_id KELAS JASA RUMAH SAKIT TOTAL 1 "" KAMAR "" 2 VIP I 600000.0 800000.0 3 VIP II 500000.0 700000.0 4 Utama I 300000.0 450000.0 5 Utama II 250000.0 350000.0 6 Kelas I 165000.0 250000.0 7 Kelas II 125000.0 200000.0 8 Kelas III 75000.0 140000.0 9 Perinatologi 75000.0 95000.0 10 ICU / ICCU / PICU / NICU 490000.0 550000.0 11 HCU / IMD 125000.0 200000.0 12 "" "" "" 13 TABEL 2. "" "" 14 PELAYANAN RAWAT JALAN (PEMERIKSAAN DAN KONSULTASI) "" "" 15 "" "" "" 16 JENIS PELAYANAN JS TARIF 17 Pemeriksaan dokter spesialis (poliklinik) 6000.0 70000.0 18 Pemeriksaan dokter umum (poliklink) 6000.0 54000.0 19 Pemeriksaan dokter gigi spesialis (poliklinik) 10000.0 74000.0 20 Pemeriksaan dokter gigi (poliklinik) 10000.0 58000.0 21 Konsultasi dokter spesialis (poliklinik) 6000.0 70000.0 22 Konsultasi psikologi (poliklinik) 6000.0 41000.0 23 Asuhan gizi (poliklinik) 6000.0 41000.0 24 Konsultasi farmasi (poliklinik) 6000.0 41000.0 25 "" "" "" 26 TABEL 3. "" "" 27 PELAYANAN RAWAT DARURAT (PEMERIKSAAN DAN KONSULTASI) "" "" 28 "" "" "" 29 JENIS PELAYANAN JS TARIF 30 Pemeriksaan dokter umum 25000.0 105000.0 31 Konsultasi dokter spesialis 10000.0 115000.0 32 "" "" "" 33 TABEL 4. "" "" 34 PELAYANAN RAWAT INAP (VISITE DAN KONSULTASI) "" "" 35 "" "" "" 36 JENIS PELAYANAN JS TARIF 37 Visite dokter spesialis (rawat inap) 9000.0 81000.0 38 Visite dokter umum (rawat inap) 9000.0 59000.0 39 Konsultasi dokter spesialis (rawat inap) 9000.0 81000.0 40 Konsultasi farmasi 8000.0 46500.0 41 Konsultasi psikologi 8000.0 46500.0 42 Konsultasi dokter di atas meja operasi 0.0 210000.0 43 Konsultasi dokter (via telephone) 20000.0 60000.0 44 "" "" "" 45 TABEL 5. "" "" 46 PELAYANAN REKAM MEDIS, MEDIKOLEGAL DAN ADMINISTRASI "" "" 47 "" "" "" 48 JENIS PELAYANAN JS TARIF 49 Registrasi Rawat Jalan 6000.0 10000.0 50 Registrasi Rawat Darurat 6000.0 10000.0 51 Registrasi Rawat Inap 12000.0 20000.0 52 Kartu Berobat Pasien 5000.0 6000.0 53 Visum et repertum 30000.0 100000.0 54 Resume Medis Khusus 10000.0 50000.0 55 Administrasi Pelayanan Rawat Inap 6000.0 10000.0 56 "" "" "" 57 TABEL 6. "" "" 58 PELAYANAN FARMASI "" "" 59 "" "" "" 60 JENIS PELAYANAN JS TARIF 61 Pelayanan Farmasi klinik Rawat Jalan 3000.0 15000.0 62 Pelayanan farmasi non klinik 5000.0 13000.0 63 One day dose dispensing 3000.0 20000.0 64 dosis unit dispensing 10000.0 50000.0 65 Dispensing Total Parenteral Nutrition (TPN) 50000.0 163000.0 66 IV Admixture & Rekonstitusi sediaan non sitostatika 10000.0 25000.0 67 IV Admixture & Rekonstitusi sediaan sitostatika 75000.0 241000.0 68 evaluasi & Pemantauan penggunaan obat 10000.0 350000.0 69 MESO 10000.0 209000.0 70 Pemantauan kadar obat dalam darah 50000.0 249000.0 71 "" "" "" 72 CATATAN : "" "" 73 Pelayanan Farmasi klinik Rawat Jalan adalah per lembar resep "" "" 74 Pelayanan farmasi non klinik adalah per periode opname "" "" 75 One day dose dispensing adalah per lembar resep "" "" 76 Dosis unit dispensing adalah per hari per pasien "" "" 77 Dispensing Total Parenteral Nutrition (TPN) adalah per obat "" "" 78 IV Admixture & Rekonstitusi sediaan non sitostatika adalah per obat "" "" 79 IV Admixture & Rekonstitusi sediaan sitostatika adalah per obat "" "" 80 evaluasi & Pemantauan penggunaan obat adalah per obat "" "" 81 MESO adalah per pasien "" "" 82 Pemantauan kadar obat dalam darah adalah satu sampel pemeriksaan "" "" 83 "" "" "" 84 "" "" "" 85 "" "" "" 86 "" "" "" 87 "" "" "" 88 "" "" "" 89 TABEL 7. "" "" 90 PELAYANAN LABORATORIUM "" "" 91 "" "" "" 92 JENIS PELAYANAN JS TARIF 93 DARAH "" "" 94 DARAH RUTIN 5000.0 15000.0 95 DARAH LENGKAP (DARAH RUTIN + HITUNG JENIS LEKOSIT) 7000.0 21000.0 96 DARAH LENGKAP + RETIKULOSIT 9000.0 27000.0 97 LAJU ENDAPAN DARAH 2000.0 6000.0 98 LIMFOSIT PLASMA BIRU 2000.0 6000.0 99 PEMBEKUAN MASA 1500.0 4500.0 100 PERDARAHAN MASA 1500.0 4500.0 101 PENETAPAN GOLONGAN DARAH A, B, O, RH, DLL 1500.0 4500.0 102 FILARIA 2000.0 6000.0 103 MALARIA 2000.0 6000.0 104 "" "" "" 105 ANALISA URINE "" "" 106 URINALISIS 12000.0 25000.0 107 PROTEIN BENCE JONES 2000.0 7000.0 108 PROTEIN ESBACH 2000.0 7000.0 109 MIKROALBUMIN 11000.0 21000.0 110 "" "" "" 111 FECES "" "" 112 FECES RUTIN 12000.0 21000.0 113 DARAH SAMAR 3000.0 9000.0 114 "" "" "" 115 KIMIA DARAH "" "" 116 ASAM LAKTAT 4000.0 9000.0 117 ASAM URAT 4000.0 12000.0 118 AMILASE 4000.0 12000.0 119 ANALISA GAS DARAH 8000.0 24000.0 120 CREATININ, KINASE, MB ISO ENZYM 4000.0 12000.0 121 CREATININ,PHOSPOKINASE CPK-NAC=CREATININ KINASE-CK 4000.0 12000.0 122 LAKTAT DEHIDROGENASE/LDH 4000.0 12000.0 123 LIPASE 4000.0 12000.0 124 TROPONIN T/I 4000.0 12000.0 125 KALIUM 4000.0 12000.0 126 KALSIUM 4000.0 12000.0 127 KLORIDA 4000.0 12000.0 128 KLORIDA URINE 4000.0 12000.0 129 MAGNESIUM 4000.0 12000.0 130 NATRIUM 4000.0 12000.0 131 NATRIUM URINE 4000.0 12000.0 132 "" "" "" 133 DIABETES "" "" 134 HB GLICOSILAT / HBA1C 4000.0 12000.0 135 GLUKOSA DARAH PUASA 3500.0 10500.0 136 GLUKOSA 2 JAM PP 3500.0 10500.0 137 GLUKOSA DARAH SEWAKTU 3500.0 10500.0 138 GLUKOSA KLIK/POC (POINT OF CARE) 3 4000.0 12000.0 139 GLUKOSA TOLERANSI TEST 4000.0 12000.0 140 "" "" "" 141 FUNGSI HATI "" "" 142 ALBUMIN 4000.0 12000.0 143 ALKALI FOSFATASE 3500.0 10500.0 144 BILIRUBIN TOTAL 3500.0 10500.0 145 BILIRUBIN DIRECT 3500.0 10500.0 146 PROTEIN TOTAL, PENETAPAN KUANTITATIF 3500.0 10500.0 147 GLUTAMAT PIRUVAT TRANSMINASE/ GPT = ALT 3500.0 10500.0 148 TRANSFERASE / AST 3500.0 10500.0 149 "" "" "" 150 PANEL BESI "" "" 151 SERUM BESI 4000.0 13000.0 152 TIBC 4000.0 13000.0 153 "" "" "" 154 FUNGSI GINJAL "" "" 155 KREATININ 3500.0 10500.0 156 CREATININ CLEARANCE 4000.0 12000.0 157 UREA/BUN 3500.0 10500.0 158 "" "" "" 159 ANALISA LEMAK "" "" 160 KOLESTEROL HIGH DENSITY LIPOPROTEIN (HDL) 4000.0 12000.0 161 KOLESTEROL LOW DENSITY LIPOPROTEIN (LDL) 4000.0 12000.0 162 KOLESTEROL TOTAL 4000.0 12000.0 163 TRIGLISERIDA 4000.0 12000.0 164 "" "" "" 165 HEMATOLOGI "" "" 166 BACAAN SUMSUM TULANG 8500.0 25500.0 167 MORFOLOGI SEL 8500.0 25500.0 168 "" "" "" 169 SEROLOGI "" "" 170 ANTI HCV 4000.0 12000.0 171 ANTI HIV 5000.0 15000.0 172 ANTI TB 6000.0 18000.0 173 ANTILAPTOSPIRA IG M 4000.0 12000.0 174 ASTO 4000.0 12000.0 175 DENGUE BLOT IGG 8000.0 24000.0 176 DENGUE NS 1 10000.0 30000.0 177 FAKTOR RHEMATOID 4000.0 12000.0 178 HBS AG 4000.0 12000.0 179 SALMONELA IG M 3500.0 10500.0 180 VDRL 4000.0 12000.0 181 WIDAL 3500.0 10500.0 182 SALMONELA TUBEX 4000.0 12000.0 183 ANTI Hbs Ag 4000.0 12000.0 184 "" "" "" 185 MIKROBIOLOGI "" "" 186 SEDIAAN LANGSUNG PEWARNAAN BTA 2000.0 7000.0 187 SEDIAAN LANGSUNG PEWARNAAN GRAM 2000.0 7000.0 188 BIAKAN MIKRO ORGANISME DENGAN RESISTENSI 11000.0 51000.0 189 BIAKAN PUS DENGAN RESISTENSI 11000.0 51000.0 190 "" "" "" 191 CAIRAN TUBUH "" "" 192 ANALISA CAIRAN SENDI 4000.0 12000.0 193 ANALISA CAIRAN OTAK 4000.0 12000.0 194 ANALISA CAIRAN PLEURA 4000.0 12000.0 195 ANALISA SEMEN/ SPERMA 4000.0 12000.0 196 "" "" "" 197 DRUG MONITORING "" "" 198 AMPHETAMINE 1000.0 3000.0 199 BENZODIAZEPIN 1000.0 3000.0 200 MARIYUANA 1000.0 3000.0 201 METAMPHETAMIN 1000.0 3000.0 202 MORPHINE 1000.0 3000.0 203 "" "" "" 204 HEMOSTASIS "" "" 205 FIBRINOGEN, PENETAPAN KADAR 5000.0 15000.0 206 PROTROMBIN PLASMA, MASA 4000.0 12000.0 207 THROMBOPLASTIN, MASA PARTIAL TERAKTIVASI 3500.0 10500.0 208 "" "" "" 209 IMUNOLOGI "" "" 210 TES KEHAMILAN 2000.0 6000.0 211 "" "" "" 212 PELAYANAN BANK DARAH "" "" 213 COOMB'S, PERCOB. DIREK, INDIREK 10000.0 25000.0 214 DARAH (PER KANTONG) 47500.0 47500.0 215 PEMBUATAN PRC 47500.0 142500.0 216 UJI SILANG MAYOR/MINOR 10000.0 25000.0 217 "" "" "" 218 PARAMETER BARU "" "" 219 Anti HAV 5000.0 25000.0 220 CRP 5000.0 20000.0 221 Tropinin I Kuantitatif 15000.0 40000.0 222 CKMB Mass 15000.0 40000.0 223 Nitro pro BNP 15000.0 40000.0 224 CEA 5000.0 25000.0 225 AFP 5000.0 25000.0 226 PSA 5000.0 25000.0 227 CD4 SUBSIDI 5000.0 20000.0 228 CD4 NON SUBSIDI 5000.0 20000.0 229 "" "" "" 230 TABEL 8. "" "" 231 PELAYANAN RADIOLOGI "" "" 232 "" "" "" 233 JENIS PELAYANAN JS TARIF 234 SEDERHANA "" "" 235 THORAX AP / PA 57000.0 108000.0 236 THORAX LATERAL 57000.0 108000.0 237 THORAX OBLIQ 57000.0 108000.0 238 THORAX TOP LORDOTIK 57000.0 108000.0 239 ABDOMEN AP / SUPINE 57000.0 108000.0 240 ABDOMEN LLD 57000.0 108000.0 241 ABDOMEN ERECT / SETENGAH DUDUK 57000.0 108000.0 242 ABDOMEN LATERAL 57000.0 108000.0 243 PELVIS AP 57000.0 108000.0 244 HIP JOINT AP / L DEXTRA 57000.0 108000.0 245 HIP JOINT AP / L SINISTRA 57000.0 108000.0 246 FEMUR AP/L DEXTRA 57000.0 108000.0 247 FEMUR AP / L SINISTRA 57000.0 108000.0 248 GENU AP/L DEXTRA 57000.0 108000.0 249 GENU AP /L SINISTRA 57000.0 108000.0 250 CRURIS AP / L DEXTRA 57000.0 108000.0 251 CRURIS AP / L SINISTRA 57000.0 108000.0 252 ANKLE JOINT AP / L DEXTRA 57000.0 108000.0 253 ANKLE JOINT AP / L SINISTRA 57000.0 108000.0 254 PEDIS AP / OBLIQ DEXTRA 57000.0 108000.0 255 PEDIS AP / OBLIQ SINISTRA 57000.0 108000.0 256 CALCANEUS DEXTRA 57000.0 108000.0 257 CALCANEUS SINISTRA 57000.0 108000.0 258 CLAVICULA DEXTRA 57000.0 108000.0 259 CLAVICULA SINISTRA 57000.0 108000.0 260 SCAPULA DEXTRA 57000.0 108000.0 261 SCAPULA SINISTRA 57000.0 108000.0 262 SHOULDER JOINT DEXTRA 57000.0 108000.0 263 SHOULDER JOINT SINISTRA 57000.0 108000.0 264 HUMERUS AP / L DEXTRA 57000.0 108000.0 265 HUMERUS AP / L SINISTRA 57000.0 108000.0 266 HUMERUS AXIAL DEXTRA 57000.0 108000.0 267 HUMERUS AXIAL SINISTRA 57000.0 108000.0 268 CUBITI AP / L DEXTRA 57000.0 108000.0 269 CUBITI AP / L SINISTRA 57000.0 108000.0 270 ANTEBRAKHI AP / DEXTRA 57000.0 108000.0 271 ANTEBRAKHI AP/ L SINISTRA 57000.0 108000.0 272 WIRST JOINT AP / L DEXTRA 57000.0 108000.0 273 WIRST JOINT AP / L SINISTRA 57000.0 108000.0 274 MANUS AP / OBLIQ DEXTRA 57000.0 108000.0 275 MANUS AP / OBLIQ SINISTRA 57000.0 108000.0 276 KEPALA AP 57000.0 108000.0 277 KEPALA LATERAL 57000.0 108000.0 278 BASIS CRANII 57000.0 108000.0 279 OS MAXILARIS 57000.0 108000.0 280 OS ZIGOMATIKUM 57000.0 108000.0 281 SELLA TURSICA 57000.0 108000.0 282 SPN WATER'S 57000.0 108000.0 283 SPN FACE BONE LATERAL 57000.0 108000.0 284 TOWN'S 57000.0 108000.0 285 0S NASALE 57000.0 108000.0 286 MANDIBULA AP 57000.0 108000.0 287 MANDIBULA EISLER 57000.0 108000.0 288 RHESE/ FORAMEN OPTICUM DEXTRA 57000.0 108000.0 289 RHESE / FORAMEN OPTICUM SINISTRA 57000.0 108000.0 290 OS PALATUM 57000.0 108000.0 291 TMJ OPEN MOUTH DEXTRA 57000.0 108000.0 292 TMJ OPEN MOUTH SINISTRA 57000.0 108000.0 293 TMJ CLOSE MOUTH DEXTRA 57000.0 108000.0 294 TMJ CLOSE MOUTH SINISTRA 57000.0 108000.0 295 SCHULER'S OS MASTOID AIR CELL SINISTRA 57000.0 108000.0 296 CERVICAL AP 57000.0 108000.0 297 CERVICAL LATERAL 57000.0 108000.0 298 CERVICAL OBLIQ DEXTRA 57000.0 108000.0 299 CERVICAL OBLIQ SINISTRA 57000.0 108000.0 300 THORACAL AP 57000.0 108000.0 301 THORACAL LATERAL 57000.0 108000.0 302 THORACAL OBLIQ DEXTRA 57000.0 108000.0 303 THORACAL OBLIQ SINISTRA 57000.0 108000.0 304 LUMBAL AP 57000.0 108000.0 305 LUMBAL LATERAL 57000.0 108000.0 306 LUMBAL OBLIQ DEXTRA 57000.0 108000.0 307 LUMBAL OBLIQ SINISTRA 57000.0 108000.0 308 T - L AP 57000.0 108000.0 309 T - L LATERAL 57000.0 108000.0 310 T - L OBLIQ DEXTRA 57000.0 108000.0 311 T - L OBLIQ SINISTRA 57000.0 108000.0 312 SACRUM AP 57000.0 108000.0 313 SACRUM OBLIQ DEXTRA 57000.0 108000.0 314 SACRUM OBLIQ SINISTRA 57000.0 108000.0 315 SACRUM LATERAL 57000.0 108000.0 316 L - S AP 57000.0 108000.0 317 L - S LATERAL 57000.0 108000.0 318 L - S OBLIQ DEXTRA 57000.0 108000.0 319 L - S OBLIQ SINISTRA 57000.0 108000.0 320 COCIGEUS AP 57000.0 108000.0 321 COCIGEUS LATERAL 57000.0 108000.0 322 COCIGEUS OBLIQ DEXTRA 57000.0 108000.0 323 COCIGEUS OBLIQ SINISTRA 57000.0 108000.0 324 GIGI SERI ATAS 27000.0 78000.0 325 GIGI SERI BAWAH 27000.0 78000.0 326 GIGI INCICIVUS ATAS KANAN 27000.0 78000.0 327 GIGI INCICIVUS ATAS KIRI 27000.0 78000.0 328 GIGI INCICIVUS BAWAH KANAN 27000.0 78000.0 329 GIGI INCICIVUS BAWAH KIRI 27000.0 78000.0 330 GIGI PRE MOLAR ATAS/ KANAN 27000.0 78000.0 331 GIGI PRE MOLAR ATAS KIRI 27000.0 78000.0 332 GIGI PRE MOLAR BAWAH KANAN 27000.0 78000.0 333 GIGI PRE MOLAR BAWAH KIRI 27000.0 78000.0 334 GIGI MOLAR ATAS KANAN 27000.0 78000.0 335 GIGI MOLAR ATAS KIRI 27000.0 78000.0 336 GIGI MOLAR BAWAH KANAN 27000.0 78000.0 337 GIGI MOLAR BAWAH KIRI 27000.0 78000.0 338 "" "" "" 339 NON SEDERHANA "" "" 340 BNO IVP 287000.0 540000.0 341 CYSTOGRAPHY 230000.0 483000.0 342 URETHROGRAPHY 229672.0 482352.0 343 RPG 287000.0 540000.0 344 HSG 230000.0 483000.0 345 COR ANALISA 172254.0 377214.0 346 BNO SONDE 114836.0 319796.4 347 COLON IN LOOP 344508.0 587468.0 348 OMD 229672.0 472632.0 349 OESHOPAGUSGRAPHY 172254.0 415214.0 350 APENDIKOGRAM 114836.0 357796.0 351 FISTULOGRAPHY 172254.0 415214.0 352 BRAIN CT SCAN 572000.0 1009000.0 353 THORAX CT SCAN 572000.0 1009000.0 354 ABDOMEN CT SCAN 572000.0 1009000.0 355 PELVIS CT SCAN 572000.0 1009000.0 356 ORBITA CT SCAN 572000.0 1009000.0 357 SPN CT SCAN 572000.0 1009000.0 358 NASHOPHARYNG CT SCAN 572000.0 1009000.0 359 CERVICAL CT SCAN 572000.0 1009000.0 360 THORACAL CT SCAN 572000.0 1009000.0 361 LUMBAL CT SCAN 572000.0 1009000.0 362 EXTREMITAS CT SCAN 572000.0 1009000.0 363 CT SCAN KEPALA KONTRAS 700000.0 1254000.0 364 CT SCAN THORAX KONTRAS 700000.0 1254000.0 365 CT SCAN ABDOMEN KONTRAS 700000.0 1254000.0 366 CT NASHOPHARYNG KONTRAS 700000.0 1254000.0 367 USG 4 D 208000.0 533000.0 368 USG MAMAE 208000.0 533000.0 369 USG ABDOMEN 208000.0 533000.0 370 USG THORAX 208000.0 533000.0 371 USG TESTIS 208000.0 533000.0 372 USG SUPERFISIAL 208000.0 533000.0 373 USG TIROID 208000.0 533000.0 374 DOPPLER 208000.0 533000.0 375 USG GUIDING 208000.0 533000.0 376 PANORAMIX 115000.0 315000.0 377 "" "" "" 378 TABEL 9. "" "" 379 PELAYANAN REHABILITASI MEDIK "" "" 380 "" "" "" 381 JENIS PELAYANAN JS TARIF 382 SHORT WAVE DIATHERMI (SWD) 20000.0 47000.0 383 MICRO WAVE DIATHERMI (MWD) 20000.0 47000.0 384 INFRA RED (IR)/ ULTRA VIOLET (UV) 20000.0 47000.0 385 EXERCISE/ TERAPI MANIPULASI 20000.0 47000.0 386 ULTRA SONIC THERAPI 20000.0 47000.0 387 ELECTRICAL STIMULATION 20000.0 47000.0 388 ELECTRICAL TRACTION 25000.0 52000.0 389 PARAFIN BATH 20000.0 47000.0 390 LASER 20000.0 47000.0 391 MLDV 20000.0 101000.0 392 POSTURAL DRAINAGE 20000.0 47000.0 393 SENAM HAMIL 20000.0 58000.0 394 TERAPI WICARA 6000.0 63000.0 395 "" "" "" 396 "" "" "" 397 "" "" "" 398 TABEL 10. "" "" 399 PELAYANAN PSIKOLOGI "" "" 400 "" "" "" 401 JENIS PELAYANAN JS TARIF 402 TES KECERDASAN (PEMAHAMAN) 6000.0 20000.0 403 TES KECERDASAN (PENALARAN VERBAL) 6000.0 20000.0 404 TES KECERDASAN (RANEN) 12000.0 57000.0 405 TES KECERDASAN (KEMAMPUAN NUMERIK) 7000.0 28000.0 406 TES KECERDASAN (TEKNIS PRAKTIS) 7000.0 28000.0 407 TES KECERDASAN 7000.0 31000.0 408 TES KECERDASAN (DAYA INGAT) 7000.0 28000.0 409 TES KECERDASAN (CODING) 7000.0 28000.0 410 TES KECERDASAN (BINET - PER KUNJUNGAN) 14000.0 89000.0 411 TES KECERDASAN (WISC - PER KUNJUNGAN) 14000.0 89000.0 412 TES KECERDASAN (WAIS - PER KUNJUNGAN) 14000.0 89000.0 413 TES KECERDASAN (IST) 14000.0 109000.0 414 TES KECERDASAN (CFIT) 12000.0 57000.0 415 TES KECERDASAN (SON) PER KUNJUNGAN 14000.0 89000.0 416 TES KECERDASAN (GOOD ENOUGH HARIS) 12000.0 57000.0 417 TES KECERDASAN (BAYLEY) PER KUNJUNGAN 14000.0 89000.0 418 TES PERKEMBANGAN(AAMD) 12000.0 57000.0 419 TES MINAT (KUDER) 12000.0 57000.0 420 TES KEPRIBADIAN (EPPS) 12000.0 57000.0 421 TES KEPRIBADIAN (GRAFIS) 12000.0 57000.0 422 TES KEPRIBADIAN (WARTEGG) 12000.0 57000.0 423 TES KEPRIBADIAN (16 PF) 20000.0 80000.0 424 TES KEPRIBADIAN (TAT) 27000.0 177000.0 425 TES KEPRIBADIAN (CAT) 27000.0 177000.0 426 TES KEPRIBADIAN (WOODWORTHS Q) 12000.0 57000.0 427 TES KEPRIBADIAN (EYSENCKS Q) 12000.0 57000.0 428 TES KEPRIBADIAN (RORSCHACH) 20000.0 250000.0 429 TES KEPEMIMOINAN (LEAD) 7000.0 28000.0 430 TES KRAEPLIN 12000.0 87000.0 431 OBSERVASI/ INTERVIEW (KLINIS) PER ORANG 7000.0 37000.0 432 OBSERVASI/ INTERVIEW (PENDIDIKAN) PER ORANG 7000.0 37000.0 433 OBSERVASI/ INTERVIEW (INDUSTRI) PER ORANG 7000.0 37000.0 434 OBSERVASI/ INTERVIEW (KUNJUNGAN RUMAH/ SEKOLAH/ LINGKUNGAN LAIN/INDIVIDUAL 20000.0 158000.0 435 OBSERVASI/ INTERVIEW (CBCL) 25000.0 67000.0 436 PAKET PEMERIKSAAN (BAKAT LENGKAP) 67000.0 442000.0 437 PAKET PEMERIKSAAN (SELEKSI CALON KARYAWAN) 67000.0 442000.0 438 PAKET PEMERIKSAAN (ANAK BERKEBUTUHAN KHUSUS - ABK) 67000.0 442000.0 439 PAKET PEMERIKSAAN PSIKOLOGI FOREKSIK (PERDATA) 50000.0 425000.0 440 PAKET PEMERIKSAAN PSIKOLOGI FOREKSIK (PIDANA) 67000.0 542000.0 441 PAKET PEMERIKSAAN PSIKOLOGI FOREKSIK (MOBILE/VISITASI) 73000.0 623000.0 442 LAYANAN KLASIKAL MOBILE/VISITASI (PENINGKATAN KAPASITAS KOMUNITAS) 5000.0 25000.0 443 TES NEUROPSIKOLOGI (BNCE) ; BENDER GESTALT II) 15000.0 115000.0 444 PSIKOTERAPI SEDANG PERKUNJUNGAN 20000.0 145000.0 445 PSIKOTERAPI KOMPLEK PERKUNJUNGAN 20000.0 270000.0 446 KONSELING/ PSIKOTERAPI SEDERHANA PERKUNJUNGAN 10000.0 40000.0 447 "" "" "" 448 TABEL 11. "" "" 449 PELAYANAN ASUHAN GIZI "" "" 450 "" "" "" 451 JENIS PELAYANAN JS TARIF 452 ASUHAN GIZI SEDERHANA 10000.0 40000.0 453 ASUHAN GIZI SEDANG 10000.0 52000.0 454 ASUHAN GIZI KOMPLEKS 10000.0 59000.0 455 "" "" "" 456 TABEL 12. "" "" 457 PELAYANAN PEMULASARAAN JENAZAH "" "" 458 "" "" "" 459 JENIS PELAYANAN JS TARIF 460 PERAWATAN JENAZAH UTUH (MEMANDIKAN & MENGKAFANI ) 210000.0 360000.0 461 PERAWATAN JENAZAH TIDAK UTUH (MEMANDIKAN & MENGKAFANI) 267000.0 517000.0 462 PENGAWETAN JENAZAH (FORMALIN) 600000.0 1100000.0 463 PERBAIKAN / PENYATUAN TUBUH JENAZAH (TIDAK UTUH) 125000.0 225000.0 464 PENYIMPANAN (PENITIPAN) JENAZAH KURANG DARI ATAU SAMA DENGAN 24 JAM (PER JAM) 10000.0 17000.0 465 PENYIMPANAN (PENITIPAN) JENAZAH LEBIH DARI 24 JAM (PER HARI) 55000.0 80000.0 466 PENGADAAN PETI JENAZAH 1200000.0 1400000.0 467 "" "" "" 468 CATATAN : "" "" 469 - BIAYA PENITIPAN JENAZAH < 24 JAM = DIHITUNG PER JAM "" "" 470 - BIAYA PENITIPAN JENAZAH > 24 JAM = "" "" 471 BIAYA PENITIPAN < 24 JAM + BIAYA PENITIPAN > 24 JAM (PER HARI) "" "" 472 "" "" "" 473 "" "" "" 474 "" "" "" 475 "" "" "" 476 "" "" "" 477 "" "" "" 478 "" "" "" 479 "" "" "" 480 "" "" "" 481 "" "" "" 482 "" "" "" 483 "" "" "" 484 "" "" "" 485 TABEL 13. "" "" 486 PELAYANAN AMBULANCE "" "" 487 "" "" "" 488 JENIS TINDAKAN JS TARIF 489 AMBULANCE TRANSPORT "" "" 490 ANTAR ATAU JEMPUT PASIEN DALAM KOTA 87500.0 87500.0 491 ANTAR ATAU JEMPUT PASIEN LUAR KOTA "" "" 492 AMBULANCE JENAZAH "" "" 493 ANTAR ATAU JEMPUT JENAZAH DALAM KOTA 87500.0 87500.0 494 ANTAR ATAU JEMPUT JENAZAH LUAR KOTA "" "" 495 "" "" "" 496 CATATAN : "" "" 497 Ambulance Transport Dalam Kota : "" "" 498 Jarak maksimal : 10 KM "" "" 499 Biaya BBM 40000.0 "" 500 JP Supir 35000.0 "" 501 JP Pendamping Non Perawat 17500.0 "" 502 JP Pendamping Perawat 52500.0 "" 503 JP Pendamping Dokter Umum 105000.0 "" 504 JP Pendamping Dokter Spesialis 262500.0 "" 505 "" "" "" 506 Ambulance Transport Luar Kota : "" "" 507 Biaya BBM 6.000/km "" 508 JP Supir 1.500/km "" 509 JP Pendamping Non Perawat 750/km "" 510 JP Pendamping Perawat 1.800/km "" 511 JP Pendamping Dokter Umum 3.600/km "" 512 JP Pendamping Dokter Spesialis 9.000/km "" 513 "" "" "" 514 Ambulance Jenazah Dalam Kota : "" "" 515 Jarak maksimal : 10 KM "" "" 516 Biaya BBM 40000.0 "" 517 JP Supir 35000.0 "" 518 JP Pendamping Non Perawat 17500.0 "" 519 "" "" "" 520 Ambulance Jenazah Luar Kota : "" "" 521 Biaya BBM 6.000/km "" 522 JP Supir 1.500/km "" 523 JP Pendamping Non Perawat 750/km "" 524 "" "" "" 525 Biaya Waktu Tunggu Pemakaman 20.000/jam "" 526 "" "" "" 527 Biaya masuk Airport menjadi tanggungan pemakai "" "" 528 Biaya jalan tol dan penyeberangan tanggungan pemakai. "" "" 529 "" "" "" 530 "" "" "" 531 "" "" "" 532 "" "" "" 533 "" "" "" 534 "" "" "" 535 "" "" "" 536 "" "" "" 537 "" "" "" 538 "" "" "" 539 "" "" "" 540 "" "" "" 541 "" "" "" 542 TABEL 14. "" "" 543 PELAYANAN TINDAKAN MEDIK OPERATIF "" "" 544 "" "" "" 545 DOKTER BEDAH UMUM "" "" 546 JENIS PELAYANAN JS TARIF 547 KECIL "" "" 548 Circumsisi, La 350000.0 1110000.0 549 Eksisi Intrakeloidal Diluar Wajah, La 350000.0 1110000.0 550 Dorsumsisi, La 350000.0 1110000.0 551 Eksisi Nevus Diluar Wajah Simple, La 350000.0 1110000.0 552 Eksisi Veruka, La 350000.0 1110000.0 553 Eksterpasi Tumor Jinak, Diluar Wajah ,La 350000.0 1110000.0 554 Ektirpasi Aterom Diluar Wajah, La 350000.0 1110000.0 555 Ektirpasi Lipoma Diluar Wajah, La 350000.0 1110000.0 556 Sirkumsisi Lokal 350000.0 1110000.0 557 Alligator biopsi 350000.0 1110000.0 558 Katerisasi papilom 350000.0 1110000.0 559 Cabut kuku 350000.0 1110000.0 560 "" "" "" 561 SEDANG "" "" 562 Rigit Sigmoidiskopi+biopsi 350000.0 1870000.0 563 Biopsi 350000.0 1870000.0 564 "" "" "" 565 BESAR "" "" 566 Anuscopy dan Ligasi Hemoroid 350000.0 3400000.0 567 Apendisitis akut/sederhana 350000.0 3400000.0 568 Hernia (Lateralis,Mediana,Femoralis) sederhana 350000.0 3400000.0 569 Perianal Abses Sederhana 350000.0 3400000.0 570 Perianal Fistel sederhana 350000.0 3400000.0 571 Hemoroidectomy Non PPH 350000.0 3400000.0 572 Fissura Ani 350000.0 3400000.0 573 Sinus Umbilikalis 350000.0 3400000.0 574 Hernia Umbilikalis sederhana 350000.0 3400000.0 575 "" "" "" 576 KHUSUS "" "" 577 Hernia Umbilikalis besar/insisional 350000.0 6430000.0 578 laparaskopik Diagnostik dan Biopsi 350000.0 6430000.0 579 Ductus Urachus/Ductus Omphalomesenterikus 350000.0 6430000.0 580 Pembuatan Stoma (Jejunostomi,gastrostomi,iliostomi,kolostomi) 350000.0 6430000.0 581 Apendektomi Perforasi (Laparotomi/Non Laparatomi) 350000.0 6430000.0 582 Hernia Residif/Bilateral/Permagna 350000.0 6430000.0 583 Perianal Fistel kompleks/Residif 350000.0 6430000.0 584 Laparotomi Biopsi 350000.0 6430000.0 585 Perianal abses komplek 350000.0 6430000.0 586 Fistula perianal komplek 350000.0 6430000.0 587 Kolesistektomi Terbuka 350000.0 6430000.0 588 Perforasi Usus 350000.0 6430000.0 589 Laparatomi Tumor Intra Abdomen 350000.0 6430000.0 590 Laparoskopik Appendektomi 350000.0 6430000.0 591 Laparoskopik CAPD 350000.0 6430000.0 592 Hemoroidectomy PPH 350000.0 6430000.0 593 Splenektomi 350000.0 6430000.0 594 Ulkus Gaster/Duodenum 350000.0 6430000.0 595 Hemikolektomi kanan/kiri 350000.0 6430000.0 596 Reseksi Kolon Transversum 350000.0 6430000.0 597 Reseksi Sigmoid 350000.0 6430000.0 598 Relaparatomi 350000.0 6430000.0 599 PEG 350000.0 6430000.0 600 Laparoskopik Appendektomi Perforasi 350000.0 6430000.0 601 Laparoskopik Kolesistektomi 350000.0 6430000.0 602 Laparoskopik Perforasi Gaster 350000.0 6430000.0 603 Kelainan Usus (Invaginasi,Trombosis,Tumor Usus Halus,dsb) 350000.0 6430000.0 604 Trauma Abdomen sederhana 350000.0 6430000.0 605 Tumor Lambung, Total Gastrektomi 350000.0 6430000.0 606 Partial Gastrektomi dengan Anastomosis (Biltroth I/II) 350000.0 6430000.0 607 Anterior Perianal Resection (APR)/Milles 350000.0 6430000.0 608 Anterior Resection (AR) 350000.0 6430000.0 609 Batu Empedu Eksplorasi CBD (Non Laparoskopik) 350000.0 6430000.0 610 Batu Empedu Bilio-digestif/Double By pass 350000.0 6430000.0 611 Trauma Hepar 350000.0 6430000.0 612 LAR&Ileostomi 350000.0 6430000.0 613 Miles 350000.0 6430000.0 614 LAR/APPEAR 350000.0 6430000.0 615 Laparatomi Kelainan Esofagus Distal Achalasia (Heller) 350000.0 6430000.0 616 Laparatomi Kelainan Esofagus Distal Achalasia (Reseksi) 350000.0 6430000.0 617 Laparatomi Kelainan Esofagus Distal 350000.0 6430000.0 618 Laparatomi Kelainan Esofagus Distal Tumor 350000.0 6430000.0 619 Laparatomi Kelainan Esofagus Distal Striktur 350000.0 6430000.0 620 Reseksi Hepar/Metasektomi 350000.0 6430000.0 621 Reseksi Hepar/Segmental/Anatomi 350000.0 6430000.0 622 Hepatiko Jejunostomi 350000.0 6430000.0 623 Distal Pankreatektomi 350000.0 6430000.0 624 Kelainan Esofagus 1/3 Proksimal & 1/3 Tengah Tumor 350000.0 6430000.0 625 Kelainan Esofagus 1/3 Proksimal & 1/3 Tengah Striktur 350000.0 6430000.0 626 Whipple/Pankreatiko Duodenektomi 350000.0 6430000.0 627 Ultra LAR 350000.0 6430000.0 628 Laparoskopik Hernia Medialis 350000.0 6430000.0 629 Laparoskopik Hernia Medialis Bilateral 350000.0 6430000.0 630 Laparaskopik Achalasia (Heller) 350000.0 6430000.0 631 Laparoskopik Batu Empedu Eksplorasi CBD 350000.0 6430000.0 632 Laparoskopik Reseksi Kolon 350000.0 6430000.0 633 Laparoskopik Gastric Banding 350000.0 6430000.0 634 Laparoskopik Distal Gastrektomi 350000.0 6430000.0 635 Laparoskopik Milles 350000.0 6430000.0 636 Laparoskopik LAR 350000.0 6430000.0 637 "" "" "" 638 "" "" "" 639 "" "" "" 640 DOKTER BEDAH UROLOGI "" "" 641 JENIS PELAYANAN JS TARIF 642 KECIL "" "" 643 Sirkumsisi Lokal 350000.0 1110000.0 644 Vasektomi 350000.0 1110000.0 645 Sistoskopi Wanita 350000.0 1110000.0 646 Eksterpasi tumor jinak penis 350000.0 1110000.0 647 Aff splinting ureter kateter Wanita 350000.0 1110000.0 648 Uretroskopi Wanita 350000.0 1110000.0 649 Kalibrasi uretra 350000.0 1110000.0 650 "" "" "" 651 SEDANG "" "" 652 Sectio Alta 350000.0 1870000.0 653 Hidrokolectomi 350000.0 1870000.0 654 TESE (Biopsi Testis) 350000.0 1870000.0 655 Orchiektomi simple 350000.0 1870000.0 656 Nephrostomy temporer 350000.0 1870000.0 657 Uretrotomi 350000.0 1870000.0 658 Uretrolithotomi 350000.0 1870000.0 659 Pemasangan ureter kateter 350000.0 1870000.0 660 Open Sistostomi 350000.0 1870000.0 661 Eksterpasi tumor uretra distal 350000.0 1870000.0 662 Sistoskopi Pria 350000.0 1870000.0 663 Uretroskopi Pria 350000.0 1870000.0 664 Aff splinting ureter kateter Pria 350000.0 1870000.0 665 Sirkumisisi GA 350000.0 1870000.0 666 Sistostomi tertutup 350000.0 1870000.0 667 Biopsi Prostat 350000.0 1870000.0 668 Ganti Kateter Neprostomi 350000.0 1870000.0 669 Funikokelektomi 350000.0 1870000.0 670 Buried Penis 350000.0 1870000.0 671 Eksisi Plaque (Peyronie Disease) 350000.0 1870000.0 672 Evakuasi Bekuan Darah (Clot) 350000.0 1870000.0 673 Funikokelektomi 350000.0 1870000.0 674 Litholapaksi 350000.0 1870000.0 675 MMK / Sling Uretra 350000.0 1870000.0 676 Nefropeksi / Renopeksi 350000.0 1870000.0 677 Operasi Repair Buli Trauma 350000.0 1870000.0 678 Pasang Kateter Tenckhoff Untuk Capd 350000.0 1870000.0 679 Reparasi Penis 350000.0 1870000.0 680 Ureterouretostomi 350000.0 1870000.0 681 "" "" "" 682 BESAR "" "" 683 Johanson I 350000.0 3400000.0 684 Amputasi penis 350000.0 3400000.0 685 Orchidopeksi 350000.0 3400000.0 686 Ureterolithotomi, 350000.0 3400000.0 687 Pyelolithotomi simple 350000.0 3400000.0 688 Open prostatectomi 350000.0 3400000.0 689 Diverticulectomy 350000.0 3400000.0 690 Orchiektomi extended 350000.0 3400000.0 691 RPG 350000.0 3400000.0 692 Dorkumsisi 350000.0 3400000.0 693 Nefrektomi simple 350000.0 3400000.0 694 Palomo/operasi varikokel cara lain 350000.0 3400000.0 695 Insisi abses 350000.0 3400000.0 696 Operasi Gangren Fournier 350000.0 3400000.0 697 Insisi abses Skrotum 350000.0 3400000.0 698 Inguinal orchiodektomi 350000.0 3400000.0 699 Orchiodektomi ligasi tinggi 350000.0 3400000.0 700 Orchiodektomi inguinal 350000.0 3400000.0 701 Orchiodektomi subkapsuler 350000.0 3400000.0 702 Spermatokelektomi 350000.0 3400000.0 703 Eksisi Webbed Penis 350000.0 3400000.0 704 Operasi Sistokel 350000.0 3400000.0 705 Operasi Urakhus / Reseksi Urakhus 350000.0 3400000.0 706 Vasoeepididimostomi 350000.0 3400000.0 707 Vasovasostomi 350000.0 3400000.0 708 "" "" "" 709 KHUSUS "" "" 710 Uretrotomi interna - sachse 350000.0 6430000.0 711 Lithotripsi 350000.0 6430000.0 712 Percutaneus nephrolitotripsi (PCNL) 350000.0 6430000.0 713 Uretroplasty 350000.0 6430000.0 714 Johanson II 350000.0 6430000.0 715 Maskulinisasi 350000.0 6430000.0 716 Extended pielolitotomi 350000.0 6430000.0 717 Pielocalikalitomi 350000.0 6430000.0 718 Pieloplasty 350000.0 6430000.0 719 Transuretral Reseksi prostat (TURP) 350000.0 6430000.0 720 Transuretral Insisi prostat (TUIP) 350000.0 6430000.0 721 Chordectomi 350000.0 6430000.0 722 Reseksi anastomosis urethra/ureter 350000.0 6430000.0 723 Partial nefrektomi 350000.0 6430000.0 724 Hemi nefrektomi 350000.0 6430000.0 725 Partial cystektomi 350000.0 6430000.0 726 Insersi double J stent /ureter kateter (RPG) 350000.0 6430000.0 727 Ureterolisis 350000.0 6430000.0 728 Rekonstruksi Trauma Buli-buli 350000.0 6430000.0 729 Open prostatectomi & Sectio Alta 350000.0 6430000.0 730 ESWL 350000.0 6430000.0 731 Biopsi Ginjal Terbuka 350000.0 6430000.0 732 Deroofing / Unroofing Kista 350000.0 6430000.0 733 Divertikulektomi Buli 350000.0 6430000.0 734 Divertikulum Uretra 350000.0 6430000.0 735 Eksisi Fibroma / Rekonstruksi Penis 350000.0 6430000.0 736 Epispadia 350000.0 6430000.0 737 Fistulektomi / Repair Fistel Uretra 350000.0 6430000.0 738 Operasi Priapismus (Prosedur Winter) (Besar) 350000.0 6430000.0 739 Operasi Trauma Ginjal 350000.0 6430000.0 740 Orkhidopeksi (Torsio Testis) (Besar) 350000.0 6430000.0 741 Psoas Hitch / Boari Flap 350000.0 6430000.0 742 Railroading Ruptur Uretra 350000.0 6430000.0 743 Reimplantasi Ureter Bilateral 350000.0 6430000.0 744 Tur Tumor Buli 350000.0 6430000.0 745 Lithotripsi 350000.0 6430000.0 746 Total cystectomi 350000.0 6430000.0 747 Radikal cystectomi 350000.0 6430000.0 748 Radikal neprectomi 350000.0 6430000.0 749 TUL/URS 350000.0 6430000.0 750 Retroperitoneal 350000.0 6430000.0 751 Lymphadenektomi 350000.0 6430000.0 752 Radical prostatektomi 350000.0 6430000.0 753 Operasi tumor supra renalis 350000.0 6430000.0 754 Augmentasi bladder 350000.0 6430000.0 755 Bivalve nefrolitotomi 350000.0 6430000.0 756 Coffey prosedur 350000.0 6430000.0 757 TUUC (Trans Uretero Ureteral Cutaneostomy) 350000.0 6430000.0 758 Breaker Prosedur 350000.0 6430000.0 759 Nefrektomi donor cangkok ginjal 350000.0 6430000.0 760 (TURP) & Litotripsi 350000.0 6430000.0 761 Koreksi Horseshoe Kidney 350000.0 6430000.0 762 Nefroureteroktomi 350000.0 6430000.0 763 Deroofing Kista Ginjal Per Laparoskopi 350000.0 6430000.0 764 Diseksi Kelenjar Getah Bening Pelvis Per Laparoskopi 350000.0 6430000.0 765 Eksplorasi Testis (Microsurgery) 350000.0 6430000.0 766 Laparoskopi Adrenalektomi 350000.0 6430000.0 767 Ligasi V. Spermatika Interna (Microsurgery) 350000.0 6430000.0 768 Rekonstruksi Renovaskuler 350000.0 6430000.0 769 Repair Fistel Enterovesika 350000.0 6430000.0 770 Repair Fistel Vesikorektal 350000.0 6430000.0 771 Sistektomi Per Laparoskopi 350000.0 6430000.0 772 Repair Fistel Vesikovagina 350000.0 6430000.0 773 Neobladder (Buli-Buli) 350000.0 6430000.0 774 Neobladder (Diversi Urin / Conduit) 350000.0 6430000.0 775 Resipian cangkok ginjal 350000.0 6430000.0 776 Rekonstruksi Ekstrofia Buli-buli 350000.0 6430000.0 777 "" "" "" 778 DOKTER BEDAH PLASTIK "" "" 779 JENIS PELAYANAN JS TARIF 780 KECIL "" "" 781 Circumsisi, La 350000.0 1110000.0 782 Eksisi Intrakeloidal Diluar Wajah, La 350000.0 1110000.0 783 Dorsumsisi, La 350000.0 1110000.0 784 Eksisi Nevus Diluar Wajah Simple, La 350000.0 1110000.0 785 Eksisi Veruka, La 350000.0 1110000.0 786 Eksterpasi Tumor Jinak, Diluar Wajah ,La 350000.0 1110000.0 787 Ektirpasi Aterom Diluar Wajah, La 350000.0 1110000.0 788 Ektirpasi Lipoma Diluar Wajah, La 350000.0 1110000.0 789 Eksisi Ganglion, La 350000.0 1110000.0 790 Eksisi Kista Dermoid, La 350000.0 1110000.0 791 Eksisi Nevus Diluar Wajah Multiple, La 350000.0 1110000.0 792 Ektirpasi Lipoma Wajah, La 350000.0 1110000.0 793 "" "" "" 794 SEDANG "" "" 795 Angkat Jahitan, Ga 350000.0 1870000.0 796 Closed Reduction + Bandage, La 350000.0 1870000.0 797 Closed Reduction With Splint, La 350000.0 1870000.0 798 Debridemen Dan Nekrotomi Dekubitus, La 350000.0 1870000.0 799 Debridement Luka Bakar Fase Akut <15%, Ga 350000.0 1870000.0 800 Debridement Luka Bakar Fase Akut <15%, La 350000.0 1870000.0 801 Eksisi Intrakeloidal Wajah, La 350000.0 1870000.0 802 Eksisi Nevus Wajah Multiple , La 350000.0 1870000.0 803 Eksisi Nevus Wajah Simple , La 350000.0 1870000.0 804 Eksisi Rinofima, La 350000.0 1870000.0 805 Eksisi Tragus Asesorius, La 350000.0 1870000.0 806 Ekstirpasi Tumor Jinak Kulit Wajah, La 350000.0 1870000.0 807 Ekstraksi Corpus Alienum, La 350000.0 1870000.0 808 Ektirpasi Aterom Wajah, La 350000.0 1870000.0 809 Escharotomy, La 350000.0 1870000.0 810 Fraktur Dan Dislokasi - Pemasangan Intramedulary Wire, La 350000.0 1870000.0 811 Fraktur Dan Dislokasi - Pemasangan Splint Tangan, La 350000.0 1870000.0 812 Incisi Absces Perikondritis, Ga 350000.0 1870000.0 813 Injeksi Haemangioma Dengan Skleroting Agent Atau Triamcinolon Acetonid, La 350000.0 1870000.0 814 Injeksi Skleroting Agent, La 350000.0 1870000.0 815 Jahit Luka Di Wajah Dengan Kerusakan Sedang, Ga 350000.0 1870000.0 816 Jahit Luka Di Wajah Dengan Kerusakan Sedang, La 350000.0 1870000.0 817 Lobuloplasty, La 350000.0 1870000.0 818 Melakukan Nekrotomi Sedang, La 350000.0 1870000.0 819 Rouzerplasty, La 350000.0 1870000.0 820 Simple Advancement Flap (Flap Kulit Sederhana), La 350000.0 1870000.0 821 "" "" "" 822 BESAR "" "" 823 Amputasi Sederhana, Ga 350000.0 3400000.0 824 Boutonnniere Deformity Repair, La 350000.0 3400000.0 825 Debridement Luka Bakar Fase Akut 15 - 30 %, Ga 350000.0 3400000.0 826 Eksisi Fistel Preaurikula, La 350000.0 3400000.0 827 Eksisi Intrakeloidal + Jahit Primer, La 350000.0 3400000.0 828 Eksisi Keloid + Skin Grafting, La 350000.0 3400000.0 829 Eksisi Polidaktili Simple Dewasa, La 350000.0 3400000.0 830 Ekstirpasi Tumor Jinak Kulit Diluar Wajah, Ga 350000.0 3400000.0 831 Escharectomy Dengan Tangensial Eksisi, Ga 350000.0 3400000.0 832 Fasciotomy Burned Compartement Syndrome, Ga 350000.0 3400000.0 833 Finger Tip Injury Repair - Composite Graft, La 350000.0 3400000.0 834 Finger Tip Injury Repair - Skin Flap Lokal, La 350000.0 3400000.0 835 Finger Tip Injury Repair - Skin Grafting, La 350000.0 3400000.0 836 Full Thickness Skin Graft (Ftsg) Daerah Diluar Wajah, La 350000.0 3400000.0 837 Full Thickness Skin Graft (Ftsg) Pada Wajah, La 350000.0 3400000.0 838 Injeksi Haemangioma Dengan Skleroting Agent Atau Triamcinolon Acetonid, Ga 350000.0 3400000.0 839 Insersi Tulang Rawan Telinga Akibat Avulsi Telinga, La 350000.0 3400000.0 840 Ioid + Archbarr Fraktur 1 Sisi, Ga 350000.0 3400000.0 841 Ioid + Archbarr Fraktur 2 Sisi, Ga 350000.0 3400000.0 842 Ioid + Imf(Eyelet) Fraktur 1 Sisi, Ga 350000.0 3400000.0 843 Jahit Luka Di Wajah Daerah Estetik Unit, La 350000.0 3400000.0 844 Jahit Luka Di Wajah Dengan Kerusakan Komplek, La 350000.0 3400000.0 845 Kontraktur Tangan Dan Jari, La 350000.0 3400000.0 846 Labioplasty Pada Microform, La 350000.0 3400000.0 847 Labioplasty Sumbing Bibir Unilateral, Ga 350000.0 3400000.0 848 Mallet Finger Repair, La 350000.0 3400000.0 849 Melakukan Nekrotomi Luas, Ga 350000.0 3400000.0 850 Pasang Archbarr 1 Sisi, La 350000.0 3400000.0 851 Pasang Archbarr 2 Sisi, La 350000.0 3400000.0 852 Release Kontraktur Dengan Dermagram, La 350000.0 3400000.0 853 Repair Cleft Ear Lobe, La 350000.0 3400000.0 854 Repair Trauma Telinga Simple, La 350000.0 3400000.0 855 Revisi Dengan Simple Z Plasty, La 350000.0 3400000.0 856 Revisi Labioplasty, La 350000.0 3400000.0 857 Revisi Parut Dengan Simple Advancement Flap, La 350000.0 3400000.0 858 Revisi Parut, La 350000.0 3400000.0 859 Revisi Stump, La 350000.0 3400000.0 860 Revisis Parutdiluar Wajah, La 350000.0 3400000.0 861 Rhynophyma Repair, La 350000.0 3400000.0 862 Simple Advancement Flap, La 350000.0 3400000.0 863 Skin Flap Lokal Sederhana, La 350000.0 3400000.0 864 Skin Flap Sederhana , La 350000.0 3400000.0 865 Split Thickness Skin Graft (Stsg) Sederhana, La 350000.0 3400000.0 866 Surgical Debridement/Sharp Debridement, Ga 350000.0 3400000.0 867 "" "" "" 868 KHUSUS "" "" 869 Alveolar Bone Graft Dengan Allograft, Ga 350000.0 6430000.0 870 Amputasi Komplek, Ga 350000.0 6430000.0 871 Chordee Excision, Ga 350000.0 6430000.0 872 Circumferential Wiring + Archbarr, Ga 350000.0 6430000.0 873 Closed Recuction + Imf(Eyelet), Ga 350000.0 6430000.0 874 Closed Reduction + Archbarr, Ga 350000.0 6430000.0 875 Commissuroplasty - Direct Closure, La 350000.0 6430000.0 876 Commissuroplasty - Ear Cartilage Graft, La 350000.0 6430000.0 877 Commissuroplasty - Regional Flap, La 350000.0 6430000.0 878 Commissuroplasty - Skin Flap Lokal, La 350000.0 6430000.0 879 Commissuroplasty, La 350000.0 6430000.0 880 Debridement Luka Bakar Fase Akut > 30 %, Ga 350000.0 6430000.0 881 Double Rotation Skin Flap, La 350000.0 6430000.0 882 Eksisi Basalioma Dengan Skin Flap, La 350000.0 6430000.0 883 Eksisi Haemangioma Dengan Composite Flap, La 350000.0 6430000.0 884 Eksisi Haemangioma Dengan Simple Advancement Flap, La 350000.0 6430000.0 885 Eksisi Haemangioma Dengan Skin Flap Lokal, La 350000.0 6430000.0 886 Eksisi Haemangioma Dengan Skingrafting, La 350000.0 6430000.0 887 Eksisi Keloid + Skin Grafting - Revisi Dengan Multiple Z Plast, Ga 350000.0 6430000.0 888 Eksisi Keloid + Skin Grafting - Revisi Dengan Simple Advancement, Ga 350000.0 6430000.0 889 Eksisi Keloid + Skin Grafting - Revisi Dengan Single Z Plasty, Ga 350000.0 6430000.0 890 Eksisi Keloid + Skin Grafting , Ga 350000.0 6430000.0 891 Eksisi Keloid Dengan Flap, La 350000.0 6430000.0 892 Ekstirpasi Tumor Jinak Kulit Wajah, Ga 350000.0 6430000.0 893 Labioplasty Unilateral Dengan Nasoplasty, La 350000.0 6430000.0 894 Labioplasty Unilateral Dengan Nasoplasty, Ga 350000.0 6430000.0 895 Operasi Rekonstruksi : Tangan Dan Jari Jari, La 350000.0 6430000.0 896 Operasi Rekonstruksi : Tangan Dan Jari Jari, Ga 350000.0 6430000.0 897 Operasi Rekonstruksi : Telinga, La 350000.0 6430000.0 898 Operasi Skin Flap Yang Lain Yang Lebih Komplek, La 350000.0 6430000.0 899 Ops. Rekonstruksi : Defek/ Kelainan Muka, La 350000.0 6430000.0 900 Ops.Rek. : Defak/Kelainan Tubuh Yang Lain, La 350000.0 6430000.0 901 Orbital Bone And Eye Socket Reconstruction, Ga 350000.0 6430000.0 902 Orif + Orbital Wall Reconstruction Dengan Ribs Bone Graft, Ga 350000.0 6430000.0 903 Rekonstruksi Dengan Skin Flap Komplek, La 350000.0 6430000.0 904 Rekonstruksi Dengan Skin Grafting, La 350000.0 6430000.0 905 Rekonstruksi Kelainan Genetalia Eksterna Yang Lain, La 350000.0 6430000.0 906 Rekonstruksi Kelainan Telinga Yang Lain, La 350000.0 6430000.0 907 Rekonstruksi Softtissue Pada Hipertelorism, La 350000.0 6430000.0 908 Rekonstruksi Telinga - Repair Lobulus Dan Kelainan Penyerta, La 350000.0 6430000.0 909 Rekonstruksi Vermilion, Ga 350000.0 6430000.0 910 Release Burried Penis, La 350000.0 6430000.0 911 Release Burried Penis, Ga 350000.0 6430000.0 912 Release Ekstropion, La 350000.0 6430000.0 913 Release Ekstropion, Ga 350000.0 6430000.0 914 Release Kontraktur Dengan Skin Flap, La 350000.0 6430000.0 915 Release Kontraktur Dengan Skingraft, La 350000.0 6430000.0 916 Release Kontraktur Dengan Z Plasty, La 350000.0 6430000.0 917 Release Kontraktur Leher, La 350000.0 6430000.0 918 Release Kontraktur Linier, La 350000.0 6430000.0 919 Release Vagina Acreta, La 350000.0 6430000.0 920 Repair Palpebra Dengan Local Skin Flap, La 350000.0 6430000.0 921 Repair Palpebra Simple, La 350000.0 6430000.0 922 Repair Soft Tissue Komplek, La 350000.0 6430000.0 923 Repair Softtisue Simple, La 350000.0 6430000.0 924 Repair Tendon Ekstensor Tangan Tunggal, La 350000.0 6430000.0 925 Repair Tendon Fleksor Tangan Tunggal, La 350000.0 6430000.0 926 Reposisi Dislokasi Tmj, Ga 350000.0 6430000.0 927 Revisi Dengan Multiple Z Plasty/W Plasty, La 350000.0 6430000.0 928 Revisi Dengan Flap Lokal, La 350000.0 6430000.0 929 Revisi Dengan Simple Z Plasty, Ga 350000.0 6430000.0 930 Revisi Parut Dengan Simple Advancement Flap, Ga 350000.0 6430000.0 931 Revisi Parut Wajah, La 350000.0 6430000.0 932 Revisi Parut, Ga 350000.0 6430000.0 933 Nailbed Reconstruction, Ga 350000.0 6430000.0 934 Secondary Repair Labioplasty, La 350000.0 6430000.0 935 Secondary Rhynoplasty, La 350000.0 6430000.0 936 Semi Open Reduction (Gillies Procedure), Ga 350000.0 6430000.0 937 Single Rotation/ Transposition Skin Flap, Ga 350000.0 6430000.0 938 Single Rotation/ Transposition Skin Flap, La 350000.0 6430000.0 939 Skin And Fascial Grafts, La 350000.0 6430000.0 940 Skin Flap Lokal Komplek, La 350000.0 6430000.0 941 Skin Flap Lokal Sederhana, Ga 350000.0 6430000.0 942 Soft Tissue Rekonstruksi, La 350000.0 6430000.0 943 Split Thickness Skin Graft (Stsg) Sederhana, Ga 350000.0 6430000.0 944 Stiff Finger Joint - Capsuloyomy-Tenolysis, La 350000.0 6430000.0 945 Stiff Finger Joint - Volar Plate Release, La 350000.0 6430000.0 946 Tangensial Eksisi Dini Dengan Skin Grafting , La 350000.0 6430000.0 947 Tendon Repair, La 350000.0 6430000.0 948 Commissuroplasty - Skin Graft, Ga 350000.0 6430000.0 949 Distant Flap, Ga 350000.0 6430000.0 950 Double Rotation Skin Flap, Ga 350000.0 6430000.0 951 Eksisi Haemangioma Dengan Simple Advancement Flap, Ga 350000.0 6430000.0 952 Eksisi Haemangioma Dengan Skin Flap, Ga 350000.0 6430000.0 953 Eksisi Haemangioma Dengan Skingrafting, Ga 350000.0 6430000.0 954 Eksisi Keloid + Skin Grafting - Komplek, Ga 350000.0 6430000.0 955 Eksisi Polydactyly Complex, Ga 350000.0 6430000.0 956 Eksisi Poydactyly Simple, Ga 350000.0 6430000.0 957 Eksisi Rinofima, Ga 350000.0 6430000.0 958 Fasciocutaneus Flap, Ga 350000.0 6430000.0 959 Full Thickness Skin Graft (Ftsg) Daerah Diluar Wajah, Ga 350000.0 6430000.0 960 Full Thickness Skin Graft (Ftsg) Pada Wajah, Ga 350000.0 6430000.0 961 Jahit Luka Di Wajah Daerah Estetik Unit, Ga 350000.0 6430000.0 962 Labioplasty Bilateral, Ga 350000.0 6430000.0 963 Operasi Rekonstruksi : Palpebra, La 350000.0 6430000.0 964 Orif + Titanium Mini Plate Approach Ektra Oral 1 Sisi, Ga 350000.0 6430000.0 965 Orif Dengan 1 Approach, Ga 350000.0 6430000.0 966 Orif Dengan Ginggivo-Bucal Approach, Ga 350000.0 6430000.0 967 Orif Dengan Infraciliar Approach, Ga 350000.0 6430000.0 968 Orif Dengan Transconjunctival Approach, Ga 350000.0 6430000.0 969 Orif Untuk Fraktur Le Fort I, Ga 350000.0 6430000.0 970 Palatoplasty Complete, Ga 350000.0 6430000.0 971 Palatoplasty Incomplete, Ga 350000.0 6430000.0 972 Reconstruction Of Central Ray Deficiency, Ga 350000.0 6430000.0 973 Reconstruction Of Radial Ray Deficiency, Ga 350000.0 6430000.0 974 Rekonstruksi Dengan Menggunakan Tissue Expantion, Ga 350000.0 6430000.0 975 Rekonstruksi Dengan Skin Flap Lokal, La 350000.0 6430000.0 976 Rekonstruksi Dengan Skin Grafting, Ga 350000.0 6430000.0 977 Rekonstruksi Kelainan Telinga Yang Lain, Ga 350000.0 6430000.0 978 Release Kontraktur Dengan Skin Flap, Ga 350000.0 6430000.0 979 Release Kontraktur Dengan Z Plasty, Ga 350000.0 6430000.0 980 Repair Palpebra Dengan Oral Mucosal Graft, Ga 350000.0 6430000.0 981 Repair Palpebra Dengan Posterior Lamellar Reconstruction, Ga 350000.0 6430000.0 982 Repair Trauma Telinga Komplek, Ga 350000.0 6430000.0 983 Secondary Lip Repair , Ga 350000.0 6430000.0 984 Separasi Complete Syndacttly, Ga 350000.0 6430000.0 985 Separasi Syndactyly, Ga 350000.0 6430000.0 986 Skin Flap Lokal Komplek, Ga 350000.0 6430000.0 987 Skingrafting Yang Sederhana, Ga 350000.0 6430000.0 988 Split Thickness Skin Graft (Stsg) Luas, Ga 350000.0 6430000.0 989 Tangensial Eksisi Dini Dengan Skin Grafting, Ga 350000.0 6430000.0 990 Ankylosis Release, Ga 350000.0 6430000.0 991 Bedah Mikro, Ga 350000.0 6430000.0 992 Buried Dermal Flap (Thompson Procedure), Ga 350000.0 6430000.0 993 Chordee Excision + Urethroplasty 1 Tahap, Ga 350000.0 6430000.0 994 Commissuroplasty - Composite Flap(Microsurgery), Ga 350000.0 6430000.0 995 Commissuroplasty - Gastro Omental Free Flap(Microsurgery), Ga 350000.0 6430000.0 996 Commissuroplasty - Jejunal Free Autograft (Microsurgery), Ga 350000.0 6430000.0 997 Cross-Facial Verve Graft, Ga 350000.0 6430000.0 998 Eksisi Haemangioma Dengan Composite Flap, Ga 350000.0 6430000.0 999 Endoscopic Reconstructive Surgery, Ga 350000.0 6430000.0 1000 Facial Sling Dengan Alograft, Ga 350000.0 6430000.0 1001 Finger Tip Injury Repair - Neurovascular Island/Distant Flap, Ga 350000.0 6430000.0 1002 Finger Tip Injury Repair - Toe Transfer, Ga 350000.0 6430000.0 1003 Fraktur Dan Dislokasi - Orif Dengan Miniplate, Ga 350000.0 6430000.0 1004 Free Flap, Ga 350000.0 6430000.0 1005 Free Gracillis Transfer, Ga 350000.0 6430000.0 1006 Frontozygomaticomaxillary Suspension, Ga 350000.0 6430000.0 1007 Jahit Luka Di Wajah Dengan Kerusakan Komplek, Ga 350000.0 6430000.0 1008 Kontraktur Tangan Dan Jari, Ga 350000.0 6430000.0 1009 Le Fort I Osteotomy, Ga 350000.0 6430000.0 1010 Mandibular Distraction, Ga 350000.0 6430000.0 1011 Mandibular Reconst With Non Vascularized Bone Graft, Ga 350000.0 6430000.0 1012 Mandibular Reconst With Tmj Plate Rekonstruction, Ga 350000.0 6430000.0 1013 Mandibular Reconst With Vascularized Bone Graft(Mikro) - Defek Boyd T, Ga 350000.0 6430000.0 1014 Mastopexy, Ga 350000.0 6430000.0 1015 Maxillary Reconst.With Non Vascularized Bone Graft, Ga 350000.0 6430000.0 1016 Maxillary Reconst.With Vascularized Bone Graft(Mikro), Ga 350000.0 6430000.0 1017 Medial/Lateral Canthoplasty, Ga 350000.0 6430000.0 1018 Musculocutaneus Flap, Ga 350000.0 6430000.0 1019 Myocutaneus Flap, Ga 350000.0 6430000.0 1020 Omental Flap, Ga 350000.0 6430000.0 1021 Open Reduction With Implant And Septoplasty, La 350000.0 6430000.0 1022 Open Reduction With Wire/Titanium Implant, Ga 350000.0 6430000.0 1023 Operasi Bedah Mikro Yang Lain, Ga 350000.0 6430000.0 1024 Operasi Rekonstruksi : Hidung, La 350000.0 6430000.0 1025 Operasi Rekonstruksi : Hidung, Ga 350000.0 6430000.0 1026 Operasi Rekonstruksi : Palpebra, Ga 350000.0 6430000.0 1027 Operasi Rekonstruksi : Telinga, Ga 350000.0 6430000.0 1028 Operasi Rekonstruksi : Wajah, Ga 350000.0 6430000.0 1029 Operasi Rekonstruksi : Wajah, Ga 350000.0 6430000.0 1030 Operasi Rekonstruksi : Payudara Dan Sekitarnya, Ga 350000.0 6430000.0 1031 Operasi Rekonstruksi : Bokong, Ga 350000.0 6430000.0 1032 Operasi Rekonstruksi : Genitalia Eksterna Dan Sekitarnya, Ga 350000.0 6430000.0 1033 Operasi Skin Flap Yang Lain Yang Lebih Komplek, Ga 350000.0 6430000.0 1034 Ops. Rekonstruksi : Defek/ Kelainan Muka, Ga 350000.0 6430000.0 1035 Ops.Rek. : Defak/Kelainan Tubuh Yang Lain, Ga 350000.0 6430000.0 1036 Orif + Orbital Wall Reconstruction Dengan Silicon Plate, Ga 350000.0 6430000.0 1037 Orif + Titanium Mini Plate Approach Ektra Oral 2 Sisi, Ga 350000.0 6430000.0 1038 Orif Dengan 2 Approach, Ga 350000.0 6430000.0 1039 Orif Dengan 3 Approach, Ga 350000.0 6430000.0 1040 Orif Untuk Fraktur Le Fort Ii, Ga 350000.0 6430000.0 1041 Orif Untuk Fraktur Le Fort Iii Bicoronal Approach, Ga 350000.0 6430000.0 1042 Osseointegrated Mandibular Implant - Close Primary, Ga 350000.0 6430000.0 1043 Osseointegrated Mandibular Implant - Distant/Free Flap, Ga 350000.0 6430000.0 1044 Osseointegrated Mandibular Implant, Ga 350000.0 6430000.0 1045 Pharyngoplasty, Ga 350000.0 6430000.0 1046 Primary/Secondary Repair Nerve Injury (Bedah Mikro), Ga 350000.0 6430000.0 1047 Rekonstruksi Dengan Composite Flap (Microsurgery), Ga 350000.0 6430000.0 1048 Rekonstruksi Dengan Composite Flap (Microsurgery), Ga 350000.0 6430000.0 1049 Rekonstruksi Dengan Free Vascularized Bone Graft, Ga 350000.0 6430000.0 1050 Rekonstruksi Dengan Muscle Flap Dengan Skin Graft, Ga 350000.0 6430000.0 1051 Rekonstruksi Dengan Musculocutaneus Flap, Ga 350000.0 6430000.0 1052 Rekonstruksi Dengan Skin Flap Komplek, Ga 350000.0 6430000.0 1053 Rekonstruksi Dengan Skin Flap Lokal, Ga 350000.0 6430000.0 1054 Rekonstruksi Dengan Tissue Expantion+Skin Flap, Ga 350000.0 6430000.0 1055 Rekonstruksi Ibu Jari - Bone Graft + Myocutaneus Free Flap, Ga 350000.0 6430000.0 1056 Rekonstruksi Ibu Jari - Bone Graft + Regional Flap, Ga 350000.0 6430000.0 1057 Rekonstruksi Ibu Jari - Deepening First Digital Web Space, La 350000.0 6430000.0 1058 Rekonstruksi Ibu Jari - Policization, Ga 350000.0 6430000.0 1059 Rekonstruksi Ibu Jari - Toe To Thumb Transfer, Ga 350000.0 6430000.0 1060 Rekonstruksi Kelainan Genetalia Eksterna Yang Lain, Ga 350000.0 6430000.0 1061 Rekonstruksi Mandibula Dengan Costochondral Graft, Ga 350000.0 6430000.0 1062 Rekonstruksi Soft Tissue Dan Tulang, Ga 350000.0 6430000.0 1063 Rekonstruksi Soft Tissue Yang Lain, Ga 350000.0 6430000.0 1064 Rekonstruksi Softtissue Pada Hipertelorism, Ga 350000.0 6430000.0 1065 Rekonstruksi Telinga - Elevasi Flap Daun Telinga + Skin Graft, Ga 350000.0 6430000.0 1066 Rekonstruksi Telinga - Operasi Insersi Graft Tulang Rawan, Ga 350000.0 6430000.0 1067 Rekonstruksi Telinga - Repair Lobulus Dan Kelainan Penyerta, Ga 350000.0 6430000.0 1068 Rekostruksi Softtissue Dan Tulang Pada Hipertelorism, Ga 350000.0 6430000.0 1069 Release Kontraktur Dengan Free Flap, Ga 350000.0 6430000.0 1070 Release Kontraktur Dengan Skingraft, Ga 350000.0 6430000.0 1071 Release Kontraktur Leher, Ga 350000.0 6430000.0 1072 Release Kontraktur Linier, Ga 350000.0 6430000.0 1073 Release Vagina Acreta, Ga 350000.0 6430000.0 1074 Repair Blepharoptosis, La 350000.0 6430000.0 1075 Repair Blepharoptosis, Ga 350000.0 6430000.0 1076 Repair Bibir Dengan - Estlander Flap, Ga 350000.0 6430000.0 1077 Repair Bibir Dengan Bernard-Burows Flap, Ga 350000.0 6430000.0 1078 Repair Bibir Dengan Karapandzic Methode, Ga 350000.0 6430000.0 1079 Repair Camptodactyly, Ga 350000.0 6430000.0 1080 Repair Clinodactyly, Ga 350000.0 6430000.0 1081 Repair Creeple Hypospadia, Ga 350000.0 6430000.0 1082 Repair Ductus Nasolacrimalis, Ga 350000.0 6430000.0 1083 Repair Ductus Parotis, Ga 350000.0 6430000.0 1084 Repair Epispadia, Ga 350000.0 6430000.0 1085 Repair Fistel Palatum Dengan Bucal Atau Lingual Flap, Ga 350000.0 6430000.0 1086 Repair Fistel Palatum, Ga 350000.0 6430000.0 1087 Repair Fistel Urethra Complex, Ga 350000.0 6430000.0 1088 Repair Fistel Urethra Sederhana, Ga 350000.0 6430000.0 1089 Repair Involutional Ptosis, La 350000.0 6430000.0 1090 Repair Involutional Ptosis, Ga 350000.0 6430000.0 1091 Repair Palpebra Dengan Tarsoconjunctival Graft, Ga 350000.0 6430000.0 1092 Repair Palpebra Dengan Hard Palate Mucosal Graft, Ga 350000.0 6430000.0 1093 Repair Palpebra Dengan Local Skin Flap, Ga 350000.0 6430000.0 1094 Repair Palpebra Dengan Septal Chondromucosal Graft, Ga 350000.0 6430000.0 1095 Repair Palpebra Dengan Skin Flap Regional, La 350000.0 6430000.0 1096 Repair Palpebra Dengan Skin Graft, La 350000.0 6430000.0 1097 Repair Palpebra Dengan Sliding Transconjunctival Flap, La 350000.0 6430000.0 1098 Repair Palpebra Komplek, Ga 350000.0 6430000.0 1099 Repair Polysyndactyly, Ga 350000.0 6430000.0 1100 Repair Syaraf Tepi, Ga 350000.0 6430000.0 1101 Repair Symbrachydactyly, Ga 350000.0 6430000.0 1102 Repair Tendon Ekstensor Tangan Multiple, Ga 350000.0 6430000.0 1103 Repair Tendon Fleksor Tangan Multipel+ Pulley Reconst., Ga 350000.0 6430000.0 1104 Repair Tendon Fleksor Tangan Multiple, Ga 350000.0 6430000.0 1105 Repair Tendon Fleksor Tangan Tunggal + Pulley Reconst., Ga 350000.0 6430000.0 1106 Repalatoplasty, Ga 350000.0 6430000.0 1107 Replantasi Jari Multiple, Ga 350000.0 6430000.0 1108 Replantasi Jari Tunggal, Ga 350000.0 6430000.0 1109 Reseksi Rahang, Ga 350000.0 6430000.0 1110 Restorasi Dan Rekonstruksi Softissue+ Bone Dengan Multiple Approach, Ga 350000.0 6430000.0 1111 Revaskularisasi Jari Multiple, Ga 350000.0 6430000.0 1112 Revaskularisasi Jari Tunggal, Ga 350000.0 6430000.0 1113 Revisi Dengan Multiple Z Plasty/W Plasty, Ga 350000.0 6430000.0 1114 Revisi Dengan Flap Jauh, Ga 350000.0 6430000.0 1115 Revisi Dengan Flap Lokal, Ga 350000.0 6430000.0 1116 Separasi Complex Syndactyly, Ga 350000.0 6430000.0 1117 Skin Flap Komplek Lebih Dari Satu Flap, Ga 350000.0 6430000.0 1118 Skin Flap Komplek, Ga 350000.0 6430000.0 1119 Skin Grafting Yang Luas, Ga 350000.0 6430000.0 1120 Skin Grafting Dengan Luas Sedang, Ga 350000.0 6430000.0 1121 Split Thickness Skin Graft (Stsg) Luas Dengan Perawatan Khusus, Ga 350000.0 6430000.0 1122 Staged Subcutaneous Excision Underneath Flaps, Ga 350000.0 6430000.0 1123 Stiff Finger Joint - Finger Arthoplasty With Silicone Implant, Ga 350000.0 6430000.0 1124 Stiff Finger Joint - Finger Arthoplasty With Titanium Implant, Ga 350000.0 6430000.0 1125 Supraorbital Bone Reconstruction, Ga 350000.0 6430000.0 1126 Temporalis Muscle Fascia Transfer, Ga 350000.0 6430000.0 1127 Tendon Transfer Multiple, Ga 350000.0 6430000.0 1128 Tendon Transfer Tunggal, Ga 350000.0 6430000.0 1129 Tendoplasty, Ga 350000.0 6430000.0 1130 Tissue Expantion, Ga 350000.0 6430000.0 1131 Tmj Arthroscopy And Treatment, Ga 350000.0 6430000.0 1132 Tmj Arthrotomy, Ga 350000.0 6430000.0 1133 Tmj Lavage Dengan C-Arm, Ga 350000.0 6430000.0 1134 Total Cranial Vault Reconstruction, Ga 350000.0 6430000.0 1135 Total Joint Repl With Vascularized Bone Graft, Ga 350000.0 6430000.0 1136 Total Joint Replacement With Implant, Ga 350000.0 6430000.0 1137 Total Skin And Subcutaneous Tissue Excision Dg Skingraft (Charles), Ga 350000.0 6430000.0 1138 Transeksual Female To Male, Ga 350000.0 6430000.0 1139 Transeksual Male To Female, Ga 350000.0 6430000.0 1140 Transplatation Penis, Ga 350000.0 6430000.0 1141 Urethroplasty, Ga 350000.0 6430000.0 1142 Facial Bone Countouring - Angle Reshaping, Ga 350000.0 6430000.0 1143 Facial Bone Countouring - Genioplasty With Silicone Implant, Ga 350000.0 6430000.0 1144 Facial Bone Countouring - Malarplasty With Silicone Implant, Ga 350000.0 6430000.0 1145 Facial Bone Countouring - Osseous Genioplasty, Ga 350000.0 6430000.0 1146 Facial Bone Countouring - Osseous Malarplasty, Ga 350000.0 6430000.0 1147 Facial Bone Countouring - Split Mandible Osteotomy, Ga 350000.0 6430000.0 1148 Orif Untuk Fraktur Le Fort Iii, Ga 350000.0 6430000.0 1149 Biopsi, La 350000.0 6430000.0 1150 Incisi Absces Perikondritis, La 350000.0 6430000.0 1151 Incisi Abscess, La, La 350000.0 6430000.0 1152 Kauterisasi Lesi Kulit Jinak, La 350000.0 6430000.0 1153 Kauterisasi Papiloma Kulit , La 350000.0 6430000.0 1154 Secondary Hechting, La 350000.0 6430000.0 1155 "" "" "" 1156 DOKTER BEDAH THORAX / VASKULAR "" "" 1157 JENIS PELAYANAN JS TARIF 1158 KECIL "" "" 1159 Pasang jarum Jet Can 350000.0 1110000.0 1160 Amputasi 1 digiti 350000.0 1110000.0 1161 "" "" "" 1162 BESAR "" "" 1163 Biopsi scalen 350000.0 1870000.0 1164 Debridement luas 350000.0 1870000.0 1165 Extirpasi hemangioma simple 350000.0 1870000.0 1166 Embolectomi (kh1) 350000.0 1870000.0 1167 Pemasangan akses vena port (VAP) 350000.0 1870000.0 1168 Removal VAP 350000.0 1870000.0 1169 Amputasi below knee 350000.0 1870000.0 1170 Amputasi above knee (kh 1) 350000.0 1870000.0 1171 Amputasi lengan 350000.0 1870000.0 1172 HD Cath ( open method ) 350000.0 1870000.0 1173 "" "" "" 1174 KHUSUS "" "" 1175 Torakotomisimpatektomi 350000.0 3400000.0 1176 Torakotomi biopsy 350000.0 3400000.0 1177 Torakotomi window 350000.0 3400000.0 1178 Ligasiarterikarotis 350000.0 3400000.0 1179 End arterectomi 350000.0 3400000.0 1180 Stripping + Extraksibabcock 350000.0 3400000.0 1181 Embolectomi + Amputasi (kh2) 350000.0 3400000.0 1182 Extirpasihemangioma duplex/kompleks 350000.0 3400000.0 1183 Repair arteri perifer tanpa graf 350000.0 3400000.0 1184 Repair AV fistula (kh2) 350000.0 3400000.0 1185 Eksisi tumor dinding dada 350000.0 3400000.0 1186 AV Shunt radialis 350000.0 3400000.0 1187 Stripping simple 350000.0 3400000.0 1188 Simpatektomi lumbal/abdominal 350000.0 3400000.0 1189 Reseksi tumor pleura 350000.0 3400000.0 1190 Torakotomi simple 350000.0 3400000.0 1191 Torakotomi dekortikasi 350000.0 3400000.0 1192 Torakotomi reseksi kosta / Sternum 350000.0 3400000.0 1193 Torakotomi ORIF kosta 350000.0 3400000.0 1194 Torakotomi segmentektomi (kh3) 350000.0 3400000.0 1195 Torakotomi removal korpal 350000.0 3400000.0 1196 Torakotomi Repair hernia diafragmatika (kh3) 350000.0 3400000.0 1197 Simpatektomi duplex 350000.0 3400000.0 1198 AV shunt cubiti 350000.0 3400000.0 1199 Reseksi aneurisma arteri perifer 350000.0 3400000.0 1200 Stripping duplex / komplex 350000.0 3400000.0 1201 Repair arteri dengan graf 350000.0 3400000.0 1202 Torakoscopi Biopsi 350000.0 3400000.0 1203 Torakoscopi Evakuasi 350000.0 3400000.0 1204 Torakoscopi Tutup Vistel 350000.0 3400000.0 1205 Pneumektomi 350000.0 3400000.0 1206 Rekonstruksi aneurisma aorta abdominalis per laparotomi 350000.0 3400000.0 1207 Rekonstruksi aneurisma aorta abdominalis suprarenal per laparotomi 350000.0 3400000.0 1208 Rekonstruksi aneurisma arteri iliaka per laparotomi 350000.0 3400000.0 1209 Reseksi tumor oesophagus + Rekonstruksi dengan conduid 350000.0 3400000.0 1210 Rekonstruksi dinding dada 350000.0 3400000.0 1211 Torakotomi Lobektomi 350000.0 3400000.0 1212 Reseksi tumor mediastinum 350000.0 3400000.0 1213 Reseksi tumor paru 350000.0 3400000.0 1214 Torakotomi dekortikasi dan plumbage 350000.0 3400000.0 1215 By pass arterifemoralis 350000.0 3400000.0 1216 Repair perforasi oesophagus 350000.0 3400000.0 1217 Repair bronchus 350000.0 3400000.0 1218 Repair trachea 350000.0 3400000.0 1219 Splenorenal shunt 350000.0 3400000.0 1220 Toracoskopi Reseksi paru 350000.0 3400000.0 1221 Toracoskopi Simpatektomi 350000.0 3400000.0 1222 Toracoskopi Pengambilan Korpal intra parenchym Paru 350000.0 3400000.0 1223 Toracoskopi Ligasi arteri 350000.0 3400000.0 1224 "" "" "" 1225 DOKTER BEDAH ANAK "" "" 1226 JENIS PELAYANAN JS TARIF 1227 KECIL "" "" 1228 Insisi dan drainase abses 350000.0 1110000.0 1229 Aplikasi silversulfadiazin, betadin, merkurokroom, antibiotika topikal pada omphalocele 350000.0 1110000.0 1230 Sirkumsisi Lokal 350000.0 1110000.0 1231 "" "" "" 1232 SEDANG "" "" 1233 Eksisi Kista dermoid 350000.0 1870000.0 1234 Skleroterapi lymphangioma dengan injeksi bleomycin, OK 432 350000.0 1870000.0 1235 Eksisi, biopsi lymphadenopaty 350000.0 1870000.0 1236 Eksisi biopsi soft tissue tumor leher, dinding perut 350000.0 1870000.0 1237 Eksisi tongue tie 350000.0 1870000.0 1238 eksisi granuloma umbilikal 350000.0 1870000.0 1239 Release synechia 350000.0 1870000.0 1240 Insisi imperforate hymen 350000.0 1870000.0 1241 "" "" "" 1242 BESAR "" "" 1243 Eksisi preauricular remnant/ extratragus 350000.0 3400000.0 1244 Eksisi kista, fistula branchial ( I, II, III ) 350000.0 3400000.0 1245 Eksisi Kista, fistula thyroglosus 350000.0 3400000.0 1246 Eksisi lymphangioma 350000.0 3400000.0 1247 Lobektomi thyroid 350000.0 3400000.0 1248 Eksisi, marsupialisasi ranula 350000.0 3400000.0 1249 Eksisi epignagthus 350000.0 3400000.0 1250 Gastrostomi 350000.0 3400000.0 1251 esofagostomi 350000.0 3400000.0 1252 Subkutaneus mastektomi ginekomastia 350000.0 3400000.0 1253 Herniotomi umbilikal 350000.0 3400000.0 1254 tutup defek dinding perut dengan silo 350000.0 3400000.0 1255 Fundoplikasi 350000.0 3400000.0 1256 Pyloromiotomy 350000.0 3400000.0 1257 Liver biopsi 350000.0 3400000.0 1258 Appendektomi 350000.0 3400000.0 1259 Eksisi tumor, biopsy neuroblastoma, teratoma, rabdomyosarkoma 350000.0 3400000.0 1260 Sphincterotomi anal, stretching anal 350000.0 3400000.0 1261 Thiersch procedure 350000.0 3400000.0 1262 Herniotorni, ligasi tinggi proc. vaginalis 350000.0 3400000.0 1263 Detorsio testis, orkhidopeksi, orkhidektomi 350000.0 3400000.0 1264 Eksisi kista baker's 350000.0 3400000.0 1265 Koreksi polidaktili 350000.0 3400000.0 1266 "" "" "" 1267 KHUSUS "" "" 1268 Lengthening m. sternokleidomastoideus 350000.0 6430000.0 1269 Thorakotomi Reseksi anastomosis esophagus 350000.0 6430000.0 1270 Esofagomyotomi achalasia 350000.0 6430000.0 1271 Thorakotomi tutup defek diafragma kongenital 350000.0 6430000.0 1272 Laparotomi tutup defek diafragma kongenital 350000.0 6430000.0 1273 Thorakotomy Plikasi diafragma 350000.0 6430000.0 1274 Laparotomi plikasi diafragma 350000.0 6430000.0 1275 Eksisi sinus, fistula dan kista omphalomesenterikus 350000.0 6430000.0 1276 Eksisi sinus, fistula dan kista urakhus 350000.0 6430000.0 1277 Repair dinding perut (abdominal closure) gastroskisis dan omphalokel 350000.0 6430000.0 1278 Abdominoplasty, urine diversion, orkhidopeksi pada prune belly syndrome 350000.0 6430000.0 1279 Gatropexy, reduction of valvulus, gastrostomi pada gangguan rotasi usus kongenital 350000.0 6430000.0 1280 Eksisi diafragma, mocosal ablation pada gastric diafragma atau pre antral web 350000.0 6430000.0 1281 Closure of perforation, gastrostomi 350000.0 6430000.0 1282 Foreign bodies and bezoar extraction per endoskopi, laparotomi 350000.0 6430000.0 1283 Ablasio duplikasi gastrointestinal 350000.0 6430000.0 1284 Duodenoduodenostomy, duodenojejunostomy 350000.0 6430000.0 1285 Reseksi pankreas 350000.0 6430000.0 1286 Kistojejunostomi R&Y, pada pseudokista pankreas 350000.0 6430000.0 1287 Hepatikojejunostomi R&Y pada kista duktus koledukus 350000.0 6430000.0 1288 Hepaticojejunostomy, portoenterostomy (Kasai) 350000.0 6430000.0 1289 Kholedokholitotomi, kholesistektomi 350000.0 6430000.0 1290 Total splenectomy, 350000.0 6430000.0 1291 Partial splenectomy 350000.0 6430000.0 1292 Splenoraphy 350000.0 6430000.0 1293 Reseksi anastomosis, ileostomi (Bishop­Koop/ Santulli, Mickulicz) pada obstruksi usus halus kongenital 350000.0 6430000.0 1294 Intraperitoneal lavage 350000.0 6430000.0 1295 Reduksi volvulus, Ladd procedure, appendeektomi 350000.0 6430000.0 1296 Wedge resection, reseksi anastomosis 350000.0 6430000.0 1297 Reduksi intususepsi per laparotomi 350000.0 6430000.0 1298 Reseksi anatomosis usus 350000.0 6430000.0 1299 Eksisi kista oinentum, mesenterial 350000.0 6430000.0 1300 Pull-through procedure (Swenson, Soave, Duhamel, transanal), myektomi (Lynn) 350000.0 6430000.0 1301 PSRHD 350000.0 6430000.0 1302 Nefrektomi total 350000.0 6430000.0 1303 Nefrektomi parsial 350000.0 6430000.0 1304 Pyeloplasti 350000.0 6430000.0 1305 Reimplantasi ureter, tapering, plikasi„ folding. 350000.0 6430000.0 1306 Eksisi ureterocele 350000.0 6430000.0 1307 Augmentation cystoplasty pada neurogenik bladder 350000.0 6430000.0 1308 Release chordee 350000.0 6430000.0 1309 Urethroplasty 350000.0 6430000.0 1310 Scrotoplasty 350000.0 6430000.0 1311 Vaginoplasty, urethroplasty pada sinus urogenitalis 350000.0 6430000.0 1312 Koreksi polidaktili 350000.0 6430000.0 1313 Koreksi syndaktili 350000.0 6430000.0 1314 Kholesistektomi 350000.0 6430000.0 1315 esophageal replacement (colon, gastric tube, jejenum, gastric pull-up) 350000.0 6430000.0 1316 thorakoskopi Reseksi anastomosis esophagus 350000.0 6430000.0 1317 Intestinal lengthening, 350000.0 6430000.0 1318 laparoskopi tutup defek diafragma kongenital 350000.0 6430000.0 1319 Reseksi liver, lobektomi, 350000.0 6430000.0 1320 Reduksi intususepsi per laparoskopy 350000.0 6430000.0 1321 laparoskopy appendektomy 350000.0 6430000.0 1322 PSARP (postero sagital anorectoplasti) 350000.0 6430000.0 1323 PSARUVP (posterosagital anorecto uretero vagino plasty 350000.0 6430000.0 1324 ASARP (anterosagital anorecto plasty) 350000.0 6430000.0 1325 abdominosakroperineal pulltrough 350000.0 6430000.0 1326 laparoskopi Fundoplikasi 350000.0 6430000.0 1327 laparoskopy assisted pulltrough 350000.0 6430000.0 1328 Genitoplasty, clitoral reduction, vaginoplasty, urethroplasty pada ambigous genital 350000.0 6430000.0 1329 Rectal closure, bladder closure, kolostomi, anorektoplasti, epispadia repair, continent surgery pada cloaca extrofia 350000.0 6430000.0 1330 Bladder closure, epispadia repair, continent surgery 350000.0 6430000.0 1331 Valve ablation pada posyterior uretral valve 350000.0 6430000.0 1332 laparoskopi herniotomi 350000.0 6430000.0 1333 laparoskopy pyeloplasty 350000.0 6430000.0 1334 laparoskopy reseksi usus 350000.0 6430000.0 1335 laparoskopi pyloromyotomi 350000.0 6430000.0 1336 laparoskopy splenektomi 350000.0 6430000.0 1337 laparoskopi kolesistektomi 350000.0 6430000.0 1338 thorakostomi koreksi pectus exavatus 350000.0 6430000.0 1339 intestinal transplantation 350000.0 6430000.0 1340 Twin separation surgery 350000.0 6430000.0 1341 Liver transplantation 350000.0 6430000.0 1342 "" "" "" 1343 DOKTER BEDAH TUMOR "" "" 1344 JENIS PELAYANAN JS TARIF 1345 KECIL "" "" 1346 Alligator biopsi 350000.0 1110000.0 1347 Katerisasi papilom 350000.0 1110000.0 1348 Cabut kuku 350000.0 1110000.0 1349 Biopsi, La 350000.0 1110000.0 1350 Incisi Absces Perikondritis, La 350000.0 1110000.0 1351 Incisi Abscess, La, La 350000.0 1110000.0 1352 Kauterisasi Lesi Kulit Jinak, La 350000.0 1110000.0 1353 Kauterisasi Papiloma Kulit , La 350000.0 1110000.0 1354 Secondary Hechting, La 350000.0 1110000.0 1355 Sirkumsisi Lokal 350000.0 1110000.0 1356 Eksisi Veruka, La 350000.0 1110000.0 1357 Eksterpasi Tumor Jinak, Diluar Wajah ,La 350000.0 1110000.0 1358 Ektirpasi Aterom Diluar Wajah, La 350000.0 1110000.0 1359 Ektirpasi Lipoma Diluar Wajah, La 350000.0 1110000.0 1360 "" "" "" 1361 SEDANG "" "" 1362 Eksisi papiloma GA 350000.0 1870000.0 1363 Eksisi atheroma GA 350000.0 1870000.0 1364 Debridement GA 350000.0 1870000.0 1365 Rehecting 350000.0 1870000.0 1366 Incisi abses GA 350000.0 1870000.0 1367 "" "" "" 1368 BESAR "" "" 1369 Eksisi papiloma multipel 350000.0 3400000.0 1370 Eksisi atheroma multipel 350000.0 3400000.0 1371 Biopsi dengan generalanestesi 350000.0 3400000.0 1372 Limfadenektomi dengan general anestesi 350000.0 3400000.0 1373 Eksisi FAM single 350000.0 3400000.0 1374 Eksisi Mastopati single 350000.0 3400000.0 1375 Subcutan mastektomi unilateral 350000.0 3400000.0 1376 Rekonstruksi nipple areolar complek unilateral 350000.0 3400000.0 1377 Eksisi tumor < 5cm 350000.0 3400000.0 1378 STSG/FTSG < 5cm 350000.0 3400000.0 1379 CWL procedure 350000.0 3400000.0 1380 Eksisi baker's cyst unilateral 350000.0 3400000.0 1381 Debridement +rehecting 350000.0 3400000.0 1382 "" "" "" 1383 KHUSUS "" "" 1384 Simple mastektomi 350000.0 6430000.0 1385 Eksisi FAM multiple / bilateral 350000.0 6430000.0 1386 Eksisi Mastopati multipel / bilateral 350000.0 6430000.0 1387 Rekonstruksi nipple areoler complek bilateral 350000.0 6430000.0 1388 Subcutan mastektomi bilateral 350000.0 6430000.0 1389 Istmolobektomi tiroid 350000.0 6430000.0 1390 Hemiglosektomi 350000.0 6430000.0 1391 Radikal Neck Dissection unilateral 350000.0 6430000.0 1392 Inguinal dissection unilateral 350000.0 6430000.0 1393 Axillary dissection unilateral 350000.0 6430000.0 1394 Eksisi luas tumor ≥ 5cm 350000.0 6430000.0 1395 Guttering abses 350000.0 6430000.0 1396 Eksisi mama acessories unilateral 350000.0 6430000.0 1397 Eksisi tumor submandibula unilateral 350000.0 6430000.0 1398 Core biopsi 350000.0 6430000.0 1399 Parsial / Hemimandibulektomi 350000.0 6430000.0 1400 Parotidektomi unilateral 350000.0 6430000.0 1401 Maxillektomi unilateral 350000.0 6430000.0 1402 Delay rekonstruksi maxilla/mandibulla 350000.0 6430000.0 1403 Delay rekonstruksi payudara unilateral (Flap/implant) 350000.0 6430000.0 1404 STSG/FTSG ≥ 5cm 350000.0 6430000.0 1405 Amputasi 350000.0 6430000.0 1406 Reanimasi N7 unilateral 350000.0 6430000.0 1407 Eksisi tumor intraoral unilateral 350000.0 6430000.0 1408 Cystrunk procedure 350000.0 6430000.0 1409 Tracheostomi tumor headneck 350000.0 6430000.0 1410 Eksisi baker's cyst bilateral 350000.0 6430000.0 1411 (Modified) Radikal Mastektomi 350000.0 6430000.0 1412 BCT (Breast Concerving Treatment) 350000.0 6430000.0 1413 Skin/NAC sparing mastektomi 350000.0 6430000.0 1414 Eksisi FAM multiple dan bilateral 350000.0 6430000.0 1415 Eksisi Mastopati multipel dan bilateral 350000.0 6430000.0 1416 Subtotal/neartotal/total tiroidektomi 350000.0 6430000.0 1417 Hemiglosektomi+Radikal Neck dissection unilateral 350000.0 6430000.0 1418 Eksisi mama acessories bilateral 350000.0 6430000.0 1419 Eksisi tumor submandibula bilateral 350000.0 6430000.0 1420 Hemimandibulektomi +reconstruksi(implant/FLAP) 350000.0 6430000.0 1421 Total mandibulektomi 350000.0 6430000.0 1422 Parotidektomi unilateral +neck disection 350000.0 6430000.0 1423 Maxillektomi + rekonstruksi (Implant/FLAP) 350000.0 6430000.0 1424 Maksilektomi bilateral 350000.0 6430000.0 1425 Delay rekonstruksi payudara bilateral (Flap/implant) 350000.0 6430000.0 1426 Pasang/lepas Port A Cath/VAP/Cell Side 350000.0 6430000.0 1427 Eksisi tumor intraoral bilateral 350000.0 6430000.0 1428 Eksisi tumor intraoral unilateral +neck dissection 350000.0 6430000.0 1429 Rekonstruksi hidung, bibir dengan flap/implant 350000.0 6430000.0 1430 Eksisi luas tumor ≥ 5cm +FLAP/graft 350000.0 6430000.0 1431 Muscle Group Excision 350000.0 6430000.0 1432 Debulking Tumor 350000.0 6430000.0 1433 (Modified) Radikal Mastektomi+rekonstruksi payudara dengan implant/ flap 350000.0 6430000.0 1434 Skin/NAC sparing mastektomi +rekonstruksi implant/flap 350000.0 6430000.0 1435 Total tiroidektomi + Neck dissection unilateral 350000.0 6430000.0 1436 Hemiglosektomi+Radikal Neck dissection bilateral 350000.0 6430000.0 1437 Endoskopi tiroidektomi 350000.0 6430000.0 1438 Sentinel node biopsi 350000.0 6430000.0 1439 Total mandibulektomi +rekonstruksi implant/ FLAP 350000.0 6430000.0 1440 Total maksilektomi +rekonstruksi implant/FLAP 350000.0 6430000.0 1441 Hemipelvektomi 350000.0 6430000.0 1442 Fore quarter amputasi 350000.0 6430000.0 1443 Hind quarter amputasi 350000.0 6430000.0 1444 Parotidektomi bilateral +rekonstruksi flap 350000.0 6430000.0 1445 Parotidektomi bilateral +neck dissection 350000.0 6430000.0 1446 Distant/ microsurgery flap (TRAM, LD, Gluteal,forearm, costa, fibula,pectoralis ) 350000.0 6430000.0 1447 "" "" "" 1448 DOKTER BEDAH SARAF "" "" 1449 JENIS PELAYANAN JS TARIF 1450 KECIL "" "" 1451 Blok saraf perifer (Pain Management Sederhana) 350000.0 1110000.0 1452 Punctie subgaleal hematom 350000.0 1110000.0 1453 Pemasangan Cervical Traksi / Halo Cast 350000.0 1110000.0 1454 Punctie Ventrikel 350000.0 1110000.0 1455 Biopsi saraf perifer 1 (ICD 9 CM 04) 350000.0 1110000.0 1456 Punctie Kranial 1 (IC 9 CM 01.0) 350000.0 1110000.0 1457 Ventrikulo Shunt (ICD 9 CM No 02.3) 350000.0 1110000.0 1458 "" "" "" 1459 SEDANG "" "" 1460 Ekstirpasi eksostosis tulang 350000.0 1870000.0 1461 Eksternal ventrikulostomi 350000.0 1870000.0 1462 Ekstirpasi kista dermoid/epidermoid cranium 350000.0 1870000.0 1463 Kranioplasty (Other Operation On Skull, Brain and Meninges (ICD 9 CM No 02.00) 350000.0 1870000.0 1464 Punctie Kranial 1 (ICD 9 CM 01.1) 350000.0 1870000.0 1465 "" "" "" 1466 BESAR "" "" 1467 Koreksi depressed frakture simple ( lama operasi < 1 jam ) 350000.0 3400000.0 1468 Saraf perifer : Dekompresi saraf perifer tanpa anastomosis ( dekompresi tunnel syndrome ) 350000.0 3400000.0 1469 Simple functional neurosurgery : Percutaneus Facet Denervation, Percutaneus Rhizotomi 350000.0 3400000.0 1470 Vaskuler surgery : ligasi karotis pada fistula karotikocavernosa 350000.0 3400000.0 1471 Operasi tulang belakang /Laminektomi 1 (ICD 9 CM 03.0) 350000.0 3400000.0 1472 Kraniotomi dan Kraniektomi 1 (ICD 9 CM 01.2) 350000.0 3400000.0 1473 Repair Meningocele dan Spina Bifida (ICD 9 CM 02.1) 350000.0 3400000.0 1474 Operasi Saraf Perifer 2 (ICD 9 CM 04.5) 350000.0 3400000.0 1475 "" "" "" 1476 KHUSUS "" "" 1477 Craniotomi/Kraniektomi neoplasma/ proses desak ruang : Neoplasma ekstra aksial supra tentorial : meningiomakonveksitas, Sitoreduksi/Ekstirpasi tumor superfisial 350000.0 6430000.0 1478 Endoskopic surgery 350000.0 6430000.0 1479 Stereotaktic surgery 350000.0 6430000.0 1480 Functional neurosurgery complicated : Kordotomi,Para vertebral /Visceral Blok / Simpatektomi 350000.0 6430000.0 1481 Kraniotomi Osteoma / Fibrous dysplasia 350000.0 6430000.0 1482 Kranioplasty defek kranium 350000.0 6430000.0 1483 Ekstirpasi cele (meningoencefalocele Anterior / Posterior . Lumbalis (Spina Bifida) 350000.0 6430000.0 1484 Koreksi depressed fraktur non complicated ( laserasi durameter . Duraplasty / duraraphy) 350000.0 6430000.0 1485 Spinal Surgery : Laminektomi dekompresi tanpa fiksasi : Kanal stenosis, Hernia Nukleus Polposus 350000.0 6430000.0 1486 Kranitomi epidural hematom supra tentorial, Burrhole kraniektomi subdural hematom kronis 350000.0 6430000.0 1487 Pemasangan pintasan LCS : Ventrikulo peritoneal shunt (VP Shunt) 350000.0 6430000.0 1488 Saraf perifer : Eksplorasi dengan neuroplasty / anastomosis saraf perifer 350000.0 6430000.0 1489 Kraniotomi dan Kraniektomi 2 (ICD 9 CM 01.2) 350000.0 6430000.0 1490 Operasi Saraf Perifer 3 (ICD 9 CM 04.4 350000.0 6430000.0 1491 Operasi tulang belakang /Laminektomi 2 (ICD 9 CM 03.5) 350000.0 6430000.0 1492 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 tumor 350000.0 6430000.0 1493 Koreksi/Rekonstruksi likworhoe, complicated depressed frakture (laserasi serebri dengan reseksi serebri) 350000.0 6430000.0 1494 Vaskuler surgery : Eksisi AVM, Aneurysma, Evakuasi perdarahan stroke 350000.0 6430000.0 1495 Kraniotomi dekompresi duraplasty Subdural hemato aku, Kraniotomi Epidural hematom supra dan atau Kraniektomi suboccipital Epidural Hematomi 350000.0 6430000.0 1496 Epileptic Surgery 350000.0 6430000.0 1497 Spinal Surgery Anterior/Posterior Fusion /Fixation, Laminektomi ekstirpasi tumor spinal 350000.0 6430000.0 1498 Pemasangan pintasan LCS : Atrio ventrikular shunt (AV Shunt) 350000.0 6430000.0 1499 Saraf perifer : Eksplorasi dengan neuroplasty/transposisi/anastomosis saraf 350000.0 6430000.0 1500 Endovaskuler DSA Serebral Diagnostik 350000.0 6430000.0 1501 Endovaskuler Coiling 1 350000.0 6430000.0 1502 Endovaskuler Coiling 2 350000.0 6430000.0 1503 Endovaskuler Coiling 3 350000.0 6430000.0 1504 Endovaskuler Baloning 1 350000.0 6430000.0 1505 Endovaskuler Baloning 2 350000.0 6430000.0 1506 Endovaskuler Embolisasi 1 350000.0 6430000.0 1507 Endovaskuler Embolisasi 2 350000.0 6430000.0 1508 Endovaskuler Embolisasi 3 350000.0 6430000.0 1509 Endovaskuler Trombolysis 350000.0 6430000.0 1510 Endovaskuler Trombus Removal Ischemic Stroke 350000.0 6430000.0 1511 Endovaskuler Carotid Arterial Stenting CAS 350000.0 6430000.0 1512 "" "" "" 1513 DOKTER BEDAH ORTHOPEDI "" "" 1514 JENIS PELAYANAN JS TARIF 1515 KECIL "" "" 1516 Release 1 Trigger Finger 350000.0 1110000.0 1517 Amputasi 1 jari 350000.0 1110000.0 1518 Atrodisis 1 jari 350000.0 1110000.0 1519 Excisi Ganglion carpi 350000.0 1110000.0 1520 "" "" "" 1521 SEDANG "" "" 1522 Amputasi 2 jari 350000.0 1870000.0 1523 Atrodisis 2 jari 350000.0 1870000.0 1524 Skin Grafting 350000.0 1870000.0 1525 Operasi arteri dengan tuntunan Arthroskopi 350000.0 1870000.0 1526 ORIF 1 jari 350000.0 1870000.0 1527 ORIF 1 metatarsal 350000.0 1870000.0 1528 ORIF 1 metacarpal 350000.0 1870000.0 1529 Debridement open fraktur 350000.0 1870000.0 1530 Release > 2 trigger finger 350000.0 1870000.0 1531 Blind External Fixasi 350000.0 1870000.0 1532 Discografi 350000.0 1870000.0 1533 Facet Vertebra Block dengan Fluoroscopy 350000.0 1870000.0 1534 Cabut inplant 350000.0 1870000.0 1535 "" "" "" 1536 BESAR "" "" 1537 Amputasi > 2 jari 350000.0 3400000.0 1538 Amputasi pergelangan tangan 350000.0 3400000.0 1539 Amputasi lengan bawah 350000.0 3400000.0 1540 Amputasi lengan atas 350000.0 3400000.0 1541 Amputasi pergelangan kaki 350000.0 3400000.0 1542 Amputasi tungkai bawah 350000.0 3400000.0 1543 Amputasi pedis 350000.0 3400000.0 1544 Amputasi siku 350000.0 3400000.0 1545 Amputasi paha 350000.0 3400000.0 1546 Amputasi lutut 350000.0 3400000.0 1547 Atrodesis > 2 jari 350000.0 3400000.0 1548 Atrodesis pergelangan tangan 350000.0 3400000.0 1549 Atrodesis sendi siku 350000.0 3400000.0 1550 Atrodesis sendi ankle 350000.0 3400000.0 1551 Atrodesis sendi lutut 350000.0 3400000.0 1552 ORIF 350000.0 3400000.0 1553 Fasciotomy 350000.0 3400000.0 1554 Arthrotomy + pinning 350000.0 3400000.0 1555 Squesterectomy 350000.0 3400000.0 1556 Arthrotomy + Debridement 350000.0 3400000.0 1557 Reposisi + pinning + pasang gip 350000.0 3400000.0 1558 Debridement + Reposisi + Pinning + pasang gip 350000.0 3400000.0 1559 Cabut wire dalam kulit dengan fluoroscopy 350000.0 3400000.0 1560 ORIF tibia Simple 350000.0 3400000.0 1561 ORIF Humerus Simple 350000.0 3400000.0 1562 Nailing femur Simple 350000.0 3400000.0 1563 ORIF Fibula Simple 350000.0 3400000.0 1564 ORIF 1 malleollus 350000.0 3400000.0 1565 ORIF Radius Simple 350000.0 3400000.0 1566 ORIF Ulna Simple 350000.0 3400000.0 1567 ORIF > 2 jari 350000.0 3400000.0 1568 ORIF > 2 Metatarsal 350000.0 3400000.0 1569 ORIF > 2 Metacarpal 350000.0 3400000.0 1570 ORIF Radius Distal 350000.0 3400000.0 1571 ORIF Femur Simple 350000.0 3400000.0 1572 ORIF Clauvicula 350000.0 3400000.0 1573 Debridement open fractore + ORIF tersebut diatas 350000.0 3400000.0 1574 ORIF Olecranon 350000.0 3400000.0 1575 ORIF Patella 350000.0 3400000.0 1576 Instra Discal Elektrotermal terapy 350000.0 3400000.0 1577 Tenoraphy > 2 Tendo 350000.0 3400000.0 1578 Neuraraphy > 2 Nervus 350000.0 3400000.0 1579 Excisi Tumor Jinak Tulang 350000.0 3400000.0 1580 External Fixasi + Reposisi terbuka 350000.0 3400000.0 1581 Minimal Invasive percutaneus Osteosynthesis 350000.0 3400000.0 1582 Release 1 Syndactyli 350000.0 3400000.0 1583 External Fixasi + Reposisi terbuka 350000.0 3400000.0 1584 Minimal Invasive percutaneus Osteosynthesis 350000.0 3400000.0 1585 Excisi Ganglion Poplitea 350000.0 3400000.0 1586 Tenoraphy 1 Tendo 350000.0 3400000.0 1587 Neuraraphy 1 Nervus 350000.0 3400000.0 1588 Release compressi saraf perifer 350000.0 3400000.0 1589 Neulolysis/Neurectomy dengan Fluoroscopy 350000.0 3400000.0 1590 "" "" "" 1591 KHUSUS "" "" 1592 Semua rekonstruksi 350000.0 6430000.0 1593 ORIF Tibia + Fibula 350000.0 6430000.0 1594 ORIF Malleolus Lateralis + Medialis 350000.0 6430000.0 1595 ORIF Radius + ULNA 350000.0 6430000.0 1596 ORIF Intercondiler Humeri 350000.0 6430000.0 1597 ORIF Intercondiler Femur 350000.0 6430000.0 1598 ORIF Intertroohanter Femur 350000.0 6430000.0 1599 Release CTEV 350000.0 6430000.0 1600 ORIF > 2 Metacarpal 350000.0 6430000.0 1601 Debridement open fracture + ORIF tersebut diatas 350000.0 6430000.0 1602 Rekonstruksi Blast Injury 350000.0 6430000.0 1603 Rekonstruksi Tendo/ 350000.0 6430000.0 1604 ORIF 1 Condilus Humeri 350000.0 6430000.0 1605 ORIF Collum humeri 350000.0 6430000.0 1606 ORIF Caput Humeri 350000.0 6430000.0 1607 ORIF Caput Femur 350000.0 6430000.0 1608 Release Contractur 1 sendi 350000.0 6430000.0 1609 ORIF tibia Kominutif 350000.0 6430000.0 1610 ORIF Humerus Kominutif 350000.0 6430000.0 1611 Nailing femur Kominutif 350000.0 6430000.0 1612 ORIF Fibula Kominutif 350000.0 6430000.0 1613 ORIF Ankle 350000.0 6430000.0 1614 ORIF Radius Kominutif 350000.0 6430000.0 1615 ORIF Ulna Kominutif 350000.0 6430000.0 1616 ORIF Femur Kominutif 350000.0 6430000.0 1617 Myocutan free vascularizeo flapping 350000.0 6430000.0 1618 Free vascularizeo bone grafting 350000.0 6430000.0 1619 Arthroscopy + Rekonstruksi sendi 350000.0 6430000.0 1620 Rekonstruksi ligament/tendo sendi bahu 350000.0 6430000.0 1621 Shish kebab nailling + osteotomy 350000.0 6430000.0 1622 Rekonstruksi Negleted Fraktur dan / atau Dislocasi 350000.0 6430000.0 1623 Triple Arthrodesis 350000.0 6430000.0 1624 Hemi Arthroplasty 350000.0 6430000.0 1625 Arthrodesis sendi coxae 350000.0 6430000.0 1626 Arthrodesis sendi bahu 350000.0 6430000.0 1627 Release Contracture> 2 sendi 350000.0 6430000.0 1628 Release contracture + Ostetomy + ORIF 350000.0 6430000.0 1629 ORIF Malunion Fracture 350000.0 6430000.0 1630 ORIF Nonunion Fracture 350000.0 6430000.0 1631 High Tibial Osteotomy 350000.0 6430000.0 1632 Supra condiler osteotomy 350000.0 6430000.0 1633 Varus/Valgus osteotomy 350000.0 6430000.0 1634 ORIF Pelvis 350000.0 6430000.0 1635 Excisi tumor jinak tulang + Rekonstruksi dengan Inplant/Bonecement. 350000.0 6430000.0 1636 Excisi tumor ganas tulang+ Rekonstruksi + Inplant /Bonecement 350000.0 6430000.0 1637 External Fixasi + Reposisi terbuka Cominnutive Fracture Dekat Sendi 350000.0 6430000.0 1638 French Osteotomy 350000.0 6430000.0 1639 Ligament > 2 Jari 350000.0 6430000.0 1640 Ilizarof Procedure 350000.0 6430000.0 1641 Release Syndactily > 2 350000.0 6430000.0 1642 Tendon Transfer 1-2 tendon 350000.0 6430000.0 1643 Rekonstruksi Ligamen/Tendo sendi Ankle 350000.0 6430000.0 1644 Release 1 Syndactyli 350000.0 6430000.0 1645 Release Ring Contriction Syndrome 350000.0 6430000.0 1646 Rekonstruksi Ligament/Tendo 1 Jari 350000.0 6430000.0 1647 Achiles Tendo Lengtening 350000.0 6430000.0 1648 Myocutan flapping 350000.0 6430000.0 1649 Meniscectomy 350000.0 6430000.0 1650 Reattachment osteochondritis 350000.0 6430000.0 1651 Cabut inplant tulang belakang 350000.0 6430000.0 1652 Explorasi plexus Brachialis 350000.0 6430000.0 1653 Debridement + Tenoraphy + Neuroraphy + Anas-tomose Vasculer. 350000.0 6430000.0 1654 Rekonstruksi Ligamen/Tendo sendi lutut 350000.0 6430000.0 1655 Tendon Transfer > 3 Tendon 350000.0 6430000.0 1656 Rekonstruksi Club Hand 350000.0 6430000.0 1657 Krukenberg Procedure 350000.0 6430000.0 1658 Juvara Procedure 350000.0 6430000.0 1659 Hand Surgery Rekonstruksi 350000.0 6430000.0 1660 Rekonstruksi Tulang pelvis 350000.0 6430000.0 1661 Total knee replacement 350000.0 6430000.0 1662 Total hip replacement 350000.0 6430000.0 1663 Kyphoplasty 350000.0 6430000.0 1664 Vertebroplasty 350000.0 6430000.0 1665 Micro Discectomy 350000.0 6430000.0 1666 Replantasi 350000.0 6430000.0 1667 Operasi tulang belakang dengan pasang instrument 350000.0 6430000.0 1668 Operasi tulang belakang dengan tuntunan endoscopy 350000.0 6430000.0 1669 Mikro surgery dengan mikroskop 350000.0 6430000.0 1670 Calotaxis/Lenghtening dengan Inplant/External fixasi 350000.0 6430000.0 1671 "" "" "" 1672 DOKTER MATA "" "" 1673 JENIS PELAYANAN JS TARIF 1674 KECIL "" "" 1675 Epilasi 350000.0 1110000.0 1676 "" "" "" 1677 SEDANG "" "" 1678 Anestesi Injeksi Subkonjungtiva 350000.0 1870000.0 1679 Anestesi Injeksi Retrobulbar/Parabulbar 350000.0 1870000.0 1680 Amotio Corpal Konjungtiva 350000.0 1870000.0 1681 Irigasi Mata 350000.0 1870000.0 1682 Aff Hecting Palpebra 350000.0 1870000.0 1683 Ganti Tampon 350000.0 1870000.0 1684 Toilet Luka 350000.0 1870000.0 1685 "" "" "" 1686 BESAR "" "" 1687 Injeksi Intravitreal 350000.0 3400000.0 1688 Amotio Corpal Kornea 350000.0 3400000.0 1689 Anel Test 350000.0 3400000.0 1690 Ekskokleasi Hordeolum/Kalazion 350000.0 3400000.0 1691 Eksisi Pterigium Bare Sclera 350000.0 3400000.0 1692 Eksisi Pterigium McReynold 350000.0 3400000.0 1693 Eksisi Pterigium Autograf dengan Jahitan 350000.0 3400000.0 1694 Sondasi 350000.0 3400000.0 1695 Ekstirpasi Kista Konjungtiva 350000.0 3400000.0 1696 Biopsi 350000.0 3400000.0 1697 Tarsorafi 350000.0 3400000.0 1698 Parasentesis 350000.0 3400000.0 1699 Amotio Lithiasis 350000.0 3400000.0 1700 Eksisi Granuloma 350000.0 3400000.0 1701 Ekstirpasi Nevus 350000.0 3400000.0 1702 Repair Palpebra 350000.0 3400000.0 1703 Iridektomi Perifer 350000.0 3400000.0 1704 Cyclocryotherapy (CCT) 350000.0 3400000.0 1705 Eksisi Tumor Konjungtiva 350000.0 3400000.0 1706 SBL Tarsotomi 350000.0 3400000.0 1707 Transplantasi Membran Amnion 350000.0 3400000.0 1708 Transplantasi Stem Cell 350000.0 3400000.0 1709 Flap Konjungtiva 350000.0 3400000.0 1710 Repair Entropion/Ektropion 350000.0 3400000.0 1711 Repair Kornea 350000.0 3400000.0 1712 Eviserasi 350000.0 3400000.0 1713 Enukleasi 350000.0 3400000.0 1714 Eksenterasi 350000.0 3400000.0 1715 Dermo-Fat Graft (DFG) 350000.0 3400000.0 1716 Repair Avulsi Kanalis Lacrimalis 350000.0 3400000.0 1717 ICCE 350000.0 3400000.0 1718 Laser Retina 350000.0 3400000.0 1719 Laser Iridotomi 350000.0 3400000.0 1720 Laser Kapsulotomi PCO 350000.0 3400000.0 1721 Aff Hecting Kornea 350000.0 3400000.0 1722 Fundus Florescein Angiography (FFA) 350000.0 3400000.0 1723 "" "" "" 1724 "" "" "" 1725 KHUSUS "" "" 1726 Eksisi Pterigium dengan Fibrin Glue 350000.0 6430000.0 1727 ECCE + IOL 350000.0 6430000.0 1728 SICS + IOL 350000.0 6430000.0 1729 Implantasi IOL Sekunder 350000.0 6430000.0 1730 Trabekulektomi 350000.0 6430000.0 1731 Orbitotomi Anterior 350000.0 6430000.0 1732 Repair Ptosis 350000.0 6430000.0 1733 Eksisi Luas (Wide Excision) 350000.0 6430000.0 1734 Scleral Buckle 350000.0 6430000.0 1735 Dekompresi Orbita 350000.0 6430000.0 1736 Repair Strabismus 350000.0 6430000.0 1737 Blefaroplasti 350000.0 6430000.0 1738 Evakuasi Silicon Oil 350000.0 6430000.0 1739 Combined Trabekulektomi + ECCE + IOL 350000.0 6430000.0 1740 Combined Trabekulektomi + SICS + IOL 350000.0 6430000.0 1741 Keratoplasti 350000.0 6430000.0 1742 Phacoemulsification + IOL 350000.0 6430000.0 1743 Combined Trabeklektomi + Phaco + IOL 350000.0 6430000.0 1744 Vitrectomy 350000.0 6430000.0 1745 Darcryocystorhynostomy (DCR) 350000.0 6430000.0 1746 "" 350000.0 6430000.0 1747 "" "" "" 1748 DOKTER SPESIALIS OBSTETRI DAN GINEKOLOGI "" "" 1749 JENIS PELAYANAN JS TARIF 1750 KECIL "" "" 1751 Closed/transuretral biopsy of bladder 350000.0 1110000.0 1752 Culdotomy 350000.0 1110000.0 1753 Diagnostic procedures on vulva (biopsi vulva) 350000.0 1110000.0 1754 Percutaneus aspiration of bartholin's gland (cyst) 350000.0 1110000.0 1755 Incision of Bartholin's gland (cyst)/ insisi abses bartolin 350000.0 1110000.0 1756 Excision or other destruction of Bartholin's 350000.0 1110000.0 1757 Suture of laceration of vulva and perineum 350000.0 1110000.0 1758 Repair of other current obstetric laceration (episioperineoraphy, perineorafi ruptur perineum grade 1-2) 350000.0 1110000.0 1759 "" "" "" 1760 SEDANG "" "" 1761 Other excision or destruction lession of uterus (pedunculata myoma) 350000.0 1870000.0 1762 Reclosure of postoperative disruption of abdominal wall 350000.0 1870000.0 1763 Transuretral cystoscopy 350000.0 1870000.0 1764 Bilateral endoscopic destruction or occlusion of fallopian tubes (laparoscopic MOW) 350000.0 1870000.0 1765 Other bilateral destruction or occlusion of fallopian tubes (Sterilisasi minilaparotomi) 350000.0 1870000.0 1766 unilateral destruction or occlusion of fallopian tube 350000.0 1870000.0 1767 Repair of internal cervical os (cerclage of isthmus uteri, shirodcard operation) 350000.0 1870000.0 1768 Dilation and curettage of uterus (for termination of pregnancy or following delivery or abortion, Diagnostic Currettage) 350000.0 1870000.0 1769 Aspiration curettage of uterus 350000.0 1870000.0 1770 Incision of vulva and perineum (Labia & vulva adhesion, enlargement introitus) 350000.0 1870000.0 1771 Removal of cerclage material from cervix 350000.0 1870000.0 1772 Hymenotomy 350000.0 1870000.0 1773 Suture of laceration of vagina 350000.0 1870000.0 1774 Marsupialization of Bartholin's gland (cyst) 350000.0 1870000.0 1775 Pubiotomy to assist delivery 350000.0 1870000.0 1776 Repair of current obstetric laceration of cervic 350000.0 1870000.0 1777 Repair of current obstetric laceration of rectum and spincter ani (Ruptur perineum grade 3 & 4) 350000.0 1870000.0 1778 "" "" "" 1779 BESAR "" "" 1780 Cesarean section and removal of fetus 350000.0 3400000.0 1781 Exploratory laparotomy 350000.0 3400000.0 1782 Reopening of recent laparotomy site 350000.0 3400000.0 1783 Other Laparotomy ( drainase of intraperitoneal abses or hematom/TOA) 350000.0 3400000.0 1784 Delayed closure of granulating abdominal wound 350000.0 3400000.0 1785 Oophorotomy 350000.0 3400000.0 1786 Diagnostic procedures on ovaries (aspirasi biopsi, biopsi) 350000.0 3400000.0 1787 Local excision or destruction of ovarian lesion or tissue (cystectomy) 350000.0 3400000.0 1788 Unilateral oophorectomy 350000.0 3400000.0 1789 Unilateral salpingo-oophorectomy 350000.0 3400000.0 1790 Bilateral oophorectomy 350000.0 3400000.0 1791 Bilateral salpingo-oophorectomy 350000.0 3400000.0 1792 Repair of ovary 350000.0 3400000.0 1793 Lysis of adhesions of ovary and fallopian tube 350000.0 3400000.0 1794 Manual rupture of ovarian cyst 350000.0 3400000.0 1795 Release of torsion of ovary 350000.0 3400000.0 1796 Salpingotomy and salpingostomy 350000.0 3400000.0 1797 Diagnostic procedures on fallopian tubes (biopsy of fallopian tube) 350000.0 3400000.0 1798 Total unilateral salpingectomy 350000.0 3400000.0 1799 Total bilateral salpingectomy 350000.0 3400000.0 1800 Other salpingectomy (cautherization, coagulation, electrocoagulation, excision) 350000.0 3400000.0 1801 Aspiration of fallopian tubes 350000.0 3400000.0 1802 Burying of fimbriae in uterine wall 350000.0 3400000.0 1803 Hysterotomy 350000.0 3400000.0 1804 Open biopsy of uterine ligament 350000.0 3400000.0 1805 Other excision or destruction lession of uterus (uterine myomectomy) 350000.0 3400000.0 1806 Subtotal abdominal hysterectomy 350000.0 3400000.0 1807 Excision or destruction of lesion or tissue of uterus and supporting structures 350000.0 3400000.0 1808 Uterine repair (hysteroraphy non obstetric) 350000.0 3400000.0 1809 Caesarean section of unspecified type ( Hysterotomy to terminate pregnancy) 350000.0 3400000.0 1810 Repair of current obstetric laceration of uterus 350000.0 3400000.0 1811 Repair of other current obstetric laceration (Blader and uretra) 350000.0 3400000.0 1812 Lysis of intraluminal adhesions of vagina 350000.0 3400000.0 1813 Other vaginotomy (vaginal septum/eksisi septum vaginal, drainase hematom of vaginal cuff) 350000.0 3400000.0 1814 Other repair of vagina (Colpoperineoplasty, Repair old obstetric laceration of vagina) 350000.0 3400000.0 1815 "" "" "" 1816 KHUSUS "" "" 1817 Insufflation of fallopian tube (hydrotubasi) 350000.0 6430000.0 1818 Conization of cervix excluding electrical/cryo 350000.0 6430000.0 1819 Amputation of cervix (fortegil operation) 350000.0 6430000.0 1820 Closed biopsy of uterine ligament (laparoscopy biopsy of uterine ligament) 350000.0 6430000.0 1821 Closed biopsy of uterus (laparoscopy or hysteroscopy) 350000.0 6430000.0 1822 Devision of endometrial synechia 350000.0 6430000.0 1823 Total abdominal hysterectomy 350000.0 6430000.0 1824 Vaginal hysterectomy (prolaps uteri) 350000.0 6430000.0 1825 Other local excision or destruction of vulva and perineum 350000.0 6430000.0 1826 Operations on clitoris 350000.0 6430000.0 1827 Hymenoraphy 350000.0 6430000.0 1828 Other repair of vulva and perineum (repair of old obstetric laceration of vulva or perineum) 350000.0 6430000.0 1829 Caeraean section with previous C-section or complicated pregnancy 350000.0 6430000.0 1830 Levator muscle operation for urethrovesical suspension 350000.0 6430000.0 1831 Other ( TOT, TVT-O, TVT) 350000.0 6430000.0 1832 Other and unspecific hysterectomy (Caesarean Hysterectomi) 350000.0 6430000.0 1833 Other repair of urinary bladder (repair fistula involving bladder and instestin/ rectovesikovaginal, vesicosigmoidovaginal) 350000.0 6430000.0 1834 Repair of other fistula of bladder (cervicovesical, uretroperineovesical, uterovesical, vaginovesical) 350000.0 6430000.0 1835 Other repair of bladder (repair of old obstetric laceration of bladder) 350000.0 6430000.0 1836 Plication of uretrovesical junction (Kelly Kenedy operation on uretra, Kelly stoeckel operation) 350000.0 6430000.0 1837 Suprapubic sling operation (Goebel-Frangenheim-Stoeckel urethrovesical suspension, Millin-Read uretrovesical suspension, Oxford operation for urinary incontinence, urethrocystopexy by suprapubic suspension, purandare) 350000.0 6430000.0 1838 Retropubic uretral suspension (Marshall-Marchetti-Krantz operation, Suture of periurethral tissue to symphysis pubis) 350000.0 6430000.0 1839 Paraurethral suspension 350000.0 6430000.0 1840 Repair of fallopian tube 350000.0 6430000.0 1841 Removal of prosthesis of fallopian tube 350000.0 6430000.0 1842 Hysteroscopy diagnostic 350000.0 6430000.0 1843 Incisin or excision of congernital uterus (Jones operation) 350000.0 6430000.0 1844 Vaginal hysterectomy (nondescent, exclude myoma) 350000.0 6430000.0 1845 Repair of uterine supporting structures (watkin procedure, manchester operation, plication ligament) 350000.0 6430000.0 1846 Obliteration and total excision of vagina:Vaginectomy (lefort operation & vaginectomy)/kolpokleisis 350000.0 6430000.0 1847 Vaginal construction and reconstruction (neovagina) 350000.0 6430000.0 1848 Obliteration of vaginal vault 350000.0 6430000.0 1849 Other vulvectomy (unilateral & bilateral vulvectomy/vulvektomi sederhana) 350000.0 6430000.0 1850 Removal of extratubal of ectopic pregnancy (abdonimal pregnancy) 350000.0 6430000.0 1851 Repair of rectovaginal fistule 350000.0 6430000.0 1852 Vaginal suspension and fixation (Burch suspension) 350000.0 6430000.0 1853 Repair of fistula of vulva or perineum 350000.0 6430000.0 1854 Amnioscopy (fetoscopy, laparoamnioscopy) 350000.0 6430000.0 1855 Other and unspecific hysterectomy (AVRUEL operation) 350000.0 6430000.0 1856 Laparoscopy 350000.0 6430000.0 1857 Closured of other fistula of ureter (vesicoureterovaginal fistulectomy) 350000.0 6430000.0 1858 Cystouretroplasty and plastic repair of bladder neck (plication of spincter of urinary bladder, VY plasty of bladder neck) 350000.0 6430000.0 1859 Aspiration of ovary (OPU) 350000.0 6430000.0 1860 Transplantation of ovary 350000.0 6430000.0 1861 Ovarian denervation 350000.0 6430000.0 1862 Implantation or replacement of prothesis of fallopian tube 350000.0 6430000.0 1863 Vaginal hysterectomy (laparoscopically assisted vaginal) 350000.0 6430000.0 1864 Vaginal hysterectomy (nondescent due to myoma) 350000.0 6430000.0 1865 Radical abdominal hysterectomy (wertheim, POA) 350000.0 6430000.0 1866 Radical vaginal hysterectomy 350000.0 6430000.0 1867 Pelvic eviceration 350000.0 6430000.0 1868 Paracervical uterine denervation 350000.0 6430000.0 1869 Local excision or destruction of vagina and rectouterine pouch (hymenectomy, endometrectomy of cul de sac) 350000.0 6430000.0 1870 Repair of cystocele and rectocele 350000.0 6430000.0 1871 Radical vulvectomy 350000.0 6430000.0 1872 Other intrauterine operations on fetus and amnion 350000.0 6430000.0 1873 Other operation on cervix and uterus (Hysteroscopy therapetic) 350000.0 6430000.0 1874 Repair of colovaginal fistule 350000.0 6430000.0 1875 Repair of other vaginoenteric fistule 350000.0 6430000.0 1876 Correction of fetal defect 350000.0 6430000.0 1877 "" "" "" 1878 DOKTER SPESIALIS THT "" "" 1879 JENIS PELAYANAN JS TARIF 1880 KECIL "" "" 1881 Insisi Abses (septum, furunkel, tonsil peritonsil, preauricula) 350000.0 1110000.0 1882 Explorasi Nashofarinx 350000.0 1110000.0 1883 Extirpasi (kista, atheroma, granuloma, papiloma) 350000.0 1110000.0 1884 Extraksi benda asing (telinga, hidung, orofaring) 350000.0 1110000.0 1885 Evakuasi serumen/ kolesteatoma dengan penyakit 350000.0 1110000.0 1886 Insisi hematoma telinga (othematoma/pseudocyst) 350000.0 1110000.0 1887 Penggantian arteficial laring (provox) esofagus (NGT) 350000.0 1110000.0 1888 Parasentesis 350000.0 1110000.0 1889 Biopsi tumor (telinga, hidung, orofaring) 350000.0 1110000.0 1890 Biopsi insisi tumor leher 350000.0 1110000.0 1891 "" "" "" 1892 SEDANG "" "" 1893 Miringotomi 350000.0 1870000.0 1894 Pemasangan Grommet 350000.0 1870000.0 1895 Extraksi benda asing telinga dengan penyulit 350000.0 1870000.0 1896 Extraksi kolesteatoma dengan penyulit 350000.0 1870000.0 1897 Extirpasi fistel preaurikuler 350000.0 1870000.0 1898 Reposisi fraktur os nasal 350000.0 1870000.0 1899 Extraksi polip nasal 350000.0 1870000.0 1900 Irigasi sinus 350000.0 1870000.0 1901 Sinuskopi diagnostik 350000.0 1870000.0 1902 Extraksi benda asing hidung dengan penyulit 350000.0 1870000.0 1903 Konkotomi 350000.0 1870000.0 1904 Antrostomi Intranasal 350000.0 1870000.0 1905 Trakeostomi elektif 350000.0 1870000.0 1906 Pasang dan ganti stent laring 350000.0 1870000.0 1907 Laringoskopi diagnostik 350000.0 1870000.0 1908 Intubasi dengan 'flexible Bronchoscopy) 350000.0 1870000.0 1909 Explorasi abses submandibula 350000.0 1870000.0 1910 Adenoidektomi 350000.0 1870000.0 1911 Sialendoskopi diagnostik 350000.0 1870000.0 1912 Reposisi fraktur arkus Zygomatikus 350000.0 1870000.0 1913 Esofaguskopi diagnostik 350000.0 1870000.0 1914 Multple explorasi biopsi tumor 350000.0 1870000.0 1915 Insisi biopsi kelenjar leher 350000.0 1870000.0 1916 Extirpasi tumor jinak sinunasal, kavitas oral 350000.0 1870000.0 1917 Extirpasi tumor jinak kelenjar liur 350000.0 1870000.0 1918 "" "" "" 1919 BESAR "" "" 1920 Miringoplasti 350000.0 3400000.0 1921 Kanaloplasti 350000.0 3400000.0 1922 Timpanoplasti 350000.0 3400000.0 1923 Meatoplasti 350000.0 3400000.0 1924 Mastoidektomi sederhana 350000.0 3400000.0 1925 Septum reseksi 350000.0 3400000.0 1926 Turbinoplasti 350000.0 3400000.0 1927 Septoplasti 350000.0 3400000.0 1928 Rinoplasti 350000.0 3400000.0 1929 Antrostomi extranasal (Caldwell Luc) 350000.0 3400000.0 1930 Sinuskopi dengan tindakan 350000.0 3400000.0 1931 Fronto ethmoidektomi external 350000.0 3400000.0 1932 Tonsillo adenoidektomi 350000.0 3400000.0 1933 Trakeostomi emergensi dengan penyulit 350000.0 3400000.0 1934 Laryngoskopi dengan tindakan 350000.0 3400000.0 1935 Explorasi abses parafaring, retrofaring 350000.0 3400000.0 1936 Explorasi abses multiple 350000.0 3400000.0 1937 Rekakeaonstruksi fraktur laring-trakea 350000.0 3400000.0 1938 Bedah mikro laring 350000.0 3400000.0 1939 Esofaguskopi dengan tindakan/penyulit 350000.0 3400000.0 1940 Sialendoskopi terapi/dilatasi 350000.0 3400000.0 1941 Labioplasti 350000.0 3400000.0 1942 Palatoplasti 350000.0 3400000.0 1943 Faringeal flap 350000.0 3400000.0 1944 Forehead flap 350000.0 3400000.0 1945 Laringofisur 350000.0 3400000.0 1946 Operasi tumor kelenjar liur 350000.0 3400000.0 1947 Laringektomi parsial 350000.0 3400000.0 1948 Tiroidektomi subtotal 350000.0 3400000.0 1949 Parotidektomi superfisial 350000.0 3400000.0 1950 Hemiglosektomi 350000.0 3400000.0 1951 Wide eksisi tumor tonsil, orofaring 350000.0 3400000.0 1952 Ligasi a. karatis externa 350000.0 3400000.0 1953 Extirpasi Angiofibroma Nasofaring 350000.0 3400000.0 1954 Maxilektomi parsial 350000.0 3400000.0 1955 Mandibulektomi parsial 350000.0 3400000.0 1956 Mini FESS 350000.0 3400000.0 1957 Uvulo-Palatofaringoplasti (UPPP) 350000.0 3400000.0 1958 "" "" "" 1959 KHUSUS "" "" 1960 Maxilektomi total 350000.0 6430000.0 1961 Mandibulektomi total 350000.0 6430000.0 1962 Laringektomi total + Deseksi Leher 350000.0 6430000.0 1963 Tiroidektomi total 350000.0 6430000.0 1964 Parotidektomi total 350000.0 6430000.0 1965 Hemiglosektomi + Deseksi Leher 350000.0 6430000.0 1966 Deseksi Leher Radikal 350000.0 6430000.0 1967 Timpano- Mastoidektomi 350000.0 6430000.0 1968 Mastoidektomi Modifikasi Radikal 350000.0 6430000.0 1969 Mastoidektomi Radikal 350000.0 6430000.0 1970 Osikuloplasti 350000.0 6430000.0 1971 Stapedektomi 350000.0 6430000.0 1972 Dekompresi nervus fasialis 350000.0 6430000.0 1973 Reseksi tulang temporal 350000.0 6430000.0 1974 Septorinoplasti 350000.0 6430000.0 1975 Rinoplasti augmentasi 350000.0 6430000.0 1976 FESS (funtional endoscopy sinus surgery) 350000.0 6430000.0 1977 ESS (endoscopy sinus surgery) 350000.0 6430000.0 1978 Otoplasti 350000.0 6430000.0 1979 Implan Koklea 350000.0 6430000.0 1980 Rekonstruksi fraktur rahang/wajah 350000.0 6430000.0 1981 Rekonstruksi telinga, mikrotia + aural atresia) 350000.0 6430000.0 1982 "" "" "" 1983 DOKTER SPESIALIS PARU "" "" 1984 JENIS PELAYANAN JS TARIF 1985 KECIL "" "" 1986 Aspirasi/incisi abses paru 350000.0 1110000.0 1987 Aspirasi/incisi empyema 350000.0 1110000.0 1988 Pungsi pleura / needle thoraccoentesis evakuasi 350000.0 1110000.0 1989 Pungsi pleura / needle thoraccoentesis evakuasi emergensi/cito 350000.0 1110000.0 1990 Pemasangan mini WSD 350000.0 1110000.0 1991 Injeksi intra vacum pleura 350000.0 1110000.0 1992 "" "" "" 1993 SEDANG "" "" 1994 Transthoracal needle aspiration/ TTNA 350000.0 1870000.0 1995 Transthoracal biopsy/ TTB 350000.0 1870000.0 1996 Transbronchial needle aspiration/biopsi (TBNA/TBNB) 350000.0 1870000.0 1997 Pleurodesis 350000.0 1870000.0 1998 "" "" "" 1999 BESAR "" "" 2000 Biopsi pleura 350000.0 3400000.0 2001 Pemasangan WSD /tube thoracocentesis WSD dg lokal anestesi (OPERATIF) 350000.0 3400000.0 2002 Pemasangan WSD /tube thoracocentesis WSD dg lokal anestesi emergensi/cito (OPERATIF) 350000.0 3400000.0 2003 "" "" "" 2004 TABEL 15. "" "" 2005 PELAYANAN TINDAKAN PERSALINAN "" "" 2006 "" "" "" 2007 JENIS PELAYANAN JS TARIF 2008 PERSALINAN TANPA PENYULIT (NORMAL) 300000.0 1163000.0 2009 PERSALINAN DENGAN PENYULIT PER VAGINAM 602000.0 2092000.0 2010 INDUKSI PERSALINAN (PARTUS GAGAL) 20000.0 71000.0 2011 "" "" "" 2012 TABEL 16. "" "" 2013 PELAYANAN ASUHAN KEPERAWATAN "" "" 2014 "" "" "" 2015 JENIS PELAYANAN JS TARIF 2016 ASKEP PASIEN SELF CARE 10000.0 50000.0 2017 ASKEP PASIEN PARSIAL CARE 10000.0 90000.0 2018 ASKEP PADA PASIEN TOTAL CARE 10000.0 130000.0 2019 ASKEP PADA PASIEN INTENSIVE CARE 10000.0 160000.0 2020 "" "" "" 2021 TABEL 17. "" "" 2022 PELAYANAN ANESTESI "" "" 2023 "" "" "" 2024 JENIS TINDAKAN JS TARIF 2025 TINDAKAN MEDIK ANESTESI KECIL 350000.0 730000.0 2026 TINDAKAN MEDIK ANESTESI SEDANG 350000.0 1110000.0 2027 TINDAKAN MEDIK ANESTESI BESAR 350000.0 1870000.0 2028 TINDAKAN MEDIK ANESTESI KHUSUS 350000.0 3390000.0 2029 "" "" "" 2030 TABEL 18. "" "" 2031 PELAYANAN DIKLAT "" "" 2032 "" "" "" 2033 JENIS PELAYANAN JS TARIF 2034 PRAKTEK DAN PENELITIAN TENAGA KEPERAWATAN / KEBIDANAN : "" "" 2035 Profesi / orang / minggu 60000.0 150000.0 2036 Sarjana / orang / minggu 40000.0 100000.0 2037 Diploma / orang / minggu 30000.0 75000.0 2038 PRAKTEK DAN PENELITIAN TENAGA KESEHATAN LAIN : "" "" 2039 Profesi / orang / minggu 60000.0 150000.0 2040 Sarjana / orang / minggu 40000.0 100000.0 2041 Diploma / orang / minggu 30000.0 75000.0 2042 PRAKTEK DAN PENELITIAN TENAGA NON KESEHATAN : "" "" 2043 SLTA sederajat / orang / minggu 16000.0 40000.0 2044 Diploma / orang / minggu 20000.0 50000.0 2045 Diploma IV atau S1 / orang / minggu 30000.0 75000.0 2046 S2 / orang / minggu 60000.0 150000.0 2047 Penelitian DIII / orang / paket 50000.0 125000.0 2048 Penelitian S1 / orang / paket 80000.0 200000.0 2049 Penelitian S2 / orang / paket 100000.0 250000.0 2050 Uji Validitas 20000.0 50000.0 2051 Job Training Keterampilan Khusus (peminatan) / paket 3 bln 1000000.0 2500000.0 2052 Job Training perawat dan bidan / paket 3 bln 480000.0 1200000.0 2053 Job Training tenaga kesehatan lain (gizi, farmasi, radiologi, fisioterapi dll) / paket 3 bln 360000.0 900000.0 2054 Job Training tenaga non kesehatan (akuntansi, IT, dll) / paket 3 bln 300000.0 750000.0 2055 Kunjungan siswa SLTA / hari / orang / tempat 8000.0 20000.0 2056 Kunjungan mahasiswa DIII / hari / orang / tempat 10000.0 25000.0 2057 Kunjungan mahasiswa DIV atau S1 / hari / orang / tempat 12000.0 30000.0 2058 Kunjungan mahasiswa S2 / hari / orang / tempat 14000.0 35000.0 2059 Kunjungan / hari (pegawai atau peserta diklat) / orang / tempat 24000.0 60000.0 2060 Kunjungan dari RS lain / paket / kunjungan / orang 100000.0 250000.0 2061 "" "" "" 2062 "" "" "" 2063 TABEL 19. "" "" 2064 SEWA LAHAN "" "" 2065 "" "" "" 2066 JENIS PELAYANAN JS TARIF 2067 RUANG PERTEMUAN "" "" 2068 Sewa Ruang Pertemuan/Aula ( paket/hari ) kapasitas max 25 orang 250000.0 250000.0 2069 Sewa Ruang Pertemuan/Aula ( paket/hari ) kapasitas max 75 orang 750000.0 750000.0 2070 Sewa Ruang Pertemuan/Aula ( paket/hari ) kapasitas max 150 orang 1000000.0 1000000.0 2071 Biaya Tambahan Fasilitas & Penyiapannya bila diperlukan 0.0 0.0 2072 Proses alih media arsip ke video / disk 150000.0 150000.0 2073 Sewa Tempat dan Bangunan 0.0 0.0 2074 Areal 1 / M2 / Bln 70000.0 70000.0 2075 Areal 2 / M2 / Bln 50000.0 50000.0 2076 "" "" "" 2077 CATATAN SEWA LAHAN: "" "" 2078 Area 1 adalah untuk area bisnis yang berada di lokasi strategis "" "" 2079 Area 2 adalah untuk area non bisnis "" "" 2080 "" "" "" 2081 TABEL 20. "" "" 2082 PELAYANAN HIV-AIDS "" "" 2083 "" "" "" 2084 JENIS PELAYANAN JS TARIF 2085 Staging klinis ODHA 6000.0 24000.0 2086 Paket VCT Mobile (per kunjungan / org)* 75000.0 108000.0 2087 Paket in house Training HIV-AIDS** 150000.0 2650000.0 2088 Konseling Pelayanan HIV-AIDS 6000.0 41000.0 2089 "" "" "" 2090 CATATAN : "" "" 2091 Paket VCT Mobile adalah konseling dan pemeriksaan HIV di RS / klinik swasta di Kota Cilacap "" "" 2092 Paket in house training HIV-AIDS adalah pemberian training, meliputi KIE dasar HIV-AIDS, pemeriksaan, pengelolaan kasus, perawatan, dukungan dan pengobatan ODHA "" "" 2093 "" "" "" 2094 "" "" "" 2095 TABEL 21. "" "" 2096 PELAYANAN HOME CARE "" "" 2097 "" "" "" 2098 JENIS PELAYANAN JS TARIF 2099 PELAYANAN MEDIS : 0.0 "" 2100 Pemeriksaan dokter umum 20000.0 110000.0 2101 Pemeriksaan dokter Spesialis 25000.0 185000.0 2102 Konsultasi dokter Spesialis 15000.0 90000.0 2103 Tindakan Medis : "" "" 2104 Plebotomi 24000.0 74000.0 2105 Pungsi 24000.0 74000.0 2106 Tranfusi Albumin 3000.0 14000.0 2107 Tranfusi Darah 11000.0 86000.0 2108 Nebulizer 12000.0 22000.0 2109 Pemberian obat Suppositoria 3000.0 7000.0 2110 Lepas dan atau pasang canul Tracheostomy oleh dokter 6000.0 56000.0 2111 Tindakan Akupunktur 10000.0 60000.0 2112 "" "" "" 2113 PELAYANAN KEPERAWATAN : 0.0 0.0 2114 Kunjungan Perawat / Bidan 7000.0 70000.0 2115 Tindakan Keperawatan : 0.0 0.0 2116 Perawatan Luka : 0.0 0.0 2117 PLK Kecil 3000.0 9000.0 2118 PLK Sedang 3000.0 11000.0 2119 PLK Besar 4000.0 14000.0 2120 Pasang NGT/SONDE 4000.0 16000.0 2121 Pasang DC 4000.0 15000.0 2122 Pasang Infus 4000.0 15000.0 2123 Injeksi : 3000.0 12000.0 2124 Suction Sputum 3000.0 7000.0 2125 Manual faeces 3000.0 12000.0 2126 Lavement 3000.0 14000.0 2127 Memandikan pasien 3000.0 14000.0 2128 Mencuci rambut 3000.0 14000.0 2129 Periksa Gula Darah Manual 8000.0 13000.0 2130 Bantuan Pernapasan/RJP 34000.0 44000.0 2131 Oral Higiene 1000.0 6000.0 2132 Vulva Higiene 1000.0 6000.0 2133 Pembersihan telinga 1000.0 6000.0 2134 Evakuasi Serumen prop oleh dokter 2000.0 12000.0 2135 Menunggu pasien oleh perawat / bidan "" "" 2136 Pukul 07.00 - 14.00 6000.0 44000.0 2137 Pukul 14.00 - 21.00 6000.0 44000.0 2138 Pukul 21.00 - 07.00 8000.0 58000.0 2139 "" "" "" 2140 PEMERIKSAAN PENUNJANG "" "" 2141 EKG 23000.0 53000.0 2142 Ambil lab : "" "" 2143 Sampel darah, urin, dan tinja 4000.0 21000.0 2144 Sampel darah 3000.0 14000.0 2145 Sampel urin / tinja 3000.0 9000.0 2146 "" "" "" 2147 REHABILITASI MEDIS "" "" 2148 Kunjungan Fisioterapi 18000.0 68000.0 2149 Okupasiterapi 18000.0 68000.0 2150 Terapi Wicara 20000.0 95000.0 2151 "" "" "" 2152 PELAYANAN AHLI GIZI "" "" 2153 Kunjungan Ahli Gizi "" 40000.0 2154 Penyusunan menu makanan 14000.0 59000.0 2155 "" "" "" 2156 "" "" "" 2157 PELAYANAN PSIKOLOGI "" "" 2158 Kunjungan Psikolog 25000.0 150000.0 2159 "" "" "" 2160 PELAYANAN TRANSPORTASI (AMBULANCE) "" "" 2161 Transportasi / Ambulance Dalam Kota 87500.0 87500.0 2162 Supir 0.0 35000.0 2163 "" "" "" 2164 Transportasi / Ambulance Luar Kota "" "" 2165 Supir (1500 / km) "" "" 2166 Biaya BBM (6000/km) "" "" 2167 "" "" "" 2168 SEWA ALAT 87500.0 122500.0 2169 Bed / tempat tidur pasien 6000.0 6000.0 2170 Kursi roda 3000.0 3000.0 2171 Kasur dekubitus 8000.0 8000.0 2172 Tabung O2 (kosong) 8000.0 8000.0 2173 Regulator 8000.0 8000.0 2174 Suction 13000.0 13000.0 2175 Nebulizer 13000.0 13000.0 2176 Tiang Infus 2000.0 2000.0 2177 Urinal 2000.0 2000.0 2178 Pispot 2000.0 2000.0 2179 Peralatan ganti balut 8000.0 8000.0 2180 Catatan Home Care: "" "" 2181 Tarip sewa alat dihitung perhari. "" "" 2182 Seluruh biaya tarif belum termasuk obat "" "" 2183 "" "" "" 2184 TABEL 22. "" "" 2185 PELAYANAN CSSD DAN LOUNDRY "" "" 2186 "" "" "" 2187 JENIS PELAYANAN JS TARIF 2188 CSSD DAN LOUNDRY KATAGORI KECIL 57400.0 82000.0 2189 CSSD DAN LOUNDRY KATAGORI SEDANG 65800.0 94000.0 2190 CSSD DAN LOUNDRY BESAR 74200.0 106000.0 2191 "" "" "" 2192 CATATAN : "" "" 2193 Peralatan terdiri dari : "" "" 2194 Duk Lubang Besar "" "" 2195 Duk penolong "" "" 2196 Jas OP "" "" 2197 Klem "" "" 2198 Pinset "" "" 2199 Gunting "" "" 2200 Hack "" "" 2201 Handel mess "" "" 2202 Nalpoeder "" "" 2203 Peritonium Klem "" "" 2204 Doek Klem "" "" 2205 Suction Canule "" "" 2206 Klem Besar "" "" 2207 Selang Sucsen "" "" 2208 "" "" "" 2209 TABEL 23. "" "" 2210 PELAYANAN MEDICAL CHECK UP "" "" 2211 "" "" "" 2212 A. Pemeriksaan Kesehatan Dasar "" "" 2213 JENIS PELAYANAN JS TARIF 2214 Pemeriksaan Dokter Umum 6000.0 54000.0 2215 Laboratorium : "" "" 2216 Darah lengkap 7000.0 21000.0 2217 Urin rutin 12000.0 25000.0 2218 Feces rutin 12000.0 21000.0 2219 Golongan darah 1500.0 4500.0 2220 Rontgen foto thoraks 57000.0 108000.0 2221 Administrasi 7000.0 10000.0 2222 Total "" 243500.0 2223 "" "" "" 2224 B. Pemeriksaan Kesehatan Dasar Plus Perempuan "" "" 2225 JENIS PELAYANAN JS TARIF 2226 Pemeriksaan Dokter Spesialis Dalam 6000.0 70000.0 2227 Pemeriksaan Dokter spesialis THT (rutin) 6000.0 70000.0 2228 Pemeriksaan Dokter spesialis Mata (funduskopi) 38000.0 128000.0 2229 Pemeriksaan Dokter spesialis obsgyn (papsmear) 17500.0 56000.0 2230 Laboratorium : "" "" 2231 Darah lengkap 7000.0 21000.0 2232 Urin rutin 12000.0 25000.0 2233 Feces rutin 12000.0 21000.0 2234 Golongan darah 1500.0 4500.0 2235 SGPT 3500.0 10500.0 2236 SGOT 3500.0 10500.0 2237 Gula darah puasa 3500.0 10500.0 2238 Gula darah 2 jam setelah makan 3500.0 10500.0 2239 Ureum 3500.0 10500.0 2240 Kreatinin 4000.0 12000.0 2241 Kolesterol 4000.0 12000.0 2242 Trigliserid 4000.0 12000.0 2243 Rontgen foto thoraks 57000.0 108000.0 2244 Administrasi 7000.0 10000.0 2245 EKG simple 38000.0 128000.0 2246 Total "" 730000.0 2247 "" "" "" 2248 C. Pemeriksaan Kesehatan Dasar Plus Laki-laki "" "" 2249 JENIS PELAYANAN JS TARIF 2250 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2251 Pemeriksaan Dokter spesialis THT (rutin) 6000.0 70000.0 2252 Pemeriksaan Dokter spesialis Mata (funduskopi) 38000.0 128000.0 2253 Laboratorium : "" "" 2254 Darah lengkap 7000.0 21000.0 2255 Urin rutin 12000.0 25000.0 2256 Feces rutin 12000.0 21000.0 2257 Golongan darah 1500.0 4500.0 2258 SGPT 3500.0 10500.0 2259 SGOT 3500.0 10500.0 2260 Gula darah puasa 3500.0 10500.0 2261 Gula darah 2 jam setelah makan 3500.0 10500.0 2262 Ureum 3500.0 10500.0 2263 Kreatinin 4000.0 12000.0 2264 Kolesterol 4000.0 12000.0 2265 Trigliserid 4000.0 12000.0 2266 Rontgen foto thoraks 57000.0 108000.0 2267 Administrasi 7000.0 10000.0 2268 EKG simple 38000.0 128000.0 2269 Total "" 674000.0 2270 "" "" "" 2271 D. Pemeriksaan Kesehatan Standar Perempuan "" "" 2272 JENIS PELAYANAN JS TARIF 2273 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2274 Pemeriksaan Dokter spesialis THT (audiometri) 38000.0 128000.0 2275 Pemeriksaan Dokter spesialis Mata (funduskopi) 38000.0 128000.0 2276 Pemeriksaan Dokter spesialis obsgyn (papsmear) 17500.0 56000.0 2277 Pemeriksaan Dokter spesialis gigi 6000.0 70000.0 2278 Laboratorium : "" "" 2279 Darah Lengkap 7000.0 21000.0 2280 Urin rutin 12000.0 25000.0 2281 Feces rutin 12000.0 21000.0 2282 Golongan darah 1500.0 4500.0 2283 SGPT 3500.0 10500.0 2284 SGOT 3500.0 10500.0 2285 Gula darah puasa 3500.0 10500.0 2286 Gula darah 2 jam setelah makan 3500.0 10500.0 2287 Ureum 3500.0 10500.0 2288 Kreatinin 3500.0 10500.0 2289 Kolesterol 4000.0 12000.0 2290 Trigliserid 4000.0 12000.0 2291 GTT 4000.0 12000.0 2292 Alkali fosfatase 3500.0 10500.0 2293 HDL Cholesterol Direk 4000.0 12000.0 2294 LDL Cholesterol Direk 4000.0 12000.0 2295 HBS Ag 4000.0 12000.0 2296 Rontgen foto thoraks 57000.0 108000.0 2297 Administrasi 7000.0 10000.0 2298 EKG 38000.0 128000.0 2299 Total "" 915000.0 2300 "" "" "" 2301 E. Pemeriksaan Kesehatan Standar Laki-laki "" "" 2302 JENIS PELAYANAN JS TARIF 2303 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2304 Pemeriksaan Dokter spesialis THT (audiometri) 38000.0 128000.0 2305 Pemeriksaan Dokter spesialis Mata (funduskopi) 38000.0 128000.0 2306 Pemeriksaan Dokter spesialis gigi 6000.0 70000.0 2307 Laboratorium : "" "" 2308 Darah Lengkap 7000.0 21000.0 2309 Urin rutin 12000.0 25000.0 2310 feces rutin 12000.0 21000.0 2311 Golongan darah 1500.0 4500.0 2312 SGPT 3500.0 10500.0 2313 SGOT 3500.0 10500.0 2314 Gula darah puasa 3500.0 10500.0 2315 Gula darah 2 jam setelah makan 3500.0 10500.0 2316 Ureum 3500.0 10500.0 2317 Kreatinin 4000.0 12000.0 2318 Kolesterol 4000.0 12000.0 2319 Trigliserid 4000.0 12000.0 2320 GTT 4000.0 12000.0 2321 Alkali fosfatase 3500.0 8500.0 2322 HDL Cholesterol Direk 4000.0 12000.0 2323 LDL Cholesterol Direk 4000.0 12000.0 2324 HBS Ag 4000.0 12000.0 2325 Rontgen foto thoraks 57000.0 108000.0 2326 Administrasi 7000.0 10000.0 2327 EKG 38000.0 128000.0 2328 Total "" 858500.0 2329 "" "" "" 2330 F. Pemeriksaan Kesehatan Lengkap Perempuan "" "" 2331 JENIS PELAYANAN JS TARIF 2332 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2333 Pemeriksaan Dokter spesialis THT (audiometri) 38000.0 128000.0 2334 Pemeriksaan Dokter spesialis Mata (funduskopi) 38000.0 128000.0 2335 Pemeriksaan Dokter spesialis obsgyn (papsmear) 17500.0 56000.0 2336 Pemeriksaan Dokter spesialis gigi 6000.0 70000.0 2337 Laboratorium : "" "" 2338 Darah rutin (HMX) 9000.0 27000.0 2339 Urin rutin 12000.0 25000.0 2340 feces rutin 12000.0 21000.0 2341 Golongan darah 1500.0 4500.0 2342 SGPT 3500.0 8500.0 2343 SGOT 3500.0 8500.0 2344 Gula darah puasa 3500.0 8500.0 2345 Gula darah 2 jam setelah makan 3500.0 8500.0 2346 Ureum 3500.0 8500.0 2347 Kreatinin 3500.0 8500.0 2348 Kolesterol 4000.0 9000.0 2349 Trigliserid 4000.0 14000.0 2350 GTT 4000.0 14000.0 2351 Alkali fosfatase 3500.0 10500.0 2352 HDL Cholesterol Direk 4000.0 12000.0 2353 LDL Cholesterol Direk 4000.0 12000.0 2354 HBS Ag 4000.0 12000.0 2355 Albumin 4000.0 12000.0 2356 Globulin 4000.0 12000.0 2357 Anti HBs 4000.0 12000.0 2358 HBc 4000.0 12000.0 2359 Anti HBc 4000.0 12000.0 2360 VDRL 4000.0 12000.0 2361 TPHA 5000.0 20000.0 2362 Rontgen foto thoraks 57000.0 108000.0 2363 Administrasi 7000.0 10000.0 2364 EKG 38000.0 128000.0 2365 Total "" 1002000.0 2366 "" "" "" 2367 G. Pemeriksaan Kesehatan Lengkap Laki-laki "" "" 2368 JENIS PELAYANAN JS TARIF 2369 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2370 Pemeriksaan Dokter spesialis THT (audiometri) 38000.0 128000.0 2371 Pemeriksaan Dokter spesialis Mata (funduskopi) 38000.0 128000.0 2372 Pemeriksaan Dokter spesialis gigi 6000.0 70000.0 2373 Laboratorium : "" "" 2374 Darah lengkap 9000.0 27000.0 2375 Urin rutin 12000.0 25000.0 2376 feces rutin 12000.0 21000.0 2377 Golongan darah 1500.0 4500.0 2378 SGPT 3500.0 8500.0 2379 SGOT 3500.0 8500.0 2380 Gula darah puasa 3500.0 8500.0 2381 Gula darah 2 jam setelah makan 3500.0 8500.0 2382 Ureum 3500.0 8500.0 2383 Kreatinin 3500.0 8500.0 2384 Kolesterol 4000.0 9000.0 2385 Trigliserid 4000.0 14000.0 2386 GTT 4000.0 14000.0 2387 Alkali fosfatase 3500.0 10500.0 2388 HDL Cholesterol Direk 4000.0 12000.0 2389 LDL Cholesterol Direk 4000.0 12000.0 2390 HBS Ag 4000.0 12000.0 2391 Albumin 4000.0 12000.0 2392 Globulin 4000.0 12000.0 2393 Anti HBs 4000.0 12000.0 2394 HBc 4000.0 12000.0 2395 Anti HBc 4000.0 12000.0 2396 VDRL 4000.0 12000.0 2397 TPHA 5000.0 20000.0 2398 Rontgen foto thoraks 57000.0 108000.0 2399 Administrasi 7000.0 10000.0 2400 EKG 38000.0 128000.0 2401 Total "" 946000.0 2402 "" "" "" 2403 J. Pemeriksaan Kesehatan Calon Pegawai "" "" 2404 JENIS PELAYANAN JS TARIF 2405 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2406 Laboratorium : "" "" 2407 Darah lengkap 7000.0 21000.0 2408 Urin rutin 12000.0 25000.0 2409 feces rutin 12000.0 21000.0 2410 Golongan darah 1500.0 4500.0 2411 SGPT 3500.0 10500.0 2412 SGOT 3500.0 10500.0 2413 UREUM 3500.0 10500.0 2414 Asam Urat 4000.0 12000.0 2415 Rontgen foto thoraks 57000.0 108000.0 2416 Pemeriksaan Dokter spesialis Mata (Visus,TBW,fund) 6000.0 70000.0 2417 Pemeriksaan Kesehatan Jiwa 6000.0 70000.0 2418 Tes Psikologi Industri 6000.0 70000.0 2419 Administrasi 7000.0 10000.0 2420 Total "" 513000.0 2421 "" "" "" 2422 K. Pemeriksaan Kesehatan Sederhana Calon Mahasiswa "" "" 2423 JENIS PELAYANAN JS TARIF 2424 Pemeriksaan fisik spesialis penyakit dalam 6000.0 70000.0 2425 Pemeriksaan Spesialis Mata 6000.0 70000.0 2426 Tes Psikologi Pendidikan (sesuai jenis tes) "" 2427 Biaya Administrasi 7000.0 10000.0 2428 Total "" 150000.0 2429 "" "" "" 2430 L. Pemeriksaan Kesehatan Calon Mahasiswa dengan Lab. Bebas Narkoba "" "" 2431 JENIS PELAYANAN JS TARIF 2432 Pemeriksaan kesehatan Jiwa 6000.0 70000.0 2433 Laboratorium narkoba 5 parameter 5000.0 20000.0 2434 Tes Psikologi Klinis (sesuai jenis tes) "" 2435 Biaya Administrasi 7000.0 10000.0 2436 Total "" 100000.0 2437 "" "" "" 2438 M. Surat Keterangan Sehat "" "" 2439 JENIS PELAYANAN JS TARIF 2440 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2441 Biaya Administrasi 7000.0 10000.0 2442 Total "" 80000.0 2443 "" "" "" 2444 N.Paket General Check UP TKI "" "" 2445 JENIS PELAYANAN JS TARIF 2446 Pendaftaran 7000.0 10000.0 2447 Pemeriksaan Fisik 6000.0 70000.0 2448 Rontgen Thorax 57000.0 108000.0 2449 Pemeriksaan Mata ( buta warna ) 6000.0 70000.0 2450 Pemeriksaan Dokter spesialis THT (audiometri) 38000.0 128000.0 2451 Laboratorium : "" "" 2452 Hematocrit 9000.0 27000.0 2453 Urin Rutin 12000.0 25000.0 2454 SGOT 3500.0 8500.0 2455 SGPT 3500.0 8500.0 2456 Cholesterol Total 4000.0 9000.0 2457 Golongan Darah 1500.0 4500.0 2458 Hbs Ag 4000.0 12000.0 2459 VDRL 4000.0 12000.0 2460 TPHA 5000.0 20000.0 2461 HIV Rapid 117756.0 364698.0 2462 Total "" 877198.0 2463 "" "" "" 2464 O. Pemeriksaan Kesehatan Calon Pegawai Negeri Sipil "" "" 2465 JENIS PELAYANAN JS TARIF 2466 Pemeriksaan Dokter Spesialis penyakit dalam 6000.0 70000.0 2467 Pemeriksaan Dokter spesialis Mata (Visus,TBW,fund) 6000.0 70000.0 2468 Pemeriksaan Dokter Spesialis Gigi 6000.0 70000.0 2469 Laboratorium : "" "" 2470 Darah lengkap 7000.0 21000.0 2471 Urin rutin 12000.0 25000.0 2472 Golongan darah 1500.0 4500.0 2473 SGPT 3500.0 10500.0 2474 3500.0 10500.0 2475 UREUM 3500.0 10500.0 2476 Kreatin 3500.0 10500.0 2477 Rontgen foto thoraks 57000.0 108000.0 2478 Administrasi 7000.0 10000.0 2479 Total "" 420500.0 2480 "" "" "" 2481 "" "" "" 2482 TABEL 24. "" "" 2483 PELAYANAN DIAGNOSTIK ELEKTROMEDIK "" "" 2484 "" "" "" 2485 JENIS PELAYANAN JS TARIF 2486 ANAL TEST 38000.0 128000.0 2487 ANOSCOPY 38000.0 128000.0 2488 AUDIOMETRI 38000.0 128000.0 2489 BIOMETRI 38000.0 128000.0 2490 CTG/ KEBIDANAN 38000.0 128000.0 2491 ECG 38000.0 128000.0 2492 EEG (BRAIN MAPPING) 250000.0 400000.0 2493 EEG 160000.0 307000.0 2494 EMG/ BERA 38000.0 128000.0 2495 FACIALIS PARASE 38000.0 128000.0 2496 FREE FIELD TEST 38000.0 128000.0 2497 FUNDUSCOPY 38000.0 128000.0 2498 GONIUSCOPY 38000.0 128000.0 2499 KAMPIMETRI 38000.0 128000.0 2500 OPTHALMOSCOPY 38000.0 128000.0 2501 PEAK FLOW RATE (PFR) 38000.0 128000.0 2502 REFRAKSI 38000.0 128000.0 2503 SLIT LAMP EXAMINATION 38000.0 128000.0 2504 SPEECH AUDIOMETER 40000.0 115000.0 2505 TELEMETRI 40000.0 115000.0 2506 TEST TEMPEL SELEKTIF 40000.0 115000.0 2507 TIMPANOMETRI 40000.0 115000.0 2508 TONEDECAY 40000.0 115000.0 2509 TONOGRAFI 40000.0 115000.0 2510 TONOMETRI 40000.0 115000.0 2511 COLONOSKOPI 540000.0 1350000.0 2512 COLONOSKOPI + BIOPSI 578000.0 2078000.0 2513 RECTOSIGMOIDOSCOPY 540000.0 1350000.0 2514 RECTOSIGMOIDOSCOPY + BIOPSI 578000.0 2078000.0 2515 RECTOSIGMOIDOSCOPY + SCLEROSING 578000.0 2078000.0 2516 USG OBSGIN 35000.0 95000.0 2517 LAPARASKOPI DIAGNOSTIK 540000.0 1350000.0 2518 USG TRANSVAGINAL 36000.0 115000.0 2519 ESOFAGOGASTRODUODENOSKOPI (EGD) 578000.0 2078000.0 2520 EGD + BIOPSI 578000.0 2078000.0 2521 SCLERO THERAPI VARISES ESOFAGUS (STE) 578000.0 2078000.0 2522 LIGASI VARISES EOFAGUS 655000.0 2155000.0 2523 BRONKOSKOPI DIAGNOSIS 540000.0 1350000.0 2524 BRONKOSKOPI + BIOPSI JARUM 578000.0 2078000.0 2525 BRONKOSKOPI + FORCEP 578000.0 2078000.0 2526 BRONKOSKOPI + BRUSHING 578000.0 2078000.0 2527 BRONKOSKOPI + BIOPSI JARUM + FORCEP 578000.0 2078000.0 2528 BRONKOSKOPI + BIOPSI JARUM + FORCEP + BRUSHING 578000.0 2078000.0 2529 BRONKOSKOPI TERAPI (PENGAMBILAN BENDA ASING, BRONCHIAL TOILET, STOP PERDARAHAN 578000.0 2078000.0 2530 BRONKOSKOPI DENGAN GA 612000.0 1530000.0 2531 "" "" "" 2532 TABEL 25. "" "" 2533 PELAYANAN TINDAKAN MEDIK NON OPERATIF "" "" 2534 "" "" "" 2535 JENIS PELAYANAN JS TARIF 2536 KECIL "" "" 2537 ASPIRASI HEMARTROSIS 17500.0 56000.0 2538 ALLERGI TEST / PATCH TEST 17500.0 56000.0 2539 BILAS LAMBUNG 17500.0 56000.0 2540 DILATASI PHIMOSIS 17500.0 56000.0 2541 EKSISI CLAVUS 17500.0 56000.0 2542 EKSISI CONDILOMA ACCUMINATA 17500.0 56000.0 2543 EKSISI GRANULOMA PYOGENIKUM 17500.0 56000.0 2544 EKSISI KELOID < 5 CM 17500.0 56000.0 2545 EKSISI SYRINGOMA 17500.0 56000.0 2546 EKSISI VERUKA VULGARIS 17500.0 56000.0 2547 EKSTRAKSI KALIUM OXALAT 17500.0 56000.0 2548 EKTERPASI KISTA ATEROMA / LIPOMA / GANGLION < 2 CM 17500.0 56000.0 2549 EKTRAKSI KUKU 17500.0 56000.0 2550 EPILASI BULU MATA 17500.0 56000.0 2551 FNA (FINE NEEDLE ASPIRATION) 17500.0 56000.0 2552 INSISI FURUNKEL / ABSES 17500.0 56000.0 2553 IPPB (INTERMITEN POSITIVE PRESSURE BREATHING) 17500.0 56000.0 2554 IRIGASI TELINGA 17500.0 56000.0 2555 KAUSTIK 17500.0 56000.0 2556 LOBULAPLASTI 1 TELINGA 17500.0 56000.0 2557 MANTOUX TEST/ IMUNISASI 17500.0 56000.0 2558 NEKROTOMI 17500.0 56000.0 2559 PAPSMEAR (PENGAMBILAN SEKRET) 17500.0 56000.0 2560 PARASENTENSE TELINGA 17500.0 56000.0 2561 PEMASANGAN / ANGKAT IMPLANT / IUD 17500.0 56000.0 2562 PEMASANGAN / ANGKAT JAHIT SEDERHANA 17500.0 56000.0 2563 PEMASANGAN INFUS UMBILICAL 17500.0 56000.0 2564 PEMASANGAN PISARIUM 17500.0 56000.0 2565 PEMASANGAN BELOG TAMPON 17500.0 56000.0 2566 PEMASANGAN KATETHER 17500.0 56000.0 2567 PENGOBATAN EPISTAKSIS 17500.0 56000.0 2568 PUNKSI HEMATOMA TELINGA 17500.0 56000.0 2569 REPOSISI TRAUMA HIDUNG SEDERHANA 17500.0 56000.0 2570 SONDAGE CANALCULI LACRIMALIS 17500.0 56000.0 2571 SPOOLING BOLA MATA 17500.0 56000.0 2572 SPOOLING CERUMEN TELINGA 17500.0 56000.0 2573 TINDAKAN BUSINASI 17500.0 56000.0 2574 TINDAKAN CUCI SINUS (PERAWATAN) 17500.0 56000.0 2575 TINDAKAN NEBULIZER 17500.0 56000.0 2576 TINDAKAN PADA KERATOSIS SEBOROIKA 17500.0 56000.0 2577 TINDAKAN ROSER PLASTY 17500.0 56000.0 2578 WATER DRINKING TEST 17500.0 56000.0 2579 KOREKSI VISUS 17500.0 56000.0 2580 KURESTASU ALVEOLITIS/ OSTEOMIELITIS 17500.0 56000.0 2581 FISUR SILEN 17500.0 56000.0 2582 GRINDING, POLISHING, DLL 17500.0 56000.0 2583 AKUPUNTUR 17500.0 56000.0 2584 TERAPI OKUPASI 17500.0 56000.0 2585 PEMASANGAN RENSEL VERBAN 17500.0 56000.0 2586 MOLUSKUM 17500.0 56000.0 2587 EKSPRESI ACNE / KOMEDO 17500.0 56000.0 2588 PASANG SPALK 17500.0 56000.0 2589 CROS INSISI 17500.0 56000.0 2590 CHALENGE TEST 17500.0 56000.0 2591 SLIM SEHER (SUCTION) PER HARI 17500.0 56000.0 2592 ASSEMENT NEUROLOGI 17500.0 56000.0 2593 TES FUNGSI LUHUR (DEMENSIA) 17500.0 56000.0 2594 TES BARTHEL INDEX 17500.0 56000.0 2595 TES MC GILL 17500.0 56000.0 2596 TES AFASIA / AGNOSIA 17500.0 56000.0 2597 TES NEUROPATY PERIFERAL 17500.0 56000.0 2598 INJEKSI INTRA ARTRICULER 17500.0 56000.0 2599 DETEKSI OVULASI 17500.0 56000.0 2600 TEST MMPI/IKJI 17500.0 56000.0 2601 TEST WW EISANK 17500.0 56000.0 2602 TINDAKAN PSIKOTERAPI/KONSELING SUPPORTIF 17500.0 56000.0 2603 TINDAKAN PSIKOTERAPI/KONSELING CBT 17500.0 56000.0 2604 PENKES ( PENDIDIKAN KESEHATAN ) 17500.0 56000.0 2605 MANAGEMEN LAKTASI 17500.0 56000.0 2606 Uji Toleransi Air/Water Drinking Test 17500.0 56000.0 2607 Perawatan luka bakar < 25% 17500.0 56000.0 2608 Perawatan Luka / Ganti balutan < 10cm 17500.0 56000.0 2609 Pemasangan Infus 17500.0 56000.0 2610 Pemasangan Neck Colar 17500.0 56000.0 2611 Pemasangan elastik verban 17500.0 56000.0 2612 Pemasangan Spinal Korset 17500.0 56000.0 2613 Pemberian Obat IM, SC, IV dan IC 17500.0 56000.0 2614 Edukasi penyuntikan insulin 17500.0 56000.0 2615 Pengambilan darah vena / arteri untuk pemeriksaan laboratorium 17500.0 56000.0 2616 "" "" "" 2617 SEDANG "" "" 2618 EKSISI CHALAZION 52000.0 129000.0 2619 EKSISI HORDEULUM / GRANULOMA 52000.0 129000.0 2620 INSISI ABSES GLUTEA / MAMMAE (BESAR) 52000.0 129000.0 2621 INSISI EPULIS 52000.0 129000.0 2622 INSISI INTRA ORAL 52000.0 129000.0 2623 LOBULOPLASTI 2 TELINGA 52000.0 129000.0 2624 PEMASANGAN / ANGKAT JAHIT LUKA BESAR / KOMPLEKS 52000.0 129000.0 2625 PEMASANGAN / BUKA GIPS SIRKULAR 52000.0 129000.0 2626 PEMBERIAN SITOSTATIKA 52000.0 129000.0 2627 PENGANGKATAN NEURO FIBROMA 52000.0 129000.0 2628 PENGANGKATAN NEVUS 52000.0 129000.0 2629 PENGANGKATAN SKIN TAG 52000.0 129000.0 2630 PENGANGKATAN TANDUR KULIT 52000.0 129000.0 2631 TINDAKAN BEDAH BEKU 52000.0 129000.0 2632 TINDAKAN BEDAH FLAP 52000.0 129000.0 2633 TINDAKAN CRYOSURGERY 52000.0 129000.0 2634 TINDAKAN DERMABRASI 52000.0 129000.0 2635 TINDAKAN PUNKSI LUMBAL 52000.0 129000.0 2636 REPOSISI DISLOKASI MANDIBULA 52000.0 129000.0 2637 KEMOTHERAPI 52000.0 129000.0 2638 PEMASANGAN SKIN TRAKSI 52000.0 129000.0 2639 PHOTOTHERAPI 52000.0 129000.0 2640 PUNGSI CAVUM DAUGLAS 52000.0 129000.0 2641 ANGKAT IUD DENGAN PENYULIT 52000.0 129000.0 2642 PUNGSI ACITES 52000.0 129000.0 2643 SCALING-POLISHING (PER RAHANG 52000.0 129000.0 2644 KONTROL ALTA ORTODONTIK LEPASAN (PER RAHANG) 52000.0 129000.0 2645 TOPIKAL APLIKASI FLUOR (PER RAHANG) 52000.0 129000.0 2646 KONTROL SPACE MAN\INTAINER/ SPACE REGAINER (PER RA) 52000.0 129000.0 2647 PREPARASI TUMPATAN INLAI/ ONLAI 52000.0 129000.0 2648 BLEACHING (PER GIGI) 52000.0 129000.0 2649 PENJAHITAN PERINEUM (PARTUS LUAR) 52000.0 129000.0 2650 KAUTERISASI KONDILOMA 52000.0 129000.0 2651 PENANGANAN SYOK 52000.0 129000.0 2652 PENANGANAN PERDARAHAN 52000.0 129000.0 2653 BMP (BONE MARROW PUNKSI) 52000.0 129000.0 2654 TINDAKAN AMPUTASI JARI (IGD) 52000.0 129000.0 2655 TINDAKAN TINDIK (PASANG ANTING) 52000.0 129000.0 2656 TINDAKAN SUBSCAPULA INJEKSI (BRACHACEIA) 52000.0 129000.0 2657 HIDROTUBASI 52000.0 129000.0 2658 DILATASI SERVIK 52000.0 129000.0 2659 INFANT WARMER 52000.0 129000.0 2660 INCUBATOR 52000.0 129000.0 2661 Perawatan luka/ganti balutan ( Lk > 10 cm ) 52000.0 129000.0 2662 Pemasangan NGT 52000.0 129000.0 2663 Pemasanagan Oksigen RM - NRM 52000.0 129000.0 2664 Cross Incisi 52000.0 129000.0 2665 Perawatan luka bakar > 25% 52000.0 129000.0 2666 Pemasangan Infus dengan penyulit 52000.0 129000.0 2667 Pemasangan Syringe Pump 52000.0 129000.0 2668 Pemasangan Infus Pump 52000.0 129000.0 2669 Tranfusi Darah 52000.0 129000.0 2670 Pemasangan Tampon Abses/Fistula 52000.0 129000.0 2671 Perawatan Colostomi 52000.0 129000.0 2672 Pemasangan OPA / Mayo Tube 52000.0 129000.0 2673 Pengambilan sekret vaginal 52000.0 129000.0 2674 Ekstubasi 52000.0 129000.0 2675 Pemasangan Laminaria 52000.0 129000.0 2676 Hecting Perineum > 10 jahitan 52000.0 129000.0 2677 Perawatan Luka Ulkus/Gangren 52000.0 129000.0 2678 Manual Placenta 52000.0 129000.0 2679 Tindakan Scortsteen 52000.0 129000.0 2680 Pemasangan Implant / IUD 52000.0 129000.0 2681 Pemasangan Balon Cateter 52000.0 129000.0 2682 Penanganan Perdarahan Ante - Post Partum 52000.0 129000.0 2683 Resusitasi Jantung Paru Sederhana 52000.0 129000.0 2684 Pemasangan Cateter Urine dgn penyulit 52000.0 129000.0 2685 Perawatan AV Shunt 52000.0 129000.0 2686 Bronchial Washing 52000.0 129000.0 2687 Lavement / Pemberian Enema 52000.0 129000.0 2688 Pemeriksaan Pulse Oxymetri 52000.0 129000.0 2689 Pengambilan Corpus Alienum 52000.0 129000.0 2690 Blass Punksi 52000.0 129000.0 2691 "" "" "" 2692 BESAR "" "" 2693 EKSISI PTERGIUM 121000.0 275000.0 2694 EKTIRPASI FIBROMA 121000.0 275000.0 2695 ENUCLEATIE KISTA 121000.0 275000.0 2696 INJEKSI HAEMOROID (TERMASUK OBAT) 121000.0 275000.0 2697 INJEKSI VARISES (TERMASUK OBAT) 121000.0 275000.0 2698 INSISI MUCOCELE 121000.0 275000.0 2699 OPERCULECTOMY 121000.0 275000.0 2700 PEMASANGAN TRAKSI VERTEBRA (TULANG BELAKANG) 121000.0 275000.0 2701 PEMASANGAN WSD 121000.0 275000.0 2702 PENUTUPAN OROANTRAL FISTULA 121000.0 275000.0 2703 PUNKSI / IRIGASI PLEURA 121000.0 275000.0 2704 PUNKSI SUMSUM TULANG 121000.0 275000.0 2705 REPOSISI DENGAN ANESTESI LOKAL 121000.0 275000.0 2706 TINDAKAN DEEPENING SULCUS 121000.0 275000.0 2707 TINDAKAN MANUAL PLASENTA 121000.0 275000.0 2708 ANGKAT IUD DENGAN NARKOSE 121000.0 275000.0 2709 CIRCUMSISI 121000.0 275000.0 2710 REPOSISI INVERSIO UTERI 121000.0 275000.0 2711 TINDAKAN PADA ATONIA UTERI 121000.0 275000.0 2712 PENJAHITAN LASERASI JALAN LAHIR (SERVIK, PORSIO) 121000.0 275000.0 2713 REHECTING DEHISENSI 121000.0 275000.0 2714 KURETASE TANPA NARKOSE 121000.0 275000.0 2715 EKSISI KELOID > 5 CM 121000.0 275000.0 2716 EKTIRPASI KISTA ATERIUM / LIPOMA / GANGLION > 2 CM 121000.0 275000.0 2717 PERSPIRASI / SENSIBILITAS 121000.0 275000.0 2718 TINDAKAN INJEKSI INTRATECHAL 121000.0 275000.0 2719 INSEMINASI BUATAN SUAMI 121000.0 275000.0 2720 SONO HISTERO SALFINGOGRAFI 121000.0 275000.0 2721 Jahit Tendon Ruptur 121000.0 275000.0 2722 Jahit luka > 20 jahitan ( luka tak beraturan ) 121000.0 275000.0 2723 Perawatan luka bakar > 50% 121000.0 275000.0 2724 IPPB : Bagging 121000.0 275000.0 2725 Penanganan Shock 121000.0 275000.0 2726 Manajemen Atonia Uteri 121000.0 275000.0 2727 Manajemen PEB 121000.0 275000.0 2728 Resusitasi Jantung Paru kompleks 121000.0 275000.0 2729 Perawatan luka > 30 menit 121000.0 275000.0 2730 Resusitasi Jantuing Paru Bayi komplek 121000.0 275000.0 2731 Pemberian tranfusi pada bayi/anak 121000.0 275000.0 2732 "" "" "" 2733 KHUSUS "" "" 2734 PEMASANGAN ENDOTRACHEAL TUBE (ET) 150000.0 457000.0 2735 VENTILATOR 150000.0 457000.0 2736 DEFIBRILASI 150000.0 457000.0 2737 PEMASANGAN TRANSCUTANEUS PACE MAKER (TPM) 150000.0 457000.0 2738 PEMASANGAN CENTRAL VENOUS PRESSURE (CVP) 150000.0 457000.0 2739 PEMASANGAN HEMODIALISIS (HD) CATHETER 150000.0 457000.0 2740 PEMASANGAN VENA DALAM 150000.0 457000.0 2741 Vena Sectie 150000.0 457000.0 2742 Perawatan luka bakar > 75% 150000.0 457000.0 2743 Pemasangan CPAP 150000.0 457000.0 2744 Pemasangan CVC 150000.0 457000.0 2745 Punksi Asites "" "" 2746 Pemasangan Arteri Line 150000.0 457000.0 2747 Pemberian terapy Trombolitik 150000.0 457000.0 2748 "" "" "" 2749 DOKTER SPESIALIS PARU "" "" 2750 JENIS PELAYANAN JS TARIF 2751 KECIL "" "" 2752 Konsultasi/ edukasi berhenti merokok 17500.0 56000.0 2753 Konsultasi/ edukasi batuk 17500.0 17500.0 2754 "" "" "" 2755 SEDANG "" "" 2756 Edukasi terapi inhalasi 52000.0 129000.0 2757 "" "" "" 2758 BESAR "" "" 2759 Spirometri 121000.0 275000.0 2760 Konsultasi dan bimbingan program berhenti merokok 121000.0 275000.0 2761 Fine needle aspiration Biopsy/ FNAB 121000.0 275000.0 2762 Pungsi pleura / needle thoracocentesis diagnosis 121000.0 275000.0 2763 Spirometri + bronkodilator test 121000.0 275000.0 2764 Aspirasi pneumothorax 121000.0 275000.0 2765 "" "" "" 2766 KHUSUS "" "" 2767 Reposisi WSD 150000.0 457000.0 2768 Spooling WSD 150000.0 457000.0 2769 Lepas WSD 150000.0 457000.0 2770 Rehecting WSD 150000.0 457000.0 2771 Incisi emfisema subcutis 150000.0 457000.0 2772 Spirometri + Uji provokasi bronkus 150000.0 457000.0 2773 USG paru/thorax 150000.0 457000.0 2774 Baging / resusitasi dengan masker oksigen / ambu bag 150000.0 457000.0 2775 Pungsi pleura / needle thoracocentesis evakuasi 150000.0 457000.0 2776 Pemasangan mini WSD 150000.0 457000.0 2777 Injeksi intra cavum pleura 150000.0 457000.0 2778 Pungsi pleura/ needle thoracocentesis evakuasi emergensi/cito 150000.0 457000.0 2779 "" "" "" 2780 "" "" "" 2781 DOKTER SPESIALIS SARAF "" "" 2782 JENIS PELAYANAN JS TARIF 2783 SEDANG "" "" 2784 Tes Fungsi luhur (diagnostik) 52000.0 129000.0 2785 "" "" "" 2786 BESAR "" "" 2787 Lumbal Punksi (di poliklinik) 121000.0 275000.0 2788 Spinal nerve root injection 121000.0 275000.0 2789 Trigger Point Injections (TPIs) Manual 121000.0 275000.0 2790 Carpal Tunnel Syndrome Manual (injections) 121000.0 275000.0 2791 De Quervain Syndrome Manual ( inj.) 121000.0 275000.0 2792 Tennis Elbow Manual (injections) 121000.0 275000.0 2793 Tendinitis Bicipitalis Manual (injections) 121000.0 275000.0 2794 Acromio Clavicular Joint (injections) 121000.0 275000.0 2795 Fascitis Plantaris Manual (injections) 121000.0 275000.0 2796 "" "" "" 2797 KHUSUS "" "" 2798 Lumbal Punksi 150000.0 457000.0 2799 TCD (Trans cranial doppler) 150000.0 457000.0 2800 Carpal Tunnel Syndrome USG( injections) 150000.0 457000.0 2801 De Quervin Syndrome USG ( injections ) 150000.0 457000.0 2802 Guyon Syndrome Manual (injections) 150000.0 457000.0 2803 Guyon Syndrome USG (injection) 150000.0 457000.0 2804 Tennis Elbow USG (injections) 150000.0 457000.0 2805 Tendinitis Bicipitalis USG (injections) 150000.0 457000.0 2806 Trigger Finger Manual (injections) 150000.0 457000.0 2807 Sacroiliac Joint Disfunction USG (injections) 150000.0 457000.0 2808 Sacral Epidural Injection Manual (injections) 150000.0 457000.0 2809 Sacral Epidural Injection Manual (injections) 150000.0 457000.0 2810 Piriformis Syndrom USG (injections) 150000.0 457000.0 2811 "" "" "" 2812 DOKTER GIGI "" "" 2813 JENIS PELAYANAN JS TARIF 2814 KECIL "" "" 2815 Cabut Gigi SulungTopikal 17500.0 56000.0 2816 Perawatan Pulpa dan sal akar Capping 17500.0 56000.0 2817 Perawatan pulpa dan sal akar Eugenol, TKF, chkf 17500.0 56000.0 2818 Hecting / Jumlah 17500.0 56000.0 2819 Drainase/ Open Bor 17500.0 56000.0 2820 Konsul Post Op/ Incisi/ Exo 17500.0 56000.0 2821 "" "" "" 2822 SEDANG "" "" 2823 Penambalan Glass Ionomer Kecil 52000.0 129000.0 2824 Penambalan Glass Ionomer Besar 52000.0 129000.0 2825 Penambalan Komposit LC Kecil 52000.0 129000.0 2826 Penambalan Komposit LC Besar 52000.0 129000.0 2827 Penambalan Amalgam Kecil 52000.0 129000.0 2828 Penambalan Amalgam Besar 52000.0 129000.0 2829 Cabut Gigi Sulung Injeksi 52000.0 129000.0 2830 Cabut Gigi Tetap Normal 52000.0 129000.0 2831 Gingivectomy per gigi 52000.0 129000.0 2832 Frenectomy 52000.0 129000.0 2833 Incisi epulis 52000.0 129000.0 2834 Reaming, Filing Gigi Tunggal/ Depan 52000.0 129000.0 2835 Pengisian Saluran Akar 52000.0 129000.0 2836 Scalling per rahang 52000.0 129000.0 2837 Scalling per rahang 52000.0 129000.0 2838 Akrilik gigi Selanjutnya 52000.0 129000.0 2839 Termoplastik selanjutnya 52000.0 129000.0 2840 "" "" "" 2841 BESAR "" "" 2842 Cabut Gigi Tetap Penyulit 121000.0 275000.0 2843 Incisi abses 121000.0 275000.0 2844 Overculectomy 121000.0 275000.0 2845 Reaming, Filling Gigi Jamak/ Belakang 121000.0 275000.0 2846 Pasak Cor 121000.0 275000.0 2847 Pasak Fiber 121000.0 275000.0 2848 Veneer Komposit Langsung 121000.0 275000.0 2849 Akrilik gigi 1 121000.0 275000.0 2850 Reparasi 121000.0 275000.0 2851 "" "" "" 2852 KHUSUS "" "" 2853 Odontectomy Kl I 150000.0 457000.0 2854 Odontectomy Kl II 150000.0 457000.0 2855 Odontectomy Kl III 150000.0 457000.0 2856 Alveolectomy/ Regio 150000.0 457000.0 2857 Kuretase per Regio 150000.0 457000.0 2858 Splinting Per Regio 150000.0 457000.0 2859 Bone Graft 1-3 Gigi 150000.0 457000.0 2860 Inlay, Onlay 150000.0 457000.0 2861 Mahkota Penuh Akrilik/ Komposit 150000.0 457000.0 2862 Mahkota Penuh Porselen 150000.0 457000.0 2863 Veneer Porselen 150000.0 457000.0 2864 Termoplastik 1 150000.0 457000.0 2865 Frame Sebagian 150000.0 457000.0 2866 Frame Penuh 150000.0 457000.0 2867 Braidge/ Jembatan Porselen/ Unit 150000.0 457000.0 2868 Baidge/ Jembatan Akrilik/ Unit 150000.0 457000.0 2869 FRC 150000.0 457000.0 2870 Implant 150000.0 457000.0 2871 "" "" "" 2872 DOKTER SPESIALIS KESEHATAN JIWA "" "" 2873 JENIS PELAYANAN JS TARIF 2874 KECIL "" "" 2875 Test grafis 17500.0 56000.0 2876 Test MMSE 17500.0 56000.0 2877 Test CDT ( Clock Drawing Test ) 17500.0 56000.0 2878 Test untuk depresi(BDI,HDRS,CDI) 17500.0 56000.0 2879 Test untuk kecemasan (BAI, HARS) 17500.0 56000.0 2880 Test untuk Autis 17500.0 56000.0 2881 Test untuk ADHD 17500.0 56000.0 2882 Test untuk narkoba ( Manson's Test ) 17500.0 56000.0 2883 Test untuk obsesif kompulsif ( YBOC ) 17500.0 56000.0 2884 Test untuk gangguan bipolar 17500.0 56000.0 2885 Psikoterapi sederhana perkunjungan 17500.0 56000.0 2886 "" "" "" 2887 SEDANG "" "" 2888 Psikoterapi sedang perkunjungan 52000.0 129000.0 2889 Psikoterapi komplek perkunjungan 52000.0 129000.0 2890 Test WW-Eysenk 52000.0 129000.0 2891 "" "" "" 2892 BESAR "" "" 2893 Paket pemeriksaan untuk surat sehat jiwa 121000.0 275000.0 2894 Test MMPI/TKMI 121000.0 275000.0 2895 "" "" "" 2896 KHUSUS "" "" 2897 ECT ( Per tindakan ) 150000.0 457000.0 2898 Permintaan pelayanan extra RS (per kunjungan ) "" "" 2899 - Forensik 150000.0 457000.0 2900 - Non forensik 150000.0 457000.0 2901 "" "" "" 2902 TABEL 26. "" "" 2903 PELAYANAN HEMODIALISA "" "" 2904 "" "" "" 2905 JENIS PELAYANAN JS TARIF 2906 PELAYANAN HEMODIALISA 110000.0 300000.0 2907 "" "" "" 2908 "" "" "" 2909 "" "" "" 2910 "" "" "" 2911 "" "" "" 2912 "" BUPATI CILACAP "" 2913 "" "" "" 2914 "" "" "" 2915 "" "" "" 2916 "" "" "" 2917 "" TATTO SUWARTO PAMUDJI ""