TARIF PELAYANAN / TINDAKAN KELAS III RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014 NO
1
JENIS
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp ) 3 4 5
PELAYANAN 2
XVII. TINDAKAN INSTALASI BEDAH PUSAT (DALAM KAMAR OPERASI) A. BEDAH DIGESTIVE 1. Sedang I 1 Herniorafi tanpa penyulit 2 Appendictomy tanpa penyulit 3 Hemoridectomy Parsial Rubber 4 Gastroctomy Temporer 5 Biopsi Hepar dengan Jamur 6 Biopsi Tumor Intra Abdominal dgn ins.Sd 7 Ekstirpasi Polip Recti Trans An. 8 Pemasangan Flocare 9 Ekstraksi benda asing di saluran cerna bagian atas/bawah 10 Hemostasis saluran cerna bagian Atas/bawah 11 Savary Baogic 12 Skleroterapi varises Esofagus 2. Sedang II 1 Apendoktomi Perforata 3. Besar 1 Herniorafi dengan Mesh 2 Herniorafi dengan penyulit (inker) 3 Hemoroidectomy sirkuler 4 Fistulectomy "High Anal" / Beral 5 Laparactomy eksplorasi 6 Kolesistectomy terbuka 7 Drainase abses hepar 8 Repair sed. Perforasi lambung 9 Drainase ekst. Abses/kista panker 10 Jahitan sed.Ruptur hati (Hepato) 11 Ligasia A hepatika 12 Eksterpasi kista Hepar (kecil) 13 Reseksi/Eksisi baji anestomosis 14 Drainase perianal fistula sederhana 15 Repair Sed. Perforasi usus halus 16 Lateral spinchterectomy 17 Open cholecisectomy 18 Eksplorasi duktus Koledektus 19 Laparotomy VC 20 Transeksi esofagus 21 Adesiolis sed. Usus 22 Splenorafi/Splenectomy 23 Operasi Appendicities perforata 24 Drainase abses periappendix 25 Eksisi luas tumor dinding abdomen 26 Eksisi Tumor intra/retro peritonial 27 Repair "wound distruption" Dindi 28 Repair hernia insionalis 29 Operasi notaras (Prolaps Rekti) 30 Repair sprincterectomy 31 Kolostomy/Ileustomy 32 Diverticulectomy (Divertikel M) 33 Pankreatorafi Sederhana 34 Diagnosa Peritonial lauvage 35 Pankreaktorafi sederhana 36 Diagnosa peritoneal lauvage 37 Fistelectomy Anal 4. Khusus I 1 Eks. Tumor lbh besar 10 cm intra/retro 2 Reseksi kolon transversum 3 Hemikolectomy kanan/kiri 4 Low anterior resection/sphinct 5 Hartman procedures 6 Operasi Heller (Achalasia - Esofagus) 7 Funduplikasi Esofagus (Anti Ref) 8 Berbagai macam Vagotomi 1
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
1,968,000
1,312,000
3,280,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
JENIS
NO
5
6
B.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
9 Terminal esofagus-Proxim (Teps) 10 Transeksi esofagus 11 Repair Entero 12 Adhesiolisis usus dengan penyulit 13 Laparascopy diagnostic 14 Laparascopy Biopsi 15 Laparascopy Fundus Ligasi 16 Stappler Haemorrhoidectomy 17 Total Colectomy 18 Bypass Pseudocysat pancreas 19 Debulking Tumor 20 Repair Hernia Hiatus Esofagus 21 Prosedur By Pass Traktus Gasir 22 Reseksi Hepar/Labektomi/Segmen 23 Laparaskopik Kolesistektomi 24 Mega Kolon Hierchprung 25 Repair Enterocutaneous Fistel 26 Kolesistektomi 27 Relaparastomy 28 Repair Enterokutaneus fistula 29 PTDB (open) 30 Long Mire's Operation 31 Embilisasi Vena porta 32 Explore CBD Tube 33 Total Gastrectomy 34 Laparascopy Mile's Operation 35 Laparascopy Hemicolectomy kanan/kiri 36 Pelvic Exenteration Khusus II 1 Operasi Bill Roth I/II 2 Operasi Miles 3 Laparascopy Appendictomy 4 Spelenektomi 5 Reseksi Hepar Major Khusus III 1 Pancreaktomi 2 Koledocoduodenostomy 3 Reseksi Esofagus + Interposisi Kolon 4 Extended cholecystetomy
BEDAH VASKULER 1. Sedang I 1 Sclerotherapy vena periver 2 Ligasi vena periver dengan lokal anasthesi 3 Ekstirpasi Fibroma 4 Debriment Ulang Vaskuler/Debriment dengan amputasi mayor/minor 5 Resciotomi 6 Flebektomi 7 Rekontruksi Vaskuler Sederhana 8 Reapir Komplikasi AV Shunt 9 Thrombektomi/Lysis dengan catheter for vein 10 Double Lumen 2. Sedang II 1 Semua tindakan yang dilakukan dengan narkose rengau 2 Penyakit pembuluh darah perifer 3 Cimino 4 Cimino Ulang 5 Eksplorasi Abses Multiple 3. Besar 1 Semua tindakan yang dilakukan dengan narkose dan mempunyai risiko 2 tinggi Solenektomi 3 Operasi Tumor pembuluh darah 4 Pendarahan karena kerusakan pembuluh darah 5 Graf vena membuat A vistula 6 Simpatektomi 7 Amputasi Gangron 8 Embolectomy 2
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
10,800,000 10,800,000 10,800,000 10,800,000
7,200,000 7,200,000 7,200,000 7,200,000
18,000,000 18,000,000 18,000,000 18,000,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
1,968,000 1,968,000 1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000 3,280,000 3,280,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
JENIS
NO
4.
5.
6.
C.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
9 Skin Laser Treatment Khusus I 1 Semua tindakan yang dilakukan dengan narkose & memerlukan teknik Operasi khusus vaskuler yang memerlukan teknik vaskuler khusus, memakai 2 operasi 3 monitor Shuntinginvasive : a. Splenorenal b. Fermoralis c. Poplitea/Tibialis 4 AV Shunt cubiti 5 Simpatektomi 6 AV Shunt radial (Brescia-Cimino) 7 Debridement & tutup defek pada gangren diabetik 8 Eksisi & rekonstruksi limfedema & reduksi massa 9 Skleroterapi dengan anestesi 10 Grafting pada Arterial Insufisiensi 11 Operasi Aneurisma Aorta 12 Operasi Arteri Carotis 13 Operasi Arteri Renalis Stenosis 14 Lumbal simpatektomi bilateral 15 Lumbal simpatektomi unilateral Khusus II 1 Grafting pd arteri insufisiensi 2 Limfadenektomi Ileoinguinal 3 Pasang akses port celsite 4 Simpatektomi per laparoskopi/thorakoskopi unilateral 5 Trombektomi dengan atau tanpa debridement 6 Stripping varises 1 tungkai dengan flebektomi 7 Stripping varises 1 tungkai, debridement ligasi vena perforantes/penyulit 8 Stripping varises 2 tungkai dengan multipel flebektomi 9 AV Shunt radial/cubiti dengan pasang double lumen 10 Debridement AVM 11 Eksisi ligasi & rekonstruksi malformasi vaskuler sederhana 12 Endovenous Laser Treatment 13 Endovenous Laser Treatment dengan multipel flebektomi Khusus III 1 Splenektomi ec. Hipertensi Portal/kelainan hematologi lain 2 Graf Vena membuat A Vistula 3 Eksisi & rekonstruksi vaskuler pada malformasi vaskuler 4 Eksisi luas malformasi vaskuler 5 Rekonstruksi komplikasi AV Shunt (pseudoaneurisma) 6 Rekonstruksi komplikasi pasca trauma (AV fistula/ pseudoaneurisma) 7 Rekonstruksi vaskuler aneurisma perifer 8 AV Shunt dengan graft vena/sintetis 9 Rekonstruksi vena-vena abdomen pelvis 10 Karotis endarterektomi 11 Eksplorasi dan rekonstruksi vaskuler pada trauma vaskuler akut 12 Rekonstruksi kerusakan katup vena dalam tungkai pada DVT Kronik atau 13 CVI Rekonstruksi vaskuler arteri tungkai/lengan pada Chronic Critical Limb 14 Ischemic Rekonstruksi vaskuler pada AAA/arteri iliaka per laparotomi 15 Rekonstruksi vaskuler pada AAA dan arteri tungkai 16 Thoracotomi
BEDAH ORTOPEDI 1. Sedang II 1 Reposisi Dislocation MCP/PIP/DIP Joint dengan GA 2 Reposisi Patellar Dislocation dengan GA 3 Manipulasi dengan GA 4 Angkat Nail Tanpa Penyulit 5 Angkat Plate Tibia 6 Release de Quervain Single dgn GA 7 Angkat K. Wire Multi dgn GA ( 2 Wire ) 8 Open Biopsi Superfisial 9 Eksterpasi Tumor Kulit dan Bawah Kulit ( Sub Kutis ) lebih dari 2 dengan GA 10 Incisi Abses Kulit dgn diameter lebih dari 2 cm dgn GA 11 Excisi Keloid dgn diameter lebih dari 2 cm dgn GA 12 Incisi Hematomi Kulit dgn diameter lebih dari 2 cm dgn GA 13 Eksterpasi Tumor Jinak Kulit dan Bawah Kulit ( Sub Kutis ) diameter > 2 cm dengan GA 3
2,532,000
1,688,000
4,220,000
4,050,000 4,050,000
2,700,000 2,700,000
6,750,000 6,750,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000
7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000
18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000
1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000
NO
JENIS
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
14 Insisi Abses Kulit diameter > 2 cm dgn GA 15 Insisi Hematoma diameter > 2 cm dgn GA 16 Excisi Keloid diameter > 2 cm dgn GA 17 Reposisi Dislocation Meta Tarsal Phalanx (MTP) / Inter Phalanx (IP) Joint GA Metacarpal / Tarsal Single 18 dengan Angkat Plate 19 Amputasi Jari Single dengan GA 20 Angkat Plate Phalanx Single 21 Biopsi Kelenjar Getah Bening Leher 22 Angkat Plate Tibia Fibula 23 Angkat Nail dgn Penyulit 24 Angkat Screw ( Hip / Ankle / Patella / Condylair) 25 Angkat External Fixasi 26 Angkat Plate / Pinning Clavicula 27 Angkat K. Wire Multiple dgn GA ( > 6 Wire ) 28 Angkat K. Wire Multi dgn GA ( 3 - 6 ) 29 Angkat Plate Metacarpal / Tarsal Multiple 30 Angkat Plate Phalanx Multiple 31 Insisi Abses dgn GA ( Abses Tulang ) 32 Open Biopsi Deep 33 Incisi Abses dgn GA 34 Angkat lllizarov 35 Debridement & Pengegipan 36 Debridement Sendi-sendi lain 37 Corection of Congenital Deformity : Release Syndactily 38 Corection of Congenital Deformity : Polidactily 39 Corection of Congenital Deformity : Release Constrition Band 40 Excisional Biopsi & Debulking 41 Osteotomy, Realigment, ORIF 42 Reposisi Dislocation Gleno Humeral Anterior dengan GA (Closed Reposisi) 43 ORIF Fr. Metatarsal 1 Jari 44 ORIF Fr. Phalanx Pedis 1 Jari 45 ORIF Tibia Middle Third Distal Third Simple & Fibula 46 ORIF Fr. Metacarpal 1 Jari 47 ORIF Fr. Phalanx Manus 1 Jari 48 Release de Quervain dgn GA 49 Release Trigger Finger dgn GA 50 Release Carpal Tunel Syndrome dgn GA 51 Amputasi Jari 1 buah 52 Release Compartment Syndrome 53 Eksisi Head Radius 54 Eksplorasi Orthopaedi 55 Abdominal Flap 1 (satu ) Jari 56 Bone Graft 57 Tenotomy 58 Revisi Illizarov 59 Trimming Bone 60 Achiles Tendo Lengthening ( ATL) 61 Reposisi tertutup dilokasi 62 Laporotomy Appendectomy 63 Eksisi Luas dan Rekonstruksi Sederhana 64 Flap Kulit / Otot 65 Fiksasi Internal Iga 66 Rekonstruksi Vaskuler Perifer (Trauma ) 67 Tandur Alih Kulit 68 Amputasi Rekonstruksi 69 Amputasi Ekstermitas Atas atau Bawah 70 Thendoraphy Single 71 Angkat Nail dan Plate Femur 72 Angkat Nail dan Plale Cruris 73 ORIF Fr. Tibia Pillon 74 ORIF Mandibula/Maxilla (Fr. Mandibula Segmental/Communitif) 75 Removal of Implant 2. Besar 1 ORIF Fr. Phalanx Pedis > 2 Jari 2 ORIF Fr. Metatarsal > 2 Jari 3 ORIF Fr. Patella 4 ORIF Fr. Tallus 4
1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000
2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000
JENIS
NO 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
ORIF Fr. Calcaneal ORIF Fr. Bimaleolalr ORIF Fr. Ankle ORIF Fr. Os Illium ORIF Fr. Os Pubis Release fraktur + Skeletal Traksi Malunion Femur tibia ORIF Fr. Tibia Plateau Simple ORIF Fr. Cruris ORIF Fr. Supracondylair Femur OMPG (Terpisah dgn Tind. Screwing / ORIF) ORIF Fr. Collum Femur ORIF Fr. Femur Arthroscopy Diagnostic Tenoraphy Achilles Tendon Rekonstruksi Patella Open Menisectomy Arthrodesis Fibular Graft ORIF Fr. Metacarpal > 2 Jari ORIF Fr. Phalanx Manus > 2 Jari ORIF Sternoclaviculair Disloc. ORIF Fr. Radius Ulna (Antebrachii) ORIF Fr. Condylus Lateralis / Medialis Humeri ORIF Ruptur Acromio Claviculair Ligament ORIF Eksisi Prosesus Coracoid Rotation Muscle Flap Muscle Skin Flap Muscle STSG / Skin Graft Reposisi terbuka sendi panggul/siku/bahu ORIF Disloc. Coxae ORIF Lateral end Clavicula ORIF Fraktur SCH ( Supra Condylair Humeri) ORIF Fr. Humerus Prox.Third/Distal Third/Middle Fragmented Release CTEV Amputasi Jari Multiple ( > 2 Jari) Release Dupuytren Repair Finger Hip Injury Multiple Rekonstruksi Bicipital Tendinitis Fractura of Scapula Pro. Acromialis Rekonstruksi Bicipital Tendinitis Fractura of Scapula Corpus Scapula Koreksl Hallux Valgus Repair Ligament Repair Arteri Single Repair Nervus Single Debridement Knee (Gonitis)-- goniotomi Rekonstruksi Patellar Habital Disloc. Release Z Plasty ORIF Fr. Collum Humeri ORIF Fr. Intercondylair Humeri Refracturasi, ORIF ORIF Fr. Femur Segmental ORIF Fr. Radius Ulna Segmental Repair Finger Hip Injury Multiple Rekonstruksi Bicipital Tendinitis Fracture of Scapula Pro. Acromialis ORIF. Fr. Humerus Segmental ORIF Old Dislocation Insisi Abses (Abses dalam Tulang ) dengan GA Excisi Ganglion dgn dia. lebih dari 2 cm dgn GA Debridement Open Fraktur Grade > 2 Reposisi Gips Ekstermitas Atas dgn GA Reposisi Gips Ekstermitas Bawah dgn GA Operasi Tumor Jaringan Lunak Angkat Plate Femur Schaft Gips Corset / Hemispica /Body Jacket dengan GA Angkat Plate Femur Proximal / Distal 5
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
JENIS
NO
3.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
72 Body Jacket dengan GA 73 Debridement Coxae / Hip ( Coxitis ) 74 Eksternal Fiksasi Pelvis 75 Angkat Plate Radius & Ulna 76 Angkat Plate Humeri 77 Angkat K. Wire Multiple dgn GA ( > 6 Wire ) 78 Body Jacket/Corset Dewasa dengan GA 79 Debridement & Drilling 80 Debridement, Squesterectomy & Guttering 81 Eksternal Fiksasi pada Fr. Terbuka III A - III B 82 Angkat Plate Tulang Belakang 83 External Fixasi pada Fraktur terbuka Grade IIIC 84 Debridement, Amputasi Gangren Diabetik / Penyakit Lainnya 85 Repair Syaraf Perifer 86 Debredement Osteomylitis 87 Thendoraphy multiple 88 Reattachment Avulsi Patellar Tendon 89 Angkat Plate dengan Penyulit 90 Angkat Kichner dengan Penyulit/dengan C-Arm 91 High Tibia Osteotomy 92 ORIF FR. Humerus Middle Third Simple 93 Release Kontraktur 94 Rekonstruksi atau Shoulder Habitual Disloc 95 Release Volkmann, Ischemic Contracture 96 ORIF Fr. Trochanter Femur 97 ORIF Fr. Tibia Plateau Communitif dengan Bone Graft 98 ORIF Fr. Intercondylair Femur 99 ORIF Fr. Tibia Segmental 100 Amputasi Rekonstruksi 101 Amputasi Ekstermitas Atas atau Bawah Khusus I 1 Repair Meniscus/Menisectomy 2 Disarticulatio Knee 3 Fore Quarter Amputation 4 Fusi Corpus Vetebrata 5 Limfadenektomi Ileoinguenal 6 Limfadenektomi Retroperitoneal 7 ORIF, Symphisiolisis 8 Release Hip Contracture 9 ORIF Fr. Acetabulum Anterior 10 Hip Arthrodesis 11 ORIF Fr. Acetabulum Posterior 12 Fase Quarter Amputasi 13 Hemipelvictomy 14 Open Red Old Hip Disloc 15 ORIF Fr. Trimalleolar 16 Cassebaum Procedure 17 Rekonstruksi Patellar Habitual Disloc 18 Release Knee Contracture 19 Arthrodesis Triple Ankle Joint 20 Pemasagan Illizarov 21 Release Elbow Contracture 22 Release Torticolis 23 Repair arteri, Vena, Syaraf (masing-masing satu) 24 Repair Bankart Lesion 25 Bone Lengthening Procedure 26 Ekplorasi Repair PI. Brachialis 27 Fractura of Scapula Articular Surface 28 ORIF Fr. Tulang Belakang 29 Release Z Plasty > 2 30 Disartlculatio Hip / Shoulder 31 Juvara Procedure 32 Total Hip Replacement ( THR ) 33 Total Knee Replacement ( TKR ) 34 THR ( Old Disloc Hip ) 35 Repair Meniscus / Menisectomy 36 Free Vascularized Fibular Graft 6
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
JENIS
NO
4.
5.
37 Free Vascularlzed Muscle Flap 38 Toracolaparotomy Darurat 39 Pericardiosintesis Terbuka 40 Operasi Hernia Diafragmatika 41 Radical Neck Dissesction ( RND ) Klasik 42 Operasi Miles 43 Anastomosis Tarik Terobos 44 Pemasangan Illizarov dengan Rekonstruksi 45 Laminectomy HNP 46 Debridement Spodylitis TBC Thoracalis 47 Rekonstruksi ACL ( Open ) 48 Rekontruksi PCL ( Open ) 49 Total Shoulder Replacement (TSR ) 50 Total Elbow Replacement ( TER ) 51 Colecistectomy laparoscopic 52 Repair PCL 53 Repair LCL 54 Repair Patellar Tendon / Ligament 55 Reatrachment ACL 56 Reattachment PCL 57 ORIF, Sacroilliaka Joint Disruption 58 Simpatektomi Torakal 59 Open Red Old Shoulder Disloc 60 Release CTEV with Bone Procedure 61 TKR dengan Penggantian Patella 62 Revisi AMP/TKR/TSR/TER 63 Removal AMP Cementles, Removal THR 64 Rekonstruksi of Mal Union/Non Union 65 Radial Club Hand (Centralization) 66 Hemiarthroplasty 67 Arthroscopy for / with Corpus Alienum Ectraction 68 Arthroscopy for / with Debridement / Shaving 69 Sterno Claviculair Dislocation dgn GA 70 French Osteotomy 71 Interlocking Nail Femur 72 Interlocking Nail Humeri 73 Debridement Coxae/HIP (Coxitis) dan Gride Stone Procedure Khusus II 1 Koreksi Impresi Fraktur 2 Fraktur yang Kompleks (Fraktur Acetabulum, Tulang Belakang, fraktur pelvis)Sendi (Total Knee, HIP, Elbow) tidak termasuk alat 3 Ganti 4 Anterior dan Posterior Surgery in Deformity with Stabilization/ Instrumentation. dan Posterior Surgery in Spinal Disease with Stabilization/ 5 Anterior Instrumentation. Laminectomy + Stabilization 6 Decompression 7 Decompression Laminectomy for HNP with Stabilization 8 Decompression Laminectomy for Tumor and Spinal Stenosis with Stabilization 9 Spinal Osteotomy 10 Amputasi Forequarter 11 Spinal Osteotomy for Ankylossing Spondylitis dengan forward gaze kurang dari III 3m Khusus 1 2 3 4 5 6
D.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
Release Carpal Tunnel Syndrome Bilateral Release Carpal Tunnel Syndrome Unilateral Ganti Sendi (Arthroplasty) tidak termasuk alat Operasi Fraktur kompleks (Acetabulum, Tulang Belakang, Pelvis) Koreksi Scoliosis Koreksi Spondilitis
BEDAH GIGI DAN MULUT 1 Sedang I 1 Enuklease Kista Kecil 2 Marsupialisasi Ranula 3 Sequesyerectomy dgn Narkose 4 Ekstirpati Tumor 5 Excochliasi 6 Odentectomy >2 elemen 7 Palatoplasty 8 Labioplasty Bilateral 7
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000
7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000
18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
JENIS
NO
2
3
4
9 Alveolectomi 10 Apek reseksi (gigi) 11 Fistulectomi 12 Frenectomi 13 Gingivectomy 14 Insisi Mucocele 15 Operculectomy 16 Pencabutan gigi dengan komplikasi 17 Penutupan Oroantral Fistula Sedang II 1 Exterpatie Plunging Ranula 2 Reposisi Fixatie (compucate) 3 Tindakan Blok Resectie Besar 1 Enuklease Kista ( Besar ) 2 Reposisi Tertutup Fiksasi IDW +IMW frak. Mand & Max 3 Athroplasty 4 Rekonstruksi Palatolabio schisis 5 Debridement Squesterectomy,Osteomyelitis 6 Extirpatie Plunging Ranula 7 Frontoethmoidektomi (Estranasal) 8 Resectie Rahang 9 Hemiglosektomi 10 Mandibulektomi Marginalis 11 Condilotomy mandibula 12 Removal Implant (Plate, Nail, Screw) Khusus 1 fasial lain LeFort I,II,III 2 3 4 5 6 7 8 9 10 11 12 13 14
E.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
Eksterpasi/Insisi Luas Tumor Ganas R. Mulut Rekonstruksi Komp Labio Palato Gnato schisis Kondilektomi mj pd ankylosys Orthognatic Surgery Maxillectomy Mandibulectomy tumor ganas R. Mulut Eksisi Luas Radikal + Rekonstruksi Glosektomi Total Hemiglosektomi + RND Hemipelvektomi Koreksi Impresif Fraktur Maksilektomi Total Mandibulektomi Total Mandibulektomi Partialis dengan rekonstruksi
BEDAH UROLOGI 1. Sedang I 1 Semua tindakan yg dilakukan dgn narcose tanpa resiko tinggi 2 Sistotomi 3 Meatotami 4 Vasektomy 5 Sectio Alta 6 Vericocele / Palomo 7 Orchidektomi 8 Spermatocele 9 RPG/APG 10 Nefrostomi percutan 11 Cabut DJ Stent 12 Operasi Hernia tanpa komplikasi 13 Operasi Hydrokel 2. Sedang II 1 Biopsi Prostat 2 Biopsi Testis 3 Biopsi Ginjal Perkutan 4 Sistokopy 5 Drainage Periureter 6 Hidrokel per skrotal 7 Orchidektomi/Orchidektomi subkapsuler 8 Operasi priapismus (prosedur Winter) 9 Pasang Kateter Tenckhoff untuk CAPD 8
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000
NO
JENIS
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
10 Spermatokelektomi 11 Uretreskopi/Uretrosistoskopi 12 Vasografi 3. Besar 1 Semua tindakan yg dilakukan dgn narcose mempunyai resiko tinggi. 2 Enukleasi kista ginjal 3 Open renal biopsi 4 Pyelolithotomi 5 Ureterolithotomi 6 Ureterolysis 7 Ureterostomi 8 Open nefrostomi 9 Ureterolifthotomi 10 Drainage periureter 11 Koreksi priapismus 12 Orchiopexie (Torsio Testis) 13 Vasografi 14 ekstraksi batu 15 Deroofing/unroofing kista 16 Eksisi webbed penis 17 Anastomosis end to end ureter 18 Evakuasi bekuan darah 9clot) 19 Simple nefrektomi 20 Partial Nefrektomi 21 Horseshoe kidney koreksi 22 Nefropexi 23 Nefrektomi simple 24 Pyeloplasty 25 Ureterocutaneostomi 26 Insersi DJ Stent 27 Prostatektomi terbuka & sectio A 28 Fistula enterovesika 29 Johanson 30 Johanson I 31 Laparotomi eksplorasi 32 MMK/sling uretra 33 Reparasi fistula vesico vaginal 34 Nefropeksi/Renopeksi 35 Nefrostomi terbuka/permanen 36 Operasi repair buli trauma 37 Orkhidektomi extended 38 Orchidektomi Ligasi Tinggi 39 Penektomi Parsial 40 Fistulektomi/Repair Fistel Uretra 41 Hidrokel per Inguinal/Ligasi Tinggi 42 Prostatetectomy retropabik 43 Urethrectomy 44 Diverticulectomy 45 Epispadia 46 Prothese penis 47 Reseksi partial vesika 48 Reseksi urachus 49 Rekonstruksi vesika 50 Sistoplasty reduksi 51 Rekonstruksi bladdemeck 52 Psoas hitch / boari flap 53 Diverticulectomy visika 54 Prostatektomi terbuka 55 Repair Fistel vesikokutan 56 Skrotopasti 4. Khusus I 1 Semua tindakan yg dilakukan dgn Narcose & memerlukan Teknik Operasi Khusus. 2 Urethropplasty Satu Tahap 3 Transplantasi Ginjal 4 Heminefrektomi 5 Longitudinal nefrolithotomi (kadet) 6 Extended nepphrolithotomy / gilvernet 9
1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
NO
JENIS
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
7 Ureterolithomi distal 8 Hipospadia 9 URS (Ureteronoskopy) 10 Percutaneus Nefrolitekfripis (PCN) 11 Laparoscopi urologi 12 Bladder Neck Incision 13 Extended Pyelolithorny 14 Uretroskopy (Litotripsi dan Biopsi) 15 Lithotripsy 16 Reseksi Ureterocele 17 Sistektomi 18 Eksisi Chordae/Chordektomi 19 Eksisi fibroma/ rekonstruksi penis 20 TUR Prostat 21 TUR Tumor Buli-buli 22 Internal Urethoromi (Sachse) 23 Limfadenectomy Ileonguinal 24 Percutaneous Nephrolitotripsy 25 Rekonstruksi Renovasculer 26 Eksisi plaque (Peyronie disease) 27 Operasi sistokel 28 Operasi urakhus/ reseksi urakhus 29 Penektomi total/ amputasi penis 30 PER (primary endoscopic realignment) 31 Punksi dan sklerosing kista ginjal 32 Reseksi-anastomosis uretra 33 Uretrotomi interna (Sachse) 34 Diseksi kelenjar getah bening Inguinal 35 Explorasi testis mikro surgery 36 Johanson II 37 Limfadenektomi Ileoinguinal 38 Mikrosurgeri Ligasi Vena Sprematika 39 Railroading ruptur uretra 40 Tailoring ureter 41 Transuretero-ureterostomi 42 Insisi posterior urethral valve 43 Pielokalikotomi 44 Psoas Hitch/ Boari flap 45 Rekonstruksi Renovaskuler 46 Ureterokutaneostomi 47 Uretroplasti hipospadia 48 Vasostomi 49 Augmentasi buli 50 Orkhidopeksi (UDT) 51 Ureterouretostomi 52 Koreksi Priapismus 5. Khusus II 1 Horseshoe Kidney Koreksi 2 Ileal Conduit (Bricker) 3 Adrenalektomi abdominotorakal 4 Epididimovasostomi 5 Repair vesico vagina fistel 6 Nefro Ureterectomi 7 Radikal Nefrektomi 8 Extended Pyelolithotomy 9 Litholapaksi 10 Bladder Neck Rekonstruksi 11 Divertikulektomi Buli 12 Operasi trauma ginjal 13 Pyeloplasty 14 Reimplantasi ureter bilateral 15 Reimplantasi ureter Unilateral/Ureteroneosistostomi 16 Urethrektomi 6. Khusus III 1 Deroofing Kista Ginjal per laparoskopi 2 Diseksi kelenjar getah bening pelvis per laparoskopi 3 Laparoskopi Adrenalektomi 10
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 -
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 -
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 -
10,800,000 10,800,000 10,800,000
7,200,000 7,200,000 7,200,000
18,000,000 18,000,000 18,000,000
JENIS
NO 4 5 6 7 8 9 10 11 F.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
Orkhidopeksi per laparoskopi Pieloplasti Per Laparoskopi Nefrektomi Per Laparoskopi Retro Peritoneal Lymp Node Dissection (RPLND) RPLND Ekstrofi buli rekonstruksi Radikal Prostatektomi Radikal Sistektomi
BEDAH ONKOLOGI 1. Sedang II 1 Biopsi Eksisi/Insisi dengan anasthesi umum 2 Marsupialisasi 3 Trakeostomi elektif 4 Limfedenektomi 5 Pemasangan WSD 6 Ekstirpasi tumor jinak 7 Eksisi Sederhana 8 Gastrostomi 9 Eksisi FAM single 10 Laparatomy Eksplorasi 2. Besar I 1 Mastektomi Simple/sederhana 2 Mastektomi Sub. Kutan 3 Eksisi mamma Aberran 4 Eksisi tumor jinak payudara multiple/penyulit 5 Mikrodoektomi papiloma intraduktal mamma 6 Repair fistel oesophagus pasca op. tiroid 7 Trakeostomi emergensi 8 Cald Well Luc Anthrostomi 9 Debulking tumor ganas 10 Amputasi lengan/tungkai sederhana 11 Rekonstruksi sederhana : 12 Flap lokal, rotasi flap 13 Mandibulotomy 3. Besar II 1 Unroofing maksila 2 Eksisi Hemangioma besar/multiple 3 Eksisi Higroma/Limpangioma 4 Skin Graft full/ split thicknes 5 Mandibulectomy Segmental/marginal 6 Eksisi kista Tiroglusus 7 Isthmulobectomy + Potong beku 8 Partial Glosectomy 9 Eksisi tumor submandibula / Sub lingual 10 Eksisi bronchogenic 11 Hemiglosektomi 12 Breast conserving treatment (BCT) 13 Rekonstruksi Payudara TRAM/LD FLAP 4. Khusus I 1 Mastektomi radikal klasik/modifikasi 2 Diseksi aksila LI/LII 3 Parotidektomi 4 Maksilektomi 5 Diseksi KGB/Pelvis 6 Glosektomi Total 7 Rekonstruksi Mandibula 8 Eksisi luas tumor ganas 9 Rekonstruksi defek luas 10 Subkutan mastektomi kanker payudara 11 Operasi Commando 12 Buttockectomy 13 Hip Joint Articulation 5. Khusus II 1 Pembedahan forequater 2 Hemipelvektomi 3 Total Tiroidektomi + berrypicking (limfadenektomi) 11
10,800,000 10,800,000 10,800,000 10,800,000 -
7,200,000 7,200,000 7,200,000 7,200,000 -
18,000,000 18,000,000 18,000,000 18,000,000 -
1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000 3,375,000
2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000 2,250,000
5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000 5,625,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000
JENIS
NO 4 5 6 7 8 9 G.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
Diseksi leher radikal modifikasi/fungsional (RND) Hemamandibulektomi Mandibulektomi Total Endoscopy Tiroidectomy (MIVAT) Rekonstruksi/Skin Graft yang kompleks dan luas Bone Graft
BEDAH PLASTIK 1. Sedang I 1 Semua tindakan yang dilakukan dgn narkose risiko tinggi 2 Labioplasty sumbing bibir bilateral 3 Ekstripasi tumor jinak 4 Rozerplasty 5 Ekstirpasi di muka 6 Skin graft sederhana 7 Potong flap 8 Revisi parut 9 Skingrafting yang tidak luas 10 Eksisi Chordae Hipospadia 11 Repair Fistel urethra pascauretroplasti 12 Reposisi fraktur sederhana os nassal 13 Terapi Sklerosing 14 Debridement Luka Bakar 2. Besar 1 Semua tindakan yang dilakukan dengan narkose dan mempunyai risiko 2 tinggi Labioplasty sumbing bilateral 3 Rekonstrukasi defek/kelainan tubuh lain 4 Skingrafting yang luas 5 Kontraktur tangan dan jari 6 Kontraktur leher 7 Tendoplasty 8 Fraktur rahang sederhana 9 Palatoplasty 10 Repair luka pada wajah kompleks 11 Repair tendon 12 Hemiglosektomi 13 Mandibulektomi Marginalis 14 Debridement Luka Bakar Luas 4. Khusus 1 Semua tindakan yg dilakukan dgn narkose dan memerlukan teknik operasi khusus.Mikro > 5 jam 2 Bedah 3 Gabungan 2 atau lebih Operasi Besar dgn Sedang atau Besar dengan Besar 4 Reduksi Mamma 5 Fraktur Muka dengan Miniplate Screw 6 Mikrotia 7 Rekontruksi parah Ablatio Tumor dengan Flap 8 Eksisi Hemagina Besar + Rekonstruksi dgn Flap 9 Eksisi Hemagroma + Rekonstruksi dgn Skin graft 10 Free Flap Surgery 11 Eksisi Luas Radikal + Rekonstruksi 12 Hemiglosektomy + RND 13 Glosektomy Total 14 Hemipelvektomy Total 15 Wide Eksisi Carcirona Kulit 16 FR. Nasal 17 Wide Eksisi Carcirona Kulit 18 FR. Nasal 19 Eksisi Lymphagiona 20 Ortogratic Surgery 21 Eksisi Chordae Hipospadi Khusus 22 Urethroplasty Hipospadi Khusus 23 Operasi Rekonstruksi (Pallpebra, Telinga, Hidung, Tangan dan Jari) 24 Mammaplasty 25 Blepharoplasty Khusus 26 Faclift Khusus 27 Abbodinal Lipectomy Khusus 28 Mandibulektomy Total 12
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
JENIS
NO
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
29 Mandibulektomy Partialis dangan rekonstruksi 30 Koreksi Impresif Fraktur 31 Maksilektomi Total H.
BEDAH SYARAF 1. Besar 1 Koreksi impresif fraktur sederhana kurang dari 1 jam 2 Pemutusan dan eksisi syaraf 3 Dekompresi saraf perifer 4 PPRG ( Percutaneus Retro Gassenan Pnizotomi ) 5 Koreksi impresif fraktur sederhana lebih dari 1 jam 6 Pemasangan fiksasi interna 7 Fungsi cairan otak 8 Biopsi syaraf kutaneus 9 Ekstirpasi tumor ekstrakarnial 10 Trakeostomi 2. Khusus I 1 Ekstirpasi Tumor Scalp / Cranium 2 Pemasangan Traksi Cervical / dan pemasangan HaloVest 3 Ventrikulostomi / VE Drainage 4 Fronto-orbital advancement pada craniosynostosis 5 Dekompresi Syaraf tepi 6 Neurektomi/Neurolise 7 Pemasangan Pintasan VA / VP Shunt 8 EMG / Evoked untuk intra operatif monitoring (IOM) 3. Khusus II 1 Pemasangan fiksasi interna pada kasus bedah syaraf/instrumentasi 2 Koreksi Scoliosis 3 Koreksi Spondilitis 4 Complicated Functional Neuro Percuteneus/Paraverteb/Visceral block 5 Laminektomi Sederhana (single level) 6 Operasi Fusi Korpus Vertebra Approach Anterior 7 Operasi konvensial Plexus Brakhialis / Lumbalis Sacralis / Cranialis / Perifer 8 Spinalis Rekontruksi Meningokel Kranial (anterior/pasterior) 9 Rekontruksi Meningokel Spina bifida 10 Tumor spinal Daerah Torakolumbal 11 HNP Lumbalis Kompleks (lebih dari 1 segmen approach posterior 12 Kraniotomi/trepanasi konvensional 13 HNP Lumbalis Kompleks (lebih dari 1 segmen approach anterior 4. Khusus III 1 Complicated Functional Neuro Percuteneus Kordotomi 2 Laminektomi Kompleks (multilevel) 3 Operasi HNP / penyempitan syaraf / tulang belakang 4 Operasi Kranioplasti / Koreksi Fraktur 5 Tumor spinal Daerah Cervikal 6 Pembedahan tulang belakang lain ( tumor spinal, cloward, spina bifida ) approachstereotaktik posterior maupun anterior 7 Operasi dan neuroendoskopi 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
I.
Koreksi impresif fraktur komplikata (midline) Eksplorasi kelainan otak supratentorial (biopsi) Infratentorial serta hipofise tumor (tumor pasca posterior Infratentorial serta hipofise (SLTH) Pengangkatan tumor otak Operasi stabilisasi dan reposisi fraktur tulang belakang Operasi HNP penyempitan syaraf/tulang belakang Kraniotomi+Bedah Mikro Kraniotomi+Endoskopi Operasi Mikro Cranialis / Spinalis Perifer Complicated Functional Neuro Stereotaxy sederhana Tumor spinal Daerah Kraniospinal Operasi Fusi Korpus Vertebra Approach Posterior Operasi Miko Plexus Brakhialis / Lumbalis Sacralis Complicated Functional Neuro Stereotaxy kompleks
BEDAH THORAX 1 Besar 1 Thorax Drainage, WSD 2 Open Windows pada Empyema 13
4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000
10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000 10,800,000
7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000 7,200,000
18,000,000 18,000,000 18,000,000 18,000,000 18,000,000
2,532,000 2,532,000
1,688,000 1,688,000
4,220,000 4,220,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000
JENIS
NO
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
3 Open Biopsi Tumor Paru, Mediastinum 4 Resectie IGA & Bone Graft 5 Debridement 2. Khusus I 1 Dekorticasi 2 Lobectomy Paru 3 Operasi tumor mediastinum, dll 4 Toracotomy corpus alineum 3. Khusus II 1 Torakotomi 2 Open thoracotomi 3 PPA : Lobectomi 4 Dekorticasi 5 Lobektomi paru 6 Operasi tumor mediastrium 7 Air Plumbage 8 Muscle Plombage 9 Pnemonektomi 10 Segmentektomi 11 Omentumpexy 12 Reseksi Trachea 13 Slevece Lobektomi 14 Slevece Pnemonemoktomi 15 Trakeoplasi J.
BEDAH ANAK 1. Sedang I 1 Biopsi Insisi tumor dengan narkose 2 Biopsi / Eksisi KGB, Lipoma, Ateroma, Ganglion 3 Insisi drainase / debridemen abses 4 Insisi tongue tie 5 Eksisi Gynecomastia 6 Eksisi Granuloma Umbilikal 7 Eksisi Hemangioma kecil 8 Release Sinekhia vulva 9 Biopsi rektum 'full thickness' 10 Polipektomy rektum 2. Sedang II 1 Herniotomi / Appendektomi 2 Ligasi Tinggi 3 Orchidectomy 4 Kolostomi pada anak 5 Gastrostomi pada anak 6 Eksisi kista branchial 7 Eksisi Higroma / Limfangioma simple 8 Eksisi kista duktus tiroglosus (Operasi Systrunk) 9 Repair defek hernia umbilikalis 10 Eksisi Baker cyst 11 Potong stump 12 Septectomy (potong septum) 13 Sphincterotomy / Lynn procedure 14 Prosedur Tiersch (prolapsus rekti) 15 Fistulektomi perianal 16 Gastroduodenoskopi 17 Kolonoskopi 3. Besar 1 Kolostomi neonatos 2 Gastrostomi pada neonatos 3 Herniotomy pada hernia inkarserata/strangulata 4 Herniotomy bilateral 5 Higroma colli / limfangioma besar 6 Eksisi hemangioma besar / multiple 7 Eksisi hemangioma dengan skin graft STSG / FTSG 8 Laparotomi+Appendektomi pada Appendix perforasi 9 Laparotomi + milking / reseksi pada invaginasi 10 Laparotomi pada trauma abdomen 11 Laparotomi pada perforasi usus 14
2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
JENIS
NO
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
12 Laparotomi + reseksi usus halus / kolon 13 Proof laparotomy / biopsi per laparotomy 14 Splenectomy pada trauma 15 Eksisi kista urachus 16 Skrotoplasti 17 Khordektomi 18 Detorsi testis + Orchidopexy 19 Anoplasty / limited PSARP 20 Repair fistel recto-vaginal 4. Khusus 1 Thoracotomi + anastomosis esofagus 2 Esofagostomi + gastrostomi ( atresia esofagus ) 3 Esofagomyotomi (Operasi Heller) 4 Reseksi + anastomosis esofagus 5 Esophageal replacement procedure ( transposisi kolon, transposisi gaster, gastrichygroma pull-up) colli / axilla neonatus 6 Eksisi 7 Fundoplikasi gaster 8 Reseksi gaster 9 Pyloromyotomi (Operasi Fredet-Ramstedt) 10 Duodenoduodenostomi / Duodenojejunostomi 11 Ladd"s procedure 12 Laparotomi pada peritonitis neonatal 13 Penutupan Defek Hernia Diafragmatika 14 Plikasi diafragma 15 Reseksi Hepar (Tumor, Trauma) 16 Portoenterostomi (operasi Kasai) 17 Eksisi kista saluran empedu 18 Cystojejunostomi 19 Reseksi anastomosis pada atresia usus, duplikasi usus 20 Repair defek dinding perut (omphalocele,gastroschizis) 21 Herniotomy+laparotomy+reseksi+anastomosis 22 Abdominoperineal pull-through (malformasi anorectal) 23 Abdominorectal pull - through / Swenson procedure 24 Endorectal pull-through / Soave-Boley procedure 25 Retrorectal pull-through / Duhamel procedure 26 Postero Sagittal Anorectoplasty / PSARP 27 PSARP + laparatomi (abdomino perineal approach) 28 Postero Sagittal Anorectovaginourethroplasty / PSARVUP 29 Eksisi neuroblastoma 30 Eksisi Teratoma retroperitoneal 31 Eksisi Teratoma sacrococcygeal 32 Eksisi Teratoma ovarium 33 Splenektomi (thalasemia, hipersplenisme) 34 Nefrektomi parsial 35 Nefrouretektomi tumor Wilms' 36 Pyeloplasty 37 Reimplantasi ureter 38 Genitoplasty (clitoroplasty, vaginoplasty, phalloplasty) 39 Urethroplasty 40 Scrotoplasty + Chordectomy 41 Repair cloacal extrophy 42 Repair Bladder extrophy 43 Endoscopy teurapeutic 44 Bedah laparoskopi anak K.
BEDAH MATA 1. Sedang I 1 Iridectomy perifer / sektoral 2 Parasentese 3 Eviscreatie / Enuclatio 4 Blepharoplasty 5 Symblepharon luas 6 Koreksi entropion 7 Congenital fornik plastik 8 Silikon intubasi 9 Rekanalisasi rupture 10 Trans kanal 15
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
JENIS
NO
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
11 Koreksi entropion congenital 12 Argon laser/kenon dengan anestesi lokal 13 Cyclodeatheral 14 Fotokoagulasi argon laser 15 Aplikasi cryo 2. Besar 1 Goniotomi 2 Anterior Scleroktomi 3 Cyclodialysa 4 Tridencleisis 5 Posterior Scleroktomi 6 Trabeculectomi 7 Ablatio Retina 8 Vitrectomy 9 Blow Out Fraktura 10 Rekonstruksi Saket 11 Katarak (ECCE, ICCE, Ekstraksi Linear, Ekstraksi Inplant/IOL) 12 Ekstraksi Corpus Alienum Intraoculer 13 ECCE + Lensa Inplant 14 ICCE + Lensa Inplant 15 Ekstraksi Inplant 16 Inplant Lensa Sekunder 17 Keratoplasti Lamelar 18 Strabismus Koreksi 19 Enucleasi / cangkok lemak 3. Khusus I 1 Rekonstruksi Saket Berat 2 Rekonstruksi Kelopak Berat 3 Pasca Trauma Mekanik/ Non Kekanik Dekompresi 4 Rekonstruksi Orbita Kongenital 5 Koreksi Blefaro Fimosis Lengkap 6 Orbitotomi Lateral 7 dengan Glaukoma. 8 Refrektif Surgery 9 Eximer Laser 5. Khusus II 1 Fraktur Tripodo / Multiple 2 Triple Procedure Keratoplasti dgn Inplant IOL & ECCE 3 Phacoemulsifikasi 4 Trabekulektomi + ECCE/Phacoemulsifikasi 5 Strabismus 3 - 4 Otot 6 Syndroma Blefarophimosis 7 Tumor Ganas / Adnexa Luas dengan Rekonstruksi 8 Vitrektomi + Endo Laser + SB + Silikon Oil/Gas L.
BEDAH THT 1. Sedang I 1 Ekstraksi Granulasi Liang Telinga (Bius Umum) 2 Adenoidektomi (Bius Umum) 3 Tampon Bellocq 4 Labioplasty (Bius Lokal) 5 Insisi Abses / Abses Sub Periostal ( Retroaurikular ) 6 (Bius Umum) 7 Insisi Abses Septum (Bius Umum) 8 Miringoplasty 2. Besar 1 Reposisi Nasal 2 Trepanasi Sinus Frontalis 3 Cadwell Luc op 4 Mikrolaringoskopy 5 Reseksi konka Buloga 6 Konkotomi 7 Tonsilektomi dengan Anastesi Umum 8 Polipektomi dengan Anastesi Umum 9 Esofaguskopy 10 Mostoidektomi Simpel 11 Tracheostomy 16
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
JENIS
NO
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
3. Khusus I 1 Mastoidektomi Radikal/Dekompresi Fasialis 2 Laringektomi 3 Degloving / Transpalatal / Rinotomi Lateral 4 Maksilektomi 5 FESS 6 Stapedektomi 7 Glosektomi Total 8 Radical Neck Dissection 9 Rekonsruksi Liang Telinga / Meatoplasty 10 Timpanomastoidektomi 11 Konkoplasty 12 Septorinoplasty THT 13 Rekonstruksi Laring / Laringofissure 14 Struktur Trakes / Trakeofissure 15 Palatoplasti 16 Reposisi Maxilofacial 17 Bronchoscopy 18 Rinoplasty 19 Septoplasty 20 Parotidectomy 21 Extraksi Duktus Triglosus 4. Khusus II 1 Stapedektomi 2 Implantansi Koklea 3 Reimplantasi Koklea 4 Laringektomi + RND THT 5 Myocutaneus Flap/Pectoral Mayor 6 Neuroktomi Saraf Vidian M.
BEDAH OBGYN 1. Sedang I 1 Biopsi Ca. Cervix 2 Biopsi Ca. Vulva 3 Fungsi Ascites 4 Kauterisasi 5 Kriotherapi 6 Eksisi Bartholimi Cyst 7 Hidro Tubasi 8 Removal Implanoe / Jadena Norplant 9 Biopsi Endometrium 10 Kuretase dengan Penyulit 11 Sectio Sesarea 2. Sedang II 1 Sterilisasi Minilaparatomi / Laparoskopi 2 Ekstraksi Vacuum / Forceps 3 Laparatomy Percobaan 4 Perineoraphi / Kolporaphia 5 Embriotomy 6 Sterilisasi Post Partum 7 Mini Laparatomy 3. Besar 1 Tumor ovarium jinak 2 Myomectomy 3 Laparactomy Kehamilan Ektopik 4 Salpingo-ooforectomy 5 Histerectomy Simple 6 Sectio Sesarea dengan Komplikasi 4. Khusus 1 Radikal Histerektomi (Ca. Cervix) 2 Radikal Vulvectomy (Ca. Vulva) 3 Surgical Staging Ca. Ovarium 4 Surgical Staging Ca. Endometrium / Corpus 5 TVH + Kolposkopi Anterior & Posterior 6 Tuboplasty 7 Laparaskopi Operatif 8 Operasi Fistula Genitalis 17
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
5,850,000 5,850,000 5,850,000 5,850,000 5,850,000 5,850,000
3,900,000 3,900,000 3,900,000 3,900,000 3,900,000 3,900,000
9,750,000 9,750,000 9,750,000 9,750,000 9,750,000 9,750,000
1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000
936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000
2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000 2,340,000
1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000 1,968,000
1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000 1,312,000
3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000 3,280,000
2,532,000 2,532,000 2,532,000 2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000 1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000 4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
JENIS
NO 9 10 11 12 13 N.
BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )
PELAYANAN
Histereskopi Operatif Operasi Purundane Adenolisis Eksisi Kista Urachus Repair Fistel
BEDAH KULIT DAN KELAMIN 1. Sedang I a. Ekstirpasi Tumor 2. Sedang II a. Reduksi Scalap 3. Besar 1 Blepharoplasty 2 Dermabrasi 3 Transplantasi Rambut 4. Khusus 1 Bedah Sedot Lemak 2 Repigmentasi Vitiligo 3 Skin Flap 4 Skin Graft
18
4,050,000 4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000 6,750,000
1,404,000
936,000
2,340,000
1,968,000
1,312,000
3,280,000
2,532,000 2,532,000 2,532,000
1,688,000 1,688,000 1,688,000
4,220,000 4,220,000 4,220,000
4,050,000 4,050,000 4,050,000 4,050,000
2,700,000 2,700,000 2,700,000 2,700,000
6,750,000 6,750,000 6,750,000 6,750,000
