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C . TARIF PELAYANAN

Tabel 9

Jasa Medis Dokter Umum dan Spesiais

No Jasa Medis Tari! " Rp #

1 2 3

1 Dokter Umum 10,000

2 Dokter Spesialis 20,000

Tabel 10

Tari! Pea$anan %ese&atan Dasar

No Jenis Pea$anan Tari! " Rp #

1 2 3 4 5

1 Pelayanan KB1Pil KB 4,500 3 13,500

2Suntik KB 10,000 10 100,000

3!UD 30,000 2 "0,000

15 11,5"""#

2 Biaya !munisasi Dasar 15,000 15,000

3 Persalinan $ormal 500,000

Tabel 11

Tari! Dokter 'i(i "Pea$anan %ese&atan 'i(i#


1 2 3 4 5

1 Pemeriksaan 10,000 2 20,000

2 Tambal Sementara 15,000 15 225,000

3 Tambal Permanen 20,000 13 2"0,000

4 %abut &i'i susu 15,000 5 #5,000

5 %abut &i'i Permanen 25,000 ( 200,000

"%abut &i'i )' Komplikasi 50,000 4 200,000

*umla+ 4# 9(0,000

ata-rata biaya pelayanan kese+atan 'i'i )asar 20,(51

Per)andin(an

Pea$anan

Tota *ia$a

"Rp#

ata-ata Biaya Untuk Palayanan

KB

Per)andin(anPea$anan

Tota *ia$a"Rp#

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Tabel 12

Tari! Ra+at Jaan Tin(kat II

No J e n i s Tari! " Rp #

1 2 3

Penun.an' Dia'nostik

1 ont'en 32,000

2 /aboratorium 40,000

3Pemeriksaan K+usus 43,000

4 P+atolo'i natomi 25,000

Tabel 13

Tari! Ra+at Inap "Ruma& Sakit#

No J e n i s

1 2 3

1 Biaya Kamar (0,000

2 Biaya perasi #(5,(9#

3 isioterapi 10,000

4 Peraatan K+usus !%%U termasuk obat,/ab )an lkes 1,500,000

5 Persalinan p+atolo'is6)en'an komplikasi 1,500,000

" 7mer'en8y6pelayanan !&D konsul,tin)akan,alkes bat (50,000

# Tran:usi )ara+ 90,000

( Pin, sre )an plate 500,000

Tabel 14

Tari! Pea$anan %&usus


1 2 3

1 Ka8a ;ata 200,000

2 &i'i Palsu 250,000

3 Protesa n''ota &erak 400,000

4 lat Bantu Den'ar 300,000

5 ;ata Palsu 500,000

*ia$a rata,rata" Rp #

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Tabel 15

Tari! Tindakan Medis Dokter Umum


1 2 3 4 5

1 Pembersi+an /uka 10,000 14 140,000

2 *a+it luka < 5 .a+itan 15,000 ( 120,000

3 *a+it luka = 5 .a+itan 30,000 3 90,000

4 7ksisi 30,000 4 120,000

5 !nsisi 10,000 4 40,000

" 7ksplorasi 30,000 5 150,000

# 7ksterpasi 30,000 1 30,000

( 7kstrasi kuku 30,000 2 "0,000

*umla+ 41 #50,000

ata-rata biaya tin)akan me)is )okter umum 1(,293

Tabel 1"

Tari! Tindakan Medis Dokter Spesiais


1 2 3 4 5

1 >or)eolum 114,000 1 114,000

2 Pteri'ium ((,400 1 ((,400

3 !nsisi ((,400 4 353,"00

4 7ksisi ((,400 3 2"5,200

5 Sirkumsisi 114,000 1 114,000

" 7ksterpasi 114,000 1 114,000

# 7ksplorasi 114,000 2 22(,000

*umla+ 13 1,2##,200

ata-rata biaya tin)akan me)is )okter spesialis 9(,24"

Tabel 1#

Tari! Tindakan Medis 'i(i


1 2 3 4 5

1 )onte8tomi #5,000 ( "00,000

2 l?eole8tomi 25,000 2 50,000

3 !nisi 32,000 3 9",000

4 7ksisi 40,000 1 40,000

*umla+ 14 #(",000ata-rata biaya tin)akan k+usus 'i'i 5",143


Tota *ia$a"Rp#

Per)andin(an

Pea$anan

Tota *ia$a

"Rp#


Tota *ia$a"Rp#

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Tabel 1(

Tari! Tindakan k&usus di Ruma& sakit


1 2 3 4 5

1 Biopsi *arin'an 150,000 3 450,000

2 un'si s8ites 150,000 4 "00,000

3 un'si Pleura 150,000 2 300,000

4 @SD 150,000 1 150,000

*umla+ 10 1,500,000

ata-rata biaya tin)akan k+usus )i S 150,000


Tota *ia$a"Rp#

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D.*IAYA -*AT

Tabel 19

*ia$a -)at Ra+at Jaan Tin(kat I

No Jenis Pen$akit

1 2 3 4 5

1 !SP 10,35(#5 33 3,41(39

2 Diare (,00125 15 1,20019

3 &astritis6Tukak /ambun' 1,49250 11 1"41(

4 Penyakit Kulit ",30250 10 "3025

5 ebris Demam 5,9#"25 9 53#("

" %un.un'ti?itis 12,000 # (4000

# Demam (,000 " 4(000

( %aries &i'i6Penyon''a ;ulut 12,000 4 4(0009 a)an' Telin'a Ten'a+ 20,000 3 "0000

10 nemia6atiAue Kelela+an 4,000 2 (000

*umla+ 100 /012.3

NB : kolom 4 = Ratio Utilisasi

Tabel 20

*ia$a -)at Ra+at Jaan Tin(kat II

No Jenis Pen$akit

1 2 3 4 5

1 Tuber8ulosis Paru 1","1250 2( 4,"5150

2 Bron8+itis 14,55000 1# 2,4#350

3 >ipertensi 4(,14"50 12 5,###5(

4 D; 139,9(#50 10 13,99(#5

5 sma 25,55200 ( 2,0441"

" !n:eksi Saluran Urolo'i 2",04225 # 1,(229"

# &astritis kronis 19,(5#05 # 1,3(999

( Dermatitis 3",200 5 1,(10009 bser?asi ebris 1#,"00 4 #0400

10 Tonsilitis 2",(00 2 53"00

*umla+ 100 14/52.00


*ia$a rata,

rata " Rp #

Per)andin(an

Pea$anan "6#

Tota *ia$a

"Rp#

*ia$a rata,

rata " Rp #

Per)andin(an

Pea$anan "6#

Tota *ia$a

"Rp#

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Tabel 21

*ia$a -)at Ra+at Inap "RS#

No Jenis Pen$akit

1 2 3 4 5

1 T+ipoi) 5"0,"49#5 23 12(,94944

2 D> 33#,25000 21 #0,(2250

3 Diare 219,43400 14 30,#20#"

4 Bronk+opneomoni 142,34"(( 10 14,234"9

5 >ipertensi 252,1##3( 9 22,"959"

" Persalinan $ormal 145,00000 # 10,15000

# Ke.an' (5,53531 5 4,2#"##

( Persalinan bnormal 324,00000 4 12,9"000

9 Post op tumor .inak 152,03(#5 2 3,040#(

10 !n:eksi Saluran Urolo'i 122,00000 2 2,44000

*umla+ 9# 122/572.72


*ia$a rata,rata " Rp #

Per)andin(anPea$anan "6#

Tota *ia$a"Rp#

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E.*IAYA PENUNJAN' MEDIS

Tabel 22

*ia$a Penun8an( Dia(nostik Seder&ana


1 2 3 4 5

1 Dara+ utin 12,500 2 25,000

2 Urine utin 9,#50 2 19,500

3 ae8es 5,200 1 5,200

*umla+ 5 49,#00

ata-rata biaya penun.an' )ia'ostik 9,940

Tabel 23

*ia$a Ront(en

No Pemeriksaan Radioo(i Tari! " Rp #

1 2 3 4 5

1 T+ora 25,200 10 252,000

2 Kepala 33,"00 2 "#,200

3 7kstremitas 25,200 2 50,400

4 Pel?is 25,200 1 25,200

5 /ambun' 25,200 2 50,400

" Bno !?p "#,(00 3 203,400

# ;yelo'ra:i 233,000 1 233,000

*umla+ 21 ((1,"00

ata-rata biaya ra)iolo'i 41,9(1

Tabel 24

*ia$a La)oratorium

No Tari! " Rp #

1 2 3 4 5

1 >ematolo'i 2(,900 ( 231,200

2 un'si *antun' 90,(00 3 2#2,400

3 un'si >ati #2,190 4 2((,#"0

4 un'si &in.al 53,3"0 3 1"0,0(0

5 un'si T+ypoi) 199,9(0 1 199,9(0

" T+ipoi) 34,000 " 204,000

# un'si Pankreas 20,100 3 "0,300

( Pemeriksaan Cirus 149,4"0 2 29(,920

*umla+ 30 1,#15,"40ata-rata biaya laboratorium 5#,1((

Rata,Rata

Juma&%asus9*uan

Tota *ia$a"Rp#

Rata,RataJuma&

%asus9*uan

Tota *ia$a"Rp#

PemeriksaanLa)oratorium

Rata,Rata

Juma&%asus9*uan

Tota *ia$a"Rp#

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Tabel 25

*ia$a Pemeriksaan %&usus

No Pemeriksaan %&usus Tari! " Rp #

1 2 3 4 5

1 US& 50,(12 ( 40",49"

2 7K& 20,5#5 12 24",900

3 77& 50,000 2 100,000

4 7;& 50,000 1 50,000

5 7n)os8opy 222,500 2 445,000

" Bronk+os8opy 23#,500 1 23#,500

# u)imetri 25,(50 2 51,#00

( Spirometri 25,(50 2 51,#00

*umla+ 30 1,5(9,29"ata-rata biaya 52,9##

Tabel 2"

*ia$a Patoo(i Anatomi

No Pemeriksaan %&usus Tari! " Rp #

1 2 3 4 5

1 Poton'an Baku 32,"00 5 1"3,000

2 Sitolo'i 32,"00 5 1"3,000

*umla+ 10 32",000

ata-rata biaya 32,"00

Rata,Rata

Juma&%asus9*uan

Tota *ia$a"Rp#

Rata,Rata

Juma&%asus9*uan

Tota *ia$a"Rp#

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Didik SunaryadiKP MAK 04

Tabel 27

7KP!TU/S! P7>!TU$&$ B! KP!

N- JENIS PELAYANAN RASI- %UNJUN'AN TARIF RIIL

1 2 3 4

:. RA;AT JALAN T% I " 6 # " Rp #

a Dokter Umum 140000 10,000

b Dokter &i'i 0"000 20,(51

8 bat-obatan6resep 140000 (,431

) Penun.an' Dia'nostik Se)er+ana 01000 9,940

e Tin)akan ;e)is Umum 03000 1(,293

: Tin)akan ;e)is &i'i 02000 5",143

' Keluar'a Beren8ana 04000 11,5"#

+ !munisasi 00100 15,000

i Persalinan 03400 500,000Sub Total 29.9500

5. RA;AT JALAN T% II

a Dokter Spesialis 03900 20,00000b bat-obatan6resep 03900 35,20(448 Tin)akan ;e)is )okter Spesialis 00001 9(,24"15) Penun.an' Dia'nostik

1ont'en 01(00 32,000002/aboratorium 04500 40,000003Pemeriksaan K+usus 01000 43,000004P+atolo'i natomi 0000( 25,00000

Sub Total 1.51091. RA;AT INAP "RS#

a Biaya kamar 01(00 (0,000b bat-obatan6esep 01(00 300,2918 perasi 005(0 #(5,(9#) Peraatan K+usus 00030 1,500,000e Persalinan P+atolo'is 00200 1,500,000: Penun.an' Dia'nostik

1ont'en 00(00 41,9(12/aboratorium 03200 5#,1((3Pemeriksaan K+usus 00(00 52,9##4P+atolo'i natomi

00400 32,"00' Tin)akan K+usus 000#0 150,000+ /ain-lain

1/abu )ara+ 00000 -2Trans:usi Dara+ 00200 90,0003Pin, Plate, S8re 00001 500,000

i isioterapi 00001 10,000. 7mer'en8y 00001 (50,000

Sub Total 0.9883

0. PELAYANAN %

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Sub Total 0.0183

T-TAL 15.03=4

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S!

%APITASI

5

" Rp #

1,40000

12511

1,1(032

994

54((

11229

4"2#

150

1,#00004,630.30

#(00

13#31

010

5#"0

1(000

4300

020

496.21

14400

54052

455(2

4500

30000

335(

1(300

423(

13041050

-

1(00

050

001

0(5

1,787.21

2(00

1000

040030

050

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39.20

3/745.75

002 ds

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