Post on 06-Jul-2018
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LAMPIRAN 1.a. : USULAN PERDA TARIF RETRIBUSI PELAYANAN KE
NO PEMERIKSAAN & TINDAKAN MEDIK SATUANRETRIBUSI
A ADMINISTRASI MEDIK
1. Family Folder 1 set / KK Rp 1,00
2. Kartu Indeks Berobat 1 lbr Rp 50
3. Kartu status 1 lbr Rp 50
4. K! 1 lbr Rp 50
B. RAWAT JALAN
1 POLI UMUM
" #emeriksaan dasar $ %bat dasar 1 & Rp 3,00
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d.2. &o *i*i susu den*an ) 1 Bt* Rp 4,50
d.3. &o *i*i tetap 'nterior 1 Bt* Rp ,00
d.4. &o *i*i tetap #osterior 1 Bt* Rp +,00
d.5. &o Komplikasi 1 Bt* Rp 10,00
e.umpatan
e.1. umpatan !ementara 1 lb* Rp 3,00
e.2 umpatan etap
" 'mal*am
Kls I 1 lb* Rp ,00Kls II 1 lb* Rp 10,00
Kls 1 lb* Rp ,00
" 6lass Ionomer
Kls I 1 lb* Rp ,00
Kls II 1 lb* Rp 10,00
Kls III 1 lb* Rp ,00
Kls I 1 lb* Rp 10,00
Kls 7 1 lb* Rp ,00
" i*8t )ure
Kls I 1 lb* Rp 15,00
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9. #era:atan !aluran 'kar
9.1 %pen Bur
" *i*i anterior 1 & Rp 5,00
" *i*i posterior 1 & Rp ,00
9.2 &tirpasi, reamin*, ;llin*
" *i*i anterior 1 & Rp 10,00
" *i*i posterior 1 & Rp 15,00
9.3 6anti %bat 1 & Rp 5,00
9.4 #en*isian !aluran 'kar
" *i*i anterior 1 & Rp 10,00
" *i*i posterior 1 & Rp 15,00
" *i*i anterior 1 & Rp 12,00
" *i*i posterior 1 & Rp 1,00
*. #ulp )appin* 1 & Rp 5,00
8. Bon*kar ambalan #ermanen 1 lb* Rp 3,00
i. !allin*
i.1 1 ra8an* < R' / RB = 1 & Rp 15,00
C #en*isian !aluran 'kar Kon7ensional
C #en*isian !aluran 'kar den*an 3 mi&
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" kstraksi kuku 1 & Rp 10,00
" !irkumsisi de:asa 1 & Rp 25,00
" !irkumsisi anak 1 & Rp 25,00
" #emasan*an ransel 7rband 1 & Rp 10,00
" ksisi tumor 1 & Rp 10,00
" Inisi abes 1 & Rp 5,00
" Imobilisasi d* spalk 1 & Rp 10,00
" ksplorasi luka 1 & Rp 5,00
" #era:atan uka 1 & Rp 4,00
" -ebridement luka bakar @ 20D 1 & Rp 5,00
" -ebridement luka bakar A 20D 1 & Rp 10,00
" Reposisi andibula 1 & Rp 5,00
" Bilas ambun* 1 & Rp 5,00
" Rendan Bokon* 1 & Rp 2,00
" #asan* Kateter 1 & Rp 5,00
E. indakan Kepera:atan
" !untikan 1&/8ari 1 & Rp 50
" !untikan 2"5&/8ari 1 & Rp 1,00
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. indakan edis 'nastesi
" Resusitasi ?antun* paru
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d. pisiotomi
" 6rade I " III < Bidan = 1 & Rp 10,00
" 6rade I " III < -okter mum = 1 & Rp 15,00
" 6rade I " III < -okter !pesialis = 1 & Rp 20,00
" 6rade I < dokter !pesialis = 1 & Rp 25,00
e. ksplorasi a*ina
" Bidan 1 & Rp 15,00
" -okter mum 1 & Rp 20,00
" -okter !pesialis 1 & Rp 30,00
9. anual plasenta
" Bidan 1 & Rp 20,00
" -okter mum 1 & Rp 30,00
" -okter !pesialis 1 & Rp 40,00
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C PENUNJANG DIAGNOSTIK
1 E!"#$%!'()
a. Radiolo*i
" 8ora& #' 1 & Rp 10,00
" 'bdomen #' 1 & Rp 10,00
" #el7is '# 1 & Rp 10,00
" )la7iula < -/! = '# 1 & Rp 10,00
" aters open mout8 #' 1 & Rp 10,00
" op ordoti
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" anpa ;lm 1 & Rp 15,00
" -en*an ;lm 1 & Rp 15,00
2 La*%$a#%$(+
a. Gematolo*i " Gematokrit 1 & Rp 1,00
" Gb 1 & Rp 1,00
" euoyt 1 & Rp 1,00
" -iJ )ount / Gitun* enis 1 & Rp 2,00
" BB! / - 1 & Rp 2,00
" alaria 1 & Rp 1,00
" rytroyt 1 & Rp 1,00
" romboyt 1 & Rp 1,00
" Bloodin* ime 1& Rp 1,000
" )8lot8in* ime 1& Rp 1,000
" 6olon*an -ara8 1 & Rp 3,00
b. rine 'nalis
" #rotein 1 & Rp 1,00
" Reduksi 1 & Rp 1,00
" Bilirubin 1 & Rp 1,00
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. Faees
" akroskopis 1 & Rp 2,00
" ikroskopis 1 & Rp 2,00
d. ikrobilo*i " B' 1 & Rp 2,00
" !eret a*ina 1 & Rp 2,00
" K%G 1 & Rp 2,00
e. Kimia -ara8
" 6ula -ara8 1 & Rp 3,00
" )8olesterol 1 & Rp 3,00
" ri*liserid 1 & Rp 3,00
" ri 'id 1 & Rp 3,00
9. !erolo*i
" -en*ue est 1 & Rp 5,00
#emeriksaan )yto / -iluar ?am ker?a tari9 ditamba8
25D & tari9 dasar
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3 #emeriksaan edial )alon Karya:an
a. #emeriksaan medial standar 1 & Rp 32,00
b. aboratorium b.1 -ara8
" Gitun* enis 1 & Rp 2,00
" a?u ndap -ara8 1 & Rp 2,00
" Bloodin* ime
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4 #emeriksaan edial )alon amaa8 Ga?i
a. 'namnese > pemeriksaan ;sik, ?i:a > Bart8el inde& 1 & Rp 5,00
b. #emeriksaan penun?an*
b.1 aboratorium " -ara8
1 & Rp 1,00
1 & Rp 2,00
1 & Rp 1,00
1 & Rp 3,00
1 & Rp 3,00
1 & Rp 3,00
" rine
1 & Rp 2,00
1 & Rp 4,00
1 & Rp 1,00
1 & Rp 5,00
b.2 K6 1 & Rp 5,00
b.3 Radiolo*i
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G RAWAT INAP
1 K!a- U#aa
1 8r Rp 5,00
" -okter spesialis 1 8r Rp
" -okter mum / 6i*i 1 8r Rp
C isit -okter Ra:at 6abun*
" -okter spesialis 1 8r Rp
" -okter mum / 6i*i 1 8r Rp
C )yto konsul
" -okter spesialis 1 & Rp
" -okter mum / 6i*i 1 & Rp
2 K!a- I
1 8r Rp 40,00
" -okter spesialis 1 8r Rp
" -okter mum / 6i*i 1 8r Rp
C isit -okter Ra:at 6abun*
" -okter spesialis 1 8r Rp
C 'komodasi
C isit -okter
C 'komodasi
C isit -okter
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EHATAN MEDIS DI PUSKESMAS
TARIF
JASA PELAYANAN
TOTAL JASA MEDIS JUMLAH
Rp 1,000 Rp +,000 Rp ,000 Rp 10,000
Rp " Rp 3,500 Rp 3,500 Rp 4,000
Rp " Rp 500 Rp 500 Rp 1,000
Rp " Rp 4,500 Rp 4,500 Rp 5,000
Rp 5,000 Rp 2,000 Rp ,000 Rp 10,000
BAHAN HABIS
PAKAI/SARANA
PRASARANA
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Rp 4,500 Rp 3,000 Rp ,500 Rp 12,000
Rp 10,000 Rp E,000 Rp 1E,000 Rp 23,000
Rp 11,000 Rp ,000 Rp 1+,000 Rp 2E,000
Rp 15,000 Rp 10,000 Rp 25,000 Rp 35,000
Rp 2,000 Rp 5,000 Rp ,000 Rp 10,000
Rp 14,000 Rp ,000 Rp 23,000 Rp 30,000
Rp 15,000 Rp 10,000 Rp 25,000 Rp 35,000
Rp 14,000 Rp ,000 Rp 23,000 Rp 30,000
Rp 1,000 Rp 11,000 Rp 2+,000 Rp 35,000
Rp 1+,000 Rp 12,000 Rp 30,000 Rp 40,000
Rp 1,000 Rp 11,000 Rp 2+,000 Rp 35,000
Rp 1+,000 Rp 12,000 Rp 30,000 Rp 40,000
Rp 1,000 Rp 11,000 Rp 2+,000 Rp 35,000
Rp 2,000 Rp 1+,000 Rp 45,000 Rp E0,000
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Rp ,000 Rp E,000 Rp 15,000 Rp 20,000
Rp 11,000 Rp ,000 Rp 1+,000 Rp 25,000
Rp 12,000 Rp +,000 Rp 20,000 Rp 30,000
Rp 15,000 Rp 10,000 Rp 25,000 Rp 40,000
Rp E,000 Rp 4,000 Rp 10,000 Rp 15,000
Rp 12,000 Rp +,000 Rp 20,000 Rp 30,000
Rp 15,000 Rp 10,000 Rp 25,000 Rp 40,000
Rp 14,000 Rp ,000 Rp 23,000 Rp 35,000
Rp 1,000 Rp 11,000 Rp 2+,000 Rp 45,000
Rp ,000 Rp E,000 Rp 15,000 Rp 20,000
Rp ,000 Rp 5,000 Rp 12,000 Rp 15,000
Rp 2,000 Rp 1+,000 Rp 45,000 Rp E0,000
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Rp 25,000 Rp 15,000 Rp 40,000 Rp 50,000
Rp 250,000 Rp 5,000 Rp 325,000 Rp 350,000
Rp 200,000 Rp 5,000 Rp 25,000 Rp 300,000
Rp 30,000 Rp 10,000 Rp 40,000 Rp 50,000Rp 35,000 Rp 15,000 Rp 50,000 Rp E0,000
Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000
Rp 15,000 Rp 15,000 Rp 30,000 Rp 40,000
Rp 15,000 Rp 10,000 Rp 25,000 Rp 30,000
Rp +,000 Rp +,000 Rp 1E,000 Rp 20,000
Rp 15,000 Rp 15,000 Rp 30,000 Rp 35,000
Rp 20,000 Rp 20,000 Rp 40,000 Rp 50,000
Rp 25,000 Rp 15,000 Rp 40,000 Rp 45,000
Rp 25,000 Rp 10,000 Rp 35,000 Rp 40,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000
Rp 1,500 Rp 1,000 Rp 2,500 Rp 3,000
Rp 2,500 Rp 1,500 Rp 4,000 Rp 5,000
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Rp 40,000 Rp 10,000 Rp 50,000 Rp E0,000
Rp 15,000 Rp 10,000 Rp 25,000 Rp 30,000
Rp 12,500 Rp 10,000 Rp 22,500 Rp 30,000
Rp 10,000 Rp 5,000 Rp 15,000 Rp 20,000
Rp 2,500 Rp 5,000 Rp ,500 Rp 10,000
Rp ,500 Rp ,500 Rp 15,000 Rp 20,000
Rp 5,000 Rp 10,000 Rp 15,000 Rp 20,000
Rp 15,000 Rp 10,000 Rp 25,000 Rp 30,000
Rp ,500 Rp ,500 Rp 15,000 Rp 20,000
Rp 12,500 Rp 12,500 Rp 25,000 Rp 30,000
Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000
Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000
Rp 10,000 Rp 10,000 Rp 20,000 Rp 25,000
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Rp 30,000 Rp 10,000 Rp 40,000 Rp 50,000
Rp 45,000 Rp 15,000 Rp E0,000 Rp 5,000Rp E0,000 Rp 20,000 Rp +0,000 Rp 100,000
Rp 150,000 Rp 25,000 Rp 15,000 Rp 200,000
Rp 50,000 Rp 10,000 Rp E0,000 Rp 5,000
Rp E5,000 Rp 15,000 Rp +0,000 Rp 100,000
Rp 150,000 Rp 25,000 Rp 15,000 Rp 205,000
Rp 110,000 Rp 20,000 Rp 130,000 Rp 150,000
Rp 10,000 Rp 30,000 Rp 220,000 Rp 250,000
Rp 20,000 Rp 40,000 Rp 310,000 Rp 350,000
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Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 15,000 Rp 25,000 Rp 40,000 Rp 50,000
Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000
Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000
Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000
Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000
Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000
Rp 20,000 Rp 35,000 Rp 55,000 Rp 0,000
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Rp 20,000 Rp 15,000 Rp 35,000 Rp 50,000
Rp 25,000 Rp 20,000 Rp 45,000 Rp E0,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 5,000 Rp 12,000 Rp 1,000 Rp 20,000
Rp 2,000 Rp 1,500 Rp 3,500 Rp 4,500
Rp 2,000 Rp 1,500 Rp 3,500 Rp 4,500
Rp 2,000 Rp 1,500 Rp 3,500 Rp 4,500
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Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 10,000 Rp 3,000 Rp 13,000 Rp 15,000
Rp 10,000 Rp 3,000 Rp 13,000 Rp 15,000
Rp 10,000 Rp 3,000 Rp 13,000 Rp 15,000
Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000
Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000
Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000
Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000
Rp 5,000 Rp 25,000 Rp 30,000 Rp 35,000
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Rp 42,000 Rp E0,500 Rp 102,500 Rp 134,500
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 4,000 Rp E,000 Rp 10,000 Rp 14,000
Rp 10,000 Rp 40,000 Rp 50,000 Rp E0,000
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Rp 30,000 Rp 15,000 Rp 45,000 Rp 50,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 5,000 Rp 12,000 Rp 1,000 Rp 20,000
Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000
Rp 4,000 Rp 23,000 Rp 2,000 Rp 30,000
Rp 5,000 Rp 3,000 Rp +,000 Rp 10,000
Rp 4,000 Rp E,000 Rp 10,000 Rp 14,000
Rp 2,000 Rp 1,000 Rp 3,000 Rp 4,000
Rp 3,000 Rp 12,000 Rp 15,000 Rp 20,000
Rp 15,000 Rp 15,000 Rp 30,000 Rp 35,000
Rp 10,000 Rp 30,000 Rp 40,000 Rp 55,000
Rp 5,000 Rp ,000 Rp 12,000 Rp 14,000
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Rp 5,000 Rp 100,000 Rp 15,000 Rp 250,000
Rp 44,000 Rp 2E,000 Rp 0,000 Rp 0,000
Rp 3+,000 Rp 22,000 Rp E0,000 Rp E0,000
Rp 52,000 Rp 3+,000 Rp 0,000 Rp 0,000
Rp 3,000 Rp 2+,000 Rp E5,000 Rp E5,000
Rp 100,000 Rp " Rp 100,000 Rp 100,000
Rp 45,000 Rp " Rp 45,000 Rp 45,000
Rp 40,000 Rp 0,000 Rp 110,000 Rp 150,000
Rp 40,000 Rp 25,000 Rp E5,000 Rp E5,000
Rp 32,000 Rp 1+,000 Rp 50,000 Rp 50,000
Rp 4E,000 Rp 24,000 Rp 0,000 Rp 0,000
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USULAN TARIF PELAYANAN KESEHATAN MASYARAKAT UMUM
PPK,BLUD UPT PUSKESMAS TELUK SEBONG TH.211
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
A ADMINISTRASI MEDIK
1. Family Folder 1 set / KK Rp 1,000 Rp 1,000 Rp +,000
2. Kartu Indeks Berobat 1 lbr Rp 500 Rp " Rp 3,500
3. Kartu status 1 lbr Rp 500 Rp " Rp 500
4. K! 1 lbr Rp 500 Rp " Rp 4,500
B. RAWAT JALAN
1 POLI UMUM
" #emeriksaan dasar $ %bat dasar 1 & Rp E,000 Rp 10,000 Rp 4,000
2 POLI SPESIALIS
" #emeriksaan $ %bat dasar 1 & Rp 10,000 Rp 50,000 Rp 20,000
3 POLI KEBIDANAN
" '() 1 & Rp E,000 Rp 10,000 Rp 4,000
PENDAPATAN
BLUDBAHAN HABIS
PAKAI/SARANA
PRASARANA
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NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" #enimban*an Bayi 1 & Rp 1,000 Rp " Rp 1,000
" !untik KB 1 bulan 1 & Rp 1E,000 Rp +,000 Rp 1E,000
" !untik KB 3 bulan 1 & Rp 10,000 Rp +,000 Rp 12,000
" #asan* Implant 1 & Rp 30,000 Rp 50,000 Rp E0,000
" Buka Implant 1 & Rp 30,000 Rp 50,000 Rp E0,000
" Buka #asan* Implant 1 & Rp 40,000 Rp +0,000 Rp +0,000
" #asan* I- 1 & Rp 1+,000 Rp 30,000 Rp 22,000
" Buka I- 1 & Rp 1+,000 Rp 30,000 Rp 22,000
" Buka #asan* I- 1 & Rp 30,000 Rp E0,000 Rp 30,000
" Imunisasi ! 1 & Rp 4,000 Rp +,000 Rp 1+,000
" Imunisasi )aten 1 &
" !untik Rp 4,000 Rp +,000 Rp 1+,000
" #re* est Rp 10,000 Rp E,000 Rp 24,000
" !urat Keteran*an Rp 4,000 Rp 4,000 Rp 12,000
Rp 1+,000 Rp 1+,000 Rp 54,000
4 TINDAKAN MEDIK
4.1 POLI GIGI
a. #emeriksaan dan obat dasar 1 & Rp E,000 Rp 10,000 Rp 4,000
b. Konsultasi 1 & Rp 1,000 Rp ,000 Rp 2,000
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NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
. !pulin* Betadine 1 & Rp 4,000 Rp 4,000 Rp 2,000
d. &tratri
d.1. &o *i*i susu den*an ido 1 Bt* Rp 10,000 Rp 1E,000 Rp 10,000
d.2. &o *i*i susu den*an ) 1 Bt* Rp ,000 Rp ,000 Rp E,000
d.3. &o *i*i tetap 'nterior 1 Bt* Rp 14,000 Rp 20,000 Rp 12,000
d.4. &o *i*i tetap #osterior 1 Bt* Rp 1E,000 Rp 22,000 Rp 14,000
d.5. &o Komplikasi 1 Bt* Rp 20,000 Rp 30,000 Rp 20,000
e.umpatan
e.1. umpatan !ementara 1 lb* Rp E,000 Rp 4,000 Rp 10,000
e.2 umpatan etap
" 'mal*am
Kls I 1 lb* Rp 14,000 Rp 2+,000 Rp 1+,000
Kls II 1 lb* Rp 20,000 Rp 30,000 Rp 20,000
Kls 1 lb* Rp 14,000 Rp 2+,000 Rp 1+,000
" 6lass Ionomer
Kls I 1 lb* Rp 14,000 Rp 34,000 Rp 22,000
Kls II 1 lb* Rp 20,000 Rp 3E,000 Rp 24,000
Kls III 1 lb* Rp 14,000 Rp 34,000 Rp 22,000
Kls I 1 lb* Rp 20,000 Rp 3E,000 Rp 24,000
Kls 7 1 lb* Rp 14,000 Rp 34,000 Rp 22,000
" i*8t )ure
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NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
Kls I 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000
Kls II 1 lb* Rp 40,000 Rp EE,000 Rp 44,000
Kls III 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000
Kls I 1 lb* Rp 40,000 Rp EE,000 Rp 44,000
Kls 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000
9. #era:atan !aluran 'kar
9.1 %pen Bur
" *i*i anterior 1 & Rp 10,000 Rp 1+,000 Rp 12,000
" *i*i posterior 1 & Rp 14,000 Rp 22,000 Rp 14,000
9.2 &tirpasi, reamin*, ;llin*
" *i*i anterior 1 & Rp 20,000 Rp 24,000 Rp 1E,000
" *i*i posterior 1 & Rp 30,000 Rp 30,000 Rp 20,000
9.3 6anti %bat 1 & Rp 10,000 Rp 12,000 Rp +,000
9.4 #en*isian !aluran 'kar
" *i*i anterior 1 & Rp 20,000 Rp 24,000 Rp 1E,000
" *i*i posterior 1 & Rp 30,000 Rp 30,000 Rp 20,000
" *i*i anterior 1 & Rp 24,000 Rp 2+,000 Rp 1+,000
" *i*i posterior 1 & Rp 34,000 Rp 34,000 Rp 22,000
*. #ulp )appin* 1 & Rp 10,000 Rp 1+,000 Rp 12,000
C #en*isian !aluran 'kar Kon7ensional
C #en*isian !aluran 'kar den*an 3 mi&
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NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
8. Bon*kar ambalan #ermanen 1 lb* Rp E,000 Rp 14,000 Rp 10,000
i. !allin*
i.1 1 ra8an* < R' / RB = 1 & Rp 30,000 Rp 54,000 Rp 3E,000
i.2 2 ra8an* < R' > RB = 1 & Rp E0,000 Rp 10+,000 Rp 2,000
?. Inisi 'bses
?.1 Intra %ral 1 & Rp 10,000 Rp 30,000 Rp 20,000
?.2 &tra %ral 1 & Rp 20,000 Rp 42,000 Rp 2+,000
k. perulektomi 1 re* Rp 30,000 Rp 54,000 Rp 3E,000
l. 'l7eolektomi 1 re* Rp 40,000 Rp 2,000 Rp 4+,000
m.%dontektomi 1 bt* Rp +0,000 Rp 240,000 Rp +0,000
n. Kontrol pasa beda8 1 & Rp E,000 Rp ,000 Rp 5,000
o. Buka ?a8itan 1 & Rp E,000 Rp ,000 Rp 5,000
4.2 UNIT GAWAT DARURAT
1. #emeriksaan dokter umum $ administrasi 1 & Rp 4,000 Rp 20,000 Rp E,000
2. #emeriksaan dokter *i*i $ administrasi 1 & Rp 4,000 Rp 20,000 Rp E,000
3. #emeriksaan dokter spesialis $ administrasi 1 & Rp 10,000 Rp 40,000 Rp 10,000
4. indakan edik 'nak
" Imunisasi 1 & Rp 10,000 Rp +,000 Rp 22,000
" antau& est 1 & Rp 20,000 Rp 40,000 Rp 1+0,000
" Resusitasi 1 & Rp 20,000 Rp 40,000 Rp 30,000
8/17/2019 Usulan Tarif Blud
30/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" !irumsisi bayi perempuan 1 & Rp 10,000 Rp 30,000 Rp 20,000
" indik 1 & Rp 10,000 Rp 30,000 Rp 20,000
5. indakan edik beda8
" 6anti balutan @ 10 m 1 & Rp 10,000 Rp 10,000 Rp 10,000
" 6anti balutan A 10 m 1 & Rp 1E,000 Rp 14,000 Rp 10,000
" a8it luka
5 ?a8itan pertama 1 & Rp 10,000 Rp 30,000 Rp 20,000
!elan?utnya pen?a8itan 1 & Rp 2,000 Rp 2,000 Rp 2,000
" Buka ?a8itan @ 5 ?a8itan 1 & Rp 5,000 Rp 15,000 Rp 10,000
!elan?utnya pen?a8itan 1 & Rp 1,000 Rp 1,000 Rp 1,000
" kstraksi kuku 1 & Rp 20,000 Rp 50,000 Rp 30,000
" !irkumsisi de:asa 1 & Rp 50,000 Rp 500,000 Rp 150,000
" !irkumsisi anak 1 & Rp 50,000 Rp 400,000 Rp 150,000
" #emasan*an ransel 7rband 1 & Rp 20,000 Rp E0,000 Rp 20,000
" ksisi tumor 1 & Rp 20,000 Rp 0,000 Rp 30,000
" Inisi abes 1 & Rp 10,000 Rp 20,000 Rp 20,000
" Imobilisasi d* spalk 1 & Rp 20,000 Rp 30,000 Rp 30,000
" ksplorasi luka 1 & Rp 10,000 Rp 30,000 Rp 20,000
" #era:atan uka 1 & Rp +,000 Rp 1E,000 Rp 1E,000
" -ebridement luka bakar @ 20D 1 & Rp 10,000 Rp 30,000 Rp 30,000
8/17/2019 Usulan Tarif Blud
31/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" -ebridement luka bakar A 20D 1 & Rp 20,000 Rp 40,000 Rp 40,000
" Reposisi andibula 1 & Rp 10,000 Rp 50,000 Rp 30,000
" Bilas ambun* 1 & Rp 10,000 Rp 50,000 Rp 20,000
" Rendan Bokon* 1 & Rp 4,000 Rp 10,000 Rp E,000
" #asan* Kateter 1 & Rp 10,000 Rp 20,000 Rp 20,000
E. indakan Kepera:atan
" !untikan 1&/8ari 1 & Rp 1,000 Rp 3,000 Rp 2,000
" !untikan 2"5&/8ari 1 & Rp 2,000 Rp 5,000 Rp 3,000
" #en*ambilan sampel dara8 1 & Rp 1,000 Rp 5,000 Rp 4,000
" #emasan*an In9us 1 & Rp 20,000 Rp 3E,000 Rp 24,000
" #enabutan In9us 1 & Rp 2,000 Rp E,000 Rp 2,000
" Klisma 1 & Rp 5,000 Rp 15,000 Rp 10,000
" !ution/8ari 1 & Rp 10,000 Rp 30,000 Rp 20,000
" #emasan*an (6 1 & Rp 20,000 Rp 50,000 Rp 30,000
. indakan edis 'nastesi
" Resusitasi ?antun* paru
8/17/2019 Usulan Tarif Blud
32/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" est is8i8ara 1 & Rp 5,000 Rp 5,000 Rp 10,000
" 6anti erband mata 1 & Rp 10,000 Rp 15,000 Rp 15,000
. indakan edik #aru
" In8alasi/(ebulier 1 & Rp 10,000 Rp 10,000 Rp 20,000
10. indakan edik G
" kstraksi serumen 1 & Rp 10,000 Rp 30,000 Rp 20,000
" ampon telin*a 1 & Rp 10,000 Rp 15,000 Rp 15,000
" kstraksi orpus alienum di telin*a 1 & Rp 10,000 Rp 25,000 Rp 25,000
" #asan* tampon anterior 1 & Rp 10,000 Rp 20,000 Rp 20,000
" )abut tampon anterior 1 & Rp 10,000 Rp 20,000 Rp 20,000
" #asan* tampon posterior 1 & Rp 10,000 Rp 20,000 Rp 20,000
" )abut tampon posterior 1 & Rp 10,000 Rp 20,000 Rp 20,000
" BeloH tampon 1 & Rp 10,000 Rp 20,000 Rp 20,000
" kstraksi orpus alienum di 8idun* 1 & Rp 10,000 Rp 30,000 Rp 20,000
" indik
8/17/2019 Usulan Tarif Blud
33/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" #apiloma 1 & Rp 30,000 Rp 0,000 Rp 50,000
" ar7a mi*ran 1 & Rp 10,000 Rp 20,000 Rp 10,000
12. Keraunan 1 & Rp 20,000 Rp 40,000 Rp E0,000
13. -i*i*it Binatan* 1 & Rp 10,000 Rp 30,000 Rp 20,000
4.3 TINDAKAN KEBIDANAN
a. #artus normal
" Bidan 1 & Rp 100,000 Rp 300,000 Rp 100,000
" -okter mum 1 & Rp 100,000 Rp 500,000 Rp 200,000
" -okter !pesialis 1 & Rp 100,000 Rp +00,000 Rp 300,000
b. #artus den*an induksi
" Bidan 1 & Rp 150,000 Rp 350,000 Rp 100,000
" -okter mum 1 & Rp 150,000 Rp 550,000 Rp 200,000
" -okter !pesialis 1 & Rp 150,000 Rp 1,000,000 Rp 250,000
. #artus den*an penyulit
" Bidan 1 & Rp 200,000 Rp 400,000 Rp 200,000
" -okter mum 1 & Rp 200,000 Rp E00,000 Rp 200,000
" -okter !pesialis 1 & Rp 200,000 Rp 1,200,000 Rp 200,000
8/17/2019 Usulan Tarif Blud
34/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
d. pisiotomi
" 6rade I " III < Bidan = 1 & Rp 20,000 Rp E0,000 Rp 20,000
" 6rade I " III < -okter mum = 1 & Rp 30,000 Rp 0,000 Rp 30,000
" 6rade I " III < -okter !pesialis = 1 & Rp 40,000 Rp 120,000 Rp 40,000
" 6rade I < dokter !pesialis = 1 & Rp 50,000 Rp 300,000 Rp 50,000
e. ksplorasi a*ina
" Bidan 1 & Rp 30,000 Rp 100,000 Rp 20,000
" -okter mum 1 & Rp 40,000 Rp 130,000 Rp 30,000
" -okter !pesialis 1 & Rp E0,000 Rp 300,000 Rp 50,000
9. anual plasenta
" Bidan 1 & Rp 40,000 Rp 220,000 Rp 40,000
" -okter mum 1 & Rp E0,000 Rp 3+0,000 Rp E0,000
" -okter !pesialis 1 & Rp +0,000 Rp 540,000 Rp +0,000
C PENUNJANG DIAGNOSTIK
1 E!"#$%!'()
a. Radiolo*i
" 8ora& #' 1 & Rp 20,000 Rp 30,000 Rp 50,000
C 1 posisi 1 ;lm
8/17/2019 Usulan Tarif Blud
35/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" 'bdomen #' 1 & Rp 20,000 Rp 30,000 Rp 50,000
" #el7is '# 1 & Rp 20,000 Rp 30,000 Rp 50,000
" )la7iula < -/! = '# 1 & Rp 20,000 Rp 30,000 Rp 50,000
" aters open mout8 #' 1 & Rp 20,000 Rp 30,000 Rp 50,000
" op ordoti
8/17/2019 Usulan Tarif Blud
36/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" !inus :aters open mout8 " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" open " lose mout8 1 & Rp 40,000 Rp 50,000 Rp 100,000" %s Gumerus '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" ert t8orao lumbal '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" ert lumbal '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" umbo saral '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" !arum '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" )oy& '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" Gip '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" Femur '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000" )ruris '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" #edis '# " ateral 1 & Rp 40,000 Rp 50,000 Rp 100,000
" 'bdomen 3 posisi 1 & Rp E0,000 Rp E0,000 Rp 240,000
" )er7ial '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000
" 8orao umbal '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000
" 8oraal '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000
" umbal '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000
" umbo " !aral '#/ateral/%bliH kanan " kiri 1 & Rp E0,000 Rp E0,000 Rp 240,000
1 & Rp 10,000 Rp 10,000 Rp 30,000
. letroardio*ra; 1 & Rp 10,000 Rp 30,000 Rp 30,000
C 3 " 4 posisi 3 " 4 ;lm
C Intra %ral
8/17/2019 Usulan Tarif Blud
37/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
d. !6
" anpa ;lm 1 & Rp 30,000 Rp 40,000 Rp 30,000
" -en*an ;lm 1 & Rp 30,000 Rp 50,000 Rp 40,000
2 La*%$a#%$(+
a. Gematolo*i
" Gematokrit 1 & Rp 2,000 Rp 4,000 Rp 2,000
" Gb 1 & Rp 2,000 Rp 4,000 Rp 2,000
" euoyt 1 & Rp 2,000 Rp 4,000 Rp 2,000
" -iJ )ount / Gitun* enis 1 & Rp 4,000 Rp 10,000 Rp E,000
" BB! / - 1 & Rp 4,000 Rp 10,000 Rp E,000
" alaria 1 & Rp 2,000 Rp 4,000 Rp 2,000
" rytroyt 1 & Rp 2,000 Rp 4,000 Rp 2,000
" romboyt 1 & Rp 2,000 Rp 4,000 Rp 2,000
" Bloodin* ime 1& Rp 2 Rp 4,000 Rp 2,000
" )8lot8in* ime 1& Rp 2 Rp 4,000 Rp 2,000
" 6olon*an -ara8 1 & Rp E,000 Rp 10,000 Rp 24,000
b. rine 'nalis
" #rotein 1 & Rp 2,000 Rp 4,000 Rp 3,000
" Reduksi 1 & Rp 2,000 Rp 4,000 Rp 3,000
" Bilirubin 1 & Rp 2,000 Rp 4,000 Rp 3,000
" !edimen 1 & Rp 2,000 Rp 4,000 Rp 3,000
8/17/2019 Usulan Tarif Blud
38/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" #re* est 1 & Rp 10,000 Rp E,000 Rp 24,000
" or;n 1 & Rp E,000 Rp 20,000 Rp 4,000
" G) / 6an?a 1 & Rp E,000 Rp 20,000 Rp 4,000
" 'm9etamine 1 & Rp E,000 Rp 20,000 Rp 4,000
" )oaine 1 & Rp E,000 Rp 20,000 Rp 4,000
" Benodiaepin 1 & Rp E,000 Rp 20,000 Rp 4,000
" %pium 1 & Rp E,000 Rp 20,000 Rp 4,000
. Faees
" akroskopis 1 & Rp 4,000 Rp 10,000 Rp E,000
" ikroskopis 1 & Rp 4,000 Rp 10,000 Rp E,000
d. ikrobilo*i
" B' 1 & Rp 4,000 Rp 20,000 Rp E,000
" !eret a*ina 1 & Rp 4,000 Rp 20,000 Rp E,000
" K%G 1 & Rp 4,000 Rp 20,000 Rp E,000
e. Kimia -ara8
" 6ula -ara8 1 & Rp E,000 Rp +,000 Rp 4E,000
" )8olesterol 1 & Rp E,000 Rp +,000 Rp 4E,000
" ri*liserid 1 & Rp E,000 Rp +,000 Rp 4E,000
" ri 'id 1 & Rp E,000 Rp +,000 Rp 4E,000
8/17/2019 Usulan Tarif Blud
39/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
9. !erolo*i
" -en*ue est 1 & Rp 10,000 Rp 10,000 Rp 50,000
#emeriksaan )yto / -iluar ?am ker?a tari9 ditamba8
25D & tari9 dasar
D PELAYANAN MEDICOLEGAL
1 #emberian 9ormalin 1 & Rp 200,000 Rp 1,000,000 Rp +00,000
E MEDICAL CHECK UP
1 KIR Kese8atan Biasa
a. 'namnese > #emeriksaan Fisik
" #oli mum 1 & Rp E,000 Rp 10,000 Rp 4,000
" #oli 6i*i 1 & Rp 1,000 Rp ,000 Rp 2,000
b. aboratorium
" -ara8 rutin
8/17/2019 Usulan Tarif Blud
40/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
2 #emeriksaan edial !tandar
a. 'namnese > #emeriksaan Fisik " #oli mum 1 & Rp E,000 Rp 10,000 Rp 4,000
" #oli 6i*i 1 & Rp 1,000 Rp ,000 Rp 2,000
b. #emeriksaan isus 1 & Rp 2,000 Rp E,000 Rp 2,000
. #emeriksaan Buta arna 1 & Rp 1,000 Rp 3,000 Rp 2,000
d. 8ora& 9oto 1 & Rp 30,000 Rp 20,000 Rp E0,000
e.aboratorium
" -ara8 rutin 1 & Rp E,000 Rp 12,000 Rp E,000
" rin rutin 1 & Rp +,000 Rp 12,000 Rp ,000
" 6olon*an dara8 1 & Rp E,000 Rp 10,000 Rp 24,000
9. !urat keteran*an / administrasi 1 & Rp 4,000 Rp 4,000 Rp 12,000
Rp E4,000 Rp +4,000 Rp 121,000
3 #emeriksaan edial )alon Karya:an
a. #emeriksaan medial standar 1 & Rp E4,000 Rp +4,000 Rp 121,000
b. aboratorium
b.1 -ara8
" Gitun* enis 1 & Rp 4,000 Rp 10,000 Rp E,000
" a?u ndap -ara8 1 & Rp 4,000 Rp 10,000 Rp E,000
" Bloodin* ime
8/17/2019 Usulan Tarif Blud
41/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" )8lot8in* ime
8/17/2019 Usulan Tarif Blud
42/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" -ara8
1 & Rp 2,000 Rp 4,000 Rp 2,0001 & Rp 4,000 Rp 10,000 Rp E,000
1 & Rp 2,000 Rp 4,000 Rp 2,000
1 & Rp E,000 Rp 10,000 Rp 24,000
1 & Rp E,000 Rp +,000 Rp 4E,000
1 & Rp E,000 Rp +,000 Rp 4E,000
" rine
1 & Rp 4,000 Rp 10,000 Rp E,000
1 & Rp +,000 Rp +,000 Rp 12,000
1 & Rp 2,000 Rp 4,000 Rp 2,000
1 & Rp 10,000 Rp E,000 Rp 24,000
b.2 K6 1 & Rp 10,000 Rp 30,000 Rp 30,000
b.3 Radiolo*i
8/17/2019 Usulan Tarif Blud
43/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
F LAIN , LAIN
1 !urat Keteran*an
" Kela8iran 1 & Rp E,000 Rp E,000 Rp 1+,000
" !akit 1 & Rp 2,000 Rp 3,000 Rp 5,000
" -ira:at 1 & Rp 4,000 Rp E,000 Rp 10,000
" aik (aik #esa:at 1 & Rp 4,000 Rp E,000 Rp 10,000
" Kematian 1 & Rp 4,000 Rp E,000 Rp 10,000
2 'mbulane
1 & Rp 1E,000 Rp 34,000 Rp 30,000
!elebi8nya/km 1 & Rp 2,000 Rp 2,400 Rp 2,E00
" uar #ulau
" belum termasuk biaya penyebran*an
" 2& tari9 dalam pulau
3 asa #etu*as #endampin* Ru?ukan
" -okter 1 &
Rp 10,000 Rp 50,000 Rp "
C !elebi8nya / km Rp 2,000 Rp 5,000 Rp "
C uar pulau
8/17/2019 Usulan Tarif Blud
44/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" #era:at / Bidan 1 &
Rp 3,000 Rp 12,000 Rp "
C !elebi8nya / km Rp 500 Rp 1,000 Rp "
C uar pulau
8/17/2019 Usulan Tarif Blud
45/142
TOTAL JUMLAH
Rp ,000 Rp 10,000
Rp 3,500 Rp 4,000
Rp 500 Rp 1,000
Rp 4,500 Rp 5,000
Rp 14,000 Rp 20,000
Rp 0,000 Rp +0,000
Rp 14,000 Rp 20,000
8/17/2019 Usulan Tarif Blud
46/142
TOTAL JUMLAH
Rp 1,000 Rp 2,000
Rp 24,000 Rp 40,000Rp 20,000 Rp 30,000
Rp 110,000 Rp 140,000
Rp 110,000 Rp 140,000
Rp 1E0,000 Rp 200,000
Rp 52,000 Rp 0,000
Rp 52,000 Rp 0,000
Rp 0,000 Rp 120,000
Rp 2E,000 Rp 30,000
Rp 2E,000 Rp 30,000
Rp 30,000 Rp 40,000
Rp 1E,000 Rp 20,000
Rp 2,000 Rp 0,000
Rp 14,000 Rp 20,000
Rp ,000 Rp 10,000
8/17/2019 Usulan Tarif Blud
47/142
TOTAL JUMLAH
Rp E,000 Rp 10,000
Rp 2E,000 Rp 3E,000
Rp 15,000 Rp 24,000
Rp 32,000 Rp 4E,000
Rp 3E,000 Rp 52,000
Rp 50,000 Rp 0,000
Rp 14,000 Rp 20,000
Rp 4E,000 Rp E0,000
Rp 50,000 Rp 0,000
Rp 4E,000 Rp E0,000
Rp 5E,000 Rp 0,000
Rp E0,000 Rp +0,000
Rp 5E,000 Rp 0,000
Rp E0,000 Rp +0,000
Rp 5E,000 Rp 0,000
8/17/2019 Usulan Tarif Blud
48/142
TOTAL JUMLAH
Rp 0,000 Rp 120,000
Rp 110,000 Rp 150,000Rp 0,000 Rp 120,000
Rp 110,000 Rp 150,000
Rp 0,000 Rp 120,000
Rp 30,000 Rp 40,000
Rp 3E,000 Rp 50,000
Rp 40,000 Rp E0,000
Rp 50,000 Rp +0,000
Rp 20,000 Rp 30,000
Rp 40,000 Rp E0,000
Rp 50,000 Rp +0,000
Rp 4E,000 Rp 0,000
Rp 5E,000 Rp 0,000
Rp 30,000 Rp 40,000
8/17/2019 Usulan Tarif Blud
49/142
TOTAL JUMLAH
Rp 24,000 Rp 30,000
Rp 0,000 Rp 120,000
Rp 1+0,000 Rp 240,000
Rp 50,000 Rp E0,000
Rp 0,000 Rp 0,000
Rp 0,000 Rp 120,000
Rp 120,000 Rp 1E0,000
Rp 320,000 Rp 400,000Rp 14,000 Rp 20,000
Rp 14,000 Rp 20,000
Rp 2E,000 Rp 30,000
Rp 2E,000 Rp 30,000
Rp 50,000 Rp E0,000
Rp 30,000 Rp 40,000
Rp 220,000 Rp 240,000
Rp 0,000 Rp 0,000
8/17/2019 Usulan Tarif Blud
50/142
TOTAL JUMLAH
Rp 50,000 Rp E0,000
Rp 50,000 Rp E0,000
Rp 20,000 Rp 30,000
Rp 24,000 Rp 40,000
Rp 50,000 Rp E0,000
Rp 4,000 Rp E,000
Rp 25,000 Rp 30,000Rp 2,000 Rp 3,000
Rp +0,000 Rp 100,000
Rp E50,000 Rp 00,000
Rp 550,000 Rp E00,000
Rp +0,000 Rp 100,000
Rp 100,000 Rp 120,000
Rp 40,000 Rp 50,000
Rp E0,000 Rp +0,000Rp 50,000 Rp E0,000
Rp 32,000 Rp 40,000
Rp E0,000 Rp 0,000
8/17/2019 Usulan Tarif Blud
51/142
TOTAL JUMLAH
Rp +0,000 Rp 100,000
Rp +0,000 Rp 0,000Rp 0,000 Rp +0,000
Rp 1E,000 Rp 20,000
Rp 40,000 Rp 50,000
Rp 5,000 Rp E,000
Rp +,000 Rp 10,000
Rp ,000 Rp 10,000Rp E0,000 Rp +0,000
Rp +,000 Rp 10,000
Rp 25,000 Rp 30,000
Rp 50,000 Rp E0,000
Rp +0,000 Rp 100,000
Rp 100,000 Rp 120,000
Rp 50,000 Rp E0,000
Rp 45,000 Rp E0,000
Rp 30,000 Rp 40,000
8/17/2019 Usulan Tarif Blud
52/142
8/17/2019 Usulan Tarif Blud
53/142
TOTAL JUMLAH
Rp 140,000 Rp 10,000
Rp 30,000 Rp 40,000
Rp 100,000 Rp 120,000
Rp 50,000 Rp E0,000
Rp 400,000 Rp 500,000
Rp 00,000 Rp +00,000Rp 1,100,000 Rp 1,200,000
Rp 450,000 Rp E00,000
Rp 50,000 Rp 00,000
Rp 1,250,000 Rp 1,400,000
Rp E00,000 Rp +00,000
Rp +00,000 Rp 1,000,000
Rp 1,400,000 Rp 1,E00,000
8/17/2019 Usulan Tarif Blud
54/142
TOTAL JUMLAH
Rp +0,000 Rp 100,000
Rp 120,000 Rp 150,000
Rp 1E0,000 Rp 200,000
Rp 350,000 Rp 400,000
Rp 120,000 Rp 150,000
Rp 1E0,000 Rp 200,000Rp 350,000 Rp 410,000
Rp 2E0,000 Rp 300,000
Rp 440,000 Rp 500,000
Rp E20,000 Rp 00,000
Rp +0,000 Rp 100,000
8/17/2019 Usulan Tarif Blud
55/142
TOTAL JUMLAH
Rp +0,000 Rp 100,000
Rp +0,000 Rp 100,000
Rp +0,000 Rp 100,000
Rp +0,000 Rp 100,000
Rp +0,000 Rp 100,000
Rp +0,000 Rp 100,000
Rp +0,000 Rp 100,000
Rp 110,000 Rp 140,000
Rp 110,000 Rp 140,000Rp 110,000 Rp 140,000
Rp 110,000 Rp 140,000
Rp 110,000 Rp 140,000
Rp 110,000 Rp 140,000
Rp 110,000 Rp 140,000
Rp 110,000 Rp 140,000
Rp 150,000 Rp 10,000Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
8/17/2019 Usulan Tarif Blud
56/142
TOTAL JUMLAH
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 150,000 Rp 10,000
Rp 300,000 Rp 3E0,000
Rp 300,000 Rp 3E0,000
Rp 300,000 Rp 3E0,000
Rp 300,000 Rp 3E0,000
Rp 300,000 Rp 3E0,000
Rp 300,000 Rp 3E0,000
Rp 40,000 Rp 50,000
Rp E0,000 Rp 0,000
8/17/2019 Usulan Tarif Blud
57/142
TOTAL JUMLAH
Rp 0,000 Rp 100,000
Rp 0,000 Rp 120,000
Rp E,000 Rp +,000
Rp E,000 Rp +,000
Rp E,000 Rp +,000
Rp 1E,000 Rp 20,000
Rp 1E,000 Rp 20,000Rp E,000 Rp +,000
Rp E,000 Rp +,000
Rp E,000 Rp +,000
Rp E,000 Rp 4,000
Rp E,000 Rp 4,000
Rp 34,000 Rp 40,000
Rp ,000 Rp ,000Rp ,000 Rp ,000
Rp ,000 Rp ,000
Rp ,000 Rp ,000
8/17/2019 Usulan Tarif Blud
58/142
TOTAL JUMLAH
Rp 30,000 Rp 40,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp 1E,000 Rp 20,000
Rp 1E,000 Rp 20,000
Rp 2E,000 Rp 30,000
Rp 2E,000 Rp 30,000
Rp 2E,000 Rp 30,000
Rp 54,000 Rp E0,000
Rp 54,000 Rp E0,000Rp 54,000 Rp E0,000
Rp 54,000 Rp E0,000
8/17/2019 Usulan Tarif Blud
59/142
TOTAL JUMLAH
Rp E0,000 Rp 0,000
Rp 1,+00,000 Rp 2,000,000
Rp 14,000 Rp 20,000
Rp ,000 Rp 10,000
Rp 1+,000 Rp 24,000
Rp 21,000 Rp 2,000
Rp 34,000 Rp 40,000Rp 1E,000 Rp 20,000
Rp 112,000 Rp 143,000
8/17/2019 Usulan Tarif Blud
60/142
TOTAL JUMLAH
Rp 14,000 Rp 20,000
Rp ,000 Rp 10,000
Rp +,000 Rp 10,000
Rp 5,000 Rp E,000
Rp +0,000 Rp 110,000
Rp 1+,000 Rp 24,000
Rp 21,000 Rp 2,000
Rp 34,000 Rp 40,000
Rp 1E,000 Rp 20,000
Rp 205,000 Rp 2E,000
Rp 205,000 Rp 2E,000
Rp 1E,000 Rp 20,000
Rp 1E,000 Rp 20,000
Rp E,000 Rp +,000
8/17/2019 Usulan Tarif Blud
61/142
TOTAL JUMLAH
Rp E,000 Rp +,000
Rp 1E,000 Rp 20,000
Rp 20,000 Rp 2+,000
Rp 100,000 Rp 120,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp 4,000 Rp 100,000
Rp E0,000 Rp 0,000
Rp +21,000 Rp E3,000
Rp 0,000 Rp 100,000
8/17/2019 Usulan Tarif Blud
62/142
TOTAL JUMLAH
Rp E,000 Rp +,000
Rp 1E,000 Rp 20,000
Rp E,000 Rp +,000
Rp 34,000 Rp 40,000
Rp 54,000 Rp E0,000
Rp 54,000 Rp E0,000
Rp 1E,000 Rp 20,000
Rp 20,000 Rp 2+,000
Rp E,000 Rp +,000
Rp 30,000 Rp 40,000
Rp E0,000 Rp 0,000
Rp +0,000 Rp 110,000
Rp 24,000 Rp 2+,000
Rp 4E,000 Rp E00,000
8/17/2019 Usulan Tarif Blud
63/142
TOTAL JUMLAH
Rp 24,000 Rp 30,000
Rp +,000 Rp 10,000
Rp 1E,000 Rp 20,000
Rp 1E,000 Rp 20,000
Rp 1E,000 Rp 20,000
Rp E4,000 Rp +0,000
Rp 5,000 Rp ,000
Rp 50,000 Rp E0,000
Rp 5,000 Rp ,000
8/17/2019 Usulan Tarif Blud
64/142
TOTAL JUMLAH
Rp 12,000 Rp 15,000
Rp 1,000 Rp 1,500
Sebong, 28 Januari 2011
T Puskesmas Teluk Sebong
URNIANSYAH, SKM
19811208 200502 1 00
USULAN TARIF PELAYANAN KESEHATAN KARYAWAN / TANGGUNGAN PERU
PPK,BLUD UPT PUSKESMAS TELUK SEBONG TH.211
KHUSUS KLINIK PARIWISATA LAGOI
8/17/2019 Usulan Tarif Blud
65/142
KHUSUS KLINIK PARIWISATA LAGOI
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
A ADMINISTRASI MEDIK
1. Family Folder 1 set / KK Rp 1,000 Rp 1,000 Rp +,000
2. Kartu Indeks Berobat 1 lbr Rp 500 Rp " Rp 3,500
3. Kartu status 1 lbr Rp 500 Rp " Rp 500
4. K! 1 lbr Rp 500 Rp " Rp 4,500
B. RAWAT JALAN
1 POLI UMUM
" #emeriksaan dasar $ %bat dasar 1 & Rp 10,000 Rp 12,000 Rp 1+,000
2 POLI SPESIALIS
" #emeriksaan $ %bat dasar 1 & Rp 15,000 Rp 5,000 Rp 30,000
3 POLI KEBIDANAN
" '() 1 & Rp ,000 Rp 15,000 Rp E,000
PENDAPATAN
BLUD
BAHAN HABIS
PAKAI/SARANAPRASARANA
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANAPENDAPATAN
BAHAN HABIS
8/17/2019 Usulan Tarif Blud
66/142
JASA MEDISBLUDBAHAN HABIS
PAKAI/SARANA
PRASARANA
" #enimban*an Bayi 1 & Rp 1,500 Rp " Rp 1,500
" !untik KB 1 bulan 1 & Rp 24,000 Rp 12,000 Rp 24,000
" !untik KB 3 bulan 1 & Rp 15,000 Rp 12,000 Rp 1+,000" #asan* Implant 1 & Rp 45,000 Rp 5,000 Rp 0,000
" Buka Implant 1 & Rp 45,000 Rp 5,000 Rp 0,000
" Buka #asan* Implant 1 & Rp E0,000 Rp 120,000 Rp 120,000
" #asan* I- 1 & Rp 2,000 Rp 45,000 Rp 33,000
" Buka I- 1 & Rp 2,000 Rp 45,000 Rp 33,000
" Buka #asan* I- 1 & Rp 45,000 Rp 0,000 Rp 45,000
" Imunisasi ! 1 & Rp E,000 Rp 12,000 Rp 2,000
" Imunisasi )aten 1 &
" !untik Rp E,000 Rp 12,000 Rp 2,000
" #re* est Rp 15,000 Rp ,000 Rp 3E,000
" !urat Keteran*an Rp E,000 Rp E,000 Rp 1+,000
Rp 2,000 Rp 2,000 Rp +1,000
4 TINDAKAN MEDIK
4.1 POLI GIGI
a. #emeriksaan dan obat dasar 1 & Rp 10,000 Rp 12,000 Rp 1+,000
b. Konsultasi 1 & Rp 1,500 Rp 10,500 Rp 3,000
. !pulin* Betadine 1 & Rp E,000 Rp E,000 Rp 3,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANAPENDAPATAN
BAHAN HABIS
8/17/2019 Usulan Tarif Blud
67/142
JASA MEDISBLUDBAHAN HABIS
PAKAI/SARANA
PRASARANA
d. &tratri
d.1. &o *i*i susu den*an ido 1 Bt* Rp 15,000 Rp 24,000 Rp 15,000
d.2. &o *i*i susu den*an ) 1 Bt* Rp 13,500 Rp 13,500 Rp ,000d.3. &o *i*i tetap 'nterior 1 Bt* Rp 21,000 Rp 30,000 Rp 1+,000
d.4. &o *i*i tetap #osterior 1 Bt* Rp 24,000 Rp 33,000 Rp 21,000
d.5. &o Komplikasi 1 Bt* Rp 30,000 Rp 45,000 Rp 30,000
e.umpatan
e.1. umpatan !ementara 1 lb* Rp ,000 Rp E,000 Rp 15,000
e.2 umpatan etap
" 'mal*am
Kls I 1 lb* Rp 21,000 Rp 42,000 Rp 2,000
Kls II 1 lb* Rp 30,000 Rp 45,000 Rp 30,000
Kls 1 lb* Rp 21,000 Rp 42,000 Rp 2,000
" 6lass Ionomer
Kls I 1 lb* Rp 21,000 Rp 51,000 Rp 33,000
Kls II 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000
Kls III 1 lb* Rp 21,000 Rp 51,000 Rp 33,000
Kls I 1 lb* Rp 30,000 Rp 54,000 Rp 3E,000
Kls 7 1 lb* Rp 21,000 Rp 51,000 Rp 33,000
" i*8t )ure
Kls I 1 lb* Rp 45,000 Rp +1,000 Rp 54,000
Kls II 1 lb* Rp E0,000 Rp ,000 Rp EE,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANAPENDAPATAN
BAHAN HABIS
8/17/2019 Usulan Tarif Blud
68/142
JASA MEDISBLUDBAHAN HABIS
PAKAI/SARANA
PRASARANA
Kls III 1 lb* Rp 45,000 Rp +1,000 Rp 54,000
Kls I 1 lb* Rp E0,000 Rp ,000 Rp EE,000
Kls 1 lb* Rp 45,000 Rp +1,000 Rp 54,0009. #era:atan !aluran 'kar
9.1 %pen Bur
" *i*i anterior 1 & Rp 15,000 Rp 2,000 Rp 1+,000
" *i*i posterior 1 & Rp 21,000 Rp 33,000 Rp 21,000
9.2 &tirpasi, reamin*, ;llin*
" *i*i anterior 1 & Rp 30,000 Rp 3E,000 Rp 24,000
" *i*i posterior 1 & Rp 45,000 Rp 45,000 Rp 30,000
9.3 6anti %bat 1 & Rp 15,000 Rp 1+,000 Rp 12,000
9.4 #en*isian !aluran 'kar
" *i*i anterior 1 & Rp 30,000 Rp 3E,000 Rp 24,000
" *i*i posterior 1 & Rp 45,000 Rp 45,000 Rp 30,000
" *i*i anterior 1 & Rp 3E,000 Rp 42,000 Rp 2,000
" *i*i posterior 1 & Rp 51,000 Rp 51,000 Rp 33,000
*. #ulp )appin* 1 & Rp 15,000 Rp 2,000 Rp 1+,000
8. Bon*kar ambalan #ermanen 1 lb* Rp ,000 Rp 21,000 Rp 15,000
i. !allin*
i.1 1 ra8an* < R' / RB = 1 & Rp 45,000 Rp +1,000 Rp 54,000
C #en*isian !aluran 'kar Kon7ensional
C #en*isian !aluran 'kar den*an 3 mi&
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANAPENDAPATAN
BLUDBAHAN HABIS
8/17/2019 Usulan Tarif Blud
69/142
JASA MEDISBLUD PAKAI/SARANAPRASARANA
i.2 2 ra8an* < R' > RB = 1 & Rp 0,000 Rp 1E2,000 Rp 10+,000
?. Inisi 'bses
?.1 Intra %ral 1 & Rp 15,000 Rp 45,000 Rp 30,000 ?.2 &tra %ral 1 & Rp 30,000 Rp E3,000 Rp 42,000
k. perulektomi 1 re* Rp 45,000 Rp +1,000 Rp 54,000
l. 'l7eolektomi 1 re* Rp E0,000 Rp 10+,000 Rp 2,000
m.%dontektomi 1 bt* Rp 120,000 Rp 3E0,000 Rp 120,000
n. Kontrol pasa beda8 1 & Rp ,000 Rp 13,500 Rp ,500
o. Buka ?a8itan 1 & Rp ,000 Rp 13,500 Rp ,500
4.2 UNIT GAWAT DARURAT
1. #emeriksaan dokter umum $ administrasi 1 & Rp E,000 Rp 30,000 Rp ,000
2. #emeriksaan dokter *i*i $ administrasi 1 & Rp E,000 Rp 30,000 Rp ,000
3. #emeriksaan dokter spesialis $ administrasi 1 & Rp 15,000 Rp E0,000 Rp 15,000
4. indakan edik 'nak
" Imunisasi 1 & Rp 15,000 Rp 12,000 Rp 33,000
" antau& est 1 & Rp 30,000 Rp E0,000 Rp 20,000
" Resusitasi 1 & Rp 30,000 Rp E0,000 Rp 45,000
" !irumsisi bayi perempuan 1 & Rp 15,000 Rp 45,000 Rp 30,000
" indik 1 & Rp 15,000 Rp 45,000 Rp 30,000
5. indakan edik beda8
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANAPENDAPATAN
BLUDBAHAN HABIS
8/17/2019 Usulan Tarif Blud
70/142
JASA MEDISBLUD PAKAI/SARANAPRASARANA
" 6anti balutan @ 10 m 1 & Rp 15,000 Rp 15,000 Rp 15,000
" 6anti balutan A 10 m 1 & Rp 24,000 Rp 21,000 Rp 15,000
" a8it luka 5 ?a8itan pertama 1 & Rp 15,000 Rp 45,000 Rp 30,000
!elan?utnya pen?a8itan 1 & Rp 3,000 Rp 3,000 Rp 3,000
" Buka ?a8itan @ 5 ?a8itan 1 & Rp ,500 Rp 22,500 Rp 15,000
!elan?utnya pen?a8itan 1 & Rp 1,500 Rp 1,500 Rp 1,500
" kstraksi kuku 1 & Rp 30,000 Rp 5,000 Rp 45,000
" !irkumsisi de:asa 1 & Rp 5,000 Rp 50,000 Rp 225,000
" !irkumsisi anak 1 & Rp 5,000 Rp E00,000 Rp 225,000
" #emasan*an ransel 7rband 1 & Rp 30,000 Rp 0,000 Rp 30,000
" ksisi tumor 1 & Rp 30,000 Rp 105,000 Rp 45,000
" Inisi abes 1 & Rp 15,000 Rp 30,000 Rp 30,000
" Imobilisasi d* spalk 1 & Rp 30,000 Rp 45,000 Rp 45,000
" ksplorasi luka 1 & Rp 15,000 Rp 45,000 Rp 30,000
" #era:atan uka 1 & Rp 12,000 Rp 24,000 Rp 24,000
" -ebridement luka bakar @ 20D 1 & Rp 15,000 Rp 45,000 Rp 45,000
" -ebridement luka bakar A 20D 1 & Rp 30,000 Rp E0,000 Rp E0,000
" Reposisi andibula 1 & Rp 15,000 Rp 5,000 Rp 45,000
" Bilas ambun* 1 & Rp 15,000 Rp 5,000 Rp 30,000
" Rendan Bokon* 1 & Rp E,000 Rp 15,000 Rp ,000
" #asan* Kateter 1 & Rp 15,000 Rp 30,000 Rp 30,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
8/17/2019 Usulan Tarif Blud
71/142
JASA MEDISBLUD PAKAI/SARANAPRASARANA
E. indakan Kepera:atan
" !untikan 1&/8ari 1 & Rp 1,500 Rp 4,500 Rp 3,000" !untikan 2"5&/8ari 1 & Rp 3,000 Rp ,500 Rp 4,500
" #en*ambilan sampel dara8 1 & Rp 1,500 Rp ,500 Rp E,000
" #emasan*an In9us 1 & Rp 30,000 Rp 54,000 Rp 3E,000
" #enabutan In9us 1 & Rp 3,000 Rp ,000 Rp 3,000
" Klisma 1 & Rp ,500 Rp 22,500 Rp 15,000
" !ution/8ari 1 & Rp 15,000 Rp 45,000 Rp 30,000
" #emasan*an (6 1 & Rp 30,000 Rp 5,000 Rp 45,000
. indakan edis 'nastesi
" Resusitasi ?antun* paru
8/17/2019 Usulan Tarif Blud
72/142
JASA MEDISBLUD PAKAI/SARANAPRASARANA
10. indakan edik G
" kstraksi serumen 1 & Rp 15,000 Rp 45,000 Rp 30,000
" ampon telin*a 1 & Rp 15,000 Rp 22,500 Rp 22,500" kstraksi orpus alienum di telin*a 1 & Rp 15,000 Rp 3,500 Rp 3,500
" #asan* tampon anterior 1 & Rp 15,000 Rp 30,000 Rp 30,000
" )abut tampon anterior 1 & Rp 15,000 Rp 30,000 Rp 30,000
" #asan* tampon posterior 1 & Rp 15,000 Rp 30,000 Rp 30,000
" )abut tampon posterior 1 & Rp 15,000 Rp 30,000 Rp 30,000
" BeloH tampon 1 & Rp 15,000 Rp 30,000 Rp 30,000
" kstraksi orpus alienum di 8idun* 1 & Rp 15,000 Rp 45,000 Rp 30,000
" indik
8/17/2019 Usulan Tarif Blud
73/142
JASA MEDISBLUD PAKAI/SARANAPRASARANA
a. #artus normal
" Bidan 1 & Rp 150,000 Rp 450,000 Rp 150,000
" -okter mum 1 & Rp 150,000 Rp 50,000 Rp 300,000" -okter !pesialis 1 & Rp 150,000 Rp 1,200,000 Rp 450,000
b. #artus den*an induksi
" Bidan 1 & Rp 225,000 Rp 525,000 Rp 150,000
" -okter mum 1 & Rp 225,000 Rp +25,000 Rp 300,000
" -okter !pesialis 1 & Rp 225,000 Rp 1,500,000 Rp 35,000
. #artus den*an penyulit
" Bidan 1 & Rp 300,000 Rp E00,000 Rp 300,000
" -okter mum 1 & Rp 300,000 Rp 00,000 Rp 300,000
" -okter !pesialis 1 & Rp 300,000 Rp 1,+00,000 Rp 300,000
d. pisiotomi
" 6rade I " III < Bidan = 1 & Rp 30,000 Rp 0,000 Rp 30,000
" 6rade I " III < -okter mum = 1 & Rp 45,000 Rp 135,000 Rp 45,000
" 6rade I " III < -okter !pesialis = 1 & Rp E0,000 Rp 1+0,000 Rp E0,000
" 6rade I < dokter !pesialis = 1 & Rp 5,000 Rp 450,000 Rp 5,000
e. ksplorasi a*ina
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
8/17/2019 Usulan Tarif Blud
74/142
JASA MEDISBLUD PAKAI/SARANAPRASARANA
" Bidan 1 & Rp 45,000 Rp 150,000 Rp 30,000
" -okter mum 1 & Rp E0,000 Rp 15,000 Rp 45,000
" -okter !pesialis 1 & Rp 0,000 Rp 450,000 Rp 5,000
9. anual plasenta
" Bidan 1 & Rp E0,000 Rp 330,000 Rp E0,000
" -okter mum 1 & Rp 0,000 Rp 50,000 Rp 0,000
" -okter !pesialis 1 & Rp 120,000 Rp +10,000 Rp 120,000
C PENUNJANG DIAGNOSTIK
1 E!"#$%!'()
a. Radiolo*i
" 8ora& #' 1 & Rp 30,000 Rp 45,000 Rp 5,000
" 'bdomen #' 1 & Rp 30,000 Rp 45,000 Rp 5,000
" #el7is '# 1 & Rp 30,000 Rp 45,000 Rp 5,000
" )la7iula < -/! = '# 1 & Rp 30,000 Rp 45,000 Rp 5,000
" aters open mout8 #' 1 & Rp 30,000 Rp 45,000 Rp 5,000
" op ordoti
8/17/2019 Usulan Tarif Blud
75/142
JASA MEDIS PAKAI/SARANAPRASARANA
" rist oint '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000
" lbo: oint '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000
" -i*iti '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000" 'ntebra8i '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000
" )alaneus '&ial " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000
" 'nkle oint '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000
" 6enu '# " ateral 1 & Rp 45,000 Rp E0,000 Rp 105,000
" 8ora& #' " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" )er7ial '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" !kull '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000" 8orakal '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" !inus :aters open mout8 " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" open " lose mout8 1 & Rp E0,000 Rp 5,000 Rp 150,000
" %s Gumerus '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" ert t8orao lumbal '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" ert lumbal '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" umbo saral '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" !arum '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" )oy& '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" Gip '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" Femur '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
C 2 posisi 2 ;lm
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
8/17/2019 Usulan Tarif Blud
76/142
JASA MEDIS PAKAI/SARANAPRASARANA
" )ruris '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" #edis '# " ateral 1 & Rp E0,000 Rp 5,000 Rp 150,000
" 'bdomen 3 posisi 1 & Rp 0,000 Rp 0,000 Rp 3E0,000
" )er7ial '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000
" 8orao umbal '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000
" 8oraal '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000
" umbal '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000
" umbo " !aral '#/ateral/%bliH kanan " kiri 1 & Rp 0,000 Rp 0,000 Rp 3E0,000
1 & Rp 15,000 Rp 15,000 Rp 45,000
. letroardio*ra; 1 & Rp 15,000 Rp 45,000 Rp 45,000d. !6
" anpa ;lm 1 & Rp 45,000 Rp E0,000 Rp 45,000
" -en*an ;lm 1 & Rp 45,000 Rp 5,000 Rp E0,000
2 La*%$a#%$(+
a. Gematolo*i
" Gematokrit 1 & Rp 3,000 Rp E,000 Rp 3,000
" Gb 1 & Rp 3,000 Rp E,000 Rp 3,000
" euoyt 1 & Rp 3,000 Rp E,000 Rp 3,000
" -iJ )ount / Gitun* enis 1 & Rp E,000 Rp 15,000 Rp ,000
" BB! / - 1 & Rp E,000 Rp 15,000 Rp ,000
" alaria 1 & Rp 3,000 Rp E,000 Rp 3,000
C 3 " 4 posisi 3 " 4 ;lm
C Intra %ral
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
8/17/2019 Usulan Tarif Blud
77/142
JPRASARANA
" rytroyt 1 & Rp 3,000 Rp E,000 Rp 3,000
" romboyt 1 & Rp 3,000 Rp E,000 Rp 3,000
" Bloodin* ime 1& Rp 3 Rp E,000 Rp 3,000" )8lot8in* ime 1& Rp 3 Rp E,000 Rp 3,000
" 6olon*an -ara8 1 & Rp ,000 Rp 15,000 Rp 3E,000
b. rine 'nalis
" #rotein 1 & Rp 3,000 Rp E,000 Rp 4,500
" Reduksi 1 & Rp 3,000 Rp E,000 Rp 4,500
" Bilirubin 1 & Rp 3,000 Rp E,000 Rp 4,500
" !edimen 1 & Rp 3,000 Rp E,000 Rp 4,500
" #re* est 1 & Rp 15,000 Rp ,000 Rp 3E,000" or;n 1 & Rp ,000 Rp 30,000 Rp 111,000
" G) / 6an?a 1 & Rp ,000 Rp 30,000 Rp 111,000
" 'm9etamine 1 & Rp ,000 Rp 30,000 Rp 111,000
" )oaine 1 & Rp ,000 Rp 30,000 Rp 111,000
" Benodiaepin 1 & Rp ,000 Rp 30,000 Rp 111,000
" %pium 1 & Rp ,000 Rp 30,000 Rp 111,000
. Faees
" akroskopis 1 & Rp E,000 Rp 15,000 Rp ,000
" ikroskopis 1 & Rp E,000 Rp 15,000 Rp ,000
d. ikrobilo*i
" B' 1 & Rp E,000 Rp 30,000 Rp ,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
8/17/2019 Usulan Tarif Blud
78/142
JPRASARANA
" !eret a*ina 1 & Rp E,000 Rp 30,000 Rp ,000
" K%G 1 & Rp E,000 Rp 30,000 Rp ,000
e. Kimia -ara8
" 6ula -ara8 1 & Rp ,000 Rp 12,000 Rp E,000
" )8olesterol 1 & Rp ,000 Rp 12,000 Rp E,000
" ri*liserid 1 & Rp ,000 Rp 12,000 Rp E,000
" ri 'id 1 & Rp ,000 Rp 12,000 Rp E,000
9. !erolo*i
" -en*ue est 1 & Rp 15,000 Rp 15,000 Rp 5,000
#emeriksaan )yto / -iluar ?am ker?a tari9 ditamba8
25D & tari9 dasar
D PELAYANAN MEDICOLEGAL
1 #emberian 9ormalin 1 & Rp 300,000 Rp 1,500,000 Rp 1,200,000
E MEDICAL CHECK UP
1 KIR Kese8atan Biasa
a. 'namnese > #emeriksaan Fisik
" #oli mum 1 & Rp ,000 Rp 15,000 Rp E,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
8/17/2019 Usulan Tarif Blud
79/142
PRASARANA
" #oli 6i*i 1 & Rp 1,500 Rp 10,500 Rp 3,000
b. aboratorium
" -ara8 rutin
8/17/2019 Usulan Tarif Blud
80/142
PRASARANA
3 #emeriksaan edial )alon Karya:an
a. #emeriksaan medial standar 1 & Rp E,000 Rp 12E,000 Rp 1+1,500
b. aboratorium b.1 -ara8
" Gitun* enis 1 & Rp E,000 Rp 15,000 Rp ,000
" a?u ndap -ara8 1 & Rp E,000 Rp 15,000 Rp ,000
" Bloodin* ime
8/17/2019 Usulan Tarif Blud
81/142
PRASARANA
. K6 1 & Rp 15,000 Rp 45,000 Rp 45,000
Rp 213,000 Rp 30,000 Rp +41,500
4 #emeriksaan edial )alon amaa8 Ga?i
a. 'namnese > pemeriksaan ;sik, ?i:a > Bart8el inde& 1 & Rp 15,000 Rp 0,000 Rp 45,000
b. #emeriksaan penun?an*
b.1 aboratorium
" -ara8
1 & Rp 3,000 Rp E,000 Rp 3,000
1 & Rp E,000 Rp 15,000 Rp ,000
1 & Rp 3,000 Rp E,000 Rp 3,000
1 & Rp ,000 Rp 15,000 Rp 3E,0001 & Rp ,000 Rp 12,000 Rp E,000
1 & Rp ,000 Rp 12,000 Rp E,000
" rine
1 & Rp E,000 Rp 15,000 Rp ,000
1 & Rp 12,000 Rp 12,000 Rp 1+,000
1 & Rp 3,000 Rp E,000 Rp 3,000
1 & Rp 15,000 Rp ,000 Rp 3E,000
b.2 K6 1 & Rp 15,000 Rp 45,000 Rp 45,000b.3 Radiolo*i
8/17/2019 Usulan Tarif Blud
82/142
PRASARANA
F LAIN , LAIN
1 !urat Keteran*an
" Kela8iran 1 & Rp ,000 Rp ,000 Rp 2,000" !akit 1 & Rp 3,000 Rp 4,500 Rp ,500
" -ira:at 1 & Rp E,000 Rp ,000 Rp 15,000
" aik (aik #esa:at 1 & Rp E,000 Rp ,000 Rp 15,000
" Kematian 1 & Rp E,000 Rp ,000 Rp 15,000
2 'mbulane
1 & Rp 24,000 Rp 51,000 Rp 45,000
!elebi8nya/km 1 & Rp 3,000 Rp 3,E00 Rp 3,00
" uar #ulau
" belum termasuk biaya penyebran*an
" 2& tari9 dalam pulau
3 asa #etu*as #endampin* Ru?ukan
" -okter 1 &
Rp 15,000 Rp 5,000 Rp "
C !elebi8nya / km Rp 3,000 Rp ,500 Rp "
C uar pulau
8/17/2019 Usulan Tarif Blud
83/142
PRASARANA
C !elebi8nya / km Rp 50 Rp 1,500 Rp
C uar pulau
8/17/2019 Usulan Tarif Blud
84/142
TOTAL JUMLAH
Rp ,000 Rp 10,000
Rp 3,500 Rp 4,000
Rp 500 Rp 1,000
Rp 4,500 Rp 5,000
Rp 30,000 Rp 40,000
Rp 105,000 Rp 120,000
Rp 21,000 Rp 30,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
85/142
Rp 1,500 Rp 3,000
Rp 3E,000 Rp E0,000
Rp 30,000 Rp 45,000
Rp 1E5,000 Rp 210,000
Rp 1E5,000 Rp 210,000
Rp 240,000 Rp 300,000
Rp +,000 Rp 105,000
Rp +,000 Rp 105,000
Rp 135,000 Rp 1+0,000
Rp 3,000 Rp 45,000
Rp 3,000 Rp 45,000
Rp 45,000 Rp E0,000
Rp 24,000 Rp 30,000
Rp 10+,000 Rp 135,000
Rp 30,000 Rp 40,000
Rp 13,500 Rp 15,000
Rp ,000 Rp 15,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
86/142
Rp 3,000 Rp 54,000
Rp 22,500 Rp 3E,000
Rp 4+,000 Rp E,000
Rp 54,000 Rp +,000
Rp 5,000 Rp 105,000
Rp 21,000 Rp 30,000
Rp E,000 Rp 0,000
Rp 5,000 Rp 105,000
Rp E,000 Rp 0,000
Rp +4,000 Rp 105,000
Rp 0,000 Rp 120,000
Rp +4,000 Rp 105,000
Rp 0,000 Rp 120,000
Rp +4,000 Rp 105,000
Rp 135,000 Rp 1+0,000
Rp 1E5,000 Rp 225,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
87/142
Rp 135,000 Rp 1+0,000
Rp 1E5,000 Rp 225,000
Rp 135,000 Rp 1+0,000
Rp 45,000 Rp E0,000
Rp 54,000 Rp 5,000
Rp E0,000 Rp 0,000
Rp 5,000 Rp 120,000
Rp 30,000 Rp 45,000
Rp E0,000 Rp 0,000
Rp 5,000 Rp 120,000
Rp E,000 Rp 105,000
Rp +4,000 Rp 135,000
Rp 45,000 Rp E0,000Rp 3E,000 Rp 45,000
Rp 135,000 Rp 1+0,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
88/142
Rp 20,000 Rp 3E0,000
Rp 5,000 Rp 0,000
Rp 105,000 Rp 135,000
Rp 135,000 Rp 1+0,000
Rp 1+0,000 Rp 240,000
Rp 4+0,000 Rp E00,000
Rp 21,000 Rp 30,000
Rp 21,000 Rp 30,000
Rp 3,000 Rp 45,000
Rp 3,000 Rp 45,000
Rp 5,000 Rp 0,000
Rp 45,000 Rp E0,000
Rp 330,000 Rp 3E0,000
Rp 105,000 Rp 135,000
Rp 5,000 Rp 0,000Rp 5,000 Rp 0,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
89/142
Rp 30,000 Rp 45,000
Rp 3E,000 Rp E0,000
Rp 5,000 Rp 0,000
Rp E,000 Rp ,000
Rp 3,500 Rp 45,000
Rp 3,000 Rp 4,500
Rp 120,000 Rp 150,000
Rp 5,000 Rp 1,050,000
Rp +25,000 Rp 00,000
Rp 120,000 Rp 150,000
Rp 150,000 Rp 1+0,000
Rp E0,000 Rp 5,000
Rp 0,000 Rp 120,000
Rp 5,000 Rp 0,000
Rp 4+,000 Rp E0,000
Rp 0,000 Rp 105,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 135,000Rp 105,000 Rp 120,000
Rp 24,000 Rp 30,000
Rp E0,000 Rp 5,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
90/142
Rp ,500 Rp ,000
Rp 12,000 Rp 15,000
Rp 13,500 Rp 15,000
Rp 0,000 Rp 120,000
Rp 12,000 Rp 15,000
Rp 3,500 Rp 45,000
Rp 5,000 Rp 0,000
Rp 120,000 Rp 150,000
Rp 150,000 Rp 1+0,000
Rp 5,000 Rp 0,000
Rp E,500 Rp 0,000
Rp 45,000 Rp E0,000
Rp 22,500 Rp 30,000
Rp 45,000 Rp E0,000
Rp 45,000 Rp E0,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
91/142
Rp 5,000 Rp 0,000
Rp 45,000 Rp E0,000
Rp 5,000 Rp 0,000
Rp E0,000 Rp 5,000
Rp E0,000 Rp 5,000
Rp E0,000 Rp 5,000
Rp E0,000 Rp 5,000
Rp E0,000 Rp 5,000
Rp 5,000 Rp 0,000
Rp E0,000 Rp 5,000
Rp 135,000 Rp 150,000
Rp 1+0,000 Rp 210,000
Rp 210,000 Rp 255,000
Rp 45,000 Rp E0,000
Rp 150,000 Rp 1+0,000
Rp 5,000 Rp 0,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
92/142
Rp E00,000 Rp 50,000
Rp 1,050,000 Rp 1,200,000
Rp 1,E50,000 Rp 1,+00,000
Rp E5,000 Rp 00,000
Rp 1,125,000 Rp 1,350,000
Rp 1,+5,000 Rp 2,100,000
Rp 00,000 Rp 1,200,000
Rp 1,200,000 Rp 1,500,000
Rp 2,100,000 Rp 2,400,000
Rp 120,000 Rp 150,000
Rp 1+0,000 Rp 225,000
Rp 240,000 Rp 300,000
Rp 525,000 Rp E00,000
TOTAL JUMLAH
Rp 1+0 000 Rp 225 000
8/17/2019 Usulan Tarif Blud
93/142
Rp 1+0,000 Rp 225,000
Rp 240,000 Rp 300,000
Rp 525,000 Rp E15,000
Rp 30,000 Rp 450,000
Rp EE0,000 Rp 50,000
Rp 30,000 Rp 1,050,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 150,000
Rp 120,000 Rp 150,000
Rp 1E5,000 Rp 210,000
TOTAL JUMLAH
Rp 1E5 000 Rp 210 000
8/17/2019 Usulan Tarif Blud
94/142
Rp 1E5,000 Rp 210,000
Rp 1E5,000 Rp 210,000
Rp 1E5,000 Rp 210,000
Rp 1E5,000 Rp 210,000
Rp 1E5,000 Rp 210,000
Rp 1E5,000 Rp 210,000
Rp 1E5,000 Rp 210,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
TOTAL JUMLAH
Rp 225 000 Rp 2+5 000
8/17/2019 Usulan Tarif Blud
95/142
Rp 225,000 Rp 2+5,000
Rp 225,000 Rp 2+5,000
Rp 450,000 Rp 540,000
Rp 450,000 Rp 540,000
Rp 450,000 Rp 540,000
Rp 450,000 Rp 540,000
Rp 450,000 Rp 540,000
Rp 450,000 Rp 540,000
Rp E0,000 Rp 5,000
Rp 0,000 Rp 105,000
Rp 105,000 Rp 150,000
Rp 135,000 Rp 1+0,000
Rp ,000 Rp 12,000
Rp ,000 Rp 12,000
Rp ,000 Rp 12,000
Rp 24,000 Rp 30,000
Rp 24,000 Rp 30,000
Rp ,000 Rp 12,000
TOTAL JUMLAH
Rp ,000 Rp 12,000
8/17/2019 Usulan Tarif Blud
96/142
Rp ,000 Rp 12,000
Rp ,000 Rp 12,000
Rp ,000 Rp 4,000
Rp ,000 Rp 4,000
Rp 51,000 Rp E0,000
Rp 10,500 Rp 13,500
Rp 10,500 Rp 13,500
Rp 10,500 Rp 13,500
Rp 10,500 Rp 13,500
Rp 45,000 Rp E0,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
Rp 24,000 Rp 30,000
Rp 24,000 Rp 30,000
Rp 3,000 Rp 45,000
TOTAL JUMLAH
Rp 3,000 Rp 45,000
8/17/2019 Usulan Tarif Blud
97/142
p , p ,
Rp 3,000 Rp 45,000
Rp +1,000 Rp 0,000
Rp +1,000 Rp 0,000
Rp +1,000 Rp 0,000
Rp +1,000 Rp 0,000
Rp 0,000 Rp 105,000
Rp 2,00,000 Rp 3,000,000
Rp 21,000 Rp 30,000
TOTAL JUMLAH
Rp 13,500 Rp 15,000
8/17/2019 Usulan Tarif Blud
98/142
p p
Rp 2,000 Rp 3E,000
Rp 31,500 Rp 43,500
Rp 51,000 Rp E0,000
Rp 24,000 Rp 30,000
Rp 1E+,000 Rp 214,500
Rp 21,000 Rp 30,000
Rp 13,500 Rp 15,000
Rp 12,000 Rp 15,000
Rp ,500 Rp ,000
Rp 120,000 Rp 1E5,000
Rp 2,000 Rp 3E,000
Rp 31,500 Rp 43,500
Rp 51,000 Rp E0,000
Rp 24,000 Rp 30,000
Rp 30,500 Rp 403,500
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
99/142
Rp 30,500 Rp 403,500
Rp 24,000 Rp 30,000
Rp 24,000 Rp 30,000
Rp ,000 Rp 12,000
Rp ,000 Rp 12,000
Rp 24,000 Rp 30,000
Rp 30,000 Rp 42,000
Rp 150,000 Rp 1+0,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
Rp 141,000 Rp 150,000
TOTAL JUMLAH
Rp 0,000 Rp 105,000
8/17/2019 Usulan Tarif Blud
100/142
Rp 1,231,500 Rp 1,444,500
Rp 135,000 Rp 150,000
Rp ,000 Rp 12,000
Rp 24,000 Rp 30,000
Rp ,000 Rp 12,000
Rp 51,000 Rp E0,000
Rp +1,000 Rp 0,000
Rp +1,000 Rp 0,000
Rp 24,000 Rp 30,000
Rp 30,000 Rp 42,000
Rp ,000 Rp 12,000
Rp 45,000 Rp E0,000
Rp 0,000 Rp 105,000
Rp 120,000 Rp 1E5,000
Rp 3E,000 Rp 42,000
Rp 44,000 Rp 00,000
TOTAL JUMLAH
8/17/2019 Usulan Tarif Blud
101/142
Rp 3E,000 Rp 45,000
Rp 12,000 Rp 15,000
Rp 24,000 Rp 30,000
Rp 24,000 Rp 30,000
Rp 24,000 Rp 30,000
Rp E,000 Rp 120,000
Rp ,500 Rp 10,500
Rp 5,000 Rp 0,000
Rp ,500 Rp 10,500
Rp 1+,000 Rp 22,500
TOTAL JUMLAH
Rp 1,500 Rp 2,250
8/17/2019 Usulan Tarif Blud
102/142
2011
k !ebon*
00
USULAN TARIF PELAYANAN KESEHATAN WARGA NEGARA ASING 0WN
PPK,BLUD UPT PUSKESMAS TELUK SEBONG TH.211
KHUSUS KLINIK PARIWISATA LAGOI
TARIF
8/17/2019 Usulan Tarif Blud
103/142
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN JASA PELAYANA
JASA MEDIS
A ADMINISTRASI MEDIK
1. Family Folder 1 set / KK Rp 2,000 Rp 2,000 Rp 1E,000
2. Kartu Indeks Berobat 1 lbr Rp 1,000 Rp " Rp ,000
3. Kartu status 1 lbr Rp 1,000 Rp " Rp 1,000
4. K! 1 lbr Rp 1,000 Rp " Rp ,000
B. RAWAT JALAN
1 POLI UMUM
" #emeriksaan dasar $ %bat dasar 1 & Rp E,000 Rp 110,000 Rp 44,000
2 POLI SPESIALIS
" #emeriksaan $ %bat dasar 1 & Rp 1E0,000 Rp 500,000 Rp 220,000
3 POLI KEBIDANAN
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" '() 1 & Rp E,000 Rp 100,000 Rp 44,000
8/17/2019 Usulan Tarif Blud
104/142
p , p , p ,
" #enimban*an Bayi 1 & Rp 1E,000 Rp " Rp 11,000
" !untik KB 1 bulan 1 & Rp 25E,000 Rp +0,000 Rp 1E,000" !untik KB 3 bulan 1 & Rp 1E0,000 Rp +0,000 Rp 132,000
" #asan* Implant 1 & Rp 4+0,000 Rp 500,000 Rp EE0,000
" Buka Implant 1 & Rp 4+0,000 Rp 500,000 Rp EE0,000
" Buka #asan* Implant 1 & Rp E40,000 Rp +00,000 Rp ++0,000
" #asan* I- 1 & Rp 2++,000 Rp 300,000 Rp 242,000
" Buka I- 1 & Rp 2++,000 Rp 300,000 Rp 242,000
" Buka #asan* I- 1 & Rp 4+0,000 Rp E00,000 Rp 330,000
" Imunisasi ! 1 & Rp E4,000 Rp +0,000 Rp 1+,000" Imunisasi )aten 1 &
" !untik Rp E4,000 Rp +0,000 Rp 1+,000
" #re* est Rp 1E0,000 Rp E0,000 Rp 2E4,000
" !urat Keteran*an Rp E4,000 Rp 40,000 Rp 132,000
Rp 2++,000 Rp 1+0,000 Rp 54,000
4 TINDAKAN MEDIK
4.1 POLI GIGI
a. #emeriksaan dan obat dasar 1 & Rp E,000 Rp 100,000 Rp 44,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
b. Konsultasi 1 & Rp 1E,000 Rp 0,000 Rp 22,000
8/17/2019 Usulan Tarif Blud
105/142
p p p
. !pulin* Betadine 1 & Rp E4,000 Rp 40,000 Rp 22,000
d. &tratri d.1. &o *i*i susu den*an ido 1 Bt* Rp 1E0,000 Rp 1E0,000 Rp 110,000
d.2. &o *i*i susu den*an ) 1 Bt* Rp 144,000 Rp 0,000 Rp EE,000
d.3. &o *i*i tetap 'nterior 1 Bt* Rp 224,000 Rp 200,000 Rp 132,000
d.4. &o *i*i tetap #osterior 1 Bt* Rp 25E,000 Rp 220,000 Rp 154,000
d.5. &o Komplikasi 1 Bt* Rp 320,000 Rp 300,000 Rp 220,000
e.umpatan
e.1. umpatan !ementara 1 lb* Rp E,000 Rp 40,000 Rp 110,000
e.2 umpatan etap " 'mal*am
Kls I 1 lb* Rp 224,000 Rp 2+0,000 Rp 1+,000
Kls II 1 lb* Rp 320,000 Rp 300,000 Rp 220,000
Kls 1 lb* Rp 224,000 Rp 2+0,000 Rp 1+,000
" 6lass Ionomer
Kls I 1 lb* Rp 224,000 Rp 340,000 Rp 242,000
Kls II 1 lb* Rp 320,000 Rp 3E0,000 Rp 2E4,000
Kls III 1 lb* Rp 224,000 Rp 340,000 Rp 242,000
Kls I 1 lb* Rp 320,000 Rp 3E0,000 Rp 2E4,000
Kls 7 1 lb* Rp 224,000 Rp 340,000 Rp 242,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" i*8t )ure
8/17/2019 Usulan Tarif Blud
106/142
Kls I 1 lb* Rp 4+0,000 Rp 540,000 Rp 3E,000
Kls II 1 lb* Rp E40,000 Rp EE0,000 Rp 4+4,000
Kls III 1 lb* Rp 4+0,000 Rp 540,000 Rp 3E,000
Kls I 1 lb* Rp E40,000 Rp EE0,000 Rp 4+4,000
Kls 1 lb* Rp 4+0,000 Rp 540,000 Rp 3E,000
9. #era:atan !aluran 'kar
9.1 %pen Bur
" *i*i anterior 1 & Rp 1E0,000 Rp 1+0,000 Rp 132,000
" *i*i posterior 1 & Rp 224,000 Rp 220,000 Rp 154,000
9.2 &tirpasi, reamin*, ;llin* " *i*i anterior 1 & Rp 320,000 Rp 240,000 Rp 1E,000
" *i*i posterior 1 & Rp 4+0,000 Rp 300,000 Rp 220,000
9.3 6anti %bat 1 & Rp 1E0,000 Rp 120,000 Rp ++,000
9.4 #en*isian !aluran 'kar
" *i*i anterior 1 & Rp 320,000 Rp 240,000 Rp 1E,000
" *i*i posterior 1 & Rp 4+0,000 Rp 300,000 Rp 220,000
" *i*i anterior 1 & Rp 3+4,000 Rp 2+0,000 Rp 1+,000
" *i*i posterior 1 & Rp 544,000 Rp 340,000 Rp 242,000
C #en*isian !aluran 'kar Kon7ensional
C #en*isian !aluran 'kar den*an 3 mi&
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
*. #ulp )appin* 1 & Rp 1E0,000 Rp 1+0,000 Rp 132,000
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8. Bon*kar ambalan #ermanen 1 lb* Rp E,000 Rp 140,000 Rp 110,000
i. !allin*
i.1 1 ra8an* < R' / RB = 1 & Rp 4+0,000 Rp 540,000 Rp 3E,000
i.2 2 ra8an* < R' > RB = 1 & Rp E0,000 Rp 1,0+0,000 Rp 2,000
?. Inisi 'bses
?.1 Intra %ral 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
?.2 &tra %ral 1 & Rp 320,000 Rp 420,000 Rp 30+,000
k. perulektomi 1 re* Rp 4+0,000 Rp 540,000 Rp 3E,000
l. 'l7eolektomi 1 re* Rp E40,000 Rp 20,000 Rp 52+,000
m.%dontektomi 1 bt* Rp 1,2+0,000 Rp 2,400,000 Rp ++0,000n. Kontrol pasa beda8 1 & Rp E,000 Rp 0,000 Rp 55,000
o. Buka ?a8itan 1 & Rp E,000 Rp 0,000 Rp 55,000
4.2 UNIT GAWAT DARURAT
1. #emeriksaan dokter umum $ administrasi 1 & Rp E4,000 Rp 200,000 Rp EE,000
2. #emeriksaan dokter *i*i $ administrasi 1 & Rp E4,000 Rp 200,000 Rp EE,000
3. #emeriksaan dokter spesialis $ administrasi 1 & Rp 1E0,000 Rp 400,000 Rp 110,000
4. indakan edik 'nak " Imunisasi 1 & Rp 1E0,000 Rp +0,000 Rp 242,000
" antau& est 1 & Rp 320,000 Rp 400,000 Rp 1,+0,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" Resusitasi 1 & Rp 320,000 Rp 400,000 Rp 330,000
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" !irumsisi bayi perempuan 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
" indik 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
5. indakan edik beda8
" 6anti balutan @ 10 m 1 & Rp E0,000 Rp 100,000 Rp 110,000
" 6anti balutan A 10 m 1 & Rp E,000 Rp 140,000 Rp 110,000
" a8it luka
5 ?a8itan pertama 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
!elan?utnya pen?a8itan 1 & Rp 32,000 Rp 20,000 Rp 22,000
" Buka ?a8itan @ 5 ?a8itan 1 & Rp +0,000 Rp 150,000 Rp 110,000!elan?utnya pen?a8itan 1 & Rp 1E,000 Rp 10,000 Rp 11,000
" kstraksi kuku 1 & Rp 320,000 Rp 500,000 Rp 330,000
" !irkumsisi de:asa 1 & Rp +00,000 Rp 5,000,000 Rp 1,E50,000
" !irkumsisi anak 1 & Rp +00,000 Rp 4,000,000 Rp 1,E50,000
" #emasan*an ransel 7rband 1 & Rp 320,000 Rp E00,000 Rp 220,000
" ksisi tumor 1 & Rp 320,000 Rp 00,000 Rp 330,000
" Inisi abes 1 & Rp 1E0,000 Rp 200,000 Rp 220,000
" Imobilisasi d* spalk 1 & Rp 320,000 Rp 300,000 Rp 330,000" ksplorasi luka 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
" #era:atan uka 1 & Rp 12+,000 Rp 1E0,000 Rp 1E,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" -ebridement luka bakar @ 20D 1 & Rp 1E0,000 Rp 300,000 Rp 330,000
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" -ebridement luka bakar A 20D 1 & Rp 320,000 Rp 400,000 Rp 440,000
" Reposisi andibula 1 & Rp 1E0,000 Rp 500,000 Rp 330,000
" Bilas ambun* 1 & Rp 1E0,000 Rp 500,000 Rp 220,000
" Rendan Bokon* 1 & Rp E4,000 Rp 100,000 Rp EE,000
" #asan* Kateter 1 & Rp 1E0,000 Rp 200,000 Rp 220,000
E. indakan Kepera:atan
" !untikan 1&/8ari 1 & Rp 1E,000 Rp 30,000 Rp 22,000
" !untikan 2"5&/8ari 1 & Rp 32,000 Rp 50,000 Rp 33,000
" #en*ambilan sampel dara8 1 & Rp 1E,000 Rp 50,000 Rp 44,000" #emasan*an In9us 1 & Rp 320,000 Rp 3E0,000 Rp 2E4,000
" #enabutan In9us 1 & Rp 32,000 Rp E0,000 Rp 22,000
" Klisma 1 & Rp +0,000 Rp 150,000 Rp 110,000
" !ution/8ari 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
" #emasan*an (6 1 & Rp 320,000 Rp 500,000 Rp 330,000
. indakan edis 'nastesi
" Resusitasi ?antun* paru
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" est is8i8ara 1 & Rp +0,000 Rp 50,000 Rp 110,000
" 6anti erband mata 1 & Rp 1E0,000 Rp 150,000 Rp 1E5,000
. indakan edik #aru
" In8alasi/(ebulier 1 & Rp 1E0,000 Rp 100,000 Rp 220,000
10. indakan edik G
" kstraksi serumen 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
" ampon telin*a 1 & Rp 1E0,000 Rp 150,000 Rp 1E5,000
" kstraksi orpus alienum di telin*a 1 & Rp 1E0,000 Rp 250,000 Rp 25,000" #asan* tampon anterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000
" )abut tampon anterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000
" #asan* tampon posterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000
" )abut tampon posterior 1 & Rp 1E0,000 Rp 200,000 Rp 220,000
" BeloH tampon 1 & Rp 1E0,000 Rp 200,000 Rp 220,000
" kstraksi orpus alienum di 8idun* 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
" indik
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" #apiloma 1 & Rp 4+0,000 Rp 00,000 Rp 550,000
" ar7a mi*ran 1 & Rp 1E0,000 Rp 200,000 Rp 110,000
12. Keraunan 1 & Rp 320,000 Rp 400,000 Rp EE0,000
13. -i*i*it Binatan* 1 & Rp 1E0,000 Rp 300,000 Rp 220,000
4.3 TINDAKAN KEBIDANAN
a. #artus normal
" Bidan 1 & Rp 1,E00,000 Rp 3,000,000 Rp 1,100,000
" -okter mum 1 & Rp 1,E00,000 Rp 5,000,000 Rp 2,200,000" -okter !pesialis 1 & Rp 1,E00,000 Rp +,000,000 Rp 3,300,000
b. #artus den*an induksi
" Bidan 1 & Rp 2,400,000 Rp 3,500,000 Rp 1,100,000
" -okter mum 1 & Rp 2,400,000 Rp 5,500,000 Rp 2,200,000
" -okter !pesialis 1 & Rp 2,400,000 Rp 10,000,000 Rp 2,50,000
. #artus den*an penyulit " Bidan 1 & Rp 3,200,000 Rp 4,000,000 Rp 2,200,000
" -okter mum 1 & Rp 3,200,000 Rp E,000,000 Rp 2,200,000
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" -okter !pesialis 1 & Rp 3,200,000 Rp 12,000,000 Rp 2,200,000
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d. pisiotomi
" 6rade I " III < Bidan = 1 & Rp 320,000 Rp E00,000 Rp 220,000
" 6rade I " III < -okter mum = 1 & Rp 4+0,000 Rp 00,000 Rp 330,000
" 6rade I " III < -okter !pesialis = 1 & Rp E40,000 Rp 1,200,000 Rp 440,000
" 6rade I < dokter !pesialis = 1 & Rp +00,000 Rp 3,000,000 Rp 550,000
e. ksplorasi a*ina
" Bidan 1 & Rp 4+0,000 Rp 1,000,000 Rp 220,000
" -okter mum 1 & Rp E40,000 Rp 1,300,000 Rp 330,000" -okter !pesialis 1 & Rp E0,000 Rp 3,000,000 Rp 550,000
9. anual plasenta
" Bidan 1 & Rp E40,000 Rp 2,200,000 Rp 440,000
" -okter mum 1 & Rp E0,000 Rp 3,+00,000 Rp EE0,000
" -okter !pesialis 1 & Rp 1,2+0,000 Rp 5,400,000 Rp ++0,000
C PENUNJANG DIAGNOSTIK
1 E!"#$%!'() a. Radiolo*i
C 1 posisi 1 ;lm
NO PEMERIKSAAN & TINDAKAN MEDIK SATUAN
TARIF
JASA PELAYANA
JASA MEDIS
PENDAPATANBLUD
BAHAN HABIS
PAKAI/SARANA
PRASARANA
" 8ora& #' 1 & Rp 320,000 Rp 300,000 Rp 550,000
'bdomen #' 1 & Rp 320 000 Rp 300 000 Rp 550 000
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" 'bdomen #' 1 & Rp 320,000 Rp 300,000 Rp 550,000
" #el7is '# 1 & Rp 320,000