LAMPIRAN III PERATURAN DAERAH PROVINSI BANTEN NOMOR 1 TAHUN 2016 TENTANG RETRIBUSI PELAYANAN KESEHATAN
STRUKTUR DAN BESARAN TARIF BALAI KESEHATAN KERJA MASYARAKAT UPT DINAS KESEHATAN PROVINSI BANTEN NO NO JENIS 1
A
Jasa Sarana (Rp)
JENIS PELAYANAN
Jasa Pelayanan (Rp)
Jumlah (Rp)
LABORATORIUM 1 Pemeriksaan Darah a. Hemoglobin b. Hematokrit c. Eritrosit d. Lekosit e. Trombosit f. Darah Lengkap ( DL ) g. Darah Rutin ( DR ) h. Masa pendarahan i. Laju Endap Darah j. Retraksi bekuan k. Masa pembekuan l. Golongan Darah m. Cross match n. Ver/Her/Kher o. Malaria p. Rhesus factor
5,000 5,000 5,000 5,000 5,000 40,000 40,000 5,000 5,000 5,000 5,000 5,000 10,000 10,000 12,500 12,500
10,000 10,000 10,000 10,000 10,000 15,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 12,500 12,500
15,000 15,000 15,000 15,000 15,000 55,000 50,000 15,000 15,000 15,000 15,000 15,000 20,000 20,000 25,000 25,000
2 Pemeriksaan Kimia Darah a. Glucosa darah puasa b. Glucosa 2 jam pp c. Gula Darah Sewaktu d. SGOT e. SGPT f. Amilase g. Urea h. Creatinine i. Asam urat j. Kalsium k. Fosfat l. Lipase
10,000 10,000 10,000 13,000 13,000 30,000 13,000 13,000 13,000 30,000 20,000 20,000
10,000 10,000 10,000 12,000 12,000 20,000 12,000 12,000 12,000 20,000 10,000 10,000
20,000 20,000 20,000 25,000 25,000 50,000 25,000 25,000 25,000 50,000 30,000 30,000
131
Klorida Protein Total Magnesium Lipida Total Acid Fospatase Alkali Fospatase Bilirubin Total Bilirubin Direct Bilirubin Indirect Albumin Globulin Cholesterol Total HDL Cholesterol LDL Cholesterol Trigliserida Klirens Ureum Klirens Kreatinin LDH HBDH CK-NAK CK-MB
30,000 13,000 30,000 20,000 30,000 20,000 13,000 13,000 13,000 13,000 13,000 13,000 13,000 13,000 13,000 22,000 22,000 22,000 22,000 40,000 50,000
Jasa Pelayanan (Rp) 20,000 12,000 20,000 10,000 20,000 10,000 12,000 12,000 12,000 12,000 12,000 12,000 12,000 12,000 12,000 18,000 18,000 18,000 18,000 20,000 30,000
3 Pemeriksaam Serologi a. Dengue,IGD,IGM b. Rhematoid Factor c. Widal Test d. PP Test e. ASTO f. HBs Ag g. CRP h. Anti HIV
95,000 30,000 25,000 7,500 25,000 45,000 25,000 35,000
35,000 15,000 15,000 7,500 15,000 20,000 15,000 15,000
130,000 45,000 40,000 15,000 40,000 65,000 40,000 150,000
4 Pemeriksaan Bakteriologi a. Pewarnaan Gram b. Pewarnaan BTA c. Pewarnaan KOH d. Pewarnaan Difleri e. Pewarnaan GO
10,000 10,000 10,000 10,000 10,000
10,000 10,000 10,000 10,000 10,000
20,000 20,000 20,000 20,000 20,000
NO NO JENIS
Jasa Sarana (Rp)
JENIS PELAYANAN m. n. o. p. q. r. s. t. u. v w. x. y. z. aa. ab. ac. ad. ae. af. ag.
5 Pemeriksaan Urine a. Urine Rutin
Jumlah (Rp) 50,000 25,000 50,000 30,000 50,000 30,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000 25,000 40,000 40,000 40,000 40,000 60,000 80,000
30,000 132
NO NO JENIS
Jasa Sarana (Rp)
JENIS PELAYANAN b. c. d. e.
Esbach Sedimen Reduksi/protein Urine Lengkap
B
POLI GIGI 1 Pemeriksaan dan Pengobatan 2 Cabut gigi satu a. Gigi sulung b. Gigi tetap c. Gigi tetap dengan komplikasi 3 Penambalan satu gigi a. Tambalan sementara b. Fulp caping c. Pengisian perawatan endo d. Tambalan amalgam /silikat
10 11
e. Tambal composite Scaling atas atau bawah Alveolektomi atas atau bawah Upercolektomi Odontectomi Buka jahitan eksterpasi Gigi tiruan lepas a. Gigi pertama b. Gigi berikutnya Jacket Crown Porcelain Reparasi
1 2 3 4 5 6
RADIOLOGI ThoraxPA Bahu/Shoulder Joint AP/Lat Clavicula AP/Lat Scapula AP/Lat Manus AP/Lat Pergelangan tangan /wrist
4 5 6 7 8 9
III
C
Jumlah (Rp) 25,000 25,000 25,000 40,000
6 Pemeriksaan Faeses a. Rutin II
Jasa Pelayanan (Rp)
133
9,000
6,000
15,000
6,500
3,500
10,000
6,500 20,000 25,000
3,500 15,000 25,000
10,000 35,000 50,000
5,000 10,000 10,000
10,000 10,000 10,000
15,000 20,000 20,000
15,000
15,000
30,000
20,000 10,000 20,000 20,000 250,000 10,000
20,000 15,000 20,000 20,000 50,000 10,000
40,000 25,000 40,000 40,000 300,000 20,000
25,000 5,000 50,000 10,000
75,000 20,000 250,000 40,000
100,000 25,000 300,000 50,000
25,000 30,000 30,000 30,000 30,000 30,000
25,000 30,000 30,000 30,000 30,000 30,000
50,000 60,000 60,000 60,000 60,000 60,000
NO NO JENIS 7 8 9 10 11 12 13 14 15 IV
D 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
V
E
30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 60,000
Jasa Pelayanan (Rp) 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 40,000
10,000 10,000 15,000
10,000 5,000 10,000
20,000 15,000 25,000
25,000
15,000
40,000
75,000 15,000 12,500 7,500 25,000 9,500 6,000 30,000 20,000 30,000 45,000 15,000 40,000 3,000 20,000
75,000 10,000 7,500 2,500 20,000 5,500 4,000 20,000 10,000 10,000 25,000 30,000 20,000 2,000 10,000
150,000 25,000 20,000 10,000 45,000 15,000 10,000 50,000 30,000 40,000 70,000 45,000 50,000 5,000 30,000
30,000
65,000
95,000
10,000
5,000
15,000
Jasa Sarana (Rp)
JENIS PELAYANAN Antebrachii Ap/Lat Cubiti AP/Lat Humerus AP/Lat Pedis AP/Lat Ankle AP/Lat Calcaneus AP/Lat Cruris AP/Lat Genu AP/Lat ThoraxPA + Lat TINDAKAN MEDIK UMUM Pemeriksaan dan pengobatan Perawatan luka tanpa jahitan perawatan luka dengan jahitan 1 s/d 5 Perawatan luka dengan jahitan 6 s/d 10 Khitanan Kateterisasi kandung kemih Insici Ganti balutan Ekstraksi benda asing Buka jahitan Epistaksis packing anterior Ekstraksi kuku Perawatan luka bakar < 5% Perawatan luka bakar < 10% Perawatan luka bakar > 10% Jahitan luka kecil ( palpebra) Nebulizer Injeksi im/iv/subkutan Oksigen (per jam)
PEMERIKSAAN DAN PELAYANAN KIA/KB 1 Pemeriksaan dan pengobatan dengan dokter spesialis 2 Pemeriksaan dan pengobatan dengan bidan
134
Jumlah (Rp) 60,000 60,000 60,000 60,000 60,000 60,000 60,000 60,000 100,000
NO NO JENIS
JENIS PELAYANAN
3 4 5 6 7 8 9 10 11 12 13 14 15 16 VI
VII
VIII
F
G
Pemasangan / pencabutan IUD Pemasangan implant Pencabutan implant KB suntik Depo provera KB suntik Cyclofem KB pil microgynon KB pil exluton KB pil planotab Kb pil Microdiol USG kehamilan USG kehamilan dengan print Tindik telinga KB suntik 3 bulan KB suntik 1 bulan
PEMERIKSAAN KESEHATAN (KEURING) 1 Pemeriksaan kesehatan umum /pelamar kerja 2 Pemeriksaan kesehatan umum /anak sekolah PEMERIKSAAN LAIN LAIN 1 Pemeriksaan kesehatan visum et repartum 2 Buta warna
H 1 2 3 4 5 6
30,000
Jasa Pelayanan (Rp) 35,000
30,000 30,000 5,000 5,000
35,000 35,000 5,000 5,000
30,000 45,000 10,000 7,500 5,000
30,000 30,000 20,000 7,500 15,000
65,000 65,000 10,000 10,000 10,000 10,000 5,000 10,000 60,000 75,000 30,000 15,000 20,000
8,000
2,000
10,000
3,000
2,000
5,000
7,500
2,500
10,000
3,000
2,000
5,000
30,000 30,000 20,000 50,000
30,000 30,000 20,000 100,000
60,000 60,000 40,000 150,000
50,000
100,000
150,000
350,000
400,000
750,000
Jasa Sarana (Rp)
PELAYANAN KESEHATAN EKG Audiometri Spirometri Konsultasi /Rujukan dokter Spesialis Konsultasi Kesehatan Kerja (Gizi kerja,Ergonomi,dll) Penyuluhan Kesehatan Kerja /jam
135
Jumlah (Rp) 65,000
NO NO JENIS
JENIS PELAYANAN
7 Pelatihan P3K Kerja (sesuai jenis industri) per kelompok maksimal 20 orang per 2 jam 8 Pelatihan Kesehatan Kerja (Ergonomi,APD,Emergency Respon Plan) per kelompok, maksimal 20 orang per materi 9 Pemeriksaan Kesehatan Pekerja standar (MCU -Job Related)
IX
i
REHABILITASI MEDIK
1
Rehabilitasi a. Electrical Stimulation/ES b. Exercise c. Exercise ringan d. Exercise sedang e. Exercise berat f. IR (UKG) g. Kinesio taping h. Lumbal Traksi i. Magnetic Theraphy j. Manual Theraphy k. MWD l. Parafin Bath m. SWD n. SWT o. TENS p. Theraphy manipulasi / Massage q. USD r. Whirl Pool
2
1,000,000
1,000,000
2,000,000
25,000
100,000
125,000
Jumlah (Rp) 2,000,000
18,480 18,480 15,400 17,600 17,600 18,480 15,400 18,480 46,200 22,000 18,480 18,480 18,480 46,200 18,480 17,600
23,520 23,520 19,600 22,400 22,400 23,520 19,600 23,520 58,800 28,000 23,520 23,520 23,520 58,800 23,520 22,400
42,000 42,000 35,000 40,000 40,000 42,000 35,000 42,000 105,000 50,000 42,000 42,000 42,000 105,000 42,000 40,000
18,480 24,200
23,520 30,800
42,000 55,000
24,200 28,600
30,800 36,400
55,000 65,000
OKUPASI TERAPI a. Sensory Integrasi b. Theraphy Okupasi
3
1,000,000
Jasa Pelayanan (Rp) 1,000,000
Jasa Sarana (Rp)
TERAPI WICARA 136
NO NO JENIS
Jasa Sarana (Rp)
JENIS PELAYANAN
a. Theraphy wicara b. Theraphy wicara dengan bantuan Alat
4
24,200 28,600
Jasa Pelayanan (Rp)
Jumlah (Rp)
30,800 36,400
55,000 65,000
22,400
40,000
DOKTER SPESIALIS REHABILITASI MEDIK a. Laser
17,600
GUBERNUR BANTEN, ttd RANO KARNO
137
138
139
140
141
142
143
144
