TINDAKAN KELAS III RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014 BESARAN TARIF TA NO

TARIF PELAYANAN / TINDAKAN KELAS III RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014 JENIS

NO

1 I.

II.

BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp ) 3 4 5

PELAYANAN 2

INSTALASI RAWAT JALAN A. Karcis Harian 1. Poliklinik 2. Kartu Identitas Pasien (Embosar) 3. Administrasi Sistem Informasi B. Tarif Konsultasi Medis Spesialisasi Rawat Jalan 1. Dokter Spesialis 2. Dokter Gigi 3. Gizi / Farmasi 4. Konsultasi / Konseling HIV/AIDS 5. Psikologi 6. Dll Keterangan : a. Tarif Karcis Harian tersebut diatas untuk 1 (satu) kali kunjungan dan berlaku untuk pemeriksaan tindakan standar di Poliklinik. b. Apabila ada pemeriksaan Penunjang Diagnostik, Tindakan Medik dan Radio Therapi, Rehabilitasi Medik dibayar sesuai dengan tarif RS. c. Konsultasi Medis Spesialis Pasien Rawat Jalan, harus berdasarkan Rujukan Intern dari Bagian / SMF yang memerlukan hal tersebut ke Bagian / SMF lain, Gizi, Farmasi, Posyansus dan Psikolog untuk keperluan tindak lanjut Observasi, Diagnosa, pengobatan dan pelayanan kesehatan lainnya tanpa tinggal di Ruang Rawat Inap. d. Kartu Identitas pasien (Embosar) hanya dibayar untuk 1 (satu) kali untuk Pasien Umum dan Askes, tidak berlaku untuk Pasien Jamkesmas. Apabila Kartu Identitas hilang, harus membayar lagi sesuai tarif yang berlaku (berlaku untuk Pasien Umum, Askes & Jamkesmas) e. Pasien Rawat Inap yang dilakukan Pemeriksaan / Tindakan atau Konsultasi di Instalasi Rawat Jalan maka Tarifnya diberlakukan sesuai dengan Kelas Rawatannya. TARIF INSTALASI GAWAT DARURAT A. Karcis Harian - Administrasi Sistem Informasi tindakan standar di IGD. B. RUANG TRIASE 1. Konsultasi Dokter Spesialis 1x C. 1. EKG 2. Kumbah Lambung 3. Dilatasi Phimosis 4. Eksisi Clavus 5. Eksisi Condiloma A. 6. Eksisi Keloid 7. Eksisi Veruka Vulgaris 8. Ekstraksi Kuku 9. Ganti Balut (Khusus Gangren Diabetika & Luka ) 10. Insisi Furunkel / Abses 11. Irigasi Telinga 12. Nekrotomi 13. Pasang / Angkat Implant / IUD 14. Tindakan Hecting 15. Pasang Infus Umbilikalis (Pediatric) 16. Pasang Belog Tampon 17. Pasang Kateter (Kasus Non Operasi) 18. Ekstirpasi Corpus Alienum 19. Pengobatan Epistaksis 20. Pungsi Hematoma Telinga 21. Tindakan Businasi 22. Tindakan Cuci Sinus (Perawatan) 23. Tindakan Nebulizer 24. Tindakan pembuatan Visum et Repertum (Korban Hidup / berkaitan dengan dan Hukum) 25. Asuransi Pasang NGT 26. 27. 28. 29. 30. 31.

Pasang ETT Pasang Infus Cuci Luka Tindakan Suction Ganti Balut Pasang Spalk 1

8,000 4,000 1,500

2,000 1,000 -

10,000 5,000 1,500

3,300 3,300 2,400 3,300 2,400 2,400

13,200 13,200 9,600 13,200 9,600 9,600

16,500 16,500 12,000 16,500 12,000 12,000

20,000 1,500

5,000 -

25,000 1,500

5,000 30,000 120,000 75,000 75,000 75,000 75,000 75,000 42,000 24,000 60,000 30,000 60,000 42,000 42,000 108,000 42,000 24,000 30,000 30,000 30,000 42,000 24,000 24,000 21,000 24,000 60,000 15,000 24,000 24,000 24,000 24,000

20,000 20,000 80,000 50,000 50,000 50,000 50,000 50,000 28,000 16,000 40,000 20,000 40,000 28,000 28,000 72,000 28,000 16,000 20,000 20,000 20,000 28,000 16,000 16,000 14,000 16,000 40,000 10,000 16,000 16,000 16,000 16,000

25,000 50,000 200,000 125,000 125,000 125,000 125,000 125,000 70,000 40,000 100,000 50,000 100,000 70,000 70,000 180,000 70,000 40,000 50,000 50,000 50,000 70,000 40,000 40,000 35,000 40,000 100,000 25,000 40,000 40,000 40,000 40,000

JENIS

NO

D.

E. F.

G.

BESARAN TARIF TA. 2014 JS JP JLH ( Rp ) ( Rp ) ( Rp )

PELAYANAN

32. Tindakan Extubasi 33. Penanganan Luka Bakar < 10% 33. Penanganan Luka Bakar 10% - 30% 34. Penanganan Luka Bakar > 30% 35. Resisutasi Jantung Paru 36. Sirkumsisi 37. Monitor EKG 38. Colar Neck 39. Aspirasi Pneumotoraks 40. Eksisi Khalazion 41. Eksisi Hordeolum / Granuloma 42. Insisi Abses Besar 43. Jahit Luka Palpebra 44. Pasang Gips 45. Pengangkatan Nevus 46. Tindakan Pungsi Lumbal 47. Ekstirpasi Fibroma 48. Injeksi Varises (termasuk obat) 49. Insisi Mucocele 50. Pemasangan WSD 51. Pungsi Pleura 52. Pungsi sum-sum tulang 53. Reposisi dengan Anestesi Lokal 54. Sistostomi dengan Anestesi Lokal 55. Tindakan Manual Plasenta 56. Vena Seksi 1. Ruang Observasi (> 6 Jam tanpa Monitoring) 2. Ruang Resusitasi dengan Monitoring 3. Ruang Observasi Intensive / HCU 4. Ruang Recovery / Intermediate (Post Operatif > 4 jam) 5. One Day Care DC Shock, Defibrilator, Ventilator, Temporary Pace Maker, Incubator, Nebulizer, dll Tarifnya disesuaikan dengan 1. Bronchial Provocation TestTarif ICCU. 2. Bronchoscopy 3. Bronchoscopy + Biopsi 4. Bronchospirometri 5. Laryngoscopy 6. Sinuscopy 7. USG Organ TINDAKAN MEDIS OPERATIF 1. Bedah Digestive a. Sedang I b. Sedang II c. Besar d. Khusus I e. Khusus II f. Khusus III 2. Bedah Vaskuler a. Sedang I b. Sedang II c. Besar d. Khusus I e. Khusus II f. Khusus III 3. Bedah Orthopedi a. Sedang II b. Besar c. Khusus I d. Khusus II e. Khusus III 4. Bedah Gimul a. Sedang I b. Sedang II c. Besar d. Khusus 5. Bedah Urologi a. Sedang I 2

24,000 30,000 60,000 105,000 60,000 60,000 60,000 24,000 60,000 75,000 75,000 75,000 75,000 60,000 45,000 60,000 75,000 195,000 75,000 180,000 180,000 180,000 180,000 180,000 180,000 180,000 60,000 90,000 150,000 150,000 90,000

16,000 20,000 40,000 70,000 40,000 40,000 40,000 16,000 40,000 50,000 50,000 50,000 50,000 40,000 30,000 40,000 50,000 130,000 50,000 120,000 120,000 120,000 120,000 120,000 120,000 120,000 40,000 60,000 100,000 100,000 60,000

40,000 50,000 100,000 175,000 100,000 100,000 100,000 40,000 100,000 125,000 125,000 125,000 125,000 100,000 75,000 100,000 125,000 325,000 125,000 300,000 300,000 300,000 300,000 300,000 300,000 300,000 100,000 150,000 250,000 250,000 150,000

102,000 282,000 300,000 342,000 90,000 45,000 72,000

68,000 188,000 200,000 228,000 60,000 30,000 48,000

170,000 470,000 500,000 570,000 150,000 75,000 120,000

1,875,000 2,625,000 3,375,000 5,400,000 7,800,000 13,500,000

1,250,000 1,750,000 2,250,000 3,600,000 5,200,000 9,000,000

3,125,000 4,375,000 5,625,000 9,000,000 13,000,000 22,500,000

1,875,000 2,625,000 3,375,000 6,000,000 9,000,000 14,400,000

1,250,000 1,750,000 2,250,000 4,000,000 6,000,000 9,600,000

3,125,000 4,375,000 5,625,000 10,000,000 15,000,000 24,000,000

2,625,000 3,375,000 5,400,000 9,000,000 13,200,000

1,750,000 2,250,000 3,600,000 6,000,000 8,800,000

4,375,000 5,625,000 9,000,000 15,000,000 22,000,000

1,875,000 2,625,000 3,375,000 5,400,000

1,250,000 1,750,000 2,250,000 3,600,000

3,125,000 4,375,000 5,625,000 9,000,000

1,875,000

1,250,000

3,125,000

NO

JENIS


PELAYANAN

b. Sedang II c. Besar d. Khusus I e. Khusus II f. Khusus III 6. Bedah Onkologi a. Sedang I b. Sedang II c. Besar d. Khusus I e. Khusus II 7. Bedah Plastik a. Sedang I b. Besar c. Khusus 8. Bedah Syaraf a. Besar b. Khusus I c. Khusus II d. Khusus III 9. Bedah Thorax a. Besar b. Khusus I c. Khusus II 10. Bedah Anak a. Sedang I b. Sedang II c. Besar d. Khusus 11. Bedah Mata a. Sedang I b. Besar c. Khusus I d. Khusus II 12. Bedah THT a. Sedang I b. Besar c. Khusus I d. Khusus II 13. Bedah Obgyn a. Sedang I b. Sedang II c. Besar d. Khusus I 14. Bedah Kulit dan Kelamin a. Sedang I b. Sedang II c. Besar d. Khusus I Keterangan : 1. Jasa Sarana (JS) sudah termasuk Bahan Habis Pakai tidak termasuk Alat kesehatan. 2. Pelayanan Operasi Komulatif (Multiple / Beberapa operasi dalam satu waktu) yang dilakukan oleh satu dokter atau operator : a. 2 (dua) macam operasi : * tarif operasi utama sesuai tarifnya * tarif operasi kedua sama dengan 60 % dari tarifnya b. 3 (tiga) macam operasi : * tarif operasi utama sesuai tarifnya * tarif operasi selebihnya sama dengan 50 % dari tarifnya 3. Pasien baru yang berobat masuk melalui IGD, tarif Bedah disesuaikan dengan Tarif IBP Kelas II. 4. Pasien Rawat Inap yang dilakukan tindakan Operasi di IGD diluar jam kerja maka tarif tindakan operasi untuk pasien Kelas III dikenakan tarif Kelas II dan untuk pasien Kelas II, I, VIP diberlakukan sesuai dengan kelas perawatannya. 5. Apabila ada dilakukan tindakan selain tindakan tersebut diatas, maka dihitung Tarif Tindakan Kelas II (Poli Rawat 3

2,625,000 3,375,000 5,400,000 7,800,000 10,800,000

1,750,000 2,250,000 3,600,000 5,200,000 7,200,000

4,375,000 5,625,000 9,000,000 13,000,000 18,000,000

1,875,000 2,625,000 3,375,000 5,400,000 7,800,000

1,250,000 1,750,000 2,250,000 3,600,000 5,200,000

3,125,000 4,375,000 5,625,000 9,000,000 13,000,000

1,875,000 3,375,000 5,400,000

1,250,000 2,250,000 3,600,000

3,125,000 5,625,000 9,000,000

3,375,000 5,400,000 7,800,000 10,800,000

2,250,000 3,600,000 5,200,000 7,200,000

5,625,000 9,000,000 13,000,000 18,000,000

3,375,000 5,400,000 7,800,000

2,250,000 3,600,000 5,200,000

5,625,000 9,000,000 13,000,000

1,875,000 2,625,000 3,375,000 5,400,000

1,250,000 1,750,000 2,250,000 3,600,000

3,125,000 4,375,000 5,625,000 9,000,000

1,875,000 3,375,000 5,400,000 7,800,000

1,250,000 2,250,000 3,600,000 5,200,000

3,125,000 5,625,000 9,000,000 13,000,000

1,875,000 3,375,000 5,400,000 7,800,000

1,250,000 2,250,000 3,600,000 5,200,000

3,125,000 5,625,000 9,000,000 13,000,000

1,875,000 2,625,000 3,375,000 5,400,000

1,250,000 1,750,000 2,250,000 3,600,000

3,125,000 4,375,000 5,625,000 9,000,000

1,875,000 2,625,000 3,375,000 5,400,000

1,250,000 1,750,000 2,250,000 3,600,000

3,125,000 4,375,000 5,625,000 9,000,000

JENIS

NO

6. 7.


PELAYANAN

Jalan dan Instalasi Penunjang Medik) Tarif tindakan medik operatif dan operatif diatas berlaku untuk bedah elektif. Tarif tindakan medik operatif dan operatif diatas untuk bedah sesuai perjanjian dengan dokter diberlakukan tarif Kelas II.

H.

1. Persalinan Tanpa Penyulit 2. Persalinan Dengan Penyulit per Vaginam 3. Inspeculo 4. Kuretase tanpa Narkose I. PELAYANAN GAS MEDIS 1. Oksigen / liter 2. Oksigen Bayi (Perinato) / liter 3. Oksigen Perinato dengan head box / liter 4. Oksigen dengan Ventilator / liter 5. N2O / liter 6. Udara Tekan (UT) / liter 7. CO2 / liter / menit 8. CO2 / Tabung ukuran 2 kg 9. CO2 / Tabung ukuran 5 kg 10. CO2 / Tabung ukuran 25 kg 11. O2 / Tabung 6m3 12. O2 / Tabung 2m3 13. O2 / Tabung 1m3 14. Respiflo / flash

III.

A. TARIF RUANGAN RAWAT INAP TERPADU (RINDU) A, B dan KARDIOVASKULER 1. Akomodasi Ruangan 2. Visite / Konsultasi Spesialis 1 kali 3. Visite Tim Spesialis berkelompok 3 orang yang berbeda/1 kali 4. Visite Dokter PPDS 5. Visite/Konsultasi oleh Dokter Spesialis untuk pasien kiriman RS swasta atau kiriman Dokter Praktek Swasta 6. Konsultasi Gizi/Farmasi

210,000 450,000 24,000 180,000

140,000 300,000 16,000 120,000

350,000 750,000 40,000 300,000

25 30 50 70 300 70 9,000 50,000 65,000 270,000 125,000 50,000 40,000 66,000

5 5 15 20 100 10 3,000 10,000 20,000 80,000 9,000

30 35 65 90 400 80 12,000 60,000 85,000 350,000 125,000 50,000 40,000 75,000

31,500 9,000 6,600 -

13,500 20,000 40,000 6,000 32,000 6,000 9,900 5,000

45,000 20,000 40,000 6,000

74,400 25,800 35,700 19,200 26,400 84,000 15,000 84,000 18,600 9,000 180,000 36,000 36,000 54,000 72,000 120,000 270,000

49,600 17,200 23,800 12,800 17,600 56,000 10,000 56,000 12,400 6,000 120,000 24,000 24,000 36,000 48,000 80,000 180,000

124,000 43,000 59,500 32,000 44,000 140,000 25,000 140,000 31,000 15,000 300,000 60,000 60,000 90,000 120,000 200,000 450,000

7. Konsultasi/Konseling HIV/AIDS 8. Konsultasi Kemotherapy Keterangan : 1. Tarif pemeriksaan Penunjang Diagnostik, Tindakan Medik dan Therapy, Rehabilitasi Medik dan pelayanan kesehatan lainnya apabila ada, dibayar terpisah oleh pasien sesuai tarif pemeriksaan/tindakan sesuai dengan Kelas rawatan. 2. Visite dan Konsultasi Medis dilaksanakan oleh Dokter Spesialis/PPDS dan disetujui pasien dan atau keluarganya pada setiap pergantian Dokter Spesialis/PPDS. 3. Konseling/konsultasi HIV/AIDS dilakukan oleh Petugas Pusyansus (Pusat Pelayanan Khusus). 4. Visite dan Konsultasi Medis lebih dari 1 (satu) kali per hari maka dikenakan Tarif tambahan 50 % dari Visite/Konsul terdahulu. 5. JP untuk Visite diatas adalah JDA. 6. Untuk Tarif Pemeriksaan di Poliklinik dan Penunjang Medis jika dilaksanakan di Ruangan Rawat Inap maka dikenakan Biaya Tarif sesuai dengan Kelas rawatan. B. TINDAKAN DI RINDU A, RINDU B DAN KARDIOVASKULER 1. WSD Continue 2. Punctie Pleura Proef 3. Punctie Pleura Therapi 4. Punctie Ascites 5. Aspirasi Jarum Halus 6. Biopsi 7. Pasang Nebulizer /1x 8. Pasang Gip's 9. Wash Out 10. Penyampuran Obat Kemotherapy 11. Tindakan Kemotherapy 12. Audiometri 13. Timpanometri 14. Timpanometri + Refleks Akustik 15. Timpanometri + Refleks Akustik + Tes Fungsi Tuba 16. BMP 17. Fleurodesis Catatan : Untuk tindakan keperawatan seperti : ganti verban kecil, sedang , besar; ganti luka bakar ringan, 4

32,000 15,000 16,500 5,000

NO

JENIS


PELAYANAN

sedang, berat; pasang infus; pasang transfusi; pasang kateter urine; pasang NGT; klisma; suction per hari; ambil sample kultur; aff / cabut hecting; vulva higiene / vaginal swab; perawatan tali pusat; syringe pump; infus pump; light therapy; monitor catheter umbilical; yang dilakukan di ruang rawat, bahan habis pakai obat-obatan yang digunakan pasien di bayar sesuai tarif harga Instalasi Farmasi. C. TINDAKAN DI RINDU B OBGIN 1. Partus Normal 135,000 90,000 2. Extrasi Vacum 165,000 110,000 3. Manual Aid 159,600 106,400 4. Curetase 180,000 120,000 5. Abortus 180,000 120,000 6. Vaginal Touch ( VT) / hari 18,000 12,000 7. Manual Plasenta 117,000 78,000 8. USG 36,000 24,000 9. USG Trans Vagina 60,000 40,000 10. Pasang Tampon 10,500 7,000 11. Inspekulo 18,000 12,000 12. Aspirasi Abdomen 15,000 10,000 13. Secunder Hecting 105,000 70,000 14. Ressusitasi Perinatologi 15,000 10,000 15. Lumbal Fungsi 30,000 20,000 Keterangan : 1. JDA (Jasa Dokter Ahli) tersebut harus terlebih dahulu disetorkan ke Bendaharawan Penerima melalui Petugas Kasir. 2. Tarif tersebut diatas tidak termasuk alat kesehatan dan obat-obatan standar. IV. PEMERIKSAAN LABORATORIUM PATOLOGI KLINIK A. KIMIA DARAH 1 Amylase Serum 2 Amylase Urin 3 Analisa Batu Ginjal 4 Analisa Gas Darah 5 AGDA (iSTAT) 6 AGDA + Na, K, Ion Calcium (iSTAT) 7 Asam Empedu 8 Asam Urat 9 Asam Lactat 10 Calcium Ion 11 Chlorida Darah 12 Chlorida Urin 13 Cholinesterase (Che) 14 CK ( Cratine Kinase ) 15 Ck-MB 16 Pro BNP 17 Serum Protein Elektroforese 18 Fosfatase Asam / Acid Phosphatase 19 LDH 20 Kalium Darah 21 Kalium Urin 22 Kalsium Darah 23 Kalsium Urin 24 Lipase Darah 25 Lipase Urin 26 Magnesium 27 Natrium Darah 28 Natrium Urine 29 Phosphat Darah (Phospor inorganik) 30 Phosphat Urine 31 Troponin T 32 Troponin I 33 Homosystein 34 Vitamin D 35 Vitamin D (untuk Penelitian Peserta Didik/PPDS) B. DIABETES 1 Glikolysis HB / HbA1c 2 Glukosa Darah ( Rapid) 3 Glukosa Darah PP 5

225,000 275,000 266,000 300,000 300,000 30,000 195,000 60,000 100,000 17,500 30,000 25,000 175,000 25,000 50,000

31,125

10,375

41,500

24,750 74,250 93,000 144,375 185,625 27,375 23,250 41,250 33,000 18,000 18,000 24,750 69,750 69,750 286,125 109,875 57,750 27,375 18,000 18,000 18,000 18,000 51,750 51,750 33,000 18,000 18,000 25,500 25,500 127,500 165,000 132,000 231,000 231,000

8,250 24,750 31,000 48,125 61,875 9,125 7,750 13,750 11,000 6,000 6,000 8,250 23,250 23,250 95,375 36,625 19,250 9,125 6,000 6,000 6,000 6,000 17,250 17,250 11,000 6,000 6,000 8,500 8,500 42,500 55,000 44,000 154,000 99,000

33,000 99,000 124,000 192,500 247,500 36,500 31,000 55,000 44,000 24,000 24,000 33,000 93,000 93,000 381,500 146,500 77,000 36,500 24,000 24,000 24,000 24,000 69,000 69,000 44,000 24,000 24,000 34,000 34,000 170,000 220,000 176,000 385,000 330,000

111,375 20,625 15,375

37,125 6,875 5,125

148,500 27,500 20,500

JENIS

NO

C.

D.

E.

F.

G.


PELAYANAN

4 Glukosa Darah Puasa 5 Glukosa Darah Sewaktu 6 Glukosa Toleransi Test 7 Urin 4 porsi / kurve harian 8 Insulin 9 C - peptide FUNGSI HATI 1 Albumin 2 Alkali Phospatase 3 Bilirubin Direct/ Indirect 4 Bilirubin Total 5 Gamma GT 6 Globulin 7 Protein Total 8 SGOT 9 SGPT FUNGSI GINJAL 1 Creatinine 2 Creatinine Clearence 3 Urea Clearance 4 Ureum ANALISA LEMAK 1 Cholesterol HDL 2 Cholesterol LDL 3 Cholesterol Total 4 Trigliceride 5 Apo A 6 Apo B HEMATOLOGI 1 Darah Lengkap ( Full Blood Count ) 2 Hitung Eosinophil 3 Retikulosit 4 Golongan Darah ABO + Rhesus Factor 5 Filaria 6 Malaria 7 Waktu Perdarahan 8 Rumple Leed 9 Asam Folat 10 Elektroforesisi Hb 11 Ferritin 12 G6PD 13 Coomb's Test 14 Ham's Test 15 Hb F 16 Morfologi Apus Darah Tepi 17 Aspirasi sumsum tulang (BMP) dan Morfologi Sum-sum tulang 18 Nerve Action Potential (NAP) 19 Pewarnaan Acid Phophatase 20 Pewarnaan Besi 21 Pewarnaan sum-sum tulang 22 Serum Iron Binding Capacity (SIBC) 23 Sugar Water Test 24 Total Iron Binding Capacity (TIBC) 25 Transferin SEROLOGI 1 ACA IgG 2 ACA IgM 3 Anti Amuba 4 Anti Chikungunya 5 Anti CMV IgG 6 Anti CMV IgM 7 Anti HAV IgM 8 HAV Total 9 Anti HBc IgM 10 HBc Total 11 Anti Hbe 12 Anti HBs 6

15,375 15,375 51,750 25,500 123,750 144,375

5,125 5,125 17,250 8,500 41,250 48,125

20,500 20,500 69,000 34,000 165,000 192,500

18,750 18,750 18,000 20,625 36,000 16,500 18,750 20,625 20,625

6,250 6,250 6,000 6,875 12,000 5,500 6,250 6,875 6,875

25,000 25,000 24,000 27,500 48,000 22,000 25,000 27,500 27,500

19,875 36,000 27,375 19,875

6,625 12,000 9,125 6,625

26,500 48,000 36,500 26,500

23,250 18,000 28,125 28,125 99,000 77,625

7,750 6,000 9,375 9,375 33,000 25,875

31,000 24,000 37,500 37,500 132,000 103,500

40,500 10,875 14,625 13,875 14,625 18,375 10,125 10,125 149,250 178,500 137,250 75,750 28,500 27,375 57,375 51,375 411,750 68,625 57,375 37,500 37,500 49,500 19,875 49,500 109,875

13,500 3,625 4,875 4,625 4,875 6,125 3,375 3,375 49,750 59,500 45,750 25,250 9,500 9,125 19,125 17,125 137,250 22,875 19,125 12,500 12,500 16,500 6,625 16,500 36,625

54,000 14,500 19,500 18,500 19,500 24,500 13,500 13,500 199,000 238,000 183,000 101,000 38,000 36,500 76,500 68,500 549,000 91,500 76,500 50,000 50,000 66,000 26,500 66,000 146,500

393,375 393,375 164,625 219,750 68,625 68,625 115,500 148,500 87,375 61,875 165,000 74,250

131,125 131,125 54,875 73,250 22,875 22,875 38,500 49,500 29,125 20,625 55,000 24,750

524,500 524,500 219,500 293,000 91,500 91,500 154,000 198,000 116,500 82,500 220,000 99,000

NO

JENIS


PELAYANAN

13 Anti HCV 14 Helicobacter Pylori IgG 15 Helicobacter Pylori IgM 16 Anti HSV I IgG 17 Anti HSV I IgM 18 Anti HSV II IgG 19 Anti HSV II IgM 20 Anti Influenza A-B 21 Anti Japanese B Encephalitis 22 Anti Leptospira 23 Anti Malaria 24 Anti Rubella IgG 25 Anti Rubella IgM 26 Anti TB / IgG TB 27 Anti Toxoplasma IgG 28 Anti Toxoplasma IgM 29 Anti Streptolysin Titer O (ASTO) 30 CMV IgG Avidity 31 Clamydia Ig G 32 Clamydia Ig M 33 C- Reaktif Protein (CRP) 34 hsCRP 35 Antibodi Dengue Ig G / Ig M 36 Faktor Rhematoid 37 FTA - ABS 38 Hainn Test TB 39 HBe Ag 40 HBs Ag 41 IgM Salmonella Typhi ( Tubex TF) 42 NS 1 Ag Dengue 43 PCR Influenza A H1N1 44 PCR Influenza A H1N5 45 Treponema Palidium H Antigen (TPHA) 46 Veneral Disease Research Laboratory (VDRL) 47 Widal 48 Procalcitonin H. MIKROBIOLOGI 1 Pewarnaan BTA (3x) 2 Pewarnaan Methylen Blue 3 Pemeriksaan Jamur (KOH) 4 Kultur / Sensitivity darah/cairan otak/sendi (Medium Cair) 5 Kultur Sputum, Pus, dll ( Medium Padat) 6 Kultur M. Tuberculose 7 Kultur / Sensitivity TBC / Anaerob 8 Biakan Jamur 9 Biakan Salmonela Shigela (Biakan SS) 10 BTA 3 x Biakan Medium Cair 11 BTA 3 x Biakan Medium Padat 12 Resistensi OAT Lini 1 (SIRE) 13 Resistensi OAT Lini 2 (kana, oflox) 14 Sediaan langsung Pewarnaan BTA I. URINE 1 Urinalisa 2 Esbach 3 Hemosiderin 4 Oval Fat Body 5 Protein Kwantitatif 6 Protein Urine 24 Jam 7 Protein Bence Jones J. HORMON 1 Estradiol 2 Estrogen 3 Free T3 4 Free T4 5 FSH 6 LH 7 Progesteron 7

115,500 68,625 68,625 109,875 109,875 109,875 109,875 274,500 219,750 169,500 154,875 109,875 169,500 169,500 169,500 169,500 50,250 219,750 205,875 205,875 59,625 91,500 114,375 45,750 55,125 283,875 183,000 91,500 219,750 183,000 274,500 274,500 39,750 39,750 45,750 274,500

38,500 22,875 22,875 36,625 36,625 36,625 36,625 91,500 73,250 56,500 51,625 36,625 56,500 56,500 56,500 56,500 16,750 73,250 68,625 68,625 19,875 30,500 38,125 15,250 18,375 94,625 61,000 30,500 73,250 61,000 91,500 91,500 13,250 13,250 15,250 91,500

154,000 91,500 91,500 146,500 146,500 146,500 146,500 366,000 293,000 226,000 206,500 146,500 226,000 226,000 226,000 226,000 67,000 293,000 274,500 274,500 79,500 122,000 152,500 61,000 73,500 378,500 244,000 122,000 293,000 244,000 366,000 366,000 53,000 53,000 61,000 366,000

48,000 14,625 15,750 274,500 205,875 87,000 160,125 50,250 78,000 338,625 169,500 169,500 169,500 27,375

16,000 4,875 5,250 91,500 68,625 29,000 53,375 16,750 26,000 112,875 56,500 56,500 56,500 9,125

64,000 19,500 21,000 366,000 274,500 116,000 213,500 67,000 104,000 451,500 226,000 226,000 226,000 36,500

18,375 15,750 32,250 20,625 18,375 22,500 6,375

6,125 5,250 10,750 6,875 6,125 7,500 2,125

24,500 21,000 43,000 27,500 24,500 30,000 8,500

173,250 72,750 127,875 103,125 148,500 148,500 176,625

57,750 24,250 42,625 34,375 49,500 49,500 58,875

231,000 97,000 170,500 137,500 198,000 198,000 235,500

JENIS

NO

K.

L.

M. N.

O.

P.


PELAYANAN

8 Prolactin 9 T3 10 T4 11 T3 Up Take 12 Testosteron 13 Tiroid Stimulating Hormon (TSH ) 14 Cortisol 15 PTH 16 β HCG CAIRAN TUBUH 1 Analisa Cairan Otak 2 Analisa Cairan Pleura 3 Analisa Cairan Ascites 4 Analisa Cairan Sendi 5 Analisa Sperma 6 Fruktosa Sperma FAECES 1 Analisa Faeces ( pencernaan ) 2 Benzidine Test / Darah Samar DRUG MONITORING 1 Aminophylin HEMOSTASIS 1 Aggregasi Trombosit (ADP) 2 Anti Faktor Xa 3 Anti Trombin III 4 APTT ( Masa Tromboplastin Parsial ) 5 Assay Faktor IX 6 Assay Faktor VIII 7 Beta 2 Glycoprotein 1 (B2GP-1) 8 F. Von Wiilebrands 9 FIBRINOGEN 10 D. Dimer 11 Inhibitor VIII 12 Lupus Anticoagulan 13 Masa Iisis Euglobolin 14 PROTEIN S 15 PROTEIN C 16 PT (Prothorombin Time) + INR 17 Tromboplastin Generation Time (TGT) 18 Thrombotest 19 TT(THROMBINE TIME) 20 IT Ratio IMUNOLOGI 1 Alfa 1 Antitrifsin Kwantitatif 2 Alfa 2 Makro Globulin Kwantitatif 3 ANA Test 4 Anti-ds DNA 5 Anti Kappa 6 Anti Lamda 7 Anti HIV (Elisa) 8 Anti Body Sperma 9 Complement C3 10 Complement C4 11 Cryoglobulin 12 IgA / IgG / IgM 13 IgE 14 Imuno Elektroforesisi Anti Ig G / Ig A / Ig M 15 Imuno Elekktroforesis Whole Anti Serum 16 Paket Diagnostik HIV ( 3 metode ) 17 Sel LE 18 SMA (Smooth Muscle Anti Body) 19 T Sel dan B Sel 20 Test Kehamilan TUMOR MARKER 1 AFP 2 CA 125 3 CA 15-3 8

148,500 72,375 72,375 57,750 231,000 82,500 142,500 162,375 162,375

49,500 24,125 24,125 19,250 77,000 27,500 47,500 54,125 54,125

198,000 96,500 96,500 77,000 308,000 110,000 190,000 216,500 216,500

171,750 171,750 192,375 100,875 91,500 41,250

57,250 57,250 64,125 33,625 30,500 13,750

229,000 229,000 256,500 134,500 122,000 55,000

18,375 55,125

6,125 18,375

24,500 73,500

338,625

112,875

451,500

137,250 201,375 126,000 57,375 228,750 228,750 507,750 196,875 82,500 171,750 256,125 192,375 55,125 256,125 256,125 56,625 91,500 91,500 57,375 21,750

45,750 67,125 42,000 19,125 76,250 76,250 169,250 65,625 27,500 57,250 85,375 64,125 18,375 85,375 85,375 18,875 30,500 30,500 19,125 7,250

183,000 268,500 168,000 76,500 305,000 305,000 677,000 262,500 110,000 229,000 341,500 256,500 73,500 341,500 341,500 75,500 122,000 122,000 76,500 29,000

81,375 57,375 146,625 210,375 64,125 64,125 100,875 100,875 67,500 67,500 22,875 87,750 82,500 87,750 87,750 151,125 31,125 48,375 62,625 28,500

27,125 19,125 48,875 70,125 21,375 21,375 33,625 33,625 22,500 22,500 7,625 29,250 27,500 29,250 29,250 50,375 10,375 16,125 20,875 9,500

108,500 76,500 195,500 280,500 85,500 85,500 134,500 134,500 90,000 90,000 30,500 117,000 110,000 117,000 117,000 201,500 41,500 64,500 83,500 38,000

99,000 198,000 198,000

33,000 66,000 66,000

132,000 264,000 264,000

JENIS

NO

Q. R.

S.

T.


PELAYANAN

4 CA 19-9 5 CA 72-4 6 CEA 7 Cyfra 21 8 MCA 9 Neuron Specific Enollase (NSE) 10 Prostat Specific Antigen (PSA) 11 Free PSA 12 Squamous Cell Carcinoma (SCC) BONE MARKER / PETANDA TULANG 1 N-MID OSTEOCALCIN NARKOBA 1 Methamphetamin 2 Morphin 3 Amphetamine 4 Cocaine 5 Barbiturates 6 THC (Ganja) 7 Benzodiazepine 8 THC + MOP + Met (PAKET) PCR 1 HIV RNA 2 HCV RNA : a. Kwalitatif b. Kwantitatif 3 HBV-DNA Kwantitatif 4 Mycobacterium TBC DNA 5 CMV DNA Kwantitatif 6 Chlamydia Trachomatis 7 Bakteri Gonorhoae (DNA) IMMUNOPHENOTYPING FLOWCYTOMETRI 1 CD 4 2 CD 8

198,000 141,375 103,125 478,500 74,250 255,750 144,375 247,500 255,750

66,000 47,125 34,375 159,500 24,750 85,250 48,125 82,500 85,250

264,000 188,500 137,500 638,000 99,000 341,000 192,500 330,000 341,000

165,000

55,000

220,000

40,500 40,500 40,500 40,500 40,500 40,500 40,500 70,500

13,500 13,500 13,500 13,500 13,500 13,500 13,500 23,500

54,000 54,000 54,000 54,000 54,000 54,000 54,000 94,000

684,000

228,000

912,000

684,000 1,262,625 1,368,000 442,875 105,375 977,250 371,625

228,000 420,875 456,000 147,625 35,125 325,750 123,875

912,000 1,683,500 1,824,000 590,500 140,500 1,303,000 495,500

100,875 100,875

33,625 33,625

134,500 134,500

10,500 10,850 10,850 10,850 10,850 105,000 105,000 105,000 17,150 52,500 52,500 105,000 -

30,000 31,000 31,000 31,000 31,000 300,000 300,000 300,000 49,000 150,000 150,000 300,000 -

178,750 276,250 357,500 260,000 276,250 113,750 195,000 292,500

96,250 148,750 192,500 140,000 148,750 61,250 105,000 157,500

275,000 425,000 550,000 400,000 425,000 175,000 300,000 450,000

97,500 81,250

52,500 43,750

150,000 125,000

V. PEMERIKSAAN MIKROBIOLOGI KLINIK 1. Sediakan Langsung Pewarnaan BTA 19,500 2. Sediakan Langsung Pewarnaan Gram 20,150 3. Direct Gonorrhoe 20,150 20,150 4. Direct Difteri 20,150 5. Pemeriksaan Jamur (KOH) 6. Biakan Mikro Organisme Aerob Medium Cair dengan Resistensi 195,000 7. Biakan Mikro Organisme Anerob Medium Cair dengan Resistensi 195,000 8. Biakan Mikro Organisme Jamur Medium Cair dengan Resistensi 195,000 9. Biakan Jamur Medium Padat (bahan : kerokan) 31,850 10. BTA 3x, Biakan Medium Padat 97,500 11. Resistensi OAT Lini 1 (SIRE) 97,500 12. Biakan N. Gonorrhoeae dan Uji Resistensi 195,000 13. PMDT 14. Sediaan Langsung Pewarnaan BTA - TB/HIV 15. Pemeriksaan Resistensi OAT - Gene Expert 16. Sediaan Langsung Pewarnaan BTA - POLI DOTS Keterangan: Pemeriksaan yang berharga 0 (nol) karena dibiayai oleh Program PMDT dan Program TB DOTS Kemenkes RI VI. PEMERIKSAAN PATOLOGI ANATOMI A. HISTOPATOLOGI 1. Histopatologi Kecil 2. Histopatologi Sedang 3. Histopatologi Besar 4. Biopsi Khusus (hati, ginjal,sumsum tulang) 5. PA Potong Beku (VC) + imprint 6. Histokimia ( untuk 1 jenis pemeriksaan ) 7. Imunohistokimia ( untuk 1 jenis pemeriksaan ) 8. Visum Jaringan B. SITOLOGI 1. Hormonal serial 4x 2. Sitologi (pap smear, cairan, dll) 9

JENIS

NO 3. 4. 5. 6. 7. 8.


PELAYANAN

FNAB (biasa) dengan tindakan FNAB lebih dari 1 lokasi Sitologi 3x serial Sputum 1x Sputum 3x serial, cairan, sikatan, aspirasi Urine serial 3x

VII. PEMERIKSAAN / PELAYANAN DIAGNOSTIK ELEKTROMEDIK A. SEDERHANA 1. Spirometri 2. EKG B. SEDANG 1. TTLB 2. TTLB dengan USG 3. Biopsi Pleura 4. EMG / Evoke Potensial SSP 5. EEG Mapping 6. Fungsi Cairan Asites 7. Fungsi Pluera 8. Biopsi Hati 9. USG Color Dopler P. Dalam, Ginjal 10. USG Color Dopler Thorax / Paru 11. USG Tuntunan Biopsi 12. Biopsi Prostat 13. Biopsi Ginjal 14. Transcranial Dopler (TCD) C. CANGGIH 1. Skleroterapy Gastroscopy / Varices Esophagus 2. Colonoskopy 3. Colonoskopy + Polipeptomy 4. Colonoskopy + Biopsi 5. Colonoskopy dengan Clipping 6. Colonoskopy dengan Anestesi Umum 7. Gastroskopy 8. Gastroskopy Biopsi 9. Gastroskopy dengan Clipping 10. Gastroskopy Dilatasi Esopagus (Pumping) 11. Gastroskopy dengan Anestesi Umum 12. Skleroterapy Varices Esophagus 13. Ligasi Varices Esophagus 14. Savary Bougy Esophagus 15. a. ERCP Tidak Berhasil - ERCP Diagnostik b. ERCP Berhasil - ERCP Spirinterektomy - ERCP Stenting - ERCP Basket (Seluruh tindakan ERCP memakai anasthesi) 20. Fibroscan 21. Urocystoskopy 22. RPG 23. ESWL 24. ESWL Fase II 25. Bronchoskopy 26. Bronchoskopy + Biopsi 27. Bronchoskopy + Sikatan 28. Bronchoskopy + Bilasan 29. Bronchoskopy dengan Anestesi Umum 30. Pengambilan Benda Asing dengan Bronchoskopy 31. Thoracoscopy + Biopsi 32. Treadmill Test 33. Double Lumen Tunnel 34. Double Lumen Tunnel (Temporer) 35. Repair Double Lumen VIII. PEMERIKSAAN RADIOLOGI (RADIO DIAGNOSTIK) A. KECIL 10

195,000 243,750 61,750 130,000 357,500 65,000

105,000 131,250 33,250 70,000 192,500 35,000

300,000 375,000 95,000 200,000 550,000 100,000

90,000 18,000

60,000 12,000

150,000 30,000

360,000 450,000 300,000 165,000 120,000 600,000 516,000 600,000 150,000 300,000 94,500 600,000 600,000 180,000

240,000 300,000 200,000 110,000 80,000 400,000 344,000 400,000 100,000 200,000 63,000 400,000 400,000 120,000

600,000 750,000 500,000 275,000 200,000 1,000,000 860,000 1,000,000 250,000 500,000 157,500 1,000,000 1,000,000 300,000

780,000 450,000 510,000 510,000 510,000 720,000 390,000 450,000 480,000 2,052,000 720,000 390,000 390,000 390,000

520,000 300,000 340,000 340,000 340,000 1,080,000 260,000 300,000 320,000 1,368,000 1,080,000 260,000 260,000 260,000

1,300,000 750,000 850,000 850,000 850,000 1,800,000 650,000 750,000 800,000 3,420,000 1,800,000 650,000 650,000 650,000

750,000

500,000

1,250,000

1,860,000 1,860,000 1,860,000

1,240,000 1,240,000 1,240,000

3,100,000 3,100,000 3,100,000

300,000 150,000 600,000 1,200,000 940,000 510,000 570,000 570,000 570,000 720,000 720,000 1,080,000 120,000 1,440,000 900,000 450,000

200,000 100,000 400,000 1,800,000 1,410,000 340,000 380,000 380,000 380,000 1,080,000 1,080,000 1,620,000 80,000 960,000 600,000 300,000

500,000 250,000 1,000,000 3,000,000 2,350,000 850,000 950,000 950,000 950,000 1,800,000 1,800,000 2,700,000 200,000 2,400,000 1,500,000 750,000

JENIS

NO

B.

C.


PELAYANAN

1. Scheedel AP / L 2. Sinus Paranasal 3. Mastoid Kiri 4. Mastoid Kanan 5. Mastoid Kiri dan Kanan (Duplex) 6. Mandibula (satu sisi) PA + Eisler 7. Mandibula (dua sisi) PA + Eisler Kiri + Kanan 8. TMJ (Temporo Mandibular Joint ) Kiri 9. TMJ (Temporo Mandibular Joint ) Kanan 10. TMJ ( Dua Sisi) Kiri dan Kanan 11. Scheedel Basis 12. Thorax Anak Ap. 13. Thorax Dewasa PA 14. Manus Kiri AP / Oblique 15. Manus Kanan AP / Oblique 16. Manus Kiri dan Kanan AP / Oblique 17. Wrist Joint Kiri AP / Lateral 18. Wrist Joint Kanan AP / Lateral 19. Wrist Joint Kiri dan Kanan AP / Lateral 20. Ante Brachii Kiri AP / Lateral 21. Ante Brachii Kanan AP / Lateral 22. Ante Brachii Kiri dan Kanan AP / Lateral 23. Elbow Joint Kiri AP / L 24. Elbow Joint Kanan AP / L 25. Humerus Kiri AP / L 26. Humerus Kanan AP / L 27. Articulatio Humerus / Shoulder Joint Kiri 28. Articulatio Humerus / Shoulder Joint Kanan 29. Clavicula Kiri 30. Clavicula Kanan 31. Scapula Kiri 32. Scapula Kanan 33. Sternum 34. Pedis Kiri AP / Oblique 35. Pedis Kanan AP / Oblique 36. Pedis Kiri dan Kanan AP / Oblique 37. Ankle Joint Kiri AP / Lateral 38. Ankle Joint Kanan AP / Lateral 39. Cruris Kiri AP / Lateral 40. Cruris Kanan AP / Lateral 41. Genu (Sendi Lutut) Kiri AP / Lateral 42. Genu (Sendi Lutut) Kanan AP / Lateral 43. Patella Kiri 44. Patella Kanan 45. Femur Kiri AP/Lateral 46. Femur Kanan AP/Lateral 47. Articulatio Coxae / Hip Joint Kiri 48. Articulatio Coxae / Hip Joint Kanan 49. Pelvis 50. BNO / Abdomen SEDANG 1. Thorax PA / L (2 Posisi) 2. Cervical PA / L (2 Posisi) 3. Thoracal PA / L 2 Posisi 4. Lumbal PA / L (2 Posisi) 5. Sacrum PA / L (2 Posisi) 6. Coccygis PA / L (2 Posisi) 7. Pelvimetri 8. Cervical PA / L (4 Posisi) / Oblique ki-ka (4 posisi ) 9. Thoracal PA / L (4Posisi) / Oblique ki-ka ( 4 posisi ) 10. Lumbal PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 11. Sacrum AP / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 12. Thorax PA / L (4 Posisi) / Oblique ki-ka ( 4 posisi ) 13. Abdomen 3 Posisi KHUSUS 1. Mammografi 2. Cor Analisa 11

58,500 58,500 58,500 58,500 97,500 65,000 97,500 65,000 65,000 97,500 65,000 52,000 52,000 52,000 52,000 78,000 52,000 52,000 78,000 52,000 52,000 78,000 52,000 52,000 52,000 52,000 52,000 52,000 58,500 58,500 58,500 58,500 58,500 58,500 58,500 78,000 52,000 52,000 65,000 65,000 65,000 65,000 65,000 65,000 65,000 65,000 52,000 52,000 58,500 58,500

31,500 31,500 31,500 31,500 52,500 35,000 52,500 35,000 35,000 52,500 35,000 28,000 28,000 28,000 28,000 42,000 28,000 28,000 42,000 28,000 28,000 42,000 28,000 28,000 28,000 28,000 28,000 28,000 31,500 31,500 31,500 31,500 31,500 31,500 31,500 42,000 28,000 28,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 28,000 28,000 31,500 31,500

90,000 90,000 90,000 90,000 150,000 100,000 150,000 100,000 100,000 150,000 100,000 80,000 80,000 80,000 80,000 120,000 80,000 80,000 120,000 80,000 80,000 120,000 80,000 80,000 80,000 80,000 80,000 80,000 90,000 90,000 90,000 90,000 90,000 90,000 90,000 120,000 80,000 80,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 80,000 80,000 90,000 90,000

81,250 81,250 81,250 81,250 81,250 81,250 81,250 162,500 162,500 162,500 162,500 162,500 130,000

43,750 43,750 43,750 43,750 43,750 43,750 43,750 87,500 87,500 87,500 87,500 87,500 70,000

125,000 125,000 125,000 125,000 125,000 125,000 125,000 250,000 250,000 250,000 250,000 250,000 200,000

162,500 164,450

87,500 88,550

250,000 253,000

JENIS

NO

D.

E.

F.


PELAYANAN

3. Panoramic 4. Chepalografi 5. Panoramic + Chepalografi 6. AnteBrachii ka/ki, Femur ka/ki, Cruris ka/ki) 7. BNO-IVP (Dengan Kontras Intravena) 8. Larynx / Oesophagus (Non Kontras) 9. Dacryografi FLUOROSCOPI 1. Fluoroscopi C - Arm tanpa kontras 2. Fluoroscopi C - Arm dengan kontras 3. Apendix dengan BaSO4 4. Cholecistografi Oral dengan kontras 5. Cholangiografigrafi T. Tube dengan kontras 6. Urethrografi dengan kontras 7. MDF dengan BaSO4 8. Usus Halus / Follow Through (kontras BaSO4) 9. Usus Besar / Colon in Loop (kontras BaSO4) 10. Cystografi dengan kontras 11. Barium Oesphagus dengan kontras 12. Myelografi dengan kontras 13. Fistulografi dengan kontras 14. APG / RPG dengan kontras 15. ERCP Fluoroscopy (Tanpa Kontras) 16. ERCP Fluoroscopy (Dengan Kontras) 17. Sialografi dengan kontras 18. HSG / Histero Salphingografi (T. Kontras) 19. Discografi 20. Ductulografi 21. Fluoroskopi / Spot Fluoroskopi 22. Foto OMD (Osesophagus Maag Duodenum) 23. Lopografi 24. Phlebografi dengan pesawat fluoroskopi (1 ekst) 25. Phlebografi dengan pesawat fluoroskopi (2 ekst) 26. Sacroiliac joint injection USG 1. USG Liver 2. USG Spleen 3. USG GB / Billary 4. USG Upper Abdomen 5. USG Lower Abdomen / Pelvic 6. USG Upper - Lower Abdomen 7. USG Ginjal/Tract Urinarius 8. USG Thorax 9. USG Small Organ (Breast, Thyroid, Testis) 10. USG Peripheral Vascular 11. USG Organ Superfisial 12. USG Vaskuler Access Dopler 13. Tuntunan USG pada Biopsi 14. USG Kepala Bayi 15. USG Transvaginal / Transrectal 16. Appendix CT SCAN SINGLE SLICE 1. CT Scan Head / Brain 2. CT Scan Head dengan I.V Contrast 3. CT Scan Sinus Paranasal 4. CT Scan Sinus Paranasal dengan I.V Contrast 5. CT Scan Mastoid 6. CT Scan Mastoid dengan I.V Contrast 7. CT Scan Thyroid 8. CT Scan Thyroid dengan I.V Contrast 9. CT Scan Neck/Larynx 10. CT Scan Neck/Larynx dengan I.V Contrast 11. CT Scan Nasoparing 12. CT Scan Nasoparing dengan I.V Contrast 13. CT Scan Upper Abdomen 14. CT Scan Upper Abdomen dengan I.V Contrast 15. CT Scan Lower Abdomen 12

48,750 48,750 97,500 354,900 260,000 64,350 162,500

26,250 26,250 52,500 191,100 140,000 34,650 87,500

75,000 75,000 150,000 546,000 400,000 99,000 250,000

162,500 276,250 162,500 195,000 260,000 260,000 227,500 260,000 260,000 260,000 227,500 260,000 260,000 276,250 164,450 260,000 260,000 164,450 1,235,000 260,000 121,875 260,000 260,000 520,000 1,040,000 1,235,000

87,500 148,750 87,500 105,000 140,000 140,000 122,500 140,000 140,000 140,000 122,500 140,000 140,000 148,750 88,550 140,000 140,000 88,550 665,000 140,000 65,625 140,000 140,000 280,000 560,000 665,000

250,000 425,000 250,000 300,000 400,000 400,000 350,000 400,000 400,000 400,000 350,000 400,000 400,000 425,000 253,000 400,000 400,000 253,000 1,900,000 400,000 187,500 400,000 400,000 800,000 1,600,000 1,900,000

104,000 104,000 104,000 227,500 162,500 325,000 175,500 156,000 156,000 156,000 156,000 260,000 156,000 156,000 227,500 156,000

56,000 56,000 56,000 122,500 87,500 175,000 94,500 84,000 84,000 84,000 84,000 140,000 84,000 84,000 122,500 84,000

160,000 160,000 160,000 350,000 250,000 500,000 270,000 240,000 240,000 240,000 240,000 400,000 240,000 240,000 350,000 240,000

325,000 552,500 325,000 552,500 325,000 487,500 325,000 487,500 325,000 552,500 325,000 552,500 455,000 650,000 455,000

175,000 297,500 175,000 297,500 175,000 262,500 175,000 262,500 175,000 297,500 175,000 297,500 245,000 350,000 245,000

500,000 850,000 500,000 850,000 500,000 750,000 500,000 750,000 500,000 850,000 500,000 850,000 700,000 1,000,000 700,000

JENIS

NO

G.


PELAYANAN

16. CT Scan Lower Abdomen dengan I.V Contrast 17. CT Scan Whole Abdomen 18. CT Scan Whole Abdomen dengan I.V Contrast 19. CT Scan Thorax 20. CT Scan Thorax dengan I.V Contrast 21. CT Extermitas 22. CT Extermitas dengan I.V Contrast 23. CT Scan Spine/Vertebra ( 3-4 corpus ) 24. CT Scan Spine/Vertebra dengan I.V Contrast 25. CT Biopsi CT SCAN MULTI SLICE 64 1. MSCT Scan Head / Brain 2. MSCT Scan Head dengan I.V Contrast 3. MSCT Scan Orbita 4. MSCT Scan Orbita dengan I.V Contrast 5. MSCT Scan Sinus Paranasal 6. MSCT Scan Sinus Paranasal dengan I.V Contrast 7. MSCT Scan Mastoid / Temporal 8. MSCT Scan Mastoid dengan I.V Contrast 9. MSCT Scan Thyroid 10. MSCT Scan Thyroid dengan I.V Contrast 11. MSCT Scan Neck / Larynx 12. MSCT Scan Neck / Larynx dengan I.V Contrast 13. MSCT Scan Nasoparing 14. MSCT Scan Nasoparing dengan I.V Contrast 15. MSCT Scan Upper Abdomen 16. MSCT Scan Upper Abdomen dengan I.V Contrast 17. MSCT Scan Lower Abdomen / Pelvic 18. MSCT Scan Lower Abdomen dengan I.V Contrast 19. MSCT Scan Whole Abdomen 20. MSCT Scan Whole Abdomen dengan I.V Contrast 21. MSCT Scan Thorax 22. MSCT Scan Thorax dengan I.V Contrast 23. MSCT Extremitas 24. MSCT Extremitas dengan I.V Contrast 25. MSCT Myelografi 26. MSCT Scan Spine / Vertebra ( 3-4 corpus ) 27. MSCT Scan Spine / Vertebra dengan I.V Contrast MSCT KHUSUS 28. MSCT Cardiac dengan I.V Contrast 29. MSCT Urologi 30. MSCT Angiografi dengan I.V Contrast 31. MSCT Virtual Colonoscopy 32. MSCT Muskuloskeletal 33. Guiding MSCT Biopsi 34. 3D Kontras (Bahu-Muka-Pelvic-Lumbal) 35. 3D Kontras Karotis 36. Whole Body 3 Phase (Thorax-Abdomen) dengan Kontras 37. CT Perfusion

H. PEMERIKSAAN GAMMA CAMERA / KEDOKTERAN NUKLIR H.1. DIAGNOSTIK IN VIVO PEMERIKSAAN KELENJAR TIROID 1. Thyroid scan dengan Tc-99m 2. Thyroid uptake & scan 3. Whole body scan dengan Nal-131 4. Whole body scan dengan MIBI 5. Paratiroid scan dengan MIBI PEMERIKSAAN FUNGSI JANTUNG 1. First pass study 2. Cardioscintigraphy stress exercise 3. Cardioscintigraphy stress farmakologik 4. Cardioscintigraphy rest 5. Cardioscintigraphy stress exercise-rest 6. Cardioscintigraphy stress farmakologik-rest 7. Red blood pool scan dengan Tc-99m stannnous agent 8. Infark miokard acute scan 13

650,000 585,000 975,000 455,000 650,000 293,150 464,750 455,000 585,000 1,218,750

350,000 315,000 525,000 245,000 350,000 157,850 250,250 245,000 315,000 656,250

1,000,000 900,000 1,500,000 700,000 1,000,000 451,000 715,000 700,000 900,000 1,875,000

474,500 780,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 520,000 1,105,000 715,000 1,072,500 715,000 1,072,500 845,000 1,137,500 715,000 1,072,500 520,000 975,000 1,072,500 650,000 1,072,500

255,500 420,000 280,000 595,000 280,000 595,000 280,000 595,000 280,000 595,000 280,000 595,000 280,000 595,000 385,000 577,500 385,000 577,500 455,000 612,500 385,000 577,500 280,000 525,000 577,500 350,000 577,500

730,000 1,200,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 800,000 1,700,000 1,100,000 1,650,000 1,100,000 1,650,000 1,300,000 1,750,000 1,100,000 1,650,000 800,000 1,500,000 1,650,000 1,000,000 1,650,000

2,080,000 1,137,500 1,690,000 1,755,000 975,000 1,218,750 1,170,000 1,040,000 1,755,000 1,040,000

1,120,000 612,500 910,000 945,000 525,000 656,250 630,000 560,000 945,000 560,000

3,200,000 1,750,000 2,600,000 2,700,000 1,500,000 1,875,000 1,800,000 1,600,000 2,700,000 1,600,000

292,500 325,000 390,000 1,300,000 1,300,000

157,500 175,000 210,000 700,000 700,000

450,000 500,000 600,000 2,000,000 2,000,000

975,000 1,300,000 1,950,000 1,300,000 2,275,000 2,600,000 975,000 1,300,000

525,000 700,000 1,050,000 700,000 1,225,000 1,400,000 525,000 700,000

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

NO

JENIS


PELAYANAN

PEMERIKSAAN FUNGSI GINJAL DAN SALURAN KEMIH 1. Renal scan/renogram dengan Tc-99m cuplikan plasma 2. Renal scan/renogram dengan Tc-99m pemantauan eksternal 3. Renogram dengan Tc-99m pemantauan eksternal : - Konvensional - Diuresis - Kaptopril 4. Renogram/ERPF dengan Tc-99m 5. Renal scan (DMSA) dengan hippuran I-131 6. Cystography 7. Scrotal Scan PEMERIKSAAN FUNGSI TULANG 1. Bone scanning dengan Tc-99m + kit : - Statik (1 fase) - Dinamik (3 fase) - SPECT PEMERIKSAAN GASTROINTESTINAL 1. Gastric Emptying Time 2. Oesopagus motility scan 3. Oesopagus feflux scan 4. Divertikulum Meckel scan 5. Intestinal bleeding scan PEMERIKSAAN HEPATOBILIER 1. Liver scanning dengan Tc-99m sulfur colloid 2. Hepatobiliary scan 3. Hepatogram 4. Limpa/spleen scanning dengan Tc-99m sulfur colloid PEMERIKSAAN PARU 1. Perfusion lung scan 2. Ventilation lung scan Tc-99m 3. Ventilation perfusion scan (V/Q scan) LAIN - LAIN 1. Brain scan dengan Tc-99m + kit (HMPAO) 2. Brain spect 3. Cysternogram dengan Tc-99m + kit 4. Phlebografi 5. Venography 6. Lymphoskintigrafi 7. Skintimammografi 8. Infeksi scan dengan infekton 9. Sentinel node/gamma probe detection 10. Dakriosistografi H.2 DIAGNOSTIK IN VITRO 1. T3 RIA 2. T4 RIA 3. TSHS IRMA 4. ANTITIROGLOBULIN 5. TIROGLOBULIN 6. TERAPI : 1) Hipertiroid - < 5 mCi - 5-10 mCi - 11-15 mCi - 16-20 mCi - 21-30 mCi - 40-50 mCi 2) Ablasi karsinoma tiroid - 80-100 mCi - 100-150 mCi - 150-200 mCi - 200-300 mCi 3) Paliatif - Samarium - Rhenium 4) Terapi hemangioma.keloid 5) Permintaan tambahan film - Copy film thyroid 14

520,000 520,000

280,000 280,000

800,000 800,000

650,000 975,000 975,000 650,000 650,000 455,000 975,000

350,000 525,000 525,000 350,000 350,000 245,000 525,000

1,000,000 1,500,000 1,500,000 1,000,000 1,000,000 700,000 1,500,000

1,040,000 1,300,000 1,625,000

560,000 700,000 875,000

1,600,000 2,000,000 2,500,000

1,625,000 1,625,000 1,625,000 975,000 1,950,000

875,000 875,000 875,000 525,000 1,050,000

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

1,625,000 1,625,000 1,625,000 1,625,000

875,000 875,000 875,000 875,000

2,500,000 2,500,000 2,500,000 2,500,000

975,000 1,300,000 1,625,000

525,000 700,000 875,000

1,500,000 2,000,000 2,500,000

2,600,000 2,925,000 1,300,000 975,000 1,105,000 1,300,000 2,275,000 1,300,000 1,300,000 325,000

1,400,000 1,575,000 700,000 525,000 595,000 700,000 1,225,000 700,000 700,000 175,000

4,000,000 4,500,000 2,000,000 1,500,000 1,700,000 2,000,000 3,500,000 2,000,000 2,000,000 500,000

97,500 97,500 113,750 260,000 260,000

52,500 52,500 61,250 140,000 140,000

150,000 150,000 175,000 400,000 400,000

357,500 520,000 650,000 780,000 975,000 1,300,000

192,500 280,000 350,000 420,000 525,000 700,000

550,000 800,000 1,000,000 1,200,000 1,500,000 2,000,000

2,600,000 3,250,000 3,900,000 4,550,000

1,400,000 1,750,000 2,100,000 2,450,000

4,000,000 5,000,000 6,000,000 7,000,000

2,600,000 2,600,000 975,000

1,400,000 1,400,000 525,000

4,000,000 4,000,000 1,500,000

32,500

17,500

50,000

NO

JENIS


PELAYANAN

- Copy film bone scanning - Copy film renogram/renmal scan - Copy film cardioscintigraphy - Copy film pemeriksaan lainnya IX. PELAYANAN TINDAKAN RADIASI EKSTERNA (UMUM) UNIT RADIOTHERAPY 1. PESAWAT + SIMULATOR Kuratif Defenitif Paliatif 2. PESAWAT + SIMULATOR + TPS Kuratif Defenitif Paliatif Rad. Kastrasi / Non Keganasan 3. PESAWAT + SIMULATOR + TPS + ALAT BANTU Kuratif Defenitif Paliatif 3. 3 D Kuratif Defenitif Paliatif 4. CONFORMAL 5. Konsul Dokter & Follow Up / 1 (satu) kali Keterangan : Untuk tindakan pelayanan di unit Radiotherapy adalah merupakan Pelayanan Paket : a. Kuratif = Penyinaran yang dilakukan sebanyak 25 kali (25 kali penyinaran) b. Defenitif = Penyinaran yang dilakukan lebih dari 25 kali ( > 25 kali penyinaran) c. Paliatif = Penyinaran yang dilakukan kurang dari 25 kali ( < 25 kali penyinaran) X. PELAYANAN BRACHITERAPI A. Ovoid 1. 2x Tindakan + 2x Penyinaran + 2x Anastesi 2. 3x Tindakan + 3x Penyinaran + 3x Anastesi B. Cervix Intra Caviter Lengkap 1. 2x Tindakan + 2x Penyinaran + 2x Anastesi 2. 3x Tindakan + 3x Penyinaran + 3x Anastesi C. Nasopharing Intralumen 1. 1x Tindakan + 4x Penyinaran + 1x Anastesi 2. 1x Tindakan + 6x Penyinaran + 1x Anastesi D. Perineal Inplantasi 1. 1x Tindakan + 1x Penyinaran + 1x Anastesi 2. 1x Tindakan + 2x Penyinaran + 1x Anastesi 3. 1x Tindakan + 3x Penyinaran + 1x Anastesi E. Cervix Inplant 1. 1x Tindakan + 2x Penyinaran + 1x Anastesi 2. 1x Tindakan + 4x Penyinaran + 1x Anastesi 3. 1x Tindakan + 6x Penyinaran + 1x Anastesi F. Lidah Anterior 1. 1x Tindakan + 4x Penyinaran + 1x Anastesi 2. 1x Tindakan + 6x Penyinaran + 1x Anastesi G. Base of Tongue 1. 1x Tindakan + 4x Penyinaran + 1x Anastesi 2. 1x Tindakan + 6x Penyinaran + 1x Anastesi XI. PEMERIKSAAN INTERVENSI RADIOLOGI Tindakan Angiography tanpa menggunakan Micro Cateter 1 DSA / Angiografi (Tanpa menggunakan microcateter) 2 TACI/TACE/TAE (Angiografi tanpa menggunakan mikrocateter)

65,000 65,000 130,000 97,500

35,000 35,000 70,000 52,500

5,586,000 6,384,000 3,192,000

3,724,000 4,256,000 2,128,000

9,310,000 10,640,000 5,320,000

6,384,000 7,980,000 4,788,000 2,793,000

4,256,000 5,320,000 3,192,000 1,862,000

10,640,000 13,300,000 7,980,000 4,655,000

7,980,000 9,576,000 5,586,000

5,320,000 6,384,000 3,724,000

13,300,000 15,960,000 9,310,000

9,576,000 12,000,000 6,702,000 1,350,000 -

6,384,000 8,000,000 4,468,000 900,000 80,000

15,960,000 20,000,000 11,170,000 2,250,000 100,000

7,800,000 8,580,000

5,200,000 5,720,000

13,000,000 14,300,000

9,000,000 10,140,000

6,000,000 6,760,000

15,000,000 16,900,000

9,000,000 11,700,000

6,000,000 7,800,000

15,000,000 19,500,000

7,800,000 8,580,000 9,000,000

5,200,000 5,720,000 6,000,000

13,000,000 14,300,000 15,000,000

8,580,000 10,140,000 12,480,000

5,720,000 6,760,000 8,320,000

14,300,000 16,900,000 20,800,000

12,480,000 14,820,000

8,320,000 9,880,000

20,800,000 24,700,000

14,820,000 17,940,000

9,880,000 11,960,000

24,700,000 29,900,000

7,605,000 7,605,000

4,095,000 4,095,000

11,700,000 11,700,000

Keterangan : 1. Tarif tersebut diatas sudah termasuk seluruh AKHP dan obat-obatan yang dibutuhkan (Paket) tidak termasuk micro cateter 2.7 2. Tarif diatas sudah termasuk pemeriksaan penunjang (Lab. Klinik) yang dibutuhkan yaitu : - Pungsi Hepar (Hbs Ag, SGOT, SGPT) - Pungsi Ginjal - Darah Rutin (HBHT, Trombosis) 15

100,000 100,000 200,000 150,000

JENIS

NO 3. 4. 5. 6. 7.


PELAYANAN

JDA (Jasa Dokter Ahli) terlebih dahulu disetorkan ke Bendahara Penerima melalui Petugas Kasir. Tarif diatas hanya untuk tindakan Angiografi, belum termasuk ruang rawat inap, ICCU, HCU bila diperlukan. Apabila dilakukan pemeriksaan penunjang diluar butir 2 (dua) maka dikenakan biaya pemeriksaan yang dilakukan sesuai dengan tarif kelas II yang berlaku. Pasien yang berasal dari rujukan prakter dokter, rujukan dari RS luar dikenakan tambahan biaya 25% dari tarif tindakan yang dilakukan. Bahan Habis Pakai dan Obat-obatan (Paket) diatas telah disediakan oleh Inst. Farmasi.

XII. REHABILITASI MEDIS A. DOKTER REHABILITASI MEDIK 1. Pemeriksaan Physik Diagnostik B. FISIOTERAPI 1. ASSESMENT a. Assesment Fleksibilitas dan Lingkup Gerak b. Assesment Fungsi Eksekusi Gerak c. Assesment Fungsi Kardiorespirasi d. Assesment Fungsi Lokomotor e. Assesment Fungsi Integral Sensori Motor f. Assesment Fungsi Kebugaran g. Assesment Fungsi Kekuatan Otot h. Assesment Fungsi Keseimbangan Statik dan Dinamik i. Assesment motorik Halus j. Assesment Pola Jalan k. Assesment Fungsi Postur Control l. Assesment Sensibilitas 2. TINDAKAN a. Sederhana 1). Infra Red 2). Massage / Vibrator b. Sedang 1). Chest Fisioterapi 2). Manual Therapy 3). Exercise Therapy 4). MWD / SWD 5). IT/ TENS / FARADIK 6). Traksi L/C 7). Nebulizer 8). Crio Jet Therapy 9). Vacuum Unit Therapy 10). Parafin Bath 11). Magnetic Therapy 12). Ultra Sound 13). Stimulasi Sensory (Tumbuh Kembang) c. Canggih 1). Endolaser Therapy 2). EMG Bio Feedback C. TERAPI WICARA 1. ASSESMENT a. Assesment Umum b. Assesment Komunikasi c. Assesment Fungsi Menelan d. Assesment Fungsi Kognisi e. Assesment Memory 2. TERAPI WICARA a. Speech Defect Training b. Other Speech Training c. Training in use of lead dog for the blind 3. TERAPI FUNGSI BAHASA a. Dysphasia Training b. Play Therapy 4. TERAPI FUNGSI MENELAN a. Eshopageal Speech Training (Voca Stimulation) D. PELAYANAN OKUPASI TERAPI 1. ASSESMENT a. Assesment Fungsi Kognisi b. Assesment Kemampuan Fungsional dan Perawatan Diri 2. Tindakan Sederhana 16

21,000

14,000

35,000

21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000 21,000

14,000 14,000 14,000 14,000 14,000 14,000 14,000 14,000 14,000 14,000 14,000 14,000

35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000 35,000

15,000 15,000

10,000 10,000

25,000 25,000

15,000 15,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 18,000 21,000

10,000 10,000 12,000 12,000 12,000 12,000 12,000 12,000 12,000 12,000 12,000 12,000 14,000

25,000 25,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 30,000 35,000

21,000 21,000

14,000 14,000

35,000 35,000

21,000 21,000 21,000 21,000 21,000

14,000 14,000 14,000 14,000 14,000

35,000 35,000 35,000 35,000 35,000

18,000 18,000 18,000

12,000 12,000 12,000

30,000 30,000 30,000

18,000 18,000

12,000 12,000

30,000 30,000

21,000

14,000

35,000

21,000 21,000

14,000 14,000

35,000 35,000

JENIS

NO

E.


PELAYANAN

a. Edukasi b. Home Program 3. Tindakan Sedang a. ADL b. Produktivity c. Leisure d. Terapi Kelompok 4. Tindakan Khusus a. Snoezelen b. Sensori Integrasi c. Behavior Therapy d. Relaksasi ORTOTIK PROSTETIK 1. Assesment a. Assesment Umum b. Fitting and Chech Out Ortosis and Protesis 2. Tindakan Sederhana a. Stik b. Tripot c. Axilla Cruches Aluminium / Kruk d. Cervical Collar 1). Anak 2). Dewasa e. Mallet Splint/ 1 Jari f. Arch Support 1). Anak 2). Dewasa g. Cock Up Splint Aluminium 1). Anak 2). Dewasa h. Resting Splint Aluminium 1). Anak 2). Dewasa i. Splint Siku Aluminium 1). Anak 2). Dewasa j. Splint Lutut Aluminium 1). Anak 2). Dewasa 3. Tindakan Sedang Aluminium a. Walker 1). Anak 2). Dewasa b. Lumbal Korset 1). Kecil 2). Sedang 3). Besar 4). Elastis c. Thoracolumbal Karset 1). Kecil 2). Sedang 3). Besar d. Lumbal Ortosis Chair Back 1). Anak 2). Dewasa c. Thoracolumbel Ortosis 1). Knight Taylor Brace a). Anak b). Dewasa 2). Taylor Brace Dural + AL a). Anak b). Dewasa 3). Extension Brace Dural + AL a). Anak b). Dewasa d. Long Leg Brace 1). Anak 17

15,000 15,000

10,000 10,000

25,000 25,000

18,000 18,000 18,000 18,000

12,000 12,000 12,000 12,000

30,000 30,000 30,000 30,000

24,000 27,000 24,000 24,000

16,000 18,000 16,000 16,000

40,000 45,000 40,000 40,000

18,000 18,000

12,000 12,000

30,000 30,000

192,500 229,000 315,000

5,000 5,000 35,000

197,500 234,000 350,000

78,500 89,500 63,000

5,000 5,000 5,000

83,500 94,500 68,000

48,500 56,500

5,000 5,000

53,500 61,500

122,500 133,500

5,000 5,000

127,500 138,500

139,000 150,000

5,000 5,000

144,000 155,000

160,000 211,000

5,000 5,000

165,000 216,000

166,500 254,500

5,000 5,000

171,500 259,500

394,000 394,000

10,000 10,000

404,000 404,000

164,000 189,500 194,000 340,000

10,000 10,000 10,000 10,000

174,000 199,500 204,000 350,000

193,000 204,000 221,000

10,000 10,000 10,000

203,000 214,000 231,000

335,000 368,500

10,000 10,000

345,000 378,500

415,000 431,500

10,000 10,000

425,000 441,500

244,000 259,500

10,000 10,000

254,000 269,500

214,000 315,000

10,000 10,000

224,000 325,000

NO

JENIS


PELAYANAN

a). 1 Buah 889,500 10,000 899,500 b). 1 Pasang 1,769,000 10,000 1,779,000 2). Dewasa a). 1 Buah 1,153,500 10,000 1,163,500 b). 1 Pasang 2,097,000 10,000 2,107,000 e. Short Leg Brace 1). Anak a). 1 Buah 518,900 10,000 528,900 b). 1 Pasang 903,900 10,000 913,900 2). Dewasa a). 1 Buah 579,400 10,000 589,400 b). 1 Pasang 1,106,900 10,000 1,116,900 f. Flexor Dynamic Splint Aluminium 1). Anak 188,200 10,000 198,200 2). Dewasa 238,600 10,000 248,600 g. Sepatu 567,200 1). Spring Shoes 557,200 10,000 2). Shoes Orthopedic 390,000 10,000 400,000 3). Shoes T.Shop 421,200 10,000 431,200 4). Arm Sling 165,000 10,000 175,000 5). Kne Support 198,000 10,000 208,000 6). Ankle Support 180,000 10,000 190,000 4. Tindakan Canggih Protese / Kaki Palsu a. Bellow Knee PTB Fiber Blass 1). Anak 4,530,000 10,000 4,540,000 2). Dewasa 4,690,000 10,000 4,700,000 b. Above Knee Fiber Blass 1). Anak 5,980,000 10,000 5,990,000 2). Dewasa 6,102,000 10,000 6,112,000 c. Bellow Knee Convensional 1). Anak 5,078,200 10,000 5,088,200 2). Dewasa 5,101,000 10,000 5,111,000 F. PELAYANAN PSIKOLOGI 1. Psikoterapi / Konsultasi 18,000 12,000 30,000 2. Psikoterapi / Test Inteligensi 30,000 20,000 50,000 3. Psikoterapi / Test Kepribadian 26,400 17,600 44,000 4. Psikoterapi / Test Bakat 48,000 32,000 80,000 Keterangan : 1. Tarif diatas sudah termasuk bahan yang dibutuhkan dan bilamana bahan tersebut tidak disediakan oleh RS maka besaran tarif diatas dikurangi tarif / harga bahan. 2. Ket. Fisioterapi : Tindakan Sederhana yaitu Infra Red dan Massage/Vibrator; Tindakan Sedang yaitu Exercise Therapy, MWD/ SWD, US, IT/TENS/FARADIK, Traksi L/C, Nebulaizer, Crio Jet Therapy dan Vacuum Unit Therapy; Tindakan Canggih yaitu Endolaser Therapy, EMG Bio Feedback, Pulky Computer, Magnetic Therapy serta Tindakan Khusus yaitu Cyber Norm, Treed Mill dan Butterfly Bath - Pasien Rawat Jalan dengan Rujukan Puskesmas dihitung Tarif Kelas III - Pasien Rawat Jalan tanpa Rujukan Puskesmas dihitung Tarif Kelas II 4. Keterangan Ortotik Prostetik : I. Tindakan Sederhana : a. Pasien Rawat Jalan / Rawat Inap Kelas III Dengan Rujukan dari Puskesmas digolongkan Tarif Kelas III. b. Pasien Rawat Jalan Tanpa Rujukan dari Puskesmas digolongkan Tarif Kelas II. II. Tindakan Sedang dan Canggih : a. Pasien Rawat Jalan / Rawat Inap di Kelas III Tarifnya dihitung Tarif Kelas II. b.Pasien Rujukan Umum masuk pada Tarif Kelas II. XIII. PELAYANAN REHABILITASI JANTUNG A. 1. Konsultasi Program Rehabilitasi 5,000 45,000 2. Prosedur EKG 27,000 18,000 3. Prosedur 18,000 12,000 4. Prosedur Nebulizer + Exercise 27,000 18,000 5. Telemetri 45,000 30,000 6. Treadmill Test 120,000 80,000 7. Prosedur Rehab di Ruangan / Kunjungan (Fase I) 45,000 30,000 8. Rehab Fase II / Kunjungan 30,000 20,000 9. Rehab Fase III / Kunjungan 18,000 12,000 B. Paket Rehab FASE II 390,000 260,000 C. Paket Rehab PASIEN BARU 90,000 60,000 Keterangan : 1. Pembayaran dilakukan di Kasir (Bag. Mob. Dana & Perbendaharaan) yang ditunjuk setelah dibuat Nota Biaya oleh Petugas Verifikasi (Bagian Akuntansi dan Verifikasi). 2. Paket Rehab FASE II terdiri dari : Konsultasi Rehab, EKG, Telemetri 1 (satu) kali, Kunjungan 24 kali. 18

75,000 45,000 30,000 45,000 75,000 200,000 75,000 50,000 30,000 650,000 150,000

JENIS

NO

3.


PELAYANAN

Paket Rehab FASE II ini dilakukan 3 kali seminggu selama 2 (dua) bulan. Paket Rehab PASIEN BARU terdiri dari : Konsultasi Program Rehabilitasi, EKG, Telemetri, Kunjungan 1 kali.

XIV. UNIT TRANSFUSI DARAH 1. Whole Blood (WB) Per 350 cc / Bag 220,000 50,000 2. Packet Red Cell (PRC) 220,000 50,000 3. Pencucian Darah (Wash PRC) 220,000 50,000 4. Trombosit Concentrate (TC) 220,000 50,000 5. Fresh Frozen Plasma (FFP) 220,000 50,000 6 Crayo Precipitate - AHF 220,000 50,000 7. Apheresis : a. Trombosit Apheresis (Amicus Seperator) 3,190,000 660,000 b. Trombosit Pheresis (Haemonetic Mcs +) 3,190,000 660,000 c. Therapeutic Plasma Exchange 4,250,000 2,200,000 d. Leucoreduction 4,250,000 2,200,000 8. Cross Matching 38,000 7,000 9. Phlebotomie 40,000 55,000 10. Golongan Darah Reverse & Forward 58,000 12,000 11. Filter : - Red Cell 225,000 - Trombosit Concentrate (TC) 343,200 12. Coomb's Test 34,000 6,000 a. Direct b. Indirect 13. Antibody Screening 34,000 6,000 14. Antibody Identification 300,000 50,000 15. Golongan Darah Rhesus CcEe 34,000 6,000 16. Nucleic Acid Test (NAT) terdiri dari: HBV, HCV dan HIV 300,000 50,000 Penjelasan : Untuk pelayanan Whole Blood (WB) dan Packet Red Cell (PRC) wajib membawa donor satu orang (per kantong) XV. HAEMODIALISA 1. Haemodialisa A 2. Haemodialisa B 3. Double Lumen Keterangan : - Haemodialisa A : Dengan Reuse - Haemodialisa B : Tanpa Reuse XVI. PELAYANAN GAS MEDIS 1. Oksigen liter 2. Oksigen Bayi (Perinato) / liter 3. Oksigen Perinato dengan head box / liter 4. Oksigen dengan Ventilator / liter 5. N2O / liter 6. Udara Tekan (UT) / liter 7. CO2 / liter / menit 8. CO2 / tabung ukuran 2 kg 9. CO2 / tabung ukuran 5 kg 10. CO2 / tabung ukuran 25 kg 3 11. O2 / tabung 6m 3 12. O2 / tabung 2m

270,000 270,000 270,000 270,000 270,000 270,000 3,850,000 3,850,000 6,450,000 6,450,000 45,000 95,000 70,000 225,000 343,200 40,000

40,000 350,000 40,000 350,000

385,000 490,000 1,225,000

165,000 210,000 525,000

550,000 700,000 1,750,000

25 30 50 70 300 70 9,000 50,000 65,000 270,000 125,000 50,000 40,000 66,000

5 5 15 20 100 10 3,000 10,000 20,000 80,000 9,000

30 35 65 90 400 80 12,000 60,000 85,000 350,000 125,000 50,000 40,000 75,000

936,000

2,340,000

13. O2 / Tabung 1m3 14. Respiflo / flash Keterangan : 1. Pembayaran dilakukan di Kasir (Bag. Mob. Dana & Perbendaharaan) yang ditunjuk setelah dibuat Nota Biaya oleh Petugas Verifikasi (Bagian Akuntansi dan Verifikasi). 2. Untuk pemakaian Tabung Gas O2 (Oksigen) yang dibawa pulang oleh pasien harus menyerahkan uang jaminan sebesar : 3 - Tabung 6m = Rp.1.600.000,3 Tabung 2m = Rp. 750.000,Uang jaminan dipegang oleh Benadahara Penerima melalui kasir yang bertugas dan pengembalian uang jaminan dilakukan apabila Tabung telah diserahkan kembali ke RS. XVII. TINDAKAN INSTALASI BEDAH PUSAT (DALAM KAMAR OPERASI) A. BEDAH DIGESTIVE 1. Sedang I 1 Herniorafi tanpa penyulit 19

1,404,000

NO

JENIS


PELAYANAN

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 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 20

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

1,312,000

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 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

JENIS

NO

5

6

B.


PELAYANAN

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 9 Skin Laser Treatment 4. 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 21

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

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 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

2,700,000 2,700,000

6,750,000 6,750,000

4,050,000 4,050,000

2,700,000 2,700,000

6,750,000 6,750,000

JENIS

NO


PELAYANAN

c. Poplitea/Tibialis AV Shunt cubiti Simpatektomi AV Shunt radial (Brescia-Cimino) Debridement & tutup defek pada gangren diabetik Eksisi & rekonstruksi limfedema & reduksi massa Skleroterapi dengan anestesi Grafting pada Arterial Insufisiensi Operasi Aneurisma Aorta Operasi Arteri Carotis Operasi Arteri Renalis Stenosis Lumbal simpatektomi bilateral 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 4 5 6 7 8 9 10 11 12 13 14 15

5.

6.

C.

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 GA Kulit diameter > 2 cm dgn GA 14 dengan Insisi Abses 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 22

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 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 1,968,000 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

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

NO

JENIS


PELAYANAN

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 5 ORIF Fr. Calcaneal 6 ORIF Fr. Bimaleolalr 7 ORIF Fr. Ankle 8 ORIF Fr. Os Illium 9 ORIF Fr. Os Pubis 10 Release fraktur + Skeletal Traksi Malunion Femur tibia 11 ORIF Fr. Tibia Plateau Simple 23

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

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 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 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 72 73 74 75 76 77 78


PELAYANAN

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 Body Jacket dengan GA Debridement Coxae / Hip ( Coxitis ) Eksternal Fiksasi Pelvis Angkat Plate Radius & Ulna Angkat Plate Humeri Angkat K. Wire Multiple dgn GA ( > 6 Wire ) Body Jacket/Corset Dewasa dengan GA 24

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.


PELAYANAN

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 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 25

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

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 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

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

JENIS

NO

4.

5.

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.


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 9 Alveolectomi 10 Apek reseksi (gigi) 11 Fistulectomi 12 Frenectomi 13 Gingivectomy 14 Insisi Mucocele 15 Operculectomy 26

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

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 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000

936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000

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 2,340,000

JENIS

NO

2

3

4

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.


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 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 27

1,404,000 1,404,000

936,000 936,000

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 1,968,000 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

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

1,688,000 1,688,000 1,688,000

4,220,000 4,220,000 4,220,000

NO

JENIS


PELAYANAN

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 7 Ureterolithomi distal 8 Hipospadia 9 URS (Ureteronoskopy) 10 Percutaneus Nefrolitekfripis (PCN) 11 Laparoscopi urologi 12 Bladder Neck Incision 13 Extended Pyelolithorny 28

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

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 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

NO

JENIS


PELAYANAN

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 4 Orkhidopeksi per laparoskopi 5 Pieloplasti Per Laparoskopi 6 Nefrektomi Per Laparoskopi 7 Retro Peritoneal Lymp Node Dissection (RPLND) 8 RPLND 9 Ekstrofi buli rekonstruksi 10 Radikal Prostatektomi 29

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

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 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 -

18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 18,000,000 -

JENIS

NO


PELAYANAN

11 Radikal Sistektomi F.

-

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) 4 Diseksi leher radikal modifikasi/fungsional (RND) 5 Hemamandibulektomi 6 Mandibulektomi Total 7 Endoscopy Tiroidectomy (MIVAT) 8 Rekonstruksi/Skin Graft yang kompleks dan luas 9 Bone Graft

30

-

-

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 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

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

JENIS

NO G.

H.


PELAYANAN

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 29 Mandibulektomy Partialis dangan rekonstruksi 30 Koreksi Impresif Fraktur 31 Maksilektomi Total BEDAH SYARAF 1. Besar 1 Koreksi impresif fraktur sederhana kurang dari 1 jam 31

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 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

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

2,532,000

1,688,000

4,220,000

JENIS

NO


PELAYANAN

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 Koreksi impresif fraktur komplikata (midline) 9 Eksplorasi kelainan otak supratentorial (biopsi) 10 Infratentorial serta hipofise tumor (tumor pasca posterior 11 Infratentorial serta hipofise (SLTH) 12 Pengangkatan tumor otak 13 Operasi stabilisasi dan reposisi fraktur tulang belakang 14 Operasi HNP penyempitan syaraf/tulang belakang 15 Kraniotomi+Bedah Mikro 16 Kraniotomi+Endoskopi 17 Operasi Mikro Cranialis / Spinalis Perifer 18 Complicated Functional Neuro Stereotaxy sederhana 19 Tumor spinal Daerah Kraniospinal 20 Operasi Fusi Korpus Vertebra Approach Posterior 21 Operasi Miko Plexus Brakhialis / Lumbalis Sacralis 22 Complicated Functional Neuro Stereotaxy kompleks I.

BEDAH THORAX 1 Besar 1 Thorax Drainage, WSD 2 Open Windows pada Empyema 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 32

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

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 2,532,000 2,532,000 2,532,000

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

4,050,000 4,050,000 4,050,000

2,700,000 2,700,000 2,700,000

6,750,000 6,750,000 6,750,000

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


PELAYANAN

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 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 33

4,050,000

2,700,000

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 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

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


PELAYANAN

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 11 Koreksi entropion congenital 12 Argon laser/kenon dengan anestesi lokal 13 Cyclodeatheral 14 Fotokoagulasi argon laser 15 Aplikasi cryo 2. Besar 1 Goniotomi 34

2,532,000 2,532,000

1,688,000 1,688,000

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 1,404,000 1,404,000 1,404,000 1,404,000 1,404,000

936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000 936,000

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 2,340,000

2,532,000

1,688,000

4,220,000

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


PELAYANAN

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 3. Khusus I 1 Mastoidektomi Radikal/Dekompresi Fasialis 2 Laringektomi 3 Degloving / Transpalatal / Rinotomi Lateral 4 Maksilektomi 5 FESS 6 Stapedektomi 35

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

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

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

JENIS

NO


PELAYANAN

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.

N.

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 9 Histereskopi Operatif 10 Operasi Purundane 11 Adenolisis 12 Eksisi Kista Urachus 13 Repair Fistel BEDAH KULIT DAN KELAMIN 36

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

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 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

JENIS

NO


PELAYANAN

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 XVIII. TINDAKAN MEDIK NON OPERATIF DAN OPERATIF KECIL DILUAR KAMAR OPERASI A. POLIKLINIK PENYAKIT ANAK 1. Transiluminasi : a. Funduskopy b. Punsi lumbal c. Fungsi Subdurol d. Biopsi Ginjal e. Punsi Sumsum Tulang f. Fungsi Pericardial g. Test Mantoux h. Fungsi Plural 2. Screening Tumbuh Kembang 3. Speech Therapy 4. Test Kepribadian dan Konsultasi a. Grafis b. CAT c. FAT d. TAT e. Rop f. GPPT g. EPPS h. E K G 5. Test Bakat dan Konsultasinya (GABT) 6. Psikoterapi : a. Terapi Bermain b. Relaksasi c. Modifikasi d. Remidial e. Group Therapy f. Family Theraphy 7. Terapi Inhalasi 8. PPD Test 9. Suntik Sitostatika 10. Tindik 11. Vaksin/ Imunisasi Wajib (PPI) 12. Vaksin/ Imunisasi Anjuran ( Non PPI ) a. Vaksin Hib b. Vaksin Hepatitis A c. Vaksin Vacirella d. Vaksin MMR e. Vaksin DPaT f. Vaksin Tifoid B.

POLIKLINIK KEBIDANAN DAN PENYAKIT KANDUNGAN 1. Vaginal Swab 2. Vulva Hygiene 3. Paps Smear 4. Tutul Albothyl 5. Tamponade 6. Pasang IUD / Pasang Spiral 7. Angkat IUD / Buka Spiral 8. Pasang KB Susuk 9. Angkat KB Susuk 37

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

49,500 75,900 75,900 75,900 75,900 100,200 63,600 110,100 15,000 15,000

33,000 50,600 50,600 50,600 50,600 66,800 42,400 73,400 10,000 10,000

82,500 126,500 126,500 126,500 126,500 167,000 106,000 183,500 25,000 25,000

4,800 6,000 4,800 6,000 12,300 9,300 9,300 18,000 22,200

3,200 4,000 3,200 4,000 8,200 6,200 6,200 12,000 14,800

8,000 10,000 8,000 10,000 20,500 15,500 15,500 30,000 37,000

12,300 10,500 10,500 10,500 10,500 12,300 21,600 11,400 37,800 4,800 11,400

8,200 7,000 7,000 7,000 7,000 8,200 14,400 7,600 25,200 3,200 7,600

20,500 17,500 17,500 17,500 17,500 20,500 36,000 19,000 63,000 8,000 19,000

113,700 144,000 208,800 64,500 155,400 83,400

75,800 96,000 139,200 43,000 103,600 55,600

189,500 240,000 348,000 107,500 259,000 139,000

18,000 12,000 17,100 10,500 10,500 22,500 15,900 25,800 25,800

12,000 8,000 100,400 7,000 7,000 200,000 200,600 300,200 300,200

30,000 20,000 117,500 17,500 17,500 222,500 216,500 326,000 326,000

JENIS

NO 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. C.


PELAYANAN

KB Suntik Inseminasi UPS UMS Periksa Hamil Tindakan Metilen Blue Pasang Busi Pasang Ring Angkat Ring Kontrol Ring Kuret Bertingkat Hidrotubasi Kontrol Post Operasi Ganti Verban Visum Biopsi Cauter Kontrol Pasca Melahirkan KTG USG Dopler 2 Dimensi (Obgin) USG Dopler 3 Dimensi (Obgin) Kolposkopi Krio Terapi Amnioinfussion Sono Histerografi

POLIKLINIK BEDAH 1. Incisi Abses Kecil 2. Incisi Abses Sedang 3. Incisi Abses Besar 4. Pasang Foley Catheter 5. Pasang Metal Catheter 6. Bouginasi 7. Circumsisi 8. Ekstirpasi 9. Biopsi Insisi 10. Tindakan Hecting < 5 kali 11. Tindakan Hecting 5 s/d 15 kali 12. Tindakan Hecting > 15 kali 13. Gips Kecil Anak 14. Gips Kecil Dewasa 15. Gips Sedang Anak 16. Gips Sedang Dewasa 17. Gips Besar Anak 18. Gips Besar Dewasa 19. Ganti Verban Kecil ( s/d 15 cm ) 20. Ganti Verban Sedang ( 16 cm s/d 50 cm ) 21. Ganti Verban Besar ( > 50 cm ) 22. Angkat Jahitan 23. Minor Kecil 24. Minor Sedang 25. Minor Besar 26. Nigel Ekstraksi 27. Insisial Biopsi 28. Eksisi Biopsi 29. Pasang Busi Laretra 30. Cuci Kaki Diabetik 31. Polip Recti 32. Fibioma recti 33. Biopsi Punch 34. Insisi drainase/kuretase 35. Biopsi Insisi dengan anastesi lokal 36. Pleurodesis 37. Core Biopsi 38. Insisi Abses Skrotum 39. Insisi Abses Perincal 40. Biopsi Penis 38

4,800 40,200 18,000 18,000 12,000 17,700 12,000 23,100 23,100 36,000 64,800 18,000 10,200 12,000 10,200 28,800 28,800 15,900 19,200 36,000 60,000 57,000 172,200 450,000 300,000

50,200 1,000,800 12,000 12,000 100,000 100,800 50,000 100,400 100,400 100,000 200,200 200,000 100,800 100,000 300,800 200,200 300,200 100,600 100,800 100,000 200,000 400,000 400,800 500,000 400,000

55,000 1,041,000 30,000 30,000 112,000 118,500 62,000 123,500 123,500 136,000 265,000 218,000 111,000 112,000 311,000 229,000 329,000 116,500 120,000 136,000 260,000 457,000 573,000 950,000 700,000

54,000 70,800 99,600 55,800 55,800 22,200 61,000 71,000 30,000 21,000 72,000 102,000 138,000 282,000 306,000 447,000 579,000 678,000 18,000 39,000 69,000 10,500 36,000 48,000 63,000 75,000 42,000 59,000 24,000 24,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000

36,000 47,200 66,400 37,200 37,200 14,800 468,000 468,000 468,000 14,000 48,000 75,000 92,000 188,000 204,000 298,000 386,000 452,000 12,000 26,000 75,000 7,000 468,000 468,000 468,000 468,000 28,000 468,000 16,000 75,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000

90,000 118,000 166,000 93,000 93,000 37,000 529,000 539,000 498,000 35,000 120,000 177,000 230,000 470,000 510,000 745,000 965,000 1,130,000 30,000 65,000 144,000 17,500 504,000 516,000 531,000 543,000 70,000 527,000 40,000 99,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000

JENIS

NO


PELAYANAN

41. Dilatasi Urethra D.

E.

F.

G.

702,000

468,000

1,170,000

POLIKLINIK BEDAH SYARAF 1. Pasang Catheter 2. Ekstirpasi 3. Tindakan Hecting < 5 kali 4. Ganti Verban Kecil 5. Ganti Verban Kecil + Angkat Jahitan 6. Ganti Verban Sedang 7. Ganti Verban Sedang + Angkat Jahitan 8. Insisi Biopsi (onkologi) 9. Exsisi 10. Aspirasi Cairan Kepala 11. Aspirasi Cairan Omaya/Vp Shunt 12. Aspirasi Vp Shunt Anak-anak 13. Aspirasi Vp Shunt Dewasa 14. Ventricular Tapping Anak-anak 15. Ventricular Tapping Dewasa 16. Lumbal Punksi Anak-anak 17. Lumbal Punksi Dewasa

83,700 109,500 31,500 27,000 58,500 36,000 76,500 63,000 88,200 45,000 480,000 120,000 180,000 120,000 180,000 120,000 180,000

55,800 73,000 21,000 18,000 39,000 24,000 51,000 42,000 58,800 30,000 320,000 80,000 120,000 80,000 120,000 80,000 120,000

139,500 182,500 52,500 45,000 97,500 60,000 127,500 105,000 147,000 75,000 800,000 200,000 300,000 200,000 300,000 200,000 300,000

POLIKLINIK BEDAH ORTHOPEDI 1. Incisi Kecil 2. Incisi Sedang 3. Incisi Besar 4. Tindakan Jahitan < 5 kali 5. Tindakan Jahitan 5 s/d 15 kali 6. Tindakan Jahitan > 15 kali 7. Gips Kecil Anak 8. Gips Kecil Dewasa 9. Gips Sedang Anak 10. Gips Sedang Dewasa 11. Gips Besar Anak 12. Gips Besar Dewasa 13. Ganti Verban Kecil ( s/d 15 cm ) 14. Ganti Verban Sedang ( 16 cm s/d 50 cm ) 15. Ganti Verban Besar ( diatas 50 cm ) 16. Angkat Jahitan 17. Minor Kecil 18. Minor Sedang 19. Minor Besar 20. Cabut K-Wire 21. Plaster Cast 22. Secondary Sutures 23. Pemasangan Plaster Cast

114,000 130,800 159,600 81,000 192,000 282,000 198,000 342,000 426,000 567,000 759,000 858,000 48,000 99,000 159,000 40,500 96,000 138,000 183,000 141,000 141,000 141,000 141,000

76,000 87,200 106,400 54,000 128,000 188,000 132,000 228,000 284,000 378,000 506,000 572,000 32,000 66,000 106,000 27,000 64,000 92,000 122,000 94,000 94,000 94,000 94,000

190,000 218,000 266,000 135,000 320,000 470,000 330,000 570,000 710,000 945,000 1,265,000 1,430,000 80,000 165,000 265,000 67,500 160,000 230,000 305,000 235,000 235,000 235,000 235,000

30,000 18,000 30,000 30,000 30,000 30,000 900,000

20,000 12,000 20,000 20,000 20,000 20,000 600,000

50,000 30,000 50,000 50,000 50,000 50,000 1,500,000

37,800 46,200 10,800

25,200 30,800 7,200

63,000 77,000 18,000

24,000 30,000 36,000 18,000 30,000 60,000

16,000 20,000 24,000 12,000 20,000 40,000

40,000 50,000 60,000 30,000 50,000 100,000

POLIKLINIK PENYAKIT DALAM DIVISI ENDOKRIN DAN METABOLIK 1. Perawatan Kulit dan Kuku Kaki 2. Kontrol Luka 3. Kapalan 4. Luka dengan Nekrotoni 5. Luka dengan Ganggren 6. ABI 7. Minor Amputasi DIVISI ENOKRINOLOGI DAN METABOLIK 1. Spirometri 2. Aspirasi 3. Proef POLIKLINIK THT 1. Cerumen 2. Epidermis Prof 3. Timpanometri 4. Ganti Verban 5. Caustik Tenggorokan 6. Caustik Hidung 39

JENIS

NO 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. H.


PELAYANAN

Caustik Telinga Test Alergi Audiogram C. Alineum Tenggorokan C. Alineum Hidung C. Alineum Telinga dengan lokal Anestesi Kalori Test Buka Jahitan Kateter Tuba Eustachius Parasentese Swab Nasal Swab Throat Swab Telinga Test Berbisik / Penalu Check-Up THT Kaak Spoeling Insisi Abses Peritonsil Insisi Abses Retroauricular Irigasi/Cuci Hidung Nasoendoskopy Nasoendoskopy + Biopsi Laringoskopy Optic Tampon Belloque Timpanometri + Refleks Akustik Timpanometri + Refleks Akustik + Tes Fungsi Tuba Mikroskop Telinga + Biopsi Mikroskop Telinga + Ekstraksi Grabulasi Mikroskop Telinga + Kolesteatoma Eksterna Ekstraksi Granulasi Liang Telinga (Bius Lokal) Ekstraksi Polip Nasal (Bius Lokal) Irigasi Sinus Maksila (Bius Lokal) Tampon Anterior Irigasi Abses Septum (Bius Lokal) Adenoidektomi (Bius Lokal) Insisi Abses Retroaurikular (Bius Lokal) Insisi Abses Peritonsiler Insisi Othematom Biopsi Eksplorasi Nasofaring

POLIKLINIK KULIT DAN KELAMIN I. Kecil 1. Elektrodesikasi lesi < 5 mm 2. Ekstraksi Komedo 3. Kuretase 4. Insisi Abses 5. Injeksi Triamcinolon ID 6. Ganti Verban / Kompres 7. Biopsi Kulit 8. Tampon 9. Eksisi lesi < 5 mm 10. Aff Hecting 11. KOH Direct 12. Lampu Wood 13. Pewarnaan Gram / Pemeriksaan Basah 14. Mikroskop Lapangan Gelap 15. Tutul TCA 16. Tuberkulin Test 17. Pemeriksaan BTA Kusta 18. Uji Tusuk (Prick Test) 19. Peeling 20. Uji Tempel (Patch Test) II. Sedang 1. Elektro Desikasi Sedang 2. Bedah Sayat (Shaving) 3. Kuretase dan Elektrodesikasi 4. Eksisi lesi 5 mm - 2 cm 40

60,000 165,000 36,000 45,000 30,000 60,000 30,000 18,000 30,000 30,000 24,000 24,000 24,000 15,000 60,000 240,000 109,800 90,000 18,000 90,000 105,000 120,600 240,000 54,000 72,000 105,000 120,000 150,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000 702,000

40,000 110,000 24,000 30,000 20,000 40,000 20,000 12,000 20,000 20,000 16,000 16,000 16,000 10,000 40,000 160,000 73,200 60,000 12,000 60,000 70,000 80,400 160,000 36,000 48,000 70,000 80,000 100,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000 468,000

100,000 275,000 60,000 75,000 50,000 100,000 50,000 30,000 50,000 50,000 40,000 40,000 40,000 25,000 100,000 400,000 183,000 150,000 30,000 150,000 175,000 201,000 400,000 90,000 120,000 175,000 200,000 250,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000 1,170,000

58,800 87,000 78,000 63,000 48,000 18,000 78,000 70,800 121,800 37,800 40,200 70,200 40,200 88,200 36,000 40,200 36,000 90,000 76,200 90,000

39,200 58,000 52,000 42,000 32,000 12,000 52,000 47,200 81,200 25,200 26,800 46,800 26,800 58,800 24,000 26,800 24,000 60,000 50,800 60,000

98,000 145,000 130,000 105,000 80,000 30,000 130,000 118,000 203,000 63,000 67,000 117,000 67,000 147,000 60,000 67,000 60,000 150,000 127,000 150,000

87,000 117,000 117,000 220,800

58,000 78,000 78,000 147,200

145,000 195,000 195,000 368,000

JENIS

NO


PELAYANAN

5. Ekstirpasi 6. Ekstraksi 7. Elektrodesikasi Lesi Multiple 8. Sirkumsisi 9. Cryosurgery III. Besar 1. Revisi Parut (Scar Revision) 2. Eksisi lesi > 2 cm 3. Blepharoplasty 4. Dermabrasi 5. Transplantasi Rambut IV. Khusus 1. Skin Graf 2. Bedah Sedot Lemak (Liposuction) 3. Skin Flap I.

J.

K.

POLIKLINIK PENYAKIT JIWA (PSIKIATRI) 1. ECT 2. Pelayanan : a). Farmakoterapi b). Psikoterapi I Psikoterapi II Psikoterapi III 3. Test Kepribadian MMPI-2 4. Surat Keterangan Narkoba 5. Surat Keterangan Sehat Jiwa 6. Tindakan : Injeksi a. Zyprexa 10 mg b. Diazepam c. Delladryl d. Haloperidol 7. Day care Keterangan : a. Pasien Pribadi / Kiriman Dokter Praktek dikenakan Tarif VIP (Utama II) b. Pasien IGD dikenakan Tarif Kelas II. c. Untuk pemeriksaan Test Kepribadian MMPI-2, BHP sudah termasuk kedalam JS sebesar Rp. 60.000,-. POLIKLINIK PARU 1. BAL (Broncho Alveolar Lavage) 2. Biopsi Bronkus 3. Biopsi Pleura 4. Biopsi Trans Torakal / TTNA / TTLB 5. Bronkoskopi 6. Ganti Verban 7. Kumbah Pleura 8. Mantoux Test 9. Pleurodesis 10. Sikatan Bronkus 11. Spirometri 12. Torakosentesis / Pungsi Pleura 13. Torakoskopi 14. USG Paru 15. WSD / Thorax Drainage 16. Nebulizer 17. Revitalisasi WSD 18. Cabut WSD 19. Dekompresi Thorax 20. Insersi jarum pada Emfisema Subkutan POLIKLINIK GIGI DAN MULUT I. Kecil 1. Extraksi (tanpa komplikasi) 2. Extraksi (dengan komplikasi) 3. Tambalan Sementara / Ganti Obat 4. Tambalan Amalgam / Silikat 5. Composit Light Curing 41

250,800 220,800 235,200 241,200 400,800

167,200 147,200 156,800 160,800 267,200

418,000 368,000 392,000 402,000 668,000

700,800 736,800 736,800 736,800 791,400

467,200 491,200 491,200 491,200 527,600

1,168,000 1,228,000 1,228,000 1,228,000 1,319,000

1,200,000 1,200,000 1,200,000

800,000 800,000 800,000

2,000,000 2,000,000 2,000,000

66,000

44,000

110,000

12,000 90,000 120,000 150,000 150,000 30,000 45,000

8,000 60,000 80,000 100,000 100,000 20,000 30,000

20,000 150,000 200,000 250,000 250,000 50,000 75,000

126,000 40,800 33,000 45,000 150,000

84,000 27,200 22,000 30,000 100,000

210,000 68,000 55,000 75,000 250,000

300,000 300,000 300,000 300,000 510,000 27,000 270,000 72,000 300,000 300,000 90,000 300,000 1,620,000 300,000 660,000 30,000 300,000 180,000 300,000 285,000

200,000 700,000 400,000 700,000 540,000 18,000 380,000 48,000 200,000 200,000 60,000 400,000 2,080,000 200,000 940,000 20,000 400,000 240,000 400,000 390,000

500,000 1,000,000 700,000 1,000,000 1,050,000 45,000 650,000 120,000 500,000 500,000 150,000 700,000 3,700,000 500,000 1,600,000 50,000 700,000 420,000 700,000 675,000

45,000 90,000 21,000 24,000 51,000

30,000 60,000 14,000 16,000 34,000

75,000 150,000 35,000 40,000 85,000

JENIS

NO


PELAYANAN

6. 7.

Trepanasi Scalling per rahang : a. Manual b. Elektrik 8. Curritage 9. Insici Abses : a. Intra Oral b. Extra Oral 10. Dental Radiografi II. Sedang 1. Alveolectomy / Segmen / rahang 2. Frenectomy / Operculectomi 3. Splinting / rahang 4. Interdental Wiring / rahang 5. Odentektomi 6. Apeksreseksi 7. Enuklease Kista Kecil 8. Mococele 9. Epulis / Fibroma 10. Extirpasi soft tissue tumor III. Khusus 1. Prothesa Lepas Sebagian 1 Gigi 2. Tambah Per 1 (satu) Gigi 3. Prothesa Full per Rahang 4. Orthodontic Cekat 5. Onlay / Uplay 6. Orthodontic Sederhana / Lepasan 7. Crown Porselen 8. STIF Crown / Porselen 9. Frame Prothesa Per 1 (satu) Gigi 10. Inlay L.

POLIKLINIK MATA I. Operasi Kecil 1. USG per mata 2. Korpus alienum 3. Irrigatie Trauma Asam Basa 4. Chalazion 5. Hordeolum 6. Nevus Kecil 7. Nevus Besar 8. Cyste Kecil 9. Cyste Besar 10. Pteregium 11. Ellips Incision 12. Cangkok Lemak (SBL) 13. Tarsotomi 14. Angkat jahitan 15. Taitoage Kornea 16. Scraping Kornea 17. Tarsoraphi 18. Cantoraphi 19. Symblepharon Ringan 20. Koreksi Entropion 21. Jahitan Luka Kecil Palpebra 22. Granuloma 23. Biopsi Adnexa 24. Probing Ductus Nasalacrimalis 25. Keratometer / Per Satu Mata 26. Biometri / Per Satu Mata 27. Xanthelesma Catatan : Operasi Kecil ini dilakukan di Kamar Bedah Kecil Poliklinik Mata II. Pemeriksaan Diagnostik Sederhana 1. Visus (Refraksi) pemberian resep k.m 2. Slit Lamp Examination 3. Tonometri (Ton. Schiotz / Applanasi) 4. Schimer Test (Anel Test) 42

12,000

8,000

20,000

36,000 60,000 30,000

24,000 40,000 20,000

60,000 100,000 50,000

90,000 270,000 18,000

60,000 180,000 12,000

150,000 450,000 30,000

240,000 240,000 240,000 600,000 450,000 360,000 240,000 240,000 240,000 240,000

160,000 160,000 160,000 400,000 300,000 240,000 160,000 160,000 160,000 160,000

400,000 400,000 400,000 1,000,000 750,000 600,000 400,000 400,000 400,000 400,000

300,000 60,000 900,000 2,700,000 360,000 720,000 480,000 540,000 600,000 360,000

200,000 40,000 600,000 1,800,000 240,000 480,000 320,000 360,000 400,000 240,000

500,000 100,000 1,500,000 4,500,000 600,000 1,200,000 800,000 900,000 1,000,000 600,000

102,000 66,000 30,000 72,000 72,000 72,000 105,000 60,000 105,000 132,000 210,000 210,000 180,000 36,000 180,000 45,000 105,000 132,000 105,000 240,000 90,000 90,000 72,000 45,000 24,000 39,000 210,000

68,000 44,000 20,000 48,000 48,000 48,000 70,000 40,000 70,000 88,000 140,000 140,000 120,000 24,000 120,000 30,000 70,000 88,000 70,000 160,000 60,000 60,000 48,000 30,000 16,000 26,000 140,000

170,000 110,000 50,000 120,000 120,000 120,000 175,000 100,000 175,000 220,000 350,000 350,000 300,000 60,000 300,000 75,000 175,000 220,000 175,000 400,000 150,000 150,000 120,000 75,000 40,000 65,000 350,000

9,000 9,000 9,000 9,000

6,000 6,000 6,000 6,000

15,000 15,000 15,000 15,000

JENIS

NO


PELAYANAN

5. Keratometer / Auto Refraktometer 12,000 8,000 20,000 6. Syniophthopore 9,000 6,000 15,000 7. Funduskopy Direct 9,000 6,000 15,000 8. Surat Keterangan Buta Warna / Mata 18,000 12,000 30,000 9. Ganti Verban 6,000 4,000 10,000 III. Pemeriksaan Diagnostik Sedang 1. Funduskopy Indirect 15,000 10,000 25,000 2. Foto Fundus Berwarna 120,000 80,000 200,000 3. USG : 125,000 1). Biometri 75,000 50,000 4. Perimetri (Gold Man, Tangan Screen) 15,000 10,000 25,000 5. Three Miror Gonioskopy 13,800 9,200 23,000 IV. Pemeriksaan Canggih 1. Foto Coagulasi Laser 153,000 102,000 255,000 2. Laser Yag Capsulotomi 210,000 140,000 350,000 3. Laser Iridotomi 240,000 160,000 400,000 4. Laser Trabekulektomi 300,000 200,000 500,000 5. Fundus Fluoresin Angiografi 300,000 200,000 500,000 6. Epilasi 12,000 8,000 20,000 7. Operasi Katarak Paket I (ECCE + IOL) 600,000 900,000 1,500,000 8. Operasi Katarak Paket II (SICS / PHACO + IOL) 1,000,000 1,500,000 2,500,000 Keterangan untuk Operasi Katarak : 1. Tarif Operasi Katarak diatas sudah termasuk Bahan Habis Pakai (BHP) yang dibutuhkan termasuk IOL Posteriol / IOL Anterior (Paket disediakan RS). 2. JDA (Jasa Dokter Ahli) tersebut belum dikurangkan PPh Pasal 21 sebesar 7,5 %. 3. Tarif diatas hanya untuk tindakan operasi saja, tidak termasuk obat makan setelah operasi. 4. Paket diatas sudah termasuk Konsul/Kontrol setelah operasi sebanyak 3 (tiga) kali. 5. Apabila diperlukan pemeriksaan penunjang medis maka dikenakan biaya sesuai tarif Kelas III yang berlaku. 6. Apabila diperlukan rawat inap maka dikenakan biaya rawat inap sesuai dengan kelas yang ditempati pasien. 7. Tindakan operasi untuk Paket I dan Paket II dilaksanakan di OK Poliklinik Mata. M.

N.

O.

POLIKLINIK NEUROLOGI 1. Lumbal Punksi 2. Funduscopy 3. EEG 4. TCD 5. EMG 6. Perpirasi Test 7. Tensilon Test 8. Caloric Test

120,000 49,500 108,000 180,000 180,000 60,000 72,000 48,000

80,000 33,000 72,000 120,000 120,000 40,000 48,000 32,000

200,000 82,500 180,000 300,000 300,000 100,000 120,000 80,000

POLIKLINIK KARDIOLOGI 1. Alat Echoclor Dopler Cardiografi 2. E K G

180,000 18,000

120,000 12,000

300,000 30,000

900,000

600,000

1,500,000

1,200,000

800,000

2,000,000

360,000

240,000

600,000

1,200,000

800,000

2,000,000

POLIKLINIK NYERI 1. Tindakan untuk Penanganan Nyeri Akut 1). Penanganan Nyeri Pasca Bedah dan Trauma a). Pemasangan Epidural Catheter Continue b). Pemasangan Intrathecal Catheter Continue c). Pemasangan Kateter Blok Saraf Perifer Continue d). Patient Controlled Analgesia System 2). Penanganan Nyeri Persalinan a). Intrathecal Labor Analgesia b). Epidural Labor Analgesia c). Systemic Analgesia 2. Penanganan Nyeri Kronik dan Kanker 1). Kategori Tindakan Sederhana a). Triger Point Miofasial b). Transcutaneus Elektric Nerve Stimulation c). Accupunture Analgesia (Electro Accupunture Analgesia) d). Injeksi Saraf Ferifer (N. Occipital, Suprascapular, Lateral Femoral Cutaneus, dll) Tanpa Penuntun USG 2). Kategori Tindakan Kecil a). Injeksi Intraartikuler b). Patient Controlled Analgesia System c). Injeksi Saraf Ferifer (N. Occipital, Suprascapular, Lateral Femoral Cutaneus, dll) d). Injeksi Epidural Intralaminer dan Caudal Tanpa Penuntun C-Arm Fluoroskopi 43

JENIS

NO 3).

4).

5).

6).

P.


PELAYANAN

Kategori Tindakan Sedang a). Injeksi Epidural : Intralaminer, Transforaminal dan Caudal dengan Penuntun C-ArmFacet Fluoroscopy b). Injeksi Sendi Lumbal dan Thoracic dengan Penuntun C-Arm Fluoroscopy c). Blok Saraf Medial Branch Lumbal dan Thoracic untuk Sendi Facet dengan Penuntun C-Arm Fluoroscopy d). Injeksi Sacro-Iliaca dengan Penuntun USG dan C-Arm Fluoroscopy e). Injeksi Saraf Ganglion : Ganglion Stellate, Impar dengan Penuntun USG dan C-Arm Fluoroscopy f). Blok Saraf Paravertebral dan Injeksi Radiks Saraf (Nerve Root Injection) Kategori Tindakan Besar a). Injeksi Sendi Facet Cervical dengan Penuntun C-Arm Fluoroscopy b). Blok Saraf Medial Branch Cervical untuk Sendi Facet dengan Penuntun CArm Fluoroscopy c). Injeksi Ganglion Simpatik Lumbal dan Thoracic dengan Penuntun C-Arm Fluoroscopy d). Blok Saraf N. Splancnic dan Plexus Coeliac dengan Penuntun C-Arm Fluoroscopy e). Blok Saraf Trigeminal dengan Penuntun C-Arm Fluoroscopy f). Blok Dorsal Roof Ganglion (DRG) Lumbal, Thoracic dan Cervical dengan PenuntunTindakan C-Arm Fluoroscopy Kategori Khusus a). Radiofrekuensi Ablation pada Serabut Saraf (N. Splanchnic, N. Media Branch, N. Trigeminal, dll)Ganglia, dengan Penuntun C-Arm dan Fluoroskopi b). Ganglion (Dorsal Root Tellate Ganglion, Lumbar Sympathetic, GanglionTindakan Impar, dll)Canggih dengan Penuntun C-Arm dan Fluoroskopi Kategori a). Spinal Cord Stimulation (SCS) b). Intra Discal Electrothermal Therapy c). Epiduroskopi d). Vertebroplasty

POLIKLINIK KONSULTASI PSIKOLOGI 1. Konsultasi 2. Tes Kepribadian a. Grafis b. CAT c. FAT d. TAT e. EPPS 3. Tes Bakat dan Konsultasi 4. Psikoterapi a. Terapi Bermain b. Relaksasi c. Modifikasi d. Group Therapy e. Familly Therapy 5. Tes Kecerdasan a. IST b. SPM c. CPM d. WAIS e. WBIS f. WISC g. Binet h. CFIT i. TKD j. PAULI 6. Tes Kepribadian a. Ronchach b. MMPI c. CIQ d. DISC 7. TERAPI a. Autis b. Hiperaktif c. Gangguan Prilaku d. Gangguan Perkembangan e. Gangguan Pola Asuh f. Terlambat Bicara g. Kesulitan Belajar 8. Tes Lengkap / Psikotest

XIX. TARIF LAIN - LAIN A. POLIKLINIK RUMATAN METADON 1. Karcis 44

2,400,000

1,600,000

4,000,000

3,600,000

2,400,000

6,000,000

6,000,000

4,000,000

10,000,000

12,000,000

8,000,000

20,000,000

15,000

35,000

50,000

15,000 18,000 18,000 18,000 18,000 21,000

35,000 42,000 42,000 42,000 42,000 49,000

50,000 60,000 60,000 60,000 60,000 70,000

13,500 16,500 16,500 13,500 15,000

31,500 38,500 38,500 31,500 35,000

45,000 55,000 55,000 45,000 50,000

16,500 16,500 16,500 18,000 18,000 18,000 16,500 16,500 16,500 16,500

38,500 38,500 38,500 42,000 42,000 42,000 38,500 38,500 38,500 38,500

55,000 55,000 55,000 60,000 60,000 60,000 55,000 55,000 55,000 55,000

18,000 18,000 18,000 16,500

42,000 42,000 42,000 38,500

60,000 60,000 60,000 55,000

21,000 21,000 21,000 21,000 21,000 21,000 21,000 45,000

49,000 49,000 49,000 49,000 49,000 49,000 49,000 105,000

70,000 70,000 70,000 70,000 70,000 70,000 70,000 150,000

6,000

9,000

15,000

JENIS

NO


PELAYANAN

2. Kartu Berobat 3. Konsul Dokter Spesialis 4. Periksa Urine Narkoba : a. THC (Ganja) b. MOP (Opiat) c. AMP (Amphetamine) d. BNZ (Benzodiazepam) 5. Minum Metadone

2,000 12,000

18,000

2,000 30,000

21,800 21,800 21,800 21,800 5,000

1,200 1,200 1,200 1,200 10,000

23,000 23,000 23,000 23,000 15,000

Keterangan : 1 Pembayaran dilakukan di Kasir yang ditunjuk setelah dibuat Nota Biaya oleh Petugas Verifikasi. 2. Pemeriksaan Urine Narkotika (Ganja, Opiat, Amphetamine, Benzodiazepam) dilaksanakan di Klinik PTRM. BHP (berupa stick pemeriksaan) disediakan pihak RSUP. H. Adam Malik. B.

PELAYANAN CSSD (INSTALASI STERIL SENTRAL) 1. STERILISASI UAP PANAS (GETTINGE 66) a. Kecil ( kemasan < 20 cm x 30 cm x 5 cm ) 21,000 b. Sedang ( kemasan 40 cm x 21 cm x 8 cm ) 28,200 c. Besar ( kemasan 41 cm x >31 cm x > 8,1 cm ) 45,000 2. STERILISASI ETILEN OKSIDA a. Kategori I ( ukuran 30 cm x 30 s/d 50 cm ) 31,200 b. Kategori II ( ukuran 20 cm x 20 s/d 60 cm ) 28,200 c. Kategori III ( ukuran 15 cm x 20 s/d 60 cm ) 24,000 d. Kategori IV ( ukuran 10 cm x 20 s/d 110 cm ) 22,800 e. Kategori V ( ukuran 7,5 cm x 50 s/d 110 cm ) 21,000 3. STERILISASI UAP PANAS/STEAM (HS 1000 Double Door) a. Kecil ( kemasan < 20 cm x 30 cm x 5 cm ) 8,400 b. Sedang ( kemasan 40 cm x 21 cm x 8 cm ) 13,800 c. Besar ( kemasan 41 cm x >31 cm x > 8,1 cm ) 34,500 4. STERILISASI UAP PANAS/STEAM (HS 1000 Single Door) a. Kecil ( kemasan < 20 cm x 30 cm x 5 cm ) 6,600 b. Sedang ( kemasan 40 cm x 21 cm x 8 cm ) 11,100 c. Besar ( kemasan 41 cm x >31 cm x > 8,1 cm ) 27,600 5. STERILISASI PLASMA a. Kecil ( ukuran 10 cm x 20 s/d 110 cm ) 24,000 b. Sedang ( ukuran 20 cm x 20 s/d 60 cm ) 35,400 c. Besar ( ukuran 30 cm x 30 s/d 90 cm ) 235,800 Keterangan : 1. Tarif tersebut diatas berlaku bagi keluarga pasien dan Instalasi luar yang menggunakan fasilitas tersebut.

45

14,000 18,800 30,000

35,000 47,000 75,000

20,800 18,800 16,000 15,200 14,000

52,000 47,000 40,000 38,000 35,000

5,600 9,200 23,000

14,000 23,000 57,500

4,400 7,400 18,400

11,000 18,500 46,000

16,000 23,600 157,200

40,000 59,000 393,000

TINDAKAN KELAS III RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014 BESARAN TARIF TA NO

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