Hitungan Tarif Asuransi

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Ruangan Perawatan 1. VIP 3,250,000 30% 2. Kelas I 2,600,000 30% 3. Kelas II 1,950,000 30% 5. Kelas III 1,300,000 30% 6. ICU/NICU 6,500,000 30% 7. Perinatologi 2,600,000 30% Tarif Administrasi rawat jalan NO. KETERANGAN 1. Pasien baru + Kartu baru 2. Pasien lama 3. Penggantian kartu hilang 4. Buku pasien ibu 5. Buku pasien anak NO KETERANGAN 1. Dokter unit gawat darurat 2. Dokter poliklinik umum 3. Dokter poliklinik gigi 4 Poliklinik spesialis 4.1. Dokter anak 4.2. Dokter penyakit dalam 4.4 Dokter syaraf 4.5 Dokter bedah (umum/anak) 5. Konsultasi kandungan oleh bidan 6. Konsultasi gizi oleh ahli gizi 7. Tarif kamar perawatan umum / hari Jasa dokter,bidan & ahli gizi " rawat jalan " 4.3 Dokter kebidanan dan Konsultasi tim dokter spesialis

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Page 1: Hitungan Tarif Asuransi

Ruangan Perawatan1. VIP 3,250,000 30% 32500002. Kelas I 2,600,000 30% 26000003. Kelas II 1,950,000 30% 19500005. Kelas III 1,300,000 30% 13000006. ICU/NICU

6,500,000 30% 65000007. Perinatologi

2,600,000 30% 2600000

Tarif Administrasi rawat jalanNO. KETERANGAN

1. Pasien baru + Kartu baru

2. Pasien lama

3. Penggantian kartu hilang

4. Buku pasien ibu

5. Buku pasien anak

NO KETERANGAN1. Dokter unit gawat darurat2. Dokter poliklinik umum3. Dokter poliklinik gigi4 Poliklinik spesialis

4.1. Dokter anak4.2. Dokter penyakit dalam

4.3 Dokter kebidanan dan kandungan

4.4 Dokter syaraf4.5 Dokter bedah (umum/anak)

5. Konsultasi kandungan oleh bidan6. Konsultasi gizi oleh ahli gizi7. Konsultasi tim dokter spesialis luar RSIA

Tarif kamar perawatan umum / hari

Jasa dokter,bidan & ahli gizi " rawat jalan "

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No. JENIS KAMAR dan FASILITAS1. VIP2 Kelas I3. Kelas II4. Kelas III6. HCU/ICU/NICU

Tarif kamar perawatan Ibu dan Anak/hariNo. JENIS KAMAR dan FASILITAS

1. VIP2 Kelas I3. Kelas II4. Kelas III5. HCU/ICU/NICU6. Perinatologi7. VK

8. Ruanga Bayi Sehat

Tarif tambahan :1. Sinar lampu blue lift2. Inkubator3. Pasang CPAP4. Sewa CPAP

Tarif Visiting Rawat inapNo. KETERANGAN Visite

1 Kelas VIP 150,000 270,0002 Kelas I 135,000 220,0003 Kelas II 110,000 180,0005 Kelas III 90,000 150,0006 ICU/NICU 120,000 200,0007 Perinatologi 100,000 180,000

Dokter Spesialis (Rp)

Dokter Sub Spesialis (Rp)

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Tarif pemeriksaan diagnostik

No. PERIKSAANII I VIP

(Rp) (Rp) (Rp)1 EKG 80,000 85,000 90,0002 ISERTIA IUD 135,000 140,000 145,0003 ANGKAT IMPLANT 200,000 205,000 210,0004 HYDROTUBASI 135,000 140,000 145,0005 A.I.H 135,000 140,000 145,0007 DOPPLER BJJ/kali 50,000 55,000 60,0008 RESPIRATOR 55,000 60,000 65,000

Tarif Poliklinik kebidananNO. TINDAKAN1. USG 2D (Tanpa print)2. USG 2D (Print)3. USG (Tanpa film)4 USG Transvaginal5 USG (Print) Transvaginal6 USG 4D (Tanpa print)7 USG 4D (Print)8 Ekstraksi IUD9 Hidrotubasi/Partubasi10 Mikro Kuretase/ Biopsi Cervix15 A.I.H16 Kauterisasi18 Vaginal Toilet19 Pap Smear20 Pasang IUD21 Ekstraksi dan Insertie IUD22 Kultur Uap Vagina23 PCT/UPS (Uji Pasca Senggama)29 Ganti Pesarium30 Pasang Pesarium31 Angkat Pesarium32 Pasang Tampon33 Angkat Tampon34 Relaktasi35 Kontrol Jahitan SC

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Tarif persalinan

No. TINDAKAN II (Rp) I (Rp) VIP (Rp)1 Partus Normal 5500000 7500000 95000002 Partus Letak Sungsang 3200000 4200000 52000003 Partus Gemelly 3500000 4500000 55000004 Partus Placenta Manual 3200000 4200000 52000005 Partus Ekstraksi Vakum/Forceps 3600000 4600000 56000007 Partus ILA 4400000 5400000 64000009 Partus Induksi 3300000 4300000 5300000

10 Partus dengan Penyulit 5000000 6000000 700000011 Partus dengan Vaccum 6500000 8500000 950000012 Sectio Casaria (SC) 7500000 10000000 14000000

Tindakan khusus kebidananNo. TINDAKAN II (Rp) I (Rp) VIP (Rp)1 Incisi Exterpasi 2,700,000 3,700,000 4,700,0002 A.I.H (Inseminasi Buatan) 2,560,000 3,560,000 4,560,0003 Ekstraksi IUD, Anestesi Umum 2,950,000 3,950,000 4,950,0004 Angkat Implan 2,950,000 3,950,000 4,950,0005 Her Hecting 2,040,000 3,040,000 4,040,0006 Hecting Trauma 2,240,000 3,240,000 4,240,0007 Kuretase 1,750,000 3,750,000 4,750,0008 Kolpoperineorafi 2,500,000 3,500,000 4,500,00010 Tubektomi/Steril 6,250,000 7,250,000 8,250,00011 PPN 5,725,000 6,725,000 7,725,00012 Histerektomi 7,400,000 8,400,000 8,400,00013 Kistektomi & Miomektomi 10,000,000 11,000,000 12,000,000

Tarif home visit care

No. KETERANGAN1. Radius < 5 Km2. Radius 6-10 Km3. Radius > 11 Km

Tarif Poliklinik AnakNo. NAMA VAKSINA GENERIK

( Pasien yang melahirkan di RSIA Petukangan

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1. Polio (= Polio)2. Campak (= Campak)3. BCG (= BCG)4. DTP dan HB (=DTP dan Hepatitis B)5.6. PPD RT (2 TU), (= Mantoux)7. TT (= Tetanus Toxoid)B PATEN1. Hiberix (= Haemophilus Influenzae B)2. Havrix 720 (= Hepatitis A)3. Engerix - B 0.5 ml (= Hepatitis B)4. Infanrix (= DPT)5. Infanrix HiB (= DPT dan HiB)6.7. Pediacel (= DPT dan HiB dan Polio)8. Synflorix (= PVC/ Pneumococcus)9. Vaxigrip 0.25 ml (= Influenzae)10. Vaxigrip 0.5 ml (= Influenzae)11.

Tarif poliklinik GigiNo. JENIS TINDAKAN PERAWATAN A KONSERVASI GIGI1. Konsultasi Gigi Umum/Kontrol2. Tumpatan Sementara3. Tumpatan Amalgram 1 Sisi4. Tumpatan Amalgram 2 Sisi5. Tumpatan GIC Kecil6. Tumpatan GIC Sedang7. Tumpatan GIC Besar8. Tumpatan Komposit Kecil9. Tumpatan Komposi Sedang10. Tumpatan Komposi Besar11.

12. Bongkar Crown/Imlay/Onlay per Elemen13. Penutupan Pit & Fissure dengan Komposit14. Inlay/Onlay Logam15. Inlay/Onlay Logam Facing Porselain16. Labial Veneering Komposit

Hepatitis Rekombinian 0.5 ml (= Hepatitis B)

Infanrix IPV HiB (= DPT dan HiB dan Polio)

Pentabio 0.5 ml (= DPT dan HiB dan Hepatitis B)

Bongkar Restorasi Amalgram/Komposit per Elemen

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17. Labial Veneering Porselain18. Pin Stabilok/Post Screw per Buah19. Pasak Skrup per Buah20. Pasak Tuang per Buah21.22. Cementasi Sementara per Elemen23. Polishing per ElemenB ENDODONTIK1. Pulp Capping Direk/Indirek2. Endodontik One Visite Akar Tunggal3. Endodontik One Visite Akar Ganda4.5.6.7.

8.

9.

10. Trepanasi/Ganti Obat/Medikasi11. Open Bor/Devitalisasi Pulpa12. Pengisian Saluran Akar Tunggal13. Pengisian Saluran Akar Ganda Sederhana14. Pengisian Saluran Akar Ganda Kompleks15. Pengisian Saluran Akar Kondisi Khusus16.17. Bleaching Gigi Vital Paket 12 Elemen18. Pulpotomi/Mumifikasi per KunjunganC PERIODONTIK1.2.3.4. Kuret/Root Planing per Kuadran5. Kuret/Root Planing per Gigi6.

7. Gingivektomi per Kuadran8. Bedah Flap per Kuadran9. Frenektomi10. Splinting Ligature per Kuadran

Cementasi Inlay/Onlay/Crown Lepas per Elemen

Vital Pulpektomi & Eksterpasi Pulpa Akar TunggalVital Pulpektomi & Eksterpasi Pulpa Akar GandaPreparasi Saluran Akar Nonvital Akar TunggaPreparasi Saluran Akar Nonvital Akar Ganda Sederhana

Preparasi Saluran Akar Nonvital Akar Ganda Kompleks

Preparasi Saluran Akar Nonvital Akar Kondisi Khusus

Bleaching Gigi Nonvital per Gigi per Kunjungan

Pembersihan Karang Gigi Kelas I per RahangPembersihan Karang Gigi Kelas II per RahangPembersihan Karang Gigi Kelas III per Rahang

Kuret/Root Planing dengan Ties (Metronidazole) per Gigi

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11. Splinting Ligature per Gigi12.13. Occulusal Adjustment per Kuadran14. Pejahitan15. Buka Jahitan16. Gingival Pack per Kuadran17. Kontrol/PremedikasiD PROSTODONTIK1. Konsultasi2.

3. Mahkota Sementara4. Mahkota Metal Facing Akrylik5. Mahkota Metal Facing Porcelain6. Mahkota Maryland Bridge7. Mahkota/Onlay/Inlay Logam Penuh8. Onlay/Inlay Metal Porcelain9. Pasak Sekrup10. Pasak Tuang11. Pin Stabilok per Buah12. Cementasi Mahkota/Inlay/Omlay Lepas13. Cementasi Sementara14. Bongkar Crown/Inlay/Onlay15. Kontrol Protesa

GIGI TIRUAN SEBAGIAN LEPAS16.

17.

18.19.

20. Penambahan Gigi per ElemenGIGI TIRUAN PENUH LEPAS

21. GTP Akrylik Rahang Atas/Bawah22. GTP Akrylik Rahang Atas dan Bawah

LAIN-LAIN23. Reparasi Gigi Tiruan Tanpa Cetak24. Reparasi Gigi Tiruan Dengan Cetak25. Tambahan Klammer per Buah

Splinting Ligature per Gigi dengan Komposit

Mencetak Rahang Atas dan Rahang BawahMAHKOTA dan JEMBATAN (GIGI TIRUAN CEKAT)

Plat Akrylik dengan Satu Gigi per Rahang Atas/Bawah

Plat Metal dengan Satu Gigi per Rahang Atas/Bawah

Valplast dengan Satu Gigi per Rahang Atas/BawahPlat Kombinasi Metal & Valplast per Rahang Atas/Bawah

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26. Rebase27. RelineE BEDAH MULUT1.2.3. Pencabutan Gigi Permanen4. Pencabutan Gigi Permanen Komplikasi5. Pencabutan Gigi M3 Erupsi Sempurna6. Pencabutan Gigi Komplikasi dengan Flap7. Alveolektomi8. Apeks Reseksi dengan Pengisian9. Operkulektomi10. Odontektomi Kelas I

TARIF POLIKLINIK GIGINo. JENIS TINDAKAN PERAWATAN E BEDAH MULUT

11. Odontektomi Kelas II12. Odontektomi Kelas III13. Buka Jahitan/Kontrol14. Perawatan Dry Soket per Kunjungan15. EnukleasiF ORTHODONTIK1.2.3. Orthodonti Fixed Metal Kasus Ringan4. Orthodonti Fixed Metal Kasus Sedang5. Orthodonti Fixed Metal Kasus Berat6.7. Ganti Bracket, Kawat, Alat Lain8. Orthodonti Fixed Ceramic Kasus Ringan9. Orthodonti Fixed Ceramic Kasus Sedang10. Orthodonti Fixed Ceramic Kasus Berat11.12. Retensi Plat Akrylik per Rahang13. Retensi Transparan per Rahang14. Retensi Lingual Rahang Bawah15. Pasang Bracket Lepas per ElemenG PEDODONTIK1. Porcelain2. Pontic Porcelain

Pencabutan Gigi Susu dengan Topikal AnestesiPencabutan Gigi Susu dengan Lokal Anestesi

Orthodonti Lepasan per Rahang dan EkspansiKontrol Orthodonti Lepasan per Kunjungan

Kontrol Orthodonti Fixed Metal per Kunjungan

Kontrol Orthodonti Fixed Ceramic per Kunjungan

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3. All Metal Porcelain4. Inlay/Onlay5. Down/Pin6. Full Crown/Akrylik7. Tempron per Elemen8. Crown Metal Facing Akrylik9. Crown Metal Facing Porcelain10. Pontic Metal Facing Akrylik11. Pontic Metal Facing Porcelain12. Pontic Metal13. Frame Dental Full per Rahang14. Frame Dental Partial per Rahang15. Frame Dental Saddle per Unit16.

17. Penambahan/Elemen18. Full Denture Akrylik (New Italdent)19.

20.

21.

22.

23.24. Tiap Penambahan Gigi Porcelain25.26.27. Knop Klammer28. Rest29. Nance Holder30. Palatal/Lingual Arch31. Solder Quad Helix32. Solder per Point33. Solder Rapid Palatal Expander34. Inclined Plane35. Lingual Crib36. Expand Coffin37. Oral Screen38. Bionator

Partial Denture Akrylik Gigi Pertama (New Italdent)

Full Denture Akrylik Gigi Akrylik per Rahang (Ortholux)

Full Denture Akrylik Gigi Porcelain per Rahang per Gigi

Partial Denture Plat Akrylik dengan Gigi Akrylik Pertama

Partial Denture Plat Akrylik dengan Gigi Porcelain Pertama

Tiap Penambahan Gigi Akrylik (Ortholux)

Orthodonti Plat Tanpa Expansion Screw + SolderOrthodonti Plat Dengan Expansion Screw + Solder

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39. Bite Tracer40. Space Retainer41. Studi Model42. Reparasi Retak/Patah43. Occulusal Splint44. Obturator45. Prothesa Mata46. Prothesa Hidung47. Prothesa Telinga48. Prothesa Jari49. Rebasing/Relining50. Sendok Pribadi/Rahang51. Removable Retainer52. Removable Orthodontie Appliance53.

H LAIN-LAIN1. Tambalan Sementara per Elemen2.3.4.

5. Amalgam (tambalan permanen)6.7.8.9.10.11.12. Scalling Kecil13. Scalling Sedang14. Scalling Besar15. Pasang Tampon Gigi

TARIF INSTALASI GAWAT DARURAT (IGD)No. TINDAKAN1. Konsul Dokter Umum2. Konsul Dokter Spesialis

Removable Orthodontie Appliance with Expnatie Screw

Semi Permanen per Elemen (tambalan sementara)Pulp Capping per Elemen (tambalan sementara)Pit dan Fissur Sealant per Elemen (tambalan sementara)

GIC Cement per Elemen (tambalan permanen)GIC Filling per Elemen (tambalan permanen)Komposit Resin Kelas II/IV (tambalan permanen)Simple Ligh Cure Filling (tambalan permanen)Complex Ligh Cure Filling (tambalan permanen)Ligh Cure Labial Veneering (tambalan permanen)

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3. Konsul via Telepon Dokter Spesialis4. Pasang Bidai/Spalk5. Pertolongan Luka Bakar Kecil6. Pertolongan Luka Bakar Besar7. Defibrilasi8. Insisi/Cross Incision Benjolan9. Ekstraksi Kuku per Jari10. Dilatasi Phimosis11. Suctioning per Hari12. Jahitan Luka 1 s/d 5 Jahitan13. Jahitan Luka 6 s/d 10 Jahitan14. Jahitan Luka 11 Jahitan ke atas15. Ekstraksi Corpus Alienum16. Pasang Tampon Hidung17. Pasang Ransel Verban18. Surface Cooling19. Reposisi Mandibula20. Reposisi Sendi Bahu21. Gliserin Spuit (Tanpa Penyulit)22. Gliserin Spuit (Dengan Penyulit)23. Pemasangan Nasopharingael Tube24. Lavage Lambung25. Pasang NGT Darurat26. Sirkumsisi (Sunat) Darurat27. Punctie Kandung Kemih28. Punctie Pleura29. Irigasi Mata (per Sisi)30. Pemasangan/Pergantian Canula Trachea31. Vena Sectie32. Fiksasi/Spalk33. Bilas Kandung Kemih34. Bilas Lambung35. Plebotomi (Sampel Laboratorium)36. Pertologan Luka Robek Kecil/Sedang37. Pertologan Luka Robek Multiple38. Jahitan Permukaan Multiple39. Pasang Infus Dewasa oleh Perawat40. Pasang Infus Neonatus oleh Perawat41. Pasang Blood Set Dewasa oleh Perawat42. Pasang Infus Dewasa oleh Dokter Umum43. Pasang Infus Neonatus oleh Dokter

Umum

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44.45. Pasang Catheter oleh Perawat46. Nebulizer oleh Perawat47. Nebulizer (Ventolin) Anak48. Nebulizer (Ventolin) Dewasa49. Paket Suction Pump oleh Perawat

Tarif Instalasi Gawat Darurat (IGD)LAIN-LAIN

1. Room Charge 2-4 jam pertama2. Room Charge setiap 1 Jam berikutnya3. Room Charge Kamar Tindakan4. Instrumen Dasar 5. Instrumen Catheter6. Instrumen Hecting Up7. Instrumen Partus Set8. Instrumen Vena Sectie9. Instrumen Madrin10. Observasi 1 s/d 8 jam11. Observasi setiap 4 jam berikutnya12. Pasang Gips (BackSlab)13. Injeksi Intra Artikuler 2 Sendi Kecil14. Injeksi Intra Artikuler 2 Sendi Besar15. Injeksi Trigger Poin 4-8 Titik16. Injeksi Trigger Poin > 8 Titik

TARIF TINDAKAN UMUMNo. TINDAKAN1. Pasang NGT2. Pasang Dower Catheter3. Pasang Kondom Catheter4. Ganti Verban Kecil/Sedang5. Ganti Verban Besar6. Pasang Balut Elastis7. Angkat Jahitan8. Dressing

Pasang Blood Set Dewasa oleh Dokter Umum

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9. Transfusi Darah per Kantong10. Klisma11. Suntik 1x12. Suntik Berulang per Hari13. Irigasi Kolostomi14. Pemberian Kemoterapi15. Sunat Bayi Perempuan16. Tindik17. Bilas Kandung Kemih18. Suction Pump19. Pasang Catheter Umbilical20. Lepas Catheter Umbilical21. Oral Hygine22. Tindakan Efusipleura23. Pasang NST/CTG24. Pemeriksaan Echocardio ke luar25. Debridement Tanpa Bius Umum26. Sewa Monitor27. Panoramic Rujukan Luar

28. Lumbal Punksi29 Pemeriksaan Fungsi Luhur30 Pemasangan Longline31. Pemasangan CVP32. USG Intip Abdomen (Tanpa Print)33. USG Intip Abdomen (Dengan Print)

TARIF BEDAH

No TINDAKAN RJ/III (Rp)II

(Rp)

A OPERASI MINOR

1 Tumor Kulit < 1 cm 1,825,000 1,907,500

2 Angkat T. Tube 825,000 907,500

3 Insisi Abses < 1 cm 825,000 907,500

4 Insisi Biobsi 825,000 907,500

5 Pleurosintesis 825,000 907,500

6 Klavus < 1 cm 825,000 907,500

7 Core Biopsi 825,000 907,500

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8 Tumor Kulit < 1 cm 825,000 907,500

9 Ekstirpasi Tumor Kulit < 3 cm 825,000 907,500

10 Angkat Kuku 825,000 907,500

11 Insisi Abses Hematoma 825,000 907,500

12 Vena Secti 825,000 907,500

B OPERASI MODERATE 1

1 Tumor Kulit 1-3 cm 1,320,000 1,650,000

2 Insisi Abses 1-3 cm 1,320,000 1,650,000

3 Klavus 1-3 cm 1,320,000 1,650,000

4 Ekstirpasi Tumor Daerah Muka < 1 cm 1,320,000 1,650,000

5 Maetotomi 1,320,000 1,650,000

6 Jahitan Sekunder 1,320,000 1,650,000

7 Tumor Kulit/Asbes/Clavus > 3 cm 1,320,000 1,650,000

8 Biopsi Rectum 1,320,000 1,650,000

9 Rozer Plastry 1,320,000 1,650,000

10 Sirkumsisi (Sunat) 1,320,000 1,650,000

11 Explorasi Benda Asing 1,320,000 1,650,000

12 FAM < 3 cm 1,320,000 1,650,000

13 Labuloplastry 1,320,000 1,650,000

14 Operasi Tumor < 3 cm 1,320,000 1,650,000

15 Biopsi Tumor Rectum 1,320,000 1,650,000

16 Extirpasi Tumor Daerah Muka/Kulit 1,320,000 1,650,000

17 Sklerosing dan Rubber Band 1,320,000 1,650,000

18 Trakhestomi 1,320,000 1,650,000

19 Vasektomi 1,320,000 1,650,000

C OPERASI MODERATE 2

1 Operasi tumor 3-5 cm 1,485,000 1,815,000

2 Explorasi Benda Asing 1,485,000 1,815,000

D OPERASI MODERATE 3

1 Nekrotomi 1,815,000 2,310,000

2 Biopsi KGB Colli/Inguinal/Aksila < 2 cm 1,815,000 2,310,000

3 Pleuridesis 1,815,000 2,310,000

E OPERASI MAYOR 1.

1 Eksisi Ganglion 2,145,000 2,640,000

2 Explorasi Benda Asing Agak Dalam 2,145,000 2,640,000

3 Nekrotomi/Debridement 5-7 cm 2,145,000 2,640,000

4 Tumor Kulit 3-5 cm 2,145,000 2,640,000

5 FAM 3-5 cm 2,145,000 2,640,000

6 Biopsi KGB Colli/Inguinal/Aksila > 2 cm 2,145,000 2,640,000

7 Nekrotomi/Debridement 7-10 cm 2,145,000 2,640,000

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8 Tumor Kulit Jinak 5-7 cm 2,145,000 2,640,000

9 FAM 5-7 cm 2,145,000 2,640,000

10 Eksisi Hemangioma Superfisial < 5 cm 2,145,000 2,640,000

11 Tumor Kulit > 10 cm 2,640,000 3,300,000

12 Ganglion Poplitae 2,640,000 3,300,000

13 Eksisi Mammae Aberans 2,640,000 3,300,000

14 Debridement Luas 2,640,000 3,300,000

15 Nekrotomi Luas 2,640,000 3,300,000

16 Skin Graft 2,640,000 3,300,000

17 Apendiktomi 2,640,000 3,300,000

18 Herniotomi 2,640,000 3,300,000

19 Fistlektomi 2,640,000 3,300,000

20 Operasi BW 2,640,000 3,300,000

21 Operasi Palmo 2,640,000 3,300,000

22 Kolesistostomi 2,640,000 3,300,000

23 Haemoroidektomi 2,640,000 3,300,000

24 Tumor >7 cm 2,640,000 3,300,000

25 Sectio Alta 2,640,000 3,300,000

26 Orchidectomi 2,640,000 3,300,000

27 Extirpasi Ganglion Poplitae 2,640,000 3,300,000

28 Labioplasty 2,640,000 3,300,000

F OPERASI MAYOR 2

1 Apendiktomi dengan Perforasi Lokal/Inf 3,300,000 3,960,000

2 Herniotomi dan Reseksi Omentum 3,300,000 3,960,000

3 Gastrostomi 3,300,000 3,960,000

4 Jejunostomi 3,300,000 3,960,000

5 Reparasi Hernia Umbilikasi 3,300,000 3,960,000

6 Ileustomi 3,300,000 3,960,000

7 Multiple FAM 3,300,000 3,960,000

8 Continuos Ambulatory Peritonael Dealis 3,300,000 3,960,000

9 Kolostomi Lokal 3,300,000 3,960,000

10 Sub Cutaneus Mastectomi untuk Gynecon 3,300,000 3,960,000

G OPERASI MAYOR 3

1 Apendiktomi dengan Perforasi Umum 4,455,000 5,445,000

2 Herniotomi dengan Reseksi Anastosmasis 4,455,000 5,445,000

H OPERASI KHUSUS 1

1 Repair Hernia Umbilikalis 4,620,000 5,445,000

2 Eksisi Kista Duktus Thyroglosus 4,620,000 5,445,000

3 Apendiktomi dengan Insisi para Rectal 4,620,000 5,445,000

4 Kolesistostomi 4,620,000 5,445,000

5 Hernia Umbilikaslis 4,620,000 5,445,000

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6 Giant FAM 4,620,000 5,445,000

7 Tumor Piloides 4,620,000 5,445,000

8 Laparatomi Explorasi 4,620,000 5,445,000

9 Laparatomi + Apendiktomi 4,620,000 5,445,000

10 Open Cholecystomi 4,620,000 5,445,000

11 Laparatomi + Colostomi 4,620,000 5,445,000

12 Simple Mastectomi 4,620,000 5,445,000

13 Sub Total Lobectomi 4,620,000 5,445,000

14 Herniotomi + Mesh 4,620,000 5,445,000

15 Tutup Cholostomi 4,620,000 5,445,000

16 Palatoplasty 4,620,000 5,445,000

TARIF BEDAH

No TINDAKANII I

(Rp) (Rp)

I OPERASI KHUSUS 2

1 Eksisi Mammae Aberans Besar 5,115,000 5,445,000 6,270,000

2 Wide Eksisi 5,115,000 5,445,000 6,270,000

3 Herniotomi + Mesh (Residif) 5,115,000 5,445,000 6,270,000

4 Apendiktomi dengan Insisi Mediana 5,115,000 5,445,000 6,270,000

5 Laparatomi + Reaksi Anastomosis 5,115,000 5,445,000 6,270,000

6 Splenoktomi 5,115,000 5,445,000 6,270,000

7 Explorasi CDB + Tube 5,115,000 5,445,000 6,270,000

8 Simple Mastectomi + Skin Graft 5,115,000 5,445,000 6,270,000

9 Sub Total Tirodektomi 5,115,000 5,445,000 6,270,000

10 Total Labektomi 5,115,000 5,445,000 6,270,000

11 Pyelolitotomi 5,115,000 5,445,000 6,270,000

12 Cimino/Repair Cimino 5,115,000 5,445,000 6,270,000

13 Uretro Lithotomi 5,115,000 5,445,000 6,270,000

14 Nefrektomi 5,115,000 5,445,000 6,270,000

15 Laparatomi Explorasi + Pembebasan 5,115,000 5,445,000 6,270,000

16 Perlengkatan 5,115,000 5,445,000 6,270,000

J OPERASI KHUSUS 3

1 Sub Cutaneus Mastetomi Tumor Jinak 6,105,000 6,600,000 7,920,000

2 Apendiktomi dengan Insisi Mediana 6,105,000 6,600,000 7,920,000

3 Laparaskopi Cholecystectomi 6,105,000 6,600,000 7,920,000

4 Laparaskopi Apendiktomi 6,105,000 6,600,000 7,920,000

5 Laparaskopi Herniotomi 6,105,000 6,600,000 7,920,000

6 Miles 6,105,000 6,600,000 7,920,000

7 Reseksi Anterior 6,105,000 6,600,000 7,920,000

8 Kristo Jejunostomi 6,105,000 6,600,000 7,920,000

9 Gastro Jejunostomi 6,105,000 6,600,000 7,920,000

RJ/III/III Utama (Rp)

Page 17: Hitungan Tarif Asuransi

10 Bilio Digestif 6,105,000 6,600,000 7,920,000

11 Total Mastectomi 6,105,000 6,600,000 7,920,000

12 Total Paratidektomi 6,105,000 6,600,000 7,920,000

13 LAR 6,105,000 6,600,000 7,920,000

14 Gasterctomi 6,105,000 6,600,000 7,920,000

15 Reseksi Hepar 6,105,000 6,600,000 7,920,000

16 Reseksi Tumor Intra Abdomen 6,105,000 6,600,000 7,920,000

17 Anoplastry Definitif (DSA) 6,105,000 6,600,000 7,920,000

18 Hirch Definitif 6,105,000 6,600,000 7,920,000

K OPERASI KHUSUS 4

1 Whipe 7,260,000 7,920,000 9,570,000

2 Total Gasterctomi 7,260,000 7,920,000 9,570,000

3 RND 7,260,000 7,920,000 9,570,000

L OPERASI KHUSUS 5

1 Histerektomi Radikal 8,415,000 9,075,000 9,570,000

2 Surgical Staging 8,415,000 9,075,000 9,570,000

3 Wide Eksisi Vulva 8,415,000 9,075,000 9,570,000

M OPERASI KHUSUS 6

1 Ektenterasi 10,395,000 12,210,000 13,695,000

2 Vulvektomi Radikal 10,395,000 12,210,000 13,695,000

TARIF BEDAH

No TINDAKANII I

(Rp) (Rp)

N OPERASI LAIN

1 Keloid 4,500,000 5,000,000 5,500,000

2 Kutis dan subkutis 1,000,000 1,150,000 1,300,000

3 Genitalia Externa 1,000,000 1,150,000 1,300,000

4 Anuskopi 1,000,000 1,150,000 1,300,000

5 Kauterisasi 1,000,000 1,150,000 1,300,000

6 Insisi Dokter Umum 273,000 283,500 294,000

Page 18: Hitungan Tarif Asuransi

TARIF TINDAKAN ANAK/BAYINo. TINDAKAN

1

2 Pasang NGT

3 Lampu penghangat per Hari

4 Pompa ASI per Hari

5 Doppler BJJ per Hari

6 Sunat Bayi Perempuan

7 Tindik

8 Inhalasi Terapi (Tanpa Obat)

9 Inhalasi Terapi (Termasuk Obat)

10

11 Pemasangan CPAP ke-1

12 Pasang Infus Umbilikal

Pasang Infus Neonatus Anak/Bayi oleh Perawat

Inhalasi Terapi (Termasuk Obat), Chest Physiotherapy

Page 19: Hitungan Tarif Asuransi

TARIF TINDAKAN ICUNo. TINDAKAN

1 Pemasangan CVP

2 Pemasangan CPAP ke-1

3 Sewa Ventilator per Hari

4 Intubasi Anak

5 Intubasi Dewasa

6 Pemasangan NGT

7 Pembelian Darah per Kantong

8 Oksigen/Tabung per Hari

9 Ventilator + Oksigen per Hari

10 Oral Hygine

11 Pemasangan Dower Catheter

12 Decubitor per Hari

13 Bed Side Monitor

TARIF SEWA ALATNo. TINDAKAN

1 Ventilator per Hari

2 Bed Side Monitor

Page 20: Hitungan Tarif Asuransi

3 Mesin Anestesi

4 Monitor Anestesi

5 Apnu Alarm

6 Suction Pump

7 Decubitor per Hari

8 Syringe Pump

9 Infus Pump

10 Blood Warmer per Hari

11 Capnometry per Hari

12 Jaundicemeter per Kali

13 Patient Warmer per Kali

;314 Bilirubin Meter per Kali

15 Ekstaraktor Vacuum per Kali

16 ACT per Kali

Keterangan:

Khusus Tarif “VENTILATOR”, tambahan “Disposible Item”, dikenakan Tarif Tersendiri dilihat dari pemakaian.

Page 21: Hitungan Tarif Asuransi

TARIF PENUNJANG MEDIS RADIOLOGI

No TINDAKANII I VIP

(Rp) (Rp) (Rp)

1 USG Abdomen Atas 357,500 371,250 385,000

2 USG Abdomen Bawah 357,500 371,250 385,000

3 USG Abdomen Atas-Bawah 500,500 519,750 539,000

4 USG Thyroid 325,000 337,500 350,000

5 USG Mammae 325,000 337,500 350,000

6 USG Tractus Urinarius 325,000 337,500 350,000

7 USG Obstetri 325,000 337,500 350,000

8 USG Kepala 325,000 337,500 350,000

9 Sewa Alat USG Umum 195,000 202,500 210,000

10 Sewa Alat USG Keliling - - -

11 Pyelography I.V 845,000 877,500 910,000

12 318,500 330,750 343,000

13 Urethrography 695,500 722,250 749,000

14 Cystography 546,000 567,000 588,000

15 HSG 863,200 896,400 929,600

16 Creanium AP/LAT 143,000 148500 154,000

17 Sinus Paranasal 157,300 163,350 169,400

18 Mastoid 143,000 148500 154,000

19 Temporo Mandibular Joint 223,600 232,200 240,800

20 Mandibulla 143,000 148,500 154,000

21 Zygomaticum 143,000 148,500 154,000

22 Orbita 143,000 148,500 154,000

23 Os Nasal/Sella Tursica 143,000 148,500 154,000

24 Thorax 117,000 121,500 126,000

25 Thorax AP/LAT 171,600 178,200 184,800

26 Abdomen 117,000 121,500 126,000

27 Pelvis 117,000 121,500 126,000

28 Manus 117,000 121,500 126,000

29 Wrist Joint 117,000 121,500 126,000

30 Anetebrachi 117,000 121,500 126,000

31 Art. Cubiti 117,000 121,500 126,000

32 Humerus 117,000 121,500 126,000

33 Clavicula 117,000 121,500 126,000

34 Scapula 117,000 121,500 126,000

Appendicogram (Kontras beli di Instalasi Farmasi)

Page 22: Hitungan Tarif Asuransi

35 Art. Humeri 117,000 121,500 126,000

36 Art. Humeri Exo/Endo 228,800 237,600 246,400

37 Pedis 117,000 121,500 126,000

38 Ankle Joint 117,000 121,500 126,000

39 Calcaneus 117,000 121,500 126,000

40 Cruris (1 sisi) 143,000 148,500 154,000

41 Art Genu ( 1 sisi) 143,000 148,500 154,000

42 Art Genu Skyline 117,000 121,500 126,000

43 Femur (1 sisi) 143,000 148,500 154,000

44 Art. Coxae 117,000 121,500 126,000

45 Cervical AP/LAT 143,000 148,500 154,000

46 Cervical AP/LAT/Oblique 228,800 237,600 246,400

47 Thoracolumbal AP/LAT 143,000 148,500 154,000

48 Thoracal AP/LAT 171,600 121,500 184,800

49 Thoracal AP/LAT/Oblique 243,100 252,450 261,800

50 Lumbosacral AP/LAT 171,600 121,500 184,800

TARIF PENUNJANG MEDIS RADIOLOGI

No TINDAKANII I VIP

(Rp) (Rp) (Rp)

51 Lumbosacral AP/LAT/Oblique 243,100 252,450 261,800

52 Sacrum 157,300 163,350 169,400

53 Bone Survey (Tanpa Tulang Panjang) 858,000 891,000 924,000

54 Bone Survey (Dengan Tulang Panjang) 1,430,000 1,485,000 1,540,000

55 Top Lordotik 117,000 121,500 126,000

56 Dental Foto 71,500 74,250 77,000

57 Toplordotik 117,000 121,500 126,000

TARIF PENUNJANG MEDIS LABORATORIUM

No TINDAKANII I VIP

(Rp) (Rp) (Rp)

A HEMATOLOGI

1 Hema 1 (Hb, Ht, L, T) 84,500 87,750 91,000

2 Hema 2 (Hema 1, Diff, LED, E) 88,400 91,800 95,200

3 Hema 2 (Hema 2, Rt) 143,000 148,500 154,000

Page 23: Hitungan Tarif Asuransi

4 Hitung Jenis/Diff Count 39,000 40,500 42,000

5 Gambaran Darah Tepi (GDT) 208,000 216,000 224,000

6 Retikulosit (Rt) 65,000 67,500 70,000

7 Index Eritrosit: (MCV, MCH, MCHC) 52,000 54,000 56,000

8 Malaria 65,000 67,500 70,000

9 Mikrofilaria 65,000 67,500 70,000

10 Blooding Time (BT0/Chloting Time (CT) 32,500 33,750 35,000

11 Laju Endap Darah (LED) 36,400 37,800 39,200

12 Golongan Darah (Goldar) 45,500 47,250 49,000

13 Viskositas Darah 104,000 108,000 112,000

14 G-6PD 312,000 324,000 336,000

B KIMIA DARAH

1 Lemak Darah:

a. Cholesterol Darah 52,000 54,000 56,000

b. Trigliserida 52,000 54,000 56,000

c. HDL Cholesterol 58,500 60,750 63,000

d. LDL Cholesterol 52,000 54,000 56,000

234,000 243,000 252,000

f. Total Lipid 87,100 90,450 93,800

2 Fungsi Ginjal:

a. Ureum 45,500 47,250 49,000

b. Creatinin 45,500 47,250 49,000

c. Asam Urat (Urid Acid) 45,500 47,250 49,000

d. Paket RFT : Ureum,Creatinin, Asam Urat 130,000 135,000 140,000

e. Creatinin Clearens Test (CCT) 97,500 101,250 105,000

3 Fungsi Hati:

a. Total Protein 58,500 60,750 63,000

b. Albumin 58,500 60,750 63,000

169,000 175,500 182,000

d. Bilirubin Total 58,500 60,750 63,000

e. Bilirubin Total Bayi 58,500 60,750 63,000

f. Bilirubin Direk 58,500 60,750 63,000

169,000 175,500 182,000

h. SGOT 46,800 48,600 50,400

i. SGPT 46,800 48,600 50,400

j. Gamma GT 78,000 81,000 84,000

k. Alkali Phosfatase 62,400 64,800 67,200

l. Globulin 58,500 60,750 63,000

TARIF PENUNJANG MEDIS LABORATORIUM

No TINDAKAN RJ/III (Rp) II (Rp) I (Rp)

e. Lemak lengkap : cholesterol, trigliserida, HDL Cholesterol, LDL Cholesterol

c. Paket Protein: total protein, albumin, globulin

g. Paket Bilirubin : Bilirubin Total, direk, indirek

Page 24: Hitungan Tarif Asuransi

B KIMIA DARAH

4 Fungsi Jantung:

a. LDH 90,000 117,000 121,500

b. CK 130,000 169,000 175,500

c. CKMB 250,000 325,000 337,500

d. Paket Enzim Jantung : LDH, CK, CKMB 470,000 611,000 634,500

e. Troponin T 325,000 422,500 438,750

5 Diabetes (DM):

a. Glukosa Sewaktu 28,000 36,400 37,800

b. Glukosa Puasa 28,000 36,400 37,800

c. Glukosa 2 jam, PP 28,000 36,400 37,800

d. Glukosa Puasa & 2 Jam PP 28,000 36,400 37,800

e. Glukosa Toleransi Test Oral (GGTO) 99,000 128,700 133,650

f. HbA1C 195,000 253,500 263,250

g. Keton Darah 40,000 52,000 54,000

C ELEKTROLIT dan ANALISA GAS DARAH

1 Analisa Gas Darah (AGD)/Astrup 193,000 250,900 260,550

2 Elektrolit (Na, K, Cl) 220,000 286,000 297,000

3 Calcium Total 61,000 79,300 82,350

4 Calsium Ion 198,000 257,400 267,300

5 Paket 1 (AGD, Elektrolit) 352,000 457,600 475,200

6 Paket 2 (AGD, Elektrolit, Calcium Ion) 462,000 600,600 623,700

D HEMOSTATIS

1 PT 176,000 228,800 237,600

2 APTT 110,000 143,000 148,500

3 INR 165,000 214,500 222,750

4 Masa Trombin (TT) 154,000 200,200 207,900

5 D-Dimer 451,000 586,300 608,850

6 Fibrinogen 176,000 228,800 237,600

7 Agregasi Trombosit 264,000 343,200 356,400

E IMUNOSEROLOGI

1 HBsAg 121,000 157,300 163,350

2 Anti HBsAg 138,000 179,400 186,300

3 HbeAg 341,000 443,300 460,350

4 Anti Hbe 413,000 536,900 557,550

5 Anti HAVlgM 308,000 400,400 415,800

6 WIDAL 84,000 109,200 113,400

7 NSI Ag 330,000 429,000 445,500

8 Anti Dengue lgG/lgM 330,000 429,000 445,500

9 Paket (NSI Ag Anti Dengue lgG/M) 440,000 572,000 594,000

10 Anti Salmonella lgM (Tubex TF) 209,000 271,700 282,150

11 Asto Kualitatif 88,000 114,400 118,800

12 Asto Kuantitatif 132,000 171,600 178,200

Page 25: Hitungan Tarif Asuransi

13 RF Kualitatif 88,000 114,400 118,800

14 Rf Kuantitatif 132,000 171,600 178,200

15 CRP Kualitatif 99,000 128,700 133,650

16 CRP Kuantitatif 215,000 279,500 290,250

TARIF PENUNJANG MEDIS LABORATORIUM

No TINDAKAN II (Rp) I (Rp)

F TIROID

1 FT3 386,100 400,950

2 FT4 328,900 341,550

3 TSHs 257,400 267,300

4 T3 (Total) 236,600 245,700

5 T4 (Total) 236,600 245,700

6 AFP 314,600 326,700

7 CEA 293,800 305,100

8 CA 15-3 (Breast) 572,000 594,000

9 CA 19-9 (Pancreas) S 643,500 668,250

10 PSA Total 414,700 430,650

11 Free PSA 843,700 876,150

G URINALISA

1 Urine Lengkap 54,600 56,700

2 Glukosa Urine/Reduksi Urine 28,600 29,700

3 Keton Urine 28,600 29,700

4 Bilirubin Urine 28,600 29,700

5 Protein Urine Kualitatif 28,600 29,700

6 Protein Urine Kuantitatif 55,900 58,050

7 Protein Bence Jones 67,600 70,200

8 Sedimen Urine 28,600 29,700

9 HCG Urine (Tes Kehamilan) 100,100 103,950

10 Paket Narkoba (A, M, THC) 299,000 310,500

11 Amphetamine (A) 117,000 121,500

12 Morphine (M) 117,000 121,500

13 THC 117,000 121,500

H FEACES

1 Feaces Lengkap 71,500 74,250

2 Darah Samar 107,900 112,050

3 Paket Feaces (Feaces Lengkap, Darah Samar) 153,400 159,300

I MIKROBIOLOGI

1 Darah 393,900 409,050

2 Urine 371,800 386,100

3 Feaces 429,000 445,500

Page 26: Hitungan Tarif Asuransi

4 Sputum 429,000 445,500

5 Secret 429,000 445,500

6 Swab 429,000 445,500

7 Pus 429,000 445,500

J BAKTERIOLOGI

1 Pewarnaan BTA 3x 71,500 74,250

2 Pewarnaan Gram 71,500 74,250

3 Perapatan GO 71,500 74,250

4 Rectal Swab 65,000 67,500

K TORCH

1 Anti Toxoplasma lgA 286,000 297,000

2 Anti Toxoplasma lgG 286,000 297,000

3 Anti Rubella lgG 386,100 400,950

4 Anti Rubella lgM 293,800 305,100

TARIF MEDICAL CHECK UP (MCU)No. PEMERIKSAANA1 Darah lengkap/Hema 22 Urine rutin3 SGOT4 SGPT5 Ureum6 Creatinin7 HCG Urine (Tes Kehamilan)

SUB TOTAL8 Paket narkoba

TOTALB LENGKAP1 Darah lengkap/Hema 22 Urine rutin3 SGOT4 SGPT5 Ureum6 Creatinin7 Faeces rutin8 Cholesterol

CALON KARYAWAN/KARYAWAN/MAHASI

SWA

Page 27: Hitungan Tarif Asuransi

9 Urin acid10 Glukosa puasa11 Glukosa 2 jam, PP

TOTALC SEDERHANA1 Darah lengkap/Hema 22 Urine rutin3 Glukosa sewaktu

TOTAL

TARIF MOBIL (AMBULAN dan JENAZAH)No WILAYAH II (Rp) I (Rp) VIP (Rp)A EVAKUASI MEDIS (MOBIL AMBULAN IGD)1 Zona 1 (1 s/d 5) Km 193700 201150 2086002 Zona 2 (Diatas 5 s/d 10) Km 228800 237600 2464003 Zona 3 (Diatas 10 s/d 15) Km 300300 311850 3234004 Zona 4 (Diatas 15 s/d 20) Km 429000 445500 4620005 Zona 5 (Diatas 20 Km) 536900 557550 578200B MOBIL JENAZAH (Kerjasama Pihak Luar RSIA)1 DKI JAKARTA

1. Jakarta Barat - - -2. Jakarta Utara - - -3. Jakarta Pusat - - -4. Jakarta Timur - - -5. Jakarta Selatan - - -

2 BANTEN: - - -1. Depok - - -

Keterangan :

Tarif dapat berubah sewaktu-waktu

Page 28: Hitungan Tarif Asuransi

2. Curug - - -3. Tanggerang - - -4. Teluk Naga - - -5. Kresek - - -6. Cipondoh - - -7. Tiga Raksa - - -8. Rajeg - - -9. Mauk - - -10. Ciledug - - -11. Cisoka - - -12. Balaraja - - -13. Kronjo - - -14. Sapatan - - -15. Pasar Kemis - - -16. Cikupa - - -17. Pondok Aren - - -18. Pamulang - - -19. Ciputat - - -20. Batu Ceper - - -21. Legok - - -22. Jati Uwung - - -23. Serpong - - -

TARIF LAINNo KETERANGAN1 Pengurusan Akta Lahir2.

Penentuan Zona dilihat dari informasi pada website Google Maps.

Bea Materai Rp 6000 (Ranap/Rajal/Jual Bebas)

Page 29: Hitungan Tarif Asuransi

TARIF KHUSUS (CPAP Prorata di Perina)Harga Pemakaian : Rp 3.500.000 per Hari

No KETERANGAN1 0-6 Jam2 6-12 Jam3 12-18 Jam4 18-24 Jam

TARIF KHUSUS (CPAP Prorata di ICU)Harga Pemakaian : Rp 3.800.000 per Hari

No. KETERANGAN1 0-6 Jam2 6-12 Jam3 12-18 Jam4 18-24 Jam

TARIF KHUSUS (VENTILATOR Prorata)Harga Pemakaian : Rp 1.000.000 per Hari

No. KETERANGAN1 0-6 Jam2 6-12 Jam3 12-18 Jam4 18-24 Jam

TARIF KHUSUS (O2)No. KETERANGAN1 1-3 Liter/menit2 Diatas 3 liter/menit

Page 30: Hitungan Tarif Asuransi

I VIP

(Rp) (Rp)

OPERASI MINOR

1,072,500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

Page 31: Hitungan Tarif Asuransi

1..072.500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

1,072,500 1,237,500

OPERASI MODERATE 1

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000

1,980,000 2,475,000

1..980.000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

1,980,000 2,475,000

OPERASI MODERATE 2

2,310,000 2,805,000

2,310,000 2,805,000

OPERASI MODERATE 3

2,805,000 3,465,000

2,805,000 3,465,000

2,805,000 3,465,000

OPERASI MAYOR 1.

3,300,000 3,960,000

3,300,000 3,960,000

3,300,000 3,960,000

3,300,000 3,960,000

3,300,000 3,960,000

3,300,000 3,960,000

3,300,000 3,960,000

2..475.000

Page 32: Hitungan Tarif Asuransi

3,300,000 3,960,000

3,300,000 3,960,000

3,300,000 3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

3,960,000

OPERASI MAYOR 2

4,785,000

4,785,000

4,785,000

4,785,000

4,785,000

4,785,000

4,785,000

4,785,000

4,785,000

4,785,000

OPERASI MAYOR 3

6,600,000

6,600,000

OPERASI KHUSUS 1

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

Page 33: Hitungan Tarif Asuransi

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

7,095,000

VIP

(Rp)

OPERASI KHUSUS 2

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

7,920,000

OPERASI KHUSUS 3

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

Page 34: Hitungan Tarif Asuransi

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

9,570,000

OPERASI KHUSUS 4

11,220,000

11,220,000

11,220,000

OPERASI KHUSUS 5

14,025,000

14,025,000

14,025,000

OPERASI KHUSUS 6

17,325,000

17,325,000

VIP

(Rp)

OPERASI LAIN

5,500,000

1,300,000

1,300,000

1,300,000

1,300,000

294,000

Page 35: Hitungan Tarif Asuransi

VIP (Rp)

Page 36: Hitungan Tarif Asuransi

KIMIA DARAH

126,000

182,000

350,000

658,000

455,000

39,200

39,200

39,200

39,200

138,600

273,000

56,000

ELEKTROLIT dan ANALISA GAS DARAH

270,200

308,000

85,400

277,200

492,800

646,800

HEMOSTATIS

246,400

154,000

231,000

215,600

631,400

246,400

369,600

IMUNOSEROLOGI

169,400

193,200

477,400

578,200

431,200

117,600

462,000

462,000

616,000

292,600

123,200

184,800

Page 37: Hitungan Tarif Asuransi

123,200

184,800

138,600

301,000

VIP (Rp)

TIROID

415,800

354,200

277,200

254,800

254,800

338,800

316,400

616,000

693,000

446,600

908,600

URINALISA

58,800

30,800

30,800

30,800

30,800

60,200

72,800

30,800

107,800

322,000

126,000

126,000

126,000

FEACES

77,000

116,200

165,200

MIKROBIOLOGI

424,200

400,400

462,000

Page 38: Hitungan Tarif Asuransi

462,000

462,000

462,000

462,000

BAKTERIOLOGI

77,000

77,000

77,000

70,000

TORCH

308,000

300,008

415,800

316,400