XVII. TINDAKAN INSTALASI BEDAH PUSAT (DALAM KAMAR OPERASI) A. BEDAH DIGESTIVE 1. Sedang I - Tarif Kelas III TINDAKAN INSTALASI BEDAH PUSAT DALAM KAMAR OPERASI
J S J P JLH ( Rp ) ( Rp ) ( Rp )
RSUP. H. ADAM MALIK TAHUN ANGGARAN 2014
NO J E N I S P E L A Y A N A N BESARAN TARIF TA. 20143
4
5 XVII. TINDAKAN INSTALASI BEDAH PUSAT (DALAM KAMAR OPERASI)
1
2
A. BEDAH DIGESTIVE
3 Hemoridectomy Parsial Rubber 1,404,000 936,000 2,340,000
32 Diverticulectomy (Divertikel M) 2,532,000 1,688,000 4,220,000
19 Laparotomy VC 2,532,000 1,688,000 4,220,000
20 Transeksi esofagus 2,532,000 1,688,000 4,220,000
21 Adesiolis sed. Usus 2,532,000 1,688,000 4,220,000
22 Splenorafi/Splenectomy 2,532,000 1,688,000 4,220,000
23 Operasi Appendicities perforata 2,532,000 1,688,000 4,220,000
24 Drainase abses periappendix 2,532,000 1,688,000 4,220,000
25 Eksisi luas tumor dinding abdomen 2,532,000 1,688,000 4,220,000
26 Eksisi Tumor intra/retro peritonial 2,532,000 1,688,000 4,220,000
27 Repair "wound distruption" Dindi 2,532,000 1,688,000 4,220,000
28 Repair hernia insionalis 2,532,000 1,688,000 4,220,000
29 Operasi notaras (Prolaps Rekti) 2,532,000 1,688,000 4,220,000
30 Repair sprincterectomy 2,532,000 1,688,000 4,220,000
31 Kolostomy/Ileustomy 2,532,000 1,688,000 4,220,000
33 Pankreatorafi Sederhana 2,532,000 1,688,000 4,220,000
17 Open cholecisectomy 2,532,000 1,688,000 4,220,000
34 Diagnosa Peritonial lauvage 2,532,000 1,688,000 4,220,000
35 Pankreaktorafi sederhana 2,532,000 1,688,000 4,220,000
36 Diagnosa peritoneal lauvage 2,532,000 1,688,000 4,220,000
37 Fistelectomy Anal 2,532,000 1,688,000 4,220,000
4. Khusus I
1 Eks. Tumor lbh besar 10 cm intra/retro 4,050,000 2,700,000 6,750,000
2 Reseksi kolon transversum 4,050,000 2,700,000 6,750,000
3 Hemikolectomy kanan/kiri 4,050,000 2,700,000 6,750,000
4 Low anterior resection/sphinct 4,050,000 2,700,000 6,750,000
5 Hartman procedures 4,050,000 2,700,000 6,750,000
6 Operasi Heller (Achalasia - Esofagus) 4,050,000 2,700,000 6,750,000
7 Funduplikasi Esofagus (Anti Ref) 4,050,000 2,700,000 6,750,000
8 Berbagai macam Vagotomi 4,050,000 2,700,000 6,750,000
18 Eksplorasi duktus Koledektus 2,532,000 1,688,000 4,220,000
16 Lateral spinchterectomy 2,532,000 1,688,000 4,220,000
4 Gastroctomy Temporer 1,404,000 936,000 2,340,000
3 Hemoroidectomy sirkuler 2,532,000 1,688,000 4,220,000
5 Biopsi Hepar dengan Jamur 1,404,000 936,000 2,340,000
6 Biopsi Tumor Intra Abdominal dgn ins.Sd 1,404,000 936,000 2,340,000
7 Ekstirpasi Polip Recti Trans An. 1,404,000 936,000 2,340,000
8 Pemasangan Flocare 1,404,000 936,000 2,340,000
9 Ekstraksi benda asing di saluran cerna bagian atas/bawah 1,404,000 936,000 2,340,000
10 Hemostasis saluran cerna bagian Atas/bawah 1,404,000 936,000 2,340,000
11 Savary Baogic 1,404,000 936,000 2,340,000
12 Skleroterapi varises Esofagus 1,404,000 936,000 2,340,000
2. Sedang II
1 Apendoktomi Perforata 1,968,000 1,312,000 3,280,000
3. Besar
1 Herniorafi dengan Mesh 2,532,000 1,688,000 4,220,000
2 Herniorafi dengan penyulit (inker) 2,532,000 1,688,000 4,220,000
4 Fistulectomy "High Anal" / Beral 2,532,000 1,688,000 4,220,000
15 Repair Sed. Perforasi usus halus 2,532,000 1,688,000 4,220,000
5 Laparactomy eksplorasi 2,532,000 1,688,000 4,220,000
6 Kolesistectomy terbuka 2,532,000 1,688,000 4,220,000
7 Drainase abses hepar 2,532,000 1,688,000 4,220,000
8 Repair sed. Perforasi lambung 2,532,000 1,688,000 4,220,000
9 Drainase ekst. Abses/kista panker 2,532,000 1,688,000 4,220,000
2 Appendictomy tanpa penyulit 1,404,000 936,000 2,340,000
1 Herniorafi tanpa penyulit 1,404,000 936,000 2,340,000
9 Drainase ekst. Abses/kista panker 2,532,000 1,688,000 4,220,000
10 Jahitan sed.Ruptur hati (Hepato) 2,532,000 1,688,000 4,220,000
11 Ligasia A hepatika 2,532,000 1,688,000 4,220,000
1. Sedang I
13 Reseksi/Eksisi baji anestomosis 2,532,000 1,688,000 4,220,000
14 Drainase perianal fistula sederhana 2,532,000 1,688,000 4,220,000
12 Eksterpasi kista Hepar (kecil) 2,532,000 1,688,000 4,220,000
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
4 Debriment Ulang Vaskuler/Debriment dengan amputasi mayor/minor 1,404,000 936,000 2,340,000
9 Thrombektomi/Lysis dengan catheter for vein 1,404,000 936,000 2,340,000
8 Reapir Komplikasi AV Shunt 1,404,000 936,000 2,340,000
2,340,000
7 Rekontruksi Vaskuler Sederhana 1,404,000 936,000
6 Flebektomi 1,404,000 936,000 2,340,000
5 Resciotomi 1,404,000 936,000 2,340,000
3 Ekstirpasi Fibroma 1,404,000 936,000 2,340,000
2. Sedang II
2,340,000
2 Ligasi vena periver dengan lokal anasthesi 1,404,000 936,000
1 Sclerotherapy vena periver 1,404,000 936,000 2,340,000
1. Sedang I
4 Extended cholecystetomy 10,800,000 7,200,000 18,000,000
3 Reseksi Esofagus + Interposisi Kolon 10,800,000 7,200,000 18,000,000
10 Double Lumen 1,404,000 936,000 2,340,000
1 Semua tindakan yang dilakukan dengan narkose rengau 1,968,000 1,312,000
1 Pancreaktomi 10,800,000 7,200,000 18,000,000
3 Operasi Tumor pembuluh darah 2,532,000 1,688,000 4,220,000
8 Embolectomy 2,532,000 1,688,000 4,220,000
7 Amputasi Gangron 2,532,000 1,688,000 4,220,000
6 Simpatektomi 2,532,000 1,688,000 4,220,000
4,220,000
5 Graf vena membuat A vistula 2,532,000 1,688,000
4 Pendarahan karena kerusakan pembuluh darah 2,532,000 1,688,000 4,220,000
2 Solenektomi 2,532,000 1,688,000 4,220,000
3,280,000
1 Semua tindakan yang dilakukan dengan narkose dan mempunyai risiko 2,532,000 1,688,000 4,220,000
3. Besar
5 Eksplorasi Abses Multiple 1,968,000 1,312,000 3,280,000
4 Cimino Ulang 1,968,000 1,312,000 3,280,000
3 Cimino 1,968,000 1,312,000 3,280,000
2 Penyakit pembuluh darah perifer 1,968,000 1,312,000 3,280,000
2 Koledocoduodenostomy 10,800,000 7,200,000 18,000,000
6 Khusus III
9 Terminal esofagus-Proxim (Teps) 4,050,000 2,700,000 6,750,000
17 Total Colectomy 4,050,000 2,700,000 6,750,000
23 Laparaskopik Kolesistektomi 4,050,000 2,700,000 6,750,000
22 Reseksi Hepar/Labektomi/Segmen 4,050,000 2,700,000 6,750,000
21 Prosedur By Pass Traktus Gasir 4,050,000 2,700,000 6,750,000
20 Repair Hernia Hiatus Esofagus 4,050,000 2,700,000 6,750,000
19 Debulking Tumor 4,050,000 2,700,000 6,750,000
18 Bypass Pseudocysat pancreas 4,050,000 2,700,000 6,750,000
16 Stappler Haemorrhoidectomy 4,050,000 2,700,000 6,750,000
25 Repair Enterocutaneous Fistel 4,050,000 2,700,000 6,750,000
15 Laparascopy Fundus Ligasi 4,050,000 2,700,000 6,750,000
14 Laparascopy Biopsi 4,050,000 2,700,000 6,750,000
13 Laparascopy diagnostic 4,050,000 2,700,000 6,750,000
12 Adhesiolisis usus dengan penyulit 4,050,000 2,700,000 6,750,000
11 Repair Entero 4,050,000 2,700,000 6,750,000
10 Transeksi esofagus 4,050,000 2,700,000 6,750,000
24 Mega Kolon Hierchprung 4,050,000 2,700,000 6,750,000
26 Kolesistektomi 4,050,000 2,700,000 6,750,000
5 Reseksi Hepar Major 5,850,000 3,900,000 9,750,000
36 Pelvic Exenteration 4,050,000 2,700,000 6,750,000
4 Spelenektomi 5,850,000 3,900,000 9,750,000
3 Laparascopy Appendictomy 5,850,000 3,900,000 9,750,000
2 Operasi Miles 5,850,000 3,900,000 9,750,000
1 Operasi Bill Roth I/II 5,850,000 3,900,000 9,750,000
1 Operasi Bill Roth I/II 5,850,000 3,900,000 9,750,000
5 Khusus II
35 Laparascopy Hemicolectomy kanan/kiri 4,050,000 2,700,000 6,750,000
27 Relaparastomy 4,050,000 2,700,000 6,750,000
34 Laparascopy Mile's Operation 4,050,000 2,700,000 6,750,000
33 Total Gastrectomy 4,050,000 2,700,000 6,750,000
32 Explore CBD Tube 4,050,000 2,700,000 6,750,000
31 Embilisasi Vena porta 4,050,000 2,700,000 6,750,000
30 Long Mire's Operation 4,050,000 2,700,000 6,750,000
29 PTDB (open) 4,050,000 2,700,000 6,750,000
28 Repair Enterokutaneus fistula 4,050,000 2,700,000 6,750,000
B. BEDAH VASKULER
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
4. Khusus I
7 Rekonstruksi vaskuler aneurisma perifer 10,800,000 7,200,000 18,000,000
12 Rekonstruksi kerusakan katup vena dalam tungkai pada DVT Kronik atau 10,800,000 7,200,000 18,000,000
11 Eksplorasi dan rekonstruksi vaskuler pada trauma vaskuler akut 10,800,000 7,200,000 18,000,000
10 Karotis endarterektomi 10,800,000 7,200,000 18,000,000
18,000,000
9 Rekonstruksi vena-vena abdomen pelvis 10,800,000 7,200,000
8 AV Shunt dengan graft vena/sintetis 10,800,000 7,200,000 18,000,000
5 Rekonstruksi komplikasi AV Shunt (pseudoaneurisma) 10,800,000 7,200,000 18,000,000
6 Rekonstruksi komplikasi pasca trauma (AV fistula/ pseudoaneurisma) 10,800,000 7,200,000 18,000,000
14 Rekonstruksi vaskuler pada AAA/arteri iliaka per laparotomi 10,800,000 7,200,000
18,000,000
4 Eksisi luas malformasi vaskuler 10,800,000 7,200,000
3 Eksisi & rekonstruksi vaskuler pada malformasi vaskuler 10,800,000 7,200,000 18,000,000
2 Graf Vena membuat A Vistula 10,800,000 7,200,000 18,000,000
1 Splenektomi ec. Hipertensi Portal/kelainan hematologi lain 10,800,000 7,200,000 18,000,000
6. Khusus III
13 Rekonstruksi vaskuler arteri tungkai/lengan pada Chronic Critical Limb 10,800,000 7,200,000 18,000,000
15 Rekonstruksi vaskuler pada AAA dan arteri tungkai 10,800,000 7,200,000 18,000,000
18,000,000
7 Angkat K. Wire Multi dgn GA ( 2 Wire ) 1,968,000 1,312,000 3,280,000
13 Eksterpasi Tumor Jinak Kulit dan Bawah Kulit ( Sub Kutis ) diameter > 2 cm 1,968,000 1,312,000 3,280,000
12 Incisi Hematomi Kulit dgn diameter lebih dari 2 cm dgn GA 1,968,000 1,312,000 3,280,000
11 Excisi Keloid dgn diameter lebih dari 2 cm dgn GA 1,968,000 1,312,000 3,280,000
3,280,000
10 Incisi Abses Kulit dgn diameter lebih dari 2 cm dgn GA 1,968,000 1,312,000
9 Eksterpasi Tumor Kulit dan Bawah Kulit ( Sub Kutis ) lebih dari 2 dengan GA 1,968,000 1,312,000 3,280,000
8 Open Biopsi Superfisial 1,968,000 1,312,000 3,280,000
6 Release de Quervain Single dgn GA 1,968,000 1,312,000 3,280,000
9 Skin Laser Treatment 2,532,000 1,688,000 4,220,000
3,280,000
5 Angkat Plate Tibia 1,968,000 1,312,000
4 Angkat Nail Tanpa Penyulit 1,968,000 1,312,000 3,280,000
3 Manipulasi dengan GA 1,968,000 1,312,000 3,280,000
2 Reposisi Patellar Dislocation dengan GA 1,968,000 1,312,000 3,280,000
1 Reposisi Dislocation MCP/PIP/DIP Joint dengan GA 1,968,000 1,312,000 3,280,000
16 Thoracotomi 10,800,000 7,200,000 18,000,000
9,750,000
13 Endovenous Laser Treatment dengan multipel flebektomi 5,850,000 3,900,000
12 Endovenous Laser Treatment 5,850,000 3,900,000 9,750,000
6,750,000
10 Grafting pada Arterial Insufisiensi 4,050,000 2,700,000 6,750,000
6,750,000
9 Skleroterapi dengan anestesi 4,050,000 2,700,000
8 Eksisi & rekonstruksi limfedema & reduksi massa 4,050,000 2,700,000 6,750,000
7 Debridement & tutup defek pada gangren diabetik 4,050,000 2,700,000 6,750,000
6 AV Shunt radial (Brescia-Cimino) 4,050,000 2,700,000 6,750,000
5 Simpatektomi 4,050,000 2,700,000 6,750,000
4 AV Shunt cubiti 4,050,000 2,700,000
11 Eksisi ligasi & rekonstruksi malformasi vaskuler sederhana 5,850,000 3,900,000 9,750,000
c. Poplitea/Tibialis 4,050,000 2,700,000 6,750,000
b. Fermoralis 4,050,000 2,700,000 6,750,000
a. Splenorenal 4,050,000 2,700,000 6,750,000
3 Shunting :
6,750,000
2 Operasi vaskuler yang memerlukan teknik vaskuler khusus, memakai 4,050,000 2,700,000
1 Semua tindakan yang dilakukan dengan narkose & memerlukan teknik 4,050,000 2,700,000 6,750,000
11 Operasi Aneurisma Aorta 4,050,000 2,700,000 6,750,000
12 Operasi Arteri Carotis 4,050,000 2,700,000 6,750,000
13 Operasi Arteri Renalis Stenosis 4,050,000 2,700,000 6,750,000
14 Lumbal simpatektomi bilateral 4,050,000 2,700,000
10 Debridement AVM 5,850,000 3,900,000 9,750,000
9 AV Shunt radial/cubiti dengan pasang double lumen 5,850,000 3,900,000 9,750,000
9 AV Shunt radial/cubiti dengan pasang double lumen 5,850,000 3,900,000 9,750,000
9,750,000
8 Stripping varises 2 tungkai dengan multipel flebektomi 5,850,000 3,900,000
7 Stripping varises 1 tungkai, debridement ligasi vena perforantes/penyulit 5,850,000 3,900,000 9,750,000
6 Stripping varises 1 tungkai dengan flebektomi 5,850,000 3,900,000 9,750,000
5 Trombektomi dengan atau tanpa debridement 5,850,000 3,900,000 9,750,000
4 Simpatektomi per laparoskopi/thorakoskopi unilateral 5,850,000 3,900,000 9,750,000
9,750,000
3 Pasang akses port celsite 5,850,000 3,900,000
2 Limfadenektomi Ileoinguinal 5,850,000 3,900,000 9,750,000
1 Grafting pd arteri insufisiensi 5,850,000 3,900,000 9,750,000
5. Khusus II
15 Lumbal simpatektomi unilateral 4,050,000 2,700,000 6,750,000
6,750,000
C. BEDAH ORTOPEDI
1. Sedang II
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
56 Bone Graft 1,968,000 1,312,000 3,280,000
62 Laporotomy Appendectomy 1,968,000 1,312,000
61 Reposisi tertutup dilokasi 1,968,000 1,312,000 3,280,000
60 Achiles Tendo Lengthening ( ATL) 1,968,000 1,312,000 3,280,000
59 Trimming Bone 1,968,000 1,312,000 3,280,000
58 Revisi Illizarov 1,968,000 1,312,000 3,280,000
3,280,000
57 Tenotomy 1,968,000 1,312,000
55 Abdominal Flap 1 (satu ) Jari 1,968,000 1,312,000 3,280,000
63 Eksisi Luas dan Rekonstruksi Sederhana 1,968,000 1,312,000 3,280,000
54 Eksplorasi Orthopaedi 1,968,000 1,312,000 3,280,000
53 Eksisi Head Radius 1,968,000 1,312,000 3,280,000
3,280,000
52 Release Compartment Syndrome 1,968,000 1,312,000
51 Amputasi Jari 1 buah 1,968,000 1,312,000 3,280,000
50 Release Carpal Tunel Syndrome dgn GA 1,968,000 1,312,000 3,280,000
49 Release Trigger Finger dgn GA 1,968,000 1,312,000 3,280,000
3,280,000
64 Flap Kulit / Otot 1,968,000 1,312,000 3,280,000
3,280,000
73 ORIF Fr. Tibia Pillon 1,968,000 1,312,000 3,280,000
4 ORIF Fr. Tallus 2,532,000 1,688,000 4,220,000
3 ORIF Fr. Patella 2,532,000 1,688,000 4,220,000
2 ORIF Fr. Metatarsal > 2 Jari 2,532,000 1,688,000 4,220,000
4,220,000
1 ORIF Fr. Phalanx Pedis > 2 Jari 2,532,000 1,688,000
75 Removal of Implant 1,968,000 1,312,000 3,280,000
74 ORIF Mandibula/Maxilla (Fr. Mandibula Segmental/Communitif) 1,968,000 1,312,000 3,280,000
3,280,000
65 Fiksasi Internal Iga 1,968,000 1,312,000 3,280,000
72 Angkat Nail dan Plale Cruris 1,968,000 1,312,000
71 Angkat Nail dan Plate Femur 1,968,000 1,312,000 3,280,000
70 Thendoraphy Single 1,968,000 1,312,000 3,280,000
69 Amputasi Ekstermitas Atas atau Bawah 1,968,000 1,312,000 3,280,000
68 Amputasi Rekonstruksi 1,968,000 1,312,000 3,280,000
3,280,000
67 Tandur Alih Kulit 1,968,000 1,312,000
66 Rekonstruksi Vaskuler Perifer (Trauma ) 1,968,000 1,312,000 3,280,000
48 Release de Quervain dgn GA 1,968,000 1,312,000 3,280,000
47 ORIF Fr. Phalanx Manus 1 Jari 1,968,000 1,312,000
14 Insisi Abses Kulit diameter > 2 cm dgn GA 1,968,000 1,312,000 3,280,000
3,280,000
28 Angkat K. Wire Multi dgn GA ( 3 - 6 ) 1,968,000 1,312,000 3,280,000
3,280,000
27 Angkat K. Wire Multiple dgn GA ( > 6 Wire ) 1,968,000 1,312,000
26 Angkat Plate / Pinning Clavicula 1,968,000 1,312,000 3,280,000
25 Angkat External Fixasi 1,968,000 1,312,000 3,280,000
24 Angkat Screw ( Hip / Ankle / Patella / Condylair) 1,968,000 1,312,000 3,280,000
23 Angkat Nail dgn Penyulit 1,968,000 1,312,000 3,280,000
22 Angkat Plate Tibia Fibula 1,968,000 1,312,000
30 Angkat Plate Phalanx Multiple 1,968,000 1,312,000 3,280,000
21 Biopsi Kelenjar Getah Bening Leher 1,968,000 1,312,000 3,280,000
20 Angkat Plate Phalanx Single 1,968,000 1,312,000 3,280,000
19 Amputasi Jari Single dengan GA 1,968,000 1,312,000 3,280,000
18 Angkat Plate Metacarpal / Tarsal Single 1,968,000 1,312,000 3,280,000
3,280,000
17 Reposisi Dislocation Meta Tarsal Phalanx (MTP) / Inter Phalanx (IP) Joint 1,968,000 1,312,000
16 Excisi Keloid diameter > 2 cm dgn GA 1,968,000 1,312,000 3,280,000
15 Insisi Hematoma diameter > 2 cm dgn GA 1,968,000 1,312,000 3,280,000
29 Angkat Plate Metacarpal / Tarsal Multiple 1,968,000 1,312,000 3,280,000
31 Insisi Abses dgn GA ( Abses Tulang ) 1,968,000 1,312,000 3,280,000
46 ORIF Fr. Metacarpal 1 Jari 1,968,000 1,312,000 3,280,000
40 Excisional Biopsi & Debulking 1,968,000 1,312,000 3,280,000
45 ORIF Tibia Middle Third Distal Third Simple & Fibula 1,968,000 1,312,000 3,280,000
44 ORIF Fr. Phalanx Pedis 1 Jari 1,968,000 1,312,000 3,280,000
43 ORIF Fr. Metatarsal 1 Jari 1,968,000 1,312,000 3,280,000
43 ORIF Fr. Metatarsal 1 Jari 1,968,000 1,312,000 3,280,000
3,280,000
42 Reposisi Dislocation Gleno Humeral Anterior dengan GA (Closed Reposisi) 1,968,000 1,312,000
41 Osteotomy, Realigment, ORIF 1,968,000 1,312,000 3,280,000
39 Corection of Congenital Deformity : Release Constrition Band 1,968,000 1,312,000 3,280,000
32 Open Biopsi Deep 1,968,000 1,312,000
38 Corection of Congenital Deformity : Polidactily 1,968,000 1,312,000 3,280,000
3,280,000
37 Corection of Congenital Deformity : Release Syndactily 1,968,000 1,312,000
36 Debridement Sendi-sendi lain 1,968,000 1,312,000 3,280,000
35 Debridement & Pengegipan 1,968,000 1,312,000 3,280,000
34 Angkat lllizarov 1,968,000 1,312,000 3,280,000
33 Incisi Abses dgn GA 1,968,000 1,312,000 3,280,000
3,280,000
2. Besar
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
47 Repair Ligament 2,532,000 1,688,000 4,220,000
53 ORIF Fr. Collum Humeri 2,532,000 1,688,000
52 Release Z Plasty 2,532,000 1,688,000 4,220,000
51 Rekonstruksi Patellar Habital Disloc. 2,532,000 1,688,000 4,220,000
50 Debridement Knee (Gonitis)-- goniotomi 2,532,000 1,688,000 4,220,000
49 Repair Nervus Single 2,532,000 1,688,000 4,220,000
4,220,000
48 Repair Arteri Single 2,532,000 1,688,000
46 Koreksl Hallux Valgus 2,532,000 1,688,000 4,220,000
54 ORIF Fr. Intercondylair Humeri 2,532,000 1,688,000 4,220,000
45 Fractura of Scapula Corpus Scapula 2,532,000 1,688,000 4,220,000
44 Rekonstruksi Bicipital Tendinitis 2,532,000 1,688,000 4,220,000
4,220,000
43 Fractura of Scapula Pro. Acromialis 2,532,000 1,688,000
42 Rekonstruksi Bicipital Tendinitis 2,532,000 1,688,000 4,220,000
41 Repair Finger Hip Injury Multiple 2,532,000 1,688,000 4,220,000
40 Release Dupuytren 2,532,000 1,688,000 4,220,000
4,220,000
55 Refracturasi, ORIF 2,532,000 1,688,000 4,220,000
4,220,000
64 Excisi Ganglion dgn dia. lebih dari 2 cm dgn GA 2,532,000 1,688,000 4,220,000
70 Gips Corset / Hemispica /Body Jacket dengan GA 2,532,000 1,688,000 4,220,000
69 Angkat Plate Femur Schaft 2,532,000 1,688,000 4,220,000
4,220,000
68 Operasi Tumor Jaringan Lunak 2,532,000 1,688,000
67 Reposisi Gips Ekstermitas Bawah dgn GA 2,532,000 1,688,000 4,220,000
66 Reposisi Gips Ekstermitas Atas dgn GA 2,532,000 1,688,000 4,220,000
65 Debridement Open Fraktur Grade > 2 2,532,000 1,688,000 4,220,000
4,220,000
56 ORIF Fr. Femur Segmental 2,532,000 1,688,000 4,220,000
63 Insisi Abses (Abses dalam Tulang ) dengan GA 2,532,000 1,688,000
62 ORIF Old Dislocation 2,532,000 1,688,000 4,220,000
61 ORIF. Fr. Humerus Segmental 2,532,000 1,688,000 4,220,000
60 Fracture of Scapula Pro. Acromialis 2,532,000 1,688,000 4,220,000
59 Rekonstruksi Bicipital Tendinitis 2,532,000 1,688,000 4,220,000
4,220,000
58 Repair Finger Hip Injury Multiple 2,532,000 1,688,000
57 ORIF Fr. Radius Ulna Segmental 2,532,000 1,688,000 4,220,000
39 Amputasi Jari Multiple ( > 2 Jari) 2,532,000 1,688,000 4,220,000
38 Release CTEV 2,532,000 1,688,000
5 ORIF Fr. Calcaneal 2,532,000 1,688,000 4,220,000
4,220,000
19 Rekonstruksi Patella 2,532,000 1,688,000 4,220,000
4,220,000
18 Tenoraphy Achilles Tendon 2,532,000 1,688,000
17 Arthroscopy Diagnostic 2,532,000 1,688,000 4,220,000
16 ORIF Fr. Femur 2,532,000 1,688,000 4,220,000
15 ORIF Fr. Collum Femur 2,532,000 1,688,000 4,220,000
14 OMPG (Terpisah dgn Tind. Screwing / ORIF) 2,532,000 1,688,000 4,220,000
13 ORIF Fr. Supracondylair Femur 2,532,000 1,688,000
21 Arthrodesis 2,532,000 1,688,000 4,220,000
12 ORIF Fr. Cruris 2,532,000 1,688,000 4,220,000
11 ORIF Fr. Tibia Plateau Simple 2,532,000 1,688,000 4,220,000
10 Release fraktur + Skeletal Traksi Malunion Femur tibia 2,532,000 1,688,000 4,220,000
9 ORIF Fr. Os Pubis 2,532,000 1,688,000 4,220,000
4,220,000
8 ORIF Fr. Os Illium 2,532,000 1,688,000
7 ORIF Fr. Ankle 2,532,000 1,688,000 4,220,000
6 ORIF Fr. Bimaleolalr 2,532,000 1,688,000 4,220,000
20 Open Menisectomy 2,532,000 1,688,000 4,220,000
22 Fibular Graft 2,532,000 1,688,000 4,220,000
37 ORIF Fr. Humerus Prox.Third/Distal Third/Middle Fragmented 2,532,000 1,688,000 4,220,000
31 Muscle Skin Flap 2,532,000 1,688,000 4,220,000
36 ORIF Fraktur SCH ( Supra Condylair Humeri) 2,532,000 1,688,000 4,220,000
35 ORIF Lateral end Clavicula 2,532,000 1,688,000 4,220,000
34 ORIF Disloc. Coxae 2,532,000 1,688,000 4,220,000
34 ORIF Disloc. Coxae 2,532,000 1,688,000 4,220,000
4,220,000
33 Reposisi terbuka sendi panggul/siku/bahu 2,532,000 1,688,000
32 Muscle STSG / Skin Graft 2,532,000 1,688,000 4,220,000
30 Rotation Muscle Flap 2,532,000 1,688,000 4,220,000
23 ORIF Fr. Metacarpal > 2 Jari 2,532,000 1,688,000
29 ORIF Eksisi Prosesus Coracoid 2,532,000 1,688,000 4,220,000
4,220,000
28 ORIF Ruptur Acromio Claviculair Ligament 2,532,000 1,688,000
27 ORIF Fr. Condylus Lateralis / Medialis Humeri 2,532,000 1,688,000 4,220,000
26 ORIF Fr. Radius Ulna (Antebrachii) 2,532,000 1,688,000 4,220,000
25 ORIF Sternoclaviculair Disloc. 2,532,000 1,688,000 4,220,000
24 ORIF Fr. Phalanx Manus > 2 Jari 2,532,000 1,688,000 4,220,000
4,220,000
71 Angkat Plate Femur Proximal / Distal 2,532,000 1,688,000 4,220,000
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
94 Rekonstruksi atau Shoulder Habitual Disloc 2,532,000 1,688,000 4,220,000
89 Angkat Plate dengan Penyulit 2,532,000 1,688,000 4,220,000
90 Angkat Kichner dengan Penyulit/dengan C-Arm 2,532,000 1,688,000
4,220,000
91 High Tibia Osteotomy 2,532,000 1,688,000 4,220,000
92 ORIF FR. Humerus Middle Third Simple 2,532,000 1,688,000 4,220,000
93 Release Kontraktur 2,532,000 1,688,000 4,220,000
95 Release Volkmann, Ischemic Contracture 2,532,000 1,688,000
87 Thendoraphy multiple 2,532,000 1,688,000 4,220,000
4,220,000
96 ORIF Fr. Trochanter Femur 2,532,000 1,688,000 4,220,000
97 ORIF Fr. Tibia Plateau Communitif dengan Bone Graft 2,532,000 1,688,000 4,220,000
98 ORIF Fr. Intercondylair Femur 2,532,000 1,688,000 4,220,000
99 ORIF Fr. Tibia Segmental 2,532,000 1,688,000 4,220,000 100 Amputasi Rekonstruksi 2,532,000 1,688,000
4,220,000
88 Reattachment Avulsi Patellar Tendon 2,532,000 1,688,000 4,220,000
86 Debredement Osteomylitis 2,532,000 1,688,000 4,220,000
72 Body Jacket dengan GA 2,532,000 1,688,000 4,220,000
78 Body Jacket/Corset Dewasa dengan GA 2,532,000 1,688,000 4,220,000
73 Debridement Coxae / Hip ( Coxitis ) 2,532,000 1,688,000 4,220,000
74 Eksternal Fiksasi Pelvis 2,532,000 1,688,000 4,220,000
75 Angkat Plate Radius & Ulna 2,532,000 1,688,000
4,220,000
76 Angkat Plate Humeri 2,532,000 1,688,000 4,220,000
77 Angkat K. Wire Multiple dgn GA ( > 6 Wire ) 2,532,000 1,688,000 4,220,000
79 Debridement & Drilling 2,532,000 1,688,000 4,220,000
4,220,000
80 Debridement, Squesterectomy & Guttering 2,532,000 1,688,000
4,220,000
81 Eksternal Fiksasi pada Fr. Terbuka III A - III B 2,532,000 1,688,000 4,220,000
82 Angkat Plate Tulang Belakang 2,532,000 1,688,000 4,220,000
83 External Fixasi pada Fraktur terbuka Grade IIIC 2,532,000 1,688,000 4,220,000
84 Debridement, Amputasi Gangren Diabetik / Penyakit Lainnya 2,532,000 1,688,000 4,220,000
85 Repair Syaraf Perifer 2,532,000 1,688,000
101 Amputasi Ekstermitas Atas atau Bawah 2,532,000 1,688,000 4,220,000 101 Amputasi Ekstermitas Atas atau Bawah 2,532,000 1,688,000 4,220,000
3. Khusus I
2 Disarticulatio Knee 4,050,000 2,700,000 6,750,000
6,750,000
22 Release Torticolis 4,050,000 2,700,000 6,750,000
23 Repair arteri, Vena, Syaraf (masing-masing satu) 4,050,000 2,700,000
6,750,000
24 Repair Bankart Lesion 4,050,000 2,700,000 6,750,000
25 Bone Lengthening Procedure 4,050,000 2,700,000 6,750,000
26 Ekplorasi Repair PI. Brachialis 4,050,000 2,700,000 6,750,000
27 Fractura of Scapula Articular Surface 4,050,000 2,700,000 6,750,000
28 ORIF Fr. Tulang Belakang 4,050,000 2,700,000
29 Release Z Plasty > 2 4,050,000 2,700,000 6,750,000
20 Pemasagan Illizarov 4,050,000 2,700,000 6,750,000
30 Disartlculatio Hip / Shoulder 4,050,000 2,700,000 6,750,000
31 Juvara Procedure 4,050,000 2,700,000 6,750,000
32 Total Hip Replacement ( THR ) 4,050,000 2,700,000 6,750,000
33 Total Knee Replacement ( TKR ) 4,050,000 2,700,000
6,750,000
34 THR ( Old Disloc Hip ) 4,050,000 2,700,000 6,750,000
35 Repair Meniscus / Menisectomy 4,050,000 2,700,000 6,750,000
36 Free Vascularized Fibular Graft 4,050,000 2,700,000 6,750,000
21 Release Elbow Contracture 4,050,000 2,700,000 6,750,000
19 Arthrodesis Triple Ankle Joint 4,050,000 2,700,000 6,750,000
3 Fore Quarter Amputation 4,050,000 2,700,000
10 Hip Arthrodesis 4,050,000 2,700,000 6,750,000
6,750,000
1 Repair Meniscus/Menisectomy 4,050,000 2,700,000 6,750,000
5 Limfadenektomi Ileoinguenal 4,050,000 2,700,000 6,750,000
6 Limfadenektomi Retroperitoneal 4,050,000 2,700,000 6,750,000
7 ORIF, Symphisiolisis 4,050,000 2,700,000 6,750,000
8 Release Hip Contracture 4,050,000 2,700,000
6,750,000
9 ORIF Fr. Acetabulum Anterior 4,050,000 2,700,000 6,750,000
11 ORIF Fr. Acetabulum Posterior 4,050,000 2,700,000 6,750,000
6,750,000
12 Fase Quarter Amputasi 4,050,000 2,700,000 6,750,000
13 Hemipelvictomy 4,050,000 2,700,000
6,750,000
14 Open Red Old Hip Disloc 4,050,000 2,700,000 6,750,000
15 ORIF Fr. Trimalleolar 4,050,000 2,700,000 6,750,000
16 Cassebaum Procedure 4,050,000 2,700,000 6,750,000
17 Rekonstruksi Patellar Habitual Disloc 4,050,000 2,700,000 6,750,000
18 Release Knee Contracture 4,050,000 2,700,000
4 Fusi Corpus Vetebrata 4,050,000 2,700,000 6,750,000
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
3 Ganti Sendi (Total Knee, HIP, Elbow) tidak termasuk alat 5,850,000 3,900,000 9,750,000
8 Decompression Laminectomy for Tumor and Spinal Stenosis with 5,850,000 3,900,000 9,750,000
7 Decompression Laminectomy for HNP with Stabilization 5,850,000 3,900,000 9,750,000
9,750,000
6 Decompression Laminectomy + Stabilization 5,850,000 3,900,000
5 Anterior dan Posterior Surgery in Spinal Disease with Stabilization/ 5,850,000 3,900,000 9,750,000
4 Anterior dan Posterior Surgery in Deformity with Stabilization/ 5,850,000 3,900,000 9,750,000
2 Fraktur yang Kompleks (Fraktur Acetabulum, Tulang Belakang, fraktur 5,850,000 3,900,000 9,750,000
10 Amputasi Forequarter 5,850,000 3,900,000 9,750,000
9,750,000
1 Koreksi Impresi Fraktur 5,850,000 3,900,000
4. Khusus II
73 Debridement Coxae/HIP (Coxitis) dan Gride Stone Procedure 4,050,000 2,700,000 6,750,000
72 Interlocking Nail Humeri 4,050,000 2,700,000 6,750,000
71 Interlocking Nail Femur 4,050,000 2,700,000 6,750,000
6,750,000
9 Spinal Osteotomy 5,850,000 3,900,000 9,750,000
11 Spinal Osteotomy for Ankylossing Spondylitis dengan forward gaze kurang 5,850,000 3,900,000
69 Sterno Claviculair Dislocation dgn GA 4,050,000 2,700,000 6,750,000
1 Enuklease Kista Kecil 1,404,000 936,000 2,340,000
8 Labioplasty Bilateral 1,404,000 936,000 2,340,000
7 Palatoplasty 1,404,000 936,000 2,340,000
6 Odentectomy >2 elemen 1,404,000 936,000 2,340,000
5 Excochliasi 1,404,000 936,000 2,340,000
4 Ekstirpati Tumor 1,404,000 936,000 2,340,000
3 Sequesyerectomy dgn Narkose 1,404,000 936,000 2,340,000
2 Marsupialisasi Ranula 1,404,000 936,000 2,340,000
6 Koreksi Spondilitis 10,800,000 7,200,000 18,000,000
9,750,000
5 Koreksi Scoliosis 10,800,000 7,200,000 18,000,000
18,000,000
4 Operasi Fraktur kompleks (Acetabulum, Tulang Belakang, Pelvis) 10,800,000 7,200,000
3 Ganti Sendi (Arthroplasty) tidak termasuk alat 10,800,000 7,200,000 18,000,000
2 Release Carpal Tunnel Syndrome Unilateral 10,800,000 7,200,000 18,000,000
1 Release Carpal Tunnel Syndrome Bilateral 10,800,000 7,200,000 18,000,000
5. Khusus III
70 French Osteotomy 4,050,000 2,700,000
68 Arthroscopy for / with Debridement / Shaving 4,050,000 2,700,000 6,750,000
37 Free Vascularlzed Muscle Flap 4,050,000 2,700,000 6,750,000
45 Laminectomy HNP 4,050,000 2,700,000
6,750,000
50 Total Elbow Replacement ( TER ) 4,050,000 2,700,000
49 Total Shoulder Replacement (TSR ) 4,050,000 2,700,000 6,750,000
48 Rekontruksi PCL ( Open ) 4,050,000 2,700,000 6,750,000
47 Rekonstruksi ACL ( Open ) 4,050,000 2,700,000 6,750,000
46 Debridement Spodylitis TBC Thoracalis 4,050,000 2,700,000 6,750,000
6,750,000
44 Pemasangan Illizarov dengan Rekonstruksi 4,050,000 2,700,000 6,750,000
67 Arthroscopy for / with Corpus Alienum Ectraction 4,050,000 2,700,000 6,750,000
43 Anastomosis Tarik Terobos 4,050,000 2,700,000 6,750,000
42 Operasi Miles 4,050,000 2,700,000 6,750,000
41 Radical Neck Dissesction ( RND ) Klasik 4,050,000 2,700,000 6,750,000
6,750,000
40 Operasi Hernia Diafragmatika 4,050,000 2,700,000
39 Pericardiosintesis Terbuka 4,050,000 2,700,000 6,750,000
38 Toracolaparotomy Darurat 4,050,000 2,700,000 6,750,000
51 Colecistectomy laparoscopic 4,050,000 2,700,000 6,750,000
52 Repair PCL 4,050,000 2,700,000 6,750,000
53 Repair LCL 4,050,000 2,700,000 6,750,000
54 Repair Patellar Tendon / Ligament 4,050,000 2,700,000 6,750,000
66 Hemiarthroplasty 4,050,000 2,700,000 6,750,000
66 Hemiarthroplasty 4,050,000 2,700,000 6,750,000
6,750,000
65 Radial Club Hand (Centralization) 4,050,000 2,700,000
64 Rekonstruksi of Mal Union/Non Union 4,050,000 2,700,000 6,750,000
63 Removal AMP Cementles, Removal THR 4,050,000 2,700,000 6,750,000
62 Revisi AMP/TKR/TSR/TER 4,050,000 2,700,000 6,750,000
61 TKR dengan Penggantian Patella 4,050,000 2,700,000 6,750,000
6,750,000
60 Release CTEV with Bone Procedure 4,050,000 2,700,000
59 Open Red Old Shoulder Disloc 4,050,000 2,700,000 6,750,000
58 Simpatektomi Torakal 4,050,000 2,700,000 6,750,000
57 ORIF, Sacroilliaka Joint Disruption 4,050,000 2,700,000 6,750,000
56 Reattachment PCL 4,050,000 2,700,000 6,750,000
6,750,000
55 Reatrachment ACL 4,050,000 2,700,000
D. BEDAH GIGI DAN MULUT
1 Sedang I
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
3 Meatotami 1,404,000 936,000 2,340,000
8 Spermatocele 1,404,000 936,000 2,340,000
7 Orchidektomi 1,404,000 936,000 2,340,000
6 Vericocele / Palomo 1,404,000 936,000 2,340,000
2,340,000
5 Sectio Alta 1,404,000 936,000
4 Vasektomy 1,404,000 936,000 2,340,000
2 Sistotomi 1,404,000 936,000 2,340,000
10 Nefrostomi percutan 1,404,000 936,000
1 Semua tindakan yg dilakukan dgn narcose tanpa resiko tinggi 1,404,000 936,000 2,340,000
14 Mandibulektomi Partialis dengan rekonstruksi 4,050,000 2,700,000 6,750,000
13 Mandibulektomi Total 4,050,000 2,700,000 6,750,000
12 Maksilektomi Total 4,050,000 2,700,000 6,750,000
11 Koreksi Impresif Fraktur 4,050,000 2,700,000 6,750,000
10 Hemipelvektomi 4,050,000 2,700,000 6,750,000
9 RPG/APG 1,404,000 936,000 2,340,000
2,340,000
9 Alveolectomi 1,404,000 936,000 2,340,000
4 Sistokopy 1,968,000 1,312,000 3,280,000
9 Pasang Kateter Tenckhoff untuk CAPD 1,968,000 1,312,000 3,280,000
8 Operasi priapismus (prosedur Winter) 1,968,000 1,312,000 3,280,000
7 Orchidektomi/Orchidektomi subkapsuler 1,968,000 1,312,000 3,280,000
3,280,000
6 Hidrokel per skrotal 1,968,000 1,312,000
5 Drainage Periureter 1,968,000 1,312,000 3,280,000
3 Biopsi Ginjal Perkutan 1,968,000 1,312,000 3,280,000
11 Cabut DJ Stent 1,404,000 936,000 2,340,000
2 Biopsi Testis 1,968,000 1,312,000 3,280,000
3,280,000
1 Biopsi Prostat 1,968,000 1,312,000
2. Sedang II
13 Operasi Hydrokel 1,404,000 936,000 2,340,000
12 Operasi Hernia tanpa komplikasi 1,404,000 936,000 2,340,000
9 Hemiglosektomi + RND 4,050,000 2,700,000 6,750,000
8 Glosektomi Total 4,050,000 2,700,000 6,750,000
7 Eksisi Luas Radikal + Rekonstruksi 4,050,000 2,700,000 6,750,000
17 Penutupan Oroantral Fistula 1,404,000 936,000 2,340,000
1 Enuklease Kista ( Besar ) 2,532,000 1,688,000 4,220,000
3 Besar
3 Tindakan Blok Resectie 1,968,000 1,312,000 3,280,000
2 Reposisi Fixatie (compucate) 1,968,000 1,312,000 3,280,000
1 Exterpatie Plunging Ranula 1,968,000 1,312,000 3,280,000
2 Sedang II
16 Pencabutan gigi dengan komplikasi 1,404,000 936,000 2,340,000
6 Maxillectomy Mandibulectomy tumor ganas R. Mulut 4,050,000 2,700,000 6,750,000
15 Operculectomy 1,404,000 936,000 2,340,000
14 Insisi Mucocele 1,404,000 936,000 2,340,000
13 Gingivectomy 1,404,000 936,000 2,340,000
12 Frenectomi 1,404,000 936,000 2,340,000
11 Fistulectomi 1,404,000 936,000 2,340,000
10 Apek reseksi (gigi) 1,404,000 936,000 2,340,000
2 Reposisi Tertutup Fiksasi IDW +IMW frak. Mand & Max 2,532,000 1,688,000 4,220,000
3 Athroplasty 2,532,000 1,688,000 4,220,000
4 Rekonstruksi Palatolabio schisis 2,532,000 1,688,000 4,220,000
5 Debridement Squesterectomy,Osteomyelitis 2,532,000 1,688,000 4,220,000
5 Orthognatic Surgery 4,050,000 2,700,000 6,750,000
4 Kondilektomi mj pd ankylosys 4,050,000 2,700,000 6,750,000
3 Rekonstruksi Komp Labio Palato Gnato schisis 4,050,000 2,700,000 6,750,000
3 Rekonstruksi Komp Labio Palato Gnato schisis 4,050,000 2,700,000 6,750,000
2 Eksterpasi/Insisi Luas Tumor Ganas R. Mulut 4,050,000 2,700,000 6,750,000
1 fasial lain LeFort I,II,III 4,050,000 2,700,000 6,750,000
4 Khusus
12 Removal Implant (Plate, Nail, Screw) 2,532,000 1,688,000 4,220,000
11 Condilotomy mandibula 2,532,000 1,688,000 4,220,000
10 Mandibulektomi Marginalis 2,532,000 1,688,000 4,220,000
9 Hemiglosektomi 2,532,000 1,688,000 4,220,000
8 Resectie Rahang 2,532,000 1,688,000 4,220,000
7 Frontoethmoidektomi (Estranasal) 2,532,000 1,688,000 4,220,000
6 Extirpatie Plunging Ranula 2,532,000 1,688,000 4,220,000
E. BEDAH UROLOGI
1. Sedang I
J S J P JLH ( Rp ) ( Rp ) ( Rp ) NO J E N I S P E L A Y A N A N
40 Fistulektomi/Repair Fistel Uretra 2,532,000 1,688,000
4,220,000
45 Epispadia 2,532,000 1,688,000
44 Diverticulectomy 2,532,000 1,688,000 4,220,000
43 Urethrectomy 2,532,000 1,688,000 4,220,000
42 Prostatetectomy retropabik 2,532,000 1,688,000 4,220,000
41 Hidrokel per Inguinal/Ligasi Tinggi 2,532,000 1,688,000 4,220,000
4,220,000
39 Penektomi Parsial 2,532,000 1,688,000 4,220,000
47 Reseksi partial vesika 2,532,000 1,688,000 4,220,000
38 Orchidektomi Ligasi Tinggi 2,532,000 1,688,000 4,220,000
37 Orkhidektomi extended 2,532,000 1,688,000 4,220,000
36 Operasi repair buli trauma 2,532,000 1,688,000 4,220,000
4,220,000
35 Nefrostomi terbuka/permanen 2,532,000 1,688,000
34 Nefropeksi/Renopeksi 2,532,000 1,688,000 4,220,000
33 Reparasi fistula vesico vaginal 2,532,000 1,688,000 4,220,000
46 Prothese penis 2,532,000 1,688,000 4,220,000
48 Reseksi urachus 2,532,000 1,688,000 4,220,000
31 Laparotomi eksplorasi 2,532,000 1,688,000 4,220,000
56 Skrotopasti 2,532,000 1,688,000 4,220,000
5 Longitudinal nefrolithotomi (kadet) 4,050,000 2,700,000 6,750,000
4 Heminefrektomi 4,050,000 2,700,000 6,750,000
6,750,000
3 Transplantasi Ginjal 4,050,000 2,700,000
2 Urethropplasty Satu Tahap 4,050,000 2,700,000 6,750,000
1 Semua tindakan yg dilakukan dgn Narcose & memerlukan Teknik Operasi 4,050,000 2,700,000 6,750,000