KAMAR VIP I 600000.0800000.0 VIP II 500000.0700000.0 Utama I 300000.0450000.0 Utama II 250000.0350000.0 Kelas I165000.0250000.0 Kelas II125000.0200000.0 Kelas III75000.0140000.0 Perinatologi75000.095000.0 ICU / ICCU / PICU / NICU490000.0550000.0 HCU / IMD125000.0200000.0 TABEL 2. PELAYANAN RAWAT JALAN (PEMERIKSAAN DAN KONSULTASI) JENIS PELAYANANJSTARIF Pemeriksaan dokter spesialis (poliklinik)6000.070000.0 Pemeriksaan dokter umum (poliklink)6000.054000.0 Pemeriksaan dokter gigi spesialis (poliklinik)10000.074000.0 Pemeriksaan dokter gigi (poliklinik)10000.058000.0 Konsultasi dokter spesialis (poliklinik)6000.070000.0 Konsultasi psikologi (poliklinik)6000.041000.0 Asuhan gizi (poliklinik)6000.041000.0 Konsultasi farmasi (poliklinik)6000.041000.0 TABEL 3. PELAYANAN RAWAT DARURAT (PEMERIKSAAN DAN KONSULTASI) JENIS PELAYANANJSTARIF Pemeriksaan dokter umum 25000.0105000.0 Konsultasi dokter spesialis 10000.0115000.0 TABEL 4. PELAYANAN RAWAT INAP (VISITE DAN KONSULTASI) JENIS PELAYANANJSTARIF Visite dokter spesialis (rawat inap)9000.081000.0 Visite dokter umum (rawat inap)9000.059000.0 Konsultasi dokter spesialis (rawat inap)9000.081000.0 Konsultasi farmasi 8000.046500.0 Konsultasi psikologi8000.046500.0 Konsultasi dokter di atas meja operasi0.0210000.0 Konsultasi dokter (via telephone)20000.060000.0 TABEL 5. PELAYANAN REKAM MEDIS, MEDIKOLEGAL DAN ADMINISTRASI JENIS PELAYANANJSTARIF Registrasi Rawat Jalan6000.010000.0 Registrasi Rawat Darurat6000.010000.0 Registrasi Rawat Inap12000.020000.0 Kartu Berobat Pasien 5000.06000.0 Visum et repertum30000.0100000.0 Resume Medis Khusus10000.050000.0 Administrasi Pelayanan Rawat Inap6000.010000.0 TABEL 6. PELAYANAN FARMASI JENIS PELAYANANJSTARIF Pelayanan Farmasi klinik Rawat Jalan3000.015000.0 Pelayanan farmasi non klinik 5000.013000.0 One day dose dispensing3000.020000.0 dosis unit dispensing 10000.050000.0 Dispensing Total Parenteral Nutrition (TPN)50000.0163000.0 IV Admixture & Rekonstitusi sediaan non sitostatika10000.025000.0 IV Admixture & Rekonstitusi sediaan sitostatika75000.0241000.0 evaluasi & Pemantauan penggunaan obat10000.0350000.0 MESO10000.0209000.0 Pemantauan kadar obat dalam darah50000.0249000.0 CATATAN : Pelayanan Farmasi klinik Rawat Jalan adalah per lembar resep Pelayanan farmasi non klinik adalah per periode opname One day dose dispensing adalah per lembar resep Dosis unit dispensing adalah per hari per pasien Dispensing Total Parenteral Nutrition (TPN) adalah per obat IV Admixture & Rekonstitusi sediaan non sitostatika adalah per obat IV Admixture & Rekonstitusi sediaan sitostatika adalah per obat evaluasi & Pemantauan penggunaan obat adalah per obat MESO adalah per pasien Pemantauan kadar obat dalam darah adalah satu sampel pemeriksaan TABEL 7. PELAYANAN LABORATORIUM JENIS PELAYANANJSTARIF DARAH DARAH RUTIN5000.015000.0 DARAH LENGKAP (DARAH RUTIN + HITUNG JENIS LEKOSIT)7000.021000.0 DARAH LENGKAP + RETIKULOSIT9000.027000.0 LAJU ENDAPAN DARAH 2000.06000.0 LIMFOSIT PLASMA BIRU2000.06000.0 PEMBEKUAN MASA 1500.04500.0 PERDARAHAN MASA 1500.04500.0 PENETAPAN GOLONGAN DARAH A, B, O, RH, DLL 1500.04500.0 FILARIA 2000.06000.0 MALARIA 2000.06000.0 ANALISA URINE URINALISIS12000.025000.0 PROTEIN BENCE JONES2000.07000.0 PROTEIN ESBACH 2000.07000.0 MIKROALBUMIN 11000.021000.0 FECES FECES RUTIN12000.021000.0 DARAH SAMAR 3000.09000.0 KIMIA DARAH ASAM LAKTAT4000.09000.0 ASAM URAT 4000.012000.0 AMILASE 4000.012000.0 ANALISA GAS DARAH8000.024000.0 CREATININ, KINASE, MB ISO ENZYM 4000.012000.0 CREATININ,PHOSPOKINASE CPK-NAC=CREATININ KINASE-CK 4000.012000.0 LAKTAT DEHIDROGENASE/LDH 4000.012000.0 LIPASE4000.012000.0 TROPONIN T/I 4000.012000.0 KALIUM 4000.012000.0 KALSIUM 4000.012000.0 KLORIDA 4000.012000.0 KLORIDA URINE 4000.012000.0 MAGNESIUM 4000.012000.0 NATRIUM 4000.012000.0 NATRIUM URINE 4000.012000.0 DIABETES HB GLICOSILAT / HBA1C 4000.012000.0 GLUKOSA DARAH PUASA 3500.010500.0 GLUKOSA 2 JAM PP3500.010500.0 GLUKOSA DARAH SEWAKTU 3500.010500.0 GLUKOSA KLIK/POC (POINT OF CARE) 34000.012000.0 GLUKOSA TOLERANSI TEST 4000.012000.0 FUNGSI HATI ALBUMIN 4000.012000.0 ALKALI FOSFATASE 3500.010500.0 BILIRUBIN TOTAL 3500.010500.0 BILIRUBIN DIRECT3500.010500.0 PROTEIN TOTAL, PENETAPAN KUANTITATIF 3500.010500.0 GLUTAMAT PIRUVAT TRANSMINASE/ GPT = ALT 3500.010500.0 TRANSFERASE / AST 3500.010500.0 PANEL BESI SERUM BESI 4000.013000.0 TIBC4000.013000.0 FUNGSI GINJAL KREATININ 3500.010500.0 CREATININ CLEARANCE 4000.012000.0 UREA/BUN 3500.010500.0 ANALISA LEMAK KOLESTEROL HIGH DENSITY LIPOPROTEIN (HDL) 4000.012000.0 KOLESTEROL LOW DENSITY LIPOPROTEIN (LDL) 4000.012000.0 KOLESTEROL TOTAL 4000.012000.0 TRIGLISERIDA 4000.012000.0 HEMATOLOGI BACAAN SUMSUM TULANG8500.025500.0 MORFOLOGI SEL 8500.025500.0 SEROLOGI ANTI HCV 4000.012000.0 ANTI HIV 5000.015000.0 ANTI TB 6000.018000.0 ANTILAPTOSPIRA IG M4000.012000.0 ASTO 4000.012000.0 DENGUE BLOT IGG 8000.024000.0 DENGUE NS 110000.030000.0 FAKTOR RHEMATOID4000.012000.0 HBS AG 4000.012000.0 SALMONELA IG M 3500.010500.0 VDRL4000.012000.0 WIDAL 3500.010500.0 SALMONELA TUBEX4000.012000.0 ANTI Hbs Ag4000.012000.0 MIKROBIOLOGI SEDIAAN LANGSUNG PEWARNAAN BTA 2000.07000.0 SEDIAAN LANGSUNG PEWARNAAN GRAM 2000.07000.0 BIAKAN MIKRO ORGANISME DENGAN RESISTENSI11000.051000.0 BIAKAN PUS DENGAN RESISTENSI 11000.051000.0 CAIRAN TUBUH ANALISA CAIRAN SENDI 4000.012000.0 ANALISA CAIRAN OTAK 4000.012000.0 ANALISA CAIRAN PLEURA4000.012000.0 ANALISA SEMEN/ SPERMA 4000.012000.0 DRUG MONITORING AMPHETAMINE 1000.03000.0 BENZODIAZEPIN 1000.03000.0 MARIYUANA 1000.03000.0 METAMPHETAMIN 1000.03000.0 MORPHINE 1000.03000.0 HEMOSTASIS FIBRINOGEN, PENETAPAN KADAR 5000.015000.0 PROTROMBIN PLASMA, MASA 4000.012000.0 THROMBOPLASTIN, MASA PARTIAL TERAKTIVASI 3500.010500.0 IMUNOLOGI TES KEHAMILAN 2000.06000.0 PELAYANAN BANK DARAH COOMB'S, PERCOB. DIREK, INDIREK 10000.025000.0 DARAH (PER KANTONG) 47500.047500.0 PEMBUATAN PRC 47500.0142500.0 UJI SILANG MAYOR/MINOR 10000.025000.0 PARAMETER BARU Anti HAV5000.025000.0 CRP5000.020000.0 Tropinin I Kuantitatif15000.040000.0 CKMB Mass15000.040000.0 Nitro pro BNP15000.040000.0 CEA5000.025000.0 AFP5000.025000.0 PSA5000.025000.0 CD4 SUBSIDI5000.020000.0 CD4 NON SUBSIDI5000.020000.0 TABEL 8. PELAYANAN RADIOLOGI JENIS PELAYANANJSTARIF SEDERHANA THORAX AP / PA57000.0108000.0 THORAX LATERAL57000.0108000.0 THORAX OBLIQ57000.0108000.0 THORAX TOP LORDOTIK57000.0108000.0 ABDOMEN AP / SUPINE57000.0108000.0 ABDOMEN LLD57000.0108000.0 ABDOMEN ERECT / SETENGAH DUDUK57000.0108000.0 ABDOMEN LATERAL57000.0108000.0 PELVIS AP57000.0108000.0 HIP JOINT AP / L DEXTRA57000.0108000.0 HIP JOINT AP / L SINISTRA57000.0108000.0 FEMUR AP/L DEXTRA57000.0108000.0 FEMUR AP / L SINISTRA57000.0108000.0 GENU AP/L DEXTRA57000.0108000.0 GENU AP /L SINISTRA57000.0108000.0 CRURIS AP / L DEXTRA57000.0108000.0 CRURIS AP / L SINISTRA57000.0108000.0 ANKLE JOINT AP / L DEXTRA57000.0108000.0 ANKLE JOINT AP / L SINISTRA57000.0108000.0 PEDIS AP / OBLIQ DEXTRA57000.0108000.0 PEDIS AP / OBLIQ SINISTRA57000.0108000.0 CALCANEUS DEXTRA57000.0108000.0 CALCANEUS SINISTRA57000.0108000.0 CLAVICULA DEXTRA57000.0108000.0 CLAVICULA SINISTRA57000.0108000.0 SCAPULA DEXTRA57000.0108000.0 SCAPULA SINISTRA57000.0108000.0 SHOULDER JOINT DEXTRA57000.0108000.0 SHOULDER JOINT SINISTRA57000.0108000.0 HUMERUS AP / L DEXTRA57000.0108000.0 HUMERUS AP / L SINISTRA57000.0108000.0 HUMERUS AXIAL DEXTRA57000.0108000.0 HUMERUS AXIAL SINISTRA57000.0108000.0 CUBITI AP / L DEXTRA57000.0108000.0 CUBITI AP / L SINISTRA57000.0108000.0 ANTEBRAKHI AP / DEXTRA57000.0108000.0 ANTEBRAKHI AP/ L SINISTRA57000.0108000.0 WIRST JOINT AP / L DEXTRA57000.0108000.0 WIRST JOINT AP / L SINISTRA57000.0108000.0 MANUS AP / OBLIQ DEXTRA57000.0108000.0 MANUS AP / OBLIQ SINISTRA57000.0108000.0 KEPALA AP57000.0108000.0 KEPALA LATERAL57000.0108000.0 BASIS CRANII57000.0108000.0 OS MAXILARIS57000.0108000.0 OS ZIGOMATIKUM57000.0108000.0 SELLA TURSICA57000.0108000.0 SPN WATER'S57000.0108000.0 SPN FACE BONE LATERAL57000.0108000.0 TOWN'S57000.0108000.0 0S NASALE57000.0108000.0 MANDIBULA AP57000.0108000.0 MANDIBULA EISLER57000.0108000.0 RHESE/ FORAMEN OPTICUM DEXTRA57000.0108000.0 RHESE / FORAMEN OPTICUM SINISTRA57000.0108000.0 OS PALATUM57000.0108000.0 TMJ OPEN MOUTH DEXTRA57000.0108000.0 TMJ OPEN MOUTH SINISTRA57000.0108000.0 TMJ CLOSE MOUTH DEXTRA57000.0108000.0 TMJ CLOSE MOUTH SINISTRA57000.0108000.0 SCHULER'S OS MASTOID AIR CELL SINISTRA57000.0108000.0 CERVICAL AP57000.0108000.0 CERVICAL LATERAL57000.0108000.0 CERVICAL OBLIQ DEXTRA57000.0108000.0 CERVICAL OBLIQ SINISTRA57000.0108000.0 THORACAL AP57000.0108000.0 THORACAL LATERAL57000.0108000.0 THORACAL OBLIQ DEXTRA57000.0108000.0 THORACAL OBLIQ SINISTRA57000.0108000.0 LUMBAL AP57000.0108000.0 LUMBAL LATERAL57000.0108000.0 LUMBAL OBLIQ DEXTRA57000.0108000.0 LUMBAL OBLIQ SINISTRA57000.0108000.0 T - L AP57000.0108000.0 T - L LATERAL57000.0108000.0 T - L OBLIQ DEXTRA57000.0108000.0 T - L OBLIQ SINISTRA57000.0108000.0 SACRUM AP57000.0108000.0 SACRUM OBLIQ DEXTRA57000.0108000.0 SACRUM OBLIQ SINISTRA57000.0108000.0 SACRUM LATERAL57000.0108000.0 L - S AP57000.0108000.0 L - S LATERAL57000.0108000.0 L - S OBLIQ DEXTRA57000.0108000.0 L - S OBLIQ SINISTRA57000.0108000.0 COCIGEUS AP57000.0108000.0 COCIGEUS LATERAL57000.0108000.0 COCIGEUS OBLIQ DEXTRA57000.0108000.0 COCIGEUS OBLIQ SINISTRA57000.0108000.0 GIGI SERI ATAS27000.078000.0 GIGI SERI BAWAH27000.078000.0 GIGI INCICIVUS ATAS KANAN27000.078000.0 GIGI INCICIVUS ATAS KIRI27000.078000.0 GIGI INCICIVUS BAWAH KANAN27000.078000.0 GIGI INCICIVUS BAWAH KIRI27000.078000.0 GIGI PRE MOLAR ATAS/ KANAN27000.078000.0 GIGI PRE MOLAR ATAS KIRI27000.078000.0 GIGI PRE MOLAR BAWAH KANAN27000.078000.0 GIGI PRE MOLAR BAWAH KIRI27000.078000.0 GIGI MOLAR ATAS KANAN27000.078000.0 GIGI MOLAR ATAS KIRI27000.078000.0 GIGI MOLAR BAWAH KANAN27000.078000.0 GIGI MOLAR BAWAH KIRI27000.078000.0 NON SEDERHANA BNO IVP287000.0540000.0 CYSTOGRAPHY230000.0483000.0 URETHROGRAPHY229672.0482352.0 RPG287000.0540000.0 HSG230000.0483000.0 COR ANALISA172254.0377214.0 BNO SONDE114836.0319796.4 COLON IN LOOP344508.0587468.0 OMD229672.0472632.0 OESHOPAGUSGRAPHY172254.0415214.0 APENDIKOGRAM114836.0357796.0 FISTULOGRAPHY172254.0415214.0 BRAIN CT SCAN572000.01009000.0 THORAX CT SCAN572000.01009000.0 ABDOMEN CT SCAN572000.01009000.0 PELVIS CT SCAN 572000.01009000.0 ORBITA CT SCAN572000.01009000.0 SPN CT SCAN572000.01009000.0 NASHOPHARYNG CT SCAN572000.01009000.0 CERVICAL CT SCAN572000.01009000.0 THORACAL CT SCAN572000.01009000.0 LUMBAL CT SCAN572000.01009000.0 EXTREMITAS CT SCAN572000.01009000.0 CT SCAN KEPALA KONTRAS700000.01254000.0 CT SCAN THORAX KONTRAS700000.01254000.0 CT SCAN ABDOMEN KONTRAS700000.01254000.0 CT NASHOPHARYNG KONTRAS700000.01254000.0 USG 4 D208000.0533000.0 USG MAMAE208000.0533000.0 USG ABDOMEN208000.0533000.0 USG THORAX208000.0533000.0 USG TESTIS208000.0533000.0 USG SUPERFISIAL208000.0533000.0 USG TIROID208000.0533000.0 DOPPLER208000.0533000.0 USG GUIDING208000.0533000.0 PANORAMIX115000.0315000.0 TABEL 9. PELAYANAN REHABILITASI MEDIK JENIS PELAYANANJSTARIF SHORT WAVE DIATHERMI (SWD)20000.047000.0 MICRO WAVE DIATHERMI (MWD)20000.047000.0 INFRA RED (IR)/ ULTRA VIOLET (UV)20000.047000.0 EXERCISE/ TERAPI MANIPULASI20000.047000.0 ULTRA SONIC THERAPI20000.047000.0 ELECTRICAL STIMULATION20000.047000.0 ELECTRICAL TRACTION25000.052000.0 PARAFIN BATH20000.047000.0 LASER20000.047000.0 MLDV20000.0101000.0 POSTURAL DRAINAGE20000.047000.0 SENAM HAMIL20000.058000.0 TERAPI WICARA6000.063000.0 TABEL 10. PELAYANAN PSIKOLOGI JENIS PELAYANANJSTARIF TES KECERDASAN (PEMAHAMAN)6000.020000.0 TES KECERDASAN (PENALARAN VERBAL)6000.020000.0 TES KECERDASAN (RANEN)12000.057000.0 TES KECERDASAN (KEMAMPUAN NUMERIK)7000.028000.0 TES KECERDASAN (TEKNIS PRAKTIS)7000.028000.0 TES KECERDASAN 7000.031000.0 TES KECERDASAN (DAYA INGAT)7000.028000.0 TES KECERDASAN (CODING)7000.028000.0 TES KECERDASAN (BINET - PER KUNJUNGAN)14000.089000.0 TES KECERDASAN (WISC - PER KUNJUNGAN)14000.089000.0 TES KECERDASAN (WAIS - PER KUNJUNGAN)14000.089000.0 TES KECERDASAN (IST)14000.0109000.0 TES KECERDASAN (CFIT)12000.057000.0 TES KECERDASAN (SON) PER KUNJUNGAN 14000.089000.0 TES KECERDASAN (GOOD ENOUGH HARIS)12000.057000.0 TES KECERDASAN (BAYLEY) PER KUNJUNGAN 14000.089000.0 TES PERKEMBANGAN(AAMD)12000.057000.0 TES MINAT (KUDER)12000.057000.0 TES KEPRIBADIAN (EPPS)12000.057000.0 TES KEPRIBADIAN (GRAFIS)12000.057000.0 TES KEPRIBADIAN (WARTEGG)12000.057000.0 TES KEPRIBADIAN (16 PF)20000.080000.0 TES KEPRIBADIAN (TAT)27000.0177000.0 TES KEPRIBADIAN (CAT)27000.0177000.0 TES KEPRIBADIAN (WOODWORTHS Q)12000.057000.0 TES KEPRIBADIAN (EYSENCKS Q)12000.057000.0 TES KEPRIBADIAN (RORSCHACH)20000.0250000.0 TES KEPEMIMOINAN (LEAD)7000.028000.0 TES KRAEPLIN12000.087000.0 OBSERVASI/ INTERVIEW (KLINIS) PER ORANG7000.037000.0 OBSERVASI/ INTERVIEW (PENDIDIKAN) PER ORANG7000.037000.0 OBSERVASI/ INTERVIEW (INDUSTRI) PER ORANG7000.037000.0 OBSERVASI/ INTERVIEW (KUNJUNGAN RUMAH/ SEKOLAH/ LINGKUNGAN LAIN/INDIVIDUAL20000.0158000.0 OBSERVASI/ INTERVIEW (CBCL)25000.067000.0 PAKET PEMERIKSAAN (BAKAT LENGKAP)67000.0442000.0 PAKET PEMERIKSAAN (SELEKSI CALON KARYAWAN)67000.0442000.0 PAKET PEMERIKSAAN (ANAK BERKEBUTUHAN KHUSUS - ABK)67000.0442000.0 PAKET PEMERIKSAAN PSIKOLOGI FOREKSIK (PERDATA)50000.0425000.0 PAKET PEMERIKSAAN PSIKOLOGI FOREKSIK (PIDANA)67000.0542000.0 PAKET PEMERIKSAAN PSIKOLOGI FOREKSIK (MOBILE/VISITASI)73000.0623000.0 LAYANAN KLASIKAL MOBILE/VISITASI (PENINGKATAN KAPASITAS KOMUNITAS)5000.025000.0 TES NEUROPSIKOLOGI (BNCE) ; BENDER GESTALT II)15000.0115000.0 PSIKOTERAPI SEDANG PERKUNJUNGAN 20000.0145000.0 PSIKOTERAPI KOMPLEK PERKUNJUNGAN 20000.0270000.0 KONSELING/ PSIKOTERAPI SEDERHANA PERKUNJUNGAN10000.040000.0 TABEL 11. PELAYANAN ASUHAN GIZI JENIS PELAYANANJSTARIF ASUHAN GIZI SEDERHANA10000.040000.0 ASUHAN GIZI SEDANG10000.052000.0 ASUHAN GIZI KOMPLEKS10000.059000.0 TABEL 12. PELAYANAN PEMULASARAAN JENAZAH JENIS PELAYANANJSTARIF PERAWATAN JENAZAH UTUH (MEMANDIKAN & MENGKAFANI )210000.0360000.0 PERAWATAN JENAZAH TIDAK UTUH (MEMANDIKAN & MENGKAFANI)267000.0517000.0 PENGAWETAN JENAZAH (FORMALIN)600000.01100000.0 PERBAIKAN / PENYATUAN TUBUH JENAZAH (TIDAK UTUH)125000.0225000.0 PENYIMPANAN (PENITIPAN) JENAZAH KURANG DARI ATAU SAMA DENGAN 24 JAM (PER JAM) 10000.017000.0 PENYIMPANAN (PENITIPAN) JENAZAH LEBIH DARI 24 JAM (PER HARI)55000.080000.0 PENGADAAN PETI JENAZAH1200000.01400000.0 CATATAN : - BIAYA PENITIPAN JENAZAH < 24 JAM = DIHITUNG PER JAM - BIAYA PENITIPAN JENAZAH > 24 JAM = BIAYA PENITIPAN < 24 JAM + BIAYA PENITIPAN > 24 JAM (PER HARI) TABEL 13. PELAYANAN AMBULANCE JENIS TINDAKANJSTARIF AMBULANCE TRANSPORT ANTAR ATAU JEMPUT PASIEN DALAM KOTA87500.087500.0 ANTAR ATAU JEMPUT PASIEN LUAR KOTA AMBULANCE JENAZAH ANTAR ATAU JEMPUT JENAZAH DALAM KOTA87500.087500.0 ANTAR ATAU JEMPUT JENAZAH LUAR KOTA CATATAN : Ambulance Transport Dalam Kota : Jarak maksimal : 10 KM Biaya BBM 40000.0 JP Supir 35000.0 JP Pendamping Non Perawat17500.0 JP Pendamping Perawat 52500.0 JP Pendamping Dokter Umum 105000.0 JP Pendamping Dokter Spesialis262500.0 Ambulance Transport Luar Kota : Biaya BBM 6.000/km JP Supir 1.500/km JP Pendamping Non Perawat750/km JP Pendamping Perawat 1.800/km JP Pendamping Dokter Umum 3.600/km JP Pendamping Dokter Spesialis9.000/km Ambulance Jenazah Dalam Kota : Jarak maksimal : 10 KM Biaya BBM 40000.0 JP Supir 35000.0 JP Pendamping Non Perawat17500.0 Ambulance Jenazah Luar Kota : Biaya BBM 6.000/km JP Supir 1.500/km JP Pendamping Non Perawat750/km Biaya Waktu Tunggu Pemakaman20.000/jam Biaya masuk Airport menjadi tanggungan pemakai Biaya jalan tol dan penyeberangan tanggungan pemakai. TABEL 14. PELAYANAN TINDAKAN MEDIK OPERATIF DOKTER BEDAH UMUM JENIS PELAYANANJSTARIF KECIL Circumsisi, La350000.01110000.0 Eksisi Intrakeloidal Diluar Wajah, La350000.01110000.0 Dorsumsisi, La350000.01110000.0 Eksisi Nevus Diluar Wajah Simple, La350000.01110000.0 Eksisi Veruka, La350000.01110000.0 Eksterpasi Tumor Jinak, Diluar Wajah ,La 350000.01110000.0 Ektirpasi Aterom Diluar Wajah, La350000.01110000.0 Ektirpasi Lipoma Diluar Wajah, La350000.01110000.0 Sirkumsisi Lokal350000.01110000.0 Alligator biopsi350000.01110000.0 Katerisasi papilom350000.01110000.0 Cabut kuku350000.01110000.0 SEDANG Rigit Sigmoidiskopi+biopsi350000.01870000.0 Biopsi350000.01870000.0 BESAR Anuscopy dan Ligasi Hemoroid 350000.03400000.0 Apendisitis akut/sederhana350000.03400000.0 Hernia (Lateralis,Mediana,Femoralis) sederhana350000.03400000.0 Perianal Abses Sederhana350000.03400000.0 Perianal Fistel sederhana350000.03400000.0 Hemoroidectomy Non PPH350000.03400000.0 Fissura Ani350000.03400000.0 Sinus Umbilikalis350000.03400000.0 Hernia Umbilikalis sederhana350000.03400000.0 KHUSUS Hernia Umbilikalis besar/insisional350000.06430000.0 laparaskopik Diagnostik dan Biopsi350000.06430000.0 Ductus Urachus/Ductus Omphalomesenterikus350000.06430000.0 Pembuatan Stoma (Jejunostomi,gastrostomi,iliostomi,kolostomi)350000.06430000.0 Apendektomi Perforasi (Laparotomi/Non Laparatomi)350000.06430000.0 Hernia Residif/Bilateral/Permagna350000.06430000.0 Perianal Fistel kompleks/Residif350000.06430000.0 Laparotomi Biopsi350000.06430000.0 Perianal abses komplek350000.06430000.0 Fistula perianal komplek350000.06430000.0 Kolesistektomi Terbuka350000.06430000.0 Perforasi Usus350000.06430000.0 Laparatomi Tumor Intra Abdomen350000.06430000.0 Laparoskopik Appendektomi350000.06430000.0 Laparoskopik CAPD350000.06430000.0 Hemoroidectomy PPH350000.06430000.0 Splenektomi350000.06430000.0 Ulkus Gaster/Duodenum350000.06430000.0 Hemikolektomi kanan/kiri350000.06430000.0 Reseksi Kolon Transversum350000.06430000.0 Reseksi Sigmoid350000.06430000.0 Relaparatomi350000.06430000.0 PEG350000.06430000.0 Laparoskopik Appendektomi Perforasi350000.06430000.0 Laparoskopik Kolesistektomi350000.06430000.0 Laparoskopik Perforasi Gaster350000.06430000.0 Kelainan Usus (Invaginasi,Trombosis,Tumor Usus Halus,dsb)350000.06430000.0 Trauma Abdomen sederhana350000.06430000.0 Tumor Lambung, Total Gastrektomi350000.06430000.0 Partial Gastrektomi dengan Anastomosis (Biltroth I/II)350000.06430000.0 Anterior Perianal Resection (APR)/Milles350000.06430000.0 Anterior Resection (AR)350000.06430000.0 Batu Empedu Eksplorasi CBD (Non Laparoskopik)350000.06430000.0 Batu Empedu Bilio-digestif/Double By pass350000.06430000.0 Trauma Hepar350000.06430000.0 LAR&Ileostomi350000.06430000.0 Miles350000.06430000.0 LAR/APPEAR350000.06430000.0 Laparatomi Kelainan Esofagus Distal Achalasia (Heller)350000.06430000.0 Laparatomi Kelainan Esofagus Distal Achalasia (Reseksi)350000.06430000.0 Laparatomi Kelainan Esofagus Distal350000.06430000.0 Laparatomi Kelainan Esofagus Distal Tumor350000.06430000.0 Laparatomi Kelainan Esofagus Distal Striktur350000.06430000.0 Reseksi Hepar/Metasektomi350000.06430000.0 Reseksi Hepar/Segmental/Anatomi350000.06430000.0 Hepatiko Jejunostomi350000.06430000.0 Distal Pankreatektomi350000.06430000.0 Kelainan Esofagus 1/3 Proksimal & 1/3 Tengah Tumor350000.06430000.0 Kelainan Esofagus 1/3 Proksimal & 1/3 Tengah Striktur350000.06430000.0 Whipple/Pankreatiko Duodenektomi350000.06430000.0 Ultra LAR350000.06430000.0 Laparoskopik Hernia Medialis350000.06430000.0 Laparoskopik Hernia Medialis Bilateral350000.06430000.0 Laparaskopik Achalasia (Heller)350000.06430000.0 Laparoskopik Batu Empedu Eksplorasi CBD350000.06430000.0 Laparoskopik Reseksi Kolon350000.06430000.0 Laparoskopik Gastric Banding350000.06430000.0 Laparoskopik Distal Gastrektomi350000.06430000.0 Laparoskopik Milles350000.06430000.0 Laparoskopik LAR350000.06430000.0 DOKTER BEDAH UROLOGI JENIS PELAYANANJSTARIF KECIL Sirkumsisi Lokal350000.01110000.0 Vasektomi350000.01110000.0 Sistoskopi Wanita350000.01110000.0 Eksterpasi tumor jinak penis350000.01110000.0 Aff splinting ureter kateter Wanita350000.01110000.0 Uretroskopi Wanita350000.01110000.0 Kalibrasi uretra350000.01110000.0 SEDANG Sectio Alta350000.01870000.0 Hidrokolectomi350000.01870000.0 TESE (Biopsi Testis)350000.01870000.0 Orchiektomi simple350000.01870000.0 Nephrostomy temporer350000.01870000.0 Uretrotomi350000.01870000.0 Uretrolithotomi350000.01870000.0 Pemasangan ureter kateter350000.01870000.0 Open Sistostomi350000.01870000.0 Eksterpasi tumor uretra distal350000.01870000.0 Sistoskopi Pria350000.01870000.0 Uretroskopi Pria350000.01870000.0 Aff splinting ureter kateter Pria350000.01870000.0 Sirkumisisi GA350000.01870000.0 Sistostomi tertutup350000.01870000.0 Biopsi Prostat350000.01870000.0 Ganti Kateter Neprostomi350000.01870000.0 Funikokelektomi350000.01870000.0 Buried Penis350000.01870000.0 Eksisi Plaque (Peyronie Disease)350000.01870000.0 Evakuasi Bekuan Darah (Clot)350000.01870000.0 Funikokelektomi350000.01870000.0 Litholapaksi350000.01870000.0 MMK / Sling Uretra350000.01870000.0 Nefropeksi / Renopeksi350000.01870000.0 Operasi Repair Buli Trauma350000.01870000.0 Pasang Kateter Tenckhoff Untuk Capd350000.01870000.0 Reparasi Penis350000.01870000.0 Ureterouretostomi350000.01870000.0 BESAR Johanson I350000.03400000.0 Amputasi penis350000.03400000.0 Orchidopeksi350000.03400000.0 Ureterolithotomi,350000.03400000.0 Pyelolithotomi simple350000.03400000.0 Open prostatectomi350000.03400000.0 Diverticulectomy350000.03400000.0 Orchiektomi extended350000.03400000.0 RPG350000.03400000.0 Dorkumsisi350000.03400000.0 Nefrektomi simple350000.03400000.0 Palomo/operasi varikokel cara lain350000.03400000.0 Insisi abses350000.03400000.0 Operasi Gangren Fournier350000.03400000.0 Insisi abses Skrotum350000.03400000.0 Inguinal orchiodektomi350000.03400000.0 Orchiodektomi ligasi tinggi350000.03400000.0 Orchiodektomi inguinal350000.03400000.0 Orchiodektomi subkapsuler350000.03400000.0 Spermatokelektomi350000.03400000.0 Eksisi Webbed Penis350000.03400000.0 Operasi Sistokel350000.03400000.0 Operasi Urakhus / Reseksi Urakhus350000.03400000.0 Vasoeepididimostomi350000.03400000.0 Vasovasostomi350000.03400000.0 KHUSUS Uretrotomi interna - sachse350000.06430000.0 Lithotripsi350000.06430000.0 Percutaneus nephrolitotripsi (PCNL)350000.06430000.0 Uretroplasty350000.06430000.0 Johanson II350000.06430000.0 Maskulinisasi350000.06430000.0 Extended pielolitotomi350000.06430000.0 Pielocalikalitomi350000.06430000.0 Pieloplasty350000.06430000.0 Transuretral Reseksi prostat (TURP)350000.06430000.0 Transuretral Insisi prostat (TUIP)350000.06430000.0 Chordectomi350000.06430000.0 Reseksi anastomosis urethra/ureter350000.06430000.0 Partial nefrektomi350000.06430000.0 Hemi nefrektomi350000.06430000.0 Partial cystektomi350000.06430000.0 Insersi double J stent /ureter kateter (RPG)350000.06430000.0 Ureterolisis350000.06430000.0 Rekonstruksi Trauma Buli-buli350000.06430000.0 Open prostatectomi & Sectio Alta350000.06430000.0 ESWL350000.06430000.0 Biopsi Ginjal Terbuka350000.06430000.0 Deroofing / Unroofing Kista350000.06430000.0 Divertikulektomi Buli350000.06430000.0 Divertikulum Uretra350000.06430000.0 Eksisi Fibroma / Rekonstruksi Penis350000.06430000.0 Epispadia350000.06430000.0 Fistulektomi / Repair Fistel Uretra350000.06430000.0 Operasi Priapismus (Prosedur Winter) (Besar)350000.06430000.0 Operasi Trauma Ginjal350000.06430000.0 Orkhidopeksi (Torsio Testis) (Besar)350000.06430000.0 Psoas Hitch / Boari Flap350000.06430000.0 Railroading Ruptur Uretra350000.06430000.0 Reimplantasi Ureter Bilateral350000.06430000.0 Tur Tumor Buli350000.06430000.0 Lithotripsi350000.06430000.0 Total cystectomi350000.06430000.0 Radikal cystectomi350000.06430000.0 Radikal neprectomi350000.06430000.0 TUL/URS350000.06430000.0 Retroperitoneal350000.06430000.0 Lymphadenektomi350000.06430000.0 Radical prostatektomi350000.06430000.0 Operasi tumor supra renalis350000.06430000.0 Augmentasi bladder350000.06430000.0 Bivalve nefrolitotomi350000.06430000.0 Coffey prosedur350000.06430000.0 TUUC (Trans Uretero Ureteral Cutaneostomy)350000.06430000.0 Breaker Prosedur350000.06430000.0 Nefrektomi donor cangkok ginjal350000.06430000.0 (TURP) & Litotripsi350000.06430000.0 Koreksi Horseshoe Kidney350000.06430000.0 Nefroureteroktomi350000.06430000.0 Deroofing Kista Ginjal Per Laparoskopi350000.06430000.0 Diseksi Kelenjar Getah Bening Pelvis Per Laparoskopi350000.06430000.0 Eksplorasi Testis (Microsurgery)350000.06430000.0 Laparoskopi Adrenalektomi350000.06430000.0 Ligasi V. Spermatika Interna (Microsurgery)350000.06430000.0 Rekonstruksi Renovaskuler350000.06430000.0 Repair Fistel Enterovesika350000.06430000.0 Repair Fistel Vesikorektal350000.06430000.0 Sistektomi Per Laparoskopi350000.06430000.0 Repair Fistel Vesikovagina350000.06430000.0 Neobladder (Buli-Buli)350000.06430000.0 Neobladder (Diversi Urin / Conduit)350000.06430000.0 Resipian cangkok ginjal350000.06430000.0 Rekonstruksi Ekstrofia Buli-buli350000.06430000.0 DOKTER BEDAH PLASTIK JENIS PELAYANANJSTARIF KECIL Circumsisi, La350000.01110000.0 Eksisi Intrakeloidal Diluar Wajah, La350000.01110000.0 Dorsumsisi, La350000.01110000.0 Eksisi Nevus Diluar Wajah Simple, La350000.01110000.0 Eksisi Veruka, La350000.01110000.0 Eksterpasi Tumor Jinak, Diluar Wajah ,La 350000.01110000.0 Ektirpasi Aterom Diluar Wajah, La350000.01110000.0 Ektirpasi Lipoma Diluar Wajah, La350000.01110000.0 Eksisi Ganglion, La350000.01110000.0 Eksisi Kista Dermoid, La350000.01110000.0 Eksisi Nevus Diluar Wajah Multiple, La350000.01110000.0 Ektirpasi Lipoma Wajah, La350000.01110000.0 SEDANG Angkat Jahitan, Ga350000.01870000.0 Closed Reduction + Bandage, La350000.01870000.0 Closed Reduction With Splint, La350000.01870000.0 Debridemen Dan Nekrotomi Dekubitus, La350000.01870000.0 Debridement Luka Bakar Fase Akut <15%, Ga350000.01870000.0 Debridement Luka Bakar Fase Akut <15%, La350000.01870000.0 Eksisi Intrakeloidal Wajah, La350000.01870000.0 Eksisi Nevus Wajah Multiple , La350000.01870000.0 Eksisi Nevus Wajah Simple , La350000.01870000.0 Eksisi Rinofima, La350000.01870000.0 Eksisi Tragus Asesorius, La350000.01870000.0 Ekstirpasi Tumor Jinak Kulit Wajah, La350000.01870000.0 Ekstraksi Corpus Alienum, La350000.01870000.0 Ektirpasi Aterom Wajah, La350000.01870000.0 Escharotomy, La350000.01870000.0 Fraktur Dan Dislokasi - Pemasangan Intramedulary Wire, La350000.01870000.0 Fraktur Dan Dislokasi - Pemasangan Splint Tangan, La350000.01870000.0 Incisi Absces Perikondritis, Ga350000.01870000.0 Injeksi Haemangioma Dengan Skleroting Agent Atau Triamcinolon Acetonid, La350000.01870000.0 Injeksi Skleroting Agent, La350000.01870000.0 Jahit Luka Di Wajah Dengan Kerusakan Sedang, Ga350000.01870000.0 Jahit Luka Di Wajah Dengan Kerusakan Sedang, La350000.01870000.0 Lobuloplasty, La350000.01870000.0 Melakukan Nekrotomi Sedang, La350000.01870000.0 Rouzerplasty, La350000.01870000.0 Simple Advancement Flap (Flap Kulit Sederhana), La350000.01870000.0 BESAR Amputasi Sederhana, Ga350000.03400000.0 Boutonnniere Deformity Repair, La350000.03400000.0 Debridement Luka Bakar Fase Akut 15 - 30 %, Ga350000.03400000.0 Eksisi Fistel Preaurikula, La350000.03400000.0 Eksisi Intrakeloidal + Jahit Primer, La350000.03400000.0 Eksisi Keloid + Skin Grafting, La350000.03400000.0 Eksisi Polidaktili Simple Dewasa, La350000.03400000.0 Ekstirpasi Tumor Jinak Kulit Diluar Wajah, Ga350000.03400000.0 Escharectomy Dengan Tangensial Eksisi, Ga350000.03400000.0 Fasciotomy Burned Compartement Syndrome, Ga350000.03400000.0 Finger Tip Injury Repair - Composite Graft, La350000.03400000.0 Finger Tip Injury Repair - Skin Flap Lokal, La350000.03400000.0 Finger Tip Injury Repair - Skin Grafting, La350000.03400000.0 Full Thickness Skin Graft (Ftsg) Daerah Diluar Wajah, La350000.03400000.0 Full Thickness Skin Graft (Ftsg) Pada Wajah, La350000.03400000.0 Injeksi Haemangioma Dengan Skleroting Agent Atau Triamcinolon Acetonid, Ga350000.03400000.0 Insersi Tulang Rawan Telinga Akibat Avulsi Telinga, La350000.03400000.0 Ioid + Archbarr Fraktur 1 Sisi, Ga350000.03400000.0 Ioid + Archbarr Fraktur 2 Sisi, Ga350000.03400000.0 Ioid + Imf(Eyelet) Fraktur 1 Sisi, Ga350000.03400000.0 Jahit Luka Di Wajah Daerah Estetik Unit, La350000.03400000.0 Jahit Luka Di Wajah Dengan Kerusakan Komplek, La350000.03400000.0 Kontraktur Tangan Dan Jari, La350000.03400000.0 Labioplasty Pada Microform, La350000.03400000.0 Labioplasty Sumbing Bibir Unilateral, Ga350000.03400000.0 Mallet Finger Repair, La350000.03400000.0 Melakukan Nekrotomi Luas, Ga350000.03400000.0 Pasang Archbarr 1 Sisi, La350000.03400000.0 Pasang Archbarr 2 Sisi, La350000.03400000.0 Release Kontraktur Dengan Dermagram, La350000.03400000.0 Repair Cleft Ear Lobe, La350000.03400000.0 Repair Trauma Telinga Simple, La350000.03400000.0 Revisi Dengan Simple Z Plasty, La350000.03400000.0 Revisi Labioplasty, La350000.03400000.0 Revisi Parut Dengan Simple Advancement Flap, La350000.03400000.0 Revisi Parut, La350000.03400000.0 Revisi Stump, La350000.03400000.0 Revisis Parutdiluar Wajah, La350000.03400000.0 Rhynophyma Repair, La350000.03400000.0 Simple Advancement Flap, La350000.03400000.0 Skin Flap Lokal Sederhana, La350000.03400000.0 Skin Flap Sederhana , La350000.03400000.0 Split Thickness Skin Graft (Stsg) Sederhana, La350000.03400000.0 Surgical Debridement/Sharp Debridement, Ga350000.03400000.0 KHUSUS Alveolar Bone Graft Dengan Allograft, Ga350000.06430000.0 Amputasi Komplek, Ga350000.06430000.0 Chordee Excision, Ga350000.06430000.0 Circumferential Wiring + Archbarr, Ga350000.06430000.0 Closed Recuction + Imf(Eyelet), Ga350000.06430000.0 Closed Reduction + Archbarr, Ga350000.06430000.0 Commissuroplasty - Direct Closure, La350000.06430000.0 Commissuroplasty - Ear Cartilage Graft, La350000.06430000.0 Commissuroplasty - Regional Flap, La350000.06430000.0 Commissuroplasty - Skin Flap Lokal, La350000.06430000.0 Commissuroplasty, La350000.06430000.0 Debridement Luka Bakar Fase Akut > 30 %, Ga350000.06430000.0 Double Rotation Skin Flap, La350000.06430000.0 Eksisi Basalioma Dengan Skin Flap, La350000.06430000.0 Eksisi Haemangioma Dengan Composite Flap, La350000.06430000.0 Eksisi Haemangioma Dengan Simple Advancement Flap, La350000.06430000.0 Eksisi Haemangioma Dengan Skin Flap Lokal, La350000.06430000.0 Eksisi Haemangioma Dengan Skingrafting, La350000.06430000.0 Eksisi Keloid + Skin Grafting - Revisi Dengan Multiple Z Plast, Ga350000.06430000.0 Eksisi Keloid + Skin Grafting - Revisi Dengan Simple Advancement, Ga350000.06430000.0 Eksisi Keloid + Skin Grafting - Revisi Dengan Single Z Plasty, Ga350000.06430000.0 Eksisi Keloid + Skin Grafting , Ga350000.06430000.0 Eksisi Keloid Dengan Flap, La350000.06430000.0 Ekstirpasi Tumor Jinak Kulit Wajah, Ga350000.06430000.0 Labioplasty Unilateral Dengan Nasoplasty, La350000.06430000.0 Labioplasty Unilateral Dengan Nasoplasty, Ga350000.06430000.0 Operasi Rekonstruksi : Tangan Dan Jari Jari, La350000.06430000.0 Operasi Rekonstruksi : Tangan Dan Jari Jari, Ga350000.06430000.0 Operasi Rekonstruksi : Telinga, La350000.06430000.0 Operasi Skin Flap Yang Lain Yang Lebih Komplek, La350000.06430000.0 Ops. Rekonstruksi : Defek/ Kelainan Muka, La350000.06430000.0 Ops.Rek. : Defak/Kelainan Tubuh Yang Lain, La350000.06430000.0 Orbital Bone And Eye Socket Reconstruction, Ga350000.06430000.0 Orif + Orbital Wall Reconstruction Dengan Ribs Bone Graft, Ga350000.06430000.0 Rekonstruksi Dengan Skin Flap Komplek, La350000.06430000.0 Rekonstruksi Dengan Skin Grafting, La350000.06430000.0 Rekonstruksi Kelainan Genetalia Eksterna Yang Lain, La350000.06430000.0 Rekonstruksi Kelainan Telinga Yang Lain, La350000.06430000.0 Rekonstruksi Softtissue Pada Hipertelorism, La350000.06430000.0 Rekonstruksi Telinga - Repair Lobulus Dan Kelainan Penyerta, La350000.06430000.0 Rekonstruksi Vermilion, Ga350000.06430000.0 Release Burried Penis, La350000.06430000.0 Release Burried Penis, Ga350000.06430000.0 Release Ekstropion, La350000.06430000.0 Release Ekstropion, Ga350000.06430000.0 Release Kontraktur Dengan Skin Flap, La350000.06430000.0 Release Kontraktur Dengan Skingraft, La350000.06430000.0 Release Kontraktur Dengan Z Plasty, La350000.06430000.0 Release Kontraktur Leher, La350000.06430000.0 Release Kontraktur Linier, La350000.06430000.0 Release Vagina Acreta, La350000.06430000.0 Repair Palpebra Dengan Local Skin Flap, La350000.06430000.0 Repair Palpebra Simple, La350000.06430000.0 Repair Soft Tissue Komplek, La350000.06430000.0 Repair Softtisue Simple, La350000.06430000.0 Repair Tendon Ekstensor Tangan Tunggal, La350000.06430000.0 Repair Tendon Fleksor Tangan Tunggal, La350000.06430000.0 Reposisi Dislokasi Tmj, Ga350000.06430000.0 Revisi Dengan Multiple Z Plasty/W Plasty, La350000.06430000.0 Revisi Dengan Flap Lokal, La350000.06430000.0 Revisi Dengan Simple Z Plasty, Ga350000.06430000.0 Revisi Parut Dengan Simple Advancement Flap, Ga350000.06430000.0 Revisi Parut Wajah, La350000.06430000.0 Revisi Parut, Ga350000.06430000.0 Nailbed Reconstruction, Ga350000.06430000.0 Secondary Repair Labioplasty, La350000.06430000.0 Secondary Rhynoplasty, La350000.06430000.0 Semi Open Reduction (Gillies Procedure), Ga350000.06430000.0 Single Rotation/ Transposition Skin Flap, Ga350000.06430000.0 Single Rotation/ Transposition Skin Flap, La350000.06430000.0 Skin And Fascial Grafts, La350000.06430000.0 Skin Flap Lokal Komplek, La350000.06430000.0 Skin Flap Lokal Sederhana, Ga350000.06430000.0 Soft Tissue Rekonstruksi, La350000.06430000.0 Split Thickness Skin Graft (Stsg) Sederhana, Ga350000.06430000.0 Stiff Finger Joint - Capsuloyomy-Tenolysis, La350000.06430000.0 Stiff Finger Joint - Volar Plate Release, La350000.06430000.0 Tangensial Eksisi Dini Dengan Skin Grafting , La350000.06430000.0 Tendon Repair, La350000.06430000.0 Commissuroplasty - Skin Graft, Ga350000.06430000.0 Distant Flap, Ga350000.06430000.0 Double Rotation Skin Flap, Ga350000.06430000.0 Eksisi Haemangioma Dengan Simple Advancement Flap, Ga350000.06430000.0 Eksisi Haemangioma Dengan Skin Flap, Ga350000.06430000.0 Eksisi Haemangioma Dengan Skingrafting, Ga350000.06430000.0 Eksisi Keloid + Skin Grafting - Komplek, Ga350000.06430000.0 Eksisi Polydactyly Complex, Ga350000.06430000.0 Eksisi Poydactyly Simple, Ga350000.06430000.0 Eksisi Rinofima, Ga350000.06430000.0 Fasciocutaneus Flap, Ga350000.06430000.0 Full Thickness Skin Graft (Ftsg) Daerah Diluar Wajah, Ga350000.06430000.0 Full Thickness Skin Graft (Ftsg) Pada Wajah, Ga350000.06430000.0 Jahit Luka Di Wajah Daerah Estetik Unit, Ga350000.06430000.0 Labioplasty Bilateral, Ga350000.06430000.0 Operasi Rekonstruksi : Palpebra, La350000.06430000.0 Orif + Titanium Mini Plate Approach Ektra Oral 1 Sisi, Ga350000.06430000.0 Orif Dengan 1 Approach, Ga350000.06430000.0 Orif Dengan Ginggivo-Bucal Approach, Ga350000.06430000.0 Orif Dengan Infraciliar Approach, Ga350000.06430000.0 Orif Dengan Transconjunctival Approach, Ga350000.06430000.0 Orif Untuk Fraktur Le Fort I, Ga350000.06430000.0 Palatoplasty Complete, Ga350000.06430000.0 Palatoplasty Incomplete, Ga350000.06430000.0 Reconstruction Of Central Ray Deficiency, Ga350000.06430000.0 Reconstruction Of Radial Ray Deficiency, Ga350000.06430000.0 Rekonstruksi Dengan Menggunakan Tissue Expantion, Ga350000.06430000.0 Rekonstruksi Dengan Skin Flap Lokal, La350000.06430000.0 Rekonstruksi Dengan Skin Grafting, Ga350000.06430000.0 Rekonstruksi Kelainan Telinga Yang Lain, Ga350000.06430000.0 Release Kontraktur Dengan Skin Flap, Ga350000.06430000.0 Release Kontraktur Dengan Z Plasty, Ga350000.06430000.0 Repair Palpebra Dengan Oral Mucosal Graft, Ga350000.06430000.0 Repair Palpebra Dengan Posterior Lamellar Reconstruction, Ga350000.06430000.0 Repair Trauma Telinga Komplek, Ga350000.06430000.0 Secondary Lip Repair , Ga350000.06430000.0 Separasi Complete Syndacttly, Ga350000.06430000.0 Separasi Syndactyly, Ga350000.06430000.0 Skin Flap Lokal Komplek, Ga350000.06430000.0 Skingrafting Yang Sederhana, Ga350000.06430000.0 Split Thickness Skin Graft (Stsg) Luas, Ga350000.06430000.0 Tangensial Eksisi Dini Dengan Skin Grafting, Ga350000.06430000.0 Ankylosis Release, Ga350000.06430000.0 Bedah Mikro, Ga350000.06430000.0 Buried Dermal Flap (Thompson Procedure), Ga350000.06430000.0 Chordee Excision + Urethroplasty 1 Tahap, Ga350000.06430000.0 Commissuroplasty - Composite Flap(Microsurgery), Ga350000.06430000.0 Commissuroplasty - Gastro Omental Free Flap(Microsurgery), Ga350000.06430000.0 Commissuroplasty - Jejunal Free Autograft (Microsurgery), Ga350000.06430000.0 Cross-Facial Verve Graft, Ga350000.06430000.0 Eksisi Haemangioma Dengan Composite Flap, Ga350000.06430000.0 Endoscopic Reconstructive Surgery, Ga350000.06430000.0 Facial Sling Dengan Alograft, Ga350000.06430000.0 Finger Tip Injury Repair - Neurovascular Island/Distant Flap, Ga350000.06430000.0 Finger Tip Injury Repair - Toe Transfer, Ga350000.06430000.0 Fraktur Dan Dislokasi - Orif Dengan Miniplate, Ga350000.06430000.0 Free Flap, Ga350000.06430000.0 Free Gracillis Transfer, Ga350000.06430000.0 Frontozygomaticomaxillary Suspension, Ga350000.06430000.0 Jahit Luka Di Wajah Dengan Kerusakan Komplek, Ga350000.06430000.0 Kontraktur Tangan Dan Jari, Ga350000.06430000.0 Le Fort I Osteotomy, Ga350000.06430000.0 Mandibular Distraction, Ga350000.06430000.0 Mandibular Reconst With Non Vascularized Bone Graft, Ga350000.06430000.0 Mandibular Reconst With Tmj Plate Rekonstruction, Ga350000.06430000.0 Mandibular Reconst With Vascularized Bone Graft(Mikro) - Defek Boyd T, Ga350000.06430000.0 Mastopexy, Ga350000.06430000.0 Maxillary Reconst.With Non Vascularized Bone Graft, Ga350000.06430000.0 Maxillary Reconst.With Vascularized Bone Graft(Mikro), Ga350000.06430000.0 Medial/Lateral Canthoplasty, Ga350000.06430000.0 Musculocutaneus Flap, Ga350000.06430000.0 Myocutaneus Flap, Ga350000.06430000.0 Omental Flap, Ga350000.06430000.0 Open Reduction With Implant And Septoplasty, La350000.06430000.0 Open Reduction With Wire/Titanium Implant, Ga350000.06430000.0 Operasi Bedah Mikro Yang Lain, Ga350000.06430000.0 Operasi Rekonstruksi : Hidung, La350000.06430000.0 Operasi Rekonstruksi : Hidung, Ga350000.06430000.0 Operasi Rekonstruksi : Palpebra, Ga350000.06430000.0 Operasi Rekonstruksi : Telinga, Ga350000.06430000.0 Operasi Rekonstruksi : Wajah, Ga350000.06430000.0 Operasi Rekonstruksi : Wajah, Ga350000.06430000.0 Operasi Rekonstruksi : Payudara Dan Sekitarnya, Ga350000.06430000.0 Operasi Rekonstruksi : Bokong, Ga350000.06430000.0 Operasi Rekonstruksi : Genitalia Eksterna Dan Sekitarnya, Ga350000.06430000.0 Operasi Skin Flap Yang Lain Yang Lebih Komplek, Ga350000.06430000.0 Ops. Rekonstruksi : Defek/ Kelainan Muka, Ga350000.06430000.0 Ops.Rek. : Defak/Kelainan Tubuh Yang Lain, Ga350000.06430000.0 Orif + Orbital Wall Reconstruction Dengan Silicon Plate, Ga350000.06430000.0 Orif + Titanium Mini Plate Approach Ektra Oral 2 Sisi, Ga350000.06430000.0 Orif Dengan 2 Approach, Ga350000.06430000.0 Orif Dengan 3 Approach, Ga350000.06430000.0 Orif Untuk Fraktur Le Fort Ii, Ga350000.06430000.0 Orif Untuk Fraktur Le Fort Iii Bicoronal Approach, Ga350000.06430000.0 Osseointegrated Mandibular Implant - Close Primary, Ga350000.06430000.0 Osseointegrated Mandibular Implant - Distant/Free Flap, Ga350000.06430000.0 Osseointegrated Mandibular Implant, Ga350000.06430000.0 Pharyngoplasty, Ga350000.06430000.0 Primary/Secondary Repair Nerve Injury (Bedah Mikro), Ga350000.06430000.0 Rekonstruksi Dengan Composite Flap (Microsurgery), Ga350000.06430000.0 Rekonstruksi Dengan Composite Flap (Microsurgery), Ga350000.06430000.0 Rekonstruksi Dengan Free Vascularized Bone Graft, Ga350000.06430000.0 Rekonstruksi Dengan Muscle Flap Dengan Skin Graft, Ga350000.06430000.0 Rekonstruksi Dengan Musculocutaneus Flap, Ga350000.06430000.0 Rekonstruksi Dengan Skin Flap Komplek, Ga350000.06430000.0 Rekonstruksi Dengan Skin Flap Lokal, Ga350000.06430000.0 Rekonstruksi Dengan Tissue Expantion+Skin Flap, Ga350000.06430000.0 Rekonstruksi Ibu Jari - Bone Graft + Myocutaneus Free Flap, Ga350000.06430000.0 Rekonstruksi Ibu Jari - Bone Graft + Regional Flap, Ga350000.06430000.0 Rekonstruksi Ibu Jari - Deepening First Digital Web Space, La350000.06430000.0 Rekonstruksi Ibu Jari - Policization, Ga350000.06430000.0 Rekonstruksi Ibu Jari - Toe To Thumb Transfer, Ga350000.06430000.0 Rekonstruksi Kelainan Genetalia Eksterna Yang Lain, Ga350000.06430000.0 Rekonstruksi Mandibula Dengan Costochondral Graft, Ga350000.06430000.0 Rekonstruksi Soft Tissue Dan Tulang, Ga350000.06430000.0 Rekonstruksi Soft Tissue Yang Lain, Ga350000.06430000.0 Rekonstruksi Softtissue Pada Hipertelorism, Ga350000.06430000.0 Rekonstruksi Telinga - Elevasi Flap Daun Telinga + Skin Graft, Ga350000.06430000.0 Rekonstruksi Telinga - Operasi Insersi Graft Tulang Rawan, Ga350000.06430000.0 Rekonstruksi Telinga - Repair Lobulus Dan Kelainan Penyerta, Ga350000.06430000.0 Rekostruksi Softtissue Dan Tulang Pada Hipertelorism, Ga350000.06430000.0 Release Kontraktur Dengan Free Flap, Ga350000.06430000.0 Release Kontraktur Dengan Skingraft, Ga350000.06430000.0 Release Kontraktur Leher, Ga350000.06430000.0 Release Kontraktur Linier, Ga350000.06430000.0 Release Vagina Acreta, Ga350000.06430000.0 Repair Blepharoptosis, La350000.06430000.0 Repair Blepharoptosis, Ga350000.06430000.0 Repair Bibir Dengan - Estlander Flap, Ga350000.06430000.0 Repair Bibir Dengan Bernard-Burows Flap, Ga350000.06430000.0 Repair Bibir Dengan Karapandzic Methode, Ga350000.06430000.0 Repair Camptodactyly, Ga350000.06430000.0 Repair Clinodactyly, Ga350000.06430000.0 Repair Creeple Hypospadia, Ga350000.06430000.0 Repair Ductus Nasolacrimalis, Ga350000.06430000.0 Repair Ductus Parotis, Ga350000.06430000.0 Repair Epispadia, Ga350000.06430000.0 Repair Fistel Palatum Dengan Bucal Atau Lingual Flap, Ga350000.06430000.0 Repair Fistel Palatum, Ga350000.06430000.0 Repair Fistel Urethra Complex, Ga350000.06430000.0 Repair Fistel Urethra Sederhana, Ga350000.06430000.0 Repair Involutional Ptosis, La350000.06430000.0 Repair Involutional Ptosis, Ga350000.06430000.0 Repair Palpebra Dengan Tarsoconjunctival Graft, Ga350000.06430000.0 Repair Palpebra Dengan Hard Palate Mucosal Graft, Ga350000.06430000.0 Repair Palpebra Dengan Local Skin Flap, Ga350000.06430000.0 Repair Palpebra Dengan Septal Chondromucosal Graft, Ga350000.06430000.0 Repair Palpebra Dengan Skin Flap Regional, La350000.06430000.0 Repair Palpebra Dengan Skin Graft, La350000.06430000.0 Repair Palpebra Dengan Sliding Transconjunctival Flap, La350000.06430000.0 Repair Palpebra Komplek, Ga350000.06430000.0 Repair Polysyndactyly, Ga350000.06430000.0 Repair Syaraf Tepi, Ga350000.06430000.0 Repair Symbrachydactyly, Ga350000.06430000.0 Repair Tendon Ekstensor Tangan Multiple, Ga350000.06430000.0 Repair Tendon Fleksor Tangan Multipel+ Pulley Reconst., Ga350000.06430000.0 Repair Tendon Fleksor Tangan Multiple, Ga350000.06430000.0 Repair Tendon Fleksor Tangan Tunggal + Pulley Reconst., Ga350000.06430000.0 Repalatoplasty, Ga350000.06430000.0 Replantasi Jari Multiple, Ga350000.06430000.0 Replantasi Jari Tunggal, Ga350000.06430000.0 Reseksi Rahang, Ga350000.06430000.0 Restorasi Dan Rekonstruksi Softissue+ Bone Dengan Multiple Approach, Ga350000.06430000.0 Revaskularisasi Jari Multiple, Ga350000.06430000.0 Revaskularisasi Jari Tunggal, Ga350000.06430000.0 Revisi Dengan Multiple Z Plasty/W Plasty, Ga350000.06430000.0 Revisi Dengan Flap Jauh, Ga350000.06430000.0 Revisi Dengan Flap Lokal, Ga350000.06430000.0 Separasi Complex Syndactyly, Ga350000.06430000.0 Skin Flap Komplek Lebih Dari Satu Flap, Ga350000.06430000.0 Skin Flap Komplek, Ga350000.06430000.0 Skin Grafting Yang Luas, Ga350000.06430000.0 Skin Grafting Dengan Luas Sedang, Ga350000.06430000.0 Split Thickness Skin Graft (Stsg) Luas Dengan Perawatan Khusus, Ga350000.06430000.0 Staged Subcutaneous Excision Underneath Flaps, Ga350000.06430000.0 Stiff Finger Joint - Finger Arthoplasty With Silicone Implant, Ga350000.06430000.0 Stiff Finger Joint - Finger Arthoplasty With Titanium Implant, Ga350000.06430000.0 Supraorbital Bone Reconstruction, Ga350000.06430000.0 Temporalis Muscle Fascia Transfer, Ga350000.06430000.0 Tendon Transfer Multiple, Ga350000.06430000.0 Tendon Transfer Tunggal, Ga350000.06430000.0 Tendoplasty, Ga350000.06430000.0 Tissue Expantion, Ga350000.06430000.0 Tmj Arthroscopy And Treatment, Ga350000.06430000.0 Tmj Arthrotomy, Ga350000.06430000.0 Tmj Lavage Dengan C-Arm, Ga350000.06430000.0 Total Cranial Vault Reconstruction, Ga350000.06430000.0 Total Joint Repl With Vascularized Bone Graft, Ga350000.06430000.0 Total Joint Replacement With Implant, Ga350000.06430000.0 Total Skin And Subcutaneous Tissue Excision Dg Skingraft (Charles), Ga350000.06430000.0 Transeksual Female To Male, Ga350000.06430000.0 Transeksual Male To Female, Ga350000.06430000.0 Transplatation Penis, Ga350000.06430000.0 Urethroplasty, Ga350000.06430000.0 Facial Bone Countouring - Angle Reshaping, Ga350000.06430000.0 Facial Bone Countouring - Genioplasty With Silicone Implant, Ga350000.06430000.0 Facial Bone Countouring - Malarplasty With Silicone Implant, Ga350000.06430000.0 Facial Bone Countouring - Osseous Genioplasty, Ga350000.06430000.0 Facial Bone Countouring - Osseous Malarplasty, Ga350000.06430000.0 Facial Bone Countouring - Split Mandible Osteotomy, Ga350000.06430000.0 Orif Untuk Fraktur Le Fort Iii, Ga350000.06430000.0 Biopsi, La350000.06430000.0 Incisi Absces Perikondritis, La350000.06430000.0 Incisi Abscess, La, La350000.06430000.0 Kauterisasi Lesi Kulit Jinak, La350000.06430000.0 Kauterisasi Papiloma Kulit , La350000.06430000.0 Secondary Hechting, La350000.06430000.0 DOKTER BEDAH THORAX / VASKULAR JENIS PELAYANANJSTARIF KECIL Pasang jarum Jet Can350000.01110000.0 Amputasi 1 digiti350000.01110000.0 BESAR Biopsi scalen350000.01870000.0 Debridement luas350000.01870000.0 Extirpasi hemangioma simple350000.01870000.0 Embolectomi (kh1)350000.01870000.0 Pemasangan akses vena port (VAP)350000.01870000.0 Removal VAP350000.01870000.0 Amputasi below knee350000.01870000.0 Amputasi above knee (kh 1)350000.01870000.0 Amputasi lengan350000.01870000.0 HD Cath ( open method )350000.01870000.0 KHUSUS Torakotomisimpatektomi350000.03400000.0 Torakotomi biopsy350000.03400000.0 Torakotomi window350000.03400000.0 Ligasiarterikarotis350000.03400000.0 End arterectomi350000.03400000.0 Stripping + Extraksibabcock350000.03400000.0 Embolectomi + Amputasi (kh2)350000.03400000.0 Extirpasihemangioma duplex/kompleks350000.03400000.0 Repair arteri perifer tanpa graf350000.03400000.0 Repair AV fistula (kh2)350000.03400000.0 Eksisi tumor dinding dada 350000.03400000.0 AV Shunt radialis350000.03400000.0 Stripping simple350000.03400000.0 Simpatektomi lumbal/abdominal350000.03400000.0 Reseksi tumor pleura350000.03400000.0 Torakotomi simple350000.03400000.0 Torakotomi dekortikasi350000.03400000.0 Torakotomi reseksi kosta / Sternum350000.03400000.0 Torakotomi ORIF kosta350000.03400000.0 Torakotomi segmentektomi (kh3)350000.03400000.0 Torakotomi removal korpal350000.03400000.0 Torakotomi Repair hernia diafragmatika (kh3)350000.03400000.0 Simpatektomi duplex350000.03400000.0 AV shunt cubiti350000.03400000.0 Reseksi aneurisma arteri perifer350000.03400000.0 Stripping duplex / komplex350000.03400000.0 Repair arteri dengan graf350000.03400000.0 Torakoscopi Biopsi350000.03400000.0 Torakoscopi Evakuasi350000.03400000.0 Torakoscopi Tutup Vistel350000.03400000.0 Pneumektomi350000.03400000.0 Rekonstruksi aneurisma aorta abdominalis per laparotomi350000.03400000.0 Rekonstruksi aneurisma aorta abdominalis suprarenal per laparotomi350000.03400000.0 Rekonstruksi aneurisma arteri iliaka per laparotomi350000.03400000.0 Reseksi tumor oesophagus + Rekonstruksi dengan conduid350000.03400000.0 Rekonstruksi dinding dada350000.03400000.0 Torakotomi Lobektomi350000.03400000.0 Reseksi tumor mediastinum350000.03400000.0 Reseksi tumor paru350000.03400000.0 Torakotomi dekortikasi dan plumbage350000.03400000.0 By pass arterifemoralis350000.03400000.0 Repair perforasi oesophagus350000.03400000.0 Repair bronchus350000.03400000.0 Repair trachea350000.03400000.0 Splenorenal shunt350000.03400000.0 Toracoskopi Reseksi paru350000.03400000.0 Toracoskopi Simpatektomi 350000.03400000.0 Toracoskopi Pengambilan Korpal intra parenchym Paru350000.03400000.0 Toracoskopi Ligasi arteri350000.03400000.0 DOKTER BEDAH ANAK JENIS PELAYANANJSTARIF KECIL Insisi dan drainase abses350000.01110000.0 Aplikasi silversulfadiazin, betadin, merkurokroom, antibiotika topikal pada omphalocele350000.01110000.0 Sirkumsisi Lokal350000.01110000.0 SEDANG Eksisi Kista dermoid350000.01870000.0 Skleroterapi lymphangioma dengan injeksi bleomycin, OK 432350000.01870000.0 Eksisi, biopsi lymphadenopaty350000.01870000.0 Eksisi biopsi soft tissue tumor leher, dinding perut350000.01870000.0 Eksisi tongue tie350000.01870000.0 eksisi granuloma umbilikal350000.01870000.0 Release synechia350000.01870000.0 Insisi imperforate hymen350000.01870000.0 BESAR Eksisi preauricular remnant/ extratragus350000.03400000.0 Eksisi kista, fistula branchial ( I, II, III )350000.03400000.0 Eksisi Kista, fistula thyroglosus350000.03400000.0 Eksisi lymphangioma350000.03400000.0 Lobektomi thyroid350000.03400000.0 Eksisi, marsupialisasi ranula350000.03400000.0 Eksisi epignagthus350000.03400000.0 Gastrostomi350000.03400000.0 esofagostomi350000.03400000.0 Subkutaneus mastektomi ginekomastia350000.03400000.0 Herniotomi umbilikal350000.03400000.0 tutup defek dinding perut dengan silo350000.03400000.0 Fundoplikasi350000.03400000.0 Pyloromiotomy350000.03400000.0 Liver biopsi350000.03400000.0 Appendektomi 350000.03400000.0 Eksisi tumor, biopsy neuroblastoma, teratoma, rabdomyosarkoma350000.03400000.0 Sphincterotomi anal, stretching anal350000.03400000.0 Thiersch procedure350000.03400000.0 Herniotorni, ligasi tinggi proc. vaginalis350000.03400000.0 Detorsio testis, orkhidopeksi, orkhidektomi350000.03400000.0 Eksisi kista baker's350000.03400000.0 Koreksi polidaktili350000.03400000.0 KHUSUS Lengthening m. sternokleidomastoideus350000.06430000.0 Thorakotomi Reseksi anastomosis esophagus350000.06430000.0 Esofagomyotomi achalasia350000.06430000.0 Thorakotomi tutup defek diafragma kongenital350000.06430000.0 Laparotomi tutup defek diafragma kongenital350000.06430000.0 Thorakotomy Plikasi diafragma 350000.06430000.0 Laparotomi plikasi diafragma350000.06430000.0 Eksisi sinus, fistula dan kista omphalomesenterikus350000.06430000.0 Eksisi sinus, fistula dan kista urakhus350000.06430000.0 Repair dinding perut (abdominal closure) gastroskisis dan omphalokel350000.06430000.0 Abdominoplasty, urine diversion, orkhidopeksi pada prune belly syndrome350000.06430000.0 Gatropexy, reduction of valvulus, gastrostomi pada gangguan rotasi usus kongenital350000.06430000.0 Eksisi diafragma, mocosal ablation pada gastric diafragma atau pre antral web350000.06430000.0 Closure of perforation, gastrostomi350000.06430000.0 Foreign bodies and bezoar extraction per endoskopi, laparotomi350000.06430000.0 Ablasio duplikasi gastrointestinal350000.06430000.0 Duodenoduodenostomy, duodenojejunostomy350000.06430000.0 Reseksi pankreas350000.06430000.0 Kistojejunostomi R&Y, pada pseudokista pankreas 350000.06430000.0 Hepatikojejunostomi R&Y pada kista duktus koledukus350000.06430000.0 Hepaticojejunostomy, portoenterostomy (Kasai)350000.06430000.0 Kholedokholitotomi, kholesistektomi350000.06430000.0 Total splenectomy, 350000.06430000.0 Partial splenectomy350000.06430000.0 Splenoraphy350000.06430000.0 Reseksi anastomosis, ileostomi (Bishop­Koop/ Santulli, Mickulicz) pada obstruksi usus halus kongenital350000.06430000.0 Intraperitoneal lavage350000.06430000.0 Reduksi volvulus, Ladd procedure, appendeektomi350000.06430000.0 Wedge resection, reseksi anastomosis350000.06430000.0 Reduksi intususepsi per laparotomi350000.06430000.0 Reseksi anatomosis usus350000.06430000.0 Eksisi kista oinentum, mesenterial350000.06430000.0 Pull-through procedure (Swenson, Soave, Duhamel, transanal), myektomi (Lynn) 350000.06430000.0 PSRHD 350000.06430000.0 Nefrektomi total350000.06430000.0 Nefrektomi parsial350000.06430000.0 Pyeloplasti350000.06430000.0 Reimplantasi ureter, tapering, plikasi„ folding.350000.06430000.0 Eksisi ureterocele350000.06430000.0 Augmentation cystoplasty pada neurogenik bladder350000.06430000.0 Release chordee350000.06430000.0 Urethroplasty350000.06430000.0 Scrotoplasty350000.06430000.0 Vaginoplasty, urethroplasty pada sinus urogenitalis350000.06430000.0 Koreksi polidaktili350000.06430000.0 Koreksi syndaktili350000.06430000.0 Kholesistektomi350000.06430000.0 esophageal replacement (colon, gastric tube, jejenum, gastric pull-up)350000.06430000.0 thorakoskopi Reseksi anastomosis esophagus350000.06430000.0 Intestinal lengthening,350000.06430000.0 laparoskopi tutup defek diafragma kongenital350000.06430000.0 Reseksi liver, lobektomi, 350000.06430000.0 Reduksi intususepsi per laparoskopy350000.06430000.0 laparoskopy appendektomy350000.06430000.0 PSARP (postero sagital anorectoplasti)350000.06430000.0 PSARUVP (posterosagital anorecto uretero vagino plasty350000.06430000.0 ASARP (anterosagital anorecto plasty)350000.06430000.0 abdominosakroperineal pulltrough350000.06430000.0 laparoskopi Fundoplikasi350000.06430000.0 laparoskopy assisted pulltrough350000.06430000.0 Genitoplasty, clitoral reduction, vaginoplasty, urethroplasty pada ambigous genital350000.06430000.0 Rectal closure, bladder closure, kolostomi, anorektoplasti, epispadia repair, continent surgery pada cloaca extrofia350000.06430000.0 Bladder closure, epispadia repair, continent surgery350000.06430000.0 Valve ablation pada posyterior uretral valve350000.06430000.0 laparoskopi herniotomi350000.06430000.0 laparoskopy pyeloplasty350000.06430000.0 laparoskopy reseksi usus350000.06430000.0 laparoskopi pyloromyotomi350000.06430000.0 laparoskopy splenektomi350000.06430000.0 laparoskopi kolesistektomi350000.06430000.0 thorakostomi koreksi pectus exavatus350000.06430000.0 intestinal transplantation350000.06430000.0 Twin separation surgery350000.06430000.0 Liver transplantation350000.06430000.0 DOKTER BEDAH TUMOR JENIS PELAYANANJSTARIF KECIL Alligator biopsi350000.01110000.0 Katerisasi papilom350000.01110000.0 Cabut kuku350000.01110000.0 Biopsi, La350000.01110000.0 Incisi Absces Perikondritis, La350000.01110000.0 Incisi Abscess, La, La350000.01110000.0 Kauterisasi Lesi Kulit Jinak, La350000.01110000.0 Kauterisasi Papiloma Kulit , La350000.01110000.0 Secondary Hechting, La350000.01110000.0 Sirkumsisi Lokal350000.01110000.0 Eksisi Veruka, La350000.01110000.0 Eksterpasi Tumor Jinak, Diluar Wajah ,La350000.01110000.0 Ektirpasi Aterom Diluar Wajah, La350000.01110000.0 Ektirpasi Lipoma Diluar Wajah, La350000.01110000.0 SEDANG Eksisi papiloma GA350000.01870000.0 Eksisi atheroma GA350000.01870000.0 Debridement GA350000.01870000.0 Rehecting350000.01870000.0 Incisi abses GA350000.01870000.0 BESAR Eksisi papiloma multipel350000.03400000.0 Eksisi atheroma multipel350000.03400000.0 Biopsi dengan generalanestesi350000.03400000.0 Limfadenektomi dengan general anestesi350000.03400000.0 Eksisi FAM single 350000.03400000.0 Eksisi Mastopati single 350000.03400000.0 Subcutan mastektomi unilateral350000.03400000.0 Rekonstruksi nipple areolar complek unilateral350000.03400000.0 Eksisi tumor < 5cm350000.03400000.0 STSG/FTSG < 5cm350000.03400000.0 CWL procedure350000.03400000.0 Eksisi baker's cyst unilateral350000.03400000.0 Debridement +rehecting350000.03400000.0 KHUSUS Simple mastektomi 350000.06430000.0 Eksisi FAM multiple / bilateral350000.06430000.0 Eksisi Mastopati multipel / bilateral350000.06430000.0 Rekonstruksi nipple areoler complek bilateral350000.06430000.0 Subcutan mastektomi bilateral350000.06430000.0 Istmolobektomi tiroid350000.06430000.0 Hemiglosektomi350000.06430000.0 Radikal Neck Dissection unilateral350000.06430000.0 Inguinal dissection unilateral 350000.06430000.0 Axillary dissection unilateral 350000.06430000.0 Eksisi luas tumor ≥ 5cm350000.06430000.0 Guttering abses350000.06430000.0 Eksisi mama acessories unilateral350000.06430000.0 Eksisi tumor submandibula unilateral350000.06430000.0 Core biopsi350000.06430000.0 Parsial / Hemimandibulektomi350000.06430000.0 Parotidektomi unilateral350000.06430000.0 Maxillektomi unilateral350000.06430000.0 Delay rekonstruksi maxilla/mandibulla350000.06430000.0 Delay rekonstruksi payudara unilateral (Flap/implant)350000.06430000.0 STSG/FTSG ≥ 5cm350000.06430000.0 Amputasi 350000.06430000.0 Reanimasi N7 unilateral350000.06430000.0 Eksisi tumor intraoral unilateral350000.06430000.0 Cystrunk procedure350000.06430000.0 Tracheostomi tumor headneck350000.06430000.0 Eksisi baker's cyst bilateral350000.06430000.0 (Modified) Radikal Mastektomi 350000.06430000.0 BCT (Breast Concerving Treatment) 350000.06430000.0 Skin/NAC sparing mastektomi350000.06430000.0 Eksisi FAM multiple dan bilateral350000.06430000.0 Eksisi Mastopati multipel dan bilateral350000.06430000.0 Subtotal/neartotal/total tiroidektomi350000.06430000.0 Hemiglosektomi+Radikal Neck dissection unilateral350000.06430000.0 Eksisi mama acessories bilateral350000.06430000.0 Eksisi tumor submandibula bilateral350000.06430000.0 Hemimandibulektomi +reconstruksi(implant/FLAP)350000.06430000.0 Total mandibulektomi350000.06430000.0 Parotidektomi unilateral +neck disection350000.06430000.0 Maxillektomi + rekonstruksi (Implant/FLAP)350000.06430000.0 Maksilektomi bilateral350000.06430000.0 Delay rekonstruksi payudara bilateral (Flap/implant)350000.06430000.0 Pasang/lepas Port A Cath/VAP/Cell Side350000.06430000.0 Eksisi tumor intraoral bilateral350000.06430000.0 Eksisi tumor intraoral unilateral +neck dissection350000.06430000.0 Rekonstruksi hidung, bibir dengan flap/implant350000.06430000.0 Eksisi luas tumor ≥ 5cm +FLAP/graft350000.06430000.0 Muscle Group Excision350000.06430000.0 Debulking Tumor350000.06430000.0 (Modified) Radikal Mastektomi+rekonstruksi payudara dengan implant/ flap350000.06430000.0 Skin/NAC sparing mastektomi +rekonstruksi implant/flap350000.06430000.0 Total tiroidektomi + Neck dissection unilateral 350000.06430000.0 Hemiglosektomi+Radikal Neck dissection bilateral350000.06430000.0 Endoskopi tiroidektomi350000.06430000.0 Sentinel node biopsi350000.06430000.0 Total mandibulektomi +rekonstruksi implant/ FLAP350000.06430000.0 Total maksilektomi +rekonstruksi implant/FLAP350000.06430000.0 Hemipelvektomi350000.06430000.0 Fore quarter amputasi350000.06430000.0 Hind quarter amputasi350000.06430000.0 Parotidektomi bilateral +rekonstruksi flap350000.06430000.0 Parotidektomi bilateral +neck dissection350000.06430000.0 Distant/ microsurgery flap (TRAM, LD, Gluteal,forearm, costa, fibula,pectoralis )350000.06430000.0 DOKTER BEDAH SARAF JENIS PELAYANANJSTARIF KECIL Blok saraf perifer (Pain Management Sederhana)350000.01110000.0 Punctie subgaleal hematom350000.01110000.0 Pemasangan Cervical Traksi / Halo Cast350000.01110000.0 Punctie Ventrikel350000.01110000.0 Biopsi saraf perifer 1 (ICD 9 CM 04)350000.01110000.0 Punctie Kranial 1 (IC 9 CM 01.0)350000.01110000.0 Ventrikulo Shunt (ICD 9 CM No 02.3)350000.01110000.0 SEDANG Ekstirpasi eksostosis tulang350000.01870000.0 Eksternal ventrikulostomi350000.01870000.0 Ekstirpasi kista dermoid/epidermoid cranium350000.01870000.0 Kranioplasty (Other Operation On Skull, Brain and Meninges (ICD 9 CM No 02.00)350000.01870000.0 Punctie Kranial 1 (ICD 9 CM 01.1)350000.01870000.0 BESAR Koreksi depressed frakture simple ( lama operasi < 1 jam )350000.03400000.0 Saraf perifer : Dekompresi saraf perifer tanpa anastomosis ( dekompresi tunnel syndrome )350000.03400000.0 Simple functional neurosurgery : Percutaneus Facet Denervation, Percutaneus Rhizotomi350000.03400000.0 Vaskuler surgery : ligasi karotis pada fistula karotikocavernosa350000.03400000.0 Operasi tulang belakang /Laminektomi 1 (ICD 9 CM 03.0)350000.03400000.0 Kraniotomi dan Kraniektomi 1 (ICD 9 CM 01.2)350000.03400000.0 Repair Meningocele dan Spina Bifida (ICD 9 CM 02.1)350000.03400000.0 Operasi Saraf Perifer 2 (ICD 9 CM 04.5)350000.03400000.0 KHUSUS Craniotomi/Kraniektomi neoplasma/ proses desak ruang : Neoplasma ekstra aksial supra tentorial : meningiomakonveksitas, Sitoreduksi/Ekstirpasi tumor superfisial 350000.06430000.0 Endoskopic surgery350000.06430000.0 Stereotaktic surgery350000.06430000.0 Functional neurosurgery complicated : Kordotomi,Para vertebral /Visceral Blok / Simpatektomi350000.06430000.0 Kraniotomi Osteoma / Fibrous dysplasia350000.06430000.0 Kranioplasty defek kranium350000.06430000.0 Ekstirpasi cele (meningoencefalocele Anterior / Posterior . Lumbalis (Spina Bifida)350000.06430000.0 Koreksi depressed fraktur non complicated ( laserasi durameter . Duraplasty / duraraphy)350000.06430000.0 Spinal Surgery : Laminektomi dekompresi tanpa fiksasi : Kanal stenosis, Hernia Nukleus Polposus350000.06430000.0 Kranitomi epidural hematom supra tentorial, Burrhole kraniektomi subdural hematom kronis350000.06430000.0 Pemasangan pintasan LCS : Ventrikulo peritoneal shunt (VP Shunt)350000.06430000.0 Saraf perifer : Eksplorasi dengan neuroplasty / anastomosis saraf perifer350000.06430000.0 Kraniotomi dan Kraniektomi 2 (ICD 9 CM 01.2)350000.06430000.0 Operasi Saraf Perifer 3 (ICD 9 CM 04.4350000.06430000.0 Operasi tulang belakang /Laminektomi 2 (ICD 9 CM 03.5)350000.06430000.0 Craniotomi/Kraniektomi neoplasma/ proses desak ruang : Neoplasma skullbase : Giant meningioma supratentorial Sfenoid ridge, Olfactory groove, Sagital, Torcular Tumor infra tentorial : Meningioma Cerebellopontine angle tumor,Medullobiastoma Sito reduksi / ekstirpasi deep seated tumor350000.06430000.0 Koreksi/Rekonstruksi likworhoe, complicated depressed frakture (laserasi serebri dengan reseksi serebri)350000.06430000.0 Vaskuler surgery : Eksisi AVM, Aneurysma, Evakuasi perdarahan stroke350000.06430000.0 Kraniotomi dekompresi duraplasty Subdural hemato aku, Kraniotomi Epidural hematom supra dan atau Kraniektomi suboccipital Epidural Hematomi350000.06430000.0 Epileptic Surgery350000.06430000.0 Spinal Surgery Anterior/Posterior Fusion /Fixation, Laminektomi ekstirpasi tumor spinal350000.06430000.0 Pemasangan pintasan LCS : Atrio ventrikular shunt (AV Shunt)350000.06430000.0 Saraf perifer : Eksplorasi dengan neuroplasty/transposisi/anastomosis saraf350000.06430000.0 Endovaskuler DSA Serebral Diagnostik350000.06430000.0 Endovaskuler Coiling 1350000.06430000.0 Endovaskuler Coiling 2350000.06430000.0 Endovaskuler Coiling 3350000.06430000.0 Endovaskuler Baloning 1350000.06430000.0 Endovaskuler Baloning 2350000.06430000.0 Endovaskuler Embolisasi 1350000.06430000.0 Endovaskuler Embolisasi 2350000.06430000.0 Endovaskuler Embolisasi 3350000.06430000.0 Endovaskuler Trombolysis350000.06430000.0 Endovaskuler Trombus Removal Ischemic Stroke350000.06430000.0 Endovaskuler Carotid Arterial Stenting CAS350000.06430000.0 DOKTER BEDAH ORTHOPEDI JENIS PELAYANANJSTARIF KECIL Release 1 Trigger Finger350000.01110000.0 Amputasi 1 jari350000.01110000.0 Atrodisis 1 jari350000.01110000.0 Excisi Ganglion carpi350000.01110000.0 SEDANG Amputasi 2 jari350000.01870000.0 Atrodisis 2 jari350000.01870000.0 Skin Grafting350000.01870000.0 Operasi arteri dengan tuntunan Arthroskopi350000.01870000.0 ORIF 1 jari350000.01870000.0 ORIF 1 metatarsal350000.01870000.0 ORIF 1 metacarpal350000.01870000.0 Debridement open fraktur350000.01870000.0 Release > 2 trigger finger350000.01870000.0 Blind External Fixasi350000.01870000.0 Discografi350000.01870000.0 Facet Vertebra Block dengan Fluoroscopy350000.01870000.0 Cabut inplant350000.01870000.0 BESAR Amputasi > 2 jari350000.03400000.0 Amputasi pergelangan tangan350000.03400000.0 Amputasi lengan bawah350000.03400000.0 Amputasi lengan atas350000.03400000.0 Amputasi pergelangan kaki350000.03400000.0 Amputasi tungkai bawah350000.03400000.0 Amputasi pedis350000.03400000.0 Amputasi siku350000.03400000.0 Amputasi paha350000.03400000.0 Amputasi lutut350000.03400000.0 Atrodesis > 2 jari350000.03400000.0 Atrodesis pergelangan tangan350000.03400000.0 Atrodesis sendi siku350000.03400000.0 Atrodesis sendi ankle350000.03400000.0 Atrodesis sendi lutut350000.03400000.0 ORIF350000.03400000.0 Fasciotomy 350000.03400000.0 Arthrotomy + pinning350000.03400000.0 Squesterectomy350000.03400000.0 Arthrotomy + Debridement350000.03400000.0 Reposisi + pinning + pasang gip350000.03400000.0 Debridement + Reposisi + Pinning + pasang gip350000.03400000.0 Cabut wire dalam kulit dengan fluoroscopy350000.03400000.0 ORIF tibia Simple350000.03400000.0 ORIF Humerus Simple350000.03400000.0 Nailing femur Simple350000.03400000.0 ORIF Fibula Simple350000.03400000.0 ORIF 1 malleollus350000.03400000.0 ORIF Radius Simple350000.03400000.0 ORIF Ulna Simple350000.03400000.0 ORIF > 2 jari350000.03400000.0 ORIF > 2 Metatarsal350000.03400000.0 ORIF > 2 Metacarpal350000.03400000.0 ORIF Radius Distal350000.03400000.0 ORIF Femur Simple350000.03400000.0 ORIF Clauvicula350000.03400000.0 Debridement open fractore + ORIF tersebut diatas350000.03400000.0 ORIF Olecranon350000.03400000.0 ORIF Patella350000.03400000.0 Instra Discal Elektrotermal terapy350000.03400000.0 Tenoraphy > 2 Tendo350000.03400000.0 Neuraraphy > 2 Nervus350000.03400000.0 Excisi Tumor Jinak Tulang350000.03400000.0 External Fixasi + Reposisi terbuka350000.03400000.0 Minimal Invasive percutaneus Osteosynthesis350000.03400000.0 Release 1 Syndactyli350000.03400000.0 External Fixasi + Reposisi terbuka350000.03400000.0 Minimal Invasive percutaneus Osteosynthesis350000.03400000.0 Excisi Ganglion Poplitea350000.03400000.0 Tenoraphy 1 Tendo350000.03400000.0 Neuraraphy 1 Nervus350000.03400000.0 Release compressi saraf perifer350000.03400000.0 Neulolysis/Neurectomy dengan Fluoroscopy350000.03400000.0 KHUSUS Semua rekonstruksi350000.06430000.0 ORIF Tibia + Fibula350000.06430000.0 ORIF Malleolus Lateralis + Medialis350000.06430000.0 ORIF Radius + ULNA350000.06430000.0 ORIF Intercondiler Humeri350000.06430000.0 ORIF Intercondiler Femur350000.06430000.0 ORIF Intertroohanter Femur350000.06430000.0 Release CTEV350000.06430000.0 ORIF > 2 Metacarpal350000.06430000.0 Debridement open fracture + ORIF tersebut diatas350000.06430000.0 Rekonstruksi Blast Injury350000.06430000.0 Rekonstruksi Tendo/350000.06430000.0 ORIF 1 Condilus Humeri350000.06430000.0 ORIF Collum humeri350000.06430000.0 ORIF Caput Humeri350000.06430000.0 ORIF Caput Femur350000.06430000.0 Release Contractur 1 sendi350000.06430000.0 ORIF tibia Kominutif350000.06430000.0 ORIF Humerus Kominutif350000.06430000.0 Nailing femur Kominutif350000.06430000.0 ORIF Fibula Kominutif350000.06430000.0 ORIF Ankle350000.06430000.0 ORIF Radius Kominutif350000.06430000.0 ORIF Ulna Kominutif350000.06430000.0 ORIF Femur Kominutif350000.06430000.0 Myocutan free vascularizeo flapping350000.06430000.0 Free vascularizeo bone grafting350000.06430000.0 Arthroscopy + Rekonstruksi sendi350000.06430000.0 Rekonstruksi ligament/tendo sendi bahu350000.06430000.0 Shish kebab nailling + osteotomy350000.06430000.0 Rekonstruksi Negleted Fraktur dan / atau Dislocasi350000.06430000.0 Triple Arthrodesis350000.06430000.0 Hemi Arthroplasty350000.06430000.0 Arthrodesis sendi coxae350000.06430000.0 Arthrodesis sendi bahu350000.06430000.0 Release Contracture> 2 sendi350000.06430000.0 Release contracture + Ostetomy + ORIF350000.06430000.0 ORIF Malunion Fracture350000.06430000.0 ORIF Nonunion Fracture350000.06430000.0 High Tibial Osteotomy350000.06430000.0 Supra condiler osteotomy350000.06430000.0 Varus/Valgus osteotomy350000.06430000.0 ORIF Pelvis350000.06430000.0 Excisi tumor jinak tulang + Rekonstruksi dengan Inplant/Bonecement.350000.06430000.0 Excisi tumor ganas tulang+ Rekonstruksi + Inplant /Bonecement350000.06430000.0 External Fixasi + Reposisi terbuka Cominnutive Fracture Dekat Sendi350000.06430000.0 French Osteotomy350000.06430000.0 Ligament > 2 Jari350000.06430000.0 Ilizarof Procedure350000.06430000.0 Release Syndactily > 2350000.06430000.0 Tendon Transfer 1-2 tendon350000.06430000.0 Rekonstruksi Ligamen/Tendo sendi Ankle350000.06430000.0 Release 1 Syndactyli350000.06430000.0 Release Ring Contriction Syndrome350000.06430000.0 Rekonstruksi Ligament/Tendo 1 Jari350000.06430000.0 Achiles Tendo Lengtening350000.06430000.0 Myocutan flapping350000.06430000.0 Meniscectomy350000.06430000.0 Reattachment osteochondritis350000.06430000.0 Cabut inplant tulang belakang350000.06430000.0 Explorasi plexus Brachialis350000.06430000.0 Debridement + Tenoraphy + Neuroraphy + Anas-tomose Vasculer.350000.06430000.0 Rekonstruksi Ligamen/Tendo sendi lutut350000.06430000.0 Tendon Transfer > 3 Tendon350000.06430000.0 Rekonstruksi Club Hand350000.06430000.0 Krukenberg Procedure350000.06430000.0 Juvara Procedure350000.06430000.0 Hand Surgery Rekonstruksi350000.06430000.0 Rekonstruksi Tulang pelvis350000.06430000.0 Total knee replacement350000.06430000.0 Total hip replacement350000.06430000.0 Kyphoplasty350000.06430000.0 Vertebroplasty350000.06430000.0 Micro Discectomy350000.06430000.0 Replantasi350000.06430000.0 Operasi tulang belakang dengan pasang instrument350000.06430000.0 Operasi tulang belakang dengan tuntunan endoscopy350000.06430000.0 Mikro surgery dengan mikroskop350000.06430000.0 Calotaxis/Lenghtening dengan Inplant/External fixasi350000.06430000.0 DOKTER MATA JENIS PELAYANANJSTARIF KECIL Epilasi350000.01110000.0 SEDANG Anestesi Injeksi Subkonjungtiva350000.01870000.0 Anestesi Injeksi Retrobulbar/Parabulbar350000.01870000.0 Amotio Corpal Konjungtiva350000.01870000.0 Irigasi Mata350000.01870000.0 Aff Hecting Palpebra350000.01870000.0 Ganti Tampon350000.01870000.0 Toilet Luka350000.01870000.0 BESAR Injeksi Intravitreal350000.03400000.0 Amotio Corpal Kornea350000.03400000.0 Anel Test350000.03400000.0 Ekskokleasi Hordeolum/Kalazion350000.03400000.0 Eksisi Pterigium Bare Sclera350000.03400000.0 Eksisi Pterigium McReynold350000.03400000.0 Eksisi Pterigium Autograf dengan Jahitan350000.03400000.0 Sondasi350000.03400000.0 Ekstirpasi Kista Konjungtiva350000.03400000.0 Biopsi 350000.03400000.0 Tarsorafi350000.03400000.0 Parasentesis 350000.03400000.0 Amotio Lithiasis350000.03400000.0 Eksisi Granuloma350000.03400000.0 Ekstirpasi Nevus350000.03400000.0 Repair Palpebra350000.03400000.0 Iridektomi Perifer350000.03400000.0 Cyclocryotherapy (CCT)350000.03400000.0 Eksisi Tumor Konjungtiva350000.03400000.0 SBL Tarsotomi350000.03400000.0 Transplantasi Membran Amnion350000.03400000.0 Transplantasi Stem Cell350000.03400000.0 Flap Konjungtiva350000.03400000.0 Repair Entropion/Ektropion350000.03400000.0 Repair Kornea350000.03400000.0 Eviserasi350000.03400000.0 Enukleasi350000.03400000.0 Eksenterasi350000.03400000.0 Dermo-Fat Graft (DFG)350000.03400000.0 Repair Avulsi Kanalis Lacrimalis350000.03400000.0 ICCE350000.03400000.0 Laser Retina350000.03400000.0 Laser Iridotomi350000.03400000.0 Laser Kapsulotomi PCO350000.03400000.0 Aff Hecting Kornea350000.03400000.0 Fundus Florescein Angiography (FFA)350000.03400000.0 KHUSUS Eksisi Pterigium dengan Fibrin Glue350000.06430000.0 ECCE + IOL350000.06430000.0 SICS + IOL350000.06430000.0 Implantasi IOL Sekunder350000.06430000.0 Trabekulektomi350000.06430000.0 Orbitotomi Anterior350000.06430000.0 Repair Ptosis350000.06430000.0 Eksisi Luas (Wide Excision)350000.06430000.0 Scleral Buckle350000.06430000.0 Dekompresi Orbita350000.06430000.0 Repair Strabismus350000.06430000.0 Blefaroplasti350000.06430000.0 Evakuasi Silicon Oil350000.06430000.0 Combined Trabekulektomi + ECCE + IOL350000.06430000.0 Combined Trabekulektomi + SICS + IOL350000.06430000.0 Keratoplasti350000.06430000.0 Phacoemulsification + IOL350000.06430000.0 Combined Trabeklektomi + Phaco + IOL350000.06430000.0 Vitrectomy350000.06430000.0 Darcryocystorhynostomy (DCR)350000.06430000.0 350000.06430000.0 DOKTER SPESIALIS OBSTETRI DAN GINEKOLOGI JENIS PELAYANANJSTARIF KECIL Closed/transuretral biopsy of bladder350000.01110000.0 Culdotomy350000.01110000.0 Diagnostic procedures on vulva (biopsi vulva)350000.01110000.0 Percutaneus aspiration of bartholin's gland (cyst)350000.01110000.0 Incision of Bartholin's gland (cyst)/ insisi abses bartolin350000.01110000.0 Excision or other destruction of Bartholin's350000.01110000.0 Suture of laceration of vulva and perineum350000.01110000.0 Repair of other current obstetric laceration (episioperineoraphy, perineorafi ruptur perineum grade 1-2)350000.01110000.0 SEDANG Other excision or destruction lession of uterus (pedunculata myoma)350000.01870000.0 Reclosure of postoperative disruption of abdominal wall350000.01870000.0 Transuretral cystoscopy350000.01870000.0 Bilateral endoscopic destruction or occlusion of fallopian tubes (laparoscopic MOW)350000.01870000.0 Other bilateral destruction or occlusion of fallopian tubes (Sterilisasi minilaparotomi)350000.01870000.0 unilateral destruction or occlusion of fallopian tube350000.01870000.0 Repair of internal cervical os (cerclage of isthmus uteri, shirodcard operation)350000.01870000.0 Dilation and curettage of uterus (for termination of pregnancy or following delivery or abortion, Diagnostic Currettage)350000.01870000.0 Aspiration curettage of uterus350000.01870000.0 Incision of vulva and perineum (Labia & vulva adhesion, enlargement introitus)350000.01870000.0 Removal of cerclage material from cervix350000.01870000.0 Hymenotomy350000.01870000.0 Suture of laceration of vagina350000.01870000.0 Marsupialization of Bartholin's gland (cyst)350000.01870000.0 Pubiotomy to assist delivery350000.01870000.0 Repair of current obstetric laceration of cervic350000.01870000.0 Repair of current obstetric laceration of rectum and spincter ani (Ruptur perineum grade 3 & 4)350000.01870000.0 BESAR Cesarean section and removal of fetus350000.03400000.0 Exploratory laparotomy350000.03400000.0 Reopening of recent laparotomy site350000.03400000.0 Other Laparotomy ( drainase of intraperitoneal abses or hematom/TOA)350000.03400000.0 Delayed closure of granulating abdominal wound350000.03400000.0 Oophorotomy350000.03400000.0 Diagnostic procedures on ovaries (aspirasi biopsi, biopsi)350000.03400000.0 Local excision or destruction of ovarian lesion or tissue (cystectomy)350000.03400000.0 Unilateral oophorectomy350000.03400000.0 Unilateral salpingo-oophorectomy350000.03400000.0 Bilateral oophorectomy350000.03400000.0 Bilateral salpingo-oophorectomy350000.03400000.0 Repair of ovary350000.03400000.0 Lysis of adhesions of ovary and fallopian tube350000.03400000.0 Manual rupture of ovarian cyst350000.03400000.0 Release of torsion of ovary350000.03400000.0 Salpingotomy and salpingostomy350000.03400000.0 Diagnostic procedures on fallopian tubes (biopsy of fallopian tube)350000.03400000.0 Total unilateral salpingectomy350000.03400000.0 Total bilateral salpingectomy350000.03400000.0 Other salpingectomy (cautherization, coagulation, electrocoagulation, excision)350000.03400000.0 Aspiration of fallopian tubes350000.03400000.0 Burying of fimbriae in uterine wall350000.03400000.0 Hysterotomy350000.03400000.0 Open biopsy of uterine ligament350000.03400000.0 Other excision or destruction lession of uterus (uterine myomectomy)350000.03400000.0 Subtotal abdominal hysterectomy350000.03400000.0 Excision or destruction of lesion or tissue of uterus and supporting structures350000.03400000.0 Uterine repair (hysteroraphy non obstetric)350000.03400000.0 Caesarean section of unspecified type ( Hysterotomy to terminate pregnancy)350000.03400000.0 Repair of current obstetric laceration of uterus350000.03400000.0 Repair of other current obstetric laceration (Blader and uretra)350000.03400000.0 Lysis of intraluminal adhesions of vagina350000.03400000.0 Other vaginotomy (vaginal septum/eksisi septum vaginal, drainase hematom of vaginal cuff)350000.03400000.0 Other repair of vagina (Colpoperineoplasty, Repair old obstetric laceration of vagina)350000.03400000.0 KHUSUS Insufflation of fallopian tube (hydrotubasi)350000.06430000.0 Conization of cervix excluding electrical/cryo350000.06430000.0 Amputation of cervix (fortegil operation)350000.06430000.0 Closed biopsy of uterine ligament (laparoscopy biopsy of uterine ligament)350000.06430000.0 Closed biopsy of uterus (laparoscopy or hysteroscopy)350000.06430000.0 Devision of endometrial synechia350000.06430000.0 Total abdominal hysterectomy350000.06430000.0 Vaginal hysterectomy (prolaps uteri)350000.06430000.0 Other local excision or destruction of vulva and perineum350000.06430000.0 Operations on clitoris350000.06430000.0 Hymenoraphy350000.06430000.0 Other repair of vulva and perineum (repair of old obstetric laceration of vulva or perineum)350000.06430000.0 Caeraean section with previous C-section or complicated pregnancy350000.06430000.0 Levator muscle operation for urethrovesical suspension350000.06430000.0 Other ( TOT, TVT-O, TVT)350000.06430000.0 Other and unspecific hysterectomy (Caesarean Hysterectomi)350000.06430000.0 Other repair of urinary bladder (repair fistula involving bladder and instestin/ rectovesikovaginal, vesicosigmoidovaginal)350000.06430000.0 Repair of other fistula of bladder (cervicovesical, uretroperineovesical, uterovesical, vaginovesical)350000.06430000.0 Other repair of bladder (repair of old obstetric laceration of bladder)350000.06430000.0 Plication of uretrovesical junction (Kelly Kenedy operation on uretra, Kelly stoeckel operation)350000.06430000.0 Suprapubic sling operation (Goebel-Frangenheim-Stoeckel urethrovesical suspension, Millin-Read uretrovesical suspension, Oxford operation for urinary incontinence, urethrocystopexy by suprapubic suspension, purandare)350000.06430000.0 Retropubic uretral suspension (Marshall-Marchetti-Krantz operation, Suture of periurethral tissue to symphysis pubis)350000.06430000.0 Paraurethral suspension350000.06430000.0 Repair of fallopian tube350000.06430000.0 Removal of prosthesis of fallopian tube350000.06430000.0 Hysteroscopy diagnostic350000.06430000.0 Incisin or excision of congernital uterus (Jones operation)350000.06430000.0 Vaginal hysterectomy (nondescent, exclude myoma)350000.06430000.0 Repair of uterine supporting structures (watkin procedure, manchester operation, plication ligament)350000.06430000.0 Obliteration and total excision of vagina:Vaginectomy (lefort operation & vaginectomy)/kolpokleisis350000.06430000.0 Vaginal construction and reconstruction (neovagina)350000.06430000.0 Obliteration of vaginal vault350000.06430000.0 Other vulvectomy (unilateral & bilateral vulvectomy/vulvektomi sederhana)350000.06430000.0 Removal of extratubal of ectopic pregnancy (abdonimal pregnancy)350000.06430000.0 Repair of rectovaginal fistule350000.06430000.0 Vaginal suspension and fixation (Burch suspension)350000.06430000.0 Repair of fistula of vulva or perineum350000.06430000.0 Amnioscopy (fetoscopy, laparoamnioscopy)350000.06430000.0 Other and unspecific hysterectomy (AVRUEL operation)350000.06430000.0 Laparoscopy350000.06430000.0 Closured of other fistula of ureter (vesicoureterovaginal fistulectomy)350000.06430000.0 Cystouretroplasty and plastic repair of bladder neck (plication of spincter of urinary bladder, VY plasty of bladder neck)350000.06430000.0 Aspiration of ovary (OPU)350000.06430000.0 Transplantation of ovary350000.06430000.0 Ovarian denervation350000.06430000.0 Implantation or replacement of prothesis of fallopian tube350000.06430000.0 Vaginal hysterectomy (laparoscopically assisted vaginal)350000.06430000.0 Vaginal hysterectomy (nondescent due to myoma)350000.06430000.0 Radical abdominal hysterectomy (wertheim, POA)350000.06430000.0 Radical vaginal hysterectomy350000.06430000.0 Pelvic eviceration350000.06430000.0 Paracervical uterine denervation350000.06430000.0 Local excision or destruction of vagina and rectouterine pouch (hymenectomy, endometrectomy of cul de sac)350000.06430000.0 Repair of cystocele and rectocele350000.06430000.0 Radical vulvectomy350000.06430000.0 Other intrauterine operations on fetus and amnion350000.06430000.0 Other operation on cervix and uterus (Hysteroscopy therapetic)350000.06430000.0 Repair of colovaginal fistule350000.06430000.0 Repair of other vaginoenteric fistule350000.06430000.0 Correction of fetal defect350000.06430000.0 DOKTER SPESIALIS THT JENIS PELAYANANJSTARIF KECIL Insisi Abses (septum, furunkel, tonsil peritonsil, preauricula)350000.01110000.0 Explorasi Nashofarinx350000.01110000.0 Extirpasi (kista, atheroma, granuloma, papiloma)350000.01110000.0 Extraksi benda asing (telinga, hidung, orofaring)350000.01110000.0 Evakuasi serumen/ kolesteatoma dengan penyakit350000.01110000.0 Insisi hematoma telinga (othematoma/pseudocyst)350000.01110000.0 Penggantian arteficial laring (provox) esofagus (NGT)350000.01110000.0 Parasentesis350000.01110000.0 Biopsi tumor (telinga, hidung, orofaring)350000.01110000.0 Biopsi insisi tumor leher350000.01110000.0 SEDANG Miringotomi350000.01870000.0 Pemasangan Grommet350000.01870000.0 Extraksi benda asing telinga dengan penyulit350000.01870000.0 Extraksi kolesteatoma dengan penyulit350000.01870000.0 Extirpasi fistel preaurikuler350000.01870000.0 Reposisi fraktur os nasal350000.01870000.0 Extraksi polip nasal350000.01870000.0 Irigasi sinus350000.01870000.0 Sinuskopi diagnostik350000.01870000.0 Extraksi benda asing hidung dengan penyulit350000.01870000.0 Konkotomi350000.01870000.0 Antrostomi Intranasal350000.01870000.0 Trakeostomi elektif350000.01870000.0 Pasang dan ganti stent laring350000.01870000.0 Laringoskopi diagnostik350000.01870000.0 Intubasi dengan 'flexible Bronchoscopy)350000.01870000.0 Explorasi abses submandibula350000.01870000.0 Adenoidektomi350000.01870000.0 Sialendoskopi diagnostik350000.01870000.0 Reposisi fraktur arkus Zygomatikus350000.01870000.0 Esofaguskopi diagnostik350000.01870000.0 Multple explorasi biopsi tumor350000.01870000.0 Insisi biopsi kelenjar leher350000.01870000.0 Extirpasi tumor jinak sinunasal, kavitas oral350000.01870000.0 Extirpasi tumor jinak kelenjar liur350000.01870000.0 BESAR Miringoplasti350000.03400000.0 Kanaloplasti350000.03400000.0 Timpanoplasti350000.03400000.0 Meatoplasti350000.03400000.0 Mastoidektomi sederhana350000.03400000.0 Septum reseksi350000.03400000.0 Turbinoplasti350000.03400000.0 Septoplasti350000.03400000.0 Rinoplasti350000.03400000.0 Antrostomi extranasal (Caldwell Luc)350000.03400000.0 Sinuskopi dengan tindakan350000.03400000.0 Fronto ethmoidektomi external350000.03400000.0 Tonsillo adenoidektomi350000.03400000.0 Trakeostomi emergensi dengan penyulit350000.03400000.0 Laryngoskopi dengan tindakan350000.03400000.0 Explorasi abses parafaring, retrofaring350000.03400000.0 Explorasi abses multiple350000.03400000.0 Rekakeaonstruksi fraktur laring-trakea350000.03400000.0 Bedah mikro laring350000.03400000.0 Esofaguskopi dengan tindakan/penyulit350000.03400000.0 Sialendoskopi terapi/dilatasi350000.03400000.0 Labioplasti350000.03400000.0 Palatoplasti350000.03400000.0 Faringeal flap350000.03400000.0 Forehead flap350000.03400000.0 Laringofisur350000.03400000.0 Operasi tumor kelenjar liur350000.03400000.0 Laringektomi parsial350000.03400000.0 Tiroidektomi subtotal350000.03400000.0 Parotidektomi superfisial350000.03400000.0 Hemiglosektomi350000.03400000.0 Wide eksisi tumor tonsil, orofaring350000.03400000.0 Ligasi a. karatis externa350000.03400000.0 Extirpasi Angiofibroma Nasofaring350000.03400000.0 Maxilektomi parsial350000.03400000.0 Mandibulektomi parsial350000.03400000.0 Mini FESS350000.03400000.0 Uvulo-Palatofaringoplasti (UPPP)350000.03400000.0 KHUSUS Maxilektomi total350000.06430000.0 Mandibulektomi total350000.06430000.0 Laringektomi total + Deseksi Leher350000.06430000.0 Tiroidektomi total350000.06430000.0 Parotidektomi total350000.06430000.0 Hemiglosektomi + Deseksi Leher350000.06430000.0 Deseksi Leher Radikal350000.06430000.0 Timpano- Mastoidektomi350000.06430000.0 Mastoidektomi Modifikasi Radikal350000.06430000.0 Mastoidektomi Radikal350000.06430000.0 Osikuloplasti350000.06430000.0 Stapedektomi350000.06430000.0 Dekompresi nervus fasialis350000.06430000.0 Reseksi tulang temporal350000.06430000.0 Septorinoplasti350000.06430000.0 Rinoplasti augmentasi350000.06430000.0 FESS (funtional endoscopy sinus surgery)350000.06430000.0 ESS (endoscopy sinus surgery)350000.06430000.0 Otoplasti350000.06430000.0 Implan Koklea350000.06430000.0 Rekonstruksi fraktur rahang/wajah350000.06430000.0 Rekonstruksi telinga, mikrotia + aural atresia)350000.06430000.0 DOKTER SPESIALIS PARU JENIS PELAYANANJSTARIF KECIL Aspirasi/incisi abses paru350000.01110000.0 Aspirasi/incisi empyema350000.01110000.0 Pungsi pleura / needle thoraccoentesis evakuasi 350000.01110000.0 Pungsi pleura / needle thoraccoentesis evakuasi emergensi/cito350000.01110000.0 Pemasangan mini WSD350000.01110000.0 Injeksi intra vacum pleura350000.01110000.0 SEDANG Transthoracal needle aspiration/ TTNA350000.01870000.0 Transthoracal biopsy/ TTB350000.01870000.0 Transbronchial needle aspiration/biopsi (TBNA/TBNB)350000.01870000.0 Pleurodesis350000.01870000.0 BESAR Biopsi pleura350000.03400000.0 Pemasangan WSD /tube thoracocentesis WSD dg lokal anestesi (OPERATIF)350000.03400000.0 Pemasangan WSD /tube thoracocentesis WSD dg lokal anestesi emergensi/cito (OPERATIF)350000.03400000.0 TABEL 15. PELAYANAN TINDAKAN PERSALINAN JENIS PELAYANANJSTARIF PERSALINAN TANPA PENYULIT (NORMAL)300000.01163000.0 PERSALINAN DENGAN PENYULIT PER VAGINAM602000.02092000.0 INDUKSI PERSALINAN (PARTUS GAGAL)20000.071000.0 TABEL 16. PELAYANAN ASUHAN KEPERAWATAN JENIS PELAYANANJSTARIF ASKEP PASIEN SELF CARE10000.050000.0 ASKEP PASIEN PARSIAL CARE10000.090000.0 ASKEP PADA PASIEN TOTAL CARE10000.0130000.0 ASKEP PADA PASIEN INTENSIVE CARE10000.0160000.0 TABEL 17. PELAYANAN ANESTESI JENIS TINDAKANJSTARIF TINDAKAN MEDIK ANESTESI KECIL350000.0730000.0 TINDAKAN MEDIK ANESTESI SEDANG 350000.01110000.0 TINDAKAN MEDIK ANESTESI BESAR 350000.01870000.0 TINDAKAN MEDIK ANESTESI KHUSUS350000.03390000.0 TABEL 18. PELAYANAN DIKLAT JENIS PELAYANANJSTARIF PRAKTEK DAN PENELITIAN TENAGA KEPERAWATAN / KEBIDANAN : Profesi / orang / minggu60000.0150000.0 Sarjana / orang / minggu40000.0100000.0 Diploma / orang / minggu30000.075000.0 PRAKTEK DAN PENELITIAN TENAGA KESEHATAN LAIN : Profesi / orang / minggu60000.0150000.0 Sarjana / orang / minggu40000.0100000.0 Diploma / orang / minggu30000.075000.0 PRAKTEK DAN PENELITIAN TENAGA NON KESEHATAN : SLTA sederajat / orang / minggu16000.040000.0 Diploma / orang / minggu20000.050000.0 Diploma IV atau S1 / orang / minggu30000.075000.0 S2 / orang / minggu60000.0150000.0 Penelitian DIII / orang / paket50000.0125000.0 Penelitian S1 / orang / paket80000.0200000.0 Penelitian S2 / orang / paket100000.0250000.0 Uji Validitas20000.050000.0 Job Training Keterampilan Khusus (peminatan) / paket 3 bln1000000.02500000.0 Job Training perawat dan bidan / paket 3 bln480000.01200000.0 Job Training tenaga kesehatan lain (gizi, farmasi, radiologi, fisioterapi dll) / paket 3 bln360000.0900000.0 Job Training tenaga non kesehatan (akuntansi, IT, dll) / paket 3 bln300000.0750000.0 Kunjungan siswa SLTA / hari / orang / tempat8000.020000.0 Kunjungan mahasiswa DIII / hari / orang / tempat10000.025000.0 Kunjungan mahasiswa DIV atau S1 / hari / orang / tempat12000.030000.0 Kunjungan mahasiswa S2 / hari / orang / tempat14000.035000.0 Kunjungan / hari (pegawai atau peserta diklat) / orang / tempat24000.060000.0 Kunjungan dari RS lain / paket / kunjungan / orang100000.0250000.0 TABEL 19. SEWA LAHAN JENIS PELAYANANJSTARIF RUANG PERTEMUAN Sewa Ruang Pertemuan/Aula ( paket/hari ) kapasitas max 25 orang 250000.0250000.0 Sewa Ruang Pertemuan/Aula ( paket/hari ) kapasitas max 75 orang 750000.0750000.0 Sewa Ruang Pertemuan/Aula ( paket/hari ) kapasitas max 150 orang 1000000.01000000.0 Biaya Tambahan Fasilitas & Penyiapannya bila diperlukan0.00.0 Proses alih media arsip ke video / disk150000.0150000.0 Sewa Tempat dan Bangunan0.00.0 Areal 1 / M2 / Bln70000.070000.0 Areal 2 / M2 / Bln50000.050000.0 CATATAN SEWA LAHAN: Area 1 adalah untuk area bisnis yang berada di lokasi strategis Area 2 adalah untuk area non bisnis TABEL 20. PELAYANAN HIV-AIDS JENIS PELAYANANJSTARIF Staging klinis ODHA6000.024000.0 Paket VCT Mobile (per kunjungan / org)*75000.0108000.0 Paket in house Training HIV-AIDS**150000.02650000.0 Konseling Pelayanan HIV-AIDS6000.041000.0 CATATAN : Paket VCT Mobile adalah konseling dan pemeriksaan HIV di RS / klinik swasta di Kota Cilacap Paket in house training HIV-AIDS adalah pemberian training, meliputi KIE dasar HIV-AIDS, pemeriksaan, pengelolaan kasus, perawatan, dukungan dan pengobatan ODHA TABEL 21. PELAYANAN HOME CARE JENIS PELAYANAN JSTARIF PELAYANAN MEDIS :0.0 Pemeriksaan dokter umum20000.0110000.0 Pemeriksaan dokter Spesialis25000.0185000.0 Konsultasi dokter Spesialis15000.090000.0 Tindakan Medis : Plebotomi24000.074000.0 Pungsi24000.074000.0 Tranfusi Albumin3000.014000.0 Tranfusi Darah11000.086000.0 Nebulizer 12000.022000.0 Pemberian obat Suppositoria3000.07000.0 Lepas dan atau pasang canul Tracheostomy oleh dokter6000.056000.0 Tindakan Akupunktur10000.060000.0 PELAYANAN KEPERAWATAN :0.00.0 Kunjungan Perawat / Bidan7000.070000.0 Tindakan Keperawatan :0.00.0 Perawatan Luka :0.00.0 PLK Kecil3000.09000.0 PLK Sedang3000.011000.0 PLK Besar4000.014000.0 Pasang NGT/SONDE4000.016000.0 Pasang DC4000.015000.0 Pasang Infus4000.015000.0 Injeksi :3000.012000.0 Suction Sputum3000.07000.0 Manual faeces3000.012000.0 Lavement3000.014000.0 Memandikan pasien3000.014000.0 Mencuci rambut3000.014000.0 Periksa Gula Darah Manual8000.013000.0 Bantuan Pernapasan/RJP34000.044000.0 Oral Higiene1000.06000.0 Vulva Higiene1000.06000.0 Pembersihan telinga1000.06000.0 Evakuasi Serumen prop oleh dokter2000.012000.0 Menunggu pasien oleh perawat / bidan Pukul 07.00 - 14.006000.044000.0 Pukul 14.00 - 21.006000.044000.0 Pukul 21.00 - 07.008000.058000.0 PEMERIKSAAN PENUNJANG EKG 23000.053000.0 Ambil lab : Sampel darah, urin, dan tinja4000.021000.0 Sampel darah3000.014000.0 Sampel urin / tinja3000.09000.0 REHABILITASI MEDIS Kunjungan Fisioterapi 18000.068000.0 Okupasiterapi18000.068000.0 Terapi Wicara20000.095000.0 PELAYANAN AHLI GIZI Kunjungan Ahli Gizi40000.0 Penyusunan menu makanan14000.059000.0 PELAYANAN PSIKOLOGI Kunjungan Psikolog25000.0150000.0 PELAYANAN TRANSPORTASI (AMBULANCE) Transportasi / Ambulance Dalam Kota87500.087500.0 Supir 0.035000.0 Transportasi / Ambulance Luar Kota Supir (1500 / km) Biaya BBM (6000/km) SEWA ALAT87500.0122500.0 Bed / tempat tidur pasien6000.06000.0 Kursi roda3000.03000.0 Kasur dekubitus 8000.08000.0 Tabung O2 (kosong) 8000.08000.0 Regulator 8000.08000.0 Suction13000.013000.0 Nebulizer 13000.013000.0 Tiang Infus2000.02000.0 Urinal2000.02000.0 Pispot2000.02000.0 Peralatan ganti balut8000.08000.0 Catatan Home Care: Tarip sewa alat dihitung perhari. Seluruh biaya tarif belum termasuk obat TABEL 22. PELAYANAN CSSD DAN LOUNDRY JENIS PELAYANAN JSTARIF CSSD DAN LOUNDRY KATAGORI KECIL57400.082000.0 CSSD DAN LOUNDRY KATAGORI SEDANG65800.094000.0 CSSD DAN LOUNDRY BESAR 74200.0106000.0 CATATAN : Peralatan terdiri dari : Duk Lubang Besar Duk penolong Jas OP Klem Pinset Gunting Hack Handel mess Nalpoeder Peritonium Klem Doek Klem Suction Canule Klem Besar Selang Sucsen TABEL 23. PELAYANAN MEDICAL CHECK UP A. Pemeriksaan Kesehatan Dasar JENIS PELAYANANJSTARIF Pemeriksaan Dokter Umum6000.054000.0 Laboratorium : Darah lengkap7000.021000.0 Urin rutin12000.025000.0 Feces rutin12000.021000.0 Golongan darah1500.04500.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 Total243500.0 B. Pemeriksaan Kesehatan Dasar Plus Perempuan JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis Dalam6000.070000.0 Pemeriksaan Dokter spesialis THT (rutin)6000.070000.0 Pemeriksaan Dokter spesialis Mata (funduskopi)38000.0128000.0 Pemeriksaan Dokter spesialis obsgyn (papsmear)17500.056000.0 Laboratorium : Darah lengkap7000.021000.0 Urin rutin12000.025000.0 Feces rutin12000.021000.0 Golongan darah1500.04500.0 SGPT3500.010500.0 SGOT3500.010500.0 Gula darah puasa3500.010500.0 Gula darah 2 jam setelah makan3500.010500.0 Ureum3500.010500.0 Kreatinin4000.012000.0 Kolesterol4000.012000.0 Trigliserid4000.012000.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 EKG simple38000.0128000.0 Total730000.0 C. Pemeriksaan Kesehatan Dasar Plus Laki-laki JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Pemeriksaan Dokter spesialis THT (rutin)6000.070000.0 Pemeriksaan Dokter spesialis Mata (funduskopi)38000.0128000.0 Laboratorium : Darah lengkap7000.021000.0 Urin rutin12000.025000.0 Feces rutin12000.021000.0 Golongan darah1500.04500.0 SGPT3500.010500.0 SGOT3500.010500.0 Gula darah puasa3500.010500.0 Gula darah 2 jam setelah makan3500.010500.0 Ureum3500.010500.0 Kreatinin4000.012000.0 Kolesterol4000.012000.0 Trigliserid4000.012000.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 EKG simple38000.0128000.0 Total674000.0 D. Pemeriksaan Kesehatan Standar Perempuan JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Pemeriksaan Dokter spesialis THT (audiometri)38000.0128000.0 Pemeriksaan Dokter spesialis Mata (funduskopi)38000.0128000.0 Pemeriksaan Dokter spesialis obsgyn (papsmear)17500.056000.0 Pemeriksaan Dokter spesialis gigi6000.070000.0 Laboratorium : Darah Lengkap7000.021000.0 Urin rutin12000.025000.0 Feces rutin12000.021000.0 Golongan darah1500.04500.0 SGPT3500.010500.0 SGOT3500.010500.0 Gula darah puasa3500.010500.0 Gula darah 2 jam setelah makan3500.010500.0 Ureum3500.010500.0 Kreatinin3500.010500.0 Kolesterol4000.012000.0 Trigliserid4000.012000.0 GTT4000.012000.0 Alkali fosfatase3500.010500.0 HDL Cholesterol Direk 4000.012000.0 LDL Cholesterol Direk4000.012000.0 HBS Ag4000.012000.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 EKG38000.0128000.0 Total915000.0 E. Pemeriksaan Kesehatan Standar Laki-laki JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Pemeriksaan Dokter spesialis THT (audiometri)38000.0128000.0 Pemeriksaan Dokter spesialis Mata (funduskopi)38000.0128000.0 Pemeriksaan Dokter spesialis gigi6000.070000.0 Laboratorium : Darah Lengkap7000.021000.0 Urin rutin12000.025000.0 feces rutin12000.021000.0 Golongan darah1500.04500.0 SGPT3500.010500.0 SGOT3500.010500.0 Gula darah puasa3500.010500.0 Gula darah 2 jam setelah makan3500.010500.0 Ureum3500.010500.0 Kreatinin4000.012000.0 Kolesterol4000.012000.0 Trigliserid4000.012000.0 GTT4000.012000.0 Alkali fosfatase3500.08500.0 HDL Cholesterol Direk 4000.012000.0 LDL Cholesterol Direk4000.012000.0 HBS Ag4000.012000.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 EKG38000.0128000.0 Total858500.0 F. Pemeriksaan Kesehatan Lengkap Perempuan JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Pemeriksaan Dokter spesialis THT (audiometri)38000.0128000.0 Pemeriksaan Dokter spesialis Mata (funduskopi)38000.0128000.0 Pemeriksaan Dokter spesialis obsgyn (papsmear)17500.056000.0 Pemeriksaan Dokter spesialis gigi6000.070000.0 Laboratorium : Darah rutin (HMX)9000.027000.0 Urin rutin12000.025000.0 feces rutin12000.021000.0 Golongan darah1500.04500.0 SGPT3500.08500.0 SGOT3500.08500.0 Gula darah puasa3500.08500.0 Gula darah 2 jam setelah makan3500.08500.0 Ureum3500.08500.0 Kreatinin3500.08500.0 Kolesterol4000.09000.0 Trigliserid4000.014000.0 GTT4000.014000.0 Alkali fosfatase3500.010500.0 HDL Cholesterol Direk 4000.012000.0 LDL Cholesterol Direk4000.012000.0 HBS Ag4000.012000.0 Albumin4000.012000.0 Globulin4000.012000.0 Anti HBs4000.012000.0 HBc4000.012000.0 Anti HBc4000.012000.0 VDRL4000.012000.0 TPHA5000.020000.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 EKG38000.0128000.0 Total1002000.0 G. Pemeriksaan Kesehatan Lengkap Laki-laki JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Pemeriksaan Dokter spesialis THT (audiometri)38000.0128000.0 Pemeriksaan Dokter spesialis Mata (funduskopi)38000.0128000.0 Pemeriksaan Dokter spesialis gigi6000.070000.0 Laboratorium : Darah lengkap9000.027000.0 Urin rutin12000.025000.0 feces rutin12000.021000.0 Golongan darah1500.04500.0 SGPT3500.08500.0 SGOT3500.08500.0 Gula darah puasa3500.08500.0 Gula darah 2 jam setelah makan3500.08500.0 Ureum3500.08500.0 Kreatinin3500.08500.0 Kolesterol4000.09000.0 Trigliserid4000.014000.0 GTT4000.014000.0 Alkali fosfatase3500.010500.0 HDL Cholesterol Direk 4000.012000.0 LDL Cholesterol Direk4000.012000.0 HBS Ag4000.012000.0 Albumin4000.012000.0 Globulin4000.012000.0 Anti HBs4000.012000.0 HBc4000.012000.0 Anti HBc4000.012000.0 VDRL4000.012000.0 TPHA5000.020000.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 EKG38000.0128000.0 Total946000.0 J. Pemeriksaan Kesehatan Calon Pegawai JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Laboratorium : Darah lengkap7000.021000.0 Urin rutin12000.025000.0 feces rutin12000.021000.0 Golongan darah1500.04500.0 SGPT3500.010500.0 SGOT3500.010500.0 UREUM3500.010500.0 Asam Urat4000.012000.0 Rontgen foto thoraks57000.0108000.0 Pemeriksaan Dokter spesialis Mata (Visus,TBW,fund)6000.070000.0 Pemeriksaan Kesehatan Jiwa6000.070000.0 Tes Psikologi Industri 6000.070000.0 Administrasi7000.010000.0 Total513000.0 K. Pemeriksaan Kesehatan Sederhana Calon Mahasiswa JENIS PELAYANANJSTARIF Pemeriksaan fisik spesialis penyakit dalam6000.070000.0 Pemeriksaan Spesialis Mata6000.070000.0 Tes Psikologi Pendidikan (sesuai jenis tes) Biaya Administrasi7000.010000.0 Total150000.0 L. Pemeriksaan Kesehatan Calon Mahasiswa dengan Lab. Bebas Narkoba JENIS PELAYANANJSTARIF Pemeriksaan kesehatan Jiwa6000.070000.0 Laboratorium narkoba 5 parameter5000.020000.0 Tes Psikologi Klinis (sesuai jenis tes) Biaya Administrasi7000.010000.0 Total100000.0 M. Surat Keterangan Sehat JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Biaya Administrasi7000.010000.0 Total80000.0 N.Paket General Check UP TKI JENIS PELAYANANJSTARIF Pendaftaran7000.010000.0 Pemeriksaan Fisik6000.070000.0 Rontgen Thorax57000.0108000.0 Pemeriksaan Mata ( buta warna )6000.070000.0 Pemeriksaan Dokter spesialis THT (audiometri)38000.0128000.0 Laboratorium : Hematocrit9000.027000.0 Urin Rutin12000.025000.0 SGOT3500.08500.0 SGPT3500.08500.0 Cholesterol Total4000.09000.0 Golongan Darah1500.04500.0 Hbs Ag4000.012000.0 VDRL4000.012000.0 TPHA5000.020000.0 HIV Rapid117756.0364698.0 Total877198.0 O. Pemeriksaan Kesehatan Calon Pegawai Negeri Sipil JENIS PELAYANANJSTARIF Pemeriksaan Dokter Spesialis penyakit dalam6000.070000.0 Pemeriksaan Dokter spesialis Mata (Visus,TBW,fund)6000.070000.0 Pemeriksaan Dokter Spesialis Gigi6000.070000.0 Laboratorium : Darah lengkap7000.021000.0 Urin rutin12000.025000.0 Golongan darah1500.04500.0 SGPT3500.010500.0 3500.010500.0 UREUM3500.010500.0 Kreatin3500.010500.0 Rontgen foto thoraks57000.0108000.0 Administrasi7000.010000.0 Total420500.0 TABEL 24. PELAYANAN DIAGNOSTIK ELEKTROMEDIK JENIS PELAYANANJSTARIF ANAL TEST38000.0128000.0 ANOSCOPY38000.0128000.0 AUDIOMETRI38000.0128000.0 BIOMETRI38000.0128000.0 CTG/ KEBIDANAN38000.0128000.0 ECG38000.0128000.0 EEG (BRAIN MAPPING)250000.0400000.0 EEG160000.0307000.0 EMG/ BERA38000.0128000.0 FACIALIS PARASE38000.0128000.0 FREE FIELD TEST38000.0128000.0 FUNDUSCOPY38000.0128000.0 GONIUSCOPY38000.0128000.0 KAMPIMETRI38000.0128000.0 OPTHALMOSCOPY38000.0128000.0 PEAK FLOW RATE (PFR)38000.0128000.0 REFRAKSI38000.0128000.0 SLIT LAMP EXAMINATION38000.0128000.0 SPEECH AUDIOMETER40000.0115000.0 TELEMETRI40000.0115000.0 TEST TEMPEL SELEKTIF40000.0115000.0 TIMPANOMETRI40000.0115000.0 TONEDECAY40000.0115000.0 TONOGRAFI40000.0115000.0 TONOMETRI40000.0115000.0 COLONOSKOPI 540000.01350000.0 COLONOSKOPI + BIOPSI578000.02078000.0 RECTOSIGMOIDOSCOPY540000.01350000.0 RECTOSIGMOIDOSCOPY + BIOPSI578000.02078000.0 RECTOSIGMOIDOSCOPY + SCLEROSING578000.02078000.0 USG OBSGIN35000.095000.0 LAPARASKOPI DIAGNOSTIK540000.01350000.0 USG TRANSVAGINAL36000.0115000.0 ESOFAGOGASTRODUODENOSKOPI (EGD)578000.02078000.0 EGD + BIOPSI578000.02078000.0 SCLERO THERAPI VARISES ESOFAGUS (STE)578000.02078000.0 LIGASI VARISES EOFAGUS655000.02155000.0 BRONKOSKOPI DIAGNOSIS540000.01350000.0 BRONKOSKOPI + BIOPSI JARUM578000.02078000.0 BRONKOSKOPI + FORCEP578000.02078000.0 BRONKOSKOPI + BRUSHING578000.02078000.0 BRONKOSKOPI + BIOPSI JARUM + FORCEP578000.02078000.0 BRONKOSKOPI + BIOPSI JARUM + FORCEP + BRUSHING578000.02078000.0 BRONKOSKOPI TERAPI (PENGAMBILAN BENDA ASING, BRONCHIAL TOILET, STOP PERDARAHAN578000.02078000.0 BRONKOSKOPI DENGAN GA612000.01530000.0 TABEL 25. PELAYANAN TINDAKAN MEDIK NON OPERATIF JENIS PELAYANANJSTARIF KECIL ASPIRASI HEMARTROSIS17500.056000.0 ALLERGI TEST / PATCH TEST17500.056000.0 BILAS LAMBUNG17500.056000.0 DILATASI PHIMOSIS17500.056000.0 EKSISI CLAVUS17500.056000.0 EKSISI CONDILOMA ACCUMINATA17500.056000.0 EKSISI GRANULOMA PYOGENIKUM17500.056000.0 EKSISI KELOID < 5 CM17500.056000.0 EKSISI SYRINGOMA17500.056000.0 EKSISI VERUKA VULGARIS17500.056000.0 EKSTRAKSI KALIUM OXALAT17500.056000.0 EKTERPASI KISTA ATEROMA / LIPOMA / GANGLION < 2 CM17500.056000.0 EKTRAKSI KUKU17500.056000.0 EPILASI BULU MATA17500.056000.0 FNA (FINE NEEDLE ASPIRATION)17500.056000.0 INSISI FURUNKEL / ABSES17500.056000.0 IPPB (INTERMITEN POSITIVE PRESSURE BREATHING)17500.056000.0 IRIGASI TELINGA17500.056000.0 KAUSTIK17500.056000.0 LOBULAPLASTI 1 TELINGA17500.056000.0 MANTOUX TEST/ IMUNISASI17500.056000.0 NEKROTOMI17500.056000.0 PAPSMEAR (PENGAMBILAN SEKRET)17500.056000.0 PARASENTENSE TELINGA17500.056000.0 PEMASANGAN / ANGKAT IMPLANT / IUD17500.056000.0 PEMASANGAN / ANGKAT JAHIT SEDERHANA17500.056000.0 PEMASANGAN INFUS UMBILICAL17500.056000.0 PEMASANGAN PISARIUM17500.056000.0 PEMASANGAN BELOG TAMPON17500.056000.0 PEMASANGAN KATETHER 17500.056000.0 PENGOBATAN EPISTAKSIS17500.056000.0 PUNKSI HEMATOMA TELINGA17500.056000.0 REPOSISI TRAUMA HIDUNG SEDERHANA17500.056000.0 SONDAGE CANALCULI LACRIMALIS17500.056000.0 SPOOLING BOLA MATA17500.056000.0 SPOOLING CERUMEN TELINGA17500.056000.0 TINDAKAN BUSINASI17500.056000.0 TINDAKAN CUCI SINUS (PERAWATAN)17500.056000.0 TINDAKAN NEBULIZER17500.056000.0 TINDAKAN PADA KERATOSIS SEBOROIKA17500.056000.0 TINDAKAN ROSER PLASTY17500.056000.0 WATER DRINKING TEST17500.056000.0 KOREKSI VISUS17500.056000.0 KURESTASU ALVEOLITIS/ OSTEOMIELITIS17500.056000.0 FISUR SILEN17500.056000.0 GRINDING, POLISHING, DLL17500.056000.0 AKUPUNTUR17500.056000.0 TERAPI OKUPASI17500.056000.0 PEMASANGAN RENSEL VERBAN17500.056000.0 MOLUSKUM17500.056000.0 EKSPRESI ACNE / KOMEDO17500.056000.0 PASANG SPALK17500.056000.0 CROS INSISI17500.056000.0 CHALENGE TEST17500.056000.0 SLIM SEHER (SUCTION) PER HARI17500.056000.0 ASSEMENT NEUROLOGI17500.056000.0 TES FUNGSI LUHUR (DEMENSIA)17500.056000.0 TES BARTHEL INDEX17500.056000.0 TES MC GILL17500.056000.0 TES AFASIA / AGNOSIA17500.056000.0 TES NEUROPATY PERIFERAL17500.056000.0 INJEKSI INTRA ARTRICULER17500.056000.0 DETEKSI OVULASI17500.056000.0 TEST MMPI/IKJI17500.056000.0 TEST WW EISANK17500.056000.0 TINDAKAN PSIKOTERAPI/KONSELING SUPPORTIF17500.056000.0 TINDAKAN PSIKOTERAPI/KONSELING CBT17500.056000.0 PENKES ( PENDIDIKAN KESEHATAN )17500.056000.0 MANAGEMEN LAKTASI17500.056000.0 Uji Toleransi Air/Water Drinking Test17500.056000.0 Perawatan luka bakar < 25%17500.056000.0 Perawatan Luka / Ganti balutan < 10cm17500.056000.0 Pemasangan Infus 17500.056000.0 Pemasangan Neck Colar17500.056000.0 Pemasangan elastik verban17500.056000.0 Pemasangan Spinal Korset17500.056000.0 Pemberian Obat IM, SC, IV dan IC 17500.056000.0 Edukasi penyuntikan insulin17500.056000.0 Pengambilan darah vena / arteri untuk pemeriksaan laboratorium17500.056000.0 SEDANG EKSISI CHALAZION52000.0129000.0 EKSISI HORDEULUM / GRANULOMA52000.0129000.0 INSISI ABSES GLUTEA / MAMMAE (BESAR)52000.0129000.0 INSISI EPULIS52000.0129000.0 INSISI INTRA ORAL52000.0129000.0 LOBULOPLASTI 2 TELINGA52000.0129000.0 PEMASANGAN / ANGKAT JAHIT LUKA BESAR / KOMPLEKS52000.0129000.0 PEMASANGAN / BUKA GIPS SIRKULAR52000.0129000.0 PEMBERIAN SITOSTATIKA52000.0129000.0 PENGANGKATAN NEURO FIBROMA52000.0129000.0 PENGANGKATAN NEVUS52000.0129000.0 PENGANGKATAN SKIN TAG52000.0129000.0 PENGANGKATAN TANDUR KULIT52000.0129000.0 TINDAKAN BEDAH BEKU52000.0129000.0 TINDAKAN BEDAH FLAP52000.0129000.0 TINDAKAN CRYOSURGERY52000.0129000.0 TINDAKAN DERMABRASI52000.0129000.0 TINDAKAN PUNKSI LUMBAL52000.0129000.0 REPOSISI DISLOKASI MANDIBULA52000.0129000.0 KEMOTHERAPI52000.0129000.0 PEMASANGAN SKIN TRAKSI52000.0129000.0 PHOTOTHERAPI52000.0129000.0 PUNGSI CAVUM DAUGLAS52000.0129000.0 ANGKAT IUD DENGAN PENYULIT52000.0129000.0 PUNGSI ACITES52000.0129000.0 SCALING-POLISHING (PER RAHANG52000.0129000.0 KONTROL ALTA ORTODONTIK LEPASAN (PER RAHANG)52000.0129000.0 TOPIKAL APLIKASI FLUOR (PER RAHANG)52000.0129000.0 KONTROL SPACE MAN\INTAINER/ SPACE REGAINER (PER RA)52000.0129000.0 PREPARASI TUMPATAN INLAI/ ONLAI52000.0129000.0 BLEACHING (PER GIGI)52000.0129000.0 PENJAHITAN PERINEUM (PARTUS LUAR)52000.0129000.0 KAUTERISASI KONDILOMA52000.0129000.0 PENANGANAN SYOK52000.0129000.0 PENANGANAN PERDARAHAN52000.0129000.0 BMP (BONE MARROW PUNKSI)52000.0129000.0 TINDAKAN AMPUTASI JARI (IGD)52000.0129000.0 TINDAKAN TINDIK (PASANG ANTING)52000.0129000.0 TINDAKAN SUBSCAPULA INJEKSI (BRACHACEIA)52000.0129000.0 HIDROTUBASI52000.0129000.0 DILATASI SERVIK52000.0129000.0 INFANT WARMER52000.0129000.0 INCUBATOR52000.0129000.0 Perawatan luka/ganti balutan ( Lk > 10 cm )52000.0129000.0 Pemasangan NGT52000.0129000.0 Pemasanagan Oksigen RM - NRM52000.0129000.0 Cross Incisi52000.0129000.0 Perawatan luka bakar > 25%52000.0129000.0 Pemasangan Infus dengan penyulit52000.0129000.0 Pemasangan Syringe Pump52000.0129000.0 Pemasangan Infus Pump 52000.0129000.0 Tranfusi Darah 52000.0129000.0 Pemasangan Tampon Abses/Fistula52000.0129000.0 Perawatan Colostomi52000.0129000.0 Pemasangan OPA / Mayo Tube52000.0129000.0 Pengambilan sekret vaginal52000.0129000.0 Ekstubasi52000.0129000.0 Pemasangan Laminaria52000.0129000.0 Hecting Perineum > 10 jahitan52000.0129000.0 Perawatan Luka Ulkus/Gangren52000.0129000.0 Manual Placenta52000.0129000.0 Tindakan Scortsteen52000.0129000.0 Pemasangan Implant / IUD52000.0129000.0 Pemasangan Balon Cateter52000.0129000.0 Penanganan Perdarahan Ante - Post Partum52000.0129000.0 Resusitasi Jantung Paru Sederhana52000.0129000.0 Pemasangan Cateter Urine dgn penyulit52000.0129000.0 Perawatan AV Shunt52000.0129000.0 Bronchial Washing52000.0129000.0 Lavement / Pemberian Enema52000.0129000.0 Pemeriksaan Pulse Oxymetri52000.0129000.0 Pengambilan Corpus Alienum52000.0129000.0 Blass Punksi52000.0129000.0 BESAR EKSISI PTERGIUM121000.0275000.0 EKTIRPASI FIBROMA121000.0275000.0 ENUCLEATIE KISTA121000.0275000.0 INJEKSI HAEMOROID (TERMASUK OBAT)121000.0275000.0 INJEKSI VARISES (TERMASUK OBAT)121000.0275000.0 INSISI MUCOCELE121000.0275000.0 OPERCULECTOMY121000.0275000.0 PEMASANGAN TRAKSI VERTEBRA (TULANG BELAKANG)121000.0275000.0 PEMASANGAN WSD121000.0275000.0 PENUTUPAN OROANTRAL FISTULA121000.0275000.0 PUNKSI / IRIGASI PLEURA121000.0275000.0 PUNKSI SUMSUM TULANG121000.0275000.0 REPOSISI DENGAN ANESTESI LOKAL121000.0275000.0 TINDAKAN DEEPENING SULCUS121000.0275000.0 TINDAKAN MANUAL PLASENTA121000.0275000.0 ANGKAT IUD DENGAN NARKOSE121000.0275000.0 CIRCUMSISI121000.0275000.0 REPOSISI INVERSIO UTERI121000.0275000.0 TINDAKAN PADA ATONIA UTERI121000.0275000.0 PENJAHITAN LASERASI JALAN LAHIR (SERVIK, PORSIO)121000.0275000.0 REHECTING DEHISENSI121000.0275000.0 KURETASE TANPA NARKOSE121000.0275000.0 EKSISI KELOID > 5 CM121000.0275000.0 EKTIRPASI KISTA ATERIUM / LIPOMA / GANGLION > 2 CM121000.0275000.0 PERSPIRASI / SENSIBILITAS121000.0275000.0 TINDAKAN INJEKSI INTRATECHAL121000.0275000.0 INSEMINASI BUATAN SUAMI121000.0275000.0 SONO HISTERO SALFINGOGRAFI121000.0275000.0 Jahit Tendon Ruptur121000.0275000.0 Jahit luka > 20 jahitan ( luka tak beraturan )121000.0275000.0 Perawatan luka bakar > 50%121000.0275000.0 IPPB : Bagging 121000.0275000.0 Penanganan Shock 121000.0275000.0 Manajemen Atonia Uteri121000.0275000.0 Manajemen PEB121000.0275000.0 Resusitasi Jantung Paru kompleks121000.0275000.0 Perawatan luka > 30 menit 121000.0275000.0 Resusitasi Jantuing Paru Bayi komplek121000.0275000.0 Pemberian tranfusi pada bayi/anak121000.0275000.0 KHUSUS PEMASANGAN ENDOTRACHEAL TUBE (ET)150000.0457000.0 VENTILATOR150000.0457000.0 DEFIBRILASI150000.0457000.0 PEMASANGAN TRANSCUTANEUS PACE MAKER (TPM)150000.0457000.0 PEMASANGAN CENTRAL VENOUS PRESSURE (CVP)150000.0457000.0 PEMASANGAN HEMODIALISIS (HD) CATHETER150000.0457000.0 PEMASANGAN VENA DALAM150000.0457000.0 Vena Sectie 150000.0457000.0 Perawatan luka bakar > 75%150000.0457000.0 Pemasangan CPAP150000.0457000.0 Pemasangan CVC150000.0457000.0 Punksi Asites Pemasangan Arteri Line150000.0457000.0 Pemberian terapy Trombolitik150000.0457000.0 DOKTER SPESIALIS PARU JENIS PELAYANANJSTARIF KECIL Konsultasi/ edukasi berhenti merokok17500.056000.0 Konsultasi/ edukasi batuk17500.017500.0 SEDANG Edukasi terapi inhalasi52000.0129000.0 BESAR Spirometri121000.0275000.0 Konsultasi dan bimbingan program berhenti merokok121000.0275000.0 Fine needle aspiration Biopsy/ FNAB121000.0275000.0 Pungsi pleura / needle thoracocentesis diagnosis121000.0275000.0 Spirometri + bronkodilator test121000.0275000.0 Aspirasi pneumothorax121000.0275000.0 KHUSUS Reposisi WSD150000.0457000.0 Spooling WSD150000.0457000.0 Lepas WSD150000.0457000.0 Rehecting WSD150000.0457000.0 Incisi emfisema subcutis150000.0457000.0 Spirometri + Uji provokasi bronkus150000.0457000.0 USG paru/thorax150000.0457000.0 Baging / resusitasi dengan masker oksigen / ambu bag150000.0457000.0 Pungsi pleura / needle thoracocentesis evakuasi150000.0457000.0 Pemasangan mini WSD150000.0457000.0 Injeksi intra cavum pleura150000.0457000.0 Pungsi pleura/ needle thoracocentesis evakuasi emergensi/cito150000.0457000.0 DOKTER SPESIALIS SARAF JENIS PELAYANANJSTARIF SEDANG Tes Fungsi luhur (diagnostik)52000.0129000.0 BESAR Lumbal Punksi (di poliklinik)121000.0275000.0 Spinal nerve root injection121000.0275000.0 Trigger Point Injections (TPIs) Manual121000.0275000.0 Carpal Tunnel Syndrome Manual (injections)121000.0275000.0 De Quervain Syndrome Manual ( inj.)121000.0275000.0 Tennis Elbow Manual (injections)121000.0275000.0 Tendinitis Bicipitalis Manual (injections)121000.0275000.0 Acromio Clavicular Joint (injections)121000.0275000.0 Fascitis Plantaris Manual (injections)121000.0275000.0 KHUSUS Lumbal Punksi 150000.0457000.0 TCD (Trans cranial doppler) 150000.0457000.0 Carpal Tunnel Syndrome USG( injections)150000.0457000.0 De Quervin Syndrome USG ( injections )150000.0457000.0 Guyon Syndrome Manual (injections)150000.0457000.0 Guyon Syndrome USG (injection)150000.0457000.0 Tennis Elbow USG (injections)150000.0457000.0 Tendinitis Bicipitalis USG (injections)150000.0457000.0 Trigger Finger Manual (injections)150000.0457000.0 Sacroiliac Joint Disfunction USG (injections)150000.0457000.0 Sacral Epidural Injection Manual (injections)150000.0457000.0 Sacral Epidural Injection Manual (injections) 150000.0457000.0 Piriformis Syndrom USG (injections)150000.0457000.0 DOKTER GIGI JENIS PELAYANANJSTARIF KECIL Cabut Gigi SulungTopikal17500.056000.0 Perawatan Pulpa dan sal akar Capping17500.056000.0 Perawatan pulpa dan sal akar Eugenol, TKF, chkf17500.056000.0 Hecting / Jumlah17500.056000.0 Drainase/ Open Bor17500.056000.0 Konsul Post Op/ Incisi/ Exo17500.056000.0 SEDANG Penambalan Glass Ionomer Kecil52000.0129000.0 Penambalan Glass Ionomer Besar52000.0129000.0 Penambalan Komposit LC Kecil52000.0129000.0 Penambalan Komposit LC Besar52000.0129000.0 Penambalan Amalgam Kecil52000.0129000.0 Penambalan Amalgam Besar52000.0129000.0 Cabut Gigi Sulung Injeksi52000.0129000.0 Cabut Gigi Tetap Normal52000.0129000.0 Gingivectomy per gigi52000.0129000.0 Frenectomy52000.0129000.0 Incisi epulis52000.0129000.0 Reaming, Filing Gigi Tunggal/ Depan52000.0129000.0 Pengisian Saluran Akar52000.0129000.0 Scalling per rahang52000.0129000.0 Scalling per rahang52000.0129000.0 Akrilik gigi Selanjutnya52000.0129000.0 Termoplastik selanjutnya52000.0129000.0 BESAR Cabut Gigi Tetap Penyulit121000.0275000.0 Incisi abses121000.0275000.0 Overculectomy121000.0275000.0 Reaming, Filling Gigi Jamak/ Belakang121000.0275000.0 Pasak Cor121000.0275000.0 Pasak Fiber121000.0275000.0 Veneer Komposit Langsung121000.0275000.0 Akrilik gigi 1121000.0275000.0 Reparasi121000.0275000.0 KHUSUS Odontectomy Kl I150000.0457000.0 Odontectomy Kl II150000.0457000.0 Odontectomy Kl III150000.0457000.0 Alveolectomy/ Regio150000.0457000.0 Kuretase per Regio150000.0457000.0 Splinting Per Regio150000.0457000.0 Bone Graft 1-3 Gigi150000.0457000.0 Inlay, Onlay150000.0457000.0 Mahkota Penuh Akrilik/ Komposit150000.0457000.0 Mahkota Penuh Porselen150000.0457000.0 Veneer Porselen150000.0457000.0 Termoplastik 1150000.0457000.0 Frame Sebagian150000.0457000.0 Frame Penuh150000.0457000.0 Braidge/ Jembatan Porselen/ Unit150000.0457000.0 Baidge/ Jembatan Akrilik/ Unit150000.0457000.0 FRC150000.0457000.0 Implant150000.0457000.0 DOKTER SPESIALIS KESEHATAN JIWA JENIS PELAYANANJSTARIF KECIL Test grafis17500.056000.0 Test MMSE17500.056000.0 Test CDT ( Clock Drawing Test )17500.056000.0 Test untuk depresi(BDI,HDRS,CDI)17500.056000.0 Test untuk kecemasan (BAI, HARS)17500.056000.0 Test untuk Autis17500.056000.0 Test untuk ADHD17500.056000.0 Test untuk narkoba ( Manson's Test )17500.056000.0 Test untuk obsesif kompulsif ( YBOC )17500.056000.0 Test untuk gangguan bipolar17500.056000.0 Psikoterapi sederhana perkunjungan17500.056000.0 SEDANG Psikoterapi sedang perkunjungan52000.0129000.0 Psikoterapi komplek perkunjungan52000.0129000.0 Test WW-Eysenk52000.0129000.0 BESAR Paket pemeriksaan untuk surat sehat jiwa121000.0275000.0 Test MMPI/TKMI121000.0275000.0 KHUSUS ECT ( Per tindakan )150000.0457000.0 Permintaan pelayanan extra RS (per kunjungan ) - Forensik150000.0457000.0 - Non forensik150000.0457000.0 TABEL 26. PELAYANAN HEMODIALISA JENIS PELAYANANJSTARIF PELAYANAN HEMODIALISA110000.0300000.0 BUPATI CILACAP TATTO SUWARTO PAMUDJI