LAMPIRAN I
PERATURAN WALIKOTA TANGERANG SELATAN
NOMOR51 TAHUN 2 015
TENTANG
TARIF PELAYANAN KESEHATAN BADAN LAYANAN
UMUM DAERAH PADA RUMAH SAKIT UMUM
KOTA TANGERANG SELATAN
T A R I F P E L A Y A N A N GAWAT D A R U R A T
NO
JENIS PELAYANAN
JASA SARANA
JASA
PELAYANAN
TARIF
NO
JENIS PELAYANAN
(Rp)
(Rp)
(Rp)
1 Pemeriksaan D o k t e r U m u m I G D / h a r i **
35,000
4 0 , 0 0 0
75,000
2 Pemeriksaan D o k t e r Spesialis/ h a r i **
35,000
80,000
115,000
3 Pemeriksaan D o k t e r S u b Spesialis/ h a r i **
35,000
100,000
135,000
4 K o n s u l Dokter Spesialis/ h a r i **
5,000
30,000
35,000
5 K o n s u l Dokter S u b Spesialis/ h a r i **
5,000
40,000
45,000
6 R u a n g Observasi K e g a w a t d a r u r a t a n / I G D per
h a r i (lebih d a r i 2 4 jam)
70,000
45,000
115,000
7 R u a n g B e r s a l i n (VK) per h a r i
70,000
45,000
115,000
8 A s u h a n Keperawatan I G D / V K < 6 j a m
50,000
100,000
150,000
A s u h a n Keperawatan I G D / V K > 6 j a m
5 0 0 0 0
200,000
250,000
9 A s u h a n Keperawatan M a n d i r i *
60,000
90,000
150,000
A s u h a n Keperawatan Parsial *
100,000
150,000
250,000
A s u h a n Keperawatan Total *
160,000
240,000
4 0 0 , 0 0 0
* ditagihkan apabila, Perawatan > 24 j a m
LAMPIRAN I I
PERATURAN WALIKOTA TANGERANG SELATAN NOMOR 51 TAHUN 2015
TENTANG
TARIF PELAYANAN KESEHATAN BADAN LAYANAN U M U M DAERAH PADA RUMAH SAKIT U M U M KOTA TANGERANG SELATAN
T A R I F PELAYANAN RAWAT JALAN
NO J E M S PELAYANAN JASA SARANA JASA PELAYANAN TARIF
NO J E M S PELAYANAN
(Rp) (Rp) (Rp)
1 Pemeriksaan/ Konsultasi Dokter U m u m / dokter gigi
di Poliklinik 20,000 30,000 50,000
2 Pemeriksaan/ Konsultasi Dokter Spesialis di
Poliklinik 20,000 80,000 100,000
3 Pemeriksaan/Konsultasi Dokter Sub Spesialis di
Poliklinik 20,000 100,000 120,000
POLIKLINIK
A. PELAYANAN M E D I S MATA
1 Amotio Corpal Ekstra Okuler 55,000 70,000 125,000
2 Amotio Corpus Alieneum Conjungtiva 60,000 65,000 125,000
3 Amotio Gram Kornea 114,000 170,000 284,000
4 Amotio Granuloma 135,000 90,000 225,000 5 Aneltest 60,000 40,000 100,000 6 Auto Refraktometer 12,000 8,000 20,000 7 Ekspolrasi 39,000 86,000 125,000 8 Ekstirpasi Lithiasis 60,000 40,000 100,000 9 Ekstirpasi M i l l i u m 60,000 40,000 100,000
10 Ekstirpasi Nevus Conjungtiva Kecil 100,000 200,000 300,000
11 Ekstirpasi Xanthelesasma Kecil 200,000 400,000 600,000
12 Epilasi 39,000 61,000 100,000
13 Flouresin Test 36,000 24,000 60,000
14 Funduscopy Direk 15,000 10,000 25,000
15 Funduscopy Indirek 18,000 12,000 30,000
16 Injeksi Subconjungtiva 42,000 33,000 75,000
17 Insisi Abses Palpebra 76,500 51,000 127,500
18 Insisi Hodeoulum/Khlalazion 240,000 160,000 400,000
19 Irigasi Mata/Spooling 39,000 61,000 100,000
20 Ishihara Test 12,000 13,000 25,000
2 1 Kampimetri 10,000 15,000 25,000
22 Laserasi Palpebra/Wing Toilet 195,000 130,000 325,000
23 Literasi (Lemak Mata) 195,000 130,000 325,000
24 Pemeriksaan Biometry 39,000 26,000 65,000 25 Pemeriksaan Keratometer 60,000 40,000 100,000 26 Penjahitan Konjungtiva 420,000 430,000 850,000 27 Refraksi 15,000 10,000 25,000 28 Schemer Test 12,000 23,000 35,000 29 Simblevarektomi 57,000 38,000 95,000 30 Slit Lamp 12,000 8,000 20,000 30 Strike Retinoscopy . 105,000 70,000 175,000
2
31 Tonometri n o n contact 18,000 ' 32,000 50,000
B. PELAYANAN MEDIS T H T
1 Audiometri 48,000 32,000 80,000
2 Audiometri Nada M u r n i 20,000 25,000 45,000
3 Biopsi aproach Cad Well-Luc (CWL) 55,000 36,500 91,500
4 Biopsi Cavum Nasi 45,000 30,000 75,000
5 Biopsi dan Nasopharyngeal Cancer (NPC) 30,000 20,000 50,000
6 Biopsi Larynx 55,000 150,000 205,000
7 Biopsi Nasopharyng 45,000 30,000 75,000
8 Biopsi Oropharyng 45,000 30,000 75,000
9 Biopsi Palatum 30,000 20,000 50,000
10 Biopsi Tonsil 55,000 195,000 250,000
11 Biopsi Tumor Colli 55,000 150,000 205,000
12 Biopsi Tumor Lidah 55,000 30,000 85,000
13 Pasang / B u k a Tampon Anterior H i d u n g 20,000 25,000 45,000
14 Pasang / B u k a Tampon Posterior H i d u n g 55,000 45,000 100,000
15 Cuci Sinus 66,000 44,000 110,000
16 Corpus Alienum H i d u n g / Lubang Telinga 30,000 70,000 100,000
17 Corpus Alienum Hidung / Lubang Telinga dgn
Penyulit 48,000 72 000 120 000 x 4mi vy y vy vy vy
18 Debridement Luka (SpTHT) 30,000 55,000 85,000
19 Dekanulasi 30,000 55,000 85,000
20 external carotid artery (ECA) Hypopharinx dgn
Inderect Laryng 30 000 20 000 50 000
21 external carotid artery (ECA) Telinga 28,500 19,000 47,500
22 external carotid artery (ECA) Tenggorokan 18,000 12,000 30,000
24 Ekstraksi Corpus Alienum Tenggorokan 30,000 55,000 85,000
25 Evacuasi Cholesteatoma 18,000 12,000 30,000
26 Somato Senseric Evoked Potensial (SSEP) 20,000 13,000 33,000
27 Gips Telinga 18,000 12,000 30,000
28 Imunoterapi 20,000 13,000 33,000
29 Injeksi Imunoterapi 20,000 13,000 33,000
31
Tn*5i«ii rlnn/fltmi irifya^i AVwe^ Ppritnrwil / Tonsil
lllOldl UCUX / CLLd11 11 ItlClOl n U o l o 1 1h1 1 LUlloll / IVJllOll 24,000 16 000 40 000
32 Insisi Mastoid 60,000 40,000 100,000
33 Insisi Retropharyngeal 55,000 36,500 91,500
34 Insisi Septal Abses 30,000 20,000 50,000
35 Insisi Septum Nasi 60,000 60,000 120,000
36 Kauter Konkha Hidung 30,000 20,000 50,000
37 Kauter Pharyng 30,000 20,000 50,000
38 Kauter Veruka 55,000 36,500 91,500
39 Laringoscopy Fiber Optik Tanpa Gambar 55,000 36,500 91,500
40 Nasopharyngoscopy dengan biopsi 55,000 36,500 91,500
4 1 Nasopharyngoscopy tanpa biopsi 20,000 71,500 91,500
42 Oto Aksutik Emission 20,000 13,000 33,000
43 Parasentese Telinga 18,000 27,000 45,000 46 Perawatan Epistaxis 30,000 20,000 50,000 47 Perawatan Telinga 18,000 12,000 30,000 48 Punchtie Perinchondritis 18,000 12,000 30,000 49 Rhinoscopy Posterior 18,000 12,000 30,000 50 Spooling Cerumen 36,000 24,000 60,000 51 Spooling H202 3% 20,000 13,000 33,000 52 Suction Telinga 36,000 24,000 60,000
3
53 Test Alergi 30,000 55,000 85,000
54 Test Fungsi Tuba 20,000 25,000 45,000
55 Test Kalori (SpTHT, SpSyaraf) 30,000 25,000 55,000
56 Tympanometri 20,000 13,000 33,000
C. PELAYANAN S Y A R A F
1 Injeksi Carpal Tunnel Syndrome 30,000 120,000 150,000
2 Injeksi Dequarvain 30,000 120,000 150,000
3 Injeksi Epidural 30,000 215,000 245,000
4 Injeksi Neuro Vaskuler (Trigger Point)
a. 1 s/d 2 titik 30,000 90,000 120,000
b. > 2 titik 30,000 120,000 150,000
5 Injeksi Trigger Finger
a. 1 Sisi 30,000 90,000 120,000
b. 2 Sisi 30,000 120,000 150,000
6 Injeksi Trigger T h u m b
a. 1 Sisi 30,000 90,000 120,000
b. 2 Sisi 30,000 120,000 150,000
7 Skrining Awal Fungsi L u h u r (MMSE 8s CDT) 20,000 90,000 110,000
8 Skrining TOAB (Test Orientasi Amnesia Balvaston)
pada Pasien Pasca Cedera Kepala on nnn 4U,UUU nn nnn yu,uuu 1 111U,000 n nnn
9 NCV 40 000 1 14 000 1 54 000 X J T ) U U u 10 EMG 40,000 n ^ a yv /-\ y\ 114,000 154,000 11 NCV + EMG 40,000 191,000 231,000 12 Evoked Potential 40,000 114,000 154,000 13 PSG 100 000 x vy vy j w vy 230 000 330 000 vy vy vy j vy vy vy 14 t U M 110,000 o341,000 A 1 Ann A C 1 f\r\C\ 451,000 15 STMS (Diagnostik) 40,000 114,000 154,000 16 RTMS (Terapeutik) 40,000 191,000 231,000 17 Pemeriksaan MOCA-INA 10,000 12,000 22,000
18 Pemeriksaan Digit Spam Alternate Attention 10,000 12,000 22,000
19 Pemeriksaan Token Test 10,000 17,500 27,500
20 Pemeriksaan Tadir 10,000 17,500 27,500
91 Pemeriksaan BNT 10,000 17,500 27,500
99 Pemeriksaan Memory Cerad 10,000 17,500 27,500
99 Pemeriksaan Restricted Remending Test 5,000 6,000 11,000
94
^ T Pemeriksaan CDT 5,000 11,500 16,500
25 Pemeriksaan Fungsi Visuospatial 5,000 11,500 16,500
96 Pemeriksaan Hamilton's Depretion Score 5,000 11,500 16,500
97 Pemeriksaan FAQ 5,000 11,500 16,500
99 Fungsi Luhur - Paket Diagnostik 50,000 115,000 165,000
29 Injeksi Lokal (SpSyaraf) 24,000 31,000 55,000
31 Injeksi Ekstra Artikuler (SpSyaraf) 40,000 42,500 82,500
33 Injeksi Intra Artikuler (SpSyaraf) 60,000 77,500 137,500
35 Pemeriksaan Kontrol Postural 10,000 17,500 27,500
36 Pemeriksaan Gait 10,000 17,500 27,500
37 Pemeriksaan Balans 10,000 17,500 27,500
38
vJO Pemeriksaan ARM 8s Hand Function 10,000 17,500 27,500
39 Pemeriksaan Barthel Index . 4,000 7,000 11,000
40 Pemeriksaan Rankin Scale 4,000 7,000 11,000
41
~ X Pemeriksaan Orpingthon Scale 4,000 7,000 11,000
42 Pemeriksaan Fungsi Menelan 10,000 17,500 27,500
43 Pemeriksaan Fungsi Kognitif 10,000 17,500 27,500
44 Paket Pemeriksaan Neurorestorasi 60,000 105,000 165,000
45
1 vJ Neurorestorasi Manuver Epley 15 6,000 10,500 16,500
46 Neurorestorasi Manuver Brantd - Darop 6,000 10,500 16,500
47 Neurorestorasi Manuver Semont 6,000 10,500 16,500
48 Neurorestorasi Manuver Side Lying 6,000 10,500 16,500
49 Neurorestorasi Log Roll 6,000 10,500 16,500
4 C I
O 1 Mm l r(M*oof A I * H oi UArmrta T3H-AV1 /H*H A A H D A P I H I A H I
iNeuroresiorasi Jrorciue iToiongeu r o s i n o n c nnn iU,bUU iO,bUU
oz Neurorestorasi Manuver Cowthorne - Cooksey c6,U0U n n n 1iU,bUU n c n n 1 A c n n
CO
oo Paket Neurorestorasi Vertigo
o A n n n
24,000
A n n n n
42,U0U 66,000 ALA n n n
C /I Neurorestorasi Manuver Peldenkreis A r\ AAA
4U,U0U
H A n n n
70,000 110,000
C c
bo Neurorestorasi Manuver Bobat A o c\r\r\ 4o,UUU
O A n n n 13^,000
c c
bt> Neurorestorasi Manuver Stimulasi Dispagia A A AAA
4U,UUU 7n n n n
i i n n o A 11U,UUU CO
6/ Neurorestorasi Manuver Stimulasi Kognitif
A A AAA
4U,UUl> v n n n n /U,UUU 1 1 A AAA
110,000 CQ
bo Pemeriksaan Romberg Test A C\C\f\ 4,UUU i-r
n n n
/ ,UUU 1 11 1,000 AAA
c n
59 Pemeriksaan Tandem Test
A AAA 4,UU(J 7 n n n 1 1 AAA 11,000 60 Pemeriksaan F u k u d a Test A r\f\f\ 4,000 7 n n n 7,000 1 1 AAA 11,000
61 Pemeriksaan Hallpike Manuver c n n n
6,000
1 n c n n
10,500 1 a c n n
16,500
62 Pemeriksaan Halmagyi - Kurthois y r\r~\r\
6,000
i n c n n
10,500 i £L c r\r\
16,500 y o
63 Pemeriksaan Tuning Fork
/-' n n n
6,006 i n c n n lU,bUU
1 c c n n
- 16,600 y -i
64 Pemeriksaan Optokinetik Nistagmus (OKN)
a n n n
b,00U i n c n n 10,b00 116,600 c c n n
bo Pemeriksaan Test Kalori (SpTHT, SpSyaraf) 20,000 35,000 55,000
y y
bb Pemeriksaan Frenzel Glass 10,000 17,500 27,500
D. PELAYANAN K E D O K T E R A N JIWA/ PSYCHOLOGY
i 1 Psikoterapi
a. Kurang dari 30 menit 10,000 90,000 100,000
b. Lebih dari 30 menit 10,000 140,000 150,000
2 Surat Keterangan Bebas Narkoba (SBN) 10,000 65,000 75,000
3 Surat Keterangan Sehat Rohani 10,000 15,000 25,000
4 Surat Keterangan Bebas Tembakau 5,000 20,000 25,000
5 Test Psikometri
a. MMSE (Tes Memori Pada Manula) 20,000 80,000 100,000
b. ADL / IADL (Tes Fungsi Kehidupan Sehari-hari) 12,500 35,000 47,500
c. GDS (Tes Depresi Pada Manula) 12,500 35,000 47,500
d. Minnesota Multiphasic Personality Inventory
(MMPI) 100,000 150,000 250,000
e. PANNS (Tes Monitoring Kemajuan Terapi AP) 12,500 35,000 47,500
f. SCL-90 10,000 35,000 45,000
g. Tes Minat Bakat 50,000 200,000 250,000
h. TesIQ 30,000 120,000 150,000
6 ; Konseling Perkawinan 10,000 90,000 100,000
7 Konseling HIV AIDS 10,000 90,000 100,000
8 Surat Keterangan Visum et Repertum
Phychiatricum 110,000 275,000 385,000
9 Saksi Ahli 380,000 420,000 800,000
10 Injeksi Scizoad 20,000 55,000 75,000
E . PELAYANAN GIGI MULUT 1) PENAMBALAN
1 Inlay/Uplay 200,000 150,000 350,000
2 Perawatan Saluran Akar/ Pengisian 51,600 78,400 130,000
3 Pulp caping 45,000 65,000 110,000
4 Tambal Amalgam Kompleks 30,000 70,000 100,000
5 Tambal Amalgam Simpleks 30,000 45,000 75,000
6 Tambal Light Curing 1 Permukaan Besar 100,000 150,000 250,000
7 Tambal Light Curing 1 Permukaan Kecil 75,000 110,000 185,000
8 Tambal Light Curing 2 Permukaan Besar 125,000 190,000 315,000
9 Tambal Sementara 30,000 45,000 75,000
10 Tambal Sementara Perawatan
5
2) PENCABUTAN
1 Gigi Sulung dengan Suntik 30,000 45,000 75,000
2 Gigi Sulung Topikal 24,000 36,000 60,000
3 Gigi Tetap dengan Komplikasi 50,000 75,000 125,000
4 Gigi Tetap Tanpa Komplikasi 40,000 60,000 100,000
5 Molar 3 dengan Komplikasi 400,000 600,000 1,000,000
6 Molar 3 tanpa Komplikasi 50,000 300,000 350,000
3) PERIODONTAL
1
SAPIIIITTcr /Pf^mV>f=*T*ciiVifin T^arnricr C\\cri fr^T-VilaHrnnl OV^dllll4^,/ r c i i i u t i OllicUi IVCllCUlg VJlj^l ^IJCl IvUClUl d i l l
7n nnn i n^ nnn 17c nnn
2 Alvelectomy 170,000 250,000 420,000
3 Curetage per regio 100,000 65,000 165,000
4 Frenektomi 150,000 200,000 350,000
5 Ginggivektomi per regio 280,000 220,000 500,000
6 Hecting per 1 j a h i t a n 25,000 30,000 55,000
7 Insisi Abses Ekstra Oral 84,000 66,000 150,000
8 Insisi Abses Intra Oral 70,000 50,000 120,000
9 Operculectomy 150,000 200,000 350,000
10 Perawatan Periodontal 37,500 50,000 87,500
11 Splinting wire per gigi 50,000 50,000 100,000
4) R E M O V A B L E P R O T H E S E
1 Full prothese satu rahang 700,000 460,000 1,160,000
2 Full/Prothese/Rahang Atas 8s Rahang Bawah 1,500,000 1,250,000 2,750,000
3 Protese Partial Gigi Berikutnya 55,000 40,000 96,000
4 Prothese Partial Gigi Pertama 240,000 160,000 400,000
5 Rebase Prothese Full Rahang Atas/Bawah 392,000 265,000 657,000
6 Reparasi Prothese 126,000 85,000 211,000
5) F I X E D P R O T H E S E
1 Bridge Acrylic Metal Procelin per-Elemen 336,000 225,000 561,000
2 Full Post Crown 210,000 140,000 350,000
3 Gigi Implant + Crown PFM 8,000,000 5,500,000 13,500,000
4 Jacket Crown All Acrylic 300,000 200,000 500,000
5 Procelin Crown per-Gigi 616,000 584,000 1,200,000
6) B E D A H MULUT DENGAN A N E S T E S I L O K A L A) K e c i l
1 Apex Reseksi 1 Elemen 250,000 800,000 1,050,000
2 Eksisi Mucocel/ Epulis 250,000 800,000 1,050,000
3 Eksisi Biopsi 250,000 800,000 1,050,000 4 Insisi Biopsi 250,000 800,000 1,050,000 5 Debridement (SpBM) 250,000 800,000 1,050,000 6 Transplantasi 250,000 800,000 1,050,000 B)Sedang 1 Odontectomy 480,000 900,000 1,380,000 2 Alveolectomy 480,000 900,000 1,380,000 3 Reposisi Dislokasi T M J 480,000 900,000 1,380,000 4 Enukleasi Kista 480,000 900,000 1,380,000 5 Insisi Abses EO 480,000 900,000 1,380,000
6
C) Besar
1 Marsupialisasi 800,000 1,500,000 2,300,000
2 Fiksasi Fraktur 800,000 1,500,000 2,300,000
Tindakan medik di Ruang Operasi Bedah Sentral disesuaikan dengan tarif bedah sentral
7) ORTHODONTI
Pencetakan Alginate Rahang Atas+ Bawah 168,000 112,000 280,000
A) Pemasangan
1 Alat Ortodonti Lepas RA+RB 1,400,000 950,000 2,350,000
2 Alat Ortodonti Lepas RA/RB 625,000 520,000 1,145,000
3 Alat Ortodonti Cekat RA+RB 3,640,000 2,400,000 6,040,000
4 Alat Ortodonti Cekat RA/RB 2,000,000 1,500,000 3,500,000
5 Alat Ortodonti Secsional 750,000 750,000 1,500,000
B) Kontrol
1 Kontrol Cekat 112,000 75,000 187,000
2 Kontrol Removeable 56,000 40,000 96,000
C) Pemasangan Alat Tambahan
1 Alat ekstra oral - Face Mask 2,400,000 1,600,000 4,000,000
2 Alat ekstra oral - Head Gear 900,000 800,000 1,700,000
3 Bate Raiser Posterior/Anterior (Removible) 300,000 200,000 500,000
4 Chin Cap + Head 1,000,000 500,000 1,500,000
5 Lip Bumper 900,000 600,000 1,500,000
6 Plat Retensi RA/RB (Retainer) 420,000 380,000 800,000
7 Trans Palatal Acrch (RPE) 500,000 500,000 1,000,000
F . PELAYANAN MEDICAL C H E C K UP
1 Pemeriksaan U n t u k Surat Keterangan Sehat 5,000 30,000 35,000
2 Pemeriksaan Kesehatan Standard 90,000 60,000 150,000
Terdiri dari:
a. Pemeriksaan dr. U m u m b. Pemeriksaan Thorax Photo
c. LAB Sederhana (Urine Lengkap + Darah rutin)
3 MCU Paket I 210,000 140,000 350,000
Terdiri dari :
a. Pemeriksaan dr. U m u m b. Pemeriksaan Thorax Photo c. EKG
d. LAB SederhanafUhne Lengkap + Darah Lengkap + Fungsi Hati (SGOT, SGPT) + GDS + Fungsi Ginjal + Kolesterol Total)
4 MCU Paket I I 510,000 340,000 850,000
Terdiri dari:
a. Pemeriksaan dr. U m u m b. Pemeriksaan dr. Spesialis c. Pemeriksaan Thorax Photo d. USG Abdomen Lengkap e. EKG
7 f. LAB(Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,SGPT, Gamma GT)+ GDS, GDP + Fungsi Ginjal (Ureum, Kreatinin) + Fungsi Lemak + (Kolesterol Total, HDL, LDL, Trigliserida) + Hepatitis
(HbsAG/strip) 5 MCU Paket I I I 693,000 462,000 1,155,000 Terdiri dari: a. Pemeriksaan dr. U m u m b. Pemeriksaan dr. Spesialis c. Pemeriksaan Mata d. Pemeriksaan THT
e. Pemeriksaan Thorax Photo f. USG Abdomen Lengkap g. EKG
h . LAB (Urine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,SGPT, Gamma GT) + GDS, GDP + Fungsi Ginjal (Ureum, Kreatinin) + Fungsi Lemak +
(Kolesterol Total, HDL, LDL, Tnglisenda) + Hepatitis
(t-th^A Ci/vtrinl + Anfi HRQ + Acnm Tfrntl
[noo/iu/otrif'/ T mui l i i j o ~ sisum UTUIJ
6 MCU Paket IV 750,000 500,000 1,250,000
Terdiri dari:
a. Pemeriksaan dr. U m u m b. Pemeriksaan dr. Spesialis c. Pemeriksaan Mata
d. Pemeriksaan Ginekologi (Khusus Wanita) e. Pemeriksaan THT
f. Pemeriksaan Thorax Photo g. USG Abdomen Lengkap h . Gizi
i . EKG
j . LABfUrine Lengkap + Darah Lengkap + Fungsi Hati (SGOT,SGPT, Gamma GT) + GDS, GDP + Fungsi Ginjal (Ureum, Kreatinin) + Fungsi Lemak +
(Kolesterol Total, HDL, LDL, Trigliserida) + Hepatitis (HbsAG/strip) + Anti HBS + Asam Urat)
G. PELAYANAN ANDROLOGI
1 Analisa sperma 120,000 80,000 200,000
2 Injeksi therapi hormon 120,000 80,000 200,000
3 Paket IUI (intra uterine insemimation) persiapan
1,800,000 1,200,000 3,000,000
4 Test anilin + hiosin 150,000 100,000 250,000
5 Test fructosa + alpha glukosidase 150,000 100,000 250,000
6
Tindakan PLI (paternal leucocyte immunization) 540,000 360,000 900,000
7 Washing sperm 1,500,000 1,000,000 2,500,000
8 Bayi Tabung terdiri dari : 20,000,000 15,000,000 35,000,000
a. Ovum pick u p b. Embryo c. Embryo ransfer d. Frezzing sperma
8
H. PELAYANAN ANAK
1 Sitostatika Intratekal 5,000 22,500 27,500
2 Suntik Desensitisasi 5,000 50,000 55,000
3 Suntik Imunisasi BCG (PPI) 5,000 22,500 27,500
4 Suntik Imunisasi Campak (PPI) 5,000 22,500 27,500
5 Suntik Imunisasi Hepatitis / DPT (PPI) 5,000 22,500 27,500
6 Suntik Imunisasi Non PPI 5,000 22,500 27,500
7 Imunissasi Polio (PPI) 5,000 22,500 27,500
8 Konseling Gizi 5,000 50,000 55,000
9 Konseling T u m b u h Kembang 5,000 50,000 55,000
10 Penilaian DDST 5,000 50,000 55,000
11 Penilaian Milestone 5,000 50,000 55,000
12 Mantoux Test Anak 5,000 88,500 93,500
13 Nebulizer Anak 5,000 50,000 55,000
14 Konsultasi Paru Anak 5,000 28,000 33,000
15 Konseling Nebulisasi 5,000 28,000 33,000
16 Konseling Pemberian Obat Inhaler/Intranasal 5,000 50,000 55,000
17 Expertise Electrokardiografi 5,000 45,000 50,000
18 Penilaian Pertumbuhan 5,000 50,000 55,000
19 Penilaian Perkembangan 5,000 72,000 77,000
20 Konsultasi Laktasi , 5,000 72,000 77,000
21 Konseling Relaktasi 5,000 72,000 77,000
22 Konseling Perawatan Metode Kangguru 5,000 72,000 77,000
23 Penilaian Target Height/Parental Height 5,000 50,000 55,000
24 Penilaian Status Kematangan Seksual Anak 5,000 50,000 55,000
25 Pemberian Obat Perectal 5,000 22,500 27,500
I. PELAYANAN K U L I T KELAMIN
1 Aplikasi TCA Ringan 15,840 23,760 39,600
2 Aplikasi TCA Sedang 21,120 31,680 52,800
3 Aplikasi TCA Luas 34,320 51,480 85,800
4 Ekstraksi Komedo Ringan 23,760 35,640 59,400
5 Ekstraksi Komedo Sedang 36,960 55,440 92,400
6 Ekstraksi Komedo Luas 42,240 63,360 105,600
7 Elektrokauter Ringan 29,040 43,560 72,600
8 Elektrokauter Sedang 39,600 59,400 99,000
9 Elektrokauter Luas 66,000 99,000 165,000
10 Penyemprotan Khloretil 26,400 39,600 66,000
11 Rawat Luka (SMF Kulit) 13,200 19,800 33,000
12 Suntik Keloid Tanpa Obat 14,960 22,440 37,400
13 Suntik Keloid Dengan Obat 15,840 23,760 39,600
14 Facial 26,400 39,600 66,000
15 Peeling Glic Acid 2 0 % 39,600 59,400 99,000
16 Peeling Glic Acid 3 5 % 44,880 67,320 112,200
17 Peeling Glic Acid 5 0 % 55,440 83,160 138,600
18 Ekstirpasi Tumor Kecil 63,360 95,040 158,400
19 Ekstirpasi Tumor Sedang 87,120 130,680 217,800
20 Injeksi Triamsinolon Asettonid Kecil 15,840 23,760 39,600
21 Injeksi Triamsinolon Asettonid Sedang 26,400 39,600 66,000
22 Ekskohelasi Ringan 15,840 23,760 39,600
23 Ekskohelasi Sedang 21,120 31,680 52,800
24 Aplikasi Podofilin Kecil 26,400 39,600 66,000
25 Aplikasi Podofilin Sedang 52,800 79,200 132,000
26 Biopsi Jaringan Kulit 79,200 118,800 198,000
27 Suntikan Kenacort Acne Keloid 15,840 23,760 39,600
9
29 Injeksi Acne 6 s/d 10 26,400 39,600 66,000
30 Injeksi Acne > 10 39,600 59,400 99,000
31 Eksisi Tumor Wajah 132,000 198,000 330,000
32 Eksisi Tumor Non Wajah 100,000 150,000 250,000
33 Aspirasi Kista 26,400 39,600 66,000 34 Insisi Abses 22,000 33,000 55,000 35 Ekstirpasi Kista 83,600 125,400 209,000 36 Keratosis Seboroika 98,800 148,200 247,000 37 Syringoma 98,800 148,200 247,000 38 Radiotom Kecil 15,840 23,760 39,600 39 Radiotom Sedang 26,400 39,600 66,000 40 Radiotom Luas 71,280 106,920 178,200 41 Kaustik 99,000 148,500 247,500 42 Dermabrasi 70,400 105,600 176,000 43 Neurofibroma 70,400 105,600 176,000 44 Tandur Kulit 70,400 105,600 176,000 45 Trepanasi 70,400 105,600 176,000 46 Tes Alergi 22,000 33,000 55,000 47 Elektrokoagulasi Kecil 26,400 39,600 66,000 48 Elektrokoagulasi Sedang 39,600 59,400 99,000 J . PELAYANAN KEBIDANAN i i Biopsi 50,000 75,000 125,000
2 Couterisasi Condiloma Acuminata Ringan . 20,000 46,000 66,000
3 Couterisasi Condiloma Acuminata Sedang 52,500 79,500 132,000
4 Couterisasi Condiloma Acuminata Berat 52,500 198,300 250,800
5 Dopier 9,000 17,400 26,400
6 Douglas Punktio 75,000 103,200 178,200
7 Ekstirpasi Polip Servik 150,000 213,000 363,000
8 Hydrotubasi 202,500 135,000 337,500
9 Incisi Kista Bartholini 54,000 147,300 201,300
10 Jahit Luka Khusus / Portio J a h i t L u k a 40,500 269,700 310,200
11 J a h i t Luka / Repair Perinium 60,000 40,000 100,000
12 Lepas Intra Uterine Devices (IUD) 48,000 62,000 110,000
13 Lepas Pasang Susuk 52,500 107,000 159,500
14 Manual Aid Ekstraksi Kaki 132,000 88,000 220,000
15 Melepas Stent / drain 21,000 14,000 35,000
16 Melepas Tampon Vagina 25,500 17,000 42,500
17 Memasang Tampon Vagina 40,500 27,000 67,500
18 Mikro Kuret 52,500 35,000 87,500
19 Nonstress test (NST) 15,000 97,200 112,200
20 Pap Smear 45,000 59,500 104,500
2 1 Partus dengan Penyulit 500,000 750,000 1,250,000
22 Partus Normal 350,000 525,000 875,000
23 Partus Presipitatus 300,000 200,000 500,000
24 Pasang / Lepas Lamineria 21,000 342,000 363,000
25 Pasang Intra Uterine Devices (IUD) 48,000 24,600 72,600
26 Pasang Intra Uterine Devices (IUD) oleh dokter
dengan penyulit 48,000 321,600 369,600
27 Pasang Pesarium 21,000 45,000 66,000
28 Pemeriksaan Fisik Bayi/ hari 16,000 10,000 26,000
29 Penanganan Pasien dengan Eklamsi 75,000 50,000 125,000
10
31 Penanganan Pasien dengan Konservatif selain
Penanganan Pre Eklamsi/Perdarahan/HEG i en nnn i nn nnn O C A nnn
32
PP T I f t n P " f i n a n Pfi^ipn Hpncfin PrppVlamcii Rprat fPPR^ J. U l i a i Ig^CV-l 1CX11 X CLOi.V^J.1 VXtoil^CUX r i GCxvlcUllol D C l a l I i XL XJ1
i 3n nnn i nn nnn otcn nnn
33 Penanganan Pasien dengan Pendarahan 110,000 73,000 183,000
34 Perawatan Tali Pusat 18,000 12,000 30,000
35 Plasenta Manual oleh dokter spesialis 240,000 160,000 400,000
36 Scurent 12,000 8,000 20,000
37 Jahit Luka Stradle Injury 55,500 37,000 92,500
38 Vacum Extraksi 120,000 80,000 200,000
39 Vaginal Touche (VT) 12,000 14,400 26,400
40 Suntik KB 9,000 24,000 33,000
K. PELAYANAN JANTUNG DAN PEMBULUH DARAH
1 EKG 20,000 30,000 50,000
2 Treadmill Test 80,000 120,000 200,000
3 Echocardiografi Elektif Dewasa 250,000 100,000 350,000
4 Echocardiografi Elektif Anak 250,000 100,000 350,000
5 Echocardiografi Hemodinamik 250,000 100,000 350,000
6 Echocardiografi Transesofagal 250,000 245,000 495 000
> —y vy y vy vy vy 7 USG Doppler Vaskular Ekstrimitas Atas 180 000
x vy vy j vy vy vy
120 000
x .xh vy, vy vy vy
300 000
o vy vy j vy vy vy 8 TT3G Donnler Vp«iku1flr Ek^triTrnta^ Rawah
UkJU JL/\J L» VJXKtl V ClOXvLliClX XHZVO Li. llllt LO.O J—'ClWCUi
180 000 x vy vy j V/ vy vy 190 nnn X yi Vy j Vy vx vy ovy vy jVy vy vy 9 USG Carotis 180,000 120,000 300,000 10 Perikardiosintesis 1,500,000 1,000,000 2,500,000
11 Central Venous Line 100,000 373,000 473,000
12 Pemasangan Temporary Pace Maker 1,500,000 1,250,000 2,750,000
13 Kardioversi Elektrik 150,000 100,000 250,000 14 Kardioversi Farmakologis 200,000 100,000 300,000 15 DC Shock 52,500 75,000 127,500 16 Resusitasi Jantung-Paru-Otak 80,000 127,500 207,500 17 Trombolitik Intravena 100,000 400,000 500,000 18 Heparinisasi 50,000 100,000 150,000 19 Digitalisasi 50,000 100,000 150,000
20 Melepas Pacu J a n t u n g Temporer 55,440 83,160 138,600
21 Melepas Piqtail Kateter 55,440 83,160 138,600
22 Melepas Sheath kateter post DCA/PTCA 55,440 83,160 138,600
23 Melepas Swan Ganz Kateter 55,440 83,160 138,600
L. PELAYANAN PARU 1 Biopsi Pleura 246,400 369,600 616,000 2 Bronkkoskopi (Fleksibel) 313,200 469,800 783,000 3 Faal ParuT 108,000 162,000 270,000 4 Faal Paru I I 55,200 82,800 138,000 5 Fluoroskopi 168,000 252,000 420,000 6 Fnab Paru 168,000 252,000 420,000
7 Mantoux test dewasa 45,600 68,400 114,000
8 Memasang Chest Tube 312,000 468,000 780,000
9 Aspirasi Pneumothorax 152,000 228,000 380,000
10 Peakflowmeter - 40,000 60,000 100,000
11 Pleurodesis 312,000 468,000 780,000
12 Punksi Percobaan Pleura 31,200 46,800 78,000
13 Punksi Thorak/Pleura 152,000 228,000 380,000
14 Resusitasi Paru 76,000 114,000 190,000
11
16 Torakoskopi 312,000 468,000 780,000
17 6 Minute Walk test 76,000 114,000 190,000
18 Torakosentesis / Pungsi Pleura Dengan M i n i WSD
205,200 307,800 513,000
19 Torakosentesis / Pungsi Pleura Dengan Pig Tail 205,200 307,800 513,000
20 Torakesentesi / Pungsi Pleura Dengan Seldinger
205,200 307,800 513,000
21 Wound Tilet Chest Tube 20,000 30,000 50,000
22 Uji Alergi 20,000 30,000 50,000
23 Uji Kortikokosteroid 20,000 30,000 50,000
24 Uji Nox 20,000 30,000 50,000
25 Terapi Inhalasi Dengan Nebulizer 20,000 30,000 50,000
LAMPIRAN I I I
PERATURAN WALIKOTA TANGERANG SELATAN NOMOR TAHUN
TENTANG
TARIF PELAYANAN KESEHATAN BADAN LAYANAN U M U M DAERAH PADA RUMAH SAKIT U M U M KOTA TANGERANG SELATAN
T A R I F PELAYANAN RAWAT INAP
M O UiVLNloTTTMTQ rUtLtril P T T T A V A M A M AIN/YLN
JASA q AT? ANA OrtI\A\ll/\
JASA
P E T A V A N A N TARIF KE1ERANGAN M O UiVLNloTTTMTQ rUtLtril P T T T A V A M A M AIN/YLN
(Rp) (Rp) (Rp)
KE1ERANGAN
1
I Ruang Rawat Inap Kelas (III) T n n n n 1 1 c n n n Akomodasi, Visite
dokter spesialis o
2, Ruang Rawat Inap Kelas (II) C\C\ C\f\C\
yUjUuu
>~7r\ f\r\r\ /U,UUU 1 a c\ c\c\r\ 1 D U , U U U Akomodasi, Visite
dokter spesialis 3 Ruang Rawat Inap Kelas (I) •1 r*r\ r\f\r\
150,000 70,000 220,000
Akomodasi, Visite dokter spesialis 4 Ruang Rawat Inap VIP 430,000 70,000 500,000 A.KOII10Cltiol, V l S l l C dokter spesialis
5 Ruang Rawat Inap W 1 P 640,000 70,000 710,000
6 Ruang Rawat Inap Isolasi 150,000 70,000 220,000
7 One Day Care (ODC) 115,000 70,000 185,000
8 Ruang Perawatan Pasca Operasi 105,000 70,000 175,000
9 Ruang Perawatan Kesehatan J i w a 175,000 70,000 245,000
10 Ruang Perinatologi 115,000 70,000 185,000
11 Pemeriksaaan Dokter U m u m / Case Manager (paket 1 hari/3 shift)
40,000 40,000
12 Asuhan Keperawatan Mandiri * 60,000 90,000 150,000
Asuhan Keperawatan Parsial * 100,000 150,000 250,000
LAMPIRAN IV
PERATURAN WALIKOTA TANGERANG SELATAN NOMOR TAHUN
TENTANG
TARIF PELAYANAN KESEHATAN BADAN LAYANAN U M U M DAERAH PADA R U M A H SAKIT U M U M KOTA TANGERANG SELATAN
T A R I F P E L A Y A N A N RAWAT I N T E N S I F
NO JENIS PELAYANAN J A S A S A R A N A JASA PELAYANAN TARIF
NO JENIS PELAYANAN (Rp) (Rp) (Rp) 1 Ruang H C U 550,000 100,000 650,000 2 R u a n g ICU/ICCU/NICU/PICU 650,000 150,000 800,000 3 R u a n g ICU/ICCU/NICU/PICU Isolasi 850,000 150,000 1,000,000 4 A s u h a n Keperawatan M a n d i r i * 60,000 9 0 , 0 0 0 150,000 A s u h a n Keperawatan Parsial * 100,000 150,000 250,000 A s u h a n Keperawatan T o t a l * 160,000 2 4 0 , 0 0 0 400,000
LAMPIRAN V
PERATURAN WALIKOTA TANGERANG SELATAN NOMOR 51 TAHUN 2015
TENTANG
TARIF PELAYANAN KESEHATAN BADAN LAYANAN U M U M DAERAH PADA RUMAH SAKIT U M U M KOTA TANGERANG SELATAN
T A R I F PELAYANAN TINDAKAN M E D I S O P E R A T I F
NO JENIS PELAYANAN JASA SARANA JASA PELAYANAN TARIF
NO JENIS PELAYANAN (Rp) (Rp) (Rp) 1 Operasi Kecil 750,000 800,000 1,550,000 2 Operasi Sedang 1,000,000 2,500,000 3,500,000 3 Operasi Besar 2,500,000 4,500,000 7,000,000 4 Operasi Khusus 4,000,000 8,000,000 12,000,000 Keterangan:
Bilamana tindakan operasi kecil atau sedang disertai dengan tindakan anestesi u m u m dan atau komplikasi maka tindakan tersebut disesuaikan menjadi tindakan operasi sedang atau besar. Kewenangan penyesuaian tarif didelegasikan kepada Tim Verifikator Tarif
RINCIAN: A. Operasi K e c i l i • J . Curetage z Debridemant Kecil q Dilatasi Anus A
T- : Insisi dan atau Drainase Abses C
o Eksisi Veruca, Clavus, Nevus p.
o Ekstirpasi Dermoid
1 Ekstirpasi Ganglion
Q
O Ekstirpasi Kista Atheroma Q Ekstirpasi lipoma
1 n
1U Orchidektomi dengan lokal
1 1 Pasang Skeletal Traksi
12 Pasang Skin Traksi 13 Pasang WSD/Chest tube 14 Phymosis dengan lokal 15 Rooserplasty
16 Sirkumsisi dengan lokal 17 Tumor < 2cm
18 Vasektomi dengan lokal 19 Probing Nasolakrimalis
20 Incisi Hordeolum dengan penyulit 21 dekanulasi dengan penyulit 22 ekstirpasi kista auricula 23 ekstraksi korpus laring 24 miringoplasti
25 nasoendoscopi GA 26 incisi othematom
2
27 ganti k a n u l dengan penyulit 28 kaustik septum
29 laringoscopi direkta GA 30 incisi abses peritonsil GA
31 tampon bellog/posterior dengan GA 32 Injeksi Intra Vitreal
33 Repair nail bed laseration 34 Businasi urethra
35 Insisi Abses Maksilofasial atau Mandibula 36 Eksplorasi benda asing THT dengan Penyulit 37 Ektraksi Serumen dengan penyulit
38 Parasintesis
39 Foto Koagulasi Laser 40 Eksisi Tumor adnexa kecil
41 Repair r u p t u r palpebra sederhana 42 ReposisiTOL 43 Reposisi Iris 44 Nefrostomi 45 Retcam + Narkose 46 YAG Laser 47 Sirklase 48 Tubaplasty 49 Histeroskopi
50 Cone Biopsi (OBGYN)
51 Insisi Abses Bartolin dengan Komplikasi 52 Extirpasi Naevus dengan penyulit 53 Extirpasi Xantelesma dengan penyulit 54 Palatoplasty
55
ekstraksi f?ranulasi liana telinaa denaan komDlikasi 56 Aspirasi Hifema Intra Okuler
57 Kolonoskopi
58 Pasang CDL PRO HD 59 endoskopi
60 bronkoskopi fleksibel
B. Operasi Sedang
1 Amputasi Phalang (jari) 2 Appendiktomi A k u t / Kronis 3 Biopsi Tumor
4 Bone Open Biopsi 5 Cimino
6 Debridement dan Nekrotomi L u k a Mayor 7 Debridement fraktur terbuka pada anak 8 Debridement Sedang
9 Eksisi Ginekomastia
10 Eksisi Ganglion/ Lipoma, Atheroma, Granuloma + narkose
11 Eksisi Hemangioma u k u r a n > 2 cm 12 Eksisi Keloid Besar
13 Eksisi Mammae aberan
14 Eksisi Multiple Veruka dengan komplikasi 15 Eksisi tumor jaringan l u n a k u k u r a n kecil > 2 c m
3
16 Eksisi tumor Punggung < 5 cm 17 Ekstirpasi Bursitis
18 Ekstirpasi FAM 19 Ekstirpasi Funicocele
20 Ekstirpasi Ganglion dengan penyulit 21 Ekstirpasi Lipoma > 2 cm dengan penyulit 22 Ekstirpasi Poliprekti
23 Ekstirpasi Tumor < 5 c m 24 Ekstirpasi Lymphadenopati 25 Ekstirpasi Lymphadenopati colli 26 FAM Sincole
27 Gips Body Jacket 28 Herniotomi Anak 29 Herniotomi Inguinal
30 Injeksi botoks pada kasus cerebral palsy 31
OllKUIIlolol pdUd. IlipUopdLlld / UCWdoa ClCllgdll IldrKOSC 32
IVldyUI I_/CglUVlllj£; VVUU.11U. U.CUHU.CII1CI1L Ul lllC opine
33 Meatotomi
34 Orchidektomi + Narkose 35 Orchidektomi Bilateral 36 Palomo Prosedure 37 Phymosis + Narkose
38 Release Compartment Syndrome+debridement 39
T?pmr\\Tpz imnlorit Irwrirf* r\r^n(TQY~\ Q f i P ^ t p c i ' TV^cnoncil / Vvlr^r-X/'
IxClUUVC lliipicu.lL xvWil C LICilgcUi cUlCoLCol IC^KJllcU/ UlUGrL 40 Remove implant kwire dengan narkose
41 Tumor Payudara < 5 c m 42 Vasektomi + Narkose 43 Vulvus Multiple + Narkose 44 Extirpasi Pterygium (Bare Sclera)
45 Extirpasi Tumor Kecil Palpebra + narkose dan atau anestesi u k u r a n > 2cm
46 Incisi Khalazion + narkose d a n anastesi 47 Penyakit Pembuluh darah Perifer 48 Tonsiloadenoidectomi
49 Repair Palpebra dengan R u p t u r Margo Palpebra 50 RPG/ ARG
51 Tridektomi 52 Tarsoraphi 53
Operasi Mikrotia (Rekonstruksi Kelainan D a u n Telinga) 54 Potong Flap
55 ekstirpasi d u k t u s tiroglosus 56 Segmentektomi
57 Eksisi Kelenjar Air l i u r Sub M a n d i b u l a 58 ekstirpasi t u m o r rongga m u l u t
59 ekstraksi granulasi kolesteatosis 60 turbinektomi
61 irigasi sinus dengan penyulit + narkose 62 nasoendoscopi GA dgn biopsi
4
64 trakeostomi 65 trakeoskopi 66 polipektomi
67 incisi abses leher dalam 68 uvulektomi
69 Urethroscopy 70 Orchiopexy
71 Eksisi Kista Epididimis
72 Biopsi prostat transrectal / Biopsi Testis 73 Punksi cairan otak
74 Biopsi Syaraf Kutaneus 75 Blok Saraf Tepi
76 Repair Luka Robek Sederhana
77 Repair Fistel Urethra Pasca Urethroplasty 78 Terapi Sklerosing
79 Cystostomy 80 Cystoscopy
8 1 Cadwell Luc Anthrostomy 82 Sperraatocelle 83 Ureterolisis 84 Drainage Periureter 85 Torsio Testis 86 Koreksi Priapismus 87 Vasografi 88 Reseksi Septum 89 Eksisi Chodeevasicolithotomi
90 Debridement dan drainage Abses Perianal 91 Ligasi Tinggi Hidrocele / Ligasi Varicocele 92 Eksisi 8s Marsupialisasi Ranula
93 Eksisi Kista Bronkiogeniik 94 Hidrokolektomi (B-W Procedure) 95 Repair Kriptokhismus
96 Tandur allih Kulit
97 Pasang CVP/CVC dengan penyulit dan komplikasi 98 Pemasangan T-Tube
99 Pemasangan Pipa Shepard
100 Eksplorasi Parafaringeal/Nasopharyng 101 Eksplorasi Kista Tiroid
102 Atrostomi & Adensindektomi
103 Ekstraksi Benda Asing dengan Penyulit 104 Ekstraksi Serumen dengan penyulit 105 Insisi Abses Peritonsil
106 Insisi Abses Septum 107 Reparasi Hidung 108 reposisi fraktur nasi 109 Reduksi Konka
110 Radiofrekuensi Dasar Lidah 111 Laringoskopi diagnostik 112 Insisi Subperiosteal Abses 113 Argon Laser
5
114 Goniotomi
115 Koreksi Entropion/ekstropion 116 Symblepharon
117 Congenital Fornix Plastik 118 Cyclodia Terni
119 Rekanalisasi r u p t u r a / Transkanal 120 Ptisis Bulbi
121 Kistektomi
122 Remove implan pada area selain Spine
123 Ekstraksi Katarak (EKEK/IKIK/SICS) dengan IOL 124 esofagoskopi dengan atau tanpa biopsi
125 EGD + Biopsi (Gaster / Kolon) 126 EGD + Ligasi
127 Bronchoscopy rigid
C. Operasi Besar
1 Amputasi Ekstremitas Atas 2 Amputasi Ekstremitas Bawah 3 Amputasi/ repair stump finger 4 Appendiktomi Perforata 5 Cholesistektomi
6 Colostomy/ Ileostomi 7 Debridement + Gangren D M 8 Debridement + Luka Bakar
9 Debridement + Nekrotomi necrotic tissue > 1 kompartemen
10 Debridement + r e k o n t r u k s i
11 Debridement finger injury dengan komplikasi dan regional blok anastesi
12 Debridement Luas
13 Debridement open reduction Fiksasi Paket Tindakan 14 Disekti Tumor Axila
15 Drainage deep infection finger
16 Drainage superficial infection dengan komplikasi 17 Eksisi Hemangioma > 5 cm
18 Eksisi Keloid Multiple dengan komplikasi 19 Eksisi Mammae Oberon Bilateral
20 Eksisi Polidactily 21 Eksisi Skar Multiple
22 Eksisi Tattoo tanpa skin graft 23 Eksisi tumor buli-buli
24 Eksisi Tumor Punggung > 5 c m 25 Sequestrektomi
26 Eksplorasi Luka tembak
27 Eksplorasi Luka t u s u k + Narkose 28 Ekstirpasi Lipoma > 5 cm
29 Excisi Tumor Colli dengan komplikasi 30 Facet Block 1 Level
31 FAM Bilateral 32 FAM Multiple
33 Fiksasi Rahang Atas reduksi t e r t u t u p 34
6 35 Ganglion Poplitea 36 Haemorridektomy Konvensional 37 Herniotomi + MESS 38 Herniotomi inkarserata 39 Herniotomi Scrotalis 40 Herniotomi Umbilicalis 4 1 Hidroselectomy 42 Labioplasty 43 Limb Ablasi 1 j a r i
44 Manipulation & Reduction of simple spine fracture and dislocation w i t h GA
45 Multiple Vulnus Laceratum + Narkose 46 Percutaneous tendon tenotomy
48 Reposisi tertutup + gips pada fraktur (yang m e m b u t u h k a n anastesi u m u m )
49 Rupture Tendon
50 SC + Air ketuban warna hijau 51 SC +bilateral 52 SC + MOW 53 SC + Salpingektomy 54 SC Cito 55 SC+IUD 56 Sectio Caesaria (SC) 57 Trauma m u k a + V u l n u s multiple 58 Tumor Payudara > 5 cm 59 Uretrotomi 60 Vesicolitotomi
61 Extirpasi Tumor Sedang > 5 cm 62 Extirpasi Pterygium Autograft 63 Rekonstruksi Palpebra Berat 64 Dacyocystorhinostomi (DCR) 65 Repair Ruptur Kanalikuli 66 Orbitotomi Anterior 67 Orbitotomi Lateral
68 Eviserasi + Dermofat Graft 69 Exentrasi
70 Repair Ptosis 71 total laringektomi
72 ekstraksi angiofibroma juvenile 73 meatoplasti
74 mastoidektomi radikal dengan rekonstruksi 75 stapedektomi 76 Hysterectomi 77 Megacolon Hysprung 78 Rekonstruksi Renovaskuler 79 Limfadenektomi Ileoinguinal 80 Limfadenektomi Retroperitoneal 81 Tur Prostat
82 Tur Tumor Buli-Buli 83 Ureteroneo Retostomi 84 Uretroplasty Hipospadia 85 Ureteronoscopy (URS) 86 Uretheroplasty
7 87 Ruptur Kornea/Sclera 88 Trabekulektomi 89 Enukleasi 90 Glosektomi parsial 91 Divertikulektomi Vesika 92 pasang gromet 93 rinotomi lateral 94 septoplasti 95 timpanoplasti 96 tiroidektomi
97 Ekstraksi Katarak (EKEK/IKIK/SICS) + IOL Implant dengan penyulit
98 bedah laring mikroskopik 99 diseksi leher fungsional 100 koreksi atresi koanal 101 operasi sinus frontal 102 ethmoidektomi
103 decompresi nervus fasialis
104 operasi kelenjar dan saluran air l i u r 105 paratiroidektomi
106 Phacoemusifikasi+IOL Implant
107 E/ivSlI culol lYUlUiUri ^Hil\H/iY/ llYiI\./ O I V H O J ~ lllipicLUL 108 hysterectomi parsial
109 myomectomy 110 Adenolisis 111 Simpatektomi 112 Ishtobektomi
113 Enukleasi Kista Ginjal 114 Ureterosigmoidostomy 115 Ureteroculaneustomi 116 Ureterostomi
117 Reseksi Parsial Vesika 118 Reseksi Urhacus 119 Rekontruksi Vesika 120 Sistoplasti Reduksi 121 Rekonstruksi Blassmeck 122 Psoas Hitch / Boari flap 123 Prostatektomi Retropubik 124 Urethektomi 125 Internal Urethrotomi 126 Nefrostomi open 127 Nefrophyxy 128 Orchydopexi
129 draignase pankreatitis darurat 130 Thyroidektomi
131 arthroplasti
132 eksplorasi abses leher dalam 133 atresia esofagus
134 Penectomy
135 Pasang Tenckhoff catheter (CAPD)
D. Operasi Khusus
8
2 ACL / PCL Rekontruksi 3 Amputasi Ekstremitas Bawah 4 Anastomosis Usus
5 Appendictomi Laparoskopi 6 Arthrocopy Diagnostic 7 Arthrodesis
8 Arthroscopy Debridement knee 9 Arthroscopy diagnostic shoulder 10 Arthroscopy remove loose body 11 Biopsi Vertebrae
12 Bone bridge release pada kasus tarsal coalition 13 Bone curetage + bone graft
14 Cholesistektomi per laparoskopi
15 Close reduction 8s pemasangan hemispica fraktur femur pada anak
16 Corrective Ostetomy Surgery 17 Craniotomi
18 U/CUllUCiUCiU. T iHCUlUii.Cft.lUUU T OLUUiiiSclSi r u s i c i i u i 19 Debridement + Sinovektomy
20 : Debridement + Skin graft 21 Debridement + Synevectomy 22 Dekompresi Laminektomy 23 Discektomy
24 Eksisi Hemangioma Besar + S k i n Graft 25 Eksisi Tattoo + skin graft
26 Eksisi Tumor Colli Multiple
27 Eksisi tumor j i n a k > 10 cm dengan komplikasi 28 Fiksasi cannulated screw pada SCFE
29 Haemorridektomy + Stapler 30 Hemiarthroplasty
31 Hemicolektomi 32 Hernioraphy Bilateral
33 Hernioraphy per laparoskopi 34 Herniorapy + MESH
36 Herniotomi Inkarserata + reseksi Usus 37 Herniotomi Scrotalis Bilateral
38 IDET 1 level
39 Koneksi Syndactili / Polidactili 40 Kuretase + Bone graft
41 Labioplasty Bilateral
42 laparatomy + Peritonitis Difusa 43 Laparatomy Eksplorasi
44 Laparotomi + Trauma Abdomen 45 Marginal margin Eksisi t u m o r t u l a n g 46 Mastektomi
47 Minimal invasive platting osteosinthesis 48 Open biopsy t u m o r i n spine
49 Open disectomy 1 level 50 Open Prostatektomi
51 Open reduction + Internal Fiksasi (ORIF) 52 ORIF Fraktur
53 Osteotomi
9
55 Rekontruksi Malunion F r a k t u r 56 Release Carpal Tunnel
57 Release Kontraktur
58 Release Trigger Finger (Multipel) 59 Remove Implant i n spine
60 Repair Tendon Multipel
61 Reposisi dan Fiksasi F r a k t u r Mandibula/ Maksilla 62 Reposisi tertutup & percutaneous pinning pada
fracture seputar sendi siku
63 pinning pada fracture seputar sendi 64 siku
65 l?ATincici
T^*T~tntiltl ar"trincrr*QTn T+ V i p m i C T I I P Q ria^o HTIH
ixcpusisi iciiuLup, ai iiiugictxxi cx> iiciuispicu paua uun 66 Reseksi Mandibula/ Maksilla
67 Rhinoplasty Augmentasi
68 Rupture Arteri, Vena dan Nervus 69 Rupture Tendon Multiple
70 Salpingho-ovarektomi Bilateral/ SOB laparoscopi 71 Salpingooverektomi Unilateral/ SOD/ SOS 72 Sirkumsisi dengan komplikasi
73 Skin graft luas
74 Splenektomi/Nefrektomi
75 Thoracotomy + Hemato Thorax 76 Thyroidektomi
77 Total Hip Replacement (THR) 78 Total Knee Replacement (TKR) 79 Total Patellectomy
80 Trauma rectum (stradel Injury) 81 Ureterolithotomi
82 Wide Excidion Tumor 83 Tendon flap
84 diseksi leher radikal 85 Hysterectomy radical
86 Pull Through (Soave, Duhamel, Swenson) 87 Postero Sagital Anorectoplasty (PSARP) 88 Gastrectomi Billroth 1 & 2
89 Koledoko jejunostomi
90 Laparascopic koleksistectomi 9 1 Miles operation
92 Pankreaktetomi
93 Reseksi Esofagus + interposisi kolon 94 Reseksi Hepar
95 Adrenalektomi (Abdominotorakal) 96 Diseksi KGB per laparaskopi 97 Epididimovasostomi
98 Explorasi Testis M i k r o Surgery 99 Extended Pyelolithektomi 100 Horseshoe Kidney Koreksi 101 Ileal Condoit (Bncker)
102 T *J_ J * 1 TIT C 1 *h_1 A. tTT J \ T ^ x
Longitudinal Nefrohthotomy (Kad) Et 103 Mikro Surgery Ligasi Vena Sprematika 104 Nefrektomi Partial
10
106 Nefrostomi Percutan 107 Percutaneous N e p h r o l i t h o s t r i p s i (PCNL) 108 Radikal Cystektomi 109 Radikal Nefrektomi 110 Radikal Prostatektomi111 Repair Vesico Vagina Fistel Complex
112 Retro Perotoneal L y m p Node Dissection (RPLND) 113 Pyeloplasty
114 L i t h o t r i p s i / ESWL Ginjal/Bladder/Ureter 115 U r e t h r o t o m y I n t e r n a (Sachse)
116 Laparascopy u r e t e r o l i t h o t a r y / CAPD / Unroofing 117 Combined/Triple Procedure (Trabekulektomi+Katarak
E k s t r a k s i + IOL Implant) 118 Glosektomi total
LAMPIRAN V I
PERATURAN WALIKOTA TANGERANG SELATAN NOMOR 5 1 T A H U N 2015
TENTANG
TARIF PELAYANAN KESEHATAN BADAN LAYANAN U M U M DAERAH PADA R U M A H SAKIT U M U M KOTA TANGERANG SELATAN
T A R I F P E L A Y A N A N TINDAKAN M E D I S NON O P E R A T I F
NO J E N I S PELAYANAN JASA SARANA JASA PELAYANAN TARIF
NO J E N I S PELAYANAN (Rp) 1 X PELAYANAN M E D I S NON I N V A S I F 1 X A n g k a t D r a i n t h o r a x 15,000 25,000 40,000 9 A n g k a t J a h i t a n > 10 s a m p u l dst 24,000 2 6 , 0 0 0 50,000 3 A n g k a t J a h i t a n 1 s/d 5 s a m p u l 9,000 4 0 , 0 0 0 4 9 , 0 0 0 4 A n g k a t J a h i t a n 6 s/d 10 s a m p u l 15,000 20,000 35,000 K o A n u s k o p i 50,000 33,000 83,000 a. D Atropinisasi 15,000 10,000 25,000 7 Back Slap ;• 7,500 5,000 12,500 R O Bilas L a m b u n g 30,000 55,000 85,000
Q Body Jacket - Dewasa 22,500 15,000 37,500
1U Bulectomy / Rawat J a l a n 102,000 6 8 , 0 0 0 170,000 1 9 DC Shock 52,500 75,000 127,500 1 3 Decompresi Anak 52,500 35,000 87,500 1 c 1 J Dilatasi Phymosis 75,000 50,000 125,000 ID E k s t r a s i komedo m i l i u m 37,500 25,000 62,500 1 7 Ekstirpasi 120,000 80,000 200,000 E k s t i r p a s i - K u l i t 120,000 80,000 200,000 i n
i.y E k s t i r p a s i benda asing d i k o r n e a 30,000 20,000 50,000
OK
AO Gips J a r i Tanga n 37,500 25,000 62,500
A C
ZD Gips Sepatu - Dewasa 6 0 , 0 0 0 4 0 , 0 0 0 100,000
q 1
01 Injeksi I n t r a a r t i k u l a r 50,000 75,000 125,000
39
oz Injeksi Keloid 20,000 30,000 50,000
33 Insis Abses (Loop) 6 0 , 0 0 0 40,000 100,000
34 I n t u b a s i Endotracheal 37,500 60,000 97,500
35 Irigasi / Spooling Catheter 30,000 20,000 50,000
36 Irigasi T r a u m a Kimia.LA 30,000 20,000 50,000 37 J a h i t Konjungtiva (Loop) LA 30,000 20,000 50,000 38 J a h i t L u k a > 10 c m 45,000 40,000 85,000 39 J a h i t L u k a 5 - 1 0 c m 36,000 34,000 70,000 40 J a h i t L u k a < 5 c m 21,000 24,000 45,000 4 1 J a h i t Palpebra. LA 37,500 25,000 6 2 , 5 0 0 42 K a u s t i k K i m i a K o n k a Nasal 1-2 60,000 40,000 100,000 46 Lepas Kateter U r i n e 12,000 8,000 20,000 48 Lepas WSD 52,500 35,000 87,500 5 1 M a n i p u l a s i 8s Reposisi F r a k t u r 150,000 100,000 2 5 0 , 0 0 0 52 M a n t o u x Test 36,000 24,000 60,000
2
Do Memasang / Melepas T a m p o n 40,500 27,000 67,500
o4 Memasang Dolles V e r b a n d 30,000 2 0 , 0 0 0 50,000
55 Memasang Gips Long Leg 150,000 100,000 250,000
56 Memasang Gips Nasal 12,000 8,000 20,000
57 Memasang Rek V e r b a n d 37,500 25,000 62,500
58 Memasang Sirculair Gips 60,000 A /V AS AS AS
4 0 , 0 0 0 100,000 5y Memasang Uslyp V e r b a n d ts A / v / v AS 84,000 56,000 140,000 z A 60 Memasang Vellpen V e r b a n d *"V AS /V /V /V 30,000 2 0 , 0 0 0 50,000 63 M e m a s u k k a n Obat S i t o s t a t i k a 30,000 220,000 250,000 64 n *• 1 i O H J T - /"V • tS 11
M e m b u a t & M e m a s a n g Gips Spalk 60,000 40,000 100,000
65 H IT _ _ _ V A AS i i 9 Mencabut Cystostomi 15,000 10,000 25,000 67 M u l t i p l e Incisi 52,500 35,000 87,500 68 Nail Extraction /V/V TV/V TV 90,000 60,000 150,000 s- AS 69 A T 1 1 ! Nebulizer 18,000 12,000 30,000
70 Nekrotomi D e b n d e m e n Besar TV /V H-\ y~\ /v
90,000 6 0 , 0 0 0 150,000 7 1 T\ T 1 j • T V 1 • 1 TT ' 1 Nekrotomi D e b n d e m e n Kecil 30,000 20,000 50,000 72 H T V i • T V 1 * 1 IS 1 Nekrotomi D e b n d e m e n Sedang 60,000 40,000 100,000 73 Pemasangan 0 2 > 10 L per j a m 6 5 , 0 0 0 43,000 108,000 74 TV *"V /V -1 i"VT J I f 1 • Pemasangan 0 2 l - 3 L / M / j a m 25,000 — 2 5 , 0 0 0 75 TV f \ AS A • A~ T / V ff / ' Pemasangan 0 2 4 - 6 L / M / j a m 35,000 35,000 76 TV AS n / " n i /T * / ' Pemasangan 0 2 6 - 8 L / M / j a m 45,000 • AS AS AS AS AS 30,000 /—T f— AS AS AS 75,000 77 TV AS f~\ • Ci ~t f\T 1 Ti if t ' Pemasangan 0 2 8 - 1 0 L / M / j a m 55,000 36,000 9 1 , 0 0 0
78 Aff gips/ cast AS /S AS /S AS
20,000 AS r~ AS AS /s r\ 250,000 A f 7 A AS AS AS 270,000 80 Pasang B i d a i Besar 60,000 A /V AS AS AS 40,000 V AS AS AS AS AS 100,000 8 1 Pasang B i d a i Sedang 52,500 35,000 87,500 82 I n t u b a s i Endotracheal V /V AS / V / V / V 100,000 AS2 0 0 , 0 0 0 AS AS AS AS AS AS AS AS AS AS AS 300,000 Aff Endotracheal 60,000 4 0 , 0 0 0 100,000
83 Pasang dan Lepas Naso Gastric Tube (NGT) /Oral
Gastric l u b e ( O u l ) 21,000 14,000 35,000
O A
84 Pasang dan Lepas NGT/OGT dengan Penyulit 4 2 , 0 0 0 28,000 70,000
85 Pasang d a n Lepas Schoorsteen 28,500 19,000 47,500
86 Pasang D r a i n A AS /V /V /V
42,000 (V A AS AS AS 2 8 , 0 0 0 f—r AS AS AS AS 70,000 87 TV T V 1 AS J_1 i
Pasang Fowley Catheter AS AS r\r\r\ 30,000 AS2 0 , 0 0 0 /s 50,000
88 TV T / J_ i . / T V J * T T * \
Pasang Kateter ( Retensi U r i n e ) 42,000 AS O / V / V / V 2 8 , 0 0 0 t—j AS fS
(S IS 70,000 90 Pasang Kateterisasi LA 88,500 59,000 147,500 9 1 Pasang Ransel V e r b a n d 60,000 A AS TV AS AS 40,000 V AS AS AS AS AS 100,000 92 Pasang S k i n T r a k s i AS AS AS AS AS 90,000 6 0 , 0 0 0 V H" AS AS AS AS 150,000 93 Pasang Spalk LA 88,500 59,000 V A l~7 r - AS AS 147,500 94 Pasang T a m p o n H a e m o r h o i d AS r— C t~\f\ 25,500 17,000 42,500 A AS t~ASfS 99 TV T C T T 1 *
Pemasangan Infus U m b i h k a h s 40,000 A /s i i r\ r\rs/s 110,000 1 cr r\ r\rsis 150,000 107 TV i T V T V "I AS /V /V / Perawatan L u k a B a k a r < 30 % 82,500 55,000 1137,500 AS A~f v r\r\ 108 TV * T V T V V fV ZV f \ A Perawatan L u k a B a k a r > 3 0 % AS r " r~ AS / v /v 255,000 v T170,000 A S ASASAS 425,000 A ASr" AS AS AS 110 Perawatan L u k a Besar diameter > 15 c m 42,000 AS AS AS AS AS
28,000 f—J AS AS AS7 0 , 0 0 0 AS
111 Perawatan L u k a Kecil diameter < 5 c m 21,000 14,000 35,000
112 Perawatan L u k a K h u s u s 30,000 f—t AS AS AS AS
7 0 , 0 0 0
V AS AS AS AS AS
100,000 113 TV i T V v i • i r~* v r *
Perawatan L u k a sedang diameter 5 - 1 5 c m 30,000 20,000 50,000
114 Peripherally Inserted Central Catheter (PICC
Insertion) 50,000 100,000 150,000
115 Resusitasi Bayi B a r u L a h i r (Paket per hari) 45,000 105,000 150,000
116 Resusitasi A n a k (Paket per hari) 45,000 55,000 100,000
3
1 1 Q Transfusi Darah Anak / Bayi
15,000 22,500 37,500 i i n l i y Transfusi D a r a h Dewasa 12,000 8,000 20,000 1 rv r\ 120 Transfusion Exchange 150,000 300,000 450,000
121 Fototerapi / Blue light 20,000 80,000 100,000
2 T Y T 7 * T A T T A A T A A T A ttYST\ T£"» T A T T T A P » T T P E L A Y A N A N M E D I S I N V A S I F •f 1 A m p u t a s i sederhana 225,000 AS AS F" AS A\ A\ 150,000 375,000 2 CVC (Central V e n u s Chateter) V AS AS AS AS AS 100,000 330,000 4 3 0 , 0 0 0 <s 3 E k s i s i Dengan Anastesi l o k a l V A\ A\ AS AS AS 100,000 150,000 250,000 A 4 Incisi Besar 60,000 40,000 100,000 5 Incisi Biasa 21,000 14,000 35,000 6 Incisi Sedang 40,500 AS ^T AS AS AS 2 7 , 0 0 0 67,500 7 Pleurodesis -t AS AS y~v /V 100,000 V ^T F™175,000 AS AS AS 275,000 8 Punctie Acites 54,000 85,000 139,000
9 Punctie Cephal Hematome 54,000 AS AS AS AS AS
80,000 V134,000 AS JA AS AS AS 10 Punctie L u m b a l AS AS AS AS AS 90,000 155,000 245,000 l l Punctie Pleura V ^T I — AS AS AS 175,000 250,000 425,000 12 Punctie S u m s u m T u l a n g 75,000 50,000 125,000 13 Sedasi Anastesi 30,000 60,000 90,000 14 Venasectie V I- AS AS AS AS 150,000 100,000 250,000
15 w a i e r s e a i uramage \wou) / s i s i u s t u i m /• cxiest • T,ll>n _ _ V AS A AS AS AS 134,000 2 3 4 , 5 0 0 368,500 AS A" AS AS AS 16 Phlebotomy 24,000 36,000 6 0 , 0 0 0 17 T i n d i k 24,000 36,000 60,000 3 P E L A Y A N A N P E N U N J A N G K L I N I K
1 Bed Side M o n i t o r (sewa alat per hari) 30,000 30,000 60,000
2 B l a n k e t W a r m e r 10,000 5,000 15,000
3 Blood W a r m e r 25,500 19,500 45,000
4 C o n t i n u o u s Positive Airway Pressure (CPAP) 55,000 45,000 100,000
5 I n c u b a t o r 50,000 25,000 75,000
6 Infused P u m p 45,000 10,000 55,000
7 Pulse Oxymetry 20,000 30,000 50,000
8 Respirator (Sewa) 45,000 30,000 75,000
9 hari) Sewa L e m a r i Pendingin J e n a z a h per h a r i (Max 5 50,000 35,000 85,000
10 Syringe P u m p 35,000 20,000 55,000 11 Ventilator 135,000 50,000 185,000 12 CTG M o n i t o r per h a r i 40,000 30,000 70,000 13 Neopuff per h a r i 45,000 30,000 75,000 14 Spirometri 33,000 49,500 82,500 15 gastroscopy 4 1 8 , 0 0 0 627,000 1,045,000 16 esofagogastroduodenoscopy 308,000 4 6 2 , 0 0 0 770,000 17 rectosigmoidescopy 286,000 429,000 715,000 18 t r a n s b r o n c h i a l l u n g biopsi 616,000 924,000 1,540,000 19 Vo2 Max 77,000 115,500 192,500 4 PELAYANAN V A K S I N A S I V a k s i n a s i 10,000 10,000 20,000
4
5 P E L A Y A N A N E D U K A S I K E S E H A T A N 1 K M C (Kanggoroo M o t h e r Care) 20,000 30,000 50,000 2 Manajemen L a k t a s i 10,000 30,000 4 0 , 0 0 0 3 Home Care 100,000 100,000 200,000 4 G r o w t h a n d Development 100,000 75,000 175,000 5 Konseling KesPro d a n K B 30,000 30,000 60,000LAMPIRAN V I I
PERATURAN WALIKOTA TANGERANG SELATAN NOMOR 5 1 T A H U N 2015
TENTANG
TARIF PELAYANAN KESEHATAN BADAN LAYANAN U M U M DAERAH PADA R U M A H SAKIT U M U M KOTA TANGERANG SELATAN
T A R I F P E L A Y A N A N PENUNJANG M E D I S
NO JENIS PELAYANAN JASA SARANA JASA PELAYANAN TARIF
NO JENIS PELAYANAN (Rp) (Rp) (Rp) 1 P E L A Y A N A N L A B O R A T O R I U M P A T O L O G I K l J N I K A. H E M A T O L O G I 1 Asam Folat 36,000 12,000 48,000 2 D a r a h Lengkap 40,500 19,500 60,000 3 D a r a h R u t i n 21,000 7,000 28,000 4 F e r r i t i n 90,000 AS AS AS AS AS 30,000 120,000
5 G6PD (Glukosa 6 Posfat Dehidrogenase) 56,250 18,750 75,000
6 G a m b a r a n D a r a h Tepi 18,000 42,000 60,000
7 Golongan D a r a h (ABO + Rhesus) 16,500 11,500 28,000
8 HAM's Test 27,000 9,000 36,000
9 H b F (Haemoglobin Fetus) 19,875 6,625 26,500
10 H i t u n g Eosinofil 18,000 12,000 30,000
11 H i t u n g Jenis Leukosit 15,000 5,000 20,000
12 I T R a s i o 15,000 15,000 30,000
13 LED (Laju E n d a p Darah) 18,000 6,000 24,000
14 Malaria/Filaria 25,000 15,000 40,000
15 NAP (Neutrofil Alkaline Phosfatase) 56,250 18,750 75,000
16 NSE (Non Specific Enolase) 36,000 12,000 48,000
17 Perwarnaan Besi 119,250 50,750 170,000
18 Pewarnaan Acid Phosphatase 56,250 18,750 75,000
19 Pewarnaan S u m s u m T u l a n g 108,750 36,250 145,000
20 Retikulosit 18,000 14,000 32,000
21 Sel LE (Lupus Eritematosus) 25,500 8,500 34,000
22 s i g a e r u m n u n j utb«^ ( l u i a i n o n D U U I I U 45,000 25,000 70,000
23 SIBC (Serum I r o n B o u n d Capacity) 56,250 18,750 70,000
24 Sudan Black B 45,000 15,000 60,000
25 Sugar Water Test 93,750 31,250 125,000
26 T r a n s f e r r i n 37,500 37,500 75,000 B. U R I N A L I S I S 1 K a l i u m u r i n e 37,500 12,500 50,000 2 K a l s i u m Urine 37,500 12,500 50,000 3 Lipase u r i n e 45,000 15,000 60,000 4 Phospate u r i n e 37,500 12,500 50,000
5 Protein Bence Jones 18,000 17,000 35,000
6 Protein K u a n t i t a t i f 27,000 9,000 36,000
7 Reduksi U r i n / P r o t e i n U r i n (3 parameter) 12,000 4,000 16,000
2
9 1 Do IW^lldlllllClll UCVlCC 1 A. n n n 4 Rnn 1 q c n n
10 U r i n Lengkap (Rutin + Sedimen) 21,000 9,000 30,000
C. H E M O S T A S I S
1 1
n r u (rvcuvcueu r a i u a i i m u m uupias Line
t : ™ „ i 56,250 23,750 80,000 9 z D-dimer 124,500 100,500 225,000 •3 O Fibrinogen 82,500 42,500 125,000 4 Masa Pembekuan 16,500 5,500 22,000 C u Masa Perdarahan 16,500 5,500 22,000 V J Masa p r o t r o m b i n (PT) 54,000 18,000 72,000 7 fi i r i u u u m u u i i m i e j + I I M K p i u e n i a u o n a i • 90,000 60,000 150,000 D. T I N J A 1 1 D a r a h samar 30,000 15,000 45,000 9
z Lengkap (Rutin + p H + Reduksi) 37,500 12,500 50,000
E . K I M I A D A R A H i 1 Amilase Darah 45,000 15,000 60,000 o z Amilase U r i n e 60,000 20,000 80,000 q o A l b u m i n 21,000 7,000 28,000
4 ALP (Alkalis Posfatase) 25,500 8,500 34,000
C Analisa b a t u ginjal 120,000 40,000 160,000
c:
O Analisa Gas D a r a h 106,500 35,500 142,000
/ Analisa Gas D a r a h + elektrolit 120,000 40,000 J% A\ A\ AS AS 160,000
Q O A s a m empedu 21,000 7,000 28,000 Q y A s a m u r a t 21,000 7,000 28,000 i n Bilirubin direk 21,000 7,000 28,000 11 11 B i l i r u b i n i n d i r e k 21,000 7,000 28,000 1 9 1Z B i l i r u b i n total 21,000 7,000 28,000 1 q 13 C a l s i u m I o n 37,500 12,500 50,000 1 A Cholinesterase 72,000 AS A AS AS AS 24,000 96,000 l o CK-MB (Creatinkinase Isoenzim MB) 75,000 50,000 125,000 1 P,
it) CK-total (Creatin Posfokinase Total) 72,000 24,000 96,000
1 7 Clorida (CL) Darah 37,500 12,500 50,000
1 Q
l o Clorida (CL) U r i n e 37,500 12,500 50,000
i y u x i v iDzeauu ruyiuKiuasej U U H K aua ig 82,500 27,500 110,000
ZU Elektroforese p t o t e i n 174,000 58,000 232,000 9 1 Z1 F l u k t o s a m i n 29,000 9,500 38,500 oo ZZ Fosfatase A l k a l i 26,250 11,250 37,500 oq Z3 Fosfatase asam 30,000 10,000 40,000 OA zt G a m m a GT (Globulin Test) 24,000 8,000 32,000 OK ZO G L D H (enzim g l u t a m a t dehidrogenase) 64,000 2 1 , 0 0 0 85,000 OP, ZO Glycosilated Hemoglobin 37,500 12,500 50,000 97 Z / G l o b u l i n 16,500 5,500 22,000 953 Zo Glukosa d a r a h 16,500 5,500 22,000 9Q zy Glukosa d a r a h s t i k 16,500 5,500 22,000 qn
3U Glukosa Toleransi test 54,500 18,167 72,667
q i o l H B A l c (Hemoglobin A Glikosilasi) 106,500 35,500 142,000 qo 6Z H B D H (hidrokasi butiratdehidrogenase) 30,000 10,000 40,000 33 K a l i u m d a r a h 37,500 12,500 50,000 34 K a l s i u m (Ca) 37,500 12,500 50,000 35 K a l s i u m d a r a h 37,500 12,500 50,000
oo Kolesterol H D L (High Density Lipoprotein) 25,500 8,500 34,000
37 Kolesterol L D L (Low Density Lipoprotein) 25,500 8,500 34,000
