LAMPIRAN I

PERATURAN WALIKOTA LUBUKLINGGAU

TAHUN NOMOR
TENTANG TARIF PELAYANAN KESEHATAN
PADA RUMAH SAKIT UMUM DAERAH
SITI AISYAH KOTA LUBUKLINGGAU

TARIF PELAYANAN KESEHATAN PADA

RUMAH SAKIT UMUM DAERAH SITI AISYAH KOTA LUBUKLINGGAU

A. TARIF PELAYANAN RAWAT JALAN (KLINIK SPESIALIS)

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
Medis Non Medis
No. Jenis Pelayanan medis Tarif

40%
60%
70% 25% 5%
1 PEMERIKSAAN RAWAT JALAN
1 Administrasi 15,000
2 Rawat Jalan Tingkat I
(Dokter Umum dan Dokter Gigi) 27,000 12,600 4,500 900 45,000
3 Rawat Jalan tingkat II
(Dokter Spesialis/Ahli) 48,000 22,400 8,000 1,600 80,000

2 TARIF TINDAKAN RAWAT JALAN (KLINIK SPESIALIS)

2.1 Klinik Mata
a. Pemeriksaan Rutin
1 Tonometri 42,000 15,400 9,800 2,800 70,000
2 Visus/Refraksi 18,000 6,600 4,200 1,200 30,000
3 Auto Refraktometer 72,000 26,400 16,800 4,800 120,000
4 Koreksi 18,000 6,600 4,200 1,200 30,000
5 Anel Tes 49,500 18,150 11,550 3,300 82,500
6 Slit Lamps 36,000 13,200 8,400 2,400 60,000
7 Funduscopy 18,000 6,600 4,200 1,200 30,000
8 Compusvisi 18,000 6,600 4,200 1,200 30,000
9 Fluorescent Test 36,000 13,200 8,400 2,400 60,000
10 Kantopeksi/Tarsoraphy/Tarsotomi 48,000 17,600 11,200 3,200 80,000
11 Perimetri 48,000 17,600 11,200 3,200 80,000
12 Ishihara Test 18,000 6,600 4,200 1,200 30,000

b. Pemeriksaan Tambahan
1 Streak Retinoskopi 27,000 9,900 6,300 1,800 45,000
2 Water Drinking Test 15,000 5,500 3,500 1,000 25,000

c. Pemeriksaan Khusus
1 Kontak Lens 24,000 8,800 5,600 1,600 40,000
2 Geneoskopi 30,000 11,000 7,000 2,000 50,000
3 Keratometri 60,000 22,000 14,000 4,000 100,000
4 Biometri 60,000 22,000 14,000 4,000 100,000
5 USG Mata Per 1 Mata 60,000 22,000 14,000 4,000 100,000

d. Tindakan Sederhana
1 Epilasi Bulu Mata 45,000 16,500 10,500 3,000 75,000
2 Epilasi Trichiasis 45,000 16,500 10,500 3,000 75,000
3 Irigasi Trauma Kimia 21,000 7,700 4,900 1,400 35,000
4 Angkat Jahitan 21,000 7,700 4,900 1,400 35,000
5 Perawatan Pre Operasi Katarak 24,000 8,800 5,600 1,600 40,000
6 GV post operasi 21,000 7,700 4,900 1,400 35,000

e. Tindakan Kecil

1 Insisi Hordeolum 171,000 62,700 39,900 11,400 285,000

2 Insisi Granuloma 171,000 62,700 39,900 11,400 285,000
3 Spooling Bethadine Mata 48,000 17,600 11,200 3,200 80,000
4 Exterpasi Corpus Alienum Conjungtiva 90,000 33,000 21,000 6,000 150,000
5 Exterpasi Corpus Alienum Kornea 90,000 33,000 21,000 6,000 150,000
6 Exterpasi Pterigium 240,000 88,000 56,000 16,000 400,000

Page 1
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
Medis Non Medis
No. Jenis Pelayanan medis Tarif

40%
60%
70% 25% 5%
7 Exterpasi Xatelasma 150,000 55,000 35,000 10,000 250,000
8 Exterpasi Kista 150,000 55,000 35,000 10,000 250,000
9 Insisi Abses Palpebra 45,000 16,500 10,500 3,000 75,000
10 Jahit Luka Kecil Palpebra 60,000 22,000 14,000 4,000 100,000
11 Operasi Sebelum Entropion 60,000 22,000 14,000 4,000 100,000
12 Repair Konjungtiva 372,000 136,400 86,800 24,800 620,000
13 Ekstraksi Miliu/Moluskum 48,000 17,600 11,200 3,200 80,000
14 Probing Ductus Nasolacrimalis 72,000 26,400 16,800 4,800 120,000
15 Graft Amnion 192,000 70,400 44,800 12,800 320,000
16 Repair Rupture pelpebra 372,000 136,400 86,800 24,800 620,000
17 Litiasis 42,000 15,400 9,800 2,800 70,000
18 Pterigium 120,000 44,000 28,000 8,000 200,000

2.2 Klinik THT

1 Audiologi Nada Murni 72,000 26,400 16,800 4,800 120,000
2 Tympanometri 72,000 26,400 16,800 4,800 120,000
3 OAE 72,000 26,400 16,800 4,800 120,000
4 Tes Keseimbangan Sederhana 72,000 26,400 16,800 4,800 120,000
5 Irigasi Liang Telinga/Spooling (Satu Telinga) 72,000 26,400 16,800 4,800 120,000
6 Ekstraksi benda asing liang telinga 90,000 33,000 21,000 6,000 150,000
7 Insisi Abses 150,000 55,000 35,000 10,000 250,000
8 Biopsi Otologi 120,000 44,000 28,000 8,000 200,000
9 Ekstraksi Jaringan Granulasi 90,000 33,000 21,000 6,000 150,000
10 Parasintesis 120,000 44,000 28,000 8,000 200,000
11 Otomikroskopi Diagnostik 75,000 27,500 17,500 5,000 125,000
12 Ear Toilet Per Telinga 60,000 22,000 14,000 4,000 100,000
13 Benda Asing dengan Penyulit 120,000 44,000 28,000 8,000 200,000
14 Ambil Bahan Kultur 75,000 27,500 17,500 5,000 125,000
15 Ekstraksi benda asing telinga dengan penyulit 150,000 55,000 35,000 10,000 250,000
16 Kaustik jaringan Granulasi 75,000 27,500 17,500 5,000 125,000
17 Ekstraksi Serumen Per Telinga 72,000 26,400 16,800 4,800 120,000
18 Ekstraksi Serumen dengan Penyulit Per Telinga 102,000 37,400 23,800 6,800 170,000
19 Pasang Tampon Anterior 120,000 44,000 28,000 8,000 200,000
20 Pasang Tampon Posterior 150,000 55,000 35,000 10,000 250,000
21 Angkat Tampon Anterior 90,000 33,000 21,000 6,000 150,000
22 Angkat Tampon Posterior 120,000 44,000 28,000 8,000 200,000
23 Kaustik hidung 60,000 22,000 14,000 4,000 100,000
24 Ekstraksi Benda Asing Hidung 105,000 38,500 24,500 7,000 175,000
25 Nasoendoskopi 120,000 44,000 28,000 8,000 200,000
26 Nasoendoskopi dengan Tindakan 240,000 88,000 56,000 16,000 400,000
27 Penatalaksanaan Epistaksis 150,000 55,000 35,000 10,000 250,000
28 Insisi Abses / Hematum Septum 120,000 44,000 28,000 8,000 200,000
29 Insisi Abses Peritonsil 180,000 66,000 42,000 12,000 300,000
30 Biopsi Tumor Oral Cavity 240,000 88,000 56,000 16,000 400,000
31 Pasang NGT 120,000 44,000 28,000 8,000 200,000
32 Kaustik Faring 90,000 33,000 21,000 6,000 150,000
33 Nasolaringoskopi 90,000 33,000 21,000 6,000 150,000
34 Pseudoksia THT dengan gips 180,000 66,000 42,000 12,000 300,000
35 Injeksi Kenacort THT 90,000 33,000 21,000 6,000 150,000
36 Tampon telinga 72,000 26,400 16,800 4,800 120,000
37 Tes Fungsi Pendengaran 72,000 26,400 16,800 4,800 120,000
38 Irigasi Sinus 150,000 55,000 35,000 10,000 250,000
39 Penutupan Stoma Trakeostomi 120,000 44,000 28,000 8,000 200,000
40 Tes Fungsi N VII 120,000 44,000 28,000 8,000 200,000
41 Tes Perala 60,000 22,000 14,000 4,000 100,000
42 Cuci Kanul Trakeostomi 72,000 26,400 16,800 4,800 120,000
43 Cuci Luka (Operasi Hidung/Telinga) 60,000 22,000 14,000 4,000 100,000
44 Angkat NGT 72,000 26,400 16,800 4,800 120,000
45 Ganti Verban/Drain 72,000 26,400 16,800 4,800 120,000

Page 2
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
Medis Non Medis
No. Jenis Pelayanan medis Tarif
40%
60%
70% 25% 5%
46 Angkat Jahitan Operasi 60,000 22,000 14,000 4,000 100,000
47 Ekstraksi Benda Asing Mulut 72,000 26,400 16,800 4,800 120,000
48 Ekstraksi Benda Asing Tonsil-Faring 90,000 33,000 21,000 6,000 150,000
49 Ekstraksi Benda Asing Tonsil-Faring dengan 120,000 44,000 28,000 8,000 200,000
Endoskopi
50 Tindik Telinga 72,000 26,400 16,800 4,800 120,000
51 Biopsi Telinga Luar 90,000 33,000 21,000 6,000 150,000
52 Incisi abses per auricular 120,000 44,000 28,000 8,000 200,000
53 Ekstraksi Kolesteatum Eksterna 120,000 44,000 28,000 8,000 200,000
54 Incisi abses retro auricula 150,000 55,000 35,000 10,000 250,000
55 Ekstraksi Massa Hidung 150,000 55,000 35,000 10,000 250,000

56 Biopsi Hidung 150,000 55,000 35,000 10,000 250,000

57 Eksisi lesi hidung lainnya (sinenia, pelebaran ostium) 150,000 55,000 35,000 10,000 250,000
58 Jahit luka hidung 120,000 44,000 28,000 8,000 200,000

59 Antrostomi 360,000 132,000 84,000 24,000 600,000

60 Biopsi Lidah 150,000 55,000 35,000 10,000 250,000

2.3 Klinik Kebidanan dan Kandungan

a. Pelayanan Kebidanan dan Kandungan
1 Heating perineum 49,500 18,150 11,550 3,300 82,500
2 Pengambilan spesimen untuk Pap Smear 33,000 12,100 7,700 2,200 55,000
3 GV post operasi 18,000 6,600 4,200 1,200 30,000
4 Bilas vagina 46,200 16,940 10,780 3,080 77,000
5 Periksa Dalam 46,200 16,940 10,780 3,080 77,000
6 Inspekulo 46,200 16,940 10,780 3,080 77,000
7 Tindakan Medis Sedang 46,200 16,940 10,780 3,080 77,000
8 SIS 540,000 198,000 126,000 36,000 900,000
9 Transvaginal 120,000 44,000 28,000 8,000 200,000
10 USG 4 Dimensi 120,000 44,000 28,000 8,000 200,000
11 Rectal Touch 46,200 16,940 10,780 3,080 77,000
12 Vulpa Hygiene 30,000 11,000 7,000 2,000 50,000
13 Biopsi Servic 270,000 99,000 63,000 18,000 450,000
14 Angkat Jahitan Perineum 18,000 6,600 4,200 1,200 30,000
15 Kuldo Synthesis 72,000 26,400 16,800 4,800 120,000
16 Imunisasi Ibu Hamil 18,000 6,600 4,200 1,200 30,000
21 Kolposkopi 276,000 101,200 64,400 18,400 460,000

22 Krioteraphy 306,000 112,200 71,400 20,400 510,000

25 ANC Kebidanan 60,000 22,000 14,000 4,000 100,000
b. Pelayanan Keluarga Berencana
1 Suntik KB (termasuk BHP dan obat) 15,000 5,500 3,500 1,000 25,000
2 Pasang implant 180,000 66,000 42,000 12,000 300,000
3 Buka Implant 90,000 33,000 21,000 6,000 150,000
4 Pasang IUD 180,000 66,000 42,000 12,000 300,000
5 Buka IUD 150,000 55,000 35,000 10,000 250,000

2.4 Klinik Anak

1 Nebulizer Anak 51,000 18,700 11,900 3,400 85,000
2 EKG Anak 51,000 18,700 11,900 3,400 85,000
3 USG Anak 90,000 33,000 21,000 6,000 150,000
4 Tes Mantoux/PPD Tes 36,000 13,200 8,400 2,400 60,000
5 Tindik 15,000 5,500 3,500 1,000 25,000

6 Vaksinasi BCG/DPT/Hepatitis B/Polio/Campak 60,000 22,000 14,000 4,000 100,000

2.5 Tindakan Medis Poliklinik Gigi dan Mulut

a. Tindakan Poliklinik Gigi
1 Odontektomi Klas I 600,000 220,000 140,000 40,000 1,000,000

2 Odontektomi Klas II 900,000 330,000 210,000 60,000 1,500,000

3 Odontektomi Klas III 1,200,000 440,000 280,000 80,000 2,000,000

Page 3
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis

40%
60%
70% 25% 5%
4 Eksisi Tumor I 600,000 220,000 140,000 40,000 1,000,000

5 Eksisi Tumor II 900,000 330,000 210,000 60,000 1,500,000

6 Eksisi Tumor III 1,200,000 440,000 280,000 80,000 2,000,000

7 Ekstirpasi Mucocele I 240,000 88,000 56,000 16,000 400,000

8 Ekstirpasi Mucocele II 300,000 110,000 70,000 20,000 500,000

9 Ekstirpasi Mucocele III 360,000 132,000 84,000 24,000 600,000

10 Alveolectomi per gigi 300,000 110,000 70,000 20,000 500,000

11 Reposisi Fiksasi per gigi 90,000 33,000 21,000 6,000 150,000

12 Insisi abses Intra Oral 60,000 22,000 14,000 4,000 100,000

13 Insisi abses Ekstra Oral 72,000 26,400 16,800 4,800 120,000

14 Insisi Mukokal Kecil 72,000 26,400 16,800 4,800 120,000

15 Insisi Mukokal Besar 84,000 30,800 19,600 5,600 140,000

16 Bongkar Tambalan 30,000 11,000 7,000 2,000 50,000

17 Scaling per Rahang 75,000 27,500 17,500 5,000 125,000

18 Tambalan Sementara 36,000 13,200 8,400 2,400 60,000

19 Tambalan GIC Kecil dan Sedang 36,000 13,200 8,400 2,400 60,000

20 Tambalan GIIC Besar 43,200 15,840 10,080 2,880 72,000

21 Tambalan Light Curing Kecil dan Sedang 54,000 19,800 12,600 3,600 90,000

22 Tambalan Light curing Besar 60,000 22,000 14,000 4,000 100,000

23 Ekstraksi tetap 42,000 15,400 9,800 2,800 70,000

24 Ekstraksi komplikasi 90,000 33,000 21,000 6,000 150,000

25 Ekstraksi gigi susu tanpa injeksi 18,000 6,600 4,200 1,200 30,000

26 Ekstraksi gigi susu dengan injeksi 24,000 8,800 5,600 1,600 40,000

27 Fiksasi fraktur per gigi 60,000 22,000 14,000 4,000 100,000

28 Jacket Crown 150,000 55,000 35,000 10,000 250,000

29 Overculectomi 180,000 66,000 42,000 12,000 300,000

b. Aplikasi Gigi Tiruan

1. Gigi Lepasan
a. Akrilik Gigi pertama (diluar Lab gigi) 72,000 26,400 16,800 4,800 120,000
b. Akrilik Gigi berikut (diluar Lab gigi) 30,000 11,000 7,000 2,000 50,000
2. Gigi Tiruan Logam
a. Gigi pertama (diluar Lab gigi) 108,000 39,600 25,200 7,200 180,000
b. Gigi berikut (diluar Lab gigi) 42,000 15,400 9,800 2,800 70,000

3. Gigi cekat
a. Akrilik satu gigi (diluar Lab gigi) 120,000 44,000 28,000 8,000 200,000
b. Akrilik backing logam (diluar Lab gigi) 30,000 11,000 7,000 2,000 50,000

c. Porselen satu gigi (diluar Lab gigi) 180,000 66,000 42,000 12,000 300,000
d. Pin (diluar Lab gigi) 36,000 13,200 8,400 2,400 60,000
e. Pin crown porselen (diluar Lab gigi) 252,000 92,400 58,800 16,800 420,000
f. Pin crown cobalt (diluar Lab gigi) 54,000 19,800 12,600 3,600 90,000
4. Gigi tiruan penuh

a. Akrilik rahang per rahang (diluar Lab 480,000 176,000 112,000 32,000 800,000
gigi)
b. Akrilik kasus flabby (diluar Lab gigi) 570,000 209,000 133,000 38,000 950,000
c. Akrilik kasus flat (diluar Lab gigi) 720,000 264,000 168,000 48,000 1,200,000
d. Logam Rahang (diluar Lab gigi) 720,000 264,000 168,000 48,000 1,200,000
e. Logam per Rahang (diluar Lab gigi) 372,000 136,400 86,800 24,800 620,000
5. Obturator (diluar lab gigi) 108,000 39,600 25,200 7,200 180,000
6. Feeding Plate 42,000 15,400 9,800 2,800 70,000
7. Reparasi

Page 4
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
Medis Non Medis
No. Jenis Pelayanan medis Tarif

40%
60%
70% 25% 5%
a. Rebasing 30,000 11,000 7,000 2,000 50,000
b. Relining 42,000 15,400 9,800 2,800 70,000
c. Retak/patah 21,000 7,700 4,900 1,400 35,000
8. Perawatan jaringan lunak dan syaraf
a. kuretase per regio 48,000 17,600 11,200 3,200 80,000
b. extirpasi / kunjungan 60,000 22,000 14,000 4,000 100,000
c. Gingivectomy per gigi 72,000 26,400 16,800 4,800 120,000
d. root canal filling 60,000 22,000 14,000 4,000 100,000
e. Devitec/ Mematikan saraf gigi 48000 17600 11200 3200 80000
f. Dressing atau sterilisasi saluran akar 48000 17600 11200 3200 80000

2.6 Klinik Bedah

1 Angkat Jahitan 60,000 22,000 14,000 4,000 100,000
2 Ganti verban besar 36,000 13,200 8,400 2,400 60,000
3 Ganti verban kecil 30,000 11,000 7,000 2,000 50,000
4 Pasang kateter 36,000 13,200 8,400 2,400 60,000
5 Up Kateter 24,000 8,800 5,600 1,600 40,000
6 WT Luka Bakar < 10% 21,000 7,700 4,900 1,400 35,000
7 WT Luka Bakar 10 -20% 30,000 11,000 7,000 2,000 50,000
8 WT Luka Bakar > 20% 60,000 22,000 14,000 4,000 100,000
9 Nekrotomi Sedang 48,000 17,600 11,200 3,200 80,000
10 Nekrotomi Kecil 30,000 11,000 7,000 2,000 50,000
2.7 Klinik Penyakit Dalam
1 USG Lutut 120,000 44,000 28,000 8,000 200,000
2 Injeksi Intra Astivuler 108,000 39,600 25,200 7,200 180,000
3 Aspirasi Cairan Sendi 108,000 39,600 25,200 7,200 180,000
4 Echocardiography Hitam Putih 180,000 66,000 42,000 12,000 300,000
5 USG Abdomen/TUG Hitam Putih 150,000 55,000 35,000 10,000 250,000
6 USG Abdomen Berwarna 150,000 55,000 35,000 10,000 250,000
7 Echocardiography Berwarna 180,000 66,000 42,000 12,000 300,000
8 Carotis Echocardiography 180,000 66,000 42,000 12,000 300,000
9 EKG 45,000 16,500 10,500 3,000 75,000
10 Nebulizer Dewasa 42,000 15,400 9,800 2,800 70,000
11 Spirometri 90,000 33,000 21,000 6,000 150,000
12 Treadmill Test 255,000 93,500 59,500 17,000 425,000
13 USG Mamae 150,000 55,000 35,000 10,000 250,000
14 USG Tiroid 150,000 55,000 35,000 10,000 250,000
15 USG Musculoskeletal 150,000 55,000 35,000 10,000 250,000
16 Echocardiography Vertebralis 210,000 77,000 49,000 14,000 350,000
2.8 Klinik Kulit dan Kelamin
1 Eksplorasi luka kecil 60,000 22,000 14,000 4,000 100,000
2 Debridement Luka Kecil 60,000 22,000 14,000 4,000 100,000
3 Debridement Luka Luas 75,000 27,500 17,500 5,000 125,000
4 Aspirasi Pseudo Kista 60,000 22,000 14,000 4,000 100,000
5 Bedah Sayat Biopsi Kelenjar 168,000 61,600 39,200 11,200 280,000
6 Bedah Sayat Ekscisi 168,000 61,600 39,200 11,200 280,000
7 Tutul Fenol 30% 60,000 22,000 14,000 4,000 100,000
8 Tutul Fenol Tinctura 60,000 22,000 14,000 4,000 100,000
9 Tutul Tinctural Piodophylin 60,000 22,000 14,000 4,000 100,000

10 Bedah Listrik Lokasi Sedikit 120,000 44,000 28,000 8,000 200,000

11 Bedah Listrik Lokasi Banyak 150,000 55,000 35,000 10,000 250,000
12 Bedah Cutting Sedikit 120,000 44,000 28,000 8,000 200,000
13 Bedah Listrik Cutting Banyak (Veruka) 150,000 55,000 35,000 10,000 250,000
14 Flap Graf Kecil 2,700,000 990,000 630,000 180,000 4,500,000
15 Flap Graf Besar/Luas 3,450,000 1,265,000 805,000 230,000 5,750,000
16 Injeksi Intralesi Keloid Sedikit 60,000 22,000 14,000 4,000 100,000
17 Injeksi Intralesi Keloid Banyak 90,000 33,000 21,000 6,000 150,000
18 Ekstraksi Kuku 270,000 99,000 63,000 18,000 450,000
19 Bedah Sayat Enukleasi/Enukleasi moluskum 90,000 33,000 21,000 6,000 150,000
kontagiosum,

Page 5
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
Medis Non Medis
No. Jenis Pelayanan medis Tarif Baru
40%
60%
70% 25% 5%
20 Operasi keloid cuping telinga 120,000 44,000 28,000 8,000 200,000
21 Chlorethyl Spray (Bedah Kuku) 60,000 22,000 14,000 4,000 100,000
22 Eksterpasi Atheoma, Lipoma, Nevus 720,000 264,000 168,000 48,000 1,200,000
23 Xanteplasma Banyak 900,000 330,000 210,000 60,000 1,500,000
24 Eksterpasi xantelasma Sedikit 720,000 264,000 168,000 48,000 1,200,000
25 Anestesi Block 60,000 22,000 14,000 4,000 100,000
26 Anestesi Tumeseent 90,000 33,000 21,000 6,000 150,000
27 Perawatan kulit skin care, 90,000 33,000 21,000 6,000 150,000
28 Feeling superfisialis 120,000 44,000 28,000 8,000 200,000
2.9 KLINIK SYARAF
1 Injeksi Lokal 90,000 33,000 21,000 6,000 150,000
2 Injeksi Khusus 132,000 48,400 30,800 8,800 220,000
3 Lumbal Fungsi Diagnostik 210,000 77,000 49,000 14,000 350,000
4 Pemeriksaan Perpirasi 132,000 48,400 30,800 8,800 220,000
5 Pembacaan EEG 42,000 15,400 9,800 2,800 70,000
6 Pembacaan EMG 42,000 15,400 9,800 2,800 70,000
7 Injeksi Vitamin 12,000 4,400 2,800 800 20,000

2.10 KLINIK PARU

1 Spirometri 156,540 57,398 36,526 10,436 260,900
2 Spirometri + DLCO 510,240 187,088 119,056 34,016 850,400
3 Bodypletysmograph 510,240 187,088 119,056 34,016 850,400
4 Bronchial provocation test 474,120 173,844 110,628 31,608 790,200
5 Cardiopulmonary exercise test 951,600 348,920 222,040 63,440 1,586,000
6 Terapi inhalasi 153,000 56,100 35,700 10,200 255,000
7 Uji jalan 6 menit 75,000 27,500 17,500 5,000 125,000
8 Polisomnogram (sleep test) 930,960 341,352 217,224 62,064 1,551,600
9 Pungsi pleura 414,480 151,976 96,712 27,632 690,800
10 Torakoskopi 1,750,200 641,740 408,380 116,680 2,917,000
11 Mediastinoskopi 1,750,200 641,740 408,380 116,680 2,917,000
12 USG thoraks 296,340 108,658 69,146 19,756 493,900
13 Biopsi jarum halus/ FNAB 353,400 129,580 82,460 23,560 589,000
14 Biopsi pleura 473,700 173,690 110,530 31,580 789,500
15 Water Sealed Drainage 824,580 302,346 192,402 54,972 1,374,300
16 Pigtail (chest tube insertion) 824,580 302,346 192,402 54,972 1,374,300
17 Cabut selang WSD/ pigtail 207,660 76,142 48,454 13,844 346,100
18 Pleurodesis 414,960 152,152 96,824 27,664 691,600
19 Pleurodesis pada pneumotoraks 414,960 152,152 96,824 27,664 691,600
20 Irigasi pleura 414,960 152,152 96,824 27,664 691,600
21 TTNA (transthoracal needle aspiration) 669,360 245,432 156,184 44,624 1,115,600
22 Biopsi paru dengan jarum core 940,200 344,740 219,380 62,680 1,567,000
23 Bronkoskopi 852,300 312,510 198,870 56,820 1,420,500
24 Bronkoskopi rigid 1,050,600 385,220 245,140 70,040 1,751,000
25 Bronkoskopi dengan sikatan, bilasan, biopsi 852,300 312,510 198,870 56,820 1,420,500
26 Bronkoskopi dengan Bronchoalveolar lavage 852,300 312,510 198,870 56,820 1,420,500
27 Bronkoskopi TBLB, TBNA, biopsy Ebus 1,050,600 385,220 245,140 70,040 1,751,000
28 Bronkoskopi Lung Volume Reduction 1,389,000 509,300 324,100 92,600 2,315,000
29 Bronkoskopi + pemasangan katup bronkus 1,389,000 509,300 324,100 92,600 2,315,000
30 Bronkoskopi + ekstraksi benda asing 1,050,600 385,220 245,140 70,040 1,751,000
31 Bronkoskopi + pemasangan stent 1,350,600 495,220 315,140 90,040 2,251,000
32 Bronkoskopi + Laser atau Cryo, Kauter 1,389,000 509,300 324,100 92,600 2,315,000
33 Bronkoskopi + toilette 852,300 312,510 198,870 56,820 1,420,500
34 Bronkoskopi + whole lung lavage 998,700 366,190 233,030 66,580 1,664,500
35 Bronkoskopi + prosedur lainnya 998,700 366,190 233,030 66,580 1,664,500
36 Intermittent positive pressure breathing (IPPB) 333,780 122,386 77,882 22,252 556,300
37 Non Invasive ventilation 333,780 122,386 77,882 22,252 556,300
38 Continuous positive airway pressure (CPAP) 513,780 188,386 119,882 34,252 856,300
39 Continuous negative pressure ventilation (CNP) 333,780 122,386 77,882 22,252 556,300
40 Postural drainage 333,780 122,386 77,882 22,252 556,300
41 Pemeriksaan NO udara ekspirasi 240,000 88,000 56,000 16,000 400,000
42 Pemeriksaan CO udara ekspirasi 60,000 22,000 14,000 4,000 100,000

Page 6
B. PELAYANAN GAWAT DARURAT
Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif Baru
medis
40%
60%
70% 25% 5%
1 PEMERIKSAAN RAWAT JALAN
1 Administrasi 15,000
2 Dokter Rawat Darurat/IGD 27,000 12,600 4,500 900 45,000

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif Baru
medis
40%
60%
55% 35% 10%
2 TINDAKAN MEDIS RAWAT DARURAT
1 Injeksi IM/IV/SC 18,000 6,600 4,200 1,200 30,000
2 Pasang Infus 18,000 6,600 4,200 1,200 30,000
3 Heacting Kecil 1-6 Jahitan 48,000 17,600 11,200 3,200 80,000
4 Heacting Sedang 7-20 Jahitan 102,000 37,400 23,800 6,800 170,000
5 Heacting Besar > 20 Jahitan 192,000 70,400 44,800 12,800 320,000
6 Hecting Rekonstruksi 108,000 39,600 25,200 7,200 180,000
7 Hecting Luka Episiotomi 90,000 33,000 21,000 6,000 150,000
8 Hecting Sambung Tendon Kecil < 5 tendon 120,000 44,000 28,000 8,000 200,000
9 Hecting Sambung Tendon Kecil > 5 tendon 180,000 66,000 42,000 12,000 300,000
10 Necrotomi Jaringan 30,000 11,000 7,000 2,000 50,000
11 Debridement Luka Kecil 9,000 3,300 2,100 600 15,000
12 Debridement Luka Luas 30,000 11,000 7,000 2,000 50,000
13 Debridement Gigitan Binatang 30,000 11,000 7,000 2,000 50,000
14 Doopler Per Kali 18,000 6,600 4,200 1,200 30,000
15 Ganti verban ringan < 5 Jahitan 18,000 6,600 4,200 1,200 30,000
16 Ganti verban Sedang 6 s/d 15 Jahitan 27,000 9,900 6,300 1,800 45,000
17 Ganti verban Besar > 15 Jahitan 36,000 13,200 8,400 2,400 60,000
18 Angkat Jahitan < 5 Jahitan 24,000 8,800 5,600 1,600 40,000
19 Angkat Jahitan > 5 Jahitan 60,000 22,000 14,000 4,000 100,000
20 Insisi Abses Ringan 31,200 11,440 7,280 2,080 52,000
21 Insisi Abses Besar 54,000 19,800 12,600 3,600 90,000
22 Cross Insisi 36,000 13,200 8,400 2,400 60,000
23 Eksterpasi Corpus Alineum THT 48,000 17,600 11,200 3,200 80,000
24 Eksterpasi Corpus Alineum Mata/Tubuh 42,000 15,400 9,800 2,800 70,000
25 Vena Sectie 150,000 55,000 35,000 10,000 250,000
26 Tracheostomi 216,000 79,200 50,400 14,400 360,000
27 Punctie Peritoneal 216,000 79,200 50,400 14,400 360,000
28 Sircumsisi Tanpa Penyulit 210,000 77,000 49,000 14,000 350,000

29 Sircumsisi Dengan Penyulit 360,000 132,000 84,000 24,000 600,000

30 Sirkumsisi dengan couterisasi 300,000 110,000 70,000 20,000 500,000
31 Pasang Kateter 36,000 13,200 8,400 2,400 60,000
32 Buka Kateter 16,500 6,050 3,850 1,100 27,500
33 Pasang NGT 33,000 12,100 7,700 2,200 55,000
34 Pemasangan ETT 159,000 58,300 37,100 10,600 265,000
35 Pasang Splaks Tangan 54,000 19,800 12,600 3,600 90,000
36 Pasang Splaks Kaki 82,500 30,250 19,250 5,500 137,500
36 Pasang Splaks Kaki 82,500 30,250 19,250 5,500 137,500
37 Gips Sirculer Atas 78,000 28,600 18,200 5,200 130,000
38 Gips Sirculer Bawah 78,000 28,600 18,200 5,200 130,000

39 Pemasangan Elastic Verban 18,000 6,600 4,200 1,200 30,000

40 Pemasangan Ransel Verban 30,000 11,000 7,000 2,000 50,000

41 Resusitasi Jantung Paru 96,000 35,200 22,400 6,400 160,000
42 Nebulizer Per Kali 39,000 14,300 9,100 2,600 65,000
43 Bilas Lambung/Usus 99,000 36,300 23,100 6,600 165,000
48 WT Luka Bakar < 10% 12,000 4,400 2,800 800 20,000
49 WT Luka Bakar 10 -20% 18,000 6,600 4,200 1,200 30,000
50 WT Luka Bakar > 20% 36,000 13,200 8,400 2,400 60,000
51 Suction Per Kali 6,000 2,200 1,400 400 10,000
52 Rectal/Vaginal Toucher 18,600 6,820 4,340 1,240 31,000
53 Inspeculo/Periksa Dalam 27,000 9,900 6,300 1,800 45,000
54 Pemasangan Ventilator 120,000 44,000 28,000 8,000 200,000
55 Pemakaian Monitor Vital Sign Per 3 jam 12,000 4,400 2,800 800 20,000

Page 7
 56 Supra Pubic Punctie (SPP) 46,200 16,940 10,780 3,080 77,000
57 Tampon Epistaksis (Vaselin) 52,800 19,360 12,320 3,520 88,000
58 Tampon Epistaksis (Adrenalin) 52,800 19,360 12,320 3,520 88,000

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
Medis Non Medis
No. Jenis Pelayanan medis Tarif Baru
40%
60%
70% 25% 5%
59 Amputasi 1 jari Ekstremitas 100,000 55,000 35,000 10,000 250,000
60 Angkat Peluru / gram 96,000 35,200 22,400 6,400 160,000
61 Angkat CA Pada Telinga / Hidung 51,000 18,700 11,900 3,400 85,000
62 Angkat CA Gram Pada Mata 51,000 18,700 11,900 3,400 85,000
63 Angkat CA Tulang 60,000 22,000 14,000 4,000 100,000
64 Exsplorasi Tusukan Paku 33,000 12,100 7,700 2,200 55,000
65 DC Shock 60,000 22,000 14,000 4,000 100,000
66 Rangsang Muntah 60,000 22,000 14,000 4,000 100,000
67 Nagel Bor 30,000 11,000 7,000 2,000 50,000
68 Pemasangan Mitela 18,000 6,600 4,200 1,200 30,000
69 Cervikal Coller 66,000 24,200 15,400 4,400 110,000
70 Tes ATS / ABU / SAR 18,000 6,600 4,200 1,200 30,000
71 TT 0,5 27,000 9,900 6,300 1,800 45,000
72 Tes Antibiotik / Skin Tes 18,000 6,600 4,200 1,200 30,000
73 Wound Toilet Kecil 18,000 6,600 4,200 1,200 30,000
74 Wound Toilet Sedang 26,400 9,680 6,160 1,760 44,000
75 Wound Toilet Besar 42,900 15,730 10,010 2,860 71,500
76 Pasang Gudel / Mayo 15,000 5,500 3,500 1,000 25,000
77 Pasang Spalk Infus 9,000 3,300 2,100 600 15,000
78 Buka Drain 15,000 5,500 3,500 1,000 25,000
79 Irigasi mata 49,500 18,150 11,550 3,300 82,500
80 Pemasangan Schorstein 15,000 5,500 3,500 1,000 25,000
81 Punctie Thorax 59,400 21,780 13,860 3,960 99,000
82 Reposisi prolaps Hemoroid 42,900 15,730 10,010 2,860 71,500
83 Tampon Belcoque 59,400 21,780 13,860 3,960 99,000
84 Tampon Anterior 30,000 11,000 7,000 2,000 50,000
85 Angkat Aterum 120,000 44,000 28,000 8,000 200,000
86 Angkat Lipoma 120,000 44,000 28,000 8,000 200,000
87 Angkat Ganglion 120,000 44,000 28,000 8,000 200,000
88 Angkat Klavus 120,000 44,000 28,000 8,000 200,000
89 Eks. Korpus alienum 99,000 36,300 23,100 6,600 165,000
90 Eks. Papiloma 99,000 36,300 23,100 6,600 165,000
91 Reposisi Palpasi Hernia 33,000 12,100 7,700 2,200 55,000
92 Reposisi Palpasi Haemoroid 33,000 12,100 7,700 2,200 55,000
93 Recre Touch Untuk Prostat 49,500 18,150 11,550 3,300 82,500
94 Biopsi jaringan kecil 42,900 15,730 10,010 2,860 71,500
95 Biopsi jaringan sedang 55,800 20,460 13,020 3,720 93,000
96 Biopsi jaringan besar 66,000 24,200 15,400 4,400 110,000
97 Irigasi MAE 39,600 14,520 9,240 2,640 66,000
98 Ekstraksi Cerumen 42,900 15,730 10,010 2,860 71,500
99 Irigasi Sinus 231,000 84,700 53,900 15,400 385,000
100 Spoel Urine 36,000 13,200 8,400 2,400 60,000
101 Pemakaian Oksigen Per Jam 12,000 4,400 2,800 800 20,000
102 Pemasangan CVP 150,000 55,000 35,000 10,000 250,000

103 ODC (One Day Care) Per Jam 48,000 17,600 11,200 3,200 80,000
104 Persalinan Normal IGD 180,000 66,000 42,000 12,000 300,000
105 Perawatan Bayi Baru Lahir IGD 12,000 4,400 2,800 800 20,000
106 Manual Placenta 90,000 33,000 21,000 6,000 150,000
107 Transfusi Darah 15,000 5,500 3,500 1,000 25,000

Page 8
C PELAYANAN RAWAT INAP
1 TARIF RAWAT INAP UMUM (SEWA KAMAR, JASA, DAN VISITE DOKTER)

1.1 RAWAT INAP V.VIP TARIF

1 Sewa Kamar 700,000
2 Jasa Paramedis 120,000
3 Jasa Non Medis 55,000
5 Visite dr. Umum 60,000
6 Visite dr. Spesialis 100,000

1.2 RAWAT INAP VIP A TARIF

1 Sewa Kamar 500,000
2 Jasa Paramedis 100,000
3 Jasa Non Medis 45,000
5 Visite dr. Umum 55,000
6 Visite dr. Spesialis 85,000

1.3 RAWAT INAP VIP B TARIF

1 Sewa Kamar 450,000
2 Jasa Paramedis 90,000
3 Jasa Non Medis 40,000
5 Visite dr. Umum 50,000
6 Visite dr. Spesialis 80,000

1.4 RAWAT INAP KELAS I TARIF

1 Sewa Kamar 350,000
2 Jasa Paramedis 80,000
3 Jasa Non Medis 35,000
5 Visite dr. Umum 45,000
6 Visite dr. Spesialis 70,000

1.5 RAWAT INAP KELAS II TARIF

1 Sewa Kamar 250,000
2 Jasa Paramedis 60,000
3 Jasa Non Medis 25,000
5 Visite dr. Umum 40,000
6 Visite dr. Spesialis 60,000

1.6 RAWAT INAP KELAS III TARIF

1 Sewa Kamar 100,000

2 Jasa Paramedis 40,000
3 Jasa Non Medis 15,000
4 Jasa pengelola makanan 8,000
5 Visite dr. Umum 30,000
6 Visite dr. Spesialis 45,000

1.7 RAWAT INAP ICU TARIF

1 Visite dr. Umum 60,000
2 Visite dr. Spesialis 100,000
3 Jasa Perawat 120,000

4 Sewa Kamar 500,000

1.8 SEWA ALAT/HARI DI RUANG RAWAT ICU

NO ALAT TARIF KETERANGAN
1 Monitor 150,000
2 Ventilator Per Jam 60,000 O2 Dihitung
Tersendiri
3 Infus Pump Per Unit 120,000
4 Syringe Pump Per Unit 120,000
5 Foto therapy 50,000
6 Incubator 500,000 Jika memakai
incubator,
sewa kamar
tidak dihitung

7 CPAP 75,000 O2 Dihitung

Tersendiri
8 Kasur Dikubitus 30,000

Page 9
 9 Blanket Warmer 30,000
10 Blood Warmer 30,000
11 BHP Rutin 15,000

2 TINDAKAN MEDIS UMUM RAWAT INAP

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Medis Paramedis Non Medis
No Tindakan Tarif

40%
60%
55% 35% 10%
1 Ganti verban (GV) 19,800 7,260 4,620 1,320 33,000
2 Angkat jahitan 19,200 7,040 4,480 1,280 32,000
3 Insisi Abses 99,000 36,300 23,100 6,600 165,000
4 Scorstain 19,800 7,260 4,620 1,320 33,000
5 Suction 19,800 7,260 4,620 1,320 33,000
6 Pasang NGT 33,000 12,100 7,700 2,200 55,000
7 Injeksi Formalin 165,000 60,500 38,500 11,000 275,000
8 Tampon Epistaksis (Vaselin) 52,800 19,360 12,320 3,520 88,000
9 Tampon Epistaksis (Adrenalin) 52,800 19,360 12,320 3,520 88,000
10 Injeksi Intra Muscular (IM) 16,500 6,050 3,850 1,100 27,500
11 Injeksi Subcutan (SC) 16,500 6,050 3,850 1,100 27,500
12 Injeksi Intra Vena (IV) 16,500 6,050 3,850 1,100 27,500
13 Huknah 33,000 12,100 7,700 2,200 55,000
14 DC Shock 1 Kali 39,600 14,520 9,240 2,640 66,000
15 DC Shock 2 Kali 79,200 29,040 18,480 5,280 132,000
16 DC Shock 3 Kali 118,800 43,560 27,720 7,920 198,000
17 Bilas Lambung Dengan NGT 92,400 33,880 21,560 6,160 154,000
18 Rangsang Muntah 52,800 19,360 12,320 3,520 88,000
19 Reposisi Lengan / Tungkai Tanpa Luka 39,600 14,520 9,240 2,640 66,000
20 Nagel Bor 26,400 9,680 6,160 1,760 44,000
21 Supra Pubic Puncti (SPP) 46,200 16,940 10,780 3,080 77,000
22 Pemasangan Mitela 16,500 6,050 3,850 1,100 27,500
23 Cervikal Coller 51,000 18,700 11,900 3,400 85,000
24 Tes ATS / ABU / SAR 16,500 6,050 3,850 1,100 27,500
25 Tes Antibiotik / Skin Tes 13,200 4,840 3,080 880 22,000
26 Pasang Spalk Tangan 49,500 18,150 11,550 3,300 82,500
27 Pasang Spalk Lengan 49,500 18,150 11,550 3,300 82,500
28 Pasang Spalk Tungkai 82,500 30,250 19,250 5,500 137,500
29 Wound Toilet Kecil 16,500 6,050 3,850 1,100 27,500
30 Wound Toilet Sedang 26,400 9,680 6,160 1,760 44,000
31 Wound Toilet Besar 42,900 15,730 10,010 2,860 71,500
36 Kateter 16,500 6,050 3,850 1,100 27,500
37 Kateterisasi 30,000 11,000 7,000 2,000 50,000
38 Tampon Beloq 56,100 20,570 13,090 3,740 93,500
39 Nebulizer Tanpa Bahan 21,000 7,700 4,900 1,400 35,000
40 Necrotomi jaringan 33,000 12,100 7,700 2,200 55,000
41 Eks. Papiloma 99,000 36,300 23,100 6,600 165,000
42 Spul urine 36,300 13,310 8,470 2,420 60,500
43 Reposisi Palpasi Hernia 33,000 12,100 7,700 2,200 55,000
44 Reposisi Palpasi Haemoroid 33,000 12,100 7,700 2,200 55,000
45 Recre Touch Untuk Prostat 49,500 18,150 11,550 3,300 82,500
46 GV Post Operasi 16,500 6,050 3,850 1,100 27,500
47 Pasang Gibs 66,000 24,200 15,400 4,400 110,000
48 pasang Infus 16,500 6,050 3,850 1,100 27,500
49 Irigasi MAE (Meatus Acusticus Externa) 39,600 14,520 9,240 2,640 66,000
50 Ekstraksi Cerumen 42,900 15,730 10,010 2,860 71,500

51 Irigasi Sinus 231,000 84,700 53,900 15,400 385,000

52 Perawatan Bayi 24,000 8,800 5,600 1,600 40,000

53 Breast Care 15,000 5,500 3,500 1,000 25,000
54 Elastis Verban 22,800 8,360 5,320 1,520 38,000
55 Pemberian makanan melalui sonde per kali pemberian 3,000 1,100 700 200 5,000
56 Pemberian Obat Per Rectal 3,000 1,100 700 200 5,000
57 Fiksasi Infus 15,000 5,500 3,500 1,000 25,000
58 Monitoring VS Per 15 menit 18,000 6,600 4,200 1,200 30,000

Page 10
 59 Buka Tampon (Hidung, Telinga, Rectal) 18,960 6,952 4,424 1,264 31,600
60 Buka Drain 19,800 7,260 4,620 1,320 33,000
61 Buka Cateter/NGT/Infus/WSD 16,500 6,050 3,850 1,100 27,500
62 Necrotomi dan Perawatan Gangren < 10 cm 75,600 27,720 17,640 5,040 126,000
63 Necrotomi dan Perawatan Gangren > 10 cm 111,000 40,700 25,900 7,400 185,000
64 Pemakaian Monitor Rawat Inap 90,000 33,000 21,000 6,000 150,000
65 BSS tiap kali pemeriksaan di ruangan rawat inap 7,200 2,640 1,680 480 12,000
66 ECG 30,000 11,000 7,000 2,000 50,000

Jasa Pelayanan
Jasa Sarana
Rumah Sakit
Medis Paramedis Non Medis
No Tindakan Tarif

40%
60%
45% 45% 10%

67 Pengambilan sampel labor 13,800 5,060 3,220 920 23,000

68 Perawatan personal hygiene 24,600 9,020 5,740 1,640 41,000

69 Perawatan WSD 72,000 26,400 16,800 4,800 120,000
70 Pijat bayi 30,000 11,000 7,000 2,000 50,000
71 Fototerapi Bayi 30,000 11,000 7,000 2,000 50,000
72 Perawatan Traceostomi 19,800 7,260 4,620 1,320 33,000

3. TINDAKAN MEDIS RAWAT INAP KEBIDANAN

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Medis Paramedis Non Medis
No Tindakan Tarif

40%
60%
45% 45% 10%
3.1 Persalinan Normal oleh Dokter Spesialis Kelas 3 810,000 243,000 243,000 54,000 1,350,000
Kelas 2 1,050,000 315,000 315,000 70,000 1,750,000
Kelas 1 1,320,000 396,000 396,000 88,000 2,200,000

VVIP 1,620,000 486,000 486,000 108,000 2,700,000

3.2 Persalinan Abnormal oleh Dokter Spesialis Kelas 3 1,500,000 450,000 450,000 100,000 2,500,000
Kelas 2 1,800,000 540,000 540,000 120,000 3,000,000
Kelas 1 1,920,000 576,000 576,000 128,000 3,200,000

VIP 2,100,000 630,000 630,000 140,000 3,500,000

VVIP 2,280,000 684,000 684,000 152,000 3,800,000
3.3 Persalinan Spontan Kepala Oleh Bidan Kelas 3 600,000 180,000 180,000 40,000 1,000,000
Kelas 2 810,000 243,000 243,000 54,000 1,350,000
Kelas 1 1,050,000 315,000 315,000 70,000 1,750,000
VIP 1,500,000 450,000 450,000 100,000 2,500,000
VVIP 1,650,000 495,000 495,000 110,000 2,750,000
3.4 Persalinan dengan Gameli Spontan oleh Bidan Kelas 3 750,000 225,000 225,000 50,000 1,250,000
Kelas 2 990,000 297,000 297,000 66,000 1,650,000

Kelas 1 1,290,000 387,000 387,000 86,000 2,150,000

VIP 1,920,000 576,000 576,000 128,000 3,200,000
VVIP 2,100,000 630,000 630,000 140,000 3,500,000

3.5 Persalinan Spontan Kepala dengan PEB Kelas 3 780,000 234,000 234,000 52,000 1,300,000
Kelas 2 1,020,000 306,000 306,000 68,000 1,700,000
Kelas 1 1,320,000 396,000 396,000 88,000 2,200,000

VIP 1,950,000 585,000 585,000 130,000 3,250,000

VVIP 2,160,000 648,000 648,000 144,000 3,600,000

3.6 Persalinan Spontan Kepala dengan KPSW Kelas 3 660,000 198,000 198,000 44,000 1,100,000
Kelas 2 840,000 252,000 252,000 56,000 1,400,000
Kelas 1 1,080,000 324,000 324,000 72,000 1,800,000
VIP 1,620,000 486,000 486,000 108,000 2,700,000
VVIP 1,800,000 540,000 540,000 120,000 3,000,000

3.7 Persalinan dengan Vacum Ekstraksi Kelas 3 900,000 270,000 270,000 60,000 1,500,000
Kelas 2 1,200,000 360,000 360,000 80,000 2,000,000

Kelas 1 1,560,000 468,000 468,000 104,000 2,600,000

VIP 2,100,000 630,000 630,000 140,000 3,500,000
VVIP 2,220,000 666,000 666,000 148,000 3,700,000

3.8 Persalinan Bokong Kelas 3 690,000 207,000 207,000 46,000 1,150,000

Page 11
 Kelas 2 900,000 270,000 270,000 60,000 1,500,000
Kelas 1 1,140,000 342,000 342,000 76,000 1,900,000
VIP 1,680,000 504,000 504,000 112,000 2,800,000

VVIP 1,860,000 558,000 558,000 124,000 3,100,000

3.9 Abortus Incomptens dengan Avm Kelas 3 780,000 234,000 234,000 52,000 1,300,000

Kelas 2 1,020,000 306,000 306,000 68,000 1,700,000

Kelas 1 1,320,000 396,000 396,000 88,000 2,200,000

VIP 1,950,000 585,000 585,000 130,000 3,250,000

VVIP 2,160,000 648,000 648,000 144,000 3,600,000

3.10 Abortus Incomptens dengan Kuretase Kelas 3 900,000 270,000 270,000 60,000 1,500,000

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Medis Paramedis Non Medis
No Tindakan Tarif
40%
60%
55% 35% 10%

Kelas 3 900,000 270,000 270,000 60,000 1,500,000

3.11 Mola hidatidosa dengan Kuretase
Kelas 2 1,200,000 360,000 360,000 80,000 2,000,000
Kelas 1 1,560,000 468,000 468,000 104,000 2,600,000
VIP 2,100,000 630,000 630,000 140,000 3,500,000
VVIP 2,220,000 666,000 666,000 148,000 3,700,000
3.12 Manual Placenta Kelas 3 510,000 153,000 153,000 34,000 850,000
Kelas 2 660,000 198,000 198,000 44,000 1,100,000
Kelas 1 840,000 252,000 252,000 56,000 1,400,000
VIP 1,500,000 450,000 450,000 100,000 2,500,000
VVIP 1,620,000 486,000 486,000 108,000 2,700,000

4 TINDAKAN MEDIS RAWAT INAP ICU

Jasa Sarana Jasa Pelayanan
Rumah Sakit Medis Paramedis Non Medis
No Tindakan Tarif
40%
60%
50% 40% 10%
1 Suction 21,000 7,000 5,600 30,000 35,000
2 Pemasangan CVP - 150,000 120,000 6,600 750,000
3 Ventilator - 33,000 26,400 6,000 165,000
4 Resusitasi - 30,000 24,000 6,000 150,000
5 Defibrilator/DC SHOCK - 30,000 24,000 8,400 150,000
6 Intubasi tracheal - 42,000 33,600 6,000 210,000
7 EKG Monitor - 30,000 24,000 3,300 150,000
8 Infus pump - 16,500 13,200 3,300 82,500
9 Syringe pump - 16,500 13,200 3,300 82,500
10 Nebuliezer - 16,500 13,200 4,200 82,500
11 Ekstubasi - 21,000 16,800 16,000 105,000
12 Echo Kardiografi - 80,000 64,000 3,520 400,000
13 Huknah - 17,600 14,080 3,520 88,000
14 Bilas Lambung Dengan NGT - 17,600 14,080 1,400 88,000
15 Cervical Coller - 7,000 5,600 1,100 35,000
16 Pasang Spalk Tangan - 5,500 4,400 2,200 27,500
17 Pasang Spalk Lengan - 11,000 8,800 2,640 55,000
18 Pasang Spalk Tungkai - 13,200 10,560 800 66,000
19 Pasang Gudel / Mayo - 4,000 3,200 4,800 20,000
20 Necrotomi jaringan - 24,000 19,200 4,400 120,000
21 Pasang Gibs - 22,000 17,600 4,400 110,000
22 Pemasangan NGT - 22,000 17,600 2,200 110,000
23 Pelepasan NGT - 11,000 8,800 4,400 55,000
24 Pemasangan Kateter - 22,000 17,600 2,200 110,000
25 Pelepasan Kateter - 11,000 8,800 1,600 55,000
26 Kondom Kateter - 8,000 6,400 10,000 40,000
27 Tracheostomy - 50,000 40,000 - 250,000

Page 12
45,000 -
45,000

90,000

4,500 4,500 6,000

70,000 18,000 18,000 24,000

30,000 18,000 18,000 24,000
120,000 18,000 18,000 24,000
30,000 22,500 22,500 30,000
82,500 7,500 7,500 10,000

Page 13
 620,000 15,000 15,000 20,000
70,000 7,500 7,500 10,000
200,000 22,500 22,500 30,000

175000

200000
200000 200,000

100,000

125,000

Page 14
 21,000 21,000 28,000

82,500 Tambahan Tindakan d 135,000 135,000 180,000

55,000 tolong di konsulkan ke perawat Siti Maryam\
30,000
77,000 4,500 4,500 6,000
77,000 45,000 45,000 60,000
77,000 15,000 15,000 20,000
77,000 45,000 45,000 60,000
900,000 15,000 15,000 20,000

25,000
300,000 7,500 7,500 10,000
300,000 60,000 60,000 80,000
250,000
-

22,500 22,500 30,000

37,500 37,500 50,000

2,000,000 7,500 7,500 30,000

Page 15
 Err:520 23,625 23,625 31,500

Err:520 22,950 22,950 30,600

Err:520 15,750 15,750 21,000

100,000

70,000 26,775 26,775 35,700

150,000 10,080 10,080 13,440

30,000

40,000 47,250 47,250 63,000

100,000 17,325 17,325 23,100

250,000

300,000

47,250 47,250 63,000

120,000 12,600 12,600 16,800

50,000 78,750 78,750 105,000

15,750 15,750 21,000

180,000 110,250 110,250 147,000

70,000 23,625 23,625 31,500

200,000 211,050 211,050 281,400

50,000 252,000 252,000 336,000
300,000 315,000 315,000 420,000
60,000 315,000 315,000 420,000
420,000 157,500 157,500 210,000
90,000 39,375 39,375 52,500
18,900 18,900 25,200

800,000
950,000 12,600 12,600 16,800
1,200,000 18,900 18,900 25,200

1,200,000 7,875 7,875 10,500

620,000

180,000 26,775 26,775 35,700

70,000 15,750 15,750 21,000
67,500 67,500 90,000

Page 16
 100,000
120,000
100,000
Err:520

Page 17
Page 18
 33,000 30,000

22,000 40,000

165,000 52,000

500,000

55,000 55,000

88,000 88,000
88,000 88,000
200,000
159,500 160,000
85,000 82,500 85,000
85,000 85,000
100,000 100,000

Page 19
55,000 55,000
66,000 100,000
88,000 100,000

50,000 50,000

30,000
110,000
30,000
45,000
25,000

82,500 30,000 30,000 40,000

25,000 30,000 30,000 40,000
99,000 45,000 45,000 60,000
71,500 45,000 45,000 60,000
99,000 16,500 16,500 22,000

200,000 15,000 15,000 20,000

200,000 22,500 22,500 30,000
200,000 22,500 22,500 30,000
200,000 22,500 22,500 30,000
165,000 30,000 30,000 40,000
165,000 7,500 7,500 10,000
55,000
55,000
82,500
71,500
93,000
110,000
66,000 7,500 7,500 10,000
71,500 7,500 7,500 10,000
385,000 7,500 7,500 10,000
185,000
55,000 20,000

450,000 60,000
335,000

Page 20
 Err:520 Err:520
55,275

Err:520

Err:520

75,000 75,000 100,000

Page 21
 75,000 75,000 100,000

50,000 14,175 14,175 18,900

120,000 37,800 37,800 50,400
125,000 378,000 37,800 50,400

Page 22
3,800,000 2660000 1140000 3800000

1,250,000 1,250,000 750,000 500,000

Page 23
Page 24
15,000

60,000
60,000
60,000
75,000
25,000

Page 25
50,000
25,000
75,000

Page 26
 70,000

450,000

15,000
150,000
50,000
150,000
50,000

25,000
200,000

75,000

125,000

75,000

Page 27
 78,750

76,500

52,500

89,250

33,600

157,500

57,750

157,500

42,000

262,500

52,500

367,500

78,750

703,500
840,000
1,050,000
1,050,000
525,000
131,250
63,000

42,000
63,000

26,250

89,250
52,500
225,000

Page 28
Page 29
Page 30
Page 31
100,000
100,000
150,000
150,000
55,000

50,000
75,000
75,000
75,000
100,000
25,000

25,000
25,000
25,000

Page 32
250,000

Page 33
250,000

47,250
126,000
126,000

Page 34
Page 35
Page 36
D PELAYANAN TINDAKAN MEDIS OPERATIF
Sarana
Dokter
Rumah Operator Perawat OK Jasas Anstesi Non Medis
Pendamping
No. BEDAH Sakit Tarif
40%
60%
45% 15% 25% 5% 10%
1 Tindakan medis operatif kecil
Tarif per Tindakan
Kelas III 400,000 144,000 48,000 80,000 16,000 32,000 800,000
Kelas II 500,000 180,000 60,000 100,000 20,000 40,000 1,000,000
Kelas I 600,000 216,000 72,000 120,000 24,000 48,000 1,200,000
VIP 700,000 252,000 84,000 140,000 28,000 56,000 1,400,000
VVIP 800,000 288,000 96,000 160,000 32,000 64,000 1,600,000

Tindakan medis operatif sedang

2
Tarif per Tindakan
Kelas III 1,750,000 630,000 210,000 350,000 70,000 140,000 3,500,000
Kelas II 1,875,000 675,000 225,000 375,000 75,000 150,000 3,750,000
Kelas I 2,125,000 765,000 255,000 425,000 85,000 170,000 4,250,000
VIP 2,375,000 855,000 285,000 475,000 95,000 190,000 4,750,000
VVIP 2,750,000 990,000 330,000 550,000 110,000 220,000 5,500,000

3 Tindakan medis operatif besar

Tarif per Tindakan
Kelas III 2,750,000 990,000 330,000 550,000 110,000 220,000 5,500,000
Kelas II 3,000,000 1,080,000 360,000 600,000 120,000 240,000 6,000,000
Kelas I 3,250,000 1,170,000 390,000 650,000 130,000 260,000 6,500,000
VIP 3,500,000 1,260,000 420,000 700,000 140,000 280,000 7,000,000
VVIP 3,750,000 1,350,000 450,000 750,000 150,000 300,000 7,500,000

4 Tindakan Medis Operatif Canggih

Kelas III 5,500,000 1,980,000 660,000 1,100,000 220,000 440,000 11,000,000
Kelas II 6,000,000 2,160,000 720,000 1,200,000 240,000 480,000 12,000,000
Kelas I 6,500,000 2,340,000 780,000 1,300,000 260,000 520,000 13,000,000
VIP 7,000,000 2,520,000 840,000 1,400,000 280,000 560,000 14,000,000
VVIP 7,500,000 2,700,000 900,000 1,500,000 300,000 600,000 15,000,000

Note :
Macam-macam Tindakan Operasi Per Kategorinya lihat pada lampiran II.

E. TARIF LAYANAN PENUNJANG MEDIK

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
40%
60%
55% 35% 10%
1 Laboratorium
a. Darah
Hematologi CBC (8 parameter) 45,600 16,720 10,640 3,040 76,000
Hematologi CBC + Diff (14 parameter) 53,400 19,580 12,460 3,560 89,000
Hematologi CBC + Diff + Reti 77,400 28,380 18,060 5,160 129,000
Morfologi Darah Tepi 84,000 30,800 19,600 5,600 140,000
Feritin 122,400 44,880 28,560 8,160 204,000
Laju Endap Darah 18,000 6,600 4,200 1,200 30,000
Hemaglobin 17,400 6,380 4,060 1,160 29,000
Waktu Pendarahan 14,400 5,280 3,360 960 24,000
Waktu Pembekuan - - - -
Golongan Darah ABO 17,400 6,380 4,060 1,160 29,000
Golongan Darah Rhesus 34,200 12,540 7,980 2,280 57,000
Waktu Protrombin 90,000 33,000 21,000 6,000 150,000
APTT 72,000 26,400 16,800 4,800 120,000

b. Urine (Paket)
Urine Rutin 23,400 8,580 5,460 1,560 39,000
Reduksi Urine 17,400 6,380 4,060 1,160 29,000
Protein Urine 17,400 6,380 4,060 1,160 29,000
Bilirubin Urine 17,400 6,380 4,060 1,160 29,000
Protein Esbach 29,400 10,780 6,860 1,960 49,000
Tes Kehamilan 26,400 9,680 6,160 1,760 44,000
Feses Rutin 20,400 7,480 4,760 1,360 34,000
c. Faeces Rutin (Paket)
Konsistensi (paket): 16,800 6,160 3,920 1,120 28,000
Darah
Lendir
Sel Darah Merah
Sel Darah Putih
Amoeba
Cyste
Telur Cacing

Page 21
 Jasa Sarana Jasa Pelayanan
Rumah Sakit Para
Medis Non Medis
No. Jenis Pelayanan medis Tarif
40%
60%
55% 35% 10%
d. Kimia Darah
1 Billirubin Total 30,000 11,000 7,000 2,000 50,000
2 Billirubin Direct/ Indirect 30,000 11,000 7,000 2,000 50,000
3 SGOT 26,400 9,680 6,160 1,760 44,000
4 SGPT 26,400 9,680 6,160 1,760 44,000
5 Protein total 35,400 12,980 8,260 2,360 59,000
6 Asam Urat 29,400 10,780 6,860 1,960 49,000
7 Albumin/ Globulin 35,400 12,980 8,260 2,360 59,000
8 Ureum 23,400 8,580 5,460 1,560 39,000
9 CRAETININ 23,400 8,580 5,460 1,560 39,000
10 CHOLESTEROL 25,200 9,240 5,880 1,680 42,000
11 HDL Cholesterol 31,800 11,660 7,420 2,120 53,000
12 LDL Cholesterol 31,800 11,660 7,420 2,120 53,000
13 TRIGLYSERIDE 25,800 9,460 6,020 1,720 43,000
14 Gula darah puasa 17,400 6,380 4,060 1,160 29,000
15 Gula darah 2 jam PP 17,400 6,380 4,060 1,160 29,000
16 Gula darah sewaktu 17,400 6,380 4,060 1,160 29,000
17 CKMB 96,000 35,200 22,400 6,400 160,000
e. Mikrobiologi
1 Preparat Gram 29,400 10,780 6,860 1,960 49,000
2 Preparat BTA 29,400 10,780 6,860 1,960 49,000
3 Preparat Jamur 29,400 10,780 6,860 1,960 49,000
4 Preparat Difteri 29,400 10,780 6,860 1,960 49,000
5 Preparat Malaria 29,400 10,780 6,860 1,960 49,000
6 Apus Tenggorok 29,400 10,780 6,860 1,960 49,000
7 Apus Mata 29,400 10,780 6,860 1,960 49,000
8 Apus Vagina 29,400 10,780 6,860 1,960 49,000
9 Apus Uretra 29,400 10,780 6,860 1,960 49,000

f. Elektrolit
Elektrolit (K, Na, Cl) 120,000 44,000 28,000 8,000 200,000
Kalsium 42,000 15,400 9,800 2,800 70,000
Magnesium 42,000 15,400 9,800 2,800 70,000
Analisa Gas Darah 240,000 88,000 56,000 16,000 400,000

g. Imunologi Serologi
HBsAg 74,400 27,280 17,360 4,960 124,000
Widal 47,400 17,380 11,060 3,160 79,000
Anti HBsAg 89,400 32,780 20,860 5,960 149,000
Anti HCV 98,400 36,080 22,960 6,560 164,000
Anti HAV 152,400 55,880 35,560 10,160 254,000
Anti HIV 122,400 44,880 28,560 8,160 204,000
Anti HIV 3 Metode 212,400 77,880 49,560 14,160 354,000
Dengue IgG 182,400 66,880 42,560 12,160 304,000
Dengue IgM 182,400 66,880 42,560 12,160 304,000
CRF 77,400 28,380 18,060 5,160 129,000
ASTO 54,000 19,800 12,600 3,600 90,000
RF 55,200 20,240 12,880 3,680 92,000
AFP 144,000 52,800 33,600 9,600 240,000
CEA 132,000 48,400 30,800 8,800 220,000

h. NAPZA
Tes Skrining Narkoba 176,400 64,680 41,160 11,760 294,000
i. TORCH
Anti Toksoplasma IgG 132,000 48,400 30,800 8,800 220,000
Anti Toksoplasma IgM 132,000 48,400 30,800 8,800 220,000
Anti Rubela IgG 132,000 48,400 30,800 8,800 220,000
Anti Rubela IgM 150,000 55,000 35,000 10,000 250,000
Anti CMV IgG 126,000 46,200 29,400 8,400 210,000
Anti CMV IgM 186,000 68,200 43,400 12,400 310,000
Anti HSV 1 IgG 144,000 52,800 33,600 9,600 240,000
Anti HSV 1 IgM 144,000 52,800 33,600 9,600 240,000
Anti HSV 2 IgG 132,000 48,400 30,800 8,800 220,000
Anti HSV 2 IgM 132,000 48,400 30,800 8,800 220,000

j. Tiroid
T3 (Total) 121,200 44,440 28,280 8,080 202,000

Page 21
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
40%
60%
55% 35% 10%
T4 (Total) 121,200 44,440 28,280 8,080 202,000
TSHS 121,200 44,440 28,280 8,080 202,000

k. Lain-lain
Analisa Sperma 39,000 14,300 9,100 2,600 65,000
Analisa Cairan Sendi 39,000 14,300 9,100 2,600 65,000

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
22%
78%
50% 40% 10%

2 INSTALASI HEMODIALISA
a. Hemodialisa (Satu kali tindakan) 764,400 107,800 86,240 21,560 980,000

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
40%
60%
55% 35% 10%
3 PEMERIKSAAN DIANOGSIS ELEKTROMEDIS

1. Ultra Sono Grafi (USG)

a USG 2 Dimensi 32,000 17,600 11,200 3,200 80,000
b USG 3 Dimensi 60,000 33,000 21,000 6,000 150,000
c. USG 4 Dimensi 80,000 44,000 28,000 8,000 200,000
2. Elektro Kardio Grafi (EKG) 20,000 11,000 7,000 2,000 50,000

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
40%
60%
55% 35% 10%
4 Pemerikasaan Radiologi
4.1 Sederhana
1 Thorax 54,000 19,800 12,600 3,600 90,000
2 Thorax Anak 46,800 17,160 10,920 3,120 78,000
3 Panoramic 90,000 33,000 21,000 6,000 150,000
4 Abdomen Anak 46,800 17,160 10,920 3,120 78,000
5 Abdomen Dewasa 62,100 22,770 14,490 4,140 103,500
6 Scheidel 62,100 22,770 14,490 4,140 103,500
7 Water's 62,100 22,770 14,490 4,140 103,500
8 Basis Cranii 62,100 22,770 14,490 4,140 103,500
9 Orbita 62,100 22,770 14,490 4,140 103,500
10 Mandibula AP/Lat 62,100 22,770 14,490 4,140 103,500
11 TMJ 62,100 22,770 14,490 4,140 103,500
12 Mastoid 62,100 22,770 14,490 4,140 103,500
13 Nasal Bone 62,100 22,770 14,490 4,140 103,500
14 Vert. Cervical 62,100 22,770 14,490 4,140 103,500
15 Vert. Thoracal 62,100 22,770 14,490 4,140 103,500
16 Vert. Lumbal 62,100 22,770 14,490 4,140 103,500
17 Vert. Thoracal Lumbal 62,100 22,770 14,490 4,140 103,500
18 Vert. Lumbo-Sacral 62,100 22,770 14,490 4,140 103,500
19 Os. Sacrum 62,100 22,770 14,490 4,140 103,500
20 Os. Coccygis 62,100 22,770 14,490 4,140 103,500
21 Hip Joint 62,100 22,770 14,490 4,140 103,500
22 Pelvis anak 51,300 18,810 11,970 3,420 85,500
23 Coxae/Pelvis 62,100 22,770 14,490 4,140 103,500
24 Scapula 51,300 18,810 11,970 3,420 85,500
25 Clavicula 51,300 18,810 11,970 3,420 85,500
26 Shoulder Joint 51,300 18,810 11,970 3,420 85,500
27 Humerus 51,300 18,810 11,970 3,420 85,500
28 Elbow Joint 51,300 18,810 11,970 3,420 85,500
29 Antebrachii 51,300 18,810 11,970 3,420 85,500
30 Wrist Joint 51,300 18,810 11,970 3,420 85,500
31 Manus 51,300 18,810 11,970 3,420 85,500
32 Femur 51,300 18,810 11,970 3,420 85,500
33 Genu 51,300 18,810 11,970 3,420 85,500
34 Cruris 51,300 18,810 11,970 3,420 85,500
35 Ankle 51,300 18,810 11,970 3,420 85,500
36 Pedis 51,300 18,810 11,970 3,420 85,500

Page 21
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
40%
60%
55% 35% 10%
37 Soft Tissue 51,300 18,810 11,970 3,420 85,500
38 Gigi/Dental 51,300 18,810 11,970 3,420 85,500
39 CT SCAN - - - -
Tanpa Kontras
Scan Kepala 360,000 132,000 84,000 24,000 600,000
Scan Sinus 456,600 167,420 106,540 30,440 761,000
Scan Orbita 456,600 167,420 106,540 30,440 761,000
Scan Nasopharynx 456,600 167,420 106,540 30,440 761,000
Scan Mastoid 456,600 167,420 106,540 30,440 761,000
Scan Tulang 456,600 167,420 106,540 30,440 761,000
Scan Cervical 456,600 167,420 106,540 30,440 761,000
Scan Thorax 596,400 218,680 139,160 39,760 994,000
Scan Vert Seluruh 710,400 260,480 165,760 47,360 1,184,000
Scan Abdomen Seluruh 750,000 275,000 175,000 50,000 1,250,000
Dengan Kontras
Scan Kepala 540,000 198,000 126,000 36,000 900,000
Scan Tulang 676,800 248,160 157,920 45,120 1,128,000
Scan Thorax 903,000 331,100 210,700 60,200 1,505,000
Scan Vert Seluruh 825,000 302,500 192,500 55,000 1,375,000
Scan Abdomen Seluruh 1,236,000 453,200 288,400 82,400 2,060,000
Scan Cervical 676,800 248,160 157,920 45,120 1,128,000

4.2 Pemeriksaan Sedang

1 Cor analisa 86,250 31,625 20,125 5,750 143,750
2 Cor analisa anak 86,250 31,625 20,125 5,750 143,750
3 Bone Survey 220,800 80,960 51,520 14,720 368,000
4.3 Pemeriksaan Canggih
1 BNO-IVP 207,000 75,900 48,300 13,800 345,000
2 BNO-IVP Anak 172,500 63,250 40,250 11,500 287,500
3 Colon Inloop 189,750 69,575 44,275 12,650 316,250
4 Colon Inloop Anak 155,250 56,925 36,225 10,350 258,750
5 Appendicogram 100,050 36,685 23,345 6,670 166,750
6 Oesophagogram 110,400 40,480 25,760 7,360 184,000
7 Maag Duodenum 138,000 50,600 32,200 9,200 230,000
8 OMD 155,250 56,925 36,225 10,350 258,750
9 Cystogram 138,000 50,600 32,200 9,200 230,000
10 HSG 189,750 69,575 44,275 12,650 316,250

5 TARIF LAYANAN GIZI

5.1. TARIF MAKAN PASIEN UNTUK RAWAT INAP

Jasa Sarana Jasa Pelayanan

Rumah Sakit
MEDIS (PELAYANAM GIZI) Non Medis
No. KELAS PERAWATAN Tarif
60% 40%
30% 10%

1 VVIP 51,900 10,380 3,460 86,500

2 VIP 37,200 7,440 2,480 62,000
3 Kelas I 35,400 7,080 2,360 59,000
4 Kelas II 29,400 5,880 1,960 49,000
5 Kelas III 21,000 4,200 1,400 35,000

5.2. TARIF LAYANAN KONSUL GIZI

Jasa Rumah Jasa Pelayanan
Sakit
Medis Para Non Medis
medis
No. Ruang Perawatan Tarif
60% 40%
55% 35% 10%
1 VVIP 30,000 11,000 7,000 2,000 45,000
2 VIP dan Kelas I 24,000 8,800 5,600 1,600 30,000
3 Kelas II 21,000 7,700 4,900 1,400 20,000
4 Kelas III 15,000 5,500 3,500 1,000 18,000
5 Klinik Gizi (Rawat Jalan) 21,000 11,000 7,000 1,400 25,000

Page 21
F. TARIF LAYANAN REHABILITASI MEDIK

Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
40%
60%
55% 35% 10%
1 Nebulizer/inhalasi 42,000 15,400 9,800 2,800 70,000
2 Short wave diathermi 33,000 12,100 7,700 2,200 55,000
3 Short Wave Theraphy 75,000 27,500 17,500 5,000 125,000
4 Exercise khusus 21,000 7,700 4,900 1,400 35,000
5 Exercise biasa 15,000 5,500 3,500 1,000 25,000
6 Traksi lumbal/cervikal 33,000 12,100 7,700 2,200 55,000
7 Infra Red 16,500 6,050 3,850 1,100 27,500
8 Ultra sound diathermi 42,000 15,400 9,800 2,800 70,000
9 Faradiasi 33,000 12,100 7,700 2,200 55,000
10 TENS 33,000 12,100 7,700 2,200 55,000
11 Terapi Wicara 23,100 8,470 5,390 1,540 38,500
12 Terapi okupasi 42,900 15,730 10,010 2,860 71,500
13 Paket dua alat 62,700 22,990 14,630 4,180 104,500
14 Paket tiga alat 79,200 29,040 18,480 5,280 132,000
15 Paket lebih dari tiga alat 99,000 36,300 23,100 6,600 165,000

G. TARIF LAYANAN KHUSUS, MEDICOLEGAL DAN ASURANSI

1. TARIF LAYANAN KONSULTASI PSIKOLOGI 50,000
Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
No. Jenis Pelayanan Medis Non Medis Tarif
medis
40%
60%
55% 35% 10%
1.1 Konsultasi Psikologi
- Konseling Umum 30,000 11,000 7,000 2,000 50,000

1.2 Penunjang Diagnose

- Kecerdasan 36,000 13,200 8,400 2,400 60,000
- Kepribadian 51,000 18,700 11,900 3,400 85,000

1.3 Tumbuh Kembang Anak

- Kecerdasan 36,000 13,200 8,400 2,400 60,000
- Kepribadian 34,800 12,760 8,120 2,320 58,000
- Konseling 30,000 11,000 7,000 2,000 50,000

1.4 Persyaratan Masuk SLB

- Kecerdasan 36,000 13,200 8,400 2,400 60,000

1.5 Bimbingan Study

- Kecerdasan 36,000 13,200 8,400 2,400 60,000
- Kepribadian 34,800 12,760 8,120 2,320 58,000
- Minat Bakat 34,800 12,760 8,120 2,320 58,000

1.6 Recruitment/Promosi Placement Pegawai

- Kecerdasan 30,000 11,000 7,000 2,000 50,000
- Kepribadian 34,800 12,760 8,120 2,320 58,000
- Minat Bakat 34,800 12,760 8,120 2,320 58,000
- Kemampuan Kerja 34,800 12,760 8,120 2,320 58,000
- Wawancara 30,000 11,000 7,000 2,000 50,000

1.7 Usulan Pensiun Dini/Karyawan Bermasalah

- Kecerdasan 36,000 13,200 8,400 2,400 60,000
- Kepribadian 34,800 12,760 8,120 2,320 58,000
- Kemampuan Kerja 34,800 12,760 8,120 2,320 58,000
1.8 Bimbingan Karir
- Kecerdasan 48,000 17,600 11,200 3,200 80,000
- Kepribadian 34,800 12,760 8,120 2,320 58,000
- Minat Bakat 34,800 12,760 8,120 2,320 58,000
- Kemampuan Kerja 34,800 12,760 8,120 2,320 58,000
- Konseling 30,000 11,000 7,000 2,000 50,000

1.9 Pemeriksaan Kesehatan Jiwa (Calon Pejabat Negara)

- Kecerdasan 72,000 26,400 16,800 4,800 120,000
- Kepribadian 72,000 26,400 16,800 4,800 120,000
- Minat Bakat 72,000 26,400 16,800 4,800 120,000
- Kemampuan Kerja 72,000 26,400 16,800 4,800 120,000
- Wawancara 57,000 20,900 13,300 3,800 95,000

1.10 Pemeriksaan Kesehatan Jiwa (Calon Anggota Legislatif)

- Psikotes 195,000 71,500 45,500 13,000 325000

2 PEMERIKSAAN KESEHATAN (MEDICAL CHECK UP

2.1 Surat Keterangan Sehat :

Page 21
 Jasa Pelayanan
Jasa Sarana
Rumah Sakit Para
Medis Non Medis
medis
No. Jenis Pelayanan Tarif
40%
60%
55% 35% 10%
a Pelajar / Mahasiswa (diluar Biaya Laboratorium dan Rontgen) 19,600 10,780 3,850 770 35,000
b KIR umum 25,200 13,860 4,950 990 45,000
2.2 Medical Chek up Sederhana (diluar Biaya 33,600 18,480 6,600 1,320 60,000
Laboratorium dan Rontgen)
2.3 Visum Et Repertum
Visum mati 56,000 30,800 11,000 2,200 100000
Visum hidup 42,000 23,100 8,250 1,650 75000
2.4 Surat Keterangan Kesehatan (Asuransi) 28,000 15,400 5,500 1,100 50000

H. TARIF LAYANAN PEMULASARAN/PERAWATAN JENAZAH

Jasa Sarana Jasa Pelayanan
Rumah Sakit
Medis
Non Medis
No. Jenis Pelayanan Tarif
60% 40%
30% 10%
1 Exchumasi (Gali Kubur) dalam kota 900,000 180,000 60,000 1,500,000
2 Exchumasi (Gali Kubur) luar kota 1,800,000 360,000 120,000 3,000,000
3 Pemeriksaan luar jenazah 72,000 14,400 4,800 120,000
4 Pemeriksaan dalam jenazah (otopsi) 330,000 66,000 22,000 550,000
5 Perawatan/pemulasaran jenazah 510,000 102,000 34,000 850,000
6 Penyiapan sampel untuk toksikologi 132,000 26,400 8,800 220,000
7 Penyegelan 30,000 6,000 2,000 50,000
8 Penyimpanan/penitipan jenazah dari dalam RS 72,000 14,400 4,800 120,000
per hari
Penyimpanan/penitipan jenazah dari luar RS per 150,000
9 hari 90,000 18,000 6,000

10 Pengawetan jenazah 180,000 36,000 12,000 300,000

11 Rekonstruksi Jenazah Berat 360,000 72,000 24,000 600,000
12 Rekonstruksi Jenazah Sedang 150,000 30,000 10,000 250,000
13 Rekonstruksi Jenazah Ringan 150,000 60,000 20,000 500,000
14 Surat Keterangan Asuransi 90,000 18,000 6,000 150,000
15 Jasa bilal, pendeta, romo, suhu untuk jenazah 60,000 40,000 100,000
16 normal
Jasa bilal, pendeta, romo, suhu untuk jenazah 48,000 24,000 80,000
yang busuk belatungan/ infeksi/ HIV/ Hepatitis

I. TARIF LAYANAN PENUNJANG NON MEDIK

1 UNIT PENGEMBANGAN SDM
Jasa
60% 40%
No. Jenis Pelayanan Tarif Keterangan
Jasa Sarana
Jasa Pegawai
Rumah Sakit
1.1 Praktek Kerja Lapangan, Magang, Pra Penelitian, Penelitian
- SLTA/SEDERAJAT PER ORANG PER BULAN
- Non Kesehatan 18,000 12,000 30,000
- Kesehatan 18,000 12,000 30,000
- D I, D III, D IV, S I Per Orang Per Bulan
Non Kesehatan :
*DI 30,000 20,000 50,000
* D III 60,000 40,000 100,000
* D IV 72,000 48,000 120,000
*S1 72,000 48,000 120,000
*S2 120,000 80,000 200,000
*S3 120,000 80,000 200,000
Kesehatan :
*DI 30,000 20,000 50,000
* D III 60,000 40,000 100,000
* D IV 72,000 48,000 120,000
*S1 72,000 48,000 120,000
*S2 120,000 80,000 200,000
*S3 120,000 80,000 200,000

b Kerjasama Bidang Pendidikan

- Pemerintah 600,000 400,000 1,000,000 murni di ambil
- Swasta 1,500,000 1,000,000 2,500,000 oleh RS

c Pendamping/Pembimbing Lapangan
- Pemerintah 200,000 200,000 Mutlak diberikan
kepada
Pembimbingnya
- Swasta 300,000 300,000

d Studi Banding / Orang / Hari 120,000 80,000 200,000

catatan :
Bagi Instansi yang melakukan kerjasama di bidang pendidikan maka pegawai/mahasiswa :
- Yang akan melakukan penelitian atau praktek lapangan akan dikenakan biaya .
D3 = Rp. 75.000,-
S1/D4 = Rp.100.000,-
S2 = Rp. 125.000,-
S3 = Rp. 150.000,-

- Untuk pembimbing lapangan

D3 = Rp.100.000,-
S1/D4 = Rp. 100.000,-
S2 = Rp. 200.000,-
S3 = Rp. 300.000,-

Page 21
2. TARIF PEMAKAIAN AMBULANCE DAN MOBIL JENAZAH
No. Jenis Pelayanan Tarif

2.1 PELAY8ANAN MOBIL AMBULANCE / JENAZAH

1 Dalam Kota
2 Luar Kota berdasarkan jarak antar ditambah rp.8.500/KM + Rp.100.000 (Biaya Administrasi) 100.000 +
8.500/KM
2.2 PELAYANAN DOKTERPERAWAT PENDAMPING ATAU SOPIR PASIEN RUJUKAN LUAR KOTA
1) Dokter
1 Dalam Kota 200,000
2 Luar kota (0-350 km) 750,000
3 Luar Kota (>350 Km) 2,000,000
* Untuk Daerah > 350 KM Rumah Sakit mendapat 20% dari Jasa Pendamping
2) Perawat Pendamping
1 Dalam Kota 150,000
2 Luar kota (0-350 km) 500,000
3 Luar Kota (>350 Km) 1,500,000
* Untuk Daerah > 350 KM Rumah Sakit mendapat 20% dari Jasa Pendamping

2.3 PELAYANAN PEMINJAMAN AMBULANCE RUJUKAN LUAR KOTA

1. Peminjaman ambulance (dalam kota) per jam 25,000
2. Peminjaman amblance dengan sopir (luar kota) per 8500/KM ditambah Rp. 100.000 +
8.000/KM
3. TARIF LAYANAN LOUNDRY DAN CSSD
Jasa Pegawai
Jasa Sarana
Rumah Sakit Petugas Non Medis
No. Jenis Pelayanan Tarif
40%
60%
70% 30%
1 Laundry
- Baju Operasi 1,500 700 300 2,500
- Baju Pasien Non Steril 1,560 728 312 2,600
- Celana Operasi 1,500 700 300 2,500
- Duk Biru 900 420 180 1,500
- Duk Pembungkus 2,100 980 420 3,500
- Duk Rapat Steril 1,500 700 300 2,500
- Jas Operasi Non Steril 3,000 1,400 600 5,000
- Linen Operasi 39,000 18,200 7,800 65,000
- Linen Sedang 39,000 18,200 7,800 65,000
- Linen Set 39,000 18,200 7,800 65,000
- Masker 13,200 6,160 2,640 22,000
- Sarung Meja Mayo 1,200 560 240 2,000
- Sarung Trolley 1,200 560 240 2,000

2 CSSD
- Ambu 24,000 11,200 4,800 40,000
- Angkat Jahit 7,200 3,360 1,440 12,000
- Apendik 15,000 7,000 3,000 25,000
- Arteri Klem 3,600 1,680 720 6,000
- Bak Spuit 4,800 2,240 960 8,000
- Bedah Syaraf 15,000 7,000 3,000 25,000
- Biopsi 7,200 3,360 1,440 12,000
- Bor Tangan 7,800 3,640 1,560 13,000
- Botol Lab 4,200 1,960 840 7,000
- Botol O2 24,000 11,200 4,800 40,000
- Botol Obat 4,200 1,960 840 7,000
- Botol Suction 24,000 11,200 4,800 40,000
- Bugie 3,000 1,400 600 5,000
- Carneo Facial 15,000 7,000 3,000 25,000
- Com Bengkok 6,000 2,800 1,200 10,000
- Com Kecil 2,400 1,120 480 4,000
- Com Respirator 24,000 11,200 4,800 40,000
- Cop Vacuum Karet 18,000 8,400 3,600 30,000
- Deper Kacang 960 448 192 1,600
- Drain 13,200 6,160 2,640 22,000
- Eseter 13,200 6,160 2,640 22,000
- Exerpatie 7,200 3,360 1,440 12,000
- Extetion 13,200 6,160 2,640 22,000
- Extra 7,200 3,360 1,440 12,000
- Forcef Tang 7,200 3,360 1,440 12,000
- Ganti Luka 7,200 3,360 1,440 12,000
- Garisan 3,000 1,400 600 5,000
- Gass Perut 11,100 5,180 2,220 18,500
- Gudel 12,600 5,880 2,520 21,000
- Gunting 3,300 1,540 660 5,500

Page 21
 Jasa Sarana Jasa Pegawai
Rumah Sakit Petugas Non Medis
No. Jenis Pelayanan 40% Tarif
60%
70% 30%
- Heacting 7,200 3,360 1,440 12,000
- Heacting Up 7,200 3,360 1,440 12,000
- Hernia 15,000 7,000 3,000 25,000
- Humedifier 24,000 11,200 4,800 40,000
- Hydrocubator 6,600 3,080 1,320 11,000
- Inspeculo 6,000 2,800 1,200 10,000
- Jarum Functie 13,200 6,160 2,640 22,000
- Jelly 13,200 6,160 2,640 22,000
- Kabel Corter 24,000 11,200 4,800 40,000
- Kantong Plastik 13,200 6,160 2,640 22,000
- Kanula 16,800 7,840 3,360 28,000
- Cup Lampu 17,400 8,120 3,480 29,000
- Kapas Gigi 600 280 120 1,000
- Kapas Sublimat/Gulung 300 140 60 500
- Kasa Besar 1,800 840 360 3,000
- Kasa Kecil 900 420 180 1,500
- Kasa Sedang 960 448 192 1,600
- Cut Suction 12,600 5,880 2,520 21,000
- Kateter Logam 3,000 1,400 600 5,000
- Kateter Merah 17,400 8,120 3,480 29,000
- Koher 3,600 1,680 720 6,000
- Kom Tutup 4,800 2,240 960 8,000
- Kondom 13,200 6,160 2,640 22,000
- Connector 13,200 6,160 2,640 22,000
- Laparatomi Anak 14,400 6,720 2,880 24,000
- Laparatomi Bayi 14,400 6,720 2,880 24,000
- Laparatomi Dewasa 14,400 6,720 2,880 24,000
- Lidi Kapas 600 280 120 1,000
- Maslang 17,400 8,120 3,480 29,000
- Mastoid 7,800 3,640 1,560 13,000
- Mata bor 7,800 3,640 1,560 13,000
- Myotomi 14,400 6,720 2,880 24,000
- Nebulyzer 24,000 11,200 4,800 40,000
- NGT 24,000 11,200 4,800 40,000
- Ortopedi 15,000 7,000 3,000 25,000
- Pap Smear 13,200 6,160 2,640 22,000
- Feeding Tube 13,200 6,160 2,640 22,000
- Partus 7,200 3,360 1,440 12,000
- Pinset 3,600 1,680 720 6,000
- Pinset + Tempat 5,100 2,380 1,020 8,500
- Pisau 3,600 1,680 720 6,000
- Pompa Asi 23,400 10,920 4,680 39,000
- Fregment 16,800 7,840 3,360 28,000
- PTP Set 7,200 3,360 1,440 12,000
- Respirator 24,000 11,200 4,800 40,000
- Role Gas 10,500 4,900 2,100 17,500
- Sectio 14,400 6,720 2,880 24,000
- Selang ETT 13,200 6,160 2,640 22,000
- Selang Suction 23,400 10,920 4,680 39,000
- Selang Sceris 23,400 10,920 4,680 39,000
- Set Besar 14,400 6,720 2,880 24,000
- Set BMP 6,600 3,080 1,320 11,000
- Kuretase 6,600 3,080 1,320 11,000
- Set Dawo 7,800 3,640 1,560 13,000
- Set Dower 7,200 3,360 1,440 12,000
- Set ET 14,400 6,720 2,880 24,000
- Set HPP 7,200 3,360 1,440 12,000
- Set HSG 14,400 6,720 2,880 24,000
- Set Infus 4,500 2,100 900 7,500
- Set Kecil 4,500 2,100 900 7,500
- Set Korentang 4,800 2,240 960 8,000
- Set LD 7,800 3,640 1,560 13,000
- Set LP 7,200 3,360 1,440 12,000
- Set Makan 13,800 6,440 2,760 23,000
- Set Mandi 7,200 3,360 1,440 12,000
- Set Mata 7,200 3,360 1,440 12,000
- Set OPU 14,400 6,720 2,880 24,000
- Set Orthopedi 14,400 6,720 2,880 24,000
- Set Plastik 7,800 3,640 1,560 13,000
- Set Pomoroy 14,400 6,720 2,880 24,000
- Set Sedang 7,800 3,640 1,560 13,000
- Set Syaraf 14,400 6,720 2,880 24,000
- Set Terbel Tapel 7,800 3,640 1,560 13,000
- Sircumsisi 7,200 3,360 1,440 12,000
- Slang O2 17,400 8,120 3,480 29,000
- Slang Silicon 13,200 6,160 2,640 22,000
- Slang WSD 23,400 10,920 4,680 39,000
- Slim Seger 17,400 8,120 3,480 29,000
- Sonde 13,200 6,160 2,640 22,000
- Speculum 3,300 1,540 660 5,500
- Spuit Gliserin 3,300 1,540 660 5,500
- Spuit Plasma 3,300 1,540 660 5,500
- Tampon Rool 6,300 2,940 1,260 10,500
- Tampon Vagina 3,900 1,820 780 6,500
- Tempat Korentang 4,500 2,100 900 7,500
- Tepis 13,200 6,160 2,640 22,000
- Tip Kuning 23,400 10,920 4,680 39,000
- Tissu 4,200 1,960 840 7,000
- Tong Spatel 3,300 1,540 660 5,500
- Tonsil 7,200 3,360 1,440 12,000
- Tracheatomi 7,800 3,640 1,560 13,000
- Transducer 18,000 8,400 3,600 30,000
- Tri way 13,200 6,160 2,640 22,000
- TRM Besar 9,600 4,480 1,920 16,000
- TRM Kecil 6,000 2,800 1,200 10,000
- TRM Sedang 7,800 3,640 1,560 13,000
- Umbilical 7,200 3,360 1,440 12,000
- Uterus Sonde 3,300 1,540 660 5,500
- Vagina Toilet 7,200 3,360 1,440 12,000
- Vaseline 4,800 2,240 960 8,000
- Vena Sectie 7,200 3,360 1,440 12,000
3 Laundry Kiloan Khusus Keluarga Pasien
Laundry 4,200 1,960 840 7,000

Page 21
J. TARIF PENGGUNAAN SARANA/PERALATAN RSUD SITI AISYAH LUBUKLINGGAU

No. Jenis Pelayanan Tarif

1. Sewa Ruangan 1,500,000

Sewa Ruang Seminar/hari 800,000
Sewa Ruang Rapat/hari 2,000
Penggunaan WC Umum (Per kali/ orang) 4,000
Penggunaan Kamar Mandi (Per Kali/orang)
2 Sewa Lahan dan Bangunan 35,000
Sewa Lahan/meter/bulan 75,000
Sewa Bangunan/meter/bulan 600,000
Sewa Kounter/Unit 25,000
3 Pengolahan limbah padat medis menggunakan incenerator per kg (minimal 5 kg) 1,000,000
4 Pengolahan limbah cair menggunakan IPAL per m3 (minimal 5 m3)
5 Retribusi sampah untuk pedagang di lingkungan RSUD Siti Aisyah Lubuklinggau 15,000
- Kios kecil (per bulan) 50,000
- Kantin/Kios besar (per bulan) 5,000
6 Kompos (Per bungkus)
7 Pemakaian Oksigen
Pemakaian Oksigen Per Jam 7,500
Pengisian O2 Tabung Kecil 22,000
Pengisian O2 Tabung Sedang 86,000
Pengisian O2 Tabung Besar 169,000

Di tetapkan di Lubuklinggau
Pada tanggal,
Walikota Lubuklinggau

H.SN. Prana Putra Sohe

Page 21
 LAMPIRAN II
PERATURAN WALIKOTA LUBUKLINGGAU
TAHUN NOMOR
TENTANG TARIF PELAYANAN KESEHATAN
PADA RUMAH SAKIT UMUM DAERAH
SITI AISYAH KOTA LUBUKLINGGAU

KATEGORI JENIS OPERASI

A. OPERASI BESAR

1. Pengangkatan Neuro Fibroma

2. Pengangkatan Tandur Kulit
3. Tindahkan Bedah Beku
4. Tindakan Bedah Flap
5. Tindakan Cryosurgery
6. Tindakan Dermabrasi
7. Tindakan Punksi Lumbal
8. Spooling Sinus / 1 Kali
9. Alveolectomi
10. Gingivectomy
11. Injeksi Haemoroid ( termasuk obat)
12. Injeksi Varises ( termasuk Obat)
13. Apendektomi laparoskopi
14. Excochliasi kdelitiasis
15. Kolostomi
16. Labioplasti Unilateral
17. Laparatomy percobaan
18. Marsupialisasi Ranula
19. Punksi cairan otak dengan narkose
20. rekontruksi kelainan jari/ ekstremitas ( Polidaktili, sidaktili, construction hanf) sederhana
21. Repair fistel urethra pascauretroplasti
22. Repair Komplikasi AV Shunt
23. Reshaping untuk Torus // Tumor Tulang
24. Sequesterectomy dengan narkose
25. Sirklase
26. Tonsilektomi
27. Turbinektomi
28. Adenolisis
29. Amputasi Transmedular
30. Apendektomi perforata
31. Atrostomi dan adenoidektomi
32. Caldwell luc Anthrostomi
33. Drainagr kista pankreas
34. drainage periureter
35. Eksisi Hogroma
36. Eksisi Kista Tiroglosus
37. Eksisi Kista Urachus
38. Eksplorasi Kista Ductus Tiroglosus
39. Eksplorasi kista Tiroid
40. Ethmoidektomi ( Intranasal)
41. Extirpatie Plunging Ranula
42. Fiksasi Interna yang Kompleks
43. Hystrecktomy Partial
44. Kehamilan Ektopik terganggu (KET)
45. Kistektomi
46. Koreksi Disartikulasi
47. Koreksi Extropion/ Entropion
48. Koreksi Priaspismus
49. Koreksi Symblepharon
50. labioplasti Bilateral
51. Mastektoi Subkutaneus
52. Myomectomy
53. Operasi Hernia Incarcerata
54. Operasi Hernia dengan Komplikasi
55. Operasi Hypospadia
56. Operasi Manchester Fortegil
57. Operasi Mikrotia
58. Operasi palatoplasti
59. Orchidektomi Subkapsuler
60. Pemasangan T Tube
61. Penektomi
62. Potong Flap
63. Rekanalisasi Reptura / Transkanal
64. Rekontruksi Kontraktur
65. Repair fistel
66. Repair Fraktur Penis
67. Repair Luka Pada wajah kompleks
68. Salpingoofarektomi unilateral
69. Segmentektomi
70. Seksio Cesaria
71. Septum Reseksi
72. Tansilo Adenoidectomi
73. Ureterostomi

Page 25
74. Vasografi
75. Amputasi Eksisi kista Branchiogenik
76. Anterior / Posterior Sklerotomi
77. Arthrosplasty
78. Detorsi Testis dengan Orchidopexi
79. Devertikulektomi
80. Eksporasi Duktus Koledokus
81. Enukleasi Kista Ginjal
82. Extraksi Linear
83. Fistula Uretervesika
84. Frontoethmoidektomii ( Ekstranasal)
85. Goniotomi
86. Graf Vena membuat A Vistula
87. Hemiglosektomi
88. Herniatomi Bilateral
89. Hystrecktomi Total
90. Internal Urethrotomi
91. Isthobektomi
99. Kolesistektomi
100. Koreksi atresia ani
101. Koreksi CTEV ( congenital talipes equino Varus)
102. Koreksi Fraktur Rahang Multiple / kompleks
103. Koreksi Strabismus
104. Labiopalatoplasti Bilateral
105. Laparatomi Eksplorasi
106. Laparotomi VC
107. Litotripsi
108. Maksilektomi Partialis
109. Mandibulektomi marginalis
110. Mastektomi simpleks
111. Mastoidektommi Radikal
112. Myringoplasty
113. Nefropexie
114. Nefrostomi Open
115. Neurektomi Sraf Vidian
116. Open reduksi Fraktur / Dislokasi Lama
117. Operasi Cyclodialysa
118. Operasi Peyronie
119. Operasi Psoas Hiscth / Boari Flap
120. Operasi Tumor Jinak Ovarium
121. Operasi Tumor Pembuluh Darah
122. Orchidektomi Surgery
123. Pembedahan Kompartemental
124. Prostatektomi Retropublik
125. Pyelolithotomi
126. Pyeloplasty
127. Rekontruksi Kontraktur Kompleks
128. Rekontruksi Blassemeck
129. Rekontruksi Defek / Kelainan Tubuh yang Kompleks
130. Rekontruksi Vesika
131. Reparasi Fistula Vesiko Vagina
132. Resectie Rahang
133. Reseksi Adenomiosis
134. Reseksi Anastomosis
135. Reseksi Partial Vesika
136. Reseksi Urachus
137. Rinotomi Lateralis
138. Salpingo Ophorektomi Bilateral
139. Salpingoofarektomi Bilateral
140. Salbaging Operasi Mikro
141. Simpatektomi
142. Tindakan Dekompresi Fasialis
143. Tindakan Pharyngeal Flap
144. Tirodektomi
145. Trabekulektomi
146. Transeksi Esofagus
147. Tumor Ganas/ Adneksa luas dengan rekonstruksi
148. Uretero Sigmoidostomi
149. Uretero Ureterostomi
150. Ureterocutaneostomi
151. Ureterolithotomi
152. Urethrektomi
153. Uretroplasti
154. Uretroplasti

Page 25
B. OPERASI SEDANG

1. Angkat K - Wire dengan Hekting

2. Eksis Chalazio
3. Insisi Abses Glutea / Mammae (Besar)
4. Insisi Intra Oral
5. Lobuloplasti 2 telinga
6. Pemberian Sitostatika
7. Pengangkatan Skin tag
8. Amputasi Jari ( Tanpa Narkose)
9. Eksisi Pterigium
10. Ektirpasi Fibroma
11. Enucleatie Kista
12. Fistulectomi
13. Frenectomi
14. Odontectomy dengan lokal anatesi
15. Operculectomy
16. Penutupan Oroantral Fistula
17. Punksi / Irigasi Pleura
18. Reposisi dengan anatesi lokal
19. Sistostomi
20. Tindakan deepening Sulcus
21. Vena seksi
22. Sirkumsisi
23. Pemasangan WSD
24. Tubektomi
25. Vasektomi
26. Angkat Pen
27. Apendektomi Akut
28. Biopsi prostat
29. Biopsi Saraf kuntaneus / otot
30. Biopsi testis
31. Dibredement fraktur terbuka
32. Dilatasi Urethra
33. Eksisi/Konisasi
34. Enucleatie Kista
35. Extirpasi polip
36. Extirpasi Tumor
37. Fiksasi Externa Sederhana
38. Fistulektomi
39. Flebektomi
40. Hemoroidektomi
41. Herniotomi
42. Kuretase dengan narkose
43. Meatotomi
44. Operasi Hernia Tanpa Komplikasi
45. Operasi Hydrokel
46. Operasi katarak ICCE / ECCE (tak termasuk IOL)
47. Pengangkatan Fibro Adenom Mamae
48. Pengangkatan Ganglion Poplitea dengan Narkose
49. Repair luka robek sederhana pada wajah
50. Reposisi fraktur sederhana os nassal
51. Sirkumsisi pada Phymosis dengan narkose
52. Sistostomi
53. Terapi Sklerosing
54. Anoplasti sederhana ( Cut Back)
55. Debridement pada luka bakar
56. eksisi Chodee
57. Eksisi abses Parafaringeal
58. Eksplorasi Kista Branchial
59. Fissurektomi
60. Fissurektomi Peri anal
61. Koreksi Tarsio Testis
62. Ligasi tinggi hidrokel
63. Open renal Biopsi
64. Operasi pada Spermatocele
65. Operasi pada Varicocele / Palomo
66. Pemasangan Cimino
67. Potong Flap
68. Repair tendon jari
69. Reposisi Fixatie ( Compucate)
70. Reposisi Fraktur / Dislokasi dalam narkose
71. Reposisi Faktur rahang sederhana
72. Reposisi faktur rahang simple
73. Skingrafting yang tidak luas
74. Tindakan Congenital Fornix plastik
75. Tidakan Argon Leser / Kenon
76. Tindakan Blok Resectie
77. Tindakan Cyclodia Termi
78. Tindakan pada Kolpodeksis
79. Tracheostomi
80. Ureterostomi
81. Vesicolithotomi ( Section alta)
82. Anterior / Posterior Sklerotomi
83. Eksisi Angiofibroma Nasofaring

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 84. Eksisi Mamma Aberran
85. Fare Head Flap
86. Faringotomi
87. Keratoplastie Lamelar
88. Parptidektomi
89. Reposisi Fraktur Maksila / Zygoma

C. OPERASI KECIL

1. Aspirasi Pneumotoraks
2. Eksisi Chalazio
3. Eksisi Hordeulum / Granuloma
4. Eksterpasi Kista Ateramo / lipoma/Ganglion > 2cm
5. Insisi Epulis
6. Jahit luka palpebra
7. Pengangkatan Nevus
8. Insisi Mucocele
9. Kuretase tanpa Narkose
10. Sirkumsisi
11. Biopsi Testis

D. OPERASI CANGGIH

1. Laparoskopi

Di tetapkan di Lubuklinggau
Pada tanggal,
Walikota Lubuklinggau

H.SN. Prana Putra Sohe

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