usulan tarif blud

8/17/2019 Usulan Tarif Blud

1/142

LAMPIRAN 1.a. : USULAN PERDA TARIF RETRIBUSI PELAYANAN KE

NO PEMERIKSAAN & TINDAKAN MEDIK SATUANRETRIBUSI

A ADMINISTRASI MEDIK

1. Family Folder 1 set / KK Rp 1,00

2. Kartu Indeks Berobat 1 lbr Rp 50

3. Kartu status 1 lbr Rp 50

4. K! 1 lbr Rp 50

B. RAWAT JALAN

1 POLI UMUM

" #emeriksaan dasar $ %bat dasar 1 & Rp 3,00


2/142

d.2. &o *i*i susu den*an ) 1 Bt* Rp 4,50

d.3. &o *i*i tetap 'nterior 1 Bt* Rp ,00

d.4. &o *i*i tetap #osterior 1 Bt* Rp +,00

d.5. &o Komplikasi 1 Bt* Rp 10,00

e.umpatan

e.1. umpatan !ementara 1 lb* Rp 3,00

e.2 umpatan etap

" 'mal*am

Kls I 1 lb* Rp ,00Kls II 1 lb* Rp 10,00

Kls 1 lb* Rp ,00

" 6lass Ionomer

Kls I 1 lb* Rp ,00

Kls II 1 lb* Rp 10,00

Kls III 1 lb* Rp ,00

Kls I 1 lb* Rp 10,00

Kls 7 1 lb* Rp ,00

" i*8t )ure

Kls I 1 lb* Rp 15,00


3/142

9. #era:atan !aluran 'kar

9.1 %pen Bur

" *i*i anterior 1 & Rp 5,00

" *i*i posterior 1 & Rp ,00

9.2 &tirpasi, reamin*, ;llin*


" *i*i posterior 1 & Rp 15,00

9.3 6anti %bat 1 & Rp 5,00

9.4 #en*isian !aluran 'kar





*. #ulp )appin* 1 & Rp 5,00

8. Bon*kar ambalan #ermanen 1 lb* Rp 3,00

i. !allin*

i.1 1 ra8an* < R' / RB = 1 & Rp 15,00

C #en*isian !aluran 'kar Kon7ensional

C #en*isian !aluran 'kar den*an 3 mi&


4/142

" kstraksi kuku 1 & Rp 10,00

" !irkumsisi de:asa 1 & Rp 25,00

" !irkumsisi anak 1 & Rp 25,00

" #emasan*an ransel 7rband 1 & Rp 10,00

" ksisi tumor 1 & Rp 10,00

" Inisi abes 1 & Rp 5,00

" Imobilisasi d* spalk 1 & Rp 10,00

" ksplorasi luka 1 & Rp 5,00

" #era:atan uka 1 & Rp 4,00

" -ebridement luka bakar @ 20D 1 & Rp 5,00

" -ebridement luka bakar A 20D 1 & Rp 10,00

" Reposisi andibula 1 & Rp 5,00

" Bilas ambun* 1 & Rp 5,00

" Rendan Bokon* 1 & Rp 2,00

" #asan* Kateter 1 & Rp 5,00

E. indakan Kepera:atan

" !untikan 1&/8ari 1 & Rp 50

" !untikan 2"5&/8ari 1 & Rp 1,00


5/142

. indakan edis 'nastesi

" Resusitasi ?antun* paru


6/142

d. pisiotomi

" 6rade I " III < Bidan = 1 & Rp 10,00

" 6rade I " III < -okter mum = 1 & Rp 15,00

" 6rade I " III < -okter !pesialis = 1 & Rp 20,00

" 6rade I < dokter !pesialis = 1 & Rp 25,00

e. ksplorasi a*ina

" Bidan 1 & Rp 15,00

" -okter mum 1 & Rp 20,00

" -okter !pesialis 1 & Rp 30,00

9. anual plasenta

" Bidan 1 & Rp 20,00

" -okter mum 1 & Rp 30,00

" -okter !pesialis 1 & Rp 40,00


7/142

C PENUNJANG DIAGNOSTIK

1 E!"#$%!'()

a. Radiolo*i

" 8ora& #' 1 & Rp 10,00

" 'bdomen #' 1 & Rp 10,00

" #el7is '# 1 & Rp 10,00

" )la7iula < -/! = '# 1 & Rp 10,00

" aters open mout8 #' 1 & Rp 10,00

" op ordoti


8/142

" anpa ;lm 1 & Rp 15,00

" -en*an ;lm 1 & Rp 15,00

2 La*%$a#%$(+

a. Gematolo*i " Gematokrit 1 & Rp 1,00

" Gb 1 & Rp 1,00

" euoyt 1 & Rp 1,00

" -iJ )ount / Gitun* enis 1 & Rp 2,00

" BB! / - 1 & Rp 2,00

" alaria 1 & Rp 1,00

" rytroyt 1 & Rp 1,00

" romboyt 1 & Rp 1,00

" Bloodin* ime 1& Rp 1,000

" )8lot8in* ime 1& Rp 1,000

" 6olon*an -ara8 1 & Rp 3,00

b. rine 'nalis

" #rotein 1 & Rp 1,00

" Reduksi 1 & Rp 1,00

" Bilirubin 1 & Rp 1,00


9/142

. Faees

" akroskopis 1 & Rp 2,00

" ikroskopis 1 & Rp 2,00

d. ikrobilo*i " B' 1 & Rp 2,00

" !eret a*ina 1 & Rp 2,00

" K%G 1 & Rp 2,00

e. Kimia -ara8

" 6ula -ara8 1 & Rp 3,00

" )8olesterol 1 & Rp 3,00

" ri*liserid 1 & Rp 3,00

" ri 'id 1 & Rp 3,00

9. !erolo*i

" -en*ue est 1 & Rp 5,00

#emeriksaan )yto / -iluar ?am ker?a tari9 ditamba8

25D & tari9 dasar


10/142

3 #emeriksaan edial )alon Karya:an

a. #emeriksaan medial standar 1 & Rp 32,00

b. aboratorium b.1 -ara8

" Gitun* enis 1 & Rp 2,00

" a?u ndap -ara8 1 & Rp 2,00

" Bloodin* ime


11/142

4 #emeriksaan edial )alon amaa8 Ga?i

a. 'namnese > pemeriksaan ;sik, ?i:a > Bart8el inde& 1 & Rp 5,00

b. #emeriksaan penun?an*

b.1 aboratorium " -ara8

1 & Rp 1,00

1 & Rp 2,00

1 & Rp 1,00

1 & Rp 3,00

1 & Rp 3,00

1 & Rp 3,00

" rine

1 & Rp 2,00

1 & Rp 4,00

1 & Rp 1,00

1 & Rp 5,00

b.2 K6 1 & Rp 5,00

b.3 Radiolo*i


12/142

G RAWAT INAP

1 K!a- U#aa

1 8r Rp 5,00

" -okter spesialis 1 8r Rp

" -okter mum / 6i*i 1 8r Rp

C isit -okter Ra:at 6abun*



C )yto konsul

" -okter spesialis 1 & Rp

" -okter mum / 6i*i 1 & Rp

2 K!a- I

1 8r Rp 40,00



C isit -okter Ra:at 6abun*


C 'komodasi

C isit -okter

C 'komodasi

C isit -okter


13/142

EHATAN MEDIS DI PUSKESMAS

TARIF

JASA PELAYANAN

TOTAL JASA MEDIS JUMLAH

Rp 1,000 Rp +,000 Rp ,000 Rp 10,000

Rp " Rp 3,500 Rp 3,500 Rp 4,000

Rp " Rp 500 Rp 500 Rp 1,000

Rp " Rp 4,500 Rp 4,500 Rp 5,000

Rp 5,000 Rp 2,000 Rp ,000 Rp 10,000

BAHAN HABIS

PAKAI/SARANA

PRASARANA


14/142

Rp 4,500 Rp 3,000 Rp ,500 Rp 12,000

Rp 10,000 Rp E,000 Rp 1E,000 Rp 23,000

Rp 11,000 Rp ,000 Rp 1+,000 Rp 2E,000

Rp 15,000 Rp 10,000 Rp 25,000 Rp 35,000

Rp 2,000 Rp 5,000 Rp ,000 Rp 10,000

Rp 14,000 Rp ,000 Rp 23,000 Rp 30,000

Rp 15,000 Rp 10,000 Rp 25,000 Rp 35,000

Rp 14,000 Rp ,000 Rp 23,000 Rp 30,000

Rp 1,000 Rp 11,000 Rp 2+,000 Rp 35,000

Rp 1+,000 Rp 12,000 Rp 30,000 Rp 40,000

Rp 1,000 Rp 11,000 Rp 2+,000 Rp 35,000

Rp 1+,000 Rp 12,000 Rp 30,000 Rp 40,000

Rp 1,000 Rp 11,000 Rp 2+,000 Rp 35,000

Rp 2,000 Rp 1+,000 Rp 45,000 Rp E0,000


15/142

Rp ,000 Rp E,000 Rp 15,000 Rp 20,000

Rp 11,000 Rp ,000 Rp 1+,000 Rp 25,000

Rp 12,000 Rp +,000 Rp 20,000 Rp 30,000

Rp 15,000 Rp 10,000 Rp 25,000 Rp 40,000

Rp E,000 Rp 4,000 Rp 10,000 Rp 15,000

Rp 12,000 Rp +,000 Rp 20,000 Rp 30,000

Rp 15,000 Rp 10,000 Rp 25,000 Rp 40,000

Rp 14,000 Rp ,000 Rp 23,000 Rp 35,000

Rp 1,000 Rp 11,000 Rp 2+,000 Rp 45,000

Rp ,000 Rp E,000 Rp 15,000 Rp 20,000

Rp ,000 Rp 5,000 Rp 12,000 Rp 15,000

Rp 2,000 Rp 1+,000 Rp 45,000 Rp E0,000


16/142

Rp 25,000 Rp 15,000 Rp 40,000 Rp 50,000

Rp 250,000 Rp 5,000 Rp 325,000 Rp 350,000

Rp 200,000 Rp 5,000 Rp 25,000 Rp 300,000

Rp 30,000 Rp 10,000 Rp 40,000 Rp 50,000Rp 35,000 Rp 15,000 Rp 50,000 Rp E0,000

Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000

Rp 15,000 Rp 15,000 Rp 30,000 Rp 40,000

Rp 15,000 Rp 10,000 Rp 25,000 Rp 30,000

Rp +,000 Rp +,000 Rp 1E,000 Rp 20,000

Rp 15,000 Rp 15,000 Rp 30,000 Rp 35,000

Rp 20,000 Rp 20,000 Rp 40,000 Rp 50,000

Rp 25,000 Rp 15,000 Rp 40,000 Rp 45,000

Rp 25,000 Rp 10,000 Rp 35,000 Rp 40,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000

Rp 1,500 Rp 1,000 Rp 2,500 Rp 3,000

Rp 2,500 Rp 1,500 Rp 4,000 Rp 5,000


17/142

Rp 40,000 Rp 10,000 Rp 50,000 Rp E0,000

Rp 15,000 Rp 10,000 Rp 25,000 Rp 30,000

Rp 12,500 Rp 10,000 Rp 22,500 Rp 30,000

Rp 10,000 Rp 5,000 Rp 15,000 Rp 20,000

Rp 2,500 Rp 5,000 Rp ,500 Rp 10,000

Rp ,500 Rp ,500 Rp 15,000 Rp 20,000

Rp 5,000 Rp 10,000 Rp 15,000 Rp 20,000

Rp 15,000 Rp 10,000 Rp 25,000 Rp 30,000

Rp ,500 Rp ,500 Rp 15,000 Rp 20,000

Rp 12,500 Rp 12,500 Rp 25,000 Rp 30,000

Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000

Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000

Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000


18/142

Rp 30,000 Rp 10,000 Rp 40,000 Rp 50,000

Rp 45,000 Rp 15,000 Rp E0,000 Rp 5,000Rp E0,000 Rp 20,000 Rp +0,000 Rp 100,000

Rp 150,000 Rp 25,000 Rp 15,000 Rp 200,000

Rp 50,000 Rp 10,000 Rp E0,000 Rp 5,000

Rp E5,000 Rp 15,000 Rp +0,000 Rp 100,000

Rp 150,000 Rp 25,000 Rp 15,000 Rp 205,000

Rp 110,000 Rp 20,000 Rp 130,000 Rp 150,000

Rp 10,000 Rp 30,000 Rp 220,000 Rp 250,000

Rp 20,000 Rp 40,000 Rp 310,000 Rp 350,000


19/142

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000

Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000

Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000

Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000

Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000

Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000

Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000


20/142

Rp 20,000 Rp 15,000 Rp 35,000 Rp 50,000

Rp 25,000 Rp 20,000 Rp 45,000 Rp E0,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 5,000 Rp 12,000 Rp 1,000 Rp 20,000

Rp 2,000 Rp 1,500 Rp 3,500 Rp 4,500

Rp 2,000 Rp 1,500 Rp 3,500 Rp 4,500

Rp 2,000 Rp 1,500 Rp 3,500 Rp 4,500


21/142

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 10,000 Rp 3,000 Rp 13,000 Rp 15,000

Rp 10,000 Rp 3,000 Rp 13,000 Rp 15,000

Rp 10,000 Rp 3,000 Rp 13,000 Rp 15,000

Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000

Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000

Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000

Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000

Rp 5,000 Rp 25,000 Rp 30,000 Rp 35,000


22/142

Rp 42,000 Rp E0,500 Rp 102,500 Rp 134,500

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 4,000 Rp E,000 Rp 10,000 Rp 14,000

Rp 10,000 Rp 40,000 Rp 50,000 Rp E0,000


23/142

Rp 30,000 Rp 15,000 Rp 45,000 Rp 50,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 5,000 Rp 12,000 Rp 1,000 Rp 20,000

Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000

Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000

Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000

Rp 4,000 Rp E,000 Rp 10,000 Rp 14,000

Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000

Rp 3,000 Rp 12,000 Rp 15,000 Rp 20,000

Rp 15,000 Rp 15,000 Rp 30,000 Rp 35,000

Rp 10,000 Rp 30,000 Rp 40,000 Rp 55,000

Rp 5,000 Rp ,000 Rp 12,000 Rp 14,000


24/142

Rp 5,000 Rp 100,000 Rp 15,000 Rp 250,000

Rp 44,000 Rp 2E,000 Rp 0,000 Rp 0,000

Rp 3+,000 Rp 22,000 Rp E0,000 Rp E0,000

Rp 52,000 Rp 3+,000 Rp 0,000 Rp 0,000

Rp 3,000 Rp 2+,000 Rp E5,000 Rp E5,000

Rp 100,000 Rp " Rp 100,000 Rp 100,000

Rp 45,000 Rp " Rp 45,000 Rp 45,000

Rp 40,000 Rp 0,000 Rp 110,000 Rp 150,000

Rp 40,000 Rp 25,000 Rp E5,000 Rp E5,000

Rp 32,000 Rp 1+,000 Rp 50,000 Rp 50,000

Rp 4E,000 Rp 24,000 Rp 0,000 Rp 0,000


25/142

USULAN TARIF PELAYANAN KESEHATAN MASYARAKAT UMUM

PPK,BLUD UPT PUSKESMAS TELUK SEBONG TH.211

NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN

TARIF

JASA PELAYANA

JASA MEDIS


1. Family Folder 1 set / KK Rp 1,000 Rp 1,000 Rp +,000

2. Kartu Indeks Berobat 1 lbr Rp 500 Rp " Rp 3,500

3. Kartu status 1 lbr Rp 500 Rp " Rp 500

4. K! 1 lbr Rp 500 Rp " Rp 4,500

B. RAWAT JALAN

1 POLI UMUM

" #emeriksaan dasar $ %bat dasar 1 & Rp E,000 Rp 10,000 Rp 4,000

2 POLI SPESIALIS

" #emeriksaan $ %bat dasar 1 & Rp 10,000 Rp 50,000 Rp 20,000

3 POLI KEBIDANAN

" '() 1 & Rp E,000 Rp 10,000 Rp 4,000

PENDAPATAN

BLUDBAHAN HABIS

PAKAI/SARANA

PRASARANA


26/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" #enimban*an Bayi 1 & Rp 1,000 Rp " Rp 1,000

" !untik KB 1 bulan 1 & Rp 1E,000 Rp +,000 Rp 1E,000

" !untik KB 3 bulan 1 & Rp 10,000 Rp +,000 Rp 12,000

" #asan* Implant 1 & Rp 30,000 Rp 50,000 Rp E0,000

" Buka Implant 1 & Rp 30,000 Rp 50,000 Rp E0,000

" Buka #asan* Implant 1 & Rp 40,000 Rp +0,000 Rp +0,000

" #asan* I- 1 & Rp 1+,000 Rp 30,000 Rp 22,000

" Buka I- 1 & Rp 1+,000 Rp 30,000 Rp 22,000

" Buka #asan* I- 1 & Rp 30,000 Rp E0,000 Rp 30,000

" Imunisasi ! 1 & Rp 4,000 Rp +,000 Rp 1+,000

" Imunisasi )aten 1 &

" !untik Rp 4,000 Rp +,000 Rp 1+,000

" #re* est Rp 10,000 Rp E,000 Rp 24,000

" !urat Keteran*an Rp 4,000 Rp 4,000 Rp 12,000

Rp 1+,000 Rp 1+,000 Rp 54,000

4 TINDAKAN MEDIK

4.1 POLI GIGI

a. #emeriksaan dan obat dasar 1 & Rp E,000 Rp 10,000 Rp 4,000

b. Konsultasi 1 & Rp 1,000 Rp ,000 Rp 2,000


27/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

. !pulin* Betadine 1 & Rp 4,000 Rp 4,000 Rp 2,000

d. &tratri

d.1. &o *i*i susu den*an ido 1 Bt* Rp 10,000 Rp 1E,000 Rp 10,000

d.2. &o *i*i susu den*an ) 1 Bt* Rp ,000 Rp ,000 Rp E,000

d.3. &o *i*i tetap 'nterior 1 Bt* Rp 14,000 Rp 20,000 Rp 12,000

d.4. &o *i*i tetap #osterior 1 Bt* Rp 1E,000 Rp 22,000 Rp 14,000

d.5. &o Komplikasi 1 Bt* Rp 20,000 Rp 30,000 Rp 20,000

e.umpatan

e.1. umpatan !ementara 1 lb* Rp E,000 Rp 4,000 Rp 10,000

e.2 umpatan etap

" 'mal*am

Kls I 1 lb* Rp 14,000 Rp 2+,000 Rp 1+,000

Kls II 1 lb* Rp 20,000 Rp 30,000 Rp 20,000

Kls 1 lb* Rp 14,000 Rp 2+,000 Rp 1+,000

" 6lass Ionomer

Kls I 1 lb* Rp 14,000 Rp 34,000 Rp 22,000

Kls II 1 lb* Rp 20,000 Rp 3E,000 Rp 24,000

Kls III 1 lb* Rp 14,000 Rp 34,000 Rp 22,000

Kls I 1 lb* Rp 20,000 Rp 3E,000 Rp 24,000

Kls 7 1 lb* Rp 14,000 Rp 34,000 Rp 22,000

" i*8t )ure


28/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

Kls I 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000

Kls II 1 lb* Rp 40,000 Rp EE,000 Rp 44,000

Kls III 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000

Kls I 1 lb* Rp 40,000 Rp EE,000 Rp 44,000

Kls 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000


9.1 %pen Bur

" *i*i anterior 1 & Rp 10,000 Rp 1+,000 Rp 12,000

" *i*i posterior 1 & Rp 14,000 Rp 22,000 Rp 14,000


" *i*i anterior 1 & Rp 20,000 Rp 24,000 Rp 1E,000


9.3 6anti %bat 1 & Rp 10,000 Rp 12,000 Rp +,000




" *i*i anterior 1 & Rp 24,000 Rp 2+,000 Rp 1+,000


*. #ulp )appin* 1 & Rp 10,000 Rp 1+,000 Rp 12,000




29/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

8. Bon*kar ambalan #ermanen 1 lb* Rp E,000 Rp 14,000 Rp 10,000

i. !allin*

i.1 1 ra8an* < R' / RB = 1 & Rp 30,000 Rp 54,000 Rp 3E,000

i.2 2 ra8an* < R' > RB = 1 & Rp E0,000 Rp 10+,000 Rp 2,000

?. Inisi 'bses

?.1 Intra %ral 1 & Rp 10,000 Rp 30,000 Rp 20,000

?.2 &tra %ral 1 & Rp 20,000 Rp 42,000 Rp 2+,000

k. perulektomi 1 re* Rp 30,000 Rp 54,000 Rp 3E,000

l. 'l7eolektomi 1 re* Rp 40,000 Rp 2,000 Rp 4+,000

m.%dontektomi 1 bt* Rp +0,000 Rp 240,000 Rp +0,000

n. Kontrol pasa beda8 1 & Rp E,000 Rp ,000 Rp 5,000

o. Buka ?a8itan 1 & Rp E,000 Rp ,000 Rp 5,000

4.2 UNIT GAWAT DARURAT

1. #emeriksaan dokter umum $ administrasi 1 & Rp 4,000 Rp 20,000 Rp E,000

2. #emeriksaan dokter *i*i $ administrasi 1 & Rp 4,000 Rp 20,000 Rp E,000

3. #emeriksaan dokter spesialis $ administrasi 1 & Rp 10,000 Rp 40,000 Rp 10,000

4. indakan edik 'nak

" Imunisasi 1 & Rp 10,000 Rp +,000 Rp 22,000

" antau& est 1 & Rp 20,000 Rp 40,000 Rp 1+0,000

" Resusitasi 1 & Rp 20,000 Rp 40,000 Rp 30,000


30/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" !irumsisi bayi perempuan 1 & Rp 10,000 Rp 30,000 Rp 20,000

" indik 1 & Rp 10,000 Rp 30,000 Rp 20,000

5. indakan edik beda8

" 6anti balutan @ 10 m 1 & Rp 10,000 Rp 10,000 Rp 10,000

" 6anti balutan A 10 m 1 & Rp 1E,000 Rp 14,000 Rp 10,000

" a8it luka

5 ?a8itan pertama 1 & Rp 10,000 Rp 30,000 Rp 20,000

!elan?utnya pen?a8itan 1 & Rp 2,000 Rp 2,000 Rp 2,000

" Buka ?a8itan @ 5 ?a8itan 1 & Rp 5,000 Rp 15,000 Rp 10,000


" kstraksi kuku 1 & Rp 20,000 Rp 50,000 Rp 30,000

" !irkumsisi de:asa 1 & Rp 50,000 Rp 500,000 Rp 150,000

" !irkumsisi anak 1 & Rp 50,000 Rp 400,000 Rp 150,000

" #emasan*an ransel 7rband 1 & Rp 20,000 Rp E0,000 Rp 20,000

" ksisi tumor 1 & Rp 20,000 Rp 0,000 Rp 30,000

" Inisi abes 1 & Rp 10,000 Rp 20,000 Rp 20,000

" Imobilisasi d* spalk 1 & Rp 20,000 Rp 30,000 Rp 30,000

" ksplorasi luka 1 & Rp 10,000 Rp 30,000 Rp 20,000

" #era:atan uka 1 & Rp +,000 Rp 1E,000 Rp 1E,000

" -ebridement luka bakar @ 20D 1 & Rp 10,000 Rp 30,000 Rp 30,000


31/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" -ebridement luka bakar A 20D 1 & Rp 20,000 Rp 40,000 Rp 40,000

" Reposisi andibula 1 & Rp 10,000 Rp 50,000 Rp 30,000

" Bilas ambun* 1 & Rp 10,000 Rp 50,000 Rp 20,000

" Rendan Bokon* 1 & Rp 4,000 Rp 10,000 Rp E,000

" #asan* Kateter 1 & Rp 10,000 Rp 20,000 Rp 20,000


" !untikan 1&/8ari 1 & Rp 1,000 Rp 3,000 Rp 2,000

" !untikan 2"5&/8ari 1 & Rp 2,000 Rp 5,000 Rp 3,000

" #en*ambilan sampel dara8 1 & Rp 1,000 Rp 5,000 Rp 4,000

" #emasan*an In9us 1 & Rp 20,000 Rp 3E,000 Rp 24,000

" #enabutan In9us 1 & Rp 2,000 Rp E,000 Rp 2,000

" Klisma 1 & Rp 5,000 Rp 15,000 Rp 10,000

" !ution/8ari 1 & Rp 10,000 Rp 30,000 Rp 20,000

" #emasan*an (6 1 & Rp 20,000 Rp 50,000 Rp 30,000




32/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" est is8i8ara 1 & Rp 5,000 Rp 5,000 Rp 10,000

" 6anti erband mata 1 & Rp 10,000 Rp 15,000 Rp 15,000

. indakan edik #aru

" In8alasi/(ebulier 1 & Rp 10,000 Rp 10,000 Rp 20,000

10. indakan edik G

" kstraksi serumen 1 & Rp 10,000 Rp 30,000 Rp 20,000

" ampon telin*a 1 & Rp 10,000 Rp 15,000 Rp 15,000

" kstraksi orpus alienum di telin*a 1 & Rp 10,000 Rp 25,000 Rp 25,000

" #asan* tampon anterior 1 & Rp 10,000 Rp 20,000 Rp 20,000

" )abut tampon anterior 1 & Rp 10,000 Rp 20,000 Rp 20,000

" #asan* tampon posterior 1 & Rp 10,000 Rp 20,000 Rp 20,000

" )abut tampon posterior 1 & Rp 10,000 Rp 20,000 Rp 20,000

" BeloH tampon 1 & Rp 10,000 Rp 20,000 Rp 20,000

" kstraksi orpus alienum di 8idun* 1 & Rp 10,000 Rp 30,000 Rp 20,000

" indik


33/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" #apiloma 1 & Rp 30,000 Rp 0,000 Rp 50,000

" ar7a mi*ran 1 & Rp 10,000 Rp 20,000 Rp 10,000

12. Keraunan 1 & Rp 20,000 Rp 40,000 Rp E0,000

13. -i*i*it Binatan* 1 & Rp 10,000 Rp 30,000 Rp 20,000

4.3 TINDAKAN KEBIDANAN

a. #artus normal

" Bidan 1 & Rp 100,000 Rp 300,000 Rp 100,000

" -okter mum 1 & Rp 100,000 Rp 500,000 Rp 200,000

" -okter !pesialis 1 & Rp 100,000 Rp +00,000 Rp 300,000

b. #artus den*an induksi

" Bidan 1 & Rp 150,000 Rp 350,000 Rp 100,000

" -okter mum 1 & Rp 150,000 Rp 550,000 Rp 200,000

" -okter !pesialis 1 & Rp 150,000 Rp 1,000,000 Rp 250,000

. #artus den*an penyulit

" Bidan 1 & Rp 200,000 Rp 400,000 Rp 200,000

" -okter mum 1 & Rp 200,000 Rp E00,000 Rp 200,000



34/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

d. pisiotomi

" 6rade I " III < Bidan = 1 & Rp 20,000 Rp E0,000 Rp 20,000

" 6rade I " III < -okter mum = 1 & Rp 30,000 Rp 0,000 Rp 30,000

" 6rade I " III < -okter !pesialis = 1 & Rp 40,000 Rp 120,000 Rp 40,000

" 6rade I < dokter !pesialis = 1 & Rp 50,000 Rp 300,000 Rp 50,000

e. ksplorasi a*ina

" Bidan 1 & Rp 30,000 Rp 100,000 Rp 20,000

" -okter mum 1 & Rp 40,000 Rp 130,000 Rp 30,000

" -okter !pesialis 1 & Rp E0,000 Rp 300,000 Rp 50,000

9. anual plasenta

" Bidan 1 & Rp 40,000 Rp 220,000 Rp 40,000

" -okter mum 1 & Rp E0,000 Rp 3+0,000 Rp E0,000

" -okter !pesialis 1 & Rp +0,000 Rp 540,000 Rp +0,000


1 E!"#$%!'()

a. Radiolo*i

" 8ora& #' 1 & Rp 20,000 Rp 30,000 Rp 50,000

C 1 posisi 1 ;lm


35/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" 'bdomen #' 1 & Rp 20,000 Rp 30,000 Rp 50,000

" #el7is '# 1 & Rp 20,000 Rp 30,000 Rp 50,000

" )la7iula < -/! = '# 1 & Rp 20,000 Rp 30,000 Rp 50,000

" aters open mout8 #' 1 & Rp 20,000 Rp 30,000 Rp 50,000

" op ordoti


36/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" !inus :aters open mout8 " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" open " lose mout8 1 & Rp 40,000 Rp 50,000 Rp 100,000" %s Gumerus '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" ert t8orao lumbal '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" ert lumbal '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" umbo saral '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" !arum '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" )oy& '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" Gip '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" Femur '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000" )ruris '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" #edis '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000

" 'bdomen 3 posisi 1 & Rp E0,000 Rp E0,000 Rp 240,000

" )er7ial '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000

" 8orao umbal '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000

" 8oraal '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000

" umbal '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000

" umbo " !aral '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000

1 & Rp 10,000 Rp 10,000 Rp 30,000

. letroardio*ra; 1 & Rp 10,000 Rp 30,000 Rp 30,000

C 3 " 4 posisi 3 " 4 ;lm

C Intra %ral


37/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

d. !6

" anpa ;lm 1 & Rp 30,000 Rp 40,000 Rp 30,000

" -en*an ;lm 1 & Rp 30,000 Rp 50,000 Rp 40,000

2 La*%$a#%$(+

a. Gematolo*i

" Gematokrit 1 & Rp 2,000 Rp 4,000 Rp 2,000

" Gb 1 & Rp 2,000 Rp 4,000 Rp 2,000

" euoyt 1 & Rp 2,000 Rp 4,000 Rp 2,000

" -iJ )ount / Gitun* enis 1 & Rp 4,000 Rp 10,000 Rp E,000

" BB! / - 1 & Rp 4,000 Rp 10,000 Rp E,000

" alaria 1 & Rp 2,000 Rp 4,000 Rp 2,000

" rytroyt 1 & Rp 2,000 Rp 4,000 Rp 2,000

" romboyt 1 & Rp 2,000 Rp 4,000 Rp 2,000

" Bloodin* ime 1& Rp 2 Rp 4,000 Rp 2,000

" )8lot8in* ime 1& Rp 2 Rp 4,000 Rp 2,000

" 6olon*an -ara8 1 & Rp E,000 Rp 10,000 Rp 24,000

b. rine 'nalis

" #rotein 1 & Rp 2,000 Rp 4,000 Rp 3,000

" Reduksi 1 & Rp 2,000 Rp 4,000 Rp 3,000

" Bilirubin 1 & Rp 2,000 Rp 4,000 Rp 3,000

" !edimen 1 & Rp 2,000 Rp 4,000 Rp 3,000


38/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" #re* est 1 & Rp 10,000 Rp E,000 Rp 24,000

" or;n 1 & Rp E,000 Rp 20,000 Rp 4,000

" G) / 6an?a 1 & Rp E,000 Rp 20,000 Rp 4,000

" 'm9etamine 1 & Rp E,000 Rp 20,000 Rp 4,000

" )oaine 1 & Rp E,000 Rp 20,000 Rp 4,000

" Benodiaepin 1 & Rp E,000 Rp 20,000 Rp 4,000

" %pium 1 & Rp E,000 Rp 20,000 Rp 4,000

. Faees

" akroskopis 1 & Rp 4,000 Rp 10,000 Rp E,000

" ikroskopis 1 & Rp 4,000 Rp 10,000 Rp E,000

d. ikrobilo*i

" B' 1 & Rp 4,000 Rp 20,000 Rp E,000

" !eret a*ina 1 & Rp 4,000 Rp 20,000 Rp E,000

" K%G 1 & Rp 4,000 Rp 20,000 Rp E,000

e. Kimia -ara8

" 6ula -ara8 1 & Rp E,000 Rp +,000 Rp 4E,000

" )8olesterol 1 & Rp E,000 Rp +,000 Rp 4E,000

" ri*liserid 1 & Rp E,000 Rp +,000 Rp 4E,000

" ri 'id 1 & Rp E,000 Rp +,000 Rp 4E,000


39/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

9. !erolo*i

" -en*ue est 1 & Rp 10,000 Rp 10,000 Rp 50,000


25D & tari9 dasar

D PELAYANAN MEDICOLEGAL

1 #emberian 9ormalin 1 & Rp 200,000 Rp 1,000,000 Rp +00,000

E MEDICAL CHECK UP

1 KIR Kese8atan Biasa

a. 'namnese > #emeriksaan Fisik

" #oli mum 1 & Rp E,000 Rp 10,000 Rp 4,000

" #oli 6i*i 1 & Rp 1,000 Rp ,000 Rp 2,000

b. aboratorium

" -ara8 rutin


40/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

2 #emeriksaan edial !tandar

a. 'namnese > #emeriksaan Fisik " #oli mum 1 & Rp E,000 Rp 10,000 Rp 4,000

" #oli 6i*i 1 & Rp 1,000 Rp ,000 Rp 2,000

b. #emeriksaan isus 1 & Rp 2,000 Rp E,000 Rp 2,000

. #emeriksaan Buta arna 1 & Rp 1,000 Rp 3,000 Rp 2,000

d. 8ora& 9oto 1 & Rp 30,000 Rp 20,000 Rp E0,000

e.aboratorium

" -ara8 rutin 1 & Rp E,000 Rp 12,000 Rp E,000

" rin rutin 1 & Rp +,000 Rp 12,000 Rp ,000

" 6olon*an dara8 1 & Rp E,000 Rp 10,000 Rp 24,000

9. !urat keteran*an / administrasi 1 & Rp 4,000 Rp 4,000 Rp 12,000

Rp E4,000 Rp +4,000 Rp 121,000


a. #emeriksaan medial standar 1 & Rp E4,000 Rp +4,000 Rp 121,000

b. aboratorium

b.1 -ara8

" Gitun* enis 1 & Rp 4,000 Rp 10,000 Rp E,000

" a?u ndap -ara8 1 & Rp 4,000 Rp 10,000 Rp E,000

" Bloodin* ime


41/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" )8lot8in* ime


42/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" -ara8

1 & Rp 2,000 Rp 4,000 Rp 2,0001 & Rp 4,000 Rp 10,000 Rp E,000

1 & Rp 2,000 Rp 4,000 Rp 2,000

1 & Rp E,000 Rp 10,000 Rp 24,000

1 & Rp E,000 Rp +,000 Rp 4E,000

1 & Rp E,000 Rp +,000 Rp 4E,000

" rine

1 & Rp 4,000 Rp 10,000 Rp E,000

1 & Rp +,000 Rp +,000 Rp 12,000

1 & Rp 2,000 Rp 4,000 Rp 2,000

1 & Rp 10,000 Rp E,000 Rp 24,000

b.2 K6 1 & Rp 10,000 Rp 30,000 Rp 30,000

b.3 Radiolo*i


43/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

F LAIN , LAIN

1 !urat Keteran*an

" Kela8iran 1 & Rp E,000 Rp E,000 Rp 1+,000

" !akit 1 & Rp 2,000 Rp 3,000 Rp 5,000

" -ira:at 1 & Rp 4,000 Rp E,000 Rp 10,000

" aik (aik #esa:at 1 & Rp 4,000 Rp E,000 Rp 10,000

" Kematian 1 & Rp 4,000 Rp E,000 Rp 10,000

2 'mbulane

1 & Rp 1E,000 Rp 34,000 Rp 30,000

!elebi8nya/km 1 & Rp 2,000 Rp 2,400 Rp 2,E00

" uar #ulau

" belum termasuk biaya penyebran*an

" 2& tari9 dalam pulau

3 asa #etu*as #endampin* Ru?ukan

" -okter 1 &

Rp 10,000 Rp 50,000 Rp "

C !elebi8nya / km Rp 2,000 Rp 5,000 Rp "

C uar pulau


44/142


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" #era:at / Bidan 1 &

Rp 3,000 Rp 12,000 Rp "

C !elebi8nya / km Rp 500 Rp 1,000 Rp "

C uar pulau


45/142

TOTAL JUMLAH

Rp ,000 Rp 10,000

Rp 3,500 Rp 4,000

Rp 500 Rp 1,000

Rp 4,500 Rp 5,000

Rp 14,000 Rp 20,000

Rp 0,000 Rp +0,000

Rp 14,000 Rp 20,000


46/142

TOTAL JUMLAH

Rp 1,000 Rp 2,000

Rp 24,000 Rp 40,000Rp 20,000 Rp 30,000

Rp 110,000 Rp 140,000

Rp 110,000 Rp 140,000

Rp 1E0,000 Rp 200,000

Rp 52,000 Rp 0,000

Rp 52,000 Rp 0,000

Rp 0,000 Rp 120,000

Rp 2E,000 Rp 30,000

Rp 2E,000 Rp 30,000

Rp 30,000 Rp 40,000

Rp 1E,000 Rp 20,000

Rp 2,000 Rp 0,000

Rp 14,000 Rp 20,000

Rp ,000 Rp 10,000


47/142

TOTAL JUMLAH

Rp E,000 Rp 10,000

Rp 2E,000 Rp 3E,000

Rp 15,000 Rp 24,000

Rp 32,000 Rp 4E,000

Rp 3E,000 Rp 52,000

Rp 50,000 Rp 0,000

Rp 14,000 Rp 20,000

Rp 4E,000 Rp E0,000

Rp 50,000 Rp 0,000

Rp 4E,000 Rp E0,000

Rp 5E,000 Rp 0,000

Rp E0,000 Rp +0,000

Rp 5E,000 Rp 0,000

Rp E0,000 Rp +0,000

Rp 5E,000 Rp 0,000


48/142

TOTAL JUMLAH

Rp 0,000 Rp 120,000

Rp 110,000 Rp 150,000Rp 0,000 Rp 120,000

Rp 110,000 Rp 150,000

Rp 0,000 Rp 120,000

Rp 30,000 Rp 40,000

Rp 3E,000 Rp 50,000

Rp 40,000 Rp E0,000

Rp 50,000 Rp +0,000

Rp 20,000 Rp 30,000

Rp 40,000 Rp E0,000

Rp 50,000 Rp +0,000

Rp 4E,000 Rp 0,000

Rp 5E,000 Rp 0,000

Rp 30,000 Rp 40,000


49/142

TOTAL JUMLAH

Rp 24,000 Rp 30,000

Rp 0,000 Rp 120,000

Rp 1+0,000 Rp 240,000

Rp 50,000 Rp E0,000

Rp 0,000 Rp 0,000

Rp 0,000 Rp 120,000

Rp 120,000 Rp 1E0,000

Rp 320,000 Rp 400,000Rp 14,000 Rp 20,000

Rp 14,000 Rp 20,000

Rp 2E,000 Rp 30,000

Rp 2E,000 Rp 30,000

Rp 50,000 Rp E0,000

Rp 30,000 Rp 40,000

Rp 220,000 Rp 240,000

Rp 0,000 Rp 0,000


50/142

TOTAL JUMLAH

Rp 50,000 Rp E0,000

Rp 50,000 Rp E0,000

Rp 20,000 Rp 30,000

Rp 24,000 Rp 40,000

Rp 50,000 Rp E0,000

Rp 4,000 Rp E,000

Rp 25,000 Rp 30,000Rp 2,000 Rp 3,000

Rp +0,000 Rp 100,000

Rp E50,000 Rp 00,000

Rp 550,000 Rp E00,000

Rp +0,000 Rp 100,000

Rp 100,000 Rp 120,000

Rp 40,000 Rp 50,000

Rp E0,000 Rp +0,000Rp 50,000 Rp E0,000

Rp 32,000 Rp 40,000

Rp E0,000 Rp 0,000


51/142

TOTAL JUMLAH

Rp +0,000 Rp 100,000

Rp +0,000 Rp 0,000Rp 0,000 Rp +0,000

Rp 1E,000 Rp 20,000

Rp 40,000 Rp 50,000

Rp 5,000 Rp E,000

Rp +,000 Rp 10,000

Rp ,000 Rp 10,000Rp E0,000 Rp +0,000

Rp +,000 Rp 10,000

Rp 25,000 Rp 30,000

Rp 50,000 Rp E0,000

Rp +0,000 Rp 100,000

Rp 100,000 Rp 120,000

Rp 50,000 Rp E0,000

Rp 45,000 Rp E0,000

Rp 30,000 Rp 40,000


52/142


53/142

TOTAL JUMLAH

Rp 140,000 Rp 10,000

Rp 30,000 Rp 40,000

Rp 100,000 Rp 120,000

Rp 50,000 Rp E0,000

Rp 400,000 Rp 500,000

Rp 00,000 Rp +00,000Rp 1,100,000 Rp 1,200,000

Rp 450,000 Rp E00,000

Rp 50,000 Rp 00,000

Rp 1,250,000 Rp 1,400,000

Rp E00,000 Rp +00,000

Rp +00,000 Rp 1,000,000

Rp 1,400,000 Rp 1,E00,000


54/142

TOTAL JUMLAH

Rp +0,000 Rp 100,000

Rp 120,000 Rp 150,000

Rp 1E0,000 Rp 200,000

Rp 350,000 Rp 400,000

Rp 120,000 Rp 150,000

Rp 1E0,000 Rp 200,000Rp 350,000 Rp 410,000

Rp 2E0,000 Rp 300,000

Rp 440,000 Rp 500,000

Rp E20,000 Rp 00,000

Rp +0,000 Rp 100,000


55/142

TOTAL JUMLAH

Rp +0,000 Rp 100,000

Rp +0,000 Rp 100,000

Rp +0,000 Rp 100,000

Rp +0,000 Rp 100,000

Rp +0,000 Rp 100,000

Rp +0,000 Rp 100,000

Rp +0,000 Rp 100,000

Rp 110,000 Rp 140,000

Rp 110,000 Rp 140,000Rp 110,000 Rp 140,000

Rp 110,000 Rp 140,000

Rp 110,000 Rp 140,000

Rp 110,000 Rp 140,000

Rp 110,000 Rp 140,000

Rp 110,000 Rp 140,000

Rp 150,000 Rp 10,000Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000


56/142

TOTAL JUMLAH

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 150,000 Rp 10,000

Rp 300,000 Rp 3E0,000

Rp 300,000 Rp 3E0,000

Rp 300,000 Rp 3E0,000

Rp 300,000 Rp 3E0,000

Rp 300,000 Rp 3E0,000

Rp 300,000 Rp 3E0,000

Rp 40,000 Rp 50,000

Rp E0,000 Rp 0,000


57/142

TOTAL JUMLAH

Rp 0,000 Rp 100,000

Rp 0,000 Rp 120,000

Rp E,000 Rp +,000

Rp E,000 Rp +,000

Rp E,000 Rp +,000

Rp 1E,000 Rp 20,000

Rp 1E,000 Rp 20,000Rp E,000 Rp +,000

Rp E,000 Rp +,000

Rp E,000 Rp +,000

Rp E,000 Rp 4,000

Rp E,000 Rp 4,000

Rp 34,000 Rp 40,000

Rp ,000 Rp ,000Rp ,000 Rp ,000

Rp ,000 Rp ,000

Rp ,000 Rp ,000


58/142

TOTAL JUMLAH

Rp 30,000 Rp 40,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp 1E,000 Rp 20,000

Rp 1E,000 Rp 20,000

Rp 2E,000 Rp 30,000

Rp 2E,000 Rp 30,000

Rp 2E,000 Rp 30,000

Rp 54,000 Rp E0,000

Rp 54,000 Rp E0,000Rp 54,000 Rp E0,000

Rp 54,000 Rp E0,000


59/142

TOTAL JUMLAH

Rp E0,000 Rp 0,000

Rp 1,+00,000 Rp 2,000,000

Rp 14,000 Rp 20,000

Rp ,000 Rp 10,000

Rp 1+,000 Rp 24,000

Rp 21,000 Rp 2,000

Rp 34,000 Rp 40,000Rp 1E,000 Rp 20,000

Rp 112,000 Rp 143,000


60/142

TOTAL JUMLAH

Rp 14,000 Rp 20,000

Rp ,000 Rp 10,000

Rp +,000 Rp 10,000

Rp 5,000 Rp E,000

Rp +0,000 Rp 110,000

Rp 1+,000 Rp 24,000

Rp 21,000 Rp 2,000

Rp 34,000 Rp 40,000

Rp 1E,000 Rp 20,000

Rp 205,000 Rp 2E,000

Rp 205,000 Rp 2E,000

Rp 1E,000 Rp 20,000

Rp 1E,000 Rp 20,000

Rp E,000 Rp +,000


61/142

TOTAL JUMLAH

Rp E,000 Rp +,000

Rp 1E,000 Rp 20,000

Rp 20,000 Rp 2+,000

Rp 100,000 Rp 120,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp 4,000 Rp 100,000

Rp E0,000 Rp 0,000

Rp +21,000 Rp E3,000

Rp 0,000 Rp 100,000


62/142

TOTAL JUMLAH

Rp E,000 Rp +,000

Rp 1E,000 Rp 20,000

Rp E,000 Rp +,000

Rp 34,000 Rp 40,000

Rp 54,000 Rp E0,000

Rp 54,000 Rp E0,000

Rp 1E,000 Rp 20,000

Rp 20,000 Rp 2+,000

Rp E,000 Rp +,000

Rp 30,000 Rp 40,000

Rp E0,000 Rp 0,000

Rp +0,000 Rp 110,000

Rp 24,000 Rp 2+,000

Rp 4E,000 Rp E00,000


63/142

TOTAL JUMLAH

Rp 24,000 Rp 30,000

Rp +,000 Rp 10,000

Rp 1E,000 Rp 20,000

Rp 1E,000 Rp 20,000

Rp 1E,000 Rp 20,000

Rp E4,000 Rp +0,000

Rp 5,000 Rp ,000

Rp 50,000 Rp E0,000

Rp 5,000 Rp ,000


64/142

TOTAL JUMLAH

Rp 12,000 Rp 15,000

Rp 1,000 Rp 1,500

Sebong, 28 Januari 2011

T Puskesmas Teluk Sebong

URNIANSYAH, SKM

19811208 200502 1 00

USULAN TARIF PELAYANAN KESEHATAN KARYAWAN / TANGGUNGAN PERU


KHUSUS KLINIK PARIWISATA LAGOI


65/142



TARIF

JASA PELAYANA

JASA MEDIS


1. Family Folder 1 set / KK Rp 1,000 Rp 1,000 Rp +,000

2. Kartu Indeks Berobat 1 lbr Rp 500 Rp " Rp 3,500

3. Kartu status 1 lbr Rp 500 Rp " Rp 500

4. K! 1 lbr Rp 500 Rp " Rp 4,500

B. RAWAT JALAN

1 POLI UMUM

" #emeriksaan dasar $ %bat dasar 1 & Rp 10,000 Rp 12,000 Rp 1+,000

2 POLI SPESIALIS

" #emeriksaan $ %bat dasar 1 & Rp 15,000 Rp 5,000 Rp 30,000

3 POLI KEBIDANAN

" '() 1 & Rp ,000 Rp 15,000 Rp E,000

PENDAPATAN

BLUD

BAHAN HABIS

PAKAI/SARANAPRASARANA


TARIF

JASA PELAYANAPENDAPATAN

BAHAN HABIS


66/142

JASA MEDISBLUDBAHAN HABIS

PAKAI/SARANA

PRASARANA

" #enimban*an Bayi 1 & Rp 1,500 Rp " Rp 1,500

" !untik KB 1 bulan 1 & Rp 24,000 Rp 12,000 Rp 24,000

" !untik KB 3 bulan 1 & Rp 15,000 Rp 12,000 Rp 1+,000" #asan* Implant 1 & Rp 45,000 Rp 5,000 Rp 0,000

" Buka Implant 1 & Rp 45,000 Rp 5,000 Rp 0,000

" Buka #asan* Implant 1 & Rp E0,000 Rp 120,000 Rp 120,000

" #asan* I- 1 & Rp 2,000 Rp 45,000 Rp 33,000

" Buka I- 1 & Rp 2,000 Rp 45,000 Rp 33,000

" Buka #asan* I- 1 & Rp 45,000 Rp 0,000 Rp 45,000

" Imunisasi ! 1 & Rp E,000 Rp 12,000 Rp 2,000

" Imunisasi )aten 1 &

" !untik Rp E,000 Rp 12,000 Rp 2,000

" #re* est Rp 15,000 Rp ,000 Rp 3E,000

" !urat Keteran*an Rp E,000 Rp E,000 Rp 1+,000

Rp 2,000 Rp 2,000 Rp +1,000

4 TINDAKAN MEDIK

4.1 POLI GIGI

a. #emeriksaan dan obat dasar 1 & Rp 10,000 Rp 12,000 Rp 1+,000

b. Konsultasi 1 & Rp 1,500 Rp 10,500 Rp 3,000

. !pulin* Betadine 1 & Rp E,000 Rp E,000 Rp 3,000


TARIF


BAHAN HABIS


67/142


PAKAI/SARANA

PRASARANA

d. &tratri

d.1. &o *i*i susu den*an ido 1 Bt* Rp 15,000 Rp 24,000 Rp 15,000

d.2. &o *i*i susu den*an ) 1 Bt* Rp 13,500 Rp 13,500 Rp ,000d.3. &o *i*i tetap 'nterior 1 Bt* Rp 21,000 Rp 30,000 Rp 1+,000

d.4. &o *i*i tetap #osterior 1 Bt* Rp 24,000 Rp 33,000 Rp 21,000


e.umpatan

e.1. umpatan !ementara 1 lb* Rp ,000 Rp E,000 Rp 15,000

e.2 umpatan etap

" 'mal*am

Kls I 1 lb* Rp 21,000 Rp 42,000 Rp 2,000

Kls II 1 lb* Rp 30,000 Rp 45,000 Rp 30,000

Kls 1 lb* Rp 21,000 Rp 42,000 Rp 2,000

" 6lass Ionomer

Kls I 1 lb* Rp 21,000 Rp 51,000 Rp 33,000

Kls II 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000

Kls III 1 lb* Rp 21,000 Rp 51,000 Rp 33,000

Kls I 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000

Kls 7 1 lb* Rp 21,000 Rp 51,000 Rp 33,000

" i*8t )ure

Kls I 1 lb* Rp 45,000 Rp +1,000 Rp 54,000

Kls II 1 lb* Rp E0,000 Rp ,000 Rp EE,000


TARIF


BAHAN HABIS


68/142


PAKAI/SARANA

PRASARANA

Kls III 1 lb* Rp 45,000 Rp +1,000 Rp 54,000

Kls I 1 lb* Rp E0,000 Rp ,000 Rp EE,000

Kls 1 lb* Rp 45,000 Rp +1,000 Rp 54,0009. #era:atan !aluran 'kar

9.1 %pen Bur

" *i*i anterior 1 & Rp 15,000 Rp 2,000 Rp 1+,000



" *i*i anterior 1 & Rp 30,000 Rp 3E,000 Rp 24,000


9.3 6anti %bat 1 & Rp 15,000 Rp 1+,000 Rp 12,000


" *i*i anterior 1 & Rp 30,000 Rp 3E,000 Rp 24,000


" *i*i anterior 1 & Rp 3E,000 Rp 42,000 Rp 2,000


*. #ulp )appin* 1 & Rp 15,000 Rp 2,000 Rp 1+,000

8. Bon*kar ambalan #ermanen 1 lb* Rp ,000 Rp 21,000 Rp 15,000

i. !allin*

i.1 1 ra8an* < R' / RB = 1 & Rp 45,000 Rp +1,000 Rp 54,000




TARIF


BLUDBAHAN HABIS


69/142

JASA MEDISBLUD PAKAI/SARANAPRASARANA

i.2 2 ra8an* < R' > RB = 1 & Rp 0,000 Rp 1E2,000 Rp 10+,000

?. Inisi 'bses

?.1 Intra %ral 1 & Rp 15,000 Rp 45,000 Rp 30,000 ?.2 &tra %ral 1 & Rp 30,000 Rp E3,000 Rp 42,000

k. perulektomi 1 re* Rp 45,000 Rp +1,000 Rp 54,000

l. 'l7eolektomi 1 re* Rp E0,000 Rp 10+,000 Rp 2,000

m.%dontektomi 1 bt* Rp 120,000 Rp 3E0,000 Rp 120,000

n. Kontrol pasa beda8 1 & Rp ,000 Rp 13,500 Rp ,500

o. Buka ?a8itan 1 & Rp ,000 Rp 13,500 Rp ,500


1. #emeriksaan dokter umum $ administrasi 1 & Rp E,000 Rp 30,000 Rp ,000

2. #emeriksaan dokter *i*i $ administrasi 1 & Rp E,000 Rp 30,000 Rp ,000

3. #emeriksaan dokter spesialis $ administrasi 1 & Rp 15,000 Rp E0,000 Rp 15,000

4. indakan edik 'nak

" Imunisasi 1 & Rp 15,000 Rp 12,000 Rp 33,000

" antau& est 1 & Rp 30,000 Rp E0,000 Rp 20,000

" Resusitasi 1 & Rp 30,000 Rp E0,000 Rp 45,000

" !irumsisi bayi perempuan 1 & Rp 15,000 Rp 45,000 Rp 30,000

" indik 1 & Rp 15,000 Rp 45,000 Rp 30,000



TARIF


BLUDBAHAN HABIS


70/142


" 6anti balutan @ 10 m 1 & Rp 15,000 Rp 15,000 Rp 15,000

" 6anti balutan A 10 m 1 & Rp 24,000 Rp 21,000 Rp 15,000

" a8it luka 5 ?a8itan pertama 1 & Rp 15,000 Rp 45,000 Rp 30,000


" Buka ?a8itan @ 5 ?a8itan 1 & Rp ,500 Rp 22,500 Rp 15,000



" !irkumsisi de:asa 1 & Rp 5,000 Rp 50,000 Rp 225,000

" !irkumsisi anak 1 & Rp 5,000 Rp E00,000 Rp 225,000

" #emasan*an ransel 7rband 1 & Rp 30,000 Rp 0,000 Rp 30,000


" Inisi abes 1 & Rp 15,000 Rp 30,000 Rp 30,000

" Imobilisasi d* spalk 1 & Rp 30,000 Rp 45,000 Rp 45,000

" ksplorasi luka 1 & Rp 15,000 Rp 45,000 Rp 30,000

" #era:atan uka 1 & Rp 12,000 Rp 24,000 Rp 24,000

" -ebridement luka bakar @ 20D 1 & Rp 15,000 Rp 45,000 Rp 45,000

" -ebridement luka bakar A 20D 1 & Rp 30,000 Rp E0,000 Rp E0,000

" Reposisi andibula 1 & Rp 15,000 Rp 5,000 Rp 45,000

" Bilas ambun* 1 & Rp 15,000 Rp 5,000 Rp 30,000

" Rendan Bokon* 1 & Rp E,000 Rp 15,000 Rp ,000

" #asan* Kateter 1 & Rp 15,000 Rp 30,000 Rp 30,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS


71/142



" !untikan 1&/8ari 1 & Rp 1,500 Rp 4,500 Rp 3,000" !untikan 2"5&/8ari 1 & Rp 3,000 Rp ,500 Rp 4,500

" #en*ambilan sampel dara8 1 & Rp 1,500 Rp ,500 Rp E,000

" #emasan*an In9us 1 & Rp 30,000 Rp 54,000 Rp 3E,000

" #enabutan In9us 1 & Rp 3,000 Rp ,000 Rp 3,000

" Klisma 1 & Rp ,500 Rp 22,500 Rp 15,000

" !ution/8ari 1 & Rp 15,000 Rp 45,000 Rp 30,000

" #emasan*an (6 1 & Rp 30,000 Rp 5,000 Rp 45,000




72/142


10. indakan edik G

" kstraksi serumen 1 & Rp 15,000 Rp 45,000 Rp 30,000

" ampon telin*a 1 & Rp 15,000 Rp 22,500 Rp 22,500" kstraksi orpus alienum di telin*a 1 & Rp 15,000 Rp 3,500 Rp 3,500

" #asan* tampon anterior 1 & Rp 15,000 Rp 30,000 Rp 30,000

" )abut tampon anterior 1 & Rp 15,000 Rp 30,000 Rp 30,000

" #asan* tampon posterior 1 & Rp 15,000 Rp 30,000 Rp 30,000

" )abut tampon posterior 1 & Rp 15,000 Rp 30,000 Rp 30,000

" BeloH tampon 1 & Rp 15,000 Rp 30,000 Rp 30,000

" kstraksi orpus alienum di 8idun* 1 & Rp 15,000 Rp 45,000 Rp 30,000

" indik


73/142


a. #artus normal

" Bidan 1 & Rp 150,000 Rp 450,000 Rp 150,000

" -okter mum 1 & Rp 150,000 Rp 50,000 Rp 300,000" -okter !pesialis 1 & Rp 150,000 Rp 1,200,000 Rp 450,000


" Bidan 1 & Rp 225,000 Rp 525,000 Rp 150,000

" -okter mum 1 & Rp 225,000 Rp +25,000 Rp 300,000


. #artus den*an penyulit

" Bidan 1 & Rp 300,000 Rp E00,000 Rp 300,000

" -okter mum 1 & Rp 300,000 Rp 00,000 Rp 300,000

" -okter !pesialis 1 & Rp 300,000 Rp 1,+00,000 Rp 300,000

d. pisiotomi

" 6rade I " III < Bidan = 1 & Rp 30,000 Rp 0,000 Rp 30,000

" 6rade I " III < -okter mum = 1 & Rp 45,000 Rp 135,000 Rp 45,000

" 6rade I " III < -okter !pesialis = 1 & Rp E0,000 Rp 1+0,000 Rp E0,000

" 6rade I < dokter !pesialis = 1 & Rp 5,000 Rp 450,000 Rp 5,000

e. ksplorasi a*ina


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA


74/142


" Bidan 1 & Rp 45,000 Rp 150,000 Rp 30,000

" -okter mum 1 & Rp E0,000 Rp 15,000 Rp 45,000

" -okter !pesialis 1 & Rp 0,000 Rp 450,000 Rp 5,000

9. anual plasenta

" Bidan 1 & Rp E0,000 Rp 330,000 Rp E0,000

" -okter mum 1 & Rp 0,000 Rp 50,000 Rp 0,000

" -okter !pesialis 1 & Rp 120,000 Rp +10,000 Rp 120,000


1 E!"#$%!'()

a. Radiolo*i

" 8ora& #' 1 & Rp 30,000 Rp 45,000 Rp 5,000

" 'bdomen #' 1 & Rp 30,000 Rp 45,000 Rp 5,000

" #el7is '# 1 & Rp 30,000 Rp 45,000 Rp 5,000

" )la7iula < -/! = '# 1 & Rp 30,000 Rp 45,000 Rp 5,000

" aters open mout8 #' 1 & Rp 30,000 Rp 45,000 Rp 5,000

" op ordoti


75/142

JASA MEDIS PAKAI/SARANAPRASARANA

" rist oint '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000

" lbo: oint '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000

" -i*iti '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000" 'ntebra8i '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000

" )alaneus '&ial " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000

" 'nkle oint '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000

" 6enu '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000

" 8ora& #' " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" )er7ial '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" !kull '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000" 8orakal '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" !inus :aters open mout8 " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" open " lose mout8 1 & Rp E0,000 Rp 5,000 Rp 150,000

" %s Gumerus '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" ert t8orao lumbal '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" ert lumbal '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" umbo saral '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" !arum '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" )oy& '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" Gip '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" Femur '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

C 2 posisi 2 ;lm


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA


76/142

JASA MEDIS PAKAI/SARANAPRASARANA

" )ruris '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" #edis '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000

" 'bdomen 3 posisi 1 & Rp 0,000 Rp 0,000 Rp 3E0,000

" )er7ial '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000

" 8orao umbal '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000

" 8oraal '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000

" umbal '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000

" umbo " !aral '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000

1 & Rp 15,000 Rp 15,000 Rp 45,000

. letroardio*ra; 1 & Rp 15,000 Rp 45,000 Rp 45,000d. !6

" anpa ;lm 1 & Rp 45,000 Rp E0,000 Rp 45,000

" -en*an ;lm 1 & Rp 45,000 Rp 5,000 Rp E0,000

2 La*%$a#%$(+

a. Gematolo*i

" Gematokrit 1 & Rp 3,000 Rp E,000 Rp 3,000

" Gb 1 & Rp 3,000 Rp E,000 Rp 3,000

" euoyt 1 & Rp 3,000 Rp E,000 Rp 3,000

" -iJ )ount / Gitun* enis 1 & Rp E,000 Rp 15,000 Rp ,000

" BB! / - 1 & Rp E,000 Rp 15,000 Rp ,000

" alaria 1 & Rp 3,000 Rp E,000 Rp 3,000

C 3 " 4 posisi 3 " 4 ;lm

C Intra %ral


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA


77/142

JPRASARANA

" rytroyt 1 & Rp 3,000 Rp E,000 Rp 3,000

" romboyt 1 & Rp 3,000 Rp E,000 Rp 3,000

" Bloodin* ime 1& Rp 3 Rp E,000 Rp 3,000" )8lot8in* ime 1& Rp 3 Rp E,000 Rp 3,000

" 6olon*an -ara8 1 & Rp ,000 Rp 15,000 Rp 3E,000

b. rine 'nalis

" #rotein 1 & Rp 3,000 Rp E,000 Rp 4,500

" Reduksi 1 & Rp 3,000 Rp E,000 Rp 4,500

" Bilirubin 1 & Rp 3,000 Rp E,000 Rp 4,500

" !edimen 1 & Rp 3,000 Rp E,000 Rp 4,500

" #re* est 1 & Rp 15,000 Rp ,000 Rp 3E,000" or;n 1 & Rp ,000 Rp 30,000 Rp 111,000

" G) / 6an?a 1 & Rp ,000 Rp 30,000 Rp 111,000

" 'm9etamine 1 & Rp ,000 Rp 30,000 Rp 111,000

" )oaine 1 & Rp ,000 Rp 30,000 Rp 111,000

" Benodiaepin 1 & Rp ,000 Rp 30,000 Rp 111,000

" %pium 1 & Rp ,000 Rp 30,000 Rp 111,000

. Faees

" akroskopis 1 & Rp E,000 Rp 15,000 Rp ,000

" ikroskopis 1 & Rp E,000 Rp 15,000 Rp ,000

d. ikrobilo*i

" B' 1 & Rp E,000 Rp 30,000 Rp ,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA


78/142

JPRASARANA

" !eret a*ina 1 & Rp E,000 Rp 30,000 Rp ,000

" K%G 1 & Rp E,000 Rp 30,000 Rp ,000

e. Kimia -ara8

" 6ula -ara8 1 & Rp ,000 Rp 12,000 Rp E,000

" )8olesterol 1 & Rp ,000 Rp 12,000 Rp E,000

" ri*liserid 1 & Rp ,000 Rp 12,000 Rp E,000

" ri 'id 1 & Rp ,000 Rp 12,000 Rp E,000

9. !erolo*i

" -en*ue est 1 & Rp 15,000 Rp 15,000 Rp 5,000


25D & tari9 dasar

D PELAYANAN MEDICOLEGAL

1 #emberian 9ormalin 1 & Rp 300,000 Rp 1,500,000 Rp 1,200,000

E MEDICAL CHECK UP

1 KIR Kese8atan Biasa

a. 'namnese > #emeriksaan Fisik

" #oli mum 1 & Rp ,000 Rp 15,000 Rp E,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA


79/142

PRASARANA

" #oli 6i*i 1 & Rp 1,500 Rp 10,500 Rp 3,000

b. aboratorium

" -ara8 rutin


80/142

PRASARANA


a. #emeriksaan medial standar 1 & Rp E,000 Rp 12E,000 Rp 1+1,500

b. aboratorium b.1 -ara8

" Gitun* enis 1 & Rp E,000 Rp 15,000 Rp ,000

" a?u ndap -ara8 1 & Rp E,000 Rp 15,000 Rp ,000

" Bloodin* ime


81/142

PRASARANA

. K6 1 & Rp 15,000 Rp 45,000 Rp 45,000

Rp 213,000 Rp 30,000 Rp +41,500

4 #emeriksaan edial )alon amaa8 Ga?i

a. 'namnese > pemeriksaan ;sik, ?i:a > Bart8el inde& 1 & Rp 15,000 Rp 0,000 Rp 45,000

b. #emeriksaan penun?an*

b.1 aboratorium

" -ara8

1 & Rp 3,000 Rp E,000 Rp 3,000

1 & Rp E,000 Rp 15,000 Rp ,000

1 & Rp 3,000 Rp E,000 Rp 3,000

1 & Rp ,000 Rp 15,000 Rp 3E,0001 & Rp ,000 Rp 12,000 Rp E,000

1 & Rp ,000 Rp 12,000 Rp E,000

" rine

1 & Rp E,000 Rp 15,000 Rp ,000

1 & Rp 12,000 Rp 12,000 Rp 1+,000

1 & Rp 3,000 Rp E,000 Rp 3,000

1 & Rp 15,000 Rp ,000 Rp 3E,000

b.2 K6 1 & Rp 15,000 Rp 45,000 Rp 45,000b.3 Radiolo*i


82/142

PRASARANA

F LAIN , LAIN

1 !urat Keteran*an

" Kela8iran 1 & Rp ,000 Rp ,000 Rp 2,000" !akit 1 & Rp 3,000 Rp 4,500 Rp ,500

" -ira:at 1 & Rp E,000 Rp ,000 Rp 15,000

" aik (aik #esa:at 1 & Rp E,000 Rp ,000 Rp 15,000

" Kematian 1 & Rp E,000 Rp ,000 Rp 15,000

2 'mbulane

1 & Rp 24,000 Rp 51,000 Rp 45,000

!elebi8nya/km 1 & Rp 3,000 Rp 3,E00 Rp 3,00

" uar #ulau

" belum termasuk biaya penyebran*an

" 2& tari9 dalam pulau

3 asa #etu*as #endampin* Ru?ukan

" -okter 1 &

Rp 15,000 Rp 5,000 Rp "

C !elebi8nya / km Rp 3,000 Rp ,500 Rp "

C uar pulau


83/142

PRASARANA

C !elebi8nya / km Rp 50 Rp 1,500 Rp

C uar pulau


84/142

TOTAL JUMLAH

Rp ,000 Rp 10,000

Rp 3,500 Rp 4,000

Rp 500 Rp 1,000

Rp 4,500 Rp 5,000

Rp 30,000 Rp 40,000

Rp 105,000 Rp 120,000

Rp 21,000 Rp 30,000

TOTAL JUMLAH


85/142

Rp 1,500 Rp 3,000

Rp 3E,000 Rp E0,000

Rp 30,000 Rp 45,000

Rp 1E5,000 Rp 210,000

Rp 1E5,000 Rp 210,000

Rp 240,000 Rp 300,000

Rp +,000 Rp 105,000

Rp +,000 Rp 105,000

Rp 135,000 Rp 1+0,000

Rp 3,000 Rp 45,000

Rp 3,000 Rp 45,000

Rp 45,000 Rp E0,000

Rp 24,000 Rp 30,000

Rp 10+,000 Rp 135,000

Rp 30,000 Rp 40,000

Rp 13,500 Rp 15,000

Rp ,000 Rp 15,000

TOTAL JUMLAH


86/142

Rp 3,000 Rp 54,000

Rp 22,500 Rp 3E,000

Rp 4+,000 Rp E,000

Rp 54,000 Rp +,000

Rp 5,000 Rp 105,000

Rp 21,000 Rp 30,000

Rp E,000 Rp 0,000

Rp 5,000 Rp 105,000

Rp E,000 Rp 0,000

Rp +4,000 Rp 105,000

Rp 0,000 Rp 120,000

Rp +4,000 Rp 105,000

Rp 0,000 Rp 120,000

Rp +4,000 Rp 105,000

Rp 135,000 Rp 1+0,000

Rp 1E5,000 Rp 225,000

TOTAL JUMLAH


87/142

Rp 135,000 Rp 1+0,000

Rp 1E5,000 Rp 225,000

Rp 135,000 Rp 1+0,000

Rp 45,000 Rp E0,000

Rp 54,000 Rp 5,000

Rp E0,000 Rp 0,000

Rp 5,000 Rp 120,000

Rp 30,000 Rp 45,000

Rp E0,000 Rp 0,000

Rp 5,000 Rp 120,000

Rp E,000 Rp 105,000

Rp +4,000 Rp 135,000

Rp 45,000 Rp E0,000Rp 3E,000 Rp 45,000

Rp 135,000 Rp 1+0,000

TOTAL JUMLAH


88/142

Rp 20,000 Rp 3E0,000

Rp 5,000 Rp 0,000

Rp 105,000 Rp 135,000

Rp 135,000 Rp 1+0,000

Rp 1+0,000 Rp 240,000

Rp 4+0,000 Rp E00,000

Rp 21,000 Rp 30,000

Rp 21,000 Rp 30,000

Rp 3,000 Rp 45,000

Rp 3,000 Rp 45,000

Rp 5,000 Rp 0,000

Rp 45,000 Rp E0,000

Rp 330,000 Rp 3E0,000

Rp 105,000 Rp 135,000

Rp 5,000 Rp 0,000Rp 5,000 Rp 0,000

TOTAL JUMLAH


89/142

Rp 30,000 Rp 45,000

Rp 3E,000 Rp E0,000

Rp 5,000 Rp 0,000

Rp E,000 Rp ,000

Rp 3,500 Rp 45,000

Rp 3,000 Rp 4,500

Rp 120,000 Rp 150,000

Rp 5,000 Rp 1,050,000

Rp +25,000 Rp 00,000

Rp 120,000 Rp 150,000

Rp 150,000 Rp 1+0,000

Rp E0,000 Rp 5,000

Rp 0,000 Rp 120,000

Rp 5,000 Rp 0,000

Rp 4+,000 Rp E0,000

Rp 0,000 Rp 105,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 135,000Rp 105,000 Rp 120,000

Rp 24,000 Rp 30,000

Rp E0,000 Rp 5,000

TOTAL JUMLAH


90/142

Rp ,500 Rp ,000

Rp 12,000 Rp 15,000

Rp 13,500 Rp 15,000

Rp 0,000 Rp 120,000

Rp 12,000 Rp 15,000

Rp 3,500 Rp 45,000

Rp 5,000 Rp 0,000

Rp 120,000 Rp 150,000

Rp 150,000 Rp 1+0,000

Rp 5,000 Rp 0,000

Rp E,500 Rp 0,000

Rp 45,000 Rp E0,000

Rp 22,500 Rp 30,000

Rp 45,000 Rp E0,000

Rp 45,000 Rp E0,000

TOTAL JUMLAH


91/142

Rp 5,000 Rp 0,000

Rp 45,000 Rp E0,000

Rp 5,000 Rp 0,000

Rp E0,000 Rp 5,000

Rp E0,000 Rp 5,000

Rp E0,000 Rp 5,000

Rp E0,000 Rp 5,000

Rp E0,000 Rp 5,000

Rp 5,000 Rp 0,000

Rp E0,000 Rp 5,000

Rp 135,000 Rp 150,000

Rp 1+0,000 Rp 210,000

Rp 210,000 Rp 255,000

Rp 45,000 Rp E0,000

Rp 150,000 Rp 1+0,000

Rp 5,000 Rp 0,000

TOTAL JUMLAH


92/142

Rp E00,000 Rp 50,000

Rp 1,050,000 Rp 1,200,000

Rp 1,E50,000 Rp 1,+00,000

Rp E5,000 Rp 00,000

Rp 1,125,000 Rp 1,350,000

Rp 1,+5,000 Rp 2,100,000

Rp 00,000 Rp 1,200,000

Rp 1,200,000 Rp 1,500,000

Rp 2,100,000 Rp 2,400,000

Rp 120,000 Rp 150,000

Rp 1+0,000 Rp 225,000

Rp 240,000 Rp 300,000

Rp 525,000 Rp E00,000

TOTAL JUMLAH

Rp 1+0 000 Rp 225 000


93/142

Rp 1+0,000 Rp 225,000

Rp 240,000 Rp 300,000

Rp 525,000 Rp E15,000

Rp 30,000 Rp 450,000

Rp EE0,000 Rp 50,000

Rp 30,000 Rp 1,050,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 150,000

Rp 120,000 Rp 150,000

Rp 1E5,000 Rp 210,000

TOTAL JUMLAH

Rp 1E5 000 Rp 210 000


94/142

Rp 1E5,000 Rp 210,000

Rp 1E5,000 Rp 210,000

Rp 1E5,000 Rp 210,000

Rp 1E5,000 Rp 210,000

Rp 1E5,000 Rp 210,000

Rp 1E5,000 Rp 210,000

Rp 1E5,000 Rp 210,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

TOTAL JUMLAH

Rp 225 000 Rp 2+5 000


95/142

Rp 225,000 Rp 2+5,000

Rp 225,000 Rp 2+5,000

Rp 450,000 Rp 540,000

Rp 450,000 Rp 540,000

Rp 450,000 Rp 540,000

Rp 450,000 Rp 540,000

Rp 450,000 Rp 540,000

Rp 450,000 Rp 540,000

Rp E0,000 Rp 5,000

Rp 0,000 Rp 105,000

Rp 105,000 Rp 150,000

Rp 135,000 Rp 1+0,000

Rp ,000 Rp 12,000

Rp ,000 Rp 12,000

Rp ,000 Rp 12,000

Rp 24,000 Rp 30,000

Rp 24,000 Rp 30,000

Rp ,000 Rp 12,000

TOTAL JUMLAH

Rp ,000 Rp 12,000


96/142

Rp ,000 Rp 12,000

Rp ,000 Rp 12,000

Rp ,000 Rp 4,000

Rp ,000 Rp 4,000

Rp 51,000 Rp E0,000

Rp 10,500 Rp 13,500

Rp 10,500 Rp 13,500

Rp 10,500 Rp 13,500

Rp 10,500 Rp 13,500

Rp 45,000 Rp E0,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

Rp 24,000 Rp 30,000

Rp 24,000 Rp 30,000

Rp 3,000 Rp 45,000

TOTAL JUMLAH

Rp 3,000 Rp 45,000


97/142

p , p ,

Rp 3,000 Rp 45,000

Rp +1,000 Rp 0,000

Rp +1,000 Rp 0,000

Rp +1,000 Rp 0,000

Rp +1,000 Rp 0,000

Rp 0,000 Rp 105,000

Rp 2,00,000 Rp 3,000,000

Rp 21,000 Rp 30,000

TOTAL JUMLAH

Rp 13,500 Rp 15,000


98/142

p p

Rp 2,000 Rp 3E,000

Rp 31,500 Rp 43,500

Rp 51,000 Rp E0,000

Rp 24,000 Rp 30,000

Rp 1E+,000 Rp 214,500

Rp 21,000 Rp 30,000

Rp 13,500 Rp 15,000

Rp 12,000 Rp 15,000

Rp ,500 Rp ,000

Rp 120,000 Rp 1E5,000

Rp 2,000 Rp 3E,000

Rp 31,500 Rp 43,500

Rp 51,000 Rp E0,000

Rp 24,000 Rp 30,000

Rp 30,500 Rp 403,500

TOTAL JUMLAH


99/142

Rp 30,500 Rp 403,500

Rp 24,000 Rp 30,000

Rp 24,000 Rp 30,000

Rp ,000 Rp 12,000

Rp ,000 Rp 12,000

Rp 24,000 Rp 30,000

Rp 30,000 Rp 42,000

Rp 150,000 Rp 1+0,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

Rp 141,000 Rp 150,000

TOTAL JUMLAH

Rp 0,000 Rp 105,000


100/142

Rp 1,231,500 Rp 1,444,500

Rp 135,000 Rp 150,000

Rp ,000 Rp 12,000

Rp 24,000 Rp 30,000

Rp ,000 Rp 12,000

Rp 51,000 Rp E0,000

Rp +1,000 Rp 0,000

Rp +1,000 Rp 0,000

Rp 24,000 Rp 30,000

Rp 30,000 Rp 42,000

Rp ,000 Rp 12,000

Rp 45,000 Rp E0,000

Rp 0,000 Rp 105,000

Rp 120,000 Rp 1E5,000

Rp 3E,000 Rp 42,000

Rp 44,000 Rp 00,000

TOTAL JUMLAH


101/142

Rp 3E,000 Rp 45,000

Rp 12,000 Rp 15,000

Rp 24,000 Rp 30,000

Rp 24,000 Rp 30,000

Rp 24,000 Rp 30,000

Rp E,000 Rp 120,000

Rp ,500 Rp 10,500

Rp 5,000 Rp 0,000

Rp ,500 Rp 10,500

Rp 1+,000 Rp 22,500

TOTAL JUMLAH

Rp 1,500 Rp 2,250


102/142

2011

k !ebon*

00

USULAN TARIF PELAYANAN KESEHATAN WARGA NEGARA ASING 0WN



TARIF


103/142

NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN JASA PELAYANA

JASA MEDIS


1. Family Folder 1 set / KK Rp 2,000 Rp 2,000 Rp 1E,000

2. Kartu Indeks Berobat 1 lbr Rp 1,000 Rp " Rp ,000

3. Kartu status 1 lbr Rp 1,000 Rp " Rp 1,000

4. K! 1 lbr Rp 1,000 Rp " Rp ,000

B. RAWAT JALAN

1 POLI UMUM

" #emeriksaan dasar $ %bat dasar 1 & Rp E,000 Rp 110,000 Rp 44,000

2 POLI SPESIALIS

" #emeriksaan $ %bat dasar 1 & Rp 1E0,000 Rp 500,000 Rp 220,000

3 POLI KEBIDANAN

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" '() 1 & Rp E,000 Rp 100,000 Rp 44,000


104/142

p , p , p ,

" #enimban*an Bayi 1 & Rp 1E,000 Rp " Rp 11,000

" !untik KB 1 bulan 1 & Rp 25E,000 Rp +0,000 Rp 1E,000" !untik KB 3 bulan 1 & Rp 1E0,000 Rp +0,000 Rp 132,000

" #asan* Implant 1 & Rp 4+0,000 Rp 500,000 Rp EE0,000

" Buka Implant 1 & Rp 4+0,000 Rp 500,000 Rp EE0,000

" Buka #asan* Implant 1 & Rp E40,000 Rp +00,000 Rp ++0,000

" #asan* I- 1 & Rp 2++,000 Rp 300,000 Rp 242,000

" Buka I- 1 & Rp 2++,000 Rp 300,000 Rp 242,000

" Buka #asan* I- 1 & Rp 4+0,000 Rp E00,000 Rp 330,000

" Imunisasi ! 1 & Rp E4,000 Rp +0,000 Rp 1+,000" Imunisasi )aten 1 &

" !untik Rp E4,000 Rp +0,000 Rp 1+,000

" #re* est Rp 1E0,000 Rp E0,000 Rp 2E4,000

" !urat Keteran*an Rp E4,000 Rp 40,000 Rp 132,000

Rp 2++,000 Rp 1+0,000 Rp 54,000

4 TINDAKAN MEDIK

4.1 POLI GIGI

a. #emeriksaan dan obat dasar 1 & Rp E,000 Rp 100,000 Rp 44,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

b. Konsultasi 1 & Rp 1E,000 Rp 0,000 Rp 22,000


105/142

p p p

. !pulin* Betadine 1 & Rp E4,000 Rp 40,000 Rp 22,000

d. &tratri d.1. &o *i*i susu den*an ido 1 Bt* Rp 1E0,000 Rp 1E0,000 Rp 110,000

d.2. &o *i*i susu den*an ) 1 Bt* Rp 144,000 Rp 0,000 Rp EE,000

d.3. &o *i*i tetap 'nterior 1 Bt* Rp 224,000 Rp 200,000 Rp 132,000

d.4. &o *i*i tetap #osterior 1 Bt* Rp 25E,000 Rp 220,000 Rp 154,000


e.umpatan

e.1. umpatan !ementara 1 lb* Rp E,000 Rp 40,000 Rp 110,000

e.2 umpatan etap " 'mal*am

Kls I 1 lb* Rp 224,000 Rp 2+0,000 Rp 1+,000

Kls II 1 lb* Rp 320,000 Rp 300,000 Rp 220,000

Kls 1 lb* Rp 224,000 Rp 2+0,000 Rp 1+,000

" 6lass Ionomer

Kls I 1 lb* Rp 224,000 Rp 340,000 Rp 242,000

Kls II 1 lb* Rp 320,000 Rp 3E0,000 Rp 2E4,000

Kls III 1 lb* Rp 224,000 Rp 340,000 Rp 242,000

Kls I 1 lb* Rp 320,000 Rp 3E0,000 Rp 2E4,000

Kls 7 1 lb* Rp 224,000 Rp 340,000 Rp 242,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" i*8t )ure


106/142

Kls I 1 lb* Rp 4+0,000 Rp 540,000 Rp 3E,000

Kls II 1 lb* Rp E40,000 Rp EE0,000 Rp 4+4,000

Kls III 1 lb* Rp 4+0,000 Rp 540,000 Rp 3E,000

Kls I 1 lb* Rp E40,000 Rp EE0,000 Rp 4+4,000

Kls 1 lb* Rp 4+0,000 Rp 540,000 Rp 3E,000


9.1 %pen Bur

" *i*i anterior 1 & Rp 1E0,000 Rp 1+0,000 Rp 132,000


9.2 &tirpasi, reamin*, ;llin* " *i*i anterior 1 & Rp 320,000 Rp 240,000 Rp 1E,000

" *i*i posterior 1 & Rp 4+0,000 Rp 300,000 Rp 220,000

9.3 6anti %bat 1 & Rp 1E0,000 Rp 120,000 Rp ++,000



" *i*i posterior 1 & Rp 4+0,000 Rp 300,000 Rp 220,000

" *i*i anterior 1 & Rp 3+4,000 Rp 2+0,000 Rp 1+,000





TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

*. #ulp )appin* 1 & Rp 1E0,000 Rp 1+0,000 Rp 132,000


107/142

8. Bon*kar ambalan #ermanen 1 lb* Rp E,000 Rp 140,000 Rp 110,000

i. !allin*

i.1 1 ra8an* < R' / RB = 1 & Rp 4+0,000 Rp 540,000 Rp 3E,000

i.2 2 ra8an* < R' > RB = 1 & Rp E0,000 Rp 1,0+0,000 Rp 2,000

?. Inisi 'bses

?.1 Intra %ral 1 & Rp 1E0,000 Rp 300,000 Rp 220,000

?.2 &tra %ral 1 & Rp 320,000 Rp 420,000 Rp 30+,000

k. perulektomi 1 re* Rp 4+0,000 Rp 540,000 Rp 3E,000

l. 'l7eolektomi 1 re* Rp E40,000 Rp 20,000 Rp 52+,000

m.%dontektomi 1 bt* Rp 1,2+0,000 Rp 2,400,000 Rp ++0,000n. Kontrol pasa beda8 1 & Rp E,000 Rp 0,000 Rp 55,000

o. Buka ?a8itan 1 & Rp E,000 Rp 0,000 Rp 55,000


1. #emeriksaan dokter umum $ administrasi 1 & Rp E4,000 Rp 200,000 Rp EE,000

2. #emeriksaan dokter *i*i $ administrasi 1 & Rp E4,000 Rp 200,000 Rp EE,000

3. #emeriksaan dokter spesialis $ administrasi 1 & Rp 1E0,000 Rp 400,000 Rp 110,000

4. indakan edik 'nak " Imunisasi 1 & Rp 1E0,000 Rp +0,000 Rp 242,000

" antau& est 1 & Rp 320,000 Rp 400,000 Rp 1,+0,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" Resusitasi 1 & Rp 320,000 Rp 400,000 Rp 330,000


108/142

" !irumsisi bayi perempuan 1 & Rp 1E0,000 Rp 300,000 Rp 220,000

" indik 1 & Rp 1E0,000 Rp 300,000 Rp 220,000


" 6anti balutan @ 10 m 1 & Rp E0,000 Rp 100,000 Rp 110,000

" 6anti balutan A 10 m 1 & Rp E,000 Rp 140,000 Rp 110,000

" a8it luka

5 ?a8itan pertama 1 & Rp 1E0,000 Rp 300,000 Rp 220,000


" Buka ?a8itan @ 5 ?a8itan 1 & Rp +0,000 Rp 150,000 Rp 110,000!elan?utnya pen?a8itan 1 & Rp 1E,000 Rp 10,000 Rp 11,000


" !irkumsisi de:asa 1 & Rp +00,000 Rp 5,000,000 Rp 1,E50,000

" !irkumsisi anak 1 & Rp +00,000 Rp 4,000,000 Rp 1,E50,000

" #emasan*an ransel 7rband 1 & Rp 320,000 Rp E00,000 Rp 220,000


" Inisi abes 1 & Rp 1E0,000 Rp 200,000 Rp 220,000

" Imobilisasi d* spalk 1 & Rp 320,000 Rp 300,000 Rp 330,000" ksplorasi luka 1 & Rp 1E0,000 Rp 300,000 Rp 220,000

" #era:atan uka 1 & Rp 12+,000 Rp 1E0,000 Rp 1E,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" -ebridement luka bakar @ 20D 1 & Rp 1E0,000 Rp 300,000 Rp 330,000


109/142

" -ebridement luka bakar A 20D 1 & Rp 320,000 Rp 400,000 Rp 440,000

" Reposisi andibula 1 & Rp 1E0,000 Rp 500,000 Rp 330,000

" Bilas ambun* 1 & Rp 1E0,000 Rp 500,000 Rp 220,000

" Rendan Bokon* 1 & Rp E4,000 Rp 100,000 Rp EE,000

" #asan* Kateter 1 & Rp 1E0,000 Rp 200,000 Rp 220,000


" !untikan 1&/8ari 1 & Rp 1E,000 Rp 30,000 Rp 22,000

" !untikan 2"5&/8ari 1 & Rp 32,000 Rp 50,000 Rp 33,000

" #en*ambilan sampel dara8 1 & Rp 1E,000 Rp 50,000 Rp 44,000" #emasan*an In9us 1 & Rp 320,000 Rp 3E0,000 Rp 2E4,000

" #enabutan In9us 1 & Rp 32,000 Rp E0,000 Rp 22,000

" Klisma 1 & Rp +0,000 Rp 150,000 Rp 110,000

" !ution/8ari 1 & Rp 1E0,000 Rp 300,000 Rp 220,000

" #emasan*an (6 1 & Rp 320,000 Rp 500,000 Rp 330,000




110/142

" est is8i8ara 1 & Rp +0,000 Rp 50,000 Rp 110,000

" 6anti erband mata 1 & Rp 1E0,000 Rp 150,000 Rp 1E5,000

. indakan edik #aru

" In8alasi/(ebulier 1 & Rp 1E0,000 Rp 100,000 Rp 220,000

10. indakan edik G

" kstraksi serumen 1 & Rp 1E0,000 Rp 300,000 Rp 220,000

" ampon telin*a 1 & Rp 1E0,000 Rp 150,000 Rp 1E5,000

" kstraksi orpus alienum di telin*a 1 & Rp 1E0,000 Rp 250,000 Rp 25,000" #asan* tampon anterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000

" )abut tampon anterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000

" #asan* tampon posterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000

" )abut tampon posterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000

" BeloH tampon 1 & Rp 1E0,000 Rp 200,000 Rp 220,000

" kstraksi orpus alienum di 8idun* 1 & Rp 1E0,000 Rp 300,000 Rp 220,000

" indik


111/142

" #apiloma 1 & Rp 4+0,000 Rp 00,000 Rp 550,000

" ar7a mi*ran 1 & Rp 1E0,000 Rp 200,000 Rp 110,000

12. Keraunan 1 & Rp 320,000 Rp 400,000 Rp EE0,000

13. -i*i*it Binatan* 1 & Rp 1E0,000 Rp 300,000 Rp 220,000

4.3 TINDAKAN KEBIDANAN

a. #artus normal

" Bidan 1 & Rp 1,E00,000 Rp 3,000,000 Rp 1,100,000

" -okter mum 1 & Rp 1,E00,000 Rp 5,000,000 Rp 2,200,000" -okter !pesialis 1 & Rp 1,E00,000 Rp +,000,000 Rp 3,300,000


" Bidan 1 & Rp 2,400,000 Rp 3,500,000 Rp 1,100,000

" -okter mum 1 & Rp 2,400,000 Rp 5,500,000 Rp 2,200,000

" -okter !pesialis 1 & Rp 2,400,000 Rp 10,000,000 Rp 2,50,000

. #artus den*an penyulit " Bidan 1 & Rp 3,200,000 Rp 4,000,000 Rp 2,200,000

" -okter mum 1 & Rp 3,200,000 Rp E,000,000 Rp 2,200,000


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" -okter !pesialis 1 & Rp 3,200,000 Rp 12,000,000 Rp 2,200,000


112/142

d. pisiotomi

" 6rade I " III < Bidan = 1 & Rp 320,000 Rp E00,000 Rp 220,000

" 6rade I " III < -okter mum = 1 & Rp 4+0,000 Rp 00,000 Rp 330,000

" 6rade I " III < -okter !pesialis = 1 & Rp E40,000 Rp 1,200,000 Rp 440,000

" 6rade I < dokter !pesialis = 1 & Rp +00,000 Rp 3,000,000 Rp 550,000

e. ksplorasi a*ina

" Bidan 1 & Rp 4+0,000 Rp 1,000,000 Rp 220,000

" -okter mum 1 & Rp E40,000 Rp 1,300,000 Rp 330,000" -okter !pesialis 1 & Rp E0,000 Rp 3,000,000 Rp 550,000

9. anual plasenta

" Bidan 1 & Rp E40,000 Rp 2,200,000 Rp 440,000

" -okter mum 1 & Rp E0,000 Rp 3,+00,000 Rp EE0,000

" -okter !pesialis 1 & Rp 1,2+0,000 Rp 5,400,000 Rp ++0,000


1 E!"#$%!'() a. Radiolo*i

C 1 posisi 1 ;lm


TARIF

JASA PELAYANA

JASA MEDIS

PENDAPATANBLUD

BAHAN HABIS

PAKAI/SARANA

PRASARANA

" 8ora& #' 1 & Rp 320,000 Rp 300,000 Rp 550,000

'bdomen #' 1 & Rp 320 000 Rp 300 000 Rp 550 000


113/142

" 'bdomen #' 1 & Rp 320,000 Rp 300,000 Rp 550,000

" #el7is '# 1 & Rp 320,000

usulan tarif blud

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