LAMPIRAN II PERATURAN DAERAH PROVINSI BANTEN …jdihukum.bantenprov.go.id/hukum/90Perda No. 1 Tahun 2016 (Lampiran... · Persalinan Dengan Penyulit Oleh Dokter jahit perineum > 20

A. TARIF PEMERIKSAAN DOKTER, TINDAKAN MEDIS DAN TINDAKAN KEPERAWATAN

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Jasa

layanan

Jasa

Sarana Total

Jasa

layanan

Jasa

Sarana Total

Jasa

layanan Jasa Sarana Total

Jasa

layanan

Jasa

Sarana Total

Jasa

layanan Jasa Sarana Total

Jasa

layanan

Jasa

Sarana Total

Jasa

layanan

Akomodasi Rawat Inap33,000 42,000 75,000 52,800 67,200 120,000 66,000 84,000 150,000 110,000 140,000 250,000 176,000 224,000 400,000 110,000

1

Jasa

layanan

Jasa

Sarana Total

Jasa

layanan

Jasa

Sarana Total

1.1

19,800 25,200 45,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800

1.2

22,000 28,000 50,000 28,600 36,400 65,000 15,400 19,600 35,000 17,600 22,400 40,000 24,200 30,800 55,000 35,200 44,800 80,000 48,400 61,600

110,000

26,400 33,600 60,000 26,400

1.3

8,800 11,200 20,000 11,000 14,000 25,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800

1.4

11,000 14,000 25,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 8,800

1.5 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 8,400 15,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800 11,200 20,000 8,800

1.6

11,000 14,000 25,000 19,800 25,200 45,000 8,800 11,200 20,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 1.7

15,400 19,600 35,000 - - 8,800 11,200 20,000 11,000 14,000 25,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400

1.8

- - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 11,000

1.9

6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600

1.10

6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600

- - - - - - - - - - - - - - - - -

2TINDAKAN MEDIS - - - - - - - - - - - - - - - - -

2.1

- - - - - - - - - - - - - - - - - 2.2

22,000 28,000 50,000 26,400 33,600 60,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000 2.3

USG 2D ( + hasil foto ) 44,000 56,000 100,000 66,000 84,000 150,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 57,200 72,800 130,000 35,200 44,800 80,000 35,200

2.4

USG 3D ( + hasil foto ) 132,000 168,000 300,000 165,000 210,000 375,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 132,000 2.5

USG 4D ( + hasil foto ) 132,000 168,000 300,000 165,000 210,000 375,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 132,000 2.6

Visum Kebidanan 44,000 56,000 100,000 66,000 84,000 150,000 26,400 33,600 60,000 26,400 33,600 60,000 30,800 39,200 70,000 66,000 84,000 150,000 88,000 112,000 200,000 44,000 56,000 100,000 -

I

RAWAT INAP

IGD/VK

VIP VVIP

BAGIAN OBSTETRI

GINEKOLOGI

Konsultasi Pasien Pulang

Pemeriksaan / Konsultasi

Bidan / Perawat

Konsultasi Gizi

2

NO JENIS TINDAKAN


/ Visite Dokter Spesialis

Diluar Hari/Jam Kerja


/ Visite Dokter Spesialis


Dokter Umum diluar

Hari/Jam Kerja

RAWAT JALAN RAWAT JALAN EXECUTIVE

III

STRUKTUR DAN BESARAN TARIF RUMAH SAKIT UMUM DAERAH MALINGPING

II

ICU/HCU


Dokter Gigi


Dokter Gigi diluar

Hari/Jam Kerja

Konsultasi Dokter

Spesialis Via Telepon

PEMERIKSAAN DAN KONSULTASI


Dokter Umum

Biopsi / Pengambilan

Jaringan

LAMPIRAN IIPERATURAN DAERAH PROVINSI BANTENNOMOR 1 TAHUN 2016 TENTANG RETRIBUSI PELAYANAN KESEHATAN

108

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2

NO JENIS TINDAKAN RAWAT JALAN RAWAT JALAN EXECUTIVE

III II

ICU/HCU

2.7

Manual Plasenta - - - - 88,000 112,000 200,000 96,800 123,200 220,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 88,000 112,000 200,000 88,000 2.8

Hidrotubasi 132,000 168,000 300,000 143,000 182,000 325,000 88,000 112,000 200,000 96,800 123,200 220,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 88,000 112,000 200,000 88,000 2.9

Kardiotokografi 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 11,000 2.10

Curatese di VK - - - - - - - - - - - - - - 264,000 336,000 600,000 - 2.11

- - - - - - - - - - - - - - 352,000 448,000 800,000 - 2.12

- - - - - - - - - - - - - - 528,000 672,000 1,200,000

-

2.13 44,000 56,000

100,000 52,800 67,200 120,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000 -

2.14

33,000 42,000 75,000 44,000 56,000 100,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 33,000 42,000 75,000

22,000 2.15

13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 26,400 33,600 60,000 35,200 44,800 80,000 13,200 16,800 30,000

- 2.16

44,000 56,000 100,000 52,800 67,200 120,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000

- 2.17

2,200 2,800 5,000 3,080 3,920 7,000 2,200 2,800 5,000 2,200 2,800 5,000 2,200 2,800 5,000 4,400 5,600 10,000 6,600 8,400 15,000 2,200 2,800 5,000 6,600 2.18

8,800 11,200 20,000 13,200 16,800 30,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 33,000 42,000 75,000 8,800 11,200 20,000 33,000 2.19

22,000 28,000 50,000 33,000 42,000 75,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 22,000 2.20

6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 7,040 8,960 16,000 11,000 14,000 25,000 15,400 19,600 35,000 17,600 22,400 40,000 6,600 8,400 15,000 8,800 2.21

22,000 28,000 50,000 26,400 33,600 60,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 22,000 28,000 50,000 22,000 2.22

inseminasi - - - - 220,000 280,000 500,000 330,000 420,000 750,000 440,000 560,000 1,000,000 660,000 840,000 1,500,000 880,000 1,120,000 2,000,000 - - -

2.23

jahit parinum 1-5 6,600 8,400 15,000 11,000 14,000 25,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 6,600 8,400 15,000 22,000 2.24

jahit parinum 6-10 8,800 11,200 20,000 15,400 19,600 35,000 11,000 14,000 25,000 8,800 11,200 20,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 8,800 11,200 20,000 26,400 2.25

jahit parinum 11-15 13,200 16,800 30,000 19,800 25,200 45,000 15,400 19,600 35,000 13,200 16,800 30,000 19,800 25,200 45,000 24,200 30,800 55,000 30,800 39,200 70,000 13,200 16,800 30,000 30,800 2.26

jahit parinum 15-20 17,600 22,400 40,000 24,200 30,800 55,000 19,800 25,200 45,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 17,600 22,400 40,000 35,200 2.27

22,880 29,120 52,000 29,480 37,520 67,000 25,080 31,920 57,000 22,880 29,120 52,000 29,480 37,520 67,000 33,880 43,120 77,000 40,480 51,520 92,000 22,880 29,120 52,000 40,480 2.28

konsultasi laktasi 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 2.29

4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 4,400 5,600 10,000 13,200 2.30

- - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 8,800 11,200 20,000 11,000 2.31

- - - - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 2.32

- - - - 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 2.33

22,000 28,000 50,000 33,000 42,000 75,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 22,000 28,000 50,000 - 2.34

8,800 11,200 20,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 8,800 11,200 20,000 13,200 2.35

6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 6,600 8,400 15,000 11,000 2.36

8,800 11,200 20,000 17,600 22,400 40,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 8,800 11,200 20,000 13,200 2.37

26,400 33,600 60,000 33,000 42,000 75,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 26,400 33,600 60,000 26,400 2.38

15,400 19,600 35,000 19,800 25,200 45,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 22,000 28,000 50,000 33,000 42,000 75,000 15,400 19,600 35,000 26,400 2.39

22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 28,600 36,400 65,000 30,800 2.40

15,400 19,600 35,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 22,000

observasi 1-6 jam

Persalinan Dengan

Penyulit Oleh Dokter

jahit perineum > 20 per

jahitan + 2.000

pasang implant

pasang iud

pasang laminaria

observasi 6-12 jam

observasi 12-24 jam

pap smear

pasang pessarium

pasang tampon

pasang folley cateter

cukur

dilatasi serviks

douglas punksi

genek (periksa dalam)

Persalinan Normal Oleh

Dokter

lepas drainage

buka implant

angkat iud

biopsi

bladder training

incisi himen impervorata

pasang balon cateter

untuk dilatasi serviks

109

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

2.41

- - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 22,000 2.42

- - - - 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 44,000 56,000 100,000 - 2.43

26,400 33,600 60,000 33,000 42,000 75,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 26,400 33,600 60,000 - 2.44

13,200 16,800 30,000 22,000 28,000 50,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 - 2.45

6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 11,000 14,000 25,000 - 2.46

- - - - 6,600 8,400 15,000 11,000 14,000 25,000 15,400 19,600 35,000 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 - 2.47

- - - - 44,000 56,000 100,000 77,000 98,000 175,000 132,000 168,000 300,000 198,000 252,000 450,000 264,000 336,000 600,000 198,000 252,000 450,000 -

2.48

- - - - 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 17,600 22,400 40,000 6,600 8,400 15,000 - 2.49

4,400 5,600 10,000 8,800 11,200 20,000 3,520 4,480 8,000 4,400 5,600 10,000 6,600 8,400 15,000 11,000 14,000 25,000 17,600 22,400 40,000 6,600 8,400 15,000 - 2.50

4,400 5,600 10,000 6,600 8,400 15,000 2,200 2,800 5,000 3,520 4,480 8,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 2,200 2,800 5,000 - 2.51

39,600 50,400 90,000 44,000 56,000 100,000 22,000 28,000 50,000 44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 132,000 168,000 300,000 39,600 50,400 90,000 39,600

2.52

22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000 2.53

- - - - 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 26,400 33,600 60,000 26,400 2.54

- - - - - - - - - - - - - - 44,000 56,000 100,000 - 2.55

- - - - - - - - - - - - - - 39,600 50,400 90,000 - 2.56

- - - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 6,600

Persalinan Normal - - - - - - - - - - - - - - - - - 2.57

- - - - 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 440,000 560,000 1,000,000 528,000 672,000 1,200,000 308,000 392,000 700,000 308,000

2.58

- - - - 220,000 280,000 500,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 264,000 336,000 600,000 -

2.59

- - - - 176,000 224,000 400,000 220,000 280,000 500,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 220,000 280,000 500,000 -

Persalinan Patologis - - - - - - - - - - - - - - - - - 4.1

- - - - 352,000 448,000 800,000 396,000 504,000 900,000 440,000 560,000 1,000,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 396,000 504,000 900,000 352,000

4.2

- - - - 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 440,000 560,000 1,000,000 308,000 392,000 700,000 -

4.3

- - - - 220,000 280,000 500,000 264,000 336,000 600,000 3,080,000 3,920,000 7,000,000 352,000 448,000 800,000 396,000 504,000 900,000 264,000 336,000 600,000 -

3 BAGIAN ANAK - - - - - - - - - - - - - - - - - 3.1

Resusitasi Bayi / Anak - - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 13,200 16,800 30,000 - 3.2

- - - - 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 17,600 22,400 40,000 - 3.3

Infus Intra Osteous - - - - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 22,000 28,000 50,000 11,000 14,000 25,000 -

4 BAGIAN BEDAH - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - 4.1

1-5 jahitan - - - - - - - - - - - - - - - - - - - - - 13 000 17,000 30,000 4.2

6-10 jahitan - - - - - - - - - - - - - - - - - - - - - 20,000 25,000 45,000 4.3

11-15 jahitan - - - - - - - - - - - - - - - - - - - - - 23,000 32,000 55,000 4.4

16-20 jahitan - - - - - - - - - - - - - - - - - - - - - 27,000 38,000 65,000 4.5

- - - - - - - - - - - - - - - - - - - - -

1500/

jahitan

2000/jah

itan

3500/jah

itan 4.6

Insisi kecil 28,600 36,400

65,000 33,000 42,000 75,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 28,600 36,400 65,000 -

visum kebidanan

Perawatan luka dengan

hecting

lebih dari 20

jahitan

tindik bayi

tutul abothyl

usg dengan klise

usg tanpa klise

pemeriksaan dengan ctg

pencabutan implant

usg trans vaginal

versi luar

perawatan luka

episiotomi

perawatan payudara

punksi amniotomi

tindakan doppler

tindakan hidrotubasi

vulva higiene

dokter spesialis

dokter umum

bidan

dokter spesialis

dokter umum

bidan

pasang tampon > 6 jam

Resusitasi Bayi Baru Lahir

110

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

4.7

Insisi sedang 33,000 42,000

75,000 37,400 47,600 85,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 33,000 42,000 75,000 - 4.8

Insisi besar 44,000 56,000 100,000 55,000 70,000 125,000

24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 44,000 56,000 100,000

- - - 4.9

- - - - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 - - -

4.10 - -

- - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000

66,000 84,000 150,000 88,000 112,000 200,000

- - - 4.11

Sirkumsisi 110,000 140,000 250,000 132,000 168,000 300,000 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 99,000 126,000 225,000 132,000 168,000 300,000 - - -

4.12

Ektirpasi kecil 55,000 70,000 125,000

59,400 75,600 135,000

30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 33,000 42,000 75,000 - 4.13

Ekstirpasi sedang 66,000 84,000 150,000

70,400 89,600 160,000

35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000

- - - 4.14

Ekstirpasi besar 74,800 95,200 170,000

79,200 100,800 180,000

44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 - -

- 4.15

Eksisi Fibroma 264,000 336,000 600,000 286,000 364,000 650,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 - - -

4.16 264,000 336,000 600,000 286,000 364,000 650,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 - - -

4.17

Open prostat - -

- - 880,000 1,120,000 2,000,000 1,100,000 1,400,000 2,500,000 1,320,000 1,680,000 3,000,000 1,540,000 1,960,000 3,500,000 1,760,000 2,240,000 4,000,000 - - -

4.18 66,000 84,000 150,000

77,000 98,000 175,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 72,600 92,400 165,000 - - -

4.19

77,000 98,000 175,000 88,000

112,000 200,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 72,600 92,400 165,000 77,000 98,000 175,000 - - -

4.20 48,400 61,600 110,000

52,800 67,200 120,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 30,800 39,200 70,000 -

4.21

66,000 84,000 150,000 70,400 89,600

160,000 33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 44,000 56,000 100,000 48,400 61,600 110,000 44,000 56,000 100,000 -

4.22

Angkat jahitan < 5 11,000 14,000

25,000 13,200 16,800 30,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 7,040 8,960 16,000 7,920 10,080 18,000 7,040 8,960 16,000 -

4.23 2000/

jahitan

2000/

jahitan 2000/

jahitan

2000/

jahitan

2000/

jahitan

2000/

jahitan 2000/ jahitan

2000/

jahitan -

4.24 66,000 84,000 150,000

77,000 98,000 175,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 30,800 39,200 70,000 -

4.25

Amputasi Jari 132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - 132,000 168,000 300,000 -

4.26

Dilatasi Pimosis 22,000 28,000 50,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 - 4.27

DC Shock - - - - 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000 4.28

Eksisi Clavus 35,200 44,800 80,000 44,000 56,000 100,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 35,200 44,800 80,000 - 4.29

44,000 56,000 100,000 52,800 67,200 120,000 33,000 42,000 75,000 35,200 44,800 80,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 33,000 42,000 75,000 33,000 4.30

44,000 56,000 100,000 52,800 67,200 120,000 33,000 42,000 75,000 35,200 44,800 80,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 33,000 42,000 75,000 33,000 4.31

35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 30,800 39,200 70,000 44,000 56,000 100,000 66,000 84,000 150,000 77,000 98,000 175,000 35,200 44,800 80,000 - 4.32

66,000 84,000 150,000 88,000 112,000 200,000 44,000 56,000 100,000 44,000 56,000 100,000 66,000 84,000 150,000 88,000 112,000 200,000 110,000 140,000 250,000 44,000 56,000 100,000 - 4.33

Eksisi Syiringoma 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 35,200 44,800 80,000 37,400 47,600 85,000 30,800 39,200 70,000 44,000 4.34

Eksisi Veruca Vulgaris 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 35,200 44,800 80,000 37,400 47,600 85,000 30,800 39,200 70,000 44,000 4.35

Eksplorasi Luka 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 24,200 30,800 55,000 11,000 14,000 25,000 11,000 4.36

Ekstraksi Batu Urethra 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000 4.37

22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 44,000 56,000 100,000 22,000 28,000 50,000 22,000 4.38

Ekstraksi Kuku 26,400 33,600 60,000 35,200 44,800 80,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 26,400 33,600 60,000 - 4.39

66,000 84,000 150,000 74,800 95,200 170,000

52,800 67,200 120,000

55,000 70,000 125,000

66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 -

Perawatan luka gigitan

binatang ( ular ,

monyet,dll)

Pemasangan Collar neck

(termasuk alat)

Angkat jahitan > 5

Baougenasi punksi

kandung kemih

Pengangkatan aterom /

lipoma / ganglion

Reposisi,traksi,dislokasi

dengan spalk (anak)

Reposisi,traksi,dislokasi

dengan spalk (dewasa)

Perawatan luka gigitan

serangga

Eksisi Keloid Kecil > 5 cm

Eksisi Keloid Besar < 5 cm

Ekstraksi Corpus Alineum

Ekstrakpasi Kista Aterum

Eksisi Condiloma

Acuminata

Eksisi Granuloma

Piogenicum

Pemasangan kateter

anestesi

111

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

4.40

Ekstrakpasi Lipoma 66,000 84,000 150,000 74,800 95,200 170,000

52,800 67,200 120,000

55,000 70,000 125,000

66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 - 4.41

Ekstrakpasi Ganglion 66,000 84,000 150,000 74,800 95,200 170,000

52,800 67,200 120,000

55,000 70,000 125,000

66,000 84,000 150,000 74,800 95,200 170,000 79,200 100,800 180,000 66,000 84,000 150,000 - 4.42

Ekstrakpasi Fibroma 110,000 140,000 250,000 132,000 168,000 300,000 88,000 112,000 200,000 101,200 128,800 230,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 110,000

4.43

123,200 156,800 280,000 132,000 168,000 300,000 110,000 140,000 250,000 118,800 151,200 270,000 123,200 156,800 280,000 132,000 168,000 300,000 154,000 196,000 350,000 123,200 156,800 280,000 -

4.44

123,200 156,800 280,000 132,000 168,000 300,000 110,000 140,000 250,000 118,800 151,200 270,000 123,200 156,800 280,000 132,000 168,000 300,000 154,000 196,000 350,000 123,200 156,800 280,000 -

4.45

Pasang Guedel 13,200 16,800 30,000 17,600 22,400 40,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200 4.46

Pasang WSD 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 121,000 154,000 275,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 132,000 168,000 300,000 132,000

4.47

4,400 5,600 10,000 6,600 8,400 15,000 3,520 4,480 8,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 4.48

Sirkumsisi 110,000 140,000 250,000 132,000 168,000 300,000 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 110,000 140,000 250,000 132,000

4.49

Blast Punksi 66,000 84,000 150,000

70,400 89,600 160,000

44,000 56,000 100,000

52,800 67,200 120,000

66,000 84,000 150,000 74,800 95,200 170,000 88,000 112,000 200,000 66,000 84,000 150,000 66,000 4.50

22,000 28,000 50,000 - - 17,600 22,400 40,000 22,000 28,000 50,000 22,000 28,000 50,000 30,800 39,200 70,000 35,200 44,800 80,000 22,000 28,000 50,000 22,000 4.51

- - - - - - - - - - - - - - 66,000 84,000 150,000 -

- - - - - - - - - - - - - - - - -

5 BAGIAN THT - - - - - - - - - - - - - - - - -

Tindakan Sederhana - - - - - - - - - - - - - - - - - 5.1

Tes Penala 6,600 8,400 15,000 8,800 11,200 20,000 6,600 8,400 15,000 6,600 8,400 15,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 - 5.2

15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 15,400 19,600 35,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 15,400 19,600 35,000 -

Tindakan Sedang - - - - - - - - - - - - - - - - - 5.3

44,000 56,000 100,000

52,800 67,200 120,000

22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 - - - 5.4

22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.5

Irigasi Telinga / Hidung 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.6

Kaustik Hidung 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.7

Kaustik Tenggorok 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.8

17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 - - -

Tindakan Khusus - - - - - - - - - - - - - - - - - 5.9

6,600 8,400 15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 5.10

Audiogram 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 30,800 39,200 70,000 39,600 50,400 90,000 - - - 5.11

Biopsi Cavum Nasi 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - - 5.12

Biopsi Nasofaring 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - - 5.13

Biopsi Orofaring 22,000 28,000 50,000 26,400 33,600 60,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 - - - 5.14

33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 - 5.15

33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 - 5.16

Ekstraksi Benda Asing 33,000 42,000 75,000 39,600 50,400 90,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 24,200 30,800 55,000 - 5.17

Gips Telinga 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - - 5.18

Insisi Abses Mastoid 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - - 5.19

Insisi Abses Peritonsil 44,000 56,000 100,000 52,800 67,200 120,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -

Angkat Jaringan Granulasi

di Telinga

Angkat/Pasang Tampon

Hidung

Pasang Drain

Handscoen/kasa

Ekstraksi Serumen

Profunda / Toilet

Visum Mayat (Periksa

Luar)

Insisi Pseudokista dg

Pemasangan Verban Tekan

Punksi Pseudokista Daun

Telinga

Injeksi Varises (tidak

termasuk obat)

Visum et repertum (korban

hidup)

Injeksi Hemoroid (tidak

termasuk obat)

Ekstraksi Post Aurikular

Kista

Ekstraksi Pre Aurikular

Kista

112

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

5.20

57,200 72,800 130,000 66,000 84,000 150,000 39,600 50,400 90,000 44,000 56,000 100,000

48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 - - - 5.21

Insisi Septum Nasi 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 5.22

Irigasi Sinus Maksila 55,000 70,000 125,000 66,000 84,000 150,000

39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 - - - 5.23

Parasintese 22,000 28,000 50,000 26,400 33,600 60,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - - 5.24

17,600 22,400 40,000 22,000 28,000 50,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - - 5.25

Rhinoscope Posterior 11,000 14,000 25,000 15,400 19,600 35,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 12,320 15,680 28,000 15,400 19,600 35,000 - - - 5.26

Suction Telinga (OMP) 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,920 10,080 18,000 11,000 14,000 25,000 - - - 5.27

39,600 50,400 90,000 44,000 56,000 100,000

30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 44,000 56,000 100,000 - - - 5.28

Up Hecting 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,920 10,080 18,000 11,000 14,000 25,000 6,600 8,400 15,000 -

- - - - - - - - - - - - - - - - -

6 BAGIAN MATA - - - - - - - - - - - - - - - - -

Tindakan Sederhana - - - - - - - - - - - - - - - - - 6.1

Atropinisasi 4,400 5,600 10,000 6,600 8,400 15,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 - 6.2

Epilasi 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 - - - 6.3

22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 - 6.4

22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 19,800 25,200 45,000 26,400 33,600 60,000 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 - 6.5

Keratometri 39,600 50,400 90,000 44,000 56,000 100,000

35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 48,400 61,600 110,000 55,000 70,000 125,000 - - - 6.6

Koreksi Refraksi 8,800 11,200 20,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 - - - 6.7

6,600 8,400 15,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 11,000 14,000 25,000 - 6.8

6,600 8,400 15,000 11,000 14,000 25,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 - - - 6.9

4,400 5,600 10,000 6,600 8,400 15,000 3,520 4,480 8,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 - 6.10

Slit Lamp 11,000 14,000 25,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 17,600 22,400 40,000 - - -

- - - - - - - - - - - - - - - - -

Tindakan Sedang - - - - - - - - - - - - - - - - - 6.11

22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.12

39,600 50,400 90,000 44,000 56,000 100,000

35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000

55,000 70,000 125,000 66,000 84,000 150,000 - - - 6.13

15,400 19,600 35,000 22,000 28,000 50,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.14

19,800 25,200 45,000 26,400 33,600 60,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.15

22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 33,000 42,000 75,000 - - - 6.16

Refraktometri 22,000 28,000 50,000 26,400 33,600 60,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 28,600 36,400 65,000 44,000 56,000 100,000 - - - 6.17

Strikretinoskopi 19,800 25,200 45,000 26,400 33,600 60,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 - - - 6.18

17,600 22,400 40,000 22,000 28,000 50,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 - - -

- - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - 6.19

Ekstirpasi Gram/Kornea 39,600 50,400 90,000 44,000 56,000 100,000

22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 - - -

Pemeriksaan Pantocain,

Antibiotik, Verband

Pemeriksaan Tonometri

Pemeriksaan Fundus Kopi

Indireksi

Perawatan

Epistaksis/Tampon Bagian

Depan

Tampon Hidung Bagian

Belakang (Belloque

Tampon)

Irigasi Auqades Pada

Konjungtiva

anal test

Penetesan Mediatrika

Efrisell

Ekstirpasi Corpus

Aleneum Ekstra Okuler

Fluerosin Test

Irigasi Auqades Pada

Trauma Kimia

Suntikan Sub Konjungtiva

Tindakan Sedang dengan

Lokal Anestesi

Pengangkatan Jahitan di

Konjungtiva, Kornea dan

Sklera

Insisi Abses Sub

Mandibula

113

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

6.20

44,000 56,000 100,000

52,800 67,200 120,000

30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - - 6.21

Ekstirpasi Litiasis 44,000 56,000 100,000

52,800 67,200 120,000

30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - - 6.22

Ekstirpasi Ptegrium 55,000 70,000 125,000

66,000 84,000 150,000

39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 46,200 58,800 105,000 48,400 61,600 110,000 - - - 6.23

39,600 50,400 90,000

48,400 61,600 110,000

39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 46,200 58,800 105,000 48,400 61,600 110,000 - - - 6.24

Insisi Abses 66,000 84,000 150,000

77,000 98,000 175,000

39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 44,000 56,000 100,000 - 6.25

Insisi Hordeolum 33,000 42,000 75,000

44,000 56,000 100,000

22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 35,200 44,800 80,000 - 6.26

37,400 47,600 85,000

48,400 61,600 110,000

22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 - - - 6.27

Jahitan Kurang dari 2 cm 33,000 42,000 75,000

44,000 56,000 100,000

22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 35,200 44,800 80,000 - - - 6.28

Biometri 33,000 42,000 75,000

44,000 56,000 100,000

22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 35,200 44,800 80,000 - - -

#REF!

6.29

USG A Scan ( Organ Mata ) 44,000 56,000 100,000

55,000 70,000 125,000

30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 37,400 47,600 85,000 44,000 56,000 100,000 - - -

- - - - - - - - - - - - - - - - -

7 - - - - - - - - - - - - - - - - - 7.1

Pencabutan Gigi dengan Flap 55,000 70,000 125,000 66,000 84,000 150,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 - - -

7.2 55,000 70,000 125,000 66,000 84,000 150,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 - - -

7.3 88,000 112,000 200,000 101,200 128,800 230,000 57,200 72,800 130,000 66,000 84,000 150,000 74,800 95,200 170,000 83,600 106,400 190,000 99,000 126,000 225,000 - - -

7.4

Insisi Plegmon 81,400 103,600 185,000 88,000 112,000 200,000 66,000 84,000 150,000 70,400 89,600 160,000 74,800 95,200 170,000 79,200 100,800 180,000 83,600 106,400 190,000 - - -

7.5 88,000 112,000 200,000 110,000 140,000 250,000 66,000 84,000 150,000 68,200 86,800 155,000 70,400 89,600 160,000 72,600 92,400 165,000 79,200 100,800 180,000 - - -

7.6

Alveolectomi / Regio 176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -

7.7

Operculectomi 176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -

7.8

Gingivectomi 176,000 224,000 400,000 198,000 252,000 450,000 101,200 128,800 230,000 110,000 140,000 250,000 121,000 154,000 275,000 143,000 182,000 325,000 165,000 210,000 375,000 - - -

7.9

OD M3 IMP KLI 264,000 336,000 600,000 308,000 392,000 700,000 198,000 252,000 450,000 242,000 308,000 550,000 286,000 364,000 650,000 330,000 420,000 750,000 396,000 504,000 900,000 - - -

7.10

OD M3 IMP KLI II 352,000 448,000 800,000 396,000 504,000 900,000 330,000 420,000 750,000 374,000 476,000 850,000 440,000 560,000 1,000,000 484,000 616,000 1,100,000 528,000 672,000 1,200,000 - - -

7.11 176,000 224,000 400,000 198,000 252,000 450,000 88,000 112,000 200,000 110,000 140,000 250,000 154,000 196,000 350,000 176,000 224,000 400,000 330,000 420,000 750,000 - - -

7.12

Apex Reseksi 220,000 280,000 500,000 264,000 336,000 600,000 202,400 257,600 460,000 220,000 280,000 500,000 242,000 308,000 550,000 264,000 336,000 600,000 330,000 420,000 750,000 - - -

7.13

Windowing 110,000 140,000 250,000 154,000 196,000 350,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 220,000 280,000 500,000 - - -

7.14 88,000 112,000 200,000 110,000 140,000 250,000 66,000 84,000 150,000 77,000 98,000 175,000 83,600 106,400 190,000 92,400 117,600 210,000 110,000 140,000 250,000 - - -

7.15

Debridement Berat 253,000 322,000 575,000 264,000 336,000 600,000 176,000 224,000 400,000 264,000 336,000 600,000 352,000 448,000 800,000 528,000 672,000 1,200,000 616,000 784,000 1,400,000 - - -

7.16 330,000 420,000 750,000 352,000 448,000 800,000 198,000 252,000 450,000 242,000 308,000 550,000 286,000 364,000 650,000 330,000 420,000 750,000 440,000 560,000 1,000,000 - - -

7.17 374,000 476,000 850,000 396,000 504,000 900,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 484,000 616,000 1,100,000 - - -

7.18 374,000 476,000 850,000 396,000 504,000 900,000 264,000 336,000 600,000 308,000 392,000 700,000 352,000 448,000 800,000 396,000 504,000 900,000 484,000 616,000 1,100,000 - - -

7.19 55,000 70,000 125,000 66,000 84,000 150,000 44,000 56,000 100,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 70,400 89,600 160,000 - - -

#REF!

7.20 2,640,000 3,360,000 6,000,000 3,080,000 3,920,000 7,000,000 1,980,000 2,520,000 4,500,000 2,640,000 3,360,000 6,000,000 3,080,000 3,920,000 7,000,000 3,520,000 4,480,000 8,000,000 3,960,000 5,040,000 9,000,000 - - -

- - - - - - - - - - - - - - - - -

8 - - - - - - - - - - - - - - - - -

Ekstirpasi Granulasi Tanpa

Jahit

Buka Jahitan / Angkat

Jahitan ( Bedah Mulut )

BAGIAN GIGI DAN

MULUT

Implant Dental Titanium 1

Unit

Insisi Abses ( Bedah Mulut

)

Ekstirpasi Veruca Nevus

Palpebra

Insisi Khalazion dengan

Kuretase

Insisi Biopsi Intra Oral

dengan Bius Lokal

Eksisi Tumor Jinak /

Ekstripsi Epulis ? Ekstra

Oral

Reposisi Dislokasi Tmj

Secara Manual

Reposisi Fiksasi dengan

Arch Bar ( 1 Rahang )

Reposisi Fiksasi dengan

Arch Bar ( RA / RB )

Debridement Ringan /

Sedang

Enukleasi Kista Kecil /

Sedang / besar

BAGIAN BEDAH

MULUT

114

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

Penambahan - - - - - - - - - - - - - - - - -

8.1Fuji 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -

8.2Sinar 55,000 70,000 125,000 66,000 84,000 150,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 77,000 98,000 175,000 88,000 112,000 200,000 - - -

8.3Scalling 77,000 98,000 175,000 88,000 112,000 200,000 44,000 56,000 100,000 52,800 67,200 120,000 61,600 78,400 140,000 110,000 140,000 250,000 154,000 196,000 350,000 - - -

- - - - - - - - - - - - - - - - -

Pengobatan - - - - - - - - - - - - - - - - -

8.4Pengisian Saluran Akar 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -

8.5Tambal Sementara 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -

- - - - - - - - - - - - - - - - -

Pencabutan - - - - - - - - - - - - - - - - -

8.6

Curretage Per Regio 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -

8.7

Gigi Tetap 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -

8.8 44,000 56,000 100,000 48,400 61,600 110,000 33,000 42,000 75,000 39,600 50,400 90,000 48,400 61,600 110,000 57,200 72,800 130,000 66,000 84,000 150,000 - - -

8.9

Gigi Susu dengan Suntik 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 35,200 44,800 80,000 44,000 56,000 100,000 - - -

8.10

Gigi Susu tanpa Suntik 19,800 25,200 45,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 17,600 22,400 40,000 -

8.11

Insisi abses/intr oral 26,400 33,600

60000 33,000 42,000 75000 22,000 28,000 50000 24,200 30,800 55000 26,400 33,600 60000 28,600 36,400 65000 33,000 42,000 75,000 - - -

Orthodonty - -

- - - - - - - - - - - - - - - 8.12

198,000 252,000 450000 220,000 280,000 500000 110,000 140,000 250000 132,000 168,000 300000 154,000 196,000 350000 176,000 224,000 400000 220,000 280,000 500,000 - - -

8.13

Control Orto Lepas 22,000 28,000 50000 26,400 33,600 60000 - - - - - - - - - - - - -

Prothesa - - - - - - - - - - - - - - - - -

8.14

Plat + 1 Elemen 110,000 140,000 250,000 132,000 168,000 300,000 77,000 98,000 175,000 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 220,000 280,000 500,000 - - -

8.15 26,400 33,600 60,000 33,000 42,000 75,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 39,600 50,400 90,000 - - -

8.16

Full Denture 660,000 840,000 1,500,000 770,000 980,000 1,750,000 440,000 560,000 1,000,000 484,000 616,000 1,100,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 660,000 840,000 1,500,000 - - -

8.17

Rebasing ( Per rahang ) 110,000 140,000 250,000 132,000 168,000 300,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 275,000 350,000 625,000 385,000 490,000 875,000 - - -

8.18

Reparasi 88,000 112,000 200,000 110,000 140,000 250,000 88,000 112,000 200,000 105,600 134,400 240,000 123,200 156,800 280,000 220,000 280,000 500,000 308,000 392,000 700,000 - - -

Fix Protesa - - - - - - - - - - - - - - - - -

8.19

Jaket crown Acrilic 154,000 196,000 350,000 176,000 224,000 400,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 220,000 280,000 500,000 - - -

8.20 176,000 224,000 400,000 198,000 252,000 450,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 264,000 336,000 600,000 - - -

8.21

Jaket Crown Porselen 264,000 336,000 600,000 308,000 392,000 700,000 176,000 224,000 400,000 198,000 252,000 450,000 220,000 280,000 500,000 242,000 308,000 550,000 264,000 336,000 600,000 - - -

Fixed Ortodonty - - - - - - - - - - - - - - - - -

8.22

Perahang 770,000 980,000

1,750,000 836,000 1,064,000 1,900,000 528,000 672,000 1,200,000 572,000 728,000 1,300,000 616,000 784,000 1,400,000 660,000 840,000 1,500,000 704,000 896,000 1,600,000 - - -

8.23

Rahang atas + bawah 1,100,000 1,400,000

2,500,000 1,144,000 1,456,000 2,600,000 1,012,000 1,288,000 2,300,000 1,056,000 1,344,000 2,400,000 1,100,000 1,400,000 2,500,000 1,144,000 1,456,000 2,600,000 1,188,000 1,512,000 2,700,000 - - -

9 BAGIAN PSIKIATRI - - - - - - - - - - - - - - - - -

9.1Psikoterapi > 30 menit 26,400 33,600 60,000 33,000 42,000 75,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - -

9.2Psikoterapi < 30 menit 19,800 25,200 45,000 26,400 33,600 60,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 - - -

9.3Psikometri Sedang 39,600 50,400 90,000 44,000 56,000 100,000 33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 46,200 58,800 105,000 52,800 67,200 120,000 - - -

9.4Psikometri Komplek 88,000 112,000 200,000 110,000 140,000 250,000 70,400 89,600 160,000 74,800 95,200 170,000 79,200 100,800 180,000 83,600 106,400 190,000 88,000 112,000 200,000 - - -

Jaket crown Acrilic

Backing Metal

Ortho lepas kasus berat

perahang

Penambalan PerElemen

Gigi

Gigi Tetap dengan Jahitan

/ Komplikasi

115

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

10

- - - - - - - - - - - - - - - - -

10.1 22,000 28,000 50,000 33,000 42,000 75,000 13,200 16,800 30,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 26,400 33,600 60,000 22,000 28,000 50,000 -

10.2

- - 66,000 84,000 150,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - 39,600

10.3

- - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 - - 110,000

10.4

Lepas Selang WSD - - - - 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 33,000 42,000 75,000 -

10.5 154,000 196,000 350,000 176,000 224,000 400,000 70,400 89,600 160,000 77,000 98,000 175,000 83,600 106,400 190,000 92,400 117,600 210,000 110,000 140,000 250,000 - - 83,600

10.6 17,600 22,400 40,000 26,400 33,600 60,000 11,000 14,000 25,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 30,800 39,200 70,000 - - 19,800

10.7

Pleurodesis - - - - 66,000 84,000 150,000 77,000 98,000 175,000 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 - - 88,000

10.8

Pasang Continous Suction - - - - 44,000 56,000 100,000 52,800 67,200 120,000 61,600 78,400 140,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000

10.9

Pasang Drain Suction - - - - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 - - 44,000

10.10

Reposisi Selang WSD - - - - 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000

10.11

Spirometri 66,000 84,000 150,000 70,400 89,600 160,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - 39,600

10.12

Thoracostomi (WSD) - - - - 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 198,000 252,000 450,000 - - 154,000

10.13

Endotracheal Tube (ETT) - - - - 22,000 28,000 50,000 33,000 42,000 75,000 44,000 56,000 100,000 55,000 70,000 125,000 66,000 84,000 150,000 - - 44,000

10.14 - - - - 44,000 56,000 100,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000

10.15 - - - - 44,000 56,000 100,000 48,400 61,600 110,000 55,000 70,000 125,000 66,000 84,000 150,000 77,000 98,000 175,000 - - 55,000

10.16

Needle Decompresi - - - - - - - - - - - - - - 66,000 84,000 150,000 -

10.17

Vena Sectie - - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 88,000 112,000 200,000 88,000

10.18

Peak Flow Rate 33,000 42,000 75,000 39,600 50,400 90,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 26,400

10.19

Infus Intra Osteous 35,200 44,800 80,000 39,600 50,400 90,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 39,600 50,400 90,000 37,400 47,600 85,000 37,400

10.20 - - - - 6,600 8,400 15,000 7,920 10,080 18,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 11,000 14,000 25,000 11,000

10.21

Pemasangan Ventilator - - - - - - - - - - - - - - - - 55,000

10.22 - - - - - - - - - - - - - - - - 44,000

10.23 - - - - - - - - - - - - - - - - 308,000

10.24 - - - - - - - - - - - - - - - 22,000

11 HEMODIALISA - - - - - - - - - - - - - - - - -

11.1HEMODIALISA 330,000 420,000 750,000 - - 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000 420,000 750,000 330,000

12

- - - - - - - - - - - - - - - - -

12.1

Angkat Wire 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 30,800

12.2 44,000 56,000 100,000 48,400 61,600 110,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 66,000 84,000 150,000 - - -

12.3

Aspirasi Kista 44,000 56,000 100,000 48,400 61,600 110,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 66,000 84,000 150,000 - - 44,000

12.4

BMD 22,000 28,000 50,000 33,000 42,000 75,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - 35,200

12.5

Ganglion 55,000 70,000

125,000 57,200 72,800 130,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 66,000 84,000 150,000 52,800 67,200 120,000 52,800

Pemasangan CVP /

Perawatan

Pemasangan Monitor ECG

/ Hari

Biopsi Pleura /

Transthoracal Needle

Biopsi (Blind)

Punksi Pleura

(Thoracocentesis)

Punksi Percobaan ("Proef

Punctie")

Punksi Ascites (Diluar

Bahan Dan Alat)

Punksi Sendi (Diluar

Bahan Dan Alat)

Angkat Wire Dengan

Jahitan

Pemasangan Kateter

Double Lumen

BAGIAN PENYAKIT

DALAM DAN PARU

Biopsi Kelanjer Leher /

Biopsi Jarum Halus KGB

Angkat Jahitan Post WSD

Perawatan Ventilator/Hari

BAGIAN ORTHOPEDI

116

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

12.6

44,000 56,000 100,000 48,400 61,600 110,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 52,800 67,200 120,000 - - 44,000

12.7

55,000 70,000 125,000 57,200 72,800 130,000 48,400 61,600 110,000 55,000 70,000 125,000 61,600 78,400 140,000 70,400 89,600 160,000 77,000 98,000 175,000 - - -

12.8

39,600 50,400 90,000 44,000 56,000 100,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -

12.9

77,000 98,000 175,000 81,400 103,600 185,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 70,400 89,600 160,000 - - -

12.10

55,000 70,000 125,000 59,400 75,600 135,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - -

12.11

99,000 126,000 225,000 110,000 140,000 250,000 88,000 112,000 200,000 96,800 123,200 220,000 105,600 134,400 240,000 114,400 145,600 260,000 123,200 156,800 280,000 - - -

12.12

44,000 56,000 100,000 48,400 61,600 110,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - -

12.13

55,000 70,000 125,000 59,400 75,600 135,000 41,800 53,200 95,000 46,200 58,800 105,000 50,600 64,400 115,000 55,000 70,000 125,000 66,000 84,000 150,000 - - -

12.14

39,600 50,400 90,000 4,400 5,600 10,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 - - -

12.15 55,000 70,000 125,000 59,400 75,600 135,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 - - -

12.16 99,000 126,000 225,000 110,000 140,000 250,000 79,200 100,800 180,000 83,600 106,400 190,000 88,000 112,000 200,000 92,400 117,600 210,000 96,800 123,200 220,000 - - -

12.17

Punksi Abses 33,000 42,000 75,000 44,000 56,000 100,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 33,000 42,000 75,000 35,200 44,800 80,000 - - -

12.18

Pasang Skin Traksi 154,000 196,000 350,000 176,000 224,000 400,000 92,400 117,600 210,000 96,800 123,200 220,000 101,200 128,800 230,000 105,600 134,400 240,000 110,000 140,000 250,000 - - -

12.19

Pasang Ransel Verband 35,200 44,800 80,000 39,600 50,400 90,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 - - -

- - - - - - - - - - - - - - - - -

13 BAGIAN SYARAF - - - - - - - - - - - - - - - - -

13.1

Lumbal Punksi - - - - 39,600 50,400 90,000 52,800 67,200 120,000 66,000 84,000 150,000 79,200 100,800 180,000 88,000 112,000 200,000 - - 66,000

13.2 - - - - 88,000 112,000 200,000 110,000 140,000 250,000 132,000 168,000 300,000 154,000 196,000 350,000 176,000 224,000 400,000 - - 132,000

13.3 88,000 112,000 200,000 110,000 140,000 250,000 52,800 67,200 120,000 57,200 72,800 130,000 61,600 78,400 140,000 66,000 84,000 150,000 70,400 89,600 160,000 - - 66,000

13.4 66,000 84,000 150,000 70,400 89,600 160,000 39,600 50,400 90,000 44,000 56,000 100,000 48,400 61,600 110,000 52,800 67,200 120,000 57,200 72,800 130,000 - - 48,400

13.5

EEG 66,000 84,000 150,000 77,000 98,000 175,000 55,000 70,000 125,000 59,400 75,600 135,000 63,800 81,200 145,000 68,200 86,800 155,000 74,800 95,200 170,000 - - 63,800

13.6

Carotid Doppler 66,000 84,000 150,000 77,000 98,000 175,000 57,200 72,800 130,000 63,800 81,200 145,000 70,400 89,600 160,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000

13.7

Vascular Doppler 66,000 84,000 150,000 77,000 98,000 175,000 57,200 72,800 130,000 63,800 81,200 145,000 70,400 89,600 160,000 77,000 98,000 175,000 88,000 112,000 200,000 - - 77,000

14 - - - - - - - - - - - - - - - - -

14.1

Aspirasi Kista 33,000 42,000 75,000 44,000 56,000 100,000 - - - - - - - - - - - - -

14.2

Biopsi / Eksisi Wajah 132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - - - -

14.3 110,000 140,000 250,000 132,000 168,000 300,000 - - - - - - - - - - - - -

14.4

Chlorethyl Spray 66,000 84,000 150,000 88,000 112,000 200,000 - - - - - - - - - - - - -

14.5

Dermabrasi 110,000 140,000 250,000 132,000 168,000 300,000 - - - - - - - - - - - - -

14.6 22,000 28,000 50,000 26,400 33,600 60,000 - - - - - - - - - - - - -

Skrining Amnestia

Traumatic Brain Injury

Elektro Desikasi Keratosis

Injeksi Dequarvain (Diluar

Bahan Dan Alat)

Injeksi Carpal Tunnel

Syndrome (Diluar Bahan

Dan Alat)

Injeksi Keloid (Diluar

Bahan Dan Alat)

Punksi Sum-Sum Tulang

(BMP)

Skrining Fungsi Luhur

(Untuk Pasien Umum)

Injeksi Trigger Finger 2 Jari

(Diluar Bahan Dan Alat)

Injeksi Trigger Thumb 1

Jari (Diluar Bahan Dan

Alat)

Injeksi Trigger Thumb 2

Jari (Diluar Bahan Dan

Alat)

Injeksi Intra Artikuler 1

Knee (Diluar Bahan dan

Alat)

Injeksi Intra Artikuler 2

Knee (Diluar Bahan dan

Alat)

Injeksi Trigger Finger 1 Jari

(Diluar Bahan Dan Alat)

BAGIAN KULIT DAN

KELAMIN

Punksi / Aspirasi 1 Lutut

Biopsi / Eksisi Non Wajah

Punksi / Aspirasi 2 Lutut

117

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

14.7

110,000 140,000 250,000 154,000 196,000 350,000 - - - - - - - - - - - - -

14.8

154,000 196,000 350,000 176,000 224,000 400,000 - - - - - - - - - - - - -

14.9 132,000 168,000 300,000 154,000 196,000 350,000 - - - - - - - - - - - - -

14.10

125,400 159,600 285,000 154,000 196,000 350,000 - - - - - - - - - - - - -

14.11

176,000 224,000 400,000 198,000 252,000 450,000 - - - - - - - - - - - - -

14.12

Enukleasi Komedo 44,000 56,000 100,000 52,800 67,200 120,000 - - - - - - - - - - - - -

14.13 66,000 84,000 150,000 77,000 98,000 175,000 - - - - - - - - - - - - -

14.14

Elektrokauter Wajah 116,600 148,400 265,000 132,000 168,000 300,000 - - - - - - - - - - - - -

14.15 88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -

14.16

Facial Care / Skin Care 33,000 42,000 75,000 44,000 56,000 100,000 - - - - - - - - - - - - -

14.17

Insisi Abses Banal 66,000 84,000 150,000 77,000 98,000 175,000 - - - - - - - - - - - - -

14.18 24,200 30,800 55,000 28,600 36,400 65,000 - - - - - - - - - - - - -

14.19

Injeksi Kenacort 77,000 98,000 175,000 79,200 100,800 180,000 - - - - - - - - - - - - -

14.20

Perawatan Luka 8,800 11,200 20,000 13,200 16,800 30,000 - - - - - - - - - - - - -

14.21

Prick Test 88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -

14.22

Patch Test 88,000 112,000 200,000 99,000 126,000 225,000 - - - - - - - - - - - - -

14.23

Peeling Oleh Dokter 44,000 56,000 100,000 55,000 70,000 125,000 - - - - - - - - - - - - -

14.24

Peeling Oleh Perawat 22,000 28,000 50,000 26,400 33,600 60,000 - - - - - - - - - - - - -

14.25 44,000 56,000 100,000 55,000 70,000 125,000 - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - -

15 TINDAKAN KEPERAWATAN - - - - - - - - - - - - - - - - -

15.1

Bilas Lambung - - - - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 17,600 22,400 40,000 13,200

15.2

Blue Light Per Hari - -

- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 22,000 28,000 50,000 13,200 16,800 30,000 13,200 15.3

4,400 5,600 10,000 8,800 11,200 20,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600

15.4 11,000 14,000

25,000 15,400 19,600 35,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 9,680 12,320 22,000 9,680 15.5

Buka Gips (Long) 39,600 50,400

90,000 44,000 56,000 100,000

22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 - 15.6

Buka Gips (Short) 35,200 44,800

80,000 37,400 47,600 85,000

19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 39,600 50,400 90,000 28,600 36,400 65,000 - 15.7

Buka Gips Berat 66,000 84,000 150,000

70,400 89,600 160,000

33,000 42,000 75,000 37,400 47,600 85,000 41,800 53,200 95,000 46,200 58,800 105,000 55,000 70,000 125,000 44,000 56,000 100,000 - 15.8

Buka Gips Ringan 55,000 70,000 125,000

61,600 78,400 140,000

26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 39,600 50,400 90,000 44,000 56,000 100,000 39,600 50,400 90,000 - 15.9

Buka Infus - -

- - 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 4,400 5,600 10,000 4,400 15.10

Buka Jendela Gips 48,400 61,600 110,000

52,800 67,200 120,000

35,200 44,800 80,000 37,400 47,600 85,000 39,600 50,400 90,000 41,800 53,200 95,000 44,000 56,000 100,000 39,600 50,400 90,000 - 15.11

Buka Kateter 6,600 8,400

15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.12

Buka NGT - -

- - 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 7,480 9,520 17,000 8,800 11,200 20,000 6,600 8,400 15,000 6,600

Elektro Desikasi Melasma

Fleseboroik & Keratosis

Elektrokauterisasi Verucca

Vulgaris, Veruca Plana

Ekstirpasi Clavus, Nevus

Pada Wajah

Elektrokauterisasi

Syiringoma Trichocolium

Elektrokauter Non Wajah

Test Penisilin Dan Procain

Ekstirpasi Fibroma Molle,

Granuloma Pyogenikum

Ekstirpasi Total Tumor

Jinak Non Muka

Injeksi Varices (Diluar

Bahan Dan Obat)

Buka Drain Handscoen /

Kassa

Buka Drain Tube / Suction

118

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

15.13

Buka Spalk 6,600 8,400

15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.14

Buka WSD - -

- - 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 44,000 56,000 100,000 30,800 39,200 70,000 30,800 15.15

EKG 22,000 28,000

50,000 26,400 33,600 60,000 11,000 14,000 25,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800 15.16

22,000 28,000 50,000 26,400 33,600 60,000 11,000 14,000 25,000 17,600 22,400 40,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 19,800 25,200 45,000 19,800

15.17

Ganti Verban 13,200 16,800

30,000 17,600 22,400 40,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200 15.18

Gliserin Spuit - -

- - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.19

8,800 11,200 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800

15.20 8,800 11,200

20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800 15.21

8,800 11,200 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800

15.22 8,800 11,200

20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800 15.23

8,800 11,200 20,000 11,000 14,000 25,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 - - 8,800

15.24 - -

- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 - - 13,200 15.25

Klisma / Lavamen - -

- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000 15.26

33,000 42,000 75,000 37,400 47,600 85,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 30,800 39,200 70,000 35,200 44,800 80,000 - - 35,200

15.27

Nebulizer/Hari 22,000 28,000

50,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 11,000 14,000 25,000 11,000 15.28

Necrotomi 33,000 42,000

75,000 35,200 44,800 80,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 - 15.29

- - - - 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 26,400 33,600 60,000 17,600 22,400 40,000 -

15.30

Pasang Cerobong Angin - -

- - 4,400 5,600 10,000 8,800 11,200 20,000 13,200 16,800 30,000 17,600 22,400 40,000 22,000 28,000 50,000 13,200 16,800 30,000 13,200 15.31

44,000 56,000 100,000 48,400 61,600 110,000 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 44,000 56,000 100,000 33,000 42,000 75,000 28,600

15.32

Pasang Gips (Short) 35,200 44,800

80,000 39,600 50,400 90,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 22,000 28,000 50,000 19,800 15.33

Pasang Infus Anak - -

- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 8,800 15.34

Pasang Infus Bayi - -

- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 15.35

Pasang Infus Dewasa - -

- - 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600 15.36

Pasang Kateter Folley - -

- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 11,880 15,120 27,000 13,200 16,800 30,000 11,000 14,000 25,000 8,800 15.37

Pasang Kateter Kondom - -

- - 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 8,800 11,200 20,000 6,600 15.38

Pasang NGT - -

- - 6,600 8,400 15,000 8,800 11,200 20,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 8,800 11,200 20,000 8,800 15.39

Pasang NGT Pessarium - -

- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 15.40

Pasang Spalk 22,000 28,000

50,000 26,400 33,600 60,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200 15.41

Pasang Tampon Luka 6,600 8,400

15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000 15.42

Pasang Tampon Vagina 8,800 11,200

20,000 13,200 16,800 30,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200 15.43

1,320 1,680 3,000 1,760 2,240 4,000 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 6,600 8,400 15,000 4,400 5,600 10,000 4,400

15.44 - -

- - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.45

- - - - 2,200 2,800 5,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 4,400

15.46 6,600 8,400

15,000 8,800 11,200 20,000 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 6,600 8,400 15,000 6,600

Pasang Gips (Long)

termasuk dan bahan

Pemberian Obat Melalui

NGT. OGT/Kali

Pemeriksaan Kehamilan

Dengan Doppler

Imunisasi Campak (Diluar

Obat)

Imunisasi Hepatitis B

(Diluar Obat)

Kateterisasi vena

Umbilikalis

Mantoux Test (Dengan

Obat)

Observasi Khusus Pada

Pasien Post Op. BPH

Imunisasi Polio (Diluar

Obat)

Ganti Balutan + Perawatan

Luka / Hari

Pemberian Obat

IM,SC/Kali

Imunisasi BCG (Diluar

Obat)

Imunisasi DPT (Diluar

Obat)

Pemberian Supositori/Kali

119

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

15.47 - -

- - 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 13,200 16,800 30,000 13,200 15.48

- - - - 4,400 5,600 10,000 6,600 8,400 15,000 7,480 9,520 17,000 8,800 11,200 20,000 11,000 14,000 25,000 6,600 8,400 15,000 6,600

15.49 - -

- - 6,600 8,400 15,000 8,800 11,200 20,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 9,680 12,320 22,000 9,680 15.50

- - - - 6,600 8,400 15,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 13,200 16,800 30,000 13,200

15.51 33,000 42,000

75,000 37,400 47,600 85,000 19,800 25,200 45,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 26,400 33,600 60,000 22,000 15.52

Perawatan Jenazah - -

- - 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 11,000 14,000 25,000 11,000 15.53

- - - - 19,800 25,200 45,000 24,200 30,800 55,000 28,600 36,400 65,000 33,000 42,000 75,000 37,400 47,600 85,000 28,600 36,400 65,000 28,600

15.54 - -

- - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 17,600 22,400 40,000 17,600 15.55

- - - - 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 24,200 30,800 55,000 22,000 28,000 50,000 22,000 28,000 50,000 22,000

15.56 6,600 8,400

15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000 15.57

- - - - 22,000 28,000 50,000 24,200 30,800 55,000 26,400 33,600 60,000 28,600 36,400 65,000 30,800 39,200 70,000 22,000 28,000 50,000 22,000

15.58 - -

- - 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 11,000 14,000 25,000 11,000 15.59

- - - - 13,200 16,800 30,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 15,400 19,600 35,000 15,400

15.60 6,600 8,400

15,000 11,000 14,000 25,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 11,000 14,000 25,000 15,400 19,600 35,000 6,160 7,840 14,000 11,000 15.61

Perawatan Tali Pusat - -

- - 4,400 5,600 10,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 8,800 11,200 20,000 8,800 15.62

8,800 11,200 20,000 13,200 16,800 30,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 8,800 11,200 20,000 -

15.63

Repair Perineum - -

- - 38,720 49,280 88,000 46,200 58,800 105,000 52,800 67,200 120,000 96,800 123,200 220,000 135,520 172,480 308,000

- - 96,800 15.64

Spooling Infus/hari - -

- - 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,480 9,520 17,000 4,400 5,600 10,000 4,400 15.65

Spooling Kateter/hari - -

- - 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 7,480 9,520 17,000 4,400 5,600 10,000 4,400 15.66

Suctioning/hari - -

- - 6,600 8,400 15,000 7,920 10,080 18,000 9,680 12,320 22,000 11,000 14,000 25,000 13,200 16,800 30,000 9,680 12,320 22,000 9,680 15.67

Suntik Insulin/Kali - -

- - 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 6,600 8,400 15,000 4,400 5,600 10,000 4,400 15.68

Tes Buta Warna 8,800 11,200

20,000 13,200 16,800 30,000 4,400 5,600 10,000 5,280 6,720 12,000 6,160 7,840 14,000 7,480 9,520 17,000 8,800 11,200 20,000 5,280 6,720 12,000 - 15.69

Ganti Veerboden/sprei - -

- - 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 - - 3,080 15.70

Mobilisasi Pasien - -

- - 1,320 1,680 3,000 2,200 2,800 5,000 3,080 3,920 7,000 4,400 5,600 10,000 5,280 6,720 12,000 - - 3,080

16 - - - - - - - - - - -

Tindakan dengan elektropterapi -

- - - - - - - - - - 16.1

microwave diathermi 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.2

ultra sound 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.3

elecktrikal stimulasi 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.4

traksi cervikal/lumbal 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.5

ultraviolet lamp 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.6

infra lamp 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.7

whirl pool 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.8

hot pack 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000

Pelayanan fisioterapi

Perawatan Luka Operasi

Besar / Hari


Kecil / Hari


Sedang / Hari

Perawatan Payudara

Bermasalah

Perawatan Normal Oeh

Bidan

Pengambilan Darah Vena (

SST )


SST + EDTA )

Perawatan Luka Bakar

Besar ( > 50% )


Kecil (< 30% )


Sedang ( 30 - 50 % )


Vac + EDTA )

Pengambilan Darah Arteri

Perawatan Luka

Episiotomi

Perawatan Fraktur

Terbuka

120

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

16.9

nebuliser 15,400 19,600

35,000 17,600 22,400 40,000 8,800 11,200 20,000 15,400 19,600 35,000 17,600 22,400 40,000 19,800 25,200 45,000 22,000 28,000 50,000 16.10

parafin bath 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000

- - - - - - - - - - - - - -

16.11

terapi manipulasi 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.12

massage 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.13

latihan anggota gerak 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.14

latihan pernafasan 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.15

latihan pola hidup sehari-hari 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.16

latihann kekuatan otot 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.17

senam asam 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.18

senam stroke 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.19

senam hamil 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000 16.20

senam nifas 8,800 11,200

20,000 11,000 14,000 25,000 6,600 8,400 15,000 8,800 11,200 20,000 11,000 14,000 25,000 13,200 16,800 30,000 15,400 19,600 35,000

17 Pelayanan tindakan bedah- - - - - - - - - -

- - - - - - - - - -

17.1operasi kecil 88,000 112,000 200,000 99,000 126,000 225,000 110,000 140,000 250,000 121,000 154,000 275,000 132,000 168,000 300,000

17.2operasi kecil dengan narkose 352,000 448,000 800,000 462,000 588,000 1,050,000 792,000 1,008,000 1,800,000 968,000 1,232,000 2,200,000 1,188,000 1,512,000 2,700,000

17.3operasi sedang 704,000 896,000 1,600,000 792,000 1,008,000 1,800,000 1,364,000 1,736,000 3,100,000 1,628,000 2,072,000 3,700,000 2,068,000 2,632,000 4,700,000

17.4operasi besar 1,540,000 1,960,000 3,500,000 1,980,000 2,520,000 4,500,000 2,112,000 2,688,000 4,800,000 3,080,000 3,920,000 7,000,000 3,520,000 4,480,000 8,000,000

17.5operasi besar khusus 1,980,000 2,520,000 4,500,000 2,420,000 3,080,000 5,500,000 2,552,000 3,248,000 5,800,000 2,948,000 3,752,000 6,700,000 3,828,000 4,872,000 8,700,000

- - - - - - - - - - 17.6

operasi kecil 132,000 168,000 300,000 143,000 182,000 325,000 154,000 196,000 350,000 165,000 210,000 375,000 176,000 224,000 400,000 17.7

operasi kecil dengan narkose 440,000 560,000 1,000,000 550,000 700,000 1,250,000 198,000 252,000 450,000 1,056,000 1,344,000 2,400,000 1,276,000 1,624,000 2,900,000 17.8

operasi sedang 924,000 1,176,000 2,100,000 1,012,000 1,288,000 2,300,000 1,584,000 2,016,000 3,600,000 1,848,000 2,352,000 4,200,000 2,288,000 2,912,000 5,200,000 17.9

operasi besar 1,760,000 2,240,000 4,000,000 2,200,000 2,800,000 5,000,000 2,332,000 2,968,000 5,300,000 3,300,000 4,200,000 7,500,000 3,740,000 4,760,000 8,500,000

17.10

operasi besar khusus 2,200,000 2,800,000 5,000,000 2,640,000 3,360,000 6,000,000 2,772,000 3,528,000 6,300,000 3,168,000 4,032,000 7,200,000 4,048,000 5,152,000 9,200,000

18 BAGIAN JANTUNG - - - - - - - - - - - - - - - - -

18.1EKG 22,000 28,000 50,000 26,400 33,600 60,000 15,400 19,600 35,000 19,800 25,200 45,000 24,200 30,800 55,000 33,000 42,000 75,000 44,000 56,000 100,000 19,800 25,200 45,000 19,800

18.2Echokardiografi 35000 40000 75000 40000 45000 85000 26400 33,600 60000 33000 42,000 75000 35,200 44800 80000 39600 50400 90000 44000 56,000 100,000 39600

Tindakan sederhana

Operasi Cito

Operasi elektif

121

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

122

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

123

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

124

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

125

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

126

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

127

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

128

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

129

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

130

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

131

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

132

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

133

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

134

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

135

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

136

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

137

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

138

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

139

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

140

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

141

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

142

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I

RAWAT INAP

IGD/VK

VIP VVIP

2


III II

ICU/HCU

143

28 28 30 31 32

Jasa

Sarana Total

Jasa

layanan

Jasa

Sarana Total

140,000 250,000 110,000 140,000 250,000

- -

- -

25,200 45,000 19,800 25,200 45,000

33,600 60,000 26,400 33,600 60,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

14,000 25,000 11,000 14,000 25,000

19,600 35,000 15,400 19,600 35,000

14,000 25,000 6,600 8,400 15,000

8,400 15,000 6,600 8,400 15,000

8,400 15,000 6,600 8,400 15,000

- - -

- - -

- - -

28,000 50,000 22,000 28,000 50,000

44,800 80,000 35,200 44,800 80,000

168,000 300,000 132,000 168,000 300,000

168,000 300,000 132,000 168,000 300,000

- - -

PERINATOLOGI

STRUKTUR DAN BESARAN TARIF RUMAH SAKIT UMUM DAERAH MALINGPING

ICU/HCU

PERATURAN DAERAH PROVINSI BANTEN

RETRIBUSI PELAYANAN KESEHATAN

144

28 28 30 31 32

PERINATOLOGIICU/HCU

112,000 200,000 88,000 112,000 200,000

112,000 200,000 88,000 112,000 200,000

14,000 25,000 11,000 14,000 25,000

- - -

- - -

- - -

- - -

28,000 50,000 - -

- - -

- - -

8,400 15,000 - -

42,000 75,000 - -

28,000 50,000 - -

11,200 20,000 - -

28,000 50,000 - -

- - -

28,000 50,000 - -

33,600 60,000 - -

39,200 70,000 - -

44,800 80,000 - -

51,520 92,000 - -

8,400 15,000 6,600 8,400 15,000

16,800 30,000 13,200 16,800 30,000

14,000 25,000 11,000 14,000 25,000

19,600 35,000 15,400 19,600 35,000

25,200 45,000 19,800 25,200 45,000

- - -

16,800 30,000 - -

14,000 25,000 - -

16,800 30,000 - -

33,600 60,000 - -

33,600 60,000 - -

39,200 70,000 - -

28,000 50,000 - -

145

28 28 30 31 32

PERINATOLOGIICU/HCU

28,000 50,000 - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- 6,600 8,400 15,000

- - -

50,400 90,000 - -

28,000 50,000 - -

33,600 60,000 - -

- - -

- - -

8,400 15,000 - -

- - -

392,000 700,000 - -

- - -

- - -

- - -

448,000 800,000 - -

- - -

- - -

- - -

- 13,200 16,800 30,000

- 17,600 22,400 40,000

- 11,000 14,000 25,000

- - -

- - -

146

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

28,000 50,000 22,000 28,000 50,000

- - -

42,000 75,000 33,000 42,000 75,000

42,000 75,000 33,000 42,000 75,000

- - -

- - -

56,000 100,000 44,000 56,000 100,000

56,000 100,000 44,000 56,000 100,000

14,000 25,000 11,000 14,000 25,000

28,000 50,000 22,000 28,000 50,000

28,000 50,000 22,000 28,000 50,000

- - -

- - -

147

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

- - -

140,000 250,000 110,000 140,000 250,000

- - -

- - -

16,800 30,000 13,200 16,800 30,000

168,000 300,000 132,000 168,000 300,000

5,600 10,000 4,400 5,600 10,000

168,000 300,000 132,000 168,000 300,000

84,000 150,000 66,000 84,000 150,000

28,000 50,000 22,000 28,000 50,000

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

8,400 15,000 - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

148

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

149

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

150

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

151

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

- - -

50,400 90,000 - -

140,000 250,000 - -

- - -

106,400 190,000 - -

25,200 45,000 - -

112,000 200,000 - -

98,000 175,000 - -

56,000 100,000 - -

70,000 125,000 - -

50,400 90,000 - -

196,000 350,000 - -

56,000 100,000 - -

70,000 125,000 - -

70,000 125,000 - -

- - -

112,000 200,000 - -

33,600 60,000 - -

47,600 85,000 - -

14,000 25,000 - -

70,000 125,000 55,000 70,000 125,000

56,000 100,000 44,000 56,000 100,000

392,000 700,000 308,000 392,000 700,000

28,000 50,000 22,000 28,000 50,000

- - -

420,000 750,000 330,000 420,000 750,000

- - -

39,200 70,000 - -

- - -

56,000 100,000 - -

44,800 80,000 - -

67,200 120,000 - -

152

28 28 30 31 32

PERINATOLOGIICU/HCU

56,000 100,000 - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

84,000 150,000 66,000 84,000 150,000

168,000 300,000 132,000 168,000 300,000

84,000 150,000 66,000 84,000 150,000

61,600 110,000 48,400 61,600 110,000

81,200 145,000 63,800 81,200 145,000

98,000 175,000 77,000 98,000 175,000

98,000 175,000 77,000 98,000 175,000

- - -

- - -

- - -

- - -

- - -

- - -

- - -

153

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

- - -

16,800 30,000 - -

16,800 30,000 13,200 16,800 30,000

8,400 15,000 6,600 8,400 15,000

12,320 22,000 9,680 12,320 22,000

- - -

- - -

- - -

- - -

5,600 10,000 4,400 5,600 10,000

- - -

11,200 20,000 8,800 11,200 20,000

8,400 15,000 6,600 8,400 15,000

154

28 28 30 31 32

PERINATOLOGIICU/HCU

11,200 20,000 8,800 11,200 20,000

39,200 70,000 30,800 39,200 70,000

25,200 45,000 19,800 25,200 45,000

25,200 45,000 19,800 25,200 45,000

16,800 30,000 13,200 16,800 30,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

11,200 20,000 8,800 11,200 20,000

16,800 30,000 22,000 28,000 50,000

14,000 25,000 - -

44,800 80,000 35,200 44,800 80,000

14,000 25,000 11,000 14,000 25,000

- - -

- - -

16,800 30,000 - -

36,400 65,000 - -

25,200 45,000 - -

11,200 20,000 8,800 11,200 20,000

14,000 25,000 11,000 14,000 25,000

8,400 15,000 6,600 8,400 15,000

11,200 20,000 8,800 11,200 20,000

8,400 15,000 6,600 8,400 15,000

11,200 20,000 8,800 11,200 20,000

14,000 25,000 11,000 14,000 25,000

16,800 30,000 13,200 16,800 30,000

14,000 25,000 8,800 11,200 20,000

16,800 30,000 - -

5,600 10,000 4,400 5,600 10,000

11,200 20,000 8,800 11,200 20,000

5,600 10,000 4,400 5,600 10,000

8,400 15,000 - -

155

28 28 30 31 32

PERINATOLOGIICU/HCU

16,800 30,000 22,000 28,000 50,000

8,400 15,000 6,600 8,400 15,000

12,320 22,000 9,680 12,320 22,000

16,800 30,000 13,200 16,800 30,000

28,000 50,000 - -

14,000 25,000 11,000 14,000 25,000

36,400 65,000 - -

22,400 40,000 - -

28,000 50,000 - -

14,000 25,000 - -

28,000 50,000 - -

14,000 25,000 - -

19,600 35,000 - -

14,000 25,000 - -

11,200 20,000 - -

- 8,800 11,200 20,000

123,200 220,000 - -

5,600 10,000 4,400 5,600 10,000

5,600 10,000 4,400 5,600 10,000

12,320 22,000 9,680 12,320 22,000

5,600 10,000 - -

- - -

3,920 7,000 3,080 3,920 7,000

3,920 7,000 3,080 3,920 7,000

156

28 28 30 31 32

PERINATOLOGIICU/HCU

- - -

25,200 45,000 19,800 25,200 45,000

50400 90000

157

28 28 30 31 32

PERINATOLOGIICU/HCU

158

28 28 30 31 32

PERINATOLOGIICU/HCU

159

28 28 30 31 32

PERINATOLOGIICU/HCU

160

28 28 30 31 32

PERINATOLOGIICU/HCU

161

28 28 30 31 32

PERINATOLOGIICU/HCU

162

28 28 30 31 32

PERINATOLOGIICU/HCU

163

28 28 30 31 32

PERINATOLOGIICU/HCU

164

28 28 30 31 32

PERINATOLOGIICU/HCU

165

28 28 30 31 32

PERINATOLOGIICU/HCU

166

28 28 30 31 32

PERINATOLOGIICU/HCU

167

28 28 30 31 32

PERINATOLOGIICU/HCU

168

28 28 30 31 32

PERINATOLOGIICU/HCU

169

28 28 30 31 32

PERINATOLOGIICU/HCU

170

28 28 30 31 32

PERINATOLOGIICU/HCU

171

28 28 30 31 32

PERINATOLOGIICU/HCU

172

28 28 30 31 32

PERINATOLOGIICU/HCU

173

28 28 30 31 32

PERINATOLOGIICU/HCU

174

28 28 30 31 32

PERINATOLOGIICU/HCU

175

28 28 30 31 32

PERINATOLOGIICU/HCU

176

28 28 30 31 32

PERINATOLOGIICU/HCU

177

28 28 30 31 32

PERINATOLOGIICU/HCU

178

28 28 30 31 32

PERINATOLOGIICU/HCU

179

Documents

LAMPIRAN II PERATURAN DAERAH PROVINSI BANTEN …jdihukum.bantenprov.go.id/hukum/90Perda No. 1 Tahun 2016 (Lampiran... · Persalinan Dengan Penyulit Oleh Dokter jahit perineum > 20