BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN PUSKESMAS DAN JARINGANYA DI KABUPATEN PEKALONGAN

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LAMPIRAN I

PERATURAN DAERAH KABUPATEN PEKALONGAN NOMOR 1 TAHUN 2012

TENTANG RETRIBUSI DAERAH

Jasa Sarana Jasa Pelayanan Jumlah I Rawat Jalan Puskesmas

Biaya Pelayanan Rawat Jalan 1,500 1,500 3,000 ( Administrasi, pemeriksaan dan obat)

II Biaya Rawat Inap

a. Sewa kamar / hari kelas III 10,000 5,000 15,000 Sewa kamar / hari kelas II 15,000 7,500 22,500 Sewa kamar / hari kelas I 20,000 10,000 30,000 b. Bangsal UGD 10,000 5,000 15,000

d. Asuhan Keperawatan 10,000 10,000

III TINDAKAN

1. Pertolongan Pertama

a. Debridemen luka 5,000 5,000 10,000 b. Jahitan kurang dari 5 7,500 7,500 15,000 c. Jahitan 5 sampai 10 10,000 10,000 20,000 d. Jahitan lebih dari 10 ( d tambah perjahitan Rp 1000,-)

f. Cross Insisi 7,500 7,500 15,000 i. Ransel verband 10,000 10,000 20,000 j. Spalk 6,000 6,000 12,000 k.Gigitan Binatang 6,250 6,250 12,500 l. Luka Bakar 11,750 11,750 23,500 m. Lain-lain yang termasuk ringan 5,000 5,000 10,000 n. RJP 5,000 5,000 10,000 2. Tindakan Umum

a. Perawatan Luka lama 5,000 5,000 10,000 b. Insisi dengan anestesi lokal 10,000 10,000 20,000 c. Insisi tanpa anestesi 6,250 6,250 12,500 d. Exterpasi Corpus Allenium 5,000 5,000 10,000 e. Lepas jahitan per kegiatan 5,000 5,000 10,000 f. Pasang Kateter 5,000 5,000 10,000 g. Lavement 5,000 5,000 10,000 h. Skorstain 5,000 5,000 10,000 i. Resusitasi 10,000 10,000 20,000 j. Sirkumsisi ( Khitan ) 50,000 50,000 100,000 k. Ektraksi kuku 7,500 7,500 15,000 l. Operasi kecil ( lipoma aeteroma ) 25,000 25,000 50,000 m. Operasi Katarak 150,000 150,000 300,000 n. Pasang Infus 5,000 5,000 10,000 o. Tindik telinga sepasang 5,000 5,000 10,000 p. Penggunaan Oksigen Per Liter 5,000 5,000 10,000 q. Nabulezer 5,000 5,000 10,000 r. EKG (elektrokardiograf) 7,500 7,500 15,000 s. Radiologi

a. Thorax / AP 10,000 15,000 25,000 b. Thorax AP/LAT 20,000 25,000 45,000 c. BNO tanpa kontas 10,000 15,000 25,000 d. Ekstremitas 10,000 15,000 25,000 3. Tindakan Kebidanan dan KB

a. Persalinan Normal 125,000 125,000 250,000 b. Persalinan dengan penyulit 175,000 175,000 350,000 c. Manual Placenta 25,000 25,000 50,000 d. Tindakan ringan kebidanan 5,000 5,000 10,000 e. Pasang implant 7,500 7,500 15,000 f. Cabut Impalnt 10,000 10,000 20,000 g. Pasang IUD/ Spiral 10,000 10,000 20,000 h. Cabut IUD/Spiral 12,500 12,500 25,000 i. Curetase/Abourtus 50,000 50,000 100,000 j. Papssmear 12,500 12,500 25,000 k. Vasektomi 25,000 25,000 50,000 l. Suntik KB Mandiri 6,000 6,000 12,000 m. Tindakan pengalolaan bayi baru lahir 12,500 12,500 25,000 n. Persalinan dengan resiko tinggi yang ditangani

Puskesmas PONED 175,000 175,000 350,000 o. Deteksi Dini kamker rahim 7,500 7,500 15,000 p. Tindakan Creoterapi 25,000 25,000 50,000 q. Konsultasi Dokter Spesialis 5,000 10,000 15,000

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN PUSKESMAS DAN JARINGANYA DI KABUPATEN PEKALONGAN

TARIF

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IV TINDAKAN GIGI

A. Penambalan Gigi Permanen

- Amalgam 10,000 10,000 20,000 - Glass ionomer 15,000 15,000 30,000 - Komposit / laser 20,000 20,000 40,000 b. Penambalan gigi susu

- Amalgam 7,500 7,500 15,000 - Glass ionomer 10,000 10,000 20,000

- Komposit / laser 15,000 15,000 30,000

c. Perawatan syaraf gigi

- Perawatan syaraf gigi vital tiap tahap 5,000 5,000 10,000 - Perawatan syaraf gigi non vital tiap tahap 6,250 6,250 12,500 d. Penambalan gigi sementara

- gigi permanen 6,250 6,250 12,500 - gigi susu 5,000 5,000 10,000 e. Pencabutan gigi susu

- dengan injeksi anestesi 7,500 7,500 15,000 - dengan topikal anestesi 6,250 6,250 12,500 f. Pencabutan gigi permanen

- tanpa penyulit 12,500 12,500 25,000 - dengan penyulit 25,000 25,000 50,000 g. Tindakan lain

- Pembersihan karang gigi per rahang 10,000 10,000 20,000 - Grinding 5,000 5,000 10,000 - Jahit operasi kurang dari 5 7,500 7,500 15,000 - Jahit operasi 5 sampai 10 10,000 10,000 20,000 - Lepas jahitan operasi 5,000 5,000 10,000 - Incisi abses intra oral 7,500 7,500 15,000 - Incisi abses extra oral 25,000 25,000 50,000 - Perawatan pasca incisi 5,000 5,000 10,000 - Operasi Impected Mesio Angular 100,000 100,000 200,000 - Overculectomy 100,000 100,000 200,000 - Operasi epulis 25,000 25,000 50,000 - Kuretase dry socket 12,500 12,500 25,000 - Perawatan gigi abses 5,000 5,000 10,000 V Pemeriksaan Laboratorium A Hematologi ( Darah ) 1 Darah Lengkap Rp 1,750 Rp 1,500 Rp 3,250 2 Hb Sahli Rp 1,750 Rp 6,500 Rp 8,250 3 Hb. Hemoque Rp 1,750 Rp 1,500 Rp 3,250 4 Leukosit Rp 1,750 Rp 1,500 Rp 3,250 5 Eritrosit Rp 1,750 Rp 1,500 Rp 3,250 6 LED Rp 1,750 Rp 1,500 Rp 3,250

7 Hitung jenis / Diffcount Rp 2,250 Rp 2,000 Rp 4,250

8 Trombosit Rp 1,750 Rp 2,000 Rp 3,750 9 Hematokrit Rp 750 Rp 1,250 Rp 2,000 10 Retikulosit Rp 750 Rp 1,250 Rp 2,000 11 Hitung Eosinofil Rp 750 Rp 1,250 Rp 2,000 12 Golongan Darah Rp 2,000 Rp 1,500 Rp 3,500 13 Waktu perdarahan ( BT ) Rp 2,000 Rp 1,350 Rp 3,350 14 Waktu pembekuan ( CT ) Rp 2,000 Rp 1,350 Rp 3,350 B Urine 1 Reduksi I Rp 1,000 Rp 1,000 Rp 2,000 2 Reduksi II Rp 1,000 Rp 1,000 Rp 2,000 3 Reduksi sewaktu Rp 1,000 Rp 1,000 Rp 2,000 4 PH Rp 1,000 Rp 1,000 Rp 2,000 5 Protein Rp 1,000 Rp 1,000 Rp 2,000 6 Bilirubin Rp 1,000 Rp 1,000 Rp 2,000 7 Urobilin Rp 1,000 Rp 1,000 Rp 2,000 8 Urin Combur Rp 1,000 Rp 3,500 Rp 4,500 9 Urin Sedimen Rp 1,000 Rp 1,000 Rp 2,000 C Kimia Klinik 1 Gula Darah Rp 2,500 Rp 3,000 Rp 5,500 - Terumo - Cair

2 Gula darah Stik Rp 2,500 Rp 3,900 Rp 6,400 Accuntrend 3 Cholesterol ( Stik ) Rp 500 Rp 5,500 Rp 6,000 4 Cholesterol ( Cair ) Rp 500 Rp 3,600 Rp 4,100 5 Trigliseride ( Stik ) Rp 500 Rp 6,600 Rp 7,100 6 Trigliseride ( Cair ) Rp 500 Rp 4,800 Rp 5,300 7 SGOT Rp 750 Rp 3,250 Rp 4,000 8 SGPT Rp 750 Rp 3,375 Rp 4,125

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9 Asam Urat Rp 500 Rp 4,200 Rp 4,700 10 Ureum Rp 750 Rp 3,375 Rp 4,125 11 Creatinin Rp 750 Rp 3,375 Rp 4,125 12 Albumin Rp 750 Rp 2,750 Rp 3,500 13 Total Protein Rp 750 Rp 2,250 Rp 3,000 14 Bilirubin D / T Rp 750 Rp 5,750 Rp 6,500 15 HDL - LDL Rp 750 Rp 5,750 Rp 6,500 D Serologi 1 Dengue Blood Rp 750 Rp 32,750 Rp 33,500 Ig G dan Ig M 2 Test Kehamilan Rp 1,300 Rp 2,200 Rp 3,500 3 Widal ( 3 Jenis ) Rp 3,500 Rp 4,500 Rp 8,000 4 Narkoba ( 6 Parameter ) Rp 1,000 Rp 30,000 Rp 31,000 5 HBSAg Rp 1,750 Rp 5,250 Rp 7,000 6 Anti HBsAg Rp 1,000 Rp 10,250 Rp 11,250 7 ASTO Rp 1,000 Rp 10,250 Rp 11,250 VI LAIN-LAIN

A. Pembuatan Visum et Repertum

a. Visum luar hidup 3,750 3,750 7,500 b. Visum luar mati 7,500 7,500 15,000 B. Pengujian Kesehatan

a. Kir Pelajar/ Mahasiswa 2,000 2,000 4,000 b. Kir melamar pekerjaan/ pekerjaan lain 7,500 7,500 15,000 c. Kir calon pengantin 10,000 10,000 20,000 d. Kir Calon Haji tahap I 5,000 10,000 15,000 e. Kir Calon Haji tahap II 25,000 25,000 50,000 C. Surat Keterangan Kematian 2,500 2,500 5,000 D. Sewa Ambulance

- kurang dari 30 km 25,000 25,000 50,000 - 31-50 km 35,000 35,000 70,000 - selebihnya per 1 km 1,000 1,000 2,000

Keterangan

- Tarif retribusi untuk tindakan pada bayi barulahir sebesar 50 % dari tindakan Dokter atau Bidan yang melaksanakan

- Jasa konsul Dokter sesuai dengan jasa dokter

- Tarif tindakan untuk penderita dibangsal rawat inap ditentukan sama dengan yang lainnya

- Jasa pemeriksaan laboratorium untuk penderita rawat inap sama dengan yang lain

- Tarif tersebut belum termasuk bahan habis pakai

I. PELAYANAN PEMERIKSAAN LABORATORIUM A Hematologi ( Darah ) 1 Darah Rutin Rp 1,750 Rp 5,000 Rp 6,750 2 Darah Lengkap Rp 1,750 Rp 1,500 Rp 3,250 3 Hb Sahli Rp 1,750 Rp 6,500 Rp 8,250 Hb. Hemoque Rp 1,750 Rp 1,500 Rp 3,250 4 Leukosit Rp 1,750 Rp 1,500 Rp 3,250 5 Eritrosit Rp 1,750 Rp 1,500 Rp 3,250 6 LED Rp 1,750 Rp 1,500 Rp 3,250

7 Hitung jenis / Diffcount Rp 2,250 Rp 2,000 Rp 4,250

8 Trombosit Rp 1,750 Rp 2,000 Rp 3,750 9 Hematokrit Rp 750 Rp 1,250 Rp 2,000 10 Retikulosit Rp 750 Rp 1,250 Rp 2,000 11 Hitung Eosinofil Rp 750 Rp 1,250 Rp 2,000 12 Golongan Darah Rp 2,000 Rp 1,500 Rp 3,500 13 Waktu perdarahan ( BT ) Rp 2,000 Rp 1,350 Rp 3,350 14 Waktu pembekuan ( CT ) Rp 2,000 Rp 1,350 Rp 3,350 B Urine 1 Urine rutin Rp 1,000 Rp 2,700 Rp 3,700 2 Reduksi I Rp 1,000 Rp 1,000 Rp 2,000 3 Reduksi II Rp 1,000 Rp 1,000 Rp 2,000 4 Reduksi sewaktu Rp 1,000 Rp 1,000 Rp 2,000 5 PH Rp 1,000 Rp 1,000 Rp 2,000 6 Protein Rp 1,000 Rp 1,000 Rp 2,000

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN

UPT LABORATORIUM KESEHATAN DAERAH KABUPATEN PEKALONGAN

TARIF ( Rp ) PRASARANA PELAYANAN

JENIS PELAYANAN

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7 Bilirubin Rp 1,000 Rp 1,000 Rp 2,000 8 Urobilin Rp 1,000 Rp 1,000 Rp 2,000 9 Urin Combur Rp 1,000 Rp 3,500 Rp 4,500 10 Urin Sedimen Rp 1,000 Rp 1,000 Rp 2,000 C Kimia Klinik 1 Gula Darah Rp 2,500 Rp 3,000 Rp 5,500 - Terumo - Cair

2 Gula darah Stik Rp 2,500 Rp 3,900 Rp 6,400 Accuntrend 3 Cholesterol ( Stik ) Rp 500 Rp 5,500 Rp 6,000 4 Cholesterol ( Cair ) Rp 500 Rp 3,600 Rp 4,100 5 Trigliseride ( Stik ) Rp 500 Rp 6,600 Rp 7,100 6 Trigliseride ( Cair ) Rp 500 Rp 4,800 Rp 5,300 7 SGOT Rp 750 Rp 3,250 Rp 4,000 8 SGPT Rp 750 Rp 3,375 Rp 4,125 9 Asam Urat Rp 500 Rp 4,200 Rp 4,700 10 Ureum Rp 750 Rp 3,375 Rp 4,125 11 Creatinin Rp 750 Rp 3,375 Rp 4,125 12 Albumin Rp 750 Rp 2,750 Rp 3,500 13 Total Protein Rp 750 Rp 2,250 Rp 3,000 14 Bilirubin D / T Rp 750 Rp 5,750 Rp 6,500 15 HDL - LDL Rp 750 Rp 5,750 Rp 6,500 D Serologi 1 Dengue Blood Rp 750 Rp 32,750 Rp 33,500 Ig G dan Ig M 2 Test Kehamilan Rp 1,300 Rp 2,200 Rp 3,500 3 Widal ( 3 Jenis ) Rp 3,500 Rp 4,500 Rp 8,000 4 Narkoba ( 6 Parameter ) Rp 1,000 Rp 30,000 Rp 31,000 5 HBSAg Rp 1,750 Rp 5,250 Rp 7,000 6 Anti HBsAg Rp 1,000 Rp 10,250 Rp 11,250 7 ASTO Rp 1,000 Rp 10,250 Rp 11,250 E Mikrobiologi 1 BTA Paru Rp 2,300 Rp 1,700 Rp 4,000 2 BTA Kusta Rp 1,300 Rp 1,700 Rp 3,000 3 Malaria Rp 1,300 Rp 1,700 Rp 3,000

4 Faeces ( Telur cacing ) Rp 1,300 Rp 1,700 Rp 3,000 5 Mikrofilaria Rp 1,300 Rp 1,700 Rp 3,000 F Pemeriksaan Air

1 Fisik Rp 2,500 Rp 5,000 Rp 7,500

Bau, Rasa, Suhu, Warna, Kekeruhan

2 Bakteriologi Rp 2,500 Rp 8,500 Rp 11,000 3 Secara Kimiawi a Total Hardnes Rp 2,500 Rp 21,000 Rp 23,500 b Chlorine Rp 2,500 Rp 2,000 Rp 4,500 c Chloride Rp 2,500 Rp 6,000 Rp 8,500 d Mangan Rp 2,500 Rp 2,500 Rp 5,000 e Flour Rp 2,500 Rp 6,000 Rp 8,500 f Fe Rp 2,500 Rp 4,000 Rp 6,500 g NO 2 sebagai Nitrit Rp 2,500 Rp 2,000 Rp 4,500 h NO 3 sebagai Nitrat Rp 2,500 Rp 7,000 Rp 9,500 i NH 4 Rp 2,500 Rp 8,000 Rp 10,500 j Cyanida Rp 2,500 Rp 6,000 Rp 8,500 k PH Rp 2,500 Rp 1,000 Rp 3,500 G Pemeriksaan Makmin 1 Borak Rp 1,500 Rp 3,500 Rp 5,000 2 Formalin Rp 1,500 Rp 3,500 Rp 5,000 3 Pewarna Rp 1,500 Rp 3,500 Rp 5,000 4 Pemanis ( Sakarin ) Rp 1,500 Rp 3,500 Rp 5,000 II. PELAYANAN MOBILE LABORATORIUM

A KIMIA AIR a Total Hardnes Rp 5,000 Rp 23,500 Rp 28,500 b Chlorine Rp 5,000 Rp 4,500 Rp 9,500 c Chloride Rp 5,000 Rp 8,500 Rp 13,500 d Mangan Rp 5,000 Rp 5,000 Rp 10,000 e Flour Rp 5,000 Rp 8,500 Rp 13,500 f Fe Rp 5,000 Rp 6,500 Rp 11,500 g NO 2 sebagai Nitrit Rp 5,000 Rp 4,500 Rp 9,500 h NO 3 sebagai Nitrat Rp 5,000 Rp 9,500 Rp 14,500 i NH 4 Rp 5,000 Rp 10,500 Rp 15,500

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j Cyanida Rp 5,000 Rp 8,500 Rp 13,500 k PH Rp 5,000 Rp 3,500 Rp 8,500 B PEMERIKSAAN MAKMIN 1 Borak Rp 6,500 Rp 8,500 Rp 15,000 2 Formalin Rp 6,500 Rp 8,500 Rp 15,000 3 Pewarna Rp 6,500 Rp 8,500 Rp 15,000 4 Pemanis ( Sakarin ) Rp 6,500 Rp 8,500 Rp 15,000 NB : Tarif tersebut belum Reagent dan bahan habis pakai.

A. Pemeriksaan.

No. Katagori Jasa Jasa Tarif

Pelayanan Sarana Pelayanan ( Rp. )

1 2 3 4 5

1 Poli Umum 5,000 10,000 15,000

2 Poli Spesialis 5,000 15,000 20,000

3 Poli Gigi 5,000 10,000 15,000

Keterangan :

1 Tarif tersebut untuk 1 (satu) kali Pemeriksaan.

2 Tarif tersebut belum termasuk Tindakan Medis, Pemeriksaan Penunjang, Obat & Bahan Habis Pakai. 3 Tarif Konsultasi Paviliun 3 kali lipat tarif dasar

B. Tindakan Rawat Jalan

1. Tarif tindakan di Poliklinik Spesialis

1 2 3 4 5

1 Sederhana 5,000 20,000 25,000

2 Kecil 10,000 45,000 55,000

3 Sedang 20,000 100,000 120,000

2. Tarif tindakan di poliklinik gigi dan mulut

1 2 3 4 5 1 Sederhana 6,000 11,000 17,000 2 Kecil 1 10,000 20,000 30,000 3 Kecil 2 20,000 30,000 50,000 4 Sedang 30,000 50,000 80,000 Catatan :

1. Tarif pelayanan tindakan medis tersebut diatas adalah untuk satu kali tindakan.

2. Besarnya tarif pelayanan Tindakan Medis di Poliklinik yang bersifat amat segera/ Cito ditambah 25 % dari tarif masing-masing katagori pelayanan.

3. Tarif tindakan paviliun 2 kali tarif dasar 3. Tarif Hemodialisa

Pelayanan Sarana Pelayanan (Rp.)

1 2 3 4 5

1. Non VIP 140,000 200,000 340,000

2. VIP 140,000 260,000 400,000

3. VVIP 140,000 300,000 440,000

Catatan :

1. Tarif tersebut diatas adalah untuk satu kali tindakan. 2 Tarif tersebut belum termasuk bahan habis pakai.

3. Besarnya tarif pelayanan Tindakan Medis yang bersifat amat segera ditambah 25 % dari tarif masing-masing katagori pelayanan dan kelas perawatannya.

4. Tarif pelayanan tindakan medis pasien rawat inap menyesuaikan kelas perawatannya. 5. Obat dan bahan habis pakai untuk tindakan operatif akan diresepkan.

4. Tarif tindakan medis non operatif.

1 2 3 4 5

1 Sederhana 3,000 7,000 10,000

2 Kecil 4,000 9,000 13,000

3 Sedang 9,000 20,000 29,000

Catatan :

1. Tarif pelayanan tindakan medis non operatif tersebut diatas adalah untuk satu kali tindakan. 2. Besarnya tarif pelayanan Tindakan Medis operatif non operatif yang bersifat amat segera

ditambah 25 % dari tarif masing-masing katagori pelayanan.

BESARAN TARIF RETRIBUSI PELAYANAN KESEHATAN RUMAH SAKIT PEMERINTAHAN TIPE C DAN D

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II. Rawat Darurat. 1. Pemeriksaan.

1 2 3 4 5

1 Dokter Umum 5,000 15,000 20,000

2 Dokter Spesialis 5,000 25,000 30,000

3 Dokter Gigi dan Mulut 5,000 15,000 20,000

2. Tindakan Medis di IGD.

1 2 3 4 5

1 Sederhana 5,000 10,000 15,000

3 Kecil 10,000 15,000 25,000

4 Sedang 30,000 40,000 70,000

Catatan :

1. Tarif pelayanan tindakan medis operatif tersebut diatas adalah untuk satu kali tindakan. 2. Tarif pelayanan tindakan medis rawat inap menyesuaikan kelas perawatannya

3 Tarif tersebut belum termasuk bahan habis pakai.

4 Tarif tindakan medis non operatif di IGD disesuakan dengan tarif tindakan medis non operatif rawat jalan III. Akomodasi Rawat Inap

No. Kelas Tarif

( Rp. ) 1 2 3 1 III 10,000 2 II. 20,000 3 I. 40,000 5 VIP. 120,000 6 VVIP. 150,000 150,000 Catatan :

1. Tarif tersebut diatas belum termasuk biaya makan / gizi.

2. Setiap pasien rawat inap dikenakan biaya adminsitrasi kelas III s/d kelas II : Rp. 5.000,- Kelas I sebesar Rp. 10.000,- untuk pasien ruang Intensif dan untuk VIP sebesasr Rp.

15.000,-3. Khusus bagi penderita rawat inap kleas I, dan VIP terlebih dahulu diwajibkan membayar dimuka biaya perawatan yang diperhitungkan selama 5 ( lima ) hari perawatan.

4. Apabila waktu 5 ( lima ) hari sebagaimana dimaksud pada point 2 berakhir dan rawat inap diteruskan, penderita diwajibkan membayar perawatan untuk 5 (lima) hari berikutnya dan demikian seterusnya.

5. Jumlah hari rawat inap dihitung mulai penderita masuk rawat inap sampai dengan penderita keluar dari RSU 6. Bayi normal dan sehat yang dilahirkan di RSUD dikenakan tarif rawat inap sebesar 50 % ( lima puluh

persen ) dari tarif kelas perawatan yang ditempati ibunya.

7. Untuk bayi bermasalah yang memerlukan perawatan khusus dikenakan biaya rawat inap sebesar tarif kelas perawatan yang ditempati ibunya.

8. Penunggu pasien dikenakan biaya akomodasi sebesasr Rp. 5.000,- setiap hari. 9. biaya akomodasi belum termasuk biaya loundry

IV. Loundry

No. Katagori Jasa Sarana Jasa Pelayanan Tarif

Pelayanan ( Rp. )

1 2 3 4 5

A. Paket pelayanan loundry 1 x pelayanan 1500 2500 4000

Catatan

1. Biaya paket pelayanan londry meliputi pelayanan loundry rawat inap dan atau pelayanan loundry kamar operasi/ VK bila pasien mendapatkan tindakan operasi/persalinan

2. Biaya loundry dihitung sesuai jumlah paket pelayanan loundry Visite / Konsul.

Pelayanan ( Rp. ) 1 2 3 4 5 A. Dokter Spesialis. III 10,000 15,000 25,000 II. 10,000 20,000 30,000 I. 10,000 30,000 40,000 VIP 10,000 40,000 50,000 VVIP 10,000 55,000 65,000

B. Dokter Sub Spesialis

III 10,000 30,000 40,000

II. 10,000 40,000 50,000

I. 10,000 55,000 65,000

VIP 10,000 80,000 90,000

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C. Dokter Umum/Gigi. III 10,000 8,000 18,000 II. 10,000 11,000 21,000 I. 10,000 15,000 25,000 VIP 10,000 22,000 32,000 VVIP 10,000 30,000 40,000 Catatan :

1. Tarif tersebut diatas adalah tarif untuk satu kali pemeriksaan/konsultasi.

2. Konsultasi medis per telpon dihitung sama dengan satu kali konsultasi/visite dan maksimal dipungut satu kali dalam 24 jam sejak konsultasi terakhir.

Pelayanan Makanan Pasien

Pelayanan ( Rp. ) 1 2 3 4 5 1 III 3,000 5,000 8,000 2 II 3,000 7,000 10,000 3 I 3,000 9,000 12,000 4 VIP 3,000 13,000 16,000 5 VVIP 3,000 17,000 20,000 Keterangan :

- Tarif tersebut untuk satu hari pelayanan gizi IV. Tarif Asuhan Keperawatan

Jasa Sarana Jasa Tarif

Pelayanan ( Rp. ) 1 2 3 4 5 6 1 TINGGI III 9,000 15,000 24,000 II 9,000 19,000 28,000 I 9,000 24,000 33,000 VIP 9,000 30,000 39,000 VVIP 9,000 38,000 47,000 2 SEDANG III 7,000 10,000 17,000 II 7,000 13,000 20,000 I 7,000 16,000 23,000 VIP 7,000 20,000 27,000 VVIP 7,000 25,000 32,000 3 RENDAH III 5,000 7,000 12,000 II 5,000 10,000 15,000 I 5,000 11,000 16,000 VIP 5,000 14,000 19,000 VVIP 5,000 18,000 23,000 4 ICU III 15,000 25,000 40,000 II 15,000 32,000 47,000 I 15,000 40,000 55,000 VIP 15,000 50,000 65,000 VVIP 15,000 62,000 77,000 Catatan :

1. Kriteria Asuhan Keperawatan Ketergantungan Rendah :

* Kebersihan diri, mandi, ganti pakaian, makan minum dilakukan sendiri * Ambulasi dengan pengawasan minimal

* Observasi tanda - tanda vital dilakukan setiap shief * Pengobatan minimal, status psikologis stabil * Persiapan prosedur memerlukan pengobatan

2. Kriteria Asuhan Keperawatan Ketergantungan Sedang : * Kebersihan diri dibantu, makan minum dibantu * Ambulasi dibantu, pengobatan lebih dari sekali * Observasi tanda - tanda vital dilakukan setiap shief * Volly chateter, nake out put dicatat.

* Klien dengan terpasang infus, persiapan pengobatan memerukan prosedur 3. Kriteria Asuhan Keperawatan Ketergantungan Tinggi :

* Segala diberikan / dibantu

* Makan minum memerukan NGT, terapi intravena. * Pemakaian suction

* Gelisah / disorientasi

4. Asuhan Keperawatan ICU : Asuhan Keperawatan di ICU

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V. TARIF RAWAT INTENSIF PELAYANAN DI RUANG ICU

Katagori Jasa Jasa Tarif

1 2 3 4 5

1 Pasien dari Kelas III 110,000 40,000 150,000

2 Pasien dari Kelas II 180,000 46,000 226,000

3 Pasien dari Kelas I 250,000 50,000 300,000

4 Pasien dari Kelas VIP 275,000 60,000 335,000

5 Pasien dari Kelas VVIP 330,000 70,000 400,000

Keterangan :

1 Tarif tersebut untuk satu hari perawatan

2 Tarif tersebut tidak termasuk makan/minum, asuhan keperawatan,

penggunaan paket instrumentasi ICU, kecuali untuk ventilator diberi tarif khusus Penderita IGD / Ruangan kelas III yg dimasukkan ke ICU ,

tarif disesuaikan dg tarif kls II

4 tarif tersebut belum termasuk obat, oksigen, tindakan medis, penunjang medis, bahan habis pakai 5 Bila diperlukan rawat bersama,maka besaran jasa dokter tersebut masing-masing sebesar jasa medis VI. PENGGUNAAN ALAT VENTILATOR

1 2 3 4 5 1 kelas 2 100,000 30,000 130,000 2 kelas 1 120,000 35,000 155,000 3 kelas VIP 130,000 50,000 180,000 4 kelas VVIP 150,000 60,000 210,000 VII. Tindakan Medis.

a. Tindakan Medis Operatif Umum

1 2 3 4 5 6 1 Kecil III 25,000 130,000 155,000 II 35,000 165,000 200,000 I 45,000 195,000 240,000 VIP 50,000 245,000 295,000 VVIP 55,000 300,000 355,000 2 Sedang III 100,000 490,000 590,000 II 125,000 540,000 665,000 I 150,000 580,000 730,000 VIP 175,000 630,000 805,000 VVIP 200,000 700,000 900,000 3 Besar III 150,000 650,000 800,000 II 175,000 700,000 875,000 I 200,000 800,000 1,000,000 VIP 350,000 930,000 1,280,000 VVIP 400,000 1,000,000 1,400,000 4 Khusus III 200,000 930,000 1,130,000 II 300,000 1,000,000 1,300,000 I 350,000 1,200,000 1,550,000 VIP 600,000 1,400,000 2,000,000 VVIP 650,000 1,500,000 2,150,000 Keterangan

1 Tarif tersebut untuk satu kali Pelayanan.

2 Tarif tersebut belum termasuk Obat & Bahan Habis Pakai.

3 Tarif Tindakan Operatif Cito (amat Segera), Jasa Pelayanan ditambah 25 %

4 Bila Pasien Pindah Kelas, Tindakan Medis diperhitungkan dari Kelas Tertinggi yang ditempati. 5 Tindakan minimal infasif masuk tindakan khusus kelas II

b. Tindakan Medis Non Operatif

1 2 3 4 5 5 1 Sederhana III 3,000 11,000 14,000 II 3,000 13,000 16,000 I 4,000 16,000 20,000 VIP 5,000 18,000 23,000 VVIP 6,000 25,000 31,000 2 Kecil III 5,000 27,000 32,000 II 6,000 35,000 41,000 I 7,000 50,000 57,000 VIP 12,000 60,000 72,000 VVIP 15,000 70,000 85,000 No. No. No. Kelas No. Kelas

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3 Sedang III 7,000 40,000 47,000 II 9,000 50,000 59,000 I 11,000 60,000 71,000 VIP 14,000 70,000 84,000 VVIP 20,000 75,000 95,000 4 Besar III 14,000 85,000 99,000 II 22,000 90,000 112,000 I 27,000 108,000 135,000 VIP 32,000 125,000 157,000 VVIP 45,000 135,000 180,000 Keterangan :

1 Tindakan Medis Non Operatif tersebut belum termasuk Obat & Bahan Habis Pakai.

2 Bila dilaksanakan dengan Anestesi maka dikenakan tambahan Tarif sesuai Tindakan Medis Operatif dengan Kategori sama.

3 Tarif tersebut untuk satu kali Pelayanan. VIII. PELAYANAN KEBIDANAN

A

PELAYANAN TINDAKAN KEBIDANAN

1 2 3 4 5 6 1 Kecil III 25,000 130,000 155,000 II 30,000 150,000 180,000 I 35,000 170,000 205,000 VIP 40,000 200,000 240,000 VVIP 55,000 300,000 355,000 2 Sedang III 100,000 440,000 540,000 II 125,000 450,000 575,000 I 150,000 500,000 650,000 VIP 175,000 600,000 775,000 VVIP 200,000 700,000 900,000 3 Besar III 150,000 600,000 750,000 II 175,000 700,000 875,000 I 200,000 800,000 1,000,000 VIP 350,000 930,000 1,280,000 VVIP 400,000 1,000,000 1,400,000 4 Khusus III 200,000 880,000 1,080,000 II 300,000 1,000,000 1,300,000 I 350,000 1,200,000 1,550,000 VIP 600,000 1,400,000 2,000,000 VVIP 650,000 1,500,000 2,150,000 Keterangan :

1 Tarif tersebut untuk satu kali Pelayanan.

2 Tarif tersebut belum termasuk Obat, & Bahan Habis Pakai.

3 Tarif Tindakan Operatif Cito (amat Segera), Jasa Pelayanan ditambah 25 %

4 Bila Pasien Pindah Kelas, Tindakan Medis diperhitungkan dari Kelas Tertinggi yang ditempati. 5 Jasa medis operatif anak hanya pada tindakan sectio caesaria

B

PELAYANAN PERSALINAN

1 2 3 4 5 6

1 Persalinan Normal III 92,000 138,000 230,000 II 128,000 192,000 320,000 I 168,000 252,000 420,000 VIP 228,000 342,000 570,000 VVIP 312,000 468,000 780,000 2 Persalinan dengan III 112,000 168,000 280,000

Penyulit Sedang II 156,000 234,000 390,000

I 200,000 300,000 500,000 VIP 270,000 405,000 675,000 VVIP 360,000 540,000 900,000 3 Persalinan dengan III 140,000 210,000 350,000

Penyulit Berat II 196,000 294,000 490,000

I 252,000 378,000 630,000 VIP 342,000 513,000 855,000 VVIP 456,000 684,000 1,140,000 Keterangan :

1 Tarif tersebut belum termasuk Obat & Bahan Habis Pakai.

2 Bila dilaksanakan dengan Anestesi, maka dikenakan tambahan Tarif sesuai Tindakan Medis Operatif dengan Kategori yang Sama.

3 Bila Pasien Pindah Kelas, maka Tindakan Medis diperhitungkan dari Kelas Tertinggi yang ditempati.

No. Kelas

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IX. PENUNJANG MEDIK

Jenis Jasa Jasa Tarif

Pemeriksaan Sarana Pelayanan ( Rp. )

1 2 3 4 5 6 1 Hematologi III 500 1,500 2,000 per parameter II 600 1,900 2,500 I 700 2,300 3,000 VIP 1,000 3,000 4,000 VVIP 2,000 4,000 6,000 2 Hb Cyanmeth III 2,000 4,000 6,000 II 2,100 5,900 8,000 I 2,500 7,500 10,000 VIP 3,000 10,000 13,000 VVIP 4,000 12,000 16,000

3 Darah Lengkap III 2,000 6,000 8,000

Auto Analizer II 2,000 8,000 10,000

I 2,500 9,500 12,000

VIP 3,000 12,000 15,000

VVIP 3,500 14,500 18,000

4 Golongan Darah III 500 1,500 2,000

II 500 2,000 2,500

I 700 2,300 3,000

VIP 1,000 3,000 4,000

VVIP 1,500 3,500 5,000

5 Tes Kehamilan III 2,000 3,000 5,000

II 2,000 5,000 7,000

I 2,500 6,000 8,500

VIP 3,000 7,000 10,000

VVIP 3,600 8,400 12,000

6 Preparat dengan III 2,000 5,000 7,000

Pengecatan II 2,300 5,700 8,000

( Malaria, BTA, Kusta, I 2,500 6,500 9,000

Jamur ) VIP 3,000 8,000 11,000 VVIP 3,500 10,000 13,500 7 Serologi III 2,000 7,000 9,000 ( VDRL, Widal, ASTO, II 2,100 8,900 11,000 CRP, RF ) I 2,500 10,500 13,000 VIP 3,000 12,000 15,000 VVIP 3,600 14,400 18,000

8 Kimia Klinik Sedang III 2,000 5,000 7,000

( Gula, OT, PT, Chol, UA, II 2,100 5,900 8,000

TP, Alb, Ur, Cre ) I 2,500 6,500 9,000

VIP 3,000 8,000 11,000

VVIP 3,500 10,000 13,500

9 Kimia Klinik Canggih III 2,000 5,500 7,500

( Tg, ALP, GGT, Bil T, II 2,100 6,400 8,500

Bil D, HDL LDL, CKMB ) I 2,500 7,000 9,500

VIP 3,000 8,500 11,500

VVIP 3,500 10,000 13,500

10 Imunologi - Serologi III 3,000 10,000 13,000

( HBS-Ag, Anti HBS, HIV, II 3,500 12,500 16,000

DB Ig G Ig M, Ig G Anti TB ) I 4,000 15,000 19,000

VIP 5,000 17,000 22,000

VVIP 6,000 20,000 26,000

11 Urin Lengkap III 2,000 6,000 8,000

II 2,100 7,900 10,000

I 2,500 9,500 12,000

VIP 3,000 12,000 15,000

VVIP 3,600 14,400 18,000

12 Feses Lengkap III 2,000 6,000 8,000

II 2,100 7,900 10,000 I 2,500 9,500 12,000 VIP 3,000 12,000 15,000 VVIP 3,600 14,400 18,000 13 Elektrolit III 3,000 15,000 18,000 II 3,500 16,500 20,000 I 4,000 18,000 22,000 VIP 5,000 20,000 25,000 VVIP 6,000 24,000 30,000 14 Narkoba III 3,000 15,000 18,000 II 3,500 16,500 20,000 I 4,000 18,000 22,000 VIP 5,000 20,000 25,000 VVIP 6,000 24,000 30,000 A. PEMERIKSAAN LABORATORIUM No Kelas

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Keterangan :

1. Tarif tersebut untuk satu kali pemeriksaan.

2. Pasien rawat jalan disesuaikan dengan tarif kelas II.

3. Bila ada tambahan jenis pemeriksaan baru, tarif akan di tentukan kemudian. 4. Tarif belum termasuk bahan habis pakai.

B. PEMERIKSAAN RADIO DIAGNOSTIK

1 2 3 4 5 6 III 9,000 15,000 24,000 II 9,000 16,500 25,500 I 9,000 18,000 27,000 VIP 9,000 19,500 28,500 VVIP 9,000 25,000 34,000 III 18,000 30,000 48,000 THORAX II 18,000 33,000 51,000 AP/LAT I 18,000 36,000 54,000 VIP 18,000 39,000 57,000 VVIP 18,000 47,000 65,000 III 9,000 15,000 24,000 II 9,000 16,500 25,500 I 9,000 18,000 27,000 VIP 9,000 19,500 28,500 VVIP 9,000 23,500 32,500 III 18,000 30,000 48,000 BNO II 18,000 33,000 51,000 2 POSISI I 18,000 36,000 54,000 VIP 18,000 39,000 57,000 VVIP 18,000 47,000 65,000 III 9,000 15,000 24,000 II 9,000 16,500 25,500 I 9,000 18,000 27,000 VIP 9,000 19,500 28,500 VVIP 9,000 24,000 33,000 III 18,000 30,000 48,000 PELVIS II 18,000 33,000 51,000 AP/LAT I 18,000 36,000 54,000 VIP 18,000 39,000 57,000 VVIP 18,000 47,000 65,000 III 9,000 15,000 24,000 EXTRIMITAS II 9,000 16,500 25,500 1 POSISI I 9,000 18,000 27,000 VIP 9,000 19,500 28,500 VVIP 9,000 23,500 32,500 III 18,000 30,000 48,000 EXTRIMITAS II 18,000 33,000 51,000 2 POSISI I 18,000 36,000 54,000 VIP 18,000 39,000 57,000 VVIP 18,000 47,000 65,000 III 18,000 30,000 48,000 COLUMNA VERTEBRA II 18,000 33,000 51,000 2 POSISI I 18,000 36,000 54,000 VIP 18,000 39,000 57,000 VVIP 18,000 47,000 65,000 III 36,000 50,000 86,000 COLUMNA VERTEBRA II 36,000 55,000 91,000 4 POSISI I 36,000 60,000 96,000 VIP 36,000 65,000 101,000 VVIP 36,000 78,000 114,000 III 18,000 30,000 48,000 CRANIUM / II 18,000 33,000 51,000 SPN I 18,000 36,000 54,000 VIP 18,000 39,000 57,000 VVIP 18,000 47,000 65,000 III 27,000 45,000 72,000 MASTOID / TMJ / II 27,000 49,500 76,500 ORBITA I 27,000 54,000 81,000 VIP 27,000 58,500 85,500 VVIP 27,000 70,000 97,000 III 36,000 75,000 111,000 OSEFAGUS / II 36,000 82,500 118,500 OMD I 36,000 90,000 126,000 VIP 36,000 97,500 133,500 VVIP 36,000 117,000 153,000 1 3 BNO 5 THORAX 4 2 No Kelas 13 PELVIS 6 7 8 9 10 11 12

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III 45,000 75,000 120,000 COLON IN LOOP / II 45,000 82,500 127,500 FOLLOW THROUGH I 45,000 90,000 135,000 VIP 45,000 97,500 142,500 VVIP 45,000 117,000 162,000 III 45,000 75,000 120,000 CYSTOGRAFI / II 45,000 82,500 127,500 URETRCYSTOGRAFI I 45,000 90,000 135,000 VIP 45,000 97,500 142,500 VVIP 45,000 117,000 162,000 III 45,000 75,000 120,000 FISTULOGRAFI / II 45,000 82,500 127,500 GENITOGRAFI I 45,000 90,000 135,000 VIP 45,000 97,500 142,500 VVIP 45,000 117,000 162,000 III 45,000 75,000 120,000 II 45,000 82,500 127,500 I 45,000 90,000 135,000 VIP 45,000 97,500 142,500 VVIP 45,000 117,000 162,000

18 BONE SURVEY III 90,000 150,000 240,000

II 90,000 165,000 255,000

I 90,000 180,000 270,000

VIP 90,000 195,000 285,000

VVIP 90,000 234,000 324,000

Keterangan :

1 Tarif tersebut untuk satu kali Pemeriksaan. 2 Tarif tersebut belum termasuk Bahan Habis Pakai.

3 Bila ada tambahan Jenis Pemeriksan Baru, Tarif akan ditentukan kemudian. 4 Tarif Cito ditambah 1 (satu) kali Jasa Pelayanan.

C. Tarif Pelayanan Diagnostik & Tindakan Khusus.

1 2 3 4 5 6 1 U S G III 34,000 26,000 60,000 II 34,000 33,500 67,500 I 34,000 43,000 77,000 VIP 34,000 46,000 80,000 VVIP 34,000 56,000 90,000 2 E K G III 10,500 24,500 35,000 II 12,000 28,000 40,000 I 13,500 31,500 45,000 VIP 15,000 35,000 50,000 VVIP 16,500 38,500 55,000

3 Vasculer doppler / TCD III 48,000 112,000 160,000

( Transcranial Doppler ) II 54,000 126,000 180,000

USG Mata I 60,000 140,000 200,000

VIP 66,000 154,000 220,000

VVIP 72,000 168,000 240,000

4 Doppler ( Kandungan ) III 67,500 50,000 117,500

II 67,500 100,000 167,500

I 67,500 150,000 217,500

VIP 67,500 200,000 267,500

VVIP 67,500 250,000 317,500

5 EEG dan Brain - III 32,000 128,000 160,000

Mapping II 36,000 144,000 180,000 I 40,000 160,000 200,000 VIP 44,000 176,000 220,000 VVIP 48,000 192,000 240,000 6 AUDIOMETRI III 10,000 9,500 19,500 II 15,000 15,000 30,000 I 20,000 21,000 41,000 VIP 29,000 27,000 56,000 VVIP 35,000 35,000 70,000

7 Slit Lamp & Opthal Moskope III 8,000 32,000 40,000

II 10,000 40,000 50,000

I 12,000 48,000 60,000

VIP 14,000 56,000 70,000

VVIP 16,000 64,000 80,000

8 Cauter Dermatologi III 6,000 8,000 14,000

II 8,000 12,000 20,000 I 15,000 16,000 31,000 VIP 27,000 31,000 58,000 VVIP 32,000 37,000 69,000 14 No Kelas 15 16 17 BNO-IVP

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9 C T G III 10,000 17,500 27,500 II 12,500 22,500 35,000 I 17,500 32,500 50,000 VIP 28,000 52,000 80,000 VVIP 33,600 62,400 96,000 10 ENMG III 32,000 128,000 160,000

( Elektro Neuro Myografi) II 36,000 144,000 180,000

I 40,000 160,000 200,000

VIP 44,000 176,000 220,000

VVIP 48,000 192,000 240,000

11 Infant Warmer - III 10,000 7,500 17,500

Incubator II 14,000 11,000 25,000

I 15,000 15,500 30,500

VIP 20,000 20,000 40,000

VVIP 24,000 24,000 48,000

12 Blue Light III 10,000 7,500 17,500

II 14,000 11,000 25,000

I 15,000 15,500 30,500

VIP 20,000 20,000 40,000

VVIP 24,000 24,000 48,000

Keterangan :

1 Tarif tersebut untuk satu kali Pemeriksaan. 2 Tarif tersebut belum termasuk Bahan Habis Pakai.

3 Bila ada tambahan Jenis Pemeriksan Baru, Tarif akan ditentukan kemudian. 4 Tarif Cito ditambah 1 (satu) kali Jasa Pelayanan.

D. Tarif Tindakan Spesialis Rehab Medik dan Fisioterapi.

1 2 3 4 5 6

I SEDERHANA

1 Latihan Lokal III 3,000 6,000 9,000

II 5,000 7,500 12,500

I 7,000 10,000 17,000

VIP 9,500 17,000 26,500

VVIP 11,500 20,500 32,000

2 Latihan General III 5,000 7,500 12,500

II 7,000 10,500 17,500

I 9,000 17,500 26,500

VIP 11,500 23,500 35,000

VVIP 13,800 28,200 42,000

3 Latihan Gymnasium III 3,000 6,000 9,000

II 5,000 7,500 12,500 I 7,000 10,000 17,000 VIP 9,500 17,000 26,500 VVIP 11,500 20,500 32,000 4 Massage III 3,000 6,000 9,000 II 5,000 7,500 12,500 I 7,000 10,000 17,000 VIP 9,500 17,000 26,500 VVIP 11,500 20,500 32,000

5 Infra Red III 3,000 6,000 9,000

Microwave Diathermi II 5,000 7,500 12,500

I 7,000 10,000 17,000

VIP 9,500 17,000 26,500

VVIP 11,500 20,500 32,000

6 Chest Vibrator III 3,000 6,000 9,000

II 5,000 7,500 12,500

I 7,000 10,000 17,000

VIP 9,500 17,000 26,500

VVIP 11,500 20,500 32,000

II SEDANG

7 Cervical Traction III 5,000 7,500 12,500

II 7,000 10,500 17,500

I 9,000 17,500 26,500

VIP 11,500 23,500 35,000

VVIP 13,800 28,200 42,000

8 Lumbal Traction III 5,000 7,500 12,500

II 7,000 10,500 17,500

I 9,000 17,500 26,500

VIP 11,500 23,500 35,000

VVIP 13,800 28,200 42,000

9 Electrical Stimulation III 5,000 7,500 12,500

II 7,000 10,500 17,500

I 9,000 17,500 26,500

VIP 11,500 23,500 35,000

VVIP 13,800 28,200 42,000

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10 TENS III 5,000 7,500 12,500 (Transcutaneus II 7,000 10,500 17,500 Electrical Nerve I 9,000 17,500 26,500 Stimulation ) VIP 11,500 23,500 35,000 VVIP 13,800 28,200 42,000 11 USD III 5,000 7,500 12,500 (Ultrasound Therapi) II 7,000 10,500 17,500 I 9,000 17,500 26,500 VIP 11,500 23,500 35,000 VVIP 13,800 28,200 42,000 12 SWD III 5,000 7,500 12,500 (Short Wave II 7,000 10,500 17,500 Diathermy) I 9,000 17,500 26,500 VIP 11,500 23,500 35,000 VVIP 13,800 28,200 42,000 13 MWD III 5,000 7,500 12,500 (Micro Wave II 7,000 10,500 17,500 Diathermy) I 9,000 17,500 26,500 VIP 11,500 23,500 35,000 VVIP 13,800 28,200 42,000 Keterangan :

1 Tarif tersebut untuk satu kali tindakan

2 Tarif tersebut belum termasuk Bahan Habis Pakai. X. Pelayanan Lain-lain.

A Konsultasi Remaja, Keluarga, Pelayanan Psikologi dan Tumbuh kembang Anak

1 2 3 4 5 1. Pemeriksaan Awal. - Intake interview 5,500 10,000 15,500 - Psikhologi dasar. 5,500 17,000 22,500 - Psikhiatri dasar. 5,500 17,000 22,500 2. Konsultasi - Psikhiatri/Psykholog 5,500 20,000 25,500 lanjutan 45 menit. - Dokter ahli. 5,500 20,000 25,500 3. Tes/Pemeriksaan Lanjutan - Tes Bendergestali 11,500 34,000 45,500 - Tes Rochaach 11,500 34,000 45,500 - Tes WAIS 11,500 34,000 45,500

- Test Tumbuh Kembang anak 11,500 45,000 56,500

4. Terapi.

- Gestalt Terapi/ 45 menit. 11,500 34,000 45,500

- Suport Terapi/ 45 menit. 11,500 34,000 45,500

- Terapi perilaku/45 menit 11,500 34,000 45,500

- Terapi Kelompok/45 menit 11,500 34,000 45,500

- Marital Terapi/45 menit 11,500 34,000 45,500

- Famili Terapi 45 menit. 11,500 34,000 45,500

5. Psichotest.

- Seleksi/Promosi Karyawan. 11,500 34,000 45,500

- Untuk penjurusan/minat/bakat 11,500 34,000 45,500

- Test Intelegensi 11,500 34,000 45,500

- Konsultasi tanpa tes penunjang 11,500 34,000 45,500

- Konsultasi dengan test psycho penunjang 11,500 34,000 45,500

B. Konsultasi Gizi.

No. Katagori Pelayanan Jasa Jasa Tarif

Kelas. Sarana Pelayanan ( Rp. )

1 2 3 4 5

1 Pasien Rawat Jalan. 2,500 5,000 7,500

2 Pasien Rawat Inap.

III 2,500 6,500 9,000 II. 2,500 8,500 11,000 I. 2,500 9,000 11,500 VIP. 2,500 12,500 15,000 VVIP 2,500 16,000 18,500 No

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C. Pelayanan Pemulasaraan Jenazah

Katagori Pelayanan Jasa Sarana Jasa Pelayanan Tarif

Kelas. (Rp.) (Rp.) (Rp.) 1 2 3 4 5 1 Perawatan Jenazah. III 50,000 135,000 185,000 II. 50,000 150,000 200,000 I. 50,000 160,000 210,000 VIP. 50,000 225,000 275,000 VVIP. 50,000 250,000 300,000 2 Konservasi/Pengawetan Jenazah. III 100,000 130,000 230,000 II. 100,000 135,000 235,000 I. 100,000 140,000 240,000 VIP. 100,000 145,000 245,000 VVIP. 100,000 160,000 260,000 3 Rekontruksi Jenazah. III 150,000 100,000 250,000 II. 150,000 105,000 255,000 I. 150,000 110,000 260,000 VIP. 150,000 120,000 270,000 VVIP. 150,000 130,000 280,000 4 Penitipan Jenazah dari RSUD per hari.

III 100,000 60,000 160,000

II. 100,000 65,000 165,000

I. 100,000 70,000 170,000

VIP. 100,000 80,000 180,000

VVIP. 100,000 85,000 185,000

5 Penitipan Jenazah dari luar RSUD per hari.

III 100,000 60,000 160,000 II. 100,000 65,000 165,000 I. 100,000 70,000 170,000 VIP. 100,000 80,000 180,000 VVIP. 100,000 85,000 185,000 6 Pembongkaran Jenazah 200,000 250,000 450,000 7 Pemakaman Jenazah. III 198,000 225,000 423,000 II. 198,000 234,000 432,000 I. 198,000 243,000 441,000 VIP. 198,000 270,000 468,000 VVIP. 198,000 315,000 513,000 8 Otopsi 1,800,000 1,800,000 9 Visum Jenazah. III 13,500 31,500 45,000 II. 13,500 36,000 49,500 I. 13,500 40,500 54,000 VIP. 13,500 49,500 63,000 VVIP. 13,500 58,500 72,000

D. Pelayanan Ambulance/Mobil Jenazah.

Tarif Tarif ( Rp. ) Keraton

1 2 3

1 Sampai dengan jarak 10 Km. 75,000

2 Lebih dari 10 km dihitung 1km x harga bensin E. Pelayanan Mediko Legal.

Jasa Sarana Jasa Pelayanan Tarif

(Rp.) (Rp.) ( Rp. )

1 2 3 4 5

1 Pembongkaran Jenazah.

- Jarak sampai dengan 10 Km. 150,000 250,000 400,000

- Jarak 10 Km s/d 30 Km. 250,000 300,000 550,000

- Jarak lebih dari 30 Km ditambah Rp. setiap 1 Km.

2 Surat Keterangan Rumah Sakit. 5,000 10,000 15,000

3 Permintaan Visum et Repertum.

III 9,000 9,000 18,000 II. 9,000 15,000 24,000 I. 9,000 20,000 29,000 VIP. 9,000 30,000 39,000 No. Katagori Pelayanan No.

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F. PELAYANAN FARMASI

No. U r a i a n Jasa Jasa Tarif

Sarana Pelayanan ( Rp. )

1 2 3 4 5

1 RAWAT JALAN Rx1,125 R x 0, 150 R x 1,275

2 RAWAT INAP R x 1,125 R x 0,125 R x 1,250

Keterangan :

- Harga Obat / Bahan sesuai Faktur Terakhir.

G. Pemeriksaan Kesehatan untuk Pemberian Surat Keterangan Kesehatan

(Rp.) (Rp.) ( Rp. )

1 2 3 4 5

1 Orang Sakit dan Hamil/Bersalin/Masa Nifas 2,500 2,500 5,000

2 Malanjutkan Sekolah 2,500 2,500 5,000 3 Malamar Pekerjaan 2,500 2,500 5,000 4 Mengikuti Kursus 2,500 2,500 5,000 5 Keluar Negeri 11,250 11,250 22,500 6 Keperluan Asuransi 13,500 13,500 27,000 7 Test CPNS 5,400 8,100 13,500

8 Tes Buta Warna 10,000 15,000 25,000

Pelayanan Penunjang Medik. A. Pemeriksaan Laboratorium.

Jasa Sarana Jasa Pelayanan TARIF

(Rp.) (Rp.) (Rp.) 1 2 3 4 5 I. SEDERHANA I 1. III. 1,600.00 1,100.00 2,700.00 II 1,600.00 1,500.00 3,100.00 I 1,600.00 2,000.00 3,600.00 VIP 1,600.00 2,400.00 4,000.00 VVIP 1,600.00 2,900.00 4,500.00

II. SEDERHANA II.

2. III. 2,000.00 2,500.00 4,500.00 II 2,000.00 3,000.00 5,000.00 I 2,000.00 3,500.00 5,500.00 VIP 2,000.00 4,000.00 6,000.00 VVIP 2,000.00 4,500.00 6,500.00 3. SEDANG I. III. 2,800.00 3,000.00 5,800.00 II 2,800.00 3,500.00 6,300.00 I 2,800.00 4,000.00 6,800.00 VIP 2,800.00 5,000.00 7,800.00 VVIP 2,800.00 5,700.00 8,500.00 4. SEDANG II. III. 6,500.00 6,000.00 12,500.00 II 6,500.00 9,000.00 15,500.00 I 6,500.00 11,000.00 17,500.00 VIP 6,500.00 14,000.00 20,500.00 VVIP 6,500.00 18,500.00 25,000.00 5. CANGGIH III. 16,000.00 16,000.00 32,000.00 II 16,000.00 21,000.00 37,000.00 I 16,000.00 25,000.00 41,000.00 VIP 16,000.00 35,000.00 51,000.00 VVIP 16,000.00 39,000.00 55,000.00

6. Dengue Blot IgG + IgM

III. 9,000.00 9,000.00 18,000.00 II 12,000.00 12,000.00 24,000.00 I 15,000.00 15,000.00 30,000.00 VIP 18,000.00 18,000.00 36,000.00 VVIP 21,000.00 21,000.00 42,000.00 7. Hematologi (Autoanalyzer) III. 4,200.00 4,200.00 8,400.00 II 5,900.00 5,900.00 11,800.00 I 7,000.00 7,000.00 14,000.00 VIP 8,400.00 8,400.00 168,000.00 VVIP 9,800.00 9,800.00 19,600.00

8. Blood Gaz Analyzer (BGA)

III. 9,000.00 9,000.00 18,000.00 II 12,000.00 12,000.00 24,000.00 I 15,000.00 15,000.00 30,000.00 VIP 18,000.00 18,000.00 42,000.00 VVIP 21,000.00 21,000.00 45,000.00 Katagori Pelayanan No. JENIS PEMERIKSAAN No.

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Catatan :

1. Tarif pemeriksaan tersebut belum termasuk bahan habis pakai / reagen

2. Tarif pemeriksaan laboratorium pasien dari poliklinik RSUD, Puskesmas dan RSUD Pemerintah lainnya sesuai tarif kelas III.

3. Tarif pemeriksaan loboratorium untuk pemeriksaan kesehatan pegawai Negeri/TNI POLRI untuk melanjutkan Sekolah, Tenaga Kerja Keluar Neger sesuai tarif kelas III.

4. Tarif pemeriksaan loboratorium pasien dari praktek swasta, RSU Swasta, pemeriksaan kesehatan Pegawai Swasta dan General Check Up sesuai tarif kelas II.

5. Pemeriksaan laboratorium yang bersifat amat segera ( Cito ) dikenakan tambahan sebesar 25 % dari jasa pelayanan masing-masing katagori pelayanan dan kelas perawatannya. B. Pemeriksaan Radiodiagnostik

No. JENIS PEMERIKSAAN

Sarana Pelayanan TARIF

(Rp.) (Rp.) (Rp.) 1 2 3 4 5 I. SEDERHANA III. 22,500.00 10,000.00 32,500.00 II 22,500.00 16,000.00 38,500.00 I 22,500.00 20,000.00 42,500.00 VIP 22,500.00 22,500.00 47,500.00 VVIP 22,500.00 25,000.00 57,500.00 II. SEDANG III. 43,500.00 22,000.00 56,500.00 II 43,500.00 23,500.00 58,000.00 I 43,500.00 25,000.00 59,500.00 VIP 43,500.00 26,500.00 62,500.00 VVIP 43,500.00 28,000.00 70,000.00 III. CANGGIH. III. 40,500.00 40,500.00 81,000.00 II 40,500.00 44,500.00 85,000.00 I 40,500.00 46,000.00 86,500.00 VIP 40,500.00 48,000.00 90,500.00 VVIP 40,500.00 50,000.00 95,000.00 Catatan :

1. Tarif pemeriksaan tersebut belum termasuk bahan habis pakai.

2. Tarif pemeriksaan Radiodiagnostik tersebut sudah termasuk jasa pembacaan hasil

3. Tarif pemeriksaan Radiodiagnostik pasien dari poliklinik RSUD, IGD, Puskesmas dan RSUD Pemerintah lainnya sesuai tarif kelas III.

4. Tarif pemeriksaan Radiodiagnostik untuk pemeriksaan kesehatan pegawai Negeri/TNI POLRI untuk melanjutkan Sekolah, Tenaga Kerja Keluar Neger sesuai tarif kelas III.

5. Tarif pemeriksaan Radiodiagnostik pasien dari praktek swasta, RSU Swasta, pemeriksaan kesehatan Pegawai Swasta dan General Check Up sesuai tarif kelas II.

6. Pemeriksaan Radiodiagnostik yang bersifat amat segera ( Cito ) dikenakan tambahan sebesar 25 % dari jasa pelayanan masing-masing katagori pelayanan dan kelas perawatannya.

7. Pemeriksaan Radiodiagnostik bersifat amat segera ( Cito ) apabila dikerjakan setelah jam 13. /setelah jam kerja.

C. Tarif Pelayanan Diagnostik & Tindakan Khusus.

No. Katagori Pelayanan Jasa Sarana Jasa Pelayanan Tarif Baru

Kelas. (Rp.) (Rp.) ( Rp. ) 1 2 3 4 5 1 EKG. III 30,000.00 25,000.00 55,000.00 II. 30,000.00 35,000.00 65,000.00 I. 30,000.00 45,000.00 75,000.00 VIP. 30,000.00 55,000.00 85,000.00 VVIP. 30,000.00 70,000.00 100,000.00 2 ECHOCARDIOGRAFI. III 90,000.00 115,000.00 205,000.00 II. 90,000.00 175,000.00 265,000.00 I. 90,000.00 225,000.00 315,000.00 VIP. 90,000.00 240,000.00 330,000.00 VVIP. 90,000.00 260,000.00 350,000.00 3 ULTRASONOGRAFI (USG) III 51,500.00 23,500.00 75,000.00 II. 51,500.00 29,500.00 81,000.00 I. 51,500.00 44,500.00 96,000.00 VIP. 51,500.00 59,500.00 111,000.00 VVIP. 51,500.00 69,500.00 121,000.00 J A S A

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D. Tarif pemakaian alat.

No. Katagori Pelayanan Tarif

( Rp. )

1 2 3

1. Infant Warmer (per jam) 5,500.00

2. Blue Light (per jam) 6,800.00

3. Incubator per hari 13,500.00

4. Bedside Monitor per hari 78,000.00

5. Syringe Pump per hari 77,200.00

6. Infusion Pump per hari 77,500.00

7. Ventilator per hari 150,000.00

E. Tarif Tindakan Spesialis Rehab Medik dan Fisioterapi.

No. Katagori Pelayanan Jasa Sarana Jasa Pelayanan Tarif

Kelas. (Rp.) (Rp.) ( Rp. ) 1 2 3 4 5 1 Sederhana. III 5,000.00 7,500.00 12,500.00 II. 5,000.00 10,000.00 15,000.00 I. 5,000.00 15,000.00 20,000.00 VIP. 5,000.00 20,000.00 25,000.00 VVIP. 5,000.00 25,000.00 30,000.00 2 Sedang. III 9,000.00 13,000.00 22,000.00 II. 9,000.00 16,000.00 25,000.00 I. 9,000.00 21,000.00 30,000.00 VIP. 9,000.00 31,000.00 40,000.00 VVIP. 9,000.00 41,000.00 50,000.00 Pelayanan Lain-lain.

A. Konsultasi Remaja & Keluarga Pelayanan Psikologi.

(Rp.) (Rp.) ( Rp. ) 1 2 3 4 5 1. Pemeriksaan Awal. - Intake interview 3,750.00 11,250.00 15,000.00 - Psikhologi dasar. 6,250.00 18,750.00 25,000.00 - Psikhiatri dasar. 6,250.00 18,750.00 25,000.00 2. Konsultasi - Psikhiatri/Psykholog 7,500.00 22,500.00 30,000.00 lanjutan 45 menit. - Dokter ahli. 7,500.00 22,500.00 30,000.00 3. Tes/Pemeriksaan Lanjutan - Tes Bendergestali 12,500.00 37,500.00 50,000.00 - Tes Rochaach 12,500.00 37,500.00 50,000.00 - Tes WAIS 12,500.00 37,500.00 50,000.00 4. Terapi.

- Gestalt Terapi/ 45 menit. 12,500.00 37,500.00 50,000.00

- Suport Terapi/ 45 menit. 12,500.00 37,500.00 50,000.00

- Terapi perilaku/45 menit 12,500.00 37,500.00 50,000.00

- Terapi Kelompok/45 menit 12,500.00 37,500.00 50,000.00

- Marital Terapi/45 menit 12,500.00 37,500.00 50,000.00

- Famili Terapi 45 menit. 12,500.00 37,500.00 50,000.00

5. Psichotest.

- Seleksi/Promosi Karyawan. 12,500.00 37,500.00 50,000.00

- Untuk penjurusan/minat/bakat 12,500.00 37,500.00 50,000.00

- Test Intelegensi 12,500.00 37,500.00 50,000.00

- Konsultasi tanpa tes penunjang 12,500.00 37,500.00 50,000.00

- Konsultasi dengan test psycho penunjang 12,500.00 37,500.00 50,000.00

B. Konsultasi Gizi.

Katagori Pelayanan Jasa Sarana Jasa Pelayanan Tarif

Kelas. (Rp.) (Rp.) ( Rp. )

1 2 3 4 5

1 Pasien Rawat Jalan. 2,250.00 5,250.00 7,500.00

2 Pasien Rawat Inap.

III 2,250.00 5,250.00 7,500.00 II. 2,250.00 7,250.00 9,500.00 I. 2,250.00 9,250.00 11,500.00 VIP. 2,250.00 13,750.00 16,000.00 VVIP. 2,250.00 17,750.00 20,000.00 Katagori Pelayanan No. No.

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C. Pelayanan CSSD ( Strerilitasi ). Autoclave ( Steam ).

(Rp.) (Rp.) ( Rp. )

1 2 3 4 5

1 Pelayanan Biasa.

- Linen s/d 5 Kg. 7,500.00 7,500.00 15,000.00

- Linen diatas 5 kg tambahan per Kg. 1,750.00 1,750.00 3,500.00

- Iinstrumen umum s/d 5 kg 7,500.00 7,500.00 15,000.00

- Diatas 5 kg tambahan per Kg. 2,500.00 2,500.00 5,000.00

- Iinstrumen khusus s/d 5 kg 12,500.00 12,500.00 25,000.00

2. Pelayanan Cito dalam jam kerja.

- Linen s/d 5 Kg. 10,000.00 10,000.00 20,000.00

3. Pelayanan Cito diluar jam kerja.

- Linen s/d 50 Kg. 75,000.00 75,000.00 150,000.00

- Diatas 5 0kg tambahan per Kg. 3,500.00 3,500.00 7,000.00

Autoclave ( Formaline ).

(Rp.) (Rp.) ( Rp. )

1 2 3 4 5

1 Pelayanan Biasa.

- Linen s/d 5 Kg. 4,500.00 4,500.00 9,000.00

2. Pelayanan Cito dalam jam kerja.

- Linen s/d 5 Kg. 7,500.00 7,500.00 15,000.00

3. Pelayanan Cito diluar jam kerja.

- Lenin s/d 50 Kg. 75,000.00 75,000.00 150,000.00

- Diatas 5 0kg tambahan per Kg. 6,000.00 6,000.00 12,000.00

Catatan :

1. Biaya dikenakan untuk :

Titipan alat, bahan milik pribadi institusi diluar RSUD yang diseterilkan, yang digunakan diluar RSUD 2. Sifat Pelayanan.

a. Biaya : Alat/Bahan siap steril, setelah 3 (tiga) jam ( dalam jam kerja ).

b. Cito : Dalam Jam kerja : alat/bahan siap steril setelah 1 (satu) jam Diluar jam kerja : alat/bahan siap steril setelah 1 (satu) jam 3. Jenis alat :

a. Linen

b. Instrumen umum : Instrumen bukan disposibel. c. Instrumen khusus : Instrumen disposibel.

d. Plastik dan karet : Alat Medis habis pakai, sarung tangan. 4. Jenis Sterilisasi :

a. Autoclave - steam : Untuk linen, instrumen, kaca, plastik tahan panas, karet. b. Autoclave-Formaline : Untuk kaca, plastik tidak tahan panas tinggi.

Katagori Pelayanan No.

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D. Pemulasaraan Jenazah.

Katagori Pelayanan Bahan habis Jasa Sarana Jasa Pelayanan Tarif

Kelas. pakai (Rp.) (Rp.) ( Rp. ) 1 2 3 4 5 6 1 Perawatan Jenazah. III 139,000.00 52,000.00 150,000.00 341,000.00 II. 139,000.00 52,000.00 165,000.00 356,000.00 I. 139,000.00 52,000.00 180,000.00 371,000.00 VIP. 139,000.00 52,000.00 250,000.00 441,000.00 VVIP. 139,000.00 52,000.00 250,000.00 441,000.00 2 Konservasi/Pengawetan Jenazah. III 85,500.00 96,000.00 142,500.00 324,000.00 II. 85,500.00 96,000.00 147,500.00 329,000.00 I. 85,500.00 96,000.00 152,500.00 334,000.00 VIP. 85,500.00 96,000.00 162,500.00 344,000.00 VVIP. 85,500.00 96,000.00 178,500.00 360,000.00 3 Rekontruksi Jenazah. III 12,000.00 37,500.00 112,500.00 162,000.00 II. 12,000.00 37,500.00 117,500.00 167,000.00 I. 12,000.00 37,500.00 122,500.00 172,000.00 VIP. 12,000.00 37,500.00 132,500.00 182,000.00 VVIP. 12,000.00 37,500.00 142,500.00 192,000.00 4 Penitipan Jenazah dari RSUD per hari.

III 12,000.00 83,000.00 65,000.00 160,000.00

II. 12,000.00 83,000.00 70,000.00 165,000.00

I. 12,000.00 83,000.00 75,000.00 170,000.00

VIP. 12,000.00 83,000.00 85,000.00 180,000.00

VVIP. 12,000.00 83,000.00 95,000.00 190,000.00

5 Penitipan Jenazah dari luar RSUD per hari.

III 12,000.00 83,000.00 70,000.00 165,000.00 II. 12,000.00 83,000.00 75,000.00 170,000.00 I. 12,000.00 83,000.00 80,000.00 175,000.00 VIP. 12,000.00 83,000.00 90,000.00 185,000.00 VVIP. 12,000.00 83,000.00 95,000.00 190,000.00 6 Pembongkaran Jenazah 39,000.00 120,000.00 239,000.00 398,000.00 7 Pemakaman Jenazah. III 100,000.00 220,000.00 250,000.00 570,000.00 II. 100,000.00 220,000.00 260,000.00 580,000.00 I. 100,000.00 220,000.00 270,000.00 590,000.00 VIP. 100,000.00 220,000.00 300,000.00 620,000.00 VVIP. 100,000.00 220,000.00 350,000.00 670,000.00 8 Visum Jenazah. III 13,000.00 15,000.00 35,000.00 63,000.00 II. 13,000.00 15,000.00 40,000.00 68,000.00 I. 13,000.00 15,000.00 45,000.00 73,000.00 VIP. 13,000.00 15,000.00 55,000.00 83,000.00 VVIP. 13,000.00 15,000.00 65,000.00 93,000.00

E. Pelayanan Ambulance/Mobil Jenazah.

Tarif ( Rp. )

1 2 3

1 Sampai dengan jarak 10 Km. 60,000.00

2 Jarak lebih dari 10 Km, ditambah setiap 1 Km.

F. Pelayanan Mediko Legal.

(Rp.) (Rp.) ( Rp. )

1 2 3 4 5

1 Pembongkaran Jenazah.

- Jarak sampai dengan 10 Km. 159,000.00 239,000.00 398,000.00

- Jarak 10 Km s/d 30 Km. 249,000.00 239,000.00 488,000.00

- Jarak lebih dari 30 Km ditambah Rp. setiap 1 Km.

2 Surat Keterangan Rumah Sakit. 2,500.00 2,500.00 5,000.00

3 Permintaan Visum et Repertum.

III 10,000.00 10,000.00 20,000.00 II. 10,000.00 12,500.00 22,500.00 I. 10,000.00 15,000.00 25,000.00 UTAMA 10,000.00 17,500.00 27,500.00 VIP. 10,000.00 20,000.00 30,000.00 No. No. Katagori Pelayanan Katagori Pelayanan No.

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G. Pemeriksaan Kesehatan untuk Pemberian Surat Keterangan Kesehatan.

(Rp.) (Rp.) ( Rp. )

1 2 3 4 5

1 Orang Sakit dan Hamil/Bersalin/Masa Nifas 2,500.00 2,500.00 5,000.00

2 Malanjutkan Sekolah 2,500.00 2,500.00 5,000.00

3 Malamar Pekerjaan 2,500.00 2,500.00 5,000.00

4 Mengikuti Kursus 2,500.00 2,500.00 5,000.00

5 Keluar Negeri 12,500.00 12,500.00 25,000.00

6 Keperluan Asuransi 15,000.00 15,000.00 30,000.00

PEMERIKSAAN RADIO DIAGNOSTIK CITO. A. Dewasa.

No. JENIS PEMERIKSAAN BA J A S A

KLAS RS MEDIS 1 2 3 4 5 6 I. SEDERHANA 1. Thorax 35,000.00 III. B 0.00 0.00 35,000.00 III. A 4,375.00 4,375.00 35,000.00 II 8,750.00 8,750.00 35,000.00 I 10,625.00 10,625.00 35,000.00 Utama 12,500.00 12,500.00 35,000.00 VIP 15,000.00 15,000.00 2. BNO 35,000.00 III. B 0.00 0.00 35,000.00 III. A 4,375.00 4,375.00 35,000.00 II 8,750.00 8,750.00 35,000.00 I 10,625.00 10,625.00 35,000.00 Utama 12,500.00 12,500.00 35,000.00 VIP 15,000.00 15,000.00 3. Clauicula 25,000.00 III. B 0.00 0.00 25,000.00 III. A 4,375.00 4,375.00 25,000.00 II 8,750.00 8,750.00 25,000.00 I 10,625.00 10,625.00 25,000.00 Utama 12,500.00 12,500.00 25,000.00 VIP 15,000.00 15,000.00 4. Scapula 25,000.00 III. B 0.00 0.00 25,000.00 III. A 4,375.00 4,375.00 25,000.00 II 8,750.00 8,750.00 25,000.00 I 10,625.00 10,625.00 25,000.00 Utama 12,500.00 12,500.00 25,000.00 VIP 15,000.00 15,000.00 5. Pelvis 35,000.00 III. B 0.00 0.00 35,000.00 III. A 4,375.00 4,375.00 35,000.00 II 8,750.00 8,750.00 35,000.00 I 10,625.00 10,625.00 35,000.00 Utama 12,500.00 12,500.00 35,000.00 VIP 15,000.00 15,000.00 6. Manus 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 7. Amtebrachi 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 8. Humerus 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 9. Wrist 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 10. Cubiti 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00

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11. Shoulder 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 12. Pedis 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 13. Cruris 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 14. Angkle 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 15. Genu 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 16. Femur 35,000.00 III. B 0.00 0.00 35,000.00 III. A 8,750.00 8,750.00 35,000.00 II 17,500.00 17,500.00 35,000.00 I 21,250.00 21,250.00 35,000.00 Utama 25,000.00 25,000.00 35,000.00 VIP 30,000.00 30,000.00 17. Patella 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00

18. Hip Joint 35,000.00 III. B 0.00 0.00

35,000.00 III. A 8,750.00 8,750.00 35,000.00 II 17,500.00 17,500.00 35,000.00 I 21,250.00 21,250.00 35,000.00 Utama 25,000.00 25,000.00 35,000.00 VIP 30,000.00 30,000.00 II. SEDANG 1. VC 50,000.00 III. B 0.00 0.00 50,000.00 III. A 7,187.50 7,187.50 50,000.00 II 14,375.00 14,375.00 50,000.00 I 17,812.50 17,812.50 50,000.00 Utama 21,250.00 21,250.00 50,000.00 VIP 25,000.00 25,000.00 2. V L 70,000.00 III. B 0.00 0.00 70,000.00 III. A 7,187.50 7,187.50 70,000.00 II 14,375.00 14,375.00 70,000.00 I 17,812.50 17,812.50 70,000.00 Utama 21,250.00 21,250.00 70,000.00 VIP 25,000.00 25,000.00 3. V T 70,000.00 III. B 0.00 0.00 70,000.00 III. A 7,187.50 7,187.50 70,000.00 II 14,375.00 14,375.00 70,000.00 I 17,812.50 17,812.50 70,000.00 Utama 21,250.00 21,250.00 70,000.00 VIP 25,000.00 25,000.00 4. VL - S 70,000.00 III. B 0.00 0.00 70,000.00 III. A 7,187.50 7,187.50 70,000.00 II 14,375.00 14,375.00 70,000.00 I 17,812.50 17,812.50 70,000.00 Utama 21,250.00 21,250.00 70,000.00 VIP 25,000.00 25,000.00

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5. VL - L 70,000.00 III. B 0.00 0.00 70,000.00 III. A 7,187.50 7,187.50 70,000.00 II 14,375.00 14,375.00 70,000.00 I 17,812.50 17,812.50 70,000.00 Utama 21,250.00 21,250.00 70,000.00 VIP 25,000.00 25,000.00

6. Thorax AP/LAT. 70,000.00 III. B 0.00 0.00

70,000.00 III. A 7,187.50 7,187.50

70,000.00 II 14,375.00 14,375.00

70,000.00 I 17,812.50 17,812.50

70,000.00 Utama 21,250.00 21,250.00

70,000.00 VIP 25,000.00 25,000.00

7. BNO 2 Posisi 70,000.00 III. B 0.00 0.00

70,000.00 III. A 7,187.50 7,187.50 70,000.00 II 14,375.00 14,375.00 70,000.00 I 17,812.50 17,812.50 70,000.00 Utama 21,250.00 21,250.00 70,000.00 VIP 25,000.00 25,000.00 8. Cranium 50,000.00 III. B 0.00 0.00 50,000.00 III. A 7,187.50 7,187.50 50,000.00 II 14,375.00 14,375.00 50,000.00 I 17,812.50 17,812.50 50,000.00 Utama 21,250.00 21,250.00 50,000.00 VIP 25,000.00 25,000.00 9. S P N 50,000.00 III. B 0.00 0.00 50,000.00 III. A 7,187.50 7,187.50 50,000.00 II 14,375.00 14,375.00 50,000.00 I 17,812.50 17,812.50 50,000.00 Utama 21,250.00 21,250.00 50,000.00 VIP 25,000.00 25,000.00 10. O P G 40,000.00 III. B 0.00 0.00 40,000.00 III. A 7,187.50 7,187.50 40,000.00 II 14,375.00 14,375.00 40,000.00 I 17,812.50 17,812.50 40,000.00 Utama 21,250.00 21,250.00 40,000.00 VIP 25,000.00 25,000.00 11. U S G 40,000.00 III. B 0.00 0.00 40,000.00 III. A 15,000.00 15,000.00 40,000.00 II 30,000.00 30,000.00 40,000.00 I 35,625.00 35,625.00 40,000.00 Utama 41,875.00 41,875.00 40,000.00 VIP 50,000.00 50,000.00 III. CANGGIH. 1. Mastoid 100,000.00 III. B 0.00 0.00 100,000.00 III. A 14,375.00 14,375.00 100,000.00 II 29,375.00 29,375.00 100,000.00 I 36,250.00 36,250.00 100,000.00 Utama 43,125.00 43,125.00 100,000.00 VIP 50,625.00 50,625.00 2. Orbita 100,000.00 III. B 0.00 0.00 100,000.00 III. A 14,375.00 14,375.00 100,000.00 II 29,375.00 29,375.00 100,000.00 I 36,250.00 36,250.00 100,000.00 Utama 43,125.00 43,125.00 100,000.00 VIP 50,625.00 50,625.00 3. Oesophagus 197,000.00 III. B 0.00 0.00 197,000.00 III. A 28,750.00 28,750.00 197,000.00 II 57,500.00 57,500.00 197,000.00 I 70,937.50 70,937.50 197,000.00 Utama 86,250.00 86,250.00 197,000.00 VIP 100,625.00 100,625.00 4. Cystogram 235,000.00 III. B 0.00 0.00 235,000.00 III. A 28,750.00 28,750.00 235,000.00 II 57,500.00 57,500.00 235,000.00 I 70,937.50 70,937.50 235,000.00 Utama 86,250.00 86,250.00 235,000.00 VIP 100,625.00 100,625.00

5. Uretro Cystogram 235,000.00 III. B 0.00 0.00

235,000.00 III. A 28,750.00 28,750.00

235,000.00 II 57,500.00 57,500.00

235,000.00 I 70,937.50 70,937.50

235,000.00 Utama 86,250.00 86,250.00

(24)

6. Colon in Loop 250,000.00 III. B 0.00 0.00 250,000.00 III. A 28,750.00 28,750.00 250,000.00 II 57,500.00 57,500.00 250,000.00 I 70,937.50 70,937.50 250,000.00 Utama 86,250.00 86,250.00 250,000.00 VIP 100,625.00 100,625.00

7. BNO IUP 315,000.00 III. B 0.00 0.00

315,000.00 III. A 28,750.00 28,750.00

315,000.00 II 57,500.00 57,500.00

315,000.00 I 70,937.50 70,937.50

315,000.00 Utama 86,250.00 86,250.00

315,000.00 VIP 100,625.00 100,625.00

8. Bone Survey 640,000.00 III. B 0.00 0.00

640,000.00 III. A 28,750.00 28,750.00 640,000.00 II 57,500.00 57,500.00 640,000.00 I 70,937.50 70,937.50 640,000.00 Utama 86,250.00 86,250.00 640,000.00 VIP 100,625.00 100,625.00 B. Anak-anak

No. JENIS PEMERIKSAAN BA J A S A

KLAS RS MEDIS 1 2 3 4 5 6 I. SEDERHANA 1. Thorax 25,000.00 III. B 0.00 0.00 25,000.00 III. A 4,375.00 4,375.00 25,000.00 II 8,750.00 8,750.00 25,000.00 I 10,625.00 10,625.00 25,000.00 Utama 12,500.00 12,500.00 25,000.00 VIP 15,000.00 15,000.00 2. BNO 25,000.00 III. B 0.00 0.00 25,000.00 III. A 4,375.00 4,375.00 25,000.00 II 8,750.00 8,750.00 25,000.00 I 10,625.00 10,625.00 25,000.00 Utama 12,500.00 12,500.00 25,000.00 VIP 15,000.00 15,000.00 3. Clauicula 25,000.00 III. B 0.00 0.00 25,000.00 III. A 4,375.00 4,375.00 25,000.00 II 8,750.00 8,750.00 25,000.00 I 10,625.00 10,625.00 25,000.00 Utama 12,500.00 12,500.00 25,000.00 VIP 15,000.00 15,000.00 4. Scapula 25,000.00 III. B 0.00 0.00 25,000.00 III. A 4,375.00 4,375.00 25,000.00 II 8,750.00 8,750.00 25,000.00 I 10,625.00 10,625.00 25,000.00 Utama 12,500.00 12,500.00 25,000.00 VIP 15,000.00 15,000.00 5. Pelvis 25,000.00 III. B 0.00 0.00 25,000.00 III. A 4,375.00 4,375.00 25,000.00 II 8,750.00 8,750.00 25,000.00 I 10,625.00 10,625.00 25,000.00 Utama 12,500.00 12,500.00 25,000.00 VIP 15,000.00 15,000.00 6. Manus 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 7. Amtebrachi 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00 8. Humerus 25,000.00 III. B 0.00 0.00 25,000.00 III. A 8,750.00 8,750.00 25,000.00 II 17,500.00 17,500.00 25,000.00 I 21,250.00 21,250.00 25,000.00 Utama 25,000.00 25,000.00 25,000.00 VIP 30,000.00 30,000.00