39
2. Persalinan Normal Oleh Dokter Umum No
Kelas Perawatan Jasa Sarana
Jasa Pelayanan Jumlah
1 VIP
Rp 250,000 Rp 500,000
Rp 750,000 2
Kelas I Rp 200,000
Rp 400,000 Rp 600,000
3 KELAS II
Rp 150,000 Rp 300,000
Rp 450,000 4
KELAS III Rp 125,000
Rp 200,000 Rp 325,000
3. Persalinan Normal Oleh Perawat Bidan No
Kelas Perawatan Jasa Sarana
Jasa Pelayanan Jumlah
1 VIP
Rp 200,000 Rp 350,000
Rp 550,000 2
Kelas I Rp 150,000
Rp 300,000 Rp 450,000
3 KELAS II
Rp 120,000 Rp 250,000
Rp 370,000 4
KELAS III Rp 100,000
Rp 200,000 Rp 300,000
XII. Pelayanan Persalinan Dengan Tindakan 1. Persalinan Dengan Tindakan Oleh Dokter Spesialis
No Kelas Perawatan
Jasa Sarana Jasa Pelayanan
Jumlah
1 VIP
Rp 300,000 Rp 600,000
Rp 900,000 2
Kelas I Rp 200,000
Rp 475,000 Rp 675,000
3 KELAS II
Rp 150,000 Rp 360,000
Rp 510,000 4
KELAS III Rp 100,000
Rp 300,000 Rp 400,000
2. Persalinan Dengan Tindakan Oleh Dokter Umum No
Kelas Perawatan Jasa Sarana
Jasa Pelayanan Jumlah
1 VIP
Rp 300,000 Rp 480,000
Rp 780,000 2
Kelas I Rp 200,000
Rp 360,000 Rp 560,000
3 KELAS II
Rp 175,000 Rp 300,000
Rp 475,000 4
KELAS III Rp 150,000
Rp 270,000 Rp 420,000
XIII. Tindakan Obsgyn 1. Tindakan Curet, Marsupisialisasi, Extirpasi, Incici Abses Bartolini
No Jenis Tindakan
Jasa Sarana Jasa Pelayanan
Jumlah
1 VIP
Rp 450,000 Rp 1,005,000
Rp 1,455,000 2
Kelas I Rp 350,000
Rp 690,000 Rp 1,040,000
3 Kelas II
Rp 250,000 Rp 550,000
Rp 800,000 4
Kelas III Rp 150,000
Rp 430,000 Rp 580,000
2. Manual Placenta Oleh Dokter No
Jenis Tindakan Jasa Sarana
Jasa Pelayanan Jumlah
1 VIP
Rp 200,000 Rp 450,000
Rp 650,000 2
Kelas I Rp 150,000
Rp 260,000 Rp 410,000
3 Kelas II
Rp 120,000 Rp 200,000
Rp 320,000 4
Kelas III Rp 100,000
Rp 170,000 Rp 270,000
3. Digital Oleh Bidan No
Jenis Tindakan Jasa Sarana
Jasa Pelayanan Jumlah
1 VIP
Rp 200,000 Rp 300,000
Rp 500,000 2
Kelas I Rp 150,000
Rp 150,000 Rp 300,000
3 Kelas II
Rp 120,000 Rp 120,000
Rp 240,000 4
Kelas III Rp 100,000
Rp 100,000 Rp 200,000
40
VIII. Tindakan Medik Non Operatif No
Jenis Pelayanan
Jasa pelayanan Jasa
Sarana Kelas III
Kelas II Kelas I
VIP ICU
Neonatal
1 KATEGORI I
Rp 25,000 Rp 30,000
Rp 35,000 Rp 40,000
Rp 45,000 Rp 35,000
Rp. 50,000 2
KATEGORI II Rp 30,000
Rp 35,000 Rp 40,000
Rp 45,000 Rp 50,000
Rp 40,000 Rp. 60,000
3 KATEGORI III
Rp 40,000 Rp 45,000
Rp 50,000 Rp 55,000
Rp 60,000 Rp 50,000
Rp. 80,000 4
KATEGORI IV Rp 50,000
Rp 55,000 Rp 60,000
Rp 65,000 Rp 70,000
Rp 60,000 Rp. 100,000
IX. Pelayanan Tindakan Khusus Neonatus No
Jenis Tindakan Jasa Sarana
Jasa Pelayanan Jumlah
1 Fhototerapy per hari
Rp 39.600 Rp 15,000
Rp 54,600 5000
2 Resusitasi oleh Dokter. Spesialis
Rp 15,000 Rp 250,000
Rp 265,000 15000
3 Resusitasi oleh Dokter. Umum
Rp 15,000 Rp 150,000
Rp 165,000 15000
4 Resusitasi oleh perawat
Rp 15,000 Rp 80,000
Rp 95,000 15000
X. PELAYANAN DAN TINDAKAN PENUNJANG 1. Pelayanan Pemeriksaan Radio Diagnostik
a. Kelas VIP I dan II NO
Jenis Pelayanan BESAR TARIF Rp
KELAS VIP
Kelas 1 Kelas 2
JS J P
JML JS
J P JML
JS J P
JML A. Tanpa Kontras
1 Cranium AP PA
40,000 45,000
100,000 40,000
42,500 87,500
40,000 35,000
75,000 2
Cranium Lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
3 SPN Woters
40,000 45,000
100,000 40,000
42,500 87,500
40,000 35,000
75,000 4
SPN lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
5 Temporo Madibula Joint
80,000 72,000
182,000 80,000
72,500 162,500
80,000 56,000
136,000 6
Mastoid 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
7 Orbita
80,000 72,000
182,000 80,000
72,500 162,500
80,000 56,000
136,000 8
Maxila dan Zygomaticum 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
9 Mandibula PA dan Axila
80,000 72,000
182,000 80,000
72,500 162,500
80,000 56,000
136,000 10
Nasal Bone 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
11 Thorax AP PA
40,000 45,000
100,000 40,000
42,500 87,500
40,000 35,000
75,000 12
Thorax Lateral 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
13 Thorax Top Lordotic
40,000 60,000
115,000 40,000
52,500 97,500
40,000 50,000
90,000 14
Sternum Oblique 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
15 Sternum Lateral
40,000 60,000
115,000 40,000
52,500 97,500
40,000 50,000
90,000 16
Abdoment BNO Polos 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
17 BNO 3 POSISI
120,000 90,000
255,000 120,000
85,000 220,000
120,000 70,000
190,000 18
BNO 2 POSISI Wongstan 80,000
90,000 200,000
80,000 85,000
175,000 80,000
70,000 150,000
19 Pelvic AP
40,000 45,000
100,000 40,000
42,500 87,500
40,000 35,000
75,000 20
Pelvic Axial 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
21
Extrimitas Atas
a. Manus AP dan LatOblq 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
b. Wrist Joint AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
c. Antebrachi AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
d. Elbow Joint AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
e. Humerus AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
f. Shoulder Joint AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
g. Shoulder Joint Axila 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
41
h. Clavicula Axila 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
i. Scapula AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
j. Scapula Oblique 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
22
Extrimitas Bawah
a. Pedis AP dan LatObliq 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
b. Calcaneus Axial dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
c. Ankle Joint AP dan lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
d. Cruris AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
e. Genu AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
f. Femur AP dan Lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
g. Coxea AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
h. Coxea Oblique axial 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
i. Patella axial dan lat 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
23
Columna Vertebralis
a. Cervical AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
b. Cervical Lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
c. Cervical RAO LAO 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
d. Thoracal AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
e. Thoracal Lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
f. Thoraco RAO LAO 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
g. Lumbo sacral AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
h. Lumbo sacral Lateral 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
i. Lumbo sacral RAO LAO 80,000
72,000 182,000
80,000 72,500
162,500 80,000
56,000 136,000
j. Coxigius AP 40,000
45,000 100,000
40,000 42,500
87,500 40,000
35,000 75,000
k. Coxigius Lateral 40,000
27,000 82,000
40,000 30,000
75,000 40,000
21,000 61,000
24 Dental Gigi
25,000 40,000
75,000 25,000
30,000 60,000
25,000 25,000
50,000 25
Panoramic 40,000
60,000 115,000
40,000 52,500
97,500 40,000
50,000 90,000
26 Ultrasonografi USG
27,500 60,000
100,000 27,500
55,000 85,000
27,500 47,500
75,000
B. Dengan Kontras
1 Intra Vena Pylografi IVP
500,000 425,000
950,000 500,000
400,000 900,000
500,000 385,000
875,000 2
OMD Barium meal 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
3 Maag Deudenum Follow
tr 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
4 Colon In Loop
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000 5
Uretrografi 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
6 Uretro cystografi
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000 7
Cystografi 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
8 Fistulografi
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000 9
Hystero Salpingografi 300,000
255,000 580,000
300,000 235,000
535,000 300,000
210,000 500,000
10 Colesistografi
300,000 255,000
580,000 300,000
235,000 535,000
300,000 210,000
500,000
2. Kelas III, ICUneonatal dan Rawat Jalan NO
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