Pergub 141 2018 Lampiran

Lampiran : Keputusan Gubernur Provinsi Daerah Khusus
Ibukota Jakarta
Nomor 141 TAHUN 2018

Tanggal 14 Desember 2018
TARIF LAYANAN RUMAH SAKIT UMUM DAERAH KELAS C DAN D
NO USULAN
NAMA LAYANAN
TARIF BARU
A PEMERIKSAAN DAN KONSULTASI
1 Konsultasi Spesialis by Phone (di luar jam praktek) 20,000

2 Konsultasi Gizi di Instalasi Rawat map 25,000
3 Konsultasi Gizi di Instalasi Rawat Jalan 25,000
Konsultasi Dokter Umum di Ruang Rawat map Isolasi
4 30,000
dan Intensif
Konsultasi Emergency Spesialis by Phone (Jam 23.00 -
5 30,000
07.00 WIB)
6 Konsultasi Psikolog Klinis di Instalasi Rawat Jalan 30,000
7 Konsultasi Psikologi Klinis di Instalasi Rawat map 30,000
8 Pemeriksaan / konsultasi Dokter Umum/ Dokter Gigi 30,000

Konsultasi Dokter Spesialis di Ruang Rawat map
9 40,000
Isolasi dan Intensif
Pemeriksaan / konsultasi Spesialis Internal (non
10 40,000
DPJP)
11 Pemeriksaan / konsultasi Spesialis Perioperatif 40,000
12 Pemeriksaan / konsultasi Spesialis Rawat map 40,000
13 Pemeriksaan IGD 40,000
14 Pemeriksaan / konsultasi S sesialis Rawat Jalan 60,000
B INSTALASI GAWAT DARURAT
1 Injeksi 20,000
2 Injeksi TT 20,000
3 Klisma ' 20,000
4 Oksigen 1 - 3 Liter / Jam 20,000
5 Pasang Infus 20,000
6 Pemasangan Oropharingeal Gastric Tube 20,000
7 Aff Kateter 25,000

8 Irigasi Telinga 25,000
9 Wound Toilet Kecil 25,000
10 Observasi < 8 Jam 30,000

11 Pasang Kateter Urine 30,000
2
12 Pasang Spalk 30,000

13 Pemasangan Nasopharingeal Gastric Tube 30,000
14 Cabut Jahitan 0-10 Jahitan 35,000

15 Inhalasi 35,000
17 Hecting 1-5 40,000

18 Infus Pump 40,000
19 Irigasi Mata 40,000
20 Syringe Pump 40,000
21 Toilet Hidung 40,000
22 Visum Luar 40,000
23 Cabut Jahitan > 10 Jahitan 45,000

24 Insisi Cross 45,000
25 Monitor 45,000
26 EKG 50,000
27 Ekstraksi Corpus Alienum 50,000
28 Hecting >5 50,000
29 Observasi 8 Jam 50,000
30 Pemasangan jalur intraosseseus 50,000
31 Suction 50,000
32 Wound Toilet Sedang 50,000
33 Oksigen > 7 Liter / Jam 60,000

34 Pasang Tampon Hidung 60,000
35 Pasang Tampon Telinga 60,000
36 Intubasi Endotracheal 65,000

37 Krikotiroidektomi 65,000
38 WT Combustio 5. 30 % 65,000
39 Aspirasi Cairan 80,000

40 Ekstraksi Kuku 80,000
41 Kumbah Lambung 80,000
42 Wound Toilet Besar 80,000
43 WT Combustio > 30 % 80,000
44 Punksi Vesica Urinaria 150,000

45 Resusitasi 150,000
46 Oksigen 1 - 3 Liter / Hari 200,000

48 Pasang Chest Tube 250,000
49 Punksi Pleura 300,000

50 Oksigen > 7 Liter / Hari 300,000
51 Pasang CVC 300,000
3
52 Vena Secti 300,000

53 Pasang CPAP 350,000
54 Pasang Ventilator 500,000
C INSTALASI RAWAT JALAN
1 Aff Contact Lens 20,000

2 Edukasi Kelompok per Orang 20,000
3 Injeksi (ic, sc, iv, im) 20,000
4 Injeksi TT 20,000
5 Ischiara Test 20,000
6 Klisma 20,000
7 Memory/MMSE 20,000
8 MMT 20,000
11 Patching 20,000
13 Pemeriksaan Garpu Tala 20,000
14 Pemeriksaan Posture 20,000
15 Penilaian MMT 20,000
16 ROM 20,000
17 Senam Hamil 20,000
18 Vaksinasi dasar 20,000

20 Auditory Retraining 25,000
21 Ingatan Bahasa 25,000
22 Irigasi Telinga 25,000
23 Klinik Memori 25,000
24 Sensor-Motory Retraining 25,000
25 Train The Brain 25,000
26 Visual Retraining 25,000
28 Aff Tampon Nasal 30,000

29 Tes Daya Tahan/ Kebugaran 30,000
30 Ekstraksi Clavus 30,000
31 Ekstraksi Corpus Alienum Palpebra 30,000
32 Ekstraksi Kolesteatom 30,000
33 Ekstraksi Serumen 30,000
34 Fitting Bandange Lens (1 Eye) 30,000
35 IVA Test 30,000
36 Kaustik Tenggorok 30,000
37 Keseimbangan Dan Koordinasi 30,000
38 Observasi < 8 Jam 30,000
41 Pedagogic 30,000
42 Pelatihan Posture 30,000
4

44 Pernafasan Dan Relaksasi 30,000
45 Probing 30,000
46 Refraksi Anak 30,000
47 Refraksi Dewasa 30,000
48 Terapi Kerja 30,000
49 Terapi Wicara 30,000
51 Vitalisasi Otak (Ikhtisar) 30,000

53 Inhalasi 35,000
55 Vaginal Hygiene 35,000
56 Ekstraksi Corpus Alienum Kornea 40,000

57 Epilasi 40,000
58 Hecting 1-5 40,000
59 Hecting Palpebra 40,000
61 Irigasi Mata 40,000
62 Stimulasi - Terapi Behavior 40,000
63 Stimulasi - Terapi Fisioterapi 40,000
64 Stimulasi - Terapi Occupational 40,000
65 Stimulasi - Terapi Speech 40,000
68 Visum 40,000

70 Insisi Cross 45,000
71 Kaustik Telinga 45,000
72 Tindik 45,000
73 Aff susuk KB 50,000

74 Baby Gym 50,000
75 Baby Massage 50,000
76 Baby Spa 50,000
77 Benda Asing Hidung Tanpa Anastesi 50,000
78 Benda Asing Telinga Tanpa Anastesi 50,000
79 Chloretyl Spray 50,000
80 Dis Hallpike Manuver 50,000
81 Ekstraksi Corpus Alienum 50,000
82 Hecting >5 50,000
83 Imobilisasi Dengan Elastic Verban 50,000
84 Observasi .?_ 8 Jam 50,000
86 Slit Lamp 50,000
87 Snozelen/Sensory-Integrasi, Stimulasi-Terapi 50,000
88 Suction 50,000
5
90 Drainage Abses 55,000

91 Akupunktur Penyakit 60,000
92 Audiometri Nada Murni 60,000
93 Benda Asing Tenggorokan 60,000
94 Ekstraksi Komedo 60,000
95 Elektroakupunktur 60,000
96 Facial 60,000
97 Infus Vitamin C Per Kunjungan 60,000
98 KIL 60,000
100 Pasang Tampon Hidung 60,000
101 Pasang Tampon Telinga 60,000
102 Podofilin 60,000

104 WT Combustio 5 30 % 65,000
70,000
105 Endoskopi Hidung
70,000
106 Endoskopi Telinga
70,000
107 Endoskopi Tenggorok
70,000
108 Mantoux Test
70,000
109 Paresentase/Miringotomi
75,000
110 Aff IUD
75,000
111 Cek Permanen Pace Maker
Aquapunktur 80,000
112
Aspirasi Cairan 80,000
113
114 Debridement 80,000
115 Ekstraksi Kuku 80,000
116 Elektrokauter 80,000
117 Eustachius Tube Function 80,000
Injeksi Intra Artikuler 80,000
118
Pasang Implan 80,000
120
121 Pasang IUD 80,000
122 Refleks Akustik 80,000
124 WT Combustio > 30 % 80,000
125 Akupunktur Estetika 100,000

126 Audiometri Tutur 100,000
127 Insisi 100,000
128 Insisi Abses Peritonsil 100,000
129 Pap Smear 100,000
130 Pasang susuk KB dengan anastesi lokal 100,000
131 Peeling 100,000
132 Psiko test 100,000
6
133 Biopsi 120,000

134 Brand Daroft Manuver 120,000
135 Laserpunktur 120,000
136 Reposisi 120,000
137 Buka Gips Sesisi 125,000
138 Aff Implan 150,000

139 Insisi Hordoleum/Khalazion/Abses 150,000
140 MMPI 150,000
141 Punksi Asites 150,000
145 Sensory Aqustic Level 150,000
146 Buka Gips Sirkular 175,000

147 Buka Gips Tabung 175,000
148 Oto Acustic Emission 175,000
149 Cryo 180,000

150 Mikrodermabrasi 180,000
151 Pleurodesis 180,000
152 BERA tanpa sedasi 200,000

153 Biopsi Jarum Halus (FNAB) 200,000
154 Ekstirpasi 200,000
155 FNAB guided USG 200,000
156 Insisi Bartolin 200,000
157 Pelayanan Hiperbarik Per Pelayanan 200,000
158 Pungsi Asites/Pleura/Vesica guided USG 200,000
159 Akupunktur Tanam Benang 250,000

160 Eksisi 250,000
161 Ekstirpasi Pterygium 250,000
162 Holler Monitoring 250,000
163 Kauter Condyloma 250,000
164 Pasang Chest Tube 250,000
165 Stress Echo Treadmill 250,000
166 Tinitus Retaining Theraphy 250,000
167 Pasang Gips Sesisi 300,000

168 Pasang Gips Sirkular 300,000
169 Pasang Gips Tabung 300,000
170 Pasang WSD 300,000
171 Sirkumsisi 300,000
173 Carotid Duplex Doppler 400,000

174 Dermaroller 400,000
175 Vasektomi 400,000
7
176 Stress Echo Dobutamin (DSE) 500,000

177 Vascular Tungkai Doppler 500,000
178 Laser IPL 700,000
D TINDAKAN GIGI DAN MULUT
1 Ekstraksi Gigi Sulung (Chlorethyl) 35,000

2 Open Bur 35,000
3 Bongkar Amalgam Filling 40,000

4 Penambalan Sementara 40,000
5 Terapi: Stomatitis, Ulkus/Kunjungan 40,000
6 Ekstraksi Gigi Sulung dengan Injeksi 50,000

7 Grinding 50,000
8 Lepas bracket 75,000

9 Penambahan open coil 75,000
10 Penggantian wire 75,000
11 Activier Ortho Removable 80,000

12 Amalgam Filling Per Gigi 80,000
13 Cementasi Per Gigi 80,000
14 Cetak Per Rahang 80,000
15 Composite Filling Per Gigi 80,000
16 Debridement Gigi 80,000
17 Flouridasi 80,000
18 Insisi Abses Intra Oral 80,000
19 Oclusal Adjusment Per Gigi 80,000
20 Operculectomy Per Gigi 80,000
21 Oral Profilaksis 80,000
22 Pasang Pin Per Gigi 80,000
23 Penambalan Composite 80,000
24 Penambalan Glass Ionomer 80,000
25 Perawatan Penyakit Mulut 80,000
26 Perawatan Saluran Akar 80,000
27 Pit Dan Fissur Sealant 80,000
28 Terapi: Temporo Mandibular Junction / Kunjungan 80,000
29 Trepanasi 80,000
30 Activier Ortho Appliance 90,000

31 Activier Ortho Dengan Penambahan Alat 90,000
32 Apeksifikasi 90,000
33 Ekstraksi Gigi Tetap 90,000
34 Kuretase Gigi 90,000
35 Scalling Per Rahang 90,000
36 Penggantian bracket / pcs 100,000

8
37 Gigi Tiruan Per Gigi 150,000

38 Pengisian Saluran Akar (2 akar) 150,000
39 Composite Crown 170,000

40 Tambah Gigi Berikutnya 170,000
41 Bleaching gigi non vital (per gigi) 200,000

42 Core Build Up 200,000
43 Ekstraksi Gigi Dengan Penyulit 200,000
44 Insisi Abses Extra Oral 200,000
45 Mahkota Sementara 200,000
46 Reparasi Plat Ortho Dan Cetak 200,000
47 Copping 250,000
48 Gingivectomy Per Regio 250,000
49 Labial Veneering Per Gigi 250,000
50 Post Core 250,000
51 Reline 250,000
52 Reparasi Dan Cetak 250,000
53 Alveolectomy 300,000
54 Crown And Bridge Pfm Per Gigi 300,000
55 Frenektomy 300,000
56 Ling-ual Arct 300,000
57 Occlusal Splint Per Gigi 300,000
58 Palatal Arct 300,000
59 Pengisian Saluran Akar 300,000
60 Pengisian Saluran Akar Multiple (>3) 300,000
61 Skin Prick Test 300,000
62 Space Maintainer 300,000
63 Bruxism 400,000
64 Obturator Tanpa Gigi 400,000
65 Plat Ortho Lepasan Per Rahang 400,000
66 Rebase 400,000
67 Bridge Work Dan Precious Metal Per Gigi 450,000

68 Fiksasi Fraktur Rahang 450,000
69 Free Gingival Graft 450,000
70 Palatal Crib 450,000
71 Porcelin Veneer (Facing) 450,000
72 Crown Metal 500,000

73 Gigi Tiruan Flexi 500,000
74 Gigi Tiruan Sebagian 500,000
75 Inlay/Outlay 500,000
76 Maryland Bridge Per Gigi 500,000
77 Retainer ortho per Rahang 500,000
78 Odontectomy 800,000
9
79 Crown Porcelin 1,300,000

80 Gigi Tiruan Lengkap Logam 1 Elemen 1,300,000
81 Gigi Tiruan Loam 1,300,000
82 Gigi Tiruan Penuh 1 Rahang 1,300,000
83 Fixed Appliance Gigi Standar Per Rahang 2,300,000
84 Fixed Appliance Gigi Transparan Per Rahang 2,300,000
E KAMAR RAWAT INAP
1 Tarif Kamar Bayi / Perawatan Bayi Sehat Per Hari 100,000
2 Tarif Kamar ICU/ICCU 1,000,000

3 Tarif Kamar Intermediate / HCU Per Hari 200,000
4 Tarif Kamar Kelas I per Hari 300,000
5 Tarif Kamar Kelas II per Hari 200,000
6 Tarif Kamar Kelas III Per Hari 100,000
7 Tarif Kamar NICU Per Hari 800,000
Tarif Kamar Perinatologi / Perawatan Bayi Sakit Per
8 200,000
Hari
9 Tarif Kamar VIP 500,000
10 Tarif Rawat Gabung Per Hari 150,000
F TINDAKAN RAWAT INAP
1 Aff Infus 15,000

3 Aff Nasogastric tube 20,000

4 Kasur Dekubitus 20,000
5 Klisma 20,000
6 Oksigen 1 - 3 Liter / jam 20,000

9 Penis Hygiene 25,000
11 Aff Tampon Nasal 30,000

12 Ekstraksi Corpus Alienum Palpebra 30,000
13 Minimal Care 30,000

18 Inhalasi 35,000
19 Oksigen 4 - 6 Liter / jam 35,000

10

24 Injeksi Intra Artikuler 45,000
25 Partial Care 45,000
26 Imobilisasi Dengan Elastic Verban 50,000

28 Suction 50,000
30 Drainage Abses 55,000

32 WT Combustio 30 % 65,000

36 Pasang Iud 80,000
38 WT Combustio > 30 % 80,000
39 Aff WSD 100,000

40 Arthrocentresis 100,000
41 Biopsi Jarum Halus (FNAB) 100,000
42 Insisi 100,000
43 Lumbal Pungsi 150,000

44 Punksi Asites 150,000
48 Tindakan Pemasangan Transfusi 170,000

49 Oto Acustic Emission 175,000
50 Eksisi 180,000
51 Ekstirpasi 180,000


G RAWAT INAP ISOLASI DAN INTENSIF
1 Warmer Blanket Per Jam 10,000

11
4 Kasur Dekubitus 25,000

5 Oral Hygine 25,000
6 Perawatan Bayi Baru Lahir 25,000
7 Penis Hygiene 30,000

12 Single Nasal Pronge 35,000
13 Surface Cooling 35,000
14 Inhalasi 40,000
16 Monitor 45,000
17 Pasang Inkubator Transport 45,000
18 Ekstubasi 50,000
20 Suction 50,000
22 Aff CPAP 60,000

23 Oksigen > 7 Liter / jam 60,000
24 Total Care 60,000

27 Blue Light Per Hari 75,000

28 WT Combustio < 30 % 75,000
29 WT Combustio > 30 % 85,000

33 Resusitasi Neonatus 150,000
34 Warmer Blanket per Hari 150,000

37 Pasang Kateter Umbilikal 200,000

12
41 Pasang Arteri Line 350,000

42 Pasang CPAP 350,000
43 CPAP hari berikutnya 200,000
44 Pasang CVP 350,000
46 Pasang Ventilator 500,000

47 Ventilator hari berikutnya 350,000
H PERSALINAN
1 Inspekulo 20,000
3 Perawatan Tali Pusat 20,000
4 Induksi Dengan Folley Catether 30,000

5 Pemeriksaan Air Ketuban 30,000
8 Douglas Pungsi 50,000

10 Induksi/Akselerasi Persalinan 70,000
11 Aff IUD 80,000

12 Pasang IUD 80,000
13 Eksplorasi Placenta 100,000

14 Kompresi Bimanual Eksternal 100,000
15 Kompresi Bimanual internal 100,000
16 Doppler 150,000
17 Forceps 150,000
18 Vacuum 150,000
20 Hidrotubasi 200,000
22 Kuret Dengan AVM 200,000
24 Pasang Laminaria 200,000

26 Hecting Perineum 270,000
27 Hecting Portio 300,000

29 Manual Plasenta 400,000

13
,
30 Manual Plasenta dengan narkose 500,000
31 Kauter Condyloma 750,000
32 Circlage 850,000
33 Kuretase 900,000
34 Persalinan Normal 1,000,000
35 Persalinan Dengan Penyulit 1,350,000
36 Persalinan Dengan Penyulit II 1,700,000
37 Persalinan Dengan Penyulit III 2,100,000
I HAEMODIALISA
1 Aff Double Lumen 200,000

2 Pasang Double Lumen 350,000
3 Haemodialisa Re-Use 600,000
4 Haemodialisa 800,000
5 Haemodialisa Emergency 900,000
J RADIOLOGI
1 Dental 60,000
2 Abdomen Polos 90,000
3 Ankle Joint 90,000
4 Clavicula 90,000
5 Hip Joint 90,000
6 Humerus 90,000
7 Mandibula 90,000
8 Manus 90,000
9 Mastoid (Schuller) 90,000
10 Pedis 90,000
11 Pelvis 90,000
12 Scapula 90,000
13 Shoulder Joint 90,000
14 Sinus Paranasal Water'S-Lateral 90,000
15 Temporomandibular Joint 90,000
16 Vertebrae Coccygeus 90,000
17 Wrist Joint 90,000
18 Anklejoint AP-Lateral 100,000

19 Antebrachi AP-Lateral 100,000
20 Cruris AP-Lateral 100,000
21 Cubiti AP-Lateral 100,000
22 Femur AP-Lateral 100,000
23 Genu AP- Lateral 100,000
24 Humerus AP-Lateral 100,000
25 Manus AP-Oblique 100,000
26 Nasal AP-Lateral 100,000
27 Pedis AP-Oblique 100,000
28 Thorax AP/Lateral 100,000
29 Thorax Top Lordotic 100,000
30 Vertebrae Cervikal 2 Posisi 100,000
14
31 Wrist Joint AP-Lateral 100,000
32 Schedell AP-Lateral 110,000

33 Vertebrae Lumbal 110,000
34 Vertebrae Lumbosacral 110,000
35 Abdomen 2 Posisi 120,000

36 Appedicogram 120,000
37 Cephalometri 120,000
38 Vertebrae Thoracal 120,000
39 Vertebrae Thoracolumbal 120,000
40 Babygram 140,000
41 Abdomen 3 Posisi 150,000
42 Sinus Paranasalis 3 Posisi 150,000
43 Cephalometri 170,000
44 Panoramic 170,000
45 USG Abdomen 200,000

46 USG Buli Buli 200,000
47 USG Ginjal 200,000
48 USG Kebidanan 200,000
49 USG Kepala Bayi 200,000
50 USG Liver Dan Kandung Empedu 200,000
51 USG Mammae 200,000
52 USG Mata 200,000
53 USG Muskuloskeletal 200,000
54 USG Prostat 200,000
55 USG Testis 200,000
56 USG Thorax 200,000
57 USG Thyroid 200,000
58 USG Vascular Dopler 200,000
59 Vertebrae Cervikal 4 Posisi 200,000
60 Oesofagografi 250,000
61 RPG 250,000
62 HSG 300,000
63 BNO/IVP 400,000
K LAB 0 RATORIUM KLI NI K
1 Pemeriksaan cross check (Rujukan Uji Silang) 10,000

2 Eosinofil 15,000
3 Feses Rutin 15,000
4 Filaria 15,000
5 LED 15,000
6 Retikulosit 15,000
7 Sediaan Jamur (KOH) 15,000
8 Sedimen Urine 15,000
9 Waktu Pembekuan 15,000
10 Waktu Perdarahan 15,000
15
11 Glukosa 2 Jam PP 25,000

12 Glukosa Puasa 25,000
13 Glukosa Sewaktu 25,000
14 Golongan Darah + Rhesus 25,000
15 Beta hCG Urine 30,000

16 Sediaan BTA MH 30,000
17 SGOT 30,000
18 SGPT 30,000
19 Sputum BTA 3X 30,000
20 Urine Lengkap 30,000
21 Albumin 35,000
22 Asam Urat 35,000
23 Asam Urat Urine 24 Jam 35,000
24 Biliribin Indirect 35,000
25 Bilirubin Direct 35,000
26 Bilirubin Total 35,000
27 Globulin 35,000
28 Kolesterol Total 35,000
29 Kreatinin 35,000
30 Kreatinin Urine 24 Jam 35,000
31 Malaria 35,000
32 Pewarnaan Gram 35,000
33 Protein Total 35,000
34 Trigliserida 35,000
35 Ureum 35,000
36 Ureum Urine 24 Jam 35,000
37 Darah Rutin (Hb+Ht+Leuko+Trombo) 40,000

38 Feses Lengkap 40,000
39 Alkali Fosfatase 45,000
40 Calcium Total 45,000
41 Gamma GT 45,000
42 Magnesium 45,000
43 RPR 45,000
44 Amphetamine 50,000
45 ASTO 50,000
46 Benzodiazepin 50,000
47 Calcium Urine 50,000
Darah Lengkap (Darah Rutin+Hitung
50,000
48 Jenis+E+NER+LED)
49 HDL 50,000
50 IT-Ratio 50,000
51 LDH 50,000
52 LDL 50,000
53 Magnesium Urine 50,000
54 Mariyuana 50,000
16
55 Morfin/Opiat 50,000
56 Phospor 50,000
57 Phospor Urine 50,000
58 Rheumatoid Faktor 50,000
Tes Cepat Molekuler tanpa Cartridge (subsidi / hibah) 50,000
59
60 TTGO 50,000
61 VDRL 50,000
62 Widal 50,000
63 Bersihan Kreatinin Urine 24 Jam 60,000

64 CK-MB 75,000
65 Gambaran Darah Tepi 75,000
Pemeriksaan Laboratorium Anti HCV (Rapid Test/
75,000
66 RDT)
67 Amylase 80,000
68 Analisa Sperma 80,000
69 Chlorida 80,000
70 Kalium 80,000
71 Kolinesterase 80,000
72 Leptospira Igl\d 80,000
73 Natrium 80,000
74 TPHA 80,000
75 Aprr 90,000
76 CRP 90,000
77 PT 90,000
78 Anti HBs 100,000

79 Anti HCV (ELISA) 100,000
80 Elektrolit (Na, K, Cl) 100,000
81 Fibrinogen 100,000
82 HbsAg 100,000
83 Salmonella IgM Typhi (Tubex) 100,000
84 Serum Iron 100,000
85 TIBC 100,000
86 Trombin Time 100,000
87 Agregasi Trombosit 120,000
88 Analisa Gas Darah 120,000
89 D Dimer 120,000
90 HbsAg (ELISA) 120,000
91 Mikro Albumin Urin 24 Jam 120,000
92 T3 120,000
93 T4 120,000
94 TSH 120,000
95 CD4 130,000
96 CD8 130,000
17
97 AFP 140,000
98 Anti HbsAg (ELISA) 140,000
99 Anti HIV 140,000
100 Apo B 140,000
101 CEA 140,000
102 G6PD 140,000
103 Dengue Antigen NS1 150,000

104 Dengue IgG IgM 150,000
105 Analisa Batu 160,000

106 Feritin 160,000
107 HbalC 160,000
108 Peroksidase 160,000
109 Anti CMV IgG 180,000

110 Anti HIV 1-2 (ELISA) 180,000
111 Anti HSV 1 IgG 180,000
112 Anti HSV 1 IgM 180,000
113 Anti HSV 2 IgG 180,000
114 Anti HSV 2 IgM 180,000
115 Anti Toksoplasma IgG (ELISA) 180,000
116 Anti Toxoplasma IgM (Elisa) 180,000
117 Apo A 180,000
118 Elektrolit Urine (Na, K, Cl) 180,000
119 Free T4 180,000
120 Troponin T 180,000
121 Anti Rubella IgG 200,000

122 Anti Rubella IgM 200,000
123 CRP Kuantitatif 200,000
124 ANA 225,000

125 Anti CMV IgM 225,000
126 Anti HAV IgM 225,000
127 Anti HAV Total 225,000
128 Anti TB IgG Titer 225,000
129 FSH 225,000
130 IDT, ICT (Amoeba) 225,000
131 IgE Total 225,000
132 LH 225,000
133 MCA (Payudara) 225,000
134 Prolactin 225,000
135 Sudan Black B 225,000
136 Transferin 225,000
137 Analisa Hb 250,000

138 Anti ds-DNA 250,000
139 Beta hCG Serum 250,000
140 Calcium Ion 250,000
18
141 Cortisol 250,000

142 C-Peptide 250,000
143 Estradiol 250,000
144 Faktor VIII 250,000
145 LP (a) 250,000
146 Progesteron 250,000
147 PSA (total) 250,000
148 Salmonella IgG Typhi 250,000
Tes Cepat Molekuler dengan Cartridge (TBRO,
250,000
149 Hepatitis)
150 Testosteron 250,000
151 C3 Komplemen 300,000

152 C4 Komplemen 300,000
153 Ca 15-3 (Payudara) 300,000
154 Comb Test 300,000
155 Cyfra 21-1 (Paru) 300,000
156 Kultur MO + Resistensi Anaerob 300,000
157 ACA IgG 350,000

158 ACA IgM 350,000
159 Ca-125 (Ovarium) 350,000
160 Ca-19-9 (Pankreas) 350,000
161 Tes EID RNA DNA 400,000

162 Asam Folat 450,000
163 Ca 724 (Lambung) 450,000
164 Protein C 500,000

165 Protein S 500,000
166 Measles IgG 700,000

167 Measles IgM 700,000
168 Viral Load (HIV) 1,000,000

169 Western Blood 1,000,000
L LABOFZATORIUM PATOLOGI ANATOMI
1 Pulasan Khusus: BTA, H.Pylori 50,000

2 Serviks/Vagina/Sputum 1 x 100,000
3 Bilasan Bronkus 250,000
4 Cairan Pleura 250,000
5 FNAB 250,000
6 Serviks Thin Prep 250,000
7 Sikatan Bronkus 250,000
8 Sputum 3 x 250,000
9 Urine 250,000
10 Biopsi/Jaringan Kecil (Apendiks, Kuret, KGB, Kulit) 350,000
19
11 FNAB (tindakan oleh DSPA) 350,000
12 Jaringan Besar (Mastektomi, Histerektomi, Usus) 500,000
13 Imunohistokimia 800,000
14 Potong Beku 1,000,000
15 Imuhistokimia 1,500,000
M BANK DARAH
1 Biaya Darah Titip 30,000

2 Ice Packed 30,000
3 Pemeriksaan Golongan Darah Metode Slide 30,000
4 Cool Box Lengkap 50,000
5 Biaya Cross Match 70,000
6 Buku Formulir Permintaan Darah Rangkap 4 70,000
7 Pemeriksaan Golongan Darah Metode Tabung 70,000
8 Sel Panel Kecil untuk Skrining Antibodi 90,000
9 Fresh Frozen Plasma (FFP) 250,000
10 Packed Red Blood Cell (PRC) 250,000
11 Trombocyt Concentrate (TC) 250,000
12 Wash Eritrocyt (WE) 250,000
13 Whole Blood (WB) 250,000
14 Pemeriksaan Rhesus Typing 350,000
15 Pemeriksaan Comb Test 400,000
16 Pemeriksaan Incompatible 400,000
17 Sel Panel Besar untuk Identifikasi Antibodi 550,000
Sel Panel Lengkap yaitu Sel Panel Besar dan Kecil 600,000
18
19 Darah NAT 800,000
N KAMAR OPERAS!
1 Operasi Kecil 2,000,000

2 Operasi Aulvulsi Pterygium 2,000,000
3 Operasi Eksisi Granulasi Telinga 2,000,000
4 Operasi Sirkumsisi 2,000,000
5 Operasi Sedang 3,000,000

6 Operasi Abses Submandibula 3,000,000
7 Operasi Adheliolisis 3,000,000
8 Operasi Aff Implan 3,000,000
9 Operasi Alveolectomy 3,000,000
10 Operasi Anoplastik 3,000,000
11 Operasi Antrostomi Unilateral 3,000,000
12 Operasi Biopsi Dalam Tubuh (Berbagai Jenis) 3,000,000
13 Operasi Biopsi Saraf Kutaneus/Otot 3,000,000
14 Operasi Blok Saraf Tepi 3,000,000
15 Operasi Dilatasi Dan Kuretase Untuk Biopsi 3,000,000
16 Operasi Drainase (Insisi Abses Ekstra Oral) 3,000,000
17 Operasi Drainase Abses Pada Otot 3,000,000
20
18 Operasi Duktus Thyroglosus Simple 3,000,000

19 Operasi Eksisi Arthoplasti Sendi Kecil 3,000,000
20 Operasi Eksisi Dengan Penyulit 3,000,000
21 Operasi Eksisi FAM 3,000,000
22 Operasi Eksisi Fibroma 3,000,000
23 Operasi Eksisi Ginekomasti 3,000,000
24 Operasi Eksisi Hemangioma 3,000,000
25 Operasi Eksisi Mamae Aberans 3,000,000
26 Operasi Eksisi Tumor < 1 cm Konjunctiva Lokal 3,000,000
27 Operasi Eksisi Tumor > lcm Konjunctiva Lokal 3,000,000
28 Operasi Eksplorasi Plexus Cervical/Branchialis 3,000,000
29 Operasi Eksplorasi Vagina 3,000,000
30 Operasi Ekstirpasi (Leher) 3,000,000
31 Operasi Ekstirpasi Kista Bartholin 3,000,000
32 Operasi Ekstirpasi Mioma Geburt 3,000,000
33 Operasi Ekstraksi Gigi Dan Komplikasi 3,000,000
34 Operasi Excochleatie 86 Ekstraksi Gigi 3,000,000
35 Operasi Fistulektomi 3,000,000
36 Operasi Ganglion 3,000,000
37 Operasi Gastrostomi Paliatif 3,000,000
38 Operasi Glosectomi 3,000,000
39 Operasi Hernia Umbilical 3,000,000
40 Operasi Hidrocelectomi 3,000,000
41 Operasi Katarak SICS +IOL (ECCE) 3,000,000
42 Operasi Keloid Multipel > 5 3,000,000
43 Operasi Konisasi 3,000,000
44 Operasi Koreksi Osteotomi Simpel 3,000,000
45 Operasi Laparoscopy Diagnostic 3,000,000
46 Operasi Lipoma > 3 3,000,000
47 Operasi Mc. Donald/Shirodcar 3,000,000
48 Operasi Odontektomi 2 Gigi 3,000,000
49 Operasi Pasang Gips Telinga 86 Hidung 3,000,000
50 Operasi Pengambilan Dislokasi IUD 3,000,000
51 Operasi Penutupan Oaf 3,000,000
52 Operasi Perineum 3,000,000
53 Operasi Polip Rekti 3,000,000
54 Operasi Pungsi Cairan Otak 3,000,000
55 Operasi Repair Otot 3,000,000
56 Operasi Reparasi Burst Abdomen 3,000,000
57 Operasi Replantasi Gigi 3,000,000
58 Operasi Reposisi Uterus Pada Inversio Uteri 3,000,000
59 Operasi Reseksi Apex Gigi Belakang (>1 Akar) 3,000,000
60 Operasi Sirklase 3,000,000
61 Operasi Tonsilektomi tanpa Adenoidektomi 3,000,000
62 Operasi Tubektomi Post Partum 3,000,000
63 Operasi Tumor Lid Margin < 1/3 Palpebra Lokal 3,000,000
64 Operasi Tumor Lid Margin > 1/3 Palpebra Lokal 3,000,000
65 Operasi WSD Kasus Trauma 3,000,000
66 Operasi Tonsilektomi dengan Adenoidektomi 3,500,000

21
67 Operasi Bone Graft 4,000,000

68 Operasi Eksisi + Graft 4,000,000
69 Operasi Eksternal Drainage 4,000,000
70 Operasi Fiksasi Rahang 4,000,000
71 Operasi Kistektomy 4,000,000
72 Operasi Necrotomi/Debridement 4,000,000
73 Operasi Pungsi Kista Bedah Mulut 4,000,000
74 Operasi Sectio Caesarea 4,000,000
75 Operasi Sequestrektomi 4,000,000
76 Operasi Eksisi Tumor Jaringan Lunak 4,000,000
77 Operasi Tumor Mammae 4,000,000
78 Operasi Varicocelektomi 4,000,000
79 Operasi Besar 4,500,000

80 Operasi Anastomosis Ileum Desenden 4,500,000
81 Operasi Antrostomi Bilateral 4,500,000
82 Operasi Appendiktomi 4,500,000
83 Operasi CAPD 4,500,000
84 Operasi Colostomi 4,500,000
85 Operasi Colosystectomi 4,500,000
86 Operasi Diseksi KGB Retroperitoneal 4,500,000
87 Operasi Drainage Abses Liver 4,500,000
88 Operasi Eksisi Tumor < lcm Konjungtiva 4,500,000
89 Operasi Eksisi Tumor > 1 cm Konjungtiva 4,500,000
90 Operasi Eksisi Tumor Kistik 4,500,000
Operasi Ekstirpasi Tumor < lcm Palpebra
91 4,500,000
Superior/Inferior Lokal
Operasi Ekstirpasi Tumor > lcm Palpebra
92 4,500,000
Superior/Inferior Lokal
93 Operasi Enukleasi (Ekstirpasi) Kompleks Bedah Mulut 4,500,000
94 Operasi Eviserasi 4,500,000

95 Operasi Fistulektomi Bedah Mulut 4,500,000
96 Operasi Hemoroidektomi Interna 4,500,000
97 Operasi Hernia Incarcerata 4,500,000
98 Operasi Herniatomi 4,500,000
99 Operasi Herniatomi Bilateral 4,500,000
100 Operasi Herniatomi Residif 4,500,000
101 Operasi Impaksi Sisi Khusus Bedah Mulut 4,500,000
102 Operasi Kista Duktus Thyroglosus 4,500,000
103 Operasi Kista Ovarium 4,500,000
104 Operasi Kolesistektomi 4,500,000
105 Operasi Kolpodeksis 4,500,000
106 Operasi Kontraktur Released 4,500,000
107 Operasi Laparascopy MOW 4,500,000
108 Operasi Laparatomi KET 4,500,000
109 Operasi Lateral Sphinterotomi 4,500,000
110 Operasi Manchester Fortegil 4,500,000
111 Operasi Mastektomi 4,500,000
22
112 Operasi Mastektomi Simple 4,500,000

113 Operasi Medistinoscopy 4,500,000
114 Operasi Obstruksi Usus/Invaginasi 4,500,000
115 Operasi Pembuluh Darah Simple 4,500,000
116 Operasi Pengangkatan Tumor Ovarium 4,500,000
117 Operasi Perineoraphi Kasus Lama / Penyulit 4,500,000
118 Operasi Quandrantektomy Mammae 4,500,000
119 Operasi Released Interdigiti 4,500,000
120 Operasi Repair Arteri 4,500,000
121 Operasi Repair Pembulur Darah Besar 4,500,000
122 Operasi Repair Ruptur Kornea Lokal 4,500,000
123 Operasi Repair Tendon + Debridement 4,500,000
124 Operasi Repair Tendon > 1 Jani 4,500,000
125 Operasi Reposisi Nasal 4,500,000
126 Operasi Reseksi Adenomiosis 4,500,000
127 Operasi Reseksi Gaster 4,500,000
128 Operasi Rotational Flap _ 4,500,000
129 Operasi RPG 4,500,000
130 Operasi Skin Graft 4,500,000
131 Operasi Splenectomi 4,500,000
132 Operasi Stripping 4,500,000
133 Operasi Struma 4,500,000
134 Operasi STSG (Skin Graft Luas) 4,500,000
135 Operasi Superfisial Paratiroidektomi 4,500,000
Operasi Thyroidektomi
136 4,500,000
Subtotal/ Lobectomi/ Strumektomi / I smuslobektomi
137 Operasi Tubektomi 4,500,000
138 Operasi Tumor Lid Margin < 1/3 Palpebra 4,500,000
139 Operasi Khusus

140 Operasai Total Disc Replacement Bedah Mulut 6,000,000
141 Operasi Close Reduction Complex Bedah Mulut 5,000,000
142 Operasi Debulking 5,000,000
143 Operasi Diseksi Leher Radikal 5,000,000
144 Operasi Duhamel 5,000,000
145 Operasi Eksenterasi Pelvis 5,000,000
146 Operasi Eksenterasi Tumor 5,000,000
147 Operasi Eksplorasi Duktus Kholedokus 5,000,000
148 Operasi end to End Anastomosis 5,000,000
149 Operasi Fore Quater Amputation 5,000,000
150 Operasi Gastrectomi 5,000,000
151 Operasi Gastrokisis Repair 5,000,000
152 Operasi Gnatoplasty 5,000,000
153 Operasi Hemikolektomi 5,000,000
154 Operasi Hemimandibulektomi (Hemimaksilektomi) 5,000,000
155 Operasi Hemoroidektomi 5,000,000
156 Operasi Histerektomi 8,000,000
23
Operasi Histerektomi Radikal (dengan

157 5,000,000
lympadenektomi regional)
158 Operasi Histerektomi Supravaginal / Subtotal 5,000,000
159 Operasi Histerektomi Total dan SOB/TAH + BSO 5,000,000
160 Operasi Interposisi Kolon 5,000,000
161 Operasi Jugular, Subclavia, Femoral 5,000,000
162 Operasi Katarak Fakoemulsifikasi 6,000,000
163 Operasi Kholedoku Jejunostomi 5,000,000
164 Operasi Kholedokuduodenostomi 5,000,000
165 Operasi Kolesistektomi + Eksplorasi CBD 5,000,000
166 Operasi Komando 5,000,000
167 Operasi Laparatomi Explorasi 8,000,000
168 Operasi Laparoscopy Operatif 5,000,000
169 Operasi Laparotomi + Drainage Abses Hepar 5,000,000
Operasi Laparotomi + Herniotomi dengan komplikasi
170 5,000,000
(reseksi usus)
171 Operasi Laparotomi Eksplorasi (staging) 5,000,000
172 Operasi Lithotripsi 5,000,000
173 Operasi Low Anterior Resection 5,000,000
174 Operasi Mastoidektomi 5,000,000
175 Operasi Mega Kolon Hisrchprung 5,000,000
176 Operasi Miles Operation 5,000,000
177 Operasi Miomektomi 5,000,000
178 Operasi Miomektomi/Kistektomi dengan Laparoscopy 5,000,000
179 Operasi Mrm + STSG/Flap 5,000,000
180 Operasi Odontektomi 4 Gigi 5,000,000
181 Operasi 0_pen Reduction Internal Fixation 6,000,000
182 Operasi Operasi Nonunion &Delayed Union 6,000,000
183 Operasi Orif.Fraktur Patella 5,000,000
184 Operasi Pankreatektomi 5,000,000
185 Operasi Pemasangan Arteri/Vena Access 5,000,000
186 Operasi Prolaps Rekti 5,000,000
187 Operasi Prosedur Bypass/Hemicolectomy 5,000,000
188 Operasi Radikal Mastektomi/MRM 5,000,000
189 Operasi Rebola 5,000,000
Operasi Reduksi Terbuka 86 Eksternal Fiksasi Bedah
190 4,500,000
Mulut
Operasi Reduksi Terbuka 86 Eksternal Fiksasi Dengan
191 4,500,000
Plate 8; Screw
Operasi Reduksi Terbuka 86 Eksternal Fiksasi Dengan
192 4,500,000
Wire 86 Screw
193 Operasi Reimplantasi Satu Gigi 6,000,000
194 Operasi Rekonstruksi Arteri/Vena Besar 5,000,000
195 Operasi Repair Cleft Lip Bilateral 6,000,000
196 Operasi Repair Cleft Lip Unilateral 5,000,000
197 Operasi Repair Cleft Palate Complete 6,000,000
198 Operasi Repair Cleft Palate Incomplete 5,000,000
199 Operasi Repair Ruptur Kornea 5,000,000
200 Operasi Repair Tendon 1 Jani 5,000,000
24
201 Operasi Reparasi Fistal 5,000,000

202 Operasi Reseksi Anterior 5,000,000
Operasi Reseksi Esofagus dengan Interposisi
203 5,000,000
Kolon/ Gaster
204 Operasi Reseksi Hepar (Penyulit) 5,000,000
205 Operasi Reseksi Iga 5,000,000
206 Operasi Reseksi Sebagian Mandibula (Maksila) 5,000,000
207 Operasi Reseksi Segmental 5,000,000
208 Operasi Reseksi Usus - Anastomosis 5,000,000
209 Operasi Reseksi Usus Radikal 5,000,000
210 Operasi Ripstein Procedure 5,000,000
211 Operasi Salpingektomi 8,000,000
212 Operasi SC + Histerektomi Total 5,000,000
213 Operasi Surgical Staging 5,000,000
214 Operasi Swenson 5,000,000
215 Operasi Thoracotomy 5,000,000
216 Operasi Thorak Abdominal 5,000,000
217 Operasi Timpanoplasti 5,000,000
218 Operasi Total Glosektomi 5,000,000
219 Operasi Transeksi Esofagus 5,000,000
220 Operasi Tromboembolektomi 5,000,000
221 Operasi 'Fubaplasti 5,000,000
222 Operasi Tumor Ganas Ovarium 5,000,000
223 Operasi Tumor Lid Margin > 1/3 Palpebra 5,000,000
224 Operasi Uretroskopi (litotripsi/biopsi) 5,000,000
225 Operasi URS - Lithoclast 5,000,000
226 Operasi Vaginal Histerektomi 5,000,000
227 Operasi Vaginoplasty (Kolporafi ant/post) 5,000,000
228 Operasi Vulvektomi 5,000,000
229 Operasi Whipple (Pankreatiko Duedenoktomi) 5,000,000
230 Operasio Bilio Digestive 5,000,000
0 AMBULANCE
1 Ambulance Darat 450,000

2 Ambulance Laut 15,000,000
P ELEKTROMEDIK
1 Doppler 40,000
2 Tonometri Schiotz 45,000
3 EKG 50,000
4 Funduscopy Direct 50,000
5 Funduscopy Indirect 50,000
6 Tonometri Non Contact 50,000
7 Tympanometri + Interpretasi 50,000
8 Audiometri Anak 60,000

9 Audiometri Interpretasi 60,000
25
10 Biometri 60,000
11 CTG 60,000
12 Anel test 80,000

13 Spirometri 80,000
14 Anuscopy 100,000
15 Monitor EKG 150,000

16 Treadmill 150,000
17 Echo Cardiography Doppler 200,000

18 EEG tanpa Warna 200,000
19 EMG 200,000
20 Kecepatan Hantar Syaraf 200,000
21 Somato Sensory Evoked Potential 200,000
22 Spasmofili 200,000
23 Visual Evoked Potential 200,000
24 Blink Refleks + EMG 250,000

25 EEG Berwarna 250,000
26 Kecepatan Hantar Syaraf + EMG 250,000
27 Brain Mapping 300,000

28 Brain Mapping tanpa EEG 300,000
Q REHABILITASI MEDIK
1 Infra Red 30,000

2 Massage 30,000
3 MWD Kecil / Diathermy 30,000
4 SWD 30,000
5 Electrical Stimulasi/TENS 35,000

6 Electrical Traction 35,000
7 Exercise Aktif 35,000
8 Exercise Terapi Ringan 35,000
9 MWD Sedang 35,000
10 Ultrasound Therapy 35,000
11 Exercise Terapi Sedang 40,000

12 Inhalasi/Nebulizer 40,000
13 Manual Therapy 40,000
14 Exercise Pasif 50,000

15 Exercise Terapi Berat 50,000
16 Exercise Terapi Khusus 50,000
R KAMAR JENAZAH
26
Pemulasaran Jenazah Anak 400,000

1
Pemulasaran Jenazah Dewasa 500,000
2
Penyimpanan Jenazah Ruangan Cool Storage per 24 100,000
3
Jam
Penyimpanan Jenazah/Ruangan Biasa 2 Jam Pertarna 30,000
4
5 Perawatan Jenazah dan Kain Laken Anak 50,000
6 Perawatan'Jenazah dan Kain Laken Bayi 30,000
7 Perawatan Jenazah dan Kain Laken Dewasa 60,000
8 Perawatan Jenazah/Ruangan Biasa per 24 Jam 60,000
9 Tambahan per Sampel 60,000
10 Tindakan Formalin Jenazah Anak 700,000
11 Tindakan Formalin Jenazah Dewasa 900,000
S LAIN-LAIN
1 Magang, per orang/hari 10,000

Pengambilan Data, per orang/siklus, maksimal 2
2 150,000
bulan
3 Homecare (diluar tindakan) 200,000
4 Penelitian, per orang/siklus, maksimal 2 bulan 250,000
5 Sewa Aula per Hari 350,000
6 Biaya Kaji Etik 1,500,000
maksimal
7 Layanan Obat dan Farmasi Lainnya 120% dani
harga beli
GUBERNUR PRO VINSI DAERAH KHUSUS

IBUKOTA JAKARTA,
ttd
ANIES BASWEDAN

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Lampiran : Keputusan Gubernur Provinsi Daerah Khusus

Nomor 141 TAHUN 2018

TARIF LAYANAN RUMAH SAKIT UMUM DAERAH KELAS C DAN D

1 Konsultasi Spesialis by Phone (di luar jam praktek) 20,000

7 Konsultasi Psikologi Klinis di Instalasi Rawat map 30,000

8 Pemeriksaan / konsultasi Dokter Umum/ Dokter Gigi 30,000

B INSTALASI GAWAT DARURAT

7 Aff Kateter 25,000

10 Observasi < 8 Jam 30,000

12 Pasang Spalk 30,000

14 Cabut Jahitan 0-10 Jahitan 35,000

17 Hecting 1-5 40,000

23 Cabut Jahitan > 10 Jahitan 45,000

33 Oksigen > 7 Liter / Jam 60,000

36 Intubasi Endotracheal 65,000

39 Aspirasi Cairan 80,000

44 Punksi Vesica Urinaria 150,000

46 Oksigen 1 - 3 Liter / Hari 200,000

49 Punksi Pleura 300,000

52 Vena Secti 300,000

C INSTALASI RAWAT JALAN

1 Aff Contact Lens 20,000

19 Aff Kateter 25,000

28 Aff Tampon Nasal 30,000

43 Pemasangan Nasopharingeal Gastric Tube 30,000

52 Cabut Jahitan 0-10 Jahitan 35,000

56 Ekstraksi Corpus Alienum Kornea 40,000

69 Cabut Jahitan > 10 Jahitan 45,000

73 Aff susuk KB 50,000

89 Wound Toilet Sedang 50,000

90 Drainage Abses 55,000

103 Intubasi Endotracheal 65,000

125 Akupunktur Estetika 100,000

133 Biopsi 120,000

138 Aff Implan 150,000

146 Buka Gips Sirkular 175,000

149 Cryo 180,000

152 BERA tanpa sedasi 200,000

159 Akupunktur Tanam Benang 250,000

167 Pasang Gips Sesisi 300,000

173 Carotid Duplex Doppler 400,000

176 Stress Echo Dobutamin (DSE) 500,000

D TINDAKAN GIGI DAN MULUT

1 Ekstraksi Gigi Sulung (Chlorethyl) 35,000

3 Bongkar Amalgam Filling 40,000

6 Ekstraksi Gigi Sulung dengan Injeksi 50,000

8 Lepas bracket 75,000

11 Activier Ortho Removable 80,000

28 Terapi: Temporo Mandibular Junction / Kunjungan 80,000

30 Activier Ortho Appliance 90,000

36 Penggantian bracket / pcs 100,000

37 Gigi Tiruan Per Gigi 150,000

39 Composite Crown 170,000

41 Bleaching gigi non vital (per gigi) 200,000

67 Bridge Work Dan Precious Metal Per Gigi 450,000

72 Crown Metal 500,000

79 Crown Porcelin 1,300,000

E KAMAR RAWAT INAP

1 Tarif Kamar Bayi / Perawatan Bayi Sehat Per Hari 100,000