LAMPIRAN I : PERATURAN DAERAH KABUPATEN KULON PROGO NOMOR 4 TAHUN 2012 TENTANG RETRIBUSI PELAYANAN KESEHATAN PADA UNIT PELAKSANA TEKNIS DINAS KESEHATAN KABUPATEN KULON PROGO RETRIBUSI PELAYANAN KESEHATAN PADA UPTD PUSKESMAS BIAYA LANGSUNG
NO
1 A. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
JENIS PELAYANAN
KARTU PASIEN DAN REKAM MEDIS
2 3 PEMERIKSAAN DAN TINDAKAN DI KLINIK UMUM DASAR Rawat Jalan Umum 1,000.00 Keur Dokter 1,000.00 Pemeriksaan Caten 1,000.00 Perawatan luka sobek 1,000.00 Jahit luka 4 jahitan 1,000.00 Jahit luka 5-10 jahitan 1,000.00 Jahit luka >10 jahitan 1,000.00 Perawatan luka bakar < 10 % 1,000.00 Perawatan luka bakar 10-20% 1,000.00 Incisi/Eksisi 1,000.00 Gigitan Binatang 1,000.00 Exterpasi Nail 1,000.00 Dawir kanan/kiri 1,000.00 ATS 1,000.00 Hordeolum / Chalazion 1,000.00 Cerumen Prop 1,000.00 Ekstraksi Corpus Alienum Mata 1,000.00 Corpus Alienum pada Telinga 1,000.00 Corpus Alienum pada Hidung 1,000.00 Pasang Kateter 1,000.00 Lepas Jahitan 1,000.00
BAHAN MEDIS HABIS PAKAI
OBAT
AKOMODASI
4
5
6
0.00 0.00 0.00 3,900.00 17,950.00 29,450.00 43,550.00 28,200.00 75,600.00 15,300.00 1,100.00 20,450.00 19,150.00 34,550.00 11,150.00 1,250.00 12,100.00 3,100.00 3,100.00 20,400.00 1,750.00
4,500.00 0.00 0.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
BIAYA TIDAK LANGSUNG (ADMINISTRASI KANTOR, LISTRIK, AIR TELEPON, BAHAN BAKAR, PEMELIHARAAN PRASARANA DAN SARANA KESEHATAN
JASA PELAYANAN (Rp.)
7
8
3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
2,000.00 5,000.00 5,000.00 5,000.00 10,000.00 15,000.00 20,000.00 10,000.00 15,000.00 15,000.00 10,000.00 15,000.00 25,000.00 5,000.00 10,000.00 10,000.00 10,000.00 10,000.00 10,000.00 15,000.00 5,000.00
TARIP SUBSIDI TARIP RETRIBUSI WARGA RETRIBUSI (Rp.) DAERAH (Rp.) WARGA (Rp.)
9
10,750.00 9,250.00 9,250.00 17,650.00 36,700.00 53,200.00 72,300.00 46,950.00 99,350.00 39,050.00 19,850.00 44,200.00 52,900.00 48,300.00 29,900.00 20,000.00 30,850.00 21,850.00 21,850.00 44,150.00 15,500.00
10
4,500.00 0.00 0.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00
11
6,250.00 9,250.00 9,250.00 13,150.00 32,200.00 48,700.00 67,800.00 42,450.00 94,850.00 34,550.00 15,350.00 39,700.00 48,400.00 43,800.00 25,400.00 15,500.00 26,350.00 17,350.00 17,350.00 39,650.00 11,000.00
1 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
2 Ganti Verban Pasang Infus Lepas infus Perbaikan infus Ganti cairan infus Injeksi (tindakan terpisah) Corpal di kulit Pemberian oksigen / hari Perawatan luka DM (nekrotik) Semprot cutaneus larva Lepas kateter Pemasangan slang NGT Bilas lambung Lepas slang NGT Injeksi ABU (Anti Bisa Ular) Pemberian Nebulizer Irigasi telinga Irigasi mata Tampon hidung Pemasangan bidai Pemasangan gipspalk Pemberian obat melalui anus Rectal Toucher Operasi tumor jinak
3 1,000.00 1,000.00 1,000.00 1,000.00 0.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
46 47 48 49 50 51 52
PENGEMBANGAN Imobilisasi Dislokasi Sederhana Circumsisi Visum luar di Puskesmas Visum luar di TKP Infra red (fisio therapy) Treadmill Pemeriksaan spirometri/spiroanalyzer
1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
62,400.00 31,600.00 3,700.00 3,700.00 2,000.00 0.00 1,000.00
53 54 55 56 57 58 59 60 61
PEMERIKSAAN DAN TINDAKAN DI KLINIK IBU DAN ANAK DASAR Pemeriksaan KIA 1,000.00 KB Suntik 1,000.00 KB Pil 1,000.00 KB IUD 1,000.00 Pelepasan IUD 1,000.00 Pelepasan IUD dg penyulit 1,000.00 Pemasangan Implant 1,000.00 Pelepasan Implant 1,000.00 Jahit Luka Perineum 1,000.00
550.00 7,700.00 5,400.00 5,400.00 15,000.00 15,000.00 10,550.00 15,950.00 28,800.00
B.
4 5 3,300.00 4,500.00 34,900.00 4,500.00 6,000.00 0.00 5,000.00 0.00 0.00 7,000.00 2,500.00 3,000.00 2,500.00 3,000.00 17,500.00 14,400.00 18,000.00 4,500.00 55,000.00 4,500.00 7,000.00 4,500.00 21,000.00 0.00 21,000.00 4,500.00 5,000.00 0.00 5,000.00 49,500.00 15,000.00 4,500.00 8,000.00 4,500.00 12,000.00 4,500.00 6,000.00 4,500.00 20,000.00 4,500.00 107,000.00 4,500.00 4,000.00 39,500.00 4,200.00 0.00 33,350.00 4,500.00
6 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
7 3,250.00 3,250.00 0.00 3,250.00 0.00 0.00 0.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
8 5,000.00 10,000.00 5,000.00 5,000.00 1,000.00 1,500.00 1,500.00 5,000.00 10,000.00 5,000.00 5,000.00 15,000.00 15,000.00 5,000.00 5,000.00 5,000.00 5,000.00 5,000.00 5,000.00 5,000.00 10,000.00 5,000.00 15,000.00 20,000.00
9 17,050.00 53,650.00 12,000.00 14,250.00 8,000.00 8,000.00 8,000.00 41,150.00 36,750.00 68,750.00 20,750.00 40,250.00 44,750.00 14,250.00 63,750.00 28,750.00 21,750.00 25,750.00 19,750.00 33,750.00 125,750.00 52,750.00 23,450.00 62,100.00
10 4,500.00 4,500.00 0.00 0.00 7,000.00 3,000.00 3,000.00 14,400.00 4,500.00 4,500.00 4,500.00 0.00 4,500.00 0.00 49,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 39,500.00 0.00 4,500.00
11 12,550.00 49,150.00 12,000.00 14,250.00 1,000.00 5,000.00 5,000.00 26,750.00 32,250.00 64,250.00 16,250.00 40,250.00 40,250.00 14,250.00 14,250.00 24,250.00 17,250.00 21,250.00 15,250.00 29,250.00 121,250.00 13,250.00 23,450.00 57,600.00
0.00 4,500.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00
3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 10,000.00 3,250.00
20,000.00 30,000.00 15,000.00 30,000.00 5,000.00 5,000.00 5,000.00
86,650.00 70,350.00 22,950.00 37,950.00 11,250.00 16,000.00 10,250.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00
86,650.00 70,350.00 22,950.00 37,950.00 11,250.00 16,000.00 10,250.00
4,500.00 0.00 0.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
2,000.00 6,300.00 2,000.00 15,000.00 15,000.00 25,000.00 30,000.00 50,000.00 40,000.00
11,300.00 18,250.00 11,650.00 29,150.00 38,750.00 48,750.00 49,300.00 74,700.00 77,550.00
4,500.00 0.00 0.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00
6,800.00 18,250.00 11,650.00 24,650.00 34,250.00 44,250.00 44,800.00 70,200.00 73,050.00
1 62 63 64 65 66 67 68 69 70
2 Evakuasi Manual Placenta Tindik Telinga Kontrol nifas Kontrol IUD Kontrol implant Pemeriksaan IVA Kontrol MOW Pemeriksaan gynaecology Pemeriksaan doppler
3 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
4 43,550.00 2,100.00 1,000.00 1,000.00 1,000.00 2,500.00 4,000.00 5,000.00 2,000.00
5 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 0.00 4,500.00
1,000.00 1,000.00 1,000.00
43,550.00 5,000.00 7,500.00
74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89
PEMERIKSAAN DAN TINDAKAN DI KLINIK GIGI DASAR Pemeriksaan Gigi Premedikasi Ekstraksi gigi anak Ekstr. gigi anak dg komplikasi Ekstraksi gigi dewasa Ekstr. gigi dewasa dg komplikasi Tambalan amalgam Tambalan Glass Ionomer Perawatan Pulpa Capping Perawatan Syaraf A Perawatan Syaraf B Perawatan Syaraf C Incisi Abses Operculektomi Koreksi Oklusi Ekstrasi gigi dewasa dengan injeksi intra septal
1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
90 91 92 93 94 95 96 97
PENGEMBANGAN Scaling Karang Gigi/regio Operasi Gigi Tambalan sinar Light Curing Scaling OHIS Ringan Scaling OHIS Sedang Scaling OHISBerat Protesa gigi lepasan 1 gigi pertama Tambahan 1 gigi berikutnya
1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
PENGEMBANGAN 71 Kuretase aspirasi vaum manual 72 Fototherapy 73 Pemakaian inkubator C.
6 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
7 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
8 50,000.00 2,500.00 3,000.00 3,000.00 3,000.00 5,000.00 5,000.00 7,500.00 2,000.00
9 102,300.00 13,350.00 12,750.00 12,750.00 12,750.00 16,250.00 17,750.00 16,750.00 12,750.00
10 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 0.00 4,500.00
11 97,800.00 8,850.00 8,250.00 8,250.00 8,250.00 11,750.00 13,250.00 16,750.00 8,250.00
4,500.00 0.00 0.00
0.00 0.00 0.00
3,250.00 10,000.00 10,000.00
75,000.00 10,000.00 5,000.00
127,300.00 26,000.00 23,500.00
0.00 0.00 0.00
127,300.00 26,000.00 23,500.00
0.00 1,200.00 2,650.00 3,250.00 2,950.00 7,250.00 10,200.00 11,050.00 2,150.00 5,750.00 4,450.00 6,100.00 9,600.00 7,900.00 3,850.00 10,500.00
0.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 0.00 0.00 0.00 0.00 0.00 0.00 4,500.00 4,500.00 0.00 4,500.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
2,000.00 2,000.00 3,000.00 5,000.00 10,000.00 20,000.00 5,000.00 5,000.00 6,000.00 5,000.00 5,000.00 7,000.00 10,000.00 10,000.00 5,000.00 10,000.00
6,250.00 11,950.00 14,400.00 17,000.00 21,700.00 36,000.00 19,450.00 20,300.00 12,400.00 15,000.00 13,700.00 17,350.00 28,350.00 26,650.00 13,100.00 29,250.00
0.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00 0.00 0.00 0.00 0.00 0.00 0.00 4,500.00 4,500.00 0.00 4,500.00
6,250.00 7,450.00 9,900.00 12,500.00 17,200.00 31,500.00 19,450.00 20,300.00 12,400.00 15,000.00 13,700.00 17,350.00 23,850.00 22,150.00 13,100.00 24,750.00
4,000.00 30,350.00 35,400.00 10,900.00 15,900.00 20,900.00 75,000.00 30,000.00
0.00 4,500.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
7,500.00 30,000.00 10,000.00 7,500.00 7,500.00 7,500.00 30,000.00 10,000.00
15,750.00 69,100.00 49,650.00 22,650.00 27,650.00 32,650.00 109,250.00 44,250.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
15,750.00 69,100.00 49,650.00 22,650.00 27,650.00 32,650.00 109,250.00 44,250.00
1 D.
2
PELAYANAN DI KLINIK KONSULTASI 98 Konsultasi dokter/dokter gigi 99 Konsultasi sanitasi/gizi/KIA
E. 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134
PENUNJANG DIAGNOSTIK DASAR LED HB LEUKOSIT ERITROSIT HITUNG JENIS TROMBOCIT HEMATOKRIT GOLONGAN DARAH MALARIA PH / BJ / Protein/Uro/Bilirubin SEDIMEN URINE FAECES LENGKAP WIDAL PP TES GULA DARAH BTA NEISSERIA CLOTING TIME BLEEDING TIME Darah Rutin Manual (5 parameter) Darah lengkap Manual (17 parameter) Darah lengkap Automatik Kreatinin Ureum HDL Kholesterol LDL Kholesterol SGOT SGPT Bilirubin Total Bilirubin Direct AMPHETAMIN BENZODIASEPHINE Jamur Protein Total Albumin
3
4
5
6
7
8
9
10
11
1,000.00 1,000.00
0.00 0.00
0.00 0.00
0.00 0.00
0.00 0.00
2,000.00 1,500.00
3,000.00 2,500.00
0.00 0.00
3,000.00 2,500.00
1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
2,650.00 950.00 1,200.00 1,100.00 2,350.00 2,000.00 1,550.00 1,750.00 2,200.00 4,800.00 850.00 1,250.00 8,450.00 7,600.00 7,900.00 2,500.00 4,150.00 2,050.00 700.00 12,850.00 17,000.00 29,450.00 12,300.00 12,300.00 11,850.00 11,850.00 12,650.00 12,650.00 12,250.00 12,250.00 22,350.00 22,350.00 5,750.00 12,250.00 12,250.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 4,270.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
2,000.00 1,500.00 2,500.00 2,500.00 2,500.00 2,500.00 2,500.00 2,000.00 1,500.00 2,000.00 2,000.00 2,500.00 3,000.00 2,500.00 2,500.00 2,000.00 2,000.00 2,000.00 2,000.00 11,000.00 16,000.00 5,000.00 2,500.00 2,500.00 2,500.00 2,500.00 2,500.00 2,500.00 2,500.00 2,500.00 3,000.00 3,000.00 2,500.00 2,500.00 2,500.00
8,900.00 6,700.00 7,950.00 7,850.00 9,100.00 8,750.00 8,300.00 8,000.00 7,950.00 11,050.00 7,100.00 8,000.00 15,700.00 14,350.00 14,650.00 8,750.00 10,400.00 8,300.00 6,950.00 28,100.00 38,270.00 38,700.00 19,050.00 19,050.00 18,600.00 18,600.00 19,400.00 19,400.00 19,000.00 19,000.00 29,600.00 29,600.00 12,500.00 19,000.00 19,000.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
8,900.00 6,700.00 7,950.00 7,850.00 9,100.00 8,750.00 8,300.00 8,000.00 7,950.00 11,050.00 7,100.00 8,000.00 15,700.00 14,350.00 14,650.00 8,750.00 10,400.00 8,300.00 6,950.00 28,100.00 38,270.00 38,700.00 19,050.00 19,050.00 18,600.00 18,600.00 19,400.00 19,400.00 19,000.00 19,000.00 29,600.00 29,600.00 12,500.00 19,000.00 19,000.00
1 135 136 137 138 139 140 141 142 143 144 145 146
2 Globulin Bilirubin Indirect Gama GT Urin lengkap Pemeriksaan Gram Filaria Telur Cacing pada faeses Telur Cacing pada tanah Anti Hbs Analisa Sperma VDRL Pengambilan papsmear
PENGEMBANGAN ASAM URAT KOLESTEROL TRIGLISERID HBS AG EKG USG Rontgen Foto ukuran 30x40 ukuran 35x35 ukuran 24x30 ukuran 18x24 154 Rontgen Foto gigi 147 148 149 150 151 152 153
F. 155 156 157 158 159
RAWAT INAP Rawat Pasien Umum Rawat Pasien Bersalin Persalinan patologis Rawat bayi Rawat bayi patologis
G. LAIN-LAIN G.1. OPERASI KATARAK 160 Operasi Katarak
3 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
4 12,250.00 12,250.00 12,250.00 8,000.00 5,750.00 4,500.00 6,500.00 8,000.00 10,500.00 8,000.00 9,000.00 9,500.00
1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00 1,000.00
5 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
6 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
7 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
8 2,500.00 2,500.00 2,500.00 2,000.00 2,000.00 2,000.00 2,000.00 2,000.00 1,500.00 3,000.00 3,000.00 7,500.00
9 19,000.00 19,000.00 19,000.00 14,250.00 12,000.00 10,750.00 12,750.00 14,250.00 16,250.00 15,250.00 16,250.00 21,250.00
12,650.00 17,450.00 20,450.00 14,050.00 14,650.00 10,200.00 25,000.00 22,500.00 18,500.00 16,500.00 5,000.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 4,500.00 4,500.00 4,500.00 4,500.00 4,500.00
2,500.00 2,500.00 2,500.00 2,500.00 10,000.00 15,000.00 12,000.00 12,000.00 12,000.00 12,000.00 6,000.00
2,000.00 2,000.00 2,000.00 2,000.00 2,000.00
0.00 0.00 0.00 0.00 0.00
21,900.00 21,900.00 21,900.00 21,900.00 21,900.00
17,700.00 19,200.00 19,200.00 3,000.00 23,400.00
10,000.00 15,000.00 25,000.00 15,000.00 30,000.00
32,500.00 217,500.00 360,000.00 32,500.00 35,000.00
2,000.00
45,000.00
4,500.00
100,000.00
10,000.00
10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
11 19,000.00 19,000.00 19,000.00 14,250.00 12,000.00 10,750.00 12,750.00 14,250.00 16,250.00 15,250.00 16,250.00 21,250.00
19,400.00 24,200.00 27,200.00 20,800.00 28,900.00 29,450.00 42,500.00 40,000.00 36,000.00 34,000.00 16,500.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
19,400.00 24,200.00 27,200.00 20,800.00 28,900.00 29,450.00 42,500.00 40,000.00 36,000.00 34,000.00 16,500.00
84,100.00 275,600.00 428,100.00 74,400.00 112,300.00
21,900.00 21,900.00 21,900.00 21,900.00 21,900.00
62,200.00 253,700.00 406,200.00 52,500.00 90,400.00
1,200,000.00 1,361,500.00
0.00
1,361,500.00
1
2
3
4
5
6
7
8
9
10
11
G.2. PENGOLAHAN LIMBAH 161 Incenerator setiap kg
0.00
350.00
0.00
0.00
4,150.00
3,000.00
7,500.00
0.00
7,500.00
G.3. PELAYANAN AMBULANCE DAN MOBIL JENAZAH 162 Pelayanan Ambulance / Mobil jenazah - 5 kilometer pertama - kelebihan jarak /km berikutnya
0.00 0.00
22,500.00 4,500.00
0.00 0.00
0.00 0.00
3,250.00 0.00
25,000.00 500.00
50,750.00 5,000.00
0.00 0.00
50,750.00 5,000.00
Keterangan : Untuk pelayanan di luar jam kerja , penambahan jasa pelayanan sebesar :
dr Spesialis dr umum Paramedis
20,000.00 10,000.00 5,000.00
Wates, 9 April 2012 BUPATI KULON PROGO, Cap/ttd HASTO WARDOYO
LAMPIRAN II : PERATURAN DAERAH KABUPATEN KULON PROGO NOMOR 4 TAHUN 2012 TENTANG RETRIBUSI PELAYANAN KESEHATAN PADA UNIT PELAKSANA TEKNIS DINAS KESEHATAN KABUPATEN KULON PROGO RETRIBUSI PELAYANAN KESEHATAN PADA UPTD LABORATORIUM KESEHATAN BIAYA LANGSUNG NO
JENIS PELAYANAN BAHAN HABIS PAKAI
1 A. A. 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
2 PEMERIKSAAN SAMPEL LINGKUNGAN MPN Coliform (Air Bersih) MPN Coli tinja (Air Minum) Angka Kuman Suhu Rasa Warna TDS / Zat Padat Terlarut Kekeruhan PH / Derajat Keasaman Chlorida Kesadahan Nitrat Nitrit (Air) Besi Mangan Fluorida Sulfat COD / Kebutuhan Kimia akan Oksigen BOD / Kebutuhan Biologi akan Oksigen Sisa Chlor Kualitas Air Minum Terbatas Kualitas Air Bersih Terbatas
3
BIAYA TIDAK LANGSUNG (ADMINISTRASI KANTOR, LISTRIK, AIR TELEPON, BAHAN BAKAR, PEMELIHARAAN PRASARANA DAN SARANA KESEHATAN
4
24,950.00 43,550.00 24,300.00 1,200.00 0.00 0.00 1,200.00 1,200.00 2,100.00 8,650.00 11,400.00 7,000.00 6,100.00 17,400.00 7,500.00 8,200.00 15,600.00 18,000.00 15,250.00 8,000.00 131,000.00 112,450.00
JASA TARIP SUBSIDI TARIP PELAYANAN RETRIBUSI WARGA RETRIBUSI (Rp.) (Rp.) DAERAH (Rp.) WARGA (Rp.)
5
4,000.00 4,000.00 4,000.00 3,250.00 0.00 0.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00 3,250.00
5,000.00 5,000.00 5,000.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,000.00 1,000.00 1,000.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,000.00 24,500.00 24,500.00
6
33,950.00 52,550.00 33,300.00 5,950.00 1,500.00 1,500.00 5,950.00 5,950.00 6,350.00 12,900.00 15,650.00 11,750.00 10,850.00 22,150.00 12,250.00 12,950.00 20,350.00 22,750.00 20,000.00 12,250.00 158,750.00 140,200.00
7
8
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
33,950.00 52,550.00 33,300.00 5,950.00 1,500.00 1,500.00 5,950.00 5,950.00 6,350.00 12,900.00 15,650.00 11,750.00 10,850.00 22,150.00 12,250.00 12,950.00 20,350.00 22,750.00 20,000.00 12,250.00 158,750.00 140,200.00
1 A.2. 23 24 25 26 27 28 29 30 31 32 33 34 35
2 PEMERIKSAAN SAMPEL MAKANAN Borax Formalin Nitrit (Pengawet) Benzoat Salisilat Siklamat Sakarin Pewarna Kadar Gula Kadar Air Kadar Abu Logam Berat Garam Beryodium
3
4
8,500.00 21,600.00 11,700.00 17,850.00 18,750.00 18,750.00 18,750.00 22,100.00 15,000.00 9,000.00 9,000.00 25,000.00 3,400.00
5
3,250.00 3,250.00 4,000.00 4,000.00 4,000.00 4,000.00 4,000.00 4,000.00 4,000.00 3,250.00 3,250.00 6,000.00 3,250.00
6
1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 4,500.00 3,000.00 3,000.00 7,500.00 2,000.00
13,250.00 26,350.00 17,200.00 23,350.00 24,250.00 24,250.00 24,250.00 27,600.00 23,500.00 15,250.00 15,250.00 38,500.00 8,650.00
Wates, 9 April 2012 BUPATI KULON PROGO, Cap/ttd HASTO WARDOYO
7
8
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
13,250.00 26,350.00 17,200.00 23,350.00 24,250.00 24,250.00 24,250.00 27,600.00 23,500.00 15,250.00 15,250.00 38,500.00 8,650.00
