f
WALI KOTA BALIKPAPAN PROVINSI KALIMANTAN TIMUR
PERATURAN WALI KOTA BALIKPAPAN NOMOR 32 TAHUN 2020
TENTANG
PERUBAHAN ATAS PERATURAN WALI KOTA NOMOR 4 TAHUN 2 0 1 4 TENTANG TARIF PELAYANAN KESEHATAN PADA RUMAH SAKIT KHUSUS
BERSALIN SAYANG IBU “KELAS B” KOTA BALIKPAPAN
DENGAN RAHMAT TUHAN YANG MAHA ESA WALI KOTA BALIKPAPAN,
M en im b an g . a. b a h w a P e ra tu ra n W ali K ota N om or 4 T a h u n 2 0 1 4 te n ta n g T arif P e la y a n a n K e se h a ta n P a d a R u m a h S a k it K h u s u s B ersalin S a y a n g Ib u ”K elas B” K ota B a lik p a p an s u d a h tid a k s e s u a i d e n g a n k o n d isi s a a t ini seh in g g a p e rlu p e n y e su a ia n ;
b. b a h w a b e rd a s a rk a n p e rtim b a n g a n s e b a g a im a n a d im a k su d d a la m h u r u f a p e rlu m e n e ta p k a n P e ra tu ra n W ali K ota te n ta n g P e ru b a h a n A tas P e ra tu ra n W ali K ota N om or 4 T a h u n 2 0 1 4 te n ta n g T arif P e lay a n an K e se h a ta n p a d a R u m a h S a k it K h u s u s B ersalin S ay an g Ib u “K elas B”
K ota B a lik p ap an ;
M engingat : 1. P a sa l 18 a y a t (6) U n d a n g -U n d a n g D a sa r N egara R ep u b lik In d o n e sia T a h u n 1945;
2. U n d a n g -U n d a n g Nom or 27 T a h u n 1959 te n ta n g P e n e ta p a n U n d a n g -U n d a n g D a ru ra t Nom or 3 T a h u n 1953 te n ta n g P e rp a n ja n g a n P e m b e n tu k a n D a era h T in g k at II di K a lim a n ta n (L em baran N egara R ep u b lik
U n d a n g (L em baran N egara R ep u b lik In d o n e s ia T a h u n 1959 N om or 72, T a m b a h a n L em b aran N egara R epublik In d o n e s ia Nom or 1820);
3. U n d a n g -U n d a n g Nom or 2 3 T a h u n 2 0 1 4 te n ta n g P e m e rin ta h a n D a e ra h (L em baran N egara R epublik In d o n e sia T a h u n 2 0 1 4 N om or 244, T a m b a h a n L em b aran N egara R ep u b lik In d o n e s ia N om or 5587) se b a g a im a n a te la h d iu b a h b e b e ra p a k ali te ra k h ir d e n g a n U n d an g - U n d a n g Nom or 9 T a h u n 2 0 1 5 te n ta n g P e ru b a h a n K edua A tas U n d a n g -U n d a n g N om or 23 T a h u n 2 0 1 4 te n ta n g P e m e rin ta h a n D a era h (L em baran N egara R epublik In d o n e sia T a h u n 2 0 1 5 N om or 58, T a m b a h a n L em b aran N egara R ep u b lik In d o n e sia N om or 5679);
4. P e ra tu ra n M enteri D alam Negeri N om or 79 T a h u n 2 0 1 8 te n ta n g B a d a n L ay a n an U m u m D a e ra h (B erita N egara R ep u b lik In d o n e s ia T a h u n 2 0 1 8 N om or 1213);
5. P e ra tu ra n W ali K ota B a lik p a p a n N om or 4 T a h u n 2 0 1 4 te n ta n g T arif P e la y a n a n K e se h a ta n p a d a R u m a h S a k it K h u s u s B e rsalin S a y a n g Ib u “K elas B” K ota B a lik p a p a n (B erita D a e ra h K ota B a lik p a p a n T a h u n 2 0 1 4 N om or 4);
MEMUTUSKAN:
M e n e ta p k a n : PERATURAN WALI KOTA TENTANG PERUBAHAN ATAS PERATURAN WALI KOTA NOMOR 4 TAHUN 2 0 1 4 TENTANG TARIF PELAYANAN KESEHATAN PADA RUMAH SAKIT KHUSUS BERSALIN SAYANG IBU “KELAS B ” KOTA BALIKPAPAN.
P a sa l I
L am p iran d a la m P e ra tu ra n W ali K ota N om or 4 T a h u n 201 4 te n ta n g T arif P e la y a n a n K e se h a ta n p a d a R u m ah S a k it K h u s u s B ersalin S a y a n g Ibu “K elas B ” K ota B a lik p a p a n (B erita D a e ra h K ota B a lik p a p an T a h u n 2 0 1 4 Nom or 4) d iu b a h seh in g g a b e rb u n y i se b a g a im a n a te rc a n tu m d a la m L am p iran y a n g m e ru p a k a n b ag ian tid a k te rp is a h k a n d a ri P e ra tu ra n W ali Kota ini.
P a sa l II
P e ra tu ra n W ali K ota in i m u la i b e rla k u p a d a tan g g al d iu n d a n g k a n .
Agar s e tia p o ra n g m e n g e ta h u in y a , m e m e rin ta h k a n p e n g u n d a n g a n P e ra tu ra n W alikota ini d e n g a n p e n e m p a ta n n y a d a la m B e rita D a e ra h Kota B a lik p a p an .
D ite ta p k a n di B a lik p a p an p a d a tan g g al 19 Oktober 2020 WALI KOTA BALIKPAPAN,
Ttd.
M. RIZAL EFFENDI
D iu n d a n g k a n di B a lik p a p a n p a d a tan g g a l 20 Oktober 2020
SEKRETARIS DAERAH KOTA BALIKPAPAN, Ttd.
SAYID MN FADLI
BERITA DAERAH KOTA BALIKPAPAN TAHUN 2020 NOMOR 32
S a lin a n s e s u a i d e n g a n a slin y a
SEKRETARIAT DAERAH KOTA BALIKPAPAN Pit. KEPALA BAGIAN HUKUM,
YEMMIE H/ENDRAWAN PUTRA
LAMPIRAN
PERATURAN WALI KOTA BALIKPAPAN
NOMOR 32 TAHUN 2020 TENTANG
PERUBAHAN ATAS PERATURAN WALI KOTA
NOMOR 4 TAHUN 2 0 1 4 TENTANG TARIF
PELAYANAN KESEHATAN PADA RUMAH SAKIT KHUSUS BERSALIN SAYANG IBU “KELAS B”
KOTA BALIKPAPAN
TARIF KEGIATAN PELAYANAN DAN NON PELAYANAN
D. INSTALASI RAWAT INAP
1 P e ra w a ta n K elas III 9 3 .7 5 0
2 P e ra w a ta n K elas II 118.750
3 P e ra w a ta n K elas I 3 1 2 .5 0 0
4 P e ra w a ta n Bayi K h u s u s 125.000
E. INSTALASI GAWAT DARURAT
1 P e m e rik sa a n D o k ter 2 5 .0 0 0
2 P e m e rik sa a n O b ste tri 3 1 .2 5 0
3 P e n a n g a n a n L u k a 5 0 .0 0 0
4 P e ra w a ta n L u k a 5 0 .0 0 0
5 P e m a s a n g a n iv C a th e te r 5 0 .0 0 0
6 P e m a s a n g a n C a th e te r 3 7 .5 0 0
7 T erapi In h a la si 3 7 .5 0 0
8 J a h i t L u k a 7 5 .0 0 0
9 P e n a n g a n a n K ejang 4 3 .7 5 0
10 E k s tra k s i K uku 7 5 .0 0 0
11 S irk u m sisi 5 0 0 .0 0 0
12 E k s tra k s i C o p ru s A lienum 8 1 .2 5 0
13 Irigasi L am b u n g 125.000
14 In cisi A bces 3 7 .5 0 0
15 P e m e rik sa a n EKG 9 3 .7 5 0
16 R e su sita s i 3 1 2 .5 0 0
17 T indik T elinga 4 3 .7 5 0
18 P e n a n g a n a n lu k a b a k a r 5 0 .0 0 0
19 Irigasi m a t a / telin g a 5 0 .0 0 0
20 P e m b erian in jek si 3 1 .2 5 0
21 T in d a k a n m ed is n o n o p e ra tif b e s a r 150.000 22 T in d a k a n n o n o p e ra tif se d an g 6 2 .5 0 0
23 T in d a k a n n o n o p e ra tif kecil 3 7 .5 0 0
F. RUANG OPERASI
1 SC + S u p r a V aginal H isterek to m i (SVH), B ilateral S alpingo O oforektom i (BSO) / Salpingo
O oforektom i D e k stra / S in istra (SO D /S)
6.000.00C
2 SC + T otal A bdom inal H isterek to m i (TAH), B S O /S O D /S
6.000.00C)
3 SC + B - L ynch P ro ced u re 6.000.00C
4 Total A bdom inal H isterek to m i (TAH) 6.000.00C
5 TAH + BSO 6.000.00C
6 TAH + SOD / SD S? 6 .0 0 0 .0 0 0
7 SVH + BSO 6 .0 0 0 .0 0 0
8 SVH + SOD / SOS 6 .0 0 0 .0 0 0
9 SC + K istektom i 5 .5 0 0 .0 0 0
10 SC + A dhesiolysis 5 .5 0 0 .0 0 0
11 K istektom i D /S 5 .5 0 0 .0 0 0
12 S u p ra v a g in a l (parsial) H isterek to m i (SVH) 5 .5 0 0 .0 0 0
13 A hesiolisis 5 .5 0 0 .0 0 0
14 M yom ektom i 5 .5 0 0 .0 0 0
15 Sectio C a e s a ria ( SC ) 4 .4 0 0 .0 0 0
16 H isterek to m i to T erm in ate P reg n an cy 4 .4 0 0 .0 0 0 17 SC + M etode O p e ratif W an ita (MOW) 3 .1 2 5 .0 0 0 18 S alp in g ek to m i d e n g a n p e n g a n g k a ta n k e h a m ila n
E k to p ik
3 .1 2 5 .0 0 0
19 B - L ynch P ro ced u re 3 .1 2 5 .0 0 0
20 S alpingoooforektom i D e k stra / S in is tra (SOD / SDS)
3 .1 2 5 .0 0 0
21 S alp in g ek to m i D /S 3 .1 2 5 .0 0 0
22 E k sisi K ista B a rth o lin i 3 .1 2 5 .0 0 0
23 In sisi d a n M a rsu p ia lisa si k is ta B a rth o lin i 3 .1 2 5 .0 0 0
24 K u ret M ola / S u c tio n K u ret 3 .1 2 5 .0 0 0
25 MOW (M inilaparotom i) Ligasi B ilateral T u b a Falopii
1 .5 0 0 .0 0 0
26 K a u te risa si C o ndilom a A ccu m in ata 1.500.00C
G. RUANG PERSALINAN
1 P e rs a lin a n n o rm a l 5 2 5 .0 0 0
2 P e rs a lin a n d e n g a n tin d a k a n 7 0 0 .0 0 0
3 J a s a S p esialis 6 2 5 .0 0 0
4 CTG (C ardiotocography) 9 3 .7 5 0
5 R ep air v ag in a 2 5 0 .0 0 0
6 M a n u al p la c e n ta 125.000
H. LABORATOR1UM H I. H em a to lo g i
1 D a ra h r u tin 6 7 .5 0 0
2 H em oglobin 3 7 .5 0 0
3 LED 16.250
4 Gol. D a ra h ABO 17.500
5 R e su s 12.500
6 W ak tu p e m b e k u a n 12.500
7 W ak tu p e n d a r a h a n 12.500
8 M alaria/D D R 4 8 .0 0 0
9 ICT M alaria 155.000
10 F ilaria 4 8 .0 0 0
11 CD4 3 0 6 .0 0 0
H2. H e m o s ta s is
1 PTT 9 0 .0 0 0
2 APTT 9 0 .0 0 0
3 INR 9 0 .0 0 0
4 D -D im er 2 2 4 .0 0 0
5 F ibrinogen 5 3 8 .0 0 0
H 3. K im ia Darah
1 G lu k o sa D a ra h S tik 2 7 .5 0 0
2 G lu k o sa D a ra h 2 1 .2 5 0
3 U re u m 2 1 .2 5 0
4 K reatin in 2 1 .2 5 0
5 A sam U ra t 2 2 .5 0 0
6 K olesterol Total 2 3 .7 5 0
7 K olesterol HDL 5 0 .0 0 0
8 K olesterol LDL 2 5 .0 0 0
9 Trigliserid 2 8 .7 5 0
10 T otal Lipid 2 2 .5 0 0
11 B iliru b u n Total 2 2 .5 0 0
12 B iliru b in D irek 2 2 .5 0 0
13 B iliru b in In d irek 2 2 .5 0 0
14 SG O T / AST 2 1 .2 5 0
15 SG PT / ALT 2 1 .2 5 0
16 G a m m a GT 3 2 .5 0 0
17 F o sfata se Alkali 2 7 .5 0 0
18 P ro tein T otal 2 2 .5 0 0
19 A lbum in 2 2 .5 0 0
20 G lobulin 2 2 .5 0 0
22 R ivalta 2 6 .0 0 0
23 E s b a c h 2 6 .0 0 0
24 N onne 2 6 .0 0 0
25 P an d y 2 6 .0 0 0
26 Alkali F o sfatase 4 3 .0 0 0
27 G a m m a G T/G G T 4 5 .0 0 0
28 CKMB 113.000
29 CK (C reatin in e Kinase) 6 5 .0 0 0
30 LDH 5 0 .0 0 0
31 T ro p o n in I/T 2 1 0 .0 0 0
32 G lobulin 4 0 .0 0 0
33 CCT (C reatin in e K lirens Test) 4 8 .0 0 0
34 T rigliserida 4 3 .0 0 0
35 HDL 7 0 .0 0 0
36 LDL 7 5 .0 0 0
37 TTGO 110.000
38 H bA lC 2 2 8 .0 0 0
39 K alsium 2 0 5 .0 0 0
40 SI 105.000
41 TIBC 105.000
42 E lek tro lit Na, K, Cl 2 1 8 .0 0 0
H 4. M ik rob iologi
1 G ram 3 8 .0 0 0
2 BTATB 3 8 .0 0 0
3 BTAM H 3 8 .0 0 0
4 J a m u r (KOH) 3 8 .0 0 0
5 D ifteri (Neisser) 7 0 .0 0 0
6 S e k re t (m ata, v ag in a, u re tra ) 3 8 .0 0 0
7 K u ltu r d a ra h 5 5 .0 0 0
8 K u ltu r s p u tu m 5 5 .0 0 0
9 K u ltu r se k re t 5 5 .0 0 0
10 K u ltu r p u s 5 5 .0 0 0
11 K u ltu r p le u ra 5 5 .0 0 0
12 K u ltu r LCS 5 5 .0 0 0
13 K u ltu r c a ira n tu b u h lain 5 5 .0 0 0
14 K u ltu r u rin e 5 5 .0 0 0
15 K u ltu r faeces 5 5 .0 0 0
16 K u ltu r SS 5 5 .0 0 0
17 K u ltu r D ifteri/sw a b la in n y a 5 5 .0 0 0
18 K u ltu r J a m u r 5 5 .0 0 0
19 K u ltu r M alaria 5 5 .0 0 0
20 K u ltu r T u b e rc u lo sis 5 5 .0 0 0
H 5. I m u n o / S ero lo g i
1 HBsAg K u alitatif 6 1 .2 5 0
2 HBsAb K u alitatif 6 6 .2 5 0
3 VDRL RPR 8 0 .0 0 0
4 T ubex 175.000
5 Weil Felix 8 0 .0 0 0
6 A STO / ASO 6 5 .0 0 0
7 R h e u m a to id facto r (RF) 110.000
8 CRP k u a lita tif 130.000
9 CRP k u a n tita tif 2 0 0 .0 0 0
10 A nti TB 125.000
11 A nti HAV IgM 2 1 2 .0 0 0
12 A nti HAV Total 3 0 0 .0 0 0
13 HBe Ag 3 0 0 .0 0 0
14 A nti H be 3 0 0 .0 0 0
15 A nti HBc IgM 3 0 0 .0 0 0
16 A nti HCV (kualitatif) 125.000
17 A nti to x o p la sm a IgM 2 4 5 .0 0 0
18 A nti to x o p la sm a IgG 2 4 5 .0 0 0
19 A nti R u b ella IgM 2 4 5 .0 0 0
20 A nti R u b ella IgG 2 4 5 .0 0 0
21 A nti CMV IgM 2 4 5 .0 0 0
22 A nti CMV IgG 2 4 5 .0 0 0
23 A nti HSV 1 IgM 2 4 5 .0 0 0
24 A nti HSV 1 IgG 2 4 5 .0 0 0
25 A nti HSV 2 IgM 2 4 5 .0 0 0
26 A nti HSV 2 IgG 2 4 5 .0 0 0
27 TPHA 190.000
28 TSH 2 4 5 .0 0 0
29 FT4 2 4 5 .0 0 0
30 T3 2 4 5 .0 0 0
31 C a 125 3 7 0 .0 0 0
32 B e ta HCG 2 8 0 .0 0 0
33 AFP 2 2 0 .0 0 0
34 CEA 2 2 0 .0 0 0
36 IgE T otal 2 4 5 .0 0 0
37 A nti SAKS COV-2 2 6 0 .0 0 0
38 R apid
Covid
- 19 150.000H6. A n a lisis Gas D arah 3 1 2 .2 5 0
H 7. U rine
1 U rine L engkap 2 5 .0 0 0
2 U rine C o m b u r 2 2 .5 0 0
3 T est K eh am ilan 2 7 .5 0 0
4 N arkoba 2 1 8 .7 5 0
5 P e m e rik sa a n U rid Acid 2 5 .0 0 0
6 D engue IgL 2 7 .5 0 0
7 D engue lgM 2 5 .0 0 0
8 B eta hC G U rine ICT 4 5 .0 0 0
9 B e ta hC G U rine tite r 5 5 .0 0 0
10 P a k e t Tes N ark o b a (7 p aram eter) 2 9 7 .5 0 0 H 8. F e s e s
1 F aeces len g k ap 3 5 .0 0 0
2 F aecal o c cu lt blood te s t (FOBT) 4 5 .0 0 0
H 9. In fe k si L ain-lain
1 W idal S trip 121.250
2 W idal Slide 2 5 .0 0 0
3 D en g u e T est 187.500
4 NS1 2 5 0 .0 0 0
5 M alaria S trip 106.000
6 A nti HIV 8 1 .2 5 0
H 1 0 . P em erik sa a n K h u su s
1 BMP (Tindakan) 150.000
2 BMP (Pem bacaan) 110.000
3 Morfologi d a r a h tepi 180.000
4 IT R atio 180.000
5 R etik u lo sit 180.000
6 Sel LE 180.000
7 Sel S ezary 180.000
8 A n alisis c a ira n o ta k 180.000
9 A nalisis c a ira n p le u ra 180.000
10 A n alisis c a ira n se n d i 180.000
11 A n alisis c a ira n a s ite s 180.000
12 A n alisis c a ira n p e rik a rd iu m 180.000
13 U rine L ep to sp ira 180.000
I. LAYANAN GIZI
1 P e la y a n a n Gizi D iet B iasa 7 5 .0 0 0
2 P e lay a n an Gizi D iet T idak M eran g san g 7 5 .0 0 0
3 P e la y a n a n Gizi D iet R G /H a ti 7 5 .0 0 0
4 P e la y a n a n Gizi D iet TKTP 8 5 .0 0 0
5 P e la y a n a n Gizi D iet DM 9 0 .0 0 0
J . PELAYANAN FARMASI
1 R acik an 1.000
2 Non R a cik an 7 0 0
3 B iaya R acik an P u y e r/K a p s u l 3 0 0
K. PELAYANAN MEDICO LEGAL
1 S u r a t K eteran g an D o k ter 12.000
2 V isum H id u p K ecelak aan L alu L in ta s (KLL) 3 0 .0 0 0
3 V isum P e rk o sa a n 6 0 .0 0 0
4 V isum M a ti/M a y a t 6 0 .0 0 0
5 V isum u n tu k A s u ra n si 3 0 .0 0 0
L. PELAYANAN LAINNYA
L I. P e la y a n a n R u ju k a n T ra n s p o rta s i d a la m K ota 6 0 .0 0 0 L2. P e lay a n an R u ju k a n T ra n sp o rta si L u ar K ota
d e n g a n tu ju a n
1 S a m a rin d a 5 4 0 .0 0 0
2 B o n ta n g 9 6 0 .0 0 0
3 T enggarong 6 6 0 .0 0 0
4 P a se r 1 .0 8 0 .0 0 0
5 M u a ra B a d a k 9 0 0 .0 0 0
6 S a n g a tta 1 .2 0 0 .0 0 0
7 B a n ja rm a s in 2 .7 0 0 .0 0 0
8 P e n a ja m P a se r U ta ra 6 0 0 .0 0 0
M. TARIF NON PELAYANAN
M l. Sew a P etak 2 0 0 .0 0 0 /B ulan/P etak
WALI KOTA BALIKPAPAN, Ttd.
M. RIZAL EFFENDI
S a lin a n s e s u a i d e n g a n a slin y a
SEKRETARIAT DAERAH KOTA BALIKPAPAN Pit. KEPALA BAGIAN HUKUM,
YEMMIE
