TarifKIT

KDPMRLM Kode
Tarif
ADM001
ADM002
ADM003
ADM004
ADM005
ADM006
18.001.00
AKP001
18.002.01
AKP002
18.006.00
AKP003
18.002.02
AKP004
18.002.03
AKP005
18.002.04
AKP006
18.002.05
AKP007
18.002.06
AKP008
18.003.01
AKP009
18.003.02
AKP010
18.003.03
AKP011
18.004.00
AKP012
18.005.00
AKP013
18.005.01
AKP014
18.005.02
AKP015
18.006.00
AKP016
18.007.01
AKP017
18.007.02
AKP018
18.008.01
AKP019
18.008.02
AKP020
18.009.01
AKP021
18.009.02
AKP022
18.010.01
AKP023
18.010.02
AKP024
18.010.03
AKP025
18.010.04
AKP026
18.010.05
AKP027
18.010.06
AKP028
18.010.07
AKP029
18.010.08
AKP030
18.010.09
AKP031
AKP032
AKP033
01.100.01
AMB001
01.100.02
AMB002
01.100.03
AMB003
01.100.04
AMB004
01.100.05
AMB005
01.101.01
AMB006
01.101.02
AMB007
01.101.03
AMB008
01.101.04
AMB009
20.001.00
ANK001
20.002.00
ANK002

NAMAPMR

PHRS
PHDR
RS
Dokter
BIAYA ADMINISTRASI PASIEN BARU
15,000.00
0.00
BIAYA ADMINISTRASI
10,000.00
0.00
BIAYA ADMINISTRASI KARYAWAN
0.00
0.00
VISUME
15,000.00
0.00
PEMBUATAN KARTU PASIEN
5,000.00
0.00
ECG TANPA EXPERTISE
50,000.00
0.00
STIMULATOR AKUPUNKTUR (10 JARUM PER TINDAKAN) 7,500.00
0.00
AKUPUNKTUR PELANGSINGAN
12,000.00
18,000.00
PAKET AKUPUNKTUR PELANGSINGAN (5 KALI DLM 1 BLN)54,000.00
81,000.00
AKUPUNKTUR PERAWATAN KANTONG MATA
12,000.00
18,000.00
AKUPUNKTUR PERAWATAN FLEK-FLEK HITAM WAJAH 12,000.00
18,000.00
PERAWATAN JERAWAT
12,000.00
18,000.00
PERAWATAN KETOMBE
12,000.00
18,000.00
PERAWATAN KEBOTAKAN
12,000.00
18,000.00
AKUPUNKTUR DM
12,000.00
18,000.00
AKUPUNKTUR POST STROKE
12,000.00
18,000.00
AKUPUNKTUR VERTIGO
12,000.00
18,000.00
AQUAPUNKTUR PROLENE+ I CARNITINE/REDOXON
32,000.00
48,000.00
AKUPUNKTUR BADAN & WAJAH
24,000.00
36,000.00
AKUPUNKTUR WAJAH (1 KALI)
12,000.00
18,000.00
PAKET AKUPUNKTUR WAJAH (5 KALI DLM 1 BULAN)
54,000.00
81,000.00
PAKET AKUPUNKTUR KESEHATAN (5 KALI DLM 1 BULAN) 54,000.00
81,000.00
MENGECILKAN LENGAN (1 KALI)
12,000.00
18,000.00
PAKET MENGECILKAN LENGAN (5 KALI DLM 1 BULAN)
54,000.00
81,000.00
MENGECILKAN PERUT (1 KALI)
12,000.00
18,000.00
PAKET MENGECILKAN PERUT (5 KALI DLM 1 BULAN)
54,000.00
81,000.00
MENGECILKAN PAHA (1 KALI)
12,000.00
18,000.00
PAKET MENGECILKAN PAHA (5 KALI DLM 1 BULAN)
54,000.00
81,000.00
AQUAPUNKTUR : INJEKSI (CARLINE + LIDOCAIN 2%)
62,000.00
93,000.00
VITAMIN C / LAROS CORBINE
54,000.00
81,000.00
PLACENTA COMPOSITUM
62,000.00
93,000.00
COLLAGEN RODOTEX
54,000.00
81,000.00
THATIONIL
62,000.00
93,000.00
VITAMIN E
62,000.00
93,000.00
H3 / GEOVITAL
54,000.00
81,000.00
VITACICOL
82,000.00 123,000.00
REDOXON
28,000.00
42,000.00
PAKET 6 KALI TINDAKAN AKUPUNTUR
240,000.00 360,000.00
PAKET 12 KALI TINDAKAN AKUPUNTUR
480,000.00 720,000.00
AMBULANCE JARAK < 5 KM
100,000.00
0.00
AMBULANCE JARAK 5 - 10 KM
150,000.00
0.00
AMBULANCE JARAK 10 - 20 KM
250,000.00
0.00
AMBULANCE JARAK > 20 KM (DKI & BOTABEK)
400,000.00
0.00
ADMINISTRASI AMBULANCE UNTUK RUJUKAN
100,000.00
0.00
AMBULANCE DENGAN DOKTER JARAK < 5 KM
200,000.00
0.00
AMBULANCE DENGAN DOKTER JARAK 5 - 10 KM
250,000.00
0.00
AMBULANCE DENGAN DOKTER JARAK 10 - 20 KM
350,000.00
0.00
AMBULANCE DENGAN DOKTER JARAK > 20 KM (DKI & BOTABEK)
500,000.00
0.00
JASA SUNTIK (IMUNISASI)
10,000.00
0.00
TINDIK TELINGA BAYI
15,000.00
60,000.00

Page 1

TarifKIT

20.003.00
20.004.01
20.004.02
20.004.03
20.004.04
20.004.05
20.004.06
05.001.01
05.001.02
05.001.03
05.002.00
05.003.00
05.004.01
05.004.02
05.005.01
05.005.02
05.006.00
05.007.01
05.007.02
05.007.03
05.007.04
05.007.05
05.009.01
05.009.02

05.009.03
05.010.00
05.011.01
05.011.02
05.011.03
05.012.00
05.013.00
05.014.00
05.015.01
05.015.02
05.016.00
05.017.00
05.018.00
05.019.01
05.019.02
05.019.03
05.020.00
05.021.00
05.022.00
05.008.00

ANK003
ANK004
ANK005
ANK006
ANK007
ANK008
ANK009
ANK010
BDH001
BDH002
BDH003
BDH004
BDH005
BDH006
BDH007
BDH008
BDH009
BDH010
BDH011
BDH012
BDH013
BDH014
BDH015
BDH016
BDH017
BDH018
BDH019
BDH020
BDH021
BDH022
BDH023
BDH024
BDH025
BDH026
BDH027
BDH028
BDH029
BDH030
BDH031
BDH032
BDH033
BDH034
BDH035
BDH036
BDH037
BDH038
BDH040
BDH041
BDH042
BDH043
BDH044
BDH045

SUNAT BAYI PEREMPUAN

10,000.00
40,000.00
TEST MANTOUX
50,000.00
0.00
VAKSIN BCG
20,000.00
0.00
VAKSIN DPT
15,000.00
0.00
VAKSIN DT
15,000.00
0.00
VAKSIN POLIO
10,000.00
0.00
VAKSIN CAMPAK
20,000.00
0.00
VAKSIN HEPATITIS (UNTUK 3 KALI SUNTIK)
60,000.00
0.00
AF HECHTING (1 - 5)
10,000.00
40,000.00
AF HECHTING (6 -10)
15,000.00
60,000.00
AF HECHTING (> 10)
20,000.00
80,000.00
ANUSCOPY
30,000.00 120,000.00
BIOPSI ( PUNCH BIOPSY )
80,000.00 320,000.00
BUKA GIPS MAYOR ( TUNGKAI BAWAH )
60,000.00 240,000.00
BUKA GIPS MINOR ( TUNGKAI ATAS )
20,000.00
80,000.00
CIRCUMCISI ANAK-ANAK (< 12 Th)
300,000.00 300,000.00
CIRCUMCISI DEWASA
400,000.00 400,000.00
DILATASI PREPUTIUM
25,000.00 100,000.00
EKSTIRPASI ATHEROMA LIPOMA BESAR
100,000.00 400,000.00
EKSTIRPASI ATHEROMA LIPOMA SEDANG
80,000.00 320,000.00
EKSTIRPASI ATHEROMA LIPOMA KECIL
50,000.00 200,000.00
EKSTIRPASI GANGLION SEDANG
120,000.00 480,000.00
EKSTIRPASI GANGLION KECIL
80,000.00 320,000.00
GANTI VERBAN KECIL
10,000.00
15,000.00
GANTI VERBAN SEDANG
16,000.00
24,000.00
PAKET ALKES GANTI VERBAN (INCL ALKES : MAX 10-15 PCS
25,000.00
KASA)
0.00
PAKET ALKES GANTI VERBAN (INCL ALKES : 15 - 20 PCS KASA)
30,000.00
0.00
GANTI VERBAN BESAR
30,000.00
45,000.00
INCISI ABSES
30,000.00 120,000.00
INJEKSI VARICES ( SCLERO THERAPY )
50,000.00 200,000.00
INJEKSI INTRARTIBULAR
30,000.00 120,000.00
INJEKSI KELOID
30,000.00 120,000.00
HECHTING SEKUNDER
40,000.00 160,000.00
LIGASI HEMOROID (OK)
100,000.00 400,000.00
PASANG FOLLEY CHATETER
35,000.00
15,000.00
PASANG GIPS MAYOR (EKSTREMITAS)
140,000.00 560,000.00
PASANG GIPS MINOR (JARI)
70,000.00 280,000.00
ROZERPLASTY ( EKSTRAKSI KUKU ) / NAEGEL EKSTRASI 40,000.00 160,000.00
SKLEROTHERAPY HEMOROID
60,000.00 240,000.00
VENA SEKSI
60,000.00 240,000.00
NEKROTOMI KECIL
20,000.00
80,000.00
NEKROTOMI SEDANG
30,000.00 120,000.00
NEKROTOMI BESAR
40,000.00 160,000.00
DEBRIDEMENT
40,000.00 160,000.00
PASANG SPALK
20,000.00
80,000.00
PASANG CLOSTHE BANDAGE
20,000.00
80,000.00
EKSPLORASI / ANGKAT BENDA ASING
70,000.00 280,000.00
SEWA SET GV
5,000.00
0.00
ASPIRING ASPIRASI
50,000.00
75,000.00
GANTI VERBAN KECIL ( INCL ALKES : MAX 10 - 15 PCS KAIN
35,000.00
KASSA ) 15,000.00
GANTI VERBAN KECIL ( INCL ALKES : MAX 15 - 20 PCS KAIN
40,000.00
KASSA ) 15,000.00
GANTI VERBAN SEDANG ( INCL ALKES : MAX 10 - 15 PCS KAIN
41,000.00
KASSA )24,000.00

Page 2

TarifKIT

31.500.02
31.500.03
31.500.04
31.500.01

19.001.00
19.002.01
19.002.02

BDH046
BDH047
BDH048
BDM001
BDM002
BDM003
BDM004
DOK001
DOK002
DOK003
DOK004
DOK005
DOK006
DOK007
DOK008
DOK009
DOK010
DOK011
DOK012
DOK013
DOK014
DOK015
DOK016
DOK017
DOK018
DOK019
DOK020
DOK021
DOK022
DOK023
DOK024
DOK025
DOK026
DOK027
DOK028
DOK029
DOK030
DOK031
DOK032
DOK033
DOK034
DOK035
DOK036
DOK037
DOK038
DOK039
DOK040
DOK041
FIS
FIS001
FIS002
FIS003

GANTI VERBAN SEDANG ( INCL ALKES : MAX 15 - 20 PCS KAIN

46,000.00
KASSA )24,000.00
GANTI VERBAN BESAR ( INCL ALKES : MAX 10 - 15 PCS KAIN
55,000.00
KASSA ) 45,000.00
GANTI VERBAN BESAR ( INCL ALKES : MAX 15 - 20 PCS KAIN
60,000.00
KASSA ) 45,000.00
BONE DENSITOMETRI 1 OBY
300,000.00
0.00
BONE DENSITOMETRI 2 OBY
375,000.00
0.00
BONE DENSITOMETRI 3 OBY
395,000.00
0.00
ERCP
375,000.00 175,000.00
JASA DOKTER JAGA ICU
0.00
90,000.00
JASA KONSUL DOKTER UGD - 08.01 - 21.00
30,000.00
30,000.00
JASA KONSUL DOKTER UGD - 21.01 - 08.00
35,000.00
35,000.00
JASA KONSULTASI AHLI AKUPUNKTUR (PRAKTEK KTK) 35,000.00
35,000.00
JASA KONSULTASI DOKTER GIZI
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS ANAK
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS ANAK (PRAKTEK KTK)
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS BEDAH MULUT 20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS BEDAH SYARAF 20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS BEDAH TULANG 20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS BEDAH UMUM
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS BEDAH UROLOGI 20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS JANTUNG & PEMBULUH
20,000.00
DARAH85,000.00
JASA KONSULTASI DOKTER SPESIALIS KEBIDANAN DAN KANDUNGAN
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS KESEHATAN JIWA20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS KULIT & KELAMIN 20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS MATA
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS PARU & ASMA
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS PATOLOGI KLINIK20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS PENYAKIT DALAM20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS PERIODONTIST 20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS PROSTHODONTIST
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS PSIKOLOGI
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS RM (PRAKTEK KTK)
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS SYARAF
20,000.00
85,000.00
JASA KONSULTASI DOKTER SPESIALIS T H T
20,000.00
85,000.00
JASA KONSULTASI DOKTER UMUM
30,000.00
30,000.00
JASA KONSULTASI DOKTER UMUM KECANTIKAN (SPA) 24,000.00
36,000.00
JASA KONSULTASI FISIOTERAPI
0.00
0.00
JASA KONSULTASI FISIOTERAPI_KTK
0.00
0.00
JASA KONSULTASI FISIOTERAPI_SPA
0.00
0.00
ON CALL DOKTER SPESIALIS
30,000.00 120,000.00
ON DUTY DOKTER SPESIALIS
20,000.00
85,000.00
VISITE DOKTER KELAS 1
0.00
90,000.00
VISITE DOKTER KELAS 2A
0.00
80,000.00
VISITE DOKTER KELAS 2B
0.00
80,000.00
VISITE DOKTER KELAS 3
0.00
60,000.00
VISITE DOKTER SVIP
0.00 125,000.00
VISITE DOKTER VIP
0.00 110,000.00
VISITE DOKTER NICU
0.00
90,000.00
ORDER PEMERIKSAAN FISIOTERAPI
0.00
0.00
MEDICAL MASSAGE (PER REGIO)
28,000.00
7,000.00
EXERCISE TERAPI - EXERCISE
28,000.00
7,000.00
EXERCISE TERAPI - GENERAL EXERCISE
48,000.00
12,000.00

Page 3

TarifKIT

19.003.00
19.004.01
19.005.01
19.005.02
19.005.03
19.005.04
19.005.05
19.005.06
19.005.07
19.005.08
19.006.01
19.006.02
19.006.03
19.007.00
19.008.00
19.009.01
19.009.02
19.009.03
06.100.01
06.100.02
06.100.03
06.100.04
06.101.00
06.102.00
06.103.00
06.104.01
06.104.02
06.105.00
06.201.00
06.301.00
06.302.00
06.303.00
06.401.01
06.401.02
06.401.03
06.402.01
06.402.02
06.402.03
06.403.01
06.403.02
06.404.01
06.404.02
06.405.01
06.405.02
06.406.00
06.501.00
06.502.00
06.503.01
06.503.02
06.504.01
06.504.02

FIS004
FIS005
FIS006
FIS007
FIS008
FIS009
FIS010
FIS011
FIS012
FIS013
FIS014
FIS015
FIS016
FIS017
FIS018
FIS019
FIS020
FIS021
FIS022
GGI001
GGI002
GGI003
GGI004
GGI005
GGI006
GGI007
GGI008
GGI009
GGI010
GGI011
GGI012
GGI013
GGI014
GGI015
GGI016
GGI017
GGI018
GGI019
GGI020
GGI021
GGI022
GGI023
GGI024
GGI025
GGI026
GGI027
GGI028
GGI029
GGI030
GGI031
GGI032
GGI033

LASER
80,000.00
20,000.00
AKTINOTERAPI - INFRA RED
24,000.00
6,000.00
ELEKTROTERAPI - SWD (SHORT WAVE DIATHERMY)
28,000.00
7,000.00
ELEKTROTERAPI - MWD (MICRO WAVE DIATHERMY)
28,000.00
7,000.00
ELEKTROTERAPI - US (ULTRA SOUND)
28,000.00
7,000.00
ELEKTROTERAPI - ES (ELEKTRICAL STIMULATION)
28,000.00
7,000.00
ELEKTROTERAPI - TENS (TRANCUTANEUS ELEKTRICAL NERVE
28,000.00
STIMULATION)
7,000.00
ELEKTROTERAPI - MODALITAS 2 ALAT YANG BERBEDA UNTUK
52,000.00
AREA YANG
13,000.00
SAMA
ELEKTROTERAPI - MODALITAS 3 ALAT YANG BERBEDA UNTUK
76,000.00
AREA YANG
19,000.00
SAMA
ELEKTROTERAPI - MODALITAS 4 ALAT YANG BERBEDA UNTUK
100,000.00
AREA YANG
25,000.00
SAMA
NEBULIZER - INHALASI + CHEST TERAPI
48,000.00
12,000.00
NEBULIZER - INHALASI + MWD + CHEST TERAPI
64,000.00
16,000.00
NEBULIZER - INHALASI + IR + CHEST TERAPI
56,000.00
14,000.00
TRAKSI LUMBAL
28,000.00
7,000.00
TRAKSI CERVICAL
28,000.00
7,000.00
HIDROTERAPI - PARAFIN BATH
24,000.00
6,000.00
HIDROTERAPI - COLD PACK
24,000.00
6,000.00
HIDROTERAPI - HOT PACK
24,000.00
6,000.00
MODALITAS UNTUK AREA YANG LAIN
25,000.00
0.00
KONSULTASI DOKTER GIGI UMUM
20,400.00
30,600.00
KONSULTASI DOKTER GIGI SPESIALIS
36,000.00
54,000.00
PREMEDIKASI DOKTER GIGI UMUM
21,600.00
32,400.00
PREMEDIKASI DOKTER GIGI SPESIALIS
43,200.00
64,800.00
SCREENING
72,000.00 108,000.00
BUKA JAHITAN
36,000.00
54,000.00
KONTROL PASKA OPERASI
21,600.00
32,400.00
CETAK MODEL GIGI 1 RAHANG
21,600.00
32,400.00
CETAK MODEL GIGI 2 RAHANG
36,000.00
54,000.00
MOUTH GUARD 1 RAHANG
162,000.00 378,000.00
FOTO DENTAL (PER FOTO)
21,600.00
32,400.00
DHE & ORAL PROFILAKSIS
54,000.00
81,000.00
FLUORIDASI TOPIKAL
72,000.00 108,000.00
PIT & FISSURE SEALANT
54,000.00
81,000.00
TUMPATAN GIC KECIL
54,000.00
81,000.00
TUMPATAN GIC SEDANG
72,000.00 108,000.00
TUMPATAN GIC BESAR
90,000.00 135,000.00
RAINBOW FILLING KECIL
54,000.00
81,000.00
RAINBOW FILLING SEDANG
72,000.00 108,000.00
RAINBOW FILLING BESAR
90,000.00 135,000.00
PUPOTOMI DOKTER GIGI UMUM
36,000.00
54,000.00
PUPOTOMI DOKTER GIGI SPESIALIS
54,000.00
81,000.00
ENDODONTIK GIGI SUSU DOKTER GIGI UMUM
36,000.00
54,000.00
ENDODONTIK GIGI SUSU DOKTER GIGI SPESIALIS
54,000.00
81,000.00
EKSTRAKSI GIGI SUSU TANPA INJEKSI
36,000.00
54,000.00
EKSTRAKSI GIGI SUSU DENGAN INJEKSI
54,000.00
81,000.00
SPACE MAINTAINER
126,000.00 189,000.00
TUMPATAN SEMENTARA
54,000.00
81,000.00
PULP CAPPING
54,000.00
81,000.00
PERAWATAN ENDODONTIK PER KUNJUNGAN AKAR TUNGGAL
54,000.00
81,000.00
PERAWATAN ENDODONTIK PER KUNJUNGAN AKAR GANDA
72,000.00 108,000.00
TUMPATAN KOMPOSIT KECIL
72,000.00 108,000.00
TUMPATAN KOMPOSIT SEDANG
90,000.00 135,000.00

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06.504.03
06.505.01
06.505.02
06.506.00
06.507.00
06.601.01
06.601.02
06.601.03
06.601.04
06.602.01
06.602.02
06.602.03
06.603.00
06.604.00
06.605.00
06.606.00
06.607.00
06.608.00
06.609.00
06.610.00
06.611.00
06.612.00
06.613.00
06.701.01
06.701.02
06.701.03
06.701.04
06.701.05
06.702.00
06.703.00
06.704.00
06.705.01
06.705.02
06.706.01
06.706.02
06.707.00
06.708.01
06.708.02
06.709.01
06.709.02
06.710.01
06.710.02
06.711.01
06.711.02
06.711.03
06.712.00
06.713.01
06.713.02
06.713.03
06.714.01
06.714.02
06.714.03

GGI034
GGI035
GGI036
GGI037
GGI038
GGI039
GGI040
GGI041
GGI042
GGI043
GGI044
GGI045
GGI046
GGI047
GGI048
GGI049
GGI050
GGI051
GGI052
GGI053
GGI054
GGI055
GGI056
GGI057
GGI058
GGI059
GGI060
GGI061
GGI062
GGI063
GGI064
GGI065
GGI066
GGI067
GGI068
GGI069
GGI070
GGI071
GGI072
GGI073
GGI074
GGI075
GGI076
GGI077
GGI078
GGI079
GGI080
GGI081
GGI082
GGI083
GGI084
GGI085

TUMPATAN KOMPOSIT BESAR

108,000.00
INLAY / ONLAY / UPLAY METAL
234,000.00
INLAY / ONLAY / UPLAY KERAMIK
324,000.00
HOME BLEACHING
900,000.00
OFFICE BLEACHING
1,440,000.00
EKSTRAKSI GIGI PERMANEN
72,000.00
EKSTRAKSI GIGI PERMANEN KOMPLIKASI KASUS MUDAH
108,000.00
EKSTRAKSI GIGI PERMANEN KOMPLIKASI KASUS SEDANG
126,000.00
EKSTRAKSI GIGI PERMANEN KOMPLIKASI KASUS SULIT 144,000.00
ODONTECTOMY KELAS I
540,000.00
ODONTECTOMY KELAS II
720,000.00
ODONTECTOMY KELAS III
900,000.00
ALVEOLECTOMY PER REGIO
180,000.00
IMPLANT
6,480,000.00
INSISI ABSES INTRA ORAL
72,000.00
INSISI ABSES EXTRA ORAL
216,000.00
EKSISI
270,000.00
APEX RESEKSI PER GIGI
540,000.00
OPERCULETOMY
180,000.00
EKSTIRPASI MUCOCEL
270,000.00
BONE GRAFT
2,160,000.00
FIKSASI FRAKTUR
540,000.00
KURET DRY SOCKET
72,000.00
JACKET CROWN METAL ACRYLIC
216,000.00
JACKET CROWN METAL PORCELAIN
450,000.00
JACKET CROWN ALL ACRYLIC
144,000.00
JACKET CROWN ALL PORCELAIN
720,000.00
JACKET CROWN ALL METAL
198,000.00
PIN FIBER & CROWN
900,000.00
PIN METAL & CROWN
540,000.00
MAHKOTA SEMENTARA
72,000.00
SEMENTASI CROWN (1-2 GIGI)
72,000.00
SEMENTASI CROWN (> 2 GIGI)
54,000.00
PLAT AKRILIK & 1 GIGI AKRILIK
198,000.00
PLAT AKRILIK & 1 GIGI PORSELEN
288,000.00
PLAT FRAME
540,000.00
FLEXY DENTURE SADDLE & 1 GIGI
360,000.00
FLEXY DENTURE BILATERAL & 1 GIGI
360,000.00
SINGLE COMPLETE DENTURE AKRILIK
792,000.00
SINGLE COMPLETE DENTURE PORSELEN
990,000.00
FULL DENTURE AKRILIK RA & RB
1,584,000.00
FULL DENTURE PORSELEN RA & RB
1,800,000.00
ELEMEN GIGI TIRUAN AKRILIK
63,000.00
ELEMEN GIGI TIRUAN PORSELEN
90,000.00
ELEMEN GIGI TIRUAN FLEXY DENTURE
54,000.00
CENGKERAM (PER CENGKRAM)
36,000.00
REPARASI KASUS MUDAH
72,000.00
REPARASI KASUS SEDANG
90,000.00
REPARASI KASUS SULIT
288,000.00
RELINING KASUS MUDAH
108,000.00
RELINING KASUS SEDANG
144,000.00
RELINING KASUS SULIT
270,000.00

Page 5

162,000.00
351,000.00
486,000.00
1,350,000.00
2,160,000.00
108,000.00
162,000.00
189,000.00
216,000.00
810,000.00
1,080,000.00
1,350,000.00
270,000.00
9,720,000.00
108,000.00
324,000.00
405,000.00
810,000.00
270,000.00
405,000.00
3,240,000.00
810,000.00
108,000.00
324,000.00
675,000.00
216,000.00
1,080,000.00
297,000.00
1,350,000.00
810,000.00
108,000.00
108,000.00
81,000.00
297,000.00
432,000.00
810,000.00
540,000.00
540,000.00
1,188,000.00
1,485,000.00
2,376,000.00
2,700,000.00
94,500.00
135,000.00
81,000.00
54,000.00
108,000.00
135,000.00
162,000.00
162,000.00
216,000.00
405,000.00

TarifKIT

06.715.01
06.715.02
06.715.03
06.716.00
06.801.01
06.801.02
06.801.03
06.802.01
06.802.02
06.803.00
06.804.01
06.804.02
06.805.01
06.805.02
06.805.01
06.805.02
06.806.00
06.807.00
06.901.01
06.901.02
06.901.03
06.902.00
06.903.00
06.904.00
06.905.00
24.800.01
24.800.02
24.800.03
24.800.04
24.800.05
24.800.06
24.800.07
24.800.08
24.800.09
24.800.10
24.800.11
24.800.12
24.900.00

GGI086
GGI087
GGI088
GGI089
GGI090
GGI091
GGI092
GGI093
GGI094
GGI095
GGI096
GGI097
GGI098
GGI099
GGI100
GGI101
GGI102
GGI103
GGI104
GGI105
GGI106
GGI107
GGI108
GGI109
GGI110
GGI111
HCR001
HCR002
HCR003
HCR004
HCR005
HCR006
HCR007
HCR008
HCR009
HCR010
HCR011
HCR012
HCR013
HCR014
HCR015
HCR016
HCR017
HCR018
HCR019
HCR020
HCR021
HCR022
HCR023
HCR024
HCR025
HCR026

REBASING KASUS MUDAH

REBASING KASUS SEDANG
REBASING KASUS SULIT
BONGKAR CROWN
SCALING PER RAHANG KELAS I
SCALING PER RAHANG KELAS II
SCALING PER RAHANG KELAS III
KURETASE (1 GIGI)
KURETASE (> 1 GIGI)
FLAP (PER REGIO)
SPLINTING (2 GIGI)
SPLINTING (> 2 GIGI)
GINGGIVEKTOMI (1-2 GIGI)
GINGGIVEKTOMI (> 2 GIGI)
DESENSITISASI (1 GIGI)
DESENSITISASI (> 2 GIGI)
SELECTIVE GRINDING
RECONTOURING
FIXED PER RAHANG KASUS MUDAH
FIXED PER RAHANG KASUS SEDANG
FIXED PER RAHANG KASUS SULIT
FIXED CERAMIC PER RAHANG
REMOVABLE
PEMASANGAN BRACKET LEPAS
AKTIVASI FIXED
AKTIVASI REMOVABLE
CREAMBATH TRADITIONAL
CREAMBATH NR
HAIR SPA LOREAL
HAIR MASKER STRUKTURA
CAT RAMBUT LOREAL
CUCI RAMBUT
CUCI BLOW
BLOW SOFT
BLOW CATOK
BLOW VARIASI
BLOW SPIRAL
PERAWATAN RAMBUT NUTRIOL
REFLEKSI
CAT RAMBUT MAKARIZO
HIGH LIGTH
TONING RAMBUT
SMOOTHING TANPA PRODUK
BLEACHING
CREAM BATH TANPA PRODUK
BILA TANPA CAT
SMOOTHING TANPA PRODUK
GUNTING PAKET
GUNTING RAMBUT
CABUT ALIS
CAT RAMBUT PAKET
TONING RAMBUT PAKET

Page 6

99,000.00
144,000.00
198,000.00
126,000.00
36,000.00
45,000.00
54,000.00
54,000.00
36,000.00
180,000.00
108,000.00
36,000.00
72,000.00
54,000.00
54,000.00
36,000.00
36,000.00
72,000.00
900,000.00
1,170,000.00
1,440,000.00
4,320,000.00
324,000.00
54,000.00
54,000.00
36,000.00
25,000.00
40,000.00
60,000.00
70,000.00
200,000.00
10,000.00
25,000.00
10,000.00
35,000.00
35,000.00
35,000.00
125,000.00
30,000.00
165,000.00
200,000.00
200,000.00
350,000.00
15,000.00
25,000.00
150,000.00
200,000.00
35,000.00
20,000.00
15,000.00
165,000.00
0.00

148,500.00
216,000.00
297,000.00
189,000.00
54,000.00
67,500.00
81,000.00
81,000.00
54,000.00
270,000.00
162,000.00
54,000.00
108,000.00
81,000.00
81,000.00
54,000.00
54,000.00
108,000.00
1,350,000.00
1,755,000.00
2,160,000.00
6,480,000.00
486,000.00
81,000.00
81,000.00
54,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

TarifKIT

HCR027
HCR028
HD0001
HD0002
17.001.00
HDR001
17.002.01
HDR002
17.002.02
HDR003
17.002.03
HDR004
17.002.04
HDR005
INJ001
JSD001
JSD002
JSD003
JSD004
JSD005
JSD006
JSD007
JSD008
JSD009
JSD010
JSD011
13.001.00
JTG001
13.002.00
JTG002
13.003.00
JTG003
13.004.00
JTG004
13.005.01
JTG005
13.005.02
JTG006
13.006.00
JTG007
13.007.00
JTG008
13.008.00
JTG009
14.001.00
JWA001
11.001.00
KBK001
11.002.01
KBK002
11.002.02
KBK003
11.003.00
KBK004
11.004.00
KBK005
11.005.00
KBK006
11.006.01
KBK007
11.006.02
KBK008
11.007.00
KBK009
11.008.01
KBK010
11.008.02
KBK011
11.009.01
KBK012
KBK013
11.009.02
KBK014
11.009.03
KBK015
11.010.00
KBK016
11.011.00
KBK017
KBK018
11.001.00.01KBK019
11.002.01.01KBK020
11.002.02.01KBK021

JASA TINDAKAN CAT RAMBUT

60,000.00
JASA TINDAKAN TONING
0.00
PAKET TREATMENT 1 (HAEMODIALISA)
830,000.00
PAKET TREATMENT II ( HAEMODALISA )
726,000.00
CLEANCING COLON
160,000.00
PAKET CLEANSING COLON 3X
440,000.00
PAKET CLEANSING COLON 6X
880,000.00
PAKET CLEANSING COLON 9X
1,320,000.00
PAKET CLEANSING COLON 10X
1,440,000.00
INJEKSI KENACORT
24,000.00
JASA PEMERIKSAAN - DOKTER UMUM
30,000.00
JASA PEMERIKSAAN - DOKTER GIGI
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS ANAK
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS PENYAKIT DALAM
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS JANTUNG
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS MATA
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS THT
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS KEBIDANAN 20,000.00
JASA PEMERIKSAAN - DOKTER GIGI SPESIALIS
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS SARAF
20,000.00
JASA PEMERIKSAAN - DOKTER SPESIALIS KESEHATAN JIWA
20,000.00
ECG
35,000.00
PLEURA PUNKSI
50,000.00
SPIROMETRI
30,000.00
TREADMILL
175,000.00
USG (ECHO RADIOGRAPHIC)
125,000.00
USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER
175,000.00
JASA SUNTIK (IMUNISASI)
10,000.00
TEST MANTOUX
50,000.00
NEBULIZER
60,000.00
MMPI
52,500.00
ANGKAT PESARIUM
20,000.00
CABUT IMPLANON (JASA )
60,000.00
CABUT IUD (JASA)
20,000.00
EKSTIRPASI ( OBSGYN )
220,000.00
JASA SUNTIK (IMUNISASI)
10,000.00
MICRO CURRATAGE / PA
220,000.00
PASANG IMPLANON (JASA)
80,000.00
PASANG IUD (JASA)
60,000.00
PAP SMEAR / VAGINAL SMEAR
15,000.00
PASANG LAMINARIA
60,000.00
PASANG PESARIUM ( DI LUAR ALKES )
20,000.00
USG 2-D & PRINT OUT
32,500.00
USG 2-D NON PRINT OUT
19,500.00
USG 4-D & PRINT OUT
292,500.00
USG TRANSVAGINAL
97,500.00
HIDROTUBASI
70,000.00
CTG
25,000.00
BIOPSY SERVIC
280,000.00
ANGKAT PESARIUM ( TERMASUK ALKES )
20,000.00
CABUT IMPLANON ( TERMASUK ALKES )
50,000.00
CABUT IUD ( TERMASUK ALKES )
20,000.00

Page 7

0.00
0.00
0.00
0.00
40,000.00
110,000.00
220,000.00
330,000.00
360,000.00
96,000.00
30,000.00
85,000.00
85,000.00
85,000.00
85,000.00
85,000.00
85,000.00
85,000.00
85,000.00
85,000.00
85,000.00
15,000.00
200,000.00
30,000.00
175,000.00
125,000.00
175,000.00
0.00
0.00
0.00
122,500.00
80,000.00
240,000.00
80,000.00
880,000.00
0.00
880,000.00
320,000.00
240,000.00
60,000.00
240,000.00
80,000.00
17,500.00
10,500.00
157,500.00
52,500.00
280,000.00
25,000.00
70,000.00
80,000.00
200,000.00
80,000.00

TarifKIT

11.003.00.01KBK022
11.005.00.01KBK023
11.006.01.01KBK024
11.006.02.01KBK025
11.007.00.01KBK026
11.008.01.01KBK027
11.008.02.01KBK028
11.010.00.01KBK029
11.011.00.01KBK030
KBK031
KKK001
KKK002
KKK003
KKK004
KKK005
KKK006
KKK007
KKK008
KKK009
KKK010
KKK011
KKK012
KKK013
KKK014
KKK015
KKK016
KKK017
KKK018
KKK019
KKK020
KKK021
KKK022
KKK023
KKK024
KKK025
KKK026
KKK027
KKK028
KKK029
KKK030
KKK031
KKK032
KKK033
KKK034
KKK035
KKK036
KKK037
KKK038
KKK039
31.700.01
KON001
31.700.02
KON002
31.700.03
KON003

EKSTIRPASI ( OBSGYN )( TERMASUK ALKES )

220,000.00
MICRO CURRATAGE / PA ( TERMASUK ALKES )
220,000.00
PASANG IMPLANON (JASA + ALKES )
80,000.00
PASANG IUD (JASA + ALKES)
50,000.00
PAP SMEAR / VAGINAL SMEAR ( TERMASUK ALKES )
15,000.00
PASANG LAMINARIA ( TERMASUK ALKES )
40,000.00
PASANG PESARIUM ( TERMASUK ALKES )
20,000.00
HIDROTUBASI ( TERMASUK ALKES )
70,000.00
CTG ( TERMASUK ALKES )
25,000.00
BIOPSY SERVIC ( TERMASUK ALKES )
70,000.00
PEELING KECIL
120,000.00
PEELING SEDANG
132,000.00
PEELING BESAR
144,000.00
CAUTER KECIL
135,000.00
CAUTER SEDANG
180,000.00
CAUTER BESAR
240,000.00
EKSTRAKSI KECIL
75,000.00
EKSTRAKSI SEDANG
99,000.00
EKSTRAKSI BESAR
120,000.00
KIL KECIL
150,000.00
KIL SEDANG
165,000.00
INJEKSI KENOCART
24,000.00
BIOPSY
99,000.00
ELEKTRO CAUTER BADAN KECIL
42,000.00
ELEKTRO CAUTER BADAN SEDANG
55,000.00
ELEKTRO CAUTER BADAN BESAR
80,000.00
ELEKTRO CAUTER WAJAH KECIL
47,500.00
ELEKTRO CAUTER WAJAH SEDANG
74,500.00
ELEKTRO CAUTER WAJAH BESAR
86,300.00
EKSISI NEVUS
111,000.00
ENUKKASI KECIL
24,000.00
ENUKKASI SEDANG
35,000.00
ENUKKASI BESAR
47,000.00
EKSTIRPASI LIPOMA
80,000.00
EKSTRAKSI KOMEDO KECIL
17,000.00
EKSTRAKSI KOMEDO SEDANG
25,000.00
EKSTRAKSI KOMEDO BESAR
36,000.00
INSISI ABCESS
65,000.00
INSISI ABCESS BARTHOLINI
106,000.00
PEELING NEOSTRATA 20-35%
90,000.00
PENGOBATAN KONDILOMA (DGN PODOFILLIN) KECIL
36,000.00
PENGOBATAN KONDILOMA (DGN PODOFILLIN) SEDANG 52,000.00
PENGOBATAN KONDILOMA (DGN PODOFILLIN) BESAR
66,000.00
ALKES ELEKTRO CAUTER
60,000.00
ALKES EKSISI
60,000.00
ALKES ENUKKASI
60,000.00
ALKES EKSTIRPASI ( TANPA BENANG )
65,000.00
ALKES EKSTRASI KOMEDO
60,000.00
ALKES INSISI ( DENGAN BENANG )
75,000.00
OMNIPAQUE 20 ML
132,000.00
OMNIPAQUE 50 ML
269,500.00
IOPAMIRO 30 ML
220,000.00

Page 8

880,000.00
880,000.00
320,000.00
200,000.00
60,000.00
160,000.00
80,000.00
280,000.00
25,000.00
280,000.00
80,000.00
88,000.00
96,000.00
90,000.00
120,000.00
160,000.00
50,000.00
66,000.00
80,000.00
100,000.00
110,000.00
96,000.00
396,000.00
168,000.00
220,000.00
320,000.00
190,000.00
298,000.00
345,200.00
444,000.00
96,000.00
140,000.00
188,000.00
320,000.00
68,000.00
100,000.00
144,000.00
260,000.00
424,000.00
135,000.00
54,000.00
78,000.00
99,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

TarifKIT

31.700.04

KON004
KRT001
KRT002
KRT003
KRT004
KRT005
KRT006
20.004.01
KTK001
20.004.02.01KTK002
20.004.02.02KTK003
20.004.02.03KTK004
20.004.02.04KTK005
20.004.03.01KTK006
20.004.03.02KTK007
20.004.03.03KTK008
20.004.03.04KTK009
20.004.04.01KTK010
20.004.04.02KTK011
20.004.04.03KTK012
20.004.04.04KTK013
20.004.04.05KTK014
20.005.01.01KTK015
20.005.01.02KTK016
KTK017
LAB001
LAB002
LAB003
LAB004
LAB005
LAB006
LAB007
LAB008
LAB009
LAB010
LAB011
LAB012
LAB013
LAB014
LAB015
LAB016
LAB017
LAB018
LAB019
LAB020
LAB021
LAB022
LAB023
LAB024
LAB025
LAB026
LAB027
LAB028

IOPAMIRO 50 ML
313,500.00
0.00
JASA OPERATOR - KURET
0.00 1,500,000.00
SHARE OPERATOR - KURET
0.00 1,200,000.00
JASA ANASTESI - KURET
0.00 600,000.00
SHARE ANESTESI - KURET
0.00 480,000.00
KAMAR BERSALIN - KURET
200,000.00
0.00
KAMAR OBSERVASI - KURET
85,000.00
0.00
SENSORI INTEGRASI
70,000.00
0.00
TERAPI (FISIOTERAPI) 45 MENIT - TERAPI 1 SESSION
50,000.00
0.00
TERAPI (FISIOTERAPI) 45 MENIT - TERAPI KELAS 1 BULAN
350,000.00
0.00
TERAPI (FISIOTERAPI) 45 MENIT - TERAPI KELAS 2 BULAN
750,000.00
0.00
TERAPI (FISIOTERAPI) 45 MENIT - TERAPI KELAS 3 BULAN
1,150,000.00
0.00
TERAPI (OKUPASI TERAPI) - TERAPI 1 SESSION
50,000.00
0.00
TERAPI (OKUPASI TERAPI) - TERAPI KELAS 1 BULAN
350,000.00
0.00
TERAPI (OKUPASI TERAPI) - TERAPI KELAS 2 BULAN
750,000.00
0.00
TERAPI (OKUPASI TERAPI) - TERAPI KELAS 3 BULAN 1,150,000.00
0.00
TERAPI (SPEECH TERAPI) - TERAPI 1 SESSION
50,000.00
0.00
TERAPI (SPEECH TERAPI) - TERAPI KELAS 1 BULAN
350,000.00
0.00
TERAPI (SPEECH TERAPI) - TERAPI KELAS 2 BULAN
750,000.00
0.00
TERAPI (SPEECH TERAPI) - TERAPI KELAS 3 BULAN
1,150,000.00
0.00
TERAPI (SPEECH TERAPI) - FEEDING PROBLEM THERAPY60,000.00
0.00
PELATIHAN MASSAGE BAYI - TEORI (OLEH DOKTER RM)
0.00 100,000.00
PELATIHAN MASSAGE BAYI - PRAKTEK
75,000.00
0.00
MASSAGE BAYI
50,000.00
0.00
DARAH RUTIN
45,000.00
0.00
DARAH LENGKAP
50,000.00
0.00
PAKET DHF
40,000.00
0.00
HEMOGLOBIN
15,000.00
0.00
HEMATOKRIT
15,000.00
0.00
JUMLAH LEKOSIT
15,000.00
0.00
JUMLAH TROMBOSIT
15,000.00
0.00
JUMLAH RETIKULOSIT
15,000.00
0.00
JUMLAH EOSINOFIL
15,000.00
0.00
MALARIA
25,000.00
0.00
GOLONGAN DARAH ABO RHESUS
15,000.00
0.00
GAMBARAN DARAH TEPI
100,000.00
0.00
GAMBARAN SUMSUM TULANG
287,000.00
0.00
RUMPELL LEEDE
15,000.00
0.00
MASA PENDARAHAN / BT
15,000.00
0.00
MASA PROTROMBIN (PT) & INR
93,500.00
0.00
MASA TROMBOPLASTIN PARSIAL / A P I T
85,000.00
0.00
MASA TROMBIN ( TT )
71,500.00
0.00
MASA TROMBIN SERIAL
236,500.00
0.00
FIBRINOGEN
99,000.00
0.00
D - DIMER
236,500.00
0.00
TROMBOTEST
93,500.00
0.00
ANTI TROMBIN III ( AT III )
290,500.00
0.00
PROTEIN C
350,000.00
0.00
PROTEIN S
350,000.00
0.00
AGREGASI TROMBOSIT
179,000.00
0.00
SI - TIBC
190,000.00
0.00
FERITIN
160,000.00
0.00

Page 9

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LAB029
LAB030
LAB031
LAB032
LAB033
LAB034
LAB035
LAB036
LAB037
LAB038
LAB039
LAB040
LAB041
LAB042
LAB043
LAB044
LAB045
LAB046
LAB047
LAB048
LAB049
LAB050
LAB051
LAB052
LAB053
LAB054
LAB055
LAB056
LAB057
LAB058
LAB059
LAB060
LAB061
LAB062
LAB063
LAB064
LAB065
LAB066
LAB067
LAB068
LAB069
LAB070
LAB071
LAB072
LAB073
LAB074
LAB075
LAB076
LAB077
LAB078
LAB079
LAB080

ELEKTROFORESIS HB
VITAMIN B 12
ASAM FOLAT
G6PD ERITROSIT
RESISTENSI OSMOTIK
COOMB'S TEST
HAM'S & SUGAR TEST
ANTIBODI TROMBOSIT
VISKOSITAS DARAH / PLASMA
SEL LE
PEWARNAAN SITOKIMIA - NAP
PEWARNAAN SITOKIMIA - SBB
PEWARNAAN SITOKIMIA - MGG
CROSSMATCH
PROTEIN TOTAL - ALB - GLOB
ALBUMIN
ELEKTROFORESIS PROTEIN
BILLIRUBIN TOT - DIR - IND
FOSFATASE ALKALI
SGOT - SGPT
GAMMA GT (GGT)
CHOLISNESTERASE (CHE)
ASAM EMPEDU
AMONIA
TRIGLISERIDA
KOLESTEROL TOTAL
HDL KOLESTEROL
LDL KOLESTEROL
APO - A
APO - B
LP (A)
LDH
HBDH
CK TOTAL
CK - MB
TROPONIN KUALITATIF
TROPONIN KUANTITATIF
HOMOCYSTEIN
HIGH SENSITIVE C R P
GLUKOSA SEWAKTU
GLUKOSA PUASA
GLUKOSA 2 JAM PP
KURVA HARIAN GLUKOSA
TES TOLERANSI GLUKOSA / GTT
GLIKO HB (HBA 1C)
FRUKTOSAMIN
UREUM
CREATININ
ASAM URAT
CREATININ CLEARANCE ( BERSIHAN CLEARANCE )
CYSTATIN C
NATRIUM

Page 10

160,000.00
415,000.00
350,000.00
110,000.00
44,000.00
150,000.00
0.00
111,000.00
100,000.00
35,000.00
250,000.00
250,000.00
270,000.00
0.00
50,000.00
30,000.00
117,000.00
50,000.00
49,500.00
46,000.00
48,000.00
94,000.00
300,000.00
328,000.00
25,000.00
30,000.00
30,000.00
30,000.00
160,000.00
125,000.00
195,000.00
83,000.00
104,000.00
101,000.00
146,000.00
220,000.00
385,000.00
275,000.00
180,000.00
18,000.00
18,000.00
18,000.00
55,000.00
75,000.00
145,000.00
176,000.00
23,000.00
23,000.00
23,000.00
55,000.00
255,000.00
37,500.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

TarifKIT

LAB081
LAB082
LAB083
LAB084
LAB085
LAB086
LAB087
LAB088
LAB089
LAB090
LAB091
LAB092
LAB093
LAB094
LAB095
LAB096
LAB097
LAB098
LAB099
LAB100
LAB101
LAB102
LAB103
LAB104
LAB105
LAB106
LAB107
LAB108
LAB109
LAB110
LAB111
LAB112
LAB113
LAB114
LAB115
LAB116
LAB117
LAB118
LAB119
LAB120
LAB121
LAB122
LAB123
LAB124
LAB125
LAB126
LAB127
LAB128
LAB129
LAB130
LAB131
LAB132

KALIUM URIN
CHLORIDA
CALSIUM TOTAL
CALSIUM ION
FOSFOR ORGANIK / ANORGANIK
MAGNESIUM TOTAL
ANALISA GAS DARAH
AMILASE
AMILASE PANKREATIK
LIPASE
FOSFATASE ASAM
FOSFATASE ASAM PROSTAT ( PAP )
AMINOPHYLIN / THEOPHILIN
DIGOXIN
CLYCOSPORIN
PHENOBARBITAL
VDRL / RPR
TPHA
WIDAL
ANTI DENGUE IGG - IGM
ANTI TB IGG / ICT TB
HELICOBACTER PYLORI IGG
ANTI HIV
WESTERN BLOT
SERAMOEBA / DT
CRP KUANTITATIF
ASTO
RF
HBSAG
ANTI HBS (TITER)
HBE AG
ANTI HBE
ANTI HBC TOTAL
ANTI HBC IGM
HBV - DNA KUALITATIF
HBV - DNA KUANTITATIF
ANTI HAV IGM
ANTI HCV TOTAL
ANTI HCV IGM
HCV - RNA KUALITATIF
HCV - RNA KUANTITATIF
AFP ( HATI )
CEA ( COLON )
CA 125 ( OVARIUM )
CA 19-9 ( PANKREAS )
CA 15-3 ( MAMMA )
PSA TOTAL ( PROSTATE )
FREE PSA ( PROSTATE )
NSE ( PARU )
SCC ( CERVIX )
ANTI TOKSOPLASMA IGG
ANTI TOKSOPLASMA IGM

Page 11

37,500.00
37,500.00
41,000.00
225,000.00
41,000.00
41,000.00
140,000.00
100,000.00
154,000.00
167,000.00
132,000.00
229,000.00
369,000.00
290,000.00
550,000.00
525,000.00
40,000.00
62,500.00
65,000.00
260,000.00
150,000.00
286,000.00
199,000.00
700,000.00
215,000.00
82,500.00
115,500.00
73,000.00
89,000.00
102,000.00
250,000.00
295,000.00
167,000.00
310,000.00
800,000.00
1,400,000.00
195,000.00
230,000.00
564,000.00
1,000,000.00
1,800,000.00
142,500.00
142,500.00
275,000.00
275,000.00
275,000.00
199,000.00
420,000.00
330,000.00
253,000.00
155,000.00
159,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

TarifKIT

LAB133
LAB134
LAB135
LAB136
LAB137
LAB138
LAB139
LAB140
LAB141
LAB142
LAB143
LAB144
LAB145
LAB146
LAB147
LAB148
LAB149
LAB150
LAB151
LAB152
LAB153
LAB154
LAB155
LAB156
LAB157
LAB158
LAB159
LAB160
LAB161
LAB162
LAB163
LAB164
LAB165
LAB166
LAB167
LAB168
LAB169
LAB170
LAB171
LAB172
LAB173
LAB174
LAB175
LAB176
LAB177
LAB178
LAB179
LAB180
LAB181
LAB182
LAB183
LAB184

ANTI RUBELLA IGG

ANTI RUBELLA IGM
ANTI CMV IGG
ANTI CMV IGM
ANTI HSV I IGG
ANTI HSV I IGM
ANTI HSV II IGG
ANTI HSV II IGM
ANTI CHLAMYDIA IGG
ANTI CHLAMYDIA IGM
IGG
IGA
IGM
IGE TOTAL
IGE SPESIFIK
KOMPLEMEN C3
KOMPLEMEN C4
ALFA ANTITRIPSIN
ANA
ANTI DS DNA
ACA IGG
ACA IGM
AMA
SMA
IMUNOFIKSASI
LIMFOSIT T
LIMFOSIT SUBSET ( CD4, CD8, CD19, NK )
LIMFOSIT B
T4 TOTAL
T3 TOTAL
TSH SENSITIF
T4 BEBAS ( FREE T4 )
T3 BEBAS ( FREE T3 )
THYROGLOBULIN
ANTI THYROGLOBULIN
ANTI T P O
TSH NEONATUS
LH
FSH
PROLAKTIN
ESTRADIOL
ESTROGEN
PROGESTERON
TESTOTERON
B HCG KUANTITATIF
INSULIN
VMA
ACTH
PTH
URINALISIS LENGKAP
PROTEIN (ALBUMIN)
REDUKSI / GLUKOSA - URIN LENGKAP

Page 12

167,000.00
182,000.00
159,000.00
182,000.00
160,000.00
164,000.00
160,000.00
164,000.00
325,000.00
325,000.00
240,000.00
240,000.00
240,000.00
170,000.00
750,000.00
245,000.00
245,000.00
115,000.00
250,000.00
260,000.00
330,000.00
330,000.00
80,000.00
80,000.00
375,000.00
350,000.00
360,000.00
350,000.00
125,000.00
125,000.00
137,500.00
175,000.00
200,000.00
357,000.00
190,000.00
0.00
165,000.00
185,000.00
185,000.00
180,000.00
220,000.00
1,080,000.00
220,000.00
198,000.00
250,000.00
170,000.00
120,000.00
1,440,000.00
350,000.00
27,500.00
12,500.00
12,500.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

TarifKIT

LAB185
LAB186
LAB187
LAB188
LAB189
LAB190
LAB191
LAB192
LAB193
LAB194
LAB195
LAB196
LAB197
LAB198
LAB199
LAB200
LAB201
LAB202
LAB203
LAB204
LAB205
LAB206
LAB207
LAB208
LAB209
LAB210
LAB211
LAB212
LAB213
LAB214
LAB215
LAB216
LAB217
LAB218
LAB219
LAB220
LAB221
LAB222
LAB223
LAB224
LAB225
LAB226
LAB227
LAB228
LAB229
LAB230
LAB231
LAB232
LAB233
LAB234
LAB235
LAB236

SEDIMEN - URIN LENGKAP

KETON - URIN LENGKAP
PROTEIN BENCE JONES
MIKRO ALBUMIN
TEST KEHAMILAN EIA
PROTEIN KUANTITATIF
UREUM - URIN KIMIA
CREATININ - URIN KIMIA
NATRIUM - URIN KIMIA
CLORIDA - URIN KIMIA
CALSIUM - URIN KIMIA
MORPHIN
MARIJUANA / THC
COCAIN
BENZODIAZEPIN
AMPHETAMIN
TINJA RUTIN
PENCERNAAN
DARAH SAMAR
ANALISA CAIRAN OTAK ( RUTIN )
PROTEIN - CAIRAN OTAK
GLUKOSA - CAIRAN OTAK
CHLORIDA - CAIRAN OTAK
CAIRAN TUBUH RUTIN
RATIO PROTEIN
RATIO LDH
GLUKOSA CAIRAN TUBUH
ANALISA SPERMA
ANALISA BATU GINJAL
ANALISA CAIRAN SENDI
PEWARNAAN GRAM
PEWARNAAN BTA
BIAKAN KUMAN AEROB
BIAKAN KUMAN ANAEROB
RESISTENSI
BIAKAN MYCOBACTERIUM TB
PCR MYCOBACTERIUM TB
PCR SALMONELLA TYPHI
PAP SMEARS
P A JARINGAN KECIL
MASA PEMBEKUAN / CT
IT RATIO
BILIRUBIN NEONATUS
P A JARINGAN BESAR
GO / SEKTED / GONORRHOE ???
GALL ( EMPEDU )
HBA 1C
CA 19-9 ( PAYUDARA ) ---PANKREAS
MYCOBACTERIUM / BTA ?????
KETON DARAH
LAJU ENDAP DARAH (LED)
HITUNG JENIS (DIFF)

Page 13

15,000.00
15,000.00
33,000.00
90,000.00
55,000.00
100,000.00
23,000.00
23,000.00
37,500.00
37,500.00
42,000.00
60,000.00
60,000.00
60,000.00
60,000.00
60,000.00
20,000.00
15,000.00
30,000.00
100,000.00
40,000.00
20,000.00
41,000.00
100,000.00
55,000.00
110,000.00
35,000.00
165,000.00
125,000.00
155,000.00
35,000.00
35,000.00
192,500.00
262,000.00
192,500.00
263,000.00
300,000.00
300,000.00
100,000.00
250,000.00
15,000.00
15,000.00
50,000.00
500,000.00
175,000.00
192,500.00
145,000.00
275,000.00
263,000.00
40,000.00
15,000.00
15,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

TarifKIT

LAB237
LAB238
LAB239
LAB240
LAB241
LAB242
LAB243
LAB244
LAB245
LAB246
LAB247
LAB248
LAB249
LAB250
LAB251
LAB252
LAB253
LAB254
LAB255
LAB256
LAB257
LAB258
LAB259
LAB260
LAB261
LAB262
LAB263
LAB264
LAB265
LAB266
LAB267
LAB268
LAB269
LAB270
LAB271
LAB272
LAB273
LAB274
LAB275
LAB276
LAB277
LAB278
LAB279
LAB280
LAB281
LAB282
LAB283
LAB284
LAB285
LAB286
LAB287
LAB288

SGOT
SGPT
NILAI ERITROSIT ( MCV, MCH, MCHC )
EOSINOFIL INGUS
G6PD NEONATUS
LE REAKSI
TRANSFERIN
RETRAKSI BEKUAN
INR
STT
ASTRUP
PROTEIN TOTAL
C - PEPTIDE
INSULIN PUASA
LIPID TOTAL
REDUKSI / GLUKOSA
METAMPHETAMIN
CANABIS / MARIYUANA
ANALISA FECES ANAK
ANALISA CAIRAN PLEURA ( RUTIN )
ANTI HAV TOTAL
RHEUMATOID FAKTOR
C - REACTIVE PROTEIN
ANTI DENGUE IGG
ANTI DENGUE IGM
HELICOBACTER PYLORI IGM
ANTI CARDIOLIPIN IGG
ANTI CARDIOLIPIN IGM
T3 UPTAKE
FTI
CA 72 - 4
CORTISOL
JAMUR ?????
SALMONELLA TYPHI M
LEPTOSPIROSIS
LDH CAIRAN TUBUH
TEST E I A
SALMONELA IGM/TUBEX
KALIUM DARAH
KULTUR JAMUR
CANDIDA
ASPERGILLUS
HITOPLASMA
KRIPTO COCCUS
PREPARAT JAMUR
ICT MALARIA
MAGNESIUM URIN
CIFRA 21
ADINAFIN DIAMINASE
VIRAL LOAD HIV
PCR MALARIA
PRACALEITONIN

Page 14

23,000.00
23,000.00
15,000.00
15,000.00
120,000.00
45,000.00
162,500.00
12,000.00
85,000.00
236,500.00
140,000.00
25,000.00
210,000.00
190,000.00
50,000.00
12,500.00
60,000.00
60,000.00
120,000.00
100,000.00
239,000.00
71,500.00
82,500.00
120,000.00
140,000.00
282,000.00
330,000.00
330,000.00
195,000.00
220,000.00
525,000.00
231,000.00
192,500.00
165,000.00
110,000.00
55,000.00
55,000.00
150,000.00
37,500.00
192,500.00
162,000.00
162,000.00
162,000.00
162,000.00
35,000.00
159,000.00
38,500.00
360,000.00
180,000.00
1,020,000.00
300,000.00
396,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

TarifKIT

10.001.00
10.003.00
10.004.01
10.004.02
10.004.03
10.005.00
10.006.00
10.007.00
10.008.00
10.009.00
10.010.00
10.011.00
10.012.00
10.013.00
10.014.00
10.015.00
10.016.00

LAB289
LAB290
LAB291
LAB292
LAB293
LAB294
LAB295
LAB296
LAB297
LAB298
LAB299
LAB300
LAB301
MCU001
MCU002
MCU003
MCU004
MCU005
MCU006
MCU007
MCU008
MCU009
MCU010
MCU011
MCU012
MCU013
MCU014
MCU015
MCU016
MTA001
MTA002
MTA003
MTA004
MTA005
MTA006
MTA007
MTA008
MTA009
MTA010
MTA011
MTA012
MTA013
MTA014
MTA015
MTA016
MTA017
MTA018
MTA019
MTA020
MTA021
MTA022
MTA023

ANALISA SPERMA
165,000.00
IDT AMOEBA
252,000.00
ANALISA BATU EMPEDU
143,000.00
LIMFOSIT T SUBSET (CD4, CD8 )
240,000.00
CD4
132,000.00
CD8
132,000.00
SALMONELLA TYPHI G
165,000.00
ANALISA CAIRAN LAMBUNG
155,000.00
ASAM LAKTAT
150,000.00
MIKROFILARIA
88,000.00
BARBITURAT
65,000.00
CHICKUNGUNYA
200,000.00
NS-1 DENGUE ( RAPID )
250,000.00
MCU PURI SILVER
381,000.00
MCU PURI GOLD
780,000.00
MCU PURI PLATINUM - PRIA
916,000.00
MCU PURI PLATINUM - WANITA
1,010,000.00
MCU PURI DIAMOND - PRIA
1,611,000.00
MCU PURI DIAMOND - WANITA
2,052,500.00
MCU PURI COORPORATE STANDAR - DASAR
281,000.00
MCU PURI COORPORATE STANDAR - PRIMA
741,000.00
MCU PURI PRE MARITAL - PRIA
716,000.00
MCU PURI GOLD FOR KIDS
0.00
MCU PURI PLATINUM FOR KIDS
0.00
MCU CALON KARYAWAN KONTRAK RSPMK
200,000.00
MCU PURI PRE MARITAL - WANITA
716,000.00
MCU KARYAWAN TETAP RSPMK
281,500.00
PRODIA - THORAX
45,000.00
PAKET MCU
791,500.00
ANGKAT JAHITAN (PALPEBRA/KONJUNGTIVA/KORNEA) 20,000.00
CHALAZION / INCISI
80,000.00
EKSTRAKSI CORPUS ALIENUM DI KORNEA
25,000.00
EKSTRAKSI CORPUS ALIENUM DI KONJUNGTIVA
20,000.00
EKSTRAKSI LITHIASIS
20,000.00
FITTING LENSA KONTAK
10,000.00
HORDEOLUM ( INCISI )
80,000.00
ANEL TEST
20,000.00
AVULSI PTERIGIUM / PTERIGIUM KECIL
100,000.00
TONOMETRI (SCHIOTZ)
6,000.00
AUTOREF + KOREKSI VISUS
6,000.00
EPILASI
15,000.00
OPHTALMOSCOPE INDIRECT W/ MIDRIACYL
6,000.00
OPHTALMOSCOPE DIRECT W/ MIDRIACYL
5,000.00
DEBRIDEMENT KORNEA
10,000.00
SCHIMMER TEST
4,000.00
ISHIHARA TEST (TEST BUTA WARNA)
6,000.00
TRICHIASIS
6,000.00
INFRAKSI / REFRAKSI
7,000.00
SLIT LAMP
4,000.00
LIGASI / SPOOLING
5,000.00
IRIGASI
30,000.00
REFRAKSI MATA
13,000.00

Page 15

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
69,000.00
119,000.00
384,000.00
454,000.00
588,000.00
658,000.00
69,000.00
109,000.00
159,000.00
0.00
0.00
50,000.00
159,000.00
50,000.00
15,000.00
290,000.00
80,000.00
320,000.00
100,000.00
80,000.00
80,000.00
40,000.00
320,000.00
80,000.00
400,000.00
24,000.00
24,000.00
60,000.00
24,000.00
20,000.00
40,000.00
16,000.00
24,000.00
24,000.00
28,000.00
16,000.00
20,000.00
120,000.00
52,000.00

TarifKIT

28.011.01
28.011.02
28.011.03
28.011.04
28.012.01
28.012.02
28.012.03
28.012.04
28.014.01
28.014.02
28.014.03
28.014.04
28.015.01
28.015.02
28.015.03
28.015.04
28.015.01
28.015.01
28.015.01
28.015.01
28.015.02
28.015.02
28.015.02
28.015.02
28.015.03
28.015.03
28.015.03
28.015.03
28.015.04
28.015.04
28.015.04
28.015.04
28.015.05
28.015.05
28.015.05
28.015.05
28.015.06
28.015.06
28.015.06
28.015.06
28.015.07
28.015.07
28.015.07
28.015.07
28.015.08
28.015.08
28.015.08
28.015.08
28.015.09
28.015.09
28.015.09

MTA024
ODC001
ODC002
ODC003
ODC004
ODC005
ODC006
ODC007
ODC008
ODC009
ODC010
ODC011
ODC012
ODC013
ODC014
ODC015
ODC016
OKK001
OKK002
OKK003
OKK004
OKK005
OKK006
OKK007
OKK008
OKK009
OKK010
OKK011
OKK012
OKK013
OKK014
OKK015
OKK016
OKK017
OKK018
OKK019
OKK020
OKK021
OKK022
OKK023
OKK024
OKK025
OKK026
OKK027
OKK028
OKK029
OKK030
OKK031
OKK032
OKK033
OKK034
OKK035

PAKET KOMPLAMI
140,000.00
0.00
KAMAR TINDAKAN / VK - ODC KURET
200,000.00
0.00
KAMAR OBSEVASI - ODC KURET
150,000.00
0.00
DOKTER KANDUNGAN - ODC KURET
0.00 1,250,000.00
DOKTER ANASTESI - ODC KURET
0.00 500,000.00
KAMAR OK MINOR - ODC STERIL
450,000.00
0.00
KAMAR OBSERVASI - ODC STERIL
150,000.00
0.00
DOKTER KANDUNGAN - ODC STERIL
0.00 1,400,000.00
DOKTER ANASTESI - ODC STERIL
0.00 560,000.00
KAMAR OK MINOR - ODC FAM/HIDROKEL
450,000.00
0.00
KAMAR OBSERVASI - ODC FAM/HIDROKEL
150,000.00
0.00
DOKTER BEDAH - ODC FAM/HIDROKEL
1,500,000.00
0.00
DOKTER ANASTESI - ODC FAM/HIDROKEL
0.00 600,000.00
JASA DOKTER OPERATOR - ODC CEMINO
0.00 1,500,000.00
KAMAR OK MINOR - ODC CEMINO
450,000.00
0.00
KAMAR OBSERVASI - ODC CEMINO
150,000.00
0.00
SEWA ALAT SET BULDOK - ODC CEMINO
300,000.00
0.00
JASA ANESTESI OBS KOND KHUSUS - SC + STERIL / KISTEKTOMI
0.00/ MINIMAL
1,600,000.00
MIOMEKTOMI
JASA DOKTER ANAK OBS KOND KHUSUS - SC + STERIL / KISTEKTOMI
0.00 1,000,000.00
/ MINIMAL MIOMEKTOM
JASA OPERATOR OBS KOND KHUSUS - SC + STERIL / KISTEKTOMI
0.00 /4,000,000.00
MINIMAL MIOMEKTOMI
SEWA KAMAR OK OBS KOND KHUSUS - SC + STERIL / KISTEKTOMI
2,500,000.00 / MINIMAL
0.00
MIOMEKTOMI
JASA ANESTESI OBS KOND KHUSUS - SC + CITO / PERMINTAAN
0.00 1,500,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - SC + CITO / PERMINTAAN
0.00 750,000.00
JASA OPERATOR OBS KOND KHUSUS - SC + CITO / PERMINTAAN
0.00 3,750,000.00
SEWA KAMAR OK OBS KOND KHUSUS - SC + CITO / PERMINTAAN
2,500,000.00
0.00
JASA ANESTESI OBS KOND KHUSUS - SC BEKAS LAPARATOMI0.00
+ CITO
2,000,000.00
/ PERMINTAAN
JASA DOKTER ANAK OBS KOND KHUSUS - SC BEKAS LAPARATOMI
0.00 1,000,000.00
+ CITO / PERMINTAAN
JASA OPERATOR OBS KOND KHUSUS - SC BEKAS LAPARATOMI
0.00
+ CITO
5,000,000.00
/ PERMINTAAN
SEWA KAMAR OK OBS KOND KHUSUS - SC BEKAS LAPAROTOMI
2,500,000.00
+ CITO / PERMINTAAN
0.00
JASA ANESTESI OBS KOND KHUSUS - SC + STERIL + CITO / PERMINTAAN
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - SC + STERIL + CITO0.00
/ PERMINTAAN
1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - SC + STERIL + CITO / PERMINTAAN
0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - SC + STERIL + 2,500,000.00
CITO / PERMINTAAN 0.00
JASA ANESTESI OBS KOND KHUSUS - SC BEKAS LAPAROTOMI0.00
+ STERIL
2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - SC BEKAS LAPAROTOMI
0.00 1,000,000.00
+ STERIL
JASA OPERATOR OBS KOND KHUSUS - SC BEKAS LAPAROTOMI
0.00
+ STERIL
5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - SC BEKAS LAPAROTOMI
2,500,000.00
+ STERIL 0.00
JASA ANESTESI OBS KOND KHUSUS - SC GEMELI + CITO / PERMINTAAN
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - SC GEMELI + CITO /0.00
PERMINTAAN
1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - SC GEMELI + CITO / PERMINTAAN
0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - SC GEMELI + CITO
2,500,000.00
/ PERMINTAAN 0.00
JASA ANESTESI OBS KOND KHUSUS - SC GEMELI + STERIL
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - SC GEMELI + STERIL
0.00 1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - SC GEMELI + STERIL 0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - SC GEMELI + STERIL
2,500,000.00
0.00
JASA ANESTESI OBS KOND KHUSUS - SC + HISTEREKTOMI + CITO
0.00 /2,240,000.00
PERMINTAAN
JASA DOKTER ANAK OBS KOND KHUSUS - SC + HISTEREKTOMI
0.00
+ CITO
1,000,000.00
/ PERMINTAAN
JASA OPERATOR OBS KOND KHUSUS - SC + HISTEREKTOMI + 0.00
CITO5,600,000.00
/ PERMINTAAN
SEWA KAMAR OK OBS KOND KHUSUS - SC + HISTEREKTOMI
2,500,000.00
+ CITO / PERMINTAAN
0.00
JASA ANESTESI OBS KOND KHUSUS - RE SC
0.00 1,600,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC
0.00 1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - RE SC
0.00 4,000,000.00

Page 16

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28.015.10
28.015.10
28.015.10
28.015.10
28.015.11
28.015.11
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28.015.11
28.015.12
28.015.12
28.015.12
28.015.12
28.015.13
28.015.13
28.015.13
28.015.13
28.015.14
28.015.14
28.015.14
28.015.14
28.015.15
28.015.15
28.015.15
28.015.15
28.015.16
28.015.16
28.015.16
28.015.16
28.015.17
28.015.17
28.015.17
28.015.17
28.015.18
28.015.18
28.015.18
28.015.18
28.015.19
28.015.19
28.015.19
28.015.19
28.015.20
28.015.20
28.015.20
28.015.20
28.015.21
28.015.21
28.015.21
28.015.21
28.015.22
28.015.22
28.015.22

OKK036
OKK037
OKK038
OKK039
OKK040
OKK041
OKK042
OKK043
OKK044
OKK045
OKK046
OKK047
OKK048
OKK049
OKK050
OKK051
OKK052
OKK053
OKK054
OKK055
OKK056
OKK057
OKK058
OKK059
OKK060
OKK061
OKK062
OKK063
OKK064
OKK065
OKK066
OKK067
OKK068
OKK069
OKK070
OKK071
OKK072
OKK073
OKK074
OKK075
OKK076
OKK077
OKK078
OKK079
OKK080
OKK081
OKK082
OKK083
OKK084
OKK085
OKK086
OKK087

SEWA KAMAR OK OBS KOND KHUSUS - RE SC

2,500,000.00
0.00
JASA ANESTESI OBS KOND KHUSUS - RE SC + STERIL
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + STERIL
0.00 1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - RE SC + STERIL
0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - RE SC + STERIL
2,500,000.00
0.00
JASA ANESTESI OBS KOND KHUSUS - RE SC + CITO / PERMINTAAN
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + CITO / PERMINTAAN
0.00 1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - RE SC + CITO / PERMINTAAN
0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - RE SC + CITO /2,500,000.00
PERMINTAAN
0.00
JASA ANESTESI OBS KOND KHUSUS - RE SC PADA BEKAS LAPARATOMI
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC PADA BEKAS0.00
LAPARATOMI
1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - RE SC PADA BEKAS LAPARATOMI
0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - RE SC PADA BEKAS
2,500,000.00
LAPARATOMI 0.00
JASA ANESTESI OBS KOND KHUSUS - RE SC PADA BEKAS LAPARATOMI
0.00 2,400,000.00
+ CITO
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC PADA BEKAS0.00
LAPARATOMI
1,000,000.00
+ CITO
JASA OPERATOR OBS KOND KHUSUS - RE SC PADA BEKAS LAPARATOMI
0.00 6,000,000.00
+ CITO
SEWA KAMAR OK OBS KOND KHUSUS - RE SC PADA BEKAS
2,500,000.00
LAPARATOMI +0.00
CITO
JASA ANESTESI OBS KOND KHUSUS - RE SC + GEMELI
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + GEMELI
0.00 1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - RE SC + GEMELI
0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - RE SC + GEMELI
2,500,000.00
0.00
JASA ANESTESI OBS KOND KHUSUS - RE SC + GEMELI + STERIL
0.00
/ CITO
2,400,000.00
/ PERMINTAAN
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + GEMELI + STERIL
0.00 1,000,000.00
/ CITO / PERMINTAAN
JASA OPERATOR OBS KOND KHUSUS - RE SC + GEMELI + STERIL
0.00/ 6,000,000.00
CITO / PERMINTAAN
SEWA KAMAR OK OBS KOND KHUSUS - RE SC + GEMELI
2,500,000.00
+ STERIL + CITO / PERMINTAAN
0.00
JASA ANESTESI OBS KOND KHUSUS - RE SC + GEMELI + STERIL
0.00
+ CITO
2,720,000.00
/ PERMINTAAN
JASA DOKTER ANAK OBS KOND KHUSUS - RE SC + GEMELI + STERIL
0.00 1,000,000.00
+ CITO / PERMINTAAN
JASA OPERATOR OBS KOND KHUSUS - RE SC + GEMELI + STERIL
0.00+6,800,000.00
CITO / PERMINTAAN
SEWA KAMAR OK OBS KOND KHUSUS - RE SC + GEMELI
2,500,000.00
+ STERIL / CITO / PERMINTAAN
0.00
JASA ANESTESI OBS KOND KHUSUS - RE RE SC
0.00 2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC
0.00 1,000,000.00
JASA OPERATOR OBS KOND KHUSUS - RE RE SC
0.00 5,000,000.00
SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC
2,500,000.00
0.00
JASA ANESTESI OBS KOND KHUSUS - RE RE SC + STERIL / KISTA
0.00UNILATERAL
2,400,000.00/ MIOMA
JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC + STERIL 0.00
/ KISTA
1,000,000.00
UNILATERAL / MIOMA
JASA OPERATOR OBS KOND KHUSUS - RE RE SC+STERIL / KISTA
0.00UNILATERAL
6,000,000.00 / MIOMA
SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC + STERIL
2,500,000.00
/ KISTA UNILATERAL
0.00 / MIOMA
JASA ANESTESI OBS KOND KHUSUS - RE RE SC BEKAS LAPARATOMI
0.00 2,560,000.00
+ CITO / PERMINTAAN
JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC BEKAS LAPARATOMI
0.00 1,000,000.00
+ CITO / PERMINT
JASA OPERATOR OBS KOND KHUSUS - RE RE SC BEKAS LAPARATOMI
0.00 6,400,000.00
+ CITO / PERMINTAAN
SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC BEKAS
2,500,000.00
LAPARATOMI + CITO
0.00/ PERMINTAA
JASA ANESTESI OBS KOND KHUSUS - RE RE SC + STERIL + CITO
0.00/ PERMINTAAN
2,720,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - RE RE SC + STERIL 0.00
+ CITO
1,000,000.00
/ PERMINTAAN
JASA OPERATOR OBS KOND KHUSUS - RE RE SC + STERIL + CITO
0.00 /6,800,000.00
PERMINTAAN
SEWA KAMAR OK OBS KOND KHUSUS - RE RE SC + STERIL
2,500,000.00
+ CITO / PERMINTAAN
0.00
JASA ANESTESI OBS KOND KHUSUS - KISTEKTOMI BILATERAL0.00
+ BEKAS
2,000,000.00
LAPARATOMI
JASA DOKTER ANAK OBS KOND KHUSUS - KISTEKTOMI BILATERAL
0.00 + BEKAS0.00
LAPARATOMI
JASA OPERATOR OBS KOND KHUSUS - KISTEKTOMI BILATERAL
0.00
+ BEKAS
5,000,000.00
LAPARATOMI
SEWA KAMAR OK OBS KOND KHUSUS - KISTEKTOMI BILATERAL
2,500,000.00
+ BEKAS LAPARATOMI
0.00
JASA ANESTESI OBS KOND KHUSUS - MIOMEKTOMI PADA BEKAS
0.00LAPARATOMI
2,000,000.00
JASA DOKTER ANAK OBS KOND KHUSUS - MIOMEKTOMI PADA0.00
BEKAS LAPARATOMI
0.00
JASA OPERATOR OBS KOND KHUSUS - MIOMEKTOMI PADA BEKAS
0.00 5,000,000.00
LAPARATOMI

Page 17

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28.015.22
28.015.23
28.015.23
28.015.23
28.015.23

OKK088
OKK089
OKK090
OKK091
OKK092
OOK001
OOK002
OOK003
OOK004
OOK005
OOK006
OOK007
OOK008
OOK009
OOK010
OOK011
OOK012
OOK013
OOK014
OOK015
OOK016
OOK017
OOK018
OOK019
OOK020
OOK021
OOK022
OOK023
OOK024
OOK025
OOK026
OOK027
OOK028
OOK029
OOK030
OOK031
OOK032
OOK033
OOK034
OOK035
OOK036
OOK037
OOK038
OOK039
OOK040
OOK041
OOK042
OOK043
OOK044
OOK045
OOK046
OOK047

SEWA KAMAR OK OBS KOND KHUSUS - MIOMEKTOMI PADA

2,500,000.00
BEKAS LAPARATOMI
0.00
JASA ANESTESI OBS KOND KHUSUS - RE LAPARATOMI ( MIOMA
0.00
+ KISTA
2,000,000.00
BILATERAL )
JASA DOKTER ANAK OBS KOND KHUSUS - RE LAPARATOMI ( MIOMA
0.00 + KISTA
0.00
BILATERAL )
JASA OPERATOR OBS KOND KHUSUS - RE LAPARATOMI ( MIOMA
0.00+ 5,000,000.00
KISTA BILATERAL )
SEWA KAMAR OK OBS KOND KHUSUS - RE LAPARATOMI
2,500,000.00
( MIOMA + KISTA BILATERAL
0.00
)
JASA OPERATOR BEDAH OBSGYN - OPERASI KHUSUS 612,500.00 2,450,000.00
JASA OPERATOR BEDAH OBSGYN - OPERASI BESAR
490,000.00 1,960,000.00
JASA OPERATOR BEDAH OBSGYN - OPERASI SEDANG 400,000.00 1,600,000.00
JASA OPERATOR BEDAH OBSGYN - OPERASI KECIL
240,000.00 960,000.00
JASA OPERATOR BEDAH UMUM - OPERASI KHUSUS
612,500.00 2,450,000.00
JASA OPERATOR BEDAH UMUM - OPERASI BESAR
490,000.00 1,960,000.00
JASA OPERATOR BEDAH UMUM - OPERASI SEDANG
400,000.00 1,600,000.00
JASA OPERATOR BEDAH UMUM - OPERASI KECIL
240,000.00 960,000.00
JASA OPERATOR BEDAH TULANG - OPERASI KHUSUS 800,000.00 3,200,000.00
JASA OPERATOR BEDAH TULANG - OPERASI BESAR
650,000.00 2,600,000.00
JASA OPERATOR BEDAH TULANG - OPERASI KECIL
300,000.00 1,200,000.00
JASA OPERATOR BEDAH TULANG - OPERASI SEDANG 500,000.00 2,000,000.00
JASA OPERATOR BEDAH THT - OPERASI KHUSUS
0.00 3,000,000.00
JASA OPERATOR BEDAH THT - OPERASI BESAR
0.00 2,200,000.00
JASA OPERATOR BEDAH THT - OPERASI SEDANG
0.00 1,700,000.00
JASA OPERATOR BEDAH THT - OPERASI KECIL
0.00 1,000,000.00
JASA OPERATOR BEDAH MATA - OPERASI KHUSUS
0.00 3,000,000.00
JASA OPERATOR BEDAH MATA - OPERASI BESAR
0.00 2,200,000.00
JASA OPERATOR BEDAH MATA - OPERASI SEDANG
0.00 1,700,000.00
JASA OPERATOR BEDAH MATA - OPERASI KECIL
0.00 1,000,000.00
JASA OPERATOR BEDAH SARAF - OPERASI KHUSUS 1,600,000.00 6,400,000.00
JASA OPERATOR BEDAH SARAF - OPERASI BESAR
1,200,000.00 4,800,000.00
JASA OPERATOR BEDAH SARAF - OPERASI SEDANG
900,000.00 3,600,000.00
JASA OPERATOR BEDAH SARAF - OPERASI KECIL
600,000.00 2,400,000.00
JASA ANASTESI BEDAH OBSGYN - OPERASI KHUSUS
245,000.00 980,000.00
JASA ANASTESI BEDAH OBSGYN - OPERASI BESAR
196,000.00 784,000.00
JASA ANASTESI BEDAH OBSGYN - OPERASI SEDANG
160,000.00 640,000.00
JASA ANASTESI BEDAH OBSGYN - OPERASI KECIL
96,000.00 384,000.00
JASA ANASTESI BEDAH UMUM - OPERASI KHUSUS
245,000.00 980,000.00
JASA ANASTESI BEDAH UMUM - OPERASI BESAR
196,000.00 784,000.00
JASA ANASTESI BEDAH UMUM - OPERASI SEDANG
160,000.00 640,000.00
JASA ANASTESI BEDAH UMUM - OPERASI KECIL
96,000.00 384,000.00
JASA ANASTESI BEDAH TULANG - OPERASI KHUSUS
320,000.00 1,280,000.00
JASA ANASTESI BEDAH TULANG - OPERASI BESAR
260,000.00 1,040,000.00
JASA ANASTESI BEDAH TULANG - OPERASI SEDANG
200,000.00 800,000.00
JASA ANASTESI BEDAH TULANG - OPERASI KECIL
120,000.00 480,000.00
JASA ANASTESI BEDAH THT - OPERASI KHUSUS
0.00 1,200,000.00
JASA ANASTESI BEDAH THT - OPERASI BESAR
0.00 880,000.00
JASA ANASTESI BEDAH THT - OPERASI SEDANG
0.00 680,000.00
JASA ANASTESI BEDAH THT - OPERASI KECIL
0.00 400,000.00
JASA ANASTESI BEDAH MATA - OPERASI KHUSUS
0.00 1,200,000.00
JASA ANASTESI BEDAH MATA - OPERASI BESAR
0.00 880,000.00
JASA ANASTESI BEDAH MATA - OPERASI SEDANG
0.00 680,000.00
JASA ANASTESI BEDAH MATA - OPERASI KECIL
0.00 400,000.00
JASA ANASTESI BEDAH SARAF - OPERASI KHUSUS
640,000.00 2,560,000.00
JASA ANASTESI BEDAH SARAF - OPERASI BESAR
480,000.00 1,920,000.00
JASA ANASTESI BEDAH SARAF - OPERASI SEDANG
360,000.00 1,440,000.00

Page 18

TarifKIT

51.001.00
51.002.00
51.003.00
51.004.00
51.005.00
51.006.00
51.007.00
51.008.00
51.009.00
51.010.00
13.001.00
13.002.00
13.003.00
13.004.00
13.005.01
13.005.02
13.006.00
13.007.00
13.008.00

OOK048
OOK049
OOK050
OOK051
OOK052
OOK053
OOK054
OOK055
OOK056
OOK057
OOK058
OOK059
OOK060
OOK061
OOK062
OOK063
OOK064
OOK065
OOK066
OOK067
OOK068
OOK069
OOK070
OOK071
OOK072
OOK073
OOK074
OOK075
OOK076
OOK077
OTR001
OTR002
OTR003
OTR004
OTR005
OTR006
OTR007
OTR008
OTR009
OTR010
PDL001
PDL002
PDL003
PDL004
PDL005
PDL006
PDL007
PDL008
PDL009
PRO001
PRO002
PRO003

JASA ANASTESI BEDAH SARAF - OPERASI KECIL

240,000.00
SEWA KAMAR OK BEDAH OBSGYN - OPERASI KHUSUS1,800,000.00
SEWA KAMAR OK BEDAH OBSGYN - OPERASI BESAR 1,350,000.00
SEWA KAMAR OK BEDAH OBSGYN - OPERASI SEDANG1,000,000.00
SEWA KAMAR OK BEDAH OBSGYN - OPERASI KECIL
700,000.00
SEWA KAMAR OK BEDAH UMUM - OPERASI KHUSUS 1,800,000.00
SEWA KAMAR OK BEDAH UMUM - OPERASI BESAR
1,350,000.00
SEWA KAMAR OK BEDAH UMUM - OPERASI SEDANG 1,000,000.00
SEWA KAMAR OK BEDAH UMUM - OPERASI KECIL
700,000.00
SEWA KAMAR OK BEDAH TULANG - OPERASI KECIL
700,000.00
SEWA KAMAR OK BEDAH THT - OPERASI KECIL
700,000.00
SEWA KAMAR OK BEDAH MATA - OPERASI KECIL
700,000.00
SEWA KAMAR OK BEDAH SARAF - OPERASI KECIL
1,000,000.00
SEWA KAMAR OK BEDAH TULANG - OPERASI KHUSUS2,000,000.00
SEWA KAMAR OK BEDAH THT - OPERASI KHUSUS
2,000,000.00
SEWA KAMAR OK BEDAH MATA - OPERASI KHUSUS 2,000,000.00
SEWA KAMAR OK BEDAH SARAF - OPERASI KHUSUS 2,500,000.00
SEWA KAMAR OK BEDAH TULANG - OPERASI BESAR 1,500,000.00
SEWA KAMAR OK BEDAH THT - OPERASI BESAR
1,500,000.00
SEWA KAMAR OK BEDAH MATA - OPERASI BESAR
1,500,000.00
SEWA KAMAR OK BEDAH SARAF - OPERASI BESAR
2,000,000.00
SEWA KAMAR OK BEDAH TULANG - OPERASI SEDANG1,000,000.00
SEWA KAMAR OK BEDAH THT - OPERASI SEDANG
1,000,000.00
SEWA KAMAR OK BEDAH MATA - OPERASI SEDANG 1,000,000.00
SEWA KAMAR OK BEDAH SARAF - OPERASI SEDANG 1,400,000.00
JASA DOKTER ANAK BEDAH OBSGYN - OPERASI KHUSUS
0.00
JASA OPERATOR ANUSCOPY PAKET OK
120,000.00
JASA ANASTESI ANUSCOPY PAKET OK
48,000.00
SEWA KAMAR OK ANUSCOPY PAKET OK
350,000.00
ADMINISTRASI ANUSCOPY PAKET OK
70,000.00
SENSORI INTEGRASI
70,000.00
LATIHAN ADL RINGAN
35,000.00
LATIHAN ADL GENERAL
60,000.00
PROPER BODY MEKANIK
35,000.00
ANALISA PERSIAPAN KERJA
75,000.00
LATIHAN RELAKSASI RINGAN
35,000.00
LATIHAN RELAKSASI GENERAL
60,000.00
ANALISA & INTERVENSI, PERSEPSI, KOGNITIF, PSIKOMOTOR
50,000.00
JASA PEMBUATAN ALAT SPLINT
150,000.00
JASA MODIFIKASI / PEMBUATAN ALAT
75,000.00
ECG
35,000.00
PLEURA PUNKSI
50,000.00
SPIROMETRI
30,000.00
TREADMILL
175,000.00
USG (ECHO RADIOGRAPHIC)
125,000.00
USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER
175,000.00
JASA SUNTIK (IMUNISASI)
10,000.00
TEST MANTOUX
50,000.00
NEBULIZER
60,000.00
PRODIA - TREADMILL
125,000.00
PRODIA - USG ABDOMEN ATAS
130,000.00
PRODIA - ABDOMEN BAWAH
101,000.00

Page 19

960,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
480,000.00
192,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
15,000.00
200,000.00
30,000.00
175,000.00
125,000.00
175,000.00
0.00
0.00
0.00
125,000.00
70,000.00
54,000.00

TarifKIT

13.001.00
13.002.00
13.003.00
13.004.00
13.005.01
13.005.02
13.006.00
13.007.00
13.008.00
31.100.01
31.100.02
31.100.03
31.100.04
31.100.05
31.100.06
31.100.07
31.100.08
31.100.09
31.100.10
31.100.11
31.100.12
31.100.13
31.100.14
31.100.15
31.100.16
31.100.17
31.100.18
31.100.19
31.100.20
31.100.21
31.100.22
31.100.23
31.200.01
31.200.02
31.200.03
31.200.04
31.200.05
31.200.06
31.200.07
31.200.08
31.200.09
31.200.10
31.200.11
31.200.12
31.200.13
31.200.14
31.200.15

PRO004
PRO005
PRO006
PRO007
PRO008
PRU001
PRU002
PRU003
PRU004
PRU005
PRU006
PRU007
PRU008
PRU009
RAD001
RAD002
RAD003
RAD004
RAD005
RAD006
RAD007
RAD008
RAD009
RAD010
RAD011
RAD012
RAD013
RAD014
RAD015
RAD016
RAD017
RAD018
RAD019
RAD020
RAD021
RAD022
RAD023
RAD024
RAD025
RAD026
RAD027
RAD028
RAD029
RAD030
RAD031
RAD032
RAD033
RAD034
RAD035
RAD036
RAD037
RAD038

PRODIA - ABDOMEN ATAS & BAWAH

PRODIA - USG GYNECOLOGY / TRANSVAGINAL
PRODIA - USG OBSTETRI
PRODIA - USG OBSTETRI 4D
PRODIA - PEMERIKSAAN FISIK DOKTER UMUM
ECG
PLEURA PUNKSI
SPIROMETRI
TREADMILL
USG (ECHO RADIOGRAPHIC)
USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER
JASA SUNTIK (IMUNISASI)
TEST MANTOUX
NEBULIZER
ANKLE AP/LAT
ART. HUMERUS
BASIS CRANII
BNO/ABDOMEN POLOS
CALCANEUS LAT/AKSIAL
CLAVICULA
COSTAE
ELBOW/CUBITI
FORAMEN OPTICUM
ORBITA
OS NASAL
PANORAMIC
PEDIS AP/LAT
PELVIS
RLD THORAX
STERNUM
THORAX FOTO (AP / LATERAL)
THORAX PA + LATERAL
TMJ SATU SISI
TOP LORDOTIC
TOWNE
WRIST JOIINT
MANUS AP/LAT
ABDOMEN 2 POSISI
ANTEBRACHI AP/LAT
CEPHALOMETRI
CERVICAL AP/LAT
CRURIS AP/LAT
FEMUR AP/LAT
GENU AP/LAT
HUMERUS AP/LAT
LUMBAL AP/LAT
MANDIBULA ESHLER KANAN KIRI
MASTOID KANAN KIRI
PELVIS AP/LAT
SACRUM AP/LAT
SCHEDEL AP/LAT
SHOULDER EXO/ENDO

Page 20

162,500.00
87,750.00
32,500.00
227,500.00
30,000.00
35,000.00
50,000.00
30,000.00
175,000.00
125,000.00
175,000.00
10,000.00
50,000.00
60,000.00
59,500.00
59,500.00
59,500.00
63,750.00
59,500.00
59,500.00
59,500.00
63,750.00
59,500.00
59,500.00
59,500.00
68,000.00
63,750.00
63,750.00
63,750.00
59,500.00
68,000.00
127,500.00
80,750.00
59,500.00
59,500.00
59,500.00
59,500.00
119,000.00
63,750.00
93,500.00
93,500.00
85,000.00
119,000.00
63,750.00
85,000.00
114,750.00
85,000.00
102,000.00
114,750.00
106,250.00
102,000.00
102,000.00

87,500.00
47,250.00
17,500.00
122,500.00
30,000.00
15,000.00
200,000.00
30,000.00
175,000.00
125,000.00
175,000.00
0.00
0.00
0.00
17,500.00
17,500.00
17,500.00
18,750.00
17,500.00
17,500.00
17,500.00
18,750.00
17,500.00
17,500.00
17,500.00
20,000.00
18,750.00
18,750.00
18,750.00
17,500.00
20,000.00
37,500.00
23,750.00
17,500.00
17,500.00
17,500.00
17,500.00
35,000.00
18,750.00
27,500.00
27,500.00
25,000.00
35,000.00
18,750.00
25,000.00
33,750.00
25,000.00
30,000.00
33,750.00
31,250.00
30,000.00
30,000.00

TarifKIT

31.200.16
31.200.17
31.200.18
31.300.01
31.300.02
31.300.03
31.300.04
31.300.05
31.300.06
31.300.07
31.300.08
31.300.09
31.300.10
31.300.11
31.300.12
31.300.13
31.300.14
31.300.15
31.300.16
31.400.01
31.400.02
31.400.03
31.400.04
31.400.05
31.400.06
31.400.07
31.400.08
31.400.09
31.400.10
31.400.11
31.400.12
31.400.13

RAD039
RAD040
RAD041
RAD042
RAD043
RAD044
RAD045
RAD046
RAD047
RAD048
RAD049
RAD050
RAD051
RAD052
RAD053
RAD054
RAD055
RAD056
RAD057
RAD058
RAD059
RAD060
RAD061
RAD062
RAD063
RAD064
RAD065
RAD066
RAD067
RAD068
RAD069
RAD070
RAD071
RAD072
RAD073
RSC001
RSC002
RSC003
RSC004
RSC005
RSC006
RSC007
RSC008
RSC009
RSC010
RSC011
RSC012
RSC013
RSC014
RSC015
RSC016
RSC017

SPN 3 POSISI
106,250.00
THORACAL AP/LAT
114,750.00
THORACOLUMBAL AP/LAT
114,750.00
ABDOMEN 3 POSISI
148,750.00
ANTEBRACHI 2 POSISI KA/KI
127,500.00
APPENDICOGRAM
191,250.00
CERVICAL AP/LAT/OBL
127,500.00
COR ANALISA
127,500.00
CRURIS AP/LAT KA-KI
148,750.00
ESOFAGOGRAM
148,750.00
FEMUR AP/LAT KA-KI
148,750.00
GENU AP/LAT/SKY LINE
136,000.00
HUMERUS KA/KI BANDING
127,500.00
LUMBAL AP/LAT/OBL
153,000.00
MAMMOGRAFI
153,000.00
PELVIS DENGAN SONDE
127,500.00
SHOULDER 2 POSISI ENDING
148,750.00
THORACAL AP/LAT/OBL
153,000.00
TMJ KA/KI PERBANDINGAN
148,750.00
BNO - IVP*
262,500.00
BONE SURVEY
318,750.00
COLON IN LOOP*
300,000.00
CYSTOGRAM
195,000.00
FISTULOGRAFI*
243,750.00
FOLLOW THROUGH*
262,500.00
HSG*
187,500.00
MD*
225,000.00
MSU*
281,250.00
OMD*
281,250.00
RPG / APG*
262,500.00
URETHROCYSTOGRAM
262,500.00
URETHROCYSTOGRAM BIPOLAR
281,250.00
GENU BILATERAL
105,000.00
CEPHALOMETRI PA / LATERAL
52,500.00
ORDER PEMERIKSAAN RADIOLOGI
0.00
SEWA OK SC RUJUKAN BIDAN
500,000.00
JASA TINDAKAN DOKTER OBSGYN SC RUJUKAN BIDAN
0.00
JASA TINDAKAN DOKTER ANESTESI SC RUJUKAN BIDAN
0.00
JASA TINDAKAN DOKTER ANAK SC RUJUKAN BIDAN
0.00
VISITE RUANGAN DOKTER OBSGYN SC RUJUKAN BIDAN
0.00
VISITE RUANGAN DOKTER ANAK SC RUJUKAN BIDAN
0.00
SEWA KAMAR IBU SC RUJUKAN BIDAN
240,000.00
SEWA KAMAR PERAWATAN ANAK SC RUJUKAN BIDAN 150,000.00
SEWA VK - PAKET OD KURET
200,000.00
JASA DOKTER OBSGYN - PAKET ODC KURET
0.00
JASA DOKTER ANESTESI - PAKET ODC KURET
0.00
SEWA KAMAR OK MINOR - PAKET ODC STERIL
300,000.00
SEWA KAMAR OBSERVASI - PAKET ODC STERIL
100,000.00
JASA TINDAKAN DOKTER OBSGYN - PAKET ODC STERIL
0.00
JASA TINDAKAN DOKTER ANESTESI - PAKET ODC STERIL
0.00
SEWA VK - PARTUS TINDAKAN NON SC
200,000.00
JASA TINDAKAN DOKTER OBSGYN - PARTUS TINDAKAN NON 0.00

Page 21

31,250.00
33,750.00
33,750.00
43,750.00
37,500.00
56,250.00
37,500.00
37,500.00
43,750.00
43,750.00
43,750.00
40,000.00
37,500.00
45,000.00
45,000.00
37,500.00
43,750.00
45,000.00
43,750.00
122,500.00
148,750.00
140,000.00
91,000.00
113,750.00
122,500.00
87,500.00
105,000.00
131,250.00
131,250.00
122,500.00
122,500.00
131,250.00
45,000.00
22,500.00
0.00
0.00
1,750,000.00
612,500.00
437,500.00
180,000.00
180,000.00
0.00
0.00
0.00
1,200,000.00
420,000.00
0.00
0.00
1,200,000.00
420,000.00
0.00
1,000,000.00

TarifKIT

24.101.00

24.200.01
24.200.02
24.200.03
24.200.04
24.200.05
24.300.00
24.400.01
24.400.02
24.400.03
24.500.01
24.500.02
24.500.03
24.500.04
24.500.05
24.600.00
24.102.00
24.103.00
24.104.01
24.104.02
24.105.00
24.600.00
24.700.00

15.001.00

RSC018
RSC019
RSC020
RSC021
RSC022
SPA001
SPA002
SPA003
SPA004
SPA005
SPA006
SPA007
SPA008
SPA009
SPA010
SPA011
SPA012
SPA013
SPA014
SPA015
SPA016
SPA017
SPA018
SPA019
SPA020
SPA021
SPA022
SPA023
SPA024
SPA025
SPA026
SPA027
SPA028
SPA029
SPA030
SPA031
SPA032
SPA033
SPA034
SPA035
SPA036
SPA037
SPA038
SPA039
SPA040
SPA041
SPA042
SPA043
SPA044
SPA43
SRF001

JASA TINDAKAN DOKTER ANAK - PARTUS TINDAKAN NON S 0.00

VISITE RUANGAN DOKTER OBSGYN - PARTUS TINDAKAN NON0.00
VISITE RUANGAN DOKTER - PARTUS TINDAKAN NON SC
0.00
SEWA KAMAR PERAWATAN IBU - PARTUS TINDAKAN NON
240,000.00
SC
SEWA KAMAR PERAWATAN ANAK - PARTUS TINDAKAN NON
150,000.00
SC
MINI FACIAL
50,000.00
ELEKTROTERAPI FACIAL
70,000.00
ACUPRESSURE FACIAL
60,000.00
PAKET PERAWATAN KULIT SENSITIF
125,000.00
PAKET PERAWATAN KULIT FLEK
160,000.00
PAKET PERAWATAN KULIT BERMINYAK / BERJERAWAT 140,000.00
PAKET PERAWATAN KULIT KERING / KUSAM
160,000.00
PAKET PERAWATAN KULIT BERPORI-PORI BESAR
140,000.00
PAKET PERAWATAN KULIT NORMAL
140,000.00
BASIC PEELING / TINDAKAN PEELING WAJAH ( 1 OBAT ) 62,500.00
INTENSIVE PEELING / TINDAKAN PEELING WAJAH ( 2 OBAT
72,500.00
)
PEELING NEOSTRATA 20%
PEELING MATA
20,000.00
INJEKSI JERAWAT
25,000.00
INJEKSI KELOID
50,000.00
INJEKSI PEMUTIH DENGAN 1 OBAT
62,500.00
TINDAKAN CAUTER
50,000.00
SIMPLE MASSAGE
120,000.00
SIMPLE MASSAGE + SCUB
150,000.00
SIMPLE MASSAGE + ALAT UMDT
225,000.00
SIMPLE MASSAGE + STEAM BLANKET
225,000.00
MASSAGE LENGKAP
250,000.00
EAR WAX CANDLE
50,000.00
MANICURE
75,000.00
PEDICURE
75,000.00
MANICURE - PEDICURE
140,000.00
KAKI BAU / FOOT ODOR
90,000.00
KAPALAN / CALLUSE
90,000.00
KAKI KERING / DRY FOOT
90,000.00
PECAH - PECAH / CRACKS SKIN
90,000.00
LETIH / RELAXATION
90,000.00
EYE TREATMENT
35,000.00
FACE LIFT FACIAL
100,000.00
DETOX & SPA FACIAL
100,000.00
PERAWATAN KULIT ACNE
100,000.00
PERAWATAN KULIT KOMEDOGENIC
100,000.00
FLEK - FLEK HITAM ( TPW CARE )
200,000.00
EYE COMPLEX
20,000.00
NAIL ART
25,000.00
JASA TINDAKAN SCUB
15,000.00
INJEKSI PEMUTIH DENGAN 2 OBAT
87,500.00
INJEKSI PEMUTIH DENGAN 3 OBAT
112,500.00
INJEKSI PEMUTIH DENGAN 4 OBAT
137,500.00
PRODUC CAT MAKARIZO
65,000.00
PRODUC CAT LORPAL
75,000.00
INJEKSI SLIMING 1 OBAT
35,000.00
EEG
100,000.00

Page 22

250,000.00
180,000.00
180,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
47,500.00
67,500.00
20,000.00
25,000.00
50,000.00
62,500.00
50,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
62,500.00
62,500.00
62,500.00
0.00
0.00
35,000.00
100,000.00

TarifKIT

16.001.01
16.001.02
16.002.01
16.002.02
16.003.00
16.004.00
16.005.01
16.005.02
16.005.03
16.006.01
16.006.02
16.006.03
16.007.00
16.008.01
16.008.02
16.008.03
16.008.04
16.008.05
16.009.00
16.010.01
16.010.02
16.011.00
16.012.00
16.013.00
16.014.00
16.015.00
16.016.00

28.016.01
28.016.01
28.016.01
28.016.01
28.016.02
28.016.02
28.016.02
28.016.02
30.001.01
30.001.02
30.001.03
30.002.00
30.003.00
30.004.00
30.005.00
30.006.01
30.006.02
30.006.03
30.007.00
30.008.00
30.009.00
30.010.00
30.011.00

THT001
THT002
THT003
THT004
THT005
THT006
THT007
THT008
THT009
THT010
THT011
THT012
THT013
THT014
THT015
THT016
THT017
THT018
THT019
THT020
THT021
THT022
THT023
THT024
THT025
THT026
THT027
THT028
THT029
TOK001
TOK002
TOK003
TOK004
TOK005
TOK006
TOK007
TOK008
TRI001
TRI002
TRI003
TRI004
TRI005
TRI006
TRI007
TRI008
TRI009
TRI010
TRI011
TRI012
TRI013
TRI014
TRI015

ANGKAT SERUMEN TANPA PENYULIT

ANGKAT SERUMEN DENGAN PENYULIT
ASPIRASI ABSES PERITONSIL / DI TEMPAT LAIN
ASPIRASI PSEUDOKISTA DAUN TELINGA
AUDIOMETRI/AUDIOGRAM KLINIK
BELLOQUE TAMPON
CAUSTIK FARING
CAUSTIK HIDUNG
CAUSTIK TELINGA
CORPUS ALIENUM HIDUNG
CORPUS ALIENUM TELINGA
CORPUS ALIENUM TENGGOROK
ENDOSCOPY NASOFARING
INCISI ABSES HIDUNG
INCISI ABSES PERITONSILER
INCISI ABSES PRE AURICULER
INCISI ABSES RETRO AURICULER
INCISI ABSES RETRO FARINGEAL
INHALASI
IRIGASI SINUS MAKSILARIS
IRIGASI SINUS MAKSILARIS DUPLEKS
PARACENTASE MEMBRAN TIMPANI
PERIKONDRITIS/ABSES DAUN TELINGA
PUNGSI & IRIGASI SINUS MAKSILARIS
TAMPON HIDUNG (SATU LUBANG)
TIMPANOMETRI
AFF TAMPON
IRIGASI TELINGA / EAR TOILET
ENDOSCOPY INTIP
JASA OPERATOR - KURET NORMAL
JASA ANASTESI - KURET NORMAL
KAMAR BERSALIN - KURET NORMAL
KAMAR OBSERVASI - KURET NORMAL
JASA OPERATOR - KURET PLASENTA
JASA ANESTESI - KURET PLASENTA
KAMAR BERSALIN - KURET PLASENTA
KAMAR OBSERVASI - KURET PLASENTA
AF HECHTING (1 - 5)
AF HECHTING (6 -10)
AF HECHTING (> 10)
CLYSMA
ECG
EEG
INTUBASI
PUNGSI LUMBAL
PUNGSI FLEURA
PUNGSI ASCITES
PASANG FOLLEY CATHETER
PASANG INFUS
PASANG NGT
SITOSTATIKA
SPIROMETRI

Page 23

10,000.00
40,000.00
25,000.00 100,000.00
35,000.00 140,000.00
35,000.00 140,000.00
35,000.00
35,000.00
40,000.00 160,000.00
10,000.00
40,000.00
10,000.00
40,000.00
10,000.00
40,000.00
30,000.00 120,000.00
30,000.00 120,000.00
30,000.00 120,000.00
125,000.00 125,000.00
40,000.00 160,000.00
40,000.00 160,000.00
40,000.00 160,000.00
40,000.00 160,000.00
90,000.00 360,000.00
30,000.00
0.00
50,000.00 200,000.00
60,000.00 240,000.00
40,000.00 160,000.00
40,000.00 160,000.00
80,000.00 320,000.00
10,000.00
40,000.00
15,000.00
60,000.00
8,000.00
32,000.00
10,000.00
40,000.00
62,500.00
62,500.00
240,000.00 960,000.00
96,000.00 384,000.00
200,000.00
0.00
150,000.00
0.00
300,000.00 1,200,000.00
120,000.00 480,000.00
200,000.00
0.00
150,000.00
0.00
11,500.00
46,000.00
18,000.00
72,000.00
23,000.00
92,000.00
12,000.00
48,000.00
12,000.00
48,000.00
46,000.00 184,000.00
60,000.00 240,000.00
60,000.00 240,000.00
60,000.00 240,000.00
60,000.00 240,000.00
11,500.00
46,000.00
11,500.00
46,000.00
11,500.00
46,000.00
140,000.00 560,000.00
14,000.00
56,000.00

TarifKIT

30.012.00
30.013.00
30.014.00
30.015.00
30.016.00
30.017.00
30.018.00
30.019.01
30.019.02

30.015.00
30.016.00
30.017.01
30.017.02
30.017.03
30.018.00
30.019.01
30.019.02
52.001.00
52.002.00
52.003.00
52.004.00
52.005.00
52.006.00
01.001.01
01.001.02
01.001.03
01.002.01
01.002.02
01.003.00
01.004.01
01.004.02
01.004.03
01.004.04
01.005.01
01.005.02
01.005.03
01.006.01
01.006.02
01.007.01
01.008.00
01.009.00
01.010.00

01.011.00

TRI016
TRI017
TRI018
TRI019
TRI020
TRI021
TRI022
TRI023
TRI024
TRI025
TRI026
TRI027
TRI028
TRI029
TRI030
TRI031
TRI032
TRI033
TRI034
TRI035
TRI036
TRI037
TRI038
TRI039
TWC001
TWC002
TWC003
TWC004
TWC005
TWC006
UGD001
UGD002
UGD003
UGD004
UGD005
UGD006
UGD007
UGD008
UGD009
UGD010
UGD011
UGD012
UGD013
UGD014
UGD015
UGD016
UGD017
UGD018
UGD019
UGD020
UGD021
UGD022

VENA SEKSI
TINDIK TELINGA BAYI
SUNAT BAYI PEREMPUAN
PEMASANGAN UMBILICAL CATHETER
EXCHANGE TRANSFUSI
SPOOL DRAIN
AF WSD
AF DRAIN NON CRANIOTOMI
AF DRAIN CRANIOTOMI
PASANG CATHETER DG MANDREN
PUNGSI PUS
NEKROTOMI KECIL
NEKROTOMI SEDANG
NEKROTOMI BESAR
PASANG CVP
MERAWAT DECUBITUS / HARI
MERAWAT GANGRENE / HARI
LUKA BAKAR RINGAN ( < 20% )
LUKA BAKAR SEDANG (20-40%)
LUKA BAKAR BERAT ( >40% )
LABU DARAH / KANTONG
PENGELOLAAN 1 KANTONG LABU DARAH
PEMBUATAN AKTE KELAHIRAN - WNI
PEMBUATAN AKTE KELAHIRAN - WNI KETURUNAN
FUNGSI BICARA ( DEWASA )
FUNGSI BICARA ( ANAK )
FUNGSI BAHASA / LAKU ( DEWASA )
FUNGSI BAHASA / LAKU ( ANAK )
FUNGSI MENELAN ( DEWASA )
FUNGSI MENELAN ( ANAK )
AF HECTING (1 - 5)
AF HECTING (6 - 10)
AF HECTING (>10)
AMPUTASI JARI RUAS I
AMPUTASI JARI RUAS II
BILAS LAMBUNG (Intoksikasi Baygon/Drug)
CORPUS ALIENUM HIDUNG
CORPUS ALIENUM MATA (Satu mata)
CORPUS ALIENUM TELINGA (Satu telinga)
CORPUS ALIENUM TENGGOROK
DEBRIDEMENT LUKA BAKAR BERAT
DEBRIDEMENT LUKA BAKAR RINGAN
DEBRIDEMENT LUKA BAKAR SEDANG
DEFIBRILATOR (= 3 kali)
DEFIBRILATOR (> 3 kali)
ECG
EKSPLORASI / CROSS INCISI
EKSTIRPASI KECIL
EKSTRAKSI KUKU ( 1 KUKU )
GANTI VERBAN (Incl alkes : max 10-15 pcs kasa)
GANTI VERBAN (Incl alkes : 15 - 20 pcs kasa)
GANTI VERBAN KECIL

Page 24

46,000.00
18,000.00
14,000.00
46,000.00
92,000.00
9,000.00
19,000.00
19,000.00
23,000.00
58,000.00
11,500.00
23,000.00
35,000.00
46,000.00
70,000.00
23,000.00
23,000.00
17,500.00
29,000.00
41,000.00
210,000.00
35,000.00
145,000.00
215,000.00
35,000.00
50,000.00
35,000.00
50,000.00
40,000.00
60,000.00
10,000.00
15,000.00
20,000.00
40,000.00
60,000.00
40,000.00
40,000.00
40,000.00
40,000.00
40,000.00
80,000.00
24,000.00
40,000.00
40,000.00
80,000.00
35,000.00
40,000.00
50,000.00
50,000.00
25,000.00
25,000.00
10,000.00

184,000.00
72,000.00
56,000.00
184,000.00
368,000.00
36,000.00
76,000.00
76,000.00
92,000.00
232,000.00
46,000.00
92,000.00
140,000.00
184,000.00
280,000.00
92,000.00
92,000.00
70,000.00
116,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
15,000.00
22,500.00
30,000.00
60,000.00
90,000.00
60,000.00
60,000.00
60,000.00
60,000.00
60,000.00
120,000.00
36,000.00
60,000.00
60,000.00
120,000.00
15,000.00
60,000.00
75,000.00
75,000.00
0.00
0.00
10,000.00

TarifKIT

01.011.00
01.011.00
01.012.01
01.012.02
01.012.03
01.013.00
01.014.00
01.015.00
01.016.00
01.017.01
01.017.02
01.017.03
01.018.00
01.019.00
01.020.00
01.021.00
01.022.00
01.023.00
01.024.00
01.025.00
01.026.00
01.027.00
01.028.00
01.029.00
01.030.00
01.031.00
01.032.00
01.033.00

01.001.01
01.001.02
01.001.03
01.002.01
01.002.02
01.003.00
01.004.01
01.004.02
01.004.03
01.004.04
01.005.01
01.005.02
01.005.03
01.006.01
01.006.02
01.007.01
01.008.00

UGD023
UGD024
UGD025
UGD026
UGD027
UGD028
UGD029
UGD030
UGD031
UGD032
UGD033
UGD034
UGD035
UGD036
UGD037
UGD038
UGD039
UGD040
UGD041
UGD042
UGD043
UGD044
UGD045
UGD046
UGD047
UGD048
UGD049
UGD050
UGD051
UGD052
UGD053
UGD054
UGD055
UGD056
UGD057
UMM001
UMM002
UMM003
UMM004
UMM005
UMM006
UMM007
UMM008
UMM009
UMM010
UMM011
UMM012
UMM013
UMM014
UMM015
UMM016
UMM017

GANTI VERBAN SEDANG

GANTI VERBAN BESAR
HECHTING BESAR ( > 10 )
HECHTING KECIL ( 1 - 5 )
HECHTING SEDANG ( 6 - 10 )
INCISI ABSES
INHALASI TANPA OBAT
INTUBASI
IRIGASI MATA
JAHIT OTOT DENGAN EKSPLORASI ( BESAR )
JAHIT OTOT DENGAN EKSPLORASI ( KECIL )
JAHIT OTOT DENGAN EKSPLORASI ( SEDANG )
LAVAMENT / CLYSMA
O2 / 3 JAM
RUANG OBSERVASI S/D 8 JAM
PASANG CATHETER
PASANG CVP
PASANG INFUS
ANGKAT SERUMEN TANPA PENYULIT
PASANG NGT
PASANG SPALK
PASANG TAMPON (HIDUNG DAN TELINGA)
PLEURA PUNKSI / WSD MINI
SPOOLING / IRIGASI TELINGA
SUNTIK
TAMPON POSTERIOR EPISTAKSIS
VENA SEKSI
CPR
CIRCUMSISI ANAK ( < 15 TAHUN )
CIRCUMSISI DEWASA
WOUND TOILET KECIL
WOUND TOILET SEDANG
WOUND TOILET BESAR
ECG MONITOR PER 3 JAM
IRIGASI TELINGA / EAR TOILET
AF HECTING (1 - 5)
AF HECTING (6 - 10)
AF HECTING (>10)
AMPUTASI JARI RUAS I
AMPUTASI JARI RUAS II
BILAS LAMBUNG (Intoksikasi Baygon/Drug)
CORPUS ALIENUM HIDUNG
CORPUS ALIENUM MATA (Satu mata)
CORPUS ALIENUM TELINGA (Satu telinga)
CORPUS ALIENUM TENGGOROK
DEBRIDEMENT LUKA BAKAR BERAT
DEBRIDEMENT LUKA BAKAR RINGAN
DEBRIDEMENT LUKA BAKAR SEDANG
DEFIBRILATOR (= 3 kali)
DEFIBRILATOR (> 3 kali)
ECG
EKSPLORASI / CROSS INCISI

Page 25

12,500.00
12,000.00
36,000.00
24,000.00
30,000.00
50,000.00
12,000.00
80,000.00
40,000.00
80,000.00
40,000.00
60,000.00
50,000.00
10,000.00
120,000.00
14,000.00
160,000.00
10,000.00
20,000.00
15,000.00
50,000.00
8,000.00
60,000.00
12,000.00
7,500.00
24,000.00
60,000.00
40,000.00
250,000.00
400,000.00
15,000.00
15,000.00
25,000.00
100,000.00
30,000.00
10,000.00
15,000.00
20,000.00
40,000.00
60,000.00
40,000.00
40,000.00
40,000.00
40,000.00
40,000.00
80,000.00
24,000.00
40,000.00
40,000.00
80,000.00
35,000.00
40,000.00

12,500.00
18,000.00
54,000.00
36,000.00
45,000.00
75,000.00
18,000.00
120,000.00
60,000.00
120,000.00
60,000.00
90,000.00
0.00
0.00
0.00
21,000.00
240,000.00
0.00
30,000.00
0.00
0.00
12,000.00
90,000.00
18,000.00
0.00
36,000.00
90,000.00
60,000.00
150,000.00
200,000.00
0.00
0.00
0.00
0.00
20,000.00
15,000.00
22,500.00
30,000.00
60,000.00
90,000.00
60,000.00
60,000.00
60,000.00
60,000.00
60,000.00
120,000.00
36,000.00
60,000.00
60,000.00
120,000.00
15,000.00
60,000.00

TarifKIT

01.009.00
01.010.00

UMM018
UMM019
UMM020
UMM021
01.011.00
UMM022
01.011.00
UMM023
01.011.00
UMM024
01.012.01
UMM025
01.012.02
UMM026
01.012.03
UMM027
01.013.00
UMM028
01.014.00
UMM029
01.015.00
UMM030
01.016.00
UMM031
01.017.01
UMM032
01.017.02
UMM033
01.017.03
UMM034
01.018.00
UMM035
01.019.00
UMM036
01.020.00
UMM037
01.021.00
UMM038
01.022.00
UMM039
01.023.00
UMM040
01.024.00
UMM041
01.025.00
UMM042
01.026.00
UMM043
01.027.00
UMM044
01.028.00
UMM045
01.029.00
UMM046
01.030.00
UMM047
01.031.00
UMM048
01.032.00
UMM049
01.033.00
UMM050
UMM051
UMM052
UMM053
31.600.01
USG001
31.600.02
USG002
31.600.03
USG003
31.600.04
USG004
31.600.05
USG005
31.600.06
USG006
31.600.07.01USG007
31.600.07.02USG008
31.600.07.03USG009
31.600.08.01USG010
31.600.08.02USG011
31.600.09.01USG012
31.600.09.02USG013
31.600.09.03USG014
31.600.09.04USG015
31.600.09.05USG016

EKSTIRPASI KECIL
EKSTRAKSI KUKU ( 1 KUKU )
GANTI VERBAN (Incl alkes : max 10-15 pcs kasa)
GANTI VERBAN (Incl alkes : 15 - 20 pcs kasa)
GANTI VERBAN KECIL
GANTI VERBAN SEDANG
GANTI VERBAN BESAR
HECHTING BESAR ( > 10 )
HECHTING KECIL ( 1 - 5 )
HECHTING SEDANG ( 6 - 10 )
INCISI ABSES
INHALASI TANPA OBAT
INTUBASI
IRIGASI MATA
JAHIT OTOT DENGAN EKSPLORASI ( BESAR )
JAHIT OTOT DENGAN EKSPLORASI ( KECIL )
JAHIT OTOT DENGAN EKSPLORASI ( SEDANG )
LAVAMENT / CLYSMA
O2 / 3 JAM
RUANG OBSERVASI S/D 8 JAM
PASANG CATHETER
PASANG CVP
PASANG INFUS
ANGKAT SERUMEN TANPA PENYULIT
PASANG NGT
PASANG SPALK
PASANG TAMPON (HIDUNG DAN TELINGA)
PLEURA PUNKSI / WSD MINI
SPOOLING / IRIGASI TELINGA
SUNTIK
TAMPON POSTERIOR EPISTAKSIS
VENA SEKSI
CPR
CIRCUMSISI ANAK ( < 15 TAHUN )
CIRCUMSISI DEWASA
ECG MONITOR PER 3 JAM
USG ABDOMEN ATAS
USG ABDOMEN PELVIS
USG ABDOMEN ATAS & BAWAH
USG - MAMMAE
USG - THYROID
USG KEPALA
USG - GYNEKOLOGY / TRANSVAGINAL
USG - OBSTETRI 2D
USG - OBSTETRI 4D
USG - TESTIS ANAK
USG - SOFT TISSUE/MUSC. SKELETAL
USG KHUSUS - THORAX
USG - GUIDE BIOPSI
USG VASKULER/DOPPLER
USG (ECHO RADIOGRAPHIC)
USG (ECHO RADIOGRAPHIC) DENGAN DOPPLER

Page 26

50,000.00
50,000.00
20,000.00
25,000.00
10,000.00
12,500.00
12,000.00
36,000.00
24,000.00
30,000.00
50,000.00
12,000.00
80,000.00
40,000.00
80,000.00
40,000.00
60,000.00
50,000.00
10,000.00
120,000.00
14,000.00
160,000.00
10,000.00
20,000.00
15,000.00
50,000.00
8,000.00
60,000.00
12,000.00
7,500.00
24,000.00
60,000.00
40,000.00
250,000.00
400,000.00
100,000.00
172,500.00
131,250.00
225,000.00
168,750.00
168,750.00
131,250.00
112,500.00
37,500.00
337,500.00
150,000.00
150,000.00
150,000.00
187,500.00
281,250.00
187,500.00
262,500.00

75,000.00
75,000.00
0.00
0.00
10,000.00
12,500.00
18,000.00
54,000.00
36,000.00
45,000.00
75,000.00
18,000.00
120,000.00
60,000.00
120,000.00
60,000.00
90,000.00
0.00
0.00
0.00
21,000.00
240,000.00
0.00
30,000.00
0.00
0.00
12,000.00
90,000.00
18,000.00
0.00
36,000.00
90,000.00
60,000.00
150,000.00
200,000.00
0.00
80,500.00
61,250.00
105,000.00
78,750.00
78,750.00
61,250.00
52,500.00
17,500.00
157,500.00
70,000.00
70,000.00
70,000.00
87,500.00
131,250.00
87,500.00
122,500.00

TarifKIT

VAG001
VKN001
VKN002
VKN003
VKN004
VKN005
VKN006
VKN007
VKN008
VKN009
VKN010
VKN011
VKN012

VAGINA TOILET
KAMAR BERSALIN
RUANG OBSERVASI KEBIDANAN
RUANG OK MINOR
ONE DAY CARE
KAMAR VK PARTUS NORMAL DENGAN DOKTER
JASA DOKTER OBSGYN PARTUS NORMAL
JASA DOKTER ANAK PARTUS NORMAL
KAMAR VK PARTUS NORMAL DENGAN BIDAN
JASA BIDAN PARTUS NORMAL
SHARE OPERATOR PARTUS NORMAL
SHARE DOKTER ANAK PARTUS NORMAL
SHARE BIDAN PARTUS NORMAL

Page 27

37,500.00
37,500.00
200,000.00
0.00
150,000.00
0.00
450,000.00
0.00
150,000.00
0.00
200,000.00
0.00
0.00 1,800,000.00
0.00 450,000.00
200,000.00
0.00
0.00 720,000.00
0.00 1,440,000.00
0.00 360,000.00
0.00 360,000.00

TarifKIT

PHSU
Obat

PHNM
Alkes
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Total
15,000.00
10,000.00
0.00
15,000.00
5,000.00
50,000.00
7,500.00
30,000.00
135,000.00
30,000.00
30,000.00
30,000.00
30,000.00
30,000.00
30,000.00
30,000.00
30,000.00
80,000.00
60,000.00
30,000.00
135,000.00
135,000.00
30,000.00
135,000.00
30,000.00
135,000.00
30,000.00
135,000.00
155,000.00
135,000.00
155,000.00
135,000.00
155,000.00
155,000.00
135,000.00
205,000.00
70,000.00
600,000.00
1,200,000.00
100,000.00
150,000.00
250,000.00
400,000.00
100,000.00
200,000.00
250,000.00
350,000.00
500,000.00
10,000.00
75,000.00

Total Baru
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 28

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

50,000.00
0.00
50,000.00
0.00
20,000.00
0.00
15,000.00
0.00
15,000.00
0.00
10,000.00
0.00
20,000.00
0.00
60,000.00
0.00
50,000.00
70,000.00
75,000.00
95,000.00
100,000.00
120,000.00
150,000.00
230,000.00
400,000.00
0.00
300,000.00
0.00
100,000.00
0.00
600,000.00
0.00
800,000.00
0.00
125,000.00
0.00
500,000.00
600,000.00
400,000.00
96,000.00
250,000.00
300,000.00
600,000.00
500,000.00
400,000.00
580,000.00
25,000.00
35,000.00
40,000.00
50,000.00
25,000.00
50,000.00
30,000.00
75,000.00
75,000.00
75,000.00
150,000.00
200,000.00
250,000.00
500,000.00
150,000.00
500,000.00
150,000.00
200,000.00
200,000.00
0.00
500,000.00
0.00
50,000.00
100,000.00
700,000.00
0.00
350,000.00
0.00
200,000.00
250,000.00
300,000.00 1,000,000.00
300,000.00
500,000.00
100,000.00
0.00
150,000.00
0.00
200,000.00
0.00
200,000.00
0.00
100,000.00
150,000.00
100,000.00
150,000.00
350,000.00
0.00
5,000.00
0.00
125,000.00
0.00
50,000.00
0.00
55,000.00
0.00
65,000.00
75,000.00

Page 29

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

70,000.00
100,000.00
105,000.00
300,000.00
375,000.00
395,000.00
550,000.00
90,000.00
60,000.00
70,000.00
70,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
60,000.00
60,000.00
0.00
0.00
0.00
150,000.00
105,000.00
90,000.00
80,000.00
80,000.00
60,000.00
125,000.00
110,000.00
90,000.00
0.00
35,000.00
35,000.00
60,000.00

75,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 30

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
270,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
225,000.00
0.00
0.00
0.00
0.00
0.00
0.00

100,000.00
30,000.00
35,000.00
35,000.00
35,000.00
35,000.00
35,000.00
65,000.00
95,000.00
125,000.00
60,000.00
80,000.00
70,000.00
35,000.00
35,000.00
30,000.00
30,000.00
30,000.00
25,000.00
51,000.00
90,000.00
54,000.00
108,000.00
180,000.00
90,000.00
54,000.00
54,000.00
90,000.00
540,000.00
54,000.00
135,000.00
180,000.00
135,000.00
135,000.00
180,000.00
225,000.00
135,000.00
180,000.00
225,000.00
90,000.00
135,000.00
90,000.00
135,000.00
90,000.00
135,000.00
315,000.00
135,000.00
135,000.00
135,000.00
180,000.00
180,000.00
225,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 31

TarifKIT

0.00
0.00
270,000.00
0.00 180,000.00
585,000.00
0.00 315,000.00
810,000.00
0.00
0.00 2,250,000.00
0.00
0.00 3,600,000.00
0.00
0.00
180,000.00
0.00
0.00
270,000.00
0.00
0.00
315,000.00
0.00
0.00
360,000.00
0.00
0.00 1,350,000.00
0.00
0.00 1,800,000.00
0.00
0.00 2,250,000.00
0.00
0.00
450,000.00
0.00
0.00 16,200,000.00
0.00
0.00
180,000.00
0.00
0.00
540,000.00
0.00
0.00
675,000.00
0.00
0.00 1,350,000.00
0.00
0.00
450,000.00
0.00
0.00
675,000.00
0.00
0.00 5,400,000.00
0.00
0.00 1,350,000.00
0.00
0.00
180,000.00
0.00
0.00
540,000.00
0.00
0.00 1,125,000.00
0.00
0.00
360,000.00
0.00
0.00 1,800,000.00
0.00
0.00
495,000.00
0.00
0.00 2,250,000.00
0.00
0.00 1,350,000.00
0.00
0.00
180,000.00
0.00
0.00
180,000.00
0.00
0.00
135,000.00
0.00
0.00
495,000.00
0.00
0.00
720,000.00
0.00
0.00 1,350,000.00
0.00
0.00
900,000.00
0.00
0.00
900,000.00
0.00 720,000.00 1,980,000.00
0.00 1,125,000.00 2,475,000.00
0.00 1,440,000.00 3,960,000.00
0.00 2,250,000.00 4,500,000.00
0.00
67,500.00
157,500.00
0.00 135,000.00
225,000.00
0.00 135,000.00
135,000.00
0.00
0.00
90,000.00
0.00
90,000.00
180,000.00
0.00 135,000.00
225,000.00
0.00
0.00
450,000.00
0.00
90,000.00
270,000.00
0.00 180,000.00
360,000.00
0.00 225,000.00
675,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 32

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

157,500.00
247,500.00
225,000.00
360,000.00
315,000.00
495,000.00
0.00
315,000.00
0.00
90,000.00
0.00
112,500.00
0.00
135,000.00
0.00
135,000.00
0.00
90,000.00
0.00
450,000.00
0.00
270,000.00
0.00
90,000.00
0.00
180,000.00
0.00
135,000.00
0.00
135,000.00
0.00
90,000.00
0.00
90,000.00
0.00
180,000.00
1,350,000.00 2,250,000.00
1,575,000.00 2,925,000.00
1,800,000.00 3,600,000.00
2,700,000.00 10,800,000.00
315,000.00
810,000.00
0.00
135,000.00
0.00
135,000.00
0.00
90,000.00
0.00
25,000.00
0.00
40,000.00
0.00
60,000.00
0.00
70,000.00
0.00
200,000.00
0.00
10,000.00
0.00
25,000.00
0.00
10,000.00
0.00
35,000.00
0.00
35,000.00
0.00
35,000.00
0.00
125,000.00
0.00
30,000.00
0.00
165,000.00
0.00
200,000.00
0.00
200,000.00
0.00
350,000.00
0.00
15,000.00
0.00
25,000.00
0.00
150,000.00
0.00
200,000.00
0.00
35,000.00
0.00
20,000.00
0.00
15,000.00
0.00
165,000.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 33

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
30,000.00
65,000.00
30,000.00

60,000.00
0.00
830,000.00
726,000.00
200,000.00
550,000.00
1,100,000.00
1,650,000.00
1,800,000.00
120,000.00
60,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
105,000.00
50,000.00
250,000.00
60,000.00
350,000.00
250,000.00
350,000.00
10,000.00
50,000.00
60,000.00
175,000.00
100,000.00
300,000.00
100,000.00
1,100,000.00
10,000.00
1,100,000.00
400,000.00
300,000.00
75,000.00
300,000.00
100,000.00
50,000.00
30,000.00
450,000.00
150,000.00
350,000.00
50,000.00
350,000.00
100,000.00
250,000.00
100,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 34

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

30,000.00
30,000.00
65,000.00
30,000.00
30,000.00
30,000.00
30,000.00
30,000.00
30,000.00
30,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

1,100,000.00
1,100,000.00
400,000.00
250,000.00
75,000.00
200,000.00
100,000.00
350,000.00
50,000.00
350,000.00
200,000.00
220,000.00
240,000.00
225,000.00
300,000.00
400,000.00
125,000.00
165,000.00
200,000.00
250,000.00
275,000.00
120,000.00
495,000.00
210,000.00
275,000.00
400,000.00
237,500.00
372,500.00
431,500.00
555,000.00
120,000.00
175,000.00
235,000.00
400,000.00
85,000.00
125,000.00
180,000.00
325,000.00
530,000.00
225,000.00
90,000.00
130,000.00
165,000.00
60,000.00
60,000.00
60,000.00
65,000.00
60,000.00
75,000.00
132,000.00
269,500.00
220,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 35

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

313,500.00
1,500,000.00
1,200,000.00
600,000.00
480,000.00
200,000.00
85,000.00
70,000.00
50,000.00
350,000.00
750,000.00
1,150,000.00
50,000.00
350,000.00
750,000.00
1,150,000.00
50,000.00
350,000.00
750,000.00
1,150,000.00
60,000.00
100,000.00
75,000.00
50,000.00
45,000.00
50,000.00
40,000.00
15,000.00
15,000.00
15,000.00
15,000.00
15,000.00
15,000.00
25,000.00
15,000.00
100,000.00
287,000.00
15,000.00
15,000.00
93,500.00
85,000.00
71,500.00
236,500.00
99,000.00
236,500.00
93,500.00
290,500.00
350,000.00
350,000.00
179,000.00
190,000.00
160,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
55,000.00
0.00
20,000.00
20,000.00
20,000.00
20,000.00
20,000.00
20,000.00
35,000.00
20,000.00
0.00
230,000.00
20,000.00
20,000.00
100,000.00
0.00
100,000.00
250,000.00
120,000.00
240,000.00
110,000.00
0.00
450,000.00
450,000.00
180,000.00
160,000.00
0.00

Page 36

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

160,000.00
415,000.00
350,000.00
110,000.00
44,000.00
150,000.00
0.00
111,000.00
100,000.00
35,000.00
250,000.00
250,000.00
270,000.00
0.00
50,000.00
30,000.00
117,000.00
50,000.00
49,500.00
46,000.00
48,000.00
94,000.00
300,000.00
328,000.00
25,000.00
30,000.00
30,000.00
30,000.00
160,000.00
125,000.00
195,000.00
83,000.00
104,000.00
101,000.00
146,000.00
220,000.00
385,000.00
275,000.00
180,000.00
18,000.00
18,000.00
18,000.00
55,000.00
75,000.00
145,000.00
176,000.00
23,000.00
23,000.00
23,000.00
55,000.00
255,000.00
37,500.00

250,000.00
445,000.00
425,000.00
132,000.00
100,000.00
182,000.00
0.00
0.00
0.00
40,000.00
350,000.00
0.00
0.00
0.00
55,000.00
0.00
120,000.00
55,000.00
49,500.00
50,000.00
0.00
0.00
0.00
0.00
0.00
0.00
35,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
300,000.00
0.00
20,000.00
20,000.00
20,000.00
0.00
0.00
0.00
0.00
25,000.00
25,000.00
25,000.00
60,000.00
0.00
50,000.00

Page 37

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

37,500.00
37,500.00
41,000.00
225,000.00
41,000.00
41,000.00
140,000.00
100,000.00
154,000.00
167,000.00
132,000.00
229,000.00
369,000.00
290,000.00
550,000.00
525,000.00
40,000.00
62,500.00
65,000.00
260,000.00
150,000.00
286,000.00
199,000.00
700,000.00
215,000.00
82,500.00
115,500.00
73,000.00
89,000.00
102,000.00
250,000.00
295,000.00
167,000.00
310,000.00
800,000.00
1,400,000.00
195,000.00
230,000.00
564,000.00
1,000,000.00
1,800,000.00
142,500.00
142,500.00
275,000.00
275,000.00
275,000.00
199,000.00
420,000.00
330,000.00
253,000.00
155,000.00
159,000.00

0.00
50,000.00
45,000.00
0.00
50,000.00
50,000.00
200,000.00
0.00
0.00
0.00
150,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
750,000.00
0.00
110,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
240,000.00
650,000.00
0.00
0.00
155,000.00
155,000.00
310,000.00
310,000.00
285,000.00
200,000.00
450,000.00
350,000.00
260,000.00
0.00
0.00

Page 38

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

167,000.00
182,000.00
159,000.00
182,000.00
160,000.00
164,000.00
160,000.00
164,000.00
325,000.00
325,000.00
240,000.00
240,000.00
240,000.00
170,000.00
750,000.00
245,000.00
245,000.00
115,000.00
250,000.00
260,000.00
330,000.00
330,000.00
80,000.00
80,000.00
375,000.00
350,000.00
360,000.00
350,000.00
125,000.00
125,000.00
137,500.00
175,000.00
200,000.00
357,000.00
190,000.00
0.00
165,000.00
185,000.00
185,000.00
180,000.00
220,000.00
1,080,000.00
220,000.00
198,000.00
250,000.00
170,000.00
120,000.00
1,440,000.00
350,000.00
27,500.00
12,500.00
12,500.00

170,000.00
215,000.00
0.00
0.00
178,000.00
178,000.00
168,000.00
168,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
120,000.00
125,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
225,000.00
0.00
225,000.00
200,000.00
0.00
190,000.00
0.00
0.00
375,000.00
30,000.00
15,000.00
15,000.00

Page 39

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

15,000.00
15,000.00
33,000.00
90,000.00
55,000.00
100,000.00
23,000.00
23,000.00
37,500.00
37,500.00
42,000.00
60,000.00
60,000.00
60,000.00
60,000.00
60,000.00
20,000.00
15,000.00
30,000.00
100,000.00
40,000.00
20,000.00
41,000.00
100,000.00
55,000.00
110,000.00
35,000.00
165,000.00
125,000.00
155,000.00
35,000.00
35,000.00
192,500.00
262,000.00
192,500.00
263,000.00
300,000.00
300,000.00
100,000.00
250,000.00
15,000.00
15,000.00
50,000.00
500,000.00
175,000.00
192,500.00
145,000.00
275,000.00
263,000.00
40,000.00
15,000.00
15,000.00

0.00
0.00
0.00
95,000.00
0.00
0.00
41,000.00
41,000.00
58,000.00
58,000.00
0.00
0.00
0.00
0.00
0.00
0.00
25,000.00
25,000.00
40,000.00
200,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
200,000.00
0.00
200,000.00
0.00
0.00
0.00
0.00
0.00
20,000.00
20,000.00
55,000.00
0.00
0.00
200,000.00
0.00
310,000.00
0.00
75,000.00
20,000.00
20,000.00

Page 40

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

23,000.00
23,000.00
15,000.00
15,000.00
120,000.00
45,000.00
162,500.00
12,000.00
85,000.00
236,500.00
140,000.00
25,000.00
210,000.00
190,000.00
50,000.00
12,500.00
60,000.00
60,000.00
120,000.00
100,000.00
239,000.00
71,500.00
82,500.00
120,000.00
140,000.00
282,000.00
330,000.00
330,000.00
195,000.00
220,000.00
525,000.00
231,000.00
192,500.00
165,000.00
110,000.00
55,000.00
55,000.00
150,000.00
37,500.00
192,500.00
162,000.00
162,000.00
162,000.00
162,000.00
35,000.00
159,000.00
38,500.00
360,000.00
180,000.00
1,020,000.00
300,000.00
396,000.00

0.00
0.00
0.00
0.00
132,000.00
51,000.00
180,000.00
0.00
100,000.00
0.00
0.00
0.00
0.00
0.00
0.00
15,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
323,000.00
475,000.00
0.00
200,000.00
0.00
130,000.00
0.00
0.00
160,000.00
50,000.00
200,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
450,000.00
200,000.00
0.00
0.00
0.00

Page 41

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
0.00
0.00
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0.00
0.00
0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

165,000.00
252,000.00
143,000.00
240,000.00
132,000.00
132,000.00
165,000.00
155,000.00
150,000.00
88,000.00
65,000.00
200,000.00
250,000.00
450,000.00
899,000.00
1,300,000.00
1,464,000.00
2,199,000.00
2,710,500.00
350,000.00
850,000.00
875,000.00
0.00
0.00
250,000.00
875,000.00
331,500.00
60,000.00
1,081,500.00
100,000.00
400,000.00
125,000.00
100,000.00
100,000.00
50,000.00
400,000.00
100,000.00
500,000.00
30,000.00
30,000.00
75,000.00
30,000.00
25,000.00
50,000.00
20,000.00
30,000.00
30,000.00
35,000.00
20,000.00
25,000.00
150,000.00
65,000.00

0.00
0.00
0.00
250,000.00
140,000.00
140,000.00
0.00
0.00
280,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 42

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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

140,000.00
200,000.00
150,000.00
1,250,000.00
500,000.00
450,000.00
150,000.00
1,400,000.00
560,000.00
450,000.00
150,000.00
1,500,000.00
600,000.00
1,500,000.00
450,000.00
150,000.00
300,000.00
1,600,000.00
1,000,000.00
4,000,000.00
2,500,000.00
1,500,000.00
750,000.00
3,750,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,240,000.00
1,000,000.00
5,600,000.00
2,500,000.00
1,600,000.00
1,000,000.00
4,000,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,400,000.00
1,000,000.00
6,000,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,400,000.00
1,000,000.00
6,000,000.00
2,500,000.00
2,720,000.00
1,000,000.00
6,800,000.00
2,500,000.00
2,000,000.00
1,000,000.00
5,000,000.00
2,500,000.00
2,400,000.00
1,000,000.00
6,000,000.00
2,500,000.00
2,560,000.00
1,000,000.00
6,400,000.00
2,500,000.00
2,720,000.00
1,000,000.00
6,800,000.00
2,500,000.00
2,000,000.00
0.00
5,000,000.00
2,500,000.00
2,000,000.00
0.00
5,000,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

2,500,000.00
2,000,000.00
0.00
5,000,000.00
2,500,000.00
3,062,500.00
2,450,000.00
2,000,000.00
1,200,000.00
3,062,500.00
2,450,000.00
2,000,000.00
1,200,000.00
4,000,000.00
3,250,000.00
1,500,000.00
2,500,000.00
3,000,000.00
2,200,000.00
1,700,000.00
1,000,000.00
3,000,000.00
2,200,000.00
1,700,000.00
1,000,000.00
8,000,000.00
6,000,000.00
4,500,000.00
3,000,000.00
1,225,000.00
980,000.00
800,000.00
480,000.00
1,225,000.00
980,000.00
800,000.00
480,000.00
1,600,000.00
1,300,000.00
1,000,000.00
600,000.00
1,200,000.00
880,000.00
680,000.00
400,000.00
1,200,000.00
880,000.00
680,000.00
400,000.00
3,200,000.00
2,400,000.00
1,800,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 45

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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
0.00
0.00
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0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

1,200,000.00
1,800,000.00
1,350,000.00
1,000,000.00
700,000.00
1,800,000.00
1,350,000.00
1,000,000.00
700,000.00
700,000.00
700,000.00
700,000.00
1,000,000.00
2,000,000.00
2,000,000.00
2,000,000.00
2,500,000.00
1,500,000.00
1,500,000.00
1,500,000.00
2,000,000.00
1,000,000.00
1,000,000.00
1,000,000.00
1,400,000.00
0.00
600,000.00
240,000.00
350,000.00
70,000.00
70,000.00
35,000.00
60,000.00
35,000.00
75,000.00
35,000.00
60,000.00
50,000.00
150,000.00
75,000.00
50,000.00
250,000.00
60,000.00
350,000.00
250,000.00
350,000.00
10,000.00
50,000.00
60,000.00
250,000.00
200,000.00
155,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
60,000.00
0.00
70,000.00
0.00
0.00
0.00
25,000.00
65,000.00
0.00
0.00
0.00
0.00

Page 46

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
0.00
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0.00
0.00
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0.00
0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
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0.00
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0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

250,000.00
135,000.00
50,000.00
350,000.00
60,000.00
50,000.00
250,000.00
60,000.00
350,000.00
250,000.00
350,000.00
10,000.00
50,000.00
60,000.00
77,000.00
77,000.00
77,000.00
82,500.00
77,000.00
77,000.00
77,000.00
82,500.00
77,000.00
77,000.00
77,000.00
88,000.00
82,500.00
82,500.00
82,500.00
77,000.00
88,000.00
165,000.00
104,500.00
77,000.00
77,000.00
77,000.00
77,000.00
154,000.00
82,500.00
121,000.00
121,000.00
110,000.00
154,000.00
82,500.00
110,000.00
148,500.00
110,000.00
132,000.00
148,500.00
137,500.00
132,000.00
132,000.00

0.00
0.00
0.00
0.00
0.00
60,000.00
0.00
70,000.00
0.00
0.00
0.00
15,000.00
15,000.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
0.00
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0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 47

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0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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0.00
0.00
0.00

0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00

137,500.00
148,500.00
148,500.00
192,500.00
165,000.00
247,500.00
165,000.00
165,000.00
192,500.00
192,500.00
192,500.00
176,000.00
165,000.00
198,000.00
198,000.00
165,000.00
192,500.00
198,000.00
192,500.00
385,000.00
467,500.00
440,000.00
286,000.00
357,500.00
385,000.00
275,000.00
330,000.00
412,500.00
412,500.00
385,000.00
385,000.00
412,500.00
150,000.00
75,000.00
0.00
500,000.00
1,750,000.00
612,500.00
437,500.00
180,000.00
180,000.00
240,000.00
150,000.00
200,000.00
1,200,000.00
420,000.00
300,000.00
100,000.00
1,200,000.00
420,000.00
200,000.00
1,000,000.00

0.00
0.00
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0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 48

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

250,000.00
180,000.00
180,000.00
240,000.00
150,000.00
50,000.00
70,000.00
60,000.00
125,000.00
160,000.00
140,000.00
160,000.00
140,000.00
140,000.00
110,000.00
140,000.00
0.00
40,000.00
50,000.00
100,000.00
125,000.00
100,000.00
120,000.00
150,000.00
225,000.00
225,000.00
250,000.00
50,000.00
75,000.00
75,000.00
140,000.00
90,000.00
90,000.00
90,000.00
90,000.00
90,000.00
35,000.00
100,000.00
100,000.00
100,000.00
100,000.00
200,000.00
20,000.00
25,000.00
15,000.00
150,000.00
175,000.00
200,000.00
65,000.00
75,000.00
70,000.00
200,000.00

0.00
0.00
0.00
0.00
0.00
60,000.00
80,000.00
70,000.00
135,000.00
170,000.00
150,000.00
170,000.00
150,000.00
150,000.00
120,000.00
150,000.00
200,000.00
50,000.00
60,000.00
110,000.00
150,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
160,000.00
180,000.00
0.00
0.00
0.00
80,000.00
0.00

Page 49

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

50,000.00
125,000.00
175,000.00
175,000.00
70,000.00
200,000.00
50,000.00
50,000.00
50,000.00
150,000.00
150,000.00
150,000.00
250,000.00
200,000.00
200,000.00
200,000.00
200,000.00
450,000.00
30,000.00
250,000.00
300,000.00
200,000.00
200,000.00
400,000.00
50,000.00
75,000.00
40,000.00
50,000.00
125,000.00
1,200,000.00
480,000.00
200,000.00
150,000.00
1,500,000.00
600,000.00
200,000.00
150,000.00
57,500.00
90,000.00
115,000.00
60,000.00
60,000.00
230,000.00
300,000.00
300,000.00
300,000.00
300,000.00
57,500.00
57,500.00
57,500.00
700,000.00
70,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 50

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

230,000.00
90,000.00
70,000.00
230,000.00
460,000.00
45,000.00
95,000.00
95,000.00
115,000.00
290,000.00
57,500.00
115,000.00
175,000.00
230,000.00
350,000.00
115,000.00
115,000.00
87,500.00
145,000.00
41,000.00
210,000.00
35,000.00
145,000.00
215,000.00
35,000.00
50,000.00
35,000.00
50,000.00
40,000.00
60,000.00
25,000.00
37,500.00
50,000.00
100,000.00
150,000.00
100,000.00
100,000.00
100,000.00
100,000.00
100,000.00
200,000.00
60,000.00
100,000.00
100,000.00
200,000.00
50,000.00
100,000.00
125,000.00
125,000.00
25,000.00
25,000.00
20,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
400,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 51

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

25,000.00
30,000.00
90,000.00
60,000.00
75,000.00
125,000.00
30,000.00
200,000.00
100,000.00
200,000.00
100,000.00
150,000.00
50,000.00
10,000.00
120,000.00
35,000.00
400,000.00
10,000.00
50,000.00
15,000.00
50,000.00
20,000.00
150,000.00
30,000.00
7,500.00
60,000.00
150,000.00
100,000.00
400,000.00
600,000.00
15,000.00
15,000.00
25,000.00
100,000.00
50,000.00
25,000.00
37,500.00
50,000.00
100,000.00
150,000.00
100,000.00
100,000.00
100,000.00
100,000.00
100,000.00
200,000.00
60,000.00
100,000.00
100,000.00
200,000.00
50,000.00
100,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
250,000.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 52

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

125,000.00
125,000.00
20,000.00
25,000.00
20,000.00
25,000.00
30,000.00
90,000.00
60,000.00
75,000.00
125,000.00
30,000.00
200,000.00
100,000.00
200,000.00
100,000.00
150,000.00
50,000.00
10,000.00
120,000.00
35,000.00
400,000.00
10,000.00
50,000.00
15,000.00
50,000.00
20,000.00
150,000.00
30,000.00
7,500.00
60,000.00
150,000.00
100,000.00
400,000.00
600,000.00
100,000.00
253,000.00
192,500.00
330,000.00
247,500.00
247,500.00
192,500.00
165,000.00
55,000.00
495,000.00
220,000.00
220,000.00
220,000.00
275,000.00
412,500.00
275,000.00
385,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 53

TarifKIT

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

75,000.00
200,000.00
150,000.00
450,000.00
150,000.00
200,000.00
1,800,000.00
450,000.00
200,000.00
720,000.00
1,440,000.00
360,000.00
360,000.00

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Page 54

A.ADMINISTRASI
NO
1

KETERANGAN
RAWAT JALAN
a. Dokter Umum
b. Dokter spesialis & Gigi
c. Bidan
c. Penunjang medis
( Laboratorium,.Radiologi,Fisiotherapi,Elektromedik,dll)

15,000
20,000
15,000
10,000

Observasi
Ruang observasi s/d 8 Jam

RAWAT INAP

TAMBAHAN
Kartu Kunjungan Pasien
Buku Catatan Pasien Kebidanan dan Kandungan

TARIF ( RP.)

Jasa Service

100,000
5% dari Sub Total

5,000
10,000
10% dari Tarif Kamar

A.ADMINISTRASI

B. KONSULTASI RAWAT JALAN

NO

KETERANGAN

DOKTER SPESIALIS

Konsultasi
DOKTER UMUM

TARIF ( RP,)

100,000

Konsultasi

Pukul 08.00-21.00 WIB

40,000

Pukul 21.00-08.00 WIB

50,000

Sabtu - Minggu / Libur Nasional

50,000

BIDAN
Konsultasi

KB
Dokter GIGI

20,000
10,000

Konsultasi Gigi Umum

60,000

Konsultasi Gigi Spesialis

90,000

C.TARIF RAWAT JALAN POLI UMUM & UGD

01.001.03 UGD003
01.002.01
01.002.02
01.003.00
01.004.01
01.004.02
01.004.03
01.004.04
01.005.01
01.005.02
01.005.03
01.007.01
01.008.00
01.009.00
01.010.00
01.011.00
01.011.00
01.011.00
01.012.01
01.012.02
01.012.03
01.013.00
01.014.00
01.015.00
01.016.00
01.017.01
01.017.02
01.017.03
01.018.00
01.019.00

UGD004
UGD005
UGD006
UGD007
UGD008
UGD009
UGD010
UGD011
UGD012
UGD013
UGD016
UGD017
UGD018
UGD019
UGD022
UGD023
UGD024
UGD025
UGD026
UGD027
UGD028
UGD029
UGD030
UGD031
UGD032
UGD033
UGD034
UGD035
UGD036

01.020.00
01.021.00
01.022.00
01.023.00
01.024.00
01.025.00
01.026.00
01.027.00
01.028.00
01.029.00
01.030.00
01.031.00
01.032.00
01.033.00
01.034.00
01.035.00
01.036.00
01.036.00
01.037.00
01.038.00
01.039.00
01.040.00

UGD037
UGD038
UGD039
UGD040
UGD041
UGD042
UGD043
UGD044
UGD045
UGD046
UGD047
UGD048
UGD049
UGD050
UGD051
UGD052
UGD053
UGD054
UGD055
UGD056
UGD057
UGD058

AF HECTING (>10)
AF HECTING (-10)
AMPUTASI JARI RUAS I
AMPUTASI JARI RUAS II
BILAS LAMBUNG (Intoksikasi Baygon/Drug)
CORPUS ALIENUM HIDUNG
CORPUS ALIENUM MATA (Satu mata)
CORPUS ALIENUM TELINGA (Satu telinga)
CORPUS ALIENUM TENGGOROK
DEBRIDEMENT LUKA BAKAR BERAT
DEBRIDEMENT LUKA BAKAR RINGAN
DEBRIDEMENT LUKA BAKAR SEDANG
ECG
EKSPLORASI / CROSS INCISI
EKSTIRPASI KECIL
EKSTRAKSI KUKU ( 1 KUKU )
GANTI VERBAN KECIL
GANTI VERBAN SEDANG
GANTI VERBAN BESAR
HECHTING BESAR ( > 10 )
HECHTING KECIL ( 1 - 5 )
HECHTING SEDANG ( 6 - 10 )
INCISI ABSES
INHALASI TANPA OBAT
INTUBASI
IRIGASI MATA
JAHIT OTOT KESULITAN TINGGI
JAHIT OTOT KESULITAN RENDAH
JAHIT OTOT KESULITAN SEDANG
LAVAMENT / CLYSMA
O2 /1- 3 JAM
O2/3-8 JAM
O2/8-24 JAM
RUANG OBSERVASI S/D 8 JAM
PASANG CATHETER
PASANG CVP
PASANG INFUS
ANGKAT SERUMEN TANPA PENYULIT
PASANG NGT
PASANG SPALK
PASANG TAMPON (HIDUNG DAN TELINGA)
PLEURA PUNKSI / WSD MINI ( DR SPESIALIS )
SPOOLING TELINGA
SUNTIK
TAMPON POSTERIOR EPISTAKSIS
VENA SEKSI
CPR
CIRCUMSISI ANAK ( < 15 TAHUN )
CIRCUMSISI DEWASA
WOUND TOILET KECIL
WOUND TOILET SEDANG
WOUND TOILET BESAR
ECG MONITOR PER 3 JAM
IRIGASI TELINGA / EAR TOILET
VISUM

TOTAL
50,000.00
35,000.00
100,000.00
150,000.00
100,000.00
100,000.00
100,000.00
100,000.00
100,000.00
200,000.00
100,000.00
150,000.00
60,000.00
100,000.00
125,000.00
125,000.00
25,000.00
30,000.00
40,000.00
90,000.00
60,000.00
75,000.00
125,000.00
30,000.00
180,000.00
100,000.00
250,000.00
125,000.00
175,000.00
50,000.00
50,000.00
100,000.00
150,000.00
100,000.00
35,000.00
400,000.00
15,000.00
50,000.00
15,000.00
30,000.00
30,000.00
300,000.00
30,000.00
7,500.00
60,000.00
250,000.00
100,000.00
150,000.00
300,000.00
25,000.00
30,000.00
40,000.00
100,000.00
50,000.00
15,000.00
3

D.TINDAKAN RAWAT JALAN POLI KEBIDANAN

11.001.00

KBK001

ANGKAT PESARIUM

100,000

11.002.01

KBK002

CABUT IMPLANON (JASA )

200,000

11.002.02

KBK003

CABUT IUD (JASA)

200,000

11.003.00

KBK004

EKSTIRPASI ( OBSGYN )

11.004.00

KBK005

JASA SUNTIK (IMUNISASI)

11.005.00

KBK006

MICRO CURRATAGE (JASA)

800,000

11.006.01

KBK007

PASANG IMPLANON (JASA)

250,000

11.006.02

KBK008

PASANG IUD (JASA)

250,000

11.007.00

KBK009

PAP SMEAR / VAGINAL SMEAR (JASA)

11.008.01

KBK010

PASANG LAMINARIA

300,000

11.008.02

KBK011

PASANG PESARIUM ( DI LUAR ALKES )

100,000

11.009.01

KBK012

USG 2-D & PRINT OUT

105,000

KBK013

USG 2-D NON PRINT OUT

11.010.00

KBK016

HIDROTUBASI

11.011.00

KBK017

CTG

75,000

11.012.00

KBK018

VAGINA TOILET

80,000

1,000,000
20,000

75,000

90,000
350,000

E.TINDAKAN RAWAT JALAN POLI ANAK

13.001.00 ANK001

ECG

75,000.00

13.002.00 ANK002

PLEURA PUNKSI

13.006.00 ANK003

JASA SUNTIK (IMUNISASI)

20,000.00

13.007.00 ANK004

TEST MANTOUX (JASA)

40,000.00

13.008.00 ANK005

IMUNISASI POLIO

10,000.00

13.009.00 ANK006

HEPASTITIS B

15,000.00

13.010.00 ANK007

NEBULIZER

65,000.00

300,000.00

F.TINDAKAN RAWAT JALAN POLI PENYAKIT DALAM

13.001.00 PDL001

ECG

75,000.00

13.002.00 PDL002

PLEURA PUNKSI

13.003.00 PDL003

SPIROMETRI

13.005.01 PDL005

USG (ABDOMEN ATAS)

150,000.00

13.005.02 PDL006

USG (ABDOMEN BAWAH)

150,000.00

USG (ABDOMEN ATAS & BAWAH)

275,000.00

300,000.00

75,000.00

13.006.00 PDL007

JASA SUNTIK (IMUNISASI)

20,000.00

13.007.00 PDL008

TEST MANTOUX (JASA)

40,000.00

13.008.00 PDL009

NEBULIZER

65,000.00

G.POLI GIGI

KODE

JENIS PELAYANAN

TARIF

UMUM
PGM.U.01 Konsultasi drg. Umum

60,000

PGM.S.02 Konsultasi drg. Spesialis

110,000

PGM.U.03 Buka Jahitan

110,000

PGM.U.04 Kontrol Paska Operasi

PGM.U.05 Cetak Model Gigi / Rahang

60,000
75,000

PGM.U.06 Mouth Guard 1 Rahang

RONTGEN

900,000

PGM.U.07 Foto Dental (Per Foto)

PREVENTIF

60,000

PGM.U.08 Fluoridasi Topikal / Gigi

50,000

PGM.U.09 Pit & Fissure Sealant *

PEDODONTI

165,000

Tumpatan GIC
PGM.U.10 Tumpatan GIC Kecil

165,000

PGM.U.11 Tumpatan GIC Sedang

220,000

PGM.U.12 Tumpatan GIC Besar

275,000

PGM.U.13 Pulpotomi

110,000

PGM.U.14 Endodontik Gigi Susu

110,000

Ekstraksi Gigi Susu

PGM.U.15 Ekstraksi Gigi Susu Tanpa Injeksi *

100,000

PGM.U.16 Ekstraksi Gigi Susu Dengan Injeksi *

PGM.U.17 Space Maintainer **

150,000
660,000

KONSERVASI
PGM.U.18 Tumpatan Sementara *

100,000

PGM.U.19 Pulp Capping *

100,000

PGM.U.20 Perawatan Endodontik

165,000

PGM.U.21 Tumpatan Komposit Lokal

150,000

PGM.U.22 Tumpatan Komposit Kecil

200,000

PGM.U.23 Tumpatan Komposit Sedang

225,000

PGM.U.24 Tumpatan Komposit Besar

300,000

PGM.U.25 Veneering Komposit

350,000

PGM.U.26 Inlay / Onlay / Uplay Metal *

930,000

PGM.U.27 Inlay / Onlay / Uplay Keramik *

1,375,000

PGM.S.28 Home Bleacing

PGM.S.29 Office Bleaching

2,200,000
4,400,000

BEDAH MULUT
PGM.S.30 Ekstraksi Gigi Kasus Mudah

150,000

PGM.S.31 Ekstraksi Gigi Kasus Sedang

200,000

PGM.S.32 Ekstraksi Gigi Permanen Komplikasi Kasus Mudah

330,000

PGM.S.33 Ekstraksi Gigi Permanen Komplikasi Kasus Sedang

385,000

PGM.S.34 Ekstraksi Gigi Permanen Komplikasi Kasus Sulit

440,000

PGM.S.35 Odontectomy Kelas I

1,100,000

PGM.S.36 Odontectomy Kelas II

2,200,000

PGM.S.37 Odontectomy Kelas III

2,750,000

PGM.S.38 Alveolectomy Per Regio ***

PGM.S.39 Implant *

550,000
19,800,000

PGM.S.40 Insisi Abses Intra Oral

150,000

PGM.S.41 Insisi Abses Ekstra Oral

300,000

PGM.S.42 Apex Reseksi Per Gigi

1,650,000

PGM.S.43 Operculetomy

550,000

PGM.S.44 Ekstirpasi Mucocel

825,000

PGM.S.45 Bone Graft

6,600,000

PGM.S.46 Fiksasi Fraktur

PGM.S.47 Kuret Dry Socket

1,650,000
150,000

PROSTODONTI
Jacket Crown
PGM.S.48 Jacket Crown Metal Acrylic *
PGM.S.49 Jacket Crown Metal Porcelain *
PGM.S.50 Jacket Crown All Acrylic *
PGM.S.51 Jacket Crown All Porcelain *
PGM.S.52 Jacket Crown All Metal *

660,000
1,375,000
440,000
2,200,000
605,000

PGM.S.53 Pin Fiber & Crown *

2,200,000

PGM.S.54 Pin Metal & Crown *

1,650,000

PGM.S.55 Mahkota Sementara *

220,000

Plat Akrilik
PGM.S.56 Plat Akrilik & 1 Gigi Akrilik **

605,000

PGM.S.57 Plat Akrilik & 1 Gigi Porselen **

880,000

PGM.S.58 Plat Frame **

1,650,000

Flexy Denture
PGM.S.59 Flexy Denture Saddle & 1 Gigi **

1,100,000

PGM.S.60 Flexy Denture Bilateral & 1 Gigi **

1,100,000

Single Complete Denture

PGM.S.61 Single Complete Denture Akrilik **

3,300,000

PGM.S.62 Single Complete Denture Porselen **

4,400,000

Full Denture Akrilik

PGM.S.63 Full Denture Akrilik RA & RB

6,600,000

PGM.S.64 Full Denture Porselen RA & RB

8,250,000

Elemen Gigi Tiruan

PGM.S.65 Elemen Gigi Tiruan Akrilik *

150,000

PGM.S.66 Elemen Gigi Tiruan Porselen *

175,000

PGM.S.67 Elemen Gigi Tiruan Flexy Denture *

225,000

Reparasi
PGM.S.68 Reparasi Kasus Mudah **

330,000

PGM.S.69 Reparasi Kasus Sedang **

440,000

PGM.S.70 Reparasi Kasus Sulit **

550,000

Relining
PGM.S.71 Relining Kasus Mudah **
PGM.S.72 Relining Kasus Sedang **
PGM.S.73 Relining Kasus Sulit **

440,000
660,000
1,100,000

Rebasing
PGM.S.74 Rebasing Kasus Mudah **

400,000

PGM.S.75 Rebasing Kasus Sedang **

600,000

PGM.S.76 Rebasing Kasus Sulit **

PGM.S.77 Bongkar Crown *

800,000
350,000

PERIODONTI
PGM.U.78 Scaling Per Rahang Lokal

75,000

PGM.U.79 Scaling Per Rahang Kelas I

110,000

PGM.U.80 Scaling Per Rahang Kelas II

130,000

PGM.U.81 Scaling Per Rahang Kelas III

250,000

Kuretase
PGM.U.82 Kuretase (1 Gigi) *

150,000

PGM.U.83 Kuretase (>1 Gigi) *

PGM.S.84 Flap (Per Regio) ***

100,000
550,000

Splinting
PGM.S.85 Splinting (2 Gigi)

330,000

PGM.S.86 Splinting (>2 Gigi)

110,000

Ginggivektomi
PGM.U.87 Ginggivektomi (1-2 Gigi) *

220,000

PGM.U.88 Ginggivektomi (>1 Gigi) *

165,000

Desensitisasi
PGM.U.89 Desensitisasi (1 Gigi) *
PGM.U.90 Selective Grinding *
PGM.U.91 Recontouring *

50,000
110,000
220,000

ORTHODONTI
Fixed Per Rahang
PGM.S.92 Fixed Per Rahang Kasus Mudah

4,000,000

PGM.S.93 Fixed Per Rahang Kasus Sedang

5,000,000

PGM.S.94 Fixed Per Rahang Kasus Sulit

Fixed Ceramic Per Rahang
PGM.S.95 Removable **

6,000,000
16,500,000
1,000,000

PGM.S.96 Pemasangan Bracket Lepas ****

100,000

PGM.S.97 Aktivasi Fixed

100,000

PGM.S.98 Aktivasi Removable

100,000

Keterangan :
* Per Gigi
** Per Rahang
*** Per Regio
**** Per Bracket

H.LABORATORIUM
KODE

KETERANGAN

TARIF

HEMATOLOGI
55,000

Darah Lengkap
Hemoglobin

12,500

Leukosit

12,500

Trombosit

12,500

Hematokrit

12,500

Hitung Jenis/Diff Count

12,500

Darah Rutin 1 (Hb, Leuko, Trombo, Ht)

50,000

Darah Rutin 2 (Hb, Leuko, Diff Count, LED)

45,000

Darah Rutin 3 (Hb, Diff Count, Trombo, LED, Ht)

50,000

DPL (Hb, Diff Count, Eri, Trombo, LED)

55,000

APT/Masa Protrombin

60,000

Elektroforesa

200,000

Feritin

190,000

Fibrinogen

60,000

Gambaran Darah Tepi

55,000

Golongan Darah/Rhesus

25,000

Hitung Eosinofil

30,000

LED / Laju Endap Darah

15,000

Masa Pembekuan (CT)

15,000

Masa Perdarahan (BT)

15,000

Mikrofilaria

25,000

Reaksi LE

40,000

Resistensi Osmotik

200,000

Retikulosit

30,000

Retraksi Bekuan

20,000

Rumpell Leed

15,000

Sel LE

40,000

Serum Iron

80,000

Tes Comb Direct/Indirect

200,000

TIBC

80,000

Trombo Test/INR

60,000

URINE
Urine Rutin/Lengkap

30,000

Darah Samar

70,000

Protein Bence Jones

20,000

Tes Kehamilan

40,000

HEMOSTASIS
Waktu pembekuan perdarahan
KIMIA DARAH

30,000

GDS/Puasa/2 jam PP @
Alkali Fosfatase
APTT
Asam Urat
Bilirubin total : direct/indirect
CPK
Elektrolit/Na/K/Cl/Ca
Gamma GT
HDL & LDL Kolesterol
Kolesterol Total
Kurva Harian
LDH
Lipase
Protein Total : Albumin & Globulin
SGOT & SGPT
Trigliserida
Ureum & Creatinin
SEROLOGI / IMUNOLOGI
Widal CRP
Anti HBs
Anti HIV
HBsAg
Malaria
Papsmear
T3 uptake/ T3 / T4 total
Tes Mantoux
FAECES
Rutin / Lengkap
Darah Samar

CATATAN
**Cito/Panggilan/Libur Tarif + 25%
**Pemeriksaan di atas jam 21.00 WIB + 25%
**Tarif dikenakan biaya administrasi penunjang sebesar 10% dari pemeriksaaan
**Untuk pasien tanpa pemeriksaan dokter dikenakan tambahan biaya administrasi
sebesar Rp. 5.000,-/orang

75,000
30,000
60,000
60,000
80,000
70,000
120,000
40,000
80,000
30,000
75,000
70,000
120,000
80,000
60,000
30,000
60,000

50,000
120,000
135,000
85,000
25,000
75,000
500,000
70,000

25,000
30,000

I.RADIOLOGI
NO
1

KETERANGAN
Kepala
Schedell
Sinus Paranasal
Mandibula
Truncus
Cervical AP/Lat/Oblique
Thoracal AP/Lat
Thoracal PA/Lat
Lumbal AP/Lat
Lumbo Sacral
Sacral AP/Lat
Anggota Gerak
Extremitas Atas AP/Lat
Extremitas Bawah Ap/Lat
Persendian/Articulatio/Joint
Antebrachii
Abdomen
Abdomen/BNO

TARIF

KETERANGAN
USG KEBIDANAN
1. USG Kebidanan
Print per gambar @
2. USG Transvaginal
Print per gambar @
USG PENY.DALAM/BEDAH/LAIN
USG Abdomen
Abdomen Atas/Bawah @
Whole Abdomen
USG Mammae/Thyroid
USG Pelvis
Print per gambar @

TARIF

110,000
120,000
120,000
110,000
120,000
150,000
120,000
120,000
120,000
100,000
100,000
100,000
100,000
100,000

USG
NO
A

90,000
15,000
100,000
15,000

150,000
275,000
150,000
150,000
15,000

CATATAN
Cito/panggilan/libur tarif + 25%
**
Tarif di atas belum termasuk cairan kontras/obat-obatan
**
Tarif dikenakan tambahan biaya administrasi penunjang sebesar Rp.10.000,-/orang
**

J.TARIF FISOTERAPI
NO

JENIS TINDAKAN

TARIF

MWD ( Micro Wave Diathermy )

35,000

US ( Ultra Sound )

35,000

Tens / ES

35,000

IR ( Infra Red )

30,000

Nebulizer :

Inhalasi + Chest Terapi

65,000

Inhalasi + IR + Chest Terapi

75,000

Inhalasi + MWD + Chest Terapi

85,000

Exercise Terapi :
Ringan waktunya 15 menit

35,000

Sedang waktunya 30 menit

50,000

Berat waktunya 45 menit

65,000

Massage

50,000

MWD + Tens / ES + Exercise

75,000

MED + Tens / ES + US + Exercise

10

IR + Exercise

11

Paket :

12

13

100,000
60,000

dengan 2 alat yang berbeda untuk area yang sama

70,000

dengan 3 alat yang berbeda untuk area yang sama

100,000

Paket Nebulizer ( Inhalasi ) :

3 X Terapi ( Inhalasi + Chest Terapi )

229,500

3 X Terapi ( Inhalasi + IR + Chest Terapi )

262,500

3 X Terapi ( Inhalasi + MWD + Chest Terapi )

295,000

Pakt Elektro Terapi :

3 X Terapi ( MWD + Tens / ES + Exercise

262,500

3 X Terapi ( MWD + Tens / ES + US + Exercise

345,000

3 X Terapi ( IR + Exercise )

213,000

Keterangan
1. Tarif inhalasi sudah termasuk obat untuk inhalasi
2. Tarif dikenakan biaya tambahan administrasi penunjang sebesar Rp.15.000,- per orang
3. Tarif paket nebulizer dan paket elektro terapi di atas sudah ditambahkan biaya administrasi
( Paket 3 X Terapi -> diskon 10 % administrasi Rp. 15.000 )

10

10

K.TINDAKAN TARIF RAWAT INAP

KELAS III & II
30.001.01 TRI001

AF HECHTING (< 10 )

35,000.00

30.001.03 TRI003

AF HECHTING (> 10 )

50,000.00

30.002.00 TRI004

CLYSMA

60,000.00

30.003.00 TRI005

ECG

75,000.00

30.005.00 TRI007

INTUBASI

300,000.00

30.006.01 TRI008

PUNGSI LUMBAL

300,000.00

30.006.02 TRI009

PUNGSI FLEURA

300,000.00

30.006.03 TRI010

PUNGSI ASCITES

300,000.00

30.007.00 TRI011

PASANG FOLLEY CATHETER

50,000.00

30.008.00 TRI012

PASANG INFUS

50,000.00

30.009.00 TRI013

PASANG NGT

50,000.00

30.012.00 TRI016

VENA SEKSI

30.013.00 TRI017

TINDIK TELINGA BAYI

30.015.00 TRI019

PEMASANGAN UMBILICAL CATHETER

230,000.00

30.016.00 TRI020

EXCHANGE TRANSFUSI

400,000.00

30.017.00 TRI021

SPOOL DRAIN

50,000.00

30.018.00 TRI022

AF WSD

90,000.00

TRI026

PUNGSI PUS

75,000.00

TRI027

NEKROTOMI KECIL

130,000.00

TRI028

NEKROTOMI SEDANG

160,000.00

TRI029

NEKROTOMI BESAR

200,000.00

TRI030

PASANG CVP

350,000.00

30.015.00 TRI031

MERAWAT DECUBITUS / HARI

100,000.00

30.016.00 TRI032

MERAWAT GANGRENE / HARI

125,000.00

30.017.01 TRI033

LUKA BAKAR RINGAN ( < 20% )

90,000.00

30.017.02 TRI034

LUKA BAKAR SEDANG (20-40%)

125,000.00

30.017.03 TRI035

LUKA BAKAR BERAT ( >40% )

150,000.00

30.018.00 TRI036
30.020.00 TRI037
TRI038
TRI039

LABU DARAH / KANTONG ( Biaya transport/1 X )

O2 /1- 3 JAM
O2/3-8 JAM
O2/8-24 JAM

100,000.00
50,000.00
100,000.00
150,000.00

225,000.00
75,000.00

11

KELAS 1&VIP
50,000.00
70,000.00
85,000.00
100,000.00
400,000.00
400,000.00
400,000.00
400,000.00
50,000.00
50,000.00
50,000.00
300,000.00
75,000.00
275,000.00
500,000.00
75,000.00
120,000.00
100,000.00
165,000.00
200,000.00
240,000.00
400,000.00
125,000.00
150,000.00
120,000.00
150,000.00
180,000.00
100,000.00
50,000.00
100,000.00
150,000.00

11

L.TARIF KAMAR
NO

KAMAR

KELAS 3

KELAS 2

KELAS 1

VIP

LANTAI 1

85,000

150,000

225,000

LANTAI 2

85,000

125,000

175,000

R.I ANAK LANTAI 2

85,000

INKUBATOR ( PER HARI )

75,000

BLUE LIGHT ( PER HARI )

75,000

JASA VISITE SPESIALIS

70,000

80,000

90,000

100,000

Dr. UMUM

25,000

25,000

40,000

40,000

NO

KETERANGAN

KAMAR BERSALIN ( VK )
KELAS 3 & 2
KELAS 1 & VIP
350,000

350,000

KAMAR OPERASI ( OK )
KELAS 3 & 2
KELAS 1 & VIP

350,000

PARTUS

TINDAKAN KECIL

500,000

700,000

TINDAKAN SEDANG

600,000

850,000

TINDAKAN BESAR

750,000

1,000,000

TINDAKAN KHUSUS

1,000,000

1,400,000

12

M. TARIF JASA TINDAKAN

NO
KETERANGAN
1 JASA OPERATOR
DOKTER SPESIALIS OBGYN / BEDAH UMUM

VIP

TINDAKAN KECIL
TINDAKAN SEDANG
TINDAKAN BESAR
TINDAKAN KHUSUS
PARTUS NORMAL
SECTIO CAESARIA

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

KELAS 1

KELAS 2

1,250,000
2,250,000
2,750,000
3,500,000
1,200,000
1,800,000

KELAS 3

1,000,000
2,000,000
2,500,000
3,000,000
900,000
1,550,000

Macam Tindakan
OBGYN

800,000 Kuret/Retensio Plasenta

1,800,000
2,250,000
2,500,000
700,000
1,200,000

DOKTER UMUM
PARTUS NORMAL
TINDAKAN KECIL
TINDAKAN SEDANG
2

JASA RESUSITASI
DOKTER SPESIALIS
DOKTER UMUM
JASA ANESTESI

50% dari Operator Utama

2X dari nilai visite sesuai kamar perawatan

2X dari nilai visite sesuai kamar perawatan
DOKTER SPESIALIS

40% dari Operator Utama

Jasa Operator dg penyulit/diluar jam kerja naik 20%

Bila ada kenaikan tarif Jasa Operator maka Tarif Kamar OK naik sebesar 20%
Dokter Anestesi 40% dari Operator
Dokter Anak 25% dari Operator

13

Bedah Umum
Incisi Abses/Mata Ikan
Appendictomy

13

N.TARIF TINDAKAN PAKET

TINDAKAN

UTAMA

KELAS I

KELAS II

KELAS III

KURET

4,250,000

3,800,000

3,200,000

2,850,000

KURET PLASENTA

5,000,000

4,500,000

3,500,000

3,050,000

PARTUS NORMAL

6,200,000

5,200,000

4,200,000

3,200,000

SECTIO CESARIA

10,800,000

9,500,000

7,750,000

6,500,000

Keterangan :
Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIB
Bila diluar hari dan jam kerja, maka tarif naik sebesar 12% dari total
Tarif hanya berlaku untuk SC tanpa penyulit,non gemelli dll
Bila terdapat penyulit, maka tarif di atas tidak berlaku
Tarif meliputi sewa kamar pasien dan bayi,obat-obatan sesuai standar RS
Obat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

14

O.AMBULANCE
KODE

KETERANGAN
Antar atau Jemput
Radius < 5 km
Radius > 5 km, per km +

TARIF

100,000
10,000

Antar dan Jemput

Radius < 5 km
Radius > 5 km, per km +

150,000
15,000

Rujuk Pemeriksaan
Radius < 5 km
Radius > 5 km, per km +

50,000
5,000

Pengambilan Darah
PMI Jakarta

150,000

Keterangan :
**
Tarif di atas belum termasuk bahan habis pakai/obat-obatan, jasa tenaga medis, administrasi

BREAK DOWN PAKET KURET

KODE

JENIS PELAYANAN
KURET
Pemeriksaan Awal
Jasa Operator(100%)
Jasa Anestesi(100%)

TARIF
UTAMA

KELAS I

KELAS II

90,000
1,200,000

90,000
1,000,000

90,000
800,000

480,000
120,000
700,000
300,000

400,000
100,000
700,000
200,000

320,000
80,000
500,000
150,000

TOTAL

55,000
20,000
20,000
20,000
600,000
30,000
3,635,000
181,750
545,250
4,362,000

55,000
20,000
20,000
20,000
600,000
20,000
3,225,000
161,250
483,750
3,870,000

55,000
20,000
20,000
20,000
600,000
15,000
2,670,000
133,500
400,500
3,204,000

USULAN TARIF

4,250,000

3,800,000

3,200,000

JASA ASISTEN
Sewa OK
Sewa Alat Kuret
Sewa Kmr Perawatan
Laboratorium
- Drh lengkap
- CT
- BT
- GDS
Farmasi (obat2an & alkes)
Jasa service (10% dari kmr perawatan)
Subtotal
Adm (5% dari subtotal)
Marketing Fee (10% dari subtotal)

Keterangan :
Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIB
Bila diluar hari dan jam kerja, maka tarif naik sebesar 12%
Bila terdapat penyulit, maka tarif di atas tidak berlaku
Obat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

KELAS III
90,000
640,000

256,000
64,000
500,000
75,000
55,000
20,000
20,000
20,000
600,000
7,500
2,347,500
117,375
352,125
2,817,000
2,850,000

BREAK DOWN KURET PLASENTA

KODE

JENIS PELAYANAN
KURET
Pemeriksaan Awal
Jasa Operator(100%)
Jasa Anestesi(100%)

TARIF
UTAMA

KELAS I

KELAS II

90,000
1,300,000

90,000
1,100,000

90,000
900,000

520,000
130,000
700,000
300,000

440,000
110,000
700,000
200,000

360,000
90,000
500,000
150,000

TOTAL

55,000
20,000
20,000
20,000
900,000
30,000
4,085,000
204,250
612,750
4,902,000

55,000
20,000
20,000
20,000
900,000
20,000
3,675,000
183,750
551,250
4,410,000

55,000
20,000
20,000
20,000
700,000
15,000
2,920,000
146,000
438,000
3,504,000

USULAN TARIF

5,000,000

4,500,000

3,500,000

JASA ASISTEN
Sewa OK
Sewa Alat Kuret
Sewa Kmr Perawatan
Laboratorium
- Drh lengkap
- CT
- BT
- GDS
Farmasi (obat2an & alkes)
Jasa service (10% dari kmr perawatan)
Subtotal
Adm (5% dari subtotal)
Marketing Fee (15% dari subtotal)

Keterangan :
Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIB
Bila terdapat penyulit, maka tarif di atas tidak berlaku
Obat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

KELAS III
90,000
700,000

280,000
70,000
500,000
75,000
55,000
20,000
20,000
20,000
700,000
7,500
2,537,500
126,875
380,625
3,045,000

3,050,000

BREAK DOWN PARTUS NORMAL

UTAMA

TARIF
KELAS I
KELAS II

350,000
2,000,000

350,000
1,600,000

Kamar Bayi (50% dr kamar Ibu)

200,000
500,000
600,000
300,000

Visite dr SpOG

200,000

Visite dr SpA

KODE

JENIS PELAYANAN

KELAS III

PARTUS NORMAL (2 hari 1 malam)

350,000

350,000

200,000

160,000
400,000
400,000
200,000
180,000
180,000

1,300,000
130,000
325,000
300,000
150,000
160,000
160,000

1,000,000
100,000
250,000
150,000
75,000
140,000
140,000

55,000
20,000
20,000

55,000
20,000
20,000

55,000
20,000
20,000

55,000
20,000
20,000

TOTAL

25,000
700,000
90,000
5,260,000
263,000
263,000
5,786,000

25,000
700,000
60,000
4,350,000
217,500
217,500
4,785,000

25,000
500,000
45,000
3,540,000
177,000
177,000
3,894,000

500,000
22,500
2,822,500
141,125
141,125
3,104,750

HARGA JUAL

6,200,000

5,200,000

4,200,000

3,200,000

Sewa VK
Jasa SpOG
Jasa Bidan (asisten operator)
Jasa Dokter Anak
Kamar Perawatan Ibu

Laboratorium :
Ibu :
- darah lengkap
- CT
- BT
Anak :
- golongan darah
Farmasi (obat2an & alkes)
Jasa service (10% dari kmr perawatan)
Subtotal
Adm (5% dari sub total)
Marketing Fee (5% dari sub total)

Keterangan :
Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIB
Bila diluar hari dan jam kerja, maka tarif naik sebesar 12%
Bila terdapat penyulit, maka tarif di atas tidak berlaku
Tarif meliputi sewa kamar pasien dan bayi,obat-obatan sesuai standar RS
Obat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk didalam paket tarif

BREAK DOWN TARIF SECTIO CAESAREA

KODE

JENIS PELAYANAN
SECTIO CAESAREA (3 HARI 2 MALAM)
Sewa OK
Jasa Operator

TARIF
KELAS III

Share
Dokter

750,000
1,250,000

Rs.
750,000

1,250,000

Jasa Dokter Anestesi

500,000

500,000

Jasa Dokter Anak

Jasa Paramdis
Kamar Perawatan Ibu
Kamar Bayi ( 50% dari kamar Ibu )
Visite dr.SpOG
Visite dr.SpA

312,500
187,500
225,000
112,500
210,000
210,000

312,500
187,500
225,000
112,500
210,000
210,000

225,000
112,500
210,000
210,000

70,000

70,000

70,000

-Darah Lengkap
-Masa pendarahan
-Masa Pembekuan

50,000
20,000
20,000

50,000
20,000
20,000

50,000
20,000
20,000

-GDS
CTG
Anak:
-Golongan Darah
-Billirubin Neonatus

25,000
-

25,000
-

25,000
-

1,500,000

1,500,000

1,500,000

Visite dr.SpAn

Laboratorium
Ibu :

Farmasi ( Obat-obatan dan Alkes )

Jasa Service ( 10% dari kamar perawatan )

33,750

33,750

33,750

Subtotal

5,476,250

4,726,250

3,226,250

Adm ( 5% dari sub total )

Marketing fee ( 10% dari sub total )

TOTAL

273,813
547,625
6,297,688

236,313
472,625
5,435,188

161,313
322,625
3,710,188

USULAN TARIF

6,500,000

Keterangan :
Tarif diatas berlaku pada hari dan jam kerja, senin s/d jum'at,jam 08.00 s/d 21.00 WIB
Bila diluar hari dan jam kerja, maka tarif naik sebesar 12%
Tarif hanya berlaku untuk SC tanpa penyulit,non gemelli dll
Bila terdapat penyulit, maka tarif di atas tidak berlaku
Tarif meliputi sewa kamar pasien dan bayi,obat-obatan sesuai standar RS
Obat-obat yang diresepkan diluar paket dan yang dibawa pulang tidak termasuk0didalam paket tarif