586 17,303,467 5,767,822 23,071,289 20,764,160 6,921,387 27,685,547 6 Ekstraksi Benda Asing Bronkus 17,138,672 5,712,891 22,851,563 19,709,473 6,569,824 26,279,297 21,423,340 7,141,113 28,564,453 25,708,008 8,569,336 34,277,344 PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL 1 Konsultasi 371,094 123,698 494,792 426,758 142,253 569,010 463,867 154,622 618,490 556,641 185,547 742,188 2 Bedah Skapel I 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 3 Bedah Skapel II 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 4 Bedah Skapel III 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 5 skin graft 1 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 6 skin graft 2 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 7 skin flap 1 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 8 skin flap 2 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 9 Bedah Listrik I 2,636,719 878,906 3,515,625 3,032,227 1,010,742 4,042,969 3,295,898 1,098,633 4,394,531 3,955,078 1,318,359 5,273,438 10 Bedah Listrik II 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 11 Bedah Listrik III 2,832,031 944,010 3,776,042 3,256,836 1,085,612 4,342,448 3,540,039 1,180,013 4,720,052 4,248,047 1,416,016 5,664,063 12 Steroid Intralesi I 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 13 Steroid Intralesi II 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 14 Steroid Intralesi III 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 15 Angkat jahitan / Ganti verban 341,797 113,932 455,729 393,066 131,022 524,089 427,246 142,415 569,661 512,695 170,898 683,594 16 Nitrogen cair I 1,855,469 618,490 2,473,958 2,133,789 711,263 2,845,052 2,319,336 773,112 3,092,448 2,783,203 927,734 3,710,938 17 Nitrogen cair II 1,855,469 618,490 2,473,958 2,133,789 711,263 2,845,052 2,319,336 773,112 3,092,448 2,783,203 927,734 3,710,938 18 Nitrogen cair III 1,855,469 618,490 2,473,958 2,133,789 711,263 2,845,052 2,319,336 773,112 3,092,448 2,783,203 927,734 3,710,938 19 Ekstrasi komedo I 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 20 Ekstrasi komedo II 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 21 Ekstrasi komedo III 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 22 Subsicion I (1- 2 lesi) 927,734 309,245 1,236,979 1,066,895 355,632 1,422,526 1,159,668 386,556 1,546,224 1,391,602 463,867 1,855,469 23 Subsicion II (3-5 lesi) 976,563 325,521 1,302,083 1,123,047 374,349 1,497,396 1,220,703 406,901 1,627,604 1,464,844 488,281 1,953,125 24 Subsicion III (6-8 lesi) 1,025,391 341,797 1,367,188 1,179,199 393,066 1,572,266 1,281,738 427,246 1,708,984 1,538,086 512,695 2,050,781 25 Cantharidin I (< 5 lesi) 927,734 309,245 1,236,979 1,066,895 355,632 1,422,526 1,159,668 386,556 1,546,224 1,391,602 463,867 1,855,469 26 Cantharidin II (> 5 lesi) 927,734 309,245 1,236,979 1,066,895 355,632 1,422,526 1,159,668 386,556 1,546,224 1,391,602 463,867 1,855,469 27 Enukleasi moluskum I (1 - 5 Lesi) 927,734 309,245 1,236,979 1,066,895 355,632 1,422,526 1,159,668 386,556 1,546,224 1,391,602 463,867 1,855,469 28 Enukleasi moluskum II (> 5 lesi) 976,563 325,521 1,302,083 1,123,047 374,349 1,497,396 1,220,703 406,901 1,627,604 1,464,844 488,281 1,953,125 29 Uji tusuk Standar 1,269,531 423,177 1,692,708 1,459,961 486,654 1,946,615 1,586,914 528,971 2,115,885 1,904,297 634,766 2,539,063 30 Uji tusuk obat 1,269,531 423,177 1,692,708 1,459,961 486,654 1,946,615 1,586,914 528,971 2,115,885 1,904,297 634,766 2,539,063 31 Uji tempel Standar 1,367,188 455,729 1,822,917 1,572,266 524,089 2,096,354 1,708,984 569,661 2,278,646 2,050,781 683,594 2,734,375 32 Uji tempel obat 1,367,188 455,729 1,822,917 1,572,266 524,089 2,096,354 1,708,984 569,661 2,278,646 2,050,781 683,594 2,734,375 33 Uji penisilin 1,367,188 455,729 1,822,917 1,572,266 524,089 2,096,354 1,708,984 569,661 2,278,646 2,050,781 683,594 2,734,375 34 Uji Provokasi obat 1,367,188 455,729 1,822,917 1,572,266 524,089 2,096,354 1,708,984 569,661 2,278,646 2,050,781 683,594 2,734,375 35 Uji Serum autolog 1,269,531 423,177 1,692,708 1,459,961 486,654 1,946,615 1,586,914 528,971 2,115,885 1,904,297 634,766 2,539,063 36 UV Localized I 1,220,703 406,901 1,627,604 1,403,809 467,936 1,871,745 1,525,879 508,626 2,034,505 1,831,055 610,352 2,441,406 37 UV Whole body II 1,220,703 406,901 1,627,604 1,403,809 467,936 1,871,745 1,525,879 508,626 2,034,505 1,831,055 610,352 2,441,406 38 Peeling Wajah ( AHA , TCA ) 1,269,531 423,177 1,692,708 1,459,961 486,654 1,946,615 1,586,914 528,971 2,115,885 1,904,297 634,766 2,539,063 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS KULIT KELAMIN RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 39 Peeling wajah & Leher ( AHA, TCA ) 1,269,531 423,177 1,692,708 1,459,961 486,654 1,946,615 1,586,914 528,971 2,115,885 1,904,297 634,766 2,539,063 40 Laser CO2 1 2,636,719 878,906 3,515,625 3,032,227 1,010,742 4,042,969 3,295,898 1,098,633 4,394,531 3,955,078 1,318,359 5,273,438 41 Laser CO2 II 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 42 Laser CO2 III 2,832,031 944,010 3,776,042 3,256,836 1,085,612 4,342,448 3,540,039 1,180,013 4,720,052 4,248,047 1,416,016 5,664,063 43 Injeksi Filler I ( 1 syringe) 3,662,109 1,220,703 4,882,813 4,211,426 1,403,809 5,615,234 4,577,637 1,525,879 6,103,516 5,493,164 1,831,055 7,324,219 44 Injeksi Filler II (2 syringe) 3,808,594 1,269,531 5,078,125 4,379,883 1,459,961 5,839,844 4,760,742 1,586,914 6,347,656 5,712,891 1,904,297 7,617,188 45 Injeksi Botox I (< 50 unit) 3,662,109 1,220,703 4,882,813 4,211,426 1,403,809 5,615,234 4,577,637 1,525,879 6,103,516 5,493,164 1,831,055 7,324,219 46 Injeksi Botox II (> 50 unit) 3,808,594 1,269,531 5,078,125 4,379,883 1,459,961 5,839,844 4,760,742 1,586,914 6,347,656 5,712,891 1,904,297 7,617,188 47 Pengambilan spesimen kerokan kulit + Woods lamp 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 48 Pemeriksaan spesimen pus untuk Gram 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 49 Pengambilan spesimen kerokan kulit utk KOH /kultur 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 50 Clamidia quick strip 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 51 Peniskopi 927,734 309,245 1,236,979 1,066,895 355,632 1,422,526 1,159,668 386,556 1,546,224 1,391,602 463,867 1,855,469 52 Insisi Abses 976,563 325,521 1,302,083 1,123,047 374,349 1,497,396 1,220,703 406,901 1,627,604 1,464,844 488,281 1,953,125 53 Podopilin 25 % I (1 - 5 Lesi) 927,734 309,245 1,236,979 1,066,895 355,632 1,422,526 1,159,668 386,556 1,546,224 1,391,602 463,867 1,855,469 54 Podopilin 25 % II (> 5 Lesi) 927,734 309,245 1,236,979 1,066,895 355,632 1,422,526 1,159,668 386,556 1,546,224 1,391,602 463,867 1,855,469 55 Pengambilan Spesimen Duh Pria 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 56 Pengambilan Spesimen Duh Wanita tanpa spekulum 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 57 Pengambilan Spesimen Duh Wanita dengan spekulum 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 58 Pemeriksaan Ph Vagina 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 59 Tes amin 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 60 Tes Asam asetat 488,281 162,760 651,042 561,523 187,174 748,698 610,352 203,451 813,802 732,422 244,141 976,563 61 Biopsi I 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 62 Biopsi II 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 63 Biopsi III 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 64 Laser V Beam I (< 50) 2,636,719 878,906 3,515,625 3,032,227 1,010,742 4,042,969 3,295,898 1,098,633 4,394,531 3,955,078 1,318,359 5,273,438 65 Laser V Beam II (< 51-100) 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 66 Laser V Beam III (>100-120) 2,832,031 944,010 3,776,042 3,256,836 1,085,612 4,342,448 3,540,039 1,180,013 4,720,052 4,248,047 1,416,016 5,664,063 67 Laser NDYag I (1/4 wajah) 2,636,719 878,906 3,515,625 3,032,227 1,010,742 4,042,969 3,295,898 1,098,633 4,394,531 3,955,078 1,318,359 5,273,438 68 Laser NDYag II (1/2 wajah) 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 69 Laser NDYag III 2,832,031 944,010 3,776,042 3,256,836 1,085,612 4,342,448 3,540,039 1,180,013 4,720,052 4,248,047 1,416,016 5,664,063 70 Miniliposuction perut (satu sisi) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 71 Miniliposuction paha (satu sisi) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 72 Miniliposuction lengan atas (satu sisi) 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 73 Miniliposuction punggung (satu sisi) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 74 Fat Transfer 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 75 Perawatan Ulkus I (1-5 lesi) 976,563 325,521 1,302,083 1,123,047 374,349 1,497,396 1,220,703 406,901 1,627,604 1,464,844 488,281 1,953,125 76 Perawatan Ulkus II (5 lesi) 1,074,219 358,073 1,432,292 1,235,352 411,784 1,647,135 1,342,773 447,591 1,790,365 1,611,328 537,109 2,148,438 77 debridement 1,855,469 618,490 2,473,958 2,133,789 711,263 2,845,052 2,319,336 773,112 3,092,448 2,783,203 927,734 3,710,938 78 face lift I (1/3 atas) (satu sisi) 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 79 face lift II (2/3 atas) (satu sisi) 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL HAND - - - - - - - - 1 Jari, extra digit, amputasi 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 2 Jari, various lesions, Ray amputasi (single) 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 3 Jari, various lesions, amputasi (multiple) 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 4 Jari, polydactyly, amputasi with rekonstruksi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 5 Jari, various, amputation (single) ** 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 6 Angkat K-Wire with anestesia regional 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 7 Sendi (wrist), various lesions, arthrodesis 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 8 Nerve, Various Lesions, biopsy 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 9 Sendi (jari), contracture, capsulectomy/ capsulotomy 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 10 Jari, injury, debridement 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS ORTHOPAEDI & TRAUMATOLOGI RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 11 Jari, crush injuries (complex) wound debridement 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 12 Jari, crush injury (simple), wound debridement 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 13 Jari, macrodactyly, debulking 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 14 Nerve (Ekstremitas atas), Entrapment Syndrome (other), Decompression (unilateral) 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 15 Nerve (ekstremitas atas), entrapment syndrome (other) decompression (bilateral) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 16 Nerve (ekstremitas atas), entrapment syndrome (other) decompression with nerve transportation/ endoneurolysis 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 17 Tendon sheath (ekstremitas atas), tenosynovitis (multiple), drainage 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 18 Tendon Sheath (extremitas atas), tenosynovitis (single), drainage 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 19 Jari, superficial infection, drainage 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 20 Jari, deep infection, drainage 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 21 Jaringan lunak (palmar space), abscess, drainage 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 22 Jari, jaringan lunak tumor, excision 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 23 Jari, wart/com/naevus, excision 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 24 Tendon sheath (extremitas atas) ganglion / villo nodular synovitis, excision 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 25 Tendon Sheath & jaringan Subkutis, ganglion/small bursa, excision 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 26 Elbow (medical epicondyle), fracture, excision bony fragment 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 27 Jari, tumors, excision with dissection of neurovasculer bundle 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 28 Kulit dan jaringan subkus, defect (deep) staged distant flap (division) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 29 Kulit dan jaringan subkultis, Defect (single digit), free full thickness graft 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 30 Nerve defect, peripheral graft 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 31 Tendon-flexor (ekstremitas atas) injury, tendon graft 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 32 Tendon-flexor (ekstremitas atas), Defect grafting (single) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 33 Jari, ring construction (single), koreksi 11,523,438 3,841,146 15,364,583 13,251,953 4,417,318 17,669,271 14,404,297 4,801,432 19,205,729 17,285,156 5,761,719 23,046,875 34 Thumb, Deformitas, Koreksi 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 35 Jari, ring cnstriction (multiple), koreksi 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 36 Jari, swan neck/ Boutonniere deformity (single), koreksi 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 37 Jari, deformities, koreksi 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 38 Jari, Syndactyly (single) koreksi 11,523,438 3,841,146 15,364,583 13,251,953 4,417,318 17,669,271 14,404,297 4,801,432 19,205,729 17,285,156 5,761,719 23,046,875 39 Kulit dan jaringan subkutis, defect (multiple digits) staged local flap (division) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 40 Thumb, paralysis, oppnens plasty 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 41 Jari, deformities, osteotomy 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 42 Tendon (ekstremitas atas), Bowstringing/entrapment, pulley rekonstruksi 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 43 Carpus, fracture/dislocation, reduksi terbuka dan fiksasi interna * 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 44 Jari, fracture/dislocation, reduksi terbuka dan fiksasi interna (multiple) * 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 45 Jari, Closed Tracture/ dislocation, reduksi terbuka dan fixation (single) 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 46 Jari, deformities, major reconstruction procedure 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 47 Jari, Defect/contracture (single) Rekonstruksi 15,039,063 5,013,021 20,052,083 17,294,922 5,764,974 23,059,896 18,798,828 6,266,276 25,065,104 22,558,594 7,519,531 30,078,125 48 Jari, defect/contracture (multiple) rekonstruksi 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 49 Carpus, delayed/non union, rekonstruksi 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 50 Nerve (Ekstremitas atas), Guyon's Tunnel Syndrome, Release (unilateral) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 51 Tendon Sheath (ekstremitas atas), De Quervain's (unilateral), Release 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 52 Tendon Sheath (Ekstremitas atas), Trigger Jari (multiple), Release 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 53 Nerve (ekstremitas atas), carpal tunnel syndorme, release (bilateral with 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 54 Nerve (ekstremitas atas), Guyon's tunnel syndrome, release (bilateral with endoneurolysis) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 55 Tendon Sheath (ekstremitas atas), De Quarvain's (bilateral), release 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 56 Jari, syndactyly (multiple) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 57 Elbow, tennis elbow, release 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 58 Jari, deformity, instrinsic muscle release 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 59 Tendon sheath (extremitas atas), trigger jari (single) release 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 60 Jari, deformity, instrinsic muscle extensor relocation 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 61 Sendi (Extremitas Atas) Rush Rods / Wires / Screw Removal 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 62 Jari, foreign body (superficial), removal with mobilization of neurovascular bundle 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 63 Tendon-extensor (extremitas atas) injury, repair (single) 11,523,438 3,841,146 15,364,583 13,251,953 4,417,318 17,669,271 14,404,297 4,801,432 19,205,729 17,285,156 5,761,719 23,046,875 64 Tendon-extensor (ekstremitas atas) injury, repair (multiple) 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 65 Nail bed, Laceration, repair (single) 11,523,438 3,841,146 15,364,583 13,251,953 4,417,318 17,669,271 14,404,297 4,801,432 19,205,729 17,285,156 5,761,719 23,046,875 66 Artery, large, injury, repair with grafting 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 67 Nerve digital, injury, primary repair 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 68 Kulit dan Jaringan subkutis, laceration ( superficial ) of more than 7 cm , repair 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 69 Nerve-digital, injury, microsurgical repair (multiple) 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 70 Nail Bed, Laceration, Repair (multiple) 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 71 Nerve digital, Injury, microsurgical (single) 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 72 Nerve (ekstremitas atas), major, injury, microsurgical, repair (single) 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 73 Nerve various lesions, primary/ secondary suture 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 74 Sendi (jari), various lesions, replacement arthoplasty 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 75 Replantasi 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 76 Jari/Digit, Stump, Revision 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 77 Jari, Scar, Revision Osteotomy 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 78 Tendon-flexor (ekstremitas atas) adhesion, tenolysis (single) 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 79 Tendon-flexor (ekstremitas atas), adhesion, Tenolysis (multiple) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 80 Tendon (wkstremitas atas) , contracture, tenotomy 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 81 Jari, Trauma, Terminalisation (single) 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 82 Jari, trauma, terminalisation (multiple) 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 83 Jari, deformity, instrinsic muscle transfer 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 23,437,500 7,812,500 31,250,000 84 Nerve ulnar, entrapment, transposition 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 SPINE - - - - - - - - 1 Plaster application of the spine 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 2 Facet Block Multilevel 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 3 Facet Block (1 level) 12,304,688 4,101,563 16,406,250 14,150,391 4,716,797 18,867,188 15,380,859 5,126,953 20,507,813 18,457,031 6,152,344 24,609,375 4 Foraminal Block Multilevel 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 5 Foraminal Block (1 level) 12,304,688 4,101,563 16,406,250 14,150,391 4,716,797 18,867,188 15,380,859 5,126,953 20,507,813 18,457,031 6,152,344 24,609,375 6 Manipulation & Reduction of simple fracture and dislocation with general anaesthesia 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 7 Biopsy Vertebra (1 level) * 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 8 Anterior Cervical Corpectomy + Fusion (ACCF) * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 9 Anterior cervcal discetomy + Fusion (ACDF) * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 10 Anterior dan Posterior Surgery in Spinal Disease with Stabilization/ Instrumentation. 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 11 Anterior dan Posterior Surgery in Deformity with Stabilization/ Instrumentation. 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 12 Scoliosis kurva kurang dari 70o Corrective Surgery * 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 13 Spinal Osteotomy for Ankylossing Spondylitis* 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 14 Scoliosis kurva lebih dari 70o Corrective Surgery * 26,757,813 8,919,271 35,677,083 30,771,484 10,257,161 41,028,646 33,447,266 11,149,089 44,596,354 40,136,719 13,378,906 53,515,625 15 Spinal Osteotomy for Ankylossing Spondylitis dengan forward gaze kurang dari 3 m * 26,757,813 8,919,271 35,677,083 30,771,484 10,257,161 41,028,646 33,447,266 11,149,089 44,596,354 40,136,719 13,378,906 53,515,625 16 Mayor desloughing, wound debridement of the spine * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 17 Debridement and anterior fusion in TB Spine * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 18 Total Disc Replacement (Multilevel) * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 19 Discograph (1 level) * 12,304,688 4,101,563 16,406,250 14,150,391 4,716,797 18,867,188 15,380,859 5,126,953 20,507,813 18,457,031 6,152,344 24,609,375 20 Discograph Multilevel * 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 21 Open Disestomy (1 Level)--> Alat Medis Khusus * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 22 Micro endoscopic Disectomy (1 level) * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 23 Microscopic Disectomy (1 Level) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 24 Open Disectomy Multilevel * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 25 Posterolateral Fusion * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 26 Alar transverse fusion * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 27 Laminectomy (1 Level) pada simple spine stenosis * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 28 Decompression Laminectomy for Spondilolisthesis + Stabilization * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 29 Decompression Laminectomy for Tumor and Spinal Stenosis with Stabilization 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 30 Decompression Laminectomy for HNP with Stabilization * 16,212,559 5,404,186 21,616,745 18,644,442 6,214,814 24,859,257 20,265,698 6,755,233 27,020,931 24,318,838 8,106,279 32,425,117 31 Open Reduction and stabilisation of Spinal Fracture * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 32 Posterior Lumbar Interbody Fusion (FLIF) + Posterior stabilisation * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 33 Posterior Cervical Fusion * 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 34 Removal of implants (Plate, Nail, Screw) * 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 35 Arthroscopy Debridement Knee 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 36 Arthroscopy Diagnostic Shoulder 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 37 Arthroscopy Remove Loose Body 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 38 Arthroscopy Debridement Shoulder 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 39 Rotator Cuff Repair by Arthroscopy 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 40 Arthroscopy Meniscus Repair 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 41 Arthroscopy Minisectomy, Arthroscopy Synevectomy Knee 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 42 Arthroscopy Remove Loose Body Shoulder 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 43 Arthroscopy Diagnostic 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 44 Open Knee Debridement 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 45 Shoulder Hemiarthroplasty 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 46 Anterior Cruciate Ligament Reconstruction 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 47 Posterior Cruciate Ligamnet Reconstruction 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 48 Lateral Collateral Ligament Reconstruction 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 49 Medial Collateral Ligament Reconstruction 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 50 Recurrent Shoulder Dislocation Repair TUBS and AMBRI 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 51 Revisi Total knee replacement 14,648,438 4,882,813 19,531,250 16,845,703 5,615,234 22,460,938 18,310,547 6,103,516 24,414,063 21,972,656 7,324,219 29,296,875 52 Revisi Total Shoulder replacement 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 53 Total Knee Replacement 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 54 Total Shoulder Replacement 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 ONCOLOGY - - - - - - - - 1 Ray Amputation Jari 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 2 Open Biopsy : Soft Tissue 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 3 Open Biopsy Bone Tumor 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 4 Tumor jinak tulang ( curettage + bonegraft) 10,937,500 3,645,833 14,583,333 12,578,125 4,192,708 16,770,833 13,671,875 4,557,292 18,229,167 16,406,250 5,468,750 21,875,000 5 Marginal margine Excision Soft Tissue Tumor 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 6 Wide excision Soft Tisue Sarcoma/ 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 7 Excision Soft Tissue Tumor < 5 cm (kecil) 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 8 Hemiartroplasty : Metastatic Bone Disease 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 9 Hemipelvectomy 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 10 Limb ablation: above/below knee amputation Soft Tissue Tumor/sarcoma 12,695,313 4,231,771 16,927,083 14,599,609 4,866,536 19,466,146 15,869,141 5,289,714 21,158,854 19,042,969 6,347,656 25,390,625 11 Limb ablation : above /below knee amputation Bone Tumor 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 12 Forequarter amputation 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 13 Limb salvage Surgery Tahap 1 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 14 Limb salvage Surgery Tahap 2 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 15 Limb salvage Surgery : resection adan rekonstruksi dengan fibular transfer/hemiartroplasty 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 16 Limb salvage Surgery : Tumor Resection only 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 17 Limb salvage Surgery : Scapular Reconstruction 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 18 Limb salvage Surgery :dan rekonstruksi dengan artrodesis 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 19 ORIF : MBD 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 20 Total Patellectomy dan rekonstruksi 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 PAEDIATRIC - - - - - - - - 1 Bony bridge release pada kasus Tarsal Coalition 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 2 Reposisi tertutup dan gips pada fraktur anak kecuali fraktur femur 9,375,000 3,125,000 12,500,000 10,781,250 3,593,750 14,375,000 11,718,750 3,906,250 15,625,000 14,062,500 4,687,500 18,750,000 3 Koreksi curly toe 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 4 Koreksi overriding toe polidactily 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 5 Koreksi syrdactyly kaki 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 6 Debridement fraktur terbuka pada anak 9,375,000 3,125,000 12,500,000 10,781,250 3,593,750 14,375,000 11,718,750 3,906,250 15,625,000 14,062,500 4,687,500 18,750,000 7 Nekrotomy 9,375,000 3,125,000 12,500,000 10,781,250 3,593,750 14,375,000 11,718,750 3,906,250 15,625,000 14,062,500 4,687,500 18,750,000 8 Injeksi Botoks pada kasus Cerebral Palsy 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 9 Skin Graft 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 10 Percutaneous Tendon Tenotomy 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 11 Open Achilles Tendon Lengthening 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 12 Reposisi tertutup, Arthrogram, dan Hemispica pada DDH 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 13 Closed Reduction dan pemasangan gips fraktur femur pada anak 9,375,000 3,125,000 12,500,000 10,781,250 3,593,750 14,375,000 11,718,750 3,906,250 15,625,000 14,062,500 4,687,500 18,750,000 14 Synovectomy arthroscopy pada penderita hemoplili 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 15 Fiksasi Cannualted Screw pada SCFE 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 16 Soft tissue release pada kelainan Cerebral Palsy, Arthrogryposis, Spina Bifida, torticollis 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 17 Posteromedial soft tissue release CTEV 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 18 Soft tissue release dan Enhancement pada kasus habitual dislokasi lutut pada anak 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 19 Debridement dan soft tissue release pada infeksi sendi 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 20 Reposisi tertutup dan Percutaneous Pinning pada fraktur seputar sendi siku pada anak 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 21 Debridement, Nekrotomy, dan Saucerization pada Chronic Osteomyelits 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 22 Reposisi terbuka dan fiksasi interna fraktur tulang panjang pada anak 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 23 Tendon transfer ekstremitas bawah pada kasus Neuromuskular anak 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 24 Reposisi terbuka dan fiksasi interna kasus fraktur intra Artikular pada anak 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 25 Reposisi terbuka & Fiksasi Interna pada kasus fraktur Salter Harris III - IV 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 26 Operasi rekonstruksi ibu jari kaki pada Hallux Valgus 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 27 Double Osteotomy pelvis pada exstrophy bladder 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 28 Arthrodesis sendi ( panggul , wrist, ankle , triple arthrodesis ) 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 29 Acetabuloplasty (Salter Innominate, Pemberton, Dega) pada kasus panggul 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 30 Open Reduction dislokasi panggul tanpa Acetabuloplasty 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 31 Open Reduction dislokasi panggul dengan Acetabuloplasty dan Femoral Osteomy 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 32 Bony Reconstruction pada ekstremitas atas anak ( Misalnya malunion fraktur supracondylar, lateral condyle) 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 33 Bony Reconstruction pada ekstremitas bawah anak ( Misalnya CTEV, Blount disease, kelainan kongenital , malunion fraktur) 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 34 Limb Lengthening atau operasi rekonstruksi pada anak yang menggunakan alat khusus 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 TRAUMA - - - - - - - - 1 Joint Kompleks Destruction/ OA Post Trauma - Total Joint Arthroplasty 14,648,438 4,882,813 19,531,250 16,845,703 5,615,234 22,460,938 18,310,547 6,103,516 24,414,063 21,972,656 7,324,219 29,296,875 2 Nekrotik Tissue > 1 Kompartemen - Debridement 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 3 Nekrotik Tissue - Debridement 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 4 Jaringan Granulasi - STSG 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 5 Non Union = Bone graft 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 6 Fraktur collum femur pada orang tua 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 7 Fraktur intertrochanter femur pada orang tua 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 8 Joint Stiffness - Liberation 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 9 Multiple Fracture Tulang Panjang-MIPO/ORIF & Removal Implant > 1 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 10 Fraktur Tulang Panjang - MIPO/ORIF & Implat Removal (Long Bone) 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 11 Open Fraktur shaft tibia grade 3 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 12 Open Fraktur shaft femur grade 3 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 13 Open Fraktur shaft radius grade 3 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 14 Open Fraktur shaft ulna grade 3 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 15 Open Fraktur shaft humerus grade 3 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 16 osteomyelitis 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 17 Fracture Pelvis Simple - Fiksasi Eksterna Pelvic/ORIF Fracture Pelvic Simple 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 18 Fracture Artikuler - > MIPO/ ORIF Artikuler (Alat medik khusus) 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 19 Closed Fraktur shaft tibia 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 20 Closed Fraktur distal tibia 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 21 Closed Fraktur shaft femur * 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 22 Closed Fraktur shaft radius 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 23 Closed Fraktur shaft ulna 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 24 Closed Fraktur shaft humerus * 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 25 Fraktur subtrochanter femur pada orang tua (>60) 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 26 Open Fraktur shaft tibia grade 1 dan 2 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 27 Open Fraktur shaft femur grade 1 dan 2 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 28 Open Fraktur shaft radius grade 1 dan 2 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 29 Open Fraktur shaft ulna grade 1 dan 2 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 30 Open Fraktur shaft humerus grade 1 dan 2 10,839,844 3,613,281 14,453,125 12,465,820 4,155,273 16,621,094 13,549,805 4,516,602 18,066,406 16,259,766 5,419,922 21,679,688 31 Fraktur Acetabulum & Pelvic -ORIF Acetabulum & Pelvic 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 32 Fracture Acetabulum 1 Collum - ORIF (TR.14) 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 33 Closed Fraktur proksimal tibia involve intraartikular 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 34 Closed Fraktur supracondylar femur 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 35 Closed Fraktur intercondylar femur 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 36 Fraktur collum femur pada anak muda (<60) 10,839,844 3,613,281 14,453,125 12,465,820 4,155,273 16,621,094 13,549,805 4,516,602 18,066,406 16,259,766 5,419,922 21,679,688 37 Fraktur subtrochanter femur pada anak muda (<60) 10,839,844 3,613,281 14,453,125 12,465,820 4,155,273 16,621,094 13,549,805 4,516,602 18,066,406 16,259,766 5,419,922 21,679,688 38 Fraktur intertrochanter femur pada anak muda (<60) 10,839,844 3,613,281 14,453,125 12,465,820 4,155,273 16,621,094 13,549,805 4,516,602 18,066,406 16,259,766 5,419,922 21,679,688 39 Fraktur galeazi 10,839,844 3,613,281 14,453,125 12,465,820 4,155,273 16,621,094 13,549,805 4,516,602 18,066,406 16,259,766 5,419,922 21,679,688 40 Fraktur montegia 10,839,844 3,613,281 14,453,125 12,465,820 4,155,273 16,621,094 13,549,805 4,516,602 18,066,406 16,259,766 5,419,922 21,679,688 41 Fraktur neck humerus pada anak muda (<60) 10,839,844 3,613,281 14,453,125 12,465,820 4,155,273 16,621,094 13,549,805 4,516,602 18,066,406 16,259,766 5,419,922 21,679,688 42 Fraktur neck humerus pada orang tua (>60) 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 43 Instability Joint Infection (TR.05) 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 44 Limb Leg Inequality - Bone Lengthening Transport 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 45 Neglected Case - Bone Reconstruction 13,867,188 4,622,396 18,489,583 15,947,266 5,315,755 21,263,021 17,333,984 5,777,995 23,111,979 20,800,781 6,933,594 27,734,375 46 Kompartemen Otot 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 47 Acute Ankle joint dislocation 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 48 Acute Knee joint dislocation 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 49 Acute Hip joint dislocation 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 50 Acute elbow joint dislocation 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 51 Acute glenohumeral joint dislocation * 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 NO NAMA TINDAKAN - - - - - - - - #VALUE! #VALUE! TOTAL #VALUE! #VALUE! TOTAL #VALUE! #VALUE! TOTAL #VALUE! #VALUE! TOTAL 1 ALVEOLAR BONE GRAFT DENGAN ALLOGRAFT, GA * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 2 AMPUTASI KOMPLEK, GA 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 3 AMPUTASI SEDERHANA, GA ** 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 4 ANGKAT JAHITAN, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 5 ANKYLOSIS RELEASE, GA 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 6 BEDAH MIKRO, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 7 BIOPSI, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 8 BOUTONNNIERE DEFORMITY REPAIR, LA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 9 BURIED DERMAL FLAP (THOMPSON PROCEDURE), GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 10 CHORDEE EXCISION + URETHROPLASTY 1 TAHAP, GA 13,476,563 4,492,188 17,968,750 15,498,047 5,166,016 20,664,063 16,845,703 5,615,234 22,460,938 20,214,844 6,738,281 26,953,125 11 CHORDEE EXCISION, GA ** 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 12 CIRCUMFERENTIAL WIRING + ARCHBARR, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 13 CIRCUMSISI, LA *** 2,148,438 716,146 2,864,583 2,470,703 823,568 3,294,271 2,685,547 895,182 3,580,729 3,222,656 1,074,219 4,296,875 14 CLOSED RECUCTION + IMF(EYELET), GA 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 15 CLOSED REDUCTION + ARCHBARR, GA 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 16 CLOSED REDUCTION + BANDAGE, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 17 CLOSED REDUCTION WITH SPLINT, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 18 COMMISSUROPLASTY - COMPOSITE FLAP(MICROSURGERY), GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 19 COMMISSUROPLASTY - DIRECT CLOSURE, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 20 COMMISSUROPLASTY - EAR CARTILAGE GRAFT, LA 11,523,438 3,841,146 15,364,583 13,251,953 4,417,318 17,669,271 14,404,297 4,801,432 19,205,729 17,285,156 5,761,719 23,046,875 21 COMMISSUROPLASTY - GASTRO OMENTAL FREE FLAP(MICROSURGERY), GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 22 COMMISSUROPLASTY - JEJUNAL FREE AUTOGRAFT (MICROSURGERY), GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 23 COMMISSUROPLASTY - REGIONAL FLAP, LA 13,476,563 4,492,188 17,968,750 15,498,047 5,166,016 20,664,063 16,845,703 5,615,234 22,460,938 20,214,844 6,738,281 26,953,125 24 COMMISSUROPLASTY - SKIN FLAP LOKAL, LA 11,132,813 3,710,938 14,843,750 12,802,734 4,267,578 17,070,313 13,916,016 4,638,672 18,554,688 16,699,219 5,566,406 22,265,625 25 COMMISSUROPLASTY - SKIN GRAFT, GA 8,007,813 2669270.833 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 26 COMMISSUROPLASTY, LA 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 27 CROSS-FACIAL VERVE GRAFT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 28 DEBRIDEMEN DAN NEKROTOMI DEKUBITUS, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 29 DEBRIDEMENT LUKA BAKAR FASE AKUT > 30 %, GA 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 30 DEBRIDEMENT LUKA BAKAR FASE AKUT 15 - 30 %, GA 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 31 DEBRIDEMENT LUKA BAKAR FASE AKUT <15%, GA * 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 32 DEBRIDEMENT LUKA BAKAR FASE AKUT <15%, LA 3,125,000 1,041,667 4,166,667 3,593,750 1,197,917 4,791,667 3,906,250 1,302,083 5,208,333 4,687,500 1,562,500 6,250,000 33 DISTANT FLAP, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 34 DORSUMSISI, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 35 DOUBLE ROTATION SKIN FLAP, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 36 DOUBLE ROTATION SKIN FLAP, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 37 EKSISI BASALIOMA DENGAN SKIN FLAP, LA 11,132,813 3,710,938 14,843,750 12,802,734 4,267,578 17,070,313 13,916,016 4,638,672 18,554,688 16,699,219 5,566,406 22,265,625 38 EKSISI FISTEL PREAURIKULA, LA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 39 EKSISI GANGLION, LA 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 40 EKSISI HAEMANGIOMA DENGAN COMPOSITE FLAP, GA 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 41 EKSISI HAEMANGIOMA DENGAN COMPOSITE FLAP, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 42 EKSISI HAEMANGIOMA DENGAN SIMPLE ADVANCEMENT FLAP, GA 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 43 EKSISI HAEMANGIOMA DENGAN SIMPLE ADVANCEMENT FLAP, LA ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS BEDAH PLASTIK, REKONSTRUKSI, DAN ESTETIK RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 44 EKSISI HAEMANGIOMA DENGAN SKIN FLAP LOKAL, LA ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 45 EKSISI HAEMANGIOMA DENGAN SKIN FLAP, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 46 EKSISI HAEMANGIOMA DENGAN SKINGRAFTING, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 47 EKSISI HAEMANGIOMA DENGAN SKINGRAFTING, LA** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 48 EKSISI INTRAKELOIDAL + JAHIT PRIMER, LA ** 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 49 EKSISI INTRAKELOIDAL DILUAR WAJAH, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 50 EKSISI INTRAKELOIDAL WAJAH, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 51 EKSISI KELOID + SKIN GRAFTING - KOMPLEK, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 52 EKSISI KELOID + SKIN GRAFTING - REVISI DENGAN MULTIPLE Z PLAST, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 53 EKSISI KELOID + SKIN GRAFTING - REVISI DENGAN SIMPLE ADVANCEMENT, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 54 EKSISI KELOID + SKIN GRAFTING - REVISI DENGAN SINGLE Z PLASTY, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 55 EKSISI KELOID + SKIN GRAFTING , GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 56 EKSISI KELOID + SKIN GRAFTING, LA 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 57 EKSISI KELOID DENGAN FLAP, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 58 EKSISI KISTA DERMOID, LA * 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 59 EKSISI NEVUS DILUAR WAJAH SIMPLE, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 60 EKSISI NEVUS DILUAR WAJAH MULTIPLE, LA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 61 EKSISI NEVUS WAJAH MULTIPLE , LA 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 62 EKSISI NEVUS WAJAH SIMPLE , LA 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 63 EKSISI POLIDAKTILI SIMPLE DEWASA, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 64 EKSISI POLYDACTYLY COMPLEX, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 65 EKSISI POYDACTYLY SIMPLE, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 66 EKSISI RINOFIMA, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 67 EKSISI RINOFIMA, LA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 68 EKSISI TRAGUS ASESORIUS, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 69 EKSISI VERUKA, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 70 EKSTIRPASI TUMOR JINAK, DILUAR WAJAH ,LA * 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 71 EKSTIRPASI TUMOR JINAK KULIT DI LUAR WAJAH, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 72 EKSTIRPASI TUMOR JINAK KULIT WAJAH, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 73 EKSTIRPASI TUMOR JINAK KULIT WAJAH, LA 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 74 EKSTRAKSI CORPUS ALIENUM, LA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 75 EKTIRPASI ATEROM DILUAR WAJAH, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 76 EKTIRPASI ATEROM WAJAH, LA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 77 EKTIRPASI LIPOMA DILUAR WAJAH, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 78 EKTIRPASI LIPOMA WAJAH, LA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 79 ENDOSCOPIC RECONSTRUCTIVE SURGERY, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 80 ESCHARECTOMY DENGAN TANGENSIAL EKSISI, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 81 ESCHAROTOMY, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 82 FACIAL SLING DENGAN ALOGRAFT, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 83 FASCIOCUTANEUS FLAP, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 84 FASCIOTOMY BURNED COMPARTEMENT SYNDROME, GA * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 85 FINGER TIP INJURY REPAIR - COMPOSITE GRAFT, LA 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 86 FINGER TIP INJURY REPAIR - NEUROVASCULAR ISLAND/DISTANT FLAP, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 87 FINGER TIP INJURY REPAIR - SKIN FLAP LOKAL, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 88 FINGER TIP INJURY REPAIR - SKIN GRAFTING, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 89 FINGER TIP INJURY REPAIR - TOE TRANSFER, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 90 FRAKTUR DAN DISLOKASI - ORIF DENGAN MINIPLATE, GA * 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 91 FRAKTUR DAN DISLOKASI - PEMASANGAN INTRAMEDULARY WIRE, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 92 FRAKTUR DAN DISLOKASI - PEMASANGAN SPLINT TANGAN, LA 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 93 FREE FLAP, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 94 FREE GRACILLIS TRANSFER, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 95 FRONTOZYGOMATICOMAXILLARY SUSPENSION, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 96 FULL THICKNESS SKIN GRAFT (FTSG) DAERAH DI LUAR WAJAH, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 97 FULL THICKNESS SKIN GRAFT (FTSG) DAERAH DI LUAR WAJAH, LA * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 98 FULL THICKNESS SKIN GRAFT (FTSG) PADA WAJAH, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 99 FULL THICKNESS SKIN GRAFT (FTSG) PADA WAJAH, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 100 INSISI ABSES PERIKONDRITIS, GA 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 101 INSISI ABSES PERIKONDRITIS, LA * 1,171,875 390,625 1,562,500 1,347,656 449,219 1,796,875 1,464,844 488,281 1,953,125 1,757,813 585,938 2,343,750 102 INSISI ABSCESS, LA 1,171,875 390,625 1,562,500 1,347,656 449,219 1,796,875 1,464,844 488,281 1,953,125 1,757,813 585,938 2,343,750 103 INJEKSI HAEMANGIOMA DENGAN SKLEROTING AGENT ATAU TRIAMCINOLON ACETONID, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 104 INJEKSI HAEMANGIOMA DENGAN SKLEROTING AGENT ATAU TRIAMCINOLON ACETONID, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 105 INJEKSI SKLEROTING AGENT, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 106 INSERSI TULANG RAWAN TELINGA AKIBAT AVULSI TELINGA, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 107 IOID + ARCHBARR FRAKTUR 1 SISI, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 108 IOID + ARCHBARR FRAKTUR 2 SISI, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 109 IOID + IMF(EYELET) FRAKTUR 1 SISI, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 110 JAHIT LUKA DI WAJAH DAERAH ESTETIK UNIT, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 111 JAHIT LUKA DI WAJAH DAERAH ESTETIK UNIT, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 112 JAHIT LUKA DI WAJAH DENGAN KERUSAKAN KOMPLEK, GA 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 113 JAHIT LUKA DI WAJAH DENGAN KERUSAKAN KOMPLEK, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 114 JAHIT LUKA DI WAJAH DENGAN KERUSAKAN SEDANG, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 115 JAHIT LUKA DI WAJAH DENGAN KERUSAKAN SEDANG, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 116 KAUTERISASI LESI KULIT JINAK, LA 2,148,438 716,146 2,864,583 2,470,703 823,568 3,294,271 2,685,547 895,182 3,580,729 3,222,656 1,074,219 4,296,875 117 KAUTERISASI PAPILOMA KULIT , LA 2,148,438 716,146 2,864,583 2,470,703 823,568 3,294,271 2,685,547 895,182 3,580,729 3,222,656 1,074,219 4,296,875 118 KONTRAKTUR TANGAN DAN JARI, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 119 KONTRAKTUR TANGAN DAN JARI, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 120 LABIOPLASTY BILATERAL, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 121 LABIOPLASTY PADA MICROFORM, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 122 LABIOPLASTY SUMBING BIBIR UNILATERAL, GA * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 123 LABIOPLASTY UNILATERAL DENGAN NASOPLASTY, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 124 LABIOPLASTY UNILATERAL DENGAN NASOPLASTY, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 125 LE FORT I OSTEOTOMY, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 126 LOBULOPLASTY, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 127 MALLET FINGER REPAIR, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 128 MANDIBULAR DISTRACTION, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 129 MANDIBULAR RECONST WITH NON VASCULARIZED BONE GRAFT, GA ** 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 130 MANDIBULAR RECONST WITH TMJ PLATE REKONSTRUCTION, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 131 MANDIBULAR RECONST WITH VASCULARIZED BONE GRAFT(MIKRO) - DEFEK BOYD T, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 132 MASTOPEXY, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 133 MAXILLARY RECONST.WITH NON VASCULARIZED BONE GRAFT, GA * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 134 MAXILLARY RECONST.WITH VASCULARIZED BONE GRAFT(MIKRO), GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 135 MEDIAL/LATERAL CANTHOPLASTY, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 136 MELAKUKAN NEKROTOMI LUAS, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 137 MELAKUKAN NEKROTOMI SEDANG, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 138 MUSCULOCUTANEUS FLAP, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 139 MYOCUTANEUS FLAP, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 140 OMENTAL FLAP, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 141 OPEN REDUCTION WITH IMPLANT AND SEPTOPLASTY, LA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 142 OPEN REDUCTION WITH WIRE/TITANIUM IMPLANT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 143 OPERASI BEDAH MIKRO YANG LAIN, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 144 OPERASI REKONSTRUKSI : HIDUNG, LA * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 145 OPERASI REKONSTRUKSI : HIDUNG, GA 13,476,563 4,492,188 17,968,750 15,498,047 5,166,016 20,664,063 16,845,703 5,615,234 22,460,938 20,214,844 6,738,281 26,953,125 146 OPERASI REKONSTRUKSI : PALPEBRA, LA * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 147 OPERASI REKONSTRUKSI : PALPEBRA, GA 13,476,563 4,492,188 17,968,750 15,498,047 5,166,016 20,664,063 16,845,703 5,615,234 22,460,938 20,214,844 6,738,281 26,953,125 148 OPERASI REKONSTRUKSI : TANGAN DAN JARI JARI, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 149 OPERASI REKONSTRUKSI : TANGAN DAN JARI JARI, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 150 OPERASI REKONSTRUKSI : TELINGA, LA * 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 151 OPERASI REKONSTRUKSI : TELINGA, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 152 OPERASI REKONSTRUKSI : WAJAH, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 153 OPERASI REKONSTRUKSI : WAJAH, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 154 OPERASI REKONSTRUKSI : PAYUDARA DAN SEKITARNYA, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 155 OPERASI REKONSTRUKSI : BOKONG, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 156 OPERASI REKONSTRUKSI : GENITALIA EKSTERNA DAN SEKITARNYA, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 157 OPERASI SKIN FLAP YANG LAIN YANG LEBIH KOMPLEK, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 158 OPERASI SKIN FLAP YANG LAIN YANG LEBIH KOMPLEK, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 159 OPS. REKONSTRUKSI : DEFEK/ KELAINAN MUKA, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 160 OPS. REKONSTRUKSI : DEFEK/ KELAINAN MUKA, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 161 OPS.REK. : DEFAK/KELAINAN TUBUH YANG LAIN, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 162 OPS.REK. : DEFAK/KELAINAN TUBUH YANG LAIN, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 163 ORBITAL BONE AND EYE SOCKET RECONSTRUCTION, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 164 ORIF + ORBITAL WALL RECONSTRUCTION DENGAN RIBS BONE GRAFT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 165 ORIF + ORBITAL WALL RECONSTRUCTION DENGAN SILICON PLATE, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 166 ORIF + TITANIUM MINI PLATE APPROACH EKTRA ORAL 1 SISI, GA 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 167 ORIF + TITANIUM MINI PLATE APPROACH EKTRA ORAL 2 SISI, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 168 ORIF DENGAN 1 APPROACH, GA * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 169 ORIF DENGAN 2 APPROACH, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 170 ORIF DENGAN 3 APPROACH, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 171 ORIF DENGAN GINGGIVO-BUCAL APPROACH, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 172 ORIF DENGAN INFRACILIAR APPROACH, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 173 ORIF DENGAN TRANSCONJUNCTIVAL APPROACH, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 174 ORIF UNTUK FRAKTUR LE FORT I, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 175 ORIF UNTUK FRAKTUR LE FORT II, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 176 ORIF UNTUK FRAKTUR LE FORT III BICORONAL APPROACH, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 177 ORIF UNTUK FRAKTUR LE FORT III, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 178 OSSEOINTEGRATED MANDIBULAR IMPLANT - CLOSE PRIMARY, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 179 OSSEOINTEGRATED MANDIBULAR IMPLANT - DISTANT/FREE FLAP, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 180 OSSEOINTEGRATED MANDIBULAR IMPLANT, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 181 PALATOPLASTY COMPLETE, GA ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 182 PALATOPLASTY INCOMPLETE, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 183 PASANG ARCHBARR 1 SISI, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 184 PASANG ARCHBARR 2 SISI, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 185 PHARYNGOPLASTY, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 186 PRIMARY/SECONDARY REPAIR NERVE INJURY (BEDAH MIKRO), GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 187 RECONSTRUCTION OF CENTRAL RAY DEFICIENCY, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 188 RECONSTRUCTION OF RADIAL RAY DEFICIENCY, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 189 REKONSTRUKSI DENGAN COMPOSITE FLAP (MICROSURGERY), GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 190 REKONSTRUKSI DENGAN COMPOSITE FLAP (MICROSURGERY), GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 191 REKONSTRUKSI DENGAN FREE VASCULARIZED BONE GRAFT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 192 REKONSTRUKSI DENGAN MENGGUNAKAN TISSUE EXPANSION, GA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 193 REKONSTRUKSI DENGAN MUSCLE FLAP DENGAN SKIN GRAFT, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 194 REKONSTRUKSI DENGAN MUSCULOCUTANEUS FLAP, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 195 REKONSTRUKSI DENGAN SKIN FLAP KOMPLEK, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 196 REKONSTRUKSI DENGAN SKIN FLAP KOMPLEK, LA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 197 REKONSTRUKSI DENGAN SKIN FLAP LOKAL, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 198 REKONSTRUKSI DENGAN SKIN FLAP LOKAL, LA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 199 REKONSTRUKSI DENGAN SKIN GRAFTING, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 200 REKONSTRUKSI DENGAN SKIN GRAFTING, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 201 REKONSTRUKSI DENGAN TISSUE EXPANTION+SKIN FLAP, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 202 REKONSTRUKSI IBU JARI - BONE GRAFT + MYOCUTANEUS FREE FLAP, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 203 REKONSTRUKSI IBU JARI - BONE GRAFT + REGIONAL FLAP, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 204 REKONSTRUKSI IBU JARI - DEEPENING FIRST DIGITAL WEB SPACE, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 205 REKONSTRUKSI IBU JARI - POLICIZATION, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 206 REKONSTRUKSI IBU JARI - TOE TO THUMB TRANSFER, GA 13,476,563 4,492,188 17,968,750 15,498,047 5,166,016 20,664,063 16,845,703 5,615,234 22,460,938 20,214,844 6,738,281 26,953,125 207 REKONSTRUKSI KELAINAN GENITALIA EKSTERNA YANG LAIN, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 208 REKONSTRUKSI KELAINAN GENITALIA EKSTERNA YANG LAIN, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 209 REKONSTRUKSI KELAINAN TELINGA YANG LAIN, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 210 REKONSTRUKSI KELAINAN TELINGA YANG LAIN, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 211 REKONSTRUKSI MANDIBULA DENGAN COSTOCHONDRAL GRAFT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 212 REKONSTRUKSI SOFT TISSUE DAN TULANG, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 213 REKONSTRUKSI SOFT TISSUE YANG LAIN, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 214 REKONSTRUKSI SOFTTISSUE PADA HIPERTELORISM, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 215 REKONSTRUKSI SOFTTISSUE PADA HIPERTELORISM, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 216 REKONSTRUKSI TELINGA - ELEVASI FLAP DAUN TELINGA + SKIN GRAFT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 217 REKONSTRUKSI TELINGA - OPERASI INSERSI GRAFT TULANG RAWAN, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 218 REKONSTRUKSI TELINGA - REPAIR LOBULUS DAN KELAINAN PENYERTA, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 219 REKONSTRUKSI TELINGA - REPAIR LOBULUS DAN KELAINAN PENYERTA, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 220 REKONSTRUKSI VERMILION, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 221 REKOSTRUKSI SOFTTISSUE DAN TULANG PADA HIPERTELORISM, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 222 RELEASE BURIED PENIS, LA 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 223 RELEASE BURIED PENIS, GA * 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 224 RELEASE EKSTROPION, LA * 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 225 RELEASE EKSTROPION, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 226 RELEASE KONTRAKTUR DENGAN DERMAGRAM, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 227 RELEASE KONTRAKTUR DENGAN FREE FLAP, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 228 RELEASE KONTRAKTUR DENGAN SKIN FLAP, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 229 RELEASE KONTRAKTUR DENGAN SKIN FLAP, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 230 RELEASE KONTRAKTUR DENGAN SKINGRAFT, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 231 RELEASE KONTRAKTUR DENGAN SKINGRAFT, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 232 RELEASE KONTRAKTUR DENGAN Z PLASTY, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 233 RELEASE KONTRAKTUR DENGAN Z PLASTY, LA 10,351,563 3,450,521 13,802,083 11,904,297 3,968,099 15,872,396 12,939,453 4,313,151 17,252,604 15,527,344 5,175,781 20,703,125 234 RELEASE KONTRAKTUR LEHER, LA 11,914,063 3,971,354 15,885,417 13,701,172 4,567,057 18,268,229 14,892,578 4,964,193 19,856,771 17,871,094 5,957,031 23,828,125 235 RELEASE KONTRAKTUR LEHER, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 236 RELEASE KONTRAKTUR LINIER, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 237 RELEASE KONTRAKTUR LINIER, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 238 RELEASE VAGINA ACRETA, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 239 RELEASE VAGINA ACRETA, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 240 REPAIR BLEPHAROPTOSIS, LA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 241 REPAIR BLEPHAROPTOSIS, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 242 REPAIR BIBIR DENGAN - ESTLANDER FLAP, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 243 REPAIR BIBIR DENGAN BERNARD-BUROWS FLAP, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 244 REPAIR BIBIR DENGAN KARAPANDZIC METHODE, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 245 REPAIR CAMPTODACTYLY, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 246 REPAIR CLEFT EAR LOBE, LA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 247 REPAIR CLINODACTYLY, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 248 REPAIR CREEPLE HYPOSPADIA, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 249 REPAIR DUCTUS NASOLACRIMALIS, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 250 REPAIR DUCTUS PAROTIS, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 251 REPAIR EPISPADIA, GA * 13,281,250 4,427,083 17,708,333 15,273,438 5,091,146 20,364,583 16,601,563 5,533,854 22,135,417 19,921,875 6,640,625 26,562,500 252 REPAIR FISTEL PALATUM DENGAN BUCAL ATAU LINGUAL FLAP, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 253 REPAIR FISTEL PALATUM, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 254 REPAIR FISTEL URETHRA COMPLEX, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 255 REPAIR FISTEL URETHRA SEDERHANA, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 256 REPAIR INVOLUTIONAL PTOSIS, LA 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 257 REPAIR INVOLUTIONAL PTOSIS, GA * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 258 REPAIR PALPEBRA DENGAN TARSOCONJUNCTIVAL GRAFT, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 259 REPAIR PALPEBRA DENGAN HARD PALATE MUCOSAL GRAFT, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 260 REPAIR PALPEBRA DENGAN LOCAL SKIN FLAP, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 261 REPAIR PALPEBRA DENGAN LOCAL SKIN FLAP, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 262 REPAIR PALPEBRA DENGAN ORAL MUCOSAL GRAFT, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 263 REPAIR PALPEBRA DENGAN POSTERIOR LAMELLAR RECONSTRUCTION, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 264 REPAIR PALPEBRA DENGAN SEPTAL CHONDROMUCOSAL GRAFT, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 265 REPAIR PALPEBRA DENGAN SKIN FLAP REGIONAL, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 266 REPAIR PALPEBRA DENGAN SKIN GRAFT, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 267 REPAIR PALPEBRA DENGAN SLIDING TRANSCONJUNCTIVAL FLAP, LA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 268 REPAIR PALPEBRA KOMPLEK, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 269 REPAIR PALPEBRA SIMPLE, LA * 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 270 REPAIR POLYSYNDACTYLY, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 271 REPAIR SOFT TISSUE KOMPLEK, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 272 REPAIR SOFTTISUE SIMPLE, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 273 REPAIR SYARAF TEPI, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 274 REPAIR SYMBRACHYDACTYLY, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 275 REPAIR TENDON EKSTENSOR TANGAN MULTIPLE, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 276 REPAIR TENDON EKSTENSOR TANGAN TUNGGAL, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 277 REPAIR TENDON FLEKSOR TANGAN MULTIPEL+ PULLEY RECONST, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 278 REPAIR TENDON FLEKSOR TANGAN MULTIPLE, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 279 REPAIR TENDON FLEKSOR TANGAN TUNGGAL + PULLEY RECONST, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 280 REPAIR TENDON FLEKSOR TANGAN TUNGGAL, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 281 REPAIR TRAUMA TELINGA KOMPLEK, GA * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 282 REPAIR TRAUMA TELINGA SIMPLE, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 283 REPALATOPLASTY, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 284 REPLANTASI JARI MULTIPLE, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 285 REPLANTASI JARI TUNGGAL, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 286 REPOSISI DISLOKASI TMJ, GA * 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 287 RESEKSI RAHANG, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 288 RESTORASI DAN REKONSTRUKSI SOFTISSUE+ BONE DENGAN MULTIPLE APPROACH, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 289 REVASKULARISASI JARI MULTIPLE, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 290 REVASKULARISASI JARI TUNGGAL, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 291 REVISI DENGAN MULTIPLE Z PLASTY/W PLASTY, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 292 REVISI DENGAN MULTIPLE Z PLASTY/W PLASTY, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 293 REVISI DENGAN FLAP JAUH, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 294 REVISI DENGAN FLAP LOKAL, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 295 REVISI DENGAN FLAP LOKAL, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 296 REVISI DENGAN SIMPLE Z PLASTY, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 297 REVISI DENGAN SIMPLE Z PLASTY, LA 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 298 REVISI LABIOPLASTY, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 299 REVISI PARUT DENGAN SIMPLE ADVANCEMENT FLAP, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 300 REVISI PARUT DENGAN SIMPLE ADVANCEMENT FLAP, LA 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 301 REVISI PARUT WAJAH, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 302 REVISI PARUT, GA 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 303 REVISI PARUT, LA 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 304 REVISI STUMP, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 305 REVISIS PARUTDILUAR WAJAH, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 306 RHYNOPHYMA REPAIR, LA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 307 ROUZERPLASTY, LA 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 308 NAILBED RECONSTRUCTION, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 309 SECONDARY LIP REPAIR , GA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 310 SECONDARY HECHTING, LA 1,269,531 423,177 1,692,708 1,459,961 486,654 1,946,615 1,586,914 528,971 2,115,885 1,904,297 634,766 2,539,063 311 SECONDARY REPAIR LABIOPLASTY, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 312 SECONDARY RHYNOPLASTY, LA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 313 SEMI OPEN REDUCTION (GILLIES PROCEDURE), GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 314 SEPARASI COMPLETE SYNDACTTLY, GA 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 315 SEPARASI COMPLEX SYNDACTYLY, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 316 SEPARASI SYNDACTYLY, GA 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 317 SIMPLE ADVANCEMENT FLAP (FLAP KULIT SEDERHANA), LA 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 318 SIMPLE ADVANCEMENT FLAP, LA 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 319 SINGLE ROTATION/ TRANSPOSITION SKIN FLAP, GA 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 320 SINGLE ROTATION/ TRANSPOSITION SKIN FLAP, LA 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 321 SKIN AND FASCIAL GRAFTS, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 322 SKIN FLAP KOMPLEK LEBIH DARI SATU FLAP, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 323 SKIN FLAP KOMPLEK, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 324 SKIN FLAP LOKAL KOMPLEK, GA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 325 SKIN FLAP LOKAL KOMPLEK, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 326 SKIN FLAP LOKAL SEDERHANA, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 327 SKIN FLAP LOKAL SEDERHANA, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 328 SKIN FLAP SEDERHANA , LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 329 SKIN GRAFTING YANG LUAS, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 330 SKIN GRAFTING DENGAN LUAS SEDANG, GA 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 331 SKINGRAFTING YANG SEDERHANA, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 332 SOFT TISSUE REKONSTRUKSI, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 333 SPLIT THICKNESS SKIN GRAFT (STSG) LUAS DENGAN PERAWATAN KHUSUS, GA 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 334 SPLIT THICKNESS SKIN GRAFT (STSG) LUAS, GA 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 335 SPLIT THICKNESS SKIN GRAFT (STSG) SEDERHANA, GA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 336 SPLIT THICKNESS SKIN GRAFT (STSG) SEDERHANA, LA 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 337 STAGED SUBCUTANEOUS EXCISION UNDERNEATH FLAPS, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 338 STIFF FINGER JOINT - FINGER ARTHOPLASTY WITH SILICONE IMPLANT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 339 STIFF FINGER JOINT - CAPSULOYOMY-TENOLYSIS, LA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 340 STIFF FINGER JOINT - FINGER ARTHOPLASTY WITH TITANIUM IMPLANT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 341 STIFF FINGER JOINT - VOLAR PLATE RELEASE, LA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 342 SUPRAORBITAL BONE RECONSTRUCTION, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 343 SURGICAL DEBRIDEMENT/SHARP DEBRIDEMENT, GA 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 344 TANGENSIAL EKSISI DINI DENGAN SKIN GRAFTING , LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 345 TANGENSIAL EKSISI DINI DENGAN SKIN GRAFTING, GA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 346 TEMPORALIS MUSCLE FASCIA TRANSFER, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 347 TENDON REPAIR, LA 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 348 TENDON TRANSFER MULTIPLE, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 349 TENDON TRANSFER TUNGGAL, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 350 TENDOPLASTY, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 351 TISSUE EXPANTION, GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 352 TMJ ARTHROSCOPY AND TREATMENT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 353 TMJ ARTHROTOMY, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 354 TMJ LAVAGE DENGAN C-ARM, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 355 TOTAL CRANIAL VAULT RECONSTRUCTION, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 356 TOTAL JOINT REPL WITH VASCULARIZED BONE GRAFT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 357 TOTAL JOINT REPLACEMENT WITH IMPLANT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 358 TOTAL SKIN AND SUBCUTANEOUS TISSUE EXCISION DG SKIN GRAFT (CHARLES), GA 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 359 TRANSEKSUAL FEMALE TO MALE, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 360 TRANSEKSUAL MALE TO FEMALE, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 361 TRANSPLATATION PENIS, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 362 URETHROPLASTY, GA * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 363 FACIAL BONE COUNTOURING - ANGLE RESHAPING, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 364 FACIAL BONE COUNTOURING - GENIOPLASTY WITH SILICONE IMPLANT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 365 FACIAL BONE COUNTOURING - MALARPLASTY WITH SILICONE IMPLANT, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 366 FACIAL BONE COUNTOURING - OSSEOUS GENIOPLASTY, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 367 FACIAL BONE COUNTOURING - OSSEOUS MALARPLASTY, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 368 FACIAL BONE COUNTOURING - SPLIT MANDIBLE OSTEOTOMY, GA 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL 1 KRANIOTOMI/TREPANASI KONVENSIONAL - - - - - - - - Neoplasma / proses desak ruang - - - - - - - - 2 a. lama operasi lebih dari 4 jam 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 3 b. lama operasi kurang dari 4 jam 16,601,563 5,533,854 22,135,417 19,091,797 6,363,932 25,455,729 20,751,953 6,917,318 27,669,271 24,902,344 8,300,781 33,203,125 4 Koreksi likworhoe 10,937,500 3,645,833 14,583,333 12,578,125 4,192,708 16,770,833 13,671,875 4,557,292 18,229,167 16,406,250 5,468,750 21,875,000 5 Penyakit vaskuler 20,117,188 6,705,729 26,822,917 23,134,766 7,711,589 30,846,354 25,146,484 8,382,161 33,528,646 30,175,781 10,058,594 40,234,375 6 Epidural/Subdural hematoma 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 KRANIOTOMI/TREPANASI BEDAH MIKRO - - - - - - - - Neoplasma basis kranium - - - - - - - - 7 a. lama operasi lebih dari 4 jam 26,757,813 8,919,271 35,677,083 30,771,484 10,257,161 41,028,646 33,447,266 11,149,089 44,596,354 40,136,719 13,378,906 53,515,625 8 b. lama operasi kurang dari 4 jam 23,632,813 7,877,604 31,510,417 27,177,734 9,059,245 36,236,979 29,541,016 9,847,005 39,388,021 35,449,219 11,816,406 47,265,625 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS BEDAH SARAF RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP AVM/Aneurisma - - - - - - - - 9 a. lama operasi lebih dari 4 jam 25,195,313 8,398,438 33,593,750 28,974,609 9,658,203 38,632,813 31,494,141 10,498,047 41,992,188 37,792,969 12,597,656 50,390,625 10 b. lama operasi kurang dari 4 jam 23,632,813 7,877,604 31,510,417 27,177,734 9,059,245 36,236,979 29,541,016 9,847,005 39,388,021 35,449,219 11,816,406 47,265,625 11 Transphenoidal approach 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 OPERASI ENDOSKOPI - - - - - - - - 12 a. lama operasi lebih dari 4 jam 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 13 b. lama operasi kurang dari 4 jam 16,601,563 5,533,854 22,135,417 19,091,797 6,363,932 25,455,729 20,751,953 6,917,318 27,669,271 24,902,344 8,300,781 33,203,125 OPERASI ENDOVASKULAR - - - - - - - - Diagnostik - - - - - - - - 14 a. Angiografi cerebral 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 15 b. Angiografi spinal 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 16 c. Balloon Occlusion Test 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 17 d. WADA Tes 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 Terapi - - - - - - - -
a.Aneurysma - - - - - - - - 18 * Coilling < 4 coil 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 19 * Coilling > 4 Coil 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125
b.Embolisasi AVM - - - - - - - - 20 * Simple 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 21 * Kompleks 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 22 c. Embolisasi Dural Arteri-Vena Fistula 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 23 d. Oklusi Carotid Cavernous Fistula 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 24 e. Intra-arterial trombolisis 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 25 f. Intra-arterial trombektomi 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 KRANIOPLASTI - - - - - - - - 26 A. lama operasi lebih dari 4 jam 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 27 B. lama operasi kurang dari 4 jam 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 KOREKSI IMPRESI FRAKTUR KOMPLIKATA DISERTAI LASERASI CEREBRI - - - - - - - - 28 A. lama operasi lebih dari 4 jam 11,132,813 3,710,938 14,843,750 12,802,734 4,267,578 17,070,313 13,916,016 4,638,672 18,554,688 16,699,219 5,566,406 22,265,625 29 B. lama operasi kurang dari 4 jam 8,984,375 2,994,792 11,979,167 10,332,031 3,444,010 13,776,042 11,230,469 3,743,490 14,973,958 13,476,563 4,492,188 17,968,750 REKONSTRUKSI MENINGOENSEFALOKEL - - - - - - - - 30 A. Kranial anterior / posterior 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 31 B. Spinal (Spina Bifida) 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 PEMBEDAHAN TULANG BELAKANG - - - - - - - - Fusi korpus vertebra - - - - - - - -
a.approach anterior - - - - - - - - 32 * Anterior cervical corpectomy + fusion (ACCF) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 33 * Anterior cervical discectomy + fusion (ACDF ) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 34 * Total Disc Replacement (Multilevel) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 35 * Anterior Lumbar Interbody Fusion (ALIF) 12,695,313 4,231,771 16,927,083 14,599,609 4,866,536 19,466,146 15,869,141 5,289,714 21,158,854 19,042,969 6,347,656 25,390,625
b.approach posterior - - - - - - - - - - - - 36 * Posterior Lumbar Interbody Fusion (PLIF) + Posterior stabilisation 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 Laminektomi - - - - - - - -
a.laminektomi kompleks - - - - - - - - 37 * Fusi posterior servikal 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 38 * Laminektomi dekompresikasus spondilolistesis dan stabilisasi 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 39 * Posterior Lumbar Interbody Fusion (FLIF) + Stabilisasi posterior 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 40 * Diskektomi terbuka 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 41 *Diskektomi perendoscopi 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 42 * Diskektomi Microskopik 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 43 * Diskektomi terbuka multilevel 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875
b.laminektomi sederhana - - - - - - - - 44 * Laminectomy (1 Level) pada simple spine stenosis 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 45 * Laminectomy Decompresi HNP with Stabilization 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 Tumor spinal - - - - - - - - 46 a. daerah kranioservikal 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 47 b. daerah servikal 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 48 c. daerah torakolumbal 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 Deformitas spinal - - - - - - - - 49 Deformitas Atlanto-axial 14,648,438 4,882,813 19,531,250 16,845,703 5,615,234 22,460,938 18,310,547 6,103,516 24,414,063 21,972,656 7,324,219 29,296,875 50 Anterior dan Posterior Surgery in Spinal Disease with Stabilization/ Instrumentation. 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 51 Anterior dan Posterior Surgery in Deformity with Stabilization/ Instrumentation. 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 52 Scoliosis kurva kurang dari 70 o Corrective Surgery 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 53 Spinal Osteotomy for Ankylossing Spondylitis 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 54 Scoliosis kurva lebih dari 70 o Corrective Surgery 26,757,813 8,919,271 35,677,083 30,771,484 10,257,161 41,028,646 33,447,266 11,149,089 44,596,354 40,136,719 13,378,906 53,515,625 55 Spinal Osteotomy for Ankylossing Spondylitis dengan forward gaze kurang dari 3 cm 26,757,813 8,919,271 35,677,083 30,771,484 10,257,161 41,028,646 33,447,266 11,149,089 44,596,354 40,136,719 13,378,906 53,515,625 Prosedur lain - - - - - - - - 56 Percutaneous vertebroplasty 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 57 Biopsi vertebra (1 level) 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 58 Mayor desloughing, wound debridement of the spine 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 59 Debridement and anterior fusion in TB Spine 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 60 Discograph (1 level) 12,304,688 4,101,563 16,406,250 14,150,391 4,716,797 18,867,188 15,380,859 5,126,953 20,507,813 18,457,031 6,152,344 24,609,375 61 Discograph Multilevel 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 62 Posterolateral Fusion 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 63 Alar transverse fusion 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 64 Open Reduction and stabilisation of Spinal Fracture 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 65 Removal of implants (Plate, Nail, Screw) 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 NEUROPLASTI/ANASTOMOSIS & EKSPLORASI - - - - - - - - A. Bedah Mikro - - - - - - - - 66 * Pleksus Brakhialis 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 67 * Saraf Perifer 8,007,813 2,669,271 10,677,083 9,208,984 3,069,661 12,278,646 10,009,766 3,336,589 13,346,354 12,011,719 4,003,906 16,015,625 B. Konvensional 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 ANASTOMOSIS/PEMASANGAN PINTASAN - - - - - - - - 68 Ventriculoatrium (VA-Shunt) 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 69 Ventriculoperitonium (VP-Shunt) 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 COMPLICATED FUNCTIONAL NEUROSURGERY - - - - - - - - 70 Operasi Stereotaktik 12,500,000 4,166,667 16,666,667 14,375,000 4,791,667 19,166,667 15,625,000 5,208,333 20,833,333 18,750,000 6,250,000 25,000,000 71 Perkutaneus Paravertebral / Viseral Blok 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 72 Perkutaneus Kordotomi 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 KOREKSI IMPRESI FRAKTUR SEDERHANA - - - - - - - - 73 a. lama operasi lebih dari 1 jam 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 74 b. lama operasi kurang dari 1 jam 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 75 Pemasangan Fiksasi Interna 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 PEMUTUSAN DAN EKSISI SARAF - - - - - - - - 76 Neurektomie / neurolise 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 77 Dekompresi saraf perifer 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 78 Reseksi ligamentum 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 SIMPLE FUNCTIONAL NEUROSURGERY - - - - - - - - 79 Perkutaneus Rhizotomi (PRGR) 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 80 Perkutaneus Facet Denervasi 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 EKSTIRPASI TUMOR - - - - - - - - 81 Ekstirpasi kista jinak kranium 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 82 Ekstirpasi eksostose tulang 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 VENTRIKULOSTOMI - - - - - - - - 83 Continuous ventricular drainage 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 84 Pemasangan traksi servikal 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 85 Pungsi Cairan Otak per 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 86 Paket pengobatan - - - - - - - - 87 Biopsi saraf kutaneus / otot 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 88 Blok Saraf perifer 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS BEDAH ANAK RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL 1 Abdominoperineal Pull Through (Malformasi Anorectal) 20,703,125 6,901,042 27,604,167 23,808,594 7,936,198 31,744,792 25,878,906 8,626,302 34,505,208 31,054,688 10,351,563 41,406,250 2 Abdominorectal Pull Through (Swenson Procedure) 20,703,125 6,901,042 27,604,167 23,808,594 7,936,198 31,744,792 25,878,906 8,626,302 34,505,208 31,054,688 10,351,563 41,406,250 3 Amputasi Eksisi Kista Bronchiogenik 11,523,438 3,841,146 15,364,583 13,251,953 4,417,318 17,669,271 14,404,297 4,801,432 19,205,729 17,285,156 5,761,719 23,046,875 4 Appendektomi * 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 5 Bedah Laparoskopi Anak 12,304,688 4,101,563 16,406,250 14,150,391 4,716,797 18,867,188 15,380,859 5,126,953 20,507,813 18,457,031 6,152,344 24,609,375 6 Billroth I & li/Reseksi Gaster Parsial 24,218,750 8,072,917 32,291,667 27,851,563 9,283,854 37,135,417 30,273,438 10,091,146 40,364,583 36,328,125 12,109,375 48,437,500 7 Biopsi Rektum "Full Thickness" 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 8 Biopsi Eksisional Dalam Narkose 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 9 Biopsi Insisional Dalam Narkose 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 10 Biopsi Perlaparatomi 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 11 Biopsi/Eksisi KGB, Lipoma. Ateroma, Ganglion 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 12 CDH (Paediatrik) 21,484,375 7,161,458 28,645,833 24,707,031 8,235,677 32,942,708 26,855,469 8,951,823 35,807,292 32,226,563 10,742,188 42,968,750 13 Chordektomi 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 14 Cystojejenostomi 17,382,813 5,794,271 23,177,083 19,990,234 6,663,411 26,653,646 21,728,516 7,242,839 28,971,354 26,074,219 8,691,406 34,765,625 15 Debulking 17,382,813 5,794,271 23,177,083 19,990,234 6,663,411 26,653,646 21,728,516 7,242,839 28,971,354 26,074,219 8,691,406 34,765,625 16 Detorsi Testis + Orcidopexy ** 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 17 Duodenoduodenostomi/Duodenojejunostomi 21,484,375 7,161,458 28,645,833 24,707,031 8,235,677 32,942,708 26,855,469 8,951,823 35,807,292 32,226,563 10,742,188 42,968,750 18 Eksisi Baker Cyst 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 19 Eksisi Granuloma Umbilikal 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 20 Eksisi Hemangioma Besar/Multiple 14,648,438 4,882,813 19,531,250 16,845,703 5,615,234 22,460,938 18,310,547 6,103,516 24,414,063 21,972,656 7,324,219 29,296,875 21 Eksisi Hemangioma Dengan Skin Graft STSG/FTSG 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 22 Eksisi Hemangioma Kecil 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 23 Eksisi Higroma Colli/Limfangioma Simple * 6,250,000 2,083,333 8,333,333 7,187,500 2,395,833 9,583,333 7,812,500 2,604,167 10,416,667 9,375,000 3,125,000 12,500,000 24 Eksisi Higroma Colli/Axilla Pada Neonatus 15,820,313 5,273,438 21,093,750 18,193,359 6,064,453 24,257,813 19,775,391 6,591,797 26,367,188 23,730,469 7,910,156 31,640,625 25 Eksisi Kelenjar Getah Bening 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 26 Eksisi Kelenjar Liur Submandibula 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 27 Eksisi Kista Brachial 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 28 Eksisi Kista Duktus Tiroglosus 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 29 Eksisi Kista Saluran Empedu 20,898,438 6,966,146 27,864,583 24,033,203 8,011,068 32,044,271 26,123,047 8,707,682 34,830,729 31,347,656 10,449,219 41,796,875 30 Eksisi Kista Urachus 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 31 Eksisi Neuroblastoma 21,484,375 7,161,458 28,645,833 24,707,031 8,235,677 32,942,708 26,855,469 8,951,823 35,807,292 32,226,563 10,742,188 42,968,750 32 Eksisi Teratoma Retroperitoneal 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 33 Eksisi Teratoma Sacrococcygeal 12,304,688 4,101,563 16,406,250 14,150,391 4,716,797 18,867,188 15,380,859 5,126,953 20,507,813 18,457,031 6,152,344 24,609,375 34 Eksisi Tumor Jaringan Lunak Ukuran Kecil (Marginal Margin Excisi) 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 35 Ekstirpasi Tumor Jinak Kulit <3 Cm ** 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 36 Ekstirpasi Tumor Jinak Kulit >3 Cm 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 37 Endorectal Pull Through (Soave-Bolley Procedure) 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 38 Esofagomyotomi (Operasi Heller) 16,992,188 5,664,063 22,656,250 19,541,016 6,513,672 26,054,688 21,240,234 7,080,078 28,320,313 25,488,281 8,496,094 33,984,375 39 Esofagostomi + Gastrostomi (Atresia Esofagus) 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 40 Esophagus Replacement Procedure 21,484,375 7,161,458 28,645,833 24,707,031 8,235,677 32,942,708 26,855,469 8,951,823 35,807,292 32,226,563 10,742,188 42,968,750 41 Fistulektomi Kompleks 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 42 Fundoplikasi Gaster 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 43 Gastrostomi Anak * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 44 Gastrostomi Neonatus 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 45 Genitoplasty (Clitoroplasty, Vaginoplasty, Phalioplasty) 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 46 Glosektomi Totalis 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 47 Hemiglosektomi 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 48 Hemimandibulektomi 10,937,500 3,645,833 14,583,333 12,578,125 4,192,708 16,770,833 13,671,875 4,557,292 18,229,167 16,406,250 5,468,750 21,875,000 49 Herniotomi 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 50 Herniotomi Bilateral 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 51 Herniotomi Pada Hernia Strangulata 8,593,750 2,864,583 11,458,333 9,882,813 3,294,271 13,177,083 10,742,188 3,580,729 14,322,917 12,890,625 4,296,875 17,187,500 52 Herniotomi Residif 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 53 Herniotomi Umbilikalis * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 54 Herniotomy + Laparotomy + Reseksi + Anastomosis 8,984,375 2,994,792 11,979,167 10,332,031 3,444,010 13,776,042 11,230,469 3,743,490 14,973,958 13,476,563 4,492,188 17,968,750 55 Ligasi Tinggi Kelas II (Narkose) ** 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 56 Ileostomi * 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 NO NAMA TINDAKAN 57 Insisi Abses Perianal 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 58 Insisi Drainase/Debridement Abses 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 59 Insisi Tongue Tie * 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 60 Jari, Polydactyly, Amputasi With Rekonstruksi 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 61 Jari, Ring Constriction (Multiple), Koreksi 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 62 Jarj, Ring Constriction (Single), Koreksi 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 63 Jari, Syndactyly (Multiple) 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 64 Jari, Syndactyly (Single) Koreksi 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 65 Kelainan Umbilikus 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 66 Kolesistektomi 8,984,375 2,994,792 11,979,167 10,332,031 3,444,010 13,776,042 11,230,469 3,743,490 14,973,958 13,476,563 4,492,188 17,968,750 67 Kolostomi Anak 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 68 Kolostomi Neonatus 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 69 Ladd 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 70 Laparaskopik Appendektomi 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 71 Laparaskopik Diagnostik/Biopsi 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 72 Laparaskopik Gastrektomi 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 73 Laparaskopik Lobektomi 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 74 Laparatomi + Appendektomi Pada App Perforasi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 75 Laparatomi + Milking/Reseksi Pada Invaginasi 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 76 Laparatomi + Reseksi Anasm 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 77 Laparatomi + Reseksi Usus Halus/Kolon 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 78 Laparatomi Adhesiolisis 9,570,313 3,190,104 12,760,417 11,005,859 3,668,620 14,674,479 11,962,891 3,987,630 15,950,521 14,355,469 4,785,156 19,140,625 79 Laparatomi Eksplorasi/Biopsi 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 80 Laparatomi Pada Perforsi Usus 9,960,938 3,320,313 13,281,250 11,455,078 3,818,359 15,273,438 12,451,172 4,150,391 16,601,563 14,941,406 4,980,469 19,921,875 81 Laparatomi Pada Trauma Abdomen 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 82 Laparatomi Pada Peritonitis Neonatus 17,968,750 5,989,583 23,958,333 20,664,063 6,888,021 27,552,083 22,460,938 7,486,979 29,947,917 26,953,125 8,984,375 35,937,500 83 Limpoma, Atheroma, dll 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 84 Lobektomi Sub Totalis (Tiroid) 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 85 Marsupialisasi dengan Ranula (Kelas 2) 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 86 Minimal/Limited PSARP 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 87 Near Total Tiroidektomi 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 88 Nefrektomi Parsial * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 89 Nefrouretektomi Tumor Wilms 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 90 Orchidektomi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 91 Orchidektomi Bilateral 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 92 Orchidektomy Sub Kabsuler 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 93 Parotidektomi Radikal 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 94 Parotidektomi Superfisialis 11,718,750 3,906,250 15,625,000 13,476,563 4,492,188 17,968,750 14,648,438 4,882,813 19,531,250 17,578,125 5,859,375 23,437,500 95 Parotidektomi Totalis 12,109,375 4,036,458 16,145,833 13,925,781 4,641,927 18,567,708 15,136,719 5,045,573 20,182,292 18,164,063 6,054,688 24,218,750 96 Pasang Akses Port Ceisite * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 97 Pasang PEG 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 98 Pemasangan Double Lumen Kateter Dengan Lokal Anestesi 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 99 Plikasi Diafragma 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 100 Polipektomi 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 101 Polipektomi Rektum 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 102 Portoenterostomi (Operas! Kassai) 25,000,000 8,333,333 33,333,333 28,750,000 9,583,333 38,333,333 31,250,000 10,416,667 41,666,667 37,500,000 12,500,000 50,000,000 103 Postero Sagital Anorectoplaty/PSARP 14,843,750 4,947,917 19,791,667 17,070,313 5,690,104 22,760,417 18,554,688 6,184,896 24,739,583 22,265,625 7,421,875 29,687,500 104 Posterosagital Anorectovaginourethroplasty/PSARVUP 21,484,375 7,161,458 28,645,833 24,707,031 8,235,677 32,942,708 26,855,469 8,951,823 35,807,292 32,226,563 10,742,188 42,968,750 105 Potong Stump 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 106 Prosedur Tiersch Pada Prolap Rekti 8,789,063 2,929,688 11,718,750 10,107,422 3,369,141 13,476,563 10,986,328 3,662,109 14,648,438 13,183,594 4,394,531 17,578,125 107 PSARP + Laparotomy 15,429,688 5,143,229 20,572,917 17,744,141 5,914,714 23,658,854 19,287,109 6,429,036 25,716,146 23,144,531 7,714,844 30,859,375 108 Pyeloplasty 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 109 Pyloromyotomi (Operasi Fredet Ramstedt) 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 110 Release Sinekhia Vulva 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 111 Repair Bladder Extrophy 25,000,000 8,333,333 33,333,333 28,750,000 9,583,333 38,333,333 31,250,000 10,416,667 41,666,667 37,500,000 12,500,000 50,000,000 112 Repair Cloacal Extrophy 25,000,000 8,333,333 33,333,333 28,750,000 9,583,333 38,333,333 31,250,000 10,416,667 41,666,667 37,500,000 12,500,000 50,000,000 113 Repair Defek Dinding Perut (Omphalocele/Gastroschizis) 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 114 Repair Defek Hernia Umbilikalis * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 115 Repair Fistel Rectovaginal 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 116 Repair Ruptura Perineum Lama 10,937,500 3,645,833 14,583,333 12,578,125 4,192,708 16,770,833 13,671,875 4,557,292 18,229,167 16,406,250 5,468,750 21,875,000 117 Repair Vesika Urinaria 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 118 Reseksi + Anastomosis Esofagus 16,601,563 5,533,854 22,135,417 19,091,797 6,363,932 25,455,729 20,751,953 6,917,318 27,669,271 24,902,344 8,300,781 33,203,125 119 Reseksi Anastomosis Pada Atresia Usus, Duplikasi 11,718,750 3,906,250 15,625,000 13,476,563 4,492,188 17,968,750 14,648,438 4,882,813 19,531,250 17,578,125 5,859,375 23,437,500 120 Reseksi Esofagus & Rekonstruksi 25,000,000 8,333,333 33,333,333 28,750,000 9,583,333 38,333,333 31,250,000 10,416,667 41,666,667 37,500,000 12,500,000 50,000,000 121 Reseksi Gaster 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 122 Reseksi Hepar (Tumor, Trauma) 25,000,000 8,333,333 33,333,333 28,750,000 9,583,333 38,333,333 31,250,000 10,416,667 41,666,667 37,500,000 12,500,000 50,000,000 123 Reseksi Sigmoid 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 124 Reseksi Urachus 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 125 Retrorectal Pull Through (Duhamel Procedure) 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 126 Salpingo Oophorektomi Bilateral 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 127 Sirkumsisi (Narkose) *** 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 128 Sistostomi 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 129 Skleroterapi Dengan Anestesi 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 130 Sphincterotomy 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 131 Splenectomi Pada Trauma * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 132 Splenektomi Ec. Hipertensi Portal/Kelainan Hematologi Lain 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 133 Suntik Scleroting Agent Malformasi Vaskular 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 134 Thoracotomi +Anastomosis Esofagus 18,359,375 6,119,792 24,479,167 21,113,281 7,037,760 28,151,042 22,949,219 7,649,740 30,598,958 27,539,063 9,179,688 36,718,750 135 Tiroidektomi Subtotalis ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 136 Total Gastrektomi Dan Rekonstruksi 21,484,375 7,161,458 28,645,833 24,707,031 8,235,677 32,942,708 26,855,469 8,951,823 35,807,292 32,226,563 10,742,188 42,968,750 137 Tracheostomi ** 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 138 Transanal Mucosektomy 18,945,313 6,315,104 25,260,417 21,787,109 7,262,370 29,049,479 23,681,641 7,893,880 31,575,521 28,417,969 9,472,656 37,890,625 139 Uretero Neosistostomi 13,085,938 4,361,979 17,447,917 15,048,828 5,016,276 20,065,104 16,357,422 5,452,474 21,809,896 19,628,906 6,542,969 26,171,875 140 Uretroplasty (Hipopadia) * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 141 Vena Seksi Dan Pasang Akses Vaskuler 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 142 Yeyunostomi 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 - - - - - - - - PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL 1 Pemasangan PDT (temporary percutaneus dilatational tracheostomy) 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 2 Trakheostomi ** 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 3 Trakheostomi dengan penyulit *** 5,468,750 1,822,917 7,291,667 6,289,063 2,096,354 8,385,417 6,835,938 2,278,646 9,114,583 8,203,125 2,734,375 10,937,500 4 Trakheostomi trakhea mediastinal 10,546,875 3,515,625 14,062,500 12,128,906 4,042,969 16,171,875 13,183,594 4,394,531 17,578,125 15,820,313 5,273,438 21,093,750 5 Eksisi trakhea (simpel) 8,398,438 2,799,479 11,197,917 9,658,203 3,219,401 12,877,604 10,498,047 3,499,349 13,997,396 12,597,656 4,199,219 16,796,875 6 Repair trakhea / revisi trakheostomi dalam anestesi lokal 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 7 Repair trakhea (servikalis) dalam anestesi Syaraf 17,773,438 5,924,479 23,697,917 20,439,453 6,813,151 27,252,604 22,216,797 7,405,599 29,622,396 26,660,156 8,886,719 35,546,875 8 Repair trakhea mediastinal / karina 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 9 Biopsi terbuka bronkhus (diagnostik)* 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 10 Biopsi terbuka paru (diagnostik) * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 11 Eksisi terbatas (simpel) pada bronkhus 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 12 Eksisi terbatas (simpel) pada paru 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 13 Eksisi terbatas (simpel) pada paru dengan Torakoskopik (VATS) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 14 Plikasi Bulae / Emfisematosa 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 15 Reseksi segmental / lobektomi parsial paru * 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 16 Reseksi segmental / lobektomi parsial dengan Torakoskopik (VATS) 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 17 Lobektomi / bilobektomi 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 18 Lobektomi / bilobektomi dengan Torakoskopik (VATS) 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 19 Pneumonektomi * 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 20 Pneumonektomi dengan Torakoskopik (VATS) 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 21 Lung Volume Reduction 19,921,875 6,640,625 26,562,500 22,910,156 7,636,719 30,546,875 24,902,344 8,300,781 33,203,125 29,882,813 9,960,938 39,843,750 22 Dekortikasi * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 23 Dekortikasi dengan Torakoskopik (VATS) 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS BEDAH TORAKS KARDIOVASKULAR+A1915 RSUD PROPINSI SULAWESI BARAT TAHUN MULAI 2020 NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 24 Air plumbage 19,921,875 6,640,625 26,562,500 22,910,156 7,636,719 30,546,875 24,902,344 8,300,781 33,203,125 29,882,813 9,960,938 39,843,750 25 Torakoplasti 19,921,875 6,640,625 26,562,500 22,910,156 7,636,719 30,546,875 24,902,344 8,300,781 33,203,125 29,882,813 9,960,938 39,843,750 26 Operasi kolaps paru lainnya 19,921,875 6,640,625 26,562,500 22,910,156 7,636,719 30,546,875 24,902,344 8,300,781 33,203,125 29,882,813 9,960,938 39,843,750 27 Operasi repair paru/bronkhus (laserasi,ruptur,fistula,hemostasis,dll) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 28 Pemasangan Chest Drainage Interkostal (WSD, kateter) * 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 29 Pemasangan Chest Drainage pada kasus Distres Pernapasan 7,519,531 2,506,510 10,026,042 8,647,461 2,882,487 11,529,948 9,399,414 3,133,138 12,532,552 11,279,297 3,759,766 15,039,063 30 Evakuasi efusi/empiema melalui torakoskopik (VATS) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 31 Pleural Window (Eloeser Flap) * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 32 Mediastinoskopi 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 33 Biopsi dinding dada * 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 34 Biopsi pleura terbuka * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 35 Biopsi pleura dengan torakoskopik (VATS) * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 36 Biopsi mediastinum per kutan 5,273,438 1,757,813 7,031,250 6,064,453 2,021,484 8,085,938 6,591,797 2,197,266 8,789,063 7,910,156 2,636,719 10,546,875 37 Biopsi mediastinum terbuka * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 38 Biopsi diafragma * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 39 Eksisi Timor Mediastinum 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 40 Tiroidektomi substernal 12,695,313 4,231,771 16,927,083 14,599,609 4,866,536 19,466,146 15,869,141 5,289,714 21,158,854 19,042,969 6,347,656 25,390,625 41 Timektomi 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 42 Timektomi dengan penyulit 20,703,125 6,901,042 27,604,167 23,808,594 7,936,198 31,744,792 25,878,906 8,626,302 34,505,208 31,054,688 10,351,563 41,406,250 43 Timektomi dengan Torakoskopik (VATS) 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 44 Simpatektomi torakal terbuka 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 45 Simpatektomi torakal dengan torakoskop 15,820,313 5,273,438 21,093,750 18,193,359 6,064,453 24,257,813 19,775,391 6,591,797 26,367,188 23,730,469 7,910,156 31,640,625 46 Pleurektomi * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 47 Pleurodesis (pleurosklerosis) terbuka * 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 48 Repair dinding dada tanpa torakotomi (laserasi, trauma) 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 49 Repair fistula melalui torakotomi (fistula bronkopleural, bronkopleurokutan) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 50 Rekonstruksi Dinding Dada / Eksisi Tumor Dinding Dada * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 51 Repair kelainan Pektus Ekskavatum / Karinatum 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 52 Repair kelainan Pektus Ekskavatum / Karinatum dengan VATS 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 53 Eksisi lesi / jaringan pada diafragma 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 54 Repair laserasi Diafragma * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 55 Repair Hernia Diafragmatika 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 56 Plikasi Diafragma * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 57 Insisi esofageal web 6,835,938 2,278,646 9,114,583 7,861,328 2,620,443 10,481,771 8,544,922 2,848,307 11,393,229 10,253,906 3,417,969 13,671,875 58 Esofagostomi servikal 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 59 Biopsi terbuka esofagus (torakotomi) 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 60 Eksisi lokal lesi esofagus servikal 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 61 Eksisi lokal lesi esofagus (torakotomi) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 62 Esofagektomi parsial 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 63 Esofagektomi total 18,945,313 6,315,104 25,260,417 21,787,109 7,262,370 29,049,479 23,681,641 7,893,880 31,575,521 28,417,969 9,472,656 37,890,625 64 Anastomosis dan rekonstruksi esofagus di intra torakal 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 65 Anastomosis dan rekonstruksi esofagus antesternal 15,429,688 5,143,229 20,572,917 17,744,141 5,914,714 23,658,854 19,287,109 6,429,036 25,716,146 23,144,531 7,714,844 30,859,375 66 Esofagomiotomi 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 67 Repair laserasi esofagus (torakotomi) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 68 Tutup esofagostomi servikal 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 69 Tutup esofagostomi torakal (torakotomi) 10,742,188 3,580,729 14,322,917 12,353,516 4,117,839 16,471,354 13,427,734 4,475,911 17,903,646 16,113,281 5,371,094 21,484,375 70 Repair fistula esofagus (torakotomi) 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 71 Repair striktur esofagus (torakotomi) 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 72 Dilatasi esofagus (torakotomi) 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 73 Ligasi Duktus Torasikus terbuka 16,015,625 5,338,542 21,354,167 18,417,969 6,139,323 24,557,292 20,019,531 6,673,177 26,692,708 24,023,438 8,007,813 32,031,250 74 Ligasi Duktus Torasikus dengan VATS 16,406,250 5,468,750 21,875,000 18,867,188 6,289,063 25,156,250 20,507,813 6,835,938 27,343,750 24,609,375 8,203,125 32,812,500 75 Ekstraksi Korpus Alienum Saluran Napas / Paru Terbuka * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 76 Ekstraksi Korpus Alienum Saluran Napas / Paru dengan VATS * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 77 Fiksasi Costae (clipping, wire) * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 78 Fiksasi Sternum (wire, plate) * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 79 Debridement Leher 9,667,969 3,222,656 12,890,625 11,118,164 3,706,055 14,824,219 12,084,961 4,028,320 16,113,281 14,501,953 4,833,984 19,335,938 80 Debridement Mediastinitis (sternotomi) * 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 81 Torakosintesis * 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 82 Torakotomi / Sternotomi Eksplorasi * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 83 Torakotomi Eksplorasi pada Trauma Jantung / Repair Laserasi Jantung 19,042,969 6,347,656 25,390,625 21,899,414 7,299,805 29,199,219 23,803,711 7,934,570 31,738,281 28,564,453 9,521,484 38,085,938 84 Redo Torakotomi * 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 85 Valvuloplasti tanpa penggantian (replacement) dengan operasi terbuka 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 86 Penggantian katup jantung (replacement) 22,070,313 7,356,771 29,427,083 25,380,859 8,460,286 33,841,146 27,587,891 9,195,964 36,783,854 33,105,469 11,035,156 44,140,625 87 Operasi pada struktur lain katup jantung 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 88 Repair otot papiler katup jantung 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 89 Repair Korda Tendinea 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 90 Annuloplasti katup jantung 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 91 Septostomi / Prosedur Rashkind dengan operasi terbuka 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 92 Septostomi dengan Prosedur Blalock-Hanlon 19,531,250 6,510,417 26,041,667 22,460,938 7,486,979 29,947,917 24,414,063 8,138,021 32,552,083 29,296,875 9,765,625 39,062,500 93 Repair ASD dengan prostesis, operasi terbuka 19,531,250 6,510,417 26,041,667 22,460,938 7,486,979 29,947,917 24,414,063 8,138,021 32,552,083 29,296,875 9,765,625 39,062,500 94 Repair VSD dengan prostesis, operasi terbuka 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 95 Repair AVSD (endocardial cushion defect) dengan prostesis, operasi terbuka 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 96 Repair Total pada Tetralogi Falllot (TOF) 22,070,313 7,356,771 29,427,083 25,380,859 8,460,286 33,841,146 27,587,891 9,195,964 36,783,854 33,105,469 11,035,156 44,140,625 97 Repair Total pada Total Anomolous Pulmonary Veins Connenction (TAPVC) 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 98 Repair Total pada Trunkus Arteriosus 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 99 Koreksi Total pada Transposition of Great Arteries (TGA), Arterial Switch Operation (ASO) 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 100 Kreasi Konduit/shunt Ventrikel Kanan dan Arteri Pulmonal, BT-Shunt (Rastelli) 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 101 Kreasi Konduit/shunt Ventrikel Kiri dan Aorta 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 102 Kreasi Konduit/shunt Atrium Kanan dan Arteri Pulmonal, Prosedur Fontan 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 103 Operasi revisi pada operasi koreksi jantung sebelumnya 21,679,688 7,226,563 28,906,250 24,931,641 8,310,547 33,242,188 27,099,609 9,033,203 36,132,813 32,519,531 10,839,844 43,359,375 104 Angioplasti dengan operasi terbuka, end-arterectomy / pemasangan stent 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 105 CABG, 1 vessel 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 106 CABG, 2 vessels 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 107 CABG, 3 vessels 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 108 CABG, 4 vessels / lebih 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 109 CABG, 1 vessel dengan penyulit 25,976,563 8,658,854 34,635,417 29,873,047 9,957,682 39,830,729 32,470,703 10,823,568 43,294,271 38,964,844 12,988,281 51,953,125 110 CABG, 2 vessels dengan penyulit 25,976,563 8,658,854 34,635,417 29,873,047 9,957,682 39,830,729 32,470,703 10,823,568 43,294,271 38,964,844 12,988,281 51,953,125 111 CABG, 3 vessels dengan penyulit 25,976,563 8,658,854 34,635,417 29,873,047 9,957,682 39,830,729 32,470,703 10,823,568 43,294,271 38,964,844 12,988,281 51,953,125 112 CABG, 4 vessels / lebih dengan penyulit 25,976,563 8,658,854 34,635,417 29,873,047 9,957,682 39,830,729 32,470,703 10,823,568 43,294,271 38,964,844 12,988,281 51,953,125 113 Endoscopic/thoracoscopic revascularization 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 114 Repair aneurisma arteri koronaria 14,648,438 4,882,813 19,531,250 16,845,703 5,615,234 22,460,938 18,310,547 6,103,516 24,414,063 21,972,656 7,324,219 29,296,875 115 Perikardiosintesis * 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 116 Perikardiotomi / pericardial window * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 117 Biopsi perikardium (sternotomi parsial) * 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 118 Biopsi jantung (sternotomi) 10,937,500 3,645,833 14,583,333 12,578,125 4,192,708 16,770,833 13,671,875 4,557,292 18,229,167 16,406,250 5,468,750 21,875,000 119 Perikardiektomi * 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 120 Repair aneurisma jantung 19,921,875 6,640,625 26,562,500 22,910,156 7,636,719 30,546,875 24,902,344 8,300,781 33,203,125 29,882,813 9,960,938 39,843,750 121 Prosedur ablasi, prosedur Maze 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 122 Ventricular remodelling, prosedur Batista 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 123 Remodelling Atrium kiri (eksisi, koreksi) (tanpa disertai tindakan koreksi lain) 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 124 Implantasi Cardiac/Ventricular Support Device (epikardial/surface of the heart), operasi terbuka 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 125 Pemasangan Bi ventrikular Heart Assist System (eksternal -ekstrakorporeal) 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 126 Pemasangan IABP 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 127 Pemasangan CPB temporer untuk Heart Assist 19,335,938 6,445,313 25,781,250 22,236,328 7,412,109 29,648,438 24,169,922 8,056,641 32,226,563 29,003,906 9,667,969 38,671,875 128 Repair Bi ventrikular Heart Assist System (eksternal -ekstrakorporeal) 15,820,313 5,273,438 21,093,750 18,193,359 6,064,453 24,257,813 19,775,391 6,591,797 26,367,188 23,730,469 7,910,156 31,640,625 129 Pelepasan Bi ventrikular Heart Assist System (eksternal -ekstrakorporeal) 15,820,313 5,273,438 21,093,750 18,193,359 6,064,453 24,257,813 19,775,391 6,591,797 26,367,188 23,730,469 7,910,156 31,640,625 130 Pemasangan Implantable Heart Assist System: LVAD, RVAD, rotary pump 19,726,563 6,575,521 26,302,083 22,685,547 7,561,849 30,247,396 24,658,203 8,219,401 32,877,604 29,589,844 9,863,281 39,453,125 131 Insersi pacemaker permanen (inisial atau replacement) 5,957,031 1,985,677 7,942,708 6,850,586 2,283,529 9,134,115 7,446,289 2,482,096 9,928,385 8,935,547 2,978,516 11,914,063 132 Pengangkatan atau revisi pacemaker permanen 5,371,094 1,790,365 7,161,458 6,176,758 2,058,919 8,235,677 6,713,867 2,237,956 8,951,823 8,056,641 2,685,547 10,742,188 133 Internal Resusitasi / Cardiac Massage (operasi terbuka) 13,183,594 4,394,531 17,578,125 15,161,133 5,053,711 20,214,844 16,479,492 5,493,164 21,972,656 19,775,391 6,591,797 26,367,188 134 Embolektomi / trombektomi pembuluh daerah servikal (karotis, jugular) * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 135 Embolektomi / trombektomi pembukuh darah ekstremitas atas (radialis, ulnaris, poplitea) * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 136 Embolektomi / trombektomi Aorta * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 137 Embolektomi / trombektomi Pembuluh Arteri Abdominal * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 138 Embolektomi / trombektomi Pembuluh Darah Arteri Ekstremitas Bawah * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 139 Embolektomi / trombektomi Pembuluh Darah Vena Ekstremitas Bawah * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 140 Biopsi pembuluh darah (perifer) * 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 141 Eksisi Hemangioma ** 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 142 Repair pembuluh daerah servikal (karotis, jugular) * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 143 Repair pembuluh darah ekstremitas atas (radialis, ulnaris, poplitea) 8,984,375 2,994,792 11,979,167 10,332,031 3,444,010 13,776,042 11,230,469 3,743,490 14,973,958 13,476,563 4,492,188 17,968,750 144 Repair Aorta (Abdominalis) * 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 145 Repair Aorta Torakalis 22,070,313 7,356,771 29,427,083 25,380,859 8,460,286 33,841,146 27,587,891 9,195,964 36,783,854 33,105,469 11,035,156 44,140,625 146 Repair Pembuluh Arteri Abdominal 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 147 Repair Pembuluh Darah Arteri Ekstremitas Bawah 10,937,500 3,645,833 14,583,333 12,578,125 4,192,708 16,770,833 13,671,875 4,557,292 18,229,167 16,406,250 5,468,750 21,875,000 148 Repair Pembuluh Darah Vena Ekstremitas Bawah 10,937,500 3,645,833 14,583,333 12,578,125 4,192,708 16,770,833 13,671,875 4,557,292 18,229,167 16,406,250 5,468,750 21,875,000 149 Reseksi dan replacement pembuluh daerah servikal (karotis, jugular) 18,164,063 6,054,688 24,218,750 20,888,672 6,962,891 27,851,563 22,705,078 7,568,359 30,273,438 27,246,094 9,082,031 36,328,125 150 Reseksi dan replacement pembuluh darah ekstremitas atas (radialis, ulnaris, poplitea) 11,132,813 3,710,938 14,843,750 12,802,734 4,267,578 17,070,313 13,916,016 4,638,672 18,554,688 16,699,219 5,566,406 22,265,625 151 Reseksi dan replacement Aorta (Abdominalis) 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 152 Reseksi dan replacement Aorta Torakalis 23,242,188 7,747,396 30,989,583 26,728,516 8,909,505 35,638,021 29,052,734 9,684,245 38,736,979 34,863,281 11,621,094 46,484,375 153 Reseksi dan replacement Pembuluh Arteri Abdominal 18,554,688 6,184,896 24,739,583 21,337,891 7,112,630 28,450,521 23,193,359 7,731,120 30,924,479 27,832,031 9,277,344 37,109,375 154 Reseksi dan replacement Pembuluh Darah Arteri Ekstremitas Bawah 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 155 Reseksi dan replacement Pembuluh Darah Vena Ekstremitas Bawah 12,890,625 4,296,875 17,187,500 14,824,219 4,941,406 19,765,625 16,113,281 5,371,094 21,484,375 19,335,938 6,445,313 25,781,250 156 Ligasi dan stripping vena 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 157 Pemasangan arterial line (pungsi) 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 158 Pemasangan CVP (double lumen) 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 159 Vena Seksi * 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 160 Pintas arteri sistemik - pulmonal 19,531,250 6,510,417 26,041,667 22,460,938 7,486,979 29,947,917 24,414,063 8,138,021 32,552,083 29,296,875 9,765,625 39,062,500 161 Pintas vena intra-abdominal (mesokaval, portokaval) 14,648,438 4,882,813 19,531,250 16,845,703 5,615,234 22,460,938 18,310,547 6,103,516 24,414,063 21,972,656 7,324,219 29,296,875 162 Bypass aorta-subklavia-karotis 22,460,938 7,486,979 29,947,917 25,830,078 8,610,026 34,440,104 28,076,172 9,358,724 37,434,896 33,691,406 11,230,469 44,921,875 163 Bypass aorta-renal 18,554,688 6,184,896 24,739,583 21,337,891 7,112,630 28,450,521 23,193,359 7,731,120 30,924,479 27,832,031 9,277,344 37,109,375 164 Bypass aorta-iliaka-femoral 18,554,688 6,184,896 24,739,583 21,337,891 7,112,630 28,450,521 23,193,359 7,731,120 30,924,479 27,832,031 9,277,344 37,109,375 165 Anastomosis untuk hemodialisis (AV Shunt/Cimino shunt) 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 166 Bypass pembuluh lainnya (femoro-femoral, femoro-popliteal, femorotibial) 14,648,438 4,882,813 19,531,250 16,845,703 5,615,234 22,460,938 18,310,547 6,103,516 24,414,063 21,972,656 7,324,219 29,296,875 167 Sutur (jahit) pembuluh arteri (perifer) 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 168 Sutur (jahit) pembuluh vena (perifer) 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 169 Revisi AV-shunt * 4,687,500 1,562,500 6,250,000 5,390,625 1,796,875 7,187,500 5,859,375 1,953,125 7,812,500 7,031,250 2,343,750 9,375,000 170 Tutup / angkat AV-shunt 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 171 Repair AV fistula (clipping, ligasi, divisi) (perifer) 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 172 Repair pembuluh (perifer) dengan jaringan tubuh 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 173 Repair pembuluh (perifer) dengan patch graft 9,179,688 3,059,896 12,239,583 10,556,641 3,518,880 14,075,521 11,474,609 3,824,870 15,299,479 13,769,531 4,589,844 18,359,375 174 Endovaskular repair 8,984,375 2,994,792 11,979,167 10,332,031 3,444,010 13,776,042 11,230,469 3,743,490 14,973,958 13,476,563 4,492,188 17,968,750 175 Implantasi Graft Aorta endovaskular 16,210,938 5,403,646 21,614,583 18,642,578 6,214,193 24,856,771 20,263,672 6,754,557 27,018,229 24,316,406 8,105,469 32,421,875 176 Insersi non-drug-eluting stent ke pembuluh darah perifer 11,132,813 3,710,938 14,843,750 12,802,734 4,267,578 17,070,313 13,916,016 4,638,672 18,554,688 16,699,219 5,566,406 22,265,625 177 Injeksi Sklerosing Agent ke Vena * 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL Tindakan Bedah Minor - - - - - - - - 1 Eksisi Chalazion/Hordeolum 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 2 Corpus alineum dengan operating microscope 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 3 Injeksi botox pada blefarospasme 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 4 Laser 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 5 Goniotomi 1,171,875 390,625 1,562,500 1,347,656 449,219 1,796,875 1,464,844 488,281 1,953,125 1,757,813 585,938 2,343,750 6 Laser Iridotomy 1,171,875 390,625 1,562,500 1,347,656 449,219 1,796,875 1,464,844 488,281 1,953,125 1,757,813 585,938 2,343,750 7 Fotokoagulasi Laser 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 8 Laser Trabeculoplasty (POLTRAB) (SLT) 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 9 Photo Dynamic Theraphy ( PDT) 1,953,125 651,042 2,604,167 2,246,094 748,698 2,994,792 2,441,406 813,802 3,255,208 2,929,688 976,563 3,906,250 10 YAG Laser 1,171,875 390,625 1,562,500 1,347,656 449,219 1,796,875 1,464,844 488,281 1,953,125 1,757,813 585,938 2,343,750 Kamar Bedah - - - - - - - - 11 Angkat jahitan Kornea 1,367,188 455,729 1,822,917 1,572,266 524,089 2,096,354 1,708,984 569,661 2,278,646 2,050,781 683,594 2,734,375 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS MATA NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 12 Aspirasi / irigasi/ Reformasi COA 1,367,188 455,729 1,822,917 1,572,266 524,089 2,096,354 1,708,984 569,661 2,278,646 2,050,781 683,594 2,734,375 13 Flap Conjungtiva/Amnion Graft 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 14 DSAEK 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 15 ECCE/ICCE/SICS 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 16 ECCE/SICS + IOL 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 17 Eksisi Pterigium 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 18 Keratoplasty tembus 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 19 Lasik 1 (satu) mata 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 20 Limbal Relaxing Incision (LRI) 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 21 Phaco 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 22 Phaco + IOL 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 23 Phaco + IOL multIfokal /torik 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 24 Phakik IOL 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 25 Repair of laceration, cornea, non perforating 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 26 Repair of laceration, cornea and/or sclera, perforating 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 27 Reposisi IOL 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 28 Reposisi Iris 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 29 Sekunder IOL 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 30 Tatto cornea 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 31 Ekstraksi IOL 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 32 Ekstraksi Corpus alienum cornea 1,367,188 455,729 1,822,917 1,572,266 524,089 2,096,354 1,708,984 569,661 2,278,646 2,050,781 683,594 2,734,375 33 Anterior lamellar keratoplasty 5,078,125 1,692,708 6,770,833 5,839,844 1,946,615 7,786,458 6,347,656 2,115,885 8,463,542 7,617,188 2,539,063 10,156,250 34 Implantasi Piggyback IOL 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 35 Implantasi iris artifisial 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 36 Keratoprosthesis 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 37 PTK : Phototherapeutic keratectomy 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 38 Ekstirpasi kelainan kornea 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 39 Ekstraksi Corpus alienum segmen anterior 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 40 Repair iridodyalisis 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 41 Exchange IOL 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 42 Ekstraksi epithelial downgrowth 2,929,688 976,563 3,906,250 3,369,141 1,123,047 4,492,188 3,662,109 1,220,703 4,882,813 4,394,531 1,464,844 5,859,375 Glaukoma - - - - - - - - 43 Anterior / Posterior Sklerotomi 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 44 Cyclo Cryo 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 45 Gonioplasty/Goniotomy 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 46 Iridektomi perifer 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 47 Paracentesis 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 48 Tindakan Cyclodia Termi 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 49 Trabekulektomi 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 50 Trabekulektomi + Phaco +IOL 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 51 Tubes implan 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 52 Tubes implan + Phaco + IOL 8,984,375 2,994,792 11,979,167 10,332,031 3,444,010 13,776,042 11,230,469 3,743,490 14,973,958 13,476,563 4,492,188 17,968,750 53 Transkleral Foto Coagulasi 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 54 Revisi Blab 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 55 Reformasi COA 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 56 Trabekulotomi (pada anak/bayi) 3,906,250 1,302,083 5,208,333 4,492,188 1,497,396 5,989,583 4,882,813 1,627,604 6,510,417 5,859,375 1,953,125 7,812,500 57 Trabekulotomi + trabekulektomi (pada anak/bayi) 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 58 Vitreo Retina - - - - - - - - 59 Evakuasi silicon oil 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 60 Evakuasi silicon oil + Phaco/ECCE + IOL 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 61 Evakuasi silicon oil + ECCE 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 62 Injeksi intravitreal 1,464,844 488,281 1,953,125 1,684,570 561,523 2,246,094 1,831,055 610,352 2,441,406 2,197,266 732,422 2,929,688 63 Pengangkatan encircling silicone band 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 64 Pneumatic retinopexy 2,050,781 683,594 2,734,375 2,358,398 786,133 3,144,531 2,563,477 854,492 3,417,969 3,076,172 1,025,391 4,101,563 65 Posterior vitrectomy +/- Sceral buckling 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 66 Posterior vitrectomy+ endo laser dengan atau tanpa Silikon Oil/Gas + injeksi intravitreal 7,617,188 2,539,063 10,156,250 8,759,766 2,919,922 11,679,688 9,521,484 3,173,828 12,695,313 11,425,781 3,808,594 15,234,375 67 Posterior vitrectomy + Phaco + IOL 11,132,813 3,710,938 14,843,750 12,802,734 4,267,578 17,070,313 13,916,016 4,638,672 18,554,688 16,699,219 5,566,406 22,265,625 68 Posterior vitektomi + SB + Endo laser + Silikon Oil/Gas + Phaco+ IOL 11,328,125 3,776,042 15,104,167 13,027,344 4,342,448 17,369,792 14,160,156 4,720,052 18,880,208 16,992,188 5,664,063 22,656,250 69 Scleral buckling 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 70 Scleral Buckle + Cryo + C3F8 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 71 Scleral buckling + Phaco +IOL 8,984,375 2,994,792 11,979,167 10,332,031 3,444,010 13,776,042 11,230,469 3,743,490 14,973,958 13,476,563 4,492,188 17,968,750 Strabismus - - - - - - - - 72 Strabismus 1 otot 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 73 Strabismus 2 otot 7,031,250 2,343,750 9,375,000 8,085,938 2,695,313 10,781,250 8,789,063 2,929,688 11,718,750 10,546,875 3,515,625 14,062,500 74 Strabismus 3 otot 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 75 Strabismus 4 otot 8,593,750 2,864,583 11,458,333 9,882,813 3,294,271 13,177,083 10,742,188 3,580,729 14,322,917 12,890,625 4,296,875 17,187,500 76 Injeksi botox pada strabismus 2,050,781 683,594 2,734,375 2,358,398 786,133 3,144,531 2,563,477 854,492 3,417,969 3,076,172 1,025,391 4,101,563 Rekonstruksi Bedah Mata - - - - - - - - 77 Blefaroplasty 2 kelopak 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 78 Cryo/cauter pada trichiasis 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 79 Eksternal DCR + silikon tube 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 80 Eksisi tumor kecil kelopak 2,734,375 911,458 3,645,833 3,144,531 1,048,177 4,192,708 3,417,969 1,139,323 4,557,292 4,101,563 1,367,188 5,468,750 81 Endoskopi DCR + silikon tube 10,156,250 3,385,417 13,541,667 11,679,688 3,893,229 15,572,917 12,695,313 4,231,771 16,927,083 15,234,375 5,078,125 20,312,500 82 Ekstirpasi Tumor Adneksa + rekosntruksi 13,671,875 4,557,292 18,229,167 15,722,656 5,240,885 20,963,542 17,089,844 5,696,615 22,786,458 20,507,813 6,835,938 27,343,750 83 Ektropion 1 kelopak * 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 84 Entropion 1 kelopak 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 85 Eviserasi /enukleasi+implan 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 86 Eviserasi /enukleasi 4,492,188 1,497,396 5,989,583 5,166,016 1,722,005 6,888,021 5,615,234 1,871,745 7,486,979 6,738,281 2,246,094 8,984,375 87 Fraktur Multiple 14,453,125 4,817,708 19,270,833 16,621,094 5,540,365 22,161,458 18,066,406 6,022,135 24,088,542 21,679,688 7,226,563 28,906,250 88 Koreksi Ptosis * 5,859,375 1,953,125 7,812,500 6,738,281 2,246,094 8,984,375 7,324,219 2,441,406 9,765,625 8,789,063 2,929,688 11,718,750 89 Koreksi Lagoftalmos dengan beban emas 4,101,563 1,367,188 5,468,750 4,716,797 1,572,266 6,289,063 5,126,953 1,708,984 6,835,938 6,152,344 2,050,781 8,203,125 90 Graft Bibir pada Ptisis Bulbi 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 91 Oklusi punctum lakrimal 781,250 260,417 1,041,667 898,438 299,479 1,197,917 976,563 325,521 1,302,083 1,171,875 390,625 1,562,500 92 Koreksi simblefaron 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 93 Probing 2,343,750 781,250 3,125,000 2,695,313 898,438 3,593,750 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 94 Rekonstruksi fraktur dasar orbita 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 95 Rekonstruksi Palpebra dengan Graft * 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 96 Rekonstruksi soket kontraktur 10,156,250 3,385,417 13,541,667 11,679,688 3,893,229 15,572,917 12,695,313 4,231,771 16,927,083 15,234,375 5,078,125 20,312,500 97 Rekonstruksi soket landai 7,812,500 2,604,167 10,416,667 8,984,375 2,994,792 11,979,167 9,765,625 3,255,208 13,020,833 11,718,750 3,906,250 15,625,000 98 Repair Ruptur palpebra * 4,296,875 1,432,292 5,729,167 4,941,406 1,647,135 6,588,542 5,371,094 1,790,365 7,161,458 6,445,313 2,148,438 8,593,750 99 Repair Ruptur palpebra (dengan rupture canalis lacrimalis) 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 100 Tarsorafi 2,539,063 846,354 3,385,417 2,919,922 973,307 3,893,229 3,173,828 1,057,943 4,231,771 3,808,594 1,269,531 5,078,125 Tumor - - - - - - - - 101 Orbitotomi anterior 4,882,813 1,627,604 6,510,417 5,615,234 1,871,745 7,486,979 6,103,516 2,034,505 8,138,021 7,324,219 2,441,406 9,765,625 102 Orbitotomi lateral 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 103 Orbitotomi lateral + superior/medial 9,765,625 3,255,208 13,020,833 11,230,469 3,743,490 14,973,958 12,207,031 4,069,010 16,276,042 14,648,438 4,882,813 19,531,250 104 orbital dekompresi 1 tulang 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 105 orbital dekompresi 2 tulang 7,421,875 2,473,958 9,895,833 8,535,156 2,845,052 11,380,208 9,277,344 3,092,448 12,369,792 11,132,813 3,710,938 14,843,750 106 orbital dekompresi 3 tulang 13,671,875 4,557,292 18,229,167 15,722,656 5,240,885 20,963,542 17,089,844 5,696,615 22,786,458 20,507,813 6,835,938 27,343,750 107 Biopsi tumor orbita 3,710,938 1,236,979 4,947,917 4,267,578 1,422,526 5,690,104 4,638,672 1,546,224 6,184,896 5,566,406 1,855,469 7,421,875 108 Biopsi tumor kelopak 3,515,625 1,171,875 4,687,500 4,042,969 1,347,656 5,390,625 4,394,531 1,464,844 5,859,375 5,273,438 1,757,813 7,031,250 109 Eksenterasi 7,226,563 2,408,854 9,635,417 8,310,547 2,770,182 11,080,729 9,033,203 3,011,068 12,044,271 10,839,844 3,613,281 14,453,125 110 Eksisi tumor adneksa 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 111 Ekstirpasi Tumor Orbita 6,445,313 2,148,438 8,593,750 7,412,109 2,470,703 9,882,813 8,056,641 2,685,547 10,742,188 9,667,969 3,222,656 12,890,625 112 Extended Eksenterasi 8,203,125 2,734,375 10,937,500 9,433,594 3,144,531 12,578,125 10,253,906 3,417,969 13,671,875 12,304,688 4,101,563 16,406,250 Pediatric oftalmologi - - - - - - - - 113 Pediatric Cataract 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 114 Hemangioma : injeksi intralesi 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 115 Combined Trabeculotomy dan trabeculectomy (Pediatric) 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 116 Pupilloplasty, membranectomy, anterior vitrectomy, secondary IOL 6,640,625 2,213,542 8,854,167 7,636,719 2,545,573 10,182,292 8,300,781 2,766,927 11,067,708 9,960,938 3,320,313 13,281,250 117 RetCam+Narkose (Pediatric) 6,054,688 2,018,229 8,072,917 6,962,891 2,320,964 9,283,854 7,568,359 2,522,786 10,091,146 9,082,031 3,027,344 12,109,375 118 Trabeculotomy, untuk glaucoma congenital (Pediatric) 5,664,063 1,888,021 7,552,083 6,513,672 2,171,224 8,684,896 7,080,078 2,360,026 9,440,104 8,496,094 2,832,031 11,328,125 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS BEDAH MULUT PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL PELAYANAN SARANA TOTAL 1 Kuretase 830,078 276,693 1,106,771 1,015,625 338,542 1,354,167 1,660,156 553,385 2,213,542 2,011,719 670,573 2,682,292 2 Ekstraksi per gigi 830,078 276,693 1,106,771 1,015,625 338,542 1,354,167 1,660,156 553,385 2,213,542 2,011,719 670,573 2,682,292 3 Ekstraksi gigi /fragmen fraktur gigi dengan flap per gigi 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 4 Insisi/Eksisi Abses 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 5 Odontektomy kelas I pergigi 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 6 Opperkulektomy peregio 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 7 Penutupan fistula ekstraoral 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 8 Ridge Augmentasi perkuadran 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 9 Apex reseksi/apikoektomy pergigi 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 10 Excisi Biopsi 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 11 Insisi Biopsi 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 12 Wiring per rahang 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 13 Nekrotomi perkuadran 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 14 Reposisi dislokasi mandibula 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 15 Repair wound Gingiva 2,246,094 748,698 2,994,792 3,320,313 1,106,771 4,427,083 4,296,875 1,432,292 5,729,167 5,273,438 1,757,813 7,031,250 16 Pengambilan fragmen gigi dalam sinus 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 17 Sinus Lifting 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 18 Penutupan fistula oroantral (Buccal/palatal flap) 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 19 Sequesterectomy perkuadran 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 20 Odontectomy kelas 2 pergigi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 21 Odontectomy kelas 3 pergigi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 22 Frenektomy per Rahang 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 23 Exposure mahkota gigi terpendam pergig 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 24 Alveolektomi perkuadran 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 25 Vestibuloplasty per rahang 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 26 Excisi torus peregio 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 27 Excisi Hiperplasia denture 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 28 Gingivektomi/Gingivoplasty Peregio 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 29 Aspirasi Biopsi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 30 Extirpasi Biopsi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 31 Enukleasi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 32 Marsupialisasi perkuadran 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 33 Eksisi/ekstirpasi Sialolitiasis/Ranula 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 34 Sialadenectomy 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 35 Reseksi Marginal 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 36 Reseksi Segmental 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 37 Fraktur Edentulous/per rahang 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 38 Fraktur dentoalveolar per rahang 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 39 Splinting pekuadran 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 40 Penjahitan perkuadran 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 41 Replantasi gigi asli per gigi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 42 Veloplasty 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 43 Repair wound kulit peregio 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 44 Repair wound lidah 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 45 Repair wound mukosa,otot peregio 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 46 Ekstraksi 2 gigi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 47 Ekstraksi 4 Gigi 4,833,984 1,611,328 6,445,313 6,054,688 2,018,229 8,072,917 6,542,969 2,180,990 8,723,958 7,275,391 2,425,130 9,700,521 48 Metode dredging 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 49 Fiksasi fraktur Le Fort I 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 50 Fiksasi Fraktur le Fort 2 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 51 Fiksasi fraktur Le Fort 3 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 52 Fiksasi fraktur Mandibula 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 53 Fiksasi fraktur Zygoma 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 TARIF JASA MEDIK UMUM OPERASI DOKTER SPESIALIS BEDAH MULUT NO NAMA TINDAKAN KELAS III KELAS II KELAS I VIP 54 Refraktur rahang 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 55 Transplantasi gigi Asli per gigi 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 56 Implantasi gigi per gigi 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 57 Labioplasty primer Bilateral 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 58 Labioplasty primer Unilateral 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 59 Palatoplasty primer unilateral 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 60 Palatoplasty primer bilateral 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 61 Rekonstruksi Sekunder labioplasty 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 62 Rekonstruksi Sekunder Palatoplasty 7,421,875 2,473,958 9,895,833 8,789,063 2,929,688 11,718,750 8,984,375 2,994,792 11,979,167 9,277,344 3,092,448 12,369,792 63 Ekstraksi 6 gigi 8,398,438 2,799,479 11,197,917 10,253,906 3,417,969 13,671,875 10,742,188 3,580,729 14,322,917 10,937,500 3,645,833 14,583,333 64 Hemimandibulektomy 8,398,438 2,799,479 11,197,917 10,253,906 3,417,969 13,671,875 10,742,188 3,580,729 14,322,917 10,937,500 3,645,833 14,583,333 65 Hemimaksilektomi 8,398,438 2,799,479 11,197,917 10,253,906 3,417,969 13,671,875 10,742,188 3,580,729 14,322,917 10,937,500 3,645,833 14,583,333 66 Mandibulektomi 8,398,438 2,799,479 11,197,917 10,253,906 3,417,969 13,671,875 10,742,188 3,580,729 14,322,917 10,937,500 3,645,833 14,583,333 67 Maksilektomi 8,398,438 2,799,479 11,197,917 10,253,906 3,417,969 13,671,875 10,742,188 3,580,729 14,322,917 10,937,500 3,645,833 14,583,333 - 2929687.5 976562.5 PELAYANAN SARANA TOTAL 38,281,250 12,760,417 51,041,667 24,218,750 8,072,917 32,291,667 21,093,750 7,031,250 28,125,000 - - 14,062,500 4,687,500 18,750,000 14,062,500 4,687,500 18,750,000 18,359,375 6,119,792 24,479,167 14,843,750 4,947,917 19,791,667 15,234,375 5,078,125 20,312,500 8,593,750 2,864,583 11,458,333 14,843,750 4,947,917 19,791,667 14,843,750 4,947,917 19,791,667 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 14,843,750 4,947,917 19,791,667 11,718,750 3,906,250 15,625,000 8,593,750 2,864,583 11,458,333 14,062,500 4,687,500 18,750,000 19,140,625 6,380,208 25,520,833 18,359,375 6,119,792 24,479,167 14,062,500 4,687,500 18,750,000 14,843,750 4,947,917 19,791,667 14,843,750 4,947,917 19,791,667 19,140,625 6,380,208 25,520,833 30,468,750 10,156,250 40,625,000 28,906,250 9,635,417 38,541,667 36,718,750 12,239,583 48,958,333 29,687,500 9,895,833 39,583,333 19,531,250 6,510,417 26,041,667 19,140,625 6,380,208 25,520,833 8,593,750 2,864,583 11,458,333 22,656,250 7,552,083 30,208,333 23,437,500 7,812,500 31,250,000 29,687,500 9,895,833 39,583,333 - - 15,625,000 5,208,333 20,833,333 8,203,125 2,734,375 10,937,500 8,593,750 2,864,583 11,458,333 10,937,500 3,645,833 14,583,333 13,281,250 4,427,083 17,708,333 14,062,500 4,687,500 18,750,000 15,625,000 5,208,333 20,833,333 13,671,875 4,557,292 18,229,167 14,843,750 4,947,917 19,791,667 14,843,750 4,947,917 19,791,667 13,671,875 4,557,292 18,229,167 14,843,750 4,947,917 19,791,667 13,671,875 4,557,292 18,229,167 14,062,500 4,687,500 18,750,000 14,843,750 4,947,917 19,791,667 14,843,750 4,947,917 19,791,667 17,578,125 5,859,375 23,437,500 VVIP - - 29,687,500 9,895,833 39,583,333 19,140,625 6,380,208 25,520,833 12,500,000 4,166,667 16,666,667 19,140,625 6,380,208 25,520,833 29,687,500 9,895,833 39,583,333 13,671,875 4,557,292 18,229,167 14,062,500 4,687,500 18,750,000 14,062,500 4,687,500 18,750,000 29,687,500 9,895,833 39,583,333 14,843,750 4,947,917 19,791,667 29,687,500 9,895,833 39,583,333 14,843,750 4,947,917 19,791,667 29,687,500 9,895,833 39,583,333 14,843,750 4,947,917 19,791,667 19,140,625 6,380,208 25,520,833 11,718,750 3,906,250 15,625,000 10,937,500 3,645,833 14,583,333 8,593,750 2,864,583 11,458,333 8,593,750 2,864,583 11,458,333 11,328,125 3,776,042 15,104,167 22,656,250 7,552,083 30,208,333 14,843,750 4,947,917 19,791,667 19,140,625 6,380,208 25,520,833 14,453,125 4,817,708 19,270,833 11,718,750 3,906,250 15,625,000 - - 29,687,500 9,895,833 39,583,333 18,359,375 6,119,792 24,479,167 14,843,750 4,947,917 19,791,667 32,812,500 10,937,500 43,750,000 - - 8,203,125 2,734,375 10,937,500 9,375,000 3,125,000 12,500,000 26,562,500 8,854,167 35,416,667 9,375,000 3,125,000 12,500,000 10,156,250 3,385,417 13,541,667 14,843,750 4,947,917 19,791,667 13,281,250 4,427,083 17,708,333 10,937,500 3,645,833 14,583,333 11,328,125 3,776,042 15,104,167 12,500,000 4,166,667 16,666,667 8,203,125 2,734,375 10,937,500 8,203,125 2,734,375 10,937,500 8,593,750 2,864,583 11,458,333 8,203,125 2,734,375 10,937,500 8,203,125 2,734,375 10,937,500 14,062,500 4,687,500 18,750,000 13,671,875 4,557,292 18,229,167 14,062,500 4,687,500 18,750,000 8,203,125 2,734,375 10,937,500 15,625,000 5,208,333 20,833,333 8,984,375 2,994,792 11,979,167 - - 8,203,125 2,734,375 10,937,500 8,203,125 2,734,375 10,937,500 10,546,875 3,515,625 14,062,500 11,718,750 3,906,250 15,625,000 22,656,250 7,552,083 30,208,333 14,453,125 4,817,708 19,270,833 10,937,500 3,645,833 14,583,333 25,781,250 8,593,750 34,375,000 13,671,875 4,557,292 18,229,167 - - 8,203,125 2,734,375 10,937,500 8,203,125 2,734,375 10,937,500 11,718,750 3,906,250 15,625,000 4,296,875 1,432,292 5,729,167 11,718,750 3,906,250 15,625,000 10,937,500 3,645,833 14,583,333 15,234,375 5,078,125 20,312,500 11,718,750 3,906,250 15,625,000 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 14,062,500 4,687,500 18,750,000 8,203,125 2,734,375 10,937,500 8,203,125 2,734,375 10,937,500 12,890,625 4,296,875 17,187,500 11,718,750 3,906,250 15,625,000 11,328,125 3,776,042 15,104,167 11,718,750 3,906,250 15,625,000 10,937,500 3,645,833 14,583,333 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 10,937,500 3,645,833 14,583,333 12,500,000 4,166,667 16,666,667 14,062,500 4,687,500 18,750,000 17,578,125 5,859,375 23,437,500 11,328,125 3,776,042 15,104,167 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 11,328,125 3,776,042 15,104,167 8,593,750 2,864,583 11,458,333 8,593,750 2,864,583 11,458,333 10,937,500 3,645,833 14,583,333 16,015,625 5,338,542 21,354,167 15,625,000 5,208,333 20,833,333 8,203,125 2,734,375 10,937,500 13,281,250 4,427,083 17,708,333 11,328,125 3,776,042 15,104,167 - - 13,671,875 4,557,292 18,229,167 8,203,125 2,734,375 10,937,500 8,593,750 2,864,583 11,458,333 10,546,875 3,515,625 14,062,500 17,578,125 5,859,375 23,437,500 10,546,875 3,515,625 14,062,500 9,375,000 3,125,000 12,500,000 9,375,000 3,125,000 12,500,000 9,765,625 3,255,208 13,020,833 15,234,375 5,078,125 20,312,500 3,906,250 1,302,083 5,208,333 7,812,500 2,604,167 10,416,667 14,062,500 4,687,500 18,750,000 14,062,500 4,687,500 18,750,000 11,328,125 3,776,042 15,104,167 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 8,984,375 2,994,792 11,979,167 8,593,750 2,864,583 11,458,333 14,843,750 4,947,917 19,791,667 14,453,125 4,817,708 19,270,833 8,203,125 2,734,375 10,937,500 9,765,625 3,255,208 13,020,833 9,765,625 3,255,208 13,020,833 9,765,625 3,255,208 13,020,833 3,906,250 1,302,083 5,208,333 3,906,250 1,302,083 5,208,333 5,859,375 1,953,125 7,812,500 11,328,125 3,776,042 15,104,167 7,812,500 2,604,167 10,416,667 - - - - PELAYANAN SARANA TOTAL 7,421,875 2,473,958 9,895,833 9,765,625 3,255,208 13,020,833 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 5,078,125 1,692,708 6,770,833 7,812,500 2,604,167 10,416,667 11,328,125 3,776,042 15,104,167 10,546,875 3,515,625 14,062,500 12,109,375 4,036,458 16,145,833 13,671,875 4,557,292 18,229,167 14,453,125 4,817,708 19,270,833 6,640,625 2,213,542 8,854,167 10,546,875 3,515,625 14,062,500 10,546,875 3,515,625 14,062,500 8,203,125 2,734,375 10,937,500 12,109,375 4,036,458 16,145,833 11,718,750 3,906,250 15,625,000 10,546,875 3,515,625 14,062,500 12,109,375 4,036,458 16,145,833 11,328,125 3,776,042 15,104,167 12,109,375 4,036,458 16,145,833 14,843,750 4,947,917 19,791,667 19,531,250 6,510,417 26,041,667 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 12,890,625 4,296,875 17,187,500 VVIP 5,468,750 1,822,917 7,291,667 14,062,500 4,687,500 18,750,000 11,718,750 3,906,250 15,625,000 9,375,000 3,125,000 12,500,000 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 7,421,875 2,473,958 9,895,833 5,078,125 1,692,708 6,770,833 5,078,125 1,692,708 6,770,833 5,078,125 1,692,708 6,770,833 13,671,875 4,557,292 18,229,167 14,453,125 4,817,708 19,270,833 16,796,875 5,598,958 22,395,833 12,109,375 4,036,458 16,145,833 8,203,125 2,734,375 10,937,500 8,984,375 2,994,792 11,979,167 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 16,015,625 5,338,542 21,354,167 12,109,375 4,036,458 16,145,833 8,593,750 2,864,583 11,458,333 15,234,375 5,078,125 20,312,500 15,234,375 5,078,125 20,312,500 19,140,625 6,380,208 25,520,833 14,453,125 4,817,708 19,270,833 8,984,375 2,994,792 11,979,167 12,109,375 4,036,458 16,145,833 6,640,625 2,213,542 8,854,167 14,453,125 4,817,708 19,270,833 8,984,375 2,994,792 11,979,167 14,843,750 4,947,917 19,791,667 5,468,750 1,822,917 7,291,667 11,718,750 3,906,250 15,625,000 13,671,875 4,557,292 18,229,167 10,156,250 3,385,417 13,541,667 12,109,375 4,036,458 16,145,833 12,500,000 4,166,667 16,666,667 12,109,375 4,036,458 16,145,833 13,671,875 4,557,292 18,229,167 16,796,875 5,598,958 22,395,833 12,109,375 4,036,458 16,145,833 16,796,875 5,598,958 22,395,833 16,796,875 5,598,958 22,395,833 10,546,875 3,515,625 14,062,500 12,109,375 4,036,458 16,145,833 9,375,000 3,125,000 12,500,000 13,671,875 4,557,292 18,229,167 4,687,500 1,562,500 6,250,000 9,375,000 3,125,000 12,500,000 9,375,000 3,125,000 12,500,000 8,203,125 2,734,375 10,937,500 9,765,625 3,255,208 13,020,833 9,765,625 3,255,208 13,020,833 13,671,875 4,557,292 18,229,167 7,421,875 2,473,958 9,895,833 5,468,750 1,822,917 7,291,667 11,718,750 3,906,250 15,625,000 14,843,750 4,947,917 19,791,667 10,937,500 3,645,833 14,583,333 15,625,000 5,208,333 20,833,333 9,375,000 3,125,000 12,500,000 11,718,750 3,906,250 15,625,000 9,375,000 3,125,000 12,500,000 9,375,000 3,125,000 12,500,000 9,375,000 3,125,000 12,500,000 8,203,125 2,734,375 10,937,500 16,015,625 5,338,542 21,354,167 5,078,125 1,692,708 6,770,833 7,421,875 2,473,958 9,895,833 9,765,625 3,255,208 13,020,833 8,984,375 2,994,792 11,979,167 10,937,500 3,645,833 14,583,333 16,796,875 5,598,958 22,395,833 7,812,500 2,604,167 10,416,667 12,109,375 4,036,458 16,145,833 15,234,375 5,078,125 20,312,500 14,453,125 4,817,708 19,270,833 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 9,375,000 3,125,000 12,500,000 11,718,750 3,906,250 15,625,000 12,109,375 4,036,458 16,145,833 19,921,875 6,640,625 26,562,500 13,281,250 4,427,083 17,708,333 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 13,671,875 4,557,292 18,229,167 10,937,500 3,645,833 14,583,333 9,375,000 3,125,000 12,500,000 10,546,875 3,515,625 14,062,500 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 13,671,875 4,557,292 18,229,167 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 9,375,000 3,125,000 12,500,000 7,421,875 2,473,958 9,895,833 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 9,375,000 3,125,000 12,500,000 10,546,875 3,515,625 14,062,500 10,937,500 3,645,833 14,583,333 5,859,375 1,953,125 7,812,500 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 13,671,875 4,557,292 18,229,167 5,078,125 1,692,708 6,770,833 11,328,125 3,776,042 15,104,167 13,671,875 4,557,292 18,229,167 15,234,375 5,078,125 20,312,500 15,234,375 5,078,125 20,312,500 15,234,375 5,078,125 20,312,500 14,453,125 4,817,708 19,270,833 14,453,125 4,817,708 19,270,833 14,453,125 4,817,708 19,270,833 7,421,875 2,473,958 9,895,833 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 16,015,625 5,338,542 21,354,167 12,109,375 4,036,458 16,145,833 14,843,750 4,947,917 19,791,667 16,406,250 5,468,750 21,875,000 16,406,250 5,468,750 21,875,000 15,234,375 5,078,125 20,312,500 12,109,375 4,036,458 16,145,833 5,859,375 1,953,125 7,812,500 8,984,375 2,994,792 11,979,167 16,406,250 5,468,750 21,875,000 7,812,500 2,604,167 10,416,667 8,203,125 2,734,375 10,937,500 14,843,750 4,947,917 19,791,667 16,796,875 5,598,958 22,395,833 19,140,625 6,380,208 25,520,833 12,500,000 4,166,667 16,666,667 15,234,375 5,078,125 20,312,500 15,234,375 5,078,125 20,312,500 10,937,500 3,645,833 14,583,333 10,546,875 3,515,625 14,062,500 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 7,421,875 2,473,958 9,895,833 9,765,625 3,255,208 13,020,833 9,375,000 3,125,000 12,500,000 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 19,921,875 6,640,625 26,562,500 12,890,625 4,296,875 17,187,500 8,984,375 2,994,792 11,979,167 11,328,125 3,776,042 15,104,167 16,015,625 5,338,542 21,354,167 8,203,125 2,734,375 10,937,500 6,640,625 2,213,542 8,854,167 10,937,500 3,645,833 14,583,333 8,984,375 2,994,792 11,979,167 8,203,125 2,734,375 10,937,500 7,421,875 2,473,958 9,895,833 16,015,625 5,338,542 21,354,167 7,421,875 2,473,958 9,895,833 11,328,125 3,776,042 15,104,167 8,203,125 2,734,375 10,937,500 14,453,125 4,817,708 19,270,833 19,140,625 6,380,208 25,520,833 16,796,875 5,598,958 22,395,833 9,765,625 3,255,208 13,020,833 19,921,875 6,640,625 26,562,500 15,234,375 5,078,125 20,312,500 14,453,125 4,817,708 19,270,833 11,328,125 3,776,042 15,104,167 15,234,375 5,078,125 20,312,500 15,234,375 5,078,125 20,312,500 15,234,375 5,078,125 20,312,500 9,765,625 3,255,208 13,020,833 9,765,625 3,255,208 13,020,833 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 7,812,500 2,604,167 10,416,667 9,765,625 3,255,208 13,020,833 15,234,375 5,078,125 20,312,500 13,671,875 4,557,292 18,229,167 11,718,750 3,906,250 15,625,000 10,937,500 3,645,833 14,583,333 9,375,000 3,125,000 12,500,000 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 10,937,500 3,645,833 14,583,333 19,531,250 6,510,417 26,041,667 19,921,875 6,640,625 26,562,500 13,671,875 4,557,292 18,229,167 19,921,875 6,640,625 26,562,500 17,578,125 5,859,375 23,437,500 16,015,625 5,338,542 21,354,167 8,984,375 2,994,792 11,979,167 7,421,875 2,473,958 9,895,833 7,812,500 2,604,167 10,416,667 15,234,375 5,078,125 20,312,500 9,765,625 3,255,208 13,020,833 9,765,625 3,255,208 13,020,833 5,078,125 1,692,708 6,770,833 8,984,375 2,994,792 11,979,167 8,984,375 2,994,792 11,979,167 14,453,125 4,817,708 19,270,833 12,109,375 4,036,458 16,145,833 8,203,125 2,734,375 10,937,500 13,281,250 4,427,083 17,708,333 11,718,750 3,906,250 15,625,000 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 14,453,125 4,817,708 19,270,833 9,375,000 3,125,000 12,500,000 15,625,000 5,208,333 20,833,333 4,687,500 1,562,500 6,250,000 12,109,375 4,036,458 16,145,833 14,843,750 4,947,917 19,791,667 16,406,250 5,468,750 21,875,000 12,109,375 4,036,458 16,145,833 13,281,250 4,427,083 17,708,333 5,078,125 1,692,708 6,770,833 12,109,375 4,036,458 16,145,833 11,328,125 3,776,042 15,104,167 14,843,750 4,947,917 19,791,667 12,109,375 4,036,458 16,145,833 19,921,875 6,640,625 26,562,500 19,140,625 6,380,208 25,520,833 19,921,875 6,640,625 26,562,500 19,140,625 6,380,208 25,520,833 16,796,875 5,598,958 22,395,833 16,796,875 5,598,958 22,395,833 10,156,250 3,385,417 13,541,667 7,812,500 2,604,167 10,416,667 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 19,531,250 6,510,417 26,041,667 16,015,625 5,338,542 21,354,167 11,718,750 3,906,250 15,625,000 13,671,875 4,557,292 18,229,167 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 18,359,375 6,119,792 24,479,167 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 16,015,625 5,338,542 21,354,167 19,140,625 6,380,208 25,520,833 9,765,625 3,255,208 13,020,833 12,109,375 4,036,458 16,145,833 9,375,000 3,125,000 12,500,000 15,625,000 5,208,333 20,833,333 8,593,750 2,864,583 11,458,333 5,859,375 1,953,125 7,812,500 6,640,625 2,213,542 8,854,167 6,640,625 2,213,542 8,854,167 15,234,375 5,078,125 20,312,500 16,015,625 5,338,542 21,354,167 16,796,875 5,598,958 22,395,833 14,843,750 4,947,917 19,791,667 16,015,625 5,338,542 21,354,167 9,375,000 3,125,000 12,500,000 8,203,125 2,734,375 10,937,500 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 9,765,625 3,255,208 13,020,833 9,765,625 3,255,208 13,020,833 8,984,375 2,994,792 11,979,167 15,234,375 5,078,125 20,312,500 11,718,750 3,906,250 15,625,000 12,109,375 4,036,458 16,145,833 8,203,125 2,734,375 10,937,500 15,234,375 5,078,125 20,312,500 16,015,625 5,338,542 21,354,167 4,296,875 1,432,292 5,729,167 4,687,500 1,562,500 6,250,000 15,234,375 5,078,125 20,312,500 12,890,625 4,296,875 17,187,500 12,109,375 4,036,458 16,145,833 16,015,625 5,338,542 21,354,167 11,328,125 3,776,042 15,104,167 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 13,671,875 4,557,292 18,229,167 12,109,375 4,036,458 16,145,833 13,281,250 4,427,083 17,708,333 16,015,625 5,338,542 21,354,167 8,203,125 2,734,375 10,937,500 17,578,125 5,859,375 23,437,500 9,375,000 3,125,000 12,500,000 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 13,281,250 4,427,083 17,708,333 12,500,000 4,166,667 16,666,667 23,437,500 7,812,500 31,250,000 13,281,250 4,427,083 17,708,333 10,937,500 3,645,833 14,583,333 5,468,750 1,822,917 7,291,667 4,687,500 1,562,500 6,250,000 10,546,875 3,515,625 14,062,500 16,015,625 5,338,542 21,354,167 10,937,500 3,645,833 14,583,333 11,328,125 3,776,042 15,104,167 14,453,125 4,817,708 19,270,833 23,437,500 7,812,500 31,250,000 4,687,500 1,562,500 6,250,000 23,437,500 7,812,500 31,250,000 11,718,750 3,906,250 15,625,000 PELAYANAN SARANA TOTAL 292,969 97,656 390,625 292,969 97,656 390,625 292,969 97,656 390,625 390,625 130,208 520,833 781,250 260,417 1,041,667 585,938 195,313 781,250 781,250 260,417 1,041,667 #VALUE! #VALUE! Gratis 781,250 260,417 1,041,667 781,250 260,417 1,041,667 781,250 260,417 1,041,667 781,250 260,417 1,041,667 1,953,125 651,042 2,604,167 878,906 292,969 1,171,875 585,938 195,313 781,250 781,250 260,417 1,041,667 781,250 260,417 1,041,667 585,938 195,313 781,250 781,250 260,417 1,041,667 292,969 97,656 390,625 585,938 195,313 781,250 292,969 97,656 390,625 781,250 260,417 1,041,667 292,969 97,656 390,625 VVIP 117,188 39,063 156,250 781,250 260,417 1,041,667 1,464,844 488,281 1,953,125 3,027,344 1,009,115 4,036,458 585,938 195,313 781,250 3,320,313 1,106,771 4,427,083 4,882,813 1,627,604 6,510,417 585,938 195,313 781,250 1,367,188 455,729 1,822,917 1,953,125 651,042 2,604,167 3,906,250 1,302,083 5,208,333 3,906,250 1,302,083 5,208,333 3,320,313 1,106,771 4,427,083 7,031,250 2,343,750 9,375,000 10,156,250 3,385,417 13,541,667 11,718,750 3,906,250 15,625,000 12,890,625 4,296,875 17,187,500 - - 2,929,688 976,563 3,906,250 2,929,688 976,563 3,906,250 2,929,688 976,563 3,906,250 3,515,625 1,171,875 4,687,500 3,515,625 1,171,875 4,687,500 3,515,625 1,171,875 4,687,500 3,515,625 1,171,875 4,687,500 3,515,625 1,171,875 4,687,500 3,515,625 1,171,875 4,687,500 3,515,625 1,171,875 4,687,500 - - 3,906,250 1,302,083 5,208,333 3,906,250 1,302,083 5,208,333 3,906,250 1,302,083 5,208,333 3,906,250 1,302,083 5,208,333 3,906,250 1,302,083 5,208,333 - - 7,031,250 2,343,750 9,375,000 7,031,250 2,343,750 9,375,000 - - 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 - - - - 3,515,625 1,171,875 4,687,500 1,367,188 455,729 1,822,917 - - 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 7,812,500 2,604,167 10,416,667 - - 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 - - 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 - - - - 7,031,250 2,343,750 9,375,000 7,031,250 2,343,750 9,375,000 7,031,250 2,343,750 9,375,000 7,031,250 2,343,750 9,375,000 - - 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 13,671,875 4,557,292 18,229,167 - - 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 17,578,125 5,859,375 23,437,500 - - 19,921,875 6,640,625 26,562,500 19,921,875 6,640,625 26,562,500 PELAYANAN SARANA TOTAL - - 8,349,609 2,783,203 11,132,813 VVIP 8,789,063 2,929,688 11,718,750 11,865,234 3,955,078 15,820,313 11,865,234 3,955,078 15,820,313 11,865,234 3,955,078 15,820,313 11,865,234 3,955,078 15,820,313 11,865,234 3,955,078 15,820,313 12,304,688 4,101,563 16,406,250 12,304,688 4,101,563 16,406,250 12,304,688 4,101,563 16,406,250 14,941,406 4,980,469 19,921,875 15,820,313 5,273,438 21,093,750 15,820,313 5,273,438 21,093,750 16,699,219 5,566,406 22,265,625 19,335,938 6,445,313 25,781,250 19,775,391 6,591,797 26,367,188 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 22,851,563 7,617,188 30,468,750 28,125,000 9,375,000 37,500,000 28,125,000 9,375,000 37,500,000 - - 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 8,789,063 2,929,688 11,718,750 9,228,516 3,076,172 12,304,688 9,228,516 3,076,172 12,304,688 11,865,234 3,955,078 15,820,313 11,425,781 3,808,594 15,234,375 11,865,234 3,955,078 15,820,313 11,865,234 3,955,078 15,820,313 12,304,688 4,101,563 16,406,250 13,183,594 4,394,531 17,578,125 15,380,859 5,126,953 20,507,813 15,380,859 5,126,953 20,507,813 15,380,859 5,126,953 20,507,813 16,699,219 5,566,406 22,265,625 16,699,219 5,566,406 22,265,625 20,654,297 6,884,766 27,539,063 21,093,750 7,031,250 28,125,000 25,488,281 8,496,094 33,984,375 28,125,000 9,375,000 37,500,000 28,125,000 9,375,000 37,500,000 28,125,000 9,375,000 37,500,000 - - - 7,031,250 2,343,750 9,375,000 7,031,250 2,343,750 9,375,000 7,470,703 2,490,234 9,960,938 8,349,609 2,783,203 11,132,813 9,228,516 3,076,172 12,304,688 9,228,516 3,076,172 12,304,688 12,304,688 4,101,563 16,406,250 8,349,609 2,783,203 11,132,813 8,349,609 2,783,203 11,132,813 8,349,609 2,783,203 11,132,813 15,820,313 5,273,438 21,093,750 14,941,406 4,980,469 19,921,875 16,699,219 5,566,406 22,265,625 14,941,406 4,980,469 19,921,875 14,941,406 4,980,469 19,921,875 14,941,406 4,980,469 19,921,875 16,259,766 5,419,922 21,679,688 18,896,484 6,298,828 25,195,313 19,775,391 6,591,797 26,367,188 18,896,484 6,298,828 25,195,313 - - 12,304,688 4,101,563 16,406,250 14,941,406 4,980,469 19,921,875 18,457,031 6,152,344 24,609,375 19,775,391 6,591,797 26,367,188 27,685,547 9,228,516 36,914,063 34,277,344 11,425,781 45,703,125 PELAYANAN SARANA TOTAL 742,188 247,396 989,583 10,937,500 3,645,833 14,583,333 11,328,125 3,776,042 15,104,167 11,718,750 3,906,250 15,625,000 14,453,125 4,817,708 19,270,833 15,234,375 5,078,125 20,312,500 14,453,125 4,817,708 19,270,833 15,234,375 5,078,125 20,312,500 5,273,438 1,757,813 7,031,250 5,468,750 1,822,917 7,291,667 5,664,063 1,888,021 7,552,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 683,594 227,865 911,458 3,710,938 1,236,979 4,947,917 3,710,938 1,236,979 4,947,917 3,710,938 1,236,979 4,947,917 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 1,855,469 618,490 2,473,958 1,953,125 651,042 2,604,167 2,050,781 683,594 2,734,375 1,855,469 618,490 2,473,958 1,855,469 618,490 2,473,958 1,855,469 618,490 2,473,958 1,953,125 651,042 2,604,167 2,539,063 846,354 3,385,417 2,539,063 846,354 3,385,417 2,734,375 911,458 3,645,833 2,734,375 911,458 3,645,833 2,734,375 911,458 3,645,833 2,734,375 911,458 3,645,833 2,539,063 846,354 3,385,417 2,441,406 813,802 3,255,208 2,441,406 813,802 3,255,208 2,539,063 846,354 3,385,417 VVIP 2,539,063 846,354 3,385,417 5,273,438 1,757,813 7,031,250 5,468,750 1,822,917 7,291,667 5,664,063 1,888,021 7,552,083 7,324,219 2,441,406 9,765,625 7,617,188 2,539,063 10,156,250 7,324,219 2,441,406 9,765,625 7,617,188 2,539,063 10,156,250 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 1,855,469 618,490 2,473,958 1,953,125 651,042 2,604,167 1,855,469 618,490 2,473,958 1,855,469 618,490 2,473,958 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 976,563 325,521 1,302,083 10,546,875 3,515,625 14,062,500 10,937,500 3,645,833 14,583,333 11,328,125 3,776,042 15,104,167 5,273,438 1,757,813 7,031,250 5,468,750 1,822,917 7,291,667 5,664,063 1,888,021 7,552,083 5,273,438 1,757,813 7,031,250 5,468,750 1,822,917 7,291,667 5,664,063 1,888,021 7,552,083 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 19,140,625 6,380,208 25,520,833 20,703,125 6,901,042 27,604,167 14,453,125 4,817,708 19,270,833 1,953,125 651,042 2,604,167 2,148,438 716,146 2,864,583 3,710,938 1,236,979 4,947,917 17,578,125 5,859,375 23,437,500 19,140,625 6,380,208 25,520,833 PELAYANAN SARANA TOTAL - - 14,453,125 4,817,708 19,270,833 14,453,125 4,817,708 19,270,833 14,453,125 4,817,708 19,270,833 19,140,625 6,380,208 25,520,833 7,812,500 2,604,167 10,416,667 14,453,125 4,817,708 19,270,833 20,703,125 6,901,042 27,604,167 16,015,625 5,338,542 21,354,167 18,359,375 6,119,792 24,479,167 19,140,625 6,380,208 25,520,833 VVIP 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 20,703,125 6,901,042 27,604,167 19,531,250 6,510,417 26,041,667 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 23,046,875 7,682,292 30,729,167 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 23,046,875 7,682,292 30,729,167 20,703,125 6,901,042 27,604,167 31,250,000 10,416,667 41,666,667 31,250,000 10,416,667 41,666,667 31,250,000 10,416,667 41,666,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 22,656,250 7,552,083 30,208,333 31,250,000 10,416,667 41,666,667 30,078,125 10,026,042 40,104,167 31,250,000 10,416,667 41,666,667 31,250,000 10,416,667 41,666,667 20,703,125 6,901,042 27,604,167 19,531,250 6,510,417 26,041,667 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 19,531,250 6,510,417 26,041,667 20,703,125 6,901,042 27,604,167 19,140,625 6,380,208 25,520,833 20,703,125 6,901,042 27,604,167 23,046,875 7,682,292 30,729,167 24,218,750 8,072,917 32,291,667 23,046,875 7,682,292 30,729,167 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 31,250,000 10,416,667 41,666,667 27,734,375 9,244,792 36,979,167 31,250,000 10,416,667 41,666,667 31,250,000 10,416,667 41,666,667 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 39,453,125 13,151,042 52,604,167 31,250,000 10,416,667 41,666,667 31,250,000 10,416,667 41,666,667 19,531,250 6,510,417 26,041,667 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 19,531,250 6,510,417 26,041,667 20,703,125 6,901,042 27,604,167 31,250,000 10,416,667 41,666,667 20,703,125 6,901,042 27,604,167 - - 15,625,000 5,208,333 20,833,333 26,171,875 8,723,958 34,895,833 24,609,375 8,203,125 32,812,500 26,171,875 8,723,958 34,895,833 24,609,375 8,203,125 32,812,500 26,171,875 8,723,958 34,895,833 22,656,250 7,552,083 30,208,333 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 53,515,625 17,838,542 71,354,167 53,515,625 17,838,542 71,354,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 24,609,375 8,203,125 32,812,500 26,171,875 8,723,958 34,895,833 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,425,117 10,808,372 43,233,490 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 26,171,875 8,723,958 34,895,833 24,218,750 8,072,917 32,291,667 27,734,375 9,244,792 36,979,167 24,218,750 8,072,917 32,291,667 27,734,375 9,244,792 36,979,167 27,734,375 9,244,792 36,979,167 24,218,750 8,072,917 32,291,667 27,734,375 9,244,792 36,979,167 26,171,875 8,723,958 34,895,833 24,218,750 8,072,917 32,291,667 19,140,625 6,380,208 25,520,833 27,734,375 9,244,792 36,979,167 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 27,734,375 9,244,792 36,979,167 29,296,875 9,765,625 39,062,500 27,734,375 9,244,792 36,979,167 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 - - 15,625,000 5,208,333 20,833,333 22,656,250 7,552,083 30,208,333 19,140,625 6,380,208 25,520,833 21,875,000 7,291,667 29,166,667 35,937,500 11,979,167 47,916,667 32,421,875 10,807,292 43,229,167 19,140,625 6,380,208 25,520,833 32,812,500 10,937,500 43,750,000 35,937,500 11,979,167 47,916,667 25,390,625 8,463,542 33,854,167 20,703,125 6,901,042 27,604,167 35,937,500 11,979,167 47,916,667 35,937,500 11,979,167 47,916,667 35,937,500 11,979,167 47,916,667 35,937,500 11,979,167 47,916,667 35,937,500 11,979,167 47,916,667 35,937,500 11,979,167 47,916,667 35,937,500 11,979,167 47,916,667 32,812,500 10,937,500 43,750,000 24,218,750 8,072,917 32,291,667 - - 20,703,125 6,901,042 27,604,167 18,750,000 6,250,000 25,000,000 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 18,750,000 6,250,000 25,000,000 18,750,000 6,250,000 25,000,000 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 18,750,000 6,250,000 25,000,000 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 20,703,125 6,901,042 27,604,167 25,781,250 8,593,750 34,375,000 25,781,250 8,593,750 34,375,000 25,781,250 8,593,750 34,375,000 25,781,250 8,593,750 34,375,000 25,781,250 8,593,750 34,375,000 39,453,125 13,151,042 52,604,167 36,328,125 12,109,375 48,437,500 46,484,375 15,494,792 61,979,167 43,359,375 14,453,125 57,812,500 28,906,250 9,635,417 38,541,667 39,453,125 13,151,042 52,604,167 39,453,125 13,151,042 52,604,167 39,453,125 13,151,042 52,604,167 - - 29,296,875 9,765,625 39,062,500 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 24,218,750 8,072,917 32,291,667 27,734,375 9,244,792 36,979,167 27,734,375 9,244,792 36,979,167 25,781,250 8,593,750 34,375,000 24,218,750 8,072,917 32,291,667 19,140,625 6,380,208 25,520,833 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 19,140,625 6,380,208 25,520,833 24,218,750 8,072,917 32,291,667 10,937,500 3,645,833 14,583,333 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 10,937,500 3,645,833 14,583,333 26,171,875 8,723,958 34,895,833 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 21,679,688 7,226,563 28,906,250 22,656,250 7,552,083 30,208,333 22,656,250 7,552,083 30,208,333 22,656,250 7,552,083 30,208,333 22,656,250 7,552,083 30,208,333 22,656,250 7,552,083 30,208,333 21,679,688 7,226,563 28,906,250 21,679,688 7,226,563 28,906,250 21,679,688 7,226,563 28,906,250 21,679,688 7,226,563 28,906,250 21,679,688 7,226,563 28,906,250 21,679,688 7,226,563 28,906,250 27,734,375 9,244,792 36,979,167 24,218,750 8,072,917 32,291,667 24,218,750 8,072,917 32,291,667 27,734,375 9,244,792 36,979,167 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 5,468,750 1,822,917 7,291,667 - - #VALUE! #VALUE! TOTAL 9,375,000 3,125,000 12,500,000 10,546,875 3,515,625 14,062,500 7,812,500 2,604,167 10,416,667 5,078,125 1,692,708 6,770,833 20,703,125 6,901,042 27,604,167 36,718,750 12,239,583 48,958,333 5,078,125 1,692,708 6,770,833 7,421,875 2,473,958 9,895,833 21,484,375 7,161,458 28,645,833 26,953,125 8,984,375 35,937,500 11,718,750 3,906,250 15,625,000 10,937,500 3,645,833 14,583,333 4,296,875 1,432,292 5,729,167 10,546,875 3,515,625 14,062,500 10,546,875 3,515,625 14,062,500 5,078,125 1,692,708 6,770,833 5,078,125 1,692,708 6,770,833 36,718,750 12,239,583 48,958,333 16,015,625 5,338,542 21,354,167 23,046,875 7,682,292 30,729,167 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 26,953,125 8,984,375 35,937,500 22,265,625 7,421,875 29,687,500 16,015,625 5,338,542 21,354,167 13,671,875 4,557,292 18,229,167 36,718,750 12,239,583 48,958,333 5,078,125 1,692,708 6,770,833 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 8,593,750 2,864,583 11,458,333 6,250,000 2,083,333 8,333,333 15,625,000 5,208,333 20,833,333 5,078,125 1,692,708 6,770,833 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 22,265,625 7,421,875 29,687,500 7,421,875 2,473,958 9,895,833 10,156,250 3,385,417 13,541,667 20,703,125 6,901,042 27,604,167 16,015,625 5,338,542 21,354,167 11,718,750 3,906,250 15,625,000 9,375,000 3,125,000 12,500,000 9,375,000 3,125,000 12,500,000 15,625,000 5,208,333 20,833,333 15,625,000 5,208,333 20,833,333 9,375,000 3,125,000 12,500,000 7,421,875 2,473,958 9,895,833 5,078,125 1,692,708 6,770,833 10,937,500 3,645,833 14,583,333 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 7,812,500 2,604,167 10,416,667 10,937,500 3,645,833 14,583,333 5,468,750 1,822,917 7,291,667 5,078,125 1,692,708 6,770,833 7,421,875 2,473,958 9,895,833 10,156,250 3,385,417 13,541,667 7,812,500 2,604,167 10,416,667 16,015,625 5,338,542 21,354,167 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 15,625,000 5,208,333 20,833,333 5,078,125 1,692,708 6,770,833 5,078,125 1,692,708 6,770,833 4,687,500 1,562,500 6,250,000 7,421,875 2,473,958 9,895,833 10,937,500 3,645,833 14,583,333 7,812,500 2,604,167 10,416,667 7,421,875 2,473,958 9,895,833 5,078,125 1,692,708 6,770,833 7,421,875 2,473,958 9,895,833 5,078,125 1,692,708 6,770,833 7,421,875 2,473,958 9,895,833 36,718,750 12,239,583 48,958,333 7,421,875 2,473,958 9,895,833 5,078,125 1,692,708 6,770,833 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 9,375,000 3,125,000 12,500,000 7,812,500 2,604,167 10,416,667 21,484,375 7,161,458 28,645,833 21,484,375 7,161,458 28,645,833 10,937,500 3,645,833 14,583,333 36,718,750 12,239,583 48,958,333 21,484,375 7,161,458 28,645,833 10,937,500 3,645,833 14,583,333 7,031,250 2,343,750 9,375,000 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 21,484,375 7,161,458 28,645,833 15,625,000 5,208,333 20,833,333 9,375,000 3,125,000 12,500,000 21,484,375 7,161,458 28,645,833 16,015,625 5,338,542 21,354,167 4,687,500 1,562,500 6,250,000 2,343,750 781,250 3,125,000 2,343,750 781,250 3,125,000 7,421,875 2,473,958 9,895,833 5,078,125 1,692,708 6,770,833 5,078,125 1,692,708 6,770,833 10,937,500 3,645,833 14,583,333 7,421,875 2,473,958 9,895,833 7,421,875 2,473,958 9,895,833 7,421,875 2,473,958 9,895,833 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 20,703,125 6,901,042 27,604,167 16,015,625 5,338,542 21,354,167 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 4,296,875 1,432,292 5,729,167 4,296,875 1,432,292 5,729,167 21,484,375 7,161,458 28,645,833 26,171,875 8,723,958 34,895,833 15,625,000 5,208,333 20,833,333 16,015,625 5,338,542 21,354,167 7,421,875 2,473,958 9,895,833 10,937,500 3,645,833 14,583,333 15,625,000 5,208,333 20,833,333 36,718,750 12,239,583 48,958,333 5,078,125 1,692,708 6,770,833 10,937,500 3,645,833 14,583,333 36,718,750 12,239,583 48,958,333 14,843,750 4,947,917 19,791,667 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 14,843,750 4,947,917 19,791,667 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 7,421,875 2,473,958 9,895,833 5,078,125 1,692,708 6,770,833 21,484,375 7,161,458 28,645,833 21,484,375 7,161,458 28,645,833 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 15,625,000 5,208,333 20,833,333 26,953,125 8,984,375 35,937,500 15,625,000 5,208,333 20,833,333 26,953,125 8,984,375 35,937,500 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 16,406,250 5,468,750 21,875,000 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 16,015,625 5,338,542 21,354,167 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 16,406,250 5,468,750 21,875,000 26,171,875 8,723,958 34,895,833 11,718,750 3,906,250 15,625,000 21,093,750 7,031,250 28,125,000 26,171,875 8,723,958 34,895,833 15,625,000 5,208,333 20,833,333 15,625,000 5,208,333 20,833,333 15,625,000 5,208,333 20,833,333 15,625,000 5,208,333 20,833,333 21,093,750 7,031,250 28,125,000 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 21,093,750 7,031,250 28,125,000 9,375,000 3,125,000 12,500,000 15,625,000 5,208,333 20,833,333 16,015,625 5,338,542 21,354,167 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 15,625,000 5,208,333 20,833,333 15,625,000 5,208,333 20,833,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 21,093,750 7,031,250 28,125,000 15,625,000 5,208,333 20,833,333 21,093,750 7,031,250 28,125,000 15,625,000 5,208,333 20,833,333 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 26,171,875 8,723,958 34,895,833 26,953,125 8,984,375 35,937,500 21,484,375 7,161,458 28,645,833 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 16,015,625 5,338,542 21,354,167 21,484,375 7,161,458 28,645,833 10,937,500 3,645,833 14,583,333 36,718,750 12,239,583 48,958,333 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 8,984,375 2,994,792 11,979,167 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 21,093,750 7,031,250 28,125,000 21,484,375 7,161,458 28,645,833 21,093,750 7,031,250 28,125,000 20,703,125 6,901,042 27,604,167 23,828,125 7,942,708 31,770,833 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 21,093,750 7,031,250 28,125,000 21,484,375 7,161,458 28,645,833 21,093,750 7,031,250 28,125,000 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 7,421,875 2,473,958 9,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 26,562,500 8,854,167 35,416,667 26,171,875 8,723,958 34,895,833 21,093,750 7,031,250 28,125,000 26,171,875 8,723,958 34,895,833 21,093,750 7,031,250 28,125,000 9,375,000 3,125,000 12,500,000 11,718,750 3,906,250 15,625,000 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 21,093,750 7,031,250 28,125,000 15,625,000 5,208,333 20,833,333 15,625,000 5,208,333 20,833,333 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 21,484,375 7,161,458 28,645,833 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 8,593,750 2,864,583 11,458,333 21,093,750 7,031,250 28,125,000 16,015,625 5,338,542 21,354,167 10,937,500 3,645,833 14,583,333 36,718,750 12,239,583 48,958,333 21,093,750 7,031,250 28,125,000 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 21,484,375 7,161,458 28,645,833 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 21,093,750 7,031,250 28,125,000 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 8,593,750 2,864,583 11,458,333 21,093,750 7,031,250 28,125,000 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 26,171,875 8,723,958 34,895,833 21,093,750 7,031,250 28,125,000 16,015,625 5,338,542 21,354,167 10,937,500 3,645,833 14,583,333 7,812,500 2,604,167 10,416,667 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 7,812,500 2,604,167 10,416,667 16,015,625 5,338,542 21,354,167 10,156,250 3,385,417 13,541,667 7,031,250 2,343,750 9,375,000 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 21,484,375 7,161,458 28,645,833 5,078,125 1,692,708 6,770,833 10,937,500 3,645,833 14,583,333 16,015,625 5,338,542 21,354,167 2,539,063 846,354 3,385,417 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 10,937,500 3,645,833 14,583,333 16,406,250 5,468,750 21,875,000 21,093,750 7,031,250 28,125,000 16,406,250 5,468,750 21,875,000 5,468,750 1,822,917 7,291,667 7,031,250 2,343,750 9,375,000 11,328,125 3,776,042 15,104,167 10,156,250 3,385,417 13,541,667 16,015,625 5,338,542 21,354,167 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 16,015,625 5,338,542 21,354,167 16,015,625 5,338,542 21,354,167 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 21,484,375 7,161,458 28,645,833 15,625,000 5,208,333 20,833,333 16,015,625 5,338,542 21,354,167 21,093,750 7,031,250 28,125,000 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 7,421,875 2,473,958 9,895,833 16,015,625 5,338,542 21,354,167 16,015,625 5,338,542 21,354,167 26,171,875 8,723,958 34,895,833 16,015,625 5,338,542 21,354,167 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 26,171,875 8,723,958 34,895,833 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 15,625,000 5,208,333 20,833,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 36,718,750 12,239,583 48,958,333 PELAYANAN SARANA TOTAL - - - - 39,453,125 13,151,042 52,604,167 33,203,125 11,067,708 44,270,833 21,875,000 7,291,667 29,166,667 40,234,375 13,411,458 53,645,833 21,093,750 7,031,250 28,125,000 - - - - 53,515,625 17,838,542 71,354,167 47,265,625 15,755,208 63,020,833 VVIP - - 50,390,625 16,796,875 67,187,500 47,265,625 15,755,208 63,020,833 26,171,875 8,723,958 34,895,833 - - 36,328,125 12,109,375 48,437,500 33,203,125 11,067,708 44,270,833 - - - - 10,937,500 3,645,833 14,583,333 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 - - - - 15,625,000 5,208,333 20,833,333 17,578,125 5,859,375 23,437,500 - - 15,625,000 5,208,333 20,833,333 17,578,125 5,859,375 23,437,500 16,015,625 5,338,542 21,354,167 15,625,000 5,208,333 20,833,333 14,843,750 4,947,917 19,791,667 15,625,000 5,208,333 20,833,333 - - 16,406,250 5,468,750 21,875,000 13,281,250 4,427,083 17,708,333 - - 22,265,625 7,421,875 29,687,500 17,968,750 5,989,583 23,958,333 - - 14,843,750 4,947,917 19,791,667 15,625,000 5,208,333 20,833,333 - - - - - - 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 25,390,625 8,463,542 33,854,167 - - - 32,421,875 10,807,292 43,229,167 - - - - 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 - - 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 - - 36,328,125 12,109,375 48,437,500 36,328,125 12,109,375 48,437,500 26,171,875 8,723,958 34,895,833 - - 29,296,875 9,765,625 39,062,500 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 53,515,625 17,838,542 71,354,167 53,515,625 17,838,542 71,354,167 - - 14,453,125 4,817,708 19,270,833 16,406,250 5,468,750 21,875,000 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 24,609,375 8,203,125 32,812,500 26,171,875 8,723,958 34,895,833 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 26,171,875 8,723,958 34,895,833 - - - - 24,218,750 8,072,917 32,291,667 16,015,625 5,338,542 21,354,167 11,328,125 3,776,042 15,104,167 - - 17,578,125 5,859,375 23,437,500 13,281,250 4,427,083 17,708,333 - - 25,000,000 8,333,333 33,333,333 22,656,250 7,552,083 30,208,333 22,656,250 7,552,083 30,208,333 - - 17,578,125 5,859,375 23,437,500 16,796,875 5,598,958 22,395,833 22,656,250 7,552,083 30,208,333 - - 17,578,125 5,859,375 23,437,500 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 - - 13,281,250 4,427,083 17,708,333 12,500,000 4,166,667 16,666,667 - - 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 - - 11,328,125 3,776,042 15,104,167 8,984,375 2,994,792 11,979,167 7,421,875 2,473,958 9,895,833 - - 5,078,125 1,692,708 6,770,833 8,203,125 2,734,375 10,937,500 VVIP PELAYANAN SARANA TOTAL 41,406,250 13,802,083 55,208,333 41,406,250 13,802,083 55,208,333 23,046,875 7,682,292 30,729,167 8,984,375 2,994,792 11,979,167 24,609,375 8,203,125 32,812,500 48,437,500 16,145,833 64,583,333 10,937,500 3,645,833 14,583,333 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 21,093,750 7,031,250 28,125,000 9,765,625 3,255,208 13,020,833 42,968,750 14,322,917 57,291,667 11,718,750 3,906,250 15,625,000 34,765,625 11,588,542 46,354,167 34,765,625 11,588,542 46,354,167 12,500,000 4,166,667 16,666,667 42,968,750 14,322,917 57,291,667 10,156,250 3,385,417 13,541,667 13,671,875 4,557,292 18,229,167 29,296,875 9,765,625 39,062,500 36,328,125 12,109,375 48,437,500 14,453,125 4,817,708 19,270,833 12,500,000 4,166,667 16,666,667 31,640,625 10,546,875 42,187,500 10,156,250 3,385,417 13,541,667 10,156,250 3,385,417 13,541,667 21,093,750 7,031,250 28,125,000 14,843,750 4,947,917 19,791,667 41,796,875 13,932,292 55,729,167 14,062,500 4,687,500 18,750,000 42,968,750 14,322,917 57,291,667 32,421,875 10,807,292 43,229,167 24,609,375 8,203,125 32,812,500 10,546,875 3,515,625 14,062,500 7,421,875 2,473,958 9,895,833 10,546,875 3,515,625 14,062,500 35,937,500 11,979,167 47,916,667 33,984,375 11,328,125 45,312,500 18,359,375 6,119,792 24,479,167 42,968,750 14,322,917 57,291,667 13,281,250 4,427,083 17,708,333 28,906,250 9,635,417 38,541,667 7,421,875 2,473,958 9,895,833 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 21,875,000 7,291,667 29,166,667 10,937,500 3,645,833 14,583,333 11,328,125 3,776,042 15,104,167 17,187,500 5,729,167 22,916,667 11,328,125 3,776,042 15,104,167 9,375,000 3,125,000 12,500,000 17,968,750 5,989,583 23,958,333 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 10,546,875 3,515,625 14,062,500 7,812,500 2,604,167 10,416,667 10,937,500 3,645,833 14,583,333 14,453,125 4,817,708 19,270,833 10,546,875 3,515,625 14,062,500 13,671,875 4,557,292 18,229,167 13,281,250 4,427,083 17,708,333 13,281,250 4,427,083 17,708,333 17,968,750 5,989,583 23,958,333 14,062,500 4,687,500 18,750,000 17,578,125 5,859,375 23,437,500 22,656,250 7,552,083 30,208,333 16,796,875 5,598,958 22,395,833 16,796,875 5,598,958 22,395,833 26,171,875 8,723,958 34,895,833 29,687,500 9,895,833 39,583,333 19,140,625 6,380,208 25,520,833 19,140,625 6,380,208 25,520,833 14,843,750 4,947,917 19,791,667 19,531,250 6,510,417 26,041,667 19,140,625 6,380,208 25,520,833 17,578,125 5,859,375 23,437,500 19,921,875 6,640,625 26,562,500 32,421,875 10,807,292 43,229,167 35,937,500 11,979,167 47,916,667 7,421,875 2,473,958 9,895,833 14,843,750 4,947,917 19,791,667 13,281,250 4,427,083 17,708,333 18,359,375 6,119,792 24,479,167 14,843,750 4,947,917 19,791,667 14,843,750 4,947,917 19,791,667 16,406,250 5,468,750 21,875,000 14,062,500 4,687,500 18,750,000 14,062,500 4,687,500 18,750,000 14,062,500 4,687,500 18,750,000 24,218,750 8,072,917 32,291,667 23,437,500 7,812,500 31,250,000 24,218,750 8,072,917 32,291,667 7,421,875 2,473,958 9,895,833 13,671,875 4,557,292 18,229,167 11,328,125 3,776,042 15,104,167 17,578,125 5,859,375 23,437,500 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 50,000,000 16,666,667 66,666,667 29,687,500 9,895,833 39,583,333 42,968,750 14,322,917 57,291,667 10,937,500 3,645,833 14,583,333 17,578,125 5,859,375 23,437,500 30,859,375 10,286,458 41,145,833 21,093,750 7,031,250 28,125,000 21,093,750 7,031,250 28,125,000 13,281,250 4,427,083 17,708,333 50,000,000 16,666,667 66,666,667 50,000,000 16,666,667 66,666,667 36,718,750 12,239,583 48,958,333 9,375,000 3,125,000 12,500,000 28,906,250 9,635,417 38,541,667 21,875,000 7,291,667 29,166,667 21,093,750 7,031,250 28,125,000 33,203,125 11,067,708 44,270,833 23,437,500 7,812,500 31,250,000 50,000,000 16,666,667 66,666,667 26,171,875 8,723,958 34,895,833 50,000,000 16,666,667 66,666,667 14,843,750 4,947,917 19,791,667 14,062,500 4,687,500 18,750,000 26,171,875 8,723,958 34,895,833 14,062,500 4,687,500 18,750,000 8,593,750 2,864,583 11,458,333 10,937,500 3,645,833 14,583,333 10,937,500 3,645,833 14,583,333 13,281,250 4,427,083 17,708,333 13,281,250 4,427,083 17,708,333 18,359,375 6,119,792 24,479,167 10,937,500 3,645,833 14,583,333 36,718,750 12,239,583 48,958,333 9,375,000 3,125,000 12,500,000 42,968,750 14,322,917 57,291,667 10,937,500 3,645,833 14,583,333 37,890,625 12,630,208 50,520,833 26,171,875 8,723,958 34,895,833 15,625,000 5,208,333 20,833,333 10,937,500 3,645,833 14,583,333 14,062,500 4,687,500 18,750,000 - - PELAYANAN SARANA TOTAL 10,546,875 3,515,625 14,062,500 5,468,750 1,822,917 7,291,667 10,937,500 3,645,833 14,583,333 21,093,750 7,031,250 28,125,000 16,796,875 5,598,958 22,395,833 8,593,750 2,864,583 11,458,333 35,546,875 11,848,958 47,395,833 43,359,375 14,453,125 57,812,500 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 32,812,500 10,937,500 43,750,000 16,406,250 5,468,750 21,875,000 36,328,125 12,109,375 48,437,500 43,359,375 14,453,125 57,812,500 44,921,875 14,973,958 59,895,833 16,406,250 5,468,750 21,875,000 44,921,875 14,973,958 59,895,833 39,843,750 13,281,250 53,125,000 13,281,250 4,427,083 17,708,333 36,328,125 12,109,375 48,437,500 VVIP 39,843,750 13,281,250 53,125,000 39,843,750 13,281,250 53,125,000 39,843,750 13,281,250 53,125,000 32,421,875 10,807,292 43,229,167 7,812,500 2,604,167 10,416,667 15,039,063 5,013,021 20,052,083 32,421,875 10,807,292 43,229,167 9,375,000 3,125,000 12,500,000 13,671,875 4,557,292 18,229,167 7,421,875 2,473,958 9,895,833 11,718,750 3,906,250 15,625,000 11,718,750 3,906,250 15,625,000 10,546,875 3,515,625 14,062,500 11,718,750 3,906,250 15,625,000 9,375,000 3,125,000 12,500,000 36,328,125 12,109,375 48,437,500 25,390,625 8,463,542 33,854,167 36,328,125 12,109,375 48,437,500 41,406,250 13,802,083 55,208,333 36,328,125 12,109,375 48,437,500 28,906,250 9,635,417 38,541,667 31,640,625 10,546,875 42,187,500 15,625,000 5,208,333 20,833,333 4,687,500 1,562,500 6,250,000 12,890,625 4,296,875 17,187,500 32,421,875 10,807,292 43,229,167 9,375,000 3,125,000 12,500,000 39,453,125 13,151,042 52,604,167 46,484,375 15,494,792 61,979,167 14,062,500 4,687,500 18,750,000 11,718,750 3,906,250 15,625,000 28,906,250 9,635,417 38,541,667 14,843,750 4,947,917 19,791,667 13,671,875 4,557,292 18,229,167 14,062,500 4,687,500 18,750,000 28,906,250 9,635,417 38,541,667 14,453,125 4,817,708 19,270,833 32,421,875 10,807,292 43,229,167 36,328,125 12,109,375 48,437,500 37,890,625 12,630,208 50,520,833 46,484,375 15,494,792 61,979,167 30,859,375 10,286,458 41,145,833 32,812,500 10,937,500 43,750,000 32,421,875 10,807,292 43,229,167 14,062,500 4,687,500 18,750,000 21,484,375 7,161,458 28,645,833 32,812,500 10,937,500 43,750,000 32,812,500 10,937,500 43,750,000 25,781,250 8,593,750 34,375,000 32,031,250 10,677,083 42,708,333 32,812,500 10,937,500 43,750,000 11,718,750 3,906,250 15,625,000 14,843,750 4,947,917 19,791,667 13,281,250 4,427,083 17,708,333 13,281,250 4,427,083 17,708,333 19,335,938 6,445,313 25,781,250 12,109,375 4,036,458 16,145,833 8,203,125 2,734,375 10,937,500 13,281,250 4,427,083 17,708,333 38,085,938 12,695,313 50,781,250 14,843,750 4,947,917 19,791,667 39,453,125 13,151,042 52,604,167 44,140,625 14,713,542 58,854,167 43,359,375 14,453,125 57,812,500 43,359,375 14,453,125 57,812,500 43,359,375 14,453,125 57,812,500 39,453,125 13,151,042 52,604,167 39,453,125 13,151,042 52,604,167 39,062,500 13,020,833 52,083,333 39,062,500 13,020,833 52,083,333 43,359,375 14,453,125 57,812,500 44,921,875 14,973,958 59,895,833 44,140,625 14,713,542 58,854,167 44,921,875 14,973,958 59,895,833 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 39,453,125 13,151,042 52,604,167 39,453,125 13,151,042 52,604,167 43,359,375 14,453,125 57,812,500 43,359,375 14,453,125 57,812,500 32,421,875 10,807,292 43,229,167 44,921,875 14,973,958 59,895,833 44,921,875 14,973,958 59,895,833 46,484,375 15,494,792 61,979,167 46,484,375 15,494,792 61,979,167 51,953,125 17,317,708 69,270,833 51,953,125 17,317,708 69,270,833 51,953,125 17,317,708 69,270,833 51,953,125 17,317,708 69,270,833 44,921,875 14,973,958 59,895,833 29,296,875 9,765,625 39,062,500 8,203,125 2,734,375 10,937,500 11,718,750 3,906,250 15,625,000 14,062,500 4,687,500 18,750,000 21,875,000 7,291,667 29,166,667 13,281,250 4,427,083 17,708,333 39,843,750 13,281,250 53,125,000 28,906,250 9,635,417 38,541,667 44,921,875 14,973,958 59,895,833 32,421,875 10,807,292 43,229,167 32,421,875 10,807,292 43,229,167 39,453,125 13,151,042 52,604,167 11,328,125 3,776,042 15,104,167 38,671,875 12,890,625 51,562,500 31,640,625 10,546,875 42,187,500 31,640,625 10,546,875 42,187,500 39,453,125 13,151,042 52,604,167 11,914,063 3,971,354 15,885,417 10,742,188 3,580,729 14,322,917 26,367,188 8,789,063 35,156,250 9,375,000 3,125,000 12,500,000 9,375,000 3,125,000 12,500,000 15,625,000 5,208,333 20,833,333 11,718,750 3,906,250 15,625,000 9,375,000 3,125,000 12,500,000 9,375,000 3,125,000 12,500,000 5,468,750 1,822,917 7,291,667 9,375,000 3,125,000 12,500,000 15,625,000 5,208,333 20,833,333 17,968,750 5,989,583 23,958,333 19,531,250 6,510,417 26,041,667 44,140,625 14,713,542 58,854,167 36,328,125 12,109,375 48,437,500 21,875,000 7,291,667 29,166,667 21,875,000 7,291,667 29,166,667 36,328,125 12,109,375 48,437,500 22,265,625 7,421,875 29,687,500 44,921,875 14,973,958 59,895,833 46,484,375 15,494,792 61,979,167 37,109,375 12,369,792 49,479,167 25,781,250 8,593,750 34,375,000 25,781,250 8,593,750 34,375,000 14,062,500 4,687,500 18,750,000 7,421,875 2,473,958 9,895,833 7,421,875 2,473,958 9,895,833 5,468,750 1,822,917 7,291,667 39,062,500 13,020,833 52,083,333 29,296,875 9,765,625 39,062,500 44,921,875 14,973,958 59,895,833 37,109,375 12,369,792 49,479,167 37,109,375 12,369,792 49,479,167 11,718,750 3,906,250 15,625,000 29,296,875 9,765,625 39,062,500 8,203,125 2,734,375 10,937,500 8,203,125 2,734,375 10,937,500 9,375,000 3,125,000 12,500,000 8,593,750 2,864,583 11,458,333 15,234,375 5,078,125 20,312,500 18,359,375 6,119,792 24,479,167 18,359,375 6,119,792 24,479,167 17,968,750 5,989,583 23,958,333 32,421,875 10,807,292 43,229,167 22,265,625 7,421,875 29,687,500 4,687,500 1,562,500 6,250,000 PELAYANAN SARANA TOTAL - - 2,929,688 976,563 3,906,250 2,929,688 976,563 3,906,250 3,906,250 1,302,083 5,208,333 3,906,250 1,302,083 5,208,333 2,343,750 781,250 3,125,000 2,343,750 781,250 3,125,000 3,906,250 1,302,083 5,208,333 2,929,688 976,563 3,906,250 3,906,250 1,302,083 5,208,333 2,343,750 781,250 3,125,000 - - 2,734,375 911,458 3,645,833 VVIP 2,734,375 911,458 3,645,833 7,421,875 2,473,958 9,895,833 14,843,750 4,947,917 19,791,667 11,718,750 3,906,250 15,625,000 12,109,375 4,036,458 16,145,833 5,078,125 1,692,708 6,770,833 12,890,625 4,296,875 17,187,500 5,859,375 1,953,125 7,812,500 4,687,500 1,562,500 6,250,000 12,109,375 4,036,458 16,145,833 12,109,375 4,036,458 16,145,833 13,281,250 4,427,083 17,708,333 8,984,375 2,994,792 11,979,167 5,859,375 1,953,125 7,812,500 11,718,750 3,906,250 15,625,000 7,031,250 2,343,750 9,375,000 4,687,500 1,562,500 6,250,000 8,984,375 2,994,792 11,979,167 7,031,250 2,343,750 9,375,000 5,859,375 1,953,125 7,812,500 2,734,375 911,458 3,645,833 10,156,250 3,385,417 13,541,667 7,031,250 2,343,750 9,375,000 7,031,250 2,343,750 9,375,000 14,843,750 4,947,917 19,791,667 7,421,875 2,473,958 9,895,833 7,421,875 2,473,958 9,895,833 7,421,875 2,473,958 9,895,833 7,421,875 2,473,958 9,895,833 7,421,875 2,473,958 9,895,833 5,859,375 1,953,125 7,812,500 - - 4,687,500 1,562,500 6,250,000 4,687,500 1,562,500 6,250,000 4,687,500 1,562,500 6,250,000 2,929,688 976,563 3,906,250 4,687,500 1,562,500 6,250,000 4,687,500 1,562,500 6,250,000 4,687,500 1,562,500 6,250,000 14,843,750 4,947,917 19,791,667 8,984,375 2,994,792 11,979,167 17,968,750 5,989,583 23,958,333 4,687,500 1,562,500 6,250,000 2,929,688 976,563 3,906,250 2,929,688 976,563 3,906,250 7,812,500 2,604,167 10,416,667 8,593,750 2,864,583 11,458,333 - - 4,687,500 1,562,500 6,250,000 14,453,125 4,817,708 19,270,833 12,890,625 4,296,875 17,187,500 2,929,688 976,563 3,906,250 7,421,875 2,473,958 9,895,833 4,101,563 1,367,188 5,468,750 11,718,750 3,906,250 15,625,000 15,234,375 5,078,125 20,312,500 22,265,625 7,421,875 29,687,500 22,656,250 7,552,083 30,208,333 8,593,750 2,864,583 11,458,333 8,593,750 2,864,583 11,458,333 17,968,750 5,989,583 23,958,333 - - 9,765,625 3,255,208 13,020,833 14,062,500 4,687,500 18,750,000 14,843,750 4,947,917 19,791,667 17,187,500 5,729,167 22,916,667 4,101,563 1,367,188 5,468,750 - - 16,406,250 5,468,750 21,875,000 4,687,500 1,562,500 6,250,000 14,843,750 4,947,917 19,791,667 5,468,750 1,822,917 7,291,667 20,312,500 6,770,833 27,083,333 27,343,750 9,114,583 36,458,333 8,984,375 2,994,792 11,979,167 8,984,375 2,994,792 11,979,167 14,453,125 4,817,708 19,270,833 8,984,375 2,994,792 11,979,167 28,906,250 9,635,417 38,541,667 11,718,750 3,906,250 15,625,000 8,203,125 2,734,375 10,937,500 7,421,875 2,473,958 9,895,833 1,562,500 520,833 2,083,333 8,593,750 2,864,583 11,458,333 4,687,500 1,562,500 6,250,000 19,531,250 6,510,417 26,041,667 15,625,000 5,208,333 20,833,333 20,312,500 6,770,833 27,083,333 15,625,000 5,208,333 20,833,333 8,593,750 2,864,583 11,458,333 14,843,750 4,947,917 19,791,667 5,078,125 1,692,708 6,770,833 - - 9,765,625 3,255,208 13,020,833 14,843,750 4,947,917 19,791,667 19,531,250 6,510,417 26,041,667 14,453,125 4,817,708 19,270,833 14,843,750 4,947,917 19,791,667 27,343,750 9,114,583 36,458,333 7,421,875 2,473,958 9,895,833 7,031,250 2,343,750 9,375,000 14,453,125 4,817,708 19,270,833 12,890,625 4,296,875 17,187,500 12,890,625 4,296,875 17,187,500 16,406,250 5,468,750 21,875,000 - - 11,328,125 3,776,042 15,104,167 11,328,125 3,776,042 15,104,167 12,109,375 4,036,458 16,145,833 13,281,250 4,427,083 17,708,333 12,109,375 4,036,458 16,145,833 11,328,125 3,776,042 15,104,167 PELAYANAN SARANA TOTAL 3,017,578 1,005,859 4,023,438 3,017,578 1,005,859 4,023,438 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 7,910,156 2,636,719 10,546,875 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 10,913,086 3,637,695 14,550,781 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 VVIP 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 13,916,016 4,638,672 18,554,688 16,406,250 5,468,750 21,875,000 16,406,250 5,468,750 21,875,000 16,406,250 5,468,750 21,875,000 16,406,250 5,468,750 21,875,000 16,406,250 5,468,750 21,875,000 JASA SARANA JASA PELAYANAN 1 Diagnostik koorner, penyadapan jantung klanan , ADRTOGRAPHY 2,137,500Rp 2,137,500Rp 4,275,000Rp 2 PCI (STENTING) DENGAN 1 STENT (Lebih Satu Stebt ditambah 2 1,951,500Rp 1,951,500Rp 3,903,000Rp 3 PTCA (BALLON) 1 pembuluh Darah (Lebih Satu P Darah, Tambah 1 4,500,000Rp 4,500,000Rp 9,000,000Rp 4 TPM (Temporary Pacemaker) 2,250,000Rp 2,250,000Rp 4,500,000Rp 5 PPM (Permanen Pacemaker) 3,250,000Rp 3,250,000Rp 6,500,000Rp 6 BVM/PTMC/BALLOOM MITRAL VALVULOPLASTI 6,750,000Rp 6,750,000Rp 13,500,000Rp 7 Pericardiocentesis 2,250,000Rp 2,250,000Rp 4,500,000Rp 8 posisi pacemake/kanulasi vena sentral 225,000Rp 225,000Rp 450,000Rp G. KAMAR OPERASI JANTUNG NO JENIS PELAYANAN TARIF JUMLAH : : : : 1 Konsultasi + Pemeriksaan Fisik Rp 27,500 27,500Rp 55,000Rp 1 Rp 32,500 32,500Rp 65,000Rp 1 Konsultasi + Pemeriksaan Fisik Rp 37,500 37,500Rp 75,000Rp 1 32,500Rp 32,500Rp 65,000Rp 2 40,000Rp 40,000Rp 80,000Rp 3 12,500Rp 12,500Rp 25,000Rp 4 60,000Rp 60,000Rp 120,000Rp 5 83,000Rp 83,000Rp 166,000Rp 6 12,500Rp 12,500Rp 25,000Rp 7 25,000Rp 25,000Rp 50,000Rp 8 50,000Rp 50,000Rp 100,000Rp 9 50,000Rp 50,000Rp 100,000Rp 10 75,000Rp 75,000Rp 150,000Rp 11 12,500Rp 12,500Rp 25,000Rp 12 15,000Rp 15,000Rp 30,000Rp 13 30,000Rp 30,000Rp 60,000Rp E. POLI KLINIK 1 250,000Rp 250,000Rp 500,000Rp 2 200,000Rp 200,000Rp 400,000Rp 3 300,000Rp 300,000Rp 600,000Rp 4 200,000Rp 200,000Rp 400,000Rp 1 25,000Rp 25,000Rp 50,000Rp 2 125,000Rp 125,000Rp 250,000Rp 1 25,000Rp 25,000Rp 50,000Rp 1 25,000Rp 25,000Rp 50,000Rp 2 10,000Rp 10,000Rp 20,000Rp 1 50,000Rp 50,000Rp 100,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 27,500Rp 27,500Rp 55,000Rp 4 40,000Rp 40,000Rp 80,000Rp 5 75,000Rp 75,000Rp 150,000Rp NO
1. 4.INTERNA (HIV) JUMLAH JUMLAH JUMLAH PEMERIKSAAN DENGAN TINDAKAN PEMERIKSAAN NEUROLOGI DASAR TES PESPIRASI JASA SARANA JASA PELAYANAN JUMLAH D. TINDAKAN DASAR KEPERAWATAN JASA SARANA GANTI VERBAN BESAR PASANG KATETER NEBULIZER INJEKSI AFF HECTING ˂ 5 PERAWATAN LUKA (RINGAN) PERAWATAN LUKA (SEDANG) JENIS PEMERIKSAAN Pemeriksaan Fisik JENIS PEMERIKSAAN Konsultasi + Pemeriksaan Fisik Pemeriksaan ECG JASA PELAYANAN B. POLIKLINIK SPESIALIS/ SUB SPESIALIS NO JASA SARANA JASA PELAYANAN JASA PELAYANAN C. POLIKLINIK KONSULEN NO JASA SARANA NO
2. 5.SYARAF (NEUROLOGI)
3. 1.JANTUNG (CARDIO)
4. 2.INTERNA
5. 3.INTERNA (GERIATRI) LAMPIRAN JENIS PEMERIKSAAN JENIS PEMERIKSAAN NOMOR TANGGAL TENTANG PERATURAN GUBERNUR SULAWESI BARAT 31 TAHUN 2022 13 SEPTEMBER 2022 PERUBAHAN ATAS PERATURAN GUNERNUR SULAWESI BARAT NOMOR 4 TAHUN 2021 TENTANG TARIF LAYANAN BADAN LAYANAN UMUM DAERAH RUMAH SAKIT UMUM DAERAH JUMLAH I. PELAYAN MEDIS
6. 1.RAWAT JALAN A. POLIKLINIK UMUM, POLIKLINIK KIA /KB, UGD DAN GIGI NO JASA SARANA JASA PELAYANAN PERAWATAN LUKA (BERAT) AFF KATETER GANTI VERBAN KECIL TREADMILL Rectal Touch Aspirasi dan Injeksi intra artikular RECTAL TOUCH KONSELING RECTAL TOUCH AFF HECTING ≥ 5 POLI/POLIKLINIK/INSTALASI Pemeriksaan ECHO USG Vaskuler TEE TES VESTIBULER PEMERIKSAAN FUNDOSCOPY TES MMSE/MOCA INA 6 35,000Rp 35,000Rp 70,000Rp 7 40,000Rp 40,000Rp 80,000Rp 8 100,000Rp 100,000Rp 200,000Rp 9 100,000Rp 100,000Rp 200,000Rp 10 17,000Rp 17,000Rp 34,000Rp 100,000Rp 100,000Rp 200,000Rp 125,000Rp 125,000Rp 250,000Rp 150,000Rp 150,000Rp 300,000Rp 11 50,000Rp 50,000Rp 100,000Rp 12 50,000Rp 50,000Rp 100,000Rp 13 25,000Rp 25,000Rp 50,000Rp 14 275,000Rp 275,000Rp 550,000Rp 15 275,000Rp 275,000Rp 550,000Rp 16 275,000Rp 275,000Rp 550,000Rp 17 150,000Rp 150,000Rp 300,000Rp 1 25,000Rp 25,000Rp 50,000Rp 2 30,000Rp 30,000Rp 60,000Rp 3 30,000Rp 30,000Rp 60,000Rp 4 30,000Rp 30,000Rp 60,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 42,500Rp 42,500Rp 85,000Rp 7 75,000Rp 75,000Rp 150,000Rp 8 75,000Rp 75,000Rp 150,000Rp 9 65,500Rp 65,500Rp 131,000Rp 10 125,000Rp 125,000Rp 250,000Rp 11 36,500Rp 36,500Rp 73,000Rp 12 100,000Rp 100,000Rp 200,000Rp 13 75,000Rp 75,000Rp 150,000Rp 14 25,000Rp 25,000Rp 50,000Rp 15 30,000Rp 30,000Rp 60,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 50,000Rp 50,000Rp 100,000Rp 18 117,000Rp 117,000Rp 234,000Rp 19 153,500Rp 153,500Rp 307,000Rp 20 155,000Rp 155,000Rp 310,000Rp 21 103,500Rp 103,500Rp 207,000Rp 22 135,500Rp 135,500Rp 271,000Rp 23 25,000Rp 25,000Rp 50,000Rp 24 37,500Rp 37,500Rp 75,000Rp 25 50,000Rp 50,000Rp 100,000Rp 26 100,000Rp 100,000Rp 200,000Rp 27 50,000Rp 50,000Rp 100,000Rp 28 100,000Rp 100,000Rp 200,000Rp 29 75,000Rp 75,000Rp 150,000Rp 30 100,000Rp 100,000Rp 200,000Rp 31 37,500Rp 37,500Rp 75,000Rp 32 75,000Rp 75,000Rp 150,000Rp 33 50,000Rp 50,000Rp 100,000Rp 34 75,000Rp 75,000Rp 150,000Rp 35 150,000Rp 150,000Rp 300,000Rp 36 50,000Rp 50,000Rp 100,000Rp 37 60,000Rp 60,000Rp 120,000Rp EXTRAKSI CORPUS ALIENUM MAE (TANPA PENYULIT) EXTRAKSI CORPUS ALIENUM MAE (KOMPLIKASI) EXTIRPASI GRANULASI MAE GANTI VERBAN POST OPERASI THT INSISI ABSES TELINGA/KISTA TOILET TELINGA + CRUUM NESI TOILET TELINGA + ZALF IRIGASI TELINGA TAMPON BUROWI TELINGA PARASINTESIS IRIGASI SINUS MAXILARIS EXTRAKSI CORPUS ALIENUM HIDUNG INSISI ABSES SEPTUM
7. 6.POLI THT LUMBAL FUNGSI PEMERIKSAAN PKL INJEKSI LOKAL * RINGAN * SEDANG TES HALPIKE PEMERIKSAAN FUNDOSCOPY PEMERIKSAAN MEDIK ELECTRO ENCEPHALOGRAPH EEG ELECTRO MYO GRAPH TRANS CRANIAL DOPPLER INJEKSI INTRAARTICULAR * BESAR PEMERIKSAAN NEUROLOGI TAMBAHAN TES DEMENSIA KONSUL NEUROLOGI PEMERIKSAAN PENUNJANG POLIPEKTOMI SIMPLEX REPOSISI HIDUNG INJEKSI PERIKONDRITIS (TELINGA) TES AUDOUMETRI TES VESTIBULER TOILET HIDUNG TAMPON HIDUNG SEMENTARA INSISI ABSES TENGGOROKAN ASPIRASI ABSES TENGGOROKAN PERAWATAN STOMA TRAKEA EXTRAKSI CORPUS ALIENUM TENGGOROKAN TANPA PENYULIT EXTRAKSI CORPUS ALIENUM TENGGOROKAN DENGAN PENYULIT TAMPON BOORZALF HIDUNG TAMPON BELLOQUE HIDUNG FARINGOSKOPI THT LARINGOSKOPI INDIRECT KAUSTIK THT EXTRAKSI RINOLITH TERAPI REPOSISI OTOLIT TES GARPUTALA ENDOSCOPY DIAGNOSTIK HIDUNG/TELINGA EXTRAKSI CORUMEN OBTURANS EXTRAKSI CORUMEN OBTURANS DENGAN PENYULIT OTORED/OAE 38 75,000Rp 75,000Rp 150,000Rp 39 100,000Rp 100,000Rp 200,000Rp 40 50,000Rp 50,000Rp 100,000Rp 41 41,000Rp 41,000Rp 82,000Rp 42 100,000Rp 100,000Rp 200,000Rp 43 100,000Rp 100,000Rp 75,000Rp 1 137,500Rp 137,500Rp 275,000Rp 2 175,000Rp 175,000Rp 350,000Rp 3 100,000Rp 100,000Rp 200,000Rp 4 25,000Rp 25,000Rp 50,000Rp 5 500,000Rp 500,000Rp 1,000,000Rp 6 25,000Rp 25,000Rp Rp 50,000 7 37,500Rp 37,500Rp Rp 75,000 8 50,000Rp 50,000Rp Rp 100,000 9 277,500Rp 277,500Rp Rp 555,000 10 50,000Rp 50,000Rp Rp 100,000 11 75,000Rp 75,000Rp Rp 150,000 12 1,600,000Rp 1,600,000Rp Rp 3,200,000 13 1,600,000Rp 1,600,000Rp Rp 3,200,000 14 25,000Rp 25,000Rp Rp 50,000 15 50,000Rp 50,000Rp Rp 100,000 16 125,000Rp 125,000Rp Rp 250,000 17 100,000Rp 100,000Rp Rp 200,000 18 25,000Rp 25,000Rp Rp 50,000 1 162,500Rp 162,500Rp 325,000Rp 2 150,000Rp 150,000Rp 300,000Rp 3 25,000Rp 25,000Rp 50,000Rp 4 32,500Rp 32,500Rp 65,000Rp 5 30,000Rp 30,000Rp 600,000Rp 6 40,000Rp 40,000Rp 80,000Rp 7 100,000Rp 100,000Rp 200,000Rp 8 100,000Rp 100,000Rp 200,000Rp 9 50,000Rp 50,000Rp 100,000Rp 10 30,000Rp 30,000Rp 60,000Rp 11 20,000Rp 20,000Rp 40,000Rp 12 50,000Rp 50,000Rp 100,000Rp 13 40,000Rp 40,000Rp 80,000Rp 14 50,000Rp 50,000Rp 100,000Rp 15 100,000Rp 100,000Rp 200,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 100,000Rp 100,000Rp 200,000Rp 18 100,000Rp 100,000Rp 200,000Rp 19 20,000Rp 20,000Rp 40,000Rp 20 75,000Rp 75,000Rp 150,000Rp 21 40,000Rp 40,000Rp 80,000Rp 22 32,500Rp 32,500Rp 65,000Rp 23 50,000Rp 50,000Rp 100,000Rp 24 100,000Rp 100,000Rp 200,000Rp
8. 8.POLI ANAK
9. 7.POLI BEDAH PENATALAKSANAAN EPISTAKSIS TES TYMPANOMETRI ANGKAT TAMPON ANTERIOR EKSTRAKSI KUKU RECTAL TOUCHEA SIRKUMSISI HECTING RINGAN HECTING SEDANG SPOLING TELINGA LARINGOSKOPI PLEKSIBEL TES KESEIMBANGAN SEDERHANA INSISI ABSES KECIL INSISI ABSES BESAR EXTIRPASI BIOPSI CROS INSISI RECTAL TOUCHEA ASPIRASI DAN INJEKSI INTRA ARTIKULAR PUNKSI CAIRAN HECTING BERAT DEBRIDEMEN INJEKSI KORTIKOSTEROID R INJEKSI KORTIKOSTEROID S ASPIRASI BIOPSI PENGUKURAN ANTROPOMETRI PENILAIAN/INTERPRETASI ANTROPOMETRI PELAYANAN GIZI PEMERIKSAAN FISIK ANAK DAN NEONATUS PEMERIKSAAN NEOROLOGI ANAK Pasang Elastis Verban TUBERKULIN TEST SPIROMETRI RAWAT TALI PUSAT INJEKSI VIT.K IMUNISASI KONSULTASI TUMBUH KEMBANG ANAK KONSULTASI KETERLAMBATAN PERKEMBANGAN SENSORI MOTORIK DAN BAHASA PADA ANAK MENGUKUR TEKANAN DARAH PEMASANGAN OGT/NGT AFF OGT/NGT TEST MANTOUX/TUBERKULIN TEST PERAWATAN LUKA PERAWATAN TALI PUSAT NEBULIZER SPIROMETRI INJEKSI IV/IM/SC/IC EKG FRENTOMY 25 100,000Rp 100,000Rp 200,000Rp 26 100,000Rp 100,000Rp 200,000Rp 27 50,000Rp 50,000Rp 100,000Rp 28 30,000Rp 30,000Rp 60,000Rp 29 30,000Rp 30,000Rp 60,000Rp 1 10,000Rp 10,000Rp 20,000Rp 2 25,000Rp 25,000Rp 50,000Rp 3 40,000Rp 40,000Rp 80,000Rp 4 22,500Rp 22,500Rp 45,000Rp 1 75,000Rp 75,000Rp 150,000Rp 2 125,000Rp 125,000Rp 250,000Rp 3 100,000Rp 100,000Rp 200,000Rp 4 125,000Rp 125,000Rp 250,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 25,000Rp 25,000Rp 50,000Rp 7 50,000Rp 50,000Rp 100,000Rp 8 32,500Rp 32,500Rp 65,000Rp 9 100,000Rp 100,000Rp 200,000Rp 10 50,000Rp 50,000Rp 100,000Rp 11 50,000Rp 50,000Rp 100,000Rp 12 75,000Rp 75,000Rp 150,000Rp 13 50,000Rp 50,000Rp 100,000Rp 14 30,000Rp 30,000Rp 60,000Rp 15 75,000Rp 75,000Rp 150,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 175,000Rp 175,000Rp 350,000Rp 18 32,500Rp 32,500Rp 65,000Rp 19 100,000Rp 100,000Rp Rp 200,000 20 125,000Rp 125,000Rp Rp 250,000 21 150,000Rp 150,000Rp Rp 300,000 22 200,000Rp 200,000Rp 400,000Rp 23 24 90,000Rp 110,000Rp Rp 200,000 25 90,000Rp 110,000Rp Rp 200,000 26 180,000Rp 220,000Rp Rp 400,000 27 90,000Rp 110,000Rp 200,000Rp 28 135,000Rp 165,000Rp 300,000Rp 29 58,500Rp 71,500Rp Rp 130,000 11 1 60,000Rp 60,000Rp 120,000Rp 2 35,000Rp 35,000Rp 70,000Rp 3 47,500Rp 47,500Rp 95,000Rp 4 37,500Rp 37,500Rp 75,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 50,000Rp 50,000Rp 100,000Rp 7 25,000Rp 25,000Rp 50,000Rp 8 25,000Rp 25,000Rp 50,000Rp 9 35,000Rp 35,000Rp 70,000Rp 10 75,000Rp 75,000Rp 150,000Rp 11 25,000Rp 25,000Rp 50,000Rp 12 25,000Rp 25,000Rp 50,000Rp
10. 9.POLI KIA KONSELING MENYUSUI PIJAT BAYI TINDIK ANGKAT JAHIT GANTI BALUT PASANG IMPLAN BUKA IMPLANT IUD DENGAN PENYULITAN/PERLENGKETAN PAPSMEAR/IVA TEST TAMPON VAGINA IMUNISASI PADA IBU HAMIL PEMERIKSAAN IBU HAMIL TINDIK TELINGA INJEKSI KB BIOPSI
11. 10.KANDUNGAN (OBGYN) USG OBSTETRI/GINEKOLOGI INSPEKULO KONTROL HECTING/AFF HECTING PUNKSI USG TRANSVAGINAL TOILET VAGINA VAGINA TOUCHEA/RECTAL TOUCHER PASANG/BUKA PASSARIUM RECTAL TOUCHEA AMNIOSCOPY Cabut IUD dengan penyulit KB Penyulit Pasang IUD tanpa penyulit Buka IUD tanpa penyulit Buka implant dengan penyulit USG 4 DIMENSI KONSUL + PEMERIKSAAN FISIK pasangg implan tanpa penyulit Cabut implan tanpa penyulit Pasang implan dengan penyulit PENCABUTAN GIGI ANAK (BIASA) PENCABUTAN GIGI ANAK/GIGI -CITOJECT PENAMBALAN GIGI SEMENTARA REPARASI SALURAN GIGI/GIGI ESTIRPASI GANTI OBAT Cuci vagina Kreyterapi Doopler POLI GIGI DAN MULUT PENCABUTAN GIGI DEWASA TINDAKAN PEMERIKSAAN KHUSUS ORAL DIAGNOSES SOLUX BUKA JAHITAN KONTROL ORTHODONTIC REMOVABLE DENTAL RONTGEN FOTO NON RUJUKAN CURRETAGE POCKET/GIGI 1 75,000Rp 75,000Rp 150,000Rp 2 75,000Rp 75,000Rp 150,000Rp 3 125,000Rp 125,000Rp 250,000Rp 4 75,000Rp 75,000Rp 150,000Rp 5 75,000Rp 75,000Rp 150,000Rp 6 100,000Rp 100,000Rp 200,000Rp 7 125,000Rp 125,000Rp 250,000Rp 8 75,000Rp 75,000Rp 150,000Rp 9 62,500Rp 62,500Rp 125,000Rp 10 32,500Rp 32,500Rp 65,000Rp 11 175,000Rp 175,000Rp 350,000Rp 12 125,000Rp 125,000Rp 250,000Rp 13 125,000Rp 125,000Rp 250,000Rp 14 175,000Rp 175,000Rp 350,000Rp 15 100,000Rp 100,000Rp 200,000Rp 16 100,000Rp 100,000Rp 200,000Rp 17 100,000Rp 100,000Rp 200,000Rp 18 125,000Rp 125,000Rp 250,000Rp 1 100,000Rp 100,000Rp 200,000Rp 2 100,000Rp 100,000Rp 200,000Rp 3 100,000Rp 100,000Rp 200,000Rp 4 100,000Rp 100,000Rp 200,000Rp 5 400,000Rp 400,000Rp 800,000Rp 6 250,000Rp 250,000Rp 500,000Rp 7 1,000,000Rp 1,000,000Rp 2,000,000Rp 8 500,000Rp 500,000Rp 1,000,000Rp 9 150,000Rp 150,000Rp 300,000Rp 10 750,000Rp 750,000Rp 1,500,000Rp 11 500,000Rp 500,000Rp 1,000,000Rp 12 175,000Rp 175,000Rp 350,000Rp 13 175,000Rp 175,000Rp 350,000Rp 14 375,000Rp 375,000Rp 750,000Rp 15 175,000Rp 175,000Rp 350,000Rp 16 250,000Rp 250,000Rp 500,000Rp 17 150,000Rp 150,000Rp 300,000Rp 18 50,000Rp 50,000Rp 100,000Rp 19 50,000Rp 50,000Rp 100,000Rp 20 50,000Rp 50,000Rp 100,000Rp 21 100,000Rp 100,000Rp 200,000Rp 22 100,000Rp 100,000Rp 200,000Rp 23 175,000Rp 175,000Rp 350,000Rp 24 225,000Rp 225,000Rp 450,000Rp 25 250,000Rp 250,000Rp 500,000Rp 26 425,000Rp 425,000Rp 850,000Rp 27 800,000Rp 800,000Rp 1,600,000Rp 28 2,500,000Rp 2,500,000Rp 5,000,000Rp 29 2,500,000Rp 2,500,000Rp 5,000,000Rp 30 300,000Rp 300,000Rp Rp 600,000 31 150,000Rp 150,000Rp Rp 300,000 PENCABUTAN GIGI DEWASA CITOJECT PEMASANGAN JACKET LEPAS/TEMPORARY CROWN PENCABUTAN GIGI KOMPLIKASI INCISI ABSES, BIOPSI TINDAKAN PEMERIKSAAN SEDANG : ONTROL ORTHODONTIC CEKAT/KUNJUNGAN (GANTI KARET) ALVEOLECTOMY/ROGIO PREPARASI SALURAN AKAR TAMBALAN COMPOSITE-SINAR/GIGI REBASING/RELINING PROTHESA PEMBERSIHAN KARANG GIGI/RAHANG SEDERHANA PEMBERSIHAN KARANG GIGI/RAHANG KOMPLEKS TAMBALAN PERMANEN AMALGAM TANPA KOMPLIKASI TAMBALAN GLASS LOMONER KONTROL ORTHODONTIC CEKAT/KUNJUNGAN (GANTI WIRE) - ENUKLEASI MUCOCELE - FRACTURE RAHANG SEDERHANA - ODONTECTOMY-ED - APEKS RESEKSI - JACKET CROWN/GIGI ACRYLIC REPARASI PROTHESA OPERCULECTOMY REPOSISI DISLOKASI TMJ OBTURASI/PENGISIAN SALURAN AKAR/GIGI - ENUKLEASI KISTA TINDAKAN PEMERIKSAAN KHUSUS - FRENECTOMY - GINGIVECTOMY/GIGI - SPLIN OKLUSAL - SQUESTERECTOMY/REGIO - OBTURATOR - JACKET CROWN/GIGI PORCELAIN - PLAT STEEL DENTURE - PEMASANGAN PIN SCREW/GIGI - PIN CROWN/BAHAN PORCELAIN KHUSUS - ORTHODONTIC REMOVEABLE/RAHANG PERAWATAN MUMIFIKASI PROTESA AKRILIK 1 SAMPAI 3 GIGI PROTESA AKRILIK 4 SAMPAI 6 GIGI PROTESA AKRILIK 7 SAMPAI 8 GIGI FULL PERRAHANG RESTORASI POST ENDODONTIK DEVITALISASI SALURAN AKAR PERAWATAN PULP CAPPING APLIKASI EUGONAL RETREATMENT/UP CUTTA PERCHA FULL DENTURE RA DAN RB PROTESA FLEXI DENTURE FULL PROTESA FLEXI PARSIAL Gigitiruan penuh RA dan RB akrilik Gigitiruan penuh RA akrilik 32 150,000Rp 150,000Rp Rp 300,000 33 50,000Rp 50,000Rp Rp 100,000 34 100,000Rp 100,000Rp Rp 200,000 35 125,000Rp 125,000Rp Rp 250,000 36 85,000Rp 85,000Rp Rp 170,000 37 310,000Rp 310,000Rp Rp 620,000 1 30,000Rp 30,000Rp 60,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 50,000Rp 50,000Rp 100,000Rp 1 50,000Rp 50,000Rp 100,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 50,000Rp 50,000Rp 100,000Rp 5 50,000Rp 50,000Rp 100,000Rp 6 300,000Rp 300,000Rp 600,000Rp 1 150,000Rp 150,000Rp 300,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 150,000Rp 150,000Rp 300,000Rp 5 125,000Rp 125,000Rp 250,000Rp 6 250,000Rp 250,000Rp 500,000Rp 7 400,000Rp 400,000Rp 800,000Rp 8 125,000Rp 125,000Rp 250,000Rp 9 250,000Rp 250,000Rp 500,000Rp 10 400,000Rp 400,000Rp 800,000Rp 11 125,000Rp 125,000Rp 250,000Rp 12 250,000Rp 250,000Rp 500,000Rp 13 400,000Rp 400,000Rp 800,000Rp 14 150,000Rp 150,000Rp 300,000Rp 15 200,000Rp 200,000Rp 400,000Rp 16 300,000Rp 300,000Rp 600,000Rp 17 400,000Rp 400,000Rp 800,000Rp 18 250,000Rp 250,000Rp 500,000Rp 19 175,000Rp 175,000Rp 350,000Rp 20 600,000Rp 600,000Rp 1,200,000Rp 21 350,000Rp 350,000Rp 700,000Rp 22 450,000Rp 450,000Rp 900,000Rp 23 600,000Rp 600,000Rp 1,200,000Rp 24 200,000Rp 200,000Rp 400,000Rp 25 400,000Rp 400,000Rp 800,000Rp TINDAKAN MEDIS BEDAH KULIT - PEMERIKSAAN GRAM, TRICHOMONAS - PEMERIKSAAN WHIFF TES - PEMERIKSAAN SARCOPTES PEMERIKSAAN LAMPU WOOD PEMERIKSAAN SEROLOGI ANTI PGL-1 - PUNCH BIOPSI - INJEKSI KORTIKOSTEROID (TRIAMCINOLON) ˂ 2 cm (KECIL) - INJEKSI KORTIKOSTEROID (TRIAMCINOLON) 2 cm - ˂ 5 cm (SEDANG) Gigitiruan penuh RB akrilik Gigitiruan akrilik1-3 gigi 4-6 gigi akrilik 7-8 gigi akrilik Reparasi gigitiruan - INJEKSI KORTIKOSTEROID (TRIAMCINOLON) ˃ 5 cm (BESAR) - ELEKTROCAUTER (KECIL) 1-5 Membuat ulang gigitiruan per rahang KONSULTASI - INSPECULO (SPECULUM) - TES SENSIBILITAS MORBUS HANSEN - PEMERIKSAAN KOH - EKSTRAKSI MILIA 1-10 - EKSTRAKSI MILIA 10 - 20 TINDAKAN PEMERIKSAAN SEDERHANA :
12. 12.POLI KULIT DAN KELAMIN PEMERIKSAAN PENUNJANG - EKSTRAKSI MILIA ˃ 20 - INSISI ABSES EKSISI/EKSTIRPASI KECIL (˂ 2 CM) - ELEKTROCAUTER 6-10 - ELEKTROCAUTER > 10 - ENUKLEASI MOLUSKUM KECIL 1-10 - ENUKLEASI MOLUSKUM BESAR 10-20 - ENUKLEASI MOLUSCUM BESAR > 20 EKSISI NEVUS (˂ 2 CM) EKSISI NEVUS ( ˃ 2 CM s/d ˂ 5 CM) EKSISI NEVUS ( ˃ 5 CM) ELEKTROCAUTER CONDILOMA 1 - 5 (KECIL) ELEKTROCAUTER CONDILOMA 5 - 10 EKSISI/EKSTIRPASI SEDANG ( ˃ 2 CM s/d ˂ 5 CM) EKSISI/EKSTIRPASI KECIL ( 7,5 CM) - MARSUPIALISASI - EKSTRAKSI KUKU (BESAR) EKSISI XANTELASMA 26 600,000Rp 600,000Rp 1,200,000Rp 27 200,000Rp 200,000Rp 400,000Rp 28 350,000Rp 350,000Rp 700,000Rp 29 450,000Rp 450,000Rp 900,000Rp 30 650,000Rp 650,000Rp 1,300,000Rp 31 300,000Rp 300,000Rp 600,000Rp 1 75,000Rp 75,000Rp 150,000Rp 2 125,000Rp 125,000Rp 250,000Rp 3 150,000Rp 150,000Rp 300,000Rp 4 125,000Rp 125,000Rp 250,000Rp 5 200,000Rp 200,000Rp 400,000Rp 6 175,000Rp 175,000Rp 350,000Rp 7 500,000Rp 500,000Rp 1,000,000Rp 8 750,000Rp 750,000Rp 1,500,000Rp 9 650,000Rp 650,000Rp 1,300,000Rp 10 1,250,000Rp 1,250,000Rp 2,500,000Rp 11 500,000Rp 500,000Rp 1,000,000Rp 12 1,000,000Rp 1,000,000Rp 2,000,000Rp 13 1,250,000Rp 1,250,000Rp 2,500,000Rp 14 1,500,000Rp 1,500,000Rp 3,000,000Rp 15 750,000Rp 750,000Rp 1,500,000Rp 16 1,000,000Rp 1,000,000Rp 2,000,000Rp 17 1,250,000Rp 1,250,000Rp 2,500,000Rp 1 400,000Rp 400,000Rp 800,000Rp 2 500,000Rp 500,000Rp 1,000,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 200,000Rp 200,000Rp 400,000Rp 5 50,000Rp 50,000Rp 100,000Rp 6 125,000Rp 125,000Rp 250,000Rp 7 300,000Rp 300,000Rp 600,000Rp 1 55,000Rp 55,000Rp 110,000Rp 2 75,000Rp 75,000Rp 150,000Rp 3 135,000Rp 135,000Rp 270,000Rp 4 800,000Rp 800,000Rp 1,600,000Rp 5 525,000Rp 525,000Rp 1,050,000Rp 6 400,000Rp 400,000Rp 800,000Rp 7 550,000Rp 550,000Rp 1,100,000Rp 8 525,000Rp 525,000Rp 1,050,000Rp 9 800,000Rp 800,000Rp 1,600,000Rp 10 175,000Rp 175,000Rp 350,000Rp 11 1,250,000Rp 1,250,000Rp 2,500,000Rp TINDAKAN KOSMETIK MEDIK NEBULIZER/TERAPI INHALASI FUNGSI PLEURA/PROEF PANKSI/TRIAL EVALUATION SPIROMETRI BRONCOSHCOPY/FOB THORA COSINTESIS / EVALUATION C PLEURA IRIGASI PLEURA / SPOOLING PLEURODESIS
13. 13.POLI PARU PEMERIKSAAN DENGAN TINDAKAN TCA KARDIOVASKULER RISK TINGGI FACIAL CHEMICAL PEELING AHA LOKAL CHEMICAL PEELING AHA IMPORT CHEMICAL PEELING TEA ELEKTROCAUTER CONDILOMA ≥10 BEDAH LISTRIK KERATOSIS SEBOROIK 1 - 5 BEDAH LISTRIK KERATOSIS SEBOROIK 5 - 10 BEDAH LISTRIK KERATOSIS SEBOROIK 10 s/d 20 BEDAH LISTRIK KERATOSIS SEBOROIK ˃ 20 LASER CO2 BERAT LASER PROYELLOW UNTUK LESI ˂ 5 cm LASER PROYELLOW UNTUK LESI ˃ 5 cm s/d 10 cm LASER PROYELLOW UNTUK LESI ˃10 cm LASER PROYELLOW UNTUK LESI FULL FACE MIKRODERMABRASI INJEKSI WHITENING STANDAR DERMAROLIER STANDAR DERMAROLIER PREMIUM LASER CO2 RINGAN TERAPI CREEPING ERUPTION/SEMPROT CHLOR ETHYL FOTOTHERAPY - VITILIGO RINGAN ˂ 5 LESI - VITILIGO RINGAN ≥ 5 - 10 LESI - VITILIGO BERAT/LUAS ≥ 10 LESI LASER NOYAG UNTUK LESI ˂ 5 cm LASER NOYAG UNTUK LESI ≥ 5 cm LASER NOYAG UNTUK LESI FULL FACE SKIN PRICK TEST SKIN PATCH TEST TES ALERGI PLEURODESIS PADA PNEUMOTORAKS PASANG CHEST TUBE/WSB AFF CHEST TUBE/WSD BRONCOSHCOPY + BIOPSI +WASHING + BROSHING 12 1,500,000Rp 1,500,000Rp 3,000,000Rp 13 325,000Rp 325,000Rp 650,000Rp 14 105,000Rp 105,000Rp 210,000Rp 15 300,000Rp 300,000Rp 600,000Rp 16 600,000Rp 600,000Rp 1,200,000Rp 17 250,000Rp 250,000Rp 500,000Rp 18 12,500Rp 12,500Rp 25,000Rp 19 12,500Rp 12,500Rp 25,000Rp 1 34,000Rp 34,000Rp 68,000Rp 2 25,000Rp 25,000Rp 50,000Rp 3 25,000Rp 25,000Rp 50,000Rp 4 25,000Rp 25,000Rp 50,000Rp 5 25,000Rp 25,000Rp 50,000Rp 6 100,000Rp 100,000Rp 200,000Rp 7 42,500Rp 42,500Rp 85,000Rp 8 25,000Rp 25,000Rp 50,000Rp 9 25,000Rp 25,000Rp 50,000Rp 10 35,000Rp 35,000Rp 70,000Rp 11 25,000Rp 25,000Rp 50,000Rp 12 25,000Rp 25,000Rp 50,000Rp 13 25,000Rp 25,000Rp 50,000Rp 14 25,000Rp 25,000Rp 50,000Rp 15 37,500Rp 37,500Rp 75,000Rp 16 25,000Rp 25,000Rp 50,000Rp 17 75,000Rp 75,000Rp 150,000Rp 18 50,000Rp 50,000Rp 100,000Rp 19 600,000Rp 600,000Rp 1,200,000Rp 20 Rp 25,000 Rp 25,000 Rp 50,000 21 Rp 131,250 Rp 131,250 Rp 262,500 22 Rp 12,500 Rp 12,500 Rp 25,000 23 42,500Rp 42,500Rp 85,000Rp 24 90,000Rp 90,000Rp 180,000Rp 25 42,500Rp 42,500Rp 85,000Rp 26 3,250,000Rp 3,250,000Rp 6,500,000Rp 27 1,050,000Rp 1,050,000Rp 2,100,000Rp 28 100,000Rp 100,000Rp 200,000Rp 29 1,250,000Rp 1,250,000Rp 2,500,000Rp 1 12,500Rp 12,500Rp 25,000Rp 2 20,000Rp 20,000Rp 40,000Rp 3 10,000Rp 10,000Rp 20,000Rp 4 25,000Rp 25,000Rp 50,000Rp 1 75,000Rp 75,000Rp 150,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 32,500Rp 32,500Rp 65,000Rp 4 42,500Rp 42,500Rp 85,000Rp
14. 14.POLI MATA PEMERIKSAAN DENGAN TINDAKAN POSTURAL DRAINAGE UJI JALAN 6 MENIT FNAB (FINE NEEDLE ASPIRASI BIOPSI) TTNA (TRANS TORACAL NEEDLE ASPIRASI) USG THORAKS BRONCOSHCOPY + EKSTRAKSI BENDA ASING GANTI PERBAN - FUNDOSCOFIE - EXTERPASI CORPUS ALIENUM - SPULLING BOLA MATA - EPILASI BULU MATA INJEKSI SKIN TEST SLIT LAMP TONOMETRI SHIOTS TONOMETRI APPLARASI GOLDMAN - CHECK UP MATA - SLIT LAMP + FOTO - GUNTING BULU MATA / CILIA - KOREKSI KACA MATA - TES ANNCL - MASSAGE MATA - INJEKSI SUBKONJUNGTIVA - REKFRAKSIMETER - TESFLOURESENDS/TESCIDEL - VISUS/REGFRAKSI - USG MATA - KERATOMETRI - PHACO EMULSIFIKASI - YAG LASER / LASER IRIDOKTOMI - GONIOSKOPY - OPERASI PTEREYGIUM - PEMERIKSAAN BUTA WARNA - INSISI HORDEUUWM/KALAZION - AFF HECTING/HECTING - BIOMETRI Wawancara Awal dan Pemeriksaan Psikiatri Psikoterapi Suportif Psikoedukasi Individu Psikoedukasi Keluarga - EKSISI PTERYGIUM + GRAFT KONJUTIVA PENGUKURAN ANTROPOMETRI - PERHITUNGAN KEBUTUHAN KALORI - PENETAPAN STATUS GIZI - PENYULUHAN GIZI
15. 15.POLI GIZI
16. 16.POLI JIWA 5 50,000Rp 50,000Rp 100,000Rp 6 50,000Rp 50,000Rp 100,000Rp 7 75,000Rp 75,000Rp 150,000Rp 8 42,500Rp 42,500Rp 85,000Rp 9 50,000Rp 50,000Rp 100,000Rp 10 62,500Rp 62,500Rp 125,000Rp 13 125,000Rp 125,000Rp 250,000Rp 14 125,000Rp 125,000Rp 250,000Rp 15 50,000Rp 50,000Rp 100,000Rp 16 50,000Rp 50,000Rp 100,000Rp 17 50,000Rp 50,000Rp 100,000Rp 18 125,000Rp 125,000Rp 250,000Rp 19 42,500Rp 42,500Rp 85,000Rp 20 42,500Rp 42,500Rp 85,000Rp 21 50,000Rp 50,000Rp 100,000Rp 22 42,500Rp 42,500Rp 85,000Rp 1 48,500Rp 48,500Rp 97,000Rp 2 102,500Rp 102,500Rp 205,000Rp 4 32,500Rp 32,500Rp 65,000Rp 5 277,500Rp 277,500Rp 555,000Rp 6 277,500Rp 277,500Rp 555,000Rp 7 277,500Rp 277,500Rp 555,000Rp 8 750,000Rp 750,000Rp 1,500,000Rp 9 750,000Rp 750,000Rp 1,500,000Rp 10 750,000Rp 750,000Rp 1,500,000Rp 11 750,000Rp 750,000Rp 1,500,000Rp 12 750,000Rp 750,000Rp 1,500,000Rp 13 750,000Rp 750,000Rp 1,500,000Rp 14 750,000Rp 750,000Rp 1,500,000Rp 15 750,000Rp 750,000Rp 1,500,000Rp 16 750,000Rp 750,000Rp 1,500,000Rp 17 750,000Rp 750,000Rp 1,500,000Rp 18 750,000Rp 750,000Rp 1,500,000Rp 19 750,000Rp 750,000Rp 1,500,000Rp 20 750,000Rp 750,000Rp 1,500,000Rp 21 1,600,000Rp 1,600,000Rp 3,200,000Rp 22 1,600,000Rp 1,600,000Rp 3,200,000Rp 23 1,600,000Rp 1,600,000Rp 3,200,000Rp 24 1,600,000Rp 1,600,000Rp 3,200,000Rp 25 1,600,000Rp 1,600,000Rp 3,200,000Rp 26 1,600,000Rp 1,600,000Rp 3,200,000Rp 27 1,600,000Rp 1,600,000Rp 3,200,000Rp 28 1,600,000Rp 1,600,000Rp 3,200,000Rp 29 1,600,000Rp 1,600,000Rp 3,200,000Rp 30 1,600,000Rp 1,600,000Rp 3,200,000Rp 31 1,600,000Rp 1,600,000Rp 3,200,000Rp 32 1,600,000Rp 1,600,000Rp 3,200,000Rp 33 1,600,000Rp 1,600,000Rp 3,200,000Rp 34 1,600,000Rp 1,600,000Rp 3,200,000Rp 35 1,600,000Rp 1,600,000Rp 3,200,000Rp 36 1,600,000Rp 1,600,000Rp 3,200,000Rp Terapi Kognitif MMPI Dewasa MMPI Anak & Remaja Krisis Intervensi (30 menit) Konseling Adiksi Terapi Pernikahan (Marital Therapy) Terapi Perilaku Terapi Kognitif Perilaku (CBT) Terapi Keluarga ≤ 60 menit Terapi Keluarga > 60 menit Play Therapy Ganti verban kecil Bedah Mulut Ganti verban besar Bedah Mulut Aff Hacting Gigi Bedah Mulut Debridemen Bedah Mulut Kuretase Hipnoterapi Terapi Relaksasi Fiksasi Mekanik Fiksasi Kimiawi (injeksi/neuroleptisasi cepat) Pemeriksaan Tingkat Kecemasan/Depresi/Mania
17. 17.POLI BEDAH MULUT Penutupan fistula ekstraoral Ridge Augmentasi perkuadran Apex reseksi/apikoektomy pergigi Excisi Biopsi Insisi Biopsi Ekstraksi per gigi Ekstraksi gigi /fragmen fraktur gigi dengan flap per gigi Insisi/Eksisi Abses Odontektomy kelas I pergigi Opperkulektomy peregio Sinus Lifting Penutupan fistula oroantral (Buccal/palatal flap) Sequesterectomy perkuadran Odontectomy kelas 2 pergigi Odontectomy kelas 3 pergigi Wiring per rahang Nekrotomi perkuadran Reposisi dislokasi mandibula Repair wound Gingiva Pengambilan fragmen gigi dalam sinus Excisi Hiperplasia denture Gingivektomi/Gingivoplasty Peregio Aspirasi Biopsi Extirpasi Biopsi Enukleasi Frenektomy per Rahang Exposure mahkota gigi terpendam pergig Alveolektomi perkuadran Vestibuloplasty per rahang Excisi torus peregio 37 1,600,000Rp 1,600,000Rp 3,200,000Rp 38 1,600,000Rp 1,600,000Rp 3,200,000Rp 39 1,600,000Rp 1,600,000Rp 3,200,000Rp 40 1,600,000Rp 1,600,000Rp 3,200,000Rp 41 1,600,000Rp 1,600,000Rp 3,200,000Rp 42 1,600,000Rp 1,600,000Rp 3,200,000Rp 43 1,600,000Rp 1,600,000Rp 3,200,000Rp 44 1,600,000Rp 1,600,000Rp 3,200,000Rp 45 1,600,000Rp 1,600,000Rp 3,200,000Rp 46 1,600,000Rp 1,600,000Rp 3,200,000Rp 1 50,000Rp 50,000Rp 100,000Rp 2 37,500Rp 37,500Rp 75,000Rp 3 42,500Rp 42,500Rp 85,000Rp 4 60,000Rp 60,000Rp 120,000Rp 5 60,000Rp 60,000Rp 120,000Rp 6 50,000Rp 50,000Rp 100,000Rp 7 60,000Rp 60,000Rp 120,000Rp 8 50,000Rp 50,000Rp 100,000Rp 9 42,500Rp 42,500Rp 85,000Rp 10 65,000Rp 65,000Rp 130,000Rp JASA SARANA JASA PELAYANAN 1 390,000Rp 390,000Rp 780,000Rp 2 70,000Rp 70,000Rp 140,000Rp 3 82,500Rp 82,500Rp 165,000Rp 4 51,500Rp 51,500Rp 103,000Rp 5 85,000Rp 85,000Rp 170,000Rp A Tindakan Medik Spesialistik 1 450,000Rp 450,000Rp 900,000Rp 2 337,500Rp 337,500Rp 675,000Rp 3 187,500Rp 187,500Rp 375,000Rp 4 487,500Rp 487,500Rp 975,000Rp 5 247,500Rp 247,500Rp 495,000Rp 6 120,000Rp 120,000Rp 240,000Rp 7 150,000Rp 150,000Rp 300,000Rp 8 93,750Rp 93,750Rp 187,500Rp 9 157,500Rp 157,500Rp 315,000Rp 10 92,500Rp 92,500Rp 185,000Rp 11 78,750Rp 78,750Rp 157,500Rp 12 51,250Rp 51,250Rp 102,500Rp 13 202,500Rp 202,500Rp 405,000Rp 14 75,000Rp 75,000Rp 150,000Rp 15 225,000Rp 225,000Rp 450,000Rp B. 112,500Rp 112,500Rp 225,000Rp 17 600,000Rp 600,000Rp 1,200,000Rp NO
18. 19.POLI ORTHOPEDI
19. 18.POLI PENYAKIT MULUT TARIF JUMLAH Penjahitan perkuadran Replantasi gigi asli per gigi Repair wound kulit peregio Repair wound lidah Repair wound mukosa,otot peregio Marsupialisasi perkuadran Eksisi/ekstirpasi Sialolitiasis/Ranula Fraktur Edentulous/per rahang Fraktur dentoalveolar per rahang Splinting pekuadran perwatan jamur,virus,bakteri perawatan lesi keratosis,non keratosis perawan kelainan kelenjar liur perawan bekala biopsi jarum halus (FNAB) Oral Healt Care Pemeriksaan sitologi pemeriksaan hapudsan microba perawatan keradangan/mukositis Perawatan Lesi Ulserasi/laserasi Pearawatan Luka Infeksi Subspesialistik Orthopedi Pemasangan Gips Besar (Body Spice, Long leg cast) Pemasangan Gips Sedang (Short leg cast, Long arm cast, short arm cast)) Pemasangan Gips Kecil (Back slab, hand) JENIS PELAYANAN Pemasangan Gips Aff Gips Aff K'wire Aspirasi Remove Gips Besar & Sedang Remove Gips Kecil Insisi Abses pd ekstremitas Evakuasi hematom sublingual Ekstirpasi kuku / roserplasty Pemasangan Gips Khusus (body jacket, hip spica) Pemasangan Gips Splint (slab) Remove wire Buka wire (dengan anastesi) Buka wire (tanpa anastesi) Reposisi fraktur tertutup Pasang Skin Traksi Buka Skeletal Traksi Injeksi Hyaluronat 18 135,000Rp 135,000Rp 270,000Rp 19 53,000Rp 53,000Rp 106,000Rp 20 62,500Rp 62,500Rp 125,000Rp 21 90,000Rp 90,000Rp 180,000Rp 22 25,000Rp 25,000Rp 50,000Rp 23 35,000Rp 35,000Rp 70,000Rp 24 50,000Rp 50,000Rp 100,000Rp 25 25,000Rp 25,000Rp 50,000Rp 26 25,000Rp 25,000Rp 50,000Rp JASA SARANA JASA PELAYANAN 1. 82,500Rp 82,500Rp 165,000Rp 82,500Rp 82,500Rp 165,000Rp 40,000Rp 40,000Rp 80,000Rp 36,000Rp 36,000Rp 72,000Rp 2 112,500Rp 112,500Rp 225,000Rp 92,500Rp 92,500Rp 185,000Rp 75,000Rp 75,000Rp 150,000Rp 67,500Rp 67,500Rp 135,000Rp 3 152,500Rp 152,500Rp 305,000Rp 152,500Rp 152,500Rp 305,000Rp 100,000Rp 100,000Rp 200,000Rp 90,000Rp 90,000Rp 180,000Rp 5 75,000Rp 75,000Rp 150,000Rp 60,000Rp 60,000Rp 120,000Rp 50,000Rp 50,000Rp 100,000Rp 45,000Rp 45,000Rp 90,000Rp 6 110,000Rp 110,000Rp 220,000Rp 90,000Rp 90,000Rp 180,000Rp 75,000Rp 75,000Rp 150,000Rp 67,500Rp 67,500Rp 135,000Rp 7 150,000Rp 150,000Rp 300,000Rp 120,000Rp 120,000Rp 240,000Rp 100,000Rp 100,000Rp 200,000Rp 90,000Rp 90,000Rp 180,000Rp 9 38,500Rp 38,500Rp 77,000Rp 33,000Rp 33,000Rp 66,000Rp 27,500Rp 27,500Rp 55,000Rp 24,500Rp 24,500Rp 49,500Rp 10 76,500Rp 76,500Rp 153,000Rp 60,000Rp 60,000Rp 120,000Rp 2O. PSIKOLOGI NO TARIF JUMLAH Rawat Luka Infeksi Kecil Rawat Luka Infeksi Sedang Rawat Luka Infeksi Berat Ganti Verban Ringan Ganti Verban Sedang Aspirasi hematom VIP Kelas 1 kelas 2 Kelas 3 Psikoterapi Sedang Ganti Verban Berat Pasang Elastis Verban Aff Drain JENIS PELAYANAN Psikoterapi Dasar Vip Kelas 1 Kelas 2 Kelas 3 Terapi Anak Kecil Vip Kelas 1 Kelas 2 Kelas 3 Psikoterapi Kompleks Vip Kelas 1 Kelas 2 Kelas 3 Terapi Anak Besar Vip Kelas 1 Kelas 2 Kelas 3 Terapi Anak Sedang Vip Kelas 1 Kelas 2 Kelas 3 Psikotes Sederhana Vip Kelas 1 Kelas 2 Kelas 3 Psikologi Dasar Vip Kelas 1 50,000Rp 50,000Rp 100,000Rp 45,000Rp 45,000Rp 90,000Rp 11 231,000Rp 231,000Rp 462,000Rp 231,000Rp 231,000Rp 462,000Rp 137,500Rp 137,500Rp 275,000Rp 123,500Rp 123,500Rp 247,500Rp 12 309,500Rp 309,500Rp 619,000Rp 240,000Rp 240,000Rp 480,000Rp 200,000Rp 200,000Rp 400,000Rp 180,000Rp 180,000Rp 360,000Rp 14 56,250Rp 56,250Rp 112,500Rp 45,000Rp 45,000Rp 90,000Rp 37,500Rp 37,500Rp 75,000Rp 33,750Rp 33,750Rp 67,500Rp 15 101,250Rp 101,250Rp 81,250Rp 81,250Rp 162,500Rp 67,500Rp 67,500Rp 135,000Rp 78,750Rp 78,750Rp 157,500Rp 16 131,250Rp 131,250Rp 262,500Rp 105,000Rp 105,000Rp 210,000Rp 87,500Rp 87,500Rp 175,000Rp 62,500Rp 62,500Rp 125,500Rp 18 76,500Rp 76,500Rp 153,000Rp 76,500Rp 76,500Rp 153,000Rp 37,500Rp 37,500Rp 75,000Rp 33,500Rp 33,500Rp 67,500Rp 19 101,250Rp 101,250Rp 202,500Rp 85,000Rp 85,000Rp 170,000Rp 67,500Rp 67,500Rp 135,000Rp 62,500Rp 62,500Rp 125,500Rp 20 131,000Rp 131,000Rp 262,500Rp 130,000Rp 130,000Rp 260,000Rp 87,500Rp 87,500Rp 175,000Rp 78,500Rp 78,500Rp 157,500Rp 1 150,000Rp 150,000Rp 300,000Rp 2 50,000Rp 50,000Rp 100,000Rp 3 75,000Rp 75,000Rp 150,000Rp 4 100,000Rp 100,000Rp 200,000Rp 5 125,000Rp 125,000Rp 250,000Rp 6 150,000Rp 150,000Rp 300,000Rp 7 150,000Rp 150,000Rp 300,000Rp 8 150,000Rp 150,000Rp 300,000Rp 9 375,000Rp 375,000Rp 750,000Rp
20. 21.POLI UROLOGI Vip Kelas 1 Kelas 2 Kelas 3 Psikotes Kompleks Kelas 2 Kelas 3 Psikotes Sedang Vip Kelas 1 Kelas 2 Kelas 3 Psikoedukasi Sedang Vip Kelas 1 Kelas 2 Kelas 3 Psikoedukasi Dasar Vip Kelas 1 Kelas 2 Kelas 3 Konseling Dasar Vip Kelas 1 Kelas 2 Kelas 3 Psikoedukasi Kompleks Vip Kelas 1 Kelas 2 Kelas 3 Konseling Kompleks Vip Kelas 1 Kelas 2 Kelas 3 Konseling Sedang Ganti Catheter Ganti Cytostomy Inj LHRH agonist Inj. Kenacort (peyronie) Inj. Papaverin / Impotence test Vip Kelas 1 Kelas 2 Kelas 3 CIC (Clien Intermitten Self Cateterisasi) Inj. Profasi Instilasi kandung kemih / sistostatika Pasang kateter dengan mandrain 10 50,000Rp 50,000Rp 100,000Rp 11 40,000Rp 40,000Rp 80,000Rp 12 75,000Rp 75,000Rp 150,000Rp 13 100,000Rp 100,000Rp 200,000Rp 14 100,000Rp 100,000Rp 200,000Rp 15 250,000Rp 250,000Rp 500,000Rp 16 750,000Rp 750,000Rp 1,500,000Rp 17 1,000,000Rp 1,000,000Rp 2,000,000Rp 18 150,000Rp 150,000Rp 300,000Rp 19 150,000Rp 150,000Rp 300,000Rp 20 62,500Rp 62,500Rp 125,000Rp 21 75,000Rp 75,000Rp 150,000Rp 22 150,000Rp 150,000Rp 300,000Rp 23 150,000Rp 150,000Rp 300,000Rp JASA PELAYANAN JASA SARANA TARIF VENDOR TARIF TOTAL KETERANGAN 24 125,000Rp 125,000Rp 250,000Rp 500,000Rp Pihak ke Tiga 25 1,250,000Rp 1,250,000Rp 2,500,000Rp 5,000,000Rp Pihak ke Tiga JASA LAYANAN JASA SARANA 1 Rp - Rp 10,000 5,000Rp 15,000 2 Rp 15,000 Rp 12,500 5,000Rp 32500 3 Rp 20,000 Rp 12,500 5,000Rp 37500 JUMLAH PKRTL TARIF 22.TELEMEDICINE HOSPITAL BASED NO FKTP JENIS PELAYANAN Pemasangan DK (Dower kateter) Rawat Luka Spoeling Kandung Kemih TRUS TRUS + Biopsi Pelepasan Cystostomy Pelepasan DK (Lepas Dower Kateter) Telekonsultasi Klinis TELE EKG* TELE USG* Konsultasi poliklinik infertilitas pria Tindakan UGD dan perawatan khusus TINDAKAN Uroflowmetri PVR ESWL Urodinamik Uroflowmetri PVR USG Urologi Businasi/ dilatasi uretra poli Konsultasi poliklinik umum JASA SARANA JASA PELAYANAN HEMATOLOGI RUTIN 1 HEMATOLOGI RUTIN 45,000 45,000 90,000 2 HEMATOLOGI RUTIN (HITUNG JENIS DIFF COUNT) 65,000 65,000 130,000 3 LAJU ENDAP DARAH AUTOMATIC 30,000 30,000 60,000 4 LAJU ENDAP DARAH MANUAL 17,500 17,500 35,000 5 HEMOGLOBIN (POCT) 27,500 27,500 55,000 6 APUSAN DARAH TEPI 55,000 55,000 110,000 7 IT RATIO 50,000 50,000 100,000 HEMOSTASIS 1 CLOTTING TIME (CT) 10,000 10,000 20,000 2 BLEEDING TIME (BT) 10,000 10,000 20,000 3 ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) 77,500 77,500 155,000 4 PROTHROMBIN TIME (PT) 77,500 77,500 155,000 KIMIA DARAH DIABETIC 1 GLUKOSA DARAH SEWAKTU 20,000 20,000 40,000 2 GLUKOSA DARAH PUASA 20,000 20,000 40,000 3 GLUKOSA DARAH 2 JAM PP 20,000 20,000 40,000 4 GLUKOSA DARAH (POCT) 20,000 20,000 40,000 5 HBA1C 125,000 125,000 250,000 PROFIL LIPID - - 1 CHOLESTEROL HDL 35,000 35,000 70,000 2 CHOLESTEROL LDL 55,000 55,000 110,000 3 CHOLESTEROL TOTAL 22,500 22,500 45,000 4 TRIGLISERIDA 27,500 27,500 55,000 FALL HATI - - 1 ALBUMIN 22,500 22,500 45,000 2 ALKALI PHOSHATASE 30,000 30,000 60,000 3 BILIRUBIN DIRECT 30,000 30,000 60,000 4 BILIRUBIN INDIRECT 30,000 30,000 60,000 5 BILIBURIN TOTAL 30,000 30,000 60,000 6 GLOBULIN 22,500 22,500 45,000 7 PROTEIN TOTAL 30,000 30,000 60,000 8 SGOT/AST 22,500 22,500 45,000 9 SGPT/ALT 22,500 22,500 45,000 FAAL GINJAL - - 1 ASAM URAT 22,500 22,500 45,000 2 CREATININ 25,000 25,000 50,000 3 UREUM 22,500 22,500 45,000
21. 1.LABORATORIUM III. PELAYANAN PENUNJANG MEDIS NO JENIS PELAYANAN TARIF JUMLAH A. TARIF LAYANAN LABORATORIUM, RADIOLOGI,FISIOTERAPI FAAL JANTUNG - - 1 CK 70,000 70,000 140,000 2 CRP 40,000 40,000 80,000 3 LDH 35,000 35,000 70,000 4 TROPONIN I 42,500 42,500 85,000 TIROID - - 1 FT4 125,000 125,000 250,000 2 TSHS 87,500 87,500 175,000 ELEKTROLIT - - 1 PAKET ELEKTROLIT (Na, K, Cl) 150,000 150,000 300,000 ANALISA GAS DARAH - - 1 ANALISA GAS DARAH 225,000 225,000 450,000 IMUNOLOGI - - 1 ANTI DENGUE IgG/IgM RAPID 105,000 105,000 210,000 2 ANTI HBs RAPID 50,000 50,000 100,000 3 ANTI HCV RAPID 45,000 45,000 90,000 4 ANTI SYPHILIS RAPID 45,000 45,000 90,000 5 CD4 125,000 125,000 250,000 6 GOLONGAN DARAH 12,500 12,500 25000 7 RHESUS 12,500 12,500 25,000 8 HBsAg RAPID 37,500 37,500 75,000 9 MALARIA RAPID 45,000 45,000 90,000 10 NARKOBA 3P 70,000 70,000 140,000 11 NARKOBA 5P 100,000 100,000 200,000 12 NARKOBA 6P 140,000 140,000 280000 13 PLANO TEST 17,500 17,500 35,000 14 SYPHILIS RAPID 32,500 32,500 65,000 15 WIDAL 32,500 32,500 65,000 URINALISA 1 URINE RUTIN 22,500 22,500 45,000 2 SEDIMEN URIN 15,000 15,000 30,000 ANALISA FESES 1 FESES RUTIN 22,500 22,500 45,000 2 FESES DARAH SAMAR (FOB) 25,000 25,000 50,000 MIKROBIOLOGI 1 BTA MIKROSKOPIK 25,000 25,000 50,000 2 MALARIA MIKROSKOPIK 25,000 25,000 50,000 3 TCM 200,000 200,000 400,000 4 Test HIV 55,000Rp 55,000Rp 110,000Rp 5 Test Rapid Antigen Covid-19 40,000Rp 40,000Rp 80,000Rp I. PEMERIKSAAN KONVENSIONAL KONTRAS - - 1 SEDERHANA MANUAL SATU KALI EKS AP ATAU 75,000 75,000 150,000 LAT DALAM 1 FILM - - 2 SEDERHANA MANUAL DUA KALI EKS AP DAN 75,000 75,000 150,000 LAT DALAM 1 FILM - - 3 SEDERHANA CR/DR SATU KALI EKS AP DAN 95,000 95,000 190,000 LAT DALAM 1 FILM - - 4 SEDERHANA CR/DR DUA KALI EKS AP DAN 107,500 107,500 215,000 LAT DALAM 1 FILM - - + OBLIQ 132,500 132,500 265,000 5 GIGI GELIGI SATU KALI EKS 82,500 82,500 165,000 6 MAMMOGRAFI 225,000 225,000 450,000 7 PANORAMIC 140,000 140,000 280,000 8 ABDOMEN 3 POSISI 170,000 170,000 340,000 9 ABDOMEN 3 POSISI CR/DR 170,000 170,000 340,000 II. MENGGUNAKAN MEDIA KONTRAS - - 1 BNO-IVP MANUAL 600,000 600,000 1,200,000Rp 2 BNO-IVP CR/DR 600,000 600,000 1,200,000Rp 3 COLON IN LOOP MANUAL 600,000 600,000 1,200,000Rp 4 COLON IN LOOP CR/DR 600,000 600,000 1,200,000Rp 5 URETROGRAFI/CYSTOGRAFI MANUAL 450,000 450,000 900,000Rp 6 URETROGRAFI/CYSTOGRAFI CR/DR 450,000 450,000 900,000Rp 7 FISTULOGRAFI MANUAL 450,000 450,000 900,000Rp 8 FISTULOGRAFI CR/DR 450,000 450,000 900,000Rp 9 COR ANILIS MANUAL 250,000 250,000 500,000Rp 10 COR ANILIS CR/DR 250,000 250,000 500,000Rp 11 APPENDICOGRAM MANUAL 387,500 387,500 775,000Rp 12 APPENDICOGRAM CR/DR 387,500 387,500 775,000Rp 13 OMD MANUAL 400,000 400,000 800,000Rp 14 OMD CR/DR 400,000 400,000 800,000Rp 15 DACRIOGRAFI MANUAL 400,000 400,000 800,000Rp 16 DACRIOGRAFI CR/DR 400,000 400,000 800,000Rp 17 CHOLECYSTOGRAFI MANUAL 400,000 400,000 800,000Rp 18 CHOLECYSTOGRAFI CR/DR 400,000 400,000 800,000Rp 19 HISTEROSALPHINGOGRAFI MANUAL 500,000 500,000 1,000,000Rp 20 HISTEROSALPHINGOGRAFI CR/DR 500,000 500,000 1,000,000Rp 21 MD MANUAL 350,000 350,000 700,000Rp 22 MD CR/DR 350,000 350,000 700,000Rp OESOPHAGOGRAFI MANUAL 350,000 350,000 700,000Rp OESOPHAGOGRAFI CR/DR 350,000 350,000 700,000Rp MAMMOGRAFI CR/DR 387,500 387,500 775,000Rp RETROGRADAPYELOGRAFI RPG\APG MANUAL 550,000 550,000 1,100,000Rp RETROGRADAPYELOGRAFI RPG\APG CR/DR 550,000 550,000 1,100,000Rp III. PEMERIKSAAN USG - - 1 ABDOMEN ATAS/BAWAH 150,000 150,000 300,000Rp 2 WHOLE ABDOMEN 175,000 175,000 350,000Rp 3 LEHER 200,000 200,000 400,000Rp 4 MAMMAE 200,000 200,000 400,000Rp 5 EKSTREMITAS BAWAH/ATAS 200,000 200,000 400,000Rp 6 KEPALA BAYI 200,000 200,000 400,000Rp 7 WAJAH BAYI 250,000 250,000 500,000Rp 8 OTOT 200,000 200,000 400,000Rp 9 COLOR DOPPLER/PEMBULUH DARAH 225,000 225,000 450,000Rp IV. PEMERIKSAAN CT SCAN - - A NON KONTRAS - - 1 KEPALA/MAXILLA/MANDIBULA 632,500 632,500 1,265,000Rp 2 SPN CORONAL/AXIAL 632,500 632,500 1,265,000Rp 3 EKSTREMITAS BAWAH/ATAS 632,500 632,500 1,265,000Rp 4 CUBITI/PATELLA 632,500 632,500 1,265,000Rp 5 THORAX 682,500 682,500 1,365,000Rp 6 ABDOMEN ATAS/BAWAH 682,500 682,500 1,365,000Rp 7 ABDOMEN BAWAH 682,500 682,500 1,365,000Rp 8 WHOLE ABDOMEN 782,500 782,500 1,565,000Rp 9 CV.CERVICALIS 682,500 682,500 1,365,000Rp 10 CV.THORACAL/LUMBAL/SACRAL 682,500 682,500 1,365,000Rp 11 NASOPHARINX/LARINX 682,500 682,500 1,365,000Rp 12 ORBITA 682,500 682,500 1,365,000Rp 13 CT SCAN 3D - - B. DENGAN KONTRAS 40 cc- 60 cc - - 1 KEPALA/MAXILLA/MANDIBULA 1,132,500 1,132,500 2,265,000Rp 2 SPN CORONAL/AXIAL 1,132,500 1,132,500 2,265,000Rp 3 MASTOID CORONAL/AXIAL 1,132,500 1,132,500 2,265,000Rp 4 EKSTREMITAS BAWAH/ATAS 1,132,500 1,132,500 2,265,000Rp 5 CUBITI/PATELLA 1,132,500 1,132,500 2,265,000Rp C. DENGAN KONTRAS 80 cc- 100 cc - - 1 THORAX 1,132,500 1,132,500 2,265,000Rp 2 ABDOMEN ATAS 1,132,500 1,132,500 2,265,000Rp 3 ABDOMEN BAWAH 1,132,500 1,132,500 2,265,000Rp 4 WHOLE ABDOMEN 1,450,000 1,450,000 2,900,000Rp 5 CV.CERVICALIS 1,312,500 1,312,500 2,625,000Rp 6 CV.THORACAL/LUMBAL/SACRAL 1,312,500 1,312,500 2,625,000Rp 7 NASOPHARINX/LARINX 1,312,500 1,312,500 2,625,000Rp 8 ORBITA 1,312,500 1,312,500 2,625,000Rp 9 CT SCAN 3D 1,312,500 1,312,500 2,625,000Rp V. CT SCAN CARDIAC 1,750,000 1,750,000 3,500,000Rp VI. CT SCAN ANGIOGRAFI 1,500,000 1,500,000 3,000,000Rp
22. 1.PEMERIKSAAN KHUSUS 1 - MANUAL THERAPY (VERTEB & EXTREMITY 27,500 27,500 55,000 2 - NEURAL MOBILISATION 27,500 27,500 55,000 3 - POSTURAL DRAINAGE 18,000 18,000 36,000 4 - TILTING TABLE 18,000 18,000 36,000 5 - BREATING EXERCISE 18,000 18,000 36,000 6 - GAIT TRAINING 29,750 29,750 59,500 7 - MANIPULATION THERAPY (massage dan MLDV) 29,750 29,750 59,500 8 - NEBULIZER 27,250 27,250 54,500 9 - TREDMILL 27,250 27,250 54,500 10 - MAGNETO THERAPY 27,000 27,000 54,000 11 - TERAPI TUMBUH KEMBANG 27,000 27,000 54,000
23. 2.TINDAKAN UMUM - - 1 - SHORT WAVE DIATHERMI 23,500 23,500 47,000 2 - MICRO WAVE DIATHERMI 23,500 23,500 47,000 3 - INFRARED RAYS 20,000 20,000 40,000 4 - TENS 23,500 23,500 47,000 5 - INTERFERENSI 23,500 23,500 47,000 6 - PARAPHIN BATH 23,000 23,000 46,000 7 - FARADIC/GALFANIC 23,500 23,500 47,000 8 - ULTRA SOUND THERAPY 23,500 23,500 47,000 9 LASER THERAPHY 23,500 23,500 47,000 10 TRAKSI LUMBAL/CERVICAL 30,000 30,000 60,000 11 TREAD MILLS 72,000 72,000 144,000 12 ULTRA SOUND DIATHERMI 23,500 23,500 47,000 13 EXERCISE THERAPHY 19,750 19,750 39,500 14 MANUAL THERAPHY 25,000 25,000 50,000 15 WALKING EXERCISE 24,750 24,750 49,500 16 HYDRO THERAPY 75,000 75,000 150,000 17 TERAPI TUMBUH KEMBANG 33,500 33,500 67,000 18 TILTING TABLE 23,500 23,500 47,000 19 TAPPING 25,000 25,000 50,000
24. 3.TINDAKAN TERAPI WICARA - - 20 AFASIA ANAK 24,500 24,500 49,000 C. FISIOTERAPI 21 AFASIA DEWASA 24,500 24,500 49,000 22 DISFAGIA 24,500 24,500 49,000 23 DISARTRIA 24,500 24,500 49,000 24 DISAUDIA 24,500 24,500 49,000 25 DISGLOSIA 24,500 24,500 49,000 26 SPEECH DELAYED 24,500 24,500 49,000 27 IRAMA KELANCARAN 24,500 24,500 49,000 28 EXERCISE /LATIHAN WICARA 24,500 24,500 49,000 29 VOCASTERM 49,500 49,500 99,000 30 VITASTERM 49,500 49,500 99,000 NO JENIS PELAYANAN SARANA JASA PELAYANAN TOTAL 1 PENGELOLAAN DARAH 150,000 150,000 300,000 2 PENGELOLAAN KOMPONEN DARAH 175,000 175,000 350,000 NO URAIAN JASA SARANA JASA PELAYANAN JUMLAH 1 Kelas III 37,500Rp 37,500-Rp 75,000Rp 2 Kelas II 45,000Rp 45,000-Rp 90,000Rp 3 Kelas I 60,000Rp 60,000-Rp 120,000Rp 4 VIP 75,000Rp 75,000-Rp 150,000Rp 5 SUPER VIP 90,000Rp 90,000-Rp 180,000Rp 6 HCU 30,000Rp 30,000-Rp 60,000Rp 7 ICU/PICU/NICU 30,000Rp 30,000-Rp 60,000Rp 8 ISOLASI 30,000Rp 30,000-Rp 60,000Rp JASA SARANA JASA PELAYANAN 1 Memandikan jenazah 350,000Rp 350,000Rp 700,000Rp 2 memandikan jenazah infeksius 400,000Rp 400,000Rp 800,000Rp 3 Jasa Rohaniawan 100,000Rp 100,000Rp 200,000Rp 6 biaya Pemakaian Kamar Jenazah (Penitipan)
a.Tarif dalam Rumah Sakit 60,000Rp 60,000Rp 120,000Rp
b.Tarif Luar Rumah Sakit 100,000Rp 100,000Rp 200,000Rp
c.Jasa Pelayanan Dalam RS 350,000Rp 350,000Rp 700,000Rp d.Jasa Pelayanan Luar RS 4,000Rp 4,000Rp 8,000Rp 7 Biaya Pemakaian mesin Pengawet Jenazah/Hari
a.Jasa Sarana 15,000Rp 15,000Rp 30,000Rp
b.Jenis Pelayanan 5,000Rp 5,000Rp 10,000Rp 8 Biaya Pelayanan Pengawetan Jenazah 1,000,000Rp 1,000,000Rp 2,000,000Rp NO JENIS PELAYANAN RENCANA TARIF JUMLAH B. PELAYANAN UNIT TRASFUSI DARAH C. PELAYANAN INSTALASI GIZI PER HARI D. PEMULASARAN JENAZAH NO REKAM MEDIK JASA SARANA JASA PELAYANAN JUMLAH A Pasien Lama 1 Map 4,250 4,250 8,500 2 Format 11,750 11,750 23,500 3 Kartu 5,000 5,000 10,000 4 Gelang 2,500 2,500 5,000 5 Jasa Pelayanan 8,750 8,750 17,500 B Pasien Baru 1 Format 11,750 11,750 23,500 2 Gelang 2,500 2,500 5,000 3 Jasa Pelayanan 17,500 17,500 35,000 JASA SARANA JASA PELAYANAN
1. 1.Isi Ulang Tabung Gas Medik (O2) Tabung 6 M³ 67,500Rp 67,500Rp 135,000Rp 2 Isi Ulang Tabung Gas Medik (O2) Tabung 3 M³ 33,750Rp 33,750Rp 67,500Rp 3 Isi Ulang Tabung Gas Medik (O2) Tabung 2 M³ 28,750Rp 28,750Rp 57,500Rp 4 Isi Ulang Tabung Gas Medik (O2) Tabung 1 M³ 23,750Rp 23,750Rp 47,500Rp JASA SARANA JASA PELAYANAN
2. 1.(O2) Tabung 6 M³/Liter 100Rp 100Rp 200Rp 2 (O2) Tabung 3 M³/Liter 100Rp 100Rp 200Rp
3. 3.TARIF LAUNDRY 1 Mencuci 3,000Rp 3,000Rp 6,000Rp 2 Setrika 3,000Rp 3,000Rp 6,000Rp 3 Cuci + Setrika 3,500Rp 3,500Rp 7,000Rp 4 Ekspers 4,500Rp 4,500Rp 9,000Rp 5 Boneka Kecil 8,000Rp 8,000Rp 16,000Rp Sedang 10,000Rp 10,000Rp 20,000Rp Besar 11,500Rp 11,500Rp 23,000Rp Jumbo/ Besar sekali 12,500Rp 12,500Rp 25,000Rp 6 Selimut Tipis Kecil 7,500Rp 7,500Rp 15,000Rp besar 9,000Rp 9,000Rp 18,000Rp 7 Selimut Tebal Kecil 14,000Rp 14,000Rp 28,000Rp Besar 15,000Rp 15,000Rp 30,000Rp 8 Bed Cover Singel 12,500Rp 12,500Rp 25,000Rp Quen 14,000Rp 14,000Rp 28,000Rp king 15,000Rp 15,000Rp 30,000Rp NO URAIAN SARANA PELAYAN JUMLAH IV. PENUNJANG NON MEDIS
4. 1.REKAM MEDIK 2.UNIT GAS MEDIK NO JENIS PELAYANAN TARIF JUMLAH TARIF JUMLAH
b.Tarif Penggunaan O2
a.Tarif Isi Ulanf Tabung Gas Medik NO JENIS PELAYANAN 9 Bantal Kecil 1,500Rp 1,500Rp 3,000Rp Besar 2,000Rp 2,000Rp 4,000Rp 1 PEMPROSESAN ALAT DAN STERILISASI SET INSTRUMEN INSTRUMEN KECIL 35,000 35,000 70,000 2 PEMPROSESAN ALAT DAN STERILISASI SET INSTRUMEN INSTRUMEN SEDANG 87,500 87,500 175,000 3 PEMPROSESAN ALAT DAN STERILISASI SET INSTRUMEN INSTRUMEN BESAR 122,500 122,500 245,000 4 PEMPROSESAN ALAT DAN STERILISASI SET INSTRUMEN INSTRUMEN KHUSUS 122,500 122,500 245,000 5 PEMPROSESAN ALAT PER SATUAN 4,900 4,900 9,800 6 PEMILAHAN, PENIMBANGAN,PENCUCIAN, PENGERINGAN DAN PENDISTIBUSIAN (NON INFEKSIUS) PER KG 5,000 5,000 10,000 7 PEMILAHAN, PENIMBANGAN,PENCUCIAN, PENGERINGAN DAN PENDISTIBUSIAN (INFEKSIUS) PER KG 12,500 12,500 25,000 8 LINEN s/d 5 KG 7,500 7,500 15,000 9 LINEN DIATAS 5 KG TAMBAHAN PER KG 1,750 1,750 3,500 10 STERILISASI KASA (PAKET) 7,500 7,500 15,000 5 TARIF PARKIRAN A. TARIF PARKIR MOBIL NO TARIF PARKIRAN MOBIL JASA SARANA JASA PELAYANAN JUMLAH 1 2 (Dua) Jam pertama 2,800Rp 1,200Rp 4,000Rp 2 setiap jam berikutnya 1,400Rp 600Rp 2,000Rp 3 paket sehari 11,200Rp 4,800Rp 16,000Rp 4 paket rawat inap 31,500Rp 13,500Rp 45,000Rp 5 Maksimal Drpff off 5 menit Rp. 0,- B. TARIF PARKIR MOTOR NO TARIF PARKIRAN MOTOR JASA SARANA JASA PELAYANAN JUMLAH 1 2 (Dua) Jam pertama 1,400Rp 600Rp 2,000Rp 2 setiap jam berikutnya 700Rp 300Rp 1,000Rp 3 paket sehari 5,600Rp 2,400Rp 8,000Rp 4 paket rawat inap 14,000Rp 6,000Rp 20,000Rp 5 Maksimal Drpff off 5 menit Rp. 0,- 4.TARIF PELAYANAN CSSD Pj. GUBERNUR SULAWESI BARAT, ttd AKMAL MALIKSalinan Sesuai Dengan Aslinya KEPALA BIRO HUKUM, ttd Dr. SUYUTI MARZUKI, SPi, MT, M.Sc Pangkat : Pembina Tk.I/IV.b NIP. : 19690820 199903 1 005

Peraturan Gubernur (PERGUB) Provinsi Sulawesi Barat Nomor 31 Tahun 2022

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Peraturan Gubernur (PERGUB) Provinsi Sulawesi Barat Nomor 4 Tahun 2021